Viscocanalostomy for open-angle glaucoma in black African patients

PURPOSE: To study the clinical effectiveness of viscocanalostomy in a population of black African patients with open-angle glaucoma that was uncontrolled on medical treatment. SETTING: Department of Ophthalmology, Medical University of Southern Africa, Medunsa, South Africa. METHODS: In this prospective study viscocanalostomy was performed in 214 eyes of 157 black African patients with open-angle glaucoma that was poorly controlled by medical therapy. The procedure involves the production of superficial and deep scleral flaps. The deep flap is disserted to the plane of Schlemm's canal. From this plane, an intact window in Descemet's membrane is created by gentle pressure at the level of Schwalbe's line using a cellulose sponge. Aqueous humor diffuses through this window into a subscleral space (lake). Reflection of the inner flap unroofs Schlemm's canal, creating a trough leading to 2 entrances into Schlemm's canal (surgical ostia). A delicate cannula is introduced into the entrance of Schlemm's canal left and right and high-viscosity sodium hyaluronate is gently injected into the canal for 4 to 6 mm. The deeper scleral flap is excised (deep sclerectomy) and the superficial flap is sutured securely using 5, 11-0 polyester fiber (Mersilene) sutures. High-viscosity sodium hyaluronate is then injected into the subscleral lake to act as a physical barrier to fibrinogen migration postoperatively. RESULTS: Postoperative intraocular pressure (IOP) of 22 mm Hg or less was achieved without medical therapy in 82.7% of eyes. If a beta blocker was added to the cases not achieving 22 mm Hg or less postoperatively, the success rate increased to 89.0%. The average follow-up was 35 months (range 6 to 64 months). CONCLUSION: Viscocanalostomy produced an encouraging long-term reduction in the IOP of black African patients with glaucoma who would otherwise have had a poor prognosis.     

Primary trabeculectomy with 5-fluorouracil for glaucoma secondary to uveitis

Raised intraocular pressure occurs in a significant proportion of patients with uveitis, and may lead to glaucomatous visual loss. Medical therapy often proves inadequate in controlling intraocular pressure, necessitating surgical intervention but conventional filtering procedures such as trabeculectomy are known to fail more frequently in this group than in non-inflamed eyes. Adjunctive subconjunctival 5-fluorouracil (5-FU) has been shown to improve the success of trabeculectomy in a variety of secondary glaucomas. This retrospective study examined the effect of postoperative 5-FU administration on the outcome of trabeculectomy in uveitis-related glaucoma in 28 eyes of 26 patients. Eyes treated with adjunctive 5-FU showed a more prolonged control of intraocular pressure, and a longer median time to failure of control than untreated eyes. Trabeculectomy failure was more common and occurred earlier when a limbus-based conjunctival flap had been used, in patients of black ethnic origin, and if there had been previous intraocular surgery. Additional hypotensive therapy with topical ?-blockers was required more frequently in eyes which had not received 5-FU, and where a limbus-based conjunctival flap had been employed, all eyes in the latter group requiring ?-blockers one year after surgery. Intraocular inflammation was under satisfactory control in all patients at the time of surgery, and no deleterious effect on control of uveitis in relation to surgical intervention was observed.     

Ahmed valve implantation in glaucoma secondary to chronic uveitis

PURPOSE: To evaluate the efficacy of Ahmed valve (AV) implantation in patients with uveitic glaucoma. METHODS: In total, 18 patients (19 eyes) with glaucoma secondary to chronic uveitis, who underwent AV implantation were retrospectively reviewed. Visual acuity, intraocular pressure (IOP), and glaucoma medications at the most recent examination prior to surgery, were compared with those of last postoperative examination. The surgical success was defined as IOP less than 21 mmHg and greater than 4 mmHg without loss of light perception and visually devastating complications at the last postoperative examination. Decrease in the number of glaucoma medications was also a criterion for surgical success. RESULTS: The mean follow-up period was 26+/-9.7 months. The mean preoperative and postoperative IOPs were 33.3+/-9.7 (range, 20-57) mmHg and 17.3+/-10.8 (range, 6-40) mmHg respectively (P<0.0001). The mean number of antiglaucoma medications was 3.5+/-0.8 (range, 2-5) preoperatively and 1.4+/-1.3 (range, 0-4) postoperatively (P<0.0001). Valve occlusion (five eyes, 26.3%) was the most commonly observed complication. Surgical success was achieved in 13 eyes (68.4%). The cumulative probability of success was 94.4% at 1 year and 60% at 2 years. Five eyes (26.3%) with IOP greater than 21 mmHg and one (5.3%) with corneal decompensation requiring penetrating keratoplasty were considered as failures. CONCLUSIONS: The implantation of AV is an effective surgical procedure for the management of uveitic glaucoma. The inflammatory background might contribute to the occurrence of valve occlusion, which is the most common complication. Prevention of this complication is an essential factor for improving the surgical outcome.     

