Microincisional cataract surgery and Thinoptx rollable intraocular lens implantation

Cinhuseyinoglu N, Celik L, Yaman A, Arikan G, Kaynak T, Kaynak S.
Ophthalmology Clinic, SSK Okmeydani Hospital, Istanbul, Turkey.

BACKGROUND: Microincisional cataract surgery is a safe procedure with a very short learning period for an experienced cataract surgeon and rollable ultrathin intraocular lenses eliminate the need for enlargement of corneal incision. The purpose of the study was to evaluate the safety and efficacy of cataract surgery through a corneal microincision and implantation of rollable ultrathin intraocular lenses. The setting was Dokuz Eylul University Medical Faculty, Ophthalmology Department, Izmir, Turkey and SSK Okmeydani Hospital, Ophthalmology Clinic, Istanbul, Turkey. PATIENTS AND METHODS: Ninety eyes in 85 patients were operated on through clear corneal microincisions with sleeveless phacoemulsification and rollable intraocular lenses were implanted. Forty-six of the patients were men and 39 were women between the ages of 27 and 83, with a mean of 51 years. Two eyes had atrophic senile macular degeneration, 4 eyes had nonspecific retinal pigment epithelial changes with chorioretinal atrophy, and 4 patients had diabetes mellitus without retinopathy. Three eyes had posterior capsular opacifications of unknown etiology. Two eyes had primary open angle glaucoma (PAAG) with cup to disc ratios of about 0.5. Three eyes had dense nuclear sclerosis of grade 4 with very low visibility of retinal structures. Other patients had no ocular or systemic pathology other than nuclear/corticonuclear cataract of grade 2-3. Uncorrected and best spectacle-corrected distance and near visual acuities, keratometric values, and refractive status were noted preoperatively and 1 week, 1 month, and 6 months postoperatively. Statistical analysis of keratometric changes between preoperative and postoperative findings was performed using the paired samples t test. RESULTS: At 6 months postoperatively, 1 patient had a best spectacle-corrected visual acuity (BSCVA) of 0.2, the patient with atrophic senile macular degeneration. The rest of the eyes achieved a BSCVA of 0.63 or better. At 6 months postoperatively, 55 (61.11%) eyes had uncorrected visual acuities (UCVA) equal to or better than 0.8 and 83 (92.22%) eyes had BSCVA equal to or better than 0.8 according to the Snellen chart. The mean postoperative corneal astigmatisms at 1 week, 1 month, and 6 months were 0.69+/-0.43 D, 0.66+/-0.46 D and 0.65+/-0.48 D respectively. Statistical analysis revealed a significant change in corneal astigmatisms at the 1st week visit (p<0.05), but not at the 1st and 6th month visits (p>0.05) compared with preoperative findings. CONCLUSION: Based on the limited data in the literature and in this study, it is not possible to make concrete decisions about the benefits and disadvantages of the ThinOptx IOL for longer durations. Intraoperatively, this IOL apparently eliminates the need for enlargement of the corneal incision during implantation. However, the statistical insignificance of induced astigmatisms after microincisions and classical phacoincisions should also be taken into consideration. We conclude that ThinOptx IOL is a pioneering intraocular lens implant that will contribute to the exciting future of cataract refractive surgical procedures. However, both clinical and laboratory investigations are needed to clearly describe the long-term effectiveness of this new rollable IOL.

Effects of caffeine on intraocular pressure: the Blue Mountains Eye Study

Chandrasekaran S, Rochtchina E, Mitchell P.
Centre for Vision Research, Department of Ophthalmology and the Westmead Millennium Institute, the University of Sydney, Australia.

PURPOSE: To examine the relationship between coffee and caffeine intakes and intraocular pressure (IOP). MATERIALS AND METHODS: The Blue Mountains Eye Study examined 3654 participants aged 49+ years in an area west of Sydney, Australia. A detailed medical history questionnaire included average daily intakes of coffee and tea. The eye examination included Goldmann applanation tonometry and automated perimetry. Participants using glaucoma medications or who had previous cataract or glaucoma surgery or signs of pigmentary glaucoma/pigment dispersion, were excluded. Mean and maximum IOP calculations were used. RESULTS: Participants with open-angle glaucoma (OAG) who reported regular coffee drinking had significantly higher mean IOP (19.63 mm Hg) than participants who said that they did not drink coffee (16.84 mm Hg), after multivariate adjustment, P = 0.03. Participants consuming > or = 200 mg caffeine per day had higher mean IOP (19.47 mm Hg) than those consuming < 200 mg caffeine per day (17.11 mm Hg), after adjusting for age, sex, and systolic blood pressure (SBP), P = 0.06. This association did not reach statistical significance after multivariate adjustment. No association between coffee or caffeine consumption and higher IOP was found in participants with ocular hypertension (OH) and those without open-angle glaucoma. CONCLUSIONS: In participants with open-angle glaucoma, this study identified a positive cross-sectional association between coffee consumption/higher caffeine intakes and elevated intraocular pressure.

Therapeutic strategies for normal-tension glaucoma

Orgul S, Zawinka C, Gugleta K, Flammer J.
University Eye Clinic, Basel, Switzerland. sorguel@uhbs.ch

Treatment of normal-tension glaucoma has been a subject of debate for several years. Glaucomatous damage cannot be influenced directly, and current treatment modalities in normal-tension glaucoma are aimed at the control of risk factors. Intraocular pressure is a widely accepted risk factor and its reduction can improve the prognosis in normal-tension glaucoma patients. The repeated demonstration of the importance of hemodynamic factors in normal-tension glaucoma has, however, not been paralleled by a comparable progress in the development of therapeutic modalities capable of influencing favorably ocular blood flow. Today, calcium channel blockers seem to be the most promising adjunctive treatment to be considered in patients with glaucomatous optic neuropathy without increased intraocular pressure. Copyright 2005 S. Karger AG, Basel.

Primary lensectomy following acute primary angle closure glaucoma

Jacobi PC.
Arzte fur Augenheilkunde, VENI VIDI, Koln.

Recent developments and clinical studies indicate that primary phacoemulsification and intraocular lens implantation are safe and effective for the surgical treatment of primary angle closure glaucoma (ACG) compared to conventional iridectomy or laser-iridotomy. When compared to control eyes treated using standard peripheral iridectomy, the outcome in terms of intraocular pressure control, adjunct anti-glaucoma medication, visual acuity, and the necessity for successive surgical interventions favored primary phacoemulsification and intraocular lens implantation. Earlier biometric data underline the importance of the "lens factor" in the pathogenesis of relative pupillary block in ACG obtained by Scheimflug image processing and ultrasound biomicroscopy. Thevast improvements in modern cataract surgery combined with our current understanding of the pathogenesis of relative pupillary block in ACG indicate that lens extraction is a better procedure in uncontrolled angle closure glaucoma than conventional iridectomy.

Otago Glaucoma Surgery Outcome Study: follow-up of young patients who underwent Molteno implant surgery

Ah-Chan JJ, Molteno AC, Bevin TH, Herbison P.
Eye Department, Dunedin Hospital, Dunedin, New Zealand.

OBJECTIVE: To provide data on the results of patients with nonneovascular juvenile glaucoma who had Molteno implant surgery in the province of Otago, New Zealand. DESIGN: Prospective noncomparative case series. PARTICIPANTS: Fifty-five operations in 52 eyes of 45 patients with nonneovascular juvenile glaucoma who had Molteno implant surgery between the ages of 9 and 49 years from 1976 to 2003 at Dunedin Hospital and were observed for a mean of 12.2 years (range, 0.1-25). INTERVENTION: Insertion of a Molteno implant. MAIN OUTCOME MEASURES: Intraocular pressure (IOP) and visual acuity (VA). RESULTS: Insertion of a Molteno implant controlled IOP at < or =21 mmHg with probabilities of 0.89 (95% confidence interval [CI], 0.81-0.97) at both 1 and 2 years and 0.85 (95% CI, 0.75-0.95), 0.78 (95% CI, 0.66-0.90), and 0.71 (95% CI, 0.58-0.85) at 5, 10, and 15 years, respectively. Mean VA was 20/100 preoperatively; improved to 20/60 at 1 year; and stabilized at 20/120 at 5, 10, and 15 years postoperatively. Twenty-nine eyes had their preoperative VA maintained or improved at final follow-up, and the VAs of 17 eyes deteriorated but were at least light perception at final follow-up. CONCLUSION: The use of Molteno implants in cases of nonneovascular juvenile glaucoma controlled IOP with a probability of 0.71 15 years postoperatively, whereas 53% maintained or improved their vision from their preoperative VA at final follow-up.

Recent progress in ocular drug delivery for posterior segment disease: Emphasis on transscleral iontophoresis

Myles ME, Neumann DM, Hill JM.
Department of Ophthalmology, LSU Health Sciences Center, New Orleans, LA, USA.

Age-related macular degeneration, diabetic retinopathy, posterior uveitis, and retinitis due to glaucoma are leading causes of vision loss in the United States and other developed countries. Because these diseases are located in the posterior segment of the eye, topical application of ophthalmic medicines is of limited benefit, since topically applied drugs rarely reach therapeutic levels in the affected posterior tissues such as the choroid and retina. Intravitreal injections can deliver drugs to the posterior segment without the side effects associated with systemic administration. However, the repeated and long-term injections often needed may cause complications, such as vitreous hemorrhage, retinal detachment, or endophthalmitis. Recent advances in ocular drug delivery methods and the development of novel biopharmaceutical agents could lead to new regimens for the treatment of disease of the posterior retina, choroids, and macula. This review will summarize recent literature concerning ocular drug delivery of bioactive compounds to the posterior segment of the eye with emphasis on transscleral iontophoresis.

