Long-term outcomes of antiproliferative agents in primary trabeculectomy

Purpose: To evaluate and compare long-term outcomes of trabeculectomies with subconjunctival injections of 5-fluorouracil (5-FU) after sugery or use of mitomycin C (MMC) during surgery. Methods: Retrospective study of 133 eyes who underwent primary trabeculectomy. Results: Intraocular pressure levels were not statistically significant at any of the postoperative visits when comparing the 5-fluorouracil and mitomycin C groups. In each group, analyzed separately, the intra-ocular pressure levels showed no statistically significant difference before or after surgery. The incidence of postoperative complications was not statistically significant as well, except for a greater incidence of the corneal epithelial defects, more frequent in the 5-fluorouracil group. In both groups, a greater incidence of development/progression of cataract was noted. Conclusion: Both mitomycin C and 5-fluorouracil promoted an important and stable decrease in intraocular pressure with similar complication rates.Objetivo: Avaliar comparativamente a longo prazo os resultados cirúrgicos de trabeculectomias nas quais foram utilizadas injeções subconjuntivais de 5-fluorouracil (5-FU) no pós-operatório ou aplicações de mitomicina C (MMC) peroperatória. Métodos: Estudo retrospectivo de 133 olhos submetidos a trabeculectomia primária. Resultados: A pressão ocular não apresentou valores estatisticamente significantes em nenhuma das visitas de pós-operatório quando comparados os grupos em que se utilizou a mitomicina C ou 5-fluorouracil. Em cada um dos grupos analisados separadamente, os níveis da pressão ocular não apresentaram diferenças estatisticamente significantes nos períodos pré e pós-operatório. A incidência de complicações pós-operatórias também não apresentou diferença estatisticamente significante à exceção de alterações epiteliais na córnea, mais freqüentes no grupo tratado com 5-fluorouracil. Nos dois grupos, destacou-se a elevada incidência de desenvolvimento/progressão de catarata. Conclusão: O uso de mitomicina C ou 5-fluorouracil promoveu redução importante e estável da pressão ocular, com índices de complicações semelhantes.Universidade Federal de São Paulo (UNIFESP) Departamento de OftalmologiaUniversidade de Miami Bascom Palmer Eye InstituteUNIFESP, Depto. de OftalmologiaSciEL

Longitudinal changes in peripapillary atrophy in the ocular hypertension treatment study: A case-control assessment

To explore the association between peripapillary atrophy (PPA) area and conversion from ocular hypertension (OHT) to glaucoma

Postoperative Complications in the Ahmed Baerveldt Comparison Study During Five Years of Follow-up

To compare the late complications in the Ahmed Baerveldt Comparison Study during 5 years of follow-up

Algorithms for optimizing drug therapy

BACKGROUND: Drug therapy has become increasingly efficient, with more drugs available for treatment of an ever-growing number of conditions. Yet, drug use is reported to be sub optimal in several aspects, such as dosage, patient's adherence and outcome of therapy. The aim of the current study was to investigate the possibility to optimize drug therapy using computer programs, available on the Internet. METHODS: One hundred and ten officially endorsed text documents, published between 1996 and 2004, containing guidelines for drug therapy in 246 disorders, were analyzed with regard to information about patient-, disease- and drug-related factors and relationships between these factors. This information was used to construct algorithms for identifying optimum treatment in each of the studied disorders. These algorithms were categorized in order to define as few models as possible that still could accommodate the identified factors and the relationships between them. The resulting program prototypes were implemented in HTML (user interface) and JavaScript (program logic). RESULTS: Three types of algorithms were sufficient for the intended purpose. The simplest type is a list of factors, each of which implies that the particular patient should or should not receive treatment. This is adequate in situations where only one treatment exists. The second type, a more elaborate model, is required when treatment can by provided using drugs from different pharmacological classes and the selection of drug class is dependent on patient characteristics. An easily implemented set of if-then statements was able to manage the identified information in such instances. The third type was needed in the few situations where the selection and dosage of drugs were depending on the degree to which one or more patient-specific factors were present. In these cases the implementation of an established decision model based on fuzzy sets was required. Computer programs based on one of these three models could be constructed regarding all but one of the studied disorders. The single exception was depression, where reliable relationships between patient characteristics, drug classes and outcome of therapy remain to be defined. CONCLUSION: Algorithms for optimizing drug therapy can, with presumably rare exceptions, be developed for any disorder, using standard Internet programming methods

