Intra-individual comparison after combined phaco-trabecular aspiration in pairs of pseudoexfoliative eyes.

BACKGROUND: Trabecular aspiration is used for combined glaucoma-cataract surgery in coexisting pseudoexfoliation syndrome (XFS) or glaucoma (XFG). Reports on this technique are limited to a few small-scale studies. In this study, we wanted to elucidate whether the result of combined phacoemulsification with trabecular aspiration in the first operated eye is predictive for outcome in the contralateral eye. METHODS: In a retrospective analysis we compared the results from 80 eyes of 40 patients with pseudoexfoliation syndrome or glaucoma, who had undergone bilateral but consecutive phacoemulsification with implantation of a posterior chamber lens combined with trabecular aspiration between 2003 and 2005. RESULTS: The IOP level and medication score after phaco-trabecular aspiration were shown to be significantly lower than the preoperative values after 2 years (p < 0.0001 and p = 0.047). A significant correlation between the first and second eye was detected for reduction of IOP and medication score after 1 year. Kaplan-Meier graphs of the first and second eyes showed an almost parallel trend from 1 day after surgery until 35 months after surgery. CONCLUSIONS: The postoperative outcome in an eye after combined phaco-trabecular aspiration is predictive for the second eye. If this procedure succeeded in the first eye, the prognosis for the same strategy in the fellow eye is also good.

A novel approach to suprachoroidal drainage for the surgical treatment of intractable glaucoma.

PURPOSE: In glaucoma surgery, scarring of the artificial fistula is the limiting factor for long-term control of intraocular pressure (IOP). Several devices and surgical techniques have been developed for artificial aqueous humor drainage in intractable glaucoma. The authors describe a novel surgical technique that uses a silicone tube as a shunt for aqueous flow from the anterior chamber to the suprachoroidal space. PATIENTS AND METHODS: Thirty-one eyes of 31 patients with uncontrollable refractory glaucoma were included in this prospective consecutive case-control study. Each eye had undergone an average of 3.5+/-1.9 previous interventions for glaucoma. The baseline IOP was 44.25+/-8.7 mm Hg despite maximum therapy. As in trabeculectomy, a limbus-based scleral flap was prepared. The suprachoroidal space was accessed via a deep posterior scleral flap. The silicone tube was inserted as an intrascleral connection from the anterior chamber to the suprachoroidal space. Cyclodialysis was avoided by this surgical approach. Success was defined as a lowering of IOP to below 21 mm Hg without the need for further medication or intervention. RESULTS: The mean functional shunt survival was 55.9+/-45.6 weeks. IOP was reduced to 12.9+/-5.2 mm Hg in 70% of all eyes after 30 weeks postoperatively. After 52 weeks, 60% of the eyes could be classified as representing success, and 76 weeks after surgery, 40% of the eyes still showed controlled IOP. In none of the eyes were severe postoperative hypotony or suprachoroidal bleeding observed. No localized or general inflammation or infection was seen in connection with the silicon tube. Two patients needed anterior chamber lavage because of bleeding. In 2 patients the tube had to be removed because of corneal endothelial contact. Shunt failure of the tube was caused in some cases by connective tissue formation at the posterior lumen of the tube. CONCLUSION: This novel surgical approach and the placement of the silicone tube described here have several advantages. Its intrascleral course minimizes the risk of conjunctival erosion and associated infections. No cyclodialysis is performed. Connection to the suprachoroidal space exploits the resorptive capability of the choroid. It guarantees drainage but also provides a natural counterpressure, avoiding severe postoperative hypotony. The suprachoroidal shunt presented here achieves good follow-up results in terms of IOP control. No serious complications have been observed. This new method promises to be an effective surgical technique and presents a new therapeutic option in intractable glaucoma. Fibroblast reaction obstructing the posterior lumen, seemed to be the only factor limiting drainage. Further studies and experiments will be needed to elucidate the exact physiologic mechanisms underlying the draining, the capacity and duration of the draining effect, and the histologic background of suprachoroidal scarring.

