Intraocular hemorrhage after systemic thrombolytic therapy in a patient with exudative macular degeneration.

PURPOSE: To report a hemorrhagic complication from thrombolytic therapy in a patient with exudative macular degeneration. CASE REPORT: A 75 year old patient with exudative macular degeneration developed pain and loss of vision in the left eye shortly after receiving tissue plasminogen activator (t-PA) for a myocardial infarction. Examination revealed the patient to be in angle closure. A CT scan revealed the etiology of the angle closure to be a dense vitreous hemorrhage pushing the iris-lens diaphragm forward. Intraocular pressure was treated successfully, but the final visual acuity was only light perception. CONCLUSIONS: Thrombolytic therapy can lead to devastating intraocular hemorrhages. The presence of exudative macular degeneration may potentially increase the risk of developing such complications.

Early results of hyperopic and astigmatic laser in situ keratomileusis in eyes with secondary hyperopia.

PURPOSE: To assess the safety and efficacy of laser in situ keratomileusis (LASIK) for secondary hyperopia and hyperopic astigmatism and to develop a VISX STAR S2 LASIK nomogram (VISX Inc., Santa Clara, CA) for consecutive hyperopia after prior myopic refractive surgery. DESIGN: Prospective, nonrandomized, self-controlled interventional study. PARTICIPANTS: Thirty patients with consecutive hyperopia or hyperopia and astigmatism after LASIK, photorefractive keratectomy, automated lamellar keratoplasty, or radial keratotomy. INTERVENTION/METHODS: Prospective evaluation of LASIK in 30 secondary eyes with fogged manifest sphere from +0.5 to +6.0 diopters (D) and cylinder from 0 to +5.0 D. MAIN OUTCOME MEASURES: Uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), and spherical equivalent (SE). RESULTS: Mean manifest SE was +1.73 +/- 0.79 D before surgery, -0.13 +/- 1.00 D at 6 months after surgery, and -0.18 +/- 1.08 D at 1 year after surgery. At 6 months, 84% of patients with secondary hyperopia had UCVA of 20/40 or better; 76% were within +/-1 D of emmetropia. At 1 year, 85% had UCVA of 20/40 or better and 85% were within +/-1 D of emmetropia. No patients with secondary hyperopia lost 2 or more lines of BCVA at 1 year. Complications included intraoperative bleeding (3.3%), intraoperative epithelial defect (3.3%), transient interface debris (3.3%), significant dry eye (3.3%), blood in interface (3.3%), irregular astigmatism (6.7%), slight decentration (6.7%), trace haze (6.7%), or mild epithelial ingrowth not requiring removal (3.3%). CONCLUSIONS: These early data suggest that LASIK for consecutive hyperopia from +0.5 to +5.50 D and astigmatism from 0 to +2.75 D using the VISX STAR S2 benefits from a nomogram adjusted for preoperative refraction, age, and prior refractive surgery, and is safe and effective.

Evaluation of giant-cell deposits on foldable intraocular lenses after combined cataract and glaucoma surgery.

PURPOSE: To compare the incidence of inflammatory giant-cell deposits (IGCDs) on various foldable intraocular lenses (IOLs) after combined cataract and glaucoma surgery. SETTING: The Phillips Eye Institute, Minneapolis, Minnesota, USA. METHODS: In this prospective randomized clinical trial, 128 patients were randomized to receive a single-piece, first-generation silicone lens (n = 36); a 3-piece acrylic lens (n = 40); or 3-piece, second-generation silicone lens (n = 52). All patients had combined phacoemulsification and trabeculectomy with mitomycin-C by 1 surgeon using a standardized technique. Dilated biomicroscopy was used to identify and quantitate IGCDs on the surface of the IOLs using a 6-point grading scale. RESULTS: Inflammatory giant-cell deposits were identified on 21 of 128 IOLs. Lens design was the most significant risk factor for deposit formation (P =.004). Inflammatory giant-cell deposits were most common in the first-generation silicone plate lens group (33%), less common in the acrylic lens group (15%), and least common in the 3-piece, second-generation silicone group (5.8%). Density of the deposits was significantly greater on the plate lens than the acrylic or the 3-piece silicone lenses (P <.0001). Although IOL design was the most significant risk factor for IGCD formation, other significant risk factors included intraoperative pupil stretch (P =.02) and preoperative miotic use (P =.04). CONCLUSION: Inflammatory giant-cell deposit formation was significantly greater on first-generation silicone plate IOLs than on acrylic or second-generation silicone IOLs. The deposits were somewhat more common on acrylic IOLs than on second-generation silicone IOLs. However, this difference was not clinically or statistically significant.

