Exact matching of trabectome-mediated ab interno trabeculectomy to conventional trabeculectomy with mitomycin C followed for 2 years.

PURPOSE: We used exact matching for a highly balanced comparison of ab interno trabeculectomy (AIT) with the trabectome to trabeculectomy with mitomycin C (TRAB). METHODS: A total of 5485 patients who underwent AIT were exact-matched to 196 TRAB patients by baseline intraocular pressure (IOP), number of glaucoma medications, and glaucoma type. Nearest-neighbor-matching was applied to age. Success was defined as a final IOP of less than 21 mmHg, IOP reduction of at least 20% reduction from baseline, and no secondary surgical interventions. Outcomes were measured at 1, 3, 6, 12, 18, and 24 months. RESULTS: A total of 165 AIT could be matched to 165 TRAB. The mean baseline IOP was 22.3 ± 5.6 mmHg, and the baseline number of glaucoma medications was 2.7 ± 1.1 in both groups. At 24 months, IOP was reduced to 15.8 ± 5.2 mmHg in AIT and 12.4 ± 4.7 mmHg in TRAB. IOP was lower than baseline at all visits (p < 0.01) and lower in TRAB than AIT (p < 0.01). Glaucoma medications were reduced to 2.1 ± 1.3 in AIT and 0.2 ± 0.8 in TRAB. Compared to baseline, patients used fewer drops postoperatively (p < 0.01) and more infrequently in TRAB than in AIT (p > 0.01). Secondary surgical interventions had the highest impact on success and became necessary in 15 AIT and 59 TRAB patients. Thirty-two challenging events occurred in TRAB and none in AIT. CONCLUSION: Both AIT and TRAB reduced IOP and medications. This reduction was more significant in TRAB but at the expense of four times as many secondary interventions.

[Comparison of canaloplasty with trabeculectomy]. / Kanaloplastik und Trabekulektomie im Vergleich.

BACKGROUND: Trabeculectomy (TET) is still the gold standard in incisional glaucoma surgery. It achieves an efficient intraocular pressure (IOP) reduction. Unfortunately postsurgical complications of the procedure are frequent. Canaloplasty is a non-penetrating procedure, which aims at restoration of the natural aqueous outflow pathways, without subconjunctival drainage. AIM: This study has compared both surgical procedures concerning IOP, defined success criteria, postoperative medication, visual acuity and postoperative complications/interventions. PATIENTS AND METHODS: In a retrospective study 22 eyes after trabeculectomy and 22 eyes after canaloplasty were included. IOP, complete and qualified success, postoperative medication, visual acuity and complications/interventions were recorded at 6 month, 12 month and at last follow-up postoperatively. RESULTS: The mean IOP in the trabeculectomy and canaloplasty groups decreased from 23.91 ± 10.68 mmHg to 10.82 ± 3.67 mmHg and from 23.68 ± 7.57 mmHg to 14.50 ± 3.80 mmHg, respectively. The postoperative complications and interventions between the two groups did not reveal a statistically significant difference. Complete success (IOP < 21 mmHg and 20 % IOP reduction from baseline without medication) was achieved in 18 eyes (81.8 %) after trabeculectomy and in 11 eyes (50.0 %) after canaloplasty (p = 0.026). CONCLUSION: Canaloplasty and trabeculectomy are safe and effective procedures in the treatment of open-angle glaucoma. Both surgical methods reduce the IOP and the postoperative medication to a statistically significant extent. Trabeculectomy attains higher long-term complete success rates accompanied by slightly increased early postoperative complication rates (n. s.), compared to canaloplasty.

[Tonometry and pachymetry to evaluate fluctuations of intraocular pressure in the context of SCUBA diving]. / Tonometrie und Pachymetrie zur Erfassung der Augeninnendruckschwankungen beim Scuba-Tauchen.

