Anjali M. Bhorade

Variability of Intraocular Pressure Measurements in Observation Participants in the Ocular Hypertension Treatment Study

PURPOSE To describe variability of intraocular pressure (IOP) measurements within the same eye and between right and left eyes over a 60-month period in participants in the Ocular Hypertension Treatment Study. DESIGN Analysis of data from a prospective, randomized clinical trial. PARTICIPANTS Eight hundred ten participants randomized to the observation group. METHODS Intraocular pressure measurements were obtained at the baseline visit and every 6 months thereafter. Pearson correlation coefficients were calculated for IOP measurements in the same eye between visits and for IOP measurements between right and left eyes of participants at each visit. Differences in IOP measurements between visits are reported in percent change (>15%, >20%, and >30%) and in millimeters of mercury (<3 mmHg, 3-5 mmHg, and >5 mmHg). The effects of regression to the mean, consistency in time of day, and sequence of IOP measurement of right and left eyes were examined. MAIN OUTCOME MEASURES Correlation of IOP measurements between consecutive 6-month visits. RESULTS The correlation of IOP measurements within the same eye between consecutive visits was r = 0.62, whereas the correlation of IOP measurements between right and left eyes at the same visit was r = 0.72. Thirteen percent of eyes had >20% change in IOP between consecutive visits. Sixty-six percent of eyes had a change in IOP within 3 mmHg, and 10% of eyes had a change in IOP >5 mmHg between visits. Eyes with a higher baseline IOP had a lower IOP at 6 months. There was a stronger correlation of IOP measured within 2 hours of the time of day between visits (r = 0.56) than >2 hours apart (r = 0.39). IOP of the right eye, which was measured first, was 0.3+/-2.8 mmHg higher than the left eye. CONCLUSIONS The variability of IOP measurements in the same eye between consecutive visits is moderate and is greater than the variability of IOP measurements between right and left eyes at the same visit. Factors affecting the variability of IOP measurement include regression to the mean, time of day, and measurement order. Knowledge of variability in IOP and its measurements may help clinicians establish a more accurate baseline IOP, target IOP, and assessment of medication effect.

Repeated Intravitreous Ranibizumab Injections for Diabetic Macular Edema and the Risk of Sustained Elevation of Intraocular Pressure or the Need for Ocular Hypotensive Treatment

IMPORTANCE For the management of retinal disease, the use of intravitreous injections of anti-vascular endothelial growth factor has increased. Recent reports have suggested that this therapy may cause sustained elevation of intraocular pressure (IOP) and may potentially increase the risk of glaucoma for patients with retinal disease. OBJECTIVE To assess the risk of sustained IOP elevation or the need for IOP-lowering treatments for eyes with diabetic macular edema following repeated intravitreous injections of ranibizumab. DESIGN, SETTING, AND PARTICIPANTS An exploratory analysis was conducted within a Diabetic Retinopathy Clinical Research Network randomized clinical trial. Study enrollment dates were from March 20, 2007, to December 17, 2008. Of 582 eyes (of 486 participants) with center-involved diabetic macular edema and no preexisting open-angle glaucoma, 260 were randomly assigned to receive a sham injection plus focal/grid laser treatment, and 322 were randomly assigned to receive ranibizumab plus deferred or prompt focal/grid laser treatment. MAIN OUTCOMES AND MEASURES The cumulative probability of sustained IOP elevation, defined as IOP of at least 22 mm Hg and an increase of at least 6 mm Hg from baseline at 2 consecutive visits, or the initiation or augmentation of ocular hypotensive therapy, through 3 years of follow-up. RESULTS The mean (SD) baseline IOP in both treatment groups was 16 (3) mm Hg (range, 5-24 mm Hg). The cumulative probability of sustained IOP elevation or of initiation or augmentation of ocular hypotensive therapy by 3 years, after repeated ranibizumab injections, was 9.5% for the participants who received ranibizumab plus prompt or deferred focal/grid laser treatment vs 3.4% for the participants who received a sham injection plus focal/grid laser treatment (difference, 6.1% [99% CI, -0.2% to 12.3%]; hazard ratio, 2.9 [99% CI, 1.0-7.9]; P = .01). The distribution of IOP and the change in IOP from baseline at each visit through 3 years were similar in each group. CONCLUSIONS AND RELEVANCE In eyes with center-involved diabetic macular edema and no prior open-angle glaucoma, repeated intravitreous injections of ranibizumab may increase the risk of sustained IOP elevation or the need for ocular hypotensive treatment. Clinicians should be aware of this risk and should consider this information when following up with patients who have received intravitreous injections of anti-vascular endothelial growth factor for the treatment of diabetic macular edema.

Home Lighting Assessment for Clients With Low Vision

OBJECTIVE The goal was to develop an objective, comprehensive, near-task home lighting assessment for older adults with low vision. METHOD A home lighting assessment was developed and tested with older adults with low vision. Interrater and test-retest reliability studies were conducted. Clinical utility was assessed by occupational therapists with expertise in low vision rehabilitation. RESULTS Interrater reliability was high (intraclass correlation coefficient [ICC] = .83-1.0). Test-retest reliability was moderate (ICC = .67). Responses to a Clinical Utility Feedback Form developed for this study indicated that the Home Environment Lighting Assessment (HELA) has strong clinical utility. CONCLUSION The HELA provides a structured tool to describe the quantitative and qualitative aspects of home lighting environments where near tasks are performed and can be used to plan lighting interventions. The HELA has the potential to affect assessment and intervention practices of rehabilitation professionals in the area of low vision and improve near-task performance of people with low vision.

