The role of scanning laser polarimetry using the GDx variable corneal compensator in the management of glaucoma suspects.

AIM: To determine the role of scanning laser polarimetry using the GDx variable corneal compensator (VCC) in the management of glaucoma suspects. METHODS: Over a 12-month period, 43 of 447 (9.6%) patients referred to a glaucoma screening clinic were classified as "glaucoma suspects" when it was not possible to categorise the optic disc appearance and visual fields as definitely glaucomatous or definitely normal. Of these patients, 39 underwent a full ophthalmic review, including assessment of the visual fields and analysis of the retinal nerve fibre layer with the GDx VCC. RESULTS: After the review, 17 of 39 (43.6%) patients were discharged because of normal GDx VCC results. The remaining 22 of 39 (56.4%) were considered to be at risk of developing progressive glaucoma, and further follow-up in the hospital eye service was recommended. 3 (7.7%) patients received treatment. Of the 22 patients, 12 were considered to have pre-perimetric normal tension glaucoma, 7 normal tension glaucoma and 1 primary open-angle glaucoma (POAG). In 19 of these patients, abnormal GDx VCC results were found, particularly inter-eye asymmetry in the nerve fibre layer thickness. However, in 2 of 39 (5.1%) patients the GDx VCC was normal, despite the presence of a neuroretinal rim defect in the optic disc with corresponding visual field loss, and in 1 patient with POAG. CONCLUSIONS: Scanning laser polarimetry using the GDx VCC is an important tool in defining the management strategies of glaucoma suspects. In screening for glaucoma, however, GDx VCC results should not be used in isolation, but in conjunction with conventional methods of optic disc and visual field assessment.

Predisposing factors for chronic angle-closure glaucoma.

Chronic angle-closure glaucoma is the commonest form of glaucoma in Sino Mongaloid populations. It is an anatomical disorder of the anterior segment of the eye characterised by permanent closure of part of the filtration angle as a result of iris apposition to the trabecular meshwork. Two pathways lead to this condition: recurrent pupillary block and "creeping" angle closure. East or Southeast Asian ethnic background is an important risk factor for the development of chronic angle-closure glaucoma. Other demographical risk factors include ageing, female gender and a familial tendency. Eyes with chronic angle-closure glaucoma have different anterior segment anatomical relationships when compared to normals. Those eyes at risk tend to be hypermetropic with a shallow anterior chamber, a relatively anteriorly positioned lens and a short axial length. The role of the ciliary body anatomy and ciliary processes in the pathogenesis of this condition requires further investigation.

Outcomes of referrals by community optometrists to a hospital glaucoma service.

AIM: To determine the outcomes resulting from optometric referrals to a specialist glaucoma screening clinic over a 10 year period. METHODS: Details of the initial clinical assessment of all new patients referred to the adult glaucoma screening clinic at Oxford Eye Hospital were collected prospectively from July 1994 to June 2004. RESULTS: Optometrists working in community practice initiated 2505 referrals. Of these, glaucoma was confirmed in 510 patients (20.4%), including 160 with normal intraocular pressure (IOP). A diagnosis of ocular hypertension was made in 747 patients (29.8% of referrals) and 125 (5.0%) were categorised as glaucoma suspects. There was no evidence of a diagnostic trend over the period of data collection. Treatment to lower IOP was commenced in 458 patients (18.3%). Nearly half of those referred, 1148 (45.8%), were discharged from ophthalmological review at the first visit. CONCLUSION: In this survey, the largest of its nature, only one in five subjects had glaucoma and nearly half were discharged from hospital ophthalmological review. The findings provide a baseline against which the effectiveness of any future system of glaucoma detection in the United Kingdom can be compared.

Direct costs of glaucoma and severity of the disease: a multinational long term study of resource utilisation in Europe.

