Mean Final Intraocular Pressure Research Articles

LONG-TERM TRENDS IN INTRAOCULAR PRESSURE AFTER PARS PLANA VITRECTOMY

To evaluate the effect of vitrectomy on intraocular pressure (IOP). Retrospective cohort study. Medical records of 101 eyes of 101 patients undergoing nonemergent vitrectomy were reviewed for rates of open-angle glaucoma, increased IOP of >4 mmHg from baseline, change in IOP from baseline, and cataract formation. Preoperative and last measured IOPs were recorded. Baseline risk characteristics including lens status and diabetes were analyzed. Main outcome measures were 1) incidence of open-angle glaucoma; 2) increase in IOP of >4 mmHg; and 3) change in IOP. Mean follow-up was 49 months (range, 12-105 months). Mean baseline IOP was 15.3 mmHg, and mean final IOP was 15.8 mmHg (P = 0.3). At the most recent examination, 35 study eyes had a decrease in IOP from baseline, while 14 eyes had no change and 52 eyes had an increase in IOP. Four study eyes were newly diagnosed with ocular hypertension. No study eye developed open-angle glaucoma or required medical, laser, or surgical treatment for glaucoma. Incidence of increased IOP of >4 was 7% at 4 years and 34% at 8 years. Subgroup analysis of 66 patients comparing study eyes with nonvitrectomized fellow eyes demonstrated no significant difference in rates of increased IOP of >4 (P = 0.85). Neither diabetes nor pseudophakia was associated with significantly increased IOP. In this series, vitrectomy does not appear to increase IOP even after removal of the crystalline lens.

Cataract surgery in the first year of life: aphakic glaucoma and visual outcomes

Objective: To report the incidence of aphakic glaucoma following lensectomy in infants in their first year of life and examine the impact of this diagnosis on visual outcome. Design: Retrospective cohort study. Participants: All patients who had lensectomy for congenital cataract during the first year of life at British Columbia Children’s Hospital between 1995 and 2006. Methods: Retrospective review of medical records. Results: Seventy-five eyes of 46 patients (29 bilateral, 17 unilateral) were included. The mean age at lensectomy was 93 days (range, 2–364 days) with a mean follow-up of 77.5 months (range, 36–166 months). Patients with bilateral cataracts had a better visual outcome than those with unilateral cataracts ( p = 0.032). Of the patients with measurable visual acuity (VA), 34 of 45 eyes (75.6%) with bilateral cataracts and only 3 of 16 eyes (18.8%) with unilateral cataract achieved a VA of 20/40 or better. Eighteen of 75 eyes (24%) developed aphakic glaucoma at a mean of 30 months following lensectomy. Nine patients (50%) achieved final vision of 20/40 or better. The development of aphakic glaucoma was not associated with worse visual outcomes ( p = 0.315). The mean intraocular pressure (IOP) at diagnosis was 28.6 ± 5.9 mm Hg and mean final IOP was 14.1 ± 3.0 mm Hg, a significant reduction ( p > 0.0001). Fifteen of 18 eyes with aphakic glaucoma (83.3%) required surgical intervention to achieve IOP control. Conclusions: Children with aphakic glaucoma may have good visual outcomes if it is recognized early and managed appropriately. A significant proportion of patients required surgical intervention to control IOP.

Surgical treatment for 42 patients with traumatic annular ciliochoroidal detachment.

