Journal of Glaucoma 11:189196

2002 Lippincott Williams & Wilkins, Inc.

Trabeculectomy with Antiproliferative Agents in

Uveitic Glaucoma

*Elizenda M. Ceballos, MD, *Allen D. Beck, MD, and Michael J. Lynn, MS

*Department of Ophthalmology, Emory University School of Medicine and Department of Biostatistics, Rollins School of Public
Health of Emory University, Atlanta, Georgia

Purpose: To evaluate the outcome of trabeculectomy with antiproliferative agents

in patients with uveitic glaucoma
Methods: A retrospective chart review of 44 eyes of 44 patients with uveitic
glaucoma who underwent trabeculectomy with mitomycin C or 5-fluorouracil. The
authors defined complete success as an intraocular pressure of 21 mm Hg or lower
without pressure-lowering medications, qualified success as an intraocular pressure of
21 mm Hg or lower with medications, and failure as an intraocular pressure of more
than 21 mm Hg with medications, loss of light perception, or the need for reoperation.
Results: The cumulative probability of complete or qualified success was 78% at 1
year and 62% at 2 years. At 2 years, success rates were 39% in males and 71% in
females (P 0.02), 74% in white patients and 55% in black patients (P 0.58), and
45% in patients with idiopathic uveitis and 74% in patients with sarcoid uveitis (P
0.17). Sixteen of 31 (51.6%) phakic patients developed new cataracts or had progres-
sion of existing cataracts and required cataract extraction. Four of 16 eyes (25%) lost
intraocular pressure control and needed repeat trabeculectomy after undergoing cata-
ract surgery.
Conclusions: Patients with uveitic glaucoma can have good outcomes after trabec-
ulectomy with antiproliferative agents. Male gender was the only statistically signifi-
cant risk factor for trabeculectomy failure. Cataract management in the presence of a
filtering bleb poses a treatment dilemma between improvement of visual acuity and
loss of intraocular pressure control.
Key Words: 5-FluorouracilMitomycin CTrabeculectomyUveitis.

The management of uveitic glaucoma that is refractory
to medical therapy is complex and challenging. Although
the reported success rate for trabeculectomy in uveitic
glaucoma is highly variable, it is historically lower than
the success rate for trabeculectomy in nonuveitic pa-
tients.16 The variable success rates have led to a diver-
Received July 17, 2001; sent for revision October 18, 2001; accepted
January 10, 2002.
This work was supported in part by an unrestricted grant from Re-
search to Prevent Blindness, New York, NY, and a departmental core
grant from the NEI (P30 EY06360)
Address correspondence and reprint requests to Allen D. Beck, MD,
Emory University School of Medicine, Department of Ophthalmology,
1365B Clifton Road NE, Atlanta, GA 30322; e-mail: abeck@emory.
edu
sity of opinions regarding the initial surgical manage-
ment of uveitic glaucoma, ranging from trabeculectomy
without antimetabolites5,6 to trabeculectomy with 5-flu-
orouracil or mitomycin C712 to aqueous shunt proce-
dures.13,14,28,29 Trabeculectomy with 5-fluorouracil or
mitomycin C might have enhanced the success rate of
trabeculectomy for uveitic glaucoma in small series of
patients with relatively short follow-up period, and one
study noted a 67% success rate at 5 years using 5-fluo-
rouracil.712 Trabeculectomy failure in black patients
was significantly more common in the 5-fluorouracil
study by Towler et al.,12 though only six black patients
were enrolled in this study. The intermediate and long-
term success rate of trabeculectomy with mitomycin C in

