The Ultima foldable scleral fixation intraocular lens: a 2-year follow-up.

PURPOSE: To describe a new scleral fixation foldable intraocular lens (IOL): the Ultima. METHODS: The novel IOL is a new scleral fixation acrylic hydrophilic foldable lens that offers a 360 degrees sulcus support due to its round geometry. It can be folded and inserted through a 4 mm clear cornea incision. Twenty-five eyes implanted with the Ultima lens were followed for 2 years. RESULTS: Twenty-two eyes showed visual improvement, two eyes had no functional improvement, and one eye had visual deterioration. The IOL remained well centered and showed no signs of tilting in all patients during the entire follow-up. CONCLUSIONS: The main advantages of the Ultima IOL include the lack of tilting and the minimum postoperative astigmatism. It also allows a clear retinal examination and provides an excellent barrier for silicone oil between vitreous cavity and anterior chamber.

OCT Glaucoma Staging System: a new method for retinal nerve fiber layer damage classification using spectral-domain OCT.

PurposeTo describe a new method, the Optical Coherence Tomography (OCT) Glaucoma Staging System, for classifying retinal nerve fiber layer (RNFL) damage assessed with OCT.Patients and methodsThe OCT Glaucoma Staging System was created based on data obtained from Nidek RS 3000 spectral-domain (sd)-OCT. This system uses the superior and inferior quadrant RNFL thickness values, plotted on an x-y diagram for staging structural damage severity in glaucoma. A non-linear equation and two regression lines describe the boundary lines which separate the different sectors of the diagram. These mathematical formulas have been used to create a software, which provides a quick classification of the RNFL damage. Sensitivity and specificity of the system were assessed in a different cohort including 64 patients with early OAG, and 62 normal subjects.ResultsThree hundred and two OCT tests from 98 healthy controls and 284 patients affected by either ocular hypertension or chronic open-angle glaucoma were considered in order to design the new classification system. The OCT Glaucoma Staging System classifies RNFL defects into 6 stages of increasing severity ranging from borderline to stage 5, and 3 groups according to defect localization (superior, inferior, or diffuse). Sensitivity and specificity in discriminating between healthy and glaucomatous eyes were 95.2 and 91.9%, respectively, considering borderline results as abnormal.ConclusionsThe OCT Glaucoma Staging System appears to provide a standardized and objective classification of glaucomatous RNFL damage. It can be used in day-to-day clinical practice for an easy and fast interpretation of RNFL measurements obtained with OCT.

Expression of haematopoietic stem cell markers, CD133 and CD34 on human corneal keratocytes.

AIM: To study the expression of CD133 and CD34 antigens on cultured human keratocytes over time. METHODS: Primary cultures of human corneal stromal cells were established from explants derived from cadaver eye donors. The cultures were sorted for CD133+ and CD34+ cells using magnetic beads. Both the primary cultures and secondary passages of sorted cells were further analysed by flow cytometry and western blot analysis for expression of the same antigens over time. RESULTS: Four different cell populations-namely, CD133+, CD133-, CD34+ and CD34-, were identified in the culture samples. Two further specific subgroups were identified by flow cytometry: CD133+/CD34- cells and CD133+/CD34+ cells. Expression of CD133 declines more than CD34 with time in cell cultures. Although most cells lost expression of these markers, small populations retained staining up to 5 weeks in culture. CONCLUSION: Human keratocytes express the haematopoietic stem cell markers CD133 and CD34. This expression decreases with time in culture, with most but not all cells losing expression. On the basis of these markers, the corneal stroma shows a heterogeneous population of cells. Expression or down regulation of expression of these molecules could represent different stages of activation of these cells.

Pupil size influence on the intraocular performance of the multifocal AMO-Array intraocular lens in elderly patients.

