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A 30-year-old male presented with diplopia 1 month after implantation of an orbital floor plate for a blowout fracture. The orbital plate was removed 3 months later, however, the fixation bar was left in place as it had migrated full thickness through the inferior oblique muscle, sclera, choroid, and retina. After 5 years of head tilt, the patient was referred to our department with a metallic intraocular foreign body visible in fundo and an important elevation deficit. CT imaging confirmed our clinical suspicion of a retained fixation bar. The extraocular part of the fixation bar was removed via a transconjunctival inferior orbitotomy, leaving the intraocular part in place due to the high risk of ocular complications upon removal. Postoperative ocular motility improved greatly and the patient no longer experiences diplopia in daily life. Orbital plate migration is a rare complication that should be considered in de novo diplopia after orbital reconstruction.

Background/ObjectiveAnterior segment optical coherence tomography (AS-OCT) and ultrasound biomicroscopy (UBM) are two non-invasive imaging techniques used for the measurement of tumour thickness in corneal and bulbar conjunctival tumours. Histopathology (HP), however, remains the gold standard for the measurement of tumour thickness. The aim of this study was to determine whether AS-OCT and UBM are as accurate as HP for measuring tumour thickness.MethodsForty-two corneal and bulbar conjunctival tumours were imaged using AS-OCT and UBM. Images were assessed and tumour thickness was measured. Eleven patients subsequently underwent surgical excision. All specimens were measured during histopathological analysis. The correlation of the thickness measurement on HP to AS-OCT and UBM was then statistically analysed. In cases where the tumour was not excised, thickness measurement comparisons between AS-OCT and UBM were analysed.ResultsAS-OCT and UBM measurements of tumour thickness were found to be significantly positively correlated (p=ConclusionBoth AS-OCT and UBM are useful techniques to image and measure the thickness of corneal and conjunctival bulbar tumours. While AS-OCT provides better details than UBM, it was more limited in visualising the posterior boundary of the tumour, particularly in malignant tumours. While thickness measurements of both methodologies were correlated, neither should yet be considered as replacements to the gold standard of HP.

Purpose: Evaluating the use of Indomethacin, Dexamethasone, and no anti-inflammatory treatment immediately after selective laser trabeculoplasty (SLT). Materials and Methods: Prospective randomized clinical trial of 132 eyes. Both eyes of the patient underwent SLT. One of the eyes was treated with Indomethacin 0.1% or Dexamethasone 0.1% 3 times daily for 1 week; the other eye did not receive any anti-inflammatory treatment. Intraocular pressure (IOP) and inflammatory parameters were recorded at 1 hour, 1 week, 1, 3, and 6 months. Results: Cells in the anterior chamber were present in 57% to 71% of the patients after 1 hour. About 16% to 37% of the patients reported pain/discomfort after 1 hour. Redness was present before SLT in 29% to 34% of the patients, probably due to antiglaucoma medication. After 1 hour, the amount of redness recorded raised to 32% to 42%, but the amount of patients with redness returned to pretreatment levels after 1 week. An IOP peak of >5 mm Hg above baseline IOP 1 hour after laser was present in 3% to 9% of the patients. IOP lowered 11% to 21% compared with IOP at baseline. The number of medications needed changed from 1.45 to 1.49 before, to 0.23 to 0.45 six months after SLT. No differential effects based on the kind of anti-inflammatory treatment or no treatment were found for any of the parameters. Conclusions: SLT induces little inflammation: anti-inflammatory drops do not make a significant difference in pain, redness, cells in anterior chamber, or peak IOP following SLT. The IOP-lowering effect of the SLT is not influenced by the use of Indomethacin or Dexamethasone.

Pterygium is a common eye disease, linked to an increased exposure to UV radiation and dry environments. The associated pathology culminates in visual impairment and, in some rare cases, blindness. However, there remains a lot of uncertainty concerning the pathogenesis of this fibrovascular lesion. As the composition of the tear film provides a reflection into the pathological changes at the ocular surface, tear analysis represents an ideal approach to gain insight in the progression of disease following pterygiectomy. This study enrolled 19 patients and age/gender-matched healthy controls. Tear film levels of interleukin- (IL-) 6, IL-8, and vascular endothelial growth factor (VEGF) were investigated over time, and preoperative concentrations were linked to corneal neovascularization and pterygium size. Diminished tear film levels were found in unilateral patients who show no clinical signs of pterygium recurrence over a period of one year. Hence, our results highlight the potential of using the course of IL-6, IL-8, and VEGF levels in tears as biomarkers for recovery. In addition, when focusing on the affected eyes (i.e., primary and recurrent pterygium), we detected fold changes in preoperative cytokine concentrations to correspond with disease severity. As our proposed biomarkers did not reveal a linear relationship with corneal neovascularization nor the invasive behaviour of pterygium, no exact role in the pterygium pathology could be established. Hence, our data point to these factors being contributors rather than decisive players in the pathological processes.

