The Finnish current care guideline for open-angle glaucoma.

This article is an English translation of the 4th Finnish Current Care Guideline for diagnostics, treatment and follow-up of primary open-angle glaucoma, normal-tension glaucoma and pseudoexfoliative glaucoma. This guideline is based on systematic literature reviews and expert opinions with Finland's geographical and operational healthcare environment in mind.

Peripapillary retinal nerve fibre layer thickness and macular ganglion cell layer volume in association with motor and cognitive outcomes in 11-year-old children born very preterm.

PURPOSE: The purpose of the study was to study the association between retinal parameters and motor and cognitive outcomes in children born very preterm. METHODS: This study is part of a prospective cohort study of very preterm infants (birth weight ≤ 1500 grams/gestational age < 32 weeks). At 11 years of age, the ophthalmological assessment included a retinal optical coherence tomography (OCT) examination of the peripapillary retinal nerve fibre layer (PRNFL) and the macular ganglion cell layer (GCL). The motor performance was assessed with the Movement Assessment Battery for Children-Second Edition (Movement ABC-2), and the cognitive outcome with the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV). RESULTS: A total of 141 children were included. The mean (SD) average PRNFL was 95 µm (10.2 µm). The mean (SD) macular GCL volume was 0.34 mm3 (0.03 mm3 ). Higher PRNFL thickness associated with higher percentiles for total scores in the motor assessment (b = 0.5, 95% CI 0.1-0.8, p = 0.01) and higher macular GCL volume with higher scores in the cognitive assessment (b = 1.4, 95% CI 0.5-2.3, p = 0.002), also when adjusted for gender, birth weight z-score (birth weight in relation to gestational age) and major brain pathology at term. CONCLUSION: The associations between higher average PRNFL thickness and better motor performance as well as higher macular GCL volume and better cognitive performance refer to more generalized changes in the brain of 11-year-old children born very preterm. Retinal OCT examinations might provide a deeper insight than mere eyesight in long-term neurodevelopmental follow-up of children born very preterm.

Effects of bariatric surgery on retinal microvascular architecture in obese patients.

STUDY AIM: Retinal microvasculature changes reflect systemic small vessel damage from obesity. The impact of bariatric surgery induced weight loss on the microvasculature is relatively unknown. We hypothesized that weight loss following bariatric surgery would be associated with improved structural changes in the retinal microvasculature, reflecting an overall improvement in microvascular health. METHODS: The study included 22 obese subjects scheduled for bariatric surgery (laparoscopic Roux-en-Y gastric bypass or a sleeve gastrectomy) and 15 lean, age-matched controls. Ophthalmic examination, including fundus photography, was performed at baseline and 6-months. Retinal microvasculature caliber was analysed quantitatively using a semi-automated computer program and summarized as central retinal artery equivalent (CRAE) and venular equivalent (CRVE). RESULTS: Mean weight loss at 6 months was 26.1 kg ± 8 kg in the bariatric surgery group. Retinal artery caliber increased (136.0 ± 1.4 to 141.4 ± 1.4 µm, p = 0.013) and venular caliber decreased (202.9 ± 1.9 to 197.3 ± 1.9 µm, p = 0.046) in the bariatric surgery group by 6 months, with no change in arteriolar (136.6 ± 1.1 to 134.5 ± 1.2, p = 0.222) or venular (195.1 ± 2.1 to 193.3 ± 2.2, p = 0.550) caliber in the control group. The arteriolar to venular ratio increased in the bariatric surgery group, with no change in the control group at 6 months. CONCLUSIONS: The findings suggest obesity-related microvascular changes are reversible after bariatric surgery-induced weight loss. The capacity for the retinal microvasculature to improve following bariatric surgery suggests plasticity of the human microvasculature early in the disease course.

The effect of bariatric surgery on intraocular pressure.

