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BACKGROUND/PURPOSE To present a novel case of paracentral acute middle maculopathy associated with bilateral optic disk swelling. METHODS Retrospective case report. RESULTS A 67-year-old woman presented with sudden onset of central vision loss and subsequent bilateral optic disk edema, retinal vessel attenuation, and anterior uveitis. Cerebrospinal fluid analysis showed signs of inflammation. Spectral domain optical coherence tomography demonstrated the pathognomonic hyperreflectivity of the middle retinal layers consistent with paracentral acute middle maculopathy. Swept-source optical coherence tomography angiography with custom vessel analysis demonstrated a 18.3% decrease in the deep retinal vascular density and 2.4 times increase in absent flow area in the affected eye compared with the fellow eye. CONCLUSION This case demonstrates a novel association between paracentral acute middle maculopathy and bilateral optic disk swelling secondary to central nervous system inflammation and possible infection. Although spectral domain optical coherence tomography is valuable in detecting paracentral acute middle maculopathy, optical coherence tomography angiography with vessel analysis can provide additional insight into the disease mechanism.

To report a series of patients who developed punctal stenosis secondary to the use of topical netarsudil 0.02% for treatment of glaucoma.Case series.Patients using topical netarsudil for management of glaucoma and noted to have punctal stenosis ipsilateral to the eye(s) being treated with netarsudil were included.Each enrolled patient's chart was reviewed, and alternative causes of punctal stenosis were sought. Photographs were obtained to document punctal stenosis for some patients.Presence of punctal stenosis after topical netarsudil use and resolution of punctal stenosis after cessation of therapy.Sixteen patients had punctal stenosis; 13 developed unilateral punctal stenosis while using netarsudil unilaterally, and 3 patients developed bilateral punctal stenosis with bilateral use. Time from initiation of netarsudil to recognition of symptoms or documentation of punctal stenosis ranged from 2 to 35 months (median, 12; mean, 14.0 ± 8.7 months). Thirteen patients endorsed tearing, but 2 had no symptoms. Ectropion was seen in 1 eye. Corneal verticillata was noted in 14 patients (87.5%). In 8 cases, netarsudil was discontinued, and the punctal stenosis was reversed, with resolution of associated symptoms.Netarsudil use can lead to the development of reversible punctal stenosis. This inflammation-mediated stenosis may cause tearing and associated symptoms and may be of sufficient severity to necessitate discontinuation of treatment. In this case series, all patients who discontinued treatment had reversal of their punctal stenosis and associated symptoms.

Importance: Create validated criteria to identify orbital fracture patients at higher risk for significant ocular injuries. Objective: Determine history and physical examination findings in orbital...

Purpose To describe two cases of medium-sized uveal melanoma presenting with hemorrhagic choroidal detachments. Observations The first case is a 39-year-old man who presented with choroidal hemorrhage and angle closure glaucoma. The second case is a 42-year-old man who presented with choroidal hemorrhage and posterior scleritis. Vitrectomy with transvitreous fine needle aspiration biopsy was ultimately required to diagnose malignant uveal melanoma in each case. Conclusions and importance Intraocular hemorrhage is a rare presenting sign of uveal melanoma. When it does occur, it is typically associated with large tumors. Hemorrhagic choroidal detachments are particularly rare in uveal melanoma, and can limit the diagnostic utility of clinical exam, B-scan ultrasonography, and magnetic resonance imaging. Although it is uncommon, it is important to maintain a high index of suspicion for choroidal melanoma in any patient with unexplained choroidal hemorrhage.

PRECIS We found significant differences in macular vascular microcirculation between normal and glaucomatous eyes using optical coherence tomography angiography (OCTA). Macular vascular microcirculation changes also showed significant correlations with visual field (VF) severity classification systems. PURPOSE To correlate VF severity defined by different classification systems and macular vascular microcirculation in eyes with glaucoma using OCTA. PATIENTS AND METHODS Twenty normal and 58 open-angle glaucoma (OAG) eyes were scanned using a swept-source OCTA (Plex Elite 9000) and macular vascular microcirculation was measured by calculating the overall blood flux index (BFI) and vessel area density (VAD) over the entire 6×6 mm area excluding the big retinal vessels. Glaucomatous eyes were staged into severity groups based on 4 VF severity classifications: Hodapp-Parrish-Anderson scale, Glaucoma Severity Staging system, ICD-10 glaucoma staging definitions, and VF mean deviation. Central 10-degree VF mean sensitivity (CMS) was calculated based on 24-2 VF. One-way analysis of variance was used to analyze the differences and correlation between macular vascular microcirculation and other clinical parameters. RESULTS Glaucomatous eyes had significantly lower ganglion cell and inner plexiform layer BFI and VAD (P

