Search

Improving adherence to ocular hypertension (OH)/glaucoma therapy is highly likely to prevent or reduce progression of optic nerve damage. The present study used a behaviour change counselling intervention to determine whether education and support was beneficial and cost-effective in improving adherence with glaucoma therapy. A randomised controlled trial with a 13-month recruitment and 8-month follow-up period was conducted. Patients with OH/glaucoma attending a glaucoma clinic and starting treatment with travoprost were approached. Participants were randomised into two groups and adherence was measured over 8 months, using an electronic monitoring device (Travalert® dosing aid, TDA). The control group received standard clinical care, and the intervention group received a novel glaucoma education and motivational support package using behaviour change counselling. Cost-effectiveness framework analysis was used to estimate any potential cost benefit of improving adherence. Two hundred and eight patients were recruited (102 intervention, 106 control). No significant difference in mean adherence over the monitoring period was identified with 77.2% (CI, 73.0, 81.4) for the control group and 74.8% (CI, 69.7, 79.9) for the intervention group (p = 0.47). Similarly, there was no significant difference in percentage intraocular pressure reduction; 27.6% (CI, 23.5, 31.7) for the control group and 25.3% (CI, 21.06, 29.54) for the intervention group (p = 0.45). Participants in the intervention group were more satisfied with information about glaucoma medication with a mean score of 14.47/17 (CI, 13.85, 15.0) compared with control group which was 8.51 (CI, 7.72, 9.30). The mean intervention cost per patient was GB£10.35 (

AIM—To apply survival analysis in assessing the long term outcome of Molteno tube implantation and to identify risk factors for failure. METHODS—A retrospective, 10 year, consecutive case series study of 119 eyes that underwent implantation of a Molteno tube. The main outcome measures considered were intraocular pressure (IOP), visual acuity, and complications. RESULTS—A 30% or greater reduction in IOP was achieved in 68.9% of cases. However, the overall, "complete success" rate (IOP

Objective: The aim of the study was to evaluate the long-term outcomes of a large series of ‘modern’ trabeculectomies with specific respect to traditional risk factors for failure. Methods: 636 consecutive ‘modern’, augmented ‘safe-technique’ trabeculectomies performed over an 11-year period (1998-2008) were assessed in a single centre, observational, cohort study. Traditional risk factors for failure (previous surgery, long-term exposure to topical medication, young age, secondary glaucoma and trainee surgeon) were assessed using various success outcome criteria. Success survival was defined with respect to various intraocular pressure (IOP) targets, using criteria for both complete and two categories of qualified success. A multivariate logistic regression analysis was performed to account for the significant number of patients with more than one risk factor. Results: The mean follow-up period was 65.5 (± 35.7) months. At final follow-up the mean IOP for all eyes was reduced from 23.4 (± 6.2) mmHg pre-operatively to 11.9 (± 4.2) mmHg (p

Background: Ofloxacin is a potent broad-spectrum fluoroquinolone antibiotic commercially available as a topical ophthalmic preparation. The authors compared ofloxacin (0.3%) as a single therapy with their conventional dual therapy of specially prepared, fortified gentamicin (1.5%) and cefuroxime (5.0%) drops for the treatment of suspected microbial keratitis. Methods: The authors enrolled 122 patients with a clinical diagnosis of microbial keratitis in a prospective, randomized, controlled, double-masked study to compare the two therapies. The ofloxacin drops were decanted into identical-looking bottles to the conventional treatment and dispensed with a second bottle containing saline only. The initial and subsequent assessments noted any risk factors, the size and location of the ulcer, and any evidence of corneal and conjunctival toxicity. All ulcers were scraped for microbiologic culture, and isolated organisms were tested for sensitivity to the trial antibiotics. For statistical analysis, a "cure" was defined as complete healing of the ulcer (no epithelial defect). A ratio of the two outcome proportions and its confidence limits was used to compare the two treatment groups. Multiple regression analysis using Poisson models was used to adjust for confounding factors that may have modified the outcome ratios. Results: There was no difference in the treatment success between the two treatments, with 67.9% of the conventional treatment group and 62.1 % of the of loxacin group being cured within 14 days (ratio, 1.09; [95% confidence interval, 0.83-1.43]; P = 0.59). However, there was significantly more toxicity encountered with the conventional treatment group (50.8% vs. 10.2%; ratio, 5.00 [95% confidence interval, 2.25-11.11 ]; P Conclusions: The authors found that the treatment outcomes with ofloxacin monotherapy compared favorably with their conventional therapy and were associated with less toxicity.

PURPOSE We examined the association of corneal hysteresis (CH) with Heidelberg retina tomograph (HRT)- and Glaucoma Detection with Variable Corneal Compensation scanning laser polarimeter (GDxVCC)-derived measures in a British population. METHODS The EPIC-Norfolk Eye Study is nested within a multicenter cohort study--the European Prospective Investigation of Cancer. Ocular response analyzer (ORA), HRT3, and GDxVCC measurements were taken at the research clinic. Three ORA measurements were taken per eye, and the single best value used. Participants meeting predefined criteria were referred for a second examination, including Goldmann applanation tonometry (GAT) and central corneal thickness (CCT) measurement. Generalized estimating equation models were used to examine the associations of CH with HRT and GDxVCC parameters, adjusted for disc area. The GDxVCC analyses were adjusted further for typical scan score to handle atypical retardation. RESULTS There were complete research clinic data from 5134 participants. Corneal hysteresis was associated positively with HRT rim area (P < 0.001), and GDxVCC retinal nerve fiber layer (RNFL) average thickness (P = 0.006) and modulation (P = 0.003), and associated negatively with HRT linear cup-to-disc ratio (LCDR, P < 0.001), after adjustment for Goldmann-correlated IOP and other possible confounders. In the 602 participants undergoing the second examination, CH was associated negatively with LCDR (P = 0.008) after adjustment for GAT, CCT, and other possible confounders. CONCLUSIONS Lower CH was associated with HRT and GDxVCC parameters in a direction that is seen in glaucoma and with ageing. Further research is required to establish if this is a causal relationship, or due to residual confounding by age, IOP, or CCT.