Effect of additive preoperative latanoprost treatment on the outcome of filtration surgery

Berthold S, Pfeiffer N.
Department of Ophthalmology, University Hospital of Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany, Silke.Berthold@web.de.

BACKGROUND: Long-term glaucoma medication has been suspected to be a risk factor for bleb failure following trabeculectomy. It was the goal of our study to investigate whether additive preoperative treatment with latanoprost has an effect on the outcome of subsequent trabeculectomy. METHODS: We retrospectively analysed the outcome of trabeculectomy in 32 eyes of 16 patients who had received bilateral trabeculectomy within the Mainz-II study. This study had been designed to examine the effect of 6 months' use of topical latanoprost therapy on iris darkening. The first eye of each patient was operated upon without preoperative latanoprost therapy; the other eye was operated on after 6 months' treatment with latanoprost in addition to existing medical glaucoma treatment. We analysed the outcome of these patients and compared success rates and average intra-ocular pressures (IOPs) between the latanoprost-treated and the untreated partner eyes. Success was defined as an average postoperative IOP of 18 mmHg or less. RESULTS: We obtained IOP values from 13 of 16 patients, with a mean follow-up period of 6.8 years. Three patients were lost to follow-up. In both groups eight eyes (61.5%) had an average postoperative IOP (average of all IOPs measured in the follow-up period) of 18 mmHg or less. The mean average postoperative IOPs in the control group and in the latanoprost group were 15.2 mmHg and 15.8 mmHg, respectively. Intra-individual comparison revealed that one pair of eyes had equal IOPs, while six eyes in each group showed better postoperative IOP control than the respective partner eye. However, mean delta IOPs (maximum preoperative IOP minus average postoperative IOP) were 17.8 mmHg and 14.2 mmHg for the control group and latanoprost group, respectively. CONCLUSION: In this small group 6 months of additive preoperative treatment with latanoprost did not have a statistically significant effect on the success rate of trabeculectomy or on the postoperative IOP level following trabeculectomy. However, trabeculectomy in eyes preoperatively receiving latanoprost for 6 months might lead to a slightly smaller delta IOP than in eyes naive to prostaglandins.

Long-term clinical results of selective laser trabeculoplasty in the treatment of primary open angle glaucoma

Weinand FS, Althen F.
Department of Ophthalmology, University Eye Clinic, Giessen - Germany.

PURPOSE. To investigate the long-term efficacy of selective laser trabeculoplasty (SLT) in primary open-angle glaucoma, the authors performed a non-randomized, prospective, non-comparative clinical case series. METHODS. Fifty-two eyes of 52 patients (19 male, 33 female) with primary open angle glaucoma were treated with SLT. Patients were treated with the Coherent Selecta 7000 (Coherent, Palo Alto, CA, USA) frequency-doubled q-switched Nd:YAG laser (532 nm). A total of approximately 50 non-overlapping spots were placed over 180 degrees of the trabecular meshwork at energy levels ranging from 0.6 to 1.4 mJ per pulse. After surgery, patients were maintained with the drug regimen identical to that before treatment. RESULTS. After 1 year the average reduction in intraocular pressure (IOP) from the baseline was 24.3% (6.0 mmHg), after 2 years 27.8% (6.12 mmHg), after 3 years 24.5% (5.53 mmHg), and after 4 years 29.3% (6.33 mmHg). A Kaplan-Meier survival analysis revealed a 1-year success rate of 60%, a 2-year success rate of 53%, a 3-year success rate of 44%, and a 4-year success rate of 44%. CONCLUSIONS. Despite a declining success rate, SLT is an effective method to lower IOP over an extended period of time. (Eur J Ophthalmol 2006; 16: 100-4).

Short- and medium-term intraocular pressure lowering effects of combined phacoemulsification and non-penetrating deep sclerectomy without scleral

Moreno-Lopez M, Perez-Alvarez MJ.
Servicio de Oftalmologia, Hospital Universitario de Guadalajara, Espana.

PURPOSE: To examine the short- and medium-term intraocular pressure (IOP) lowering effects of combined phacoemulsification and non-penetrating deep sclerectomy without the use of scleral implant or antifibrotics in open-angle glaucoma (primary and pseudoexfoliative) and coexisting cataract in eyes with no known risk factors for bleb failure. METHODS: Retrospective study of 15 eyes of 12 patients with medically uncontrolled open-angle glaucoma or open-angle glaucoma treated with two or more drugs and coexisting cataract with no known risk factors for glaucoma surgery failure. All patients received combined phacoemulsification and non-penetrating deep sclerectomy without scleral implant or antifibrotics performed by the same surgeon. Nd-YAG perforation of the trabeculodescemetic membrane and/or needling with mitomycin-C was performed postoperatively for IOP control. Main outcome measures were postoperative IOP, percentage of eyes with IOP <17mmHg, complications and final visual acuity (VA). Median follow-up was 12.0 months (SD: 0.6) and ranged from 1 to 30 months. RESULTS: Mean preoperative IOP with medical treatment was 21.80 mmHg (SD: 5.14) and decreased to 14.42 mmHg (SD: 2.15) at 12-month visit. Mean antiglaucoma medication preoperative was 1.93 (SD: 0.70) and was reduced to 0.13 (DE: 0.35) postoperative. At 12-month visit, 80% had an IOP lower than 17 mmHg with a mean VA gain of 2.50 Snellen lines. Conjuntival wound leakage was the most frequent complication (20%; 3/15). CONCLUSIONS: Primary combined phacoemulsification and non-penetrating deep sclerectomy without collagen implant or antifibrotics in primary open-angle glaucoma with coexisting cataract, significantly lowers IOP in the short- and medium term in low-risk cases for glaucoma surgery failure, allowing for rapid visual improvement with a low complication rate (Arch Soc Esp Oftalmol 2006; 81: 93-100)

Bimatoprost: a pharmacoeconomic review of its use in open-angle glaucoma and ocular hypertension

Plosker GL, Keam SJ.
Adis International Limited, Auckland, New Zealand.

Bimatoprost (Lumigan((R))) is a prostamide analogue used for the reduction of elevated intraocular pressure (IOP) in patients with open-angle glaucoma or ocular hypertension. In comparative clinical trials of up to 1 year in duration, administration of 0.03% bimatoprost ophthalmic solution once daily was more effective than 0.5% timolol twice daily and at least as effective as the prostaglandin analogues 0.005% latanoprost and 0.004% travoprost once daily in terms of reducing IOP and/or achieving target IOP levels. Bimatoprost was also more effective than twice-daily administration of 0.5%/2% timolol/dorzolamide in patients refractory to topical timolol therapy. Although generally well tolerated, bimatoprost is associated with a higher incidence of conjunctival hyperaemia than latanoprost, timolol or the combination of timolol and dorzolamide.Three fully published modelled cost-effectiveness analyses of bimatoprost evaluating cost per treatment success in patients with glaucoma or ocular hypertension have been conducted in the US. The analyses incorporated results of randomised, multicentre clinical trials and used a 1-year time horizon. In the treatment algorithm used in the models, patients not achieving target IOP levels with bimatoprost or comparator required additional medical visits and adjunctive therapy. Bimatoprost was associated with lower costs per treatment success than latanoprost, timolol or timolol/dorzolamide across a range of clinically relevant target IOPs. Results were sensitive to changes in treatment success rates and/or drug acquisition costs. Along with the inherent limitations of economic models, other possible criticisms of the analyses are the use of selected IOP data, and the lack of inclusion of costs associated with conjunctival hyperaemia or other adverse effects of therapy.Various other cost-effectiveness analyses of bimatoprost are available, primarily as abstracts and/or posters. In general, most of these studies have also been favourable for bimatoprost, despite having been conducted in different countries and/or from different perspectives.In conclusion, in patients with open-angle glaucoma or ocular hypertension, bimatoprost is an effective and generally well tolerated therapeutic option, albeit with a relatively high incidence of conjunctival hyperaemia. Although results of modelled cost-effectiveness analyses should be interpreted with due consideration of the limitations of the studies, available pharmacoeconomic data generally support the use of bimatoprost as a cost-effective treatment in this patient population.

Trabeculectomy for the management of uveitic glaucoma

Souissi K, El Afrit MA, Trojet S, Kraiem A.
Service d'Ophtalmologie, Centre Hospitalo-Universitaire Habib Thameur, Tunis, Tunisie.

PURPOSE: To report middle-term results of trabeculectomy in patients with uveitic glaucoma resistant to medical therapy. PATIENTS AND METHODS: Seventeen eyes of 14 patients with uveitic glaucoma resistant to medical therapy were treated by trabeculectomy without antimetabolites from 1994 to 2001. The patients'mean age was 48.1 years (range, 23-63 years). All had their uveitis controlled for at least 3 months before surgery by an anti-inflammatory therapy. RESULTS: Mean follow-up was 52.1 months. Success was obtained in 11 eyes (64.7%). It was complete in five eyes (45.5%) and relative in six eyes (54.5%). Failure was noted in six eyes (35.3%), which were treated with a second filtering surgery. Intraocular pressure was reduced from a mean preoperative value of 34.2mmHg to a mean postoperative value of 18.6 (45.6% reduction). Antiglaucomatous medication was reduced from a mean of 2.8 medications preoperatively to 1.1 medications (60.7% reduction). Postoperative complications included three cases of lens opacity, two cases of hyphema, two cases of transitory hypotony, one case of flat anterior chamber, and one case of inflammation relapse. CONCLUSION: In the absence of failure risk factors except inflammation, trabeculectomy without antimetabolites can be successful in uveitic glaucoma not controlled by medical therapy, with good results even at the middle term.

