Gonioscopy in the laser age

Gonioscopy in the laser age

Paul Palmberg

Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, FL, USA

Introduction

The performance of gonioscopy in cases of glaucoma or in those with a suspicion of glaucoma will often yield vital information that can be obtained in no other way. Consider these cases:

•A 35-year-old Haitian pediatrician with uveitic glaucoma presented with no signs or symptoms of uveitus other than keratic precipitates (KP) seen in the trabecular meshwork (Fig. 1a). Topical steroids brought the pressure from 35 to 14, eliminated the KP, and avoided progressive synechial angle closure from developing.

•Findings of angle recession (Fig. 1b) explained a case of unilateral glaucoma and prompted careful examination for zonular and retinal tears.

•Subtle signs of angle neovascularization (Fig. 1c) in both eyes of a diabetic patient led to prompt panretinal photocoagulation and a reduction of IOP from the 40s to the mid-20s, with medical control then being achieved in this patient referred with an incorrect diagnosis of primary open-angle glaucoma.

•Discovery of a ciliary body melanoma (Fig. 1d) with unilateral glaucoma due to

an increase in angle pigmentation or tumor seeding called for an ocular oncology consultation.

Also, even in cases already suspected of having angle closure, it is important to differentiate appositional from synechial angle closure, and to differentiate appositional closure due to pupillary block from that due to plateau iris syndrome.1

Gonioprisms and techniques

Audience surveys indicate that about 65% of general ophthalmologists use a Goldmann type of gonioprism when looking for angle-closure glaucoma, and 35% use a Zeiss 4-mirror or similar gonioprism. Among glaucoma specialists, 5% use the Goldmann and 95% the Zeiss. Why is there such a difference in lens preference between generalists and glaucoma specialists, and what difference does it make?

Address for correspondence: Paul Palmberg, MD, PhD, Bascom Palmer Eye Institute, University of Miami School of Medicine, P.O. Box 016880, Miami, FL 33101, USA

Glaucoma in the New Millennium, pp. 65–76

Proceedings of the 50th Annual Symposium of the New Orleans Academy of Ophthalmology, New Orleans, LA, USA, April 6-8, 2001

edited by Jonathan Nussdorf

© 2003 Kugler Publications, The Hague, The Netherlands

a.

b.

d.

c.

Fig. 1. Important causes of secondary glaucoma only revealed by gonioscopic examination. a. Keratic precipitates of uveitic glaucoma. b. Traumatic angle recession, posterior displacement of the insertion of the ciliary body. c. Angle neovascularization, with new vessels from the iris passing over the scleral spur and arborizing over the trabecular meshwork. d. A ciliary body melanoma visible in the peripheral iris and angle.

The Goldmann single-mirror gonioprism has an inner diameter of 11 mm (which fits over the cornea) and a second, outer diameter of 14 mm, which sits on the sclera (Fig. 2). The vault of the lens is filled with a viscous solution for optical coupling. When the lens is quickly placed on the eye (as it should be to avoid loss of the fluid), some of the fluid is expelled by the pressure applied and a suctioncup effect is created. This has the advantage of holding the lens in place. It gives a steady view since it will not slide from side to side. However, the suction cup also increases the IOP, resulting in a stretching of the scleral-corneal ring, and also resulting in a backward rotation of the iris and ciliary body, potentially opening a closed angle.

The Zeiss gonioprism has 4 mirrors, a diameter of 9 mm, and fits on the cornea (Fig. 2). Optical coupling can be achieved with tears or saline. There is no suctioncup effect, so to keep the lens in place for steady viewing and to avoid inadvert-

Fig. 2. Goldmann (round) and Zeiss (square) gonioprisms.

Fig. 3. a and b. Proper support for the elbow, use of two fingers on the cheek to steady the hand, and gentle application of the Zeiss lens using the thumb and second and third fingers, with avoidance of inadvertent pressure on the cornea.

ently pressing on the cornea, which would also increase the IOP and potentially open a closed angle, the examiner should adequately support his elbow, and can rest the side of the hand (fourth and fifth fingers) on the side of the cheek (Fig. 3a). The lens is then held between the thumb and first and second fingers, and gently allowed to contact the cornea (Fig. 3b).

Identifying angle structures

When viewing the drainage angle through a gonioprism, three techniques are quite reliable in proper feature identification. The first is the use of a projected thin line of light in the corneal light wedge or parallelepiped method. The beam penetrates the transparent cornea, forming a three-dimensional figure of light, but, as we move our point of attention to the border between the cornea and the trabecular meshwork, the reflected beam is seen to collapse to a two-dimensional figure of light (Fig. 4). This border, at which there is also a slight transition of curvature, is called the Schwalbe line. If the examiner were to see a three-dimensional figure of light all the way to the point where the iris meets the wall of the eye, this would mean that the angle was closed.

The second technique is to look at the character and distribution of pigment particles in pigmented lines in the angle. When the pigment particles are large, gray-brown, and form a discontinuous line, giving a ‘salt and pepper’ appearance, look out! This may be a Sampaolasi line of pigment on or near the Schwalbe line, and not the pigmented portion of a true trabecular meshwork. When the trabecular meshwork has a pigmented region (over Schlemm’s canal), as it usually does to some degree, the pigment particles are light brown and are distributed as a continuous line (at least for a few clock hours). This has the appearance of ‘fine powdered brown sugar’ (Fig. 5).

The third technique is indentation gonioscopy, which can be performed with a Zeiss-type lens, but not with a Goldmann lens.2 The examiner first views the angle in its undisturbed state (Fig. 6a), having the patient look in the direction of the

b.

a.

Fig. 4. a. The parallelepiped method of identifying the transition from peripheral cornea to the trabecular meshwork. b. An arrow points to the Schwalbe line.

Fig. 5. Recognizing the coarse and discontinuous pigmentation of a Sampaolasi line (upper arrow, at or near the Schwalbe line) and the fine, powdered brown-sugar appearance of pigment on the functional portion of the trabecular meshwork (lower arrow). The pigment deposits are dense in this case of pigmentary glaucoma.

b.

a.

Fig. 6. a and b. An appositionally closed angle is pushed open with indentation gonioscopy. The arrows in 6b point to low PAS.

mirror, and then instructs the patient to look only slightly in the direction of the mirror for indentation gonioscopy. To view the superior angle, the examiner has the patient now look only slightly down, and both pushes in and lifts on the Zeiss lens, selectively pushing inwards on the inferior cornea. As a result, the IOP increases in the eye and the iris and ciliary body rotate backwards, and the examiner allows selective deepening of the superior angle (since the cornea is not being pushed in there). Angle structures that were not visible due to appositional angle

closure now come into view (Fig. 6b). The iris in the region of any peripheral anterior synechias (PAS) is tethered and cannot fully rotate backwards, while the iris in adjacent regions does bow backwards (Fig. 7). When the only visible pigmented line is composed of coarse granules in a discontinuous line, indentation gonioscopy may then reveal the true trabecular meshwork. In Figure 8a there is a seemingly wide approach to a pigmented line, but this is a Sampaolasi line, and indentation reveals extensive PAS to the true trabecular meshwork, seen in Figure 8b. In Figure 9a there are two lines with discontinuous pigment, and in Figure 9b, with indentation gonioscopy, the angle that was appositionally closed is pushed open, revealing a continuous line of pigment on the true trabecular meshwork.

Fig. 7. Indentation gonioscopy accentuates the PAS. The rise of IOP produced by the indentation causes the iris to each side of the PAS to rotate posteriorly (white arrow), while the tethering of the iris by adhesions holds it in place in the region of the PAS (black arrow).

Fig. 8. a. A Sampaolasi line (arrow) mimicking a true trabecular meshwork in an angle with a wide angle of approach. b. With indentation gonioscopy, the angle opens and the previously seen Sampaolasi line (upper arrow) is visible, as well as extensive PAS to the trabecular meshwork (lower arrow).

Fig. 9. a. A patient with a Sampaolasi line (arrow) and a second line of pigment in the peripheral cornea. b. Upon indentation gonioscopy, the Sampaolasi line is visible (upper arrow) and the continuous line of pigment on the trabecular meshwork can now be seen, resembling fine powdered brown sugar.

Artifacts to avoid1

•If light is allowed to pass through the pupil or if the patient is looking at a fixation target during gonioscopy, the pupil will constrict and an angle that is actually closed in the dark will open. Therefore, gonioscopy should also be done in a dark room. The examiner can use a widening and narrowing of the slit beam during gonioscopy to dynamically open and close angles, for confirmation of a diagnosis (Figs. 10a and b).

•The use of a Goldmann lens (Fig. 11a) artifactually opens closed angles created by means of a suction-cup effect that increases the IOP (Fig. 11b).

•Inadvertent indentation with a Zeiss lens can open closed angles. Conversely, inadvertent pressure over the portion of the angle being viewed can push closed a narrow, but open angle.

Fig. 10. The effect of the pupillary light response upon an appositional closed angle. a. The angle is closed when light is not allowed to pass through the pupil. b. The angle opens with pupillary constriction to light.

Fig. 11. a. The appositionally closed angle opens as a result of the use of: b. a Goldmann lens, which produces a suction-cup effect that elevates IOP, resulting in stretching of the corneascleral ring and posterior rotation of the ciliary body and iris.

Fig. 12. After performance of an adequate laser iridotomy (a), an angle appositionally closed on the basis of plateau iris syndrome (b) can be seen to open with indentation gonioscopy, with the peripheral iris draped over a prominent last roll of the iris (c). Following peripheral iridoplasty, the angle is opened to grade III (d).

Plateau iris syndrome

Angle-closure glaucoma can also be produced by a forward rotation of the ciliary body processes, which occurs spontaneously for unknown reasons in plateau iris syndrome, and which also occurs in a variety of conditions in which the ciliary body is congested, as may occur due to, and complicate the management of, a pupillary block angle-closure glaucoma attack, or due to the application of extensive panretinal photocoagulation, or due to placement of a tight scleral buckle, or to a fresh central retinal vein occlusion.

Upon gonioscopy in such cases, the iris plane is usually flat, without the characteristic forward bowing of a pupillary block mechanism, and there is a prominent last roll of the iris. During indentation gonioscopy, and in the presence of a patent iridotomy, the iris moves backwards over the peripheral lens, and is then draped even more prominently over the ciliary body processes, such that the outline of the individual processes can be detected (Figs. 12a, b and c). After peripheral iridoplasty, the angle is opened to grade III (Fig. 12d).