BACKGROUND: It is currently still not clarified whether diving using a self-contained breathing apparatus (SCUBA) is associated with intraocular pressure (IOP) fluctuations of clinical relevance and whether intensive diving could exacerbate the damage in glaucoma patients. OBJECTIVE: This study aimed to evaluate the effect of SCUBA diving on IOP in healthy volunteers without prior eye injuries or surgery. HYPOTHESIS: recreational diving does not lead to significant increases or fluctuations of the IOP. MATERIAL AND METHODS: The study included 16 divers (5 female) who performed a total of 96 dives with air or nitrox32 to a depth of 20-30 m for an average of 50 min. The central cornea thickness was measured using ultrasonic pachymetry Pocket IITM (Quantel Medical Pocket II™, Quantel Medical, Clermont-Ferrand, France), and the IOP was measured using an Icare® PRO (Icare® PRO, Icare Finland Oy, Espoo, Finland) directly before the dive and 10 min after surfacing. RESULTS: All data refer to the right eye. Average IOP values ranged from 15.6 to 19.2 mm Hg pre-dive and 16.8 to 18.2 mm Hg post-dive. The range of IOP values was 2.2-11.5 mm Hg pre-dive (∆ = 9.3 mm Hg) and 2.7-14.8 mm Hg post-dive (∆ = 12.1 mm Hg). Of the divers 11.5% vs. 18.8% had increased IOP values > 21 mm Hg (pre-dive vs. post-dive). CONCLUSION: This study found no significant differences in IOP values between pre-dive and post-dive measurements in healthy SCUBA divers. Therefore, recreational SCUBA diving is unlikely to affect the IOP in healthy individuals.

Bleb needling in encapsulated filtering blebs: evaluation by optical coherence tomography.

PURPOSE: To evaluate the role of anterior segment optical coherence tomography (OCT) in describing the morphology and outcome of encapsulated filtering blebs after bleb needling. PROCEDURES: Prospective assessment of 9 patients - before, 2 days and 6 months after filtering bleb needling with 5-FU - using slit-lamp examination, Goldmann tonometry and OCT. RESULTS: Before the needling, the average internal height of the cyst was 1.3 +/- 0.8 mm. Two days after the needling procedure, the cyst collapsed in 5 patients. After 6 months, the average internal cyst height was 0.7 +/- 0.4 mm. All patients with a collapsed cyst at day 2 after needling had controlled regulated IOP without glaucoma medication. CONCLUSIONS: The preoperative internal height of the cyst does not correlate with the outcome of the needling. A collapsed cyst at day 2 after needling is an indicator of controlled intraocular pressure, whereas a prominent cyst after 6 months indicates poor function.

[Corneal epitheliopathy following trabeculectomy with postoperative adjunctive 5-fluorouracil]. / Korneale Epitheliopathie nach Trabekulektomie mit postoperativer subkonjunktivaler 5-Fluorouracil-Injektion.

PURPOSE: The success of trabeculectomy in glaucoma not sufficiently controlled by maximal medical therapy substantially depends on postoperative scarring of the filtering bleb. This process of scarring can be inhibited by antimetabolites like mitomycin C (MMC) and 5-fluorouracil (5-FU). The aim of this study is the evaluation of incidence and long-term outcome of corneal surface defects and intraocular pressure following MMC- or 5FU-trabeculectomy using different doses of postoperative 5FU. METHODS: A retrospective, non-randomised comparative study of 381 patients undergoing trabeculectomy with intraoperative application of either 5FU (group A, n = 169) or MMC (group B, n = 212) was performed. Based on the Wuerzburg bleb classification score (WBCS) for postoperative wound healing evaluation, 30 of these operations of group A (group B: n = 26) did not receive 5 FU postoperatively (controls), 67 (93) received up to 7 postoperative injections of 5 mg 5 FU (normal dosage group), and 72 (93) received more than 7 injections (high dosage group). Surface epithelial defects were routinely assessed by slit-lamp microscopy and fluorescein staining. Intraocular pressure (IOP) was measured by Goldmann applanation tonometry. RESULTS: In the normal dosage group the mean total dose of 5 FU was 25.8 ± 9.1 mg in group A (group B: 28.4 ± 7.5 mg) and in the high dosage group 54.2 ± 10.9 mg 5 FU (51.7 ± 11.8 mg), respectively. Increased doses of postoperative 5 FU induced more frequent corneal erosions in both groups. Corneal erosions were seen in controls in 16.7 % (26.9 %), in the normal dosage group in 55.2 % (47.3 %) and in the high dosage group in 77.8 % (59.1 %) in group A and group B, respectively. The incidence of a corneal erosion between group A and group B did not differ significantly (p = 0.074). The mean reduction of intraocular pressure in mmHg did not show a significant difference 12 months after trabeculectomy between controls and postoperative 5-FU operations. CONCLUSION: In eyes with beginning scarring of the filtering bleb after trabeculectomy the subconjunctival injection of 5-FU allows a similar reduction of intraocular pressure as in eyes without scarring. Corneal epitheliopathy following trabeculectomy and postoperative 5 FU is dose-dependent with higher doses leading to a higher incidence of corneal erosions. As serious corneal long-term complications are rare, risk-benefit analysis justifies the application of 5-FU after filtrating glaucoma surgery.