To analyze the clinical features of traumatic annular ciliochoroidal detachment (CCD) with ultrasound biomicroscopy (UBM) images, to investigate the surgical outcomes of ciliary body suturing and the prognostic factors. Forty-two patients with traumatic annular CCD who had undergone ciliary body suturing were enrolled for complete ocular examinations, including visual acuity (VA), slitlamp microscopy, tonometer, indirect ophthalscopy and UBM. Comparisons of clinical features were performed among baseline and follow-ups, and the morphologic alterations on UBM images were analyzed between pre- and post-surgery. The mean intraocular pressure (IOP) was 5.54mmHg, and the median VA was 0.1 in traumatic eyes at baseline. The pre-surgical morphological features on UBM images consisted of supraciliochoroidal effusion (33.33%), multilayer splits (40.48%) and CCD with cyclodialysis cleft (26.19%). After surgery, the median VA was 0.4 at the final follow-up. IOPs were significantly increased, which the mean final IOP was to 10.36mmHg (P<0.01). UBM images displayed complete reattachment in 40.48% of patients, partial reattachment in 50.00% of patients and 360-degree detachment in 9.52% of patients. Analyzing the prognostic factors, the significant factors were duration, VA at baseline, ocular laterality (P<0.01), gender, age and the presence of hypotonous maculopathy (P<0.05). Ciliary body suturing is the optimized procedure for traumatic annular CCD. UBM is a useful equipment for diagnosis and monitoring post-surgical morphological changes. The periodical detection of IOP and UBM is necessary for the observation of surgical outcomes.

Surgical outcomes with 360-degree suture trabeculotomy in poor-prognosis primary congenital glaucoma and glaucoma associated with congenital anomalies or cataract surgery

To evaluate the outcomes of 360-degree suture trabeculotomy in childhood glaucoma with poor prognosis. A nonrandomized, retrospective chart review was performed on pediatric patients (younger than 18 years of age) treated with a 360-degree suture trabeculotomy for glaucoma. The cases were categorized into the following groups: (1) primary congenital glaucoma with birth-onset presentation accompanied by corneal clouding noted at birth, (2) primary congenital glaucoma with onset or presentation after 1 year of age, (3) primary congenital glaucoma with previous failed goniotomy surgery, (4) infantile-onset glaucoma following congenital cataract surgery, and (5) infantile-onset glaucoma with associated ocular/systemic anomalies. A total of 45 eyes of 33 patients were analyzed. The mean preoperative intraocular pressure (IOP) was 34.3±6.7 mm Hg on an average of 1.5 medications. Median age at time of surgery was 7 months. Mean final IOP (median last follow-up or failure, 12 months) was 22.2±7.1 mm Hg on an average of 1.5 medications. The probability of success according to time after surgery was 87% at 6 months, 63% at 1 year, and 58% at 2 years. Kaplan-Meier analysis of Groups 1-4 versus Group 5 failed to demonstrate a statistically significant difference (p=0.13). Of 5 eyes with port wine mark-related glaucoma, 2 had a large (>50%), persistent postoperative hyphema, and concurrent vitreous hemorrhage. Children with a range of ocular pathologies can be successfully treated with 360-degree suture trabeculotomy. Further evaluation of this surgical technique in primary congenital glaucoma and open-angle glaucoma following congenital cataract surgery is warranted.

Measurement of treatment compliance using a medical device for glaucoma patients associated with intraocular pressure control: a survey.

To identify and characterize treatment compliance profiles of glaucoma patients and evaluate the association with intraocular pressure (IOP). A computerized device (Travalert((R))) that recorded daily instillation times and eye-drop counts was given for 3 months. Patients were declared compliant when at least 2 drops were instilled per day. Compliance rates were calculated for weekdays and weekends, separately, over 8 consecutive weeks. A principal components analysis (PCA) was followed by an ascendant hierarchical classification (AHC) to identify compliance groups. 140 patients were recruited (mean age 65.5 years; 51.8% female) of whom 83.6% had primary open-angle glaucoma with mean IOP 23.9 mmHg before Travalert((R)) use. 60.7% were treated with DuoTrav((R)) (travoprost timolol fixed combination) and 39.3% with travoprost. The PCA identified two axes (compliance and treatment weeks). The AHC identified 3 compliance groups: 'high' (56.6%, approx. 80% compliance), 'medium' (21.2%, approx. 50% compliance), and 'low' (22.1%, approx. 20% compliance). Demographics and glaucoma parameters did not predict low compliance. Final mean IOP was 16.1 mmHg, but higher in the low compliance group (17.7 mmHg, P = 0.02). Compliance measurement by a medical device showed compliance rates <80% by 50% (approx.) of patients, significantly impacting IOP control. No demographic or glaucoma variable was associated with low compliance.

