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Retinal Vein Occlusion After Trabeculectomy With Mitomycin C
BRIEF REPORTS Retinal Vein Occlusion After Trabeculectomy With Mitomycin C Sundeep Dev, M.D., Leon Herndon, M.D., and M. Bruce Shields, M.D. PURPOSE: To evaluate acute retinal vein occlu sion as a potential complication of trabeculectomy with mitomycin C in cases of advanced glaucoma. METHODS: The records of three patients who developed retinal vein occlusions immediately af ter uncomplicated trabeculectomy with mitomycin C were reviewed. RESULTS: All three patients had advanced openangle glaucoma with total cupping of the optic nerve, severe visual field loss, and evidence of systemic vascular disease. A marked decrease in intraocular pressure was noted in the postopera tive period in all of the patients. CONCLUSION: A shift in the lamina cribrosa, associated with the perioperative intraocular pres sure change, may have contributed to occlusion of the venous outflow system in these susceptible patients.
W
E STUDIED THE RECORDS OF THREE PATIENTS
who underwent standard uncomplicated tra beculectomy with mitomycin C and were found to have retinal vein occlusions in the immediate post operative period. • CASE 1: A 69-year-old African-American
man
with advanced open-angle glaucoma, which was previously treated with laser trabeculoplasty, underAccepted for publication May 1, 1996. Department of Ophthalmology, Duke University. Inquiries to M. Bruce Shields, M.D., Duke University Eye Center, Box 3802, Durham, NC 27710; fax: (919) 681-6474; E-mail: SheiOOUt/MC.DUKE.edu
574
went trabeculectomy with mitomycin C. He had been receiving pilocarpine, apraclonidine hydrochloride, dipivefrin, metipranolol, and methazolamide. His preoperative intraocular pressure was 23 mm Hg, his optic nerve was totally cupped with an otherwise normal retina, and he had a small central island of visual field remaining. His medical history disclosed hypertension, mild obstructive pulmonary disease, and peripheral vascular disease treated with lisinopril, ticlopidine hydrochloride, aspirin, and albuterol. O n postoperative day 1, visual acuity was unchanged at 20/40, and the patient had an elevated filtration bleb, a formed anterior chamber, and an intraocular pres sure of 1 mm Hg. At his one-week postoperative visit, visual acuity was still 20/40, and an avascular microcystic filtration bleb was present with an intraocular pressure of 14 mm Hg. Ophthalmoscopic examina tion disclosed an asymptomatic hemiretinal vein occlusion. The occlusion remained unchanged, as did his vision and filtration bleb over the next several postoperative visits. • CASE 2: A n 83-year-old white man with advanced open-angle glaucoma, previously treated with laser trabeculoplasty, underwent trabeculectomy with mi tomycin C. He had been receiving pilocarpine, timolol, and methazolamide. His preoperative intra ocular pressure was 21 mm Hg, his optic nerve was totally cupped with two flame hemorrhages noted at the disk, and there was a 5-degree central island of visual field. His medical history disclosed coronary artery disease with bypass surgery, which was treated with dipyridamole and aspirin. O n postoperative day 1, visual acuity had decreased to counting fingers from 20/200 preoperatively. His intraocular pressure was 4 mm Hg with an elevated filtration bleb, a formed anterior chamber, and a central retinal vein occlusion. At six months postoperatively, vision im proved slightly, intraocular pressure was 14 mm Hg, and the retina was unchanged.
AMERICAN JOURNAL OF OPHTHALMOLOGY
OCTOBER 1996
• CASE 3: A 72-year-old white man with advanced open-angle glaucoma, previously treated with laser trabeculoplasty, underwent trabeculectomy with mitomycin C. He had been receiving pilocarpine, betaxolol, dipivefrin, and acetazolamide. Preoperative intraocular pressure was 24 mm Hg, with totally cupped optic nerves, normal retina, and double arcuate scotomas. The patient took no systemic medications. On postoperative day 1, visual acuity had dropped from 20/40 to hand motions, intraocular pressure was 3 mm Hg with a diffuse filtration bleb, and there was a formed anterior chamber. Five days later, visual acuity was light perception, intraocular pressure was 8 mm Hg, and fundus examination disclosed a central retinal vein occlusion. A few days later the patient had a transient ischemie attack and was started on aspirin by a neurologist. Eight months after trabeculectomy, the patient had a failed filtration bleb, an intraocular pressure of 16 mm Hg, and visual acuity of no light perception. All three of our patients had advanced open-angle glaucoma with a totally cupped optic nerve and severe visual field loss, as well as evidence of systemic vascular disease. Additionally, all patients had preop erative intraocular pressures greater than 20 mm Hg, with postoperative intraocular pressures of less than 5 mm Hg. No postoperative pressure increases were noted. Acute retinal vein occlusion was noted in all three patients in the immediate postoperative period. Retinal hemorrhages have been reported after trabeculectomy.1 All patients in that report also had relatively high preoperative intraocular pressures. Vis ual results were unaffected by the hemorrhages, which nearly completely resolved. Our cases differed in that the hemorrhages were typical for retinal vein occlu sions, two of which were central occlusions with poor visual outcomes. An association of total retinal vasculature occlu sion with mitomycin C has been reported.2 In this case, however, mitomycin C was injected subconjunctivally to treat early filtration bleb failure after trabec ulectomy. After the injection, the patient developed an occlusion of both the arterial and venous systems. Diffusion of mitomycin C into the vitreous cavity causing retinal toxicity was the presumed mechanism. One possible mechanism of retinal vein occlusion immediately after filtering surgery is an anterior shift VOL. 122, NO. 4