[Beyond TGF-beta: wound healing modulation in filtering glaucoma surgery]. / Wundheilungsmodulation nach filtrierenden Glaukomoperationen: Was kommt nach TGF-beta?

Conjunctival scarring remains the major problem in filtering glaucoma surgery. Antimetabolites afford a reduction of scar formation, but considerable side effects limit their application. Here, we review the mechanisms and peculiarities of wound healing following glaucoma surgery and report on new developments in the field of wound healing modulation. The growth factor TGF-beta has a central role in wound healing and scarring. Therefore, novel concepts of wound healing modulation comprise scavenging of TGF-beta and specific inhibition of disinct downstream intracellular signalling pathways. Several compounds have entered preclinical evaluation and offer new potential to modulate scarring in future combination therapies.

[Combined XEN and Baerveldt implant-principles and management of complications]. / Kombiniertes XEN-Baerveldt-Implantat ­ Prinzip und Management von Komplikationen.

The treatment of congenital glaucoma requires special expertise and often novel surgical approaches. The combined use of a XEN and a Baerveldt implant is an alternative to conventional tube implants and may be less harmful for long-term corneal endothelial damage. If this technique does not provide sufficient long-term control of intraorbital pressure (IOP), a direct implantation of the Baerveldt tube can be easily performed in a second intervention.

[Postoperative care after glaucoma filtration surgery]. / Nachsorge nach filtrierenden Glaukomoperationen.

Scarring of the filtering bleb is the main complication after glaucoma filtration surgery. Postoperative care most importantly determines success or failure of the operation. Both, preoperative antiinflammatory treatment and reduction or discontinuation of topical medication have a positive effect on postoperative conjunctival wound healing. After conventional postoperative care only about 40% of patients reach target pressures in the long-term without topical medication. Intensified postoperative care (IPC) increases the success rate by 25% after 5 years. Central to the concept of IPC is a wound modulating therapy which is adapted to the phases of wound healing of the filtering bleb. Evaluation of filtering bleb morphology is a prerequisite for the application of topical steroids and 5-fluorouracil. In addition, dedicated counseling of the patient and close follow-up are mandatory. In order to further increase the success rate of penetrating glaucoma surgery and decrease the side effects of the current antimetabolite therapy more research on wound healing as well as specific therapy to prevent scarring are necessary.

Filtering bleb function after clear cornea phacoemulsification: a prospective study.

AIM: To evaluate the influence of clear cornea phacoemulsification on filtering bleb morphology, function, and intraocular pressure (IOP) in glaucomatous eyes with previously successful filtering surgery. METHODS: The clinical course of 30 patients (30 eyes) who underwent clear cornea phacoemulsification after successful filtering glaucoma surgery was prospectively evaluated. Mean IOP and filtering bleb morphology (standardised assessment criteria and score 0-12, 12 = optimum) were determined before surgery, and 3 days, 6 months, and 12 months after surgery. The control group consisted of 36 patients with glaucoma after clear cornea phacoemulsification without previous filtering surgery. RESULTS: Mean IOP increased after phacoemulsification by about 2 mm Hg (preoperatively 14.28 (SD 3.71) mm Hg, 12 months postoperatively 16.33 (3.31) mm Hg, p = 0.006). 15 patients (50%) showed an IOP increase of >2 mm Hg, 11 patients (36.7%) had no IOP difference (within 2 mm Hg), and in four patients (13.3%) IOP decreased >2 mm Hg. Mean score of filtering bleb morphology 1 year after surgery decreased from 9.5 to 9.0 (p = 0.154). In three of 30 preoperatively IOP regulated eyes the postoperative IOP was 21 mm Hg. The control group showed an average IOP decrease of 2.01 mm Hg (p = 0.014) 12 months after cataract surgery. CONCLUSION: An increase in IOP was found 1 year after phacoemulsification in half of the filtered glaucomatous eyes. IOP in glaucomatous eyes without previous filtering surgery decreased in the same period. Cataract extraction using clear cornea phacoemulsification may be associated with a partial loss of the previously functioning filter and with an impairment of filtering bleb morphology.

