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AIM: To apply survival analysis in assessing the long term outcome of Molteno tube implantation and to identify risk factors for failure. METHODS: A retrospective, 10 year, consecutive case series study of 119 eyes that underwent implantation of a Molteno tube. The main outcome measures considered were intraocular pressure (IOP), visual acuity, and complications. RESULTS: A 30% or greater reduction in IOP was achieved in 68.9% of cases. However, the overall, "complete success" rate (IOP <22 mm Hg with no medications) after a mean (SD) follow up period of 43 (33) months (range 6-120) was only 33.6% despite a fall in mean (SD) IOP from 38.2 (8.2) mm Hg to 20.1 (11.0) mm Hg. The "qualified success" rate (IOP <22 mm Hg with or without medications) was 60.5%. Failure was most common in the first postoperative year but could occur after several years, the survival curve having an exponential shape. The only statistically significant risk factor for failure identified was pseudophakia, although eyes with neovascular glaucoma tended to fare poorly. Postoperative IOP tended to be lower after double plate than after single plate implantation. There was no significant difference in outcome based on age, sex, race, previous penetrating keratoplasty, or previous conjunctival surgery. CONCLUSIONS: In eyes at high risk of trabeculectomy failure, implantation of an aqueous shunt device should be considered. Pseudophakia should be considered an additional risk factor for failure. Early failure appeared relatively more common but long term follow up of all cases is recommended to ensure adequate management of late failures.

AimTo compare pulsatile ocular blood flow (POBF) and intraocular pressure (IOP) between eyes of patients receiving either peribulbar (with and without balloon compression) or subconjunctival local anaesthesia (LA).Methods30 eyes of 30 patients undergoing cataract surgery by phacoemulsification were investigated in a study of parallel group design. Ten patients had peribulbar LA and 10 minutes compression with a Honan's balloon (group A). A further 10 patients who received peribulbar LA alone (group B) acted as controls for the effects of balloon compression. Ten other patients were given subconjunctival LA (group C). POBF and IOP were measured using a modified Langham pneumatonometer. Three measurements were made in each eye, the first recording immediately before LA, the second 1 minute after, and the third 10 minutes after LA.ResultsNo significant change in POBF or IOP was recorded in eyes receiving subconjunctival LA. In the peribulbar groups (A and B), there was a drop in median POBF of 252 and 138 μl/min respectively 1 minute after LA, which was statistically significant in both groups (p<0.01). By 10 minutes, POBF tended to return to baseline levels, but remained significantly reduced in group B (p<0.05). In addition, there was a significant (p<0.05) reduction in IOP (mean drop of 4.82 mm Hg) in group A following peribulbar LA with balloon compression.ConclusionsPOBF was significantly reduced after peribulbar LA but was unchanged after subconjunctival LA. Balloon compression reduced IOP and improved POBF following peribulbar LA. The findings may have clinical implications in patients with compromised ocular circulation or significant glaucomatous optic neuropathy.

Aims/background To study the vasoactivity of glaucoma patients with four previously described and distinct disc appearances potentially representative of primary open angle glaucoma subgroups. Methods Patients with pure examples of four glaucomatous optic disc types--focal ischaemic, myopic glaucomatous, senile sclerotic, and those with generalised cup enlargement, were selected. A detailed ophthalmic, systemic, drug, and smoking history was taken from the patients who, in addition, underwent assessment of peripheral vasospasm with a laser Doppler flowmeter. Differences between the groups were evaluated using an analysis of variance, Student's t test, Pearson's χ² test, Fisher's exact test together with Spearman's and Pearson's correlation tests. Results 38 patients with focal ischaemic, 37 with myopic glaucomatous, 24 with senile sclerotic, and 24 with discs characterised by generalised cup enlargement met the selection criteria. The group of patients with focal ischaemic discs contained more women (66% versus 32%-50% in the other three groups; p=0.01) and had a higher prevalence of vasospasm (63% versus 25%-49%; p=0.01), migraine (32% versus 8%-19%; p=0.02), and cold extremities (66% versus 17%-30%; p=0.00003). The group of patients with senile sclerotic discs had a higher prevalence of systemic cardiovascular disease (58% versus 21%-30% in the other three groups; p=0.01) and thyroid disease (21% cf 0%-8%; p=0.01) and although their mean age was greater (76 years cf 55-65 years; p<0.00001) the findings were independent of age. Smoking was unrelated to optic disc type. Conclusion Vasospasm, previously associated with normal tension glaucoma, and generalised cardiovascular disease both appear to be specific risk factors for the development of particular subgroups of glaucoma and may be independent of absolute intraocular pressure levels exerting effects in patients with both "normal" or "raised" intraocular pressure. The simple assessment as to whether a glaucoma patient suffers from colder extremities than average appeared to be better at distinguishing the focal ischaemic type of glaucoma than the more complex determination of vasospasm using the laser Doppler flowmeter.

AIMS: To determine the ability of cyclodiode laser treatment to relieve discomfort in painful blind glaucomatous eyes. METHODS: 30 eyes underwent cyclodiode to reduce intraocular pressure (IOP) and relieve pain. Patients graded their pre-cyclodiode and post-cyclodiode pain. RESULTS: After a minimum follow up of 6 months, a single cyclodiode treatment lowered mean IOP from 51 mm Hg (95% CI plus or minus 3.7 mm Hg) to 26 mm Hg (95% CI plus or minus 5.8 mm Hg) providing pain relief in 73.3% (22/30). After retreatment of six eyes, mean IOP was reduced to 22 (95% CI plus or minus 5.3) mm Hg and pain relief was obtained in 96.7% (29/30). For eyes achieving pain relief after one treatment, IOP was reduced by >30% in 81.0% (17/21). For eyes not achieving pain relief after one treatment, IOP was reduced by >30% in only 22.2% (2/9) (p=0.0042, Fisher's exact test). CONCLUSION: Cyclodiode was highly successful in providing pain relief in painful blind hypertensive glaucomatous eyes. The best predictor of successful pain relief was IOP reduction of > 30% from baseline.