Observational survey on the use of dual therapy in ocular hypertension or glaucoma treatment

Bron A, Nordmann JP, Rouland JF, Baudouin C, Sartral M.
Service d'Ophtalmologie, CHU, Dijon.

Aim: To ascertain why ophthalmologists shift therapy to a fixed-combination or non-fixed-combination drug therapy. PATIENTS AND METHODS: A prospective multicenter observational study was conducted among French ophthalmologists working in private or mixed practice. The study included adult patients with open-angle glaucoma or ocular hypertension, treated with monotherapy or dual therapy and needing to modify their initial treatment. The patients had to fill out a self-questionnaire 15 days after the change in therapy, evaluating the compliance and assessment of the new treatment. RESULTS: The analysis was made on 775 questionnaires filled out by ophthalmologists between March 1st and July 31st 2003 on 5734 patients. The mean age was 66.4+/-12.4 years and women represented 53.6% of the patients. The diagnosis had been made, on average, 7.5+/-7.3 years before. The mean initial intraocular pressure under treatment was 19.8+/-4.1 mmHg in both eyes. Initially, 58.2% of the patients had monotherapy, 40.4% dual therapy and 1.4% triple therapy. The main reasons for shifting therapy were "high intraocular pressure under treatment" for 63.5% of the patients and "simplification of the treatment" for 39.1% of the patients (several reasons per patient were accepted). Most of the patients were satisfied with their new therapy (71%), which in most cases was a fixed-combination therapy (95.2%). DISCUSSION: This study has shown that the use of at least two active principles is a common practice in the treatment of glaucoma and ocular hypertension. An additive therapy is given in order to better control the intraocular pressure, mainly with a fixed combination.

Glaucoma in children: are we making progress?

Biglan AW.
University of Pittsburgh School of Medicine, Department of Ophthalmology, Cranberry Township, PA, USA.

Background: Glaucoma in children presents difficult clinical challenges. Even when appropriately treated, blindness can occur. Design: Retrospective interventional case series and literature review. Methods: All clinical records of children seen by the author with a diagnosis of glaucoma established before 16 years of age were reviewed from 1977 to 2003. Glaucoma was classified as primary infantile, aphakic, syndrome-related, and secondary. The best-corrected visual acuity, refractive error, configuration of the optic nerve cup, and perimetry were recorded. The intraocular pressure (IOP) for each visit was recorded. IOP measurements of 19 mm Hg or less were considered "good." The percentage of "good" readings was calculated for each eye. Representative visual acuities, refractive errors, IOP, disk configuration, and perimetry were recorded at 6, 12, 18, and 24 years of age for each patient. The admitting ophthalmologic diagnosis for each child at the Western Pennsylvania School for Blind Children was recorded from 1887 to 2003. Results: One hundred twenty-six children (204 eyes) were studied: infantile glaucoma, 52 eyes; aphakic glaucoma, 40 eyes; syndrome associated, 69 eyes; and secondary glaucoma, 43 eyes. The mean follow-up was 11.6 years (1 to 30 years). Overall, 60 (29.4%) of 204 eyes had a 6/12 (20/40) or better corrected visual acuity at the most recent visit. The percentage with this acuity remained stable throughout the follow-up period. Eyes with infantile glaucoma had the best acuity, and 40% had 6/12 (20/40) or better. Amblyopia was common and responded to treatment. Eyes with aphakic glaucoma had the worst acuity with only 10% achieving 6/12 or better. These eyes had a bimodal onset of glaucoma; eyes with an early onset had an angle closure configuration and eyes with a delayed onset had an open angle. Early cataract removal and microcornea were risk factors for glaucoma. If the IOP was maintained at 19 mm Hg or less (good) on 80% of the determinations over time, the optic nerve cup compared with the diameter of the optic nerve (C/D ratios) were stable. Eight patients had multiple, good quality, visual fields performed over 3 to 15 years. If the patients had "good" IOP on 70% of the measurements, the visual fields remained stable. A historical perspective of glaucoma control was gained by looking at the admitting diagnosis at the Western Pennsylvania School for Blind Children. From 1910 to 1970, an average of 9.2 children blind due to glaucoma were admitted each decade. From 1971 to 2003, there were only three children with glaucoma admitted over 30 years. Conclusion: Removal of congenital cataracts should be delayed until 3 to 4 weeks of age. Consideration should be given for using 19 mm Hg or less to measure the success of glaucoma treatment in children. Treatment of amblyopia is as important as IOP control in children. Imaging technology such as optical coherence tomography and measurement of central corneal thickness may play an important future role in the assessment of children with suspected or known glaucoma.

Baerveldt glaucoma implant in paediatric patients

van Overdam KA, de Faber JT, Lemij HG, de Waard PW.
The Rotterdam Eye Hospital, Schiedamse Vest 180, 3011 BH Rotterdam, Netherlands.

AIM: To evaluate the Baerveldt glaucoma implant (BGI) in paediatric glaucoma treatment. METHODS: In a retrospective non-comparative case series 55 eyes of 40 consecutive paediatric patients (< or =16 years) with primary or secondary glaucoma underwent Baerveldt (350 mm2) implantation. Surgical outcome was evaluated by Kaplan-Meier table analysis. RESULTS: The overall success rate was 80% at last follow up, with a mean follow up of 32 (range 2-78) months. Cumulative success was 94% at 12 months and 24 months, 85% at 36 months, 78% at 48 months, and 44% at 60 months. 11 eyes (20%) failed postoperatively because of an IOP >21 mm Hg (eight eyes), persistent hypotony (two eyes), and choroidal haemorrhage following cataract surgery (one eye). The most frequent complication needing surgery was tube related (20%). A new observation was mild to moderate dyscoria in 22% of the eyes, all buphthalmic, caused by entrapment of a tuft of peripheral iris in the tube track. CONCLUSIONS: The BGI is effective and safe in the management of primary and secondary glaucoma. When angle surgery has proved to be unsuccessful or inappropriate in paediatric patients, a BGI is a good treatment option. One must be prepared to deal with the tube related problems.

24-hour intraocular pressure control obtained with evening- versus morning-dosed travoprost in primary open-angle glaucoma

Konstas AG, Mikropoulos D, Kaltsos K, Jenkins JN, Stewart WC.
Glaucoma Unit, Department of Ophthalmology, A University, AHEPA Hospital, Thessaloniki, Greece.

PURPOSE: To evaluate the quality of 24-hour intraocular pressure (IOP) control between morning- and evening-dosed travoprost in primary open-angle glaucoma patients. DESIGN: Prospective, crossover, double-masked comparison. METHODS: After a 6-week medicine-free period, 33 patients were randomized to receive travoprost dosed in the morning or evening. After 8 weeks of treatment, a 24-hour IOP curve was performed at 6 am, 10 am, 2 pm, 6 pm, 10 pm, and 2 am. Patients were then treated with the opposite dosing regimen for another 8 weeks, after which the 24-hour IOP curve was repeated. MAIN OUTCOME MEASURES: Twenty-four-hour IOP. RESULTS: The untreated mean 24-hour IOP was 23.6+/-2.0 mmHg. There were no differences for mean 24-hour IOP between the morning (17.5+/-1.9 mmHg) and evening (17.3+/-1.9 mmHg) dosings (P = 0.7). At 10 am, the evening dosing provided a statistically lower IOP (17.2+/-2.1 mmHg) than the morning dosing (19.1+/-2.5 mmHg) (P = 0.02). Evening dosing demonstrated a statistically lower 24-hour fluctuation of IOP (3.2+/-1.0 mmHg) than morning dosing (4.0+/-1.5 mmHg) (P = 0.01). Safety was similar, with conjunctival hyperemia being the most common adverse event (n = 9 [27% for morning dosing] and n = 11 [33% for evening dosing], P = 0.6). CONCLUSIONS: This study suggests that both morning and evening dosings of travoprost provide effective 24-hour IOP reduction. However, the evening dosing of travoprost demonstrates slightly greater daytime efficacy, with a narrower range of 24-hour pressure.

The effect of aspirin and warfarin therapy in trabeculectomy

Cobb CJ, Chakrabarti S, Chadha V, Sanders R.
1Department of Ophthalmology, Ninewells Hospital and Medical School, Dundee, UK.

Aim: The management of patients on antiplatelet and anticoagulation therapy (APACT) in glaucoma surgery currently has no specific recommendations. We aimed to establish the risk of haemorrhagic complications and surgical outcome in patients on APACT in glaucoma surgery.MethodsWe retrospectively examined 367 consecutive trabeculectomies performed between 1994 and 1998. Preoperatively 60 (16.4%) patients were on APACT (55 on aspirin and five on warfarin). The incidence of hyphaema and haemorrhagic complications between patients with and without APACT was documented. Surgical success was defined in two categories as an intraocular pressure (IOP) <21 mmHg and an IOP <16 mmHg 2 years following trabeculectomy with and without antiglaucoma medication.ResultsNone of the patients on aspirin suffered significant intra or postoperative haemorrhage. Aspirin was associated with a significantly higher risk of hyphaema (P=0.0015) but this was not found to significantly affect IOP control at 2 years. Patients on warfarin suffered haemorrhagic complications and trabeculectomy failure.ConclusionsAspirin appears to be safe to continue with during trabeculectomy. Patients on aspirin have an increased risk of hyphaema following trabeculectomy. This however does not appear to affect surgical outcome. Warfarinised patients are at risk of serious bleeding complications. They require careful monitoring pre- and postoperatively and are at risk of trabeculectomy failure.Eye advance online publication, 3 March 2006; doi:10.1038/sj.eye.6702277.

