Corticosteroid-induced ocular hypertension. II. An acquired form.

Thirty-five patients with unilateral closed-angle glaucoma treated by peripheral iridectomy and prophylactic peripheral iridectomy in the fellow eyes were subjected to corticosteroid provocative test in both eyes. 51% of the eyes with closed-angle glaucoma and 11% of their fellow eyes had a positive corticosteroid pressure response. The closed-angle glaucoma eyes had their fellow eyes responded differently as shown by the frequency distribution graphs and also by the difference between the corticosteroid-induced change in pressure (Wilcoxon test, z=-4.80, p less than 0.0001). These results provide evidence for an acquired form of corticosteroid-induced ocular hypertension and the possible pathogenic factors for the first time. The clinical significance of an acquired form of corticosteroid-induced ocular hypertension is discussed.     

Can the pilocarpine phenylephrine provocative test be used to detect covert angle closure?

Mapstone introduced the term 'partial angle closure' to describe how eyes with apparently open angles could be damaged by a covert angle closing mechanism, identifiable by a positive result of the pilocarpine phenylephrine provocative test (PPPT). This paper presents a 10-year follow-up of 68 patients with narrow but open anterior chamber angles who, on the basis of a positive PPPT, underwent peripheral iridectomy (PI) or laser iridotomy LI). In the 42 patients with glaucoma or ocular hypertension the mean intraocular pressure (IOP) was unchanged following iridectomy; 45% of eyes which showed glaucomatous optic disc damage at presentation and 25.6% of ocular hypertensive eyes subsequently required trabeculectomy to achieve IOP control. In 16 patients with no ocular abnormality other than a narrow angle 19 eyes had positive PPPTs and underwent PI. After a 10-year follow-up only one of the 13 untreated fellow eyes developed angle closure glaucoma. As this is usually bilateral, many of the positive tests in this group of patients may therefore have been false positives. This study shows that eyes with narrow angles which had positive PPPT results did not benefit from PI iridectomy or LI and therefore a positive PPPT is not indicative of the presence of an angle closing mechanism.     

The presentation and prognosis of glaucoma in pseudoexfoliation of the lens capsule

In a series of 519 patients with pseudoexfoliation of the lens capsule (PXF), more than half (286) presented with glaucoma, most either bilateral (61) or unilateral (157) chronic open-angle glaucoma and some acute glaucomas (65). In unilateral PXF glaucoma, the presence of PXF in the fellow eye was a serious risk factor--a raised intraocular pressure (IOP) developed in almost three quarters of these eyes and glaucoma in nearly one quarter. Because glaucoma developed in one quarter of eyes with ocular hypertension on presentation, careful treatment of this hypertension is indicated. If the IOP was not raised on presentation, it developed in only one of eight eyes, and glaucoma developed in one third of these; therefore, regular follow-up only is necessary. Acute glaucoma was usually open-angle PXF glaucoma. The response to medical treatment though good initially, usually fialed on follow-up. Although laser trabeculoplasty was often effective, usually with medical treatment, surgery was often necessary and usually successful though often with adjuvant medical treatment.     

Outflow changes in normal eyes after closed-angle glaucoma.

Twenty-four patients with spontaneous acute closed-angle glaucoma in one eye were selected for study. All 24 eyes had a peripheral iridectomy, were normotensive, and had no gonioscopically visible peripheral anterior synechiae. Of the 24 contralateral eyes 14 gave a positive response to provocative tests and had peripheral iridectomy. The remaining 10 eyes did not give positive responses to the tests and were on no treatment. The 24 pairs of eyes were provoked with pilocarpine and phenylephrine. Tonography was performed at the start of the test, 1 1/2 hours later, and at its termination. At the start of the test the 24 eyes that had had spontaneous closed-angle glaucoma showed a higher pressure and lower outflow facility than the 24 contralateral eyes. This difference disappeared as the test progressed. It is concluded that apparently normal eyes--after an acute attack--do none the less show a significant degree of damage to the outflow system. Ten pairs of eyes from 10 normal persons were provoked in a similar fashion and at no point did a significant difference appear between right and left eyes.     

