Reay H. Brown

Ocular Involvement in Patients with Fungal infections

Autopsy findings of 133 patients who died following fungemia or with invasive fungal infection were reviewed. Common clinical factors included antibiotic therapy, chemotherapy, corticosteroid administration, hyperalimentation, malignancy, and bone marrow transplantation. Fungal infection was seldom diagnosed antemortem and fungemia was detected in only 24 patients (18%). Ocular involvement occurred in 14 patients (Candida 11, Aspergillus 2, and Cryptococcus 1). The eye was the fifth most commonly involved organ at autopsy among patients with candida infection. Ocular involvement occurred with a significantly greater frequency in patients with Candida tropicalis than with Candida albicans infections (P less than 0.05). Although only about 10% of patients with fungal infections had ocular involvement, all those with ocular lesions had widely disseminated disease. Realizing the potential toxicity of antifungal therapy, we recommend that screening ophthalmologic examinations be performed on patients with fungemia or patients at high risk for development of fungal infection. The presence of ocular lesions consistent with fungal disease, in the appropriate setting, is a strong indication for investigation of possible systemic fungal infection and therapy once a definitive diagnosis is established.

The Use of Dorzolamide and Pilocarpine as Adjunctive Therapy to Timolol in Patients with Elevated Intraocular Pressure

PURPOSE To report the results of two studies on the use of dorzolamide as adjunctive therapy to timolol in patients with elevated intraocular pressure (IOP). In the larger study, the additive effect of dorzolamide administered twice daily also was compared with 2% pilocarpine. METHODS Both studies were parallel, randomized, double-masked, placebo-controlled comparisons. In the pilot study, 32 patients received 0.5% timolol twice daily plus either 2% dorzolamide twice daily or placebo twice daily for 8 days. In the Pilocarpine Comparison Study, 261 patients received 0.5% timolol twice daily plus 0.7% dorzolamide twice daily, 2% dorzolamide twice daily, 2% pilocarpine four times daily, or placebo (twice daily or 4 times daily) for 2 weeks. Patients then entered a 6-month extension period and received 0.5% timolol twice daily plus either 0.7% dorzolamide twice daily, 2% dorzolamide twice daily, or 2% pilocarpine four times daily. RESULTS In the pilot study, after 8 days, additional mean percent reductions in IOP for 2% dorzolamide and placebo were 17% and 3% at morning trough and 19% and 2% at peak, respectively. In the Pilocarpine Comparison Study, after 6 months, additional mean percent reductions in IOP (morning trough) were 9%, 13%, and 10% for 0.7% dorzolamide, 2% dorzolamide, and 2% pilocarpine, respectively. Patients receiving 2% pilocarpine had the highest rate of discontinuation due to a clinical adverse experience, and the use of dorzolamide was not associated with systemic side effects commonly observed with the use of oral carbonic anhydrase inhibitors. CONCLUSION Dorzolamide twice daily was effective and well tolerated by the patients in these studies as adjunctive therapy to timolol. The larger study demonstrated that both concentrations of dorzolamide produce similar IOP-lowering effects to 2% pilocarpine.

Filtering Bleb Thrombolysis with Tissue Plasminogen Activator

The Journal welcomes letters that describe unusual clinical or pathologic findings, experimental results, and new instruments or techniques. The title and the names of all authors appear in the Table of Contents and are retrievable through the Index Medicus and other standard indexing services. Letters must not duplicate data previously published or submitted for publication. Each letter must be accompanied by a signed disclosure statement and copyright transfer agreement published in each issue of The Journal. Letters must be typewritten, double-spaced, on 8 1/2 x 11-inch bond paper with 1 1/2-inch margins on all four sides. (See Instructions to Authors.) They should not exceed 500 words of text. A maximum of two black-and-white figures may be used; they should be cropped to a width of 3 inches (one column). Color figures cannot be used. References should be limited to five. Letters may be referred to outside editorial referees for evaluation or may be reviewed by members of the Editorial Board. All letters are published promptly after acceptance. Authors do not receive galley proofs but if the editorial changes are extensive, the corrected typescript is submitted to them for approval. These instructions markedly limit the opportunity for an extended discussion or review. Therefore, The Journal does not publish correspondence concerning previously published letters.

