Combined phacoemulsification and trabeculectomy versus trabeculectomy alone: a comparison study using mitomycin-C.

BACKGROUND AND OBJECTIVE: To compare the results of combined phacoemulsification and trabeculectomy (PEM/TRAB) plus mitomycin-C with those of trabeculectomy alone (TRAB) plus mitomycin-C. PATIENTS AND METHODS: The authors retrospectively reviewed 42 eyes in 38 consecutive patients who underwent combined PEM/TRAB with mitomycin-C. An age-matched control group of 42 patients who underwent TRAB with mitomycin-C during the same time period was randomly selected from 248 consecutive patients. All patients had a minimum of 12 months of follow-up. RESULTS: Mean preoperative intraocular pressure (IOP) and number of glaucoma medications were similar for the two groups (22.8 +/- 6.9 mm Hg vs 22.9 +/- 6.8 mm Hg, 2.12 +/- 0.8 vs 2.26 +/- 1.0 medications, combined PEM/TRAB vs TRAB, respectively). Postoperative IOP was significantly lower at all follow-up intervals. At final follow-up after a mean of 21.8 +/- 6.0 months, IOP averaged 13.9 +/- 5.1 mm Hg in the PEM/TRAB group and 12.3 +/- 4.7 mm Hg in the TRAB group. Bleb survival was excellent in both groups, although slightly higher in the TRAB group (37 of 42 PEM/TRAB vs 41 of 42 TRAB). Both groups required significantly fewer glaucoma medications at final follow-up (0.38 +/- 0.6 vs 0.5 +/- 0.8, PEM/TRAB vs TRAB). Complications were similar between the two groups. CONCLUSION: The success rate for combined PEM/TRAB appears to approach that of TRAB alone.

Hemorrhagic ocular complications associated with the use of systemic thrombolytic agents.

OBJECTIVE: This study aimed to report three patients with hemorrhagic ocular and orbital complications associated with the use of systemic thrombolytic agents. DESIGN: The study design was a retrospective small case series. PARTICIPANTS: Three eyes of three patients were studied. INTERVENTION: Surgical procedures to reduce intraocular pressure or relieve optic nerve compression were performed. MAIN OUTCOME MEASURES: Visual acuity and intraocular pressure were measured. RESULTS: Three patients received an intravenous thrombolytic agent on diagnosis of an acute myocardial infarction. One patient had a spontaneous suprachoroidal hemorrhage develop with secondary acute angle closure glaucoma shortly after receiving tissue plasminogen activator. Another patient had an orbital hemorrhage develop on receiving tissue plasminogen activator 4 days after an uncomplicated cataract extraction. The third patient experienced an orbital hemorrhage while receiving streptokinase 1 day after undergoing an external levator resection. Two patients suffered significant visual loss due to glaucoma or compressive optic neuropathy. CONCLUSIONS: The onset of eye pain or visual loss after the administration of a systemic thrombolytic agent should alert the physician to the possibility of an ocular or adnexal hemorrhage. Prompt diagnosis and treatment can improve the likelihood of a favorable visual outcome.

Brimonidine tartrate: a one-month dose response study.

BACKGROUND: Brimonidine tartrate is a relatively selective alpha2-agonist that effectively reduces mean intraocular pressure (IOP) and the incidence of IOP spikes after laser trabeculoplasty. The authors were interested in evaluating the dose response of brimonidine when applied topically for a longer duration in patients with elevated IOPs. METHODS: The authors conducted a 1-month, multicentered, double-masked, randomized, placebo-controlled, parallel clinical study in 194 patients with ocular hypertension or glaucoma (mean IOP, 25.6 +/- 3.2 mmHg). The authors administered three concentrations of brimonidine (0.08%, 0.2%, and 0.5%) or placebo bilaterally every 12 hours for 1 month. The authors evaluated the following parameters: IOP, heart rate, blood pressure, visual acuity, pupil size, basal tear secretion as well as patient comfort at baseline, day 1, week 1, week 3, and week 4. RESULTS: All concentrations of brimonidine significantly reduced IOP, compared to baseline and placebo, at all follow-up visits. Maximum mean IOP decreases from baseline of 20.8%, 27.2%, and 30.1% were observed for the 0.08%, 0.20%, and 0.5% treatment groups, respectively. On days 1 and 21, the 0.2% and 0.5% treatment groups exhibited significantly greater IOP decreases than did the 0.08% group. After the initial steep decline in IOP, the effect decreased slightly and stabilized at day 14 at the level that was maintained throughout the study. The most frequent side effects reported were fatigue and dry mouth. No significant changes in heart rate were reported. Statistically significant decreases in mean blood pressure without clinical symptoms were observed within the 0.2% and 0.5% treatment groups. CONCLUSION: Brimonidine 0.2% is well tolerated, efficacious, and shows potential as an agent in the long-term treatment of elevated IOP.

