Combined ab externo and ab interno revision of failed filtering blebs with adjunctive mitomycin C.

PURPOSE: To report the results of combined ab externo and ab interno revision with mitomycin C (MMC) of failed filtering blebs in glaucoma patients. METHODS: Glaucoma patients with a failed trabeculectomy who had undergone internal and external revision with MMC in the last 6 years with at least 12 months of follow-up were considered. All study patients followed the same protocol in the operating room: injection of 0.2 mL of MMC (0.4 mg/mL) 2 cm lateral from the bleb followed by internal revision with an iris spatula and external revision with a 26-G × ½" needle. Success was defined as an intraocular pressure (IOP) ≥6 mm Hg and ≤18 mm Hg with (qualified) or without (absolute) any ocular hypotensive drugs. RESULTS: The study included 25 eyes of 22 glaucoma patients. Mean age was 65.2 ± 10.5 years. Mean follow-up was 26.9 ± 10.3 months. The IOP was reduced from 24.5 ± 6.0 mm Hg preoperatively to 10.0 ± 3.3 mm Hg at the last visit (p<0.001). The number of ocular hypotensive medications was reduced from 1.8 ± 1.0 to 0.2 ± 0.6 (p<0.001). There was no change in visual acuity (0.83 ± 0.75 vs 0.83 ± 0.74, p = 0.7). Three patients developed choroidal detachment, another eye had a transient hypotony with maculopathy, and 2 patients developed cataract. Absolute success was achieved in 80% of eyes, and qualified success in 16% of eyes. CONCLUSIONS: Combined ab externo and ab interno revision with MMC can be an effective technique to revitalize failed filtering blebs in glaucoma patients with minimal complications.

Use of rituximab for periocular and intraocular mucosa-associated lymphoid tissue lymphoma.

The clinical efficacy of rituximab therapy in systemic mucosa-associated lymphoid tissue (MALT) lymphoma with both periocular and intraocular involvement is described. Ophthalmic examination and radiologic imaging demonstrated tumor with bilateral periorbital, lacrimal, and subconjunctival infiltration, a pseudohypopyon in one eye, and extensive systemic lymph node involvement. Lymph node biopsy confirmed the pathologic findings of a low-grade MALT lymphoma. The patient had a complete remission within 3 months of starting rituximab therapy. A recurrence 6 months later remitted with a second round of rituximab therapy and the patient remained tumor-free at 1 year.

Comparing the measurement of diurnal fluctuations in intraocular pressure in the same day versus over different days in glaucoma.

PURPOSE: To compare the measurement of diurnal fluctuations in intraocular pressure (IOP) in the same day versus over different days in primary open-angle glaucoma. METHODS: Twenty-five eyes from 25 patients with primary open-angle glaucoma were submitted to a diurnal curve on the same day, 5 measurements, 2.5 hours apart, from 8:00 am to 6:00 pm. For the measurements on different days, we randomly selected one time point from the diurnal curve for each patient. All patients were then instructed to return every 3-7 days to complete all 5 measurements. The maximum, minimum, and IOP fluctuation were compared between the 2 methods. RESULTS: The IOP fluctuation (maximum-minimum) was similar when we measured the IOP on different days (5.0+/-2.6 mmHg vs 4.0+/-1.2 mmHg, p=0.08). There was no difference regarding the minimum or maximum IOP assessed in the diurnal curve or over different days. There was a high correlation for the maximum IOP (r=0.863, p<0.001) and the minimum IOP (r=0.708, p<0.001) by either method of measuring during the same day or different days, as well as for all measurements (8:00 am: r=0.718, p<0.001; 10:30 am: r=0.479, p=0.01; 1:00 pm: r=0.628, p=0.001; 3:30 pm: r=0.757, p<0.001; and 6:00 pm: r=0.910, p<0.001). CONCLUSIONS: IOP fluctuation in primary open-angle glaucoma can be assessed using IOP measures on different days, at different time points, which strongly correlate to a diurnal curve.

Violation of the ISNT rule in Nonglaucomatous pediatric optic disc cupping.

PURPOSE: To determine whether nonglaucomatous optic disc cupping in children violates the ISNT rule (which states that for normal optic discs the neuroretinal rim width is greatest in the order inferior >or= superior >or= nasal >or= temporal). METHODS: Digital ocular fundus photographs from a random cohort of children with large optic disc cups of nonglaucomatous origin were analyzed in masked fashion by using computer graphic software. The diameter and perimeter of each optic disc and optic cup and the width of the neuroretinal rim were drawn and measured. Measurements were compared to a random cohort of normal pediatric optic discs. RESULTS: The ISNT rule was intact in 9 (16%) of 55 eyes of nonpremature children with nonglaucomatous cupping, in 6 (21%) of 28 eyes of children with a history of prematurity and nonglaucomatous cupping, and in 35 (73%) of 48 eyes with normal discs. CONCLUSIONS: Violation of the ISNT rule occurs with greater frequency in the pediatric population with large optic disc cups of nonglaucomatous origin, compared with the pediatric population with normal optic discs. In discs with small cups, neuroretinal rim width conforms to the overall oval shape of the disc, which is usually greatest in vertical dimension, whereas discs with large cups possess greater variability of relative neuroretinal rim width around the disc, greater relative vertical cup/disc ratio versus horizontal cup/disc ratio, and lower predictability of the ISNT rule.

