Richard J. Simmons

Argon Laser Trabeculoplasty in the Presurgical Glaucoma Patient

The trabecular meshwork in 334 eyes of 260 patients with medically uncontrolled primary and secondary open-angle glaucoma was treated with the argon laser. The average intraocular pressure reduction obtained was 7.1 mm Hg. Tonographic data showed significant increase in the facility of outflow. Glaucoma surgical intervention was avoided in 87.5% of phakic eyes and in 62.1% of aphakic eyes. Laser trabeculoplasty was found to be effective in primary open-angle glaucoma, pseudoexfoliation glaucoma, pigmentary glaucoma, angle recession glaucoma, glaucoma secondary to uveitis, and in eyes with failed glaucoma surgical procedures. The length of follow-up in this series ranged from one week to 21 months, with an average of five months. The major complication noted was a rise in intraocular pressure following treatment. In one eye, a small central island of vision was lost due to this intraocular pressure elevation. Treating one-half of the angle in each of two treatment sessions separated by a few weeks reduces the degree of this pressure elevation. The glaucoma status of 3% eyes was made worse after treatment with trabeculoplasty.

Extracapsular Cataract Extraction and Posterior Chamber Intraocular Lens Implantation in Glaucomatous Eyes

Two hundred ninety-six eyes of 250 patients undergoing extracapsular cataract extraction (ECCE) with or without the implantation of a posterior chamber intraocular lens (PC-IOL) were studied. Pre-existing glaucoma of varying severity was present in 139 eyes and no known ocular pathology other than cataract in 157 eyes. During the first eight weeks following surgery, intraocular pressure elevations greater than or equal to 15 mmHg above baseline were seen in 23% of glaucomatous eyes controlled before surgery with glaucoma medications, in 39% of glaucomatous eyes controlled before surgery with argon laser trabeculoplasty, and in only 3% of nonglaucomatous eyes. The implantation of a PC-IOL did not influence the incidence of postoperative intraocular pressure (IOP) elevations. Among glaucomatous eyes with severe preoperative visual field loss (split fixation or central island less than or equal to 10 degrees), 9.7% had worsening of visual field after surgery. Open angle glaucoma of unclear etiology developed in 1.4% of normal eyes following uncomplicated ECCE with PC-IOL implantation. Surgical techniques the authors have found useful in glaucomatous eyes undergoing ECCE with PC-IOL implantation are discussed.

Progressive low-tension glaucoma treatment to stop glaucomatous cupping and field loss when these progress despite normal intraocular pressure

Our thesis, inspired by the experience and teaching of Paul A. Chandler, is that after the optic discs have developed cupping and atrophy from elevated intraocular pressure they tend to become abnormally vulnerable and, in some cases, may continue to deteriorate even if the intraocular pressure is brought to the teens. At this stage they behave the same as in eyes with so-called low-tension glaucoma, which have developed progressive cupping and atrophy with pressures always in the teens. In either case, we find that the progression of cupping and field loss can be stopped by reducing the intraocular pressure to lower levels, preferably to 10 mm Hg or less. We have found that such low pressures are most reliably attained by surgery, using a special technique we call the shell tamponade filtration procedure, which involves the use of a glaucoma shell in conjunction with standard (full-thickness sclerostomy) filtration operations and certain specific operative and perioperative maneuvers. We present nine case reports illustrating our thesis. Glaucomatous cupping and loss of visual field were progressing relentlessly at normal pressures in each case. This progressive deterioration was shown to be arrested by reduction of the pressure to less than 12 mm Hg in 13 eyes.

Angle-Closure Glaucoma in Nanophthalmos

Two patients had nanophthalmos with uveal effusion and angle-closure glaucoma. They were treated with a method based on the use of the laser, not only to perform iridotomy but to shrink the iris stroma, which appears to open the anterior chamber angle even without iridotomy. Additionally, we introduced three factors that may be diagnostic of nanophthalmos.

Laser Suture Lysis after Trabeculectomy

In an effort to achieve the early postoperative safety and stability provided by trabeculectomy plus the late lower intraocular pressure (IOP) advantages of full-thickness glaucoma filtration surgery, 43 eyes of 38 patients with chronic open-angle glaucoma had laser suture lysis after primary trabeculectomy. The technique of laser suture lysis afforded serial release of resistance to aqueous outflow through the newly performed trabeculectomy, allowing initial tight closure of the trabeculectomy to avoid the dangers of hypotony. Serial gradual loosening of the trabeculectomy closure decreased resistance to outflow through the trabeculectomy and thereby lowered the IOP to desired levels in a controlled, titrated manner. Complications decreased with experience. For 25 eyes with at least 6 months follow-up (average, 54 weeks), the average IOP decreased from 25.0 mmHg preoperatively to 12.2 mmHg postoperatively.

The essential iris atrophies.

