Intraocular pressure response to topically administered fluorometholone.

Certain corticosteroids, including fluorometholone, have been reported to have a low propensity for elevating intraocular pressure. Our clinical impression was that the incidence of IOP increase with fluorometholone may be higher than reported. This study was to determine the incidence and degree of IOP response to 0.1% fluorometholone suspension in 43 patients demonstrated to be responsive to 0.1% dexamethasone sodium phosphate solution. Twenty-six patients (60.5%) had IOP increases of 5 mm Hg or more while receiving fluorometholone, and three patients (7%) demonstrated pressure rises greater than 15 mm Hg. Fluorometholone can significantly raise IOP in a significant number of corticosteroid responders.

Betaxolol vs timolol. A six-month double-blind comparison.

Betaxolol hydrochloride (0.5%) and timolol maleate (0.5%) were compared in a six-month randomized, double-blind study involving 29 patients with glaucoma. The two drugs were comparable with regard to efficacy in lowering intraocular pressure. Betaxolol effected an average reduction of 7.6 mm Hg (26%); timolol, 8.4 mm Hg (29%). No patient required adjunctive medications during this study. Ocular side effects were mild and similar for both treatments. Neither drug affected corneal sensitivity, visual acuity, basal tear production, or pupil size. Since betaxolol has been shown to have little effect on the cardiopulmonary system, it should be strongly considered for the treatment of glaucoma.

Evaluation of dexamethasone acetate as a topical ophthalmic formulation.

Penetration of an ophthalmic suspension of 0.1% dexamethasone acetate into the rabbit cornea and aqueous humor was unaffected by the status of the corneal epithelium or by the presence or absence of intraocular inflammation. However, the total quantity of this corticosteroid that could be measured in the cornea or aqueous humor was significantly less than that produced by either dexamethason alcohol or dexamethasone sodium phosphate. Despite this, dexamethasone acetate was the most effective of the three dexamethasone derivatives in suppressing inflammation in the cornea, which indicates that following topical administration to the eye it is the most potent of the dexamethasone derivatives studied. This greater therapeutic effect does not seem to be accompanied by a greater propensity to increase intraocular pressure. Comparison of the intraocular pressureincreasing effect in known corticosteroid responders of dexamethasone acetate with that of dexamethasone sodium phosphate, the least effective of the dexamethasone products studied, demonstrated no difference between the two drugs. These data support the conclusion that dexamethasone acetate is superior to the commercially available dexamethasone derivatives for use as a topical ocular anti-inflammatory agent.

Angle-closure glaucoma in nanophthalmos.

Two patients had nanophthalmos with uveal effusion and angle-closure glaucoma. They were treated with a method based on the use of the laser, not only to perform iridotomy but to shrink the iris stroma, which appears to open the anterior chamber angle even without iridotomy. Additionally, we introduced three factors that may be diagnostic of nanophthalmos.

Periocular cutaneous pigmentary changes associated with topical betaxolol.

PURPOSE: We report two cases of periocular cutaneous hypopigmentation and one case of hyperpigmentation which appeared while the patients were on betaxolol. We propose several possible explanations for this phenomenon. METHODS: Charts of three patients with glaucoma who developed periocular cutaneous pigmentary changes while on betaxolol were reviewed retrospectively. RESULTS: Case #1 was a 47-year-old black man with primary open angle glaucoma, started on betaxolol 0.5% in both eyes in January 1981. Bilateral hypopigmentation of the eyelids was first documented in October 1987. Betaxolol was discontinued in November 1987. In December 1990 the pigmentation had returned to normal. Case #2 was a 4-month-old white boy with unilateral primary infantile glaucoma who was started in September 1992 on betaxolol 0.25% in the left eye. Left lower eyelid hypopigmentation was seen in April 1993. Betaxolol was discontinued in July 1993. Since that time the pigmentation has returned to normal. Case #3 was a 75-year-old black man with primary open angle glaucoma. He was placed on betaxolol 0.5% in both eyes in 1987 and in March 1988 hyperpigmentation of the eyelids was seen bilaterally. Betaxolol was discontinued, and by December 1990 the pigmentation had returned to normal. CONCLUSION: These three case histories suggest that the periocular cutaneous changes described herein are secondary to local instillation of betaxolol.

A modified cyclodialysis spatula.

A cyclodialysis spatula specifically designed for glaucoma surgery is presented which facilitates the performance of the cyclodialysis procedure alone or in combination with cataract extraction and decreases the chance of inadvertent damage to the eye.

