The Long-term Outcomes of Mitomycin C Trabeculectomy of Phakic versus Pseudophakic Eyes of Patients with Exfoliative Glaucoma

Purpose@#To determine whether previous cataract surgery affected the surgical prognosis of primary trabeculectomy with mitomycin- C (MMC) to treat exfoliative glaucoma (XFG). @*Methods@#This retrospective, consecutive study included 51 phakic eyes and 40 pseudophakic eyes of XFG patients that had previously undergone phacoemulsification via a temporal, clear corneal incision. All patients underwent primary trabeculectomy with MMC. Complete success was defined by an intraocular pressure (IOP) <18 mmHg and an IOP reduction ≥ 20% without any glaucoma medication. The cumulative probabilities of success were compared using Kaplan-Meier survival analysis, and risk factors for surgical failure were analyzed using the Cox’s proportional hazards model. @*Results@#The mean follow-up period was 44.7 ± 28.0 months. The IOP had decreased by 4.5 mmHg in phakic eyes and 11.1 mmHg in pseudophakic eyes at the last visits after surgery (p = 0.005). The cumulative complete success rates were 78.4% at 1 year and 15.0% at 5 years for phakic eyes, and 85.0% and 31.5% for pseudophakic eyes. The complete success rates thus tended to be lower for phakic than pseudophakic eyes (p = 0.068). The risk factors associated with surgical failure were early postoperative hypotony (hazard ratio = 2.81, p = 0.016, complete success) and phakic status (hazard ratio = 1.97, p = 0.040, complete success). @*Conclusions@#The long-term outcomes of XFG patients whose pseudophakic eyes had undergone phacoemulsification prior to primary trabeculectomy with MMC were comparable to or better than those of patients with phakic eyes. Therefore, performing phacoemulsification first, followed by trabeculectomy, may be the better option if trabeculectomy is required by XFG patients with cataracts.

The Long-term Outcomes of Mitomycin C Trabeculectomy of Phakic versus Pseudophakic Eyes of Patients with Exfoliative Glaucoma

Purpose@#To determine whether previous cataract surgery affected the surgical prognosis of primary trabeculectomy with mitomycin- C (MMC) to treat exfoliative glaucoma (XFG). @*Methods@#This retrospective, consecutive study included 51 phakic eyes and 40 pseudophakic eyes of XFG patients that had previously undergone phacoemulsification via a temporal, clear corneal incision. All patients underwent primary trabeculectomy with MMC. Complete success was defined by an intraocular pressure (IOP) <18 mmHg and an IOP reduction ≥ 20% without any glaucoma medication. The cumulative probabilities of success were compared using Kaplan-Meier survival analysis, and risk factors for surgical failure were analyzed using the Cox’s proportional hazards model. @*Results@#The mean follow-up period was 44.7 ± 28.0 months. The IOP had decreased by 4.5 mmHg in phakic eyes and 11.1 mmHg in pseudophakic eyes at the last visits after surgery (p = 0.005). The cumulative complete success rates were 78.4% at 1 year and 15.0% at 5 years for phakic eyes, and 85.0% and 31.5% for pseudophakic eyes. The complete success rates thus tended to be lower for phakic than pseudophakic eyes (p = 0.068). The risk factors associated with surgical failure were early postoperative hypotony (hazard ratio = 2.81, p = 0.016, complete success) and phakic status (hazard ratio = 1.97, p = 0.040, complete success). @*Conclusions@#The long-term outcomes of XFG patients whose pseudophakic eyes had undergone phacoemulsification prior to primary trabeculectomy with MMC were comparable to or better than those of patients with phakic eyes. Therefore, performing phacoemulsification first, followed by trabeculectomy, may be the better option if trabeculectomy is required by XFG patients with cataracts.

