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

Background/objectives: Tablet-based perimetry could be used to test for glaucomatous visual field defects in settings without easy access to perimeters, although few studies have assessed diagnostic accuracy of tablet-based tests. The goal of this study was to determine the diagnostic accuracy of iPad perimetry using the visualFields Easy application., Subjects/methods: This was a prospective, cross-sectional study of patients undergoing their first Humphrey Field Analyser (HFA) visual field test at a glaucoma clinic in India. Participants underwent 24-2 SITA Standard HFA testing and iPad-based perimetry with the visualFields Easy application. Reference standards for both visual field loss and suspected glaucoma were determined by ophthalmologist review of HFA results and optic disc photographs. Receiver operating characteristic curves were constructed to assess diagnostic accuracy at various test thresholds., Results: 203 eyes from 115 participants were included, with 82 eyes classified as moderate or worse glaucoma. iPad perimetry had an area under the receiver operating characteristic (AUROC) curve of 0.64 (95% CI 0.57 to 0.71) for detection of any visual field defect relative to HFA and an AUROC of 0.68 (0.59 to 0.76) for detection of moderate or worse glaucoma relative to ophthalmologist examination. At a set specificity of 90%, the sensitivity of iPad perimetry for detection of moderate or worse glaucoma was 35% (22-48%)., Conclusions: iPad perimetry using the visualFields Easy application had inadequate diagnostic accuracy to be used as a screening tool for glaucoma in this South Indian population., (© 2022. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Purpose: Portable perimetric testing could be useful for community-based glaucoma screening programs. Frequency-doubling technology (FDT) and the Moorfields motion displacement test (MDT) are portable perimeters that have shown promise as potential screening tools for glaucoma. This study's goal was to determine the diagnostic accuracy of FDT and MDT for visual field defects and glaucoma., Design: Prospective, cross-sectional, diagnostic accuracy study., Participants: A consecutive series of patients aged ≥ 50 years who presented to a glaucoma clinic in South India and had never undergone Humphrey field analyzer (HFA) visual field testing in the past., Methods: Participants underwent 24-2 Swedish Interactive Thresholding Algorithm (SITA) Standard HFA perimetry, FDT perimetry, MDT perimetry, and iPad perimetry using visualFields Easy in random order. Ophthalmologist grades of HFA and optic nerve head photographs were used as reference standards for glaucoma and field defect presence. Receiver operating characteristic curves were constructed to assess the diagnostic accuracy of various parameters for each test., Main Outcome Measures: Sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC)., Results: Overall, 292 eyes from 173 participants were included, with 112 eyes classified as moderate or worse glaucoma. For moderate or worse glaucoma detection, the best parameter on FDT was mean deviation (MD) (AUROC, 0.84; 95% confidence interval [CI], 0.79-0.89) and the best parameter on MDT was global probability of true damage (GPTD) (AUROC, 0.87; 95% CI, 0.82-0.91). When specificity was set to 90%, the sensitivity for detection of moderate or worse glaucoma was 55% (95% CI, 39%-68%) for FDT MD and 62% (95% CI 52%-71%) for MDT GPTD., Conclusions: Frequency-doubling technology and MDT perimetry had fair diagnostic accuracy for glaucoma detection when administered to naïve test takers in this South Indian population. Although not appropriate for use as a sole glaucoma screening test, these perimetric tests may be useful as ancillary tests., Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references., (Copyright © 2022 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Prcis: Corneal hysteresis (CH) measurements are relatively stable during routine follow up of glaucoma patients over an intermediate time frame. Cataract surgery does not change the CH significantly after an average follow up of 6 months., Purpose: The aim was to assess the repeatability of CH measurements in glaucoma patients over time, during routine follow up and after cataract surgery., Materials and Methods: Retrospective analysis of patients records in a glaucoma clinic where routine measurements by the Ocular Response Analyzer were done. Patients with at least 2 CH measurements were included. Repeatability was assessed using the intraclass correlation coefficient (ICC)., Results: A total of 164 eyes (87 patients) were included. Twenty-eight of them had measurements before and after cataract surgery with mean follow up time of 29.64±9.63 weeks. There was no evidence for a difference in CH between the before and after cataract surgery measurements (ICC=0.79, 95% confidence interval: 0.60-0.89). In the remaining 136 eyes, without any surgical treatment between measurements, there was moderate agreement among the repeated CH measurements (ICC=0.64, 95% confidence interval: 0.61-0.82) with mean time of 32.06±25.32 weeks between first and last measurement., Conclusion: CH measurements in glaucoma patients were repeatable over a 6-month period during routine follow up or following cataract surgery. These findings suggest that the intraocular pressure reduction following cataract surgery is unlikely to be because of a change in this biomechanical property., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To determine the diagnostic accuracy of potential screening tests for moderate to advanced glaucoma., Design: Prospective diagnostic test accuracy study., Participants: The study enrolled a consecutive series of patients aged ≥50 years who presented to a glaucoma clinic in South India without ever having received automated visual field testing., Methods: All participants underwent 8 index tests: OCT of the peripapillary retinal nerve fiber layer, optic disc photography, Moorfield's Motion Displacement Test (MDT), frequency doubling technique perimetry, noncontact tonometry, pneumatonometry, presenting visual acuity, and best-corrected visual acuity. Participants also underwent stereoscopic photographs and Humphrey visual fields, which were used by 2 ophthalmologists to arrive at the reference standard diagnosis of moderate to advanced glaucoma., Main Outcome Measures: Sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio., Results: A total of 217 people were enrolled; 321 eyes from 180 participants had all tests performed. Of these, 127 eyes (40%) were classified as having moderate to advanced glaucoma. Among the 8 tests, OCT best optimized sensitivity (84%, 95% confidence interval [CI], 76-90) and specificity (75%, 95% CI, 68-81). Moorfield's Motion Displacement Test was the best perimetric test, with a sensitivity of 91% (95% CI, 85-96) and specificity of 53% (95% CI, 44-61). Pressure and vision tests were not sensitive (e.g., sensitivity of 16%, 95% CI, 9-23 for noncontact tonometry and 23%, 95% CI, 15-31 for best-corrected visual acuity). Moorfield's Motion Displacement Test identified 16 of 127 eyes (13%) with glaucoma that were not captured by OCT, but also had false-positive results in 65 of 194 eyes (34%) without glaucoma that OCT correctly classified as negative., Conclusions: OCT had moderate sensitivity and fair specificity for diagnosing moderate to advanced glaucoma and should be prioritized during an initial assessment for glaucoma., (Copyright © 2021 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

