Ocular injuries among patients with major trauma in England and Wales from 2004 to 2021.

BACKGROUND: Ocular trauma is a significant cause of blindness and is often missed in polytrauma. No contemporary studies report eye injuries in the setting of severe trauma in the UK. We investigated ocular injury epidemiology and trends among patients suffering major trauma in England and Wales from 2004 to 2021. METHODS: We conducted a retrospective study utilising the Trauma Audit and Research Network (TARN) registry. Major trauma cases with concomitant eye injuries were included. Major trauma was defined as Injury Severity Score >15. Ocular injuries included globe, cranial nerve II, III, IV, and VI, and tear duct injuries. Orbital fractures and adnexal and lid injuries were not included. Demographics, injury profiles, and outcomes were extracted. We report descriptive statistics and 3-yearly trends. RESULTS: Of 287 267 major trauma cases, 2368 (0.82%) had ocular injuries: prevalence decreased from 1.87% to 0.66% over the 2004-2021 period (P < 0.0001). Males comprised 72.2% of ocular injury cases, median age was 34.5 years. The proportion of ocular injuries from road traffic collisions fell from 43.1% to 25.3% while fall-related injuries increased and predominated (37.6% in 2019/21). Concomitant head injury occurred in 86.6%. The most common site of ocular injury was the conjunctiva (29.3%). Compared to previous TARN data (1989-2004), retinal injuries were threefold more prevalent (5.9% vs 18.5%), while corneal injuries were less (31.0% vs 6.6%). CONCLUSIONS: Whilst identifying eye injuries in major trauma is challenging, it appears ocular injury epidemiology in this setting has shifted, though overall prevalence is low. These findings may inform prevention strategies, guideline development and resource allocation.

Effects of socioeconomic status on baseline values and outcomes at 24 months in the Treatment of Advanced Glaucoma Study randomised controlled Trial.

BACKGROUND/AIMS: Socioeconomic status (SES) is associated with late disease presentation and poorer outcomes. We evaluate the effect of SES on treatment outcomes and report the correlation between SES and baseline characteristics of participants in the Treatment of Advanced Glaucoma Study. METHODS: Pragmatic multicentre randomised controlled trial. Four hundred and fifty-three patients presenting with advanced open-angle glaucoma in at least one eye (Hodapp-Parrish-Anderson classification). Participants were randomised to either glaucoma drops (medical arm) or trabeculectomy (surgery arm). Clinical characteristics, Quality of life measurement (QoL) and SES defined by the Index of Multiple Deprivation are reported. Subgroup analysis explored treatment effect modifications of SES at 24 months. Correlation between SES and baseline characteristics was tested with the χ2 test of association for dichotomous variables and pairwise Pearson's correlation for continuous variables. RESULTS: The mean visual field mean deviation was -17.2 (6.7)dB for the most deprived quintile of participants and -13.0 (5.5) for the least deprived quintile in the index eye. At diagnosis, there was a strong correlation between SES and ethnicity, age, extent of visual field loss and number of visits to opticians prior to diagnosis. At 24 months, there was no evidence that the treatment effect was moderated by SES. CONCLUSIONS: In patients presenting with advanced glaucoma. SES at baseline is correlated with poorer visual function, poorer Visual Function Questionnaire-25 QoL, ethnicity, age and number visits to an optician in the years preceding diagnosis. SES at baseline does not have an effect of the success of treatment at 24 months. TRIAL REGISTRATION NUMBER: ISRCTN56878850.

Effect of COVID-19 pandemic on glaucoma surgical practices in the UK.

