Proactive Decision Support for Glaucoma Treatment: Predicting Surgical Interventions with Clinically Available Data.

A longitudinal ophthalmic dataset was used to investigate multi-modal machine learning (ML) models incorporating patient demographics and history, clinical measurements, optical coherence tomography (OCT), and visual field (VF) testing in predicting glaucoma surgical interventions. The cohort included 369 patients who underwent glaucoma surgery and 592 patients who did not undergo surgery. The data types used for prediction included patient demographics, history of systemic conditions, medication history, ophthalmic measurements, 24-2 VF results, and thickness measurements from OCT imaging. The ML models were trained to predict surgical interventions and evaluated on independent data collected at a separate study site. The models were evaluated based on their ability to predict surgeries at varying lengths of time prior to surgical intervention. The highest performing predictions achieved an AUC of 0.93, 0.92, and 0.93 in predicting surgical intervention at 1 year, 2 years, and 3 years, respectively. The models were also able to achieve high sensitivity (0.89, 0.77, 0.86 at 1, 2, and 3 years, respectively) and specificity (0.85, 0.90, and 0.91 at 1, 2, and 3 years, respectively) at an 0.80 level of precision. The multi-modal models trained on a combination of data types predicted surgical interventions with high accuracy up to three years prior to surgery and could provide an important tool to predict the need for glaucoma intervention.

A Model of Progression to Help Identify Macular Damage Due to Glaucoma.

The central macula contains a thick donut shaped region of the ganglion cell layer (GCL) that surrounds the fovea. This region, which is about 12 degrees (3.5 mm) in diameter, is essential for everyday functions such as driving, reading, and face recognition. Here, we describe a model of progression of glaucomatous damage to this GCL donut. This model is based upon assumptions supported by the literature, and it predicts the patterns of glaucomatous damage to the GCL donut, as seen with optical coherence tomography (OCT). After describing the assumptions and predictions of this model, we test the model against data from our laboratory, as well as from the literature. Finally, three uses of the model are illustrated. One, it provides an aid to help clinicians focus on the essential central macula and to alert them to look for other, non-glaucomatous causes, when the GCL damage does not fit the pattern predicted by the model. Second, the patterns of progression predicted by the model suggest alternative end points for clinical trials. Finally, the model provides a heuristic for future research concerning the anatomic basis of glaucomatous damage.

Towards detection of biomarkers in the eye using an aptamer-based graphene affinity nanobiosensor.

We present an approach to enable the sensitive and specific detection of biomarkers in undiluted tears in the eye using an aptamer-based graphene affinity nanosensor. The nanosensor is a graphene field-effect transistor, in which a nucleic acid aptamer and a biomolecule-permeable polyethylene glycol (PEG) nanolayer are immobilized on the graphene surface. The aptamer is capable of specifically recognize the target biomarker and induce a change in the carrier concentration of the graphene, which is measured to determine the biomarker concentration. The PEG nanolayer minimizes nonspecific adsorption of background molecules in the sample that would otherwise interfere with the biomarker detection. Experimental results show that tumor necrosis factor alpha (TNF-alpha), an inflammatory cytokine, can be sensitively and specifically detected in undiluted artificial tears with a limit of detection of 0.34 pM. This ability to detect and measure biomarkers in undiluted physiological fluids allows the nanosensor to be potentially used in applications where sample dilutions are not practical, such as wearable measurements of tear-borne biomarkers in the eye.

Relationship between optic disc hemorrhage and corneal hysteresis.

