Postoperative Glaucoma Medications Research Articles

Surgical outcomes of the Ex-PRESS glaucoma filtration device in African American and white glaucoma patients

PurposeTo compare the surgical outcomes of the Ex-PRESS glaucoma filtration device in African American and white glaucoma patients.DesignRetrospective comparative case series.MethodsThis was a comparative case series of 36 eyes of 36 African Americans and 43 eyes of 43 whites that underwent placement of the Ex-PRESS glaucoma filtration device under a partial-thickness scleral flap for uncontrolled glaucoma. All eyes received intraoperative mitomycin C. The primary outcome measures were intraocular pressure (IOP), number of postoperative glaucoma medications, and surgical success. Surgical success was defined as IOP between 5 and 18 mm Hg, with or without glaucoma medications, without further glaucoma surgery, or loss of light perception vision.ResultsAverage follow-up was 31.9 ± 9.8 (range, 14.6–47) months for African Americans and 30.7 ± 8.6 (range, 14.3–47) months for whites. At 33 months, surgical success was 80.0% in the African American group and 83.3% in the white group (P = 1.00). Reasons for surgical failure included increased IOP (3 eyes, 3.8%), persistent hypotony with maculopathy (1 eye, 1.3%), and further surgery (4 eyes, 5.06%). Compared with preoperative values, the mean postoperative IOP and number of glaucoma medications were significantly reduced in both groups, and no statistical difference was observed between the two groups at 33 months. Postoperative complications were similar in the two groups.ConclusionsSimilar surgical outcomes were observed in African American and white glaucoma patients after implantation of the Ex-PRESS glaucoma filtration device. This latest modification of glaucoma filtration surgery may be a better surgical option for African Americans given its potential advantages of no tissue removal, predictable outcomes related to consistent lumen size and controlled flow, fewer postoperative complications, and overall reduced inflammation.

Can Topical Ketorolac 0.5% Improve the Function of Ahmed ® Glaucoma Drainage Devices?

To determine whether postoperative use of topical ketorolac tromethamine 0.5% affects intraocular pressure (IOP) following Ahmed glaucoma drainage device (New World Medical, Inc., Rancho Cucamonga, CA) implantation. Patients undergoing Ahmed implantation at the University of Michigan from January 2002 to June 2008 were reviewed. Fourteen eyes received ketorolac after surgery; 50 eyes did not. Preoperative and postoperative IOP and glaucoma medications were recorded for both groups; the two-sided Student's t test was used to compare these parameters. Mean preoperative IOP was similar in the two groups (35.1 ± 11.9 vs 37.0 ± 12.2 mm Hg; P = .60). At postoperative month 6, the ketorolac group had significantly lower IOP compared with the no ketorolac group (13.1 ± 3.7 vs 19.5 ± 9.3 mm Hg, respectively; P = .0003). There was no difference in the number of glaucoma medications postoperatively between the two groups. Ketorolac may lead to lower postoperative IOP following Ahmed implantation.

Adjunctive Bevacizumab in Patients Undergoing Ahmed Valve Implantation: A Pilot Study

To report on preliminary findings of adjunctive subconjunctival bevacizumab (SCB) injections in patients undergoing Ahmed valve implantation (AVI) (New World Medical, Rancho Cucamonga, CA). The study was approved by the institution's ethics committee. Patients were prospectively recruited during a 1-month period and randomized to receive AVI with postoperative SCB (days 1 and 7, n = 7) or AVI without SCB (n = 6). Baseline intraocular pressure (IOP) in the treatment (AVI+SCB) group was 19.4 ± 8.6 mm Hg, whereas baseline IOP in the control (AVI) group was 32.1 ± 17.7 mm Hg (P = .119). Final IOP was 13.8 mm Hg (n = 7) for the treatment group and 12.7 mm Hg for the control group (n = 5, P = .790). One eye in the control group required further glaucoma intervention at day 45 and was considered a failure. The pre-massage postoperative IOP was significantly lower for the treatment group only at day 45 (16.1 vs 26.0 mm Hg, P = .012). Mean post-massage IOP was significantly lower in the treatment group at day 15 (11.28 vs 17.16 mm Hg, P = .004), day 30 (11.28 vs 20.83 mm Hg, P = .015), and day 45 (12.16 vs 21.33 mm Hg, P = .001), and similar at month 3. Mean change in bleb area was 11.4 mm(2) in the treatment group and -0.4 mm(2) in the control group (P = .036 and P = .361, respectively, Student's paired samples t test). Bevacizumab was associated with a less aggressive hypertensive period as measured by post-massage IOP measurements, postoperative glaucoma medications, and cross-sectional bleb area by ultrasound. Further prospective studies are needed to better understand the utility of SCB at the time of AVI surgery.