Direct costs of glaucoma and severity of the disease: a multinational long term study of resource utilisation in Europe.

BACKGROUND: Resource utilisation and direct costs associated with glaucoma progression in Europe are unknown. As population progressively ages, the economic impact of the disease will increase. METHODS: From a total of 1655 consecutive cases, the records of 194 patients were selected and stratified by disease severity. Record selection was based on diagnoses of primary open angle glaucoma, glaucoma suspect, ocular hypertension, or normal tension glaucoma; 5 years minimum follow up were required. Glaucoma severity was assessed using a six stage glaucoma staging system based on static threshold visual field parameters. Resource utilisation data were abstracted from the charts and unit costs were applied to estimate direct costs to the payer. Resource utilisation and estimated direct cost of treatment, per person year, were calculated. RESULTS: A statistically significant increasing linear trend (p = 0.018) in direct cost as disease severity worsened was demonstrated. The direct cost of treatment increased by an estimated 86 for each incremental step ranging from 455 euro per person year for stage 0 to 969 euro per person year for stage 4 disease. Medication costs ranged from 42% to 56% of total direct cost for all stages of disease. CONCLUSIONS: These results demonstrate for the first time in Europe that resource utilisation and direct medical costs of glaucoma management increase with worsening disease severity. Based on these findings, managing glaucoma and effectively delaying disease progression would be expected to significantly reduce the economic burden of this disease. These data are relevant to general practitioners and healthcare administrators who have a direct influence on the distribution of resources.

[Botulinum toxin injection-treatment of upper lid retraction in thyroid eye disease]. / Transkonjunktivale Botulinumtoxininjektion zur Behandlung der Oberlidretraktion bei endokriner Orbitopathie.

OBJECTIVE: Upper lid retraction associated with thyroid eye disease may result in conjunctival and corneal exposure as well as in an esthetic problem. We evaluated the effect of botulinum toxin injections in order to lower the upper lid. METHODS: This prospective study included 19 eyes of 13 female patients presenting with scleral exposure aged 28-50 years. We injected 5-15 IE botulinum toxin A (Botox) transconjunctivally into the levator muscle. Lid position, negative side effects, and patient satisfaction were evaluated. RESULTS: Lid retraction improved from 2.4 mm (+/-1.4 mm) prior to injection to 0.5 mm (+/-2.3 mm) 4 weeks after injection. In 11 of 19 eyes 4 weeks after injection and in 8 of 14 eyes 12 weeks after injection scleral exposure had resolved. Diplopia did not occur and tear production was not influenced. Two eyes had transient ptosis. Lid lag increased from 0.34 (+/-0.6 mm) to 0.84 mm (+/-0.9 mm). Of 13 patients, 8 were satisfied with the result. CONCLUSION: Botulinum toxin A injection provides effective treatment especially in mild lid retraction and as a temporary solution for patients with unstable thyroid disease.

Function of retinal nerve fibers depends on perfusion pressure: neurophysiologic investigations during acute intraocular pressure elevation.

Field potentials of the ganglion cell axons were recorded in the cat from the retinal surface during electrical stimulation of the optic tract. Using this technique during intraocular pressure (IOP) elevation, the impulse conduction was investigated independent of the neuronal input to the retinal ganglion cells. By infusing Na-Nitroprusside intravenously, the mean arterial blood pressure (BPm) of the animal was adjusted to levels between 50 and 130 mmHg. Thus, by setting the perfusion pressure (PP) to values between +30 and -20 mmHg, a large range of IOPs was tested. A PP of +20 mmHg or more left the axonal impulse conduction unimpaired, independent of whether the absolute IOP was 40 or 135 mmHg. Interruption of impulse conduction occurred first at a PP of +10 mmHg. At a PP of 0 mmHg or less, the impulse conduction ceased after a constant time interval (80-120 sec, when 20 Hz electrical stimulation was used). Recovery of the field potentials after restoring normal IOP was independent of the preceding IOP or PP. This data demonstrates that in short-term IOP elevation the electrical function of the ganglion cell axon depends on the PP and not on the absolute height of the IOP.

Color Doppler imaging: a new technique to assess orbital blood flow in patients with diabetic retinopathy.

