Management of uncontrolled glaucoma with the Molteno system

In glaucomatous eyes refractory to medication, laser techniques and conventional drainage surgery, intraocular pressure is often high, and visual loss rapid. In this situation a reliable, robust artificial outflow system is required. Molteno has evolved a plastic tube and plate device combined with a fibrosis suppression medication regimen. Thirty-eight eyes of 32 patients with uncontrolled glaucoma were treated with the Molteno system. Six months after operation mean intraocular pressure had been reduced from 41.0 +/- 13.6 to 16.2 +/- 5.6 mmHg. Eighteen eyes had pressures of 20 mmHg or less on no hypotensive therapy, 17 on reduced treatment. Three eyes had a pressure of 21 to 35 mmHg on treatment at six months. The 13 aphakic eyes responded as well as 25 phakic eyes. Five eyes with rubeotic glaucoma demonstrated pressures of less than 20 mmHg without therapy, four eyes with traumatic glaucoma required continuing medication with three having pressures below 22 mmHg. Of the seven eyes with uveitic glaucoma, one was lost, two required maintenance therapy; five of six surviving eyes had pressures below 20 mmHg. Fifteen eyes with congenital or juvenile glaucoma achieved pressures below 20 mmHg, three of these with timolol drops, three with timolol and acetazolamide, and nine with no treatment. While seven of seven eyes with refractory primary open-angle glaucoma attained pressures below 20 mmHg, all seven needed continuing mild hypotensive therapy. Eleven eyes underwent a one-stage procedure, while 27 eyes required a two-stage operation. Twenty-eight eyes received fibrosis suppression medication after the second stage, and 24 maintained or improved their preoperative visual acuity. Results have been encouraging: in general the Molteno system is recommended as the second drainage operation in all glaucomatous eyes in which conventional therapy has failed, and as the primary surgical procedure (after laser techniques) in eyes with rubeotic and uveitic glaucoma. Ciliary body destructive procedures should be restricted to control of symptoms in blind eyes.     

Molteno implant for control of glaucoma in eyes after penetrating keratoplasty

Seventeen patients (17 eyes) underwent implantation of a single plate Molteno implant for medically uncontrollable intraocular pressures after penetrating keratoplasty. Most of the eyes had extensive peripheral anterior synechiae, and 16 of 17 (94%) were pseudophakic or aphakic following keratoplasty. Other glaucoma procedures had been performed previously on 13 eyes: argon laser trabeculoplasty (one eye), trabeculectomy (seven eyes), transpupillary argon laser cyclophotocoagulation (three eyes), and cyclocryotherapy (three eyes). Follow-up ranged from 5 to 28 months (mean, 13 months). Three eyes underwent repeat Molteno implantation when intraocular pressure (IOP) was not satisfactorily reduced after the first procedure. Considering one eye with chronic hypotony as a failure, 12 of 17 eyes (71%) had IOPs of less than 21 mmHg at the time of the three most recent postoperative examinations after a single Molteno implant. Repeat implants in three eyes increased the number of eyes with IOPs of less than 21 mmHg to 14 (82%). Corneal allograft rejection after Molteno implantation occurred in seven eyes; two of these were successfully reversed with corticosteroid therapy. Three of the five eyes with irreversible graft rejection were regrafted, and two of these grafts have remained clear. Including the regrafted eyes, 13 eyes had clear grafts and controlled IOPs at the most recent postoperative examination. The Molteno implant may prove useful in the management of medically uncontrollable glaucoma following penetrating keratoplasty; however, there appears to be a substantial risk of postoperative graft rejection.     

