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Exfoliation syndrome (XFS) is the most common known risk factor for secondary glaucoma and a major cause of blindness worldwide. Variants in two genes, LOXL1 and CACNA1A, have previously been associated with XFS. To further elucidate the genetic basis of XFS, we collected a global sample of XFS cases to refine the association at LOXL1, which previously showed inconsistent results across populations, and to identify new variants associated with XFS. We identified a rare protective allele at LOXL1 (p.Phe407, odds ratio (OR) = 25, P = 2.9 × 10 -14 ) through deep resequencing of XFS cases and controls from nine countries. A genome-wide association study (GWAS) of XFS cases and controls from 24 countries followed by replication in 18 countries identified seven genome-wide significant loci (P < 5 × 10 -8 ). We identified association signals at 13q12 (POMP), 11q23.3 (TMEM136), 6p21 (AGPAT1), 3p24 (RBMS3) and 5q23 (near SEMA6A). These findings provide biological insights into the pathology of XFS and highlight a potential role for naturally occurring rare LOXL1 variants in disease biology.

Purpose: To evaluate the results of phacoemulsification and intraocular lens (IOL) implantation in eyes with pseudoexfoliation (PEX) and zonular weakness., Methods: Two hundred and ninety-five patients (295 eyes) were recruited. This study is a retrospective case review of 143 PEX eyes with preoperative (Group 1) and intraoperative (Group 2) signs of zonular weakness, 76 PEX eyes (Group 3) and 76 non-PEX eyes without zonular weakness (Group 4) undergoing phacoemulsification and IOL implantation performed by single surgeon from year 1988 to 2010. Outcome measures included frequency of postoperative pseudophakodonesis, anterior capsule contraction and IOL decentration/dislocation. Postoperative vision, intraocular pressure (IOP) and glaucoma medication requirements were also assessed. A subanalysis on identical postoperative outcomes of capsular tension ring (CTR) implantation was performed. Comparisons were made for 52 PEX eyes with zonular weakness receiving nonsutured CTR implantation (Group A), 91 PEX eyes with zonular weakness not receiving CTR implantation (Group B) and 142 PEX eyes without zonular weakness (Group C)., Results: Mean follow-up was 4.08 ± 0.48 years and maximum was 8.3 years. Both Groups 1 and 2 showed higher incidence of complications than Groups 3 and 4 (p < 0.01). Vision, IOP and glaucoma medication requirements were similar postoperatively for all four groups. Groups A and B had a significantly higher proportion of postoperative complications than Group C (p < 0.01). There was no significant difference in risk of developing these complications between Groups A and B (p = 0.64)., Conclusion: Postoperative complication rates are higher in PEX eyes with preoperative and/or intraoperative signs of zonular weakness undergoing phacoemulsification. Nonsutured CTR implantation does not prevent IOL and capsular complications postoperatively., (© 2016 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: To evaluate safety and clinical outcomes of a novel supraciliary device, the CyPass Micro-Stent, for surgical treatment of open-angle glaucoma when implanted in conjunction with cataract surgery., Patients and Methods: Subjects (n=142) with open-angle glaucoma and cataract underwent combined phacoemulsification, with intraocular lens insertion, and microstent implantation into the supraciliary space of study eyes (n=167). Two analysis cohorts were prespecified based upon medicated baseline intraocular pressure (IOP): ≥21 mm Hg (cohort 1, n=65) or <21 mm Hg (cohort 2, n=102). Glaucoma medications were discontinued or tapered at surgery, and restarted at investigator discretion. The main postoperative outcome measures were adverse events, IOP changes, and number of IOP-lowering medications., Results: Mean±SD follow-up was 294±121 days. No major intraoperative or postoperative complications occurred. Preoperative baseline mean IOP was 20.2±6.0 mm Hg and mean number of IOP-lowering medications was 2.0±1.1. Cohort 1 showed a 35% decrease in mean IOP and a 49% reduction in mean glaucoma medication usage; cohort 2 demonstrated a 75% reduction in mean medication usage while maintaining mean IOP<21 mm Hg. For all eyes, mean IOP at 12 months was 15.9±3.1 mm Hg (14% reduction from baseline). Early and late postoperative IOP elevation occurred in 1.2% and 1.8% of eyes, respectively. Two subjects developed mild transient hyphema, and none exhibited prolonged inflammation, persistent hypotony, or hypotony maculopathy., Conclusions: CyPass Micro-Stent implantation, combined with cataract surgery, resulted in minimal complications and reduced IOP and IOP-lowering medication use at 12 months postoperatively.

Purpose: To report 3-year results evaluating the effect on safety and efficacy of canaloplasty to treat open-angle glaucoma when combined with cataract surgery., Patients and Methods: This was a retrospective subset analysis of a prospective, international, multicenter study evaluating 133 eyes of 133 adult, open-angle glaucoma patients who underwent canaloplasty with tensioning suture placement. Eighty-two phakic eyes that received canaloplasty alone were compared with 51 eyes that underwent cataract surgery before or during canaloplasty., Results: Phakic eyes that received combined cataract-canaloplasty surgery (phacocanaloplasty) had a mean±SD baseline IOP of 23.5±5.2 mm Hg and mean glaucoma medication usage of 1.5±1.0 decreasing to a mean IOP of 13.6±3.6 mm Hg on 0.3±0.5 medications at 3 years postoperatively. Pseudophakic eyes undergoing canaloplasty had a mean baseline IOP of 23.9±5.2 mm Hg on a mean of 1.8±0.8 glaucoma medications decreasing to 15.6±3.5 mm Hg on 1.1±0.8 medications at 3 years. In phakic eyes, reductions in IOP were significantly greater and less postoperative IOP lowering medication was needed after undergoing phacocanaloplasty compared to eyes which had canaloplasty alone., Conclusions: Clear corneal phacoemulsification performed before or in combination with canaloplasty is a safe and effective surgical procedure to reduce IOP in adult patients with open-angle glaucoma.

