The simply modified intrascleral fixation using round flange (SMURF) technique for intrascleral intraocular lens fixation.

We describe a simply modified intrascleral fixation using round flange (SMURF) technique and report the clinical outcomes of the surgery. Forty-one eyes of 41 consecutive patients, with intraocular lens (IOL) dislocation, crystalline lens subluxation, and zonular weakness, who underwent surgery using the SMURF technique were included. The modified technique included the use of a conventional 27-gauge needle, a non-bent needle, oblique sclerotomy, direct threading of the leading haptic, and simple placement of the following haptic. IOLs were successfully placed and showed good centring. There were no cases of wound leakage or hypotony during the early postoperative period. Postoperative complications included vitreous haemorrhage in one eye (2.4%), intraocular pressure elevation in one eye (2.4%), and iris capture in six eyes (14.6%). There were no cases of postoperative retinal detachment, cystoid macular oedema, endophthalmitis, or IOL dislocation during the follow-up period. We proposed a few modifications in the intrascleral flanged technique for IOL fixation. The modified technique is a simple, easy, and minimally invasive procedure for successful IOL intrascleral fixation.

Influence of intraocular pressure reduction on progression of normal-tension glaucoma with myopic tilted disc and associated risk factors.

Purpose To evaluate the influence of intraocular pressure (IOP) reduction on progression of normal-tension glaucoma (NTG) with myopic tilted disc and to demonstrate the associated risk factors. METHODS: The medical records on 109 eyes of 109 NTG patients with myopic tilted discs who were followed up for more than 5 years and treated with topical medications were reviewed. Glaucoma progression was defined according to either structural or functional deterioration. Patients were divided into tertile groups according to the percent IOP reduction from the baseline, and the cumulative probability of NTG nonprogression of the upper- and lower-tertile groups was compared using Kaplan-Meier survival analysis. The multivariate Cox proportional hazards model was used to identify the risk factors for glaucoma progression. RESULTS: Forty-nine of 109 eyes (45.0%) showed glaucoma progression after the average follow-up period of 7.55 ± 1.79 years. The Kaplan-Meier analysis revealed a greater cumulative probability of nonprogression for the upper-tertile group (percent IOP reduction >20.9%) than for the lower-tertile group (percent IOP reduction<12.9%; P = 0.016). The Cox proportional hazards model indicated that presence of disc hemorrhage was a factor associated with glaucoma progression (HR = 3.664; P = 0.001). CONCLUSIONS: Lower-percent reduction in IOP was associated with NTG progression in eyes with myopic tilted discs, and the presence of disc hemorrhage was a risk factor for NTG progression.

Factors Associated with Loss of Visual Function in Medically Treated Advanced Normal Tension Glaucoma.

PURPOSE: To investigate the risk factors associated with a progressive loss of visual function (LV) in medically treated advanced normal tension glaucoma (NTG). METHODS: In this retrospective observational study, a total of 87 eyes of the 87 NTG patients with a baseline visual field (VF) mean deviation (MD) of worse than -10 decibel (dB) (average follow-up period: 5.3 years) were included. All the participants were categorized into two groups according to the baseline VF MD [group 1 (≥-16 dB) and group 2 (<-16 dB), respectively]. The participants were also divided into older (≥64 years) and younger (<64 years) groups according to the median split of baseline age. Hazard ratios (HRs) for the association between potential risk factors and LV were obtained using the Cox proportional hazards models. RESULTS: Fifty-one eyes were classified as group 1 (VF MD; -13.5 ± 1.8 dB), and 36 eyes as group 2 (-21.0 ± 4.1 dB). LV occurred in 33 eyes (64.7%) in group 1 and in 29 eyes (80.6%) in group 2 during the follow-up period. In total participants, younger age (HR; 0.971, p = 0.008) and lower initial best-corrected visual acuity (BCVA) (HR; 18.4, p = 0.007) were found to be significant risk factors for LV. In group 1, younger age and lower baseline BCVA were associated with LV; whereas, no significant risk factor was found in group 2. In the younger group, myopia and disc hemorrhage were found to be the risk factors. CONCLUSION: The risk factors associated with progressive LV differed according to the baseline VF stages or the age among advanced medically treated NTG patients.