Outcome of Baerveldt glaucoma drainage implants for the treatment of uveitic glaucoma

To evaluate the efficacy and safety of Baerveldt glaucoma drainage devices in the management of uveitic glaucoma. Retrospective, noncomparative case series. Twenty-four eyes of 24 patients who underwent implantation of Baerveldt glaucoma drainage devices between 1996 and 2000 for the treatment of uveitic glaucoma refractory to medical therapy. Implantation of Baerveldt glaucoma drainage device. Control of intraocular pressure (IOP), number of glaucoma medications needed for adequate IOP control, visual acuity, complications associated with the surgery, and the effect of subsequent surgery on the ability of the device to control IOP. Success was defined as IOP >/=5 and </=21 mmHg with or without antiglaucoma medications and without need for further glaucoma surgery, loss of light perception, or phthisis. Cumulative life-table success rates were 95.8% at 3 months and 91.7% at 6 months, 12 months, and 24 months. The mean postoperative follow-up was 20.8 months. The IOP was reduced from a preoperative mean of 30.5 +/- 8.96 mmHg with 3.1 +/- 0.99 antiglaucoma medications to a postoperative mean at 6 months or 1 year of 13.0 +/- 4.6 mmHg (P < 0.001) with 0.8 +/- 0.8 antiglaucoma medications (P < 0.001). At last follow-up 14 of 24 eyes (58.3%) required no antiglaucoma medications. Best-corrected visual acuity improved or remained within 2 lines of preoperative visual acuity in 19 (79.2%) eyes. The most common complications were choroidal effusions in four (16.7%), hypotony in three (12.5%) eyes, cystoid macular edema in three (12.5%) eyes, and failure of corneal grafts in two (8.3%). Seven of 22 eyes (31.8%) in which successful control of IOP with the Baerveldt implant was achieved underwent subsequent nonglaucoma-related incisional surgery. None of these eyes (0%) lost IOP control after the subsequent procedure. The Baerveldt glaucoma drainage device offers reasonable safety and effectiveness for the control of IOP in eyes with uveitis and refractory glaucoma

Clinical trial of povidone-iodine (Betadine) versus placebo in the pretreatment of corneal ulcers

To investigate antimicrobial effectiveness of povidone-iodine (Betadine) in reducing bacterial load of corneal ulcers before patients were given antibiotics. Patients with corneal ulcers were randomized to Betadine or placebo group. Ulcers were cultured before and after a 10-minute application of 5% Betadine or preservative-free artificial tears. All patients were then treated with standard antibiotic medications. The number of colony-forming units before and after Betadine or placebo was compared. Eighteen patients were randomized to Betadine and 17 to placebo group. In the Betadine group, 8 (44%) of 18 ulcers were culture-positive, either before and/or after pretreatment, and in the control group, 9 (53%) of 17 were culture positive. There was No statistical difference in colony-forming units change after Betadine versus artificial tears application was detected (P-value = 0.16, t-test). In Betadine group, 3 (17%) of 18 of patients showed improvement, ie, had fewer colonies after drop application; and in the placebo group, 7 (41%) of 17 showed improvement, (P = 0.15, Fisher exact t test.) A single application of 5% Betadine did not reduce the bacterial load of corneal ulcers more than just scraping/rinsing alone. This is likely the result of the lack of penetration deep into the corneal stroma and number of organisms present. Other factors may be involved

