Effect of Femtosecond Laser Cataract Surgery on Peripapillary Retinal Nerve Fiber Layer Thickness.

PRCIS: Femtosecond laser-assisted cataract surgery (FLACS) may cause thinning of the peripapillary retinal nerve fiber layer (pRNFL) in healthy eyes. PURPOSE: This prospective cohort study aimed to compare changes of pRNFL after FLACS using a liquid patient interface and conventional phacoemulsification cataract surgery (CPCS). PATIENTS AND METHODS: Included were 261 eyes (261 patients) with age-related cataracts and no ocular diseases scheduled either for FLACS (222 eyes) or CPCS (39 eyes). FLACS was performed using a Ziemer LDV Z8 laser. Average and quadrant pRNFL thickness was measured using optical coherence tomography before surgery and at 1, 3, and 6 months postoperatively. Postoperative changes in pRNFL thickness were compared within and between groups. RESULTS: Mean quadrant and average pRNFL thicknesses significantly increased after both surgeries (P<0.001). However, pRNFL thinning occurred after FLACS and CPCS (17% vs. 5.1%, respectively, P>0.05). FLACS eyes showed a significant and stable decrease of average pRNFL thickness (P=0.057) and a gradual decrease in pRNFL thickness of all quadrants (P≤0.018). CPCS eyes showed an initial increase of pRNFL thickness, followed by a decrease only in the nasal quadrant and average pRNFL. Preoperative pRNFL thickness was associated with thinning of the temporal quadrant (P=0.04). CONCLUSIONS: Both FLACS and CPCS demonstrated pRNFL thinning in some healthy eyes. Although the higher rate of pRNFL thinning after FLACS compared with CPCS lacked statistical significance, a consistent decrease in pRNFL thickness occurred in all quadrants and average pRNFL of FLACS eyes, suggesting that FLACS may lead to pRNFL thinning. Eyes with thinner preoperative pRNFL may be prone to temporal quadrant thinning after FLACS.

Clinical Outcomes After Ahmed Glaucoma Valve Implantation for Pediatric Glaucoma After Congenital Cataract Surgery.

PRCIS: Ahmed valve success for glaucoma following congenital cataract surgery lasts at least 5 years in most eyes, and >10 years in some cases. The procedure is a valuable option for these patients. PURPOSE: The aim of the study was to report on the results of Ahmed valve implantation in children with glaucoma following congenital cataract surgery. PATIENTS AND METHODS: Medical records were reviewed for 41 pediatric eyes (27 patients) with glaucoma after congenital cataract surgery with Ahmed glaucoma valve (AGV) implantation between 2007 and 2018. The primary outcome measure was surgical success, defined as intraocular pressure (IOP) ≤22 mm Hg (with or without glaucoma medications) on 2 consecutive follow-up visits, without glaucoma reoperation, and without significant visual complications during the follow-up period. RESULTS: Median age at the time of AGV implantation was 80 months (range: 14 to 146 mo) and the mean follow-up period was 61.1±46.5 months. The cumulative probability of surgical success was 95.1%, 89.8%, 83.1%, and 72.6% at 12, 24, 60, and 84 months, respectively. IOP significantly decreased from 35.8±7.4 mm Hg before valve implantation to 18.7±6.5 mm Hg at the last recorded visit (51.4% decrease; P<0.0001). Most eyes (79%) required medications for pressure control. Complications occurred in 14 eyes (34%), with 12 of these remaining successful. Early hypotony was the most common complication (19.5%). Retinal detachment occurred in 1 eye. CONCLUSIONS: Despite a decrease in surgical success over time, AGV implantation was successfully used for IOP control in the majority of our pediatric eyes with glaucoma after congenital cataract surgery. Most complications were managed effectively and surgical success was maintained.

Glaucoma is an autoimmune disease.

