Evaluation of the Consistency of Glaucomatous Visual Field Defects Using a Clustered SITA-Faster Protocol.

PURPOSE: Frontloading SITA-Faster (SFR) visual fields (2 tests per eye on the same visit) has been shown to provide repeatable perimetric data at minimal time cost. This study reports the outcomes of using frontloaded SFR in the evaluation of pointwise visual field (VF) defects in a cohort of patients with glaucoma when transitioned from SITA-Standard (SS). DESIGN: Prospective, cross-sectional study. PARTICIPANTS: A total of 144 eyes of 91 patients with confirmed or suspected glaucoma who had an SS test on a previous visit. METHODS: Two SFR tests (T1, T2) per eye on the same visit. MAIN OUTCOME MEASURES: Global sensitivity, reliability indices, and pointwise deviation map probability scores from the pattern deviation grid of each patient were compared across the 3 sequential tests to evaluate the consistency of VF defects. RESULTS: The mean age was 68.6 years, and 79.2% of patients had a diagnosis of glaucoma. There was no significant difference in mean deviation (MD) across the 3 tests (-5.83 decibels [dB], -5.28 dB, and -5.71 dB in SS, SFR1, and SFR2, respectively, repeated-measures analysis of variance [ANOVA], P = 0.48). The frontloaded SFR tests provided repeatable VFs that confirmed existing pointwise data on the SS in 4661 (62.3%) locations, reversed an SS defect in 614 (8.2%) locations, and demonstrated a new repeatable defect in 406 (5.4%) locations of the pattern deviation grid. A new defect of at least 3 contiguous points was identified in 20.1% of eyes. The non-repeatable points on the 2 SFR tests displayed no significant difference in the distribution of defect/nondefect points based on test order or peripheral versus central locations. There was no significant difference in the rate of obtaining at least 1 reliable test result between SS and the frontloaded SFR T1 and T2 (P = 0.77). Test duration significantly decreased from SS to SFR1/2 (379 vs. 160 vs. 158 seconds, P < 0.0001). CONCLUSIONS: Frontloading SFR tests can provide repeatable data for the evaluation of the consistency of pattern deviation defects in glaucoma, with no observable decline in performance from test fatigue. This is achieved at equivalent duration and reliability as a single SS test. Frontloading SFR may be helpful in increasing testing frequency/quantity to meet recommended guidelines for progression analysis. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Factors Affecting Adherence to Topical Glaucoma Therapy: A Quantitative and Qualitative Pilot Study Analysis in Sydney, Australia.

PURPOSE: To assess which factors in the lives and disease of patients with glaucoma affect their adherence to topical glaucoma therapy and the quantitative significance of this effect. To assess qualitatively the most influential barriers to adherence from the perspective of the patient. DESIGN: Multicenter, prospective, cross-sectional pilot study. PARTICIPANTS: A total of 145 patients, attending outpatient metropolitan glaucoma clinics in Sydney, Australia, who were prescribed topical glaucoma medications. METHODS: A structured interview-based questionnaire was conducted with 145 individuals using glaucoma eye drops that had been prescribed at least 2 weeks previously. The questionnaire involved 2 novel questions on adherence, 29 questions on factors identified or postulated in the literature as affecting adherence for quantitative analysis, and 1 open-response question on patient-identified causes of nonadherence for qualitative analysis. This questionnaire represents the broadest coverage of factors hypothesized to affect adherence in a single study in the glaucoma medication adherence literature to date. MAIN OUTCOME MEASURES: Adherence rate, risk factors for poor adherence, and patient-identified barriers to adherence. RESULTS: In response to the question "How many days have you missed a drop in the last 2 weeks," 69.7% of patients reported total adherence. Four factors were significantly related to an increased likelihood of reporting having missed drops in the last 2 weeks. These were difficulty applying drops (odds ratio [OR], 2.35; 95% confidence interval [CI], 1.02-5.44; P < 0.05), a past or current diagnosis of depression (OR, 3.61; 95% CI, 1.53-8.52; P < 0.01), patient self-rating of own memory ≤ 7 of 10 (OR, 3.15; 95% CI, 1.36-7.30; P < 0.01), and self-reported motivation score ≤ 6 of 10 (OR, 10.94; 95% CI, 3.00-39.81; P < 0.01). Patient understanding of glaucoma, ethnicity, and socioeconomic status were among the 25 factors found not to have a statistically significant correlation with adherence. CONCLUSIONS: There is a significant proportion of patients taking their topical glaucoma medications less often than prescribed. Adherence to topical glaucoma therapies is negatively correlated to several factors: difficulty applying drops, a past or current diagnosis of depression, poor self-rating of own memory, and poor self-rating of own motivation. These may prove useful in designing interventions to improve adherence in these patients.