A clinical study of peripapillary crescents of the optic disc in chronic experimental glaucoma in monkey eyes.

OBJECTIVE: We produced chronic experimental glaucoma in 41 monkey eyes and assessed the long-term effects of elevated intraocular pressure on the presence of, and changes in, peripapillary crescents. METHODS: Three readers independently plotted peripapillary crescent size and location using stereo fundus photographs before and after chronic elevation of intraocular pressure in 41 monkey eyes. RESULTS: Crescents were found in a majority of normal eyes. After chronically elevated intraocular pressure, new peripapillary crescents developed in only two eyes. Using planimetric analysis, crescent size was enlarged in five (22%) of the 23 eyes with preexisting crescents. Preexisting crescents became more apparent without change in size in a majority of eyes (reader A, 15 [68%] of 22 eyes; reader B, 17 [74%] of 23 eyes; and reader C, 13 [68%] of 19 eyes). CONCLUSIONS: We conclude that peripapillary crescents are often present in normal monkey eyes but that they do not often undergo dramatic changes in size with chronic intraocular pressure elevation. The presence of a crescent was not significantly associated with the development of optic disc cup enlargement in the experimental monkey eye.

Late argon laser suture lysis after mitomycin C trabeculectomy.

BACKGROUND: Argon laser suture lysis has been effectively used in the early post-operative period to enhance filtration after trabeculectomy. The most substantial reductions in intraocular pressure (IOP) occur when laser suture lysis is performed during the first 2 postoperative weeks, and virtually no effect has been reported after the fourth postoperative week. Mitomycin C, used as adjunct therapy, improves the success rate of trabeculectomy in high-risk eyes and may change the time course for effective suture lysis. METHODS: The authors used late laser suture lysis in five high-risk patients after mitomycin C trabeculectomy. The mean patient age was 66.8 +/- 15.7 years, and laser suture lysis was performed an average of 13 +/- 5.8 weeks (range, 7-21 weeks) after surgery. RESULTS: The mean IOP before suture lysis was 20.2 +/- 3.8 mmHg. The average IOP reduction immediately after suture lysis was 11.4 +/- 3.9 mmHg. The average IOP 3 to 4 months after laser suture lysis was 9.4 +/- 3.4 mmHg. CONCLUSION: The authors postulate that adjunctive mitomycin C therapy markedly delays wound healing and appears to extend the period that laser suture lysis is clinically effective.

Once-daily versus twice-daily levobunolol (0.5%) therapy. A crossover study.

The authors executed a two-period, randomized, double-masked, crossover study comparing once-daily to twice-daily levobunolol hydrochloride (0.5%) in 20 patients with elevated intraocular pressure (IOP). Modified diurnal curves were performed at four times for each study arm: baseline, day 1, day 14, and day 28. The mean diurnal corrected decrease in IOP from baseline ranged from 16% +/- 11% to 22% +/- 9% when the subjects were treated twice daily, and from 14% +/- 10% to 18% +/- 8% when the same subjects were treated once daily. At day 1, patients had a significantly greater IOP lowering after twice-daily therapy than after once-daily therapy (P less than 0.05). At 14 and 28 days, there was no clinically significant difference between the two treatment regimens. The results of our crossover study suggest that once-daily treatment with levobunolol (0.5%) is as effective as twice-daily treatment.

An evaluation of optic disc and nerve fiber layer examinations in monitoring progression of early glaucoma damage.

From annual examinations of 813 ocular hypertensive eyes, the authors compared optic disc and nerve fiber layer photographs in 2 age-matched subgroups: 37 eyes that converted to abnormal visual field tests at the end of a 5-year period and 37 control eyes that retained normal field tests. Disc change was detected in only 7 of 37 (19%) converters to field loss and in 1 of 37 (3%) controls. Progressive nerve fiber layer atrophy was observed in 18 of 37 (49%) converters and in 3 of 37 (8%) controls. Serial nerve fiber layer examination was more sensitive than color disc evaluation in the detection of progressive glaucoma damage at this early stage of glaucoma. The evaluation of cup-to-disc ratio or of the nerve fiber layer appearance in the initial photograph taken 5 years before field loss were equally predictive of future field damage. The position of nerve fiber layer defects was highly correlated with the location of subsequent visual field loss.

The predictability of infant visual-evoked response testing on future visual acuity.

