Postural effects on blood pressure, intraocular pressure, and ocular perfusion pressure in patients with spinal cord injury.

BACKGROUND: Reduced ocular perfusion pressure (OPP) from hypotension and consistent OPP variability due to blood pressure (BP) fluctuations are predisposing factors for glaucoma. Low resting BP and orthostatic hypotension (OH) in spinal cord injury (SCI) patients may increase the risk of glaucoma post-injury. This study investigated BP, intraocular pressure (IOP), and OPP changes between supine and sitting positions in SCI and normal individuals. METHODS: Twenty SCI cases (high paraplegia, T1-T6 n = 6; low paraplegia, T7-L3 n = 14) and matched controls (1:1) were included. Systolic and diastolic BP (SBP and DBP) were measured digitally, and IOP with rebound tonometry. Measurements were taken one minute apart in both positions. Mean arterial pressure (MAP) was calculated, and OPP was determined using position-specific formulas. RESULTS: No SCI subjects exhibited OH. Both groups experienced significant BP increment (P < 0.05) from supine to sitting. SBP increased by 4.4 ± 8.4 mmHg (SCI) and 3.6 ± 6.2 mmHg (normal), while DBP increased by 4.2 ± 5.1 mmHg (SCI) and 6.7 ± 5.5 mmHg (normal). IOP and OPP decreased significantly (P < 0.05) after postural change in both groups, yet differences between them were not significant. Analysis by injury level revealed lower parameter values in high paraplegia than in low paraplegia, with the latter group showing a more significant reduction in OPP after postural change. CONCLUSION: Postural changes differently affect BP, IOP, and OPP in SCI compared to normal individuals, with variations based on the level of SCI. While not directly assessing glaucoma, the study offers insights into ocular hemodynamics in SCI compared to normals.

Isolated Abducens Nerve Palsy Following Spinal Anesthesia.

A healthy 28-year-old lady, para 1, presented to the emergency department with persistent frontal headache, nausea, and vomiting following an emergency cesarean section four days ago. She experienced difficulties with six failed attempts of spinal anesthesia intrapartum before conversion to general anesthesia. A 25-gauge Whitacre needle was utilized for administering spinal anesthesia under a sitting position. The anesthetist noticed a loss of resistance upon needle insertion, but only a negligible amount of cerebrospinal fluid was obtained upon removing the stylet. The patient underwent an emergency cesarean section due to fetal distress, and she was not in labor during the attempts of spinal anesthesia. Otherwise, the cesarean section lasted for an hour and was uneventful. No intrapartum eclampsia or pre-eclampsia. She was diagnosed with post-dural puncture headache, and her symptoms improved after receiving intravenous hydration, oral caffeine, and non-steroidal anti-inflammatory drug (NSAIDs). However, on the sixth day after the spinal anesthesia, she suddenly developed double vision. Examination showed bilateral visual acuity was measured at 6/7.5. No proptosis or ptosis was noted. The relative afferent pupillary defect was negative with no anisocoria. Both eyes were orthophoria with normal head posture. Extraocular muscles revealed a right abduction restriction of -1 with the patient complaining of binocular horizontal diplopia at the right gaze, consistent with right abducens nerve palsy. Systemic neurological findings were normal, and imaging results were unremarkable. Diagnosis of right abducens nerve palsy post-dural puncture was made clinically. The patient was keen on conservative management instead of blood patch therapy. Hence, she was treated supportively via uni-ocular patching to relieve diplopia. Spontaneous complete recovery of the right abducens nerve palsy was observed after three weeks. Cranial nerve palsy is a rare complication reported following spinal anesthesia, with the abducens nerve being the commonest nerve involved. Although it is not always benign, the presented case showed spontaneous complete recovery of the right abducens nerve palsy after three weeks. Awareness of this uncommon complication will avoid unnecessary distress and investigative burden to both the patient and the doctor.

Trichosporon Endophthalmitis Following Cataract Surgery: A Case Report.