Long-term follow-up of traumatic glaucoma treated with Molteno implants

PURPOSE: To determine the long-term outcomes of patients with traumatic glaucoma treated with Molteno implants at Dunedin Hospital, New Zealand. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Thirty-eight patients with traumatic glaucoma and with a mean follow-up of 10.9 years. INTERVENTION: Insertion of Molteno implant. MAIN OUTCOME MEASURES: Intraocular pressure (IOP) and intraocular pressure-related surgical interventions after Molteno implant insertion. RESULTS: Insertion of a Molteno implant controlled the IOP at 21 mmHg or less (with or without hypotensive medication) with a probability of 0.80 (95% confidence interval [CI], 0.66, 0.93) at 5 years and 0.72 (95% CI, 0.56, 0.88) at 10 years. At final follow-up, intraocular pressure was controlled solely with the implant in 26 cases and controlled with the addition of hypotensive medication in three cases, whereas nine eyes were failures. Eleven patients (29%) underwent intervention for implant repositioning or tube orifice blockage. Thirty-four double- and six single-plate Molteno implants were inserted. Two patients had implants replaced. Seventy-nine percent became aphakic or pseudophakic from their trauma before or at the time of Molteno implant insertion. There were no exclusions resulting from extensive ocular damage. CONCLUSIONS: Insertion of Molteno implants in traumatic glaucoma produced intraocular pressure control at long-term follow-up in 76% of cases.     

Combined small-incision cataract surgery and trabeculectomy-technique and results

In a prospective study 35 eyes of 25 patients with coexisting cataract and glaucoma underwent trabeculectomy, phacoemulsification and implantation of a folded polyHema intraocular lens through the trabeculectomy opening. Follow-up ranged from 6 to 27 months (mean 13.3). The mean age was 76.4 (68 to 88 years). 22 eyes suffered from primary open angle glaucoma, 10 eyes from a pseudoexfoliation glaucoma and 3 eyes had a chronic angle closure glaucoma. Preoperatively intraocular pressure was controlled in 10 eyes with a mean medication of 2.1 but uncontrolled in 25 eyes (mean medication: 2.5). The preoperative visual acuity ranged from 20/40 to hand motions. Postoperatively intraocular pressure was controlled (<18 mmHg) in all (100%) eyes and without therapy in 32 (91%) eyes. Three (9%) eyes had to be treated with topical timolol twice a day after surgery. Mean intraocular pressure dropped from 21.2±6.0 mmHg preoperatively to 13.5± 2.1 mmHg postoperatively. Vision improved in all but 4 eyes, 25 (74%) achieving a visual acuity of 20/40 or better. The causes for failed improvement or deterioration of vision were senile macular degeneration in 2 eyes and central retinal vein occlusion and vascular optic nerve atrophy in one eye respectively. Postoperative complications included hyphema in 9 (26%) eyes, fibrin effusion to a various extent into the anterior chamber in 19 (54%) eyes and delayed hypotony (<5 mmHg) with chorioidal effusion in 1 (3%) eye. Fibrin effusion was frequently observed in eyes with intraocular pressure below 10 mmHg, iris surgery and hyphema. Finally the complications did not effect the results regarding visual acuity or glaucoma control. In summary we conclude that the combination of small-incision cataract surgery and trabeculectomy is an effective surgical approach to obtain visual rehabilitation and glaucoma control with one single surgical intervention.     

Subconjunctival Bevacizumab as an Adjunct to Trabeculectomy in Eyes with Refractory Glaucoma: A Case Series

This prospective observational case series study included 6 eyes of 6 consecutive glaucomatous patients. Each patient underwent trabeculectomy with mitomycin C, and received a 1.25 mg of subconjunctival bevacizumab injection at completion of the trabeculectomy. Study eyes included two with neovascular glaucoma, three with uveitic glaucoma, and one with secondary glaucoma following vitrectomy. All eyes had undergone failed glaucoma laser/surgical treatment or an intraocular surgical procedure. Intraocular pressure (IOP) at the following postoperative visits: preoperative, 1 week, 1 month, 2 months, 3 months, and 6 months, was measured. We also evaluated postoperative bleb findings and complications. IOP measured at each visit was 37.5±14.4 mmHg, 6.2±3.4 mmHg, 8.3±7.2 mmHg, 12.0±4.4 mmHg, 10.8±3.1 mmHg, and 12.2±3.3 mmHg, respectively, for each visit. All eyes had functioning blebs with normal IOP at postoperative 6 months with no additional IOP-lowering medication.     

XEN‐45 collagen implant for the treatment of uveitic glaucoma

Importance

The XEN‐45 implant, a hydrophilic collagen implant which drains aqueous to the subconjunctival space, has not been investigated in the context of uveitic glaucoma.

