Autologous conjunctival resurfacing of leaking filtering blebs.

PURPOSE: To present a case series of a new technique to repair late bleb leaks. DESIGN: Retrospective, noncomparative, consecutive case series. PARTICIPANTS: Forty-seven autologous conjunctival resurfacings of late bleb leaks were performed by four surgeons at two institutions. METHODS: Autologous conjunctival grafts were placed over existing de-epithelialized leaking blebs. MAIN OUTCOME MEASURES: Leak-free, Seidel-negative blebs and controlled glaucoma. RESULTS: After a mean follow-up of 14 +/- 12 months, one patient continued to have bleb leak at the last follow-up, and one frank leak resolved with aqueous suppression. Intraocular pressure increased from 6.6 +/- 4.4 mmHg (0.13 glaucoma medications) to 11.9 +/- 4.1 mmHg (0.41 glaucoma medications). CONCLUSIONS: Conjunctival resurfacing with autologous tissue is an effective technique to repair late bleb leaks.

Timolol hemihydrate vs timolol maleate to treat ocular hypertension and open-angle glaucoma.

PURPOSE: We compared the therapeutic efficacy and safety of timolol hemihydrate to timolol maleate in patients with ocular hypertension and chronic open-angle glaucoma. METHODS: We conducted this three-month study as a multicentered, masked, parallel group comparison. Both the 0.25% and 0.5% concentrations were evaluated against similar concentrations of timolol maleate. Dosing was twice daily. An open-label, nine-month study followed the masked portion of the protocol, in which all patients received either 0.25% or 0.5% timolol hemihydrate. A total of 371 patients were included in both the 0.25% and 0.5% studies. RESULTS: We found statistically similar intraocular pressures with both the 0.25% (18.3 and 18.6 mm Hg for the hemihydrate and maleate groups, respectively) and 0.5% (19.9 and 19.5 mm Hg for the hemihydrate and maleate groups, respectively) concentrations of timolol hemihydrate and timolol maleate after three months of masked treatment. Likewise, peak intraocular effect at two hours after taking the medication was statistically similar between medicines at both concentrations. Likewise, both ocular and systemic safety were similar between the maleate and hemihydrate preparations at both concentrations. In the nine-month open-label protocol, therapeutic efficacy (19.9 and 19.1 mm Hg for the 0.25% and 0.5% concentrations, respectively) and safety of timolol hemihydrate were similar to effect and safety of the three-month protocol. CONCLUSIONS: This study suggests that timolol hemihydrate had an ocular hypotensive efficacy and safety profile statistically equivalent to that of timolol maleate for up to three months of therapy. Timolol hemihydrate showed efficacy and safety similar to that observed within the first three months, for up to one year of therapy.

A ten-year follow-up on a prospective, randomized trial of postoperative corticosteroids after trabeculectomy.

PURPOSE: Patients prospectively enrolled in a clinical trial to evaluate the effect of corticosteroid use after guarded filtration procedure (trabeculectomy) were re-evaluated after 10 years to determine whether (1) there were differences in intraocular pressure (IOP) level and stability of glaucoma between treated and nontreated eyes, (2) surgery had altered the clinical course of the patients, and (3) there was any relation between level of IOP and glaucoma control. METHODS: Forty-six eyes of 35 patients were evaluated individually. Stabilization/ progression of glaucoma was established based on IOP, clinical evaluation of visual fields, and stereoscopic analysis of disc using ophthalmoscopy and photography. RESULTS: The nonsteroid-treated eyes underwent more additional glaucoma surgeries, were treated with more glaucoma medicines, and had higher IOPs. Glaucoma was stabilized in 82.8% of the steroid-treated eyes and 67% of the nonsteroid-treated eyes. There was a direct correlation between level of IOP and stabilization of optic nerve and visual field in both groups. CONCLUSION: The use of corticosteroids after guarded filtration procedure was correlated with better glaucoma control. Patients with lower IOPs were more likely to be stabilized than those with higher pressures.

Interoperator variability in images obtained by laser polarimetry of the nerve fiber layer.