Prevalence of Pseudoexfoliation Syndrome and Associated Factors in South Koreans: The Korean National Health and Nutrition Examination Survey.

PURPOSE: To investigate the prevalence of pseudoexfoliation syndrome (PXS) and factors associated with PXS in South Koreans by analyzing data from the Korean National Health and Nutrition Examination Survey (KNHANES). METHODS: Using the KNHANES database of 2009-2012, 13,223 participants aged 50 years or older were included. Participants underwent standardized interviews and systemic and ocular examinations. Systemic factors analyzed included age, sex, daily length of sun exposure, presence of Raynaud phenomenon or migraine, hypertension, diabetes mellitus, body mass index, serum lipid profile, duration and frequency of smoking, and alcohol consumption. Evaluated ocular factors were refractive error, presence of cataract and glaucoma, intraocular pressure, and peripheral anterior chamber depth. Logistic regression analysis was performed to identify factors associated with the presence of PXS. RESULTS: PXS was found in 16 participants (0.12%). When compared with the non-PXS group, eyes with PXS showed a higher prevalence of cataract (p = 0.020). In logistic regression analysis, age (odds ratio, OR, 1.04, 95% confidence interval, CI, 0.99-1.09; p = 0.016) and the presence of cataract (OR 8.17, 95% CI 1.06-62.84; p = 0.044) were associated with the presence of PXS. Sun exposure for ≥5 hours/day was marginally associated with the presence of PXS (OR 2.76, 95% CI 0.96-7.95; p = 0.060). CONCLUSION: The prevalence of PXS per 1000 persons was 1.10 in South Koreans aged ≥50 years. Participants with PXS had a higher prevalence of cataract, were older, and were more likely to be exposed to the sun for ≥5 hours/day than participants without PXS.

Is Myopic Optic Disc Appearance a Risk Factor for Rapid Progression in Medically Treated Glaucomatous Eyes With Confirmed Visual Field Progression?

PURPOSE: To investigate visual field (VF) progression rates in glaucomatous eyes with myopic optic disc appearance, refractive error, and progressive VF changes and to compare the rates with those of a nonmyopic group. PATIENTS AND METHODS: Data on 158 eyes from 131 patients with open-angle glaucoma who had progressive VF deterioration during follow-up were retrospectively analyzed. The myopic and nonmyopic groups were compared in terms of rates of change of mean thresholds in global and regional areas using central 10 degrees, peripheral 10 to 24 degrees, and glaucoma hemifield test maps by using a linear-mixed model and controlling for confounding covariates. Clinical factors associated with rapid VF progression at global and regional VF areas were investigated in each group. RESULTS: The 2 groups did not significantly differ in the mean global VF progression rate (-0.36 vs. -0.35 dB/y, respectively; P=0.951). Likewise, both groups showed similar VF progression rates at all regional clusters (P>0.05). No significant association was found between the rate of VF change and clinical factors in the myopic group. The mean follow-up intraocular pressure was significantly associated with VF progression rates in the nonmyopic group (P<0.05). CONCLUSIONS: Open-angle glaucoma eyes with myopic optic disc appearance experiencing progressive VF changes showed similar VF progression rates globally and regionally when compared with nonmyopic eyes after controlling for clinical factors related to VF progression. None of the clinical factors in the myopic group were significantly associated with VF progression rate, whereas the mean follow-up intraocular pressure was in the nonmyopic group.

Relationship Between Nocturnal Intraocular Pressure Elevation and Diurnal Intraocular Pressure Level in Normal-Tension Glaucoma Patients.

