Glaucoma surgery treatment patterns of ASCRS members--2000 survey.

A survey of glaucoma surgery parameters was mailed to all the United States members of the American Society of Cataract and Refractive Surgery in 1999 and 2000. Of the 5659 surveys mailed, 725 (13%) were returned. The survey assessed parameters used in glaucoma surgical treatment. Preferred surgery treatment patterns were cross-tabulated with fellowship training in glaucoma (9.3%) and geographic location. This report summarizes current practice styles and patterns of comprehensive ophthalmologists in the United States as derived from the survey.

Anterior chamber maintainer versus viscoelastic material for intraocular lens implantation: case-control study.

PURPOSE: To compare best corrected visual acuity (BCVA) and intraocular pressure (IOP) in eyes that had a foldable intraocular lens (IOL) implanted with the use of an anterior chamber maintainer (ACM) in 1 eye and hyaluronate 3.0% (Vitrax) viscoelastic material in the other eye. SETTING: Private practice in a large urban center. METHODS: Sixty-six eyes of 33 patients had consecutive bilateral cataract extraction by the same surgeon using an identical temporal approach, clear corneal phacoemulsification, and implantation of an Allergan SI-40NB or SA-40NB IOL through an injection delivery system. The first operative eye was arbitrarily assigned to the ACM or Vitrax group, while the fellow eye received the opposite technique. Patients with coexisting ocular pathology that could influence the measured outcomes (eg, glaucoma, age-related macular degeneration) were excluded. Patients were evaluated preoperatively and 1 day and 3 to 6 weeks postoperatively. RESULTS: No serious intraoperative or postoperative complications were reported. The only statistical difference in BCVA or IOP was on the first postoperative day, when the mean IOP was approximately 2 mm Hg lower in the ACM group than in the Vitrax group. CONCLUSION: The use of an ACM for implantation of an injected 3-piece silicone IOL may lower IOP on the first postoperative day.

Evaluation of intraocular pressure in the immediate period after phacoemulsification.

PURPOSE: To determine the incidence of hypotony or intraocular pressure (IOP) spikes in the early period after clear corneal phacoemulsification in normal and glaucomatous eyes. SETTING: Ambulatory surgical center. METHODS: This retrospective analysis comprised 112 eyes that had clear corneal phacoemulsification. Postoperative IOP measurements were collected 30 minutes, 1 day, and 1 month after surgery. RESULTS: Twenty-three eyes had an IOP of 5 mm Hg or below 30 minutes postoperatively. The IOP at 30 minutes was lower than at 1 day in both the normal and the glaucoma group. The mean IOP in the normal group was 10.0 mm Hg +/- 4.3 (SD) at 30 minutes and 16.9 +/- 4.4 mm Hg at 1 day (P < or = .005). The means in the glaucoma group were 9.6 +/- 3.9 mm Hg and 16.9 +/- 5.7 mm Hg, respectively (P < or = .0002). The IOPs at 30 minutes and 1 day were not significantly different between the 2 groups. CONCLUSIONS: A significant percentage of eyes having clear corneal phacoemulsification had an IOP of 5 mm Hg or less 30 minutes after surgery. Even though there were no postoperative complications from hypotony and there was a relative absence of significant IOP elevation 1 day postoperatively, the frequency of low IOP at 30 minutes suggests that consideration be given to leaving postoperative eyes with a higher IOP at the completion of phacoemulsification rather than with the estimated 10 mm Hg tactile IOP strived for in this study.

Matrix metalloproteinases and TIMPs: properties and implications for the treatment of chronic obstructive pulmonary disease.

The matrix metalloproteinases (MMPs) are a unique family of metalloenzymes that, once activated, can destroy connective tissue. The active enzymes are all inhibited by tissue inhibitors of metalloproteinases (TIMPs). The relative amounts of active MMPs and TIMPs are important in determining whether tissues are broken down in disease. Although elastase is often regarded as the target enzyme in chronic obstructive pulmonary disease (COPD), both the neutrophils and macrophages in the lung contain metalloproteinases and both collagen and elastin are degraded in disease. Transgenic studies have shown that when MMP1 is over-expressed, pulmonary emphysema develops in mice, while MMP12 knockout mice do not develop pulmonary emphysema when exposed to cigarette smoke. New drugs that can specifically block active MMPs are now available. These potent inhibitors are effective in vitro and prevent the destruction of tissue in animal models. Future patient trials will test the effectiveness of these compounds in preventing tissue destruction.

Glaucoma laser treatment parameters and practices of ASCRS members--1999 survey. American Society of Cataract and Refractive Surgery.

