[Retinal angiomatous proliferation not associated with age-related macular degeneration. Favourable outcome after photodynamic therapy]. / Proliferación angiomatosa retiniana no relacionada con degeneración macular asociada a la edad. Buena respuesta al tratamiento con terapia fotodinámica.

CASE: A 55-year-old male was diagnosed with exudative-hemorrhagic maculopathy, with no signs observed of drusen or pigmentary epithelium defects suggestive of age-related macular degeneration (ARMD). Fluorescein angiography (FA) and indocyanine green choroidal angiography (ICGA) showed retinal angiomatous proliferation (RAP). Afferent arteriole and retinal drainage venule connection was also observed. Treatment with a single Photodynamic Therapy provided an optimal outcome. DISCUSSION: RAP is a form of neovascular ARMD described in recent years; it consists of an angiomatous proliferation that originates from the retinal capillary system and extends posteriorly into the subretinal space. Our patient showed typical RAP findings without any sign of ARMD

[Optical coherence tomography of retinal pigment epithelial tears]. / Optical coherence tomography en desgarro del epitelio pigmentario retiniano.

CASE REPORTS: Three cases of pigmentary epithelial tears are described in this study. One of them was related to previous extrafoveal photocoagulation, whereas the other two were idiopathic. Fluorescein angiography (FA) and optical coherence tomography (OCT) were performed to confirm the clinical diagnosis. DISCUSSION: Few studies using OCT to assess pigmentary retinal epithelial (RPE) tears have been published in the world literature. The main findings of our study included hyper-reflectant line breaks, choroidal hyper-reflectance due to the lack of RPE and RPE double layering where it was folded. Images were frequently associated with RPE tears and neurosensorial retinal detachment.

[Pseudophakic cystoid macular edema. Assessment with optical coherence tomography]. / Edema macular quístico pseudofáquico. Detección mediante "optical coherence tomography".

PURPOSE: To determine the incidence of cystoid macular edema (CME) by means of clinical evaluation and subclinical assessment by means of ocular coherence tomography (OCT), and to compare the incidence between diabetic and non-diabetic groups of patients. METHODS: Prospective study of 260 consecutive cataract surgeries operated from September 2004 to March 2005. The procedures were performed by means of phacoemulsification plus intraocular acrylic lens implantation. Group A: 208 eyes of non-diabetic patients; Group B: 42 eyes of patients with diabetes and Group C: 10 eyes of diabetic patients with macular edema that received an intravitreal injection of triamcinolone at the end of surgery. Postoperative follow-up visits were performed 6 days (basal visit), 5 weeks and 12 weeks after surgery. Each visit included posterior pole biomicroscopy and OCT. RESULTS: Central macular thickness measured by OCT was significantly increased in group B compared with group A (241.6 versus 204.6 microm; p<0.001). No clinical evidence of CME was found in group A, although 4 eyes (1.92%) showed macular thickness equal to or greater than 43.74 microm (2 standard deviations of the basal value for group A). In group B, clinical evidence of CME was found in 6 eyes, with decreased visual acuities (14.2%). The differences between these groups were statistically significant (p<0.001). The 10 eyes that received an intravitreal injection of triamcinolone after the surgical procedure showed a mean decrease in central retinal thickness of 77 microm after 12 weeks postoperative. CONCLUSIONS: This study has shown a low incidence of clinical CME. OCT showed increased macular thickness in both groups of patients in a small percentage of cases, and significantly increased macular thickness in diabetic patients.

[Idiopathic polypoidal choroidal vasculopathy]. / Vasculopatía coroidea polipoidal idiopática.

PURPOSE: To evaluate the incidence, clinical features and evolution of polypoidal choroidal vasculopathy (PCV) in our population. METHODS: Retrospective study of patients diagnosed with exudative and/or hemorrhagic maculopathy including age-related macular degeneration in the last two years and who have undergone a complete ophthalmologic exploration and videoangiography with fluorescein and indocyanine green. RESULTS: 250 patients were included in the study, 8 patients (3.2%) had clinical and angiographic criteria of PCV. The mean age was 68 years-old, 62.5% were men and 85.7% were caucasian. Ninety percent of cases presented clinically as a predominantly hemorrhagic macular detachment. The initial clinical diagnosis before indocyanine green angiography was exudative age-related macular degeneration in 90% of cases. The mean visual acuity was 0.2 at baseline and after follow-up. Laser treatment was performed in 4 eyes, achieving good anatomic and visual acuity results in 2 of them; both eyes of one patient were treated by photodynamic therapy with poor angiographic and functional outcome. CONCLUSIONS: Polypoidal choroidal vasculopathy is a clinical entity which is relatively frequent among patients previously diagnosed with exudative maculopathy. Indocyanine green angiography increases the number of correct diagnoses. Treatment must be individualized depending on the location of the lesions and the severity of the disease.

