Orbital leiomyosarcoma metastasis presenting prior to diagnosis of the primary tumor.

Leiomyosarcomas, neoplasms of smooth muscle, are rarely found within the orbit. Orbital leiomyosarcoma may be primary, metastatic, or secondary to radiation. When they are metastatic, patients almost exclusively have a history of a primary leiomyosarcoma, often occurring in the spermatic cord, skin, gastrointestinal tract, or the uterus. We present the case of 48-year-old woman who presented with a metastatic orbital leiomyosarcoma, which was identified before the primary tumor.

Effect of central corneal thickness on the long-term outcome of selective laser trabeculoplasty as primary treatment for ocular hypertension and primary open-angle glaucoma.

PURPOSE: To determine if central corneal thickness (CCT) impacts the intraocular pressure (IOP)-lowering effect of selective laser trabeculoplasty (SLT) in patients with ocular hypertension (OHT) and primary open-angle glaucoma (POAG). METHODS: A retrospective chart review of consecutive patients, who underwent SLT as primary treatment for OHT and POAG, between 2002 and 2005, was performed. Partial correlation analysis was performed to correlate the CCT to the percentage of IOP reduction at 3 to 30 months after SLT. Independent samples t test was performed to compare mean percentage of IOP reduction in eyes with CCT less than 555 µm versus CCT 555 µm or greater. RESULTS: Eighty eyes of 47 patients were identified. The partial correlation coefficient value between the CCT and percentage of IOP reduction after SLT at 3 months was -0.253 (P = 0.025), at 12 months it was -0.22 (P = 0.049), and at 30 months it was 0.301 (P = 0.007). Independent samples t test showed that the mean percentage of IOP reduction in eyes with thinner corneas (CCT < 555 µm) was greater than that in thicker corneas (CCT ≥ 555 µm) at 3-, 6-, 9-, 12-, and 30-month post-SLT (P < 0.05). CONCLUSIONS: In patients with POAG and OHT, percentage of IOP reduction after SLT was significantly greater in eyes with thinner corneas (CCT < 555 µm). These findings indicate that patients treated with SLT as primary therapy who had thinner corneas demonstrated better IOP control for at least 30 months after SLT.

Use of processed pericardium graft to plug patulous old sclerostomy track during glaucoma shunt revision for exposure.

The authors demonstrate a reproducible technique using processed pericardium to seal sclerostomy track during glaucoma shunt revision. The suggested method involves placement of a wedge-shaped processed pericardial graft into the old sclerostomy tract following tube explantation. The graft is trimmed and sutured to the sclera. The tube is reinserted into a new sclerostomy and then sutured in place and covered in the usual fashion. This method allowed relatively easy treatment of three patients with patulous sclerostomy with necrotic edges. A successful tube revision and repositioning of the tube using this technique was performed on three patients with exposed tubes. The intraocular pressure was between 8 and 12 mm Hg from postoperative day 1. The authors suggest the use of pericardium plug to adequately seal the old sclerostomy track during glaucoma shunt revision. The plug allows tube repositioning at a new site without the need to suture the friable sclerostomy edges.

Autoimmune basis of glaucoma.

Glaucoma is one of the leading causes of blindness worldwide. The current view of glaucoma is that it is a multifactorial disease. Elevated IOP is a recognized etiologic factor which can trigger initial damage through biomechanical and ischemic injury to the retinal ganglion cells. However, elevated intraocular pressure cannot be entirely responsible for the development of glaucoma. Accumulating evidence suggests that abnormal immunity may be contributing to the glaucomatous optic neuropathy. Autoimmunity may be responsible for initiating or exacerbating glaucoma. This review provides an evaluation of the potential role of autoimmunity in some patients with glaucoma.

Posner-Schlossman glaucomatocyclitic crisis.