Long-term results of Molteno implant insertion in cases of neovascular glaucoma

Every SG, Molteno AC, Bevin TH, Herbison P.
Section of Ophthalmology, Department of Medical and Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.

OBJECTIVE: To describe the long-term outcomes of cases of neovascular glaucoma drained by Molteno implants. METHODS: A prospective study of 145 eyes (130 patients) followed up for a mean of 3.3 years (range, 0.02 year [5 days] to 18.1 years) in the province of Otago, New Zealand, from 1979 to 2002. RESULTS: Insertion of a Molteno implant controlled the intraocular pressure at 21 mm Hg or less with a probability (95% confidence interval) of 0.72 (0.64-0.80), 0.60 (0.51-0.69), and 0.40 (0.29-0.50) at 1, 2, and 5 years, respectively. Failure to control intraocular pressure at 1, 2, and 5 years was significantly correlated with persistent iris neovascularization (P<.001, P<.001, and P = .01, respectively). Visual acuity at final follow-up in nonenucleated eyes was maintained or improved in 56 eyes (39%) and deteriorated to light perception or better in 25 (17%) or no light perception in 47 (32%). Seventeen eyes (12%) were enucleated. CONCLUSIONS: The insertion of Molteno implants for neovascular glaucoma maintained or improved vision in 39% of eyes, whereas 12% were eventually enucleated (all of which initially had visual acuity <20/1200). The outcome depended mainly on progression of the underlying vascular disease.

Ahmed Glaucoma Valve implantation in African American and white patients

Ishida K, Netland PA.
Hamilton Eye Institute, University of Tennessee Health Science Center, Memphis 38163, USA.

OBJECTIVE: To evaluate the results of Ahmed Glaucoma Valve implantation in African American and white patients. METHODS: In this retrospective, comparative case-control study, we reviewed 86 eyes of 86 patients, comparing the surgical outcomes in white patients (n = 43) with matched African American patients (n = 43). Success was defined as an intraocular pressure (IOP) between 6 mm Hg and 21 mm Hg with or without glaucoma medicines, without further glaucoma surgery, and without loss of light perception (definition 1) and an IOP between 6 mm Hg and 21 mm Hg and achievement of a 20% reduction in IOP from the preoperative level (definition 2). RESULTS: The mean follow-up was 2.3 years for white patients and 2.5 years for African American patients (P = .50). At the last follow-up, the mean +/- SD IOP was 15.3 +/- 3.3 mm Hg and 15.3 +/- 3.5 mm Hg (P = .77) in white and African American patients, respectively. Life table analysis showed a significantly lower success rate for African American patients compared with white patients by both definition 1 (P = .03) and definition 2 (P = .006). Cox proportional hazards regression analysis detected African American race as a risk factor for surgical failure by both definitions. Visual outcomes and complications were comparable between the 2 groups. CONCLUSION: African American patients have a greater risk of surgical failure after Ahmed Glaucoma Valve implantation compared with white patients.

Treating ocular hypertension to reduce glaucoma risk : when to treat?

Higginbotham EJ.
Morehouse School of Medicine, Atlanta, Georgia, USA.

When to treat the patient who presents with ocular hypertension has been a question that has 'stumped' the ophthalmic community for decades. Population-based studies and intervention trials have provided the basis for understanding why we consider treating such patients. Although the EGPS (European Glaucoma Prevention Study) did not demonstrate that reducing intraocular pressure (IOP) with dorzolamide prevented the onset of glaucoma compared with individuals receiving a placebo, the investigators of the OHTS (Ocular Hypertension Treatment Study) found that the treatment of ocular hypertension can be delayed with topical medication when treated patients were compared with an observation group. There are differences in inclusion criteria, study design and retention rates between the EGPS and the OHTS, which may have led to the discrepancies in outcomes between these two studies. These differences provide a basis for understanding the relevance of the findings of both trials to clinical practice. The clinician should consider key risk factors such as age, thin corneal thickness measurements, large cup-to-disc ratio and mean IOP when determining who should be treated. However, the ultimate decision of when to treat will be determined by other issues such as life expectancy, the general health of the patient and the number of risk factors. Clearly, the treatment of only high-risk patients with ocular hypertension should be considered.

Rescula as an alternative therapy for Beta-blockers with long-term drift effect in glaucoma patients

Chen CL, Tseng HY, Wu KY.
Department of Ophthalmology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.

The purpose of this study was to evaluate both the intraocular pressure (IOP)-decreasing and neuroprotective effects of Rescula (0.12% unoprostone isopropyl) as an alternative therapy to betablockers with a long-term drift effect in patients with glaucoma. Twenty-eight patients with unilateral or bilateral glaucoma were treated with Rescula instead of the original beta-blocker therapy. IOP was measured using a Goldmann applanation tonometer, and visual field defects were evaluated quantitatively by Humphrey automatic perimetry central 30-2 threshold test. The mean follow-up time was at least 1 year. Rescula achieved a significant (p = 0.00001) and long-lasting reduction in IOP (from 20.78 +/- 2.71 to 17.14 +/- 2.70 mmHg) in patients with open-angle glaucoma after 12 months of follow-up. It also demonstrated a significant (p = 0.02) IOP-reducing effect (from 20.67 +/- 3.60 to 16.36 +/- 3.67 mmHg) in patients with angleclosure glaucoma 12 months later. The mean deviation of visual field defects changed from -13.27 dB baseline to -10.64 dB at 12 months as evaluated by Humphrey field analyzer II central 30-2 threshold test after Rescula; however, there was no statistical difference (p = 0.098). Our results showed that Rescula has a significant IOP-reducing effect as an alternative therapy to beta-blockers with long-term drift effect in patients with open-angle and angle-closure glaucoma. However, a neuroprotective effect to prevent further progression of the visual field defect in patients with glaucoma was not demonstrated in this study.

Effects of bimatoprost 0.03% on ocular hemodynamics in normal tension glaucoma

Chen MJ, Cheng CY, Chen YC, Chou CK, Hsu WM.
Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan., School of Medicine, National Yang-Ming University, Taipei, Taiwan.

Purpose: The aim of this study was to investigate the effects of bimatoprost 0.03% on ocular hemodynamics in patients with normal tension glaucoma (NTG). Methods: Twenty-two (22) patients with NTG were consecutively recruited. After basic eye examination and diurnal intraocular pressure (IOP) measurement, color Doppler imaging was used to measure the peak systolic and end diastolic velocities and resistive index of the central retinal, lateral posterior ciliary, and medial posterior ciliary arteries. Patients received bimatoprost 0.03% for 4 weeks, and these measurements were then repeated. The worse eye of each NTG patient was used in the statistical analysis. Results: Bimatoprost 0.03% significantly reduced mean IOP from 15.1 +/- 3.8 mmHg at baseline to 12.0 +/- 2.9 mmHg after treatment in our sample of NTG patients (P < 0.001). No significant changes in blood velocities or resistance indices were observed in the retrobulbar vessels after the 4-week treatment. Conclusions: Topical bimatoprost 0.03% significantly reduced IOP in our NTG patients without causing significant hemodynamic changes in the retrobulbar vessels.

Long-term outcome of pediatric aphakic glaucoma

Bhola R, Keech RV, Olson RJ, Petersen DB.
Department of Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City, Iowa.

Purpose: To determine the long-term outcome in pediatric patients with aphakic glaucoma. Methods: A retrospective analysis of 130 patients diagnosed with aphakic glaucoma between 1969 and 2004 was performed. A total of 36 patients (55 eyes) were included in this study after excluding those who had cataract extraction after age 10 and those patients with other ocular conditions, systemic syndromes, traumatic cataracts, congenital glaucoma, or inadequate follow-up (less than 1 year). Outcome variables studied included visual acuity, number of medication changes required over the course of the follow-up, maximum number of medications used at a time for more than 6 months to control intraocular pressures, and surgical interventions required. Mean follow-up period was 18.7 years (range, 6.9-35 years). Results: At the time of last follow-up, 54.5% of the patients had visual acuity 20/40 or better, 34.5% had 20/50 to 20/200, and 11% had acuity worse than 20/200. During the course of follow-up, 34% required 1 to 2 medication changes for controlling glaucoma, 33% required 3 to 5 medication changes, and 33% required 6 or more medication changes. Thirty-six percent of the eyes required a maximum of 1 to 2 medications for more than 6 months during the course of follow-up, 33% required 3, and 31% required 4 or more medications for controlling intraocular pressure. Of the 55 eyes, 15 eyes (27%) required surgical intervention. Six of the 15 eyes (40%) required 1 surgery, 8 eyes (53%) required 2 to 3 surgeries, and 1 eye (7%) required 4 to 6 surgeries. Conclusion: Patients with glaucoma after pediatric cataract surgery can have a good visual outcome although multiple medications and surgical interventions may be required to control the glaucoma.

Prospective, long-term evaluation of steroid-induced glaucoma

Sihota R, Konkal VL, Dada T, Agarwal HC, Singh R.
Glaucoma Research Facility, Dr Rajendra Prasad Center for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.

