Non-steroidal drug-induced glaucoma.

Numerous systemically used drugs are involved in drug-induced glaucoma. Most reported cases of non-steroidal drug-induced glaucoma are closed-angle glaucoma (CAG). Indeed, many routinely used drugs that have sympathomimetic or parasympatholytic properties can cause pupillary block CAG in individuals with narrow iridocorneal angle. The resulting acute glaucoma occurs much more commonly unilaterally and only rarely bilaterally. CAG secondary to sulfa drugs is a bilateral non-pupillary block type and is due to forward movement of iris-lens diaphragm, which occurs in individuals with narrow or open iridocorneal angle. A few agents, including antineoplastics, may induce open-angle glaucoma. In conclusion, the majority of cases with glaucoma secondary to non-steroidal medications are of the pupillary block closed-angle type and preventable if the at-risk patients are recognized and treated prophylactically.

Intraocular pressure control after Nd:YAG laser posterior capsulotomy in eyes with glaucoma.

BACKGROUND AND OBJECTIVES: To evaluate the long-term intraocular pressure (IOP) control of glaucomatous eyes following Nd:YAG laser capsulotomy. MATERIALS AND METHODS: We performed a retrospective study of 69 glaucoma patients who underwent an Nd:YAG laser posterior capsulotomy over a 3 year period, following cataract extraction or a combined cataract-glaucoma procedure. All patients had a minimum follow-up period of at least 6 months and a median follow-up period of 2 years. We assessed IOP control, number of glaucoma medications required and whether the patient needed additional glaucoma surgery following the capsulotomy. Based on these outcome measures, we strictly defined "disease progression" as one of the following: an IOP rise of at least 5 mm Hg on two consecutive visits, addition of one or more glaucoma medications and additional glaucoma surgery following the capsulotomy. We calculated Kaplan-Meier event rate curves for these eyes with "disease progression". RESULTS: The rate of "disease progression" was 11.6% at 4 months, 20.3% at 6 months, 38.1% at 12 months, 46.1% at 24 months, 52.1% at 36 months and 52.1% at 47 months following the capsulotomy. CONCLUSION: Gradual IOP elevation or a need for more aggressive therapy is common in glaucoma patients following Nd:YAG laser posterior capsulotomy. It is unclear whether this progression is related directly to the Nd:YAG laser procedure or whether it is an independent progression of the patient's glaucoma unrelated to the Nd:YAG laser procedure.

Selective laser trabeculoplasty: predictive value of early intraocular pressure measurements for success at 3 months.

AIM: To determine the predictive value of the 2 week post-selective laser trabeculoplasty (SLT) intraocular pressure (IOP) by comparing it to the 4 week and 3 month values. METHODS: A retrospective chart review of eyes that underwent SLT between 2001 and 2004 was performed. The primary outcome measure was IOP. Demographic and medical data were collected for correlational analysis. RESULTS: 132 eyes of 95 patients were identified, none was excluded. Of the eyes that exhibited a decrease in IOP of >1 mm Hg at 2 weeks postoperatively, 99.24% continued to show a lowered IOP at the 4 week and 3 month visits. For these patients, the Pearson's r value between 2 weeks and 4 weeks was 0.708 (p value = 0.01) while the r value between 2 weeks and 3 months was 0.513 (p value = 0.01). CONCLUSIONS: The 2 week visit post-SLT predicted the 4 week and 3 month visits if the 2 week visit demonstrated a decrease in IOP. These findings suggest that those patients who had a decreased IOP at 2 weeks and are at their goal IOP may not need to be screened until 3 months postoperatively.

Comparison of the 20-MHz ultrasound probe with ultrasound biomicroscopy in glaucoma.

The 20-MHz ultrasound probe was compared with ultrasound biomicroscopy to determine its usefulness in imaging various glaucomatous conditions. Ten patients with glaucoma underwent anterior segment imaging with both the 20-MHz probe, which attaches to the I3 B-scan (Innovative Imaging Inc., Sacramento, CA), and the Ultrasonic BioMicroscope (UBM; Paradigm Medical Industries, Salt Lake City, UT). All pathology was easily demonstrable using the 20-MHz probe, in one case showing a retinal detachment not seen with the UBM. However, anterior findings such as fluid in the suprachoroidal space and sclerostomy sites in postoperative trabeculectomy cases were more difficult to view with the 20-MHz probe. The use of coupling enhanced the quality of the latter images. The 20-MHz ultrasound probe may be a viable aid in diagnosis and follow-up of certain glaucomatous conditions, and the use of a coupling device enhances its images.