Trabeculectomy with OloGen versus trabeculectomy for the treatment of glaucoma: a pilot study

To present the preliminary results of our study comparing the outcomes of trabeculectomy with or without OloGen implant in patients requiring glaucoma surgery for uncontrolled intraocular pressure (IOP). Forty eyes of 40 patients were assigned randomly to undergo trabeculectomy either with OloGen implant (study group) or without implant (control group). Preoperative data included age, gender, type of glaucoma, IOP and number of preoperative glaucoma medications. Postoperative IOP, number of postoperative glaucoma medications and postoperative complications were recorded. Each patient was followed up for at least 6 months. There were no significant differences between the groups in terms of age, gender, type of glaucoma, preoperative IOP and number of antiglaucoma medications. Mean IOPs for both groups were significantly lower than preoperative levels at all intervals (P < 0.05) The number of glaucoma medications used dropped from a preoperative mean of 3.5 +/- 0.7 to a 6-month postoperative mean of 0.3 +/- 0.7 (P < 0.001) in the study group and from 3.7 +/- 0.4 to 0.5 +/- 1.1 (P < 0.001) in the control group. No statistically significant differences between the two groups were observed in terms of postoperative complications. In this pilot study it appears that trabeculectomy with OloGen does not seem to offer any significant advantages compared with trabeculectomy alone. Additionally, even though there were no statistical differences between the two groups as far as complications were concerned, one eye from the study group developed endophthalmitis 10 days after surgery and two eyes presented with positive Seidel test and flat anterior chamber and required additional suturing. Studies with larger numbers of patients and longer follow-ups are required to confirm these findings and to examine the safety and long-term outcomes of trabeculectomy with OloGen.

Influential factors on the survival of endothelial cells after penetrating keratoplasty

To evaluate the factors that influence the survival of corneal endothelial cells after penetrating keratoplasty. We retrospectively reviewed the medical records of 83 eyes of 83 patients who had undergone penetrating keratoplasty and whose corneal endothelial cell density was more than 2,000 cells/mm2 at postoperative 1 month. The patients were divided into 3 groups: keratoconus (Group 1), bullous keratopathy (Group 2), and herpetic keratitis with uveitis (Group 3), based on the underlying disease and the recipient's corneal endothelial state. We analyzed the difference of endothelial cell loss among the 3 groups and some risk factors such as preoperative glaucoma, postoperative increased intraocular pressure, graft rejection, peripheral corneal disease, and the donor trephine size. The corneal endothelium cell loss was significantly higher in Groups 2 and 3 than in Group 1 after 2 years. There were statistically significant differences of the rate of corneal endothelium cell loss for the eyes with preoperative glaucoma, postoperative glaucoma medication with more than 2 agents, graft rejection, and peripheral corneal disease, but the donor trephine size was not a significant factor for corneal endothelium cell loss. For the eyes with bullous keratopathy and herpetic keratitis with uveitis, the survival rate of the endothelium was lower than that for the eyes with keratoconus. We should carefully manage patients who have risk factors such as graft rejection, peripheral corneal disease, and perioperative glaucoma to minimize the loss of corneal endothelium and to reduce graft failure after penetrating keratoplasty.

Two-site Phacotrabeculectomy versus Bimanual Microincision Cataract Surgery Combined with Trabeculectomy

To compare the results of two-site phacotrabeculectomy with microincision cataract surgery (MICS) and trabeculectomy. Fifty-eight eyes with coexisting cataract and glaucoma were randomly assigned to have a trabeculectomy in a superior quadrant combined with phacoemulsification and intraocular lens (IOL) implantation through temporal clear corneal incision (two-site phacotrabeculectomy group), or a trabeculectomy in a superior quadrant combined with MICS followed by IOL implantation from the trabeculectomy incision (MICS + trabeculectomy group). The main outcome measures were preoperative and postoperative intraocular pressure (IOP), number of glaucoma medications, best-corrected visual acuity (BCVA), and complications. Follow-up was period was 12 months. Twenty-eight two-site phacotrabeculectomies and 30 MICS + trabeculectomies were performed. Mean age of the subjects was 67.4 years. Mean preoperative IOP was 24.6+/-5.7 mmHg in the two-site phacotrabeculectomy group and 23.7+/-5.5 mmHg in the MICS + trabeculectomy group (p=0.52). At 12 months postoperatively mean IOP was 14.5+/-3.0 and 14.3+/-3.4 mmHg in two-site phacotrabeculectomy and MICS + trabeculectomy groups, respectively (p=0.8). Preoperative and postoperative glaucoma medication numbers were similar and mean number of glaucoma medications decreased in both groups after the surgery (p<0.05). BCVA improved in both groups. Twenty-six of 28 eyes (92%) in the two-site + trabeculectomy group and 27 of 30 (90%) in the MICS + trabeculectomy group had clinically apparent filtering blebs at 12 months (p=0.71). Postoperative complications were comparable. MICS + trabeculectomy provided 1 year IOP control comparable to that with two-site phacotrabeculectomy with similar amount of complications and similar final BCVA.