The effects of antiglaucoma and systemic medications on ocular blood flow.

Based on the body of evidence implicating ocular blood flow disturbances in the pathogenesis of glaucoma, there is great interest in the investigation of the effects of antiglaucoma drugs and systemic medications on the various ocular vascular beds. The primary aim of this article was to review the current data available on the effects of antiglaucoma drugs and systemic medications on ocular blood flow. We performed a literature search in November 2002, which consisted of a textword search in MEDLINE for the years 1968-2002. The results of this review suggest that there is a severe lack of well-designed long-term studies investigating the effects of antiglaucoma and systemic medications on ocular blood flow in glaucomatous patients. However, among the 136 articles dealing with the effect of antiglaucoma drugs on ocular blood flow, only 36 (26.5%) investigated the effects of medications on glaucoma patients. Among these 36 articles, only 3 (8.3%) were long-term studies, and only 16 (44.4%) were double-masked, randomized, prospective trials. Among the 33 articles describing the effects of systemic medications on ocular blood flow, only 11 (33.3%) investigated glaucoma patients, of which only one (9.1%) was a double-masked, randomized, prospective trial. Based on this preliminary data, we would intimate that few antiglaucoma medications have the potential to directly improve ocular blood flow. Unoprostone appears to have a reproducible antiendothelin-1 effect, betaxolol may exert a calcium-channel blocker action, apraclonidine consistently leads to anterior segment vasoconstriction, and carbonic anhydrase inhibitors seem to accelerate the retinal circulation. Longitudinal, prospective, randomized trials are needed to investigate the effects of vasoactive substances with no hypotensive effect on the progression of glaucoma.

The impact of ocular blood flow in glaucoma.

Two principal theories for the pathogenesis of glaucomatous optic neuropathy (GON) have been described--a mechanical and a vascular theory. Both have been defended by various research groups over the past 150 years. According to the mechanical theory, increased intraocular pressure (IOP) causes stretching of the laminar beams and damage to retinal ganglion cell axons. The vascular theory of glaucoma considers GON as a consequence of insufficient blood supply due to either increased IOP or other risk factors reducing ocular blood flow (OBF). A number of conditions such as congenital glaucoma, angle-closure glaucoma or secondary glaucomas clearly show that increased IOP is sufficient to lead to GON. However, a number of observations such as the existence of normal-tension glaucoma cannot be satisfactorily explained by a pressure theory alone. Indeed, the vast majority of published studies dealing with blood flow report a reduced ocular perfusion in glaucoma patients compared with normal subjects. The fact that the reduction of OBF often precedes the damage and blood flow can also be reduced in other parts of the body of glaucoma patients, indicate that the hemodynamic alterations may at least partially be primary. The major cause of this reduction is not atherosclerosis, but rather a vascular dysregulation, leading to both low perfusion pressure and insufficient autoregulation. This in turn may lead to unstable ocular perfusion and thereby to ischemia and reperfusion damage. This review discusses the potential role of OBF in glaucoma and how a disturbance of OBF could increase the optic nerve's sensitivity to IOP.

Latanoprost stimulates secretion of matrix metalloproteinases in tenon fibroblasts both in vitro and in vivo.

