Correlation between structural progression in glaucoma and obstructive sleep apnea.

BACKGROUND/OBJECTIVES: To investigate the correlation between obstructive sleep apnea (OSA) severity and the structural and functional progression in patients with glaucoma. SUBJECTS/METHODS: This retrospective comparative cohort study included subjects from the polysomnography database in Chang Gung Memorial Hospital between June 1, 2009, and June 1, 2017, by identifying patients who had received diagnoses of primary open-angle glaucoma (POAG), normal-tension glaucoma (NTG), or glaucoma suspect. Patients with follow-up time of <3 years and/or <3 consecutive reliable optical coherence tomography (OCT) or visual field (VF) tests were excluded. Progression of overall peripapillary retinal nerve fiber layer (RNFL) thickness on OCT scans and VF mean deviation (MD) or VF index (VFI) were determined through linear regression trend analysis. RESULTS: Thirty-two patients were included. There was a trend to higher percentage of progression on RNFL thickness and VF in higher OSAS severity. After stratifying patients to no OSA/mild OSA (group 1) and moderate/severe OSA (group 2), group 2 exhibited a significantly higher percentage of RNFL thickness progression than did group 1 (64.7% vs 26.7%, P = 0.042). Multivariate Cox regression analysis showed that severe OSA had an 8.448-fold higher risk of RNFL thickness progression after age, sex, diabetes mellitus, hypertension, hyperlipidemia, and body mass index adjustment (95% confidence interval, 1.464-48.752, P = 0.017). CONCLUSIONS: Severe OSA is significantly correlated with a higher risk of structural deterioration in patients with glaucoma.

Anterior Chamber Angle and Anterior Segment Structure of Eyes in Children With Early Stages of Retinopathy of Prematurity.

PURPOSE: To compare structural differences in the anterior chamber angle (ACA) and related optic components in children with or without retinopathy of prematurity (ROP). DESIGN: Prospective cross-sectional study. METHODS: Setting: A referred medical center in Taiwan. STUDY POPULATION: The patients included preterm children with a history of ROP who had undergone laser therapy. The controls included age-matched healthy full-term children. OBSERVATION PROCEDURE: The ACA structures were evaluated using gonioscopy. MAIN OUTCOME MEASURES: The angularity of the anterior chamber and associated anatomic changes. RESULTS: We examined 54 eyes of 29 preterm children with ROP and 134 eyes of 67 children born at term. The eyes of the ROP children exhibited a narrower ACA, steeper iris curvature, and more anteriorly inserted iris than those of the full-term children (P < .001, P = .002, and P = .08, respectively). The eyes of the ROP children also exhibited steeper corneas, shallower anterior chamber depths, thicker lenses, and higher degrees of refractive errors (all P < .001) than those of the full-term children. The axial lengths did not differ between the 2 groups (P = .15). CONCLUSIONS: The eyes of the ROP children presented a narrower ACA and a more anteriorly curved and inserted iris than those of the full-term children. A steeper cornea, shallower anterior chamber, and greater lens thickness were the main structural changes in the anterior segment components of these patients. Further research is needed to investigate the association between these structural changes and the development of certain ocular diseases, such as glaucoma, in these patients.

Regional Relationship between Macular Retinal Thickness and Corresponding Central Visual Field Sensitivity in Glaucoma Patients.