Goniotomy for glaucoma secondary to chronic childhood uveitis

PURPOSE: To evaluate the safety and efficacy of standard goniotomy surgery for young patients with refractory glaucoma associated with chronic childhood uveitis. DESIGN: Interventional case series. METHODS: We retrospectively reviewed all goniotomies performed at our institution for patients with a diagnosis of refractory glaucoma associated with chronic childhood uveitis from 1994 to 2000 (this was our first-line surgery for such patients during these years). Uveitis was medically controlled in all cases for at least 6 weeks before surgery. The main outcome measure was time after surgery without failure. Success was defined as final intraocular pressure (IOP) or=6 months or until surgical failure. RESULTS: Nineteen goniotomies were performed on 16 eyes (12 patients). Diagnoses included uveitic glaucoma associated with juvenile rheumatoid arthritis, sarcoidosis, and idiopathic uveitis. The mean patient age at first goniotomy was 15.3 years (range, 6.5-30), with mean follow-up 32.4 months (range, 6-84). Cases included were phakic (10 eyes), aphakic (four eyes), and pseudophakic (two eyes). The mean preoperative IOP was 32.3 +/- 4.6 mm Hg. Surgical success was achieved in 12 of 16 (75%) eyes with a mean postoperative IOP of 12 +/- 2.5 mm Hg for these eyes (mean IOP reduction, 20.0 mm Hg, P <.0001). In 10 of 16 eyes (60%), surgical success was achieved after a single goniotomy. Uveitis was stable in all patients after the early post-operative period. Successful eyes used, on average, 1.4 +/- 1.1 glaucoma medications after goniotomy. Complications were mild and included transient hyphema in nine cases (56%) and worsening of a preexisting cataract in a single case (6%). CONCLUSIONS: Goniotomy represents a safe and effective first-line surgery for young patients with refractory glaucoma associated with chronic uveitis, although the majority of patients require glaucoma medication after the procedure.     

Viscocanalostomy with mitomycin-C: a preliminary study

PURPOSE: To compare the results of viscocanalostomy with and without mitomycin-C (MMC). METHODS: Retrospective results of 15 standard viscocanalostomy (VCO) operations (Group 1) were compared with the prospective results of 15 VCO operations performed with intraoperative adjunctive MMC (Group 2). MMC (0.2 mg/mL) was applied over and under the superficial scleral flap for 3 minutes in Group 2 before the deep flap was prepared. Each patient was followed up for at least 1 year, and results of examinations in the first 12 months were used in the statistical comparison of the two groups. Surgical success was defined as intraocular pressure (IOP) < or = 18 mmHg. RESULTS: Preoperative mean intraocular pressures (IOP) in Group 1 and Group 2 were 35.3+/-11.0 and 39.1+/-8.9, respectively. Mean IOP levels at the 12th month were 14.4+/-2.6 and 11.9+/-4.0, respectively, showing a significant decrease in both groups (p<0.001). Postoperative IOP course appeared to be lower in the MMC group, however, the difference was not statistically significant (p=0.554). Complete success rates without medications were 40% in Group 1 and 67% in Group 2. No significant difference was found between the two groups in terms of early and late postoperative complications, pre- and postoperative number of antiglaucoma medications, and surgical success rates at the end of the study period (p>0.05 for all). A significant difference was verified between the two groups of eyes considering the conjunctival bleb types, as low-lying, localized blebs were the most frequent type in Group 1 and thin-walled, avascular blebs were more predominant in the MMC group (p=0.004). CONCLUSIONS: Intraoperative adjunctive MMC use might improve the long-term results of viscocanalostomy by facilitating subconjunctival filtration and might widen the indication range of the technique.     

