Satisfactory Intraocular Pressure Control Research Articles

Reconstruction of Filtering Blebs with Free Conjunctival Autografts

Situations arise in which the surgical repair or revision of filtering blebs is either technically impossible or inadequate, and total reconstruction becomes necessary. This is most frequently encountered in eyes that have undergone multiple procedures, resulting in significant bulbar conjunctival scarring and episcleral fibrosis. To preserve the pre-existing filtration site, the authors successfully treated five such patients in whom conjunctival scarring adjacent to and surrounding the blebs precluded local revision, by transplanting free conjunctival autografts. Two patients required grafting from the fellow eye. Specific modifications from previously reported conjunctival flap techniques were used to enhance graft healing and continued filtration. Satisfactory intraocular pressure control was maintained in all patients receiving minimal to no anti-glaucomatous medications with an average follow-up of 42.6 months (range, 7-90 months). No patient had a significant decrease in visual acuity or surgical complications. Free conjunctival autografting techniques are a useful adjunct in the surgical revision of leaking, failed, or migrating filtration blebs.

Restoring the function of the failed bleb

AbstractFailure of the filtering bleb after trabeculectomy with a gonioscopically patent drainage cleft is likely to be due to: encapsulation of the bleb; flattening of the bleb; or cystoid bleb.Encapsulated blebs and flattened blebs are usually associated with a high intraocular pressure (IOP) while cystoid blebs are not, but corneal ulceration due to the prominent cystoid bleb may make revision of the bleb necessary. If the IOP is raised it is best to proceed quickly to needling of the bleb using 5‐fluorouracil. Sixteen patients underwent needling of the bleb, eight with encapsulated, six flattened and two cystoid blebs. Chronic open‐angle glaucoma (10 cases) was the commonest glaucoma. Twelve patients obtained satisfactory control of IOP with mean pre‐needling IOP for encapsulated blebs of 32 mmHg (4.27 kPa), flattened blebs 36 mmHg (4.8 kPa) and cystoid blebs 16mmHg (2.13 kPa), while post‐needling IOP for encapsulated blebs was 12 mmHg (1.6kPa), flattened blebs 13 mmHg (1.73 kPa) and cystoid blebs 12 mmHg (1.6 kPa). Mean follow‐up for encapsulated blebs was 15, flattened blebs 11 and for cystoid blebs nine months. Mean time between trabeculectomy and needling was: for encapsulated blebs 16 days; flattened blebs 24 days; and cystoid blebs 19 months.

Restoring the function of the failed bleb

Failure of the filtering bleb after trabeculectomy with a gonioscopically patent drainage cleft is likely to be due to: encapsulation of the bleb; flattening of the bleb; or cystoid bleb. Encapsulated blebs and flattened blebs are usually associated with a high intraocular pressure (IOP) while cystoid blebs are not, but corneal ulceration due to the prominent cystoid bleb may make revision of the bleb necessary. If the IOP is raised it is best to proceed quickly to needling of the bleb using 5-fluorouracil. Sixteen patients underwent needling of the bleb, eight with encapsulated, six flattened and two cystoid blebs. Chronic open-angle glaucoma (10 cases) was the commonest glaucoma. Twelve patients obtained satisfactory control of IOP with mean pre-needling IOP for encapsulated blebs of 32 mmHg (4.27 kPa), flattened blebs 36 mmHg (4.8 kPa) and cystoid blebs 16 mmHg (2.13 kPa), while post-needling IOP for encapsulated blebs was 12 mmHg (1.6 kPa), flattened blebs 13 mmHg (1.73 kPa) and cystoid blebs 12 mmHg (1.6 kPa). Mean follow-up for encapsulated blebs was 15, flattened blebs 11 and for cystoid blebs nine months. Mean time between trabeculectomy and needling was: for encapsulated blebs 16 days; flattened blebs 24 days; and cystoid blebs 19 months.

The Molteno implant in intractable glaucoma.

The long term results in ninety-six cases of intractable glaucoma managed with the Molteno seton are presented. Over 50% of cases achieved satisfactory intraocular pressure control and visual stabilisation.

Treatment of Congenital Glaucoma

We reviewed 37 consecutive patients who had undergone at least one goniotomy, filtering surgery, and patching for amblyopia because of congenital glaucoma between 1969 and 1979. Of 32 eyes treated for uncomplicated congenital glaucoma, 25 (78%) achieved satisfactory control of intraocular pressure. Seven of the 12 eyes (58%) for which Snellen visual acuities could be obtained had visual acuities of 6/15 (20/50) or better. Of eight eyes treated for complicated congenital glaucoma, four (50%) achieved satisfactory control of intraocular pressure, but the visual acuities of these patients could not be tested.

Long-term treatment with timolol ophthalmic solution in open-angle glaucoma.

A preselected population of 96 patients (67 glaucomas, 29 ocular hypertensions) were followed for an average period of 30 months. Timolol eye drops were administered either alone, in dosage strengths of 0.25 or 0.5% or in combination with other antiglaucoma drugs. 9 patients were lost to follow-up after a mean treatment duration of 15.3 months; glaucoma had been stabilized in all of them. 10 patients had unsatisfactory intraocular pressure control and 7 had to undergo trabeculectomy (9 of these 10 patients had campimetric glaucoma at the beginning of the study), whereas 76 patients had satisfactory intraocular pressure control and, in the majority, stabilization of glaucoma had been obtained. In 77% of this preselected population glaucoma was stabilized over a period of 3 years (i.e. close to two thirds of those starting treatment, 70% of which had campimetric glaucoma).

Comparison of the pupillary, refractive, and hypotensive effects of Ocusert-40 and pilocarpine eyedrops in the treatment of chronic simple glaucoma.

Twelve patients with chronic simple glaucoma were treated for 1 week with Ocusert-40, and the effects on the pupil, intraocular pressure, and refraction were measured. A comparison was made with the effects of pilocarpine eyedrop therapy in 8 of these patients. Both forms of pilocarpine treatment gave satisfactory control of intraocular pressure and both constricted the pupil to a similar degree shortly after initiation of treatment. During the week on Ocusert-40 the pupils redilated, so that 54% of the initial miosis remained after 7 days' wear. There was, however, considerable variability in the pupillary sensitivity to Ocusert-40 within and between eyes, and it is suggested that this may have been partly due to variable release rates of pilocarpine. Only minor decreases in visual acuity and refraction resulted from pilocarpine in either form. Seven of the 12 patients rejected Ocusert-40 because of discomfort or inability to retain the device.