Purpose. To investigate the relationship between macular retinal thickness (MRT) and central visual field sensitivity (VFS) in patients with glaucoma. Methods. This retrospective study enrolled patients diagnosed with open-angle glaucoma. All study patients underwent Humphrey 10-2 visual field (VF) test and Spectralis spectral-domain optical coherence tomography (SD-OCT) exam for MRT measurement. Results. Sixty-eight eyes of 68 patients were examined. The correlation coefficients between VFS and MRT were 0.331 (P = 0.006) and 0.491 (P = 0.000) in the superior and inferior hemispheres, respectively. The average MRT in the eyes with abnormal 10-2 VF hemifields was significantly thinner than that in the eyes without abnormal hemifields in both hemispheres (P = 0.005 and 0.000 in the superior and inferior hemisphere, resp.). The average MRT values with an optimal sensitivity-specificity balance for discriminating the abnormal VF hemifield from the normal hemifield were 273.5 µm and 255.5 µm in the superior and inferior hemisphere, respectively. The area under the receiver operating characteristic curve was 0.701 in the superior hemisphere and 0.784 in the inferior hemisphere (both P < 0.05). Conclusions. MRT measured through SD-OCT was significantly correlated with central VFS. Lower MRT values might be a warning sign for central VF defects in glaucoma patients.

The relationship of bleb morphology and the outcome of needle revision with 5-fluorouracil in failing filtering bleb.

To investigate the risk factors for failure of needling revision with 5-fluorouracil (5-FU) and to identify the correlation of outcomes of needling revision and the morphological features of dysfunctional filtration blebs using Moorfields bleb grading system.This retrospective, nonrandomized, comparative case-control study included 41 consecutive patients (41 eyes) who underwent 5-FU needling revision for failed or failing filtration blebs between July 2012 and August 2014 in Chang Gung Memorial Hospital, a referral center in Taiwan. The main outcome measures were the bleb survival and the correlation factors of bleb morphology before revision. The secondary outcome measure was the identification of any study factor associated with bleb failure.Forty-one eyes of 41 patients were included in this study. The most frequent glaucoma diagnoses were 10 cases (24%) of neovascular glaucoma and 8 cases (19%) of chronic open-angle glaucoma. Survival of bleb at 6, 12, and 24 months was 42%, 39%, and 23%. Fourteen cases (34%) maintained overall success at the last follow-up, with an average follow-up of 22.7 ±â€Š9.4 months (range: 12-48 months). The central bleb area and height were significantly different between the successful needling group and the failed needling group (P = 0.03 and 0.04, respectively). Further trend test confirmed that smaller central bleb extension and flatter height were associated with a higher chance of failure (P = 0.02 and 0.02, respectively). Time from initial trabeculectomy to needling of less than 4 months and higher intraocular pressure (IOP) in the first postoperative week also led to significantly higher risk for failure (P = 0.01 and 0.03, respectively).A small central area and the flat height of dysfunctional blebs were more likely to fail after the needle revision. Cautious case selections, taking account of the time from the initial filtering surgery and postoperative IOP, may improve the surgical outcome.

Anterior chamber depth and angle-closure glaucoma after central retinal vein occlusion.

BACKGROUND: The purpose of this study was to report the anterior chamber (AC) depth and the attack of angle-closure glaucoma (ACG) in eyes with the recent onset of central retinal vein occlusion (CRVO). METHODS: This retrospective case series included 24 patients with recent onset of CRVO (within one month of attack) from July 2001 to December 2002. The mean follow-up period of the patients was 46 months (range: 3 to 92 months). AC depth was measured using an ultrasound biomicroscopy. Clinical data, including systemic disorders, intraocular pressure, and visual outcomes were recorded. The main outcome measures were AC depth in the diseased eye and the fellow eye of the same patient and the attack of ACG after CRVO. RESULTS: The mean AC depth in the diseased eyes was significantly shallower than in the unaffected fellow eyes (2.43 ± 0.45 mm vs. 2.55 ± 0.46 mm; p < 0.001). Four patients (17 %) developed ACG after the onset of CRVO within one month of the CRVO attack. In these four patients, the mean AC depth in the diseased eyes was 1.91 ± 0.21 mm, which was much shallower than the eyes without ACG attack (2.53 ± 0.40 mm). CONCLUSIONS: AC depth is significantly shallower following the onset of CRVO. ACG can occur in patients after the onset of CRVO.

Acute angle-closure glaucoma in retinopathy of prematurity following pupil dilation.

