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Background/aims: To determine the mortality within 20 years of diagnosis of chronic open-angle glaucoma (COAG) and visual acuity and visual field progression of a cohort followed for 20 years., Methods: Twenty years following the diagnosis of COAG in 68 of 436 (16%) patients seen in a glaucoma case-finding clinic, visual and mortality outcomes were audited from medical records. Causes of death were obtained from general practitioner records and death certificates. Probability of death was calculated using a Kaplan-Meier survival curve. The visual field of each eye of survivors was graded using a nine-stage severity scale. Visual outcome was analysed at the 20-year follow-up visit., Results: From 68, 14 (21%) were lost to follow-up. In the remaining 54, 20 (37%) were alive 20 years after diagnosis. Of 63% who died, mean age of death was 84 years, most commonly due to vascular disease. Mean age at presentation of those who died was 73.7 years versus 63.2 years for survivors (P=0.001). The median time to death was 16 years. On visual field analysis, nearly half (48.9%) of eyes did not deteriorate, but 28.3% eyes deteriorated by more than two stages. Those who died had worse final visual acuity than survivors (P<0.001). Three who died were registered severely visually impaired mainly from macular disease, but no survivors were registered (P<0.001)., Conclusion: In this cohort, approximately two-thirds of patients with glaucoma died within 20 years of diagnosis. In most older patients with glaucoma, the overall goal of preventing visual handicap and blindness is achievable 20 years after diagnosis., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Importance: Ocular surface disease (OSD) is common and can reduce treatment compliance and quality of life., Background: To determine whether a punctal plug improves OSD and reduces intraocular pressure (IOP) in patients using prostaglandin analogue monotherapy., Design: Randomized controlled trial., Participants: Sixty eligible subjects aged >18 years with symptomatic OSD from glaucoma clinics were invited to participate. Lacrimal or glaucoma surgery, lid malposition and contact lens wear were exclusion criteria., Methods: One eye received an inferior punctal plug, leaving the fellow eye as a control., Main Outcome Measures: Ocular surface disease index (OSDI), tear film breakup time (TF-BUT), Oxford cornea score, tear osmolarity and IOP were compared at baseline and 6 weeks by masked investigators., Results: From 60 eligible, 48 (80.0%) participated (mean age 69.6 years; 60.0% female). OSDI reduced following plug insertion (mean difference [MD] 14.5, 95% confidence interval [CI] 5.06-23.94, P < 0.001). Compared to control eyes, in eyes receiving plugs the TF-BUT increased (MD 2.3 s, 95% CI 1.4-3.2, P < 0.001), the Oxford cornea score decreased (MD 0.5, 95% CI 0.3-0.7, P < 0.001), and tear osmolarity decreased (MD 10 mOsm/L, 95% CI 3.5-16.5, P = 0.003). Punctal plugs resulted in a significantly lowered IOP (MD 1.5 mmHg, 95% CI 0.1-2.9, P = 0.032). Sub-group analyses showed similar efficacy regardless of prostaglandin preservative status or lubricant drop use. Plugs were well tolerated but extrusion occurred in 8.5%, and epiphora increased in 6.5% eyes., Conclusions and Relevance: Punctal plug insertion improves subjective and objective measures of OSD and results in a reduced IOP in patients with symptomatic ocular surface disease using prostaglandin analogue monotherapy., (© 2018 Royal Australian and New Zealand College of Ophthalmologists.)

Purpose: To determine whether microperimetry or optical coherence tomography (OCT) imaging can detect early disease in the fellow eye of patients with unilateral focal ischaemic glaucoma., Methods: Thirty-seven consecutive adult patients with unilateral focal ischaemic glaucoma with a unilateral split-fixation visual field defect on standard automated perimetry (SAP) with normal SAP in the fellow eye were selected. All patients underwent microperimetry (MAIA, CenterVue, Italy) of the central 10 degrees and OCT imaging (Spectralis, Heidelberg Engineering, Germany) of the retinal nerve fibre layer of both eyes. The main outcome measures were reduced retinal sensitivity on microperimetry and/or retinal nerve fibre layer thinning on OCT imaging of the fellow eye., Results: Thirty fellow eyes had abnormal global thresholds on microperimetry, and 20 had abnormal OCT imaging studies. Kappa agreement between tests in fellow eyes was poor (p = 0.2546). Fixation was significantly poorer in fellow eyes on microperimetry when compared to eyes with glaucoma (p < 0.003). In the fellow eyes that were abnormal, microperimetry identified reduced retinal sensitivity at fixation., Conclusion: Microperimetry detects reduced retinal sensitivity close to fixation and OCT detects focal thinning of the retinal nerve fibre layer in the fellow eye of most patients with presumed unilateral focal ischaemic glaucoma. Further studies are required to correlate specific optic disc features on OCT imaging with microperimetry in the fellow eye of this patient group.

Purpose: To determine the functional and structural effects of trabeculectomy surgery on patients with advanced glaucoma and central visual field defects in the early post-operative period., Methods: Thirty consecutive adult subjects with advanced glaucoma requiring trabeculectomy surgery and an established visual field defect within 10° of fixation underwent microperimetry (MAIA MP-1, CenterVue, Padova, Italy) and optic disc optical coherence tomography (OCT) imaging (Spectralis, Heidelberg Engineering, Germany) pre-operatively, and 1 month and 3 months following trabeculectomy surgery. Main outcome measures were post-trabeculectomy change in mean threshold on microperimetry and nerve fibre layer thickness on OCT. Fellow eyes were used as controls., Results: The mean change in MP average threshold values from pre-operative to post-operative was 0.6 ± 1.9 dB for treated eyes and 0.1 ± 1.3 dB for control eyes (p = 0.14) at 1 month and 0.2 ± 2.3 and -0.3 ± 1.6 dB at 3 months (p = 0.22). Mean change in global nerve fibre layer thickness was -0.6 and -0.5 µm for operated and control eyes, respectively (p = 0.83), at 1 month and 0.8 and -0.4 µm at 3 months (p = 0.88). The kappa agreement for structure-function correlation between OCT and MP was 0.735 (confidence interval 0.59-0.88) (p < 0.005)., Conclusions: Central visual function and retinal nerve fibre layer thickness appear to be preserved in glaucoma patients with central visual field defects undergoing trabeculectomy surgery in the early post-operative period. These data may inform glaucoma surgeons considering trabeculectomy surgery in this patient group.

