Bilateral effects of long-term monocular timolol therapy

We studied the bilateral intraocular pressure lowering effect of long-term unilateral timolol maleate 0.5% in 30 patients in whom early primary open-angle glaucoma had recently been diagnosed. A significant intraocular pressure reduction was found in the untreated fellow eyes (21.9 mm Hg from 26.4 mm Hg at baseline) (P less than .001), as well as in the treated eyes (21.0 mm Hg from 28.5 mm Hg at baseline) (P less than .001). Fourteen patients (47%) showed a significant bilateral intraocular pressure reduction (P less than .001), with little difference between the treated (8.2 mm Hg) and the untreated eyes (7.7 mm Hg) (P greater than .8).     

Difference of optic disc topography between a low-tension group and a high-tension group in normal-tension glaucoma patients

PURPOSE: Glaucomatous visual field loss and optic disc damage differ by intraocular pressure (IOP) levels. In this study, we compared the optic disc topography in the high-tension group and the low-tension group in normal-tension glaucoma (NTG). METHOD: We selected NTG patients with mean deviation (MD) > or = -10.00 dB and the highest recorded IOP of < 14 mmHg or > or = 17 mmHg without glaucoma treatment. We classified NTG eyes into the following two groups: 1) a low-tension group with the highest recorded IOP of < 14 mmHg, 2) a high-tension group with the highest recorded IOP of > or = 17 mmHg. The optic disc parameters in the low-tension group eyes were compared with those in the high-tension group eyes using a Heidelberg Retina Tomograph. RESULTS: Nineteen eyes of nineteen patients were selected for each group. The cup/disc area ratio in the global sector, and the rim volume in the nasal sector of the low-tension group had deteriorated more than in the high-tension group. CONCLUSIONS: The disc topography is different between the low-tension group and the high-tension group in the nasal sector, suggesting that different pathogenetic mechanisms exist in the optic disc damage in NTG.     

Central corneal thickness in low-tension glaucoma

BACKGROUND: It is possible that the intraocular pressure (IOP) is underestimated in eyes whose central cornea is thinner than normal. The objective of this study was to determine and establish the significance of central corneal thickness in patients with low-tension (normal-tension) glaucoma compared with those with chronic open-angle glaucoma (COAG) or ocular hypertension and healthy eyes. METHODS: The study was carried out from February 1998 to May 1999. Central corneal thickness was measured by ultrasonic pachymetry and IOP was measured by Goldmann applanation tonometry in 25 patients with low-tension glaucoma (untreated IOP less than 21 mm Hg with evidence of optic nerve head damage and corresponding visual field loss on automated perimetry), 80 patients with COAG (untreated IOP 21 mm Hg or greater with evidence of optic nerve head damage and corresponding visual field loss on automated perimetry), 16 patients with ocular hypertension (untreated IOP 21 mm Hg or greater, with normal optic nerve head and no history of glaucoma or elevated IOP, and normal visual field on automated perimetry) and 50 control subjects (untreated IOP less than 21 mm Hg with normal optic nerve head and no history of glaucoma or elevated IOP). Analysis with Pearson's product-moment correlation was performed to determine the correlation of IOP and central corneal thickness, and one-way analysis of variance was used to compare corneal thickness between groups. RESULTS: The central cornea was significantly thinner in the low-tension glaucoma group (mean 513.2 mu [standard deviation (SD) 26.1 mu]) than in the COAG group (mean 548.2 mu [SD 35.0 mu]) and the control group (mean 556.7 mu [SD 35.9 mu]) (p < 0.001). No significant difference in corneal thickness was found between the COAG and control groups. The ocular hypertension group had significantly thicker corneas (mean 597.5 mu [SD 23.6 mu]) than the three other groups (p < 0.001). INTERPRETATION: Patients with low-tension glaucoma may have thinner corneas than patients with COAG and healthy subjects. This results in underestimation of their IOP. Corneal thickness should be taken into account when managing these patients to avoid undertreatment.     

