Scott J. Fudemberg

Pregnancy and glaucoma.

Glaucoma, primarily a disease of the older population, may affect women of childbearing age. Pregnancy affects the intraocular pressure (IOP) of women with pre-existing glaucoma. Both elevations and reductions of IOP have been reported during pregnancy. Additionally, visual field test results may fluctuate during pregnancy. In managing the pregnant glaucoma patient with medical therapy, one must consider not only the systemic side effects on the mother, but also any potentially harmful effects on the developing fetus. All anti-glaucoma medications are categorized as class C by the Food and Drug Administration, except brimonidine and nonspecific adrenergic agonists, which belong to class B. In general, the lowest effective dosage of medication should be used. Systemic absorption can be reduced by punctal occlusion, eyelid closure, and blotting the excess drops away during administration. In those patients who need surgery, most local anesthetics may be used safely because they have not been shown to be teratogenic in humans. Antifibrotic agents commonly used adjunctively in trabeculectomy, however, should be avoided. Glaucoma laser procedures, such as laser peripheral iridotomy and laser trabeculoplasty, have been employed without identifiable teratogenic effects or increased risk of side effects for pregnant women.

Efficacy, safety, and current applications of brimonidine

Background: The use of brimonidine to lower intraocular pressure has been the subject of considerable investigation. Variations of the initially approved drug including agents of a lower concentration (Alphagan® P 0.15 and 0.1%, Allergan, Inc., Irvine, CA, USA) and a fixed-combination mating brimonidine with timolol (Combigan®, Allergan) evolved the marketing and application of this therapy. Objective: We review available evidence regarding the efficacy and side effect profile of brimonidine as well as its role in glaucoma management. Results/conclusion: Brimonidine is an important component of topical glaucoma treatment that is most limited by local ocular intolerance.

Visual loss caused by corticosteroid-induced glaucoma: how to avoid it.

Visual Loss Caused by Corticosteroid-Induced Glaucoma: How to Avoid It The initial report of elevation of intraocular pressure (IOP) in response to corticosteroids was that by McLean,1 who, in 1950, noted that adrenocorticotropic hormone (ACTH) could have such an effect. The report by Francois2 on pressure elevation caused by topical steroids appeared in 1954, and much is now known about its pathogenesis. Nevertheless, visual loss caused by steroid-induced glaucoma continues to occur. Concerns about this entity have increased after the institution of intravitreal corticosteroid treatment, primarily for retinal diseases.3 This commentary does not deal with the benefits of intravitreal, topical, or systemic corticosteroid treatment for ocular disease. Although the appropriate role of corticosteroids in comparison with other treatments is controversial, there is evidence that such treatments can be effective in preventing visual loss from uveitis, can improve the success of glaucoma-filtering surgery,4 and can have temporary or long-term benefits in some patients with some types of retinal disease.5–16 Clearly, no treatment of any kind is indicated unless there is a reasonable likelihood of a clinical benefit from that treatment. Herein, we do not concern ourselves with the important “benefit” side of the risk/benefit ratio, but rather examine in detail one of the many risks associated with the use of corticosteroids, specifically visual loss from glaucoma. The sequence leading to glaucomatous disability in cases of steroid-induced glaucoma is, first, elevation of IOP; second, neuronal damage; third, visual loss; and fourth, disability (we define glaucoma as a visual disability when vision loss prevents a person from doing that which they would otherwise want and be able to do). We want to stress that the only clinical significance of steroid-induced elevation of IOP is that such elevation of IOP may, in some cases, lead to nerve damage and cause visual disability, decreasing the quality of life. Given this sequence, the appropriate approach to the issue of disability caused by steroid-induced glaucoma is 1) to use steroids only when appropriate; 2) to know who is at risk of developing steroid-induced glaucomatous disability; 3) to monitor the IOP appropriately for each individual; and 4) to use appropriate means of controlling IOP where this is needed to prevent disability. Those at risk of developing steroid-induced glaucomatous disability are listed in Table 1. By far, those at greatest risk are those who already have severe glaucomatous optic nerve damage from primary openangle glaucoma. The likelihood of patients with primary open-angle glaucoma developing a rise in IOP secondary to corticosteroids administered by any route is great. Well over three fourths of those receiving topical dexamethasone for 4 weeks will develop a marked rise in IOP. Those who already have enough glaucomatous optic nerve damage to have disability have earlier demonstrated that their optic nerves can be damaged by IOP and, furthermore, that any further damage will increase the disability that already exists. Those with definite glaucoma, but who as yet have no disability, are also at a considerable risk, because they, too, have shown that they can be damaged by IOP. However, because their nerves are healthier, there must be a greater or longer period of IOP elevation before they develop sufficient damage to become visually disabled.