Fungal infections always pose a predicament to management and prognosis. The saprophytic fungus, Trichosporon inkin commonly causes endogenous infection in immunocompromised individuals. We report a case of exogenous T. inkin endophthalmitis successfully treated with voriconazole, pars plana vitrectomy, and removal of the source of infection. A 51-year-old gentleman with suboptimal control of diabetes presented with a right painful red eye for a week after undergoing an uneventful phacoemulsification with a posterior chamber intraocular lens implant more than a month prior. He presented with intense inflammation in the right anterior chamber that did not respond to steroid challenge. Ultrasound B scan showed vitreous opacities with no loculations. The culture of vitreous humor was negative. Systemic investigations were also normal. Despite being given multiple intravitreal antibiotics, his right eye got worse. He then underwent vitrectomy and intraocular lens explantation, in which the culture of the lens grew Trichosporon Inkin. He was subsequently started on the appropriate antifungals (topical, intravitreal, and systemic) based on the minimum inhibitory concentration of the antifungal sensitivity test. The patient eventually showed significant clinical improvement, and intraocular inflammation was subsiding after six months of treatment. His best corrected visual acuity improved to 6/12 with Snellen's visual acuity chart.

Ocular Jarisch-Herxheimer Reaction in the Treatment of Ocular Syphilis: A Case Report and Review of the Literature.

Jarisch-Herxheimer reaction (JHR) is a transient clinical phenomenon in patients with syphilis who receive antibiotic treatment. A 31-year-old man with an underlying HIV infection presented with worsening vision in the right eye two days after being treated with oral doxycycline for presumed left-eye neuroretinitis. Prior history revealed two episodes of penile discharge and ulcers that were not investigated. Examination showed bilateral optic disc swelling with right eye placoid chorioretinitis around the macula. Optical coherence tomography (OCT) demonstrated right macular edema and left macular thinning. Blood investigations confirmed syphilis infection. Subsequently, the patient was scheduled for a contrasted brain CT with oral steroid coverage due to underlying allergies. His vision incidentally improved soon after the short course of steroids. Repeated OCT demonstrated marked improvement of right macular edema, which we believe was secondary to JHR initiated by the earlier doxycycline treatment. Following oral steroid addition, improvement in vision and ocular findings were seen. At six-month post-treatment, there was right macular atrophy as a sequela of the macular edema. Ophthalmologists should be aware of ocular-related JHR complications, particularly in potentiating macular atrophy following macular edema upon initiating antibiotic treatment in syphilitic disease.

Risk factors affecting cataract surgery outcome: The Malaysian cataract surgery registry.

This is a 5 years multicentre database study that recruited subjects from the Malaysian Ministry of Health Cataract Surgery Registry (MOH CSR), aimed to determine risk factors that affect cataract surgery visual outcome and evaluates post-cataract surgery vision. All age-related cataract surgeries with primary intraocular lens (IOL) implantation were included. Cases with secondary cataract, previous ocular surgeries and incomplete data were excluded. A total of 131425 cases were included in the study. Amongst all types of cataract surgery, 92.9% attained post-operative best-corrected visual acuity better than 6/18 and the outcome improved to 97.1% when ocular comorbidities were excluded. Factors with Odds Ratio (OR) >1.5 associated with an impaired visual outcome included: elderly patients of 80 years old and above; systemic disease such as renal failure; ocular co-morbidities; pre-operative vision worse than 6/60; general anaesthesia, retrobulbar anaesthesia or subconjunctival anaesthesia; extracapsular cataract extraction (ECCE), intracapsular cataract extraction (ICCE), anterior chamber intraocular lens (ACIOL) implantation or combined cataract surgery; the presence of intra- and post-operative complications. In conclusion, a good visual outcome was achieved after cataract surgery in most cases. This large multicentre study provides information about risk factors for poor visual outcome post-cataract surgery and may serve as a basis for evidence-based guidelines.

Sinonasal Lymphoma Presenting as Cavernous Sinus Syndrome: Case Report and Review of the Literature.

A 37-year-old man presented with a 1-week history of diplopia. He was under investigation by otorhinolaryngology for left sinonasal malignancy after imaging of the paranasal sinuses had revealed a large homogenous mass in the left nasal cavity. His visual acuity was 6/9 in each eye with no relative afferent pupillary defect. The left pupil, though was mid-dilated and unresponsive to light. He had a left-sided ptosis. Extraocular movements of the left eye were restricted in all directions of gaze and there was with limited abduction, dextroelevation and dextrodepression of the right eye. A trans-nasal biopsy revealed extranodal natural killer/T-cell lymphoma. Further imaging showed a large enhancing nasopharyngeal mass with intracranial extension to the cavernous sinuses and local infiltration together with intracranial abscesses. The patient was started on empirical intravenous antibiotics and supportive treatment. While awaiting institution of lymphoma chemotherapy, he died. The involvement of the cavernous sinus in sinonasal lymphoma represents an advanced stage. This case highlights that lymphoma should be considered in any patient presenting with a cavernous sinus syndrome and sinonasal disease.