PURPOSE To describe Heidelberg Retina Tomograph (HRT) measures, their principal components, and their associations in a British population. METHODS The European Prospective Investigation of Cancer (EPIC)-Norfolk Eye Study is nested within a multicenter cohort study. Measurements were taken with the HRT-2 and the software subsequently updated to yield HRT-3 parameters. Principal components analysis (PCA) was used to identify distinct components of the HRT variables. Generalized estimating equation models were used to examine associations of these components with age, sex, height, body mass index (BMI), blood pressure, social class, education, alcohol intake, smoking status, axial length, IOP, and lens status. RESULTS Complete data were available from 10,859 eyes of 6430 participants with a mean age of 68 years. Principal components analysis identified three components with an eigenvalue greater than 1, explaining 79.9% of the variance of all the HRT measures. These were named cup, retinal nerve fiber layer (RNFL), and rim based on the factor loadings they were most correlated with. Older age was significantly associated with a greater cup (P = 0.003), smaller RNFL (P < 0.001), and smaller rim (P < 0.001). Female sex (P = 0.001), higher education (P < 0.001), and shorter axial length (P < 0.001) were associated with a greater RNFL. Lower BMI and higher IOP were associated with a greater cup (both, P < 0.001) and a smaller rim (BMI, P = 0.001; IOP, P < 0.001). CONCLUSIONS Heidelberg Retina Tomograph measures in this cohort were largely explained by three principal components related to optic disc cup, RNFL, and rim. Associations with cup and rim were distinct to associations with RNFL, suggesting different underlying determinants.

PURPOSE To describe GDxVCC retinal nerve fiber layer (RNFL) measures and associations in a predominantly white British population. METHODS The EPIC-Norfolk Eye Study is nested within a large multicenter cohort study, the European Prospective Investigation of Cancer. RNFL measurements were taken using the GDxVCC. Generalized estimating equation models were used to assess associations of RNFL measures with age, sex, body mass index (BMI), height, blood pressure, social class, education level, alcohol intake, smoking status, axial length, intraocular pressure, and lens status. Models were linearly adjusted for typical scan score to handle scans with atypical retardation. RESULTS There were complete data from 11,030 eyes of 6309 participants with mean age 68 years (48-90 years). Older age (-1.53 μm/decade [95% confidence interval {CI} -1.73, -1.33], P < 0.001), male sex (-0.44 μm [95% CI -0.04, -0.84], P = 0.031), shorter axial length (-0.15 μm/mm [95% CI -0.02, -0.28], P = 0.024), and pseudophakia (-0.49 μm [95% CI -0.94, -0.04], P = 0.033) were associated with thinner RNFL after adjustment for possible confounders. Higher BMI was associated with a thinner RNFL in men only (-0.30 μm/5 kg/m(2) [95% CI -0.58, -0.02], P = 0.039). CONCLUSIONS This analysis of associations with RNFL thickness in a largely healthy population may provide insight into the determinants of glaucoma, suggesting higher risk in those who are older, in men, and in men with a higher BMI.

Objectives To summarise the methods of the European Prospective Investigation of Cancer (EPIC)-Norfolk Eye Study, and to present data on the prevalence of visual impairment and associations with visual impairment in the participants. Design A population-based cross-sectional study nested within an on-going prospective cohort study (EPIC). Setting East England population (the city of Norwich and its surrounding small towns and rural areas). Participants A total of 8623 participants aged 48–92 years attended the Eye Study and underwent assessment of visual acuity, autorefraction, biometry, tonometry, corneal biomechanical measures, scanning laser polarimetry, confocal scanning laser ophthalmoscopy, fundal photography and automated perimetry. Outcome measures Visual impairment was defined according to the WHO classification and the UK driving standard, and was based on presenting visual acuity. Summary measures of other ophthalmic measurements are also presented. Results The prevalence (95% CI) of WHO-defined moderate-to-severe visual impairment and blindness was 0.74% (0.55% to 0.92%). The prevalence (95% CI) of presenting visual acuity worse than the UK driving standard was 5.87% (5.38% to 6.37%). Older age was significantly associated with visual impairment or blindness (p

To evaluate the efficacy and safety of current trabeculectomy surgery in the United Kingdom.Cross-sectional, multicenter, retrospective follow-up.A total of 428 eyes of 395 patients.Consecutive trabeculectomy cases with open-angle glaucoma and no previous incisional glaucoma surgery from 9 glaucoma units were evaluated retrospectively. Follow-up was a minimum of 2 years.Surgical success, intraocular pressure (IOP), visual acuity, complications, and interventions. Success was stratified according to IOP, use of hypotensive medications, bleb needling, and resuturing/revision for hypotony. Reoperation for glaucoma and loss of perception of light were classified as failures.Antifibrotics were used in 400 cases (93%): mitomycin C (MMC) in 271 (63%), 5-fluorouracil (5-FU) in 129 (30%), and no antifibrotic in 28 (7%). At 2 years, IOP (mean ± standard deviation) was 12.4 ± 4 mmHg, and 342 patients (80%) achieved an IOP ≤ 21 mmHg and 20% reduction of preoperative IOP without IOP-lowering medication, whereas 374 patients (87%) achieved an IOP ≤ 21 mmHg and 20% reduction of preoperative IOP overall. An IOP ≤18 mmHg and 20% reduction of preoperative IOP were achieved by 337 trabeculectomies (78%) without IOP-lowering treatment and by 367 trabeculectomies (86%) including hypotensive medication. Postoperative treatments included suture manipulation in 184 patients (43%), resuturing or revision for hypotony in 30 patients (7%), bleb needling in 71 patients (17%), and cataract extraction in 111 of 363 patients (31%). Subconjunctival 5-FU injection was performed postoperatively in 119 patients (28%). Visual loss of2 Snellen lines occurred in 24 of 428 patients (5.6%). A total of 31 of the 428 patients (7.2%) had late-onset hypotony (IOP6 mmHg after 6 months). In 3 of these, visual acuity decreased by2 Snellen lines. Bleb leaks were observed in 59 cases (14%), 56 (95%) of which occurred within 3 months. Two patients developed blebitis. Bleb-related endophthalmitis developed in 1 patient within 1 month postoperatively and in 1 patient at 3 years. There was an endophthalmitis associated with subsequent cataract surgery.This survey shows that good trabeculectomy outcomes with low rates of surgical complications can be achieved, but intensive proactive postoperative care is required.

