Optic disc morphology on presentation of chronic glaucoma.
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Glaucoma, Open-Angle↗
Biomedical subjects
D C Broadway
Publications and source records attributed to D C Broadway.
Cyclodiode laser therapy to control intraocular pressure during pregnancy.
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Adult↗
Agreement among clinicians in the recognition of patterns of optic disk damage in glaucoma.
PURPOSE: To determine the interobserver and intraobserver agreement in the recognition of different patterns of glaucomatous optic disk damage and evaluate if these patterns changed over time in patients followed for a number of years. METHODS: Patients with early to moderate glaucoma (n = 105) were consecutively enrolled to participate in a prospective observational study. In the first part of the present study, optic disk photographs obtained closest to patient's entry date in the prospective study were classified in a masked fashion by three observers according to the pattern of optic disk damage into one of the following: (1) focal, (2) myopic, (3) senile sclerotic, (4) concentric cup enlargement, (5) normal appearance, or (6) miscellaneous (those disks that did not qualify for any of the other groups). The observers were also asked to assign a confidence score for each classification, ranging from 1 (low confidence) to 5 (highest confidence). The three observers reclassified the photographs after a minimal period of 2 months, in order to assess intraobserver agreement. In a second part of the study, one observer reviewed, in a masked fashion, all the optic disk photographs that had been taken during the routine follow-up of the 105 patients in order to evaluate whether the classification of disk pattern changed over time. RESULTS: Intraobserver agreement yielded kappa values (95% confidence interval [CI]) from 0.51 (CI, 0.40 to 0.62) to 0.85 (CI, 0.77 to 0.93) depending on the observer. Interobserver agreement kappa values between all three observers was 0.40 (CI, 0.35 to 0.46), but it improved if photographs classified with moderate or higher degrees of confidence were included (0.52 [CI, 0.44 to 0.60]). During a mean follow-up period of 8.2 +/- 4.8 years, 41.6% of the eyes were always classified into the same group and 23.6% of the eyes were classified at least once into two or more of the four patterns of damage (groups 1 to 4). CONCLUSIONS: Intraobserver agreement on the pattern of optic disk damage was generally very good, with some variation among the observers. Interobserver agreement was reasonable and increased proportionally with the confidence in the classification. During long-term follow-up, the pattern of optic disk damage usually did not change. This type of classification can probably be used accurately in clinical practice.
Female↗
Trabeculectomy, risk factors for failure and the preoperative state of the conjunctiva.
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Black People↗
Cyclodiode laser therapy for painful, blind glaucomatous eyes.
AIMS: To determine the ability of cyclodiode laser treatment to relieve discomfort in painful blind glaucomatous eyes. METHODS: 30 eyes underwent cyclodiode to reduce intraocular pressure (IOP) and relieve pain. Patients graded their pre-cyclodiode and post-cyclodiode pain. RESULTS: After a minimum follow up of 6 months, a single cyclodiode treatment lowered mean IOP from 51 mm Hg (95% CI plus or minus 3.7 mm Hg) to 26 mm Hg (95% CI plus or minus 5.8 mm Hg) providing pain relief in 73.3% (22/30). After retreatment of six eyes, mean IOP was reduced to 22 (95% CI plus or minus 5.3) mm Hg and pain relief was obtained in 96.7% (29/30). For eyes achieving pain relief after one treatment, IOP was reduced by >30% in 81.0% (17/21). For eyes not achieving pain relief after one treatment, IOP was reduced by >30% in only 22.2% (2/9) (p=0.0042, Fisher's exact test). CONCLUSION: Cyclodiode was highly successful in providing pain relief in painful blind hypertensive glaucomatous eyes. The best predictor of successful pain relief was IOP reduction of > 30% from baseline.
Aged↗
Survival analysis for success of Molteno tube implants.
AIM: To apply survival analysis in assessing the long term outcome of Molteno tube implantation and to identify risk factors for failure. METHODS: A retrospective, 10 year, consecutive case series study of 119 eyes that underwent implantation of a Molteno tube. The main outcome measures considered were intraocular pressure (IOP), visual acuity, and complications. RESULTS: A 30% or greater reduction in IOP was achieved in 68.9% of cases. However, the overall, "complete success" rate (IOP <22 mm Hg with no medications) after a mean (SD) follow up period of 43 (33) months (range 6-120) was only 33.6% despite a fall in mean (SD) IOP from 38.2 (8.2) mm Hg to 20.1 (11.0) mm Hg. The "qualified success" rate (IOP <22 mm Hg with or without medications) was 60.5%. Failure was most common in the first postoperative year but could occur after several years, the survival curve having an exponential shape. The only statistically significant risk factor for failure identified was pseudophakia, although eyes with neovascular glaucoma tended to fare poorly. Postoperative IOP tended to be lower after double plate than after single plate implantation. There was no significant difference in outcome based on age, sex, race, previous penetrating keratoplasty, or previous conjunctival surgery. CONCLUSIONS: In eyes at high risk of trabeculectomy failure, implantation of an aqueous shunt device should be considered. Pseudophakia should be considered an additional risk factor for failure. Early failure appeared relatively more common but long term follow up of all cases is recommended to ensure adequate management of late failures.