Experience in managing glaucoma filtration surgery complications with oral doxycycline: A case series.

PURPOSE: To report the clinical profile and effectiveness of oral doxycycline as a non-invasive treatment for glaucoma filtering surgery complications. METHOD: Prospective case series. RESULTS: Doxycycline is widely used in treating corneal melts, ocular surface diseases, meibomian gland disease, recurrent epithelial cell erosion, rosacea, and keratitis sicca. This prospective case series highlights the successful treatment of five patients with leaking blebs and conjunctiva erosion from glaucoma filtration surgery with the use of oral doxycycline. There was no adverse event reported in our cases. CONCLUSIONS: This study suggests that oral doxycycline may be a feasible non-surgical treatment modality due to its ability to inhibit collagenolysis, restore the Meibomian gland function, thereby stopping breakdown and promote conjunctival tissue healing.

Effects of regular exercise on intraocular pressure.

BACKGROUND: Exercise may potentially provide an adjunctive measure to help control intraocular pressure in glaucoma patients. However, currently, there is still no substantial evidence that regular exercise can produce a prolonged effect of intraocular pressure reduction. We aim to determine the effects of regular exercise on intraocular pressure in healthy individuals. METHODS: We conducted a prospective, interventional study at the University of Malaya Medical Centre. Our subjects consist of 45 healthy participants in the intervention arm, and 38 healthy control participants who were age- and gender-matched. The intervention arm was enrolled into a supervised exercise programme for a 6-week period, where controls were asked to continue their usual daily lifestyle. The intervention consists of three sessions every week, which focused on aerobic exercise and strength training. RESULTS: Baseline intraocular pressure was measured, and then remeasured again at the end of 6 weeks of exercise conditioning. In the intervention group, there was a reduction of baseline intraocular pressure from pre-intervention mean intraocular pressure of 15.55 ± 2.63 mmHg, down to 13.36 ± 3.16 mmHg at 6 weeks, a statistically significant reduction of -2.18 ± 2.25 mmHg (p < 0.001) post-intervention. On the other hand, the control group recorded a non-statistically significant mean increase of 0.63 ± 2.47 mmHg (p = 0.123) at 6 weeks. CONCLUSIONS: Our study concluded that regular exercise results in a significant intraocular pressure reduction in healthy individuals.

Contrast sensitivity is associated with frailty.

PURPOSE: Using data from the Malaysian Elders Longitudinal Research (MELoR), this study investigated the association between visual function (visual acuity and contrast sensitivity) and frailty in a group of urban-dwelling older adults. METHODS: This was a cross-sectional study. 1332 participants aged ≥ 55 years were selected by random sampling from the parliamentary electoral register. Only 1274 participants completed the frailty assessment and 1278 participants completed the contrast sensitivity assessment. Impaired vision was defined as a Snellen visual acuity of worse than 6/12 in the better eye. Poor contrast sensitivity was defined as a score on the Pelli Robson chart of lower than 1.65. Frailty was defined with the Fried's phenotype criteria. Inter-group comparisons were determined with the independent T-test for continuous variables and the Pearson's Chi-squared test for categorical variables. The odds ratio (OR) with 95% confidence interval (CI) was used to evaluate the cross-sectional association between frailty and visual function. RESULTS: The mean age of participants was 68.8 ± 7.5 years, of which 58.1% (774) were women. Impaired vision and poor contrast sensitivity were present in 187 (14%) and 271 (21.2%) subjects respectively. 73 (5.8%) individuals were classified as frail, 1161 (91.0.%) pre-frail, and 40 (2.8%) non-frail. There was no significant difference in frailty phenotypes between those with good and impaired vision (p = 0.241). Fried's component of handgrip strength, gait speed and exhaustion were significantly better in those with good visual function (p < 0.05). Participants with poor contrast sensitivity were significantly more likely to be frail (OR: 5.34, p = 0.004). CONCLUSION: Poor contrast sensitivity was significantly associated with frailty. This highlights the importance of incorporating assessment of contrast sensitivity in those at risk of frailty.