Comparison between intraocular pressure spikes with water loading and postural change.

BACKGROUND: To compare the agreement between peak intraocular pressures measured through the water drinking test and the supine test, in patients with primary open angle glaucoma. DESIGN: Consecutive, prospective, blinded. PARTICIPANTS: Twenty-one patients from the Glaucoma Unit, Prince of Wales Hospital, Sydney, Australia. METHODS: For the supine test, intraocular pressure was recorded immediately after the patient had lain down and at 20 and 40 min. At the second evaluation, intraocular pressure was measured in each patient after drinking 10 mL/kg body weight of water for the water drinking test. Again, all patients had their intraocular pressure measured at 20 and 40 min (t = 20 and t = 40, respectively). Patients were excluded from the study if they had pre-existing cardiac, renal or pulmonary complications or had concurrent ocular disease or an anatomical abnormality (including angle recession, peripheral anterior synechiae and developmental anomalies of the angle) that may have influenced intraocular pressure. MAIN OUTCOME MEASURE: Bland-Altman analysis. RESULTS: Bland-Altman analysis indicated an overall excellent agreement in terms of mean difference between methods (1.0, -1.0 and -0.90 mmHg, at 0, 20 and 40 min, respectively). Further, with the exception of t = 40, all measured time points had 95% confidence intervals within 6.5 mmHg of their mean difference on the Bland-Altman plot. CONCLUSIONS: There was close agreement between the intraocular pressure values of the supine test and water drinking test. However, as the water drinking test may be uncomfortable and potentially hazardous, there is potential that the supine test may be a safer and more comfortable alternative.

Technique to exclude temporal lash incursion in phacoemulsification surgery.

UNLABELLED: We describe the use of a Steri-Strip to exclude lashes in cataract surgery cases in which the lashes impinge on the operative field. The technique has been used in 25 cases and achieved uniformly successful lash exclusion. In 6 cases, the strip became partially dislodged and required repositioning intraoperatively, after which it achieved complete lash exclusion. No complications have been observed. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Glaucoma filtration surgery following sustained elevation of intraocular pressure secondary to intravitreal anti-VEGF injections.

BACKGROUND AND OBJECTIVE: To document cases of sustained elevation of intraocular pressure (IOP) while receiving intravitreal anti-vascular endothelial growth factor (VEGF) agents and subsequent management. PATIENTS AND METHODS: A retrospective series of all cases managed by the authors and colleagues was performed. RESULTS: Six patients developed sustained elevated IOP; five received ranibizumab and one bevacizumab. Four received unilateral and two received bilateral injections. Two had preexisting primary open-angle glaucoma and one had pseudoexfoliative glaucoma, all with stable IOP prior to anti-VEGF treatment. Angles were open in all cases. Peak IOP averaged 43 mm Hg (range: 34 to 60 mm Hg). The mean number of injections preceding the IOP increase was 10 (range: 1 to 20). Four patients required trabeculectomy, one selective laser trabeculoplasty, and one multiple topical medications. CONCLUSION: A sustained increase in IOP requiring glaucoma filtering surgery is a rare but important treatment complication for patients receiving intravitreal anti-VEGF therapy, especially those with preexisting glaucoma or glaucoma risk factors.

Orbital emphysema following removal of bilateral midfacial implants.

