- Email: [email protected]
Management of pupillary block glaucoma in phakic patients after vitrectomy with silicone oil injection
of need for treatment with external beam radiotherapy or enucleation. Am J Ophthalmol 2002;133:657– 664. 2. Shields CL, Honavar SG, Shields JA, Demirci H, Meadows AT, Naduvilath TJ. Factors predictive of recurrence of retinal tumor, vitreous seeds and subretinal seeds following chemoreduction for retinoblastoma. Arch Ophthalmol 2002;120:460 – 464.
solidation of each tumor in all cases. The lack of variance in our protocol provided a clearer picture of the success or failure of these medications. All data were analyzed using Kaplan-Meier life-table analyses to account for the slight differences in follow-up. The eyes were grouped according to stage of disease to allow for adequate comparison with other studies. In comparison, Balasubramanya and associates employed both a four-drug and three-drug regimen, with several chemotherapy agents differing from those that we employed. The number of cycles averaged 10, but the proposed cycle number is not elaborated. It is not clear whether the 4-year follow-up is a mean, median, maximum, minimum, or Kaplan-Meier estimate. Furthermore, it is not clear whether the “risk factors” are estimates of the most common findings or whether they are the results of univariate or multivariate Cox proportional hazards regressions. With these differences in mind, their results indicated that enucleation was necessary for 39% of those treated with the four-drug regimen and 44% of those who received the three-drug regimen. These results would appear comparatively favorable if most of the eyes were Reese-Ellsworth stage V retinoblastoma, but on the other hand, these results would be unfavorable if the eyes were mostly stage III. This information is not available in their letter. Balasubramanya and colleagues inquired about our results of chemoreduction for vitreous and subretinal retinoblastoma seeds. We share their concern regarding the importance of this information to the success of chemoreduction. We published this information recently2 and emphasized that recurrence of vitreous and subretinal tumor seeds after chemoreduction is particularly problematic. Of those eyes that presented with vitreous seeds at initial examination, at least one vitreous seed recurred after six cycles of our chemoreduction protocol in 50% of cases by 5 years. Similarly, of those with subretinal tumor seeds at presentation, at least one subretinal seed recurred in 62% by 3 years and no further increase by 5 years. This underscores the need for cautious, competent follow-up of such patients. Despite these differences, we have much to learn from our colleagues in India. Their experience with the management of advanced extraocular retinoblastoma is valuable to those of us in countries where this presentation is uncommon. We look forward to future publications on such subjects from this busy retinoblastoma center.
Management of Pupillary Block Glaucoma in Phakic Patients After Vitrectomy With Silicone Oil Injection EDITOR: WE READ WITH INTEREST THE BRIEF REPORT OF JACKSON
and associates regarding a series of phakic and pseudophakic patients who developed pupillary block glaucoma after vitrectomy with silicone oil injection (Am J Ophthalmol 132:414 – 416, 2001). These patients were initially managed with laser iridotomy or surgical iridectomy. Recurrent pupillary block was often observed in their series, as both the laser and surgical iridectomies had a tendency to close, and all patients ultimately required complete silicone oil removal to control the intraocular pressure (IOP). We have now managed a series of seven phakic patients with pupillary block glaucoma associated with silicone oil tamponade for repair of retinal detachment. We were able to control the IOP in our patients without removal of the silicone oil. This allowed elective removal of the oil once the retina had stabilized. Our patients presented within 1 to 60 days after surgery. Intraocular pressures ranged from 45 to 70 mm Hg, and all patients had silicone oil noted in the pupillary space and over the borders of the iris, as revealed by a characteristic shiny reflex. The angle was closed and the anterior chamber (AC) was shallow. In each case, medical management alone was not effective in controlling the intraocular pressure. Facedown positioning alone broke the attack in one case. An argon laser inferior peripheral iridotomy was attempted in three of seven cases and was successful in two. In those two cases we observed frank evidence of aqueous misdirection—the oil fill appeared to be of only 70% until the laser peripheral iridotomy broke the block and normalized the pressure. The oil fill was greater than 90% thereafter, indicating an egress of aqueous through the iridotomy into the anterior chamber. The five other cases were successfully managed with a relatively large (2 to 3 mm) inferior surgical iridectomy. After the inferior laser iridotomy or surgical iridectomy, an oil droplet remained in the AC, which was considered small (⬍20% of the AC volume) in four cases but large (⬎50%) in three cases. In the later cases we performed an AC washout by injecting a viscoelastic through an inferior