Long-term Longitudinal Changes in Choroidal Thickness with Intraocular Pressure Reduction after Glaucoma Surgery

PURPOSE: We investigated the long-term longitudinal changes in axial length (AL), mean ocular perfusion pressure (MOPP), and choroidal thickness (CT) according to the reduction of intraocular pressure (IOP) after glaucoma surgery. The potential variables associated with CT changes were also evaluated.METHODS: This was a prospective study for 1 year after glaucoma surgery, which included 71 eyes of 71 patients with primary open-angle glaucoma. The subfoveal CT (SFCT) and peripapillary CT (PPCT) were measured using spectral-domain optical coherence tomography preoperatively and 1 week, 1 month, 2 months, 6 months, and 1 year postoperatively. MOPP was calculated from the IOP and blood pressure. The AL was measured using partial coherence interferometry. Regression analysis was conducted to assess the possible association of variables.RESULTS: The AL decreased and the MOPP, SFCT, and PPCT increased significantly with IOP reduction at 1 year post-operatively (all, p < 0.001). The changes in SFCT and PPCT were significantly associated with IOP reduction at 1 year postoperatively (r = −0.519 and r = −0.528, respectively). Importantly, greater increases in SFCT and PPCT were found in patients with IOP reduction more than 30% from baseline, when compared with those with less than 30% reduction (p = 0.001 and p = 0.002, respectively). The SFCT increased more significantly in patients with AL ≤ 24 mm, compared with patients with AL > 24 mm (p = 0.044).CONCLUSIONS: Reduction in the IOP, increase in the MOPP, decrease in the AL, and increase in the CT after glaucoma surgery persisted for 1 year during a long-term follow-up. These results suggested that glaucoma surgery reduced mechanical compression on the optic nerve fiber and increased intraocular blood flow.

Association between Normal-tension Glaucoma and Allergic Rhinitis in a Korean Population-based Study

PURPOSE: The purpose of this study was to investigate the association between normal-tension glaucoma (NTG) and allergic rhinitis in a population-based setting using data from the Korea National Health and Nutrition Exam Survey (2010–2012). METHODS: The authors selected a total of 8,614 participants aged 40 years and older for this study. All participants completed an ophthalmic examination required for diagnosis of NTG based on the International Society for Geographical and Epidemiological Ophthalmology criteria. An interview regarding nasal symptoms was also performed. The included participants were classified into NTG (n = 604) and control (n = 8,010) groups. The authors compared the groups in terms of prevalence of allergic rhinitis and identified risk factors of NTG. RESULTS: In NTG patients, allergic rhinitis prevalence was 29.1% (176/604), which was significantly higher than that of the control group (25.0%, 2,000/8,010; p = 0.023). There were significant associations between NTG and allergic rhinitis (odds ratio [OR]= 1.34, 95% confidence interval [CI] = 1.12–1.62, p = 0.002), even after adjusting for potential confounders (age, sex, diabetes, hypertension, number, of family members, household income quartile, frequency of eating out, and smoking status). In particular, patients with NTG aged 60–69 years, those aged 70–79 years, and those who were male had significantly higher ORs for prior allergic rhinitis compared with control subjects (OR = 1.62, 95% CI = 1.16–2.26, p = 0.005; OR = 1.52, 95% CI = 1.06–2.18, p = 0.024; and OR = 1.42, 95% CI = 1.10–1.83, p = 0.007, respectively). CONCLUSIONS: This study showed a significant association between NTG incidence and allergic rhinitis, especially in males and elderly patients (>60 years of age). These results suggested that allergic rhinitis may have a potential role in the development of NTG. Therefore, ophthalmologists and allergic rhinitis patients should remain vigilant to this potential risk factor.

