Postoperative 5-fluorouracil Research Articles

Combined preoperative irradiation and direct postoperative 5-fluorouracil without negative effects on early anastomotic healing in the rat colon

Background and purpose: Preoperative irradiation with direct postoperative chemotherapy could benefit patients undergoing surgery for colorectal cancer. This study was designed to examine, in an experimental model, if such treatment is feasible without detrimental effects on early anastomotic healing. Material and methods: A colonic segment was irradiated (25 Gy) in 3 groups ( n = 10 each) of male Wistar rats. After 5 days, a colonic resection was performed with anastomotic construction; only the distal limb consisted of irradiated bowel. Postoperatively, animals received daily intraperitoneal 5-fluorouracil (5-FU, group I/CH: 17.5 mg/kg; group I/CL: 12.5 mg/kg) or saline (group I). Three additional groups were treated similarly, but with sham-irradiation: CH, CL, and C, respectively. All rats were killed 7 days postoperatively. Parameters measured were: weight, serum albumin and protein, and anastomotic bursting pressure, breaking strength and hydroxyproline content. Results: Body weight was diminished significantly in rats receiving chemotherapy. Serum albumin and protein was significantly lower in irradiated groups. At sacrifice, 40% of I/CH rats had functional rectal stenosis. The average bursting pressure ( P = 0.0005) and the average breaking strength ( P = 0.012) were only reduced significantly in the CH group. The anastomotic hydroxyproline content was significantly higher in the I/CH and I/CL groups vs. the control group. Conclusion: High-dose direct postoperative 5-FU leads to reduced anastomotic strength. Although the combination of preoperative irradiation (25 Gy) and direct postoperative high-dose 5-FU does not reduce early anastomotic strength, some stenosis may occur. The combination of preoperative irradiation and low-dose 5-FU has no such effect.

Postoperative 5-fluorouracil plus levamisole combined with radiation therapy for high risk rectal cancer patients

Adjuvant chemotherapy in rectal cancer patients is aimed at decreasing the relapse rate of the disease, increasing the disease-free and the overall survival of the patients. The combinations of radiation therapy and several drugs have been tested, but the efficacy of 5-fluorouracil plus levamisole in rectal cancer is not determined yet. Sixty-two consecutive Dukes' B2 or C rectal cancer patients were enrolled into a prospective phase II study. Within 4 to 6 weeks following en-block resection of the tumor and lymphatics, adjuvant chemotherapy had to be started. Combination of 5-FU 375 mg/m(2)/day was given intravenously over 15-20 min for 5 consecutive days, every 4 weeks for 1 year. Levamisole 50 mg t.i.d. was administered orally during the first 3 days of each course of chemotherapy. Radiation therapy included 50 Gy, given by a linear accelerator 8 MV, to a pelvic BOX field. Dose per fraction was 1.8-2.0 Gy daily, administered for 5 consecutive days a week. Follow-up time of the whole group ranges from 7 to 53 months (median 18). Failure rate was 32.3%. The most common site for first relapse was the liver followed by recurrence in the pelvis or the surgical bed. Age, sex, tumor grade and number of involved lymph nodes were not associated with rate nor with site of relapse. Fifty-five percent of the relapses were observed in patients during the year of the adjuvant treatment. Toxicity included diarrhea (33.9%), nausea and vomiting (19.4%), weakness and mucositis. The disease-free survival rate for a median follow-up of 18 months in our study is 75%. The 3.5 year disease-free survival is 67% for the whole group. Our phase II study results point to the feasibility and acceptable toxicity of post-operative combination of 5-FU plus low-dose levamisole and radiation therapy in rectal cancer patients.