Adult↗
Local anaesthetic techniques and pulsatile ocular blood flow.
AIM: To compare pulsatile ocular blood flow (POBF) and intraocular pressure (IOP) between eyes of patients receiving either peribulbar (with and without balloon compression) or subconjunctival local anaesthesia (LA). METHODS: 30 eyes of 30 patients undergoing cataract surgery by phacoemulsification were investigated in a study of parallel group design. Ten patients had peribulbar LA and 10 minutes compression with a Honan's balloon (group A). A further 10 patients who received peribulbar LA alone (group B) acted as controls for the effects of balloon compression. Ten other patients were given subconjunctival LA (group C). POBF and IOP were measured using a modified Langham pneumatonometer. Three measurements were made in each eye, the first recording immediately before LA, the second 1 minute after, and the third 10 minutes after LA. RESULTS: No significant change in POBF or IOP was recorded in eyes receiving subconjunctival LA. In the peribulbar groups (A and B), there was a drop in median POBF of 252 and 138 microl/min respectively 1 minute after LA, which was statistically significant in both groups (p<0. 01). By 10 minutes, POBF tended to return to baseline levels, but remained significantly reduced in group B (p<0.05). In addition, there was a significant (p<0.05) reduction in IOP (mean drop of 4.82 mm Hg) in group A following peribulbar LA with balloon compression. CONCLUSIONS: POBF was significantly reduced after peribulbar LA but was unchanged after subconjunctival LA. Balloon compression reduced IOP and improved POBF following peribulbar LA. The findings may have clinical implications in patients with compromised ocular circulation or significant glaucomatous optic neuropathy.
Aged↗
Optic disk appearances in primary open-angle glaucoma.
Primary open-angle glaucoma almost certainly develops in a multifactorial manner, with interplay between numerous risk factors affecting the disease. These risk factors, in addition to intraocular pressure, include a number of cardiovascular factors. Some of these factors may determine the appearance of the damaged glaucomatous optic nerve head. Patients with four specific optic disk appearances have been investigated, and differences have been identified in their demographic characteristics, prevalence of certain risk factors, the pattern of visual field damage, and circulatory abnormalities in their retrobulbar vessels. The findings provide evidence of the existence of subgroups of primary open-angle glaucoma with correlations between risk factor and type of optic disk. A reliable method by which the different disk appearances could be distinguished in an objective manner would be clinically valuable, and the scanning laser ophthalmoscope has shown potential promise to achieve this. The results of studies relating to various glaucomatous optic disk appearances are presented and discussed.
Diagnosis, Differential↗
The ability of scanning laser ophthalmoscopy to identify various glaucomatous optic disk appearances.
PURPOSE: To compare four distinct glaucomatous disk appearances using scanning laser ophthalmoscopy and determine the ability of a previously described discriminant analysis to detect glaucomatous damage for each group. METHODS: Two thousand three hundred eighty-eight stereoscopic optic disk photographs of 2,388 subjects with glaucoma or suspicion of glaucoma were reviewed to select four pure glaucomatous optic disk types. Twenty-three topographic, volumetric, and morphometric scanning laser ophthalmoscopic variables from one optic disk of each selected subject were compared. Differences between the groups were evaluated using an analysis of variance and the Pearson chi-square test. RESULTS: Forty-four focal ischemic disks, 38 myopic glaucomatous disks, 30 senile sclerotic disks, and 28 disks characterized by generalized cup enlargement were studied. Significant intergroup differences were found for the majority of the evaluated optic disk variables. The accuracy with which the discriminant analysis model was able to detect disks with glaucomatous visual field damage was 93.2% for focal ischemic disks, 81.6% for myopic disks, 66.7% for senile sclerotic disks, and 78.6% for disks with generalized cup enlargement. CONCLUSIONS: By comparing mean values for certain optic disk variables, scanning laser ophthalmoscopic optic disk assessment can distinguish groups of disks with specific appearances. However, the ability of presently available software to detect glaucomatous damage varied considerably with disk appearance. Expert clinical optic disk evaluation remains an important part of the assessment of patients suspected of having glaucoma, although refinement of computerized scanning laser ophthalmoscopic disk assessment may eventually make this easier.