In 1989, I encountered the following case: A woman who had undergone an adequate surgical iridectomy in each eye in 1979 for angle-closure glaucoma again presented with angle-closure symptoms. Gonioscopy showed angle closure, and indentation gonioscopy revealed that the closure was only appositional and that there was a prominent last roll of the iris (Figs. 13a and b). Looking through the iridectomy, the forward rolled ciliary processes lifting the peripheral iris against the trabecular meshwork could be seen (Fig. 13c). In the site of the iridectomy, the ciliary processes were seen to be directly rolled up to the trabecular meshwork (Fig. 13d). During indentation gonioscopy, the ciliary processes rolled backwards, opening the angle (Fig. 13e). Peripheral iridoplasty (24 applications of a 500 µm argon spot through an iridotomy lens at 0.18 W in a brown eye and 0.22 W in a blue one, with one-second duration) opened the angles. (This case resolved a longrunning debate I had been having with Bob Ritch since the early 1980s as to the mechanism of plateau iris syndrome.)

In 1992, Ritch and colleagues published ultrasound biomicroscopy images that confirmed the mechanism and documented the effect of his technique of peripheral iridoplasty (Figs. 14a and b).3 Ritch also realized that Paul Chandler had beaten both of us to discovering the mechanism, since he had reported and properly understood a case similar to mine.4

Gonioscopy for trabeculoplasty

When performing trabeculoplasty, the suction-cup effect of the Goldmann lens is an advantage, since it steadies the eye and even allows the surgeon to achieve a fine focus of the beam on the trabecular meshwork by allowing him to pull the eye side to side, up and down, and in or out, in order to bring the eye to the laser beam. The surgeon instructs the patient to look away from the beam (Figs. 15a and b) in order to obtain as perpendicular an application as possible, and thus a round, focused spot, and since this also helps to avoid having the energy skim backwards and hitting and inflaming the ciliary body.

b.

a.

d.

c.

Fig. 13. a. The patient had recurrent angle-closure glaucoma in the presence of a large surgical iridectomy. b. The angle has been appositionally closed. c. When the angle is pushed open by indentation gonioscopy, a prominent last roll of the iris can be seen. d. Looking through the surgical iridectomy, the ciliary processes can be seen to be rotated forwards, lifting the peripheral iris against the angle. e. In the area of the iridectomy, the forward rotation of the ciliary body processes can be seen. f. Those processes rotate posteriorly with indentation.

a.

b.

Fig. 14. a. Ultrasound biomicroscopy illustrates forward rotation of the ciliary processes, lifting the peripheral iris against the trabecular meshwork. b. The angle is open after peripheral iridoplasty heat has shrunk the peripheral iris. (Reproduced by courtesy of Robert Ritch, MD.3)

Fig. 15. a. The trabecular meshwork is seen at an oblique angle through a Goldmann lens when the patient looks straight ahead. b. A more perpendicular view of the meshwork is obtained when the patient looks away from the direction of the mirror, an advantage when applying laser trabeculoplasty.

Summary

Gonioscopy is essential in the diagnosis of any suspected case of glaucoma, since the examiner must know the cause of glaucoma before he can decide upon the most appropriate treatment. The use of a Zeiss-type of lens, with a proper arm and hand support, the use of the parallelepiped method, recognition of the character and distribution of angle pigment, control of the pupil response to light, and the use of indentation gonioscopy allow the surgeon confidently to assess the type of glaucoma present.

References

1.Palmberg P: Gonioscopy. In: Ritch R, Shields MB, Krupin T (eds) The Glaucomas, 2nd Edn. St Louis, MO: CV Mosby 1996

2.Forbes M: Gonioscopy with corneal indentation: a method for distinguishing between appositional closure and synechial closure. Arch Ophthalmol 76:488-492, 1966

3.Pavlin CJ, Ritch R, Foster FS: Ultrasound biomicroscopy in plateau iris syndrome. Am J Ophthalmol 113:381, 1992

4.Chandler PA, Grant M: Lecture Notes in Glaucoma. Philadelphia, PA: Lea and Febiger 1965

Round table

How I make the decision to do a peripheral iridotomy: my laser, lens and settings

Paul Palmberg, MD, PhD, presiding

Panel: George A. (Jack) Cioffi, MD

Harry A. Quigley, MD

Dr Palmberg: Welcome to the rectangular table discussion, as somebody pointed out. First, I’d like to ask what lens you are using to do your laser iridotomies. I would point out, just as an historical footnote, that Irvin Pollack of Baltimore, I think, was the first to put a +66 lens on top of a fundus contact lens and to use it to make laser iridotomies, and really pioneered that. At that point, Charles Munderland, who was with a company, wanted to make a lens commercially, so he went to Dr Pollack and said, “Can I call this the Pollack lens?” and Pollack said, “No, I don’t think I really want to do that”. So they went to Dr Wise, who said, “Sure”. At any rate, I am not sure where the idea came from, but maybe they both independently did it. The question is, what lens do you use. Do you use an Abraham, a Wise, or what’s your favorite? Do you have any pearls on that?

Dr Cioffi: I use a YAG Abraham and I think there are probably about ten lenses out there that you can use. I don’t know how much difference it makes, to be honest. I think we will talk about that in a second. But I often, in a congested eye, will pretreat with argon prior to doing YAG, but I use a YAG Abraham on a straightforward PI.

Dr Palmberg: That was the next question, is anybody here doing argon laser iridotomies, just argon for the whole thing? Maybe we should ask the audience too. How many are using argon laser to do your laser iridotomies, not YAGs? A few. And it certainly works.

Dr Quigley: We can talk about the lens thing. Some of you may have been around long enough that you did iridotomies without a lens. We did that initially. Clearly, some lens is beneficial because it holds the eye open. You go into tetany after a while trying to hold somebody’s eyelids open to get them in focus. So the lens helps hold the eyelid open. The extra button magnification lens is useful, but not absolutely necessary. The way it helps you is twofold. First, it probably does concentrate the energy so that there is a tighter, smaller area within which the energy is delivered, so you have a greater effect on the iris. Second, when you have one

Glaucoma in the New Millennium, pp. 77–87

Proceedings of the 50th Annual Symposium of the New Orleans Academy of Ophthalmology, New Orleans, LA, USA, April 6-8, 2001

edited by Jonathan Nussdorf

© 2003 Kugler Publications, The Hague, The Netherlands

of these with the button lens glued on the more peripheral aspect of the lens that you are using, you can actually see better into the periphery. I flunked optics, but there is some sort of prismatic effect whereby you can see further in, and you will produce an iridotomy with the button iridotomy lens and then later you will look at the patient with the slit lamp and you will think, how the heck did I get out that far in the periphery. I can hardly even see the darned thing. Partly that is because you used pilocarpine during the treatment to pull the pupil down, and after the pilocarpine wears off, the iris moves back out more peripherally. But part of it is because the prismatic effect of the lens takes you more into the periphery. I think the advantage of that is to be sure that you keep the iridotomy as far out peripherally as possible and as superior as possible, especially if you had one or two of these folks complaining of double vision, and it’s a real phenomenon.

Dr Palmberg: That leads to the next question, which has to do with the location of the iridotomy.

Dr Cioffi: Actually, Paul, before we go on to that, I agree with both of Harry’s points, and the third thing I would add is that the magnification button often allows you to identify nice iris crypts much more easily, where you are going to find that you can poke through with a single or two shots from your YAG. I always try to find a thin point if I can, which just makes the procedure quicker and easier, and less of an issue for the patient.

Dr Palmberg: When using YAGs, I want to ask, if many of you, as I do, generally like to do some argon pretreatment. I put in a 500-micron spot of basically an iridoplasty burn where I am going to go through with the YAG laser later, for a couple of reasons. It deepens the angle so that what you are treating is farther away from the edematous cornea, if it is edematous; and secondly, it contracts the blood vessels in that region so that you don’t get that annoying bleeding that can develop while you are making the laser iridotomy, and it keeps the tissue from fracturing into little pieces. So I always like to put one iridoplasty burn with about a 0.2-watt 500-micron spot applied for about 0.2 to 0.5 seconds, and then go on down to the YAG laser and punch through. I usually use 3 to 7 millijoules, one or two pulses per burst. Any markedly different way of doing that? What kind of YAG laser settings do you use?

Dr Cioffi: I don’t routinely pretreat on a quiet eye. But I do routinely pretreat an acute angle closure eye for all the reasons Paul just mentioned – stops bleeding. You essentially do a little sector iridoplasty. It deepens things, it may pull the angle open a bit, and it makes it easier to do the YAG afterwards. But on a quiet eye, I generally will not pretreat with argon. I use settings very similar to yours. I usually start at about 3 to 3.5 millijoules and work up if I need to, but usually you don’t have to go over 4 to 5, if it’s not a really thick iris.

Dr Quigley: I think it depends on whether you’ve got both lasers in the same room. If you have to walk over to the hospital to get to the continuous wave laser, but the YAG is sitting in your office, there is a tendency to do the thing where you and the patient don’t have to walk 100 miles to do it, or buy into a facility charge. I would routinely not pretreat an eye that is blue or green, because the chance you

are going to be able to make a hole with fewer than three shots is so high that there is really no value to further inflame an eye with pretreatment.

Dr Palmberg: What is a blue eye?

Dr Quigley: It’s anything that doesn’t look brown. When I went to visit in Singapore, and I told my colleagues there why I never use argon pretreatment, and they said, “Why don’t you come and look at a couple of eyes here, Chinese folk, and why don’t you try what you do at home in Baltimore.” And I learned why they pretreat eyes there. If it’s uniform brown and all you see is uniform brown, you are probably going to be better off pretreating. Look all around the superior iris and see somewhere where it looks thinner. You can tell it’s thinner if you can see the white blood vessel lines. So it’s a thick iris, it doesn’t have a thin spot, but why not, if you want, if you would have to walk across the street to find the argon laser and the YAG is sitting right here, why not take two shots with the YAG. Tell the patient, “I’m going to do a preliminary treatment. If I get through, great; otherwise, we are going across the street.” And if you happen to make a hole with three shots, fine; but if you don’t, you’re going to say, “Okay, now we’re going to go across the street.” What have I done, though? I have inflamed the eye ahead of the argon, then I have to do argon and come back for YAG.

