Cyclophotocoagulation: a report by the American Academy of Ophthalmology.

OBJECTIVE: This document describes cyclophotocoagulation procedures for glaucoma and examines the evidence to answer key questions about patient selection, and efficacy of transscleral and endoscopic techniques. METHODS: A literature search conducted for the years 1968 to 2000 retrieved 130 citations. The author reviewed 34 of these articles and selected 19 for the panel methodologist to review and rate according to the strength of evidence. A Level I rating is assigned to properly conducted, well-designed, randomized clinical trials; a Level II rating is assigned to well-designed cohort and case-control studies; and a Level III rating is assigned to case series and poorly designed prospective and retrospective studies, including case-control studies. RESULTS: The predominant problem with all studies on cyclophotocoagulation is the lack of a uniform definition of success, which makes comparisons difficult. One randomized controlled trial (Level I evidence) compared the efficacy of transscleral cyclophotocoagulation with noncontact Nd:YAG and semiconductor diode laser. It found no significant difference between the two, although a significant problem was the variability allowed with laser parameters. Most of the literature consists of noncomparative case series that provide evidence that is limited and often not convincing. CONCLUSION: Cyclophotocoagulation is indicated for patients with refractory glaucoma who have failed trabeculectomy or tube shunt procedures, patients with minimal useful vision and elevated intraocular pressure, and patients who have no visual potential and need pain relief (based on Level III evidence). It may be useful for patients whose general medical condition precludes invasive surgery or who refuse more aggressive surgery (i.e., filter or tube). It is also useful in emergent situations, such as the acute onset of neovascular glaucoma. There is insufficient evidence to definitively compare the relative efficacy of the cyclophotocoagulation procedures for glaucoma. It is the panel's opinion, however, that semiconductor diode systems appear to possess the best combination of effectiveness (based on Level III evidence), portability, expense, and ease of use at this time.

Topical verapamil in glaucoma filtration surgery.

PURPOSE: Because of the reported antifibroblastic effect of verapamil, a calcium-channel blocker, we investigated the potential benefit of adjunctive topical verapamil in patients undergoing glaucoma filtration surgery. METHODS: This prospective, double-masked, randomized study included 56 eyes of 56 consecutive patients with chronic open-angle glaucoma undergoing trabeculectomy (primary or surgical revision of failed trabeculectomy), trabeculectomy combined with cataract surgery, or Molteno drainage device implantation. Postoperatively, the treated eyes received verapamil (0.25%) or one drop of placebo four times a day for 1 month in addition to 1% prednisolone four times a day and corticosteroid-antibiotic ophthalmic ointment at bedtime. RESULTS: There were no significant differences in preoperative mean intraocular pressure, mean number of medications, and glaucoma severity between the verapamil and placebo groups. There were also no significant differences between the two groups in filtration success rate, mean intraocular pressure, and mean number of medications on postoperative days 1, 4, or 7 and at postoperative months 1, 2, 3, 4, 5, and 6 (P > 0.05). CONCLUSION: There was no significant benefit of adjunctive topical verapamil when it was used after trabeculectomy, trabeculectomy combined with cataract surgery, or Molteno drainage device implantation.

Transscleral suture fixation of posterior chamber lenses combined with trabeculectomy.

