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OBJECTIVE To compare the efficacy of the nonvalved double-plate Molteno implant with two valved implants, the Krupin Eye Valve with Disc and the Ahmed Glaucoma Valve, in the treatment of recalcitrant glaucoma. PATIENTS AND METHODS The authors performed a nonrandomized retrospective review of patients who received the Molteno implant (n = 27), Krupin Eye Valve with Disc (n = 13), or Ahmed Glaucoma Valve (n = 13), with adjunctive mitomycin C. RESULTS Kaplan-Meier life-table analysis showed that the Molteno implant patients were more likely to maintain an intraocular pressure between 5 and 15 mm Hg than Ahmed Glaucoma Valve patients (P = 0.03). Success rates at 1 year were 80% (95% CI, 66-97%) for the Molteno implant, 39% (19-77%) for the Krupin Eye Valve with Disc, and 35% (15-82%) for the Ahmed Glaucoma Valve. However, Ahmed Glaucoma Valve patients were less likely to experience complications requiring reoperation or loss of two or more lines of visual acuity (P < 0.01) than Molteno implant or Krupin Eye Valve with Disc patients. CONCLUSIONS This nonrandomized study suggests that the Molteno implant with mitomycin C is more likely to result in intraocular pressures in the lower teens than the Ahmed Glaucoma Valve with mitomycin C. The findings suggest that the Ahmed implant is less likely to create problems leading to reoperations or visual acuity loss than the Molteno or Krupin implants.

Purpose The purpose of this study is to evaluate effects of vitrectomy (PPV) and lens extraction with intraocular lens implantation (PE/IOL) on molecular oxygen (pO2) distribution, aqueous humor antioxidant-oxidant balance, aqueous humor dynamics, and histopathologic changes in the trabecular meshwork (TM) in the older macaque monkey. Methods Six rhesus monkeys underwent PPV followed by PE/IOL. pO2, outflow facility, and intraocular pressure (IOP) were measured. Aqueous and vitreous humor specimens were analyzed for antioxidant status and 8-hydroxy-2'-deoxyguanosine (8-OHdG), a marker of oxidative damage. TM specimens were obtained for immunohistochemical and quantitative PCR analysis. Results pO2 at baseline revealed steep gradients in the anterior chamber and low levels in the posterior chamber (PC) and around the lens. Following PPV and PE/IOL, pO2 significantly increased in the PC, around the IOL, and angle. IOP increased following both surgical interventions, with no change in outflow facility. Histopathologic analysis did not show changes in TM cell quantification, but there was an increase in 8-OHdG. Quantitative PCR did not reveal significant differences in glaucoma-related gene expression. Aqueous and vitreous humor analysis revealed decreased ascorbate and total reactive antioxidant potential and increased 8-OHdG in the aqueous humor only in the surgical eyes. Conclusions Oxygen distribution in the older rhesus monkey is similar to humans at baseline and following surgical interventions. Our findings of histopathologic changes of TM oxidative damage and alterations in the oxidant-antioxidant balance suggest a potential correlation of increased oxygen exposure with oxidative stress/damage and the development of open angle glaucoma.

Purpose: To determine efficacy and safety of latanoprost, a prostaglandin analog for glaucoma, during 1 year of treatment. Methods: After baseline measurements, 0.005% latanoprost was topically applied once daily for 12 months in patients from Scandinavia, the United Kingdom, and the United States who had elevated intraocular pressure (IOP). Diagnoses included ocular hypertension, chronic open-angle glaucoma, exfoliation syndrome, and pigment dispersion syndrome. Treatment was masked for the first 6 months and open-label during the second 6 months. Results: Of the 272 patients initially enrolled, withdrawals were due to inadequate IOP control (1 %), increased iris pigmentation (5%), other ocular problems (3%), systemic medical problems (3%), and nonmedical reasons (14%). Latanoprost significantly ( P Conclusion: Latanoprost safely and effectively reduces IOP for 1 year in patients of diverse nationalities, providing further evidence for its usefulness in chronic glaucoma therapy.

Recent reports from large clinical trials have clearly demonstrated that lowering intraocular pressure (IOP) in persons with ocular hypertension has a beneficial effect on reducing the progression of glaucomatous disease. Few studies of this effect have been conducted in controlled laboratory settings, however, none have been conducted using non-human primates, the model of experimental glaucoma considered most similar to the human disease. Using data collected retrospectively from a trabeculectomy study using 16 cynomolgous monkeys with experimental ocular hypertension, we evaluated both the threshold of elevated IOP required to cause clinically observable damage to the optic nerve head and also if lowering IOP below this threshold prevents further damage. An index of the level of elevated IOP experienced by experimental eyes (the Pressure Insult) was calculated as the slope of the difference in cumulative IOP between experimental and control eyes during four intervals of time over the course of the experiment, while damage to the optic nerve head was evaluated by measuring the Cup:Disc ratio for each eye from stereoscopic photographs taken at the end of each interval. An increase in the Cup:Disc ratio was significantly associated with both the maximum IOP obtained in the experimental eye during each interval (r = 0.573, P < 0.001) and the Pressure Insult (r = 0.496, P < 0.001). Pressure Insult values less than 11 mm Hg Days/Day were not associated with glaucomatous damage in monkey eyes, whereas values greater than 11 showed a significant correlation with increasing Cup:Disc ratios (P < 0.001). Trabeculectomy to reduce the Pressure Insult below 11 was correlated with an attenuation of the rate of progression of the Cup:Disc ratio in eyes that had exhibited damage before surgery. These results contribute further to our understanding of this model of experimental glaucoma by demonstrating a threshold at which IOP needs to be elevated to stimulate damage, while also providing corroborating evidence that lowering IOP in ocular hypertensive monkeys can attenuate the progression of glaucomatous disease.

