Glaucoma Awareness and Knowledge Among Ethiopians in a Tertiary Eye Care Center.

INTRODUCTION: Glaucoma outcomes are closely associated with patients' awareness of the disease. However, little is known about glaucoma awareness and knowledge in Addis Ababa, a densely populated and ethnolinguistically diverse capital city in Ethiopia, the second largest country in Africa. METHODS: We performed a cross-sectional survey in the ophthalmology waiting room at St. Paul's Hospital, a tertiary care center in Addis Ababa. Respondents included patients, patient family members, and non-clinical staff. Participants were asked if they had read or heard about glaucoma to gauge basic awareness of the disease; those with awareness were asked to take a quiz to measure their objective glaucoma knowledge. We performed multivariable regression to identify factors associated with glaucoma awareness, quiz performance, and self-rated ability to use eye drops. RESULTS: Of 298 respondents, 145 (48.7%) were female, and the average age was 44.9 ± 17.2 years. A majority (167; 56.0%) had primary school or less than primary school education. Only 131 (44.0%) had basic glaucoma awareness. Of these, 95 (72.5%) knew that glaucoma causes permanent vision loss, 103 (78.6%) knew glaucoma is often asymptomatic in early stages, 62 (47.3%) identified elevated intraocular pressure as a glaucoma risk factor, and 124 (94.7%) knew glaucoma was treatable. A majority of this subset (126; 96.2%) said they would be willing to use medicated eye drops, and 130 (99.2%) indicated a willingness to undergo surgery if recommended. Education level was independently associated with glaucoma awareness (p < 0.001) and glaucoma quiz performance (p = 0.03). CONCLUSION: In a population sample from an ophthalmology waiting room in Addis Ababa, glaucoma awareness was poor and most strongly associated with education level. Educational interventions at public health and provider-patient levels are warranted. Our results suggest high receptiveness to both medical and surgical treatment.

Fluorometholone 0.1% as Ancillary Therapy for Trachomatous Trichiasis Surgery: Randomized Clinical Trial.

PURPOSE: To assess the hypothesis that fluorometholone 0.1% eye drops are safe and effective as adjunctive therapy for trachomatous trichiasis (TT) surgery; determining the most promising dose. DESIGN: Randomized, placebo-controlled, double-masked parallel dose-ranging clinical trial. METHODS: Patients undergoing upper lid TT surgery at a rural Ethiopian hospital were randomized to fluorometholone 0.1% twice daily for 4 weeks, 4 times daily for 4 weeks, 4 times daily for 8 weeks, or matching frequency placebo in a 3:1:3:1:3:1 ratio for 1 eye. Randomization was stratified by TT severity (1-4 vs ≥5 lashes touching the globe). Safety outcomes (intraocular pressure [IOP] elevation, cataract, and other dose-limiting toxicities) and postoperative TT incidence were assessed over 1 year. RESULTS: Subjects randomized were 39:13:39:13:38:13 in the respective groups, and 1 subject in the 8-weeks fluorometholone group was withdrawn. Of 154 subjects, 148 (96.1%) completed 1 year's follow-up. Among 76 eyes receiving fluorometholone 4 times daily, 1 developed IOP elevation ≥ 30 mm Hg (to 37 mm Hg) and 1 had an allergic reaction attributed to the study drug; each resolved upon drug cessation without sequelae. No cataract or other dose-limiting toxicity events occurred. Postoperative TT within 1 year occurred in 29.3% of placebo eyes vs 17.7%, 19.6%, and 23.2% among the respective fluorometholone groups (P = .29 comparing placebo vs all active treatments combined). CONCLUSIONS: The results suggest fluorometholone 0.1% is likely to be safe and efficacious to reduce postoperative TT following TT surgery, and 1 drop twice daily for 4 weeks is the most promising dose. Confirmation in a full-scale clinical trial is needed before programmatic implementation.

The Risk of Intraocular Pressure Elevation in Pediatric Noninfectious Uveitis.