Purpose: To analyze the outcomes of surgery for dislocated intraocular lenses (IOLs) in patients with pseudoexfoliation (PXF)., Setting: Private practice, Boston, Massachusetts, USA., Design: Retrospective case study., Methods: Eyes with PXF and IOL dislocations that had IOL exchange or repositioning were reviewed. An outcomes analysis compared the surgical techniques with regard to corrected distance visual acuity (CDVA), intraocular pressure (IOP), and glaucoma medication requirements., Results: The IOL exchange was performed in 64 eyes (79%) and IOL repositioning in 17 eyes (21%). The CDVA improved in all eyes, from a preoperative mean of 0.78 logMAR ± 0.50 (SD) to a mean of 0.35 ± 0.31 logMAR at the final follow-up (mean 2.5 ± 2.6 years) (P<.0001). The mean IOP was reduced by 4.2 mm Hg at the final follow-up (P<.0001). The mean glaucoma medication requirement remained stable at the final follow-up compared with the preoperative levels (P>.05). There were no significant differences in the mean CDVA, IOP, or glaucoma medication requirement between eyes that had IOL exchange and eyes that had IOL repositioning. There were no significant intraoperative complications. The most common postoperative complication was a transient decrease in IOP to 5 mm Hg or lower or an increase in IOP to 30 mm Hg or higher., Conclusions: Patients with PXF having surgical treatment of IOL dislocation have the potential for excellent visual outcomes with minimal intraoperative and postoperative complications., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2013 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the short- and long-term effect of uneventful phacoemulsification, posterior chamber intraocular lens (IOL) implantation, and trabeculectomy on intraocular pressure (IOP) and glaucoma medication requirements in eyes with pseudoexfoliation glaucoma (PXG) and compare the results with those in eyes that had uneventful phacoemulsification only (reported in a previous study of the same cohort of pseudoexfoliation eyes)., Setting: Private practice, Boston, Massachusetts, USA., Design: Comparative case series., Methods: A retrospective analysis was performed of consecutive PXG eyes that had uneventful combined phacoemulsification and trabeculectomy by the same surgeon. The change in IOP, glaucoma medication requirements, and logMAR corrected distance visual acuity was compared between the combined surgery group and the phaco-alone group., Results: The combined-surgery group (n = 138) had statistically significant reduced mean IOP and glaucoma medication requirements through 10 years postoperatively (P<.018). The change in IOP and glaucoma medication requirements was greater in the combined-surgery group than in the phaco-alone group (n = 240); this was statistically significant up to 7 years postoperatively (P<.022). The reduction in mean postoperative IOP was greater in eyes with a higher mean preoperative IOP. In the combined-surgery group, 13.8% of eyes required subsequent laser trabeculoplasty, glaucoma surgery, or both., Conclusions: Uneventful phacoemulsification, IOL implantation, and trabeculectomy resulted in significant long-term reduction in IOP and glaucoma medication requirements in eyes with PXG. Combined procedures resulted in greater and more longstanding reductions in IOP and glaucoma medication requirements and fewer 1-day postoperative IOP spikes than phacoemulsification alone., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To report 3-year results of the safety and efficacy of canaloplasty, a procedure involving circumferential viscodilation and tensioning of the inner wall of Schlemm canal to treat open-angle glaucoma., Setting: Multicenter surgical sites., Design: Nonrandomized multicenter clinical trial., Methods: This study comprised adult open-angle glaucoma patients having canaloplasty or combined cataract-canaloplasty surgery. Qualifying preoperative intraocular pressures (IOPs) were at least 16 mm Hg with historical IOPs of at least 21 mm Hg. A flexible microcatheter was used to viscodilate the full circumference of the canal and to place a trabecular tensioning suture. Primary outcome measures included IOP, glaucoma medication use, and adverse events., Results: Three years postoperatively, all study eyes (n = 157) had a mean IOP of 15.2 mm Hg ± 3.5 (SD) and mean glaucoma medication use of 0.8 ± 0.9 compared with a baseline IOP of 23.8 ± 5.0 mm Hg on 1.8 ± 0.9 medications. Eyes with combined cataract-canaloplasty surgery had a mean IOP of 13.6 ± 3.6 mm Hg on 0.3 ± 0.5 medications compared with a baseline IOP of 23.5 ± 5.2 mm Hg on 1.5 ± 1.0 medications. Intraocular pressure and medication use results in all eyes were significantly decreased from baseline at every time point (P<.001). Late postoperative complications included cataract (12.7%), transient IOP elevation (6.4%), and partial suture extrusion through the trabecular meshwork (0.6%)., Conclusion: Canaloplasty led to a significant and sustained IOP reduction in adult patients with open-angle glaucoma and had an excellent short- and long-term postoperative safety profile., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the frequency and results of cataract surgery with concurrent vitrectomy due to zonule weakness in eyes with pseudoexfoliation (PXF)., Setting: Private practice, Boston, Massachusetts, USA., Methods: This retrospective nonrandomized study assessed consecutive eyes with PXF having cataract surgery. High risk was defined as preoperative phacodonesis, iridodonesis, or lens subluxation (subgroup 1); preoperative anterior chamber depth or angle-depth asymmetry between eyes confirmed by slitlamp biomicroscopy or gonioscopy, respectively (subgroup 2); or complicated cataract extraction related to zonule weakness in the fellow eye (subgroup 3). Exclusion criteria were previous vitrectomy, scleral buckle, or trabeculectomy surgery and combined cataract-glaucoma surgery. A comparative analysis of outcome parameters was performed., Results: Of the 1059 eyes evaluated, 38 had vitrectomy. Concurrent vitrectomy was required in 19 (15.6%) of 122 high-risk eyes and 19 (2.0%) of 937 non-high-risk eyes (P<.00001). The need for concurrent vitrectomy was greatest in subgroup 3 (72.7%) and subgroup 1 (42.9%). There was no statistically significant difference between the vitrectomy group and the no-vitrectomy group in the mean improvement in logMAR corrected distance visual acuity (CDVA) (P = .38) or mean change in intraocular pressure (IOP) (mean decrease 2.6 mm Hg +/- 1.5 [SD] and 1.6 +/- 0.5 mm Hg, respectively) (P = .47)., Conclusion: Despite the need for vitrectomy and the attendant increased demands in postoperative care, both the vitrectomy group and no-vitrectomy group had improved logMAR CDVA and IOP., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright 2010 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

As the rate of terrorism increases, it is important for health care providers to become familiar with the management of injuries inflicted by blasts and explosions. This article reviews the ocular injuries associated with explosive blasts, providing basic concepts with which to approach the blast-injured patient with eye trauma. We conducted a literature review of relevant articles indexed in PubMed between 1948 and 2007. Two hundred forty-four articles were reviewed. We concluded that ocular injury is a frequent cause of morbidity in blast victims, occurring in up to 28% of blast survivors. Secondary blast injuries, resulting from flying fragments and debris, cause the majority of eye injuries among blast victims. The most common blast eye injuries include corneal abrasions and foreign bodies, eyelid lacerations, open globe injuries, and intraocular foreign bodies. Injuries to the periorbital area can be a source of significant morbidity, and ocular blast injuries have the potential to result in severe vision loss.

This review provides a comprehensive assessment of intraocular pressure (IOP), phacoemulsification techniques, and intraocular lenses (IOLs) in pseudoexfoliation (PXF) eyes having cataract surgery. Pseudoexfoliation is ubiquitous and the most common cause for open-angle glaucoma worldwide. Cataracts occur with increased frequency in PXF eyes, and surgery is potentially complicated by the presence of small pupils and zonule laxity and significantly affects IOP in these eyes. Preoperative evaluation and the options for intraoperative management of cataract are presented with recommendations for the use of adjunctive pupil and zonule support devices. Postoperative complications such as capsule contraction and IOL instability are discussed and laser and surgical options to manage these special problems presented.

