[Low dose intravitreal triamcinolone acetonide in the treatment of neovasular glaucoma]. / Injection intravitreenne de faible dose d'acetonide de triamcinolone dans le traitement du glaucome neovasculaire.

PURPOSE: To report the effect of an intravitreal injection of 4 mg of crystalline triamcinolone acetonide (Kenacort) as symptomatic treatment of neovascular glaucoma. MATERIAL AND METHODS: This clinical study is based on clinical and experimental investigations that examined the tolerability and the angiostatic effect of triamcinolone acetonide. The study includes prospectively 8 eyes of 8 patients with neovascular glaucoma secondary to ischemic central retinal vein occlusion (n=8). All patients received an intravitreal injection of 4 mg of crystalline triamcinolone acetonide (0.1 cc) as the only procedure or in combination with transscleral cyclodiode as glaucoma treatment. Their mean age was 74.5 +/- 14.4 years. Mean intraocular pressure (IOP) was 38.9 +/- 9.3 mmHg. Mean follow-up was 6 months. RESULTS: 4 of 8 patients were treated by crystalline triamcinolone acetonide as the only procedure (n=3). Twenty seven days after intravitreal kenacort injection, the others four patients have been treated by transscleral cyclodiode (n=4) as glaucoma treatment. After injection, including the first postoperative day, patients report a subjective reduction of ocular pain. Furthermore no intra- or extraocular inflammatory reactions were observed during the follow-up. Intraocular pressure was significantly reduced to 18 +/- 6.2 mm Hg at the end of the follow-up period. When considering only the four patients in which the intraocular cortisone injection was the only procedure performed, mean intraocular pressure decreased from 41.75 +/- 7.05 mm Hg to 20.5 +/- 6.6 mm Hg. Iris neovascularisation was significantly decreased from grade IV to grade I in all patients at the end of the follow-up CONCLUSION: Intravitreal injection of 4 mg triamcinolone acetonide contributes to a better management of the neovascular glaucoma.

[Acute glaucoma crisis]. / Le glaucome aigu.

Acute glaucoma crisis is an emergency in ophthalmology. Ocular and systemic clinical signs are typical and due to a paroxystic and severe increase of intraocular pressure. It is a biometric disease: little eye with a big lens. Main factors triggering the acute crisis are: stress, sympathicomimetics, parasympathicomimetics and parasympathicolytics drugs. Treatment is surgical: iridectomy, cataract extraction, trabeculectomy or combined surgery.

[Non perforating trabecular surgery with reticulated hyaluronic acid implant]. / La chirurgie non perforante du trabéculum avec implant d'acide hyaluronique réticulé.

Non perforating trabecular surgery (NPTS) with reticulated hyaluronic acid implant (Skgel) allows aqueous humor to leave anterior chamber through a thin trabeculo-Descemet's membrane into a sclerocorneal space filled with Skgel implant and then via the outflow physiological channels. Good IOP results are obtained with less or without external filtration decreasing the incidence of per- and postoperative complications described after trabeculectomy. This surgery is actually only indicated for primary open angle glaucoma, the trabeculectomy still remaining the gold standard procedure for the other glaucoma cases.

[Surgical indications in coexisting cataracts and glaucoma]. / Indications chirurgicales dans la coexistence de cataracte et de glaucome.

