Ya-Ping Jin

Effect of Sleeping in a Head-Up Position on Intraocular Pressure in Patients with Glaucoma

PURPOSE To determine whether a 30-degree head-up sleeping position decreases nocturnal intraocular pressure (IOP) compared with lying flat in patients with glaucoma. DESIGN Prospective, nonrandomized comparative case series. PARTICIPANTS Seventeen eyes of 17 patients with glaucoma with controlled IOP and new disc hemorrhage. METHODS Patients with a new disc hemorrhage despite well-controlled IOP were evaluated in a sleep laboratory on 2 separate nights, the first night lying flat and the second night in a 30-degree head-up position. Intraocular pressure and blood pressure (BP) were measured every 2 hours from 6 PM to 8 AM. For the 6 PM, 8 PM, 10 PM, and 8 AM measurements (awake period) the subjects were sitting for both nights. For the midnight, 2 AM, 4 AM, and 6 AM measurements (sleep period), the subjects were supine for the first night and 30 degrees head up for the second night. MAIN OUTCOME MEASURE Difference in IOP during the sleep period (midnight to 6 AM) between lying flat and 30-degree head-up positions. RESULTS Seventeen eyes of 17 patients were included. There were no significant differences (P=0.68) between the 2 study visits in IOP during the awake period (6 PM, 8 PM, 10 PM, and 8 AM) when patients were sitting upright. During the sleep period (midnight to 6 AM) the mean IOP was 3.2 mmHg lower in the 30-degree head-up position compared with the flat position (P=0.03; 95% confidence interval, 0.25-6.1 mmHg). Sixteen of 17 patients (94.1%) had lower IOP in the 30-degree head-up position. The reduction in IOP in the 30-degree head-up position was 20% or more in 35% of patients (6/17). There were no differences in BP or ocular perfusion pressure between the 2 positions. CONCLUSIONS The 30-degree head-up sleeping position lowers IOP compared with the flat position. Although this effect varies between individual patients, mean IOP was 20% lower in one third of patients in this series. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any materials discussed in this article.

Comparison of visual recovery following ex-PRESS versus trabeculectomy: results of a prospective randomized controlled trial.

Purpose:To compare the rate of visual recovery after Ex-PRESS implantation versus standard trabeculectomy. Patients and Methods:Subjects enrolled in a prospective randomized controlled trial comparing Ex-PRESS to trabeculectomy were analyzed for postoperative changes in visual acuity (VA). Risk factors for visual loss (split fixation, cup-disc ratio, intraocular pressure, visual field mean deviation, and hypotony) were evaluated. Results:Sixty-four subjects were enrolled (33 Ex-PRESS, 31 trabeculectomy). There was no significant difference in mean logMAR VA between groups at baseline or any study visit. VA was significantly reduced up to week 2 following surgery in both the groups. However, by month 1, VA in the Ex-PRESS group was no longer significantly different from baseline (P=0.23) and remained nonsignificant at subsequent visits up to 6 months. In the trabeculectomy group, VA remained significantly lower than baseline at each study visit. At 6 months, 47% of the trabeculectomy eyes compared with 16% of the Ex-PRESS eyes had lost ≥2 Snellen lines (P=0.01). Reasons for VA loss included cataract, central retinal vein occlusion, and diabetic retinopathy, however, in a significant number of cases no cause could be determined. None of the risk factors evaluated were associated with vision loss. Conclusions:Although there was no difference in mean VA between the Ex-PRESS and trabeculectomy groups at any time point, trabeculectomy eyes were more likely to lose ≥2 Snellen lines. In addition, VA recovered faster in the Ex-PRESS group.

Eye care utilization in Canada: disparity in the publicly funded health care system.