Analysis of Serum Homocysteine and Risk of Coronary Heart Disease in Patients with Pseudoexfoliation Syndrome

PURPOSE: To investigate levels of serum homocysteine in patients with pseudoexfoliation syndrome and the association between serum homocysteine levels and risk of coronary heart disease. METHODS: From March 2013 to September 2013, 37 patients with pseudoexfoliation syndrome and 59 age-matched patients (control group) were enrolled in this prospective study. Serum homocysteine levels were compared between the 2 groups. We compared the estimated 10-year risk of coronary heart disease based on Framingham risk score between the 2 groups. Additionally, we analyzed correlations between risk of coronary heart disease and serum homocysteine levels. RESULTS: The mean homocysteine level of patients with pseudoexfoliation syndrome was significantly higher than the control group (13.3 ± 6.8 µmol/L vs. 10.0 ± 5.2 µmol/L, p = 0.009). The rate of high risk defined as a 10-year coronary heart disease risk >20% in the patients with pseudoexfoliation syndrome was significantly higher than in the control group (21.4% vs. 4.4%, p = 0.048). Correlation between serum homocysteine levels and estimated 10-year risk of coronary heart disease was statistically significant (r = 0.578, p < 0.001). CONCLUSIONS: Hyperhomocysteinemia and high risk of coronary heart disease were observed in patients with pseudoexfoliation syndrome. Therefore, we suggest efforts to prevent coronary heart disease in pseudoexfoliation syndrome patients with hyperhomocysteinemia are necessary.

Comparative Results of Trabeculectomy with Mitomycin C in Uveitic Glaucoma versus Primary Open-Angle Glaucoma

PURPOSE: In this study we evaluated the long-term outcomes and prognostic factors of trabeculectomy with mitomycin C (MMC) in eyes with uveitic glaucoma (UG) compared with primary open-angle glaucoma (POAG). METHODS: We performed a retrospective chart review of 60 eyes with UG and 402 eyes with POAG that were followed up for at least 1 year after trabeculectomy with MMC between June 2000 and December 2012. The review included intraocular pressure (IOP), number of anti-glaucoma medications, and postoperative complications. Surgical success was analyzed using the Kaplan-Meier life-table method based on 2 definitions of successful IOP control with topical anti-glaucoma medications: Definition A (IOP < or = 15 mm Hg) and Definition B (IOP < or = 18 mm Hg). Risk factors for surgical failure of trabeculectomy were analyzed using the Cox proportional hazards model. RESULTS: Success rate at 5 years after trabeculectomy was lower in UG than in POAG (65.8% vs. 76.4%, Definition B), but without significant difference. However, UG had a significantly lower cumulative probability of success than POAG based on Kaplan-Meier survival curves (p = 0.049 and 0.044, respectively). Postoperative hypotony and hypotony maculopathy was more frequent in UG (p = 0.044 and 0.044, respectively). In UG, the Cox proportional hazards model showed postoperative shallow anterior chamber was associated with surgical failure in both Definition A and B. CONCLUSIONS: Long-term results of trabeculectomy with MMC in eyes with UG showed successful IOP control similar to POAG. Trabeculectomy with MMC is a reasonable surgical option for the management of UG.

Risk Factors for Early Postoperative Intraocular Pressure Elevation after Phacoemulsification in Trabeculectomized Eyes

PURPOSE: In this study, we investigated the frequency and risk factors for early postoperative intraocular pressure (IOP) elevation after phacoemulsification in patients with a prior trabeculectomy. METHODS: We performed a retrospective chart review of 200 eyes (172 patients, study group) with filtering bleb after previous trabeculectomy and 207 eyes (144 patients, control group) without previous trabeculectomy, who underwent temporal clear corneal phacoemulsification with posterior chamber lens implantation. Twelve possible risk factors including age, gender, glaucoma type, interval from trabeculectomy to phacoemulsification, axial length, preoperative IOP, preoperative bleb morphology (height, vascularity), glaucoma medication, and concomitant intraoperative procedures (iris manipulation, anterior vitrectomy, subconjunctival mitomycin C injection) were analyzed to identify independent risk factors using a multivariate logistic regression method. Early postoperative IOP elevation was defined as IOP value > or = 25 mm Hg or an IOP increase > or = 10 mm Hg the morning after surgery compared to the preoperative IOP. RESULTS: There was a significant difference in the frequency of IOP elevation between the study group (25 eyes, 12.5%) and control group (6 eyes, 2.9%; p < 0.001). The mean early postoperative IOP (15.2 +/- 6.7 mm Hg) was significantly higher than preoperative IOP (12.5 +/- 4.4 mm Hg) in the study group (p < 0.001). Risk factors for early postoperative IOP elevation were low bleb height (odds ratio; OR = 9.995, p = 0.003) and iris manipulation (OR = 4.831, p = 0.026) in the study group while risk factors were preoperative use of glaucoma medication (OR = 3.492, p = 0.004) and iris manipulation (OR = 34.249, p = 0.009) in the control group. CONCLUSIONS: Phacoemulsification increases the risk of IOP spike in prior trabeculectomized eyes, especially those with low bleb height and intraoperative iris manipulation. We suggest intraoperative and postoperative efforts to minimize intraocular inflammation and earlier follow-up examination in these patients.