OBJECTIVE: To determine the relationship between optic disc hemorrhage (DH) and corneal hysteresis (CH). METHODS: Consecutive patients with prior or current photographic evidence of unilateral DH who had undergone CH measurement with the Ocular Response Analyzer (ORA; Reichert, Buffalo, NY) were enrolled. Eyes with a history of corneal disease, refractive surgery, or bilateral DH were excluded. Central corneal thickness (CCT), visual field data, 5 consecutive previous intraocular pressures (IOPs), and maximum documented peak IOP were obtained by chart review. Vertical cup-to-disc ratio (VCDR), the presence of neuroretinal rim notching, number of clock hours of beta zone parapapillary atrophy (ßPPA), and eye with greater ßPPA width were determined from photographs by 2 masked expert examiners. RESULTS: We identified and analyzed 49 patients with photographically documented unilateral DH. Compared to fellow non-DH eyes, eyes with DH had lower CH (8.7 ± 1.9 vs 9.2 ± 1.7; p = 0.002), higher IOP (15.6 ± 3.6 vs 14.3 ± 4.1; p = 0.017), and greater VCDR (0.79 ± 0.13 vs 0.68 ± 0.23; p < 0.001), but were similar with respect to CCT, ßPPA extent, rim notching, peak IOP, and visual field damage (all p > 0.05). Using multivariate conditional logistic regression analysis, only CH (p = 0.012) and VCDR (p = 0.004) predicted the laterality of the DH. CONCLUSIONS: Lower CH and greater VCDR are independently associated with DH. This suggests that CH may be a structural biomarker for an abnormality of the optic nerve complex that may be associated with progressive glaucoma. Eyes in which DH were detected had lower CH.

Effect of Topical Periocular Steroid Use on Intraocular Pressure: A Retrospective Analysis.

PURPOSE: To study the effect of periocular steroid use on intraocular pressure (IOP). METHODS: Charts of adult patients with atopic dermatitis or eczema treated with topical periocular steroid creams and ointments from January 1st, 2007 to October 1st, 2017 were reviewed. Patients with the following were excluded: glaucoma, ocular hypertension, known systemic/topical/injectable steroid history, and lack of documented IOP prior to or during treatment with periocular steroid ointment. Patient data were collected regarding gender, treatment regimen, as well as IOP prior to and during treatment. Steroid responders were identified. Statistical analysis was performed using linear mixed effects models adjusting for follow-up time to test the relationship between pre and posttreatment IOP change adjusting for intereye correlations. RESULTS: Thirty-one patients were identified. Twenty-one were treated bilaterally and 10 unilaterally. Five patients were glaucoma suspects. The mean treatment period was 14.2 weeks with a range of 0.1-83.9 weeks. Patients were treated with fluorometholone (42%), loteprednol etabonate (23%), dexamethasone-neomycin-polymyxin B (13%), hydrocortisone 1% or 2.5% (3%), and tobramycin-dexamethasone (19%). In the combined sample, there was no significant IOP change even after adjusting for follow-up time (mean change: +0.44 mm Hg, p = 0.126). However, eyes with baseline IOP ≥ 14 mm Hg had a significant increase (+0.73 mm Hg/year, p = 0.032). Individual steroid responses included the following: 1 intermediate and 30 low responders, of which 19 patients had an IOP change of <1 mm Hg. One patient had a clinically significant intermediate steroid response of 7 mm Hg. CONCLUSIONS: Periocular steroid treatment causes a statistically significant rise in IOP in eyes with higher baseline IOP measurements, the risk of which increases with follow up. While this change is not always correlated with a clinically significant rise in IOP, clinicians should monitor more closely patients at greatest risk of steroid response.

Measurement of cytokine biomarkers using an aptamer-based affinity graphene nanosensor on a flexible substrate toward wearable applications.

We present an approach for the label-free detection of cytokine biomarkers using an aptamer-functionalized, graphene-based field effect transistor (GFET) nanosensor on a flexible, SiO2-coated substrate of the polymer polyethylene naphthalate (PEN). The nanosensor conforms to the underlying nonplanar surface and performs GFET-based rapid transduction of the aptamer-biomarker binding, thereby potentially allowing the detection of cytokine biomarkers that are sampled reliably from human bodily fluids (e.g., sweat) in wearable sensing applications. In characterizing the suitability of the nanosensor for wearable applications, we investigate the effects of substrate bending on the equilibrium dissociation constant between the aptamer and the biomarker as well as the graphene transconductance. The utility of the nanosensor is demonstrated by the detection of tumor necrosis factor-α (TNF-α), an inflammatory cytokine biomarker. Experimental results show that the flexible nanosensor can specifically respond to changes in the TNF-α concentration within 5 minutes with a limit of detection as low as 26 pM in a repeatable manner.