PURPOSE: Study purpose was to investigate the effects of bariatric surgery on intraocular pressure (IOP) and other ophthalmic parameters in a prospective observational follow-up study. METHODS: Ophthalmic examination was performed on 22 obese women before and 6 months after bariatric surgery. A control group of 15 non-obese age-matched women were studied twice 6 months apart. IOP was measured with the Goldmann applanation tonometer (GAT) and the Pascal dynamic contour tonometer (PDCT). None of the subjects had glaucoma. RESULTS: Average weight loss 6 months after bariatric surgery was 25 ±8 kg, (p < 0.05). Visual acuity (VA), pachymetry and systolic as well as diastolic blood pressures did not differ between the obese and control groups and no change between the visits was detected. At baseline, IOP was significantly higher in the obese group than in the controls (16.6 ± 3.0 mmHg GAT and 18.1 ± 2.2 mmHg PDCT compared with 14.3 ± 1.5 mmHg GAT and 16.5 ± 1.9 mmHg PDCT respectively). After bariatric surgery, IOP was significantly lower (15.2 ± 2.7 mmHg GAT and 16.5 ± 2.0 mmHg PDCT, p < 0.05) and no significant difference was detected between the operated and control groups. In the whole data at baseline, IOP correlated with weight, body mass index, waist circumference, body fat per cent and systolic blood pressure values. CONCLUSION: Intraocular pressure (IOP) is significantly higher in obese women than in non-obese age-matched controls. Obese subjects had a decrease in IOP after bariatric surgery with no change in IOP in the control group. This change in obese group may be related to weight loss. Different measures of obesity correlated with IOP at baseline.

Long-term results of deep sclerectomy in normal-tension glaucoma.

PURPOSE: To study the long-term outcome of deep sclerectomy with and without mitomycin-C (MMC) in patients with normal-tension glaucoma (NTG). METHODS: We prospectively analysed consecutive patients randomized to surgery performed either with (MMC group) or without (non-MMC) MMC. Surgery was considered totally successful if, after surgery, the preoperative intra-ocular pressure (IOP) level was reduced by 25% without medication, and a qualified success if medication was required to achieve the same limits. RESULTS: A total of 37 patients were enrolled, 15 in the MMC and 22 in the non-MMC group. The median (range) follow-up was 7.9 (1.0-9.0) years, with a drop-out of three (8%) patients. The preoperative IOP was 15 (11-21) mmHg in the MMC and 15 (10-19) mmHg in the non-MMC group. At the last 6- to 9-year follow-up, IOP was significantly reduced to 9 (2-13) mmHg (p = 0.002) and 10 (5-13) mmHg (p < 0.001). The overall (groups combined) complete and qualified success rates were 50% and 71%, with no significant difference between groups (p = 0.48 and p = 0.25). Goniopuncture was performed in 87% and 100% of eyes in the MMC and non-MMC groups (p = 0.14). Needling with MMC injection was performed 0 (0-1) times in the MMC group and 0.5 (0-4) times in the non-MMC group (p = 0.056). We encountered no cases of hyphema, shallow anterior chamber, hypotony maculopathy, choroidal effusion, late bleb leakage, blebitis, endophthalmitis or malignant glaucoma. CONCLUSION: In NTG, long-term significant IOP reduction can be achieved with deep sclerectomy with a low incidence of sight-threatening complications.

Changes in anterior ocular structures and macula following deep sclerectomy with collagen implant.

PURPOSE: To determine the effect of intraocular pressure (IOP) lowering with deep sclerectomy (DS) on visual acuity, macular structures, and anterior ocular dimensions during the early postoperative period. METHODS: We prospectively analyzed 35 eyes of 35 patients scheduled for DS. Our focus with the measurements was on early postoperative changes in anterior ocular and macular structures related to IOP lowering during the first month after DS. In addition to a clinical ophthalmologic examination, our measurements included corneal topography, measurement of ocular dimensions with optical biometry, and examination of macular structure with optical coherence tomography. These measurements were repeated 1, 2, and 4 weeks postoperatively. RESULTS: Best-corrected visual acuity (BCVA) decreased 1 week postoperatively to 0.22 (0.20) LogMAR (p = 0.006). The BCVA then increased to its preoperative level, 0.17 (0.18) (p = 0.28), after 4 weeks. Axial length decreased from 24.12 (1.81) mm to 24.04 (1.81) (p<0.001) 4 weeks postoperatively. The steeper meridian of corneal curvature and average corneal power increased postoperatively; central corneal thickness was decreased. No significant change appeared in other measurements. CONCLUSIONS: We found changes in corneal curvature and ocular dimensions after DS. These changes were relatively small and do not completely explain the decrease in visual acuity postoperatively. Macular structures showed no changes.