Introduction: The evidence for low cerebrospinal fluid pressure (CSFP) as a key parameter in the pathogenesis of glaucoma is increasing. Primate models have demonstrated the onset normal tension glaucoma (NTG) from experimentally induced chronic intrathecal hypotension; an approach not possible in human subjects., Case Presentation: A 27-year-old man presented with a central scotoma in his left eye. He had undergone 8 CSF shunt revision procedures over a 25-year period secondary to recurrent low CSFP following surgical excision of a pinealoblastoma, aged 2. A focal nerve fiber layer defect was detected in the left eye associated with reduced retinal sensitivity on microperimetry. Three adjacent optic disc hemorrhages had been documented in the same position over an 18-month period. A diagnosis of left-sided NTG was made; the patient was started on Latanoprost 0.005%. A new generation CSF shunting device (ProGAV)-which neutralizes CSFP fluctuations analogously to trabeculectomy surgery for intraocular pressure-was considered necessary in this patient to alleviate persistent headaches and reduce the risk of progressive glaucomatous visual loss., Conclusions: This exceptional case illustrates how premature onset NTG may occur as a result of chronic, recurrent intrathecal hypotension-a "pure" human model. We describe an original management approach of implanting an adjustable, programmable CSF shunt valve (ProGAV) to reduce fluctuations in the translaminar cribrosa pressure difference, and reduce the risk of glaucomatous visual loss.

Background: Iridoschisis is a rare disorder characterized by splitting of the anterior and posterior iris stroma, resulting in disintegrated iris fibrils which float freely in the anterior chamber. We report an exceptional case of bilateral iridoschisis occurring in conjunction with keratoconus and severe allergic eye disease., Case Presentation: A 24-year-old white man had had periocular contact dermatitis and allergic eye disease from the age of 3 years. He was allergic to grass, animal hair, and pollen and worked grooming horses. He compulsively rubbed his eyes. There was no history of previous blunt trauma to either eye. There were signs of bilateral iridoschisis and keratoconus with allergic conjunctivitis, all of which were more severe in his right eye. An open drainage angle was identified bilaterally on gonioscopy, excluding primary angle closure. There was no evidence of glaucoma in either eye., Conclusions: There are two previous cases reporting the combination of iridoschisis and keratoconus, but no clear common etiology has been identified. In this case there was no evidence of angle closure but there were signs of allergic conjunctivitis. This amalgamation of signs might be explained on the basis of habitual eye rubbing. Treating the allergic eye disease has attenuated this behavior.

Primary angle closure glaucoma (PACG) is a major cause of blindness worldwide. We conducted a genome-wide association study (GWAS) followed by replication in a combined total of 10,503 PACG cases and 29,567 controls drawn from 24 countries across Asia, Australia, Europe, North America, and South America. We observed significant evidence of disease association at five new genetic loci upon meta-analysis of all patient collections. These loci are at EPDR1 rs3816415 (odds ratio (OR) = 1.24, P = 5.94 × 10(-15)), CHAT rs1258267 (OR = 1.22, P = 2.85 × 10(-16)), GLIS3 rs736893 (OR = 1.18, P = 1.43 × 10(-14)), FERMT2 rs7494379 (OR = 1.14, P = 3.43 × 10(-11)), and DPM2-FAM102A rs3739821 (OR = 1.15, P = 8.32 × 10(-12)). We also confirmed significant association at three previously described loci (P < 5 × 10(-8) for each sentinel SNP at PLEKHA7, COL11A1, and PCMTD1-ST18), providing new insights into the biology of PACG.

Persistent hyperplastic primary vitreous (PHPV) is an ocular developmental disorder resulting from incomplete apoptosis of the embryonic hyaloid vasculature. Unilateral PHPV is traditionally associated with a poor prognosis because of the challenges associated with managing progressive anisometropic amblyopia. We report a child with unilateral PHPV who underwent cataract extraction, primary posterior capsulotomy with anterior vitrectomy and intraocular lens implantation followed by combined trabeculectomy/trabeculotomy within the first 8 weeks of life. Intensive optometric and orthoptic input was required for many years to manage the increasing anisometropic amblyopia with final visual acuity of 20/40 unaided in the affected eye and without evidence of glaucomatous optic neuropathy. This case illustrates the excellent visual outcome possible in a child with complex, unilateral PHPV using an intensive management approach comprising: early surgical intervention for congenital cataract and secondary glaucoma, meticulous monitoring of refraction, visual acuity and intraocular pressure and motivated parents who engaged in the management., (2015 BMJ Publishing Group Ltd.)

