Efficacy and Safety of Selective Laser Trabeculoplasty among Ethiopian Glaucoma Patients.

BACKGROUND: Selective laser trabeculoplasty (SLT) is a safe and effective treatment modality for lowering intraocular pressure (IOP). PURPOSE: To determine the efficacy and safety of SLT among Ethiopian patients with primary open-angle glaucoma (POAG), pseudoexfoliation glaucoma (PXG), and ocular hypertension (OHT). METHOD: A prospective, nonrandomized interventional study was conducted at Menelik II Hospital, Ethiopia. Patients on antiglaucoma medication with uncontrolled IOP and those patients treated for the first time with 360 degrees of SLT were included. Success was defined as an IOP lowering of > 20% from baseline without repeat treatment. RESULT: A total of 95 eyes of 61 patients with a diagnosis of OAG and OHT were enrolled. The diagnosis was POAG in 55 (57.9%) eyes, PXG in 22 (23.2%) eyes, and OHT in 18 (18.9%) eyes. Seventy (73.7%) eyes were on medications, and 25 (26.3%) eyes were treated with laser as primary therapy. The mean (SD) baseline IOP and medication were 24.3 ± 2.5 mmHg and 1.29 ± 1.01, respectively. The one-year mean (SD) IOP reduction was 6.7 ± 4.2 mmHg and medication reduction was 0.26 ± 1.34. The overall IOP reduction at 12 months was 27.6%, and the success rate was 60%. The mean IOP (SD) reduction for patients who were treated for the first time with laser and on antiglaucoma medication was 6.5 ± 3.1 mmHg and 6.8 ± 2.8 mmHg, respectively. Post-SLT, patients experienced transient ocular pain, brow ache, headache, and/or blurring of vision in 31.6%, anterior chamber reaction in 36.8%, and IOP spike ≥ 6 mmHg in 11.6%. CONCLUSION: SLT is an effective and safe treatment modality for OHT, POAG, and PXG among Ethiopian patients either as a first-line treatment or as an adjunct to topical glaucoma treatment.

Selective laser trabeculoplasty versus argon laser trabeculoplasty: results from a 1-year randomised clinical trial.

AIMS: To compare selective laser trabeculoplasty (SLT) and argon laser trabeculoplasty (ALT), in terms of intraocular pressure (IOP) lowering, in patients with open-angle glaucoma. METHODS: 176 eyes of 152 patients were enrolled in this study, 89 in the SLT and 87 in the ALT groups. Patients were randomised to receive either SLT or ALT treatment to 180 degrees of the trabecular meshwork. Patients were followed up to 12 months after treatment. The main outcome measured was IOP lowering at 12 months after treatment, compared between the SLT and ALT groups. RESULTS: No significant difference (p = 0.846) was found in mean decrease in IOP between the SLT (5.86 mm Hg) and ALT (6.04 mm Hg) groups at 1 year or at any other time points, nor were there any significant differences in the rate of early or late complications between the two groups. CONCLUSIONS: SLT is equivalent to ALT in terms of IOP lowering at 1 year, and is a safe and effective procedure for patients with open-angle glaucoma.

Intraocular pressure following phacoemulsification in patients with and without exfoliation syndrome: a 2 year prospective study.

AIM: To determine the long term intraocular pressure (IOP) response to phacoemulsification in patients with and without exfoliation syndrome (XFS). METHODS: Prospective, multicentre, cohort study with the following inclusion criteria: age over 50 years, open iridocorneal angle, and cataract. Two groups were enrolled: those with XFS and those without. The main outcome was mean IOP reduction 2 years after phacoemulsification cataract extraction (PCE). Univariate and multivariate analyses were performed. RESULTS: 183 patients were enrolled, 71 with and 112 without XFS. There were 29 patients with glaucoma in both groups. Mean baseline IOP was higher in XFS compared to control eyes (17.60 (SD 3.23) mm Hg v 16.08 (3.18) mm Hg, p = 0.002). Overall IOP reduction was significantly greater in the XFS group at the 2 year time point (-1.85 mm Hg v -0.62 mm Hg in the controls (p = 0.0037)). Multivariate analysis demonstrated that the IOP lowering effect in the XFS group may be related to irrigation volume at the time of surgery. In the subgroup analyses IOP lowering was significantly greater in the XFS and XFG patients than in controls without glaucoma, and POAG controls, respectively. The percentage of patients with a postoperative IOP spike was similar and relatively high in both XFS and control groups (34% v 25%; p = 0.54). CONCLUSION: IOP decreases more in patients with XFS following PCE compared to control eyes without XFS. This effect is more pronounced in glaucoma patients and persists for at least 2 years.

