CASE REPORTS AND SMALL CASE SERIES UnoprostoneLatanoprost Unoprostone Increase of Intraocular 60 Pressure After Topical Cyclophotocoagulation Administration of 50 Prostaglandin Analogs 40 Several prostaglandins have been demonstrated to reduce intraocular 30 pressure (IOP) in normal, hyperten- sive, and glaucomatous eyes.1-3 Two mm Hg IOP, OD 20 different prostaglandin analogs are commercially available: unopros- 10 tone (Rescula; Ciba Vision Ophthal- OS mics, Duluth, Ga) and latanoprost (Xalatan; Pharmacia Inc, Colum- 0 October 5, 1996 October 10, 1996 October 2, 1997 October 7, 1997 bus, Ohio). We observed an inverse Time reaction after topical administration Time course of intraocular pressure (IOP) for both eyes. Arrows indicate application of prostaglandin of both analogs. derivates or cyclophotocoagulation only of the left eye. Report of a Case. A 29-year-old wom- an had retinitis pigmentosa with of treatment with unoprostone, the and visual acuity increased to 6/20 typical ophthalmoscopic findings, a IOP returned to 15 mm Hg. During (Figure). ring scotoma, and a flat electro- the following weeks the IOP again There were no signs of acute retinogram. Juvenile glaucoma was ranged between 1 and 35 mm Hg. anterior segment inflammation af- diagnosed at the age of 12 years. Be- Five months after this trial with uno- ter the prostaglandin applications. A cause of the characteristic malforma- prostone, another prostaglandin ana- marked atrophy of the ciliary body tion of the anterior segment it was log, latanoprost, became available. At was observed with high-resolution classifiedasRiegersyndrome.Theini- this time, the IOP again was about 30 ultrasound biomicroscopy. tial IOP at the time of glaucoma de- mm Hg despite maximum tolerated tection was 50 mm Hg. Both eyes un- medical therapy without prostaglan- Comment. In the literature, we could derwent Elliot operation. The left eye din analogs. As with unoprostone, the not find any other reports of seri- required an additional cryocoagula- IOP immediately increased to 55 ous, reproducible IOP increase after tion of the ciliary body. After these mm Hg after 2 drops of latanoprost. unoprostone or latanoprost admin- operations, the IOP of the right eye This increase of IOP was again ac- istration. These prostaglandin ana- was between 8 and 14 mm Hg with- companied by corneal edema and a logs are known to be safe and effec- out further medication. The IOP of decrease in visual acuity. With intra- tive in reducing IOP.1-3 It is presumed the left eye was below 21 mm Hg un- venous 20% mannitol, the IOP rap- that they facilitate the uveoscleral out- til the patient was 26 years old. The idly dropped to 20 mm Hg and later flow, whereas trabecular outflow may IOP then began to increase, and a sec- returned to 30 mm Hg. be slightly impaired.4 One might ond cryocoagulation was performed. We now decided to perform a speculate that, in our patient, uveo- After the second cryocoagulation, the stepwise diode laser cyclophotoco- scleral outflow was considerably al- IOP varied between 0 mm Hg (with- agulation. After 4 treatments with 2 terated by the disease itself (Rieger out therapy) and 41 mm Hg OS (with burns each, the IOP ranged be- syndrome and retinitis pigmentosa) maximum tolerated medical therapy tween 10 mm Hg and 20 mm Hg OS. or by the cryoprocedures. The atro- without prostaglandin analogs). At However, 5 months after the last phy of the ciliary body supports this this time visual acuity was 6/30 OD laser treatment, IOP decreased to 0 theory. Because of these alterations, and 6/12 OS. mm Hg and remained at this hypo- prostaglandins perhaps could not fur- After a 9-week period of IOP tonous level for 3 weeks. Treatment ther improve uveoscleral outflow. values between 30 and 34 mm Hg OS, with systemic and local steroids failed Thus, the slight impairment of tra- we decided to try an additional treat- to increase IOP, and visual acuity was becular outflow could have caused ment of 2 drops of unoprostone, 1 in only 6/120. This was the reason why the IOP increase. the morning and 1 in the evening. In we now tried to elevate IOP using less than 24 hours, the IOP in- prostaglandin analogs. In fact, after Thomas Ness, MD creased to 56 mm Hg, accompanied 2 drops of unoprostone, IOP in- Jens Funk, PhD, MD by corneal edema. After withdrawal creased to 55 mm Hg within 36 hours Freiburg, Germany ARCH OPHTHALMOL / VOL 117, DEC 1999 WWW.ARCHOPHTHALMOL.COM 1646 ©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 Corresponding author: Thomas Ness, Treatment with topical 0.5% levobu- OD and 38 cm/s OS and central reti- MD, Universita¨ts-Augenklinik nolol and 0.2% bromonidine and nal artery blood flow velocities of Freiburg, Killianstr. 5, D-79106 oral neptazane was initiated. The in- 15.26 cm/s OD and 11.89 cm/s OS. Freiburg, Germany. traocular pressure stabilized in the The intraocular pressure in the left low 20s and visual acuity remained eye at the time of the postoperative 1. Alm A, Stjernschantz J. Effects on intraocular pressure and side effects of 0.005% latanoprost counting fingers OS at 0.3 m due to color Doppler study was un- applied once daily, evening or morning. Oph- a central corneal scar. changed at 22 mm Hg. The blood thalmology. 