Penetration of ofloxacin and ciprofloxacin into the aqueous humor of eyes with functioning filtering blebs: a randomized trial.

OBJECTIVE: To determine concentrations of ofloxacin and ciprofloxacin hydrochloride in aqueous humor after topical or combined topical and oral administration in eyes with filtering blebs. DESIGN: A prospective, investigator-masked, randomized, controlled comparative study involving 36 eyes of 34 patients with functioning filtering blebs who were to undergo cataract surgery. Treatment groups received either topical ofloxacin or topical ciprofloxacin (instillation of 0.3% ophthalmic solution every 30 minutes for 4 hours before surgery), or a combined topical plus oral regimen (ciprofloxacin hydrochloride, four 100-mg tablets, or ofloxacin, one 400-mg tablet, administered 24-26, 12-14, and 2 hours preceding surgery). The main outcome measure was antibiotic concentration measured by chromatographic separation and mass spectrometry of aqueous samples obtained during surgery. RESULTS: Topical antibiotic treatment yielded mean concentrations of ofloxacin, 0.75 microg/mL, and ciprofloxacin, 0.21 microg/mL, in aqueous. With combined topical and oral therapy, significantly more ofloxacin was measured than ciprofloxacin (3.84 microg/mL vs 0.35 microg/mL [P<.001]). The combination regimen produced significantly greater ofloxacin levels than did topical therapy alone (P =.007). CONCLUSIONS: Ofloxacin penetrates better than ciprofloxacin into the aqueous of eyes with filtering blebs, particularly after combined topical and oral administration, by which ofloxacin reaches more than a 10-fold greater concentration than does ciprofloxacin. Combined topical and oral therapy with ofloxacin may be beneficial in the treatment of bleb-associated infections.

The outcome of the functioning filter after subsequent cataract extraction.

OBJECTIVE: To evaluate and compare the outcome of functioning filtration surgery followed by cataract surgery with posterior intraocular lens implantation by both phacoemulsification and extracapsular cataract extraction (ECCE) techniques in glaucomatous eyes. PATIENTS AND METHODS: We retrospectively evaluated the clinical course of 77 eyes (68 patients) that after successful trabeculectomy, underwent cataract surgery by either phacoemulsification or ECCE techniques. We determined the frequency of partial and absolute failure following cataract surgery by either phacoemulsification or ECCE in eyes with functioning trabeculectomies. Partial failure of intraocular pressure (IOP), control after cataract extraction was defined as the need for an increased number of antiglaucoma medications or argon laser trabeculoplasty to maintain IOP < or =21mm Hg. Complete failure of IOP control after cataract surgery was defined as an IOP >21 mm Hg on at least two consecutive measurements one or more weeks apart or the performance of additional filtration surgery. Failure rates were calculated using the Kaplan-Meier actuarial method. Failure rates between phacoemulsification and ECCE subgroups were compared using the log rank test. RESULTS: The probability of partial failure by the third postoperative year after cataract surgery was 39.5% in the phacoemulsification subgroup and 37.3% in the ECCE subgroup. This small difference is not statistically significant (P = 0.48). The probability of complete failure by the fourth postoperative year after cataract surgery was 12.0% in the phacoemulsification subgroup and 12.5% in the ECCE subgroup. This difference is also not statistically significant (P = 0.77). At the 6-month follow-up visit, visual acuity of both groups improved one or more lines in 87.0% of patients, and worsened one or more lines in 3.9% of patients. Sixty-one percent achieved visual acuity of 20/40 or better. The most frequent complication was posterior capsular opacification requiring laser capsulotomy that occurred in 31.2% of patients. CONCLUSION: Cataract extraction by either phacoemulsification or ECCE following trabeculectomy surgery may be associated with a partial loss of the previously functioning filter and the need for more antiglaucoma medications to control IOP.

Penetrating keratoplasty in iridocorneal endothelial syndrome.