Purpose: To evaluate 2-year postsurgical safety and efficacy of canaloplasty (circumferential viscodilation and tensioning of the inner wall of Schlemm canal) to treat open-angle glaucoma (OAG)., Setting: Multicenter surgical sites., Methods: This international prospective study comprised adult OAG patients having glaucoma surgery or combined glaucoma-cataract surgery. Qualifying preoperative intraocular pressure (IOP) was at least 16 mm Hg and historical IOP, at least 21 mm Hg. The full circumference of the canal was viscodilated and a trabecular tensioning suture placed with a microcatheter. Primary outcome measures included IOP and glaucoma medication use., Results: At 24 months, all 127 eyes (127 patients) had a mean IOP of 16.0 mm Hg +/- 4.2 (SD) and mean glaucoma medication use of 0.5 +/- 0.8 (baseline values 23.6 +/- 4.8 mm Hg and 1.9 +/- 0.8 medications). Eyes with canaloplasty alone had a mean IOP of 16.3 +/- 3.7 mm Hg and 0.6 +/- 0.8 medications (baseline values 23.2 +/- 4.0 mm Hg and 2.0 +/- 0.8 medications). Eyes with combined glaucoma-cataract surgery had a mean IOP of 13.4 +/- 4.0 mm Hg and 0.2 +/- 0.4 medications (baseline values 23.1 +/- 5.5 mm Hg and 1.7 +/- 1.0 medications). The IOP and medication use results at all time points were statistically significant versus baseline (P <.001). The late postoperative follow-up identified 3 patients with elevated IOP. No other serious ocular or nonocular complications were reported., Conclusion: Canaloplasty was safe and effective in reducing IOP in adult patients with OAG.

Purpose: To assess the effect of phacoemulsification with posterior chamber intraocular lens (IOL) implantation performed by a single surgeon on intraocular pressure (IOP) and glaucoma medication requirements in pseudoexfoliation (PFX) eyes with or without glaucoma., Setting: Private practice, Boston, Massachusetts, USA., Methods: This retrospective analysis comprised 1122 eyes with PFX having uneventful phacoemulsification with IOL implantation. Of the eyes, 882 did not have glaucoma (PFX group) and 240 had glaucoma (PXG group). A comparative outcomes analysis was performed; the analysis focused on IOP and change in glaucoma medication requirements between the 2 groups., Results: The mean IOP was statistically significantly reduced through 7 years postoperatively compared with preoperatively in the PFX group. The PXG group had reduced mean IOP for 1 year and reduced glaucoma medication requirements at almost all postoperative time intervals. Higher mean preoperative IOP was associated with a greater reduction in mean IOP postoperatively in both groups. Intraocular pressure spikes (> 30 mm Hg) 1 day postoperatively occurred in 4% in the PFX group and 17% in the PXG group. Postoperatively, 2.7% of PFX eyes progressed to a need for glaucoma medication and 3.7% of PXG eyes progressed to a need for laser and/or glaucoma surgery., Conclusions: A long-term reduction in mean IOP occurred in PFX eyes with and without glaucoma. The IOP reduction was proportional to the preoperative IOP; higher preoperative IOP was associated with a greater reduction in IOP. Glaucoma progression in both groups was low, suggesting a protective effect of phacoemulsification on IOP in these eyes.

Purpose: To compare intraoperative and postoperative complications, best corrected visual acuity, intraocular pressure (IOP), and glaucoma medication requirements between eyes with clinically apparent pseudoexfoliation (PEX) and fellow eyes without PEX in patients having bilateral cataract surgery., Setting: Private practice, Boston, Massachusetts, USA., Methods: This retrospective study comprised 1000 consecutive patients who had cataract surgery performed by the same surgeon. Of the 1000 patients, 137 had unilateral PEX and bilateral cataract surgery. Patients with previous or concurrent glaucoma surgery were eliminated from the study. Two-way analysis of variance and Tukey post hoc tests were used for statistical analysis., Results: Complications were few, with no significant differences between the 2 groups intraoperatively (zonule instability) or postoperatively (corneal edema, cystoid macular edema, intraocular lens decentration). Both groups had improved visual acuity, with no statistically significant between- group difference in acuity at 1 year. Both groups had decreased IOP postoperatively, although the eyes with PEX had a significantly greater mean Delta IOP than the fellow eyes without PEX (P<.016). The PEX group required more glaucoma medications overall (P<.003) and needed more glaucoma medications at 3 to 5 years than preoperatively; the medication requirement in the fellow-eye group remained stable., Conclusions: The presence of clinically apparent PEX had an impact on IOP reduction and glaucoma medication requirements. There were no differences in intraoperative or postoperative complications between eyes with PEX and fellow eyes without PEX.

Purpose: To determine the incidence of hypotony and intraocular pressure (IOP) elevation in the immediate and early postoperative period after temporal posterior limbal phacoemulsification and intraocular lens (IOL) implantation., Setting: Ambulatory surgical center., Methods: This prospective analysis comprised 310 eyes that had temporal posterior limbal phacoemulsification with IOL implantation. Surgical parameters included keratome incision of 2.85 mm, incision length of 2.5 mm, peribulbar anesthesia, case-completion IOP of 20 mm Hg, and postoperative lid taping. The IOP measurements were collected preoperatively and 30 minutes and 1 day after surgery., Results: Nineteen eyes (6.1%) had an IOP lower than 5 mm Hg 30 minutes postoperatively in the absence of incision leakage at the paracentesis or keratome sites. Eighteen of the 19 eyes with postoperative hypotony received hydroxypropyl methylcellulose 2% (OcuCoat) and 1 received hypromellose 2% (Cellugel). None of the 23 eyes with an acrylic IOL implanted via a cylindrical lens inserter had an IOP lower than 5 mm Hg postoperatively. Suturing did not significantly affect the incidence of hypotony, and there were no postoperative complications related to hypotony. The mean IOP at 30 minutes was lower than at 1 day in the normal, glaucoma, and glaucoma-suspect groups. Twenty-one normal eyes (8.1%), 5 glaucoma eyes (15.6%), and 1 glaucoma-suspect eye (5%) had an IOP greater than 30 mm Hg 1 day postoperatively., Conclusions: Postoperative hypotony (IOP <5 mm Hg) occurred in 19 (6.1%) of 310 eyes. At 1 day, IOP higher than 30 mm Hg was more frequent in glaucoma eyes than in normal eyes. Although there were no direct problems related to hypotony at 30 minutes or to elevated IOP (>30 mm Hg) at 1 day, surgeons should be aware of and check for IOP variability (low and high) that can occur in normal, glaucoma, and glaucoma-suspect eyes within the first 24 hours after surgery.

