Use of viscoelastics post-trabeculectomy: a survey of members of the American Glaucoma Society.

BACKGROUND AND OBJECTIVE: American Glaucoma Society members were surveyed to determine the pattern of use of viscoelastics for anterior chamber reformation at the slit-lamp in the post-operative clinical management of patients who have undergone trabeculectomy in order to give ophthalmologists an indication of how these materials are being used by their colleagues. MATERIALS AND METHODS: We surveyed 196 members of the American Glaucoma Society regarding the following; (1) whether they inject viscoelastic post-operatively at the slit-lamp as an in-office procedure, (2) the type of viscoelastic used most often, (3) the criteria for injection of viscoelastic, (4) the time to first follow-up, (5) the average number of injections, and (6) the occurrence of post-injection endophthalmitis. RESULTS: One hundred twenty-five (64%) of the 196 mailed surveys were answered and returned. Ninety-four (75%) of the respondents reported injecting viscoelastics in the postoperative period at the slit-lamp as an in-office procedure. Healon (60%) (Pharmacia & Upjohn Co, Kalamazoo, MI), Viscoat (17%) (Alcon, Ft. Worth, TX), and Healon GV (7%) (Pharmacia & Upjohn Co, Kalamazoo, MI) were the three most often used viscoelastics. Hypotony, iriscornea touch, and lens-cornea touch were given as criteria for injection 19%, 47%, and 88% of the time, respectively. Range of time to first follow-up was 1 hour to 7 days, with a mean time of 1 day. Range of average number of injections was 1 to 3 with a mean of 2 injections for patients requiring injection. Only one respondent reported an incidence of endophthalmitis. CONCLUSIONS: The use of viscoelastic materials in the postoperative trabeculectomy patient in the office at the slit-lamp for anterior chamber reformation is a prevalent practice. Healon is the most commonly used viscoelastic postoperatively and lens-corneal touch is the most common criterion for injection. The average number of injections is 2, with a mean and mode follow-up time of 1 day. Endophthalmitis is a rare complication.

Subconjunctival THC:YAG laser sclerostomy under a partial thickness flap.

Holmium laser sclerostomy is a useful surgical procedure in eyes with refractory glaucoma. The success rate is 60%, comparable to the success rate with a seton, but there is a significantly lower rate of complications compared to a seton. Furthermore, the conjunctiva is minimally dissected and less surgical trauma is involved with the procedure, an advantage compared to other filtering operations. The use of a corneascleral flap producing a "guarded" Holmium sclerostomy reduces the incidence of complications and there were no flat or shallow anterior chambers in the 47 eyes operated on and reviewed in this study.

Trabeculectomy: a modified surgical technique.

A modified surgical technique is described for trabeculectomy using contemporary limbal incisional techniques for a simplified dissection of the lamellar scleral flap, a technically easier operation, with smoothly dissected surfaces. The results and complications are comparable to those using the standard method.

Subconjunctival THC:YAG laser sclerostomy under a partial-thickness corneal flap.

To evaluate the safety and effectiveness of THC:YAG laser sclerostomy in reducing intraocular pressure (IOP), we performed 16 subconjunctival sclerostomies under a partial-thickness corneal flap. We report the 3- and 6-month follow-up results in these patients, all of whom had intractable glaucoma resistant to previous surgical treatment. The mean IOP decreased from a pretreatment value of 30 mm Hg to a posttreatment value of 14 mm Hg at 3 months. Fifty-seven percent of the treated eyes achieved an IOP below 20 mm Hg at 6 months. A significant reduction in glaucoma medications is also reported among the successes. Complications were minimal.

The choice of surgical procedure in congenital, infantile, and juvenile glaucoma.

1. Trabeculotomy is successful in patients with an angle anomaly involving only the trabecular meshwork, but in those involving the trabecular meshwork with iris or cornea, trabeculotomy combined with trabeculectomy is recommended. 2. In cases of failed trabeculotomy or trabeculectomy, a Molteno implant can be tried, although it does not work well in patients with congenital glaucoma. 3. If all else fails, a cyclodestructive procedure is indicated and contact Nd:YAG laser cyclophotocoagulation is recommended.