A survey of glaucoma laser parameters and practices was mailed to all United States members of the American Society of Cataract and Refractive Surgery (ASCRS) in March 1999. Approximately 19% (947) of the 5100 surveys were returned. The survey assessed parameters used for laser trabeculoplasty, laser iridotomy, and gonioplasty. Respondents also answered questions about the application of these laser therapies in a wide variety of clinical situations. The results were cross-tabulated by age, number of laser trabeculoplasties performed per month, fellowship training in glaucoma, and geographic location.

Long-term changes in intraocular pressure after clear corneal phacoemulsification: normal patients versus glaucoma suspect and glaucoma patients.

PURPOSE: To compare the effects of clear corneal phacoemulsification on intraocular pressure (IOP) in patients without glaucoma, glaucoma suspects, and patients with glaucoma. SETTING: Urban, multisubspecialty private practice. METHODS: A retrospective analysis of patients who had clear corneal phacoemulsification with a minimum of 12 months follow-up was performed. The patients were divided into 3 groups: no glaucoma (NG), glaucoma suspects (GS), and glaucoma (GG). None had a history of prior surgery. Glaucoma suspects included patients with elevated IOPs, abnormal discs, pseudoexfoliation syndrome, or pigment dispersion syndrome on no medications and with no field defects. Glaucoma patients had received only medical treatment. Two-tailed, homoscedastic t tests were used for statistical analysis. RESULTS: There were 143 patients (164 eyes) in the NG group, 65 (75) in the GS group, and 61 (71) in the GG group. The mean preoperative IOP was 16.42 mm Hg +/- 2.77 (SD), 17.59 +/- 4.15 mm Hg, and 16.97 +/- 4.86 mm Hg in the 3 groups, respectively. At 1 year, the mean IOP was lower in all groups: 14.37 +/- 2.97 mm Hg, 15.68 +/- 3.38 mm Hg, and 15.86 +/- 4.00 mm Hg, respectively. The change was statistically significant in the NG and GS groups. Glaucoma patients showed a statistically significant reduction in the number of glaucoma medications postoperatively. CONCLUSION: Clear corneal phacoemulsification was associated with a statistically significant long-term reduction in IOP.

The regulation of MMPs and TIMPs in cartilage turnover.

The treatment of cartilage with mediators initiates the breakdown of proteoglycan followed by collagen. This is accompanied by the modulation of different proteinases and inhibitors that include members of the MMP family and TIMPs. We have evidence that a chondrocyte membrane-associated metalloproteinase cleaves aggrecan. This activity is rapidly induced after stimulation with IL-1 and OSM and is not inhibited by TIMPs-1 and -2 but is inhibited by synthetic MMP inhibitors. This same combination of cytokines also upregulates the collagenases with the subsequent release of collagen fragments, and there is a close correlation between the amount of collagen released and collagenase activity produced. Collagen release can be prevented after treatment with specific inhibitors of MAP kinases, inhibitors of MMP transcription, synthetic metalloproteinase inhibitors, TIMPs and treatment of cartilage with agents that upregulate TIMPs. The results from bovine cartilage culture models show that collagen release occurs when TIMP levels are low, collagenases are upregulated and then subsequently activated.

Phacotrabeculectomy: limbus-based versus fornix-based conjunctival flaps in fellow eyes.

OBJECTIVE: To compare the effectiveness of limbus-based and fornix-based conjunctival flaps in fellow eyes of the same patients undergoing combined trabeculectomy with phacoemulsification. DESIGN: Prospective, nonrandomized comparative (fellow eye) study. PARTICIPANTS: Forty-four patients and 88 fellow eyes. INTERVENTION: Limbus-based conjunctival flap with phacotrabeculectomy was performed in one eye, and a fornix-based conjunctival flap with phacotrabeculectomy was performed in the fellow eyes of the same patients. The patients were followed up for a minimum of 1 year postoperatively for each eye. MAIN OUTCOME MEASURES: Preoperative and postoperative visual acuity, intraocular pressure, number of antiglaucoma medications, interventions, and complications were studied. RESULTS: At last follow-up visit, visual acuity improved to 20/40 or better in 88.6% of the limbus-based group and 79.6% of the fornix-based group. Preoperatively, the mean intraocular pressure in the limbus-based group was 21.4 +/- 4.8 mmHg on a mean of 2.4 +/- 1.2 glaucoma medications; in the fornix-based group, it was 21.4 +/- 4.3 mmHg on a mean of 2.3 +/- 1.1 medications. Mean intraocular pressure decreased to 15.3 +/- 3.3 mmHg (P < 0.01) on a mean of 0.2 +/- 0.5 glaucoma medications in the limbus-based group (P < 0.01). In the fornix-based group, mean intraocular pressure at last follow-up visit decreased to 15.3 +/- 4.7 mmHg (P < 0.01) on a mean of 0.2 +/- 0.5 medications (P < 0.01). Postoperative interventions and complications were not statistically different between the two groups. CONCLUSION: With phacotrabeculectomy, limbus-based and fornix-based conjunctival flaps are equally effective in improving visual acuity and lowering intraocular pressure. This variation in conjunctival flap orientation was equally effective in fellow eyes of the same patients, with no difference in postoperative complications or outcomes.

