Jin Wook Jeoung

Macular ganglion cell imaging study: glaucoma diagnostic accuracy of spectral-domain optical coherence tomography.

PURPOSE We evaluated the diagnostic accuracy of macular ganglion cell-inner plexiform layer (GCIPL) measurements using a high-definition optical coherence tomography (Cirrus HD-OCT) ganglion cell analysis algorithm for detecting early and moderate-to-severe glaucoma. METHODS Totals of 119 normal subjects and 306 glaucoma patients (164 patients with early glaucoma and 142 with moderate-to-severe glaucoma) were enrolled from the Macular Ganglion Cell Imaging Study. Macular GCIPL, peripapillary retinal nerve fiber layer (RNFL) thickness, and optic nerve head (ONH) parameters were measured in each subject. Areas under the receiver operating characteristic curves (AUROCs) were calculated and compared. Based on the internal normative database, the sensitivity and specificity for detecting early and moderate-to-severe glaucoma were calculated. RESULTS There was no statistically significant difference between the AUROCs for the best OCT parameters. For detecting early glaucoma, the sensitivity of the Cirrus GCIPL parameters ranged from 26.8% to 73.2% and that of the Cirrus RNFL parameters ranged from 6.1% to 61.6%. For the early glaucoma group, the best parameter from the GCIPL generally had a higher sensitivity than those of the RNFL and ONH parameters with comparable specificity (P < 0.05, McNemars test). CONCLUSIONS There were no significant differences between the AUROCs for Cirrus GCIPL, RNFL, and ONH parameters, indicating that these maps have similar diagnostic potentials for glaucoma. The minimum GCIPL showed better glaucoma diagnostic performance than the other parameters at comparable specificities. However, other GCIPL parameters showed performances comparable to those of the RNFL parameters.

Factors influencing refractive outcomes after combined phacoemulsification and pars plana vitrectomy: results of a prospective study.

PURPOSE: To evaluate the factors influencing the refractive outcomes of combined phacoemulsification, foldable intraocular lens (IOL) implantation, and pars plana vitrectomy (PPV). SETTING: Department of Ophthalmology, Seoul National University Hospital, Seoul, Korea. METHODS: One hundred fifty‐four consecutive patients who had combined phacoemulsification, IOL implantation, and PPV between September 2001 and August 2004 were enrolled in a prospective study. Refractive, keratometric, and axial length measurements were performed preoperatively and 4 months postoperatively. The factors influencing the postoperative refractive outcomes were analyzed. RESULTS: The mean refractive prediction error (ie, actual minus predicted spherical equivalent [SE]) was −0.06 diopters (D) ± 0.75 (SD). In long eyes (preoperative axial length more than 24.5 mm), the mean predicted SE and actual SE were −0.81 ± 0.76 D and −1.24 ± 0.79 D, respectively; the difference was significantly different (P = .001, paired t test). Patients with a preoperative visual acuity worse than 5/200 and those with preoperative foveal detachment had a significant postoperative myopic shift (P = 0.024 and P = 0.002, respectively; paired t test). Postoperative refractive error was not influenced by the intraocular air or gas tamponade during surgery (P = 0.336, paired t test). CONCLUSIONS: The combined surgery included a small biometric error that was within the tolerable range in most cases. However, myopic shifts developed in patients with long axial lengths, poor preoperative visual acuity, and the preoperative presence of foveal detachment.

Effect of Lateral Decubitus Position on Intraocular Pressure in Glaucoma Patients with Asymmetric Visual Field Loss