Background

To determine the safety and efficacy of the XEN‐45 collagen implant in eyes with uveitic glaucoma.

Design

Exploratory prospective case series.

Participants

patients with medically uncontrolled uveitic glaucoma.

Methods

Twenty‐four consecutive patients (mean age ± standard deviation [SD] = 45.3 ± 18.1 years) were implanted with the XEN‐45 implant.

Main Outcome Measures

The primary outcome measure was intraocular pressure (IOP) reduction at 12 months as compared to baseline. Secondary outcome measures included ocular hypotensive medication use at 12 months, the requirement for further glaucoma surgery and failure. Intraoperative and postoperative complications were documented.

Results

The baseline mean ± SD IOP was 30.5 ± 9.8 mmHg and the mean ± SD number of glaucoma medications required was 3.3 ± 0.8. In 20 eyes (83.3%) in whom conventional glaucoma surgery was originally perceived to be inevitable, further surgery was not required after XEN‐45 implantation. The mean IOP was reduced by 60.2% from baseline to 12.2 ± 3.1 mmHg and mean medication usage was reduced to 0.4 ± 0.9 at 12 months (both P < 0.001). One patient had hypotony persisting beyond 2 months that required surgical revision and one patient developed blebitis. The 12‐month cumulative Kaplan–Meier survival probability was 79.2%.

Conclusions and Relevance

The XEN‐45 implant is effective for the treatment of patients with medically uncontrolled uveitic glaucoma. Potentially sight‐threatening complications, including bleb‐related ocular infection and persistent hypotony, may occur.     

Long-term efficacy of primary laser trabeculoplasty.

Sixty glaucomatous eyes of 60 patients treated with laser trabeculoplasty as primary therapy were reviewed retrospectively. There were 42 eyes with capsular glaucoma and 18 with simple glaucoma. The mean prelaser intraocular pressure (IOP) was 35.2 (SD = 6.5) mmHg. Success was defined as IOP less than or equal to 22 mmHg without medication. The probability of success was 0.73 at 1 year, 0.66 at 2 years, 0.57 at 3 years, and 0.50 at 4 years. Three eyes experienced progressive visual field loss or disc damage in spite of an intraocular pressure below 22 mmHg without medication. High prelaser pressure and the severity of the visual field defects were significant predictors of treatment failure.     

Molteno aqueous shunt as a primary surgical intervention for uveitic glaucoma: long‐term results

Purpose: To evaluate the efficacy of Molteno aqueous shunt as a primary surgical treatment in uveitic glaucoma. Methods: Nonrandomized, interventional, retrospective clinical study. The intraocular pressure (IOP), survival rate and complications were analyzed in 30 patients with uveitic glaucoma treated with Molteno implant. Results: The mean follow‐up time was 59.3 ± 18.4 months. Preoperatively, the mean ± SD IOP was 32.8 ± 7.5 mmHg (range 20–48), and the mean number of medications was 3.1 ± 0.6. The mean IOP decreased significantly (p < 0.001) to 17.7 and 15 mmHg at 3 and 6 months postoperatively. The mean number of medications decreased statistically significantly (p < 0.001) from the preoperative number 3.1 to 1.9 three months postoperatively. The number of medications continued to decrease significantly up to 3 years postoperatively. The qualified success rate (Kaplan–Meier estimate) was 97%, 93%, 90% and 85% at 1, 2, 3 and 4 years, respectively. Two patients failed because of hypotony, two patients developed conjunctival erosion and one patient had corneal decompensation. Conclusions: Molteno aqueous shunt as the first glaucoma procedure decreased IOP effectively in uveitic glaucoma. Even after 4 years, the survival estimate was quite high. The IOP decreased continuously during the first year after the surgery, and the medication was slowly tapered even up to 3 years postoperatively. It is suggested that it may be possible to postpone further surgical intervention during the first postoperative year after Molteno implantation even if the IOP is not quite optimal.     