Analysis of Variance↗
Local effects of previous conjunctival incisional surgery and the subsequent outcome of filtration surgery.
PURPOSE: Previous ocular surgery involving conjunctival incision is a risk factor for failure of filtration surgery. To determine whether using adjunctive antimetabolite therapy may have a rational basis, a study was performed to determine whether the conjunctival cellular profile was altered by such surgery. METHODS: After a mean follow-up of 5.9 years, filtration surgery outcomes for 35 patients who had undergone conjunctival incisional surgery were retrospectively compared with 29 control and 18 matched patients who had not undergone such surgery. At the time of filtration surgery, a conjunctival biopsy specimen was obtained from all 82 patients, and these were quantitatively analyzed by light microscopy in a prospective manner. RESULTS: Trabeculectomy success for the control group (93%) was significantly higher than for the previous surgery group (38%) (P < .001). Compared with control tissue, conjunctiva from the patients who had undergone previous surgery contained more fibroblasts (P < .001, P < .05), macrophages (P < .01, P < .001), and lymphocytes (P = .001, P < .01) in both superficial and deep substantia propria (respective P values). Furthermore, trabeculectomy failure was associated with an increase in number of conjunctival fibroblasts in intraoperative specimens. CONCLUSIONS: Previous ocular surgery involving the conjunctiva increases the number of conjunctival fibroblasts and inflammatory cells. This may account for the increased risk of trabeculectomy failure. Perhaps on this basis, the use of adjunctive medication may be justified in patients who have undergone previous ocular surgery involving conjunctival incision.
Adolescent↗
Anterior segment dysgenesis and congenital glaucoma associated with partial trisomy of chromosome 1 (1q32-qter).
A child born with partial trisomy of chromosome 1 (1q32-qter) survived and was seen for anterior segment dysgenesis and congenital glaucoma. Pure trisomy 1q is rarely seen in live-born infants and has not previously been described in association with congenital glaucoma. The genetic basis for glaucoma is complicated and multifactorial and probably determined by a number of genes on a variety of chromosomes. The current case provides some evidence that part of chromosome 1 may be involved with the etiology of a glaucomatous process.
Anterior Eye Segment↗
Glaucoma and vasospasm.
AIMS/BACKGROUND: To study the vasoactivity of glaucoma patients with four previously described and distinct disc appearances potentially representative of primary open angle glaucoma subgroups. METHODS: Patients with pure examples of four glaucomatous optic disc types--focal ischaemic, myopic glaucomatous, senile sclerotic, and those with generalised cup enlargement, were selected. A detailed ophthalmic, systemic, drug, and smoking history was taken from the patients who, in addition, underwent assessment of peripheral vasospasm with a laser Doppler flowmeter. Differences between the groups were evaluated using an analysis of variance, Student's t test, Pearson's chi 2 test, Fisher's exact test together with Spearman's and Pearson's correlation tests. RESULTS: 38 patients with focal ischaemic, 37 with myopic glaucomatous, 24 with senile sclerotic, and 24 with discs characterised by generalised cup enlargement met the selection criteria. The group of patients with focal ischaemic discs contained more women (66% versus 32%-50% in the other three groups; p = 0.01) and had a higher prevalence of vasospasm (63% versus 25%-49%; p = 0.01), migraine (32% versus 8%-19%; p = 0.02), and cold extremities (66% versus 17%-30%; p = 0.00003). The group of patients with senile sclerotic discs had a higher prevalence of systemic cardiovascular disease (58% versus 21%-30% in the other three groups; p = 0.01) and thyroid disease (21% cf 0%-8%; p = 0.01) and although their mean age was greater (76 years cf 55-65 years; p < 0.00001) the findings were independent of age. Smoking was unrelated to optic disc type. CONCLUSION: Vasospasm, previously associated with normal tension glaucoma, and generalised cardiovascular disease both appear to be specific risk factors for the development of particular subgroups of glaucoma and may be independent of absolute intraocular pressure levels exerting effects in patients with both "normal" or "raised" intraocular pressure. The simple assessment as to whether a glaucoma patient suffers from colder extremities than average appeared to be better at distinguishing the focal ischaemic type of glaucoma than the more complex determination of vasospasm using the laser Doppler flowmeter.
Adult↗
A comparison of healthy, ocular hypertensive, and glaucomatous optic disc topographic parameters.