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

Purpose : Previous studies have used subjective assessments to implicate darker skin color as a risk factor for glaucoma. This study used objective measurements to determine whether skin melanin is a risk factor for glaucoma. Methods: In a case-control study conducted at a tertiary eye hospital in Nepal, patients aged 40 years or older from the glaucoma clinic were enrolled as cases and age-matched patients without glaucoma from other clinics at the eye hospital were enrolled as controls. A colorimeter was used to capture melanin measurements in triplicate from the inner arm and forehead of each participant. The exposure variable of interest was the median skin melanin value, in arbitrary units. The outcome of interest was the presence of glaucoma. Results: 100 glaucoma cases and 100 matched controls were enrolled. Agreement between the triplicate melanin measurements was high, with an intra-class correlation of 0.99 (95% CI, 0.99-0.99) for inner arm measurements and 0.97 (95% CI 0.96-0.98) for forehead measurements. Mean inner arm melanin values were 604 units (standard deviation [SD] 177) in cases and 602 units (SD 179) in controls; forehead values were 650 (SD 146) in cases and 652 (SD 152) in controls. After adjusting for sex and country of residence, skin melanin was not associated with the presence of glaucoma (odds ratio 1.04, 95%CI 0.78-1.38 for inner arm values and 0.97, 95%CI 0.70-1.35 for forehead values). Conclusion: This study failed to find a significant association between skin pigmentation and glaucoma.

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

Purpose: Autorefractors allow non-specialists to quickly assess refractive error, and thus could be a useful component of large-scale vision screening programs. In order to better characterize the role of autorefraction for public health outreach programs in resource-limited settings, the diagnostic accuracy of two autorefractors was assessed relative to subjective refraction in an adult Indian population., Methods: An optometrist refracted a series of patients aged ≥50 years at an eye clinic in Bangalore, India using the Nidek ARK-900 autorefractor first, followed by the 3nethra Royal autorefractor, and then subjective refraction. The diagnostic accuracy of each autorefractor for myopia, hyperopia, and astigmatism was assessed using subjective refraction as the reference standard, and measures of agreement between refractions were calculated., Results: A total of 197 eyes in 104 individuals (mean age 63 ± 8 years, 52% female) were evaluated. Both autorefractors produced spherical equivalent estimates that were on average more hyperopic than subjective refraction, with a measurement bias of +0.16 D (95%CI +0.09 to +0.23D) for Nidek and +0.42 D (95%CI +0.28 to +0.54D) for 3nethra. When comparing pairs of measurements from autorefraction and subjective refraction, the limits of agreement were approximately ±1D for the Nidek autorefractor and ±1.75D for the 3Nethra autorefractor. The sensitivity and specificity of detecting ≥1 diopter of myopia were 94.6% (95%CI 86.8-100%) and 92.5% (95%CI 88.9-97.5%) for the Nidek, and 89.2% (95%CI 66.7-97.4) and 77.5% (95%CI 71.2-99.4%) for the 3Nethra. The accuracy of each autorefractor increased at greater levels of refractive error., Conclusions: The sensitivity and specificity of the Nidek autorefractor for diagnosing refractive error among adults ≥50 years in an urban Indian clinic was sufficient for screening for visually significant refractive errors, although the relatively wide limits of agreement suggest that subjective refinement of the eyeglasses prescription would still be necessary., Competing Interests: The authors have declared that no competing interests exist.

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

Purpose: To elucidate the vision loss and recovery course after the Ahmed tube shunt procedure 6 months postoperatively. To identify risk factors associated with significant vision loss., Design: Retrospective chart review., Participants: One eye of all adult patients who underwent an Ahmed glaucoma valve procedure from January 2008 to December 2017 with a minimum 6-month follow-up., Methods: Patients' preoperative and postoperative corrected visual acuity (CVA) were documented for 1 week, 1 month, 3 months, and 6 months postoperatively., Main Outcome Measures: Preoperative and postoperative CVA at various time points were compared using repeated-measures analysis of variance. The proportions of patients with mild (<3 lines of Snellen CVA loss), moderate (3-5 lines, inclusive), and severe (>5 lines) vision loss were calculated and compared using a chi-square test. Logistic regression analysis was conducted to identify risk factors associated with a loss of 3 or more lines of CVA 6 months after surgery., Results: A total of 375 patients were included, whose mean preoperative CVA was 0.76. At 1 week postoperatively, mean CVA worsened to 0.96 (P < 0.05), but recovered back to preoperative level by the third postoperative month (P > 0.05). In terms of any vision loss, 55.6% of patients had worse CVA than preoperation at 1 week postoperatively, including 23.5% who had 3 or more lines of vision loss; these proportions decreased to 39.2% (P < 0.001) and 9.3%, respectively, by 6 months postoperatively. The most common causes of significant vision loss were preexisting ocular conditions and cataract progression. Postoperative antimetabolite injection was associated with a lower risk of 3 or more lines of CVA loss 6 months postoperatively (odds ratio, 0.44; P = 0.023)., Conclusions: After the Ahmed tube shunt procedure, the worst CVA occurred at 1 week postoperatively and mean CVA returned to the preoperative level by month 3 postoperatively. Approximately 40% of patients had any CVA loss compared with preoperation, and 9.3% of patients had 3 or more lines of CVA loss at month 6 postoperatively. Postoperative antimetabolite injection was associated with a lower risk of 3 or more lines of postoperative vision loss., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

