Primary open-angle glaucoma in a population associated with high prevalence of primary angle-closure glaucoma: the Kumejima Study.

PURPOSE: To evaluate the prevalence of and risk factors for primary open-angle glaucoma (POAG) in a rural population of southwestern Japan. DESIGN: Population-based cross-sectional study. PARTICIPANTS: All residents 40 years of age and older in Kumejima, Okinawa, Japan. METHODS: Of the eligible 4632 residents 40 years of age and older, 3762 subjects (participant rate, 81.2%) underwent screening examinations, including visual acuity (VA) measurement, slit-lamp examination, Goldmann applanation tonometry, gonioscopy, undilated stereoscopic fundus photographs, autorefractometry, noncontact specular microscopy, pachymetry, and visual field (VF) testing using frequency-doubling technology. If glaucoma or other related ocular disorders were suspected, subjects were referred for definitive examinations including VF testing with the Humphrey Field Analyzer. The diagnosis of POAG was based on the criteria of the International Society for Geographical and Epidemiological Ophthalmology. MAIN OUTCOME MEASURES: Prevalence and risk factors of POAG. RESULTS: The prevalence of POAG was 4.0% (95% confidence interval [CI], 3.4%-4.7%); 82% of patients had an intraocular pressure (IOP) less than 22 mmHg, resulting in a prevalence of 3.3% (95% CI, 2.8%-3.9%). Because of POAG, 3 subjects had a VA worse than 20/400 in only 1 eye, and 1 subject had VA loss of worse than 20/400 bilaterally. The average IOP values (mean ± standard deviation) were 14.9 ± 3.2 and 14.6 ± 3.3 mmHg in the right and left eyes, respectively; the IOP values were higher in patients with POAG (15.4 ± 3.3 and 15.2 ± 3.3 mmHg, respectively) than in subjects without glaucoma (14.8 ± 3.1 and 14.4 ± 3.1 mmHg, respectively; P<0.045, Student t test). Multivariate analysis showed that male gender (P = 0.003), older age (P<0.001), higher IOP (P<0.001), longer axial length (P<0.001), and thinner central cornea (P = 0.006) were associated with POAG. CONCLUSIONS: High prevalence rates of POAG (4.0%) and POAG with normal IOP levels (3.3%), which were comparable with those on the Japanese mainland, were found in a southwestern rural island of Japan, where the prevalence of primary angle-closure glaucoma (previously reported as 2.2%) was considerably higher than on the Japanese mainland (0.6% in the Tajimi Study) or other countries. The risk factors for POAG included male gender, older age, higher IOP, myopia, and a thinner cornea.

Prevalence of primary angle closure and primary angle-closure glaucoma in a southwestern rural population of Japan: the Kumejima Study.

PURPOSE: To determine the prevalence and ocular biometry of primary angle closure (PAC) and primary angle-closure glaucoma (PACG) in a rural population in southwestern Japan. DESIGN: Population-based cross-sectional study. PARTICIPANTS: All residents aged 40 years or older in Kumejima, Okinawa, Japan. INTERVENTION: Of the 4632 residents 40 years of age or older, 3762 (participation rate, 81.2%) underwent a detailed ocular examination, including measurement of the best-corrected visual acuity, slit-lamp examination, Goldmann applanation tonometry, static and dynamic gonioscopy, undilated stereoscopic optic fundus photographs, autorefractometry, partial coherence laser interferometry, noncontact specular microscopy, and screening visual field (VF) testing using frequency-doubling technology. If glaucoma or related or other ocular disorders were suspected, the subject was referred for a definitive examination including VF testing with the 24-2 Swedish Interactive Thresholding Algorithm Standard program of the Humphrey Field Analyzer (Carl Zeiss Meditec, Dublin, CA). MAIN OUTCOME MEASURES: Prevalence rates of primary angle-closure suspects (PACS), PAC, PACG, and PACG suspects. RESULTS: Under the standard definitions of the International Society of Geographical and Epidemiological Ophthalmology, the prevalence rates of PACS, PAC, and PACG were 8.8%, 3.7%, and 2.0%. Extending the diagnosis of PAC and PACG to include people with narrow but open angles and primary peripheral anterior synechiae, the prevalence rates of PAC and PACG increased to 6.0% and 2.2%, respectively. Hence, broadening the diagnostic categories in PAC and PACG increased the prevalence rates by 62% and 10%. Twenty-three subjects (0.6%; 95% confidence interval, 0.4%-0.9%) had a history of or were diagnosed with acute PAC. Older age, female gender, hyperopic refractive error, short axial length, and shallow anterior chamber depth were independent predictors of an occludable angle. CONCLUSIONS: The prevalence of PACG in Kumejima (2.2%) was one of the highest reported in population-based studies, that is, 3.7 times higher than in the Tajimi Study carried out in an urban center located in the central area of the main island of Japan. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Effects of long-term topical anti-glaucoma medications on meibomian glands.