Intravitreal silicone oil achieves an effective endotamponade in patients with complex retinal detachments. Silicone oil displacement into the anterior chamber risks glaucoma and endothelial failure. We describe a 52-year-old patient with pseudophakia with silicone oil endotamponade presenting with visual loss and intraocular pressure of 60 mm Hg. Inferior YAG iridotomy was undertaken to repatriate silicone oil to the posterior segment. Despite normal intraocular pressure, acute corneal oedema occurred postiridotomy, resolving spontaneously over 2 weeks. Pupil block glaucoma secondary to silicone oil requires a management approach based on an understanding of silicone oil fluidics. Careful selection of inferior laser iridotomy site is critical to effectively reverse pupil block. Anterior migration of silicone oil in patients with pseudophakia is rare. We offer an hypothesis to explain unanticipated transient corneal oedema following silicone oil displacement from the anterior chamber. Clinicians must discuss the possibility of transient or permanent endothelial failure preoperatively in this patient group., (2014 BMJ Publishing Group Ltd.)

Purpose: New guidelines on glaucoma diagnosis and management were published by the National Institute of Clinical Excellence (NICE) in 2009. The aim of this study was to determine whether these guidelines on glaucoma referral have changed the numbers of patients diagnosed with glaucoma in Oxford and whether the severity of disease at presentation has altered between 2008 and 2010., Methods: A retrospective study was undertaken of patients referred to a glaucoma case-finding clinic at the Oxford Eye Hospital in 2008 and 2010. Severity of glaucoma was assigned on the basis of the worse eye and defined according to mean deviation (MD) on 24-2 Humphrey visual field testing, with early glaucomatous visual field defects defined as MD less than -6 dB, moderate defects as MD between -6 and -12 dB and severe defects as MD more than -12 dB. Statistical analysis was undertaken using Chi squared and Mann Whitney tests., Results: The number of referrals to this clinic increased from 521 patients in 2008, to 895 patients in 2010. 85 (16.3%) patients were diagnosed with ocular hypertension in 2008, compared to 144 (16.1%) in 2010. The number of patients diagnosed with glaucoma increased from 94 cases in 2008 to 113 cases in 2010, although the percentage of referrals diagnosed with glaucoma fell from 18.1% to 12.6%. More patients diagnosed with glaucoma in 2010 had early disease (61.9% in 2010 vs 48.8% in 2008, p = 0.03). Patients found to have glaucoma in 2010 had less severe visual field defects than in 2008: patients presented with a lower mean deviation (-6.36 dB in 2010, -7.95 dB in 2008, p = 0.03) and lower pattern standard deviation (5.44 dB in 2010, 6.64 dB in 2008, p = 0.02). However, there was no significant difference between age of presentation (65.1 years in 2010, 65.2 years in 2008, p = 0.82), and IOP (21.62 mmHg in 2010, 23.15 mmHg in 2008, p = 0.22)., Conclusions: There has been a significant increase in number of referrals to the glaucoma case-finding clinic in Oxford between 2008 and 2010. The introduction of NICE referral guidelines in 2009 has had the benefit of increasing the absolute number of patients detected with glaucoma and has resulted in more patients being diagnosed with early disease. More effort needs to be made to reduce the number of false positive referrals. In addition, the guidelines on referral of individuals with ocular hypertension need to be reconsidered., (Ophthalmic & Physiological Optics © 2013 The College of Optometrists.)

Malignant glaucoma is a rare form of glaucoma that typically follows surgery in patients with primary angle closure and primary angle-closure glaucoma. In this paper, the clinical features, classification, pathogenesis, and principles of management are discussed. Despite a high prevalence of primary angle closure glaucoma in South-East Asia, the vast majority of cases of malignant glaucoma are reported in White populations. This may reflect differing mechanisms of angle closure in White and Asian patients, which somehow reduces the likelihood of an aberrant relationship developing between the lens, ciliary body, anterior hyaloid, and vitreous structures within the eye. Although the exact underlying pathogenic mechanism remains unclear, the prognosis is good with modern medical, laser, and surgical treatment modalities.

Objective: To compare treatment persistence and costs with 3 glaucoma treatment sequences (first-line/second-line): latanoprost/latanoprost-timolol (LLT), bimatoprost/bimatoprost-timolol (BBT), and travoprost/travoprost-timolol (TTT), derived from the UK General Practitioner Research Database (UK-GPRD)., Methods: Patient records referring to ocular hypertension, topical glaucoma treatment, surgery, or laser therapy were extracted. Patients prescribed LLT, BBT, or TTT sequences were selected. Treatment failure was inferred from glaucoma prescription change (adding or removing a topical treatment, surgery, or laser therapy). Treatment durations preceding failure were compared by applying Wilcoxon's test to survival curves. Adjustment on confounding variables was performed with a Cox model and a propensity score method. Unit costs were estimated from a UK National Health Service perspective., Results: A total of 1592 patients received LLT, 110 BBT, and 114 TTT. Their mean age was 68 years and the sex ratio almost 1 male:1 female. No significant demographic or comorbidity differences were observed between treatment sequences. Treatment persistence at 36 months was achieved in 60.0% of LLT, 55.5% of BBT, and 70.3% of TTT patients (P = 0.005). Resources consumed and associated monthly costs were significantly less for the TTT group (£17.74) compared with BBT (£21.30) and LLT (£22.37) groups., Conclusion: Analysis of data obtained from the UK-GPRD suggests that the TTT treatment sequence achieved longer treatment persistence at lower cost than LLT and BBT.