Analysis of morbidity and mortality in 60 patients with peritoneal carcinomatosis treated by cytoreductive surgery and heated intraoperative intraperitoneal chemotherapy

Peritoneal carcinoma has been regarded as a uniformly lethal clinical entity. A treatment plan combining cytoreductive surgery and heated intraoperative intraperitoneal chemotherapy (HIIC) was devised and tested to treat such patients. The purpose of this study was to evaluate the morbidity and mortality associated with this treatment approach. Sixty patients with peritoneal carcinomatosis from adenocarcinoma of the colon or appendix were included in the study. Extensive cytoreductive surgery was combined with heated intraperitoneal mitomycin in an intraoperative lavage technique followed by one cycle of early postoperative intraperitoneal 5-fluorouracil. Eleven clinical variables were selected and statistically correlated with morbidity and mortality. Twenty-five complications occurred in 21 patients (morbidity = 35%). Morbidity related to gastrointestinal function included anastomotic leak (n=6), bowel perforations (n=5), bile leak (n=3), and pancreatitis (n=2). Four patients presented with severe hematologic toxicity (Grade 3 or 4). There were three cases of postoperative bleeding, one case of abdominal wound dehiscence, and one case of pulmonary embolism. Morbidity was significantly associated with three clinical factors: male sex, high intraabdominal temperature during HIIC, and duration of the surgical procedure. Enteral complications (bowel fistula and anastomotic leak) occurred in patients with a significantly higher number of peritonectomy procedures and a significantly longer operation. Three patients died within 8 weeks after the procedure (mortality = 5%). Mortality was significantly associated with age and intraabdominal temperature. Cytoreductive surgery combined with HIIC is associated with a 35% morbidity rate and a 5% mortality rate. Extensive surgery (duration and number of peritonectomy procedures) and high intraabdominal temperature represent the major risk factors for postoperative morbidity and mortality of patients treated with this new therapeutic approach.

Five-year Follow-up of the Fluorouracil Filtering Surgery Study

To determine the efficacy and safety of subconjunctival 5- fluorouracil injections after trabeculectomy in patients with poor prognoses, to determine risk factors for surgical failure and to examine the relationship of intraocular pressure and visual function. In this multicenter clinical trial, 213 patients with previous cataract surgery or previous failed filtering surgery were randomly assigned to receive either trabeculectomy alone or trabeculectomy with postoperative subconjunctival 5-fluorouracil injections. Measurements of intraocular pressure, visual acuity, and visual fields were performed throughout the five years, with the clinician masked to the treatment group. Failure was defined as a reoperation to control intraocular pressure or an intraocular pressure greater than 21 mm Hg at or after the first-year examination. Fifty-four (51%) of the 105 eyes in the 5-fluorouracil group and 80 (74%) of the 108 eyes in the standard filtering surgery group were classified as failures (P < .001, Mantel-Cox survival analysis). Risk factors for failure include high intraocular pressure, a short time interval after the last procedure involving a conjunctival incision, the number of procedures with conjunctival incisions, and Hispanic ethnicity. Patients in both treatment groups with controlled intraocular pressures were more likely to maintain visual acuity. Patients in the 5-fluorouracil group had a higher risk of late-onset bleb leaks (9% nine of 105) than those in the standard filtering surgery group (2% two of 108) (P = .032, Fisher's exact test). We recommend the use of subconjunctival 5-fluorouracil after trabeculectomy in eyes after previous cataract surgery or unsuccessful filtering surgery, but caution against its routine use in patients with good prognoses.

699 Improved treatment results in rectal cancer by postoperative radiotherapy and 5-fluorouracil

The purpose was to investigate whether a time-scheduled regimen of postoperative radiotherapy and 5-fluorouracil (5-FU) 30min. before radiation could reduce local recurrence rate and improve survival in rectal cancer Dukes' B and C. 144 patients with rectal cancer Dukes' B and C were randomized to surgery alone or surgery combined with postoperative radiotherapy 46Gy and bolus 5-FU. 136 patients were eligible. The treatment was well tolerated. After an observation time of 42–93 months, patients within the adjuvant treatment group had a cumulative local recurrence rate of 12%, compared to 30% in the surgery only group (<i>P</i>=0.01). The 5-year recurrence-free as well as overall survival was 64% in the adjuvant group compared to 46% (<i>P</i>=0.01) and 49% (<i>P</i>=0.05), respectively, in the surgery group. <h3>Conclusion</h3> The one month combination treatment improved treatment results in rectal cancer Dukes B and C, in terms of local and total recurrence rate and survival, without serious side effects. The timing of 5-FU and radiation is probably important.

