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Objective: To provide an evidence-based summary of commercially available aqueous shunts currently used in substantial numbers (Ahmed [New World Medical, Inc., Rancho Cucamonga, CA], Baerveldt [Advanced Medical Optics, Inc., Santa Ana, CA], Krupin [Eagle Vision, Inc, Memphis, TN], Molteno [Molteno Ophthalmic Ltd., Dunedin, New Zealand]) to control intraocular pressure (IOP) in various glaucomas., Methods: Seventeen previously published randomized trials, 1 prospective nonrandomized comparative trial, 1 retrospective case-control study, 2 comprehensive literature reviews, and published English language, noncomparative case series and case reports were reviewed and graded for methodologic quality., Results: Aqueous shunts are used primarily after failure of medical, laser, and conventional filtering surgery to treat glaucoma and have been successful in controlling IOP in a variety of glaucomas. The principal long-term complication of anterior chamber tubes is corneal endothelial failure. The most shunt-specific delayed complication is erosion of the tube through overlying conjunctiva. There is a low incidence of this occurring with all shunts currently available, and it occurs most frequently within a few millimeters of the corneoscleral junction after anterior chamber insertion. Erosion of the equatorial plate through the conjunctival surface occurs less frequently. Clinical failure of the various devices over time occurs at a rate of approximately 10% per year, which is approximately the same as the failure rate for trabeculectomy., Conclusions: Based on level I evidence, aqueous shunts seem to have benefits (IOP control, duration of benefit) comparable with those of trabeculectomy in the management of complex glaucomas (phakic or pseudophakic eyes after prior failed trabeculectomies). Level I evidence indicates that there are no advantages to the adjunctive use of antifibrotic agents or systemic corticosteroids with currently available shunts. Too few high-quality direct comparisons of various available shunts have been published to assess the relative efficacy or complication rates of specific devices beyond the implication that larger-surface-area explants provide more enduring and better IOP control. Long-term follow-up and comparative studies are encouraged. more...

Objective: To evaluate the current published literature on the use of optic nerve head (ONH) and retinal nerve fiber layer (RNFL) measurement devices in diagnosing open-angle glaucoma and detecting progression., Methods: A search of peer-reviewed literature was conducted on February 15, 2006 in PubMed and the Cochrane Library for the period January 2003 to February 2006. The search was limited to studies of adults in English-language journals and yielded 442 citations. The panel reviewed the abstracts of these articles and selected 159 articles of possible clinical relevance for review. Of these 159 full-text articles, 82 were determined to be relevant for the first author and methodologist to review and rate according to the quality of evidence., Results: There were no studies classified as having the highest level of evidence (level I). The ONH and RNFL imaging instruments reviewed in this assessment were determined to be highly effective in distinguishing eyes with glaucomatous visual field (VF) loss from normal eyes without VF loss, based on level II evidence. In addition, some studies demonstrated that parameters from ONH or RNFL imaging predicted the development of VF defects among glaucoma suspects. Studies on detecting glaucoma progression showed that although there was often agreement on progression between the structural and functional (VF) tests, a significant proportion of glaucoma patients progressed by either the structural or the functional test alone., Conclusions: The ONH and RNFL imaging devices provide quantitative information for the clinician. Based on studies that have compared the various available technologies directly, there is no single imaging device that outperforms the others in distinguishing patients with glaucoma from controls. Ongoing advances in imaging and related software, as well as the impracticalities associated with obtaining and assessing optic nerve stereophotographs, have made imaging increasingly important in many practice settings. The information obtained from imaging devices is useful in clinical practice when analyzed in conjunction with other relevant parameters that define glaucoma diagnosis and progression. more...

Objective: To evaluate published literature to assess whether central corneal thickness (CCT) is a risk factor for the presence, development, or progression of glaucomatous optic nerve damage related to primary open-angle glaucoma (POAG)., Methods: A PubMed literature search limited to English language articles conducted on November 15, 2004 retrieved 195 articles. The authors reviewed these abstracts and selected 57 to review in full text to determine relevance to the assessment questions. A further 24 studies of interest were identified from periodic updates to the literature search, surveillance of the literature, and reference lists of reviewed articles. From the 81 published reports identified, the first author applied specified selection criteria that yielded 37 articles for methodological review because of relevance to the assessment questions. The articles were rated according to the strength of evidence by the panel methodologist. A level I rating was assigned to well-designed properly conducted randomized clinical trials or similar quality-validated cohort studies with appropriate reference standards. A level II rating was assigned to well-designed case-control studies, exploratory cohort studies, and other nonrandomized clinical studies lacking consistently applied reference standards. A level III rating was reserved for poorly designed case-control studies, case series, and papers consisting only of expert opinion without supporting evidence. In addition, each study was graded as positive if it supported a statistical association of CCT with the risk of having or developing glaucomatous optic nerve damage or as negative if no such association was found., Results: There is strong and consistent level I and level II evidence that CCT is a risk factor for progression from ocular hypertension to POAG. Studies that were rated as providing the highest quality of evidence revealed mixed results with respect to glaucoma prevalence. One population-based study (level II) showed a positive association, another larger study (level I) revealed an association of marginal significance, and 3 studies (all level I) found no association of CCT with POAG prevalence., Conclusions: There is strong evidence that measuring CCT is an important component of a complete ocular examination, particularly for patients being evaluated for the risk of developing POAG. Therefore, CCT measurement should be included in the examination of all patients with ocular hypertension. Although the evidence supporting the necessity of measuring CCT as part of screening for POAG or as a risk factor for glaucoma progression is not as strong, intraocular pressure (IOP) is the only modifiable risk factor in the treatment of glaucoma, and CCT has the potential to significantly impact IOP measurement by applanation tonometry in all patients. more...

