Optic disc parameters and onset of glaucomatous field loss. I. Methods and progressive changes in disc morphology.

Serial stereoscopic fundus photographs taken in known relationship to the onset of glaucomatous visual field loss on 12 eyes were intermixed with those from 206 age- and race-matched controls and analyzed in randomized masked fashion. Progressive changes in the size, shape, or contour of the disc, and a newly described parameter, thickness of the nerve fiber layer as it crosses the disc rim, were readily apparent by the time of onset of glaucomatous field loss in all but two abnormal eyes (one case). In the latter instance, direct comparison of stereophotos indicated progressive pallor of the remaining disc tissue. Serial stereophotographs appear superior to fundus drawings for anticipating glaucomatous field loss.

Optic disc parameters and onset of glaucomatous field loss. II. Static screening criteria.

Stereoscopic fundus photographs of 17 abnormal eyes, taken in known temporal relationship to the onset of glaucomatous visual field loss, and 206 eyes of age- and race-matched controls were examined in randomized masked fashion. Width of the narrowest remaining disc rim, size of the vertical and horizontal physical cups, contour of the temporal and nasal slopes (vertical ovalness), and a newly described parameter, thickness of the nerve fiber layer as it crosses the disc rim, were all useful for distinguishing patients with impending or established visual field loss. None, however, was as effective as defects in the nerve fiber layer, the only parameter displaying sufficient promise as a clinical screening tool to warrant initiation of large-scale prospective evaluation.

Small choroidal melanomas. A long-term follow-up study.

Complete follow-up information was obtained on 65 patients whose eyes had been enucleated for small choroidal melanomas three months to 34 years previously. All tumors were 300 cu mm (10 x 10 x 3 mm) or less in volume. The average and median lengths of follow-up were nine years and 7.2 years, respectively. The 5-, 10-, and 15-year tumor-related death rates were found to be lower than those previously reported for small melanomas after enucleation, and the same as the estimated tumor-related mortality in patients who had not undergone enucleation. The average volume of tumors that caused metastatic death was more than twice that of tumors that did not. There were no metastatic deaths in 42 patients with tumors less than 98 cu mm (7 x 7 x 2 mm) in volume. Waiting to observe growth in tumors less than 98 cu mm in size did not appear to increase the risk of death from metastatic melanoma.

Bilateral, congenital, dermis-like choristomas overlying corneal staphylomas.

Two unrelated patients with diffuse, bilateral, congenital tumefactions overlying the corneas were seen. The tumors were protuberant, fleshy masses that partially concealed underlying corneal staphylomas. Spontaneous rupture was suspected in one eye. Histopathologic study of three specimens disclosed dermis-like tumors. In one specimen, an apocrine gland was identified, thus supporting the diagnosis of choristoma. An evisceration specimen from a ruptured globe confirmed that the ectatic cornea was an anterior staphyloma. The posterior pole seemed grossly normal. This disorder may have a genetic basis or it may result from a developmental or inflammatory insult in utero. Preoperative diagnosis is important because the associated anterior staphylomas complicate management.

Optic nerve damage in human glaucoma. II. The site of injury and susceptibility to damage.

We examined the histologic structure of the optic nerve head in 15 eyes of nine persons with a known glaucoma history. All had been seeing eyes, varying from normal visual acuity and visual field to advanced glaucoma damage. The site of damage to nerve fibers is the scleral lamina cribrosa, where there is local blockage of axonal transport. Early cup size increase prior to definite field loss results from loss of nerve fibers, not from damage to astrocytic glial cells of the nerve head. No selective damage to nerve head capillaries is seen in mildly damaged specimens. Scanning electron microscopic analysis suggests that the structure of the lamina cribrosa is an important determinant of the degree of susceptibility to damage by elevated intraocular pressure.

Extended-wear soft contact lenses for aphakic correction.

Evaluation of an extended-wear perfilcon A soft contact lens (Permalens) in 299 eyes of 244 patients showed that 266 eyes (89%) were successfully fitted and wore the lenses without important complications (mean follow-up, 23 months; range, four to 48 months). Use of the lens in 33 eyes was discontinued because of transient lens-related problems. "Overcorrected" acuity of 6/12 (20/40) or better (with spectacles plus the contact lens) was achieved in all patients who were without vitreous, retinal, or optic nerve disease. Seventy-six percent of patients could wear the lens for longer than one-month intervals, and 30% removed the lens at four- to six-month intervals. There were no cases of infectious corneal ulcers or scarring or permanent visual loss. Our more limited experience with lidofilcon B lenses (Sauflon PW) (24 eyes) and the silicone lenses (Silsoft) (25 eyes) also showed beneficial results.

Extracapsular cataract extraction and posterior chamber lens implantation in eyes with preexisting glaucoma.

