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PURPOSE: To determine the effect of acute and chronic primary angle closure glaucoma (PACG) on the trabecular meshwork. METHODS: Trabecular specimens of 16 consecutive patients with primary angle closure glaucoma (PACG)--6 acute PACG eyes, and 10 chronic PACG eyes without an acute attack--were studied by light and electron microscopy. RESULTS: Acute PACG: The trabecular meshwork revealed a generalised oedema and an accumulation of pigment in the widened trabecular spaces and Schlemm′s canal. Attenuated trabecular endothelial cells appeared to be devoid of subcellular components. Chronic PACG: In chronic PACG eyes the trabecular architecture had lost its regular arrangement, with fewer and narrower trabecular spaces and fusion of the trabecular beams in areas. There were numerous electron-dense bodies in the trabecular tissues, both within the trabecular beams and in the extracellular spaces, which had a banded fibrillar structure. An overall loss of endothelial cells was noted; the remaining cells were crowded together and were polymorphic. Melanin pigment was present both within the stroma and in the endothelial cells. CONCLUSIONS: Pigment accumulation in the trabecular spaces and within the cells and a noninflammatory degeneration appeared to be the primary changes in the trabecular meshwork after acute angle closure glaucoma. In chronic PACG eyes, there was evidence of loss of endothelial cells and reactive repair processes. These changes were present in areas away from visible peripheral anterior synechiae. A gonioscopic evaluation of the extent of peripheral anterior synechiae alone may not reflect the extent of trabecular meshwork damage in acute and chronic PACG. Patients experiencing an acute attack of PACG require a long-term follow up, because the intraocular pressure (IOP) may rise later, due to ongoing changes compromising the outflow facility, or due to the effects of aging in the trabecular meshwork.

All the presently available antiglaucoma medications have either local or systemic adverse effects. Combinations of drugs are being used not only to increase the effectivity and compliance but also to decrease the incidence and magnitude of side effects. The single dose response of open angle glaucoma eyes to pilocarpine 1%, clonidine 0.125%, a combination of pilocarpine 1% and clonidine 0.125%, and timolol 0.5% was studied in a double blind, masked, cross over study. Over a period of twelve hours the effectivity of the combination of pilocarpine 1% and clonidine 0.125% was significantly more than that of either drug alone and was found to be similar to that of timolol 0.5%. No local or systemic adverse effects were seen.

A comparative retrospective study of 164 cases of juvenile secondary gla as presenting to the glaucoma service in 1984 and 100 cases in 1988, to the changes brought about by health education and innovations in ophthalmic care is undertaken.

Clinically observed complicated cataracts, generally do not have a definite causal factor. We studied the effects of E. coli toxin injected suprachoroidally, to simulate the effect of toxins released by extraocular organisms on the lens. 79.2% of eyes had a definable cataract at the end of the 6th week of observation. The biochemical changes portrayed an increased oxidative activity in the lens, evidenced by a fall in glutathione concentration, and the consequent tertiary reorientation of proteins to increase insoluble proteins, forming a cataract.

Traumatic cataracts can nor be adequately managed with cutting aspiration systems by an anterior or pars planes approach 20 cases were randomly assured to these two approaches Pars plana lensectomy caused a more frequent uveitis and secondary glaucoma, though the visual acuity achieved post-operatively was similar in the two groups. We recommend an anterior lensectomy for patients who do not require simultaneous posterior segment surgery, because the retained posterior capsule decreases the indicence of complications.

Aims: To study the efficacy of argon laser trabeculoplasty (ALT) as a primary and secondary therapy in Indian patients with primary open angle glaucoma (POAG). Methods: ALT was performed as [...]

Purpose: To study ultrastructural changes of the trabecular meshwork in acute and chronic primary angle closure glaucoma (PACG) and primary open angle glaucoma (POAG) eyes by scanning electron microscopy.Materials and Methods: Twenty-one trabecular meshwork surgical specimens from consecutive glaucomatous eyes after a trabeculectomy and five postmortem corneoscleral specimens were fixed immediately in Karnovsky solution. The tissues were washed in 0.1 M phosphate buffer saline, post-fixed in 1% osmium tetraoxide, dehydrated in acetone series (30-100%), dried and mounted.Results: Normal trabecular tissue showed well-defined, thin, cylindrical uveal trabecular beams with many large spaces, overlying flatter corneoscleral beams and numerous smaller spaces. In acute PACG eyes, the trabecular meshwork showed grossly swollen, irregular trabecular endothelial cells with intercellular and occasional basal separation with few spaces. Numerous activated macrophages, leucocytes and amorphous debris were present. Chronic PACG eyes had a few, thickened posterior uveal trabecular beams visible. A homogenous deposit covered the anterior uveal trabeculae and spaces. Converging, fan-shaped trabecular beam configuration corresponded to gonioscopic areas of peripheral anterior synechiae. In POAG eyes, anterior uveal trabecular beams were thin and strap-like, while those posteriorly were wide, with a homogenous deposit covering and bridging intertrabecular spaces, especially posteriorly. Underlying corneoscleral trabecular layers and spaces were visualized in some areas.Conclusions: In acute PACG a marked edema of the endothelium probably contributes for the acute and marked intraocular pressure (IOP) elevation. Chronically raised IOP in chronic PACG and POAG probably results, at least in part, from decreased aqueous outflow secondary to widening and fusion of adjacent trabecular beams, together with the homogenous deposit enmeshing trabecular beams and spaces. [ABSTRACT FROM AUTHOR]