PURPOSE: We studied the relationship between nocturnal habitual position IOP elevation and diurnal IOP level in normal-tension glaucoma (NTG) patients. METHODS: A total of 70 young NTG patients with a low diurnal IOP level (mean diurnal seated IOP < 15.0 mm Hg; low IOP group) and 79 age-, axial length-, and disease severity-matched NTG patients with a high diurnal IOP level (mean diurnal seated IOP ≥ 15.0 mm Hg; high IOP group) were recruited prospectively. Intraocular pressure was recorded 11 times over a 24-hour period by a single, well-trained ophthalmology resident using a hand-held tonometer. RESULTS: The mean habitual position IOP during nighttime (14.2 mm Hg) was significantly higher than that of daytime (12.8 mm Hg) in the low IOP group (P < 0.001), whereas no such difference was found in the high IOP group (16.4 vs. 16.3 mm Hg, P = 0.706). The low IOP group showed an overall nocturnal acrophase in habitual-position IOP, with 11 patients (15.7%) having a diurnal, 30 (42.8%) a nocturnal, and 29 (41.4%) no evident acrophase. By contrast, the high IOP group showed no evident peak in habitual-position IOP, with 28 patients (35.4%) having a diurnal, 12 (15.2%) a nocturnal, and 39 (49.4%) no evident acrophase. CONCLUSIONS: In NTG eyes with a low diurnal IOP, there are significant IOP increases at nighttime in the habitual position, whereas there is no significant nocturnal IOP elevation in NTG eyes with a high diurnal IOP.

Relationship between daytime variability of blood pressure or ocular perfusion pressure and glaucomatous visual field progression.

PURPOSE: To study daytime or nighttime variability of mean arterial pressure and ocular perfusion pressure in untreated normal-tension glaucoma (NTG) patients and determine whether increased short-term mean arterial pressure and/or ocular perfusion pressure variability are associated with greater risk of visual field (VF) progression. DESIGN: Longitudinal, retrospective, observational study. METHODS: This study enrolled 237 eyes of 237 untreated NTG patients who underwent 24-hour intraocular pressure and ambulatory blood pressure monitoring in the habitual position, and had ≥5 reliable VF tests during follow-up. Kaplan-Meier analyses were performed to compare outcomes with reference to the level of short-term mean arterial pressure and ocular perfusion pressure standard deviation for VF deterioration. Hazard ratios for the association between clinical factors, including short-term mean arterial pressure and ocular perfusion pressure standard deviation, and VF progression were obtained using Cox proportional hazards models. RESULTS: Over-dipper NTG patients showed significantly larger daytime and nighttime mean arterial pressure and ocular perfusion pressure standard deviation than non-dippers or dippers. Both increased daytime and nighttime mean arterial pressure or ocular perfusion pressure standard deviation were associated with greater VF progression probabilities. Increased daytime mean arterial pressure or ocular perfusion pressure standard deviation was a significant predictor of subsequent VF progression (P = .023 and P < .001, respectively). CONCLUSIONS: Over-dipper NTG eyes showed significantly higher daytime or nighttime mean arterial pressure and ocular perfusion pressure variabilities than non-dipper and dipper NTG eyes. Increased daytime mean arterial pressure and ocular perfusion pressure standard deviation at baseline were significant predictors of future VF progression in NTG.

Macular structure-function relationship at various spatial locations in glaucoma.

BACKGROUND/AIMS: To study whether the structure-function (S-F) relationship in glaucoma differs according to macular location using spectral-domain optical coherence tomography (SD-OCT) and standard automated perimetry 10-2 and 24-2 visual fields (VFs). METHODS: We enrolled 151 eyes of 151 healthy, preperimetric and perimetric glaucomatous subjects. Macular ganglion cell-inner plexiform layer thicknesses at different parafoveal locations were measured using Cirrus SD-OCT. The mean sensitivity of 10-2 and 24-2 VFs was recorded in the decibel and 1/L scales. The topographic relationships between structure and function were assessed at different parafoveal and hemimacular locations using 'weighted' correlation coefficients. The strength of S-F relationships between macular ganglion cell-inner plexiform layer thickness measurements and VF mean sensitivity in various parafoveal locations and in superior and inferior hemimacula was compared using Steiger's test. RESULTS: The temporal parafoveal sector showed a significantly greater S-F relationship in each hemimacula compared with other parafoveal sectors (p<0.05). The inferior hemimacula showed a significantly greater S-F relationship than superior hemimacula (p<0.001). CONCLUSIONS: The strength of the S-F associations at the temporal parafoveal location is significantly greater than that of the central or nasal parafoveal location in each hemimacula. The strength of the S-F association is significantly greater in the inferior hemimacula than in the superior hemimacula.