In 1948, Posner and Schlossman first reported glaucomatocyclitic crisis, an uncommon form of glaucoma characterized by recurrent unilateral episodes of markedly elevated intraocular pressure (IOP) with mild idiopathic anterior chamber inflammation. The exact etiology of glaucomatocyclitic crisis is not clear. Although it is typically a self-limited condition, some cases with advanced optic nerve cupping and associated visual field loss have been reported. Diagnosis of Posner-Schlossman syndrome is difficult, and it may mimic a variety of ocular disorders. Treatment of this syndrome is directed towards controlling the inflammation and associated IOP elevation.

Comparison of intraocular pressure-lowering effect of every night versus every other night dosing of bimatoprost 0.03%.

PURPOSE: To compare intraocular pressure (IOP) reduction profiles of bimatoprost 0.03% administered every other night (QOD-HS) compared with every night (QHS) in patients with primary open angle glaucoma and pseudoexfoliation glaucoma. METHODS: A retrospective chart review of 68 eyes of 45 consecutive patients who were switched from QHS to QOD-HS bimatoprost due to intolerable conjunctival hyperemia between May 2005 and May 2008. IOP in the morning (AM) and afternoon (PM) of the next day after administration (day 1) and the day after (day 2) on QOD-HS regimen was compared with IOP in the AM and PM when they were on QHS regimen, 4-6 weeks after switching to QOD-HS. RESULTS: Mean IOPs on QHS bimatoprost were 15.9±3.4 mm Hg in the AM and 15.5±2.7 mm Hg in the PM, whereas mean IOPs on QOD-HS were 14±2 mm Hg (AM) and 14.2±2.5 mm Hg (PM) on day 1, and 14.7±2.6 mm Hg (AM) and 14.4±2.4 mm Hg (PM) on day 2 after administration. Differences between IOP fluctuation on QHS and QOD-HS days 1 and 2, respectively, were not significant (P=0.87 and 0.94). CONCLUSION: Every other night dosing of bimatoprost was effective in controlling IOP in this select group of patients with primary open angle glaucoma and pseudoexfoliation glaucoma who had troublesome side effects on bimatoprost 0.03% QHS regimen, and may be considered as an alternative to every day treatment.

Intraocular pressure response to selective laser trabeculoplasty in the first treated eye vs the fellow eye.

OBJECTIVE: To determine if the intraocular pressure (IOP) response to selective laser trabeculoplasty (SLT) in one eye predicts long-term response to SLT in the fellow eye. METHODS: A retrospective medical record review was performed of patients who underwent SLT as primary treatment in both eyes and who completed at least 30 months of follow-up visits. Pearson product moment correlation analysis was performed to determine correlations between the 3-month percentage of IOP reduction in the first treated eye and long-term percentages of IOP reduction in the fellow eye. RESULTS: Medical records of 80 eyes in 40 patients were reviewed. In patients with ocular hypertension, the 3-month percentage of IOP reduction in the first treated eye correlated strongly with long-term percentages of IOP reduction in the fellow eye (r > 0.652). In patients with primary open-angle glaucoma, the 3-month percentage of IOP reduction in the first treated eye correlated moderately with percentages of IOP reduction in the fellow eye up to 9 months (r > 0.367). CONCLUSIONS: In patients with ocular hypertension, the 3-month percentage of IOP reduction in the first treated eye in response to SLT was predictive of response in the fellow eye up to 30 months. In patients with primary open-angle glaucoma, the 3-month percentage of IOP reduction in the first treated eye in response to SLT was predictive of response in the fellow eye up to 9 months.

Effect of prior cataract surgery on the long-term outcome of selective laser trabeculoplasty.