Retinopathy of prematurity - from recognition of risk factors to treatment recommendations.

Retinopathy of prematurity is a proliferative retinal disorder diagnosed exclusively in prematurely born infants. In retinopathy of prematurity, growth of the retinal vasculature is disturbed, leading to hypoxia-induced pathological changes typical of retinopathy of prematurity, in the worst case resulting in retinal detachment. The most typical risk factors predisposing to the disease include hyperoxemia, low levels of insulin-like growth factor 1 (IGF-I), and low birth weight in relation to weeks of pregnancy. Laser therapy of peripheral retina is the currently established form of treatment. Screening is applied in order to recognize the pathological changes in retinopathy of prematurity early enough.

Case report: bilateral Mooren ulcer in association with hepatitis C.

BACKGROUND: Mooren ulcer has been considered as an idiopathic autoimmune keratitis. However, it has been in some cases suggested to be associated with hepatitis C, although the evidence is very vague. CASE PRESENTATION: We present a case of a man who was diagnosed with a primary Mooren ulcer in his right eye. The eye became blind despite of intensive treatment with local medications and extensive surgical procedures. After 10 years, the patient was diagnosed with the same disease, now in his left, previously healthy eye. There was no history that would suggest a secondary Mooren ulcer, but a chronic hepatitis C infection was detected. Treatment was targeted against hepatitis C (ribavirin and interferon) in addition to immunosuppressive medical and surgical treatment which resulted in a full and more than 6 years lasting remission of the disease. CONCLUSIONS: Whether the immunomodulatory and immunosuppressive medication against hepatitis C was the key reason for the good results in the treatment of the second eye, remains elusive. The causality of hepatitis C with respect to the pathogenesis of Mooren ulcer on this patient remains open, but should be considered as one of the possible etiological factors of the disease.

The effect of cataract surgery and IOL implantation on the magnification of a fundus photograph: a pilot study.

PURPOSE: The goal was to determine the effect of cataract surgery-induced change in ametropia and anterior chamber depth on the magnification of a fundus photograph. METHODS: Fundus photographs were taken from 11 subjects undergoing cataract surgery and intraocular lens (IOL) implantation before and after surgery with a telecentric Zeiss and Topcon fundus cameras. The distance between two distinct fundus landmarks, i.e. two crossings of retinal vessels, was measured before and after surgery, and the results were compared to axial length and surgery-induced change in ametropia and anterior chamber depth. In addition, the change in the conversion factor of Topcon fundus camera was calculated and its correlation to axial length, change in ametropia and anterior chamber depth was analysed. Further, the change in the mathematical location of P', i.e. the second principal point of the eye in the formula of Bennett et al. (1994), was calculated. RESULTS: Cataract surgery and IOL implantation did not significantly influence the magnification of a fundus photograph taken with a telecentric Zeiss or Topcon fundus camera even when ametropia changed markedly. Axial length and anterior chamber depth did not correlate with change in the magnification of a fundus photograph. The average change in the mathematical location P' due to surgery was -39.4%, SD 0.33. CONCLUSION: Fundus photographs taken with a telecentric Zeiss or Topcon fundus camera can be reliably used to follow the size of fundus landmarks even if ametropia and anterior chamber depth are changed after cataract surgery and IOL implantation.

Ring melanoma of the anterior chamber angle as a mimicker of pigmentary glaucoma.

A 19-year-old man noticed blurred vision in his right eye. He had an intraocular pressure of 60 versus 12 mmHg in the fellow eye. He was initially diagnosed with an atypical, advanced pigmentary glaucoma. The intraocular pressure did not respond to maximal medication, deep sclerectomy, goniopuncture, and 2 cyclophotocoagulations. Sixteen months after presentation, malignancy was first suspected, and the eye was enucleated. A ring melanoma of the anterior chamber angle was confirmed by the histopathologic examination. Normal nuclear staining for breast cancer 1 gene (BRCA1)-associated protein 1 suggested that the tumor was likely of disomy 3 type with a favorable prognosis. No local or systemic recurrence has developed within 4 years. A literature review of this rare type of minimal volume diffuse uveal melanoma identified 18 additional patients. The initial diagnosis in 18 of the 19 patients with a ring melanoma of the anterior chamber angle was unilateral glaucoma with a median intraocular pressure of 40 mmHg and an age range of 16-76 years. Liver metastasis developed in 5 of 12 patients older than 45 years. This rare subtype is estimated to account for 0.05%-0.16% of all uveal melanomas.

