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PubMedDate not supplied

Management of ocular hypertension and primary open angle glaucoma.

BACKGROUND: Glaucoma and ocular hypertension are among the most common pathologies encountered in clinical practice. Within the next 20 years, patients with these two problems will increase threefold as the population ages. The growing burden of glaucoma worldwide will also become a significant public health problem. The effective management of glaucoma will require the introduction of new screening strategies and better therapeutic approaches to these disorders. METHODS: Our current understanding of the epidemiology of primary open angle glaucoma and ocular hypertension is reviewed. Diagnosis and treatment strategies are discussed in the context of the current best available clinical trial and laboratory data. RESULTS: While few patients with ocular hypertension will require therapy, it is the conventional practice to lower the intraocular pressure by at least one-third once glaucomatous optic neuropathy is detected. Topical beta-adrenergic antagonists have been the preferred first-line therapy for primary open angle glaucoma for the past 20 years, but with the advent of topical prostaglandin analogues and alpha-2 agonists, the effectiveness of medical therapy has improved significantly. The decision to perform glaucoma filtering surgery or laser trabeculoplasty must be carefully considered and based on the past response to medication, the extent and rate of progression of any visual field loss, and on the life expectancy and wishes of the patient. CONCLUSION: The treatment of chronic glaucoma is directed at preserving vision and interfering with the quality of life of the patient as little as possible. Many older patients who develop primary open angle glaucoma may have a limited life expectancy and do not require aggressive medical therapy or surgery. Many new medications have become available that permit less frequent dosing with fewer local and systemic side-effects. In the near future, therapies that address the underlying molecular basis of glaucomatous optic neuropathy might become available and further reduce the risk of glaucoma blindness.

Journal Article↗
PubMed1984

The short-term effect of laser trabeculoplasty on the glaucomatous visual field. A prospective study using computerized perimetry.

Several earlier studies have shown improvement of glaucomatous visual fields after pressure reduction achieved by acetazolamide or filtering surgery, while other studies have given conflicting results. In the present study laser trabeculoplasty was used to reduce the IOP in 42 eyes with glaucomatous visual field defects. Although good pressure reduction was achieved, no general regression of field defects was observed. The changes of the visual field were not correlated to the degree of pressure reduction. The results do not support the hypothesis that glaucomatous field defects are reversible when the IOP is reduced.

Adult↗
PubMed1992

Long-term results of anterior chamber tube shunt to an encircling band in the treatment of refractory glaucomas.

We performed the anterior chamber tube shunt to an encircling band procedure in 34 patients (36 eyes) with refractory glaucoma, and evaluated the long-term outcome. The preoperative mean intraocular pressure (IOP) was 36.8 +/- 9.6 mmHg, the postoperative mean IOP was 21.6 +/- 13.6 mmHg, a statistically significant (p < 0.01) reduction of IOP following this procedure. The final postoperative IOP was under 21 mmHg in 23 (63.9%) of the 36 eyes. The success rate of IOP control 36 months after the operation without any elevation of post-operative IOP was 30.3% (life-table method). Complications of this procedure included flattening of the anterior chamber (61.1%), damage to the corneal endothelium (25%), hyphema (25%), and a transient IOP elevation (25%). As filtering surgery with 5-fluorouracil is more effective and simple to perform, we conclude that the anterior chamber tube shunt to an encircling band procedure should be reserved for those with refractory glaucoma who have had multiple surgical interventions.

Adolescent↗
PubMed1993

The influence of age upon inflammatory cell counts and structure of conjunctiva in chronic open-angle glaucoma.

We evaluated the influence of age upon conjunctival structure and number of inflammatory cells by studying perioperative conjunctival biopsies from 54 consecutive primary open-angle glaucoma patients undergoing initial filtering surgery (trabeculectomy alone or combined cataract extraction and trabeculectomy). All patients had received chronic topical glaucoma therapy for > 1 year. We divided the patients into three age groups for analysis: 40-60 (n = 10), 61-74 (n = 28), and > 75 (n = 16) years. We found no statistical difference (p > 0.05, chi-square) in cell counts of neutrophils, eosinophils, mast cells, macrophages, fibroblasts, lymphocytes, plasma cells and goblet cells across the three age groups. In addition, no statistical differences were observed between age groups in vascular density, epithelial thickness as well as mucopolysaccharide and collagen composition (p > 0.05, chi square). This study suggests that conjunctival structure and inflammatory cell counts change little with advancing age in primary open-angle glaucoma patients.