Glaucoma without ocular hypertension. A clinical study

One hundred eighty-four glaucomatous eyes (125 patients) with visual field defects of Stage I and II in the central visual field were examined with the Octopus perimeter 201, Program 31 or 33, and were divided into 3 groups according to maximum intraocular pressures: (1) low-tension glaucoma (21 mm Hg), (2) glaucoma simplex (22-29 mm Hg), (3) glaucoma simplex (30-39 mm Hg). In these three groups of glaucomatous eyes the cupping of the optic disk, vision and blood pressure were examined and a further check for cardiovascular risk factors was carried out by the internist. All three groups proved to have an equally high incidence of cardiac insufficiency, abnormal EKG changes and diabetes. However, a low systolic blood pressure was found to be the risk factor more often in patients with low-tension glaucoma than with glaucoma simplex. Furthermore, intraocular pressures in the low-tension glaucoma group were higher than those in the normal population. The occurrence of cupping of the optic disk, which is not present with purely vascular optic nerve diseases, and the location of visual field defects in low-tension glaucoma, which is similar to that in glaucoma simplex but different from vascular diseases, as well as the increased diurnal tension variations of diurnal tension curves compared to the normal population are all factors which indicate that low-tension glaucoma is not a purely vascular optic nerve disease, and that pressure-lowering therapy is necessary.(ABSTRACT TRUNCATED AT 250 WORDS)     

Extracapsular cataract extraction and posterior chamber intraocular lens implantation combined with trabeculectomy in patients with glaucoma

We reviewed 75 consecutive cases of extracapsular cataract extraction and posterior chamber intraocular lens implantation combined with trabeculectomy in 69 patients with glaucoma. The mean preoperative intraocular pressure was 19.3 mm Hg on an average of 2.3 glaucoma medications. Visual acuity improved in 58 eyes (77%) at two months, with an average improvement of 3.3 and 3.6 lines at two and 12 months, respectively. Of the 75 eyes, 49 (65%) achieved a visual acuity of 20/40 or better; three patients (4%) had further deterioration in vision at the completion of follow-up because of progressive glaucoma or macular disease. Postoperatively, the average intraocular pressure was 3.8 and 3.0 mm Hg lower than the preoperative level at two and 12 months (P less than .001) on 0.63 and 0.79 glaucoma medications, respectively. However, 27 (36%) of the 75 eyes had a recorded intraocular pressure greater than 30 mm Hg and 30 (40%) had a pressure 7 mm Hg or more above their preoperative level during the first six months after surgery. Despite improved long-term control of intraocular pressure, detectable conjunctival filtering blebs were present in only 31 (41%) of 75 eyes at two months and in seven (12%) of 56 eyes at 12 months. Hyphema occurred in 34 (45%) of the cases.     

Long-term outcomes of Ahmed glaucoma valve implantation in refractory glaucomas

PURPOSE: To evaluate the long-term efficacy of intraocular pressure (IOP) reduction and complications of Ahmed glaucoma valve (AGV) implantation (New World Medical, Inc, Rancho Cucamonga, California, USA) in refractory glaucoma. DESIGN: Retrospective cohort study. METHODS: Retrospective medical records from 64 patients (78 eyes) with refractory glaucoma who underwent AGV implantation with a minimum of three years of follow-up were reviewed. Data regarding age, gender, race, eye laterality, specific glaucoma diagnosis, best-corrected visual acuity (BCVA), number of medications, IOP, visual fields, surgical complications, and follow-up interval were collected from all visits and were analyzed. The primary outcome measure was cumulative probability of success defined as IOP of less than 21 mm Hg and of 5 mm Hg or more with a minimum of 15% reduction from baseline IOP, without additional glaucoma surgery or loss of light perception. Secondary outcomes included IOP and number of medications at three, six, 12, 24, 36, 48, and 60 months after surgery, surgical complications, and final BCVA. RESULTS: The cumulative probability of success was 80% and 49% at one and five years, respectively. IOP was reduced from a mean of 30.4 +/- 10.7 mm Hg to 17.0 +/- 5.0 mm Hg at 12 months and 15.9 +/- 3.0 mm Hg at 60 months (P < .001). The number of medications decreased from 3.2 +/- 1.0 medications at baseline to 1.6 +/- 0.4 at 12 months and 2.1 +/- 0.2 at 60 months (P < .001). Prior glaucoma surgery and the silicone type of AGV were statistically significant risk factors for failure (P < .001). CONCLUSIONS: Approximately 50% of single-plate AGV implantations in refractory glaucoma were considered successful after five years of follow-up. Prior glaucoma surgery was a statistically significant risk factor for failure.     