BACKGROUND: Pupil dilation is a known risk factor for acute angle-closure glaucoma. Regular retinal evaluation is necessary for retinopathy of prematurity (ROP) cases. An acute attack of angle-closure glaucoma following pupil dilation in regressed ROP has never been reported. CASE PRESENTATION: A five-year-old girl presented to the hospital for a routine retina check-up. The patient was born prematurely with a gestation age of 27 weeks and a body weight of 980 grams. She had a history of stage 4A ROP in the right eye and received scleral buckling. After pupil dilation with 1 % tropicamide and 10 % phenylephrine for retinal examination, acute elevation of intraocular pressure (IOP) was observed in the right eye. Her IOP remained over 50 mmHg in the right eye even under treatment with oral acetazolamide and maximal tolerated doses of topical anti-glaucoma medications. Ultrasound biomicroscopy (UBM) showed that the angle in the right eye was closed 360 degrees circumferentially. In order to lower IOP, trabeculectomy with mitomycin C (0.2 mg/cc) was performed under general anesthesia. Postoperatively, the cornea became clear, the filtering bleb functioned well, and IOP returned to normal values. In the two-year follow-up, IOP was kept around 15 mmHg without anti-glaucoma medications. Although mild lens opacity was noted, her postoperative VA remained 20/200 in the right eye. CONCLUSION: Regular retinal evaluation will be necessary for the increasing number of ROP cases to be seen in the future. Ophthalmologists should bear in mind that pupil dilation for a retina check-up could result in acute angle-closure glaucoma in ROP patients.

Neovascular glaucoma after central retinal vein occlusion in pre-existing glaucoma.

BACKGROUND: To determine the outcome of central retinal vein occlusion (CRVO) in pre-existing glaucoma and the predisposing factors of developing neovascular glaucoma (NVG). METHODS: We retrospectively assessed a pre-existing glaucoma CRVO group and a non-glaucoma CRVO group to elucidate the demographics, clinical course and ocular parameters of these two cohorts. Among the pre-existing glaucoma cases, the predisposing factors for the development of NVG were monitored, including the retinal capillary non-perfusion status, intraocular pressure (IOP) and best-corrected visual acuity (BCVA) at presentation. RESULTS: Of 642 CRVO patients reviewed in this 10-year cohort study, 60 (9.3%) had pre-existing glaucoma at a mean follow-up of 30.8 months, including 28 (4.4%) primary open angle glaucoma (POAG), 27 (4.2%) primary angle closure glaucoma (PACG), and 5 (0.8%) normal tension glaucoma (NTG) cases. Although the presence of glaucoma in the CRVO eyes was not significantly associated with the risk of developing NVG, the incidence of developing NVG in pre-existing glaucoma eyes was significantly higher in the group with IOP greater than 20 mmHg at CRVO presentation (P = 0.02, Chi-square test) as well as in the ischemic CRVO group compared to the non-ischemic patients (P = 0.005, Fisher's exact test). Overall, 20% of pre-existing glaucoma patients needed glaucoma surgery after a CRVO event, including 11.7% of patients who developed iris neovascularisation (INV) and 8.3% of patients who developed a high IOP without INV. CONCLUSIONS: Both the retinal non-perfusion status and uncontrolled IOP contribute to NVG in patients with pre-existing glaucoma after CRVO. Following CRVO, glaucoma surgery is necessary for pre-existing glaucoma cases with intractable elevated IOP with or without INV.

Late-onset secondary pigmentary glaucoma following foldable intraocular lenses implantation in the ciliary sulcus: a long-term follow-up study.