CAROL L. SHIELDS, MD ANNA T. MEADOWS, MD JERRY A. SHIELDS, MD
Philadelphia, Pennsylvania
REFERENCES
1. Shields CL, Honavar SG, Meadows AT, et al. Chemoreduction plus focal therapy for retinoblastoma: factors predictive
634
AMERICAN JOURNAL
OF
OPHTHALMOLOGY
OCTOBER 2002
paracentesis and displacing the oil through a superior paracentesis with the eye rotated inferiorly. The viscoelastic was left in place because attempts at removal were associated with movement of oil back into the AC. To prevent an IOP spike from the viscoelastic, we gave acetazolamide (Diamox) 500 mg intravenously at the end of surgery. Intraocular pressure was ⬍20 mm Hg on the first postoperative day in all cases. Pupillary block did not recur in any case, and silicone oil was removed at a later date on an elective basis. Pupillary block glaucoma is an unusual but potentially sight-threatening complication in phakic eyes after vitreoretinal surgery and silicone oil tamponade. In aphakic eyes, a 6-o’clock iridectomy is performed to prevent the pupillary block and to ensure the aqueous circulation to the anterior chamber.1 Pupillary block may occur in phakic and aphakic eyes when an occult defect of the lens–iris diaphragm is present.2,3 As Jackson and associates found, a surgical iridectomy alone may relieve the pupillary block, although the effect was transient in all cases. We found that a large iridectomy along with viscoelastic washout of residual silicone oil allows long-term IOP control and elective removal of silicone oil once the retina has stabilized. FELIPE NAVAS, MD DAVID S. BOYER, MD EDGAR L. THOMAS, MD ROGER L. NOVAK, MD, PHD THOMAS G. CHU, MD, PHD RON P. GALLEMORE, MD, PHD
Retina Vitreous Associates Medical Group Los Angeles, California
series, they achieved more success with the latter. Control of postoperative inflammation may explain this difference. For example we now use intensive topical steroids to try to prevent peripheral iridotomy closure in silicone-filled eyes, but were not using this therapy at the time of writing our original series. Both their description and ours illustrates that silicone can be successfully evacuated from the anterior chamber by displacement with viscoelastic. We have used sodium hyaluronate-chondroitin sulfate (Viscoat, Alcon, UK), left in situ, and treated any ensuing postoperative intraocular pressure (IOP) rise medically. Lower molecular weight viscoelastics may, reduce the chance of prolonged IOP elevation.1–3 Navas and associates describe an apparent difference from our series, in that their patients did not always require removal of silicone from the vitreous cavity. This is probably a misunderstanding of our report, and we apologize for any lack of clarity. We treated pupil block glaucoma by removing silicone, but not “complete” removal in all cases, as they indicate. In particular, we did not remove silicone from the vitreous cavity of patients whose retinas required ongoing tamponade. For example, Patient 3 in our series presented with pupil block glaucoma 1 day postoperatively. Silicone was removed from the anterior chamber and vitreous cavity, but the vitreous cavity was immediately refilled with oil. Navas and associates make the important observation that two of their patients had evidence of aqueous misdirection. We concur with this observation. This raises the issues of whether pupil block glaucoma is an appropriate term for what could also be described as silicone-induced aqueous misdirection. TIMOTHY L. JACKSON, FRCOphth
REFERENCES
MANICKAM THIAGARAJAN, FRCOphth, MRCP
1. Ando F. Intraocular hypertension resulting from pupillary block by silicone oil. Am J Opthalmol 1985;99:87– 88. 2. Zborowski-Gutman L, Treister G, Naveh N, Chen V, Blumenthal M. Acute glaucoma following vitrectomy and silicone oil injection. Br J Ophthalmol 1987;71:903–906. 3. Ardjomand N, El-Shabrawi Y. Pupillary block after silicone oil implantation in a phakic eye. Eye 2001;15:331.
RACHNA MURTHY, FRCOphth MARTIN P. SNEAD, MD, FRCS, FRCOphth DAVID WONG, MRCP, FRCS, FRCOphth TOM H. WILLIAMSON, MD, FRCOphth
London, England
REFERENCES
AUTHOR REPLY WE ARE GRATEFUL FOR THE COMMENTS OF NAVAS AND
associates, who report a series of patients with pupil block glaucoma occurring subsequent to retinal detachment repair with silicone oil injection. They observed a similar clinical appearance to our series, with presentation ranging from 1 day to several weeks postoperatively. They also observed limited success in treating pupil block glaucoma medically, and variable success with face-down positioning and laser inferior peripheral iridotomy. Compared with our VOL. 134, NO. 3
1. Embriano PJ. Postoperative pressures after phacoemulsification: sodium hyaluronate vs. sodium chondroitin sulfatesodium hyaluronate. Ann Ophthalmol 1989;21:85–90. 2. Burke S, Sugar J, Farber MD. Comparison of the effects of two viscoelastic agents, Healon and Viscoat, on postoperative intraocular pressure after penetrating keratoplasty. Ophthalmic Surg 1990;21:821– 826. 3. Lane SS, Naylor DW, Kullerstrand BS, Knauth K, Lindstrom RL. Prospective comparison of the effects of Occucoat, Viscoat and Healon on intraocular pressure and endothelial cell loss. J Cataract Refract Surg 1991;17:21–26.
