Vascular parameters and endothelin-1 measurements in glaucoma patients with low- and high-tension optic disc hemorrhages.

This prospective study aimed to compare vascular parameters (endothelin-1 [ET-1] blood levels, laser Doppler imaging [LDI] of distal phalanxes, and nailfold capillaroscopy) between open-angle glaucoma patients with low- and high-tension optic disc hemorrhages (LTDH and HTDH, respectively). The 33 enrolled patients (mean age, 62.3 ± 13 years) were classified as LTDH or HTDH if they presented at the time of DH detection an intraocular pressure (IOP) < 16 mmHg or ≥ 16 mmHg, respectively. Demographic and ophthalmological data, ET-1 concentrations, LDI (before and 1, 10, and 20 min after cold stimulation), and nailfold capillaroscopy findings were evaluated. The ET-1 blood level was 65% higher in the LTDH (2.27 ± 1.46 pg/ml) than in the HTDH (1.37 ± 0.57 pg/ml; p = 0.03) group. Moreover, there was a statistically significant negative correlation between ET-1 blood concentration and IOP at the time of DH detection (r = -0.45, p = 0.02). Blood flow measurements 10 and 20 min after cold stimulation were lower in the LTDH group than in the HTDH group (p < 0.01). Patients developing DH with lower IOPs have higher ET-1 blood levels and more peripheral vascular dysfunction as estimated by LDI than those with higher IOPs. These findings suggest that distinct underlying mechanisms may be involved in patients developing DH within different IOP ranges.

Elucidation of the role of the lamina cribrosa in glaucoma using optical coherence tomography.

Glaucoma is a chronic and progressive optic neuropathy characterized by the death of retinal ganglion cells and corresponding visual field loss. Despite the growing number of studies on the subject, the pathogenesis of the disease remains unclear. Notwithstanding, several studies have shown that the lamina cribrosa (LC) is considered an anatomic site of glaucomatous optic nerve injury, thus having a key role in the pathophysiology of glaucoma development and progression. Different morphological alterations of the LC have been described in vivo in glaucomatous eyes after the evolution of optical coherence tomography (OCT) devices. The most relevant findings were the reduction of laminar thickness, the presence of localized defects, and the posterior LC displacement. These new laminar parameters documented through OCT are not only promising as possible additional tools for glaucoma diagnosis and monitoring, but also as predictors of disease progression. In spite of the advance of technology, however, proper evaluation of the LC is not yet viable in all eyes. We describe OCT-identified LC changes related to the development and progression of glaucoma and provide future directions based on a critical data analysis, focusing on its clinical relevance and applicability.

Early-onset Exfoliation Syndrome: A Literature Synthesis.

PRECIS: We conducted a literature review of younger patients with exfoliation syndrome (XFS) in an attempt to identify case similarities and better understand disease etiology. PURPOSE: XFS that predisposes to secondary glaucoma is a strongly age-related condition. We performed a literature review of XFS and exfoliation glaucoma (XFG) in patients aged younger than 40 years to examine potential common characteristics and gain clues to its etiology. METHODS: We conducted a broad literature search with appropriate keywords and manually extracted key demographic and ocular features on younger XFS and XFG cases. Articles that did not provide past ocular history on early-onset XFS/XFG were excluded. RESULTS: We identified 12 cases of XFS and XFG in patients from 13 to 40 years old (8 females; 11 White; 5 from Iran). All had past ocular history remarkable for intraocular surgery for other glaucoma conditions (7 cases), other ocular diseases (3 cases), or ocular trauma (2 cases). CONCLUSIONS: All reported early-onset XFS and XFG cases arise in the setting of events that produced a significant disruption of the blood-aqueous barrier. Understanding the metabolic alterations of aqueous humor from such cases could provide clues regarding how exfoliation material forms.

Factors associated with the presence of parafoveal scotoma in glaucomatous eyes with optic disc hemorrhages.