Five-Year Results of Viscocanalostomy

To prospectively study the success rates and complications of viscocanalostomy. Prospective nonrandomized case series of 46 eyes (46 patients) with medically uncontrolled primary and secondary open angle glaucoma. All patients in the study underwent viscocanalostomy. Control of intraocular pressure was used to measure success. Pre and postoperative glaucoma medications, visual acuity, complications, and adjunctive procedures were recorded. At 60 months, qualified success (intraocular pressure below 21 mmHg with glaucoma medication) was achieved in 37 (82%) patients and complete success (intraocular pressure below 21 mmHg without medication) in 25 (54%) patients. Nd:YAG laser goniopuncture was performed in 33 (72%) patients with significant post laser reduction of intraocular pressure. No sight threatening complications were observed in this series. Visual acuity remained unchanged in 33 patients (72%). Viscocanalostomy appears to be a safe and effective intraocular pressure lowering procedure in eyes with primary open angle glaucoma and certain types of secondary open angle glaucoma.

One-site Versus Two-site Endoscopic Cyclophotocoagulation

To report the intraocular pressure (IOP) lowering effect of endoscopic cyclophotocoagulation (ECP) treatment through 1 versus 2 corneal incisions. This is a retrospective consecutive case review of combined ECP and phacoemulsification (PE). Group 1 included patients undergoing PE-ECP through 1 clear cornea incision and group 2 involved PE followed by ECP through 2 incisions. The 1 versus 2 site selection was performed in a nonrandomized fashion at the time of surgery. Data including age, sex, preoperative diagnosis, number of preoperative and postoperative glaucoma medications, complications, treatment failures, and IOP were collected and analyzed using analysis of variance and t tests where appropriate. Group 1 included 15 patients and group 2 included 25 patients. Age of patients in group 1 (66.07+/-17.73) and group 2 (73.48+/-11.31) were similar (P=0.11). Visual acuity in group 1 ranged from 20/40 to 20/400 and from 20/40 to counting fingers in group 2. The preoperative diagnoses were similar between the 2 groups. Preoperative IOP was 23.60+/-3.89 in group 1 and 24.48+/-8.99 in group 2 (P=0.72). IOP decreased in group 1 from 23.60+/-3.89 to 17.93+/-4.38 (P=0.0008) and in group 2 from 24.48+/-8.99 to 13.88+/-3.22 (P=0.00001) with 3 months of follow-up. IOP at 3 months was significantly lower in group 2 compared with group 1 (P=0.002). Six-month IOP data for group 1 (16.00+/-2.77) and group 2 (13.00+/-3.09) remained statistically significant in favor of 2-site PE-ECP (P=0.04). Glaucoma medication use decreased more in group 2 (2.56+/-0.71 to 0.52+/-0.59) versus group 1 (2.47+/-0.74 to 1.93+/-0.88) (P=0.00001). Two-site PE-ECP may result in statistically significant IOP lowering and less dependence on glaucoma medications compared with single site PE-ECP.

Comparison of Trabeculectomy With Ex-PRESS Miniature Glaucoma Device Implanted Under Scleral Flap

To evaluate the Ex-PRESS miniature implant (Model R 50) placed under partial-thickness scleral flap compared with standard trabeculectomy. In this retrospective comparative series of 100 eyes, we compared 50 eyes in 49 patients treated with the Ex-PRESS miniature glaucoma implant under a scleral flap with 50 matched control eyes in 47 patients treated with trabeculectomy. Success was defined as intraocular pressure (IOP) > or =5 mm Hg and < or =21 mm Hg, with or without glaucoma medications, without further glaucoma surgery or removal of implant. Early postoperative hypotony was defined as IOP <5 mm Hg during the first postoperative week. The average follow-up was 10.8 months (range 3.5 to 18) for the Ex-PRESS group and 11.2 months (range 3 to 15) for the trabeculectomy group. Although the mean IOP was significantly higher in the early postoperative period in the Ex-PRESS group compared with the trabeculectomy group, the reduction of IOP was similar in both groups after 3 months. The number of postoperative glaucoma medications in both groups was not significantly different. Kaplan-Meier survival curve analysis showed no significant difference in success between the 2 groups (P=0.594). Early postoperative hypotony and choroidal effusion were significantly more frequent after trabeculectomy compared with Ex-PRESS implant under scleral flap (P<0.001). The Ex-PRESS implant under a scleral flap had similar IOP-lowering efficacy with a lower rate of early hypotony compared with trabeculectomy.

Three and Five Year Changes in Intraocular Pressures After Clear Corneal Phacoemulsification in Open Angle Glaucoma Patients, Glaucoma Suspects, and Normal Patients

