Martin Wand

A comparison of dorzolamide–timolol combination versus the concomitant drugs☆

PURPOSE To compare the intraocular pressure (IOP) lowering effect of fixed combination dorzolamide 2% and timolol 0.5% therapy to that of concomitant administration of a topical beta-blocker and dorzolamide. METHODS Seventy-four consecutive glaucoma patients were changed from a regimen including a topical beta-blocker and dorzolamide to the fixed combination dorzolamide-timolol in 1 eye, with the other eye used as the control. The average IOP readings before and 1 month after the change were compared. RESULTS The mean baseline IOP in the entire study population was 19.4 +/- 4.2 mm Hg in the study eyes and 16.9 +/- 4.2 mm Hg in the control eyes. Four weeks after the medication change, the mean IOP was 17.3 +/- 3.9 mm Hg in the study eyes (P <.001) and 16.1 +/- 4.1 mm Hg in the control eyes (P =.02). The difference between the mean IOP change of 2.1 mm Hg in the study eyes and 0.8 mm Hg in the control eyes was found to be statistically significant (P =.01). CONCLUSION These findings suggest that the fixed combination dorzolamide-timolol therapy achieves additional lowering of the intraocular pressure compared with the concomitant administration of a beta-blocker and dorzolamide.

Cystoid macular edema associated with ocular hypotensive lipids

PURPOSE To report angiographically documented cystoid macula edema associated with the use of each of the three newly available ocular hypotensive lipids: unoprostone, travaprost, and bimatoprost. DESIGN Observational case series. METHODS Retrospective review of three patients in a clinical practice who had uncontrolled glaucoma on maximal tolerable therapy except for an ocular hypotensive lipids. All three patients also had previous cataract and filtration surgery, and all had an absent or open posterior lens capsule. The patients were informed of the potential risks of cystoid macula edema associated with the use of an ocular hypotensive lipids versus the risks of repeat filtration surgery. RESULTS An ocular hypotensive lipids was started in the affected eye in each patient, and the patient was instructed to check visual acuity everyday and report back any change in vision occurred. CONCLUSION Decreased vision of at least two lines caused by angiographically confirmed cystoid macula edema was noted in each of three patients started, respectively, on unoprostone, travaprost, and bimatoprost. The visual acuity returned to baseline, and the cystoid macula edema was angiographically resolved after discontinuation of the ocular hypotensive lipids and the initiation of a topical steroid and non-steroidal anti-inflammatory eyedrops. Until a causal relationship between cystoid macula edema and ocular hypotensive lipids is proved or disproved, caution in their use in high-risk eyes would be prudent.

Repeat Selective Laser Trabeculoplasty

PurposeTo evaluate the efficacy of repeat 360-degree selective laser trabeculoplasty (SLT) in glaucoma patients with prior successful 360-degree SLT. DesignRetrospective chart review. MethodsForty-four eyes of 35 patients, ≥18 years of age, with open-angle glaucoma (primary open-angle, pseudoexfoliation, or pigmentary glaucoma), uncontrolled on maximum tolerable medical therapy, underwent an initial 360-degree SLT (SLT1), which was successful for ≥6 months, but eventually lost efficacy and was followed by a repeat 360-degree SLT (SLT2). Patients with prior argon laser trabeculoplasty or other glaucoma surgery, before or during the study period, were excluded. Intraocular pressure (IOP) measurements were recorded before each procedure and 1 to 4 weeks, 1 to 3 months, and 5 to 8 months posttreatment and 15 to 21 weeks after the initial SLT. ResultsReduction in IOP after SLT1 and SLT2 was significantly less with repeat treatment at 1 to 3 months, with average decreases of −5.0 and −2.9 mm Hg, respectively (P=0.01), but there were no statistically significant differences between treatments at the other equivalent time points. Using a definition of “success” as ≥20% peak IOP reduction, success rates for SLT1 and SLT2 were not significantly different. There was also no significant difference in eyes that received SLT2 6 to 12 months after SLT1 compared with those that received SLT2 12 months or more after SLT1. ConclusionsOur findings suggest that repeat 360-degree SLT may be safe and effective after an initially successful 360-degree SLT has failed. These results may be achieved as early as 6 months after the first treatment.