Medical treatment patterns of ASCRS members for primary open-angle glaucoma--1998 survey.

A survey of medical treatment patterns for primary open-angle glaucoma (POAG) was mailed to all United States members of the American Society of Cataract and Refractive Surgery (ASCRS) in March 1998; 21.2% responded. Demographic information pertinent to glaucoma care was also obtained. The use of diagnostic ancillary tests, as well as the sequential order of preferred therapy, in 3 hypothetical patient populations was analyzed: patients with mild, moderate, and advanced POAG. Preferred medical therapy was cross-tabulated with number of years in practice, fellowship training in glaucoma, and geographic location.

Combined phacoemulsification, intraocular lens implantation, and trabeculectomy with a modified scleral tunnel and single-stitch closure.

In most combined phacoemulsification and filtration surgery, the standard tunnel incision is altered to create a scleral flap, usually a limbal-based scleral flap with radial suture closure. We describe a new technique that has the advantages of both scleral tunnel architecture and horizontal suture closure. It creates a scleral groove tangential to the limbus and a standard scleral tunnel. Phacoemulsification and intraocular lens implantation are performed under the scleral tunnel. A 10-0 nylon horizontal suture is positioned for scleral tunnel closure and looped aside. A central "T" relaxing incision is made at the midpoint of the scleral tunnel up to the posterior insertion of conjunctiva. A punch sclerectomy is performed. The 10-0 nylon horizontal suture is tied. The conjunctiva is closed and bleb elevation is confirmed via deepening through a corneal paracentesis incision. The results in an initial series of 24 consecutive eyes followed for a mean of seven months are presented: Mean visual acuity improved from 20/70 to 20/30 and mean intraocular pressure reduction was 5.0 +/- 2.4 mm Hg (standard deviation). By preserving standard scleral tunnel architecture and single horizontal suture closure, this technique permits rapid visual recovery and accelerated return to full activity. It also permits postoperative titration of aqueous outflow by laser suture lysis, if indicated. Against-the-rule astigmatic drift associated with limbal-based scleral flaps and antimetabolite therapy may be minimized.

Comparison of combined cataract and glaucoma surgery using planned extracapsular and phacoemulsification techniques.

BACKGROUND AND OBJECTIVE: The surgical management of coexisting cataract and glaucoma is a common problem for the ophthalmologist. PATIENTS AND METHODS: We evaluated intraocular pressure (IOP) reduction and bleb formation in combined cataract and filtration surgery, comparing planned extracapsular cataract extraction (ECCE) and phacoemulsification approaches coupled with similar trabeculectomy techniques. Seventy-two eyes with primary open-angle or pseudoexfoliation glaucoma underwent combined cataract and filtration surgery. Thirty-five eyes underwent planned ECCE, intraocular lens (IOL) implantation, and trabeculectomy, and 37 eyes underwent phacoemulsification, IOL implantation and trabeculectomy. Minimum follow-up for both groups was 1 year with a mean of 16 months. RESULTS: The mean IOP reduction for phacoemulsification/trabeculectomy eyes (5.0 +/- 4.3 mm Hg) was significantly lower than the mean IOP reduction for ECCE/trabeculectomy eyes (2.9 +/- 4.1 mm Hg; P < 0.03). There was no significant difference between the groups in terms of visual acuity improvement or glaucoma medication reduction. CONCLUSION: Combined cataract and filtration surgery using phacoemulsification is associated with greater IOP reduction than combined surgery using ECCE.

Long-term efficacy of argon laser trabeculoplasty. A 10-year follow-up study.