Raised intraocular pressure occurs in a significant proportion of patients with uveitis, and may lead to glaucomatous visual loss. Medical therapy often proves inadequate in controlling intraocular pressure, necessitating surgical intervention but conventional filtering procedures such as trabeculectomy are known to fail more frequently in this group than in non-inflamed eyes. Adjunctive subconjunctival 5-fluorouracil (5-FU) has been shown to improve the success of trabeculectomy in a variety of secondary glaucomas. This retrospective study examined the effect of postoperative 5-FU administration on the outcome of trabeculectomy in uveitis-related glaucoma in 28 eyes of 26 patients. Eyes treated with adjunctive 5-FU showed a more prolonged control of intraocular pressure, and a longer median time to failure of control than untreated eyes. Trabeculectomy failure was more common and occurred earlier when a limbus-based conjunctival flap had been used, in patients of black ethnic origin, and if there had been previous intraocular surgery. Additional hypotensive therapy with topical ß-blockers was required more frequently in eyes which had not received 5-FU, and where a limbus-based conjunctival flap had been employed, all eyes in the latter group requiring ß-blockers one year after surgery. Intraocular inflammation was under satisfactory control in all patients at the time of surgery, and no deleterious effect on control of uveitis in relation to surgical intervention was observed.

Aim To investigate the prevalence of, and demographic associations with, uncorrected refractive error (URE) in an older British population. Methods Data from 4428 participants, aged 48e89 years, who attended an eye examination in the third health check of the European Prospective Investigation into Cancer-Norfolk study and had also undergone an ophthalmic examination were assessed. URE was defined as $1 line improvement of visual acuity with pinhole-correction in the better eye in participants with LogMar presenting visual acuity (PVA)

A 56-year-old woman who wore hard contact lenses developed a keratitis due to Mycobacterium chelonei. The organism was only sensitive to imipenem and partially to ciprofloxacin and erythromycin. After an initial response to topical therapy with these antibiotics the infection relapsed and a penetrating keratoplasty was performed, with resulting cure. M. chelonei has not previously been reported as a cause of keratitis associated with hard contact lens wear; neither has its treatment with imipenem and/or ciprofloxacin. A detailed photographic record showing the natural history of the keratitis is presented. Previously reported cases of M. chelonei keratitis are reviewed.

Myotonic dystrophy (DM) is caused by a triplet repeat expansion in the non-coding region of either the DMPK (DM1) or CNBP (DM2) gene. Transcription of the expanded region causes accumulation of double-stranded RNA (dsRNA) in DM cells. We sought to determine how expression of triplet repeat RNA causes the varied phenotype typical of DM. Global transcription was measured in DM and non-DM cataract samples using Illumina Bead Arrays. DM samples were compared with non-DM samples and lists of differentially expressed genes (P≤ 0.05) were prepared. Gene set enrichment analysis and the Interferome database were used to search for significant patterns of gene expression in DM cells. Expression of individual genes was measured using quantitative real-time polymerase chain reaction. DMPK and CNBP expression was confirmed in native lens cells showing that a toxic RNA gain of function mechanism could exist in lens. A high proportion, 83% in DM1 and 75% in DM2, of the significantly disregulated genes were shared by both forms of the disease, suggesting a common mechanism. The upregulated genes in DM1 and DM2 were highly enriched in both interferon-regulated genes (IRGs) and genes associated with the response to dsRNA and the innate immune response. The characteristic fingerprint of IRGs and the signalling pathways identified in lens cells support a role for dsRNA activation of the innate immune response in the pathology of DM. This new evidence forms the basis for a novel hypothesis to explain the complex mechanism of DM.

Purpose Raised intraocular pressure is the major risk factor for glaucoma. It is therefore vitally important to understand how increased pressure impacts on retinal ganglion cells (RGC) viability. These experiments investigate the effect of “pure” hydrostatic pressure on RGC survival in human organotypic retinal cultures (HORCs). Methods In order to achieve this, we have designed and built a highly sophisticated controlled environment pressure chamber to expose cells to increased hydrostatic pressure while maintaining constancy of other parameters. Results Exposure of HORCs to constant (60mmHg) or fluctuating (0-100 mmHg; 1 cycle/min) pressure for 24 or 48h resulted in no loss of structural integrity compared to controls (n=4). No significant changes in levels of RGC markers (THY-1 mRNA or NeuN) or LDH release were observed (n=4; p>0.05). RGC-5 cells, used for comparison, showed no change in cell viability (MTS; n=4), LDH release (n=3) or apoptosis (TUNEL; n=3) with pressure at 24 or 72h (p>0.05). Oxygen/glucose deprivation in HORCs reduced RGC number (~40%) at 24h (n=9; p 0.05) whereas OGD increased activation of both (n=3; p

Sir, The paper by Ajit et al1 that was recently published in Eye described a new methodology of graphically presenting adherence data, using an electronic dosing monitor. The concept of using such a device to provide meaningful, graphical information is potentially favourable to the clinician in identifying patterns of adherence. However, the idea of collecting this information for all patients is probably unrealistic and unlikely to be cost-effective. Lowering intraocular pressure (IOP) to reduce or halt the progression of visual field loss is the only currently available intervention for patients with glaucoma. Measuring IOP to assess efficacy has been standard practice ever since topical anti-glaucoma therapy was commenced. If a therapeutic regimen is adhered to, a reduction in IOP would be expected on repeat measurement a priori. Theoretically, therapeutic outcome would be both an objective and a practical measure of adherence. However, to date there is no consistent evidence of a relationship between adherence and IOP.2 Failure to identify such a relationship could be explained by the lack of a quantified correlation, or could be attributed to the methodological quality of the studies examining such a correlation being poor. However, it is more likely that the complexities of assessing the level of IOP due to individual differences (types of glaucoma and diurnal variance), together with regression to the mean, lead to ‘noisy data'. The methodology used by Ajit et al1 stated that 100 patients at their initial interview had their IOP recorded. However, no further discussion of the IOP data was done in the paper. Assuming that Ajit et al had the intention of collecting IOP data to study any relationship between IOP and adherence, it would be interesting if their findings could be published, particularly given the potential value to the glaucoma clinician of learning how IOP measures might correlate with adherence.

