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Portable perimetric testing could be useful for community-based glaucoma screening programs. Frequency doubling technology (FDT) and the Moorfields motion displacement test (MDT) are portable perimeters which have shown promise as potential screening tools for glaucoma. This study's goal was to determine the diagnostic accuracy of FDT and MDT for visual field defects and glaucoma.Prospective, cross-sectional, diagnostic accuracy study.A consecutive series of patients aged ≥50 years who presented to a glaucoma clinic in South India and had never undergone Humphrey field analyzer (HFA) visual field testing in the past.Participants underwent 24-2 SITA Standard HFA perimetry, FDT perimetry, MDT perimetry, and iPad perimetry using visualFields Easy in random order. Ophthalmologist grades of HFA and optic nerve head photographs were used as the reference standards for glaucoma and field defect presence. Receiver operating characteristic curves were constructed to assess diagnostic accuracy of various parameters for each test.Sensitivity, specificity, area under the receiver operating characteristic curve (AUROC) RESULTS: 292 eyes from 173 participants were included, with 112 eyes classified as moderate or worse glaucoma. For moderate or worse glaucoma detection, the best parameter on FDT was mean deviation (MD) (AUROC 0.84, 95% CI 0.79 to 0.89), and the best parameter on MDT was global probability of true damage (GPTD) (AUROC 0.87, 95% CI 0.82 to 0.91). When specificity was set to 90%, the sensitivity for detection of moderate or worse glaucoma was 55% (95% CI 39 to 68%) for FDT MD and 62% (95% CI 52 to 71%) for MDT GPTD.FDT and MDT perimetry had fair diagnostic accuracy for glaucoma detection when administered to naïve test-takers in this South Indian population. Although not appropriate for use as a sole glaucoma screening test, these perimetric tests may be useful as ancillary tests.

Purpose To determine the diagnostic accuracy of potential screening tests for moderate to advanced glaucoma. Design Prospective diagnostic test accuracy study. Participants The study enrolled a consecutive series of patients aged ≥50 years who presented to a glaucoma clinic in South India without ever having received automated visual field testing. Methods All participants underwent 8 index tests: OCT of the peripapillary retinal nerve fiber layer, optic disc photography, Moorfield’s Motion Displacement Test (MDT), frequency doubling technique perimetry, noncontact tonometry, pneumatonometry, presenting visual acuity, and best-corrected visual acuity. Participants also underwent stereoscopic photographs and Humphrey visual fields, which were used by 2 ophthalmologists to arrive at the reference standard diagnosis of moderate to advanced glaucoma. Main Outcome Measures Sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio. Results A total of 217 people were enrolled; 321 eyes from 180 participants had all tests performed. Of these, 127 eyes (40%) were classified as having moderate to advanced glaucoma. Among the 8 tests, OCT best optimized sensitivity (84%, 95% confidence interval [CI], 76–90) and specificity (75%, 95% CI, 68–81). Moorfield’s Motion Displacement Test was the best perimetric test, with a sensitivity of 91% (95% CI, 85–96) and specificity of 53% (95% CI, 44–61). Pressure and vision tests were not sensitive (e.g., sensitivity of 16%, 95% CI, 9–23 for noncontact tonometry and 23%, 95% CI, 15–31 for best-corrected visual acuity). Moorfield’s Motion Displacement Test identified 16 of 127 eyes (13%) with glaucoma that were not captured by OCT, but also had false-positive results in 65 of 194 eyes (34%) without glaucoma that OCT correctly classified as negative. Conclusions OCT had moderate sensitivity and fair specificity for diagnosing moderate to advanced glaucoma and should be prioritized during an initial assessment for glaucoma.

Previous studies have used subjective assessments to implicate darker skin color as a risk factor for glaucoma. This study used objective measurements to determine whether skin melanin is a risk fa...

OBJECTIVE: To elucidate the vision loss and recovery course after Ahmed tube shunt procedure 6 months postoperatively. To identify risk factors associated with significant vision loss. DESIGN: Retrospective chart review. PARTICIPANTS: One eye of all adult patients who underwent Ahmed glaucoma valve procedure from January 2008 to December 2017 with a minimum of six-month follow-up. METHODS: Patients’ preoperative and postoperative corrected visual acuity (CVA) were documented for postoperative 1 week, 1 month, 3 months and 6 months. MAIN OUTCOME MEASURES: Pre- and postoperative CVA at various time points were compared using repeated measures ANOVA. The proportions of patients with mild (less than 3 lines of Snellen CVA loss), moderate (3–5 lines, inclusive), severe (more than 5 lines) vision loss were calculated and compared using a Chi-squared test. Logistic regression analysis was conducted to identify risk factors associated with a loss of 3 or more lines of CVA 6 months after surgery. RESULTS: A total of 375 patients were included, whose mean preoperative CVA was 0.76. At postoperative 1 week, mean CVA worsened to 0.96 (p < 0.05), but recovered back to preoperative level by the third postoperative month (p > 0.05). In terms of any vision loss, 55.6% of patients had worse CVA than pre-operation at postoperative 1 week, including 23.5% who had 3 or more lines of vision loss; these proportions decreased to 39.2% (p < 0.001) and 9.3%, respectively, by postoperative 6 months. The most common causes of significant vision loss were pre-existing ocular conditions and cataract progression. Postoperative anti-metabolite injection was associated with a lower risk of 3 or more lines of CVA loss 6 months postoperatively (OR 0.44, p = 0.023). CONCLUSIONS: After Ahmed tube shunt procedure, worst CVA occurred at 1 week postoperatively and mean CVA returned to preoperative level by the third postoperative month. About 40% of patients had any CVA loss compared to pre-operation, while 9.3% of patients had 3 or more lines of CVA loss at the 6th postoperative month. Postoperative anti-metabolite injection was associated with a lower risk of 3 or more lines of postoperative vision loss.

