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Purpose: To assess patient comfort using combined anterior sub-Tenon's, topical, and intracameral ("Blitz") anesthesia versus retrobulbar anesthesia in glaucoma surgery., Patients and Methods: In this study, 139 consecutive patients who received retrobulbar anesthesia and 139 consecutive patients who received Blitz anesthesia during glaucoma surgery were evaluated in a prospective fashion. The retrobulbar group included 49 trabeculectomies, 36 aqueous shunts, and 54 phacotrabeculectomies. The Blitz group included 49 trabeculectomies, 30 aqueous shunts, and 60 phacotrabeculectomies. Patients were asked to assess their level of ocular pain operatively and postoperatively on a 10-point visual analog scale. The operative and postoperative pain scores and postoperative sedation of patients receiving retrobulbar anesthesia were compared with those of patients receiving Blitz anesthesia during trabeculectomy, phacotrabeculectomy, and aqueous shunt surgery, separately., Results: No statistically significant difference was found in the mean operative or postoperative pain scores between the two groups during trabeculectomy, phacotrabeculectomy, or aqueous shunt surgery., Conclusions: Blitz anesthesia offers a reasonable alternative to retrobulbar anesthesia for trabeculectomy, phacotrabeculectomy, and aqueous shunt surgery.

Background and Objective: To evaluate the long-term outcome of aqueous shunts in the treatment of infantile glaucoma refractory to conventional treatment., Patients and Methods: The records of all patients up to 3 years of age managed with aqueous shunts for uncontrolled glaucoma between November 1990 and November 1996 were retrospectively reviewed. Ten eyes of 6 patients were included in the study., Results: The mean preoperative intraocular pressure (IOP) was 29.75 +/- 4.15 (mm Hg; SD), with none of the eyes on antiglaucoma medication. Postoperatively, the mean IOP was 18.25 +/- 5.34 (mm Hg; SD) at a mean follow up of 50 +/- 25.6 (SD) months with 7 eyes on topical antiglaucoma medication. At the final follow up, 6 eyes were considered successfully controlled without reintervention, 2 more were controlled after shunt revision, and 2 were considered failures., Conclusions: Aqueous shunts were relatively effective in this series of infants with recalcitrant glaucoma.

Objective: To evaluate and compare the outcome of functioning filtration surgery followed by cataract surgery with posterior intraocular lens implantation by both phacoemulsification and extracapsular cataract extraction (ECCE) techniques in glaucomatous eyes., Patients and Methods: We retrospectively evaluated the clinical course of 77 eyes (68 patients) that after successful trabeculectomy, underwent cataract surgery by either phacoemulsification or ECCE techniques. We determined the frequency of partial and absolute failure following cataract surgery by either phacoemulsification or ECCE in eyes with functioning trabeculectomies. Partial failure of intraocular pressure (IOP), control after cataract extraction was defined as the need for an increased number of antiglaucoma medications or argon laser trabeculoplasty to maintain IOP < or =21mm Hg. Complete failure of IOP control after cataract surgery was defined as an IOP >21 mm Hg on at least two consecutive measurements one or more weeks apart or the performance of additional filtration surgery. Failure rates were calculated using the Kaplan-Meier actuarial method. Failure rates between phacoemulsification and ECCE subgroups were compared using the log rank test., Results: The probability of partial failure by the third postoperative year after cataract surgery was 39.5% in the phacoemulsification subgroup and 37.3% in the ECCE subgroup. This small difference is not statistically significant (P = 0.48). The probability of complete failure by the fourth postoperative year after cataract surgery was 12.0% in the phacoemulsification subgroup and 12.5% in the ECCE subgroup. This difference is also not statistically significant (P = 0.77). At the 6-month follow-up visit, visual acuity of both groups improved one or more lines in 87.0% of patients, and worsened one or more lines in 3.9% of patients. Sixty-one percent achieved visual acuity of 20/40 or better. The most frequent complication was posterior capsular opacification requiring laser capsulotomy that occurred in 31.2% of patients., Conclusion: Cataract extraction by either phacoemulsification or ECCE following trabeculectomy surgery may be associated with a partial loss of the previously functioning filter and the need for more antiglaucoma medications to control IOP.