Glaucoma is characterized by retinal ganglion cell (RGC) neurodegeneration. Elevated intraocular pressure (IOP) is a major risk factor however, mechanisms independent of IOP play a role in RGC pathology. Both antibodies and CD4 T-cells as well as microbiota take part in the pathogenesis of both glaucoma and rheumatoid arteritis (RA).Heat shock proteins (HSPs) which originate in bacteria cross-react with RCG epitopes and were involved in rat model of retinal injury. Enhanced expression of HSPs in the retina was associated with glaucoma-like neuropathology and previous studies have also suggested a pathogenic role for HSPs in RA. In view of these data we suggest that glaucoma should be included in the spectrum of autoimmune diseases and that proven medications for RA should be adopted as an innovative IOP -independent therapeutic strategy for glaucoma.

[CHILDHOOD GLAUCOMA].

INTRODUCTION: "Childhood glaucoma" is a heterogenic group of diseases, characterized by elevated intraocular pressure (IOP) associated with optic-disc damage and other ocular comorbidities. Diagnosis requires two or more of the following: elevated IOP, optic nerve damage, enlarged cornea or Descemet's membrane ruptures, enlarged eye, high myopia and visual field defects. Childhood glaucoma is classified as primary if it occurs as an isolated ocular disease, and secondary, when the disease occurs along with other ocular anomalies or systemic diseases such as Neurofibromatosis and Sturge-Weber, or with acquired conditions such as uveitis complications, ocular trauma, cataract surgery, as well as from systemic and ocular steroid use. The clinical manifestations of childhood glaucoma depend on the age of presentation. In newborns, an enlarged eye with an enlarged cloudy cornea can be found, while infants present with an enlarged eye and signs of tearing, blinking and glare. Older children are usually asymptomatic and the disease is discovered incidentally on eye examination for other ocular problems. Treatment of childhood glaucoma is complicated and demanding. Most types of pediatric glaucoma require surgery in order control IOP, while medical treatment has a supportive role. Different types of glaucoma surgery are indicated for different types of pediatric glaucoma. Regular lifelong monitoring, including IOP control and treatment for the prevention of amblyopia is necessary to obtain and maintain good vision.

Ex-PRESS Miniature Glaucoma Shunt Versus Ahmed Glaucoma Valve in the Surgical Treatment of Glaucoma in Pseudophakic Patients.

PURPOSE: The aim of this study was to compare the 3-year outcome of Ex-PRESS miniature glaucoma shunt versus Ahmed glaucoma valve in pseudophakic patients. PATIENTS AND METHODS: We retrospectively reviewed the records of patients with a history of clear corneal phacoemulsification alone, or failed trabeculectomy following phacoemulsification, who subsequently underwent Ahmed glaucoma valve (AGV) implantation or Ex-PRESS shunt surgery. The main outcome measure, surgical success, was defined as an intraocular pressure between 5 and 21 mm Hg and a 20% intraocular pressure reduction from baseline (with/without glaucoma medications) without glaucoma reoperation. RESULTS: In total, 92 patients (92 eyes) were included (43 AGV, 49 Ex-PRESS). Overall success at 3 years was 92.7% for AGV and 66.1% for Ex-PRESS (P=0.006). AGV had a higher success rate in patients with prior phacoemulsification and failed trabeculectomy (96% AGV vs. 64.1% Ex-PRESS; P=0.023). There was no difference in success rate for patients with only previous phacoemulsification (87.5% AGV vs. 69.4% Ex-PRESS; P=0.205). Glaucoma reoperation rates were 4.6% and 30.6% in the AGV and Ex-PRESS group, respectively (P=0.001). Both procedures had similar complication rates. CONCLUSIONS: AGV compared with Ex-PRESS shunt, had a higher success rate for secondary surgeries but not primary surgeries, in patients with prior clear corneal phacoemulsification. The AGV surgery also had a lower overall glaucoma reoperation rate.

Use of Autologous Scleral Graft in Ahmed Glaucoma Valve Surgery.

