Diurnal fluctuation and concordance of intraocular pressure in glaucoma suspects and normal tension glaucoma patients

PURPOSE: The study objective was to determine the concordance of intraocular pressure (IOP) in glaucoma suspects (GS) and normal tension glaucoma (NTG) patients. METHODS: This was a retrospective review of diurnal curves of untreated GS and NTG patients. No subject had IOP greater than 21 mm Hg. We defined GS patients as having suspicious optic nerves with normal visual fields, and NTG patients as having glaucomatous optic nerves with associated visual field loss. Goldmann applanation tonometry was performed at 10:00, 13:00, 16:00, 19:00, 22:00, and 07:00. Linear association of OD and OS IOP was estimated using Pearson correlation coefficient (r). The diurnal period was divided into 7 time intervals of 3, 6, 9, 12, 15, 18, and 21 hours, and the absolute difference in change in IOP between fellow eyes and probability that it was within 3 mm Hg were calculated. RESULTS: The study included 68 GS and 95 NTG subjects. The diurnal curves of the OD and OS showed a parallel course in both groups. The average correlations (r) of OD and OS IOP over the 6 time points were 0.78 and 0.81 for GS and NTG, respectively. The mean absolute difference in IOP change between OD and OS over the 6 time intervals ranged between 1.4 and 1.9 mm Hg for GS, and 1.3 and 1.5 mm Hg for NTG subjects. The probability that this difference was within 3 mm Hg ranged between 87% and 94% for GS, and 86% and 93% for NTG subjects. CONCLUSIONS: The diurnal variation in IOP between the 2 eyes in GS and NTG is largely concordant in approximately 90% of the time.     

Primary open angle glaucoma in cornea plana masked by false normal applanation tonometry (Goldman) - a case report

BACKGROUND: Cornea plana is a rare syndrome, which leads to a flat corneal curvature due to a reduced sclero-corneal angle. Depending on the regularity of the corneal astigmatism the frequently resulting hyperopia may be difficult to compensate for. Because of the flatness of the cornea the anterior chamber is also flat, the anterior chamber angle can be restricted, and the applanatory intraocular pressures (IOPs) are measured too low. A primary open angle glaucoma is therefore not diagnosed for a long time, until changes of the optic nerve head occur.Patient and methods We report on a 66-year-old male with cornea plana. Although his intraocular pressure (IOP), measured with an applanation tonometer (Goldmann), had always been normal (< 21 mm Hg), he suffered from an increasing glaucomatous atrophy of the optic disc. We carried out a complete ophthalmological investigation, including keratometry and corneal topography analysis (TMS-1, Tomey). Furthermore, visual field was determined (G1, Octopus) and the optic nerve heads were documented and analysed by papillometry. A 48-hour tension profile was worked out for both eyes including applanation and Schi?tz tonometry.Results The central refractive power of the cornea was 31 diopters and the cornea seemed to be flattened on slit lamp evaluation. The glaucomatous atrophy of the optic disc was more pronounced in the OD than in the OS (OD=neuroretinal rim loss in the upper part, at the bottom and in the lateral part of the optic disc, OS=laterally distinct neuroretinal rim loss). While the anterior parts of the eye were shortened (depth of the anterior chamber was OD/OS=1.9 mm), a macrophthalmus posterior was stated (axial length OD=25.78 mm, OS=25.72 mm). However, the IOPs were measured below 21 mm Hg by applanation during the entire tension analysis, comparable values measured with the Schi?tz tonometer showed values above 21 mm Hg. We converted the applanatory IOP values according to the flat corneal power, as described in literature (addition of 1 mm Hg to the applanatory values per 3 diopters decreased corneal power). The tension analysis now showed increased values, as expected after observation of the glaucomatous excavated optic nerve head.Conclusion In patients with cornea plana applanatory IOPs are measured too low. Therefore in case of very flat corneas a mathematical correction of the applanatory IOP should be carried out, in order to diagnose a primary open angle glaucoma early enough.     