PURPOSE: To study the relationship between pupil size and AMO-Array multifocal intraocular lens (MIOL) performance in a population of elderly patients. METHODS: This prospective trial included 62 patients (mean age 76 years; range 70 to 86) undergoing bilateral cataract phacoemulsification and MIOL (AMO-Array SA-40N, Allergan) implantation. Patients were divided into two groups based on preoperative pupil diameter: small pupil group (pupil size of 2.5-2.9 mm; 45 subjects) and large pupil group (pupil size of 3-5 mm; 17 subjects). The analysis included uncorrected (UC) and best-corrected (BC) near and distance visual acuity (VA), spectacle dependence, and photic phenomena complaints (postoperative follow-up 16.6+/-6.2 months; range 11-26 months). RESULTS: Patients in the small pupil group showed postoperatively significantly higher distance UCVA and BCVA, but lower near UCVA compared to those in the large pupil group (Mann-Whitney test, p< or = 0.02). Patients with small pupils also tended to: be more (not statistically significant) spectacle independent for distance (73.3% versus 47.1%) and spectacle-dependent for near vision (55.6% versus 28.4%); report significantly less photic phenomena complaints (37.8% versus 93.1%, chisquare test, p<0.001); and, more satisfied with the surgery (95.5% versus 76.5%). Posterior capsular opacification (PCO) was observed in 19.4% of the patients. CONCLUSIONS: Bilateral AMO-Array MIOL implantation in elderly patients seems to be an effective and safe surgical procedure that improves distance and near UCVA, providing spectacle independence in many cases. The use of these MIOLs, however, can induce photic phenomena and cause PCO. Patients with small preoperative pupils (<3 mm) presented less photic phenomena complaints and expressed a higher visual outcome satisfaction after surgery.

Baseline factors predicting the risk of conversion from ocular hypertension to primary open-angle glaucoma during a 10-year follow-up.

PurposeTo evaluate the ability of baseline clinical, morphological, and functional factors to predict the conversion to primary open-angle glaucoma (POAG) in ocular hypertensive (OHT) patients.MethodsThis single-center prospective longitudinal observational study included 116 eyes of 116 OHT patients followed for a 10-year period. All patients had intraocular pressure (IOP) ≥24 mm Hg in one eye and >21 mm Hg in the other eye, normal visual fields (VFs) and normal optic disc (OD) appearance in both eyes at baseline. All OHT patients were untreated at baseline with subsequent treatment upon need according to clinical judgement. Only one eye per subject was randomly selected. Patient age, gender, IOP, central corneal thickness (CCT), and ibopamine test results were collected at baseline. All patients underwent standard automated perimetry, short-wavelength automated perimetry (SWAP), frequency-doubling technology, confocal scanning laser ophthalmoscopy (CSLO), and scanning laser polarimetry (SLP) at baseline and every 6 months thereafter. Main outcome measure was the conversion to POAG, defined as the development of reproducible VF and/or OD abnormalities attributable to glaucoma. Cox proportional hazards models were used to identify the baseline factors predictive of POAG conversion.ResultsDuring the 10-year follow-up, 25% of eyes converted to POAG. In multivariate Cox models, baseline factors that were significant predictors of POAG development included: older age (hazard ratio (HR) 1.0, 99% confidence intervals (CIs) 1.0-1.2, per 1 year older); SWAP Glaucoma Hemifield test 'outside normal limits' (HR 4.3, 99% CIs 1.2-17.9); greater SLP 'Inter-eye Symmetry' (HR 1.1, 99% CIs 0.4-3.0, per 1 unit lower); lower CSLO Rim Volume (HR 1.1, 99% CIs 0.3-3.2, per 0.1 mm(3) lower); and greater CSLO cup-to-disc ratio (HR 6.0, 99% CIs 3.6-16.8, per 0.1 unit greater).ConclusionsThe baseline parameters that proved to be useful in assessing the likelihood of an OHT patient to develop POAG included age, functional variables provided by SWAP, and structural variables provided by SLP and CSLO. In this cohort of patients, baseline IOP, CCT, and ibopamine provocative test results were not significant predictors of POAG conversion.

Probing glaucoma visual damage by rarebit perimetry.

AIM: To compare rarebit perimetry (RBP) with standard achromatic perimetry (SAP) in detecting early glaucomatous functional damage. METHODS: 43 patients with ocular hypertension (OH), 39 with early primary open angle glaucoma (POAG), and 41 controls were considered. Visual fields were assessed using the Humphrey field analyser (HFA) 30-2 and RBP tests. Differences among the groups were evaluated using Student-Newman-Keuls and chi(2) tests. Correlation between HFA and RBP parameters was assessed using the Pearson's correlation coefficients and regression analysis. Sensitivity and specificity of RBP in detecting early glaucomatous visual damage were calculated with different algorithms. RESULTS: RBP-mean hit rate (MHR) was respectively 88.6% (SD 4.8%) in controls; 79.1% (10.9%) in the OH group; 64.3% (13.8%) in the POAG group (differences statistically significant). Good correlation in the POAG group was found between HFA-mean deviation and RBP-MHR. Largest AROC (0.95) and optimal sensitivity (97.4%) were obtained when an abnormal RBP test was defined as having (at least 1): MHR <80%; >15 areas with a non-hit rate of >10%; > or =2 areas with a non-hit rate of >50%; at least one area with a non-hit rate of > or =70%. CONCLUSIONS: The RBP appeared to be a rapid, comfortable, and easily available perimetric test (requiring only a PC device), showing a high sensitivity and specificity in detecting early glaucomatous visual field defects.

