Outcomes of treatment of neovascular glaucoma with intravitreal bevacizumab.

BACKGROUND/AIMS: To evaluate the course of treatment and outcomes of neovascular glaucoma (NVG) treated with intravitreal bevacizumab. METHODS: The study is a retrospective, non-comparative, consecutive, interventional case series. Demographic data, past ocular history, cause of NVG and anterior chamber angle status were recorded. Visual acuity (VA), intraocular pressure (IOP), number of IOP-lowering medications and type of treatment administered were recorded at the time of NVG diagnosis and at follow-up intervals. Treatment-related complications and reasons for vision loss were recorded. RESULTS: The study included 56 eyes of 52 patients. At the time of NVG diagnosis, the median VA was count fingers, and the mean IOP (SD) was 40 (11) mm Hg. At 6 months after initial bevacizumab injection, the median VA was 1/200, and the mean IOP (SD) was 18 (15) mm Hg. Seventy-one per cent of eyes underwent panretinal photocoagulation after NVG diagnosis. Sixty-one per cent of eyes received a glaucoma drainage implant (GDI). The Kaplan-Meier cumulative proportion of eyes with open angles receiving a GDI after initial bevacizumab injection was not statistically significantly different from that of eyes with closed angles. Forty-six per cent of eyes received repeat bevacizumab injections. Eleven eyes had hyphaema after both bevacizumab injection and GDI surgery, while three eyes had hyphaema after GDI surgery but prior to initial bevacizumab injection. CONCLUSIONS: Intravitreal bevacizumab is now a frequently used adjunct for the treatment of NVG. Eyes must be monitored closely after initial injection of intravitreal bevacizumab, regardless of initial angle status, as many may still require surgery to lower IOP or repeat injections of intravitreal bevacizumab.

Pars plana vitrectomy during cataract surgery for prevention of aqueous misdirection in high-risk fellow eyes.

PURPOSE: To report the use of pars plana vitrectomy as a prophylactic measure during cataract surgery for prevention of aqueous misdirection in high-risk fellow eyes. METHODS: Chart review of two patients with severe aqueous misdirection in their first eye at the time of cataract surgery that only responded to pars plana vitrectomy. RESULTS: In both patients, cataract extraction with posterior chamber intraocular lens implantation was initially performed after pars plana vitrectomy, with the creation of hyaloido-capsulo-iridotomy to establish a communication between the vitreous cavity and the anterior chamber. CONCLUSION: Pars plana vitrectomy as a prophylactic measure during cataract surgery may have a beneficial role in fellow eyes at high risk for developing aqueous misdirection.

Elastic cord-induced cyclodialysis cleft and hypotony maculopathy.

We describe a case of hypotony maculopathy in which hypotony was due to a cyclodialysis cleft produced by an elastic cord injury. Sixteen months after being hit with an elastic cord, a 43-year-old white male presented with progressive loss of vision in the right eye. The visual acuity in the right eye was 1/200 due, in part, to a subluxated and cataractous lens. The intraocular pressure (IOP) was 4 mm Hg. Gonioscopy revealed a cyclodialysis cleft at the 2 o'clock position, and fundus examination showed hypotony maculopathy. The patient underwent pars plana vitrectomy, pars plana lensectomy, repair of the cyclodialysis cleft, placement of an anterior chamber intraocular lens, and tightly sutured trabeculectomy without antimetabolite. Sixteen months following surgery, visual acuity was stable at 20/60 and IOP was 11 mm Hg but the chorioretinal folds persisted.

Combined penetrating keratoplasty and trabeculectomy with mitomycin C.

