C. Sangermani

Comparison of Travoprost and Bimatoprost plus Timolol Fixed Combinations in Open-Angle Glaucoma Patients Previously Treated with Latanoprost plus Timolol Fixed Combination

PURPOSE To compare the ocular hypotensive effect of bimatoprost plus timolol and travoprost plus timolol fixed combinations in glaucoma patients whose disease was controlled but had not reached their target intraocular pressure (IOP) with the fixed combination of latanoprost plus timolol. DESIGN A 2 × 3-month, multicenter, prospective, randomized, double-masked, cross-over clinical trial. METHODS Eighty-nine open-angle glaucoma (OAG) patients were included. After a 6-week run-in period with latanoprost plus timolol, patients were randomized to either travoprost plus timolol or bimatoprost plus timolol for 3 months. Patients then switched to the opposite therapy for 3 additional months. The primary end point was the comparison of mean daily IOP after 3 months of each treatment. RESULTS At baseline, mean IOP was 16.5 mm Hg (95% confidence interval, 16.0 to 17.0 mm Hg) with treatment with latanoprost plus timolol. Both bimatoprost plus timolol and travoprost plus timolol statistically significantly reduced the mean IOP from baseline (P < .0001). Mean IOP at month 3 was statistically significantly lower in the bimatoprost plus timolol group compared with the travoprost plus timolol group (14.7 mm Hg [95% confidence interval, 14.3 to 15.3 mm Hg] vs 15.4 mm Hg [95% confidence interval, 15.0 to 15.9 mm Hg]; P = .0041). IOP was lower during bimatoprost plus timolol treatment at all time points and statistical significance was reached at 8 am, 11 am, and 5 pm, but not at 2 pm and 8 pm. Both treatments showed similar tolerability profile. CONCLUSIONS Bimatoprost plus timolol and travoprost plus timolol can provide additional IOP-lowering effect in patients not fully controlled with latanoprost plus timolol. The observed additional IOP reduction was greater with bimatoprost plus timolol with a similar tolerability profile.

Long-term perimetric fluctuation in patients with different stages of glaucoma

Aim To evaluate the long-term perimetric fluctuation (LF) in patients with different stages of glaucoma according to the Glaucoma Staging System 2 (GSS2). Methods This multicentre retrospective study included 161 eyes of 161 stable glaucoma patients undergoing four visual-field tests (Humphrey SITA-Standard program over the central 24° or 30°) over a 2-year period. For each patient, the stage of the disease was classified according to GSS2. LF was then calculated as the mean of the standard deviations of point-to-point threshold sensitivities in the four repetitions. LF in GSS2 stages was compared using the t test. Results LF progressively increased from stage 0 to stage 4, and then decreased at stage 5. Stage 4 had a peak of 3.19±0.94 dB, with statistically significant differences compared with all the other stages. The lowest LF (1.65±0.60 dB) was found for normal subjects, whereas similar data were found for borderline patients and those at stages 1 and 5 (2.09±0.58, 2.13±0.57 and 2.22±0.89 dB, respectively; p>0.13). Visual fields with generalised defects had a lower LF (1.90±0.81) than those with mixed (2.84±0.87, p=0.0003) and localised (2.63±0.72, p=0.004) defects. Conclusions In this study, the authors showed that the lower the visual-field defect, the lower was LF, except at stage 5 of GSS2. As test–retest changes exceeding LF could represent a sign of progression, the authors suggest that clinicians using this classification system calculate LF, in order to better differentiate true progression from variability.