Background: Various risk factors for failure of glaucoma filtering surgery, including young age, have been suggested. Methods: A retrospective study of 113 trabeculectomies in 113 patients, ranging in age between 11 and 49 years (mean, 33.3 ± 10.5 years), was carried out to determine the influence of these risk factors in young patients. Results: A successful outcome (intraocular pressure [IOP] Conclusion: A majority (74%) of the patients in our series had at least one of these risk factors, thus explaining why young patients, in general, have lower success rates for trabeculectomy.

The aim of this review is to demonstrate the spectrum of conditions encompassed by the term 'chronic progressive cicatrising conjunctivitis', to discuss mechanisms of conjunctival scar tissue formation and to describe the sequelae and therapeutic options in this potentially blinding condition. Chronic progressive cicatrising conjunctivitis is found in association with some mucocutaneous disorders (cicatricial pemphigoid, linear IgA disease), as part of paraneoplastic syndromes and after long-term treatment with certain systemic and topical medications (pseudo-pemphigoid). Recent studies on the conjunctiva of pemphigoid patients indicate that macrophages may play a pivotal role in chronic progressive conjunctival cicatrisation. They mediate the transition from inflammation to scar tissue by secretion of fibrogenic cytokines. There is evidence that similar mechanisms are involved in the other fibrosing conjunctival disorders. Sequelae of chronic conjunctival cicatrisation include the obstruction of lacrimal and meibomian glands, tear film alterations, trichiasis, keratopathy and blindness. Present possibilities and future options for the treatment of this condition are discussed.

Corneal staining (tattooing) has been advocated in the management of patients with corneal leucomata, iris malformations or following iridotomies. Functional visual benefits can result from the reduction of aberrant light directed through iris defects that may cause glare and light scatter, in addition to cosmetic improvements for those with opacification. Inks, classified as stationery or cosmetic products, offer an economic alternative to currently available classical corneal staining agents (metallic salts). Furthermore, they may be used to good clinical effect with an intrastromal lamellar pocket technique.

The aim of this study was to determine the intra- and inter-observer variation in the use of a system designed for exact measurements from standard optic nerve head photographs. The commercially available system consisted of a colour CCD Videocamera, a dedicated frame grabber and customized software run on a IBM AT compatible computer. Masked measurements were made 3 times by 2 observers, from stereophotographs of the optic nerve head of 56 eyes from 30 glaucoma suspects. The cup was defined on the basis of contour, not pallor and the disc area was defined as the area inside Elschnig's ring. Intra-observer variances were 0.001 +/- 0.001 mm2 for cup area (mean +/- SD), 0.002 +/- 0.002 mm2 for disc area and 0.002 +/- 0.003 mm2 for rim area. These values for intra-observer variance were comparable with the results obtained using manual planimetric techniques. Intra-observer variance for disc area was significantly larger for the less trained of the two experienced observers. Inter-observer variances were 0.004 +/- 0.009 mm2 for cup area, 0.008 +/- 0.013 mm2 for disc area and 0.009 +/- 0.014 mm2 for rim area. These inter-observer variances were significantly larger than those previously reported for manual planimetry. The absolute differences between the two observers ranged from -0.35 to +0.20 mm2 (-0.08 +/- 0.11 mm2) for cup area, from -0.38 to +0.15 mm2 (-0.08 +/- 0.11 mm2) for disc area and from -0.29 to +0.34 mm2 (-0.06 +/- 0.12 mm2) for rim area.(ABSTRACT TRUNCATED AT 250 WORDS)

To determine the medium-term effect of travoprost on the daytime intraocular pressure (IOP) of patients with normal tension glaucoma (NTG) METHODS: Newly diagnosed NTG patients underwent baseline, daytime, hourly IOP phasing. Patients were randomised to either treatment or no treatment (control). Treatment comprised once daily topical travoprost 0.004%. After 6 months, the participants underwent their second IOP phasing.Data from 88 participants were analysed-54 were randomised to treatment and 34 to the control group. The mean duration of treatment was 6 months. The average, maximum and minimum diurnal IOPs for treated patients were statistically significantly lower than for control patients at follow-up (p0.001). When compared with baseline IOP, the travoprost treated group demonstrated a decrease of 16.1%, 13.5% and 16.7% in the average IOP, maximum IOP, and minimum IOP respectively. Of those treated, about one-third achieved a decrease in average IOP of at least 20%; only about one-tenth achieved a reduction of at least 30%.Travoprost monotherapy had a sustained hypotensive effect in NTG and achieved a reasonable or good response (20% reduction in average IOP) in 32.9% of treated eyes. However, in the majority of eyes with NTG, travoprost monotherapy appeared unable to produce the desirable 30% reduction in average IOP.

Glaucoma is initially asymptomatic, but untreated can result in progressive visual field loss and eventual blindness. With adequate therapy progression can be halted, but poor adherence with medical therapy is a significant issue requiring further research. The aim of the present study was to gain a better understanding of the obstacles to, and the motivations for, adherence with glaucoma medication and explore potential methods to improve adherence. Participants had moderate/severe glaucoma diagnosed for >1 year, had seen ⩾2 NHS ophthalmologists, and were prescribed ⩾2 topical medications. Qualitative methodology was utilized to investigate aspects of adherence. Recruited patients either attended a focus group or had a home-based semi-structured interview. The transcripts were member-checked and the resulting data were analysed using ‘Framework’ analysis. The analysis was verified by a co-investigator and NVIVO Software was used to check data reliability. Multiple obstacles to adherence were identified, including poor education, lack of motivation, forgetfulness, drop application, and other practical issues, together with specific individual and age differences. Motivation for adherence was determined by fear of blindness and a faith in drop efficacy. Specific obstacles to adherence with anti-glaucomatous therapy should be identified as early as possible after diagnosis. A tailored approach to patient care with initial education about the consequences of non-adherence and longer-term feedback about drop efficacy may improve patients' motivations for adherence. Future research should focus on investigating methods by which initial education about glaucoma and its management should best be delivered to patients.

