Effect of a punctal plug on ocular surface disease in patients using topical prostaglandin analogues: a randomized controlled trial.

IMPORTANCE: Ocular surface disease (OSD) is common and can reduce treatment compliance and quality of life. BACKGROUND: To determine whether a punctal plug improves OSD and reduces intraocular pressure (IOP) in patients using prostaglandin analogue monotherapy. DESIGN: Randomized controlled trial. PARTICIPANTS: Sixty eligible subjects aged >18 years with symptomatic OSD from glaucoma clinics were invited to participate. Lacrimal or glaucoma surgery, lid malposition and contact lens wear were exclusion criteria. METHODS: One eye received an inferior punctal plug, leaving the fellow eye as a control. MAIN OUTCOME MEASURES: Ocular surface disease index (OSDI), tear film breakup time (TF-BUT), Oxford cornea score, tear osmolarity and IOP were compared at baseline and 6 weeks by masked investigators. RESULTS: From 60 eligible, 48 (80.0%) participated (mean age 69.6 years; 60.0% female). OSDI reduced following plug insertion (mean difference [MD] 14.5, 95% confidence interval [CI] 5.06-23.94, P < 0.001). Compared to control eyes, in eyes receiving plugs the TF-BUT increased (MD 2.3 s, 95% CI 1.4-3.2, P < 0.001), the Oxford cornea score decreased (MD 0.5, 95% CI 0.3-0.7, P < 0.001), and tear osmolarity decreased (MD 10 mOsm/L, 95% CI 3.5-16.5, P = 0.003). Punctal plugs resulted in a significantly lowered IOP (MD 1.5 mmHg, 95% CI 0.1-2.9, P = 0.032). Sub-group analyses showed similar efficacy regardless of prostaglandin preservative status or lubricant drop use. Plugs were well tolerated but extrusion occurred in 8.5%, and epiphora increased in 6.5% eyes. CONCLUSIONS AND RELEVANCE: Punctal plug insertion improves subjective and objective measures of OSD and results in a reduced IOP in patients with symptomatic ocular surface disease using prostaglandin analogue monotherapy.

There is a trend for the diagnosis of glaucoma to be made at an earlier stage in 2010 compared to 2008 in Oxford, United Kingdom.

PURPOSE: New guidelines on glaucoma diagnosis and management were published by the National Institute of Clinical Excellence (NICE) in 2009. The aim of this study was to determine whether these guidelines on glaucoma referral have changed the numbers of patients diagnosed with glaucoma in Oxford and whether the severity of disease at presentation has altered between 2008 and 2010. METHODS: A retrospective study was undertaken of patients referred to a glaucoma case-finding clinic at the Oxford Eye Hospital in 2008 and 2010. Severity of glaucoma was assigned on the basis of the worse eye and defined according to mean deviation (MD) on 24-2 Humphrey visual field testing, with early glaucomatous visual field defects defined as MD less than -6 dB, moderate defects as MD between -6 and -12 dB and severe defects as MD more than -12 dB. Statistical analysis was undertaken using Chi squared and Mann Whitney tests. RESULTS: The number of referrals to this clinic increased from 521 patients in 2008, to 895 patients in 2010. 85 (16.3%) patients were diagnosed with ocular hypertension in 2008, compared to 144 (16.1%) in 2010. The number of patients diagnosed with glaucoma increased from 94 cases in 2008 to 113 cases in 2010, although the percentage of referrals diagnosed with glaucoma fell from 18.1% to 12.6%. More patients diagnosed with glaucoma in 2010 had early disease (61.9% in 2010 vs 48.8% in 2008, p = 0.03). Patients found to have glaucoma in 2010 had less severe visual field defects than in 2008: patients presented with a lower mean deviation (-6.36 dB in 2010, -7.95 dB in 2008, p = 0.03) and lower pattern standard deviation (5.44 dB in 2010, 6.64 dB in 2008, p = 0.02). However, there was no significant difference between age of presentation (65.1 years in 2010, 65.2 years in 2008, p = 0.82), and IOP (21.62 mmHg in 2010, 23.15 mmHg in 2008, p = 0.22). CONCLUSIONS: There has been a significant increase in number of referrals to the glaucoma case-finding clinic in Oxford between 2008 and 2010. The introduction of NICE referral guidelines in 2009 has had the benefit of increasing the absolute number of patients detected with glaucoma and has resulted in more patients being diagnosed with early disease. More effort needs to be made to reduce the number of false positive referrals. In addition, the guidelines on referral of individuals with ocular hypertension need to be reconsidered.