PURPOSE: To characterize the risk and risk factors for intraocular pressure (IOP) elevation in pediatric noninfectious uveitis. DESIGN: Multicenter retrospective cohort study. PARTICIPANTS: Nine hundred sixteen children (1593 eyes) younger than 18 years at presentation with noninfectious uveitis followed up between January 1978 and December 2007 at 5 academic uveitis centers in the United States. METHODS: Medical records review by trained, certified experts. MAIN OUTCOME MEASURES: Prevalence and incidence of IOP of 21 mmHg or more and 30 mmHg or more and incidence of a rise in IOP by 10 mmHg or more. To avoid underascertainment, outcomes were counted as present when IOP-lowering therapies were in use. RESULTS: Initially, 251 (15.8%) and 46 eyes (2.9%) had IOP ≥21 mmHg and ≥30 mmHg, respectively. Factors significantly associated with presenting IOP elevation included age of 6 to 12 years (versus other pediatric ages), prior cataract surgery, pars plana vitrectomy, duration of uveitis ≥6 months, contralateral IOP elevation, presenting visual acuity worse than 20/40, and topical corticosteroid use (in a dose-response relationship). The median follow-up was 1.25 years (interquartile range, 0.4-3.66). The estimated incidence of any observed IOP elevation to ≥21 mmHg, to ≥30 mmHg, and increase in IOP by ≥10 mmHg was 33.4%, 14.8%, and 24.4%, respectively, within 2 years. Factors associated with IOP elevation included pars plana vitrectomy, contralateral IOP elevation (adjusted hazard ratio [aHR], up to 9.54; P < 0.001), and the use of topical (aHR, up to 8.77 that followed a dose-response relationship; P < 0.001), periocular (aHR, up to 7.96; P < 0.001), and intraocular (aHR, up to 19.7; P < 0.001) corticosteroids. CONCLUSIONS: Intraocular pressure elevation affects a large minority of children with noninfectious uveitis. Statistically significant risk factors include IOP elevation or use of IOP-lowering treatment in the contralateral eye and local corticosteroid use that demonstrated a dose-and route of administration-dependent relationship. In contrast, use of immunosuppressive drug therapy did not increase such risk. Pediatric eyes with noninfectious uveitis should be followed up closely for IOP elevation, especially when strong risk factors such as the use of local corticosteroids and contralateral IOP elevation are present.

Unilateral mydriasis after maxillary osteotomy: a case series and review of the literature.

PURPOSE: To present 4 cases of unilateral mydriasis associated with orthognathic surgery and to review the differential diagnosis and management related to this condition. MATERIALS AND METHODS: Four cases of unilateral mydriasis associated with orthognathic surgery were identified from the authors' institutional experience. All maxillary osteotomies performed by the authors' department from 2001 to 2013 were identified based on Current Procedural Terminology codes; 4 cases of unilateral mydriasis were found. Cases are presented and the literature is reviewed. RESULTS: Two male and 2 female patients with an age range of 16 to 34 years developed unilateral mydriasis after maxillary osteotomy; the estimated prevalence is 0.004%. Although the precise cause can be difficult to determine, in this series 1 case was attributable to swelling affecting contents of the superior orbital fissure, 1 was related to edema or medications, and 2 were pharmacologically induced. CONCLUSION: Although rare, a review of the differential diagnosis for and management of unilateral mydriasis associated with orthognathic surgery is pertinent to those who perform corrective jaw surgery.

Ophthalmologist-patient communication, self-efficacy, and glaucoma medication adherence.

OBJECTIVE: To examine the associations of provider-patient communication, glaucoma medication adherence self-efficacy, and outcome expectations with glaucoma medication adherence. DESIGN: Prospective, observational cohort study. PARTICIPANTS: Two hundred seventy-nine patients with glaucoma who were newly prescribed or taking glaucoma medications were recruited at 6 ophthalmology clinics. METHODS: Patients' visits were video recorded and communication variables were coded using a detailed coding tool developed by the authors. Adherence was measured using Medication Event Monitoring Systems for 60 days after their visits. MAIN OUTCOME MEASURES: The following adherence variables were measured for the 60-day period after their visits: whether the patient took 80% or more of the prescribed doses, percentage of the correct number of prescribed doses taken each day, and percentage of the prescribed doses taken on time. RESULTS: Higher glaucoma medication adherence self-efficacy was associated positively with better adherence with all 3 measures. Black race was associated negatively with percentage of the correct number of doses taken each day (ß = -0.16; P < 0.05) and whether the patient took 80% or more of the prescribed doses (odds ratio, 0.37; 95% confidence interval, 0.16-0.86). Physician education about how to administer drops was associated positively with percentage of the correct number of doses taken each day (ß = 0.18; P < 0.01) and percentage of the prescribed doses taken on time (ß = 0.15; P < 0.05). CONCLUSIONS: These findings indicate that provider education about how to administer glaucoma drops and patient glaucoma medication adherence self-efficacy are associated positively with adherence.

Gamma-irradiated cornea allograft for glaucoma surgery.

PURPOSE: To describe the clinical outcomes and surgical applications of γ-irradiated cornea allograft in glaucoma surgery. MATERIALS AND METHODS: We reviewed 10 consecutive patients who underwent primary or secondary glaucoma procedures using sterile cornea allograft. RESULTS: Ten eyes of 10 patients (5 males, mean age 50 y) were treated with sterile, irradiated cornea allograft. Mean follow-up was 24 months (range, 22.4 to 26.8 mo). The allograft was used for coverage of a primary glaucoma tube shunt in 3 patients, coverage of a revised glaucoma tube shunt in 5 patients, tectonic support of a revised trabeculectomy flap in 1 patient, and coverage of subconjunctival prolene sutures following a surgical iridoplasty in 1 patient. The allografts were stable and biocompatibile in all 10 cases during the follow-up period, evidenced by maintained clarity of the corneal tissue, absence of clinical signs of immunologic rejection or ocular inflammation, and integrity of the sterile cornea and the conjunctiva over the graft. Cosmetic results were satisfactory and there were no complications during the follow-up period. CONCLUSIONS: In this small case series, sterile, γ-irradiated cornea allograft appeared to be safe and effective when used in glaucoma and anterior segment surgical procedures. Our results suggest advantages of sterile cornea allograft for coverage of glaucoma drainage implant tubes, including tissue transparency, resilience, and ease of surgical use.