PRéCIS:: Publications in glaucoma have seen an increase in the number of authors and disclosures per article, authors with dual degrees, and international authors, but contributions of women to articles published remains low., Purpose: Authorship trends have been studied across many medical specialties and in ophthalmology as a whole, but not specifically in glaucoma. The authors explored the authorship trends of original scientific articles in the Journal of Glaucoma., Materials and Methods: The authors recorded the number of authors and disclosures per article, degree type of first and last authors, geographical origin of the corresponding author, and sex of first and last authors of original content from the Journal of Glaucoma published in 1992, 1997, 2002, 2007, 2012, and 2017., Results: A total of 642 articles were analyzed. From 1992 to 2017, annual published articles increased from 38 to 242 (P=0.02), the mean number of authors per article increased from 3.2 to 5.2 (P<0.01), the mean number of disclosures per article increased from 0.3 to 1.0 (P=0.04), the proportion of first and last authors with dual degrees (medical plus advanced degrees) also increased (both P<0.03), whereas the proportion with a sole medical degree decreased (both P<0.05). There was a proportional decrease in articles from North America (P=0.03), and proportional increase from the "Far East" (P=0.04) and "Other" regions (P=0.04). No significant changes in proportions of female first and last authors were found (both P>0.28)., Conclusions: Consistent with authorship trends across various other medical specialties, glaucoma has seen an increase in the number of authors and disclosures per article, authors with dual degrees, and authors from the "Far East" and "Other" regions. However, contributions of women to articles published in Journal of Glaucoma remain low.

Purpose: To evaluate the agreement between Goldmann applanation tonometry (GAT; Haag-Streit, Bern, Switzerland) and several portable tonometers that could be used for glaucoma screening programs., Design: Evaluation of a diagnostic test., Participants: Three hundred twenty-one eyes of 168 participants seeking treatment at the glaucoma clinic of a tertiary eye hospital in India., Methods: Participants underwent intraocular pressure (IOP) measurement with GAT and 4 index tests: the Icare TA01i rebound tonometer (Icare USA, Raleigh, NC), a noncontact tonometer (NCT; Topcon CT-80; Topcon; Tokyo, Japan), a pneumatonometer (Model 30; Reichert Technologies; Depew, NY), and the Tono-Pen AVIA (Reichert Technologies)., Main Outcome Measures: Estimates of reproducibility of IOP measurements between each index test and GAT, including the intraclass correlation coefficient (ICC) and the Bland-Altman 95% limits of agreement., Results: The Icare showed the greatest agreement with GAT (ICC, 0.69; 95% confidence interval, 0.61-0.74), followed by the NCT (ICC, 0.65; 95% confidence interval, 0.58-0.71), the Tono-Pen (ICC, 0.51; 95% confidence interval, 0.43-0.59), and the pneumatonometer (ICC, 0.36; 95% confidence interval, 0.27-0.44). The pneumatonometer and Tono-Pen tended to overestimate IOP relative to GAT, with a mean difference of 3.4 mmHg (95% limits of agreement [LOA], -7.3 to 14.1 mmHg) for the pneumatonometer and 3.2 mmHg (95% LOA, -6.1 to 12.6 mmHg) for the Tono-Pen. In contrast, measurements from the Icare and NCT were on average within 1 point of those for GAT (mean difference, -0.4 mmHg [95% LOA, -8.4 to 7.6 mmHg] and -0.5 mmHg [95% LOA, -8.7 to 7.6 mmHg], respectively)., Conclusions: The Icare and NCT both demonstrated good agreement with GAT across a wide range of IOPs and could be considered for glaucoma screening programs., (Copyright © 2019 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: Glaucoma screening can be performed by assessing the vertical-cup-to-disk ratio (VCDR) of the optic nerve head from fundus photography, but VCDR grading is inherently subjective. This study investigated whether computer software could improve the accuracy and repeatability of VCDR assessment., Methods: In this cross-sectional diagnostic accuracy study, 5 ophthalmologists independently assessed the VCDR from a set of 200 optic disk images, with the median grade used as the reference standard for subsequent analyses. Eight non-ophthalmologists graded each image by two different methods: by visual inspection and with assistance from a custom-made publicly available software program. Agreement with the reference standard grade was assessed for each method by calculating the intraclass correlation coefficient (ICC), and the sensitivity and specificity determined relative to a median ophthalmologist grade of ≥0.7., Results: VCDR grades ranged from 0.1 to 0.9 for visual assessment and from 0.1 to 1.0 for software-assisted grading, with a median grade of 0.4 for each. Agreement between each of the 8 graders and the reference standard was higher for visual inspection (median ICC 0.65, interquartile range 0.57 to 0.82) than for software-assisted grading (median ICC 0.59, IQR 0.44 to 0.71); P = 0.02, Wilcoxon signed-rank test). Visual inspection and software assistance had similar sensitivity and specificity for detecting glaucomatous cupping., Conclusion: The computer software used in this study did not improve the reproducibility or validity of VCDR grading from fundus photographs compared with simple visual inspection. More clinical experience was correlated with higher agreement with the ophthalmologist VCDR reference standard., Competing Interests: AS previously worked for Youth Laboratories, LLC, which is developing automated algorithms potential glaucoma detection. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.

