Reevaluation of presentation and course of idiopathic intracranial hypertension--a large cohort comprehensive study.

OBJECTIVES: We analyzed the clinical and ophthalmological findings in a large group of patients with idiopathic intracranial hypertension (IIH) trying to find factors that might influence the course of the disease. MATERIALS AND METHODS: Medical records of patients with IIH were retrospectively reviewed. The patients included were women after menarche and men older than 18 years of age who were followed up for at least 1 year. RESULTS: Eighty-two patients (89% women) with a mean age of 30.2 ± 12.0 years were included. The prevailing complaint was headache and transient visual obscurations followed by tinnitus and double vision. Eighty-two percent of patients were overweight at the time of diagnosis. Overweight patients had higher opening cerebrospinal fluid (CSF) pressure than patients with normal weight did. The grade of papilledema correlated with the CSF opening pressure. Inverse correlation was found between the depression of the visual field sensitivity and the grade of papilledema. The mean follow-up time was 61.3 ± 62.3 months. Eighty-four percent of the patients have improved while in 22% CSF diversion procedures or optic nerve decompression was required. The mean body mass index (BMI) at the end of follow-up decreased significantly. Sixty-seven percent of the patients suffered a recurrence of IIH. The number of recurrences inversely correlated with weight loss. Visual field defects on presentation were encountered more frequently in patients with recurrence. Women with recurrence had a history of more pregnancies. CONCLUSIONS: Our results confirm the strong association between overweight and IIH. The recurrence rate seemed to be influenced by the obstetrical history and the severity of visual field defects at presentation. In contrast to some previous studies, we have found an interrelation between the CSF opening pressure, grade of papilledema and depression of the visual field sensitivity.

Red and/or blonde hair association with pigmentary glaucoma in Israel.

PURPOSE: To assess the prevalence of red and/or blonde hair in a defined pigmentary glaucoma (PG) population and to compare their clinical findings with those of PG patients with black or brown hair. METHODS: Hair color was studied in 35 consecutive PG patients and 35 consecutive primary open angle glaucoma (POAG) patients who served as controls. Patients were classified into red and/or blonde hair group or into black or brown hair group. Clinical characteristics were contrasted between PG patients of red and/or blonde hair with PG patients of black or brown hair. RESULTS: Of the 35 PG patients, 19 (54.3%) had red and/or blonde hair and 16 (45.7%) had black or brown hair. Of the 35 POAG patients, two (5.8%) had red and/or blonde hair and 33 (94.2%) had black or brown hair. This difference in prevalence of hair color is highly significant (P < 0.001; chi2). Clinical characteristics of the PG patients (age at initial diagnosis, gender, positive family history for glaucoma, initial IOP, refraction, severity of optic nerve damage and prevalence of retinal detachment) were similar in the red and/or blonde hair and the black or brown hair groups. CONCLUSIONS: A very high prevalence of red and/or blonde hair was found among PG patients in Israel. Should supportive evidence for this association accumulate subsequent to this report, screening of people with these hair colors for PG may be justified.

Tono-Pen versus Goldmann tonometry after excimer laser photorefractive keratectomy.

PURPOSE: To compare intraocular pressure (IOP) measurements by the Tono-Pen 2 tonometer and Goldmann applanation tonometer (GAT) in post-photorefractive keratectomy (PRK) patients. SETTING: Refractive Surgery Center, Assaf Harofeh Medical Center, Zerifin, Israel. METHODS: In 18 patients, IOP was measured by GAT and then by Tono-Pen 2 tonometer 2 to 18 months following PRK (mean 6.6 months +/- 5.1 [SD]). Photorefractive keratectomy had been performed in 1 eye of each patient; the fellow eyes served as controls. Corneal curvature and thickness were evaluated. Ten of the 18 patients were treated with topical steroids. RESULTS: In the post-PRK eyes, mean GAT IOP was 1.8 +/- 3.1 mm Hg lower than mean Tono-Pen IOP (P = .012); there was no significant IOP difference in the control (fellow) eyes. In steroid-treated post-PRK eyes, mean GAT IOP (12.2 mm Hg) was 2.2 +/- 1.3 mm Hg lower than mean Tono-Pen IOP (14.4 mm Hg) (P = .0007). Mean Tono-Pen IOP in steroid-treated post-PRK eyes was 4.3 +/- 3 mm Hg higher than in the fellow eyes (P = .0014); mean GAT IOP was only 2.3 +/- 3.5 mm Hg higher (P = .04). In post-PRK eyes without topical steroid treatment, mean GAT IOP was 2.0 +/- 1.18 mm Hg lower than in the fellow eyes (P = .001); there was no significant difference in Tono-Pen IOP. There was a negative correlation between the difference in IOP values (Tono-Pen minus GAT) and corneal curvature in post-PRK eyes (r = 0.76, P = .0108, n = 15). CONCLUSIONS: The Tono-Pen tonometer appeared to be less affected than the GAT by the relative flattening, thinning, and anterior stromal decreased rigidity of the central cornea that occur following PRK. Post-PRK steroid-induced IOP elevation may be masked by the artifactual decrease in GAT IOP.