BACKGROUND/AIM: The aim of the study was to examine the effect of the COVID-19 pandemic on glaucoma surgical practices within the UK. METHODS: A cross-sectional online survey was distributed to all consultant glaucoma specialists who are on the UK and Eire Glaucoma Society contact list. Participants were asked specific questions regarding preferences in glaucoma surgical practices and whether these had changed subsequent to the onset of the COVID-19 pandemic. RESULTS: Trabeculectomy was the procedure of choice for 61 (87%) glaucoma specialists. A total of 51 (73%) respondents reported performing minimally invasive glaucoma surgery (MIGS) procedures before the COVID-19 pandemic. The most commonly performed MIGS procedure was the iStent inject (51%), followed by XEN 45 (36%) and Preserflo (17%). Forty-three (61%) respondents reported modifying their glaucoma surgery practice subsequent to the onset of the COVID-19 pandemic. Of the glaucoma specialists who modified their surgical practices, 21 (43%) specifically reduced the number of trabeculectomies performed. In combination, diode laser (both micropulse and conventional trans-scleral cyclodiode) was the most common alternative procedure. Glaucoma drainage devices, deep sclerectomy and Preserflo were also commonly chosen alternatives. CONCLUSION: Although trabeculectomy remains the most commonly performed established glaucoma surgery, it is being performed with reduced frequency during the COVID-19 pandemic due to the number of postoperative visits and procedures required. Alternatives such as conventional and micropulse diode laser, glaucoma drainage devices, deep sclerectomy and Preserflo appear to be the favoured alternative procedures.

Binocular Visual Function in a Pre-Presbyopic Patient with Uniocular Cataract Undergoing Cataract Surgery with a Multifocal Intraocular Lens.

BACKGROUND/AIM: An increasing number of pre-presbyopic patients are undergoing uniocular cataract extraction. We aim to compare the binocular status of subjects with uniocular cataracts, implanted either with a multifocal or a monofocal intraocular lens (IOL). MATERIALS AND METHODS: Subjects were recruited from outpatient ophthalmology clinics and randomized to an IOL type. Corrected and uncorrected LogMAR distance visual acuity (VA) and near and intermediate VA using the Radner reading test were completed. The binocular tests included the Worth Four Dot Test, fixation disparity, TNO stereoacuity and foveal suppression assessment. In addition to the near activity vision questionnaire. The trial was closed early because the chosen multifocal lens had been superseded by newer models. We report two subjects, one receiving the multifocal IOL and a monofocal IOL control with the most comparable baseline characteristics. RESULTS: Both subjects experienced uncomplicated cataract surgery, showing clinically significant improved corrected distance VA, 0.06 LogMAR and -0.16 LogMAR in the monofocal and multifocal IOL, respectively. The multifocal subject had 30 seconds of arc stereoacuity indicating normal binocular vision. Only gross binocular single vision with no stereopsis was found in the monofocal IOL subject. The latter subject also had reduced near vision quality-of-life questionnaire results. CONCLUSION: This two-patient case series demonstrates greater binocular near ability, with the multifocal IOL, in the pre-presbyopic patient undergoing uniocular cataract surgery. The case series highlights the need, and methodology for investigating further the functional and quality-of-life benefits of implanting multifocal IOLs in pre-presbyopic patients, those in their twenties and thirties, undergoing uniocular cataract surgery.

An Intraocular Pressure Polygenic Risk Score Stratifies Multiple Primary Open-Angle Glaucoma Parameters Including Treatment Intensity.

PURPOSE: To examine the combined effects of common genetic variants associated with intraocular pressure (IOP) on primary open-angle glaucoma (POAG) phenotype using a polygenic risk score (PRS) stratification. DESIGN: Cross-sectional study. PARTICIPANTS: For the primary analysis, we examined the glaucoma phenotype of 2154 POAG patients enrolled in the Australian and New Zealand Registry of Advanced Glaucoma, including patients recruited from the United Kingdom. For replication, we examined an independent cohort of 624 early POAG patients. METHODS: Using IOP genome-wide association study summary statistics, we developed a PRS derived solely from IOP-associated variants and stratified POAG patients into 3 risk tiers. The lowest and highest quintiles of the score were set as the low- and high-risk groups, respectively, and the other quintiles were set as the intermediate risk group. MAIN OUTCOME MEASURES: Clinical glaucoma phenotype including maximum recorded IOP, age at diagnosis, number of family members affected by glaucoma, cup-to-disc ratio, visual field mean deviation, and treatment intensity. RESULTS: A dose-response relationship was found between the IOP PRS and the maximum recorded IOP, with the high genetic risk group having a higher maximum IOP by 1.7 mmHg (standard deviation [SD], 0.62 mmHg) than the low genetic risk group (P = 0.006). Compared with the low genetic risk group, the high genetic risk group had a younger age of diagnosis by 3.7 years (SD, 1.0 years; P < 0.001), more family members affected by 0.46 members (SD, 0.11 members; P < 0.001), and higher rates of incisional surgery (odds ratio, 1.5; 95% confidence interval, 1.1-2.0; P = 0.007). No statistically significant difference was found in mean deviation. We further replicated the maximum IOP, number of family members affected by glaucoma, and treatment intensity (number of medications) results in the early POAG cohort (P ≤ 0.01). CONCLUSIONS: The IOP PRS was correlated positively with maximum IOP, disease severity, need for surgery, and number of affected family members. Genes acting via IOP-mediated pathways, when considered in aggregate, have clinically important and reproducible implications for glaucoma patients and their close family members.

