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CLINICAL SCIENCES

Postoperative Complications After GlaucomaSurgery for Primary Angle-Closure Glaucoma

vs Primary Open-Angle Glaucoma

Yar-Li Tan, MRCS; Pei-Fang Tsou, MBBS; Gavin S. Tan, MRCS; Shamira A. Perera, FRCOphth;Ching-Lin Ho, FRCS; Tina T. Wong, PhD, FRCS; Tin Aung, MBBS, PhD

Objectives: To investigate the incidence of postopera-tive complications arising in the first year after trabecu-lectomy and combined phacotrabeculectomy in eyes withprimary angle-closure glaucoma (PACG) vs those withprimary open-angle glaucoma (POAG).

Methods: This was a retrospective study of all glau-

coma operations done at a Singapore hospital from Janu-ary 9, 2001, to December 30, 2004. The types ofglaucomasurgery included trabeculectomy and phacotra-beculectomy, all with mitomycin C or fluorouracil. Theincidences of postoperative complications and reopera-tions were analyzed. For those who underwent bilateralor repeated operations, only thefirst operated eye of eachsubject was included.

Results: A total of 446 subjects with PACG (112 whounderwent trabeculectomy and 334 who underwentphacotrabeculectomy) and 816 subjects with POAG (208who underwent trabeculectomy and 608 who under-went phacotrabeculectomy) were analyzed. Postopera-

tive complications occurred in 65 of 1262 eyes (5.2%)overall, with 27 eyes (8.4%) in the trabeculectomy group(PACG: 8.0%; 95% confidence interval [CI], 4.3%-

14.6%; POAG: 8.7%; 95% CI, 5.5%-13.3%; P .99) and38 eyes(4.0%) in the phacotrabeculectomygroup (PACG:5.1%; 95% CI, 3.2%-8.0%; POAG: 3.5%; 95% CI, 2.3%-5.2%; P =.31). The rate of complications was signifi-cantly higher in the trabeculectomy group than thephacotrabeculectomy group overall (P =.003), but therewas no significant difference between the POAG and

PACG groups overall (POAG: 4.8%; 95% CI, 3.5%-6.5%; PACG: 5.8%; 95%CI, 4.0%-8.4%; P=.53). Thecom-monest complication found was hypotony with overfil-tration (23 cases [1.8%]), followed by bleb leak (11 cases[0.9%]). There was no significant difference in inci-dence of reoperations between POAG (2.7%; 95% CI,1.8%-4.1%) and PACG (4.0%; 95% CI, 2.6%-6.3%)(P =.27).

Conclusion: The incidences of postoperative complica-tions and reoperationsin the first year after glaucoma sur-gery were similar for PACG and POAG.

Arch Ophthalmol. 2011;129(8):987-992.Published online April 11, 2011.doi:10.1001/archophthalmol.2011.71

PR I M A R Y A N G L E -C L O S U R Eglaucoma (PACG) is a ma-jor form of glaucoma in EastAsian persons,1,2 while pri-mary open-angle glaucoma

(POAG) is the predominant form of glau-coma among Caucasian and Africanpersons.3,4 Recent glaucoma prevalencestudies in southern India found that the

prevalence of PACG in Indian persons isalso high.5,6 It is estimated that PACGblinds more people than POAG in abso-lute terms, although the number of thosewith POAG worldwide is higher.7 By 2020,PACG will affect 20 million people, and5.3 million will be blind.8

Laser peripheral iridotomy is the rec-ommended initial treatment for PACG. Itresults in the relief of pupil block. In casesrefractory to laser peripheral iridotomy and

medical therapy, often as a consequenceof angle closure associated with periph-eral anterior synechiae, filtering surgeryremains the only effective method to suf-ficiently lower the intraocular pressure(IOP) to a desirable level. The surgery of-ten consists of trabeculectomy alone orcombined phacotrabeculectomy. Bothsur-gical methods have been reported to be as-

sociated with postoperative complica-tions such as endophthalmitis, shallowanterior chamber and hypotony, aque-ous misdirection syndrome, choroidal de-tachment, and vision loss.9-11 However, asrecently emphasized in the consensusmeeting on angle-closure glaucoma orga-nized by the World Glaucoma Associa-tion in 2006,12 few data have been re-ported on the incidence of complicationsafter glaucoma surgery for PACG. There

Author Affiliations: SingaporeNational Eye Centre andSingapore Eye ResearchInstitute, Singapore.