PURPOSE: To compare the optic discs of 62 healthy individuals 68 patients who have ocular hypertension (OH), and 182 patients with primary open-angle glaucoma (132 high-tension glaucoma (HTG) and 50 normal-tension glaucoma (NTG)), and determine whether disc size exerted an influence on the group differentiation. PATIENTS AND METHODS: Standard criteria were used to define glaucoma and normality. Ocular hypertension was defined as having raised intraocular pressure, a normal visual field, and a healthy optic disc/retinal nerve fiber layer (RNFL). The optic disc of one eye from each individual was analyzed using a confocal scanning laser ophthalmoscope (Heidelberg Retina Tomograph software version 1.11, Heidelberg Engineering, Heidelberg, Germany). Thirteen topographical, volumetric, and shape parameters were compared between the three diagnostic groups. In addition, the individuals were divided into subgroups on the basis of disc size to determine any effect of disc size on the differentiating ability of the confocal scanning laser ophthalmoscope. Differences between the groups were evaluated using an analysis of variance. RESULTS: Glaucomatous optic discs were found to differ from both healthy and OH discs, although no differences in disc area between the groups were identified. On the basis of disc size, differentiating the glaucomatous discs was best for midsized discs of 2 mm2 to 3 mm2. However, no difference was found between healthy and OH discs, even when allowing for disc size. CONCLUSIONS: Ocular hypertensive optic discs (with a clinically normal appearance) could not be distinguished from healthy discs using a confocal scanning laser ophthalmoscopic technique. Glaucomatous optic discs were found to differ from both healthy and OH discs, with a limited effect of disc size.
Analysis of Variance↗
Reversal of topical antiglaucoma medication effects on the conjunctiva.
OBJECTIVE: To determine whether the adverse effects of antiglaucoma medications could be reversed before filtration surgery, potentially reducing the risk of subsequent failure. METHODS: One month before surgery, 30 patients who were receiving multiple antiglaucoma medications underwent an inferior bulbar conjunctival biopsy, ceased using sympathomimetic drops, and began treatment with topical corticosteroid, (1% fluorometholone four times daily). At the time of surgery two conjunctival biopsy specimens were obtained, one from the operation site (superior bulbar region), and one from the inferior bulbar region. The biopsy specimens were quantitatively analyzed by light microscopy. In addition, the outcome of first trabeculectomy for 16 of these patients was compared with that of 16 matched patients who had not undergone an altered preoperative regimen of topical therapy. RESULTS: During a 1-month period a notable decrease occurred in the number of fibroblasts and inflammatory cells throughout the conjunctiva. Inferior bulbar conjunctiva was found to be representative of superior bulbar conjunctiva with respect to these changes. Furthermore, evidence comparing the matched patients suggested that the altered preoperative regimen may have improved the success rate of trabeculectomy. CONCLUSIONS: The preoperative regimen used reversed the adverse conjunctival effect of topical medication. The regimen may be of clinical benefit in improving the success rate of trabeculectomy.
Administration, Topical↗
Adverse effects of topical antiglaucoma medication. I. The conjunctival cell profile.
OBJECTIVE: To determine the effect of various long-term topical antiglaucoma regimens on the cell population profile of the conjunctiva. METHODS: Conjunctival biopsy specimens from 124 patients undergoing filtration surgery were assessed quantitatively by light microscopy. Preoperatively, the patients had used a drug for only a brief period (group A; n = 28), a beta-blocker alone (group B; n = 31), a beta-blocker in combination with a miotic (group C; n = 33), or a combination of beta-blocker, miotic, and sympathomimetic (group D; n = 32). RESULTS: The conjunctiva in groups A and B was similar. Group C conjunctiva differed, but the changes were most marked in biopsy specimens from patients in group D, where there was a significant decrease in goblet cells (P < .05); increase in pale cells, macrophages, and lymphocytes within the epithelium (P < .001); and increase in fibroblasts (P < .001), macrophages (P < .001), mast cells (P < .05), and lymphocytes (P = .01) in the substantia propria. In addition, the effect of duration of therapy was assessed. Administration of topical medication for more than 3 years was found to increase the numbers of pale cells within the epithelium (P < .05); fibroblasts (P < .05), macrophages (P < .001), lymphocytes (P < .01), and mast cells (P = .001) within the superficial substantia propria; and the numbers of fibroblasts (P = .01) and macrophages (P < .05) within the deep substantia propria. CONCLUSIONS: The compared treatment regimens affected the conjunctiva to different degrees, with multiple-drug topical therapy exerting the greatest effect on the degree of subclinical inflammation within the conjunctiva. The results also indicated that administration of topical medication, irrespective of type, for 3 years or more induced a significant degree of subclinical inflammation.