Intraocular pressure reduction after phacoemulsification with intraocular lens implantation in glaucomatous and nonglaucomatous eyes: Evaluation of a causal relationship between the natural lens and open-angle glaucoma

To study the long-term effects of phacoemulsification with intraocular lens (IOL) implantation in nonglaucomatous and glaucomatous eyes. Phillips Eye Institute, Minneapolis, Minnesota, and private practice, Savannah, Georgia, USA. Intraocular pressure (IOP) after phacoemulsification with IOL implantation was retrospectively reviewed. Eyes were divided into 5 groups by preoperative IOP. Data were recorded preoperatively, 1 year postoperatively, and at the final check. Analysis included preoperative IOP versus IOP at 1 year and final IOP, percentage of eyes with elevated or reduced IOP postoperatively, patient age at surgery, and years of postoperative follow-up. The study comprised 124 eyes. The final mean IOP reduction was 8.5 mm Hg (34%) in the 29 to 23 mm Hg group, 4.6 mm Hg (22%) in the 22 to 20 mm Hg group, 3.4 mm Hg (18%) in the 19 to 18 mm Hg group, and 1.1 mm Hg (10%) in the 17 to 15 mm Hg group. In the 14 to 5 mm Hg group, IOP increased by 1.7 mm Hg (15%). Intraocular pressure reduction was proportional to preoperative IOP; the highest preoperative IOPs decreased the most and the lowest increased slightly. One-year IOP reductions were sustained for 10 years and were similar in patients of all ages. The IOP reductions were similar to previously reported reductions in nonglaucomatous eyes, indicating that the aging crystalline lens may be a major cause of ocular hypertension and glaucoma and that phacoemulsification with IOL implantation may help prevent and treat adult glaucoma.

Phaco‐microtrabeculectomy: technique and intraocular pressure control in comparison with microtrabeculectomy

To describe a modified technique for combined cataract and glaucoma drainage surgery involving a small flap (micro) trabeculectomy combined with phaco-emulsification (PMT). To assess the level of intraocular pressure (IOP) control achieved by this procedure in comparison with microtrabeculectomy (MT) alone. In this retrospective controlled case series records were reviewed for 37 consecutive low-risk patients undergoing PMT augmented with 5-fluorouracil (5-FU) and 37 low-risk subjects undergoing MT with 5-FU. IOP control was compared by survival analysis using IOP targets < or = 21 mmHg and < or = 16 mmHg at final follow up and with at least a 25% reduction from the preoperative pressure. Mean follow up was 41.7 months (range 19.0-72.0) in the PMT group and 43.5 months (range 18.0-66.0) in the MT group. A final IOP < or = 21 mmHg and with at least a 25% reduction from the preoperative pressure was achieved in 91.9% patients undergoing PMT (70.3% on no glaucoma drops). IOP < or = 16 mmHg and with at least a 25% reduction from the preoperative pressure was achieved in 67.6% (56.8% without drops). There were no significant differences in survival rates between PMT and MT for either IOP target. The mean final IOPs were 13.4 and 13.5 mmHg on a mean of 0.6 and 0.8 glaucoma drops in the PMT and MT groups, respectively. In the PMT final visual acuity improved by at least one Snellen line in 81.1% and was worse in a single eye. IOP control following combined surgery by PMT is as good as following MT alone.