OBJECTIVE: To evaluate the outcome of transscleral suture-fixated posterior chamber intraocular lens (PCIOL) implantation in glaucoma patients when combined with a trabeculectomy. DESIGN: A retrospective study of 56 consecutive glaucoma patients with a minimum follow-up of 6 months after transscleral suture-fixated PCIOL implantation combined with trabeculectomy. SETTING: Patients were drawn from the clinical glaucoma practice of the Kresge Eye Institute, Detroit, MICHIGAN: PATIENTS: Fifty-six eyes of 56 consecutive chronic glaucoma patients who had undergone transscleral suture-fixated PCIOL implantation in combination with a trabeculectomy were included in the analysis. RESULTS: The mean follow-up time was 38.5 +/- 19.1 months. Mean intraocular pressure (IOP) was significantly reduced, from 22.9 +/- 10.9 mmHg before surgery to 16.7 +/- 6.7 mmHg at the last follow-up visit (P = 0.0005), with the mean number of medications used also significantly decreased, from 2.3 +/- 0.9 to 1.9 +/- 0.9 (P = 0.0002). Postoperative IOP control to 21 mmHg or less was achieved or maintained in 84% of patients. Visual acuity improved or remained stable within two Snellen lines of the preoperative level in 39 eyes (70%) and within three Snellen lines in 45 eyes (80%) at the last follow-up visit. Overall, 46% to 68% of the patients had both stable visual acuity and satisfactory pressure control at the last postoperative visit, depending on criteria of varying stringency. However, 19 eyes (34%) required one or more additional surgical interventions for pressure control. Patients with anterior chamber intraocular lens (ACIOL) complications, diabetes mellitus, or a preoperative IOP level of more than 21 mmHg on maximum tolerated medications were especially prone to requiring additional surgical interventions. CONCLUSIONS: We conclude that transscleral suture-fixated PCIOL implantation can be combined successfully with a trabeculectomy and can be useful in glaucoma patients in need of both visual rehabilitation and IOP control. However, patients with ACIOL complications, diabetes, or preoperative IOP of more than 21 mmHg on maximum tolerated medications were prone to requiring additional surgical interventions.

Efficacy of apraclonidine 1% versus pilocarpine 4% for prophylaxis of intraocular pressure spike after argon laser trabeculoplasty.

OBJECTIVE: The authors compared the efficacy of apraclonidine 1% versus pilocarpine 4% prophylaxis of post-argon laser trabeculoplasty (ALT) intraocular pressure (IOP) spike. DESIGN: Prospective randomized clinical trial. PARTICIPANTS: Two hundred twenty-eight eyes of 228 patients with primary open-angle glaucoma undergoing ALT were studied. INTERVENTION: Patients were given 1 drop of either apraclonidine 1% (n = 114) or pilocarpine 4% (n = 114) 15 minutes before ALT. MAIN OUTCOME MEASURES: Peri-ALT IOPs and incidences of post-ALT IOP spikes at 5 minutes, 1 hour, and 24 hours were compared between the two groups. RESULTS: The two groups were similar in age, race, and medical dependency. Post-ALT mean IOPs at 5 minutes, 1 hour, and 24 hours were significantly lower than pre-ALT mean IOPs in both apraclonidine (P < 0.001) and pilocarpine (P < 0.001) groups. Incidences of IOP spikes greater than 1, 3, and 5 mmHg at 1 hour post-ALT were 21.1%, 14.9%, and 8.8% for the apraclonidine group and 12.3%, 5.3%, and 4.4% for the pilocarpine group (P = 0.076, 0.015, and 0.18 chi-square test). In the apraclonidine prophylaxis group, patients on long-term apraclonidine showed significantly higher incidence of post-ALT IOP spike than the patients without such long-term apraclonidine use (35.7%, 15 of 42 eyes, vs. 12.5%, 9 of 72 eyes; P = 0.003). In addition, peri-ALT pilocarpine prophylaxis tended to be less effective in patients undergoing long-term pilocarpine therapy but without statistical significance (17.4%, 8 of 46 eyes, vs. 9.4%, 6 of 64 eyes; P = 0.17). CONCLUSION: Peri-ALT pilocarpine 4% was at least as effective as, if not more effective than, apraclonidine 1% in post-ALT IOP spike prophylaxis. Peri-ALT apraclonidine prophylaxis was not effective in patients on long-term apraclonidine, and peri-ALT pilocarpine prophylaxis tended to be less effective in patients undergoing long-term pilocarpine therapy. Pilocarpine 4% can be considered as a first-choice drug for post-ALT IOP spike prophylaxis, especially in patients under treatment with apraclonidine.

The additive effect of latanoprost to maximum-tolerated medications with low-dose, high-dose, or no pilocarpine therapy.