Dr Palmberg: I want to share one little pearl with you. It’s something I call the shuffle technique. If, as you are doing this, a lot of pigment starts coming through and blocking your view, if you have been doing the YAG, that can sometimes happen; it happens certainly more with the argon. I had a patient who came in with Parkinson’s disease, and as the guy was shaking back and forth and I was holding the lens in place, I noticed that fluid would exchange between the anterior and posterior chambers with each one of these thrusts, and cleared all the pigment out of the way. So you can actually do this on purpose. If, as you are making a hole, you get bubbles or pigment, and it is blocking your view, you can just push in and out gently on the lens a few times, which I call the shuffle, if you’ve already got a little bit of a hole, it will spit out pigment and other things, and then you can see clearly to go ahead and complete it.

Let’s discuss the location of the iridotomy. One of the things that Doug Anderson and other people who think about optics have brought out is that if you can put it under the upper eyelid and the upper eyelid covers the limbus, and you put a hole there, the patient is not going to have the complaint of double vision from light going out and around through a more peripheral portion of the lens. But if the patient has kind of a retracted stare appearance, and their lid happens to be just a bit above and they have the meniscus of the tear film over the superior 12 o’clock position, they will have an annoying blue line across their vision. So that if you look at the natural position of the lid of the patient, that is kind of helpful in deciding where to put the iridotomy. It may be that, in somebody whose lid is retracted up just above the edge, you should actually put it off to one side a clock hour or two to avoid getting the second image. Are there thoughts on that? We’ve all seen patients complaining about this.

Dr Cioffi: I agree entirely, and as Harry mentioned, all you need is one or two of these patients in your practice. They are non-symptomatic when they come in and

they have a bit of appositional closure and you tell them they need an iridotomy to protect them, and then they have diplopia or a line or glare, and they complain to you for the rest of your and their lives. So, it is pretty annoying. In addition to Harry’s comment about the Asian eye, our population in Portland is about ten percent Asian, and it is a much more difficult iris to put a hole in. I pretreat virtually all those patients.

Dr Quigley: How many spots would you normally hit with for the pretreatment? With our colleagues in Singapore, it was 50, 60, or even 70 spots sometimes.

Dr Cioffi: I don’t do that many. I was in Australia recently and there was a woman there from Singapore who was talking about iridoplasty on virtually everybody, and extensive pretreatment. Usually, I try to do five to six shots and I will surround the area where I am going to put my hole to make it taut like a drum top, and then I will pretreat with a larger spot right in the middle for cauterization, and then I will take them over to the YAG laser.

Dr Palmberg: Let me go on to another thing. Let’s say you get somebody in who has had a kind of neglected attack, the eye is really congested, there is a lot of corneal edema, and it is kind of difficult to get that laser iridotomy in there. Do you have any other things that you find are pearls to help you get those cases done?

Dr Quigley: The usual one is that somebody has had an acute attack while having an eye exam and the doctor recognized it and tried to break it medically for much of the day, and then treated with the laser for a while and didn’t get through, and it is usually Friday afternoon. They are worried and the patient is worried, and then you get to see the patient and wind up by that point of having quite a lot of corneal edema. I have tried all sorts of things, none of which really work, but you try to get the pressure lower. I would try to take a shot at the patient, but sometimes you just have to wait overnight for things to clear, and even use osmotic agents. And on two occasions in the last four or five years, I have actually done surgical iridectomies on people in whom we could not get through, there was no way. One of the reasons for this, and it is not the doctor’s fault, and it is often not the patient’s fault either, is that there is a coincidence of corneal disease in angle closure, and there is more than one pretty good epidemiological report that guttata and angle closure go together. So these are corneas that have fallen apart. It is okay to make a hole in the iris initially out nearer to the pupil than you ultimately would want to, in the setting of the middle of an acute attack when you really have to make the hole. If later that doesn’t turn out to be something that is going to be a useful hole, because it is directly overlying the lens, you can then make a second hole out peripherally.

Dr Cioffi: Now is the most frequent time that I will use osmotics and I will hit them with virtually everything in the cabinet, but I will use isosorbide as well, Osmoglyn, one of the two. Often, waiting overnight is the secret. You put them on everything, you give them some isosorbide. It’s always Friday night, as far as I can tell. You see them back the next morning, you give them another dose of isosorbide, and then go ahead and do your treatment.

Dr Palmberg: One thing I think is really under-utilized in these circumstances is iridoplasty. You can do iridoplasty for two or three clock hours, which will, temporarily, because it does not alleviate the pupil block, open two or three clock hours of the angle. This may first of all move the iris far enough away from the cornea that you can focus on it without having the energy taken up by the cornea, and second, briefly open a portion of the angle. It may decompress the eye down to a pressure quite a bit lower, and for a few minutes, until that pupil block fills up again, the pressure may be lower and there will really be less congestion. In some desperate cases, you can put a few shots of iridoplasty right near the pupil, because you could break the attack either by making a hole in the iris or by distorting the pupil enough that you get it away from that mid-dilated position. You may, by making a few shots of iridoplasty near the pupil, get it open enough that you will see a spurt of fluid, and the pressure in the eye comes down, then you can do the iridotomy. On a couple of occasions, I have given the patient a retrobulbar block, because then they stop hurting, stop retching, and hold still so you can see what you are doing, and this lets you provide treatment. On a couple of occasions, I have used a 30-gauge needle, and this is not a technique you start doing the first thing you do with 30-gauge needles, but you can take a 30-gauge needle iris plane parallel and go into the inferior angle, well in the periphery so you are not going to hit the lens, and let a little fluid out of the eye. It doesn’t fix the block, but it gets the pressure down enough in the eye that the cornea immediately becomes less cloudy and you can then do iridoplasty and shoot a hole through.

Dr Cioffi: Glycerin works and often, as my coupling agent for the lens, I will actually fill it with glycerin instead of Goniosol, and as you are doing your procedure, it is actually working for you. I usually pre-dose them with glycerin a few times over a half hour or 45 minutes, but then I will put it in my lens as well.

Dr Palmberg: Let’s go onto to criteria for doing a laser iridotomy. Surely not every patient with a narrow angle requires a laser iridotomy. We could start out with what the history elements are that would make you do a laser iridotomy, if there was no pressure elevation in the office, no peripheral anterior synechia, nothing else. What would you like to have heard? A colored rainbow about lights, pain, coupled with a family history? What sorts of things will convince you that somebody has had angle-closure glaucoma?

Dr Quigley: We are going to go into the clinical mode now instead of what you can prove with epidemiological data. Because this is seat of the pants, “What am I going to do?” If somebody’s mother went blind from narrow-angle glaucoma and they walk in with a narrow angle, you are going to put a hole in their irides. Next question. Because that person is going to go through life saying, “My mom went blind from this disease”. Even if you can’t be sure, I think that’s the sort of business. You want to be sure that his mother really had angle-closure glaucoma. One of the things we are studying right now is how credible is the family history you get from patients. Lou Pasquali had that experience in Boston when patients who were nurses reported that they themselves had been diagnosed with glaucoma, and then they got the charts and only 50% of the time did they actually have glaucoma. So saying, “My mom had glaucoma and she went blind from this dis-

ease”, may or may not actually be accurate. So you would like to hear, “She saw this guy George Spaeth in Philadelphia and he did something with a laser to her, and after that it was too late and her vision had gone.” So you query people’s histories in more detail than you might otherwise. Someone who says, “Oh, I’m having halos around lights”. “Is it in both eyes?” “Oh, yeah.” It’s a cataract. Most of the time, visual symptoms aren’t angle-closure glaucoma. It has to be a really good story. It has to be, “I covered one eye and then I covered the other one and it was only the eye that was red that was blurry, and boy did I have a headache, and it was on that side.” It has to be that sort of striking history, because there are too many other non-specific symptoms. And a colored rainbow around a light, and I had not just been in a chlorinated pool, or any other cause for corneal edema. What about somebody who is going to go off and be a missionary in a remote area, they have a very narrow angle, and they are not going to be able to get to medical care, is that an indication?

Dr Cioffi: I think Harry’s point is right on. I think that it is an accumulation, just like when you decide to treat a glaucoma patient. It is an accumulation on an open-angle glaucoma patient, an accumulation of what you see, and it’s putting all the pieces together and the blind patient going off to a place where they are not going to have medical care or be looked after. All those things add to your concern and, rightfully, to the patient’s concern, that they could get into trouble. So, if the story is not that good, but the mother went blind and they are going to Indonesia for the next six years, you may put a laser hole in their iris. It is an accumulation of not just what you see, but what is going on for the patient.

Dr Quigley: I’ve treated somebody who is a state department employee who was going to Kazakhstan for two years, and I put holes in irises I would not have put them in otherwise. But, we take appendices out of people who are going to be astronauts. There are some interesting things we do that aren’t necessarily the typical clinical setting. I have a patient who is a mountain climber. He knows he is going to be in Tibet or Nepal for periods of time, and had occludable-looking angles with negative provocative testing and no PAS and no pressure elevation. Had he been somebody who was a sedentary guy who lived in Baltimore, I would have said, “Come on in if you have symptoms, but I’m not going to put holes in your irides”. But for this fellow, it was probably the appropriate thing to do. I will give you one other setting. There are increasing numbers of patients reading the Internet these days, who have gotten themselves a bottle of Glyrol and a bottle of pilocarpine and are carrying them around worried they are going to have the attack tonight. And a doctor has told them, “Don’t ever be without that Glyrol in your purse because you could have the attack tomorrow”. In that case, what you are doing is curing a neurosis by doing an iridotomy. A neurosis generated either by the patient or aided and abetted by us in the medical care system. And I think those patients will do very well too, unless they have a complication from the iridotomy.

Dr Palmberg: Let’s go on to people with findings. Somebody has pressures of 23 and 28, and one eye is slit to close with 23, but not quite closed, no synechiae, and no history of an attack, and the other has pressure of about 28, grade 1 angle, so there is some correspondence to it, but you don’t actually see the angle closed. We

know this is a dynamic situation. It could change from day to day, hour to hour. Is that somebody in whom you put a hole in the iris in the higher-pressure eye and see what happens?

Dr Cioffi: Maybe.

