Remo Susanna

A prospective, comparative study between endoscopic cyclophotocoagulation and the Ahmed drainage implant in refractory glaucoma.

Purpose:To compare endoscopic cyclophotocoagulation (ECP) and the Ahmed drainage implant in the treatment of refractory glaucoma. Methods:Sixty-eight eyes of 68 patients with refractory glaucoma were prospectively assigned to either ECP or Ahmed tube shunt implantation. All procedures were performed by a single surgeon. Eyes that were included were pseudophakic with a history of at least one trabeculectomy with antimetabolite, an intraocular pressure (IOP) equal to or above 35 mm Hg on maximum tolerated medical therapy, and a visual acuity better than light perception. Exclusion criteria included eyes that had had previous glaucoma drainage device implantation or a cyclodestructive procedure. Success was defined as an IOP more than 6 mm Hg and less than 21 mm Hg, with or without topical anti-hypertensive therapy. Results:The mean follow-up was 19.82 ± 8.35 months and 21.29 ± 6.42 months, for the Ahmed and ECP groups, respectively (P = 0.4). The preoperative IOP, 41.32 ± 3.03 mm Hg (Ahmed) and 41.61 ± 3.42 mm Hg (ECP) (P = 0.5), and the mean postoperative IOP, at 24 months follow-up, 14.73 ± 6.44 mm Hg (Ahmed) and 14.07 ± 7.21 mm Hg (ECP) (P = 0.7), were significantly different from baseline in both groups (P < 0.001). Kaplan-Meier survival curve analysis showed a probability of success at 24 months of 70.59% and 73.53% for the Ahmed and ECP groups, respectively (P = 0.7). Complications included choroidal detachment (Ahmed 17.64%, ECP 2.94%), shallow anterior chamber (Ahmed 17.64%, ECP 0.0%), and hyphema (Ahmed 14.7%, ECP 17.64%). Conclusion:There was no difference in the success rate between the Ahmed Glaucoma Valve and ECP in refractory glaucoma. The eyes that underwent Ahmed tube shunt implantation had more complications than those treated with ECP.

Axonal loss after traumatic optic neuropathy documented by optical coherence tomography.

PURPOSE To report longitudinal retinal nerve fiber layer (RNFL) thickness measurements using optical coherence tomography (OCT) in a patient with traumatic optic neuropathy. DESIGN Observational case report. METHODS A 14-year-old boy with severe optic nerve trauma had repeated OCT scans of the peripapillary retinal nerve fiber layer at 3 days, 20 days, 40 days, and 70 days after injury. RESULTS There was gradual loss of nerve fibers as shown by the OCT color-coded map, RNFL thickness profile, and RNFL thickness measurements around the optic disk. At 70 days of follow-up, severe thinning of the RNFL was observable. CONCLUSIONS These findings suggest that OCT is able to assess and monitor axonal loss after traumatic optic neuropathy.

A double-masked, randomized clinical trial comparing latanoprost with unoprostone in patients with open-angle glaucoma or ocular hypertension

PURPOSE To compare the intraocular pressure (IOP) reducing effect and safety of latanoprost 0.005% once daily with unoprostone 0.12% twice daily in patients with primary open-angle glaucoma (POAG) or ocular hypertension (OH). DESIGN An 8-week, double-masked, randomized, parallel-group, single-center clinical trial. PARTICIPANTS A total of 108 patients with POAG or OH were enrolled. INTERVENTIONS After completing a wash-out of ocular hypotensive medications, patients were randomized to receive either latanoprost once daily in the evening plus placebo once daily in the morning, or unoprostone twice daily (morning and evening). MAIN OUTCOME MEASURES IOP was measured at 10:00 AM and at 5:00 PM at baseline and at week 8, and before 12:00 noon at week 2. Ocular and systemic safety assessments were performed. RESULTS From an overall baseline of 24.1 mmHg, latanoprost reduced IOP by 6.7 mmHg (28%) and unoprostone reduced IOP by 3.3 mmHg (14%). The difference between the groups of 3.4 mmHg was significant (P: < 0.001, analysis of covariance; 95% confidence interval [CI]: -4.7 to -2.1) in favor of latanoprost. A >/=30% reduction in mean IOP from baseline was achieved by 44% of latanoprost-treated patients compared with 8% of unoprostone-treated patients. The incidence of adverse events was low and comparable between the groups. CONCLUSIONS Latanoprost administered once daily was significantly more effective in reducing IOP compared with unoprostone administered twice daily in patients with POAG and OH.

Comparison of quantitative imaging devices and subjective optic nerve head assessment by general ophthalmologists to differentiate normal from glaucomatous eyes.