Microperimetry and optical coherence tomography imaging in the fellow eye of patients with unilateral focal ischaemic glaucoma.

PURPOSE: To determine whether microperimetry or optical coherence tomography (OCT) imaging can detect early disease in the fellow eye of patients with unilateral focal ischaemic glaucoma. METHODS: Thirty-seven consecutive adult patients with unilateral focal ischaemic glaucoma with a unilateral split-fixation visual field defect on standard automated perimetry (SAP) with normal SAP in the fellow eye were selected. All patients underwent microperimetry (MAIA, CenterVue, Italy) of the central 10 degrees and OCT imaging (Spectralis, Heidelberg Engineering, Germany) of the retinal nerve fibre layer of both eyes. The main outcome measures were reduced retinal sensitivity on microperimetry and/or retinal nerve fibre layer thinning on OCT imaging of the fellow eye. RESULTS: Thirty fellow eyes had abnormal global thresholds on microperimetry, and 20 had abnormal OCT imaging studies. Kappa agreement between tests in fellow eyes was poor (p = 0.2546). Fixation was significantly poorer in fellow eyes on microperimetry when compared to eyes with glaucoma (p < 0.003). In the fellow eyes that were abnormal, microperimetry identified reduced retinal sensitivity at fixation. CONCLUSION: Microperimetry detects reduced retinal sensitivity close to fixation and OCT detects focal thinning of the retinal nerve fibre layer in the fellow eye of most patients with presumed unilateral focal ischaemic glaucoma. Further studies are required to correlate specific optic disc features on OCT imaging with microperimetry in the fellow eye of this patient group.

The effect of trabeculectomy surgery on the central visual field in patients with glaucoma using microperimetry and optical coherence tomography.

PURPOSE: To determine the functional and structural effects of trabeculectomy surgery on patients with advanced glaucoma and central visual field defects in the early post-operative period. METHODS: Thirty consecutive adult subjects with advanced glaucoma requiring trabeculectomy surgery and an established visual field defect within 10° of fixation underwent microperimetry (MAIA MP-1, CenterVue, Padova, Italy) and optic disc optical coherence tomography (OCT) imaging (Spectralis, Heidelberg Engineering, Germany) pre-operatively, and 1 month and 3 months following trabeculectomy surgery. Main outcome measures were post-trabeculectomy change in mean threshold on microperimetry and nerve fibre layer thickness on OCT. Fellow eyes were used as controls. RESULTS: The mean change in MP average threshold values from pre-operative to post-operative was 0.6 ± 1.9 dB for treated eyes and 0.1 ± 1.3 dB for control eyes (p = 0.14) at 1 month and 0.2 ± 2.3 and -0.3 ± 1.6 dB at 3 months (p = 0.22). Mean change in global nerve fibre layer thickness was -0.6 and -0.5 µm for operated and control eyes, respectively (p = 0.83), at 1 month and 0.8 and -0.4 µm at 3 months (p = 0.88). The kappa agreement for structure-function correlation between OCT and MP was 0.735 (confidence interval 0.59-0.88) (p < 0.005). CONCLUSIONS: Central visual function and retinal nerve fibre layer thickness appear to be preserved in glaucoma patients with central visual field defects undergoing trabeculectomy surgery in the early post-operative period. These data may inform glaucoma surgeons considering trabeculectomy surgery in this patient group.