Baseline Central Visual Field Defect as a Risk Factor For NTG Progression: A 5-Year Prospective Study.

PRECIS: This 5-year follow-up study on normal-tension glaucoma (NTG) patients demonstrated that those with baseline central visual field (VF) defect progress at a more increased rate compared with those with peripheral field defect. PURPOSE: The purpose of this study was to investigate the clinical characteristics, including 24-hour ocular perfusion pressure and risk of progression in patients with baseline central VF defect, as compared with those with peripheral VF defect in NTG. DESIGN: This was a prospective, longitudinal study. METHODS: A total of 65 NTG patients who completed 5 years of follow-up were included in this study. All the enrolled patients underwent baseline 24-hour intraocular pressure and blood pressure monitoring via 2-hourly measurements in their habitual position and had ≥5 reliable VF tests during the 5-year follow-up. Patients were assigned to two groups on the basis of VF defect locations at baseline, the central 10 degrees, and the peripheral 10- to 24-degree area. Modified Anderson criteria were used to assess global VF progression over 5 years. Kaplan-Meier analyses were used to compare the elapsed time of confirmed VF progression in the two groups. Hazard ratios for the association between clinical risk factors and VF progression were obtained by using Cox proportional hazards models. RESULTS: There were no significant differences between the patients with baseline central and peripheral VF defects in terms of demography, clinical, ocular and systemic hemodynamic factors. Eyes with baseline defects involving the central fields progressed faster (difference: ßcentral=-0.78 dB/y, 95% confidence interval=-0.22 to -1.33, P=0.007) and have 3.56 times higher hazard of progressing (95% confidence interval=1.17-10.82, P=0.025) than those with only peripheral defects. CONCLUSION: NTG patients with baseline central VF involvement are at increased risk of progression compared with those with peripheral VF defect.

Co-occurrence of acute ophthalmoplegia (without ataxia) and idiopathic intracranial hypertension.

BACKGROUND: Acute ophthalmoparesis without ataxia was designated as 'atypical Miller Fisher syndrome' as it presents with progressive, relatively symmetrical ophthalmoplegia, but without ataxia nor limb weakness, in the presence of anti-GQ1b antibody. Idiopathic intracranial hypertension is characterized by signs of raised intracranial pressure occurring in the absence of cerebral pathology, with normal composition of cerebrospinal fluid and a raised opening pressure of more than 20 cmH2O during lumbar puncture. We aim to report a rare case of acute ophthalmoplegia with co-occurrence of raised intracranial pressure. CASE DESCRIPTION: A 28-year-old gentleman with body mass index of 34.3 was referred to us for management of double vision of 2 weeks duration. His symptom started after a brief episode of upper respiratory tract infection. His best corrected visual acuity was 6/6 OU. He had bilateral sixth nerve palsy worse on the left eye and bilateral hypometric saccade. His deep tendon reflexes were found to be hyporeflexic in all four limbs. No sensory or motor power deficit was detected, and his gait was normal. Plantar reflexes were downwards bilaterally and cerebellar examination was normal. Both optic discs developed hyperaemia and swelling. Magnetic resonance imaging of brain was normal and lumbar puncture revealed an opening pressure of 50 cmH2O. Anti-GQ1b IgG and anti-GT1a IgG antibody were tested positive. CONCLUSION: Acute ophthalmoparesis without ataxia can present with co-occurrence of raised intracranial pressure. It is important to have a full fundoscopic assessment to look for papilloedema in patients presenting with Miller Fisher syndrome or acute ophthalmoparesis without ataxia.

Low nocturnal diastolic ocular perfusion pressure as a risk factor for NTG progression: a 5-year prospective study.

