Selective Laser Trabeculoplasty for Medically Uncontrolled Pseudoexfoliation Glaucoma in Korean Patients

Purpose@#This study investigated the efficacy and safety of selective laser trabeculoplasty (SLT) in Korean patients with medically uncontrolled pseudoexfoliation glaucoma (PEXG). @*Methods@#This retrospective observational study enrolled 43 medically uncontrolled PEXG patients who underwent a 360° SLT and were followed up for at least 12 months after SLT. The intraocular pressure (IOP) before and after SLT at 1 week, 1, 3, 6, and 12 months was evaluated. Treatment success was defined as an IOP reduction of ≥20% from the baseline and an IOP equal to lower than 22 mmHg without additional anti-glaucomatous intervention. Additionally, every follow-up medical record was reviewed to assess any possible side effects of SLT. @*Results@#Based on the Kaplan-Meier survival analysis, the treatment success rate at 12 months after SLT was 41.9% (18 eyes). For the success group at the 12 months follow-up, SLT showed a mean IOP reduction of 10.3 ± 5.0 mmHg (from 25.6 ± 4.4 to 15.2 ± 2.9 mmHg; 39.3%, p < 0.05). Among the 25 eyes that were considered as the treatment failure group, 14 eyes underwent glaucoma filtering surgeries, four eyes received additional SLT, and further intervention and follow-up was refused for seven eyes. During the overall follow-up period, there were no significant adverse events. @*Conclusions@#SLT is a partially effective and safe procedure for lowering IOP in Korean patients with medically refractory PEXG. Therefore, it can be considered as one of the alternative treatment modalities in patients who are at high risk for conventional filtering surgery.

Comparison of Clinical Characteristics and Progression Rates of Bilaterally and Unilaterally Progressing Glaucoma

PURPOSE: To compare the clinical characteristics of unilaterally progressing glaucoma (UPG) and simultaneously bilaterally progressing glaucoma (BPG) in medically treated cases. METHODS: Primary open angle glaucoma patients were classified as having UPG or BPG according to an assessment of optic disc and retinal nerve fiber layer photographs and visual field analysis. Risk factors including the presence of systemic diseases (hypertension, diabetes, cerebrovascular accident, migraine, and dyslipidema) were compared between the UPG and BPG groups. Baseline characteristics and pre- and post-treatment intraocular pressure (IOP) were compared between the progressing eye (PE) and the non-progressing eye (NPE) within the same patient in the UPG group and between the faster progressing eye and the slower progressing eye in the BPG group. RESULTS: Among 343 patients (average follow-up period of 4.2 years), 43 were categorized into the UPG group and 31 into the BPG group. The prevalence of all analyzed systemic diseases did not differ between the two groups. PEs in the UPG group had more severe pathology in terms of baseline visual field parameters than NPEs (mean deviation -6.9 ± 5.7 vs. -2.9 ± 3.9 dB, respectively; p < 0.001). However, baseline IOP, mean follow-up IOP, and other clinical characteristics were not significantly different between the PE and the NPE in the UPG group. The progression rate was significantly higher in the faster progressing eye in patients with BPG than in the PE for patients with UPG (-3.43 ± 3.27 vs. -0.70 ± 1.26 dB/yr, respectively; p = 0.014). CONCLUSIONS: There were no significant differences in the prevalence of systemic diseases between the UPG and BPG groups. Simultaneously bilaterally progressing patients showed much faster progression rates than those with a unilaterally progressing eye.

Clinical Characteristics of Glaucomatous Subjects Treated with Refractive Corneal Ablation Surgery

PURPOSE: To evaluate the clinical characteristics of newly diagnosed glaucomatous subjects who had a history of refractive corneal ablation surgery (RCAS). METHODS: Sixty-eight glaucomatous subjects who had a history of RCAS and 68 age- and visual field (VF) mean deviation-matched glaucomatous subjects with no history of RCAS were included. Intraocular pressure (IOP), central corneal thickness (CCT), VF, and retinal nerve fiber layer thickness determined by optical coherence tomography were assessed. Parameters were compared between patients with and without a history of RCAS. Between-eye comparisons in the same participant (more advanced vs. less-advanced eye, in terms of glaucoma severity) were performed in the RCAS group. RESULTS: With similar levels of glaucoma severity, those with a history of RCAS showed significantly lower baseline IOP and a thinner CCT than the eyes of individuals without a RCAS history (13.6 vs. 18.7 mmHg, 490.5 vs. 551.7 micrometer, all p < 0.001). However, the extent of IOP reduction after anti-glaucoma medication did not significantly differ between the two groups (17% vs. 24.3%, p = 0.144). In the between-eye comparisons of individual participants in the RCAS group, the more advanced eyes were more myopic than the less-advanced eyes (-1.84 vs. -0.58 diopter, p = 0.003). CONCLUSIONS: Eyes with a history of RCAS showed a similar level of IOP reduction as eyes without such a history after anti-glaucoma medication. Our finding that the more advanced eyes were more myopic than the less-advanced eyes in the same participant may suggest an association between glaucoma severity and myopic regression.