PURPOSE: To investigate the presence and the possible role of different matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) in Tenon capsule fibroblasts. These enzymes are essential for the control of tissue remodeling in the context of wound repair. This aspect is important to further the understanding of and possibly to influence the scarring process of filtering blebs after glaucoma surgery. METHODS: Untreated and latanoprost-treated human Tenon fibroblasts were examined for the presence of MMPs and TIMPs on the mRNA and protein levels. Assays performed included RT-PCR, real-time RT-PCR, immunocytochemistry, Western blot analysis, flow cytometry, and zymography. To investigate the changes in vivo, conjunctival specimens of rabbits treated with latanoprost eye drops were examined by immunohistochemistry. RESULTS: In all assays, both MMP-3 and TIMP-2 were detected. With the real-time RT-PCR technique, MMP-1, -2, -3, -7, -9, and -14 and TIMP-1 and -2 were detected. An upregulation of MMP-3 and TIMP-2 after latanoprost treatment of the fibroblasts was shown and found to occur on the mRNA and the protein levels. The upregulation of MMP-3 and TIMP-2 was confirmed in vivo. CONCLUSIONS: Tenon fibroblasts contain the ability on the mRNA level to synthesize all enzymes of the MMP and TIMP family that are related to remodeling of the extracellular matrix. The levels of MMP-3 and TIMP-2 increase after treatment with latanoprost. Tenon fibroblasts may be the target cells for attempts to influence the tissue levels of MMPs and TIMPs in the context of conjunctival wound healing after glaucoma surgery.

Tolerability and safety of two new preservative-free tear film substitutes.

PURPOSE: The tolerability, safety, and visual comfort of two new tear film substitutes were studied in a phase I clinical study. METHODS: Two amphipathic lipids (phosphatidylcholine, cholesterol, sphingomyelin, and gangliosides) containing solutions (I and II) of well-defined stoichiometry, free of preservatives, were studied in 20 eyes of 20 healthy volunteers (age range, 26-32 years) in a randomized, double-blind, crossover study. Randomization was achieved by treating one eye of each volunteer four times daily for 7 days with composite solution I. The contralateral eye served as a control. After a washout interval of 7 days, the same eye was treated similarly four times daily with the solution II under randomizing conditions. Slit-lamp biomicroscopy, visual acuity, visual analog scales, and side effects were monitored at the beginning of the study weekly and for 3 weeks. RESULTS: The tear substitutes proved to have no influence on the visual acuity and were safe and well tolerated. No allergic reactions or any other side effects such as hyperemia, corneal disturbance, and foreign body deposits were observed in any volunteer. CONCLUSION: The biophysical properties of the amphipathic lipids comprising the two preservative-free tear film substitutes were studied in monolayer experiments. They form reversibly compressible and expandable monomolecular films at the air-water interface, a prerequisite for the mimicry of the tear film produced normally by meibomian glands. The efficacy and safety of both medications will be investigated in patients with keratoconjunctivitis sicca and dry eye syndrome in future experiments.

Individual factors influencing trabecular morphology in glaucoma patients undergoing filtration surgery.

PURPOSE: Epidemiologic studies have shown that various lifestyle characteristics are statistically associated with the chronic open-angle glaucomas. This study was designed to investigate the influence of individual factors on the light-microscopic morphology of the trabecular meshwork in open-angle glaucomas. METHODS: Quantitative computer-assisted topographic analysis of the trabecular meshwork was performed in meridional sections of 80 trabeculectomy specimens from patients with primary open-angle (n = 36), exfoliative (n = 30) and pigment-dispersion (n = 14) glaucoma. Measurements included inner wall length of the, central thickness of the trabecular meshwork, and compactness of the Schlemm canal and trabecular meshwork. Morphologic data were correlated with individual patient data including age, duration of the disease, maximum intraocular pressure, cup-disc ratio, refraction, height, weight, body mass index, a simple morbidity index, previous surgery, and number of topical antiglaucomatous medications used. RESULTS: Inner wall length of the Schlemm canal was significantly lower in eyes with previous filtering surgery (P = 0.03), but not in eyes with a high number of topical medications (P = 0.17). There was a significant tendency for the inner wall length of the Schlemm canal to be shortened in patients where high maximum intraocular pressure was combined with long-term glaucoma (P = 0.027). Body mass index did not differ significantly between patients with primary open-angle, exfoliative, and pigment-dispersion glaucoma and showed no correlation with the quantitative data of the meshwork. The morbidity index correlated well with body mass index (0.0006) and age (P < 0.0001). CONCLUSION: Contrary to findings of experimental mice studies, we found no indication that glaucoma patients with lower body mass index have a larger lumen of the Schlemm canal than patients with a higher body mass index. Although caution should be used when interpreting data from trabeculectomy studies, there is a certain probability that a history of previous filtering surgery and of a long-term high intraocular pressure will be associated with a shortening of the Schlemm canal.