PReCIS:: We found no significant differences in peripapillary and macula microcirculation blood flow metrics in eyes with open angle glaucoma of African descent (AD) and European Descent (ED) as detected by optical coherence tomography-angiography (OCTA). Purpose To investigate the peripapillary retinal nerve fiber layer (RNFL) and macular vascular microcirculation in subjects of African descent (AD) and European descent (ED) with open-angle glaucoma using optical coherence tomography-angiography (OCTA). Patients and methods One eye from each subject was scanned using AngioPlex OCTA system (Zeiss Meditec Inc., Dublin, CA) covering both a 6 ×6▒mm scanning area centered at the optic nerve head (ONH) and at the foveola. Peripapillary RNFL and macular microcirculation were measured by calculating the overall flux and vessel area density excluding the large retinal vessels. Two-sample, independent t-tests were used to compare the OCTA metrics between AD and ED eyes. Linear regression models were used to investigate the correlation between OCTA metrics and structural and functional parameters. Results Twenty-eight eyes of AD and 56 eyes of ED were included in the study. There was no significant difference in age, sex, hypertension, anti-hypertensive medications, diabetes, systolic and diastolic blood pressure, mean ocular perfusion pressure, RNFL thickness and visual field (VF) mean deviation (MD) and VF pattern standard deviation (PSD) (P≥0.054) between AD and ED eyes included. Both groups had similar OCTA blood flow metrics (P≥0.161). OCTA blood flow metrics were significantly correlated with VF MD (r≥0.466), VF PSD (r≤-0.366) and RNFL thickness (r≥0.333). Conclusions No significant differences were found in peripapillary and macular microcirculation detected by OCTA between AD and ED glaucomatous eyes. Peripapillary and macular microcirculation were significantly correlated with disease severity in AD and ED glaucomatous eyes.

Purpose: This study evaluates the radiographic appearance of lacrimal gland tissue after placement of a glaucoma drainage implant (GDI) to characterize the impact of the device on the gland's imaging patterns. Methods: We performed retrospective chart review of departmental records at two urban academic medical centers, which were systematically searched using procedure codes to identify adult glaucoma patients who underwent unilateral superotemporal GDI from January 1995 to December 2015. Radiology records were cross-checked to identify the subset of patients who underwent postoperative orbital CT or MRI. Chart review collected data on glaucoma diagnosis, management, examination findings, and clinical complaints. Imaging studies were reviewed for orbital changes using qualitative assessment of the radiographic appearances and computer-guided calculations to quantify asymmetries. Results: A review of all eye operations in the inclusion period identified 315 patients with GDI, 13 of whom were eligible for inclusion. Elapsed time from device placement to imaging averaged 41.9 months, and the average clinical follow-up was 56.4 months. Radiographic lacrimal gland changes were appreciable in 69% (9 of 13) of patients, most commonly with posterior displacement and flattening of the gland (7 of 13). ImageJ analysis revealed significantly smaller lacrimal glands in orbits with GDI (P = 0.04). No clear correlation was found between gland changes and clinical dry eye symptoms. Conclusion: GDI placement was associated with radiographically-appreciable lacrimal gland changes in two-thirds of patients, with changes occurring in a predictable pattern of lacrimal gland flattening, posteriorization, and volume loss. Radiographic changes correlated with clinical symptoms in few patients.

PURPOSE To produce an internationally valid tool to assess skill in performing trabeculectomy surgery. METHODS A panel of 5 experts developed a tool for assessing trabeculectomy surgery by using a modified Dreyfus scale of skill acquisition and providing descriptors for each level of skill for each category. The tool was then reviewed by a panel of 10 international content experts for their constructive comments, which were incorporated into the final rubric tool. RESULTS A final rubric, incorporating the suggestions of the international panel, published here as the ICO-OSCAR: Trabeculectomy. CONCLUSIONS The tool ICO-OSCAR: Trabeculectomy has content and face validity. It can be used internationally to assess trabeculectomy surgery skill. Predictive and construct validity, and reliability are yet to be determined.

