Long-term progression at individual mean intraocular pressure levels in primary open-angle and exfoliative glaucoma.

PURPOSE: To describe progression and non-progression rates at individual mean intraocular pressure (IOP) levels for patients with primary open-angle and exfoliative glaucoma. METHODS: A meta-analysis of five previously published retrospective studies describing progression and non-progression rates at individual intraocular pressure levels over 5 or more years of follow-up. All patients had primary open-angle (four studies) or exfoliative glaucoma (one study). RESULTS: This meta-analysis included 822 patients of whom 655 (80%) had primary openangle glaucoma and 167 (20%) had exfoliative glaucoma. In total, 220 patients progressed (27%), while 602 (73%) remained stable over 5 years. The mean IOP was 20.0 for progressed and 17.1 mmHg for stable patients (p=0.0004). The peak IOP was 29.1 for progressed and 23.6 mmHg for stable patients (p=0.0014). At an IOP level >18 mmHg, 49% of patients remained stable; at 18 mmHg, 78%; between 13 and 17 mmHg, 82%; and <13 mmHg, 96%. Additional factors associated with progression were older age (p=0.0004) and exfoliative glaucoma (p=0.0001). However, multivariant regression analysis identified only mean IOP as a risk factor for progression (p=0.039). CONCLUSIONS: This study suggests that maintaining an IOP well within the normal range over 5 years in patients with primary open-angle or exfoliative glaucoma helps to prevent glaucomatousprogression.

Clinical factors associated with progression of glaucomatous optic disc damage in treated patients.

BACKGROUND: Reducing intraocular pressure (IOP) in glaucomatous eyes does not always prevent disease progression. OBJECTIVE: To determine the clinical factors associated with progressive optic disc damage in glaucomatous eyes receiving treatment to reduce IOP. METHODS: Baseline and follow-up optic disc photographs as well as demographic and clinical data were retrospectively studied in 186 eyes of 93 patients with primary open-angle glaucoma, and in 138 eyes of 69 patients with normal-pressure glaucoma. The patients with primary open-angle glaucoma were included in the study only if their treated IOPs during a follow-up period of 5 years were less than 21 mm Hg. The patients with normal-pressure glaucoma were included only if their IOPs were reduced by at least 20% during the follow-up period. The association of progressive optic disc damage with patient- and eye-specific characteristics was examined using multivariate analysis. RESULTS: During the 5-year study period, 141 (43.5%) of the 324 eyes exhibited progressive optic disc damage defined by at least a 5% decrease in the neural rim area-to-disc area ratio. Using multivariate analysis, the following were found to be strongly associated with progressive neural rim damage: a baseline smaller neural rim area-disc area ratio (P<.001); a baseline larger zone beta area-disc area ratio (P =.04); a baseline larger parapapillary atrophy length-disc circumference ratio (P =.05); a diagnosis of normal-pressure glaucoma (P =.01); and combined medical and surgical treatment prior to the study period (P =.01). CONCLUSIONS: Clinical factors other than IOP may be important indicators of subsequent progression of glaucomatous optic disc damage. Our findings suggest that eyes with advanced glaucomatous optic disc damage and normal-pressure glaucoma are more likely to progress despite receiving treatment to reduce IOP.

Factors associated with long-term progression or stability in primary open-angle glaucoma.

