Jonathan S. Myers

Boston keratoprosthesis outcomes and complications.

Purpose: To evaluate the outcomes of the Boston Keratoprosthesis (KPro) at our institution. Methods: A computerized database retrospectively identified all patients who received a Boston KPro from August 2005 to October 2007. Results: There were 37 patients, 24 (65%) were male. Mean age was 66.3 years (median 69 years, range: 24-93 years; SD = 18.1 years). Mean follow-up was 16 months (range: 6-28 months; SD = 6.0 months). There were 36 type 1 (97%) and 1 type 2 (3%) KPros. The primary indication was failed penetrating keratoplasty in 29 patients (78%)-22 (59%) from multiple failures. Preoperative comorbidities included glaucoma [27 patients (73%)] and limbal stem cell deficiency [13 patients (35%)]. No intraoperative complications occurred. Postoperative complications included retroprosthetic membrane [24 patients (65%)], increased intraocular pressure [14 patients (38%)], glaucoma progression [5 patients (13.5%)], and endophthalmitis [4 patients (11%)-3 who discontinued prophylactic antibiotics secondary to compliance]. Thirty-six KPros (97%) were retained-1 type 2 KPro (3%) in a patient with ocular cicatricial pemphigoid extruded and was replaced. Mean best-corrected visual acuities were counting fingers preoperatively (range: light perception to 20/100) and 20/90 at last follow-up (range: light perception to 20/25). At last follow-up, 31 patients (84%) improved 2 lines or greater-3 patients (8%) had worse vision. Conclusions: Retention rates were excellent, and best-corrected visual acuities improved in the vast majority of patients. Complications can occur and require frequent follow-up to monitor and treat glaucoma progression, endophthalmitis, and inflammation. Patient compliance is of paramount importance. Despite the potential complications, the Boston KPro provides visual improvement in patients with an otherwise poor prognosis.

Complementary and alternative medicine for glaucoma

Given the recent interest in complementary and alternative medicine (CAM), some patients may seek such treatments to supplement their traditional glaucoma management. The prevalence of CAM use for glaucoma is approximately 5%. We reviewed the literature to determine the potential benefit of various alternative treatments. Aside from a temporary osmotic effect from high dose intravenous ascorbic acid, there is no evidence that megavitamin supplementation has a beneficial effect on glaucoma. During exercise, autoregulation in healthy eyes seems to maintain a consistent blood flow rate to the optic nerve despite fluctuations in intraocular pressure (IOP). In a glaucomatous eye, the very modest IOP-lowering that follows exercise may be offset by the initial elevation in IOP that occurs when one first initiates exercise. At this time, there is no evidence to encourage or discourage the use of special diets, acupuncture, relaxation techniques, or therapeutic touch specifically for the treatment of glaucoma. Very little research has been done on the majority of herbal remedies with regard to their treatment of glaucoma. Marijuana can cause a profound lowering of IOP, but the high nonresponse rate, short half life, and significant toxicity are strong indicators that it is not an appropriate therapeutic agent. Ginkgo biloba and some other Chinese herbal remedies do not affect IOP, but may improve blood flow to the optic nerve and, as such, may have a beneficial effect on glaucoma. These agents have recognized toxicities. Although there are some well-designed studies of alternative treatments, many of the recommendations for using alternative treatments are currently unsupported by the data provided.

Use of latanoprost in the treatment of glaucoma associated with Sturge-Weber syndrome

PURPOSE To determine if latanoprost reduces intraocular pressure in eyes with glaucoma associated with Sturge-Weber syndrome. METHODS We conducted a prospective study in which eyes with uncontrolled intraocular pressure associated with Sturge-Weber syndrome were treated with latanoprost 0.005% once daily. All eyes were already receiving at least two other antiglaucoma medications. Intraocular pressure was measured at baseline and after treatment for at least 1 month. All intraocular pressure measurements were taken within 24 hours of drug instillation. RESULTS Six eyes of six patients received latanoprost. Two (28%) of the six eyes demonstrated an intraocular pressure decrease that averaged 8.8 mm Hg. These two responders had juvenile onset glaucoma, whereas the four nonresponders had congenital onset glaucoma. CONCLUSIONS Latanoprost may significantly reduce intraocular pressure in selected patients with glaucoma associated with Sturge-Weber syndrome.