PurposeTo evaluate the efficacy of cyclodialysis-enhanced Mitomycin c (MMC) trabeculectomy in post-keratoplasty glaucoma.DesignProspective, non-comparative, interventional case series.MethodsA total of 45 eyes of 45 consecutive patients with refractory glaucoma after penetrating glaucoma underwent a cyclodialysis-augmented trabeculectomy with MMC. The visual acuity, intraocular pressure (IOP), corneal clarity, and graft failure were evaluated over a minimum follow-up of 2 years.ResultsThe mean age of the patients was 55.4±9.4 years. The cyclodialysis-augmented MMC trabeculectomy procedure resulted in a mean reduction of IOP from 38.9±3.9mmHg (95% confidence interval (CI) 35.9–42.2) at baseline to 11.3±2.8mmHg (95% CI 9.5–12.9), at final follow up (P=0.002). Blebs were avascular, diffuse, and extended posteriorly. Postoperative UBMs revealed the presence of a cyclodialysis with a small associated suprachoroidal effusion and a subconjunctival filtering bleb in all cases.ConclusionsCyclodialysis-augmented MMC trabeculectomy provides a safe and effective method of lowering IOP in intractable glaucoma following penetrating keratoplasty, without compromising the corneal graft survival and clarity. [ABSTRACT FROM AUTHOR]

ObjectivesTo measure ocular biometric parameters in all possible untreated family members of index primary angle closure glaucoma (PACG) patients and to correlate these values among affected, unaffected, and suspected family members.MethodsAnterior chamber depth (ACD), axial length (AL), lens thickness (LT), relative lens position, and central corneal thickness (CCT) were measured in first- and second-degree relatives of index patients. These biometric parameters were compared among the relatives and index patients as well as among affected, unaffected, and suspected family members.ResultsOf the 108 family members included in the study, 34 (31.6%) were affected with primary angle closure, 19 (17.6%) were suspect, and 55 (50.7%) were unaffected family members. In comparison to index cases, ACD was 14.56% more in affected, 21.7% more in primary angle closure suspects and 34.92% more in unaffected family members. LT was 10.73, 11.1, 16% less and AL was 0.11, 3.53 and 5.37% more in affected, suspected, and unaffected family members, respectively. Lens position and CCT were not statistically different in the various subgroups.ConclusionsACD is narrowest, lens thickest, and AL shortest in family members affected with PACG compared to suspected and unaffected members. Although LT and ACD could change with advancing age, AL appears to be a marker to identify members at risk of angle closure glaucoma.Eye (2008) 22, 521–527; doi:10.1038/sj.eye.6702687; published online 16 February 2007 [ABSTRACT FROM AUTHOR]

PurposeTo evaluate changes at the anterior chamber angle during Valsalva manoeuver, in eyes having primary angle closure (PAC) and a patent laser peripheral iridotomy.MethodsTwenty-three eyes of 23 consecutive patients underwent a recording of applanation tonometry, measurement of the anterior chamber angle recess, angle opening distance, iris thickness, anterior chamber depth, and pupil size on ultrasound biomicroscopy before and during the Valsalva maneuver. The Valsalva manoeuver was standardized to a pressure of 40 mmHg for 15 s, using a manometer.ResultsThe mean baseline intraocular pressure changed from 18.86+3.79 to 26.73+4.73 mmHg during Valsalva, (P<0.0001). The anterior chamber angle recess narrowed from 16.62+6.24 to 6.5+4.02 degrees (P<0.0001). There was a significant increase in the thickness of the ciliary body from 0.92+0.25 to 1.17+0.31 mm (P=0.0006) and in the iris thickness from 0.47+0.17 to 0.57+0.11 mm (P=0.007). A significant increase in pupillary diameter (P=0.008) and a decrease in the angle opening distance (P<0.0001) also occurred during Valsalva, whereas there was no significant change in the anterior chamber depth (P=0.056). The angle recess during Valsalva had a positive correlation with the baseline anterior chamber angle (r=0.41, P=0.05) and a negative correlation with the ciliary body thickness (r=−0.52, P=0.046).ConclusionsThe induction of Valsalva maneuver in day-to-day activities can lead to significant anterior segment angle shallowing and can lead to progression from the PAC stage to primary angle closure glaucoma in such predisposed eyes. The presence of a patent laser iridotomy may not prevent irido trabecular apposition during the Valsalva maneuver.Eye (2008) 22, 389–393; doi:10.1038/sj.eye.6702646; published online 6 April 2007 [ABSTRACT FROM AUTHOR]

PurposeTo evaluate the intraocular pressure (IOP) after cessation of steroid use in steroid-induced glaucoma and its control with medication or surgery.MethodsThirty-four eyes of 34 patients having steroid-induced glaucoma were prospectively evaluated after cessation of steroid for IOP, visual acuity, and optic disc status at 3 months, and every 3 months for 18 months.ResultsTopical steroid use (73.5%) was the most frequent cause for glaucoma. The baseline IOP was 35.47±12.59 mmHg. The baseline vertical cup–disc ratio correlated with duration of steroid use (P=0.014) and the baseline IOP (P<0.0001). In 25 patients (73.5%), IOP could be controlled by topical medications alone, whereas nine patients (26.5%) required surgery. The mean baseline IOP in eyes requiring surgery was 49.67±13.28 mmHg and in eyes managed medically, 30.36±7.51 mmHg (P=0.002). The vertical cup–disc ratio in surgically treated patient was 0.87±0.13:1 as compared to 0.71±0.15:1 (P=0.012) in the medically treated group. At 6, 12, and 18 months follow-up, 22 (64.7%), 33 (97.1%), and all 34 (100%) patients were off treatment, respectively.ConclusionsPatients with steroid-induced glaucoma, who were ≤20 years old, with a higher IOP, and greater glaucomatous optic neuropathy, were more likely to need surgery. After cessation of steroid therapy, all eyes were off treatment at 18 months.Eye (2008) 22, 26–30; doi:10.1038/sj.eye.6702474; published online 23 June 2006 [ABSTRACT FROM AUTHOR]