OBJECTIVES To examine patterns in, determinants of, and barriers to eye care utilization in Canada. DESIGN Cross-sectional survey. PARTICIPANTS All 132,221 respondents to the Canadian Community Health Survey 2005. METHODS Eye care utilization was self-reported and was defined as having seen or talked on the telephone with an eye care provider (ophthalmologist or optometrist) in a 12-month period. Associations of interest were assessed by prevalence ratios (PR). RESULTS Forty percent (11 million) of Canadians aged 12 years or older reported utilization of eye care providers. The lowest utilization rates occurred in people aged 30-39 years and the highest in those aged 70 years and older. Utilization was not related to levels of education or household income in people with self-reported glaucoma, cataracts, or diabetes. Among Canadians without these conditions, significantly less utilization occurred in men, in those with less than a postsecondary education, and in those with annual household incomes under

Prospective Randomized Study Comparing Ex-PRESS to Trabeculectomy: 1-Year Results.

30,000. Canadians residing in Newfoundland and Labrador utilized eye care providers significantly less than those residing in other provinces (adjusted PR 0.80, 95% CI 0.74-0.86). Fourteen percent of glaucoma patients, 37% of diabetic patients, and 41% of people aged 65 years or older did not access eye care providers over a 12-month period. CONCLUSIONS Marked disparities occur in eye care utilization among Canadians without known eye diseases. A substantial proportion of people at a high risk of vision loss do not access eye care providers. Attributable factors are likely incomplete government coverage, asymptomatic ocular diseases, and lack of perceived benefits of eye care services.

Corticosteroids versus NSAIDs on intraocular pressure and the hypertensive phase after Ahmed glaucoma valve surgery.

Purpose:To compare the efficacy and safety of the Ex-PRESS glaucoma shunt with standard trabeculectomy. Patients and Methods:Consenting patients with medically uncontrolled open-angle glaucoma were prospectively randomized to trabeculectomy or Ex-PRESS shunt both with mitomycin-C. Exclusion criteria included previous ocular surgery with the exception of clear cornea phaco or 1 previous trabeculectomy, uveitis, and vitreous in the anterior chamber. Standardized data collection sheets were completed at baseline and postoperative day 1, weeks 1 and 2, and months 1, 2, 3, 6, and 12. Primary outcome was intraocular pressure (IOP). Complete success was defined as an IOP between 5 and 18 mm Hg and a 20% reduction from baseline without medication. A sample size calculation determined that 52 eyes were required to detect a 2.0 mm Hg IOP difference with a power of 80%. Results:Sixty-four subjects were enrolled, 33 in the Ex-PRESS and 31 in the trabeculectomy group. IOP was not statistically significantly different between groups. Baseline and 1-year mean IOP was 22.0±6.8 versus 22.7±10.3 mm Hg (P=0.76) and 11.6±4.5 versus 11.3±4.5 mm Hg (P=0.81) in the trabeculectomy versus Ex-PRESS groups, respectively. Complete success was 57% versus 70% (P=0.28) in the trabeculectomy versus Ex-PRESS groups, respectively. There were no statistically significant differences in surgical time, number of glaucoma medications, visual acuity, central corneal thickness, endothelial cell counts, complications, interventions, or bleb morphology between the trabeculectomy and the Ex-PRESS groups. Conclusions:There was no statistically significant difference between the trabeculectomy and Ex-PRESS groups regarding IOP, success rates, complications, additional interventions, and bleb morphology.

Effect of beclomethasone nasal spray on intraocular pressure in ocular hypertension or controlled glaucoma.

