The choice of surgical procedure in congenital, infantile, and juvenile glaucoma

Trabeculotomy is successful in patients with an angle anomaly involving only the trabecular meshwork, but in those involving the trabecular meshwork with iris and/or cornea trabeculotomy combined with trabeculectomy is recommended. In cases of failed trabeculotomy or trabeculectomy, a Molteno implant can be tried, although it does not work well in patients with congenital glaucoma. If all else fails, a cyclodestructive procedure is indicated and contact Nd:YAG laser cyclophotocoagulation is recommended.

Trabeculectomy for glaucoma associated with Sturge-Weber syndrome

We reviewed the results of trabeculectomy performed in six patients (seven eyes) with glaucoma associated with the Sturge-Weber syndrome. After follow-up periods ranging from 9 months to 9 years, intraocular pressure control was adequate in two eyes without the use of antiglaucoma medication; control was good in four eyes with mild medication. One eye required three trabeculectomies and postoperative medication to achieve control. There was no further deterioration of visual acuity or of the optic nerve in any of the eyes.

Long-term follow up of clear cornea trabeculectomy

We evaluated the long-term results of Cairns' clear cornea "trabeculectomy" performed on the Glaucoma Service of the Wills Eye Hospital in six patients with serious glaucoma. Although postoperative pressures initially were lower in all six, these lower pressures were not maintained. Pressure in three of the patients finally was controlled only after instituting medical treatment, including carbonic anhydrase inhibitors in two. The operation failed in the other three, two of whom underwent further surgeries. We conclude that Cairns' clear cornea trabeculectomy, in itself, is not adequate to control intraocular pressure in cases of serious glaucoma.

[Practical value of preventive posterior sclerectomy in trabeculectomy]

The results of prophylactic posterior sclerectomy, carried out to prevent ciliochoroid detachment in antiglaucoma fistulization surgery (trabeculectomy in various modifications) are analyzed. A total of 293 patients (303 eyes) were under study. In 51.8 percent of cases (157 eyes) trabeculectomy was combined with prophylactic sclerectomy, carried out both in the upper (121 eyes) and lower (36 eyes) segments of the eye. The results evidence that prophylactic posterior sclerectomy promoted a 2.3 times reduction (from 28.1 to 12.1 percent) in the incidence of ciliochoroid detachments; the site of this operation (upper of lower segment of the eye) was of no essential importance. The authors recommend prophylactic posterior sclerectomy as an effective method for prevention of ciliochoroid detachment.

[Argon laser trabeculoplasty. Methods, results and complications]

In a group of 121 eyes the author compared three methods of argon laser trabeculoplasty (ALT). Using the method of 360 degrees ALT 1.0 W 30 eyes were treated, using the method 180 degrees ALT 1.0 W 60 eyes and by the method of 180 degrees ALT 0.5 W 31 eyes. After a mean observation period of 11.5 +/- 3.6 months compensation was achieved in 81% and there were no significant differences between different methods. Improved efflux was most marked (by 100%) in method 180 degrees ALT 0.5 W where also the incidence of complications was significantly lower, as compared with the other two methods (P less than 0.01) and the postoperative course was practically without risk.

[Fistulizing reoperations in open-angle glaucoma]

The authors analyze the results of repeated fistulization surgery (traditional trabeculectomy and that combined with resection of the episclera, and valvular trabeculectomy) in 40 patients (41 eyes) with primary open-angle glaucoma. A follow-up of 6 mos to 4 yrs has shown normalization of the ophthalmic tone in 90.2% of cases, in 65.8% of these this was achieved without drugs. Vision acuity remained unchanged or improved in 58.5% of cases, visual field was preserved or improved in 80.5% of patients. These results have lead the authors to a conclusion that a stable hypotensive effect can be achieved if repeated fistulization is performed outside the site of the primary intervention. If repeated trabeculectomy has to be performed at the site of the primary intervention, it is recommended to be combined with resection of the episclera, this improving the reliability of the hypotensive effect of surgery.

[The late results of a trabeculoretraction operation]

A comprehensive analysis is made of immediate and late results of trabeculoretraction, a new pathogenetically oriented antiglaucoma surgical technique suggested by B. N. Alekseev. This operation was carried out in 178 eyes (123 patients) with various forms and stages of glaucoma; the follow-up periods were up to 5 years. Compensation of the hydrodynamics was achieved immediately after surgery in all the patients and it persisted in late periods in 98% of cases. Vision acuity and visual field improved or remained unchanged in 87% of cases. High efficacy of trabeculoretraction and no complications, that is characteristic of fistulization operations, recommend this technique for wide use in various stages of glaucoma, including the initial one.