BACKGROUND: Resource utilisation and direct costs associated with glaucoma progression in Europe are unknown. As population progressively ages, the economic impact of the disease will increase. METHODS: From a total of 1655 consecutive cases, the records of 194 patients were selected and stratified by disease severity. Record selection was based on diagnoses of primary open angle glaucoma, glaucoma suspect, ocular hypertension, or normal tension glaucoma; 5 years minimum follow up were required. Glaucoma severity was assessed using a six stage glaucoma staging system based on static threshold visual field parameters. Resource utilisation data were abstracted from the charts and unit costs were applied to estimate direct costs to the payer. Resource utilisation and estimated direct cost of treatment, per person year, were calculated. RESULTS: A statistically significant increasing linear trend (p = 0.018) in direct cost as disease severity worsened was demonstrated. The direct cost of treatment increased by an estimated 86 for each incremental step ranging from 455 euro per person year for stage 0 to 969 euro per person year for stage 4 disease. Medication costs ranged from 42% to 56% of total direct cost for all stages of disease. CONCLUSIONS: These results demonstrate for the first time in Europe that resource utilisation and direct medical costs of glaucoma management increase with worsening disease severity. Based on these findings, managing glaucoma and effectively delaying disease progression would be expected to significantly reduce the economic burden of this disease. These data are relevant to general practitioners and healthcare administrators who have a direct influence on the distribution of resources.

Ophthalmic complications after heart transplantation.

To ascertain the ophthalmic complications after heart transplantation, the authors reviewed 59 patients who had been referred to the ophthalmology department during a 4-year period and were subsequently followed for at least 1 year. Twenty-five patients (43%) were found to have lens changes in one or both eyes, which is typical of prolonged oral corticosteroid therapy. In three patients (5.2%) posterior subcapsular cataract formation progressed to a level where cataract surgery was required. In two patients (3.4%) cytomegalovirus retinitis developed within 6 months of the transplantation, and significant irreversible visual loss occurred. Retinal vascular changes were found in 22 patients (37.3%), including 18 patients with hypertensive retinopathy and one patient with background diabetic retinopathy. During the period of observation, a central retinal vein occlusion developed in one patient, an anterior ischemic optic neuropathy developed in one patient, and bilateral occipital lobe infarctions developed in one patient. Older patients and those with a longer survival time after transplantation were more likely to have ophthalmic complications (p = 0.04). Although these results indicate a low incidence of sight-threatening complications after heart transplantation, early referral of patients with visual symptoms is important. Those involved with the care of heart transplant patients should be aware of ocular complications secondary to immune suppression and underlying cardiovascular disease.

Variable expressivity of autosomal dominant microcornea with cataract.

Autosomal dominant microcornea with a cataract, previously described in four families, was documented in a seven-generation family. Eighteen family members had microcornea and a cataract, and an additional six had sclerocornea or Peters' anomaly. Most individuals with microcornea had a corneal diameter of less than 11 mm in both meridians, with moderately steep corneal curvatures. The inherited cataract progressed to form a total cataract after visual maturity had been achieved. In the four affected children who had not undergone cataract extraction, the common abnormality was a posterior polar lens opacity. The variability of expressivity of the dominant gene would suggest that the embryological origins of microcornea and sclerocornea are similar.

Granulomatous uveitis in Crohn's disease. A clinicopathologic case report.

Recurrent episodes of uveitis occurred in a young male patient with clinical as well as radiologic and histologic evidence of Crohn's ileocolitis. His left eye became blind and painful, and was enucleated. Histopathologic examination of the eye revealed a panuveitis with evidence of granuloma formation in the choroid. While granulomatous inflammation has previously been demonstrated in extraintestinal sites, to our knowledge, this is the first histopathologic evidence of granuloma formation within the eye in Crohn's disease.

The prevalence of primary angle closure glaucoma and open angle glaucoma in Mamre, western Cape, South Africa.