in the lamina cribrosa caused by the sudden decrease in pressure leading to obstruction of the venous outflow in the advanced glaucomatous eye.3,4 Each of our patients had chronic open-angle glaucoma and systemic vascular disease, known risk factors for retinal vein occlusion,5,6 further increasing their sus ceptibility to such a phenomenon. It is unlikely that mitomycin C toxicity could account for these vein occlusions since it was copiously irrigated from the scierai bed before any incision into the sclera. How ever, this possibility cannot be entirely ruled out. Retinal vein occlusion must be included as a potential complication of glaucoma filtering surgery, especially in patients with advanced optic nerve damage and coexisting systemic vascular disease. Avoiding early postoperative hypotony may help re duce this risk. REFERENCES 1. Fechtner RD, Minclder D, Weinreb RN, Frangei G, Jampol LM. Complications of glaucoma surgery: ocular decompression retinopathy. Arch Ophthalmol 1992;110:965-8. 2. Nuyts RM, Van Diemen HA, Greve HL. Occlusion of the retinal vasculature after trabeculectomy with mitomycin C. Int Ophthalmol 1994;18:167-70. 3. Yan DB, Coloma FM, Metheetrairut A, Trope GE, Heathcote JG, Ethier CR. Deformation of the lamina cribrosa by elevated intraocular pressure. Br J Ophthalmol 1994;78:643-8. 4. Minkler DS, Bunt AH. Axoplasmic transport in ocular hypotony and papilledema in the monkey. Arch Ophthalmol 1977;95:1430-6. 5. Dreyden RM. Central retinal vein occlusion and chronic simple glaucoma. Arch Ophthalmol 1965;73:659. 6. Gutman FA. Evaluation of a patient with central vein occlu sion. Ophthalmology 1983;90:481-3.
Total Cholesterol and High-Density Lipoprotein Levels as Risk Factors for Increased Intraocular Pressure William C. Stewart, M.D., Cheryl Sine, B.S., Susan Sutherland, Ph.D., and Jeanette A. Stewart, R.N. PURPOSE: To determine whether high-density lipoprotein and total cholesterol levels were risk factors for increased intraocular pressure in pa tients with chronic open-angle glaucoma or ocular hypertension. METHODS: We measured total cholesterol, highdensity lipoprotein, and total cholesterol/high-
BRIEF REPORTS
575
W
E STUDIED THE RECORDS OF THREE PATIENTS
who underwent standard uncomplicated tra beculectomy with mitomycin C and were found to have retinal vein occlusions in the immediate post operative period. • CASE 1: A 69-year-old African-American
man
with advanced open-angle glaucoma, which was previously treated with laser trabeculoplasty, underAccepted for publication May 1, 1996. Department of Ophthalmology, Duke University. Inquiries to M. Bruce Shields, M.D., Duke University Eye Center, Box 3802, Durham, NC 27710; fax: (919) 681-6474; E-mail: SheiOOUt/MC.DUKE.edu
574
went trabeculectomy with mitomycin C. He had been receiving pilocarpine, apraclonidine hydrochloride, dipivefrin, metipranolol, and methazolamide. His preoperative intraocular pressure was 23 mm Hg, his optic nerve was totally cupped with an otherwise normal retina, and he had a small central island of visual field remaining. His medical history disclosed hypertension, mild obstructive pulmonary disease, and peripheral vascular disease treated with lisinopril, ticlopidine hydrochloride, aspirin, and albuterol. O n postoperative day 1, visual acuity was unchanged at 20/40, and the patient had an elevated filtration bleb, a formed anterior chamber, and an intraocular pres sure of 1 mm Hg. At his one-week postoperative visit, visual acuity was still 20/40, and an avascular microcystic filtration bleb was present with an intraocular pressure of 14 mm Hg. Ophthalmoscopic examina tion disclosed an asymptomatic hemiretinal vein occlusion. The occlusion remained unchanged, as did his vision and filtration bleb over the next several postoperative visits. • CASE 2: A n 83-year-old white man with advanced open-angle glaucoma, previously treated with laser trabeculoplasty, underwent trabeculectomy with mi tomycin C. He had been receiving pilocarpine, timolol, and methazolamide. His preoperative intra ocular pressure was 21 mm Hg, his optic nerve was totally cupped with two flame hemorrhages noted at the disk, and there was a 5-degree central island of visual field. His medical history disclosed coronary artery disease with bypass surgery, which was treated with dipyridamole and aspirin. O n postoperative day 1, visual acuity had decreased to counting fingers from 20/200 preoperatively. His intraocular pressure was 4 mm Hg with an elevated filtration bleb, a formed anterior chamber, and a central retinal vein occlusion. At six months postoperatively, vision im proved slightly, intraocular pressure was 14 mm Hg, and the retina was unchanged.