To compare argon laser peripheral iridoplasty (ALPI) against systemic medications in treatment of acute primary angle-closure: mid-term results

To compare the clinical outcome of argon laser peripheral iridoplasty (ALPI) against systemic medications in treatment of acute primary angle-closure (APAC). Consecutive patients with APAC were recruited and randomized to receive one of two treatment options: immediate ALPI or systemic acetazolamide +/- mannitol. All eyes were followed up for at least 6 months after laser iridotomy. Main outcome measures were intraocular pressure (IOP) and requirement for glaucoma medications. A total of 41 eyes (39 patients) were randomized into the ALPI group, and 38 eyes (32 patients) into the medical treatment group. There were no significant differences between the two groups in sex, age, presenting IOP, and duration of attack. Mean follow-up duration +/- SD was 15.7 +/- 5.8 months. There were no significant differences between the two groups in mean final IOP and requirement for glaucoma medications. There were no statistically significant differences in mean IOP and requirement for glaucoma drugs between APAC eyes treated with ALPI and systemic medications.

Protocol for mitomycin C use in glaucoma surgery

To evaluate the results of a protocol described for mitomycin C (MMC) use in trabeculectomy or combined surgery (phacoemulsification and trabeculectomy). A total of 143 eyes (60 trabeculectomies and 83 combined surgeries) of 124 patients were divided into four groups: group 1 (without MMC); group 2 (with 0.1 mg/ml MMC); group 3 (with 0.2 mg/ml MMC), and group 4 (with 0.4 mg/ml MMC). Two-minute MMC was used in every case in groups 2, 3 and 4. The results were analysed after 1 year of follow-up. Intraocular pressure (IOP) and complications were evaluated. Successful IOP control was defined when IOP was <21 mmHg and <16 mmHg if advanced glaucoma was present, always without additional medical treatment. Mean preoperative IOP decreased from 24.60 mmHg (SD 1.40 mmHg) to 13.47 mmHg (SD 0.37 mmHg) (p < 0.00001), 12 months postoperatively. Control in IOP was achieved in 79.02% of eyes. No significant differences were found in final mean IOP values (p > 0.196) or in postoperative complications (p > 0.120) in groups 2, 3 and 4. With the protocol described, a selection of concentration of MMC has been made in different clinical forms of glaucoma. No significant differences in IOP control and postoperative complications were noticed among the groups.

Resultados pressóricos da esclerectomia profunda não penetrante no tratamento do glaucoma primário de ângulo aberto

OBJETIVO: O presente estudo tem como objetivo avaliar a eficacia, por meio da analise de seus resultados pressoricos, da esclerectomia profunda nao penetrante para tratamento cirurgico do glaucoma primario de ângulo aberto. METODOS: Estudo retrospectivo de 104 olhos operados pela tecnica de esclerectomia profunda nao penetrante de 1999 a 2002. Nos casos em que havia risco para falencia da bolsa filtrante (idade inferior a 45 anos, negros, cirurgia ocular previa) a mitomicina C foi utilizada. A analise dos resultados foi feita avaliando-se a pressao intra-ocular final. A taxa de sucesso foi calculada para toda a populacao e separando os grupos com e sem utilizacao de mitomicina C. RESULTADO: Para uma pressao intra-ocular pre-operatoria media de 22,57±4,92 mmHg, os autores encontraram uma pressao intra-ocular pos-operatoria media de 14,22±2,89 mmHg com tempo medio de acompanhamento de 19,4 meses. A mitomicina C foi utilizada em 80 olhos. O sucesso absoluto (pressao <18 mmHg sem medicacao) para a populacao estudada foi de 82,7%. A taxa de sobrevida ao final de 3 anos foi de 79,3% para o grupo com mitomicina C e de 67,9% para o grupo sem mitomicina C. CONCLUSAO: Embora haja ainda falta de estudos prospectivos randomizados para se avaliar o real valor desta modalidade cirurgica, estes resultados demonstram sua eficacia a longo prazo.

Bleb revision for hypotony maculopathy after trabeculectomy.