Challenges to the Common Clinical Paradigm for Diagnosis of Glaucomatous Damage With OCT and Visual Fields.

The most common clinical paradigm (CCP) for diagnosing glaucoma includes a visual field (VF) with a 6° test grid (e.g., the 24-2 or 30-2 test pattern) and an optical coherence tomography (OCT) scan of the optic disc. Furthermore, these tests are assessed based upon quantitative metrics (e.g., the pattern standard deviation [PSD] of the VF and the global retinal nerve fiber thickness of the OCT disc scan). This CCP is facing three challenges. First, the macular region (i.e., ±8° from fixation) is affected early in the glaucomatous process, and the CCP can miss and/or underestimate the damage. Second, use of the typical VF and OCT metrics underestimates the degree of agreement between structural (OCT) and functional (VF) damage. Third, resolution of the OCT scan has improved, and local glaucomatous damage can be visualized like never before. However, the clinician often does not look at the OCT scan image. Together these challenges argue for a modification of the VF test pattern and OCT protocol, replacement of metrics with a comparison of abnormal regions on VF and OCT, and careful inspection of actual OCT scan images. In principle, the CCP could be modified easily. In practice, change is facing a number of impediments.

A Comparison of Retrobulbar Versus Topical Anesthesia in Trabeculectomy and Aqueous Shunt Surgery.

PURPOSE: The purpose of this study was to compare the required supplemental anesthesia and postoperative patient pain score in individuals undergoing glaucoma surgery under topical anesthesia (TA) versus retrobulbar anesthesia (RB). MATERIALS AND METHODS: A retrospective, interventional, comparative cohort study of 261 eyes of 225 patients undergoing glaucoma and combined glaucoma with cataract surgery were included in the study. The main outcome measures were the amount of supplemental, systemic intraoperative anesthesia used and the postoperative pain scale between patients undergoing TA versus RB anesthesia. A secondary analysis was performed between combined glaucoma and cataract surgery versus glaucoma surgery alone. RESULTS: About 6.2% patients complained of pain after glaucoma surgery (8.1% among TA group and 3.1% among RB group; P=0.049). Overall, pain tended to be mild with a mean score of 0.32 of 10 for TA and 0.08 of 10 for RB (P=0.027). The amount of IV anesthetics used intraoperatively was lower in the RB anesthesia compared with the TA group (midazolam, P=0.042; fentanyl, P<0.001; propofol, P<0.001). In addition, patients undergoing RB anesthesia were less likely to use postoperative pain medication (P<0.001). There was no difference in pain score (P=0.707) or in the amount of IV anesthetics (all P>0.350) between eyes undergoing combined versus glaucoma surgery alone. CONCLUSIONS: Although supplemental anesthesia and pain scores were statistically increased in the topical group, the prevalence and the severity of pain was low. Therefore, TA is feasible and a reasonable option for glaucoma surgery. Furthermore, this conclusion applies when glaucoma surgery is performed alone or in combination with the other eye surgery.

Gluteoplasty with autologous fat tissue: experience with 106 consecutive cases.