Fifty eyes of 40 patients with glaucoma underwent extracapsular cataract extraction with posterior chamber lens implantation. Their visual results and early postoperative complications were compared with those of eyes in an age-matched group of patients without glaucoma after the same procedure. Substantial increases in early postoperative intraocular pressure (IOP) occurred in 62% of the glaucomatous eyes and in only 10% of the normal eyes. The level of best visual acuity was slightly worse (20/40) on average in the glaucomatous eyes than in the nonglaucomatous eyes (20/25). At six months after surgery, 82.5% of the nonfiltered glaucomatous eyes needed the same number of or additional glaucoma medications to maintain an IOP of less than 20 mm Hg. Ten of the glaucomatous eyes underwent trabeculectomy along with cataract surgery due to inadequate IOP control while the patient was receiving maximum medical therapy. Control was substantially improved, with 100% of these patients receiving the same number of or fewer medications at six months. By one year, only 30% of these patients required the same number of medications postoperatively as preoperatively, but all had IOP control.

The Honan intraocular pressure reducer. An experimental study.

Although use of the Honan intraocular pressure reducer is believed to be clinically safe and effective in reducing IOP and the risk of vitreous loss, the IOPs achieved during application of the device have not been directly measured. Intraocular pressure dynamics in ten eyes of five patients were measured shortly after death, using a pressure transducer within the anterior chamber as the Honan device was applied. Pressures were measured again after enucleation. The peak IOPs produced in eyes in situ were much lower than in the same eyes after enucleation. The peak IOP increased as the initial IOP was raised. The Honan device would appear to be safe for eyes undergoing routine anterior segment surgery, but the pressures that may be generated in hypertensive eyes (IOP greater than or equal to 35 mm Hg) might put these eyes at risk for vascular occlusion.

The nerve fiber layer in the diagnosis of glaucoma.

Serial fundus photographs of 14 eyes that eventually developed glaucomatous visual field defects and 110 slides from 76 eyes of race- and age-matched controls were reviewed in randomized masked fashion. Each eye that lost visual field demonstrated consistent abnormalities of the nerve fiber layer, beginning as early as 5 years (mean, 1 1/2 years) before it developed glaucomatous visual field defects on routine Goldmann perimetry. Preliminary estimates, based on regression analysis of this small series, suggest that half of these eyes (median) might demonstrate such reproducible abnormalities between four and six years before onset of their visual field defects. Only 9% of the matched controls showed similar nerve fiber layer changes, and in the one instance where analysis was possible, these were inconsistent and nonreproducible. Nerve fiber layer assessment by means of fundus photographs may be the earliest, surest means of distinguishing ocular hypertension from true glaucoma.

Biostatistical analysis of the collaborative glaucoma study. I. Summary report of the risk factors for glaucomatous visual-field defects.

A prospective collaborative study was conducted in five centers during a 13-year period to identify factors that influence the development of visual-field defects (GVFDs) of open angle glaucoma. In 5,000 subjects, GVFDs developed in only 1.7% of eyes. Statistical analysis of 26 factors at first examination identified five that were significantly related to the development of GVFDs--outflow facility, age, applanation pressure, cup-disc ratio, and pressure change after water drinking. Their absolute initial value, and not its change with time, was the important predictor. Multivariate analysis showed their collective predictive power to be undesirably poor, indicating that other factors must play an important role in the development of GVFDs. Mortality-table analysis indicated that during a period of five years, 98.54% of eyes with initial pressure less than 20 mm Hg continued to be free from GVFDs as compared with 93.34% of those with pressure of 20 mm Hg or greater.

Studies on the adrenergic systems of the eye at the Wilmer Institute.

The study of the ocular adrenergic systems at the Wilmer Institute over the last 40 years began with the examination of the formation and outflow of aqueous humor by Jonas Friedenwald and his co-workers in the early 1940's. At that time, researchers were attempting to understand the mechanisms of fluid dynamics in the eye, with the idea of altering these mechanisms to alleviate glaucoma only a distant goal. In the late 1950's, Langham and others reported on the effect of superior cervical ganglionectomy on intraocular pressure, following this work with a succession of papers on the relationship between alpha and beta adrenergic substances and aqueous humor dynamics. Sears, in collaboration with Bárány, described the effects of alpha and beta adrenergic substances on outflow resistance. Eakins, in 1963, suggested a mechanism of action for isoproterenol in the lowering of intraocular pressure. Work on timolol at Wilmer began with a report from Radius, Diamond, Pollack and Langham covering experimental studies with rabbits and clinical studies of the drug's ocular hypotensive effects on glaucoma patients. Richter and others also studied a small number of patients on maximal therapy and found further intraocular pressure reduction with added timolol.

Ocular histoplasmosis: clinicopathologic correlation of 3 cases.

The eyes of three patients followed clinically for many years with a diagnosis of macular disciform scarring, secondary to ocular histoplasmosis, were studied histopathologically. A fibrovascular scar interposed between the choroid and retina was observed in all cases. Vessels passing from the choroid through defects in Bruch's membrane into the nodule were demonstrated. Theories of the pathogenesis of the lesion are discussed.

