H. Dunbar Hoskins

Adverse Effects Experienced by Patients Taking Timolol

Adverse effects involving one or more organ systems occurred in 38 of 165 patients with various types of glaucoma when timolol was added to their glaucoma therapy. It was necessary to discontinue timolol because of these side effects in 15 (9%) of the patients. Double-masked studies will be necessary to clarify the relationship of these adverse effects to the use of timolol.

Ciliary block (malignant) glaucoma.

A review of the history, recognition, mechanisms, and therapy of ciliary block glaucoma has been given. Cycloplegic therapy is stressed in the susceptible eye.

Complications of laser trabeculoplasty.

Laser trabeculoplasty (LTP) is a relatively new procedure requiring evaluation for long-term effectiveness and associated complications. The authors review some 300 LTPs and identify complications. Among the most serious are transient or persistent rise in intraocular pressure, iritis, and progression of visual field loss. The authors recommend LTP as an alternative to glaucoma surgery in selected patients not controlled by medications.

Timolol and Pediatric Glaucomas

Thirty-eight eyes were treated by adding timolol to the medical regimen. After a suitable trial, attempts were made to reduce other glaucoma medications. Fifteen eyes with infantile glaucoma treated surgically at birth, experienced elevated intraocular pressure later in life. Another 15 eyes had glaucoma associated with congenital anomalies such as aniridia, Sturge-Weber syndrome, and mesodermal malformations. The group with infantile glaucoma demonstrated an average drop in pressure of 24% and 22% after one and three months, respectively. Six of the 15 eyes were controlled at 22 mm Hg or less. In the other group, intraocular pressure fell 30% after one month and 12% after three months. Five of the 15 eyes were controlled. Adverse effects occurred in five patients, timolol therapy was discontinued in two (7%). The IOP was not controlled in any of the eyes with timolol alone.

Laser Trabeculoplasty and the Glaucomas

A standard 100-spot laser trabeculoplasty was applied to 137 eyes of 109 presurgical patients with a variety of primary, secondary, and postsurgical glaucomas. Average follow-up was 15.3 months. Laser therapy was most successful in eyes without prior surgery (chronic open-angle glaucoma (COAG), pseudoexfoliation, pigmentary dispersion) or with only one prior operation (iridectomy, trabeculectomy, or intracapsular cataract extraction). The mean range for pressure reduction was 6 to 12 mmHg. Failures were frequently seen in eyes with angle recession, uveitis, or more than one operation. Visual field deterioration was seen in 11% of successful COAG eyes. Asymmetric responses in bilaterally treated COAG patients were seen half the time. A drift downward of 5 mmHg or more at six months after laser reversed itself by 12 months in approximately one out of eight eyes from various categories.

Subconjunctival THC:YAG Laser Thermal Scierostomy

A THC:YAG laser (thulium, holmium, chromium-doped YAG crystal) was used to create thermal sclerostomies in 21 glaucomatous eyes of 19 patients. The laser is a long-pulsed (300 microsec), compact, self-contained, solid state laser operating in the near infrared (2.1 mu). A 1-mm conjunctival stab incision was made 12 mm away from the sclerostomy site to allow entry of a specially designed 22-gauge (712 mu) optic probe that delivers energy at a right angle to the long axis of the fiber. Probe insertion produced minimal disturbance of the conjunctiva. Pulse energies of 80 mJ to 120 mJ were used with a repetition rate of 5 pulses/second. Total energy levels to produce full-thickness sclerostomies ranged from 1.4 to 4.8 J. Subconjunctival 5-fluorouracil injections were administered in 15 eyes. At 3 months the mean intraocular pressure of successful cases (16) was 14 mmHg (range, 9 to 22 mmHg). Of successful cases, the mean intraocular pressure at 6 months was 13 mmHg (range, 2 to 22 mmHg). Five cases failed within the initial 3 months, and 3 additional cases failed by 6 months. The authors conclude that this full-thickness sclerostomy technique may simplify filtering surgery without anterior chamber instrumentation and with minimal conjunctival trauma.

