Bleb-related endophthalmitis after trabeculectomy with mitomycin C.

PURPOSE: To determine whether filtering blebs resulting from adjunctive use of mitomycin C (MMC) leads to an increased risk of endophthalmitis. METHODS: The authors retrospectively reviewed the records of 232 consecutive trabeculectomies performed at the W. K. Kellogg Eye Center with adjunctive use of MMC from May 1990 through June 1993. Data obtained from the records included patient age, sex, race, type of glaucoma, site of filtration surgery, concentration and duration of exposure to MMC, presence of early or late bleb leakage, and the occurrence of endophthalmitis. RESULTS: Three patients were lost to follow-up less than 1 month after surgery. A total of 229 eyes of 192 patients (11 women and 82 men) were included in the study. Mean follow-up of patients remaining free of infection was 18.5 +/- 10.8 months (range, 1-44 months). The overall incidence of bleb-related endophthalmitis was 2.6%. Endophthalmitis developed in 8% of patients (4 or 50) in whom an inferior approach was used and in 1.1% (2 or 179) in whom a superior approach was used (P = 0.02, Fisher's exact test). The estimated odds ratio for the development of endophthalmitis after trabeculectomy with adjunctive MMC for inferior versus superior filtration sites was 7.7. CONCLUSION: Short-term follow-up of trabeculectomies performed with adjunctive use of MMC demonstrates an overall incidence of endophthalmitis comparable to filtrationprocedures performed with 5-fluorouracil or without antifibrotic agents. However, inferior trabeculectomy performed with adjunctive MMC carries a significantly increased risk of bleb-related endophthalmitis compared with filters performed superiorly.

Mitomycin C versus 5-fluorouracil in high-risk glaucoma filtering surgery. Extended follow-up.

PURPOSE: To compare the outcome of filtering surgery in high-risk patients using intraoperative mitomycin C (MMC) versus postoperative 5-fluorouracil (5-FU). METHODS: In a randomized clinical trial, the use of postoperative subconjunctival injections of 5-FU in 19 eyes of 19 patients was compared with a single intraoperative application of MMC in 20 eyes of 20 patients. All eyes were at high risk for failure of glaucoma filtering surgery. RESULTS: Follow-up ranged from 26 to 38 months (mean, 32.0 months). Three eyes in the MMC-treated group and two eyes in the 5-FU-treated group required subsequent surgery to control the IOP. Excluding these patients, intraocular pressure (IOP) averaged 9.0 +/- 4.9 mmHg in the MMC-treated eyes versus 16.3 +/- 4.6 mmHg in the 5-FU-treated eyes at the patient's last visit (P = 0.0003). Of the MMC-treated eyes, 81.3% had IOPs less than or equal to 12 mmHg compared with 26.7% of eyes in the 5-FU group (P = 0.0023). In the MMC-treated group, the average number of medications for IOP control at last visit was 0.5 +/- 0.8 compared with 1.6 +/- 1.3 in the 5-FU-treated group (P = 0.01). Late postoperative complications (those occurring more than 3 months after surgery) were similar for the two groups, with the exception of formation of a Tenon cyst in three of the eyes treated with MMC compared with none of the 5-FU-treated eyes. CONCLUSIONS: Eyes treated with MMC have lower IOP on fewer medications than eyes treated with 5-FU. Late postoperative complications are similar with the exception of an increased incidence of Tenon cyst formation in the MMC-treated eyes.

Intraoperative mitomycin versus postoperative 5-fluorouracil in high-risk glaucoma filtering surgery.

In a randomized clinical trial, the authors compared the use of postoperative subconjunctival injections of 5-fluorouracil (5-FU) in 19 eyes with a single intraoperative application of subconjunctival mitomycin (MMC) at the filtering site in 20 eyes at high risk for failure of glaucoma filtering surgery. Six months after surgery, intraocular pressures averaged 10.9 +/- 5.3 mmHg (mean +/- standard deviation) in the MMC-treated eyes versus 14.2 +/- 5.5 mmHg in the 5-FU-treated eyes (P = 0.08) and were less than or equal to 12 mmHg in 60.0% of MMC-treated eyes and 21.1% of 5-FU-treated eyes (P = 0.03). Mitomycin-treated eyes were receiving an average of 0.3 +/- 0.5 medications for intraocular pressure control, and 5-FU-treated eyes were receiving an average of 1.1 +/- 1.1 medications (P = 0.01). Drug-induced corneal epithelial defects were seen in nine 5-FU-treated eyes and in no MMC-treated eyes (P = 0.0004). These results suggest that intraoperative MMC may be a viable alternative to postoperative 5-FU, with lower overall intraocular pressures, decreased dependence on postoperative ocular antihypertensive medications, and decreased corneal toxicity.