Long-term efficacy of phototherapeutic keratectomy on recurrent corneal erosion syndrome.

PURPOSE: To assess the long-term sequelae, principally time-to-first-recurrence, of phototherapeutic keratectomy (PTK) for the treatment of recurrent corneal erosion syndrome (RCES). METHODS: A retrospective case series was performed. Thirty-nine eyes in 33 patients with RCES required PTK and were treated using the VISX STAR Excimer Laser System. The data were analyzed with the Kaplan-Meier survival estimate. RESULTS: Patients were characterized by the cause of their RCES. More than 50% had epithelial corneal dystrophies, 31% were posttraumatic, and 15% were idiopathic. Overall, 25% of eyes had a recurrence by 3 months, and 36% had a recurrence by 9 months. The mean follow-up time was 17.4 months (range, 0.4-67.6 months). Of those who had a primary recurrence, 38% had a second and 15% had a third. Visual acuity was slightly decreased within 2 weeks after surgery, and 10% of patients developed transient haze. No serious adverse effects were reported. CONCLUSION: PTK is an important treatment of RCES refractory to other therapies. Long-term data suggest that most patients treated with PTK do not develop recurrences, and side effects from PTK are minimal.

Baseline IOP predicts selective laser trabeculoplasty success at 1 year post-treatment: results from a randomised clinical trial.

BACKGROUND/AIMS: The efficacy and safety of selective laser trabeculoplasty (SLT) has been found to be equivalent to argon laser trabeculoplasty (ALT). Since SLT produces significantly less disturbance to the trabecular meshwork and is theoretically more repeatable than ALT, it has potential to replace ALT as the standard procedure to treat medically uncontrolled open angle glaucoma. This study's objective is to determine factors that predict successful SLT at 1 year post-treatment. METHODS: As part of a randomised clinical trial comparing the efficacy and safety of SLT to ALT, data on 72 SLT patients were collected, and successful SLT defined as having an SLT induced intraocular pressure (IOP) reduction of >or=20% at 1 year post-treatment follow up. RESULTS: 43 out of the 72 patients who had completed their 1 year follow up visit had an IOP reduction of >or=20% from baseline. No glaucoma risk factors studied predicted successful SLT. The amount of trabecular meshwork pigmentation was not a significant predictor. However, it was discovered that baseline IOP strongly predicted SLT success (odds ratio=1.16; p=0.0001). CONCLUSION: SLT success was significantly predicted by baseline IOP but not by age, sex, other glaucoma risk factors, type of open angle glaucoma, or by degree of trabecular meshwork pigmentation.

Nd:YAG laser corneal disruption as adjuvant treatment for infectious crystalline keratopathy.

PURPOSE: To report on the use of the Nd:YAG laser corneal disruption in the treatment of infectious crystalline keratopathy. METHOD: Case report. A 52-year-old woman with infectious crystalline keratopathy unresponsive to topical antibiotics was treated with an Nd:YAG laser to the intrastromal crystals. RESULTS: After Nd:YAG laser treatment, the infiltrate completely cleared within 4 weeks. CONCLUSIONS: Nd:YAG laser treatment may be effective in disrupting the protective glycocalyx matrix within the intrastromal crystals, rendering the bacteria susceptible to topical antibiotics. This treatment should be considered for patients with infectious crystalline keratopathy clinically resistant to topical antibiotics.

Lattice corneal dystrophy type 1 in a Canadian kindred is associated with the Arg124 --> Cys mutation in the kerato-epithelin gene. sgupta@ogh.on.ca.

