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This study determines the relation between visual field impairment, visual functioning, and global quality of life in patients with glaucoma. Binocular visual field impairment was calculated from simultaneous Esterman visual field testing using the Humphrey automated perimeter. Visual acuity impairment, defined with the American Medical Association's Guides to the Evaluation of Permanent Impairment; visual functioning, measured with the VF-14 and the field test version of the National Eye Institute-Visual Functioning Questionnaire; and global quality of life, assessed with the Medical Outcomes Study 36-Item Short Form Health Survey, were determined in 147 consecutive patients with glaucoma. None of the Medical Outcomes Study 36-Item Short Form Health Survey domains demonstrated more than a weak correlation with visual field impairment. The VF-14 scores were moderately correlated (r = -0.58). Of the National Eye Institute-Visual Functioning Questionnaire scales, peripheral vision (r = -0.60), distance activities (r = -0.56), and vision-specific dependency (r = -0.56) were moderately correlated with visual field impairment; vision-specific social functioning, near activities, vision-specific role difficulties, general vision, vision-specific mental health, color vision, and driving were modestly correlated with visual field impairment (r value between -0.32 and -0.55); visual pain was weakly correlated with visual field impairment; and general health and vision-specific expectations were not notably correlated with visual field impairment. Statistically adjusting for visual acuity weakened the correlations. The Medical Outcomes Study 36-Item Short Form Health Survey indicated that our patients with glaucoma were comparable with previously studied patients without severe systemic medical problems. However, the Medical Outcomes Study 36-Item Short Form Health Survey scores did not correlate with visual field impairment in our study. Based on the moderate correlation between binocular visual field impairment with the VF-14 and the National Eye Institute-Visual Functioning Questionnaire, these questionnaires may be useful among patients with glaucoma.

Amblyopia is a condition that, if detected and treated early, can improve vision for most children. Thus, both pediatric and ophthalmologic groups have acknowledged the need for preschool vision screening. However, vision screening is the exception rather than the rule for preschoolers, since traditional methods of vision screening are often inappropriate for the preschool population and almost impossible for those children who are preverbal or nonverbal, developmentally delayed, and/or have chronic illnesses or disabilities. This study evaluated the use of a photoscreener to detect vision problems in a preschool population. Fifty-one children ages 3 to 5 years were evaluated using the MTI PHOTOSCREENER. Results were compared with a complete ophthalmologic examination, including cycloplegia. The sensitivity and specificity calculated for this study was 83% and 68%, respectively. Findings conclude that the MTI Photoscreener detected a broad range of vision problems, seemed to require less time, and seemed more acceptable to preschoolers when compared with the traditional vision screening methods performed by registered nurses. Although the sensitivity and specificity rates for this study were less than desired, it is likely that both could be improved with additional photo interpretation training. [ABSTRACT FROM AUTHOR]

Purpose: To describe the methodology of the Primary Tube Versus Trabeculectomy (PTVT) Study., Design: Multicenter randomized clinical trial., Participants: Patients with medically uncontrolled glaucoma and no prior incisional ocular surgery., Methods: Patients are being enrolled at 16 clinical centers and randomly assigned to treatment with a tube shunt (350-mm 2 Baerveldt glaucoma implant) or trabeculectomy with mitomycin C (0.4 mg/ml for 2 minutes)., Main Outcome Measures: The primary outcome measure is the rate of surgical failure, defined as intraocular pressure (IOP) more than 21 mmHg or reduced by less than 20% from baseline, IOP of 5 mmHg or less, reoperation for glaucoma, or loss of light perception vision. Secondary outcome measures include IOP, glaucoma medical therapy, visual acuity, visual fields, and surgical complications., Conclusions: Practice patterns vary in the surgical management of glaucoma, and opinions differ among surgeons regarding the preferred primary operation for glaucoma. The PTVT Study will provide valuable information comparing the 2 most commonly performed glaucoma surgical procedures., (Copyright © 2017 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: To describe utilization trends of an ophthalmology-specific emergency department (ED)., Methods: Prospective cohort study of new patients presenting in the ophthalmology ED for at least a 30-day period in the spring of each year for five consecutive years (2010-14) at a university referral center. A data form, including information about the ED visit and patient demographics, was included in each patient chart. Data were analyzed with Pearson chi-square test and multiple logistic regression., Results: A total of 5323 chart data forms were completed. An average of 42.2 new patients per day presented to the ophthalmology ED. Most common diagnoses were viral conjunctivitis (8.7%), dry eye syndrome (6.6%), and corneal abrasion (6.6%). Non-emergent visits accounted for 35.8% of surveys completed. Factors associated with non-emergent visits included female gender, age 65 years or older, weekday visits, and patient symptom duration greater than one week (p < 0.0001 for each factor). When compared to all other insurance categories combined, patients who were members of the regional public assistance program were the most likely to present with a non-emergency (48.5% versus 34.9%, p < 0.001), while Workers' Compensation patients were least likely to present with a non-emergency (16% versus 36.5%, p < 0.001)., Conclusions: Over one-third of new patient visits were non-emergent. Factors predictive of non-emergent patient visits were female gender, age 65 years or older, duration of symptoms greater than one week, weekday visits, and the form of insurance coverage.

Competing Interests: None of the authors have any conflicts of interest to disclose.

Purpose: To investigate test-retest reproducibility of visual acuities obtained with a popular mobile application (app) and to explore the agreement with the standard clinic charts., Methods: Records of patients who had visual acuity measured during the same routine clinic visit with Snellen chart, Rosenbaum near vision card, and SightBook mobile app were reviewed. Acuities were converted to approximate ETDRS letters for statistical purposes., Results: One hundred and twenty-six patients were identified. SightBook, Snellen, and near card acuities had excellent test-retest reproducibility. SightBook acuities were significantly different from the near card acuities (mean absolute difference of 5.4 and 6.1 letters in the right and left eyes) and the Snellen acuities (mean absolute difference of 7.7 and 7.9 letters in the right and left eyes). The agreement was also poor between the near card and the Snellen acuities (mean absolute difference of 6.4 and 7.6 letters in the right and left eyes)., Conclusion: The discrepancy between SightBook mobile app and the clinic charts acuities may be large; however, the results are highly reproducible. Obtaining baseline SightBook acuity allows future vision comparisons. SightBook mobile app offers a new portable vision assessment tool for the office and remote patient monitoring.

Purpose: To compare the safety and efficacy of Baerveldt implantation (Abbott Medical Optics, Santa Ana, CA) and trabeculectomy with mitomycin C (MMC) in patients who have not undergone prior incisional ocular surgery., Design: Retrospective, comparative case series., Participants: A total of 125 patients with low-risk glaucoma undergoing primary glaucoma surgery, including 55 patients who received a 350-mm(2) Baerveldt glaucoma implant and 70 patients who underwent trabeculectomy with MMC., Methods: Eligible patients were identified using Current Procedural Terminology codes, and their medical records were reviewed retrospectively., Main Outcome Measures: The primary outcome measure was surgical success (intraocular pressure [IOP] ≤21 mmHg and reduced ≥20% from baseline, IOP >5 mmHg, no reoperation for glaucoma, no loss of light-perception vision). Secondary outcome measures included visual acuity, IOP, number of glaucoma medications, and complications., Results: The cumulative probability of success at 3 years with or without medical therapy was 87% in the Baerveldt group and 76% in the trabeculectomy group (P = 0.23). Postoperative complications occurred in 11 patients (20%) in the Baerveldt group and 20 patients (29%) in the trabeculectomy group (P = 0.27). Mean follow-up ± standard deviation was 27±19 months in the Baerveldt group and 34±20 months in the trabeculectomy group (P = 0.053)., Conclusions: Similar rates of surgical success and postoperative complications were observed in patients undergoing trabeculectomy with MMC and in those undergoing Baerveldt implantation during 3 years of follow-up. Both are viable primary glaucoma procedures in patients who have not undergone prior ocular surgery., (Copyright © 2016 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: Leber hereditary optic neuropathy (LHON) is a disorder characterized by severe and rapidly progressive visual loss when caused by a mutation in the mitochondrial gene encoding NADH:ubiquinone oxidoreductase subunit 4 (ND4). We have initiated a gene therapy trial to determine the safety and tolerability of escalated doses of an adeno-associated virus vector (AAV) expressing a normal ND4 complementary DNA in patients with a G to A mutation at nucleotide 11778 of the mitochondrial genome., Design: In this prospective open-label trial (NCT02161380), the study drug (self-complementary AAV [scAAV]2(Y444,500,730F)-P1ND4v2) was intravitreally injected unilaterally into the eyes of 5 blind participants with G11778A LHON. Four participants with visual loss for more than 12 months were treated. The fifth participant had visual loss for less than 12 months. The first 3 participants were treated at the low dose of vector (5 × 10(9) vg), and the fourth participant was treated at the medium dose (2.46 × 10(10) vg). The fifth participant with visual loss for less than 12 months received the low dose. Treated participants were followed for 90 to 180 days and underwent ocular and systemic safety assessments along with visual structure and function examinations., Participants: Five legally blind patients with G11778A LHON., Main Outcome Measures: Loss of visual acuity., Results: Visual acuity as measured by the Early Treatment Diabetic Retinopathy Study (ETDRS) eye chart remained unchanged from baseline to 3 months in the first 3 participants. For 2 participants with 90-day follow-up, acuity increased from hand movements to 7 letters in 1 and by 15 letters in 1, representing an improvement equivalent to 3 lines. No one lost vision, and no serious adverse events were observed. Minor adverse events included a transient increase of intraocular pressure (IOP), exposure keratitis, subconjunctival hemorrhage, a sore throat, and a transient increase in neutralizing antibodies (NAbs) against AAV2 in 1 participant. All blood samples were negative for vector DNA., Conclusions: No serious safety problems were observed in the first 5 participants enrolled in this phase I trial of virus-based gene transfer in this mitochondrial disorder. Additional study follow-up of these and additional participants planned for the next 4 years is needed to confirm these preliminary observations., (Copyright © 2016 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background and Objective: To determine adverse vitreoretinal outcome rates after glaucoma drainage device (GDD) surgery., Patients and Methods: Medical records from the Anne Bates Leach Eye Hospital with financial claims from 1991 to 2005 for GDD surgery coded for endophthalmitis, choroidal hemorrhage, or retinal detachment were reviewed. Cumulative incidences were calculated before and after verifying claims with chart review., Results: GDD surgery was performed in 2,661 eyes. Thirty-three cases of endophthalmitis were identified, with 10 attributable to GDD (1-, 5-, and 10-year cumulative incidences: 0.22%, 0.43%, and 0.83%, respectively). Forty cases of choroidal hemorrhage were identified, with 20 attributable to GDD (1-, 5-, and 10-year incidences: 0.81% for all time points). Rhegmatogenous retinal detachments developed in 148 eyes, with 42 attributable to GDD (1-, 5-, and 10-year incidences: 1.25%, 2.02%, and 2.67%, respectively)., Conclusion: This study's complication rates compare favorably with those previously reported. The use of claims data without chart review verification may result in overestimated event rates., (Copyright 2015, SLACK Incorporated.)