Visual field change in low-tension glaucoma over a five-year follow-up

There is some evidence that the nature and progression of disease in low-tension glaucoma may be distinct from other open-angle glaucomas. The authors assessed visual field change by retrospective case review of all patients treated for low-tension glaucoma by the Glaucoma Service, Wills Eye Hospital, for at least 5 years. Sixty-two glaucomatous eyes of 36 patients were identified. All eyes were treated medically and 40 (65%) underwent at least one surgical procedure. Twenty-eight eyes (47%) had initial field loss confined to a single hemi-field and in the remainder both hemi-fields were involved. Thirty of 57 eyes (53%) showed progression at 3 years and 38 (62%) of 57 had progressed by 5 years. A dense scotoma extending from the nasal periphery toward fixation was the most common visual field defect. The rate of field change in this population is significantly greater than in a cohort of primary open-angle glaucoma patients also seen at Wills Eye Hospital, but who had elevated intraocular pressures. Patterns of field loss and rate of progression in this low-tension glaucoma population suggest that the natural history of low-tension glaucoma differs from high-tension open-angle glaucoma.     

Factors associated with long-term progression or stability in primary open-angle glaucoma

PURPOSE: To evaluate long-term risk factors for progression or stability in patients with primary open-angle glaucoma. METHOD: We retrospectively included consecutively reviewed patients who had primary open-angle glaucoma for at least 5 years in this multicenter trial. Historical and clinical factors in these patients were evaluated for their association with stability or progression of the glaucoma. RESULTS: We included 218 patients in this study; of these, 34 progressed over an average length of follow-up of 45.5 +/- 30.0 months, and 184 were stable over an average of 72.8 +/- 18.3 months. The mean intraocular pressure over the follow-up period for the progressed group was 19.5 +/- 3.8 mm Hg and for the stable group 17. 2 +/- 3.1 mm Hg (P =.001). The average standard deviation of individual intraocular pressures was greater in the progressed group (5.1 mm Hg) than the stable group (3.9 mm Hg, P =.012). Baseline characteristics indicating a greater potential to progress were a larger cup-to-disk ratio (P <.001), a greater number of medications (P =.02), older age (P.007), and worse visual acuity (P =.003). However, no difference was observed in pressure levels that prevented progression in these subpopulations compared with the total sample size. CONCLUSIONS: This study suggests that lowering the intraocular pressure is important in the treatment of primary open-angle glaucoma to help prevent long-term progression. Lowering the pressure, however, is not uniformly effective in preventing progression. Additionally, risk factors for progression do not further help identify pressure levels that prevent worsening of glaucoma.     

Molteno/von Denffer drainage implants in therapy-refractory glaucomas

BACKGROUND: In glaucoma eyes in which the pressure regulation was not possible with drugs and surgery or which were blind already, we treated the patients with a Molteno implant by von Denffer. MATERIALS AND METHODS: In 10 years (1995 to 2004) we treated 19 eyes with a glaucoma drainage device -- the Molteno implant developed by von Denffer. The average age of the patients was 64 (range: 15 to 77) years. On average 3,1 operations were realised before the implant. The average eye pressure was 44 mm Hg preoperatively. Our patients suffered from different glaucomatous diseases: 7 primary glaucomas (congenital, open and narrow angle glaucoma) and secondary: neovascular glaucoma (4), PEX glaucoma (2), traumatic glaucoma (3) and postoperative glaucoma (3). RESULTS: The intraocular pressure had a successful outcome of under 20 mm Hg in 13 eyes, 5 patients out of these were treated with 1 to 3 drugs. Early complications (flat anterior chamber, hyphaema, hypotonia) were reversible. Late complications were phthisis bulbi (3), explantation of the implant (2) and one evisceration bulbi. We found an improvement of the visual acuity in 4 cases in traumatic and postoperative glaucoma. The stabilisation of visual acuity was possible in primary glaucoma. CONCLUSIONS: The implantation of the Molteno implant by von Denffer is an ultimate ratio in eyes with persistent high intraocular pressure. A durable reduction of the pressure is possible in two-thirds and the conservation of the bulbus was achieved in three-fourths of the patients.     