Purpose: Systemic absorption and central nervous system (CNS) penetration of timolol drops are a well-studied phenomenon, resulting in common side effects such as bradycardia, bronchospasm, fatigue, and confusion. More serious CNS side effects, such as psychosis and depression, however, are rarely attributed to eye drops. We report a case series in which patients developed visual hallucinations secondary to topical ocular timolol use., Methods: This study is a case series and review of the literature., Results: Four patients with glaucoma developed visual hallucinations while using topical timolol. The patients were all elderly, caucasian females with associated CNS pathology. All patients had resolution of symptoms upon discontinuation and a positive retrial test to confirm the association., Conclusions: The rarity of this side effect and its anecdotal predilection for elderly, caucasian females with underlying neurological dysfunction, may involve a yet unknown predisposition or hypersensitivity to beta blocker action, such as blood brain barrier disruption leading to increased susceptibility to the medication. This case series highlights an important, although rare, side effect of this medication which clinicians should be aware of especially when using it in elderly patients who may have coexisting CNS pathology. It is important that this side effect be recognized and appropriately managed to prevent otherwise unnecessary investigations and treatment.

Background: To examine the effect of mitomycin c and 5-flurouracil on treatment outcomes following Ahmed glaucoma valve implantation., Design: Retrospective consecutive case series., Participants: Fifty patients who received Ahmed glaucoma valve implantation from 1999 to 2013 in the San Francisco Veterans Administration Hospital., Methods: The +INJECTION group received intraoperative mitomycin c followed by postoperative mitomycin c and/or 5-flurouracil, whereas the -INJECTION group did not., Main Outcome Measures: Primary outcome was treatment success at 1 year post-implantation. Intraocular pressure, hypertensive phase, and the number of glaucoma medications were also examined., Results: Twenty-six patients/eyes in the +INJECTION group and 24 patients/eyes in the -INJECTION group were included. Treatment success was higher in the +INJECTION compared with the -INJECTION group (86 vs. 58%; P = 0.04). Intraocular pressure was lower in the +INJECTION compared with the -INJECTION group at 1, 3, 6 and 12 months (P ≪ 0.00001, P = 0.00003, 0.0008 and 0.024). Hypertensive phase occurred less often in the +INJECTION compared with the -INJECTION group (3.8 vs. 54%; P = 0.021). The +INJECTION group required fewer medications compared with the -INJECTION group (P = 0.02, 0.002, 0.003 and 0.008 at 1, 3, 6 and 12 months). Complication rates were comparable between groups (46.2 and 54.2%; P = 0.63)., Conclusions: Adjuvant treatment with antifibrotics following Ahmed glaucoma valve implantation decreased the hypertensive phase and improved surgical outcomes without impacting complication rates at 1 year. This study postulates a role for antifibrotics in the postoperative management of Ahmed glaucoma valves., (© 2016 Royal Australian and New Zealand College of Ophthalmologists.)

Purpose of the Study: The purpose of the study was to examine reoperation rate and complications of resident-performed glaucoma surgeries within the first 90 postoperative days., Materials and Methods: A retrospective study of resident-performed glaucoma filtering surgeries at the San Francisco Veterans Affairs Medical Center between 2002 and 2014 was performed. Patients requiring reoperation within 90 days of the initial surgery were included in our study. Combined surgeries were excluded. Complications and the rates of reoperation within the first 90 days were evaluated. Clinical outcomes for those who needed reoperations were evaluated at the 1-year follow-up., Results: Total of 180 cases were reviewed [34 trabeculectomy, 85 Ex-PRESS shunt, and 61 Ahmed glaucoma valve (AGV)]. One hundred and four eyes developed complications, most commonly choroidal effusion (65.3%), followed by hypotony (45.2%) and wound leak (32.7%). Complications were comparable among the 3 groups, except that filtering surgery had significantly more wound leak than AGV (P<0.001). Seven (3.9%) cases required reoperation within first 90 days. There was no reoperation for trabeculectomy group. Reoperation rate was 4.7% for Ex-PRESS and 4.9% for AGV (P=0.74). Indications for reoperation were persistent wound leak (4 cases) and tube occlusion/revision (3 cases). For the 7 patients who required reoperations, their intraocular pressure at 1-year postreoperation was significantly decreased compared with intraocular pressure before the initial glaucoma surgery (P<0.001) with similar number of glaucoma medications and stable visual acuity., Conclusions: Glaucoma incisional surgeries performed by third-year ophthalmology residents had acceptable and comparable reoperation rates and complication rates for patients with trabeculectomy, Ex-PRESS, and AGV. Clinical outcomes for the patients requiring reoperation were favorable.

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

Purpose: To compare intraocular pressure (IOP) reduction and complications of resident-performed argon laser trabeculoplasty (ALT) and selective laser trabeculoplasty (SLT)., Patients and Methods: This was a retrospective, interventional, comparative case series performed at the San Francisco Veterans Affairs Hospital. The study included 77 patients each undergoing 1 resident-performed ALT procedure from April 2006 through November 2009, and 81 patients each undergoing 1 resident-performed SLT procedure from November 2009 through December 2011. Reduction in IOP at 12 months and a longitudinal analysis across 24 months was determined. Secondary outcomes investigated included additional interventions of either repeat trabeculoplasty or trabeculectomy as well as change in eye drop medications., Results: There was no evidence of a difference between IOP reductions in patients undergoing ALT compared with SLT at 12 months (P=0.41, linear modeling) or across all follow-up appointments (P=0.62, linear-mixed effects regression). Patients undergoing ALT had a significantly increased number of eye drops (+0.6 vs. -0.1 drops, P<0.001, Wilcoxon rank-sum test) and trend toward increased rates of additional interventions (P=0.06, Weibull regression). There was no difference in immediate postprocedure IOP rise between the 2 groups (P=0.75, Wilcoxon rank-sum test) or any evidence of change in visual acuity., Conclusions: We found no difference in IOP reduction between patients undergoing resident-performed ALT compared with SLT. However, patients undergoing ALT had a significant increase in eye drop medications and trend toward additional interventions compared with patients undergoing SLT.