Twenty-year outcomes in patients with newly diagnosed glaucoma: mortality and visual function.

BACKGROUND/AIMS: To determine the mortality within 20 years of diagnosis of chronic open-angle glaucoma (COAG) and visual acuity and visual field progression of a cohort followed for 20 years. METHODS: Twenty years following the diagnosis of COAG in 68 of 436 (16%) patients seen in a glaucoma case-finding clinic, visual and mortality outcomes were audited from medical records. Causes of death were obtained from general practitioner records and death certificates. Probability of death was calculated using a Kaplan-Meier survival curve. The visual field of each eye of survivors was graded using a nine-stage severity scale. Visual outcome was analysed at the 20-year follow-up visit. RESULTS: From 68, 14 (21%) were lost to follow-up. In the remaining 54, 20 (37%) were alive 20 years after diagnosis. Of 63% who died, mean age of death was 84 years, most commonly due to vascular disease. Mean age at presentation of those who died was 73.7 years versus 63.2 years for survivors (P=0.001). The median time to death was 16 years. On visual field analysis, nearly half (48.9%) of eyes did not deteriorate, but 28.3% eyes deteriorated by more than two stages. Those who died had worse final visual acuity than survivors (P<0.001). Three who died were registered severely visually impaired mainly from macular disease, but no survivors were registered (P<0.001). CONCLUSION: In this cohort, approximately two-thirds of patients with glaucoma died within 20 years of diagnosis. In most older patients with glaucoma, the overall goal of preventing visual handicap and blindness is achievable 20 years after diagnosis.

Ten-year outcomes in newly diagnosed glaucoma patients: mortality and visual function.

OBJECTIVES: To determine the mortality within ten years of diagnosis of chronic open angle glaucoma and the visual field progression amongst survivors of a group of patients who were followed for 10 years. PATIENTS AND METHODS: Of the 436 patients seen in a glaucoma case-finding clinic between July 1994 and December 1995 a diagnosis of chronic open angle glaucoma was made in 65. Ten years after diagnosis the outcome of the 57 patients who were treated at the Oxford Eye Hospital was determined. The causes of death were obtained from the general practitioner records and from the official death certificates. The probability of death was analysed using a Kaplan-Meier survival curve. The visual field of each eye of survivors was graded using a nine-stage severity scale. The visual outcome was analysed at the 10-year follow up visit. FINDINGS: Seventeen patients (29.8%) died during the 10-year period, including nine from cardiovascular disease. The mean (SD) age at presentation of those that died was 76.4 years (9.7) compared with 69.5 years (10.9) for survivors (p = 0.029). Using a nine-stage grading system, 42 eyes (52.5%) did not deteriorate, 30 eyes (37.5%) deteriorated by one stage, seven eyes (8.75%) two stages and one eye (1.25%) three stages over the 10-year period. The average time to first deterioration by one stage was 8.51 years (CI 7.92 to 9.10). The mean (SD) intraocular pressure was 25.6 mmHg (5.8 mmHg) on presentation and 15.7 mmHg (3.0 mmHg) at the end of 10 years. CONCLUSION: Approximately two thirds of patients will still be under care 10 years after presentation. In older, white patients with glaucoma the overall goal of preventing visual handicap is achievable for most patients 10 years after diagnosis.

Hypotony and choroidal detachment as a complication of topical combined timolol and dorzolamide.

PURPOSE: Hypotony with choroidal detachment is a rare complication of glaucoma medication. In this study, we report on a case which supports the hypothesis that has been proposed to explain this phenomenon. DESIGN: This study was designed as an observational case report. CASE REPORT: A woman with chronic glaucoma underwent trabeculectomy on both eyes. Low intraocular pressure (IOP) developed in 1 eye only, with no visual change for many years. After cataract surgery, the IOP increased, necessitating treatment with topical timolol 0.5% and dorzolamide 2%. She developed monocular hypotony and choroidal detachment 3 months later. This complication occurred in the eye that had previously had a low IOP and resolved completely when topical medication was stopped. The choroidal detachment recurred when rechallenged with the same medication. CONCLUSIONS: Topical aqueous suppression therapy can result in hypotony and choroidal detachment in an eye in which relatively low IOP has been maintained for many years after glaucoma filtration surgery. The problem resolves on stopping the medication.