Purpose: To determine whether the use of postoperative subconjunctival 5-fluorouracil (5-FU) reduces the risk of trabeculectomy bleb failure after uncomplicated small incisional cataract surgery., Methods: Twenty-five consecutive patients with primary open-angle glaucoma and a functioning trabeculectomy bleb and who underwent uncomplicated phacoemulsification surgery were given subconjunctival injections of 5 mg 5-FU at 2, 4, and 12 weeks after cataract surgery (5-FU group). The mean postoperative intraocular pressure (IOP) over a 2-year period and the trabeculectomy survival rate, as determined by Kaplan-Meier survival analysis, was compared with a historical series of patients who had undergone cataract surgery in the presence of a filtering trabeculectomy bleb, but who had not received 5-FU (control group)., Results: After a 2-year follow-up period, there was no significant difference in the mean IOP between the 5-FU (15.1 mm Hg SD 3.1) and control (15.3 mm Hg SD 3.3) groups (P = 0.67). An IOP > 21 mm Hg at any time point after the first postoperative month after cataract surgery was found in 4.0% cases in the 5-FU group and 16.7% cases in the control group (P = 0.78). Using Kaplan-Meier survival analysis, the difference in the cumulative probability of survival between the 5-FU and control groups was not significant (P = 0.30)., Conclusion: Cataract surgery is a significant risk factor for trabeculectomy bleb failure. The use of subconjunctival 5-FU injections at 2, 4, and 12 weeks after cataract surgery in elderly white patients with primary open-angle glaucoma does not reduce the risk of trabeculectomy failure.

Introduction: The intravenous use of fluorescein 10% during retinal angiography can cause severe systemic reactions including, on rare occasions, anaphylaxis. Fluorescein 2% eye drops are used extensively for clinical examination and diagnosis, but to the best of our knowledge, they have only been reported as being responsible for a systemic anaphylactic response on two previous occasions., Case Presentation: We report the case of a 51-year-old woman who developed an anaphylactic reaction when she was administered fluorescein sodium 2% eye drops after cataract surgery. This was the second time she had been exposed to fluorescein. She had brittle asthma and a history of anaphylaxis following exposure to a variety of drug and food allergens. She was successfully resuscitated and recovered completely over a period of two days., Conclusions: Fluorescein 2% drops are universally used in general practice, ophthalmology, optometry, and casualty departments. Our case report reveals the potential for this benign eye drop to cause a life-threatening systemic reaction and emphasises the importance of considering this consequence when administering topical fluorescein 2% to a patient with a history of anaphylaxis to other allergens.

Aims: Rates of glaucoma surgery have declined in North America and continental Europe in recent years. The aim of this study was to examine trends over time and regional variation in rates of trabeculectomy in England., Methods: The hospital in-patient enquiry (HIPE), hospital episode statistics (HES), and the Oxford record linkage study (ORLS) were analysed for annual trabeculectomy admissions between 1976 and 2004., Results: Annual rates of admission for trabeculectomy rose 10-fold from 1976 to 1995: from 3.7 (95% confidence intervals 3.5-3.9) admissions per 100,000 population in 1976 to a peak of 38.7 (38.1-39.3) in 1995. Admission rates then declined sharply and have begun to reach a plateau at around 10.6 (10.3-10.9) in 2004. The highest surgical rates during the period 1997-2004 were found in the 80- to 84-year-old age group. Geographical analysis showed wide variation across local authority areas in annual rates of trabeculectomy, from 4 (2.3-5.2) to 33 (29.0-36.5) people per 100,000 population in 1998-2004. The rate of surgery by local authority showed little or no association with the level of social deprivation in each area., Conclusions: The rate of patients undergoing trabeculectomy increased substantially over 20 years. This was followed by a profound reduction in rates of trabeculectomy from 1995, which coincides with the introduction of new topical medications to reduce intraocular pressure. Wide regional variation in rates of trabulectomy was found, but there was no evidence of reduced access to glaucoma surgery in deprived areas.

Aim: Eyes that are predisposed to primary angle closure usually have a shallow anterior chamber secondary to a relatively forward position of the lens and progressive lens thickening with ageing. The aim of this study was to examine trends over time in rates of primary angle closure glaucoma (PACG) in England, and to compare these rates with rates of cataract surgery., Methods: Hospital episode statistics and the hospital inpatient inquiry were analyzed for PACG as the main diagnosis between the years 1968 and 2004, and for cataract surgery over the same period. Age-specific and sex-specific rates of PACG and cataract surgery were calculated over 3 representative time periods., Results: Annual rates of patients with PACG did not change significantly from the late 1960s to the mid-1980s and then increased until the early 1990s before reaching a plateau; from 1999 to 2004, rates of patients with PACG declined significantly. From the 1980s to 2004, annual rates of patients undergoing cataract surgery increased significantly and substantially. In the recent period of decline in PACG, the decline was greatest in older age groups, whereas rates of cataract surgery increased significantly in all age groups for both men and women throughout the whole time period., Conclusions: Rates of patients with PACG have started to decline in recent years, after a long period of increases in rates of patients undergoing cataract surgery. Although other explanations are possible, this lends support to the hypothesis that cataract surgery may reduce the likelihood of acute angle closure.

Background: Ocular episcleritis and uveitis are well-recognised extra-intestinal manifestations of Crohn's disease. Orbital myositis is rare: to our knowledge it has been associated with Crohn's disease in thirteen cases. Posterior scleritis, orbital myositis and Crohn's disease have been reported as coexisting in only two cases., Methods and Results: We describe a third case, that of a 31-year old female with Crohn's colitis for 8 years, complicated by enteropathic arthritis and pyoderma gangrenosum. She presented with intense and intractable periorbital pain, particularly at night and worse on eye movements. B-scan ultrasonography confirmed posterior scleritis and treatment with high dose oral steroids (up to 60 mg prednisolone) was initially effective, but subsequently failed to control the inflammation. There was only a partial response to infliximab. Five months after presentation, diplopia developed, with failure of abduction of the left eye. MRI scan of the orbits confirmed orbital myositis involving the left lateral and medial rectus muscles. Pulsed intravenous methylprednisolone and six cycles of intravenous cyclophosphamide over a three month period resulted in complete resolution of inflammatory symptoms., Conclusions: This case highlights a rare combination of ocular abnormality secondary to Crohn's disease and reports successful resolution with aggressive immunosuppressive therapy.