PURPOSE: To compare the efficacy of an autoscleral free-flap graft versus an autoscleral rotational flap graft in Ahmed glaucoma valve (AGV) surgery. PATIENTS AND METHODS: Medical records (2005 to 2012) of 51 consecutive patients (51 eyes) who underwent AGV surgery with the use of either an autoscleral free-flap graft or an autoscleral rotational flap graft to cover the external tube at the limbus were retrieved for review. The main outcome measure was the incidence of tube exposure associated with each surgical approach. RESULTS: Twenty-seven consecutive patients (27 eyes) received a free-flap graft and 24 consecutive patients (24 eyes) received a rotational flap graft. The mean follow-up time was 55.6 ± 18.3 months for the former and 24.2± 5 .0 months for the latter (P<0.0001). Two patients in the free-flap group (8.9%) developed tube exposure at 24 and 55 months postoperatively compared with none of the patients in the rotational flap group. Graft thinning without evidence of conjunctival erosion was observed in 15 patients (55%) in the free-flap group and in 7 patients (29.1%) in the rotational flap group. CONCLUSIONS: The use of an autoscleral rotational flap graft is an efficacious technique for primary tube patch grafting in routine AGV surgery, and yielded better results than an autoscleral free-flap graft. Its main advantages over donor graft material are availability and lower cost.

Primary care physicians' role perception and self-reported performance in glaucoma care: a survey study.

BACKGROUND: Glaucoma is a leading cause of blindness. The participation of primary care physicians (PCPs) in glaucoma care may improve health outcomes for glaucoma patients. OBJECTIVES: To investigate PCPs' attitudes towards their role in glaucoma care, perceived barriers, and self-reported performance in glaucoma management. METHODS: PCPs working in the Haifa and Western Galilee District of Clalit Health Services, Israel's largest Health Maintenance Organization (HMO) were asked to complete a self-administered structured questionnaire. Physicians were asked to rate their agreement with statements describing the PCP's role in glaucoma care, and to state how often they behave accordingly in their practice. In addition, physicians were asked to rate the extent that factors such as time constraints and knowledge gaps impede their performance in glaucoma care. RESULTS: Eighty-two physicians completed the questionnaire. The majority thought that PCPs have a major role in early detection of glaucoma (99 %), discussing the importance of adherence to treatment (93 %), and encouraging patients to make regular visits to their ophthalmologist (99 %). However, only 30 % reported asking patients about family history of glaucoma, 64 % reported discussing adherence to treatment, and only 35 % stated that they explain how to use eye drops, while most of respondents (87 %) regularly provide refill prescriptions for glaucoma medications. Sixty percent claimed that during their residency they had not acquired adequate knowledge and competence to allow them to take proper care of glaucoma patients. The main barriers reported were lack of time (43 %), lack of knowledge regarding treatment options and recommended follow-up (46 %), and not being familiar with glaucoma medications' side effects (54 %). CONCLUSIONS: There is a gap between PCPs' perceptions of their role in glaucoma care and their report on actual performance in early detection and management of glaucoma. Further research is needed to develop and assess interventions that aim at closing this gap.

[CANNABIS AND GLAUCOMA: AN ANCIENT LEGEND OR A NOVEL THERAPEUTIC HORIZON?].

Glaucoma causes damage to the optic nerve and compromises the visual field. The main risk factor of the disease is the level of the intra-ocular pressure. Therapeutic options include medical and surgical treatment, aimed to lower the intra-ocular pressure. Consumption of the cannabis plant (Cannabis Satival has been known since ancient times. It can be consumed orally, topically, intra-venous or by inhalation. The main active ingredient of cannabis is THC (Tetra-Hydro-Cannabinol). One of THC's reported effects is the reduction of intra-ocular pressure. Several studies have demonstrated temporary intra-ocular pressure decrease in both healthy subjects and glaucoma patients following topical application or systemic consumption. The effect was a short term one. It was followed by the development of resistance to the drug after prolonged intake and it was also accompanied by topical and systemic side effects. Cannabis may be considered as a therapeutic option in glaucoma. Its limited effect, development of resistance, acquired side effects and the accompanying psycho-active influence limit its advantage and cause its efficacy to be dubious. Therefore, cannabis treatment for glaucoma currently seems impractical and is not recommended by either the Israeli or the American glaucoma societies.