As ocular hypertension refers to a condition in which the intraocular pressure is consistently elevated but without development of glaucoma, study of it may provide important clues to factors that may play a protective role in glaucoma. β-amyloid, one of the key histopathological findings in Alzheimer's disease, has been reported to increase by chronic elevation of intraocular pressure in animals with experimentally induced ocular hypertension and to cause retinal ganglion cell death, pointing to similarities in molecular cell death mechanisms between glaucoma and Alzheimer's disease. On the other hand, recent studies have reported that intracranial pressure is higher in patients with ocular hypertension compared with controls, giving rise to the idea that elevated intracranial pressure may provide a protective effect for the optic nerve by decreasing the trans-lamina cribrosa pressure difference. The speculation that the higher intracranial pressure reported in ocular hypertension patients may protect against glaucoma mainly through a lower trans-lamina cribrosa pressure difference remains at least questionable. Here, we present an alternative viewpoint, according to which the protective effect of higher intracranial pressure could be due, at least in part, to a pressure-independent mechanism, namely faster cerebrospinal fluid production leading to increased cerebrospinal fluid turnover with enhanced removal of potentially neurotoxic waste products that accumulate in the optic nerve. This suggests a new hypothesis for glaucoma, which, just like Alzheimer's disease, may be considered then as an imbalance between production and clearance of neurotoxins, including β-amyloid. If confirmed, then strategies to improve cerebrospinal fluid flow are reasonable and could provide a new therapeutic approach for stopping the neurotoxic β-amyloid pathway in glaucoma.

Purpose We examined selective laser trabeculoplasty (SLT) as a replacement therapy for medically controlled open-angle glaucoma (OAG) or ocular hypertensive patients. Methods A prospective randomized interventional clinical trial on 143 glaucoma patients. Patients were randomized to either receiving SLT or to the control group that continued on pressure lowering medication. Data were recorded 1 hr, 1 week, 1, 3, 6, 12 and 18 months after SLT. Primary outcome was number of medications at 12 and 18 months while maintaining a predetermined target intraocular pressure (IOP). Results Selective laser trabeculoplasty (SLT) reduced number of medications from a mean of 1.5 at baseline, to 0.35 after 12 months and 0.29 after 18 months. Meanwhile, SLT achieved more than 20% IOP lowering in 95% of eyes and more than 30% IOP lowering in 86% of eyes after 18 months. Seventy-seven per cent of our eyes no longer needed any medication after SLT at 18 months. Conclusion Selective laser trabeculoplasty (SLT) enabled a reduction in number of medications while maintaining good IOP control. Selective laser trabeculoplasty (SLT) was able to completely replace medical therapy in 77% of eyes after 18 months. Selective laser trabeculoplasty (SLT) as replacement therapy may reduce local and systemic side-effects and prevent adherence issues.

EDITOR: We read with great interest the paper recently published in Clinical and Experimental Optometry by McMonnies.2016 We are grateful to the author for sharing his valuable review article with ...

AIM: To compare the efficacy of selective laser trabeculoplasty (SLT) in replacing medical therapy in pseudophakic and phakic eyes. METHODS: Subgroup of a prospective randomized clinical trial including patients with primary open angle glaucoma or ocular hypertension controlled with medication. Of 38 pseudophakic eyes were matched with 38 phakic eyes. SLT was offered as a way to decrease medication while maintaining the same low eye pressure. SLT was performed over 360 degrees, at 3ns, spotsize 400 mu m, 100 spots. Data [intraocular pressure (IOP), number of medications needed] were measured at 1h, 1wk, 1, 3, 6 and 12mo. An independent-samples t-test was performed to compare baseline characteristics of the phakic and the pseudophakic group and differences in evolution of mean IOP and number of used medications. Chi-squared analysis was performed to investigate proportions of fast, slow and non-responders. RESULTS: The mean IOP measurement was 13.00 +/- 2.88 mm Hg in the phakic group (38 eyes) and 13.51 +/- 3.06 mm Hg in the pseudophakic group (38 eyes) (P > 0.05). This changed little after SLT and IOP lowering effect was comparable between the two groups. Main aim however was to lower the amount of medication needed. In the phakic group medication lowered from 1.29 +/- 0.62 at baseline, to 0.15 +/- 0.46 after 12mo; a reduction of 88.37%. In the pseudophakic group, used medication changed from 1.71 +/- 1.04, to 0.41 +/- 0.61; a 76.02% reduction. The differences were not statistically significant at any time point (P > 0.05). 10P lowering occurred slightly faster in the pseudophakic group (50% of patients after one week) than in the phakic group (68% of patients after more than 4wk). The difference was not significant (P > 0.05). CONCLUSION: IOP lowering effect of SLT is comparable between phakic and pseudophakic eyes.

The pathophysiology of primary open-angle glaucoma is still largely unknown, although a joint contribution of vascular, biomechanical, and biochemical factors is widely acknowledged. Since glaucoma is a leading cause of irreversible blindness worldwide, exploring its underlying pathophysiological mechanisms is extremely important and challenging. Evidence from recent studies appears supportive of the hypothesis that a “glymphatic system” exists in the eye and optic nerve, analogous to the described “glymphatic system” in the brain. As discussed in the present paper, elucidation of a glymphatic clearance pathway in the eye could provide a new unifying hypothesis of glaucoma that can incorporate many aspects of the vascular, biomechanical, and biochemical theories of the disease. It should be stressed, however, that the few research data currently available cannot be considered as proof of the existence of an “ocular glymphatic system” and that much more studies are needed to validate this possibility. Even though nothing conclusive can yet be said, the recent reports suggesting a paravascular transport system in the eye and optic nerve are encouraging and, if confirmed, may offer new perspectives for the development of novel diagnostic and therapeutic strategies for this devastating disorder.