Objectives: To determine the mortality within ten years of diagnosis of chronic open angle glaucoma and the visual field progression amongst survivors of a group of patients who were followed for 10 years., Patients and Methods: Of the 436 patients seen in a glaucoma case-finding clinic between July 1994 and December 1995 a diagnosis of chronic open angle glaucoma was made in 65. Ten years after diagnosis the outcome of the 57 patients who were treated at the Oxford Eye Hospital was determined. The causes of death were obtained from the general practitioner records and from the official death certificates. The probability of death was analysed using a Kaplan-Meier survival curve. The visual field of each eye of survivors was graded using a nine-stage severity scale. The visual outcome was analysed at the 10-year follow up visit., Findings: Seventeen patients (29.8%) died during the 10-year period, including nine from cardiovascular disease. The mean (SD) age at presentation of those that died was 76.4 years (9.7) compared with 69.5 years (10.9) for survivors (p = 0.029). Using a nine-stage grading system, 42 eyes (52.5%) did not deteriorate, 30 eyes (37.5%) deteriorated by one stage, seven eyes (8.75%) two stages and one eye (1.25%) three stages over the 10-year period. The average time to first deterioration by one stage was 8.51 years (CI 7.92 to 9.10). The mean (SD) intraocular pressure was 25.6 mmHg (5.8 mmHg) on presentation and 15.7 mmHg (3.0 mmHg) at the end of 10 years., Conclusion: Approximately two thirds of patients will still be under care 10 years after presentation. In older, white patients with glaucoma the overall goal of preventing visual handicap is achievable for most patients 10 years after diagnosis.

Purpose: To analyse the false positive referrals by community optometrists to a glaucoma case-finding clinic over a 3-year period., Methods: A retrospective study was undertaken of the 531 patients who were referred by community optometrists and discharged after their first visit to the glaucoma case-finding clinic at the Oxford Eye Hospital between 2003 and 2005. The number of patients who were referred on the basis of one, two or three abnormal parameters was determined. The specific reason why the presumed abnormal parameter was considered normal by a glaucoma specialist was determined from the patients' records., Results: The referral was based on only one presumed abnormal parameter in 65.5-74.3% of patients (minimum-maximum percentage per year, 2003-2005). Physiological cupping was present in 21.5-29.5%, asymmetrical cupping because of asymmetrical disc size in 6.4-8.2% and asymmetrical cupping in the presence of similar disc size in 1.9-5.1%. An intraocular pressure (IOP) within the normal range was measured in 17.6-20.8% and an IOP between 22 and 25 mmHg in association with a central corneal thickness of >588 microm was found in a further 11.5-15.4%. In 11.5-16.1% of patients who were referred because of an abnormal visual field, no field defect was found when the test was repeated. A cause other than glaucoma was responsible for an abnormal visual field defect in 1.2-6%., Conclusion: This study identifies the factors responsible for false positive referrals to a hospital-based glaucoma case-finding clinic. By considering these factors and by combining test data, the number of unnecessary referrals could be reduced in the future.

Purpose: Hypotony with choroidal detachment is a rare complication of glaucoma medication. In this study, we report on a case which supports the hypothesis that has been proposed to explain this phenomenon., Design: This study was designed as an observational case report., Case Report: A woman with chronic glaucoma underwent trabeculectomy on both eyes. Low intraocular pressure (IOP) developed in 1 eye only, with no visual change for many years. After cataract surgery, the IOP increased, necessitating treatment with topical timolol 0.5% and dorzolamide 2%. She developed monocular hypotony and choroidal detachment 3 months later. This complication occurred in the eye that had previously had a low IOP and resolved completely when topical medication was stopped. The choroidal detachment recurred when rechallenged with the same medication., Conclusions: Topical aqueous suppression therapy can result in hypotony and choroidal detachment in an eye in which relatively low IOP has been maintained for many years after glaucoma filtration surgery. The problem resolves on stopping the medication.

Aim: To determine the role of scanning laser polarimetry using the GDx variable corneal compensator (VCC) in the management of glaucoma suspects., Methods: Over a 12-month period, 43 of 447 (9.6%) patients referred to a glaucoma screening clinic were classified as "glaucoma suspects" when it was not possible to categorise the optic disc appearance and visual fields as definitely glaucomatous or definitely normal. Of these patients, 39 underwent a full ophthalmic review, including assessment of the visual fields and analysis of the retinal nerve fibre layer with the GDx VCC., Results: After the review, 17 of 39 (43.6%) patients were discharged because of normal GDx VCC results. The remaining 22 of 39 (56.4%) were considered to be at risk of developing progressive glaucoma, and further follow-up in the hospital eye service was recommended. 3 (7.7%) patients received treatment. Of the 22 patients, 12 were considered to have pre-perimetric normal tension glaucoma, 7 normal tension glaucoma and 1 primary open-angle glaucoma (POAG). In 19 of these patients, abnormal GDx VCC results were found, particularly inter-eye asymmetry in the nerve fibre layer thickness. However, in 2 of 39 (5.1%) patients the GDx VCC was normal, despite the presence of a neuroretinal rim defect in the optic disc with corresponding visual field loss, and in 1 patient with POAG., Conclusions: Scanning laser polarimetry using the GDx VCC is an important tool in defining the management strategies of glaucoma suspects. In screening for glaucoma, however, GDx VCC results should not be used in isolation, but in conjunction with conventional methods of optic disc and visual field assessment.