[Serpiginous choroiditis: clinical course and treatment]. / Coroiditis serpiginosa: evolución clínica y tratamiento.

PURPOSE: To evaluate the clinical evolution and treatment of serpiginous choroiditis in 11 diagnosed patients. METHODS: Retrospective study of 11 cases diagnosed with serpiginous choroiditis in our area, from 1980 to the present. We analyzed age at onset of symptoms, systemic diseases, ophthalmological symptoms at presentation, the location of lesions, initial and final visual acuity, recurrences, treatment régime and development of subretinal neovascularization. A complete ophthalmological examination and fluorescein angiograms were performed in all of them. RESULTS: The mean period of follow-up was 4 years. Average age was 56 years, predominantly in men (10/1). Five patients had known ischemic cardiopathy and systemic hypertension, one patient underwent a kidney transplant. All of them were treated with oral prednisone (1-1.5 mg/kg/daily) in the active stages. Three patients received triple therapy (prednisone, cyclosporine and azathioprine) that did not prevent the recurrences. Five patients developed a subretinal neovascularization, bilateral in three of them. CONCLUSIONS: The serpiginous choroiditis is a rare entity and the visual outcome prognosis is determined by the macular involvement. Men are predominantly affected in our series and corticosteroid treatment is effective in acute inflammatory episodes. Recurrences could not be prevented by triple therapy with immunosuppressive agents in our three patients.

[Photodynamic therapy for choroidal neovascularization not caused by age related macular degeneration or pathologic myopia]. / Terapia fotodinámica en membrana neovascular subretiniana no relacionada con degeneración macular asociada a la edad o miopía patológica.

PURPOSE: To assess the effects of photodynamic therapy (PDT) with verteporfin on visual acuity (VA) and fluorescein angiography, in patients with subfoveal choroidal neovascularization (CNV) not secondary to age related macular degeneration (AMD) or pathologic myopia. METHODS: 113 eyes from 104 patients underwent PDT due to subfoveal CNV from July 2001 to June 2002. In this study only those patients with CNV not related to AMD or pathologic myopia were included. Fluorescein angiography and visual acuity were evaluated. RESULTS: 9 eyes from 8 patients (8.03%) showed distinct causes of CNV: 3 were idiopathic cases, 1 suffered angioid streaks, 1 was secondary to laser photocoagulation due to diabetic retinopathy, 2 had polypoidal choroidal vasculopathy and 2 central serous choroiditis. Regarding VA results, 77.7% improved or mantained the previous VA. Angiography resolution was observed in 55.5% of the cases (80% with just one PDT session). Average follow up was 10.5 months. Systemic or local complications were not observed. CONCLUSION: PDT may be useful in the treatment of different types of CNV due to causes other than AMD or high myopia.

[Topical versus contact anaesthesia in conventional trabeculectomy. Prospective randomised study]. / Anestesia tópica versus anestesia de contacto en la trabeculectomía convencional. Estudio prospectivo aleatorizado.

PURPOSE: To compare the pain rates, comfort levels and safety between conventional topical anaesthesia and the application of a long lasting lidocaine soaked film or contact anaesthesia. METHODS: Fifty patients undergoing conventional trabeculectomy with or without Mitomycin-C were included. One half received topical anaesthesia and the other half contact anaesthesia in a random fashion. Pain and discomfort rates before, during and after surgery were evaluated on a scale from 0 to 5, also, surgeon subjective stress and complications observed were included in the clinical protocol. RESULTS: Significant differences were found between both groups regarding pain rates, during and after surgery, and surgeon stress level. Sedation and change of anesthesic method were required more frequently by the patients included in the topical anaesthesia group. CONCLUSIONS: Topical anaesthesia provides sufficient level of anaesthesia for performing a trabeculectomy. Nevertheless pain rate differences between contact and conventional topical anaesthesia were patent during and after surgery. Contact anaesthesia appears to be a valid and practical alternative in a wide range of patients undergoing glaucoma surgery.