OBJECTIVE: To determine the prevalence of primary angle closure glaucoma in the so-called Cape people of mixed ethnic background. DESIGN: A population-based prevalence study. SETTING: Mamre, a village near Cape Town, South Africa. PARTICIPANTS: Individuals aged 40 years or older. Historically, their ancestors were Southeast Asians and indigenous Africans and, to a lesser extent, Europeans. Of a total of 1194 people, 987 (82.7%) were examined. MAIN OUTCOME MEASURE: Primary angle closure glaucoma was diagnosed in individuals with previous acute or intermittent symptoms of angle closure and in individuals with an "occludable" angle and an intraocular pressure of greater than 21 mm Hg or a glaucomatous visual field. MAIN RESULTS: An age-related trend toward hypermetropia was found, which was greatest in women older than age 50 years. Gonioscopy identified Shaffer grade 1 angles in 89 (9%) of 987 subjects. The prevalence of primary angle closure glaucoma was 2.3% (23 subjects) and increased with age in both sexes. Women were affected more than four times as often as men and the sex difference persisted across all age groups. In comparison, the prevalence of primary open angle glaucoma was 1.5% (15 subjects). Primary glaucoma (angle closure plus open angle) was the leading cause of bilateral blindness in the community, with a prevalence rate of 0.5% (five subjects). CONCLUSIONS: This study identified primary angle closure glaucoma as a significant public health problem in the Western Cape Province. Because of the ethnic back-ground of the people studied, these findings may also apply to the populations of Southeast Asia.

Visual loss with dancing extremities and mental disturbances.

A case is reported of a teenage girl, who presented with a profound loss of vision in the right eye, secondary to retinal vasculitis. During the preceding year, a gradual change in her personality had been noted, associated with a deterioration in her intellect. She developed an area of pigment epithelial disturbance in the macular region of the right eye, and subsequently, optic atrophy. One year after this, she had a similar, but more localized episode in the left eye. She later developed involuntary movements, and two years after initial presentation, a diagnosis of subacute sclerosing panencephalitis was made. Subsequently her clinical condition deteriorated rapidly and she died. Post-mortem examination confirmed the diagnosis of subacute sclerosing panencephalitis. This case demonstrates the insidious nature of the disease and suggests that the diagnosis of subacute sclerosing panencephalitis should be considered in any child or young adult who presents with unexplained retinal vasculitis, maculopathy or chorioretinitis.

Siderosis bulbi resulting from an intralenticular foreign body.

PURPOSE: To report a case of siderosis bulbi that resulted from a small intralenticular foreign body. METHOD: Case report. RESULTS: A 36-year-old man with normal visual acuity and a peripheral intralenticular iron foreign body in the left eye was treated conservatively. Nine weeks after the injury, he had ocular signs of siderosis bulbi, with changes in the electroretinogram. A clear lens aspiration with removal of the foreign body was performed. After removal of the iron foreign body, no progression or regression of the ocular signs of siderosis bulbi has occurred, and the electroretinogram has not changed over a 2-year period. CONCLUSIONS: Even in the presence of good vision, a patient with an intralenticular ferrous foreign body should be followed closely, and the foreign body should be removed before irreversible siderosis bulbi occurs.

Neovascular glaucoma as a complication of retinal vasculitis in Crohn disease.

PURPOSE: To report a case of neovascular glaucoma as a complication of retinal vasculitis in Crohn disease. METHODS: Case report with fluorescein angiogram. RESULTS: A 62-year-old man with biopsy-proven Crohn disease presented with bilateral uveitis, bilateral iris new vessels, and neovascular glaucoma in the left eye. Fluorescein angiography revealed signs of retinal vasculitis and capillary nonperfusion in both eyes. CONCLUSION: Crohn disease may be associated with retinal vasculitis and, thus, neovascular glaucoma. A satisfactory result can be achieved by using corticosteroids to control the retinal vascular inflammation, by applying panretinal photocoagulation and by controlling the increased intraocular pressure surgically.

Anterior uveitis as a side effect of topical brimonidine.

PURPOSE: To report anterior uveitis as a late side-effect of topical brimonidine tartrate 0.2% (Alphagan; Allergan Inc., Irvine, California). METHODS: Four patients aged 79 to 91 (mean, 83) years, who developed acute anterior uveitis while using topical brimonidine for chronic glaucoma, were clinically evaluated for causes of uveitis. When the inflammation had completely cleared, topical brimonidine was recommenced in one eye only to determine causality. RESULTS: All four patients developed acute granulomatous anterior uveitis, which resolved rapidly on stopping brimonidine and receiving treatment with topical corticosteroids. The uveitis occurred 11 to 15 (mean, 13.8) months after commencement of brimonidine 0.2% twice daily. None of the patients had a previous history of uveitis, and no other identifiable cause of uveitis was found. In all patients, on rechallenge with brimonidine instilled twice daily to one eye, uveitis recurred within 3 weeks in that eye only. CONCLUSIONS: These findings suggest that brimonidine can cause anterior uveitis as a late side effect. The inflammation settles rapidly on stopping the medication and on using topical corticosteroids and recurs on rechallenge with brimonidine.