Cataract surgery in glaucoma patients remains a controversial subjects. Indication of surgery depends on a lot of clinical parameters: diagnosis, state, evolution of glaucoma as well as compliance with medical treatment--surgical procedures of cataract and glaucoma--sites of the surgery--use of antifibrosis agents and surgeon's experience. As cataract extraction alone decreases the intraocular pressure in open angle glaucoma and mainly in uncomplicated closed angle glaucoma and trabeculectomy alone reduces the intraocular pressure more than combined surgery with less complications we recommended the following surgical options: Cataract extraction alone in patients with controlled open angle glaucoma and in patients with closed angle glaucoma. A two step procedure: filtering surgery followed by cataract extraction in patients with poorly controlled open angle glaucoma or mixed closed angle glaucoma. Ambulatory surgery and topical anesthesia permit a two stages surgery with less inconveniences. A combined procedure in patients with a chronic closed angle glaucoma where filtering procedure alone is associated with important complications. Actually, the best surgical cataract procedure is phacoemulsification with a small supero-corneal incision and implantation of a foldable intraocular lens. The best filtering procedure remains trabeculectomy, or the new non penetrating trabecular surgery for experimented surgeons, in the superior quadrant. In the future new surgical procedures and new safe and non toxic pharmacologic drugs which modulate wound healing could be found in order to increase the efficacity and indications of combined surgery.

[Non perforating trabecular surgery with reticulated hyaluronic acid implant]. / La chirurgie non perforante du trabéculum avec implant d'acide hyaluronique réticulé.

Non perforating trabecular surgery (NPTS) with reticulated hyaluronic acid implant (Skgel) allows aqueous humor to leave anterior chamber through a thin trabeculo-Descemet's membrane into a sclerocorneal space filled with Skgel implant and then via the outflow physiological channels. Good intraocular pressure results are obtained with less or without external filtration decreasing the incidence of per- and postoperative complications found after trabeculectomy. This surgery is actually only indicated for primary open angle glaucoma, the trabeculectomy still remaining the gold standard procedure for the other glaucoma cases.

[Interest in ophthalmologic examination for familial adenomatous polyposis]. / Intérêt de l'examen ophtalmologique dans la polypose adénomateuse familiale.

We describe the clinical history of four patients belonging to a familial adenomatous polyposis (FAP) family. We stress the importance of a fundus examination for the screening of carriers of the gene responsible for familial adenomatous polyposis.

[Glaucoma and cataract--surgery at two times]. / Glaucome et cataracte--chirurgie en deux temps.

Cataract surgery in glaucoma patients remains a controversial subject. Indication of surgery depends on the type and severity of glaucoma. Surgical results depend on: the technique used for cataract extraction (extracapsular or phacoemulsification), the type of filtration procedure (trabeculectomy or deep sclerectomy) as well as of the site of the surgical incision, the use of antifibrotic agents and on the surgeon's experience. As cataract extraction alone reduces the intraocular pressure in glaucoma patients (especially in angle closure glaucoma) and trabeculectomy alone reduces intraocular pressure more than combined surgery with less complications, we recommend for controlled glaucoma patients cataract extraction alone and for uncontrolled glaucoma patients a two step procedure consisting in first a trabeculectomy and second a cataract extraction. The use of an antimetabolites not necessary. The recent use of topical anesthesia permits a two staged surgery with less inconvenience.

Ambulatory blood pressure monitoring in glaucoma patients. The nocturnal systolic dip and its relationship with disease progression.

PURPOSE: This study was designed to uncover a new sensitive and specific factor for predicting the progression of glaucoma. METHODS: The 24-hour ambulatory blood pressure and diurnal curve of intra-ocular pressure were recorded in seventy patients: 51 primary open angle glaucoma (POAG) and 19 normal tension glaucoma (NTG). The mean systolic, diastolic and average arterial blood pressure were calculated, along with the nocturnal dip of systolic pressure and diastolic blood pressure. Two-year disease progression was assessed for all patients by means of retrospective analysis of visual fields defects on repeated perimetries. RESULTS: Abnormal (absence or increased) nocturnal dip of systolic blood pressure was found to be correlated with disease progression in POAG and NTG patients with a sensitivity of 86% and a specificity of 85%, whereas no significant correlation was found for the other risks factors envisaged. Furthermore, a significant relationship between stable visual field defects and the use of diuretics/laser procedure was evidenced. CONCLUSION: The nocturnal dip of systolic blood pressure should be considered as a predictive factor of disease progression in NTG and POAG. Further prospective studies are needed to ascertain whether dip normalization could help slow down the visual field loss in these patients.