A 90-year-old woman presented with 1-year history of right-sided progressive proptosis, neovascular glaucoma, blindness, and worsening ocular pain. No funduscopic examination was possible because of a corneal opacity. Head CT scan without contrast demonstrated a heterogeneous 4.1 cm (anterior-posterior) by 1.7 cm (transverse) cylindrical mass arising in the right optic nerve and extending from the retrobulbar globe to the optic canal. She underwent palliative enucleation with subtotal resection of the orbital optic nerve and tumor. Pathological examination showed effacement of the optic nerve by an infiltrative high-grade glial neoplasm with biphasic sarcomeric differentiation. Invasion into the uvea and retina was present. The neoplasm was negative for melan-A, HMB45, tyrosinase, synaptophysin, smooth muscle actin, and epithelial membrane antigen. The glioma had strongly intense, but patchy immunopositivity for glial fibrillary acidic protein. Multiple foci of neoplastic cells had pericellular reticulin staining. The overall features were diagnostic of a gliosarcoma (World Health Organization grade IV) of the optic nerve. Postoperative MRI demonstrated postsurgical changes and residual gliosarcoma with extension into the optic chiasm. The patient died 2 and a half months after her enucleation surgery at her nursing home. Autopsy was unavailable due to the caregiver wishes, making a definitive cause of death unknown. Gliosarcoma is a rare variant of glioblastoma, and this is the first documented case presenting as a primary neoplasm of the optic nerve.

Purpose To investigate the vascular microcirculation changes in the retinal nerve fiber layer (RNFL) in normal, glaucoma suspect, and open-angle glaucoma (OAG) groups using optical coherence tomography-based microangiography (OMAG). Methods One eye from each subject was scanned with a Cirrus HD-OCT 5000-based OMAG prototype system montage scanning protocol centered at the optic nerve head (ONH). Blood flow signals were extracted using OMAG algorithm. Retinal nerve fiber layer vascular microcirculation was measured by calculating the blood flux index and vessel area density within a 1.2-mm width annulus centered at the ONH with exclusion of big retinal vessels. One-way ANOVA were performed to analyze the RNFL microcirculation among groups. Linear-regression models were constructed to analyze the correlation between RNFL microcirculation and clinical parameters. Discrimination capabilities of the flow metrics were assessed with the area under the receiver operating characteristic curve (AROC). Results Twenty normal, 26 glaucoma suspect, and 42 OAG subjects were enrolled. Eyes from OAG subjects and glaucoma suspects showed significantly lower blood flux index compared with normal eyes (P ≤ 0.0015). Retinal nerve fiber layer blood flow metrics showed significant correlations with visual field indices and structural changes in glaucomatous eyes (P ≤ 0.0123). Similar discrimination capability of blood flux index compared with RNFL thickness was found in both disease groups. Conclusions Peripapillary RNFL vascular microcirculation measured as blood flux index by OMAG showed significant differences among OAG, glaucoma suspect, and normal controls and was significantly correlated with functional and structural defects. Retinal nerve fiber layer microcirculation measurement using OMAG may help physicians monitor glaucoma.

Background To investigate the differences of perfusion in the optic nerve head (ONH) between normal and glaucomatous eyes using optical microangiography (OMAG) based optical coherence tomography (OCT) angiography technique. Methods One eye from each subject was scanned with a 68 kHz Cirrus 5000 HD-OCT-based OMAG prototype system centered at the ONH (Carl Zeiss Meditec Inc, Dublin, CA, USA). Microvascular images were generated from the OMAG dataset by detecting the differences in OCT signal between consecutive B-scans. The pre-laminar layer (preLC) was isolated by a semi-automatic segmentation program. En face OMAG images for preLC were generated using signals with highest blood flow signal intensity. ONH perfusion was quantified as flux, vessel area density, and normalized flux within the ONH. Standard t-tests were performed to analyze the ONH perfusion differences between normal and glaucomatous eyes. Linear regression models were constructed to analyze the correlation between ONH perfusion and other clinical measurements. Results Twenty normal and 21 glaucoma subjects were enrolled. Glaucomatous eyes had significantly lower ONH perfusion in preLC in all three perfusion metrics compared to normal eyes (P≤0.0003). Significant correlations between ONH perfusion and disease severity as well as structural changes were detected in glaucomatous eyes (P≤0.012). Conclusions ONH perfusion detected by OMAG showed significant differences between glaucoma and normal controls and was significantly correlated with disease severity and structural defects in glaucomatous eyes. ONH perfusion measurement using OMAG may provide useful information for detection and monitoring of glaucoma.