189 DOI: 10.1097/01.IJG.0000013730.04485.CE

190 E. M. CEBALLOS

uveitic patients and the possible risk factors for failure a vitrectomy, one was a penetrating keratoplasty, and one
remain largely undetermined. was a removal of a depot corticosteroid injection (total of
In this study, we report the intermediate-term results 20 incisional procedures). The patient demographics are
of trabeculectomy with antiproliferative agents (pre- summarized in Table 1.
dominantly mitomycin C) in a population with a majority
of black patients, and explore the effects of race, sex,
type of uveitis, previous incisional surgery, and subse- Surgical Procedures
quent cataract surgery on intraocular pressure (IOP) con-
Forty-four eyes of 44 patients underwent trabeculec-
trol.
tomy with antiproliferative agents. The trabeculectomies
were performed superiorly using a limbus-based con-
PATIENTS AND METHODS junctival flap and a modified Cairns technique. Intraop-
erative mitomycin C (Mutamycin; Bristol-Myers Squibb,
Patients Princeton, NJ) in a concentration of 0.20 or 0.25 mg/mL
was applied using a 7.5-mm diameter corneal light shield
The Emory University Human Investigations Commit-
(Merocel; Zomed Surgical, Jacksonville, FL) for a mean
tee (Institutional Review Board) approved the study pro-
of 3.4 minutes (range, 15 minutes). 5-Fluorouracil
tocol. Patients who received a diagnosis of glaucoma
(Adrucil; Pharmacia, Peapack, NJ) was administered in-
associated with inflammation using ICD-9 code 365.62
traoperatively (50-mg/mL concentration soaked in a cor-
between September 1995 and January 1999 were identi-
neal light shield for 14 minutes; mean, 2.3 minutes)
fied using a computerized search of the diagnostic data-
and/or postoperatively as subconjunctival injections of
base at the Emory Eye Center. Using this search method,
undiluted 50-mg/mL solution (range, 215 injections;
159 patients with glaucoma associated with inflamma-
mean, 5.9 injections). Of the 44 cases of initial trabecu-
tion were identified. Forty-four eyes of 44 patients who
lectomy at our institution, 32 received mitomycin C, 9
underwent one or more trabeculectomies for the manage-
received 5-fluorouracil alone, and 3 received both intra-
ment of uncontrolled IOP despite maximally tolerated
operative mitomycin C and postoperative 5-fluorouracil
medical therapy were included in the study. In patients
injections. Repeat trabeculectomy was performed on 10
who underwent bilateral filtration surgery, only the first
eyes of the 44 patients in the study, and mitomycin C was
eye to undergo surgery was included in the study. Pa-
used in all 10 eyes. Uveitis was noted to be controlled
tients who did not undergo surgery or those with con-
comitant neovascular glaucoma due to proliferative dia-
betic retinopathy, secondary inflammation after intraoc- TABLE 1. Patient demographic data summary
ular surgery, or inadequate records to ensure at least 6 Patients (%)
months of follow-up were excluded from the study.
Number 44
The mean age of patients at the time of the initial Gender
surgery was 47.4 years (range, 580 years). Fourteen Male 14 (31.8)
patients (31.8%) were male and 30 (68.2%) were female. Female 30 (68.2)
Race
Twenty-five patients were black (56.8%), 16 (36.4%) White 16 (36.4)
were white, 1 was Hispanic, and 2 were of Black 25 (56.8)
other/undetermined race. The following uveitic diagnosis Hispanic 1 (2.3)
Other 2 (4.5)
were present: idiopathic inflammation (23 patients), sar- Age (years)
coidosis (9 patients), arthropathy-related uveitis (5 pa- Mean 47.4
tients; 3 with juvenile rheumatoid arthritis, 1 with adult- Standard deviation 18.3
Range 580
onset rheumatoid arthritis, 1 with ankylosing spondyli- Previous incisional surgery 14 (31.8)
tis), herpetic uveitis (3 patients), Vogt-Koyanagi-Harada Failed trabeculectomies 3
syndrome (2 patients), Fuchs heterochromic iridocyclitis Uveitis syndrome/disease
Idiopathic inflammation 23
(1 patient), and multifocal choroiditis (1 patient). Best- Sarcoidosis 9
corrected visual acuities ranged from 20/20 to hand mo- Herpes (simplex or zoster) 3
tions before surgery. Fourteen patients (31.8%) had un- Juvenile rheumatoid arthritis 3
Vogt-Koyanagi-Harada 2
dergone incisional surgery (average, 1.4 procedures per Rheumatoid arthritis (adult-onset) 1
eye) before their first surgery at our institution. Thirteen Fuchs heterochromic iridocyclitis 1
of the previous surgeries were cataract extractions, three Multifocal choroiditis 1
Ankylosing spondylitis 1
were trabeculectomies, one was a scleral buckle, one was