OBJECTIVE: To determine if pseudophakia affects selective laser trabeculoplasty (SLT) intraocular pressure (IOP) lowering effect. METHODS: A retrospective chart review was performed on 94 eyes of 75 consecutive patients who underwent SLT as primary treatment for ocular hypertension and primary open-angle glaucoma between 2002 and 2005 and completed at least 30 months follow up. Patients were excluded if they required additional glaucoma medications, laser, or ocular surgery during the follow-up period. Patients were categorized as phakics or pseudophakics. Independent-samples t-test was performed to compare the mean percentage of IOP reduction at 3, 6, 12, 18, and 30 months after SLT between the phakic and pseudophakic groups. RESULTS: Seventy-six phakic and 18 pseudophakic eyes were included. IOP reduction in phakic group was 27.4% (2 week), 29.8% (3 months), 27.7% (9 months), 27.4% at (12 months) and 27.3% at (30 months). In pseudophakic patients, the mean IOP reduction was 19.8% (2 weeks), 26.5% (3 months), 23.2% (9 months), 22.5% (12 months), and 25.9% (30 months). An independent-sample t-test compared the percentage of IOP reduction between the phakic and pseudophakic groups and revealed higher percentage of IOP reduction in the phakic group at 2 weeks by 7.6% (P = 0.01). P value for difference was 0.34 (3 months), 0.25 (6 months), 0.18 (9 months), 0.12 (12 months), 0.36 (18 months), and 0.7 (30 months) after SLT. CONCLUSIONS: SLT response was delayed in pseudophakic compared to phakic patients, while the long-term effectiveness of SLT is the same in both groups.

Long-term safety and efficacy of selective laser trabeculoplasty as primary therapy for the treatment of pseudoexfoliation glaucoma compared with primary open-angle glaucoma.

PURPOSE: To investigate the safety and efficacy of selective laser trabeculoplasty (SLT) to reduce intraocular pressure (IOP) in patients with pseudoexfoliation glaucoma (PXFG) compared with primary open-angle glaucoma (POAG). DESIGN: Non-randomized, prospective, clinical trial. METHODS: Nineteen eyes of 13 patients with POAG and 18 eyes of 13 patients with PXFG were treated with SLT. Patients were followed without antiglaucoma medications until additional medical, laser, or surgical intervention was initiated, at which time they were considered failures, had withdrawn from the study, or underwent a second SLT. RESULTS: The POAG and PXFG eyes showed similar reductions of IOP over the 49 months of follow-up. At 30 months of follow-up the POAG group showed a mean IOP of 17.6 ± 2.8 mmHg and a mean IOP reduction of 5.7 ± 2.1 mmHg; the PXFG group showed a mean IOP of 18.3 ± 4.7 and a mean IOP reduction of 5.3 ± 3.0 mmHg. Four eyes in the PXFG group and three eyes in the POAG group failed by 30 months. The cumulative probability of success was 74% for the PXFG group and 77% for the POAG group. Four PXFG eyes underwent a second SLT after 30 months of follow-up with a final IOP of 17.6 ± 2.8 mmHg. There were no serious adverse events. CONCLUSION: SLT is a safe and effective method to lower IOP in patients with PXFG as initial glaucoma therapy. Both groups showed similar IOP reductions and failure rates.

Imaging of optic nerve head drusen: improvements with spectral domain optical coherence tomography.

OBJECTIVE: To demonstrate a new algorithm that can determine the shape, location, and volume of optic nerve head drusen (ONHD), which were imaged with spectral domain optical coherence tomography (SDOCT). METHODS: One exenteration patient and 4 glaucoma patients with bilateral ONHD were recruited from the Massachusetts Eye and Ear Infirmary and from a private practice office. Images were obtained using an experimental SDOCT system developed at the Wellman Center for Photomedicine, Massachusetts General Hospital. With axial resolutions of about 6 mum, SDOCT can obtain 2-dimensional images in 1/29 of a second, compared with commercially available time domain OCT instruments with 10 mum resolution images in 1.28 seconds. The volumes of ONHD were calculated with a new algorithm and were then correlated with visual field mean deviation. RESULTS: SDOCT can display 2-dimensional images comparable with histology and 3-dimensional videos of ONHD. ONHD are signal-poor regions with high-signaled borders. Larger ONHD volumes are directly correlated with larger mean deviation absolute values on Humphrey visual field testing. CONCLUSIONS: SDOCT is a potentially better technique for ONHD imaging and may improve the diagnosis and management of patients with both OHND and glaucoma.

Neovascular glaucoma: etiology, diagnosis and prognosis.