Late hypotony as a complication of viscocanalostomy: a case report.

BACKGROUND: We report a long-term hypotony syndrome after deep sclerectomy, associated with intermittent rise in intraocular pressure (IOP) due to steroid response. PATIENT PRESENTATION: A 55-year-old woman with high myopia (RE -9.25, LE -10.50) suffering from uncontrolled pigment open-angle glaucoma, despite laser trabeculoplasty and a cyclodestructive procedure, underwent an uneventful viscocanalostomy. FOLLOW-UP: Intraocular pressure was between 9 and 17 mm Hg with local steroid medication 5 times a day, but became unstable with steroid reduction to 3 times a day and the patient developed hypotonous IOP (3-5 mm Hg) in the fourth postoperative month. With intensification of local steroid therapy, IOP rose to 49 mm Hg, and a reduction in medication was followed by hypotony. The instability of IOP with steroid medication could not be controlled and the IOP response due to steroids diminished with time; a long-term hypotony syndrome with maculopathy developed. Surgical inspection 10 months later with repeated preparation of the scleral flap showed (like ultrasound biomicroscope examination) a normal status after viscocanalostomy, without signs of leakage. CONCLUSIONS: Late hypotony syndrome should be considered as a potential complication of viscocanalostomy, perhaps especially in cases of myopia and former cyclodestructive procedures. In our case, despite nonpenetrating glaucoma surgery, the steroid response at first observed indicated additional outflow via the trabecular meshwork. After some months it could not be provoked any longer, leaving us to consider whether a gradual change in the trabecular meshwork hinders steroid medication changing aqueous outflow facility.

A prospective randomized trial of viscocanalostomy versus trabeculectomy in open-angle glaucoma: a 1-year follow-up study.

PURPOSE: To assess the intraocular pressure-lowering efficacy and the postoperative complication profile of viscocanalostomy versus trabeculectomy. PATIENTS AND METHODS: Sixty eyes of 60 patients with medically uncontrolled open-angle glaucoma were randomized either to the viscocanalostomy or to the trabeculectomy group of the trial. Viscocanalostomy was performed according to Stegmann's technique using high-molecular-weight sodium hyaluronate to fill the ostia of the Schlemm canal. For trabeculectomy, a modified Cairns-trabeculectomy was performed. Examinations were performed before surgery and postoperatively daily for 1 week. Follow-up visits were scheduled 1, 6, and 12 months after surgery. RESULTS: The mean (SD) preoperative intraocular pressure was 27.1 (7.1) mm Hg for all patients enrolled. One day after surgery, mean (SD) intraocular pressure was 15.9 (5.2) for the trabeculectomy group (P <0.001) and 15.7 (3.6) for the viscocanalostomy group (P <0.001), respectively. The success rate, defined as an intraocular pressure lower than 22 mm Hg without medication, was 56.7% in the trabeculectomy group and 30% in the viscocanalostomy group at 12 months postoperatively (P = 0.041). The number of postoperative complications was lower in the viscocanalostomy group than in the trabeculectomy group. CONCLUSIONS: In eyes with open-angle glaucoma, viscocanalostomy is less effective in reducing intraocular pressure than standard filtering surgery. However, postoperative complications are more frequent after filtering surgery.

A prospective trial of phaco-trabeculotomy combined with deep sclerectomy versus phaco-trabeculectomy.