Objective: To describe clinical results from a pilot study of a novel glaucoma surgical device., Design: Prospective interventional case series., Participants: Thirty-seven adult Hispanic and Caucasian patients (17 male, 20 female) with uncontrolled open-angle glaucoma (OAG) in one or both eyes with or without previous surgery or laser treatment were recruited from a clinical practice in Tijuana, Mexico., Intervention: Surgery was performed with the Trabectome (NeoMedix Corp., San Juan Capistrano, CA) in one eye of each patient., Main Outcome Measures: Goldmann applanation intraocular pressures and Snellen visual acuities were measured before and after surgery. Intraoperative and postoperative adverse events were tabulated, and numbers of preoperative and postoperative adjunctive medications were compared before and after surgery., Results: Preoperative pressures after 1 week of medication washout averaged 28.2+/-4.4 mmHg (n = 37). Only 3 patients were not using topical medications preoperatively. Follow-up ranged between 3 months (n = 37) and 13 months (n = 11). Mean postoperative IOPs were 18.4+/-10.9 mmHg (n = 37) at 1 day, 17.5+/-5.9 mmHg (n = 37) at 1 week, 17.4+/-3.5 mmHg (n = 25) at 6 months, and 16.3+/-2.0 mmHg (n = 15) at 12 months. Visions returned to within 2 lines of preoperative levels and remained stable in all patients beyond 3 weeks postoperatively except one, not sutured at surgery, who had a late hyphema probably associated with corneal wound gaping after accidental blunt trauma. The number of adjunctive medications decreased from 1.2+/-0.6 among preoperative patients on medications (n = 34) to 0.4+/-0.6 among all patients at 6 months (n = 25). Blood reflux occurred in all eyes on instrument withdrawal after angle surgery and was present at day 1 in 22 eyes (59%) with clearing by slit-lamp examination at a mean of 6.4+/-4.1 days postoperatively., Conclusions: The Trabectome seems to offer a safe and effective method of lowering IOP in OAG. more...

Objective: To report the longer term results of a randomized, clinical trial comparing the 350-mm2 and the 500-mm2 Baerveldt glaucoma implants., Design: Extended follow-up on a randomized, controlled trial., Participants: Between March 1991 and April 1993, 107 patients with uncontrolled intraocular pressure (IOP) due to non-neovascular glaucoma associated with aphakia, pseudophakia, or failed filters were randomly assigned for surgical placement of either the 350-mm or the 500-mm2 Baerveldt implant at the Doheny Eye Institute., Methods: A random-numbers table was used to assign each patient to one of the two groups. Preoperative IOPs and visual acuities were recorded. Clinical records were reviewed to ascertain postoperative IOPs, visual acuities, number of medications used, and implant-related complications that occurred throughout the follow-up period., Main Outcome Measures: Success was defined as IOP of 6 mmHg or greater and of 21 mmHg or less in two or more consecutive follow-up visits without further glaucoma surgery or loss of light perception attributable to glaucoma., Results: The overall success rates were 87% for the 350-mm2 group and 70% for the 500-mm2 group (P = 0.05). Average follow-up was 37 months (range, 1-76 months) for the 350-mm2 group and 34 months (range, 5-77 months) for the 500-mm2 group. The life-table success rates declined over time for both implant groups, from a high of 98% for the 350-mm2 group and 92% for the 500-mm2 group at 1 year to a cumulative success rate of 79% for the 350-mm2 group and 66% for the 500-mm2 group at 5 years. Visual acuities were better or remained the same in 50% of the patients in the 350-mm2 group and 46% of those in the 500-mm2 group. Complications during the 5-year follow-up were also statistically similar., Conclusions: The longer term results show that the 350-mm2 Baerveldt implant is more successful than the 500-mm2 implant for overall IOP control. Interval comparisons indicate a higher rate of success for the 350-mm2 implant in the first, second, third, fourth, and fifth years of implantation. Visual acuities, implant-related complications, and average IOPs were statistically indistinguishable between the two groups. more...