Purpose: To explore the association between peripapillary atrophy (PPA) area and conversion from ocular hypertension (OHT) to glaucoma., Design: Prospective, longitudinal cohort study of cases and controls., Participants: We included 279 age-matched and follow-up time-matched eyes with OHT that converted to glaucoma and 279 eyes with OHT that did not convert to glaucoma., Methods: Initial and last acceptable optic disc photos were analyzed. Disc, α-zone, and β-zone PPA were traced independently by 2 trained readers and their areas were measured with Photoshop. The α-zone and β-zone areas were expressed as a percentage of optic disc area., Main Outcome Measures: α-Zone and β-zone PPA size over time., Results: Intraclass correlation coefficients (ICCs) demonstrated that readers had good agreement on disc area (ICC = 0.97) and β-zone (ICC = 0.82), but not α-zone (ICC = 0.48). The ß-zone, as a percentage of disc area, increased in size (P < 0.001) in both eyes with incident primary open-angle glaucoma (mean, 10.6%; standard deviation, 22.6%) and matched controls (mean, 10.1%; standard deviation, 33.7) over follow-up (mean, 12.3 years). The increase in size did not differ between cases and controls (P = 0.82). Enlargement of the β-zone was not correlated with follow-up time (P = 0.39)., Conclusions: The results did not show a difference in size of the β-zone at baseline between eyes that proceed to develop glaucoma and those that do not. Moreover, the β-zone enlarges equally in case and control eyes during follow-up., (Copyright © 2015 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the effect of preinjection ocular decompression by cotton swabs on the immediate rise in intraocular pressure (IOP) after intravitreal injections., Methods: Forty-eight patients receiving 0.05 mL ranibizumab injections in a retina clinic were randomized to 2 anesthetic methods in each eye on the same day (if bilateral disease) or on consecutive visits (if unilateral disease). One method utilized cotton swabs soaked in 4% lidocaine applied to the globe with moderate pressure and the other 3.5% lidocaine gel applied without pressure. IOPs were recorded at baseline (before injection) and at 0, 5, 10, and 15 minutes after the injection until the IOP was ≤30 mm Hg. The IOP elevations from baseline were compared after the 2 anesthetic methods., Results: The preinjection mean IOP (SD, mm Hg) was 15.5 (3.3) before the cotton swabs and 15.9 (3.0) before the gel (P=0.28). Mean IOP (SD, mm Hg) change immediately after injection was 25.7 (9.2) after the cotton swabs and 30.9 (9.9) after the gel (P=0.001). Thirty-five percent of gel eyes had IOP≥50 mm Hg compared with only 10% of cotton swab eyes immediately after the injection (P<0.001)., Conclusion: Decompressing the eye with cotton swabs during anesthetic preparation before an intravitreal injection produces a significantly lower IOP spike after the injection.

Background: The aims of this study were to evaluate visual function outcomes in idiopathic intracranial hypertension (IIH) patients who underwent ventriculoperitoneal (VP) shunt for visual loss and to determine a VP shunt survival curve over time., Methods: A retrospective medical record review was performed of all new IIH patients first evaluated at our institution who underwent VP shunt placement over a 7-year period (2004-2010). There were 2 primary outcome measures: the first being visual acuity (VA) and the second being shunt survival. Patients who received VP shunt for visual loss were included in the visual outcome analysis, and all patients who received VP shunt for any reason were included in the shunt survival analysis., Results: Of the 338 new patients with IIH, 19 patients (6%) met the inclusion criteria and 17 underwent VP shunt for visual loss and 2 for headaches. Average follow-up was 21.2 months (range, 5-1,342 days). Of the 17 patients who had VP shunt for visual loss, 5 patients had optic nerve sheath fenestration (ONSF) surgery before VP shunt, and 1 patient had bilateral ONSF surgery after VP shunt. Median VA before shunt was 20/200 in the worse eye (range, 20/20 to NLP) and 20/40 in the better eye (20/20 to HM). Median VA after shunt was 20/60 in the worse eye (20/20 to lumboperitoneal) and 20/30 in the better eye (20/20 to 20/800). The improvement in VA was statistically significant in both worse eyes (P = 0.002, Wilcoxon signed-rank test) and better eyes (P = 0.028). The mean automated visual field (AVF) mean deviation (MD) of available AVFs before shunt was 223.36 dB (range, 233.38 to 27.01 dB) for the worse eye (n = 11) and 219.66 dB (230.11 to 25.91 dB) for the better eye (n = 11). Mean AVF MD deviation of available AVFs after shunt was 220.68 dB (232.13 to 23.97 dB) for the worse eye (n = 11) and 216.35 dB (232.13 to 21.00 dB) for the better eye (n = 11): this improvement was not significant (P = 0.27, P = 0.26, respectively). Independent masked record reviews by 3 neuro-ophthalmologists showed that 9 (53%) patients improved, 5 (29%) unchanged, 1 (6%) worsened, and 2 (12%) were indeterminate. Kaplan-Meier analysis showed a persistent steady decrease of functioning VP shunts over the entire period of 36 months with 80%, 65%, and 48% of VP shunts functioning without replacement, removal, or revision at 12, 24, and 36 months, respectively., Conclusion: VP shunts improve or stabilize most IIH patients presenting with severe progressive visual loss or those with visual loss refractive to medical treatment and ONSF. Survival analysis shows persistent decrease of functioning shunts over time.

Objective: To estimate the prevalence of, and factors associated with, dilated eye examination guideline compliance among patients with diabetes mellitus (DM), but without diabetic retinopathy., Research Design and Methods: Utilizing the computerized billing records database, we identified patients with International Classification of Diseases (ICD)-9 diagnoses of DM, but without any ocular diagnoses. The available medical records of patients in 2007-2008 were reviewed for demographic and ocular information, including visits through 2010 (n=200). Patients were considered guideline compliant if they returned at least every 15 months for screening. Participant street addresses were assigned latitude and longitude coordinates to assess their neighborhood socioeconomic status (using the 2000 US census data), distance to the screening facility, and public transportation access. Patients not compliant, based on the medical record review, were contacted by phone or mail and asked to complete a follow-up survey to determine if screening took place at other locations., Results: The overall screening compliance rate was 31%. Patient sociodemographic characteristics, insurance status, and neighborhood socioeconomic measures were not significantly associated with compliance. However, in separate multivariable logistic regression models, those living eight or more miles from the screening facility were significantly less likely to be compliant relative to those living within eight miles (OR=0.36 (95% CI 0.14 to 0.86)), while public transit access quality was positively associated with screening compliance (1.34 (1.07 to 1.68))., Conclusions: Less than one-third of patients returned for diabetic retinopathy screening at least every 15 months, with transportation challenges associated with noncompliance. Our results suggest that reducing transportation barriers or utilizing community-based screening strategies may improve compliance.