Differences in optical coherence tomography of the macula in advanced glaucoma and after a retinal artery occlusion.

BACKGROUND AND OBJECTIVE: Optical coherence tomography (OCT) was used to evaluate the macular thickness in eyes with advanced glaucoma compared with eyes following a retinal artery occlusion. PATIENTS AND METHODS: Ten patients with a retinal artery occlusion and 10 patients with severe glaucoma were evaluated with OCT using the macular thickness map protocol. RESULTS: The median thinnest macular sector was 183 microns (range: 152 to 223 microns) in patients with glaucoma versus 143 microns (range: 98 to 177 microns) in patients with arterial occlusion (P = .001). Median macular volume was 5.9 mm3 (range: 5.1 to 6.7 mm3) in patients with glaucoma versus 5.1 mm3 (range: 3.6 to 6.1 mm3) in patients with arterial occlusion (P = .015). CONCLUSIONS: OCT demonstrates that patients with a retinal artery occlusion have significantly reduced macular thickness compared with those with severe glaucoma.

Transcorneal tube extrusion in a child with a Baerveldt glaucoma drainage device.

We describe a clinical scenario in which a child was treated for glaucoma and aqueous misdirection with surgical placement of a tube shunt. The child then suffered extrusion of the tube through the cornea, a rare complication of such procedures. This complication has only been seen in children, and thus, young patients with tube shunts need careful and frequent monitoring, especially during the first year of the post tube shunt period to ensure that they have not developed this complication.

Efficacy of latanoprost or fixed-combination latanoprost-timolol in patients switched from a combination of timolol and a nonprostaglandin medication.

PURPOSE: To compare latanoprost with the fixed-combination latanoprost-timolol in glaucoma or ocular hypertension patients switched from a combination glaucoma therapy with timolol and another nonprostaglandin medication. DESIGN: Prospective randomized clinical trial. METHODS: Glaucoma or ocular hypertension patients receiving a combined treatment of timolol 0.5% and another nonprostaglandin medication (pilocarpine 4%, alpha-agonist, or a topical carbonic anhydrase inhibitor) underwent a 30-day washout of their medications. A masked observer then measured their intraocular pressure (IOP). The subjects were randomized to either latanoprost or fixed-combination latanoprost-timolol eyedrops to use once daily at 7 am. The IOP was measured again 30 days after the patients started using one of the study drugs by the same examiner at the same time. MAIN OUTCOME MEASURE: Comparison of the study medications' hypotensive effect. RESULTS: Fifty-three eyes (28 in the latanoprost group and 25 in the latanoprost-timolol group) from 28 patients were included in the study. The IOP reduction was greater in both study groups compared with the previous combination therapy with timolol and another nonprostaglandin medication in millimeters of mercury (7.7+/-2.3 vs. 5.5+/-2.3, P<0.001, for the latanoprost group; 8.5+/-3.5 vs. 6.3+/-2.7, P<0.001, for the latanoprost-timolol group) and percentage (35.8+/-8.2% vs. 25.6+/-8.9%, P<0.001, for the latanoprost group; 38.6+/-8.7% vs. 28.6+/-9.0%, P<0.001, for the latanoprost-timolol group). There was no statistical difference between latanoprost and fixed-combination latanoprost-timolol in reducing IOP, in either millimeters of mercury (P = 0.3) or percentage (P = 0.2). CONCLUSIONS: Both latanoprost and fixed-combination latanoprost-timolol may be viable substitutes for timolol and another nonprostaglandin medication in glaucoma or ocular hypertension patients.

Slit-lamp needle revision of failed filtering blebs using high-dose mitomycin C.

PURPOSE: To investigate the efficacy of bleb needle revision with high-dose mitomycin C in reviving failed filtering blebs after 1 year. PATIENTS AND METHODS: We reviewed the charts of 44 patients with one eye that had undergone bleb needle revision with a mixture of 0.1 mL of mitomycin (0.4 mg/mL) mixed with 0.1 mL of non-preserved 1% lidocaine. At least 12 months of follow-up were required. A successful bleb needle revision was defined as one that did not require a subsequent needling, glaucoma surgery, or medication to reach an intraocular pressure (IOP) greater than 4 mm Hg but less than 22 mm Hg. A qualified success was defined as a successful bleb needle revision that required subsequent needling or medication. RESULTS: The bleb needle revision with high-dose mitomycin was a success or qualified success after 12 months in 28 patients or 64% (95% confidence interval, 50% to 78%). The baseline IOP in these patients was 26.7 +/- 8.2 mm Hg (range 15 to 48 mm Hg) using an average of 1.5 +/- 1.5 glaucoma medications. The IOP after 1 year was 13.6 +/- 4.0 (range 6 to 21 mm Hg) with an average of 0.5 +/- 0.8 medications. Of 44 patients, 17 (39%) were successes and 11 (25%) were qualified successes. CONCLUSION: Bleb needle revision with high-dose MMC was effective in reducing the IOP in 64% of eyes with a failed filtering bleb with minimal long-term complications.