PURPOSE: To identify the mutation responsible for lattice corneal dystrophy type 1 in an extended Canadian kindred. METHODS: A search for a mutation in the candidate gene, kerato-epithelin, was carried out by single-strand conformation polymorphism and sequencing analyses. RESULTS: AC --> T mutation at position 417 was detected in exon 4 of the kerato-epithelin gene, which is expected to cause an Arg124 --> Cys change. This is the same nucleotide change described previously in two Swiss families with lattice corneal dystrophy type 1. CONCLUSION: Although the possibility that the three families (two previously described Swiss families and this Canadian kindred) are related has not been excluded, it appears that the unique phenotype of lattice corneal dystrophy type 1 is caused by this particular amino acid change.

Atopy and keratoconus: a multivariate analysis.

BACKGROUND/AIMS: The primary goal of this study was to determine if atopy is a risk factor for keratoconus. Other potential risk factors were also studied and included age, sex, race, eye rubbing, mitral valve prolapse, handedness, collagen vascular disease, ocular trauma, pigmentary retinopathy, Marfan's syndrome, Down's syndrome, and a history of contact lens wear. METHODS: A case-control study was designed (n=120) with incident cases assembled from the years 1985-99. Controls were chosen from the same person-time experience as cases and were picked from a source population with multiple outcomes ensuring that none was knowingly related to any of the potential exposures being studied. Atopy was defined based on the UK working group 1994 definition (at least 4/6 criteria = complete, 3/6 criteria = incomplete, and at least 1/6 criteria = partial). Keratoconus was defined based on clinical criteria and previously published I-S values. Multiple logistic regression was used in the analysis to obtain the odds ratios as the measure of association. RESULTS: In the univariate associations, there was an association between keratoconus and atopy as well as eye rubbing and family history of keratoconus. However, in the multivariate analysis, only eye rubbing was still a significant predictor of keratoconus (odds ratio = 6.31 p = 0.001). CONCLUSIONS: This study supports the hypothesis that the most significant cause of keratoconus is eye rubbing. Atopy may contribute to keratoconus but most probably via eye rubbing associated with the itch of atopy. No other variable measured was significantly associated with the aetiology of keratoconus.

Selective laser trabeculoplasty v argon laser trabeculoplasty: a prospective randomised clinical trial.

AIMS: To compare the effectiveness of selective laser trabeculoplasty (SLT, a 532 nm Nd:YAG laser) with argon laser trabeculoplasty (ALT) in lowering the intraocular pressure (IOP) in patients with medically uncontrolled open angle glaucoma. METHODS: A prospective randomised clinical trial was designed. Patients were randomised to treatment with either SLT or ALT and were evaluated at 1 hour, 1 week, 1, 3, and 6 months post-laser. RESULTS: There were 18 eyes in each group. Baseline characteristics were similar in both groups. In the SLT group the mean IOP at baseline, 1, 3, and 6 months was 22.8 (SD 3.0), 20.1 (4.6), 19.3 (6.0), and 17.8 (4.8) mm Hg, respectively. In the ALT group, the mean IOP at baseline, 1, 3, and 6 months was 22.5 (3.6), 19.5 (4.7), 19.6 (5.6), and 17.7 (3.3) mm Hg, respectively. There was a greater anterior chamber reaction, 1 hour after SLT v ALT (p< 0.01). Patients with previous failed ALT had a better reduction in IOP with SLT than with repeat ALT (6.8 (2. 4) v 3.6 (1.8) mm Hg; p = 0.01). CONCLUSION: SLT appears to be equivalent to ALT in lowering IOP during the first 6 months after treatment. There is a slightly greater anterior chamber reaction 1 hour after SLT. Patients with previous failed ALT had a significantly greater drop in IOP when treated with SLT v ALT. These results need to be confirmed with a larger sample size.

DNA index and S phase fraction in uveal malignant melanomas.

AIMS: To predict 5 year survival in patients with uveal malignant melanomas DNA indices were studied. METHODS: Using 45 paraffin embedded uveal malignant melanomas, the DNA index and S phase fraction of each tumour were the predictor variables recorded. RESULTS: Using the Cox proportional hazards model, aneuploid tumours and tumours which had an S phase fraction greater than 4% were significant predictors of early death. In order to demonstrate a biological gradient between a larger DNA index and shorter survival time, linear regression and transformed linear regression models were used. However, no such gradient could be demonstrated. CONCLUSION: Although this study shows promise for the use of DNA studies in the prognosis of uveal malignant melanoma, the exact role of these techniques remains to be determined.