Malignant glaucoma is a rare secondary glaucoma classically occurring after intraocular surgery in eyes with primary angle closure. Pars plana vitrectomy is reserved for the treatment of malignant glaucoma when medical and laser treatment fail. The primary aim of surgery is the removal of the anterior vitreous to reduce resistance to aqueous flow into the anterior chamber. In phakic eyes, conventional pars plana vitrectomy without lens extraction is frequently unsuccessful because of difficulty visualizing the normally transparent anterior vitreous, combined with the technical challenge of removing the anterior vitreous without damaging the crystalline lens. We describe a technique of intraocular, videoendoscope-guided, fluorescein-assisted pars plana vitrectomy that enables direct visualization and thorough removal of the anterior vitreous without the need for lens extraction in prepresbyopic patients without cataract.

Background: Resource utilisation and direct costs associated with glaucoma progression in Europe are unknown. As population progressively ages, the economic impact of the disease will increase., Methods: From a total of 1655 consecutive cases, the records of 194 patients were selected and stratified by disease severity. Record selection was based on diagnoses of primary open angle glaucoma, glaucoma suspect, ocular hypertension, or normal tension glaucoma; 5 years minimum follow up were required. Glaucoma severity was assessed using a six stage glaucoma staging system based on static threshold visual field parameters. Resource utilisation data were abstracted from the charts and unit costs were applied to estimate direct costs to the payer. Resource utilisation and estimated direct cost of treatment, per person year, were calculated., Results: A statistically significant increasing linear trend (p = 0.018) in direct cost as disease severity worsened was demonstrated. The direct cost of treatment increased by an estimated 86 for each incremental step ranging from 455 euro per person year for stage 0 to 969 euro per person year for stage 4 disease. Medication costs ranged from 42% to 56% of total direct cost for all stages of disease., Conclusions: These results demonstrate for the first time in Europe that resource utilisation and direct medical costs of glaucoma management increase with worsening disease severity. Based on these findings, managing glaucoma and effectively delaying disease progression would be expected to significantly reduce the economic burden of this disease. These data are relevant to general practitioners and healthcare administrators who have a direct influence on the distribution of resources.

Aim: To determine the outcomes resulting from optometric referrals to a specialist glaucoma screening clinic over a 10 year period., Methods: Details of the initial clinical assessment of all new patients referred to the adult glaucoma screening clinic at Oxford Eye Hospital were collected prospectively from July 1994 to June 2004., Results: Optometrists working in community practice initiated 2505 referrals. Of these, glaucoma was confirmed in 510 patients (20.4%), including 160 with normal intraocular pressure (IOP). A diagnosis of ocular hypertension was made in 747 patients (29.8% of referrals) and 125 (5.0%) were categorised as glaucoma suspects. There was no evidence of a diagnostic trend over the period of data collection. Treatment to lower IOP was commenced in 458 patients (18.3%). Nearly half of those referred, 1148 (45.8%), were discharged from ophthalmological review at the first visit., Conclusion: In this survey, the largest of its nature, only one in five subjects had glaucoma and nearly half were discharged from hospital ophthalmological review. The findings provide a baseline against which the effectiveness of any future system of glaucoma detection in the United Kingdom can be compared.

Background: /aims: In normal tension glaucoma (NTG) factors other than raised intraocular pressure have a role in the pathogenesis of the optic neuropathy. Because particular apolipoprotein E (ApoE) gene polymorphisms have been associated with cell death and survival in neurological degenerative diseases, the purpose of this study was to determine the ApoE allele frequencies in patients with normal tension glaucoma., Methods: The apolipoprotein E genotype of 155 patients with normal tension glaucoma was compared to that of 349 non-affected, control subjects from the same geographical area. A similar comparison was made between 53 patients with normal tension glaucoma who demonstrated progressive visual field loss, and control subjects. The frequencies of genotypes was compared with the chi(2) test and Mantel-Haenszel coefficent., Results: There was no significant difference in the frequency of ApoE alleles or genotypes in the normal tension glaucoma population compared to the control group. The ApoE alleles and genotypes in NTG patients with progressive disease were not different from the control group., Conclusion: ApoE gene polymorphisms are not linked to normal tension glaucoma, suggesting that this gene does not have a role in the pathogenesis of optic neuropathy in this disease.

Purpose: To examine the relationships between study factors and trabeculectomy outcome in a representative sample of United Kingdom ophthalmology surgeons and patients., Design: Cross-sectional observational study by questionnaire., Participants: All ophthalmic surgeons performing trabeculectomy in the National Health Service were invited to select their 4 most recent consecutive trabeculectomy cases satisfying study eligibility criteria before June 1996. Three hundred eighty-two surgeons supplied baseline data for 1450 patients and 1-year follow-up data for 1240 (85.3%) patients. All patients had undergone first-time trabeculectomy for chronic open-angle glaucoma., Methods: Data were collected by self-administered questionnaires at baseline and 6 and 12 months postoperatively. Univariate analysis of the relationships between study factors and success was performed by chi-square test (categorical variables) and Student's t or Mann-Whitney U tests (continuous variables). Multiple logistic regression modeling of explanatory variables significant at a P value of

Aim: To compare the long term mean intraocular pressure (IOP) reduction after non-augmented single site phacotrabeculectomy with that after trabeculectomy and to determine the relation between preoperative IOP and IOP reduction., Methods: A group of 44 consecutive patients with chronic open angle glaucoma who underwent phacotrabeculectomy were matched to a trabeculectomy control group and the results of surgery were compared. Linear regression analysis of preoperative IOP and IOP reduction was undertaken., Results: The mean IOP reduction was significantly less in the phacotrabeculectomy group (6.7 (SD 2.1) mm Hg) than in the trabeculectomy group (11.0 (1.4) mm Hg) (p=0.0017). There was a significant difference in surgical success between the groups. The preoperative IOP was significantly related to the postoperative reduction in IOP in both groups (p<0.001)., Conclusions: In elderly white patients with chronic open angle glaucoma, phacotrabeculectomy is not as effective as trabeculectomy in reducing IOP. In both procedures the magnitude of IOP reduction is proportional to the preoperative IOP.