This study evaluates the change in intraocular pressure (IOP) and glaucoma medication requirements after clear corneal phacoemulsification in open angle glaucoma patients, glaucoma suspects, and normal patients at 3 years and last follow-up (mean 5 y). This study represents a retrospective analysis of patients who had clear corneal phacoemulsification and at least 3 years of follow-up. The patients were classified into 3 groups: glaucoma (G), glaucoma suspects (GS), and no glaucoma (NG). No patient had a history of previous intraocular surgery. Single factor analysis of variance, Fisher exact tests, 2-tailed paired Student t tests and Kaplan-Meier analysis were applied. Forty-eight patients (55 eyes) in the glaucoma group, 41 patients (44 eyes) in the GS group, and 59 patients (59 eyes) in the NG group met the above criteria. At 3 years follow-up IOP was significantly decreased in all groups; (G) group decreased 1.4+/-3.3 mm Hg (P = 0.0025), GS 1.4+/-4.2 mm Hg (P = 0.004), and NG 1.7+/-3.1 mm Hg (P = 0.0005). At the final follow-up visit (mean near 5 y for all groups) the IOP was significantly decreased in all groups, (G) group 1.8+/-3.5 mm Hg (P = 0.005), GS 1.3+/-3.7 mm Hg (P = 0.025), and NG 1.5+/-2.5 mm Hg (P < 0.0001). The number of preoperative and postoperative glaucoma medications in the (G) group did not show any significant change at 3 and 5 years (P = 0.36, P = 0.87). Kaplan-Meier analysis shows that at 3 years, 85% of the (G) group, 81% of GS, and 90% of the NG had IOPs less than or equal to their preoperative IOP, with the same number of glaucoma medications or less. At 5 years the percentages were 76%, 79%, and 85%, respectively. This study demonstrates that cataract removal by clear cornea phacoemulsification in glaucoma patients, glaucoma suspects, and normal patients results in a small but significant decrease in IOP that is sustained at 3 years and a mean of 5 years in all groups. This study does not imply that cataract removal by phacoemulsification is a substitute for a combined procedure but may be an appropriate procedure for certain patients based on medication requirements and extent of optic nerve damage.

Deep sclerectomy for the treatment of exfoliation and primary open‐angle glaucoma

To retrospectively compare the efficacy of deep sclerectomy in the treatment of primary open-angle glaucoma (POAG) and exfoliation glaucoma (ExG). Deep sclerectomy with either collagen or hyaluronate implants was performed in 31 eyes (45%) with POAG and 38 eyes (55%) with ExG. Pre- and postoperative intraocular pressure (IOP) was recorded, as was the number of glaucoma medications used pre- and postoperatively in each group. The follow-up data referred to a mean period of 18 months (range: 2 weeks to 36 months). At 18 months, complete success had been achieved in 56.3% of POAG eyes and 44.9% of ExG eyes. Qualified success had been achieved in 83.1% and 71.6% of POAG and ExG eyes, respectively. The mean IOP was 18.6 mmHg in POAG eyes and 16.3 mmHg in ExG eyes. YAG-descemetotomies were performed in nine eyes in each group. There were no statistically significant differences between the groups in IOP (except at 1 week postoperatively in favour of POAG; p = 0.05), success rates, need for postoperative glaucoma medication or number of complications. Reoperations were required in three (10%) POAG eyes and seven (18%) ExG eyes. Deep sclerectomy is equally effective in controlling IOP in both POAG and ExG and has low rates of serious complications, even when the surgeon is inexperienced in the technique. Both survival rates and IOP control were similar between the groups, and there were no serious intra- or postoperative complications.

Goniosurgery for Glaucoma Secondary to Chronic Anterior Uveitis

To describe the preoperative prognostic factors that correlate with the surgical success of goniosurgery for glaucoma complicating chronic anterior uveitis and to describe the surgical technique. The medical records of 31 patients with 31 eyes with glaucoma secondary to chronic anterior uveitis for which 38 goniotomy procedures were performed were reviewed. Uveitis etiology, gender, age of onset of iritis, duration of iritis before recognition of glaucoma, duration of iritis and duration of glaucoma until initial goniosurgery, preoperative gonioscopic findings, lens status, surgical outcome, age at initial goniosurgery, duration of postoperative observation, lens status, preoperative and postoperative intraocular pressures, topical steroid, and glaucoma medication use were reviewed. Complete success was defined by an intraocular pressure (IOP) < or = 21 mm Hg, and qualified success as IOP < or = 21 mm Hg with use of glaucoma medications. The surgical technique used to perform the goniosurgery was reviewed. Overall surgical success was achieved in 22 (71%) of 31 eyes. The mean age at surgery was 10.2 +/- 4.2 years (range, 4-21 years). All but 8 patients were female. Mean follow-up interval was 10.3 +/- 6.4 years (range, 1.5-22 years). Significant correlation was found between outcome and age at initial surgery, lens status, duration of glaucoma before goniosurgery, duration of iritis before glaucoma surgery, and hours of peripheral anterior synechia (PAS). The mean number of clock hours of preoperative (PAS) was 0.5 hours in eyes with success versus 2.5 hours in eyes with failure. Age of onset of iritis, duration of iritis before recognition of glaucoma, trabecular meshwork pigmentation (TM), TM opacification, and circumferential ciliary body band narrowing did not correlate with surgical outcome. Goniosurgery is an effective treatment of glaucoma secondary to chronic anterior uveitis. The outcome of surgery was unfavorably influenced by older age, longer duration of glaucoma, and evidence of more advanced preoperative filtration angle abnormalities secondary to uveitis. Goniosurgery for this secondary glaucoma can be successfully performed utilizing the standard goniotomy technique.

Nonpenetrating deep sclerectomy: a 6-year retrospective study.