1995;102:1743-1752. Approximately 3 months after pressure and heart rate were ap- 2. Fujimori C, Yamabayashi S, Hosoda M, et al. The clinical evaluation of UF-021, a new prostaglan- the retinal detachment repair, the pa- proximately the same. din-related compound, in low-tension glau- tient complained of a several-day his- coma. Nippon Ganka Gakkai Zasshi. 1993;97: 1231-1235. tory of episodic transient visual loss Comment. To our knowledge, this 3. Ziai N, Dolan JW, Kacere RD, Brubaker RF. The (to the level of bare light percep- is the first reported case of a patient effects on aqueous dynamics of PhXA41, a new tion) in her left eye that occurred who experienced episodes of tran- prostaglandin F2 alpha analogue, after topical application in normal and ocular hypertensive when she stood from a seated or su- sient visual loss associated with human eyes. Arch Ophthalmol. 1993;111:1351- pine position. She had recently re- documented orbital hemodynamic 1358. 4. Gabelt BT, Kaufman PL. The effect of prosta- sumed normal daily physical activi- changes after scleral buckling with glandin F2 alpha on trabecular outflow facility ties after being restricted in the an encircling element. Presumably, in cynomolgus monkeys. Exp Eye Res. 1990;51: postoperative period. The episodes central retinal artery blood flow, and 87-91. were reproducible and she experi- possibly ophthalmic artery blood enced up to 10 of these episodes flow, was significantly reduced as a daily, with each episode lasting 2 to result of the encircling procedure 3 minutes. and orthostatic decreases in blood Transient Visual Loss and Examination at that time re- pressure caused a further decrease Decreased Ocular Blood vealed visual acuities of 20/20 OD in ocular perfusion. The episodes of Flow Velocities Following a and finger counting at 0.3 m OS. transient visual loss resulted from Scleral Buckling Procedure Goldmann applanation tonometry the decreased ocular perfusion. Re- revealed an intraocular pressure of moval of the encircling band re- Scleral buckling procedures with en- 23 mm Hg OS that was confirmed sulted in a resolution of the tran- circling elements have been shown by the Tonopen tonometer. The an- sient visual loss episodes and a to decrease blood flow velocities in terior segment examination re- corresponding normalization of the the central retinal artery but, in most vealed a central corneal scar with a central retinal artery and other ret- cases, leave the ophthalmic artery deep and quiet anterior chamber. robulbar artery hemodynamic pa- unaffected.1 Although these hemo- The retina was completely attached rameters as measured with color dynamic changes are well docu- with a normal-appearing posterior Doppler imaging. mented with otherwise successful pole. A moderately high 360° scleral Decreased retinal artery blood scleral buckling procedures, they are buckle indentation effect was evi- flow rate and velocity is a recog- rarely symptomatic. We report the dent peripherally. Her blood pres- nized effect of scleral buckling pro- case of a young woman who devel- sure was 110/70 mm Hg in the right cedures with encircling elements. On oped episodes of posturally related and left arms without orthostatic average, a 50% decrease in blood transient visual loss following a changes. flow velocities with an accompa- scleral buckling procedure with an Color Doppler imaging was nied increase in resistance has been encircling element. performed on the right and left eyes demonstrated in the major tempo- and revealed ophthalmic artery ral arteries and in the central reti- Report of a Case. A 26-year-old systolic blood flow velocities of 45 nal artery following scleral buck- woman had undergone surgical re- cm/s OD and 10 cm/s OS (normal ling and encircling procedures, as pair of a 12-mm full-thickness cor- mean ± SD: 31.3 ± 4.2 cm/s). The measured by laser Doppler tech- neoscleral laceration in the left eye central retinal artery blood flow ve- niques and color Doppler imag- 6 months previously. The lacera- locities were 11.0 cm/s OD and less ing.1-4 Findings on fluorescein an- tion extended from the superior lim- than 2 cm/s OS (normal mean ± SD: giography also indicate that retinal bus to the inferior limbus. Two 10.1 ± 1.9 cm/s). During the next and choroidal circulation is dimin- months after the ruptured globe re- week, the episodes of transient vi- ished by scleral buckling proce- pair, she developed an inferior sual loss increased in frequency and dures and encircling elements.5 De- macula-on retinal detachment, duration and the patient elected to spite the marked hemodynamic which was treated with pars plana undergo excision of the encircling alterations, most patients seem clini- vitrectomy and scleral buckling with element.