Comparison of intraocular pressure profiles during the water drinking test and the modified diurnal tension curve.

OBJECTIVES: To compare intraocular pressure (IOP) during the water drinking test (WDT) and modified diurnal tension curve (mDTC) in open-angle glaucoma (OAG) patients, using multimodal, observer-masked tonometry. METHODS: Open-angle glaucoma subjects were prospectively enroled, excluding those who had undergone glaucoma filtration or laser surgery. Two-hourly mDTC Goldmann applanation (GAT) and rebound tonometry (RT) was performed between 8:00 and 16:00, and every 15 min for 45 min after ingestion of 800mls of water. Blood pressure, heart rate, pupillometry measurements, and optical coherence tomography (AS-OCT) were also recorded. RESULTS: Forty-two subjects' right eyes were included. 48% were using topical glaucoma medication. Mean baseline IOP was 14.9 ± 4.52 mmHg, with mean visual field mean deviation (±SD) -5.05 ± 5.45 dB. Strong association was found between maximum IOP during mDTC and WDT (r = 0.90, 95% CI 0.82-0.95 p < 0.0001) with agreement (mDTC-WDT) bias -0.82 mmHg, 95% LoA -1.46 to -0.18. During the WDT, mean systolic blood pressure (±SD) increased from 140.0 ± 20.0 to 153.3 ± 24.0 mmHg (p < 0.0001), mean heart rate ( ± SD) reduced from 69.5 ± 11.3 bpm to 63.6 ± 10.0 bpm (p < 0.0001), and temporal iridocorneal angle increased from 29.2 ± 6.0° to 29.6 ± 5.2° (p = 0.04). CONCLUSION: This study presents repeated, observer-masked IOP data showing strong correlation between maximum IOP during mDTC and WDT using multimodal tonometry. This supports WDT as a meaningful alternative to mDTC when investigating diurnal IOP characteristics in clinic, with reduced time requirements and associated costs.

Intraocular Peak Pressure in Patients Under Treatment With Fixed Combination of Bimatoprost/Timolol/Brimonidine Once Daily Versus Twice Daily.

PRCIS: We investigate the efficacy of triple-fixed-combination of bimatoprost/brimonidine/timolol once and twice a day, demonstrating higher intraocular pressure reduction with once-a-day use, and discuss possible implications based on previous literature. PURPOSE: The purpose of this study was to compare the efficacy of a fixed combination bimatoprost-timolol-brimonidine (Triplenex) instilled once-daily with twice-daily in primary open angle glaucoma. PATIENTS AND METHODS: A randomized clinical trial at a public eye care institution. Thirty patients with primary open angle glaucoma were followed up for 3 months. The right and left eyes of these patients were randomly assigned to once-daily (10:00 pm ) or twice-daily (10:00 am ; 10:00 pm ) regimens of fixed combination bimatoprost-timolol-brimonidine. Intraocular pressure peaks were obtained with the water drinking test before the introduction of this medication (basal WDT0), 1 month (WDT1), 2 months (WDT2), and 3 months (WDT3) after starting the use of the fixed combination of bimatoprost/timolol/brimonidine (Triplenex). Variation from peak intraocular pressure at WDT3 to peak at WDT0 was compared within groups of 2 versus once-daily regimen. RESULTS: Sixty eyes of 30 patients (age: 70.67±9.70 y) were included in this study. Baseline clinical characteristics were comparable between groups. The mean reduction in peak intraocular pressure from WDT0 to WDT3 was 6.1±6.1 mm Hg (30.5%) in the eyes receiving 1 drop per day and 4.3±5.7 mm Hg (21.5%) in the eyes receiving 2 drops per day ( P =0.023). Mean reduction in peak intraocular pressure considering all WDT was also higher in the group with once-a-day treatment (5.90±6.03 vs. 4.46±4.28 mm Hg, P =0.006). CONCLUSION: Fixed combination of bimatoprost 0.01%, brimonidine tartrate 0.15%, and timolol maleate 0.5% once-a-day is more effective in reducing peak intraocular pressure as measured by the WDT than twice-a-day dosing.

Peak Intraocular Pressure Time during Water Drinking Test and Its Relationship with Glaucoma Severity.