Relationship between the lamina cribrosa, outer retina, and choroidal thickness as assessed using spectral domain optical coherence tomography.

PURPOSE: To evaluate the characteristics and relationship between peripapillary choroidal thickness (pCT), lamina cribrosa thickness (LCT), and peripapillary outer retinal layer thickness (pORT) as determined using spectral domain optical coherence tomography (SD-OCT) enhanced depth imaging (EDI). METHODS: In total, 255 participants were included (87 healthy subjects, 87 glaucoma suspects (GS), and 81 glaucoma cases). The pORT, defined as the thickness between the posterior outer plexiform layer and the retinal pigment epithelium (RPE) interface, and the pCT, between the outer margin of the RPE and the choroidal-scleral interface, were manually measured using EDI scanning of the circumpapillary retinal nerve fiber layer (RNFL). LCT was determined by EDI scanning of the optic nerve head (ONH). Baseline characteristics, including axial length (AXL) and the SD-OCT measurements of the participants, were compared among the three groups. The correlation between putative factors and pCT was determined using univariate and multivariate linear regression analyses. RESULTS: In all three groups, both pORT and pCT were thinnest in the inferior area among the four quadrants. In the healthy group, the mean peripapillary RNFL, pORT, and LCT were significantly greater in comparison with those of the GS and glaucoma groups (p < 0.001, p < 0.038, and p < 0.001, respectively). The pCT demonstrated no significant differences among the three groups (p = 0.083). Only age and AXL were associated with pCT by multivariate analysis. CONCLUSIONS: The pCT is substantially thinner in the inferior area of the ONH. In addition, the pCT demonstrates the strongest correlation with age and AXL, but was not associated with glaucoma or LCT.

Comparison between glaucomatous and non-glaucomatous eyes with unilateral retinal vein occlusion in the fellow eye.

PURPOSE: To evaluate and compare the clinical and angiographic characteristics of retinal vein occlusion (RVO) in glaucomatous and non-glaucomatous eyes with unilateral RVO in the fellow eye. METHODS: Twenty-one glaucomatous eyes (GL group) and 25 age-matched non-glaucomatous eyes (non-GL group) with unilateral RVO in the fellow eye were included in this study. Fluorescein angiographic images were assessed in both groups by 3 retina specialists in order to determine the RVO occlusion site. The occlusion site was divided into 2 types: arteriovenous (AV)-crossing and non-AV-crossing (optic cup or optic nerve sited). The clinical characteristics and prevalence of AV-crossing and non-AV-crossing RVO were compared between the 2 groups. RESULTS: The mean baseline intraocular pressures of the RVO eye and the fellow eye did not differ between the 2 groups (RVO eye: 14.3 ± 2.5 mmHg [non-GL group], 15.5 ± 3.9 mmHg [GL group], p = 0.217; fellow eye: 14.4 ± 2.5 mmHg [non-GL group], 15.7 ± 3.7 mmHg [GL group], p = 0.148). The prevalence of systemic disease did not differ between the 2 groups (e.g., diabetes mellitus and hypertension, p = 0.802 and 0.873, respectively). AV-crossing RVO was significantly more frequent in the non-GL group (19 eyes; 76%) than in the GL group (4 eyes, 19%, p < 0.001). CONCLUSIONS: Non-AV-crossing RVO, i.e., optic cup- or optic nerve-sited RVO, is more frequently associated with glaucomatous changes in the fellow eye. Therefore, this type of RVO should be monitored more carefully for indications of glaucoma in the fellow eye.