ARCH OPHTHALMOL/ VOL 129 (NO. 8), AUG 2011 WWW.ARCHOPHTHALMOL.COM987

2011 American Medical Association. All rights reserved.

wnloaded From: http://archopht.jamanetwork.com/ on 08/06/2012


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is a clinical impression that glaucoma surgery for PACGis associated with greater risk of complications such ashypotony and malignant glaucoma, but to our knowl-edge a comparison of postoperative complication ratesin eyes with PACG and those with POAG has not beenperformed.

To address this, we aimed to investigate the inci-dence of postoperative complications arising in the firstyear after trabeculectomy and combined phacotrabecu-

lectomy in eyes with PACG and to compare it with thisincidence for POAG.

METHODS

Data were obtained from an audit of all glaucoma operationsdone for PACG and POAG at the Singapore National Eye Cen-tre during a 4-year period from January 9, 2001, to December30, 2004. For this audit, the incidences of complications andreoperations within the first year after surgery were obtainedindependently by the centers audit team from a review of allof the records approximately 1 year after the surgery, and theaudit team filled in a standardized audit sheet. The records ofpatients withpostoperative complications (identified by the au-dit) were then retrospectively reviewed by 2 of us (Y.-L.T. andP.-F.T.) to confirm the complication(s) identified. Collecteddata included patient demographic characteristics, glaucomadiagnosis, details of surgery, type of antiscarring agent used,postoperative complications, and additional operations or pro-cedures done. For those who underwent bilateral or repeatedoperations, we included only the first operated eye of each sub-

ject. Eyes that underwent surgery for acute primary angle clo-sure were also excluded. Institutional review board approvalwas obtained for the study.

Glaucoma was defined as the presence of glaucomatous op-tic neuropathy (defined as loss of neuroretinal rim with a verti-cal cup-disc ratio 0.7) and associated visual field loss. A glau-comatous visualfield defectwasnoted if thefollowing werefound:(1) glaucoma hemifield test results outside the reference range;(2) a cluster of 3 or more nonedge, contiguouspointson the pat-

tern deviation plot, not crossing the horizontal meridian with aprobabilityof less than 5% being present in age-matchedcontrolsubjects (1 of whichis1%); and(3) patternstandard deviationless than 0.05. These were repeatable on 2 separate occasions.13

We defined PACG as glaucoma in associationwith a closed angle(presence of180 of angle in which the posterior trabecularmeshwork was not visible on nonindentation gonioscopy) withor without peripheral anterior synechiae.

The surgical procedure and postoperative management werebroadly similar, although multiple surgeons (8 surgeons)wereinvolved in the operations and postoperative care. For trab-eculectomy, a fornix-based conjunctival flap was created su-peronasally or superotemporally. A partial-thickness scleral flapwas dissected to clear cornea. All cases receivedan applicationof either mitomycin C (0.2-0.4 mg/mL) or fluorouracil (25-50

mg/mL) for 1 to 3 minutes, followed by irrigation with 30 mLof balanced salt solution. A sclerostomy was then created inthe scleral bed, and a peripheral iridectomy wasperformed.Thescleral flap was sutured with 10-0 nylon, and the conjunctivawas then reapproximated with 10-0 nylon. For phacotrabecu-lectomy,similar steps as describedfor trabeculectomy were per-formed, but after irrigation of mitomycin C or fluorouracil, tem-poral clear corneal phacoemulsification with intraocular lensimplantation was performed. Sclerostomy and subsequent sur-gical steps were then performed as described previously.

Postoperative treatment included a topical antibiotic and atopical steroid for 8 to 12 weeks. Patients were seen on the first

postoperative day and thereafter depending on the clinicalcondition.

Statistical analysis was performedusing SPSS statistical soft-ware version 16.0 (SPSS Inc, Chicago, Illinois). We analyzedthe relationship between type of glaucoma and postoperativecomplicationas well as theneed for reoperation.We also strati-fied the analysis by type of operation performed. The Fisherexact test was used for comparison of categoricaldata. For quan-titative variables, a t test was done to compare means. Statis-tical significance was defined as P .05. Univariate logistic re-

gression was used to delineate the relationship betweenindividual risk factors and complications. A multivariate lo-gistic model including all statistically significant riskfactorswasthen performed to assess their independent effect.