OBJECTIVE: To examine effects of long-term topical anti-glaucoma medications on meibomian gland morphology and function and assess their relationship with slit-lamp findings. METHODS: This was a cross-sectional observational case series of 31 patients with glaucoma (mean age ± standard deviation, 65.0 ± 13.0 years; mean duration of eye drop use, 7.9 ± 6.0 years) treated with topical anti-glaucoma drugs in only one eye for more than 1 year: 13 receiving prostaglandin analogues (PGs) alone, eight receiving ß-blockers alone, and ten receiving multiple treatments. Untreated contralateral eyes served as controls. Lid margin (lid margin abnormality score: 0-4) and superficial punctate keratopathy (SPK score: 0-1) were observed with a slit lamp. Upper and lower eyelids were turned over to observe meibomian glands using non-contact meibography. Meibomian gland loss was scored for each eyelid from grade 0 (no loss of meibomian glands) through grade 3 (loss >2/3 of total meibomian gland area). Meibomian lipid content (meibum) was scored (meibum score: 0-3). RESULTS: Treated eyes had significantly higher scores for lid margin abnormality (P= 0.001), SPK (P< 0.001), meibo-score (P< 0.001), and meibum (P< 0.001) than control eyes. Tear film break-up time (BUT) was significantly shorter in treated eyes than in control eyes (P= 0.001). Schirmer values were significantly lower in treated eyes than in control eyes (P= 0.0039). Subgroup analysis indicated a significantly higher meibo-score in eyes treated with PGs (P= 0.0046) and in eyes treated with ß-blockers (P= 0.0231) than in the corresponding controls. CONCLUSIONS: Long-term anti-glaucoma eye drop use affects meibomian gland morphology and function.

[Imagings of glaucoma: characteristics of ocular configurations and automated diagnosis].

Glaucoma is characterized by the coexistence of structural changes in the fundus and the corresponding functional abnormalities. The advances in imaging devices that reveal structural changes in glaucoma should facilitate reliable diagnosis of early or preperimetric glaucoma and a proper evaluation of glaucoma progression. Moreover, the increase in our knowledge of structural changes in glaucoma will provide a better platform for investigating up to now unknown glaucoma etiologies. In this review, we summarize a series of our clinical investigations of glaucoma imaging technologies. The diagnostic performance of Heidelberg Retina Tomograph (HRT) II and the characteristics of the HRT II parameters in high myopia were studied with population-based data to provide data for nerve head configuration; the correlation of parameters determined by planimetry of optic disc stereophotography with the results of the HRT II was evaluated; optic disc parameters were determined based on spectral-domain optical coherence tomography (SD-OCT); and optic disc configurations were evaluated in eyes with peripapillary atrophy and eyes with superior segmental optic nerve hypoplasia. Peripapillary retinal nerve fiber layer (RNFL) thickness was determined with SD-OCT in normal Japanese eyes; and the diagnostic performance of RNFL thickness was studied. The characteristics of each layer, including retinal nerve fiber layer, ganglion cell layer, and each complex layer in the macular area, and their correlation with the stages of glaucoma were evaluated. Finally, imaging of the anterior chamber angle using ultrasound biomicroscopy (UBM) were studied about the distribution of the UBM parameters in a Japanese population and the factors relating to the presence of peripheral anterior synechia in narrow angle eyes.

Evaluation of anterior chamber angle by van Herick grading and ultrasound biomicroscopy in light and dark conditions for finding appositional angle closure and plateau iris configuration.

PURPOSE: To evaluate association of the van Herick (VH) grades with the ultrasound biomicroscopic (UBM) parameters, appositional irido-trabecular contact (A-ITC) and plateau iris (PI) in a randomly sampled population. METHODS: A 10% random sample of all residents aged 40 or older of the Kumejima study underwent UBM under dark and light conditions in the four quadrants of right eyes. RESULTS: Of 301 right eyes with eligible UBM images, 101 (33.6%) and 200 (66.4%) were classified as VH ≤ 2 and VH ≥ 3, respectively. The UBM parameters on angle width and ciliary body configuration were significantly different between VH ≤ 2 and VH ≥ 3 eyes (p < 0.001). A-ITC was found in at least one quadrant in 54.5% and 75.2% of VH ≤ 2 eyes under light and dark conditions, respectively; and 20.5% and 45.5% of VH ≥ 3 eyes. When 'VH ≤ 2' was used to screen eyes with A-ITC in three or more quadrants, the sensitivity and specificity were 74.1% and 75.3%, respectively. A-ITC was significantly associated with shallower anterior chamber (p = 0.018) and higher intraocular pressure (p = 0.044) in VH ≥ 3 eyes. Plateau iris (PI) was found in 15.8% and 6.0% of VH ≤ 2 and VH ≥ 3 eyes, respectively. Plateau iris (PI) was significantly associated with the UBM parameters on angle width and ciliary body configuration. When 'VH ≤ 2' was used to screen eyes with PI, the sensitivity and specificity were 57.1% and 68.9%, respectively. CONCLUSIONS: The VH grade of ≤2 and ≥3 showed significant association with UBM angle width and ciliary body configuration parameters. The VH ≤ 2 criterion should be useful for screening of A-ITC and PI.