Background We report a case of bilateral central retinal artery occlusion and the evaluation of retinal vasculature and capillaries by using optical coherence tomography angiography. Case presentation A 75-year-old white man presented with central retinal artery occlusion in one eye and underwent a carotid angioplasty. Upon discontinuing anticoagulant, he had a subsequent central retinal artery occlusion in the other eye. Optical coherence tomography angiography images were obtained to compare the retinal microvasculature in both eyes. Conclusions Atrophy of the involved retina continues for several weeks after central retinal artery occlusion but the loss of retinal capillaries is immediate and stable over time. The presence of cilioretinal arteries that perfuse the central macula can prevent profound vision loss.

PURPOSE:To investigate optic disc perfusion differences in normal, primary open-angle glaucoma (POAG), and normal tension glaucoma (NTG) eyes using optical microangiography (OMAG) based optical coherence tomography (OCT) angiography technique. DESIGN:Cross-sectional, observational study. SUBJECTS:Twenty-eight normal, 30 POAG, and 31 NTG subjects. METHODS:One eye from each subject was scanned with a 68 kHz Cirrus HD-OCT 5,000-based OMAG prototype system centered at the optic nerve head (ONH) (Carl Zeiss Meditec Inc, Dublin, CA). Microvascular images were generated from the OMAG dataset by detecting the differences in OCT signal between consecutive B-scans. The pre-laminar layer (preLC) was isolated by a semi-automatic segmentation program. MAIN OUTCOME MEASURES:Optic disc perfusion, quantified as flux, vessel area density, and normalized flux (flux normalized by the vessel area) within the ONH. RESULTS:Glaucomatous eyes had significantly lower optic disc perfusion in preLC in all three perfusion metrics (p

PURPOSE To evaluate continued visual field (VF) progression in eyes with prior VF progression from open-angle glaucoma, using event-based criteria. METHODS Retrospective observational case series of 70 eyes (70 patients) with open-angle glaucoma, treated for at least 2 years, that had earlier shown 1 step of VF progression. Further VF progression required a worsening of 3 adjacent points at the same location on 2 consecutive VF tests. Potential risk factors for continued progression were evaluated. RESULTS The mean follow-up was 127±43 months. Thirty-seven eyes (55%) continued to progress. At 5, 10, and 15 years after the initial VF, the Kaplan-Meier estimate of the risk of developing 2 steps of progression was 18%, 53%, and 71%. A shorter time to the first step of progression was significantly associated with further progression (P

Purpose: To determine pathways of sympathetic nerves from the orbital apex to the eyelids in human cadaver tissue using immunohistochemistry. Methods: Human cadaver orbit tissue was sectioned and immunolabeled with a monoclonal antityrosine hydroxylase antibody. Results: In the orbital apex, the nasociliary, frontal, lacrimal, and maxillary branches of the trigeminal nerve demonstrated intense staining upon entering the orbit. Immunoreactive axons from the nasociliary and frontal nerves were observed to join the extraocular motor nerves in the posterior orbit. A plexus of immunolabeled nerves was observed to accompany the ophthalmic artery as it entered the orbital apex. The ophthalmic artery and its branches throughout the orbit demonstrated staining of nerve fibers in the peripheral muscularis. The nasociliary nerve contributed sympathetic branches to the ciliary ganglion. Nerves passing through the ciliary ganglion and a few ganglion cell bodies demonstrated mild to moderate tyrosine hydroxylase reactivity. Axons within the short and long ciliary nerves demonstrated strong tyrosine hydroxylase reactivity and were observed to enter the posterior sclera and the suprachoroidal space. The lacrimal gland demonstrated mild pericapillary staining and occasional stromal nerve fibers reactive to the antityrosine hydroxylase antibody. Muller muscle and the inferior tarsal muscle possessed a strong tyrosine hydroxylase-reactive nerve supply that appeared to originate from the anterior terminal branches of the nasociliary and lacrimal nerves. Conclusions: Sympathetic nerves enter the orbit via the first and second divisions of the trigeminal nerve and a plexus of nerves surrounding the ophthalmic artery. Extraocular motor nerves receive a sympathetic nerve supply from the sensory nerves in the posterior orbit. Some ciliary ganglion cell bodies demonstrated tyrosine hydroxylase-like reactivity, suggesting a sympathetic modulatory role for the ciliary ganglion. Sympathetics innervate ocular structures via the posterior ciliary nerves. Sympathetic axons travel anteriorly in the orbit via the nasociliary and lacrimal nerves to innervate the sympathetic eyelid muscles. Sympathetic nerves also travel with the frontal branch of the ophthalmic nerve to innervate the forehead skin. The ophthalmic artery and all of its branches contain a perivascular sympathetic nerve supply that may be involved in regulation of blood flow to ocular and orbital structures.