Correlation between intraocular pressure control and progressive glaucomatous damage in primary open-angle glaucoma

Fifty-five patients with primary open-angle glaucoma and early glaucomatous damage who had medical therapy and laser trabeculoplasty were followed up for four to 11 years or until progressive glaucomatous damage was documented. Factors associated with the stability or progression of glaucoma were evaluated. Eyes with mean intraocular pressure higher than 21 mm Hg during the follow-up period uniformly had progressive glaucomatous changes. Conversely, eyes with mean intraocular pressure less than 17 mm Hg remained stable, and approximately half of the eyes with mean intraocular pressure between 17 and 21 mm Hg had progressive glaucomatous changes. Patients who remained stable were slightly younger than those with progressive glaucomatous changes (P less than .05), but initial optic nerve head appearance, initial visual field findings, number of medicines used, medical history, and patient gender or race were not statistically associated with stability or progression of the glaucoma. These findings reinforce the importance of intraocular pressure control in primary open-angle glaucoma and the need to identify other markers that help determine the proper level of intraocular pressure for individual patients.     

Factors associated with glaucoma after penetrating keratoplasty

We conducted a retrospective analysis of 80 eyes that underwent penetrating keratoplasties to determine the factors associated with early (less than three months) and late (more than three months) postoperative increases in intraocular pressure. The patients ranged in age from 14 to 91 years (mean age, 58.5 years). The 56 patients with aphakic eyes had a mean age of 64 years and the 24 patients whose eyes had lenses had a mean age of 48 years. In the 17 eyes with preoperative glaucoma, the intraocular pressure was controlled with medication (mean intraocular pressure, 17.6 mm Hg; range, 10 to 21 mm Hg). The follow-up periods ranged from 12 to 26 months (mean, 22 months). Of the 80 eyes, 25 had early increases in intraocular pressure and 23 had late increases. Twenty eyes showed increases during both periods. Of the 17 eyes with preoperative glaucoma, 14 had early increases and 15 had late increases (P less than .001). Of the 57 aphakic eyes, 24 had early increases (P less than .001) and 21 had late increases (P less than .025). Other factors (whether vitrectomy was done, suture technique, and graft size) were not statistically significant.     

Biostatistical evidence for two distinct chronic open angle glaucoma populations.

Twenty-six eyes of 26 patients with low-tension glaucoma and 34 eyes of 34 patients with high-tension glaucoma were studied. Fifty-one measurements were available on each patient, including visual field indices, finger blood flow measurements, as well as haematological, coagulation, and biochemical and rheological variables. Multivariate analysis revealed two statistically distinct groups of patients, with low and high tension glaucoma cases equally distributed in both. The smaller group (15 patients) showed a suggestion of vasospastic finger blood flow measurements, and had a high positive correlation between the mean deviation (MD) index of field severity and the highest intraocular pressure (r = 0.715, p = 0.0008). The second, larger group (45 patients) showed disturbed coagulation and biochemical measurements, suggestive of vascular disease, and had no correlation between the MD index and the highest intraocular pressure.     

A comparison of the blue color mechanism in high- and low-tension glaucoma

Twenty-five eyes of 25 high-tension glaucoma patients and 25 eyes of 25 low-tension glaucoma patients matched for similar visual field defects had their spectral increment threshold measured. Patients with high-tension glaucoma showed significant losses in both chromatic and achromatic sensitivities when compared with low-tension glaucoma patients. The results support the hypothesis that there may be different mechanisms of damage in glaucoma.     