OBJECTIVE: To evaluate corneal graft survival and intraocular pressure control in eyes that have undergone combined penetrating keratoplasty and trabeculectomy with mitomycin C (MMC). DESIGN: Retrospective noncomparative case series. INTERVENTION: Penetrating keratoplasty combined with trabeculectomy with MMC and other surgical procedures. PARTICIPANTS: Twenty-four eyes of 22 patients undergoing combined penetrating keratoplasty and trabeculectomy with mitomycin C. MAIN OUTCOME MEASURES: Corneal graft clarity and intraocular pressure control. RESULTS: The cumulative probability of corneal graft survival was 85% at 1 year and 60% at 2 years. The cumulative probability of adequate pressure control was 67% at 3 months, 55% at 12 months, and 50% at 24 months. The incidence of bleb failure was higher in cases involving additional concomitant procedures, such as anterior vitrectomy, lens implantation or exchange, and drainage tube implantation. CONCLUSIONS: Combined penetrating keratoplasty and trabeculectomy with mitomycin C is associated with good corneal graft survival but also a risk of early failure of intraocular pressure control. Other concomitant procedures during the combined penetrating keratoplasty/trabeculectomy may increase the risk of early bleb failure.

Outcomes of primary trabeculectomy with the use of adjunctive mitomycin.

OBJECTIVE: To investigate the efficacy and safety of adjunctive mitomycin when used during a primary trabeculectomy within a series of 89 consecutive patients at 1 and 2 years postoperatively. DESIGN: A cohort study of all patients who underwent primary trabeculectomy, performed by one of us (P.F.P.), between April 1, 1991, and December 31, 1994. Patients received topical mitomycin in conjunction with a corneal safety valve incision. A trabeculectomy was considered "successful" if it resulted in an intraocular pressure (IOP) of 21 mm Hg or lower and a 30% or greater reduction in the IOP at and after 1 year of follow-up, with or without medications and without a reoperation for an elevated IOP. Survival analysis was used to calculate success rates. RESULTS: The 1- and 2-year success rates were 85.4% and 77.9%, respectively. The mean IOP was reduced from 26.3 to 11.3 mm Hg at 1 year (n=68) and to 11.9 mm Hg at 2 years (n=56), with 60 (88.2%) of 68 patients off medication at 1 year and 47 (83.9%) of 56 patients off medication at 2 years. Trabeculectomy success rates were significantly lower in black compared with nonblack patients (76.2% vs 87.5% at 1 year, P=.03). Trabeculectomy failure occurred throughout the follow-up period. Endophthalmitis occurred in 2 (2.2%) of the patients, and hypotonia requiring revision occurred in 4 (4.5%) of the patients. CONCLUSIONS: Primary trabeculectomy with the use of intraoperative mitomycin lowered the IOP by 30% or more in 78% (at 2 years) to 86% (at 1 year) of the cases and is associated with a marked reduction in the percentage of patients who require glaucoma medication. Success rates must be evaluated in light of such risks as endophthalmitis and hypotony.

Needling revision of glaucoma drainage device filtering blebs.

PURPOSE: Needling revision is an accepted method of management of poorly functioning trabeculectomy blebs. The authors present the outcome of the analogous needling revision of poorly functioning filtering blebs over glaucoma drainage device (GDD) reservoirs. METHODS: Review of 20 patients (21 eyes) who underwent needling to the bleb overlying the GDD reservoir, with or without adjunctive 5-fluorouracil injection. RESULTS: In the nine eyes (43%) that were considered successes (defined as intraocular pressure [IOP] less than or equal to 21 mmHg and decrease in IOP greater than or equal to 20% with no additional medication or glaucoma surgery), the mean IOP fell from 28.3 +/- 6.4 mmHg to 13.9 +/- 2.7 mmHg at last follow-up, after a mean of 1.7 needlings (range, 1-3 needlings) with mean follow-up of 14.6 months (range, 5-35 months [corrected]). Needling success was associated with larger GDD surface area (mean, 267 +/- 95 mm2 vs. 179 +/- 79 mm2 in eyes needled unsuccessfully, P = 0.04) and use of Baerveldt implants (six of eight eyes needled successfully). Minor complications were few. Endophthalmitis developed in one patient (5% of all eyes) after needling. CONCLUSIONS: Needling revision can be useful in the management of poorly functioning GDD blebs, although the risk for severe complications exists.

Hypotony maculopathy after filtering surgery with mitomycin C. Incidence and treatment.