Nonpenetrating trabeculectomy, also called nonpenetrating deep sclerectomy (NPDS), is a filtering surgery where the internal wall of Schlemm's canal is excised, allowing subconjunctival filtration without actually entering the anterior chamber. This, technique was developed to minimize the complications of trabeculectomy. The authors investigated its safety and efficacy in a retrospective noncomparative study. A total of 258 eyes (179 patients, mean age 61.4 +/- 11.56 years) with uncontrolled open angle glaucoma with prior medical therapy were treated. NPDS with a biocompatible collagen device (157 eyes) sutured to deep scleral bed or with the use of a 5-fluorouracil sponge (90 eyes) were analyzed. The main outcome measure was postoperative intraocular pressure (IOP) with an average follow-up of 54.4 +/- 17.07 months (range 1-85). Efficacy was determined 1 month, 3 months, and every 6 months after the procedure for 6 years. Mean preoperative IOP was 24.47 +/- 5.92 mmHg. Mean postoperative IOP was 14.44 +/- 5.31 mmHg (average lowering of the IOP was 38.94 +/- 23.81%) at 1 month, 15.16 +/- 4.57 mmHg (35.73 +/- 21.35%) at 3 months, 15.87 +/- 4.24 mmHg (32.45 +/- 20.52%) at 6 months, 16.32 +/- 4.53 mmHg (29.96 +/- 23.69%) at 12 months, 17.12 +/- 4.45 mmHg (26.51 +/- 23.93%) at 18 months, 16.77 +/- 4.44 mmHg (28.18 +/- 21.73%) at 24 months, 16.43 +/- 4.15 mmHg (28.89 +/- 23.69%) at 30 months, 16.34 +/- 4.12 mmHg (30.05 +/- 21.61%) at 36 months, 16.16 +/- 4.01 mmHg (30.06 +/- 22.55%) at 42 months, 15.71 +/- 3.74 mmHg (32.49 +/- 19.08%) at 48 months, 15.61 +/- 3.48 mmHg (31.26 +/- 21.01%) after 5 years, and 15.81 +/- 3.79 mmHg (33.73 +/- 20.9%) after 6 years. YAG goniopuncture was performed in 47.3% of cases with a mean follow-up of 12 +/- 13 months. These goniopunctures were effective in lowering IOP after a long-term follow-up (24 months). Additional 5-fluorouracil injections were used in 7% of cases. Visual field (Octopus or Humphrey mean defect and corrected loss variance or loss variance) was not modified (p < 0.01). Number of preoperative glaucoma medications was 2.01 +/- 0.58 and number of postoperative glaucoma medications was 0.85 +/- 0.92. Complications were peroperative microperforations in 27 eyes (10.5%), shallow anterior chamber in 2 eyes, hyphema in 2 eyes (0.8%), cataract in 5 eyes (2%), and dellen in 1 eye (0.4%). No cases of endophthalmitis or choroidal detachment were found. After surgery, 23 eyes (8.9%) required a new filtering surgical procedure, and diode laser cyclophotocoagulation was necessary in 2 eyes (0.8%). The probability success rate, defined as an IOP lower than 21 mmHg, was 66.46% (Kaplan Meier) at 60 months off all glaucoma medications and 80.32% with medical or new surgical treatment. NPDS appears to be an effective and safe filtering procedure for lowering IOP and could be an alternative to trabeculectomy in open angle glaucoma with the advantage of having fewer complications.

Results of phacoemulsification in eyes with preexisting glaucoma filters

A retrospective analysis was performed on 58 eyes that had temporal phacoemulsification via a clear corneal (32 eyes) or scleral tunnel (26 eyes) approach after previous filtration surgery with a minimum follow-up of 12 months. The study analyzed best-corrected visual acuity (BCVA), changes in intraocular pressure (IOP), and changes in glaucoma medication requirements. There were no statistically significant differences between the two groups in BCVA, IOP, and postoperative glaucoma medication requirements or between patients who received mitomycin C at the time of the original filter and those who did not. The mean preoperative logarithm of the minimal angle of resolution (logMAR) equivalent BCVA for all eyes was 0.8 + 0.4, which improved to a mean of 0.4 + 0.4 postoperatively (P < .0000002). The mean preoperative IOP in all eyes was 11.8 + 4.2 mm Hg and the mean final postoperative IOP was 13. 7 + 4.6 mm Hg (P < .022). The mean preoperative number of glaucoma medications for all eyes was 0.6 + 1.1 and the mean final postoperative number of glaucoma medications was 0.5 + 0.9 (not significant). Clear corneal or scleral tunnel phacoemulsification in the setting of a preexisting glaucoma filter was associated with improved BCVA, a small but statistically significant increase in IOP, and stability in the number of glaucoma medications required for IOP control over a minimum follow-up of 1 year.—Michael D. Wagoner