How do different lighting conditions affect the vision and quality of life of people with glaucoma? A systematic review.

This article is a systematic review of evidence regarding the impact of different lighting conditions on the vision and quality of life (QoL) of people with primary open-angle glaucoma (POAG). A systematic literature search was carried out using CINAHL, MEDLINE, PsycARTICLES, PsycINFO, Embase, and Ovid Nursing Database for studies: published up to April 2019; including people diagnosed with POAG; and assessing visual function or QoL in response to changing lighting/luminance levels or glare. Two researchers independently screened studies for eligibility. Data were extracted from eligible studies regarding study design, participant characteristics, outcomes, and results. Quality of included studies was critically appraised. Of 8437 studies, 56 eligible studies were included. Studies investigated the effects of lighting on the following domains among people with POAG: QoL (18/56), psychophysical measures (16/56), functional vision (10/56), activities of daily living (10/56), and qualitative findings (2/56). POAG negatively affects low-luminance contrast sensitivity, glare symptoms, and dark adaptation time and extent. In vision-related QoL questionnaires, people with POAG report problems with lighting, glare, and dark adaptation more frequently than any other domain. These problems worsen with progressing visual field loss. Early-stage POAG patients experience significantly more difficulties in low-luminance or changing lighting conditions than age-matched controls (AMCs), challenging perceptions of early-stage POAG as asymptomatic. However, performance-based studies seldom show significant differences between POAG participants and AMCs on tasks simulating daily activities under non-optimal lighting conditions. Further research with larger samples is required to optimise ambient and task-oriented lighting that can support patients' adaptation to POAG.

Developing standards for the development of glaucoma virtual clinics using a modified Delphi approach.

PURPOSE: To obtain consensus opinion for the development of a standards framework for the development and implementation of virtual clinics for glaucoma monitoring in the UK using a modified Delphi methodology. METHODS: A modified Delphi technique was used that involved sampling members of the UK Glaucoma and Eire Society (UKEGS). The first round scored the strength of agreement to a series of standards statements using a 9-point Likert scale. The revised standards were subjected to a second round of scoring and free-text comment. The final standards were discussed and agreed by an expert panel consisting of seven glaucoma subspecialists from across the UK. A version of the standards was submitted to external stakeholders for a 3-month consultation. RESULTS: There was a 44% response rate of UKEGS members to rounds 1 and 2, consisting largely of consultant ophthalmologists with a specialist interest in glaucoma. The final version of the standards document was validated by stakeholder consultation and contains four sections pertaining to the patient groups, testing methods, staffing requirements and governance structure of NHS secondary care glaucoma virtual clinic models. CONCLUSIONS: Use of a modified Delphi approach has provided consensus agreement for the standards required for the development of virtual clinics to monitor glaucoma in the UK. It is anticipated that this document will be useful as a guide for those implementing this model of service delivery.

Examining visual field loss in patients in glaucoma clinics during their predicted remaining lifetime.