Effects of short term increase of intraocular pressure on optic disc cupping

AIMS—To evaluate the effect of acute elevation of intraocular pressure (IOP) on optic disc cupping.
METHODS—10 emmetropic and 10 myopic volunteers were included in this study. The cup area (CA) and cup volume (CV) of the optic disc were determined with the Heidelberg retina tomograph (HRT). After baseline determinations, a suction cup was used to increase the intraocular pressure (IOP) to 20-25 mm Hg above the baseline and HRT images were obtained.
RESULTS—Baseline IOP was 13.5 (SD 1.3) mm Hg and 12.6 (2.6) mm Hg in the emmetropic and myopic groups, respectively. The IOP was elevated to 35.4 (3.3) mm Hg and 34.4 (2.5) mm Hg in the emmetropic and myopic groups, respectively. When compared with their baseline values, the cupping variables (CA and CV) were significantly increased (p<0.05) during the suction treatment in both emmetropic and myopic subjects.
CONCLUSION—There was a significant enlargement in the optic disc cupping during the artificial increment of intraocular pressure in both emmetropic and myopic eyes. In non-glaucomatous eyes the optic nerve head has a partially dynamic topography dependent upon the level of IOP.

Keywords: optic disc; intraocular pressure; compliance; glaucoma     

Optic disc changes following trabeculectomy: longitudinal and localisation of change

AIMS: To determine whether there were any changes in the optic disc at 2 years after trabeculectomy. To determine the factors that most influenced change and whether change was localised to any region of the optic disc. METHODS: 95 patients undergoing routine trabeculectomy as part of the ongoing Moorfields/MRC 5-fluorouracil trial were recruited into the study. Eyes were imaged preoperatively (4 (SD 3) weeks) with the Heidelberg retina tomograph (HRT, Heidelberg Engineering), and at 3 months (SD 2 weeks), 1 year (SD 1 month), and 2 years (SD 1 month) after surgery. Parameters investigated for change were rim area, rim volume, and maximum cup depth. The predefined segment analysis available on the HRT analysis software was used to determine segmental change. RESULTS: The images of 70 patients were analysed. Intraocular pressure reduced from 22.25 (SD 3.76) mm Hg, at the time of preoperative imaging to 15.27 (SD 4.96) mm Hg at 3 months, 14.38 (SD 3.89) mm Hg at 1 year, and 13.80 (SD 3.54) mm Hg at 2 years after trabeculectomy. An increase in rim area and rim volume was present at all time points after surgery, but was only found to be statistically significant at 2 years after surgery. Maximum depth of cup reduced by month 3 and month 12, but showed a slight increase at 2 years after surgery, although this was still lower than the preoperative measure. Segmental analysis found a significant change in rim volume in the nasal, inferonasal, superonasal, and superotemporal regions at 2 years after surgery. No significant regional localisation for change was found at any other time point or in any other parameter investigated. CONCLUSIONS: Reversal of disc cupping is present at 2 years after trabeculectomy. The factor most influencing change is reduction of intraocular pressure. Segmental analysis showed that change in rim volume was greatest in the nasal, inferonasal, superonasal and superotemporal regions at 2 years.     

Impact of intraocular pressure fluctuations on progression of normal tension glaucoma

AIM: To investigate short- and long-term intraocular pressure (IOP) fluctuations and further ocular and demographic parameters as predictors for normal tension glaucoma (NTG) progression. METHODS: This retrospective, longitudinal cohort study included 137 eyes of 75 patients with NTG, defined by glaucomatous optic disc or visual field defect with normal IOP (<21 mm Hg), independently from therapy regimen. IOP fluctuation, mean, and maximum were inspected with a mean follow-up of 38mo [standard deviation (SD) 18mo]. Inclusion criteria were the performance of minimum two 48-hour profiles including perimetry, Heidelberg retina tomograph (HRT) imaging, and optic disc photographs. The impact of IOP parameters, myopia, sex, cup-to-disc-ratio, and visual field results on progression of NTG were analyzed using Cox regression models. A sub-group analysis with results from optical coherence tomography (OCT) was performed. RESULTS: IOP fluctuations, average, and maximum were not risk factors for progression in NTG patients, although maximum IOP at the initial IOP profile was higher in eyes with progression than in eyes without progression (P=0.054). The 46/137 (33.5%) eyes progressed over the follow-up period. Overall progression (at least three progression confirmations) occurred in 28/137 eyes (20.4%). Most progressions were detected by perimetry (36/46). Long-term IOP mean over all pressure profiles was 12.8 mm Hg (SD 1.3 mm Hg); IOP fluctuation was 1.4 mm Hg (SD 0.8 mm Hg). The progression-free five-year rate was 58.2% (SD 6.5%). CONCLUSION: Short- and long-term IOP fluctuations do not result in progression of NTG. As functional changes are most likely to happen, NTG should be monitored with visual field testing more often than with other devices.     