PURPOSE: Color Doppler imaging is a new noninvasive technique that enables measuring blood flow velocity in small orbital vessels, arteries as well as veins. Because hemodynamic changes are seen in patients with diabetic retinopathy by other techniques, the authors compared 61 eyes with proliferative, 59 eyes with nonproliferative, and 26 eyes with preproliferative diabetic fundus changes with a matched control group of 70 patients without diabetes (128 eyes). METHODS: The central retinal artery (CRA), short posterior ciliary artery (PCA), and ophthalmic artery (OA) of all patients were examined, and the systolic, diastolic, and mean velocities were measured for each vessel. RESULTS: Differences between the groups were most prominent in the CRA. The perfusion velocity was significantly lower (P < 0.001) in proliferative eyes (Vsystolic 5.7 +/- 1.8 cm/sec) than in the control group (Vsystolic 9.4 +/- 1.2 cm/sec) or in nonproliferative eyes (Vsystolic 8.4 +/- 1.8 cm/sec). In the preproliferative group, there was greater variability in velocity distribution. Consequently, no statistically significant difference could be deduced, either in the group with background retinopathy or in the group with proliferative diabetes. In the OA and PCA, neither group showed significant differences from normal. CONCLUSIONS: Measurements indicate a correlation between severity of diabetic retinopathy and decreased flow velocity in the CRA.

The presence and properties of myocilin in the aqueous humor.

PURPOSE: To determine whether myocilin is present in the aqueous humor (AH) and to examine certain properties of this protein. METHODS: Human AH was obtained at the time of either glaucoma surgery or cataract extraction. Monkey AH was obtained at the time of death, and bovine aqueous was obtained from eyes delivered from an abattoir. Column chromatography was performed on aqueous samples to determine the approximate size of the myocilin present. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and western blot analysis were performed using antibody prepared against a peptide sequence in myocilin. Analysis of the bovine proteins present in AH that were retained by a microporous filter was also performed using western blot analysis. RESULTS: By western blot analysis, myocilin was present in human, monkey, and bovine AH. The apparent molecular size of the myocilin present in the AH were greater than 250,000 Da, when quantified with a gel filtration column. Myocilin appeared to be hydrophobic and was one of the proteins that was retained on microporous filters that were obstructed by AH. CONCLUSIONS: Myocilin is a constituent in the AH. It appears that myocilin is a hydrophobic protein that may exist in an oligomeric state or in association with other proteins. Myocilin is retained by microporous filters and may be involved in the obstruction of these filters that occurs when AH is perfused through them.

Effect of short-term intraocular pressure increase on cat retinal ganglion cell activity.

By means of microelectrode recordings receptive field properties and flicker responses of cat retinal ganglion cells were studied during elevated intraocular pressure (IOP). At moderate IOP elevation (perfusion pressure, PP, approx. 50 mm Hg), a slight increase in the maintained activity and the neuronal activation obtained from the receptive field (RF)-center or RF-periphery occurred in some of the neurons. At critical perfusion pressure (PP 30-10 mm Hg), the RF-periphery mechanisms were less sensitive to ischemia than the RF-center mechanisms. The spontaneous activity was completely suppressed at an average PP of 36.6 +/- 9.0 mm Hg, the flicker-evoked responses at 17.7 +/- 9.6 mm Hg. At critical perfusion pressures, the stimulus-response latency increased by 20 ms at stimulation frequencies of 10-20 Hz. The critical flicker frequency was already slightly reduced at a PP of 50 mm Hg and decreased further with a further decrease in PP. The threshold values of the intensity function shifted to higher luminance levels when PP was reduced to less than 40 mm Hg, but the slope remained constant. A close interneuronal correlation was found in simultaneous recordings of pairs of ganglion cells during different levels of increased IOP. This finding indicates that the interneuronal response variability to IOP increase appearing in successively recorded neurons was predominantly caused by experimental factors. The main impairment in retinal neuronal function during increased IOP seems to occur proximal to the receptors but distal to the retinal ganglion cell somata.

Ocular ochronosis in alkaptonuria patients carrying mutations in the homogentisate 1,2-dioxygenase gene.

AIMS: To assess the involvement of the recently identified human homogentisate 1,2-dioxygenase gene (HGO) in alkaptonuria (AKU) in two unrelated patients with ochronosis of the conjunctiva, sclera, and cornea. METHODS: A mutation screen of the entire coding region of the HGO gene was performed using single stranded conformational analysis after polymerase chain reaction with oligonucleotide primers flanking all 14 exons of the HGO gene. Fragments showing aberrant mobility were directly sequenced. RESULTS: Two homozygous missense mutations, L25P and M368V, were identified, each of which leads to the replacement of a highly conserved amino acid in the HGO protein. CONCLUSIONS: The authors describe a novel mutation, L25P, in the German population and bring to 18 the total number of known HGO mutations.