To assess the efficacy of a bleb revision technique with regard to improvement in intraocular pressure (IOP) and visual acuity after hypotony maculopathy and to evaluate the influence of duration of hypotony on visual outcome. : Retrospective review of a series of patients who underwent bleb revision for hypotony maculopathy (IOP less than 6 mm Hg and loss of two or more lines of central vision) following trabeculectomy. Bleb revision included excision of avascular bleb tissue, dissection posteriorly between conjunctiva and Tenon's capsule, and advancement and suturing of the conjunctiva at the limbus. Fourteen patients were included in the study. The average age was 49.8 years (range 18-85) and eight were female. Before trabeculectomy, the mean IOP was 23.2 +/- 11.8 mm Hg, and the visual acuity was 20/30-2 or better in 13 patients and 20/80 in one patient. The mean IOP before bleb revision was 1.07 +/- 0.73 mm Hg, and 12 patients had lost an average of 4.33 +/- 2.96 lines of visual acuity from baseline, while one had count fingers and another had hand motion vision. The final mean IOP after bleb revision was 11.07 +/- 3.08 mm Hg. Compared with visual acuity just prior to bleb revision, 12 patients regained an average best corrected vision of 3.08 +/- 2.67 lines, with seven returning to the pre-trabeculectomy vision level. The duration of hypotony prior to bleb revision was 1 to 24 months (average 8.36 months) with no correlation (correlation coefficient -0.13) between duration and visual outcome. Bleb revision for hypotony maculopathy following trabeculectomy is an effective technique for raising IOP and limiting visual loss, which is not influenced by duration of hypotony within the time frame of the study.

Vitreoretinal surgery for retained lens fragments after phacoemulsification.

To evaluate the prognostic factors, effect of timing and outcomes of vitreoretinal surgery for removal of retained lens fragments after phacoemulsification. A retrospective review of 43 eyes of 43 patients who had vitreoretinal surgery for retained lens fragments after phacoemulsification, between January 1998 and November 2000. Seven of the 43 patients underwent vitrectomy on the same day as cataract surgery, 20 in the first week, and 23 after the first week, with a mean of 14.8 days (0-90). Initial visual acuity was < or = 20/400 in 27 (75%, n=36) and intraocular pressure (IOP) > or = 25 mmHg in 22 (61%, n=36) eyes with or without medication. The mean preoperative IOP was 27.4 mmHg. Initial ocular findings included moderate or severe corneal edema in 17 patients (40%), uveitis in 14 (33%), retinal detachment in 1 (2%) and vitreous hemorrhage in 2 (5%). After a mean follow-up of 8.4 months, final best-corrected visual acuity (BCVA) was > or = 20/40 in 24 patients (56%) and < or = 20/400 in 7 (16%). Persistent corneal edema (one eye), cystoid macular edema (four eyes), age-related macular degeneration (one eye) and suprachoroidal hemorrhage (one eye) were the causes of BCVA < or = 20/400. Final mean IOP was 15.2 mmHg and only one case had IOP > 25 mmHg. Uveitis disappeared in all cases (p<0.001), and corneal edema persisted in only one eye. Both the BCVA and IOP differences were significant (p<0.001), but no correlation was found between pre- and postoperative BCVA and IOP as regards vitreoretinal surgery timing, posterior or anterior removal sites and IOL implantation sites or procedures. Vitreoretinal surgery is effective for removing retained lens fragments after phacoemulsification, lowering the IOP and reducing the uveitic reaction and corneal edema. BCVA > or = 20/40 can be reached in at least half the patients.

A Comparative Study of Small Incision Trabeculectomy Avoiding Tenon's Capsule With Conventional Trabeculectomy