PURPOSE To investigate the effect of the lateral decubitus position (LDP) on intraocular pressure (IOP) in glaucoma patients with asymmetric visual field loss. DESIGN Prospective, cross-sectional study. PARTICIPANTS Ninety-eight eyes of 49 consecutive bilateral glaucoma patients with asymmetric visual field loss, divided into better eye and worse eye groups for calculation of mean deviation. METHODS Intraocular pressure was measured using a Goldmann applanation tonometer and rebound tonometer (Icare PRO; Icare Finland Oy, Helsinki, Finland) in each of the following positions: sitting, supine, right LDP, and left LDP. Visual field was examined using the Humphrey Field Analyzer (HFA II; Carl Zeiss Meditec, Dublin, CA). A questionnaire on the preferred lying position during sleep was administered to each of the patients. MAIN OUTCOME MEASURES The IOPs measured by rebound tonometer for the better and worse eyes in each position were compared using paired t tests. Agreement between the Goldmann applanation tonometry and rebound tonometry results was assessed by a Bland-Altman plot. RESULTS The IOPs of the better and worse eyes in the sitting position showed no significant difference (P<0.476). The IOP of the worse eye was significantly higher than that of the better eye in the supine position (16.8 ± 3.0 mmHg vs. 15.1 ± 1.8 mmHg; P<0.001). The IOPs of the worse and better eyes in their dependent LDP were 19.1 ± 3.0 mmHg and 17.6 ± 2.3 mmHg, respectively (change in IOP, 1.6 ± 2.4 mmHg; P<0.001). Of the enrolled patients, 75.5% preferred the LDP, and 75.7% of these LDP-preferring patients preferred the worse eye dependent-LDP. The Bland-Altman plot comparing the Goldmann applanation tonometry and rebound tonometry readings showed reasonable agreement between the 2 methods (r(2)<0.001; P = 0.972). CONCLUSIONS This study showed that IOP-elevation asymmetry in LDP is associated with asymmetric visual field loss in glaucoma patients. The LDP, habitually preferred by glaucoma patients, also may be associated with asymmetric visual field damage.

Structure-function relationships in normal and glaucomatous eyes determined by time- and spectral-domain optical coherence tomography.

PURPOSE To compare the relationships between retinal mean sensitivity (MS) and retinal nerve fiber layer (RNFL) thickness, as measured by time-domain (TD) and spectral-domain (SD) optical coherence tomography (OCT). METHODS Recruited subjects were divided into normal, glaucoma suspect, and glaucoma groups. RNFL thickness was measured with TD- and SD-OCT, and MS was assessed with visual field perimetry and expressed in decibels and 1/L, where L is luminance in lamberts. The relationship between SUPERIOR MS and INFERIOR RNFL thickness (clock-hour segments 5, 6, 7, and 8) and that between INFERIOR MS and SUPERIOR RNFL thickness (clock-hour segments 10, 11, 12, 1, 2, and 3) were correlated by linear and logarithmic regression analyses. Pearsons correlation coefficients (R), for both OCTs were compared by using Hotellings t-test. RESULTS Ninety-five eyes of 76 subjects were prospectively included. Twenty-five eyes were classified as normal, 25 with glaucoma suspect, and 45 with glaucoma. In normal and glaucoma suspect eyes, there were no significant relationships between MS and RNFL thickness. In glaucomatous eyes, the associations between MS and RNFL thickness were R = 0.31 to 0.57 with TD-OCT and R = 0.47 to 0.66 with SD-OCT, and the correlation of SUPERIOR RNFL thickness with INFERIOR MS was significantly better with SD-OCT than with TD-OCT in both linear and logarithmic regression models. CONCLUSIONS The results showed that, in mild-to-moderate glaucoma, SD-OCT offers an improved structure-function correlation compared with TD-OCT, when applied to the detection of INFERIOR MS and SUPERIOR RNFL defects.

Diagnostic Classification of Macular Ganglion Cell and Retinal Nerve Fiber Layer Analysis: Differentiation of False-Positives from Glaucoma