OBJECTIVE: To assess the relationship between baseline intraocular pressure (IOP), blood pressure (BP) and ocular perfusion pressure (OPP), and the 5-year visual field progression in normal-tension glaucoma (NTG) patients. DESIGN: Prospective, longitudinal study. METHODS: Sixty-five NTG patients who were followed up for 5 years are included in this study. All the enrolled patients underwent baseline 24-h IOP and BP monitoring via 2-hourly measurements in their habitual position and were followed up for over 5 years with reliable VF tests. Modified Anderson criteria were used to assess VF progression. Univariable and multivariable analyses using Cox's proportional hazards model were used to identify the systemic and clinical risk factors that predict progression. Kaplan-Meier survival analyses were used to compare the time elapsed to confirmed VF progression in the presence or absence of each potential risk factor. RESULTS: At 5-year follow-up, 35.4% of the enrolled patients demonstrated visual field progression. There were statistically significant differences in the mean diastolic blood pressure (p < 0.05) and diastolic OPP (p < 0.05) between the progressing and the non-progressing group. There was no association between IOP parameters and NTG progression. Multivariable analysis identified low nocturnal DOPP at baseline as a significant predictive risk factor for glaucomatous visual field progression at 5 years. An mmHg decrease in nocturnal DOPP increases the hazard of progression by 1.4 times. Patients with DOPP < 35 mmHg have 2.3-fold higher probability of progressing compared to the patients with DOPP > 43.7 mmHg (log rank = 0.018). CONCLUSION: Diastolic parameters of BP and OPP were significantly lower in the NTG patients who progressed after 5 years. Low nocturnal DOPP is an independent predictor of glaucomatous visual field progression in NTG patients.

Ocular Surface Disease in Glaucoma: Effect of Polypharmacy and Preservatives.

PURPOSE: To evaluate the prevalence of ocular surface disease (OSD) in glaucoma and nonglaucoma subjects using different clinical tests and to determine the effect of number of antiglaucoma medications and preservatives on OSD. METHODS: This is a cross-sectional, case-comparison study at the Eye Clinic of the University of Malaya Medical Centre, Malaysia, between June 2012 and January 2013. Glaucoma subjects (n = 105) using topical antiglaucoma medications were compared with control subjects (n = 102) who were not on any topical medications. The presence of OSD was assessed using the tear film breakup time (TBUT) test, corneal staining, Schirmer test, and Ocular Surface Disease Index (OSDI) questionnaire grading. RESULTS: The prevalence of OSD varied from 37 to 91% in the glaucoma group, depending on the type of clinical test. More subjects in the glaucoma group had corneal staining (63% vs. 36%, p = 0.004), abnormal Schirmer tests (39% vs. 25%, p = 0.049), and moderate OSDI symptoms (17% vs. 7%, p = 0.028). The percentage with abnormal TBUT increased with higher numbers of topical medications and was high with both benzalkonium chloride-containing and preservative-free eye drops (90% and 94%, respectively, both p < 0.001). Benzalkonium chloride was associated with a nearly three times higher odds ratio of showing abnormal OSDI. CONCLUSIONS: Ocular surface disease is common in those using topical antiglaucoma medications. Abnormal TBUT is associated with increasing number of eye drops and benzalkonium chloride-containing eye drops, although this also occurs with the use of preservative-free eye drops.

Association between Ocular Pseudoexfoliation and Sensorineural Hearing Loss.

Background. Our study aimed to investigate an association between ocular pseudoexfoliation (PXF) and sensorineural hearing loss (SNHL) and to compare them with age and sex matched controls without pseudoexfoliation. Method. This was a case-control study of 123 patients which included 68 cases with PXF (at least one eye) and 55 controls without pseudoexfoliation. Pure-tone audiometry (PTA) was done for these patients at sound frequencies taken as important for speech comprehension, that is, 250 Hertz (Hz), 500 Hz, 1000 Hz, and 2000 Hz. Results. There were 41 patients with pseudoexfoliation syndrome (PXE) and 27 with pseudoexfoliative glaucoma (PXEG). The majority of patients with hearing loss (60%; n = 51) were PXF patients and the remaining 40% (n = 34) were controls. Below average hearing thresholds were significantly higher in the pseudoexfoliation group compared to the control group (P = 0.01; odds ratio (OR), 3.00; 95% confidence interval (CI), 1.25-7.19). However, there was no significant difference in the mean hearing threshold levels between the three groups (PXE, PXEG, and controls) in either ear (ANOVA, right ear: P = 0.46 and left ear P = 0.36). Conclusion. Our study found an association between PXF and SNHL, confirming that PXF can involve organs in the body other than the eye.

Novel use of 3T MRI in assessment of optic nerve volume in glaucoma.