Bilateral argon laser trabeculoplasty in primary open-angle glaucoma

We performed bilateral argon laser trabeculoplasty on 34 patients with medically uncontrolled open-angle glaucoma. Preoperative intraocular pressure was greater than 21 mm Hg, with a less than 3-mm Hg difference between the two eyes. Laser treatment (360 degrees) was performed on both eyes within a three-month interval. Mean (+/- S. D.) baseline intraocular pressure was similar in the first- (26.9 +/- 3.7 mm Hg) and second- (26.5 +/- 3.3 mm Hg) treated eyes. One hour after treatment, four first- and four second-treated eyes had a greater than 30% increase in intraocular pressure. The one-hour change in pressure was highly correlated between the two eyes (r = .794, P less than .0001). Intraocular pressure was reduced (P less than .0001) one, two, and three years after treatment in both the first and second-treated eyes. The percentages of first- and second-treated eyes with a pressure of less than or equal to 21 mm Hg were similar at one, two, and three years. Pressure response between the two eyes was correlated (P less than .0001) at year 1 (r = .815), 2 (r = .757), and 3 (r = .886) after laser therapy.     

Postural change of intraocular and blood pressures in ocular hypertension and low tension glaucoma.

The effect of body position on the intraocular and blood pressures of normal volunteers and of patients with ocular hypertension and low tension glaucoma was studied. Changing from the sitting to the supine position increased the intraocular pressure by an average of 4.4 (SD 2.0) mm Hg in the control group, 4.0 (SD 2.0) mm Hg in the ocular hypertension group, and 4.1 (SD 1.8 mm Hg) in the low-tension glaucoma group. After 30 minutes in the supine position the intraocular pressure in normal volunteers and patients with low tension glaucoma remained stable. In contrast patients with ocular hypertension showed a further significant increase in intraocular pressure of 1.6 (SD 2.8) mm Hg (p = 0.004). This was accompanied by an equally significant decrease in blood pressure (p less than 0.001). We believe that these are manifestations of different mechanism of intraocular pressure regulation between these groups.     

Ahmed glaucoma valve implant vs trabeculectomy in the surgical treatment of glaucoma: a randomized clinical trial

PURPOSE: To compare the short- and intermediate-term results of two commonly used glaucoma surgical procedures, trabeculectomy and Ahmed glaucoma valve implant. METHODS: A randomized clinical trial was performed at two international centers. One eye each of consecutive patients requiring glaucoma surgery for intraocular pressure control was randomized to receive either trabeculectomy or the Ahmed implant. RESULTS: Of the 117 patients, 62 were randomized to trabeculectomy and 55 to the Ahmed implant. With a mean follow-up of 9.7 months, the trabeculectomy group had statistically lower intraocular pressures at weeks 6 to 15 (12.6 mm Hg vs 16.4 mm Hg) and months 11 to 13 (11.4 mm Hg vs 17.2 mm Hg) than the Ahmed implant group. Compared with preoperative status, no statistically significant differences between groups were noted for visual acuity, visual field, lens status, and final anterior chamber depth. The cumulative probabilities of success (intraocular pressure <21 mm Hg and at least 15% reduction in intraocular pressure from preoperative level) were 83.6% for trabeculectomy and 88.1% for Ahmed implant (P =.43). However, the Ahmed implant group had a greater adjunctive medication requirement. On the last visit, 10 of the trabeculectomy eyes and 19 of the Ahmed implant eyes required at least one topical medication (P =.01). There was no statistically significant difference in the rate of complications between the two groups. CONCLUSIONS: Lower mean intraocular pressures were noted for the trabeculectomy group. All other results, including success (as defined in this study) and frequency of complications, were comparable between the two groups.     

A controlled five-year follow-up study of laser trabeculoplasty as primary therapy for open-angle glaucoma

We followed up 32 eyes of 32 patients with early glaucoma (22 with capsular glaucoma and ten with simple glaucoma) who received laser trabeculoplasty as a primary therapy. These eyes were compared with a matched control group of 32 eyes treated with medication initially. The success rate (intraocular pressure below 22 mm Hg with laser alone or medication alone) at five years was 50% (16 of 32 eyes) in the laser-treated group and 22% (seven of 32 eyes) in the control group (P less than .02). The control group required more modifications of their therapy to control intraocular pressure. The neuroretinal rim area in the control eyes decreased 2.5 times as much as in the laser group (P = .017). Changes in the Friedmann visual fields did not differ significantly between the two groups.     