The long-term effects of iridectomy for primary acute angle-closure glaucoma

Forty-nine eyes were treated with iridectomy for primary acute angle-closure glaucoma. Forty asymptomatic, normotensive fellow eyes were similarly treated. The duration of follow-up after surgery was 52.3 +/- 3.6 months. Thirty-seven (76%) of the eyes with acute attacks were cured by iridectomy alone and required no medical therapy. Twelve eyes (24%) developed increased intraocular pressure following iridectomy, but only one eye (2%) required filtering surgery. Eighty-eight percent of the asymptomatic, normotensive fellow eyes required no subsequent therapy, and none developed visual field defects. Visual acuity was unchanged in 22 of 49 (45%) of the acutely involved eyes and decreased more than six lines in 11 (22%) eyes. In the 40 fellow eyes, visual acuity was unchanged in 63% and decreased more than six lines in only one (2%) eye.     

Partial angle closure.

During the course of negative provocative test for closed-angle glaucoma using pilocarpine and phenylephrine 60% of eyes develop significant reductions in outflow facility at some stage during the test. It is shown that these reductions can be explained by postulating the presence of partial-angle closure since: (1) A random sample (6) of 53 eyes showing an abnormal response subsequently had a peripheral iridectomy. On reprovoking they then behaved as normal eyes with a uniform increase in outflow. (2) Fifty-eight eyes that had a peripheral iridectomy for closed-angle glaucoma (spontaneous or induced) responded to provocative testing as do normal eyes.     

Management of acute primary angle-closure glaucoma: a long-term follow-up of the results of peripheral iridectomy used as an initial procedure.

For the past 12 years peripheral iridectomy has been used as the initial surgical procedure after an acute attack of angle-closure glaucoma. The operation has been performed 2 to 5 days after the pressure has been controlled medically and has been followed routinely by prophylactic peripheral iridectomy in the fellow eye. Peripheral iridectomy for primary acute angle-closure glaucoma controlled the condition without any need for further medical or surgical therapy in 72% of cases. Careful and frequent follow-up within the first 4 postoperative months is essential to prevent further field loss, which can occur very rapidly if the pressure is not adequately controlled. If the pressure remains uncontrolled, further surgery should not be delayed. It was impossible to decide which patients would eventually need trabeculectomy when they first attended in the acute attack. Peripheral iridectomy as a prophylactic procedure was entirely effective in preventing an acute angle-closure attack in the fellow eye.     

The frequency distribution of earliest glaucomatous visual field defects documented by automatic perimetry

2500-3000 eyes with ocular hypertension, with or without established glaucoma in the fellow eye, were followed with automatic perimetry for several years. Forty-five eyes showed a documented change from repeated normal fields to reproducible glaucomatous visual field loss. The location of the defective points in the first pathological field of each eye was registered. The resulting frequency distribution is shown and discussed.     

Corticosteroid-induced ocular hypertension. I. Prevalence in closed-angle glaucoma.

Forty-eight eyes with closed-angle glaucoma and 31 eyes at risk were subjected to corticosteroid provocative tests. 65% and 9.7% respectively responded with a change in pressure greater than or equal to 6 mmHg. The responses of the 2 groups were compared with each other and also with the corticosteroid pressure response in normal eyes. The differences in behaviour between the eyes with closed-angle glaucoma and eyes at risk, and the eyes with closed-angle glaucoma and normal eyes, are statistically highly significant. The implication of this are discussed. The prevalence of corticosteroid-induced ocular hypertension in closed-angle glaucoma is higher than previously reported.     

老年性白内障膨胀期继发青光眼的易患因素及对侧眼的处理

分析老年性白内障膨胀期继发青光眼其28例56眼，结果表明其双眼的前房轴深有明显差异，对侧眼与同年龄组的正常人相比，前房较浅（P＜0．001），房用较窄，提示老年性日内障膨胀期继发青光眼发生于窄房角、浅前房人群的比例较高。随访资料说明．一眼发生老年性白内障膨胀期继发性青光眼，若对侧眼房角为窄Ⅲ或窄Ⅳ．则须做预防性周边虹膜切除术（包括激光虹膜切除术），以免对侧眼以后同样发生白内障膨胀期的继发性青光眼。     

Evaluation of laser iridectomy in angle-closure glaucoma: provocative tests.