BACKGROUND: To review the long-term outcomes of eyes with secondary pigmentary glaucoma associated with the implantation of foldable intraocular lenses (IOL) in the ciliary sulcus. METHODS: The study retrospectively reviewed a series of cases who developed secondary pigmentary glaucoma after cataract operations. Data were collected from cases that were referred between 2002 and 2011. RESULTS: Ten eyes of 10 patients who developed secondary pigmentary glaucoma after foldable IOLs implantation in the sulcus were included in this study. CONCLUSION: Secondary pigmentary glaucoma accompanying the implantation of a foldable IOL in the ciliary sulcus may present as acute IOP elevation during the early postoperative period or, more commonly, late onset of IOP elevation accompanied by advanced glaucomatous optic nerve damage. Despite treatment, the visual prognosis for these patients can be poor. Placing a foldable IOL in the ciliary sulcus could pose a threat to the vision of the patients and long-term follow-up of IOP in these patients is necessary.

Age- and gender-specific association between intraocular pressure and metabolic variables in a Taiwanese population.

BACKGROUND: To analyze the relationship between intraocular pressure, metabolic variables, and components of metabolic syndrome in different age and gender groups. METHODS: We examined 10,491 Taiwanese adults aged 21 to 79 years and categorized according to gender and age. All participants underwent examinations, including body mass index (BMI), waist circumference, blood pressure, intraocular pressure, and blood chemistry. Multiple linear regression analyses were performed to evaluate the relationships between intraocular pressure and these variables as well as to determine the relative influence of each component of metabolic syndrome. RESULTS: Intraocular pressure showed a significant reduction with aging in men but not in women. BMI had a positive association with intraocular pressure in young adults and middle-aged men. Systolic blood pressure was positively associated with intraocular pressure in most groups, whereas diastolic blood pressure was positively associated with intraocular pressure only in middle-aged and elderly men. Fasting blood sugar levels showed a significant association with high intraocular pressure in middle-aged and elderly adults. All participants with metabolic syndrome had higher intraocular pressure levels, and each component of metabolic syndrome had a distinct effect on the intraocular pressure, with blood pressure being the strongest predictor. CONCLUSION: Elevated intraocular pressure is associated with a number of metabolic variables, and each component of metabolic syndrome has a distinct impact on the intraocular pressure in individual age- and gender-specific groups. The present results may allow internal medicine specialists to manage metabolic risk factors while considering possible ocular involvement and potential treatment interactions.

Peripheral vascular endothelial dysfunction in glaucomatocyclitic crisis: a preliminary study.

PURPOSE: Glaucomatocyclitic crisis (GCC) is a syndrome of recurrent unilateral increased intraocular pressure associated with mild cyclitis and few clinical symptoms. This study was undertaken to assess brachial artery endothelium-dependent flow-mediated vasodilation (FMD) as an indicator of vascular endothelial function, to describe the association between GCC and endothelial dysfunction excluding age effects. METHODS: This prospective study was conducted from January 2007 to April 2009 and included 12 patients with GCC and 15 age-matched normal control subjects. Detailed clinical parameters were reviewed, including highly sensitive C-reactive protein (hs-CRP), homocysteine, anti-SSA, anti-cardiolipin antibodies, and HLA type. Brachial artery FMD and endothelium-independent, nitroglycerin-mediated vasodilation (NMD) were studied by using high-resolution, two-dimensional (2-D) ultrasonic imaging. RESULTS: Twelve patients with GCC were evaluated. The mean age of the patients was 36.3 years including 5 (41.6%) women and 7 (58.4%) men. There were no significant differences between patients with GCC and control subjects with regard to basal data, including body mass index, smoking, blood pressure, complete blood count, and routine blood biochemistries. Homocysteine and hs-CRP were within normal limits. Two (16.7%) patients were positive for HLA-B27, anti-SSA, and anti-cardiolipin antibodies. The nitroglycerin-mediated vasodilation in the patients with GCC was not significantly different from that of the control group. The FMD was much lower in the GCC group than in the control groups (mean 4.81% vs. 7.89%, P < 0.01). CONCLUSIONS: The significantly lower FMD in patients with GCC implies peripheral vascular endothelial dysfunction. However, in the 16.7% positive for the HLA-B27, anti-SSA, and anti-cardiolipin antibodies, these parameters are associated with GCC and abnormal FMD.