The immediate pressure response to primary laser trabeculoplasty--a comparison of one- and two-stage treatment

The immediate pressure response to primary LTP was studied prospectively in 40 eyes randomised to one- and two-stage treatment in 360 degrees of the trabecular meshwork. There were 26 eyes with glaucoma capsulare and 14 with glaucoma simplex. Mean prelaser IOP was 32.8 mmHg in the former, and 35.5 mmHg in the latter group. The frequency and magnitude of postlaser pressure increase were the same in both groups when taking into consideration the pressure spikes in both 180 degrees sessions. The pressure increase was higher than in earlier reports on LTP in presurgical glaucoma patients on maximum medication. Almost all IOP elevations appeared during the first 2 h following laser treatment. The results were the same in both groups 6 months after LTP.

Neodymium-YAG laser goniotomy vs surgical goniotomy. A preliminary study in paired eyes

Goniotomy and trabeculotomy are two widely accepted modalities of treatment for primary congenital/infantile glaucoma. Both procedures may be associated with complications. We treated 10 patients with bilateral, symmetrical congenital/infantile glaucoma and clear corneas. One eye of each patient underwent surgical goniotomy under general anesthesia, and the other was treated by neodymium-YAG laser goniotomy under oral chloral hydrate sedation (average energy, 76.6 mJ). Mean pretreatment intraocular pressure in the surgical goniotomy group was 28.4 mm Hg and in the laser goniotomy group it was 29.5 mm Hg, decreasing to 23.6 and 23.1 mm Hg, respectively, following treatment. There was a strong positive correlation (r = .81) between the percent of intraocular pressure change after laser treatment (mean, -14.4%) and that after surgery (mean, -14.3%). Our preliminary results indicate that neodymium-YAG laser goniotomy is an effective, noninvasive alternative to surgical goniotomy.

[5-Fluorouracil in trabeculectomy: preliminary report]

Subconjunctival 5-FU injections were used as an adjunctive therapy in trabeculectomy for high risk glaucoma patients. We injected 5 mg once a day for five to seven days as a routine treatment. For the first 10 eyes, the injections were started immediately after the operation. However, for the remaining 9 eyes, the injections began 24 to 48 hours postoperative. If the appearance of the bleb was not prominent or enriched in vascularity, the duration of the injections should be extended to 10 to 14 days. At least 8 months of follow-up were available for 19 eyes, including aphakic glaucoma, 8 eyes; neovascular glaucoma, 2 eyes; previous failed filter, 6 eyes; total collapse of the anterior chamber with leucoma adherence, 1 eye; glaucoma due to mesodermal dysgenesis, 1 eye; and juvenile glaucoma, 1 eye (whose fellow eye had received twice failed filtering procedures). The results revealed a success rate of 79% (intraocular pressure below 22mmHg with or without topical medication). The success rate for aphakic glaucoma was 63% (5/8), for neovascular glaucoma 100% (2/2) and for the failed filters 83% (5/6). We also presume that 5-FU injections would be effective in the treatment of to abnormally marked fibrous proliferations caused by age factors. The complications related to the use of 5-FU include corneal epithelial defect 4/9 (21%), conjunctival leak 3/9 (16%), subconjunctival hematoma 1/19 (5%), and conjunctival sterile ulcer 1/19 (5%).

[The effect of the method for forming the conjunctival flap in glaucoma fistulizing operations on the development of a stable acquired ptosis of the upper eyelid]

The relationship between the incidence rate and severity of acquired ptosis and the technique of the conjunctival flap formation in trabeculectomy were under study. A total of 117 patients were followed up. In 70 the flap was formed by the traditional method, with the foot to the limbus, and in 47 by the nontraditional technique, with the foot to the vault and radially. Stubborn (a follow-up of more than 6 mos postoperation) acquired ptosis of the upper eyelid was observed in 38.5% of patients; it was more often after the traditional technique of the conjunctival flap formation (48.6%) and rare and approximately to the same extent when nontraditional methods were used (23.4%). The incidence rate and severity of ptosis increase as the height of the incision on the conjunctiva (from the limbus), made by the traditional technique of the flap formation, grows. A more frequent development of ptosis after traditional formation of the conjunctival flap vs. the nontraditional techniques may be explained by injuries to the individual branches of the oculomotor nerve, participating in the innervation of the posterior peduncle of the levator muscle of the upper eyelid.