BACKGROUND: Combined phacoemulsification, intraocular lens implantation, and trabeculectomy (PTE) is currently the standard procedure for most ophthalmic surgeons to treat uncontrolled open-angle glaucoma and cataract at one time. This study was designed to prospectively compare a new technique of phaco-trabeculotomy plus deep sclerectomy (PDSTO) with standard phaco-trabeculectomy (PTE). METHODS: A consecutive series of 43 patients with uncontrolled open-angle glaucoma and cataract underwent combined glaucoma and cataract surgery. The procedure started as a two-site approach with phacoemulsification and IOL implantation through a temporal incision in clear cornea. Trabeculotomy and deep sclerectomy were performed in the superior quadrant. Trabeculectomy was also performed in the superior quadrant as a modified Cairns trabeculectomy. Postoperatively, examinations were performed on a daily base for 1 week. Follow-up visits were applied 1, 3, 6, and 12 months after surgery. RESULTS: The mean preoperative intraocular pressure (IOP) was 26.5 mmHg (SD 7.8) for all patients enrolled. The mean IOP was 12.3 mmHg (SD 5.1) 1 day post surgery for the PTE group (p < 0.001) and 14.4 mmHg (SD 4.0) for the PDSTO group (p < 0.001). At 12 months post surgery the success rate according to the Advanced Glaucoma Intervention Study (AGIS), defined as an IOP lower than 18mmHg without medication, was 20% in the PTE group and 50% in the PDSTO group (p = 0.03). The number of postoperative complications was equally low for both groups. No severe complications, such as bleb infection, endophthalmitis, or choroidal hemorrhage were seen in this series. CONCLUSIONS: PDSTO offered significant IOP reduction and a success rate which was higher than that of the current standard, PTE. The specific intra- and postoperative complications of deep sclerectomy, trabeculotomy, and trabeculectomy were seen in our series, although the overall rate of postoperative complications proved low.

Synergistic effects of combined cytotoxic and apoptosis-inducing drugs on Tenon's capsule fibroblasts in vitro and in vivo.

BACKGROUND: Highly toxic antimetabolites have gained access to routine clinical use to modulate and reduce the amount of postoperative scarring following glaucomatous filtering procedures. It could be speculated that by combining two different antiproliferative substances with different mechanisms of action total amounts of the substances could be decreased and side effects reduced. METHODS: Twenty-two substances were tested that had antiproliferative effects by acting cytotoxically, inhibiting growth factors, or inducing apoptosis. With combinations of each two substances, cell culture experiments using 3T3 and human Tenon's capsule fibroblasts were performed evaluating cell toxicity, proliferation and migration, the extent of free radicals, and the amount of apoptosis (TUNEL, electron microscopy). The five most potent combinations were used in an animal experiment with rabbits performing filtering procedures. The extent of episcleral scarring was evaluated by histopathology. RESULTS: The results of the various assays revealed consistently strong effects in 5 of the 462 combinations. Of these five combinations, two were highly effective in the rabbit model. Substances with strong effects when applied in combination included staurosporine, mitomycin, and CD95L. CONCLUSIONS: We found synergistic effects in assays that evaluated different aspects of cell function. The amount of scarring in an animal experiment was inhibited to a level comparable with a high single dose of mitomycin. Combination therapy of two antiproliferative acting substances may be a promising concept.

Phaco-trabeculotomy combined with deep sclerectomy, a new technique in combined cataract and glaucoma surgery: complication profile.