PURPOSE: To evaluate the proportion of patients in glaucoma clinics progressing at rates that would result in visual disability within their expected lifetime. METHODS: This retrospective study used visual field (VF) series of at least 3 years' duration from 3790 UK patients in glaucoma clinics calculating rates of loss for each eye using linear regression of mean deviation (MD) over time. Residual life expectancies derived from the UK Office of National Statistics actuarial tables for each patient were combined with these rates to estimate predicted MDs at end of expected lifetime. The proportion of patients projected to progress to visual impairment (MD: -14 dB or worse) or statutory blindness (MD: -22 dB or worse) in both eyes before end of expected lifetime was calculated. RESULTS: Only 3.0% (95% confidence interval [CI] 2.7%-3.4%) of patient eyes progressed at faster than -1.5 dB/year (n = 7149 eyes). Of those patients with both eyes followed, 5.2% (CI 4.5%-6.0%) were predicted to progress to statutory blindness, with a further 10.4% (CI 9.4%-11.4%) reaching visual impairment in their lifetime. More than 90% (CI 85.7%-94.3%) of patients predicted to progress to statutory blindness, had an MD worse than -6 dB in at least one eye at presentation. CONCLUSIONS: This modeling exercise indicates that most patients in glaucoma clinics are not at high risk of progressing to statutory blindness. The likelihood of patients suffering impairment in their lifetimes is linked to VF loss at presentation, which illuminates the importance of reliably detecting significant VF defects in primary care.

Trabeculectomy in the 21st century: a multicenter analysis.

OBJECTIVE: To evaluate the efficacy and safety of current trabeculectomy surgery in the United Kingdom. DESIGN: Cross-sectional, multicenter, retrospective follow-up. PARTICIPANTS: A total of 428 eyes of 395 patients. METHODS: Consecutive trabeculectomy cases with open-angle glaucoma and no previous incisional glaucoma surgery from 9 glaucoma units were evaluated retrospectively. Follow-up was a minimum of 2 years. MAIN OUTCOME MEASURES: Surgical success, intraocular pressure (IOP), visual acuity, complications, and interventions. Success was stratified according to IOP, use of hypotensive medications, bleb needling, and resuturing/revision for hypotony. Reoperation for glaucoma and loss of perception of light were classified as failures. RESULTS: Antifibrotics were used in 400 cases (93%): mitomycin C (MMC) in 271 (63%), 5-fluorouracil (5-FU) in 129 (30%), and no antifibrotic in 28 (7%). At 2 years, IOP (mean ± standard deviation) was 12.4 ± 4 mmHg, and 342 patients (80%) achieved an IOP ≤ 21 mmHg and 20% reduction of preoperative IOP without IOP-lowering medication, whereas 374 patients (87%) achieved an IOP ≤ 21 mmHg and 20% reduction of preoperative IOP overall. An IOP ≤18 mmHg and 20% reduction of preoperative IOP were achieved by 337 trabeculectomies (78%) without IOP-lowering treatment and by 367 trabeculectomies (86%) including hypotensive medication. Postoperative treatments included suture manipulation in 184 patients (43%), resuturing or revision for hypotony in 30 patients (7%), bleb needling in 71 patients (17%), and cataract extraction in 111 of 363 patients (31%). Subconjunctival 5-FU injection was performed postoperatively in 119 patients (28%). Visual loss of >2 Snellen lines occurred in 24 of 428 patients (5.6%). A total of 31 of the 428 patients (7.2%) had late-onset hypotony (IOP <6 mmHg after 6 months). In 3 of these, visual acuity decreased by >2 Snellen lines. Bleb leaks were observed in 59 cases (14%), 56 (95%) of which occurred within 3 months. Two patients developed blebitis. Bleb-related endophthalmitis developed in 1 patient within 1 month postoperatively and in 1 patient at 3 years. There was an endophthalmitis associated with subsequent cataract surgery. CONCLUSIONS: This survey shows that good trabeculectomy outcomes with low rates of surgical complications can be achieved, but intensive proactive postoperative care is required.

Beta radiation for glaucoma surgery.