Correlation of disc morphology quantified on stereophotographs to results by Heidelberg Retina Tomograph II, GDx variable corneal compensation, and visual field tests.

PURPOSE: Quantification of disc morphology by computer-assisted planimetry on stereophotographs and to compare the results with those by other fundus structure imaging devices and visual field tests. DESIGN: Cross-sectional study. PARTICIPANTS: Fifteen normal eyes of 15 normal subjects and 69 glaucomatous eyes of 69 open-angle glaucoma patients. METHODS: Sequential digital stereophotographs of the optic discs were obtained by a nonmydriatic fundus camera. Intraobserver reproducibility for the 3 repeated traces and interobserver reproducibility for the three individual examiners were determined. The obtained results were correlated to those by Heidelberg Retina Tomograph (HRT) II, GDx with variable corneal compensation (VCC) and visual field tests obtained within 2 months of the photography. MAIN OUTCOME MEASURES: Optic disc parameters such as disc area, cup area, rim/disc area ratio, vertical cup diameter/disc diameter (Cd/Dd) ratio and rim width/disc diameter (Rw/Dd) ratio at radial arbitrary angles. Interclass correlation coefficients (ICC) and coefficients of variance (CV) for the optic disc parameters and their correlation with HRT II, GDx VCC, and visual field test results. RESULTS: Intra- and interobserver ICC and CV were 0.88 to 0.99, 1.1% to 9.6%, and 0.72 to 0.98, 2.2% to 11.9% for area parameters, 0.81 to 0.92, 2.4% to 4.0% and 0.71 to 0.78, 4.3% to 5.0% for Cd/Dd ratio, and 0.73 to 0.91, 9.2% to 23.0% and 0.65 to 0.82, 16.9% to 27.2% for Rw/Dd ratios, respectively. Significant correlation was seen between disc and cup area and the corresponding parameters by HRT II (r(s) > 0.81; P<0.001), as well as between vertical Cd/Dd ratio and global TSNIT average by GDx VCC and visual field test indices (|r(s)| > 0.51; P<0.001), and between superior and inferior Rw/Dd ratio and their corresponding sectoral HRT II, GDx VCC and visual field test indices (r(s) > 0.31; P<0.006), respectively. Correlation with visual field test indices was comparable among stereophotographs, HRT II, and GDx VCC parameters. CONCLUSIONS: Optic disc morphologic parameters quantified on stereophotographs by our software showed satisfactory reproducibility and good correlation with those measured by other fundus structure imaging devices and visual field test results, indicating its clinical usefulness, especially in the mass screening of glaucoma.

Prevalence and causes of low vision and blindness in a rural Southwest Island of Japan: the Kumejima study.

PURPOSE: To determine the prevalence and causes of low vision and blindness in an adult population on a rural southwest island of Japan. DESIGN: Population-based, cross-sectional study. PARTICIPANTS: All residents of Kumejima Island, Japan, 40 years of age and older. METHODS: Of the 4632 residents 40 years of age and older, 3762 (response rate, 81.2%) underwent a detailed ocular examination including measurement of the best-corrected visual acuity (BCVA) with a Landolt ring chart at 5 m. The age- and gender-specific prevalence rates of low vision and blindness were estimated and causes were identified. MAIN OUTCOME MEASURES: Low vision and blindness were defined, according to the definition of the World Health Organization, as a BCVA in the better eye below 20/60 to a lower limit of 20/400 and worse than 20/400, respectively. RESULTS: The prevalence of bilateral low vision was 0.58% (95% confidence interval [CI], 0.38-0.89). The primary causes of low vision were cataract (0.11%), corneal opacity (0.08%), retinitis pigmentosa (RP; 0.06%), and diabetic retinopathy (0.06%). The prevalence of bilateral blindness was 0.39% (95% CI, 0.23-0.65). The primary causes of blindness were RP (0.17%) and glaucoma (0.11%). The primary causes of monocular low vision were cataract (0.65%), corneal opacity (0.16%), age-related macular degeneration (0.16%), and diabetic retinopathy (0.11%), whereas those of monocular blindness were cataract (0.29%), trauma (0.25%), and glaucoma (0.22%). Logistic analysis showed that female gender (P = 0.001; odds ratio [OR], 7.37; 95% CI, 2.20-24.71) and lower body weight (P = 0.015; OR, 0.94; 95% CI, 0.90-0.99) were associated significantly with visual impairment. CONCLUSIONS: The prevalences of low vision and blindness in the adult residents of an island in southwest Japan were 1.5 to 3 times higher than the prevalences reported in an urban city on the Japanese mainland. The prevalence of visual impairment caused by RP on this island was much higher than on the mainland, suggesting a genetic characteristic of the population. Furthermore, the prevalence of visual impairment resulting from cataract and corneal opacity was higher than that on the mainland. The prevalence of visual impairment resulting from myopic macular degeneration was less.