Purpose: The aim of this study was to assess the effect of various tube parameters on corneal endothelial cell density (ECD) after insertion of Ahmed valves., Methods: Thirty-nine eyes of 33 patients with previous superotemporal (ST) Ahmed valve implantation and 20 eyes of 13 participants with previous uncomplicated phacoemulsification and intraocular lens implantation but no history of glaucoma surgery were evaluated. Various tube parameters were measured with anterior segment optical coherence tomography. ST, central, and inferonasal (IN) ECD and pachymetry were measured. Endothelial cell loss and corneal thickness in the ST cornea was compared with those in the IN cornea., Results: The mean age of the operated patients was 58 ± 22 years, and the mean time since glaucoma surgery was 2.5 ± 2.6 years. Thirty-two of the 39 study eyes were pseudophakic. The ECD was significantly lower in the ST endothelium than in the IN endothelium in eyes with glaucoma tube surgery (P < 0.001), although this relative reduction in ST ECD was not greater than that seen in pseudophakic control eyes (P = 0.16). In univariate analysis, tube angle relative to the cornea and distance from the tip of the tube to the cornea were significant risk factors for decreased ST endothelial cell loss when assessed relative to the IN ECD (P = 0.01 and P = 0.02, respectively). In multivariate analysis, only the distance of the tube tip to the cornea remained significantly associated with ST endothelial cell loss., Conclusions: Although this was a retrospective study with inherent limitations, tubes that are closer to the cornea seem to lead to increased loss of adjacent endothelial cells.

IMPORTANCE To our knowledge, this is the first study to investigate effectiveness and complication rates of resident-performed selective laser trabeculoplasty (SLT). OBJECTIVES To evaluate the effectiveness and complications of SLT performed by resident ophthalmologists and to identify predictors for success. DESIGN, SETTING, AND PARTICIPANTS Retrospective case series of 81 patients with open-angle glaucoma undergoing 110 SLT procedures from November 17, 2009, through December 16, 2011, at the San Francisco Veterans Affairs Medical Center. INTERVENTION Resident-performed SLT. MAIN OUTCOMES AND MEASURES Intraocular pressure (IOP) reduction. Secondary outcomes included change in eyedrop medications, complication rates, and predictors of SLT success defined as a 20% reduction in IOP. RESULTS The mean IOP at baseline, defined as the average IOP of the 2 appointments prior to the SLT procedure, was 18.7 mm Hg. The mean decrease in postoperative IOP compared with baseline was 2.2 mm Hg (12%; 95% CI, 5%-19%) at 12 months and 3.3 mm Hg (18%; 95% CI, 13%-23%), 2.8 mm Hg (15%; 95% CI, 10%-21%), and 3.6 mm Hg (19%; 95% CI, 11%-27%) at 3, 6, and 24 months, respectively (all P &lt; .001, linear mixed-effects regression). Success rates were 36% (95% CI, 27%-47%) at 12 months and 41% (95% CI, 31%-53%), 50% (95% CI, 40%-60%), and 39% (95% CI, 26%-53%) at 3, 6, and 24 months, respectively. The most common complication was a temporary IOP spike, with increases of at least 6 mm Hg occurring in 7% (95% CI, 4%-14%) of the population. The largest IOP spike was 11 mm Hg. Increased number of laser shots performed was not associated with better IOP control but was associated with a reduction in number of eyedrop medications (P = .02). Increased baseline IOP was associated with an odds ratio for success of 1.24 (95% CI, 1.08-1.44) at 3 months, 1.20 (95% CI, 1.05-1.37) at 6 months, and 1.31 (95% CI, 1.13-1.53) at 12 months of follow-up (P = .003, P = .006, and P &lt; .001, respectively, logistic regression). In a multivariate analysis, baseline IOP remained the greatest predictor of effectiveness. CONCLUSIONS AND RELEVANCE Resident-performed SLT obtains outcomes similar to the IOP reduction reported in the literature for attending-performed SLT with low levels of complications. Increasing the number of shots in a treatment session may lead to less long-term need for eyedrop medications. In this patient group, higher baseline IOP was the strongest predictor of treatment effectiveness.

Purpose: To determine the flow characteristics of the 3 different models of the Ex-PRESS miniature glaucoma device in a controlled laboratory study., Materials and Methods: The 3 different Ex-PRESS models (P-50, R-50, and P-200; Optonol Ltd; now Alcon Lab) were tested using a gravity-driven flow test. Three samples of each of the 3 Ex-PRESS models were subjected to a constant gravitational force of fluid at 5 different pressure levels (5 to 25 mm Hg). Four measurements per sample were taken at each pressure level. The main outcome measure was flow rate (Q) (µL/min). Resistance (R) was calculated by dividing pressure (P) by the measured flow (Q)., Results: The flow rate was primarily pressure dependent. The P-200 model (internal diameter 200 µm) showed a statistically significant higher flow rate and lower resistance compared with both the P-50 and R-50 models (internal diameter 50 µm) (P<0.0001). The P-50 and R-50 models demonstrated similar flow rates (P=0.08) despite their difference in tube length (2.64 vs. 2.94 mm)., Conclusions: The 3 models of the Ex-PRESS mini shunt behaved in vitro as simple flow resistors by creating a relatively constant resistance to flow. Tube diameter was the only parameter with significant impact on flow and resistance. All models demonstrated flow rates per unit of pressure much higher than the outflow facility of a healthy human eye.