Purpose: To describe the incidence and outcomes of reoperations for glaucoma in the Tube Versus Trabeculectomy (TVT) Study., Design: Cohort study of patients in a multicenter randomized clinical trial., Methods: The TVT Study enrolled 212 patients with medically uncontrolled glaucoma who had previous cataract and/or glaucoma surgery. Randomization assigned 107 patients to surgery with a tube shunt (350 mm(2) Baerveldt glaucoma implant) and 105 patients to trabeculectomy with mitomycin C (0.4 mg/mL for 4 minutes). Data were analyzed from patients who failed their assigned treatment and had additional glaucoma surgery. Outcome measures included intraocular pressure (IOP), use of glaucoma medications, visual acuity, surgical complications, and failure (IOP >21 mm Hg or not reduced by 20%, IOP ≤5 mm Hg, additional glaucoma surgery, or loss of light perception vision)., Results: Additional glaucoma surgery was performed in 8 patients in the tube group and 18 patients in the trabeculectomy group in the TVT Study, and the 5-year cumulative reoperation rate was 9% in the tube group and 29% in the trabeculectomy group (P = .025). Follow-up (mean ± SD) after additional glaucoma surgery was 28.0 ± 16.0 months in the tube group and 30.5 ± 20.4 months in the trabeculectomy group (P = .76). At 2 years after a glaucoma reoperation, IOP (mean ± SD) was 15.0 ± 5.5 mm Hg in the tube group and 14.4 ± 6.6 mm Hg in the trabeculectomy group (P = .84). The number of glaucoma medications (mean ± SD) after 2 years of follow-up was 1.1 ± 1.3 in the tube group and 1.4 ± 1.4 in the trabeculectomy group (P = .71). The cumulative probability of failure at 1, 2, 3, and 4 years after additional glaucoma surgery was 0%, 43%, 43%, and 43%, respectively, in the tube group, and 0%, 9%, 20%, and 47% in the trabeculectomy group (P = .28). Reoperations to manage complications were required in 1 patient in the tube group and 5 patients in the trabeculectomy group (P = .63)., Conclusions: The rate of reoperation for glaucoma was higher following trabeculectomy with mitomycin C than tube shunt surgery in the TVT Study. Similar surgical outcomes were observed after additional glaucoma surgery, irrespective of initial randomized treatment in the study., (Copyright © 2014 Elsevier Inc. All rights reserved.)

IMPORTANCE Establishing the natural history of G11778A Leber hereditary optic neuropathy (LHON) is important to determine the optimal end points to assess the safety and efficacy of a planned gene therapy trial. OBJECTIVE To use the results of the present natural history study of patients with G11778A LHON to plan a gene therapy clinical trial that will use allotopic expression by delivering a normal nuclear-encoded ND4 gene into the nuclei of retinal ganglion cells via an adeno-associated virus vector injected into the vitreous. DESIGN, SETTING, AND PARTICIPANTS A prospective observational study initiated in 2008 was conducted in primary and referral institutional practice settings. Participants included 44 individuals with G11778A LHON, recruited between September 2008 and March 2012, who were evaluated every 6 months and returned for 1 or more follow-up visits (6-36 months) as of August 2012. EXPOSURES Complete neuro-ophthalmic examination and main measures. MAIN OUTCOMES AND MEASURES Visual acuity, automated visual field testing, pattern electroretinogram, and spectral-domain optical coherence tomography. RESULTS Clinical measures were stable during the follow-up period, and visual acuity was as good as or better than the other visual factors used for monitoring patients. Based on a criterion of 15 or more letters from the Early Treatment Diabetic Retinopathy Study chart, 13 eyes of 8 patients (18%) improved, but 24 months after the onset of symptoms, any further improvements were to no better than 20/100. Acuity recovery occurred in some patients despite continued marked retinal nerve fiber layer thinning indistinguishable from that in patients who did not recover visual acuity. CONCLUSIONS AND RELEVANCE Spontaneous improvement of visual acuity in patients with G11778A LHON is not common and is partial and limited when it occurs, so improvements in vision with adeno-associated virus-mediated gene therapy of a synthetic wild-type ND4 subunit gene should be possible to detect with a reasonable sample size. Visual acuity appears to be the most suitable primary end point for the planned clinical trial.

Objective: To analyze ophthalmologists who are National Institutes of Health (NIH) K grant awardees to characterize clinician-scientists in ophthalmology., Design: Cohort study., Participants: Ophthalmologists who have received a K award from 1996 through 2010., Methods: K08 and K23 grant awardees were identified through the NIH Research Portfolio Online Reporter database. Information including gender, institution, educational degrees, and success in obtaining an R01 grant was analyzed., Main Outcome Measures: Receipt of an R01 grant., Results: One hundred five ophthalmologists were identified who received K08 or K23 grants from the National Eye Institute from 1996 through 2010. Overall, 75% of these were male, although 43% of K awardees were women from 2006 through 2010. Sixty-five percent (68/105) of individuals came from ophthalmology departments that ranked in the top 20 of NIH funding in 2010. The most predominant subspecialties represented were retina (32%), cornea (22%), and glaucoma (15%). Among the K awardees, 40% (42/105) had a doctor of philosophy (PhD) degree in addition to their medical doctor degree. From 1996 through 2000, 61% (23/38) were successful in obtaining an R01 grant, whereas only 13% (5/39) from 2001 through 2005 obtained R01 grants (P<0.001)., Conclusions: Gender disparities exist among K awardees in ophthalmology, but these seem to be improving over time. None of the other variables studied-gender, PhD degree, specialty, or funding tier-was associated with obtaining R01 funding. This study helps to characterize the clinician-scientist cohort in ophthalmology and to identify areas to improve the recruitment of these individuals., Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article., (Copyright © 2013 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: To compare same-day and next-day pain control and safety of two anesthetic techniques utilizing 4% liquid lidocaine applied with sterile cotton swabs versus 3.5% lidocaine gel for intravitreal injections. Main outcome measures were: discomfort during anesthetic preparation and needle penetration, 1 and 24 h after injection., Methods: Patients were randomized to alternate anesthetic method at two consecutive injections in one eye or in different eyes on the same day if requiring bilateral injections. Overall satisfaction, corneal staining, and subconjunctival hemorrhage (SCH) were compared., Results: Fifty patients were enrolled. Both methods resulted in similar mild discomfort during anesthetic preparation, 1 and 24 h later. The gel resulted in slightly higher discomfort during needle penetration (p = 0.026). Patients were satisfied with both techniques (p = 0.91), however, 52% patients preferred gel, 33% were indifferent, and 15% preferred cotton swabs (p = 0.002). There were significantly less corneal staining (p = 0.001) and SCH (p = 0.004) after the gel., Conclusion: Both techniques are equally effective and yield mild discomfort scores during the procedure and the next day. The gel method results in significantly less ocular surface irritation.

Purpose: To describe postoperative complications encountered in the Tube Versus Trabeculectomy (TVT) Study during 5 years of follow-up., Design: Multicenter randomized clinical trial., Settings: Seventeen clinical centers., Study Population: Patients 18 to 85 years of age who had previous trabeculectomy and/or cataract extraction with intraocular lens implantation and uncontrolled glaucoma with intraocular pressure (IOP) ≥18 mm Hg and ≤40 mm Hg on maximum tolerated medical therapy., Interventions: Tube shunt (350-mm(2) Baerveldt glaucoma implant) or trabeculectomy with mitomycin C (MMC 0.4 mg/mL for 4 minutes)., Main Outcome Measures: Surgical complications, reoperations for complications, visual acuity, and cataract progression., Results: Early postoperative complications occurred in 22 patients (21%) in the tube group and 39 patients (37%) in the trabeculectomy group (P = .012). Late postoperative complications developed in 36 patients (34%) in the tube group and 38 patients (36%) in the trabeculectomy group during 5 years of follow-up (P = .81). The rate of reoperation for complications was 22% in the tube group and 18% in the trabeculectomy group (P = .29). Cataract extraction was performed in 13 phakic eyes (54%) in the tube group and 9 phakic eyes (43%) in the trabeculectomy group (P = .43)., Conclusions: A large number of surgical complications were observed in the TVT Study, but most were transient and self-limited. The incidence of early postoperative complications was higher following trabeculectomy with MMC than tube shunt surgery. The rates of late postoperative complications, reoperation for complications, and cataract extraction were similar with both surgical procedures after 5 years of follow-up., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background and Objective: To compare visual outcomes for used glasses versus ready-made spectacles in the treatment of refractive error., Patients and Methods: In this prospective, comparative case series, undilated refractive error screening examinations were conducted over a 5-week period. Patients with bilateral refractive error were treated with used glasses and ready-made spectacles powered to match their prescriptions. Snellen visual acuity was measured with no correction, best (manifest) correction, unrefined autorefraction, used glasses, and ready-made spectacles. Main outcome measurements were the mean visual improvement from uncorrected acuity and median final visual acuity after treatment with used and ready-made spectacles., Results: One hundred forty-one patients ages 18 and older with bilateral refractive error were examined. Uncorrected visual acuity in each eye improved an average of 4.5 lines with best correction, 4.0 lines with used glasses, and 3.5 lines with ready-made spectacles, with used glasses demonstrating a statistically significant advantage over ready-made spectacles (P < .001). The median visual acuity in the better eye improved from 20/60 uncorrected to 20/25 with all types of glasses. In patients with less than 1 diopter of anisometropia and greater than 1 diopter of astigmatism in each eye (49%), the ready-made spectacles performed equally as well as the used glasses (P = .95), improving vision an average of 3.9 lines for a median final visual acuity of 20/25 in the better eye., Conclusion: Although both were effective, used glasses are better than ready-made spectacles for improving vision loss due to refractive error., (Copyright 2012, SLACK Incorporated.)