To determine the diagnostic accuracy of potential screening tests for moderate to advanced glaucoma.Prospective diagnostic test accuracy study.The study enrolled a consecutive series of patients aged ≥50 years who presented to a glaucoma clinic in South India without ever having received automated visual field testing.All participants underwent 8 index tests: OCT of the peripapillary retinal nerve fiber layer, optic disc photography, Moorfield's Motion Displacement Test (MDT), frequency doubling technique perimetry, noncontact tonometry, pneumatonometry, presenting visual acuity, and best-corrected visual acuity. Participants also underwent stereoscopic photographs and Humphrey visual fields, which were used by 2 ophthalmologists to arrive at the reference standard diagnosis of moderate to advanced glaucoma.Sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio.A total of 217 people were enrolled; 321 eyes from 180 participants had all tests performed. Of these, 127 eyes (40%) were classified as having moderate to advanced glaucoma. Among the 8 tests, OCT best optimized sensitivity (84%, 95% confidence interval [CI], 76-90) and specificity (75%, 95% CI, 68-81). Moorfield's Motion Displacement Test was the best perimetric test, with a sensitivity of 91% (95% CI, 85-96) and specificity of 53% (95% CI, 44-61). Pressure and vision tests were not sensitive (e.g., sensitivity of 16%, 95% CI, 9-23 for noncontact tonometry and 23%, 95% CI, 15-31 for best-corrected visual acuity). Moorfield's Motion Displacement Test identified 16 of 127 eyes (13%) with glaucoma that were not captured by OCT, but also had false-positive results in 65 of 194 eyes (34%) without glaucoma that OCT correctly classified as negative.OCT had moderate sensitivity and fair specificity for diagnosing moderate to advanced glaucoma and should be prioritized during an initial assessment for glaucoma.

Purpose To investigate ON-pathway versus OFF-pathway dysfunction in glaucoma using handheld electroretinography (ERG) with a temporally modulated sinusoidal flicker stimulus. Design Cross-sectional study. Participants Fifty-nine participants accounting for 104 eyes, comprised of 19 control eyes, 26 glaucoma suspect eyes, and 59 glaucoma eyes. Methods Participants underwent portable ERG testing, which included the photopic flash, photopic flicker, photopic negative response stimulus, ON-OFF stimulus, and a custom-written sinusoidal flicker stimulus that was modulated from 50 to 0.3 Hz. Main Outcome and Measures The ERG response amplitudes were measured by the handheld ERG. For the custom-written sinusoidal flicker stimulus, we derived and compared the log10 first harmonic frequency response amplitudes. Patient discomfort and fatigue after ERG testing were rated on a scale from 1 to 5 Results Baseline demographics were not significantly different between groups, except for ocular characteristics. Analysis was performed adjusting for participant age, sex, race, and dilation status, and the sinusoidal frequency responses were stratified at 10 Hz because higher frequencies are associated with the OFF-pathway, whereas lower frequencies are associated with the ON-pathway. After stratification, glaucoma eyes showed an adjusted decrease of 32.1% at frequencies of more than 10 Hz (95% confidence interval [CI], −51.8% to −4.1%; P = 0.03). For 10 Hz stimulus frequencies or less, an adjusted 11.5% reduction was found (95% CI, −39.5% to 29.1%; P = 0.50). Glaucoma suspect eyes did show a decreased response, but this was not significant at either frequency range. When comparing handheld ERG with traditional visual field assessments, participants found the handheld ERG to result in much less discomfort and fatigue. Conclusions Our finding that glaucoma participants showed greater decreases in ERG response at higher frequencies supports the hypothesis that the OFF-pathway may be more vulnerable in human glaucoma. Using a handheld ERG device with a sinusoidal flicker stimulus may provide an objective assessment of visual function in glaucoma.

Purpose To evaluate the agreement between Goldmann applanation tonometry (GAT; Haag-Streit, Bern, Switzerland) and several portable tonometers that could be used for glaucoma screening programs. Design Evaluation of a diagnostic test. Participants Three hundred twenty-one eyes of 168 participants seeking treatment at the glaucoma clinic of a tertiary eye hospital in India. Methods Participants underwent intraocular pressure (IOP) measurement with GAT and 4 index tests: the Icare TA01i rebound tonometer (Icare USA, Raleigh, NC), a noncontact tonometer (NCT; Topcon CT-80; Topcon; Tokyo, Japan), a pneumatonometer (Model 30; Reichert Technologies; Depew, NY), and the Tono-Pen AVIA (Reichert Technologies). Main Outcome Measures Estimates of reproducibility of IOP measurements between each index test and GAT, including the intraclass correlation coefficient (ICC) and the Bland-Altman 95% limits of agreement. Results The Icare showed the greatest agreement with GAT (ICC, 0.69; 95% confidence interval, 0.61–0.74), followed by the NCT (ICC, 0.65; 95% confidence interval, 0.58–0.71), the Tono-Pen (ICC, 0.51; 95% confidence interval, 0.43–0.59), and the pneumatonometer (ICC, 0.36; 95% confidence interval, 0.27–0.44). The pneumatonometer and Tono-Pen tended to overestimate IOP relative to GAT, with a mean difference of 3.4 mmHg (95% limits of agreement [LOA], –7.3 to 14.1 mmHg) for the pneumatonometer and 3.2 mmHg (95% LOA, –6.1 to 12.6 mmHg) for the Tono-Pen. In contrast, measurements from the Icare and NCT were on average within 1 point of those for GAT (mean difference, –0.4 mmHg [95% LOA, –8.4 to 7.6 mmHg] and –0.5 mmHg [95% LOA, –8.7 to 7.6 mmHg], respectively). Conclusions The Icare and NCT both demonstrated good agreement with GAT across a wide range of IOPs and could be considered for glaucoma screening programs.

AIM: To evaluate aspects of cognition impacted by individuals with and without normal tension glaucoma. METHODS: Fifty normal tension glaucoma (NTG) and 50 control patients ≥50y of age were recruited from the UCSF Department of Ophthalmology. Demographic data and glaucoma parameters were extracted from electronic medical records for both groups. Tests of executive function [Executive Abilities: Measures and Instruments for Neurobehavioral Evaluation and Research (EXAMINER)] and learning and memory [California Verbal Learning Test–Second Edition (CVLT-II)] were administered to both NTG and controls. Race, handedness, best-corrected visual acuity, maximum intraocular pressure, optic nerve cup-to-disc ratio, visual field and optic nerve optical coherence tomography parameters, and a measure of general health (Charlson Comorbidity Index) were compared between NTG and controls as well as within NTG subgroups. Multivariate linear regression was used to compare group performances on the EXAMINER battery and CVLT-II while controlling for age, sex, and years of education. RESULTS: NTG and controls were comparable with respect to age, sex, race, education, handedness, and the Charlson Comorbidity Index (P>0.05 for all). Performance on the EXAMINER composite score and the CVLT-II did not differ between NTG and controls (P>0.05 for both). CONCLUSION: This is the first prospective study in which the cognitive function of subject with NTG were evaluated using a comprehensive, computerized neurocognitive battery. Subjects with NTG do not perform worse than unaffected controls on tests of executive function, learning, and memory. Results do not support the hypothesis that individuals with NTG are at higher risk for cognitive dysfunction and/or dementia.