PURPOSE: To evaluate the clinical outcome of penetrating keratoplasty (PK) in iridocorneal endothelial (ICE) syndrome. METHODS: Clinical charts of patients who underwent penetrating keratoplasty for ICE syndrome between 1985 and 1999 were reviewed retrospectively. Glaucoma control, best corrected visual acuity pre- and post-PK, graft clarity, graft rejection episodes, improvement in pain, and additional procedures were analyzed. RESULTS: Fourteen cases were reviewed with an average follow-up of 58 months after PK. Initial grafts failed in seven patients (50%), in six cases because of rejection, and one owing to endothelial failure without signs of rejection. Repeat PKs were performed in six patients. At final follow-up, 12 grafts were clear. Glaucoma was controlled pre- and post-PK (average intraocular pressure, 16 mmHg for both eyes). Pre-PK, eight patients were using glaucoma medicines and nine had had glaucoma surgery. At the end of the follow-up, seven patients were using glaucoma medicines; six patients required glaucoma surgery after their initial PK. At the final follow-up visit, visual acuity in three patients (21%) was 20/40 or better, it ranged from 20/50 to 20/100 in four patients (29%) and 20/200 to 20/400 in five patients (36%), and in two patients with failed grafts (14%) it was counting fingers or worse. CONCLUSION: Clear grafts were achieved in 12 cases, although six patients (43%) underwent repeat PKs. All patients had glaucoma, which was controlled before and after PK by medical treatment and surgical procedures. Favorable outcomes can be achieved in patients with ICE syndrome but may require multiple corneal and glaucoma procedures.

The Advanced Glaucoma Intervention Study (AGIS): 10. Variability among academic glaucoma subspecialists in assessing optic disc notching.

PURPOSE: An analysis of data from the Advanced Glaucoma Intervention Study (AGIS) has found eyes reported to have partial optic disc rim notching (not to the edge) at baseline to have less risk of subsequent visual field loss than eyes with no notching. Because this is counterintuitive and because classification of notching had not been defined in the AGIS protocol, we have assessed AGIS ophthalmologists interobserver and intraobserver agreement on notching. METHODS: Fourteen glaucoma subspecialists classified notching in 26 pairs of stereoscopic disc photographs of eyes with mild to severe glaucomatous optic neuropathy. They classified images as showing either no notching, notching not to the edge, or notching to the edge. Several hours later, 10 of them classified the same images a second time. RESULTS: In an analysis of interobserver agreement, of 26 stereoscopic images, a plurality of ophthalmologists classified notching as absent in 9 (35%), as present but not to the edge in 7 (27%), and as present and not to the edge in 10 (38%). All 14 ophthalmologists (100%) agreed on the classification of 7 (27%) of the images, and 13 of the 14 ophthalmologists (93%) agreed on the classification of 4 additional images (15%). Of these 11 images with at least 93% agreement, notching was reported as absent in 3 (27%) and to the edge in 8 (73%). In the remaining 15 images, there was substantial disagreement about whether notching was present and, if so, whether it was to the edge. In an analysis of intraobserver agreement, none of the 10 ophthalmologists who completed the viewing a second time classified all eyes exactly the same as the first time, though 5 ophthalmologists made 4 or fewer reclassifications. Overall, 80% of the original classifications were reproduced on second reading. Of the initial classifications that were not reproduced, slightly more than half were first classified as having notching not to the edge. CONCLUSION: Without definitions or examples of optic disc rim notching, the glaucoma subspecialists had relatively high intraobserver agreement but were likely to disagree with each other in characterizing the degree of disc rim notching. We recommend development of a standard photographic classification of disc rim notching. The classification should be tested for inter- and intra-observer agreement.

Reversal of optic disc cupping after glaucoma surgery analyzed with a scanning laser tomograph.

OBJECTIVE: To detect and quantitate changes in optic nerve morphology after glaucoma surgery using the Heidelberg Retina Tomograph (HRT, Heidelberg Instruments, Heidelberg, Germany). DESIGN: Nonconsecutive observational case series. PARTICIPANTS AND INTERVENTION: The authors prospectively enrolled 21 adult patients undergoing incisional glaucoma surgery for progressive glaucoma damage. Quantitative analysis of the optic nerve head by scanning laser tomography and automated perimetry were performed before and after glaucoma surgery. MAIN OUTCOME MEASURES: Changes in optic nerve parameters were subjected to linear regression analysis with respect to percent of postoperative reduction of intraocular pressure (IOP), as well as with respect to age, refraction, preoperative cup:disc ratio, and change in visual field parameters. RESULTS: Seventeen patients had pre- and postoperative images suitable for analysis. Mean IOP at the time of image acquisition before surgery was 30.5+/-12 mm Hg, and after surgery 11.8+/-5.2 mm Hg (mean follow-up, 26+/-7 weeks). Eleven of 13 (85%) patients having IOP reduction of greater than 40% showed improvement in optic disc parameters. All four patients with less than 25% reduction in IOP showed worsening of most parameters. Changes in optic disc parameters were highly correlated with percent IOP reduction and with age. The parameters in which change most strongly correlated with percent change of IOP were cup area, rim area, cup:disc ratio, and mean cup depth (each, P<0.005). The age of the patient correlated highly with change in maximum cup depth (P<0.005). Refraction and clinically determined cup:disc ratio correlated poorly with changes in measured optic disc parameters. Clinical improvement in visual fields was correlated with the degree of improvement of cup:disc ratio (P = 0.025). CONCLUSION: Most patients showing a 40% lowering of IOP after glaucoma surgery show improved optic nerve morphology as measured by the HRT. The amount of improvement correlated highly with the percent reduction of IOP.