Purpose: This study evaluates the change in intraocular pressure (IOP) and glaucoma medication requirements after clear corneal phacoemulsification in open angle glaucoma patients, glaucoma suspects, and normal patients at 3 years and last follow-up (mean 5 y)., Patients and Methods: This study represents a retrospective analysis of patients who had clear corneal phacoemulsification and at least 3 years of follow-up. The patients were classified into 3 groups: glaucoma (G), glaucoma suspects (GS), and no glaucoma (NG). No patient had a history of previous intraocular surgery. Single factor analysis of variance, Fisher exact tests, 2-tailed paired Student t tests and Kaplan-Meier analysis were applied., Results: Forty-eight patients (55 eyes) in the glaucoma group, 41 patients (44 eyes) in the GS group, and 59 patients (59 eyes) in the NG group met the above criteria. At 3 years follow-up IOP was significantly decreased in all groups; (G) group decreased 1.4+/-3.3 mm Hg (P = 0.0025), GS 1.4+/-4.2 mm Hg (P = 0.004), and NG 1.7+/-3.1 mm Hg (P = 0.0005). At the final follow-up visit (mean near 5 y for all groups) the IOP was significantly decreased in all groups, (G) group 1.8+/-3.5 mm Hg (P = 0.005), GS 1.3+/-3.7 mm Hg (P = 0.025), and NG 1.5+/-2.5 mm Hg (P < 0.0001). The number of preoperative and postoperative glaucoma medications in the (G) group did not show any significant change at 3 and 5 years (P = 0.36, P = 0.87). Kaplan-Meier analysis shows that at 3 years, 85% of the (G) group, 81% of GS, and 90% of the NG had IOPs less than or equal to their preoperative IOP, with the same number of glaucoma medications or less. At 5 years the percentages were 76%, 79%, and 85%, respectively., Conclusions: This study demonstrates that cataract removal by clear cornea phacoemulsification in glaucoma patients, glaucoma suspects, and normal patients results in a small but significant decrease in IOP that is sustained at 3 years and a mean of 5 years in all groups. This study does not imply that cataract removal by phacoemulsification is a substitute for a combined procedure but may be an appropriate procedure for certain patients based on medication requirements and extent of optic nerve damage.

Purpose: To determine whether pupil stretch during phacoemulsification affects postoperative best corrected visual acuity (BCVA), intraocular pressure (IOP), and inflammation compared with results in patients without pupil stretch., Methods: A retrospective analysis of 115 eyes that had pupil stretch during phacoemulsification (study group) and 125 eyes without pupil stretch (control group) was performed with a minimum of 12 months follow-up. Single-factor analysis of variance and 2-tailed homoscedastic t tests were used for statistical analysis., Results: The mean preoperative logMAR equivalent BCVA was 0.5 +/- 0.3 (SD) in the study group and 0.6 +/- 0.4 in the control group. The mean preoperative IOP was 16.2 +/- 4.1 mm Hg in the study group and 16.0 +/- 3.5 mm Hg (control group). There was no statistically significant difference at postoperative follow-up of 1 year in BCVA or IOP between the 2 groups (1 year BCVA 0.2 +/- 0.2 [study group], 0.2 +/- 0.2 [control group] [P<.1]; IOP 14.5 +/- 3.5 mm Hg and 14.7 +/- 3.3 mm Hg, respectively [P<.7]). There was no significant difference in the number of glaucoma medications required for glaucoma patients preoperatively and postoperatively between the 2 groups (P<.5). Complications were rare, and there was no significant difference in the complications (ie, iritis, hyphema, cystoid macular edema, epiretinal membrane formation) between the 2 groups at 1 year., Conclusion: Pupil stretch during phacoemulsification was not associated with a statistically significant difference in BCVA, IOP, inflammation, or other complications postoperatively compared with results in the control group without pupil stretch.

Purpose: To compare the results of 1-site versus 2-site combination glaucoma filtration and phacoemulsification surgery with respect to visual acuity, intraocular pressure (IOP), and glaucoma medication requirements via a case control study., Methods: Results of 2-site phacotrabeculectomy surgery in 64 eyes of 59 patients were retrospectively reviewed with a minimum follow-up of 1 year. The 2-site procedures were compared with a randomly chosen control group of 71 1-site phacotrabeculectomies performed by the same surgeon., Results: The presurgical visual acuity, IOP, and glaucoma medication requirements did not differ significantly between the 2 groups. Mean final postoperative results at 1 year for 2-site versus 1-site eyes, respectively, were visual acuity 0.32 +/- 0.353 (SD) and 0.32 +/- 0.37 (P = .99), IOP 15.0 +/- 3.7 mm Hg and 15.1 +/- 6.3 mm Hg (P = .97), and glaucoma medication requirements 0.43 +/- 0.90 and 0.61 +/- 1.1 (P = .52)., Conclusion: There was no statistically significant difference in the final visual acuity, IOP, or glaucoma medication requirements between the 2-site and 1-site groups.

Purpose: To analyze the intraocular pressure (IOP), glaucoma medication requirements, and visual acuity after glaucoma filtration surgery in pseudophakic eyes., Setting: Private practice, Boston, Massachusetts, USA., Methods: The results of glaucoma filtration surgery in 47 eyes of 40 pseudophakic patients with a minimum follow-up of 1 year were retrospectively reviewed. Eyes with previously surgically manipulated conjunctiva in the area of filtration were compared to eyes without previous manipulation., Results: Preoperatively, the mean IOP was 25 mm Hg +/- 7.3 (SD); mean number of glaucoma medications, 3.3 +/- 1.0; and mean logMAR visual acuity, 0.41 +/- 0.38. At the final follow-up visit (mean 36.5 +/- 31.5 months), the respective means were 13.6 +/- 6.6 mm Hg (P<.001), 0.9 +/- 1.4 (P<.001), and 0.46 +/- 0.43 (P=.53). The mean postoperative IOP, glaucoma medication requirements, and visual acuity at the final follow-up in eyes with virgin conjunctiva and eyes with previously manipulated conjunctiva were, respectively, as follows: IOP, 12.5 +/- 3.2 mm Hg and 14.1 +/- 7.6 mm Hg (P=.52); medications, 1.1 +/- 1.3 and 0.9 +/- 1.4 (P=.66); and logMAR acuity, 0.6 +/- 0.52 and 0.4 +/- 0.39 (P=.23)., Conclusions: Glaucoma filtration surgery in pseudophakic eyes significantly improved IOP and reduced glaucoma medication requirements while maintaining stability of vision. There were no statistically significant differences in final IOP, glaucoma medication requirements, or visual acuity between eyes with virgin conjunctiva and eyes with previously surgically manipulated conjunctiva.