AMERICAN JOURNAL OF OPHTHALMOLOGY
OCTOBER 1996
• CASE 3: A 72-year-old white man with advanced open-angle glaucoma, previously treated with laser trabeculoplasty, underwent trabeculectomy with mitomycin C. He had been receiving pilocarpine, betaxolol, dipivefrin, and acetazolamide. Preoperative intraocular pressure was 24 mm Hg, with totally cupped optic nerves, normal retina, and double arcuate scotomas. The patient took no systemic medications. On postoperative day 1, visual acuity had dropped from 20/40 to hand motions, intraocular pressure was 3 mm Hg with a diffuse filtration bleb, and there was a formed anterior chamber. Five days later, visual acuity was light perception, intraocular pressure was 8 mm Hg, and fundus examination disclosed a central retinal vein occlusion. A few days later the patient had a transient ischemie attack and was started on aspirin by a neurologist. Eight months after trabeculectomy, the patient had a failed filtration bleb, an intraocular pressure of 16 mm Hg, and visual acuity of no light perception. All three of our patients had advanced open-angle glaucoma with a totally cupped optic nerve and severe visual field loss, as well as evidence of systemic vascular disease. Additionally, all patients had preop erative intraocular pressures greater than 20 mm Hg, with postoperative intraocular pressures of less than 5 mm Hg. No postoperative pressure increases were noted. Acute retinal vein occlusion was noted in all three patients in the immediate postoperative period. Retinal hemorrhages have been reported after trabeculectomy.1 All patients in that report also had relatively high preoperative intraocular pressures. Vis ual results were unaffected by the hemorrhages, which nearly completely resolved. Our cases differed in that the hemorrhages were typical for retinal vein occlu sions, two of which were central occlusions with poor visual outcomes. An association of total retinal vasculature occlu sion with mitomycin C has been reported.2 In this case, however, mitomycin C was injected subconjunctivally to treat early filtration bleb failure after trabec ulectomy. After the injection, the patient developed an occlusion of both the arterial and venous systems. Diffusion of mitomycin C into the vitreous cavity causing retinal toxicity was the presumed mechanism. One possible mechanism of retinal vein occlusion immediately after filtering surgery is an anterior shift VOL. 122, NO. 4
in the lamina cribrosa caused by the sudden decrease in pressure leading to obstruction of the venous outflow in the advanced glaucomatous eye.3,4 Each of our patients had chronic open-angle glaucoma and systemic vascular disease, known risk factors for retinal vein occlusion,5,6 further increasing their sus ceptibility to such a phenomenon. It is unlikely that mitomycin C toxicity could account for these vein occlusions since it was copiously irrigated from the scierai bed before any incision into the sclera. How ever, this possibility cannot be entirely ruled out. Retinal vein occlusion must be included as a potential complication of glaucoma filtering surgery, especially in patients with advanced optic nerve damage and coexisting systemic vascular disease. Avoiding early postoperative hypotony may help re duce this risk. REFERENCES 1. Fechtner RD, Minclder D, Weinreb RN, Frangei G, Jampol LM. Complications of glaucoma surgery: ocular decompression retinopathy. Arch Ophthalmol 1992;110:965-8. 2. Nuyts RM, Van Diemen HA, Greve HL. Occlusion of the retinal vasculature after trabeculectomy with mitomycin C. Int Ophthalmol 1994;18:167-70. 3. Yan DB, Coloma FM, Metheetrairut A, Trope GE, Heathcote JG, Ethier CR. Deformation of the lamina cribrosa by elevated intraocular pressure. Br J Ophthalmol 1994;78:643-8. 4. Minkler DS, Bunt AH. Axoplasmic transport in ocular hypotony and papilledema in the monkey. Arch Ophthalmol 1977;95:1430-6. 5. Dreyden RM. Central retinal vein occlusion and chronic simple glaucoma. Arch Ophthalmol 1965;73:659. 6. Gutman FA. Evaluation of a patient with central vein occlu sion. Ophthalmology 1983;90:481-3.
Total Cholesterol and High-Density Lipoprotein Levels as Risk Factors for Increased Intraocular Pressure William C. Stewart, M.D., Cheryl Sine, B.S., Susan Sutherland, Ph.D., and Jeanette A. Stewart, R.N. PURPOSE: To determine whether high-density lipoprotein and total cholesterol levels were risk factors for increased intraocular pressure in pa tients with chronic open-angle glaucoma or ocular hypertension. METHODS: We measured total cholesterol, highdensity lipoprotein, and total cholesterol/high-
BRIEF REPORTS
575