PurposeTo compare ocular biometric parameters with darkroom prone provocative test (DRPPT) in family members of primary angle closure glaucoma (PACG) patients.MethodsOne hundred and forty-nine family members of 46 PACG patients underwent ocular examination included slit lamp biomicroscopy, gonioscopy, fundus examination using +90 D lens, Goldmann applanation tonometry, darkroom prone provocative test, perimetry on Humphrey's field analyzer II and optic disc evaluation using HRT II. Ultrasonic ocular biometry and the DRPPT were then performed. IOP8 mmHg rise from baseline with iridocorneal touch was considered as a positive test.ResultsOf the 149 family members examined, 55 (36.9%) were found to have PACG. Forty (72.7%) of these had subacute PACG and 15 (27.3%) were found to have chronic PACG. Thirty-nine (70.3%) of the affected members showed a positive DRPPT. Mean anterior chamber depth (ACD) was 2.03±0.3, 2.3±0.4, 2.7±0.3 mm (P=0.0001) and mean lens thickness was 4.41±0.39, 3.99±0.5, 3.93±0.4 mm (P=0.0001) in DRPPT positives, borderlines and negatives respectively. ROC curve (ACD) plotted showed cutoff value of 2.07 mm (sensitivity 88.57%) for screening.ConclusionAnterior chamber is shallowest, lens is thickest and axial length is shortest in affected and DRPPT positive, family members of PACG patients.Eye (2007) 21, 984–989; doi:10.1038/sj.eye.6702375; published online 19 May 2006 [ABSTRACT FROM AUTHOR]

Purpose: To study changes in anterior segment morphology after laser peripheral iridotomy (LPI) in primary angle closure (PAC) and primary angle closure glaucoma (PACG) using ultrasound biomicroscopy (UBM). Methods: Ninety-three eyes of 93 patients underwent anterior segment evaluation including gonioscopy, disc evaluation with + 90D lens, applanation intraocular pressure, and standard achromatic perimetry. UBM was performed before and 2 weeks after Nd:YAG LPI to measure the trabecular-iris angle (TIA), the angle-opening distance (AOD 250/500), and the central anterior chamber depth (ACD). Results: The superior TIA widened from a mean of 7.54+/-3.15 to 15.66+/-6.69 degrees (P=0.0001), the inferior TIA increased from a mean of 9.0+/-4.7 to 15.9+/-6.8 degrees (P=0.0001) after LPI in PAC. In PACG, the mean superior angle changed from 4.55+/-2.5 to 6.12+/-3.8 degrees (P=0.4) and the inferior angle increased from 4.75+/-2.0 to 7.9+/-3.7 degrees (P=0.1). The mean ACD increased from 2.19+/-0.36 to 2.30+/-0.36 mm in PAC group (P=0.0003), with no significant change seen in the PACG group (1.79+/-0.32 vs 1.82+/-0.33 mm, P=0.13). Conclusion: LPI leads to a widening of the anterior chamber angle and a deepening of the anterior chamber in eyes with PAC. It does not significantly change any anterior segment parameters in eyes with PACG. [ABSTRACT FROM AUTHOR]

PurposeTo evaluate the intraocular pressure (IOP)-lowering effect and ocular side effects of daunorubicin (DNR) in drug-modulated trabeculectomy.MethodsA prospective pilot study was conducted in which 21 Asian patients of Indian origin with high risk factors for failure of trabeculectomy were recruited. An approval from research ethics committee and an informed consent from every patient included in the study were obtained. DNR, an antimetabolite with known antifibroblastic action was used intraoperatively. A limbus-based conjunctival flap followed by conventional trabeculectomy was performed in all eyes. During trabeculectomy, a cellulose sponge soaked in 0.2 mg/ml DNR was applied for 3 min at the proposed site of trabeculectomy before preparation of the partial thickness scleral flap. A regular follow-up was carried out for 1 year where parameters including visual acuity, IOP by applanation tonometry, and slit lamp examination were performed on each visit. An IOP of 21 mmHg or less was taken as criteria for success.ResultsFollowing DNR trabeculectomy, the IOP was lowered from baseline preoperative value of 36.19±5.9 to 16.05±2.52 mmHg at the end of 1 year. Success rate of 81% (17 out of 21 patients) was noted. None of the patients developed corneal epithelial toxicity, hypotony maculopathy, or choroidal detachment.ConclusionThe authors feel that intraoperative daunorubicin is safe and effective in lowering IOP in high-risk surgical cases of glaucoma. However, a much larger cohort study over a considerable number of years will eventually demonstrate its safety.Eye (2007) 21, 784–788; doi:10.1038/sj.eye.6702328; published online 7 April 2006 [ABSTRACT FROM AUTHOR]