A case of steroid-induced glaucoma after radial keratotomy

BACKGROUND: We report a patient who was diagnosed as having steroid-induced glaucoma after radial keratotomy(RK) and suffered from severe visual field defect. CASE: A 29-year-old man underwent RK for both eyes. After the operation, he was treated for six months with topical medication including 0.1% and 0.01% betamethasone without measuring intraocular pressure(IOP). When he consulted an ophthalmologist, his IOP was 43 mmHg in the right eye and 51 mmHg in the left eye. At our initial examination, his IOP was 8 mmHg in the right eye and 10 mmHg in the left eye with 750 mg acetazolamide peroral, 0.5% timolol maleate, and latanoprost eyedrops. There were RK 16 incisions on the cornea and we found severe glaucomatous visual field loss. Finally we performed trabeculotomy in both eyes for IOP control with conservative therapy. CONCLUSION: As the keratorefractive surgery becomes popular, we must be careful of problems, such as steroid-induced glaucoma, and the change of refraction following the change of IOP.     

Molteno implant surgery in uncontrolled glaucoma

Molteno implant surgery was performed on 33 eyes of 29 patients with complicated and uncontrolled glaucoma. Average preoperative IOP was 34.0 +/- 8.8 mmHg. After a mean postoperative follow-up period of 18.3 months the IOP was 15.8 +/- 8.3 mmHg. Three patients had an IOP over 22 mmHg. Overall, success rate was 73% with IOP and medication as criteria. In 75% of eyes visual acuity improved or remained within two lines of the preoperative value. The highest success rate was 83% (10 of 12 eyes) in congenital and uveitic glaucoma when both IOP, medication and visual acuity were taken into account. At the end of the study 52% of eyes were controlled without medication. Complications included transient hyphema (21%), flat anterior chamber with hypotony, with or without choroidal detachment (12%), tube touch to lens or cornea (9%), and tube block with vitreous (3%).     

Timolol treatment of chronic open-angle glaucoma and ocular hypertension

Maintenance effect of topical timolol was investigated or 2 years in a group of 125 glaucomatous and ocular hypertensive patients (231 eyes) who had been successfully treated with timolol alone during a 6-month period preceding this trial. Intraocular pressure (IOP) was controlled with timolol alone in 135 of 183 eyes (74%) that completed the study. At the end of the trial 142 eyes (78%) showed an IOP of less than 22 mmHg. Other glaucoma medication had to be added to timolol treatment in 18% of ocular hypertensive and 35% of glaucomatous eyes because of IOP elevation. Elevation of IOP seemed to be due to worsening of glaucoma rather than to decreased efficacy of timolol. None of the ocular hypertensive patients developed visual field defects but in ten glaucomatous patients progression of existing visual field defects was observed in association with elevated IOP. Transient adverse effects were observed in 13% of cases, but timolol treatment had to be stopped in only five cases (4%) because of side effects.     

The additive effect of timolol on open angle glaucoma patients on maximal medical therapy

Thirty-one eyes of 20 glaucomatous patients on maximum medication were treated with timolol drops for a mean period of 9 months. Adequate levels of control of intraocular pressures were obtained in 21 eyes. No significant ocular or systemic side effects were noted. Timolol has an additive effect in further lowering intraocular pressures in patients being treated with a combination of carbonic anhydrase inhibitors, pilocarpine, epinephrine, and the anticholinesterases.     

A case of steroid-induced glaucoma after radial keratotomy

Background: We report a patient who was diagnosed as having steroid-induced glaucoma after radial keratotomy (RK) and who suffered from severe visual field defect.Case: A 29-year-old man underwent RK for both eyes. After the operation, he was treated for six months with topical medication including 0.1% and 0.01% betamethasone without an intraocular pressure (IOP) measurement. When he consulted an ophthalmologist, his IOP was 43 mmHg in the right eye and 51 mmHg in the left eye. At our initial examination, his IOP was 8 mmHg in the right eye and 10 mmHg in the left eye. He was taking 750 mg acetazolamide peroral, 0.5% timolol maleate, and latanoprost eyedrops. There were 16 RK incisions on the cornea and we found severe glaucomatous visual field loss. Finally we performed trabeculotomy in both eyes for IOP control with conservative therapy.Conclusion: As keratorefractive surgery becomes popular, we must be alert for problems, such as steroid-induced glaucoma, and the change in refraction following the change in IOP. Nippon Ganka Gakkai Zasshi     