CORRESPONDENCE
635
solidation of each tumor in all cases. The lack of variance in our protocol provided a clearer picture of the success or failure of these medications. All data were analyzed using Kaplan-Meier life-table analyses to account for the slight differences in follow-up. The eyes were grouped according to stage of disease to allow for adequate comparison with other studies. In comparison, Balasubramanya and associates employed both a four-drug and three-drug regimen, with several chemotherapy agents differing from those that we employed. The number of cycles averaged 10, but the proposed cycle number is not elaborated. It is not clear whether the 4-year follow-up is a mean, median, maximum, minimum, or Kaplan-Meier estimate. Furthermore, it is not clear whether the “risk factors” are estimates of the most common findings or whether they are the results of univariate or multivariate Cox proportional hazards regressions. With these differences in mind, their results indicated that enucleation was necessary for 39% of those treated with the four-drug regimen and 44% of those who received the three-drug regimen. These results would appear comparatively favorable if most of the eyes were Reese-Ellsworth stage V retinoblastoma, but on the other hand, these results would be unfavorable if the eyes were mostly stage III. This information is not available in their letter. Balasubramanya and colleagues inquired about our results of chemoreduction for vitreous and subretinal retinoblastoma seeds. We share their concern regarding the importance of this information to the success of chemoreduction. We published this information recently2 and emphasized that recurrence of vitreous and subretinal tumor seeds after chemoreduction is particularly problematic. Of those eyes that presented with vitreous seeds at initial examination, at least one vitreous seed recurred after six cycles of our chemoreduction protocol in 50% of cases by 5 years. Similarly, of those with subretinal tumor seeds at presentation, at least one subretinal seed recurred in 62% by 3 years and no further increase by 5 years. This underscores the need for cautious, competent follow-up of such patients. Despite these differences, we have much to learn from our colleagues in India. Their experience with the management of advanced extraocular retinoblastoma is valuable to those of us in countries where this presentation is uncommon. We look forward to future publications on such subjects from this busy retinoblastoma center.
Management of Pupillary Block Glaucoma in Phakic Patients After Vitrectomy With Silicone Oil Injection EDITOR: WE READ WITH INTEREST THE BRIEF REPORT OF JACKSON
and associates regarding a series of phakic and pseudophakic patients who developed pupillary block glaucoma after vitrectomy with silicone oil injection (Am J Ophthalmol 132:414 – 416, 2001). These patients were initially managed with laser iridotomy or surgical iridectomy. Recurrent pupillary block was often observed in their series, as both the laser and surgical iridectomies had a tendency to close, and all patients ultimately required complete silicone oil removal to control the intraocular pressure (IOP). We have now managed a series of seven phakic patients with pupillary block glaucoma associated with silicone oil tamponade for repair of retinal detachment. We were able to control the IOP in our patients without removal of the silicone oil. This allowed elective removal of the oil once the retina had stabilized. Our patients presented within 1 to 60 days after surgery. Intraocular pressures ranged from 45 to 70 mm Hg, and all patients had silicone oil noted in the pupillary space and over the borders of the iris, as revealed by a characteristic shiny reflex. The angle was closed and the anterior chamber (AC) was shallow. In each case, medical management alone was not effective in controlling the intraocular pressure. Facedown positioning alone broke the attack in one case. An argon laser inferior peripheral iridotomy was attempted in three of seven cases and was successful in two. In those two cases we observed frank evidence of aqueous misdirection—the oil fill appeared to be of only 70% until the laser peripheral iridotomy broke the block and normalized the pressure. The oil fill was greater than 90% thereafter, indicating an egress of aqueous through the iridotomy into the anterior chamber. The five other cases were successfully managed with a relatively large (2 to 3 mm) inferior surgical iridectomy. After the inferior laser iridotomy or surgical iridectomy, an oil droplet remained in the AC, which was considered small (⬍20% of the AC volume) in four cases but large (⬎50%) in three cases. In the later cases we performed an AC washout by injecting a viscoelastic through an inferior
CAROL L. SHIELDS, MD ANNA T. MEADOWS, MD JERRY A. SHIELDS, MD
Philadelphia, Pennsylvania
REFERENCES
1. Shields CL, Honavar SG, Meadows AT, et al. Chemoreduction plus focal therapy for retinoblastoma: factors predictive
634
