Scleritis, uveitis, and glaucoma in a patient with rheumatic fever

PURPOSE

To determine the origin of scleritis, uveitis, and glaucoma in a boy with fever, sore throat, joint pains, and malaise.

METHODS

The patient underwent extensive hematologic, serologic, rheumatologic, and radiologic examinations.

RESULTS

The patient recovered after extensive medical therapy. He met the Jones criteria for the diagnosis of acute rheumatic fever and had an increased result for antistreptolysin O antibody titer.

CONCLUSIONS

Antistreptococcal antibody testing is helpful in diagnosing rheumatic fever as a cause of scleritis, uveitis, and glaucoma.

Pustular psoriasis precipitated by acetazolamide

We report a case of pustular psoriasis precipitated by acetazolamide, a carbonic anhydrase inhibitor. A 28-year-old man suffering from 20 years-standing generalized pustular psoriasis developed psoriatic arthritis and glaucoma and experienced a precipitation of pustular lesions and widespread erythema after initiation of oral acetazolamide for glaucoma. The cutaneous lesions and systemic symptoms improved after restriction of acetazolamide and administration of oral etretinate. Readministration of acetazolamide confirmed that generalized pustules arose within 24 hours.

[New trends in conservative treatment of glaucoma]

The two principal pathophysiological mechanisms of glaucomatous process (hydromechanical and metabolic) determine the development of two trends in the treatment of glaucoma. One treatment modality is aimed at reduction of intraocular pressure, the other at therapy of hemodynamic and metabolic disorders. General and local drug therapy and physiotherapy, including electro- and laser stimulation of the retina and optic nerve and magneto-therapy, are used to correct these disorders. Modern ocular hypotensive agents are myotics and beta-adrenoblockers, adrenergic drugs, alpha 2-agonists, carboanhydrase inhibitors, some prostaglandins, osmotic agents. The author emphasizes that drugs should be selected individually and regularly replaced in order to prevent the development of the habituation phenomenon and the negative side effects. The progress attained in conservative therapy of glaucoma should by no means be overstated. In many cases only a combination of conservative and surgical methods of treatment helps preserve vision in a glaucoma patient.

Scleritis after glaucoma filtering surgery with mitomycin C

BACKGROUND

Adjunctive intraoperative mitomycin C increases the success of glaucoma filtering surgery, but also the postoperative complications. This is the first report of scleritis after its use.

PATIENTS

In five patients, scleritis developed 3 to 24 weeks after inferior trabeculectomy with mitomycin C. The onset was characterized by acute pain, redness of the eye, and decreased vision. Three patients had anterior scleritis and two had posterior scleritis. Infection or bleb leakage was not seen in any patient.

RESULTS

All patients responded to a course of topical steroids and oral ibuprofen or prednisone.

CONCLUSION

Anterior and posterior scleritis may complicate the use of topical mitomycin C during trabeculectomy, Prompt diagnosis and treatment reverses the inflammation, maintaining the success of the surgical procedure.

Perioperative considerations of glaucoma

Perioperative nurses need to have a basic understanding of the anatomy of the globe and the physiological effects of the intraocular pressure from glaucoma. Surgical procedures are implemented initially for closed-angle (acute) and congenital glaucoma because of the emergent status of the diagnosis. The patient with open-angle (chronic) glaucoma may have a prolonged medical treatment before the need for surgical procedures.

Follow-up of argon laser trabeculoplasty: is a day-one postoperative IOP check necessary?

BACKGROUND AND OBJECTIVES

To evaluate the benefit of measuring the intraocular pressure (IOP) on the first postoperative day after argon laser trabeculoplasty (ALT).

PATIENTS AND METHODS

We retrospectively reviewed 407 ALT procedures with perioperative apraclonidine performed on 226 patients between January 1991 and December 1993. Data analyzed included type of glaucoma, extent of treatment, whether the procedure was initial or repeat, laser parameters, and IOP preoperatively and at 1 hour, 1 day, and 1 month postoperatively.

RESULTS

The percentage of patients with an IOP rise of greater than 3 mm Hg at 1 hour, 1 day, and 1 month following ALT was 11.3%, 4.2%, and 5.2% respectively. The incidence of IOP elevations greater than 10 mm Hg was 2.2%, 1.0%, and 1.5% at 1 hour, 1 day and 1 month, respectively. Of 17 cases with an IOP elevation greater than 3 mm Hg at 1 day, four eventually required a trabeculectomy. However, there were no consistent factors that distinguished which cases with elevated IOP at 1 day ultimately needed further therapy, nor did the 1-day postoperative examination predict which patients would have IOP elevation at 1 month.

CONCLUSION

IOP 1 day after ALT is rarely elevated and does not correlate with IOP elevation at 1 month. Therefore, an IOP check at 1 day is not felt to be necessary for most patients.