PURPOSE: Combined phacoemulsification, intraocular lens implantation and trabeculectomy (PTE) is currently the standard procedure for most ophthalmic surgeons for treating uncontrolled open-angle glaucoma and cataract at the same time. The present pilot study was designed to prospectively evaluate outcomes in glaucoma patients who underwent a new technique of phaco-trabeculotomy plus deep sclerectomy, with particular attention to the complication profile. METHODS: A consecutive series of 15 patients with uncontrolled open-angle glaucoma and cataract underwent combined glaucoma and cataract surgery. The procedure started as a two-site approach with phacoemulsification and intraocular lens (IOL) implantation through a temporal incision in clear cornea. Trabeculotomy and deep sclerectomy were performed in the superior quadrant. Postoperative examinations were performed daily for 1 week. Follow-up visits were carried out at 1, 3, 6 and 12 months after surgery. RESULTS: At 1 day post-surgery, mean intraocular pressure (IOP) was significantly reduced to 14.2 mmHg (SD 4.4). At 12 months post-surgery, the complete success rate, defined as IOP < 22 mmHg without medication, was 60%. Qualified success was achieved in 93.3% of patients. At 12 months post-surgery, the mean number of antiglaucoma medications had fallen to 0.4 (SD 0.6) (p < 0.001). Visual acuity improved by a mean value of 1.6 lines (SD 2.4) over baseline (p = 0.021). Specific complications such as choroidal deroofing, inadvertent perforation of the trabeculo-descemetic membrane, and non-identification of Schlemm's canal were seen among the patients in our trial. The incidence of complications due to overfiltration was low. A relatively high incidence of hyphaemas (53%) was noted in this series. All the hyphaemas were trivial and resolved quickly. No severe complications, such as bleb infection, endophthalmitis or choroidal haemorrhage were seen in this series. CONCLUSIONS: Phaco-trabeculotomy plus deep sclerectomy offered significant IOP reduction and a success rate that may be comparable with that of the current standard, PTE. Intra- and postoperative complications specific to deep sclerectomy and trabeculotomy were seen in our series, although the overall rate of postoperative complications proved low. Prospective comparative trials are needed to assess which of PTE and phaco-trabeculotomy plus deep sclerectomy is more successful.

Cyclodialysis ab interno as a surgical approach to intractable glaucoma.

PURPOSE: In glaucoma filtration surgery, the problem of subconjunctival scarring has still not been satisfactorily solved. Suprachoroidal drainage of aqueous humour offers a promising, alternative option for intractable glaucoma. We here present a clinical study on the surgical approach of gonioscopic cyclodialysis ab interno. PATIENTS AND METHODS: Twenty-eight eyes of 20 patients with intractable glaucoma were included in this prospective, consecutive, case-control study. The eyes had had a mean of 4.4 +/- 2.4 previous antiglaucomatous interventions. Baseline intraocular pressure (IOP) was 34.3 +/- 10.5 mmHg despite maximum therapy. Under gonioscopic control, cyclodialysis ab interno was performed over two clock times to gain access to the suprachoroidal space. No additional trabecular meshwork surgery was performed. Success was defined as a lowering of IOP to below 21 mmHg without the need for further medication or intervention. RESULTS: Mean postoperative IOP was 14.6 +/- 12.4 mmHg. Mean follow-up (FU) for all eyes was 121.8 days. After a mean of 60 days, 21 eyes (75%) needed further surgical intervention. Qualified success was seen in four eyes (14.3%), with a mean FU of 383.6 days. Three eyes (10.7%) showed absolute success after a mean FU period of 202.7 days. In our series, we obtained the best results for phakic eyes, followed by pseudophakic and aphakic eyes. CONCLUSION: The results of this study do not provide convincing evidence of the functional efficacy of cyclodialysis ab interno. Nevertheless, the technique is easy to perform and offers safe and atraumatic access to the resorptive capability of the choroid. Conjunctival manipulation is avoided. Contrary to reports in the current literature, in our series, the best results were obtained for phakic eyes, though the small number of eyes included does not allow reliable statistics. Further studies will need to focus on the use of different space-retaining substances or a widening of the cyclodialysis cleft to improve surgical outcome.

Postoperative application of mitomycin c improves the complete success rate of primary trabeculectomy: a prospective, randomized trial.