Adult↗
PubMed2006

Intraocular pressure alterations following intravitreal triamcinolone acetonide.

AIMS: To determine the prevalence of intraocular pressure (IOP) alterations following intravitreal injection of triamcinolone acetonide (IVTA) and to assess possible risk factors of IOP elevation in eyes receiving single and/or repeat injections. METHODS: Retrospective, consecutive case series. 570 consecutive eyes of 536 patients who received a single IVTA injection (4 mg/0.1 ml) and a second set of 43 eyes of 40 patients who received a second injection. Retrospective review of all IVTA cases performed by three vitreoretinal surgeons over a 42 month period beginning in 2000. The main outcome measure was change in IOP defined as absolute value of IOP elevation (5 mm Hg or higher, 10 mm Hg or higher), and percentage of baseline (30% or higher increase from baseline IOP). RESULTS: Of the 528 eyes receiving single injections, 281 (53.2%) had an IOP elevation; 267 eyes (50.6%) experienced an elevation of IOP of at least 30%, and 245 (45.8%) and 75 (14.2%) eyes had an increase of 5 mm Hg or 10 mm Hg or more, respectively. Baseline IOP greater than 16 mm Hg is a risk factor for post-injection IOP elevation. Of the 43 eyes which received a second injection, 28 (65.1%) experienced an increase in IOP of at least 30% of baseline. Filtering surgery was required in five (0.094%) of the single and one (2.3%) of repeat injection eyes. CONCLUSIONS: Elevated IOP after IVTA is common and patients should be monitored beyond 6 months post-injection. Patients with a baseline IOP more than 16 mm Hg or receiving a second injection should be carefully monitored for an elevated IOP.

Adolescent↗
PubMed1988

Pharmacokinetics of a 5-fluorouracil liposomal delivery system.

A liposomal delivery system was developed in an attempt to prolong ocular levels of 5-fluorouracil for glaucoma filtering surgery. The pharmacokinetics of the 5-fluorouracil liposomal delivery system were studied in normal pigmented rabbits with 5-fluorouracil labelled with carbon-14 (C-14). 14C 5-fluorouracil was incorporated into the liposomes at a concentration of 10 g/l and injected subconjunctivally in doses of 5 and 10 mg. Concentrations of 5-fluorouracil were assayed at 10 time intervals from 0.5 to 96 hours in cornea, sclera, and conjunctiva and at six time intervals from 0.5 to 12 hours in aqueous. Two peak concentrations were noted at approximately one and eight hours, with measurable levels present at 96 hours. This study demonstrates the ability of this liposomal delivery system to prolong levels of 5-fluorouracial in normal pigmented rabbits.

Animals↗
PubMed1990

Glaucoma in patients with uveitis.

The records of 100 patients (161 eyes) with uveitis were reviewed retrospectively to determine the prevalence of increased intraocular pressure, the forms of uveitis most commonly associated with glaucoma, and the forms that require specific glaucoma therapy. Secondary glaucoma was present in 23 patients (31 eyes): three of 24 patients with acute uveitis (three eyes, 12% of acute uveitis patients) and 20 of 76 patients with chronic uveitis (28 eyes, 26% of chronic uveitis patients). Eighteen patients (26 eyes, 78% of glaucoma patients) with chronic uveitis required long-term medical therapy to control intraocular pressure. Three patients (three eyes, 12% of glaucoma patients) with acute uveitis required short-term therapy to control intraocular pressure. The remaining two patients had transient increases in intraocular pressure that did not require treatment or that responded to treatment of intraocular inflammation alone. One patient with chronic uveitis (two eyes, 4% of glaucoma patients) required filtering surgery. At least five patients (eight eyes, 22% of glaucoma patients) had glaucomatous visual field defects. The results of this survey are consistent with the concept that secondary glaucoma is a management problem in patients with anterior segment inflammation and chronic rather than acute uveitis. An algorithm for the management of increased intraocular pressure in patients with uveitis is proposed.