An 18-year-old woman developed pancreatitis and a thrombotic microangiopathy but no electrolyte abnormalities. She required intubation hours after admission and was not able to communicate for 8 days. Upon recovering consciousness, she reported severely impaired vision in both eyes, but ophthalmologic evaluation and neuroimaging were not obtained until several days later. Ophthalmologic examination documented retinal infarcts and profound binocular vision loss with hourglass bilateral homonymous hemianopic visual field loss. MRI showed signal abnormalities restricted to the area of the lateral geniculate bodies (LGBs) with characteristics most suggestive of hemorrhagic infarction. Very few cases of isolated bilateral LBG lesions have been reported. Damage has been attributed to myelinolysis from osmotic demyelination or to infarction from microvascular occlusion. This case conforms more to microvascular infarction. The vulnerability of the LGB to selective microvascular infarction may be based on a combination of its unique architecture and high metabolic demand.

Objective To describe a series of patients with combined pigment dispersion syndrome (PDS) and exfoliation syndrome (XFS) and to introduce a concept, the overlap syndrome, to aid in assessing multiple risk factors for glaucomatous damage. Design Clinic-based, cross-sectional study. Setting New York Eye and Ear Infirmary. Participants Twenty-six patients identified from the glaucoma database as having combined pigment dispersion syndrome–glaucoma and exfoliation syndrome–glaucoma. Main outcome measures Quantification of patients with both pigment dispersion syndrome–glaucoma (PDS/PG) and exfoliation syndrome–glaucoma (XFS/XFG) and its clinical implications. Results Among the 26 patients (all white) having both XFS/XFG and PDS/PG, the average age was 64.3 ± 9.8 years and 19 of 26 were men. All patients had bilateral PDS/PG. Bilateral XFS/XFG was present in 9 of 26 patients and, of the 17 patients with unilateral involvement, the left eye was affected in 13. Conclusions Both XFS and PDS are common. Middle-aged patients with known PDS/PG should be suspected of having the onset of XFS if one eye escapes intraocular pressure control. Patients with unilateral XFG at presentation may also have signs of PDS/PG, often remitted. We define the term overlap syndrome to describe the sequential appearance over time of two or more risk factors for glaucomatous damage. The appearance of a new risk factor in a patient whose condition has been stable can alter the course and prognosis of the disease. This concept should prove useful in dealing with secondary and normal-tension glaucomas.

Normal tension glaucoma (NTG) is a common form of open-angle glaucoma that can lead to significant visual morbidity. There has been considerable debate as to whether NTG fits within the spectrum of primary open-angle glaucoma (POAG). The relative roles of intraocular pressure and pressure-independent factors in this disease have also been debated. This review provides an extensive analysis of key clinical features, differential diagnoses, and potential pathophysiologic mechanisms, both intraocular and systemic, of NTG. Findings of major clinical trials and evidence-based guidelines for management are also reviewed.