PURPOSE: Glaucomatous eyes with disc hemorrhage (DH) have a greater risk of paracentral visual field (VF) loss. However, not every DH eye presents with parafoveal scotoma (PFS), and contributing factors are still to be determined. In the present study, we investigated clinical and ocular factors associated with the presence of PFS in glaucomatous eyes with DH. METHODS: A case-control study was carried out. One hundred thirty glaucomatous patients with DH were enrolled. They were divided into two groups based on two reliable 24-2 VF tests: those with PFS (defined as ≥3 adjacent points with p < 5% within the central 10 degrees of fixation, ≥1 point with p < 1% lying at the innermost paracentral points, in the same hemifield) and those without PFS. Clinical and ocular data from the time of DH detection were compared between groups. Factors associated with the presence of PFS were investigated through logistic regression. RESULTS: The PFS group had a higher prevalence of Caucasian patients (82 vs. 47%; p < 0.01). Eyes with PFS had a more negative spherical equivalent and worse VF mean deviation (MD) index (p ≤ 0.01). There was a marginally significant intraocular pressure (IOP) difference between eyes with (15 mmHg) and without PFS (18 mmHg) at the time of DH detection (p = 0.10). Univariable analysis revealed PFS to be significantly associated with Caucasian race (OR, 3.02; p = 0.004), myopia (<-3 diopters; OR, 3.44; p = 0.039), and lower IOP (≤16 mmHg; OR, 2.10; p ≤ 0.047). Multivariable analysis, controlling for VF MD, revealed that only Caucasian race and myopia (as a continuous or categorical variable) remained significant in this model (p ≤ 0.038). CONCLUSIONS: Caucasian race and the presence and magnitude of myopia were found to be significantly associated with the presence of PFS in glaucomatous eyes with DH. Our results may help clinicians in the identification and surveillance of these eyes at higher risk of central VF loss.

The Association Between Clinical Features Seen on Fundus Photographs and Glaucomatous Damage Detected on Visual Fields and Optical Coherence Tomography Scans.

PURPOSE: To classify the appearance of the optic disc seen on fundus photographs of healthy subjects and patients with or suspected glaucoma whose diagnosis was based upon visual fields (VFs) and spectral-domain optical coherence tomography (sdOCT) results. PATIENTS AND METHODS: One eye of 100 patients with or suspected glaucoma and 62 healthy subjects were prospectively tested with 24-2 and 10-2 VF and macular and disc sdOCT cube scans. All eyes with or suspected glaucoma had a 24-2 mean deviation better than -6.0 dB and an abnormal appearing disc on stereophotographs. The retinal ganglion cell plus inner plexiform layer (RGC+) from the macular scans and the retinal nerve fiber layer (RNFL) from the macular and disc scans were segmented and converted to probabilities plots. An eye was considered "glaucoma" if the sdOCT probability plots showed an abnormality in a region that corresponded to a defect seen on the 24-2 and/or 10-2 VF total deviation plot. Similarly, an eye was considered "suspect" only if both the sdOCT and VF plots were normal. Healthy subjects (normal VFs and sdOCT) were classified as "controls" and used as reference for comparisons. Glaucoma specialists reviewed the stereophotographs and classified eyes based on the presence of signs suggestive of glaucomatous optic neuropathy. RESULTS: The pattern of clinical signs of glaucomatous optic neuropathy seen on stereophotographs was statistically different between glaucoma (P<0.001) and suspects (P<0.001) vs. controls and explained up to 68% of the total variance of the diagnosis based upon sdOCT and VFs. Vertical cup-to-disc>0.6, focal neuroretinal rim thinning, focal RNFL loss, and violation of the ISNT rule had the best performance to differentiate glaucoma and suspects from controls. Compared with the suspect group, glaucoma eyes (abnormal sdOCT and VF tests) were more likely to have vertical cup-to-disc>0.6 (92% vs. 69%, P=0.003), diffuse rim (53% vs. 9%, P<0.001) and RNFL (61% vs. 26%, P<0.001) thinning, and ß-zone parapapillary atrophy (68% vs. 17%, P<0.001). CONCLUSIONS: Focal and diffuse signs of glaucoma damage seen on stereophotographs often match damage shown on VFs and sdOCT. In addition, damage shown on VFs and sdOCT is often missed during clinical evaluation. Longitudinal studies ought to differentiate focal signs of glaucoma damage seen on stereophotography from false-positives or very early loss.