BACKGROUND: The outcome of glaucoma surgery can be affected by the rate at which the surgical wound heals. Beta radiation has been proposed as a rapid and simple treatment to slow down the healing response. OBJECTIVES: To assess the effectiveness of beta radiation during glaucoma surgery (trabeculectomy). SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 3), MEDLINE (January 1950 to March 2012), EMBASE (January 1980 to March 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 26 March 2012. SELECTION CRITERIA: We included randomised controlled trials comparing trabeculectomy with beta radiation to trabeculectomy without beta radiation. DATA COLLECTION AND ANALYSIS: We collected data on surgical failure (intraocular pressure > 21 mmHg), intraocular pressure and adverse effects of glaucoma surgery. We pooled data using a fixed-effect model. MAIN RESULTS: We found four trials that randomised 551 people to trabeculectomy with beta irradiation versus trabeculectomy alone. Two trials were in Caucasian people (126 people), one trial in black African people (320 people) and one trial in Chinese people (105 people). People who had trabeculectomy with beta irradiation had a lower risk of surgical failure compared to people who had trabeculectomy alone (pooled risk ratio (RR) 0.23 (95% CI 0.14 to 0.40). Beta irradiation was associated with an increased risk of cataract (RR 2.89, 95% CI 1.39 to 6.0). AUTHORS' CONCLUSIONS: Trabeculectomy with beta irradiation has a lower risk of surgical failure compared to trabeculectomy alone. A trial of beta irradiation versus anti-metabolite is warranted.

Beta radiation for glaucoma surgery

BACKGROUND: The outcome of glaucoma surgery can be affected by the rate at which the surgical wound heals. Beta radiation has been proposed as a rapid and simple treatment to slow down the healing response. OBJECTIVE: To assess the effectiveness of beta radiation during glaucoma surgery (trabeculectomy). CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW: We searched the Cochrane Central Register of Controlled Trials (Central) in The Cochrane Library (which includes the Cochrane Eyes and Vision Group Trials Register) (Issue 4 2008), Medline (January 1966 to October 2008) and Embase (January 1980 to October 2008). The databases were last searched on 24 October 2008. SELECTION CRITERIA: We included randomized controlled trials comparing trabeculectomy with beta radiation to trabeculectomy without beta radiation. DATA COLLECTION AND ANALYSIS: We collected data on surgical failure (intraocular pressure > 21 mmHg), intraocular pressure and adverse effects of glaucoma surgery. We pooled data using a fixed-effect model. MAIN RESULTS: We found four trials that randomized 551 people to trabeculectomy with beta irradiation versus trabeculectomy alone. Two trials were in Caucasian people (126 people), one trial in black African people (320 people) and one trial in Chinese people (105 people). People who had trabeculectomy with beta irradiation had a lower risk of surgical failure compared to people who had trabeculectomy alone (pooled risk ratio (RR) 0.23 (95% CI 0.14 to 0.40). Beta irradiation was associated with an increased risk of cataract (RR 2.89, 95% CI 1.39 to 6.0). AUTHORS'CONCLUSIONS: Trabeculectomy with beta irradiation has a lower risk of surgical failure compared to trabeculectomy alone. A trial of beta irradiation versus anti-metabolite is warranted.

Clinical implications of old and new genes for open-angle glaucoma.

OBJECTIVE: Genome-wide association studies have revealed new insights into the genetic determinants of open-angle glaucoma (OAG). This study was performed to determine to what extent variants within established genes (MYOC, OPTN, and WDR36) and newly identified common genetic variants (ATOH7, CDKN2B, and SIX1) contribute to the risk of OAG. DESIGN: Population-based setting, family-based setting, and a case-control study. PARTICIPANTS: The Rotterdam Study I cohort (N = 5312; mean age±standard deviation [SD], 68.0±8.4 years). Findings were replicated in the Genetic Research in Isolated Populations combined with the Erasmus Rucphen Family study (N = 1750; mean age±SD, 48.3±15.2 years), and a cohort from Southampton (N = 702; mean age±SD, 72.5±10.7 years). METHODS: After identifying common variants associated with OAG within the established genes, the risk of OAG was analyzed using logistic regression. Discriminative accuracy was assessed by comparing the area under the receiver operator characteristic curve (AUC) for models, including the number of risk alleles, intraocular pressure, age, and gender, with the AUC for the same model but without the risk alleles. MAIN OUTCOME MEASURES: Odds ratios and AUCs of individual and combined risk alleles. RESULTS: No consistent significant associations for the established genes (MYOC, OPTN, and WDR36) with OAG were found. However, when comparing the load of risk variants between cases and controls, 2 of 3 studies showed a significant increased risk of OAG for participants carrying more risk alleles of the 3 established genes. When combining all 6 genes, participants carrying a high number of risk alleles (highest tertile) had a 2.29-fold to 3.19-fold increase in risk of OAG compared with those carrying only a few risk alleles. The addition of the newly identified genes to IOP, age, and gender resulted in a higher AUC compared with the AUC without the newly identified genes (P = 0.027). CONCLUSIONS: A significant contribution to the risk of OAG was found for the new common variants identified by recent genome-wide association studies, but not for variants within the established genes. Participants carrying a high number of risk alleles had an approximately 3-fold increase in the risk of OAG compared with those with a low number of risk alleles. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Common genetic variants associated with open-angle glaucoma.