Ultrasound biomicroscopy and iris pigment dispersion: a case―control study

Background/aims The study involved eyes affected by pigment dispersion syndrome (PDS) or pigmentary glaucoma (PG) investigated by ultrasound biomicroscopy (UBM). Different irido-corneal parameters were assessed and compared with those from healthy controls. The aim was to investigate the capacity of the UBM in differentiating the cases and, potentially, in confirming the pathogenic mechanisms. Methods Patients with a first diagnosis of PDS or PG were included. A cohort of healthy volunteers matched for sex, age and refractive errors was recruited. All underwent UBM examination: the following parameters were assessed in relaxed and stimulated accommodative state in one eye: iris–lens contact (ILC), irido-corneal angle (ICA) and iris concavity (IC). A receiver operating characteristic (ROC) analysis assessed the ability of UBM to discriminate between subjects with and without PDS/PG. Results There were 24 eyes in the case group: four diagnosed as PG and the remaining 20 as PDS. There were 25 eyes in the control group. The two groups were statistically superimposable except for baseline intraocular pressure, which was higher in the case group (p=0.0001). All UBM parameters were statistically different between the two groups. ICA in near vision was the best-performing parameter, reaching a sensitivity (=specificity) of 0.875 with a cut-off at 53.0°. The second most sensitive parameter was IC, still in near vision. Conclusion All UBM parameters examined were statistically different between the two groups. ROC analysis showed ICA and IC in near vision to be the most discriminatory parameters. This evidence confirms the importance of iris movements in inducing the particular features of PDS/PG.

Ultrasound biomicroscopy in two cases of ocular siderosis with secondary glaucoma.

Editor, S iderosis bulbi is a disease caused by a retained intraocular ironcontaining foreign body (IOFB). A history of ocular trauma combined with heterochromia, mydriasis, pigmentation of the anterior chamber structures and a reduced electroretinographic response all provide an inkling of the diagnosis (Sneed & Weingeist 1990). Affected eyes can often present with a severe increase in intraocular pressure (IOP) (Talamo et al. 1985). A precise radiological and ⁄or echographic localization of the IOFB, ideally supported by histological analysis of a biological sample, are vital to the confirmation of the disease. This article describes two cases of secondary glaucoma caused by the retention of an IOFB. An ultrasound biomicroscopy (UBM) examination (UBM Model P40; Paradigm Medical Industries Inc. Salt Lake City, UT, USA) was performed in both patients and the findings are discussed below. Patient 1: An 11-year-old boy received a fragment of a bullet in his left eye. The sclera was promptly sutured but a small IOFB was overlooked. Two months later, the injured eye presented traumatic cataract with uveitis. On gonioscopy, the irido-corneal angle showed conspicuous rustbrown pigmentation in the trabecular meshwork (TM) and the IOP was 30 mmHg on average. Computed tomography showed the presence of a piece of iron in the nasal ora serrata (about 2 mm in length), which was removed surgically via pars-plana vitrectomy with polydimethylsiloxane (PDMS) tamponade and phacoemulsification of the lens. PDMS was removed uneventfully after 1 month. However, after one more month, trabeculectomy with mytomycine-C application was necessary to achieve satisfactory control over IOP. The preoperative UBM showed an unusually high reflectivity in the deep angular stroma compared to the regular echographic pattern of the fellow eye (Fig. 1A–D). Histological examination of a TM sample, taken during a subsequent surgical revision of the filtering bleb, confirmed the diagnosis of ocular siderosis. Patient 2: A 27-year-old man suffered an injury to his left eye while he was hammering metal. The IOFB, initially misdiagnosed, was found in the superior ora serrata during a parsplana vitrectomy with phacoemulsification of the lens performed 3 months after the trauma. On gonioscopy, the TM pigmentation was much more brown and dense than in the right (healthy) eye. After four more months, filtering surgery became necessary to control the IOP increase. The histological evaluation of a sample of iris and TM was positive for iron staining and showed alterations compatible with siderosis bulbi. The preoperative UBM findings were remarkably similar to those obtained in the patient described previously. The aetiopathogenesis of secondary open-angle glaucoma related to ocular siderosis has often been ascribed to trabecular fibrosclerosis, probably because of the direct toxic effect of iron ions (Appel & Barishak 1978). In the first presented case, severe glaucoma developed 2 months after the trauma with the metal foreign body still in the eye. In the second case it appeared approximately 7 months later, with an initial 3-month retention of the IOFB. IOP elevation did not resolve in either patient after IOFB removal.