J Glaucoma, Vol. 11, No. 3, 2002

 ANTIPROLIFERATIVE AGENTS 191

of 21 mm Hg or lower with the use of IOP-lowering

medications, and failure as an IOP greater than 21 mm
Hg with IOP-lowering medications, loss of light percep-
tion, or the need for reoperation (performed or recom-
mended).

Statistical Methods

The primary outcome measure was the time from the

initial surgery until the first trabeculectomy failure. Sur-
vival curves were estimated using the product-limit
method16 and comparisons of survival curves among
groups were made with the log-rank test.17 The percent-
age of patients with trabeculectomy failure was com-
pared among groups using the 2 test or Fisher exact
test.18 The change in IOP was evaluated by comparing
each patients IOP before initial surgery to the average of
FIG. 1. The product-limit estimate for the cumulative probability all IOP measurements available after surgery until failure
of success and months of follow-up after initial trabeculectomy. or the last follow-up measurement. A paired t test was
The hash marks represent patients whose procedures had not
failed at the time of the last follow-up examination. used to compare the IOP change.18 A P value of 0.05 for
any test was considered statistically significant. Given
the relatively small number of patients, a lack of statis-
before trabeculectomy in all patients undergoing non-
tical significance should be viewed with caution.
emergency surgery (1+ aqueous cellular score or better at
time of surgery). Prednisolone acetate 1% (Pred Forte;
Allergan, Irvine, CA) was used postoperatively, usually RESULTS
hourly while awake initially, with gradual titration to
maintenance levels needed to control the uveitis. Topical The forty-four eyes of 44 patients included in the
ciprofloxacin (Ciloxan; Alcon, Ft. Worth, TX) or genta- study underwent a total of 54 trabeculectomies, of which
micin sulfate (Gentamicin; Medical Ophthalmics, Tar- 44 were initial trabeculectomies at our institution and 10
pon Springs, FL) was also administered four times a day were repeat trabeculectomies after failure of the initial
during the first postoperative week. Subconjunctival or surgery. Three patients who underwent repeat trabecu-
subtenon injection of 10- or 40-mg/mL triamcinolone lectomy were lost to follow-up, leaving seven repeat tra-
acetonide (Kenalog, Bristol-Myers Squibb) was fre- beculectomies for analysis (Table 2). The average length
quently used perioperatively to assist in uveitis control. of follow-up from the time of surgery to the last visit or
Oral prednisone (Prednisone; Roxane Laboratories, Co- (in cases of failure) to repeat surgery was 27.8 months
lumbus OH) or another means of systemic immunosup- (range, 189 months). At the last follow-up examination,
pression was administered postoperatively when the pa- 29 of 44 (65.9%) initial trabeculectomies met criteria for
tient required this medication for preoperative uveitis
control. TABLE 2. Summary of trabeculectomy outcomes
Laser suture lysis was performed for increased IOP or All trabeculectomies (n 51)
inadequate filtering bleb height. Digital massage was in- Overall sucess 34 (66.7%)
stituted for signs of bleb encapsulation. Complete success 28
Qualified success 6
Failure 17 (33.3%)
Initial trabeculectomies (n 44)
Outcome Criteria Overall success 29 (65.9%)
Complete success 23
Our criteria for success or failure of the glaucoma Qualified success 6
surgery represent a modification of those used by Heuer Failure 15 (34.1%)
Repeated trabeculectomies (n 7)
et al.15 in presenting their study results of 5-fluorouracil Overall success 5 (71.4%)
and glaucoma filtering surgery. We defined complete Complete success 5
success as an IOP of 21 mm Hg or lower without the use Qualified success 0
Failure 2 (28.6%)
of any IOP-lowering agents, qualified success as an IOP