PurposeTo compare the effect of topical steroids versus nonsteroidal anti-inflammatory drugs on intraocular pressure (IOP) and the hypertensive phase (HP) after Ahmed glaucoma valve surgery. Patients and MethodsProspective, randomized, double-masked controlled trial. Twenty-eight consecutive consenting patients scheduled for Ahmed glaucoma valve surgery were randomized to receive either postoperative topical dexamethasone or ketorolac. The main outcome measure was IOP. Secondary outcomes included incidence of HP, visual acuity, number of glaucoma medications, postoperative complications, and subsequent procedures. ResultsThe mean postoperative IOP (in mm Hg) in the ketorolac versus dexamethasone arms respectively was as follows: 8.8±4.7 versus 10.0±4.5 at week 1 (P=0.500); 10.7±6.7 versus 17.5±10.4 at week 2 (P=0.053); 11.0±6.5 versus 18.0±7.3 at week 4 (P=0.013); 14.8±8.6 versus 17.5±5.2 at week 6 to 8 (P=0.323); and 14.8±9.6 versus 17.8±7.5 at week 10 to 12 (P=0.374). Four patients (31%) in the ketorolac arm versus 8 patients (53%) in the dexamethasone arm exhibited the HP (P=0.276). Wound leak was the most severe complication and there were 3 cases (23%) in the ketorolac group versus nil in the steroid group (P=0.087). Conjunctival retraction was observed in 8 patients (62%) in the ketorolac arm versus 2 patients (13%) in the dexamethasone arm (P=0.016). ConclusionsMean IOP was greater at all time points postoperatively in the steroid group with the difference between groups statistically significant at week 4. The nonsteroidal anti-inflammatory drug group showed greater wound-healing problems.

Effect of local anesthesia on trabeculectomy success.

PurposeTo evaluate the effect of 6 weeks administration of beclomethasone nasal spray on intraocular pressure (IOP) in patients with ocular hypertension or controlled primary open-angle glaucoma. Patients and MethodsRandomized double-masked controlled trial. Patients were randomized to twice daily beclomethasone versus placebo saline nasal spray. There were a total of 4 study visits: baseline and weeks 2, 4, 6 after starting the spray. Each study visit was at the same time within a 1-hour time window. Primary outcome measure was IOP. Secondary measures included visual acuity, anterior segment changes, patient reported side effects, and compliance. Study endpoint was 6 weeks from the start of treatment or an IOP increase of >20% from baseline. A sample size calculation suggested that 8 patients in each arm would be sufficient to detect a difference of 3.2 mm Hg with a power of 80%. ResultsNineteen consecutive consenting patients completed the study—9 in the steroid arm and 10 in the placebo arm. There were no statistically significant differences between groups in baseline characteristics, IOP at each study visit, or change in IOP from baseline at any time point. At 6 weeks, the change in mean IOP from baseline was +0.50±1.52 versus +0.70±1.44 mm Hg in the steroid and saline nasal spray groups, respectively (P=0.77). ConclusionsPatients with ocular hypertension and primary open-angle glaucoma showed no evidence of IOP elevation after 6 weeks use of beclomethasone nasal spray.

Meta-analysis of 1- versus 2-Site Phacotrabeculectomy.

PurposeTo compare the long-term results of trabeculectomy surgery with subconjunctival anesthesia versus topical lidocaine 2% jelly. MethodsA retrospective review of the long-term intraocular pressure (IOP) of 57 trabeculectomies previously enrolled in a prospective study comparing subconjunctival anesthesia to topical lidocaine 2% jelly. Baseline data included patient demographics, diagnosis, and ophthalmic history. Postoperative data included IOP, glaucoma therapy, and any interventions. Follow-up was conducted by reviewing the medical charts from July 2002 to August 2007. Differences between the groups were statistically assessed by the Student t test, χ2 test, Fisher exact test, and Kaplan-Meier survival analysis. ResultsData were available for 57 of the 58 original study patients, with a median age of 65 years. The median follow-up time was 4.2 years for both groups (range: 0.1 to 4.8). There were no statistically significant differences in baseline characteristics and follow-up observations. At the 4-year follow-up, 29.5% of the subconjunctival anesthesia patients versus 39.5% of the topical lidocaine 2% jelly patients were complete success (IOP between 6 to 21 mm Hg and 20% reduction without glaucoma therapy or repeat filtration surgery, P=0.15) and 82.7% of the subconjunctival anesthesia patients versus 95.8% for the topical lidocaine 2% jelly patients were qualified success (above with or without glaucoma therapy, P=0.39). ConclusionsThough small numbers observed, the 2 anesthetic techniques did not seem to influence the long-term success of trabeculectomy surgery. Further studies with more patients are warranted.