Cancer recurrence following laparoscopic colectomy

Use of laparoscopic techniques for resection of colon and rectal cancer has raised considerable controversy. There is increasing concern that wound recurrence and peritoneal dissemination may represent a potentially fatal complication of this technique. The surgical literature was reviewed, and clinical course of two patients is presented. Our two patients had tumor recurrence in the laparoscopy port sites within one year after laparoscopic assisted colectomy for Dukes B adenocarcinoma of the colon. At laparotomy, diffuse peritoneal carcinomatosis without lymph node or liver metastases were found in both patients. They were treated by surgical resection of recurrent disease combined with heated intraoperative intraperitoneal mitomycin C chemotherapy and five days of early postoperative intraperitoneal 5-fluorouracil. These patients are clinically free of disease at 1.5 years after treatment of peritoneal implants. Cancer recurrence in abdominal wall incisions after laparoscopic colectomy has been reported in an increasing number of patients. It is possible that this technique should be abandoned. Cytoreductive surgery combined with intraperitoneal chemotherapy may represent the most adequate treatment of recurrent cancer that occurs following laparoscopic colectomy.

Mitomycin C versus 5-Fluorouracil in High-risk Glaucoma Filtering Surgery: Extended Follow-up

To compare the outcome of filtering surgery in high-risk patients using intraoperative mitomycin C (MMC) versus postoperative 5-fluorouracil (5-FU). In a randomized clinical trial, the use of postoperative subconjunctival injections of 5-FU in 19 eyes of 19 patients was compared with a single intraoperative application of MMC in 20 eyes of 20 patients. All eyes were at high risk for failure of glaucoma filtering surgery. Follow-up ranged from 26 to 38 months (mean, 32.0 months). Three eyes in the MMC-treated group and two eyes in the 5-FU-treated group required subsequent surgery to control the IOP. Excluding these patients, intraocular pressure (IOP) averaged 9.0 +/- 4.9 mmHg in the MMC-treated eyes versus 16.3 +/- 4.6 mmHg in the 5-FU-treated eyes at the patient's last visit (P = 0.0003). Of the MMC-treated eyes, 81.3% had IOPs less than or equal to 12 mmHg compared with 26.7% of eyes in the 5-FU group (P = 0.0023). In the MMC-treated group, the average number of medications for IOP control at last visit was 0.5 +/- 0.8 compared with 1.6 +/- 1.3 in the 5-FU-treated group (P = 0.01). Late postoperative complications (those occurring more than 3 months after surgery) were similar for the two groups, with the exception of formation of a Tenon cyst in three of the eyes treated with MMC compared with none of the 5-FU-treated eyes. Eyes treated with MMC have lower IOP on fewer medications than eyes treated with 5-FU. Late postoperative complications are similar with the exception of an increased incidence of Tenon cyst formation in the MMC-treated eyes.