Unlabelled: To characterize the differences in technique, complications, and outcomes in a large series of cataract extractions in patients with and without pseudoexfoliation (PEX) syndrome., Setting: Ophthalmic Consultants of Boston, Boston, Massachusetts, USA., Methods: A retrospective analysis was performed of 297 cases of cataract extraction in patients with PEX and 427 cases of cataract extraction in patients without PEX. This study examined and quantified the intraoperative and postoperative complications, performed a comparative outcomes analysis of intraocular pressure (IOP) change, and determined the prevalence of systemic vascular diseases in these patients., Results: The overall rate of vitreous loss was 4% (7/297) in the PEX population and 0% (0/427) in the non-PEX group. There were no overall differences in the rate of postoperative complications. At 2 years, IOP had declined from a mean of 16.8 to 13.9 mm Hg in the PEX group and from 16.3 to 14.4 mm Hg in the non-PEX group. The decline was significantly greater in the PEX group. The prevalence of hypertension and diabetes was significantly greater in the non-PEX group (50% and 11%, respectively) than in the PEX group (38% and 5%, respectively)., Conclusions: The increased frequency of intraoperative complications during cataract extraction in PEX patients stemmed from zonular weakness rather than capsule tears. Postoperative IOP declines were greater in the PEX group even 2 years after cataract extraction, suggesting the potential for long-term improvement in outflow facility in patients with coexisting cataract and glaucoma.

Purpose: To evaluate the intraocular pressure (IOP), best corrected visual acuity (BCVA), and glaucoma medication requirements in patients having phacoemulsification after preexisting glaucoma filters., Setting: Ophthalmic Consultants of Boston, Boston, Massachusetts, USA., Methods: A retrospective analysis of 58 eyes that had temporal phacoemulsification via a clear corneal (32 eyes) or a scleral tunnel (26 eyes) approach after filtration surgery was performed with a minimum follow-up of 12 months. Two-tailed homoscedastic t tests were used for statistical analysis., Results: The mean preoperative IOP in all eyes was 11.8 mm Hg +/- 4.2 (SD), and the mean final postoperative IOP was 13.7 +/- 4.6 mm Hg (P<.022). The mean preoperative logMAR equivalent BCVA was 0.8 +/- 0.4, which improved to a mean of 0.4 +/- 0.4 postoperatively (P<.0000002). There was no statistically significant change in glaucoma medication requirements postoperatively. The differences in IOP, BCVA, and postoperative glaucoma medication requirements were not statistically significant between the clear corneal group and the scleral tunnel group or between patients who received mitomycin at the time of filtration surgery and those who did not. There were no intraoperative complications; 1 patient required additional glaucoma surgery., Conclusion: Clear corneal or scleral tunnel phacoemulsification in the setting of a preexisting glaucoma filter was associated with improved BCVA, a small but statistically significant increase in IOP, and stability in the number of glaucoma medicines required for IOP control over a minimum follow-up of 1 year.

Purpose: To study the effect of peripheral iridectomy (PI) in phacotrabeculectomy., Setting: Academic private glaucoma practice with a primarily white patient population., Methods: This retrospective study comprised 126 eyes of 117 patients randomized for PI or no PI during phacotrabeculectomy who were followed for 12 months. Postoperative parameters in both groups included intraocular pressure (IOP), bleb development, visual acuity, and complications., Results: There were no statistically significant differences between the 2 groups in visual acuity or IOP. Bleb development required significantly more 5-fluorouracil therapy in the no-PI group than in the PI group; however, bleb failure and the need for laser suture lysis were not significantly different between groups. Complications were rare in both groups., Conclusion: Phacotrabeculectomy without PI may be an acceptable alternative to the surgical management of co-existing cataract and glaucoma.

A survey of glaucoma surgery parameters was mailed to all the United States members of the American Society of Cataract and Refractive Surgery in 1999 and 2000. Of the 5659 surveys mailed, 725 (13%) were returned. The survey assessed parameters used in glaucoma surgical treatment. Preferred surgery treatment patterns were cross-tabulated with fellowship training in glaucoma (9.3%) and geographic location. This report summarizes current practice styles and patterns of comprehensive ophthalmologists in the United States as derived from the survey.

Purpose: To compare best corrected visual acuity (BCVA) and intraocular pressure (IOP) in eyes that had a foldable intraocular lens (IOL) implanted with the use of an anterior chamber maintainer (ACM) in 1 eye and hyaluronate 3.0% (Vitrax) viscoelastic material in the other eye., Setting: Private practice in a large urban center., Methods: Sixty-six eyes of 33 patients had consecutive bilateral cataract extraction by the same surgeon using an identical temporal approach, clear corneal phacoemulsification, and implantation of an Allergan SI-40NB or SA-40NB IOL through an injection delivery system. The first operative eye was arbitrarily assigned to the ACM or Vitrax group, while the fellow eye received the opposite technique. Patients with coexisting ocular pathology that could influence the measured outcomes (eg, glaucoma, age-related macular degeneration) were excluded. Patients were evaluated preoperatively and 1 day and 3 to 6 weeks postoperatively., Results: No serious intraoperative or postoperative complications were reported. The only statistical difference in BCVA or IOP was on the first postoperative day, when the mean IOP was approximately 2 mm Hg lower in the ACM group than in the Vitrax group., Conclusion: The use of an ACM for implantation of an injected 3-piece silicone IOL may lower IOP on the first postoperative day.

Purpose: To determine the incidence of hypotony or intraocular pressure (IOP) spikes in the early period after clear corneal phacoemulsification in normal and glaucomatous eyes., Setting: Ambulatory surgical center., Methods: This retrospective analysis comprised 112 eyes that had clear corneal phacoemulsification. Postoperative IOP measurements were collected 30 minutes, 1 day, and 1 month after surgery., Results: Twenty-three eyes had an IOP of 5 mm Hg or below 30 minutes postoperatively. The IOP at 30 minutes was lower than at 1 day in both the normal and the glaucoma group. The mean IOP in the normal group was 10.0 mm Hg +/- 4.3 (SD) at 30 minutes and 16.9 +/- 4.4 mm Hg at 1 day (P < or = .005). The means in the glaucoma group were 9.6 +/- 3.9 mm Hg and 16.9 +/- 5.7 mm Hg, respectively (P < or = .0002). The IOPs at 30 minutes and 1 day were not significantly different between the 2 groups., Conclusions: A significant percentage of eyes having clear corneal phacoemulsification had an IOP of 5 mm Hg or less 30 minutes after surgery. Even though there were no postoperative complications from hypotony and there was a relative absence of significant IOP elevation 1 day postoperatively, the frequency of low IOP at 30 minutes suggests that consideration be given to leaving postoperative eyes with a higher IOP at the completion of phacoemulsification rather than with the estimated 10 mm Hg tactile IOP strived for in this study.