We reviewed the records of 27 infants with abnormal eye examinations and visual-evoked response (VER) testing (mean age, 10.5 months) who subsequently underwent a long-term follow-up ophthalmology examination (mean duration, 41 months). The infants were initially diagnosed with various ocular disorders including cortical blindness (eight), optic nerve hypoplasia (six), congenital cataract (two), and retinopathy of prematurity (one). Standard optotype visual-acuity determinations were available in the follow-up records of 11 children (21 eyes), and fixation behavior was obtained in the remaining 16 children (32 eyes). Results revealed that pattern-reversal VER P1 latency was predictive (87%) of whether visual acuity was equal to (or better than) or worse than 20/100 and whether a patient would have good fixation behavior (fix and follow, FF) or poor fixation (no FF) (86%) (P less than .001). Although flash VER P1 latency was also predictive of later visual acuity or good fixation (73%), it was not statistically significant. Pattern VER P1 amplitude and flash VER P1 amplitude were not predictive of later visual function. The predictive power of pattern VER P1 latency for later visual function probably relates to its reflection of macular function and low variability. An analysis of the variability of each of the four VER factors in normal infants (n = 50) indicated that pattern VER P1 latency was the least variable, and consequently most sensitive, VER factor for detecting and quantifying pathology. Overall, the results of this retrospective study suggest that pattern VER P1 latency may have important predictive power for later visual function in infants with an initially abnormal ophthalmologic examination.

Contact lens related corneal ulcers at the Ohio State University Hospitals 1983-1987.

We reviewed the records of patients with ulcerative keratitis associated with contact lens wear admitted to The Ohio State University Hospitals from January 1, 1983 through December 31, 1987. Of 127 cases of infectious ulcerative keratitis, 25 (19%) were associated with the use of contact lenses. Of these 25, 21 cases (84%) were associated with the use of soft lenses (40% aphakic, 40% cosmetic). Seventy-six percent (19 of 25) were culture-positive; Pseudomonas was the most common isolate (12 of 19, 63% of culture-positive cases). When compared with daily wear soft contact lenses, cosmetic and aphakic extended wear contact lens related ulcers were associated with a delay in definitive diagnosis and a worse prognosis. Patching and steroid use were associated with more severe ulcers. Gram stain findings were of value only when gram-negative rods were noted. The findings emphasize the need for patients to understand: 1) the risks of extended wear; 2) the necessity of removing the lenses at the first sign of irritation; and 3) the importance of having prompt, intensive care readily available.

Toxicity of imipenem in vitreous replacement fluid.

We evaluated the ocular toxicity of imipenem when administered in the infusion fluid during vitrectomy. Imipenem concentrations of up to 16 micrograms/mL were nontoxic to the ocular structures.

The effect of human chorionic gonadotropin, dibutyryl cyclic adenosine 3',5'-monophosphate, prostaglandins, and 25-hydroxycholesterol on acute progesterone secretion by dissociated rabbit luteal cells in vitro: evidence for independent effect of human chorionic gonadotropins and lipoproteins.

Although estradiol is the established luteotropic hormone in the rabbit, the corpus luteum also contains a luteinizing hormone (LH)-activated adenylate cyclase system and cyclic adenosine 3',5'-monophosphate (cAMP)-dependent protein kinase, which suggests that LH and cAMP may play a physiological role in regulating luteal progesterone production. The present study examined whether human chorionic gonadotropin (hCG) and cAMP derivatives stimulate progesterone production by dispersed rabbit luteal cells in static and perifusion incubations. Results of this study show that progesterone production by rabbit luteal cells is significantly stimulated (p less than 0.05) by hCG concentrations at or greater than 0.1 IU/ml or by dibutyryl cAMP concentrations at or greater than 5 mM. Both agents produce maximal stimulations of approximately 4-fold. However, neither prostaglandin E2 or F2 alpha at concentrations of 0.1-3.0 micrograms/ml altered progesterone secretion. When luteal cells were incubated with maximal concentrations of hCG and lipoproteins together, the resultant progesterone secretion was additive. This suggests that the effects of hCG and lipoprotein are independent. Both responses could be blocked completely by cycloheximide (10(-4) M), and thus appear to be dependent on protein synthesis. The cholesterol derivative 25-hydroxycholesterol (20 micrograms/ml) partially overcame the steroidogenic block by cycloheximide, suggesting that transport of cholesterol, regardless of its origin, into mitochondria was an essential protein-mediated event in these cells. Inhibition of the side-chain-cleavage enzyme by aminoglutethamide blocked progesterone production by rabbit luteal cells in vitro. Although estradiol may dominate in the regulation of luteal progesterone production physiologically, this study clearly demonstrates that potential mechanisms do exist in the rabbit corpus luteum for cAMP-mediated stimulation of progesterone production in the rabbit.