BACKGROUND: The female waist-hip ratio of around 0.7 is reachable through liposuction and gluteal fat grafting. The authors evaluated the reliability of this technique. METHODS: Prospective evaluation was performed of all female patients subjected to gluteoplasty with autologous fat tissue between July of 2010 and July of 2013 without a weight change greater than 10 percent during follow-up. Results were evaluated through photographs. The degree of satisfaction (patient and surgeon) was assessed on a scale of 1 (poor outcome) to 4 (excellent improvement), and agreement was measured by Kappa statistics. The technique involved epidural anesthesia, tumescent infiltration, liposuction around the buttocks, fat decantation, and grafting with retrograde injection in different planes. RESULTS: A total of 106 patients were included. Patient age ranged between 18 and 62 years (mean, 33 years). The preoperative body mass index was between 19 and 31.6 kg/m (mean, 24.8 kg/m). The volume grafted to the buttocks ranged between 180 and 840 cc (mean, 505 cc). There were no medical complications. Five patients (4.7 percent) had seroma in the donor area, 103 patients felt satisfied (97.1 percent), scoring 3 and 4, one patient (0.94 percent) complained of volume resorption 4 months postoperatively, and two patients (1.88 percent) asked to diminish their lateral gluteal volume (score 2) and underwent revision surgery 6 months postoperatively. CONCLUSIONS: This gluteoplasty technique is simple and inexpensive, with minimal morbidity and excellent results. A good result depends on harmoniously combining fat elimination by liposuction and fat grafting for buttocks sculpting, with lasting results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A new index to monitor central visual field progression in glaucoma.

PURPOSE: The visual field index (VFI) summarizes global visual field (VF) data and was developed to monitor glaucoma progression using 24-2 and 30-2 strategies. We applied similar principles and statistical procedures to develop a new parameter, the central field index (CFI), to monitor 10-2 VF progression. DESIGN: Retrospective cohort. PARTICIPANTS: Glaucoma patients with paracentral defects seen on 24-2 perimetry and followed up with at least 5 10-2 VF tests. METHODS: The CFI was developed by calculating age-corrected defect depth at test points obtained during 10-2 examinations. The sensitivities at these points were scored as percentages similar to the method described for the VFI: 100-[(|total deviation|/age-corrected normal threshold) × 100]. A weighting procedure was applied based on published estimates of the occipital cortical spatial magnification. For validation, we performed mixed linear model testing for the association between CFI rates of change (%/year) and known risk factors for glaucoma progression in a population with established glaucoma and at least 5 10-2 VF tests. To determine whether the CFI was affected by cataract, as is known to occur with mean deviation (MD), we conducted a pilot evaluation comparing rates of CFI change in 3 groups: (1) eyes with cataract, (2) pseudophakic eyes, and (3) eyes in which cataract surgery was performed in the middle of the series. MAIN OUTCOME MEASURES: Rates of CFI and MD change. RESULTS: Central field index values were calculated for 176 eyes of 142 patients. The mean rate of CFI change of the entire sample was -1.10%/year (95% confidence interval, -1.03 to -1.16%/year). Elevated intraocular pressure (P<0.001) was associated significantly with faster CFI change, whereas lens status did not influence CFI rates of change (P>0.100) CONCLUSIONS: We developed and validated a new index to monitor central field progression that is minimally affected by the presence or removal of cataract and that correlates significantly with an important risk factor for glaucoma progression. This new index may become useful for glaucoma management, especially when combined with conventional static perimetry strategies.

Combined Baerveldt glaucoma implant and scleral buckling surgery for patients with retinal detachment and coexisting glaucoma.

PURPOSE: To report on the usefulness of combined Baerveldt glaucoma implantation (BGI) and scleral buckling surgery for patients with glaucoma requiring a scleral buckle for retinal detachment repair. METHODS: Retrospective, consecutive, noncomparative, and interventional case series of 30 eyes (30 patients) that underwent simultaneous scleral buckle and BGI surgery, using a staged (group 1, n=21 patients) or nonstaged (group 2, n=9 patients) approach to BGI implantation. Successful intraocular pressure (IOP) control was defined as 6 mm Hg≤IOP≤18 mm Hg. RESULTS: Although not statistically significant, mean best corrected visual acuity (LogMAR) improved from 2.0 before surgery to 1.7 after surgery (P=0.13) with a mean follow-up of 27.7 months. Of the 21 patients in group 1, only 13 (62%) required second-stage tube insertion at a mean of 7.0±8.0 months (range, 1 to 24 mo) postoperatively. For these eyes combined with group 2 eyes, mean IOP was reduced from 31.1±10.8 to 12.7±6.0 mm Hg (P<0.0001), and the mean number of glaucoma medications was reduced from 2.9±1.4 to 1.2±1.3 (P<0.001). Life table rates of successful IOP control were 90% and 80% at 12 and 24 months, respectively. CONCLUSIONS: Combined scleral buckle and BGI is an effective technique for managing coexisting glaucoma and retinal detachment and provides the clinician with a useful surgical option while minimizing surgical risk.