Purpose: To study the corneal topographic response to IOP reduction in vernal keratoconjunctivitis (VKC) with steroid-induced glaucoma.Methods: A total of 42 eyes of 21 patients with VKC and steroid-induced glaucoma (Group I) and 66 eyes of 33 patients with VKC without glaucoma (Group II) underwent an evaluation by Orbscan topography. In eyes with glaucoma, the IOP was controlled medically and the corneal topography was repeated at 3 months to evaluate effect on corneal parameters.Results: The mean baseline IOP was 36.40+/-13.08 mmHg in Group I, 14.67+/-4.62 mmHg in Group II (P<0.0001). The IOP after treatment at 3 months follow-up was 15.00+/-5.41 mmHg in Group I (P<0.0001). In Group I, the mean maximum Sim K decreased from 44.86+/-3.21 D to 43.87+/-2.62 D (P=0.031) and mean posterior corneal elevation decreased from 64.9+/-22.36 microm to 35.7+/-28.91 microm at 3 months after reduction of IOP (P=0.001). There was a significant positive correlation between the reduction in the IOP and the decrease in the posterior corneal elevation (r=0.664, P=0.001).Conclusion: Eyes with VKC with and without glaucoma have similar corneal topography. Increased IOP associated with steroid-induced glaucoma and VKC may contribute to an increase in the corneal curvature and posterior corneal elevation. These changes may be reversed by a reduction in the IOP with medical therapy. [ABSTRACT FROM AUTHOR]

AimsTo evaluate the efficacy of diode laser trabeculoplasty (DLT) and frequency doubled Nd : YAG laser trabeculoplasty (YLT) in primary open angle glaucoma (POAG).MethodsA total of 52 eyes of 35 patients with POAG were included. In all, 25 eyes underwent DLT (Group I) and 27 eyes underwent YLT (Group II). IOP, gonioscopy and visual fields were evaluated before and 3, 6, and 9 months and 1 year after the laser. An IOP<21 mmHg without medications or a decrease in the number of glaucoma medications with no progression of disc and field changes was considered a success.ResultsThe mean age of patients in Group I was 57.72±8.1 years and the patients in Group II had a mean age of 59.85±7.76 years. The mean prelaser IOP was 24.93±1.49 mmHg and 25.36±1.57 mmHg. The mean IOP after DLT at 12 months follow-up was 18.0±0.93 mmHg and after YLT was 18.6±1.52 mmHg. The reduction of IOP was statistically significant in both the groups at 3, 6, 9, and 12 months (P<0.001), however there was no significant difference between the two groups. Success rates in both groups were similar, 92% in Group I and 92.6% in Group II.ConclusionsDLT and Fd YLT are equally effective in controlling IOP in eyes with POAG.Eye (2006) 20, 1352–1356. doi:10.1038/sj.eye.6702108; published online 7 October 2005 [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the circadian rhythm of intraocular pressure (IOP) in primary chronic angle closure glaucoma (PCACG), primary open angle glaucoma (POAG), and normal eyes.Methods: Cross-sectional study of newly diagnosed patients of POAG (60 eyes), PCACG following laser iridotomy (75 eyes), and age and sex matched normal controls (75 eyes). All subjects underwent applanation tonometry at 7 a.m., 10 a.m., 1 p.m., 4 p.m., 7 p.m., and 10 p.m. by a masked observer. Circadian rhythms were classified based upon the timing and presence of peak pressure.Results: Age and gender in all three groups were comparable. Diurnal IOP fluctuations were significantly higher in PCACG (7.69+3.03 mmHg) and POAG (8.31+2.58 mmHg) groups compared to normal controls (4.83 + 2.46 mmHg). PCACG eyes and controls had similarly timed circadian rhythms, with PCACG eyes having a consistently higher IOP. At 7 and 10 a.m., IOP peaked more often in POAG eyes compared to PCACG eyes. A plateau type of circadian rhythm was most common in normal eyes. The timing of peak IOP could be significantly correlated with the type of primary glaucoma examined.Conclusion: Afternoon peaks were more common in postiridotomy PCACG eyes, similar to the rhythm in normal eyes. Morning peaks were more frequent in POAG eyes. Diurnal fluctuation > 6 mmHg, associated with an IOP of 21 mmHg or more was never seen in a normal eye. [ABSTRACT FROM AUTHOR]

Purpose: This study was conducted to compare anatomical parameters, thought to be responsible for causing angle closure glaucoma (ACG), among eyes having acute, subacute or chronic ACG. Methods: Ninety consecutive patients diagnosed with a subgroup of ACG, and 30 age, sex and refraction matched controls, provided a total of 240 eyes for a prospective study. The refractive error, corneal diameter, keratometry, pachymetry, lens thickness and axial length were measured and the relative lens position was calculated. The data were analysed by paired t-test, ANOVA, signed rank test and multivariate analysis. Results: Acute ACG eyes were mildly hyperopic. All the ACG subgroups had similarly short eyeballs and a steeper corneal curvature compared to control eyes. Acute ACG lenses were thicker than all the other groups (P < 0.001), but all ACG eyes had thicker lenses than the controls. Corneal diameters and anterior chamber depths were decreased in acute and chronic ACG eyes compared with subacute ACG and controls (P < 0.001). The uninvolved fellow eyes in each subgroup differed from affected eyes only in having more posteriorly positioned lenses. Conclusions: There was a spectrum of anatomical variations seen in the subgroups of ACG. Acute ACG eyes expressed an extreme shift of anatomical features away from normal, especially, smaller corneal diameters, leading to a large mobile lens in an already crowded anterior segment. This predisposed them to a severe relative pupillary block, and to a form of ciliary block glaucoma. Chronic ACG eyes were less divergent from normal and therefore could have suffered a milder form of the same kind of angle closure, but over a more prolonged period. Subacute ACG eyes deviated least from controls, and therefore exhibited mild signs and spontaneous resolution. Further work is required to elucidate completely the pathophysiology that leads to ACG. [ABSTRACT FROM AUTHOR]