Explantation of the novel Ahmed glaucoma valve M4 implant.

Purpose:To report a series of cases involving Ahmed Glaucoma Valve M4 (AGV) explantation and to discuss the surgical technique to remove the drainage device. Methods:Four cases were identified that presented with AGV M4 postoperative complications necessitating tube shunt removal. Three patients presented with conjunctival erosion and 1 patient with persistent diplopia. AGV M4 implants were removed successfully between 1.5 and 9 months after implantation. Results:Successful explantation of the AGV M4 novel implant was achieved in all cases without intraoperative or postoperative complications. Conclusions:If necessary, AGV M4 explantation can be successfully performed in the early postoperative period.

The effects of Mozart's music on the performance of glaucoma patients on automated perimetry.

PURPOSE The purpose of this study was to examine the impact of the Mozart effect on the reliability of the Humphrey visual field (HVF; Carl Zeiss Meditec, Dublin, CA) test in subjects with glaucoma. A previous study showed improved reliability in normal subjects undergoing HVF testing. METHODS One hundred sixty subjects with glaucoma were randomized to three groups: control, headphones, or music for 10 minutes before HVF testing. The headphone group was provided noise-cancellation headphones but no music. The music group listened to Mozarts Sonata for Two Pianos in D Major. After treatment, subjects took an HVF test in both eyes. The reliability of the test was then compared between the groups and also to prior HVF results with regard to fixation losses, false positives, and false negatives. RESULTS The rate of fixation losses did not differ significantly between the three groups (P = 0.30 right eye, P = 0.24 left eye). There were also no significant differences in the rate of false positives (P = 0.82 right eye, P = 0.18 left eye) or false negatives (P = 0.91 right eye, P = 0.97 left eye). The reliability of the subjects HVF result was also compared with past field results. No improvements were seen in fixation losses (P = 0.94 right eye, P = 0.17 left eye), false positives (P = 0.85 right eye, P = 0.38 left eye), and false negatives (P = 0.13 right eye, P = 0.50 left eye). CONCLUSIONS The rate of fixation losses, false positives, and false negatives did not improve in subjects with glaucoma after they listened to Mozarts music. The Mozart effect did not enhance the reliability of the visual field test to a statistically significant degree (ClinicalTrials.gov number, NCT01027039).

Philadelphia Telemedicine Glaucoma Detection and Follow-up Study: Methods and Screening Results

PURPOSE To describe methodology and screening results from the Philadelphia Telemedicine Glaucoma Detection and Follow-up Study. DESIGN Screening program results for a prospective randomized clinical trial. METHODS Individuals were recruited who were African-American, Hispanic/Latino, or Asian over age 40 years; white individuals over age 65 years; and any ethnicity over age 40 years with a family history of glaucoma or diabetes. Primary care offices and Federally Qualified Health Centers were used for telemedicine (Visit 1). Two posterior fundus photographs and 1 anterior segment photograph were captured per eye in each participant, using a nonmydriatic, autofocus, hand-held fundus camera (Volk Optical, Mentor, Ohio, USA). Medical and ocular history, family history of glaucoma, visual acuity, and intraocular pressure measurements using the ICare rebound tonometer (ICare, Helsinki, Finland) were obtained. Images were read remotely by a trained retina reader and a glaucoma specialist. RESULTS From April 1, 2015, to February 6, 2017, 906 individuals consented and attended Visit 1. Of these, 553 participants were female (61.0%) and 550 were African-American (60.7%), with a mean age of 58.7 years. A total of 532 (58.7%) participants had diabetes, and 616 (68%) had a history of hypertension. During Visit 1, 356 (39.3%) participants were graded with a normal image. Using image data from the worse eye, 333 (36.8%) were abnormal and 155 (17.1%) were unreadable. A total of 258 (28.5%) had a suspicious nerve, 62 (6.8%) had ocular hypertension, 102 (11.3%) had diabetic retinopathy, and 68 (7.5%) had other retinal abnormalities. CONCLUSION An integrated telemedicine screening intervention in primary care offices and Federally Qualified Health Centers detected high rate of suspicious optic nerves, ocular hypertension, and retinal pathology.