Clinical use of multifocal visual-evoked potentials in a glaucoma practice: a prospective study.

PURPOSE: To test a framework that describes how the multifocal visual-evoked potential (mfVEP) technique is used in a particular glaucoma practice. METHODS: In this prospective, descriptive study, glaucoma suspects, ocular hypertensives and glaucoma patients were referred for mfVEP testing by a single glaucoma specialist over a 2-year period. All patients underwent standard automated perimetry (SAP) and mfVEP testing within 3 months. Two hundred and ten patients (420 eyes) were referred for mfVEP testing for the following reasons: (1) normal SAP tests suspected of early functional loss (ocular hypertensives, n = 43; and glaucoma suspects on the basis of suspicious optic disks, n = 52); (2) normal-tension glaucoma patients with suspected central SAP defects (n = 33); and (3) SAP abnormalities needing confirmation (n = 82). RESULTS: All the glaucoma suspects with normal SAP and mfVEP results remained untreated. Of those with abnormal mfVEP results, 68 % (15/22) were treated because the abnormal regions on the mfVEP were consistent with the abnormal regions seen during clinical examination of the optic disk. The mfVEP was abnormal in 86 % (69/80) of eyes with glaucomatous optic neuropathy and SAP damage, even though it did not result in an altered treatment regimen. In NTG patients, the mfVEP showed central defects in 44 % (12 of 27) of the eyes with apparently normal central fields and confirmed central scotomata in 92 % (36 of 39), leading to more rigorous surveillance of these patients. CONCLUSIONS: In a clinical practice, the mfVEP was used when clinical examination and subjective visual fields provided insufficient or conflicting information. This information influenced clinical management.

Corneal hysteresis and Beta-zone parapapillary atrophy.

PURPOSE: To evaluate the relationship between ß-zone parapapillary atrophy (ßPPA) and corneal hysteresis (CH) in patients with glaucoma. DESIGN: Prospective, cross-sectional study. METHODS: Glaucoma patients aged 18 to 90 years with disc photographs within 12 months of the study visit were consecutively enrolled. Exclusion criteria included ocular surgery other than clear corneal phacoemulsification, myopia >6 diopters, contact lens use, and corneal abnormality. CH was measured using the Ocular Response Analyzer (ORA). Disc photographs were evaluated in a masked fashion for ßPPA. RESULTS: We enrolled 99 patients (mean age 67.6 years; 45 men, 54 women). Univariate analysis showed no significant difference in CH between eyes with and without ßPPA (8.72 ± 0.23 vs 8.15 ± 0.27 mm Hg, P = .11). There were no differences in corneal resistance factor (CRF) (P = .47), central corneal thickness (CCT) (P = .11), ORA wave score (P = .23), age (P = .23), sex (P = .40), IOP (P = .86), or visual field mean deviation (VFMD) (P = .45). Eyes with ßPPA were more myopic (-1.49 ± 0.27 vs -0.22 ± 0.31 diopters, P = .003). Multivariate analysis showed no significant difference in CH between eyes with and without ßPPA (P = .38). Eyes with asymmetric ßPPA also showed no significant difference in CH (8.97 ± 0.22 vs 9.10 ± 0.22 mm Hg, P = .69). CONCLUSIONS: We found no significant differences in CH between eyes with and without ßPPA or between fellow eyes with asymmetric ßPPA.

Automated alternation flicker for the detection of optic disc haemorrhages.