J Glaucoma, Vol. 11, No. 3, 2002

192 E. M. CEBALLOS

TABLE 3. Intraocular pressure and medication summary (first surgery)

Mean (range)
Preoperative IOP (mm Hg) (n 44 eyes) 40.3 (1674)
Preoperative medications 2.9 (15)
Postoperative IOP, all eyes (mm Hg) 13.3 (427)
Postoperative IOP, successful eyes (n 33) (mm Hg) 10.8 (421)
Postoperative medication use, all eyes 1.3 (05)
Postoperative medication use, successful eyes (n 29) 0.4 (02)
0 medications, 23 eyes (79.3%)
1 medication, 2 eyes (6.9%)
2 medications, 4 eyes (13.8%)
Follow-up, all eyes* (months) 29.9 (390)
Follow-up, successful eyes (months) 34.7 (588)

* Postoperative follow-up to last visit in successful eyes or to repear surgery in

failures.

complete or qualified success (Table 2). The cumulative Analyses were performed to compare the percentage
probability of success was 78% at 1 year and 62% at 2 of patients with trabeculectomy failure with the risk fac-
years (Fig. 1). The IOP was reduced from a preoperative tors of race, gender, uveitis type, and previous incisional
mean of 40.3 mm Hg (range, 1674 mm Hg) on an surgery. These analyses showed a similar result to the
average of 2.9 glaucoma medications (range, 15) to analyses of time to failure, and gender was the only
13.3 mm Hg (range, 427 mm Hg) postoperatively (in- statistically significant risk factor (P 0.04, 2 test,
cluding failures) on an average of 1.3 glaucoma medi- Table 4).
cations (range, 05) . Twenty-three of 29 (79%) patients Fifteen of the 44 initial trabeculectomies failed: 1 pa-
in whom initial trabeculectomy was successful required tient with hand-motions vision preoperatively lost light
no medications postoperatively for IOP control (Table perception, a repeat trabeculectomy was recommended
3). The mean SD reduction in IOP (27 11.5 mm Hg) in 1 patient and was pending at the last follow-up, 1
was clinically and statistically significant (P 0.0001). patient whose outcome was defined as a failure was be-
Two patients with uncontrolled and widely fluctuating ing treated medically at the last follow-up, and 12 pa-
IOPs had an IOP lower than 21mm Hg on their preop- tients received subsequent surgical intervention for un-
erative visit. controlled IOP. Two of these patients had placement of
In black patients, the cumulative probability of success an aqueous shunt device, and 10 patients underwent a
for initial trabeculectomy was 55% at 2 years. In white
patients, the cumulative probability of success was 74%
at 2 years (P 0.58, log-rank test, Fig. 2). In patients
with previous incisional surgery and without previous
incisional surgery, the cumulative probabilities of suc-
cess were 70% and 58% at 2 years, respectively (P
0.59, log-rank test) (Fig. 3). In patients with idiopathic
uveitis and with sarcoid-related uveitis (the only uveitis
categories considered for statistical analysis), the cumu-
lative probabilities of success were 45% and 74% at 2
years (P 0.17, log-rank test) (Fig. 4). In males and
females, the cumulative probabilities of success were
39% and 71% at 2 years (P 0.02, log-rank test) (
Fig. 5).
Twenty of 32 (63%) patients who underwent trabec-
ulectomy with mitomycin C were successful compared
with 7 of 9 (78%) patients who received 5-fluorouracil
alone and 2 of 3 patients (67%) who received both 5-flu-
orouracil and mitomycin C. Mitomycin C and 5-fluoro- FIG. 2. The product-limit estimate for the cumulative probability
uracil were not analyzed statistically as mitomycin C was of success and months of follow-up after trabeculectomy in black
and white patients. The hash marks represent patients whose
used in cases deemed to be at higher risk for failure in trabeculectomies had not failed at the time of the last follow-up
this retrospective study. examination.

