Risk factors for failure of 5-fluorouracil needling revision for failed conjunctival filtration blebs

PURPOSE

To investigate the risk factors for failure of 5-fluorouracil (5-FU) needling revision, a useful procedure for restoring a failed filtration bleb.

DESIGN

Interventional case series.

METHODS

Retrospectively conducted study.

SETTING

Institutional.

STUDY POPULATION

Sixty-four eyes of 64 consecutive glaucoma patients that underwent 5-FU needling revisions for failed filtering bleb following either trabeculectomy or phaco-trabeculectomy with or without adjunctive mitomycin C (MMC).

OBSERVATION PROCEDURES

Goldmann applanation tonometry, Kaplan-Meier survival analysis, and Cox proportional hazards regression analysis.

MAIN OUTCOME MEASURES

Successful outcome of the initial 5-FU needling revision, arbitrarily defined as target intraocular pressure (IOP) control with not more than two topical glaucoma medications and no additional 5-FU needling or other surgical procedures, was analyzed by Kaplan-Meier survival analysis, and risk factors for failure of the initial 5-FU needling revision were analyzed by Cox proportional hazards regression analysis.

RESULTS

The cumulative success rate of the initial 5-FU needling revision was 45% at 1 year, 33% at 2 years, and 28% at 4 years. Failure of the initial 5-FU revision correlated significantly with preneedling IOP > 30 mm Hg (P =.0003), lack of MMC use during the previous filtration surgery (P =.013), and IOP >10 mm Hg immediately following needling revision (P =.0012) according to Cox's proportional hazards regression analysis.

CONCLUSIONS

Pre-needling IOP > 30 mm Hg, lack of MMC use during the previous filtration surgery, and IOP > 10 mm Hg immediately after needling were found to be significant risk factors for failure of the initial 5-FU needling procedure. Therefore, it is important to monitor IOP closely following needling revision in those patients with such risk factors. They are more likely to require additional therapeutic interventions, including repeat needling revisions.

Transscleral suture fixation of posterior chamber lenses combined with trabeculectomy

OBJECTIVE

To evaluate the outcome of transscleral suture-fixated posterior chamber intraocular lens (PCIOL) implantation in glaucoma patients when combined with a trabeculectomy.

DESIGN

A retrospective study of 56 consecutive glaucoma patients with a minimum follow-up of 6 months after transscleral suture-fixated PCIOL implantation combined with trabeculectomy.

SETTING

Patients were drawn from the clinical glaucoma practice of the Kresge Eye Institute, Detroit, MICHIGAN:

PATIENTS

Fifty-six eyes of 56 consecutive chronic glaucoma patients who had undergone transscleral suture-fixated PCIOL implantation in combination with a trabeculectomy were included in the analysis.

RESULTS

The mean follow-up time was 38.5 +/- 19.1 months. Mean intraocular pressure (IOP) was significantly reduced, from 22.9 +/- 10.9 mmHg before surgery to 16.7 +/- 6.7 mmHg at the last follow-up visit (P = 0.0005), with the mean number of medications used also significantly decreased, from 2.3 +/- 0.9 to 1.9 +/- 0.9 (P = 0.0002). Postoperative IOP control to 21 mmHg or less was achieved or maintained in 84% of patients. Visual acuity improved or remained stable within two Snellen lines of the preoperative level in 39 eyes (70%) and within three Snellen lines in 45 eyes (80%) at the last follow-up visit. Overall, 46% to 68% of the patients had both stable visual acuity and satisfactory pressure control at the last postoperative visit, depending on criteria of varying stringency. However, 19 eyes (34%) required one or more additional surgical interventions for pressure control. Patients with anterior chamber intraocular lens (ACIOL) complications, diabetes mellitus, or a preoperative IOP level of more than 21 mmHg on maximum tolerated medications were especially prone to requiring additional surgical interventions.

CONCLUSIONS

We conclude that transscleral suture-fixated PCIOL implantation can be combined successfully with a trabeculectomy and can be useful in glaucoma patients in need of both visual rehabilitation and IOP control. However, patients with ACIOL complications, diabetes, or preoperative IOP of more than 21 mmHg on maximum tolerated medications were prone to requiring additional surgical interventions.

Histopathologic study of presumed parafoveal telangiectasis

PURPOSE

To report the postmortem histopathologic features that closely resemble the clinical features of parafoveal telangiectasis.

METHODS

Light and electron microscopy.

RESULTS

Histopathologic features included macular edema; telangiectatic vessels; retinal, subretinal, and superficial retinal neovascularization; retinal pigment epithelial hyperplasia around neovascular aggregates; retinal-choroidal vascular anastomosis; and superficial pigmented cells with lipofuscin.

CONCLUSION

The postmortem histopathologic findings in a 36-year-old woman with Down syndrome and other systemic conditions correlate with features noted in previous reports of presumed parafoveal telangiectasis.

The herpes simplex virus type 1 ribonucleotide reductase is required for acute retinal disease

We have used a herpes simplex virus type 1 (HSV-1) ribonucleotide reductase (RR) null mutant (ICP6 delta) to determine if the HSV-1 RR is required for acute retinal disease. Injection of the ICP6 delta mutant into the vitreous induced mild transient signs of infection (vitreal infiltrate, retinal inflammation, and changes in retinal cytology). In contrast, the parental KOS and a revertant virus (ICP6 delta + 3.1) in which the RR gene had been restored, caused severe retinitis. Injection of media alone also induced mild transient signs of disease. Two months after infection, ICP6 delta injected eyes could not be distinguished from normal eyes. Repeated injection of ICP6 delta (3 times, 2 weeks apart) resulted in vitreal infiltrate near the site of injection but the retina did not appear damaged. The mutant, ICP6 delta, grew to peak titers 1 x 10(3) to 1 x 10(5)-fold lower and cleared faster than KOS or ICP6 delta + 3.1 in the injected eyes suggesting that the reduced virulence was due to reduced ability of the virus to grow. These results show that the viral RR is required for acute retinal disease.

Frequency of ocular metastases in patients dying of cancer in eye bank populations

AIMS

To examine the frequency of intraocular metastases in patients who had died of cancer, in an eye bank and necropsy population sample.

METHODS

The first group included 302 cancer cases received from the Wisconsin Eye Bank between 1988 and 1993. In the second group, ocular pathology records at the Wilmer Institute from 1976 to 1980 were analysed for ocular metastases in necropsy subjects dying of cancer. Nonocular cancer was the cause of death in 741 cases; among these, 510 were attributed to carcinomas.

RESULTS

In the Wisconsin Eye Bank group, three cases (1%) had gross metastases. Out of 255 carcinoma cases, one (0.4%) had gross metastases. In the Wilmer Institute group, gross metastases were observed in 35 (4.7%) cases. Of the 510 patients dying of carcinomas, six (1.2%) had macroscopic metastases. Ocular metastases were detected histopathologically in 93 of 741 (12.6%) of cases.

CONCLUSION

Even though it is difficult to assess the true frequency of ocular metastases in patients dying of cancer, the answer to this question was attempted by determining the frequency of ocular metastasis in patients who died of cancer and who donated their eyes to the Wisconsin Eye Bank or had postmortem examination at the Johns Hopkins Hospital. Microscopic metastases were found in 12.6% of cases. The frequency of gross metastases has decreased over the past 12 years from 4.7% to 1% (p value = 0.005) owing to improved treatment of leukaemia; however, the frequency of macroscopic metastases due to carcinomas has not changed (p value = 0.38).