PURPOSE: Argon laser trabeculoplasty (ALT) is commonly used in the treatment of open-angle glaucoma. Varying success rates in lowering intraocular pressure (IOP) and controlling glaucoma are reported in studies with follow-up periods from 1 to 5 years, and few reports are available with follow-up to 10 years. The authors retrospectively reviewed the efficacy of ALT in patients followed up to 10 years. METHODS: Ninety-three patients with open-angle glaucoma underwent 360 degrees ALT. Mean follow-up was 52 +/- 43 months (mean +/- standard deviation; range, 1-132 months). Successful treatment at the time of final follow-up was defined as a decrease in IOP of 3 mmHg or greater from pretreatment level, IOP of 19 mmHg or less, stable visual field, stable optic nerve, and no further laser or surgical intervention. RESULTS: The decrease in IOP was 8.9 +/- 5.4 mmHg at 1 year, 10.0 +/- 4.2 mmHg at 5 years, and 8.9 +/- 5.2 mmHg at 10 years. The probability of success at 1 year was 77%, at 5 years 49%, and at 10 years 32%. Failure was most common in the first year after treatment (23%), and thereafter failure occurred at a rate of 5% to 9% per year. The mean decrease in IOP for all 93 eyes at time of maximum follow-up was 6.1 +/- 7.1 mmHg. CONCLUSION: Argon laser trabeculoplasty is an effective means for reducing IOP in many patients followed for an extended time. However, up to one half of eyes within 5 years of ALT and two thirds of eyes within 10 years may require additional laser or surgical intervention for glaucoma control.

Contact transscleral Nd:YAG laser cyclophotocoagulation. Midterm results.

BACKGROUND: Early reports of both contact and noncontact transscleral Nd:YAG laser cyclophotocoagulation have been encouraging; however, recent evidence indicates a significant incidence of hypotony, visual loss, and phthisis with the noncontact technique with more than 6 months of follow-up. The authors sought to determine the intermediate term effects of contact transscleral Nd:YAG laser cyclophotocoagulation (CYC). METHODS: The authors followed 116 eyes of 114 patients for a minimum of 1 year after treatment of advanced glaucoma with CYC. RESULTS: The mean preoperative intraocular pressure (IOP) of 35.0 +/- 1.0 mmHg decreased to 18.6 +/- 1.1 mmHg (P less than 0.0001) during the average follow-up of 19.0 +/- 0.6 months (range, 12 to 36 months). Intraocular pressure control of 3 to 25 mmHg was achieved in 72%, 3 to 22 mmHg in 65%, and 3 to 19 mmHg in 56% of eyes. Retreatment was required in 31 of the 116 eyes (27%). Intraocular pressure decreased to less than 3 mmHg in 9 eyes and to 0 mmHg in 6 of these 9 eyes. Nineteen eyes, all with initial visual acuity of counting fingers or worse, progressed to no light perception; 17 of 36 eyes (47%) with visual acuity of 20/200 or better lost 2 or more Snellen lines. CONCLUSION: Midterm results of CYC continue to be encouraging but are tempered by a nearly 10% incidence of hypotony or phthisis and the progression of visual loss.

Argon laser gonioplasty in the treatment of angle-closure glaucoma.

We used argon laser gonioplasty to treat angle-closure glaucoma unrelieved by patent iridectomy. Laser energy (mean; 30 spots, 723 mW, and 0.2 second) was applied to the peripheral iris stroma to open the anterior chamber angle. Twenty of 32 eyes were successfully treated. After a median follow-up period of 18 months, 17 of these 20 successfully treated eyes (85%) had an intraocular pressure less than or equal to 19 mm Hg, and 19 of these 20 successfully treated eyes (95%) had an intraocular pressure less than or equal to 21 mm Hg. The 20 successfully treated eyes had a median duration of angle closure of 12 days. Twelve unsuccessfully treated eyes had a median duration of angle closure of 90 days. All successfully treated eyes had more than 50% of the treated angle opened by argon laser gonioplasty and all but three successfully treated eyes had more than three clock hours opened by argon laser gonioplasty. Argon laser gonioplasty may be successful in treating angle-closure glaucoma unrelieved by iridectomy, especially in cases that are recognized and treated soon after onset.

Secondary hemorrhage in traumatic hyphema.

We analyzed the records of 132 patients hospitalized between July 1986 and February 1989 for management of traumatic hyphema. The incidence of secondary hemorrhage was compared between patients treated with or without systemic administration of aminocaproic acid in addition to an otherwise identical protocol. Results among patients who were examined within one day of injury disclosed a 4.8% secondary hemorrhage rate in aminocaproic acid-treated patients (three of 63 patients) compared with a 5.4% rate in the patients not treated with aminocaproic acid (three of 56 patients, P = .31). All six patients sustaining secondary hemorrhage recovered visual acuities of 20/40 or better, with five of six patients achieving 20/20 visual acuities. A separate group of 13 patients who were examined more than one day after injury were found to have a secondary hemorrhage rate of 38.5% (five of 13 patients). Macular injury, not secondary hemorrhage, was most often responsible among those patients suffering permanent visual loss. In this study of a predominantly white population, patients had a relatively low incidence of secondary hemorrhage and did not demonstrate detectable benefit from aminocaproic acid administration. Because of the recognized side effects and cost of treatment, further analysis to determine which patients will benefit from treatment with aminocaproic acid is indicated.