Faculty Bibliography

OBJECTIVE: To assess the history, clinical course, and response to treatment of 14 patients with a bleb infection (blebitis) following glaucoma surgery. DESIGN: Retrospective study. SETTING: A university referral center in Atlanta, Ga. PATIENTS: Fourteen patients developed a bleb infection that ranged from 1 month to 22 years after glaucoma surgery. Infections were characterized by pain, a whitened bleb surrounded by intense conjunctival injection, marked anterior chamber reaction (hypopyon in six eyes), and a clear vitreous. Before infection, most blebs were described as thin. The results of Seidel's test were positive in six patients, and most patients had a low intraocular pressure without the use of any glaucoma medication. INTERVENTION: Treatment consisted of hospitalization, intravenous antibiotic therapy, and hourly topical fortified cefazolin sodium and gentamicin sulfate. RESULTS: The visual acuity in most patients improved to the level before the bleb infection, with only three eyes losing 2 or more lines of vision. CONCLUSIONS: Bleb infection without vitreous involvement (blebitis) may be a precursor of endophthalmitis. With aggressive treatment, bleb infection appears to have a much better prognosis for visual recovery than endophthalmitis.

Medical therapy has been the standard initial treatment for open-angle glaucoma. When some visual field has been lost and maximum tolerated and effective medical therapy does not succeed in controlling the disease, the patient is considered to have advanced glaucoma, and the first of a potential sequence of surgical treatments is usually indicated. Little is known about the long-term course and prognosis of advanced glaucoma or about the long-term effectiveness of sequential surgical treatments in controlling the disease and preventing vision loss and blindness. The Advanced Glaucoma Intervention Study was designed to study, in advanced glaucoma, the long-term clinical course and prognosis, and, in a randomized trial, the comparative outcomes of two sequences of surgical treatments. Toward these goals, 789 eyes in 591 patients were enrolled at 11 clinical centers between 1988 and 1992. Follow-up will continue until 1996. Eyes were randomly assigned to one of two sequences of surgical treatments. One sequence begins with argon laser trabeculoplasty (ALT), is followed by trabeculectomy, an incisional surgical filtering procedure, should ALT fail to control the disease, and by a second trabeculectomy should the first trabeculectomy fail. The other sequence begins with trabeculectomy, is followed by ALT should the trabeculectomy fail, and by a second trabeculectomy should ALT fail. The main outcome of interest is visual function (visual field and visual acuity). Other important outcomes are intraocular pressure, complications of surgery, time to treatment failure, and extent of need for additional medical therapy. We present in this paper the rationale, objectives, design and methods of the study, and the baseline characteristics of study patients and eyes. $$:

In this study we examined the relative effects of reducing eyedrop size (from 30 microliters to 10 microliters) and eyelid closure on the ocular efficacy and systemic absorption of 10% phenylephrine. Thirteen subjects participated in a quadruple crossover study that involved dilation with a 10-microliters and a 30-microliters drop of phenylephrine with and without eyelid closure. The 10-microliters drop was just as effective for pupillary dilation as the 30-microliters drop. Eyelid closure improved dilation for both drop sizes. Both eyelid closure and reducing the drug volume decreased systemic absorption of phenylephrine as measured by plasma concentration. When used together, eyelid closure and the smaller drop size reduced plasma concentration by 45%. The therapeutic index for 10% phenylephrine appears to be improved by using a 10-microliters drop followed by eyelid closure.

The incidence of sudden visual loss after an intraocular procedure in patients with glaucoma and visual field defects has been disputed for over a century. We examined the risk of sudden visual loss associated with trabeculectomy in glaucoma patients with advanced visual field defects. Fifty-four filtering operations performed on 44 patients were reviewed. All patients had visual field defects encroaching on or splitting fixation, a visual acuity of 20/100 or better, and a follow-up period of at least two months. Thirty-one of the 54 preoperative visual fields (57%) disclosed a fixation-splitting defect. Sudden visual loss was not observed in any patient during the two-month postoperative period. These findings suggest that the incidence of sudden postoperative visual loss is lower than previously reported.

Chronic progressive external ophthalmoplegia (CPEO) describes a recognizable clinical syndrome frequently associated with variable dysfunction in other organ systems. Histochemical and biochemical studies suggested primary dysfunction of oxidative phosphorylation. This has recently been confirmed by demonstration of partially deleted as well as normal mitochondrial DNA--heteroplasmy--in some of these patients, most of them sporadic. In the six heteroplasmic CPEO patients that we have examined to date, the partially deleted species has been detected in all tissues tested, albeit in vastly different proportions. We report here detection of physiologically significant proportions of partially deleted mitochondrial DNA in several organs taken at autopsy from a CPEO patient with severe multisystem disease. We discuss the relationship of CPEO to several other clinical phenotypes associated with mitochondrial dysfunction, and discuss the possible implications of heteroplasmy for the development of variable phenotypes.

A 59-year-old man who had previously undergone a trabeculectomy in his right eye was examined because of an enlarging pigmented lesion of the inferior portion of the iris. A fine-needle aspiration biopsy of aqueous fluid revealed spindle cells and epithelioid malignant melanoma cells. The eye was enucleated, and subsequent histopathologic examination demonstrated a mixed spindle cell and epithelioid cell melanoma of the inferior portion of the iris with seeding of melanoma cells into the conjunctival filtering bleb via the trabeculectomy site. This case illustrates the usefulness of fine-needle aspiration biopsy in the evaluation of pigmented iris lesions and illustrates that iris melanoma can seed through a trabeculectomy site.

We studied the effects on efficacy and safety of varying the drop size of a topical solution of levobunolol 0.5%. In a double-masked, crossover acute study, we administered a single drop of either 35 microL of vehicle, or 20, 35, or 50 microL of levobunolol one hour before the subjects began a ten-minute treadmill challenge electrocardiogram. After exercise the mean heart rate was 111 beats per minute (bpm) in the vehicle group and 102 to 103 bpm in the three levobunolol groups, which were significantly different from the control group but not from each other. In a randomized double-masked, parallel, chronic study, 117 patients with elevated intraocular pressure (IOP) instilled one of the three drop sizes of levobunolol twice daily for three months. Mean decreases in IOP ranged from 5.1 to 6.0 mmHg in the three groups, not significantly different from each other in mean IOP, heart rate, or blood pressure. We conclude that drop size in the range tested had no clinically significant effect on either efficacy or safety of a beta blocker such as levobunolol.