Hypotony Following Trabeculectomy

To determine the risk factors for development of postoperative hypotony and the effects of hypotony on the outcome of surgery in terms of intraocular pressure (IOP) control and final visual acuity in patients who underwent standard trabeculectomy, trabeculectomy with postoperative 5-fluorouracil injections, trabeculectomy with intraoperative mitomycin-C, or trabeculectomy with both antimetabolites. We retrospectively reviewed the outcome in 155 eyes of 155 patients who underwent standard trabeculectomy (n = 15), trabeculectomy with postoperative 5-fluorouracil injections (n = 81), trabeculectomy with intraoperative mitomycin-C (n = 55), or trabeculectomy with both antimetabolites (n = 4). Hypotony developed in 108 (69.6%) eyes (IOP < 6 mm Hg) at some point postoperatively; this was transient (< 14 days) in 75 eyes, and prolonged (> 14 days) in 33 eyes. The positive preoperative factors for the development of prolonged hypotony were young age, myopia, and preoperative use of carbonic anhydrase inhibitor. The mean age of patients in whom prolonged hypotony developed was 57.3 +/- 18.3 years (compare the mean age without prolonged hypotony, 65.3 +/- 14.5 years, p = 0.02). Sixteen of 33 (48%) patients in whom prolonged hypotony developed were myopic (p = 0.02), and 23 of 33 (70%) patients in whom prolonged hypotony developed used preoperative carbonic anhydrase inhibitor (p = 0.07). There was no difference in the incidence of hypotony between patients who received 5-fluorouracil and those who received mitomycin-C. Postoperative hypotony was associated with three types of postoperative complications: shallow anterior chamber, choroidal detachment, and hypotony maculopathy (p = 0.02, 0.000, and 0.05, respectively). Hypotony did not have any effect on the success of surgery in terms of IOP control, but did have an effect on the visual outcome. Fourteen of the 33 patients (42.4%) in whom prolonged hypotony developed had worse visual acuity (p = 0.002); of these cases, four were due to hypotony maculopathy.

Abdominal adhesions causing intestinal obstruction following cytoreductive surgery and early postoperative intraperitoneal chemotherapy

Background The purpose of this study was to evaluate the incidence and morbidity of intestinal adhesions in patients treated with cytoreductive surgery and postoperative intraperitoneal chemotherapy. Methods The records of 196 patients, who had received cytoreductive surgery and at least 1 cycle of early postoperative intraperitoneal chemotherapy 5-fluorouracil (5-FU) and intraperitoneal mitomycin C, were reviewed retrospectively. 152 patients received 3 additional cycles of adjuvant intraperitoneal 5-FU, plus systemic mitomycin C. 35 patients received 3 additional cycles of intraperitoneal 5-FU plus 3 cycles of intraperitoneal mitomycin C. Results In those patients who received 4 cycles of intraperitoneal mitomycin C, 3 patients (9%) developed peritoneal fibrosis and long term intestinal obstruction due to dense adhesions. In the 152 patients, who had early postoperative mitomycin C and 5-FU plus 3 additional cycles of intraperitoneal 5-FU and systemic mitomycin C, only 1 patient, developed adhesions requiring a reoperation with a full recovery. Conclusions Numerous cycles of intraperitoneal mitomycin C are not well tolerated and appear to cause a long term adhesive process in the abdominal cavity. However, multiple cycles of intraperitoneal 5-FU have not been associated with such complications. These patients were found to present with low incidence of adhesions requiring reoperation.

Early and Late Postoperative Application of 5-Fluorouracil Following Trabeculectomy in Refractory Glaucoma

Intraocular pressure (IOP) control was studied retrospectively in two groups of 14 consecutive patients following trabeculectomy with adjunctive postoperative 5-fluorouracil (5-FU) treatment. In one of the groups (the early-treatment group), 5-FU injections were started 2.4 +/- 0.6 days postoperatively; in the other group (the delayed-treatment group), they were started only when clinical signs suggested impending bleb failure (12.6 +/- 5.4 days postsurgery). The patients in the two groups were age-matched and had a similar history of previous failed glaucoma operations or diabetes, both of which are considered indications for postoperative 5-FU injections. The mean number of 5-FU injections and the total dose in the two groups did not differ significantly (5.3 +/- 0.8 and 5.5 +/- 1.1 injections, respectively; 26.4 +/- 3.9 and 27.5 +/- 5.3 mg 5-FU total dose, respectively). The average follow up for the two groups was 16.7 +/- 2.5 and 16.9 +/- 2.7 months, respectively. With an IOP of 18 mm Hg or less with or without medications considered a success, 42.8% of the delayed-treatment and 71.4% of the early-treatment cases were successful. More medications were required in the early-treatment group. Postoperative transient corneal epithelial defects occurred in 71.4% and 78.4% of the eyes in the late- and early-treatment groups, respectively, an insignificant difference. Conjunctival wound leak occurred in one patient (in the delayed-treatment group).(ABSTRACT TRUNCATED AT 250 WORDS)