BACKGROUND: The intraoperative application of mitomycin c for primary trabeculectomy is associated with potentially sight-threatening side-effects. This study was performed to evaluate the pressure-lowering effect of postoperative application of mitomycin c for primary trabeculectomy and to evaluate the complications of this new technique. MATERIALS AND METHODS: A randomized, prospective clinical trial with 52 consecutive patients scheduled for glaucoma surgery in one large surgical center was performed. Patients underwent routine trabeculectomy. In group 1, mitomycin c (0.05 mg/ml) was applied topically to the filtering bleb for 5 min on the 3 days after surgery (postoperative application). In group 2, no mitomycin c was applied (controls). The IOP values, visual acuity, number of antiglaucomatous medications and complications were evaluated. RESULTS: Follow-up was evaluated up to 24 months for all patients. The mean intraocular pressure decreased from 31.1 to 15.4 mmHg in group 1 and from 24.8 to 15.6 mmHg in group 2 (P=0.79; t-test). The average number of medications decreased from 2.5 and 2.4 to 0.4 and 0.6 (P=0.53; t-test) in groups 1 and 2, respectively. No cases of hypotony maculopathy occurred. An individual decrease of more than 25% of the IOP was present in 84.6% in group 1 and in 53.8% in group 2 (P<0.017). Survival analysis for eyes with a complete surgical success revealed a better outcome of eyes in group 1 as compared to the eyes in group 2 (P<0.013; log-rank test). CONCLUSIONS: To our knowledge, this is the first prospective, randomized clinical trial to evaluate the efficacy of postoperative mitomycin c application in primary trabeculectomy. The application of mitomycin significantly reduced the IOP while not increasing the rate of complications.

What do glaucoma specialists know about their patients?

BACKGROUND: Although interaction between doctor and patient is undoubtedly influenced by their mutual expectations, little information is available about the knowledge and expectations of glaucoma doctors concerning their patients' attitudes and treatment patterns. The aim of our prospective study was to compare the actual responses of glaucoma patients concerning various issues related to their disease and the responses the glaucoma doctors expected their patients to give. METHODS: Glaucoma patients consecutively sent to our glaucoma centre were asked to complete a standardised questionnaire about their glaucoma history, treatment routines and opinions on issues related to glaucoma. Ophthalmologists at the glaucoma centre were asked to predict patients' answers. RESULTS: One hundred and twenty-eight consecutive glaucoma patients completed the patients' questionnaire and 12 glaucoma specialists completed the corresponding questionnaire for doctors. Frequency of intraocular pressure (IOP) measurements and visual field testing, as well as the number of topical medications, were relatively accurately predicted by the glaucoma doctors. Differences between the doctors' predictions and patients' responses were found concerning discomfort after surgery and the influence of stress or environmental factors on IOP. The largest range of doctors' predictions (0-100%) was observed concerning the portion of patients claiming a 100% adherence to glaucoma medication. CONCLUSION: Glaucoma specialists are familiar with the treatment patterns of their patients. The knowledge of glaucoma specialists of their patients' subjective attitudes to glaucoma-related issues deserves further investigation, as discrepancies between doctors' and patients' responses were observed in this area.

Central and paracentral corneal pachymetry in patients with normal tension glaucoma and ocular hypertension.

PURPOSE: The difference in central corneal thickness among subgroups of glaucoma patients, as well as its influence on Goldmann applanation tonometry, has been well documented in several clinical trials. In the present study, possible similarities and differences between central corneal thickness and corneal thickness of paracentral quadrants in patients with normal tension glaucoma (NTG) and ocular hypertension (OHT) were investigated. METHODS: Central and paracentral corneal thickness was measured by optical slit scan pachymetry (Orbscan II). Fourteen patients (28 eyes) with NTG and 11 patients (22 eyes) with OHT were included in this study. t-Test was performed for statistical analysis. To evaluate overall corneal topography, the mean and SD values of the differences between the central corneal thickness and each peripheral quadrant were analysed. RESULTS: The following data was obtained (microm): (central, upper, temporal, nasal, inferior paracentral quadrant): OHT group 617-695-663-687-660. NTG group 568-629-593-612-616. Corneal thickness of all four paracentral quadrants differed significantly between the OHT and NTG groups. There was a more heterogeneous intraindividual pattern of overall corneal topography in the OHT group, and a more heterogeneous pattern of corneal topography among the individuals of the NTG group (interindividual heterogeneity). CONCLUSIONS: A comparison of central corneal thickness and paracentral corneal thickness revealed clinically relevant differences between the OHT and NTG groups. The presented data underlines the importance of correlating the site of applanation with the corresponding corneal thickness, especially in OHT patients. It further substantiates the necessity to obtain individual pachymetric data for each NTG patient.