Purpose: To evaluate the intraocular pressure (IOP) after cessation of steroid use in steroid-induced glaucoma and its control with medication or surgery.MethodsThirty-four eyes of 34 patients having steroid-induced glaucoma were prospectively evaluated after cessation of steroid for IOP, visual acuity, and optic disc status at 3 months, and every 3 months for 18 months.ResultsTopical steroid use (73.5%) was the most frequent cause for glaucoma. The baseline IOP was 35.47+/-12.59 mmHg. The baseline vertical cup-disc ratio correlated with duration of steroid use (P=0.014) and the baseline IOP (P<0.0001). In 25 patients (73.5%), IOP could be controlled by topical medications alone, whereas nine patients (26.5%) required surgery. The mean baseline IOP in eyes requiring surgery was 49.67+/-13.28 mmHg and in eyes managed medically, 30.36+/-7.51 mmHg (P=0.002). The vertical cup-disc ratio in surgically treated patient was 0.87+/-0.13:1 as compared to 0.71+/-0.15:1 (P=0.012) in the medically treated group. At 6, 12, and 18 months follow-up, 22 (64.7%), 33 (97.1%), and all 34 (100%) patients were off treatment, respectively.ConclusionsPatients with steroid-induced glaucoma, who were

Effects of Topical Hypotensive Drugs on Circadian IOP, Blood Pressure, and Calculated Diastolic Ocular Perfusion Pressure in Patients with Glaucoma

Quaranta L, Gandolfo F, Turano R, Rovida F, Pizzolante T, Musig A, Gandolfo E.
Clinica Oculistica, Universita degli Studi di Brescia, Brescia, Italy.

PURPOSE: To compare the short-term effects of timolol 0.5%, brimonidine 0.2%, dorzolamide 2%, and latanoprost 0.005% on intraocular pressure (IOP), blood pressure (BP), and diastolic ocular perfusion pressure (DOPP), calculated as the difference between the diastolic blood pressure (DBP) and IOP. METHODS: According to a 4 x 4 Latin squares design for repeated measures, 27 untreated patients and patients with newly diagnosed primary open-angle glaucoma (POAG) were treated with timolol 0.5% at 8 AM and 8 PM; brimonidine 0.2% at 8 AM and 8 PM; dorzolamide 2% at 8 AM, 2 PM, and 8 PM; and latanoprost 0.005% at 8 PM. The duration of each treatment course was 6-weeks, with a 4-week washout between each treatment. IOP and BP were measured at baseline and at the end of each treatment period. IOP was measured every 2 hours throughout a 24-hour period. Sitting IOP was measured from 8 AM to 10 PM by Goldmann applanation tonometry. Supine IOP was assessed from 12 to 6 AM by means of a handheld electronic tonometer (TonoPen XL; Mentor, Norwell, MA). BP monitoring was performed by means of an automated portable device (TM-2430; A & D Co., Saitama, Japan). RESULTS: All the drugs tested decreased the IOP significantly at all time points in comparison with baseline pressure. The mean 24-hour IOP after latanoprost administration (16.62 +/- 0.98 mm Hg) was significantly lower than that after timolol, brimonidine, or dorzolamide (P = 0.0001). During the 24-hour period, brimonidine induced a significant decrease in systolic BP (SBP) and DBP at all time points when compared with baseline measurements and with those after administration of the other drugs (P < 0.0001). Timolol caused a significant decrease in DBP and SBP at all the 24-hour time points when compared with the baseline and with the dorzolamide- and latanoprost-induced changes (P < 0.0001). The mean 24-hour DOPPs were 50.7 +/- 5.9 mm Hg at baseline, 53 +/- 5.5 mm Hg with timolol, 46.2 +/- 5.4 mm Hg with brimonidine, 55.9 +/- 4.6 mm Hg with dorzolamide, and 56.4 +/- 4.9 mm Hg with latanoprost. Brimonidine induced a significant decrease in the mean 24-hour DOPP compared with that at baseline (P < 0.0001), whereas dorzolamide and latanoprost induced a significant increase (P < 0.0001). CONCLUSIONS: Latanoprost seemed to induce a uniform reduction in IOP during the 24-hour period, although timolol was as effective as latanoprost during the daytime, and dorzolamide are as effective as latanoprost at night. SBP and DBP were significantly decreased by either timolol or brimonidine. In this study of patients with newly diagnosed POAG, only dorzolamide and latanoprost significantly increased mean 24-hour DOPP.

IOP-Lowering Efficacy of Bimatoprost 0.03% and Travoprost 0.004% in Patients with Glaucoma or Ocular Hypertension

BACKGROUND/AIMS: To evaluate the IOP-lowering efficacy of bimatoprost and travoprost for the treatment of glaucoma and ocular hypertension. METHODS: Prospective, randomized, investigator- masked, parallel-group clinical trial. After completing a washout from any glaucoma medications, patients (n=157) were randomized to bimatoprost or travoprost for 6 months. Visits were at baseline, week 1, and months 1, 3, and 6. IOP was measured at 9 AM at each visit and also at 1 and 4 PM at baseline and months 3 and 6. RESULTS: There were no significant between-group differences in baseline IOP at 9AM, 1PM, or 4PM (P>.741). After 6 months, both medications significantly reduced IOP at every time point (P<.001). After 6 months, mean IOP reduction at 9AM was 7.1 mm Hg (27.9%) with bimatoprost (n=76) and 5.7 mm Hg (23.3%) with travoprost (n=81) (P=.014). At 1PM, mean IOP reduction was 5.9 mm Hg with bimatoprost (25.3%) and 5.2 mm Hg (22.4%) with travoprost (P=.213). At 4 PM, the mean IOP reduction was 5.3 mm Hg (22.5%) with bimatoprost and 4.5 mm Hg (18.9%, P=.207) with travoprost. Both study medications were well tolerated, with ocular redness the most commonly reported adverse event in both treatment groups. CONCLUSIONS: Bimatoprost provided greater mean IOP reductions than travoprost.

Ocular hypotensive efficacy and safety of brinzolamide ophthalmic suspension 1% added to travoprost ophthalmic solution 0.004% therapy in patients

Franks W; Brinzolamide Study Group.
Moorfields Eye Hospital, London, UK. wendy.franks@moorfields.nhs.uk

OBJECTIVE: The primary objective of this study was to determine if combined travoprost ophthalmic solution 0.004% and brinzolamide ophthalmic suspension 1% therapy is superior in lowering intraocular pressure (IOP) compared to travoprost monotherapy for patients with open angle glaucoma or ocular hypertension. The secondary objective was to measure the percentage of patients achieving IOP levels of 18 mmHg or less. STUDY DESIGN AND METHODS: Single arm, open-label. PARTICIPANTS: eighty-two patients with inadequate IOP control with travoprost monotherapy. INTERVENTION: the addition of brinzolamide ophthalmic suspension 1% twice daily. MAIN OUTCOME MEASURES: The primary endpoint was mean IOP reduction from baseline at 4 and 12 weeks. The percentage of patients who achieved IOP values or= 18 mmHg was also measured. RESULTS: The mean age of the patients was 67 years. Ethnic origin was 92.7% Caucasian, 3.7% Black, 2.4% Asian and 1.2% other. The mean duration of travoprost treatment before the trial started was 30 weeks. Compared to the baseline data (IOP = 22.5 mmHg) with travoprost ophthalmic solution 0.004% monotherapy, IOP was decreased after 4 (n = 78) and 12 (n = 71) weeks of combined travoprost and brinzolamide therapy by an average of 3.9 mmHg (17.4%) and 4.2 mmHg (18.4%), respectively. At baseline 6.3% of patients had an IOP of 18 mmHg or less whereas at 4 and 12 weeks, 53.8% and 60.6% of patients respectively had an IOP of 18 mmHg or less. Common adverse events were mild and included ocular hyperaemia, dysgeusia and eye irritation. Study limitations: this study had a small sample size and was open-label. CONCLUSION: Patients receiving combined travoprost ophthalmic solution 0.004% and brinzolamide ophthalmic suspension 1% therapy had lower IOP values compared to those on travoprost monotherapy (p < 0.0001). Combined therapy resulted in a significantly greater percentage of patients achieving IOPs of 18 mmHg or less (p < 0.0001).

Long-term results of surgery in childhood glaucoma

Alsheikheh A, Klink J, Klink T, Steffen H, Grehn F.
University Eye Hospital Wuerzburg, Josef-Schneider-Str.11, 97080, Wuerzburg, Germany, f.grehn@augenklinik.uni-wuerzburg.de.