October 22, 2013Dear Editor,We read with great interest the paper by Janssen et al. (2013)entitled ‘The vast complexityof primaryopen angle glaucoma: Dis-ease genes, risks, molecular mechanisms and pathobiology.’ Theauthors deserve appreciation for their very informative reviewarticle.However,wewishtomakeacommentconcerningtheirdis-cussion of the potential role of intracranial pressure (ICP) in Alz-heimer’s disease (AD) and glaucoma.In the last section of their paper, Janssen and colleaguesdiscuss the potential relation between primary open angle glau-coma (POAG) and AD. As the authors mention, several studieshave found an increase in the occurrence of glaucoma in AD pa-tients. The authors state: “In our view, POAG damage could becaused by the net pressure over the optic disk, involving boththe aqueous humor pressure of the eye and cerebrospinal fluid(CSF) pressure of the brain, as described above. Also, CSF pressurechanges have been described in AD (Silverberg et al., 2006).Could these pressure changes underlie a relationship betweenPOAG and AD, and at the same time explain the apparently con-flicting association studies?” Further, the authors state: “We hy-pothesize that there is a strong association between normalpressure glaucoma and late AD, since both disease stages,following the ‘net pressure on the optic disk hypothesis’,arecharacterized by one single disease mechanism: an abnormallylow ICP.”Janssen et al. (2013) thus hypothesize that low ICP may play arole in the association between glaucoma and AD. We fully agreewith the authors since our group has previously presented this hy-pothesisforthefirsttime(Wostynetal.,2008,2009a).Intwoofourearlier manuscripts published in 2008 (Wostyn et al., 2008) and2009 (Wostyn et al., 2009a), we proposed low ICP occurring inAD as a factor leading to increased risk of glaucoma. Evidence forthishypothesiswasgainedfromCSFpressuremeasurementstudiesin AD patients and patients with glaucoma. The finding of a highoccurrence of reduced CSF pressure among patients with AD(Silverberg et al., 2006; Wostyn et al., 2009b) could be linked tothe high rate of reported comorbidity between AD and glaucoma(Bayer et al., 2002; Tamura et al., 2006), since it has been shownthat CSF pressure is lower in patients with glaucoma (Berdahlet al., 2008a, 2008b; Ren et al., 2010). This could result in anabnormally high trans-lamina cribrosa pressure difference andlead to glaucomatous damage. Given this previously advanced hy-pothesis, it was a great surprise when Janssen et al. (2013) recentlyhypothesized about the potential role of low ICP in glaucoma andAD without citing our earlier work (Wostyn et al., 2008, 2009a)or making clear the relevant precedents. The authors did cite oneof our papers, one largely focused on the high occurrence rate ofglaucoma among patients with normal pressure hydrocephalus(Wostyn et al., 2010), but this paper has no direct relevance tothe above hypothesis.Sincerely yours,Peter Wostyn, MDVeva De Groot, MD, PhDDebby Van Dam, PhDKurt Audenaert, MD, PhDPeter Paul De Deyn, MD, PhDReferences

Background Chronic treatment of glaucoma can present a challenge in patients who lack the means and/or the discipline to use daily glaucoma medication. We wondered if selective laser trabeculoplasty (SLT) could be a useful alternative. Methods Inclusion criteria: controlled trials comparing efficacy of SLT in adult patients with any form of open angle glaucoma or ocular hypertension and case reports on side effects of SLT. Two recent meta-analyses identified eight randomized clinical trials (RCTs) comparing the effect of SLT with medication (prostaglandin analogs) and with argon laser trabeculoplasty (ALT). We took these eight RCTs as reference base and calculated their success rates where they were not given. Other articles were added to elaborate on technique and side effects. Results Mean intraocular pressure (IOP) reduction after SLT was 3.88.0 mmHg after 6 months to 1 year. Mean success rate of SLT at 6 months to 1 year is 5582 %. Higher IOP before laser predicts a higher IOP-lowering effect. In terms of mean IOP reduction, reduction in number of medications and treatment success, the effect of SLT was found to show no clinically relevant difference from that of contemporary medication (prostaglandin analogs) and from ALT. Conclusions The evidence indicates that SLT is an efficacious primary or adjunctive therapy for treating glaucoma.

Purpose To assess the clinical outcomes of bag-in-the-lens intraocular lens (BIL IOL) implantation following the International Organization for Standardization (ISO) 11979-7:2006 in pediatric eyes and eyes with ocular comorbidities. Setting Antwerp University Hospital, Department of Ophthalmology, Antwerp, Belgium. Design Cohort study. Methods This cohort included the first series of patients having IOL implantation using the bag-in-the-lens technique. Surgeries were performed between December 1999 and September 2006. In addition to IOL implantation, the technique comprised creation of a primary posterior continuous curvilinear capsulorhexis (PCCC) equal in size to the anterior capsulorhexis. Results The study enrolled 807 eyes of 547 patients; 326 of the eyes (40.40%) had ocular comorbidity. In the 481 eyes without ocular comorbidity, the mean decimal corrected distance visual acuity was 0.52 ± 0.24 (SD) (0.276 ± 0.206 logMAR) preoperatively and 0.94 ± 0.18 (−0.012 ± 0.053 logMAR) postoperatively. The mean postoperative achieved spherical equivalent was 0.48 ± 0.83 diopter (D) and the mean targeted refraction, −0.24 ± 0.71 D. The A-constant was modified from 118.4 to 118.04. Posterior capsule opacification (PCO) did not occur in any adult eye during the follow-up. Retinal detachment after IOL implantation occurred in 10 eyes (1.24%). In 19 eyes, the iris was captured by the IOL haptics postoperatively. Hypopyon occurred in 3 patients and toxic anterior segment syndrome in 1 patient. Conclusion The BIL IOL met the ISO criteria; that is, primary PCCC was safe in healthy eyes and in eyes with ocular comorbidities and no eye developed PCO over a mean follow-up of 26.1 ± 21.3 months. Financial Disclosure Drs. Gobin, Mathysen, Van Looveren, and De Groot have no financial or proprietary interest in any material or method mentioned. Additional disclosure is found in the footnotes.