OBJECTIVE: To assess the efficacy of latanoprost additive therapy in patients with intraocular pressure (IOP) out of control while taking maximum-tolerated medications and to determine whether pilocarpine therapy has a dose-dependent adverse effect on the efficacy of latanoprost therapy. DESIGN: Noncomparative case series. PARTICIPANTS: Sixty-one eyes of 61 patients with chronic glaucoma with IOP out of control while receiving maximum-tolerated medications were treated with latanoprost additive therapy on a compassionate basis. MAIN OUTCOME MEASURES: Follow-up was up to 22 months with a mean of 13.9 +/- 5.7 months. Kaplan-Meier survival analysis with Mantel-Cox log-rank test was performed to determine the overall success of latanoprost additive therapy and to compare the success rates of high-dose pilocarpine, low-dose pilocarpine, and no pilocarpine therapies. The criterion for success was avoiding glaucoma surgery with IOP decrease of 20% or greater and final IOP less than 22 mmHg. The IOP change and its significance for patients satisfying and failing the criterion for success also were determined to assess the latanoprost additive therapy. In addition, a number of pretreatment variables, including pilocarpine therapy, were analyzed for a significant effect on the efficacy of latanoprost additive therapy using Cox proportional hazards regression analysis. RESULTS: Latanoprost additive therapy significantly lowered mean IOP by 3.9 +/- 5.5 mmHg at 3 months and by 3.5 +/- 5.8 mmHg at 12 months. The cumulative success rate of the latanoprost additive therapy was 70% at 1 month, 42% at 3 months, 40% at 6 months, and 30% at 12 months. Of the variables studied, only increased number of previous incisional glaucoma surgeries and IOP greater than 24 mmHg before latanoprost additive therapy were significant prognostic factors for failure of latanoprost additive therapy. Pilocarpine therapy in any dose had no significant effect. CONCLUSION: This study supports a trial of latanoprost additive therapy before glaucoma surgery in patients with IOP out of control while receiving maximum-tolerated medications irrespective of pilocarpine therapy and the pilocarpine dosage, especially when the number of previous incisional glaucoma surgery is less than three and the IOP is less than 25 mmHg.

Long-term outcome of primary glaucoma triple procedure with adjunctive 5-fluorouracil.

PURPOSE: To evaluate the long-term effect of adjunctive subconjunctival 5-fluorouracil (5-FU) on the filtration outcome of primary glaucoma triple procedure (PGTP) in primary open-angle glaucoma (POAG) patients. METHODS: Seventy-four POAG patients were randomly assigned to PGTP alone (36 patients) or PGTP with adjunctive subconjunctival 5-FU (5.0 +/- 1.3 injections of 5 mg each, total of 24.8 mg) (38 patients). After surgery, the patients were examined at regular intervals for intraocular pressure (IOP), visual acuity, medical therapy requirements, and complications. Surgical success was defined as IOP < or = 20 mmHg on postoperative medication < or = 1 without additional glaucoma surgery. RESULTS: Over an average follow-up (+/- SD) of 45.3 +/- 25.0 months, both 5-FU and control groups maintained significant improvement of IOP control and visual acuity. However, there were no statistically significant differences between the 5-FU and control groups with respect to postoperative IOP, number of glaucoma medications, visual acuity outcome, and success rate overall or in selected patients with one or more of the risk factors for filtration failure. CONCLUSIONS: The use of low-dose subconjunctival 5-FU (mean dosage of 24.8 mg in 5.0 +/- 1.3 injections) as an adjunct did not significantly improve the long-term filtration outcome of PGTP in POAG patients.

Limbus-based vs fornix-based conjunctival flap in combined glaucoma and cataract surgery with adjunctive mitomycin C.