An argon laser iridectomy was performed on 18 eyes of 14 patients with closed-angle glaucoma. The intraocular pressure (IOP) was controlled in all but one eye within normal limits. Variable amounts of pigment were found on gonioscopy in all cases. The mydriasis test was positive in one eye (5.5%) after homatropine and in 5 eyes (28%) after tropicamide drops. 80% of the positive results occurred in lightly pigmented irides. The dark-prone position test was positive in 7 eyes (38%), 71% of the positive results occurring in heavily pigmented irides. Tomography was also performed; the possibility of trabecular damage is discussed.     

Management of chronic or intermittent primary angle-closure glaucoma: a long-term follow-up of the results of peripheral iridectomy used as an initial procedure.

Patients presenting with either intermittent closed-angle glaucoma which gave to subacute congestive attacks or with chronic angle-closure glaucoma were followed up over 12 years. Peripheral iridectomy was performed as a primary procedure on these patients during this period. It was found to be a highly effective procedure in those patients without field loss at the time of presentation, but because of the figures presented here we would recommend that any patient presenting with angle closure and disc and field changes should have a trabeculectomy performed as a primary procedure. We found no way of predicting which patients would require further surgery from the history, initial intraocular pressure, or the gonioscopic findings. No patient in this series developed malignant glaucoma after trabeculectomy although it occurred in 2 eyes after peripheral iridectomy.     

Timolol in operated closed-angle glaucoma.

Tonometry in 9 eyes (7 patients) provides some evidence that timolol eye drops are useful in improving control of pressure in eyes operated for closed-angle glaucoma. In cases 1 and 2 (Figs, 1 and 2) this beta 1 and 2 blocker reduced pressure consistently. Case 3 (Fig. 3) showed that timolol 0.5% twice daily was as effective as pilocarpine 2% or 4% with adrenaline 1%. The effect of timolol 0.5% in case 4 (Fig. 4) and case 6 (Fig. 6) was additive to pilocarpine and adrenaline; in case 5 (Fig. 5) it probably improved the effect of adrenaline, but in cases 4 and 5 there may have been some loss of effect with time. Case 7 (Fig. 7) showed a good effect of timolol, reversed on withdrawal, but pressure fell again in spite of continued withholding of timolol. Timolol will be especially valuable in the control of pressure if an operation involving iridectomy has not been completely successful in open-angle glaucoma or more especially in closed-angle glaucoma because it has no effect on the pupil. Miotics will tend to produce posterior pupillary synechiae because aqueous humour will go through the iridectomy, not under the edge of the pupil. The danger will be greater in eyes with closed-angle glaucoma because the pupil is closely applied to the anterior lens surface, which will also tend to produce irritative iridocyclitis.     

Intraocular pressure abnormalities associated with central and hemicentral retinal vein occlusion

OBJECTIVE: To evaluate the prevalence of ocular hypertension (OHT) and glaucoma in patients with central retinal vein occlusion (CRVO) and hemi-CRVO (HCRVO) and of the fall in intraocular pressure (IOP) secondary to CRVO/HCRVO. DESIGN: Nonrandomized comparative case series. PARTICIPANTS AND METHODS: We investigated 674 consecutive patients who were initially seen with unilateral CRVO (n = 548) and HCRVO (n = 126) at their onset, with a normal fellow eye. The fellow uninvolved eye in each patient acted as a control. Central retinal vein occlusion and HCRVO were categorized into nonischemic and ischemic. At all visits, patients had a detailed ocular history, as well as a thorough bilateral ocular evaluation, including IOP recording with a Goldmann applanation tonometer; when the diagnosis of OHT or glaucoma was initially uncertain, the 24-hour diurnal IOP was recorded. The observed prevalence rates of OHT and glaucoma among patients with CRVO and HCRVO were compared with those in the general population. MAIN OUTCOME MEASURES: The prevalence of OHT and glaucoma, and of ocular hypotension secondary to CRVO/HCRVO. RESULTS: The overall prevalence of glaucoma was 9.9% and of OHT 16.2%. The prevalence of glaucoma/OHT was found to be significantly (P<0.0001) higher in patients with CRVO and HCRVO than in the general population. There was no significant difference in the proportion of patients with glaucoma/OHT among the various types of CRVO/HCRVO (P = 0.156). Forty-eight percent of all patients had lower IOP (>/==" BORDER="0">2 mmHg) in the CRVO/HCRVO eye than in the fellow (uninvolved) eye at their initial evaluation. The prevalence of ocular hypotension was significantly (P<0.0001) higher in patients with glaucoma/OHT not on ocular hypotensive therapy than in patients without glaucoma. Among the patients without glaucoma, the prevalence of ocular hypotension differed significantly among the various types of CRVO/HCRVO (P = 0.007). CONCLUSIONS: Central retinal vein occlusion and HCRVO have a significant association with glaucoma and OHT and with a subsequent fall in IOP in the involved eye. Few patients with CRVO/HCRVO have high IOP in the involved eye, although many of them do have it in the fellow uninvolved eye. It is important to exclude glaucoma/OHT in the fellow eye of any patient with CRVO/HCRVO; if present, elevated IOP should be treated to reduce the risk of that eye developing (1) CRVO/HCRVO and (2) glaucomatous damage. There may be no benefit to prescribing IOP-lowering drops for involved eyes whose IOP is already normal.     

