Impact of Part-time Occlusion on Visual Outcomes in Pediatric Patients With Optic Nerve Pathology.

The visual outcomes of seven children with specific optic nerve pathologies and coexisting amblyopia after at least 1 year of part-time patching demonstrated a visual acuity improvement of greater than 0.1 logMAR. The results suggest that part-time patching may lead to improvement in visual function even in the setting of optic nerve pathology, albeit with a more limited response compared to full-time patching. [J Pediatr Ophthalmol Strabismus. 2023;60(3):e19-e21.].

Axenfeld-Rieger syndrome in the pediatric population: A review.

Axenfeld-Rieger syndrome (ARS) is a rare autosomal-dominant neurocristopathy that presents with a variety of classical ocular and systemic findings. The pathophysiology of the disease involves anterior segment dysgenesis, and patients may present with ophthalmic complications early in life, including secondary glaucoma, high refractive errors, amblyopia, and permanent visual damage. There are a limited number of studies in the literature that focus primarily on pediatric patients with ARS. The purpose of this article was to review the current literature on clinical presentation, genetic associations, diagnosis, secondary complications, and treatment of ARS in pediatric patients. Evaluating the essential clinical aspects of the disease in children may allow for earlier diagnosis and treatment and prevent visual morbidity from amblyopia and secondary glaucoma that may result in permanent visual damage.

Spontaneous lens resorption in a patient with Marshall-Stickler Syndrome and glaucoma.

PURPOSE: The purpose of this case report is to describe the increased fragility of anterior capsule in patients with the rare genetic disease Marshall-Stickler syndrome. OBSERVATIONS: We describe a 3-year old patient with Marshall-Stickler Syndrome and congenital glaucoma treated with glaucoma drainage implant placement who subsequently developed spontaneous lens resorption in one eye, which was noted incidentally during one follow-up appointment. CONCLUSIONS AND IMPORTANCE: It is hypothesized that the lens material left the eye through the glaucoma drainage implant over time. This process was not associated with elevation of intraocular pressures or inflammation and did not require subsequent surgery to remove any residual lens fragments, which has not been reported before to the best of the authors' knowledge.

Visual Outcomes in Pediatric Patients with Peters Anomaly.

PURPOSE: This study aimed to evaluate the visual outcomes of pediatric patients diagnosed with Peters anomaly (PA) in a tertiary eye care center. METHODS: This was a retrospective study undertaken at a single academic center. Clinical records of pediatric patients diagnosed with PA from 2000 to 2017 were reviewed. Parameters recorded included visual acuity (VA), intraocular pressure (IOP), presence of glaucoma, and surgical procedures performed. The impact of PA type on final visual acuity levels was analyzed using generalized estimation equation models. RESULTS: Twenty-one eyes from 11 patients were analyzed. At the final visit, 9 eyes (42.8%) had a VA ≥20/200, while 12 (57%) had <20/200, ranging from 20/250 to no light perception. Of the study cohort, 15 (71.5%) eyes had type I, while six (28.5%) had type II PA. Glaucoma was present in 20 eyes (95%) at the final visit. One eye had dense central leucoma and microphthalmos where IOP could not be measured accurately. Seventeen eyes (81%) underwent at least one intraocular surgery, while the average number of surgeries per eye was 2.9 ± 2.5 (range=0- 9). The type of PA beta(se)=0.53 (0.41), p = 0.20] was not found to be a significant risk factor for worse VA. CONCLUSION: Severe visual impairment develops in the majority of patients with PA. The type of anomaly does not appear to be associated with a worse visual function in patients with PA. Glaucoma develops in a high percentage of this patient population, and thus close monitoring of IOP in this patient population is crucial.

The Relationship Between Optic Nerve Cup-to-Disc Ratio and Retinal Nerve Fiber Layer Thickness in Suspected Pediatric Glaucoma.