J Glaucoma, Vol. 11, No. 3, 2002

 ANTIPROLIFERATIVE AGENTS
FIG. 3. The product-limit estimate for the cumulative probability
success and months of follow-up after trabeculectomy in patients
with and without a history of incisional surgery. The hash marks
represent patients whose trabeculectomies had not failed at the
time of the last follow-up examination.
second trabeculectomy. Three patients who underwent
repeat trabeculectomy were lost to follow-up. Five of the
seven (71%) repeat trabeculectomies were successful at
1 year, with a mean postoperative follow-up of 12.9
months (range, 522 months).
The most common complications after trabeculectomy
FIG. 4. The product-limit estimate for the cumulative probability
of success and months of follow-up after trabeculectomy in pa-
tients with idiopathic uveitis, sarcoid uveitis, and arthropathy-
related uveitis. The hash marks represent patients whose trab-
eculectomies had not failed at the time of the last follow-up ex-
amination.
193
FIG. 5. The product-limit estimate for the cumulative probability
of success and months of follow-up after trabeculectomy in male
and female patients. The hash marks represent patients whose
trabeculectomies had not failed at the time of the last follow-up
examination.
were transient worsening of intraocular inflammation in
12 of 44 eyes (27%), serous choroidal detachments in 9
of 44 eyes (21%), shallow or flat anterior chamber in 7 of
44 eyes (16%) (4 of which required reformation), tran-
sient hyphema in 5 of 44 eyes (11%), and hypotony
maculopathy in 3 of 44 eyes (7%). One case of hypotony
maculopathy lost more than two lines of best-corrected
visual acuity. The following complications were also
noted: bleb encapsulation (2 of 44 eyes, 5%), dellen (2 of
44 eyes, 5%), malignant glaucoma (1 of 44 eyes, 2%),
cystoid macular edema (1 of 44 eyes, 2%), and late bleb
leak (1 of 44 eyes, 2%).
Thirty-one patients were phakic at the time of their
initial surgery at our institution, 16 (51.6%) of whom
developed new cataracts or had progression of preexist-
ing cataracts and underwent phacoemulsification with
posterior chamber intraocular lens implantation in the
presence of a functioning bleb, with good IOP and uve-
itis control. On average, the cataract surgery took place
13.7 months (range, 432 months) after trabeculectomy
and resulted in a mean improvement of 4.9 lines of best-
corrected Snellen visual acuity (range, 010 lines). Two
patients with advanced glaucoma or vitreoretinal pathol-
ogy did not experience objective improvement in best-
corrected visual acuity after cataract extraction. Four of
16 patients (25%) were noted to have failure of the fil-
tering bleb and loss of IOP control after cataract surgery,
necessitating repeat glaucoma surgery. In these four pa-
tients, the average postcataract extraction IOP was 25.1
mm Hg (range, 20.334.4 mm Hg) on an average of three
J Glaucoma, Vol. 11, No. 3, 2002
194 E. M. CEBALLOS
TABLE 4. Risk factors for trabeculectomy failure* (univariate analysis)
Factor Category
Gender Male
Female
Race Black
White
Uveitis Idiopathic
Herpetic
Sarcoid
Arthropathy
Previous incisional surgery Yes
No
* Initial trabeculectomy (n 44), percent failure without respect to time, P for 2 test.
glaucoma medications (range, 24). The mean postcata-
ract extraction time to trabeculectomy failure was 5.8
months (range, 015 months).
DISCUSSION
Other studies of trabeculectomy with antiproliferative
agents in uveitic patients have shown success rates rang-
ing from 50% to 90%, with lower success rates noted
with longer follow-up periods.712,15 Our cumulative
probability of success of 78% at 1 year and 62% at 2
years for trabeculectomy with antiproliferative agents
(Fig. 1) is less than the 78% success at 5 years for tra-