PURPOSE: Hypotony maculopathy after glaucoma filtering surgery with adjunctive mitomycin C has been reported to occur in 3% to 14% of cases. The authors evaluated its incidence when using a corneal safety-valve incisior intended to reduce its occurrence. The authors also evaluated a technique for reversing hypotony maculopathy by reoperation using two sets of stitches in the scleral flap, with one set tied tightly to temporarily raise the intraocular pressure, stretch the sclera, and flatten chorioretinal folds. METHODS: The authors reviewed the results of 699 procedures performed between April 1991 and October 1994. All were performed or supervised by one surgeon (PFP). RESULTS: Hypotony maculopathy developed in 9 (1.3%) of 699 eyes. There was a statistically significant higher incidence in primary filters (4%) as compared to secondary filters or combined procedures. After revision, eight (89%) of nine recovered visual acuity of greater than or equal to 20/30 and the mean intraocular pressure was 14.5 +/- 4 mmHg at a mean follow-up of 15 months. CONCLUSION: The incidence of hypotony maculopathy after glaucoma filtering surgery with mitomycin C using a corneal safety-valve incision is less than that reported in the literature without this incision. There is an increased risk in myopes, young patients, and primary filters. Early intervention with the described scleral flap revision technique usually allows restoration of prefiltration visual acuity without compromise of bleb function.

Glycosaminoglycan stratification of the juxtacanalicular tissue in normal and primary open-angle glaucoma.

PURPOSE: The juxtacanalicular tissue (JCT) is the probable site of aqueous outflow resistance in normal eyes and of the increased resistance in primary open-angle glaucoma eyes (POAG). The purpose of this histochemical study was to determine the glycosaminoglycan (GAG) composition and stratification in the JCT of POAG and age-matched normal eyes. METHODS: Five eyes from four normal donors and five eyes from four POAG donors (69 to 80 years of age) were analyzed. Using methods that histochemically preserve GAGs, GAG-degrading enzymes, Alcian blue staining, and real color discrimination to exclude pigment, nuclear staining and unstained areas, the type and amount of GAGs were estimated by compute-raided charge-coupled device color video image analysis. To examine GAG stratification, the JCT was segmented into three regions-anterior, middle, and posterior-to examine regional differences in GAG composition; each region was further divided into four 2-microns layers, from layer 1, adjacent to and including the endothelium of Schlemm's canal, to layer 4, to the first trabecular lamellae. RESULTS: The normal GAG JCT profile was as follows: hyaluronic acid (HA), 7.78 +/- 1.23 femtograms (fg)/micron2; chondroitin sulfates (CS), 8.18 +/- 0.82 fg/micron2; dermatan sulfate, 0.29 +/- 0.18 fg/micron2; the total, 18.73 +/- 0.68 fg/micron2. In contrast, the POAG GAG JCT profile was as follows: HA 0.57 +/- 0.31 fg/micron2 (P < 0.00001), a 93% decrease; CS 13.49 +/- 0.74 fg/micron2 (P < 0.0001), a 83% increase; dermatan sulfate, 0.90 +/- 0.53 fg/micron2; and the total, 17.31 +/- 0.95 fg/micron2, an 8.2% decrease. The HA was depleted in all layers of all regions of POAG JCT. CONCLUSIONS: Results indicate that the normal JCT is stratified, with HA as the predominant GAG in layers 1 and 2. The POAG JCT is depleted of HA and has an accumulation of CS, which may increase outflow resistance and, consequently, increase intraocular pressure in patients with POAG.

Endophthalmitis after filtering surgery with mitomycin.

