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Glaucoma: Sweet as Sugar
Editorial
Glaucoma: Sweet as Sugar These days one notes, unless isolated from our postal system, a remarkable profusion of ophthalmic "literature" devoted to many things including, oddly, diamond rings. Thus, it is with particular pride and a modicum of pleasure, that we can include in this issue of OPHTHALMOLOGY so many "pearls" of practical value. Our lead article honors two remarkable ophthalmologists, each of whom has sought the mother lode in that rather treacherous mine called glaucoma. Saul Sugar presents the Robert Shaffer Lecture, and it is lovely to see these two great names thus allied. Each of these gentlemen, and nowhere is the term more appropriate, has advanced our knowledge of glaucoma by keen clinical observations conducted over decades. Both of them peered beyond the known, inspired by keen eyes and guided by prepared minds. Their workplace was their office and not the formal world of Academe, and yet they truly made themselves academic, sharing their observations by lectures and written words. They have written major textbooks on the subject of glaucoma, are revered teachers, have an unabashed enthusiasm to learn, and thus, while neither is chronologically young, they refuse to age. In other words, they are ophthalmologic gems. Several articles deal with the complex subject of neovascular glaucoma. Brown and co-workers emphasize the point that if this type of glaucoma occurs without antecedent, and generally pronounced changes in the retinal vasculature, then one should look to an embarrassed carotid system as a possible inciting cause. They also noted that all of their bilateral cases occurred in patients with significant diabetic retinopathy, and reflect upon the fact that neovascular glaucoma is a rarity in individuals with sickle cell retinopathy. It is still unknown why new vessels so readily sprout from the iris in situations of posterior ocular hypoxia, but vitrectomy with or without lensectomy seems to enhance the situation. Thus, the paper of Ehrenberg et al deserves your attention. These investigators did a prospective study using preoperative fluorescein angiography of the iris in an attempt to demonstrate which patients are most likely to later develop neovascular glaucoma. New glaucoma entities surface periodically, and to the more than two dozen already described we add a pair for your consideration. First, there is congenital ectropion uveae which may have an associated glaucoma, but the finding should also alert you to the possibility that you are dealing with a neurocristopathy. Indeed, three of the eight patients reported by Ritch and friends had neurofibromatosis-which is listed in one reference as the quintessential neurocristopathy. Second, Vela and colleagues report upon eleven patients from three families who have the fascinating entity of angle closure glaucoma secondary to iris and ciliary body cysts. While this is not really a new entity, Paul Chandler previously made the association, this is the first major paper on the subject. Four articles deal with the impact of the laser in glaucoma surgery. Krupin and comrades reiterate the point that laser trabeculoplasty may cause an initial and significant rise in intraocular tension. Thus the pressure may have to be monitored carefully after such surgery, and if necessary, medical therapy should be instituted. Robin and Pollack note their experience with a powerful Q-switched Ruby laser. One burst of this device may be enough to penetrate even the toughest iris, and it can also drill holes in the trabecular meshwork with dramatic lowering of pressure within the eye. This work started around the time that the Neodymium:YAG lasers were being developed, and it seems that the latter have literally carved out a niche in the marketplace and they may, if Praegar is correct, reopen some failed filtering blebs. His article does not tell us if there are any immediate intraocular pressure rises in such eyes. It would not be surprising if such occurred, with so many bursts being given. A new book, entitled, Photocoagulation in Glaucoma and Anterior Segment Disease, by C. D. Belcher, J. V. Thomas, and R. J. Simmons, and published by Williams and Wilkins, is quite good and would be a useful addition to those of you either contemplating doing, or actually performing laser surgery for glaucoma. Two papers, emanating from the Bascom Palmer Institute, discuss the use of 5-fluorouracil experimentally in monkeys and humans to keep surgical filtering blebs open. The drug is given subconjunctivally and seems to have little side effect in the humans in whom it has been tried. So far it has been reserved for those cases where the filtering operation has been expected to do poorly. Altogether an issue without artificial sweeteners. MD, PHD Editor-in-Chief