Dr Quigley: You have to do a full eye exam here. I’m always disappointed when I don’t see a visual field test that was done on a patient who is in that setting, because there is no reason not to do a visual field test on someone in that situation. They are either an open-angle glaucoma suspect or an angle-closure suspect, and either way you ought to be doing a field test. Moreover, you are going to dilate their pupil, as I said, in order to find out what is true in their fundus, because their pressure could be elevated from a variety of other things, their narrowness, as Paul showed, could be a lot of stuff, things pushing from behind the iris. Therefore, I do a mydriatic provocative test. If, in this case, Paul, I thought there was a very high chance that dilating the pupil was going to cause an acute attack, then I would use a darkroom test, which we do in a glaucoma service about once a month maybe. So it’s not something that most average practices are going to do, but you can put somebody with their face down for 30 or 40 minutes in a room, and if their eye pressure rises 10 or 15 points that, to me, is very significant. It adds credence to the fact that I should be doing an iridotomy in the patient you just described. If I dilate them and the angle becomes even narrower, and the pressure rises more than 10 points, and I just picked out 10 here because we are talking clinically, then I would definitely feel much better about doing the iridotomy on that patient. In the setting you just presented, if both the darkroom test and the mydriatic provocative test are negative, then I won’t do an iridotomy unless somebody is in one of those other situations like trekking to Nepal, or “My mom went blind from glaucoma”. I say to them, “I can’t prove you have a disease. You have ocular hypertension. It may be due to that narrow angle. I’d like to follow you and see.” And I tell them what the symptoms of an acute attack are in case they have one. I would be seeing that patient that first year twice or three times.

Dr Palmberg: Irvin Pollack took such patients who had elevated pressures, did iridotomies on them, and found that, in most of them, the pressure would then come down to normal. But, we are emphasizing those people who had rather narrow angles, not quite closed, very narrow, but a pressure elevation. Let’s go on then to patients who don’t have a pressure elevation spontaneously, who come into your office just for a routine exam, or who saw someone and come to you for a second opinion, and they have slit angles nearly all the way around, no history of anything, no family history of anything, no damage to their nerve, they are just very narrow, and you do a darkroom provocative test, or you dilate them with Mydriacyl and the pressure goes up to 25, and half or two-thirds of the angle closes temporarily. Is that predictive of something in the real world, what would happen to them later, or if they don’t need dilation for diabetic retinopathy or retinal exams for ARMD or something, could you just watch and they would be fine without you?

Dr Cioffi: A fair number of people go up with dilation, even open angles, and if in the normal state they don’t have appositional closure, they don’t have synechiae,

they don’t have any history of attacks, without a significant pressure rise (I don’t know if 10 is the number or 8 or 15), without any other signs of disease, I probably would not do anything. I would just watch them. I look after hundreds of patients with narrow angles that I have followed over time, and they do fine. The majority of them do just fine and you just have to look at them intermittently.

Dr Palmberg: Ralph Kirsch looked at 20 people who had positive dilatation provocative tests, followed them for 20 years, and I believe that either none or only one of them ever had any spontaneous glaucoma, and even in that one nothing really happened, we just treated them. So, unless the person has to be dilated on a regular basis for some other reason, I don’t think the dilatation provocative test is really a compelling reason for doing it, but the patient is so fearful, as we brought up before, after you have told them this and done the test, maybe that would be a reason to do it.

Dr Quigley: It has been too quiet here this morning; we have been agreeing with each other all over the place. What we need, though, is a study in which a group of glaucoma people finally get their act together and say, “We want to do a prospective study to evaluate mydriatic provocative testing”. We are setting this up at the moment in Singapore, which is the place where you can get a lot of suspects for narrow angle all in one place. Our colleagues there are going to help us out with a longitudinal follow-up of people, what Paul was just talking about, in which you do a provocative test, but you don’t do an iridectomy on anybody except the most dramatically positive people who have actually had an acute attack. There’s an ethics issue here, but Paul just made it possible for us to do this trial. Because I think you ought to do an iridotomy on people who have a mydriatic provocative test that leads to a narrower angle and a pressure rise of, let’s say, 10 points. Paul thinks you shouldn’t. So now we have the ethics for doing a trial in which we don’t do the iridotomy on people until they actually develop symptoms, and we find out how good provocative testing is. Mydriatic provocative testing stinks. Why does it stink? Because it does not answer the question you want to ask. You are looking at an end point pressure rise. People could actually have intensified pupillary block without having a pressure rise. So, ultrasonic biomicroscopy or some other method is a way of doing that. We are trying to devise some new provocative testing, for example, provoking people by accommodation, to see if the internal configuration of the eye changes. We need better provocative tests. Based on what I know now, though, if Mrs Jones came to my office and, in a darkroom, her pressure rose 10 points, I would say to her, “You know what, I’ll bet lots of times you go dancing. I bet you occasionally hang out in bars. You go to the movies, don’t you?” Her eye pressure is rising during that time and darkroom provocative tests actually get better when you do an iridotomy on more people than not. Not everyone. So I am in favor of doing something when there is a positive provocative test, and I am the first to admit to you that I don’t have data to support that, and as Jack just said, I don’t yet know how many points of pressure rise is an important rise. I think there is a real difference of opinion among people, but more people agree with Paul than with me.

Dr Palmberg: I just wanted to point something out. I don’t know what the right answer is. I am just saying that somebody who did the experiment, which was to

not treat them, could get an answer. Somebody who makes a laser iridotomy, and they all do well, tells us nothing. Perhaps those people were going to do fine anyway. Certainly, it is a lot safer now that we do laser iridotomies than in the days when we would have done a surgical iridectomy on them.

Dr Quigley: Is one of your questions downside risk? Are you going to be talking about complications of iridotomy?

Dr Palmberg: Well, we could do that. I have two minutes, so I was going to ask two things. One, what about just appositional closure. Is it enough to do it without a pressure rise. What about a few synechiae starting to form. I would do it for either one of those and our panel at the American Academy, all nine of us, agreed that that’s when we were going to do it, because we thought that trabecular meshwork nutrition is being compromised when it doesn’t get aqueous, and certainly when synechiae start forming, you have anatomical changes, that iridotomy has a low downside, and we were in favor of doing it. Unless somebody disagrees, I will move on.

Dr Cioffi: Synechiae without a doubt, and appositional closure...

Dr Palmberg: Of a quadrant or more, or something.

Dr Quigley: Be very careful, because synechiae can have been made by something else. The most common cause of peripheral anterior synechiae in the USA is argon laser trabeculoplasty. And so, if somebody has had ALT, and then someone looks in and says, “Gee, they look a little narrow and they have PAS, now I am going to blow a hole in the iris”, probably not the correct mechanism. Or inflammatory PAS or PAS related to trauma, both things that you can sometimes get a history of, and both things that are much more often asymmetric, one eye compared to the other, narrow angle with PAS on one side, wide open angle on the other with no PAS, be thinking that it is not a primary-angle closure.

Dr Palmberg: And if your PAS are from angle closure, they are usually above, and if they are from inflammation, they are usually below, where the inflammation will settle. Okay, iridoplasty indications. Appositional closure after a laser iridotomy. I would do it. If you had a plateau configuration.

Dr Cioffi: The incidence of plateau is very low.

Dr Palmberg: 3%.

Dr Cioffi: I have been in Portland for over ten years now and have only seen a handful of patients with it, or who I would suspect, and while it should be one of the things on your list, I doubt that any of us are going to see large numbers of plateau iris.

Dr Quigley: I have done a total of two iridoplasties, which is an extreme viewpoint about iridoplasty. Paul does a lot more of them, and he showed you beautiful results, shown by UBM, in the case of someone who benefited from it. So I don’t

think we are expressing anything other than two facts. The first is, I have a bias against doing gonioplasty because I don’t think it is permanent, as he showed you, though it can be helpful. The second is, I think it is overdone. I think everybody thinks, well maybe I’ll improve that narrow angle some, and what do you cost the patient? You cost him 24 deliveries, inflammation, pigment release, iris atrophy, possible increased risk of cataract, a whole lot of things. So, I don’t disagree with Paul’s use of iridoplasty. I think, though, that there are extremes in the use of it, and I am down at one end.

Dr Cioffi: I think that, even in Paul’s series, though, as you pointed out, over 20 years it was 40 patients in a very busy glaucoma practice. Three percent of the laser iridotomies went on to iridoplasty.

Dr Quigley: Whereas some of our colleagues will tell you that one-third of angleclosure patients ought to get an iridoplasty. If you are somewhere in a very large city between Philadelphia and Rhode Island, you are going to get an iridoplasty if you walk in the door.

Dr Palmberg: One-third of our iridoplasties were done in eyes that were congested after an angle-closure attack, and they weren’t plateau iris syndrome. Gonioplasty was used to break a continuing attack. We are talking about two to three percent, that’s all. But I do think that if you have real appositional closure, and I have shown you photographs, then I would perform gonioplasty.

Dr Quigley: It can be cosmetically disfiguring as well. Consider that some blueeyed people really don’t like their eyes looking like a clock face.

Dr Palmberg: Two other things came up that I just wanted to comment on briefly. One was nanophthalmos, because you were mentioning de-roofing veins. It turns out that what is of benefit in that situation is making a scleral window. It could even be a posterior sclerotomy. In nanophthalmos, people with glaucoma from uveal scleral increased episcleral pressure, and in people with Sturge-Weber, it really is helpful in avoiding exudative retinal detachments to do a window. Doug Anderson and Don Gass, I think, finally worked this out very well. We have done about 20 cases of nanophthalmos now, with no catastrophes afterwards, whereas otherwise it would be about 50% of patients who have that problem. You don’t need to de-roof vortex veins. For goodness sake, don’t do that. You destroy vortex veins. All you need is a hole in the sclera. It doesn’t have to be a window all the way through the sclera, a posterior sclerotomy works very well. It lets albumin out of the suprachoroidal space, keeps it from building up in that way. And one other thing...

Dr Quigley: Can I propose that its real mechanism is that you are reducing to atmospheric pressure the space between the choroid and the sclera, so the choroid doesn’t have the tendency to expand that it did before against a sclera that is rigid. We can differ about the mechanism. It works.

Dr Palmberg: It does work, and any nanophthalmic eye you go into should have it.

Dr Quigley: Do you know what we are talking about, nanophthalmos? Does everybody know? How small does an eye have to be to be nanophthalmic? I hear 17. Anybody bid 20?

Dr Palmberg: Could be 20.

Dr Quigley: Somewhere in the high teens axial length measurement, and you will know them when you see them, especially if you open the anterior chamber.