The etiology of subretinal mass lesions is very difficult to establish. A 28-year-old man presented to us with an area of choroiditis, which progressed, despite corticosteroid and antibiotic therapy, to an exudative retinal detachment, secondary glaucoma and a painful blind eye. To develop a means of identifying the cause of such lesions, we did a subretinal fluid tap prior to enucleation. Cytopathology showed only inflammatory cells and the final histopathological diagnosis was that of a granulomatous scleritis. [ABSTRACT FROM AUTHOR]

Aim: To provide a synopsis of primary angle closure disease in India, and Indian studies on the same. Results: Primary angle closure glaucoma forms almost half of all adult primary glaucomas seen in a hospital setting in India. Anatomically, corneal diameters and anterior chamber depths were least in acute and chronic PACG eyes as compared to subacute eyes and controls. Besides relative pupillary block, a Valsalva maneuver during activities of daily living may be responsible for intermittent angle closure and raised IOP in predisposed eyes. Iridotomy alone, controlled the intraocular pressure in 66.7% of subacute eyes and 12.9% of the acute. Medical therapy was additionally required for 35.5% of the acute eyes, 12.1% of the subacute and 30.0% of the chronic cases. There was a greater mean and peak IOP reduction, achieved with 0.005% latanoprost once daily, 8.2 ± 2.0 mm Hg, compared with 0.5% timolol twice daily, 6.1 ± 1.7 mm Hg2. A progression of PACS to PAC was seen in 22%, PAC to PAC OHT in 38.7% and PAC OHT to PACG in 30.7% over 5 years. Conclusions: Primary angle closure disease is common in India, and can be managed well with iridotomy, followed by an appropriate control of IOP.

Lasers have been used in the treatment of primary open angle glaucoma (POAG) over the years, with the hope that they would eventually replace medical and surgical therapy. Laser trabeculoplasty (LT) is an application of argon, diode, or selective laser energy to the surface of the trabecular meshwork to increase the aqueous outflow. The mechanisms by which intraocular pressure (IOP) is lowered could be mechanical, biologic, or by division of adjacent cells. It is commonly used as an adjunct to medical therapy, but is contraindicated if the angle is obstructed, e.g., peripheral anterior synechia (PAS) or developmental glaucomas. About 75% of individuals will show a significant fall in IOP after argon laser trabeculoplasty (ALT), and the response is similar with selective laser trabeculoplasty (SLT). The effects of LT are not always long lasting, with about 10% of individuals showing a rise in IOP with every passing year. Laser thermal sclerostomy, ab interno or externo, is an alternative to other full-thickness filtration procedures. Longer wavelengths in the infrared range have water-absorptive characteristics that facilitate perforation of the sclera. These lasers can be used to avoid intraocular instrumentation and minimize conjunctival trauma.

Purpose: To compare the diagnostic performance of the Heidelberg retinal tomograph (HRT) glaucoma probability score (GPS) with that of Moorfield′s regression analysis (MRA). Materials and Methods: The study included 50 eyes of normal subjects and 50 eyes of subjects with early-to-moderate primary open angle glaucoma. Images were obtained by using HRT version 3.0. Results: The agreement coefficient (weighted k) for the overall MRA and GPS classification was 0.216 (95% CI: 0.119 - 0.315). The sensitivity and specificity were evaluated using the most specific (borderline results included as test negatives) and least specific criteria (borderline results included as test positives). The MRA sensitivity and specificity were 30.61 and 98% (most specific) and 57.14 and 98% (least specific). The GPS sensitivity and specificity were 81.63 and 73.47% (most specific) and 95.92 and 34.69% (least specific). The MRA gave a higher positive likelihood ratio (28.57 vs. 3.08) and the GPS gave a higher negative likelihood ratio (0.25 vs. 0.44).The sensitivity increased with increasing disc size for both MRA and GPS. Conclusions: There was a poor agreement between the overall MRA and GPS classifications. GPS tended to have higher sensitivities, lower specificities, and lower likelihood ratios than the MRA. The disc size should be taken into consideration when interpreting the results of HRT, as both the GPS and MRA showed decreased sensitivity for smaller discs and the GPS showed decreased specificity for larger discs.

Purpose: To study the effect of cataract extraction on the retinal nerve fiber layer (RNFL) thickness, and assessment by scanning laser polarimetry (SLP), with variable corneal compensation (GDx VCC), at the glaucoma service of a tertiary care center in North India. Materials and Methods: Thirty-two eyes of 32 subjects were enrolled in the study. The subjects underwent RNFL analysis by SLP (GDx VCC) before undergoing phacoemulsification cataract extraction with intraocular lens (IOL) implantation (Acrysof SA 60 AT) four weeks following cataract surgery. The RNFL thickness parameters evaluated both before and after surgery included temporal, superior, nasal, inferior, temporal (TSNIT) average, superior average, inferior average, and nerve fiber index (NFI). Results: The mean age of subjects was 57.6 ± 11.7 years (18 males, 14 females). Mean TSNIT average thickness (μm) pre- and post-cataract surgery was 49.2 ± 14.1 and 56.5 ± 7.6 ( P = 0.001). There was a statistically significant increase in RNFL thickness parameters (TSNIT average, superior average, and inferior average) and decrease in NFI post-cataract surgery as compared to the baseline values. Mean NFI pre- and post-cataract surgery was 41.3 ± 15.3 and 21.6 ± 11.8 ( P = 0.001). Conclusions: Measurement of RNFL thickness parameters by scanning laser polarimetry is significantly altered following cataract surgery. Post the cataract surgery, a new baseline needs to be established for assessing the longitudinal follow-up of a glaucoma patient. The presence of cataract may lead to an underestimation of the RNFL thickness, and this should be taken into account when analyzing progression in a glaucoma patient.