Trabeculectomy versus combined trabeculotomy-trabeculectomy in pediatric glaucoma.

PURPOSE: To compare outcomes between trabeculectomy and combined trabeculotomy-trabeculectomy in children with glaucoma. METHODS: This was a retrospective, comparative study of 40 eyes in 33 patients with pediatric glaucoma: 17 eyes treated with trabeculectomy and 23 eyes treated with combined trabeculotomy-trabeculectomy. Both groups were treated with intraoperative mitomycin C. Success was defined as intraocular pressure (IOP) of 21 mm Hg or less and greater than 5 mm Hg with no additional glaucoma surgery. RESULTS: Mean follow-up was 38.3 months. There was no significant difference in mean IOP lowering between groups during the follow-up period. Log-rank survival analysis showed a significantly higher success rate after combined surgery compared with trabeculectomy (P = .027). Treatment failures occurred in 5 patients with trabeculectomy and in 2 patients undergoing combined trabeculotomy-trabeculectomy. Failures resulted from increased IOP (n = 3) or hypotony (n = 4). There were no significant differences in complications observed after surgery in both groups. CONCLUSION: Trabeculectomy and combined trabeculotomy-trabeculectomy with mitomycin C were equally effective at lowering average IOP in children. Combined trabeculotomy-trabeculectomy was associated with greater long-term success.

What's new in laser treatment for glaucoma?

PURPOSE OF REVIEW: This review highlights recently published studies on prevailing and newer laser therapies in glaucoma and critically evaluates their roles in the treatment algorithm. RECENT FINDINGS: Recently published studies suggest a role for selective laser trabeculoplasty (SLT) as initial therapy for open-angle glaucoma and ocular hypertension and have demonstrated efficacy in other glaucoma subtypes. Novel laser applications (micropulse diode laser trabeculoplasty, titanium sapphire laser trabeculoplasty and excimer laser trabeculotomy) have shown favorable early results. Endoscopic and transscleral cyclophotocoagulation (ECP, TCP) are generally reserved for refractory glaucomas, although some recent studies report its use in patients with good visual acuity. The effectiveness of laser iridotomy with or without iridoplasty for long-term prevention of primary angle closure glaucoma is undetermined. Laser goniopuncture is an important adjunct to nonpenetrating surgery, but wide adoption of the procedure is lacking. SUMMARY: The use of lasers in glaucoma continues to evolve, with a trend towards primary and earlier intervention. SLT is assuming an expanded role in the treatment of additional subtypes of glaucoma, whereas ECP and TCP are generally reserved for refractory glaucomas. Newer laser modalities show promise as alternatives and adjuncts to topical medications and nonpenetrating surgery. Additional research is needed to better define their safety and efficacy.

Uterine papillary serous carcinoma metastatic to the choroid.

PURPOSE: To report an unusual case of choroidal metastasis from uterine papillary serous carcinoma presenting as a choroidal hemorrhage. METHODS: A 70-year-old woman with a history of Stage IV endometrial cancer presented with sudden loss of vision and pain behind the right eye. Clinical examination revealed a choroidal hemorrhage with retinal detachment. The clinical findings, results of imaging studies, and pathologic findings are described. RESULTS: The patient underwent drainage of the choroidal hemorrhage but developed a painful, blind eye resulting from secondary glaucoma that was refractory to maximal medical therapy. Examination of the drained choroidal fluid showed no malignant cells. The patient elected for enucleation of the affected eye, and histopathologic analysis was consistent with uterine papillary serous carcinoma metastatic to the choroid. The patient tolerated the procedure well. However, she entered hospice shortly after surgery to receive palliative care for her metastatic disease. CONCLUSION: Rare cases of uterine cancer metastasizing to the uvea have been reported. To our knowledge, this is the first case of uterine papillary serous carcinoma with uveal metastasis. Metastatic disease involving the uvea should be considered in the differential diagnosis for a patient presenting with pain and sudden loss of vision, particularly when the patient has a known primary malignancy. Histopathology and cytology can assist in identifying a uveal mass as metastatic.

An unusual case of retinoblastoma.

The authors describe the treatment and complications of a case of retinoblastoma with an atypical presentation. A 20-month-old girl was diagnosed as having unilateral retinoblastoma by cytopathology during pars plana vitrectomy and the right eye was enucleated. Following the enucleation, computed tomography detected a questionable focus of retinoblastoma in the residual optic nerve. Exploration of the orbit and sampling of the optic nerve stump had to be performed because the enucleated globe was lost. Histopathology of the optic nerve stump showed granulation tissue and fibrosis but no evidence of retinoblastoma. Histopathology of the enucleated globe and transected optic nerve is the gold standard for staging retinoblastoma and formulating a treatment plan. Treatment of the patient with retinoblastoma becomes more complex when histopathologic findings are not available.