Purpose: The purpose of the study was to define a newly recognized complication after glaucoma surgery and to recommend a therapeutic regimen., Methods: Eighteen patients diagnosed initially as having aqueous misdirection after glaucoma surgery, but who subsequently were found by ultrasonography to have an annular peripheral choroidal detachment that resulted in secondary angle closure glaucoma, were studied. Ten of these patients were treated with topical cycloplegics and corticosteroids, and 8 were treated with drainage of suprachoroidal fluid. Outcomes of these two treatment methods were compared., Results: Annular peripheral choroidal detachment reliably was diagnosed with ultrasonography. Of the variables studied, time elapsed before resolution of the annular peripheral choroidal detachment was noted to be statistically significant (P < 0.00005). Immediate resolution followed drainage of suprachoroidal fluid, whereas a mean of 19.6 days was required for resolution after medical therapy., Conclusions: Annular peripheral choroidal detachment should be considered in the differential diagnosis of a flat or shallow anterior chamber with normal or high intraocular pressure after glaucoma surgery. The diagnosis of annular peripheral choroidal detachment can be confirmed most reliably by ultrasonography. Medical therapy is as effective as is surgery, although a significantly longer time to resolution is required. more...

Purpose: To determine if using human cadaveric fascia lata grafts to cover glaucoma implant tubes is safe and effective., Methods: All patients who underwent glaucoma implant surgery at the Doheny Eye Institute between July 1993 and September 1993 received a fascia lata patch graft to cover the subconjunctival portion of the tube. These patients were followed prospectively for clinical signs of conjunctival breakdown, graft melt, tube erosion, graft-related inflammation, infection, and graft-related complications., Results: Twenty-two eyes of 21 patients were followed for a mean of 19 months. All eyes tolerated the fascia lata grafts well without clinical evidence of graft-related conjunctival, scleral, or intraocular inflammation. No tube erosion or melting of the graft was observed in the study group., Conclusion: Preserved donor fascia lata was well tolerated as a grafting material in glaucoma implant surgery. No clinical signs of graft rejection, foreign body reaction, tube erosion, or graft melt were observed in the study group during the follow-up period. more...

Purpose: To evaluate the timing, efficacy, and complications of laser suture lysis (LSL) after mitomycin C trabeculectomy in patients with glaucoma at high risk for failure of filtering surgery., Methods: The authors retrospectively reviewed the charts of 62 consecutive patients who underwent a total of 66 sessions of LSL after trabeculectomy with mitomycin C., Results: The interval from surgery to LSL ranged from 2 to 65 days (mean +/- standard deviation, 17.9 +/- 14.9 days). The average intraocular pressure (IOP) reduction after LSL was 11.9 +/- 8.9 mmHg (range, 3-40 mmHg). A longer interval to LSL was correlated with a lesser degree of pressure reduction (P=0.0004, Wilcoxon rank-sum test). After LSL, hypotony developed in 13 (21%) patients (IOP < 6 mmHg on 2 consecutive measurements at least 24 hours apart). This resolved spontaneously after 7 to 304 days (104.1 +/- 109.1 days) in 12 (92%) of the 13 patients. Life-table success rates (success defined as 6 mmHg more...

Purpose: The authors present a retrospective study designed to assess the effectiveness of the Baerveldt glaucoma implant in controlling intraocular pressure (IOP) and maintaining visual function in eyes with neovascular glaucoma., Methods: The medical records of all 36 patients (36 eyes) who underwent Baerveldt glaucoma implantation for medically uncontrolled neovascular glaucoma between February 1991 and December 1992 were reviewed., Results: Eighteen patients received Model 350 implants, 16 received Model 500 implants, and 2 received Model 200 implants. The 12- and 18-month life-table success rates (success defined as 6 mmHg < or = final IOP < or = 21 mmHg without additional glaucoma surgery or devastating complication) were 79% and 56%, respectively. Visual acuity remained stable or improved in 10 (31%) patients. Postoperative complications included flat anterior chamber, serous choroidal detachment, and obstruction of the proximal tube tip with fibrovascular tissue, each of which occurred in four (11%) patients. Eleven (31%) patients lost light perception. There were no significant differences between the groups receiving the Model 350 and Model 500 implants with respect to life-table success rates, percentage of postoperative IOP reduction, or complication rates. Patients in the Model 500 implant group required significantly fewer antiglaucoma medications post-operatively, but also demonstrated a significantly greater mean visual acuity reduction. Better preoperative visual acuity and increased patient age were positively correlated with a successful outcome., Conclusions: Baerveldt implantation is effective in controlling IOP elevation associated with neovascular glaucoma. Postoperative visual loss, despite adequate IOP control, is common. Young patient age and poorer preoperative visual acuity are significant predictors of surgical failure. more...