PURPOSE: To evaluate the relationship between optic nerve cup-to-disc ratio and peripapillary retinal nerve fiber layer (RNFL) thickness in suspected pediatric glaucoma with large cup-to-disc ratios. METHODS: This was a retrospective study undertaken at a single academic institution. Eighty-six eyes of 43 patients who presented with large (≥ 0.5) cup-to-disc ratios in both eyes and without elevated intraocular pressure were evaluated using spectral-domain optical coherence tomography. Global and sectoral peripapillary RNFL thickness measurements, Bruch's membrane opening size, refractive error in spherical equivalents, and intraocular pressure levels were recorded for all patients. Cup-to-disc ratios were manually derived using digital fundus images (D-cup-to-disc ratio). Parameters were compared between gender or race by t tests or analysis of variance. The differences in the relationship among the clinical parameters between two eyes were assessed using generalized estimation equation modeling followed by Pearson's correlation analysis. RESULTS: Forty-three patients (25 boys and 18 girls) with a mean age of 9.3 ± 2.7 years (range: 5 to 15 years) were included. The mean global peripapillary RNFL thickness and the D-cup-to-disc ratio of study eyes were 99.0 ± 9.2 µm and 0.66 ± 0.03, respectively. The peripapillary RNFL thickness was found to be correlated with refractive error (r = 0.404; P = .008) and Bruch's membrane opening size (r = 0.410; P = .008) but not with cup-to-disc ratios (r = 0.029; P = .858) or patient age (r = -0.044; P = .797). CONCLUSIONS: In patients with suspected pediatric glaucoma who present with large cup-to-disc ratios, RNFL thickness does not correlate with the degree of optic nerve cupping. Myopic refractive errors and Bruch's membrane opening size need to be taken into consideration to prevent misinterpretation of peripapillary RNFL measurements. [J Pediatr Ophthalmol Strabismus. 2020;57(2):90-96.].

Evaluation of All Causes of Visual Function Loss in Children With Congenital Blepharoptosis.

PURPOSE: To evaluate the overall frequency of visual function loss in pediatric patients with congenital blepharoptosis. METHODS: This retrospective study was conducted in a tertiary center. The clinical records of patients younger than 18 years who were diagnosed as having congenital blephroptosis, underwent surgery, and had at least 1 year of postoperative follow-up were evaluated. Visual acuity results, presence of structural eye abnormalities, presence and type of amblyopia and strabismus, and refractive errors were recorded. The Mann-Whitney U test, chi-square test, and stepwise regression analysis were used for statistical analyses. RESULTS: The mean final visual acuity was 0.11 ± 0.23 logarithm of the minimum angle of resolution (logMAR) (range: 0.0 to 1.0 logMAR) at the final follow-up visit for 143 eyes of 123 patients (65 male and 58 female). In this cohort, 30 patients (24.4%) had amblyopia and 5 patients (4.1%) had visual loss related to structural eye pathology, amounting to a total of 35 patients (28.5%) with visual function loss. The mean final visual acuities of patients without amblyopia, patients with amblyopia, and patients with organic eye disorders were 0.01 ± 0.03, 0.29 ± 0.28, and 0.55 ± 0.42 logMAR, respectively. Severe blepharoptosis (≥ 4 mm) was present in 25 patients (83.3%) with amblyopia. Deprivational amblyopia was detected in 25 of 36 eyes (69.4%) with amblyopia. Independent risk factors associated with final visual acuity were presence of amblyopia at presentation (correlation coefficient [ß] ± standard error [SE] = -0.29 ± 0.04; P < .001), anisometropia (ß ± SE = -0.27 ± 0.06; P < .001), and ptosis severity (ß ± SE = -0.09 ± 0.04; P = .012). Visual impairment (visual acuity < 20/40) persisted in 11.9% of eyes at the final follow-up. CONCLUSIONS: Visual function loss was present in one-third of pediatric patients with congenital blepharoptosis. Both amblyopia and structural eye disorders contribute to visual impairment in this patient population. Structural eye pathology contributes independently to 4.1% of visual loss in this clinical setting. [J Pediatr Ophthalmol Strabismus. 2020;57(2):97-102.].

Evaluation of the underlying causes of papilledema in children.