Recognizing the self-activity of matter through complexification can lead to seeing evolution as a process of union. This process approach emphasizes a metaphysics of becoming rather than of being. Advances in the science of thermodynamics lead to understanding chemical self-organization as a stage in this process of complexification.

Purpose: To compare the effect of phacoemulsification with intraocular lens (IOL) implantation on long-term intraocular pressure (IOP) control in glaucoma patients who had previous trabeculectomy with the effect on IOP control in similar patients after extracapsular cataract extraction (ECCE) with IOL implantation., Setting: Oxford Eye Hospital, Oxford, England., Methods: Twenty-eight consecutive patients who had phacoemulsification with IOL implantation (phaco group) at least 3 months after trabeculectomy were identified from hospital records, and 28 patients who had ECCE with IOL implantation (ECCE group) were matched retrospectively to the phaco group with respect to age, sex, diagnosis, and IOP. In both groups, the IOP before cataract extraction was compared with the IOP at intervals up to 2 years after cataract extraction. A Kaplan-Meier survival analysis was performed., Results: The mean IOP in the phaco group did not differ significantly from the mean IOP before cataract extraction at any interval. Twelve months after cataract extraction, the mean IOP in the ECCE group was significantly higher than preoperatively (P =.01); however, the mean IOP did not differ between groups over time (P =.704). There was significantly better long-term IOP control in the phaco group as determined by Kaplan-Meier survival analysis and the log-rank test (P =.038)., Conclusion: After trabeculectomy, phacoemulsification provided better long-term IOP control than ECCE; however, the mean IOP was not significantly lower.

Purpose: To determine the effect of phacoemulsification with intraocular lens (IOL) implantation, using a superior clear-corneal incision, on the long-term intraocular pressure (IOP) control in patients who have undergone previous trabeculectomy., Methods: Twenty-eight consecutive patients who underwent phacoemulsification with IOL implantation (phaco group) at least 3 months after trabeculectomy were identified and matched to 28 patients who underwent trabeculectomy only (trabeculectomy-only group) with respect to age, gender, IOP, and duration of follow-up. The mean IOP was compared 1 and 2 years after phacoemulsification, and the surgical success rate in each group was determined by Kaplan-Meier survival analysis., Results: The mean IOP 1 year after cataract surgery was significantly higher ( = 0.025) in the phaco group (15.6 +/- 3.5 mm Hg) than in the trabeculectomy-only group (13.4 +/- 2.5 mm Hg), but at 2 years the difference was not statistically significant (15.3 +/- 3.1 mm Hg in the phaco group compared with 14.3 +/- 3.2 mm Hg in the trabeculectomy-only group; = 0.35). Two years after surgery, 5 of 28 patients in the phaco group and 1 of 28 patients in the trabeculectomy-only group had commenced or were using additional topical medication ( = 0.089). If the introduction of glaucoma medication was considered a "failure," then the IOP control was significantly better in the trabeculectomy-only group using two different criteria for surgical failure., Conclusion: Although phacoemulsification and IOL implantation through a superior clear-corneal incision have little effect on mean IOP in a group of patients who have undergone previous trabeculectomy, this procedure may jeopardize the long-term IOP control in individual patients.

Purpose: The Dynamic Observing Tonometer (SmartLens, Ophthalmic Development Company AG, Zürich, Switzerland) is a diagnostic contact lens that allows continuous measurement of intraocular pressure, in addition to providing the investigator with a view of the posterior pole and anterior chamber angle. The purpose of this study was to determine the accuracy of this tonometer and the repeatability of the intraocular pressure measurements., Patients and Methods: The intraocular pressure was measured by Goldmann applanation tonometry in one randomly chosen eye of 40 subjects (median age 66 years, range 21-77 years). The intraocular pressure, pulse amplitude and 10-second continuous tonometric recordings were then taken using the Dynamic Observing Tonometer and a pneumatonometer. Accuracy was determined by calculating the mean bias and 95% limits of agreement of measurements made with the Dynamic Observing Tonometer against measurements made with the Goldmann and pneumatonometer. Repeatability was evaluated by calculating the differences between pairs of repeated measurements against the mean value and by calculating reliability coefficients., Results: Intraocular pressure measurements made with the Dynamic Observing Tonometer had a mean bias of +2.1 mm Hg (95% limits of agreement: -4.0 to +8.2 mm Hg) compared with Goldmann tonometry. There was a reasonable correlation between Goldmann and Dynamic Observing Tonometer intraocular pressure readings (r = 0.78, P < 0.01). In measuring pulse amplitude, the Dynamic Observing Tonometer was found to have a mean bias of +0.4 mm Hg (95% limits of agreement: -1.6 to +2.3 mm Hg) compared with the pneumatonometer (r = 0.78, P < 0.01). In assessing the repeatability of intraocular pressure measurements, the first Dynamic Observing Tonometer reading was on average 0.4 mm Hg higher than the second (95% limits of agreement: -3.8 to +4.6 mm Hg) with a coefficient of reliability of 0.91. For pulse amplitude readings, the first reading was on average 0.1 mm Hg lower than the second (95% limits of agreement: -1.4 to +1.2 mm Hg) with a coefficient of reliability of 0.90., Conclusion: Intraocular pressure measurements taken with the Dynamic Observing Tonometer had a small positive bias compared with Goldmann tonometry. The pulse amplitude values correlated well with those obtained with a pneumatonometer and the repeatability of intraocular pressure measurements was similar to that found in other commercially available tonometers.