Increased Intraocular Pressure after Extensive Conjunctival Removal: A Case Report

A 50-year-old woman, who had undergone extensive removal of conjunctiva on the right eye for cosmetic purposes at a local clinic 8 months prior to presentation, was referred for uncontrolled intraocular pressure (IOP) elevation (up to 38 mmHg) despite maximal medical treatment. The superior and inferior conjunctival and episcleral vessels were severely engorged and the nasal and temporal bulbar conjunctival areas were covered with an avascular epithelium. Gonioscopic examination revealed an open angle with Schlemm's canal filled with blood to 360 degrees in the right eye. Brain and orbital magnetic resonance imaging and angiography results were normal. With the maximum tolerable anti-glaucoma medications, the IOP gradually decreased to 25 mmHg over 4 months of treatment. Extensive removal of conjunctiva and Tenon's capsule, leaving bare sclera, may lead to an elevation of the episcleral venous pressure because intrascleral and episcleral veins may no longer drain properly due to a lack of connection to Tenon's capsule and the conjunctival vasculature. This rare case suggests one possible mechanism of secondary glaucoma following ocular surgery.

Increased Intraocular Pressure after Extensive Conjunctival Removal: A Case Report

A 50-year-old woman, who had undergone extensive removal of conjunctiva on the right eye for cosmetic purposes at a local clinic 8 months prior to presentation, was referred for uncontrolled intraocular pressure (IOP) elevation (up to 38 mmHg) despite maximal medical treatment. The superior and inferior conjunctival and episcleral vessels were severely engorged and the nasal and temporal bulbar conjunctival areas were covered with an avascular epithelium. Gonioscopic examination revealed an open angle with Schlemm's canal filled with blood to 360 degrees in the right eye. Brain and orbital magnetic resonance imaging and angiography results were normal. With the maximum tolerable anti-glaucoma medications, the IOP gradually decreased to 25 mmHg over 4 months of treatment. Extensive removal of conjunctiva and Tenon's capsule, leaving bare sclera, may lead to an elevation of the episcleral venous pressure because intrascleral and episcleral veins may no longer drain properly due to a lack of connection to Tenon's capsule and the conjunctival vasculature. This rare case suggests one possible mechanism of secondary glaucoma following ocular surgery.

Clinical Characteristics of Glaucomatous Subjects Treated with Refractive Corneal Ablation Surgery

PURPOSE: To evaluate the clinical characteristics of newly diagnosed glaucomatous subjects who had a history of refractive corneal ablation surgery (RCAS). METHODS: Sixty-eight glaucomatous subjects who had a history of RCAS and 68 age- and visual field (VF) mean deviation-matched glaucomatous subjects with no history of RCAS were included. Intraocular pressure (IOP), central corneal thickness (CCT), VF, and retinal nerve fiber layer thickness determined by optical coherence tomography were assessed. Parameters were compared between patients with and without a history of RCAS. Between-eye comparisons in the same participant (more advanced vs. less-advanced eye, in terms of glaucoma severity) were performed in the RCAS group. RESULTS: With similar levels of glaucoma severity, those with a history of RCAS showed significantly lower baseline IOP and a thinner CCT than the eyes of individuals without a RCAS history (13.6 vs. 18.7 mmHg, 490.5 vs. 551.7 micrometer, all p < 0.001). However, the extent of IOP reduction after anti-glaucoma medication did not significantly differ between the two groups (17% vs. 24.3%, p = 0.144). In the between-eye comparisons of individual participants in the RCAS group, the more advanced eyes were more myopic than the less-advanced eyes (-1.84 vs. -0.58 diopter, p = 0.003). CONCLUSIONS: Eyes with a history of RCAS showed a similar level of IOP reduction as eyes without such a history after anti-glaucoma medication. Our finding that the more advanced eyes were more myopic than the less-advanced eyes in the same participant may suggest an association between glaucoma severity and myopic regression.

