Comparison of trabeculectomy with mitomycin-C and glaucoma drainage device implantation in glaucoma management after penetrating keratoplasty

@#<p style="text-align: justify;"><strong>OBJECTIVE:</strong> To compare the intraocular pressure control of trabeculectomy with mitomycin-C (Trab MMC) versus glaucoma drainage device (GDD) implantation in glaucoma management after penetrating keratoplasty (PKP).<br /><strong>METHODS:</strong> A review of medical records of patients who developed glaucoma after penetrating keratoplasty and underwent either trabeculectomy with mitomycin-C augmentation or glaucoma drainage device implantation between October 2006 to June 2012 at a tertiary referral eye center was done. The following information were obtained for each patient: age, gender, corneal diagnosis before keratoplasty, details of keratoplasty in terms of graft versus donor size, other simultaneous operations, visual acuity (VA), intraocular pressure (IOP), number of glaucoma medications before and after PKP, graft status before glaucoma treatment and at the final visit, type of glaucoma before treatment, and the glaucoma procedure performed and its complications if any. Three primary outcomes were evaluated: graft status, postoperative IOP, and VA. Controlled IOP with or without medications was defined as IOP greater than 6 but less than 20. Paired t-test determined the significant decrease in the mean IOP control and the number of medications before and after keratoplasty. Single-factor analysis of variance (ANOVA) determined if there were significant differences in the mean between the two surgeries. Kaplan-Meier survival analysis compared the surgeries in their effects on graft clarity.<br /><strong>RESULTS:</strong> Out of the 222 medical records reviewed, 23 patients met the inclusion criteria. Twelve (52.2%) eyes had clear grafts after glaucoma surgery; 8 (72.7%) in the Trab MMC and 4 (33.3%) in the GDD groups. Twenty-one (91.3%) eyes had controlled IOP; 9 (81.8%) had Trab MMC, 12 had GDD surgeries. There was no difference (p = 0.07) in percentage of patients with controlled IOP between the 2 groups. Mean IOP in the Trab MMC (32.6 ± 4.3 to 15.1 ± 4.0, p = 0.004) and GDD (23.6 ± 4.6 to 12.5 ± 0.8, p = 0.04) groups significantly decreased after the procedures. The decrease in mean IOP was not different (p = 0.55) between the 2 groups. The number of patients with controlled IOP increased significantly (p = 0.02) in the Trab MMC group. There were no differences in the mean number of glaucoma medications between both groups before (p = 0.92) and after (p = 0.18) glaucoma surgery. There was no difference (p = 0.17) in the survival distribution of controlled IOP between the 2 surgeries.<br /><strong>CONCLUSION:</strong> Trabeculectomy with mitomycin-C augmentation and glaucoma drainage device implantation are effective methods of controlling IOP post penetrating keratoplasty. There was no difference between the two groups in controlling the IOP and in reducing the number of glaucoma medication postoperatively.</p>

A prospective, randomized comparison of Nd:YAG and sequential argon-YAG laser iridotomy in Filipino eyes

Methods: A prospective, randomized, controlled trial was performed involving patients requiring laser iridotomy who were randomized either to Nd:YAG laser or sequential argon-Nd:YAG laser iridotomy. Iris-perforation success rate, the average number of laser shots and amount of laser energy used, the intraocular pressure (IOP) after laser treatment, and the rate of complications were compared. The prelaser pupil size was correlated with the iris perforation success rate. Results: Forty-one eyes underwent laser iridotomy (23 Nd:YAG and 18 sequential). All eyes had patent iridotomies. There was no difference between the two groups in terms of the number of Nd:YAG laser shots delivered (p=0.97) and amount of Nd:YAG energy used (p=0.64). The total amount of laser energy used was higher in the sequential group (p=0.003). There was no significant difference in the IOP and complication rates after treatment. A positive correlation was seen between prelaser pupil size and number of Nd:YAG shots needed to enlarge (r=0.38, P=0.01). Conclusion: Nd:YAG laser alone and sequential argon-Nd:YAG have comparable success in attaining patency of laser iridotomy, IOP control, and rate of complications in dark irides of Filipinos.

