The Finnish evidence-based guideline for open-angle glaucoma.

In most patients, chronic open-angle glaucoma is a slowly progressive disease. Eyes with very high intraocular pressure (IOP > 30 mmHg) represent an exception to this and should be treated and followed extremely intensively. As lowering IOP is, so far, the only means of treating glaucoma, the majority of research reports deal with the IOP-lowering effect of the treatment. The primary goal of treatment, however, is to prevent glaucomatous damage to the structures and function of the eye. The effectiveness of treatment is monitored with optic disc and retinal nerve fibre layer imaging and with visual field examinations. If the glaucomatous changes are progressing, more effective treatment should be given. In the course of follow-up, it should be noted that the changes in the optic nerve structure and function appear and progress at different time-points with delays of up to several years. The assessment of abnormalities is dependent on the examination method and requires a great deal of experience on the part of the examiner. The important risk factors in glaucoma are elevated IOP (even if IOP is within normal range in half of patients ), age, positive family history, exfoliation, race and myopia.

Compression forces of haptics of selected posterior chamber lenses.

PURPOSE: To compare the compressive forces of the haptics of different intraocular lens (IOL) models and analyze the observed differences. SETTING: Central Hospital of Central Finland and University of Jyväskylä, Jyväskylä, Finland. METHODS: The haptics of 28 IOL models were compressed to a diameter of 9.0 mm. The compression forces were measured at 0.5 mm intervals. The conclusions were verified by numerical simulations of mechanical models of the lenses. RESULTS: The measured forces varied between 100 and 601 mg at a diameter of 11.0 mm, 206 and 1057 mg at a diameter of 10.0 mm, and 315 and 2094 mg at a diameter of 9.0 mm. The slopes of the force curves of the three-piece lenses were fairly linear. In general, the three-piece models were less rigid than one-piece models and underwent plastic deformations after repeated compressions. For most one-piece models, compression force increased progressively with increasing compression. The overall IOL diameter and differences in haptic thickness and length and the angle between optic at the point of haptic insertion were the main causes of the observed differences in the compression forces. The variation in forces between individual specimens of the same model, which occurred with almost all models, were mainly the result of variations in haptic thickness. CONCLUSION: Great variations in the compression forces of the IOL haptics were found. Compression behaviors should be taken into account when selecting a lens to implant.

Ophthalmic manifestations of epidemic nephropathy.

An ophthalmic examination was performed on 29 epidemic nephropathy patients consequently treated in the Central Hospital of Central Finland during the acute phase of the disease. Twenty-six of those patients were reexamined after an interval of one month. In the acute phase of the disease pathological ophthalmic changes were found in 15 cases (52%). The symptoms observed were conjunctival injection, oedema, flare and cell reaction in anterior chamber, anisochoria, retinal oedema, acute glaucoma and myopic shift of refraction. The main effect of disease on intraocular pressure was pressure-lowering. The myopic shifts were not dependent on initial refraction. In one case of acute glaucoma this shift could be explained by swelling and forward movement of the lens.

The dexamethasone provocative test: a predictive tool for glaucoma?

A retrospective follow-up study of 134 patients (84 women and 50 men) tested for their responsiveness to topically administered corticosteroids was carried out. Of the 134 patients tested, 34 (25.4%) had a high response (IOP rise greater than or equal to 16 mmHg), 66 (49.3%) an intermediate (IOP rise 6-15 mmHg) and 34 (25.4%) a low response (IOP rise less than or equal to 5 mmHg) to topically administered 0.1% dexamethasone eye drops. Follow-up time varied from 5 to 15 years (mean 7.1 years). During the follow-up period 29 (21.6%) patients developed glaucoma. Of these, 9 (31.0%) were high responders and 7 (24.0%) had a low response to corticosteroids. Log-linear analysis showed no correlation between corticosteroid response and development of glaucoma in the study eye (SD = 0.232, DF = 2, P = 0.890), the control eye (SD = 1.234, DF = 2, P = 0.540) or both eyes (SD = 0.618, DF = 2, P = 0.734). At the final examination 75 patients (56%) had an IOP of greater than or equal to 22 mmHg. Of these ocular hypertensive patients 28 (37.3%) were high responders, and 15 (20%) had a low response to corticosteroids. Of the whole material of 134 patients 44 had a family history of glaucoma. Eleven (25.1%) of these were high responders and 14 (31.8%) low responders. Of the 29 patients who developed glaucoma 8 had a family history of glaucoma. Of these 3 were high responders and 3 low responders. The results indicate that the dexaprovocative test yielded relatively limited value in the screening of patients for glaucoma.

Effect of spectacle use and accommodation on myopic progression: final results of a three-year randomised clinical trial among schoolchildren.