Acute Disease↗
PubMed1993

Post-traumatic angle recession glaucoma: a risk factor for bleb failure after trabeculectomy.

In order to determine if post-traumatic angle recession is a risk factor for failure of glaucoma filtering surgery independent of age or race, the surgical results of trabeculectomy performed in 35 consecutive patients with angle recession glaucoma were compared with those of 35 matched patients with primary open angle glaucoma. A postoperative intraocular pressure of < or = 21 mm Hg (with or without glaucoma medication) was found in 15 of the 35 (43%) patients with angle recession glaucoma compared with 26 of the 35 (74%) patients with primary open angle glaucoma. The long term success of trabeculectomy was significantly worse in angle recession glaucoma when the results were analysed using Kaplan-Meier survival curves. Bleb failure occurred a mean period of 3.1 (SD 1.2) months after trabeculectomy in angle recession glaucoma compared with 9.4 (5) months in primary open angle glaucoma (p < or = 0.001). The finding that posttraumatic angle recession is a risk factor for failure of trabeculectomy, supports the use of antimetabolite therapy to suppress fibrosis after trabeculectomy in these patients.

Adult↗
PubMed1998

Medium to long-term intraocular pressure control following small flap trabeculectomy (microtrabeculectomy) in relatively low risk eyes.

AIM: To determine the long-term efficacy of small flap trabeculectomy (microtrabeculectomy) in terms of intraocular pressure (IOP) control in relatively low risk eyes. METHOD: A review of a case series of small flap trabeculectomy procedures performed on 36 eyes from 36 patients with a minimum follow up of 24 months (mean 50.8). RESULTS: The mean (SD) intraocular pressures at presentation and preoperatively were 33.7 (7.5) and 24.6 (4.5) mm Hg. At 6 months, 1, 2, 3, 4, 5, and 6 years the mean (n, SD) IOPs (mm Hg) of those eyes followed to each time point were 11.9 (36, 4.6), 12.6 (36, 4.7), 13.2 (36, 4.6), 13.7 (29, 4.1), 13.2 (22, 4.0), 12.7 (15, 4.8), and 12.3 (8, 4.7) respectively. There was no significant difference in IOP levels at any of the analysis points by one way ANOVA. Kaplan-Meier analysis revealed survival rates of 80% at 4 years and 75% at 5 years when any postoperative IOP > 20 mm Hg is considered a failure, and 50% at 6 years when any IOP > 15 mm Hg is classed as a failure. CONCLUSION: Small flap trabeculectomy (microtrabeculectomy) is effective at reducing IOP in low risk glaucoma eyes with IOP control similar to previous reports of filtering surgery utilising larger scleral trapdoors.

Adult↗
PubMed2002

A new delivery system for 5-fluorouracil using prodrug and converting enzyme.

AIMS: To evaluate a new delivery system of 5-fluorouracil (5-FU) using 5-fluorocytosine (5-FC) as a prodrug and cytosine deaminase induced in vitro and in vivo. METHODS: Fibroblastic cells from rabbit Tenon's capsule were cultured. The cells were exposed to 5-FU and 5-FC with or without cytosine deaminase induced by recombinant adenovirus. In the in vitro study, cell proliferation and DNA synthesis were assessed by MTS, BrdU assay. The effect of 5-FC removal after the treatment of 5-FC and cytosine deaminase induction was also assayed. In the in vivo study cells with or without cytosine deaminase induction were transplanted into the subconjunctival space of mice, followed by eye drops of 1000 microg/ml of 5-FC three times a day. The mice were sacrificed at days 1, 5, and 10, then the cells transplanted were evaluated. RESULTS: Cell proliferation was inhibited by exposure to 5-FU in a dose dependent manner; however, up to 1000 microg/ml of 5-FC did not affect cell proliferation. Cell proliferation was inhibited by exposure to 5-FC in a time dependent manner with induction of cytosine deaminase following infection of recombinant adenovirus. When 5-FC was removed 3 or 6 days after the treatment, the cells grew again. The effect was reproduced in the in vivo model of subconjunctival cellular proliferation although 5-FC was administrated as eye drops. There were no cases with corneal erosion. CONCLUSION: Cell proliferation was inhibited by co-exposure of 5-FC and cytosine deaminase. This new delivery system may merit controlled delivery of 5-FU after filtering surgery.