The purpose of this study was to compare the results of small incision trabeculectomy (SIT) avoiding Tenon's capsule vis-à-vis conventional trabeculectomy, and find a safe, effective alternative to conventional trabeculectomy with or without pharmacological wound modulation. A controlled prospective study was conducted on 80 consecutive open-angle glaucoma patients requiring glaucoma filtration surgery. They were divided into two groups: Group I (n = 40): patients undergoing conventional trabeculectomy; and Group II (n = 40): patients undergoing limbal approach SIT. Patients were followed up serially for a minimum of 12 months and their intraocular pressure was monitored. Success of the procedure was defined as an intraocular pressure (IOP) <22 mm Hg with no additional antiglaucoma medication or surgery, and achieving at least a 30% reduction from the initial IOP at which optic disc cupping and/or visual field changes occurred. A significant fall (P <0.0001) in the final mean IOP was present in both groups at all time intervals in comparison to their preoperative values. The final mean intraocular pressure achieved with conventional trabeculectomy was 18.90 +/- 4.86 mm Hg versus 16.60 +/- 5.93 mm Hg with SIT. The final success rate of 90% was obtained with SIT vs 80% with conventional trabeculectomy. No major complications were encountered with either procedure although complications such as shallow anterior chamber and progression of cataractogenesis were seen more often in patients undergoing conventional trabeculectomy. Small incision trabeculectomy avoiding Tenon's capsule is a low-cost and safe alternative to conventional trabeculectomy that effectively reduces IOP in 90% of cases. The use of a small 2.5 mm limbal incision, which obviates the dissection of Tenon's capsule and absence of any major complication, suggests that this procedure be used more often in glaucomatous eyes needing filtering surgery.

Persistent hypotony after primary trabeculectomy with mitomycin C

Purpose: To describe the clinical findings and treatment modalities of persistent hypotony following primary trabeculectomy with mitomycin C. Methods: We retrospectively analyzed 9 eyes with persistent hypotony, which was defined as intraocular pressure less than or equal to 5 mmHg for more than 2 months. Results: Mean hypotony duration was 7.4 months (standard deviation (SD) ± 6.7 months, range 2 to 23 months). Associated findings included choroidal detachment (2 eyes) and maculopathy (5 eyes). All patients who developed maculopathy were relatively young (mean age = 37 years old, SD ± 16, range 18 to 79 years). Treatments included bandaged contact lens, autologous blood injection, phacoemulsification, resuturing of the scleral flap, scleral patch graft, and Simmons' shell. After treatment, intraocular pressure (IOP) raised in all patients (mean final IOP = 11.1 mmHg, SD ± 3.5). On the first day of hypotony, the mean IOP was 3 mmHg (SD ±1.7). At the last follow up, visual acuity (VA) was unchanged in 3 eyes, worsened in 2 eyes (by 2 Snellen lines), and improved (by 1 to 4 Snellen lines) in 4 eyes. Of those eyes whose VA improved, 3 had undergone phacoemulsification. Conclusion: Hypotony after trabeculectomy with mitomycin C can be reversed with possible improvement in vision.

Shunt revision versus additional tube shunt implantation after failed tube shunt surgery in refractory glaucoma

PURPOSE: To compare tube shunt revision with additional tube shunt after failed tube shunt surgery. METHODS: We identified 281 patients who underwent a primary tube shunt procedure from 1985 to 1998 at Indiana University and reviewed 33 eyes of 33 patients that had failed and required further surgery. Shunt revision was performed in 12, whereas an additional shunt was placed in 21 eyes. Intraocular pressure, antiglaucoma medications, visual acuity, and complications were noted. Success was defined as at least a 25% reduction in intraocular pressure that was deemed clinically adequate. Qualified success was defined as a 25% intraocular pressure reduction but with additional medications or a significant reduction in medications with stable intraocular pressure for preoperative intraocular pressure less than 21 mm Hg. RESULTS: Preoperative intraocular pressures (mean ± 95% confidence interval) for the revision and additional tube groups were 28.8 ± 5.8 mm Hg and 29.8 ± 2.7 mm Hg ( P = .73), with an average follow-up period of 25.2 months (range, 3 to 108 months) and 34.8 months (range, 6 to 84 months), respectively. Final mean intraocular pressure was 25.3 ± 6.7 mm Hg for the revision group and 17.7 ± 3.4 mm Hg for the additional tube group ( P = .037). Forty-two percent in the revision group versus 62% in the additional tube group achieved at least a qualified success ( P = .30, Fisher exact test). Corneal edema was a common complication, especially in the additional tube group. Limitations of this study include the small sample sizes and the uneven distribution of neovascular glaucoma between the two groups (six of 12 in the revision group vs two of 21 in the additional tube group; P = .015, Fisher exact test). CONCLUSIONS: Our series showed that after failed tube shunt surgery, an additional tube shunt offers better intraocular pressure control than revision by excision of an encapsulated bleb.