Trabeculectomy with mitomycin C for refractory glaucoma in blacks.

The use of one intraoperative application of mitomycin C at the filtration site has been effective in eyes at increased risk for failure of routine trabeculectomy. To study the efficacy and safety of this technique in patients with refractory glaucoma, we prospectively examined 30 eyes of 26 black patients in whom a 0.2-mg/ml solution of mitomycin C was applied between Tenon's capsule and the sclera for five minutes before trabeculectomy. The results were compared to those found in a matched group of 30 eyes of 28 patients who underwent trabeculectomy without mitomycin C. The mean postoperative intraocular pressures were significantly lower in the mitomycin C group than in the control group (P = .001). Of the 30 eyes in the mitomycin C group, 25 (83%) had an intraocular pressure of less than 21 mm Hg without glaucoma medication, compared to 11 of 30 (37%) in the control group (P = .00006). In the mitomycin C group, 19 eyes (63%) developed a cystic avascular thin-walled filtering bleb, four eyes (13%) a late positive Seidel test, and one eye slight scleral thinning over the area where the mitomycin C was applied. Although mitomycin C is effective when used in this manner, further study is required to determine the long-term complications.

Duane's retraction syndrome associated with chromosome 4q27-31 segment deletion.

PURPOSE/METHOD: A 15-year-old boy with bilateral blepharoptosis, bilateral type 1 Duane's retraction syndrome, and mild learning difficulties underwent chromosomal analysis. RESULTS/CONCLUSIONS: A de novo deletion of a segment of the long arm of chromosome 4 (4q27-31) was found. To our knowledge, no other individuals with this chromosome deletion have Duane's retraction syndrome. The chromosome defect lies close to the epidermal growth factor gene, 4q25, which was recently linked to Rieger's syndrome. We suggest that families with Duane's retraction syndrome should be assessed for linkage to the area of 4q27-31.

Acute scleritis in porphyria cutanea tarda.

We examined three patients who had dermatologic and biochemical manifestations of porphyria cutanea tarda and localized thinning or excavation in the sun-exposed interpalpebral sclera, adjacent to the cornea. All three patients had signs of acute scleritis. The acute scleritis responded to oral indomethacin in one patient, but systemic corticosteroids were required to control the inflammation in the other two patients. Phlebotomy, protection from sunlight, and refraining from alcohol played an important part in the treatment of the patients.

Cavernous-dural fistula with secondary angle-closure glaucoma.

PURPOSE: To report a rare case of angle-closure glaucoma, secondary to the rapid development of a choroidal effusion, in a patient with a long-standing cavernous-dural shunt. METHODS: Case report. Investigations included computed tomographic scan, magnetic resonance imaging, and carotid angiography. RESULTS: The development of the choroidal effusion occurred because of partial thrombosis of the ipsilateral superior ophthalmic vein and cavernous sinus. Drainage of the choroidal effusion resolved the angle-closure glaucoma. CONCLUSIONS: The combination of worsening signs and evidence of thrombosis indicates impending resolution of a cavernous-dural shunt. However, if a choroidal effusion causes angle-closure glaucoma, prompt surgical drainage should be considered to prevent permanent peripheral anterior synechiae formation, with the expectation that the effusion will not recur.

Long term results and complications of trabeculectomy augmented with low dose mitomycin C in patients at risk for filtration failure.