Glaucoma is associated with peripheral vascular endothelial dysfunction.

PURPOSE: To evaluate peripheral vascular endothelial function in patients with normal-tension glaucoma (NTG) and primary open-angle glaucoma (POAG) using noninvasive endothelium-dependent flow-mediated vasodilation (FMD). DESIGN: Case-control study. PARTICIPANTS: Thirty patients with NTG, 30 with POAG, and 30 healthy age- and gender-matched controls. METHODS: Participants underwent measurement of FMD and endothelium-independent nitroglycerin-mediated vasodilation (NMD) via high-resolution 2-dimensional ultrasonographic imaging of the brachial artery. All patients also underwent blood sampling for biochemistry, lipid profile, and high sensitivity C-reactive protein analysis. MAIN OUTCOME MEASURES: The association of FMD with NTG and POAG. RESULTS: The FMD values differed significantly between the patients with NTG, those with POAG, and controls: NTG, 2.70+/-2.25%; POAG, 5.33+/-2.81%; controls, 7.21+/-2.36%; P<0.001. In comparison with the POAG group and normal controls, the NTG group demonstrated markedly impaired FMD. The POAG group exhibited higher intermediate FMD than the NTG group (P<0.001) but significantly lower FMD than normal controls (P = 0.012). Multivariate analysis indicated that independent predictors for impaired FMD were presence of NTG, presence of POAG, and advanced age. Additionally, FMD values were significantly lower in glaucoma patients than in controls (4.02+/-2.85% vs. 7.21+/-2.36%; P<0.001). CONCLUSIONS: Patients with glaucoma have impaired FMD. Additionally, patients with NTG have lower FMD than those with POAG.

Systemic high-sensitivity C-reactive protein levels in normal-tension glaucoma and primary open-angle glaucoma.

PURPOSE: To determine the systemic high-sensitivity C-reactive protein (hsCRP) level in patients with normal tension glaucoma (NTG) and primary open-angle glaucoma (POAG). MATERIALS AND METHODS: With the exclusion of patients with cardiovascular and other systemic diseases, 40 patients with NTG, 40 with POAG, and 40 normal controls were enrolled in this study. Each patient underwent blood sampling for hsCRP, biochemistry, and lipid profile analysis. RESULTS: Each group had similar demographic parameters including the age, sex, body mass index, heart rate, and blood pressure. There was no statistically significant difference in the hsCRP and biochemistry results between the 3 groups. The lipid profile exhibited a mild elevation in the patients with POAG. CONCLUSIONS: Our data revealed no difference in the hsCRP level between NTG, POAG, and normal controls after exclusion of patients with cardiovascular and other systemic diseases. Systemic vascular inflammation may not be a major cause in the pathogenesis of glaucoma in those without histories of cardiovascular diseases.

Ahmed glaucoma valve implant for childhood glaucoma in Sturge-Weber syndrome with choroidal hemangioma.

We present our experience with implantation of an Ahmed glaucoma valve in a 9-year-old girl with Sturge-Weber syndrome with choroidal hemangioma. In this case of childhood glaucoma, the choice of surgical procedure should be based on the efficacy and elimination of intra-and post-operative complications. An Ahmed glaucoma valve offered safety and efficacy in controlling glaucoma. This technique avoided sudden drops in intraocular pressure and decreases the risk of intraoperative and postoperative choroidal effusion and hemorrhage. The surgical procedure was not complicated: a one-staged implant was satisfactory and a prophylactic sclerostomy was not required.

Refractive error with optimum intraocular lens power calculation after glaucoma filtering surgery.