Open-angle glaucoma (glaucoma) is a major eye disorder characterized by optic disc pathology. Recent genome-wide association studies identified new loci associated with clinically relevant optic disc parameters, such as the optic disc area and vertical cup-disc ratio (VCDR). We examined to what extent these loci are involved in glaucoma. The loci studied include ATOH7, CDC7/TGFBR3 and SALL1 for optic disc area, and CDKN2B, SIX1, SCYL1/LTBP3, CHEK2, ATOH7 and DCLK1 for VCDR. We performed a meta-analysis using data from six independent studies including: the Rotterdam Study (n= 5736), Genetic Research in Isolated Populations combined with Erasmus Rucphen Family study (n= 1750), Amsterdam Glaucoma Study (n= 296) and cohorts from Erlangen and Tübingen (n= 1363), Southampton (n= 702) and deCODE (n= 36 151) resulting in a total of 3161 glaucoma cases and 42 837 controls. Of the eight loci, we found significant evidence (P= 1.41 × 10(-8)) for the association of CDKN2B with glaucoma [odds ratio (OR) for those homozygous for the risk allele: 0.76; 95% confidence interval (CI): 0.70-0.84], for the role of ATOH7 (OR: 1.28; 95% CI: 1.12-1.47) and for SIX1 (OR: 1.20; 95% CI: 1.10-1.31) when adjusting for the number of tested loci. Furthermore, there was a borderline significant association of CDC7/TGFBR3 and SALL1 (both P= 0.04) with glaucoma. In conclusion, we found consistent evidence for three common variants (CDKN2B, ATOH7 and SIX1) significantly associated with glaucoma. These findings may shed new light on the pathophysiological protein pathways leading to glaucoma, and point to pathways involved in the growth and development of the optic nerve.

Shorter axial length and increased astigmatic refractive error are associated With socio-economic deprivation in an adult UK cohort.

PURPOSE: To evaluate whether socio-economic deprivation is associated with ocular axial length and refractive error in a British cohort. METHODS: The study population consisted of 7,652 individuals who provided data to the prospective cataract database at Portsmouth Eye unit, UK over a 4 year period (January 2004 to June 2008). Indices of multiple deprivation (IMD) scores measuring both social and economic domains for each patient's locality were calculated. The association of these measures of deprivation with axial length and refractive error (astigmatic and spherical) were evaluated using regression analyses after adjusting for age and sex. RESULTS: Socio-economically deprived areas (higher IMD scores) were inversely associated with axial lengths and astigmatic refraction. After controlling for age and sex, an inverse linear association was observed between axial length and IMD scores (-0.24 mm in highest quintile compared to lowest; 95% confidence intervals: -0.33 to -0.15) and between astigmatic refraction and IMD scores (-0.12 dioptres in highest quintile compared to lowest; 95% confidence intervals: -0.21 to -0.03). There was no association between spherical refraction and IMD scores. CONCLUSIONS: Axial length and astigmatic refraction were inversely associated with socio-economic deprivation in this population. Identification of the environmental exposures involved may identify reversible risk factors for impaired vision.

Beta radiation for glaucoma surgery.