5-Fluorouracil in Initial Trabeculectomy: A Prospective, Randomized, Muldcenter Study

Postoperative subconjunctival 5-fluorouracil (5-FU) injections increase the success of filtration surgery in eyes with prior filtration failure or cataract removal and in eyes with secondary glaucoma. The authors evaluate the safety and benefit of adjunctive 5-FU in eyes undergoing initial trabeculectomy. Patients with phakic, uncontrolled, open-angle glaucoma who were undergoing initial trabeculectomy were prospectively assigned to the 5-FU group on the first postoperative day. Patients in this group received five 5-mg injections during 2 weeks after surgery. Patients in the control group received no injections. Preoperative intraocular pressure (IOP) and number of antiglaucoma medications were similar in the 5-FU (n = 32) and control (n = 30) groups. Transient superficial punctate keratopathy was the only postoperative complication that occurred more frequently (P < 0.05) in the 5-FU (14 eyes) than in the control eyes (3 eyes). Patients were followed for a minimum of 1 year or until a study endpoint was reached: IOP of 21 mmHg or greater with maximum medical therapy (2 5-FU eyes and 8 control eyes; P < 0.03) or cataract removal after filtration (5 treated and 3 control eyes). At last follow-up (mean, > 20 months), IOP and the number of antiglaucoma medications were significantly lower (P < 0.02) in the 5-FU eyes (IOP, 12.0 +/- 1.3 mmHg; medications, 0.2 +/- 0.1) than in the control eyes (IOP, 16.8 +/- 1.3 mmHg; medications, 0.8 +/- 0.2). Intraocular pressure was 20 mmHg or lower in 94% of 5-FU eyes and in 73% of control eyes (P < 0.03) and 16 mmHg or lower in 84% of 5-FU eyes and in 57% of control eyes (P < 0.02). Adjunctive 5-fluorouracil increases the rate of success, decreases the level of postoperative IOP, and reduces the need for postoperative antiglaucoma medication in eyes with open-angle glaucoma undergoing initial trabeculectomy.

Trabeculectomy With 5-Fluorouracil vs Single-Plate Molteno Implantation

ABSTRACT We compared the results achieved in 22 consecutive patients who underwent single-plate Molteno implantation, with those achieved in a matched group who had trabeculectomy with postoperative 5-fluorouracil. Six months following surgery, the average intraocular pressure (IOP) in the Molteno group was 15.4 ± 8.0 mm Hg, and in the trabeculectomy group, 16.1 ± 5.6 mm Hg (P = .920). A mean of 1.4 antiglaucoma medications were being used in each group (P = .776). Complications following Molteno implantation included six tube revisions and three flat anterior chambers; following trabeculectomy, eight serous choroidal detachments and nine positive Seidel tests. This study suggests that Molteno implantation and trabeculectomy with adjunct i ve 5-fluorouracil provide similar IOP control, but that the two procedures are associated with different types of complications.

Early post-operative 5-fluorouracil does not affect the healing of experimental intestinal anastomoses.

5-Fluorouracil (5-FU) remains the mainstay for systemic treatment of colorectal cancer. In view of the increasing interest in peri-operative administration of antineoplastic agents, we have investigated the effects of early postoperative 5-FU on the healing of intestinal anastomoses in the rat. Animals underwent resection and anastomosis of both ileum and colon and 5-FU (20 mg/kg body weight) was given, either intravenously or intraperitoneally, on the day of surgery and the two subsequent days. Healing was assessed three and seven days after operation. Administration of 5-FU led to a reduced white blood cell count. However, anastomotic strength was not significantly reduced at either time point and anastomotic hydroxyproline content was not significantly affected. We suggest that limited use of 5-FU during or immediately after operation does not necessarily affect early anastomotic healing in the intestine.

Resection margins in carcinoma of the head of the pancreas. Implications for radiation therapy.