Clinical Features and Surgical Outcomes of Sturge-Weber Syndrome with Glaucoma

PURPOSE: To report clinical manifestations including neurocutaneous and ocular findings and to evaluate outcomes of trabeculectomy in patients with Sturge-Weber syndrome. METHODS: The medical records of 10 eyes of 8 glaucoma patients with Sturge-Weber syndrome who were followed up for at least 1 year after trabeculectomy were reviewed retrospectively. We analyzed neurocutaneous and ocular findings, cumulative surgical success rates, and complications in patients with Sturge-Weber syndrome. RESULTS: The mean patient age at the time of surgery was 12.6 +/- 13.0 years and mean follow-up period was 71.6 +/- 81.8 months. All patients showed various clinical findings including facial hemangioma (8 patients), seizure (6 patients), intracranial lesion (6 patients), developmental delay (4 patients), conjunctival/episcleral hemangioma (4 eyes), and choroidal hemangioma (4 eyes). Postoperative success was achieved in 8 out of 10 eyes (80.0%). Postoperatively, serous retinal detachment occurred in 2 out of 4 eyes with preoperative diffuse choroidal hemangioma. CONCLUSIONS: Management of glaucoma associated with Sturge-Weber syndrome requires multidisciplinary treatment because of systemic involvement. Trabeculectomy appears to be an effective and relatively safe surgical option for glaucoma associated with Sturge-Weber syndrome. However, serious complications such as serous retinal detachment should be considered when planning trabeculectomy for patients with diffuse choroidal hemangioma.

Corneal Endothelial Cell Changes in Korean Patients with Exfoliation Syndrome

PURPOSE: To compare the corneal endothelial cell changes in both eyes of Korean patients with clinically unilateral exfoliation syndrome using specular microscopy. METHODS: A total of 144 eyes of 72 patients diagnosed with clinically unilateral exfoliation syndrome at Yeungnam University Hospital between March 2000 and February 2011 were retrospectively reviewed. Comparisons of corneal morphometric analysis were made including endothelial cell density, coefficient of variation, hexagonality, and central corneal thickness between the exfoliative and fellow non-exfoliative eyes in 72 patients with naive unilateral exfoliation syndrome. If patients received intraocular surgery during the follow-up periods, the number of intraocular surgeries and changes of the above-mentioned morphometric analysis were evaluated. RESULTS: The paired exfoliative and fellow non-exfoliative eyes did not differ in endothelial cell density (2587.0 +/- 391.0 vs. 2626.8 +/- 354.6 cells/mm2, p = 0.321), in the coefficient of variation of cell size (35.9 +/- 5.1 vs. 37.1 +/- 4.7%), hexagonality (59.5 +/- 7.3 vs. 57.8 +/- 6.3%), and central corneal thickness (530.5 +/- 37.6 vs. 532.0 +/- 35.2 microm). However, the exfoliative eyes had significantly higher values for the number of intraocular surgeries (0.97 +/- 0.78 vs. 0.28 +/- 0.48, p < 0.001) and decrement of corneal endothelial cells (410.9 +/- 538.7 vs. 19.0 +/- 284.5 cells/mm2, p = 0.007). CONCLUSIONS: There were no significant morphologic differences in corneal endothelium between exfoliative eyes and fellow eyes in the present study. However, the authors suggest that specular microscopic examination be performed before intraocular surgery in eyes with exfoliation syndrome when considering the higher frequency of intraocular surgeries and the resultant corneal endothelial damages observed in the present study.