We studied 82 cases of essential iris atrophy. The findings support some traditional concepts of this complex spectrum of disorders, but conflict with others. Corneal abnormality appeared early and may be the primary disorder. A corneal endothelial disturbance was present in 55% of cases and corneal edema was present in 50%. Peripheral anterior synechiae occurred in all but one of the cases studied by gonioscopy. The pupil was distorted in 71% of the cases and was usually pulled in the direction of the most prominent synechia. The iris was stretched with stromal atrophy in 71%. Iris holes occurred in 33%. The degree of corneal and iris changes occurred as a spectrum of disorders. The prognosis for most patients with essential iris atrophy is slow progression with eventual involvement of vision because of corneal edema, secondary glaucoma, or both. Treatment of increased IOP was required in 77% of our cases, and 44% required surgical intervention.

Ghost Cells as a Cause of Glaucoma

Clinical and investigative evidence indicated a glaucoma caused mainly by degenerated red blood cells, or ghost cells. These ghost cells, with altered shape, color, and pliability, accumulated in the vitreous cavity after hemorrhage. Following disruption of the anterior hyaloid face, they passed into the anterior chamber and caused severe glaucoma. In the anterior chamber, the tiny, khakicolored cells, circulating slowly, were frequently mistaken for white blood cells. They covered the trabecular meshwork or filled the inferior angle with a pathognomonic khaki-colored layer. They were identified by phase-contrast microscopic examination of anterior chamber aspirates. The decreased pliability of these degenerated cells seemed to account for their inability to pass easily through the human trabecular meshwork and, therefore, to cause severe glaucoma.

Intraocular pressure control after contact transscleral diode cyclophotocoagulation in eyes with intractable glaucoma.

PurposeThe effect of contact transscleral diode Cyclophotocoagulation (TDC) on intraocular pressure (IOP) and its safety was determined in eyes with intractable glaucoma. MethodsThe charts of 41 consecutive patients (43 eyes) who underwent the laser procedure were reviewed. Alter surgery, data were collected from chart entries at 1 hour, 1 day, 4 to 6 weeks, 4 to 6 months, and at the final visit (6–24 months). Mean differences in IOP before and alter treatment were compared using the paired Student t test. Associated complications also were assessed. ResultsThe mean ± standard deviation follow-up period was 11.9 ± 5.3 months (range, 6–24 months). One patient who died after I month of follow-up and another patient with neovascular glaucoma who underwent an anterior chamber washout 1 week after laser to treat an uncontrolled IOP spike were excluded from the study. Repeat treatment was done in 12 (28%) eyes. At each follow-up visit postoperatively, a significant reduction from preoperative IOP was obtained (mean reduction of 50% at the final visit). At the final visit, 64% of patients achieved an IOP of <22 mmHg and a reduction of ≥20%. An IOP spike occurred in three (7%) eyes. Long-term complications included loss of vision (≥2 lines) in eight (22%) patients, corneal decompensation in one (2%), phthisis bulbi in one (2%), and corneal graft rejection in one (2%). ConclusionAlthough effective IOP reduction was demonstrated in eyes with intractable glaucoma after TDC, a significant proportion (26%) of eyes had severe long-term complications.

Effect of Pilocarpine in Treatment of Intraocular Pressure Elevation Following Neodymium:YAG Laser Posterior Capsulotomy

A prospective study was conducted in 30 eyes of 30 patients to determine if pilocarpine would prevent increased intraocular pressure following Q-switched neodymium (Nd):YAG laser posterior capsulotomy. Fifteen eyes were given pilocarpine 4%, immediately following laser therapy and every hour until bedtime. Fifteen eyes served as untreated controls. Our results show that without prophylactic therapy, 10 of 15 eyes (67%) had a post-laser intraocular pressure (IOP) elevation of greater than 10 mmHg, while only one of 15 (6.6%) of the pilocarpine-treated eyes had a rise of that magnitude. The facility of outflow was reduced by 42% in the untreated eyes in contrast to an increase of 3% in those eyes treated with pilocarpine. Thus, pilocarpine 4% is effective in reducing the incidence and magnitude of elevated IOP following Nd:YAG posterior capsulotomy.

Pupillary and iridovitreal block in pseudophakic eyes.

Twenty-six cases of pupillary and iridovitreal block in pseudophakic eyes are reported. Although ten patients presented with acute angle closure glaucoma, the majority were asymptomatic and had normal intraocular pressures. While cure was finally achieved in all cases, recurrence of block occurred in six eyes as late as two months after initial successful treatment. A variety of therapeutic modalities including argon laser iridectomy, argon laser gonioplasty (iridoplasty), surgical iridectomy, surgical vitrectomy, Q-switched Nd:YAG laser iridectomy and Nd:YAG laser photodisruption of the anterior vitreous face were needed. Despite successful relief of pupillary and iridovitreal block in these eyes with no evidence of glaucoma prior to cataract and lens implant surgery, four eyes developed eight or more clock hours of peripheral anterior synechiae, and nine eyes continue to require chronic medical therapy for glaucoma.