Optical coherence tomography angiography (OCTA) has increasingly become a clinically useful technique in ophthalmic imaging. We evaluate the repeatability and reproducibility of blood perfusion in the optic nerve head (ONH) measured using optical microangiography (OMAG)-based OCTA. Ten eyes from 10 healthy volunteers are recruited and scanned three times with a 68-kHz Cirrus HD-OCT 5000-based OMAG prototype system (Carl Zeiss Meditec Inc., Dublin, California) centered at the ONH involving two separate visits within six weeks. Vascular images are generated with OMAG processing by detecting the differences in OCT signals between consecutive B-scans acquired at the same retina location. ONH perfusion is quantified as flux, vessel area density, and normalized flux within the ONH for the prelaminar, lamina cribrosa, and the full ONH. Coefficient of variation (CV) and intraclass correlation coefficient (ICC) are used to evaluate intravisit and intervisit repeatability, and interobserver reproducibility. ONH perfusion measurements show high repeatability [CV≤3.7% (intravisit) and ≤5.2% (intervisit)] and interobserver reproducibility (ICC≤0.966) in all three layers by three metrics. OCTA provides a noninvasive method to visualize and quantify ONH perfusion in human eyes with excellent repeatability and reproducibility, which may add additional insight into ONH perfusion in clinical practice.

The development of glaucoma can occur postoperatively from corneal/refractive, cataract, and vitreoretinal surgery. Additionally, glaucoma may be noted after clinical procedures have been performed, including injections and laser procedures. This chapter is organized into two basic sections: postoperative and post-procedure glaucoma. Background: Currently little is known about the effect of refractive surgery in glaucoma patients or about patients who undergo refractive procedures and may go on to develop glaucoma. •IOP measurement •Measurement of IOP after refractive surgery can be challenging. Corneal properties that are altered after refractive surgery include corneal thickness, corneal curvature, the structural integrity (stiffness or hysteresis), as well as the overlying tear film that interacts with instruments that measure IOP. Photorefractive keratectomy (PRK) additionally ablates portions of Bowman’s layer, which may change corneal resistance. Nomograms have been developed to adjust for IOP change after corneal alteration but usually take only corneak thickness into account, which has led to little success in their use. •Goldmann applanation tonometry (GAT) assumes corneal thickness = 520 microns. Thicker corneas will overestimate IOP and thinner corneas, which result from refractive procedures such as PRK and LASIK, will underestimate IOP. Therefore, GAT may have limited value in measuring true IOP following refractive surgery. Other tonometric devices, like Pascal dynamic contour tonometry, pneumatonometry, and the Reichert ocular response analyzer, may be more accurate. There does not appear to be any simple conversion table that can be referenced in correcting measured IOP after the cornea is altered surgically. Preoperative IOP is probably the most important variable that should be recorded. •The intraoperative pressure spike associated with LASIK may occur in select patients, leading to the development of glaucomatous optic neuropathy. • Pressure-induced stromal keratitis (PISK) is a condition related to steroid-induced elevated IOP that may occur after LASIK. The clinical appearance is similar to diffuse lamellar keratitis (DLK), where there is a diffuse interlamellar haze covering the flap. DLK is an inflamatory response where IOP is not elevated and requires topical steroid treatment for resolution.

Purpose To examine the development and management of glaucoma in patients with ocular chemical burns. Design Retrospective, observational case series. Methods setting: University of Washington Eye Clinics. patient population: Twenty-nine eyes (18 patients) with ocular chemical burns seen between 1997 and 2010 with a minimum of 3 months of follow-up. observation procedure: Eyes were graded using the Roper-Hall scale. main outcome measures: Long-term use of glaucoma medications (3 months or more) and need for glaucoma surgery. Results The mean age was 45 ± 17 years, with a mean follow-up of 75 ± 47 months (median, 66 months). Roper-Hall grade III or IV eyes (n = 20) had significantly higher intraocular pressure at presentation (35.9 vs 16.4 mm Hg; P = .001) and over follow-up were more likely to require long-term glaucoma medications (P = .003) or to undergo glaucoma surgery (P = .016) than Roper-Hall grade I or II eyes. Thirteen eyes (12 Roper-Hall grade III or IV) underwent glaucoma surgery. Eight eyes underwent glaucoma tube implant surgery; 4 required at least 1 revision. Seven eyes underwent diode laser cyclophotocoagulation; 4 required repeat treatment. Most (89%) eyes had controlled intraocular pressure at the last follow-up. However, 76% of eyes with visual acuity of 20/200 or worse at initial evaluation did not have improved vision at the last follow-up. Conclusions Eyes with Roper-Hall grade III or IV ocular chemical burns were more likely to have glaucoma and to require surgery for it. Outcomes of glaucoma management generally were good, although tube implant surgeries often had complications requiring revision.