A Case of Amantadine-Induced Corneal Edema

PURPOSE: To report a rare case of corneal edema caused by amantadine. CASE SUMMARY: A 35-year-old man was diagnosed with hypoxic brain damage caused by ventricular fibrillation. The patient showed Parkinsonism and was started on treatment with amantadine. Thirty-seven months after the commencement of amantadine treatment, the patient suffered a corneal ulcer in his right eye, which healed with opacity and thinning after medical treatment. After healing, slit-lamp examination revealed a bilateral, epithelial and stromal edema without obvious guttae and keratic precipitates. The corneal edema did not improve with topical treatment of 5% NaCl and 0.02% fluorometholone in both eyes. Three months after leaving the hospital, the patient's corrected visual acuity decreased to 0.2 (-2.0 Dsph -0.5 Dcyl Ax 90) in the right eye and 0.4 (-0.75 Dsph -2.0 Dcyl Ax 90) in the left eye. Amantadine medication was discontinued after discussion with the patient's neurologist. At the 1-month follow-up, corneal examination revealed resolution of the epithelial and stromal edema in both eyes. Corrected visual acuity was improved to 0.5 (-1.5 Dsph) in the right eye and 0.7 (-1.0 Dsph -1.0 Dcyl Ax 90) in the left eye. CONCLUSIONS: In cases of corneal edema without an obvious causative disease, the patient's systemic medication list must be reviewed and amantadine should be considered as a possible cause.

Trabeculectomy with Mitomycin C versus Ahmed Valve Implantation in Pseudophakic Glaucomatous Eyes

PURPOSE: To compare the safety and efficacy of trabeculectomy using mitomycin C (MMC) with Ahmed valve implantation in pseudophakic glaucomatous eyes. METHODS: We retrospectively reviewed the medical records of 68 pseudophakic glaucoma patients (68 eyes) who had undergone trabeculectomy with MMC (group T, 41 eyes) or Ahmed valve implantation (group A, 27 eyes). Intraocular pressure reduction rates, cumulative probabilities of surgical success, and postoperative complications were compared between two groups. Also, risk factors for surgical failures were analyzed. RESULTS: Intraocular pressure levels at postoperative 12 months were significantly lower in group T (13.8+/-5.1 mmHg) than in group A (19.6+/-6.4 mmHg, p=0.001). Cumulative probabilities of surgical success at postoperative 12 months were significantly higher in group T (95.0%) than in group A (66.2%, p=0.000). No significant differences were noted in the occurrences of complications except hyphema in two groups. We found that a younger age (< or =50 years) and Ahmed valve implantation were significant risk factors for surgical failures. CONCLUSIONS: Trabeculectomy with MMC can be more effective and preferable as a primary surgical option over Ahmed valve implantation for pseudophakic glaucomatous eyes.

PAX6 Mutations and Clinical Features of Congenital Aniridia

PURPOSE: To report the PAX6 mutations and clinical features in Korean aniridia patients. METHODS: Genomic DNA was isolated from 12 aniridia patients and 5 normal controls. The coding regions of the PAX6 gene were analyzed by direct sequencing of polymerase chain reaction products. The relationship between the mutational types and the ophthalmic findings from medical records was determined. RESULTS: Mutation analysis demonstrated seven different types of mutations, five of which have not previously been reported. Notably, these mutations were confined to PD and LNK in the PAX6 gene. Although R44X and W156X were recurrent mutations, novel mutations included G18R, IVS6+1insG, A139P, A139A, and G141G. Glaucoma was found in five (42%, adult patients 30 years or older) of twelve patients, of whom four were male. CONCLUSIONS: This is the first report to identify the PAX6 gene mutations in Korean aniridia patients. Our limited data show that glaucoma was more prevalent in male and adult patients. Moreover, a patient's age along with the PAX6 genotype might be a factor related to glaucoma in aniridia patients.