Purpose Autorefractors allow non-specialists to quickly assess refractive error, and thus could be a useful component of large-scale vision screening programs. In order to better characterize the role of autorefraction for public health outreach programs in resource-limited settings, the diagnostic accuracy of two autorefractors was assessed relative to subjective refraction in an adult Indian population. Methods An optometrist refracted a series of patients aged ≥50 years at an eye clinic in Bangalore, India using the Nidek ARK-900 autorefractor first, followed by the 3nethra Royal autorefractor, and then subjective refraction. The diagnostic accuracy of each autorefractor for myopia, hyperopia, and astigmatism was assessed using subjective refraction as the reference standard, and measures of agreement between refractions were calculated. Results A total of 197 eyes in 104 individuals (mean age 63 ± 8 years, 52% female) were evaluated. Both autorefractors produced spherical equivalent estimates that were on average more hyperopic than subjective refraction, with a measurement bias of +0.16 D (95%CI +0.09 to +0.23D) for Nidek and +0.42 D (95%CI +0.28 to +0.54D) for 3nethra. When comparing pairs of measurements from autorefraction and subjective refraction, the limits of agreement were approximately ±1D for the Nidek autorefractor and ±1.75D for the 3Nethra autorefractor. The sensitivity and specificity of detecting ≥1 diopter of myopia were 94.6% (95%CI 86.8–100%) and 92.5% (95%CI 88.9–97.5%) for the Nidek, and 89.2% (95%CI 66.7–97.4) and 77.5% (95%CI 71.2–99.4%) for the 3Nethra. The accuracy of each autorefractor increased at greater levels of refractive error. Conclusions The sensitivity and specificity of the Nidek autorefractor for diagnosing refractive error among adults ≥50 years in an urban Indian clinic was sufficient for screening for visually significant refractive errors, although the relatively wide limits of agreement suggest that subjective refinement of the eyeglasses prescription would still be necessary.

PReCIS:: In a case-control study, skin pigmentation was not statistically significantly different when comparing glaucoma patients to those without glaucoma. Purpose Darker skin color has been implicated as a risk factor for glaucoma based on previous studies' subjective assessments of skin pigmentation. This study used objective measurements to determine whether cutaneous pigmentation is a risk factor for glaucoma. Methods This case-control study was conducted at Menelik II Tertiary Referral Hospital in Addis Ababa, Ethiopia. Patients aged 40 years or older from the glaucoma clinic who were being scheduled for trabeculectomy were enrolled as cases and age-matched patients without glaucoma from other clinics at Menelik II Tertiary Referral Hospital were enrolled as controls. A Dermacatch device was used to capture melanin measurements in triplicate from the inner arm of each participant. The exposure variable of interest was the median of the triplicate skin melanin measurements, in arbitrary units. The outcome of interest was presence of glaucoma. Results Agreement between the triplicate inner arm melanin measurements was high, with an intraclass correlation of 0.99 (95% confidence interval, 0.98-0.99). Mean melanin values were 704 units (SD 94) in 76 cases and 694 units (SD 93) in 152 controls. Melanin was not statistically significantly associated with glaucoma after adjusting for sex and season of measurement (ie, dry vs. rainy), with an odds ratio of 1.15 (95% confidence interval, 0.59-2.24) per 100 units of inner arm melanin. Conclusion This study failed to find a significant association between skin pigmentation and glaucoma using an objective and reproducible assessment of pigmentation.

PRéCIS:: Publications in glaucoma have seen an increase in the number of authors and disclosures per article, authors with dual degrees, and international authors, but contributions of women to articles published remains low.Authorship trends have been studied across many medical specialties and in ophthalmology as a whole, but not specifically in glaucoma. The authors explored the authorship trends of original scientific articles in the Journal of Glaucoma.The authors recorded the number of authors and disclosures per article, degree type of first and last authors, geographical origin of the corresponding author, and sex of first and last authors of original content from the Journal of Glaucoma published in 1992, 1997, 2002, 2007, 2012, and 2017.A total of 642 articles were analyzed. From 1992 to 2017, annual published articles increased from 38 to 242 (P=0.02), the mean number of authors per article increased from 3.2 to 5.2 (P0.01), the mean number of disclosures per article increased from 0.3 to 1.0 (P=0.04), the proportion of first and last authors with dual degrees (medical plus advanced degrees) also increased (both P0.03), whereas the proportion with a sole medical degree decreased (both P0.05). There was a proportional decrease in articles from North America (P=0.03), and proportional increase from the "Far East" (P=0.04) and "Other" regions (P=0.04). No significant changes in proportions of female first and last authors were found (both P0.28).Consistent with authorship trends across various other medical specialties, glaucoma has seen an increase in the number of authors and disclosures per article, authors with dual degrees, and authors from the "Far East" and "Other" regions. However, contributions of women to articles published in Journal of Glaucoma remain low.

Introduction: Glaucoma is the leading cause of irremediable blindness worldwide. The prevalence of glaucoma will continue to increase with the increased ageing of the global population. The only way to reduce the progression of vision loss due to glaucoma is to control the level of intraocular pressure (IOP). IOP control initially depends upon pharmaceutical interventions. The efficacy of IOP-lowering medications is limited by poor patient compliance, incorrect medication administration, ocular side effects and cost. When IOP-lowering medications fail to halt the progression of glaucoma, surgical intervention, such as trabeculectomy or glaucoma drainage device surgery, is indicated, but neither has been found completely satisfactory. Surgical interventions have a significant risk of complications that result in decreased vision.Areas covered: This article summarizes the design and function, as well as reviewing the efficacy, of various innovative, highly safe, surgical approaches to the treatment ...