OBJECTIVE: To identify the incidence, causative organisms, and clinical outcomes of eyes with bleb-associated endophthalmitis after glaucoma filtering procedures with adjunctive mitomycin. METHODS: Retrospective analysis of 773 consecutive eyes that underwent glaucoma filtering surgery at the Bascom Palmer Eye Institute, Miami, Fla. The course of 609 eyes from 485 patients with a minimum of 3 months of follow-up were reviewed. RESULTS: Mean follow-up was 16.0 +/- 11.5 months (range, 3-48 months). Of the 609 eyes, 13 (2.1%) developed bleb-associated endophthalmitis an average of 18.5 +/- 13.2 months after surgery (range, 1-45 months). The incidence of bleb-associated endophthalmitis was significantly greater after inferior trabeculectomy (7.8% per patient-year) than after superior trabeculectomy (1.3% per patient-year) by Kaplan-Meier estimates (P = .02, log rank test). The cumulative incidence was 13% for inferior limbal blebs and 1.6% for superior limbal blebs. Nine (69.2%) of the 13 eyes were culture positive. Streptococcus sanguis and Haemophilus influenzae (6/13 [46.2%]) were the most frequent causative organisms. The mean increase in intraocular pressure after endophthalmitis treatment was 1.2 mm Hg, with a mean decrease in visual acuity of 1.42 logMAR units. Eight (61.5%) of the 13 eyes had a final acuity of 20/400 or better. CONCLUSIONS: The incidence of bleb-associated endophthalmitis after guarded filtering surgery performed with adjunctive mitomycin is higher than the reported rate in eyes undergoing filtering surgery without the use of antifibrotic agents (0.2%-1.5%). Inferior limbal trabeculectomy carries the highest risk of infection. Eyes with mitomycin blebs maintained excellent filtration capacity. However, after treatment of the infection, the visual outcomes were generally poor.

Needle elevation of the scleral flap for failing filtration blebs after trabeculectomy with mitomycin C.

PURPOSE: To report the incidence of failing filtration blebs after trabeculectomy with mitomycin C and to report the outcome of needling procedures for failing filtration blebs in these eyes. METHODS: We conducted a retrospective analysis of 537 eyes of 434 patients who had trabeculectomy with mitomycin C and reviewed the clinical course of 441 eyes of 338 patients with a minimum of three months of follow-up. RESULTS: In 441 eyes of 338 patients followed up for three months or more after trabeculectomy with mitomycin C, 88 (20.0%) eyes from 85 patients underwent needle elevation of the scleral flap. Forty-nine (22.4%) of 219 eyes required needle revision after trabeculectomy alone, and 39 (17.6%) of 222 eyes after trabeculectomy combined with cataract extraction and intraocular lens implantation. Mean intraocular pressure (IOP) after needle revision (17.9 +/- 11.6 mm Hg) was significantly less than the mean preneedling IOP (27.1 +/- 10.4 mm Hg, P < .00001, paired Student's t test). Sixty-three eyes of 60 patients had a minimum of three months of postneedling follow-up. Successful pressure control, defined as an IOP of 22 mm Hg or less with or without topical glaucoma control medications, was achieved in 46 (73.0%) of 63 eyes. Unsuccessful outcomes correlated significantly with higher preneedling IOP (R = 0.28, P = .03, df = 61) and prior surgery involving conjunctival incisions (R = 0.53, P < .00001, df = 61). CONCLUSIONS: Needle elevation of the scleral flap may provide significantly long-lasting pressure reduction in eyes with failing mitomycin C blebs. Higher success rates are achieved in eyes with fewer prior conjunctival incisions, eyes requiring a single needle revision, and eyes with lower preneedling IOP.

Glycosaminoglycans of the human trabecular meshwork in primary open-angle glaucoma.