A child born with partial trisomy of chromosome 1 (1q32-qter) survived and was seen for anterior segment dysgenesis and congenital glaucoma. Pure trisomy 1q is rarely seen in live-born infants and has not previously been described in association with congenital glaucoma. The genetic basis for glaucoma is complicated and multifactorial and probably determined by a number of genes on a variety of chromosomes. The current case provides some evidence that part of chromosome 1 may be involved with the etiology of a glaucomatous process.

To investigate the efficacy of currently available correction factors in correcting intraocular pressure (IOP) measurements for the errors induced by the normal variations in corneal structural characteristics.Central corneal thickness (CCT) and corneal radius of curvature were measured on 324 individuals (175 normal: group 1 and 149 had either open angle glaucoma or ocular hypertension: group 2). IOP was measured in all normal subjects with the Goldmann applanation tonometer and the highest recorded IOP was obtained from patient charts for subjects with either open angle glaucoma or ocular hypertension. Regression analysis was performed on IOP, CCT, and corneal radius of curvature. The corrected IOP was also calculated using the models proposed by Ehlers and Orssengo and Pye. Linear regression analysis was used to calculate the residual association between corneal parameters and corrected IOP.There was a significant positive correlation between IOP measured using Goldmann applanation tonometer and the CCT in both groups. There was no significant correlation between corneal radius of curvature and IOP in either group. There was a significant negative correlation in both the groups between CCT and corrected IOP calculated using the models of Ehlers and Orssengo and Pye. This indicates that the Ehlers and Orssengo and Pye models may significantly overestimate the effect of CCT on IOP measurement.The effect of CCT and IOP as observed in the present study and by other studies in literature is less than predicted by both the Ehlers formula and the Orssengo and Pye model. Correcting IOP for the effect of CCT using these models could be erroneous and lead to overcorrection of IOP, thus resulting in erroneously low corrected IOP eyes with thicker cornea and erroneously high corrected IOP in eyes with thinner cornea.

The intraocular pressure rise that can complicate the use of topical or systemic corticosteroid has been recognised for 50 years. More recently, following isolation of the myocilin gene (previously known as the trabecular meshwork inducible glucocorticoid response or TIGR gene), there has been renewed interest in this steroid-responsive phenomenon. Furthermore, the currently fashionable use of injectable intraocular steroids in the management of clinically significant subretinal fluid and macular oedema has resulted in an increased incidence. Animal studies, cell biology, molecular biology, and an improved knowledge of genetics have provided a better understanding of the mechanisms behind the response. The purpose of this review is to describe the risk factors for developing corticosteroid-induced glaucoma, to discuss the underlying mechanisms and genetics of the condition and to present management options.

Purpose To evaluate the interobserver and intraobserver reliability of a commercially available, portable, ultrasonic pachymeter. Methods For the interobserver variability study, 42 healthy subjects underwent repeated ultrasonic pachymetry under topical anaesthesia performed by two observers. For the intraobserver study, another 30 further healthy subjects underwent repeated pachymetry by one of the observers. Agreement was analysed by means of Bland–Altman plots and by determination of the intraclass correlation coefficient. Results For the interobserver variability study, the mean measurement difference between observers was 0.7 μm (95% CI −0.8–2.2 μm) and the intraclass correlation coefficient was 0.9958 (95% CI 0.9922–0.9977). The Bland–Altman plot showed narrow limits of agreement with respect to central corneal thickness (CCT). For the intraobserver variability study, the mean difference between the repeated measurements was 0.9 μm (95% CI −3.1–1.3 μm). The intraclass correlation coefficient was 0.9934 (95% CI 0.9863–0.9969). A Bland–Altman plot again showed narrow limits of agreement with respect to CCT. The mean CCT for 72 subjects was 538 μm (95% CI 528–545 μm). Conclusions Measurements of CCT using the BVI Pocket Pachymeter were repeatable and had excellent interobserver reliability. Measurement variation amounted to less than 0.2% assuming a mean CCT of 538 μm.

To report the outcome of 5-fluorouracil (5-FU)-augmented bleb needling revision of failed and failing filtration blebs and to identify risk factors for failure, indicators for success, and any complications of the procedure.Prospective, observational, noncomparative, interventional case series with survival analysis.The results of 101 bleb needling procedures augmented with subconjunctival 5-FU injection were determined after a minimum follow-up of 9 months. Kaplan-Meier plots were constructed and a Cox proportional hazards regression analysis was performed to assess the association between study factors and time to failure.Reduction in intraocular pressure (IOP) by 2 criteria (22 mmHg,30%), glaucoma medications, complications, and factors associated with outcome.At the time of their last follow-up visit, 60 eyes had an IOP22 mmHg, mean IOP being reduced from 26.5 mmHg to 15 mmHg [corrected] after a median of 1 needling procedure (mean, 1.6). The median interval between the "index" filtration surgery and the first (or only) needling procedure was 3.1 months, with a range of 10 days to 11 years. There was a reduction in mean number of topical antiglaucoma agents from 0.7 to 0.2 per successful eye and a median follow-up duration of 18.7 months (range, 9.3-52.8 months [corrected]). Thus, the overall cross-sectional success rate of the procedure at the time of the last visit was 59.4%. Strong evidence was found for an association between the immediate attainment of a low IOP (11 mmHg) and longer survival times. None of the other proposed factors that may have affected outcome were identified as having a statistically significant effect; however, this may have been the result of the low statistical power for some of the factors in this study.These data suggest that bleb needling augmented with 5-FU is a safe and effective method by which a significant number of failed or failing filtration blebs can be rescued from failure. Attaining an immediate reduction in IOP to11 mmHg seems to be a favorable factor with respect to reasonably long-term efficacy .