Management and prognosis of end-stage glaucoma

Purpose : We followed, for a long term, end‐stage glaucoma patients as defined by the level of legal blindness. Methods : Follow up was for 7.7 ± 1.8 years (range 2–9) for 22 patients (13 men and nine women) having 32 eyes with functional vision. Age at exit was 74.6 ± 15.5 years (range 33–89). Humphrey computerized perimetry and applanation tonometry were used throughout. We attempted to hold intraocular pressure below 15 mmHg using as much medical therapy as required. Results : All visual fields were less than 10° diameter at exit, but at entry seven eyes of six patients still had a field between 10º and 20°, the rest were all less than 10°. Corrected visual acuity at entry was 6/9 to 6/6 in 21 eyes of 16 patients and none had less than 6/60. At exit 16 eyes had 6/9 to 6/6 and five eyes had less than 6/60, but no patient had complete loss of vision. Mean intraocular pressure (IOP) throughout was below 15 mmHg in all but four patients, whose (IOP) were less than 20 mmHg, using multiple medications if necessary. All patients had undergone prior surgery and/or laser trabeculoplasty. Conclusions : Even though visual loss slowly progressed, most patients with end‐stage glaucoma retained functional vision for a long period when intraocular pressure was held below 15 mmHg. More stringent early control of intraocular pressure may avoid the development of end‐stage glaucoma.     

Molteno implants in children

We report our experience with Molteno implants in 27 eyes of 20 children with glaucoma. Associated ocular findings included Sturge Weber syndrome (one patient), aniridia and retinoschisis (one patient), aphakia (seven patients, eight eyes), rubella syndrome (two patients), Peters anomaly (one patient), and Treacher Collins syndrome (one patient). Fifteen eyes received a single-plate implant, and 12 eyes received a double-plate implant in two stages. The patients' ages ranged from 2 months to 13 years (mean 47 +/- 55 months). The average number of previous glaucoma procedures was four per eye (range two to 10). The follow-up period ranged from 6 to 36 months (mean 20 +/- 9 months). The mean intraocular pressure before surgery was 34 +/- 4 mm Hg. The mean postoperative intraocular pressure was 19 +/- 11 mm Hg at 1 month and 19 +/- 6 mm Hg at 1 year (p < 0.001 at both times). After surgery nine eyes (33.3%) required no medication for control of intraocular pressure. Additional surgery was required in 12 eyes (44.4%). We believe the Molteno implant is a useful approach for children with glaucoma who fail to respond to standard medical and surgical treatments.     

Non-penetrating glaucoma surgery augmented with mitomycin C or 5-fluorouracil in eyes at high risk of failure of filtration surgery: long-term results

PURPOSE: To investigate the long-term efficacy and safety of non-penetrating glaucoma surgery (NPGS) augmented with mitomycin C (MMC) or 5-fluorouracil (5FU) in eyes at high risk of failure of glaucoma filtration surgery. METHODS: Prospective study of all eyes, undergoing NPGS with 0.04% MMC (1 to 2 min topical or 0.04 mL subconjunctival injection into the superior fornix) or 5FU (25 mg/mL topically for 5 min). Complete success was an intraocular pressure (IOP)or=20% drop in IOP or a reduction of at least two medications. RESULTS: Twenty-three eyes of 22 patients with a mean follow up of 41.4 months were reviewed. Fifteen eyes had failed trabeculectomy and seven had uveitic glaucoma. Mean preoperative IOP reduced from 25.8+/-7.8 to 15.4+/-4.9 mmHg at final visit, a mean change of 41%. Median number of preoperative medications decreased from 3 to 0 postoperatively. Cumulative probability of success was 100% at 2 years, 94% at 3 years and 85% at 4 years. No patient developed any long-term complications. Complete success was achieved in 11 eyes and qualified success in 10 eyes. Two eyes failed and required further surgery. CONCLUSION: NPGS augmented with small-volume MMC/5FU provides good long-term IOP control in eyes at high risk of failure with a lower incidence of complications compared with augmented trabeculectomy and eliminates the need for postoperative bleb or suture manipulation.     