Background To examine the effect of mitomycin c (MMC) and 5-flurouracil (5-FU) on treatment outcomes following Ahmed glaucoma valve (AGV) implantation. Design Retrospective consecutive case series. Participants Fifty patients who received AGV implantation from 1999–2013 in the San Francisco VA hospital. Methods The + INJECTION group received intraoperative MMC followed by postoperative injections of MMC and/or 5-FU whereas the -INJECTION group did not. Main Outcome Measures Primary outcome was treatment success at one year post-implantation. Intraocular pressure (IOP), the presence of a hypertensive phase (HP), and the number of glaucoma medications were examined at time points up to one year. Results Twenty-six patients/eyes in the + INJECTION group and 24 patients/eyes in the -INJECTION group were included. Treatment success was higher in the + INJECTION compared to the -INJECTION group (86% versus 58%; p = 0.04). IOP was lower in the + INJECTION compared to the -INJECTION group at 1, 3, 6, and 12 months (p

To compare the complication rate and effectiveness of mitomycin C (MMC), Ologen alone, and Ologen with 5-fluorouracil (5-FU) as adjunctives with Ex-PRESS mini shunt for medically uncontrolled glaucoma. Retrospective comparative study of 59 Ex-PRESS mini shunt trabeculectomy operations coupled with Ologen implantation alone, transient MMC application or Ologen implantation with 5-FU as adjunctive treatment. Eight eyes (7 patients) received Ologen alone, 37 eyes (34 patients) received MMC, and 14 eyes (14 patients) received Ologen with 5-FU as adjunctive therapy. Baseline characteristics, adjunctive used during operation, along with outcomes including intraocular pressure (IOP), number of anti-hypertensive drops, visual acuity, and complications were documented and compared. The primary outcome was IOP at 12 months. Variables were compared with r × c Fisher tests. The Ologen only group had a significantly higher IOP at 12 months (20.5 ± 10.23 mmHg) compared with Ologen combined with 5-FU (12.2 ± 1.47 mmHg) or MMC (13.8 ± 4.37 mmHg) (p = 0.015, linear mixed model). The Ologen only cohort also had a higher re-operation rate (p = 0.01, Fisher's Exact Test) and higher rate of bleb leak (p = 0.02, Fisher's Exact Test). Visual acuity was similar among all three groups. 5-FU with Ologen is as effective as MMC in maintaining IOP following Ex-PRESS shunt surgery at 1 year. However, Ologen alone may not be as effective as the other two adjunctive agents.

PURPOSE OF THE STUDY The purpose of the study was to examine reoperation rate and complications of resident-performed glaucoma surgeries within the first 90 postoperative days. MATERIALS AND METHODS A retrospective study of resident-performed glaucoma filtering surgeries at the San Francisco Veterans Affairs Medical Center between 2002 and 2014 was performed. Patients requiring reoperation within 90 days of the initial surgery were included in our study. Combined surgeries were excluded. Complications and the rates of reoperation within the first 90 days were evaluated. Clinical outcomes for those who needed reoperations were evaluated at the 1-year follow-up. RESULTS Total of 180 cases were reviewed [34 trabeculectomy, 85 Ex-PRESS shunt, and 61 Ahmed glaucoma valve (AGV)]. One hundred and four eyes developed complications, most commonly choroidal effusion (65.3%), followed by hypotony (45.2%) and wound leak (32.7%). Complications were comparable among the 3 groups, except that filtering surgery had significantly more wound leak than AGV (P

PurposeGlaucoma screening can be performed by assessing the vertical-cup-to-disk ratio (VCDR) of the optic nerve head from fundus photography, but VCDR grading is inherently subjective. This study investigated whether computer software could improve the accuracy and repeatability of VCDR assessment.MethodsIn this cross-sectional diagnostic accuracy study, 5 ophthalmologists independently assessed the VCDR from a set of 200 optic disk images, with the median grade used as the reference standard for subsequent analyses. Eight non-ophthalmologists graded each image by two different methods: by visual inspection and with assistance from a custom-made publicly available software program. Agreement with the reference standard grade was assessed for each method by calculating the intraclass correlation coefficient (ICC), and the sensitivity and specificity determined relative to a median ophthalmologist grade of ≥0.7.ResultsVCDR grades ranged from 0.1 to 0.9 for visual assessment and from 0.1 to 1.0 for software-assisted grading, with a median grade of 0.4 for each. Agreement between each of the 8 graders and the reference standard was higher for visual inspection (median ICC 0.65, interquartile range 0.57 to 0.82) than for software-assisted grading (median ICC 0.59, IQR 0.44 to 0.71); P = 0.02, Wilcoxon signed-rank test). Visual inspection and software assistance had similar sensitivity and specificity for detecting glaucomatous cupping.ConclusionThe computer software used in this study did not improve the reproducibility or validity of VCDR grading from fundus photographs compared with simple visual inspection. More clinical experience was correlated with higher agreement with the ophthalmologist VCDR reference standard.

To examine the effect of mitomycin c and 5-flurouracil on treatment outcomes following Ahmed glaucoma valve implantation.Retrospective consecutive case series.Fifty patients who received Ahmed glaucoma valve implantation from 1999 to 2013 in the San Francisco Veterans Administration Hospital.The +INJECTION group received intraoperative mitomycin c followed by postoperative mitomycin c and/or 5-flurouracil, whereas the -INJECTION group did not.Primary outcome was treatment success at 1 year post-implantation. Intraocular pressure, hypertensive phase, and the number of glaucoma medications were also examined.Twenty-six patients/eyes in the +INJECTION group and 24 patients/eyes in the -INJECTION group were included. Treatment success was higher in the +INJECTION compared with the -INJECTION group (86 vs. 58%; P = 0.04). Intraocular pressure was lower in the +INJECTION compared with the -INJECTION group at 1, 3, 6 and 12 months (P ≪ 0.00001, P = 0.00003, 0.0008 and 0.024). Hypertensive phase occurred less often in the +INJECTION compared with the -INJECTION group (3.8 vs. 54%; P = 0.021). The +INJECTION group required fewer medications compared with the -INJECTION group (P = 0.02, 0.002, 0.003 and 0.008 at 1, 3, 6 and 12 months). Complication rates were comparable between groups (46.2 and 54.2%; P = 0.63).Adjuvant treatment with antifibrotics following Ahmed glaucoma valve implantation decreased the hypertensive phase and improved surgical outcomes without impacting complication rates at 1 year. This study postulates a role for antifibrotics in the postoperative management of Ahmed glaucoma valves.