Neovascular glaucoma (NVG) is a severe form of glaucoma with devastating visual outcome attributed to new blood vessels obstructing aqueous humor outflow, usually secondary to widespread posterior segment ischemia. Invasion of the anterior chamber by a fibrovascular membrane initially obstructs aqueous outflow in an open-angle fashion and later contracts to produce secondary synechial angle-closure glaucoma. The full blown picture of NVG is characterized by iris neovascularization, a closed anterior chamber angle, and extremely high intraocular pressure (IOP) with severe ocular pain and usually poor vision.

A comparison of the intervisit intraocular pressure fluctuation after 180 and 360 degrees of selective laser trabeculoplasty (SLT) as a primary therapy in primary open angle glaucoma and ocular hypertension.

OBJECTIVE: To determine and compare the effect of 180 and 360 degrees of selective laser trabeculoplasty (SLT) treatment as a primary therapy on the intervisit intraocular pressure (IOP) fluctuation in patients followed up for a period of 2 years without any further medical or surgical intervention. METHODS: Retrospective chart review of patients with ocular hypertension and primary open angle glaucoma who received SLT as primary therapy without any subsequent medical or surgical intervention. IOP before SLT and postlaser IOP at all the visits during the follow-up period of months 6 to 24 was determined. The standard deviation (SD) of the mean IOP was used as a surrogate for IOP fluctuation. RESULTS: Forty-one eyes were treated by SLT, 19 eyes in the 180-degree group and 22 eyes in the 360-degree group. The mean reduction in IOP at 2 years was 28% in 180-degree group and 35% in 360-degree SLT group. After the SLT, the 360-degree SLT group had a lower IOP fluctuation compared with the 180-degree SLT group over the follow-up period of months 6 to 24. The percentage of eyes with intervisit IOP fluctuation (SD)

Efficacy of multiple selective trabeculoplasty in open-angle glaucoma

OBJECTIVE: To determine the reduction in intraocular pressure (IOP) of multiple selective laser trabeculoplasty (SLT) in eyes with open-angle glaucoma (OAG) and ocular hypertension (OHT). METHODS: Forty-nine OAG eyes that received multiple SLTs were retrospectivel]j studied. The first and second SLT treated 180 degrees and the third treat! 180 to 360 degrees of the trabecular meshwork. Main outcome (response rate)] was IOP reduction of a3 mm Hg from baseline at 6 months after each SLT.Only patients followed up for at least 6 months were included. CONCLUSION: Multiple selective SLT successfully lowers IOP. A second SLT lowered IO1 by 19 percent from baseline IOP after 6 months and a third by 47 percent after another f months. Eyes with baseline IOP >21 mm Hg had greater IOP reduction; higher response rates for each SLT compared to those with baseline IOP ? 21 mm Hg.

Glaucoma in retinoblastoma.

The association between retinoblastoma and secondary glaucoma is well known. The most common cause of secondary glaucoma in retinoblastoma is iris neovascularization (NVI) followed by pupillary block and tumor seeding of the anterior chamber. Although glaucoma is a secondary clinical issue in retinoblastoma (RB) management and care, awareness of its presence, revealed by a thorough ocular exam of the anterior segment, can guide the clinician in assessing the overall condition of the affected eye.

Selective laser trabeculoplasty.

Selective laser trabeculoplasty (SLT) has been shown to be safe, well tolerated, and effective in intraocular pressure (IOP) reduction as therapy in several forms of open-angle glaucoma. The preservation of trabecular meshwork (TM) architecture and the demonstrated efficacy in lowering IOP make SLT a reasonable and safe alternative to argon laser trabeculoplasty (ALT). SLT may also be effective for cases of failed ALT and is a procedure that may also be repeatable, unlike ALT. SLT is also a simple technique for an ophthalmologist to learn as the large spot size eliminates the need to locate a particular zone of treatment on the TM. SLT has been demonstrated to be effective as primary treatment for open angle glaucoma and can be an effective adjunct in the early treatment of glaucoma. Furthermore, SLT can be considered as a primary treatment option in patients who cannot tolerate or who are noncompliant with their glaucoma medications, without interfering with the success of future surgery.