OBJECTIVE: The purpose of this retrospective study was to identify the types and relative frequencies of intracranial disorders in pediatric patients who present with papilledema. DESIGN: Retrospective case series. PARTICIPANTS AND METHODS: This study was conducted in 2 pediatric ophthalmology clinics, both providing community-based care in a large inner-city urban center in the U.S. Pediatric patients aged between 0 and 16 years diagnosed with papilledema and who had an underlying etiology identified were included in the study. Patient demographic data, ophthalmologic examination findings, and diagnostic work-up results were identified from clinical records. RESULTS: The mean age of 38 study patients (19 female, 19 male) was 8.6 ± 4.8 years. Of the 38 patients, 16 (42.1%) had idiopathic intracranial hypertension (IIH) as the underlying cause of the papilledema, 7 (18.4%) had a craniosynostosis disorder, 6 (15.8%) had intracranial tumours, 2 (5.3%) had primary hydrocephalus, and 1 (2.6%) patient each had transverse sinus thrombosis related to sinusitis, hypertensive crisis, subdural hematoma, intracranial abscess, Lyme disease, presumed neurosarcoidosis, and acute disseminated encephalomyelitis. Of the 6 intracranial tumours, 2 (33.3%) presented in the sellar/parasellar region, 2 (33.3%) in the posterior fossa, and 2 (33.3%) were in cortical locations. CONCLUSION: Clinicians should have a high index of suspicion for IIH and brain tumours in children presenting with papilledema. Patients with craniosynostosis should have routine eye examinations to monitor for asymptomatic papilledema. Understanding the relative incidence of etiologies for papilledema highlights the urgency of appropriate work-up and the need to consider low-frequency etiologies.

Quality of Life of Caregivers of Children With Glaucoma in an Arab Population: A Cross-Sectional Study.

BACKGROUND: To evaluate the quality of life (QoL) measures of caregivers of children with glaucoma using the Caregiver's Congenital Glaucoma Quality of Life (CarCGQoL) questionnaire. MATERIALS AND METHODS: This was a cross-sectional study undertaken at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia. QoL of the caregivers, the main outcome, was assessed using the 20-item CarCGQoL questionnaire. Raw QoL scores of caregivers were converted to Rasch-calibrated interval level scores. A multiple linear regression analysis was performed to identify factors associated with caregivers' QoL. RESULTS: Eighty-five caregivers (46 fathers and 39 mothers) aged 42.5±7.5 years were included in the study. The mean QoL score of caregivers was 0.63 (±1.05). The presence of additional children with glaucoma in the household had the strongest negative relationship with caregivers' QoL [ß=-0.75, 95% confidence interval (CI): -1.22, -0.27; P=0.003]. A poor QoL was noted with mother caregivers (ß=-0.46, 95% CI: -0.87, -0.04; P=0.031) and those caring for blind children (vision <20/200 in the better eye) (ß=-0.52, 95% CI: -0.98,-0.05; P=0.030) when compared with their reference groups. A 22.3% variance in the QoL score was explained by these three factors (adjusted R=0.223). CONCLUSIONS: The QoL of caregivers of children with glaucoma was poor. Caregiver's relation to patients, additional children with glaucoma in the family and patient's vision in the better eye could influence a caregiver's QoL. Periodic evaluation of QoL of caregivers is recommended to plan counseling and other support services.

Sensory Adaptation to Silicone Hydrogel Contact Lens Wear Is Not Associated With Alterations in the Corneal Subbasal Nerve Plexus.