PURPOSE To investigate the rate and associated factors of false-positive diagnostic classification of ganglion cell analysis (GCA) and retinal nerve fiber layer (RNFL) maps, and characteristic false-positive patterns on optical coherence tomography (OCT) deviation maps. DESIGN Prospective, cross-sectional study. PARTICIPANTS A total of 104 healthy eyes of 104 normal participants. METHODS All participants underwent peripapillary and macular spectral-domain (Cirrus-HD, Carl Zeiss Meditec Inc, Dublin, CA) OCT scans. False-positive diagnostic classification was defined as yellow or red color-coded areas for GCA and RNFL maps. Univariate and multivariate logistic regression analyses were used to determine associated factors. Eyes with abnormal OCT deviation maps were categorized on the basis of the shape and location of abnormal color-coded area. Differences in clinical characteristics among the subgroups were compared. MAIN OUTCOME MEASURES (1) The rate and associated factors of false-positive OCT maps; (2) patterns of false-positive, color-coded areas on the GCA deviation map and associated clinical characteristics. RESULTS Of the 104 healthy eyes, 42 (40.4%) and 32 (30.8%) showed abnormal diagnostic classifications on any of the GCA and RNFL maps, respectively. Multivariate analysis revealed that false-positive GCA diagnostic classification was associated with longer axial length and larger fovea-disc angle, whereas longer axial length and smaller disc area were associated with abnormal RNFL maps. Eyes with abnormal GCA deviation map were categorized as group A (donut-shaped round area around the inner annulus), group B (island-like isolated area), and group C (diffuse, circular area with an irregular inner margin in either). The axial length showed a significant increasing trend from group A to C (P=0.001), and likewise, the refractive error was more myopic in group C than in groups A (P=0.015) and B (P=0.014). Group C had thinner average ganglion cell-inner plexiform layer thickness compared with other groups (group A=B>C, P=0.004). CONCLUSIONS Abnormal OCT diagnostic classification should be interpreted with caution, especially in eyes with long axial lengths, large fovea-disc angles, and small optic discs. Our findings suggest that the characteristic patterns of OCT deviation map can provide useful clues to distinguish glaucomatous changes from false-positive findings.

Long-term follow-up in preperimetric open-angle glaucoma: progression rates and associated factors.

PURPOSE To investigate the rate of progressive visual field (VF) loss and associated factors for structural or functional progression in preperimetric open-angle glaucoma (OAG). DESIGN Longitudinal, observational study. METHODS We included 127 eyes of 127 preperimetric OAG patients who were treated with topical medication and followed for more than 5 years. All patients underwent stereo optic disc photography, red-free retinal nerve fiber layer (RNFL) photography, frequency doubling technology perimetry, and standard automated perimetry (SAP). Progression was defined as a structural (glaucomatous change confirmed by stereo optic disc and red-free RNFL photography) or functional (new glaucomatous defect on SAP) deterioration. The progression rate of SAP mean deviation (dB/year) and factors associated with progression were evaluated. RESULTS Glaucoma progression was detected in 72 of 127 eyes (56.7%). Mean rate of VF progression was -0.39 ± 0.64 dB/year in all patients; -0.66 ± 0.60 dB/year in progressors and -0.03 ± 0.24 dB/year in nonprogressors. A multivariate Cox proportional hazard model revealed that optic disc hemorrhage (hazard ratio [HR] = 1.718, P = .031) and the percentage reduction in intraocular pressure (IOP; HR = 0.964, P = .002) were significantly associated with disease progression. Patients with disc hemorrhage had a greater cumulative probability of progression than those without disc hemorrhage (P = .014 by log-rank test). CONCLUSIONS Our results support the importance of lowering IOP, even at the preperimetric stage. Preperimetric glaucoma patients with disc hemorrhage and insufficient IOP control should be carefully monitored for greater risk of progression.

Optic Disc Hemorrhage May Be Associated with Retinal Nerve Fiber Loss in Otherwise Normal Eyes

PURPOSE To evaluate quantitatively the structural damage of the peripapillary retinal nerve fiber layer (RNFL) in eyes with disc hemorrhage (DH). DESIGN Prospective cross-sectional study. PARTICIPANTS Seventy patients with DH (70 eyes; mean age +/- standard deviation, 60.0+/-11.8 years) and 100 healthy control subjects (100 eyes; mean age +/- standard deviation, 57.7+/-8.0 years) were enrolled from the Glaucoma Clinic of Seoul National University Hospital. METHODS Normal eyes without DH (group 1: normal control group) served as controls. Eyes with DH were divided into the following groups: (1) eyes with a DH, accompanied by no visible RNFL defect according to red-free fundus photography and normal visual fields (group 2: DH only group); (2) eyes with a DH and a localized RNFL defect in the same quadrant, accompanied by normal visual fields (group 3: DH-preperimetric group); and (3) eyes with a DH and a localized RNFL defect in the same quadrant, accompanied by glaucomatous visual field defect in the corresponding hemifield location (group 4: DH-perimetric group). Optical coherence tomography (OCT)-measured RNFL thicknesses were compared. MAIN OUTCOME MEASURES Average and segmental (4 quadrants and 12 clock-hours) OCT-measured RNFL thicknesses. RESULTS The number of eyes in groups 1, 2, 3, and 4 was 100, 25, 22, and 23 eyes, respectively. The OCT-measured RNFL thickness was significantly different among the 4 groups in average RNFL thickness and in inferior, superior, and nasal quadrants (P<0.01, 1-way analysis of variance). On post hoc analysis, the eyes of groups 2 and 3 showed thinner average RNFL thickness than those of group 1, and the average RNFL thickness of group 4 was significantly lower than that of groups 2 and 3 (P<0.001, 1-way analysis of variance and Tukeys test). The OCT-measured RNFL thickness revealed a topographic relationship with the DH location. CONCLUSIONS Significant RNFL loss was already present in the DH only eyes with apparently normal RNFL configuration by red-free fundus photography, indicating that preperimetric changes of the RNFL are already present. These results suggest that OCT has the potential to detect subclinical or preperimetric RNFL loss in the eyes with DH. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Comparison of the new rebound tonometer with Goldmann applanation tonometer in a clinical setting