Comparison of brimonidine with latanoprost in the adjunctive treatment of glaucoma. ALPHAGAN/XALATAN Study Group.

OBJECTIVE: This study compared brimonidine with latanoprost as adjunctive therapy for the treatment of open-angle glaucoma and ocular hypertension. BACKGROUND: Patients with open-angle glaucoma or ocular hypertension often require >1 medication to achieve control of intraocular pressure (IOP). Both brimonidine and latanoprost effectively lower IOP, but no previously reported clinical trials have directly compared these agents as adjunctive therapy. METHODS: This was a prospective, randomized, investigator-masked, multicenter, parallel-design clinical trial. Forty patients (69 study eyes) with uncontrolled IOP of < or =34 mm Hg while using a topical beta-blocker plus dorzolamide or pilocarpine were randomly assigned to receive either brimonidine 0.2% BID or latanoprost 0.005% QD over 6 months as adjunctive therapy. Tolerability was assessed by reports of adverse events, and efficacy was determined by reduction in IOP from baseline. Clinical success was defined as the achievement of a > or =15% reduction in IOP from baseline. RESULTS: There were no significant between-group differences in any demographic variable. Most patients in each group were white, had open-angle glaucoma, and were being treated with a nonselective beta-blocker and dorzolamide. When brimonidine or latanoprost was used as an adjunctive agent with a beta-blocker and dorzolamide or pilocarpine, the rates of clinical success at month 1 were 85% (17/20 patients) with brimonidine versus 65% (13/20 patients) with latanoprost (P = 0.144). Overall mean IOP reduction at month 1 was 4.60+/-0.62 mm Hg (22.8%; P < 0.001) with brimonidine and 3.43+/-0.62 mm Hg (17.2%; P < 0.001) with latanoprost, with no significant differences between groups (P = 0.219). Among the patients with an inadequate IOP-lowering response (<15% reduction from baseline), the mean IOP reduction was 0.36+/-0.66 mm Hg with latanoprost (n = 7) and 0.50+/-2.18 mm Hg with brimonidine (n = 3). Brimonidine and latanoprost had comparable IOP-lowering efficacy in patients receiving concomitant pilocarpine therapy (mean change in IOP of -4.23 mm Hg vs -3.75 mm Hg, P = 0.173). In patients concurrently treated with dorzolamide, brimonidine produced a mean change in IOP of -5.29 mm Hg, compared with a mean change of -3.21 mm Hg in the latanoprost group (P = 0.159). Both brimonidine and latanoprost were well tolerated. Few adverse events leading to discontinuation were observed with either drug regimen (n = 2 with brimonidine; n = 0 with latanoprost). CONCLUSIONS: Both brimonidine 0.2% BID and latanoprost 0.005% QD were well-tolerated and reduced IOP in most patients when used as third-line adjunctive therapy. However, clinical success was achieved by 17 of 20 patients (85%) who received brimonidine, compared with 13 of 20 patients (65%) who received latanoprost (P = 0.144). These results suggest that brimonidine 0.2% BID may be more reliable than latanoprost 0.005% QD as adjunctive therapy for glaucoma and ocular hypertension.

Management of coincident glaucoma and cataract.

Phacoemulsification for visually significant cataract and trabeculectomy for uncontrolled glaucoma are two of the most commonly performed ophthalmic surgeries. Many articles pertaining to cataract extraction in the glaucoma patient have been published during the 1-year scanning period of this periodical. This discussion reviews the recent literature as it pertains to the management of coincident cataract and glaucoma. Important topics addressed by the recent literature include long-standing controversies such as limbus-based versus fornix-based approaches to trabeculectomy and one-site versus two-site approaches to combined surgery, as well as innovative techniques in cataract and glaucoma surgery. This article also addresses perhaps the most controversial issue with regard to coincident cataract and glaucoma surgery, that is, the indications for the procedure. It should be noted that this article is not a comprehensive review but rather discusses the literature published within the 1-year scanning period.