Surgical removal of extraocular cysticerci is fraught with complications. The effect of oral albendazole in such cases has been evaluated in a randomised, controlled, clinical trial. Of 24 ultrasonographically diagnosed, and ELISA positive cases of extraocular cysticerci, 12 received oral albendazole 15 mg/kg once daily for 1 month, while the 12 controls received a placebo. Marked clinical improvement was seen in all the cases in the treatment group at 4 weeks, with collapse of the cyst at 6 weeks (75%), and complete disappearance at 3 months (100%). No clinical or ultrasonographical change was noted in the control group. A trial of medical management with oral albendazole merits consideration in cases of extraocular cysticerci. [ABSTRACT FROM PUBLISHER]

A case is reported of bilateral aspergillus endophthalmitis in an infant without any detectable systemic predisposition or focus of infection. The patient is the youngest recorded case of endogenous aspergillus endophthalmitis so far, with an onset of symptoms at the age of 15 days. After histopathological confirmation of the aetiology by enucleation of the atrophic eye, systemic amphotericin B therapy was instituted with excellent results in the fellow eye. This is the first recorded instance of a complete clinical cure in aspergillus ocular disease on systemic amphotericin B therapy alone. [ABSTRACT FROM PUBLISHER]

Aims: The study was performed to estimate transconjunctival penetration of mitomycin C (MMC) to Tenon′s tissue following application over the intact conjunctiva before routine trabeculectomy. Settings and Design: Institution-based case series. Materials and Methods: In 41 eyes of 41 patients, MMC (0.4 mg/ml for 3 min) was applied over the intact conjunctiva before beginning trabeculectomy. Tenon′s capsule directly beneath the site of application was excised during trabeculectomy and was homogenized, centrifuged and MMC concentrations were analyzed using high-performance liquid chromatography (HPLC). Statistical Analysis Used: Statistical analysis was performed using stata0 8.0 version software (STATA Corporation, Houston, TX, USA). In this study, P -values less than 0.05 were considered as statistically significant. Results: The average weight of the sample of Tenon′s tissue excised was 5.51 ± 4.42 mg (range: 0.9-17.1) and the average estimated MMC concentration found to be present in Tenon′s tissue using HPLC was 18.67 ± 32.36 x 10−6 moles/kg of the tissue (range: 0.38-197.05 x 10−6 ). In 36 of the 41 patients (87.80%), the MMC concentration reached above 2 x 10−6 moles/kg of the tissue concentration required to inhibit human conjunctival fibroblasts. Conclusions: Mitomycin C does permeate into the subconjunctival tissue after supraconjunctival application for 3 min. Application of MMC over the conjunctiva may be a useful alternative to subconjunctival or subscleral application during routine trabeculectomy and as an adjunct for failing blebs.

Purpose: To study the current profile of secondary glaucomas for their incidence and to identify risk factors. Materials and Methods: In this retrospective chart review, 2997 patients newly diagnosed and referred with glaucoma to our tertiary glaucoma center in the year 2005 were included. Evaluation of all cases was done on the basis of a detailed history and recorded examination including vision, intraocular pressure (IOP), anterior segment examination, gonioscopy and fundus evaluation by glaucoma specialists. Demographic data, etiology of secondary glaucoma, and any other significant findings were noted. Results: Of 2997 referred patients, 2650 had glaucoma or were glaucoma suspects. Of all glaucoma patients or glaucoma suspects, 579 patients (21.84%) had secondary glaucoma. Age distribution was as follows: 25% were between 0-20 years; 27% were between 21-40 years; 30% were between 41-60 years and 18% were> 60 years. The male female ratio was 2.2. Frequent causes of secondary glaucoma were post - vitrectomy 14%, trauma 13%, corneo-iridic scar 12%, aphakia 11%, neovascular glaucoma 9%. Post-vitrectomy glaucoma eyes had vitreous substitutes in 83% cases of which 66% eyes had retained silicone oil for more than three months. Vision ≤20/200 was present in 63% eyes, 57% eyes had baseline IOP > 30 mm Hg. Of all traumatic glaucoma patients, 71% cases were < 30 years of age. Fifty per cent had baseline IOP of> 30 mm Hg and vision ≤20/200. Conclusions: Most patients with secondary glaucoma have poor vision (≤20/200) with high IOP and advanced fundus changes at presentation.

Post-penetrating keratoplasty (post-PK) glaucoma is an important cause of irreversible visual loss and graft failure. The etiology for this disorder is multifactorial, and with the use of new diagnostic equipment, it is now possible to elucidate the exact pathophysiology of this condition. A clear understanding of the various mechanisms that operate during different time frames following PK is essential to chalk out the appropriate management algorithms. The various issues with regard to its management, including the putative risk factors, intraocular pressure (IOP) assessment post-PK, difficulties in monitoring with regard to the visual fields and optic nerve evaluation, are discussed. A step-wise approach to management starting from the medical management to surgery with and without metabolites and the various cycloablative procedures in cases of failed filtering procedures and excessive perilimbal scarring is presented. Finally, the important issue of minimizing the incidence of glaucoma following PK, especially through the use of oversized grafts and iris tightening procedures in the form of concomitant iridoplasty are emphasized. It is important to weigh the risk-benefit ratio of any modality used in the treatment of this condition as procedures aimed at IOP reduction, namely trabeculectomy with antimetabolites, and glaucoma drainage devices can trigger graft rejection, whereas cyclodestructive procedures can not only cause graft failure but also precipitate phthisis bulbi. Watchful expectancy and optimal time of intervention can salvage both graft and vision in this challenging condition.

