LXII Edward Jackson Lecture: Open Angle Glaucoma After Vitrectomy
LXII Edward Jackson Lecture: Open Angle Glaucoma After Vitrectomy
STANLEY CHANG, MD
● PURPOSE: To present data and an hypothesis for the medications ⴞ 1.2 vs 2.0 medications ⴞ 1.4; P ⴝ .0215;
late development of open angle glaucoma (OAG) after n ⴝ 14).
vitrectomy. ● CONCLUSION: There is an increased risk of OAG after
● DESIGN: A retrospective observational case series. vitrectomy. The presence of the lens may be protective.
● METHODS: The records of 453 eyes that had under- In established OAG before the operation, the number
gone vitrectomy were reviewed for postoperative OAG. of antiglaucoma medications may increase after sur-
Eyes with confounding factors were excluded. Sixty-eight gery. Oxidative stress is hypothesized to have a role in
eyes of 65 patients that underwent routine vitrectomy the pathogenesis. (Am J Ophthalmol 2006;141:
were followed for a mean of 56.9 months (range, seven to 1033–1043. © 2006 by Elsevier Inc. All rights re-
192 months). For the main outcome measures, patients served.)
were classified into three groups: patients with suspected
I
glaucoma, patients in whom glaucoma developed after the AM MOST GRATEFUL TO THE AMERICAN ACADEMY OF
operation, and patients with pre-existing glaucoma. Ophthalmology and the American Journal of Ophthal-
● RESULTS: In glaucoma suspects, the mean intraocular mology for their invitation to give this lecture honoring
pressure was significantly higher in the operated eye the achievements of one of the “founding fathers” of Amer-
compared with the fellow eye (P ⴝ .0001). In eyes with ican Ophthalmology, Dr Edward Jackson. Joining ranks with
new onset glaucoma, 23 of 34 eyes (67.6%) had it in the 61 of the most prominent leaders in ophthalmology who have
vitrectomized eye only. In phakic eyes, the time interval given this lecture previously is a distinction that is both
between vitrectomy and the development of glaucoma absolutely incredible but also humbling.1 It has been exactly
(mean, 45.95 months) was significantly longer than eyes 40 years since the last Jackson Memorial Lecture was given
that were nonphakic at the time of vitrectomy (mean, by an ophthalmologist from New York, Dr Irving Leopold.
18.39 months; P ⴝ .0115). When the interval between At that time, Dr Leopold had a faculty appointment at
cataract surgery in phakic eyes to the development of Columbia University before taking the chair at Mount
glaucoma was compared with the interval from vitrec- Sinai School of Medicine the following year. Four other
tomy to glaucoma diagnosis in the nonphakic group, the Columbia faculty members have given this distinguished
difference was not statistically significant. In eyes with lecture: John Dunnington, Algernon Reese, Ludwig Von
glaucoma before the operation, the mean number of Sallman, and George Smelser. I am very pleased to share
antiglaucoma medications that were required to control this honor.
the intraocular pressure was significantly higher in the Dr Jackson exhibited leadership and excellence in many
vitrectomized eye, compared with the fellow eye (2.9 facets of ophthalmology (Figure 1).2,3 He was the quintes-
sential clinician who was analytical and precise in applying
his broad experience and knowledge to solving clinical
Accepted for publication Feb 6, 2006. problems. He was a prolific author who wrote ⬎600
From the Edward S. Harkness Eye Institute, Department of Ophthal-
mology, Columbia University, New York, New York. articles and many books on ophthalmology and refraction.