Iridoschisis and keratoconus in a patient with severe allergic eye disease and compulsive eye rubbing: a case report.

BACKGROUND: Iridoschisis is a rare disorder characterized by splitting of the anterior and posterior iris stroma, resulting in disintegrated iris fibrils which float freely in the anterior chamber. We report an exceptional case of bilateral iridoschisis occurring in conjunction with keratoconus and severe allergic eye disease. CASE PRESENTATION: A 24-year-old white man had had periocular contact dermatitis and allergic eye disease from the age of 3 years. He was allergic to grass, animal hair, and pollen and worked grooming horses. He compulsively rubbed his eyes. There was no history of previous blunt trauma to either eye. There were signs of bilateral iridoschisis and keratoconus with allergic conjunctivitis, all of which were more severe in his right eye. An open drainage angle was identified bilaterally on gonioscopy, excluding primary angle closure. There was no evidence of glaucoma in either eye. CONCLUSIONS: There are two previous cases reporting the combination of iridoschisis and keratoconus, but no clear common etiology has been identified. In this case there was no evidence of angle closure but there were signs of allergic conjunctivitis. This amalgamation of signs might be explained on the basis of habitual eye rubbing. Treating the allergic eye disease has attenuated this behavior.

Juvenile-onset Normal Tension Glaucoma From Chronic, Recurrent Low Cerebrospinal Fluid Pressure.

INTRODUCTION: The evidence for low cerebrospinal fluid pressure (CSFP) as a key parameter in the pathogenesis of glaucoma is increasing. Primate models have demonstrated the onset normal tension glaucoma (NTG) from experimentally induced chronic intrathecal hypotension; an approach not possible in human subjects. CASE PRESENTATION: A 27-year-old man presented with a central scotoma in his left eye. He had undergone 8 CSF shunt revision procedures over a 25-year period secondary to recurrent low CSFP following surgical excision of a pinealoblastoma, aged 2. A focal nerve fiber layer defect was detected in the left eye associated with reduced retinal sensitivity on microperimetry. Three adjacent optic disc hemorrhages had been documented in the same position over an 18-month period. A diagnosis of left-sided NTG was made; the patient was started on Latanoprost 0.005%. A new generation CSF shunting device (ProGAV)-which neutralizes CSFP fluctuations analogously to trabeculectomy surgery for intraocular pressure-was considered necessary in this patient to alleviate persistent headaches and reduce the risk of progressive glaucomatous visual loss. CONCLUSIONS: This exceptional case illustrates how premature onset NTG may occur as a result of chronic, recurrent intrathecal hypotension-a "pure" human model. We describe an original management approach of implanting an adjustable, programmable CSF shunt valve (ProGAV) to reduce fluctuations in the translaminar cribrosa pressure difference, and reduce the risk of glaucomatous visual loss.

Videoendoscope-guided fluorescein-assisted vitrectomy for phakic malignant glaucoma.

Malignant glaucoma is a rare secondary glaucoma classically occurring after intraocular surgery in eyes with primary angle closure. Pars plana vitrectomy is reserved for the treatment of malignant glaucoma when medical and laser treatment fail. The primary aim of surgery is the removal of the anterior vitreous to reduce resistance to aqueous flow into the anterior chamber. In phakic eyes, conventional pars plana vitrectomy without lens extraction is frequently unsuccessful because of difficulty visualizing the normally transparent anterior vitreous, combined with the technical challenge of removing the anterior vitreous without damaging the crystalline lens. We describe a technique of intraocular, videoendoscope-guided, fluorescein-assisted pars plana vitrectomy that enables direct visualization and thorough removal of the anterior vitreous without the need for lens extraction in prepresbyopic patients without cataract.