Corneal thickness and functional damage in patients with ocular hypertension.

PURPOSE: To correlate functional damage over time detected by standard automated perimetry (SAP) and frequency doubling technology (FDT) with central corneal thickness (CCT) in patients with ocular hypertension (OHT). METHODS: Seventy-eight OHT patients underwent CCT measurements, SAP, and FDT (the latter two also after 12 and 18 months). Patients were divided into three equally sized groups of 26 patients each: thin (< 540 microm), normal (540-580 microm), and thick cornea (> 580 microm). The frequency of abnormal FDT and SAP results was analyzed over time (Pearson chi2 test). RESULTS: Six of 26 patients with thin corneas (23.1%) presented an abnormal FDT test at baseline, compared to 1 of 26 (3.8%) in the normal thickness cornea group and 1 of 26 (3.8%) in the thick cornea group. After 12 months, the abnormal FDT tests were as follows, respectively: 9 of 26 (34.6%), 2 of 26 (7.7%), and 2 of 26 (7.7%). For SAP the abnormal results were as follows, respectively: 8 (30.1%), 5 (19.2%), and 2 (7.7%). After 18 months, the abnormal FDT tests were as follows, respectively: 16 (61.5%), 5 (19.2%), and 5 (19.2%). For SAP, the abnormal results were as follows, respectively: 10 (38.5%), 5 (19.2%), and 2 (7.7%). CONCLUSIONS: OHT patients with thinner corneas have a greater risk of developing functional damage over time.

Ocular hypertension and corneal thickness: a long-term prospective study. Results after two years.

PURPOSE: To study the importance of the central corneal thickness (CCT) in patients with ocular hypertension in a 2-year follow-up. METHODS: A total of 110 subjects with ocular hypertension (intraocular pressure [IOP] >21 mmHg and normal automated visual field test) were admitted to the study. All patients periodically underwent the following tests: 1) circadian IOP curve; 2) standard automated perimetry (SAP, Humphrey 30-2 SITA test); 3) short wavelength automated perimetry (SWAP); 4) frequency doubling technology perimetry (FDT, N-30 threshold test); 5) nerve fiber layer analysis with GDx; 6) ibopamine test; 7) ultrasonic pachymetry. Patients were divided into three groups, based on corneal thickness. The frequency of abnormal tests within these groups was evaluated with the Pearson's chi2 test. Baseline IOP was corrected using the Doughty and Zaman formula. CCT was also considered as a continuous variable. A control group of 48 normal subjects was also considered. RESULTS: The mean CCT was 562.8 microm +/- 37.7. The difference with respect to normal subjects was statistically significant (p < 0.01). Using the correction formula, 43 eyes (39.1%) had an IOP <21 mmHg. Abnormal test results were more frequently found with FDT. The percentage of abnormal results was found to be inversely proportional to CCT. The other tests gave inconsistent or conflicting results. Using the values of CCT as a continuous variable, no significant association was found with the GDx number and the visual field indices. CONCLUSIONS: The results of our 2-year study confirm the importance of CCT measurement in the evaluation of the risk of developing glaucomatous damage.

Discrimination between normal and early glaucomatous eyes with scanning laser polarimeter with fixed and variable corneal compensator settings.

