Martha M. Wright

Intermediate-term outcome of variable dose mitomycin C filtering surgery

PURPOSE Trabeculectomy with adjunctive mitomycin C is associated with high success rates in studies with follow-up of less than 1 year. This report evaluates the visual and intraocular pressure (IOP) outcome in eyes after trabeculectomy with adjunctive mitomycin C 1 to 3 years after surgery in a predominantly white group (98.1%). METHODS The records of 157 eyes of 157 consecutive patients, aged 18 or older, who underwent mitomycin C trabeculectomies for uncontrolled glaucoma of various causes were reviewed. All surgeries were performed between April 1991 and June 1993. The concentration of mitomycin C varied from 0.2 to 0.5 mg/ml and was applied for 30 seconds to 5 minutes (only one patient received 0.2 mg/ml). Of the 157 eyes, 110 eyes were at high risk for failure (previous surgeries or inflammatory glaucoma). Thirty-nine eyes had preoperative IOP < or = 21 mmHg. RESULTS The mean preoperative IOP was 29.4 +/- 10.3 mmHg. This was reduced to 13.0 +/- 7.6 mmHg at 1 year, 11.5 +/- 6.4 mmHg at 2 years, and 13.4 +/- 7.3 mmHg at 3 years. Cumulative survival rate by life-table analysis was 94.2% +/- 1.9% at 1 year, 92.1% +/- 2.4% at 2 years, and 88.7% +/- 4.0% at 3 years, where failure was defined as reoperation for control of IOP. Complications included cataract formation-progression (n = 31), hyphema (n = 26), choroidal detachment (n = 21), hypotony maculopathy (n = 5), and endophthalmitis (n = 2). Vision deteriorated in 29 eyes and improved by 2 or more Snellen visual acuity lines in 29 eyes. CONCLUSION The IOP reduction after mitomycin C filtering surgery is sustained in the intermediate-term, 1 to 3 years, follow-up period.

A Prospective Study of Ocular Hypertension and Glaucoma after Pediatric Cataract Surgery

BACKGROUND Late-onset glaucoma can occur after pediatric cataract surgery. However, no large prospective study of the prevalence of ocular hypertension and glaucoma after pediatric cataract surgery has been performed. METHODS A prospective glaucoma evaluation was offered to all eligible subjects at least 5 years after automated lensectomy and vitrectomy for pediatric cataracts. RESULTS Sixty-two (58%) of 107 eligible subjects received a glaucoma evaluation. One (4.5%) of 22 patients with bilateral cataracts had glaucoma, and a much higher percentage (45%) had ocular hypertension. Five (12.5%) of 40 patients with unilateral cataracts had glaucoma, and an additional 32.5% had ocular hypertension. For patients with monocular cataracts, the age and corneal diameter at the time of cataract surgery were related to the subsequent development of ocular hypertension or glaucoma. The majority of subjects were able to cooperate with a comprehensive glaucoma examination that included cycloplegic refraction, determination of intraocular pressure, examination of the optic nerve, and fundus photography, without requiring sedation. CONCLUSIONS There is a high prevalence of ocular hypertension after pediatric cataract surgery. Children who are 5 years of age and older usually are able to cooperate with a glaucoma evaluation. The natural history of ocular hypertension after pediatric cataract surgery will be determined with longitudinal studies in the future.

Intraocular pressure measurement at the choroid surface: a feasibility study with implications for implantable microsystems

AIMS To demonstrate that a sensor, which is inserted through the sclera and placed in intimate contact with the choroid, can reliably detect changes in the intraocular pressure (IOP). METHODS A manometer was used to control the IOP of three cadaver eyes in steps of 7 mm Hg. A piezoresistive pressure sensor was used to measure the pressure at the choroid through a 2.5 mm diameter hole that was surgically removed from the sclera. Data were collected for two configurations; with the sensor: (i) rigidly attached to a miniature positioning stage, and (ii) sutured to the sclera. RESULTS Both configurations accurately tracked the manometer pressure from 10 mm Hg to 47 mm Hg. For the fixed sensor cases, the average difference between the pressure measured at the choroid and in the anterior chamber was 0.8 mm Hg for the three eyes. For the sutured sensor case, the average difference was 2.1 mm Hg—although a significant portion of this was attributed to an initial offset. The standard deviations at each pressure level for all of the choroid measurements were under 1.0 mm Hg. CONCLUSIONS Small changes in IOP can be accurately measured by a sensor in contact with the surface of the choroid, for both a fixed sensor configuration and for a sensor sutured to the sclera. These results are the first step in the realisation of a surgically implantable microsensor to monitor IOP for patients suffering from low tension and other difficult to manage forms of glaucoma.