Background and Objective: To evaluate the outcome of Baerveldt implantation with adjunctive mitomycin-C in cases of complicated glaucoma., Patients and Methods: The authors reviewed the charts of all patients who had undergone Baerveldt implantation with mitomycin-C between January 1993 and March 1995. Success was defined before data collection as an intraocular pressure (IOP) between 5 and 21 mm Hg, with or without medications. The success rate was calculated using the Kaplan-Meier actuarial method., Results: Twenty-nine patients were identified. The mean preoperative IOP was 33.6 mm Hg, with an average of 2.0 antiglaucoma medications. The probability of success at 6 and 12 months for patients who received mitomycin-C during Baerveldt implantation was 82.4% and 73.3%, respectively. Choroidal effusion with a flat anterior chamber (10.3%), corneal edema (6.8%), and conjunctival erosion (6.8%) were the most frequent complications., Conclusion: In this retrospective series of complicated glaucoma, the implantation of a Baerveldt drainage device with adjunctive mitomycin-C had a satisfactory outcome. The complications encountered and the clinical efficacy were comparable to those of previously reported series in which mitomycin-C was not used.

Background and Objective: To compare the use of subconjunctival and peribulbar anesthesia for trabeculectomy., Patients and Methods: Sixty patients undergoing trabeculectomy were prospectively randomized to receive either peribulbar or subconjunctival anesthesia. Peribulbar anesthesia consisted of a 3-ml inferior and a 1-ml superior injection of a 1:1 mixture of 2% mepivacaine, 0.75% bupivacaine, and hyaluronidase. Subconjunctival anesthesia consisted of a 1- to 2-ml injection of the same mixture without hyaluronidase in the superotemporal quadrant. Intraoperative pain, presence of eye movements, and complications during surgery were evaluated., Results: The frequency and intensity of pain was statistically similar between the two groups. All episodes of pain (20% in the subconjunctival group and 6.6% in the peribulbar group) were rated as mild. Eye movement was more common in the subconjunctival group than in the peribulbar group, but it was controlled by verbal command and did not interfere with the procedure. No clinically significant complications occurred during surgery., Conclusion: Subconjunctival anesthesia is an effective alternative to peribulbar anesthesia for trabeculectomy.

Background and Objective: To determine the frequency of encapsulated blebs after guarded filtration procedures with mitomycin-C., Patients and Methods: The authors reviewed the charts of all patients who had undergone a guarded filtration procedure with mitomycin-C. There were 235 patients (283 cases) who had more than 1 month of follow-up., Results: An encapsulated bleb developed in 7 eyes (2.47%) of 6 patients. Identification of bleb encapsulation occurred at a mean follow-up time of 29.7 +/- 14.6 days after surgery. The mean intraocular pressure at that point was 24.2 +/- 13.5 mm Hg in the affected eyes. Three eyes were treated medically, and needling was performed in 4 eyes., Conclusion: There is a low frequency of encapsulated bleb formation after guarded filtration procedures with adjunctive mitomycin-C.

The goal of glaucoma filtering surgery is to achieve adequate control of intraocular pressure (IOP). This prospective study evaluates the authors' accuracy in predicting IOP for the first postoperative day (POD 1) through digital palpation of the globe and evaluation of the achieved leakage at the end of trabeculectomy. Fifty patients underwent trabeculectomy with or without the use of an antimetabolite. At the conclusion of the procedure, an IOP prediction for POD 1 was given by the surgeon. The recorded IOP readings on POD 1 were compared with this prediction. The results were evaluated by linear regression analysis. The IOP predictions were within +/- 3 mm Hg of the forecasted value for 31 patients (62%), within +/- 6 mm Hg for 44 patients (88%) and outside of +/- 6 mm Hg for 6 patients (12%). Short-term postoperative IOP control is reasonably predictable and may be adjusted for individual care.