PurposeTo compare the ability of subjective assessment of optic nerve head (ONH) and retinal nerve fiber layer (RNFL) by general ophthalmologists and by a glaucoma expert with objective measurements by optical coherence tomography (Stratus OCT, Carl Zeiss Meditec Inc), confocal scanning laser ophthalmoscope (HRT III; Heidelberg Engineering, Heidelberg, Germany), and scanning laser polarimetry (GDx enhanced corneal compensation; Carl Zeiss Meditec Inc, Dublin, CA) in discriminating glaucomatous and normal eyes. MethodsSixty-one glaucomatous and 57 normal eyes of 118 subjects were included in the study. Three independent general ophthalmologists and 1 glaucoma expert evaluated ONH stereophotographs. Receiver operating characteristic curves were constructed for each imaging technique and sensitivity at fixed specificity was estimated. Comparisons of areas under these curves (aROCs) and agreement (k) were determined between stereophoto grading and best parameter from each technique. ResultsBest parameter from each technique showed larger aROC (Stratus OCT RNFL=0.92; Stratus OCT ONH vertical integrated area=0.86; Stratus OCT macular thickness=0.82; GDx enhanced corneal compensation=0.91; HRT3 global cup-to-disc area ratio=0.83; HRT3 glaucoma probability score numeric score=0.83) compared with stereophotograph grading by general ophthalmologists (0.80) in separating glaucomatous and normal eyes. Glaucoma expert stereophoto grading provided equal or larger aROC (0.92) than best parameter of each computerized imaging device. Stereophoto evaluated by a glaucoma expert showed better agreement with best parameter of each quantitative imaging technique in classifying eyes either as glaucomatous or normal compared with stereophoto grading by general ophthalmologists. The combination of subjective assessment of the optic disc by general ophthalmologists with RNFL objective parameters improved identification of glaucoma patients in a larger proportion than the combination of these objective parameters with subjective assessment of the optic disc by a glaucoma expert (29.5% vs. 19.7%, respectively). ConclusionsDiagnostic ability of all imaging techniques showed better performance than subjective assessment of the ONH by general ophthalmologists, but not by a glaucoma expert. Objective RNFL measurements may provide improvement in glaucoma detection when combined with subjective assessment of the optic disc by general ophthalmologists or by a glaucoma expert.

MITOMYCIN AS ADJUNCT CHEMOTHERAPY WITH TRABECULECTOMY IN CONGENITAL AND DEVELOPMENTAL GLAUCOMAS

PurposeTo report on sixty-eight patients (98 eyes) who were trabeculectomized with the use of mitomycin C as adjunctive therapy. MethodsFifty-six patients (79 eyes) were followed for at least 6 months or had IOP of >21 mm HG or any complications that were considered end point for them. Forty-six were primary congenital glaucoma; one was Sturger Weber disease; five were Axenfeld-Rieger syndrome; two were Peters anomaly; one was congenital glaucoma associated with ectopia lentis and one aniridia. The mean age was 76.06 ± 81.56 months (range, 1 month to 30 years). ResultsFifty-three eyes (67.09%) were considered successful (IOP ≤ 21 mm Hg) with a mean follow-up of 17.30 ± 7.98 months (range, 6–44 months). From these, 47 eyes (59.49%) had IOP ≤ 16 mm Hg. Twenty-three eyes had IOP of > 21 mm Hg (30.37%), one developed retinal detachment, (1.26%) two developed phthisis (2.53%), eight had flat anterior chamber (10.12%), two vitreous hemorrhage (2.53%), and four choroidal detachment (5.06%). ConclusionsDespite the number of complications, some of them very serious, the use of mitomycin seems to be a reasonable approach in these eyes with very poor surgical prognosis, otherwise candidates for setons.

Agreement for Detecting Glaucoma Progression with the GDx Guided Progression Analysis, Automated Perimetry, and Optic Disc Photography

PURPOSE To evaluate the ability of the GDx Variable Corneal Compensation (VCC) Guided Progression Analysis (GPA) software for detecting glaucomatous progression. DESIGN Observational cohort study. PARTICIPANTS The study included 453 eyes from 252 individuals followed for an average of 46+/-14 months as part of the Diagnostic Innovations in Glaucoma Study. At baseline, 29% of the eyes were classified as glaucomatous, 67% of the eyes were classified as suspects, and 5% of the eyes were classified as healthy. METHODS Images were obtained annually with the GDx VCC and analyzed for progression using the Fast Mode of the GDx GPA software. Progression using conventional methods was determined by the GPA software for standard automated achromatic perimetry (SAP) and by masked assessment of optic disc stereophotographs by expert graders. MAIN OUTCOME MEASURES Sensitivity, specificity, and likelihood ratios (LRs) for detection of glaucoma progression using the GDx GPA were calculated with SAP and optic disc stereophotographs used as reference standards. Agreement among the different methods was reported using the AC(1) coefficient. RESULTS Thirty-four of the 431 glaucoma and glaucoma suspect eyes (8%) showed progression by SAP or optic disc stereophotographs. The GDx GPA detected 17 of these eyes for a sensitivity of 50%. Fourteen eyes showed progression only by the GDx GPA with a specificity of 96%. Positive and negative LRs were 12.5 and 0.5, respectively. None of the healthy eyes showed progression by the GDx GPA, with a specificity of 100% in this group. Inter-method agreement (AC(1) coefficient and 95% confidence intervals) for non-progressing and progressing eyes was 0.96 (0.94-0.97) and 0.44 (0.28-0.61), respectively. CONCLUSIONS The GDx GPA detected glaucoma progression in a significant number of cases showing progression by conventional methods, with high specificity and high positive LRs. Estimates of the accuracy for detecting progression suggest that the GDx GPA could be used to complement clinical evaluation in the detection of longitudinal change in glaucoma.