PURPOSE: To determine the efficacy and safety of limbus-based vs fornix-based conjunctival flaps in patients with primary open-angle glaucoma undergoing trabeculectomy combined with phacoemulsification and intraocular lens implantation with adjunctive subconjunctival mitomycin C. METHODS: In a prospective study, 69 eyes of 69 patients with primary open-angle glaucoma, visually symptomatic cataracts, and no previous incisional ocular surgery were randomly assigned to limbus-based and fornix-based conjunctival flap groups. All patients received trabeculectomy combined with phacoemulsification and posterior chamber lens implantation with 1-minute (0.5 mg/ ml) application of subconjunctival mitomycin C. RESULTS: The mean intraocular pressures were significantly (P < .05) lower on significantly (P < .05) fewer medications postoperatively at 1 week, 1 month, 3, 6, 9, 12, and 15 to 18 months, and at last follow-up in both groups than they had been preoperatively. However, there were no significant (P > .05) differences in postoperative mean intraocular pressure, mean number of medications, and visual acuity between the two groups at any time interval. Hypotony with wound leak was significantly (P = .019) higher in the limbus-based group. Other postoperative complications were not significantly (P > .05) different between the two groups. CONCLUSIONS: There was no notable difference in glaucoma control or visual outcome between limbus-based and fornix-based conjunctival flaps in primary trabeculectomy combined with phacoemulsification and lens implantation with adjunctive subconjunctival mitomycin C. The fornix-based flap was as safe as, if not safer than, the limbus-based flap in the glaucoma triple procedure with adjunctive subconjunctival mitomycin C.

Primary glaucoma triple procedure in patients with primary open-angle glaucoma: the effect of mitomycin C in patients with and without prognostic factors for filtration failure.

PURPOSE: To investigate the effect of adjunctive mitomycin C on primary glaucoma triple procedure in patients with primary open-angle glaucoma with and without one or more of the prognostic factors for filtration failure of primary glaucoma triple procedure. Those factors include being of African-American race, having a preoperative intraocular pressure of 20 mm Hg or more on maximum tolerated medications, and being on two or more medications preoperatively. METHODS: Study patients consisted of 197 consecutive patients with primary open-angle glaucoma who were randomly assigned to receive either no adjunctive mitomycin C (101 eyes of 101 patients) or to receive adjunctive subconjunctival mitomycin C (96 eyes of 96 patients) during the primary glaucoma triple procedure. Kaplan-Meier survival analysis comparisons were made between respective subgroups with and without prognostic indicators for filtration failures using a relatively stringent set of criteria for filtration success of primary glaucoma triple procedure. RESULTS: There was no statistically significant (P = .117) difference in filtration success of primary glaucoma triple procedure between the control and mitomycin C groups. Adjunctive mitomycin C significantly (P < .05) improved the filtration outcome of the primary glaucoma triple procedure in the subgroups with each of the three prognostic factors for filtration failure of primary glaucoma triple procedure. On the other hand, in the subgroups without the prognostic factors, adjunctive mitomycin C did not significantly (P > .05) change the filtration outcome of the primary glaucoma triple procedure. CONCLUSION: These findings establish the basis for selective use of mitomycin C in patients with primary open-angle glaucoma undergoing primary glaucoma triple procedure.

Chronic use of apraclonidine decreases its moderation of post-laser intraocular pressure spikes.

OBJECTIVE: The purpose of the study is to investigate the efficacy of 1.0% apraclonidine in preventing intraocular pressure (IOP) spike after argon laser trabeculoplasty (ALT) in patients on chronic apraclonidine therapy compared with patients not on chronic apraclonidine use. DESIGN: The study design was a prospective study. PARTICIPANTS: This study consisted of 231 consecutive eyes of patients with primary open-angle glaucoma undergoing ALT: 70 eyes (30%) were started on a regimen including chronic apraclonidine 0.5% use (group A) and 161 eyes (70%) were started on a regimen without chronic apraclonidine 0.5% use (group B). INTERVENTION: Both groups received one drop of apraclonidine 1.0% 15 minutes before ALT to 180 degrees of previously untreated trabecular meshwork. Intraocular pressure was measured before the procedure and at 5 minutes, 1 hour, and 24 hours after the laser treatment. MAIN OUTCOME MEASURES: Incidences of an IOP spike and mean IOPs at 5 minutes, 1 hour, and 24 hours after the laser treatment were compared between the two groups. Multivariate logistic regression analysis also was carried out to identify the significant risk factors for post-ALT IOP spikes despite prophylactic apraclonidine 1.0% treatment. RESULTS: The incidences of IOP spikes greater than 0 mmHg, greater than 2 mmHg, and greater than 5 mmHg at 1 hour after ALT were 32.9%, 22.9%, and 12.9%, respectively, in group A versus 13.7%, 11%, and 3.1%, respectively, in group B (P = 0.0007, P = 0.009, and P = 0.004). Chronic apraclonidine 0.5% use was found to be the only significant risk factor for IOP spikes at 1 hour after ALT by multivariate logistic regression analysis. CONCLUSIONS: The incidences of IOP spikes in group A were significantly greater than in group B and approached the reported incidences of IOP spikes without perilaser apraclonidine prophylaxis. This indicates that peri-ALT apraclonidine is relatively ineffective in patients with chronic apraclonidine 0.5% use (group A) compared with patients without chronic apraclonidine use (group B), presumably because of saturation of the ocular alpha-2 receptors with apraclonidine in patients with chronic apraclonidine use. Therefore, in patients receiving chronic apraclonidine therapy, it is especially important to monitor their post-ALT IOPs and to be prepared to treat postlaser IOP spikes using agents other than apraclonidine.