PURPOSE: To evaluate long-term risk factors for progression or stability in patients with primary open-angle glaucoma. METHOD: We retrospectively included consecutively reviewed patients who had primary open-angle glaucoma for at least 5 years in this multicenter trial. Historical and clinical factors in these patients were evaluated for their association with stability or progression of the glaucoma. RESULTS: We included 218 patients in this study; of these, 34 progressed over an average length of follow-up of 45.5 +/- 30.0 months, and 184 were stable over an average of 72.8 +/- 18.3 months. The mean intraocular pressure over the follow-up period for the progressed group was 19.5 +/- 3.8 mm Hg and for the stable group 17. 2 +/- 3.1 mm Hg (P =.001). The average standard deviation of individual intraocular pressures was greater in the progressed group (5.1 mm Hg) than the stable group (3.9 mm Hg, P =.012). Baseline characteristics indicating a greater potential to progress were a larger cup-to-disk ratio (P <.001), a greater number of medications (P =.02), older age (P.007), and worse visual acuity (P =.003). However, no difference was observed in pressure levels that prevented progression in these subpopulations compared with the total sample size. CONCLUSIONS: This study suggests that lowering the intraocular pressure is important in the treatment of primary open-angle glaucoma to help prevent long-term progression. Lowering the pressure, however, is not uniformly effective in preventing progression. Additionally, risk factors for progression do not further help identify pressure levels that prevent worsening of glaucoma.

Comparison of the efficacy and safety of latanoprost 0.005% compared to brimonidine 0.2% or dorzolamide 2% when added to a topical beta-adrenergic blocker in patients with primary open-angle glaucoma or ocular hypertension.

The purpose of this study was to evaluate the ocular hypotensive efficacy and safety of latanoprost 0.005% (Xalatan, Pharmacia & Upjohn), brimonidine (Alphagan, Allergan), and dorzolamide (Trusopt, Merck Inc.) when added to a beta-blocker in patients with ocular hypertension or primary open-angle glaucoma. This was a multicenter, retrospective analysis which included all reviewed patient records in which latanoprost, brimonidine or dorzolamide were added to a beta-blocker for at least three months. Patients who were treated for less than three months, who failed therapy due to ineffectiveness of the medicine or an adverse event also were included. The study included 141 patients. Latanoprost (n = 50) showed an intraocular pressure of 16.7 +/- 3.3 mm Hg (-6.3 +/- 4.1 mm Hg, P < 0.001), brimonidine (n = 24) 17.4 +/- 4.9 mm Hg (-4.2 +/- 4.5 mm Hg, P < 0.001), and dorzolamide (n = 67) 20.1 +/- 6.1 mm Hg (-3.1 +/- 5.1 mm Hg, P < 0.001) at three months. A significant difference was observed in the absolute level of intraocular pressure (P < 0.005) and the change from baseline between groups (P < 0.005) at three months. A significant difference was observed between groups in the success rate of therapy between latanoprost (70%), brimonidine (58%) and dorzolamide (40%) (P = 0.008). No significant differences were observed between groups for rate or type of adverse events leading to discontinued therapy. This study showed that latanoprost, when added to beta-blockers, compares favorably in ocular hypotensive efficacy and is similar in safety to brimonidine and dorzolamide.

Concordance of parapapillary chorioretinal atrophy in ocular hypertension with visual field defects that accompany glaucoma development.

OBJECTIVE: To determine whether the extent and location of progressive parapapillary chorioretinal atrophy noted in some patients with ocular hypertension are correlated with the extent and location of visual field defects that occur with progression to glaucoma. STUDY DESIGN: Retrospective cohort study. PARTICIPANTS: Thirty patients with ocular hypertension who had progressive changes of parapapillary atrophy develop before clinically detectable optic disc or visual field damage. MAIN OUTCOME MEASURES: Assessment of changes in the parapapillary atrophy and visual field parameters. METHODS: Baseline and follow-up optic disc photographs and visual field test results were retrospectively analyzed. The relationship between the extent of parapapillary atrophy observed during the ocular hypertension period and initial visual field abnormalities detected after glaucoma development, as well as their spatial relationship, was statistically analyzed. RESULTS: The extent of progressive changes of the parapapillary atrophy detected during the ocular hypertension period was correlated with the extent of changes in the visual field parameters, including corrected pattern standard deviation and mean deviation measured after glaucoma development (Mantel-Haenszel chi-square test, P = 0.026, P = 0.037, respectively). In addition, the visual field abnormalities occurred in the corresponding quadrants of the progressive parapapillary atrophy. Analysis of the spatial relationship revealed that the location of progressive changes of the parapapillary atrophy was concordant with the location of visual field abnormalities in 78% of the quadrants (94 of 120 quadrants) (chi-square test, P = 0.001). CONCLUSIONS: The extent and location of visual field abnormalities that develop in ocular hypertensive eyes with progression to glaucoma exhibit a concordance with the extent and location of progressive parapapillary atrophy noted in the ocular hypertension period. This suggests the importance of detailed examination of the parapapillary area in ocular hypertensive eyes.