BACKGROUND: The outcome of glaucoma surgery can be affected by the rate at which the surgical wound heals. Beta radiation has been proposed as a rapid and simple treatment to slow down the healing response. OBJECTIVES: To assess the effectiveness of beta radiation during glaucoma surgery (trabeculectomy). SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (which includes the Cochrane Eyes and Vision Group Trials Register) (Issue 4 2008), MEDLINE (January 1966 to October 2008) and EMBASE (January 1980 to October 2008). The databases were last searched on 24 October 2008. SELECTION CRITERIA: We included randomised controlled trials comparing trabeculectomy with beta radiation to trabeculectomy without beta radiation. DATA COLLECTION AND ANALYSIS: We collected data on surgical failure (intraocular pressure > 21 mmHg), intraocular pressure and adverse effects of glaucoma surgery. We pooled data using a fixed-effect model. MAIN RESULTS: We found four trials that randomised 551 people to trabeculectomy with beta irradiation versus trabeculectomy alone. Two trials were in Caucasian people (126 people), one trial in black African people (320 people) and one trial in Chinese people (105 people). People who had trabeculectomy with beta irradiation had a lower risk of surgical failure compared to people who had trabeculectomy alone (pooled risk ratio (RR) 0.23 (95% CI 0.14 to 0.40). Beta irradiation was associated with an increased risk of cataract (RR 2.89, 95% CI 1.39 to 6.0). AUTHORS' CONCLUSIONS: Trabeculectomy with beta irradiation has a lower risk of surgical failure compared to trabeculectomy alone. A trial of beta irradiation versus anti-metabolite is warranted.

Effect of beta radiation on success of glaucoma drainage surgery in South Africa: randomised controlled trial.

OBJECTIVE: To evaluate whether beta radiation may offer a practical method of improving surgical success for glaucoma drainage surgery in South Africa. DESIGN: Double blind, randomised controlled trial. SETTING: Three public hospitals in South Africa. PARTICIPANTS: 450 black Africans with primary glaucoma. INTERVENTIONS: Trabeculectomy with 1000 cGy beta radiation or standard trabeculectomy without beta radiation (placebo). MAIN OUTCOME MEASURES: Primary outcome measure was surgical failure within 12 months (intraocular pressure > 21 mm Hg while receiving no treatment for ocular hypotension). Secondary outcomes were visual acuity, surgical reintervention for cataract, and intraoperative and postoperative complications. RESULTS: 320 people were recruited. beta radiation was given to 164; 20 (6%) were not seen again after surgery. One year after surgery the estimated risk of surgical failure was 30% (95% confidence interval 22% to 38%) in the placebo arm compared with 5% (2% to 10%) in the radiation arm. The radiation group experienced a higher incidence of operable cataract (18 participants) than the placebo group (five participants; P = 0.01). At two years the estimated risks with placebo and beta radiation were, respectively, 2.8% (0.9% to 8.3%) and 16.7% (10.0% to 27.3%). CONCLUSION: beta radiation substantially reduced the risk of surgical failure after glaucoma surgery. Some evidence was, however, found of an increased risk for cataract surgery (a known complication of trabeculectomy) in the beta radiation arm during the two years after surgery. TRIAL REGISTRATION: ISRCTN62430622 [controlled-trials.com].

LOCS III examination at the slit lamp, do settings matter?

PURPOSE: To explore whether slit lamp settings may influence measurements made with the LOCS III grading system. The following were tested using a total of 221 subjects: 1. Test-retest variability (with and without the neutral density filter). 2. Readings with and then without the neutral density filter. 3. Readings with maximum and minimum illumination (filter and rheostat). 4. Examinations with different slit beam width. 5. Light output from 10 slit lamps (Haag-Streit 900BM) was measured using a lightmeter. RESULTS: The 95% limits of agreement (test-retest examination) for nuclear opacity (NO), nuclear colour (NC), cortical opacity (C), and posterior subcapsular lens opacity (P) were 0.66, 0.60, 0.62 and 0.39, respectively, using standard settings. Corresponding results with the neutral density filter were similar. Examinations performed with and without the neutral density filter showed that the 95% limits of agreement increased by a factor of at least 1.7 compared with test retest data (NO and NC) and 2.2 for (C and P) (p < 0.001 (f test)). Maximum vs. minimum brightness settings increased variability by a factor of at least 2.1 (NO and NC) and 3 (C and P) (p < 0.001 (f test)). Changing beam width measurements produced a significant systematic measurement bias of 0.3 for NO and 0.4 for NC (P < 0.01 (t test)), a wider beam giving a higher score. Individual slit lamps may vary by a factor of four in their light output levels for apparently identical settings. The range of illumination produced by a slit lamp is 46-fold. CONCLUSIONS: For nuclear opacity and nuclear colour measurements, changing settings between examinations increases variability without evidence of systematic bias. However, using a thicker slit beam induced a systematic bias. For cortical and posterior subcapsular lens opacity, varying the illumination had more marked effects on reproducibility without a systematic bias.