The Relationship between Intraocular Pressure Reduction and Rates of Progressive Visual Field Loss in Eyes with Optic Disc Hemorrhage

PURPOSE To evaluate rates of visual field progression in eyes with optic disc hemorrhages and the effect of intraocular pressure (IOP) reduction on these rates. DESIGN Observational cohort study. PARTICIPANTS The study included 510 eyes of 348 patients with glaucoma who were recruited from the Diagnostic Innovations in Glaucoma Study (DIGS) and followed for an average of 8.2 years. METHODS Eyes were followed annually with clinical examination, standard automated perimetry visual fields, and optic disc stereophotographs. The presence of optic disc hemorrhages was determined on the basis of masked evaluation of optic disc stereophotographs. Evaluation of rates of visual field change during follow-up was performed using the visual field index (VFI). MAIN OUTCOME MEASURES The evaluation of the effect of optic disc hemorrhages on rates of visual field progression was performed using random coefficient models. Estimates of rates of change for individual eyes were obtained by best linear unbiased prediction (BLUP). RESULTS During follow-up, 97 (19%) of the eyes had at least 1 episode of disc hemorrhage. The overall rate of VFI change in eyes with hemorrhages was significantly faster than in eyes without hemorrhages (-0.88%/year vs. -0.38%/year, respectively, P<0.001). The difference in rates of visual field loss pre- and post-hemorrhage was significantly related to the reduction of IOP in the post-hemorrhage period compared with the pre-hemorrhage period (r = -0.61; P<0.001). Each 1 mmHg of IOP reduction was associated with a difference of 0.31%/year in the rate of VFI change. CONCLUSIONS There was a beneficial effect of treatment in slowing rates of progressive visual field loss in eyes with optic disc hemorrhage. Further research should elucidate the reasons why some patients with hemorrhages respond well to IOP reduction and others seem to continue to progress despite a significant reduction in IOP levels. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Visual field progression outcomes in glaucoma subtypes.

Purpose:  To determine whether glaucoma subtype is an independent risk factor for visual field (VF) progression.

Staging Glaucoma Patient: Why and How?

Staging glaucomatous damage into appropriatecategories enhances management of the disease. Automated static perimetry is the benchmark for testing visual function in glaucoma. Numerous examples of standard automated perimetry staging systems have been proposed but difficulties such as lack of accuracy, absence of information related to location and depth of the defect(s) and need of time-consuming analysis of every visual field test result may reduce their day-to-day clinical usefulness.A new visual field staging system is proposed: the University of São Paulo Glaucoma Visual Field Staging System (USP-GVFSS). In this system, qualitative and quantitative characteristics of the visual field defect are described. The method is intuitive, comprehensible and describes severity, extension and hemi field involvement.

New findings in the evaluation of the optic disc in glaucoma diagnosis.

Purpose of review Ophthalmoscopical evaluation of the optic disc is a feasible and largely accessible method to diagnose glaucoma. Many qualitative parameters have been described in glaucomatous optic neuropathy. Considering individual variations in the details of topography or tissue components damaged by the glaucomatous process, however, adequate identification of glaucomatous optic disc signs requires training and experience. Without adequate guidelines of optic disc examination, the physician may miss important aspects that could lead to adequate diagnosis or identification of progression in a patient with established glaucoma. This paper presents a systematic approach for the examination of the optic disc and retinal nerve fiber layer to aid the detection of glaucoma. Recent findings Optic disc qualitative parameters are better than quantitative parameters in separating glaucomatous from normal eyes. The sequential evaluation of optic disc size, neuroretinal rim size and shape, retinal nerve fiber layer, presence of peripapillary atrophy, and presence of retinal or optic disc hemorrhages enhances the ability to detect glaucomatous damage and its progression. Summary Ophthalmologists should be familiar with glaucomatous optic disc signs that can be identified during clinical examination. A simple systematic approach may allow improved diagnosis and management of glaucoma.