Animals↗
PubMed2003

Mycophenolate mofetil inhibits human Tenon fibroblast proliferation by guanosine depletion.

BACKGROUND/AIM: Mycophenolate mofetil could be a useful antiproliferative drug in glaucoma filtering surgery. In this study the authors set out to investigate whether growth inhibition of mycophenolate mofetil on human Tenon fibroblasts is mediated by guanosine depletion. METHODS: Cultured human Tenon fibroblasts were incubated in various concentrations of mycophenolate mofetil with and without supplementation of guanosine. RESULTS: Growth inhibition was concentration dependent. The effect could be completely antagonised by guanosine supplement. CONCLUSION: Human Tenon fibroblasts depend on the de novo synthesis pathway of guanosine. No sufficient salvage pathway from purine degradation appears to exist.

Cell Division↗
PubMed2003

Retinectomy for treatment of intractable glaucoma: long term results.

AIM: To report long term efficacy and complications of retinectomy as an intraocular pressure lowering procedure for intractable glaucoma. METHODS: This was a consecutive interventional case series. In 44 consecutive eyes (39 patients, 22 men and 17 women) retinectomy was performed to lower the intraocular pressure (IOP) in patients with uncontrolled IOP (>35 mm Hg for more than 4 months) despite conventional filtering surgery and drug treatment. Pars plana vitrectomy was performed and the peripheral retina was surgically excised to various degrees. The procedure was concluded by an intraocular gas tamponade of 20% C(3)F(8). Included were patients with neovascular glaucoma (12 eyes), infantile and juvenile glaucoma (three eyes), secondary glaucoma due to aphakia (13 eyes), severe ocular trauma (seven eyes), uveitis (seven eyes), and glaucoma in Ehlers-Danlos syndrome (two). RESULTS: All patients underwent successful surgical retinectomy. All patients were followed for 5 years. Mean postoperative IOP after 4 years was 15.7 (SD 9.4) mm Hg, representing a decrease of IOP by 61% compared to the preoperative level (41.2 (9.4) mm Hg). In 52.3% of eyes long term regulation of IOP could be achieved without complications. Retinectomy was least effective in neovascular glaucoma because of central retinal vein occlusion (CRVO). Eyes with glaucoma secondary to uveitis showed a tendency towards low IOP levels with subsequent phthisis bulbi. The initial visual acuity of all patients was lower than 20/50 (mean 1.8 (0.8) logMAR) in the treated eye. Final visual acuity was 2.3 (0.6) logMAR. 21 out of 44 cases developed retinal complications (retinal detachment or proliferative vitreoretinopathy (PVR)) after surgery, requiring silicone tamponade in 11 eyes (52%) either for persistent low IOP or for PVR. Nine eyes developed phthisis, seven of which were enucleated during the follow up. CONCLUSIONS: Long term results after retinectomy demonstrate its efficacy in otherwise intractable glaucoma. Efficacy and safety of retinectomy are dependent on the underlying disease.

Adult↗
PubMed1997

Signal averaged P wave compared with standard electrocardiography or echocardiography for prediction of atrial fibrillation after coronary bypass grafting.