Purpose: To determine pressure-flow characteristics at physiologic flow rates in vitro and in vivo in rabbits for Ahmed, Baerveldt, Krupin disk, and OptiMed glaucoma implants. The Molteno dual-chamber implant also was evaluated in vivo only., Methods: Five samples of each glaucoma implant were studied. Baerveldt implants were ligated partially for in vitro testing. Opening and closing pressures in air or after immersion in balanced salt solution or plasma were evaluated for the valved devices (Ahmed and Krupin). Pressures were measured in vitro and in vivo in normal rabbits at flow rates preset at between 2 and 25 microliters/minute after the tubes were connected to a closed manometric system. In vivo measurements were made 24 hours after implantation. Resistance to flow was calculated using Poiseuille's equation after at least three separate flow rate readings., Results: In air, the Ahmed and Krupin valves had opening pressures of 9.2 +/- 3.4 and 7.2 +/- 0.6 mmHg and closing pressures of 5.2 +/- 0.9 and 3.9 +/- 1 mmHg, respectively. Neither opening nor closing pressures could be determined when Ahmed and Krupin valves were immersed. In vitro, the Ahmed and OptiMed devices had higher pressures than did other devices at a 2-microliters/minute flow rate of balanced salt solution. During perfusion with plasma, only the OptiMed device maintained higher pressures than with balanced salt. With all devices, pressures fell rapidly to zero after flow was stopped. The OptiMed device demonstrated the highest resistance values. In vivo, the Ahmed device provided pressures of 7.5 +/- 0.8 mmHg and the OptiMed device gave pressures of 19.6 +/- 5.6 mmHg at a 2-microliters/minute flow rate. After 15 minutes of flow shutdown, the OptiMed implant maintained pressures of 7.1 +/- 1.1 mmHg. The Baerveldt (nonligatured), Krupin, and Molteno dual-chamber implants had similar resistances and pressures in vivo. Pressures with all devices in vivo fell rapidly to zero after conjunctival wound disruption., Conclusion: Neither the Ahmed nor Krupin devices had demonstrable opening or closing pressures when tested in vitro immersed in balanced salt solution or plasma. With all devices, pressures were higher in vivo than in vitro due to tissue-induced resistance around the explant. Both Ahmed and Krupin valves functioned as flow-restricting devices at the flow rates studied, but did not close after initial perfusion with fluid. more...

Background: The Baerveldt glaucoma implant is a large equatorial aqueous shunting device that is installed through a single-quadrant conjunctival incision. The intermediate-term results of a randomized study comparing the 350- and 500-mm2 Baerveldt implants are reported., Methods: Seventy-three patients with medically uncontrollable, nonneovascular glaucomas associated with aphakia, pseudophakia, or failed filters were enrolled in a randomized, prospective study comparing 350- and 500-mm2 Baerveldt implants. Surgical success was defined as 6 mmHg < or = final intraocular pressure < or = 21 mmHg without glaucoma reoperation or devastating complication., Results: Of patients with 350- and 500-mm2 implants, 93% and 88%, respectively, achieved surgical success (18-month life-table analysis, P = 0.93). The 500-mm2 implants afforded intraocular pressure control with significantly fewer medications (0.7 versus 1.3; P = 0.006). The postoperative visual acuities remained within one line of the preoperative visual acuities or improved in 62% and 66% of patients in the 350- and 500-mm2 groups, respectively (P = 0.93). Complication rates were statistically similar. The most frequent ones in the 350- and 500-mm2 groups, respectively, were serous choroidal effusion (16% and 32%), strabismus (16% and 19%), anterior uveitis (14% and 11%), and corneal or corneal graft edema (11% each)., Conclusion: The intermediate-term results of the 350- and 500-mm2 Baerveldt implants were statistically comparable with respect to surgical and visual outcomes, as well as complications, although the larger implant was associated with a higher rate of some complications. However, the 500-mm2 Baerveldt implant afforded intraocular pressure control with fewer medications than the 350-mm2 implant. more...

Background: The Krupin Eye Valve with Disk (Krupin disk) is a glaucoma shunt that incorporates a slit valve intended to minimize early postoperative hypotony., Methods: The medical records of all patients who have undergone Krupin disk implantation at the Doheny Eye Institute between July 1990 and December 1992 (25 eyes of 25 patients) were reviewed., Results: Intraocular pressure (IOP) was reduced from a mean of 36.1 +/- 11.5 mmHg to 15.3 +/- 7.5 mmHg at follow-up intervals of 4 to 19 months (mean, 13.2 months). On the first postoperative day, IOPs ranged from 0 to 40 mmHg. In two eyes (8%), the IOP was less than 6 mmHg, and in five eyes (20%) the IOP was more than 21 mmHg. Serous choroidal effusion and/or choroidal hemorrhage occurred in seven patients (28%). Six- and 12-month life-table success rates (6 < or = IOP < or = 21 mmHg) were 84% and 66%, respectively., Conclusion: The Krupin disk lowers IOP in most patients; however, the presence of a slit valve does not eliminate either early postoperative hypotony with its attendant complications or early IOP spikes. more...

