M. Fran Smith

Results of Intraoperative 5-Fluorouracil Supplementation on Trabeculectomy for Open-angle Glaucoma

The success rate of filtration surgery has been increased by the postoperative subconjunctival injection of 5-fluorouracil, a potent antimetabolite. However, the optimal route of administration has not been determined. Trabeculectomy was performed on one eye each of 14 patients. Topical 5-fluorouracil was applied intraoperatively (50 mg/ml for five minutes) and subconjunctival 5-fluorouracil was injected postoperatively (an average of 5.8 injections) (mean total dose, 29 mg). Seven of the 14 eyes had primary open-angle glaucoma, and seven eyes had open-angle glaucoma with either uveitis, aphakia, or previous failed trabeculectomy. Mean preoperative intraocular pressure was 24.7 mm Hg during treatment with an average of three antiglaucoma medications, and mean final intraocular pressure was 11.9 mm Hg during treatment with an average of 0.2 medication. Thirteen of 14 eyes (93%) had final intraocular pressure of 18 mm Hg or less. Mean follow-up was 6.4 months (range, four to nine months). No remarkable complications occurred. Visual acuity remained stable in 13 of 14 eyes (93%). Intraoperative 5-fluorouracil may be a helpful adjunct in achieving low final intraocular pressure after trabeculectomy.

Intraoperative and post operative treatment with 5-Fluorouracil and mitomycin-c: long term effects in vivo on subconjunctival and scleral fibroblasts

Rabbits undergoing full thickness glaucoma filtering surgery were exposed to one of 4 treatments. Group 1 received intraoperative distilled water, group 2 received intraoperative mitomycin-c 0.2 mg/ml for 5 minutes, group 3 received 5 post operative injections of 5-Fluorouracil (5-FU) 5 mg in 0.1 ml, and group 4 received intraoperative 5-FU 50 mg/ml followed by 5 post operative injections of 5-FU. 30 days after the operation tissue biopsies were taken from the subconjunctival and scleral tissue at the treated area and 90 and 180 degrees from the treated area. The biopsies were then placed in tissue culture media and the outgrowths quantitated. The fibroblast outgrowths from all areas did not differ significantly from each other except for the outgrowths from the areas directly treated with mitomycin 0.2 mg/ml which were significantly smaller. In addition then cells were morphologically abnormal although there were foci of normal cells which appeared to be growing from localised areas in the tissue biopsies. The outgrowths from the areas 90 and 180 degrees from the treated area were normal. Intraoperative treatments with mitomycin-c result in long term inhibition of fibroblast proliferation limited to the treated area, when compared with intraoperative and postoperative treatment with 5-FU. Failure of filtration surgery in eyes treated with intraoperative mitomycin may in part be due to unaffected cells reproliferating.

Treatment of postfiltration bleb leaks with autologous blood

BACKGROUND Managing filtration surgery bleb leaks can be difficult as well as frustrating. Treatment options traditionally have included aqueous suppressants, patching, and bleb compression devices. Previously, if conservative management failed, surgical revision was considered. METHODS Six patients with thin avascular blebs and discrete leaking holes (2 had had full-thickness procedures, 4 had had trabeculectomy with mitomycin C) underwent subconjunctival injection of approximately 1 ml of whole autologous blood. Injections were made just lateral and just medial to the domed cystic elevation of the blebs. RESULTS Five of six eyes were leak-free by the second day after the procedure. No complications occurred. After 4 to 12 months of follow-up, four eyes are currently leak-free. In these eyes, intraocular pressure is between 8 and 12 mmHg. CONCLUSION Subconjunctival peribleb injection of autologous blood may be a safe and helpful adjunct in treating selected postfiltration surgery bleb leaks.

Selective Laser Trabeculoplasty in Phakic and Pseudophakic Eyes

The anatomic response to intravitreal bevacizumab injection in three patients with aggressive, posterior retinopathy of prematurity is described. In all cases, the worse eye was treated with a single intravitreal injection of 0.75 mg of bevacizumab as monotherapy or complementary to laser therapy. In 24 hours, all injected eyes showed regression of the tunica vasculosa lentis and iris vessel engorgement and disappearance of iris rigidity. In addition, plus disease and retinal proliferation began to regress. None of the eyes required additional treatment. Follow-up of up to 10 months

Modified aqueous drainage implants in the treatment of complicated glaucomas in eyes with pre-existing episcleral bands