A comparison of visual field and optic disc appearance depending on the peak intraocular pressure in patients with normal-tension glaucoma

PURPOSE: To investigate the clinical differences between the two groups depending on the peak intraocular pressure(IOP) in patients with normal-tension glaucoma(NTG). METHODS: We studied 96 eyes of 48 NTG patients who were hospitalized for diurnal IOP measurement. Then we selected the eye whose peak IOP was higher than the other, or the right eye if the peak IOP of both eyes was equal. We divided these eyes into a "high-teen" group (peak IOP > or = 16 mmHg) and a "low-teen" group(peak IOP < or = 15 mmHg). We compared these two groups by age, gender, refraction, IOP, visual field defect, optic disc appearance, and tomograph. We used a Humphrey C 30-2 program to estimate the visual field defect and classified the optic disc into four types according to Nicolela's criteria. 22 eyes were imaged with Heidelberg Retina Tomograph (HRT) to obtain topographic parameters of the optic disc. RESULTS: There were no significant differences in age, gender, refraction, optic disc appearance, or tomograph between two groups. The trough and variation range of diurnal IOP were significantly larger in the high-teen group(p < 0.01). The value of mean deviation(MD) given by STATPAC was statistically lower in the high-teen group(p < 0.01). CONCLUSIONS: In patients with NTG, the visual field damage tended to be greater in the high-teen group than in the low-teen group. We surmise that the IOP might influence the progression of visual field defect in NTG.     

Timolol/dorzolamide combination therapy as initial treatment for intraocular pressure over 30 mm Hg

PURPOSE: To determine the intraocular pressure (IOP)-lowering effect of a fixed timolol/dorzolamide combination (Cosopt) for patients with IOP over 30 mm Hg. STUDY DESIGN: Prospective interventional case series. METHODS: Eighteen patients being seen on the Wills Eye Hospital Glaucoma Service with at least one eye with an IOP > 30 mm Hg were recruited. None had used any glaucoma medications for at least 1 month. IOP was confirmed by diurnal testing. Cosopt was administered at 9 am and 9 pm. Trough IOP measurements were made at 9 am and peak IOP measurements at 11 am at baseline, 1 month, and 2 months. Pretreatment and posttreatment IOPs were compared using a paired-samples independent t test. RESULTS: Mean pretreatment IOP was 37.5 +/- 1.0 mm Hg. Baseline posttreatment IOP was 18.4 +/- 0.5 mm Hg (P < 0.01). At 2 months, the mean trough IOP was 21.1 +/- 0.9 mm Hg and the peak, 17.6 +/- 0.6 mm Hg (each, P < 0.01, as compared with pretreatment baseline IOP). One patient did not respond to Cosopt; two had a clinically insufficient response and did not complete the study. Data from these patients were included in the analysis. CONCLUSIONS: Over 80% of the eyes responded to Cosopt, with an average trough IOP reduction of 40% at 2 months.     

Comparison of the intraocular pressure lowering effect of latanoprost and carteolol-pilocarpine combination in newly diagnosed glaucoma