Ciliary Body Lymphangiogenesis in Uveal Melanoma with and without Extraocular Extension

TOPIC Comparison of efficacy of intraocular pressure (IOP) reduction between 1- versus 2-site phacotrabeculectomy. CLINICAL RELEVANCE The last systematic review concluded that there was weak evidence to suggest that 2-site phacotrabeculectomy provides 1- to 2-mmHg lower IOP than 1-site surgery. Since this study, there have been further publications on this topic, stimulating this meta-analysis. METHODS/LITERATURE REVIEWED Randomized controlled trials comparing 1- versus 2-site phacotrabeculectomy were searched through August 2009 using MEDLINE and the Cochrane Registry with the keyword phacotrabeculectomy. Inclusion criteria were prospective randomized controlled trials, a minimum of 12 months of follow-up, and English language. Quality of the trials was assessed using Cochrane collaborations tool of assessing risk of bias. The main outcome measure was IOP, and secondary outcomes included number of glaucoma medications, visual acuity, complications, and surgical time. RESULTS Ten articles were included. There was no statistically significant difference in the amount of IOP reduction between 1- and 2-site phacotrabeculectomy. The pooled IOP decreases from baseline (95% confidence interval) were: 7.85 mmHg (6.76-8.92 mmHg) versus 5.83 mmHg (4.72-6.94 mmHg) at 1 month; 8.03 mmHg (7.38-8.67 mmHg) versus 7.03 mmHg (6.35-7.71) at 3 months; 7.78 (7.14-8.42) versus 6.75 (6.04-7.46) at 6 months; 6.44 (5.47-7.41 mmHg) versus 6.68 mmHg (5.56-7.81 mmHg) at 12 months; 7.17 mmHg (6.45-7.89 mmHg) versus 6.56 mmHg (5.77-7.35 mmHg) at 24 months; and 7.76 mmHg (7.02-8.49 mmHg) versus 7.14 mmHg (6.36-7.92 mmHg) at 36 months for 1- versus 2-site phacotrabeculectomy, respectively. There was no significant difference in the reduction in glaucoma medications or change in visual acuity at any time point. CONCLUSIONS There is no significant difference in IOP reduction between 1- and 2-site phacotrabeculectomy.

Government-insured routine eye examinations and prevalence of nonrefractive vision problems among elderly

PURPOSE To determine whether peritumoral ciliary body lymphatics are found in uveal melanoma in the absence of extraocular extension. DESIGN Consecutive case series from 1999 to 2005. PARTICIPANTS Thirty-two uveal melanoma cases involving the ciliary body from the Ophthalmic Pathology Laboratory, University of Toronto, of which 23 showed no extraocular extension. METHODS All immunofluorescence studies and quantitative analyses were performed in a masked fashion. Sections were immunostained for the presence of lymphatic endothelium using podoplanin (D2-40 antibody) and blood vessel endothelium using CD34. MAIN OUTCOME MEASURES Identification and quantification of D2-40-positive lymphatic vessels in the ciliary body. RESULTS In every case (n = 32), D2-40-positive lymphatics were detected in the peritumoral ciliary body. Lymphatic signal was significantly increased in the peritumoral ciliary body compared with the nonperitumoral ciliary body (P < 0.0001). There was no difference in lymphatic signal between cases with and without extraocular extension (P > 0.05). Lymphatics were not detected within the tumors. CONCLUSIONS Peritumoral lymphangiogenesis was present in the ciliary body in uveal melanomas with and without extraocular extension, and as such, the presence of peritumoral lymphatics is not recommended as a prognostic marker in uveal melanoma.