The effects of subconjunctival mitomycin-C on glaucoma filtration surgery in rabbits.

A prospective, randomized, masked, placebo-controlled study was performed to determine whether a single, intraoperative subconjunctival application of a 0.5-mg/mL solution of mitomycin-C enhances the success of full-thickness filtration surgery in rabbits. Compared with control eyes, mitomycin-C-treated eyes showed significant increases in bleb duration from 8.1 +/- 2.4 to 68.0 +/- 20.8 days and in intraocular pressure reduction from 6.0 +/- 3.0 to 63.6 +/- 21.5 days. Histopathologic evaluation confirmed the inhibitory effects of mitomycin-C on fibrovascular, fibrocellular, and collagenous organization of the filtering blebs that resulted in their preservation. Transient, superficial, corneal vascularization anterior to the bleb occurred in all mitomycin-C-treated eyes. No other clinical or pathologic signs of undesirable side effects were noted. We studied the effectiveness and safety of a single intraoperative application of mitomycin-C in prolonging the success of filtration surgery in rabbits and its potential for similar use in humans.

The effect of glaucoma filtering surgery on corneal endothelial cell density.

Corneal endothelial cell counts were obtained preoperatively and 3 months postoperatively in 46 eyes undergoing glaucoma filtering surgery. Average central endothelial cell loss in eyes without postoperative iridocorneal touch was 1.6%. In eyes with iridocorneal touch (Spaeth's grades 1 and 2), the average cell counts decreased by 7.1% and 9.3%, respectively. The average loss for combined grades 1 and 2 (8.1%) approached statistical significance (P +/- .06). The average loss in two patients with corneolenticular touch (Spaeth's grade 3) was greater than 50%. These findings suggest that early postoperative iridocorneal touch is unlikely to lead to corneal compromise in most eyes, but that corneolenticular touch can result in severe endothelial cell loss.

Effects of pupillary dilation on automated perimetry in normal patients.

The effects of pupillary dilation (tropicamide 1%) on automated static threshold perimetry were studied in 18 normal subjects using the Humphrey field analyzer 30-2 and STATPAC programs. The mean defect worsened by 0.83 decibels (standard deviation, 0.92 decibels) in dilated fields as compared with baseline visual fields (P = 0.001). These findings indicate that pupillary dilation in healthy subjects who are not receiving ocular medications produces statistically significant declines in threshold sensitivities. Valid comparison of results from serial visual field testing, therefore, depends on control of or adjustment for the effect of pupillary dilation.

Clinical comparison of the Oculab Tono-Pen to the Goldmann applanation tonometer.

The Oculab Tono-Pen tonometer was compared with the Goldmann applanation tonometer through studies on 197 eyes of 103 patients with glaucoma or ocular hypertension to evaluate the reliability of the Tono-Pen in determining intraocular pressure (IOP). Patients were randomized into four groups and all applanations were done by the same investigator. The Tono-Pen initially used (Tono-Pen #1) failed to calibrate after being used on 77 eyes. Tono-Pen #2 was then obtained and tested. Each Tono-Pen showed high correlation with the Goldmann readings (r greater than or equal to 0.86 in both eyes). The overall sensitivity of the Tono-Pen in detecting IOPs of 21 mmHg or higher (as measured by the Goldmann instrument) was 62.1% in right eyes, 72.4% in left eyes, with corresponding specificities of 92.6% in the right and 97.1% in the left. Given the substantial increase in sensitivity noted with Tono-Pen #2, the Tono-Pen appears adequate for screening programs where an IOP of 21 mmHg or above is considered abnormal; however, at higher IOPs (greater than or equal to 30 mmHg) the Tono-Pens tended to underestimate Goldmann IOPs. At low IOPs (less than or equal to 9 mmHg) the Tono-Pens tended to overestimate the IOPs. Perhaps with further modifications of the instrument, it could be used for clinical diagnosis and management of glaucoma patients.

Anterior encephalocele presenting as nasolacrimal obstruction.

A case of congenital anterior encephalocele presented originally with nasolacrimal obstruction. Associated paranasal masses and hypertelorism suggested the diagnosis, which was confirmed and delineated by computed tomography. Anterior encephalocele has various clinical presentations, but the diagnosis should be suspected in a child with nasolacrimal obstruction and associated congenital anomalies, particularly paranasal masses. Early recognition is essential to prevent trauma to CNS tissue, to prompt evaluation for other congenital anomalies, and to facilitate appropriate neurosurgical repair.

A clinical comparison of visual field testing with a new automated perimeter, the Humphrey Field Analyzer, and the Goldmann perimeter.