Purpose: To report 5-year treatment outcomes in the Tube Versus Trabeculectomy (TVT) Study., Design: Multicenter randomized clinical trial., Settings: Seventeen clinical centers., Study Population: Patients 18 to 85 years of age who had previous trabeculectomy and/or cataract extraction with intraocular lens implantation and uncontrolled glaucoma with intraocular pressure (IOP) ≥18 mm Hg and ≤40 mm Hg on maximum tolerated medical therapy., Interventions: Tube shunt (350-mm(2) Baerveldt glaucoma implant) or trabeculectomy with mitomycin C ([MMC]; 0.4 mg/mL for 4 minutes)., Main Outcome Measures: IOP, visual acuity, use of supplemental medical therapy, and failure (IOP >21 mm Hg or not reduced by 20%, IOP ≤5 mm Hg, reoperation for glaucoma, or loss of light perception vision)., Results: A total of 212 eyes of 212 patients were enrolled, including 107 in the tube group and 105 in the trabeculectomy group. At 5 years, IOP (mean ± SD) was 14.4 ± 6.9 mm Hg in the tube group and 12.6 ± 5.9 mm Hg in the trabeculectomy group (P = .12). The number of glaucoma medications (mean ± SD) was 1.4 ± 1.3 in the tube group and 1.2 ± 1.5 in the trabeculectomy group (P = .23). The cumulative probability of failure during 5 years of follow-up was 29.8% in the tube group and 46.9% in the trabeculectomy group (P = .002; hazard ratio = 2.15; 95% confidence interval = 1.30 to 3.56). The rate of reoperation for glaucoma was 9% in the tube group and 29% in the trabeculectomy group (P = .025)., Conclusions: Tube shunt surgery had a higher success rate compared to trabeculectomy with MMC during 5 years of follow-up in the TVT Study. Both procedures were associated with similar IOP reduction and use of supplemental medical therapy at 5 years. Additional glaucoma surgery was needed more frequently after trabeculectomy with MMC than tube shunt placement., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose of Review: The Tube Versus Trabeculectomy (TVT) Study is a multicenter randomized clinical trial comparing the safety and efficacy of tube-shunt surgery to trabeculectomy with mitomycin C (MMC) in eyes with previous cataract and/or failed glaucoma surgery. This article interprets results from the TVT Study and applies them to clinical practice., Recent Findings: Both tube-shunt surgery and trabeculectomy with MMC produced intraocular pressure (IOP) reduction to the low teens throughout the 5-year duration of the study. Tube-shunt surgery was associated with use of more glaucoma medications than trabeculectomy with MMC during the first 2 years of the study, but medical therapy equalized with longer follow-up. Trabeculectomy with MMC had higher rates of surgical failure and reoperation for glaucoma compared with tube-shunt surgery. Vision loss occurred at a similar rate with the two surgical procedures. Early complications were more frequent after trabeculectomy with MMC relative to tube-shunt surgery, but both procedures had similar rates of late postoperative complications and serious complications., Summary: Tube-shunt surgery and trabeculectomy with MMC are both viable surgical options for managing glaucoma in patients who have undergone prior cataract and/or failed filtering surgery. Results of the TVT Study support the expanding use of tube shunts beyond refractory glaucomas.

Background: To evaluate a method for treating uncorrected refractive error in adults in the developing world., Design: Prospective, cross-sectional study in outpatient community health centres., Participants: Eight hundred and forty subjects aged 18 and older from rural villages in Haiti and Belize., Methods: Undilated refractive error screening exams were conducted over a 5-day period in rural Haiti and Belize using portable autorefractors. Isometropic, spherical, ready-made spectacles were provided to patients with bilateral refractive error, astigmatism ≤ 1 dioptre in each eye and visual acuity worse than 6/9 in each eye. Visual acuity was measured with and without corrective spectacles., Main Outcome Measures:   The mean visual improvement and median final visual acuity after treatment with ready-made glasses., Results: Eight hundred and forty patients aged 18 and older were screened with autorefractors. One hundred and eighty-nine subjects (22.5%) were found to have visually significant bilateral refractive error. Fifty-eight per cent (110/189) of these patients met criteria for treatment with ready-made spectacles. Visual acuity improved an average of 4.2 lines in the better eye and 4.1 lines in the worse eye with corrective glasses. The median visual acuity in the better eye was 6/6 after treatment., Conclusion: Autorefractors and ready-made spectacles allow for effective treatment of uncorrected refractive error in adults in the developing world., (© 2011 The Authors. Clinical and Experimental Ophthalmology © 2011 Royal Australian and New Zealand College of Ophthalmologists.)

Objective: To evaluate a new automated analysis of optic disc images obtained by spectral-domain optical coherence tomography (SD OCT). Areas of the optic disc, cup, and neural rim in SD OCT images were compared with these areas from stereoscopic photographs to represent the current traditional optic nerve evaluation. The repeatability of measurements by each method was determined and compared., Design: Evaluation of diagnostic technology., Participants: One hundred nineteen healthy eyes, 23 eyes with glaucoma, and 7 glaucoma suspect eyes., Methods: Optic disc and cup margins were traced from stereoscopic photographs by 3 individuals independently. Optic disc margins and rim widths were determined automatically in SD OCT. A subset of photographs was examined and traced a second time, and duplicate SD OCT images also were analyzed., Main Outcome Measures: Agreement among photograph readers, between duplicate readings, and between SD OCT and photographs were quantified by the intraclass correlation coefficient (ICC), by the root mean square, and by the standard deviation of the differences., Results: Optic disc areas tended to be slightly larger when judged in photographs than by SD OCT, whereas cup areas were similar. Cup and optic disc areas showed good correlation (0.8) between the average photographic reading and SD OCT, but only fair correlation of rim areas (0.4). The SD OCT was highly reproducible (ICC, 0.96-0.99). Each reader also was consistent with himself on duplicate readings of 21 photographs (ICC, 0.80-0.88 for rim area and 0.95-0.98 for all other measurements), but reproducibility was not as good as SD OCT. Measurements derived from SD OCT did not differ from photographic readings more than the readings of photographs by different readers differed from each other., Conclusions: Designation of the cup and optic disc boundaries by an automated analysis of SD OCT was within the range of variable designations by different readers from color stereoscopic photographs, but use of different landmarks typically made the designation of the optic disc size somewhat smaller in the automated analysis. There was better repeatability among measurements from SD OCT than from among readers of photographs. The repeatability of automated measurement of SD OCT images is promising for use both in diagnosis and in monitoring of progression., (Copyright © 2011 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the effect of intravitreal bevacizumab (Avastin; Genentech Inc, South San Francisco, California, USA) on visual acuity and macular thickness in patients with inflammatory choroidal neovascularization (CNV) or cystoid macular edema (CME)., Design: Retrospective, noncomparative, interventional case series., Methods: Each eye received 1.25 mg of intravitreal bevacizumab at baseline. Follow-up examinations were scheduled at 1- to 2-month intervals, with additional injections at the discretion of the physician. Comprehensive evaluations, including Snellen best-corrected visual acuity (BVCA) and optical coherence tomography measurements, were performed at each visit. Main outcome measures were BCVA and central subfield thickness (CST), as measured by optical coherence tomography., Results: Thirty-four eyes of 30 patients with inflammatory CNV (n = 21 eyes of 19 patients; 9 male, 10 female) or CME (n = 13 eyes of 11 patients; 4 male, 7 female) were identified. Median ages were 52 years (range, 7 to 83) and 67 years (range, 17 to 83) for the CNV and CME groups, respectively. The median length of follow-up for CNV eyes was 7 months (range, 1 to 28) while the median follow-up for CME eyes was 13 months (range, 1 to 20). Both groups received a median of two injections (range, 1 to 9 for CNV and 1 to 4 for CME). For eyes with CNV, BCVA improved significantly at follow-up month 1, but was not different from baseline thereafter; CST remained unchanged throughout follow-up. For eyes with CME, neither BCVA nor CST changed significantly over the course of follow-up., Conclusions: Bevacizumab appears to stabilize BCVA and CST for eyes with inflammatory CNV or CME.