Deep sclerectomy in primary open-angle glaucoma and exfoliative glaucoma.

PURPOSE: To study the effect of deep sclerectomy (DS) in primary open-angle glaucoma (POAG) and exfoliative glaucoma (EXG). METHODS: We retrospectively analyzed the intraocular pressure (IOP)-lowering effect of DS in 235 consecutive eyes. Eyes were divided into 2 groups according to glaucoma subtype: POAG (127 eyes) and EXG (108 eyes). Postoperative IOP was the main outcome measurement. We recorded complete and qualified surgical success, need for YAG-laser goniopuncture, and need for postoperative glaucoma medication. We studied factors related to outcome of surgery in a Cox regression model. RESULTS: In the POAG group, the mean (SD) IOP decreased from 22.6 (5.1) mm Hg preoperatively to 16.8 (7.5) mm Hg, with qualified success achieved in 70% of eyes. Postoperatively, 57% were without medication. In the EXG group, IOP decreased from 25.5 (6.5) mm Hg preoperatively to 16.5 (7.8) mm Hg postoperatively, with qualified success achieved in 66% of eyes. Postoperatively, 50% were without medication. Decrease in IOP was statistically significant in both groups (p<0.001). In the POAG group, 12%, and in the EXG group, 24% needed a reoperation in the follow-up period (p = 0.037). In the Cox regression model, 1 week IOP between 2 and 14 mm Hg without medication lowered the hazard rate of losing complete success by 34% (p = 0.031) and the hazard rate of losing qualified success by 54% (p = 0.004). CONCLUSIONS: The IOP 1 week postoperatively seems to be a prominent indicator of surgical success. Deep sclerectomy is effective in reducing IOP in POAG and EXG subgroups, with reoperations more common in EXG eyes.

One hundred-year-old human corneal and transplanted corneal graft endothelium.

PURPOSE: To investigate and analyse one hundred-year-old endothelial cells of human transplanted corneal grafts and compare them with intact endothelium of unoperated eyes. SUBJECTS AND METHODS: Specular microscopy was performed on seven individuals (14 eyes) aged >100 years and on seven transplanted corneas with endothelial cells of at least 100 years old. All keratoplasties were performed by the same surgeon (PR) 25-35 years before the time of examination. As controls, 14 unoperated healthy individuals (26 eyes) of 90-100 years, 12 individuals (24 eyes) of 48-52 years, 12 students (24 eyes) of 19-24 years and 11 children (22 eyes) from 10 to 14 years of age were photographed and analysed. RESULTS: The mean cell density in the oldest age group, over 100 years of age (average 102 years), was very good 2365 cells/mm(2) . The mean cell density in the transplanted corneas, the endothelial cells of which were over 100 years old (mean 106 years), was 923 cells/mm(2) (range 585-1800 cells/mm(2) ). CONCLUSION: Corneal endothelial cells may remain viable and capable to perform their function over 100 years. Donor corneas up to 70-75 years of age can be approved for transplantation, provided that the endothelial cells have been thoroughly evaluated with vital staining before the operation.

Clinical verification of the formula of Bennett et al. (1994) of determining the size of retinal features by fundus photography.

PURPOSE: To clinically verify the formula of Bennett et al. (Graefes Arch Clin Exp 1994; 232: 361) of determining the size of retinal features and to study the previously unknown conversion factor of Topcon fundus camera. METHODS: Fundus photographs were taken from 17 healthy volunteers with Topcon and telecentric Zeiss fundus cameras. The macula-disc centre distance was measured from Zeiss fundus photographs in metric units using the formula of Bennett et al. (Graefes Arch Clin Exp 1994; 232: 361). The conversion factor of Topcon fundus camera and the macula-disc centre distance in degrees were calculated. The latter was further used to calculate the theoretical location of the blind spot. The results of 12 participants were compared to the location of their physiological blind spot determined with visual field examination by octopus custom-made blind spot visual field program. RESULTS: The theoretical location of the blind spot correlated well with the corresponding location of the physiological blind spot in the visual field. The magnification of Topcon fundus camera was close to a constant, and thus, the previously unknown conversion factor could be determined. CONCLUSIONS: The location of the physiological blind spot in the visual field can be derived from fundus photographs using the formula of Bennett et al. (Graefes Arch Clin Exp 1994; 232: 361), proving it to give a close approximation of the size of retinal features. Furthermore, the conversion factor of Topcon fundus camera was close to a constant, and thus, it can be considered to function close to telecentric design.

