Persistent leak after glaucoma aqueous shunt implantation.

PURPOSE: To present 4 cases of persistent leak attributed to subconjunctival fistula formation after glaucoma aqueous shunt implantation. Our preferred method for management is also described. METHODS: Retrospective noncomparative case series. RESULTS: Four cases of persistent leak after glaucoma aqueous shunt surgery are described. Three patients had an underlying diagnosis of iridocorneal endothelial syndrome and 1 patient had a diagnosis of chronic panuveitis. Three patients had prior trabeculectomy with adjunctive periocular application of antiproliferative agents (mitomycin C and/or 5-fluorouracil). One patient had aqueous shunt implantation as a primary glaucoma procedure. Implantation of the Molteno (1 patient), Ahmed (2 patients), and Baerveldt (1 patient) aqueous shunts was uneventful in all cases. Early onset of the leak, between postoperative months 1 and 2, was typical. The use of aqueous suppressants, bandage contact lens, conjunctival photocoagulation, sutures, tissue adhesives, conjunctival autografts, and scleral patch grafts were unsuccessful in the described cases. Resolution of the leak occurred after removal of the aqueous shunt and elimination of the causative subconjunctival fistula. Histologic support for fistulization was obtained in 3 cases. Severe complications including endophthalmitis (1 patient), hypotony (4 patients), suprachoroidal hemorrhage (2 patients), and corneal decompensation (3 patients) occurred because of the persistent leaks. CONCLUSIONS: Persistent leak is a rare but important complication after glaucoma aqueous shunt implantation. Early consideration for the presence of a subconjunctival fistula, especially in patients with iridocorneal endothelial syndrome or chronic uveitis, can spare many ineffective efforts to repair the leak and prevent severe vision threatening complications.

A 2-hour information session and patient recall has minimal impact on glaucoma-treatment persistence in a mature practice.

PURPOSE: To study the impact of a 2-hour information session and 3 patients' phone calls on patient persistence with glaucoma medication. PATIENTS AND METHODS: All patients with glaucoma treatment, part of a 27-year old solo glaucoma practice, were invited to attend the information session. Patients who attended the session (n=342) were contacted by phone 1, 4, 10 months later and regular use of drops was stressed. Patients were unaware of the study. We compared the persistence of the patients before and after attending the session, and their persistence to that of patients who did not attend (n=1187). Persistence with glaucoma medication was assessed by examination of data (2002 to 2007) from a provincial medical and drug insurance database. RESULTS: Patients attending the session had glaucoma for 10 years. They had a better persistence than those who did not attend (P<0.05). Their persistence remained the same 1 year after attending the session but tended to be improved in the first 180 days (P<0.076). During the study period, there was a 4% increase in overall persistence (P<0.05). This could be due to an increase in prostaglandins prescriptions and changes in ß-blockers formulation. CONCLUSIONS: The information session and patient's recalls had a limited impact on patient persistence. This could be due to the selection of a population already persistent (78.9%). The results could have been different in less persistent patients and new patients. It could be different in another practice setting.

Comparison of newly diagnosed ocular hypertension and open-angle glaucoma: ocular variables, risk factors, and disease severity.

Purpose. To describe the distribution of ocular variables, risk factors, and disease severity in newly diagnosed ocular hypertension (OH) or open-angle glaucoma (OAG). Methods. Eligible subjects underwent a complete history and examination. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) obtained from multiple logistic regression models were used to compare OAG to OH and advanced to early/moderate OAG. Results. 405 subjects were enrolled: 292 (72.1%) with OAG and 113 (27.9%) with OH. 51.7% had early, 27.1% moderate, and 20.9% advanced OAG. The OR for OAG versus OH was 8.19 (P < 0.0001) for disc notch, 5.36 (P < 0.0001) for abnormal visual field, 1.45 (P = 0.001) for worsening mean deviation, 1.91 (P < 0.0001) for increased cupping, 1.03 for increased age (P = 0.030), and 0.36 (P = 0.010) for smoking. Conclusions. Increased age was a risk for OAG, and smoking decreased the risk of OAG compared to OH. Almost half of the OAG subjects had moderate/advanced disease at diagnosis.