To compare outcomes between resident-performed trabeculectomy and Ex-PRESS shunt implantation.A consecutive cohort of 36 Ex-PRESS shunt implantations and 57 trabeculectomies (1 eye/patient) performed by resident surgeons in their third year of ophthalmic training at the University of California, San Francisco and at the San Francisco Veterans Administration Hospital, under the supervision of a single glaucoma fellowship-trained surgeon were included in this study. Eyes with6 months of follow-up or previous glaucoma surgery were excluded. Preoperative and postoperative intraocular pressure (IOP), preoperative and postoperative number of ocular antihypertensive medications and complication rates were compared between the 2 procedures retrospectively.No difference was found in postoperative IOP (all, P≥0.099) or proportional decrease in IOP (all, P≥0.092) between the trabeculectomy and Ex-PRESS shunt groups at all follow-up points. On average, the Ex-PRESS shunt group required significantly less ocular antihypertensive medication to control IOP at 3 months postoperative (P=0.01), but no difference was found at 6 months or 1 year (all, P≥0.28). A larger proportion of Ex-PRESS shunt patients had good IOP control without medication at 3 (P=0.057) and 6 months (P=0.076) postoperatively. No difference was found in the rates of sight-threatening complications between groups (all, P≥0.22).In the hands of ophthalmology residents in their third year of training, the trabeculectomy and Ex-PRESS shunt implantation procedures perform comparably in terms of postoperative IOP control, reduction in patient dependence on ocular antihypertensive medications, and risk of complication in our population.

Epidermal nevus syndrome (ENS) is a neurocutaneous disorder characterized by epidermal hamartomas and abnormalities of the brain, eye, and other systems. We report the occurrence of congenital angle closure glaucoma in a patient with epidermal nevus syndrome. Intraoperative use of ultrasound biomicroscopy was essential in making the diagnosis.

The definition of glaucoma has changed over the decades from a simple ocular pressure disease to a systemic disorder of multivariate etiology. Glaucoma may be defined for the individual eye as a chronic ocular disease with various underlying pathophysiologic disorders. However, elevated intraocular pressure (IOP) is still the most important risk factor for an untreated glaucomatous eye to progress to a more severe stage of the disease. As the main risk factor within therapeutic reach, IOP and its appropriate measurement deserve our ongoing interest. Not only has our understanding of glaucoma changed but also our approach to the measurement of the IOP. In this article we focus our attention on the various developments in tonometry from the simple force-tonometers of the late 19th century to the high-technology pressure tonometers that were recently introduced for clinical use.

Purpose: To determine the effect of statins and aspirin on the rate of progression of optic nerve parameters in open-angle glaucoma (OAG) suspects, as defined by confocal scanning laser ophthalmoscopy (CSLO). Methods: Data of OAG suspects who had undergone at least two CSLO tests at the Beckman Vision Center at UCSF from January 2001 to June 2006 was collected. We conducted a retrospective chart review of 149 eyes from 76 patients considered suspect for glaucoma based on a cup-to-disc ratio >0.5, but with normal intraocular pressures (IOP) and visual fields. Subjects included glaucoma suspects who took statin drugs or aspirin for greater than 23 months. The control group consisted of suspects who never used statins or aspirin. The data were analysed using mixed effects regression. Results: When comparing controls with the statin group there were significant differences in the progression of multiple CSLO parameters per year, including rim volume (−13.7% controls, +26.7% statin only; P = 0.0156), retinal nerve fibre layer cross-sectional area (−12.2% controls, +24.3% statin only; P = 0.0051), and mean global retinal nerve fibre layer thickness (−10.3% controls, +26.6% statin only; P = 0.0114), with adjustment for age, gender, race, IOP, central corneal thickness, refractive error and multiple systemic comorbidities. No significant differences were found when comparing subjects taking a statin plus aspirin or aspirin alone with the controls. Conclusions: Statin drugs may be associated with slowed progression of optic nerve parameters in glaucoma suspects as measured by CSLO.

To evaluate whether treatment of systemic hypertension has an effect on progression of optic nerve parameters in glaucoma suspects using confocal scanning laser ophthalmoscopy.Two hundred eyes of 103 glaucoma suspect patients were included in this retrospective cohort study. Thirty-one patients (of whom 59 eyes were included in the study) had systemic hypertension under treatment (based on medical history). The remaining 72 age-matched normotensive controls (of whom 141 eyes were included in the study) were not on blood-pressure-lowering medications. Each patient had a follow-up period of at least 4 years with a minimum of four Heidelberg retinal tomograph tests (one baseline and three follow-up scans). The slopes of progression of optic nerve head parameters with time were studied and compared between these two groups using mixed effects regression models.Patients with systemic hypertension showed a statistically significant increase in cup area (slope 0.2, p = 0.03), cup-to-disk area ratio (slope 0.01, p = 0.007), and decrease in rim area (slope -0.4, p = 0.03), rim-to-disk area ratio (slope -0.01, p = 0.005), and global Retinal Nerve Fiber Layer (RNFL) thickness (p = 0.008) with time. The differences in slopes of progression of many parameters between hypertensives and normotensives were statistically significant.Systemic hypertension treated with hypotensive medications may be a risk factor for increased progression of optic nerve parameters in glaucoma suspects compared with age-matched normotensive subjects.

The etiology of corneal decompensation after aqueous shunt implantation remains poorly understood. With the use of anterior segment optical coherence tomography and specular microscopy, the relationship of these implants to the surrounding tissues can be investigated over time. This article will review the current knowledge pertaining to endothelial cell loss related to glaucoma and surgery and highlight possible causes that have been proposed for endothelial cell loss after aqueous shunt implantation.

To compare intraocular pressure (IOP) reduction and complications of resident-performed argon laser trabeculoplasty (ALT) and selective laser trabeculoplasty (SLT).This was a retrospective, interventional, comparative case series performed at the San Francisco Veterans Affairs Hospital. The study included 77 patients each undergoing 1 resident-performed ALT procedure from April 2006 through November 2009, and 81 patients each undergoing 1 resident-performed SLT procedure from November 2009 through December 2011. Reduction in IOP at 12 months and a longitudinal analysis across 24 months was determined. Secondary outcomes investigated included additional interventions of either repeat trabeculoplasty or trabeculectomy as well as change in eye drop medications.There was no evidence of a difference between IOP reductions in patients undergoing ALT compared with SLT at 12 months (P=0.41, linear modeling) or across all follow-up appointments (P=0.62, linear-mixed effects regression). Patients undergoing ALT had a significantly increased number of eye drops (+0.6 vs. -0.1 drops, P0.001, Wilcoxon rank-sum test) and trend toward increased rates of additional interventions (P=0.06, Weibull regression). There was no difference in immediate postprocedure IOP rise between the 2 groups (P=0.75, Wilcoxon rank-sum test) or any evidence of change in visual acuity.We found no difference in IOP reduction between patients undergoing resident-performed ALT compared with SLT. However, patients undergoing ALT had a significant increase in eye drop medications and trend toward additional interventions compared with patients undergoing SLT.

