Surgical Treatment of Scleral Ulceration as a Complication of Pterygium Excision

Mitomycin C is now being used not only as an adjunct in the surgical treatment of pterygia but also in glaucoma surgery. However, several serious complications that are possibly related to mitomycin C treatment have been reported. We report on a series of 8 patients(10 eyes) who experienced scleral ulcer after pterygium excision. The period from operation to onset of scleral ulcer was between 5 months and 20 years. Complications included corneoscleral perf oration(1 eye), scleral ulceration(9 eyes), corneal ulceration(2 eyes), complicated cataract(5 eyes) and uveitis(4 eyes). We used autogenous temporalis fascia to reinforce the weakened lesion of 10 eyes with scleral or corneoscleral ulceration. Three eyes underwent extracapsular cataract extraction and posterior chamber intraocular lens implantation after stable grafting. Grafts remained stable in 9 eyes over a mean follow-up of 10.8 +/- 10.4 months(3 to 37 months). One graft melted but regrafting salvaged the eye. Six of 10 eyes improved vision. All patients resolved their subjective symptoms after temporalis fascia grafting. We found autogenous temporalis fascia grafting is efficacious in both treating and preventing ocular perforation due to progressively destructive scleral ulceration.

Ischemic Changes in Hypertensive Choroidopathy by Fluorescein Angiography

The retinal and choroidal blood vessels respond independently to the abruptly increased arterial pressure due to their differences in the anatomic and physiologic properties, which induce hypertensive retinopathy and hypertensive choroidopathy respectively. The authors reviewed the fluorescein angiogram retrospectively to observe the ischemic changes of the choroid in 15 cases of hypertensive choroidopathy. The ischemic changes of the choroid in hypertensive choroidopathy were characterized by generalized or sectorial filling delay which was followed by staining or leakage of dye. These findings suggest that the choroidal circulation may lead to the sectorial and generalized ischemic conditions following the abruptly increased arterial pressure due to their differences in the anatomic structures. The fluorescein angiographic findings in the hypertensive choroidopathy depend on both the degree of the circulatory disturbance and the levels of the affected choroidal vessels.

Efficacy and Safety of Mitomycin C Trabeculectomy in Patients with Uncomplicated Glaucoma Compared with Refractory Glaucoma

The efficacy and safety of mitomycin C(MMC) trabeculectomy was tested in patients with uncomplicated glaucoma(low-risk group) and the result was compared with that in patients with refractory glaucoma(high-risk group). Subjects included 37 eyes of 26 consecutive patients in low-risk group and 36 eyes of 26 patients in high-risk group. The mean preoperative IOP was 32.9 +/- 9.7 mmHg and 31.9 +/- 8.7 mmHg, respectively(p=1.45). The mean number of preoperative medications was 2.8 +/- 0.8 and 2.0 +/- 0.9, respectively(p<0.05). MMC(0.25 mg/ml or 0.5 mg/ml) was applied between Tenon's capsule and the sclera during trabeculectomy for 3 minutes in low-risk group, for 5 minutes in high-risk group. Scleral-flap was closed with tight releasable sutures. Eyes followed longer than 3 months were included(mean of 14.1 +/- 8.0 months vs 11.9 +/- 6.8 months, p=0.23). The low-risk group had better postoperative results including: a lower IOP at last follow-up(13.7 +/- 3.2 vs 17.2 +/- 8.4 mmHg, p=0.02), a better success rate(94% vs 83% with or without medications, p=0.23: 83% vs 55% without medications, p=0.02), a lower postoperative need for glaucoma medications(0.2 +/- 0.4 vs 0.6 +/- 08, p=0.005). Overall complications were similar between both groups. One of 37 eyes(3%) in the low-risk group developed a hypotony(p=0.51) and one of 36 eyes(3%) in the high-risk group developed a hypotony maculopathy(p=0.49). This study suggests that MMC trabeculectomy with tight releasable scleralflap sutures is safe and effective in controlling IOP not only in refractory glaucoma but also, more successfully, in uncomplicated glaucoma.

Molteno Implantation for Neovascular Glaucoma with a Laser-Releasable Intracameral Ligature to Limit Postoperative Pressure Fluctuations

We incorporated a 9-0 nylon ligature on the intracameral portion of the Molteno tube to limit postoperative hypotony in 15 eyes of 14 neovascular glaucoma patients. Postoperative hypotony, less than 5mmHg occured in 2 eyes at 1 week, and none thereafter. Argon laser release of the ligature, performed an average of 29 +/- 24 days after surgery, resulted in intraocular pressure reduction in all cases. After 7.3 +/- 3.3 months, the intraocular pressure was significantly lower(47.3 +/- 11.5 vs 18.7 +/- 7.7mmHg, p=0.0007) on less medications(2.2 +/- 1.0 vs 0.3 +/- 0.6, p=0.0008). Thirteen eyes(87%) achieved an intraocular pressure less than 21mmHg and twelve eyes(80%) maintained or improved their preoperative visual acuity. The releasable internal ligature is effective in limiting hypotony and intraocular pressure contral.