PURPOSE: To evaluate corneal subbasal nerve alterations in contact lens (CL)-naive silicone hydrogel CL wearers and to investigate the relationship between structural subbasal nerve changes with corneal sensitivity. METHODS: Twenty eyes of 20 neophyte daily silicone hydrogel CL wearers and 20 eyes of age-matched control subjects were recruited for this prospective longitudinal study. Corneal subbasal nerve densities were evaluated using in vivo confocal microscopy. Central corneal tactile sensitivity was measured using Cochet-Bonnet esthesiometers. In vivo confocal microscopy and Cochet-Bonnet esthesiometry were performed before and at the 6-month time point after the initiation of CL wear. Two-way repeated measures analysis of variance, χ, and Wilcoxon signed-rank tests were used for statistical analyses. RESULTS: The mean ages of CL users and control subjects were 21.8 ± 1.8 years (range = 19-24 years) and 21.5 ± 2.3 years (range = 20-24 years), respectively (P = 0.579). Compared with their baseline values, there were no significant changes at the 6-month follow-up period in the mean total subbasal nerve fiber length (2266.6 ± 414.6 vs. 2277.9 ± 405.0 µm/frame; P = 0.432), mean total subbasal nerve branch density (10.4 ± 1.5 vs. 10.5 ± 1.3 nerves/frame; P = 0.655), or the mean long nerve fiber density (4.7 ± 0.7 vs. 4.8 ± 0.7 nerves/frame; P = 0.564) of CL users. Mechanical corneal sensitivity remained unaltered during the 6-month period in CL users (11.2 ± 0.5 vs. 11.2 ± 0.5; P = 1.000). No significant changes were observed in the subbasal nerve plexus or corneal tactile sensitivity of the control subjects during the study interval. CONCLUSIONS: Sensory adaptation to CL wear is not mediated through attenuation of the subbasal nerve or reduction of corneal tactile sensitivity in CL-naive users.

Update in Genetics and Surgical Management of Primary Congenital Glaucoma

Primary congenital glaucoma (PCG) continues to be an important cause of visual impairment in children despite advances in medical and surgical treatment options. The progressive and blinding nature of the disease, together with the long lifespan of the affected population, necessitates a thorough understanding of the pathophysiology of PCG and the development of long-lasting treatment options. The first part of this review discusses the genetic features and makeup of this disorder, including all currently identified genetic loci (GLC3A, GLC3B, GLC3C and GLC3D) and relevant protein targets important for trabecular and Schlemm canal dysgenesis. These target molecules primarily include CYP1B1, LTBP2, and TEK/Tie2 proteins. Their potential roles in PCG pathogenesis are discussed with the purpose of bringing the readers up to date on the molecular genetics aspect of this disorder. Special emphasis is placed on functional implications of reported genetic mutations in the setting of PCG. The second part of the review focuses on various modifications and refinements to the traditional surgical approaches performed to treat PCG, including advances in goniotomy and trabeculotomy ab externo techniques, glaucoma drainage implant surgery and cyclodiode photocoagulation techniques that ultimately provide safer surgical approaches and more effective intraocular pressure control in the 21st century.

Evaluation of Long-Term Silicone Hydrogel Use on Ocular Surface Inflammation and Tear Function in Patients With and Without Meibomian Gland Dysfunction.

OBJECTIVES: To determine whether silicone hydrogel (SH) contact lens (CL) use, with or without meibomian gland dysfunction (MGD), promotes ocular surface inflammation. METHODS: Subjects wearing SH-CL for at least 6 months who also had coexisting MGD (group 1, n=20), SH-CL users who did not have MGD (group 2, n=20), patients who had MGD but did not use CL (group 3, n=20), and healthy CL-naive individuals with no known systemic or ocular diseases (group 4, n=20) were included in this cross-sectional, single-center study. All subjects underwent tear function tests consisting of tear break-up time (tBUT), ocular surface staining, Schirmer test, and the Ocular Surface Disease Index (OSDI) questionnaire, as well as determination of tear IL-1RA, IL-1ß, IL-2, IL-2R, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12, IL-13, IL-15, IL-17, IFN-α, IFN-γ, TNF-α, granulocyte-macrophage colony-stimulating factor, IP-10, monokine induced by gamma interferon, RANTES, eotaxin, MIP-1α, MIP-1ß, and MCP-1 levels using Luminex multicytokine immunobead assay. Intergroup comparisons were made using one-way analysis of variance or Kruskal-Wallis test. RESULTS: The tBUT was lower (P=0.048) and ocular surface staining (P=0.032) as well as OSDI scores (P=0.001) were higher in group 1 but not in groups 2 or 3 when compared with those in the control group. Tear cytokine levels were similar across all groups. None of the tear cytokine levels were elevated in CL wearers (groups 1 and 2) or those with MGD (groups 1 and 3) as compared to those in control subjects. CONCLUSION: Silicone hydrogel contact lens use with concomitant MGD is not associated with cytokine-driven ocular surface inflammation but may impact tear function leading to dry eye symptoms.