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

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

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

Background: To determine the reproducibility of the multifocal visual evoked potentials (mfVEP) test results in a clinical glaucoma setting, and the factors that affect variability., Methods: This was an observational case series study. The monocular mfVEP test, having a 58-sector, pattern-reversal dartboard array, was performed twice within 4 weeks in both eyes of 29 adult open-angle glaucoma (OAG) patients and suspects, using AccuMap Opera Software (ObjectiVision Pty Ltd, Sydney, Australia). The AccuMap severity index (ASI), the mean amplitude, and the individual amplitudes in each sector were compared between the 2 tests using intraclass correlations (ICCs). The effects of the severity of mfVEP field defects and signal-to-noise ratio (SNR) on the reproducibility of these variables were determined using the McNemar test and the Spearman rank correlation, respectively., Results: The average ICCs of the ASI and amplitudes in the 2 tests were 0.84 and 0.87, respectively. Two sectors in the right eye and 6 in the left eye had significant differences between the 2 tests (Wilcoxon signed-rank p < 0.05). Larger differences were observed in patients having lower SNR (Spearman p = 0.022). Forty-six of the 58 eyes stayed within the same diagnosis category on repeating the test (i.e., within normal limits or outside normal limits)., Interpretation: Although there were some isolated examples of clinically significant differences on repeating the mfVEP test in our patients, our results suggest overall good repeat reliability. The variability of the test was higher in patients having high noise levels during the test.

Purpose: The authors' objective was to compare the visual field obtained using multifocal visual evoked potential (mfVEP) testing with the optic nerve parameters of Heidelberg retinal tomography (HRT; Heidelberg Engineering, Heidelberg, Germany; software version 2.01) in primary open-angle glaucoma (POAG) patients and normal controls and to determine which parameters correlate with visual function., Design: Cross-sectional study., Participants: Eighty-one eyes of 42 adult POAG patients and normal controls between the ages of 40 and 80 years, of which 35 patients (67 eyes; mean age+/-standard deviation [SD], 68+/-10 years) had POAG, and 7 individuals who served as normal controls (14 eyes; mean age+/-SD, 61+/-10 years) were included., Methods: A monocular mfVEP test, the AccuMap (Opera software version 2.0; ObjectiVision Pty. Ltd., Sydney, Australia), with a 58-sector pattern-reversal dart board array was recorded in both eyes per patient. These patients underwent the HRT 2 and mfVEP tests within 3 months of each other., Main Outcome Measures: Amplitudes in the superior hemisphere of the mfVEP trace were compared with the HRT parameters in the inferior hemisphere of the HRT and vice versa using mixed effects regression models., Results: Amplitudes on the superior hemisphere of the mfVEP recordings showed a significant direct correlation with rim-to-disc area ratio (P = 0.0037), rim volume (P = 0.0421), and mean retinal nerve fiber layer (RNFL) thickness (P = 0.0016) and a significant inverse correlation with cup area (P = 0.0009) and cup-to-disc area ratio (P = 0.0037) in the inferior hemisphere of the HRT results. Amplitudes on the inferior hemisphere showed a significant direct correlation with rim-to-disc area ratio (P = 0.036) and a significant inverse correlation with cup area (P = 0.0007), cup-to-disc area ratio (P = 0.036), cup volume (P<0.0001), and mean cup depth (P = 0.0012) in the superior hemisphere of the HRT results., Conclusions: Results from mfVEP and HRT showed correlation between visual function and optic nerve structure.

An 80-year-old woman with pseudoexfoliation syndrome developed subluxation of a posterior chamber intraocular lens (IOL)-capsular bag complex due to zonular rupture. She underwent a limited 25-gauge pars plana vitrectomy and iris transfixation of the subluxated IOL-capsule complex. The postoperative course was uneventful until the patient developed acute angle-closure glaucoma 3 weeks postoperatively. Ultrasound biomicroscopy confirmed pupillary block by the IOL-capsule complex. The patient was treated with intraocular pressure-lowering medications and a vitreous tap before a laser peripheral iridotomy could be performed successfully. The vision returned to normal, and the angle closure resolved. We recommend that a prophylactic surgical iridectomy be performed in patients with iris transfixation of a posterior chamber IOL-capsular bag complex.

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

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

Interindividual variability of central corneal thickness has been found to be a source of error for conventional Goldmann applanation tonometry. The dynamic contour tonometer represents a potentially new technology for non-invasive and direct intraocular pressure (IOP) measurement, and has been proposed to accurately measure the true IOP irrespective of the corneal thickness. It is based on the principle that when the tip of the device exactly matches the contour of the cornea, the pressure measured by a transducer placed on its tip is an accurate indicator of the true IOP. This device is also capable of measuring the ocular pulse amplitude, a variable that has controversial significance in the diagnosis and management of glaucoma. Even though this technique seems to be very promising, further studies are required to conclusively determine the effectiveness of the dynamic contour tonometer in patients having an abnormal or irregular corneal contour.