Purpose: To report the case of an atypical sino-orbital inflammatory myofibroblastic tumor. Methods: Case report. Results: A 71-year-old man presented slowly progressive painless diplopia followed by unilateral proptosis of the left eye with slight edema of the upper eyelid. Visual acuity was 0.4 with a relative afferent pupillary defect (RAPD). Abduction and depression of the left eye were limited. Imaging showed a left sino-orbital tumor with mass effect on the medial rectus muscle resulting in proptosis. The lesion showed intracranial extension through the superior orbital fissure with bone erosion and sclerotic bone reaction. Endoscopic ethmoidal, maxillary, and orbital biopsies revealed an inflammatory myofibroblastic tumor. Full blood count showed an eosinophilia while antineutrophil cytoplasmic antibodies and C-reactive protein were negative. To date, 7 cases of orbital myofibroblastic tumor have been described, though none of the prior studies have described bone invasion. Conclusions: This erosive sino-orbital inflammatory myofibroblastic tumor is a novel finding mimicking a malignant tumor.

Purpose To examine the centration and visual outcomes after cataract surgery using the bag-in-the-lens (BIL) implantation technique. Setting University Hospital Antwerp, Department of Ophthalmology, Edegem, Belgium. Methods This study comprised 180 eyes of 125 patients who had cataract surgery with implantation of the BIL intraocular lens (IOL) between March 2002 and September 2005. Postoperative data at 5 weeks, 6 months, and 1 year were evaluated. The geometric center of the IOL, measured on a red reflex slitlamp photograph, was compared with the geometric center of the pupil and the limbus. Results The mean decentration compared with the limbus was 0.304 mm ± 0.17 (SD) at a mean angle of −24.9 ± 113.3 degrees. Compared with the dilated pupil, the mean deviation was 0.256 ± 0.15 mm at a mean angle of −5.2 ± 119.0 degrees. The amount of decentration was stable during the postoperative follow-up period. There was no correlation between the amount of decentration and the visual outcomes (pupil: r = −0.07, P = .494; limbus: r = 0.11, P = .304). Conclusions Surgeon-controlled BIL centration was predictable 5 weeks and unchanged 6 months and 1 year postoperatively. It can therefore be concluded that capsular bag healing has no influence on BIL IOL centration over time.

In a recent review article titled "A new look at cerebrospinal fluid circulation", Brinker et al. comprehensively described novel insights from molecular and cellular biology as well as neuroimaging research, which indicate that cerebrospinal fluid (CSF) physiology is much more complex than previously believed. The glymphatic system is a recently defined brain-wide paravascular pathway for CSF and interstitial fluid exchange that facilitates efficient clearance of interstitial solutes, including amyloid-beta, from the brain. Although further studies are needed to substantiate the functional significance of the glymphatic concept, one implication is that glymphatic pathway dysfunction may contribute to the deficient amyloid-beta clearance in Alzheimer's disease. In this paper, we review several lines of evidence suggesting that the glymphatic system may also have potential clinical relevance for the understanding of glaucoma. As a clinically acceptable MRI-based approach to evaluate glymphatic pathway function in humans has recently been developed, a unique opportunity now exists to investigate whether suppression of the glymphatic system contributes to the development of glaucoma. The observation of a dysfunctional glymphatic system in patients with glaucoma would provide support for the hypothesis recently proposed by our group that CSF circulatory dysfunction may play a contributory role in the pathogenesis of glaucomatous damage. This would suggest a new hypothesis for glaucoma, which, just like Alzheimer's disease, might be considered then as an imbalance between production and clearance of neurotoxins, including amyloid-beta.

Purpose To study the cumulative neodymium:YAG (Nd:YAG) laser rate after bag-in-the-lens implantation (Morcher 89A) and lens-in-the-bag implantation (Morcher 92S) of 2 intraocular lenses (IOLs) of the same biomaterial. Setting Department of Ophthalmology, University Hospital of Antwerp, Edegem, Belgium. Methods This study comprised 100 eyes of 87 patients who had the bag-in-the-lens IOL implantation between January 2000 and August 2004. The postoperative follow-up ranged between 17 and 72 months. One hundred eyes of 94 patients of the same age and with the same follow-up period received the lens-in-the-bag IOL. The cumulative Nd:YAG laser frequency rates in both groups were calculated, and the cumulative incidence rates were defined by Kaplan-Meier survival analysis. Results No Nd:YAG laser capsulotomy was performed in eyes having bag-in-the-lens IOL implantation. A laser capsulotomy was performed in 20 eyes having lens-in-the-bag IOL implantation; the cumulative frequency in this group was 2% at 1 year and 20% at 71 months, with a plateau beginning at 42 months. The cumulative incidence rate of Nd:YAG posterior capsulotomy was approximately 2% at 1 year, increasing to approximately 28% at 42 months. Conclusions The cumulative Nd:YAG laser rate after bag-in-the-lens implantation was zero. A zero rate has not been reported with lens-in-the-bag implantation of an IOL of the same biomaterial or of other biomaterials, as published in the literature. Thus, it can be concluded that the bag-in-the-lens implantation technique has 100% effectiveness against posterior capsule opacification.