A retrospective review of the pathology and clinical course of 72 patients undergoing resection of carcinoma of the head of the pancreas was undertaken to identify the frequency of tumor involvement at standard surgical transection margins (stomach, duodenum, pancreas, and bile duct) as well as the peripancreatic soft tissue margin and the potential clinical significance of these findings. Of 72 patients undergoing resection, 37 patients (51%) were found to have tumor extension to the surgical margins. The most commonly involved margin was peripancreatic soft tissue (27 patients) followed by pancreatic transection line (14 patients) and bile duct transection line (4 patients). For 37 patients with tumor present at a resection margin, there were no survivors beyond 41 months. No difference in survival or local control was seen between 14 patients receiving postoperative radiation therapy and 5-fluorouracil (5-FU) compared with 23 patients not receiving additional treatment. In contrast, the 5-year actuarial survival and local control of 35 patients undergoing resection without tumor invasion to a resection margin was 22% and 43%, respectively. The 5-year survival and local control of 16 patients receiving adjuvant radiation therapy and 5-FU was 29% and 42%, respectively, whereas these figures were 18% and 31% for 19 patients not receiving adjuvant therapy (p > 0.10). Because residual local tumor after resection is common, preoperative radiation therapy may be beneficial in this disease. It should minimize the risk of dissemination during operative manipulation and facilitate a curative resection by promoting tumor regression. Because local failure rates approach 60% after resection and adjuvant therapy even in cases having clear resection margins, intraoperative radiation therapy to the tumor bed at the time of resection also might be considered. Protocols evaluating the feasibility and efficacy of preoperative radiation therapy and resection with intraoperative radiation therapy for patients with pancreatic cancer are underway.

Hypotonous Maculopathy After Trabeculectomy With Subconjunctival 5-Fluorouracil

Long-term success in trabeculectomy has been enhanced in recent years by postoperative subconjunctival 5-fluorouracil injections and intraoperative mitomycin C applications. During 1990 and 1991, after trabeculectomy with a small scleral flap (2 x 3 mm) augmented by antimetabolite therapy, hypotonous maculopathy developed in eight eyes of six patients. The maculopathy was characterized by loss in visual acuity, retinal striae, and choroidal folds without evidence of vascular leakage. The average loss in visual acuity was four Snellen lines. Visual acuity did not return to preoperative levels even when the hypotony could be reversed. Reversing the hypotony with various strategies aimed at stimulating subconjunctival scarring has been relatively ineffective. During that same period, an additional seven eyes in six patients had prolonged hypotony but without development of maculopathy. Features common to patients who developed maculopathy included age (mean age, 46 years; range, 32 to 60 years) and myopia (mean, -7.5 diopters; range, -0.75 to -11.75 diopters). The patients with hypotony but no maculopathy were older (mean age, 73 years; range, 63 to 82 years) and were closer to emmetropia (mean, -1.11 diopters; range, +1.50 to -9.00 diopters). The means of the ages and refractive errors were statistically significantly different in the two groups (P = .007 and .04, respectively). Trabeculectomy with adjunctive antifibrosis therapy should be used with caution in young myopic patients.

Glaucoma Filtering Surgery with Postoperative 5-Fluorouracil in Patients with Intraocular Inflammatory Disease

Twenty-one eyes of 18 patients with uncontrolled glaucoma and intraocular inflammatory disease had glaucoma filtering surgery with postoperative subconjunctival 5-fluorouracil (5-FU). Follow-up for eyes in which intraocular pressure was controlled ranged from 6 to 53 months (mean, 34 months; median, 35 months). Fifteen of 21 eyes (71%) had controlled intraocular pressure (21 mmHg or less). Control was achieved in 9 of 10 (90%) phakic eyes and in 6 of 11 (55%) aphakic or pseudophakic eyes with or without glaucoma medication. Four of six filter failures had a second filtering procedure with 5-FU, and of these four procedures, three were successful. Cataract progression occurred in 9 of 10 phakic eyes, leading to cataract surgery in 7 eyes. Other complications included corneal epithelial defects in 13 eyes, bleb leaks in 3 eyes, choroidal effusions in 13 eyes, 1 choroidal hemorrhage, 1 serous retinal detachment and macular retinal pigment epithelial disturbance associated with hypotony and choroidal effusion. Filtering surgery with postoperative subconjunctival 5-FU can successfully control intraocular pressure in eyes with ocular inflammatory disease.