Dr Cioffi: Actually, the word to the wise is, stay out of a nanophthalmic eye for as long as possible.

Dr Palmberg: If you do a window, you don’t have any trouble. Malignant glaucoma – mention was made about pars plana vitrectomy and you were talking about the mechanism, I just want to throw in one thing. Doing a pars plana vitrectomy is not going to cure all cases of malignant glaucoma, if you don’t disrupt the anterior vitreous face. In pseudophakic eyes, our retina people buzz all the way through the zonular diaphragm, all the way through the iris, into the anterior chamber. When you have a real communication all the way from the anterior chamber to the posterior chamber, zero out of 33 had any more attacks. Just doing a pars plana vitrectomy, about half of them would recur. So, it’s that compressed anterior vitreous fibrin, choroidal swelling, whatever it is, you’ve got to get rid of that by having a communication. The other way out of it, which is brilliant, and which came out of Wills, is to put a Baerveldt into the vitrectomized posterior chamber, because, if the fluid wants to misdirect, or whatever you want to call it, it can go out in the tube. So, I just wanted to throw in those pearls of wisdom, and hand over to Harry, because we are going on to his part of the session.

Round table

How I make the decision to do an argon laser trabeculoplasty: my laser, lens and settings

Claude F. Burgoyne, presiding

Panel: George A. (Jack) Cioffi, MD

Paul Palmberg, MD, PhD

Harry A. Quigley, MD

Dr Quigley: Can you really spend 25 minutes talking about argon laser trabeculoplasty (ALT)? Sure you can. Actually, we will cut it short if we don’t get into anything controversial. To start with maybe the most controversial, during the last year and a half there was a publication that suggested that argon laser angle treatment should be done differently, depending upon whether the person is European derived or African derived. A lot of my patients have read that work. It was quoted widely in the press. So I am going to ask my two colleagues, to start with – one of them at least was involved in the AGIS study, the advanced glaucoma intervention study. I’d like to hear what their view is on that particular issue, and then we will get to the issue of argon laser angle treatment and in whom should we do it, or better said, how do you present it to a patient. But first, let’s talk about the AGIS study results.

Dr Palmberg: The AGIS study randomized patients in whom, in 1988, medicine didn’t work well enough, and in whom something had to be done. They were randomized to have 360° ALT in one or two sessions, or to undergo a non-anti- metabolite filtering procedure, adding medications as they came on the market. By the time you got to five years, if you had had laser trabeculoplasty first and then went on to surgery, and met with certain criteria failure, 34% of the white patients demonstrated further progression of visual field. If they first had filtering surgery, 20% demonstrated progression. And so without doing any analysis as to who failed and for what reason, a recommendation was made in white patients to skip doing laser trabeculoplasty and go on to surgery. In black patients, it was about 26% and 27% who lost more visual field during that period of time, regardless of their treatment group, and so it was recommended to use laser first, it was safer. As a member of the monitoring committee, I was apoplectic that this recommendation was made without looking at the results, because what if you had done a laser trabeculoplasty and the pressure had come down nine points, the patient was doing great, and if you had found in looking at your data that was a very good thing to do, but what if you did laser and it went down two points, and you didn’t

Glaucoma in the New Millennium, pp. 89–104

Proceedings of the 50th Annual Symposium of the New Orleans Academy of Ophthalmology, New Orleans, LA, USA, April 6-8, 2001

edited by Jonathan Nussdorf

© 2003 Kugler Publications, The Hague, The Netherlands

meet the criterion for going over to the other side of the study and doing the filter, that’s where all your trouble was, then the clinical recommendation should be to do laser. If it works well, stick with it, and if not go on to surgery, which is what I do. Now that the analysis has been carried out and paper seven is out, it turns out that if your pressure, by whatever means, has come down very nicely, you don’t lose more visual field very often, and that’s the better strategy. The investigators have yet to come out and reverse the recommendation. Fortunately, when I asked audiences, let’s ask the audience here, how many people skip laser trabeculoplasty and go on to surgery in medically compliant patients? OK, either you don’t understand the question or you’re using laser first. You are using laser first in a medically compliant patient. So it seems that very little harm was done by that recommendation.

Dr Quigley: One of the great joys, actually, is that it has been conclusively shown that doctors pay no attention whatever to clinical trial results, and carry on doing whatever they were doing in the first place. But if you look at the results of argon laser angle treatment, it was about 60% successful in achieving the target as set in both white persons and black persons who participated in that study. It turned out that the surgery, trabeculectomy, in the persons who participated in the study, worked better in the white group than in the black one, which, in that study, made surgery for white people look better. But I think I am correct in saying to my patients, “If I were to do an argon laser angle treatment for you and you have just been on medicines and now you are up to two kinds of medicine and you are failing to achieve what I am setting as a target, I’ve got about a two out of three chance that, in five years from now, you will have achieved the targets we set without having surgery, and a one in three chance that you won’t”. Then I look at the patient and see their face and see what they are thinking. And they are going, well that sounds pretty good to me, fine. No matter what the race of the person is, let’s go ahead and do that treatment. The study you just heard about was one in which we still don’t know what would happen if they took account of how severe the glaucoma was in both the white and black persons, and we know that the black persons in that study had a different severity of glaucoma from their white counterparts. So, I have a bone to pick with how some of the statistics were done, and certainly how the politics was done, of reporting to you and the public that we ought to do one thing in black people and another in whites. There are ethnic differences, but that study didn’t do us a favor for ALT in that case. It did us a tremendous favor because it says that ALT isn’t great but it isn’t terrible either; it is somewhere in the middle.

My two colleagues – you have a patient who comes to you for a routine exam who was found to have a cup-to-disc ratio of 0.9 in one eye and 0.8 in the other, and they have visual field defects on a Humphrey, and you establish what their baseline eye pressure is through a couple of visits, and you decide to set a target number. How do you propose to the patient that you are going to lower their eye pressure? What do you tell them? Jack, what do you tell them regarding the options they now have for pressure lowering?

George A. (Jack) Cioffi, MD: It hasn’t really changed all that much for me over the last decade. I offer them medical, laser, and surgical therapy. I describe each of them in some detail, normally starting with medical therapy. I think I still hold

with that. I think of argon laser later in my treatment course. I was discouraged by the AGIS report, more by its form than what the data actually showed. I think the data were somewhat encouraging, but the way they came out with this racial difference really didn’t help us. I generally don’t offer argon laser trabeculoplasty as an initial therapy, only because I realize that, in the vast majority of patients, it is time-limited, especially in younger patients. It is not going to be there forever. On that note, though, I will tell you that I have a very mature practice. I joined Mike van Buskirk and so I have patients who have been followed by him or me for 25 years, and I will tell you that argon laser trabeculoplasty can be redone, and in patients in whom it works well initially, and I am talking about a substantial pressure-lowering of 25, 30, 40%, and lasts for a number of years, you can redo it, even if you treated the entire angle initially, or you can treat the second half of the angle. We have patients in our practice who have been treated three and four times. Because I don’t believe this is a mechanical event. I believe it is a biological process that you are kicking into action which helps to clean out, if you will, the extracellular matrix component of the trabecular meshwork. So you can retreat. I talk with the patient and give them numbers along the lines of 80% of people with argon laser trabeculoplasty will have some response. Of that group, approximately 10% will lose that response per year. The 60-65%, or the two-thirds that Harry just listed at over four or five years, is pretty close to what I would expect, so I wasn’t that surprised by the AGIS results. I don’t generally offer argon laser trabeculoplasty as a first line.

Dr Palmberg: I sit down and tell the patients that we have these three options, and I tell them that they successively have more effectiveness in some ways perhaps, but also more risk, and I also look into what the family history is, whether there is a lot of blindness, the level of understanding of the patient. We have some immigrants from some parts of the Caribbean who believe in voodoo and who don’t believe in taking more than one bottle of medicine if it hasn’t fixed them, and who really need surgery from the beginning because there is very little cultural chance that medicine is going to work for them. Also, who have no money and no insurance in the USA. There are also people who George Spaeth would say can’t be team players. Someone shows up the first time in a doctor’s office complaining that they are nearly blind in both eyes, isn’t very observant and probably not very reliable, and probably ought to be filtered in both eyes. But aside from that, a patient who shows up with lesser degrees of glaucoma, and you have reason to think that they will comply, I tell them, “This is likely to be a progressive disease in the drain of your eye. We are going to start some treatment and it is probably going to work for a while, but then we will have to do something more, and then we may need to do something more again, but it won’t matter as long as your nerve and your vision aren’t getting worse”. So at least they are prepared for this, it is not a defeat every time we go on. There are some people who say, “Doctor, I just don’t think I can take medication. It’s not natural. I don’t want to do it”, on whom I will start with laser, but it is rather rare. I usually find that I am going to go with medicine, then with laser, then with surgery. It depends on how desperate the situation is, what kind of a team player they are, and how strong their feeling is that they prefer one of these, if it is really a rational reason that they prefer one or the other.

Dr Quigley: The audience probably knows, and I am sure you follow what is considered to be the standard of care, the Academy’s publications, for example, if you feel they are authoritative, suggest that you are obligated to tell the patient what methods of pressure-lowering are available. It would be like holding out on a woman with a breast lump that she has a variety of options for surgery, and you just told her there was one kind of surgery that you do and that’s it. So you should tell them that there is laser treatment, surgery, and medicines. We have a little brochure that we hand out to patients which includes frequently asked questions about glaucoma. By the time they get in after they have waited two hours to see me, or have been dilated and other stuff, they have had a chance to read through the stuff, so some of them will say, “Yes, I read over your little brochure. I’ve seen what it says about the laser.” But you should go over it with them. There is a very small downside risk when doing argon laser angle treatment. I guess by the time Jack gets to his fourth one, he could possibly have scarred up so much of the angle that the pressure is actually going to wind up being higher, but I have had the same experience he has, of patients who had a dramatically good effect, and it worked for five years, I will present them with the option of a repeat treatment. You will have to tell them that it’s not going to work with the same frequency that the standard first treatment does, but it can be a way of them having a continued effect from the treatment. You also have to tell them no, and here’s where you can look at a clinical trial, and have a result, and nobody behaves like the clinical trial suggests they should. The glaucoma laser trial, the GLT study, found that initial laser treatment had the same result at about five years as initial medical treatment, with the proviso that almost half the people who underwent laser had to use eye drops in addition in order to achieve the target pressure by the time point of follow-up of five years. Now the medically treated people, did they start using a drop and it always kept on working? You mean eye drops never wear off in their effect? People never wind up needing two drops in two years instead of the one that worked so well at first? I disagree that laser treatment should be presented to patients as a time-limited treatment. You mean filters aren’t time-limited too? Oh yes. Everything we do for a glaucoma patient is time-limited. So I don’t think that’s a particular downside for laser treatment as opposed to something else, until and if I am shown that the wearing-off effect is dramatically greater for one of our treatments than the other. We probably have 5% of patients who pick laser first, after what I think is probably a pretty aggressive presentation of how good laser sounds. To give you an idea, I don’t think that your patients are going to be jumping into laser, or jumping into surgery first, although I had another patient choose surgery first just the other day, after having presented him with the idea that filtering surgery is often done in some countries, even developed countries, the UK being considered a developed country I think still.