RESULTS

A total of 446 subjects with PACG (112 who underwenttrabeculectomy and 334 who underwent phacotrabecu-lectomy) and 816 subjects with POAG (208 who under-went trabeculectomy and 608 who underwent phacotra-beculectomy) completed 1 year of follow-up and wereanalyzed. The demographic features and the antiscar-

ring agent used during surgery are summarized inTable 1. In both the trabeculectomy and phacotrabecu-lectomy groups, there were more men than women inthe POAG group (P .001) but more women than menin the PACGgroup (P.001). With regard to the use ofantiscarring agents, significantly more cases used mito-mycin C than fluorouracil in all of the groups (P =.008).

In our series, we found that postoperative complica-tionsoccurred in65eyes(5.2%)overall, with27eyes(8.4%)in the trabeculectomy group (PACG: 8.0%; 95% confi-dence interval [CI], 4.3%-14.6%; POAG: 8.7%; 95% CI,5.5%-13.3%; P.99) and 38 eyes (4.0%) in the phacotra-beculectomy group (PACG: 5.1%; 95% CI, 3.2%-8.0%;POAG: 3.5%; 95% CI, 2.3%-5.2%; P=.31). Theoverallrate

of complications was higher in the trabeculectomy groupthan in the phacotrabeculectomy group (P=.003). How-ever, as a whole, there was no significant difference in theincidenceof postoperative complications between thePOAGand PACG groups (POAG: 4.8%; 95% CI, 3.5%-6.5%;PACG: 5.8%; 95% CI, 4.0%-8.4%; P=.53).

The types of postoperative complications are summa-rized in Table 2. The commonest complication foundin our study was prolonged hypotony (defined as IOP5 mm Hg) due to overfiltration, which was recordedin 23 eyes (1.8%). In the trabeculectomy group, overfil-tration occurred in 4.5% (95% CI, 1.9%-10.0%) of eyeswith PACG and 1.9% (95% CI, 0.8%-4.8%) of eyes withPOAG (P =.32). In the phacotrabeculectomy group, the

incidences were 2.1% (95% CI, 1.0%-4.3%) in eyes withPACG and 1.2% (95% CI, 0.6%-2.4%) in eyes with POAG(P=.42). Bleb leak was the second commonest compli-cation found, with 11 reported cases (0.9%). This con-sisted of 7 cases (2.2%) amongthe trabeculectomy group(PACG: 0.9%; 95% CI, 0.2%-4.9%; POAG: 2.9%; 95% CI,1.3%-6.2%; P =.44) and 4 cases (0.4%) in the phacotra-beculectomy group (PACG: 0.6%; 95% CI, 0.2%-2.2%;POAG: 0.3%; 95% CI, 0.1%-1.2%; P=.88). The higher in-cidence of bleb leak in the trabeculectomy group thanin the phacotrabeculectomy group was found to be sta-





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tistically significant (P=.008). Aqueous misdirection syn-drome was found to be very rare in our series, occurringin only 1 eye with POAG following phacotrabeculec-tomy. With regard to infective complications, there were4 cases of endophthalmitis (3 with POAG and 1 with

PACG) and 2 cases of blebitis (both with POAG). Onepatient with POAG developed fluorouracil-related cor-nealepithelial toxic effects and another patient with PACGhad bleb hemorrhage, both after phacotrabeculectomy.

Overall, there was no difference in complication ratesbetween the mitomycin C and fluorouracil groups (mi-tomycin C: 5.9%; 95% CI, 4.5%-7.9%; fluorouracil: 4.0%;95% CI, 2.7%-4.0%; P =.17). However, the mitomycin Cgroup hadmore casesof overfiltration with hypotony thanthe fluorouracil group (mitomycin C: 2.6%; 95%CI, 1.7%-4.0%; fluorouracil: 0.8%; 95% CI, 0.3%-2.0%; P=.03).

Of the 65 eyes that encountered complications fol-lowing surgery, 40 eyes (3.2%) required a second opera-tion or procedure (Table 3). There were no significantdifferences comparing the overall incidence of reopera-tions between the glaucoma subtypes (POAG: 2.7%; 95%

CI,1.8%-4.1%; PACG: 4.0%; 95% CI,2.6%-6.3%; P=.27).However, there was a statistically significantly higher in-cidence of reoperations in the trabeculectomy group thanin the phacotrabeculectomy group (trabeculectomy: 5.0%;95% CI, 3.1%-8.0%; phacotrabeculectomy: 2.6%; 95% CI,1.7%-3.8%; P =.048). Twenty eyes (1.6%) with overfil-tration subsequently underwent revision of trabeculec-tomy with anterior chamber re-formation. This con-sisted of 6 in the trabeculectomy group (PACG: 3.6%;95% CI, 1.4%-8.8%; POAG: 1.0%; 95% CI, 0.3%-3.5%;P=.23)and14 in the phacotrabeculectomy group (PACG:

Table 1. Demographic Features of Study Patients and the Antimetabolite Used During Surgery

Characteristic

Trabeculectomy(n = 320)

Phacotrabeculectomy(n = 942)

Total(N = 1262)

POAG(n = 208)

PACG(n = 112)

POAG(n = 608)

PACG(n = 334)

Sex, No. (%)

Male 152 (73.1) 47 (42.0) 354 (58.2) 108 (32.3) 661 (52.4)

Female 56 (26.9) 65 (58.0) 254 (41.8) 226 (67.7) 601 (47.6)

Age, mean, y 56.9 58.3 70.3 69.1 63.7Race, No. (%)

Chinese 173 (83.2) 98 (87.5) 485 (79.8) 296 (88.6) 1052 (83.4)

Malay 18 (8.7) 6 (5.4) 42 (6.9) 20 (6.0) 86 (6.8)

Indian 11 (5.3) 6 (5.4) 54 (8.9) 9 (2.7) 80 (6.3)

Other 6 (2.9) 2 (1.8) 27 (4.4) 9 (2.7) 44 (3.5)

Antiscarring agent, No. (%)

Mitomycin C 153 (73.6) 66 (58.9) 318 (52.3) 204 (61.1) 741 (58.7)

Fluorouracil 55 (26.4) 46 (41.1) 290 (47.7) 130 (38.9) 521 (41.3)

Abbreviations: PACG, primary angle-closure glaucoma; POAG, primary open-angle glaucoma.

Table 2. Postoperative Complication Rates After Glaucoma Surgery

Complication

No. (%)



Total(N = 1262)

POAG(n = 208)

PACG(n = 112)

POAG(n = 608)

PACG(n = 334)

Overfiltration with hypotony or shallowanterior chamber, IOP5 mm Hg

4 (1.9) 5 (4.5) 7 (1.2) 7 (2.1) 23 (1.8)

Bleb leaka 6 (2.9) 1 (0.9) 2 (0.3) 2 (0.6) 11 (0.9)

Gross hyphema 2 (1.0) 2 (1.8) 4 (0.7) 2 (0.6) 10 (0.8)

Endophthalmitis 2 (1.0) 0 1 (0.2) 1 (0.3) 4 (0.3)

Blebitis 2 (1.0) 0 0 0 2 (0.2)

Conjunctival retraction requiring resuturing 0 1 (0.9) 1 (0.2) 1 (0.3) 3 (0.2)

Severe postoperative inflammation 0 0 2 (0.3) 1 (0.3) 3 (0.2)

Iris prolapse 1 (0.5) 0 0 1 (0.3) 2 (0.2)

Retinal detachment 0 0 1 (0.2) 1 (0.3) 2 (0.2)Hemispheric vein occlusion 1 (0.5) 0 1 (0.2) 0 2 (0.2)

Aqueous misdirection syndrome 0 0 1 (0.2) 0 1 (0.1)

Others 0 0 1 (0.2) 1 (0.3) 2 (0.2)Subtotal 18 (8.7) 9 (8.0) 21 (3.5) 17 (5.1) 65 (5.2)

Total 27 (8.4)a 38 (4.0)a 65 (5.2)

Abbreviations: IOP, intraocular pressure; PACG, primary angle-closure glaucoma; POAG, primary open-angle glaucoma.a P .05.





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2.1%; 95% CI, 1.0%-4.3%; POAG: 1.2%; 95% CI, 0.6%-2.4%; P=.38). Furthermore, another 10 eyes that devel-

opedblebleakrequiredconjunctival repair. Scleral bucklewith trans pars plana vitrectomy was performed in 2 eyesthat developed retinal detachment at postoperative weeks5 and 7. Three of the 5 eyes that developed endophthal-mitis underwent trans pars plana vitrectomy. One pa-tient who developed severe endophthalmitis had to un-dergo evisceration. The 1 subject who developedaqueousmisdirectionsyndromewas successfully treated withYAGcapsulotomy and trans pars plana vitrectomy.