Trabeculectomy Using Mitomycin C in Aphakic and Pseudophakic Eyes / 영남의대학술지

BACKGROUND: The safety and efficacy of trabeculectomy with Mitomycin C (MMC) for surgical treatment in aphakic and pseudophaic eyes were retrospectively evaluated. MATERIALS AND METHODS: The authors reviewed 51 eyes of 45 patients who had been followed up for at least 6 months after trabeculectomy using MMC for aphakic and pseudophakic eyes. The success rate and complications were analyzed. The success criteria included intraocular pressures of 21 mmHg or less with or without glaucoma medications and no loss of light perception. Surgical failure was defined as a postoperative loss of light perception in patients with preoperative vision better than light perception, additional glaucoma surgery, or phthisis bulbi in patients with preoperative vision of no light perception. RESULTS: The average follow up period was 27.7 months and the intraocular pressure was controlled under 21 mmHg in 36 eyes of 51 (70.6%) after the procedure with or without medication for glaucoma. Using the Kaplan-Meier survival analysis, the cumulative success rate at the 3-, 6-, 12-, 24- and 36-month intervals were 98.0%, 94.1%, 91.9%, 83.4% and 75.5%, respectively. The complications observed were hyphema (4 eyes), serous choroidal detachment (4 eyes), hypotony (3 eyes), and endophthalmitis (1 eye). CONCLUSION: Trabeculectomy using Mitomycin C for the treatment of aphakic and pseudophaic eyes was safe and effective.

Limbal Lensectomy with or without Anterior Vitrectomy for the Management of Lens Subluxation / 영남의대학술지

PURPOSE: This study was conducted to assess the surgical outcomes of limbal lensectomy with or without anterior vitrectomy for the management of lens subluxation. MATERIALS AND METHODS: The medical records of 20 consecutive patients (33 eyes) with lens subluxation who had undergone limbal lensectomy with or without anterior vitrectomy from February 1999 to January 2004 were retrospectively reviewed. RESULTS: All the patients, except one high axial myopic patient, were implanted with scleral sutured posterior chamber intraocular lens. We evaluated the preoperative, postoperative visual acuity and postoperative complications and compared the results in group I (limbal lensectomy with anterior vitrectomy, 27 eyes) to those in group II (limbal lensectomy without anterior vitrectomy, 6 eyes). The preoperative best-corrected visual acuity was 0.21 and postoperative best-corrected visual acuity was improved by 2 lines or more in all 27 eyes in group I, and in 5 eyes in group II (p>0.05). The most frequent postoperative complication was intraocular lens dislocation in four eyes (14.8%) in group I alone. No retinal detachment occurred in either group, even in patients with high myopia. CONCLUSION: Limbal lensectomy without anterior vitrectomy improved visual acuity similarly to limbal lensectomy with anterior vitrectomy without significant increase of postoperative complications. This results of this study suggest that anterior vitrectomy is not necessarily required for the management of lens subluxation.

Outcomes of Repeat Trabeculectomy with Mitomycin C for Previous Failed Trabeculectomy

PURPOSE: To evaluate the safety and efficacy of repeat trabeculectomy with mitomycin C (MMC) in the management of previous failed trabeculectomy patients. METHODS: We retrospectively reviewed the medical records of 44 eyes of 41 glaucoma patients who had been followed up for at least 6 months after repeat trabeculectomy with MMC and analyzed the success rates according to clinical factors, cumulative success rates, risk factors for surgical failure and complications. Surgical success was defined as an intraocular pressure (IOP) of 21 mmHg or less regardless of glaucoma medications and loss of vision. RESULTS: Postoperative success was obtained in 34 (77.3%) out of 44 eyes after a mean follow-up period of 38.7 months. From Kaplan-Meier survival analysis, cumulative success rates after 6, 12, 24, and 36 months were 97.7%, 89.6%, 83.5%, and 80.1%, respectively. Success rates were significantly lower in eyes with preoperative IOP of 30 mmHg or more. Postoperative complications included transient hypotony in 7 eyes, choroidal detachment in 4, hyphema in 4, and cataract progression in 4. CONCLUSIONS: The success rates of repeat trabeculectomy may be lower than of primary trabeculectomy. However, considering the relatively high success rates and low complications of repeat trabeculectomy with MMC compared to the reported results of glaucoma drainage device implantation, repeat trabeculectomy with MMC is an effective and relatively safe surgical option as the secondary surgical procedure for previously failed trabeculectomy patients.