Posner-Schlossman Syndrome (PSS), otherwise known as glaucomatocyclitic crisis, is an uncommon form of open angle glaucoma. This unilateral condition typically affects young to middle-aged individuals and is characterized by recurrent episodes of mild, nongranulomatous anterior uveitis with markedly elevated intraocular pressure (IOP). Some patients may have associated systemic disorders, mostly of allergic and gastrointestinal origin. A possible role of herpes simplex virus infection has also been postulated.

Purpose To evaluate noncompliance with follow-up in normal-tension glaucoma (NTG) suspects. Design Retrospective cohort study. Methods We reviewed 203 patient charts at a university eye clinic, identified as NTG suspects from a database of optic disk photographs. Noncompliance was defined as less than one year of follow-up and/or fewer than two completed visual field (VF) tests. Results Twenty-two patients (11%) were excluded because at least two VF tests were not ordered. The 181 patients analyzed included 45 (25%) non-Whites and 16 (9%) non-English speakers. Eighty-three patients (46%) were noncompliant. These patients were significantly younger (50.5 ± 15.0 years vs 55.1 ± 12.8 years; P = .028), were more likely to speak English ( P = .023), and were more likely to have no or unknown health insurance ( P Conclusions Almost half of NTG suspects lacked appropriate follow-up. Lack of health insurance may be a significant barrier to compliance with follow-up in this population.

Purpose To report a case of transient bilateral vision impairment with external ophthalmoplegia and internal ophthalmoplegia after blepharoplasty under local anesthesia. Design Interventional case report Methods A 70-year-old man underwent bilateral upper blepharoplasty under local anesthesia. During orbital fat removal additional anesthetic was injected into both medial fat pads for pain control. Results Immediate postoperative examination revealed bilateral decreased visual acuity and internal ophthalmoplegia in the right eye. An exotropia was present with marked limitation of right eye adduction. These findings resolved completely 3 hours postoperatively. Conclusions Local anesthesia during blepharoplasty can enervate the optic nerve, ciliary ganglion, and extraocular muscle nerves. Local anesthesia should be injected judiciously during orbital fat removal to avoid this reversible but alarming event.

Purpose To compare the intraocular pressure (IOP) of patients infected with human immunodeficiency virus (HIV) and treated with highly active antiretroviral therapy (HAART) to a control group and to determine whether HAART reverses the previously reported reduction in IOP associated with HIV infection. Design Retrospective case control study. Methods Review of patients with HIV infection on HAART compared with a matched control group. Results Among 64 patients and 56 control subjects, no significant difference in IOP was found ( P = .520), nor was correlation noted between IOP and either CD4+ T-lymphocyte counts, or viral load. Conclusion When HIV infection is treated with HAART, IOP is not significantly different from that of control subjects.

Background One barrier to patient adherence with chronic topical glaucoma treatment is an inadequate amount of medication available between prescription refills. We examined the self-reported prevalence of early exhaustion of glaucoma eye drops prior to a scheduled refill, and associated risk factors. Methods This cross-sectional survey was performed at a University-based clinical practice. Glaucoma patients at the University of Washington who were experienced with eye drop application and were on a steady regimen of self-administered glaucoma drops in both eyes took a survey at the time of clinic examination. The main outcome measure was self-reported early eye drop bottle exhaustion. Results 236 patients were eligible and chose to participate. In general, patients included were relatively healthy (mean 2.3 comorbid medical conditions). Sixty patients (25.4%) reported any problem with early exhaustion of eye drop bottles, and this was associated with visual acuity ≤ 20/70 in the better eye (P = .049). Twelve patients (5.1%) reported that they “often” (5–7 times per year), “usually” (8–11 times per year) or “always” ran out of eye drops prior to a scheduled refill. Patients affected by this higher level (≥5 times yearly) of eye drop bottle exhaustion were more likely to have poor visual acuity in their worse eye ≤ 20/70 (P = .015) and had significantly lower worse-eye logMAR (P = .043). Conclusions Self-reported early glaucoma bottle exhaustion regularly affected 5% of patients in our population and 25% reported early exhaustion at least once; the main risk factor was poor vision in at least one eye. These results may not be generalizable to a broad patient population, or to those inexperienced with eye drop self-administration. However, this pilot study compels further evaluation and consideration of early eye drop bottle exhaustion in glaucoma patients.