PURPOSE: To investigate the association between the time of occurrence of intraocular pressure (IOP) peaks during the water-drinking test (WDT) and visual field damage in a cohort of primary open-angle glaucoma (POAG) patients. METHODS: In this retrospective, cross-sectional study, 98 eyes from 49 consecutive POAG patients were followed in a referral clinical practice. The relationship between the time when IOP peaks occurred during the WDT and the visual field mean deviation (MD) assessed with 24-2 visual field was tested with mixed-effects models. RESULTS: MD value was significantly associated with the time of IOP peak occurrence (P = 0.020) when adjusting for the number of medications, but not with the IOP peak values (P = 0.238). CONCLUSION: The time of IOP peaks occurrence during the WDT was associated with glaucoma severity among treated POAG patients.

Patterns of Visual Field Loss in Early, Moderate, and Severe Stages of Open Angle Glaucoma.

PRCIS: Even in the early stages of glaucomatous visual field defects (VFDs), 49% of the defects occurred in both hemifields and 28% involved the central 5 degrees of the visual field (VF), which may have prognostic values. PURPOSE: The aim was to determine the patterns of glaucomatous VFDs in early, moderate and severe stages of primary open angle glaucoma, using the Glaucoma Staging Application. METHODS: According to the Modified University of Sao Paulo Glaucoma Visual Field Staging System Classification, patients with early, moderate and advanced VFDs were selected by the Glaucoma Staging Application using all databases of the Humphrey Visual Field Analyser of a glaucoma referral practice. We analyzed one VF of the 100 patients included in each group. The analysis consisted of classifying all exams regarding the location of the defects, the hemifields involved, and the connection to the blind spot. RESULTS: We analyzed 300 VF. In the Early group, 27% of the VFDs are connected to the physiological blind spot, 64% in the Moderate group, and 95% in the Severe group ( P <0.01). In the Early group, 28% of the defects involved the central 5 degrees of the fixation, 59% in the Moderate and 88% in the Severe group. In the Early group, 49% of the defects involved both hemifields, 80% in the Moderate and 80% in the Severe group. CONCLUSION: With increasing glaucoma severity, VFD showed a more central pattern, connected to the blind spot, and involved both hemifields. In early disease, both hemifields were commonly affected and more than a quarter of VFD involved the central 5 degrees close to fixation. Careful monitoring of the central VF in glaucoma is suggested.

Vision for the Future Project: Screening impact on the prevention and treatment of visual impairments in public school children in São Paulo City, Brazil.

OBJECTIVES: Uncorrected refractive errors are the leading cause of visual impairment in children. In this cross-sectional retrospective study, we analyzed a social visual screening program for school children in São Paulo, Brazil, evaluated its impact on the prevention and treatment of children's visual disabilities, and assessed its epidemiological outcomes to outline suggestions for its improvement. METHODS: First-grade children from public schools were submitted to prior visual screening by their teachers. Selected children were forwarded to the hospital's campaigns for a second screening by ophthalmologists and treatment if needed. Data were analyzed for age, sex, visual acuity, biomicroscopy, refractive errors, ocular movement disorders, amblyopia, number of donated spectacles, and number of children forwarded to specialized care. RESULTS: A total of 1080 children were included with mean age of 6.24±0.45 years. Children with normal ophthalmological exam, 591 (54.7%; 95% confidence interval [CI]: 51.7%-57.7%) were dismissed and considered false-positives. Myopia, hyperopia, and astigmatism components were found in 164 (15.2%; CI: 13.1%-17.4%), 190 (17.6%; CI: 15.3%-20.0%), and 330 (30.5%; CI: 27.8%-33.4%) children, respectively. Amblyopia was diagnosed in 54 (5%; CI: 3.5%-6.4%) children, and 117 (10.8%; CI: 9.8%-12.8%) presented ocular movement disorders. A total of 420 glasses were donated. CONCLUSION: Epidemiological findings for amblyopia and refractive errors are consistent with those of similar studies. The expressive number of diagnoses performed and number of glasses donated to underprivileged children depict the importance of such projects. New guidelines to improve their cost-effectiveness, such as professional training and community sensitization, are imperative.

Complete reversal of bilateral optic nerve infiltration from lymphoblastic leukemia using chemotherapy without adjuvant radiotherapy.