AIM: To determine the results and complications up to 5 years after trabeculectomy with 0.02% mitomycin C (MMC) in glaucoma patients at risk for failure of filtration surgery. METHODS: A consecutive series of 21 eyes from 20 patients who underwent trabeculectomy with MMC 0.02%, with an exposure time of 2 minutes, was retrospectively analysed and the results were compared with previously published data. RESULTS: The mean preoperative intraocular pressure (IOP) was 28 mm Hg on an average of 2.8 glaucoma medications, and the mean postoperative IOP after 3 years was 14 mm Hg on an average of 0.4 medications. Three years after trabeculectomy, 17 of 21 (80.9%) eyes had an IOP of less than 21 mm Hg without medical treatment. Using Kaplan-Meier life table analysis the 5 year probability of an IOP less than 21 mm Hg without medication was 67% and with medication was 90%. Two patients required further glaucoma surgery during the first postoperative year, and another developed hypotonous maculopathy which was reversed after bleb revision. Seven patients developed visually significant cataract as a late consequence of the surgery. There were no bleb related infections. CONCLUSION: In the long term MMC 0.02% used for 2 minutes intraoperatively is an effective adjunctive treatment in glaucoma patients at risk for bleb failure and in this dose is associated with few complications.

Long term effect on intraocular pressure of phacotrabeculectomy compared to trabeculectomy.

AIM: To compare the long term mean intraocular pressure (IOP) reduction after non-augmented single site phacotrabeculectomy with that after trabeculectomy and to determine the relation between preoperative IOP and IOP reduction. METHODS: A group of 44 consecutive patients with chronic open angle glaucoma who underwent phacotrabeculectomy were matched to a trabeculectomy control group and the results of surgery were compared. Linear regression analysis of preoperative IOP and IOP reduction was undertaken. RESULTS: The mean IOP reduction was significantly less in the phacotrabeculectomy group (6.7 (SD 2.1) mm Hg) than in the trabeculectomy group (11.0 (1.4) mm Hg) (p=0.0017). There was a significant difference in surgical success between the groups. The preoperative IOP was significantly related to the postoperative reduction in IOP in both groups (p<0.001). CONCLUSIONS: In elderly white patients with chronic open angle glaucoma, phacotrabeculectomy is not as effective as trabeculectomy in reducing IOP. In both procedures the magnitude of IOP reduction is proportional to the preoperative IOP.

Intravenous sedation for ocular surgery under local anaesthesia.

Anterior segment ophthalmic surgery is commonly performed under local anaesthesia. In order to improve patient comfort, a variety of sedation techniques has been employed in the past. The object of this study was, firstly, to determine whether continuous intravenous sedation during surgery offered any advantages in patients premedicated with temazepam and metoclopramide, and, secondly, to compare midazolam to propofol for this purpose. Forty nine patients were randomly allocated to receive no intravenous sedation (n = 15), continuous propofol infusion (n = 17), or continuous intravenous midazolam infusion (n = 17) after peribulbar anaesthesia. Each technique provided cardiovascular and respiratory stability and allowed early recovery with minimal postoperative sequelae. Unexpected ocular field movement occurred more commonly in the patients receiving intravenous sedation, although statistical significance was not shown (p = 0.06). Significantly more patients in the intravenous sedation groups reported amnesia (p = 0.03). Patient acceptability was good irrespective of the technique used. This study suggests that continuous sedation using propofol or midazolam is not beneficial and should be avoided in ophthalmic patients who have received a simple premedication.

Post-traumatic angle recession glaucoma: a risk factor for bleb failure after trabeculectomy.

In order to determine if post-traumatic angle recession is a risk factor for failure of glaucoma filtering surgery independent of age or race, the surgical results of trabeculectomy performed in 35 consecutive patients with angle recession glaucoma were compared with those of 35 matched patients with primary open angle glaucoma. A postoperative intraocular pressure of < or = 21 mm Hg (with or without glaucoma medication) was found in 15 of the 35 (43%) patients with angle recession glaucoma compared with 26 of the 35 (74%) patients with primary open angle glaucoma. The long term success of trabeculectomy was significantly worse in angle recession glaucoma when the results were analysed using Kaplan-Meier survival curves. Bleb failure occurred a mean period of 3.1 (SD 1.2) months after trabeculectomy in angle recession glaucoma compared with 9.4 (5) months in primary open angle glaucoma (p < or = 0.001). The finding that posttraumatic angle recession is a risk factor for failure of trabeculectomy, supports the use of antimetabolite therapy to suppress fibrosis after trabeculectomy in these patients.