Dr Cioffi: Harry, I don’t quite agree on the front of time-limitless. I think that a significant portion of ALT patients does fall out of control. I think there is substantial evidence that at least 10% of patients who respond initially (and they don’t all respond initially) lose some if not all of that control on a year basis. That’s not my experience with filters.

Dr Quigley: Let’s look at the 5-fluorouracil study. Paul, didn’t you guys do...

Dr Cioffi: I’m not sure I want to look at that one to make my case.

Dr Quigley: Oh, because it was well controlled and documented?

Dr Cioffi: Because I think it had other problems. At any rate, we follow our trabs on an ongoing basis and without subsequent surgery or a subsequent inflammatory event, there is very little loss over time of filtering. If they are up and running at three months, in my experience they have a decent long term, and certainly I’m not losing 10% per year. I’m not losing it in the same order that you lose with ALT, so I think it is larger with ALT.

Dr Palmberg: You talk about time-limited and about doing laser and going back and doing it again. It makes an awful lot of difference in my mind when you are thinking about going back and doing a laser if all that has happened is that, after five or six years, the pressure is back up but the field has been stable all this time, versus they have dribbled away another third of their field and I’m thinking of doing it again, I am more likely to jump and do an operation.

Dr Cioffi: I agree.

Dr Quigley: I would agree with that too. I think the choices for therapy are going to depend very much on how you perceive the patient’s initial severity and how you perceive the rapidity with which they are progressing, if at all. Because, as we’ve also learned in the last few years, the majority of patients with glaucoma do not progress under mild therapy, under your observation. In fact, half the patients in the normal-tension glaucoma study didn’t progress with no treatment. So it’s those who are progressing, and especially those who Paul is describing who are apparently progressing rapidly, who you would want to be presenting with the option of the most aggressive and risky treatment, getting their eye pressure down to the 12 range probably with surgery, although in the normal-tension study, a lot of patients got to that low target range with medicine or laser treatment.

Dr Cioffi: I do urge you – the point that Harry made about listing the options. We actually have a similar handout that is called ‘Options for Therapy’. This lists the three options. It discusses the upside and downside of each option. I think it should be given to the patient initially. You also describe it, but it gives them the chance to take something home and think about the options as well, because the decision is often not made at that first visit when you are starting your dialogue with the patient.

Dr Palmberg: In explaining the course of the disease to patients, I think it is terribly important – patients aren’t used to chronic diseases or thinking about them, and the fact that you are going to have to do something more after time. Harry’s point about time-limitless is true, even of mitofilter. 15 or 20% of them are going to fail after five to ten years. I think that, if you prepare people in advance for this sort of thing, they are much better able to cooperate and not to lose faith in the system if there are no unanticipated bad surprises as you are going along, and they understand their role. Most people are used to going to the doctor and getting something to treat an illness and getting over it. I certainly commend the idea that there

should be a booklet and an explanation at the first visit. Answer those questions, explain what is going on. There are some nice booklets from the Glaucoma Foundation in California and some other places that help out.

Dr Quigley: The data show, though, that ophthalmologists in the USA are presently doing fewer glaucoma surgeries, laser and surgery, than you were three, four or five years ago. Does that surprise you? It surprised me. The majority of trabeculectomies being done are combined procedures with cataract surgery. Does that surprise you? It surprised me.

Dr Palmberg: I think that every time a new drug comes out – when Timoptic came out in 1978 or 1979, there was a threeor four-year hiatus. When dorzolamide came out, when brimonidine came out, now with the prostaglandin drugs, it is always going to buy two or three years for a lot of patients. When laser trabeculoplasty came out, it bought some years, and then they get back on the ladder. You can expect that unless a new wonderful drug comes out, marijuana derivative or something in the next few years, that we are probably going to catch up and get back to the same numbers, because the population is aging and they are living longer and there is going to be more glaucoma out there.

Dr Cioffi: My feeling is the same; it’s just a hiatus right now, and we have had some nice drugs that have been introduced over the last decade. They have made a substantial difference. It is really the first edition medically since the 1970s with beta-blockers that has made a big difference in the last few years. This has been an explosion if you look at how many drugs we had 20, 30 years ago, and how many drugs we have now.

Dr Quigley: Mechanistically, 180° treatment or 360° treatment, and why? Paul?

Dr Palmberg: I do 360 because, when we do 180, it fails more quickly if you don’t, and you put the patient through another period of lack of control. I don’t like to have periods of lack of control. I am not going to see this person for three or four months between visits, so I do 360. Other people will have different strategies.

Dr Cioffi: I do 180 and I don’t have an absolutely good reason for it. I will re-treat the other half some years later if the response is good.

Dr Palmberg: Does it depend on the degree of damage? You’re more likely to play the whole card if there were more damage?

Dr Cioffi: Yes, possibly. Often, if they are that damaged, I am going on to surgery anyway because I am not willing even to wait the five to six weeks that you really need to get your full therapy. So in general I do 180.

Dr Quigley: I do 360 for the same reason Paul does, and I would add that, if the treatment worked so well that I only needed do half of it to get what I wanted a lot of the time, then I would do 180, but unfortunately, ALT, despite the fact I just said something very positive, that I think it is better than what people are using it for, it doesn’t work as well as I’d like. I am going to give it the full shot, “This

is the laser, this is my best shot. If it gets you to your target, wonderful, if it doesn’t, let’s move on.” Then we are either going to move on to the medicines you didn’t choose first, or we’re going to move on to surgery, if the patient was a medical failure and that’s why they were getting the laser. There is a variety of lasers that you can do this treatment with. Argon is the standard, diode laser, and so-called selective laser therapy. Paul, do you want to comment on what you use and why?

Dr Palmberg: I’m using argon, because it is what I have. The data show that the diode seems to work as well, even krypton apparently works as well for up to two or three years. I am intrigued by selective laser trabeculoplasty because of the fact that it does less damage to the tissue, at least as far as microscopy is concerned, and maybe would have the opportunity of being used over and over and over again. That’s exciting if it’s true. What is your take on it? I’m still learning about it.

Dr Cioffi: I use argon as well because I have it. We have a diode in the OR. I use a diode in the lab, but I don’t have access to it in my treatment lanes.

Dr Quigley: If you use a diode and deliver it through a slit lamp, does it have any disadvantages? Does anyone know? Are any of you using a diode? I believe it has a different spot size, so that might make a difference.

Dr Cioffi: I think the smallest diode spot size is 75 µm instead of 50 µm.

Dr Quigley: Do either of you actually use the selective laser treatment?

Dr Palmberg: I don’t have it yet.

Dr Quigley: We don’t have any specific experience with it and we can’t comment on it. I don’t think that the literature presently contains any overwhelming reason for me to think it is actually better, and I look forward to those who are either selling it or working with those who sell it to do more research, so that we can figure a better way. We need a better way to do laser treatment, no question about that. Does the lens matter?

Dr Palmberg: One thing that I think is very helpful is to have the patient look away from the direction of the mirror as you are treating, because we are not shooting perpendicular to trabecular meshwork, we’re shooting at an angle, and the more perpendicular you can get, the rounder the spot size, the less it goes down to the iris and ciliary body, and does things that are probably not helpful. When you are looking to see if an angle is open or closed, you have the patient look in the direction of the mirror so that you can get over the iris and look down the crack, but here you want to get perpendicular to the wall, so I find it very helpful to tell the patient, “Look away from the direction of the mirror”, as this gives a much clearer, nicer view.

Dr Quigley: Any other pearls, Jack, on ALT?

Dr Cioffi: I agree with Paul. I teach this and, every five weeks, I get to have another young person do their first ALT in front of me, and one of the things they have to learn is the mechanics of holding everything, and they are still learning gonioscopy. Frankly, I think ALT was the best thing that ever happened to gonioscopy, because I don’t think ophthalmologists did gonioscopy, certainly not of the nasal and temporal angle, because it is harder, until they had to do an ALT, and then they had to realize, “I’ve got to see every single little hour of the clock going around, so I’d better learn how to do this”. All of us learn gonioscopy well, thanks to this treatment. But, as you start doing it, you will sometimes look and think it was an open angle and you get at the laser and everything looks narrow, and there is a tendency to say, “Well, I guess I’ll probably have to do iridoplasty so I can see better”. I am going to urge you not to do that. But rather, do what Paul just said. Ask the patient to look a little bit to the left, a little bit to the right. Interestingly, having them look in the direction of where the mirror is, if there is only one mirror, turns out to be much more often than random chance the right way to suddenly produce a wide open angle. Because what the patient is doing is holding the other eye closed, the eye is rolled up, and you want them to look down, or you want them to look left or right. As you go around the angle, have them re-fixate (it really helps if they have vision in the other eye), to move the other eye a little bit left, a little bit right, to make it easier for you to see the angle clearly. It is really quite rare that you need to destroy the peripheral iris in order to treat the eye to do ALT. I don’t know that it is actually bad to do iridoplasty. I just don’t like the idea if I don’t have to do it, because I think it is doing more than I need to do. So, fixation of the patient during ALT is an extremely important thing for making your life easy and for seeing better.

Actually figuring out a way, as Harry alluded to, of holding the lens so that you are not constantly having to use two hands, because there is a little bit of an art to holding the lens. I actually talk about putting my middle finger underneath the lens as a support so that I can spin it on top of my middle finger, and that helps. Then you can use one hand to spin the entire angle, and so often what happens is that we’re just used to using our index finger and thumb to hold the lens. You get up there in place, you do ten spots and all of a sudden you have to readjust, your fingers are flying off, and you have to use your other hand. So bring your middle finger down underneath the lens as a support that it just rides on, then you can spin it for the whole 360°.

