Camila Zangalli

Evaluation of Risk Factors for Glaucoma Drainage Device-related Erosions: A Retrospective Case-Control Study.

Purpose:To identify risk factors for glaucoma drainage device (GDD) erosions. Patients and Methods:In a retrospective comparative case series, medical records of 1013 patients who underwent GDD surgery performed by 5 surgeons between 2006 and 2011 were reviewed. The outcome measures assessed included age, race, sex, contact lens wear, seasonal allergies, medical comorbidities, glaucoma diagnosis, preoperative oral and topical medications, type and number of preoperative surgeries and lasers, concomitant surgeries, tube type and position, patch graft material, and intraoperative use of Avastin, mitomycin-C, or Triescence. The association of variables with erosion status was evaluated using the Fisher exact test for categorical variables and the exact Wilcoxon rank-sum test for continuous variables. Results:Charts were included from 339 eyes that had complete data sets and at least 6 months of follow-up. Twenty-eight eyes (8.3%) developed conjunctival erosions. The median follow-up time was 2.03 years for the erosion group and 1.71 years for nonerosion group. Erosion was only associated with the presence of concomitant surgical procedures at the time of GDD implantation (35.7% erosion group vs. 17.4% nonerosion group, P=0.02, OR=2.64). The majority of concomitant surgeries were composed of pars plana vitrectomy (35.0%) and cataract surgery (32.0%). Variables that were suggestive of association with erosion (P<0.20) included smoking (OR=2.14), pseudoexfoliation glaucoma (OR=2.71), and history of dry eye syndrome (OR=2.22). Conclusion:History of concomitant intraocular surgery with GDD implantation may be a potential risk factor for future erosions.

What do patients with glaucoma see? Visual symptoms reported by patients with glaucoma.

Background:Vision loss from glaucoma has traditionally been described as loss of “peripheral vision.” In this prospective study, we aimed to improve our clinical understanding of the visual symptoms caused by glaucoma by asking patients specific detailed questions about how they see. Methods:Patients who were clinically diagnosed with various types and stages of glaucoma were included. All had a comprehensive ocular examination, including Octopus visual field testing. Patients were excluded if they had other ocular conditions that affected their vision, including cornea, lens or retina pathologies. Patients responded to an oral questionnaire about their visual symptoms. We investigated the visual symptoms described by patients with glaucoma and correlated the severity of visual field loss with visual symptoms reported. Results:Ninety-nine patients completed the questionnaire. Most patients (76%) were diagnosed with primary open-angle glaucoma. The most common symptoms reported by all patients, including patients with early or moderate glaucoma, were needing more light and blurry vision. Patients with a greater amount of field loss (Octopus mean defect >+9.4 dB) were more likely to report difficulty seeing objects to one or both sides, as if looking through dirty glasses and trouble differentiating boundaries and colors. Conclusions:Vision loss in patients with glaucoma is not as simple as the traditional view of loss of peripheral vision. Needing more light and blurry vision were the most common symptoms reported by patients with glaucoma.

EVALUATING CONTRAST SENSITIVITY IN AGE-RELATED MACULAR DEGENERATION USING A NOVEL COMPUTER-BASED TEST, THE SPAETH/RICHMAN CONTRAST SENSITIVITY TEST.