Results of phacoemulsification in eyes with preexisting glaucoma filters

Purpose To evaluate the intraocular pressure (IOP), best corrected visual acuity (BCVA), and glaucoma medication requirements in patients having phacoemulsification after preexisting glaucoma filters. Setting Ophthalmic Consultants of Boston, Boston, Massachusetts, USA. Methods A retrospective analysis of 58 eyes that had temporal phacoemulsification via a clear corneal (32 eyes) or a scleral tunnel (26 eyes) approach after filtration surgery was performed with a minimum follow-up of 12 months. Two-tailed homoscedastic t tests were used for statistical analysis. Results The mean preoperative IOP in all eyes was 11.8 mm Hg ± 4.2 (SD), and the mean final postoperative IOP was 13.7 ± 4.6 mm Hg ( P<.022). The mean preoperative logMAR equivalent BCVA was 0.8 ± 0.4, which improved to a mean of 0.4 ± 0.4 postoperatively ( P<.0000002). There was no statistically significant change in glaucoma medication requirements postoperatively. The differences in IOP, BCVA, and postoperative glaucoma medication requirements were not statistically significant between the clear corneal group and the scleral tunnel group or between patients who received mitomycin at the time of filtration surgery and those who did not. There were no intraoperative complications; 1 patient required additional glaucoma surgery. Conclusion Clear corneal or scleral tunnel phacoemulsification in the setting of a preexisting glaucoma filter was associated with improved BCVA, a small but statistically significant increase in IOP, and stability in the number of glaucoma medicines required for IOP control over a minimum follow-up of 1 year.

Changes in AC angle width and depth after IOL implantation in eyes with glaucoma

The elegant study by Hayashi et al demonstrated an increase in anterior chamber angle width and depth after intraocular lens implantation in eyes with glaucoma.1Hayashi K. Hayashi H. Nakao F. Hayashi F. Changes in anterior chamber angle width and depth after intraocular lens implantation in eyes with glaucoma.Ophthalmology. 2000; 107: 698-703Abstract Full Text Full Text PDF PubMed Scopus (253) Google Scholar The authors did not, however, state the indentation gonioscopic findings of those 77 eyes with angle-closure glaucoma (ACG) before and after cataract surgery. We believe this is of great relevance, because ACG patients with merely angle narrowing or appositional angle closure behave very differently from ACG patients with extensive or total synechial angle closure. In ACG patients with merely angle narrowing or appositional angle closure, we agree with Hayashi et al that cataract extraction would widen the drainage angle and thus decrease the aqueous outflow resistance, resulting in lower postoperative intraocular pressures (IOPs). In ACG patients with appositional angle closure but no cataract, the mainstay treatment should remain laser peripheral iridotomy and argon laser peripheral iridoplasty.2Ritch R. Argon laser peripheral iridoplasty an overview.J Glaucoma. 1992; 1: 206-213Crossref Scopus (35) Google Scholar In ACG patients with extensive or total synechial angle closure, however, the trabecular meshwork will remain occluded by peripheral anterior synechiae, despite anterior chamber deepening after cataract extraction. The trabecular meshwork will only be exposed if goniosynechialysis3Shingleton B.J. Chang M.A. Bellows A.R. Thomas J.V. Surgical goniosynechialysis for angle-closure glaucoma.Ophthalmology. 1990; 97: 551-556Abstract Full Text PDF PubMed Scopus (46) Google Scholar (GSL) is performed to separate adherent iris from the meshwork. To confirm this, we have performed ultrasound biomicroscopic examination of the anterior segment of an eye with 360° peripheral anterior synechiae and chronic ACG that underwent cataract extraction by phacoemulsification, intraocular lens implantation, and limited GSL over only the inferior 180° of the angle before and after surgery. Before cataract surgery and GSL, the trabecular meshwork was occluded by peripheral anterior synechiae in the whole 360° of the angle. After surgery, the anterior chamber depth and the apparent angle width increased significantly in the whole 360° of the angle as a result of the replacement of the thick cataractous lens by a thin intraocular lens. The trabecular meshwork is, however, only exposed to the aqueous in the inferior 180° of the angle, as a result of the adherent iris having been pulled away from the meshwork by GSL. In the superior 180° of the angle, the trabecular meshwork remained occluded by adherent peripheral iris despite the dramatic deepening of the anterior chamber. The trabecular meshwork had once again become accessible to aqueous in the anterior chamber only in that area where GSL was performed. Hayashi et al also stated in their article that “After cataract surgery, the IOP decreased in all three groups. No statistically significant differences were found in the mean IOPs at 1 and 6 months after surgery between the three groups, … ” Hayashi et al did not, however, report what IOP–lowering medications the glaucoma patients were receiving both before and after cataract surgery. We could not assess the IOP effects of cataract extraction without knowing the preoperative and postoperative glaucoma medications. High-resistance wind instruments and iopOphthalmologyVol. 108Issue 4Preview Full-Text PDF Author’s replyOphthalmologyVol. 108Issue 3Preview Full-Text PDF

Outcomes of combined cataract extraction, lens implantation, and trabeculectomy surgeries