PURPOSE: To study operated-related variability in images obtained by laser polarimetry of the nerve fiber layer, a new imaging technique that attempts to estimate thickness of the nerve fiber layer by using the fact that it is birefringent. METHODS: Measurements were made using a commercial device, the Nerve Fiber Analyzer (Laser Diagnostic Technologies, San Diego, CA), which uses a dedicated scanning laser ophthalmoscope to produce a retardation map of the retina adjacent to the optic nerve head. Four trained operators tested 11 subjects twice each, resulting in 88 images. Standard circles were placed around the optic disk for analysis. We analyzed five indices computed from these images: mean thickness in each of four quadrants and mean thickness under the entire circle. RESULTS: Repeated-measures analyses of variance showed significant effects of operator for four of these indices. Mean values for a given index varied by 11-14 muUm across operators, and the maximum difference across operators was approximately 22 of the mean value across subjects. CONCLUSIONS: The clinical usefulness of the device will be limited until it has been shown that new modifications successfully reduce interoperator variability.

The use of subconjunctivally administered tissue plasminogen activator after trabeculectomy.

Blockage of aqueous flow in the early postoperative period can be devastating to the success of trabeculectomy. We used tissue plasminogen activator (tPA) subconjunctivally in an attempt to release a trabeculectomy flap that appeared to be adherent to its scleral bed. No change was noted 90 minutes after injection, but a highly elevated bleb was present on the first postoperative day. Subconjunctivally administered tPA may be useful in releasing the fibrin "glue" in cases with adherent trabeculectomy flaps.

Intracameral tissue plasminogen activator: management of a fibrin clot occluding a Molteno tube.

We report the use of intracameral tissue plasminogen activator to dissolve a fibrin clot occluding a Molteno tube in the immediate postoperative period. This technique is an effective alternative to awaiting clot lysis or reoperation with minimal risk. The only complication was a small, layering hyphema.

Early clinical experience with the Baerveldt 350-mm2 glaucoma implant and associated extraocular muscle imbalance.

PURPOSE: The Baerveldt glaucoma implant is a new commercially available aqueous drainage device. Clinical data on the performance of the implant are relatively limited. The purpose of this investigation is to explore potential advantages and disadvantages of this implant over the more widely used Molteno implant. METHODS: Retrospective analysis was performed on 37 eyes of 36 patients with refractory glaucoma who underwent placement of a mid-sized Baerveldt 350-mm2 implant. Patient selection was based on previous failure of conventional medical, laser, and surgical management, with poor prognosis for further glaucoma surgery and adjunctive antifibrosis therapy. RESULTS: Significant postoperative extraocular motility restriction and heterotropia were found in the operated eyes. Twenty-three (77%) of 30 eyes measured have significant heterotropia in primary gaze and restriction of gaze into the quadrant of the implant. As a result, 11 (65%) of 17 functionally binocular patients have diplopia in primary gaze. CONCLUSIONS: Pending further study, the authors are avoiding placement of the Baerveldt 350-mm2 implant in both binocular and monocular patients due to the high frequency of induced heterotropia and motility restriction.

The effects of postoperative corticosteroids on trabeculectomy and the clinical course of glaucoma: five-year follow-up study.

A randomized, prospective study on 68 eyes of 54 patients with progressive, uncontrolled, noninflammatory open-angle glaucoma showed that eyes that received topical prednisolone 1% had a lower intraocular pressure (IOP) 18 months following trabeculectomy than the eyes that received no prednisolone. The addition of systemic prednisone had no definite further effect. In the present study, we reevealuated 58 eyes of 45 of these patients 5 years after the time of initial surgery. The number of cases lost to follow up was similar in the steroid and the nonsteroid-treated groups. Mean IOP of the steroid-treated patients was 14.5 +/- 1.8 mm Hg, and of the nonsteroid-treated patients, 19.3 +/- 2.1 mm Hg. Visual field, optic disc, and IOP were stabilized in 94% of the steroid-treated cases and in 43% of the nonsteroid-treated cases. Thus, postoperative steroids significantly increased the success rate of trabeculectomy in these eyes, and the eyes with lower IOPs had a significantly better prognosis than those with higher IOPs.

The use of Molteno implant and anterior chamber tube shunt to encircling band for the treatment of glaucoma in keratoplasty patients.