Prevalence of the use of complementary and alternative medicine for glaucoma

OBJECTIVES To estimate the prevalence of complementary and alternative medicine (CAM) for glaucoma, explore possible demographic and disease-related associations, and inquire about the perceived benefit of these treatments. DESIGN Cross-sectional study. SETTING AND PARTICIPANTS One thousand twenty-seven consecutive patients from two urban, referral glaucoma practices. MAIN OUTCOME MEASURE Use of CAM specifically for glaucoma. RESULTS The response rate was 97.4%. The percentage of people reporting use of CAM for glaucoma was 5.4% (54 of 1000 subjects) with 32 of these 54 (59%) having used more than one type. The percentages of those using the various types of nontraditional medicine were: megavitamin therapy (62.9%), herbal therapy (57.4%), exercise (24.0%), diet modification (22.2%), meditation, (1.8%), acupuncture (1.8%), faith healing (1.8%), and homeopathic remedies (1.8%). Patients who used CAM were more likely to be educated beyond high school (P = 0.0014) and less likely to be retired (P = 0.0053). Use of nontraditional therapy was not strongly associated with race (P = 0.044), age (P = 0.062), gender (P = 0.24), length of diagnosis (P = 0.91), or number of glaucoma medications (P = 0.58). Of those using nontraditional therapy, 52% believed that it was helpful, 39% were unsure, and 9% considered it not helpful; 72% discussed their use with an ophthalmologist. Seventy percent discovered it from sources other than providers of either traditional or nontraditional care. CONCLUSIONS The prevalence of CAM use for glaucoma was 5.4% (95% confidence interval, 4.0%--6.4%). Most glaucoma patients currently cared for by ophthalmologists do not use nontraditional medicine.

Visual Field Staging Systems in Glaucoma and the Activities of Daily Living

PURPOSE To compare 8 clinically relevant methods of staging visual field (VF) damage in glaucoma with a performance-based measure of the activities of daily living and self-reported quality of life. DESIGN Prospective cross-sectional study. METHODS One hundred ninety-two patients with various types of glaucoma were evaluated at the Wills Eye Institute using standard monocular and binocular VF testing, as well as an objective, performance-based measure of visual function (the Assessment of Disability Related to Vision), and a subjective, standardized measure of quality of life (the 25-item National Eye Institute Visual Function Questionnaire). Binocular VFs were scored according to the Esterman and Integrated VF Systems. Monocular VFs were scored according to the mean defect, pattern standard deviation, Hodapp-Parrish-Anderson method, glaucoma staging system, glaucoma staging system 2, and the field damage likelihood scale. Partial Spearman correlations between VF staging systems, Assessment of Disability Related to Vision scores, and 25-item National Eye Institute Visual Function Questionnaire scores were calculated. RESULTS Assessment of Disability Related to Vision scores and 25-item National Eye Institute Visual Function Questionnaire scores were associated most closely with the VF score in the better eye and the binocular VF scoring systems. CONCLUSIONS The amount of binocular VF loss and the status of the better eye most accurately predict functional ability and quality of life in glaucoma.

Effect of topical anti-transforming growth factor-β on corneal stromal haze after photorefractive keratectomy in rabbits

Purpose: To determine the relationship between anti‐transforming growth factor‐&bgr; (anti‐TGF‐&bgr;) antibodies and the amount of corneal stromal haze after excimer laser photorefractive keratectomy (PRK). Setting: Wills Eye Hospital, Philadelphia, Pennsylvania, USA. Methods: Nineteen rabbits had bilateral PRK. Dichlorotriazinyl fluorescein was used to stain the exposed stroma; all rabbits were then treated with antibiotic ointment for 4 days. Ten rabbits were randomized to treatment with topical anti‐TGF‐&bgr;1, ‐&bgr;2, and ‐&bgr;3 antibody 50 gg three times a day for 4 days; the others received diluent three times a day for 4 days. Stromal haze was graded weekly for 8 weeks on a 0 to 4+ scale. At the end of the study, all corneas were examined histopathologically. Results: All treated eyes developed appreciable haze. Seven control rabbits and one antibody‐treated rabbit had an epithelial erosion (P = .00001). Antibody‐treated rabbits had significantly less haze at 3, 4, and 5 weeks (right eyes) and 3, 4, 5, 7 and 8 weeks (left eyes) (P < .05). Histopathology and fluorescence microscopy showed subepithelial collagen deposition consistent with clinical haze. Conclusions: Topical anti‐TGF‐&bgr; antibody reduced stromal haze after PRK in the rabbit model and may be clinically beneficial in humans.

Bilateral angle closure glaucoma induced by sulphonamide-derived medications

Background:  Sulphonamide‐derived medications are widely used, although not always recognized as such. We report the occurrence of bilateral angle closure glaucoma with sulphonamide‐derived medications and highlight features of the presentation and treatment to assist in early diagnosis and management.