Outpatient trabeculectomy.

Eighty trabeculectomies were performed for medically uncontrolled adult phakic primary open angle glaucoma during the past two years. Forty-eight of these trabeculectomies were performed as outpatients and thirty-two of these trabeculectomies were performed as inpatients. We compared the complication rates of inpatients and outpatients during the first two weeks post-op. The results of this study demonstrate that early ambulation and moderate activity did not adversely influence the rate of early postoperative complications following trabeculectomy.

A method of managing flat anterior chamber following trabeculectomy.

A method of injecting an air bubble into a flat anterior chamber (iridocorneal apposition) following trabeculectomy is described. Nine of nine cases have been successfully treated. One case required a second injection of air into the anterior chamber 24 hours after the first air injection. No complications have been noted.

Complications of 10-0 nylon sutures.

Three cases are presented which document the finding that 10-0 monofilament nylon suture may cut through corneal tissue after a coup or contrecoup injury to a recently operated eye. The authors speculate that a larger gauge suture does not have the tendency to cut through recently operated corneal tissue as easily as 10-0 monifilament nylon. The authors recommend the use of a larger gauge suture in closing corneal incisions in persons whom the surgeon feels are at a greater postoperative traumatic risk.

Shell tamponade in filtering surgery for glaucoma.

The glaucoma shell tamponade technique in filtering surgery for glaucoma is a technique for (1) decreasing the incidence of flat anterior chamber and choroidal separation postoperatively, (2) promoting the development of a low diffuse filtration area, and (3) increasing the possibility of achieving very low resulting postoperative pressure. The glaucoma shell technique is applicable to all types of filtration procedures, including conventional filtering procedures utilizing no scleral flap and those utilizing a scleral flap, such as trabeculectomy. It can be used at surgery or can be applied in the postoperative period to deal with flat or shallow anterior chambers immediately at the time of onset. The shell tamponade technique can be utilized to aid in the management of some cases of leaking bleb in the early postoperative period or in the late postoperative period. The technique for operative and postoperative use of the glaucoma shell tamponade technique and its closely related pressure dressing is a demanding and exacting art. Because the technique increases the possibility of very low resulting tensions, its use should be considered especially for cases in which very low pressures are desired, such as some cases of extremely advanced cupping and field loss and low-tension glaucoma.

Pupillary block associated with posterior chamber lenses.

Two patients developed pupillary block glaucoma after extracapsular cataract extraction with implantation of a posterior chamber lens but without peripheral iridectomies. The intraocular pressure of each eye was successfully controlled with laser iridotomy. No long-term medication was necessary to control their intraocular pressures.

Long-term results with the White glaucoma pump-shunt.

A White glaucoma pump-shunt was inserted in 16 eyes in 15 patients, 2 to 76 years of age (10 female and 5 male patients; 6 were white, 6 were black, and 3 were Hispanic). Six had primary open-angle glaucoma, 2 glaucoma in aphakia, 1 congenital glaucoma, 4 secondary glaucoma, 2 neovascular glaucoma, and 1 glaucoma in pseudophakia. There were no complete successes. There were five (31.3%) "qualified successes" (ie, an intraocular pressure less than or equal to 21 mm Hg on medical treatment, without pain, and without visual acuity loss of more than two Snellen lines). This qualified success rate is far below rates reported for other setons.

D-penicillamine and the ocular myasthenic syndrome.

D-penicillamine is a potent drug used to treat rheumatoid arthritis, Wilson's disease and cystinuria. D-penicillamine has recently been found to cause myasthenia gravis in certain susceptible patients. We present a typical case of one patient who developed myasthenia while taking D-penicillamine. The withdrawal of D-penicillamine and the institution of short-term anticholinesterase therapy resulted in the resolution of this disease. The literature is reviewed and attention is focused on the point that all patients who developed myasthenia while undergoing D-penicillamine therapy had ocular symptoms.

A modified Gills' block and its effectiveness for lid muscle akinesia.

We developed a prospective clinical study to determine the effectiveness of a new method of retrobulbar anesthesia and akinesia of the levator and orbicularis muscles. This study involved 50 patients who underwent extracapsular cataract extractions (ECCE) with intraocular lens implant (IOL). We found levator and orbicularis muscle akinesia was achieved in 49 of 50 eyes. One reblock was necessary. We also wish to point out the advantages of this technique as a means of reducing the rare but serious complications associated with retrobulbar anesthesia.