PURPOSE: To determine the interobserver and intraobserver agreement in the recognition of different patterns of glaucomatous optic disk damage and evaluate if these patterns changed over time in patients followed for a number of years. METHODS: Patients with early to moderate glaucoma (n = 105) were consecutively enrolled to participate in a prospective observational study. In the first part of the present study, optic disk photographs obtained closest to patient’s entry date in the prospective study were classified in a masked fashion by three observers according to the pattern of optic disk damage into one of the following: (1) focal, (2) myopic, (3) senile sclerotic, (4) concentric cup enlargement, (5) normal appearance, or (6) miscellaneous (those disks that did not qualify for any of the other groups). The observers were also asked to assign a confidence score for each classification, ranging from 1 (low confidence) to 5 (highest confidence). The three observers reclassified the photographs after a minimal period of 2 months, in order to assess intraobserver agreement. In a second part of the study, one observer reviewed, in a masked fashion, all the optic disk photographs that had been taken during the routine follow-up of the 105 patients in order to evaluate whether the classification of disk pattern changed over time. RESULTS: Intraobserver agreement yielded kappa values (95% confidence interval [CI]) from 0.51 (CI, 0.40 to 0.62) to 0.85 (CI, 0.77 to 0.93) depending on the observer. Interobserver agreement kappa values between all three observers was 0.40 (CI, 0.35 to 0.46), but it improved if photographs classified with moderate or higher degrees of confidence were included (0.52 [CI, 0.44 to 0.60]). During a mean follow-up period of 8.2 ± 4.8 years, 41.6% of the eyes were always classified into the same group and 23.6% of the eyes were classified at least once into two or more of the four patterns of damage (groups 1 to 4) CONCLUSIONS: Intraobserver agreement on the pattern of optic disk damage was generally very good, with some variation among the observers. Interobserver agreement was reasonable and increased proportionally with the confidence in the classification. During long-term follow-up, the pattern of optic disk damage usually did not change. This type of classification can probably be used accurately in clinical practice.

Aim—To compare pulsatile ocular blood flow (POBF) and intraocular pressure (IOP) between eyes of patients receiving either peribulbar (with and without balloon compression) or subconjunctival local anaesthesia (LA). Methods—30 eyes of 30 patients undergoing cataract surgery by phacoemulsification were investigated in a study of parallel group design. Ten patients had peribulbar LA and 10 minutes compression with a Honan’s balloon (group A). A further 10 patients who received peribulbar LA alone (group B) acted as controls for the eVects of balloon compression.Ten other patients were given subconjunctival LA (group C). POBF and IOP were measured using a modified Langham pneumatonometer. Three measurements were made in each eye, the first recording immediately before LA, the second 1 minute after, and the third 10 minutes after LA. Results—No significant change in POBF or IOP was recorded in eyes receiving subconjunctival LA. In the peribulbar groups (A and B), there was a drop in median POBF of 252 and 138 µl/min respectively 1 minute after LA, which was statistically significant in both groups (p

Primary open-angle glaucoma almost certainly develops in a multifactorial manner, with interplay between numerous risk factors affecting the disease. These risk factors, in addition to intraocular pressure, include a number of cardiovascular factors. Some of these factors may determine the appearance of the damaged glaucomatous optic nerve head. Patients with four specific optic disk appearances have been investigated, and differences have been identified in their demographic characteristics, prevalence of certain risk factors, the pattern of visual field damage, and circulatory abnormalities in their retrobulbar vessels. The findings provide evidence of the existence of subgroups of primary open-angle glaucoma with correlations between risk factor and type of optic disk. A reliable method by which the different disk appearances could be distinguished in an objective manner would be clinically valuable, and the scanning laser ophthalmoscope has shown potential promise to achieve this. The results of studies relating to various glaucomatous optic disk appearances are presented and discussed.

Contemporary medical terminology frequently stems from ancient Greek origins. However, there is some controversy relating to the true derivation of the word “glaucoma”. The disorder, now defined as glaucoma, was first documented by the Ancient Greeks in 400 BC.1 “Glaucosis” was first mentioned in Hippocratic writings as a blinding disease occurring most commonly in the elderly.2 The description stated “that once the pupil has the colour of the sea – eyesight is destroyed and you will often find that the other eye is also blind”. It is thought that this condition probably included various sight-threatening conditions including cataract and keratitis in addition to glaucoma. Opacification of the cornea or the lens …

AIMS/BACKGROUND—To study the vasoactivity of glaucoma patients with four previously described and distinct disc appearances potentially representative of primary open angle glaucoma subgroups. METHODS—Patients with pure examples of four glaucomatous optic disc types—focal ischaemic, myopic glaucomatous, senile sclerotic, and those with generalised cup enlargement, were selected. A detailed ophthalmic, systemic, drug, and smoking history was taken from the patients who, in addition, underwent assessment of peripheral vasospasm with a laser Doppler flowmeter. Differences between the groups were evaluated using an analysis of variance, Student's t test, Pearson's χ2 test, Fisher's exact test together with Spearman's and Pearson's correlation tests. RESULTS—38 patients with focal ischaemic, 37 with myopic glaucomatous, 24 with senile sclerotic, and 24 with discs characterised by generalised cup enlargement met the selection criteria. The group of patients with focal ischaemic discs contained more women (66% versus 32%-50% in the other three groups; p=0.01) and had a higher prevalence of vasospasm (63% versus 25%-49%; p=0.01), migraine (32% versus 8%-19%; p=0.02), and cold extremities (66% versus 17%-30%; p=0.00003). The group of patients with senile sclerotic discs had a higher prevalence of systemic cardiovascular disease (58% versus 21%-30% in the other three groups; p=0.01) and thyroid disease (21% cf 0%-8%; p=0.01) and although their mean age was greater (76 years cf 55-65 years; p

Previous ocular surgery involving conjunctival incision is a risk factor for failure of filtration surgery. To determine whether using adjunctive antimetabolite therapy may have a rational basis, a study was performed to determine whether the conjunctival cellular profile was altered by such surgery.After a mean follow-up of 5.9 years, filtration surgery outcomes for 35 patients who had undergone conjunctival incisional surgery were retrospectively compared with 29 control and 18 matched patients who had not undergone such surgery. At the time of filtration surgery, a conjunctival biopsy specimen was obtained from all 82 patients, and these were quantitatively analyzed by light microscopy in a prospective manner.Trabeculectomy success for the control group (93%) was significantly higher than for the previous surgery group (38%) (P.001). Compared with control tissue, conjunctiva from the patients who had undergone previous surgery contained more fibroblasts (P.001, P.05), macrophages (P.01, P.001), and lymphocytes (P = .001, P.01) in both superficial and deep substantia propria (respective P values). Furthermore, trabeculectomy failure was associated with an increase in number of conjunctival fibroblasts in intraoperative specimens.Previous ocular surgery involving the conjunctiva increases the number of conjunctival fibroblasts and inflammatory cells. This may account for the increased risk of trabeculectomy failure. Perhaps on this basis, the use of adjunctive medication may be justified in patients who have undergone previous ocular surgery involving conjunctival incision.