PAUL HENKIND,
25A
Glaucoma: Sweet as Sugar These days one notes, unless isolated from our postal system, a remarkable profusion of ophthalmic "literature" devoted to many things including, oddly, diamond rings. Thus, it is with particular pride and a modicum of pleasure, that we can include in this issue of OPHTHALMOLOGY so many "pearls" of practical value. Our lead article honors two remarkable ophthalmologists, each of whom has sought the mother lode in that rather treacherous mine called glaucoma. Saul Sugar presents the Robert Shaffer Lecture, and it is lovely to see these two great names thus allied. Each of these gentlemen, and nowhere is the term more appropriate, has advanced our knowledge of glaucoma by keen clinical observations conducted over decades. Both of them peered beyond the known, inspired by keen eyes and guided by prepared minds. Their workplace was their office and not the formal world of Academe, and yet they truly made themselves academic, sharing their observations by lectures and written words. They have written major textbooks on the subject of glaucoma, are revered teachers, have an unabashed enthusiasm to learn, and thus, while neither is chronologically young, they refuse to age. In other words, they are ophthalmologic gems. Several articles deal with the complex subject of neovascular glaucoma. Brown and co-workers emphasize the point that if this type of glaucoma occurs without antecedent, and generally pronounced changes in the retinal vasculature, then one should look to an embarrassed carotid system as a possible inciting cause. They also noted that all of their bilateral cases occurred in patients with significant diabetic retinopathy, and reflect upon the fact that neovascular glaucoma is a rarity in individuals with sickle cell retinopathy. It is still unknown why new vessels so readily sprout from the iris in situations of posterior ocular hypoxia, but vitrectomy with or without lensectomy seems to enhance the situation. Thus, the paper of Ehrenberg et al deserves your attention. These investigators did a prospective study using preoperative fluorescein angiography of the iris in an attempt to demonstrate which patients are most likely to later develop neovascular glaucoma. New glaucoma entities surface periodically, and to the more than two dozen already described we add a pair for your consideration. First, there is congenital ectropion uveae which may have an associated glaucoma, but the finding should also alert you to the possibility that you are dealing with a neurocristopathy. Indeed, three of the eight patients reported by Ritch and friends had neurofibromatosis-which is listed in one reference as the quintessential neurocristopathy. Second, Vela and colleagues report upon eleven patients from three families who have the fascinating entity of angle closure glaucoma secondary to iris and ciliary body cysts. While this is not really a new entity, Paul Chandler previously made the association, this is the first major paper on the subject. Four articles deal with the impact of the laser in glaucoma surgery. Krupin and comrades reiterate the point that laser trabeculoplasty may cause an initial and significant rise in intraocular tension. Thus the pressure may have to be monitored carefully after such surgery, and if necessary, medical therapy should be instituted. Robin and Pollack note their experience with a powerful Q-switched Ruby laser. One burst of this device may be enough to penetrate even the toughest iris, and it can also drill holes in the trabecular meshwork with dramatic lowering of pressure within the eye. This work started around the time that the Neodymium:YAG lasers were being developed, and it seems that the latter have literally carved out a niche in the marketplace and they may, if Praegar is correct, reopen some failed filtering blebs. His article does not tell us if there are any immediate intraocular pressure rises in such eyes. It would not be surprising if such occurred, with so many bursts being given. A new book, entitled, Photocoagulation in Glaucoma and Anterior Segment Disease, by C. D. Belcher, J. V. Thomas, and R. J. Simmons, and published by Williams and Wilkins, is quite good and would be a useful addition to those of you either contemplating doing, or actually performing laser surgery for glaucoma. Two papers, emanating from the Bascom Palmer Institute, discuss the use of 5-fluorouracil experimentally in monkeys and humans to keep surgical filtering blebs open. The drug is given subconjunctivally and seems to have little side effect in the humans in whom it has been tried. So far it has been reserved for those cases where the filtering operation has been expected to do poorly. Altogether an issue without artificial sweeteners. MD, PHD Editor-in-Chief
PAUL HENKIND,
25A