Aqueous misdirection after glaucoma drainage device implantation

Objective To describe the clinical presentation, outcome, and possible underlying mechanism of aqueous misdirection after glaucoma drainage device implantation. Design Retrospective, noncomparative, interventional case series. Participants Ten eyes (five primary open-angle glaucoma, four chronic angle-closure glaucoma, one nanophthalmos) of nine patients with a mean age of 68.5 ± 12.0 years (range, 43–83 years). Intervention The authors reviewed the medical records of all patients with a clinical diagnosis of aqueous misdirection after Baerveldt glaucoma drainage device implantation at two tertiary care referral centers from October 1992 to October 1997. Surgery was performed in a standardized fashion; all drainage tubes were inserted in the anterior chamber and occluded with an external 7–0 polyglactin ligature. All eyes were treated with topical corticosteroids, cycloplegia, and aqueous suppressants. Eyes with persistent aqueous misdirection received neodymium:YAG (Nd:YAG) hyaloidotomy or pars plana vitrectomy. Main outcome measures Visual acuity, intraocular pressure, biomicroscopic anterior chamber depth, and antiglaucomatous medication. Results All eyes had axial shallowing of the anterior chamber, one or more patent iridotomies, and no ophthalmoscopic or B-scan ultrasonographic evidence of serous or hemorrhagic ciliochoroidal detachment. Median time to the development of angle-closure glaucoma was 33.5 days (range, 1–343 days) and mean intraocular pressure at diagnosis was 27.7 ± 18.7 mmHg (range, 10–62 mmHg). Normalization of anterior segment anatomy was achieved with aqueous suppression and cycloplegia (one eye); Nd:YAG capsulotomy (four eyes); pars plana vitrectomy alone (two eyes) or with lensectomy (one eye), and pars plana vitrectomy with intraocular lens explanation (two eyes). Mean final intraocular pressure was 14.1 ± 6.0 mmHg at a mean follow-up of 9.1 ± 7.8 months after the development of aqueous misdirection (range, 1–23 months). Conclusions Aqueous misdirection may develop days to months after glaucoma drainage device implantation. In this series, there was a poor response to medical therapy, and normalization in anterior chamber depth required aggressive laser and surgical therapy.

“Cyclodiode”: Trans-scleral Diode Laser Cyclophotocoagulation in the Treatment of Advanced Refractory Glaucoma

To analyze the results of intraocular pressure (IOP) reduction by diode laser contact cyclophotocoagulation ("cyclodiode") in cases of advanced glaucoma refractory to alternative treatments. Two hundred and ten eyes of 195 patients, ages 1 to 89 years (mean, 51 years) were followed for 3 to 30 months (mean, 10 months) after cyclodiode treatment. More than one treatment was given in 102 eyes (49%), and the overall mean number of treatments given per eye was 1.75 (range, 2-5). Mean pretreatment IOP was 34.1 mmHg (+/-10.6 mmHg). At last follow-up, mean IOP was 20.1 mmHg (+/-9.3 mmHg), and mean total medications was reduced from 2.3 to 1.7. Mean final IOP was lowest in patients with silicone oil glaucoma (17.3 mmHg), and the mean reduction in IOP was greatest in patients with neovascular glaucoma (23.9 mmHg). At last follow-up, visual acuity was worse than before treatment in 29% of eyes, unchanged in 60%, and better in 11%. Overall success rate (IOP < 22 mmHg) was 66% at a mean follow-up of 10 months. Phthisis occurred in one eye (0.5%), and chronic hypotony (0 mmHg < IOP < 5 mmHg for > 3 months) in a further two eyes (1%). Corneal graft decompensation followed treatment in two eyes, macular pucker occurred in one eye, and combined hyphema/vitreous hemorrhage in one patient. Diode laser cycloablation is relatively safe and effective at controlling IOP in eyes with advanced refractory glaucoma in the short and medium term. With the treatment parameters used, multiple applications may be needed.

