Transscleral suture fixation of posterior chamber lenses combined with trabeculectomy

OBJECTIVE

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

DESIGN

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

SETTING

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

PATIENTS

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

RESULTS

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

CONCLUSIONS

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

The effect of adjunctive mitomycin C in Molteno implant surgery

PURPOSE

The purpose of the study is to assess the effect of adjunctive intraoperative mitomycin C (MMC) in Molteno drainage device implantation for patients with recalcitrant glaucomas.

METHOD

Forty-nine eyes of 49 patients who underwent one-stage, single-plate Molteno device implantation with adjunctive intraoperative MMC (0.5 mg/ml) for 3 to 5 minutes (MMC group) were compared to a historic control group of 51 eyes of 51 patients (control group) who received one-stage, single-plate Molteno device implantation without MMC. Success (survival) was defined as an intraocular pressure (IOP) between 6 and 21 mmHg, inclusive, with (qualified success) or without (complete success) glaucoma medications and with no additional glaucoma surgery, phthisis, implant removal, or loss of light perception.

RESULTS

Preoperative conditions were similar between the two groups. There was no significant difference in surgical survival rate between the two groups (P = 0.13, log-rank test). There also were no significant differences in the postoperative IOP levels and numbers of antiglaucoma medications between the two groups at all times (P > 0.05). Visual acuity was improved or remained within one line of preoperative visual acuity in 76.1% of the MMC group and 78.7% of the control group at 1 year after surgery (P = 0.76, chi-square test). Complications and reoperation for complications were similar in both groups (P > 0.05, chi-square test) except for the incidence of early postoperative hypotony and the total number of eyes with complications not requiring reoperation, which were more common in the MMC group (P = 0.027, 0.005, respectively, chi-square test). The most common complications included hypotony with or without a flat anterior chamber or choroidal detachment, followed by hyphema and tube plugging.

CONCLUSION

Molteno device implantation with adjunctive intraoperative MMC in patients with complicated glaucoma may not offer a better chance of surgical success compared with Molteno implantation without MMC.

Adjunctive subconjunctival mitomycin C in glaucoma triple procedure

PURPOSE

To evaluate the potential benefit of adjunctive subconjunctival mitomycin in patients with primary open-angle glaucoma undergoing primary trabeculectomy combined with phacoemulsification and intraocular lens implantation.

METHODS

Seventy-eight eyes of 78 patients with primary open-angle glaucoma with visually symptomatic cataracts and no previous incisional surgery were randomized to receive either no mitomycin C or a subconjunctival application of 1-, 3-, or 5-minute mitomycin C (0.5 mg/ml).

RESULTS

Follow-up (mean +/- standard deviation) was 21.0 +/- 7.7 months. The mean postoperative intraocular pressures were significantly lower with significantly less medications than the preoperative values at each follow-up time (1, 3, 6, 9, 12, 15 months, and last follow-up) for all groups (P < 0.05 for each). However, there was no significant difference at each follow-up time in intraocular pressure, medications, or best-corrected visual acuity among the four groups or between the control and the total mitomycin C group.

CONCLUSION

Adjunctive subconjunctival mitomycin C did not further improve the final intraocular pressure outcome of the primary trabeculectomy combined with phacoemulsification and intraocular lens implantation in patients with primary open-angle glaucoma. Future studies will determine the appropriate role, if any, for adjunctive mitomycin C in selected primary glaucoma triple procedures.

Cellulose sponge punch for controlled mitomycin application

We describe a new punch for cellulose sponges that helps to standardize the application of mitomycin during glaucoma filtration surgery. The punch was used to create 40 cellulose application disks. The height, diameter, and weight were measured in both wet and dry states. The disk dimensions and weights were reproducible, with a coefficient of variation less than 5 for all categories. The punch has been very useful in our clinical practice and research.

Herpes simplex keratitis following argon laser trabeculoplasty

Many complications have been reported with argon laser trabeculoplasty (ALT). In the following article, we report the first case of Herpes simplex keratitis recurrence being triggered after ALT.