Combined extracapsular cataract extraction and trabeculectomy using a separated corneal section

A retrospective study of 35 cases of extracapsular cataract extraction with posterior chamber lens implant combined with trabeculectomy was undertaken. The cataract extractions were performed through a corneal section to separate the cataract wound from the trabeculectomy. Control of intraocular pressure was achieved without medication in 77% of cases. Median improvement in visual acuity was 3.5 lines at one year. This technique provided improved trabeculectomy drainage compared with previous reports for corneoscleral incisions. Improvement in visual acuity was poorer for a group of patients with severe preoperative field loss.

The Glaucoma Laser Trial. I. Acute effects of argon laser trabeculoplasty on intraocular pressure. Glaucoma Laser Trial Research Group

The Glaucoma Laser Trial Research Group has examined the acute effects of argon laser trabeculoplasty on immediate change in intraocular pressure and the formation of peripheral anterior synechiae among the 271 eyes assigned to argon laser trabeculoplasty as initial treatment for primary open angle glaucoma. Argon laser trabeculoplasty was administered in two sessions. Intraocular pressure rises of greater than 5 mm Hg occurred in 34% of eyes after one or both of the treatment sessions; intraocular pressure rises of greater than 10 mm Hg occurred in 12%. Eyes that had an intraocular pressure rise after the first session were more likely to have a rise after the second session than eyes with no rise after the first session. Among the many patient, eye, and treatment characteristics examined, only pigmentation of the trabecular meshwork was strongly associated with intraocular pressure rises. Forty-six percent of eyes developed greater than or equal to 1 degree of peripheral anterior synechiae. Brown iris color and posterior placement of laser burns were associated with higher rates of peripheral anterior synechiae formation.

[Trabeculectomy preceded by retinal panphotocoagulation in the treatment of secondary glaucoma with rubeosis iridis]

Fifteen patients with bilateral secondary glaucoma caused by rubeosis iridis in the course of diabetes were operated; one eye was subjected to a simple trabeculectomy, the fellow-eye to filtrating trabeculectomy by Nesterow's method; antiglaucomatous operations were preceded by a panretinal photocoagulation. After at least 3 years of observation the more stable reduction of the IOP was shown after filtering trabeculectomy.

[Trabeculectomy with intrascleral drainage]

The author describes a personal variant of the classic trabeculectomy that ensures a higher efficiency, in time, in the surgical cure of the decompensated glaucomas.

[Laser trabeculoplasty in open-angle glaucoma. Personal experience]

Twenty one patients (26 eyes) who were subjected to laser trabeculoplasty in the 360 degrees range were observed. Normalization of the intraocular pressure was obtained in 76.9 p.c. of cases. The outflow coefficient (C) increased after trabeculoplasty in 57.6 p.c. of cases. The analysis of results suggests that the trabeculoplasty surgery is less effective in young persons below 40 years of age and in cases with a very low outflow coefficient.

The effects of different energy levels in argon laser trabeculoplasty

In a retrospective survey of 143 eyes of 143 patients with chronic open-angle glaucoma, 0.2 second argon laser trabeculoplasty was found to produce a greater decrease in intra-ocular pressure, especially at higher initial values, and was associated with a reduction in the medications used. In addition, fewer patients required further intervention (repeat trabeculoplasty or drainage surgery) compared with those undergoing 0.1 second trabeculoplasty. This effect may have occurred because of the difference in the mean energy delivered between the two groups, which arose chiefly as a result of the duration employed.

Laser trabeculoplasty in glaucoma. Ten-year evaluation

Argon laser trabeculoplasty was evaluated in 134 eyes of 94 patients with glaucoma, over a follow-up period of three to ten years. Success was defined by the patient having intraocular pressures (IOPs) below 20 mm Hg under the prelaser medical regimen, or taking less medication, and having no evidence of progressive field loss. The overall success rate by three years was 70%; it decreased to 55% after six years and remained at this level thereafter. Altogether, there were 26 eyes that had controlled glaucoma for six to ten years. The favorable factors for success were age over 60 years (82%), pseudoexfoliation glaucoma (75%), and lower baseline IOPs (69.3%). Argon laser trabeculoplasty was found to be a useful means of treatment in low tension glaucoma.