The STRokE DOC trial technique: 'video clip, drip, and/or ship'.

RATIONALE: To describe the clinical trial methods of a site-independent telemedicine system used in stroke. AIMS: A lack of readily available stroke expertise may partly explain the low rate of rt-PA use in acute stroke. Although telemedicine systems can reliably augment expertise available to rural settings, and may increase rt-PA use, point-to-point systems do require fixed base stations. Site-independent systems may minimize delay. The STRokE DOC trial assesses whether site-independent telemedicine effectively and efficiently brings rt-PA to a remote population. DESIGN: STRokE DOC is a 5-year, 400-participant, noninvasive trial, comparing two consultative techniques at four remote sites. Participants are randomized to acute 'STRokE DOC telemedicine' or 'telephone' consultations. Treatment decision accuracy is adjudicated at two time points, using three levels of data availability and an independent auditor. STUDY OUTCOMES: The primary outcome measure is whether there was a 'correct decision to treat or not to treat using rt-PA' at each of three adjudication levels (primarily at Level #2). Secondary outcomes include the number of thrombolytic recommendations, intracerebral hemorrhage, and 90-day outcomes. Using the STRokE DOC system (or telephone evaluation), medical history, neurologic scales, CT interpretations, and recommendations have been completed on over 200 participants to date. Of the initial 11, nonrandomized, 'run-in' patients, six (65%) were evaluated wirelessly, and five (45%) were evaluated with a site-independent LAN or cable modem. Three (27%) received rt-PA. The adjudication methodology was able to show both agreements and disagreements in these 11 cases. It is feasible to perform site-independent stroke consultations, and adjudicate those cases, using the STRokE DOC system and trial design. Telemedicine efficacy remains to be proven.

Prospective reliability of the STRokE DOC wireless/site independent telemedicine system.

The authors evaluated a site-independent telemedicine system. Telemedicine may be limited by the need for fixed connectivity. Wireless and site-independent technologies eliminate this limitation. Twenty-five stroke patients underwent evaluations by remote and bedside examiners. Ten of 15 (67%) NIH Stroke Scale and 9 of 11 (82%) Modified NIH Stroke Scale items showed excellent interrater reliability. Spearman correlations were > or =0.93. This Internet system is reliable and valid. Further studies should assess its use in acute stroke.

Chromatic and achromatic defects in patients with progressing glaucoma.

To evaluate the pattern of losses associated with glaucomatous injury in patients with progressing glaucoma, functional losses were examined in 14 patients with progressing glaucoma using tests for which detection should be selectively mediated by one of three psychophysical mechanisms. Red-on-white increments, blue-on-white increments and critical flicker frequency were used to isolate the responses of the red-green chromatic mechanism, the blue-on chromatic mechanism, and the high-frequency flicker achromatic mechanism. For our 3.1 degrees circular stimuli, chromatic defects were found in a greater number of the patients with glaucoma than were achromatic defects. We evaluated these defects in terms of two existing hypotheses: preferential loss and reduced redundancy. The greater sensitivity to glaucomatous injury of chromatic tests, compared to achromatic tests, found in this and other studies and the apparent discrepancy between anatomical and psychophysical studies can be parsimoniously explained by differences in cortical summation of ganglion cell responses for the chromatic and achromatic pathways.

Bleb window cryopexy for the management of oversized, misplaced blebs.

PURPOSE: To describe a new technique for revising oversized blebs after trabeculectomy. METHODS: A chart review of consecutive patients undergoing bleb window cryopexy was conducted. Patients with symptomatic oversized blebs were candidates for the technique, regardless of the intraocular pressure. Under topical anesthesia, the bleb was incised and a 3 mm x 3 mm conjunctival window was removed using 0.12 forceps and Vannas scissors. Light cryotherapy was applied to the sclera through the window. A soft bandage contact lens was then placed for compression, and a patch was applied. All patients were given antibiotic drops the first day after surgery. Topical corticosteroid drops were used to minimize postoperative inflammation. Outcome measures included relief of symptoms, adequate control of intraocular pressure, and restoration of filtering bleb function without further antiglaucoma medication or surgical bleb revision. RESULTS: Nine patients met the inclusion criteria. All patients had flattening of the bleb with symptomatic relief within 2 weeks. No loss of bleb function occurred. One patient developed aqueous misdirection after the procedure. CONCLUSION: Early results showed that bleb window cryopexy is safe and effective. This minimally invasive technique can be useful for selected patients with large. symptomatic, overhanging blebs.

Autologous conjunctival resurfacing of leaking filtering blebs.