Ultrasound biomicroscopic configurations of the anterior ocular segment in a population-based study the Kumejima Study.

PURPOSE: To characterize quantitatively the configuration of the anterior ocular segment with ultrasound biomicroscopy (UBM) in a population-based setting. DESIGN: Cross-sectional study. PARTICIPANTS: Ten percent of 4632 residents aged > or =40 years of Kumejima, an island off southwest Japan, were randomly selected. METHODS: We performed UBM under light and dark conditions in the 4 quadrants of the right eyes. The anatomic landmarks on the anterior ocular segment UBM images were identified by 1 examiner to quantify the peripheral anterior chamber depth (ACD), location of the ciliary body, and iris thickness. MAIN OUTCOME MEASURES: Angle-opening distance at 250 and 500 microm from the scleral spur (AOD250, AOD500), trabecular-iris angle (TIA), trabecular-ciliary process distance (TCPD), thickness of the iris (ID), trabecular-anterior iris surface angle (TAIA), trabecular-posterior iris surface angle (TPIA), trabecular-ciliary angle (TCA), and thickness of iris measured at 1000, 2000, and 3000 microm (IT1000, IT2000 and IT3000). RESULTS: The AOD500 averaged 0.267+/-0.138 (mean +/- standard deviation) and 0.202+/-0.116 mm under light and dark conditions, respectively; TIA 22.2+/-10.0 and 17.0+/-8.9 degrees; TCPD 0.755+/-0.165 and 0.748+/-0.152 mm; and ID 0.412+/-0.053 and 0.457+/-0.062 mm. The peripheral ACD was deepest temporally, then nasally, then inferiorly, and then superiorly (P<0.05, post hoc test). The position of the ciliary body was deepest nasally, then temporally, then inferiorly, and then superiorly (P<0.05). Iris thickness did not differ significantly among the quadrants. Older subjects had a shallower peripheral ACD, more anteriorly located ciliary body, and thinner iris (analysis of covariance, P<0.015). The peripheral ACD was deeper and the ciliary body was located more deeply in men than women (P<0.05), although no intergender differences in iris thickness were seen (P>0.1). Hyperopia, short axial length, and shallow central ACD were significantly correlated with shallower peripheral ACD, anteriorly located ciliary body, and thinner iris (P<0.05). Elevated intraocular pressure was associated with a shallow peripheral ACD (P< or =0.043). CONCLUSIONS: There are significant associations of the peripheral ACD, location of the ciliary body, and iris thickness with age, gender, refractive error, axial length, and intraocular pressure.

Automated layer segmentation of macular OCT images using dual-scale gradient information.

A novel automated boundary segmentation algorithm is proposed for fast and reliable quantification of nine intra-retinal boundaries in optical coherence tomography (OCT) images. The algorithm employs a two-step segmentation schema based on gradient information in dual scales, utilizing local and complementary global gradient information simultaneously. A shortest path search is applied to optimize the edge selection. The segmentation algorithm was validated with independent manual segmentation and a reproducibility study. It demonstrates high accuracy and reproducibility in segmenting normal 3D OCT volumes. The execution time is about 16 seconds per volume (480x512x128 voxels). The algorithm shows potential for quantifying images from diseased retinas as well.

Nerve fiber layer thickness in exudative age-related macular degeneration in Japanese patients.

PURPOSE: To examine the peripapillary retinal nerve fiber (RNFL) thickness in Japanese patients with two major forms of exudative age-related macular degeneration (AMD), i.e., typical AMD and polypoidal choroidal vasculopathy (PCV). METHODS: This is a prospective observational consecutive study. One hundred patients diagnosed with unilateral exudative AMD, with the fellow eyes free of exudative change, were included. Peripapillary RNFL thickness was measured using three-dimensional Fourier-domain optical coherence tomography (3D-OCT). Peripapillary RNFL thickness was compared between the affected eyes and fellow eyes in 100 patients. RESULTS: RNFL thickness in the eyes with exudative AMD did not differ significantly from the fellow eyes. There was also no association between the lesion size and the peripapillary RNFL thickness. CONCLUSION: There is no relationship between exudative AMD and peripapillary RNFL thickness in Japanese patients.

Pseudoexfoliation syndrome and relating factors in a rural Japanese population: the Kumejima Study.