The choice of surgical procedure in congenital, infantile, and juvenile glaucoma.

Trabeculotomy is successful in patients with an angle anomaly involving only the trabecular meshwork, but in those involving the trabecular meshwork with iris and/or cornea trabeculotomy combined with trabeculectomy is recommended. In cases of failed trabeculotomy or trabeculectomy, a Molteno implant can be tried, although it does not work well in patients with congenital glaucoma. If all else fails, a cyclodestructive procedure is indicated and contact Nd:YAG laser cyclophotocoagulation is recommended.

Longitudinal study of serum antibody response to bovine corneal protein (BCP 54) in Behçet's disease.

Serum samples from a patient diagnosed as having active Behçet's syndrome with iritis were evaluated by the enzyme-linked immunosorbent assay for antibodies against a purified bovine corneal protein, molecular weight 54,000 daltons (BCP 54). Significantly elevated antibody levels to BCP 54 were found in all serum samples collected over a 2-year period. Anti-BCP 54 antibody levels remained within a very narrow range, at least twofold higher than those of controls. In contrast, no antibody to retinal S antigen was detected. These results indicate the presence of specific anti-BCP 54 autoantibodies in sera from a Behçet's patient and suggest that autoantibodies may play a role in the etiopathogenesis of uveitis.

Intraocular pressure rise after argon laser trabeculoplasty.

Eighty-four eyes received 107 argon laser trabeculoplasty treatments at Beth Israel Medical Center between 1982 and 1984 for advanced primary and secondary glaucoma. The prelaser mean pressure was 20.25 mmHg. Pressures taken 1 1/2 hours postoperatively varied widely: the pressure rose after 47 treatments and fell or remained the same after 60. Significant increases in pressure occurred in 10 eyes, after 12 treatments; 42% of these had received burns of 0.8 watts or greater. Pressure changes were correlated with laser burn energy level. Both patients who had significant increases in pressure initially were retreated again--in the same eye--at another time had similar increases in postoperative pressure again, even with lower energy levels. Comparison with the results of previous reports highlights the advantages of limited treatment to the anterior trabeculum with low energy levels.

Malignant glaucoma.

The term "malignant glaucoma" referred originally to a rare and highly feared form of glaucoma occurring in certain postoperative patients. Over time the concept of the disease was expanded to include a group of angle closure glaucomas unresponsive to traditional miotic or filtering therapy. The haphazard lumping of many disease entities under such an umbrella term has caused confusion, which we attempt to resolve through a mechanistic approach to elucidating the pathogenesis of malignant glaucoma based on the anatomical location of obstruction to normal aqueous flow; surgical treatments are suggested based on the pathogenesis. Attention is drawn to the role of the vitreous and anterior hyaloid in combination with a block to normal aqueous circulation, redirection of its flow, high intraocular pressure and vitreous swelling in precipitating malignant glaucoma and creating a vicious circle to maintain it. Surgical management is directed to correcting the obstruction to normal aqueous flow and removing aqueous accumulated in the posterior chamber, vitreous or suprachoroidal space.

Subscleral Scheie operation for advanced glaucoma.

The subscleral Scheie procedure is most effective in advanced glaucoma patients with IOP of 35 mm Hg or more and in those patients in need of a secondary or tertiary procedure. The surgical technique is described.

Cytomegalovirus retinitis: a manifestation of the acquired immune deficiency syndrome (AIDS).

Two homosexual males with the "gay bowel syndrome' experienced an acute unilateral loss of vision. Both patients had white intraretinal lesions, which became confluent. One of the cases had a depressed cell-mediated immunity; both patients ultimately died after a prolonged illness. In one patient cytomegalovirus was cultured from a vitreous biopsy. Autopsy revealed disseminated cytomegalovirus in both patients. Widespread retinal necrosis was evident, with typical nuclear and cytoplasmic inclusions of cytomegalovirus. Electron microscopy showed herpes virus, while immunoperoxidase techniques showed cytomegalovirus. The altered cell-mediated response present in homosexual patients may be responsible for the clinical syndromes of Kaposi's sarcoma and opportunistic infection by Pneumocystis carinii, herpes simplex, or cytomegalovirus.