Latanoprost for Uncontrolled Glaucoma in a Compassionate Case Protocol

PURPOSE To evaluate the ocular hypotensive response of latanoprost 0.005% administered as adjunctive therapy in patients with glaucoma who were receiving maximal tolerated medical therapy. METHODS Consecutive patients entering a latanoprost compassionate clinical trial were enrolled at two sites. Latanoprost 0.005% was administered as a single drop between 6 and 8 PM, and all other medications were continued. Intraocular pressure was measured between 2 and 4 PM. Responders were defined as having a reduction in intraocular pressure of at least 20% from baseline. RESULTS In 160 eyes of 160 patients, mean baseline intraocular pressure +/- SD was 23.3 +/- 6.9 mm Hg. Intraocular pressure was significantly reduced compared with baseline measurements (P < .01) with mean intraocular pressure measurement reductions of 4.1 +/- 5.2, 4.0 +/- 6.3, and 3.7 +/- 4.2 mm Hg at the 1-, 3-, and 6-month intervals, respectively. A reduction in intraocular pressure of at least 20% was observed in 64 (44.4%) of 144 patients, 46 (43.0%) of 107 patients, and 10 (32.3%) of 31 patients at the 1-, 3-, and 6-month visits, respectively. A 40% reduction in intraocular pressure was observed in 18 (12.5%) of 144 and nine (8.4%) of 107 patients at 1 and 3 months, respectively. Mean reduction in intraocular pressure was similar in the miotic and nonmiotic groups (P > .4 at all intervals). Eight patients (5.0%) developed ocular allergy or irritation necessitating cessation of latanoprost therapy. CONCLUSION Latanoprost 0.005% may provide significant further intraocular pressure reduction in patients already receiving maximal tolerated medical therapy.

Supraciliary Effusions and Ciliary Body Thickening after Scleral Buckling Procedures

PURPOSE The purpose of the study was to use ultrasound biomicroscopy to identify and quantity changes in anterior segment parameters after scleral buckling procedures. METHODS Ultrasound biomicroscopy was used to examine 15 patients with retinal detachment within 1 week before and after surgery. Quantitative measurements were performed of anterior chamber depth, supraciliary effusion depth, ciliary body thickness, and angle opening. RESULTS Supraciliary fluid was present after surgery in 12 patients (80%). Average supraciliary fluid depth was 0.16 +/- 0.13 mm. Ciliary body thickness measurements at a point 2-mm posterior to the scleral spur increased after surgery in all patients an average of 0.15 +/- 0.10 mm. There was a strong correlation between ciliary fluid levels and change in ciliary body thickness (r = 0.742, P < 0.01). Anterior chamber depth decreased after surgery in 14 patients (93%). A decrease of angle opening of greater than 5 degrees was noted in 11 patients (73%). In all of these 11 patients, the ciliary body and iris root were considered to be rotated anteriorly. Six (55%) of 11 of these patients showed anterior bowing of the iris, indicating pupillary block. Complete angle closure occurred over one to three quadrants in three patients, but none of these patients had complete angle closure or glaucoma. CONCLUSIONS Supraciliary effusions and ciliary body thickening are common after scleral buckling procedures and can produce conditions conducive to angle closure. Angle narrowing occurs through a combination of direct anterior iris rotation and induced pupillary block.

Neovascular Glaucoma and Carotid Artery Obstructive Disease

Carotid artery obstructive disease, although infrequently diagnosed as a primary or contributing cause of neovascular glaucoma, can produce distinctive characteristics. Decreased perfusion of the ciliary body may decrease aqueous humor production. As a result, such eyes with neovascular glaucoma may occasionally be normotensive or even hypotensive. Fluorescein angiography may show an increased arm-to-retina time and leakage from the major retinal arterioles. Panretinal photocoagulation may not eliminate the anterior segment neovascularization because of anterior segment ischemia. Endarterectomy can significantly increase intraocular pressure as perfusion to the ciliary body returns to normal. These characteristics were found in two patients, a 67-year-old woman and a 49-year-old man, with diabetes and hypertension. In both cases cyclocryotherapy significantly reduced the intraocular pressure and the rubeosis iridis regressed.

Increased periocular pigmentation with ocular hypotensive lipid use in African Americans.

PURPOSE To report increased eyelid pigmentation as an adverse side effect associated with topical ocular hypotensive lipids in African Americans. DESIGN Interventional case series. METHODS Two African-American patients with open-angle glaucoma are described in whom increased eyelid pigmentation developed 1 month to 5 months after beginning treatment with either latanoprost or bimatoprost. RESULTS Latanoprost was discontinued in an African-American patient, and pigmentation gradually diminished by 3 months after cessation of latanoprost. Increased eyelid pigmentation and increased eyelash length were noted in another African-American patient after just 4 weeks on bimatoprost. CONCLUSIONS An increase in eyelid pigmentation and eyelash growth is a possible complication of topical ocular hypotensive lipid therapy, even in African-American patients. The changes seems to present earlier after bimatoprost treatment then after latanoprost treatment. Cessation of these medications may lead to loss of induced pigmentation.