Pseudoexfoliation syndrome in Icelandic families.

AIM: To examine the distribution and clinical ophthalmic characteristics of pseudoexfoliation syndrome (pseudoexfoliation) and glaucoma in Icelandic families. METHODS: Icelandic families containing three or more members aged 70 or older with at least one member with pseudoexfoliation were identified. All family members over age 45 were invited to participate. Visual acuity, Goldmann applanation tonometry, gonioscopy, slit lamp examination before and after dilatation, and dilated fundus examination were performed on all available family members. Pertinent data were obtained from medical records, including ophthalmic history and a medical history of cardiovascular disease, cerebrovascular disease, systemic hypertension, and diabetes mellitus. Participants were classified according to affected status for pseudoexfoliation, glaucoma, and age related macular degeneration. RESULTS: Six families were identified who met the criteria for entry into the study. Of 94 family members who were invited to participate 82 were enrolled (87%). Of these 25 (30%) had pseudoexfoliation syndrome, 51 (62%) were unaffected, and six (7%) were suspects. At least one individual with pseudoexfoliation was identified in the second generation of every family. A parent with pseudoexfoliation was identified in all cases either by examination (4/6) or a review of ophthalmic records (2/6). In all cases the mother was the affected parent. The prevalence of glaucoma was significantly greater in the group with pseudoexfoliation (p <0.0001). Although the presence of age related macular degeneration (ARMD) was highly associated with the presence of pseudoexfoliation, the significance was lost after correction for age (p = 0.69). Although the sample size was small, no association between pseudoexfoliation affected status and cardiovascular disease, cerebrovascular disease, systemic hypertension, or diabetes mellitus was found. CONCLUSIONS: Multiple Icelandic families with pseudoexfoliation in two generations were identified. In all cases where determination was possible, transmission to the second generation was through an affected parent. In each case the affected parent was the mother. Pseudoexfoliation was strongly associated with the presence of glaucoma, but was not associated with either ARMD or systemic disease in this study. These data clearly indicate that pseudoexfoliation is a familial condition and although not conclusive, supports the hypothesis that pseudoexfoliation syndrome is genetically inherited.

Intraocular pressure decrease after phacoemulsification in patients with pseudoexfoliation syndrome.

PURPOSE: To determine the intraocular pressure (IOP) response to phacoemulsification cataract extraction with posterior chamber intraocular lens (PC IOL) implantation in patients with pseudoexfoliation syndrome. SETTING: Eye clinics at the University of Ottawa Eye Institute, Ottawa, Ontario, Canada. METHODS: A retrospective cohort study design assigned patients to 1 of 3 subgroups: pseudoexfoliation syndrome (PEX) (n = 21), primary open-angle glaucoma (POAG) control (n = 23), and cataract control (n = 23). Inclusion criteria consisted of age older than 50 years, open angle by gonioscopy, and a cataract requiring phacoemulsification. The IOP response was determined at intervals up to 18 months. RESULTS: Postoperative IOP changes from baseline in the PEX group were -1.81, -4.52, and -2.31 mm Hg at 3, 6, and 12 months, respectively. The changes in the POAG control group were -2.22, -2.32, and -1.88 mm Hg, respectively, and in the cataract control group, -2.49, +0.45, and +0.28 mm Hg. Patients in the PEX group had a reduction in IOP from baseline at all postoperative measurements. That reduction was significantly greater than in the POAG and cataract control groups at 6 months (P =.012 and P =.002, respectively) and 12 months (P =.001 and P =.050, respectively). CONCLUSIONS: Patients with pseudoexfoliation syndrome had a postoperative IOP reduction from baseline at all measurements and a significantly greater reduction than patients in the POAG and cataract control groups at 6 and 12 months. Phacoemulsification cataract surgery with PC IOL implantation may be effective in managing patients with pseudoexfoliation syndrome who have elevated IOP and visually significant cataract but no advanced optic nerve damage.