BACKGROUND: Leukemic involvement of the eyes is rare, therefore, treatment relies on previous case reports. The treatment of ocular complications poses additional difficulties, because the eye is considered as a pharmacological "sanctuary" for patients with acute lymphoblastic leukemia (ALL). Therefore, radiotherapy is the main therapeutic choice; however, it might lead to many important side effects. To the best of our knowledge, this is the first case report of a bilateral leukemic optic nerve infiltration that remitted with chemotherapy without adjuvant radiotherapy. CASE PRESENTATION: A 30-year-old female patient with previous history of remitted ALL presented with a one-week history of floaters in her right eye. Her ophthalmological exam showed remarkable optic disc swelling, in both eyes. She was diagnosed with ALL relapse presenting as a bilateral optic nerve leukemic infiltration. Local radiotherapy was planned for both eyes, however, due to efficient recovery with chemotherapy, it was cancelled. Allogenic bone marrow transplantation was subsequently performed. The patient is being followed up and ALL remitted. CONCLUSION: Leukemia relapse on central nervous system, despite rare, is a sign of poor prognosis and requires prompt treatment. Its occurrence on ocular tissues is even rarer. It is hypothesized that the blood-brain barrier limits the delivery of chemotherapeutic drugs to the eye and infiltration of the optic nerve by leukemic cells might prejudice the flow of cerebrospinal fluid between the cranial space and the optic disc.

Variability and Power to Detect Progression of Different Visual Field Patterns.

PURPOSE: To compare the variability and ability to detect visual field (VF) progression of 24-2, central 12 locations of the 24-2 and 10-2 VF tests in eyes with abnormal VFs. DESIGN: Retrospective, multisite cohort. PARTICIPANTS: A total of 52 806 24-2 and 11 966 10-2 VF tests from 7307 eyes from the Glaucoma Research Network database were analyzed. Only eyes with ≥ 5 visits and ≥ 2 years of follow-up were included. METHODS: Linear regression models were used to calculate the rates of mean deviation (MD) change (slopes), whereas their residuals were used to assess variability across the entire MD range. Computer simulations (n = 10 000) based on real MD residuals of our sample were performed to estimate power to detect significant progression (P < 5%) at various rates of MD change. MAIN OUTCOME MEASURES: Time required to detect progression. RESULTS: For all 3 patterns, the MD variability was highest within the -5 to -20 decibel (dB) range and consistently lower with the 10-2 compared with 24-2 or central 24-2. Overall, time to detect confirmed significant progression at 80% power was the lowest with 10-2 VF, with a decrease of 14.6% to 18.5% when compared with 24-2 and a decrease of 22.9% to 26.5% when compared with central 24-2. CONCLUSIONS: Time to detect central VF progression was reduced with 10-2 MD compared with 24-2 and C24-2 MD in glaucoma eyes in this large dataset, in part because 10-2 tests had lower variability. These findings contribute to current evidence of the potential value of 10-2 testing in the clinical management of patients with glaucoma and in clinical trial design.

Efficacy and Safety of the Susanna Glaucoma Drainage Device After 1 Year of Follow-up.

PRECIS: This study found a rate of failure of 13.6% of the new Susanna Glaucoma Drainage Device (SGDD) after 1 year of follow-up. Severe complications occurred in 1 patient (4.5%). PURPOSE: The purpose of this study was to determine the success and complications rates of the SGDD implant in refractory glaucoma. PATIENTS AND METHODS: This is a retrospective study. Medical records from all consecutive refractory glaucoma patients (failed trabeculectomies with the use of adjunctive mitomycin) followed in a private clinical practice were included in the study. All patients had undergone SGDD implant surgery from September 2016 to July 2019 were included. All surgeries were done by the same surgeon (R.S.). Primary outcome was surgical failure, defined as intraocular pressure (IOP) >18 mm Hg and/or <20% IOP reduction from baseline, IOP<5 mm Hg, reoperation for glaucoma, need of implant removal or loss of light perception vision. Secondary outcomes included mean IOP, use of supplemental medical therapy, and complications. RESULTS: In all, 22 eyes were analyzed. Mean patient age was 63±15 years (range: 27 to 87 y). Mean IOP decreased from 23±7 to 11±8 mm Hg (P<0.001, paired t test) at an average of 18±9 months after the tube implant. The mean SD number of glaucoma medications was reduced from 3.3±1 to 1.5±1.2 at the last postoperative visit (P<0.01, paired t test). No early postoperative complications occurred. There was 1 case of late persistent hypotony in a patient with previous endocyclophotocoagulation that was solved with tube ligature with silk 8-0. Failure because of high IOP occurred in 2 cases. There was no extrusion or erosion of the tube and the plate. CONCLUSION: The SGDD presented a 13.6% failure rate (86.4% success rate) with very few complications, being an efficient and safe alternative for refractory glaucoma.