Purpose: To report 3-year results of the Tube Versus Trabeculectomy (TVT) Study., Design: Multicenter randomized clinical trial., Setting: Seventeen clinical centers., Study Population: Patients 18 to 85 years of age who had previous trabeculectomy, cataract extraction with intraocular lens implantation, or both and uncontrolled glaucoma with intraocular pressure (IOP) > or =18 mm Hg and < or =40 mm Hg on maximum tolerated medical therapy., Interventions: A 350-mm(2) Baerveldt glaucoma implant or trabeculectomy with mitomycin C (MMC 0.4 mg/ml for 4 minutes)., Main Outcome Measures: IOP, visual acuity, use of supplemental medical therapy, surgical complications, and failure (IOP >21 mm Hg or not reduced by 20%, IOP < or =5 mm Hg, reoperation for glaucoma, or loss of light perception vision)., Results: A total of 212 eyes of 212 patients were enrolled, including 107 in the tube group and 105 in the trabeculectomy group. At 3 years, IOP (mean +/- standard deviation [SD]) was 13.0 +/- 4.9 mm Hg in the tube group and 13.3 +/- 6.8 mm Hg in the trabeculectomy group (P = .78). The number of glaucoma medications (mean +/- SD) was 1.3 +/- 1.3 in the tube group and 1.0 +/- 1.5 in the trabeculectomy group (P = .30). The cumulative probability of failure during the first 3 years of follow-up was 15.1% in the tube group and 30.7% in the trabeculectomy group (P = .010; hazards ratio, 2.2; 95% confidence interval, 1.2 to 4.1). Postoperative complications developed in 42 patients (39%) in the tube group and 63 patients (60%) in the trabeculectomy group (P = .004). Surgical complications were associated with reoperation and/or loss of > or =2 Snellen lines in 24 patients (22%) in the tube group and 28 patients (27%) in the trabeculectomy group (P = .58)., Conclusions: Tube shunt surgery had a higher success rate compared to trabeculectomy with MMC during the first 3 years of follow-up in the TVT Study. Both procedures were associated with similar IOP reduction and use of supplemental medical therapy at 3 years. While the incidence of postoperative complications was higher following trabeculectomy with MMC relative to tube shunt surgery, most complications were transient and self-limited.

Purpose: To determine the effect of intraocular pressure (IOP) lowering on the optic disc in patients of the Collaborative Initial Glaucoma Treatment Study (CIGTS) after 5 years., Design: Randomized clinical trial., Methods: The baseline and 5-year stereoscopic optic disc photographs of 348 eyes (patients) randomized to medical or surgical treatment of open-angle glaucoma (OAG) were assessed by 2 independent readers for change in a masked side-by-side comparison, and confirmed by an independent committee., Results: Three hundred and three (87.1%) eyes showed no change, 22 (6.3%) showed enlargement of the cup along any meridian (progression), and 23 (6.6%) showed a reduction in the cup along any meridian (reversal of cupping). Incidence of optic disc progression was higher (P = .007) in the medicine group, 18/185 (10%) than in the surgical group 4/163 (3%); and the incidence of reversal of cupping was higher (P < .001) in the surgical group, 21/163 (13%), than the medicine group, 2/185 (1%), (P < .001). Visual field (VF) worsening (mean deviation) was significantly associated with progression of optic disc cupping (P < .001). Reversal of cupping was also associated with lower postoperative IOP (P < .001). Reversal of cupping was not associated with improvement of either visual acuity or central VFs., Conclusions: Surgery prevents or delays glaucomatous progression as measured by optic disc criteria in patients with early OAG. Reversal of cupping occurs more frequently in the surgical group than in the medical treatment group. Reversal is associated with lower IOP, but is not associated with improved visual function.

Purpose: To describe the preoperative and postoperative motility disturbances encountered in the Tube Versus Trabeculectomy (TVT) Study during the first year of follow-up., Design: Multicenter randomized clinical trial., Methods: settings: Seventeen clinical centers. population: Patients 18 to 85 years old who had previous trabeculectomy and/or cataract surgery and uncontrolled glaucoma with intraocular pressure > or =18 mm Hg and < or =40 mm Hg on maximum tolerated medical therapy. interventions: 350-mm(2) Baerveldt glaucoma implant or trabeculectomy with mitomycin C (MMC). main outcome measures: Preoperative and postoperative evaluation of ocular motility and diplopia., Results: Motility disturbances were detected in 55 patients (28%) at baseline. New-onset persistent diplopia was reported in 5 patients (5%) in the tube group and no patients in the trabeculectomy group at 1 year (P = .06). A new postoperative motility disturbance developed or worsened in 7 patients (9.9%) in the tube group and no patients in the trabeculectomy group during the first year of follow-up (P = .005). Postoperative motility disturbances were also associated with increasing age (P < .001) and right eye surgery (P = .044)., Conclusions: Preoperative motility disturbances were common among patients in the TVT Study. New postoperative motility disturbances were more frequent following tube shunt surgery than trabeculectomy with MMC after 1 year of follow-up.

Purpose: To describe ocular injuries attributable to paintball-related trauma and their management and results., Design: Retrospective, interventional case series., Methods: setting: University practice and emergency department. patient population: Thirty-six eyes of 36 patients who sustained ocular injuries secondary to paintballs between July 1, 1998 and January 1, 2005. observation procedure: Age, gender, laterality, setting, eye protection, best-corrected visual acuity (BCVA), and initial diagnosis were documented. main outcome measures: Medical and surgical intervention within the first three days postinjury and further treatment after this time period were recorded. BCVA at the initial and final clinical visit were compared., Results: The mean follow-up interval was 11.7 months (one to 40). Mean age was 21 years (three to 64), 31 (86%) were male, 34 (97%) were not wearing eye-protection device when injured, and initial BCVA was worse than 20/200 in 28 eyes (78%). The most common ocular finding was hyphema in 29 eyes (81%). Initially, 20 eyes (56%) were managed medically and nine eyes (25%) required primary repair of a ruptured globe. Ultimately, 29 eyes (81%) had surgical intervention including eight eyes (22%) enucleations. Final visual acuity was 20/40 or better in 13 eyes (36%), whereas 18 eyes (50%) were worse than 20/200. Visual acuity (VA) at initial presentation correlated strongly with final VA (r = 0.64; P < .001)., Conclusions: Paintball-related ocular injuries are frequently severe and visually devastating. The compulsive use of protective eyewear may have eliminated 97% of injuries in this series and continues to need emphasis to paintball users.

Purpose: To assess polymerase chain reaction (PCR) analysis of intraocular fluid as a test for infectious uveitis of the posterior segment in a representative patient population., Design: Retrospective, interventional case series., Methods: One hundred and thirty-three patients with possible infectious chorioretinitis underwent PCR testing of aqueous or vitreous in a university setting. Baseline characteristics predictive of test positivity were identified. Positive and negative predictive values were calculated., Results: Four hundred and thirty-three PCR tests of 105 aqueous and 38 vitreous specimens (mean, 3.3 tests per patient) identified 77 of the 95 patients with a final clinical diagnosis of infectious uveitis (81%). Herpes simplex virus, varicella zoster virus, and cytomegalovirus PCR analysis were performed in almost all cases, with fewer tests for toxoplasmosis or Epstein-Barr virus. Clinical features associated with positive PCR results were retinal vascular inflammation (P < .001), optic nerve involvement (P = .008), immunocompromised state (P = .039), and extensive retinitis (P = .002). Cases sampled within one week of presentation were more likely to have positive PCR results than those sampled later (P = .071). The predictive value of positive and negative tests was 98.7% and 67.9%, respectively, in this patient group. Alteration in treatment based on PCR and syphilis serologic results led to resolution in 25 of 26 patients after treatment was changed., Conclusions: PCR testing is a useful adjunct in the diagnosis of infectious causes of posterior uveitis. Cases with vascular or optic nerve inflammation, extensive retinitis, or immunocompromise are more likely to have positive PCR results and may benefit from PCR testing of aqueous humor.