Purpose: To compare four distinct glaucomatous disk appearances using scanning laser ophthalmoscopy and determine the ability of a previously described discriminant analysis to detect glaucomatous damage for each group. Methods: Two thousand three hundred eighty-eight stereoscopic optic disk photographs of 2,388 subjects with glaucoma or suspicion of glaucoma were reviewed to select four pure glaucomatous optic disk types. Twenty-three topographic, volumetric, and morphometric scanning laser ophthalmoscopic variables from one optic disk of each selected subject were compared. Differences between the groups were evaluated using an analysis of variance and the Pearson chi-square test. Results: Forty-four focal ischemic disks, 38 myopic glaucomatous disks, 30 senile sclerotic disks, and 28 disks characterized by generalized cup enlargement were studied. Significant intergroup differences were found for the majority of the evaluated optic disk variables. The accuracy with which the discriminant analysis model was able to detect disks with glaucomatous visual field damage was 93.2% for focal ischemic disks, 81.6% for myopic disks, 66.7% for senile sclerotic disks, and 78.6% for disks with generalized cup enlargement. Conclusions: By comparing mean values for certain optic disk variables, scanning laser ophthalmoscopic optic disk assessment can distinguish groups of disks with specific appearances. However, the ability of presently available software to detect glaucomatous damage varied considerably with disk appearance. Expert clinical optic disk evaluation remains an important part of the assessment of patients suspected of having glaucoma, although refinement of computerized scanning laser ophthalmoscopic disk assessment may eventually make this easier.

PURPOSE To compare the optic discs of 62 healthy individuals 68 patients who have ocular hypertension (OH), and 182 patients with primary open-angle glaucoma (132 high-tension glaucoma (HTG) and 50 normal-tension glaucoma (NTG)), and determine whether disc size exerted an influence on the group differentiation. PATIENTS AND METHODS Standard criteria were used to define glaucoma and normality. Ocular hypertension was defined as having raised intraocular pressure, a normal visual field, and a healthy optic disc/retinal nerve fiber layer (RNFL). The optic disc of one eye from each individual was analyzed using a confocal scanning laser ophthalmoscope (Heidelberg Retina Tomograph software version 1.11, Heidelberg Engineering, Heidelberg, Germany). Thirteen topographical, volumetric, and shape parameters were compared between the three diagnostic groups. In addition, the individuals were divided into subgroups on the basis of disc size to determine any effect of disc size on the differentiating ability of the confocal scanning laser ophthalmoscope. Differences between the groups were evaluated using an analysis of variance. RESULTS Glaucomatous optic discs were found to differ from both healthy and OH discs, although no differences in disc area between the groups were identified. On the basis of disc size, differentiating the glaucomatous discs was best for midsized discs of 2 mm2 to 3 mm2. However, no difference was found between healthy and OH discs, even when allowing for disc size. CONCLUSIONS Ocular hypertensive optic discs (with a clinically normal appearance) could not be distinguished from healthy discs using a confocal scanning laser ophthalmoscopic technique. Glaucomatous optic discs were found to differ from both healthy and OH discs, with a limited effect of disc size.

A 73-year-old-woman presented following neodymium:YAG capsulotomy for posterior capsular opacification with acute glaucoma. Previous cataract surgery had left her with a subluxated lens. Cornea edema obscured detail of the anterior chamber, but the edge of the lens could be seen clearly within the pupillary space. This produced a diagnostic dilemma because no obvious cause for pupil block could be seen. She failed to respond to medical therapy and had a laser iridotomy, following which her symptoms resolved. We believe this case demonstrates the importance of a laser iridotomy to exclude pupil block glaucoma when adequate visualization of the pupillary space is obscured.

Objective To describe the prevalence and phenotypic characteristics of small eyes in the European Prospective Investigation of Cancer (EPIC)-Norfolk Eye Study. Design Community cross-sectional study. Setting East England population (Norwich, Norfolk and surrounding area). Participants 8033 participants aged 48–92 years old from the EPIC-Norfolk Eye Study, Norfolk, UK with axial length measurements. Participants underwent a standardised ocular examination including visual acuity (LogMAR), ocular biometry, non-contact tonometry, autorefraction and fundal photography. A small eye phenotype was defined as a participant with one or both eyes with axial length of 0.48 LogMAR) and one participant was blind (>1.3 LogMAR). The prevalence of unilateral visual impairment was higher in participants with a small eye. Multiple logistic regression modelling showed presence of a small eye to be significantly associated with shorter height, lower body mass index, higher systolic blood pressure and lower intraocular pressure. Conclusions The prevalence of people with small eyes is higher than previously thought. While small eyes were more common in women, this appears to be related to shorter height and lower body mass index. Participants with small eyes were more likely to be blind or to have unilateral visual impairment.

PURPOSE. There is evidence implicating ischemia and excitotoxicity in the pathogenesis of glaucoma. ATP-mediated excitotoxicity via activation of the P2X7 receptor (P2XR) has been proposed to play a role in retinal ganglion cell (RGC) degeneration in this disease. The aim of this research was to determine whether stimulation of the P2XR mediated ischemia-induced RGC death in the human retina. METHODS. Human organotypic retinal cultures were exposed to the P2XR agonist 20,30-O-(4-benzoylbenzoyl)-ATP (BzATP) and simulated ischemia (oxygen/glucose deprivation) in the presence or absence of the P2XR antagonist, Brilliant Blue G (BBG). Neuronal death in the RGC layer was quantified by neuronal nuclei (NeuN)-positive cell counts and quantitative real-time PCR for THY-1 mRNA. The P2XR was localized by immunohistochemistry and P2XR mRNA profiling using a cryosectioning technique. RESULTS. P2XR stimulation by BzATP (100 lM) induced loss of RGC markers in human organotypic retinal cultures (HORCs), which was inhibited by BBG (1 µM). Simulated ischemia led to loss of RGCs that was also inhibited by BBG, indicating that ischemia-induced RGC degeneration was mediated by the P2XR. The P2XR was immunolocalized to the outer and inner plexiform layers of the human retina, and P2XR mRNA expression was confirmed in the inner retina and ganglion cell layer. CONCLUSIONS. These studies demonstrated that stimulation of the P2XR can mediate RGC death and that this mechanism plays a role in ischemia-induced neurodegeneration in the human retina.