Vitrectomy does not increase the risk of open-angle glaucoma or ocular hypertension—a 5-year follow-up

Background

The goal of this study was to investigate the development of late onset open-angle glaucoma (OAG) or ocular hypertension after vitrectomy in phakic and pseudophakic eyes.

Methods

In this retrospective case series, the records of 441 patients who had undergone vitrectomy in one eye by a single surgeon were reviewed. The development of OAG or ocular hypertension in the vitrectomized and fellow control eyes was compared. Furthermore, the influence of the lens status (phakic or pseudophakic) on the onset of OAG or ocular hypertension in the vitrectomized and fellow control eyes was analysed. Additionally, the mean intraocular pressure (IOP) and the mean number of antiglaucomatous medications were calculated for both eyes.

Results

A mean follow-up period of 79.5?±?25.6 months was achieved. There were 19 vitrectomized eyes (4.31%) with postoperative OAG, and 19 vitrectomized eyes (4.31%) with postoperative ocular hypertension. Eleven control eyes (2.49%) had OAG, and 13 control eyes (2.95%) ocular hypertension. There were no statistically significant differences in the development of OAG or ocular hypertension between the vitrectomized and fellow control eyes. Furthermore, the lens status in vitrectomized eyes did not influence the late development of OAG or ocular hypertension. There were no significant differences in the mean IOP and the mean number of antiglaucomatous medications between the two eyes.

Conclusions

Contrary to previous reports, we could not observe an increased incidence of late onset OAG or ocular hypertension after vitrectomy. Similarly, the removal of the lens did not increase the risk of OAG or ocular hypertension in vitrectomized eyes.     

玻璃体切除硅油填充术后高眼压的临床治疗

目的探讨玻璃体切除硅油填充术后高眼压的治疗方法。方法对视网膜脱离患者行玻璃体切除硅油填充术,术后眼压大于25 mm Hg的86例（86只眼）进行药物或手术治疗。结果 61只眼（70.9%）经药物治疗眼压控制。14只眼（16.2%）经前房穿刺术后眼压控制。8只眼（9.3%）出现虹膜周切口阻塞,其中6只眼经激光打孔再通,2只眼只行手术切除周边虹膜。3只眼（3.4%）出现新生血管性青光眼,其中1只眼行睫状体冷凝,2只眼行睫状体光凝联合硅油取出后眼压控制。眼压控制后8,4只眼（97.6%）视力有不同程度提高。结论及时发现并针对病因进行药物或手术治疗可有效控制玻璃体切除硅油填充术后高眼压。     

Effects of ibopamine eye drops on intraocular pressure and aqueous humor flow in healthy volunteers and patients with open-angle glaucoma