Incidence of glaucoma in patients with uveitis

PURPOSE: To evaluate the incidence of glaucoma and elevation of intraocular pressure (IOP) in patients with inflammatory eye disease. METHODS: Retrospective review of medical records of 391 consecutive patients with uveitis attending a uveitis clinic of an academic Department of Ophthalmology from January 1999 to August 2002. Demographic, ocular and systemic variables were recorded. The diagnosis and treatment of uveitis were recorded. Uveitis was classified according to standard anatomic, etiological and clinical criteria. "Glaucoma" was defined as elevated IOP (>21 mm Hg) or glaucomatous optic nerve damage requiring medical and/or surgical anti-glaucoma treatment. Kaplan-Maier analysis and log-rank tests were used to evaluate and compare the incidence of glaucoma. RESULTS: The incidence of glaucoma as defined above at 3 and 12 months after acute uveitis was 7.6%. In patients with chronic uveitis (n = 337), the incidence of glaucoma at 1 and 5 years was 6.5% and 11.1%, respectively. There was no statistically significant difference in the incidence of glaucoma between different types of uveitis, idiopathic versus non-idiopathic, and among anterior, intermediate, posterior and panuveitis. Visual loss occurred more frequently in patients with glaucoma than in patients without glaucoma. CONCLUSION: In patients with chronic inflammatory eye disease, the presence of glaucoma was associated with an increasing risk of visual loss. The incidence of glaucoma increased with time and was similar among the different types of uveitis.     

Secondary glaucoma in patients with uveitis.

PURPOSE: To evaluate the prevalence of secondary glaucoma (SG), clinical forms of uveitis more frequently associated with glaucoma, and describe the treatment and complications encountered in a cohort of patients with glaucoma and uveitis during a 10-year period. METHODS: The hospital records of patients with uveitis referred to the Immunology Service of the Massachusetts Eye and Ear Infirmary for a decade were reviewed for cases of SG. RESULTS: One hundred and twenty of the 1,254 patients (9.6%) with uveitis developed SG. SG was more frequent in anterior uveitis (67%) but was also associated with posterior uveitis (13%) and pars planitis (4%). Herpetic keratouveitis (22%), Fuchs' iridocyclitis (19%), juvenile rheumatoid arthritis-associated iridocyclitis (16%), syphilis (14%), and sarcoidosis (12%) were the leading types of uveitis associated with SG. Despite aggressive medical and surgical therapy, SG was associated with progressive visual field loss and optic nerve damage in 39 patients (33%). CONCLUSION: SG is an underappreciated, vision-threatening complication in patients with uveitis. Increased vigilance for emergence of this complicating problem during the care of patients with uveitis is warranted, and medical and surgical treatment for reducing IOP should be especially aggressive in these patients. We hypothesize that earlier, more aggressive treatment of uveitis will reduce the presence of glaucoma as an additional vision-robbing complication of uveitis.     

葡萄膜炎继发青光眼的诊治进展

继发性青光眼是葡萄膜炎患者常见的致盲性并发症,发生率约为10%。常见类型有青光眼睫状体炎综合征、Fuchs综合征、幼年性关节炎相关的葡萄膜炎、病毒性葡萄膜炎、HLA-B27相关性葡萄膜炎、中间葡萄膜炎、Vogt-小柳原田病、Behcet病和类肉瘤病。发生机制与虹膜周边前粘连、瞳孔阻滞、小梁网炎症、Schlemm管功能异常、睫状体肿胀或长时间应用糖皮质激素滴眼液等有关。主要治疗措施是在积极抗炎的基础上应用降眼压药物治疗,眼压难以控制或发生视神经损害时应采用手术治疗,常见术式有虹膜切开术、术中加用抗代谢药物的滤过性手术、房水引流阀植入术或睫状体光凝术等,术前积极控制葡萄膜的炎症可提高手术成功率。就葡萄膜炎继发性青光眼的临床诊治进展进行综述。     