A single dose of the topical carbonic anhydrase inhibitor MK-927 decreases IOP in patients.

MK-927 is a novel topical carbonic anhydrase inhibitor (CAI). We present the first single-dose clinical trial of MK-927 in 24 patients with bilateral primary open-angle glaucoma or ocular hypertension. This investigation was conducted as a two-centre, double-masked, randomised, placebo controlled study. Patients received one drop of 2% MK-927 in one eye and placebo in the other eye. Modified diurnal intraocular pressure (IOP) curves were performed before the study and on one treatment day. A single dose of 2% MK-927 induced a peak mean IOP decrease of 10.5 mmHg at 4.5 hours postdose. With compensation for diurnal variation, as determined by the prestudy diurnal pressure curve, the net peak mean reduction of IOP caused by MK-927 was 7.5 mmHg versus a corresponding net change of 1.4 mmHg in the contralateral placebo treated eye. Thus a single dose of MK-927 gave a clinically significant IOP reduction in patients.

[5-fluorouracil in goniotrepanation with poor prognosis. Results of 1-year follow-up]. / 5-Fluorouracil bei Goniotrepanationen mit schlechter Prognose. 1-Jahres-Ergebnisse.

14 eyes of 14 patients with medically untreatable glaucoma and extremely bad surgical prognosis because of young age, secondary glaucomas or following previous surgery were treated by means of goniotrephination with a scleral flap and a fornix-based conjunctival flap. Postoperatively, all eyes received 5 mg 5-fluorouracil in 0.5 ml NaCl 0.9% subconjunctivally daily for 7 days and weekly for another 6 weeks. IOP was lowered in all eyes from 33.9 +/- 5.0 mmHg preoperatively to 15.6 +/- 8.4 mmHg 1 year postoperatively. 71% of eyes were IOP controlled without further therapy. Results were unfavourable in eyes with irido-corneo-endothelial syndrome. Local side effects were less frequent than described previously, possible due to the reduced but prolonged administration of 5-fluorouracil. Also, all eyes received corneal supportive therapy with hyaluronic acid and polyvinyl alcohol.

[Acute angle-closure glaucoma despite previous Nd:YAG laser iridotomy: a report on 13 cases]. / Akutes Winkelblockglaukom trotz vorhandener Nd:YAG-Laser-IridotomieEin Bericht über 13 Fälle.

BACKGROUND: Nd:YAG laser iridotomy is routinely used as a procedure for primary acute angle-closure glaucoma (AACG). The clear advantage of Nd:YAG laser iridotomy is to resolve pupillary block without opening the eye. Nevertheless it remains unclear whether Nd:YAG laser iridotomy is equally effective as surgical iridectomy. In this context cases in which AACG recurred despite patent Nd:YAG laser iridotomy are of interest. PATIENTS AND METHODS: In a retrospective study, we analyzed the charts of 90 patients who presented with unilateral primary AACG in our department over 3 years and were treated with a surgical iridectomy. Surgical iridectomy at the 12 o'clock position was performed using a self-sealing corneal incision. RESULTS: Of the 90 patients with primary AACG, 13 (14.4%) had already been treated with Nd:YAG laser iridotomy. Despite the laser iridotomy, these eyes developed recurrent AACG. The presenting intraocular pressure (IOP) of these 13 eyes was 49.07+/-12.65 mmHg. In 4 eyes, continuous medical glaucoma therapy was used prior to AACG, 8 eyes showed signs of glaucoma damage at the optic disk or/and the visual field. In 2 eyes, the presenting high IOP at AACG could be lowered by medication. All other eyes were operated at high IOP. The average interval between the Nd:YAG laser iridotomy and the AACG was 24.5 weeks. After surgical iridectomy, the IOP was reduced to 12.69+/-4.11 mmHg and was 16.62+/-3.86 mmHg at the end of the observation period. CONCLUSIONS: In spite of Nd:YAG laser iridotomy recurrent AACG can occur. Surgical iridectomy is capable of permanently resolving the pupillar block in these cases.