PURPOSE: To evaluate the comparative efficacy of latanoprost monotherapy versus combined carteolol and pilocarpine therapy in patients with newly diagnosed glaucoma. METHODS: Masked randomized prospective trial. This study included 51 patients (64 eyes) with newly diagnosed glaucoma or ocular hypertension. The cases were randomly divided into two treatment groups for administration of latanoprost 0.005% once daily, or of carteolol 2% twice daily and pilocarpine 2% twice daily. Mean diurnal intraocular pressure (IOP) was measured at baseline, week 2, week 4, and month 3 after the beginning of treatment. Changes in mean IOP from baseline to the 3-month visit were determined by an analysis of variance. RESULTS: Mean diurnal IOP values were 25.1 +/- 3.1 mm Hg and 25.5 +/- 2.5 mm Hg at baseline in the latanoprost monotherapy group and in the carteolol-plus-pilocarpine group, respectively. Diurnal IOP was significantly decreased from baseline to 3 months in both groups (P <.001). At this time point, latanoprost monotherapy had reduced mean diurnal IOP by 7.2 +/- 2.5 mm Hg (28.7%) and carteolol plus pilocarpine had reduced mean diurnal IOP by 7.4 +/- 2.7 mm Hg (29%). There was no difference between the groups in terms of their IOP reduction effect (P =.51). Decreased visual acuity and twilight vision, blurred vision, and headache were more frequent in the carteolol-plus-pilocarpine group than in the latanoprost group (P <.05). CONCLUSIONS: We concluded that latanoprost monotherapy was at least as effective as the carteolol-pilocarpine combination therapy in reducing mean diurnal IOP in newly diagnosed glaucoma or ocular hypertension.     

Glaucoma Management in Carotid Cavernous Fistula

Carotid cavernous fistulas (CCF) are vascular communications between the carotid artery and the cavernous sinus. Ophthalmologists are called to diagnose and manage the condition in cases that present with ocular features. A 73-year-old female was referred to our glaucoma center clinic. Eight years before, she had started receiving medication for glaucoma and had undergone laser iridotomy, but a satisfactory management of intraocular pressure (IOP) had not been achieved. The patient was complaining of intermittent diplopia, bilateral proptosis, and conjunctival chemosis over the past 6 months. Best-corrected visual acuity in the right (OD) and left eye (OS) was 9/10 and 10/10, respectively. Visual field testing showed slight paracentral field defects mostly in OS. IOP was 20 mm Hg in OD and 34 mm Hg in OS. We referred the patient to neuroradiology, and MRI angiography revealed a CCF with angiographic classification of Cognard grade 2. Closure of the CCF by transarterial embolization was performed in the neuroradiology department. One week following the procedure, the clinical signs of diplopia, proptosis, and conjunctival chemosis had greatly improved, and IOP was reduced to 12 mm Hg OD and 19 mm Hg in OS. Glaucoma treatment was maintained with topical brimatoprost, brinzolamide, and timolol. Owing to the risk of vision loss associated with vascular stasis, retinal ischemia, and high IOP, ophthalmologists must be aware of the clinical features of CCF and should request appropriate imaging studies such as MRI angiography in order to confirm the diagnosis and plan multidisciplinary treatment.     

Sublingual timolol--an alternative to topical medication in glaucoma?

AIMS--To assess whether timolol drops lower a raised intraocular pressure (IOP) when given sublingually. This route of administration would be useful for glaucoma patients who are unable to instil their own drops--for example, because of stroke, poor vision, arthritis, poor coordination, or blepharospasm. METHODS--A placebo controlled randomised, double masked, crossover study was undertaken in the glaucoma clinic of a large teaching hospital. Twelve patients with ocular hypertension with IOPs over 21 mm Hg, normal optic discs, and full visual fields were examined by Humphrey perimetry. Single dose units of timolol maleate 0.5% drops and normal saline drops were given by instillation in one eye or sublingually. The IOP of both eyes, pulse rate, and blood pressure were all measured before and after each type of drop and route of administration. RESULTS--Two hours after instillation of timolol in one eye, the IOP in the treated eye was reduced by a mean of 8.5 mm Hg (p = 0.0000), and by 1.66 mm Hg in the fellow eye (p = 0.03). Two hours after sublingual instillation of timolol, the IOP was reduced by 7.55 mm Hg in the study eye (p = 0.0000) and by 7.7 mm Hg in the fellow eye (p = 0.0000). There was an equal amount of reduction in pulse rate by either route, but there was no significant change in blood pressure. CONCLUSIONS--The results show that, at least after 2 hours, sublingual treatment is almost as effective as topical treatment in lowering a raised IOP.     