The Value of the Frontalis Suspension Procedure as a Repeat Intervention in Congenital Blepharoptosis.

PURPOSE: To evaluate the therapeutic benefits of frontalis suspension as a repeat intervention in congenital blepharoptosis. METHODS: Pediatric patients diagnosed as having congenital ptosis who had at least 2 years of postoperative follow-up were included in this retrospective study. A successful outcome was defined as a postoperative margin-reflex distance of 3 mm or greater. The chi-square, Student's t, and Mann-Whitney U tests were used in comparisons. RESULTS: Eighty-four eyes of 77 patients with a follow-up period of 8.4 ± 0.7 years were included. The initial surgery was levator resection in 29 (34.5%) eyes and frontalis suspension in 55 (65.5%) eyes. Frontalis suspension was performed for all repeat interventions (n = 20). Surgical success was achieved in 61.9% of patients with single surgery (75.9% for levator resection vs 54.5% for frontalis suspension; P = .06) and in 77.4% of patients following repeated surgeries (93.1% vs 69.1% for patients who initially underwent levator resection vs frontalis suspension, respectively; P = .012). A higher success rate was associated with better preoperative levator function (P = .01) and a higher margin-reflex distance (P = .004), and was inversely proportional to ptosis severity (P = .04). CONCLUSIONS: Frontalis suspension as a repeat intervention for congenital blepharoptosis is associated with a further increase in long-term anatomic success rates and should be considered when initial procedures fail or remain inadequate. [J Pediatr Ophthalmol Strabismus. 2017;54(5):320-323.].

In vivo Confocal Microscopy in Differentiating Ipilimumab-Induced Anterior Uveitis from Metastatic Uveal Melanoma.

This report aims to describe the facilitating role of in vivo confocal microscopy in differentiating inflammatory cells from a metastatic process in a patient with uveal melanoma and multiple systemic metastases who developed anterior uveitis while under ipilimumab treatment. A 43-year-old woman developed systemic metastases 11 months after treatment of amelanotic choroidal melanoma in her right eye with 30 Gy fractionated stereotactic radiotherapy. She first received temozolomide and then 4 cycles of ipilimumab 3 mg/kg/day. After the third cycle, severe anterior uveitis with coarse pigment clumps on the lens was seen in the left eye. Her left visual acuity declined from 20/20 to 20/80. Confocal microscopy revealed globular keratic precipitates with hyperreflective inclusions and endothelial blebs all suggestive of granulomatous uveitis. The uveitic reaction subsided after a 3-week course of topical corticosteroids, and her visual acuity was 20/20 again. Although uveal melanoma metastatic to the intraocular structures of the fellow eye is exceedingly rare and metastasis masquerading uveitis without any identifiable uveal lesion is even more unusual, it was still mandatory to rule out this distant possibility in our particular patient who already had widespread systemic metastases. Confocal microscopy was a useful complementary tool by identifying the inflammatory features of the keratic precipitates.

The Association of Chronic Topical Prostaglandin Analog Use With Meibomian Gland Dysfunction.