To compare the intraocular pressures (IOP) and ocular pulse amplitudes (OPA) in patients with different types of glaucoma, ocular hypertension (OHT), and normal controls (NC) using dynamic contour tonometry (DCT) and the goldmann applanation tonometry (GAT).906 eyes of 501 adult patients in the following five groups were included in this cross-sectional study: primary open angle glaucoma (POAG), normal tension glaucoma (NTG), Pseudoexfoliative Glaucoma (PXG), OHT, and NC. The following tests were performed simultaneously during a single visit: IOP using DCT and GAT; OPA using DCT and central corneal thickness (CCT) using ultrasound pachymetry. Mixed effects regression models were used to compare the DCT and GAT IOP measurements in the five groups; the effect of CCT on IOP and the relationship between OPA and IOP within each group.DCT consistently had higher IOP values than GAT in POAG, PXG, NTG, and controls (p0.001) but not in OHT (p = 0.84). DCT IOP did not change while GAT IOP showed a non-significant increase (p = 0.09) with increased corneal thickness in each group. OPA was found to be highest in OHT (3.61 mmHg) and lowest in the control group (2.86 mmHg) and significantly increased with IOP in all groups.DCT measures an IOP that is significantly higher than GAT IOP in glaucoma and control subjects but not in ocular hypertensives. Furthermore, the DCT may measure an IOP that is independent of the CCT, which may not be true for the GAT, which increases with the CCT. OPA was highest in OHT and may be affected by the IOP.

In an experimental laboratory investigation we compared intraocular pressure (IOP) measurements obtained by dynamic contour tonometry (DCT), Goldmann applanation tonometry (GAT), and pneumatonometry (PTG) with intracameral manometry on human cadaver corneas of different hydration conditions.Ten freshly enucleated eyes were de-epithelialized. Two tubes were placed in the anterior chamber in opposite directions and connected to a transducer and to a bottle system filled with balanced salt solution. The pressure in the eye was then adjusted between 5 mmHg and 58 mmHg by electronically altering the height of the bottle. Central corneal thickness (CCT) was registered and IOP measurements were obtained with DCT, GAT, and PTG at each manometric pressure reading. Immediately after the trial the same corneas were artificially dehydrated and the same measurement regimen was repeated.In the pressure range defined by the bottle height 10-50 cm, IOP values measured by DCT were 0.50 mmHg (95% CI=0.40-0.60) and 0.36 mmHg (95% CI=0.25-0.47) higher than manometric readings before and after dehydration, respectively. GAT showed consistently lower values than manometry, the difference being -3.48 mmHg (95% CI=-3.91 to -3.05) and -3.14 mmHg (95% CI=-3.39 to -2.89), respectively. Similar results were obtained with PGT, namely differences of -4.75 mmHg (95% CI=-5.21 to -4.29) and -3.98 mmHg (95% CI=-4.48 to -3.48) for the hydrated and the dehydrated corneal condition, respectively. Only DCT showed no significant change in accuracy between hydrated and dehydrated corneas.In this in vitro study DCT values for IOP were significantly closer to the manometric reference pressure than those obtained using GAT and PTG, independent of the state of corneal hydration.

Despite its critical importance to our daily life, the most common measurement of visual function, visual acuity, is a relatively crude and narrow one testing only a small portion of the broad range of visual functions. Visual acuity is the measurement of the ability to discriminate two stimuli separated in space at high contrast relative to the background. Clinically, this is measured by asking the subject to discriminate letters of known visual angle. The visual acuity is represented as the reciprocal of the minimal angle of resolution (the smallest letters resolved) at a given distance and at high contrast. Other measurements of visual acuity also exist, including Vernier acuity. Newer charts, such as the ETDRS chart, use letters of equal recognition difficulty and use the log of the minimal angle of resolution; these charts have significant advantages over the old Snellen-type charts. This article reviews visual measurements in children and in patients with low vision, and it reviews factors affecting visual acuity, such as pupil size, refractive error, media opacities, and pharmacologic agents.

This set of Viewpoints articles examines the merits of beta-blockers versus other medications as the primary drug treatment for glaucoma. Ophthalmologists must balance issues such as efficacy, compliance, cost, and side effects when deciding on the appropriate medication to prescribe. Dr. Stamper stresses the advantages of tailoring the choice of medication to the needs of the individual patient. Drs. Wigginton and Higginbotham review the benefits of beta-blockers and present some of the disadvantages of the non-beta-blocker class of medications. ( Surv Ophthalmol 47: 63-73, 2002. © 2002 by Elsevier Science Inc. All rights reserved.)

Importance While medication efficacy is well documented in clinical trials, less is known of medication effectiveness in real-world clinical settings. Objective To assess the effectiveness of intraocular pressure (IOP)–lowering medications in patients with open-angle glaucoma. Design, Setting, and Participants Prospective, multicenter, interventional cohort from the prerandomization phase of a randomized clinical trial at multiple ophthalmology clinics. A total of 603 patients (603 eyes) with primary open-angle glaucoma who were using up to 3 glaucoma medications were included. Interventions One IOP measurement was made while the patient was using his or her usual medications to lower IOP (ON IOP). Eligible participants underwent washout of all IOP-lowering drops, and the diurnal IOP was measured 2 to 4 weeks later (OFF IOP). Main Outcomes and Measures Difference between OFF IOP and ON IOP. The hypothesis was formulated after data collection. Results The mean (SD) ON IOPs for participants using 0 (n = 102), 1 (n = 272), 2 (n = 147), or 3 (n = 82) medications were 24.2 (3.2), 17.5 (3.2), 17.2 (3.1), and 17.2 (3.1) mm Hg, respectively. Patients not using medication had a mean (SD) IOP decrease of 0.2 (2.8) mm Hg at the OFF visit. Patients using 1, 2, and 3 medications had mean (SD) IOP increases of 5.4 (3.0), 6.9 (3.3), and 9.0 (3.8) mm Hg, respectively, at the OFF visit. The percentages of patients with less than a 25% increase in IOP were 38%, 21%, and 13% for those using 1, 2, and 3 medications, respectively. Conclusions and Relevance Discontinuation of 1, 2, and 3 medications was associated with a clinically significant increase in IOP, although with smaller effects for the second and third medications compared with the first medication. A substantial proportion of patients showed only small changes in IOP after medication washout, suggesting either that they were not using the medication effectively or that the medication itself, although used properly, was not lowering the IOP. Trial Registration clinicaltrials.gov Identifier:NCT01085357