Follow-up of angle closure glaucoma suspects after laser iridotomy in Caucasians with normal intraocular pressure at diagnosis.

OBJECTIVE: To study the long-term outcome of Caucasian eyes with iridotrabecular trabecular apposition or peripheral anterior synechiae (PAS) and fellow eyes with narrow angles only, in eyes with intraocular pressure (IOP) <22 mm Hg at diagnosis and treated with laser peripheral iridotomy (LPI). DESIGN: Cohort study. PARTICIPANTS: Two hundred and fifty-seven Caucasian phakic patients (469 eyes) with a minimum follow-up of 2 years that had both an undilated and dilated gonioscopy after LPI. METHODS: In this retrospective cohort study, we included phakic patients with a minimum follow-up of 2 years that had both an undilated and dilated gonioscopy after LPI. Excluded were patients with pseudoexfoliation, intraocular surgery, prior acute angle-closure glaucoma or antiglaucoma medication, suspicious glaucoma disk, secondary angle closure, or iridoplasty. We censored patients after any kind of intraocular surgery. Main outcome measures where the date of IOP elevation and beginning of antiglaucoma medication. RESULTS: Four hundred and sixty-nine eyes were included. Mean follow-up was 8.5 ± 5.53 years. No apposition/PAS was observed in 84.0% of the eyes after LPI. At 10 years, 38.7% of the eyes had increased IOP and 17.3% required medication. No difference in outcomes was observed between argon and neodymium-YAG LPI or between the eyes with and without apposition/PAS before LPI. Younger patients and those with no apposition/PAS after LPI had a better prognosis (p < 0.01). CONCLUSIONS: Many angle closure glaucoma suspects developed increased IOP and required medical treatment after LPI.

An information session for glaucoma patients.

BACKGROUND: A 2-hour information session to improve understanding and compliance was offered to glaucoma patients. Three studies are presented regarding the participants, their satisfaction with the presentation, and their retention of information. METHODS: One hundred consecutive patients were invited to participate. Age, sex, race, travelling distance, type of glaucoma, number of medications, duration of glaucoma, laser trabeculoplasty, trabeculectomy, medical conditions, visual acuity, visual field mean deviation, and pattern standard deviation (PSD) were documented. At the conclusion of the session, patient satisfaction was determined using a questionnaire. Responses to 6 glaucoma-related questions were requested prior to the session and again at 1, 4, and 10 months afterwards. The effects of age, sex, duration of glaucoma, drops applied, and compliance were analysed. RESULTS: The invitation was accepted by 65.2% of all subjects, including 93.4% of those who had been undergoing therapy for less than 1 year. Factors identified in nonparticipation were advanced age, a longer duration of glaucoma, coronary heart disease, and worse PSD in the worse eye. Transportation was the main reason for nonparticipation. Patient satisfaction was excellent, and 99% indicated that they would recommend the clinic to friends with glaucoma. Patient knowledge increased and persisted throughout the 10 months. Older participants had lower scores. INTERPRETATION: Most patients wanted to participate in the information session. Participants subjectively felt that the session was useful. It improved their knowledge of glaucoma, and has the potential to increase patient compliance.

Episcleral venous pressure in younger and older subjects in the sitting and supine positions.

