Adam C. Reynolds

Long-term Survival of Molteno Glaucoma Drainage Devices

PURPOSE To evaluate the long-term outcome of the Molteno implant drainage device using survival analysis. METHODS A retrospective chart review was performed on 77 eyes of 71 patients that underwent Molteno implantation for intractable glaucoma unresponsive to conventional management from October 1984 to April 1990 at the University of Washington Eye Center and had at least 6 months of follow-up data. Success was defined as a postoperative intraocular pressure of 22 mmHg or lower with (qualified success) or without (complete success) glaucoma medications and no additional glaucoma surgery, phthisis, or loss of light perception. RESULTS The median follow-up was 44 months (range, 6-107 months). Indications for Molteno implantation were aphakia/pseudophakia (n=24), neovascular glaucoma (n=20), uveitic glaucoma (n=12), failed trabeculectomy (n=9), traumatic glaucoma (n=8), and congenital glaucoma (n=4). The total success was 57% (23% complete; 34% qualified) at the last follow-up. Kaplan-Meier survival curves demonstrated a continuous and relatively linear attrition of success over at least 5 1/2 postoperative years. The uveitic glaucoma group had the highest success rate of 75%. Eyes with neovascular glaucoma failed significantly more frequently than those with uveitic glaucoma (P<0.01). There was no significant difference in outcome based on sex, race, single versus double plate, anterior chamber versus posterior chamber tube placement, or two-stage versus single-stage surgery. Younger age was associated with a significantly higher failure rate after controlling for glaucoma category (P<0.01). CONCLUSION The Molteno implant drainage device offers a reasonable long- term outcome in eyes with intractable glaucomas. However, an ongoing rate of failure, not unlike that seen after other filtration surgery, is to be expected.

Wound healing modulation in glaucoma filtering surgery.

Successful glaucoma filtering surgery is characterized by the passage of aqueous humor from the anterior chamber to the subconjunctival space, which results in the formation of a filtering bleb. Bleb failure most often results from fibroblast proliferation and subconjunctival fibrosis. This fibrosis at the level of the episclera results in a sealing of the flap and failure of the bleb. Factors associated with an increased risk of bleb failure include race, prior cataract surgery, active anterior segment neovascularization, inflammation, previously failed glaucoma filtering surgery, and previous use of topical glaucoma medications. Several surgical and pharmacologic techniques have been introduced to enhance the probability of successful surgery. This article summarizes the process of wound healing after glaucoma filtering surgery, describes factors that may affect success, and provides information regarding specific methods to improve surgical outcomes.

Management of blebitis by members of the American Glaucoma Society: a survey.

PurposeTo investigate the practice patterns among glaucoma subspecialists in the American Glaucoma Society regarding the management of blebitis. MethodsAn anonymous survey incorporating 14 questions regarding the management of blebitis was mailed to all current active American Glaucoma Society members, including provisional members, in October 1999. ResultsA total of 319 physicians received the survey, and 204 members (64%) returned surveys. Sixty-nine percent of respondents do not ask their patients with functioning blebs to use topical antibiotics at home for early symptoms of blebitis. Thirty-four percent never or almost never obtain conjunctival cultures at the onset of isolated blebitis, whereas 44% always or usually do. Fifty-one percent prescribe a topical fluoroquinolone alone as the initial empirical treatment of isolated blebitis. Twenty-three percent use a fluoroquinolone in combination with one or two other antibiotics. Twenty-one percent choose a combination of fortified topical agents, usually including a fortified aminoglycoside, vancomycin, or cephalosporin. Thirty-one percent use fortified agents in some combination with or without a fluoroquinolone. Five percent prescribe some other single agent alone. Only 6% routinely use an oral antibiotic in cases of blebitis. Sixty-two percent use topical corticosteroids in conjunction with antibiotic treatment. Of these, 68% start them after initial antibiotic treatment is established or once improvement of blebitis is noted. Fifty-six percent indicated that a moderate or severe anterior chamber reaction, including fibrin, would prompt treatment as a possible endophthalmitis. In a persistently Seidel-positive bleb, 77% generally attempt surgical bleb revision. ConclusionsMethods of the management of blebitis differ among members of the American Glaucoma Society. Treatment recommendations generated from randomized clinical trials are needed.

Probability maps of sequential Glaucoma-Scope images help identify significant change

PurposeThe purpose of this study was to identify areas of the optic disc showing high variability of repeated depth measurements, and to minimize the effect of baseline variability in interpretation of possible change over time using the Glaucoma-Scope. MethodsSeventy-four eyes from 70 subjects were analyzed with the Glaucoma-Scope. Three images were obtained on each of two separate sessions during the same day. At each location, the mean depth of the three images for each session was calculated to create a “baseline image.” A contour map of standard deviation (SD) values at each topographic location was created for each subject reflecting local variability at different parts of the disc. The contour map and disc photograph were compared to determine what photographic features predicted high variability. A modified two-sample t-test was used at each topographic location to obtain p-values for the likelihood that a difference in mean depth between sessions was attributable to measurement variability alone. ResultsContour plots of SD for most subject eyes showed high variability in steeply sloped areas of the disc and along large blood vessels, with low variability near the cup center. The use of probability plots for significance of depth changes between test sessions automatically accounted for increased pointwise variability. The proportion of topographic locations showing statistically significant change but attributable to chance variation when no true change has occurred approximated the predicted proportion based on our modified t-test model. ConclusionA contour map of standard deviations of depth based on Glaucoma-Scope baseline images can identify areas of the disc with high variability. Statistical methods such as probability maps that account for local variability in the baseline image may be helpful in distinguishing true change from artefactual change over time.