Objectives To determine the incidence of late-onset bleb-related complications following trabeculectomy with mitomycin and to report the management and outcome of bleb leaks following trabeculectomy with mitomycin. Methods A retrospective medical record review of all patients who underwent trabeculectomy with mitomycin from June 1, 1991, through April 30, 1998, at our institution was performed. The Kaplan-Meier survival method was used to estimate the probability of (1) endophthalmitis, (2) blebitis, (3) a bleb leak, and (4) the combined outcome (the first occurrence of a bleb leak, blebitis, or endophthalmitis). This survival analysis included only the first trabeculectomy in an eye, with at least 3 months of follow-up during the study period. A separate description of bleb leak management and outcome was performed. Results Two hundred thirty-nine eyes of 198 patients were included in the survival analysis. The average follow-up was 2.7 (range, 0.3-7.3) years. Twenty eyes(8%) from 19 patients experienced a bleb leak; the adjusted incidence was 3.2% per patient-year. Five eyes (2%) had an episode of blebitis. Eight eyes(3%) experienced an episode of endophthalmitis; the follow-up adjusted incidence(number of events per patient-year) was 1.3%. Twenty-seven eyes (11%) from 26 patients had at least 1 of the complications of a bleb leak, blebitis, or endophthalmitis; the adjusted incidence was 4.4% per patient-year. A Kaplan-Meier analysis estimated the 5-year probability of developing a bleb leak, blebitis, or endophthalmitis to be 17.9%, 6.3%, and 7.5%, respectively. Two hundred fifty-eight trabeculectomies in 242 eyes of 198 patients were included in the description of bleb leak management and outcome. Bleb leaks occurred in 22 eyes (9% of the 258 trabeculectomies). Seventeen eyes were successfully treated with office-based measures, and 4 ultimately underwent surgical bleb revision. One eye without infection continued to leak after 11 months of office-based therapy. Conclusions There is significant morbidity associated with a trabeculectomy with mitomycin. The incidence of a bleb leak or an infection continues at a fairly constant rate over time, such that at 5 years, up to 23% of all patients might develop one of these complications. An isolated bleb leak seems to be a relatively benign condition, as three quarters resolve with office-based methods.

Objective To determine the incidence of intraocular pressure (IOP) rise of varying degrees after laser peripheral iridotomy (LPI) in patients with and without glaucoma treated perioperatively with pilocarpine and apraclonidine. Design A retrospective chart review. Participants A total of 289 eyes in 179 patients with narrow occludable angles (NOA) (N = 148), open-angle glaucoma or ocular hypertension (OAG) (N = 115), or chronic-angle closure glaucoma (CACG) (N = 26) were reviewed. Main outcome measures The difference between preoperative and postoperative IOP, absolute postop- erative IOP, and the need for acute IOP-lowering treatment was noted. Results Only 1.1% (95% confidence interval [CI], 0.03%–5.8%; 1 of 94) of patients and 0.7% (95% CI, 0.02%–3.7%; 1 of 148) of eyes with NOA experienced a rise of more than 10 mmHg 1 to 2 hours after LPI. The incidence of postoperative IOP greater than 25 mmHg and acute postoperative IOP-lowering management was 0% (95% CI, 0%–3.8%). Intraocular pressure in 1 of 115 eyes (0.9%, 95% CI, 0.02%–4.7%) with OAG rose more than 10 mmHg, requiring acute treatment. None of the 26 CACG eyes experienced a rise of more than 10 mmHg (95% CI, 0%–13.2%). Conclusion The IOP rise that requires further intervention after LPI with the perioperative use of pilocarpine and apraclonidine is very uncommon. In patients with NOA, routine postiridotomy IOP monitoring may not be required.

Purpose: The authors assessed the efficacy of adjunctive intraoperative mitomycin C to produce lower intraocular pressures (IOPs) in patients with complicated glaucoma who underwent double-plate Molteno implantation. Methods: A pilot series of 21 consecutive patients who underwent double-plate Molteno implantation with adjunctive intraoperative mitomycin C (0.5 mg/ml) for 5 minutes was compared with a historical control group who received Molteno implants without mitomycin C (n = 18). With failure defined as an IOP greater than 21 or less than 6 mmHg at two observations 1 month apart, the addition of medication, re-operation for glaucoma, or tube removal, a life-table analysis of IOP was performed on patients with at least 3 months' follow-up. Results: Success in the mitomycin C group was higher (68% at 1 year) than the control group (17% at 1 year; P = 0.006). Loss of more than one line of vision (33%) and re-operation for complications (including flat anterior chamber, choroidal detachment, and tube blockage) (38%) were slightly but not significantly more frequent in the mitomycin C group than in the control group. Conclusion: This study suggests that intraoperative mitomycin C in conjunction with Molteno implant may offer a better chance of achieving target IOPs in the low teens in patients with complicated glaucoma than Molteno implantation alone.