Two hundred and forty mildly myopic schoolchildren aged 9-11 years were randomly allocated to three treatment groups and the progression of myopia was followed-up for three years. The treatment groups were: (1) minus lenses with full correction for continuous use (the reference group), (2) minus lenses with full correction to be used for distant vision only, and (3) bifocal lenses with +1.75 D addition. Three-year refraction values were received from 237 children. The differences in the increases of the spherical equivalents were not statistically significant in the right eye, but in the left eye the change in the distant use group was significantly higher (-1.87 D) than in the continuous use group (-1.46 D) (p = 0.02, Student's t test). There were no differences between the groups in regard to school achievement, accidents, or satisfaction with glasses. In all three groups the more the daily close work done by the children the faster was the rate of myopic progression (right eye: r = 0.253, p = 0.0001, left eye: r = 0.267, p = 0.0001). Myopic progression did not correlate positively with accommodation, but the shorter the average reading distance of the follow-up time the faster was the myopic progression (right eye: r = 0.222, p = 0.0001, left eye: r = 0.255, p = 0.001). It seems that myopic progression is connected with much use of the eyes in reading and close work and with short reading distance but that progression cannot be reduced by diminishing accommodation with bifocals or by reading without spectacles.

Intraocular pressure in exfoliation syndrome.

A retrospective follow-up study of 206 eyes with exfoliation in 164 patients was carried out. At the time exfoliation (EX) was initially diagnosed, there were 97 patients with unilateral and 42 patients (84 eyes) with bilateral exfoliation. In 25 patients the exfoliation was connected with hypertension or glaucoma in the fellow eye. The average age of the patients with unilateral EX was 66.3 years and that of the patients with bilateral EX 68.0 years. The initial mean IOP (+/- SD) of 17.9 (+/- 2.9) mmHg in 97 unilateral EX eyes was statistically significantly higher (2p less than 0.001) than in the normal fellow eye 16.1 (+/- 2.5) mmHg. Of the 97 eyes with unilateral EX, 45.3% with an initial mean IOP of 17.4 mmHg remained unchanged. The mean follow-up time was 5.0 years. Conversion of unilateral to bilateral EX was observed in 14.4% of cases. The mean time of conversion was 4.5 years. Of the 84 bilateral EX eyes with an initial mean IOP of 17.0 mmHg, 66.7% remained unchanged. Of the total sample of 206 EX eyes, 65.5% remained normotensive and 34.5% developed hypertension or glaucoma during the follow-up period. The initial mean IOP of those eyes which remained normotensive was statistically significantly lower than that of those which later on developed hypertension or glaucoma (2p less than 0.001).

A double-masked study of timolol and pilocarpine combined.

In a double-masked, randomized, multicenter study, 25 patients received timolol 0.5%-pilocarpine 2% twice a day, 25 received timolol 0.5%-pilocarpine 4% twice a day, and 25 received pilocarpine 4% four times a day. The combination drugs showed an immediate, significant reduction in intraocular pressure of 7.2 mm Hg (25%) and 10.7 mm Hg (37%), respectively. The lowered intraocular pressure level was maintained throughout the three-week test period. With pilocarpine alone, intraocular pressure was reduced 5.3 mm Hg (19%). The mean intraocular pressure 12 hours after the last dose compared to two hours after the last dose was significantly higher both in patients receiving pilocarpine four times a day and in patients receiving timolol 0.5%-pilocarpine 4% twice a day (5.1 and 3.6 mm Hg, respectively), but not in patients receiving timolol 0.5%-pilocarpine 2% twice a day (2.6 mm Hg).

Combined trabeculectomy and cataract operation. A follow-up study.

In a study of 94 combined cataract and trabeculectomy operations performed for 59 open angle simplex and 35 capsular glaucoma with coexisting cataract, followed up for 1 to 9 years, the overall control of intraocular pressure (less than or equal to 21 mm Hg) without therapy was achieved in 61 eyes (65%). The average follow-up time was 3.4 years. The success rate 76% after 1 year follow-up decreased to 63% after 2 years and went from 45 to 66% over a 3 to 8 years follow-up period. Post-surgical therapy was required in 33 eyes (35%). Of these 31 eyes were controlled with medical therapy alone. In the light of the results the maintenance of filtration was considered the most important factor of success. Most frequent complications, transient hypotony (37%) and hyphaema (30%) had no significant effect on eventual success. As regards the diagnostic categories no significant difference existed in the success rates between the simplex and capsular glaucoma groups. The importance of periodic observation is discussed.

Timolol treatment of chronic open-angle glaucoma and ocular hypertension. A 2.5-year multicenter study.