PURPOSE: On the basis of intraocular pressure measurements and fluorophotometry we assessed the effects of 2% ibopamine eye drops on aqueous humor production in normal and glaucomatous eyes. METHODS: Thirty subjects (15 healthy volunteers and 15 open-angle glaucoma patients with ocular hypertension) were included in a placebo-controlled study with random assignment of treatment from masked containers. All subjects underwent ophthalmologic examinations and intraocular pressure (IOP) measurements. Fluorophotometry was done in both eyes at baseline (without treatment) and during treatment. Each subject was treated with 1 drop of 2% ibopamine in one eye and 1 drop of placebo in the fellow eye 30 minutes before fluorophotometric scans and every hour after the first instillation (for a total of 4 times). Safety was evaluated by recording adverse events and ocular symptoms and signs. Aqueous humor flow data were analyzed using the paired t-test, comparing ibopamine and placebo-treated eyes. RESULTS: No changes in IOP were detected in normal eyes, whereas glaucomatous eyes showed a mean increase of 4 mmHg (95% CI 3.46-4.51) from baseline. The difference in IOP between healthy eyes and those with glaucoma was significant (p < 0.0001). In normal eyes and patients with glaucoma ibopamine led to a significant increase in aqueous humor flow compared with placebo-treated eyes (p < 0.01). The safety profile of ibopamine was very good. CONCLUSIONS: The results seem to confirm that ibopamine increases aqueous humor production in normal and glaucomatous eyes, raising IOP only in eyes with glaucoma.     

Pupil cycle time in primary closed-angle glaucoma

Pupil cycle time was measured in fellow eyes of 118 patients with closed-angle glaucoma and 70 age- and sex-matched control subjects. Results indicate that the duration of pupil cycle time was significantly prolonged in patients with closed-angle glaucoma as compared to the control group (p less than 0.001); in addition, the prevalence of absent pupillary oscillation was significantly increased in closed-angle glaucoma patients (p less than 0.001). The implications are discussed, with particular reference to the association between closed-angle glaucoma and systemic parasympathetic neuropathy.     

Is a general operative prophylaxis of the fellow eye in cases of acute glaucoma necessary? (author's transl)]

The fellow eyes of 136 patients suffering from acute glaucoma were checked during their hospitalization by means of provocation-tests and gonioscopy. Ten cases had a simultaneous attack of both eyes, and 27 were submitted to a peripheral iridectomy prophylactically after a positive provocation-test. Of the remaining 99 patients observed up to 12 years after the operation only 22 developed an attack in the fellow eye; 11 of them were below the age of 60 years, and only 4 over 70.     

Acute primary angle closure in an Asian population: long-term outcome of the fellow eye after prophylactic laser peripheral iridotomy

PURPOSE: To study the long-term outcome of fellow eyes of Asian patients with acute primary angle closure (APAC) who underwent prophylactic laser peripheral iridotomy (LPI). DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Ninety-six consecutive patients with APAC at presentation to one Singapore hospital from January 1990 through December 1994. METHODS: The presenting features of the fellow eye were recorded, and the subsequent long-term intraocular pressure (IOP) outcome after LPI was analyzed. All fellow eyes were initially treated with pilocarpine 2% eyedrops four times daily before LPI, which was performed within 1 week of presentation. For any eye, a rise in IOP during follow-up was defined as a rise in IOP requiring treatment by medication or surgery. MAIN OUTCOME MEASURES: Incidence of acute angle closure and IOP. RESULTS: The mean follow-up period was 50.8 months (range, 9-99 months). Of the 96 patients, 15 patients had bilateral APAC, and APAC developed in one fellow eye before LPI could be performed. The remaining 80 fellow eyes were studied. No cases of APAC developed after prophylactic LPI. Seventy-one fellow eyes (88.8%) were successfully treated with LPI alone without the need for additional glaucoma treatment in the long term. Seven eyes (8.8%) had IOPs of 21 mmHg or less on presentation, but a rise in IOP developed on follow-up despite the presence of a patent LPI. Two fellow eyes (2.5%) had signs of preexisting chronic angle closure glaucoma at presentation and required further glaucoma treatment even after LPI. There were no significant complications from the procedure in any of the fellow eyes studied. CONCLUSIONS: In this Asian population with APAC, prophylactic LPI is safe and effective in preventing acute angle closure in fellow eyes. In addition, prophylactic LPI prevents long-term rise in IOP in 88.8% of fellow eyes (with approximately 4 years of follow-up). However, because a small proportion of fellow eyes did experience a rise in IOP within the first year, despite the presence of a patent LPI, close monitoring is still advised in the follow-up of fellow eyes of patients with APAC.