Effect of transscleral Nd:YAG laser cyclophotocoagulation: research for a new manner of treatment.

Twenty-six eyes of 24 patients with advanced glaucoma refractory to conventional therapy were treated with noncontact neodymium: YAG laser cyclophotocoagulation and were followed for a minimum of 6 months postoperatively. The mean baseline intraocular pressure (IOP) was 34.2 +/- 2.0 mm Hg. Nine to 10 evenly spaced pulses per quadrant were circumferentially applied 2.0-2.5 mm posterior to the limbus. Eight to 35 pulses (mean, 19 pulses) were delivered per treatment with an energy per pulse of 3.9-5.7 J (mean, 4.7 J), and the total energy per treatment was 35.6-164.9 J (mean 91.1 J). Twelve eyes of 11 patients (46%) required 2 or more treatments (mean, 1.7). The mean final IOP was 17.0 +/- 2.1 mm Hg, and the mean percent decrease in IOP was 41.7 +/- 6.5%. Statistical analyses revealed that the IOP reached its lowest point about 1 week after treatment and remained that level through 6 months of follow-up. There were significant correlations between the percent pressure decrease and preoperative IOP, the number of administered pulses and the total energy at the last procedure. Based on these results, we introduce intentional multiple treatments as a new manner of treatment to avoid phthisis bulbi. An initial treatment is performed circumferentially for 180 degrees and if sufficient pressure reduction is not obtained, an additional treatment 180 degrees should be employed 1 week after the most recent procedure, whether initial or not.

Results of Intraoperative 5-Fluorouracil Supplementation on Trabeculectomy for Open-angle Glaucoma

The success rate of filtration surgery has been increased by the postoperative subconjunctival injection of 5-fluorouracil, a potent antimetabolite. However, the optimal route of administration has not been determined. Trabeculectomy was performed on one eye each of 14 patients. Topical 5-fluorouracil was applied intraoperatively (50 mg/ml for five minutes) and subconjunctival 5-fluorouracil was injected postoperatively (an average of 5.8 injections) (mean total dose, 29 mg). Seven of the 14 eyes had primary open-angle glaucoma, and seven eyes had open-angle glaucoma with either uveitis, aphakia, or previous failed trabeculectomy. Mean preoperative intraocular pressure was 24.7 mm Hg during treatment with an average of three antiglaucoma medications, and mean final intraocular pressure was 11.9 mm Hg during treatment with an average of 0.2 medication. Thirteen of 14 eyes (93%) had final intraocular pressure of 18 mm Hg or less. Mean follow-up was 6.4 months (range, four to nine months). No remarkable complications occurred. Visual acuity remained stable in 13 of 14 eyes (93%). Intraoperative 5-fluorouracil may be a helpful adjunct in achieving low final intraocular pressure after trabeculectomy.

Timolol plus maximum tolerated antiglaucoma therapy: A one-year followup study

Thirty-three eyes of 22 patients with primary open-angle glaucoma or severe ocular hypertension had topical timolol maleate added to their maximally tolerated medical regimens. With minimal side effects, 25 eyes (76%) could be treated medically for one year, and only eight eyes (24%) required filtering surgery. Thirteen (39%) of the medically treated eyes achieved intraocular pressures of 21 mm Hg or less. After the addition of timolol, 17 of the 33 eyes (52%) completed the one-year protocol with final mean intraocular pressure decreases of 5 mm Hg or more on medical therapy.