A 36-year-old man with Crouzon syndrome was referred post-operatively with unilateral painful limitation of eye movements and proptosis following removal of bilateral malar and orbital rim implants. Further investigation revealed right inferior orbital emphysema, caused by the intra-operative entrance of hydrogen peroxide through a suspected perforation of the orbital septum. The symptoms settled with conservative management.

Corneal indentation in the early management of acute angle closure.

PURPOSE: To describe in detail corneal indentation (CI) in the management of a series of patients treated for acute angle closure (AAC). DESIGN: Retrospective, consecutive, noncomparative case series. PARTICIPANTS: Seven consecutive patients (8 eyes) referred to the authors with the diagnosis of AAC. Patients presented to the Prince of Wales Hospital, Randwick, or to the private practices of the authors. INTERVENTION: Seven patients (8 eyes) underwent CI as part of their early management for AAC. MAIN OUTCOME MEASURES: Reduction in intraocular pressure (IOP), symptoms of AAC and pain relief. RESULTS: Of the 7 patients, complete data were available for 6. The IOP was significantly reduced (P<0.05) and 3 of 4 patients with severe acute pain reported early resolution of pain after CI. The average reduction in IOP was 20.9 mmHg (range +1 to -45). All patients subsequently underwent definitive management with laser peripheral iridotomies or lensectomy using phacoemulsification. Three patients treated acutely with CI without any medical agents had a mean IOP reduction of 21 mmHg (range, 20-23) after indentation. CONCLUSIONS: Corneal indentation is a rapid, portable, and effective method of reducing elevated IOP in the setting of AAC. It can be performed with instrumentation that is readily at hand and allows for rapid pain relief. This reduction in IOP improves corneal clarity and permits further definitive management of the patient with AAC. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

Surgical removal of intraocular antibiotic ointment after routine cataract phacoemulsification.

We report surgical removal of a droplet of intraocular chloramphenicol ointment in a 70-year-old man who had routine small-incision phacoemulsification. A spherical droplet of ointment adherent to the intraocular lens was noted 2 months postoperatively. The source was considered to be the immediate postoperative conjunctival fornix chloramphenicol ointment. Gonioscopy revealed tiny droplets adherent to the peripheral iris and angle. The droplet was surgically explanted using a minimally traumatic technique with a lens glide and ophthalmic viscosurgical device through an enlarged clear corneal incision and sent intact for laboratory biochemical analysis. The patient maintained good vision without evidence of uveitis or secondary glaucoma at 1 year of follow-up. This uncommon case also raises issues about the need for immediate postoperative antibiotic ointment for endophthalmitis prophylaxis and phacoemulsification thermal wound effects on the integrity of self-sealing clear corneal incisions.

Spectrum of clear corneal incision cataract wound infection.

PURPOSE: To describe the presentation, management, and outcome of 5 patients who presented with main-port or side-port wound infection after uneventful clear corneal cataract surgery. SETTING: Ophthalmic Surgery Centre, Chatswood, and Department of Ophthalmology, Prince of Wales Hospital, Randwick, Australia, and Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom. METHODS: This retrospective case series comprised 5 patients who had uneventful clear corneal phacoemulsification surgery and developed either a main-port or side-port wound infection. The clinical features, microbiologic studies, management, and results are reported. RESULTS: The median age of the patients was 79 years. Infection of the main-port incision occurred in 3 cases and of the side port in 2 cases. The patients presented from a few days to several weeks after uneventful phacoemulsification. In 2 cases, the bacteria Pseudomonas aeruginosa and Staphylococcus aureus were isolated. In 1 case, the fungus Aspergillus was isolated and required extensive medical and surgical treatment. In the other 2 cases; empiric antimicrobial therapy was given because no organism was isolated in 1 case, and in the other milder case, microbiological investigations were not performed. Final visual acuity was 6/4 in 2 cases and 6/5, 6/12, and 6/18 in 1 case each. CONCLUSIONS: Bacterial or fungal wound infection can present within days or even several weeks following clear corneal cataract surgery. Patients with ocular discomfort or blurred vision after such surgery should be advised to report promptly. Rapid identification and appropriate management of patients with clear corneal wound infection can result in good visual outcomes.