Ophthalmic cyclosporine in equine keratitis and keratouveitis: 11 cases

Topical cyclosporine A was safely used in a series of 11 cases of equine keratitis and keratouveitis and appeared to be an effective anti-inflammatory agent in 9 cases. The clinical diagnoses included interstitial keratouveitis, endotheliitis, multifocal punctate keratopathy and a melting stromal ulcer. In most cases, the presence or absence of insidious bacterial infection was not conclusively determined. Topical cyclosporine A had no deleterious effects in this series of cases. The authors suggest that topical cyclosporine in both aqueous and lipid base vehicles should be investigated and evaluated as an alternative mode of achieving ocular immunosuppression.

Mitomycin C versus 5-fluorouracil in high-risk glaucoma filtering surgery. Extended follow-up

PURPOSE

To compare the outcome of filtering surgery in high-risk patients using intraoperative mitomycin C (MMC) versus postoperative 5-fluorouracil (5-FU).

METHODS

In a randomized clinical trial, the use of postoperative subconjunctival injections of 5-FU in 19 eyes of 19 patients was compared with a single intraoperative application of MMC in 20 eyes of 20 patients. All eyes were at high risk for failure of glaucoma filtering surgery.

RESULTS

Follow-up ranged from 26 to 38 months (mean, 32.0 months). Three eyes in the MMC-treated group and two eyes in the 5-FU-treated group required subsequent surgery to control the IOP. Excluding these patients, intraocular pressure (IOP) averaged 9.0 +/- 4.9 mmHg in the MMC-treated eyes versus 16.3 +/- 4.6 mmHg in the 5-FU-treated eyes at the patient's last visit (P = 0.0003). Of the MMC-treated eyes, 81.3% had IOPs less than or equal to 12 mmHg compared with 26.7% of eyes in the 5-FU group (P = 0.0023). In the MMC-treated group, the average number of medications for IOP control at last visit was 0.5 +/- 0.8 compared with 1.6 +/- 1.3 in the 5-FU-treated group (P = 0.01). Late postoperative complications (those occurring more than 3 months after surgery) were similar for the two groups, with the exception of formation of a Tenon cyst in three of the eyes treated with MMC compared with none of the 5-FU-treated eyes.

CONCLUSIONS

Eyes treated with MMC have lower IOP on fewer medications than eyes treated with 5-FU. Late postoperative complications are similar with the exception of an increased incidence of Tenon cyst formation in the MMC-treated eyes.

[Multicenter double-blind study with 0.25% timolol in Gelrite (TG) once daily vs. 0.25% timolol solution (TS) twice daily. German Study Group]

In a 12-week double-masked trial we compared the ocular hypotensive effect of 0.25% timolol in Gelrite administered once daily (TG) to that of 0.25% timolol solution administered twice daily (TS). A second objective was to compare the tolerability and the safety of these treatments. Timolol in Gelrite is a new topical formulation of timolol in an anionic heteropolysaccharide gellan gum. A total of 156 patients entered the study after an appropriate wash-out. The medication schedule included one drop of test drug in each eye at 9 a.m. (active drug for both groups) and 9 p.m. (placebo for the TG group, active drug for the TS group). At trough, the mean decrease from baseline intraocular pressure (after appropriate wash-out) ranged from 5.7 to 6.3 mmHg for the TG group and from 5.9 to 6.2 mmHg for the TS group. The difference between the treatment group means ranged from -0.4 to 0.4 mmHg. At peak, the mean decrease from baseline IOP ranged from 5.3 to 6.2 mmHg for TG group and from 5.1 to 6.1 mmHg for the TS group. The difference between the treatment group means ranged from -0.7 to 0.4 mmHg. The results of this study support the hypothesis of a comparable hypotensive effect at peak and trough of 0.25% timolol in Gelrite q.d. to 0.25% timolol solution b.i.d. Furthermore, timolol in Gelrite has an acceptable tolerability profile. The incidence of blurred vision was higher in the Gelrite group, but this different was not statistically significant. The incidence of foreign body sensation was significantly higher in the Gelrite group (P < 0.022).(ABSTRACT TRUNCATED AT 250 WORDS)

Retrobulbar arterial hemodynamic effects of betaxolol and timolol in normal-tension glaucoma

PURPOSE

beta-Adrenergic blocking drugs lower intraocular pressure. The question of whether these drugs also alter, either directly or indirectly, orbital hemodynamics is potentially of great importance for patients with normal-tension glaucoma who may have some degree of reversible vasospasm.