Combined versus sequential phacotrabeculectomy with intraoperative 5-fluorouracil

PURPOSE: To determine and compare the intraocular pressure (IOP) lowering effects of single-incision combined phacoemulsification and trabeculectomy with phacoemulsification done after previous trabeculectomy, both with an intraoperative dose of 5-fluorouracil (5-FU). SETTING: Hospital Del Salvador Ophthalmology Service, Clínica Oftalmológica Pasteur, Santiago, Chile. METHODS: The effects on IOP after phacoemulsification in eyes with previous trabeculectomy using intraoperative 5-fluorouracil (5-FU) (Group 1, n = 18) were compared with those in a matched group of eyes having combined phacoemulsification and trabeculectomy, also with intraoperative 5-FU (Group 2, n = 22). The mean postoperative IOPs and survival curves for IOP values less than 20 mm Hg and 15 mm Hg or less were determined in both groups. Data were retrospectively collected. Comparisons were made with the paired Student t test, and survival curves were compared using log-rank analysis. RESULTS: Mean postoperative IOP without medications was 12.6 mm Hg in Group 1 and 12.2 mm Hg in Group 2 (P = .64). Group 2 had a significant postoperative decrease in IOP (P = .0575); Group 1 did not have a significant increase or decrease. There was no significant difference in the survival curves between groups using arbitrarily defined failure criteria: (1) IOP greater than 15 mm Hg or (2) IOP equal to or greater than 20 mm Hg, both without medication (log-rank analysis, P = .333 and P = 1.00, respectively). CONCLUSION: Combined cataract and glaucoma surgery with intraoperative 5-FU was associated with good long-term IOP control similar to that after phacoemulsification with intraoperative 5-FU in eyes with previous trabeculectomy.     

The Water-Drinking Test Revisited: An Analysis of Test Results in Subjects with Glaucoma

Purpose: The Water-Drinking Test (WDT) has been shown to predict the diurnal IOP change. This study evaluates the factors that may affect the WDT results. Methods: This study was conducted on 203 glaucoma patients who had undergone trabeculectomy (53) or tube surgery (31), or had a medically controlled open-angle (82) or closed-angle (37) glaucoma. IOP was measured at baseline and then every 15 minutes over a one-hour period after drinking water. The main outcome measures were IOP change (increase in IOP from baseline) at all measurement time points, IOP peak (highest IOP after drinking water), IOP fluctuation (difference between IOP peak and baseline), and assessing the association of these IOPs with a patient’s demographic and management modalities. Results: The mean age of the participants was 54±18 years, and 113 (56%) were male. Female patients showed greater IOP fluctuation than males (7.28 vs. 5.92 mm Hg; P=0.016), and a greater IOP peak (22.7 vs. 20.1 mm Hg; P=0.001). The observed associations between gender and IOP changes were only significant in <50 years. IOP at 60 minutes was greater in tube than trabeculectomy (5.6 vs. 3.1 mm Hg; P=0.007). The number of topical medications showed a direct independent association with IOP changes (P<0.001). Compared to other classes of topical medications, latanoprost showed lower WDT-IOP profile (P=0.0003). Conclusions: WDT-IOP change was diminished in subjects on latanoprost, and was greater in females <50 years, and those on greater number of medications.     

Topiramate-induced bilateral secondary angle closure and myopia shift

A 41-year-old female with a history of migraine had no previous ocular problems except myopia with spherical refraction of −2.25 D OD and −1.75 D OS. She experienced sudden onset of bilateral blurred vision, ocular fullness sensation, and headache after undergoing topiramate therapy for 7 days (50 mg/day). Her visual acuities with the presenting glasses were 20/200 OD and 20/50 OS. Intraocular pressures (IOPs) were 44 mmHg OD and 49 mmHg OS, respectively. Autorefraction measurement showed spherical refraction of −5.25 D OD and −4.75 D OS. Best-corrected visual acuities were 20/20 for both oculus dexter (OD) and oculus sinister (OS). Slit-lamp examination revealed bilateral conjunctival chemosis, very shallow anterior chambers, forward displacement of lens–iris diaphragm, round and sluggishly reacting pupils, and closed angles on gonioscopy. A B-scan ultrasound displayed choroidal thickening in both eyes. An ultrasound biomicroscopy demonstrated bilateral 360° ciliochoroidal effusions with forward rotation of ciliary body but no pupillary block. Impression of topiramate-induced bilateral angle-closure glaucoma and acute myopic shift was recorded. She was advised to discontinue topiramate immediately and was administered antiglaucoma medication and mydriatics. Two days later, IOP returned to normal limits and myopic shift resolved after 1 week. Her visual acuity with previous glasses improved to 20/20 OU. In addition, choroidal effusions also subsided gradually. The presented case highlights the possible side effects of topiramate, offers management and suggestion for such a condition, and brings awareness to sulfa drug complications.     