PURPOSE: Optic disc haemorrhages are associated with active glaucomatous neurodegeneration and ongoing visual field loss. We sought to determine whether automated alternation flicker enhances the detection of disc haemorrhages in serial images from patients with glaucoma when compared to side-by-side photographic evaluation and single-image display. METHODS: Serial sets of optic nerve photographs of 394 eyes from 234 patients followed for glaucoma at the authors' institutions were included in this study. Eyes with disc haemorrhages were graded for difficulty level and randomized along with nondisc haemorrhage control images into one of three presentation groups (automated alternation flicker, side-by-side or single image). Seven graders viewed all images and assessed for the presence or absence of disc haemorrhages. RESULTS: The sensitivity of automated alternation flicker for disc haemorrhage detection (0.878) was higher than side-by-side (0.705; p = 0.002) and single photographs (0.757; p = 0.01). There was no specificity difference between pairs of presentation groups (all p ≥ 0.7). CONCLUSION: Automated alternation flicker was a more sensitive method for disc haemorrhage detection than the current clinical standards and may have an important role in the management of glaucoma.

Effect of successful and partly successful filtering surgery on the velocity of glaucomatous visual field progression.

PURPOSE: We sought to determine whether filtering surgery, even when only partially successful, delays or slows visual field (VF) progression. METHODS: The records of all patients seen in a glaucoma referral practice from 1999 to 2009 were reviewed. Group A comprised eyes with ≥ 5 VFs before surgery and group B comprised eyes with ≥ 5 VFs after surgery. Eyes in group B were further divided into those requiring postoperative topical ocular hypotensive therapy (group B-2) and those that did not (group B-1). Automated pointwise linear regression was used to determine global rates (dB/y) of change and progression endpoints. A progression endpoint was determined when 2 or more adjacent test locations in the same hemifield showed a threshold sensitivity decline at a rate of ≥ 1.0 dB/year with P < 0.01. RESULTS: A total of 206 treated eyes (206 patients; mean age, 63.8 ± 13.0 y; 11.3 ± 3.1 VFs; 6.4 ± 1.8 y follow-up) were included. Mean global VF progression rates in group A (-0.86 ± 0.8 dB/y) were faster than those in group B (-0.49 ± 0.9 dB/y, P < 0.01). Group A also had a greater risk of reaching a progression endpoint compared with group B (odds ratio = 2.41, P < 0.01). Groups B-1 and B-2 had different follow-up intraocular pressure means (12.7 ± 3.7 vs. 15.5 ± 2.7 mm Hg, respectively; P < 0.01) and peaks (19.4 ± 5.2 vs. 21.2 ± 4.2 mm Hg; P = 0.08). The velocity of VF progression was similar for groups B-1 and B-2 (-0.40 ± 0.6 vs. -0.58 ± 1.1 dB/y; P = 0.22) and there was no significant difference between the 2 groups regarding the risk of reaching a progression endpoint (odds ratio = 0.83, P = 0.62). CONCLUSIONS: Filtering surgery reduces the rate of disease progression and this effect persists even if adjunctive glaucoma medical therapy is required.

Corneal hysteresis and visual field asymmetry in open angle glaucoma.

PURPOSE: To investigate the association between corneal biomechanical parameters and asymmetric primary open angle glaucoma (POAG) using the Ocular Response Analyzer (ORA). METHODS: In a prospective cross-sectional study, ORA parameters were measured in 117 POAG patients with asymmetric visual fields (VF). The asymmetry in VF was defined as a five point difference between the eyes using the Advanced Glaucoma Intervention Study (AGIS) scoring system. Subjects with previous intraocular or refractive surgery, ocular comorbidities and diabetes were excluded. RESULTS: In worse eyes, mean AGIS scores were significantly higher (8.1 ± 4.3 vs. 1.0 ± 1.6; P < 0.001) and mean corneal hysteresis (CH) was significantly lower (8.2 ± 1.9 vs. 8.9 ± 1.9 mm Hg; P < 0.001). Median ORA-corrected intraocular pressure was higher in the worse eyes (IOP(cc), 17.4 mm Hg vs. 16.9 mm Hg; P < 0.001). Worse eyes had a slightly lower mean corneal resistance factor (P = 0.04) and more myopic mean spherical equivalent (P = 0.02). No difference was seen in the central corneal thickness (CCT; P = 0.63) and Goldmann applanation tonometry (GAT; P = 0.32). On multivariate analysis, only CH retained an association with the worse eye (odds ratio, 25.9; 95% confidence interval, 10.1-66.5). ROC curves showed that only CH and IOP(cc) had a discriminative ability for the eye with worse VF (AUC, 0.82 and 0.70, respectively). CONCLUSIONS: Asymmetric POAG was associated with asymmetry in ORA parameters but not in CCT and GAT. Lower CH was associated with worse eyes independently of its effect on IOP measurement and had the best discriminability for the eye with the worse VF.