METHODS

We compared the effect of selective (betaxolol) and nonselective (timolol) beta-adrenergic blocking drugs on flow velocities (as determined by color Doppler imaging) in orbital vessels in 13 patients with normal-tension glaucoma (mean age, 62 +/- 3 years; mean intraocular pressure, 15 +/- 2 mm Hg). A one-month drug treatment double-masked crossover design, with a three-week washout before each drug, was used.

RESULTS

Neither drug changed peak systolic velocity in any of the four vessels studied (ophthalmic, nasal and temporal posterior ciliary, and central retinal arteries). Additionally, timolol did not alter end-diastolic velocity or resistance index (defined as [peak systolic velocity minus end-diastolic velocity] divided by peak systolic velocity) in any of the vessels measured. In contrast, betaxolol tended to increase end-diastolic velocity and to decrease resistance index: the four-vessel average end-diastolic velocity increased 30% (P = .08), and the four-vessel average resistance index decreased significantly (P = .04). These reductions in resistance index occurred despite that betaxolol, in contrast to timolol, did not significantly decrease intraocular pressure.

CONCLUSIONS

These results suggest that, in patients with normal-tension glaucoma, selective beta-adrenergic blockade (betaxolol) may have ocular vasorelaxant effects independent of any influence on intraocular pressure, whereas nonselective blockade (timolol) lowers intraocular pressure without apparently altering orbital hemodynamics.

Biochemical quantification of triamcinolone in subconjunctival depots

OBJECTIVE

To biochemically quantify the amount of active triamcinolone acetonide remaining after subconjunctival administration and to assess the effectiveness of surgical management for glaucoma induced by triamcinolone.

DESIGN

Case series.

PARTICIPANTS

Seven eyes of seven patients whose ages ranged from 47 to 84 years underwent excision of depot triamcinolone. Six of seven eyes required surgical intervention for medically unresponsive intraocular pressure (IOP) elevation.

RESULTS

Pharmacologically active triamcinolone was identified up to 13 months following injection (range, 3 to 13 months). The mean amount in the excised sample was 5.4 mg (range, 2.0 to 8.8 mg), and the mean percentage of the original sample remaining was 20% (range, 4.2% to 44%). Glaucoma was diagnosed a mean of 3 months after injection (range, 1 to 6 months). Mean IOP was 37 mm Hg before excision and 16 mm Hg after removal. Surgical excision of visible triamcinolone normalized IOP in six of seven patients without need for glaucoma medications.

CONCLUSIONS

Periocular injection of triamcinolone necessitates careful monitoring of IOP. Medically unresponsive IOP elevation may occur as late as 6 months following periocular triamcinolone injection. Surgical excision of remaining triamcinolone depot is an effective therapy for IOP elevation. Guidelines for safely using triamcinolone are discussed.

[The use of prostaglandin compounds in treating glaucoma]

The theoretical part of this paper presents the mechanism of the IOP lowering effect using these drugs, the indications of treatment and the main side effects. The second part consist of the experimental study made on rabbits, using the izopropilic ester of (+)Cloprostenol as an hypotensive agent. We have registered the IOP values and the main side effect--conjunctival hyperemia. The third part consist of the clinical study, made on a test lot of 23 patients. We have used the same substance and in the experimental study, as a unique treatment or in association with a beta-blocker or a pilocarpine derivative. The following-up has implied: the IOP, the ophthalmoscopic appearance of the optic disc, the visual field, the visual acuity and the main side effects. In the end, we have formulated the conclusions of these studies.

The morphology of conjunctiva after long-term topical anti-glaucoma treatment. A quantitative analysis

On biopsy material, differences in the degree of conjunctival inflammation and fibrosis between topically treated glaucoma patients and age matched controls, were examined histologically. Eighteen patients with primary glaucoma underwent goniotrephinations, because maximal medical therapy had failed. The patients had received at least two types of topical anti-glaucoma drugs for at least 12 months (mean 46 months). The control group consisted of 18 age-matched control patients without glaucoma, who had received no topical therapy. These patients underwent cataract surgery or squint surgery. Biopsies were taken from the infero-temporal bulbar quadrant with a biopsy forceps. The specimens were fixed while stabilized on a rubber support to exclude any major shrinkage. Specimens were analyzed by light microscopy for the content of inflammatory cells (plasma cells, lymphocytes, polymorphs, macrophages and mast cells), goblet cells and fibroblasts. No significant difference in the histologic parameters between the two groups could be demonstrated. The study suggests that topical treatment for periods up to 4 years with anti-glaucoma drugs does not induce morphological signs of inflammation and fibrosis of the conjunctiva.

The short-time effect of latanoprost on the intraocular pressure in normal pressure glaucoma

Latanoprost, a prostaglandin analogue, was given topically to 20 patients with normal pressure glaucoma in a double masked randomized study. Either latanoprost 0.006% or placebo (vehicle) was administered twice a day for 14 days. Latanoprost caused a statistically significant (p < 0.001) reduction in intraocular pressure from a diurnal baseline level of 16.8 to 14.3 mmHg, as measured on day 14. Latanoprost was well tolerated.