Six-month results of hyperopic and astigmatic LASIK in eyes with primary and secondary hyperopia.

PURPOSE: To assess the safety and efficacy of laser in situ keratomileusis (LASIK) for hyperopia and hyperopic astigmatism and develop a LASIK nomogram for primary hyperopia or hyperopia secondary to myopic refractive surgery using the VISX STAR S2. METHODS: Prospective evaluation of LASIK in 46 primary eyes and 29 secondary eyes with fogged manifest sphere from +0.5 diopters (D) to +6.0 D and cylinder from 0 to +5.0 D. RESULTS: Mean manifest spherical equivalent (SE) in patients with primary hyperopia was +2.50 D +/- 0.93 preoperatively and +0.70 D +/- 1.19 at 6 months. At 6 months, 79% of primary hyperopes had uncorrected visual acuity (UCVA) of 20/40 or better; 63% were within +/- 1 D of emmetropia. One primary hyperope lost 2 lines of best spectacle-corrected vision (BCVA) at 1 month. Complications included transient epithelial defect (6.5%), epithelial cells in the interface (4.3%), diffuse lamellar keratitis (4.3%), haze (2.2%), and mild irregular astigmatism (2.2%). In those with secondary hyperopia, mean manifest SE was +1.70 D +/- 0.82 preoperatively and -0.27 D +/- 0.95 at 6 months. At 6 months, 83% of secondary hyperopes had UCVA of 20/40 or better; 74% were within +/- 1 D of emmetropia. No secondary hyperope lost > or = 2 lines of BCVA. Complications included intraoperative bleeding (3.4%), intraoperative epithelial defect (3.4%), transient interface debris (3.4%), significant dry eye (3.4%), blood in interface (3.4%), irregular astigmatism (6.9%), slight decentration (6.9%), trace haze (6.9%), mild epithelial ingrowth not requiring removal (3.4%), or corneal irregularity (3.4%). CONCLUSION: These early data suggest that LASIK for hyperopia from +0.5 to +6 D and astigmatism from 0 to +5 D using the VISX STAR S2 benefits from a nomogram adjusted for preoperative refraction, age, and prior refractive surgery and is safe and effective. Patients with secondary hyperopia achieved more correction than those with primary hyperopia, although the accuracy and predictability of LASIK in both groups has improved with the nomogram adjustments.

Management of coincident cataract and glaucoma.

Combined phacoemulsification and trabeculectomy has become a common procedure in the management of coincident cataract and glaucoma. As the medical options to treat glaucoma continue to improve, more patients may not require surgical intervention until the time of cataract extraction. Current techniques using small-incision phacoemulsification and trabeculectomy with antimetabolites have vastly improved the results of combined glaucoma surgery. This article discusses many of the important issues as they relate to this subject. This is not a comprehensive review, but rather a discussion of the literature in the scanning period of this issue.

Surgical management of coincident cataract and glaucoma.

Surgical management of coincident cataract and glaucoma has become very common for ophthalmic surgeons. As the medical options continue to improve, many patients with glaucoma do not require surgical intervention until the time of cataract extraction. Therefore, combined glaucoma procedures are becoming increasingly common. With the advent of small-incision phacoemulsification and trabeculectomy with releasable sutures and antimetabolites, techniques have improved considerably in the recent decade. This article discusses many of the important topics as they relate to this subject. It is not a comprehensive review, but rather discusses the literature over the scanning period of this periodical.

Early successful treatment of postoperative necrotizing pseudomonas scleritis after trabeculectomy.

PURPOSE: The authors describe a patient who developed pseudomonas scleritis after a routine trabeculectomy. METHOD: The patient underwent trabeculectomy for poorly controlled intraocular pressure and progressive visual field loss. On the second postoperative date he developed severe pain, significant anterior chamber reaction, and hypotony. Scleral cultures taken at the time of surgical choroidal drainage grew pseudomonas aeruginosa. RESULT: Surgical reconstruction of the necrotic scleral area and intensive antibiotic treatment lead to a successful outcome. CONCLUSION: Early recognition and aggressive treatment with antibiotics initially, followed by surgical debridement of necrotic tissue, resulted in an unexpected successful outcome in a patient with pseudomonas scleritis.