PURPOSE: To present a case series of a new technique to repair late bleb leaks. DESIGN: Retrospective, noncomparative, consecutive case series. PARTICIPANTS: Forty-seven autologous conjunctival resurfacings of late bleb leaks were performed by four surgeons at two institutions. METHODS: Autologous conjunctival grafts were placed over existing de-epithelialized leaking blebs. MAIN OUTCOME MEASURES: Leak-free, Seidel-negative blebs and controlled glaucoma. RESULTS: After a mean follow-up of 14 +/- 12 months, one patient continued to have bleb leak at the last follow-up, and one frank leak resolved with aqueous suppression. Intraocular pressure increased from 6.6 +/- 4.4 mmHg (0.13 glaucoma medications) to 11.9 +/- 4.1 mmHg (0.41 glaucoma medications). CONCLUSIONS: Conjunctival resurfacing with autologous tissue is an effective technique to repair late bleb leaks.

Effects of methotrexate treatment on serum immunoreactivity of a patient with normal-pressure glaucoma.

PURPOSE: Increased serum immunoreactivity to retinal proteins may have a role in the disease process of some glaucoma patients. We describe a patient with normal-pressure glaucoma whose serum immunoreactivity to retinal proteins regressed after methotrexate treatment for rheumatoid disease. METHOD: Case report. RESULTS: In a 66-year-old white female with normal-pressure glaucoma and rheumatoid disease, sequential Western blots using patient sera against retinal proteins demonstrated a decrease in the immunoreactive bands after treatment. During the treatment period of 3 years, her visual fields appeared to have improved. Optic disk examination during the short periods without treatment, however, disclosed new, bilateral splinter hemorrhages on the optic disks. CONCLUSION: These observations suggest a potential role for immune-based intervention in similar patients.

Latanoprost-associated cystoid macular edema.

PURPOSE: To report two cases in which cystoid macular edema developed after initiation of topical latanoprost for glaucoma. METHODS: Case reports. One pseudophakic eye in each of two patients treated with latanoprost for glaucoma developed decreased vision and cystoid macular edema. Latanoprost was discontinued, and the cystoid macular edema was treated with topical corticosteroids and ketorolac. RESULTS: After discontinuing latanoprost and starting corticosteroids and ketorolac, visual acuity improved from counting fingers to 20/60 in one patient's left eye and from 20/100 to 20/25 in the other patient's right eye. The macular edema resolved in both eyes. CONCLUSIONS: Topical latanoprost may be associated with cystoid macular edema; this may be related to a prostaglandin-like action.

Visual field defects after macular hole surgery. A new finding.

PURPOSE: The purpose of the study is to report the problem of a temporal visual field defect occurring after macular hole surgery. METHODS: The authors reviewed the records of 13 patients found to have visual field defects after vitrectomy for macular holes. Fluorescein angiograms (13 patients), optic nerve photographs (13 patients), focal electroretinograms (3 patients), and nerve fiber analyses (8 patients) were performed in patients with visual field defects. RESULTS: An absolute, temporal, usually inferior field defect was noted in 13 patients. In eight patients, the defect was detected because of specific reports or retrospective field examination results. Five patients examined in a prospective manner were found to have field defects. No history of abnormal intraocular pressure or direct trauma to the optic nerve or retinal vessels was identified. Four patients showed optic nerve pallor and three had an anomalous-appearing disc. Focal electroretinograms were of similar amplitude in the involved retina compared to corresponding areas in the healthy fellow eye. Nerve fiber analysis showed a reduction in nerve fiber layer thickness correlating to the visual field defect in those eight patients in which this test was used. CONCLUSION: A significant temporal field defect may occur in patients after otherwise uncomplicated surgery for macular holes. The cause is unclear; however, reductions in nerve fiber layer thickness from the superior and nasal peripapillary area suggest that acute surgical release of the posterior hyaloid and the use of long-acting intraocular gas may in certain patients result in visual field defects.

Interoperator variability in images obtained by laser polarimetry of the nerve fiber layer.

PURPOSE: To study operated-related variability in images obtained by laser polarimetry of the nerve fiber layer, a new imaging technique that attempts to estimate thickness of the nerve fiber layer by using the fact that it is birefringent. METHODS: Measurements were made using a commercial device, the Nerve Fiber Analyzer (Laser Diagnostic Technologies, San Diego, CA), which uses a dedicated scanning laser ophthalmoscope to produce a retardation map of the retina adjacent to the optic nerve head. Four trained operators tested 11 subjects twice each, resulting in 88 images. Standard circles were placed around the optic disk for analysis. We analyzed five indices computed from these images: mean thickness in each of four quadrants and mean thickness under the entire circle. RESULTS: Repeated-measures analyses of variance showed significant effects of operator for four of these indices. Mean values for a given index varied by 11-14 muUm across operators, and the maximum difference across operators was approximately 22 of the mean value across subjects. CONCLUSIONS: The clinical usefulness of the device will be limited until it has been shown that new modifications successfully reduce interoperator variability.

Intracameral tissue plasminogen activator: management of a fibrin clot occluding a Molteno tube.

We report the use of intracameral tissue plasminogen activator to dissolve a fibrin clot occluding a Molteno tube in the immediate postoperative period. This technique is an effective alternative to awaiting clot lysis or reoperation with minimal risk. The only complication was a small, layering hyphema.