Background and Objective: To examine the hypothesis that patients with increased central corneal thickness may have an overestimation of Goldmann applanation tension and a predisposition to hypotony-related complications., Patients and Methods: A case-control analysis of patients with an intraocular pressure of 7 mm Hg or less on two consecutive postoperative visits following glaucoma filtration or drainage implant surgery was performed. Forward stepwise multiple logistic regression was used to determine the model that best predicted hypotony-related complications defined as choroidal effusion or hypotony maculopathy., Results: Forty-three eyes (17 with hypotony-related complications and 26 controls) of 43 patients were enrolled. Eyes with pseudophakia (P = .006) and lower postoperative intraocular pressure (P = .013) were significantly more likely to develop hypotony-related complications. Mean central corneal thickness was similar in eyes with hypotony-related complications (519 +/- 32 microm) and controls (525 +/- 37 microm) and was not a significant predictor of hypotony-related complications in the multivariate model (P = .90)., Conclusion: Increased central corneal thickness does not represent a risk factor for hypotony-related complications following glaucoma surgery.

Purpose: To report one-year results of the Tube Versus Trabeculectomy (TVT) Study., Design: Multicenter randomized clinical trial., Setting: 17 Clinical Centers., Study Population: Patients 18 to 85 years of age who had previous trabeculectomy and/or cataract extraction with intraocular lens implantation and uncontrolled glaucoma with intraocular pressure (IOP) > or =18 mm Hg and < or =40 mm Hg on maximum tolerated medical therapy., Interventions: 350 mm(2) Baerveldt glaucoma implant or trabeculectomy with mitomycin C (MMC)., Main Outcome Measures: IOP, visual acuity, and reoperation for glaucoma., Results: A total of 212 eyes of 212 patients were enrolled, including 107 in the tube group and 105 in the trabeculectomy group. At one year, IOP (mean +/- SD) was 12.4 +/- 3.9 mm Hg in the tube group and 12.7 +/- 5.8 mm Hg in the trabeculectomy group (P = .73). The number of glaucoma medications (mean +/- SD) was 1.3 +/- 1.3 in the tube group and 0.5 +/- 0.9 in the trabeculectomy group (P < .001). The cumulative probability of failure during the first year of follow-up was 3.9% in the tube group and 13.5% in the trabeculectomy group (P = .017)., Conclusions: Nonvalved tube shunt surgery was more likely to maintain IOP control and avoid persistent hypotony or reoperation for glaucoma than trabeculectomy with MMC during the first year of follow-up in the TVT Study. Both surgical procedures produced similar IOP reduction at one year, but there was less need for supplemental medical therapy following trabeculectomy with MMC.

Purpose: To describe the intraoperative and postoperative complications encountered during the first year of follow-up in the Tube Versus Trabeculectomy (TVT) Study., Design: Multicenter randomized clinical trial., Setting: Seventeen clinical centers., Study Population: Two hundred twelve patients aged 18 to 85 years who had undergone previous trabeculectomy and/or cataract extraction with intraocular lens implantation and uncontrolled glaucoma with intraocular pressure > or =18 mm Hg and < or =40 mm Hg on maximum tolerated medical therapy., Interventions: A 350-mm(2) Baerveldt glaucoma implant or trabeculectomy with mitomycin C (MMC)., Main Outcome Measures: Surgical complications, reoperation for complications, visual acuity, and cataract progression., Results: Intraoperative complications occurred in seven patients (7%) in the tube group and 10 patients (10%) in the trabeculectomy group (P = .59). Postoperative complications developed in 36 patients (34%) in the tube group and 60 patients (57%) in the trabeculectomy group during the first year of follow-up (P = .001). Surgical complications were associated with reoperation and/or loss of > or =2 lines of Snellen visual acuity in 18 patients (17%) in the tube group and 28 patients (27%) in the trabeculectomy group (P = .12)., Conclusions: There were a large number of surgical complications during the first year of follow-up in the study, but most were self-limited. The incidence of postoperative complications was higher after trabeculectomy with MMC than nonvalved tube shunt surgery. Serious complications resulting in reoperation and/or vision loss occurred with similar frequency with both surgical procedures.

Objective: To investigate antimicrobial effectiveness of povidone-iodine (Betadine) in reducing bacterial load of corneal ulcers before patients were given antibiotics., Methods: Patients with corneal ulcers were randomized to Betadine or placebo group. Ulcers were cultured before and after a 10-minute application of 5% Betadine or preservative-free artificial tears. All patients were then treated with standard antibiotic medications. The number of colony-forming units before and after Betadine or placebo was compared., Results: Eighteen patients were randomized to Betadine and 17 to placebo group. In the Betadine group, 8 (44%) of 18 ulcers were culture-positive, either before and/or after pretreatment, and in the control group, 9 (53%) of 17 were culture positive. There was No statistical difference in colony-forming units change after Betadine versus artificial tears application was detected (P-value = 0.16, t-test). In Betadine group, 3 (17%) of 18 of patients showed improvement, ie, had fewer colonies after drop application; and in the placebo group, 7 (41%) of 17 showed improvement, (P = 0.15, Fisher exact t test.), Conclusions: A single application of 5% Betadine did not reduce the bacterial load of corneal ulcers more than just scraping/rinsing alone. This is likely the result of the lack of penetration deep into the corneal stroma and number of organisms present. Other factors may be involved.

Purpose: To determine the effect of intraarterial cytoreductive chemotherapy (IACC) as an adjunct to conventional surgery and radiation therapy for lacrimal gland adenoid cystic carcinoma (ACC)., Design: A retrospective, comparative, interventional case series., Methods: setting: Institutional. patient population: Nine consecutive patients with lacrimal gland ACC were treated with IACC, followed by orbital exenteration and chemoradiotherapy. This case series was compared with a series of seven patients treated by conventional local therapies in the same institution. intervention procedure: Clinical records, imaging studies, histologic sections, and archival specimens from all 16 patients were reviewed. Information analyzed included site of disease, histologic characteristics, extent of disease, incidence of locoregional recurrence or distant metastases, and disease-free survival and overall survival time. main outcome measure: The effect of IACC was assessed by the radiographic and histologic response and survival outcome in comparison to a historical cohort of patients managed by conventional local therapies., Results: The difference between the carcinoma cause-specific death rate of the study group versus conventional treatment was significant (P = .029, log rank test). The cumulative 5-year carcinoma cause-specific death rate in the IACC treated group was 16.7% compared with 57.1% in the conventional treatment group. The cumulative 5-year recurrence rate in the IACC treated group was 23.8% compared with 71.4% in the conventional treatment group., Conclusions: The preliminary data suggest that IACC as an integral component of a multimodal treatment strategy is potentially effective in improving local disease control and overall disease-free survival in lacrimal gland adenoid cystic carcinoma.

Purpose: To assess the reproducibility of determining whether an eye has developed optic disk deterioration by the Optic Disc Reading Center (ODRC) in the Ocular Hypertension Treatment Study (OHTS)., Design: Test-retest reproducibility study., Methods: Masked, certified graders at the ODRC determine the occurrence of optic disk deterioration in OHTS by comparing baseline with follow-up stereoscopic optic disk photographs. To assess reproducibility, re-gradings were obtained annually by inserting masked "quality control" photographs into the usual ODRC reading stream., Results: Agreement (kappa) ranged from 0.65 to 0.83 over 5 years. Specificity ranged from 98% to 100%, and sensitivity ranged from 64% to 81%., Conclusions: The kappa statistic for test-retest agreement in OHTS is in the range considered good to excellent over 5 years. Consistency (specificity) in re-grading optic disks that did not develop deterioration was particularly high. The sensitivity results show that detecting subtle deterioration of optic disks is challenging.

Purpose: To determine the visual and survival outcomes for patients undergoing plaque radiotherapy of suspected small choroidal melanomas after observation for growth in a pilot study., Design: Noncomparative interventional case series., Participants: Forty-five patients with suspected small choroidal melanomas who were seen at the Bascom Palmer Eye Institute between 1974 and 2001 and had iodine 125 (I125) plaque radiotherapy between 1991 and 2002., Methods: Patients with suspected small choroidal melanomas were monitored by clinical examination, photography, and echography. When the melanoma grew or developed orange pigment, patients were treated with I125 plaque radiotherapy. Outcomes included visual acuity, ocular complications, tumor dimensions, metastasis, and death., Main Outcome Measure: Melanoma-specific mortality., Results: In our pilot study, 1 patient died from metastatic melanoma. One patient developed metastatic disease and is still alive. One patient developed marginal tumor recurrence after treatment and after enucleation was performed. Globe conservation was achieved in 97.8% of patients. In patients with tumor margins >2 mm from the optic nerve, vision was preserved with less than a doubling of the visual angle (within approximately 2 Snellen lines of preoperative acuity) in 90.6% (29/32) of patients at 1 year postoperatively, 65.6% (21/32) at 2 years, and 52.2% (12/23) in the long term (4-11 years)., Conclusions: Five-year melanoma-specific mortality after I125 plaque radiotherapy of suspected small choroidal melanomas was 3.9% (95% confidence interval, 0%-11.2%). This information can be used to counsel patients with small suspected choroidal melanomas and to compare with other treatment modalities.