A survey of glaucoma laser parameters and practices was mailed to all United States members of the American Society of Cataract and Refractive Surgery (ASCRS) in March 1999. Approximately 19% (947) of the 5100 surveys were returned. The survey assessed parameters used for laser trabeculoplasty, laser iridotomy, and gonioplasty. Respondents also answered questions about the application of these laser therapies in a wide variety of clinical situations. The results were cross-tabulated by age, number of laser trabeculoplasties performed per month, fellowship training in glaucoma, and geographic location.

Purpose: To compare the effects of clear corneal phacoemulsification on intraocular pressure (IOP) in patients without glaucoma, glaucoma suspects, and patients with glaucoma., Setting: Urban, multisubspecialty private practice., Methods: A retrospective analysis of patients who had clear corneal phacoemulsification with a minimum of 12 months follow-up was performed. The patients were divided into 3 groups: no glaucoma (NG), glaucoma suspects (GS), and glaucoma (GG). None had a history of prior surgery. Glaucoma suspects included patients with elevated IOPs, abnormal discs, pseudoexfoliation syndrome, or pigment dispersion syndrome on no medications and with no field defects. Glaucoma patients had received only medical treatment. Two-tailed, homoscedastic t tests were used for statistical analysis., Results: There were 143 patients (164 eyes) in the NG group, 65 (75) in the GS group, and 61 (71) in the GG group. The mean preoperative IOP was 16.42 mm Hg +/- 2.77 (SD), 17.59 +/- 4.15 mm Hg, and 16.97 +/- 4.86 mm Hg in the 3 groups, respectively. At 1 year, the mean IOP was lower in all groups: 14.37 +/- 2.97 mm Hg, 15.68 +/- 3.38 mm Hg, and 15.86 +/- 4.00 mm Hg, respectively. The change was statistically significant in the NG and GS groups. Glaucoma patients showed a statistically significant reduction in the number of glaucoma medications postoperatively., Conclusion: Clear corneal phacoemulsification was associated with a statistically significant long-term reduction in IOP.

Objective: To compare the effectiveness of limbus-based and fornix-based conjunctival flaps in fellow eyes of the same patients undergoing combined trabeculectomy with phacoemulsification., Design: Prospective, nonrandomized comparative (fellow eye) study., Participants: Forty-four patients and 88 fellow eyes., Intervention: Limbus-based conjunctival flap with phacotrabeculectomy was performed in one eye, and a fornix-based conjunctival flap with phacotrabeculectomy was performed in the fellow eyes of the same patients. The patients were followed up for a minimum of 1 year postoperatively for each eye., Main Outcome Measures: Preoperative and postoperative visual acuity, intraocular pressure, number of antiglaucoma medications, interventions, and complications were studied., Results: At last follow-up visit, visual acuity improved to 20/40 or better in 88.6% of the limbus-based group and 79.6% of the fornix-based group. Preoperatively, the mean intraocular pressure in the limbus-based group was 21.4 +/- 4.8 mmHg on a mean of 2.4 +/- 1.2 glaucoma medications; in the fornix-based group, it was 21.4 +/- 4.3 mmHg on a mean of 2.3 +/- 1.1 medications. Mean intraocular pressure decreased to 15.3 +/- 3.3 mmHg (P < 0.01) on a mean of 0.2 +/- 0.5 glaucoma medications in the limbus-based group (P < 0.01). In the fornix-based group, mean intraocular pressure at last follow-up visit decreased to 15.3 +/- 4.7 mmHg (P < 0.01) on a mean of 0.2 +/- 0.5 medications (P < 0.01). Postoperative interventions and complications were not statistically different between the two groups., Conclusion: With phacotrabeculectomy, limbus-based and fornix-based conjunctival flaps are equally effective in improving visual acuity and lowering intraocular pressure. This variation in conjunctival flap orientation was equally effective in fellow eyes of the same patients, with no difference in postoperative complications or outcomes.

A survey of medical treatment patterns for primary open-angle glaucoma (POAG) was mailed to all United States members of the American Society of Cataract and Refractive Surgery (ASCRS) in March 1998; 21.2% responded. Demographic information pertinent to glaucoma care was also obtained. The use of diagnostic ancillary tests, as well as the sequential order of preferred therapy, in 3 hypothetical patient populations was analyzed: patients with mild, moderate, and advanced POAG. Preferred medical therapy was cross-tabulated with number of years in practice, fellowship training in glaucoma, and geographic location.

In most combined phacoemulsification and filtration surgery, the standard tunnel incision is altered to create a scleral flap, usually a limbal-based scleral flap with radial suture closure. We describe a new technique that has the advantages of both scleral tunnel architecture and horizontal suture closure. It creates a scleral groove tangential to the limbus and a standard scleral tunnel. Phacoemulsification and intraocular lens implantation are performed under the scleral tunnel. A 10-0 nylon horizontal suture is positioned for scleral tunnel closure and looped aside. A central "T" relaxing incision is made at the midpoint of the scleral tunnel up to the posterior insertion of conjunctiva. A punch sclerectomy is performed. The 10-0 nylon horizontal suture is tied. The conjunctiva is closed and bleb elevation is confirmed via deepening through a corneal paracentesis incision. The results in an initial series of 24 consecutive eyes followed for a mean of seven months are presented: Mean visual acuity improved from 20/70 to 20/30 and mean intraocular pressure reduction was 5.0 +/- 2.4 mm Hg (standard deviation). By preserving standard scleral tunnel architecture and single horizontal suture closure, this technique permits rapid visual recovery and accelerated return to full activity. It also permits postoperative titration of aqueous outflow by laser suture lysis, if indicated. Against-the-rule astigmatic drift associated with limbal-based scleral flaps and antimetabolite therapy may be minimized.

Background and Objective: The surgical management of coexisting cataract and glaucoma is a common problem for the ophthalmologist., Patients and Methods: We evaluated intraocular pressure (IOP) reduction and bleb formation in combined cataract and filtration surgery, comparing planned extracapsular cataract extraction (ECCE) and phacoemulsification approaches coupled with similar trabeculectomy techniques. Seventy-two eyes with primary open-angle or pseudoexfoliation glaucoma underwent combined cataract and filtration surgery. Thirty-five eyes underwent planned ECCE, intraocular lens (IOL) implantation, and trabeculectomy, and 37 eyes underwent phacoemulsification, IOL implantation and trabeculectomy. Minimum follow-up for both groups was 1 year with a mean of 16 months., Results: The mean IOP reduction for phacoemulsification/trabeculectomy eyes (5.0 +/- 4.3 mm Hg) was significantly lower than the mean IOP reduction for ECCE/trabeculectomy eyes (2.9 +/- 4.1 mm Hg; P < 0.03). There was no significant difference between the groups in terms of visual acuity improvement or glaucoma medication reduction., Conclusion: Combined cataract and filtration surgery using phacoemulsification is associated with greater IOP reduction than combined surgery using ECCE.

