Current techniques in wound healing modulation in glaucoma surgery.

The wound healing response is the single most important determinant of the final intraocular pressure after glaucoma surgery. The use of antiscarring agents, particularly the antimetabolites 5-fluorouracil and mitomycin C, have revolutionized glaucoma surgery over the past decade. This subject has become more important with the realization that simply lowering the intraocular pressure to below 21 mm Hg is inadequate, and that optimal lowering of the intraocular pressure should be achieved in all patients undergoing surgery for glaucoma. However, the antimetabolites still have many potential problems and side effects, some of which are potentially sightthreatening. This review concentrates on the recent publications in this field that have determined the current "state of the art," with a view toward optimizing results and minimizing side effects for our patients with glaucoma in this exciting and challenging area of progress.

Screening for cytomegalovirus retinitis in HIV-positive and AIDS patients.

The ability of physicians to screen for AIDS-related cytomegalovirus retinitis (CMVR) was studied at a London AIDS centre. Patients had undergone direct ophthalmoscopy as part of their general examination by the physicians and were referred if fundal abnormalities were found, if a focus of extra-ocular CMVR was present or if the patient complained of visual symptoms. The provisional diagnoses of the physicians were compared with the final diagnoses of the ophthalmologists. Of 348 consecutive patients referred for an ophthalmic opinion, the physicians made the correct diagnosis in 69% of those referred with a provisional diagnosis of CMVR, in 66% of those with normal fundi and in 81% of those with toxoplasma chorioretinitis. Those cases of CMVR which were misdiagnosed by the physicians were usually mistaken for other retinal pathology which would warrant a specialist referral. Screening for CMVR in HIV-positive and AIDS patients may safely be undertaken by physicians familiar with the ocular manifestations of HIV-related disease.

Retinal detachment in AIDS-related cytomegalovirus retinitis.

Patients with acquired immune deficiency syndrome (AIDS) and cytomegalovirus retinitis (CMVR) are surviving longer due to the use of virostatic medicines and improved treatment of opportunistic infections. As a result, retinal detachment is likely to become an increasingly common cause of visual morbidity in these patients. The incidence and outcome of retinal detachment complicating CMVR was studied at two London AIDS centres. Patients with CMVR were identified prospectively and underwent standard treatment. Retinal detachments were diagnosed during regular follow-up. If retinal reattachment surgery was performed, a standard procedure of vitrectomy and silicone oil internal tamponade was employed. Of 147 patients with CMVR, 41 (28%) developed retinal detachments (47 eyes). Forty-three detachments were rhegmatogenous and 4 were exudative. Fifteen eyes of 9 patients with rhegmatogenous detachments underwent retinal reattachment surgery. Of these, visual acuity remained stable or improved in 12 eyes (80%) in the immediate post-operative period. At the last clinic visit, 8 eyes (53%) maintained a visual acuity of 6/60 or better. The visual results of surgery are good in selected patients, bearing in mind the progressive nature of the underlying disease and poor life expectancy.

Visual prognosis of AIDS patients with cytomegalovirus retinitis.

A prospective study of visual acuity (VA) was performed in a cohort of 147 AIDS patients with cytomegalovirus retinitis (CMVR). Patients were treated according to standard regimes, and corrected VA was recorded at regular intervals from presentation until death. Follow-up was 6 weeks to 5 years (mean 30 weeks). Fifty patients (34%) had bilateral CMVR at initial presentation; at death 81 patients (55%) had bilateral disease. Thirty-one eyes initially uninfected developed CMVR during follow-up. Of 228 infected eyes, VA at presentation was 6/12 or better in 182 eyes (80%) and 6/60 or better in 215 eyes (94%) At death, VA was 6/12 or better in 112 eyes (49%) and 6/60 or better in 171 eyes (75%). VA in the better eye at death was 6/12 or better in 113 of 147 patients (77%), 6/24 or better in 135 patients (92%) and worse than 6/60 in only 7 patients (5%). Treatment of AIDS-related CMVR minimises loss of vision and may protect previously uninfected eyes, prolonging visual independence.

The primary treatment trial: changes in the visual field analysis by computer-assisted perimetry.

Computer-assisted perimetry was performed 6-monthly on patients entered into the Primary Treatment Trial using the 30-2 program. Those patients with a minimum of five visual fields had pointwise linear regression analysis (Progressor) carried out. Two consecutive slopes significant at the 0.05 level were taken as evidence for change, either improvement or worsening. Forty-eight patients in the surgery group, 40 in the medical group and 20 in the laser group were suitable for analysis. A comparison of the eyes showing 'improvement' or 'worsening' in the surgery and medicine groups showed no difference between them. This lack occurred despite a significant difference in intraocular pressure between the two groups. The reasons for this lack of difference are discussed.

Initial treatment of glaucoma: surgery or medications.

Should surgery or medications be the initial therapy for primary open angle glaucoma? In this set of articles, Drs. Sherwood, Migdal, and Hitchings present evidence suggesting that filtration surgery provides better intraocular pressure control than does medical treatment, good (or better) visual field preservation, and visual acuity as good as that in medically treated fellow eyes. They also cite cost effectiveness, quality of life, and possible adverse effects of medical treatment on future surgery. Drs. Sharir and Zimmerman, on the other hand, favor initial medical therapy, questioning the validity of some reports on surgical results, citing the risks of complications, and noting recent and current progress in the development of antiglaucoma medications. Dr. Schultz' editorial evaluates both points of view, concluding that additional prospective randomized tests may be useful and that either approach may be a viable option, as long as it is individualized to each particular patient.

The influence of prior therapy on the success of trabeculectomy.

The role of early surgery in the management of primary open angle glaucoma is under debate. To determine whether previous medical therapy influences the outcome of subsequent trabeculectomy, we retrospectively reviewed the results of surgery in two groups of patients. The first group underwent primary trabeculectomy, having had an average of 2 weeks of preoperative medical therapy, and this group was compared with a group of patients who had received at least 1 year of topical glaucoma therapy before undergoing trabeculectomy (the multiple-treatment group). The two groups were similar in terms of a number of variables, including race, age, sex, presenting intraocular pressures, and presenting visual fields, and they differed only in the known duration of their disease. The success rate of trabeculectomy was significantly higher in the primary trabeculectomy group as compared with that in the multiple-treatment group (P less than .001). We discuss the possible reasons for this difference and its implications for the future management of primary open angle glaucoma.

Acute blinding sinusitis.

Sinusitis may produce blindness, and deterioration in visual acuity is a strong indication for urgent admission and possible surgery.

Radiation retinopathy following treatment of posterior nasal space carcinoma.

Posterior nasal space carcinoma has a high mortality and most patients are treated with radiotherapy. Radiation retinopathy was encountered in 7 out of 10 survivors included in this study. Five of the affected patients lost vision as a result of the retinopathy. One patient required laser photocoagulation and responded well to this treatment. There was a variation in the severity of the retinopathy among the patients studied despite the fact that all patients received a similar dose of radiotherapy. We suspect that previously unrecognised factors in the planning of radiotherapy fields may explain this difference.

The management of eyelid neoplasms.

The results of 377 patients treated for eyelid neoplasms are reported. A definitive histological diagnosis is essential before commencing treatment. Basal cell carcinomata were the commonest lesions encountered in this series. The various indications for radiotherapy, surgery and cryotherapy are discussed and their respective advantages and disadvantages considered. The aim of treatment is a cure of the primary condition and a satisfactory cosmetic result with the minimum of complications. In this Unit surgery is reserved for a simple excision biopsy or diathermy excision and Wolfe graft as radiotherapy appears to offer the best form of treatment in most cases.