Purpose: The treatment of glaucoma after scleral buckling surgery is often problematic. The authors investigated a series of patients in whom a silicone tube was implanted to shunt aqueous from the anterior segment to the fibrous capsule surrounding a previously placed silicone episcleral encircling element., Methods: Thirteen patients were retrospectively reviewed. In each patient, a silicone tube was inserted through a small incision into the fibrous capsule overlying the scleral explant. In most patients, no attempt was made to secure the distal end of the tube to the silicone band. The proximal end of the tube was inserted into the eye via a needle track., Results: Successful control of intraocular pressure (IOP) (6 mm Hg < or = final IOP or < 21 mmHg with or without medication) was ultimately achieved in 11 (85%) of 13 patients (3 of the successful patients underwent one or more surgical revisions to relieve obstruction of the proximal and/or distal tube opening). Follow-up in these patients ranged from 8 to 49 months (mean +/- standard deviation, 21.7 +/- 14.1 months). The final postoperative visual acuities were within one line of the preoperative visual acuities or had improved in 11 (85%) patients. Complications included serous choroidal detachment (3 patients; 23%), conjunctival wound leak (2 patients; 15%), hyphema (1 patient; 8%), and tube obstruction by lens, iris, vitreous, or episcleral fibrous tissue (4 patients; 31%)., Conclusion: Aqueous tube shunt to a pre-existing episcleral encircling element is useful in treating complicated glaucomas after scleral buckling surgery. Fibrous obstruction of the external tube opening is a frequent complication in the early postoperative period, but it may be relieved by surgical revision. more...

Background: The authors report four cases of conjunctival epithelial invasion into the fibrous capsule surrounding a Baerveldt glaucoma implant. All cases were associated with concurrent or recent prior scleral buckling surgery., Methods: Three patients had postoperative conjunctival wound leaks, one in the immediate postoperative period and the other two at 9 and 17 days postoperatively after release of the tube ligature. In the fourth patient, a fistulous tract developed over the implant after a first-stage insertion. Histopathologic confirmation of subconjunctival epithelialization was obtained in two of these patients., Results: Surgical revision was performed in all patients. Excision and debridement of all epithelium-lined subconjunctival tissues and extensive bipolar cautery were used in the three patients with wound leaks. Implant removal also was performed in one of these. Fistulectomy and bipolar cautery were used in the fourth patient. No recurrent wound leaks or other adverse sequelae were noted., Conclusions: Epithelial invasion of the subconjunctival space and inner bleb wall after implantation of glaucoma drainage devices can lead to breakdown of the conjunctival wound and persistent aqueous leak. Prior or concurrent scleral buckling surgery may predispose to this occurrence. Surgical revision involving epithelial debridement, cautery, and meticulous wound closure, with or without implant removal, has been used successfully in the management of this complication. more...

Background: The Molteno implant is a device used for surgical treatment of complicated glaucoma. Rhegmatogenous retinal detachment (RD) is a relatively rare complication of Molteno implant surgery. This study was undertaken to evaluate the clinical features including the surgical management and postoperative outcome of patients with rhegmatogenous RD after Molteno implant surgery., Methods: The authors reviewed 350 consecutive patients who had Molteno surgery and identified 16 patients with subsequent rhegmatogenous RD. They also studied one patient referred for RD repair after Molteno surgery at another institution., Results: The risk of rhegmatogenous RD was 5%. Seventy percent (12/17) of the patients presented within 4 months of the Molteno procedure. Dialysis and flap tear were the most common types of retinal break found. Forty-one percent (7/17) of the patients had proliferative vitreoretinopathy. In three patients, clinical features suggested RD resulting from the Molteno procedure. In other patients, previous ocular surgery and underlying ocular disease may have contributed to the development of RD. Retinal detachment repair was attempted in all patients. Among 16 patients with at least 6 months of follow-up, 56% (9/16) had successful retina attachment. Forty-four percent (7/16) of the patients maintained formed vision. Eighteen percent (3/16) of the patients maintained visual acuity of at least 20/40. Intractable glaucoma did not develop in any of the patients with an attached retina. Recurrent RD, endophthalmitis, cyclitic membrane, or intractable glaucoma led to phthisis bulbi or enucleation in 44% (7/16) of the patients., Conclusion: A combined approach by vitreoretinal and glaucoma surgeons can restore vision and maintain glaucoma control in patients with rhegmatogenous RD associated with Molteno implant surgery. more...