Background: Contrast sensitivity (CS) is a valuable measure of visual function in patients with age-related macular degeneration (AMD). The authors aimed to compare a novel computer-based test (the Spaeth/Richman Contrast Sensitivity test) with Pelli–Robson test for evaluating CS in patients with AMD. Methods: In this prospective cross-sectional study, CS was evaluated in patients with various stages of AMD and healthy controls using Spaeth/Richman Contrast Sensitivity test and Pelli–Robson test. Spaeth/Richman Contrast Sensitivity test determined CS scores for 5 areas of vision for each eye (central, superonasal, superotemporal, inferonasal, and inferotemporal) and the total score. Test scores between the two methods were compared using mixed-effects linear regression. Spearmans rank correlation coefficient was used to determine correlations. Test–retest reliability was determined using the intraclass correlation coefficient. Results: Of 35 participants with AMD (54 eyes) and 34 controls (66 eyes), 51% were female and 93% were of European descent. The mean Spaeth/Richman Contrast Sensitivity test score for the central area and each of the 4 peripheral quadrants was significantly lower for patients with AMD versus controls (P < 0.001 for all). The mean Pelli–Robson score was also significantly lower in patients with AMD versus controls (P < 0.001). The intraclass correlation coefficient for Spaeth/Richman Contrast Sensitivity test total score and Pelli–Robson score was 0.87 and 0.92, respectively. Conclusion: Spaeth/Richman Contrast Sensitivity test, a novel Internet-based method of testing CS, had significantly lower scores for patients with AMD compared with controls for central and peripheral vision. This test is a valuable tool for assessing CS in AMD.

Comparing Gonioscopy With Visante and Cirrus Optical Coherence Tomography for Anterior Chamber Angle Assessment in Glaucoma Patients.

Purpose:The aim of this study was to compare gonioscopy with Visante and Cirrus optical coherence tomography (OCT) for identifying angle structures and the presence of angle closure in patients with glaucoma. A secondary objective was to assess interrater agreement for gonioscopy grading among 3 independent examiners. Methods:Gonioscopy grading using Spaeth Classification and determination of angle-closure risk was performed on 1 randomly selected eye for 50 phakic patients. Images of the same eye using both Visante and Cirrus OCT were obtained in both light and dark conditions. Agreement of angle closure among 3 devices and interrater agreement for gonioscopy were determined using Cohen’s &kgr; (K) or Kendall’s coefficient of concordance (W). Results:Of the 50 patients, 60% were female, 64% were white, and the mean age was 62 years. Angle closure was detected in 18%, 16%, and 48% of quadrants with Visante, Cirrus, and gonioscopy, respectively. The scleral spur was identified in 56% and 50% of quadrants with Visante and Cirrus OCT, respectively. Visante and Cirrus OCT showed moderate agreement in detecting angle closure (K=0.42 light, K=0.53 dark) but slight-to-fair agreement with gonioscopy (Visante K=0.25, Cirrus K=0.15). Gonioscopy demonstrated substantial agreement in angle closure (K=0.65 to 0.68) and angle-closure risk assessment (W=0.83) among 3 examiners. Conclusions:Visante and Cirrus OCT imaging may have limited ability to identify angle closure because of difficulty identifying angle structures. Gonioscopy by well-trained clinicians had remarkably consistent agreement for identifying angle-closure risk.PURPOSE The aim of this study was to compare gonioscopy with Visante and Cirrus optical coherence tomography (OCT) for identifying angle structures and the presence of angle closure in patients with glaucoma. A secondary objective was to assess interrater agreement for gonioscopy grading among 3 independent examiners. METHODS Gonioscopy grading using Spaeth Classification and determination of angle-closure risk was performed on 1 randomly selected eye for 50 phakic patients. Images of the same eye using both Visante and Cirrus OCT were obtained in both light and dark conditions. Agreement of angle closure among 3 devices and interrater agreement for gonioscopy were determined using Cohens κ (K) or Kendalls coefficient of concordance (W). RESULTS Of the 50 patients, 60% were female, 64% were white, and the mean age was 62 years. Angle closure was detected in 18%, 16%, and 48% of quadrants with Visante, Cirrus, and gonioscopy, respectively. The scleral spur was identified in 56% and 50% of quadrants with Visante and Cirrus OCT, respectively. Visante and Cirrus OCT showed moderate agreement in detecting angle closure (K=0.42 light, K=0.53 dark) but slight-to-fair agreement with gonioscopy (Visante K=0.25, Cirrus K=0.15). Gonioscopy demonstrated substantial agreement in angle closure (K=0.65 to 0.68) and angle-closure risk assessment (W=0.83) among 3 examiners. CONCLUSIONS Visante and Cirrus OCT imaging may have limited ability to identify angle closure because of difficulty identifying angle structures. Gonioscopy by well-trained clinicians had remarkably consistent agreement for identifying angle-closure risk.