AMERICAN JOURNAL
OF
OPHTHALMOLOGY
OCTOBER 2002
paracentesis and displacing the oil through a superior paracentesis with the eye rotated inferiorly. The viscoelastic was left in place because attempts at removal were associated with movement of oil back into the AC. To prevent an IOP spike from the viscoelastic, we gave acetazolamide (Diamox) 500 mg intravenously at the end of surgery. Intraocular pressure was ⬍20 mm Hg on the first postoperative day in all cases. Pupillary block did not recur in any case, and silicone oil was removed at a later date on an elective basis. Pupillary block glaucoma is an unusual but potentially sight-threatening complication in phakic eyes after vitreoretinal surgery and silicone oil tamponade. In aphakic eyes, a 6-o’clock iridectomy is performed to prevent the pupillary block and to ensure the aqueous circulation to the anterior chamber.1 Pupillary block may occur in phakic and aphakic eyes when an occult defect of the lens–iris diaphragm is present.2,3 As Jackson and associates found, a surgical iridectomy alone may relieve the pupillary block, although the effect was transient in all cases. We found that a large iridectomy along with viscoelastic washout of residual silicone oil allows long-term IOP control and elective removal of silicone oil once the retina has stabilized. FELIPE NAVAS, MD DAVID S. BOYER, MD EDGAR L. THOMAS, MD ROGER L. NOVAK, MD, PHD THOMAS G. CHU, MD, PHD RON P. GALLEMORE, MD, PHD
Retina Vitreous Associates Medical Group Los Angeles, California
series, they achieved more success with the latter. Control of postoperative inflammation may explain this difference. For example we now use intensive topical steroids to try to prevent peripheral iridotomy closure in silicone-filled eyes, but were not using this therapy at the time of writing our original series. Both their description and ours illustrates that silicone can be successfully evacuated from the anterior chamber by displacement with viscoelastic. We have used sodium hyaluronate-chondroitin sulfate (Viscoat, Alcon, UK), left in situ, and treated any ensuing postoperative intraocular pressure (IOP) rise medically. Lower molecular weight viscoelastics may, reduce the chance of prolonged IOP elevation.1–3 Navas and associates describe an apparent difference from our series, in that their patients did not always require removal of silicone from the vitreous cavity. This is probably a misunderstanding of our report, and we apologize for any lack of clarity. We treated pupil block glaucoma by removing silicone, but not “complete” removal in all cases, as they indicate. In particular, we did not remove silicone from the vitreous cavity of patients whose retinas required ongoing tamponade. For example, Patient 3 in our series presented with pupil block glaucoma 1 day postoperatively. Silicone was removed from the anterior chamber and vitreous cavity, but the vitreous cavity was immediately refilled with oil. Navas and associates make the important observation that two of their patients had evidence of aqueous misdirection. We concur with this observation. This raises the issues of whether pupil block glaucoma is an appropriate term for what could also be described as silicone-induced aqueous misdirection. TIMOTHY L. JACKSON, FRCOphth
REFERENCES
MANICKAM THIAGARAJAN, FRCOphth, MRCP
1. Ando F. Intraocular hypertension resulting from pupillary block by silicone oil. Am J Opthalmol 1985;99:87– 88. 2. Zborowski-Gutman L, Treister G, Naveh N, Chen V, Blumenthal M. Acute glaucoma following vitrectomy and silicone oil injection. Br J Ophthalmol 1987;71:903–906. 3. Ardjomand N, El-Shabrawi Y. Pupillary block after silicone oil implantation in a phakic eye. Eye 2001;15:331.
RACHNA MURTHY, FRCOphth MARTIN P. SNEAD, MD, FRCS, FRCOphth DAVID WONG, MRCP, FRCS, FRCOphth TOM H. WILLIAMSON, MD, FRCOphth
London, England
REFERENCES
AUTHOR REPLY WE ARE GRATEFUL FOR THE COMMENTS OF NAVAS AND
associates, who report a series of patients with pupil block glaucoma occurring subsequent to retinal detachment repair with silicone oil injection. They observed a similar clinical appearance to our series, with presentation ranging from 1 day to several weeks postoperatively. They also observed limited success in treating pupil block glaucoma medically, and variable success with face-down positioning and laser inferior peripheral iridotomy. Compared with our VOL. 134, NO. 3
1. Embriano PJ. Postoperative pressures after phacoemulsification: sodium hyaluronate vs. sodium chondroitin sulfatesodium hyaluronate. Ann Ophthalmol 1989;21:85–90. 2. Burke S, Sugar J, Farber MD. Comparison of the effects of two viscoelastic agents, Healon and Viscoat, on postoperative intraocular pressure after penetrating keratoplasty. Ophthalmic Surg 1990;21:821– 826. 3. Lane SS, Naylor DW, Kullerstrand BS, Knauth K, Lindstrom RL. Prospective comparison of the effects of Occucoat, Viscoat and Healon on intraocular pressure and endothelial cell loss. J Cataract Refract Surg 1991;17:21–26.
CORRESPONDENCE
635