Cystoid macular edema in pseudophakia.

Cystoid macular edema after cataract surgery, with or without intraocular lens implantation, has been reported to develop in more than 50% of patients as detected by fluorescein angiography. It is associated with reduced visual acuity in up to 8% of cases. Analysis of ongoing clinical trials at the Wilmer Institute indicates that clinically significant cystoid macular edema develops in a lower percentage of cases (2% total incidence and 0.3% persistent cystoid macular edema) if the intraocular lens implantation was uncomplicated. The factors associated with cystoid macular edema and the importance of considering clinically significant rather than just fluorescein-proven cystoid macular edema are discussed. Results of intraocular lens studies reported to the Federal Drug Administration are updated, and results of an ongoing study of prostaglandin inhibitors at the Wilmer Institute are reported.

Birdshot retinochoroidopathy.

Thirteen patients had a new syndrome and entity in intraocular inflammation called birdshot retinochoroidopathy, which was characterized by a white, painless eye with minimal anterior segment inflammation but particulate debris in the anterior and posterior vitreous. There was profuse retinal vascular leakage with resultant retinal, macular, and disk edema, which are the primary causes of the decreased vision in this syndrome. Long-term follow-up (mean of ten years) revealed that only two patients seemed to respond to anti-inflammatory therapy (systemic corticosteroids) and five patients progressed to 6/60 (20/200) or less visual acuity in at least one eye.

Long-term follow-up of treated open-angle glaucoma.

We observed 16 eyes of ten glaucoma patients for a mean of 17 years (range, eight to 42 years). Each patient had typical glaucomatous damage to the optic disk and visual field. In most cases, decrease in intraocular pressure prevented further damage over extended periods. Our data reinforces the importance of intraocular pressure reduction in preventing visual loss in glaucoma.

Optic atrophy and glaucomatous cupping.

We reviewed 170 eyes of 112 patients with optic atrophy from various causes. Special attention was directed towards measured cup:disk ratios as well as presence of glaucomatous-like cupping of the optic nerve head. We observed a small but significant increase in nerve head cupping in eyes with optic atrophy when compared to contralateral eyes, as well as to eyes of 50 diabetic patients. No characteristic glaucomatous disk changes were documented. We evaluated these findings with respect to possible causes of glaucomatous disk and field changes.

Dilated episcleral vessels and open-angle glaucoma.

We studied four patients with idiopathic dilated episcleral vessels. Three of these patients had asymmetric or unilateral open-angle glaucoma in the eye with the greater degree of episcleral vascular anomaly. The fourth patient showed dilated episcleral vessels, but the intraocular pressure (IOP) was not increased. In the three patients with increased IOP, the facility of outflow was decreased. The episcleral venous pressure was not measured, but in one eye Schlemm's canal was engorged with blood despite an IOP of 35 mm Hg. We explored the possibility of a congenital vascular anomaly in the four cases.

Clear-cornea cataract extraction in eyes with functioning filtering blebs.

In 22 glaucomatous eyes with functioning filtering blebs and adequately controlled intraocular pressures (less than or equal to 22 mm Hg) that underwent clear-cornea cataract extraction, the intraocular pressure remained controlled in 20 (91%). Seven of the 21 eyes, however, required an increased dosage of antiglaucoma drugs. Sixteen eyes had final visual acuities between 6/6 and 6/9 (20/20 and 20/30) and only four eyes had final visual acuities worse than 6/60 (20/200). The only intraoperative complication was a ruptured lens capsule. Postoperative bullous keratopathy developed in two eyes, both of which had had corneal edema postoperatively. A third eye, which had undergone filtering surgery 17 years earlier, had vitreous incarceration after the sutures were removed.

Acute intraoperative choroidal effusion.

We studied five cases of acute choroidal effusion that occurred during intraocular surgery and one case of a localized choroidal hemorrhage. Acute intraoperative choroidal effusion is a poorly recognized surgical complication and may precede expulsive hemorrhage in many cases. The treatment is immediate closure of the wound, after which the intraocular pressure may rise to 80 mm Hg or more. However, the pressure will return to normal after 15 to 30 minutes and the area of effusion will remain localized. Scleral puncture to drain fluid is not indicated if the wound can be closed before there is a prolapse of the iris or other intraocular tissues.

Cystoid macular edema associated with topically applied epinephrine in aphakic eyes.

A 69-year-old man with bilateral open-angle glaucoma and nonfiltering iridencleisis scars underwent combined cataract extraction and glaucoma filtering operations in each eye. Later, he again required intensive medical therapy including topically applied echothiophate iodide, epinephrine, and acetazolamide to control his glaucoma. Topical instillation of epinephrine repeatedly resulted in reversible cystoid macular edema in each eye. The macular changes were documented by fluorescein angiography. The clinical and angiographic features of the macular edema in this patient did not differ from cystoid macular edema seen in other ocular conditions.