Purpose: To compare the intraocular pressures (IOP) and ocular pulse amplitudes (OPA) in patients with different types of glaucoma, ocular hypertension (OHT), and normal controls (NC) using dynamic contour tonometry (DCT) and the goldmann applanation tonometry (GAT)., Methods: 906 eyes of 501 adult patients in the following five groups were included in this cross-sectional study: primary open angle glaucoma (POAG), normal tension glaucoma (NTG), Pseudoexfoliative Glaucoma (PXG), OHT, and NC. The following tests were performed simultaneously during a single visit: IOP using DCT and GAT; OPA using DCT and central corneal thickness (CCT) using ultrasound pachymetry. Mixed effects regression models were used to compare the DCT and GAT IOP measurements in the five groups; the effect of CCT on IOP and the relationship between OPA and IOP within each group., Results: DCT consistently had higher IOP values than GAT in POAG, PXG, NTG, and controls (p < 0.001) but not in OHT (p = 0.84). DCT IOP did not change while GAT IOP showed a non-significant increase (p = 0.09) with increased corneal thickness in each group. OPA was found to be highest in OHT (3.61 mmHg) and lowest in the control group (2.86 mmHg) and significantly increased with IOP in all groups., Conclusions: DCT measures an IOP that is significantly higher than GAT IOP in glaucoma and control subjects but not in ocular hypertensives. Furthermore, the DCT may measure an IOP that is independent of the CCT, which may not be true for the GAT, which increases with the CCT. OPA was highest in OHT and may be affected by the IOP.

Purpose: To determine the correlation of central corneal thickness (CCT) to Goldmann applanation tonometry (GAT) and dynamic contour tonometry (DCT, PASCAL), and to glaucoma stage as assessed by cup-to-disc ratio (CDR)., Design: Prospective, cross-sectional tricenter observation study., Patients and Methods: From three glaucoma specialty practices a sample of 406 independent eyes was included. After ultrasound pachymetry, intraocular pressure was measured using PASCAL and Goldmann applanation tonometry and cup-to-disc ration was reassessed. Demographic data were included in the multivariate analysis., Results: Mean corneal thickness was 540 microm. African Americans and normal-tension glaucoma patients showed the lowest values (518 microm and 522 microm, respectively). These values were significantly thinner than the central corneal thickness of Caucasians (549 microm) and ocular hypertensives (564 microm). Intraocular pressure assessed by Goldmann applanation tonometry shows a significant correlation with central corneal thickness (r = 0.068, P < 0.001), whereas PASCAL is not significantly associated with central corneal thickness (r < 0.001, P = 0.997). Increased IOP is significantly correlated with large ocular pulse amplitudes (r = 0.13, P < 0.001), which is predominantly seen in ocular hypertensives. A significant negative correlation was detected between cup-to-disc ratio and central corneal thickness (r = 0.102, P < 0.001)., Conclusion: Glaucoma patients with thin central corneal thickness are more likely to be found at an advanced stage of the disease and among those with normal-tension glaucoma and black African ancestry. Underestimation of intraocular pressure by Goldmann applanation tonometry could be one causative factor.

Aim: To determine the acute and chronic vascular effects of endoscopic cyclophotocoagulation (ECP) versus trans-scleral cyclophotocoagulation (TCP) in a rabbit model., Methods: 20 rabbits underwent ECP in one eye and another 20 rabbits had unilateral TCP. Five treated eyes from each group underwent endoscopic fluorescein angiography (EFA) of the treated ciliary processes at each of the following time points: immediate, 1 day, 1 week, and 1 month. Five untreated rabbits were used as controls. The NIH Image software program was used to trace ciliary processes in order to determine their mean intensity, as a measure of their perfusion. Histopathology was also performed on eyes from each time point., Results: Immediately and 1 day after laser, both TCP and ECP eyes demonstrated severely reduced or non-existent blood flow in the areas of treatment. TCP treated processes essentially remained non-perfused at the 1 week and 1 month time points. ECP treated processes showed some reperfusion at 1 week and greater reperfusion by 1 month. Histopathology confirmed the overall greater vascular occlusion seen with TCP., Conclusions: Chronic poor perfusion of the ciliary body after TCP may account, in part, for its efficacy, as well as the significant complications including hypotony and phthisis. Late reperfusion of this region after ECP may provide some insight into the differences in efficacy and complication rates compared to TCP.

Objectives: To compare intraocular pressure readings of recently introduced dynamic contour tonometry (DCT) with pneumatonometry (PTG) and Goldmann applanation tonometry (GAT) and to correlate central corneal thickness (CCT) with these readings., Design: Prospective, cross-sectional observation and instrument validation study. We included 258 independent eyes with normal anterior segment examinations results, irrespective of glaucoma diagnosis or glaucoma suspect. After pachymetry, DCT, PTG, and GAT were performed in a randomized order. Intraocular pressures as measured by DCT, PTG, and GAT were compared with each other and with CCT., Results: Eyes with thinner CCTs tended to yield lower intraocular pressure measurements by GAT. A significant correlation (Pearson product moment correlation, P<.001) between CCT and GAT was found with a regression of 0.25 mm Hg per 10 microm (R2 = 0.060). Variation of CCT had no significant effect on intraocular pressure measurements by PTG (P = .10; R2 = 0.01) and DCT (P = .80; R2<0.01). A piecewise regression model showed that GAT readings are not linearly correlated with CCT. Comparison of the slopes below and above 535 microm showed the highest significance (P<.001)., Conclusions: Goldmann applanation tonometry readings are potentially influenced by CCT, whereas PTG and DCT seem to be less dependent on CCT. Correlation between CCT and GAT is not linear. A simple correction formula suggesting a linear relationship might not be correct.