Nd:YAG laser goniopuncture for late bleb failure after trabeculectomy with adjunctive mitomycin C.

IMPORTANCE: There is an increasing need to prolong trabeculectomy success rates with minimally invasive procedures. OBJECTIVE: To investigate the safety and efficacy of Nd:YAG laser goniopuncture (LGP) in lowering intraocular pressure (IOP) in eyes having late bleb failure following trabeculectomy with mitomycin C administration. DESIGN, SETTING, AND PARTICIPANTS: Prospective, noncomparative, interventional cohort at a referral glaucoma practice, including 19 eyes of 19 patients with uncontrolled glaucoma after failed trabeculectomy. INTERVENTIONS: All eyes had ischemic nonfunctioning blebs with patent internal ostia and underwent Nd:YAG LGP, followed by a 5-fluorouracil injection. MAIN OUTCOMES AND MEASURES: The IOP and the number of antiglaucoma medications before and after the procedure, as well as presurgical and postsurgical appearance of the blebs, using the Indiana Bleb Appearance Grading Scale classification. RESULTS: The mean (SD) time of LGP after trabeculectomy was 35.7 (32.3) months, and the mean (SD) follow-up period after LGP was 6.0 (1.1) months (range, 4.4-8.4 months). The mean (SD) IOP had decreased from 20.9 (4.5) mm Hg (range, 15.5-29.0 mm Hg) to 11.9 (4.1) mm Hg (range, 5.0-21.0 mm Hg) (P < .001). The only complications observed after LGP were 2 cases of hypotony, which resolved spontaneously. Compared with baseline Indiana Bleb Appearance Grading Scale classifications, 2 eyes showed an increase in bleb height and 10 eyes showed an increase in bleb extension. None of the eyes had a positive Seidel test result. The mean (SD) number of hypotensive agents per eye had decreased from 0.7 (1.1) to 0.3 (0.7) after the procedure. At the last follow-up visit, 15 eyes (79%) had achieved an IOP of 15 mm Hg or less, with a minimum IOP reduction of 20% from baseline without medication use. CONCLUSIONS AND RELEVANCE: The Nd:YAG LGP is a safe and effective procedure for lowering IOP in eyes with ischemic nonfunctioning blebs and patent trabeculectomy ostia. This is a promising solution to rescue failed trabeculectomies and can potentially prolong trabeculectomy success rates.

Association between corneal biomechanical properties and optic nerve head morphology in newly diagnosed glaucoma patients.

BACKGROUND: To investigate the association between corneal biomechanics and optic nerve head morphology in newly diagnosed primary open-angle glaucoma patients. DESIGN: Hospital based prospective study. PARTICIPANTS: Forty-two untreated newly diagnosed primary open-angle glaucoma patients. METHODS: Patients underwent corneal hysteresis measurement using the Ocular Response Analyzer and confocal scanning laser ophthalmoscopy for optic nerve head topography evaluation. One eye was selected randomly for analysis. Data collected included age, race, gender, intraocular pressure and central corneal thickness. MAIN OUTCOME MEASURES: Multiple regression analysis (controlling for baseline intraocular pressure and disc area) was used to investigate factors associated with the following optic nerve head topographic parameters: linear cup-to-disc ratio and mean cup depth. RESULTS: Mean age of participants was 66.7 ± 11.8 years. Corneal hysteresis was the only factor significantly associated with both mean cup depth (correlation coefficient [r] = -0.34, P = 0.03) and cup-to-disc ratio (r = -0.41, P = 0.01). Central corneal thickness was significantly associated with mean cup depth (r = -0.35, P = 0.02), but not with cup-to-disc ratio (r = -0.25, P = 0.13). Although a trend towards a positive association between age and cup-to-disc ratio was identified (r = 0.26, P = 0.08), age was not significantly associated with mean cup depth (r = 0.06, P = 0.72). When comparing fellow eyes of patients with bilateral glaucoma, the eye with higher corneal hysteresis had smaller cup-to-disc ratio in 75% of the cases. CONCLUSIONS: In untreated newly diagnosed primary open-angle glaucoma patients, those with thinner corneas and mainly lower corneal hysteresis values had a larger cup-to-disc ratio and deeper cup, independently of intraocular pressure values and disc size.