Dysfunctional filtering blebs.

Guarded filtration surgery, is commonly used to control the intraocular pressure (IOP) in glaucomatous patients. Filtration surgery lowers the IOP by creating a fistula between the inner compartments of the eye and the subconjunctival space (i.e., filtering bleb). There are several options to improve the function of filtering blebs and to prevent their failure. However, improvement of IOP control after guarded filtration procedures is associated with a higher frequency of bleb-related complications. Early (e.g., bleb leak, excessive filtration, flat anterior chamber, filtration failure) and late (e.g., bleb leak, excessive filtration and hypotony, symptomatic blebs, bleb encapsulation, filtration failure, bleb infection) complications associated with filtering procedures should be managed adequately to prevent further problems. Techniques to improve the function of filtering blebs and to treat postoperative complications have progressed over the past decade.

Holmium laser sclerostomy in glaucomatous eyes with prior surgery: 24-month results.

BACKGROUND AND OBJECTIVE: To evaluate the effectiveness of holmium laser sclerostomy in glaucoma patients who have had prior intraocular surgery. PATIENTS AND METHODS: The authors conducted a retrospective analysis of outcomes for 25 patients who underwent holmium laser sclerostomy from 1991 to 1993. RESULTS: Postoperative success (defined as a drop in intraocular pressure of 30% and a final intraocular pressure of less than 22 mm Hg) at 24 months ranged from 36% to 52%, depending on criteria chosen for success. There were no major complications from the procedure. CONCLUSIONS: Holmium laser sclerostomy can be successful in a highly select group of patients undergoing filtration procedures who have had prior intraocular surgery.

Evaluation of Nd:YAG laser membranectomy in blocked tubes after glaucoma tube-shunt surgery.

PURPOSE: To determine the effectiveness of Nd:YAG laser membranectomy for reopening blocked glaucoma tube shunts and maintaining the patency over time. METHODS: We reviewed retrospectively the records of 13 patients (13 eyes) who, during the period January 1990 through June 1996, underwent Nd:YAG laser membranectomy in an attempt to reopen a blocked glaucoma tube shunt. Intraocular pressure and tube patency were evaluated at each follow-up visit. RESULTS: Nd:YAG laser membranectomy effectively opened the blocked glaucoma tube shunts in 11 (84.6%) of 13 eyes. Two tubes could not be reopened. Reblockage occurred in seven eyes (53.8%) within the first 11 weeks; four tubes (30.8%) remained patent through follow-up periods of 39, 82, 106, and 169 weeks. Postlaser complications were moderate anterior chamber reaction in four eyes (30.8%), hyphema in two eyes (15.4%), corneal edema in two eyes (15.4%), pressure spike in one eye (7.7%), and shallow anterior chamber in one eye (7.7%). CONCLUSIONS: Nd:YAG laser membranectomy is effective in reopening blocked glaucoma tube shunts but is associated with a relatively high rate of subsequent reblockage in the initially successful cases.

Tube-shunt surgery versus neodymium:YAG cyclophotocoagulation in the management of neovascular glaucoma.

OBJECTIVE: To determine the relative effectiveness of neodymium:YAG (Nd:YAG) cyclophotocoagulation (CPC) and tube-shunt surgery on intraocular pressure (IOP) control in eyes with neovascular glaucoma (NVG). DESIGN: Retrospective, case-by-case matched, comparative group study. PARTICIPANTS: Twenty-four patients with NVG treated with noncontact Nd:YAG-CPC were matched with 24 patients who underwent tube-shunt surgery. Matching criteria included the underlying disorder causing angle neovascularization, the lens status, and patient's age. INTERVENTIONS: Tube-shunt surgery or Nd:YAG-CPC. MAIN OUTCOME MEASURE: Postoperative IOP (IOP > or = 6 and < or = 25 mmHg), visual acuity, and presence of any postoperative complications. RESULTS: Satisfactory IOP control (IOP < or = 25 mmHg and > or = 6 mmHg) was achieved in 9 eyes (37.5%) treated with Nd:YAG-CPC compared with 16 eyes (66.7%) receiving a tube-shunt procedure (P = 0.04) over a mean follow-up of 16.9 +/- 14.6 and 15.2 +/- 11.8 months, respectively. In the matched pairs in both groups that had nonequivalent outcomes, the proportions with persistently high IOP or hypotony were both greater in the CPC group than in the tube-shunt group. The cumulative proportion of failure in the CPC group was 20.8% at 6 months, 35.4% at 1 year, and 71.2% at 3 years postoperatively. In the tube-shunt group, the cumulative proportions of failure at 6 months and 1 year were close to those in the CPC group (12.5% and 29.2%, respectively), but lower 3 years after surgery (43.3%). Eleven eyes (45.8%) in the CPC group lost light perception versus four eyes (16.7%) in the tube-shunt group. Complication rate was higher in the tube-shunt group. CONCLUSIONS: This study suggests that, in the management of NVG, tube-shunt surgery more frequently controls IOP in a satisfactory range, with less hypotony and less visual loss, than noncontact Nd:YAG-CPC.

