Arthur L. Schwartz

Intraocular Pressure Reduction in Normal-tension Glaucoma Patients

BACKGROUND In a collaborative study, patients with untreated normal-tension glaucoma were randomly assigned to a marked intraocular pressure reduction group or to a no therapy group. It was anticipated that medical therapy and laser trabeculoplasty would generally not achieve adequate pressure lowering and that fistulizing surgery would be required. This hypothesis was examined using current observations in the study. METHODS Patients randomized to the therapy group had a pressure reduction of at least 30% from their last prerandomization level. This was achieved within 6 months by means of fistulizing surgery or with pilocarpine and/or laser trabeculoplasty. Beta-blockers and adrenergic agonists were excluded from both eyes. RESULTS Of 30 patients with documented stable 30% pressure reduction, 17 (57%) achieved this with topical medication and/or laser trabeculoplasty: 8 with pilocarpine alone, 2 with laser trabeculoplasty alone, and 7 with laser trabeculoplasty after initial topical medication. The remaining 13 (43%) patients required a single fistulizing procedure. There was no statistically significant difference between the mean follow-up time for the nonfistulized group (533.8 +/- 437.6 days) and for the fistulized group (502.7 +/- 344.7 days). Both treatment groups had similar baseline profiles. CONCLUSION Marked pressure reduction can be achieved and maintained on a long-term basis by means other than fistulizing surgery in a large proportion of patients with untreated normal-tension glaucoma.

Application of handheld cautery for reduction of symptomatic circumferential trabeculectomy blebs.

PurposeTo describe a new, in-office procedure for limiting symptomatic, circumferential conjunctival blebs occurring after trabeculectomy. PatientsTwo eyes of 2 patients status postfornix-based trabeculectomy with mitomycin C were found to have symptomatic circumferential blebs. MethodsRisks and benefits of cautery were discussed, along with alternatives including continued conservative treatment or surgical revision. The patients opted for in-office cautery. Two eyes of 2 patients underwent cauterization of their blebs with a Bovie high temperature handheld cautery in the office after topical pretreatment with 2.5% neosynephrine and 4% xylocaine. Excess fluid was drained from the bleb by expression through the puncture wounds. The wounds were Seidel negative immediately after the treatment. ResultsFlattening of the bleb occurred instantly, patients did not experience pain and their symptoms related to the extensive bleb resolved. The functioning of the bleb was not altered in these 2 cases by this procedure. ConclusionsEarly results show that handheld cautery may be a useful means of treating symptomatic circumferential blebs.

Trabeculectomy for Glaucoma-Reply

In Reply. —We appreciate Dr Backs interest in our article. His letter raises two points. The first is in regard to the need to localize exactly the Schlemm canal and the trabecular meshwork. Our point was that since a trabeculectomy works by filtration and not by having aqueous pass through the cut ends of the Schlemm canal, it is not necessary to have the Schlemm canal in the excisional space. However, we agree with Dr Back that one should be in the general area of the filtration meshwork. If ones dissection is too far toward the posterior side, the ciliary body may be encountered with bleeding, vitreous loss, or an inadvertent cyclodialysis as complications. If it is too far anteriorly, corneal problems may develop. In response to his second point, our usual scleral flap is about 5 mm × 5 mm and the tissue excised is usually a 1 mm×4