Purpose: The Tube Versus Trabeculectomy (TVT) Study will compare the safety and efficacy of nonvalved tube shunt surgery to trabeculectomy with mitomycin C in patients with previous intraocular surgery., Design: Multicenter randomized clinical trial., Setting: 17 Clinical Centers., Study Population: Patients 18 to 85 years of age who have undergone previous trabeculectomy, cataract extraction with intraocular lens implantation, or both and have inadequately controlled glaucoma with intraocular pressure (IOP) >or=18 mm Hg and

Purpose: To evaluate whether flap thickness changes after the primary laser in situ keratomileusis (LASIK) procedure and to assess the accuracy of intraoperative pachymetry and ablation depth measurements in predicting stromal bed thickness before enhancement in eyes that have had primary myopic LASIK., Setting: Bascom Palmer Eye Institute, Miami, Florida, USA., Methods: This retrospective noncomparative interventional case series comprised 57 eyes of 42 patients who had LASIK enhancement between June 2001 and September 2002. Exclusion criteria included previous ocular surgery or complications during the first LASIK procedure. Only patients who had had LASIK and enhancement by the same surgeon at our institution and had intraoperative pachymetry readings for both procedures were included. The original flap was relifted in all enhancement procedures. Corneal thickness was routinely measured intraoperatively by ultrasound pachymetry. The age, eye, refraction, date of primary LASIK, central corneal thickness (CCT) and central stromal bed thickness at primary LASIK, depth of ablation, flap thickness (subtraction pachymetry), date of enhancement, CCT and central stromal bed thickness at enhancement, and flap thickness at enhancement were recorded., Results: Thirty-one eyes of 26 patients were myopic and 26 eyes of 16 patients were hyperopic before primary LASIK. The mean time between LASIK and enhancement was 218 days +/- 115 (SD) (193 +/- 88 days in myopic eyes and 248 +/- 136 days in hyperopic eyes [P = .068]). The flap tended to be thicker at enhancement than in the primary LASIK procedure by 9.3 +/- 25.7 microm in myopic eyes (P = .054) and 10.5 +/- 16.6 microm in hyperopic eyes (P = .004). A strong correlation was found between flap thickness in the first and second procedures in myopic and hyperopic eyes (r = 0.6). In myopic eyes, the mean difference between the estimated stromal bed thickness after the first procedure (central bed thickness- ablation depth) and the stromal bed thickness measured directly at enhancement was not statistically significant (3 +/- 29 microm; P = .54, paired t test). A strong correlation was found between the 2 measurements (r = 0.8, P<.001). Another strong correlation was found in myopic eyes between the estimated corneal thickness after the primary LASIK and the corneal thickness measured at enhancement (r = 0.81, P<.001). No correlation was found between the difference in flap thickness and the time to enhancement (r = 0.09 in myopic eyes and r = 0.01 in hyperopic eyes)., Conclusions: Flap thickness tended to be thicker at enhancement than at primary LASIK. Intraoperative pachymetry and ablation depth measurements proved to be precise tools to predict stromal bed thickness before enhancement in eyes that had had primary myopic LASIK. This information may help in planning LASIK enhancements.

Purpose: To determine the predictability of flap thickness in laser in situ keratomileusis (LASIK) using the Moria M2 microkeratome and identify factors that may be related to variations in flap thickness., Setting: Laser Vision Correction Center, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida, USA., Methods: Charts of 208 patients having same-day bilateral LASIK using the Moria M2 microkeratome were reviewed. Intraoperative pachymetry was performed routinely. The right eye was always treated first. The same suction ring, stop, microkeratome head (110 microm or 130 microm), and blade were used in fellow eyes. Subtraction pachymetry was used to calculate flap thickness. Other collected data included age, keratometry, corneal diameter, and preoperative spherical equivalent (SE)., Results: With the 110 microm head and slow translation velocity in both eyes, the mean flap thickness was 151.6 microm +/- 24.0 (SD) and 148.5 +/- 24.3 microm in the right and left eyes, respectively. With the 110 microm head and fast translation velocity in both eyes, the mean thickness was 136.2 +/- 25.5 microm and 132.8 +/- 23.5 microm, respectively. With the 130 microm head and fast translation velocity, the mean flap thickness was 145.8 +/- 25.4 microm and 139.9 +/- 25.5 microm, respectively. Flaps were thinner with fast translation velocity, the 110 microm head, and presumably duller blades used in the left eyes. There was a weak but statistically significant inverse correlation between flap thickness and age and between flap thickness and SE. A stronger correlation was found in flap thickness between right and left eyes., Conclusions: Flap thickness with the Moria M2 microkeratome was variable. Fast translation velocity, a used (presumably duller) blade, and the 110 microm head produced thinner flaps. Given the potential variation in flap thickness (SD 23.5 to 25.5 microm), intraoperative pachymetry might be an adjunctive measure to prevent residual stromal beds that are thinner than planned, especially in patients with high myopia and/or thin corneas.

Purpose: To compare the results of foldable acrylic intraocular lens (IOL) implantation through a clear corneal incision with those of rigid IOL implantation in eyes having pars plana vitrectomy (PPV)., Setting: Tertiary referral-based university institute., Methods: A consecutive retrospective comparative chart review was performed in all eyes that had PPV and foldable IOL implantation between May 15, 1999, and November 1, 2000 (n = 30), and all eyes that had PPV and rigid IOL implantation between April 1, 1996, and May 14, 1999 (n = 30). Preoperative baseline data and postoperative outcome data were recorded. Pars plana vitrectomy and associated vitreoretinal procedures were performed as indicated according to individual circumstances. A minimum of 1 week of follow-up information was available for all eyes., Results: Baseline characteristics in both groups of patients, including age, sex, eye involved, and phakic state, were similar. The preoperative visual acuities were also similar, ranging from 20/30 to hand motions; the mean visual acuity was 20/200. The IOL was implanted in all eyes uneventfully and did not restrict fundoscopy. The mean follow-up was significantly longer in the rigid IOL group (20 months) than in the foldable IOL group (7 months) (P<.001), probably because of the earlier case acquisition. The mean postoperative best corrected visual acuity was 20/200 in the foldable IOL group and 20/100 in the rigid IOL group. There was no difference between the 2 groups in the rate of postoperative retinal detachment, recurrent macular hole, or repeat PPV. Elevated intraocular pressure (IOP) on the first postoperative day was more common in the rigid IOL group than in the foldable IOL group (P =.078) because more patients in the rigid IOL group had surgery for diabetic ocular complications and these patients had a greater IOP rise., Conclusion: Acrylic IOLs can be safely implanted in conjunction with PPV in selected cases.

Objective: To determine whether a single topical aqueous suppressant applied immediately after pars plana vitrectomy with long-acting gas tamponade prevents intraocular pressure (IOP) elevation., Methods: Fifty patients who met the inclusion criteria and underwent pars plana vitrectomy with long-acting gas tamponade were randomized to receive a combination of timolol maleate and dorzolamide hydrochloride, long-acting timolol alone, dorzolamide alone, or placebo at the conclusion of surgery. The IOP was checked by a portable, handheld tonometer (Tono-Pen) at the conclusion of surgery and at 5 hours, 1 day, and 1 week after surgery., Results: There were no significant differences in IOP among the groups at the conclusion of surgery. The IOP at 5 hours after surgery (27.0 vs 17.4 mm Hg; P<.001) and 1 day after surgery (26.1 vs 19.9 mm Hg; P =.01) showed a statistically significant difference between the placebo and timolol-dorzolamide groups. The timolol-dorzolamide group showed greater IOP control than either the timolol alone or the dorzolamide alone groups at 5 hours (P =.04 for both)., Conclusion: The use of a single topical aqueous suppressant (timolol-dorzolamide) given after pars plana vitrectomy with long-acting gas tamponade effectively prevents significant postoperative IOP elevation at 5 hours and 1 day after surgery.