PURPOSE: To report outcomes and their association with preoperative and intraoperative factors of 456 combined cataract and glaucoma operations. METHODS: A concurrent series (from January 1, 1987, to October 1, 1997) of one surgeon’s consecutive 585 (456 patients) combined cataract extraction, intraocular lens implantation, and trabeculectomy surgeries, some with intraoperative mitomycin C and/or postoperative subconjunctival 5-fluorouracil. The study was a retrospective outcomes analysis for the first 191 operations (before June 10, 1992) and, subsequently, concurrent outcomes analysis for the latter 394 operations. Main outcome measures included postoperative visual acuity, intraocular pressure, number of glaucoma medications, intraoperative and postoperative adverse event rates, and reoperation for glaucoma or other ocular surgical or laser intervention. RESULTS: Visual acuity was improved at the time of last follow-up in 402 (88.2%) of 456 first operated eyes of the 456 patients. Increasing age (coefficient = 0.025; CI [confidence interval], 0.017 to 0.33; P < .0001) was associated with a decreased likelihood of improved visual acuity, and a more recent operation (coefficient = 0.0037; 95% CI, −0.0064 to −0.0010, P = .0082) was associated with an increased likelihood of improved visual acuity. Forty-one (9.0%) of 456 eyes had reoperation to control intraocular pressure. Glaucoma reoperation was most strongly associated with a preoperative diagnosis other than primary open-angle, pigmentary, or pseudoexfoliative glaucoma, a history of previous ocular surgery, and high preoperative intraocular pressure. Mean intraocular pressure reduced 5.5 mm Hg from 21.8 mm Hg preoperatively to 16.3 mm Hg postoperatively and mean glaucoma medication from 2.0 to 0.9 medications. Mitomycin C or 5-fluorouracil use was significantly associated with a lower postoperative intraocular pressure and reduced postoperative glaucoma medication. Major postoperative adverse event or other reoperation (not for glaucoma) occurred in 12 (2.6%) of first operated eyes. CONCLUSIONS: Combined surgery outcomes in 456 first-operated eyes of 456 patients showed 88.2% improved visual acuity, 9% re-operation rate, 5.5 mm Hg mean intraocular pressure reduction, 1.1 glaucoma medication reduction, and a low major postoperative adverse event rate. Type of glaucoma, previous ocular surgery, and high preoperative intraocular pressure were the best predictors for the need for reoperation for glaucoma after combined surgery. Mitomycin C and/or 5-fluorouracil provided a greater reduction of mean intraocular pressure and glaucoma medication compared with patients not receiving these agents.

Comparative Study of Silicone versus Acrylic Foldable Lens Implantation in Primary Glaucoma Triple Procedure

To compare silicone versus acrylic foldable intraocular lens (IOL) implantation in primary glaucoma triple procedure (PGTP). Prospective, randomized. A total of 79 eyes of 79 primary open-angle glaucoma (POAG) patients in need of combined surgery were randomized to a silicone IOL group (36 eyes) and acrylic IOL group (43 eyes). The study eyes underwent PGTP, which consisted of primary trabeculectomy, phacoemulsification, and posterior chamber IOL implantation. Adjunctive mitomycin C (MMC) (0.5 mg/ml for 1 minute) was used selectively only in patients with one or more risk factors for filtration failure of PGTP. Snellen visual acuity, intraocular pressure (IOP), slit-lamp biomicroscopy, and number of glaucoma medications were measured, performed, or determined preoperatively and at regular intervals postoperatively. There were no significant differences in the mean number of postoperative glaucoma medications at 1, 2, 3, 4-6, and 9-12 months and at last follow-up (P > 0.05); mean change in corrected visual acuity best attained (P = 0.315) or at last follow-up (P = 0.223) between the silicone and acrylic groups. Both groups had significant decreases in mean IOP and mean number of medications postoperatively at all times (P < 0.05). However, the postoperative IOP > 25 mmHg and IOP spike > 5 mmHg above preoperative IOP during the first month were significantly higher in the acrylic group (P = 0.026). The mean postoperative IOP at 1 month in the acrylic group was also significantly higher than the silicone group (14.1 +/- 5.0, 11.2 +/- 3.9, P = 0.005). Conversely, there were no significant differences in mean postoperative IOP at 2, 3, 4-6, and 9-12 months and at last follow-up between the silicone and acrylic groups (P > 0.05). Suture removal or release occurred significantly more frequently in the acrylic IOL group during the first month and the first 2 months (48.8% and 60.5%) than the silicone group (25.0% and 36.1%, P = 0.030 and 0.031, respectively). There were no significant differences in postoperative complications or surgical interventions between the two groups (P > 0.05). During the first year following the PGTP with selective use of MMC, there were no significant differences in the medical dependency or visual outcomes or complications between the silicone and acrylic groups. Both groups attained significant decreases in IOP postoperatively. However, the mean IOP was significantly higher in the acrylic than the silicone group at 1 month postoperatively, and postoperative IOP > 25 mmHg and IOP spike > 5 mmHg above preoperative IOP were significantly greater in the acrylic group. There were significantly more suture releases in the acrylic IOL group than the silicone IOL group in the first 2 months postoperatively.