Determining the size of retinal features in prematurely born children by fundus photography.

PURPOSE: The purpose was to study the effect of prematurity on the macula-disc centre distance and whether it could be used as a reference tool for determining the size of retinal features in prematurely born children by fundus photography. METHODS: The macula-disc centre distance of the left eye was measured in pixels from digital fundus photographs taken from 27 prematurely born children aged 10-11 years with Topcon fundus camera. A conversion factor for Topcon fundus camera (194.98 pixel/mm for a 50° lens) was used to convert the results in pixels into metric units. RESULTS: The macula-disc centre distance was 4.74 mm, SD 0.29. No correlation between ametropia and the macula-disc centre distance was found (r = -0.07, p > 0.05). One child (subject 20) had high myopia and retinopathy of prematurity (ROP), and the macula-disc centre distance was longer than average (6.35 mm). DISCUSSION: The macula-disc centre distance in prematurely born children at the age of 10-11 years provides an easy-to-use reference tool for evaluating the size of retinal features on fundus photographs. However, if complications of ROP, for example temporal macular dragging or high ametropia, are present, the macula-disc centre distance is potentially altered and a personal macula-disc centre distance should be determined and used as a refined reference tool.

Change in retinal blood flow and retinal arterial diameter after intraocular pressure reduction in glaucomatous eyes.

PURPOSE: To study retinal blood flow and vessel diameter after intra-ocular pressure (IOP) reduction in high- and low-pressure glaucomas, that is, exfoliation glaucoma (ExG) and normal-tension glaucoma (NTG). METHODS: The study included 17 eyes with ExG and 20 with NTG. A minimum of 25% IOP reduction was achieved by deep sclerectomy. Blood flow in the temporal peripapillary retina was measured with scanning laser Doppler flowmetry (Heidelberg Retina Flowmeter, HRF), and retinal vessel diameters were evaluated with the retinal vessel analyser (RVA). Examinations were carried out before and 3 months after the operation. RESULTS: Pre-operative IOP was significantly higher in ExG than in NTG (median 26 mmHg, range 20-33 mmHg versus 15 mmHg, 12-20; p < 0.001). Surgery reduced IOP significantly both in ExG eyes (postoperative IOP 13 mmHg, 5-17; p < 0.001) and NTG eyes (9 mmHg, 3-13; p < 0.001). After the operation, systolic retinal flow was significantly reduced in ExG eyes, whereas in NTG, HRF parameters remained unchanged. Pre-operatively, the central retinal artery equivalent (CRAE) and arteriovenous ratio (AVR) were higher in ExG than in NTG eyes. After IOP reduction, both CRAE and AVR were reduced in ExG eyes, but remained unchanged in NTG. CONCLUSION: The study showed that before IOP reduction, arterial diameter was larger in ExG eyes than in NTG eyes. IOP reduction resulted in vasoconstriction and reduction of flow in ExG, whereas in NTG, both vessel diameter and retinal flow remained unchanged.

Deep sclerectomy in normal-tension glaucoma with and without mitomycin-c.