Evaluation of lamina cribrosa in pseudoexfoliation syndrome using spectral-domain optical coherence tomography enhanced depth imaging.

PURPOSE: To evaluate the features of the lamina cribrosa (LC) in pseudoexfoliation glaucoma (PXG) patients using enhanced depth imaging (EDI) of spectral-domain optical coherence tomography (SD OCT). The results were compared with those of patients with primary open-angle glaucoma (POAG). DESIGN: Cross-sectional study. PARTICIPANTS: Patients with PXG (n = 21) and POAG (n = 35) matched for age and visual field mean deviation (VF MD). METHODS: Participants were imaged using SD OCT. Lamina cribrosa thickness (LT) and anterior lamina cribrosa depth (ALD) were determined at 3 areas (mid superior, center, and mid inferior) by 2 examiners using an EDI mode of the optic nerve head. MAIN OUTCOME MEASURES: The LT and ALD were compared between PXG and POAG eyes. RESULTS: Mean ± standard deviation baseline untreated intraocular pressure was not significantly different between the 2 groups (PXG, 18.3 ± 8.2 mmHg; POAG, 15.3 ± 3.4 mmHg; P = 0.310). The mean VF MD was -12.7 ± 9.0 dB in the PXG group versus -11.6 ± 9.1 dB in the POAG group (P = 0.643). When compared with the POAG group, the PXG group demonstrated a significantly thinner LT in all 3 areas and a thinner mean LT (133.4 ± 14.5 µm in the POAG group vs. 121.3 ± 13.0 µm in the PXG group; P<0.001). Anterior lamina cribrosa depth did not demonstrate a significant difference in any of the 3 areas between both groups (mean ALD, 324.3 ± 91.9 µm in the POAG group vs. 358.7 ± 142.7 µm in the PXG group; P = 0.470). Of 21 eyes in the PXG group, 9 eyes demonstrated a unilateral clinical presentation. When we compared the PXG eyes and the apparently normal-looking fellow eyes of those 9 eyes, neither the LT nor ALD demonstrated a significant difference (P = 0.223 and P = 0.079, respectively). CONCLUSIONS: Eyes with PXG demonstrate a thinner LC compared with POAG eyes at similar levels of glaucoma severity. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Progression of retinal nerve fiber layer thinning in glaucoma assessed by cirrus optical coherence tomography-guided progression analysis.

PURPOSE: To evaluate the performance of Cirrus spectral domain optical coherence tomography (SD-OCT)-guided progression analysis (GPA) software to detect progression of retinal nerve fiber layer (RNFL) thinning in glaucoma patients. MATERIALS AND METHODS: This retrospective cohort study included 272 eyes of 154 glaucoma patients. Median follow-up time was 2.2 years, during which time data from at least four good-quality OCT examinations were collected. Glaucomatous eyes were classified as either early or advanced group according to visual field (VF) severity. Reference standard of glaucoma progression was defined by expert assessment of optic disc/RNFL photographs or VF GPA data, or visual field index (VFI) linear regression analysis. Sensitivity and specificity of OCT GPA, and agreement between OCT GPA findings and each reference standard strategy were estimated. RESULTS: Fifty-three eyes (19.5%) showed progression by at least one of the reference standard strategies, while OCT GPA detected progression in 36 eyes (13.2%). When expert assessment of optic disc/RNFL photographs and/or VF analysis was used as the reference standard, the sensitivity and specificity of OCT GPA employed to detect glaucoma progression were 20.8% and 88.6%. Agreement between OCT GPA and either optic disc/RNFL photographic evaluation or VF analysis was poor (κ = 0.12 and 0.03, respectively). RNFL photographic assessment in early stage glaucoma showed best agreement with OCT GPA in terms of progression detection. DISCUSSION: The Cirrus OCT GPA detected a considerable number of eyes exhibiting glaucoma progression. OCT GPA may be useful for progression detection in earlier stage of glaucoma to complement other reference standard strategies.