Purpose This study was performed to provide results 2 to 3 years after trabeculectomy with mitomycin C (MMC). Methods A consecutive series of all 68 patients who underwent trabeculectomy with MMC was analyzed using Kaplan-Meier life-table statistics and compared with other published retrospective analyses. Results At 2- and 3-year follow-up examinations, 59% (95% confidence interval [CI], 44-70%) and 47% (95% CI, 32-61%) of patients, respectively, avoided an intraocular pressure (IOP) of more than 21 mmHg or less than 20% below their preoperative level without glaucoma medication on two consecutive occasions more than 1 month apart after 3 months follow-up (75% [95% CI, 60-84%] and 70% [95% CI, 53-81%], respectively, with medication) and avoided additional glaucoma surgery. Loss of more than three lines of visual acuity on two occasions more than 1 month apart after 3 months follow-up occurred in 28% of patients (> 2 lines in 44%) at 3 years. Nonreversible causes of loss of three lines of acuity occurred in 13% of patients. Complications requiring reoperation occurred in 16% of patients and included hypotony maculopathy (4%) and late bleb leaks (4%). Conclusions At the 3-year follow-up evaluation, trabeculectomy with MMC provided an approximately 50% chance of maintaining IOPs less than 21 mmHg and a more than 20% IOP reduction without concomitant use of glaucoma medication, which increased to 70% with the addition of medication. This procedure was associated with an approximately 30% risk of substantial visual loss (approximately 15% nonreversible) and a 15% chance of reoperation for complications.

Imaging technology has rapidly developed during the past decade, and today's practitioners are faced with an increasingly bewildering list of tests to order and machines to purchase. This text attempts to help practitioners sort out which technologies are appropriate for individual patients. The content and organization of the text have origins in the New England Eye Center's Imaging in Glaucoma: The Boston Glaucoma Course 1996. Although not a direct transcript of the course, the text is written by the speakers at that meeting. The preface indicates that the intended audience is "both general ophthalmologists and glaucoma specialists" and other eye-care professionals may also benefit. The text includes discussion of all the major imaging techniques appropriate to glaucoma. Each chapter is written by an acknowledged expert in the field, and all are well-written and concise. The book is divided into 4 major sections. The first section, "Assessing the Structure of the

The third volume of the Atlas of Ophthalmic Surgery , which includes strabismus and glaucoma, is really much more than a simple atlas. The glaucoma section includes a chapter on the anatomical principles and landmarks of glaucoma surgery; a short section regarding glaucoma laser surgery; long chapters on trabeculectomy, full-thickness filtering procedures and their complications, drainage device implantation, goniotomy, trabeculotomy, and laser therapy and cryotherapy in glaucoma; and concludes with a section on combined cataract and glaucoma surgery. I was impressed with the book from the first page of the glaucoma section. The initial page on the reader's left is solid text and the accompanying diagrams are on the right. The text is complete and concise. The diagrams are in full color, well labeled, and sufficiently detailed to provide an adequate reference for new surgeons. As in all other chapters, references are provided. Beginning with the chapter on anterior chamber angle

Few areas of ophthalmology are changing as fast as the diagnosis and treatment of glaucoma.Pharmacology of Glaucomais an update of the 1983 version, which was a summary of a meeting held to celebrate the opening of the Eye Care Centre in British Columbia. On Drance's recent retirement from heading the department there, he believed it fitting to update the information on these topics to reflect the gains in knowledge made in this field over the intervening 9 years. As such, this text is an attempt to summarize the current status of medical treatment research for glaucoma as well as to share some vision of the future and what form the next decade of advances will take. The level of the text is aimed at the basic science researcher and/or astute clinician, and clearly is not intended for those new to glaucoma. The first few chapters discuss surgical pharmacology

Recent technology has greatly affected the treatment of glaucoma. New materials for setons, antimetabolite therapies, and laser sclerostomies are being actively investigated and hold promise for improving the care of glaucomatous eyes. Similar advances in the detection of glaucomatous damage and its inevitable progression are no less exciting. Much attention has been placed on psychophysical methods of functional loss measurement, including advanced computerized perimetry techniques and contrast-sensitivity measurements. The application of the new technology to the morphological changes caused by glaucoma has also been an active area of advancement. TheOptic Nerve in Glaucomaaddresses these advances and brings the reader up to date in this important area. "... will provide the practicing generalist with all the background needed to follow future developments in this fast-improving field." The preface of the text states that its purpose is to "provide the glaucoma specialist and general ophthalmologist alike a comprehensive overview of the