How are glaucoma patients identified?

PURPOSE: To determine the events that lead to the diagnosis of glaucoma. PATIENTS AND METHODS: This prospective study administered a questionnaire to consecutive patients in a university glaucoma service with questions about the visit at which their glaucoma was diagnosed. RESULTS: Among 308 patients (85% of those eligible) with glaucoma and those suspected of having glaucoma, more than half were diagnosed at a routine examination with no ocular symptom. One hundred fourteen of 202 (56%) of those patients were diagnosed with open angle glaucoma (OAG). Symptoms present at the diagnostic visit were infrequently related to glaucoma. Sixty-one percent of OAG patients (124 of 202) recalled elevated intraocular pressure (IOP) as the sole reason for their initial diagnosis; an additional 12% (24 of 202) recalled a combination of IOP with either disc or visual field findings. Only 18% (36 of 202) recalled being diagnosed due to disc or visual field damage alone. CONCLUSION: The detection of glaucoma is strongly associated with IOP measurement. Glaucoma is most frequently diagnosed at routine visits to eye care specialists at which patients either have no symptoms or have symptoms unrelated to glaucoma. Questionnaire information on large numbers of persons in the health care system may add to our knowledge of practice patterns.     

When should glaucoma be surgically treated?

The medical treatment of primary open angle glaucoma has progressively become more and more efficient and safe, and surgery is therefore mostly restricted to failure of and intolerance to antiglaucoma eyedrops. Glaucoma surgery may thus cause severe complications and a high risk of failure has tempered its prognostic. Nevertheless, when efficacious, glaucoma surgery definitively resolves two major pitfalls of medical treatment: patient compliance and eyedrops tolerance. Moreover, new surgical developments of surgery have come from the new technique of non-penetrating deep sclerectomy, which is actually an external trabeculectomy involving removal of the area of maximal resistance to aqueous outflow. This procedure has a very low risk of complications, much lower than that of standard trabeculectomy, but its efficacy is still controversial. Whatever the technique chosen for filtering surgery, antimetabolites may be used in order to limit the risk of postoperative fibrosis, but they also expose to specific, sometimes sight-threatening, complications. Therefore, the most important--and also the most difficult--choice for treating glaucoma patients still remains the best timing for surgery, either excessive, useless, and aggressive medical treatment, or systematic primary surgery.     

Orbital fat atrophy in glaucoma patients treated with topical bimatoprost--can bimatoprost cause enophthalmos?

PURPOSE: The aim of this communication is to report enophthalmos as a possible new adverse effect of topical bimatoprost treatment. PATIENTS AND METHODS: A retrospective case series of five glaucoma patients under long-term topical bimatoprost treatment was evaluated. Documentation with photo and Hertel exophthalmometry was reviewed. RESULTS: In all five patients a deep lid sulcus, reduced infraocular fat pads and enophthalmos-suspicious Hertel values were found (mean 11.9 mm; SD 2.4). Other aetiologies for enophthalmos were excluded anamnestically and by clinical examination. CONCLUSION: Bimatoprost may lead to an alteration of the eyelid with deepening of the lid sulcus and may also be responsible for an iatrogenic orbital fat atrophy. A possible mechanism of action might be the induction of apoptosis of orbital fibroblasts with a remodelling of the extracellular matrix. Prospective studies are necessary to confirm this cross-sectional observation.     

Phacolytic glaucoma: are there 2 forms?

We report a case of acute phacolytic glaucoma in which only protein was present in the anterior chamber without macrophages. We propose that this study represents a type of phacolytic glaucoma characterized by a hyperacute presentation caused by rapid leakage of degenerated lens proteins into the aqueous humor as opposed to a second type with a more gradual onset and with phacolytic macrophages in the aqueous humor resulting from an immunologic response to liquefied lens proteins. Thus, 2 forms, perhaps at ends of a spectrum of clinical manifestations of phacolytic glaucoma, may exist with distinct characteristics and pathophysiology.     

Which factors are associated with quality of life in patients with Graves' orbitopathy presenting for orbital decompression surgery?

Purpose

Graves'' orbitopathy (GO) is associated with changes in the appearance of the eyes and visual dysfunction. Patients report feeling socially isolated and unable to continue with day-to-day activities. This study aimed at investigating the demographic, clinical, and psychosocial factors associated with quality of life in patients presenting for orbital decompression surgery.

Methods

One-hundred and twenty-three adults with GO due for orbital decompression at Moorfields Eye Hospital London were recruited prospectively. Clinical measures including treatment history, exophthalmos, optic neuropathy, and diplopia were taken by an ophthalmologist. Participants completed psychosocial questionnaires, including the Graves'' Ophthalmopathy Quality of Life Scale (GO-QOL), the Hospital Anxiety and Depression Scale, and the Derriford Appearance Scale. Hierarchical multiple regression analyses were used to identify predictors of quality of life.

Results

Higher levels of potential cases of clinical anxiety (37%) and depression (26%) were found in this study sample than in patients with other chronic diseases or facial disfigurements. A total of 55% of the variance in GO-QOL visual function scores was explained by the regression model; age, asymmetrical GO and depressed mood were significant unique contributors. In all, 75% of the variance in GO-QOL appearance scores was explained by the regression model; gender, appearance-related cognitions and depressed mood were significant unique contributors.

Conclusion

Appearance-related quality of life and mood were particularly affected in this sample. Predominantly psychosocial characteristics were associated with quality of life. It is important when planning surgery for patients that clinicians be aware of factors that could potentially influence outcomes.     

Screening for primary open-angle glaucoma in the developed world: are we there yet?

BACKGROUND: In 1995, the Quebec Agency for Health Services and Technology Assessment (AETMIS) stated that a formal screening program for primary open-angle glaucoma (POAG) could not be recommended for the province of Quebec, owing to "a high degree of uncertainty and because of the high cost such a program would entail." The purpose of this article was to evaluate the possibility of instituting a POAG screening program in light of recent advances in the diagnosis and treatment of glaucoma. METHODS: We reviewed new developments that have occurred since the mid to late 1990s in the field of glaucoma. Changes that could positively influence the feasibility and organization of future glaucoma screening programs were identified. RESULTS: New technologies, including confocal scanning laser ophthalmoscopy (HRT II), optical coherence tomography (Stratus OCT), and scanning laser polarimetry with variable corneal compensation (GDx-VCC), permit early detection of optic nerve and nerve fibre layer structural damage. Together with advanced psychophysical tests (frequency doubling perimetry and short wavelength automated perimetry) for earlier detection of functional damage, they provide an increased understanding of the diagnosis and monitoring of POAG. Elevated intraocular pressure (IOP) remains the most important risk factor for glaucoma. Clinical trials indicate that lowering IOP at different stages of the disease can arrest or decrease its rate of progression. Moreover, it is important to assess pachymetry because IOP measurements are influenced by central corneal thickness. Finally, new treatments, such as prostaglandin analogues or selective laser trabeculoplasty, are safer and may also achieve lower intraocular pressures. INTERPRETATION: Health policy involves the investment of public resources, and cost-effectiveness analyses for POAG screening are heavily weighted by the degree of uncertainty that glaucoma screening can be effectively and reliably achieved. The many new developments and advancements outlined herein, combined with the possible increasing prevalence of POAG, necessitate the re-evaluation of screening for primary open-angle glaucoma.