[Interface diffuse keratitis]. / Queratitis difusa de la interfase.

Diffuse interface keratitis is a new clinical entity. It is becoming significantly more common due to the increasing of laser assisted in situ keratomileusis (LASIK) procedures. The knowledge we have about this uncommon but potentially sight-threatening complication is expanding. It appears in the early postoperatory LASIK, even in well-executed procedures. In this review we present an updated strategy for the diagnose and treatment of this syndrome, based on our own experience and an updated literature review. Early identification, evaluation, staging, and appropriate intervention, may help preventing visual loss associated with this entity.

[Dynamic angiography in age related macular degeneration]. / Angiografía dinámica: diagnóstico y tratamiento en la degeneración macular asociada a la edad.

PURPOSE: To evaluate the utility of dynamic angiography with fluorescein and indocyanine green with scanning laser ophthalmoscope (SLO) in exudative age-related macular degeneration. METHOD: We retrospectively studied 95 patients with exudative age-related macular degeneration (ARMD) between April 98 and April 01. RESULTS: We studied 102 eyes of 95 patients with ARMD. Mean age was 75.3 years with a mean follow-up time of 16.8 months. We found an occult or mixed angiographic membrane pattern with fluorescein angiography in 85 eyes (83.3%). Angiography with indocyanine green showed choroidal neovascular membranes in 94 of 102 eyes (92.1%). The most frequent location found was sub-foveal (53.2%). Laser photocoagulation was used in 55 eyes and photodynamic therapy in 5 eyes. In 17 eyes laser treatment failed to close the membrane. CONCLUSION: Dynamic angiography with fluorescein or indocyanine green allowed neovascular membrane identification in more than 90% of the cases of ARMD. Successful treatment was achieved in 42% of cases.

[Glaucomatous damage pattern in swap in the early stages of glaucoma]. / Patrón de daño campimétrico en la perimetría automatizada de longitud de onda corta (PALOC) en las fases iniciales del glaucoma.

PURPOSE: To determine with Short-Wavelength Automated Perimetry (SWAP) the patterns of early glaucomatous damage and to compare frequency of diffuse defects to localized defects. METHODS: One hundred and sixty eyes from 83 ocular hypertensive subjects who met the selection criteria (intraocular pressure greater than 21 mm Hg and normal standard visual fields) were studied. SWAP was performed with a modified Humphrey Field Analyser. Total (TD) and pattern deviation (PD) probability maps were calculated to evaluate the pattern of visual field loss. RESULTS: The frequency of defects was higher in TD than in PD for all levels of defects (p<0.001). There was also a relative topographical distribution of glaucomatous defects. CONCLUSIONS: We documented the existence of predominantly diffuse visual field defects for all depth levels at early glaucoma stages.

[Cup-to-disk ratio asymmetry: diagnostic value in glaucoma]. / Asimetría papilar: valor diagnóstico en el glaucoma.

PURPOSE: To assess visual field abnormalities in suspected glaucoma patients showing evident asymmetry in cup-to-disk ratio. MATERIAL AND METHOD: Twenty two hypertensive eyes in 11 subjects evidencing lateral differences in cup-to-disk ratio of more than 2/10 were included in the study. Conventional and short wavelength automated perimetry (SWAP) was performed with a Humphrey field analyser. A retinal nerve fiber layer (RNFL) study was also performed. RESULTS: Differences in IOP were 1.23 mmHg (p<0.05). No differences were evidenced in conventional automated perimetry between both eyes. Average sensitivity (SWAP) showed significantly lower (p<0.05) in those ayes with greater cup-to-disk ratio. RNFL showed a higher rate of defects in eyes with a higher cup-to-disk ratio. CONCLUSION: Lateral differences in cup-to-disk ratio indicate structural glaucomatous damage which is related to IOP levels. Associated functional loss was evidenced with SWAP (Arch Soc Esp Oftalmol 2002; 77: 17-22).

[The Autocad system for planimetric study of the optic disc in glaucoma: technique and reproducibility study]. / Sistema Autocad para el estudio planimétrico de la papila óptica en el glaucoma: técnica y estudio de reproducibilidad.