The effect of anthocyanosides in a multiple oral dose on night vision.

PURPOSE: In view of research demonstrating the ability of anthocyanosides in a multiple oral dose to improve night vision in normal individuals, we assessed their effect on three night vision tests: full-field absolute scotopic retinal threshold (SRT), dark adaptation rate (DAR) and mesopic contrast sensitivity (MCS). METHODS: In a double-masked, placebo-controlled, cross-over study, 18 young normal volunteers were randomly assigned to one of three different regimens of multiple oral administrations of 12 and 24 mg anthocyanosides, and a placebo, given twice daily for 4 days. A 2 week washout period was allowed between each 4 day treatment period. SRT, DAR and MCS was tested 1 day before and at days 1, 2, 3 and 4 during the treatment period. RESULTS: No significant effect was found on any of the three above-mentioned night vision tests. The study had a power of 0.95 to detect a 0.1 log unit improvement in SRT and 0.5 log unit improvement in MCS. CONCLUSIONS: Multiple oral administrations of 12 and 24 mg anthocyanosides twice a day appear to lack significant effect on night vision tests.

The effect of anthocyanosides on night vision.

PURPOSE: In view of research demonstrating the ability of anthocyanosides in a single oral dose to improve night vision in normal individuals, it was decided to evaluate their effect on three night vision tests: full-field scotopic retinal threshold (SRT), dark adaptation rate (DAR) and mesopic contrast sensitivity (MCS). METHODS: In a double-masked, placebo-controlled, cross-over study, 16 young normal volunteers were randomly assigned to one of four different regimens of single oral administrations of 12, 24 and 36 mg of anthocyanosides, and a placebo, with a 2 week washout period between doses. SRT, DAR and MCS were measured immediately before, and 4, 8 and 24 h after treatment. RESULTS: No significant effect was found on any of the three night vision tests during the 24 h following a single oral administration of 12, 24 or 36 mg anthocyanosides. The study had a power of 0.95 to detect a 0.1 log unit improvement in SRT and 0.5 log unit improvement in MCS. CONCLUSIONS: Single oral administration of 12-36 mg of anthocyanosides appears to lack significant effect on militarily relevant night vision tests.

Intraocular pressure increments after cataract extraction in glaucomatous eyes with functioning filtering blebs.

BACKGROUND AND OBJECTIVE: The effects of cataract extraction on intraocular pressure (IOP) were studied in glaucoma patients who had previously undergone trabeculectomy. PATIENTS AND METHODS: The files of 22 patients with 25 glaucomatous eyes with functioning filtering blebs who underwent cataract extraction were retrospectively reviewed. All patients had undergone pretrabeculectomy examination and had at least 18 months of follow-up after cataract surgery. Visual acuity, IOP, status of the filtering bleb, and the number of medications applied were recorded. RESULTS: The mean increase in IOP was 3.63 mm Hg, 3.84 mm Hg, 5.4 mm Hg, and 2.8 mm Hg at 3, 6, 12, and 18 months after cataract extraction, respectively. This elevation was statistically significant 3 months postoperatively (P < .001) and remained relatively constant thereafter. The postoperative IOP was still significantly lower than the pretrabeculectomy IOP (P < .001). CONCLUSIONS: Cataract extraction through corneal incisions in patients with functioning filtering blebs is followed by an increase in IOP. Cataract surgery in these patients does not neutralize the pressure-lowering effect achieved by the trabeculectomy, but it tends to elevate the post-trabeculectomy baseline pressure.

Evaluation of mid-term stability of night vision tests.