Differences in Vision Between Clinic and Home and the Effect of Lighting in Older Adults With and Without Glaucoma

IMPORTANCE Patients often report greater visual difficulties at home than expected from vision testing in the clinic. Such discordance may be owing to worse vision in the home than measured in clinic. OBJECTIVE To compare vision measured between the clinic and home and evaluate factors, including lighting, associated with these differences. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study conducted from 2005-2009 involved 126 patients with glaucoma and 49 without glaucoma recruited from the Glaucoma and Comprehensive Eye Clinics at Washington University, St Louis, Missouri. Patients underwent clinic and home visits, were aged 55 to 90 years, were consecutively recruited, and met inclusion criteria for this study. A total of 166 eligible patients refused participation. EXPOSURE Participants underwent clinic and home visits randomized to order of completion. At each visit, masked and certified examiners measured binocular distance visual acuity (DVA) with a nonbacklit chart, near visual acuity (NVA), contrast sensitivity (CS), CS with glare, and lighting. MAIN OUTCOMES AND MEASURES Differences in vision between the clinic and home. RESULTS The mean scores for all vision tests were significantly better in the clinic than home for participants with and without glaucoma (P < .05, matched-pair t tests). For DVA, 29% of participants with glaucoma read 2 or more lines better in the clinic than home and 39% with advanced glaucoma read 3 or more lines better. For the entire sample, 21% of participants read 2 or more lines better in the clinic than home for NVA and 49% read 2 or more triplets better in the clinic for CS with glare. Lighting was the most significant factor associated with differences in vision between the clinic and home for DVA, NVA, and CS with glare testing (P < .05, multiple regression model). Median home lighting was 4.3 times and 2.8 times lower than clinic lighting in areas tested for DVA and NVA, respectively. Home lighting was below that recommended in 85% or greater of participants. CONCLUSIONS AND RELEVANCE Vision measured in the clinic is generally better than vision measured at home, with differences mainly owing to poor home lighting. Knowledge that vision discrepancies between patient report and clinical testing may be owing to home lighting may initiate clinician-patient discussions to optimize home lighting and improve the vision of older adults in their homes.

Effect of endoscopic cyclophotocoagulation on refractive outcomes when combined with cataract surgery

OBJECTIVE To determine the difference between predicted and actual refractive outcomes after combined endoscopic cyclophotocoagulation and cataract surgery (phaco-ECP) in patients with open-angle glaucoma (OAG). DESIGN Retrospective case-control study of patients with OAG who underwent phaco-ECP compared with cataract surgery alone. PARTICIPANTS Eighty-three patients with OAG, aged 55 to 91 years, who underwent a combined phaco-ECP procedure and 58 biometry- and age-matched control patients with OAG who underwent cataract surgery alone. METHODS Patient records were retrospectively reviewed at the Department of Ophthalmology and Visual Sciences, Washington University School of Medicine in St. Louis (St. Louis, Mo.). The primary outcome was the difference in predicted and actual refractive outcomes in patients undergoing either phaco-ECP or standard cataract surgery. RESULTS Compared with phaco alone, the difference in predicted versus actual postoperative results was more myopic in the phaco-ECP group (0.029, -0.110, and -0.095 vs -0.169, -0.325, and -0.312 [p < 0.05] for Sanders, Retzlaff, Kraff/Theoretical, Hoffer Q, and Holladay, respectively). Moreover, the F test for variability showed significantly more variability in refractive outcomes in the phaco-ECP group compared with standard cataract surgery. CONCLUSIONS Patients undergoing phaco-ECP may have postoperative refractive errors that may vary from that predicted preoperatively more so than in cataract surgery alone. Surgeons may consider analyzing their results to determine whether any adjustment should be made to lens power selection when performing phaco-ECP.

Non-Invasive Couching Technique to Treat a Morgagnian Cataract Causing Bullous Keratopathy

A case is described in which a non-invasive couching technique was used to relieve bullous keratopathy caused by a dislocated Morgagnian cataract. This technique involved applying digital pressure to the inferior cornea to push the dislocated nucleus through the pupil and into the posterior segment. This technique may be useful in cases where relief or prevention of eye pain is the primary goal.

Diagnosis and Monitoring of Low-Tension Glaucoma

PurposeThe purpose of this review is to discuss current ideas on the definition, pathophysiology, diagnosis, and management of low-tension glaucoma (LTG).Recent FindingsWhile previously considered a distinct entity, LTG may be a continuation of primary open angle glaucoma with intraocular pressures (IOPs) within the statistical range of “normal”. Vascular dynamics, sleep apnea, and intracranial pressure may play a role in patients with LTG.SummaryLTG remains a diagnosis of exclusion. A thorough medical history and possible blood work-up and neuroimaging may help exclude nutritional deficiencies, toxicities, and intracranial masses. Vasculature dysregulation may play a role in LTG and account for its association with certain systemic conditions. IOP lowering remains the mainstay treatment of LTG, with caution advised for topical beta-blocker medications. Non-IOP-lowering therapy, such as treating underlying systemic conditions potentially affecting ocular blood flow (e.g. hypotension, anemia, sleep apnea) and nutritional supplements (Ginkgo biloba and resveratrol), may be beneficial and are currently being studied.