PURPOSE: To compare the outcome of deep sclerectomy (DS) with and without mitomycin-C (MMC) in patients with normal-tension glaucoma (NTG). METHODS: We prospectively analysed the results of 37 eyes of 37 consecutive patients with NTG (age; mean ± SD; 64 ± 7 years) who underwent DS with a collagen implant. Patients were randomized to the MMC and non-MMC groups. Subconjunctival MMC (0.4 mg/ml for 3 min) was used intraoperatively in 15 of 37 eyes. We defined total success as 25% reduction in intraocular pressure (IOP) without medication. Follow-up time was 12 months. RESULTS: The mean preoperative IOP was significantly reduced from 15.2 ± 2.8 mmHg to 9.3 ± 2.7 (p < 0.001) in the MMC group after 12-month follow-up and from 15.1 ± 2.9 mmHg to 11.8 ± 2.0 (p < 0.001) in the non-MMC group. At 12 months, the mean IOP was significantly lower in the MMC group (p = 0.003) compared with the non-MMC group. Total success was achieved in 10 of 15 eyes (67%) in MMC group and in nine of 22 eyes (41%) in non-MMC group (p = 0.12). The number of glaucoma medications was decreased from 2.2 ± 0.8 to 0.5 ± 1.2 in MMC group (p = 0.001) and from 2.6 ± 1.0 to 0.5 ± 0.7 in non-MMC group (p < 0.001). Goniopuncture was performed in seven eyes (47%) in the MMC group, compared with 16 eyes (73%) in the non-MMC group (p = 0.13). IOP < 10 mmHg was achieved in seven of 15 eyes in the MMC group and in two of 22 in the non-MMC group (p = 0.009). Complication rate was low, and no difference between groups was evident. CONCLUSION: Deep sclerectomy seems to be effective and safe in reducing IOP in patients with NTG. Intraoperative use of MMC results in lower postoperative IOP 12-month postoperatively without increased rate of complications.

Alveolar bone loss associated with age-related macular degeneration in males.

BACKGROUND: The aim of this study is to examine the relationship of selected systemic and oral health parameters and the salivary presence of six periodontal pathogens to age-related macular degeneration (AMD). METHODS: The present cross-sectional study includes data on 1,751 individuals (≥30 years old). General health information was obtained by questionnaires and interviews, including self-reported diagnosis of AMD, as well as by the general and oral health examination, including panoramic radiography and laboratory analyses. Fifty-four individuals with degenerative fundus changes formed the AMD group, and the other 1,697 formed the non-AMD group. Pearson χ(2) and analysis of variance tests were used for comparisons of categorical parameters and continuous parameters between the participant groups, respectively. A logistic regression analysis was performed to study the association of AMD with alveolar bone loss and the number of teeth by controlling for age, diabetic status, systolic blood pressure, education, and smoking, and also for the carriage of salivary bacteria. RESULTS: Advanced age, systolic blood pressure, and diabetes were associated with AMD (P <0.001), whereas the carriage rates of the examined periodontal pathogens were not. In the whole study population, the participants with AMD had fewer teeth (P <0.001) and more alveolar bone loss (P = 0.004) compared with non-AMD participants. In a logistic regression model adjusted for age, smoking, and diabetes, alveolar bone loss was associated with AMD in males with an odds ratio of 4.3 (95% confidence interval = 1.3 to 14.6, P = 0.013). CONCLUSION: In this population-based health survey, alveolar bone loss is independently associated with AMD in males.

Change in optic nerve head topography in healthy volunteers: an 11-year follow-up.

AIM: To study longitudinal changes in optic nerve head (ONH) topography in healthy volunteers. METHODS: One eye each of 36 healthy volunteers was prospectively followed for 11 (7-13) years with the Heidelberg Retina Tomograph I (HRT I). All eyes had normal visual fields, non-glaucomatous ONHs, no defects on red-free nerve fibre layer photographs and intraocular pressure (IOP) <22 mm Hg. During the follow-up, no eye developed glaucoma; visual fields remained normal, and no longitudinal changes appeared in nerve fibre layers assessed from red-free photographs or ONHs assessed from stereophotographs. The median baseline and follow-up IOPs were comparable (15 mm Hg, range 10-20 mm Hg; and 16 mm Hg; range 10 to 22 mm Hg, respectively; p=0.38). Images were re-evaluated with HRT III and ONHs graded as normal, borderline or glaucomatous with the Moorfield Regression Analysis (MRA). RESULTS Significant changes in HRT parameters indicating increased ONH cupping were detected in cup area (p=0.013), cup-to disc area ratio (p=0.015), rim area (p=0.015), mean cup depth (p=0.006) and cup shape measure (p<0.001). With the MRA classification, nine eyes (9/31, 29%) had changed for the worse in the global or any of the sector classifications. CONCLUSION: Age-dependent changes occur in ONH topography detectable with the HRT.