小切口小梁切除联合超声乳化白内障吸除术治疗青光眼合并白内障

目的　探讨 3 5mm小切口小梁切除联合超声乳化白内障吸除后房型人工晶状体植入术 (三联手术 )治疗青光眼合并白内障患者的效果。方法　应用小切口三联手术对 2 0例 (2 6只眼 )青光眼合并白内障患者进行手术治疗。术后随访 3～ 41个月 ,平均 16 1个月。结果　术前平均眼压(2 3 0 1± 2 6 3)mmHg(1mmHg =0 133kPa) ,术后随访最终平均眼压降至 (13 93± 1 85 )mmHg(P <0 0 0 1)。术后随访最终矫正视力范围 0 0 5～ 1 0 ,其中≥ 0 6者 17只眼 (6 5 % ) ,术后平均散光度0 81D ,其中 4只眼无散光度。术后早期 2只眼使用降眼压药物 ,随访后期无使用者。术后早期并发症角膜水肿 5只眼 (19% ) ,浅前房 3只眼 (12 % ) ;晚期并发症后发性白内障 6只眼 (2 3% )。结论　小切口三联手术治疗青光眼合并白内障患者 ,具有恢复有用视力、稳定眼压、减少术后用药、并发症少等理想效果。     

Surgical outcome of phacoemulsification combined with the Pearce trabeculectomy in patients with glaucoma.

The safety and efficacy of phacoemulsification and posterior chamber lens insertion combined with the Pearce trabeculectomy (PE/PCL/P-TRX) in patients with coexistent cataract and glaucoma was evaluated retrospectively. The Pearce trabeculectomy is a form of nonfiltration glaucoma surgery in which an inner block containing trabecular meshwork is excised under a scleral-pocket incision which is closed tightly. Thirty consecutive eyes sustained a reduction of mean intraocular pressure from 21.0 +/- 4.4 mm Hg to 16.6 +/- 3.3 mm Hg after PE/PCL/P-TRX at one year (P less than .001). The average number of glaucoma medications used was reduced from 1.9 to 0.8 postoperatively. At one year, 60% (18 of 30) of eyes treated with PE/PCL/P-TRX had intraocular pressures less than 21 mm Hg without medications.     

Combined pars plana vitrectomy and glaucoma drainage implant placement for refractory glaucoma

PURPOSE:To report visual acuity and intraocular pressure outcomes among patients who have undergone combined pars plana vitrectomy and placement of a glaucoma drainage implant.METHODS:The medical records of all patients who underwent combined pars plana vitrectomy and placement of a glaucoma drainage implant at the Bascom Palmer Eye Institute by one of the authors between January 1, 1990, and February 28, 1998, were reviewed. Forty patients (40 eyes) were identified, including 14 patients with neovascular glaucoma secondary to proliferative diabetic retinopathy or central retinal vein occlusion, 15 patients with other posterior segment disease, seven patients with secondary angle-closure glaucoma, and four patients with aphakia with ruptured anterior hyaloid face. Main outcome measures included visual acuity and intraocular pressure at 1 year postoperatively.RESULTS:At 1 year postoperatively, 31 (77.5%) of 40 patients had stable or improved visual acuity; three eyes (7. 5%) had a final visual acuity of no light perception and three additional eyes (7.5%) were enucleated (because of chronic pain in two eyes and endophthalmitis in one eye). Mean preoperative intraocular pressure was 34 mm Hg and the median number of preoperative antiglaucoma medications was two. At 1 year postoperatively, mean intraocular pressure was 13 mm Hg and the median number of antiglaucoma medications was zero. Twenty-two patients (55.0%) achieved an intraocular pressure greater than 5 mm Hg and less than or equal to 21 mm Hg without antiglaucoma medication, and an additional seven patients (17.5%) achieved this level of intraocular pressure control with medication. Only one patient (2.5%) underwent further glaucoma surgery for uncontrolled intraocular pressure.CONCLUSIONS:Although combined pars plana vitrectomy and placement of a glaucoma drainage implant is often a successful management option in selected patients with refractory glaucoma, visual outcome may be poor because of severe underlying ocular disease and postoperative complications.