Vision for the Future Project: Screening impact on the prevention and treatment of visual impairments in public school children in São Paulo City, Brazil

OBJECTIVES: Uncorrected refractive errors are the leading cause of visual impairment in children. In this cross-sectional retrospective study, we analyzed a social visual screening program for school children in São Paulo, Brazil, evaluated its impact on the prevention and treatment of children's visual disabilities, and assessed its epidemiological outcomes to outline suggestions for its improvement. METHODS: First-grade children from public schools were submitted to prior visual screening by their teachers. Selected children were forwarded to the hospital's campaigns for a second screening by ophthalmologists and treatment if needed. Data were analyzed for age, sex, visual acuity, biomicroscopy, refractive errors, ocular movement disorders, amblyopia, number of donated spectacles, and number of children forwarded to specialized care. RESULTS: A total of 1080 children were included with mean age of 6.24±0.45 years. Children with normal ophthalmological exam, 591 (54.7%; 95% confidence interval [CI]: 51.7%-57.7%) were dismissed and considered false-positives. Myopia, hyperopia, and astigmatism components were found in 164 (15.2%; CI: 13.1%-17.4%), 190 (17.6%; CI: 15.3%-20.0%), and 330 (30.5%; CI: 27.8%-33.4%) children, respectively. Amblyopia was diagnosed in 54 (5%; CI: 3.5%-6.4%) children, and 117 (10.8%; CI: 9.8%-12.8%) presented ocular movement disorders. A total of 420 glasses were donated. CONCLUSION: Epidemiological findings for amblyopia and refractive errors are consistent with those of similar studies. The expressive number of diagnoses performed and number of glasses donated to underprivileged children depict the importance of such projects. New guidelines to improve their cost-effectiveness, such as professional training and community sensitization, are imperative.

A review of ocular adverse events of biological anti-TNF drugs.

The recent introduction of biological agents has revolutionized the treatment of chronic immune-inflammatory diseases; however, this new therapy did not come without significant side effects.Through large controlled studies indicating decrease in the number of uveitis flares, the role of TNF inhibitors therapy for non-infectious uveitis gained more ground. Paradoxically to its therapeutic effect, there are reports associating these drugs with the onset or recurrence of inflammatory eye disease.A number of studies have suggested possible roles for anti-TNF-α agents in precipitating or worsening an underlying inflammatory process, including the hypothesis of a disequilibrium in cytokine balance, but to date the mechanisms responsible for these adverse events are not fully understood.A PubMed literature search was performed using the following terms: ophthalmic complication, uveitis, inflammatory eye disease, optic neuritis, neuropathy, adverse events, anti-TNF, TNF alpha inhibitor, infliximab, etanercept, adalimumab, golimumab, certolizumab, and biologics. The data presented in this study was mainly derived from the use of TNF inhibitors in rheumatology, essentially because these drugs have been used for a longer period in this medical field.Many of the ocular adverse events reported on this review may be considered a paradoxical effect of anti-TNF therapy. We found a variety of data associating new onset of uveitis with anti-TNF therapy for rheumatic conditions, predominantly under etanercept.In conclusion, although there is increasing data on ocular adverse events, it remains to be seen whether the suggested link between TNF inhibitors and the onset of ocular inflammation is substantiated by more quality data. Nevertheless, the awareness of potential treatment side effects with anti-TNF should be highlighted.

Comparison of Intraocular Pressure Changes During the Water Drinking Test Between Different Fluid Volumes in Patients With Primary Open-angle Glaucoma.

PURPOSE: The main objective of this study was to compare the intraocular pressure (IOP) response during the water drinking test (WDT) performed with 800 mL, 1000 mL, and 10 mL/kg of body weight and to test its relationship with body mass index (BMI). METHODS: In this prospective, observer-masked, observational study, patients treated with primary open-angle glaucoma were evaluated. In group I, 29 consecutive patients with body weight ≤60 kg underwent an 800 mL fluid challenge followed by a second WDT session with 10 mL/kg of body weight no longer than 4 months apart. Group II included 30 consecutive patients with body weight >60 kg who underwent a 1000 mL fluid challenge followed by an 800 mL test no longer than 4 months apart. IOP was measured before (baseline) and after water ingestion every 15 minutes for 45 minutes. RESULTS: In group I, there was no significant difference in baseline or peak IOP between 800 mL and 10 mL/kg of body weight tests (P=0.12 and 0.56, respectively). However, 10 mL/kg tended to lead to consistently lower IOP values and a biased response in eyes with higher IOP. In group II, there was also no significant difference in baseline or peak IOP between 800 and 1000 mL tests (P=0.26 and 0.72, respectively). No biased response was observed in this group. There was no significant association between IOP peak and BMI with 800 mL (P=0.18), 10 mL/kg (P=0.29), or 1000 mL (P=0.34). CONCLUSIONS: There was overall good agreement between WDT results with different fluid volumes. The response to the volume loads tested in this study was not influenced by the BMI.