Posture-induced intraocular pressure changes: considerations regarding body position in glaucoma patients.

Although glaucoma is a multifactorial disease, elevated intraocular pressure (IOP) remains the most important known risk factor. Different systemic and local factors are thought to influence an individual's IOP. There can be a clinically significant rise in IOP when going from upright to horizontal or inverted body positions. Although there is a significant interindividual variability, the magnitude of the IOP change is greater in glaucomatous eyes. As patients usually spend a significant portion of their lives in the horizontal position, mainly during sleep, this is highly relevant. In this review we discuss the relationship between postural changes and IOP fluctuation, including changes in both body and head position. The possible mechanisms involved and the main implications for glaucomatous eyes are discussed. Finally, considerations with regard to sleep position in glaucoma patients are made based on evidence in the literature.

Intraocular pressure variation during weight lifting.

OBJECTIVE: To evaluate the effect of weight lifting on intraocular pressure (IOP). METHODS: Subjects performed 4 repetitions of a bench press exercise in 2 ways: in mode I (right eyes), the breath was held during the last repetition; in mode II (left eyes), subjects exhaled normally during the last repetition. The IOP was measured with an electronic tonometer during the fourth repetition in both modes while the subject sustained the exercise. RESULTS: Mean IOP during exercise in mode I increased by 4.3 +/- 4.2 mm Hg (P<.001, paired t test; range, -3.6 to 17.7 mm Hg). In mode II, mean IOP increased by 2.2 +/- 3.0 mm Hg (P<.001, paired t test; range, -6.0 to 8.7 mm Hg). The IOP increased in 90% of subjects in mode I and in 62% in mode II. An increase in IOP greater than 5.0 mm Hg was observed in 9 subjects (30%) in mode I and in 6 (21%) in mode II. In 2 subjects, IOP during exercise mode I was markedly increased (>10.0 mm Hg). CONCLUSIONS: The IOP increases significantly during a bench press exercise. Breath holding during the exercise leads to a greater IOP increase.

Hipotireoidismo e glaucoma: investigaçäo de uma possível associaçäo / Possible association between glaucoma and hypothyroidism

Objetivo: investigar a associaçäo entre glaucoma primário de ângulo aberto (GPAA) e hipotireoidismo. Métodos: no primeiro estudo, 15 pacientes com hipotireoidismo primário que näo estavam recebendo complementaçäo hormonal foram investigados quanto à presença de GPAA. No segundo estudo, 65 pacientes com GPAA foram investigados quanto à ocorrência de hipotireoidismo através da dosagem de TSH. Resultados: Nenhum dos 15 pacientes com hipotireoidismo apresentou dados compatíveis com o diagnóstico de GPAA, e o nível médio da pressäo intraocular nesses pacientes foi de 15,8ñ2,3mmHg, variando entre 11 e 21mmHg. Apenas um (1,5/cento) entre os 65 pacientes glaucomatosos apresentou hipotireoidismo subclínico, diagnosticado graças aos níveis elevados de TSH. Conclusäo: Os achados deste estudo näo confirmam a hipótese de uma associaçäo entre hipotireoidismo e GPAA