Compliance in patients prescribed eyedrops for glaucoma

We studied the rate of failure to use eyedrops as prescribed for glaucoma and some of the factors possibly associated with that noncompliance by interviewing 100 patients being followed in a setting emphasizing correct usage. Fifty-nine reported they had not used their eyedrops precisely as prescribed. Factors significantly influencing compliance included daily dose frequency, forgetfulness, inconvenience, and unaffordability. Gender and race were marginally significant factors, with men and blacks reporting somewhat higher rates of missed doses than women and whites. Side effects and age were not significant causes of noncompliance.

Effect of mitomycin C and fluorouracil-supplemented trabeculectomies on the anterior segment

OBJECTIVES

To determine whether there is increased risk to the corneal endothelium when mitomycin C is used in trabeculectomy surgery instead of fluorouracil, and whether these agents play a role in accelerating cataract formation.

DESIGN, SETTINGS, AND PARTICIPANTS

We analyzed the corneal endothelium and the lens preoperatively and postoperatively in 30 eyes of 21 patients who underwent either a fluorouracil- or mitomycin C-supplemented trabeculectomy.

RESULTS

No significant differences were found between these two groups in the rate of cataract progression, magnitude of endothelial cell loss, or appearance of endothelial cell morphologic characteristics. Endothelial cell loss accounted for approximately 7% to 8% of the preoperative counts in both groups. In addition, four (27%) of 15 eyes in each group showed evidence of cataract progression as graded by the Lens Opacities Classification System II.

CONCLUSION

Fluorouracil- and mitomycin C-supplemented trabeculectomies cause similar changes in the lens and corneal endothelium.

Decrease of intraocular pressure after subconjunctival injection of mitomycin in human glaucoma

OBJECTIVE

To investigate the effects of a subconjunctival injection of mitomycin on the intraocular pressure in human eyes affected by glaucoma.

DESIGN

Consecutive case series, prospective study, intraocular pairwise comparison (paired samples Student's t test adopted).

SETTING

Hospital-based glaucoma clinic.

PATIENTS

Twelve consecutive patients with bilateral glaucoma and monolateral blindness, intraocular pressure greater than 30 mm Hg in the blind eye (mean of the two highest values of the diurnal curve, confirmed at 96-hour interval), and no previous bulbar surgery.

INTERVENTION

Subconjunctival injection of 0.5 mL of 0.2% mitomycin in the upper temporal quadrant, preceded and followed by treatment with topical indomethacin.

MAIN OUTCOME MEASURE

Analysis of the variance of the mean intraocular pressure before and after the injection of mitomycin in each eligible eye.

RESULTS

An intraocular pressure decrease was observed in each eligible eye the day after the treatment (mean [+/- SD] decrease, 7.15 +/- 1.46 mm Hg). The effect was still detectable at the end of the 60 days of follow-up (mean [+/- SD] decrease, 5.67 +/- 1.61 mm Hg). No change of intraocular pressure, in the meantime, was observed in the fellow eye.

CONCLUSIONS

Topically applied mitomycin induces a decrease of intraocular pressure in human glaucomatous eyes. Our data confirm previous results obtained in albino rabbits and support the hypothesis that mitomycin exerts a still unknown direct effect on aqueous humor dynamics in the eye.

Acute pulmonary edema associated with ocular metipranolol use

OBJECTIVE

To report a case of pulmonary edema associated with the use of ocular metipranolol, a nonselective beta-blocker.

CASE SUMMARY

A 72-year-old woman with no history of pulmonary or cardiac disease presented to the emergency room with signs and symptoms consistent with cardiogenic pulmonary edema. The patient had used metipranolol eyedrops approximately 1 hour before becoming symptomatic. When rechallenged inadvertently while hospitalized, the patient again became symptomatic. The patient's metipranolol eyedrops then were substituted with betaxolol eyedrops. She continued to be free of symptoms of pulmonary edema at subsequent clinic visits 1, 4, and 6 weeks following discharge.

DISCUSSION

This is the first reported case of pulmonary edema associated with metipranolol. There was a reasonable temporal association between use of the eyedrops and the onset of symptoms. Beta-blockers may cause cardiogenic pulmonary edema secondary to their negative inotropic and negative chronotropic effects. The drug's lipid solubility or a deficiency in the enzyme responsible for its metabolism may have allowed the drug to accumulate to a critical concentration over the 6-week period of use.

CONCLUSIONS

Ocular beta-blockers must be used with caution in patients with relative contraindications to beta-blockade. This case illustrates that these agents must be used prudently even in patients with no history of symptomatic congestive heart failure.