Long-term effects of tube-shunt procedures on management of refractory childhood glaucoma.

PURPOSE: The authors evaluated the long-term results of tube-shunt surgery in management of childhood glaucoma. METHODS: The results of tube-shunt surgery in children who had glaucoma refractory to medical or alternative surgical treatment in the Glaucoma Service of Wills Eye Hospital during the period 1986 through 1993 were reviewed. Eighteen eyes of 15 patients were included in the analysis. Follow-up ranged from 14 to 80 months (mean +/- standard deviation, 47.3 +/- 25.1 months). RESULTS: In the early postoperative course (6 months after surgery), the intraocular pressure (IOP) was between 6 and 21 mmHg in 13 eyes (72.2%) with or without glaucoma medication. Two or more years later, IOP was between 6 and 21 mmHg in four eyes without further glaucoma medication (22.2%) and four eyes (22.2%) with the addition of antihypertensive therapy. Five eyes (27.8%) lost light perception, whereas seven (38.9%) remained within one line of preoperative vision or improved. Twelve eyes underwent 28 additional surgical procedures after the tube-shunt operation, mostly to control IOP or manage tube-related complications. CONCLUSION: The limited success rate, relatively high complication rate, and need for frequent surgical intervention suggest caution regarding the prognosis of tube-shunt surgery in children with glaucoma.

Infectious keratitis in a paracentesis tract.

A paracentesis is performed in glaucoma procedures as a flat, beveled tract to allow access into the anterior chamber after the filtration fistula is made. Complications related to the paracentesis are infrequent because it is a self-sealing wound. The authors report a case of infectious keratitis that developed in a paracentesis tract.

Severe visual loss after autologous blood injection for mitomycin-C-associated hypotonous maculopathy.

It has been shown that mitomycin-C increases the success rate of trabeculectomy; however, a rise in the incidence of postoperative complications has also been reported. Consequently, the use of antimetabolite is usually reserved for patients who are at high risk of surgical failure or for patients with advanced glaucoma in whom low intraocular pressure is desired. This report describes a patient who suffered severe visual loss which was a direct result of hypotonous maculopathy after trabeculectomy with mitomycin-C and various other complications from the subsequent interventions.

Management of coexisting corneal disease and glaucoma by combined penetrating keratoplasty and trabeculectomy with mitomycin-C.

BACKGROUND AND OBJECTIVE: The management of coexistent corneal disease and uncontrolled glaucoma continues to be a challenging clinical situation. The purpose of this study is to evaluate the results of combined penetrating keratoplasty and trabeculectomy with mitomycin-C. PATIENTS AND METHODS: A retrospective study was undertaken to review the records of nine patients who had corneal edema and high intraocular pressure managed by simultaneous penetrating keratoplasty and trabeculectomy with mitomycin-C. RESULTS: The nine patients had an average pre-operative intraocular pressure of 26 mm Hg (range 17 to 41 mm Hg) and associated corneal edema. The average postoperative intraocular pressure at last follow-up was 19 mm Hg (range 5 to 53 mm Hg). Three patients needed additional procedures. Six of nine patients had intraocular pressures judged to be adequately controlled (11 +/- 5 mm Hg, range 5 to 18 mm Hg) throughout the postoperative period (average follow-up 16 months). Grafts remained clear in seven patients. The grafts failed in two cases in which additional glaucoma surgery was necessary. CONCLUSION: Combined penetrating keratoplasty and trabeculectomy with mitomycin-C should be considered for selected patients with uncontrolled glaucoma and corneal disease who have sufficient conjunctiva for a filtering procedure.