Human age-related cataract and lens epithelial cell death.

PURPOSE: To evaluate the importance of lens epithelial cell death in age-related cataract. To determine whether the large percentage of terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick-end labeling (TUNEL)-positive lens epithelial cells previously reported in human capsulotomy specimens results from apoptosis or necrosis. METHODS: Capsulotomy specimens from patients who had undergone cataract surgery and epithelia from cataractous lenses of eye bank eyes were compared with epithelia from noncataractous lenses of eye bank eyes. DNA fragmentation was assayed using the TUNEL method. Cell membrane integrity was tested using a fluorescent stain for DNA, BOBO-3, that is excluded from living cells. Cell proliferation was assayed by labeling with 5-bromo-2'-deoxyuridine (BrdU). The number of cells in different regions of the lens epithelium was measured by digital imaging and computerized counting of nuclei after staining with methyl green. RESULTS: TUNEL-positive cells were sometimes detected adjacent to denuded regions of capsulotomy specimens, especially when epithelia were not fixed immediately after surgery. TUNEL-stained cells usually stained with BOBO-3, indicating loss of plasma membrane integrity. No BrdU-labeled cells were detected in capsulotomy specimens. Cell density in cataractous lens epithelia was similar to that in normal lens epithelia. In cataractous lenses from eye bank eyes, cell density in the region of the epithelium overlying the cataract was higher than cell density in the region of the epithelium overlying the transparent part of the lens. No correlation was found between cell density and cataract severity or between cell density and age. CONCLUSIONS: TUNEL staining of lens epithelial cells in capsulotomy specimens most likely results from necrotic cell death caused by damage during or soon after cataract surgery. Loss of cells from the lens epithelium, by apoptosis or other mechanisms of cell death, does not seem to play a major role in age-related cataract formation.

Late removal of releasable sutures after trabeculectomy or combined trabeculectomy with cataract extraction supplemented with antifibrotics.

PURPOSE: Releasable scleral flap sutures have been effectively used in trabeculectomy. The suggested time for suture removal is within the first two postoperative weeks. The authors wished to determine whether the use of intraoperative antifibrotics alters the time of suture removal and the results of surgery. METHODS: The charts of 324 patients (388 eyes) undergoing trabeculectomy and 141 patients (174 eyes) undergoing combined trabeculectomy with cataract extraction with a minimum follow-up of 12 months were retrospectively reviewed. All eyes received intraoperative antifibrotics; mitomycin C in 534 eyes and 5-fluorouracil in 29 eyes. Two releasable scleral flap sutures were used in all of the eyes. RESULTS: The removal time of at least one of the two releasable sutures was later than 21 days postoperatively in 89 eyes of 83 patients with trabeculectomy (22.9%) and in 58 eyes of 55 patients with combined surgery (33.3%). The suture removal was deferred in 39 eyes because of an early complication such as hypotony (intraocular pressure (IOP) < or = 5 mm Hg), bleb leak, or shallow or flat anterior chamber. There was no complication in the other 108 eyes, but suture removal was delayed until the IOP was more than 10 mm Hg. Immediate IOP reduction was (mean +/- standard deviation) 6.3 +/- 2.8 mm Hg when suture removal was performed beyond 3 weeks. There was a decreased response as the postoperative time until suture removal increases (r = -0.57). No serious complication associated with late suture removal was noted during the follow-up period (mean +/- standard deviation, 19.8 +/- 10.1 months). CONCLUSION: Intraoperative pharmacologic modulation of wound healing in trabeculectomy and combined trabeculectomy with cataract extraction extends the period that releasable suture removal is clinically effective. However the response decreases with a longer interval to releasable suture removal.

