Alana L. Grajewski

5-Fluorouracil Filtering Surgery and Neovascular Glaucoma: Long-term Follow-up of the Original Pilot Study

BACKGROUND The long-term efficacy and safety of filtering surgery with 5-fluorouracil (5-FU) in eyes with neovascular glaucoma are unknown. METHODS Kaplan-Meier survival curve analysis of surgical outcome was performed on all 34 patients (34 eyes) enrolled from May 1982 through April 1986 in the original pilot study of filtering surgery with 5-FU. RESULTS Success rates at the 1-, 2-, 3-, 4-, and 5-year intervals were 71%, 67%, 61%, 41%, and 28%, respectively. The median filter survival time was 38.7 months (95% confidence interval: 32-45 months). Twelve (35%) of 34 patients lost light perception vision, and phthisis bulbi developed in 8 (24%) of 34 patients. Age of 50 years or younger (P < 0.0001) and type 1 diabetes (P = 0.0004) were significant risk factors for surgical failure. The 1-year success rate for patients no older than 50 years of age was 23% compared with a 95% success rate in patients older than 50 years of age. After adjustment for age, type 1 diabetes was a borderline risk factor (P = 0.06). CONCLUSION There is a high risk of long-term failure of filtering surgery with 5-FU in neovascular glaucoma. Patients 50 years of age or younger have an extremely poor prognosis. Patients older than 50 years of age have initial short-term success with an accelerated failure rate after 3 years.

Axenfeld-Rieger syndrome

Axenfeld-Rieger syndrome is a genetic disease affecting multiple organ systems. In the eye, this condition manifests with varying degrees of anterior segment dysgenesis and carries a high risk of glaucoma. Other associated systemic issues include cardiovascular outflow tract malformations, craniofacial abnormalities and pituitary abnormalities, which can result in severe endocrinological sequelae. Recent advances in molecular genetics have identified two major genes, PITX2 and FOXC1, demonstrating a wide spectrum of mutations, which aids in the molecular diagnosis of the disease, although evidence exists to implicate other loci in this condition. The management of individuals affected by Axenfeld-Rieger syndrome requires a multidisciplinary approach and would include dedicated surveillance and management of glaucoma, sensorineural hearing loss, and cardiac, endocrinological, craniofacial and orthopaedic abnormalities.

Axenfeld-Rieger syndrome: new perspectives.

Axenfeld-Rieger syndrome is a genetic disease affecting multiple organ systems. In the eye, this condition manifests with varying degrees of anterior segment dysgenesis and carries a high risk of glaucoma. Other associated systemic issues include cardiovascular outflow tract malformations, craniofacial abnormalities and pituitary abnormalities, which can result in severe endocrinological sequelae. Recent advances in molecular genetics have identified two major genes, PITX2 and FOXC1, demonstrating a wide spectrum of mutations, which aids in the molecular diagnosis of the disease, although evidence exists to implicate other loci in this condition. The management of individuals affected by Axenfeld-Rieger syndrome requires a multidisciplinary approach and would include dedicated surveillance and management of glaucoma, sensorineural hearing loss, and cardiac, endocrinological, craniofacial and orthopaedic abnormalities.

Beta-adrenergic Responsiveness of Choroidal Vasculature

Using in vitro binding methods and autoradiographs, the authors showed that choroidal vessels specifically bind iodine 125 cyanopindolol, a nonselective blocker of beta-adrenergic receptors, in albino rabbits. In humans, the presence of beta-adrenergic receptors in choroidal vessels was confirmed by showing an increased choroidal vascular tone after systemic administration of timolol maleate, a nonselective beta-adrenergic blocker. Topically administered timolol maleate lowered the intraocular pressure but did not reach the choroidal receptors in sufficient quantity to produce a measurable effect on vascular tone.

Uveitis-Glaucoma-Hyphema Syndrome and Corneal Decompensation in Association With Cosmetic Iris Implants

PURPOSE To report a case and management of uveitis-glaucoma-hyphema (UGH) syndrome and corneal decompensation associated with cosmetic iris implants. DESIGN Interventional case report. METHODS SETTINGS Department of Ophthalmology, University of Minnesota School of Medicine. PATIENTS A 29-year-old man presented with bilateral redness, severe pain, photophobia, and reduction in visual acuity. Examination revealed intraocular pressure (IOP) of 38 mm Hg and 40 mm Hg right and left eye respectively, bilateral conjunctival injection 3+, epithelial corneal edema, microhyphema, cells 3+ to 4+ and flare 2+, bilateral cosmetic iris implants, and surgical peripheral iridectomies. The patient was diagnosed with UGH syndrome and corneal decompensation associated with cosmetic iris implants. INTERVENTION Immediate medical management of inflammation and elevated IOP, anterior segment imaging, specular microscopy, Humphrey 24-2 visual field (VF) testing; following failed conservative management, combined trabeculectomy and removal of the iris implants. MAIN OUTCOME MEASURES Anterior chamber inflammation and microhyphema, IOP, and corneal edema. RESULTS Anterior segment imaging demonstrated bilateral implant-iris apposition and implant-angle structures apposition. Specular microscopy demonstrated a significant reduction of the number of endothelial cells. VF test demonstrated a right superior arcuate scotoma and a normal left VF. Following surgical treatment IOP normalized and inflammation and microhyphema subsided. However, mild corneal edema persisted. CONCLUSION Cosmetic iris implantation may lead to UGH syndrome and corneal decompensation. Therefore, its use should be reserved for patients with significant medical indications, and avoided in patients with intact natural iridies, until more short-term and long-term safety data are available.