Supported, in part, by an unrestricted grant to the Department of He led the movement to elevate the standards for training
Ophthalmology from Research to Prevent Blindness, Inc, New York, New
York, the K.K. Tse and Ku Teh Ying Endowed Professorship, and the
ophthalmologists and medical students in eye disorders. He
Louis V. Gerstner, Jr, Clinical Research Center, Columbia University was greatly respected and admired by his peers and was a
Medical Center, New York, New York. founder and first leader of professional organizations such
I would like to thank Norihiko Yoshida, MD, and Paulo Escario, MD,
Columbia University, for their diligence and precision in the review and as the Western Ophthalmologic, Otological, Laryngologi-
statistical analysis of massive amounts of data and Michael Chiang, MD, cal, and Rhinological Association (later renamed the
and James Tsai, MD, Columbia University, for their constructive review American Academy of Ophthalmology and Otolaryngol-
of the study design and their statistical support.
Inquiries to Stanley Chang, MD, Edward S. Harkness Eye Institute, ogy), the American Board of Ophthalmology, and first
635 West 165th St, New York, NY 10032; e-mail: [email protected] Editor-in-Chief of the American Journal of Ophthalmology.
CASE STUDIES
● PATIENT 1: A 57-year-old Caucasian man was referred
in September 2000 for large retinal tears in the right eye.
Four years earlier, he had had a 120-degree giant retinal
tear with three inferior horseshoe tears in the left eye that
FIGURE 5. Postoperative fundus montage of attached retina
were treated with laser photocoagulation. Three days
(Patient 2); laser photocoagulation was placed only around the
before my examination, he noted floaters in the right eye, retinal tears. The corrected visual acuity was 20/30.
and an inferior shadow developed two days later. The
visual acuity in the right eye was 20/20 with correction.
There was mild vitreous debris and hemorrhage. A bullous Because of the large posterior tears, the retinal detach-
retinal detachment was present from 10:30 to 2 o’clock, with ment in the right eye was managed by primary vitrectomy,
two large horseshoe tears at 12 and 1:30 o’clock (Figures 2 perfluorocarbon liquid tamponade, endophotocoagulation,
and 3, Top). Two additional horseshoe tears were located and perfluorocarbon gas injection. A scleral buckle was not
equatorially at 6:00 and at 7:30 o’clock. In the left eye the done. Postoperatively, one month later, the retina was
retina was attached, and the tears were surrounded by completely attached with reabsorption of the gas bubble
laser photocoagulation scars. The IOPs were OD 17 mm and corrected visual acuity of 20/25. One year later and
Hg, OS 18 mm Hg. receiving no ocular medications, his corrected visual acuity
● PATIENT 2: A 43-year-old African-American woman ● PATIENT 3: A 61-year-old Caucasian woman was seen in
was first examined in January 1991 with symptoms of June 1988 with metamorphopsia in the left eye of one month
floaters in the right eye and was found to have visual acuity duration. Her corrected visual acuity was OD 20/25, OS
of 20/20. An operculated retinal hole was found at 8 20/20. Cellophane maculopathy was noted in the left eye. In
o’clock at the equator with paravascular lattice degenera- September 1994, the visual acuity in the left eye was reduced
tion from 11 to 12 o’clock. Both areas were surrounded to 20/60-2, and the macular pucker was diagnosed. The IOPs
with laser photocoagulation. In July 1997, the patient were 19 mm Hg OU. Vitrectomy with membrane peeling was
suddenly noted a visual field defect and dimming of vision recommended, but the patient decided to wait until July 1995
in the right eye; a retinal detachment was found (Figure 4). to undergo surgery when the vision worsened slightly. Vit-
The detachment was bullous from 10 o’clock clockwise to rectomy was uncomplicated, and the recuperation was unre-
5 o’clock and extended posteriorly close to the macula. markable. The IOPs were OD 18 mm Hg and OS 20 mm Hg.
The tears superiorly had coalesced into one large poste- The patient was followed regularly, and a brunescent nuclear
quatorial retinal tear at 12 o’clock. A primary vitrectomy cataract developed in the operated left eye. In July 1998, the
with perfluorocarbon liquid, endophotocoagulation, and IOPs were measured at OD 20 mm Hg and OS 22 mm Hg at