Background: The Baerveldt glaucoma implant is an aqueous shunting device with a large surface area that is installed through a conjunctival incision in one quadrant of the eye. This study presents the initial results of the first 13 patients who underwent Baerveldt implantation as part of the Food and Drug Administration approval process., Methods: Thirteen patients with medically uncontrollable complicated glaucomas underwent one-stage implantation of either a 200- or 350-mm2 Baerveldt implant without postoperative systemic antifibrosis therapy. Surgical success was defined as intraocular pressure greater than or equal to 6 and less than or equal to 21 mmHg without glaucoma reoperation or devastating complication., Results: Eight patients (62%) had successful surgical outcomes, with a mean follow-up of 17.3 +/- 7.0 months (+/- standard deviation) (range, 6-24 months). Seven (70%) of the ten patients with glaucomas associated with aphakia or pseudophakia had successful outcomes, whereas only one (50%) of the two patients with neovascular glaucomas had a successful outcome. One patient with glaucoma associated with nanophthalmos and an unsuccessful filtering procedure had a failed outcome. The postoperative visual acuities remained within one line of the preoperative visual acuities or improved in 62% of the patients. The most frequent complications among all patients were transient serous choroidal effusion (23%) and hyphema (15%)., Conclusion: Initial results of the Baerveldt implant generally are comparable with other implants. It is easier to install and requires less extensive conjunctival dissection than other large implants. Additional studies are needed to evaluate the effectiveness of the Baerveldt implant in affording long-term intraocular pressure control. more...

Background: It is frequently impossible to determine by clinical examination alone if a filtering bleb is present over the equatorial plate(s) of a glaucoma shunt. This uncertainty can result in management dilemmas when patients with these devices have elevated intraocular pressures (IOPs). The authors describe how standardized echography can be used to determine if fluid is present around the plates and to characterize the blebs., Methods: Four hundred twenty-seven plates in 269 patients who had undergone single- or double-plate Molteno implantation underwent standardized echography (both A- and B-scan examinations) to determine if blebs were present around the plates, primarily when results of slit-lamp examinations had been inconclusive. Bleb sizes, locations, and characteristics also were evaluated., Results: Sixty-five percent of the plates had associated blebs, which were graded according to their sizes (small, medium, and large, in 29%, 44%, and 27% of plates with blebs, respectively). Fluid (which appeared as an echolucent area) could be seen underlying and/or overlying the plates (which appeared as echodense lines). Larger blebs were often associated with scleral flattening. Although bleb sizes did not necessarily correlate with the levels of IOP control, the presence of a bleb on ultrasound was indicative of tube patency., Conclusion: Standardized echography was invaluable in the postoperative management of patients who had undergone Molteno implantation because it demonstrated the presence or absence of blebs and characterized them when results of slit-lamp examinations had been inconclusive. This technique also can be used to evaluate similarly designed aqueous shunting devices. more...

Purpose: This study compares the outcomes of trabeculectomy and Molteno implantation in the treatment of glaucomas associated with uveitis., Methods: Forty-five patients with uveitis, who had undergone filtering surgery for glaucomas associated with uveitis, were reviewed retrospectively. Successful outcome was defined as final intraocular pressure (IOP) of 6 to 21 mmHg, with a minimum follow-up of 6 months without visually devastating complications or loss of light perception., Results: One- and two-year life-table success rates, respectively, were 81% and 73% with trabeculectomy (16 patients); 53% and 31% with combined trabeculectomy and first-stage (reserve) Molteno implantation (19 patients); and 79% and 79% with one-stage Molteno implantation (10 patients). In 11 patients who underwent second-stage Molteno implantation after trabeculectomy failure, 1- and 2-year life-table success rates were 79% and 79%, respectively. Complications included surgically treated choroidal effusions (1/45; 2%), choroidal hemorrhages (3/45; 7%), and chronic hypotony (3/45; 7%). Follow-up in all groups ranged from 5 to 70 months (mean +/- standard deviation, 28 +/- 17 months)., Conclusions: Trabeculectomy provides surprisingly good results in glaucomas associated with uveitis (modulation of wound healing with antimetabolites probably would afford an even higher success rate). However, when significant, immediate postoperative and/or moderate chronic postoperative inflammation is likely, aqueous drainage devices appear more likely to control IOP. more...

Purpose: Previous studies have suggested that primary double-plate Molteno implantation may be beneficial. Therefore, the authors performed a randomized clinical trial to evaluate the relative effectiveness and safety of single- versus double-plate Molteno implantation., Methods: From March 1988 to February 1990, 132 patients who underwent Molteno implantation for medically uncontrollable non-neovascular glaucomas in aphakia or pseudophakia were randomly assigned to receive either single- or double-plate implants., Results: The 1- and 2-year life-table success rates (success [survival] defined as 6 mmHg < or = final intraocular pressure [IOP] < or = 21 mmHg without additional glaucoma surgery or devastating complication) were 55% and 46% with single-plate implantation and 86% and 71% with double-plate implantation, respectively. The final postoperative visual acuities were within one line of the preoperative visual acuities or had improved in 73% and 80% of patients, respectively. Choroidal hemorrhages and/or effusions, corneal decompensation, flat anterior chambers, and phthisis bulbi were more common in the patients who had undergone double-plate Molteno implantation; however, transient elevations of IOP during the first few postoperative months were more common in the patients who had undergone single-plate Molteno implantation., Conclusions: Double-plate Molteno implantation more frequently affords IOP control than single-plate Molteno implantation; however, double plates are associated with greater risks of choroidal hemorrhages and/or effusions, corneal decompensation, flat anterior chambers, and phthisis bulbi. more...

