Penetrating keratoplasty with a valved glaucoma drainage implant for congenital glaucoma and corneal scarring secondary to hydrops.

The simultaneous management of glaucoma and corneal opacification is sometimes required in infants with severe congenital glaucoma if timely visual rehabilitation is to be achieved. A 1-month-old female infant presented with an enlarged, protuberant, opaque cornea in each eye and elevated intraocular pressure. An intrastromal, fluid-filled cleft was noted in both corneas. It resolved over 3 weeks as corneal scarring progressed. Peripheral corneal clearing allowed a view of an essentially normal anterior chamber. Penetrating keratoplasty and Ahmed (New World Medical Inc., Rancho Cucamonga, CA) valve implant surgery with mitomycin-C were performed simultaneously in the two eyes 1 months apart. At 15 months of age, the patient's grafts were clear and the intraocular pressure was well controlled in both eyes. One eye required multiple procedures for eventual glaucoma control. No postoperative overfiltration occurred. The authors conclude that the use of a valved implant should be considered in patients who require urgent simultaneous corneal and glaucoma surgery for severe congenital glaucoma. This combination may improve early postoperative control of aqueous outflow and positively affect long-term graft survival in these difficult cases.

Recalcitrant malignant glaucoma following pars plana vitrectomy, scleral buckle, and extracapsular cataract extraction with posterior chamber intraocular lens implantation.

Pars plana vitrectomy is employed to treat cases of aqueous misdirection that are refractory to medical and laser treatment. The authors describe a 65-year-old man without previous aqueous misdirection in whom this condition developed after a procedure that included pars plana vitrectomy. The aqueous misdirection recurred despite multiple interventions, including medical treatment, transiently successful Nd:YAG laser capsulo-hyaloidotomy, and surgical disruption of the anterior hyaloid face. It finally resolved after repeated pars plana vitrectomy with hyaloido-capsulo-iridectomy. There has been no recurrence 7 months after this procedure. The authors conclude that the surgical treatment of aqueous misdirection refractory to more conservative measures should include adequate disruption of the anterior hyaloid to prevent recurrence.

Combined phacoemulsification and trabeculectomy with mitomycin-C.

BACKGROUND AND OBJECTIVE: To evaluate the effectiveness of combined phacoemulsification and trabeculectomy with mitomycin-C with respect to visual rehabilitation and control of intraocular pressure in patients with coexisting cataract and glaucoma. PATIENTS AND METHODS: The authors retrospectively studied 20 consecutive cases of phacoemulsification with posterior chamber intraocular lens implantation combined with trabeculectomy using mitomycin-C. They included in their study 20 eyes of 19 patients with primary open-angle glaucoma, pseudoexfoliation glaucoma, inflammatory glaucoma, chronic angle-closure glaucoma, and normal tension glaucoma. RESULTS: After a mean postoperative follow-up time of 14.4 +/- 3.1 months, intraocular pressure was reduced from a preoperative mean of 19.2 +/- 6.1 mm Hg to a postoperative mean of 13.4 +/- 3.9 mm Hg (P = .0004). The number of required intraocular pressure-lowering medications dropped from a preoperative mean of 2.3 +/- 0.7 medications to 0.2 +/- 0.4 medications postoperatively (P < .0001), with only 4 eyes requiring the restarting of a single medication each. Mean log10 (minimum angle of resolution) visual acuity improved from a preoperative 0.66 +/- 0.53 (Snellen 20/91) to a postoperative 0.30 +/- 0.40 (Snellen 20/40) (P < .0005). The most frequent complication was a bleb leak (8 of 20 eyes [40%]), usually occurring early and responding to conservative management. One eye with later-onset bleb leak incurred endophthalmitis. In another eye, hypotony with maculopathy developed. CONCLUSIONS: Phacoemulsification combined with trabeculectomy using mitomycin-C appears to be an effective approach to the management of cataract in patients with glaucoma. It offers potential for good improvement in visual acuity as well as long-term control of intraocular pressure with reduced or no dependence on medications. Potential vision-threatening complications of this procedure, specifically hypotony maculopathy and late-onset bleb leaks, should be considered in the decision to use mitomycin-C.

Ocular hypotony after trabeculectomy with mitomycin C.

Because mitomycin C reduces the resistance to aqueous outflow normally provided by postoperative subconjunctival fibrosis, we would expect to see more frequent hypotony after trabeculectomy with mitomycin C than after standard trabeculectomy. To evaluate the incidence of hypotony in trabeculectomy with intraoperative mitomycin C use, we performed a retrospective analysis on 52 eyes of 48 patients who underwent trabeculectomy with mitomycin C. Mitomycin C concentration was 0.4 mg/ml in all eyes, and treatment time ranged from 3 1/2 to seven minutes. We defined hypotony as intraocular pressure lower than 5 mm Hg on two examinations at least four weeks apart and six weeks or more postoperatively. Overall, average intraocular pressure was 22.7 +/- 10.7 mm Hg preoperatively and 10.4 +/- 5.0 mm Hg postoperatively (P < .001), a mean reduction in intraocular pressure of 12.3 +/- 11.5 mm Hg (47.0%). Hypotony occurred in 17 of 52 eyes (32.7%). Seven eyes required trabeculectomy revision for hypotony. Hypotonous eyes received longer treatment with mitomycin C intraoperatively, with a mean application time of 5.3 +/- 1.0 minutes for hypotonous eyes and 4.7 +/- 0.8 minutes for nonhypotonous eyes (P = .03). Sixteen of 43 eyes (37.2%) undergoing primary filtration became hypotonous, as compared to one of nine (11.1%) eyes that had previous filtering procedures (chi 2 = 2.30, P = .13). Nine of 17 hypotonous eyes (52.7%) and five of 35 nonhypotonous eyes (14.3%) had loss of two or more lines of Snellen visual acuity. Hypotony occurred in nearly one third of eyes treated with mitomycin C during trabeculectomy in our study. There was a statistically significant (P = .03) association of hypotony with longer application time of mitomycin C, and a trend toward increased incidence of hypotony in primary filtration.