Hydrophobic Acrylic Intraocular Lens in Both Eyes

 PURPOSE: To report on the clinical findings of a case of late opacification of the hydrophobic acrylic intraocular lens (IOLs) in both eyes after cataract surgery. METHODS: A 79-year-old man with a history of decreased visual acuity and complaints of glare and blurred vision in both eyes over the past 3 years. He had received an uneventful phacoemulsification combined with posterior chamber IOL implantation for senile cataract in both eyes 13 years ago, and had undergone neodymium:YAG(Nd:YAG) laser posterior capsulotomy on both eyes 6 years ago, for posterior capsular opacification (PCO). The optical portion of the IOLs showed uniform gray haze. Binocular posterior capsular laser holes were clearly noted. RESULTS: IOL exchange was performed by the same surgeon on both eyes, three days apart. Postoperatively, the patient's visual acuity was elevated to 6/12 (OD) and 6/9 (OS) at 6 months, and intraocular pressure (IOP) reached 16.8 mmHg (OD) and 18.4 mmHg (OS). Neither glare or blurred vision were observed in either eye. CONCLUSION: IOL exchange can be used to effectively manage clinically significant optic opacification.       

羊膜和细胞外基质对兔眼小梁切除术后滤过泡的影响

目的探讨羊膜和结膜细胞外基质（ECM）对兔眼小梁切除术后滤过泡的影响。方法对27只新西兰白兔右眼后房注射α-糜蛋白酶,制备青光眼动物模型。将兔随机分为对照组、羊膜组、结膜ECM组,每组9只兔,行右眼手术。对照组行单纯小梁切除术,羊膜组行小梁切除联合羊膜移植术,结膜ECM组行小梁切除联合ECM移植。术后第1、7、14、21、28、35、42、56天观察小梁滤过泡形态及功能并测量术眼眼压,光学显微镜下观察小梁滤过泡下细胞的形态。结果对照组术前平均眼压（34．59±4．44）mmHg（1mmHg=0．133kPa）,术后第1、7、14、28、42、56天眼压分别为（11．31±2．76）mmHg、（19．20±5．17）mmHg、（21．17±4．36）mmHg、（22．22±1．39）mmHg、（23．90±1．97）mmHg、（23．67±1．73）mmHg。羊膜组术前平均眼压（34．38±4．20）mmHg,术后第1、7、14、28、42、56天眼压分别为（10．48±2．45）mmHg、（12．80±3．41）mmHg、（13．50±2．25）mmHg、（16．17±1．73）mmHg、（17．22±1．32）mmHg、（16．71±1．52）mmHg。结膜ECM组术前平均眼压（34．66±4．49）mmHg,术后第1、7、14、28、42、56天眼压分别为（10．94±2．75）mmHg、（11．29±2．40）mmHg、（13．93±3．55）mmHg、（15．63±3．54）mmHg、（15．70±2．44）mmHg、（15．12±3．65）mmHg。术后对照组与羊膜组和结膜ECM组眼压比较,差异有统计学意义（P〈0．01）;羊膜组与结膜ECM组眼压比较,差异无统计学意义（P〉0．05）。羊膜组、结膜ECM组术后第42、56天滤过泡轻微隆起并弥散,有较好的滤过功能。对照组术后第14、21天滤过泡区瘢痕形成,滤过功能差。组织学切片观察显示羊膜组、结膜ECM组滤过泡未形成瘢痕,成纤维细胞少,但有炎性细胞浸润。结论羊膜和结膜ECM能改善小梁切除术后滤过泡功能,减少瘢痕形成。     

Surgical outcomes of traditional limbal-based versus fornix-based trabeculectomy with corneal valve.