PURPOSE: Glycosaminoglycans (GAGs) contribute to the filtration barrier of aqueous outflow through the trabecular meshwork (TM). The purpose of this biochemical study was to identify the type and amount of GAGs in normal and in primary open-angle glaucoma (POAG) TM and adjacent anterior segment structures. METHODS: The GAGs of 21 masked individual normal and POAG human TMs, as well as iris, ciliary body, and anterior sclera, were isolated biochemically, identified by selective GAG-degrading enzymes, and quantitated by computer-enhanced densitometry. RESULTS: In 10 normal TMs (8 donors, 65 to 83 years of age), the GAG profile was: hyaluronic acid (0.77 +/- 0.26 ng/microgram dry-defatted weight +/- SEM); chondroitin 4(6-) sulfates and dermatan sulfate, collectively referred to as chondroitin sulfates (1.90 +/- 0.13 ng); keratan sulfates (0.33 +/- 0.06 ng); heparitin sulfates (2.02 +/- 0.52 ng); GAG enzyme-resistant material (0.02 +/- 0.01 ng); and total GAGs (5.05 +/- 0.70 ng). In 10 POAG TMs (6 donors, 67 to 88 years of age), the GAG profile was: hyaluronic acid (0.18 +/- 0.11 ng; P < 0.02, a 77% decrease; 6 of 10 TMs contained no detectable hyaluronic acid); chondroitin sulfates (2.39 +/- 0.31 ng); keratan sulfates (0.21 +/- 0.06 ng); heparitin sulfates (1.36 +/- 0.43 ng); GAG enzyme-resistant material (0.08 +/- 0.01 ng; P < 0.02); and total GAGs (4.09 +/- 0.33 ng; statistically insignificant). In the POAG iris, hyaluronic acid content was less (82% decrease, P < 0.02), and the chondroitin sulfates content was higher (72% increase, P < 0.02). Similarly, the POAG ciliary body and anterior sclera contained less hyaluronic acid and more chondroitin sulfates. The GAG profile of a "glaucoma suspect" donor specimen was similar to that of the POAG donor specimen. CONCLUSIONS: The data provide the first quantitative biochemical profiles of GAGs of individual normal and POAG TM, and we suggest that a depletion of hyaluronic acid and the accumulation of chondroitin sulfates may increase aqueous outflow resistance in the POAG TM:

Current cost-effective work-up of the glaucoma suspect.

Given the limited resources for medical care, ophthalmologists are increasingly being called on to provide care in a cost-effective manner without compromising quality. This review provides a framework for the difficult task of working up suspected glaucoma in a cost-effective manner. Several new developments in early detection of glaucoma will also be described.

Treatment of hypotony maculopathy after trabeculectomy.

BACKGROUND AND OBJECTIVE: To determine if resuturing of the scleral flap to increase IOP in the post-trabeculectomy eye is an effective treatment of hypotony maculopathy. PATIENTS AND METHODS: The medical records of nine consecutive patients who developed visual acuity loss after trabeculectomy related to hypotony maculopathy were reviewed to determine factors that contribute to successful restoration of visual acuity. The average age of the patients was 50 years and average refractive error was -4.25 diopters (D). Mean Snellen visual acuity dropped from 20/25 to 20/200 after the onset of hypotony. RESULTS: Six of nine eyes recovered visual acuity to within one line of initial level after treatment of the hypotony. Four of these six eyes underwent resuturing of the scleral flap to reverse the excess filtration within 6 months of the onset of hypotony maculopathy. Five of these six patients had final vision of 20/30 or better. The mean phakic preoperative refractive error in these six eyes was -2.25 D, compared with a mean refractive error of -8.50 D in the three eyes with persistent visual loss (P = 0.002). After reversal of the hypotony, the average peak intraocular pressure in the six eyes with visual recovery was 33 mm Hg, compared with an average peak IOP of 7 mm Hg in the three eyes with persistent visual loss. (P = 0.015) CONCLUSION: Although reversal of the hypotony maculopathy in six eyes was associated with a few weeks of higher than normal IOP, the final IOP was acceptably low. Five of six filtering blebs remained functional with a mean follow-up of 3 years. The final average IOP in the six eyes that were successfully treated was 12.7 mm Hg. In this series of patients, visual acuity was restored to eyes with hypotony maculopathy by increasing the IOP to higher than normal levels.

One-year follow-up results of combined mitomycin C trabeculectomy and extracapsular cataract extraction.