Surgical Management of Coexisting Glaucoma and Cataract / 영남의대학술지

The management of coincident glaucoma and cataract is not only a common clinical challenge but also an important research topic in the ophthalmic surgical field. The purpose of this article is to compare the different surgical options on the basis of their achievable postoperative intraocular pressure (IOP) control, success rates, and complication rates reported in the related literature, and to give advice on how to manage typical situations of patients with both glaucoma and cataract. Main topics were focused on indications and rationale of 3 surgical options (only cataract surgery first and later trabeculectomy, only trabeculectomy first and later cataract surgery, or simultaneous combined surgery). Modern clear corneal cataract extraction techniques resulted in a modest intermediate-term reduction of IOP and has considerably improved the success rates of combined glaucoma and cataract surgery. It also enabled future trabeculectomy to be successfully performed at a later date if necessary. Trabeculectomy alone achieved better IOP regulation than phacotrabeculectomy (combined surgery), but subsequent cataract surgery may compromise preexisting filtering bleb. Combined surgery augmented with mitomycin C achieved a lower IOP than combined surgery alone but had a higher complication rate. In conclusion, the choice of the preferred surgical method should be determined according to the target pressure, the amount of glaucomatous damage, and the grade of visual disturbance caused by the cataract. Phacotrabeculectomy with adjunctive mitomycin C offers visual improvement and achieves the best IOP lowering of all types of combined glaucoma and cataract surgery currently used but is associated with potentially sight-threatening complications.

Surgical Results of Scleral Buckling in Retinal Detachments with Subretinal Traction Band

PURPOSE: To evaluate the surgical results of scleral buckling procedure for rhegmatogenous retinal detachment with subretinal traction bands (SRTB). METHODS: We analyzed the medical records of 25 patients who had undergone only scleral buckling procedures for retinal detachment with SRTB with a minimum follow-up period of 6 months. RESULTS: Mean patient age was 33.7 years (16~80 years) and mean follow-up period was 15.8 months (6~35 months). Successful anatomic reattachment was achieved in 21 eyes (84%), and postoperative visual acuity improved in 12 eyes (48.0%). As for complications, surgical failure of the primary surgery occurred in 4 eyes (16%), temporary elevation of intraocular pressure in 3 eyes (12%), exposure of silicone sponge in 1 eye (4%), and progression of cataract in 1 eye (4%). The causes of primary failure were remaining subretinal fluid in 3 eyes and proliferative vitreoretinopathy in 1 eye. CONCLUSIONS: Scleral buckling procedure is recommended as one of the surgical methods in the management of retinal detachments with SRTB in selected cases.

Mutational Analysis of FOXL2 Gene in Blepharophimosis-Ptosis-Epicanthus Inversus Syndrome (BPES) Patients

PURPOSE: The purpose of this paper is to identify the forkhead transcription factor gene (FOXL2) mutations in Korean patients with blepharophimosis-ptosis-epicanthus inversus syndrome (BPES). METHODS: We have analyzed the mutations of FOXL2 gene in genomic DNAs extracted from 16 BPES patients and their families by PCR, PCR-SSCP, and sequencing. RESULTS: No deletion in exon 1 to 3 of the FOXL2 gene was observed by PCR. The PCR products were subjected to SSCP analysis and 9 patients showed SSCP shifts. The PCR products showing SSCP shifts were subcloned into plasmid vectors and sequenced to confirm the FOXL2 mutation. In total, 7 mutations (1 nonsense mutation, 1 deletion, and 5 duplications) in exon 2 were identified. CONCLUSIONS: The FOXL2 gene mutations were identified in the Korean BPES patients. Some of the mutations were previously reported and some were new mutations. This study will contribute to the molecular analysis and clinical counseling of BPES patients.