BACKGROUND AND OBJECTIVE: To compare the safety and efficacy of fornix-based trabeculectomy with corneal valve to traditional limbal-based trabeculectomy with mitomycin C (MMC) in eyes with open-angle glaucoma. PATIENTS AND METHODS: In this retrospective, nonrandomized, comparative study, 42 eyes that underwent limbal-based trabeculectomy with MMC were compared with 32 eyes with fornix-based trabeculectomy with corneal valve with MMC. Success was defined as final intraocular pressure (IOP) of at least 20% less than preoperative IOP and between 5 and 22 mm Hg. mean IOPs were 23.5 +/- 12.2 and 11.5 +/- 5.3 mm Hg, respectively, in the limbal-based group and 24.8 +/- 11.1 and 11.7 +/- 2.5 mm Hg, respectively, in the fornix-based group (P < .001 and P = .85, respectively). The fornix-based group had significantly less hypotony (3% vs. 21%, P < .05). CONCLUSIONS: Fornix-based corneal valve trabeculectomy with posterior placement of MMC sponges provides IOP control comparable to limbal-based traditional trabeculectomy, with decreased incidence of hypotony.     

Predictive value of early IOP in mitomycin-C augmented trabeculectomy

PURPOSE: To determine whether early intraocular pressure (IOP) after mitomycin-C (MMC) augmented trabeculectomy has any predictive value for intermediate IOP outcome. METHODS: Retrospective case note review. All cases of trabeculectomy using MMC augmentation and at least 1-year follow-up during the study period were included. Cases where a bleb leak occurred were excluded from the analysis. Only first eyes operated upon during the study period were included. Patient demographics and postoperative course were documented and analyzed. Early IOP measurements at day 1, day 7, and month 1 postoperatively were correlated to IOP at 1 year or final follow-up. RESULTS: One hundred nineteen trabeculectomies were identified. Of these 27 (22.7%) had an early bleb leak and were excluded. Further analysis was carried out on the remaining 92 cases. Mean age of cases was 70.8 years. Nine cases (9.8%) were repeat trabeculectomies. Mean follow-up time was 18.5 months (range 12 to 60 mo). Patients with a final IOP of < or =16 mm Hg (without drops or further surgery) (unqualified successes) had a mean day 1 IOP of 12.5 mm Hg compared with 17.4 mm Hg in those with an IOP more than 16 mm Hg at final follow-up (P=0.02). Patients with a final IOP of < or =16 mm Hg (with or without drops) (qualified successes) had mean day 1 IOP of 13.3 mm Hg compared with 17.1 mm Hg in those with an IOP of >16 mm Hg at final follow-up (P=0.06). At 1 month the mean IOPs were 10.7 mm Hg and 19.5 mm Hg, respectively (P<0.001). By logistic regression analysis at final recorded visit those cases in the lowest IOP quartile at 1 month were 14 times more likely to have an IOP < or =16 mm Hg without treatment than those in the highest quartile at 1 month. CONCLUSIONS: Our data suggests that a low early postoperative IOP measurement is a predictive factor for IOP value and success after intermediate length follow-up in patients undergoing trabeculectomy surgery augmented with MMC.     

Clinical outcomes of amniotic membrane loaded with 5-FU PLGA nanoparticles in experimental trabeculectomy