Unilateral persistent hyperplastic primary vitreous: intensive management approach with excellent outcome beyond visual maturation.

Persistent hyperplastic primary vitreous (PHPV) is an ocular developmental disorder resulting from incomplete apoptosis of the embryonic hyaloid vasculature. Unilateral PHPV is traditionally associated with a poor prognosis because of the challenges associated with managing progressive anisometropic amblyopia. We report a child with unilateral PHPV who underwent cataract extraction, primary posterior capsulotomy with anterior vitrectomy and intraocular lens implantation followed by combined trabeculectomy/trabeculotomy within the first 8 weeks of life. Intensive optometric and orthoptic input was required for many years to manage the increasing anisometropic amblyopia with final visual acuity of 20/40 unaided in the affected eye and without evidence of glaucomatous optic neuropathy. This case illustrates the excellent visual outcome possible in a child with complex, unilateral PHPV using an intensive management approach comprising: early surgical intervention for congenital cataract and secondary glaucoma, meticulous monitoring of refraction, visual acuity and intraocular pressure and motivated parents who engaged in the management.

Long-term effect of cataract surgery on intraocular pressure after trabeculectomy: extracapsular extraction versus phacoemulsification.

PURPOSE: To compare the effect of phacoemulsification with intraocular lens (IOL) implantation on long-term intraocular pressure (IOP) control in glaucoma patients who had previous trabeculectomy with the effect on IOP control in similar patients after extracapsular cataract extraction (ECCE) with IOL implantation. SETTING: Oxford Eye Hospital, Oxford, England. METHODS: Twenty-eight consecutive patients who had phacoemulsification with IOL implantation (phaco group) at least 3 months after trabeculectomy were identified from hospital records, and 28 patients who had ECCE with IOL implantation (ECCE group) were matched retrospectively to the phaco group with respect to age, sex, diagnosis, and IOP. In both groups, the IOP before cataract extraction was compared with the IOP at intervals up to 2 years after cataract extraction. A Kaplan-Meier survival analysis was performed. RESULTS: The mean IOP in the phaco group did not differ significantly from the mean IOP before cataract extraction at any interval. Twelve months after cataract extraction, the mean IOP in the ECCE group was significantly higher than preoperatively (P =.01); however, the mean IOP did not differ between groups over time (P =.704). There was significantly better long-term IOP control in the phaco group as determined by Kaplan-Meier survival analysis and the log-rank test (P =.038). CONCLUSION: After trabeculectomy, phacoemulsification provided better long-term IOP control than ECCE; however, the mean IOP was not significantly lower.

Phacoemulsification with intraocular lens implantation after trabeculectomy.

PURPOSE: To determine the effect of phacoemulsification with intraocular lens (IOL) implantation, using a superior clear-corneal incision, on the long-term intraocular pressure (IOP) control in patients who have undergone previous trabeculectomy. METHODS: Twenty-eight consecutive patients who underwent phacoemulsification with IOL implantation (phaco group) at least 3 months after trabeculectomy were identified and matched to 28 patients who underwent trabeculectomy only (trabeculectomy-only group) with respect to age, gender, IOP, and duration of follow-up. The mean IOP was compared 1 and 2 years after phacoemulsification, and the surgical success rate in each group was determined by Kaplan-Meier survival analysis. RESULTS: The mean IOP 1 year after cataract surgery was significantly higher ( = 0.025) in the phaco group (15.6 +/- 3.5 mm Hg) than in the trabeculectomy-only group (13.4 +/- 2.5 mm Hg), but at 2 years the difference was not statistically significant (15.3 +/- 3.1 mm Hg in the phaco group compared with 14.3 +/- 3.2 mm Hg in the trabeculectomy-only group; = 0.35). Two years after surgery, 5 of 28 patients in the phaco group and 1 of 28 patients in the trabeculectomy-only group had commenced or were using additional topical medication ( = 0.089). If the introduction of glaucoma medication was considered a "failure," then the IOP control was significantly better in the trabeculectomy-only group using two different criteria for surgical failure. CONCLUSION: Although phacoemulsification and IOL implantation through a superior clear-corneal incision have little effect on mean IOP in a group of patients who have undergone previous trabeculectomy, this procedure may jeopardize the long-term IOP control in individual patients.