PURPOSE: To report the prevalence of pseudoexfoliation (PEX) syndrome and glaucoma associated with PEX (PEX-G) and their relating factors of them in a south-western island of Japan. METHODS: A population-based survey of all residents aged ≥ 40 years was conducted in Kumejima, Okinawa, Japan, and 3762 subjects (participation rate, 81.2%) underwent detailed ophthalmic examinations. Presence of PEX material on the lens capsule, iris surface and/or pupillary margin was determined by slit-lamp biomicroscopy. Glaucoma was diagnosed according to the criteria of the International Society of Geographical and Epidemiological Ophthalmology. RESULTS: In subjects aged ≥ 40 years, prevalence rates of PEX syndrome, PEX without glaucoma and PEX-G in at least one eye were 1.5% (95% confidence interval [CI]: 1.0-1.9%), 1.3% (95% CI: 0.9-1.7%) and 0.1% (95% CI: 0.0-0.2%), respectively, excluding eyes after cataract surgery; and 2.8% (95% CI: 2.3-3.3%), 2.2% (95% CI: 1.8-2.6 %) and 0.4% (95% CI: 0.2-0.6%), respectively, including eyes after cataract surgery. Cataract surgery had been performed in 61% of subjects with PEX in at least one eye; presence of PEX showed no significant effects on the intraocular pressure (IOP). A multivariate analysis showed that PEX was associated with older age (p < 0.0001, odds ratio: 1.10 [95% CI: 1.07-1.13]) and working outdoors (p = 0.0395, odds ratio: 2.18 [95% CI: 0.99-4.82]). CONCLUSIONS: The prevalence rates of PEX syndrome and PEX-G in a south-western island of Japan were reported. PEX showed no significant effect on IOP, and age and working outdoors were significantly related with PEX.

Spatial and Temporal Relationship between Structural Progression and Disc Hemorrhage in Glaucoma in a 3-Year Prospective Study.

PURPOSE: To investigate the spatial and temporal relationship between disc hemorrhage (DH) and structural progression in patients with primary open-angle glaucoma (POAG) in a 3-year prospective study. DESIGN: Prospective cohort study. PARTICIPANTS: Patients with POAG and intraocular pressure of ≤18 mmHg on monotherapy with prostaglandin analogs. METHODS: Fundus photographs were taken at baseline and every 3 months for 3 years. Disc hemorrhage and structural progression were detected independently by flicker chronoscopy. If present, clock-hour disc locations in the right eye format and colocalization were determined. Statistical comparisons were based on mixed-effects models accounting for the correlation between different disc sites within the same eye and between fellow eyes in the same patient. MAIN OUTCOME MEASURES: Relationship between DH and structural progression at the same site. RESULTS: Among 195 eyes of 115 patients, DH appeared in 85 sites in 65 eyes (33.3%) and was most frequently at the 7 o'clock disc location (29.4%, P < 0.0001). Structural progression occurred at 63 sites of 52 eyes (26.7%) comparably in both superior and inferior hemidiscs, which was mostly detected as widening of the retinal nerve fiber layer defects (RNFLDs). Temporal RNFLD widening was common, whereas nasal widening occurred exclusively in the vertical quadrants (P = 0.035). Of 41 progression sites in eyes with DH, 28 sites (68.2%) had both DH and progression. Progression sites with DH were less common in the superior quadrant than in the inferior and temporal quadrants (P = 0.011). Eyes with DH had a significantly higher risk of progression than eyes without DH (hazard ratio, 3.72; P < 0.0001). For 63 progression sites, DH recurrence and more visits with DH at the progression site were significantly associated with shorter time to progression from baseline (P = 0.021, P = 0.017, respectively), whereas colocalization of DH and progression were not. CONCLUSIONS: In a 3-year prospective study with a Japanese POAG cohort, the relationship between DH and RNFLD and the pattern of RNFLD progression differed by disc location. The association between more frequent DH at the progression site and shorter time to progression indicates that DH may reflect vulnerability to same-site structural deterioration.

Sensitivity and specificity of the Heidelberg Retina Tomograph II Version 3.0 in a population-based study: the Tajimi Study.