PURPOSE: To develop a lens planimetry technique for the optic disc using AutoCAD. To determine variability magnitude of the optic disc morphological measurements. METHODS: We employed AutoCAD R.14.0 Autodesk: image acquisition, contour delimitation by multiple lines fitting or ellipse adjustment, image sectorialization and measurements quantification (optic disc and excavation, vertical diameters, optic disc area, excavation area, neuroretinal sector area and Beta atrophy area). Intraimage or operator and interimage o total reproducibility was studied by coefficient of variability (CV) (n=10) in normal and myopic optic discs. RESULTS: This technique allows to obtain optic disc measurement in 5 to 10 minutes time. Total or interimage variability of measurements introduced by one observer presents CV range from 1.18-4.42. Operator or intraimage measurement presents CV range from 0.30-4.21. Optic disc contour delimitation by ellipse adjustment achieved better reproducibility results than multiple lines adjustment in all measurements. CONCLUSIONS: Computer assisted AutoCAD planimetry is an interactive method to analyse the optic disc, feasible to incorporate to clinical practice. Reproducibility results are comparable to other analyzers in quantification optic disc morphology. Ellipse adjustment improves results in optic disc contours delimitation.

[Trifluoperazine's action on fibroblast proliferation in cell cultures. Comparison of different doses]. / Acción de la trifluoperazina sobre la proliferación fibroblástica en cultivos celulares. Comparación de diferentes dosis.

PURPOSE: To evaluate the effect of different doses of trifluoperazine (TFP) on fibroblastic proliferation in cell cultures of sclera and conjunctiva. METHODS: 24 brown rabbits were operated on for non-protected sclerectomy and were divided into four groups. Group 1: Subconjunctival injection of 0.5 ml of balanced saline solution (BSS) 24 h before surgery. Group 2: Intraoperative TFP 10(-2)M for five minutes on the sclera in experimental filtrating surgery. Group 3: Subconjunctival injection of 0.5 ml of TFP 10(-3) M 24 h before surgery. Group 4: Subconjunctival injection of 0.5 ml of TFP 10-4M 24 h before surgery. Conjunctiva and sclera tissue samples were taken 1 hour after surgery in the treated area and at 90 degrees from it. All of the samples were cultured in DMEM with 20% fetal calf serum. The presence of atypical cells and fibroblastic growth was assessed at 3, 6, 9 and 12 days. RESULTS: There were statistically significant differences in all the groups and in the times compared to the control group. In the treated conjunctiva, differences were found between the subconjunctiva 10(-3) M and the intraoperative 10(-2) M on the 3rd and 6th days, between the preoperative 10-2 and subconjunctiva 10(-3) M and 10(-4) after the 6th day. In conjunctiva at 90 degrees, there were significant differences between preoperative 10-2 M and subconjunctiva 10-3 after day 6, between the preoperative 10-2 M and subconjunctiva 10(-4) on days 9 and 12. There were no significant differences among the different treatments in the sclera samples, but there were differences between all them and the control group. CONCLUSIONS: TFP at a dose of 10(-2) and 10(-4) TFP has an inhibitory effect on cellular proliferation in vitro in the rabbit sclera and conjunctiva. All the doses used produce a significant inhibition of cellular proliferation without producing significant disorders in the cellular morphology.

[Predictive value of the pattern-electroretinogram in glaucoma]. / Valor predictivo del pattern-electrorretinograma en el glaucoma.

PURPOSE: To determine the ability of pattern-electroretinogram (PERG) to discriminate individual evolution of glaucomatous visual field losses in glaucoma suspects. METHODS: We studied 151 eyes of 78 GS, classified depending on their risk to develop glaucomatous damage. The initial visual field was normal. Those eyes showing at least 2 reduced amplitudes in the PERG components (P50, N95 and NP) were considered pathologic. The mean follow-up was 30 months (range: 13-50 months); the VF was evaluated at the end of the study. RESULTS: At the beginning of the study the PERG was pathologic in 65 eyes (43%); in 45 of these eyes (69%) the visual field was pathologic at the end of the study. The positive predictive value of the PERG of visual field glaucomatous changes was 69% and the negative predictive value was 80%. The N95 amplitude showed the best predictive value, with 100% and 77% in the high and medium risk groups, respectively. CONCLUSIONS: The PERG study can discriminate the glaucoma suspects that will develop visual field glaucomatous losses.