PURPOSE: To evaluate the association of long-term prostaglandin analog (PGA) use with meibomian gland dysfunction (MGD) in medically treated glaucoma patients. MATERIALS AND METHODS: This was a prospective cross-sectional study conducted at a single academic setting. In total, 70 eyes of 70 patients with a medical diagnosis of glaucoma who were on long-term (>12 mo) topical hypotensive medication(s) were included. Patients were classified based on whether they were on PGA or non-PGA class of medication(s). MGD was defined based on meibomian gland terminal duct obstruction and graded between 1 and 5 based on severity. For all subjects, ocular surface disease index questionnaire, break-up time, lissamine green staining, and Schirmer test (under topical anesthesia) was administered. Student t test, Mann-Whitney U test, and χ test was used in statistical evaluations. Forty-five age-matched healthy control subjects who were not on any topical medications were also included. RESULTS: In total, 25 patients (35.7%) were on PGA monotherapy, 21 (30.0%) were treated with fixed or unfixed PGA combination regimens, and 24 (34.3%) were on non-PGA medications. MGD prevalence was higher in patients treated with PGA monotherapy (92.0%) compared with those receiving non-PGA therapy (58.3%) (P=0.02). Obstructive type of MGD was detected in the majority of patients treated with PGAs (95.7%). Grade 2 and 3 MGD was noted in 80.5% of patients on PGA. Patients on PGA had worse ocular surface disease index and ocular surface test results (P<0.001) compared with those of control subjects. CONCLUSIONS: Long-term administration of PGA is associated with obstructive type of MGD.

Orbital Involvement and Ocular Surface Changes in IgG4-Related Systemic Disease.

PURPOSE: To evaluate ophthalmic involvement of systemic immunoglobulin-G4-related disease (IgG4-RD) and describe the changes in both ocular surface parameters and corneal subbasal nerve plexus. MATERIALS AND METHODS: Twenty eyes of 10 patients with systemic IgG4-RD and 20 eyes of 10 control subjects were enrolled in this study. Demographic information, medical history, serum IgG4 levels, orbital imaging, and follow-up data of subjects were recorded. Ocular surface tests were carried out in the order of tear break-up time (BUT), lissamine green (LG) staining, Schirmer I test with anesthesia, and ocular surface disease index (OSDI) questionnaire for all participants. Corneal subbasal nerves and basal epithelial cell layer were evaluated using in vivo confocal microscopy. RESULTS: Among the 10 patients with IgG4-RD, 11 eyes of 7 patients had orbital involvement. Among these 7 patients with IgG4-related ophthalmic disease, 4 presented with painless eyelid or periorbital swelling, 2 with diplopia and restricted ocular motility, and 1 with proptosis. Patients with IgG4-RD had higher OSDI (5.9 ± 6.6 vs. 1.7 ± 2.4, P < 0.001) and LG staining scores (0.7 ± 1.0 vs. 0.0 ± 0.0, P = 0.011) and lower BUT (5.6 ± 1.4 vs. 10.2 ± 1.0, P < 0.001) and Schirmer values (11.9 ± 10.3 vs. 18.3 ± 4.4, P = 0.021) as compared with those of control subjects. Total nerve density and nerve fiber length were found to be significantly lower in patients with IgG4-RD. CONCLUSIONS: The orbit is frequently involved during the course of IgG4-RD. These patients should be evaluated in terms of ocular surface disease and dry eye, which may be associated with lacrimal gland and/or orbital nerve involvement.

Meibomian Gland Dysfunction in Patients Receiving Long-Term Glaucoma Medications.

PURPOSE: The purpose of this study was to evaluate the impact of meibomian gland dysfunction (MGD) on the ocular surface of patients with medically treated glaucoma. MATERIALS AND METHODS: This was a cross-sectional study in which 70 subjects with glaucoma on long-term (>1 year) topical hypotensive medications were recruited. MGD was defined as the presence of signs consistent with meibomian gland terminal duct obstruction. MGD was categorized between grades 1 and 4 and plus disease according to clinical severity. The ocular surface disease index (OSDI) questionnaire was completed at the time of enrollment. Ocular surface tests consisted of tear break-up time (BUT), ocular surface staining with lissamine green (LG), and Schirmer test with anesthesia. A Student t test, χ test, and Mann-Whitney U test were used in statistical comparisons. Forty-five healthy control subjects with no evidence of intraocular or ocular surface disease were also included. RESULTS: MGD was detected in 56 (80.0%) subjects with glaucoma. Forty-seven patients (67.1%) had obstructive and 9 (12.9%) had atrophic type of MGD. Of these 56 cases, 47 (83.9%) had signs consistent with mild to moderate MGD. The ocular surface test results of patients with glaucoma with MGD and without MGD were significantly worse (P < 0.001) for all parameters compared with those of healthy controls. However, there were no significant differences between ocular surface disease index scores (P = 0.912), tear break-up time (P = 0.635), lissamine green scores (P = 0.248), and Schirmer results (P = 0.991) between patients with glaucoma with MGD and without MGD. CONCLUSIONS: Mild to moderate MGD is frequently encountered in patients with medically treated glaucoma. However, the presence of MGD does not appear to have an additional detrimental effect on the ocular surface to that already induced by chronic topical medication use.