Reducing corneal toxicity of 5-fluorouracil in the early postoperative period following glaucoma filtering surgery

To gain a better understanding of the relationship between postoperative 5-fluorouracil administration and corneal complications associated with its use, we analysed 43 consecutive filtering procedures in which it had been employed. Nine of the 43 eyes had corneal complications during that period. At the end of the three-month period, these corneal complications had all resolved. There was no correlation between postoperative intraocular pressure lowering and incidence of corneal complications. A low dose of 5-fluorouracil, and early recognition and treatment of corneal toxicity associated with its use may reduce corneal complications while maintaining filtration in eyes with poor surgical prognosis.

Complications of 5—Fluorouracil after trabeculectomy

Trabeculectomy has a very high success rate, however, certain eyes are known to be at high risk of failure due to scarring of the conjunctival bleb. Such eyes include those with a previous failed filter, eyes with glaucoma secondary to uveitis and neovascularisation and the eyes of children and young adults. Trabeculectomy is generally accepted to have less successful results in patients of African race although good results are reported from some centres. The effectiveness of treatment with 5-fluorouracil in improving the results of trabeculectomy has been established in a number of pilot studies and clinical trials. Early studies used 100 mg of 5-fluorouracil in divided doses. Serious complications were recorded and lower dose regimes have been advised to improve the safety of the technique. Similar success in improving the chance of success to trabeculectomy has been found with doses of 40 mg with a lower incidence of side effects. We report complications associated with the use of 5-fluorouracil in a total dose of 50 mg in a group of 49 eyes undergoing trabeculectomy and postoperative 5-fluorouracil and describe the previously unreported increased incidence of thin cystic blebs in these eyes.

Use of Trabeculectomy with Postoperative 5-Fluorouracil in Patients Requiring Extremely Low Intraocular Pressure Levels to Limit Further Glaucoma Progression

The authors conducted a randomized, controlled clinical trial to quantify the effect of 5-fluorouracil (5-FU) on filtration surgery. Both eyes of 17 patients with either bilateral low-tension glaucoma or advanced chronic openangle glaucoma that would be expected to progress at intraocular pressures in the normal range were included. One eye received a full-thickness filtering procedure with a modified shell tamponade technique, and the other received a trabeculectomy with postoperative 5-FU. Follow-up was equal for both eyes and averaged 9.2 months. In eyes in the shell group, the average postoperative pressure was 10.94 mmHg, and in the 5-FU group it was 6.94 mmHg, (P = 0.0001). However, the postoperative visual acuity decrease was significantly greater in the 5-FU group (P < 0.05). Choroidal detachments also were more frequent in the 5-FU group, but this was not statistically significant.

Striate Melanokeratosis Following Trabeculectomy With 5-Fluorouracil

Striate melanokeratosis is a condition in which pigment-bearing cells invade the central corneal epithelium in a whorllike pattern. It typically affects black patients with heavy limbal pigmentation and has been described in association with corneal epithelial injury (eg, infectious or exposure keratitis, cataract extraction, and penetrating keratoplasty). 1 We describe herein a patient in whom striate melanokeratosis occurred after trabeculectomy with postoperative administration of subconjunctival 5-fluorouracil. Report of a Case. —A 64-year-old black man with severe primary open angle glaucoma and a history of a failed filtering procedure in the right eye underwent an uncomplicated repeated trabeculectomy of this eye and received a 14-day course (14 injections of 5 mg each) of postoperative subconjunctival 5-fluorouracil. On the second postoperative day, a small epithelial defect was present temporally. This defect healed by the fourth postoperative day, although diffuse superficial punctate keratopathy persisted. Five weeks after surgery, a dense, whorl-like pattern