PURPOSE: When patients with glaucoma require cataract surgery, combined procedures offer important advantages over cataract surgery alone. Because mitomycin C has improved the success rate of a trabeculectomy in patients at high risk for filtration failure, the authors investigated whether it also would increase the survival rate of functioning filters in combined procedures. METHODS: Patients with both cataract and glaucoma underwent combined mitomycin C trabeculectomy, extracapsular cataract extraction, and intraocular lens implantation. Mitomycin C (0.5 mg/ml) was applied topically to the trabeculectomy site for 5 minutes before the cataract extraction. Intraocular pressure (IOP), visual acuity, and astigmatism were measured preoperatively and postoperatively. One-year results are available for 74 patients. RESULTS: At 1 year, 54 (73%) of 74 patients had IOPs of 15 mmHg or less without glaucoma medications. Visual acuity was 20/40 or better in 44 (60%) of 74 patients. Ten (15%) patients had a shift of more than 2 diopters of astigmatism against the rule compared with preoperative values. No notable corneal epithelial toxicity was present. Postoperative symptomatic hypotony with the wound construction occurred in 3 (4%) of 74 patients, with 1 patient requiring surgical revision. Other potential complications of mitomycin C include endothelial toxicity (1 patient had decreased vision due to endothelial folds) and wound stability (1 patient had wound rupture after direct ocular trauma). CONCLUSION: The 1-year survival rate of a functioning trabeculectomy using mitomycin C in combined glaucoma and cataract surgery is encouraging. The longer-term benefits and possible adverse effects of mitomycin C in combined procedures are unknown and continue to be investigated.

Glaucoma filtering surgery with 5-fluorouracil.

A life-table analysis of surgical outcomes was performed on the first eye of 155 patients who were enrolled in a pilot study of glaucoma filtering surgery with postoperative subconjunctival 5-fluorouracil (5-FU) injections. The success rates at 1-, 2-, and 3-year intervals were 68, 63, and 63%, respectively, for 88 patients with non-neovascular glaucoma in aphakia; 82, 75, and 75% for 39 patients with non-neovascular glaucoma after unsuccessful filtering surgery; and 68% at each yearly interval for 28 patients with neovascular glaucoma. Complications which resulted from filtering surgery and the 5-FU injections included corneal epithelial defects (55.5%), conjunctival wound leaks (36.8%), suprachoroidal hemorrhage (5.8%), rhegmatogenous retinal detachment (2.6%), endophthalmitis and phthisis (1.9% each), and corneal scarring, late bleb leak, malignant glaucoma, and traction retinal detachment (1.3% each). A Cox Model regression analysis failed to demonstrate a correlation between surgical success and age, race, type of filtering procedure, or total dose of 5-FU received. Postoperative subconjunctival 5-FU may increase the operative success rate for selected patients with a high risk for failure after glaucoma filtering surgery.

5-Fluorouracil and glaucoma filtering surgery. III. Intermediate follow-up of a pilot study.

Ninety-five patients (104 eyes) were enrolled in a pilot study of subconjunctival 5-fluorouracil (5-FU) injections after filtering surgery in eyes with poor surgical prognoses. At least a six-month follow-up was available on 84 patients, of whom four were excluded from the analysis of surgical outcome because they suffered retinal detachments within six months of their filtering surgery. The initial 5-FU procedures on the remaining 80 patients were successful (no further glaucoma surgical procedures were either performed or recommended, and the intraocular pressures [IOPs] were either 21 mmHg or lower with ocular hypotensive medication[s] or 25 mmHg or lower without ocular hypotensive medication) in 33 (68%) of the 48 aphakic eyes with non-neovascular glaucomas, 13 (81%) of the 16 phakic eyes with non-neovascular glaucomas after unsuccessful filtering surgery, and 12 (75%) of the 16 eyes with neovascular glaucoma (NVG). The follow-up on the successful eyes ranged from 6 to 34 months (mean +/- SD = 18.5 +/- 7.5). The visual acuities remained within one line of their preoperative levels or improved in 38 (79%) of the 48 aphakic eyes with non-neovascular glaucoma, 11 (69%) of the 16 phakic eyes with non-neovascular glaucoma after unsuccessful filtering surgery, and 12 (75%) of the 16 eyes with NVG. The initial 5-FU procedures on the 104 eyes were complicated by the following: corneal epithelial defects (50%); conjunctival wound and suture tract leaks (36%; 2% underwent surgical repair); suprachoroidal hemorrhages (9%); retinal detachments (3%); subepithelial corneal scarring (3%); endophthalmitis (2%); and malignant glaucoma (1%). It is the authors' impression that postoperative subconjunctival 5-FU increases the likelihood of achieving IOP control after filtering surgery in eyes with poor surgical prognoses; however, a randomized clinical trial is necessary to confirm this impression.