[Clinical course of cytomegalovirus retinitis with the different antiretroviral therapies in our hospital]. / Evolución de la retinitis por citomegalovirus con las diferentes terapias antirretrovirales en nuestro hospital.

PURPOSE: A study of protease inhibitors on CMV retinitis in HIV infected hospital patients. METHOD: A retrospective study was performed in 485 diagnosed of AIDS, between January, 1990 and December 1998. Among those, 81 patients who were diagnosed of CMV retinitis, the following was studied: anti-retroviral treatment, anti CMV treatment, survival time and CD4 lymphocyte count. RESULTS: Treatment with protease inhibitors in HIV patients showed an increase in life expectancy, reduced the incidence of CMV retinitis and a reduction in CMV retinitis prevention treatment was observed. CONCLUSIONS: Treatment with protease inhibitors has reduced the rate of CMV retinitis in HIV patients.

[Indocyanine green angiography and subretinal neovascularization. Patterns in age related macular degeneration]. / Angiografía con verde de indocianina y neovascularización subretiniana. Patrones en la degeneración macular asociada a la edad.

PURPOSE: To determine the different angiographic patterns of neovascular membranes with indocyanine green in age-related macular degeneration (ARMD) and to establish the phase in which neovascularizations can be visualized most frequently. MATERIAL AND METHOD: We studied 56 eyes from 55 patients with a diagnosis of ARMD between April 98 and April 99. All patients underwent indocyanine green (ICG) and fluorescein digital videoangiography. We evaluated the pattern and the moment of identification of the neovascular membrane with both procedures. RESULTS: We found that 13 out of 56 eyes (23.2%) presented well-defined subretinal neovascularization in fluorescein videoangiography while 43 (76.8%) showed an occult pattern. ICG videoangiography was able to identify choroidal neovascularization in 89.3% of cases. The following patterns were found: Type I: visible neovascularization (17.9%), Type II: well-defined membranes with hypofluorescent margin (33.9%), Type III: high fluorescent focal membranes (hot-spots) (8.9%), Type IV: hyperfluorescent plaques that appeared only in late phases (10.7%), Type V: mixed types (17.9%). A high percentage of choroidal neovascularization was observed in early or medium phases of the angiogram (85.4%). CONCLUSIONS: Choroidal neovascularization in ARMD can appear with different patterns in the ICG videoangiographic study. The most frequently found pattern was that of well-defined membranes with a hypofluorescent margin. A high percentage of cases can be already visualized in the early phases of the angiogram.

[Effect of tobramycin with topical diclofenac on arachidonic acid in endotoxin-induced uveitis]. / Efecto de tobramicina más diclofenaco tópico sobre el ácido araquidónico en la uveítis inducida por endotoxina.

PURPOSE: We studied if tobramycin associated to sodium diclofenac modifies the drug effect of the latter on arachidonic acid metabolism in an endotoxin induced uveitis (EIU) model in albino rabbits. METHODS: Experimental uveitis was induced by intravitreal injection of a 10 ng lipopolysaccharide A Salmonella typhimurium endotoxin dissolved in 5 microl saline solution in the right eye of experimental animals. We have used 48 animals (4 groups of 12 animals each). The control group (G-I) was injected with saline solution (5 microl); the endotoxin group (G-II) was injected with 5 microl of ET; group III and IV were injected with the same amount of ET and treated with topical sodium diclofenac (1%) (Group III) and tobramycin and sodium diclofenac (0.3%) (Group IV) two hours before the administration of endotoxin and then every two hours until 24 hours, when we determined E2 prostaglandin and B4 leukotriene concentration in aqueous humor obtained by paracentesis of the anterior chamber. RESULTS: We observed how the E2 prostaglandin concentration was reduced in the two treatment groups compared with the endotoxin group (p<0.01). However, there were no differences between groups III and IV (p>0.01). There was a mild increase of B4 leukotriene in both treatment groups, which was not significant in relationship to the endotoxin group (p>0.01). No differences were found between the two treatment groups (p>0.01). CONCLUSION: Using the association of tobramycin does not affect the action of sodium diclofenac in arachidonic acid metabolism in endotoxin induced uveitis.