Early clinical experience with the Baerveldt 350-mm2 glaucoma implant and associated extraocular muscle imbalance.

PURPOSE: The Baerveldt glaucoma implant is a new commercially available aqueous drainage device. Clinical data on the performance of the implant are relatively limited. The purpose of this investigation is to explore potential advantages and disadvantages of this implant over the more widely used Molteno implant. METHODS: Retrospective analysis was performed on 37 eyes of 36 patients with refractory glaucoma who underwent placement of a mid-sized Baerveldt 350-mm2 implant. Patient selection was based on previous failure of conventional medical, laser, and surgical management, with poor prognosis for further glaucoma surgery and adjunctive antifibrosis therapy. RESULTS: Significant postoperative extraocular motility restriction and heterotropia were found in the operated eyes. Twenty-three (77%) of 30 eyes measured have significant heterotropia in primary gaze and restriction of gaze into the quadrant of the implant. As a result, 11 (65%) of 17 functionally binocular patients have diplopia in primary gaze. CONCLUSIONS: Pending further study, the authors are avoiding placement of the Baerveldt 350-mm2 implant in both binocular and monocular patients due to the high frequency of induced heterotropia and motility restriction.

Presumed Sympathetic Ophthalmia Following Nd: YAG Transscleral Cyclophotocoagulation.

A 28-year-old man with iridocorneal endothelial syndrome and three failed trabeculectomies received two treatments of noncontact neody-mium-YAG transscleral cyclophotocoagulation. Four weeks afterwards he presented with the clinical signs of sympathetic ophthalmia in the unoperated eye. Intense topical and subtenons corticosteroids caused resolution of his symptoms without necessitating enucleation of the inciting eye. This represents the third reported case of presumed sympathetic ophthalmia following cyclophotocoagulation.

The use of Molteno implant and anterior chamber tube shunt to encircling band for the treatment of glaucoma in keratoplasty patients.

This retrospective study reviews the results of 35 keratoplasty patients with complex corneal and glaucoma disease, who received Molteno-type (n = 25) or anterior chamber tube shunt to encircling band (ACTSEB)-type (n = 10) implant for the treatment of difficult glaucomas. The implant was placed before the keratoplasty in 14 eyes, during the keratoplasty procedure in 6 eyes, and subsequent to the corneal surgery in 15 eyes. Mean follow-up for the keratoplasty was 25.46 months (range, 6-58 months) and 24.74 months (range, 7-42 months) for the seton procedure. Graft rejection occurred in 12 (34%) of 35 eyes and was progressive in 9 eyes. Nonimmunologic failure was seen in 9 (26%) of 35 eyes. Grafts were repeated in ten eyes with eight of these (80%) remaining clear at a mean of 14.4 months. Considering the results of the repeat grafts, 25 (71%) of 35 eyes achieved clear transplants. Overall, 46% of patients had final visual acuities of 20/100 or better and 69% had final visual acuities of 20/400 or better. The mean preoperative intraocular pressure (IOP) of 34.54 mmHg (range, 14-68 mmHg; standard deviation [SD], 11.51) was lowered to a mean of 14.65 mmHg (range, 6-30 mmHg; SD, 4.49). In the final analysis, 30 (86%) of 35 eyes were judged successful from a glaucoma standpoint. We conclude that the Molteno- and ACTSEB-type implants are viable treatment alternatives in this difficult glaucoma group.

Factors affecting the results of argon laser trabeculoplasty in open-angle glaucoma.

Argon laser trabeculoplasty (ALT) was performed in 232 eyes of 180 patients affected by uncontrolled primary open-angle glaucoma (POAG), exfoliation syndrome glaucoma (ESG) or pigment dispersion syndrome glaucoma (PDSG). Mean follow-up was 9 months (3-22). Mean IOP change was -21.6% (+/- 19) from the initial value. The effect of IOP was larger in patients with ESG, PDSG, and in POAG cases with more pigmented trabecular meshwork. No relationship was found between IOP changes and age or refraction of patients; the association with iridoplasty did not influence final results. An Octopus computerized perimeter was used for pre and post-treatment visual field tests. In 113 eyes Octopus exams met the requirements for quantitative analysis. In this group 17% of visual field improved, 64% remained stable and 19% worsened. A good functional response was more frequent among the eyes with less advanced disease.

Short- and long-term effects of postoperative corticosteroids on trabeculectomy.

All patients with primary open-angle or primary angle-closure glaucoma requiring trabeculectomy between January 1982 and January 1983 were entered into a randomized prospective study to evaluate the effect of postoperative corticosteroids. Twenty-three eyes in Group 1 received a cycloplegic and topical antibiotic. Twenty-nine eyes in Group 2 received the same treatment, with the addition of topical 1% prednisolone acetate. Twenty-three eyes in Group 3 received the same treatment as Group 2, with the addition of systemic prednisone. Success rate was significantly improved with the use of topical corticosteroids. Systemic steroids did not prove to be of any added benefit over topical use alone.