Letters RESEARCH LETTER Wearable Technology With Head-Mounted Displays and Visual Function Interest in wearable head-mounted display systems for gen- eral consumers is increasing, with multiple models in production. 1 However, their effect on vision is largely un- known. Peripheral visual field is a main component of vision and essential for daily activities such as driving, pedestrian safety, and sports. Conventional spectacle frames can reduce visual field, sometimes causing absolute scotomas (blind spots), 2 and head- mounted devices have even more pronounced frames. To quantify their effect on visual function, we compared perfor- mance on perimetric visual field tests with a head-mounted device vs regular eyewear. Methods | Three healthy emmetropic or refractively corrected individuals with 20/20 best-corrected visual acuity and nor- mal baseline visual fields were tested in April 2014. Partici- pants used a wearable device (Google Glass, Google Inc), fol- lowing manufacturer’s instructions, for a 60-minute acclimation period. Participants required minor adjustments to optimize screen visibility. To assess obstruction potential, the display prism’s position relative to the right eye pupillary axis was graded as (1) over central pupillary axis; (2) above cen- tral pupillary axis but inferior to superior limbus; or (3) above superior limbus. Immediately thereafter, participants underwent 30-2 and 60-4 threshold perimetric (visual field) testing with the Hum- phrey Visual Field Analyzer II-750i (Carl Zeiss Meditec). Test- ing was performed first with the device (with software deac- tivated to avoid distractions), followed by a control frame of similar color and temple width. The University of California, San Francisco, determined the study was exempt from insti- tutional review board review. To assess how the devices are worn by general consum- ers, photographs of people wearing the product and facing the camera, obtained from an Internet search conducted on May 1, 2014, were analyzed. 3 The image search included the term Google Glass. The full output of images was reviewed, includ- ing images posted by companies and individuals. Photo- graphs were assessed for prism position relative to the pupil with the grading system described above. Results | Figure 1 shows the baseline characteristics of partici- pants. Visual field testing demonstrated significant scotomas in all 3 participants while wearing the device (Figure 2; note variations in wearing and head position). In all 3 cases, more than 10° of visual field in the horizontal axis were subtended. Scotoma was absent with control perimetry testing with the regular frame. For the image analysis, 311 images were found, with 132 eli- gible for evaluation. The prism covered the pupillary axis in 29.5%, covered the eye but not the axis in 29.5%, and was su- perior to the limbus in 41%. Therefore, 59% had the prism in a position likely to interfere with vision. Discussion | To our knowledge, this is the first evaluation of the effect of wearable electronics with head-mounted display on vision. The device created a clinically meaningful visual field obstruction in the upper right quadrant. Defects were in- duced by the frame hardware design only and were not re- lated to a distracting effect of software-related interference. Image analysis further demonstrated that many people wear the device near or overlapping their pupillary axis, which may induce scotomas and interfere with daily function. This study is limited by the small number of participants, who may not be representative of all users. Even though the scotomas were easily identifiable, a larger sample is needed to identify factors that influence scotoma size and depth. The Figure 1. Baseline Characteristics of Participants Age, y Participant 1 Participant 2 Participant 3 Sex Male Male Male Race White Pacific Islander Asian Refraction oculus dexter (OD) a Plano Plano Best corrected visual acuity OD a Prism placed over the central pupillary axis Prism cleared the central pupillary axis but was inferior to the superior limbus Prism placed over the central pupillary axis Pupillary distance, mm Wearable device prism position a jama.com jamanetwork/2014/jama/05nov2014/jld140032 Indicates the right eye. JAMA November 5, 2014 Volume 312, Number 17 PAGE: right 1 SESS: 24 OUTPUT: Oct 17 11:34 2014

Purpose: To determine the ability of scanning laser polarimetry (GDx Nerve Fiber Analyzer; Laser Diagnostic Technologies, Inc., San Diego, CA) to separate normal eyes and those considered likely to have glaucoma in a public glaucoma screening. Methods: A 2-day public glaucoma screening program was held at two different institutions. Each subject underwent ophthalmologic examination, Humphrey perimetry (24–2 Fastpac program), and imaging using scanning laser polarimetry (GDx) in each eye for allocation into a diagnostic category: normal, ocular hypertensive, glaucoma suspect, or glaucoma. Results from the normal and glaucoma groups were analyzed, using modulation parameters calculated from a measurement band located 1.8 disc diameters from the disc, and selected parameters provided automatically by GDx software. Receiver operating characteristic curves were used to depict the sensitivity/specificity relationship at different GDx parameter cutoff levels. Results: Of 200 subjects, 197 were classified; 122 were classified as normal, 23 were classified with ocular hypertension, 30 were classified as glaucoma suspects, and 22 were classified with definite glaucoma. Three subjects had ocular diseases other than glaucoma. The maximum area under the receiver operating characteristic curve for modulation parameters was 0.935, and for the GDx software parameters was 0.901. Conclusions: Scanning laser polarimetry may be useful in glaucoma screening.

Purpose To describe the late onset of sequential multifocal bleb leaks as a postoperative complication after filtering surgery with antimetabolites. Materials Retrospectively, 385 consecutive eyes (304 patients) undergoing trabeculectomy with 5-fluorouracil (5-FU) or mitomycin C (MMC) from 1989 to 1994 were reviewed. Eyes with filtration bleb leak occurring 6 months or more after trabeculectomy were analyzed, and clinical characteristics of the filtration bleb, response to treatment, and bleb histopathology from eyes undergoing bleb excision were analyzed. Results In seven (1.8%) of 385 consecutive eyes from 304 patients undergoing glaucoma filtration surgery with 5-FU or MMC, repetitive bleb leaks in different locations of the bleb were observed from 9 to 44 months (mean, 20.4 months) after the procedure. One hundred ninety-three eyes (50%) were treated with 5-FU and the remaining eyes, with MMC. All eyes had transparent, avascular, lobular, cystic blebs. Bleb leaks occurred in five eyes treated postoperatively with subconjunctival 5-FU and in two eyes in which MMC was used intraoperatively. Three eyes (all treated with 5-FU) required surgical excision, and four eyes healed with soft contact lens, cyanoacrylate glue, or intrableb injection of autologous blood. Histopathology of the bleb leak sites demonstrated focal epithelial thinning and interruption with subjacent hypocellularity and stromal collagen degeneration. Conclusion Late sequential multifocal bleb leaks may occur after glaucoma filtration surgery with administration of antimetabolites (5-FU or MMC) and are associated with epithelial breakdown, hypocellularity, and stromal collagen necrosis in the filtration bleb.