Remodeling Filtering Blebs with the Neodymium:YAG Laser

PURPOSE To describe a new method of treating large, overfiltering, leaking blebs using a continuous-wave neodymium:YAG laser. METHODS Twenty-three eyes of 23 patients underwent YAG laser remodeling because of overfiltration and hypotony (group 1; n = 14); leaking bleb and hypotony (group 2; n = 5); and large, irritating bleb (group 3; n = 4). Using a neodymium:YAG laser in the continuous-wave multimode, a grid pattern of laser treatment was placed over the entire bleb using energy levels between 3.0 and 4.0 J and a laser offset between 0.9 and 1.2 mm. A torpedo patch then was placed directly over the bleb for 48 hours. Steroid therapy was avoided. RESULTS In group 1, 64% of eyes had an intraocular pressure increase of at least 3.0 mmHg. In group 2, 80% of bleb leaks were sealed. In group 3, 100% of patients had resolution of their discomfort. The elevation in intraocular pressure peaked at 1 to 3 months and diminished thereafter. There was improvement in vision of at least two Snellen acuity lines in 52% of eyes. Complications included the need for laser retreatment (7 eyes), creation of temporary bleb leak by the YAG laser (2 eyes), transient increase in intraocular pressure (2 eyes), and corneal edema (1 eye). CONCLUSION The continuous-wave neodymium:YAG laser can be used to effectively change the appearance and behavior of filtering blebs, although the duration of treatment effect is unknown.

Risk of Postoperative Visual Loss in Advanced Glaucoma

The incidence of sudden visual loss after an intraocular procedure in patients with glaucoma and visual field defects has been disputed for over a century. We examined the risk of sudden visual loss associated with trabeculectomy in glaucoma patients with advanced visual field defects. Fifty-four filtering operations performed on 44 patients were reviewed. All patients had visual field defects encroaching on or splitting fixation, a visual acuity of 20/100 or better, and a follow-up period of at least two months. Thirty-one of the 54 preoperative visual fields (57%) disclosed a fixation-splitting defect. Sudden visual loss was not observed in any patient during the two-month postoperative period. These findings suggest that the incidence of sudden postoperative visual loss is lower than previously reported.

Internal Sclerectomy with an Automated Trephine for Advanced Glaucoma

An automated trephine (trabecuphine) was used to perform an internal sclerectomy in seven glaucoma patients who were aphakic or had undergone previous filtering surgery that had failed or both. A patent fistula was achieved intraoperatively in all seven eyes. Postoperatively, six patients received subconjunctival injection of 5-fluorouracil (5-FI) once daily for an average of 8 days. Five of seven patients have retained a functional bleb and a controlled intraocular pressure (IOP) after surgery (follow-up, 4-24 months). The only intraoperative complication was hemorrhage from the sclerectomy site in a patient with aniridia that resulted in a 20% hyphema. The hyphema cleared quickly, and the bleb has remained functional with a pressure of 12 mmHg for 9 months. The trabecuphine makes it possible to perform a glaucoma filtering operation safely from within the anterior chamber. This technique minimizes conjunctival trauma in the filtration area. The absence of a conjunctival incision overlying the fistula simplifies the adjunctive use of antimetabolites such as 5-FU.