Excisional bleb revision to correct overfiltration or leakage.

Objectives: To evaluate the effectiveness of excisional revision of filtering blebs for hypotony or leakage when more conservative measures have failed. Patients and Methods: Retrospective review of all patients who underwent excisional revision of a filtering bleb for hypotony (intraocular pressure [IOP] <5 mm Hg) or leakage during a 3 year period. The revision consisted of excision of the avascular bleb, mobilization of the surrounding conjunctiva, and suturing of the conjunctiva at the limbus. Results: Sixteen patients were included in the study. The average age was 66.3 ± 14.8 years (range, 39–83). Revision followed trabeculectomy in 11 cases, combined phacoemulsification‐trabeculectomy in three cases, and inadvertent blebs in two cases. Five cases had bleb leaks without hypotony, four cases had hypotony alone, and seven cases had both hypotony and a bleb leak. Average follow‐up after bleb revision was 25 ± 11 months (range, 9–43). Average IOP increased from 3.8 ± 5.6 mm Hg (range, 0–22) to 11.9 ± 4.1 mm Hg (range, 3–18), with an average of 1.1 ± 1.1 medication (range, 0–3). The IOP at the last visit was <15 mm Hg in all but two patients, with 10 of the 16 patients requiring medications. At the last follow‐up examination, visual acuity had improved ≥two lines in nine patients and was reduced two lines in one patient. Five patients had early postoperative limbal wound leaks; resuturing was required in one case. Conclusions: Excisional bleb revision is an effective technique to correct hypotony or leakage after filtering surgery when other methods have failed. Intraocular pressure control is often maintained with the use of medications.

Effect of transforming growth factor β1 on stromal haze following excimer laser photorefractive keratectomy in rabbits

BACKGROUND Transforming growth factor beta (TGF-beta) has been shown to affect wound repair. Anti-transforming growth factor beta 1 antibodies have been shown to neutralize its activity. METHODS Seventeen New Zealand White rabbits underwent unilateral photorefractive keratectomy followed by corneal staining with dichlorotriazinyl fluorescein. Three groups received topical transforming growth factor beta 1: 1 microgram/ml, 10 micrograms/ml, and 100 micrograms/ml; one group topical anti-transforming growth factor beta antibody (200 micrograms/ml); and a control group vehicle only. Corneal haze was graded from 0 to 4, weekly. Rabbits were sacrificed at 5 weeks and histopathological analysis and fluorescence microscopy performed. RESULTS All treated eyes developed haze and had epithelial erosions. No statistically significant differences in haze score were seen among individual treatment groups (Kruskal Wallis p > 0.05). The anti-transforming growth factor beta antibody group had less haze than all other groups at every week after the first. Comparing all transforming growth factor beta 1 treated eyes as one group to the antibody group, significantly less haze was seen at weeks 3 and 4 in the antibody treated group (p = 0.028 and 0.013, respectively). This study is limited by small group size and further studies are needed to confirm these results. CONCLUSION TGF-beta may be involved in stromal haze formation, and topical anti-TGF-beta 1 antibody may help reduce the development of stromal haze.

Timolol/dorzolamide combination therapy as initial treatment for intraocular pressure over 30 mm Hg.

Purpose:To determine the intraocular pressure (IOP)-lowering effect of a fixed timolol/dorzolamide combination (Cosopt®) for patients with IOP over 30 mm Hg. Study Design:Prospective interventional case series. Methods:Eighteen patients being seen on the Wills Eye Hospital Glaucoma Service with at least one eye with an IOP >30 mm Hg were recruited. None had used any glaucoma medications for at least 1 month. IOP was confirmed by diurnal testing. Cosopt was administered at 9 am and 9 pm. Trough IOP measurements were made at 9 am and peak IOP measurements at 11 am at baseline, 1 month, and 2 months. Pretreatment and posttreatment IOPs were compared using a paired-samples independent t test. Results:Mean pretreatment IOP was 37.5 ± 1.0 mm Hg. Baseline posttreatment IOP was 18.4 ± 0.5 mm Hg (P < 0.01). At 2 months, the mean trough IOP was 21.1 ± 0.9 mm Hg and the peak, 17.6 ± 0.6 mm Hg (each, P < 0.01, as compared with pretreatment baseline IOP). One patient did not respond to Cosopt; two had a clinically insufficient response and did not complete the study. Data from these patients were included in the analysis. Conclusions:Over 80% of the eyes responded to Cosopt, with an average trough IOP reduction of 40% at 2 months.