Changes in measured intraocular pressure after hyperopic photorefractive keratectomy.

PURPOSE: To investigate the effect of hyperopic photorefractive keratectomy (PRK) on intraocular pressure (IOP) measurements. SETTING: University of Ottawa Eye Institute, Ottawa Hospital, Ottawa, Canada. METHODS: In this retrospective cohort study, IOP and central corneal thickness (CCT) were measured preoperatively and at 1, 2, 3, 6, 12, 18, and 24 months in 191 eyes that had hyperopic PRK with the VISX Star excimer laser. All corrections applied were between +1.00 and +6.50 diopters (D) of sphere and less than 3.75 D of cylinder. RESULTS: At all postoperative examinations, the mean IOP in the hyperopic PRK group was 1.0 to 1.8 mm Hg lower than the preoperative IOP (P <.001). A large range of IOP changes was found across the population; eg, at 6 months, 49% of the eyes had a change in IOP from baseline of at least +/-3 mm Hg. A mean reduction of 19 microm of CCT was found with pachymetry after surgery (P < .001). The change in IOP readings postoperatively was not correlated with age, sex, keratometric readings, or applied correction. Changes in IOP were strongly correlated with preoperative IOP at all time points and with preoperative CCT at 18 and 24 months (P < .001). After hyperopic PRK, the measured IOP was more likely to increase in patients with preoperative IOPs less than 14.5 mm Hg and more likely to decrease in patients with preoperative IOPs above 14.5 mm Hg. CONCLUSION: Changes in IOP after hyperopic PRK were similar to changes after myopic PRK, despite only minimal changes in the CCT. This suggests that hyperopic PRK results in biomechanical effects that modify the elastic properties of the cornea beyond the changes in rigidity expected from central corneal thinning. There was a strong negative correlation between the measured preoperative IOP and the change in IOP postoperatively that was likely the result of regression of the mean effect.

Self-induced cicatricial conjunctivitis with symblephara.

PURPOSE: Cicatricial conjunctivitis is an uncommon ocular finding with several possible origins. We report a patient whose obsessive-compulsive disorder involved constant self-induced mechanical trauma to the eyes, leading to bilateral cicatricial conjunctivitis. METHOD: Case report. RESULTS: Based on the history, physical examination, ocular surface scraping, and conjuctival biopsy, other causes of cicatrical conjunctivitis were ruled out, and a self-induced cause was confirmed. CONCLUSIONS: Inquiries pertaining to psychiatric history may be important in patients with cicatricial conjunctivitis.

Investigating a viral etiology for keratoconjunctivitis sicca among patients who are positive for human immunodeficiency virus.

PURPOSE: Herpesvirus infection of the lacrimal gland was investigated as an etiologic factor for keratoconjunctivitis sicca in patients who were positive for human immunodeficiency virus (HIV). METHODS: In this cross-sectional study, we recorded the Schirmer tests and tear break-up times (TBUTs) among 30 patients who were positive for HIV. Dry-eye state was defined as a Schirmer test of <10 mm of wetting at 5 min or a TBUT of <10 s. The polymerase chain reaction assay (PCR) for herpes family viruses [Epstein-Barr virus (EBV), cytomegalovirus (CMV), herpes simplex virus (HSV), and varicella-zoster virus (VZV)] was performed on the conjunctival and tear specimens of the 30 HIV-positive patients by using virus-specific single primers. We compared the rates of virus DNA detection among dry-eye and non-dry-eye patients by calculating the odds ratio of detection for each virus. RESULTS: The odds ratio of viral DNA detection was adjusted for age, gender, race, CD4 count, and duration of HIV positivity. The adjusted odds ratios of EBV DNA detection among dry-eye to non-dry-eye patients were 1.30 (p = 0.79) and 0.97 (p = 0.98) by using Schirmer tests and TBUTs, respectively. For CMV, the adjusted odds ratios among dry-eye to non-dry-eye patients were 1.94 (p = 0.58) with Schirmer tests and 1.02 (p = 0.99) with TBUTs. HSV and VZV DNA were not detected in any samples. CONCLUSION: Our study does not support the role of herpesvirus infection of the lacrimal gland as a causative factor in the pathogenesis of dry eyes in patients positive for HIV.