Management of coincident glaucoma and cataract.

Cataract and glaucoma are two very common conditions that frequently are coincident within the same patient. The surgical treatment of the patient with both cataract and glaucoma has changed considerably in the era of small-incision cataract surgery. Additionally, many surgeons are employing antimetabolites routinely in combined phacoemulsification and trabeculectomy. This article reviews the literature as it pertains to combined cataract and glaucoma surgery within the 1-year scanning period. This is not a comprehensive review in that many very important articles are excluded because they were published either before or after the scanning period. The important topics included within this article involve the use of mitomycin C in combined surgery, the comparison of combined phacoemulsification and combined standard extracapsular procedures, long-term results of combined cataract and glaucoma surgery, the survival of filtration blebs after cataract extraction in eyes that had previous trabeculectomy, new techniques of combined surgery including clear corneal cataract extraction combined with trabeculectomy, and the effect of phacoemulsification on intraocular pressure in patients with and without glaucoma.

Management of coincident glaucoma and cataract.

The glaucoma combined procedure continues to evolve and improve. The use of antimetabolites as pharmacologic modulators of wound healing in conjunction with argon laser suture lysis and small-incision phacoemulsification techniques has revolutionized the glaucoma combined procedure. This discussion describes the current trends in the management of coincident glaucoma and cataract. The literature from the past year is reviewed with respect to this important topic. The role of antimetabolites in combined glaucoma surgery, the implications of the pseudoexfoliation syndrome, and the various options available for small pupil phacoemulsification are addressed. The intention is not to provide a comprehensive review of this topic but to discuss current opinion on the various issues that have been addressed in literature during the past year.

Focal and diffuse visual field defects: their relationship to intraocular pressure.

The view that visual field loss in "low-tension" glaucoma (LTG) is more focal than in ordinary or "high-tension" glaucoma (HTG) is controversial. The basis of the controversy may be the inappropriate presupposition that an arbitrary intraocular pressure (IOP) level effectively differentiates these entities. We attempted to determine whether meaningful differences exist between glaucoma patients classified on the basis of pattern of visual field loss rather than IOP. One hundred consecutive glaucomatous visual fields were classified as focal or diffuse by two independent observers masked to all other clinical information. Several clinical parameters were then evaluated, comparing patients with focal visual field loss, with those with diffuse loss. Maximal pretreatment IOP was significantly lower among the patients with focal visual field loss than it was among those with diffuse loss (21.5 mm Hg +/- 5.7 vs 25.9 mm Hg +/- 4.7; P < .01). There was no difference between the two groups in terms of age, blood pressure, visual acuity, or color vision. We conclude that focal glaucomatous visual field loss occurs at a lower IOP than diffuse loss and, as such, may be a marker by which to identify patients whose optic nerves are abnormally susceptible to glaucomatous injury.

Management of coincident cataract and glaucoma.

The management of patients with coincident cataract and glaucoma is a common and challenging clinical problem. Recent technologic advances in both cataract and glaucoma surgery have made the combined procedure a more viable option than in the past. The use of small-incision cataract surgery and trabeculectomy with antimetabolites performed beneath a 4-mm scleral flap with a limbus-based conjunctival flap and releasable or laserable sutures have resulted in a combined procedure that can closely mimic the standard trabeculectomy in terms of surgical methods. This discussion reviews many of the pertinent articles that have appeared in the literature during the scanning period and that address the management of combined cataract and glaucoma. The intention is not to provide a comprehensive review of this important topic but to discuss present opinions on issues such as antimetabolites, small-pupil phacoemulsification, sutured lenses, and the pseudoexfoliation syndrome as they relate to the combined glaucoma procedure.

Zygomaticofrontal suture defect associated with orbital dermoid cyst.

The zygomaticofrontal suture is a strong joint needed for protection of the orbit. During infancy its development can be altered by local mechanical factors which prevent its complete union. The following case report of a man with a slowly growing lesion of the left orbit was found to have a large dermoid cyst communicating with the temporal fossa. Presumably, the presence of choristomatous tissue at the junction of the zygomatic and frontal bones prevented normal closure of the joint during infancy. The computed tomographic findings in this condition are pathognomonic of dermoid cyst.