Purpose To evaluate bag-in-the-lens implantation by studying the feasibility of implanting a new type of intraocular lens (IOL) and the occurrence of posterior capsule opacification (PCO) in human postmortem eyes and in eyes of living rabbits. Setting Department of Ophthalmology, University of Antwerp, Belgium, and Netherlands Research Institute of Amsterdam, Amsterdam, The Netherlands. Methods The IOL was implanted in 10 postmortem human donor eyes (in vitro study) and in 17 eyes of 10 rabbits (in vivo study). The postmortem capsular bags were cultured for 4 to 6 weeks, and the rabbits were killed 1 to 5 months after implantation. All capsular bags with the bag-in-the-lens were examined by light microscopy and scanning electron microscopy. Results The IOL design was highly effective in restricting lens epithelial cell (LEC) proliferation in the remaining lens bag in human donor eyes and in rabbit eyes. In eyes in which the capsules were not positioned well within the groove of the IOL, LEC proliferation and PCO occurred. Conclusion Bag-in-the-lens implantation was highly effective in preventing PCO in vitro and in vivo provided the anterior and posterior capsules were secured properly in the peripheral groove of the IOL.

Purpose: Photodynamic therapy (PDT) with bacteriochlorin a (BCA) has proven to be successful in the treatment of cancers and to be cytocidal for lens epithelial cells (LECs) in culture. The present study aimed to determine whether PDT with BCA is also effective in destroying LECs in the capsular bag in vivo and could therefore be a strategy for prevention of posterior capsule opacification (PCO). Materials and Methods: BCA was obtained by saponification and acid hydrolysis of bacteriochlorophyll a and was formulated in 30% polyethylene glycol, 20% ethanol and 50% water. Nine albino rabbits were anesthesized and both pupils dilated. Extracapsular lens extraction by phacoemulsification was performed on both eyes. One eye of each animal served as control. In the other eye, 1.5 ml BCA (10 or 50 µg/ml) was injected in the capsular bag and after 10 min, the eye was illuminated with a diode laser (wavelength 760 nm) for 10 or 15 min. Six weeks after surgery, the rabbits were sacrificed and the globes were enucleated, the capsular bags and the corneas removed, fixed and examined using stereomicroscopy and light microscopy. Results: In the control capsular bags, extensive proliferation of LECs and formation of a complete ring of Soemmering was found, while in the PDT-treated capsular bags, LEC proliferation was markedly diminished and an incomplete irregular and much thinner ring of Soemmering was formed. Using the presently described application, the corneas of the PDT-treated animals were opaque and swollen and had lost their endothelial lining. Conclusion: PDT with BCA induces cell death in LECs and greatly reduces the formation of a ring of Soemmering. Therefore, it could be a promising novel means of prevention of PCO, provided the total length of the treatment can be substantially reduced and the negative effects on corneal transparency avoided.

Glaucoma is one of the leading causes of irreversible blindness. Primary open-angle glaucoma (POAG), the most common type, is a progressive optic neuropathy with characteristic structural changes in the optic nerve head and functional changes in the visual field. Mechanical and vascular theories for the pathogenesis of glaucomatous optic neuropathy have been proposed. Elevated intraocular pressure (IOP) is a strong risk factor, although a subset of POAG patients has normal IOP and is designated normal tension glaucoma (NTG). Clearly, factors other than IOP are likely to be involved in retinal ganglion cell death in glaucoma. An intriguing finding of recent studies is that intracranial pressure (ICP) is lower in patients with POAG and NTG when compared with nonglaucomatous control subjects. It has been suggested that the relationship between IOP and ICP may play a fundamental role in the development of glaucoma. A decreased ICP could result in an increased trans-lamina cribrosa pressure difference (IOP minus ICP) and lead to glaucomatous damage. In the present paper, we raise the question of whether ICP fluctuations also may be important in glaucoma. The effect of ICP fluctuation might be comparable to that of IOP fluctuation, which has been recognized as an independent risk factor for glaucoma progression.