Use of topical steroid therapy in the management of nonnecrotizing anterior scleritis.

BACKGROUND: Nonnecrotizing anterior scleritis may be treated with a variety of therapies, including topical steroid therapy, systemic therapy with nonsteroidal antiinflammatory drugs (NSAIDs) and systemic steroid therapy. This study was carried out to determine the efficacy of topical steroid therapy in treating diffuse and nodular scleritis. METHODS: A phase I/II descriptive study was conducted. Thirty-two consecutive patients with nonnecrotizing anterior scleritis referred to a tertiary care ophthalmology cornea and uveitis practice in Ottawa were enrolled between September 1995 and February 1997. The patients received 1% prednisolone acetate, administered topically every 2 hours for at least 2 weeks. The drug was tapered off thereafter based on the clinical response. A successful treatment outcome was defined as resolution of scleritis without the need for systemic steroid or NSAID therapy by 2 months after initial presentation. RESULTS: The 2-month success rate was 47%. Of the 17 patients in whom treatment failed, 5 (29%) still had some evidence of scleritis at 2 months despite systemic treatment with steroids. There was no difference between the two groups in the rate of first recurrence of scleritis (log-rank test). INTERPRETATION: Although topical steroid therapy failed in over half of the patients, a significant number were spared systemic steroid therapy with its potential side effects. Despite the moderately high failure rate, topical steroid therapy could be considered as first-line treatment for nonnecrotizing anterior scleritis, especially in cases in which the likelihood of complications from systemic steroid or NSAID therapy is high.

An inventory of information on blindness and visual impairment in Canada.

BACKGROUND: Several health databases contain information on blindness and visual impairment in Canada. Such databases may permit studies of the outcomes, predictors, economic costs and meta-analysis of ocular health problems and visual disability. In this paper we summarize the existing public health information on blindness and visual impairment in Canada. METHODS: A systematic search was performed to find the information in three areas: health administrative databases, health surveys and registries. Both literature searching and Internet searching were performed. The institutions were notified by email or telephone that information pertaining to vision and blindness was desired. When necessary, we visited the institution to obtain the information. RESULTS: Health administrative databases contain information on a wide cross-section of diagnoses but are usually limited in detail and seldom provide longitudinal information. Health surveys have a limited amount of systematic information on vision-related questions and rely exclusively on self-reporting. Registries exist on a wide range of visual topics. The Canadian National Institute for the Blind (CNIB) has the most comprehensive registry. INTERPRETATION: This is the first attempt at summarizing all the public health information on blindness and visual impairment in Canada. The present population-based ocular information has numerous shortcomings. More comprehensive validation of large registries, such as that of the CNIB, is needed to provide the foundation for a longitudinal ocular surveillance system. Such a system could guide research on risk factors and the effect of treatment, economic analyses, and public policy for ocular research and service allocation.

Correction of intraocular pressure for changes in central corneal thickness following photorefractive keratectomy.

OBJECTIVE: To investigate the relation between measurements of intraocular pressure (IOP) and central corneal thickness (CCT) in myopic patients undergoing photorefractive keratectomy (PRK). DESIGN: Descriptive study. SETTING: University-affiliated eye care centre in Ottawa. PATIENTS: A total of 481 consecutive eyes of 318 patients with a mean preoperative refractive error of -6.50 dioptres treated with excimer PRK between March 1993 and December 1996. OUTCOME MEASURES: IOP measured by Goldmann applanation tonometry and CCT before and 3, 6, 12, 18 and 24 months after surgery. RESULTS: CCT was a significant predictor of IOP only before PRK and 6 months after PRK (p < or = 0.05). The relation between IOP and CCT suggests corrections for CCT that are not clinically significant (0.81 mm Hg [standard error (SE) 0.33 mm Hg] and 1.00 mm Hg [SE 0.38 mm Hg] per 100 microns of corneal thinning preoperatively and at 6 months respectively). On average, there was a significant decrease in IOP after PRK (0.96 mm Hg and 1.24 mm Hg at 12 and 24 months respectively) (p < 0.05). There was a significant correlation between change in IOP and change in CCT (decrease of 2.1 mm Hg per 100 microns of corneal thinning) (p < 0.05). For a given change in CCT, individual changes in IOP were variable, with increases or decreases of more than 5 mm Hg in some cases. CONCLUSIONS: There are individual differences in IOP changes following PRK. Until further data are available we propose that the change in IOP between the preoperative visit (or the fellow eye, if healthy or untreated) and the 12-month visit be used as an individual correction factor to be applied to IOP measurements in the operated eye.