AIM: To evaluate the effect of amniotic membrane loaded with 5-fluorouracil poly (lactic-co-glycolic acid) (PLGA) nanoparticles (5-FU-NPs) in the surgical outcomes of experimental trabeculectomy in rabbits. METHODS: Thirty-two New Zealand white rabbits were randomly categorized into four groups with 8 rabbits in each group. Group 1, the control group, performed traditional trabeculectomy without adjuvant treatment. While the experimental groups performed compound trabeculectomy with different implantations including amniotic membrane (group 2), 5-FU-NPs (group 3) and amniotic membrane loaded with 5-FU-NPs (group 4). Clinical evaluations including IOP measurement and filtration bleb analysis were performed in all groups postoperatively. RESULTS: There is no significant difference of mean IOP in all groups at first 7d after surgery. While at P14, mean IOPs of experimental group 2 (9.8±2.1 mm Hg), groups 3 (8.9±2.8 mm Hg) and group 4 (7.6±2.3 mm Hg) were significantly reduced compared to control group (12.4±2.6 mm Hg; n=8, P<0.05). At P21, mean IOPs of groups 3 (11.7±3.2 mm Hg) and group 4 (9.9±1.6 mm Hg) were significantly decreased compare to control group (17.9±1.6 mm Hg) and group 2 (16.6±2.8 mm Hg; n=8, P<0.05). At P28, mean IOPs of groups 3 (13.8±3.3 mm Hg) and group 4 (10.6±2.0 mm Hg) were also significantly reduced compare to control group (19.4±2.3 mm Hg) and group 2 (18.5±2.4 mm Hg; n=8, P<0.05). Meanwhile mean IOP of group 4 is significantly decreased compared to group 3 at P28 (n=8, P<0.05). Survival analysis of functional filtration blub in all groups revealed the longest survival time in group 4 (24.9±5.1d) compared to that in group 3 (20.6±4.3d), group 2 (15.0±5.2d) and control group (10.1±5.7d). CONCLUSION: Amniotic membrane loaded with 5-Fu-NPs may function as an effective anti-scarring implant and provides improved long-term surgical outcomes for experimental trabeculectomy in rabbits.     

24-hour monitoring of intraocular pressure in glaucoma management: a retrospective review

PURPOSE: Diurnal variation in intraocular pressure (IOP) is well recognized, yet important decisions in glaucoma management are frequently made after 1 or 2 IOP measurements. Twenty-four-hour monitoring of IOP may identify IOP variation and spikes. This study determined the value of 24-hour IOP monitoring in routine clinical practice. METHODS: Data were acquired retrospectively from case notes of 29 glaucoma patients sequentially admitted for 24-hour IOP monitoring while taking their established antiglaucoma therapy. RESULTS: While there was no difference between the mean clinic (office) and mean 24-hour IOP measurements, the peak IOP during 24-hour monitoring was on average 4.9 mm Hg higher than the peak clinic IOP (P<0.0001). In 4 (13.8%) patients, the peak IOP over 24 hours was at least 12 mm Hg higher than the clinic peak. Peak IOP values occurred outside normal office hours in 51.7% of patients. Twenty-four-hour IOP monitoring resulted in a change of clinical management in 23 (79.3%) patients, including 13 (44.8%) who were offered trabeculectomy. CONCLUSION: Twenty-four-hour monitoring of IOP frequently led to a change of glaucoma management by identifying IOP fluctuations and spikes. High IOP and wide diurnal IOP variation are considered major risk factors for glaucoma progression, and standard clinic follow-up evaluations failed to identify these phenomena.     

Extent of asymmetry and unilaterality among juvenile onset primary open angle glaucoma patients

Background: Juvenile onset open angle glaucoma (JOAG) due to its rarity is not well characterized. We aimed to assess the extent of interocular asymmetry of baseline intraocular pressure (IOP), disc morphometry and visual field defects at presentation in patients with primary JOAG. Design: Retrospective, single‐centre, hospital‐based study. Participants: Fifty‐two consecutive JOAG patients who presented with glaucomatous optic neuropathy in at least one eye, without any secondary causes of glaucoma. Methods: Participants were evaluated for baseline clinical features. The optic disc parameters were measured using scanning laser ophthalmoscopy (Heidelberg Retina Tomograph). Reliable and reproducible visual field tests using standard 30‐2 Humphrey automated perimetry were analysed. Main Outcome Measures: Interocular asymmetry of baseline IOP, vertical cup:disc ratio and mean deviation. Results: Fourteen patients (27%) had glaucomatous optic neuropathy in only one eye at initial presentation; the fellow eyes of which had IOP <21 mmHg in eight whereas six had IOP >21 mmHg. In 20 out of 52 patients (39%) one eye remained perimetrically unaffected. Patients presenting with bilateral optic neuropathy were found to be significantly younger (24.4 ± 10.6 years) in age compared to those with unilateral optic neuropathy (32 ± 8.2 years) (P = 0.02). Conclusions: One‐fourth of primary JOAG patients present as a unilateral optic neuropathy with 60% of these having normal IOP in the fellow eyes. Primary JOAG may present with considerable asymmetry with a small proportion presenting as a unilateral disease.