Nd:YAG激光虹膜切除术治疗葡萄膜炎继发闭角型青光眼

目的 评价Nd：YAG激光虹膜切除术治疗葡萄膜炎继发闭角型青光眼的临床效果。方法 回顾性分析27例葡萄膜炎继发瞳孔阻滞闭角型青光眼经Nd：YAG激光虹膜切除术治疗的情况。随诊时间2月到4年。结果1)一次激光所有患眼均成功击穿虹膜。虽经术后积极抗炎治疗．12眼(44％)发生虹膜孔关闭。多次激光治疗后，最终89％的患眼获得了通畅的激光孔。2)在46次激光治疗中，击射点数为3～376点，激光能量为12～2077mJ。所用激光能量较原发闭角型青光眼高。3)75％的患眼激光治疗后眼压控制正常，6只眼(22％)眼压不能控制行滤过手术。4)激光手术的并发症主要是激光时虹膜的出血和暂时的眼压升高。5)术前有活动性炎症的患眼，发生激光孔闭合的比例更高。结论 Nd：YAG激光虹膜切除术是治疗葡萄膜炎继发闭角型青光眼的一种安全有效的方法。为提高手术的成功率，应在积极抗炎的同时，尽早行激光虹膜切除术。若激光后虹膜孔反复关闭，应考虑手术周边虹膜切除术。     

Viscocanalostomy combined with nearly 360-degree suture trabeculotomy for the treatment of primary congenital glaucoma: a preliminary report of a novel technique for trabeculotomy

Graefe's Archive for Clinical and Experimental Ophthalmology - The aim of this study was to determine the preliminary efficacy and safety of a novel technique for trabeculotomy for the...     

Otago glaucoma surgery outcome study : long-term results of uveitis with secondary glaucoma drained by Molteno implants

OBJECTIVE: This study was undertaken in Otago, New Zealand, to provide data on the long-term results of cases of uveitis with secondary glaucoma drained by Molteno implants. DESIGN: A prospective, noncomparative case series of all cases of chronic uveitis with secondary glaucoma drained by Molteno implants from 1978 through 1998. PARTICIPANTS: Forty eyes of 35 patients. INTERVENTION: Insertion of Molteno implant. MAIN OUTCOME MEASURES: Intraocular pressure, visual acuity, and progressive visual field loss. RESULTS: Insertion of a Molteno implant was effective in controlling the intraocular pressure at 21 mmHg or less with a probability of 0.87 (95% confidence interval [CI], 0.76, 0.98) and 0.77 (95% CI, 0.60, 0.93) at 5 and 10 or more years after surgery. The mean visual acuity improved from 20/100 to 20/70 immediately after operation. This value declined to 20/130 at 5 and 10 years after surgery and then improved slightly to 20/120 at 15 years after surgery. In these eyes, the Kaplan-Meier estimated probability of retaining useful vision (visual acuity >20/400; visual field >5 degrees radius) was 0.75 (95% CI, 0.61, 0.89) and 0.71 (95% CI, 0.55, 0.87) at 5 and 7 or more years after surgery. CONCLUSIONS: The insertion of a Molteno implant controlled the intraocular pressure in 76% of cases over the follow-up period. Patients in whom the uveitis was well controlled maintained their visual acuity and visual fields, whereas the proportion of cases requiring steroids and the doses required fell progressively over the period of follow-up. Failures were related to complications of advanced disease, previous intraocular surgery, and failure to control the uveitis. The drainage system provided by the Molteno implant proved robust, continuing to function well despite continuous activity of the uveitis, acute exacerbations of the uveitis, and all subsequent intraocular surgery including cataract extraction, keratoplasty, and vitrectomy.     

小梁切除术治疗Fuchs虹膜异色性葡萄膜炎继发性青光眼的远期疗效

目的：评价小梁切除术治疗ＦＨＵ继发性青光眼的远期疗效。方法：回顾性调查于１９９４年４月￣１９９９年４月因ＦＨＵ继发性青光眼在我院住院行步梁切除术共２８例（３３眼）中,追踪到的１２例患者１３例,平均随访３１．０８个月。结果：矫正视力手术前、后相比无显著性差异（Ｐ〉０．０５）,矫正视力进步５眼（３８．４６％）,不变８眼（６１．５４％）。手术前、后眼压具有显著性差异（Ｐ〈０．００５）,术后合并或不合并药     

Goniosurgery for glaucoma secondary to chronic anterior uveitis: prognostic factors and surgical technique