Comparative study of silicone versus acrylic foldable lens implantation in primary glaucoma triple procedure.

OBJECTIVE: To compare silicone versus acrylic foldable intraocular lens (IOL) implantation in primary glaucoma triple procedure (PGTP). DESIGN: Prospective, randomized. PARTICIPANTS: A total of 79 eyes of 79 primary open-angle glaucoma (POAG) patients in need of combined surgery were randomized to a silicone IOL group (36 eyes) and acrylic IOL group (43 eyes). INTERVENTION: The study eyes underwent PGTP, which consisted of primary trabeculectomy, phacoemulsification, and posterior chamber IOL implantation. Adjunctive mitomycin C (MMC) (0.5 mg/ml for 1 minute) was used selectively only in patients with one or more risk factors for filtration failure of PGTP. MAIN OUTCOME MEASURES: Snellen visual acuity, intraocular pressure (IOP), slit-lamp biomicroscopy, and number of glaucoma medications were measured, performed, or determined preoperatively and at regular intervals postoperatively. RESULTS: There were no significant differences in the mean number of postoperative glaucoma medications at 1, 2, 3, 4-6, and 9-12 months and at last follow-up (P > 0.05); mean change in corrected visual acuity best attained (P = 0.315) or at last follow-up (P = 0.223) between the silicone and acrylic groups. Both groups had significant decreases in mean IOP and mean number of medications postoperatively at all times (P < 0.05). However, the postoperative IOP > 25 mmHg and IOP spike > 5 mmHg above preoperative IOP during the first month were significantly higher in the acrylic group (P = 0.026). The mean postoperative IOP at 1 month in the acrylic group was also significantly higher than the silicone group (14.1 +/- 5.0, 11.2 +/- 3.9, P = 0.005). Conversely, there were no significant differences in mean postoperative IOP at 2, 3, 4-6, and 9-12 months and at last follow-up between the silicone and acrylic groups (P > 0.05). Suture removal or release occurred significantly more frequently in the acrylic IOL group during the first month and the first 2 months (48.8% and 60.5%) than the silicone group (25.0% and 36.1%, P = 0.030 and 0.031, respectively). There were no significant differences in postoperative complications or surgical interventions between the two groups (P > 0.05). CONCLUSIONS: During the first year following the PGTP with selective use of MMC, there were no significant differences in the medical dependency or visual outcomes or complications between the silicone and acrylic groups. Both groups attained significant decreases in IOP postoperatively. However, the mean IOP was significantly higher in the acrylic than the silicone group at 1 month postoperatively, and postoperative IOP > 25 mmHg and IOP spike > 5 mmHg above preoperative IOP were significantly greater in the acrylic group. There were significantly more suture releases in the acrylic IOL group than the silicone IOL group in the first 2 months postoperatively.

Primary glaucoma triple procedure with or without adjunctive mitomycin. Prognostic factors for filtration failure.