Exfoliation syndrome in black South Africans.

BACKGROUND: Data on exfoliation syndrome (XFS) in Africans are scarce. OBJECTIVE: To determine the prevalence and clinical features of XFS among black South Africans. DESIGN: Random cross-sectional samples of the black population aged 40 years or older from 2 districts in South Africa: Hlabisa, in northern KwaZulu-Natal Province, and Temba, North West Province. METHODS: Standardized examination, including slitlamp biomicroscopy with pupil dilatation, gonioscopy, pachymetry, tonometry, binocular indirect ophthalmoscopy, and visual field testing. RESULTS: Among 1840 participants, the prevalence of XFS was 7.7% (95% confidence interval, 5.4%-10.5%) in Hlabisa and 6.0% (95% confidence interval, 4.1%-8.4%) in Temba. The prevalence increased with age, with 18.9% (Hlabisa) and 16.5% (Temba) of those 70 or older affected. The clinical appearance was similar to that reported in other ethnic groups. Exfoliative glaucoma accounted for approximately one fourth of open-angle glaucoma cases (OAG). Open-angle glaucoma was associated with XFS; the age-adjusted and sex-adjusted odds ratios were 2.3 (95% confidence interval, 1.0-5.2) and 2.8 (95% confidence interval, 1.2-6.3) for Hlabisa and Temba, respectively. The relationship with OAG was absent when adjusting for intraocular pressure. Exfoliative glaucoma was characterized in this predominantly untreated population by high intraocular pressure and severe visual loss. Among subjects with XFS and OAG, 16 of 18 were blind in 1 or both eyes. CONCLUSIONS: Exfoliation syndrome occurs at a high prevalence among black South Africans and incurs a moderate increase in risk of glaucoma. In this untreated population, this increased risk was dependent on raised intraocular pressure. Open-angle glaucoma in association with XFS appears to be associated with a poor prognosis.

Temba glaucoma study: a population-based cross-sectional survey in urban South Africa.

OBJECTIVE: To determine the prevalence and features of glaucoma in an urban South African black population. DESIGN: Random sampling cross-sectional population survey. PARTICIPANTS: Black residents of Temba, North West Province, South Africa, age > or =40 years. MAIN OUTCOME MEASURES: Automated visual field testing and detailed, standardized slit-lamp examination were attempted on all subjects. Glaucoma was diagnosed by use of the scheme proposed by the Working Group for Defining Glaucoma of the International Society of Geographical and Epidemiologic Ophthalmology on the basis of evidence of end-organ damage. RESULTS: Of 1120 subjects, 839 (74.9%) were examined. The age- and gender-adjusted prevalence of glaucoma of all types was 5.3% (95% confidence interval [CI], 3.9%-7.1%). Primary open-angle glaucoma (POAG) was the most common glaucoma diagnosis, with an adjusted prevalence of 2.9% (95% CI, 1.9%-4.3%). Secondary glaucoma occurred with an adjusted prevalence of 2.0% (95% CI, 1.2%-3.3%). Exfoliative glaucoma was responsible for 16% of all glaucoma cases. The prevalence of primary angle-closure glaucoma was 0.5% (95% CI, 0.13%-1.2%). Of all subjects with glaucoma, 58% were blind in at least one eye. The prevalence of all types of glaucoma increased with age. Of subjects with POAG, 87% had not been previously diagnosed. CONCLUSIONS: The prevalence of glaucoma in this South African population was higher than that found in white populations, and most cases were undiagnosed and untreated. Glaucoma is a major cause of blindness in this population.