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Carl Erb,1 Ingeborg Stalmans,2 Milko Iliev,3 Francisco José Muñoz-Negrete4 1Eye Clinic Wittenbergplatz, Berlin, Germany; 2Department of Ophthalmology, University Hospitals Leuven, Leuven, Belgium; 3Ophthalmology Department, University of Bern, Inselspital, Bern, Switzerland; 4Servicio de Oftalmología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, EspañaCorrespondence: Francisco José Muñoz-NegreteServicio de Oftalmología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, EspañaTel +34 913 36 80 00Email franciscojmunoz@telefonica.netPurpose: Patient satisfaction is important in the treatment of glaucoma. Suboptimal compliance and impaired long-term outcome are a likely result of poor tolerability. The present multicentre, international, transverse, epidemiological survey was conducted to assess the satisfaction of patients who had received preservative-free latanoprost (PFL) for at least 3 months.Patients and Methods: A total of 1872 patients from 6 European countries, treated with PFL for at least 3 months, were included in this survey. Prior to PFL treatment, patients were to be treatment naïve or currently treated for their glaucoma. During a single routine consultation, patients completed a questionnaire concerning global satisfaction and satisfaction based on tolerability.Results: In total, 76.2% had been previously treated; 69.4% had received preserved and 6.8% preservative-free (PF) topical treatment. After 3 months of PFL treatment, a large majority of patients (95.3%) were satisfied or very satisfied with their PFL treatment and were, overall, significantly (p< 0.0001) more satisfied with PFL than with their previous treatment; 4.2% were either unsatisfied or very unsatisfied. Overall, 97.3% of originally treatment-naïve patients were satisfied (50.1%) or very satisfied (47.2%) with their PFL. Ocular surface disease was diagnosed in 9.2% of patients (n=173) and was mainly mild (76.9%). Patient satisfaction with PFL was very high. Conclusion: PFL may be considered a valuable first-choice treatment in glaucoma patients.Keywords: glaucoma, prostaglandin, preservative-free latanoprost, patient satisfaction, tolerability, tear substitutes, intra-ocular pressure, ocular surface disease, conjunctival hyperaemia

Ingeborg Stalmans,1 Hans Lemij,2 Jonathan Clarke,3 Christophe Baudouin4 On behalf of the GOAL study group1Department of Ophthalmology, UZ Leuven, Leuven, Belgium; 2Glaucoma Service, Rotterdam Eye Hospital, Rotterdam, the Netherlands; 3NIHR Biomedical Research Centre - Moorfields Eye Hospital, NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK; 4Ophthalmology Unit, Quinze-Vingts National Hospital and Vision Institute, IHU ForeSight, Sorbonne University, Paris, FranceCorrespondence: Christophe BaudouinOphthalmology Unit, Quinze-Vingts National Hospital and Vision Institute, IHU ForeSight, Sorbonne University, Paris, FranceEmail cbaudouin@15-20.frAbstract: Ocular Surface Disease (OSD) and hyperemia are the most common adverse events of topical ocular medications. While active compounds may cause allergic reactions or irritation, preservatives, which are intended to prevent bacterial growth, are toxic as well. Therefore, the most recent glaucoma medications no longer contain preservatives. Despite this, local tolerability may still impact treatment compliance and patient quality of life. We conducted an observational, multi-center, international, cross-sectional study in 793 treated and stabilized glaucoma patients to assess patient satisfaction and local tolerability of their treatment. The vast majority (93.7%) of patients was satisfied or very satisfied with their treatment in terms of tolerability and only 6.3% were dissatisfied. However, ophthalmological examination showed a high frequency of ocular signs: conjunctival hyperemia (32%), OSD (42.5%) and positive conjunctival fluorescein staining (10.3%). Additionally, patients reported symptoms upon instillation (31.4%) and between instillations (57.3%); 25.1% of patients were using tear substitutes. All signs and symptoms were significantly (p< 0.001) associated with patient dissatisfaction. A logistic regression model indicated that dissatisfaction was higher in patients with symptoms upon instillation and in those using tear substitutes (OR: 3.03 and 4.63, respectively). The mean patient tolerability score to treatment was 82.7± 16.1 on a 100-point visual analogue scale. In conclusion, even if patients may be highly satisfied with their current treatment, most of them present ocular signs and symptoms. A treatment change should be considered in case of clinical signs or patient-reported symptoms.Keywords: glaucoma, tolerance, preservatives, tear substitutes, patient satisfaction, ocular surface disease