Purpose: There is a considerable body of literature relating to trabeculectomy, however there are no data representative of the national experience of trabeculectomy in the United Kingdom (UK). The Department of Health funded a national survey of trabeculectomy to establish current practice patterns and the outcome of trabeculectomy in the National Health Service (NHS). In this paper we present the reported complications of first-time trabeculectomy from a nationally representative cohort of patients with chronic open angle glaucoma., Methods: Cross-sectional study of consultant ophthalmologists performing trabeculectomy in the NHS. Participants recruited their four most recent consecutive first-time trabeculectomy cases with chronic open angle glaucoma according to study eligibility criteria and data were collected by self-administered questionnaire., Follow-Up: one year post-trabeculectomy., Main Outcome Measures: occurrence of early and late complications., Results: Clinical outcome data were available for 1240 (85.3%) of cases. Early complications were reported in 578 (46.6%) cases and late complications in 512 (42.3%) cases. Some cases had more than one complication. The most frequent early complications were hyphaema (n = 304, 24.6%), shallow anterior chamber (n = 296, 23.9%), hypotony (n = 296, 24.3%), wound leak (n = 216, 17.8%) and choroidal detachment (n = 175, 14.1%). The most frequent late complications were cataract (n = 251, 20.2%), visual loss (n = 230, 18.8%) and encapsulated bleb (n = 42, 3.4%). The occurrence of most complications was not associated with a consultant's specialist interest, level of activity, type of hospital or region. Encapsulated bleb was reported more frequently in a university hospital setting., Conclusions: The complication rates reported in this paper represent the national experience of first-time trabeculectomy for open angle glaucoma in the UK. These are similar to previous published studies and highlight in particular, the impact of trabeculectomy on visual acuity in the first year following surgery. This survey provides valid and clinically relevant data on the complications of trabeculectomy for the production of guidelines and standards for audit at regional, local and individual level.

Aim: To report periorbital dermatitis as a late side effect of topical dorzolamide hydrochloride (Trusopt), a drug used to reduce intraocular pressure., Methods: A retrospective study of 14 patients who developed periorbital dermatitis while using topical dorzolamide hydrochloride was undertaken. Six patients underwent patch testing for sensitivity to Trusopt, dorzolamide hydrochloride, and the preservative benzalkonium chloride., Results: The periorbital dermatitis occurred after a mean period of 20.4 weeks of commencing dorzolamide hydrochloride therapy. 13 patients had used preserved topical beta blocker treatment for a mean period of 34.2 months without complication before the introduction of dorzolamide. In eight (57.1%) the dermatitis resolved completely after discontinuing dorzolamide but in six (42.9%) resolution of the dermatitis did not occur until the concomitant preserved beta blocker was stopped and substituted with preservative free drops. Patch testing for sensitivity to Trusopt, dorzolamide hydrochloride, and benzalkonium chloride was negative., Conclusion: These findings suggest that dorzolamide can cause severe periorbital dermatitis. Although the dermatitis may resolve when dorzolamide is discontinued, this does not always occur and in some patients all topical medication containing benzalkonium chloride needs to be stopped.

The literature on combined surgery in the treatment of patients with cataract and primary open-angle glaucoma was comprehensively studied, and all aspects and variations of the combined procedure were assessed. Phacoemulsification has improved the success rate and reduced the complication rate previously associated with extracapsular cataract extraction combined with trabeculectomy. A mean reduction in intraocular pressure (IOP) of 5 to 8 mm Hg can be achieved. One- and 2-site techniques appear to be similarly effective. Phacotrabeculectomy augmented with mitomycin-C achieves a lower IOP than phacotrabeculectomy alone but has a higher complication rate. The use of 5-fluorouracil is not as effective as mitomycin-C and has a variable influence on the results. The development of new techniques that combine nonpenetrating glaucoma surgery with phacoemulsification offers interesting surgical alternatives, but no long-term results have been reported.

Purpose: There is a considerable body of literature relating to trabeculectomy; however, there are no data representative of the national experience of trabeculectomy in the United Kingdom (UK). The Department of Health funded a national survey of trabeculectomy to establish current practice patterns and the outcome of trabeculectomy in the National Health Service (NHS). In this paper we report variations in surgical technique and the national success rate of trabeculectomy., Methods: A cross-sectional survey was carried out of consultant ophthalmologists performing trabeculectomy in the NHS. Participants recruited their four most recent consecutive first-time trabeculectomy cases according to study eligibility criteria and data were collected by self-administered questionnaire., Follow-Up: 1 year post-trabeculectomy. Main outcome measure of success: final intraocular pressure (IOP) less than two-thirds the pre-operative IOP. Secondary outcome measures of success: final IOP less than 21 mmHg and visual field stability. Success was further defined as unqualified (excluding patients on anti-glaucoma medications at final follow-up) or qualified (including patients on anti-glaucoma medications at final follow-up). The relationship between variables characterising consultants' practice and main outcome measure was examined by chi-square test., Results: Clinical outcome data were available for 1240 (85.3%) cases. There were wide variations in operative technique. The mean post-operative IOP was 14.4 mmHg (95% CI 14.2-14.7), which is a mean reduction of 11.8 mmHg (95% CI 11.4-12.2). An unqualified success, in terms of the main outcome measure, was achieved in 66.6% of patients and a qualified success in 71.0% of cases. An unqualified success, in terms of a final IOP less than 21 mmHg, was achieved in 84.0% of cases and a qualified success in 92.0%. Visual fields were stable in 84.2%. Outcome was not related to consultants' specialist interest, level of activity, type of hospital or region., Conclusions: The success rates reported in this paper represent the national experience of first-time trabeculectomy for open angle glaucoma in the UK. The national success rate at 1 year compares favourably with many studies in the literature. This survey provides valid and clinically relevant measures of success for the production of guidelines and standards for audit at regional, local and individual level and a baseline for the comparison of new therapies.