Effectiveness of a pinhole method for visual acuity screening.

Visual acuity screening was performed in the home in an adult population, using a standardized, retroilluminated chart. A pinhole disk was utilized to retest those subjects who initially failed the screening. All subjects failing the screening with the pinholes, and an equal number of age-matched subjects passing the screening (controls), were asked to have a complete ophthalmologic examination, including a protocol refraction in an eye clinic (clinic examination). Without use of the pinhole disk, 14.4% of subjects failed to read a 20/40 line. Use of the pinholes reduced the failure rate to 6.9%. Fifty-seven percent of those failing and 55% of controls had the clinic examination. Determination of best-corrected visual acuity after protocol refraction in the clinic indicated that the false-positive rate (the percentage of subjects who failed the screening but had visual acuity of 20/40 or better on the clinic examination) for the screening was 26%, and the false-negative rate (the percentage of subjects who passed the screening but had visual acuity of worse than 20/40 on the clinic examination) was 1.5%. Use of a pinhole disk is highly effective for visual acuity screening, reducing the false-positive rate by more than half.

Trabeculectomy in aphakic eyes.

One hundred twenty-seven trabeculectomies performed on aphakic eyes at the Bascom Palmer Eye Institute (BPEI) between 1972 and 1982 were reviewed. Forty-five cases were excluded from data analysis: 28 in eyes with confounding conditions, such as neovascular glaucoma; ten with follow-up of less than six months; and seven that were the second or third trabeculectomy performed at the BPEI in six eyes. Of the remaining 82 trabeculectomies in 82 eyes: 32 (39%) were categorized as successes (eyes that achieved an intraocular pressure of less than or equal to 21 mmHg with medication or less than or equal to 25 mmHg without medication); eight (10%) were categorized as qualified failures (eyes that had an intraocular pressure of greater than 21 mmHg despite medication or greater than 25 mmHg without medication); and 42 (51%) were categorized as complete failures (eyes that underwent further glaucoma surgery, had further glaucoma surgery recommended, or lost light perception). In the 20 eyes of the patients younger than 50 years of age, only one (5%) was categorized as a success; while in the 62 eyes of the patients 50 years of age or older, 31 (50%) were categorized as successes.

5-fluorouracil and glaucoma filtering surgery. II. A pilot study.

5-Fluorouracil (5-FU) was injected subconjunctivally after glaucoma filtering surgery in a pilot study of eyes with poor surgical prognoses. Twenty-seven (79%) of the 34 aphakic eyes with glaucoma achieved an intraocular pressure (IOP) of less than or equal to 21 mmHg (range of follow-up on nonreoperated eyes, 91 -468 days). Nine (69%) of 13 eyes with neovascular glaucoma achieved an IOP of less than or equal to 21 mmHg (range of follow-up on nonreoperated eyes, 120-379 days). Eight (89%) of nine phakic eyes with glaucoma following unsuccessful filtering procedures achieved an IOP of less than or equal to 21 mmHg (range of follow-up on nonreoperated eyes, 134-394 days). Visual acuities remained within one line of their preoperative levels or improved in 32 (94%) of the 34 aphakic eyes with glaucoma, eight (62%) of the 13 eyes with neovascular glaucoma, and six (67%) of the nine phakic eyes with glaucoma following unsuccessful filtering procedures. Postoperative corneal epithelial defects occurred in 45% of the cases. Conjunctival wound and conjunctival needle tract leaks were observed in 41% of the cases, but only one eye required wound revision. No other serious side effects that we attributed to 5-FU were observed. It seems that postoperative subconjunctival 5-FU increases the likelihood of achieving IOP control following filtering surgery in eyes with poor surgical prognoses; however, a randomized clinical trial is necessary to confirm this.