Glaucoma surgery decreases the rates of localized and global visual field progression.

PURPOSE: Incisional glaucoma surgical procedures produce greater intraocular pressure (IOP) reduction and less IOP variability than medical treatment. We sought to determine the efficacy of glaucoma surgery in decreasing localized and global rates of visual field (VF) progression. DESIGN: Retrospective, interventional case series. METHODS: Subjects in the New York Glaucoma Progression Study with glaucomatous optic neuropathy, repeatable VF loss, and 10 or more Swedish interactive threshold algorithm standard VF examinations were assessed for eligibility. Patients who underwent successful glaucoma surgery (not requiring further surgical intervention and IOP < 18 mm Hg) in either eye and who were followed up for at least 2 years before and after surgery were enrolled. Automated pointwise linear regression analysis was used to calculate global and localized rates of progression before and after surgery. Eyes with other ocular conditions likely to affect the VF and an insufficient number of VF to create a slope before and after surgery were excluded. Comparisons were performed within the same eyes before and after surgery (Student paired t test). RESULTS: We enrolled 28 eyes of 28 patients (mean age, 61.2 +/- 14.5 years). The mean number +/- standard deviation of VF was 13.4 +/- 2.3, spanning 7.1 +/- 1.2 years (range, 4 to 9 years). Mean IOP +/- standard deviation decreased from 19.0 +/- 3.9 mm Hg before surgery to 11.3 +/- 3.7 mm Hg after surgery (40% reduction; P < .01). Mean global progression rates decreased from -1.48 +/- 1.4 dB/year before surgery to -0.43 +/- 0.8 dB/year after surgery (70% reduction; P = .01). Twelve eyes (42.8%) had at least 1 significantly progressing point before surgery, whereas only 2 (7.1%) had at least 1 progressing point after surgery. Each 1 mm Hg of IOP reduction after surgery resulted in a 0.1 dB/year decrease in the global rate of progression. CONCLUSIONS: Successful IOP reduction after glaucoma surgery greatly reduces both the number of progressing points and the localized and general rates of VF progression.

Association of exfoliation syndrome and central retinal vein occlusion: an ultrastructural analysis.

PURPOSE: To evaluate prospectively the frequency with which exfoliation syndrome (XFS) occurs in patients with central retinal vein occlusion (CRVO) by clinical examination and ultrastructural examination of conjunctival biopsy specimens. METHODS: Prospective observational case series. Thirty-six eyes of 36 consecutive patients with CRVO were investigated for XFS by slit-lamp examination and conjunctival biopsy when XFS was not clinically visible on examination. RESULTS: A clinical diagnosis of XFS or a positive biopsy result for exfoliation material (XFM) was present in 22 of the 36 patients (61%; 95% confidence interval 45-75%). Twelve of these 22 patients (54%) had a clinical diagnosis of XFS. Aggregates of XFM were identified ultrastructurally in the biopsy specimens in 10 of 24 patients with no clinical signs of XFS (42%). Patients with and without XFS had similar distribution of age, gender, race and prevalence of systemic disorders. Twelve of the 22 (54%) XFS patients had neither glaucoma nor ocular hypertension prior to the CRVO. CONCLUSION: In accordance with previous retrospective and histological studies, this prospective, in vivo study suggests that CRVO is commonly associated with XFS.