Purpose: Argon laser trabeculoplasty (ALT) is commonly used in the treatment of open-angle glaucoma. Varying success rates in lowering intraocular pressure (IOP) and controlling glaucoma are reported in studies with follow-up periods from 1 to 5 years, and few reports are available with follow-up to 10 years. The authors retrospectively reviewed the efficacy of ALT in patients followed up to 10 years., Methods: Ninety-three patients with open-angle glaucoma underwent 360 degrees ALT. Mean follow-up was 52 +/- 43 months (mean +/- standard deviation; range, 1-132 months). Successful treatment at the time of final follow-up was defined as a decrease in IOP of 3 mmHg or greater from pretreatment level, IOP of 19 mmHg or less, stable visual field, stable optic nerve, and no further laser or surgical intervention., Results: The decrease in IOP was 8.9 +/- 5.4 mmHg at 1 year, 10.0 +/- 4.2 mmHg at 5 years, and 8.9 +/- 5.2 mmHg at 10 years. The probability of success at 1 year was 77%, at 5 years 49%, and at 10 years 32%. Failure was most common in the first year after treatment (23%), and thereafter failure occurred at a rate of 5% to 9% per year. The mean decrease in IOP for all 93 eyes at time of maximum follow-up was 6.1 +/- 7.1 mmHg., Conclusion: Argon laser trabeculoplasty is an effective means for reducing IOP in many patients followed for an extended time. However, up to one half of eyes within 5 years of ALT and two thirds of eyes within 10 years may require additional laser or surgical intervention for glaucoma control.

We used argon laser gonioplasty to treat angle-closure glaucoma unrelieved by patent iridectomy. Laser energy (mean; 30 spots, 723 mW, and 0.2 second) was applied to the peripheral iris stroma to open the anterior chamber angle. Twenty of 32 eyes were successfully treated. After a median follow-up period of 18 months, 17 of these 20 successfully treated eyes (85%) had an intraocular pressure less than or equal to 19 mm Hg, and 19 of these 20 successfully treated eyes (95%) had an intraocular pressure less than or equal to 21 mm Hg. The 20 successfully treated eyes had a median duration of angle closure of 12 days. Twelve unsuccessfully treated eyes had a median duration of angle closure of 90 days. All successfully treated eyes had more than 50% of the treated angle opened by argon laser gonioplasty and all but three successfully treated eyes had more than three clock hours opened by argon laser gonioplasty. Argon laser gonioplasty may be successful in treating angle-closure glaucoma unrelieved by iridectomy, especially in cases that are recognized and treated soon after onset.

Background: Early reports of both contact and noncontact transscleral Nd:YAG laser cyclophotocoagulation have been encouraging; however, recent evidence indicates a significant incidence of hypotony, visual loss, and phthisis with the noncontact technique with more than 6 months of follow-up. The authors sought to determine the intermediate term effects of contact transscleral Nd:YAG laser cyclophotocoagulation (CYC)., Methods: The authors followed 116 eyes of 114 patients for a minimum of 1 year after treatment of advanced glaucoma with CYC., Results: The mean preoperative intraocular pressure (IOP) of 35.0 +/- 1.0 mmHg decreased to 18.6 +/- 1.1 mmHg (P less than 0.0001) during the average follow-up of 19.0 +/- 0.6 months (range, 12 to 36 months). Intraocular pressure control of 3 to 25 mmHg was achieved in 72%, 3 to 22 mmHg in 65%, and 3 to 19 mmHg in 56% of eyes. Retreatment was required in 31 of the 116 eyes (27%). Intraocular pressure decreased to less than 3 mmHg in 9 eyes and to 0 mmHg in 6 of these 9 eyes. Nineteen eyes, all with initial visual acuity of counting fingers or worse, progressed to no light perception; 17 of 36 eyes (47%) with visual acuity of 20/200 or better lost 2 or more Snellen lines., Conclusion: Midterm results of CYC continue to be encouraging but are tempered by a nearly 10% incidence of hypotony or phthisis and the progression of visual loss.

We analyzed the records of 132 patients hospitalized between July 1986 and February 1989 for management of traumatic hyphema. The incidence of secondary hemorrhage was compared between patients treated with or without systemic administration of aminocaproic acid in addition to an otherwise identical protocol. Results among patients who were examined within one day of injury disclosed a 4.8% secondary hemorrhage rate in aminocaproic acid-treated patients (three of 63 patients) compared with a 5.4% rate in the patients not treated with aminocaproic acid (three of 56 patients, P = .31). All six patients sustaining secondary hemorrhage recovered visual acuities of 20/40 or better, with five of six patients achieving 20/20 visual acuities. A separate group of 13 patients who were examined more than one day after injury were found to have a secondary hemorrhage rate of 38.5% (five of 13 patients). Macular injury, not secondary hemorrhage, was most often responsible among those patients suffering permanent visual loss. In this study of a predominantly white population, patients had a relatively low incidence of secondary hemorrhage and did not demonstrate detectable benefit from aminocaproic acid administration. Because of the recognized side effects and cost of treatment, further analysis to determine which patients will benefit from treatment with aminocaproic acid is indicated.

A prospective evaluation of all patients presenting with a sports-related ocular injury during a 1-year (4-season) period was conducted. Of the 202 patients evaluated, 28 (13.8%) required hospitalization and 11 (5.6%) required intraocular surgery. Twenty-six patients (12.8%) sustained permanent ocular sequelae including seven (3.5%) who suffered visual loss. Basketball accounted for 28.7%, baseball/softball 19.8%, and racquetball 11.4% of all injuries. At the time of injury, 5.1% of patients had worn protective eye wear, whereas on follow-up only 31% had used eye protection. These results indicate that sports trauma remains a significant cause of ocular morbidity.

Fifteen patients with synechial angle-closure glaucoma uncontrolled by medical and laser therapy were treated with surgical goniosynechialysis. Five patients were treated with goniosynechialysis alone, and ten were treated with goniosynechialysis in combination with other surgical procedures. The procedure was successful, in terms of reducing synechiae, in 14 eyes (93%). The extent of angle closure was reduced from 340 degrees +/- 45 degrees (mean +/- standard deviation) preoperatively to 80 degrees +/- 70 degrees postoperatively; the mean reduction was 260 degrees +/- 95 degrees (P less than 0.0001) for the group overall and 280 degrees +/- 80 degrees (P less than 0.0007) for the subgroup treated with goniosynechialysis alone. The mean preoperative intraocular pressure (IOP) was 40 +/- 4 mmHg. The mean postoperative IOP was 14 +/- 4 mmHg. The mean reduction in IOP was 26 +/- 15 mmHg (P less than 0.0001) for the group overall and 27 +/- 18 mmHg (P less than 0.015) for the subgroup treated with goniosynechialysis alone. Glaucoma medications were reduced from a mean of 2.6 +/- 1.0 preoperatively to 1.1 +/- 1.2 postoperatively for the group overall and to 1.4 +/- 1.5 for the subgroup treated with goniosynechialysis alone. Complications consisted of two eyes with intraoperative bleeding. One of these required intraoperative conversion to surgical trabeculectomy. The other was associated with a transient postoperative IOP elevation to 40 mmHg. Surgical goniosynechialysis may be an effective means of reducing synechiae and lowering IOP, either alone or in conjunction with other surgical procedures, in patients with angle closures of less than 6 months' duration.