Background: Intravitreal silicone oil injection used for managing complicated retinal detachments can be associated with elevated intraocular pressure (IOP). This study was undertaken to determine the incidence of glaucoma in patients who underwent silicone oil injection, as well as to evaluate the effectiveness of medical and surgical therapy in patients in whom glaucoma developed., Methods: The postoperative courses of 50 eyes of 47 consecutive patients who underwent pars plana vitrectomy and silicone oil injection for the management of complicated retinal detachments were reviewed retrospectively. The outcomes of patients who underwent silicone oil removal and/or glaucoma surgery also were evaluated., Results: The mean overall postoperative IOP before any glaucoma surgery was 16.7 +/- 9.3 mmHg (range, 0 to 45 mmHg), with a mean follow-up of 16.6 +/- 12.1 months (range, 2 to 51 months). Twenty-four (48%) eyes had postoperative IOPs of at least 25 mmHg and IOP elevations of at least 10 mmHg above the preoperative levels. Twenty-one (42%) eyes underwent complete removal of silicone oil and/or glaucoma surgery to effect IOP control. The IOPs were controlled to 21 mmHg or less (but > 5 mmHg) in 8 of 14 eyes that underwent removal of silicone oil alone, in 3 of 5 eyes that underwent Molteno implantation, and in 1 eye that underwent Nd:YAG transscleral cyclophotocoagulation, but not in 1 eye that underwent a modified Schocket procedure (mean follow-up, 13.5 +/- 11.0 months; range, 0.2 to 33 months)., Conclusion: Intraocular pressure elevation is a common occurrence after intravitreal silicone oil injection. The underlying mechanism may often be multifactorial in nature. Patients in whom uncontrolled IOP develops may benefit from aggressive medical and/or surgical treatment with silicone oil removal, glaucoma implants, or cyclodestructive procedures. more...

Ninety-six patients who had undergone single-plate Molteno implantation for glaucomas with poor surgical prognoses were re-evaluated for long-term results. Control of intraocular pressure was achieved with one single-plate implant to a level less than 22 mmHg (but greater than 5 mmHg) without reoperation or devastating complications in 46% of the aphakic/pseudophakic eyes, 25% of eyes after failed filters, 25% of eyes with neovascular glaucomas, and 26% of eyes in patients younger than 13 years of age (life-table analysis at 5 years). Five-year success rates improved to 53%, 71%, 40%, and 56%, respectively, when data from second plates were included. Visual acuities improved or remained the same after one or two plates were implanted in 47% of aphakic/pseudophakic eyes, 17% of eyes after failed filters, 65% of eyes with neovascular glaucomas, and 63% of eyes in patients younger than 13 years of age on whom Snellen acuity was available. The most frequent overall complications after implantation of one or two plates included: corneal edema (19%), corneal graft decompensation (13%), and cornea-tube touch, retinal detachment, and cataract (8% each). more...

Ten patients underwent combined Molteno implantation and pars plana vitrectomy as the primary nonlaser surgical treatment of neovascular glaucoma associated with diabetic retinopathy (9 patients) or central retinal vein occlusion (1 patient). Combined surgery was performed most frequently because media opacities precluded adequate preoperative retinal ablation. Follow-up ranged from 3 to 43 (mean +/- standard deviation, 18.0 +/- 13.2) months. Six patients achieved final intraocular pressures less than 22 mmHg. Visual acuities remained the same or improved in four patients. Four patients had uncomplicated courses. Among the other patients, complications included: recurrent vitreous hemorrhage and retinal detachment (3 patients each); hyphema (2 patients); and tube block, extensive fibrin formation, epiretinal membrane, and total retinal necrosis (1 patient each). more...

Seventy patients younger than 21 years of age underwent Molteno implantation for nonneovascular glaucoma. Fifty-three (76%) patients had failed angle and/or conventional filtering surgery. Final intraocular pressure less than 22 mmHg (but over 5 mmHg) was achieved in 40 (62%) of the 65 patients with at least 6-month follow-up (range, 6 to 59 months; mean +/- standard deviation, 22.7 +/- 14.1 months); however, only 22 (34%) were controlled after the initial Molteno implantation procedure, and 54 (83%) patients underwent further glaucoma and/or nonglaucoma surgical procedures. The visual acuities remained within one line of their preoperative levels or improved in 25 (68%) of the 37 patients on whom Snellen acuities were available. The most frequent complications included: tube-cornea touch (20%, transient in 3%), corneal edema (17%), retinal detachment (16%), tube block (10%), cataract (9%), chronic hypotony or phthisis (9%), pupillary or cyclitic membrane (9%), hyphema (7%), flat anterior chamber (6%), and large postoperative choroidal effusion (6%). Despite the high rates of subsequent surgical interventions and complications, Molteno implantation has been a useful approach for achieving intraocular pressure reduction in young patients with glucoma. more...