Logistic regression analysiswas usedto investigate riskfactors for postoperative complications or need for re-operations. After adjusting for age and sex, combinedphacotrabeculectomy was associated with lower risk ofany complication (odds ratio [OR]=0.467; P =.01), hy-

potony (OR= 0.356;P =.01), and endophthalmitis or ble-bitis (OR=0.256; P =.03) compared with trabeculec-tomy.Combined phacotrabeculectomy was also associatedwith fewer reoperations (OR=0.452; P =.04), while useof mitomycin C was associated with more reoperationsthan use of fluorouracil (OR=2.373; P =.02). On thewhole, PACG was not found to have any significant as-sociation with risk of complications or reoperations com-pared with POAG. On multivariate analysis, combinedphacotrabeculectomy was associated with lower risk ofany complication (OR = 0.482; P =.02), hypotony(OR=0.373; P =.02), and endophthalmitis or blebitis(OR=0.293;P=.04) compared with trabeculectomy.How-ever, there was no significant association with reopera-tions. Use of mitomycin C as an adjuvant was still asso-ciated with higher risk of reoperations than use offluorouracil (OR=2.285; P=.03).

COMMENT

In this study,the overall incidences of postoperative com-plications in the first year after glaucoma filtering sur-gery for PACG and POAG were comparable. There wasno significant difference between the PACG and POAG

groups overall or between the trabeculectomy andphacotrabeculectomy groups. Many of the complica-

tions found were caused by specific problems usually un-related to the underlying diagnoses. We found that tra-beculectomy resulted in a significantly higher overallreported incidence of postoperative complications com-paredwithphacotrabeculectomy (P=.003). However,sta-tistical analyses between the 2 groups yielded no signifi-cant differences for individual complications except forbleb leak (P =.008). The reason for this is unknown. In-terestingly, we found that there was a slightly higher in-cidence of overfiltration with hypotony in the trabecu-lectomy group than in the phacotrabeculectomy group,but thisdifference was not statisticallysignificant (P=.21).We speculate that in cases of phacotrabeculectomy, vis-coelastic material may have been left in the eye at the endof surgery either intentionally or unintentionally, therebyreducing the risk of hypotony. However, a prospectivereview of a larger group of patients would be requiredto confirm these findings.

The use of antiscarring agents fluorouracil and mito-mycin C has been shown in clinical trials to increase thesuccess rate of filtering operations.14-17 Although effec-tive in lowering IOP, their use has been associated withsight-threatening complications such as endophthalmi-tis and blebitis.18,19We found a fairly low rate of endoph-thalmitis (0.3%) in our study. In several studies, the re-ported incidence of postoperative bleb-related infectionsranged from 0.4% to 6.9%, with a composite incidence

of 1.5% per year. This incidence is likely to increase withgreater use of these agents intraoperatively.20 The over-all incidence of 0.5% for bleb-related infections withinthe first year after surgery in our patients is lower thanthat reported from previous studies.21-23 The incidenceof infections (as logically expected) was also compa-rable between PACG and POAG and between trabecu-lectomy and phacotrabeculectomy. However, a previ-ous study by Jampel et al21 suggested that combinedphacotrabeculectomy may be protective against the de-velopment of infection. Generally, bleb-related infec-

Table 3. Reoperations Required

Procedure Performed in Reoperation

No. (%)



Total(N = 1262)

POAG(n = 208)

PACG(n = 112)

POAG(n = 608)

PACG(n = 334)

Anterior chamber re-formation or revision

of trabeculectomy

2 (1.0) 4 (3.6) 7 (1.2) 7 (2.1) 20 (1.6)

Repair of bleb leak or conjunctivalresuturing

4 (1.9) 1 (0.9) 3 (0.5) 2 (0.6) 10 (0.8)

Iris repositioning 1 (0.5) 0 0 1 (0.3) 2 (0.2)

Trans pars plana vitrectomy 2 (1.0) 0 2 (0.3) 2 (0.6) 6 (0.5)

Autologous blood injection 0 1 (0.9) 0 0 1 (0.1)

Evisceration 1 (0.5) 0 0 0 1 (0.1)Subtotal 10 (4.8) 6 (5.4) 12 (2.0) 12 (3.6) 40 (3.2)

Total 16 (5.0)a 24 (2.6)a 40 (3.2)

Abbreviations: PACG, primary angle-closure glaucoma; POAG, primary open-angle glaucoma.a P .05.