PURPOSE: To assess the possibility of deriving an optimum intraocular lens (IOL) power after previous successful trabeculectomy. SETTING: Chang Gung Memorial Hospital, Linko, Taiwan. METHODS: The retrospective study included 1 eye of 22 patients who had cataract surgery after successful trabeculectomy performed by 1 surgeon. Twenty-two eyes that had cataract surgery only performed by the same surgeon were paired as a control group. The IOL power was calculated by the Sanders-Retzlaff-Kraff regression analysis formula based on the data derived after trabeculectomy. The postoperative refractive error at least 1 month after cataract surgery was recorded, and the difference was analyzed by a paired t test and 2-sample t test. RESULTS: Cataract surgery combined with trabeculectomy resulted in a mean spherical equivalent of -0.33 diopter +/- 1.58 (SD). This was not significantly different from the predicted refractive error or the result in the control group (P>.05). CONCLUSION: Although the fluctuation in pseudophakic axial length measurement after glaucoma filtering surgery was logical, a predictable pseudophakic refractive outcome was derived clinically once the intraocular pressure stabilized after trabeculectomy.

Contact diode laser transscleral cyclophotocoagulation for refractory glaucoma: comparison of two treatment protocols.

BACKGROUND: Diode laser transscleral cyclophotocoagulation has shown promising results in the treatment of refractory glaucoma. Treatment with a lower energy level per pulse and lower total energy is safer but may be less effective. We performed a study to evaluate the clinical effectiveness and safety of contact transscleral cyclophotocoagulation using two different protocols in the treatment of Chinese patients with refractory glaucoma. METHODS: Review of the records of 129 patients with refractory glaucoma who underwent contact transscleral cyclophotocoagulation for the first time performed by two different surgeons. In group 1 (73 eyes) the output was 2.5 W and the exposure time 2 seconds; in group 2 (56 eyes) the corresponding values were 2.0 W and 1.5 seconds. We recorded the number of antiglaucoma medications used, Snellen visual acuity, slit-lamp biomicroscopic findings, intraocular pressure (IOP) and findings on ophthalmoscopy with pupil dilation before and 1 day, 1 week, 1 month, 3 months and 6 months after treatment. RESULTS: The mean age of the patients was 56.4 years (standard deviation [SD] 18.3 years) in group 1 and 53.5 (SD 18.0) years in group 2. The most frequent diagnoses were neovascular glaucoma secondary to proliferative diabetic retinopathy or central retinal vein occlusion, and glaucoma associated with penetrating keratoplasty. The mean number of laser pulse applications per patient was 27 (SD 5.1) (range 10-36) in group 1 and 55 (SD 6.1) (range 40-60) in group 2. One month after treatment, the mean reduction in IOP was 20.2 mm Hg (SD 14.2 mm Hg) in group 1 and 13.7 mm Hg (SD 15.8 mm Hg) in group 2, a significant difference (p = 0.035). There was no difference between the two groups in the mean reduction in IOP at 6 months (19.1 mm Hg [SD 15.1 mm Hg] vs. 14.2 mm Hg [SD 16.3 mm Hg]). The mean reduction in the number of antiglaucoma medications was 1.2 (SD 1.1) in group 1 and 0.6 (SD 1.0) in group 2 (p = 0.003). The incidence rates of transient hyphema in the anterior chamber (23.3% vs. 7.1%) and of transient exudate in the anterior chamber (8.2% vs. 0.0%) were significantly higher in group 1 than in group 2 (p < 0.005). INTERPRETATION: To achieve greater IOP reduction with diode laser transscleral cyclophotocoagulation, an increase in energy per pulse may be more effective than an increase in total applications.

Comparison of standard white-on-white automated perimetry and short-wavelength automated perimetry in early glaucoma patients.