PURPOSE: Intraocular pressure is higher in older than younger subjects during the day and night. We attempted to determine whether episcleral venous pressure could explain the difference in the sitting and supine positions. PARTICIPANTS AND METHODS: We compared episcleral venous pressure, intraocular pressure, and blood pressure in a group of younger subjects aged 18 to 30 years and in a group of older subjects aged 65 years or older. The above measurements were performed in the sitting position and after 15 minutes in the supine position. RESULTS: The main difference between the groups was their systemic conditions. Comparing both groups, episcleral venous pressure and intraocular pressure were not different in the sitting position. However, in the supine position, episcleral venous pressure (9.6 vs. 8.3 mm Hg) (P < 0.01) and intraocular pressure (17.1 vs. 15.6 mm Hg) (P < 0.05) were higher in the older group. Statistically, a within-group analysis showed a significant increase in intraocular pressure in the supine position for both the younger (+ 0.8 mm Hg) (P < 0.001) and older subjects (+ 1.8 mm Hg) (P < 0.02). This was associated with an increased episcleral venous pressure in younger (+ 0.4 mm Hg) (P < 0.001) and older subjects (+1 mm Hg) (P < 0.02). There was no gender difference in intraocular pressure and episcleral venous pressure. No differences were found for intraocular pressure and episcleral venous pressure in subjects having certain systemic conditions. Blood pressure was higher for older subjects (P < 0.001). It decreased in the supine position for both groups (P < 0.001). CONCLUSION: Intraocular pressure and episcleral venous pressure were not different in the younger and older group in the sitting position. They were higher in the supine position for older subjects. There was no gender difference.

Founder TIGR/myocilin mutations for glaucoma in the Québec population.

Primary open-angle glaucoma (POAG) is a complex disorder characterized by a progressive and treatable degeneration of the optic nerve. TIGR/myocilin (MYOC) gene mutations are found in approximately 4% of all POAG patients. Populations with frequent founder effects, such as the French-Canadians, offer unique advantages to implement genetic testing for the disorder. To assess molecular diagnosis for POAG in this population, we determined the prevalence of TIGR/MYOC mutations in 384 unrelated glaucoma patients, 38 ocular hypertensive subjects and 18 affected families (180 patients). We further analyzed the clinical features associated with these variations. Nine coding sequence variants were defined as mutations causing mostly, but not exclusively, POAG. Four families segregated distinct mutations (Gly367Arg, Gln368Stop, Lys423Glu and Pro481Leu), while 14 unrelated glaucoma patients harbored six known mutations (Thr293Lys, Glu352Lys, Gly367Arg, Gln368Stop, Lys423Glu and Ala445Val) and two novel (Ala427Thr and Arg126Trp). The frequencies of these mutations were respectively 3.8% and 22.2% in the unrelated and family studies. The Gly367Arg and Lys423Glu variants caused the earliest ages at onset. When achievable, assessment of relatives of unrelated mutation carriers showed the Arg126Trp and Gly367Arg to be familial. Characteristic allele signatures, indicative of specific founder effects, were observed for five of the six mutations conveyed by at least two patients. Recombination probability estimates suggested that the French-Canadian population had most probably inherited these six mutations from 7-10 Québec settlers. Our data demonstrated that genetic screening for TIGR/MYOC mutations should be offered to glaucoma families and to close relatives of unrelated patients aware of a family history for the disorder.

Allergic reactions to brimonidine in patients treated for glaucoma.

BACKGROUND: Allergic reactions to ophthalmic drugs have not been studied extensively in ophthalmology. We performed a study to estimate the incidence of allergy to brimonidine in patients treated for glaucoma. METHODS: We identified all patients in a private glaucoma practice who started therapy with brimonidine between Mar. 19, 1998, and Aug. 14, 1999. We recorded the patient's diagnosis, age, sex, concomitant glaucoma medication, previous allergy to glaucoma medication and allergy to brimonidine. Allergy was defined as allergic contact dermatoconjunctivitis or follicular conjunctivitis. RESULTS: Of the 140 patients identified, 36 (25.7%) had had an allergic reaction to brimonidine. Contact dermatoconjunctivitis was noted in 19 patients (52.8%) and follicular conjunctivitis in 18 (50.0%). The rate of development of those two manifestations was linear and almost parallel throughout the study period. In logistic regression analysis previous allergy to a topically given antiglaucoma medication (t = -5.13) and concurrent use of levobunolol (t = 3.46) were retained as the most probable predictor variables of allergy to brimonidine. Life-table analysis showed a fairly linear curve, with no peak in allergy rate. Allergic reactions occurred throughout the year, with a small peak in March. INTERPRETATION: We found a rate of allergy to brimonidine of 25.7%. Concomitant levobunolol use and allergy to another glaucoma medication were associated with a higher allergy rate.