[Interest in the Heidelberg Retinal Flowmeter for measuring the retinal and papillary blood flow]. / Interet du Heidelberg Retina Flowmeter dans la mesure du flux sanguin retinien et papillaire.

The Heidelberg Retina Flowmeter is a combination of Doppler flowmetry and laser scanning technology. It is new non-invasive method performing a high definition topography of perfused microvessels of the retina and optic nerve head with simultaneous evaluation of blood flow. Recent studies prove significant decrease of optic nerve head blood flow and juxtapapillary blood flow in primary open angle glaucoma.

Effect of topical betablockers on human retinal vessels diameters.

PURPOSE: To measure the effect of topical betaxolol 0.5% and timolol 0.5% on retinal vessels diameters by means of photographic enlargement. METHODS: Thirteen glaucomatous patients (primary open angle glaucoma (POAG) and ocular hypertensive (OH)) were treated twice daily with betaxolol 0.5% for one year. These same patients were subsequently treated with timolol 0.5% during the following year. Fundus photographs were taken with Canon camera 30 degree angle at baseline and two hours after instillation at 3, 6 and 12 months of treatment for each drug. The diameters of the superior and inferior temporal vessels (arteries and veins) were measured at one and two disc radii from the margin of the disc using photographic enlargement (x 66.7) of the right eye and were analysed under double masked fashion during the same session. RESULTS: A significant increase of the mean arterial diameter (+ 7.4% p = 0.000 paired t) was found after 12 months of betaxolol treatment, while no persistent further difference (+ 1.3% NS) was found after 12 months of timolol treatment. No modification was found in venous diameter. CONCLUSION: Betaxolol treatment is associated with a beneficial effect on retinal arteries width whereas Timolol does not yield the same amplitude of benefit.

[Surgery for glaucoma and endophthalmitis]. / Chirurgie des glaucomes et endophtalmies.

The incidence of endophthalmitis after glaucoma surgery appears to be related to surgical procedures. After trabeculectomy the incidence is low from 0.06% to 0.2% but trabeculectomy with adjunctive antimetabolites increases the risk to 3% or more. Early onset endophthalmitis is due to the penetration of germs from patient's own external flora during the surgery, especially staphylococcus epidermidis.

[Value of blood pressure ambulatory monitoring in glaucoma patients: big dippers or non dippers]. / Intérêt du monitoring ambulatoire de la pression artérielle chez les patients glaucomateux: big dippers or non dippers.

Ambulatory blood pressure monitoring in glaucoma patients was useful to underline the magnitude of vascular factors in glaucomatous optic neuropathy progression.

Longterm effect of topical beta-blockers on intraocular pressure and visual field sensitivity in ocular hypertension and chronic open-angle glaucoma.

In a prospective, randomized study, nineteen patients with ocular hypertension (n = 14) or chronic open-angle glaucoma (n = 5) were treated with either betaxolol 0.5% or timolol 0.5% in both eyes twice daily. Visual field sensitivity and intraocular pressure were assessed with the Octopus perimeter (program G1) and applanation tonometry, respectively, at 3, 6, 12, 24, 36, and 48 months during treatment. Four of the nineteen patients (two timolol-treated and two betaxolol-treated) were lost to follow-up after the 36-month examination. Whereas both drugs reduced the intraocular pressure, the decrease in the timolol-treated group was statistically more pronounced than in the betaxolol-treated group at month 3, 6, and 48 (p < 0.03). In both treatment groups, the visual field mean sensitivity (MS) index decreased slightly during the first six months of treatment, but remained so only in the timolol-treated group at all subsequent examinations. In the betaxolol-treated group, there was a statistically significant increase in MS at the 12, 24, 36, and 48 month visits (p < 0.01). These findings suggest that factors other than IOP alone may determine visual field outcome.