Aim: To evaluate the effect of laser-assisted in situ keratomileusis (LASIK) on the measurement of retinal nerve fiber layer thickness by scanning laser polarimetry using customized corneal compensation in myopes. Materials and Methods: Scanning laser polarimetry was performed on 54 eyes of 54 healthy patients with myopia using the glaucoma diagnostics variable corneal compensation (GDx VCC) instrument (Laser Diagnostic Technologies, San Diego, California) before and a week after LASIK. The various parameters were compared using the Student′s t test. Results: No statistically significant change was observed in any of the retinal nerve fiber layer parameters before and after LASIK. Conclusions: While the measurement of retinal nerve fiber layer thickness by scanning laser polarimetry is affected by anterior segment birefringent properties and LASIK would be expected to produce changes in the same, customized corneal compensation using the GDx VCC seems to adequately compensate for these changes.

Purpose: This study was conducted to compare the intraocular pressure (IOP) measurements by the Goldman applanation tonometer (GAT), non contact tonometer (NCT) and the ocular blood flow (OBF) pneumotonometer in different IOP ranges in glaucomatous eyes. The effect of central corneal thickness (CCT) on IOP measurement in chronic glaucomatous eyes using the three different tonometers was also evaluated. Materials and Methods: IOP measurements of 130 eyes of primary glaucoma patients were performed using GAT by an ophthalmologist while NCT and OBF-pneumotonometer measurements were performed by an experienced optometrist. The IOP values were compared amongst the three instruments in the three different IOP ranges (0-18 mmHg,> 18 to 25 mmHg, > 25 mmHg). CCT was also measured in all patients. Results: The mean of paired difference between GAT and NCT was 0.9 ± 3.1 mmHg while that between GAT and OBF-pneumotonometer was 0.3 ± 3.4 mmHg. The OBF-pneumotonometer and NCT were more affected by corneal thickness (0.41 mmHg and 0.4 mmHg / 10 µ corneal thickness respectively) while GAT was the least affected by corneal thickness (0.3 mmHg / 10 µ corneal thickness) though the difference was not statistically significant ( P =0.42). Conclusion: With appropriate correction for corneal thickness the NCT and OBF-pneumotonometer can be used as reliably as GAT in following up glaucomatous patients.

PURPOSE: To quantitatively assess the normative values for peripapillary retinal nerve fibre layer (RNFL) thickness with Optical Coherence Tomography (OCT 3) in Indian subjects. METHODS: The peripapillary retinal nerve fibre layer of 146 normal subjects was imaged on OCT 3 in this cross-sectional study. Thickness of the RNFL around the disc was determined with three 3.4 mm diameter circle OCT scan. The RNFL thickness was measured in four quadrants; superior, nasal, inferior and temporal. The data was analysed using SAS commercial statistical software. Influence of age and gender was evaluated on various measured parameters using unpaired t test, one-way analysis variance (ANOVA) and Pearson′s correlation coefficient. RESULTS: One hundred and forty six eyes of 146 patients, 84 males and 62 females were studied. The average RNFL thickness in the sample population under study was 104.27 +/- 8.51 (95% CI 87.25-121). The RNFL was thickest in the inferior quadrant, followed by the superior quadrant, and progressively less in nasal and temporal quadrant. The difference between inferior and superior quadrants was not statistically significant. Age had a significant negative correlation with average RNFL thickness (r = -0.321, P = 0.000) and with average superior (r = -0.233, P = 0.005) and average inferior RNFL thickness (r = -0.234, P = 0.004). There was no effect of gender on various RNFL thickness parameters. CONCLUSIONS: RNFL thickness is significantly correlated with age, but not with gender. This normative database of RNFL thickness with OCT in Indian eyes is similar to previously reported values in normal Asian eyes.

Purpose: To estimate pulsatile ocular blood flow (POBF) among normal subjects and to compare various parameters in eyes of primary open angle glaucoma with high intraocular pressure (IOP). Methods: POBF was estimated in 95 eyes of 95 normal subjects above the age of 40 years and in 35 eyes of 35 primary open angle glaucoma patients using the OBF system (OBF Labs Ltd., UK). Correlation of age, gender, IOP, pulse amplitude, pulse volume and pulse rate with POBF was studied. POBF values were measured in glaucomatous patients before IOP control and one month later after control of IOP to < 22mmHg. Results: The mean POBF among normal subjects was 1382.2 + 413ml/min (range 636-2291m/min). Females had a significantly higher mean POBF (1512 + 347ml/min) than males (1193 + 312ml/min). The mean IOP among normal subjects was 12.6mmHg and in glaucoma patients, 29.1mmHg. Mean POBF in glaucomatous eyes with initially elevated IOP was 718.9 + 322.6 ml/min, which improved after IOP control to 1129 + 291ml/min. IOP had a strong (P< .01) negative correlation with POBF (r = -0.667) Conclusions: POBF among eyes of normal subjects in this study is higher than reported among Caucasian eyes. Primary open angle glaucoma eyes with high IOP have significantly reduced ocular blood flow. Therapy aimed at lowering IOP has a positive effect on ocular haemodynamics.