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

Objective: To characterize the central corneal thickness (CCT) of Asian (Chinese, Japanese, and Filipino), Caucasian, Hispanic, and African American patients in a multiethnic glaucoma practice., Design: Retrospective study (chart review)., Participants: Glaucomatous (n = 600) and nonglaucomatous (n = 201) eyes of 801 patients examined in a San Francisco glaucoma clinic from June 2002 to April 2004 who met inclusion criteria were included in the study. The 6 racial (ethnic) groups represented in the study were Caucasian (n = 186, 23.2%), Chinese (n = 157, 19.6%), Japanese (n = 121, 15.1%), Hispanic (n = 116, 14.5%), Filipino (n = 114, 14.2%), and African American (n = 107, 13.4%)., Methods: Central corneal thickness was measured by means of ultrasound pachymetry in Asian (Chinese, Japanese, and Filipino), Caucasian, Hispanic, and African American participants with glaucomatous and normal eyes. The relationship between CCT and race was investigated using multivariate regression analyses, controlling for confounders. One eye of each of 801 participants was included for analysis., Main Outcome Measures: Correlation of mean CCT with race, glaucoma diagnosis, age, spherical equivalent, gender, and history of ocular surgery., Results: The mean CCT of all participants was 542.9 mum. Central corneal thicknesses of Chinese (555.6 microm), Caucasian (550.4 microm), Filipino (550.6 microm), and Hispanic (548.1 microm) participants did not significantly differ. The CCT of Japanese participants (531.7 microm) was significantly less than that of Caucasians, Chinese, Filipinos, and Hispanics (all, P< or =0.001) and greater than that of African Americans (P = 0.03). African Americans had a CCT (521.0.0 microm) less than that of all races (P< or =0.05). Glaucoma suspects and patients with normal tension glaucoma (NTG), primary open-angle glaucoma (POAG), pseudoexfoliation glaucoma (PEX), and chronic angle-closure glaucoma (CACG) had corneas significantly thinner than those of normal participants (P< or =0.004), whereas ocular hypertensives had significantly thicker corneas (P<0.0001). Among all participants, decreasing values of CCT were significantly related to older age (P<0.01). Less negative or more positive refractive errors, gender, and history of ocular surgery were not associated with changes in CCT (P = 0.38, P = 0.50, and P = 0.97, respectively)., Conclusions: Studies examining individual Asian subpopulations in isolation suggest that differences in CCT may exist among different Asian groups. The results of this study indicate that CCT does, in fact, vary among Asian subpopulations; Japanese have thinner corneas than Chinese and Filipinos. Caucasians, Chinese, Hispanics, and Filipinos have comparable CCT measurements, whereas the corneas of African Americans are significantly thinner. Additionally, older individuals; glaucoma suspects; and participants with NTG, POAG, PEX, and CACG have thinner corneas. Ocular hypertensives, however, have thicker corneas.

Objective: To compare intraocular pressure measurements obtained by recently introduced dynamic contour tonometry (DCT), Goldmann applanation tonometry (GAT), pneumatonometry (PTG), and intracameral manometry in human cadaver eyes., Methods: Sixteen freshly enucleated human cadaver eyes were deepithelialized and dehydrated with dextran. A tube was placed in the anterior chamber and connected to a transducer and to a bottle system filled with balanced salt solution. The pressure in the eye was then altered between 5 mm Hg and 58 mm Hg. Intraocular pressure measurements were obtained with DCT, GAT, and PTG at each manometric pressure reading., Results: On average, DCT values measured 0.58 +/- 0.70 mm Hg higher than real intracameral pressure. The GAT and PGT showed consistently lower values, -4.01 +/- 1.76 mm Hg and -5.09 +/- 2.61 mm Hg, respectively. At all bottle heights, DCT values were significantly closer to the reference pressure than GAT and PTG (P<.001)., Conclusions: Measurement with DCT provides IOP values significantly closer to true manometric levels than either GAT or PTG. Further studies are warranted to determine its reliability in patients and the effect of corneal thickness.

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

Objective: To evaluate the feasibility and safety of enzymatic sclerostomy as a new modality to lower intraocular pressure in patients with open-angle glaucoma., Methods: This single-center, prospective, noncomparative, interventional case series included 15 blind symptomatic eyes of 15 patients with primary open-angle glaucoma. Enzymatic sclerostomy was performed with the patient under topical or peribulbar anesthesia. A specially designed polymethylmethacrylate enzyme applicator filled with a mean +/- SD of 123 +/- 13 microg of collagenase was introduced through a 5-mm peritomy, and affixed to the limbus by means of cyanoacrylate tissue glue. After 22 to 24 hours, the applicators were removed and the patients were followed up for 1 year. Intraocular pressure changes from baseline and complications related to the procedure were the main outcome measures., Results: Controlled thinning of the treated sclera associated with aqueous percolation and shallow filtration bleb was seen in all eyes in the immediate postoperative period. The mean +/- SD intraocular pressure decreased from 43.5 +/- 9.8 mm Hg (while the patients were receiving a mean +/- SD of 1.75 +/- 0.75 antiglaucoma medications) preoperatively to 24.8 +/- 10.6 mm Hg (a 43.0% decrease from baseline with no antiglaucoma medication) on the first postoperative day and to 34.8 +/- 10.5 mm Hg (a 20.0% decrease from baseline with no antiglaucoma medication) at the end of 1 year. Ophthalmic adverse effects were limited to the treated area and included immediate postoperative transient conjunctival reaction ranging from mild chemosis to conjunctival maceration. Immediate full-thickness perforation developed in 1 eye; the patient was treated and excluded from data analysis. Two eyes developed symptoms related to increase in intraocular pressure after 9 months; the patients were treated and excluded from further data analysis. No systemic complications were noted., Conclusions: Enzymatic sclerostomy demonstrated immediate and sustained intraocular pressure reduction and provided symptomatic relief in blind eyes with primary open-angle glaucoma. The procedure, however, needs further technical refinement.

This set of Viewpoints articles examines the merits of beta-blockers versus other medications as the primary drug treatment for glaucoma. Ophthalmologists must balance issues such as efficacy, compliance, cost, and side effects when deciding on the appropriate medication to prescribe. Dr. Stamper stresses the advantages of tailoring the choice of medication to the needs of the individual patient. Drs. Wigginton and Higginbotham review the benefits of beta-blockers and present some of the disadvantages of the non-beta-blocker class of medications.

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

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