Outcomes of glaucoma reoperations in the Tube Versus Trabeculectomy (TVT) Study

To describe the incidence and outcomes of reoperations for glaucoma in the Tube Versus Trabeculectomy (TVT) Study. Cohort study of patients in a multicenter randomized clinical trial. The TVT Study enrolled 212 patients with medically uncontrolled glaucoma who had previous cataract and/or glaucoma surgery. Randomization assigned 107 patients to surgery with a tube shunt (350 mm(2) Baerveldt glaucoma implant) and 105 patients to trabeculectomy with mitomycin C (0.4 mg/mL for 4 minutes). Data were analyzed from patients who failed their assigned treatment and had additional glaucoma surgery. Outcome measures included intraocular pressure (IOP), use of glaucoma medications, visual acuity, surgical complications, and failure (IOP >21 mm Hg or not reduced by 20%, IOP ≤5 mm Hg, additional glaucoma surgery, or loss of light perception vision). Additional glaucoma surgery was performed in 8 patients in the tube group and 18 patients in the trabeculectomy group in the TVT Study, and the 5-year cumulative reoperation rate was 9% in the tube group and 29% in the trabeculectomy group (P = .025). Follow-up (mean ± SD) after additional glaucoma surgery was 28.0 ± 16.0 months in the tube group and 30.5 ± 20.4 months in the trabeculectomy group (P = .76). At 2 years after a glaucoma reoperation, IOP (mean ± SD) was 15.0 ± 5.5 mm Hg in the tube group and 14.4 ± 6.6 mm Hg in the trabeculectomy group (P = .84). The number of glaucoma medications (mean ± SD) after 2 years of follow-up was 1.1 ± 1.3 in the tube group and 1.4 ± 1.4 in the trabeculectomy group (P = .71). The cumulative probability of failure at 1, 2, 3, and 4 years after additional glaucoma surgery was 0%, 43%, 43%, and 43%, respectively, in the tube group, and 0%, 9%, 20%, and 47% in the trabeculectomy group (P = .28). Reoperations to manage complications were required in 1 patient in the tube group and 5 patients in the trabeculectomy group (P = .63). The rate of reoperation for glaucoma was higher following trabeculectomy with mitomycin C than tube shunt surgery in the TVT Study. Similar surgical outcomes were observed after additional glaucoma surgery, irrespective of initial randomized treatment in the study

Polymerase chain reaction analysis of aqueous and vitreous specimens in the diagnosis of posterior segment infectious uveitis

To assess polymerase chain reaction (PCR) analysis of intraocular fluid as a test for infectious uveitis of the posterior segment in a representative patient population. Retrospective, interventional case series. One hundred and thirty-three patients with possible infectious chorioretinitis underwent PCR testing of aqueous or vitreous in a university setting. Baseline characteristics predictive of test positivity were identified. Positive and negative predictive values were calculated. Four hundred and thirty-three PCR tests of 105 aqueous and 38 vitreous specimens (mean, 3.3 tests per patient) identified 77 of the 95 patients with a final clinical diagnosis of infectious uveitis (81%). Herpes simplex virus, varicella zoster virus, and cytomegalovirus PCR analysis were performed in almost all cases, with fewer tests for toxoplasmosis or Epstein-Barr virus. Clinical features associated with positive PCR results were retinal vascular inflammation (P < .001), optic nerve involvement (P = .008), immunocompromised state (P = .039), and extensive retinitis (P = .002). Cases sampled within one week of presentation were more likely to have positive PCR results than those sampled later (P = .071). The predictive value of positive and negative tests was 98.7% and 67.9%, respectively, in this patient group. Alteration in treatment based on PCR and syphilis serologic results led to resolution in 25 of 26 patients after treatment was changed. PCR testing is a useful adjunct in the diagnosis of infectious causes of posterior uveitis. Cases with vascular or optic nerve inflammation, extensive retinitis, or immunocompromise are more likely to have positive PCR results and may benefit from PCR testing of aqueous humor