[Mitomycin C in glaucoma surgery]. / La mitomycin C dans la chirurgie des glaucomes.

Glaucoma filtering surgery fails because of scarring of the filtering bleb. Fibroblasts proliferation from the episclera and Tenon capsule play an important role in the scarring process. The use of antimetabolites in glaucoma filtering surgery have a beneficial effect on the lowering of intraocular pressure especially in eye at poor surgery prognosis. They inhibit the fibroblasts proliferation and subsequent scarring of filtering bleb. 5 fluorouracil improves chance of success with filtering surgery but the necessity of multiple subconjunctival injections has many disadvantages including discomfort for the patient and ocular surface problems such as corneal defect and conjunctival wound leak. Mitomycin C with its focal applications limits the toxic effects to tissue directly exposed to the drug. A single intra-operative application leads to a more hypotensive effect with less corneal complications which are two major advantages of this treatment (Kitazawa and al.): Success rate at one year without medical treatment: 88% with MMC-40% with 5 FU. Different tissue culture studies as well as clinical studies demonstrate that the antiproliferative effect of MMC is 100 times more powerful than 5 fluorouracil. Mitomycin C might probably interfere with other steps in the wound healing process. Mitomycin C seems to be a better treatment than 5 fluorouracil. Nevertheless long term randomized prospective human studies are necessary to confirm it.

Long-term effect of ophthalmic beta-adrenoceptor antagonists on intraocular pressure and retinal sensitivity in primary open-angle glaucoma.

Timolol (TIM) and betaxolol (BET) were evaluated for their effects on both intraocular pressure and retinal sensitivity as determined from visual fields in a randomized two-year parallel study in 20 patients with primary open-angle glaucoma. All treatments were twice-daily in both eyes. TIM was more effective than BET as an ocular hypotensive agent throughout the two year period. With regard to retinal sensitivity as measured by automated visual fields, there was a decrease in retinal sensitivity in the first six months in the TIM and BET treatment groups by 0.5-0.6 dB, and 0.2-0.3 dB, respectively. However, at the one and two year visits, retinal sensitivity increased 0.8-0.9 dB in the BET treatment group only. It appears that ocular hypotensive efficacy may not relate to retinal sensitivity within a period of two years or less in patients with mildly to moderately elevated intraocular pressure. Further work may reveal the reliability of this observation, and its clinical relevance.

[Primary open-angle glaucoma. Effects of an eyedrop combining timolol and pilocarpine on the ocular pressure]. / Glaucome primitif à angle ouvert. Effets d'un collyre associant le timolol et la pilocarpine sur la pression oculaire.

In a limited group of open angle glaucoma patients treated twice daily with timoptol 0.5% and having by this treatment a mean intra-ocular pressure of 21-22 mmHg, the association of timoptol 0.5% with pilocarpine 2% respectively, lowered the intra-ocular pressure to an average of 17.8 mmHg and 16.6 mmHg after one and three weeks of continuous treatment. For this study, the patients have been divided into 3 groups: A group treated with timoptol 0.5% alone throughout the 49 days of the study. A group treated with timoptol 0.5%-pilocarpine 2% (timpilo 2) from day 21 to day 49. A final group treated with timoptol 0.5% until day 21 and then with timoptol 0.5%-pilocarpine 4% (timpilo 4) through out day 49. These patients stopped the treatment before the end of the study. Intra-ocular pressures were measured on days 0, 21 and 49. We found a higher drop of pressure (-4.8 mmHg) in the timpilo 2 group than in the timoptol 0.5% group (-1 mmHg) before instillation as well as 2 hours afterwards (-5.25 mmHg and -2 mmHg respectively). The secondary local effects were due to miotics agents. The secondary systemic effects were those inherent to beta-blockers. These results are comparable with a multicentric study of 220 patients, therefore statistically significant.