Molteno管植入术治疗角膜移植术后难治性青光眼

目的:研究Molteno管植入术治疗穿透性角膜移植术后继发青光眼的手术疗效。方法:对9例眼部条件极差,经最大剂量药物治疗不能降低眼压的穿透性角膜移植术后青光眼施行Molteno管植入手术。结果:7例眼压控制在0.8～2.8kPa(1kPa=7.5mmHg)之间,成功率为77.78％(7/9);另两例需继续局部滴用β-受体阻滞剂,1例发生角膜排斤反应经药物治疗痊愈,1例角膜半透明,角膜植片透明率88.89％(8/9),术后视力有改善者4例,视力保持不变者4例,视力下降者1例,其中4例最好矫正视力大于0.05。结论:Molteno管植入术为角膜移植术后保留一定有视力而又不具作滤过性手术条件的难治性青光眼提供合理、有效的治疗方法。眼科学报1999;15:107-110。     

Long-term effects of timolol therapy in ocular hypertension: a double-masked, randomised trial

Background: Increased intraocular pressure (IOP) has been shown to be one of the most important risk factors for developing glaucoma. Yet it has not been clearly demonstrated that IOP-lowering treatment can reduce the incidence of glaucoma damage in patients with ocular hypertension. The aim of the current paper was to report the results of a long-term study addressing this very problem. Methods: We conducted a randomised, double-masked study comparing timolol and placebo treatment in 90 patients with ocular hypertension plus some additional risk factor. Patients were followed at 3-month intervals prospectively for 10 years or until glaucomatous field loss could be demonstrated with computerised perimetry. A post-study analysis was performed including all available data, thus extending maximum follow-up to 17 years. Results: After 5 years of follow-up eight patients in the placebo group and five patients in the timolol group had developed glaucomatous field loss (NS); the corresponding figures after 10 years were 15 patients in the placebo group and seven patients in the timolol group. Survival analysis showed a tendency but no statistically significant difference between treatment groups (P=0.07). Study attrition was large. Eighteen patients in each group had developed glaucomatous field loss when also post-study data were included. IOP reduction was greater in eyes passing the 10-year visit without field loss (5.7 mmHg), than in those that reached an endpoint (2.3 mmHg; P=0.0002). Conclusion: In this long-term study we found a tendency but failed to prove a beneficial effect of topical timolol treatment in patients with elevated IOP, normal visual fields and some additional risk factor. The intent-to-treat analysis showed no difference between treatment groups. The high attrition shows the difficulties associated with very long follow-up. Received: 19 April 2000 Revised: 7 June 2000 Accepted: 19 June 2000     

Uveitic Glaucoma and Rosai-Dorfman Disease (Sinus Histiocytosis)

Purpose: To report a novel association of uveitic glaucoma with Rosai-Dorfman disease. Methods: Case report. Results: A 67-year-old Caucasian woman presented with a chronic bilateral granulomatous uveitis which did not respond to conventional topical steroid therapy. She also had raised intraocular pressures, glaucomatous optic disc changes and diffuse nodular fibrous skin lesions. Subsequent skin biopsy immuno-cytochemistry showed S-100 staining, consistent with Rosai-Dorfman disease. The uveitis and glaucoma were highly resistant to standard medical treatments, but completely resolved together with the systemic features of the disease after six months. Conclusions: Rosai-Dorfman disease has not previously been reported to cause uveitic glaucoma and should be considered in non-responsive cases presenting with a rash. The disease is entirely self-limiting and early diagnosis may therefore avoid unnecessary trabeculectomy and/or systemic immune suppression.     

Timolol plus maximum tolerated antiglaucoma therapy: A one-year followup study

Thirty-three eyes of 22 patients with primary open-angle glaucoma or severe ocular hypertension had topical timolol maleate added to their maximally tolerated medical regimens. With minimal side effects, 25 eyes (76%) could be treated medically for one year, and only eight eyes (24%) required filtering surgery. Thirteen (39%) of the medically treated eyes achieved intraocular pressures of 21 mm Hg or less. After the addition of timolol, 17 of the 33 eyes (52%) completed the one-year protocol with final mean intraocular pressure decreases of 5 mm Hg or more on medical therapy.