Purpose To assess the screening efficacy and practical use of two portable devices to detect moderate to severe visual field loss rapidly in population screening. Methods Henson visual field analysis and Damato campimetry for glaucoma were performed in a healthy adult population, to determine false-positive rates; in established glaucoma patients and suspects, to determine false-negative rates; and in a general adult population, to assess practical use in actual screenings. Results There were no false-positive test failures among the 82 normal subjects who completed the Henson two-step screening. Eighty of 83 normal subjects passed Damato campimetry, resulting in a false-positive rate of 3.6%. Among 83 glaucoma suspects and patients, the Henson test identified 49 (84%) of 58 subjects whose full-threshold fields from Humphrey perimetry were abnormal, 38 (97%) of 39 of whom had moderate to severe visual field loss. The Damato campimeter detected 55 (81%) of 68 subjects with any pathologic loss on full-threshold visual fields, 44 (92%) of 48 of whom had moderate to severe visual field loss. Among 1,278 subjects tested in general population screenings, 55 subjects (4.3%) failed either or both tests. Conclusions The Henson visual field analyzer can discriminate moderately to severely diseased from normal visual fields with high sensitivity and specificity. The Damato campimeter can reliably detect moderate to severe visual field loss with a tolerably low false-positive rate. To overcome the weakness of glaucoma screening by tonometry alone, some forms of visual field testing may be acceptably brief (cost effective) and accurate (sensitive and specific).

PURPOSE: To determine the flow characteristics of the 3 different models of the Ex-PRESS miniature glaucoma device in a controlled laboratory study. MATERIALS AND METHODS: The 3 different Ex-PRESS models (P-50, R-50, and P-200; Optonol Ltd; now Alcon Lab) were tested using a gravity-driven flow test. Three samples of each of the 3 Ex-PRESS models were subjected to a constant gravitational force of fluid at 5 different pressure levels (5 to 25 mm Hg). Four measurements per sample were taken at each pressure level. The main outcome measure was flow rate (Q) (µL/min). Resistance (R) was calculated by dividing pressure (P) by the measured flow (Q). RESULTS: The flow rate was primarily pressure dependent. The P-200 model (internal diameter 200 µm) showed a statistically significant higher flow rate and lower resistance compared with both the P-50 and R-50 models (internal diameter 50 µm) (P

Doctors have not always associated elevated intraocular pressure with the vision loss from glaucoma. Although several individuals appear to have noted firmness of the eye in this condition as far back as the 10th century, elevated intraocular pressure was not routinely assessed until the latter part of the 19th century. von Graefe developed the first instrument for measuring intraocular pressure in 1865. The first reasonably accurate instrument was the Maklakoff applanation tonometer of the late 19th century; it was in widespread use throughout Eastern Europe until relatively recently. Schiötz developed an indentation tonometer that was widely used throughout the world during the first two thirds of the 20th century. Goldmann's applanation tonometer of 1950 began the era of truly accurate intraocular pressure measurement. It is still the most widely used tonometer in the world. Other devices such as the McKay-Marg tonometer (or its offspring the Tono-Pen), the pneumatonometer, and airpuff applanation tonometers are gaining adherents. The dynamic contour tonometer is the first totally new concept in tonometry in over 100 years. It is probably the most accurate of all the tonometers and is relatively independent of corneal biomechanical properties unlike its predecessors. Transpalpebral tonometers are attractive as they do not require topical anesthesia; however, they add the biomechanical properties of the eyelid to the list of potential errors and have not proven very accurate. The future should, hopefully, bring tonometers that can give diurnal or even longer indications of intraocular pressure variation. Although intraocular pressure elevation (or its absence) no longer can be counted on for diagnostic purposes, the role of intraocular pressure in the management of glaucomatous optic neuropathy remains critical.

Long-term success in trabeculectomy has been enhanced in recent years by postoperative subconjunctival 5-fluorouracil injections and intraoperative mitomycin C applications. During 1990 and 1991, after trabeculectomy with a small scleral flap (2 × 3 mm) augmented by antimetabolite therapy, hypotonous maculopathy developed in eight eyes of six patients. The maculopathy was characterized by loss in visual acuity, retinal striae, and choroidal folds without evidence of vascular leakage. The average loss in visual acuity was four Snellen lines. Visual acuity did not return to preoperative levels even when the hypotony could be reversed. Reversing the hypotony with various strategies aimed at stimulating subconjunctival scarring has been relatively ineffective. During that same period, an additional seven eyes in six patients had prolonged hypotony but without development of maculopathy. Features common to patients who developed maculopathy included age (mean age, 46 years; range, 32 to 60 years) and myopia (mean, -7.5 diopters; range, -0.75 to -11.75 diopters). The patients with hypotony but no maculopathy were older (mean age, 73 years; range, 63 to 82 years) and were closer to emmetropia (mean, -1.11 diopters; range, +1.50 to -9.00 diopters). The means of the ages and refractive errors were statistically significantly different in the two groups (P = .007 and .04, respectively). Trabeculectomy with adjunctive antifibrosis therapy should be used with caution in young myopic patients.

PURPOSE: To describe presumed activation of herpetic keratouveitis after argon laser peripheral iridotomy. METHOD: Case report. RESULTS: A 68-year-old man developed chronic, unilateral, anterior uveitis associated with decreased corneal sensation, focal keratitis, and increased intraocular pressure after argon laser peripheral iridotomy. Treatment with oral acyclovir and discontinuation of topical latanoprost resulted in prompt and continued control of both the intraocular inflammation and pressure. CONCLUSION: Herpetic keratouveitis may occur after argon laser iridotomy, and it should be considered when postoperative inflammation persists despite appropriate use of topical corticosteroids, particularly in patients with a history of herpetic eye disease.

Elevated intraocular pressure was first noted to be associated with blindness in the tenth century by an Arabic physician, At-Tabari, and was redescribed in 1622 as being associated with what came to be known as glaucoma by Richard Bannister [1]. Until the late nineteenth century, pressure was estimated by palpation through the eyelid – at best, a way to determine if the intraocular pressure (IOP) is low, medium, high, or very high. Obviously, a way to actually measure IOP was needed if glaucomatous conditions were to be diagnosed and treated effectively. This is especially true now that efficacy of lowering IOP in both ocular hypertension and glaucoma has been firmly established by large, randomized studies [2–7].