This retrospective study reviews the results of 35 keratoplasty patients with complex corneal and glaucoma disease, who received Molteno-type (n = 25) or anterior chamber tube shunt to encircling band (ACTSEB)-type (n = 10) implant for the treatment of difficult glaucomas. The implant was placed before the keratoplasty in 14 eyes, during the keratoplasty procedure in 6 eyes, and subsequent to the corneal surgery in 15 eyes. Mean follow-up for the keratoplasty was 25.46 months (range, 6-58 months) and 24.74 months (range, 7-42 months) for the seton procedure. Graft rejection occurred in 12 (34%) of 35 eyes and was progressive in 9 eyes. Nonimmunologic failure was seen in 9 (26%) of 35 eyes. Grafts were repeated in ten eyes with eight of these (80%) remaining clear at a mean of 14.4 months. Considering the results of the repeat grafts, 25 (71%) of 35 eyes achieved clear transplants. Overall, 46% of patients had final visual acuities of 20/100 or better and 69% had final visual acuities of 20/400 or better. The mean preoperative intraocular pressure (IOP) of 34.54 mmHg (range, 14-68 mmHg; standard deviation [SD], 11.51) was lowered to a mean of 14.65 mmHg (range, 6-30 mmHg; SD, 4.49). In the final analysis, 30 (86%) of 35 eyes were judged successful from a glaucoma standpoint. We conclude that the Molteno- and ACTSEB-type implants are viable treatment alternatives in this difficult glaucoma group.

A technique for accurate application of pilocarpine gel.

Pilocarpine hydrochloride 4% gel can be accurately administered by squeezing a one-half inch ribbon of gel onto the tube tip and then touching the premeasured dose to the conjunctiva.

Factors affecting the results of argon laser trabeculoplasty in open-angle glaucoma.

Argon laser trabeculoplasty (ALT) was performed in 232 eyes of 180 patients affected by uncontrolled primary open-angle glaucoma (POAG), exfoliation syndrome glaucoma (ESG) or pigment dispersion syndrome glaucoma (PDSG). Mean follow-up was 9 months (3-22). Mean IOP change was -21.6% (+/- 19) from the initial value. The effect of IOP was larger in patients with ESG, PDSG, and in POAG cases with more pigmented trabecular meshwork. No relationship was found between IOP changes and age or refraction of patients; the association with iridoplasty did not influence final results. An Octopus computerized perimeter was used for pre and post-treatment visual field tests. In 113 eyes Octopus exams met the requirements for quantitative analysis. In this group 17% of visual field improved, 64% remained stable and 19% worsened. A good functional response was more frequent among the eyes with less advanced disease.

Short- and long-term effects of postoperative corticosteroids on trabeculectomy.

All patients with primary open-angle or primary angle-closure glaucoma requiring trabeculectomy between January 1982 and January 1983 were entered into a randomized prospective study to evaluate the effect of postoperative corticosteroids. Twenty-three eyes in Group 1 received a cycloplegic and topical antibiotic. Twenty-nine eyes in Group 2 received the same treatment, with the addition of topical 1% prednisolone acetate. Twenty-three eyes in Group 3 received the same treatment as Group 2, with the addition of systemic prednisone. Success rate was significantly improved with the use of topical corticosteroids. Systemic steroids did not prove to be of any added benefit over topical use alone.

Histopathologic verification of position of laser burns in argon laser trabeculoplasty.

Surgical trabeculectomy was performed on 10 eyes of 10 patients following failure of argon laser trabeculoplasty. All specimens were examined by scanning electron microscopy to determine anatomic location of laser damage. Correlation with clinical data revealed accurate placement of laser burns in 11 out of 13 treatment sessions. The degree of laser injury varied with energy delivered and pigmentation of the posterior trabecular meshwork. Complications such as corneal endothelial, oblique, and confluent burns were present in 50% of cases studied.

Effect of varying size of scleral flap and corneal block on trabeculectomy.

Prospectively, 28 eyes of 23 patients undergoing trabeculectomy were divided into two groups. The first group received a large scleral flap (4 mm X 4 mm X 4 mm) and corneal block (3 mm X 3 mm). The second group received a small scleral flap (2 mm X 2 mm X 2 mm) and corneal block (1 mm X 1 mm). No other changes in technique were made. After a mean follow-up of 13 months, there was no significant difference in final intraocular pressure, visual acuity, or complication rates between groups.