Purpose: To observe the posterior continuous curvilinear capsulorhexis (PCCC) after cataract surgery in control eyes and eyes with an increased risk for postoperative inflammation. Setting: Department of Ophthalmology, University Hospital Antwerp, Belgium. Methods: After phacoemulsification, a PCCC was performed before intraocular lens (IOL) implantation in 20 eyes of 18 patients with ocular or systemic conditions that predisposed them for increased postoperative inflammation; e.g., diabetes, uveitis, retinitis pigmentosa (inflammation group). These eyes were compared with 20 eyes of 16 patients who had the same surgical procedure but did not present a history of medical or ocular pathology (control group). The postoperative follow-up was 6 months to 3 years. Reclosure of the PCCC was evaluated by anterior segment photographs. The reclosure was classified as partial when newly formed tissue was present at the PCCC margin and total when the proliferation covered the entire PCCC area. Results: Three types of PCCC reclosure were found: fibrotic, Elschnig pearl or multilayer, and monolayer. All 3 were seen within or at the margin of the PCCC area. Reclosure (total and partial) occurred in 8 eyes (40%) in the control group and 10 (50%) in the inflammation group. Total reclosure was more frequent in the inflammation group (4 eyes [20%]) than in the control group (1 eye [5%]). Monolayered or multilayered cellular proliferation was present in 8 eyes (40%) in the control group and 4 eyes (20%) in the inflammation group; fibrotic proliferation was found in the inflammation group only (7 eyes [35%]). Conclusion: Reclosure of the PCCC occurred in both groups, although the frequency of reclosure was slightly higher in the inflammation group. Although PCCC does not prevent posterior capsule opacification in all cases, it is useful in specific situations.

Purpose To determine surgically induced astigmatism (SIA) after monofocal spherical intraocular lens (IOL) implantation using the bag-in-the-lens (BIL) technique. Setting Department of Ophthalmology, Antwerp University Hospital, Antwerp, Belgium. Design Case series. Methods Adult patients had routine phacoemulsification followed by BIL IOL implantation, which requires a double capsulorhexis for IOL fixation. The 2.8 mm limbo-corneal self-sealing incision was temporally located. Preoperative and 3-month postoperative keratometries were measured by Scheimpflug imaging (Pentacam). The patients were divided into 2 groups based on corneal astigmatism. Group A0 consisted of eyes with physiological corneal astigmatism less than 1.00 diopter (D). Group A1 consisted of eyes with corneal astigmatism of 1.00 D or higher. Vector analysis of the corneal power was used to determine the SIA. Results The study comprised 100 eyes (58 patients). There was no difference in SIA between Group A0 and Group A1. The mean preoperative and postoperative keratometries were highly correlated in both groups (A0: r2 = 0.95; A1: r2 = 0.83). The correlation between preoperative and postoperative vectorial astigmatism was low in Group A0 (J0: r2 = 0.24; J45: r2 = 0.10). The mean postoperative SIA was 0.06 D @ –24 degrees in Group A0 and 0.09 D @ 6 degrees in Group A1, with an uncertainty of ±1.00 D. Conclusions After BIL IOL implantation, the SIA was not statistically significant. Based on these findings, the technique can be considered an option for spherocylindrical correction of corneal astigmatism of 1.00 D or more. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned. Additional disclosure is found in the footnotes.

Purpose To study the influence of neodymium:YAG (Nd:YAG) laser capsulotomy on ocular wavefront aberrations. Setting Department of Ophthalmology, Antwerp University Hospital, Edegem, Belgium. Methods The wavefront aberrations in pseudophakic eyes with posterior capsule opacification (PCO) were measured with an iTrace aberrometer before and after Nd:YAG laser capsulotomy. These results were analyzed using Zernike coefficients, the total and higher-order root-mean-square (RMS) values, and the wavefront peak–valley difference. In addition, a separate evaluation was performed of 2 intraocular lens (IOL) types: the hydrophilic 92S (hydrophilic IOL subgroup) and the hydrophobic AcrySof SA60AT (hydrophobic IOL subgroup). Results The study evaluated 62 pseudophakic eyes (56 patients). The RMS values in all eyes decreased significantly after Nd:YAG laser capsulotomy; the mean decrease in total RMS was 0.186 μm ± 0.445 (SD) and in higher-order RMS, 0.138 ± 0.223 μm. The decrease in total RMS (mean 0.325 ± 0.372 μm) was significant in the hydrophobic IOL subgroup (n = 14) but not in the hydrophilic IOL subgroup. Before capsulotomy, there was a statistically significant difference between the 2 subgroups in the higher-order astigmatism coefficient C(4,−2). After laser capsulotomy, the difference was significantly less. Conclusion Neodymium:YAG laser capsulotomy significantly reduced the wavefront RMS in the hydrophobic IOL subgroup but not in the hydrophilic IOL subgroup. The difference in the wavefront before capsulotomy may originate from a difference in the healing response of the capsular bag between the 2 IOL types.