Needle Revision of Failed Filtering Blebs Using 5- Fluorouracil and a Combined Ab-externo and Ab-interno Approach

Purpose:To evaluate a surgical technique to revise a failed filtering bleb using subconjunctival 5-Fluorouracil with a combined ab-externo and ab-interno approach. Patients and Methods:This study is a retrospective review of the outcome of 77 consecutive bleb revisions, with greater than 6-month follow-up, performed by a single glaucoma surgeon (MW). All eyes had previously functioning filtering blebs with currently inadequately controlled intraocular pressures (IOP) prior to the bleb revisions. All surgery was performed in the operating room, using a retrobulbar injection and a microscope. Visco-elastic was injected into the anterior chamber. 5-Fluorouracil (0.1 mL; 50 mg/ml) was infiltrated around the bleb. A 30-gauge needle was used to lyse subconjunctival fibrosis and episcleral scar tissue binding down the scleral flap, and elevate the scleral flap. Through an inferior paracentesis, a cyclodialysis spatula was used to confirm and enlarge the communication with the subconjunctival space. The main outcome measurements were IOP and number of glaucoma medications. A successful outcome was defined as a 20% reduction from baseline IOP and a maximum IOP of 18 mm Hg, with or without medications, and a minimal follow-up of 6 months. Results:52% of patients achieved success after one revision with an average follow-up of 29.6 ± 14.4 months. In successful cases, the mean IOP decreased from 22.7 ± 4.5 mm Hg to 11.3 ± 3.5 mm Hg and medications were reduced from an average of 2.2 ± 1.1 to 0.4 ± 0.7. Kaplan-Meier survival analysis calculated a success of 77% at 1 year, 68% at 2 years, and 58% at 3 years. Conclusions:In failed filtering blebs, needle revision with 5-Fluorouracil and a combined ab-externo and ab-interno approach results in high success and low complication rates. The outcome of this procedure compares favorably with previously reported revision techniques.

Latanoprost in glaucoma associated with Sturge-Weber syndrome: benefits and side-effects.

PURPOSE This study was conducted to evaluate the ocular hypotensive efficacy, safety, and side effects of latanoprost 0.005% administered as adjunctive therapy in patients with Sturge-Weber syndrome (SWS) and glaucoma. METHODS Commercially available latanoprost 0.005% was added as a single drop once daily to other antiglaucoma medications. Intraocular pressure (IOP) was measured at 1, 3, and 6 months of treatment. A successful response was defined as a reduction of at least 20% in IOP at the final follow-up evaluation without additional medical or surgical therapy and no adverse events related to latanoprost. RESULTS 18 eyes of 18 patients with SWS and glaucoma were enrolled from 9 clinical centers. Mean baseline IOP was 28.4 +/- 7.1 mmHg (range, 17-42 mmHg). Using Kaplan-Meier analysis, a successful response to latanoprost was observed in 3 of 18 (16.7%) patients at the 6-month interval. Seven (38.9%) patients required surgery; three (16.7%) patients required additional medical therapy, seven (38.9%) patients had no change in therapy. One (5.6%) patient discontinued latanoprost treatment because of intolerable conjunctival hyperemia. Two successfully treated patients had significantly greater episcleral vessel engorgement after initiation of latanoprost therapy. CONCLUSION Patients with SWS and glaucoma respond poorly to adjunctive latanoprost therapy and often require additional medical or surgical intervention. Increased episcleral vascular engorgement might result in greater operative risks should filtration surgery become necessary in these patients.

Antibiotic prophylaxis in eyes with filtration blebs: survey of glaucoma specialists, microbiological study, and recommendations.

PurposeBleb-related endophthalmitis is a major late complication of filtration surgery. The purpose of this study was to determine the ophthalmic practic patterns regarding long-term antibiotic prophlaxis in eyes with filtration blebs, and the effect of long-term antibiotic usage on conjunctival bacterial flora. MethodsA mail survey of members of the American Glaucoma Society (AGS) was undertaken. In addition. 41 patients who had filtation surgery and received long-term topical antibiotic therapy in one eye only had conjunctival cultures performed in both eyes. ResultsOf the responding members of the AGS, only 6% routinely prescribed long-term antibiotic prophylaxis, 28% prescribed therapy in selected cases only, and 66% did not employ antibiotic prophylaxis. Although more physicians than not had observed endophthalmitis in patients not receiving antibiotic therapy, it was evident that antibiotic prophylaxis did not guarantee that endophthalmitis would not develop in a filtered eye. A total of 49 organisms were isolated from the conjunctiva of eyes receiving antibiotic prophylaxis and 52 organisms were isolated from eyes not receiving antibiotic prophylaxis. There was no statistically significant difference in the types of organisms isolated. ConclusionLong-term antibiotic prophylaxis does not appear to be a common practice among glaucoma specialists in this country, and it cannot be depended upon as a fail-safe method to prevent bleb-related endophthalmitis. Furthermore, long-term antibiotic usage does not appear to alter the conjunctival flora. Of paramount importance are early detection and treatment of bleb-related infections. Critical in this regard is patient education. Recommendations to minimize the development of endophthalmitis in filtered eyes are reviewed.