BACKGROUND: Dark adaptation rate, scotopic retinal sensitivity and contrast sensitivity under mesopic conditions, but not visual acuity, have been shown to be directly related to the ability to identify military targets at night. These parameters can be used to select personnel for specific military tasks demanding excellent night vision, as well as to assess pharmacological effects on night vision. PURPOSE: To evaluate the mid-term (2 to 6-week period) stability of night vision tests based on assessment of the above parameters. METHODS: Dark adaptation rate, scotopic retinal sensitivity and contrast sensitivity under mesopic conditions were studied in 16 young volunteers during a 6-week period. RESULTS: Tests of scotopic retinal sensitivity (after 30 min of dark adaptation) exhibited high reproducibility and a low fluctuation rate, with a high correlation between values at week 0 and at 2-week intervals during the following 6 weeks of the study (rs (week 0 to week 6) = 0.81, p = 0.0001). The reproducibility of mesopic contrast sensitivity tests (average of 1.5, 3, 6 and 12 cycles per degree, (cpd)) was fair (rs (week 0 to week 2) = 0.67, p = 0.0045), whereas that of dark adaptation rate tests was poor. CONCLUSIONS: In view of the reproducibility characteristics of these night vision tests, assessment of night vision ability in pilots and military personnel, as well as assessment of pharmacological effects on night vision, may be based on scotopic retinal sensitivity (after 30 min of dark adaptation) and contrast sensitivity under mesopic conditions (average of 1.5, 3, 6 and 12 cpd).

Study of central retinal ganglion cell loss in experimental glaucoma in monkey eyes.

PURPOSE: The objective of this research was to compare the loss of retinal ganglion cells subserving the fovea to that of the ganglion cells in the surrounding perifoveal region in eyes with experimental glaucoma. METHODS: Ganglion cell nucleoli were counted using light microscopy from vertically oriented retinal, strips and the cell density was calculated using the modified Abercombie formula. Percent ganglion cell loss in glaucomatous eyes from five monkeys was determined for each of up to five contiguous areas within the central 12 degrees of the retina by comparison to normal fellow eyes. RESULTS: Loss of central ganglion cells was present even in eyes with mild glaucomatous damage. The percent ganglion cell loss in glaucomatous eyes at five adjacent areas within the central 12 degrees of the retina did not differ significantly (ANOVA, p = 0.77, n = 8). Cell loss in areas nearest to the fovea was indistinguishable from that in more peripheral perifoveal areas. CONCLUSIONS: Foveal ganglion cells appear to be susceptible to experimental glaucoma injury. Psychophysical testing of foveal functions may deserve renewed attention in glaucoma diagnosis and follow-up.

Impact of age, various forms of cataract, and visual acuity on whole-field scotopic sensitivity screening for glaucoma in rural Taiwan.

OBJECTIVE: To evaluate the impact of age, various forms of cataract, and visual acuity on whole-field scotopic sensitivity screening for glaucoma in a rural population. DESIGN: Clinic-based study with population-based recruitment. SETTING: Jin Shan Township near Taipei, Taiwan. SUBJECTS: Three hundred forty-six residents (ages, > or = 40 years) of Jin Shan Township. INTERVENTIONS: Whole-field scotopic testing, ophthalmoscopy with dilation of the pupils, cataract grading against photographic standards, and screening visual field testing in a random one-third subsample. MAIN OUTCOME MEASURES: Whole-field scotopic sensitivity (in decibels) and diagnostic status as a case of glaucoma, glaucoma suspect, or normal. RESULTS: Participants in Jin Shan Township did not differ significantly in the rate of blindness, low visual acuity, or family history of glaucoma from a random sample of nonrespondents. Scotopic sensitivity testing detected 100% (6/6) of subjects with open-angle glaucoma at a specificity of 80.2%. The mean +/- SE scotopic sensitivity for six subjects with open-angle glaucoma (32.78 +/- 1.51 dB) differed significantly from that of 315 normal individuals (38.51 +/- 0.22 dB), when adjusted for age and visual acuity (P = .05, t test). With linear regression modeling, factors that correlated significantly with scotopic sensitivity were intraocular pressure, screening visual field, best corrected visual acuity, presence of cortical cataract, and increasing age. CONCLUSIONS: Although cataract affects the whole-field scotopic threshold, it appears that scotopic testing may be of value in field-based screening for glaucoma.

Comparison of ganglion cell loss and cone loss in experimental glaucoma.