Parapapillary chorioretinal atrophy in patients with ocular hypertension. I. An evaluation as a predictive factor for the development of glaucomatous damage.

OBJECTIVE: To determine whether parapapillary chorioretinal atrophy is a risk factor for the development of glaucomatous optic disc or visual field damage. METHODS: The initial morphometric parameters of the optic disc and parapapillary atrophy were retrospectively investigated in 350 eyes of 175 patients with ocular hypertension. The prognostic value of parapapillary atrophy at the baseline examination and its relationship with known risk factors for the development of glaucomatous damage were analyzed by multivariate analysis. RESULTS: Visual field loss, optic disc damage, or both were detected in 98 eyes of 53 patients during the follow-up period of at least 10 years. By univariate analysis, the presence of parapapillary atrophy, as well as higher parapapillary atrophy area-disc area, zone beta area-disc area, and parapapillary atrophy length-disc circumference ratios, at the baseline examination was associated with the conversion to glaucoma. In addition, higher intraocular pressure, larger vertical cup-disc ratio, and smaller neural rim area-disc area ratio at the baseline examination were associated with subsequent glaucomatous optic nerve damage. In a multivariate regression model adjusted for other factors, intraocular pressure (relative risk, 1.19), neural rim area-disc area ratio (relative risk, 0.72), and zone beta area-disc area ratio (relative risk, 1.32) were found to be associated with the development of optic disc damage, visual field damage, or both. CONCLUSION: The presence and the size of parapapillary atrophy are related to the development of subsequent optic disc or visual field damage in patients with ocular hypertension.

Parapapillary chorioretinal atrophy in patients with ocular hypertension. II. An evaluation of progressive changes.

OBJECTIVE: To determine whether parapapillary chorioretinal atrophy in patients with ocular hypertension remained stationary or progressed along with glaucomatous optic nerve damage. METHODS: The morphometric parameters and progression of parapapillary atrophy were retrospectively investigated, using serial photographs, in 350 eyes of 175 patients with ocular hypertension. The association of parapapillary atrophy progression with subsequent glaucomatous conversion and with other baseline patient- and eye-specific characteristics was analyzed. RESULTS: Progression in the area and extension of parapapillary atrophy before noticeable optic disc or visual field changes was observed in 48 (49.0%) of 98 eyes that converted to glaucoma, while parapapillary atrophy progression was noted in 25 (9.9%) of 252 ocular hypertensive eyes that did not develop glaucomatous damage (P<.001). The predictive sensitivity and specificity of this observation were 49% and 90%, respectively. In a logistic multiple regression model, the progression of parapapillary atrophy was associated with a family history of glaucoma (odds ratio, 2.7) and the initial size of zone beta (odds ratio, 1.64, for an increase of 0.10 of the zone beta area-disc area ratio). CONCLUSION: The progression of parapapillary chorioretinal atrophy may be an early glaucomatous finding in some patients with ocular hypertension.

Comparative results of combined procedures for glaucoma and cataract: II. Limbus-based versus fornix-based conjunctival flaps.