The Effect of Reduced Eyedrop Size and Eyelid Closure on the Therapeutic Index of Phenylephrine

In this study we examined the relative effects of reducing eyedrop size (from 30 microliters to 10 microliters) and eyelid closure on the ocular efficacy and systemic absorption of 10% phenylephrine. Thirteen subjects participated in a quadruple crossover study that involved dilation with a 10-microliters and a 30-microliters drop of phenylephrine with and without eyelid closure. The 10-microliters drop was just as effective for pupillary dilation as the 30-microliters drop. Eyelid closure improved dilation for both drop sizes. Both eyelid closure and reducing the drug volume decreased systemic absorption of phenylephrine as measured by plasma concentration. When used together, eyelid closure and the smaller drop size reduced plasma concentration by 45%. The therapeutic index for 10% phenylephrine appears to be improved by using a 10-microliters drop followed by eyelid closure.

Reduced intraocular pressure after cataract surgery in patients with narrow angles and chronic angle-closure glaucoma

Purpose To evaluate the effect of cataract surgery on intraocular pressure (IOP) in patients with narrow angles and chronic angle‐closure glaucoma (ACG) and to determine whether the change in IOP was correlated with the preoperative pressure, axial length (AL), and anterior chamber depth (ACD). Setting Private practice, Atlanta, Georgia, USA. Design Retrospective case series. Methods Charts of patients with narrow angles or chronic ACG who had cataract surgery were reviewed. All eyes had previous laser iridotomies. Data recorded included preoperative and postoperative IOP, AL, and ACD. The preoperative IOP was used to stratify eyes into 4 groups. Results The charts of 56 patients (83 eyes) were reviewed. The mean reduction IOP in all eyes was 3.28 mm Hg (18%), with 88% having a decrease in IOP. There was a significant correlation between preoperative IOP and the magnitude of IOP reduction (r = 0.68, P < .001). The mean decrease in IOP was 5.3 mm Hg in eyes with a preoperative IOP above 20 mm Hg, 4.6 mm Hg in the over 18 to 20 mm Hg group, 2.5 mm Hg in the over 15 to 18 mm Hg group, and 1.4 mm Hg in the 15 mm Hg or less group. The mean follow‐up was 3.0 years ± 2.3 (SD). Conclusions Cataract surgery reduced IOP in patients with narrow angles and chronic ACG. The magnitude of reduction was highly correlated with preoperative IOP and weakly correlated with ACD. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Clear lens extraction as treatment for uncontrolled primary angle-closure glaucoma

Cataract surgery lowers intraocular pressure (IOP) and reduces the risk for acute attacks in eyes with primary angle-closure glaucoma (PACG). Since cataract surgery may lower the IOP by deepening the anterior chamber and widening the angle, it is probable that clear lens exchange (CLE) may also be effective. However, CLE is highly controversial and there are no studies of the risk/benefit of CLE PACG.We report 3 patients with PACGwho had CLE instead of a trabeculectomy for control of their IOP.

Neodymium : YAG membranectomy for pupillary membranes on posterior chamber intraocular lenses

PURPOSE To evaluate the effectiveness of neodymium: YAG laser for the removal of membranes from the anterior surface of intraocular lenses. METHODS Seven patients had reduced vision due to a membrane on the anterior surface of a posterior chamber intraocular lens (PC IOL). Six of the membranes developed after extracapsular cataract surgery and PC IOL combined with trabeculectomy and one after pars plana vitrectomy. Six of the membranes developed in the early postoperative period in association with a fibrinous reaction of the anterior chamber. One formed 7 months after surgery in an eye with iris capture behind the IOL. The membranes persisted despite intensive topical steroid therapy. A neodymium: YAG (Nd:YAG) laser was used to remove the membranes from the anterior of the IOL in all the seven cases. RESULTS The Nd:YAG laser effectively severed the peripheral connections of the membranes to the iris and lens, creating a clear central zone within the visual axis. The settings were fundamental mode, 1.2-to 3.1-mJ energy per shot and 48.3 +/- 20.1 single pulses. Vision improved significantly in six patients, whereas elevated intraocular pressure was observed in one patient. CONCLUSION Postoperative pupillary membranes may be successfully lysed with use of the Nd:YAG laser.