The Spaeth/Richman contrast sensitivity test (SPARCS): design, reproducibility and ability to identify patients with glaucoma

Aims (1) To determine the ability of a novel, internet-based contrast sensitivity test titled the Spaeth/Richman Contrast Sensitivity Test (SPARCS) to identify patients with glaucoma. (2) To determine the test-retest reliability of SPARCS. Methods A prospective, cross-sectional study of patients with glaucoma and controls was performed. Subjects were assessed by SPARCS and the Pelli-Robson chart. Reliability of each test was assessed by the intraclass correlation coefficient and the coefficient of repeatability. Sensitivity and specificity for identifying glaucoma was also evaluated. Results The intraclass correlation coefficient for SPARCS was 0.97 and 0.98 for Pelli-Robson. The coefficient of repeatability for SPARCS was ±6.7% and ±6.4% for Pelli-Robson. SPARCS identified patients with glaucoma with 79% sensitivity and 93% specificity. Conclusions SPARCS has high test-retest reliability. It is easily accessible via the internet and identifies patients with glaucoma well. Trial Registration: NCT01300949.

The disc as the basis of treatment for glaucoma

The goal of the treatment of patients with glaucoma is to prevent disability or, if disability already exists, to repair the disability or at the least to prevent further disability from developing. To achieve these goals requires knowing what will happen if there is no treatment and what will happen if there is treatment. That is, one must know the possible benefits from the therapy in comparison to the damage caused by the therapy. As we will demonstrate, the classic risk factors do not provide accurate estimates of the development of disability and do not answer these two questions. The most helpful clues are provided by what the patient says, by whether the disc is damaged and by whether the disc is deteriorating. The severity of disease is best estimated by the nature of the optic disc and how it changes. This report is primarily focused on increasing the skill of the physician in being able to estimate the nature of the optic disc and how that changes. This does not, however, lessen the tremendous importance of careful history-taking and of gonioscopy. In this report, however, we focus on the evaluation of the disc. Currently disc evaluation is often not adequate because of poor examination techniques, reliance on cup/disc ratios, and reliance on the results of image analyzers. We will present here the Disc Damage Likelihood Scale, which is a user-friendly method which correlates accurately with visual field changes.

An Education- and Telephone-Based Intervention to Improve Follow-up to Vision Care in Patients With Diabetes A Prospective, Single-Blinded, Randomized Trial

The aim was to evaluate the effectiveness of a multipronged intervention on diabetic dilated fundus examination (DFE) adherence. In a prospective trial, 521 patients with diabetes who were due for follow-up DFEs were randomized to usual care or the intervention group. Usual care received a form letter reminder to schedule and an automated reminder phone call prior to their appointment. Intervention participants received an educational brochure about diabetic eye disease and a personalized letter reminder to schedule. A research assistant called intervention participants to help schedule the appointment, and they received a reminder letter and an automated phone call prior to the scheduled visit. Patients in the intervention group were significantly more likely to schedule (63% vs 40%; P < .0001) and complete their appointment (48% vs 30%; P < .0001) compared with usual care. A multipronged intervention, including an educational mailing and telephone assistance with scheduling an appointment, significantly improved diabetic DFE adherence.