BACKGROUND: To evaluate the relationship between short-wavelength automated perimetry (SWAP) and the standard white-on-white automated perimetry (W-W) in detection of early glaucomatous visual field deficits. METHODS: Twenty-four patients suspected of having glaucoma and who had experience with automated visual field tests were evaluated by SWAP and standard W-W perimetry. Results of the mean deviation (MD), pattern standard deviation (PSD), pattern deviation probability plot, test reliability, and test time were compared. RESULTS: The average MD in the SWAP group was significantly higher than that in the W-W group (SWAP: -6.55 db, W-W: -2.69 db, p<0.001). A significant difference also existed in PSD between the 2 groups (SWAP: 3.49 db, W-W: 2.40 db, p<0.001). The test time was longer in the SWAP group than in the W-W group (SWAP: 15 min, 6 s; W-W: 13 min, 8 s, p<0.001). There was no significant difference between the 2 groups in test reliability or in the number of points that were depressed below the 1% and 5% sensitivity levels on the pattern deviation probability plot. CONCLUSIONS: This study showed that greater MD and PSD were demonstrated with SWAP. The test time was longer for SWAP. However, in order to conclude that SWAP is an early indicator of glaucomatous damage, longer follow-up and further analyses are required.

Central corneal thickness of normal-tension glaucoma and non-glaucoma populations in ethnic Chinese.

BACKGROUND: The variations in central corneal thickness can influence intraocular pressure measurement. The aim of our study was to determine whether there is a difference in the central corneal thickness between normal-tension glaucoma (NTG) and non-glaucoma populations. METHODS: This prospective study included 33 consecutive patients with NTG and 33 age- and gender-matched healthy subjects as control subjects. The NTG patients were grouped according to the refractive error into group 1 (spherical equivalent +2.5 D approximately -6.0 D) and group 2 (spherical equivalent more than -6.0 D). Central corneal thickness was measured using a ultrasonic pachymeter. The mean central corneal thickness of the NTG and healthy subjects were compared using the student t-test and Nilcoxon Rank Sum test. RESULTS: The mean (+/- SD) central corneal thickness in the healthy subjects and NTG patients was 554.1 (+/- 36.3) and 547.2 (+/- 31.4) microns, respectively. There were no statistical significant differences between these two groups (p=0.411). The median central corneal thickness in the NTG group 1 and group 2 eyes was 545, and 547.5 microns, respectively. The difference was not statistically significant, either (p=0.799). Ten patients (30%) of NTG had high myopia (group 2), and their median age was 38.5 years old, which was significantly younger than that of the group 1 patients (50 years old, p = 0.0003). CONCLUSION: This study indicated that there were no significant differences of central corneal thickness between NTG patients and healthy subjects in our clinic.

Ultrasound biomicroscopy in the diagnosis of a primary peripheral iris cyst.

A primary peripheral cyst behind the iris is difficult to detect during a routine slit lamp examination. It is usually asymptomatic unless the cyst is sufficiently large. We report on a 73-year-old woman who underwent phacoemulsification of a cataract and incidentally presented a small dark mass behind the peripheral iris. The lesion was initially suspected of being a melanoma, but it could not be localized by conventional techniques postoperatively. A diagnosis of primary iris cyst was not made until 1 year later when high-frequency ultrasound biomicroscopy (UBM) was employed. UBM displayed a distinct thin-wall cystic lesion (0.5 x 0.8 x 0.6 mm) with low internal reflectivity at the iridociliary sulcus of the inferotemporal quadrant. UBM allows good imaging access to a lesion behind the iris that is otherwise difficult to detect with traditional techniques.

Clinical experience with the Ahmed glaucoma valve implant in complicated glaucoma.