beculectomy without antiproliferative agents reported by
Stavrou and Murray6 using identical success criteria.
However, the patient population studied by Stavrou and
Murray was markedly different from ours, with a pre-
ponderance of white patients with no previous ocular
surgery. The authors speculated that the additional risk
factors of previous incisional surgery and Afro-
Caribbean race might lead to worse outcomes with tra-
beculectomy surgery in uveitic glaucoma.
Previous incisional surgery and black race have been
noted to be risk factors for failure of trabeculectomy
surgery in patients with glaucoma not associated with
uveitis.1922 Towler et al.12 reported 82% success at 2
years and 67% at 5 years with 5-fluorouracil trabeculec-
tomy in uveitic patients, noting significantly decreased
success in black patients compared with white and Asian
patients. We noted a cumulative probability of success of
74% at 2 years for white patients and 55% at 2 years for
black patients (Fig. 2). Our failure to document a statis-
tically significant difference between white and black
patients may have been because of our use of mitomycin
C with trabeculectomy (24 of 26 black patients vs. 10 of
16 white patients received mitomycin C), along with an
inadequate sample size. Our results with previous inci-
J Glaucoma, Vol. 11, No. 3, 2002
No. %
Eyes Failure P
14 57.1 0.04
30 23.3 0.57
25 40
16 31.3
23 47.8 0.19 idiopathic vs. sarcoid
3 33.3
9 22.2
5 20
14 35.7 0.9
30 33.3
sional surgery were paradoxical: patients without previ-
ous surgery had a lower success rate than those with
previous surgery (58% vs. 70%), though the difference
was not statistically significant (Fig. 3). Repeat trabecu-
lectomy on eyes that failed an initial trabeculectomy with
antiproliferative agents in our study showed a 71% cu-
mulative probability of success at 1 year, similar to our
results at 1 year with initial trabeculectomy.
A difference in outcome related to uveitis category
was noted, with a 74% success at 2 years for sarcoid-
related uveitis and a 45% success rate for idiopathic uve-
itis (Fig. 4). Although the difference between these two
groups was relatively large, a statistically significant dif-
ference was not noted, likely because of an inadequate
sample size despite an arbitrary grouping of uveitis type
into four categories.
A statistically significant difference in trabeculectomy
outcome was noted in our study, with a 39% success at
2 years in male patients compared with 71% in female
patients (P 0.02) (Fig. 5). Gender has not previously
been noted as a risk factor for trabeculectomy failure
and, this finding may be due to unequal sample size (30
female patients vs. 14 male patients), and to the fact that
a high percentage of male patients (8 of 14, 57%) had
idiopathic uveitis associated with a poor prognosis. Male
patients were also younger than female patients in our
study (42.0 vs. 49.9 years, P 0.19).
Cataract formation or progression was a frequent
event after trabeculectomy with antiproliferative agents
in our study, and 16 of 31 phakic patients (52%) required
cataract extraction. Cataract formation is a common
event in uveitic patients without glaucoma surgery due to
chronic inflammation or corticosteroid treatment.23 An
increased risk of cataract formation has been noted after
trabeculectomy in patients with normal-tension glau-
coma,24 and one study of 5-fluorouracil trabeculectomy
in uveitic patients reported cataract progression requiring
 ANTIPROLIFERATIVE AGENTS
cataract surgery in 7 of 10 phakic cases.8 The cataract
formation or progression noted in more than half of our
phakic patients was likely multifactorial due to the uve-
itic process, chronic corticosteroid treatment, or glau-
coma surgery. Management of such cases poses a treat-