Correlation Between Central Corneal Thickness and Glaucomatous Damage

PURPOSE: To evaluate the correlations between central corneal thickness (CCT) and optic disc and retinal nerve fiber layer (RNFL) parameters determined by spectral domain optical coherence tomography (SD OCT) and visual field (VF) global indices. METHODS: The present study included 151 eyes diagnosed with open-angle glaucoma (OAG) and 135 glaucoma suspect (GS) eyes. The CCT, RNFL thickness, optic disc parameters, and VF global indices were measured. The relationships between CCT and RNFL thickness, optic disc parameters, and VF global indices were assessed by linear regression analysis. RESULTS: Intraocular pressure (IOP, p < 0.001) and VF mean deviation (p = 0.005) in all participants, age (p = 0.017) and IOP (p = 0.003) in the GS group, and IOP (p = 0.002) and inferior RNFL thickness (p = 0.017) in the OAG group were significantly associated with CCT. Among the optic disc parameters, rim area, average cup/disc ratio, and vertical cup/disc ratio were significantly associated with CCT in all participants in the univariate but not multivariate analysis. CONCLUSIONS: Optic disc parameters obtained by SD OCT were not correlated with CCT in the OAG or GS group, while RNFL thickness and VF mean deviation showed associations.

Factors Associated with the Signal Strengths Obtained by Spectral Domain Optical Coherence Tomography

PURPOSE: The aim of this study was to investigate factors associated with the signal strengths (SS, image quality scores) of optic disc and macular images obtained using Cirrus spectral domain optical coherence tomography (OCT). METHODS: Ninety-two glaucomatous eyes were imaged using the Cirrus OCT macular and optic disc cube modes after pupil dilation. The influences of patient age, spherical equivalent, cataract presence, and cataract and glaucoma severity (visual field mean deviation), on the SS of images obtained using the two cube modes were compared between patients whose images showed high SS (SS > or =7) and low SS (SS <7). RESULTS: The signal strength was significantly higher in images obtained using the macular cube compared to the optic disc cube mode (7.8 +/- 1.3 vs. 6.9 +/- 1.1, respectively; p = 0.001). Age and visual acuity of patients differed significantly between the high- and low-SS groups when data acquired using the optic disc (p = 0.027 and 0.012, respectively) and macular cube modes (p = 0.046 and 0.014, respectively) were analyzed. When the optic disc cube mode was employed, the extent of cataracts was significantly related to SS, whereas when the macular cube mode was used, none of the factors analyzed was significantly associated with SS. CONCLUSIONS: Age, visual acuity, and the extent of cataracts were significantly associated with images of higher SS when the Cirrus OCT optic disc cube mode was employed.

Glaucoma Progression Detection by Retinal Nerve Fiber Layer Measurement Using Scanning Laser Polarimetry: Event and Trend Analysis

PURPOSE: To evaluate the use of scanning laser polarimetry (SLP, GDx VCC) to measure the retinal nerve fiber layer (RNFL) thickness in order to evaluate the progression of glaucoma. METHODS: Test-retest measurement variability was determined in 47 glaucomatous eyes. One eye each from 152 glaucomatous patients with at least 4 years of follow-up was enrolled. Visual field (VF) loss progression was determined by both event analysis (EA, Humphrey guided progression analysis) and trend analysis (TA, linear regression analysis of the visual field index). SLP progression was defined as a reduction of RNFL exceeding the predetermined repeatability coefficient in three consecutive exams, as compared to the baseline measure (EA). The slope of RNFL thickness change over time was determined by linear regression analysis (TA). RESULTS: Twenty-two eyes (14.5%) progressed according to the VF EA, 16 (10.5%) by VF TA, 37 (24.3%) by SLP EA and 19 (12.5%) by SLP TA. Agreement between VF and SLP progression was poor in both EA and TA (VF EA vs. SLP EA, k = 0.110; VF TA vs. SLP TA, k = 0.129). The mean (+/-standard deviation) progression rate of RNFL thickness as measured by SLP TA did not significantly differ between VF EA progressors and non-progressors (-0.224 +/- 0.148 microm/yr vs. -0.218 +/- 0.151 microm/yr, p = 0.874). SLP TA and EA showed similar levels of sensitivity when VF progression was considered as the reference standard. CONCLUSIONS: RNFL thickness as measurement by SLP was shown to be capable of detecting glaucoma progression. Both EA and TA of SLP showed poor agreement with VF outcomes in detecting glaucoma progression.