Intraoperative mitomycin-C for glaucoma associated with ocular inflammation

BACKGROUND AND OBJECTIVE The authors studied the efficacy and complications of intraoperative mitomycin-C in glaucoma associated with ocular inflammation. PATIENTS AND METHODS The authors retrospectively reviewed the medical records of 24 consecutive patients (24 eyes) with glaucoma and ocular inflammation who had been treated with trabeculectomy and intraoperative mitomycin-C. Patient ages ranged from 10 to 83 years (mean 43 years). All patients were observed for at least 6 months. RESULTS With a mean follow-up time of 14.6 months, 18 of the 24 patients (75%) retained vision and had an intraocular pressure of 21 mm Hg or lower with or without medications (range 4 to 21 mm Hg; mean 13.4 mm Hg). Fifteen of 24 patients (62%) had an intraocular pressure of 21 mm Hg or lower with no medications. Three patients required tube shunt implants. One patient had a retinal detachment and lost light perception. One patient had endophthalmitis 14 months after surgery. Seven of 24 patients lost two or more lines of Snellen acuity. CONCLUSION Trabeculectomy with mitomycin-C can control intraocular pressure in glaucoma associated with ocular inflammation, but complications are frequent.

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.

Postoperative Complications in the Ahmed Baerveldt Comparison Study During Five Years of Follow-up

PURPOSE To compare the late complications in the Ahmed Baerveldt Comparison Study during 5 years of follow-up. DESIGN Multicenter, prospective randomized clinical trial. METHODS setting: Sixteen international clinical centers. STUDY POPULATION Two hundred seventy-six subjects aged 18-85 years with previous intraocular surgery or refractory glaucoma with intraocular pressure of >18 mm Hg. INTERVENTIONS Ahmed Glaucoma Valve FP7 or Baerveldt Glaucoma Implant BG 101-350. MAIN OUTCOME MEASURES Late postoperative complications (beyond 3 months), reoperations for complications, and decreased vision from complications. RESULTS Late complications developed in 56 subjects (46.8 ± 4.8 5-year cumulative % ± SE) in the Ahmed Glaucoma Valve group and 67 (56.3 ± 4.7 5-year cumulative % ± SE) in the Baerveldt Glaucoma Implant group (P = .082). The cumulative rates of serious complications were 15.9% and 24.7% in the Ahmed Glaucoma Valve and Baerveldt Glaucoma Implant groups, respectively (P = .034), although this was largely driven by subjects who had tube occlusions in the 2 groups (0.8% in the Ahmed Glaucoma Valve group and 5.7% in the Baerveldt Glaucoma Implant group, P = .037). Both groups had a relatively high incidence of persistent diplopia (12%) and corneal edema (20%), although half of the corneal edema cases were likely due to pre-existing causes other than the aqueous shunt. The incidence of tube erosion was 1% and 3% in the Ahmed Glaucoma Valve and Baerveldt Glaucoma Implant groups, respectively (P = .04). CONCLUSIONS Long-term rates of vision-threatening complications and complications resulting in reoperation were higher in the Baerveldt Glaucoma Implant than in the Ahmed Glaucoma Valve group over 5 years of follow-up.

The efficacy of goniotomy/trabeculotomy in early-onset glaucoma associated with the Sturge-Weber syndrome.

PURPOSE To assess the efficacy of goniotomy/trabeculotomy as the initial surgical procedure in early-onset glaucoma associated with Sturge-Weber syndrome. METHODS We retrospectively analyzed 16 eyes of 14 consecutive patients with Sturge-Weber syndrome-associated glaucoma diagnosed before 4 years of age. All subjects were seen at a single institution from 1978 to 1996 and underwent goniotomy or trabeculotomy as their initial surgical procedure. RESULTS Twelve eyes underwent initial goniotomy, and 4 eyes underwent initial trabeculotomy. One subject was lost to follow-up after surgery, resulting in 15 eyes for analysis. Of the initial goniotomy eyes, two thirds required a second surgical procedure. In the initial trabeculotomy eyes, half required a second procedure. Intraocular pressure was controlled (intraocular pressure < or = 22 mm Hg) in 66.7% of the eyes (10 of 15) after one or more goniotomy or trabeculotomy procedures for a median follow-up of 5.4 years (range, 1.4 to 15 years). For eyes with only one surgical procedure, 4 of 6 eyes had controlled intraocular pressure over a median follow-up of 3.4 years (range, 3 to 12 years). Seven of the 9 eyes that required more than one procedure had controlled intraocular pressure after all procedures over a median follow-up of 4.5 years (range, 1.4 to 15 years). CONCLUSION Initial or repeated goniotomy or trabeculotomy may be an effective management choice for treatment of glaucoma associated with Sturge-Weber syndrome presenting in early childhood.

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.