[Variability of sensitivity thresholds in short-wavelength automated perimetry (SWAP) in the central vision field]. / Variabilidad de los umbrales de sensibilidad en la perimetría automatizada de longitud de onda corta (PALOC) en las porciones centrales del campo visual.

PURPOSE: To determine the distribution of sensitivity thresholds of short-wavelength automated perimetry (SWAP) in the central visual field, analysing their variability depending on the eccentricity, in normal subjects. METHODS: 128 eyes of 128 normal subjects were analyzed. They underwent a SWAP examination. A lineal regression model was used to establish a <> (SVF). The SVF determines the threshold distribution and its variability. RESULTS: The regression analysis obtained a SVF, age-corrected, which considers the influence of age in the different points of the visual field. The threshold distribution showed higher inter-subject deviations as eccentricity increased (p<0.001). CONCLUSIONS: The determination of variability of the threshold sensitivity deviations in the different points of the central visual field allows future development of perimetric algorythms for SWAP.

[Short-wavelength automated perimetry (SWAP) in subjects with suspected glaucoma (I): assessment of sensitivity thresholds]. / Perimetría automatizada de longitud de onda corta (PALOC) en sujetos sospechosos de glaucoma (I): Evaluación de los umbrales de sensibilidad.

PURPOSE: To evaluate the threshold values of short-wavelength-sensitive (SWS, or S-cone pathways) mechanisms, throughout the 30 degrees central visual field, in a glaucoma suspect population, and to compare the results with those obtained in the Retinal Nerve Fiber Layer study. METHODS: We studied the central visual field from 288 eyes of 211 subjects classified as ocular hypertensives (160 eyes) or age-matched normal controls (128 eyes). A modified Humphrey Field Analyser was used to isolate and measure the sensitivity of the SWS mechanisms. Monochromatic red-free photographs (RNFL) were taken with a wideangle fundus camera at the same period. RESULTS: Comparing normal and OHT eyes, we found significant differences in sensitivity for SWS cone pathways in the superior and inferior nasal quadrants, paracentral and peripheral region, and in the superior hemifield (p<0.05). Based on the perimetric criteria described, the SWAP was pathological in 57 cases. which represents 35.6% of the total sample. Using RNFL as early glaucoma diagnostic criterion, SWAP sensitivity and specificity values were 62% and a 89% respectively. CONCLUSIONS: SWAP is a useful test for the early detection of visual field losses. It is more sensitive than, standard automated perimetry and gives a high correlation with RNFL assessment, which has proved capable of detecting signs of glaucomatous damage several years before the onset of the typical visual field defects.

[Short-wavelength automated perimetry (SWAP) in patients with suspected glaucoma (II): correlation with a probabilistic multifactorial model of risk for developing glaucomatous damage]. / Perimetría automatizada de longitud de onda corta (PALOC) en sujetos sospechosos de glaucoma (II): correlación con un modelo multifactorial probabilístico de riesgo de desarrollar daño glaucomatoso.

PURPOSE: To evaluate the efficiency and predictability of a multifactorial probability model to assess the risk of developing glaucomatous visual field defects and to determine the correlation between retinal nerve fiber layer (RNFL) photographs and short-wavelength automated perimetry (SWAP) in a population of patients suspected of having glaucoma. METHODS: One hundred and sixty eyes belonging to 83 patients with ocular hypertension [ocular pressure figures over 21 mmHg and normal conventional automated perimetry (AP) (white-white)] were included in the study. The risk of developing glaucomatous defects was assessed by a multifactorial model that includes intraocular pressure. vertical cup-to-disk ratio, age and family background. RNFL photographs and SWAP tests were also performed. RESULTS: SWAPs were pathological in 57 cases (35.6% of the sample); 23% of the perimetries were abnormal in the low-risk group while the moderate and high risk groups showed abnormal perimetries 38% and 56% respectively. The RNFL defects at the different risk levels were consistent with the SWAP results. The multiple regression analysis of the four variables included in the model showed the relationship among the risk factors, evaluated globally, and the presence of glaucomatous damage evaluated by RNFL and SWAP (p<0.001). CONCLUSIONS: The usefulness of this probability model as predictive indicator of subsequent glaucomatous damage is based on the good correlation between the risk scale and the RNFL and SWAP assessments. These techniques evaluate structural (RNFL) and functional (SWAP) changes in early stages of the glaucomatous disease.