PURPOSE: To evaluate the sensitivity and specificity of the 3 glaucoma classification programs, the FS Mikelberg discriminant function (FSM), Moorfields Regression Analysis (MRA), and Glaucoma Probability Score (GPS) of version 3.0 of the Heidelberg Retina Tomograph (HRT) II (Heidelberg Engineering, Dossenheim, Germany), in a population-based setting for the first time. DESIGN: Population-based cross-sectional study. PARTICIPANTS: One randomly chosen eye of each subject without glaucoma, subject with glaucoma, and subject with suspected glaucoma with reliable HRT II measurements from the Tajimi study (2297 eyes of 2297 subjects) were included for analysis. METHODS: Glaucoma was diagnosed by the optic disc and visual field findings according to the criteria of the International Society of Geographical and Epidemiological Ophthalmology. The sensitivity and specificity of FSM, MRA, and GPS were calculated. Characteristics of erroneously diagnosed glaucoma (false-negative) eyes and factors that influenced specificity with the 3 programs were investigated. MAIN OUTCOME MEASURES: Sensitivity and specificity of FSM, MRA, and GPS. RESULTS: Sensitivity and specificity varied significantly among the 3 programs: 59.1%, 39.4%, and 65.2% (P = 0.02 approximately 0.003, chi-square test), and 86.7%, 96.1%, and 83.0% (P<0.0001) with FMS, MRA, and GPS, respectively. MRA gave the lowest sensitivity but the highest specificity. Positive predictive values for these programs ranged between 0.10 and 0.23, whereas negative predictive values ranged between 0.98 and 0.99. False-negative eyes had significantly better visual field indexes (P<0.01 approximately 0.002, Mann-Whitney U test) and smaller cup and larger rim parameters compared with true-positive glaucoma eyes. Older age and hyperopia were negatively correlated with the specificity of GPS but not with that of FMS and MRA. Larger disc area was significantly associated with decreased specificity of all programs. CONCLUSIONS: In a population-based setting, the sensitivity of the HRT II was unsatisfactory with any of the classification programs, whereas specificity was satisfactory. A significant percentage of the glaucoma discs were labeled as normal, and eyes in the earlier stage of the disease appear to be more likely to be misdiagnosed as normal. Factors such as age, refraction, and disc area had an influence on specificity, but the degree of its influence was different for each classification program.

Proposed diagnostic criteria for obstructive meibomian gland dysfunction.

PURPOSE: To compare clinical findings between patients with obstructive meibomian gland dysfunction (MGD) and normal controls and to propose diagnostic criteria for obstructive MGD. DESIGN: Cross-sectional, observational case series. PARTICIPANTS: Fifty-three eyes of 53 patients (18 men, 35 women; age [mean +/- standard deviation] 71.4 +/- 10.0 years) who were diagnosed with obstructive MGD and 60 eyes of 60 healthy volunteers (22 men, 38 women; 71.0 +/- 9.3 years) as a control group. METHODS: Ocular symptoms were scored from 0 to 14 according to the number of existing symptoms. Lid margin abnormality was scored from 0 to 4 depending on the number of existing abnormalities. Meibomian gland changes were scored from 0 to 6 based on noncontact meibography (meibo-score). Superficial punctuate keratopathy (SPK) was scored from 0 to 3. Meibum was graded from 0 to 3 depending on the volume and quality. Tear film production was evaluated by Schirmer's test. Receiver operating characteristic curves with calculations of area under the curve (AUC) were used to describe the accuracy of each parameter to differentiate obstructive MGD from normal eyes. MAIN OUTCOME MEASURES: Ocular symptom score, lid margin abnormality score, meibo-score, meibum score, SPK score, tear film breakup time (BUT), and the Schirmer value. RESULTS: Ocular symptom score, lid margin abnormality score, meibo-score, meibum score, and SPK score were significantly higher in the obstructive MGD group than in the control group (P<0.0001 for all scores). The BUT was significantly shorter in the obstructive MGD group than in the control group (P<0.0001). The AUC values indicated that the ocular symptom score had the highest diagnostic power as a single parameter, followed by the lid margin abnormality score, meibo-score, and BUT. CONCLUSIONS: Based on these findings, we recommend that physicians use the ocular symptom score, lid margin abnormality score, and meibo-score to diagnose MGD. Obstructive MGD should be suspected when any 2 of the 3 scores are abnormal. Obstructive MGD is very likely when all 3 scores are abnormal.

Laser scanning tomography of optic discs of the normal Japanese population in a population-based setting.

OBJECTIVE: To evaluate the optic disc characteristics using the Heidelberg retina tomograph (HRT) II in a large sample of normal Japanese subjects. DESIGN: Cross-sectional study. PARTICIPANTS: A total of 3576 eyes of 2036 normal subjects, with good-quality HRT II images, of 6042 eyes of 3021 subjects aged 40 years or more who participated in the Tajimi Study, a population-based eye study in Japan. METHODS: Optic disc parameters were obtained using HRT II, and the association of gender, age, height, weight, blood pressure, ocular perfusion pressure, refraction, intraocular pressure (IOP), central corneal thickness (CCT), and disc size on HRT parameters was assessed using simple and multiple regression analyses. MAIN OUTCOME MEASURES: HRT parameters, including disc area, cup area, rim area, cup-to-disc area ratio, cup volume, rim volume, mean cup depth, maximum cup depth, height variation contour, cup shape measure, mean retinal nerve fiber layer (RNFL) thickness, and RNFL cross-sectional area, and the crude and partial correlations of the potential confounders with the HRT parameters. RESULTS: Disc area, cup-to-disc area ratio, and rim area averaged 2.06+/-0.41 mm(2) (mean+/-standard deviation), 0.23+/-0.13, and 1.55+/-0.29 mm(2), respectively. All HRT parameters were strongly or moderately correlated between right and left eyes (Pearson's correlation coefficients = 0.45-0.83, P<0.001). Absolute inter-eye differences in several HRT parameters were positively correlated with disc area (P<0.05). Multiple regression analyses adjusting for the confounders showed weak but significant correlations of height, refractive error, IOP, and CCT with several HRT parameters (partial correlation coefficient (absolute value) = 0.04-0.16, P<0.05), and moderate or weak but significant correlations of disc area with all HRT parameters (partial correlation coefficient [absolute value] = 0.05-0.73, P<0.05). Gender, weight, blood pressure, and ocular perfusion pressure did not significantly correlate with HRT parameters. CONCLUSIONS: This report presents reference data of normality for the HRT parameters based on a large sample of normal Japanese subjects. There were small but significant influences of height, refractive error, IOP, and CCT on several HRT parameters. Many HRT parameters were moderately or weakly affected by disc size. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Nontraumatic keratomycosis caused by Alternaria in a glaucoma patient.