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tions occur several years after the initial surgery and, asstated earlier, there is a cumulative risk. This could ex-plain why we did not find many bleb-related infectionsin our study with our short postoperative follow-up of 1year. We also found that there was a higher incidence ofoverfiltration with hypotony and shallow anterior cham-ber in the mitomycin C group than in the fluorouracilgroup (P=.03). This is also not surprising as previous stud-ieshave shown that mitomycin C use hassignificant com-

plications such as excessive hypotony with choroidal ef-fusions and irreversible maculopathy.18,24,25

A few previous studies have reported surgical out-comes and complications after glaucoma surgery in eyeswith PACG,26-28 but no study to our knowledge has com-pared patients with PACG vs patients with POAG. In oneseries by Tsai et al,26 the long-term efficacy and safety ofcombined phacotrabeculectomy were compared withthose of trabeculectomy alone for PACG. A total of 16of 75 eyes (21.3%) in the phacotrabeculectomy group and8 of 24 eyes (33.3%) in the trabeculectomy group expe-rienced postoperative complications. This complicationrate was far higher than our findings. Among these were2 cases (2.7%) of shallow anterior chamber or hypotony

in the phacotrabeculectomy group and 3 cases (12.5%)in the trabeculectomy group.Hyphema occurred in 6 eyes(8.0%) that underwent phacotrabeculectomy and 1 eye(4.2%) that underwent trabeculectomy. There were nocases of wound leak, blebitis, endophthalmitis, or aque-ousmisdirection syndrome.The higher incidence of shal-low anterior chamber or hypotony in the trabeculec-tomy group as compared with the phacotrabeculectomygroup was also seen in our study (9 [2.8%] and 14[1.5%],respectively). Another study of trabeculectomy for acuteprimary angle closure also found much higher compli-cation rates than our study.28 In particular, 19.6% hadshallow anterior chamber and 12.5% had hyphema, whilethe corresponding figures for our study were 4.5% and

1.8%, respectively. The high complication rate of trab-eculectomy for acute primary angle closure in that studyis perhaps not surprising owing to the high risk of op-erating in these acutely inflamed eyes with markedly in-creased IOP. Hence, in our study, we excluded eyes withprevious acute primary angle closure so as not to con-found our results.

Our series is one of the largest analyzing Asian eyes,with a significant proportion of patients with PACG. Theaudit of complications in the records was standardizedfor all patients. The Singapore National Eye Centre hasa 100% audit of glaucoma surgery complications, and webelieve that these data accurately reflect postoperativecomplication rates after glaucoma surgery. However, any

retrospective review has its own set of limitations. Therewere multiple surgeons involved in the operations andpostoperative management of the patients. The choiceof surgery may have been affected by the complexity ofthe patients condition, and combined surgery may havebeen performed more often in less complicated cases.There may be underreporting of complications, al-though this was performed by an independent retrospec-tive audit. Twenty percent of patients were lost to fol-low-up within thefirst year, andthis couldhave decreasedour reported complication rates. Some eyes may have had

a bleb needling procedure with subconjunctival fluoro-uracil injections, the removal of conjunctival sutures, orsuture lysis, all of which may have influenced the rate ofcomplications, in particular the rates of bleb-related in-fections and overfiltration. However, these data were notavailable for analysis. Finally, we did not investigate thesurgical outcomes such as IOP results; these will be ex-amined as part of future work.

In conclusion, patients with PACG were not found to

have any higher incidence of postoperative complica-tions after either trabeculectomy or phacotrabeculec-tomy than patients with POAG. The rates of postopera-tive complications andreoperationswere found to be low,and serious complications such as aqueous misdirec-tion syndrome were rare in eyes with PACG undergoingglaucoma filtering surgery. Combined phacotrabeculec-tomy was associated with an overall lower risk of com-plications than trabeculectomy.

Submitted for Publication: October 26, 2010; final re-vision received January 25, 2011; accepted February 20,2011.Published Online: April 11, 2011. doi:10.1001

/archophthalmol.2011.71Correspondence: Tin Aung, MBBS, PhD, Singapore Na-tional Eye Centre, 11 Third Hospital Ave, Singapore168751 ([email protected]).Financial Disclosure: None reported.Funding/Support: Thisworkwas supportedby a grantfromthe National Medical Research Council, Singapore.

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Many communications,besides my own, haveappeared to show what changes are pro-duced in the membranes of the eye by thepresence of a cysticercus. However, thesewere observations made on eyes which hadundergone extensive changes, sometimesatrophic, sometimes purulent, which were

enucleated months and years after invasionof the eye by the parasite. None were basedupon the early stages of the invasion of thevitreous by the cysticercus. It is clear thatthese histologic findings are not suited toshow us which changes are really due to theaction of the parasite, and which are due tothe mere presence of the cysticercus actingas a foreign body.

Source: Cirincione. Early changes occasioned bythe invasion of the eye by the cysticercus. ArchOphthalmol. 1911;40:163.



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