BACKGROUND AND OBJECTIVE: One of the variables to be considered in a combined procedure for glaucoma and cataract is the type of conjunctival flap to be used. The objective of this study was to compare the effects of limbus-based and fornix-based conjunctival flaps on postoperative long-term intraocular pressure (IOP) control and visual acuity after combined trabeculectomy with phacoemulsification. PATIENTS AND METHODS: The authors retrospectively reviewed the charts of 189 patients (215 eyes) who underwent combined trabeculectomy with phacoemulsification, posterior chamber intraocular lens (IOL) implantation, and intraoperative mitomycin-C administration and who had a minimum follow-up of 12 months. The results of the limbus-based (151 eyes) versus fornix-based (64 eyes) conjunctival incisions used in these combined procedures were compared. RESULTS: In the limbus-based conjunctival flap group, 146 eyes (97%) achieved an IOP of less than 20 mm Hg, with or without medication; 62 eyes (97%) of the fornix-based conjunctival flap group (P > .05) achieved this result. A visual acuity of 20/40 or better was noted in 106 eyes (70%) in the limbus-based conjunctival flap group and in 45 eyes (70%) in the fornix-based conjunctival flap group (P > .05) at the last examination. Early wound leakage was observed more frequently in the fornix-based conjunctival flap group (8% vs 1%) (P = .014); however, it was not a serious clinical problem, as only 1 eye required surgical repair. Posterior capsular opacification was found more often in the limbus-based conjunctival flap group (25% vs 14%) (P = .072) and required more frequent laser capsulotomy (22% vs 9%) (P = 0.03). CONCLUSION: Limbus-based and fornix-based conjunctival flaps appear to be comparable with respect to postoperative IOP control and visual acuity after a combined trabeculectomy with phacoemulsification and posterior chamber IOL implantation in cases supplemented by intraoperative mitomycin-C.

Comparative results of combined procedures for glaucoma and cataract: I. Extracapsular cataract extraction versus phacoemulsification and foldable versus rigid intraocular lenses.

BACKGROUND AND OBJECTIVES: The refinements of small-incision cataract surgery by phacoemulsification with foldable intraocular lens (IOL) implantation have recently permitted new options for combined trabeculectomy with cataract extraction. The objectives of this study were to compare the long-term intraocular pressure (IOP) control and visual outcome between trabeculectomies combined with extracapsular cataract extraction (ECCE) versus those with phacoemulsification, and to analyze these same factors for foldable versus rigid IOLs. PATIENTS AND METHODS: The authors retrospectively reviewed the charts of 311 patients (397 eyes) who underwent combined trabeculectomy with cataract extraction and posterior chamber IOL implantation. In all of the surgeries, releasable scleral flap sutures were used. The mean follow-up was 22.9 +/- 15.1 months, with a minimum follow-up of 12 months. RESULTS: Trabeculectomy combined with phacoemulsification had a lower postoperative complication rate and was more effective than trabeculectomy combined with ECCE in reducing IOP to less than 20 mm Hg with or without medication (95% vs 82%) and in improving vision to levels of 20/40 or better (71% vs 52%) (P < .001). Regarding IOLs, foldable silicone lenses were found to be an effective alternative to polymethylmethacrylate lenses in combined surgeries in terms of a controlled IOP of less than 20 mm Hg (97% vs 97%) and visual recovery to 20/40 or better (78% vs 63%). CONCLUSION: The combination of trabeculectomy with releasable scleral flap sutures and small incision cataract surgery with foldable IOL implantation has improved postoperative IOP control and visual rehabilitation.

Plasma and aqueous humor endothelin levels in primary open-angle glaucoma.