Use of Prophylactic Antibiotics in Glaucoma Surgery: A Single Center's Experience

PURPOSE: To evaluate the use of prophylactic antibiotics in glaucoma surgery and the prevalence of postoperative endophthalmitis. METHODS: Retrospective medical record review was performed on 136 eyes which underwent glaucoma operation by one surgeon from March 2008 to February 2010 and were followed at least till 6 months postoperatively (glaucoma drainage device implantation; 95 eyes, trabeculectomy; 41 eyes). RESULTS: For intravenous antibiotics injection, 10 eyes used 3rd generation cephalosporin, 54 eyes used 4-fluoroquinolone, 72 eyes used 2nd generation cephalosporin. For oral antibiotics, 125 eyes used 3rd generation cephalosporin, 1 case used 4-fluoroquinolone, and other 10 cases did not use oral antibiotics after the surgery. Total period of systemic antibiotics use showed various distributions with 14 eyes more than 5 days, 115 eyes 4-5 days, and 8 cases less than 4 days. Six eye which used 4-fluoroquinolone and 3 eyes which used cephalosporin showed side effect such as skin lesion and nausea. There has been no single occurrence of endophthalmitis. CONCLUSIONS: Various kinds of prophylactic antibiotics were used for glaucoma surgery and the period of antibiotics use was different among patients. However, there has been no single occurrence of endophthalmitis till 6 months postoperative follow up.

Characterization of Peripapillary Atrophy Using Spectral Domain Optical Coherence Tomography

PURPOSE: To characterize the features of peripapillary atrophy (PPA), as imaged by spectral-domain optical coherence tomography (SD-OCT). METHODS: SD-OCT imaging of the optic disc was performed on healthy eyes, eyes suspected of having glaucoma, and eyes diagnosed with glaucoma. From the peripheral beta-zone, the retinal nerve fiber layer (RNFL), the junction of the inner and outer segments (IS/OS) of the photoreceptor layer, and the Bruch's membrane/retinal pigment epithelium complex layer (BRL) were visualized. RESULTS: Nineteen consecutive eyes of 10 subjects were imaged. The RNFL was observed in the PPA beta-zone of all eyes, and no eye showed an IS/OS complex in the beta-zone. The BRL was absent in the beta-zone of two eyes. The BRL was incomplete or showed posterior bowing in the beta-zone of five eyes. CONCLUSIONS: The common findings in the PPA beta-zone were that the RNFL was present, but the photoreceptor layer was absent. Presence of the BRL was variable in the beta-zone areas.

Glaucoma Diagnostic Performance of Macular and Retinal Nerve Fiber Layer by Spectral-Domain Optical Coherence Tomography

PURPOSE: To compare the performance of glaucoma diagnosis according to the macular and peripapillary retinal nerve fiber layer (RNFL) thicknesses, as determined by spectral domain optical coherence tomography (OCT). METHODS: Ninety-six normal, 63 early glaucoma and 37 moderate to advanced glaucomatous eyes were imaged by Cirrus OCT. The areas under the receiver operating characteristics curves (AUCs) of macular and RNFL thicknesses were calculated for discrimination of normal and glaucomatous eyes. The sensitivity and specificity of normative classification of each parameter were assessed. RESULTS: The glaucoma diagnostic capability determined by AUC was greater when based on the peripapillary RNFL than the macular thickness (0.914, 0.775, p<0.001). Both the early and the moderate-to-advanced group showed higher AUCs in peripapillary RNFL thickness (early glaucoma group; 0.870, 0.670, p<0.001, moderate to advanced glaucoma group; 0.990, 0.954, p=0.03). The inferior outer sector of macular thickness showed highest sensitivity among the parameters (58%). CONCLUSIONS: Although Cirrus OCT applied to determine macular thickness did not outperform that applied to determine peripapillary RNFL thickness in glaucoma diagnosis, applying Cirrus OCT to determine both thicknesses in diagnosis may help in understanding a patient's status.