Advanced glaucoma in 140 eyes of 136 patients was treated with contact transscleral continuous wave neodymium:YAG (Nd:YAG) laser cyclophotocoagulation (CYC) with a sapphire-tipped probe. The anterior edge of the probe was placed 0.5 to 1.5 mm posterior to the limbus, using 7 to 9 W of power for 0.7 seconds with 32 to 40 applications, sparing the 3 and 9 o'clock meridians. Patients were studied prospectively. The mean preoperative intraocular pressure (IOP) of 36.7 +/- 0.97 mmHg decreased to 21.2 +/- 0.99 mmHg (P = 0.004) after treatment (mean follow-up, 3.2 +/- 0.35 months) for a mean decrease in IOP of 15.5 +/- 1.21 mmHg and a mean percent decrease of 39%. Forty-one eyes were followed 6 or more months (mean, 6.7 +/- 0.25 months). The CYC reduced IOP to 25 mmHg or less in 71% of eyes, to 22 mmHg or less in 62% of eyes, and to 19 mmHg or less in 49% of eyes. Maximum lowering of IOP occurred 1 week to 1 month after treatment and remained at that level through 6 months of follow-up. Retreatment was required in 11% of patients; only one patient was retreated more than once. Four patients treated with 9 W of power developed IOPs below 5 mmHg; two of these patients had an IOP of 0 mmHg. Other complications of therapy were minimal, and patients had little pain. There was no significant change in visual acuity. Early results of this newly available therapy are encouraging.

Increased intraocular pressure (IOP) in encapsulated filtration blebs was evaluated in 49 eyes of 49 patients followed for 6 to 48 months (mean +/- standard deviation, 19.7 +/- 12.6 months). Intraocular pressure increased from 10.2 +/- 7.5 mmHg at 1 week postfiltration surgery to a peak of 26.1 +/- 10.7 mmHg at 3 weeks postoperatively and then decreased to 16.2 +/- 5.0 mmHg at 16 weeks and remained stable through the follow-up period. Thirty-nine eyes had a final IOP of 19 mmHg or less; 35 eyes required medical therapy alone (antiglaucoma drops, oral carbonic anhydrase inhibitors, and/or digital massage) with a final IOP of 14.1 +/- 3.8 mmHg; and 14 eyes required surgical reintervention for medically uncontrolled IOP elevation, and five of these eyes required two or more surgical reoperative procedures. Vigorous medical therapy, including glaucoma medications, topical steroids, and digital massage, is particularly important for encapsulated blebs during the first 2 months after surgery. After this period, IOP decreases and often remains sufficiently reduced to avoid further surgical intervention.

The authors present four cases of the dural shunt syndrome in which shallowing of the anterior chamber or rubeosis developed. All patients were female, ranging in age from 66 to 79 years, exhibiting elevated intraocular pressure (IOP), decreased extraocular movements, injected tortuous episcleral vessels, and proptosis. The authors managed these four cases with laser iridotomy, gonioplasty, panretinal photocoagulation, or medical treatment. It is important to recognize associated findings in patients with shallow anterior chambers and elevated IOPs so that a diagnosis of a dural shunt is considered and appropriately treated. Theories on the mechanisms of increased IOP in the dural shunt syndrome and the management of various types of glaucoma in four different cases are reviewed.

The ocular side effects of carmustine (a nitrosurea) are not well established. Evidence of delayed bilateral ocular toxicity developed in two of 50 patients treated with high dose intravenous (IV) carmustine (800 mg/sq m) with autologous bone marrow rescue. Symptoms or signs of ocular toxicity became apparent four weeks following IV treatment. Evidence of delayed ocular toxicity ipsilateral to the side of the infusion developed in seven of ten patients treated with intra-arterial carotid doses of carmustine to a cumulative minimum of 450 mg/sq m in two treatments. The ocular toxicity began two to 14 weeks (mean, six weeks) following intra-arterial treatment. In three of these patients, the visual loss progressed over one week to no light perception. The funduscopic manifestations of both groups included arterial narrowing, nerve fiber-layer infarcts, and intraretinal hemorrhages. Fluorescein angiography demonstrated segmental perivascular staining, wide-spread late capillary leakage, and optic disc hyperfluorescence. One patient had light and microscopic confirmation of cilioretinal artery occlusion and choroidal fibrin thrombi.

We reviewed the early results of 80 filtration procedures when used as the initial surgical treatment in a Saint Lucian West Indian black population with primary open angle glaucoma. Two techniques were used: trabeculectomy under a scleral flap with fornix-based conjunctival flap (Group 1) and full thickness posterior lip sclerectomy with limbal-based conjunctival flap (Group 2). Postoperatively, with an average follow-up of six months, Group 2 had significantly lower intraocular pressures, reduced glaucoma medication requirements, and increased cystic bleb formation. Vision did not differ significantly between the two groups postoperatively, although two Group 1 patients developed progressive glaucomatous visual loss. Complications were slightly more frequent in Group 2. The results of this study suggest that a full thickness sclerectomy technique merits consideration as the initial filtration procedure of choice in West Indian blacks with advanced open angle glaucoma.

Forty eyes in 37 patients that had previously successful 360 degrees argon laser trabeculoplasty were again found to have uncontrolled intraocular pressure (IOP) on maximally tolerated medical therapy and were retreated with argon laser trabeculoplasty to 180 degrees of the trabecular circumference. Successful retreatment was considered a decrease in IOP of 3 mmHg or more and sufficient to avoid further laser therapy or invasive glaucoma surgery. Laser trabeculoplasty retreatment was successful in 13 of the eyes treated (32%). Retreatment failed to control IOP in 27 of the retreated eyes (68%): either the IOP was not lowered by at least 3 mmHg (4 eyes) or the eyes required further laser therapy or surgery (23 eyes). The probability of successful IOP control 1 year after retreatment was 33% and only 14% after 1.75 years. No IOP elevations greater than 6 mmHg were recognized in the postlaser period. Although retreatment with argon laser trabeculoplasty can safely be used to control the IOP in some glaucomatous eyes, the likelihood of success is low.