A case of keratomycosis caused by Alternaria species in a patient with glaucoma is reported. A 55-year-old Japanese man who had been followed for developmental glaucoma presented with corneal ulcer in his right eye, which did not respond to antibacterial agents. There was no history of traumatic episode. Culture on potato dextrose agar from corneal scraping yielded Alternaria species. Topical amphotericin B treatment achieved recovery from ulceration although the corneal opacity remained.

Refractive errors in an elderly Japanese population: the Tajimi study.

PURPOSE: To evaluate the prevalence of refractive errors associated with age, gender, and central corneal thickness and to evaluate astigmatism in the refraction and keratometry in a randomly sampled elderly Japanese population. DESIGN: Population-based epidemiologic survey. PARTICIPANTS: A random sampling of residents of Tajimi, Japan, aged 40 years or older. A total of 3021 residents (participation rate, 78.1%) participated. METHODS: Each subject underwent screening examinations including autokeratorefractometry, subjective refraction, best-corrected visual acuity, central corneal thickness measurement, intraocular pressure measurement, slit-lamp examination, fundus photography, and visual field testing. MAIN OUTCOME MEASURES: The prevalence of myopia (spherical equivalent [SE], <-0.5 diopters [D]), high myopia (SE, <-5 D), hyperopia (SE, >0.5 D), refractive astigmatism (cylinder, >0.5 D), and anisometropia (difference in SE between eyes, >1.0 D), and the correlation of refractive errors with age, gender, and central corneal thickness. Astigmatism in the refraction and keratometry was analyzed using polar value analysis and the vector calculation method. RESULTS: The crude prevalence of myopia, high myopia, hyperopia, refractive astigmatism in the refraction, and anisometropia was 41.8% (95% confidence interval [CI], 40.0%-43.6%), 8.2% (95% CI, 7.2%-9.2%), 27.9% (95% CI, 26.3%-29.6%), 54.0% (95% CI, 52.1%-55.8%), and 15.1% (95% CI, 13.7%-16.4%), respectively. The prevalence of myopia decreased with age up to 70 to 79 years but increased slightly in patients 80 years and older; the prevalence of hyperopia showed the opposite trend. The prevalence of astigmatism and anisometropia was higher in the older age groups. No significant gender difference was found associated with the refractive status except for keratometric readings. Polar value analysis and the vector calculation method showed a trend toward against-the-rule astigmatism with increasing age in both refractive and keratometric astigmatism, with a discrepancy between the two. CONCLUSIONS: The overall prevalence of myopia (SE, <-0.5 diopters) was 41.8% in the study population, which is higher than that in population-based studies previously reported.

Optic disc and peripapillary morphology in unilateral nonarteritic anterior ischemic optic neuropathy and age- and refraction-matched normals.