Prophylactic Use of Brimonidine or Apraclonidine for Intraocular Pressure Elevation following Laser Iridotomy

PURPOSE: The purpose of this study was to evaluate and compare the prophylactic effect of brimonidine 0.2% and apraclonidine 0.5% in preventing intraocular pressure(IOP) elevation in patients undergoing laser iridotomy. METHODS: The 24-hour, placebo-controlled, randomized, clinical trial was conducted to determine the efficacy of brimonidine 0.2% and apraclonidine 0.5% in controlling IOP after combined argon and Nd:YAG laser peripheral iridotomy. The 110 eyes(56 eyes with angle closure glaucoma, 54 eyes with narrow occludable angle) were randomized to receive brimonidine 0.2%, apraclonidine 0.5% or artificial tear(as placebo) 20 minutes before the procedure. IOP was measured before and 1, 2, and 24 hours after the procedure by masked observer using Goldmann applanation tonometry. The difference between preoperative(baseline) IOP and the highest postoperative IOP was recorded as the maximum IOP rise. RESULTS: The mean of maximum IOP rise was 1.1+/-5.6 mmHg in the brimonidine group, 1.0+/-2.9 mmHg in the apraclonidine group and 4.7+/-7.6 mmHg in the placebo group. There was statistically significant decrease in IOP in both drug groups compared to the placebo group(p0.05). CONCLUSIONS: Both brimonidine 0.2% and apraclonidine 0.5% were significantly effective in preventing IOP spike following laser iridotomy procedure. There was a tendency toward less efficacy with brimonidine 0.2% compared to apraclonidine 0.5%, but this was statistically insignificant.

Comparison of Long-term Results of Primary Trabeculectomy with Mitomycin C in Juvenile-onset and Adult-onset Primary Open Angle Glaucoma

PURPOSE: Young age is controversial risk factor for filtration failure following trabeculectomy with adjunctive mitomycin C (MMC). This study aimed at investigating whether juvenile-onset primary open angle glaucoma (JPOAG) patients have worse long-term outcome than adult-onset primary open angle glaucom (APOAG) patients following primary trabeculectomy with adjunctive MMC. METHODS: Medical records of 162 eyes of 113 primary open angle glaucoma patients who had undergone primary trabeculectomy with MMC and minimum follow up of 12 months were retrospectively reviewed. All the patients were free of other known risk factors except young age for surgical failure following trabeculectomy. The patients were divided into two groups; juvenile group (68 eyes of 42 patients, 10~35 years of age) and adult group (51 eyes of 41 patients, age 50 years or older). Forty-three eyes of 30 patients, aged 36~49 years, were excluded from the analysis for the study purpose. Demographic, preoperative and postoperative data were collected for up to 96 months. Kaplan-Meier survival analysis was used for probability of cumulative success estimations according to success criterion (defined as postoperative intraocular pressure of 20 mmHg or less without glaucoma medications). RESULTS: Cumulative life-table success rates of juvenile group were 98.5% at 12 months, 84.6% at 48 months, and 71.2% at 96 months. Those of adult group were 98.0%, 77.0%, and 68.5% respectively. There was no statistically significant difference in overall filtration success rates between juvenile and adult groups (p=0.52). Using a Cox proportional hazard regression analysis of potential risk factors, young age was not found to significantly affect the surgical failure (p=0.97). CONCLUSIONS: Young age itself was not associated with the poor surgical outcome following primary trabeculectomy with adjunctive MMC in this study. The present results suggest that the success rate of the JPOAG compares favorably with that of the APOAG. Primary trabeculectomy with MMC in juvenile glaucoma without other concomitant risk factors may have a favorable long-term clinical outcome as adult glaucoma.