CLINICAL PERSPECTIVES ON GLAUCOMA-FILTERING SURGERY: Antiproliferative Agents

The goal of glaucoma filtering surgery is to establish a permanent flow of aqueous from the anterior chamber to the subconjunctival space and thereby lower intraocular pressure (IOP) in eyes with uncontrolled glaucoma. Although often successful when performed in previously unoperated eyes with primary open-angle glaucoma, chronic angle-closure glaucoma, and some of the secondary glaucomas (e.g., exfoliative and pigmentary glaucoma), certain risk factors reduce the likelihood of success in glaucoma filtering surgery. 74 These risk factors include aphakia or pseudophakia, previously failed filtering surgery, a history of anterior segment neovascularization, severe inflammation, youth, race, and previous medical therapy, especially with cholinergic and sympathomimetic agents. 6,7 Numerous pharmacologic and surgical techniques have been described to improve the outcome in high-risk eyes. In the early 1980s, 5-fluorouracil (5-FU) was introduced as a postoperative adjunct to glaucoma filtering surgery. 25 This agent has been clearly shown to increase surgical success not only in high-risk eyes 26,58,59,82,84 but also in primary filtering procedures. 40,50,86 The use of intraoperative mitomycin was also first reported in the early 1980s. 11 In the 1990s, use of this agent as well as intraoperative and postoperative 5-FU became widespread. This article reviews the background, rationale, and surgical indications for use of the two antiproliferative agents, 5-FU and mitomycin; appropriate operative and perioperative techniques; and management and avoidance of complications associated with their use.

Laser bleb reduction for bleb dissection with krypton green laser: technique and outcomes.

PurposeLasers have been used to treat dysfunctional blebs, but the laser remodeling of blebs that dissect into the palpebral fissure has not been reported. We describe the unique use of krypton green laser to treat dissected blebs and discuss treatment outcomes. Patients and MethodsRetrospective review of consecutive patients undergoing laser bleb reductions (LBRs) over a 6-year period. Failure was defined as persistent dissection and/or symptoms or loss of intraocular pressure (IOP) control despite medications. ResultsSixteen patients underwent a total of 23 LBRs and were followed-up for a mean of 12.4 months (median=9.5 mo). Ten patients (63%) were treated successfully, and 6 patients (37%) failed treatment. Persistent dissection and/or symptoms were the most common reasons for failure (5/6), whereas 1 patient lost IOP control. Three (30%) of those treated successfully required the reintroduction of ocular hypotensive medications for pressure control. The mean IOP increased from 9.1±5.2 mm Hg before treatment to 11.7±8.1 mm Hg after treatment (P=0.02). Common complications included intraoperative discomfort (26%), conjunctival injection (22%), postoperative discomfort (13%), and dissection into the untreated side (9%). In the failure group, more laser spots (P=0.05) and higher power levels (P=0.00001) were used. ConclusionsKrypton LBR may be a useful initial treatment modality for symptomatic bleb dissection. Success rates may be modest, but most adverse effects are mild and/or transient; however, significant loss of IOP control can occasionally occur.

A 61-Year-Old Woman With Headaches and Aphasia.

A 61-year-old woman with a history of migraine headaches and focal segmental glomerulosclerosis, chronically immunosuppressed with mycophenolate mofetil, presented to a hospital with 2 weeks of left-sided headache and word finding difficulty. She described her headaches as constant pain similar in location and character to her typical migraines and involving her left face. The day prior to presentation, she developed slowed speech, stuttering, and confusion. On admission, a noncontrast computed tomography scan of her head revealed a large hypodense lesion involving the left hemisphere with 7 mm of midline shift. Magnetic resonance imaging (MRI) of the brain showed a large, confluent area of increased T2 and decreased T1 signal involving the left frontal, parietal, and temporal lobes (Figure 1). Cerebrospinal fluid (CSF) analysis revealed 1 nucleated cell, elevated protein and normal cytology and flow cytometry (Table 1). Due to concern for vasogenic edema from an underlying mass lesion, treatment with intravenous dexamethasone 6 mg 4 times daily was initiated on hospital day 1. Subsequently, a diagnostic procedure was obtained. She was transferred to our facility on hospital day 7 for further evaluation. She reported significant improvement in her cognition and word finding difficulties after starting dexamethasone. She endorsed malaise over the past month though denied fevers, loss of consciousness, weakness, sensory changes, seizure, visual disturbance, hearing changes, nausea, or vomiting. On examination, she was alert and interactive. Her temperature was 36.0 C, blood pressure 141/78 mm Hg, and pulse 48 beats per minute. Her neurologic examination was notable for crisp discs on fundoscopic evaluation, expressive aphasia characterized by word-finding difficulty and paraphasic errors, impaired delayed recall, and mild gait ataxia. Laboratory studies revealed a white blood cell count of 14 400/mL (normal 4.3-10 thousand/mL). A repeat MRI 8 days after the initial brain MRI demonstrated interval decrease in midline shift to 3 mm and a persistent large area of confluent left hemisphere T2 hyperintensity. Susceptibility-weighted imaging (SWI) showed multiple microhemorrhages confined to the area of T2 hyperintensity that were not noted on the gradient echo (GRE) sequence of the prior MRI (Figure 1).