Bullous keratopathy as a complication of trabeculectomy with mitomycin C.

BACKGROUND: The routine use of mitomycin C to enhance glaucomatous filtering surgery has found wide acceptance. Complications of the application of mitomycin C have been repeatedly noticed. We now report a previously undescribed complication showing a toxic effect of mitomycin C to the corneal endothelium. METHODS: Patients underwent routine trabeculectomy with mitomycin C. Following surgery, the eyes were examined by biomicroscopy and specular microscopy of the corneal endothelium. RESULTS: In two cases, we observed a partial decompensation of the corneal endothelium resulting in a well-demarcated clear zone of the cornea and a second zone with thickening of the cornea and a bullous keratopathy adjacent to the filtering bleb. The specular microscopy showed marked irregularities of the endothelial cells and areas of necrosis in those parts of the cornea close to the filtering bleb. CONCLUSIONS: The two cases described here demonstrate that if the corneal endothelium is already compromised before surgery, the application of mitomycin C may have an additional toxic effect on the endothelium and may result in a partial bullous keratopathy. Surgeons should be aware of this complication.

Laser-grid trabeculectomy in rabbits: an experimental in-vivo study.

BACKGROUND: Laser-grid trabeculectomy (TE) is a modification of micro-TE designed to enhance the intra- and postoperative safety of filtering surgery by creating several small oval fistulas (max. diameter <200 microm) beneath a scleral flap without peripheral iridectomy. METHODS: After dissecting the conjunctiva and a conventional scleral flap, 10 small perforating fistulas were created in five pigmented rabbits in the region of the gray-white border using an erbium:YAG laser with a beveled side-firing 200 microm endoprobe; conventional TE with iridectomy was performed in another five animals. Anterior chamber inspection and IOP measurements of both eyes were conducted on days 1, 4, and 14 after operation. After the last inspection eyes were saved for morphological analysis. RESULTS: Both procedures (laser-grid and conventional TE) led to a reduction of intraocular pressure in the treated eye compared to the control eye. Differences between the outcomes for the two procedures were not statistically significant. Morphology of the eyes treated by laser-grid TE revealed dense scarring of perforations around the center of the ligamenta pectinata and loose tissue refilling of the more peripheral openings. CONCLUSIONS: The functional outcome of laser-grid TE in rabbits was similar to that of conventional TE in the short term. Histological examination of microperforations in the area of the trabecular meshwork after 2 weeks indicated that tissue repair was less pronounced than in the more anterior perforations. This morphologic finding may be of importance for non-penetrating glaucoma surgery.

Treatment of granular dystrophy with soft contact lenses.

PURPOSE: To prevent recurrence of granular dystrophy by treatment with soft contact lenses. METHODS: After penetrating keratoplasty, a soft contact lens was fitted in a 61-year-old woman patient with granular corneal dystrophy. The lens was worn continuously for 53 months. RESULTS: No recurrence was observed. However, the other eye, which was operated on first and not treated with a contact lens, showed severe recurrence of the underlying disease, with granular deposits in the stroma. CONCLUSIONS: Fitting of a soft contact lens should be considered in this disease after penetrating keratoplasty.