Nd: YAG cyclophotocoagulation: Outcome of treatment for uncontrolled glaucoma

We reviewed the records of 35 patients (35 eyes) treated with Nd:YAG cyclophotocoagulation for uncontrolled glaucoma and followed for 6 to 36 months or until treatment was declared a failure (loss of light perception, or intraocular pressure (IOP) greater than 21 mm Hg). The mean pretreatment intraocular pressure was 37.9 mm Hg (range, 20 to 61 mm Hg). The total energy in the initial treatment session ranged from 50.4 to 372.4 J (191.7 +/- 66.3 J). After the treatment, the mean IOP was 21.2 mm Hg (range, 0 to 53 mm Hg). The Kaplan Meier survival analysis demonstrated that failures occurred throughout the follow-up period and that the majority of patients required further intervention or lost all vision if followed long enough. Visual outcome was not correlated with energy used. Eleven eyes (31%) lost two or more lines of acuity or lost all light perception. These findings suggest that Nd:YAG cyclophotocoagulation may control IOP but cannot always save vision.

Reproducibility and agreement in evaluating retinal nerve fibre layer thickness between Stratus and Spectralis OCT

PurposeTo evaluate intra-device reproducibility of retinal nerve fibre layer (RNFL) measurements obtained using Stratus and Spectralis optical coherence tomography, and to analyze inter-device correlation and agreement for these measurements.DesignProspective observational study.MethodsA total of 30 normal individuals participated in the study. One eye of each participant was scanned three times during one session by the same operator using Spectralis and Stratus. Intra-class correlation coefficients (ICCs), correlation coefficients (R), and Bland–Altman plots (BAPs) were used to assess reproducibility, correlation, and agreement between the two devices, respectively.ResultsA significant difference in mean RNFL thickness was seen between Stratus and Spectralis (106.2±6.9 μm vs100.0±7.3 μm, P=0.0001). ICCs of RNFL thickness measurements ranged from 0.69 (clock hour 2; 95% confidence interval (95% CI): 0.54, 0.85) to 0.91 (inferior quadrant; 95% CI: 0.86, 0.96) for Stratus and were higher for Spectralis, ranging from 0.87 (temporal-superior sector; 95% CI: 0.79, 0.94) to 0.96 (global and nasal-inferior sector; 95% CI: 0.94, 0.99). Rs of RNFL thickness measurements between the two instruments ranged from 0.61 (temporal quadrant) to 0.87 (superior quadrant). BAPs demonstrated a systematic difference in RNFL values between the two devices, with Spectralis producing thinner RNFL values than Stratus.ConclusionsSpectralis demonstrated higher ICCs and thinner RNFL measurements than Stratus. Although the inter-device correlation was good, differences in RNFL measurements obtained by the two devices indicate that these measurements would not be interchangeable in clinical evaluations.

5-Fluorouracil after Trabeculectomy and the Iridocorneal Endothelial Syndrome

Nine patients (nine eyes) with iridocorneal endothelial (ICE) syndrome underwent trabeculectomy and received postoperative subconjunctival injections of 5-fluorouracil (5-FU) to enhance bleb formation (total 5-FU dose, 30-105 mg; mean, 53.8 mg). Eight eyes had undergone prior unsuccessful trabeculectomy. Four eyes had intraocular pressure (IOP) less than or equal to 21 mmHg on zero to two glaucoma medications after 6 to 54 months of follow-up (mean, 25.3 months). Five eyes required repeat surgery within 2 to 13 months and were considered failures. All five eyes that failed received a Molteno drainage implant. Progressive endothelial proliferation may explain late onset bleb failure and the relative ineffectiveness of 5-FU in this condition.

Surgical Revision of Glaucoma Shunt Implants

BACKGROUND AND OBJECTIVE To determine the efficacy of surgical revision of glaucoma shunt implants in patients with advanced glaucoma. PATIENTS AND METHODS The records of 13 patients who underwent revision of their shunt implants were retrospectively reviewed. RESULTS Surgical success was achieved in: 3 of 3 patients (100%) with drainage tube malposition or extrusion; 1 of 6 patients (17%) with occlusion of the intracameral portion of the drainage tube; and 1 of 4 patients (25%) with elevated intraocular pressure secondary to fibrous capsule formation over the implant. CONCLUSIONS Surgical revision of glaucoma shunt implants is a useful procedure in patients who develop tube malposition or extrusion. Surgical revision is much less effective in patients with tube occlusion or fibrous capsule formation. Failure of the shunts due to recurrent fibrosis is commonly observed.

Vitrectomy for pars plana placement of a glaucoma seton.

Trabeculectomy, even with supplemental antifibrosis agents, has a low success rate in controlling intraocular pressure (IOP) in certain cases; ones involving severe anterior-chamber-angle disease are particularly challenging. Ten patients with advanced, non-neovascular glaucoma underwent vitrectomy and pars plana placement of seton implants. The tube was placed through the pars plana sclerotomy in each case because severe anterior chamber angle narrowing, aphakia, or penetrating keratoplasty prevented standard placement. Previous trabeculectomy had failed to control IOP in 9 of the 10 patients. In each, the preoperative IOP was 25 mm Hg or more despite maximal medical therapy. In nine of the patients, the postoperative IOP was 19 mm Hg or less, without pressure-lowering agents. The seton appeared to be functional in all of the cases. Vision remained stable or improved in seven cases, but deteriorated in three due to graft failure, progressive traction retinal detachment, or rhegmatogenous retinal detachment (one case each). Pars plana placement of tubes for glaucoma seton implants should be considered as an alternative to anterior chamber placement in certain cases of refractory glaucoma in which the anterior chamber anatomy has been severely disrupted.