OBJECTIVE: To define the clinical value of the signal averaged P wave (SAPW) and to compare it with the standard electrocardiogram (ECG), echocardiogram, and clinical assessment for the prediction of atrial fibrillation after coronary bypass grafting (CABG). DESIGN: Prospective validation cohort study. SETTING: Regional cardiothoracic centre. PATIENTS: 201 unselected patients undergoing first elective CABG were recruited over six months. Patients requiring concomitant valve surgery were excluded. MAIN OUTCOME MEASURES: Age, sex, cardiothoracic ratio, and cardioactive drugs were noted. P wave specific SAPW recordings, ECG, and M mode echocardiograms from which left atrial diameter was measured were performed within 24 hours of surgery. Filtered P wave duration (SAPWD), spatial velocity, and energy were calculated from the SAPW. From the ECG, lead II P wave duration, P terminal force in lead V1, total P wave duration, and isoelectric interval were measured. Patients had Holter monitoring for 48 hours postoperatively and daily ECGs until discharge. RESULTS: Two patients died (1%) and 10 were unsuitable for analysis (5%). Of the remaining 189, 51 (27%) had atrial fibrillation (AF) lasting > 1 hour at a mean of 2 (0.5 to 7) days after CABG. Of the variables examined, only SAPWD (AF group 148 (SD 12), v 142 (14) ms, P = 0.008) and male sex (AF group 96%, v 78%, P < 0.01) were significantly different. A prospectively defined SAPWD of > 141 ms predicted atrial fibrillation with positive and negative predictive accuracies of 34% and 83%. Logistic regression analysis identified both male sex and SAPWD as significant independent predictors of postoperative atrial fibrillation. CONCLUSIONS: Signal averaged P wave duration was a better predictor of atrial fibrillation after coronary bypass grafting than standard electrocardiographic or echocardiographic criteria. The predictive value of this test is such that it is likely to be useful in the design of prospective trials of prophylactic antiarrhythmic treatment but is of limited use using current techniques in the clinical management of individual patients.

Atrial Fibrillation↗
PubMed1998

Phacotrabeculectomy with a small-optic PMMA implant: two-year functional and morphological results.

PURPOSE: Previous studies have documented good pressure control with combined cataract and filtering surgery. However, relatively high incidences of iridocapsular synechiae (ICS) and cell precipitates on the optic (CPO) were found. Corneal valve incisions preclude intraoperative chamber flattening and iris injury or prolapse. Rigid one-piece PMMA lenses with a small optic maintain a pronounced optic-iris clearance. In a prospective series, the effect of this approach was studied with special regard to the morphological results. METHODS: A temporary corneal lip was created in the clear cornea beneath the scleral flap to serve as a temporary valve during cataract extraction. The lip was then widened and a rigid one-piece 5-mm PMMA lens implanted. Lip and trabeculum were finally excised en bloc at a width of 3 mm. Two years' functional and morphological results were evaluated. RESULTS: Fifty-four eyes were available for evaluation. After the mean follow-up of 21 months, mean IOP had dropped from 21.6+/-3 mm Hg preoperatively to 13.9+/-2.4 mm Hg, with a mean pressure reduction of 7.7+/-3.4 mm Hg. IOP was 18 mm Hg or less in all cases. The mean medication index dropped from 2.7 to 1.0. Eyes with a preoperative IOP of 21 mm Hg or more showed a significantly greater IOP reduction than eyes with an IOP of 20 mm Hg or less (-9.2+/-3.0 vs. -6.1+/-2.9 mm Hg, p = 0.0003). Intraoperatively, the temporary valve effectively prevented chamber flattening and iris injury or prolapse. Postoperatively, 9 eyes or 6% showed hyphemas, 1 undergoing lavage. Two eyes developed a capsular hematoma, 1 requiring YAG capsulotomy. Ten eyes or 19% developed mild and 2 eyes severe but transient fibrin exudation following hypotony or iridoplasty. One eye showed grade I anterior chamber flattening, 1 developed a ciliolenticular block requiring surgery. Postoperative pressure spikes of 30-35 mm Hg were noted in 4 eyes. Three eyes showed prolonged hypotony associated with transient choroidal effusion. A pronounced optic-iris clearance was found in 87% of the eyes. Iris-optic touch developed in 1 eye with prolonged postoperative anterior chamber flattening and in 3 of the 4 eyes that had undergone intraoperative iridoplasty. Three of the latter developed extensive ICS followed by CPO. The mean optic-iris distance was 1.2 mm and the anterior chamber depth 4.2 mm. CONCLUSION: Apart from effectively lowering IOP, the surgical approach used significantly reduced the incidence of ICS and CPO.