To determine the effect of various long-term topical antiglaucoma regimens on the cell population profile of the conjunctiva.Conjunctival biopsy specimens from 124 patients undergoing filtration surgery were assessed quantitatively by light microscopy. Preoperatively, the patients had used a drug for only a brief period (group A; n = 28), a beta-blocker alone (group B; n = 31), a beta-blocker in combination with a miotic (group C; n = 33), or a combination of beta-blocker, miotic, and sympathomimetic (group D; n = 32).The conjunctiva in groups A and B was similar. Group C conjunctiva differed, but the changes were most marked in biopsy specimens from patients in group D, where there was a significant decrease in goblet cells (P.05); increase in pale cells, macrophages, and lymphocytes within the epithelium (P.001); and increase in fibroblasts (P.001), macrophages (P.001), mast cells (P.05), and lymphocytes (P = .01) in the substantia propria. In addition, the effect of duration of therapy was assessed. Administration of topical medication for more than 3 years was found to increase the numbers of pale cells within the epithelium (P.05); fibroblasts (P.05), macrophages (P.001), lymphocytes (P.01), and mast cells (P = .001) within the superficial substantia propria; and the numbers of fibroblasts (P = .01) and macrophages (P.05) within the deep substantia propria.The compared treatment regimens affected the conjunctiva to different degrees, with multiple-drug topical therapy exerting the greatest effect on the degree of subclinical inflammation within the conjunctiva. The results also indicated that administration of topical medication, irrespective of type, for 3 years or more induced a significant degree of subclinical inflammation.

Conjunctival biopsies were obtained at the time of filtration surgery from 90 patients with glaucoma; 45 of these patients were black and 45 white. Forty nine of the patients (25 black, 24 white) had undergone a primary trabeculectomy. Comparisons between black and white patients were made with respect to the results of surgery and differences in conjunctival cell profile. In agreement with many authors, trabeculectomy was found to be less successful in black patients (67% compared with 80%), although this finding was not statistically significant by survival analysis. In addition, conjunctiva from black patients was found to contain a greater number of macrophages and a smaller number of both mast cells and goblet cells in comparison with white patients. There was a tendency for conjunctiva from black patients to contain more fibroblasts. Conjunctiva obtained from the patients whose filtration surgery subsequently failed was found to contain more fibroblasts, macrophages, and basal epithelial pale cells. A greater number of conjunctival macrophages and possibly fibroblasts in black patients may partially explain the tendency for a lower success rate of filtration surgery in this group of patients.

Purpose: To investigate whether there is variation in optic disc topography as measured by the Heidelberg Retina Tomograph (HRT), in normals during office hours. Methods: Thirty normal subjects (22 females and 8 males, median age 28 years, range 18–58) underwent Goldmann tonometry and optic disc analysis with the HRT. Three HRT readings were taken at each visit and a mean topographic image (MTI) produced. Measurements were performed in the morning (07.00–09.00 hours) and were repeated later the same day (17.00–19.00 hours). We studied the following topographic parameters: cup-to-disc area ratio (CDR), rim volume (RV), cup shape measure (CSM), and retinal nerve fibre layer thickness (RNFLT) in relation to time of day and the change in intraocular pressure (IOP). Results: The median changes in the topographic parameters were as follows (a negative value indicates a larger value in the evening): CDR (median 0.001, 95% CI: −0.007 to 0.007), RV (median 0.003, 95% CI: −0.021 to 0.016), CSM (median: −0.003, 95% CI: −0.015 to 0.007) and RNFLT (median 0.006, 95% CI: −0.010 to 0.009). No parameter exhibited statistically significant change. The median morning IOP was 14 mmHg (95% CI: 13–16 mmHg) and was not significantly different (Wilcoxon's W = 234; p = 0.27) to evening IOP when it was 13 mmHg (95% CI: 12–15 mmHg). The median difference in IOP was 1 mmHg higher in the morning than the evening (range 6 mmHg higher in the morning to 4 mmHg higher in the evening). The parameter changes between the morning MTI and the evening MTI were independent of IOP changes using Kendall's tau statistic for each parameter. Conclusions: There was no variation in HRT parameters when measured during office hours. Small intraindividual changes in IOP do not significantly affect optic disc topography.

Purpose: To investigate pulsatile ocular blood flow (POBF) in a healthy Indian population and use the data derived as reference values. Methods: Two hundred and fifty-two healthy subjects (121 males, 131 females) underwent intraocular pressure and POBF measurement with the Ocular Blood Flow Analyzer (Paradigm Medical Industries, Salt Lake City, UT, USA and formerly the POBF Tonograph). Before POBF measurement, subjects underwent a complete ophthalmic examination including refraction, slitlamp examination and biomicroscopic fundoscopy and Goldmann applanation tonometry (GAT). Subjects with ocular pathology were excluded from the study. Median age was 29 years (male median 32 years, female median 27 years). Results: Average POBF in males was found to be 1052 µL min−1 (95% CI: 988–1116 µL min−1) and in females to be 1293 µL min−1 (95% CI: 1222–1364 µL min−1). Median age was significantly different between males and females (Mann–Whitney U = 6685; p = 0.0311) but POBF was found to be independent of age in both sexes. As a group, mean refractive error influenced POBF (Kendall's τ = 0.24; p = 0.0017). Conclusions: Pulsatile ocular blood flow values in Indians appear to be higher than reported in studies conducted on other racial groups. The reasons for this difference could be instrumental or anatomical (i.e axial length, ocular rigidity). Care should be taken in deriving normative data using the Ocular Blood Flow Analyzer in mixed race groups.