PURPOSE: To compare the loss of ganglion cells to cone loss in the macular area of monkey eyes with experimental glaucoma. METHODS: Experimental glaucoma was induced in eyes of three cynomolgus monkeys by argon laser applications to the trabecular meshwork. The average duration +/- S.D. of glaucoma in the experimental animals was 3.8 +/- 0.5 months. Glaucomatous damage was estimated, before the animals were killed, by evaluating stereoscopic photographs of the optic disk and red-free photographs of the nerve fiber layer. Ganglion cell nucleoli and cone pedicles were counted by using light microscopy from slides containing strips of retinal tissue. Cell density was then calculated by using the modified Abercrombie formula. Percent loss of ganglion cells and cones was determined from three eyes of three monkeys in 300-micron segments that were 900 to 1,200 microns superior and inferior to the foveal center. RESULTS: Cone loss was not found at 4.5 to 6 degrees eccentricity above and below the fovea, whether damage was mild or severe. The average loss +/- S.D. of ganglion cells was 81.1% +/- 10.7%, whereas the average cone loss was only 3.5% +/- 6.4%. CONCLUSIONS: Marked parafoveal cone loss was not found in experimental glaucoma in which extensive damage to ganglion cells occurred.

Surgical consequences in coexisting cataract and glaucoma.

Of the three classical approaches to surgery for coexisting cataract and glaucoma, last year's publications dealt with the surgical consequences of combined cataract and glaucoma operations only. When used in combined cataract and glaucoma surgery, a small-incision extracapsular cataract extraction (ECCE) with phacoemulsification (PHACO) was found to be only slightly superior to the standard manual ECCE in terms of postoperative intraocular pressure (IOP) control. Injections of 5-fluorouracil postoperatively did not improve IOP control in PHACO-ECCE-trabeculectomy or manual ECCE-trabeculectomy. A preliminary uncontrolled report suggests, however, that intraoperative mitomycin C application in PHACO-ECCE-trabeculectomy may result in excellent postoperative IOP control without antiglaucomatous medications, and with no significant mitomycin C-related complications. Controlled studies on mitomycin C application in small-incision cataract and glaucoma surgery are needed to assess its long-term effect on IOP and astigmatism.

[Cataract surgery in Israel, 1984-1991].

A review of cataract surgery and intraocular lens implantation in Israel between 1984-1991 is presented. During these 7 years the number of cataract operations increased by 50%, with a significant increase in operations in private hospitals. The proportion of intraocular lens implantations increased from 47% to 93%, predominantly posterior chamber implantations. A rapid transition from intracapsular to extracapsular extraction was documented.

Effect of cataract on a scotopic sensitivity screening test for glaucoma.

We investigated whether cataract decreases whole-field scotopic sensitivity, a measurement used for the detection of early glaucoma damage. The study population consisted of 33 patients scheduled for cataract surgery. Patients were >/=50 years old and had no ocular disease except senile cataract. The whole-field scotopic sensitivity of one eye of each subject was measured 1 day before and 3 months after cataract surgery. That of six persons of similar age without cataract was also measured twice, 3 months apart. Cataract extraction was associated with significantly improved sensitivity (p = 0.005). With stratification by cataract type, only persons with nuclear sclerosis demonstrated a significantly improved sensitivity after cataract surgery (p = 0.03). The magnitude of sensitivity improvement after surgery did not differ significantly between patients with mild compared to moderate cataract. Multiple regression analysis revealed that age, preoperative intraocular pressure, change in visual acuity, cataract type, and cataract severity were not independently significant predictors of change in sensitivity after cataract surgery. We conclude that cataract may alter the whole-field scotopic sensitivity score and may need to be taken into account in its use for glaucoma screening.

Examination methods for glaucoma prevalence surveys.

OBJECTIVE: To perform a pilot evaluation of new examination methods for the detection of glaucoma and other causes of visual impairment in rural East Africa. DESIGN: Testing was performed by local eye nurses after a brief training course. Two novel tests of visual function were used, a scotopic sensitivity test and a visual field test performed on a laptop computer. The optic disc was examined with direct ophthalmoscopy after pupillary dilation and compared with standard photographs on a laminated card. Intraocular pressure was measured with a hand-held, electronic tonometer. SETTING: Rural Tanzania. PARTICIPANTS: One hundred twenty adult villagers. RESULTS: The visual function tests could be performed on more than 90% of subjects, and the results were correlated with the size of the optic disc cup, an objective measure of glaucoma injury. CONCLUSIONS: This survey shows the practicality of instrument-based testing of visual function under field conditions.