PURPOSE: To evaluate the ability of scanning laser polarimetry (SLP) with a fixed corneal polarization compensator (GDx-FCC Nerve Fiber Analyzer) compared to one with a variable one (GDx-VCC) in the discrimination between healthy and early glaucomatous eyes. METHODS: Forty patients with early glaucomatous visual field defects, having a mean deviation of 3.1-/+1.6 dB and a pattern standard deviation of 3.1-/+0.9 dB, and 40 controls underwent both GDx-FCC and GDx-VCC. One eye per patient was considered. The cut-off point, taken as the value dividing healthy from glaucomatous eyes with highest probability, was determined for each GDx parameter. Linear discriminant functions (LDFs) were separately developed for GDx-FCC and GDx-VCC parameters. Sensitivity, specificity, and area under the receiver operating characteristic curve (AROC) for discriminating between healthy and glaucomatous eyes were calculated for each GDx parameter, both according to the GDx normative database and after the selection of new cut-off points, and for the LDFs. RESULTS: All software-provided parameters showed low sensitivity and high specificity. The selection of new cut-off points improved the performance of all GDx parameters: VCC parameters performed better than FCC parameters; the largest AROCs were associated with the superior/nasal ratio for the GDx-FCC (0.86) and with the Number for the GDx-VCC (0.87). The LDFs provided an AROC of 0.89 with both the GDx-FCC and the GDx-VCC parameters. CONCLUSIONS: The GDx-VCC showed a higher ability in the early diagnosis of glaucoma when compared with the GDx-FCC. The individuation of the right cut-off point of selected parameters with both GDx settings performed better than the software-provided parameters, and comparably to the GDx parameters-based LDFs.

Clinical use of a new method for visual field damage classification in glaucoma.

This new method, based on the use of MD and CPSD (or CLV) visual field indices, can instantly classify not only the stage of glaucomatous visual field damage, but also the type of defect (localized, generalized or mixed). This system was used to study glaucomatous visual field defects in 500 automated tests, performed with either Humphrey 30-2 or Octopus G1 threshold tests. The most common defects found were mixed, and purely local defects were very unusual, especially in advanced glaucoma.

Scleroretinal necrosis after a subconjunctival injection of gentamicin in a patient with a surgically repaired episcleral retinal detachment.

PURPOSE: To describe a case of scleroretinal necrosis after a subconjunctival injection of gentamicin in a patient who had an episcleral retinal detachment that was surgically repaired. METHODS: Case presentation. RESULTS: Thinning of the sclera due to cryosurgery and the induced localized inflammatory response resulting from the surgical procedure, in addition to the effect of the sponge buckle itself, could have played an important role in accumulation and storage of gentamicin under and adjacent to the buckle after injection. The increasingly higher concentration of the drug under the buckle could have induced a greater penetration of gentamicin through the sclera, which could have been the cause of the scleral-chorio-retinal necrosis observed in this patient. CONCLUSIONS: Attention must be given to avoid side effects from subconjunctival injection of gentamicin.

Comparison of iCare tonometer and Goldmann applanation tonometry in normal corneas and in eyes with automated lamellar and penetrating keratoplasty.

PURPOSE: To compare intraocular pressure (IOP) measurements with Goldmann applanation tonometry (GAT) and iCare tonometry in normal and post-keratoplasty corneas and to assess the influence of central corneal thickness (CCT), corneal curvature (CC), and corneal astigmatism (CA) on IOP. METHODS: This prospective cross-sectional study included one eye of 101 subjects with normal corneas (58 healthy subjects, 43 glaucoma); and 90 post-keratoplasty patients: 34 penetrating keratoplasties (PK); 20 automated-lamellar-therapeutic keratoplasties (ALTK); 19 Descemet-stripping-automated-endothelial keratoplasties (DSAEK); 17 edematous grafts. All subjects underwent GAT and iCare IOP measurements in random order, and CCT, CC, and CA evaluation. The Bland-Altman method and multivariate regression analysis were used to assess inter-tonometer agreement and the influence of CCT, CC, and CA on IOP. RESULTS: iCare significantly underestimated IOP in all groups compared with GAT (GAT minus iCare of 3.5±3.5 mm Hg, P<0.001), but overestimated IOP in the edematous grafts (GAT minus iCare of -6.5±1.9 mm Hg, P<0.001). In normal corneas, both tonometer measurements were directly related to CCT values; iCare readings appeared inversely related to CC. There was no significant relationship between IOP and CCT, CC and CA in post-keratoplasty eyes, except between CC and iCare measurements for PK eyes. CONCLUSIONS: The agreement between GAT and iCare was clinically acceptable in control, ALTK and DSAEK groups, and poor in PK and edematous grafts eyes. In normal corneas, GAT was significantly affected by CCT; iCare was influenced by CCT and CC. The iCare appeared less influenced by corneal edema when compared with GAT. High IOP readings taken with both tonometers in grafts should raise suspicion of true elevated IOP.

Agreement to detect glaucomatous visual field progression by using three different methods: a multicentre study.