PURPOSE: To measure optic nerve (ON) volume using 3 T magnetic resonance imaging (MRI), to correlate ON volume with retinal nerve fiber layer (RNFL) thickness, and to determine the viability of MRI as an objective tool in distinguishing glaucoma severity. METHODS: In this cross-sectional study, 30 severe glaucoma patients, 30 mild glaucoma patients and 30 age-matched controls were recruited. All subjects underwent standard automated perimetry, RNFL analysis and 3 T MRI examinations. Glaucoma patients were classified according to the Hodapp-Anderson-Parish classification. Pearson's correlation coefficient was used to correlate ON volume with RNFL, and receiver operating curve (ROC) analysis was performed to determine the sensitivity and specificity of ON volume in detecting glaucoma severity. RESULTS: Optic nerve volume was significantly lower in both the left and right eyes of the severe glaucoma group (168.70 ± 46.28 mm(3); 167.40 ± 45.36 mm(3)) than in the mild glaucoma group (264.03 ± 78.53 mm(3); 264.76 ± 78.88 mm(3)) and the control group (297.80 ± 71.45 mm(3); 296.56 ± 71.02 mm(3)). Moderate correlation was observed between: RNFL thickness and ON volume (r = 0.51, p <0.001), and in mean deviation of visual field and optic nerve volume (r = 0.60, p < 0.001). ON volume below 236 mm(3) was 96 % sensitive and 80 % specific for the detection of severe glaucoma. CONCLUSIONS: MRI measured optic nerve volume is a reliable method of assessing glaucomatous damage beyond the optic nerve head. A value of 236 mm(3) and below can be used to define severe glaucoma.

Darkroom prone provocative test in primary angle closure glaucoma relatives.

PURPOSE: To evaluate ocular biometric parameters and darkroom prone provocative test (DPPT) in family members of primary angle closure (PAC) glaucoma (PACG) patients and to establish any correlation between these biometric parameters and the DPPT response. METHODS: Seventy-four family members of PACG patients underwent ultrasound ocular biometry, slit lamp biomicroscopy, Goldmann applanation tonometry, fundus examination, and gonioscopy. Lastly, DPPT was performed. RESULTS: Of 74 family members examined, 6 (8.1%) were found to have PAC, 8 (10.8%) were PAC suspects, and 60 (81.1%) were unaffected. Of those affected, 4 (66.7%) had a positive DPPT response, whereas 87.5% of the PAC suspects had a positive or a borderline DPPT response. Affected and PAC suspects had the shallowest anterior chamber depth, thickest lens, shortest axial length, and most anteriorly positioned lens. Anterior chamber depth and lens thickness showed a significant correlation with positive DPPT. CONCLUSIONS: Anterior chamber depth and lens thickness and, to a lesser extent, axial length and lens position were significantly correlated with a positive DPPT response. The ocular biometric risk factors associated with PACG patients are also found in their respective family members who are affected and suspected of having PAC. We suggest a longitudinal study to determine the reliability of DPPT in identifying individuals who are at risk of PAC.

Progression of visual field loss in open angle glaucoma in the Melbourne Visual Impairment Project.

PURPOSE: To quantify the progression of visual field loss in participants with open angle glaucoma. METHODS: Cluster random samples of 3271 participants participated in this study. Each participant underwent a standardized ophthalmic examination, which included intraocular pressure measurement, Humphrey 24-2 Fastpac visual field testing and stereophotography of the optic disc. At baseline 118 participants were identified as possible, probable or definite open angle glaucoma and 74 (62.7%) of these were seen again at the follow-up examination. Progression of visual field loss was defined using three methods: the Advanced Glaucoma Intervention Study criteria, the modified Anderson criteria and the Blumenthal method. RESULTS: In total, 49% of subjects showed progressive visual field loss with at least one method. The Blumenthal criteria yielded the highest rate of progression (37%), followed by the modified Anderson method (33%) and the Advanced Glaucoma Intervention Study method (16%). The progressive visual field loss was associated with baseline glaucoma status (P = 0.02); 65% of the definite glaucoma progressed, compared with 57% of the probable glaucoma and 25% of the possible glaucoma. Participants who had been previously diagnosed with glaucoma had a higher rate of progression (54%) when compared with those who had not been diagnosed previously (47%). In total, 50% (four of eight) of those receiving glaucoma medication at baseline had progressive visual field loss; all were in the definite glaucoma category. CONCLUSION: Despite use of glaucoma medications the majority of glaucoma patients managed by their regular ophthalmologist experienced progressive visual field loss over a 5-year period.