PURPOSE: The prerequisite for selective use of adjunctive mitomycin C (MMC) in primary glaucoma triple procedure (PGTP) is a better understanding of the prognostic factors. Therefore, the authors carried out the current study on the outcome of PGTP with and without adjunctive MMC to determine the prognostic factors for filtration failure of PGTP. METHODS: The study patients consisted of 174 consecutive primary open-angle glaucoma (POAG) patients undergoing PGTP. They were assigned randomly to either no adjunctive MMC (93 eyes of 93 patients) or adjunctive subconjunctival MMC (81 eyes of 81 patients) during the PGTP. After surgery, the patients were examined at regular intervals for visual acuity, intraocular pressure (IOP) control, medical therapy requirements, and complications. Filtration failure was determined according to two different criteria: (1) a less stringent set of criteria (criterion I) and (2) a more stringent set of criteria (criterion II). RESULTS: There were no statistically significant differences between the groups with and without adjunctive MMC with respect to postoperative IOP, number of medications, and visual acuity outcome during mean follow-up (+/- standard deviation) of 25.1 +/- 5.5 months (P > 0.05 for each). However, there were prognostic factors for filtration failure in the control group but not in the MMC group. Black race, diabetes mellitus, preoperative IOP greater than or equal to 20 mmHg, and number of preoperative medications greater than two were found to be significant prognostic factors for filtration failure by criterion I. Black race, preoperative IOP greater than or equal to 20 mmHg and number of preoperative medications greater than 1 were significant prognostic factors for filtration failure by criterion II. CONCLUSION: There was no statistically significant difference in the overall outcome of PGTP between control and MMC groups of nonselected patients with primary open-angle glaucoma. Black race, diabetes mellitus (by criterion I only), preoperative IOP greater than or equal to 20 mmHg, and number of preoperative medications greater than 2 (by criterion I) or greater than 1 (by criterion II) were found to be significant independent prognostic factors for filtration failure of PGTP without adjunctive MMC but no with adjunctive MMC. The use of adjunctive subconjunctival MMC in PGTP may have to be selective, primarily in those patients with primary open-angle glaucoma with one or more of the prognostic factors for filtration failure.

Adjunctive subconjunctival mitomycin C in glaucoma triple procedure.

PURPOSE: To evaluate the potential benefit of adjunctive subconjunctival mitomycin in patients with primary open-angle glaucoma undergoing primary trabeculectomy combined with phacoemulsification and intraocular lens implantation. METHODS: Seventy-eight eyes of 78 patients with primary open-angle glaucoma with visually symptomatic cataracts and no previous incisional surgery were randomized to receive either no mitomycin C or a subconjunctival application of 1-, 3-, or 5-minute mitomycin C (0.5 mg/ml). RESULTS: Follow-up (mean +/- standard deviation) was 21.0 +/- 7.7 months. The mean postoperative intraocular pressures were significantly lower with significantly less medications than the preoperative values at each follow-up time (1, 3, 6, 9, 12, 15 months, and last follow-up) for all groups (P < 0.05 for each). However, there was no significant difference at each follow-up time in intraocular pressure, medications, or best-corrected visual acuity among the four groups or between the control and the total mitomycin C group. CONCLUSION: Adjunctive subconjunctival mitomycin C did not further improve the final intraocular pressure outcome of the primary trabeculectomy combined with phacoemulsification and intraocular lens implantation in patients with primary open-angle glaucoma. Future studies will determine the appropriate role, if any, for adjunctive mitomycin C in selected primary glaucoma triple procedures.

Adjunctive mitomycin C in primary trabeculectomy in phakic eyes.