Purpose: To determine the risk factors for hypotony maculopathy., Design: Retrospective case control study., Participants: Two hundred twenty-eight eyes of 228 patients with hypotony from one medical center., Methods: Chart review of patients with hypotony from January 1988 to April 2001. Hypotony was defined as intraocular pressure of 5 mmHg or less. Cases of hypotony maculopathy had retinal or choroidal folds or both within the arcades. Controls had hypotony alone. Risk factors were evaluated using multiple logistic regression analysis., Main Outcome Measures: Risk factors for hypotony maculopathy, including age, gender, race, refractive error, systemic illness, intraocular pressure, primary filtering surgery, use of antifibrotic agents, and presence of choroidal effusion., Results: Eighty-one case eyes with hypotony maculopathy and 147 control eyes with hypotony alone were identified. The mean age of patients with hypotony maculopathy was 50.5 years +/- 18.7 compared with 70.6 years +/- 12.7 for the control patients (P < 0.001). More patients with hypotony maculopathy were male, 54.3% (44 of 81), than controls, 33.6% (49 of 147) (P = 0.004). The refractive error was -3.02 +/- 3.67 diopters (D) for phakic eyes with hypotony maculopathy (n = 31), whereas the phakic control eyes' (n = 30) refractive error was -0.61 D +/- 2.00 (P = 0.003). Choroidal effusion was found in 21% (17 of 81) of the case eyes at diagnosis and 52.4% (77 of 147) of the control eyes (P < 0.001). Race distribution and use of antifibrotics was similar for both groups. In multivariate analyses, young age, male gender, no history of diabetes, and absence of choroidal effusion predicted the development of hypotony maculopathy; in phakic eyes myopia was also a risk factor for hypotony maculopathy., Conclusions: Young age, male gender, and myopia are significant risk factors for hypotony maculopathy. A history of diabetes and the presence of choroidal effusion are associated with a decreased risk for hypotony maculopathy.

Background and Objective: To evaluate the distribution of retinal nerve fiber layer thickness measurements in normal eyes corrected for corneal polarization axis (CPA)., Methods: Complete ocular examination, standard automated perimetry, peripapillary and macular scanning laser polarimetry imaging, and CPA measurements were performed in normal eyes. A noninvasive device mounted on a slit lamp that incorporated two crossed linear polarizers and an optical retarder to measure the slow axis of corneal birefringence was constructed. One eye per patient was enrolled. Exclusion criteria consisted of visual acuity of less than 20/40, a refractive error exceeding +/- 5.0 diopter sphere, 2.0 diopter cylinder, or both, previous intraocular surgery, or ocular disease except cataract. According to scanning laser polarimetry, peripapillary retardation parameters within 90% normal limits were recorded as "normal," parameters outside 95% normal limits were recorded as "abnormal," and parameters between 90% and 95% limits were recorded as "borderline.", Results: Fifty-one eyes of 51 subjects (14 men, 37 women) were enrolled (mean age, 51 +/- 17 years). Prediction limits (+/- 2 standard deviation outside of regression line) were calculated for 14 peripapillary retardation parameters. The prediction limits of the average thickness of the retinal nerve fiber layer (microm) were reduced 35% by correction of the CPA; for ellipse average (microm), the limits were reduced 33%. Sixteen of 51 normal eyes (31%) had at least one abnormal retardation parameter, and among these 16 eyes there was a bimodal distribution of CPA values (0 degrees to 20 degrees nasally downward, 60 degrees to 80 degrees nasally downward)., Conclusions: Correction for CPA reduces the variance of normal retardation measurements. Normal eyes with a CPA of 0 degrees to 20 degrees nasally downward and 60 degrees to 80 degrees nasally downward were characterized by "abnormal" summary retardation parameters as interby scanning laser polarimetry.

Objective: To evaluate the efficacy and safety of Baerveldt glaucoma drainage devices in the management of uveitic glaucoma., Design: Retrospective, noncomparative case series., Participants: Twenty-four eyes of 24 patients who underwent implantation of Baerveldt glaucoma drainage devices between 1996 and 2000 for the treatment of uveitic glaucoma refractory to medical therapy., Intervention: Implantation of Baerveldt glaucoma drainage device., Main Outcome Measures: Control of intraocular pressure (IOP), number of glaucoma medications needed for adequate IOP control, visual acuity, complications associated with the surgery, and the effect of subsequent surgery on the ability of the device to control IOP. Success was defined as IOP >/=5 and

Purpose: To report factors associated with the use of local anesthesia with intravenous sedation (local anesthesia/sedation) rather than general anesthesia for surgery for open globe injuries in adult reparable eyes., Design: Retrospective, nonrandomized, comparative case series., Methods: Medical records were reviewed of all patients with open globe injuries repaired at Bascom Palmer Eye Institute between 1995 and 1999. "Adult reparable eyes" (eyes in patients >/=18 years of age, not treated with primary enucleation or evisceration, followed up >/=2 months) were included., Results: In all, 220 eyes of 218 patients met inclusion criteria. General anesthesia was employed in 80 of 200 (36%) and local anesthesia/sedation in 140 of 220 (64%). Patients who had local anesthesia/sedation were significantly more likely to have an intraocular foreign body (31% vs 14%; P =.010, chi-square test), better presenting visual acuity (1.8 logMAR [logarithm of the minimum angle of resolution] units vs 2.5 logMAR units; P <.001, t test), more anterior wound location (75% corneal/limbal vs 65%; P =.003, chi-square), shorter wound length (6.3mm vs 10.8mm; P <.001, t test), and dehiscence of previous surgical wound (26% vs 12%; P =.021, chi-square) and were significantly less likely to have an afferent pupillary defect (22% vs 51%; P <.001, chi-square). There was no anesthesia-related complication in either group. The local anesthesia/sedation group had a shorter mean operating time than did the general anesthesia group (78 minutes vs 117 minutes; P <.001, t test). The general anesthesia group had a longer mean follow-up than the local anesthesia/sedation group (20.2 months vs 13.9 months, respectively; P =.002, t test). Change in visual acuity between the presenting and final examinations was similar for open globe injuries repaired with general anesthesia compared with local anesthesia/sedation (0.94 vs 0.72 logMAR units of visual acuity, respectively; P =.16, t test)., Conclusions: Local anesthesia/sedation is a reasonable alternative to general anesthesia for selected patients with open globe injuries.

Objective: To report visual acuity and anatomic outcomes, as well as complications, associated with giant retinal tear management using intraoperative perfluoro-n-octane and to investigate clinical features associated with anatomic and visual acuity outcomes., Design: A prospective, noncomparative, observational, multicenter study., Participants: Two hundred twelve patients (212 eyes) > or =15 months of age who underwent giant retinal tear management with intraoperative perfluoro-n-octane at 24 study sites between April 1994 and February 1996. Giant retinal tear was defined as a retinal tear extending > or =90 degrees., Intervention: Vitrectomy with perfluoro-n-octane intraoperative retinal tamponade., Main Outcome Measures: Visual acuity and rates of retinal reattachment, reoperation, retained perfluoro-n-octane, corneal edema, elevated intraocular pressure (IOP > 25 mmHg), hypotony (IOP < 5 mmHg), and cataract. All outcome measures were assessed at 1 day, 1 week, 1 month, 3 months, and 6 months postoperatively and at the last examination., Results: The study included 212 eyes of 212 patients followed a median of 3.5 months. Visual acuity > or =20/200 was measured in 56 (27%) patients preoperatively and 67 (47%) patients at 6 months. Postoperative visual acuity improved in 107 (59%) eyes, remained stable in 44 (24%) eyes, and worsened in 29 (16%) eyes (percentages are based on the number of patients for whom the data were available at these time points). Of the 124 patients with visual acuity < or =5/200 preoperatively, 94 (76%) had improved visual acuity at 6 months postoperatively. At 6 months, the retina was attached in 108 (76%) eyes, and retained perfluoro-n-octane was noted in 8 (6%) eyes. Throughout follow-up, 64 (30%) eyes underwent reoperation for recurrent retinal detachment. At 6 months, corneal edema, elevated IOP, and hypotony were noted in 5 (4%), 4 (3%), and 12 (9%) eyes, respectively. Of the 72 phakic eyes without cataract preoperatively, 61 (85%) had a cataract or underwent cataract extraction during study follow-up. Factors significantly (P < 0.05) associated with recurrent retinal detachment include female gender, younger age, preoperative proliferative vitreoretinopathy, prior vitrectomy, larger size of giant retinal tear, lack of scleral buckle placement, and relaxing retinotomy. Multivariate analysis demonstrated that female gender, larger size of giant retinal tear, and prior vitrectomy were significantly associated with recurrent detachment. Factors significantly associated with vision >or =20/200 include male gender, no prior vitrectomy, better preoperative vision, and no need for relaxing retinotomy. After adjusting for recurrent detachment, factors significantly associated with vision > or =20/200 include no prior vitrectomy, better preoperative vision, and no need for relaxing retinotomy., Conclusions: Retinal reattachment and preserved visual acuity were achieved in most eyes that underwent giant retinal tear management with intraoperative perfluoro-n-octane. Significant risk factors for recurrent retinal detachment include size of retinal tear, age, prior vitrectomy, and female gender. After adjusting for recurrent detachment, significant predictors of postoperative vision >or =20/200 include no prior vitrectomy, better preoperative vision, and no need for relaxing retinotomy.