Mieke Hulens,1 Frans Bruyninckx,2 Ricky Rasschaert,3 Greet Vansant,4 Peter De Mulder,5 Ingeborg Stalmans,6,7 Chris Bervoets,8,9 Wim Dankaerts1 1Department of Rehabilitation Sciences, Musculoskeletal Rehabilitation Research Unit, Faculty of Kinesiology and Rehabilitation Sciences, University of Leuven, Leuven, Belgium; 2Clinical Electromyography Laboratory, University Hospitals UZ Leuven, Leuven, Belgium; 3Department of Neurosurgery, AZ Rivierenland, Bornem, Belgium; 4Department of Social and Primary Health Care, Public Health Nutrition, University of Leuven, Leuven, Belgium; 5Department of Anesthesiology and Pain Therapy, Imelda Hospital, Bonheiden, Belgium; 6Department of Neurosciences, Ophthalmology Research Group, University of Leuven, Leuven, Belgium; 7Department of Ophthalmology, University Hospitals UZ Leuven, Leuven, Belgium; 8Department of Neurosciences, Adult Psychiatry, University of Leuven, Leuven, Belgium; 9Department of Adult Psychiatry, University Psychiatric Center UPC KULEUVEN, Leuven, BelgiumCorrespondence: Mieke Hulens Overwegstraat 14, Sint-Joris-Weert 3051, BelgiumTel +32 478 338003Fax +32 16 470559Email miekehulens@skynet.bePurpose: Increasing evidence suggests that fibromyalgia most likely represents a neurological dysfunction. We previously hypothesized that at least some fibromyalgia cases may be caused by irritation of nerve root fibers and sensory neurons due to moderately increased cerebrospinal pressure. Because of the rostro-caudal hydrostatic pressure gradient, neurogenic abnormalities are expected to be most pronounced in sacral nerve roots. The purpose was to review electrodiagnostic tests of patients with fibromyalgia.Methods: A retrospective review of electrodiagnostic test results, including the lumbar and sacral nerve root myotomes of patients diagnosed with fibromyalgia according to the 1990 criteria of the American College of Rheumatology was done.Results: All 17 patients were female. Sural nerve responses could not be elicited in 12% and S1-Hoffmann reflex latencies were increased in 41%. In 12% of the patients, fibular motor nerve distal latency and conduction velocity were outside normal limits. Needle-EMG revealed neurogenic motor unit potentials in 0% of L2, 6% of L3, 29% of L4, 71% of L5, 47% of S1, 94% of S2, and 76% of S3-S4 myotomes. S3-S4 nerve-supplied anal reflexes were delayed in 94%.Conclusion: This is the first time that electrodiagnostic data of both lumbar and sacral nerve root myotomes in fibromyalgia patients are presented. All patients showed neurogenic abnormalities that were more pronounced in the sacral than in the lumbar myotomes with a rather patchy distribution pattern. We propose that, in addition to skin punch biopsies to assess small fiber neuropathy, assessment of the anal reflex may be a useful part of the diagnostic pathway in patients with fibromyalgia.Keywords: large fiber neuropathy, anal reflex, sacral nerves, nerve conduction studies, needle EMG

Vanessa Vera,1 Arsham Sheybani,2 Dan Lindfield,3 Ingeborg Stalmans,4 Iqbal Ike K Ahmed5 1Department of Glaucoma, Unidad Oftalmologica de Caracas, Caracas, Venezuela; 2Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St Louis, MO, USA; 3Department of Ophthalmology, Royal Surrey County Hospital, Guildford, Surrey, UK; 4Glaucoma Unit, University Hospitals UZ Leuven, Leuven, Belgium; 5Glaucoma and Advanced Anterior Segment Surgery, University of Toronto, Toronto, ON, Canada Abstract: Surgical management of glaucoma offers a means of effective disease control. A gel stent that facilitates drainage to the subconjunctival space offers intraocular pressure (IOP) reduction similar to traditional glaucoma filtering surgeries in a less invasive manner. However, like all subconjunctival filtering procedures that result in a bleb, fibrosis can present as a cause of elevated IOP. The following proposed techniques and recommendations for managing elevated IOP due to bleb fibrosis after gel stent implantation are based on the clinical experience of the authors. The goal of this paper is to improve outcomes following gel stent surgery by providing guidance on assessment of bleb function and strategies for bleb enhancement. Keywords: glaucoma gel stent, bleb management, bleb fibrosis, glaucoma surgery, glaucoma filtering surgery, bleb needling