Long-term outcomes in patients initially responsive to selective laser trabeculoplasty

AIM To determine the long-term effects of selective laser trabeculoplasty (SLT) on intraocular pressure (IOP) and the number of medications used up to 5y following treatment in glaucoma patients receiving maximally tolerated medical therapy (MTMT). METHODS The Wills Eye Hospital Glaucoma Research Center retrospectively reviewed the charts of glaucoma patients who underwent SLT after receiving MTMT. Eyes that did not achieve their target pressure within 3mo following SLT were excluded from the study. Changes in mean IOP and number of glaucoma medications used were analyzed at 1, 3, and 5y following SLT. RESULTS Seventy-five eyes of 67 patients were included in the study. Fifteen eyes that received SLT failed to achieve their target pressure within 3mo and were excluded from the study. The average follow-up time was 37.4mo (±14.4). Mean IOP was significantly reduced 1y after treatment (P=0.005). It was also reduced 3, 5y after treatment without reaching statistical significance (P=0.20 and P=0.072, respectively). There was a significant decrease in mean number of medications used 1, 3, 5y after treatment (P<0.001, P<0.001, and P=0.039, respectively). In the span of 5y, 2 eyes (2.7%) underwent repeat SLT, 7 eyes (9.3%) underwent glaucoma surgery and an additional 3 eyes (4.0%) underwent both. CONCLUSION SLT significantly reduced the number of glaucoma medications used 5y following treatment in glaucoma patients receiving MTMT. SLT may delay operating-room surgery.

Segmental Analysis of Macular Layers in Patients With Unilateral Primary Open-Angle Glaucoma.

Purpose:To measure the thicknesses of the inner layers of the macula in both eyes of patients with unilateral primary open-angle glaucoma (POAG) and compare them with normal control eyes. Methods:This prospective, cross-sectional pilot study enrolled patients with unilateral POAG, who had visual field defect in only 1 eye, and controls with a normal eye examination. Horizontal and vertical B-scan images centered on the fovea were obtained using spectral domain optical coherence. Semiautomatic delineation and segmentation of the inner layers of the retina were performed to evaluate macular retinal nerve fiber layer (mRNFL), ganglion cell complex (GCC) and ganglion cell-inner plexiform layer (GC-IPL) thicknesses. Mean, superior, inferior, nasal, and temporal inner macular layer thicknesses were compared between affected eyes, fellow eyes without visual field defect, and control eyes. Results:Nineteen patients with unilateral POAG and 14 normal control eyes were enrolled. In the affected POAG eyes, thinning of the mRNFL, GCC, and GC-IPL layers on horizontal and vertical scans were significant when compared with controls (P<0.05), particularly on vertical scans (P<0.001). The mean regional macular GCC and GC-IPL were most severely thinned in the inferior and temporal perifoveal regions. The unaffected eye of patients with unilateral POAG showed significant thinning of the mRNFL only in the vertical scan when compared with normal controls (P<0.05). Conclusions:Spectral domain optical coherence tomography detected significant thinning of the mRNFL, GCC, and GC-IPL in the affected eyes of patients with unilateral POAG. Fellow eyes showed early structural changes only in the vertical mRNFL scans when compared with normal controls.

The SPARCS: a novel assessment of contrast sensitivity and its reliability in patients with corrected refractive error

Purpose To explore the reliability of the Spaeth/Richman Contrast Sensitivity (SPARCS) test and to assess the contrast sensitivity (CS) distribution among subjects with various refractive errors. Methods Cross-sectional study. Ninety-three individuals (182 eyes) with varying amounts of refractive error were included in this study and divided into six groups according to their spherical equivalent. CS was evaluated using Pelli–Robson (PR) and SPARCS assessments. Each eye was tested twice with both measurements. Outcomes included the correlations of PR and SPARCS scores, the test–retest agreement of the two measurements and the limits of agreement between tests of CS measurements. The distribution of CS among the six groups was compared. Results Pearson correlation analysis showed statistically significant correlations between SPARCS and PR scores (p<0.001). Reliability analysis showed that SPARCS had better test–retest agreement than PR, with SPARCS exhibiting a higher intraclass coefficient (ICC=0.635). Bland–Altman plots showed that the mean difference of measurements was close to 0 for both CS measurements. Among the six refractive groups, there were no significant differences in CS scores with either measurement. Conclusions SPARCS appears to be a reliable assessment for CS. The difference in CS among myopes, emmetropes and hyperopes wearing their habitual correction was statistically insignificant in this study. Clinical trial number NCT01300949, post results