Purpose To describe the clinical and histopathologic features of eyes implanted with the bag-in-the-lens (BIL), which involves the use of a twin capsulorhexis lens design, and performance of anterior and posterior capsulorhexes. Design Case series with clinicopathologic correlation. Participants Six eyes implanted with the foldable, hydrophilic acrylic BIL, obtained postmortem at different postoperative times, from 4 patients were studied. Methods On the patients' death, the eyes were enucleated, immersed in fixative, and submitted for analyses under a high-frequency ultrasound unit (Artemis, Ultralink, St. Petersburg, FL; 50 MHz), gross analyses, and histopathologic analyses. Clinical data in each case were obtained by chart review. Main Outcome Measures Clinical data obtained included patient demographics, preoperative evaluation, description of surgical implantation procedure, and postoperative outcomes. The postmortem evaluation included analyses of lens fixation and centration, as well as gross and histopathologic analyses of postoperative capsular bag opacification. Results The patients were aged 74.6±12.6 years at implantation. The postoperative time in this series ranged from 4 to 39 months. In all eyes for which the surgical implantation was uneventful (N = 5), postoperative BIL decentration was insignificant. In 1 eye, the anterior capsulorhexis was torn off, and although BIL implantation was still possible, a relative lens decentration was observed postoperatively, but without clinical significance. Although progressively larger amounts of Soemmering's ring formation were observed in the specimens with larger follow-up, the central area delimitated by the rhexis openings remained perfectly clear in all 6 eyes. Conclusions This is the first series of human eyes implanted with the BIL, obtained postmortem at different postoperative times. BIL centration depends on the performance of centered capsulorhexes of appropriate size. The results confirm the concept of the lens design in that any proliferative/regenerative material remains confined to the intercapsular space of the capsular bag remnant outside the optic rim. Financial Disclosure(s) Proprietary or commercial disclosure may be found after the references.

Purpose Several reports have demonstrated an association between glaucoma and obstructive sleep apnea (OSA), though the origin of this association remains unknown. In the present study, the influence of OSA and continuous positive airway pressure (CPAP) therapy on intraocular pressure (IOP) and ocular perfusion pressure (OPP) was examined. Methods IOP, blood pressure, and pulse rate were measured every 2 hours during 24-hour sessions in 21 patients with newly diagnosed OSA. A first series of measurements was performed before CPAP therapy, and a second series was performed 1 month after the initiation of CPAP therapy. OPP was then calculated. Results Baseline measurements showed a significant nycththemeral fluctuation in the average IOP, with the highest IOPs at night. After 1 month of CPAP therapy, the average IOP was significantly higher than baseline. The increase in overnight IOP was also significantly higher. A 24-hour IOP fluctuation of > or =8 mm Hg was found in 7 patients at baseline and in 12 patients during CPAP therapy. The mean difference between trough and peak IOP was 6.7 +/- 1.5 mm Hg at baseline and 9.0 +/- 2.0 mm Hg during CPAP therapy. Thirty minutes after CPAP cessation a significant decrease in IOP was recorded. There was a statistically significant decrease in mean OPP during CPAP therapy. Conclusions Patients with OSA demonstrated significant 24-hour IOP fluctuations, with the highest values at night. CPAP therapy causes an additional IOP increase, especially at night. Regular screening of visual fields and the optic disc is warranted for all patients with OSA, especially those treated with CPAP.

Purpose The objective of the study was to compare the intraocular pressure (IOP)-lowering efficacy and safety of travoprost 0.004%/timolol 0.5% ophthalmic solution (Trav/Tim) to latanoprost 0.005%/timolol 0.5% ophthalmic solution (Lat/Tim), dosed once daily in the morning, in patients with open-angle glaucoma (OAG) or ocular hypertension (OH). Methods This was a randomized, double-masked, multicenter, parallel group, active-controlled study conducted at 41 sites. At the eligibility visit the patients were randomized (1:1) to the assigned masked medication if they met inclusion/exclusion criteria, and the mean IOP values in the eligible eyes were ≥24 mmHg at 9 AM and ≥21 mmHg at 11 AM and 4 PM. Patients were excluded if the mean IOP in either eye was >36 mmHg. Patients were instructed to administer the assigned medication each morning at 9 AM. During the treatment phase of the study, IOP was measured at 9 AM at week 2, week 6, month 3, and month 9. At the month 6 and month 12 visits, IOP was measured at 9 AM, 11 AM, and 4 PM. Statistical methods included a repeated measures analysis of variance (ANOVA); to test for noninferiority, a 95% confidence interval for the treatment group difference was constructed based on the ANOVA results for each time point at month 12. Results Patients (n=408) with OAG or OH were enrolled at 41 sites. One patient withdrew prior to receiving medication so 207 in the Trav/Tim group and 200 in the Lat/Tim group were evaluable for safety. Baseline demographic characteristics as well as IOP values showed no statistical differences between the two groups. Trav/Tim provided lower mean IOP values than Lat/Tim that were statistically significant at the week 2 9 AM (p=0.0081), month 6 9 AM (p=0.0056), and month 6 11 AM (p=0.0128) time points and at 9 AM time point pooled across all visits (p=0.0235) when mean IOP was 0.6 mmHg lower in the Trav/Tim group. Treatment-related adverse events were mild in both groups. Although hyperemia was reported from a higher percentage of patients in Trav/Tim group, differences in average hyperemia scores between the two groups were not considered clinically relevant. Conclusions Travoprost 0.004%/timolol 0.5% ophthalmic solution produced mean IOP levels that are statistically noninferior to latanoprost 0.005%/timolol 0.5% ophthalmic solution. Furthermore, at 9:00 AM, 24 hours after dosing, IOP was statistically lower for travoprost 0.004%/timolol 0.5% pooled across all visits. Travoprost 0.004%/timolol 0.5% fixed combination ophthalmic solution is an effective treatment for reducing IOP and it is safe and well-tolerated in patients with OAG or OH. (Eur J Ophthalmol 2007; 17: 183–90)