Purpose: To study the characteristics of the optic nerve head using a scanning laser ophthalmoscope, the Heidelberg Retina Tomograph II (HRT II), in a normal population and to determine the specificity of HRT II diagnostic indices in the study population. Methods: The optic nerve heads from 275 consecutive, randomly selected normal subjects were imaged on HRT II. Stereometric parameters were studied with respect to baseline variables such as age, gender, refractive error and disc size. The stereometric parameters and the results of Moorfields regression analysis (MRA) and discriminant function analysis were recorded. Results: The average disc size in the population under study was 2.34 + 0.47 mm[2]. Age and gender had no significant effect on stereometric parameters. Myopic discs were larger than hypermetropic discs. MRA had a specificity varying between 85.5% and 98.2% depending upon the criteria used to define an abnormal disc. The specificity of MRA decreased with increasing disc size. The RB (R Bathija) and FSM (F S Mikelberg) discriminant functions had specificities of 96.4% and 87.3% respectively. Conclusions: Estimation of stereometric parameters of a normal disc can be used to indicate an abnormal one. Moorfields regression analysis and discriminant functions have a high specificity in our normal population; however, caution must be exercised in interpreting the results for a disc area larger than 3 mm 2.

Purpose: To compare the efficacy and safety of subconjunctival and intrascleral applications of mitomycin C (MMC) in trabeculectomy for high-risk glaucomas. Methodology: A randomized prospective clinical study was conducted on 41 consecutive eyes with a high risk of glaucoma surgery failure. Patients were randomized to trabeculectomy and application of subconjunctival MMC or to trabeculectomy and application of intrascleral MMC. MMC solution 0.2 mg/ml was applied for 3 minutes under the conjunctival flap overlying the proposed site of trabeculectomy in Group 1 (n=21), or intrasclerally under the superficial scleral flap in Group II (n=20) Results: After a follow-up of one year, the intraocular pressure (IOP) decreased from a mean basal IOP of 33.0 ± 8.4 mm Hg to 12.56 ± 2.54 mm Hg in Group I and from 30.9 ± 6.6 mm Hg to 11.6 ± 2.21 mm Hg in Group II. The IOP was 6 - 21 mmHg, without medication, in 90.5 % of the eyes in Group I and 75 % of the eyes Group II. Ocular hypotony, hypotony maculopathy, choroidal detachment and a shallow anterior chamber were more frequent with the intrascleral application of MMC during trabeculectomy, but the difference was not statistically significant. The overall success of the surgery at one year, i.e., achieving an IOP of 6 - 21 mmHg and a stable vision, (reduction in visual acuity of ≤2 lines), was 90.5% in Group I and 75 % in Group II. Conclusion: No significant difference was seen in overall success or complication between subconjunctival and intrascleral application of MMC-augmented trabeculectomies in glaucomatous eyes at high risk of surgical failure.

Purpose: To compare the detection and assessment of progression of visual field defects in primary open-angle glaucoma with manual suprathreshold perimetry on Goldmann perimeter and automated static threshold perimetry on Humphery visual field (HVF) analyzer. Methods: 105 eyes of 54 patients of primary open-angle glaucoma were followed up with 3-monthly perimetry on Goldmann perimeter and HVF analyzer, for a period of 9 months. Results: HVF analyzer picked up visual field defects in 48 (46%) eyes whereas Goldmann perimeter picked up visual field defects in 26 (25%) eyes. HVF analyzer demonstrated progression in 14 eyes whereas Goldmann perimeter detected progression in 7 eyes during follow up of 9 months. Conclusions: HVF analyzer is superior to Goldmann perimeter to document and to demonstrate progression of visual field defects in primary open-angle glaucoma.

We describe the occurrence of bilateral iridocorneal endothelial (ICE) syndrome with glaucoma in a young girl with Down′s syndrome. A 16-year-old girl with Down′s syndrome was found to have secondary glaucoma in the right eye with features of progressive iris atrophy in both eyes. She was uncontrolled on maximum tolerable medical therapy for glaucoma. She underwent an uneventful trabeculectomy with mitomycin-C in her right eye. Scanning electron microscopy of the trabecular meshwork obtained in this case is described.

The use of artificial drainage devices (ADDs) or "setons" in glaucoma surgery is generally restricted to patients with refractory glaucoma at high risk for failure from conventional filtration surgery. ADDs, both valved and nonvalved are currently available in this country. Recently, some of these devices have been propogated as primary treatment even for primary glaucomas. This article examines the role of ADDs in the modern management of the glaucomas. Specific indications for ADDs and methods to reduce the complication of overfiltration are discussed. The use of antimitotics, such as 5-fluorouracil or mitomycin, with traditional filtration has decreased the indications for ADDs. The literature and our experience confirm that currently there is no role for use of ADDs as a primary procedure in most glaucomas.

A prospective study of 500 consecutive patients of primary angle closure glaucoma was undertaken to study the clinical profile of the three subtypes: acute, subacute, and chronic. A record of age and sex distributions, symptomatology, the best corrected visual acuity, gonioscopy, visual fields, methods of control of intraocular pressure, and status of the second eye was maintained. Statistical analysis of these parameters and the subtypes of angle closure glaucoma was carried out using the chi-square test. Angle closure glaucoma constituted 45.9% of all primary adult glaucomas seen. 24.8% of these had acute angle closure glaucoma, 31.2% subacute, and 44% chronic glaucoma. Angle closure glaucoma occurred maximally in the sixth decade and females constituted 51.4% of those affected. The difference in symptoms among the subtypes was significant (p

A letter to the editor is presented related to neovascularization of the lens capsule (NVC) in a phakic eye without angle.