PURPOSE: Endothelins (ET) have some effects on the regulation of aqueous humor dynamics. To investigate their possible role in glaucoma, we measured plasma and aqueous humor ET levels in patients with and without primary open-angle glaucoma. METHODS: Plasma and aqueous humor samples were obtained from 31 patients with primary open-angle glaucoma and 24 patients without glaucoma. Measurements were made by radioimmunoassay (RIA) for ETs with the following cross-reactivities: ET-1, ET-2, and big ET-1, 100%; and ET-3, 70%. RESULTS: The ages (mean +/- SD) of the patients with primary open-angle glaucoma (72.3 +/- 10 years) and normal subjects (72.8 +/- 8 years) were similar (p = 0.92). There was no significant difference between plasma ET levels of the two groups (p = 0.07). However, aqueous humor ET levels (mean +/- SD) were higher in the primary open-angle glaucoma group (44.26 +/- 2.6 pg ml-1) than in normal subjects (42.17 +/- 1.6 pg ml-1) (p = 0.001). The ratios of corresponding aqueous humor to plasma levels of ETs were approximately 10% higher in the primary open-angle glaucoma group (3.76) than in normal subjects (3.41) (p = 0.0002). CONCLUSIONS: The small increase in aqueous humor endothelin levels in patients with primary open-angle glaucoma versus controls of similar age may be relevant to the understanding of the various roles of ETs in aqueous humor dynamics in these patients.

Comparative optic disc analysis in normal pressure glaucoma, primary open-angle glaucoma, and ocular hypertension.

PURPOSE: The authors wished to determine whether characteristics of optic disc and parapapillary atrophy differ between eyes with ocular hypertension, primary open-angle glaucoma (POAG) and those with normal-pressure glaucoma, including a subset of patients with normal-pressure glaucoma with evidence of serum abnormalities of humoral autoimmunity. METHODS: Three hundred ninety-two eyes of 196 patients with ocular hypertension, 394 eyes of 197 patients with POAG, and 135 eyes of 68 patients with normal-pressure glaucoma were analyzed. Nerve fiber layer hemorrhage in the optic disc region, retinal arteriolar narrowing, and morphometric parameters of optic disc and parapapillary atrophy were investigated in these groups. Parapapillary atrophy was differentiated in two different zones (alpha and beta). RESULTS: Nerve fiber layer hemorrhage and arteriolar narrowing were found more frequently in patients with normal-pressure glaucoma than in patients with POAG (P = 0.014, P = 0.004) and ocular hypertension (P < 0.0001, P < 0.0001). Zone beta was detected more often in patients with normal-pressure glaucoma than in those with ocular hypertension (P < 0.001) and POAG (P = 0.013). Although patients with normal-pressure glaucoma had more advanced neural rim loss and larger parapapillary atrophy, there were similar correlations between neural rim area and the area and extension of parapapillary atrophy in patients with normal-pressure glaucoma and POAG. Parapapillary atrophy parameters also were similar in different stages of neural rim damage in patients with normal-pressure glaucoma and POAG (P > 0.05). Optic disc characteristics were not different (P > 0.05) between the subgroups of patients with normal-pressure glaucoma. CONCLUSION: The authors' findings support the idea that besides the enlargement of the area and extension of parapapillary atrophy that accompanies neural damage in glaucoma, the severity of the parapapillary atrophy also increases as assessed by the increase in zone beta in more damaged eyes. Furthermore, the final clinical appearance of optic nerve damage is similar among patients with POAG, normal-pressure glaucoma, and the subgroups of normal-pressure glaucoma, regardless of their possibly different mechanisms of neuropathy.

Treatment of persistent glaucoma secondary to periocular corticosteroids.

PURPOSE: To describe two patients with uveitis who developed increased intraocular pressure that was unresponsive to maximum medical therapy eight and 13 months after periocular injection of triamcinolone acetonide. METHODS: Excised periocular tissue was analyzed for corticosteroid activity by gas chromatography and mass spectrometry. RESULTS: Excision of the periocular tissue, which contained visible triamcinolone acetonide, resulted in a normal intraocular pressure within 14 days in both patients. Analysis of the excised tissue disclosed residual corticosteroid in one of the two patients. CONCLUSION: Removal of periocular tissue containing injected corticosteroids may facilitate the management of patients developing increased intraocular pressure unresponsive to maximum medical therapy.

Should patients with anatomically narrow angles have prophylactic iridectomy?

In this set of articles, the authors outline methods and criteria for determining which patients with anatomically narrow angles should have laser iridectomy to prevent acute angle-closure glaucoma.