Administration, Topical↗
Adverse effects of topical antiglaucoma medication. II. The outcome of filtration surgery.
OBJECTIVE: To determine the effect of long-term topical antiglaucoma therapy on the results of glaucoma filtration surgery and to relate any differences to the cell population profile of the conjunctiva. METHODS: Filtration surgery was performed in 124 patients (trabeculectomy in 112 and triple procedures [trabeculectomy, cataract extraction, and intraocular lens implantation] in 12), and the outcome of these procedures was assessed after a minimum follow-up of 6 months. A conjunctival biopsy specimen was obtained at the time of surgery. The patients were divided into four groups according to the type of topical therapy administered. The duration of therapy tended to be greater for the patients treated with a greater number of medication types. The outcome of trabeculectomy was assessed in 106 of the patients. RESULTS: In comparison with the briefly treated-primary surgery group, the success rate of trabeculectomy (90% [n = 28]) was similar to that in the group treated with beta-blockers (93% [n = 29]). The trabeculectomy success rate for patients treated with beta-blockers and miotics was significantly lower (72%, P < .01 [n = 29]), and that for the group treated with beta-blockers, miotics, and sympathomimetics was even lower (45%, P < .001, [n = 20]). CONCLUSIONS: Various treatment regimens were associated with differential effects on the success rate of trabeculectomy. Long-term topical combination therapy was identified as a significant risk factor for failure of trabeculectomy. Preoperative conjunctival cell counts from patients whose trabeculectomies were successful were compared with those whose trabeculectomies failed. Failure was associated with significantly more pale cells (P < .01), macrophages (P < .05), and lymphocytes (P < .05) in the epithelium; fibroblasts (P < .05) and macrophages (P < .05) in the superficial substantia propria; and both macrophages and lymphocytes in the deep substantia propria (P < .01). Thus, preoperative subclinical conjunctival inflammation induced by previous topical medication was identified as a risk factor for failure of trabeculectomy.
Administration, Topical↗
Mycobacterium chelonei keratitis: a case report and review of previously reported cases.
A 56-year-old woman who wore hard contact lenses developed a keratitis due to Mycobacterium chelonei. The organism was only sensitive to imipenem and partially to ciprofloxacin and erythromycin. After an initial response to topical therapy with these antibiotics the infection relapsed and a penetrating keratoplasty was performed, with resulting cure. M. chelonei has not previously been reported as a cause of keratitis associated with hard contact lens wear; neither has its treatment with imipenem and/or ciprofloxacin. A detailed photographic record showing the natural history of the keratitis is presented. Previously reported cases of M. chelonei keratitis are reviewed.
Ciprofloxacin↗
Young patient trabeculectomy. Assessment of risk factors for failure.
BACKGROUND: Various risk factors for failure of glaucoma filtering surgery, including young age, have been suggested. METHODS: A retrospective study of 113 trabeculectomies in 113 patients, ranging in age between 11 and 49 years (mean, 33.3 +/- 10.5 years), was carried out to determine the influence of these risk factors in young patients. RESULTS: A successful outcome (intraocular pressure [IOP] < or = 21 mmHg without antiglaucoma treatment), assessed by life-table analysis, was achieved in 54% of trabeculectomies after 38 months (mean follow-up, 36.7 +/- 29.7 months). Previous ocular surgery (e.g., glaucoma filtering, cataract, or conjunctival surgery) and previous laser therapy (i.e., argon laser trabeculoplasty and YAG laser iridotomy) both significantly reduced the success rate. An IOP greater than 40 mmHg during the course of the disease was found to adversely affect the outcome. No direct correlation between success rate and age and no racial difference were demonstrated. Success rates for specific diagnoses were not significantly different. Postoperative subconjunctival injections of 5-fluorouracil (5-FU) did not significantly improve the success rate. A Cox regression analysis of various prognostic variables identified previous cataract surgery (hazard ratio, 4.4), argon laser trabeculoplasty (hazard ratio, 3.4), previous glaucoma filtering surgery (hazard ratio, 2.5), nonfiltering glaucoma surgery (hazard ratio, 2.2) and IOP greater than 40 mmHg (hazard ratio, 2.4) to be the major risk factors for glaucoma filtering surgery failure. CONCLUSION: A majority (74%) of the patients in our series had at least one of these risk factors, thus explaining why young patients, in general, have lower success rates for trabeculectomy.
Adolescent↗