PURPOSE: To compare optic disc morphologic features and peripapillary retinal nerve fiber layer (RNFL) thickness between the unaffected eyes of patients with unilateral nonarteritic anterior ischemic optic neuropathy (NAION) and their affected eyes and the eyes of age- and refraction-matched normal control subjects. DESIGN: Cross-sectional comparative study. PARTICIPANTS: Thirty-one patients with unilateral NAION and 62 age- and refraction-matched normal control subjects. METHODS: Optic disc morphologic features and peripapillary RNFL thickness were evaluated in both eyes of patients with unilateral NAION and in one randomly chosen eye of the normal control subjects. MAIN OUTCOME MEASURES: Optic disc and cup parameters were measured using the Heidelberg Retina Tomograph II (Heidelberg Engineering GmbH, Dossenheim, Germany), and RNFL thickness was measured by scanning laser polarimetry with variable corneal compensation (GDx VCC; Carl Zeiss Meditec, Dublin, CA). RESULTS: There was no significant difference in the disc area between the NAION affected eyes and the unaffected fellow eyes. The cup area, cup-to-disc area ratio, cup volume, and cup shape measure were greater, whereas the peripapillary RNFL thickness was smaller in the former than the latter (P = 0.001 to approximately 0.043). When the unaffected eyes of patients with NAION and the age- and refraction-matched normal control eyes were compared, the disc area, cup area, cup-to-disc area ratio, cup volume, mean cup depth, and cup shape measure were smaller in the former (P = 0.0006 to approximately 0.03); there was no significant difference in the RNFL thickness between the two (P>0.06). CONCLUSIONS: A comparison of the eyes with NAION and the fellow eyes indicated that the cup was slightly larger in the former than in the latter, suggesting the acquired enlargement of the cupping after NAION develops. A comparison of the unaffected fellow eyes in patients with NAION and the age- and refraction-matched normal control eyes suggested that a smaller disc area and smaller cupping were predisposing risk factors for the development of NAION.

A placebo-controlled 3-year study of a calcium blocker on visual field and ocular circulation in glaucoma with low-normal pressure.

PURPOSE: To study the 3-year effect of oral nilvadipine, a calcium antagonist, on visual field performance and ocular circulation in open-angle glaucoma (OAG) with low-normal intraocular pressure (IOP). DESIGN: A randomized, placebo-controlled, double-masked, single-center trial. PARTICIPANTS: Patients with OAG who were younger than 65 years and had untreated IOP consistently of 16 mmHg or less. INTERVENTION: Oral nilvadipine (2 mg twice daily) or placebo was assigned randomly to patients fulfilling the criteria by the minimization method of balancing the groups according to age, refraction, and the mean deviation (MD) value (Humphrey Perimeter 30-2 SITA Standard Program; Humphrey Instruments, Inc., San Leandro, CA) of the eye with less negative MD. No topical ocular hypotensive drugs were prescribed. Visual field testing was performed every 3 months; fundus examination and IOP, blood pressure, and pulse rate measurements were carried out every month; and quantitative indexes of circulation in the optic disc rim (NB(ONH)) and choroid in the foveal area (NB(fovea)) were determined using the laser speckle method at 0, 3, 6, 12, 18, 24, 30, and 36 months. MAIN OUTCOME MEASURES: The time courses of MD, NB(ONH), and NB(fovea) in the eye with less negative MD. RESULTS: Thirty-three patients were enrolled; 17 were assigned to nilvadipine and 16 were assigned to placebo; 13 in each group completed the study. No significant intergroup difference was seen in age, refraction, or baseline values of any of the parameters. During the 3-year period, the IOP averaged 12.6 mmHg in the nilvadipine group and 12.8 mmHg in the placebo group (P>0.1), and no significant change from baseline or intergroup difference was seen in blood pressure or pulse rate. The estimated slope of change in the MD was less negative in the nilvadipine than in the placebo group (-0.01 vs. -0.27 decibels/year; P = 0.040). The NB(ONH) and NB(fovea) values remained increased compared with baseline for the study period by approximately 30% to 40% only in the nilvadipine group, and the intergroup difference was significant (P = 0.003 for NB(ONH) and P = 0.007 for NB(fovea)). CONCLUSIONS: Nilvadipine (2 mg twice daily) slightly slowed the visual field progression and maintained the optic disc rim, and the posterior choroidal circulation increased over 3 years in patients with OAG with low-normal IOP.

Scanning laser polarimetry with enhanced corneal compensation in patients with open-angle glaucoma.

AIMS: To compare the retinal nerve fiber layer thickness (RNFLT) parameters obtained with newly introduced GDx with enhanced corneal compensation (ECC) and those with GDx with variable corneal compensation (VCC) and to evaluate their reproducibility and the correspondence with visual field damage (VFD) in total or sectorized fields in association with refractive errors in open-angle glaucoma (OAG) patients. PATIENTS AND METHODS: Measurement reproducibility was assessed in 30 normal and 30 OAG eyes. Correlation between the RNFLT parameters and the corresponding VFD was evaluated in 58 OAG eyes. RESULTS: All parameters of both GDx VCC and ECC showed high intraclass correlation coefficients among the repeated measurements (0.89 to 0.99), suggesting good reproducibility. All RNFLT parameters were significantly correlated between VCC and ECC (intraclass correlation coefficient=0.58-0.92, P<0.001) though they were significantly different. In OAG eyes, correlation between temporal, superior, nasal, inferior, temporal average and mean deviation of VFD was similar in both algorithms (Rs=0.58 and 0.53, P<0.001). When the OAG eyes were subgrouped by refractive error at -5 D, the correlation was significant for both ECC and VCC in the lower myopic group (>-5 D) (Rs=0.71 and 0.74, P<0.0001) but was significant only for ECC in the higher myopic group (