Maintenance effect of topical timolol was investigated for 2 years in a group of 125 glaucomatous and ocular hypertensive patients (231 eyes) who had been successfully treated with timolol alone during a 6-month period preceding this trial. Intraocular pressure (IOP) was controlled with timolol alone in 135 of 183 eyes (74%) that completed the study. At the end of the trial 142 eyes (78%) showed an IOP of less than 22 mmHg. Other glaucoma medication had to be added to timolol treatment in 18% of ocular hypertensive and 35% of glaucomatous eyes because of IOP elevation. Elevation of IOP seemed to be due to worsening of glaucoma rather than to decreased efficacy of timolol. None of the ocular hypertensive patients developed visual field defects but in ten glaucomatous patients progression of existing visual field defects was observed in association with elevated IOP. Transient adverse effects were observed in 13% of cases, but timolol treatment had to be stopped in only five cases (4%) because of side effects.

The IOP-lowering effect of timolol in simple and capsular glaucoma. A multicenter study in Finland.

Timolol maleate eye drops (0.25% and 0.5%) were used alone or in combined treatment in 220 patients with simple or capsular glaucoma. A highly significant (P less than 0.001, mean -9.4 mm Hg,-29%) decrease in the intraocular pressure (IOP) was seen in 196 (164 simple, 32 capsular) patients in the beginning of the study using timolol alone. (Inadequate control timing, deviation from the treatment definition, or adverse reactions caused the exclusion of the data of 24 patients). A total of 180 patients (151 simple, 29 capsular) completed the 6-month study. At the end of the study an IOP less than 22 mm Hg was seen in 103 (57.2%, 91 simple, 12 capsular) patients treated with timolol alone. During the follow-up period there was no significant difference in the IOP-lowering effect of timolol in the simple and the capsular group using timolol alone. Combined treatment was needed by 39 of 180 patients who completed the study. It was needed more than twice as often in the capsular group (12 patients, 41.4%) as in the simple group (27 patients, 17.9%). The IOP increased above 25 mm Hg in one-fourth of these 39 patients during the follow-up period, but there was no significant difference between the simple and the capsular group. Six patients dropped out of the study because of side-effects possibly related to timolol therapy.

Late complications of 7-0 polyglycolic (Dexon) sutures in cataract surgery.

The late complications of corneo-scleral wound healing after the 15th postoperative day were recorded in 108 routine adult cataract operations using 7-0 polyglycolic acid (Dexon) sutures and compared with 80 routine adult cataract operations using 9-0 monofilament nylon (9-10 Ethilon Nylon) sutures. In 37 eyes of the 7-0 Dexon group filtrating blebs, gaping of the corneoscleral wound, anterior chamber collapse, or decrease in the intraocular pressure were observed compared with one filtrating bleb in the 9-0 nylon group. The majority of late complications occurred 22 to 42 days after surgery. Ten filtrating blebs remained after a 5 months' follow-up period. The most probable cause of the late complications in corneo-scleral wound healing was discussed.

Congenital defects in a cohort followed for seven years.

A geographically limited cohort of Finnish children was followed from birth for seven years, and all congenital abnormalities were recorded and classified and special attention was given to the cumulative detection rate, and the time of detection of various defects. Of 3674 pregnancies 135 babies with or without defects were stillborn or died during the neonatal period. The remaining 3539 were followed up to seven years, when the percentage follow-up was 81.7%. Detailed information on 76 malformed livebirths registered in the neonatal period was available in 63 cases (82.9%). The diagnosis was found to be incorrect in 6 cases and additional defects were registered in 7 of these children. Additional congenital abnormalities detected in the follow-up study were divided into three groups: all congenital disorders or abnormalities with prenatal etiology (248 children), all congenital defects (111 of these 248) and structural malformations (31 of these 111). The cumulative detection rates in these groups increased with time and at the end of the study when the children were aged seven were 9.4%, 5.6% and 2.6%, respectively.

Definition of congenital malformations and detection of associations with maternal factors.

Data collected from a cohort of 2913 pregnancies were analyzed to determine whether the varying definitions of congenital malformations influence the statistical result in the search for possible etiological factors. According to three different definitions of congenital malformations, three study groups were formed, i.e. structural malformations, all congenital defects, and all disorders or abnormalities with possible prenatal etiology. These consisted of 93, 197 and 334 cases, respectively. The control group consisted of 2579 cases. Positive associations were noted between the study groups and some factors concerning pregnancy, and the social history of the parents. The associations were strongest in the group of structural malformations and became weaker when this group was 'diluted' by other defects with questionable prenatal origin. Hence, when comparisons for evaluating the causality of significant associations in different materials are made, the definition of the concept of congenital malformations should be taken into consideration.