Hereditary Thrombophilic Factors in Glaucoma.

PURPOSE: To evaluate the hereditary thrombophilic factors in patients with primary open-angle glaucoma, exfoliative glaucoma, and exfoliation syndrome and to compare their results with those of healthy control subjects. MATERIALS AND METHODS: The study included 75 patients [25 patients with primary open-angle glaucoma (group I), 25 patients with exfoliative glaucoma (group II), and 25 patients with exfoliation syndrome (group III)] and 25 healthy control subjects (group IV). Well-known hereditary thrombophilic factors including methylenetetrahydrofolate reductase (MTHFR) gene C677T mutation, prothrombin G20210A mutation, factor V Leiden mutation, activated protein C resistance, protein S, protein C, and antithrombin III activities, and homocysteine levels were measured in venous blood samples of all subjects. RESULTS: Fifty-one males and 49 females were included in the study. The mean age of the patients was 67.8 ± 8.7 years (range, 46 to 87 y). There was no statistically significant difference with regard to the mean age (P=0.057) and distribution of sex (P=0.391) between the study groups. The difference of homocysteine, folate, vitamin B12, antithrombin III activity, protein C activity, free protein S activity, and activated protein C resistance were not statistically significant; and the number of subjects with MTHFR C677T, prothrombin G20210A, and factor V Leiden mutations were similar between the study groups. CONCLUSION: Our results suggest that there is no significant difference between the prothrombotic inherited risk factors of glaucomatous and nonglaucomatous subjects.

In Vivo Confocal Microscopic Evaluation of Corneas in Patients With Exfoliation Syndrome.

PURPOSE: To evaluate the corneal microstructure in patients with exfoliation syndrome (XFS) with in vivo confocal microscopy (IVCM) and to compare their results with those of healthy subjects. MATERIAL AND METHODS: Fifty-five corneas of patients with XFS and 55 corneas of age-matched control subjects were included in this study. Basal epithelial cell, keratocyte, endothelial cell densities, as well as sub-basal nerves were evaluated. Central corneal thickness (CCT) was measured by ultrasonic pachymeter. RESULTS: Eyes with XFS had lower cell densities in the basal epithelium (P=0.03), posterior stroma (P ≤ 0.001), and endothelium (P=0.008) compared with normal eyes. The number of subbasal long nerve fibers, entire subbasal nerves, as well as nerve fiber density were found to be significantly lower in the corneas of patients with XFS (2.5 ± 1.1 nerve/frame, 5.6 ± 2.9 nerve/frame, and 918.9 ± 338.5 µm/frame, respectively) as compared with those of controls (2.8 ± 0.9 nerve/frame, 7.3 ± 3.1 nerve/frame, and 1089.1 ± 590.0 µm/frame, respectively, P=0.026, P=0.002, and P=0.022, respectively). There was no significant difference among eyes with XFS (537.6 ± 36.7 µm) and control group (541.8 ± 29.9 µm) with respect to the CCT (P=0.142). CONCLUSIONS: Subjects with XFS have subnormal endothelial, keratocyte, and subbasal nerve densities. Cornea appears to be diffusely altered in the setting of XFS even without overt deposition of exfoliation material on the corneal endothelium. IVCM may be helpful in the evaluation and follow-up of patients with XFS in assessing the impact of surgical interventions and topical antiglaucomatous medications on the corneal cell densities and subbasal nerve plexus.