AIM: To examine the level of agreement among nine clinicians in assessing progressive deterioration in visual field (VF) overview using three different methods of analysis. METHODS: Each visual field was assessed by Humphrey Field Analyzer (HFA), program 24-2 SITA Standard. Nine expert clinicians assessed the progression status of each series by using HFA 'overview printouts' (HFA OP), the Guided Progression Analysis (GPA) and the Guided Progression Analysis (GPA2). VF series were presented in random order, but each patient's VF remained in chronological order within a given field series. Each clinician adopted his personal methods based on his knowledge to evaluate VF progression. The level of agreement between the clinicians was evaluated by using weighted κ statistics. RESULTS: A total of 303 tests, comprising 38 visual field series of 7.9 ± 3.4 tests (mean ± SD), were assessed by the nine glaucoma specialists. When the intra-observer agreement was evaluated between HFA OP and GPA, the mean κ statistic was 0.58 ± 0.13, between HFA OP and GPA2, κ was 0.55 ± 0.06 and between GPA and GPA2 it was 0.56 ± 0.17. When the inter-observer agreement was analysed κ statistic was 0.65 for HFA OP, 0.54 for GPA and 0.70 for GPA2. CONCLUSIONS: Using any procedure for evaluating the progression of a series of VF, agreement between expert clinicians is moderate. Clinicians had higher agreement when GPA2 was used, followed by HFA OP and GPA printouts, but these differences were not significant.

Non-conventional perimetric methods in the detection of early glaucomatous functional damage.

PURPOSE: To compare the ability of frequency-doubling technology (FDT), rarebit perimetry (RBP), and pulsar perimetry (PP) in detecting early glaucomatous functional damage. METHODS: This prospective observational cross-sectional case study included 52 patients with early primary open-angle glaucoma (mean deviation -2.3+/-1.1 dB; pattern standard deviation 3.0+/-1.2 dB) and 53 healthy controls. Visual field (VF) testing included standard automated perimetry (SAP) Humphrey Field Analyzer 30-2, FDT N-30, RBP (version 4.0), and PP T30W. One eye per patient was considered. Sensitivity at fixed specificities and area under the receiver operating characteristic curve (AROC) for discriminating between healthy and glaucomatous eyes were calculated and compared. RESULTS: The parameters associated with the largest AROC, which were not statistically different (Hanley-McNeil method, P0.42-0.71) were as follows: number of locations in the pattern deviation probability (PDP) plot with P<5% for FDT (0.93); mean hit rate for RBP (0.95); and mean defect for PP (0.94). PP test duration was significantly shorter than FDT and RBP (P<0.002). CONCLUSIONS: FDT, PP, and RBP are useful non-conventional VF methods in detecting early glaucomatous VF defects with similar AROCs. The methods were rapid and easy, and PP took less than half the time than SAP. These non-conventional testing may prove to be useful in providing additional information in the diagnosis of glaucoma suspect with normal SAP results, in the therapeutic decision-making process of early glaucomatous patients, and in subjects unable to perform VF testing with SAP.

Test-retest variability of intraocular pressure and ocular pulse amplitude for dynamic contour tonometry: a multicentre study.

AIMS: To assess the test-retest variability of intraocular pressure (IOP) and ocular pulse amplitude (OPA) measurements utilising dynamic contour tonometry (DCT) and to evaluate possible influential factors. METHODS: The study included 350 consecutive subjects (175 glaucoma, 175 control; one eye per subject) from seven European centres. IOP was measured once with a Goldmann applanation tonometer (GAT) and twice by DCT (DCT1, DCT2) in a randomised sequence. OPA was also recorded for both DCT measurements. Differences (DCT1-DCT2; OPA1-OPA2; GAT-DCT1; GAT-DCT2) were assessed using the t test. The intraclass coefficient of correlation (ICC) and coefficient of variation (CoV) for DCT and OPA were calculated. RESULTS: DCT1 was 0.6+/-1.6 mm Hg higher than DCT2 (p<0.001); OPA1 was 0.1+/-0.7 mm Hg higher than OPA2 (p=0.02). Results were not influenced by randomisation test order. In both glaucoma and normal subjects, DCT and OPA showed ICC>0.90 and >0.76, and CoV=4.8-5.0% and 10.3-10.5%, respectively. DCT1 and 2 were 2.4+/-2.6 and 1.8+/-2.6 mm Hg higher respectively than GAT (p<0.001). DISCUSSION: DCT test-retest variability was almost perfect for IOP and good for OPA. Tonometry measurements with DCT tended to be overestimated compared with GAT.