Mieke Hulens,1 Ricky Rasschaert,2 Greet Vansant,3 Ingeborg Stalmans,4,5 Frans Bruyninckx,6 Wim Dankaerts1 1Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, Musculoskeletal Rehabilitation Research Unit, University of Leuven, Leuven, Belgium; 2Department of Neurosurgery, Sint-Jozefziekenhuis, Bornem, Belgium; 3Department of Social and Primary Health Care, Public Health Nutrition, University of Leuven, Leuven, Belgium; 4Department of Neurosciences, Ophthalmology Research Group, University of Leuven KU Leuven, Leuven, Belgium; 5Department of Ophthalmology, University Hospitals UZ Leuven, Leuven, Belgium; 6Clinical Electromyography Laboratory, Department of Academic Consultants, Faculty of Medicine, University Hospitals UZ Leuven, Leuven, Belgium Purpose: Idiopathic intracranial hypertension (IICH) is a condition characterized by raised intracranial pressure (ICP), and its diagnosis is established when the opening pressure measured during a lumbar puncture is elevated >20 cm H2O in nonobese patients or >25 cm H2O in obese patients. Papilledema is caused by forced filling of the optic nerve sheath with cerebrospinal fluid (CSF). Other common but underappreciated symptoms of IICH are neck pain, back pain, and radicular pain in the arms and legs resulting from associated increased spinal pressure and forced filling of the spinal nerves with CSF. Widespread pain and also several other characteristics of IICH share notable similarities with characteristics of fibromyalgia (FM) and chronic fatigue syndrome (CFS), two overlapping chronic pain conditions. The aim of this review was to compare literature data regarding the characteristics of IICH, FM, and CFS and to link the shared data to an apparent underlying physiopathology, that is, increased ICP.Methods: Data in the literature regarding these three conditions were compared and linked to the hypothesis of the shared underlying physiopathology of increased cerebrospinal pressure.Results: The shared characteristics of IICH, FM, and CFS that can be caused by increased ICP include headaches, fatigue, cognitive impairment, loss of gray matter, involvement of cranial nerves, and overload of the lymphatic olfactory pathway. Increased pressure in the spinal canal and in peripheral nerve root sheaths causes widespread pain, weakness in the arms and legs, walking difficulties (ataxia), and bladder, bowel, and sphincter symptoms. Additionally, IICH, FM, and CFS are frequently associated with sympathetic overactivity symptoms and obesity. These conditions share a strong female predominance and are frequently associated with Ehlers-Danlos syndrome.Conclusion: IICH, FM, and CFS share a large variety of symptoms that might all be explained by the same pathophysiology of increased cerebrospinal pressure. Keywords: chronic pain, fatigue, headache, Ehlers-Danlos, sympathetic activity, lymphatic olfactory pathway, small fiber neuropathy, Ménière’s disease, Tarlov cysts

Tine Van Bergen,1 Sarah Van de Velde,1 Evelien Vandewalle,3 Lieve Moons,2 Ingeborg Stalmans1,31Laboratory of Ophthalmology, KU Leuven, 2Unit Animal Physiology and Neurobiology, KU Leuven, 3Department of Ophthalmology, University Hospitals Leuven, Leuven, BelgiumAbstract: Of all the treatments currently used to lower intraocular pressure in glaucoma patients, filtration surgery is known to be the most effective. However, in a significant percentage of cases, the constructed channel closes due to excessive scar formation, resulting in surgical failure. The process of postoperative wound healing is characterized by the coagulative and inflammatory phase, followed by the proliferative and repair phase, and finally the remodeling phase. Perioperative antimitotic agents, such as mitomycin C and 5-fluorouracil, are known to modulate the process of wound healing and to improve surgical outcome, but they carry a risk of vision-threatening complications. New alternative strategies to prevent filtration failure, such as inhibition of transforming growth factor-β, vascular endothelial growth factor, and placental growth factor, have shown promising results in the improvement of surgical success. However, it remains necessary to broaden the therapeutic approach by focusing on combined therapies and on extended drug delivery.Keywords: glaucoma filtration surgery, filtration failure, wound healing, wound modulating agents