Automated threshold static perimetry with the Humphrey field analyzer and kinetic and suprathreshold static perimetry with the Goldmann perimeter were performed on 171 eyes: 69 with glaucoma or ocular hypertension, 69 with "neurologic" disorders, and 33 normal. The two fields were similar or differed only slightly in 78% of eyes overall and in 88% when both fields appeared reliable. In general, defects were slightly more extensive using the Humphrey than the Goldmann perimeter. In 21% of the eyes with glaucoma or ocular hypertension, defects were found with the Humphrey perimeter that were not present with the Goldmann perimeter. Patient fixation was more difficult to maintain on the Humphrey than Goldmann perimeter. Poor fixation accounted for 9% of the automated fields being inadequate whereas only 2% of the manual fields were inadequate. The results indicate that the Humphrey Field Analyzer is capable of reliably detecting and quantitating visual field defects.

Lens implant cyto-pathology in postoperative Proteus panophthalmitis.

The reactive membrane on a posterior chamber lens implant removed from an eye with postoperative proteus mirabilis panophthalmitis was found to be based on a continuous proteinaceous capsule exhibiting only very few fibroblast-like cells. Diffusely arranged neutrophils exhibiting evidence of phagocytosis were attached to a delicate fiber network continuous with the processes of fibroblast-like cells. There was also pus and acellular debris loosely covering the outer surface of this capsule.

Extraocular muscle involvement in Wegener's granulomatosis.

A 44-year-old man with Wegener's granulomatosis involving the upper and lower respiratory tracts developed a diplopia with involvement of three extraocular muscles of one eye and one extraocular muscle of the other eye. The ocular and orbital examinations were otherwise normal, as were computerized tomography (CT) scans of the brain and orbits. The patient was treated with systemic Cytoxan and Prednisone and the respiratory and extraocular muscle abnormalities cleared within 1 month. Because of the bilateral extraocular muscle involvement, the absence of central nervous system or orbital findings, and the rapid and complete resolution after Cytoxan and Prednisone therapy, a diffuse vasculitis affecting the extraocular muscles was implicated as the etiology of the diplopia.

A combined surgical approach to bilateral superior oblique palsy.

In two cases of bilateral superior oblique palsy the vertical component of the deviation was more prominent in one eye and the excyclotorsion more prominent in the fellow eye. A tuck of the superior oblique was performed on one eye and an adjustable Harada-Ito procedure on the fellow eye. This combined approach was used to reduce both the torsional and vertical components in these patients with complicated bilateral superior oblique palsies while effecting a more exact resolution of the torsional component.

Rubeola keratitis.

Twenty-seven young adult patients with rubeola were evaluated during the acute contagious phase of their disease. Koplik's spots were present in all patients. Conjunctivitis was present in 15 of the 27 (56%), and photophobia was present in 14 of the 27 (52%). Bilateral epithelial keratitis was present in all 27 patients. This keratitis, in otherwise healthy young adults, as in healthy children, was a benign process and required no medical therapy. The epithelial lesions were very slow to resolve completely and continued to be seen at the slit lamp after the patients had become asymptomatic. Ophthalmologists may be more involved in the future in diagnosing the ocular lesions of measles (and in making the initial diagnosis of rubeola) because of the changing nature of the susceptible population group in the United States.

Treatment of neovascular glaucoma with transscleral panretinal cryotherapy.

Transscleral panretinal cryotherapy was used to treat six eyes with neovascular glaucoma. The media of each involved eye were sufficiently cloudy at the time of treatment to prevent adequate panretinal photocoagulation. A checkerboard pattern of eight 2.5-mm cryotherapy applications was placed in each quadrant. Five of the eyes were also treated with 180 degrees of cyclocryotherapy. Within 72 hours of treatment, the intraocular pressure in each eye returned to a controllable level. The iris neovascularization in each eye regressed or totally disappeared within six weeks.

Pigmented iris angiography.

A small volume of concentrated fluorescein was used in a technique of fluorescein angiography in rabbits. The procedure is not accompanied by the usual risks of general anesthesia in rabbits. Angiographic findings demonstrated that the pigmented rabbit iris vessel pattern is similar to that found in albino rabbits.

Premature ventricular systole detection by applanation tonometry.

We first identified (and probably stimulated) premature ventricular systoles in six patients while performing Goldmann applanation tonometry. One patient developed atrial fibrillation and one patient had a follow-up electrocardiogram showing increasing numbers of these extra systoles without any other abnormalities. Just as in tonography, these were detected during applanation tonometry as rapid decreases in intraocular pressures followed by a gradual return to prior levels. The decrease in measured intraocular pressure was occasionally 8 mm Hg but usually was between 2 and 5 mm Hg. These systoles probably occurred during the first part of applanation tonometry and during the first few office visits.