Long-term follow-up of initially successful trabeculectomy with 5-fluorouracil injections

PURPOSEnTo study the long-term results (1-14 years) of trabeculectomies with 5-fluorouracil injections that were successful at 1 year.nnnDESIGNnA retrospective noncomparative case series. INTERVENTION/PARTICIPANTS: We identified 87 patients (87 eyes) who had trabeculectomies with 5-fluorouracil injections from 1984 to 1989 that were successful at 1 year and had a follow-up range of 1.0 to 14.7 years (mean, 8.1, standard deviation of 4.4 years). All patients had previously failed glaucoma surgery (66.7%), cataract surgery (47.1%), or other diagnoses making them at high risk for failure.nnnMAIN OUTCOME MEASURESnSuccessful control of intraocular pressure (IOP) was defined as IOP less than 21 mmHg or a reduction of 33% if preoperative pressure was less than 21 mmHg. Statistical analysis was performed using Kaplan-Meier life table analysis.nnnRESULTSnIf an eye is considered successful by IOP at 1 year, the probability of successful control is 61% at 5 years, 44% at 10 years, and 41% at 14 years.nnnCONCLUSIONSnDespite successful IOP control at 1 year, trabeculectomies with 5-fluorouracil injections show a continual loss of IOP control over time.

The management of elevated intraocular pressure with normal optic discs and visual fields

Editors comment. Native tribes on the Calabar coast of West Africa (now Nigeria) coerced suspects on trial for witchcraft to eat the ordeal bean of Calabar. They called the active constituent, which produced intense vomiting, sweating and convulsions, eserine. Ludwig Laqueur, 101 years ago, successfully treated his own attack of acute angle closure glaucoma with topical eserine. After using the drug to treat a few patients with chronic open angle glaucoma, he recommended administering it in all cases of glaucoma simplex.., as iridectomy in this group is almost valueless (Zentralbl Med Wissensch 14:421, 1876). In controlled studies, W. C. Posey demonstrated the ability of miotics to abort glaucomas visually damaging progress, especially if treatment were begun early, leading a colleague to suggest that patients with glaucoma use miotics day in and day out to the end of life. (Arch Ophthalmol 24:378, 1895). By the mid-Twentieth Century, ophthalmologists frequently prescribed prophylactic miotics (ordeal drops?) to prevent optic nerve damage from elevated intraocular pressure, a practice now suspect, since only a small percentage of these patients, left untreated, develop visual field loss. In this pair of articles, Drs. Anderson and Hoskins present their opinions on the management of patients with ocular hypertension and normal visual fields, not simplistically (give era drops versus follow their fields), but in terms of the risk factors which predispose optic nerve damage. Each offers practical therapeutic recommendations. (Surv Ophthalmol 21:479-493, 1977)

Subconjunctival THC:YAG (“Holmium”) Laser Thermal Sclerostomy Ab Externo: A One-year Report

BACKGROUNDnLaser sclerostomy can be performed in a less-invasive manner than standard filtering surgery. Longer wavelengths in the infrared range have water-absorptive characteristics that facilitate perforation of the sclera. The goal was to perform laser sclerostomy ab externo to avoid intraocular instrumentation and minimize conjunctival trauma.nnnMETHODSnA thulium, holmium, chromium-doped:YAG (THC:YAG) crystal laser was used to create thermal sclerostomies in 49 glaucomatous eyes of 46 patients. The laser is a long-pulsed (300-microsecond), compact, self-contained, solid-state laser operating in the near infrared (2.1 microns). Energy was delivered via a specially designed 22-gauge (712-microns) optic probe that emits energy at a right angle to the long axis of the fiber. Pulse energies of 80 to 120 mJ were used. Total energy levels to produce full-thickness sclerostomies ranged from 1.4 to 7.2 J. Subconjunctival 5-fluorouracil (5-FU) injections were administered in 46 eyes. Success was defined as an intraocular pressure (IOP) of less than or equal to 22 mmHg with or without medications. For eyes in which preoperative IOP was less than or equal to 22 mmHg, success was defined as a decrease in IOP of greater than or equal to 30%.nnnRESULTSnEstimated probability of success allowing for one retreatment was 0.75 at 6 months and 0.68 at 12 months. Mean IOP of successful cases was 13.3 mmHg at both 6 and 12 months. Twelve cases failed within the initial 6 months, and two additional cases failed by 12 months.nnnCONCLUSIONnTHC:YAG (holmium) laser thermal sclerostomy is an alternative to other full-thickness filtration procedures. Further evaluation and understanding will define its ultimate role in glaucoma management.

Ophthalmic education: where have we come from, and where are we going?

T HIS PERSPECTIVE WILL FOCUS ON SOME OF THE PAST successes and future challenges in ophthalmic education in the United States and in the international arena. Leaders from several national and international organizations and supraorganziations have contributed various portions of the summary with their individual reports and reviews. In toto, they provide both a present snapshot of ophthalmology at the start of the 21st century and a future blueprint for the practicing ophthalmologist.