PURPOSE: The aim of this study is to assess the functional results and morphological parameters in children surgically treated for glaucoma. METHODS: Data from 43 patients and 68 eyes who were operated in our department between 1990 and 2002 were collected. This retrospective trial included primary congenital glaucoma (n=36), and secondary glaucoma (n=7) in Rieger-Axenfeld syndrome and Sturge Weber syndrome. Intraocular pressure (IOP), axial length of the eyeball, visual acuity, refractive errors and orthoptic status were analysed. RESULTS: The age of patients at the first surgery was 6.0+/-5.3 months (range 0.7 to 28.0 months). The mean period of follow-up was 57.3+/-36.8 months (6.0-161.0).The mean number of surgical procedures performed on one eye was 2.5+/-2.4 procedures (1-11). The mean IOP before the first surgery was 31.0+/-7.9 mmHg (17.5-52.0), and was 15.0+/-3.9 mmHg (7.0-28.0) at the last visit. 49 eyes (72.1%) did not need any further medical treatment after the last surgical procedure. The IOP was 18 mmHg or lower without medication in 29 eyes (42.6%) after just one surgical procedure (21 trabeculotomy, 8 combined trabeculotomy/trabeculectomy with or without mitomycin-C). At the first examination, the mean axial length of the eyeball was 22.6+/-1.8 mm (the mean normal value at this age is 20.3+/-0.7 mm), and was 24.4+/-2.0 mm at the last visit (the mean normal value at this age is 22.2+/-0.6 mm). The best corrected visual acuity at the last visit was 0.25+/-4.6 lines; the normal range of visual acuity at this age is from 0.4+/-4.0 lines to 0.8+/-3.0 lines. Visual acuity was 0.32 or more in 53.0% of the eyes. Visual acuity was lower than 0.1 in only 15.2% of the eyes. Myopia was present in 57.4% of the eyes with a mean spherical equivalent of -6.1+/-3.9 dioptres. 15 patients (34.9%) developed strabismus. 22 patients (51.2%) were treated with part-time occlusion. Binocular function as assessed with the Lang-1 test was positive in 17 of 30 patients (56.7%). CONCLUSIONS: Although a good long-term IOP-control can often be achieved in childhood glaucoma, the visual acuity remains below the normal range in most cases despite close orthoptic follow-up.

Long-term follow-up of selective laser trabeculoplasty in primary open-angle glaucoma

Gracner T, Falez M, Gracner B, Pahor D.
Lehrkrankenhaus Maribor, Augenabteilung, 2000 Maribor, Slowenien. tomaz.gracner@sb-mb.si

BACKGROUND: Our aim was to investigate the outcomes of selective laser trabeculoplasty (SLT) for the treatment of primary open-angle glaucoma (POAG) in a prospective clinical study. PATIENTS AND METHODS: In 90 eyes suffering from POAG, treatment was carried out with a frequency-doubled, Q-switched Nd:YAG laser (532 nm). The intraocular pressure (IOP) was measured before the treatment and 1, 3, 6, 12, 18, 24, 30, 36, 42, 48, 54, 60, 66 and 72 months after. A failure was defined as an IOP reduction of less than 20 % of the pretreatment IOP, or a progression of visual field or optic disc damage requiring filtering surgery. The hypotensive medication during the study period remained unchanged. RESULTS: The mean follow-up time was 41.2 months (SD 20.0). The mean pretreatment IOP was 22.4 mmHg (SD 2.3). At one month of follow-up, the mean IOP reduction was 5.0 mmHg (SD 2.3) or 22.3 % and at 6 months 5.2 mmHg (SD 2.4) or 23.2 %. At 12 months of follow-up, the mean IOP reduction was 5.4 mmHg (SD 2.4) or 24.0 % and at 24 months 5.8 mmHg (SD 2.3) or 25.5 %. At 36 months of follow-up, the mean IOP reduction was 5.7 mmHg (SD 2.1) or 25.1 % and at 48 months of follow-up, the mean IOP reduction was 5.2 mmHg (SD 1.9) or 23.1 %. At 60 months of follow-up, the mean IOP reduction was 5.2 mmHg (SD 2.0) or 22.6 % and at the end of 72 months of follow-up, the mean IOP reduction was 5.4 mmHg (SD 2.3) or 22.8 %. The success rate after 12 months determined by Kaplan-Meier survival analysis was 94 %, after 24 months 85 %, after 36 months 74 %, after 48 months 68 % and after 72 months 59 %. CONCLUSION: SLT is an effective procedure offering an additional therapy option for the treatment of POAG, but the effect diminishes over time.

Efficacy of laser trabeculoplasty in phakic and pseudophakic patients with primary open-angle glaucoma.

Mahdaviani S, Kitnarong N, Kropf JK, Netland PA.
Department of Ophthalmology, Hamilton Eye Institute, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA.

BACKGROUND AND OBJECTIVE: To compare the efficacy of laser trabeculoplasty in pseudophakic and phakic patients with primary open-angle glaucoma (POAG). PATIENTS AND METHODS: Retrospective comparative case-control series of 42 eyes (21 pseudophakic eyes and 21 phakic eyes of patients matched for age and gender) with POAG not controlled using medical therapy and treated with laser trabeculoplasty. Success was reduction of intraocular pressure (IOP) of at least 3 mm Hg from baseline and no additional glaucoma surgery or laser treatment. uloplasty, there was no significant difference between pseudophakic and phakic eyes in the mean IOP and change from baseline IOP Success at 12 months was 78% for pseudophakic and 80% for phakic eyes. Kaplan-Meier survival analysis showed no statistically significant difference in success after laser trabeculoplasty comparing phakic to pseudophakic eyes (P = .87). CONCLUSION: In eyes with POAG, laser trabeculoplasty is as effective in pseudophakic eyes as in phakic eyes.

Dose, timing and frequency of subconjunctival 5-fluorouracil injections after glaucoma filtering surgery

Reinthal EK, Denk PO, Grub M, Besch D, Bartz-Schmidt KU.
Dept I, University Eye Clinic, Schleichstrasse 12, 72076, Tubingen, Germany, eva.reinthal@med.uni-tuebingen.de.

BACKGROUND: Although adjunctive postoperative 5-fluorouracil (5-FU) injections are known to improve the success rate of glaucoma surgery, it is still unknown what dose, timing and frequency of application will give the best results with respect to the inhibition of postoperative scarring and intraocular pressure regulation. We therefore designed the following retrospective investigation. METHODS: We studied 172 eyes from 172 patients who had undergone trabeculectomy with adjuvant 5-FU-therapy. Variations of dosage, timing and frequency were analysed retrospectively. Surgery was defined as a complete success when the patient reached an intraocular pressure under 21 mmHg and a reduction of 20% 12 months after the operation. A relative success was achieved with these criteria under additional local medication. Not reaching these postoperative criteria for a complete success was classified as failure. RESULTS: On average, adjunctive 5-FU-treatment was started 4.6+/-5.85 days postoperatively. The injections contained between 2 mg and 5 mg FU, and the mean total dose was 26.6+/-13.2 mg (range 5-65 mg). Surgery on 94 patients (54.65%) was classified as "complete success", that on 25 patients (14.53%) was classified as "relative success" and that on 53 eyes (30.81%) was classified as "failure" 12 months (+/-3 months) postoperatively. The best results were obtained when the treatment started on or before the first postoperative day (68.0-71.4% complete success; P<0.05). In contrast, an increase in 5-FU dosage did not result in an increased success rate of trabeculectomy. None of the 172 patients suffered from vision-threatening complications such as endophthalmitis or hypotony maculopathy. CONCLUSION: Early treatment with 5-FU significantly increases the success rates of filtering surgery.

Neovascular glaucoma : Aetiology, pathogenesis and treatment

Loffler KU.
Universitats-Augenklinik, Ernst-Abbe-Strasse 2, 53127 , Bonn, karinloeffler@uni-bonn.de.

Neovascular glaucoma, as a typical secondary glaucoma, is due to ocular or (earlier) systemic diseases. The formation of a fibrovascular membrane on the anterior surface of the iris (rubeosis iridis) and extending into the chamber angle leads to irreversible obliteration of the outflow system, with a corresponding rise in intraocular pressure. The most frequent cause is retinal ischaemia resulting either from vascular occlusion or from diabetic alterations. The differential diagnosis must include acute angle-closure glaucoma and uncontrolled open-angle glaucoma. Treatment is aimed at eliminating the actual cause or at least reducing the risk factors (e.g. by retinal laser coagulation), or consists in cyclodestructive procedures. Medicamentous therapy comprises anti-inflammatory agents (steroids, cycloplegic agents) and substances that reduce the production of aequeous humour (carbonic anhydrase antagonists, beta blockers). In the near future, antiangiogenic medication might be another effective option. For end-stage neovascular glaucoma, the implantation of drainage devices is also discussed.

The additive effect of topical dorzolamide and systemic acetazolamide in pediatric glaucoma

Sabri K, Levin AV.
Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, Canada.

BACKGROUND: The effect of adding oral to topical carbonic anhydrase inhibitors in the management of pediatric glaucoma is unknown. METHODS: We undertook a retrospective analysis of children with a diagnosis of glaucoma before the age of 16 years who initially were treated with topical dorzolamide or dorzolamide-timolol combination and then treated with oral acetazolamide. Children who had uveitic glaucoma or who had ocular surgery within 3 months before or during oral acetazolamide therapy were excluded. Various methods of intraocular pressure (IOP) measurement were used in the study. However, in each case, the IOP was measured using the same technique, once at the last visit before the addition of oral acetazolamide and once at the first examination after the addition of oral acetazolamide. RESULTS: Twenty-two patients were included in the study with an age range of 8 months to 15 years. Seventeen children were boys. Oral acetazolamide treatment was via a daily dose (13.3 to 30 mg/kg, mean 22.5 mg/kg), and duration (6 to 31 days, mean 18.1 days). The intraocular pressure (mean +/- SD) before acetazolamide (32.2 +/- 6.5 mm Hg) was significantly different than after acetazolamide (21.8 +/- 6.3 mm Hg) with a mean difference of 10.36 mm Hg (p < 0.0001) and a mean decrease in IOP of 29.6%. CONCLUSIONS: The addition of oral acetazolamide to topical dorzolamide may provide additional reduction in IOP in some children already being treated with topical carbonic anhydrase inhibitors. This possible additive effect has not been observed in adults treated with a combination of topical and systemic carbonic anhydrase inhibitors.