PURPOSE: The addition of antiproliferative agents, most recently mitomycin C, has improved the outcome of glaucoma filtering surgery in eyes with a high risk of surgical failure. We conducted the present study to determine whether adjunctive mitomycin C would increase the success rate of primary trabeculectomies in phakic eyes. METHODS: Thirty-three eyes of 33 consecutive patients with phakic primary open-angle glaucoma, who were predominantly black (24 black and nine white), who underwent primary trabeculectomy with adjunctive subconjunctival mitomycin C (0.5 mg/ml for three minutes) were compared with a demographically similar historical control group of 30 eyes of 30 consecutive patients (20 black and ten white) with phakic primary open-angle glaucoma, who had undergone primary trabeculectomy without an adjunctive antifibrotic agent. RESULTS: Although the mean preoperative intraocular pressures were similar in both groups (29.0 +/- 6.4 mm Hg in the mitomycin C group and 29.5 +/- 10.0 mm Hg in the control group, P = .61), the mean postoperative intraocular pressure at each follow-up period was significantly lower in the mitomycin C group than in the control group (10.3 +/- 7.1 vs 14.5 +/- 5.1 mm Hg at six months, P = .02; 10.5 +/- 4.9 vs 14.5 +/- 4.4 mm Hg at 12 months, P = .01; and 10.0 +/- 3.1 vs 17.2 +/- 3.0 mm Hg at 18 months, P = .004, respectively). The mean number of postoperative medications was also significantly lower in the mitomycin C group (0.2 +/- 0.4 vs 1.1 +/- 1.4 medications at six months, P = .007; 0.3 +/- 0.4 vs 0.9 +/- 1.1 medications at 12 months, P = .04; and 0.3 +/- 0.5 vs 1.7 +/- 1.2 medications at 18 months, P = .01, respectively). However, the mitomycin C group had a significantly higher incidence of prolonged hypotony (intraocular pressure less than 6 mm Hg) compared with the control group (15% vs 0% at nine months, P = .05). Younger age was associated with a higher incidence of persistent hypotony. CONCLUSIONS: Adjunctive subconjunctival mitomycin C (0.5 mg/ml for a three-minute exposure) in primary trabeculectomies of phakic eyes, while increasing the success rate by decreasing intraocular pressure and postoperative medications, is associated with a higher incidence of prolonged hypotony.

Trabeculectomy, phacoemulsification, and posterior chamber lens implantation with and without 5-fluorouracil.

Subconjunctival 5-fluorouracil has been an effective adjunct in glaucoma filtering surgery. We investigated the effectiveness of 5-fluorouracil in primary trabeculectomy combined with phacoemulsification and posterior chamber intraocular lens implantation (glaucoma triple procedure). Seventy-four patients were enrolled and randomly assigned into two groups to receive either no 5-fluorouracil (control patients) or low-dose 5-fluorouracil (mean total dose, 24.8 mg; mean number of injections, 5.0 +/- 1.3). The mean preoperative intraocular pressure was 20.1 +/- 5.4 mm Hg for the 5-fluorouracil group and 21.0 +/- 5.2 mm Hg for the control group (P = .48, Student's unpaired t-test). The mean number of medications was 2.2 +/- 1.0 and 2.0 +/- 1.0 (P = .49, Mann Whitney U test), respectively. At all postoperative visits, there were no statistically significant differences in mean intraocular pressures between the two groups. Mean follow-up was 13.2 months for 5-fluorouracil-treated patients and 15.0 months for control patients. At the last postoperative visit, mean intraocular pressures were 15.4 +/- 3.7 mm Hg and 15.0 +/- 5.0 mm Hg, respectively (P = .45, Student's unpaired t-test). Both groups showed comparable visual outcome (20/40 or better in 31 of 38 5-fluorouracil-treated patients [82%] vs 32 of 36 control patients [89%]) and a decrease in number of medications needed, 0.7 +/- 1.0 and 0.7 +/- 0.9, respectively (P = .96, Mann Whitney U test). Thus, 5-fluorouracil administered as in our study did not seem to have any effect in primary trabeculectomy combined with phacoemulsification and posterior chamber intraocular lens implantation.

Needling revision of failed filtering blebs with adjunctive 5-fluorouracil.

We investigated the outcome of needling revision with adjunctive subconjunctival 5-fluorouracil (5-FU) performed on 30 eyes of 30 consecutive glaucoma patients with failed filtering blebs 49.0 +/- 65.4 weeks after trabeculectomy. Follow up was 67.3 +/- 22.8 weeks from the time of the first needling revision and 49.9 +/- 26.2 weeks from the last needling procedure. Twenty-four (80%) of the eyes were treatment successes after 2.6 +/- 1.9 needling revisions, with a mean intraocular pressure (IOP) of 13.9 +/- 3.7 mm Hg on 1.5 +/- 1.1 medications, a significantly lower mean IOP and number of medications than before the procedure (32.5 +/- 7.8 mm Hg on 1.7 +/- 1.5 medications [P < .001, paired t-test]). Needling revision with adjunctive 5-FU appears to be a safe and effective means of reestablishing filtration.