ment dilemma between improvement of visual acuity
and possible loss of IOP control. Four of the 16 eyes
(25%) that underwent cataract extraction in our study
required repeat glaucoma surgery due to failure of the
filtering bleb and loss of IOP control, despite reinstitu-
tion of medical therapy. Cataract surgery after trabecu-
lectomy surgery is a risk factor for failure in uveitic
patients compared with patients with primary open-angle
glaucoma25. Cataract extraction combined with trabecu-
lectomy usually does not lower IOP as effectively as
trabeculectomy alone, though this procedure has not
been well studied in uveitic patients26,27. Combined cata-
ract extraction with an Ahmed glaucoma valve (New
World Medical, Rancho Cucamonga, CA) has been re-
ported to be successful in small numbers of eyes.16 Mol-
teno reported on 40 eyes of 35 patients who received a
single- or double-plate Molteno implant, and noted an
87% glaucoma control success rate at 5 years and a 77%
success at 10 years.28 Ten of 20 (50%) phakic eyes in
Moltenos study subsequently required cataract extrac-
tion, similar to the 52% noted in our study. Intraocular
pressure control was maintained in all 10 eyes after cata-
ract extraction28, similar to another study by Bhat-
tacharyya et al.29 addressing cataract extraction after
aqueous shunt placement. However, the corneal decom-
pensation rate of 27% (8 of 40 eyes) noted in Moltenos
paper is a complication well known to aqueous shunt
devices.2830 We are unable to comment on the decision
to perform trabeculectomy instead of an aqueous shunt
procedure on the basis of this study, because we per-
formed trabeculectomy with 5-fluorouracil or mitomycin
C as the initial glaucoma surgical therapy in all cases.
However, all of our patients had controlled uveitis. Hill
et al.31 noted that aqueous shunt devices were more
likely to control IOP than trabeculectomy when signifi-
cant postoperative inflammation was likely.
We report the results of a retrospective study of tra-
beculectomy surgery with antiproliferative agents, pri-
marily mitomycin C, in uveitic patients with medically
uncontrolled glaucoma. Our study suffers from limita-
tions that are common with retrospective studies, includ-
ing different surgeons and evolving antiproliferative
agent use in a nonrandomized fashion. Different concen-
trations or duration of mitomycin C application might
have led to different outcomes. We noted a statistically
significant decrease in the success rates of male patients.
Cataract formation or progression was a common occur-
195
rence after trabeculectomy with antiproliferative agents,
with relatively frequent loss of glaucoma control after
cataract surgery. The use of mitomycin C appears to
improve the chance of trabeculectomy success in black
patients with uveitis when compared with 5-fluoroura-
cil12. Further study is needed to clarify the role of anti-
proliferative agents in trabeculectomy for uveitic glau-
coma, the role of aqueous shunt devices, and surgical
strategies to avoid reoperation in patients with cataract
and uveitic glaucoma.
REFERENCES
1. Panek WC, Holland GN, Lee DA, et al. Glaucoma in patients with
uveitis. Br J Ophthalmol 1990;74:2237.
2. Krupin T, Dorfman NH, Spector SM, et al. Secondary glaucoma
associated with uveitis. Glaucoma 1988;10:8590.
3. Hoskins HD Jr, Hetherington J Jr, Shaffer RN. Surgical manage-
ment of the inflammatory glaucomas. Perspect Ophthalmol 1977;
1:17381.
4. Hill RA, Nguyen QH, Baerveldt G, et al. Trabeculectomy and
Molteno implantation for glaucomas associated with uveitis. Oph-
thalmology 1993;100:903908.
5. Stavrou P, Misson GP, Rowson NJ, et al. Trabeculectomy in uve-
itis: are antimetabolites necessary at the first procedure? Ocul Im-
munol Inflamm 1995;3:20916.