Clinical evaluation of the dynamic observing tonometer.

PURPOSE: The Dynamic Observing Tonometer (SmartLens, Ophthalmic Development Company AG, Zürich, Switzerland) is a diagnostic contact lens that allows continuous measurement of intraocular pressure, in addition to providing the investigator with a view of the posterior pole and anterior chamber angle. The purpose of this study was to determine the accuracy of this tonometer and the repeatability of the intraocular pressure measurements. PATIENTS AND METHODS: The intraocular pressure was measured by Goldmann applanation tonometry in one randomly chosen eye of 40 subjects (median age 66 years, range 21-77 years). The intraocular pressure, pulse amplitude and 10-second continuous tonometric recordings were then taken using the Dynamic Observing Tonometer and a pneumatonometer. Accuracy was determined by calculating the mean bias and 95% limits of agreement of measurements made with the Dynamic Observing Tonometer against measurements made with the Goldmann and pneumatonometer. Repeatability was evaluated by calculating the differences between pairs of repeated measurements against the mean value and by calculating reliability coefficients. RESULTS: Intraocular pressure measurements made with the Dynamic Observing Tonometer had a mean bias of +2.1 mm Hg (95% limits of agreement: -4.0 to +8.2 mm Hg) compared with Goldmann tonometry. There was a reasonable correlation between Goldmann and Dynamic Observing Tonometer intraocular pressure readings (r = 0.78, P < 0.01). In measuring pulse amplitude, the Dynamic Observing Tonometer was found to have a mean bias of +0.4 mm Hg (95% limits of agreement: -1.6 to +2.3 mm Hg) compared with the pneumatonometer (r = 0.78, P < 0.01). In assessing the repeatability of intraocular pressure measurements, the first Dynamic Observing Tonometer reading was on average 0.4 mm Hg higher than the second (95% limits of agreement: -3.8 to +4.6 mm Hg) with a coefficient of reliability of 0.91. For pulse amplitude readings, the first reading was on average 0.1 mm Hg lower than the second (95% limits of agreement: -1.4 to +1.2 mm Hg) with a coefficient of reliability of 0.90. CONCLUSION: Intraocular pressure measurements taken with the Dynamic Observing Tonometer had a small positive bias compared with Goldmann tonometry. The pulse amplitude values correlated well with those obtained with a pneumatonometer and the repeatability of intraocular pressure measurements was similar to that found in other commercially available tonometers.

Silicone oil pupil block glaucoma in a pseudophakic eye.

Intravitreal silicone oil achieves an effective endotamponade in patients with complex retinal detachments. Silicone oil displacement into the anterior chamber risks glaucoma and endothelial failure. We describe a 52-year-old patient with pseudophakia with silicone oil endotamponade presenting with visual loss and intraocular pressure of 60 mm Hg. Inferior YAG iridotomy was undertaken to repatriate silicone oil to the posterior segment. Despite normal intraocular pressure, acute corneal oedema occurred postiridotomy, resolving spontaneously over 2 weeks. Pupil block glaucoma secondary to silicone oil requires a management approach based on an understanding of silicone oil fluidics. Careful selection of inferior laser iridotomy site is critical to effectively reverse pupil block. Anterior migration of silicone oil in patients with pseudophakia is rare. We offer an hypothesis to explain unanticipated transient corneal oedema following silicone oil displacement from the anterior chamber. Clinicians must discuss the possibility of transient or permanent endothelial failure preoperatively in this patient group.