Whatever happened to abstracts from different sections of the association for research in vision and ophthalmology?

PURPOSE: The authors investigated the fate of abstracts from each ARVO section (May 1985 meeting), the overall publication percentage, and the journals in which the abstract-derived articles were published. METHODS: They performed a MEDLINE search by first author for 25 or 26 randomly selected abstracts from each section to identify those that led to full-length articles in peer-reviewed journals. RESULTS: Overall, 63% of abstracts led to full-length articles in peer-reviewed journals within our search period of 87 months. The publication rate of oral presentation abstracts (68%) was significantly higher than that of poster presentation abstracts (56%). A greater proportion of basic science-oriented abstracts (67%) led to publication than the clinically oriented abstracts (56%). The rate of publication was lowest for the Cornea section (40%) and highest for Physiology and Pharmacology (80%) and Biochemistry (76%). The abstract-derived articles were published in 67 different peer-reviewed journals, with 43% of the articles appearing in only five journals. CONCLUSIONS: The fact that the majority of abstracts led to full-length articles supports ARVO's goal of a large interdisciplinary appeal with the exchange of ideas among different investigators.

Corneal endothelial cell counts after Molteno implantation.

Implantation of a Molteno drainage shunt has been shown to be effective in advanced glaucoma. Foreign substances within the anterior chamber have been known to cause progressive endothelial cell loss. We undertook a study to evaluate the endothelial effects of an indwelling Molteno drainage shunt. Nineteen patients who underwent uneventful implantation of a Molteno drainage shunt for advanced aphakic or pseudophakic glaucoma were followed up. Serial endothelial cell counts were obtained in a masked fashion. During follow-up periods ranging from 5.4 to 25.7 months, endothelial cell loss averaged two cells per square millimeter per postoperative month with a 95% confidence interval of positive seven cells to negative ten cells per square millimeter per postoperative month. No clinically significant progressive trend in endothelial cell loss was seen in patients undergoing uncomplicated Molteno drainage procedures. Larger sample sizes with longer follow-up will be necessary to establish whether a Molteno drainage shunt causes clinically remarkable endothelial cell loss.

Visual field defects in patients with normal-tension glaucoma and patients with high-tension glaucoma.

We compared the automated visual field test results of 24 patients with normal-tension glaucoma and 24 patients with high-tension glaucoma who were closely matched for the amount of visual field loss to determine any differences in the characteristics of visual field defects between the two groups. Patients were matched with a maximum allowable difference in mean deviation of 0.3 dB. Although the normal-tension group had a greater amount of focal visual field loss (pattern standard deviation), the difference was not statistically significant (P = .628). Additionally, there was no statistically significant difference in the amount of diffuse or focal visual field damage in the superior hemifields between the two groups; however, the patients with normal-tension glaucoma had a significantly greater amount of localized visual field loss in the inferior hemifield than the patients with high-tension glaucoma (P = .015). Our data support the hypothesis that a vascular mechanism may have a greater role in the pathogenesis of optic nerve damage and visual field loss in patients with normal-tension glaucoma than in patients with high-tension glaucoma.

Adjunctive viscoelastic therapy for postoperative ciliary block.

Following Molteno device implantation, trabeculectomy, or needling revision of trabeculectomy, six eyes of six chronic glaucoma patients developed a flat anterior chamber without hypotony, ciliochoroidal detachment, pupillary block, or external wound leak. The ciliary block did not respond to vigorous medical and laser therapy. We performed an intracameral injection of sodium hyaluronate, which resulted in maintenance of a full anterior chamber and normal intraocular pressure in all of the six eyes. The use of intracameral viscoelastic appears to be a reasonable adjunct for management of ciliary block not responsive to vigorous medical therapy and intracameral air injection trial, before attempting more extensive surgery.