Transvitreal endocyclophotocoagulation

Transvitreal endophotocoagulation of the ciliary processes is a little-used option for eyes with refractory glaucoma. No histopathologic studies of animals or humans have described its effects. We sought to characterize this cilioablative procedure in an animal model, examine its effects in human eyes histopathologically, and evaluate its clinical safety and efficacy in a large series of patients with long-term follow-up.ANIMAL MODEL: Rabbit eyes were treated with lensectomy, vitrectomy, and transvitreal photocoagulation of the ciliary processes. Eyes were enucleated immediately after surgery and at weekly intervals up to 1 month. Light and electron microscopic evaluation of histopathologic changes was performed. Human Eyes: The pathology laboratory files were searched for cases with a history of endocyclophotocoagulation prior to enucleation, and three eyes were identified. Histopathologic sections were retrieved and examined. Clinical Series: A retrospective clinical review was performed of a single surgeon's experience with endolaser to the ciliary processes, including all cases with adequate data on ocular history, preoperative and postoperative visual acuity, intraocular pressure (IOP), and glaucoma medications, and details of surgery. Only eyes with at least 6 months' follow-up were included.ANIMAL MODEL: Histopathologic examination of rabbit eyes treated with endocyclophotocoagulation demonstrated acute changes of ciliary process destruction, proteinaceous exudate, stromal edema, nuclear pyknosis, and pigment dispersion. Vascular congestion was seen with some hemorrhage. Later, replacement by fibrous or fibrovascular scar developed with loss of the pigmented and nonpigmented ciliary epithelia, absence of ciliary architectural elements, and pigment rounding and clumping. Human Eyes: Histopathologic examination of enucleated human eyes revealed total ablation of the ciliary processes with fibrosis and pigment clumping in areas of treatment. Abrupt transitions between treated and untreated regions could be identified. In some areas fibrocellular membrane proliferation was found extending over the scars that replaced the ciliary processes. Clinical series: Seventy-three patients were identified ranging in age from 2 to 85 years (mean, 57.7), with follow-up of 6 to 130 months (mean, 28.6). Mean number of previous operations was 3.5; mean number of previous glaucoma operations was 1.3. Preoperative mean IOP was 38 mmHg (range, 19 to 75), postoperative mean IOP was 16 mmHg (range, 1 to 50). At 6 months, 58 of 72 eyes (81%) with available IOP data had IOP greater than 5 mmHg and less than 22. At 12 months 48 of 55 (87.3%) were successfully controlled by these criteria, and at last follow-up 50 of 73 (68%). Fifty-six of 73 eyes (77%) were considered clinically stable at the last follow-up in terms of visual acuity, anatomic integrity, and IOP < or = 23 off all glaucoma medications. Visual acuity was stable or improved in 53 of 73 eyes (73%). Complications developed in 9 eyes (12%), including IOP < or = 6 mmHg in 6 eyes (8.2%), peripheral choroidal effusion in 4 (5.5%), fibrinous anterior chamber reaction in 3 (4.1%), phthisis in 2 (2.7%), and choroidal hemorrhage in 1. Thirty-five eyes had penetrating keratoplasty performed before or at the same time as endolaser (an average of 2.14 grafts each), Graft rejection occurred in 4 eyes (11%), and long-term failure of grafts occurred in 11 of 35 (31%). In 31 eyes, additional surgical procedures were performed at the time of endocyclophotocoagulation.Endocyclophotocoagulation successfully ablates the ciliary processes, which are replaced with fibrous scar. Surgical results compare favorably with other methods of glaucoma therapy in complicated eyes in terms of IOP control, visual preservation, and complication rate. Endolaser to the ciliary body was especially successful in glaucomatous eyes after keratoplasty, although corneal graft prognosis

Trabeculectomy with Intraoperative Sponge 5-Fluorouracil

Purpose: To retrospectively assess the outcome of trabeculectomy surgery performed using intraoperative sponge 5-fluorouracil (5-FU) (50 mg/ml).Methods: Trabeculectomy with intraoperative sponge 5-FU was performed on 140 eyes of 119 patients. The reduction in intraocular pressure (IOP), the number of supplementary postoperative injections, and any treatment complications were noted.Results: The mean preoperative IOP was 25.7 ± 8.6 mmHg. The mean postoperative IOP was 12.5 ± 5.7 mmHg with a mean IOP reduction of 52% (P< 0.0001). One hundred twenty-one (86.4%) eyes required no postoperative glaucoma medications, with the mean number of glaucoma medications dropping from 2.5 ± 1.1 before operation to 0.3 ± 0.8 after operation (P < 0.001). One hundred five eyes received a mean of 5.3 ± 2.7 postoperative 5-FU injections. There was no significant difference in final IOP or success rate between low- and high-risk eyes, but high-risk eyes seemed to require supplementary postoperative 5-FU. Corneal epithelial damage arose in 52 (37%) eyes and correlated strongly with postoperative 5-FU supplementation.Conclusion: Intraoperative sponge 5-FU is a reasonably safe and effective adjunct to trabeculectomy surgery.