Familial occurrence of pigment dispersion syndrome.

BACKGROUND: Pigment dispersion syndrome affects up to 4% of the white population. It is characterized by the presence of transillumination defects, Krukenberg's spindle and dense trabecular meshwork pigmentation. Open-angle glaucoma will develop in as many as 50% of affected patients. In this study we describe the familial occurrence of pigment dispersion syndrome in six North American pedigrees and the phenotypic characteristics with respect to pigment dispersion syndrome and glaucoma. METHODS: Probands with pigment dispersion syndrome were identified in glaucoma clinics at university eye centres in Ottawa and Durham, NC. Families with two or more affected members were evaluated. All willing members in each family underwent a thorough clinical examination and were classified as affected with pigment dispersion syndrome, suspect or unaffected. The previous medical records were reviewed to obtain the past medical and ocular history, including risk factors for glaucoma. RESULTS: All six families are white. Three families show at least two generations of affected members. Of the 43 subjects examined 58% were women. All 14 affected members showed moderate to heavy trabecular meshwork pigmentation and either Krukenberg's spindle or transillumination defects. The affected members were also considerably more myopic (mean spherical equivalent for the right eye -4.72 dioptres) than the suspect group or the unaffected group (mean spherical equivalent -0.79 D and +1.19 D respectively) (p < or = 0.001), and the intraocular pressure was higher for the affected than the unaffected group (mean for the right eye 20 mm Hg vs. 16 mm Hg) (p = 0.004). Half of those affected also had open-angle glaucoma. INTERPRETATION: We have identified and phenotypically characterized six North American families with autosomal dominant pigment dispersion syndrome. Our ultimate goal is to identify the gene(s) that causes this disorder in order to clarify its molecular etiology and pathophysiology. This may give rise to a molecular classification of the disease as well as provide the foundation for genetic testing and new treatment approaches.

Treatment of CMV retinitis with intravitral ganciclovir in the HAART era.

OBJECTIVE: To describe the course and outcome of cytomegalovirus (CMV) retinitis among AIDS patients treated with intravitreal ganciclovir and systemic highly active antiretroviral therapy (HAART). The secondary objective was to compare the course of CMV retinitis between patients receiving HAART and those not receiving this treatment. DESIGN: A retrospective cohort design consisting of 21 eyes from 16 patients with AIDS and CMV retinitis consecutively enrolled between January 1996 and August 1999. All patients received intravitreal ganciclovir therapy, and half of the patients began HAART as well. Duration of intravitreal therapy and ensuing disease quiescence, as well as CD4+ T cell counts at diagnosis and at cessation of ganciclovir, were calculated. Secondly, instantaneous hazards for outcomes such as CMV retinitis progression, ocular complications and mortality were compared. SETTING: Tertiary care centre in Ottawa, Ontario. RESULTS: Five of eight patients receiving HAART discontinued intravitreal ganciclovir after a mean treatment period of 428 days. During this period, their mean CD4+ count rose from 7.5 to 190microL. Subsequently, none of these patients experienced retinitis progression during follow-up periods lasting up to 820 days (mean of 617 days). Progression of CMV retinitis was 11.4 times more likely among those not receiving HAART (P=0.049). CONCLUSIONS: On initiating HAART, patients with CMV retinitis may enjoy significant recovery in CD4+ counts and sustained retinitis quiescence without specific anti-CMV therapy. Intravitreal ganciclovir injections seem well suited to offer effective CMV control during temporary periods of decreased CD4+ counts while awaiting HAART-mediated immune system reconstitution.