Clinical Examination of the Optic Nerve

The optic nerve is a confluence of retinal ganglion cell axons that traverse the scleral canal to exit the eye. It ends as these axons merge with axons of the contralateral optic nerve at the optic chiasm. The optic nerve can be divided into (1) the intraocular part, comprising the retinal ganglion cell layer, the retinal nerve fiber layer, and the optic disc, and (2) the retrobulbar part, consisting of the intraorbital portion (about 25 mm long), the intracanalicular part within the osseous optic canal (4-20 mm), and the intracranial portion (about 10 mm), at which point the nerve fibers merge into the optic chiasm and the post-chiasmal optic tracts.

Validation of the structure–function correlation report from the heidelberg edge perimeter and spectral-domain optical coherence tomography

AbstractPurpose To compare the diagnostic assessment of glaucoma specialists with an automated structure–function correlation report combining visual field (VF) and spectral-domain optical coherence tomography (SD-OCT) imagining in subjects with glaucoma.MethodsThis prospective, cross-sectional study was conducted at Wills Eye Hospital, Philadelphia, PA, USA. Subjects with glaucoma received ophthalmic examination, VF testing, and SD-OCT imaging. An automated report was generated describing structure–function correlations between the two structural elements [retinal nerve fiber layer (RNFL) and Bruch’s membrane opening-minimum rim width (MRW)] and VF sectors. Three glaucoma specialists masked to the automated report and to each other identified clinically significant structure–function correlations between the VF and SD-OCT reports. Raw agreement and chance-corrected agreement (kappa statistics) between the automated report and the clinical assessments were compared.ResultsA total of 53 eyes from 45 subjects with glaucoma were included in this study. The overall agreement between the automated report and clinical assessment comparing MRW and VF was good at 74.8% with a kappa of 0.62 (95% CI 0.55–0.69). Agreements for the six different MRW sections were moderate to good with kappa values ranging from 0.54 to 0.69. For mean RNFL thickness and VF comparisons, agreement between the automated report and clinical assessment was 75.4% with a kappa of 0.62 (95% CI 0.54–0.70). For different RNFL sectors, kappa values ranged from 0.47 (moderate agreement) to 0.80 (good agreement).ConclusionsThis study suggests that the automated structure–function report combining results from the SD-OCT and the HEP may assist in the evaluation and management of glaucoma.

Evolution of optic nerve photography for glaucoma screening: a review: Evolution of disc photos for screening

Visual evaluation of the optic nerve has been one of the earliest and most widely used methods to evaluate patients for glaucoma. Photography has proven very useful for documentation of the nerves appearance at a given time, allowing more detailed scrutiny then, and later comparison for change. Photography serves as the basis for real‐time or non‐simultaneous review in telemedicine and screening events allowing fundus and optic nerve evaluation by experts elsewhere. Expert evaluation of disc photographs has shown diagnostic performance similar to other methods of optic nerve evaluation for glaucoma. Newer technology has made optic nerve photography simpler, cheaper and more portable creating opportunities for broader utilization in screening in underserved populations by non‐physicians. Recent investigations suggest that non‐physicians or software algorithms for disc photograph evaluation have promise to allow more screening to be done with fewer experts.

Steady-state pattern electroretinogram and short-duration transient visual evoked potentials in glaucomatous and healthy eyes

This study evaluates two rapid electrophysiological glaucoma diagnostic tests that may add a functional perspective to glaucoma diagnosis.