* BACKGROUND AND OBJECTIVE: To investigate the outcome and complication rates of trabeculectomy following the combined use of intraoperative, topical 5-fluorouracil (5-FU) and low-dose, postoperative subconjunctival 5-FU injections. * PATIENTS AND METHODS: Forty-one eyes of 41 patients with advanced, medically uncontrolled glaucoma underwent trabeculectomy with intraoperative episcleral application of 5-FU (50 mg/ml for 5 minutes). A variable number of subconjunctival 5-FU injections were administered postoperatively at the discretion of the operating surgeon. * RESULTS: Six-, 12-, and 15-month life-table success rates (5 mm Hg ≤ intraocular pressure [IOP ≤ 21 mm Hg) were 100%, 97%, and 83%, respectively. Mean postoperative IOP was 12.1 ± 4.3 mm Hg. An average of 2.2 ± 1.6 (range 0 to 7) supplemental subconjunctival 5-FU injections were administered postoperatively. Corneal epithelial erosions developed in 7 (17%) of the eyes. Five of 7 patients who underwent subsequent surgical procedures maintained successful control of IOP at an average of 11.0 ± 4.8 (range 5 to 16) months after the secondary surgery. * CONCLUSION: Trabeculectomy with intraoperative 5-FU is effective in controlling IOP while possibly minimizing the need for frequent postoperative injections and the occurrence of corneal epitheliopathy. [Ophthalmic Surg Lasers 1998;29:552-561.]

Aqueous shunts, or glaucoma drainage devices, are being used more frequently and earlier in the management of glaucoma, particularly when trabeculectomy has failed to control the intraocular pressure or is unlikely to succeed. These devices lower intraocular pressure by shunting aqueous humor through a silicone tube from the anterior chamber or vitreous cavity to an extraocular fluid reservoir produced by a fibrous capsule that forms around a plate or band of synthetic material. The aqueous fluid then passes through this fibrous membrane by simple passive diffusion and is absorbed by the orbital vasculature. The scleral explant of an aqueous shunting device is generally sutured to the sclera between and posterior to the rectus muscle insertions at the equator of the globe. The preoperative characteristics of the eye will often dictate the optimal site for placement of the scleral explant. In the majority of patients, placement of the device in the superotemporal quadrant is most desirable. This location affords the advantages of both intraoperative and postoperative exposure, and maximal coverage of the anterior portion of the tube, the patch graft, and the scleral fistula by the eyelid. It also minimizes disturbance of the superior oblique muscle, thereby reducing the high incidence of strabismus associated with drainage device insertion in the superonasal quadrant.1-3 Given the modern, small-incision techniques for cataract extraction, a superotemporal tube does not constitute a significant obstacle to subsequent cataract surgery. A variety of preexisting or anticipated ocular conditions may affect the choice of location for an aqueous shunt. Conditions affecting either positioning of the scleral explant or insertion of the tube may preclude superotemporal placement in some patients, necessitating insertion along the inferior half of the globe. The decision to place an aqueous shunt in one of the inferior quadrants may arise from factors such as the presence of extensive superior conjunctival scarring, scleral ectasia, or a preexisting drainage device in the superotemporal quadrant. The presence or anticipated need for intravitreal silicone oil, a large superior iris defect in an aphakic and incompletely vitrectomized eye (in which anterior chamber tube placement is planned), poor visibility superiorly due to corneal scarring, or extensive anterior synechiae formation in the superior angle may also necessitate inferior tube placement. Inferior placement of an aqueous shunt adds little to the technical difficulty of the surgical procedure, the postoperative management, or the complication profile. The low risk of strabismus is comparable to that seen with superotemporal shunts, making placement in either inferior quadrant preferable to the superonasal quadrant. The inferonasal quadrant offers several subtle advantages over the inferotemporal quadrant as a location for an aqueous shunt. Positioning a large-surface-area device such as a 350-mm2 Baerveldt implant 10 to 12 mm posterior to the limbus may be difficult in the inferotemporal quadrant, especially in eyes with a relatively short axial length due to the scleral insertion of the inferior oblique muscle. Due to the relative shortness of the inferior compared with the superior conjunctival fornix, exposure of the anterior portion of the scleral patch graft with the eye in primary position is greater for shunts placed in the inferior as compared with the superior quadrants (Fig. 1). The degree of exposure is generally greater in the inferotemporal than the inferonasal quadrant due to the contour of the lower lid margin. A fornix-based conjunctival flap is best suited to inferonasal shunt placement.

Background/Objectives: To investigate macular vascular biomarkers for the detection of primary open-angle glaucoma (POAG). Methods: A total of 56 POAG patients and 94 non-glaucomatous controls underwent optical coherence tomography angiography (OCTA) assessment of macular vessel density (VD) in the superficial (SCP), and deep (DCP) capillary plexus, foveal avascular zone (FAZ) area, perimeter, VD, choriocapillaris and outer retina flow area. POAG patients were classified for severity based on the Glaucoma Staging System 2 of Brusini. ANCOVA comparisons adjusted for age, sex, race, hypertension, diabetes, and areas under the receiver operating characteristic curves (AUCs) for POAG/control differentiation were compared using the DeLong method. Results: Global, hemispheric, and quadrant SCP VD was significantly lower in POAG patients in the whole image, parafovea, and perifovea (p < 0.001). No significant differences were found between POAG and controls for DCP VD, FAZ parameters, and the retinal and choriocapillaris flow area (p > 0.05). SCP VD in the whole image and perifovea were significantly lower in POAG patients in stage 2 than stage 0 (p < 0.001). The AUCs of SCP VD in the whole image (0.86) and perifovea (0.84) were significantly higher than the AUCs of all DCP VD (p < 0.05), FAZ parameters (p < 0.001), and retinal (p < 0.001) and choriocapillaris flow areas (p < 0.05). Whole image SCP VD was similar to the AUC of the global retinal nerve fiber layer (RNFL) (AUC = 0.89, p = 0.53) and ganglion cell complex (GCC) thickness (AUC = 0.83, p = 0.42). Conclusions: SCP VD is lower with increasing functional damage in POAG patients. The AUC for SCP VD was similar to RNFL and GCC using clinical diagnosis as the reference standard.