BACKGROUND: To assess clinical outcomes of the Ahmed glaucoma valve implant, an aqueous shunting device with a unidirectional valve mechanism, in eyes with refractory glaucoma. METHODS: Consecutive patients with intractable glaucoma who underwent Ahmed glaucoma valve insertion were retrospectively reviewed. Only patients with a minimum of 6 months of follow-up were included. The presence of intraocular pressure (IOP) > or = 22 mmHg in the first 6 postoperative months was defined as a hypertensive phase (HP). This study included 19 eyes in 19 patients. RESULTS: The mean preoperative IOP was 32.1 +/- 6.9 mmHg, with medication (mean times medication administered, 3.8 +/- 1.0; range, 0-3). The mean postoperative IOP was 7.8 +/- 2.2 mmHg on day 1, 11.3 +/- 4.4 mmHg at 1 week, 19.1 +/- 7.7 mm Hg at 1 month, 16.5 +/- 6.4 mmHg at 3 months, and 17.5 +/- 0.7 mmHg at 6 months, respectively. Twelve patients (63.2%) exhibited the HP. Nine patients (49.3%) experienced the HP at 1 month and 3 patients at 2 months after the operation. At the end of 6 months of follow-up, 11 patients (57.9%) who had exhibited the HP required additional anti-glaucoma medication to control the IOP (mean times medication was administered, 1.0 +/- 1.1; range, 0-2). Complications associated with the valve included hyphema in 1 case, choroidal effusion in 2 cases, iris plugging of the tube in 1 case, bleb encapsulation in 3 cases, and PK graft failure in 1 case. Postoperative hypotony resolved within 1 week. CONCLUSION: The Ahmed glaucoma valve implant was safe and effective in this series. The hypertensive phase peaked in the first to second months after surgery.

Reversal of optic disc cupping after trabeculotomy in primary congenital glaucoma.

BACKGROUND: The phenomenon of reversal of glaucomatous cupping of the optic disc following lowering of the intraocular pressure (IOP) was originally recognized in infants. We evaluated the change in optic disc cupping with normalization of the IOP after trabeculotomy in primary congenital glaucoma and assessed the factors associated with reversal of cupping. METHODS: We reviewed the records of 17 patients (24 eyes) who underwent trabeculotomy between July 1993 and June 1999 and who had been followed for at least 1 year. Surgical success was defined as IOP less than 22 mm Hg without anti-glaucoma medication, stable or reduced optic disc cupping, and lack of further corneal enlargement disproportionate to normal growth. Patients who required more than one surgical procedure to control the IOP and those with cloudy media that precluded documentation of cupping were excluded from analysis. Optic disc cupping was assessed independently before and after surgery by two clinicians. The cup:disc ratio was estimated as the percentage of surface area of the optic disc occupied by cupping in the vertical axis. We accepted a difference of 0.1 or 0.2 in the cup:disc ratio between the two observers in each subjective assessment and used the mean value of the two results for data analysis. If the difference was more than 0.2, the eye was excluded from further study. RESULTS: Of the 17 patients 4 were excluded: 2 because they received antiglaucoma medication to control the IOP postoperatively, 1 because he underwent more than one surgical procedure to control the IOP during follow-up, and 1 owing to disagreement in the assessment of the cup:disc ratio between the two observers. Eighteen eyes of 13 patients were thus included in the analysis. Twelve eyes were from boys and six, from girls. The patients were followed for a mean of 43.2 (standard deviation [SD] 30.4) months (range 12 to 90 months). The mean cup:disc ratios pre- and postoperatively were 0.74 (SD 0.20) and 0.60 (SD 0.21) respectively (p = 0.003). Of the 18 eyes 11 (61.1%) had documented reduction in optic disc cupping. The mean time to stabilization of cupping reversal was 4.8 (SD 2.8) months (range 2 to 12 months). In multivariable analysis the age of the patient at surgery was the only variable significantly associated with reversal of cupping (p = 0.027). The mean age at surgery for the 11 eyes with reduction in cupping was 6.9 (range 3 to 15) months, compared with 23.4 (range 12 to 42) months for the 7 eyes with unchanged cupping. The mean preoperative cup:disc ratio was 0.67 (SD 0.17) in the former group and 0.83 (SD 0.17) in the latter group. Six of the seven eyes with unchanged cupping had advanced cupping. INTERPRETATION: Optic disc cupping can be reversed at an early stage of primary congenital glaucoma following successful reduction of IOP. Younger age at surgery was associated with reversal of cupping.