OBJECTIVE Control of intraocular pressure (IOP) after retinal surgery with scleral band placement may be problematic. In this study, outcome after silastic drainage implant placement is reviewed. DESIGN/PARTICIPANTS A retrospective chart review of 11 eyes in 11 patients with severe glaucoma after multiple surgeries, including scleral buckle procedures. INTERVENTION Patients received silastic drainage implant surgery, either a long Krupin Denver valved implant (7) or a trimmed Baerveldt seton (4). MAIN OUTCOME MEASURES Vision, IOP, and need for further glaucoma medication or glaucoma surgery were measured. RESULTS One- and 2-year life-table success rates (either complete or qualified success) were 82% and 73%, respectively, defining success as final IOP of 21 mmHg or less without need for further glaucoma surgery and no loss of visual acuity. Half of the successful eyes required antiglaucoma medication. CONCLUSIONS Silastic drainage implants may be a viable option in the treatment of complicated glaucoma after retinal surgery.

Glaucoma medical treatment--2002: does yearly cost now equal the year?

Background. To review costs of the wide array of glaucoma medications available today as well as patient-assistance programs. Methods. Potential yearly costs for current frequently used single and multiple drug therapies were determined, taking into account the actual (not labeled) volume of drops in the bottled medications. Alternative modes for obtaining medications, such as compassionate-use programs, were also surveyed. Results. “Maximum” medical therapy may cost over

Failed glaucoma drainage implant: long-term outcomes of a second glaucoma drainage device versus cyclophotocoagulation

2000 per year. Allergan, Ciba, Merck, Pharmacia-Upjohn, and Alcon offer patient-assistance programs of variable simplicity of use. Discussion. The cost of maximum glaucoma medical therapy can assume a significant proportion of an elderly patient’s yearly income.

New Aqueous Inflow Inhibitors

Background/aims To evaluate long-term efficacy of a second glaucoma drainage device (GDD) versus cyclophotocoagulation (CPC) after failure of primary drainage implant. Methods This is a non-randomised, retrospective cohort study. A chart review was conducted of patients who underwent GDD surgery between July 1986 and November 2012 requiring further glaucoma procedures for intraocular pressure (IOP) control. An additional GDD was placed in 15 eyes, while 32 eyes underwent CPC. The main outcome measurement was IOP control and/or time to failure of secondary intervention (IOP >18 mm Hg on two sequential measurements). Results Mean follow-up after the second procedure was 63±65.8 months (range 6–254 months) in the CPC group and 132±91.8 months (range 12–254 months) in the GDD group. Thirty-four per cent (11/32 eyes) undergoing CPC later required further treatment at a mean of 13.6±10.7 months with 10/11(91%) of additional interventions occurring within 2 years. Despite an initially high success rate for IOP control in the first 5 years, eventually 60% (9/15 eyes) that underwent a second tube required additional treatment at a mean of 73.4 months with only 2/9(22%) requiring this within the first 2 years. The risk of visual acuity worsening by 2 Snellen lines or more at 12 months was 5/14 for the GDD group (36%) and 4/23(17%) for the CPC group. Conclusions After failure of an initial drainage implant to control IOP, a sequential tube had a high initial rate of success but a relatively high likelihood of long-term failure, generally after 6 years. Eyes that received CPC tended to fail earlier, often within the first year, but had relatively few late failures.

Cataract Surgery in the Glaucoma Patient: Advances and Modifications

Several new aqueous inflow inhibitors have been introduced over the past few years. These new agents include two alpha agonists, two topical carbonic anhydrase inhibitors, and a novel combination agent. All of these agent compare favorably with timolol in terms of aqueous suppression, though each has its own relative advantages and disadvantages.Several new aqueous inflow inhibitors have been introduced over the past few years. These new agents include two alpha agonists, two topical carbonic anhy-drase inhibitors, and a novel combination agent. All of these agent compare favorably with timolol in terms of aqueous suppression, though each has its own relative advantages and disadvantages. Copyright

Effects of Intraoperative 5-Fluorouracil or Mitomycin C on Glaucoma Filtration Surgery in the Rabbit

Cataract removal in the glaucoma patient is a less arduous task today than it was a decade ago, because of technological advances and modifications in surgical technique. These technological advances include excellent phacoemulsification instrumentation. Useful modifications in surgical technique include the use of combined phacotrabeculectomy with antimetabolite supplementation, when necessary. Anticipated advances in the next decade include superior viscoelastics and the widespread availability of capsular tension rings.