PURPOSE: To describe the preoperative prognostic factors that correlate with the surgical success of goniosurgery for glaucoma complicating chronic anterior uveitis and to describe the surgical technique. METHODS: The medical records of 31 patients with 31 eyes with glaucoma secondary to chronic anterior uveitis for which 38 goniotomy procedures were performed were reviewed. Uveitis etiology, gender, age of onset of iritis, duration of iritis before recognition of glaucoma, duration of iritis and duration of glaucoma until initial goniosurgery, preoperative gonioscopic findings, lens status, surgical outcome, age at initial goniosurgery, duration of postoperative observation, lens status, preoperative and postoperative intraocular pressures, topical steroid, and glaucoma medication use were reviewed. Complete success was defined by an intraocular pressure (IOP) < or = 21 mm Hg, and qualified success as IOP < or = 21 mm Hg with use of glaucoma medications. The surgical technique used to perform the goniosurgery was reviewed. RESULTS: Overall surgical success was achieved in 22 (71%) of 31 eyes. The mean age at surgery was 10.2 +/- 4.2 years (range, 4-21 years). All but 8 patients were female. Mean follow-up interval was 10.3 +/- 6.4 years (range, 1.5-22 years). Significant correlation was found between outcome and age at initial surgery, lens status, duration of glaucoma before goniosurgery, duration of iritis before glaucoma surgery, and hours of peripheral anterior synechia (PAS). The mean number of clock hours of preoperative (PAS) was 0.5 hours in eyes with success versus 2.5 hours in eyes with failure. Age of onset of iritis, duration of iritis before recognition of glaucoma, trabecular meshwork pigmentation (TM), TM opacification, and circumferential ciliary body band narrowing did not correlate with surgical outcome. CONCLUSION: Goniosurgery is an effective treatment of glaucoma secondary to chronic anterior uveitis. The outcome of surgery was unfavorably influenced by older age, longer duration of glaucoma, and evidence of more advanced preoperative filtration angle abnormalities secondary to uveitis. Goniosurgery for this secondary glaucoma can be successfully performed utilizing the standard goniotomy technique.     

葡萄膜炎继发性青光眼治疗探讨

目的:探讨葡萄膜炎继发性青光眼的治疗疗效。方法:对本院1999-01/2005-12收治的36例葡萄膜炎继发性青光眼患者,进行回顾性研究。结果:葡萄膜炎继发性青光眼患者36例(42眼),其中前葡萄膜炎28例,全葡萄膜炎7例,Fuchs综合征1例。非手术治疗组(12例)中2例眼压控制不良5mo后行小梁切除术。手术治疗组(24例)中22例眼压控制满意。结论:非手术以首次发作或反复发作治疗及时,虹膜粘连时间短者疗效显著,小梁切除术或青光眼阀植入术对葡萄膜炎继发性青光眼均有效,但要注意控制葡萄膜炎炎症。     

Angle-closure glaucoma secondary to nonspecific orbital inflammatory: case report

The nonspecific orbital inflammatory presents several clinical forms. When it evolves the posterior segment of the eye, usually by contiguity, it can lead to serious damage to vision functions. Posterior scleritis causes permanent damage to the vision and rarely progresses to acute glaucoma. CASE REPORT: E.N., a 24-year-old black man, complained of pain in the left eye (OS) for ten days, with low visual acuity, malaise, nauseas and vomiting. On ophthalmologic examination, he presented proptosis, restricted eye movements and edema on the upper left eyelid. Best-corrected visual acuity was 20/20 in OD and counting fingers at 1.5m in OS. The intraocular pressure was 14 mmHg in OD and 34 mmHg in OS. The biomicroscopy presented in OS conjunctival hyperemia cornea with keratic precipitates, shallow anterior chamber with cells and flare 2+. Gonioscopy in OS showed angle-closure of 360 masculine. The ophthalmoscopic examination revealed increased vascular tortuosity and posterior pole edema. Treatment for acute glaucoma was initiated and complementary tests were ordered. Ocular ultrasonography and orbit computerized tomography showed a diffuse thickening of the ocular wall and extrinsic muscles. Other tests were normal. The presumptive diagnosis was acute nonspecific orbital inflammation affecting the ocular bulb posterior segment together with acute glaucoma. He initiated on prednisone 60 mg/day PO. After two weeks of systemic corticotherapy, the patient was asymptomatic, with evident regression of proptosis and scleritis and normal intraocular pressure (11 mmHg in AU). Although not very frequent, acute glaucoma may be present in orbital inflammatory process and should be treated with systemic corticotherapy and topical medication.