PURPOSE. An unexplained clinical observation is the development of posterior capsular opacification (PCO), even when the central part of the posterior capsule has been removed. The purpose of this study was to investigate in vitro the mechanisms involved in the closure of the posterior capsulorrhexis in a capsular bag model. METHODS. A sham extracapsular cataract extraction was performed in 71 human donor eyes, followed by a central posterior capsulorrhexis 3 to 4 Hurt in diameter. Each capsular bag was pinned to a PMMA ring with a central hole of 5 mm and placed in a Petri dish. The capsular bags were cultured and monitored for 3 to 7 weeks by phase-contrast microscopy, after which they were prepared for light, transmission, and scanning electron microscopy. RESULTS. Proliferation of lens epithelial cells (LECs) within the posterior rhexis area was found in 22 cases (31%) of which 3 had a complete closure. In the absence of the posterior capsule, a monolayer of LECs was observed growing on a basal lamina, consisting of loosely arranged fibers. Further observations on noncultured capsular bags revealed that this basal lamina corresponds to the anterior hyaloid membrane. CONCLUSIONS. This study corroborates the clinical observation that LECs that remain after cataract extraction have the potential to proliferate, in the absence of their natural substrate, on a basal lamina of vitreous origin and are able to close the posterior capsulorrhexis partially or totally in approximately one third of cases.

Purpose: To evaluate the integrity of the aqueous-vitreous barrier by assessing the flow of fluorescein from the anterior chamber to the anterior vitreous using fluorophotometry in eyes with a posterior continuous curvilinear capsulorhexis (PCCC) and in eyes without a PCCC. Setting: University Hospital Antwerp, Edegem, Belgium. Methods: Ten patients had bilateral extracapsular cataract extraction with implantation of an intraocular lens. In 1 eye, a PCCC was performed; the other eye served as a negative control. The eyes of 2 other patients who had complicated cataract surgery with posterior capsule and anterior hyaloid membrane rupture served as positive controls. All patients had fluorophotometry of both eyes 12 to 18 months after surgery to measure the flow of fluorescein from the anterior chamber to the anterior vitreous. Results: There were no statistically significant differences in the distribution pattern of fluorescein between eyes with PCCC and eyes without PCCC. In contrast, enhanced flow was detected in both eyes with rupture of the posterior capsule and the anterior hyaloid. Conclusions: In this fluorophotometry study, a PCCC did not seem to disrupt the aqueous-vitreous barrier. Results indicate that an intact anterior vitreous membrane is crucial to maintain the barrier function between the anterior and the posterior segments of the eye. (C) 2003 ASCRS and ESCRS.

Photodynamic therapy (PDT) with bacteriochlorin a (BCA) has proven to be successful in the treatment of cancers and to be cytocidal for lens epithelial cells (LECs) in culture. The present study aimed to determine whether PDT with BCA is also effective in destroying LECs in the capsular bag in vivo and could therefore be a strategy for prevention of posterior capsule opacification (PCO).BCA was obtained by saponification and acid hydrolysis of bacteriochlorophyll a and was formulated in 30% polyethylene glycol, 20% ethanol and 50% water. Nine albino rabbits were anesthesized and both pupils dilated. Extracapsular lens extraction by phacoemulsification was performed on both eyes. One eye of each animal served as control. In the other eye, 1.5 ml BCA (10 or 50 microg/ml) was injected in the capsular bag and after 10 min, the eye was illuminated with a diode laser (wavelength 760 nm) for 10 or 15 min. Six weeks after surgery, the rabbits were sacrificed and the globes were enucleated, the capsular bags and the corneas removed, fixed and examined using stereomicroscopy and light microscopy.In the control capsular bags, extensive proliferation of LECs and formation of a complete ring of Soemmering was found, while in the PDT-treated capsular bags, LEC proliferation was markedly diminished and an incomplete irregular and much thinner ring of Soemmering was formed. Using the presently described application, the corneas of the PDT-treated animals were opaque and swollen and had lost their endothelial lining.PDT with BCA induces cell death in LECs and greatly reduces the formation of a ring of Soemmering. Therefore, it could be a promising novel means of prevention of PCO, provided the total length of the treatment can be substantially reduced and the negative effects on corneal transparency avoided.

Purpose: To report a new intraocular lens (IOL) and an IOL implantation concept, the bag-in-the-lens implantation technique, designed to prevent posterior capsule opacification (PCO). Setting: The University of Antwerp, Department of Ophthalmology, Edegem, Belgium, and the Netherlands Ophthalmic Research Institute, Department of Morphology, Amsterdam, The Netherlands. Methods: After identical curvilinear capsulorhexes are created in both the anterior and posterior capsules, the capsules are inserted in a flange of the IOL, thus the term bag-in-the-lens as opposed to the currently used lens-in-the-bag technique. The IOL was implanted in an in vitro human capsular bag model and in 10 eyes of 9 patients with cataract. Lens epithelial cell (LEG) outgrowth and PCO formation were observed. Results: When both capsular blades were well stretched around the IOL optic, the in vitro capsular bag model showed LEC proliferation only within the space of the remaining lens bag. The LEC proliferation was limited, and there was no tendency toward proliferation approaching the visual axis. In all 10 eyes, the optical axis remained clear during a follow-up between 4 and 15 months. Conclusions: This new IOL prevented LEC proliferation in vitro and seems promising in vivo. Target patients are those at risk of PCO including those with congenital cataract, uveitis, diabetes, or cataract extraction combined with vitrectomy. (C) 2002 ASCRS and ESCRS.