Trabeculectomy with implantation of the Mendez Glaucoma Seton: early results.

We present the early results in a small series of 12 eyes of 12 patients with uncontrolled glaucoma who underwent trabeculectomy with implantation of a Mendez Glaucoma Seton. All eyes, except one with neovascular glaucoma, had had multiple glaucoma surgery and all, without exception, were on maximal tolerated medical therapy prior to surgery. The follow-up period ranged from one and one fourth to three and three fourths months. The surgical technique was the same in all cases. Our success rate was 33.3% or 40%, if one eye with persistent hypotonia could be counted as a success. This result is inferior to those quoted in the literature with the use of other types of setons, and especially to the results of Dr. Antonio Mendez who used a similar implant.

Lidocaine: an anti-tussive for ophthalmic surgery.

Intravenous lidocaine suppresses the cough reflex in patients undergoing local operative procedures. Many anti-tussive agents suppress the cough reflex by suppressing the respiratory center. Intravenous lidocaine produces no respiratory depression in doses that suppress the cough reflex. Intravenous lidocaine should be available during all intraocular surgical procedures so it can be used when indicated.

Trabeculectomy and modifications of trabeculectomy.

Seventy-four trabeculectomies have been reviewed and discussed. Intraocular pressure 20 mm Hg or lower was achieved in 74.2% at the end of six months and in 66% one year postoperatively. The influence of age and sex on postoperative maintainance of intraocular pressure has also been discussed. There was not a statistical difference in results when the sex of the patients were compared. Patients under age forty did poorly in this series as compared to patients over age forty-one. Tenonectomy and cautery to the posterior edges of the scleral flap have been beneficial. The insertion of a gel film or silastic implant under the posterior edge of the scleral flap has been studied but in too few patients to draw any valid conclusions. In general, our results have been satisfactory with very few operative or postoperative complications.

Goniophotocoagulation for neovascular glaucoma.

A new treatment, goniophotocoagulation, for neovascularization of the anterior chamber angle has been applied with the argon laser to 21 eyes of 20 patients. Three of the eyes had neovascularization related to central retinal vein occlusion. In the other 18 eyes the neovascularization was related to diabetic retinopathy. A specific protocol has been followed since January 1973. The results so far indicate that closure of the angle and progression of the usual chain of pathologic events in neovascular glaucoma were prevented in 10 (77%) of the 13 eyes having an average follow-up of 22 months. We believe that goniophotocoagulation of the angle deserves more extensive, judicious, and carefully monitored clinical use. Our results suggest that this new technique is safe and reasonably effective in preventing progressive neovascularization of the angle, synechial closure, and severe nonvascular glaucoma.

Use of steroid/antibiotic prophylaxis in intraocular lens implantation: a double-masked study v placebo.

A prospective, randomized, double-masked study was conducted to compare the efficacy of steroid/antibiotic treatment to placebo in reducing postoperative ocular inflammation. Patients undergoing planned extracapsular cataract extraction with intraocular lens implantation were treated with either placebo or a combination product containing dexamethasone, neomycin, and polymyxin B for three days prior to surgery and three weeks following surgery. Five of thirteen (38%) patients treated with placebo developed significant iritis postoperatively, while none of ten (0%) patients treated with the combination product developed excessive inflammation (P = 0.027). Two patients treated with the steroid/antibiotic combination product experienced a broken suture postoperatively followed by iris prolapse, as compared to none in the placebo group (P greater than 0.10). More types and significant numbers of bacteria were isolated from the eyes of the placebo-treatment group after therapy than were found in the steroid/antibiotic-treatment group.

Norepinephrine dipivalylate dose-response in ocular hypertensive subjects.

Norepinephrine dipivalylate, a prodrug analog of the catecholamine mediator norepinephrine, was given to 12 ocular hypertensive patients. Single instillations of four concentrations, 0.05%, 0.1%, 0.25%, and 0.5%, were administered weekly to one eye only with the fellow eye receiving a placebo. Intraocular pressure, pupil size, ocular signs, subjective symptoms, heart rate, and blood pressure were monitored at 2, 4, 6, 8, and 12 hours following instillation. An intraocular pressure reduction dose response was seen. After a slow (four-hour) onset of activity, the 0.5% concentration produced clinically acceptable (less than 22 mm Hg) tensions at the 6-, 8-, and 12-hour observations which were significantly (p less than 0.05, paired t test) lower than placebo-control eyes. No clinically important side effects were seen.