Anterior Eye Segment↗
PubMed1999

Three types of retinal bleeding as a complication of hypotony after trabeculectomy.

Although small retinal bleeding has been evaluated as a complication of filtering surgery, long-standing retinal bleeding is rare. We report 3 rare cases of young patients with massive retinal hemorrhages following trabeculectomy with 5-fluorouracil or mitomycin C. The bleeding in 1 case resolved spontaneously, whereas the bleeding in the other 2 cases did not resolve and the visual acuity remained poor. Every patient showed markedly delayed retinal circulation. Possible dysfunction of the retinal blood vessels may be responsible for the development of the other two types of massive bleeding, especially in advanced glaucoma with a total cup disk: one is decompression retinopathy and another central retinal vein occlusion or hemorrhagic retinopathy.

Adolescent↗
PubMedDate not supplied

Trabeculectomy with and without mitomycin-C in a black African population.

PURPOSE: To evaluate the beneficial effects of intraoperative application of mitomycin-C during trabeculectomy in a black African population in Congo-Kinshasa. METHODS: A prospective randomized study in 22 eyes (11 patients) with open-angle glaucoma. All patients underwent trabeculectomy with application of mitomycin-C (0.4 mg/ml for 2.5 min) under the scleral flap in the right eye and trabeculectomy alone in the left eye. Assessment of the clinical outcome included intraocular pressure, visual acuity, visual field and complications. The follow-up was 20 months. Success of the filtering surgery was defined as a final IOP of 21 mmHg or lower without antiglaucoma medications and no further glaucoma surgery necessary. RESULTS: The success rate of trabeculectomy was 81.8% in eyes treated with mitomycin-C compared with 63.6% in eyes not receiving this drug. Rates of intraocular pressure reduction were 57.9% and 42.9% respectively. Complications occured in 36.3% of the eyes managed with mitomycin-C against 9% in the control eyes. CONCLUSIONS: Mitomycin-C, as adjunctive treatment during trabeculectomy in black Africans, offers great benefit in lowering IOP, but with a substantial high risk of complications. These data need to be confirmed by further studies in this population.

Adult↗
PubMedDate not supplied

Effects of latanoprost and GLC756, a novel dopamine D2 agonist and D1 antagonist, on cultured normal human dermal fibroblasts.

PURPOSE: Proliferation of subconjunctival fibroblasts plays a critical role in scarring and failure of glaucoma filtering surgery. Long-term topical glaucoma medications appear to increase fibroblast proliferation. In this study, the effects of topical antiglaucoma drugs latanoprost and GLC756, a novel dopamine D2 agonist and D1 antagonist, on cultured normal human dermal fibroblasts (NHDF) were examined. METHODS: The NHDF cell line was incubated with latanoprost, prostaglandin F2alpha (PGF2alpha), GLC756, or 5-fluorouracil as a positive control at concentrations of 3 and 30 microM for 6, 18, and 24 hours. Fibroblast growth was measured by 5-bromodeoxyuridine (BrdU) uptake using laser scanning cytometry. RESULTS: Latanoprost and PGF2alpha had a biphasic response on the number of cultured NHDF positively stained with BrdU. A stimulating effect on proliferation occurred early, 6 hours after incubation, and an inhibitory effect 18 to 24 hours after incubation. GLC756, in contrast, revealed only inhibitory effects on BrdU uptake 18 to 24 hours after incubation. The pattern of GLC756 was similar to that of the positive control 5-fluorouracil. CONCLUSIONS: Latanoprost seemed to have a biphasic response on the proliferation of cultured NHDF. First there was a stimulating thereafter a secondary negative modulating effect. GLC756 had a fully antiproliferative effect on the NHDF, indicating an additional potential of novel dopamine compounds for topical glaucoma medication.

Antihypertensive Agents↗