Dr Palmberg: One other thing is that the suction of the Goldmann lens that is your enemy for finding angle closure is your friend for doing laser trabeculoplasty, because that increase in pressure deepens the angle and gives you that wider view, which is good, and also that suction lets you move the eye left, right, up and down, and the final little focus before you shoot is not moving the slit lamp. You get close with that and then you move the eye to the beam because of the suction, and that’s when you get it right on the spot and shoot it.

Dr Quigley: During ALT, is the power set and you forget it, or do you change the power during the treatment? Jack?

Dr Cioffi: I start at 800 and look for a little bit of a cavitation bubble. If I’m getting lots of cavitation bubbles, I usually back off a little. So I will bring it up and will end up as high as 1200 milliwatts in a non-pigmented trabecular meshwork sometimes.

Dr Palmberg: I usually use 800, but I have almost a uniform 2+ trabecular pigmentation population. And if I had some that are pigmentary, I frequently go on down to 500 because I am already getting plenty of blanching and possibly even starting into bubbles, which I would rather not see much of. I like seeing a little contraction of the tissue at the spot. If you see that, I kind of feel that I’m doing enough.

Dr Quigley: A little white spot is really nice. We’re aiming at the top of the trabecular meshwork, the top of what we call the pigmented trabecular meshwork, because that whole area is trabecular meshwork. The pigmented part is simply the area where the macrophages pick up the most pigment.

Dr Cioffi: A point with this is that you only have to watch a few residents do ALTs, and you realize that they are hitting cornea, they are hitting iris, they are hitting trabecular meshwork, cornea, cornea, trabecular meshwork, and often they still work.

Dr Quigley: And it works just as well as ours.

Dr Cioffi: So the placement may not make a big difference, and so it comes back to why it works in the first place, and I believe that biological cascade that the burns initiate, and as long as you are in the area, it may not make any difference.

Question and Answer Session

Dr Loftfield: I have several questions, and we will start with this one. It’s primarily addressed to Dr Quigley, but then to everyone. If the pressure is always, as you say, higher in the posterior chamber so that the aqueous is flowing, do you then not believe in the theory of reverse pupillary block and pigmentary dispersion glaucoma, or is that an exception? And how do you feel about iridectomy for pigmentary dispersion glaucoma, and just pigmentary dispersion without glaucoma?

Dr Quigley: All eyes have reverse pupillary block. If you were to put a needle in the anterior chamber and you attempt to flush fluid back stream into the posterior chamber in an eye that does not have an iridotomy, it won’t go. The reason for this is that the iris is plastered against the front surface of the lens in that situation. So, start with the assumption that all eyes have reverse pupillary block, but eyes with pigment dispersion syndrome have something more dramatic happen when the iris, for whatever reason, drapes backward. Now why would it drape backward more? Well, perhaps it starts closer to the zonule in the first place. This is true of eyes with deep chambers, with posterior placed lenses that are myopic, so it is the set-up, it is the pigment dispersion eye that you know and love, it’s the big myopic eye. The iris is already starting out in a position where it is near the

zonule. What happens when Paul does dynamic gonioscopy? The iris goes back, right? What happens when you blink? The iris goes back. It goes back in all of us. Because you have raised the pressure in the anterior chamber by pushing in on the cornea, and that means that instead of convex forward, the iris goes concave. These folks probably have a set-up that their iris is already in a position near the zonule and they probably have a thinner peripheral iris than do persons who don’t get this syndrome. That is total speculation on my part. I can’t back it up at all. I just think it is probably true. Do you think it is true?

Dr Palmberg: There’s no question.

Dr Quigley: So, the reason why folks have pigment dispersion syndrome is a variety of the aspects of their eye, some of which are anatomical and some of which are physiological. Now, would it help to make a hole in the iris? Well, if I make a hole in the iris of many eyes, the eye is actually going to have the iris get closer to the zonule. Is that really what I want to do? I heard from my colleague, George Spaeth, that he did a number of those and it didn’t seem to affect the course of the pigmentary glaucoma. Our experience has been negative in a few cases in which we made holes in the iris, and while I think making a hole in the iris is relatively benign, it is not totally benign. The eye ought to have fluid flowing through the pupil to bathe the entire lens in aqueous humor. The aqueous humor is the blood flow of the lens. If you make a circuit breaker hole in the iris, aqueous is preferentially going to go through the hole, not through the pupils. Posterior synechiae are more likely to form, the lens is more likely, almost surely, mildly perhaps, but almost surely more likely to develop cataract earlier in life. So, if you think you are going to help someone with pigment dispersion by making a hole in their iris, in my opinion, you should also tell them that you are likely going to speed up the development of cataract, though we can’t prove either the benefit or the risk at the moment. It is a wide open area for a clinical trial, and why the glaucoma group hasn’t done it yet, I don’t know. We designed it, we handed it to our colleagues, and nobody will do it.

Dr Cioffi: Harry, I think the reason nobody will do it is because it gets back to the ethics of it, and a number of us tried a handful of cases and weren’t terribly impressed, and to enter one of these trials, you have to say to the patient, “I don’t know the answer to this and I don’t feel that I know if it’s better or worse one way or the other”, and for the reasons you just listed that an iridotomy is not totally benign, I’m not sure that I can offer this to my patients with good conscience. I think that’s why the trial hasn’t happened. My findings are the same as yours. I don’t see the dramatic change that often is described by some of our colleagues in the convexity or concavity of the iris, and in the patients I have done it in, I just haven’t seen a marked change.

Dr Palmberg: I have spent a lot of time talking to Bob Ritch and Dave Campbell about this. It turns out that there is probably a bulk transfer of fluid from the posterior to the anterior chambers when you blink. That is what is getting trapped in these eyes and pushing the iris back. I think Bob Ritch has shown very clearly that, if you have a patient not blink, this posterior bowing goes away, and if you make a large laser iridotomy, it goes away. But the little 50 µm, very small laser

iridotomy that you make for pupillary block angle closure, and that is fine for this slow, continuous flow, apparently will not stop that posterior bowing. Apparently you need quite a bit larger iridotomy. So I don’t know of anyone who has done this up until now who has useful data. I have done about 30 eyes, one eye and not the other, and I must say that, in only about four or five of them, did the pigment preferentially go away and the pressure get better. It took four or five years. So it has been disappointing. The use of pilocarpine in the past, and the Ocusert or pilocarpine that Dave Campbell used, really did clear up pigment on that side, really did improve aqueous dynamics. There has to be some way of blocking this mechanism, but apparently making a small iridotomy isn’t it. We don’t know yet.

Dr Loftfield: The next questions are about iridoplasty. First, should an iridoplasty be performed before an iridotomy in plateau iris, and secondly, can an iridoplasty cause enough inflammation to hasten and cause peripheral anterior synechiae? Lets start with Dr Palmberg.

Dr Palmberg: I don’t think it causes synechiae. I have never seen a case where I thought it did. I think it actually opens up the angle so well right away, the problem is the decay of the effect over time. In my brown-eyed patients, it doesn’t make them look ugly or cause much of a problem. In a blue-eyed patient, as Harry points out, if we had any of those people in Miami, some of them would probably be unhappy with having gray spots on their iris. So it’s not an innocuous thing that I think you should do. In a plateau iris patient, who is really plateau iris, they have an absolutely flat iris, no pupillary block, and a very clear hump over peripheral...the ciliary body rolled forward, and you push and you can see that. All that patient needs is probably an iridoplasty and Doug Anderson has actually done a couple of these when he didn’t do the iridotomies, as he was absolutely sure that this is what it was. I still haven’t got enough confidence to be absolutely sure what was going on, and I put a laser iridotomy in all those people, and in some of the ones I was quite convinced were only a plateau iris mechanism, when I put the iridotomy in, they actually opened enough so that I didn’t have to do the iridoplasty. I don’t think you can tell. I would always put the iridotomy in first and then re-evaluate.

Dr Quigley: I think that unless God told you, you don’t know whether they have plateau iris syndrome until you make an iridotomy and prove that they still get a pressure rise on dilation. Therefore, I can’t imagine that it would help very often, much as I love Doug Anderson, to think about doing iridoplasty without iridotomy, except in that pure circumstance with his kind of experience.

Dr Loftfield: The next questions are about ALT, are there any downsides to it, and do you think it is less effective after cataract surgery, and does it increase bleb failure?

Dr Cioffi: It is my impression, sitting next to Paul, that ALT does not hinder future filtration surgery, and that would have been my clinical impression. Before or after cataract surgery is an interesting question. Most of the data that talk about whether or not to do ALT first and then cataract surgery, or the reverse, come from the days of ECCE and not from modern cataract surgery.

Dr Palmberg: Or even ICCE.

Dr Cioffi: Actually, the initial report was ICCE, so I don’t know that those studies necessarily apply. Clinically, I am not impressed that there is much difference in response, whether I do it in a pseudophakic or a phakic eye. But that is just my clinical gut impression.

Dr Palmberg: I don’t know of it, but I don’t think it is going to change what you do. It works well enough.

Dr Quigley: It is not a fair comparison, because eyes that have had cataract surgery are not the same. So, does it work as well. What you care about is what the success rate is in a pseudophakic eye. So that when you are presented with a patient who is pseudophakic and you need a lower target pressure, the question is, does ALT lower it, and if so, how often. That’s true, we don’t know after phaco...what I say to patients is that it normally works two out of three times. You have already had surgery on your eye, so I think it is going to be a lower chance than that, but if it is 40% chance that it works for five years, would you take it? I think it is a reasonable approach, even though it is not backed up by huge numbers.

Dr Loftfield: The next question is, assuming that 10% of extremely narrow angles go on to angle closure and that it is a really bad thing when that happens and it is much worse than an iridotomy, why not do prophylactic iridotomy on all very narrow angles?

Dr Cioffi: Because of the 90% that don’t need it.