A randomized, prospective, double-masked study was undertaken to determine the risk of postcycloplegic intraocular pressure spikes in patients with open-angle glaucoma and to evaluate apraclonidine prophylaxis in minimizing these spikes. Patients were stratified as miotic treated or untreated and each group was randomized to receive either placebo (artificial tears) or apraclonidine in both eyes before instillation of tropicamide. In both the miotic treated and untreated groups that received placebo, there was a high incidence, (37% and 38%, respectively) of clinically significant (greater than or equal to 6 mmHg) intraocular pressure spikes after instillation of tropicamide. In both the miotic treated and untreated groups, there was a statistically significant difference in postcycloplegic intraocular pressure between the subgroup that received placebo and the group that received apraclonidine prophylaxis (P = 0.003 and P = 0.006, respectively). Additionally, four eyes that received placebo had a spike of over 10 mmHg (range, 12 to 27 mmHg), while only one eye had an increase of greater than 10 mmHg (12 mmHg) in the apraclonidine group. Thus, apraclonidine appears to be a useful agent for minimizing precipitous increases in intraocular pressure after cycloplegia in eyes of open-angle glaucoma patients prone to this complication of cycloplegia. more...

Nine patients with advanced epithelial ingrowth underwent Molteno implantation for medically uncontrollable secondary glaucomas. Substantial reductions in intraocular pressures (IOPs) were observed in most patients (preoperative IOPs ranged from 5 to 48 mmHg [mean +/- standard deviation, 33.6 +/- 14.6 mmHg]; postoperative IOPs ranged from 10 to 30 mmHg [mean +/- standard deviation, 16.0 +/- 6.5 mmHg]); follow-up ranged from 9 to 47 months (mean +/- standard deviation, 18.8 +/- 12.1 months). Seven (78%) patients had final postoperative IOPs of less than 22 mmHg, five (56%) retained formed vision (visual acuity of at least 1/200), and six (67%) remained comfortable. Postoperative complications related to Molteno implantation included one case each of: conjunctival wound leak, vitreous-tube block, tube-cornea touch, and iris-tube block (or tube retraction). Complications attributed to epithelial ingrowth included five cases of corneal decompensation with band keratopathy. Molteno implantation is an effective technique for palliative treatment of secondary glaucomas associated with advanced epithelial ingrowth, frequently maintaining modest vision and comfort in eyes in which the intraocular epithelialization is too extensive for surgical removal and/or destruction. more...

Orbital cellulitis secondary to sinusitis has been the most common cause of proptosis in children. A case report is presented which emphasizes that the signs and laboratory findings in orbital cellulitis may be confusing, especially when modified by prior antibiotics. When orbital cellulitis is a possibility, adequate antibiotic therapy should be instituted while diagnostic studies are being performed. CT scanning is a new and useful modality for the evaluation of these patients, but cautious and experienced interpretation is essential. In patients who do not respond promptly to appropriate medical therapy, surgical intervention is indicated for drainage and biopsy. more...

Ninety patients with medically uncontrollable glaucomas and poor surgical prognoses received single-plate Molteno implants (Optomat Supplies, Dunedin, New Zealand) without postoperative adjunctive systemic antifibrosis therapy. Eleven patients had insufficient follow-up for assessment of intraocular pressure (IOP) or visual acuity outcome. The initial Molteno implant procedures in the remaining 79 patients were successful (IOP less than or equal to 21 mmHg with at least 6 months' follow-up) in 26 (63%) of the 41 patients older than 12 years of age with non-neovascular glaucomas in aphakia/pseudophakia; 7 (70%) of the 10 patients older than 12 years of age with non-neovascular glaucomas in phakic eyes after failed filtering surgery; 7 (47%) of the 15 patients with neovascular glaucomas; and 7 (54%) of the 13 patients younger than 13 years of age with non-neovascular glaucomas. The visual acuities remained within one line of their preoperative levels or improved in 31 (76%) of the 41 aphakic or pseudophakic eyes with non-neovascular glaucomas; 3 (30%) of the 10 phakic eyes with non-neovascular glaucomas after failed filtering surgery; 10 (67%) of the 15 eyes with neovascular glaucomas; and 9 (100%) of the 9 eyes with non-neovascular glaucomas in patients younger than 13 years of age on whom Snellen acuity was available.(ABSTRACT TRUNCATED AT 250 WORDS) more...

An 81-year-old black woman with severe rheumatoid arthritis presented with an enlarging black lesion on the medial sclera of the left eye. Scleromalacia perforans was suspected. At surgical exploration, a deeply pigmented tumor was encountered, with extension into the orbit, along the medial rectus muscle. Biopsy revealed a benign melanocytoma. more...

Laser trabeculoplasty (LTP) is a relatively new procedure requiring evaluation for long-term effectiveness and associated complications. The authors review some 300 LTPs and identify complications. Among the most serious are transient or persistent rise in intraocular pressure, iritis, and progression of visual field loss. The authors recommend LTP as an alternative to glaucoma surgery in selected patients not controlled by medications. more...