Multiple Myeloma Manifesting as a Fluctuating Sixth Nerve Palsy

We report a case of multiple myeloma that presented as a fluctuating sixth cranial nerve palsy in the absence of widespread signs of systemic disease. A 63-year-old woman presented with horizontal diplopia of two weeks duration that subjectively changed over time. Ocular examination showed a fluctuating sixth nerve palsy. A computed tomography (CT) scan of the brain showed multiple, enhancing, soft tissue, mass-like lesions involving the left cavernous sinus and the apex of both petrous bones. Based on bone marrow biopsy and hematologic findings, she was diagnosed with multiple myeloma. Multiple myeloma may be included in the differential diagnosis of a fluctuating sixth nerve palsy, and although ophthalmic signs are rare and generally occur late in the course of multiple myeloma, they can still be its first signs.

The Clinical Result of AcrySof Toric Intraocular Lens Implantation

PURPOSE: To evaluate the short-term efficacy of astigmatism correction and rotational stability of AcrySof Toric Intraocular lens (IOL) implants. METHOD: We analyzed 27 eyes of 23 patients who underwent microcoaxial cataract surgery (MCCS) and AcrySof Toric IOL implantation between March 2008 and July 2008. We evaluated visual acuity, keratometry, and refraction. Slit-lamp retro-illumination photographs were obtained in all patients on 1 day, 1 month and 3 months postoperatively. The change of postoperative IOL axis alignment and the presence of anterior capsular shrinkage were analyzed. RESULT: The mean unaided visual acuity (LogMAR) improved from 1.02+/-0.38 to 0.10+/-0.12. Although postoperative manual keratometric value was not different from the preoperative value, post-operative astigmatism decreased from a mean value of 1.66+/-0.42D to 0.61+/-0.38D at 3 months postoperatively. The mean difference between achieved and intended lens axis was 1.63+/-2.83 degrees at the first post-operative day, and 1.91+/-2.92 degrees on the first postoperative month, with all cases within 10 degrees. There were two cases of IOL rotation between one day and one month postoperative follow-up, and severe anterior capsule contractions were found in them. CONCLUSIONS: AcrySof Toric IOL is effective for correction of astigmatism and it has good post-operative rotational stability. Because most of misalignments were found at the postoperative day 1, the precise implantation of IOL, according to the intended axis, can be important during operation and immediately after the operation.

The Relationship Between Asphericity and Visual Acuity After Wearing Reverse-Geometry Lens

PURPOSE:To report the change of corneal asphericity and the relationship between asphericity and visual acuity after wearing the reverse-geometry lens. METHODS: The authors reviewed out-patient records of 37 consecutive patients wearing reverse-geometry lenses. The patients were followed up from July 2004 to December 2007. The unaided visual acuity (VA), spherical equivalent (SE) and asphericity before and after wearing the lens were compared. The relationship of SE and final VA, initial astigmatism and final VA, and asphericity and final VA was also analyzed. In addition, the relationship between the increment of VA and asphericity was determined. RESULTS: VA and SE improved and the asphericity decreased after wearing the lens (p<0.05). There was high correlation between the spherical equivalent and final visual acuity (p<0.001), and no correlation between asphericity and final visual acuity (p=0.358) was observed. However, the lower the initial asphericity, the greater the increment of visual acuity observed (p=0.048). CONCLUSIONS: Initial corneal asphericity can be a predictor of increment of VA after wearing reverse-geometry lenses.

A Case of Familial Lecithin-cholesterol Acyltransferase (LCAT) Deficiency

PURPOSE: To report a case of a familial lecithin cholesterol acyltransferase (LCAT) deficiency patient with bilateral corneal opacities. CASE SUMMARY: A 26-year-old man with bilateral corneal opacities visited our hospital. We took slit lamp examination, corneal thickness measurement, corneal endothelial cell counts and fundus examination. Blood and urine tests were included. Kidney biopsy was done. The tissues were observed by a light microscopy and an electron microscopy. Hemolytic anemia, proteinuria, hematuria, hypertriglyceridemia, decreased HDL cholesterol level, and lecithin cholesterol acyltransferase (LCAT) deficiency were found. At kidney biopsy, electron-lucent vacuoles and lamellar inclusion body were found. CONCLUSIONS: Bilateral corneal opacities can be an imporant clinical sign of systemic disease which is caused by abnormal lipid metabolism like the familial lecithin cholesterol acyltransferase (LCAT) deficiency.