Intraocular Pressure-Lowering Effect of Adding Dorzolamide or Latanoprost to Timolol A Meta-analysis of Randomized Clinical Trials

Webers CA, Valk RV, Schouten JS, Zeegers MP, Prins MH, Hendrikse F.
Department of Ophthalmology, Maastricht University Hospital, Maastricht, The Netherlands.

OBJECTIVE: To estimate the intraocular pressure (IOP)-lowering effect of 2% dorzolamide or 0.005% latanoprost when added to 0.5% timolol. DESIGN: Meta-analysis of randomized clinical trials. PARTICIPANTS: Seventeen articles reporting on 19 study arms with 5 possible treatment combinations and 4 study arms serving as controls. METHODS: Articles written in English, German, French, or Dutch and published up to December 2004 were identified in Medline, Embase, the Cochrane Controlled Trials Register, and references from relevant articles. For the article to be considered, over 85% of the patients had to have primary open-angle glaucoma or ocular hypertension. The pooled 1- to 3-month additional IOP-lowering effect after a run-in phase on timolol was calculated by performing meta-analysis using the random effects model. MAIN OUTCOME MEASURES: Absolute and relative changes in IOP after run-in on timolol for peak moment, trough moment, or mean diurnal curve. RESULTS: The pooled change from baseline [mean (95% confidence interval)] for 0.5% timolol varied from -0.7 mmHg (-1.2 to -0.2, for the mean diurnal curve) to -2.0 mmHg (-1.3 to -2.7, at peak). Pooled changes for 2% dorzolamide in concomitant use with 0.5% timolol were -4.1 mmHg (-4.4 to -3.8) at trough and -4.9 mmHg (-5.3 to -4.5) at peak. The fixed 2% dorzolamide and 0.5% timolol combination resulted in a pooled change of -3.8 mmHg (-4.2 to -3.4) at trough and -4.9 mmHg (-5.3 to -4.5) at peak. The concomitant use of 0.005% latanoprost and 0.5% timolol gave a pooled change from baseline of -6.0 mmHg (-6.8 to -5.2) at the mean diurnal curve. The fixed combination of 0.005% latanoprost and 0.5% timolol resulted in a mean change of -3.0 mmHg (-3.8 to -2.2) at the mean diurnal curve. CONCLUSION: In this meta-analysis of clinical trials, the addition of dorzolamide or latanoprost further lowers IOP in eyes on timolol. This result may not be generalizable because these trials may have included nonresponders to timolol.

A comparative analysis of the effects of the fixed combination of timolol and dorzolamide versus latanoprost plus timolol on ocular hemodynamics and

Siesky B, Harris A, Sines D, Rechtman E, Malinovsky VE, McCranor L, Yung CW, Zalish M.
Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN.

Aims: The aim of this study was to assess the effects of fixed combination of timolol and dorzolamide and latanoprost plus timolol on retinal, choroidal, and retrobulbar hemodynamics and visual function in primary open-angle glaucoma (OAG) subjects. Methods: Sixteen (16) OAG patients (age, 63.5 +/- 10.8 years; 9 male) were evaluated in a randomized, crossover, double-blind study design after 4 weeks of treatment of latanoprost with timolol and fixed combination of timolol and dorzolamide. After randomization, 9 right eyes and 7 left eyes were included in the hemodynamic portion of the study. Measurements included: adverse events check, visual acuity, contrast sensitivity, blood pressure, heart rate, intraocular pressure (IOP), and fundus examination. Ocular blood flow was assessed using confocal scanning laser Doppler flowmetry, color Doppler imaging, and scanning laser ophthalmoscopy. Results: Both therapies were effective at lowering IOP, whereas there was no statistically significant difference between latanoprost plus timolol and the fixed combination of timolol and dorzolamide (13.9% and 12.2% reduction, respectively; P = 0.5533). Fixed combination of timolol and dorzolamide significantly increased central retinal artery end diastolic blood flow velocity (P = 0.0168) and lowered resistance to flow (P = 0.0279). Temporal posterior ciliary artery peak systolic and end diastolic velocities were significantly increased with the fixed combination of timolol and dorzolamide (P = 0.0125 and 0.0238, respectively). Latanoprost plus timolol had no significant effects on ocular blood flow during 4 weeks of treatment. There were no statistically significant differences in adverse events, blood pressure, heart rate, visual acuity, contrast sensitivity scanning laser ophthalmoscopy, or Heidelberg Retinal Flowmeter for any treatment period. Conclusions: Fixed combination of timolol and dorzolamide therapy might increase blood flow in OAG patients while attaining a similar IOP reduction compared to latanoprost plus timolol. Visual function, however, was not different in this short-term comparison between the two treatments.

Glaucoma

Tezel G, Wax MB.
Kentucky Lions Eye Center, University of Louisville School of Medicine, Louisville, Ky., USA.

Glaucoma is a chronic neurodegenerative disease of the optic nerve, in which apoptosis of retinal ganglion cells (RGCs) and progressive loss of optic nerve axons result in structural and functional deficits in glaucoma patients. This neurodegenerative disease is indeed a leading cause of blindness in the world. The glaucomatous neurodegenerative environment has been associated with the activation of multiple pathogenic mechanisms for RGC death and axon degeneration. Growing evidence obtained from clinical and experimental studies over the last decade also strongly suggests the involvement of the immune system in this neurodegenerative process. Paradoxically, the roles of the immune system in glaucoma have been described as either neuroprotective or neurodestructive. A balance between beneficial immunity and harmful autoimmune neurodegeneration may ultimately determine the fate of RGCs in response to various stressors in glaucomatous eyes. Based on clinical data in humans, it has been proposed that one form of glaucoma may be an autoimmune neuropathy, in which an individual's immune response facilitates a somatic and/or axonal degeneration of RGCs by the very system which normally serves to protect it against tissue stress.

The clinical applications of Fluorouracil in ophthalmic practice

Abraham LM, Selva D, Casson R, Leibovitch I.
Glaucoma Services, South Australian Institute of Ophthalmology, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia.

Fluorouracil (5-fluorouracil, 5-FU) is a pyrimidine analogue that was originally known for its widespread use as an anticancer drug. The ability of 5-FU to reduce fibroblastic proliferation and subsequent scarring has made it an important adjunct in ocular and periorbital surgeries. It is used in primary glaucoma filtering surgeries and in reviving failing filtering blebs, in dacryocystorhinostomy, pterygium surgery, and in vitreoretinal surgery to prevent proliferative vitreoretinopathy. In addition, 5-FU is also gaining recognition in the treatment and surgical management of ocular surface malignancies like ocular surface squamous neoplasia; however, the specific action of the drug on highly proliferating cells limits its use in primary acquired melanosis of the conjunctiva. When applied topically, this drug has a low rate of sight-threatening adverse effects, is inexpensive, and is easy to administer, making it an important tool in enhancing the success rate in ophthalmic surgery and in reducing the recurrence of ocular surface neoplasia.

Cortisone glaucoma: epidemiological, clinical, and therapeutic study

El Afrit MA, Mazlout H, Trojet S, Larguech L, Megaieth K, Belhaj S, Khemiri N, Kraiem A.
Service d'Ophtalmologie, Hopital Habib Thameur, Tunis, Tunisia. ali.elafrit@rns.tn

INTRODUCTION: Cortisone glaucoma is a secondary glaucoma induced by local or oral steroids used to treat chronic inflammatory diseases. PATIENTS AND METHODS: Retrospective study including 43 eyes of 23 patients (three patients were monophthalmos). We present epidemiological and clinical features with evaluation of functional damage (visual acuity, visual field), and therapeutic results with a follow-up period ranging from 2 to 10 years. RESULTS: Topical steroids were incriminated in 15 of 23 cases (self-medication), whereas general steroids (for chronic diseases) were used by eight patients. Visual function was seriously affected (visual acuity<1/10 in 23/43 eyes at the first visit with pronounced visual field abnormalities). Surgery was necessary in 16 of 43 eyes (deep sclerectomy with or without implant, trabeculectomy). DISCUSSION: Cortisone glaucoma is rather frequent in Tunisia where conjunctival allergy and self-medication are common. Young adults are concerned, making it a high surgical risk usually requiring surgical devices such as a T Flux implant. CONCLUSION: Cortisone glaucoma is a serious complication of steroid therapy that usually affects young adults. The disease is usually detected late, explaining the severe functional damage.

A double-masked, randomized, parallel comparison of a fixed combination of bimatoprost 0.03%/timolol 0.5% with non-fixed combination use in patients w

Hommer A.
Department of Ophthalmology, Hera Hospital, Vienna - Austria.