Foveal ganglion cell loss is size dependent in experimental glaucoma.

PURPOSE: The purpose of this study was to study the pattern of foveal ganglion cell loss in experimental glaucoma. METHODS: Retinal ganglion cell size and number in the foveal region of seven monkey eyes with experimental glaucoma was determined and compared to normal monkey eyes. Serial sections of macular retina were studied in two regions: the plateau of peak density of ganglion cells (800-1100 microns from the fovea), and within 500 microns of the foveal center. RESULTS: In normal eyes, cell densities were 37,900 +/- 2700 in the foveal plateau and 17,200 +/- 1800 cells/mm2 in the foveal center. There was selective loss of larger ganglion cells in glaucoma eyes. The degree of foveal ganglion cell loss was significantly correlated to the degree of nerve fiber loss in the temporal optic nerve of the same eye. CONCLUSIONS: Detection of early, central visual function loss in glaucoma could be enhanced by testing functions subserved by larger retinal ganglion cells.

Long-term follow up of accidental parafoveal laser burns.

The findings after 12 years of follow-up evaluation of 2 patients who sustained accidental parafoveal and juxtafoveal Nd:YAG laser injuries are reported. In both cases, the fovea was not destroyed by the initial insult and early scar formation. Both cases demonstrated, after more than a decade, minimal visual deficit without significant late complications. In spite of early decrease in visual performance, the long-term prognosis for Q-switched Nd:YAG laser retinal lesions in which the fovea was not directly involved in the injury or its repair mechanisms is relatively benign.

A whole-field scotopic retinal sensitivity test for the detection of early glaucoma damage.

We designed and evaluated a new test for the detection of early glaucoma damage in 133 persons who were classified as normal, suspected of having glaucoma, or having glaucoma. The test stimulates the entire visual field with a flashing white light under dark-adapted conditions. It can be performed easily by a high proportion of subjects and is as reproducible as present psychophysical tests. Glaucomatous eyes were discriminated from normal with a diagnostic power of 0.91 as judged by receiver operating characteristic analysis, and specificity and sensitivity were 91% and 86%, respectively. Glaucoma suspects with an abnormal response to the whole-field scotopic test were more likely to have other signs indicating early optic nerve injury, including a greater proportion of borderline field defects, nerve fiber layer defects, or glaucomatous fellow eyes. Assessment of whole-field scotopic sensitivity may be useful in glaucoma screening.

Retinal ganglion cell loss is size dependent in experimental glaucoma.

Thirty-two areas located in the temporal midperipheral retina were evaluated in whole-mount preparations from four monkeys with monocular experimental glaucoma. Diameter frequency distributions of remaining ganglion cells in the glaucomatous eye were compared with corresponding areas in the normal fellow eye. Large cells were significantly more vulnerable at each stage of cell damage as determined by linear-regression analysis. The magnitude of size-dependent loss was moderate at an early stage (20% loss), peaked at 50% total cell loss, and decreased in advanced damage (70% loss). In glaucomatous eyes, the lower retina had significantly more large cell loss than the corresponding areas of the upper retina. In optic nerve zones that matched the retinal areas studied, large axons selectively were damaged first. Psychophysical testing aimed at functions subserved by larger ganglion cells is recommended for detection and follow-up of early glaucoma; however, assessment of functions unique to small cells is more appropriate for detecting change in advanced glaucoma.

Effect of a resutured iridotomy on glare disability in glaucoma patients having cataract surgery.

Twenty-two glaucoma patients with fixed miotic pupils prior to cataract surgery were retrospectively divided into two groups: Group A in which the sector iridotomy was resutured after intraocular lens insertion; Group B in which the sector iridotomy was not resutured. The two groups were matched for average age, sex, average disease duration, glaucoma type, operation type, mean follow-up, and average intraocular pressure and cup/disc ratio. Glare disability was measured with the Miller-Nadler tester. A similar reduction in visual acuity under glare was found in the two groups: 0.55 + 1.2 and 0.45 + 0.9 Snellen lines for Groups A and B, respectively. These findings are explained by two additional observations: Reduction in visual acuity under glare was positively correlated to the degree of posterior capsule opacity (r=0.4) and not to the functional pupillary area (r=0.13). Functional pupillary area (upper lid in normal position) was 42% larger in the nonresutured group compared to 85% difference in the total pupillary area.