The diagnostic properties of a nerve-fiber analyzer in glaucoma: potential use as a screening or diagnostic tool

Methods: Patients with and without glaucoma underwent a complete eye evaluation, automated perimetry, scanning laser polarimetry with the GDx 400, and opticdisc photography. Two glaucoma experts graded each study eye. Two-by-two tables were constructed for 5 GDx parameters (average thickness, superior average, inferior average, ellipse average, and ellipse modulation) and the CDx number. Receiver operating characteristic (ROC) curves were generated. Results: The study included 355 patients (171 normal, 184 glaucoma). The mean values of the 5 GDx parameters were lower for the glaucoma than for the normal group. The sensitivity and specificity of the GDx 400 were 45.4 percent and 91.9 percent if the cut off level of the GDx number was 71. Ellipse modulation (EM) measures have the best ROC curve with area under the curve of 0.725. Conclusion: The GDx 400 nerve-fiber analyzer is primarily used as a screening tool to detect the presence or absence of glaucoma. Its accuracy can be improved with use of continuous corneal compensator.

The cost-effectiveness of management of Filipino patients with chronic primary glaucoma in a tertiary charity hospital setting

Chronic primary glaucoma affects sight very quietly - until such time that the progression of the disease is considerably advanced. The search for the ideal therapeutic approach to the disease can only provide, at best, for the arrest of the damage to the optic nerve head by bringing down the intraocular pressure to a level low enough to elude harm. Patients afflicted with the disease are bound to a therapy of a lifetime. This has implications of understated proportions in the economic scenario of a developing country. This study is conceived to determine the cost-effectiveness of chronic primary glaucoma management. A cross-sectional study design is employed to answer this objective. Medical records of 290 study eyes of 148 patients with chronic primary glaucoma (aged 14 - 88 years) are evaluated for cost-effectiveness of therapy. Results have shown that on one hand, medical therapy has a mean annual cost of PhP 5,830.00 + 278.00. On the other hand, surgical therapy has a one-time mean annual cost of PhP 8,100.00 + 359.00.Comparing cost-effectiveness using analysis of covariance (ANCOVA), one finds that filtering surgery is at least twice more cost effective than medical management (p0.001). Surgical complications, however, may hamper the effectiveness of filtering surgery. The study recommends that young patients with advanced disease and with higher IOP at the time of consult could be served more efficiently with a filter, whereas elderly patients approaching their life expectancy who can comply with the demands of effective medical management may not benefit much from it.

Intracameral mitomycin and 5-FU to prevent posterior capsular opacity in rabbits

Purpose: To prevent the occurrence of secondary cataract after ECCE with PC-IOL implantation and evaluate the safety and effectiveness of Mitomycin C and 5-FU when used intraocular as an irrigating solution for its prevention in rabbits Materials and Methods: 15 rabbits were divided into 3 groups: Group A was given 5-50 mg/ml FU in 500 cc of BSS plus solution; Group B received MMC 0.2 percent mg/ml in 500 cc BSS; and Group C served as control with pure BSS. The study was done in accordance with the guidelines published by ARVO. The investigated drug solution was used as irrigating solution in cataract extraction performed in rabbits. Postoperatively, the rabbits examined under slit lamp from the 1st post op day and every 3 days thereafter. Their globes were enucleated 2 wks post op and 4 weeks post op, and sent to Pathology Laboratory for processing Results: Group A and Group B showed clear posterior capsule with no evidence of epithelial cell migration. Group C showed evidence of minimal to moderate epithelial cell migration and proliferation with fibrosis Conclusion: Mitomycin C (MMC) and 5-FU minimized and even prevented secondary cataract formation, with no effect on ocular structures when used as an irrigating solution.

Retinal nerve fiber measurements in glaucoma suspects

Purpose: To determine the proportion of glaucoma suspects with abnormal nerve fiber layer measurement using GDx nerve fiber analyzer Methodology: The study population consisted of glaucoma suspects between ages 30-70 years, who underwent glaucoma workup including retinal nerve fiber layer measurement (GDx NFA) Results: 35 eyes of glaucoma suspects were analyzed. 28/35 were found to have normal NFL thickness; 5/35 have 1 abnormal GDx parameters; 1/35 with 3 abnormal GDx parameters; 1/35 with 3 GDx abnormal parameters. Linear regression analysis showed no correlation between C:D and GDx parameters Conclusion: This study confirms that superior maximum is useful to the other parameters but there is a need to collect more samples. (Author)