Dr Quigley: The downside risk of iridotomy – we didn’t really talk about this, so we ought to. There are eyes that develop posterior synechiae. There is probably a higher rate of cataract in persons who have iridotomy. Of course, cataract is no where near as bad as having an acute attack. But I think there is a cost-risk benefit, a trade-off here that you would have to weigh up. One of my colleagues who is a little cynical said, “Well, we ought to go to the newborn nursery and put a hole in every kid. You know, you do circumcision, you give them the Credé prophylaxis, and then you blow a hole in each iris, and you have basically cured angleclosure glaucoma in our lifetime, isn’t that wonderful”. I said, “Well, yes, but you know we vaccinate the population, but I’m not sure whether we’re talking here about vaccinating all persons with narrow angles”. It really matters which angle you’re talking about. A little bit narrow? Kind of narrow?

Dr Loftfield: They said extremely narrow.

Dr Quigley: Extremely narrow. Well, I think then that we’re back to the group of persons we were talking about here in whom it looks so narrow that you think they have a disease. And that’s a clinical judgment, isn’t it? I am not sure that we all agree about this.

Dr Palmberg: The only one I’m really sure about doing is the fellow eye of one that

has had angle closure and now this one is appositionally closed a little, or is very narrow. This has been clearly shown, that 50% of these people are going to go on. And Harry, as you say, these would be the eyes to study, to try to figure out what the difference is about them, that they are the ones who go on?

Dr Quigley: Do you know that is what we are doing, or did you guess that?

Dr Palmberg: What, 50%? That was shown.

Dr Quigley: No, that we are studying fellow eyes? The study David Friedman is engaged in right now with our Singapore colleagues is that the patient comes in with an acute attack in one eye, and in the 24 hours before they do the iridotomy in the fellow eye, we studied the heck out of the fellow eye.

Dr Palmberg: It makes me feel smaller just to know I had a similar thought.

Dr Quigley: I would not say that, at the present time, Medicare or anyone else would look favorably upon ophthalmologists suddenly deciding to do iridotomies on the indication that the angle looked narrow a little. So, I would say that you would have to have an extremely narrow angle. If that is the questioner’s question, then I think you are getting into an area of clinical judgment where, if you want to do that and you called it extremely narrow, I wouldn’t disagree with you.

Dr Loftfield: The next question goes back to the nanophthalmic eye. Do you make posterior scleral windows when you operate on these eyes during cataract surgery, or only when you do a trabeculectomy, or not at all?

Dr Cioffi: I do it for any surgery. I do a scleral window at six o’clock down below, I’ll do a cut-down through the conjunctiva, I’ll do a radial incision so that I get into the suprachoroidal space, and then actually I take my cautery and cauterize back the sides of that scleral wound a little so that it stays open, and then I put a single Vicryl in the conjunctiva over the top of it. I do that whenever I am entering a nanophthalmic, a true nanophthalmic, eye. I have operated on an eye as short as 14 mm and have got away with it. I also had one patient with a scleral window that I am fairly certain bled out through the window postoperatively after a trabeculectomy, and had a large tan-colored collection of fluid about four or five days after trabeculectomy. So I think they work. I think they make your case a lot easier for cataract surgery while you are doing it, because you can keep a chamber more easily. It is still not always easy, but I urge you to do it on any eye.

Dr Palmberg: It doesn’t need to be a window. An L-shaped sclerotomy and maybe a little cautery on the edge, as he says, that you don’t close, is the answer. This is less likely to allow an expulsive hemorrhage of the choroid to come out. As I say, we have had zero out of 20 in Miami since we first started making windows, but now getting simpler and just simply putting in an L-shaped sclerotomy, just as you would do to drain choroidals.

Dr Cioffi: In fact, what sometimes happens is that you see a patient, you know they are a bit of a hyperope with a slightly shallow chamber, and they are scheduled

for cataract surgery. You go through risks and benefits, etc., and then a week before cataract surgery, they have their A scan and you are looking over this scan and all of a sudden you realize it is a 16.5-mm eye. I call those patients back prior to surgery, and say, “Look, you know, we found something on your scan. You have to realize this increases your risk.” I talk to them. I bring them back for a second visit.

Dr Palmberg: And you ordered the 45 lens.

Dr Cioffi: Yes, exactly.

Dr Quigley: Doing trabeculectomy on those eyes, you may want to do some things that we do for anybody who has had a past expulsive hemorrhage in the other eye, or someone who you know has had severe positive pressure, and that is, you can pre-place the 10-0 suture on the trabeculectomy scleral flap and put Healon in the anterior chamber. For example, you put the 10-0 through the two corners of a square flap, but you don’t tie the knots down. You just have the 10-0 there. If you actually want to loop a slip knot, but not tie it up on each one of those. Now you have Healon in the chamber and you say to the nurse, “I would like to do this trabeculectomy in the next ten seconds, so you are going to hand me the Kelly punch and the iris scissors. Are you ready?” And we enter the chamber, Kelly punch, Kelly punch, iridectomy, and you close the two 10-0s. Healon is running out of the eye while you are doing that, but you probably haven’t generated an atmospheric pressure in the anterior chamber before you are done. In that way, you avoid as much as possible the situation where the pressure is very low at the front of the eye and is normal or higher at the back of the eye, and whatever bad is going to happen, such as an expulsive or other things, it had a very short time to happen. You are aware that, in trabeculectomy, it will sometimes take you a while between the time you do the trabeculectomy and you do the iridectomy, give me the 10-0, you drop it, you do this, you try to put it through and there is some blood, you have to clear it, it could take you a couple, three, four, five minutes to do that.

Dr Palmberg: There is another way, and it takes two seconds. When you are putting your Baerveldt in, you pull the 23-gauge needle out and stick the ligated Baerveldt in, it takes two seconds to pull one out and put the other in. You have no decompression at all. I have started doing this on Sturge-Weber cases because it was even happening with the posterior sclerotomy, some small exudative retinal detachments. If you angle this tube quite nasally and in the far periphery it will never touch the lens, no matter how dilated they are, and you are not going to have an explosive decompression. I have not seen, so far in a small series, any of these kinds of problems. So that is another potential approach.

Dr Cioffi: Then you put them on prayer q.i.d. afterwards.

Dr Palmberg: All my patients are on prayer q.i.d.

Dr Loftfield: In those patients, those rare patients who do have visual complaints after iridotomies with either double vision or a white line, and can be quite mis-

erable, what do you have to offer them in the way of treatment to make them happier?

Dr Cioffi: I haven’t actually found a good solution, to be honest. You could talk about colored contact lenses and things like that, but avoidance, in this case, is your best hope. I have a couple of them that let me know it each time they come in.

Dr Quigley: I had a patient who got to the point of almost ordering a contact lens with an artificial pupil in the center of it, and then he didn’t do it because he said his symptoms got better. He was a contact lens wearer, so it would have simply been a matter of changing to a different contact lens.

Dr Palmberg: Yes, all these colored contact lenses for changing iris color would be ideal for it if the person wanted and needed to wear a contact lens. Doug Anderson says that, if you make the laser iridotomy somewhat larger, it is less of a problem. I have never done that. I offer you that. I have one patient in whom I was going to sew it shut....They decided not to do it.

Dr Loftfield: The next goes to the physiological and provocative testing. What test do you use and, specifically, what about the water drinking test?

Dr Quigley: Who remembers water drinking tonography? Congratulations. You’re not that old. Actually, water drinking was predictive of open-angle glaucoma, development of field loss, but it is not something you would do pragmatically. A liter of water in 15 minutes is not something that we are doing now. I use a mydriatic provocative test in everyone, except in those I think are extremely narrow, as we talked about earlier, and I also perform darkroom tests. I don’t think my colleagues probably do.

Dr Loftfield: Actually, they were asking what mydriatic you use for that?

Dr Quigley: I use 1% mydriacyl, one drop.

Dr Palmberg: My darkroom provocative test is to do gonioscopy in the dark, and as you sit there watching, in about nine or ten seconds some of these narrow angles just simply close, and if they have appositional closure, I do it. I do this because of a patient who came over from Miami Beach one time for a fifth opinion, said “It is two to two, you’re going to decide.” And after I said, “Well, I think it is narrow but open”; she said, “How about a darkroom provocative test?” I just watched it in a dark room and it closed, and that is when I realized that not putting light through the pupil was important.

Dr Cioffi: I use 1% mydriacyl as well. I don’t use a darkroom provocative test. If I am that worried, I will probably put an iridotomy in.

Dr Loftfield: The last question before we break for lunch. In the last five years, have you been able to treat all acute angle closures with laser iridotomies, or have you had to do a surgical iridectomy?

Dr Cioffi: I have done one surgical iridectomy in the last five years.

Dr Palmberg: I haven’t done any in 20 years, but I think this is because the people in the community solve all these.

Dr Quigley: I have done two surgical iridectomies in a decade.

Dr George Ellis: My question is related to the role forward of the ciliary body. Last year, we heard some talks about scleral expansion in order to treat presbyopia, and I am wondering if there is any kind of relationship with this rolling forward of the ciliary body with presbyopia, and does this fit in anyway?

Dr Palmberg: At least the refractive error of these patients is not usually the high hyperopic values that you see in people with angle closure. Their amount of presbyopia did not impress us as being unusual for people between the ages of 30 and 60. We did not test their accommodative ability, but, for example, none of the people aged from 30 up to 40 required bifocals prematurely.

Dr Quigley: Did the folks who gave the lecture on scleral surgery for presbyopia give you all kinds of data, or was it mostly theory? Because I think our worry is that we don’t know enough about what would happen if large numbers of people underwent some sort of procedure. I take it they were talking about the scleral surgical procedure?

Dr Ellis: A scleral surgery procedure, yes. But I don’t think there were large controlled studies. I think this was theory and a couple of examples.

Dr Quigley: Yes, there are a couple of really smart people who proposed that, George, and when you look at what they are talking about, it really sounds plausible. So you have a plausible hypothesis. You just don’t know what is going to happen to a lot of eyes if you do it. If you told me that LASIK would work and a million people would be getting LASIK, I would have said no, so that shows you, don’t bet on what I say about the stock market. I would bet on data, though, on that procedure, and I don’t have any. It could very well change the position of the choroid and the ciliary body. For all I know, it could help. We talked about scleral windows here. I think if you thin the sclera and you allow fluid to flow faster out of the suprachoroidal space, you are probably going to help all sorts of glaucomas.

Dr Ellis: It would be interesting if people who had the ciliary body role forward had a diminished accommodative range, their ability to accommodate was less than, say, age norms or age-matched controls.

Dr Palmberg: We will check it on our next 24 patients and, when I am 96, I will come back and tell you, because it would take me 30 years to get enough patients.

Dr Loftfield: Thank you for all the questions.