Trabeculectomy with releasable sutures.

OBJECTIVE: To determine whether the use of releasable scleral-flap sutures affects the success rate and the incidence of complications following trabeculectomy. DESIGN: A retrospective chart review of a consecutive series of trabeculectomies. SETTING: A university-based referral practice. PATIENTS: Two hundred fifty-eight consecutive patients (274 eyes) undergoing trabeculectomy because of uncontrolled glaucoma. INTERVENTION: During the first year, 124 patients (128 eyes) underwent trabeculectomies with permanent scleral-flap sutures. During the second year, 134 patients (146 eyes) underwent trabeculectomies with releasable scleral-flap sutures. MAIN OUTCOME MEASURES: Incidence of flat and shallow anterior chamber, incidence of operations to drain choroidal detachment and to re-form anterior chamber, and long-term control of intraocular pressure. RESULTS: In the group with permanent sutures, 42 eyes (32.8%) had clinically detectable shallowing of the anterior chamber in the early postoperative period. In contrast, a shallow anterior chamber was noted in 21 eyes (14.4%) in the group with releasable sutures (P = .0003). Flat anterior chamber, defined as iridocorneal apposition to the pupil margin, occurred in 11 eyes with permanent sutures (8.6%) but in only two eyes (1.4%) with releasable sutures (P = .0078). Surgical intervention to drain suprachoroidal fluid and re-form the anterior chamber was required in eight eyes with permanent sutures (6.2%) but in only one eye with releasable sutures (0.7%) (P = .014). At 1-year follow-up, the two groups were similar in terms of intraocular pressure and the need for ocular hypotensive medications. CONCLUSIONS: Releasable scleral-flap sutures reduce the incidence of shallow and flat anterior chamber after trabeculectomy without compromising long-term control of intraocular pressure.

Trabeculectomy with releasable sutures.

We attempted to reduce some of the postoperative complications of trabeculectomy by using releasable scleral flap sutures. This technique allows an initial tight closure of the scleral flap with the option to increase aqueous humor outflow in the early postoperative period. We reviewed our experience with trabeculectomy and releasable sutures in 146 eyes (134 patients) and compared these cases with a prior series of 128 eyes (124 patients) that underwent trabeculectomy with permanent scleral flap sutures. In the control group, 42 eyes (32.8%) had clinically detectable shallowing of the anterior chamber in the postoperative period. In contrast, shallow anterior chamber was noted in 21 eyes (14.4%) in the group with releasable sutures (P = .0003). Flat anterior chamber, defined as iridocorneal touch to the pupil margin, occurred in 11 control eyes (8.6%) but in only 2 eyes (1.4%) with releasable sutures (P = .0078). Surgical intervention to drain suprachoroidal fluid and re-form the anterior chamber was required in eight control eyes (6.2%) but in only one study eye (0.7%) (P = .014). At 1 year of follow-up, the two groups were similar in terms of mean intraocular pressure, the need for ocular hypotensive medications, and failure rate.

Topical timolol administration reduces the incidence of glaucomatous damage in ocular hypertensive individuals. A randomized, double-masked, long-term clinical trial (1).

OBJECTIVES: A randomized, double-masked, 5-year clinical trial was conducted to determine whether topical timolol therapy was more effective than placebo in delaying or preventing the onset of glaucomatous damage in moderate-risk ocular hypertensive subjects. METHODS: One eye was chosen randomly to receive timolol therapy twice daily; the fellow eye received placebo (timolol vehicle). The primary end point of the study was reproducible visual field loss detected on three consecutive tests. Automated static threshold visual fields were added to the protocol as the study proceeded, and criteria for reproducible defects for the automated fields were developed. The secondary end point was progressive optic disc cupping confirmed by examination of stereoscopic disc photographs. Intraocular pressure was not used as an end point (i.e., eyes were not withdrawn from the study because they reached a predetermined level of intraocular pressure).