6. Stavrou P, Murray PI. Long-term follow-up of trabeculectomy
without antimetabolites in patients with uveitis. Am J Ophthalmol
1999;128:4349.
7. Jampel HD, Jabs DA, Quigley HA. Trabeculectomy with 5-fluo-
rouracil for adult inflammatory glaucoma. Am J Ophthalmol 1990;
109:16873.
8. Patitsas CJ, Rockwood EJ, Meisler DM, et al. Glaucoma filtering
surgery with postoperative 5-fluorouracil in patients with intraoc-
ular inflammatory disease. Ophthalmology 1992;99:5949.
9. Prata JA Jr, Neves RA, Minckler DS, et al. Trabeculectomy with
mitomycin c in glaucoma associated with uveitis. Opthalmic Surg
1994:25:61620.
10. Wright MM, McGehee RF, Pederson JE. Intraoperative mitomy-
cin-c for glaucoma associated with ocular inflammation. Ophthal-
mic Surg Lasers 1997;28:3706.
11. Towler HMA, Bates AK, Broadway DC, et al. Primary trabecu-
lectomy with 5-fluorouracil for glaucoma secondary to uveitis.
Ocul Immunol Inflamm 1995;3:16370.
12. Towler HMA, McCluskey P, Shaer B, et al. Long-term follow-up
of trabeculectomy with intraoperative 5-fluorouracil for uveitis-
related glaucoma. Ophthalmology 2000;107:18228.
13. Valimaki J, Airaksinen PJ, Tunlonen A. Molteno implantation for
secondary glaucoma in juvenile rheumatoid arthritis. Arch Oph-
thalmol 1997;115:12536.
14. DeMata A, Burk S, Netland PA, et al. Management of uveitic
glaucoma with Ahmed glaucoma valve implantation. Ophthalmol-
ogy 1999;106:216872.
15. Heuer DK, Parrish II RK, Gressel MG, et al. 5-Fluorouracil and
glaucoma filtering surgery: a pilot study. Ophthalmology 1984;91:
38493.
16. Kaplan EL, Meier P. Nonparametric estimation from incomplete
observations. J Am Stat Assoc 1958;53:45781.
17. Kalbfleisch JD, Prentice RL. The Statistical Analysis of Failure
Time Data. New York: John Wiley and Sons, 1980.
18. Fisher LD, Van Belle G. Biostatistics: A Methodology for the
Health Sciences. New York: John Wiley and Sons, 1993.
19. Heuer DK, Gressel MG, Parrish II RK, et al. Trabeculectomy in
aphakic eyes. Ophthalmology 1984;91:104551.
20. Tomey KF, Traverso CE. The glaucomas in aphakia and pseudo-
phakia. Surv Ophthalmol 1991;36:79112.
J Glaucoma, Vol. 11, No. 3, 2002
196 E. M. CEBALLOS
21. Freedman J, Shen E, Abrens M. Trabeculectomy in a black Ameri-
can glaucoma population. Br J Ophthalmol 1976;60:5734.
22. David R, Freedman J, Luntz MH. Comparative studies of Watsons
and Cairns trabeculectomies in a black population with open angle
glaucoma. Br J Ophthalmol 1977;61:1179.
23. Belfort R, Nusenblatt RB. Surgical approaches to uveitis. Int Oph-
thalmol Clin 1990;30:3147.
24. Collaborative Normal-Tension Glaucoma Study Group. The effec-
tiveness of intraocular pressure reduction in the treatment of nor-
mal-tension glaucoma. Am J Ophthalmol 1998;126:498505.
25. Chen PP, Weaver YK, Budenz DL, et al. Trabeculectomy function
after cataract extraction. Ophthalmology 1998;105:192835.
26. Shields MB. Another reevaluation of combined cataract and glau-
coma surgery. Am J Ophthalmol 1993;115:80611.
27. Park HJ, Weitzman M, Caprioli J. Temporal corneal phacoemul-
J Glaucoma, Vol. 11, No. 3, 2002
sification combined with superior trabeculectomy. Arch Ophthal-
mol 1997;115:31823.
28. Molteno ACB, Sayawat N, Herbison P. Otago glaucoma surgery
outcome study: Long-term results of uveitis with secondary glau-
coma drained by Molteno implants. Ophthalmology 2001;108:
60513.
29. Bhattacharyya CA, WuDunn D, Lakhani V, et al. Cataract surgery
after tube shunts. J Glaucoma 2000;9:4537.
30. Topouzis F, Coleman AL, Choplin N, et al. Follow-up of the
original cohort with the Ahmed Glaucoma Valve Implant. Am J
Ophthalmol 1999;128:198204.
31. Hill RA, Nguyen QH, Baerveldt G, et al. Trabeculectomy and
Molteno implantation for glaucomas associated with uveitis. Oph-
thalmology 1993;100:9038.