Purpose:  To evaluate the clinical usefulness of a new rebound tonometer, Icare® PRO (Icare PRO), by comparison with Goldmann applanation tonometry (GAT) in a study on patients with glaucoma.

Engineered superparamagnetic Mn0.5Zn0.5Fe2O4 nanoparticles as a heat shock protein induction agent for ocular neuroprotection in glaucoma

Ocular neuroprotection induced by localized heat shock proteins (HSPs) has been paid considerable attention as an efficacious treatment modality for glaucoma. However, the current clinical approaches to induce HSPs in the retinal ganglion cells (RGCs) are limited due to undesirable side effects. Here, we present that the induction of HSPs by local magnetic hyperthermia using engineered superparamagnetic Mn(0.5)Zn(0.5)Fe(2)O(4) nanoparticle agents (EMZF-SPNPAs) with a 5.5 nm mean particle size is promisingly feasible for a physiologically tolerable ocular neuroprotection modality. The sufficiently high specific absorption rate (SAR) (∼256.4 W/g in an agar solution) achieved at the biologically safe range of applied AC magnetic field and frequency as well as the superior biocompatibility of EMZF-SPNPA, which were confirmed from both in-vitro and in-vivo animal pilot studies, allowing it to be considered as a potential localized HSPs agent. Furthermore, the successful demonstration of a newly designed infusion technique, which diffuses the EMZF-SPNPAs through the vitreous body to the retina in a rat eye, more strongly verified the promises of this biotechnical approach to the ocular neuroprotection modality in glaucoma clinics.

Long-Term Reproducibility of Macular Ganglion Cell Analysis in Clinically Stable Glaucoma Patients.

PURPOSE To investigate the long-term reproducibility of macular ganglion cell analysis in clinically stable glaucoma patients using spectral-domain optical coherence tomography (SD-OCT). METHODS One hundred nine eyes of 109 clinically stable open-angle glaucoma patients with a localized retinal nerve fiber layer (RNFL) defect and a corresponding macular ganglion cell-inner plexiform layer (GCIPL) defect were included in this retrospective, longitudinal study. Clinical stability was defined as showing no change on serial structural (stereo-disc and RNFL photography) and functional (visual field progression analysis) assessments. Three serial SD-OCT (Cirrus-HD) peripapillary and macular scans taken at 6-month intervals were analyzed. Intraclass correlation coefficient (ICC), coefficient of variation (CV), test-retest standard deviation (TRTSD), and tolerance limit of area and angular width of GCIPL defect and GCIPL thickness measurements were assessed. RESULTS The ICC of the GCIPL thickness parameters ranged from 0.966 to 0.992, and the CV from 2.0% to 5.5%. The TRTSD was the lowest for the average GCIPL thickness (1.45 μm), the highest for the minimum GCIPL thickness (3.42 μm), and varied from 1.54 to 2.16 μm for the sectoral measurements. The ICC, CV, and TRTSD were 0.993, 3.9%, and 5.32° for angular width, and 0.930, 6.7%, and 0.27 mm2 for area of GCIPL defect. Measurement variances (TRTSD) for the GCIPL measurements showed no significant association with the glaucomatous severity. CONCLUSIONS The macular GCIPL thickness and deviation maps showed excellent long-term intervisit reproducibility. Macular ganglion cell analysis can be considered as an effective means of monitoring glaucomatous progression in macula.