PURPOSE. To compare the safety and efficacy of the fixed combination product with non-fixed combination use of the same active ingredients in separate bottles (bimatoprost once-daily [qd], and timolol twice-daily [bid]). A bimatoprost 0.03% qd treatment arm was used for validation of the study. METHOD. This was a double-masked, randomized, parallel study in 445 patients with open-angle glaucoma or ocular hypertension. They were randomized in a ratio of 2:2:1 to receive bilateral treatment with the fixed combination, non-fixed combination treatment, or bimatoprost alone. RESULTS. Comparing the fixed combination and non-fixed combination, the non-inferiority margin of 1.5 mm Hg was met at all three timepoints for mean intraocular pressure (IOP), and a margin of 1.0 mm Hg for mean diurnal IOP. The incidence of conjunctival hyperemia was statistically significantly lower (p=0.014) in the fixed combination group (8.5%, 15/176) compared with the bimatoprost group (18.9%, 17/90) and the non-fixed combination group (12.5%, 22/176). CONCLUSIONS. The fixed combination of bimatoprost 0.03%/timolol 0.5% administered once daily was comparable in ocular hypotensive efficacy to the non-fixed combination. The lower propensity of the fixed combination to elicit conjunctival hyperemia suggests a superior comparative benefit/risk assessment of the fixed combination in the treatment of elevated IOP. Members of the Ganfort(R) Investigators Group I were as follows: Investigators-W. Benton Boone, MD, Inglewood, CA; James D. Branch, MD, Winston-Salem, NC; Luca Brigatti, MD, Rochester, NY; William C. Christie, MD, Pittsburgh, PA; William S. Clifford, MD, Garden City, KS; David L. Cooke, MD, St. Joseph, MI; Joel Corwin, MD, Ventura, CA; William F. Davitt III, MD, El Paso, TX; Jason Burns, MD, Jorge De La Chapa, DO, San Antonio, TX; Donald Digby, MD, Greensboro, NC; Mark DiSclafani, MD, Bradenton, FL; Martin Dorner, MD, Bocholt, Germany; Anton Hommer, MD, Vienna, Austria; Barry Katzman, MD, San Diego, CA; Hartwig Koch-Schweitzer, MD, Mettingen, Germany; Theodore Krupin, MD, Chicago, IL; Mark A. Latina, MD, Reading, MA; Charles Lederer, MD, Kansas City, MO; Martin R. Leopold, MD, Fishkill, NY; Mark Lesk, MD, Montreal, Quebec, Canada; Arash Mansouri, MD, Fredericksburg, VA; David Manusow, MD, Winnipeg, Manitoba, Canada; Paul Murphy, MD, Saskatoon, Saskatchewan, Canada; Katherine Ochsner, MD, Wilmington, NC; Peter Otto, MD, Berlin, Germany, Norbert Pfeiffer, MD, Mainz, Germany; Roberto Piemontesi, MD, Saskatoon, Saskatchewan, Canada; Eugene Protzko, MD, Bel Air, MD; Jay Rubin, MD, San Antonio, TX; Roman Rybiczka, MD, Wien, Austria; Sonja Scholzel, MD, Berlin, Germany; Sriram Sonty, MD, Calumet City, IL; Robert H. Stewart, MD, Houston, TX; Joseph Tauber, MD, Kansas City, MO; and Thomas R. Walters, MD, Austin, TX. Organizational Center-Amy L. Batoosingh, Izabella Bossowska, MD, Connie Chou, PhD, Alison Ingram, and Gary D. Novack, PhD.

Experience with the polymer-coated hydroxyapatite implant after enucleation in 126 patients

Shields CL, Uysal Y, Marr BP, Lally SE, Rodriques E, Kharod B, Shields JA.
Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA.

OBJECTIVE: To evaluate the new polymer-coated hydroxyapatite implant. DESIGN: Retrospective nonrandomized single-center case series. PARTICIPANTS: One hundred twenty-six patients managed with enucleation and placement of the polymer-coated hydroxyapatite implant at the Ocular Oncology Service at Wills Eye Hospital of Thomas Jefferson University. METHODS: A retrospective analysis was performed on 126 patients managed with enucleation and placement of the polymer-coated hydroxyapatite implant. MAIN OUTCOME MEASURES: Ease of placement, functional ocular motility, tissue complications, and patient satisfaction. RESULTS: The preenucleation diagnoses included uveal melanoma (n = 76; 61%), retinoblastoma (n = 34; 27%), blind painful eye (n = 8; 6%), neovascular glaucoma from intraocular tumors or retinal detachment (n = 5; 4%), and others (n = 3; 2%). Previous ocular therapies for posterior segment conditions such as plaque radiotherapy, retinal detachment repair, and chemoreduction, thermotherapy, and cryotherapy had been performed in 22% of patients (n = 27). The implant size was 20 mm (n = 103; 82%), 18 mm (n = 22; 17%), and 16 mm (n = 1; 1%). Implant preparation and placement was uncomplicated in all patients, without adhesion to surrounding tissue. Four rectus muscles were attached to the implant in all patients. Socket motility was judged to be good (n = 118; 94%), fair (n = 6; 5%), and poor (n = 2; 2%). Complications included conjunctival thinning (n = 1; <1%), pyogenic granuloma (n = 1; <1%), conjunctival cyst (n = 3; 2%), implant infection (n = 1; <1%), and implant exposure (n = 3; 2%). There were no cases of implant extrusion or allergic reaction to the polymer. Patient satisfaction was reported as good (n = 123; 98%), fair (n = 2; 2%), and poor (n = 1; <1%). CONCLUSIONS: The polymer-coated hydroxyapatite implant is smoothly placed into the orbit after enucleation without the need for additional tissue wrap. With proper placement, this implant provides satisfactory functional motility and shows favorable tissue tolerance with no clinical evidence of allergic reaction or extrusion.

Endoscopic laser cyclophotocoagulation in pediatric glaucoma with corneal opacities

Al-Haddad CE, Freedman SF.
Duke University Eye Center, Durham, NC.

INTRODUCTION: Endoscopic diode cycloablation (ECP) has shown modest efficacy for the management of pediatric glaucomas. Eyes with pediatric glaucoma and corneal opacities pose obstacles to intraocular surgery. We examined the role of ECP in lowering intraocular pressure (IOP) as well as that of endoscopy in facilitating tube shunt placement in these eyes. METHODS: Retrospective chart review of 12 eyes (11 patients) with glaucoma and corneal opacities from 12/99 to 9/05. ECP was performed for IOP control with success defined as postoperative IOP

Endoscopic diode laser cyclophotocoagulation in the management of aphakic and pseudophakic glaucoma in children

Carter BC, Plager DA, Neely DE, Sprunger DT, Sondhi N, Roberts GJ.
Indiana University Medical Center, Indianapolis, Indiana.

INTRODUCTION: Endoscopic cyclophotocoagulation (ECP) has been shown to be a useful adjunct in the management of a variety of difficult pediatric and adult glaucomas. This study reports the efficacy and safety of this procedure for pediatric aphakic and pseudophakic glaucoma. METHODS: ECP was performed on 34 eyes of 25 patients under 16 years of age with aphakic or pseudophakic glaucoma between April 1994 and November 2004. Patients were followed for a minimum of 12 months or until a treatment failure had been declared. Treatment failure was defined as postoperative intraocular pressure (IOP) of >24 mm Hg and IOP lowering of less than 15% despite the addition of glaucoma medications or the occurrence of any visually significant complications. Aphakic eyes of patients with congenital glaucoma or an anterior segment dysgenesis were not included in the study group. RESULTS: Pretreatment IOP averaged 32.6 mm Hg in the 34 eyes, compared with a final postoperative average of 22.9 mm Hg. Mean follow-up period for study eyes was 44.4 months, and the average number of procedures per eye was 1.5. Overall success rate was 53% (18/34). Thirteen of the 34 eyes (38%) received one treatment only and were deemed a success. Retinal detachments developed in two eyes within the first postoperative month. CONCLUSIONS: ECP is a useful tool in the treatment of aphakic and pseudophakic glaucoma, with a low rate of visually significant complications. Retreatment of eyes improved the overall success rate, although experience with cases beyond two treatment sessions is limited. Hypotony was not encountered despite 8 of the 34 eyes receiving 360 degrees of total endocyclophotoablation to the ciliary processes.

Glaucoma surgery and retinal pathology

The occurrence of hypertonia during a surgically treated retinal disease is frequent because these disorders often involve the same population of patients. The main cause of postoperative hypertonia remains a preoperative unknown glaucoma. Hypertonia occurring before the treatment of a retinal detachment can result from angle recession glaucoma, ghost cell glaucoma, or Schwartz-Matzuo syndrome; all of which are frequently associated with trauma. Hypertonia occurring after the surgery of a retinal detachment can be caused by scleral buckling, a topical postoperative steroid treatment, or an internal tamponade with gas or silicone. The latter is responsible for severe hypertonia that is frequently resistant to treatment. Hypertonia occurring after the use of triamcinolone is usually controlled with medical treatment. Prior filtrating surgery can lead to technical problems during retinal surgery. The knowledge of pre-existing glaucoma may be reason for cautious management of retinal surgery.

Nonpenetrating glaucoma surgery: a critical evaluation

Sarodia U, Shaarawy T, Barton K.
aGlaucoma Service, Moorfields Eye Hospital, London, UK bClinique d'ophtalmologie, Hopitaux Universitaires de Geneve, Switzerland.

PURPOSE OF REVIEW: Nonpenetrating glaucoma surgery is popular in a number of countries because of its perceived superior safety profile to mitomycin-C trabeculectomy. This article critically evaluates recently published literature relating to nonpenetrating glaucoma surgery. RECENT FINDINGS: Recent modifications in nonpenetrating glaucoma surgery, including the use of implants, augmentation with antiproliferatives, and use of laser goniopuncture, appear to result in improved intraocular pressure control. Comparative studies suggest a better safety profile with nonpenetrating glaucoma surgery but higher long-term intraocular pressure than after trabeculectomy. Despite this perception, a difference in intraocular pressure control between mitomycin-C trabeculectomy and nonpenetrating glaucoma surgery, when the most recent modification has been incorporated, has not been demonstrated conclusively in randomized trials conducted over sufficiently long periods to be clinically important. SUMMARY: Nonpenetrating glaucoma surgery continues to evolve. Intraocular pressure-lowering efficacy seems to have improved with recent modifications in technique but the degree and longevity of intraocular pressure-lowering in comparison with trabeculectomy are still uncertain.