COX-2 inhibition improves retinal function in rats' ischemic eyes.

PURPOSE: Retinal ischemia is a relatively simple model for studies in pharmacological neuroprotective intervention. The role of cyclooxygenase (COX) enzymes in ischemic insult has been variously shown to either increase or decrease ischemic damage. The purpose of this study was to assess the role of COX-1 and COX-2 in rat retinal ischemic functional damage. METHODS: Ischemia was achieved by elevating intraocular pressure for 60 min. White flash electroretinogram (ERG) was recorded by contact lens electrodes containing an integral light emitting diode source. ERG was recorded on post-ischemia (PI) days-1 (baseline), 1, 3, and 7. The b-wave amplitude, b-wave implicit time, and oscillatory potentials (OPs) were analyzed. The expression of COX-2 and HSP70i was assessed by Western analysis on day 1 PI. RESULTS: Ischemia caused attenuation of OPs, a decrease in the b-wave amplitude, and an increase in b-wave implicit time, accompanied by the increased expression of COX-2 and HSP70i proteins. Selective COX-2 inhibition markedly increased b-wave amplitude and enhanced retinal HSP70i induction, whereas COX-1 or nonselective and irreversible inhibition of both COX isoenzymes did not affect the retinal function or the expression of these proteins. High-dose aspirin prevented partial recovery from ischemic damage. Administration of a synthetic PGF2α analog, or a lipoxygenase inhibitor, had little effect on ischemic damage, but affected nonischemic ERG. CONCLUSIONS: COX-2 appears to mediate some of the ischemic retinal functional damage, possibly by inhibiting the induction of HSP-70i. We propose that selective COX-2 inhibitors may be useful in pathological conditions involving ischemic retinal insult.

Factors associated with adherence to glaucoma pharmacotherapy in the primary care setting.

BACKGROUND: Primary open-angle glaucoma is a leading cause of irreversible blindness. OBJECTIVES: To identify factors associated with adherence to glaucoma pharmacotherapy in the primary care setting, focusing on physicians' role. METHODS: Patients were recruited from primary care clinics and telephone-interviewed using a structured questionnaire that addressed patient-, medication-, environment- and physicians-related factors. Patients' data on pharmacy claims were retrieved to calculate the medication possession ratio for measuring adherence. RESULTS: Seven hundred thirty-eight glaucoma patients were interviewed. The multivariate analysis identified eight variables that were associated independently with adherence. Barriers to adherence were found to be low income, believing that 'It makes no difference to my vision whether I take the drops or not' and relying on someone else for drop instillation (exp(B) = 1.91, P = 0.002; exp(B) = 2.61, P < 0.0001; exp(B) = 2.17, P = 0.001, respectively). Older age, having a glaucoma patient among close acquaintances, taking a higher number of drops per day, taking a prostaglandin drug and reporting that the ophthalmologist had discussed the importance of taking eye drops as prescribed, were found to promote adherence (exp(B) = 0.96, P < 0.0001; exp(B) = 0.54, P = 0.014; exp(B) = 0.81, P = 0.001; exp(B) = 0.37, P < 0.0001; exp(B) = 0.60, P = 0.034, respectively). No association was found between the patient's relationship with the family physician and adherence to glaucoma treatment. CONCLUSION: Adherence to glaucoma pharmacotherapy is associated with patient-related, medication-related, physician-related and environmental factors. Ophthalmologists have a significant role in promoting adherence. However, the potential role of family physicians is unfulfilled and unrecognized.

Retinal nerve fibre layer thickness measurements by optical coherence tomography in patients with sleep apnoea syndrome.

BACKGROUND: The study aims to investigate whether retinal nerve fibre layer (RNFL) abnormalities can be detected in patients with obstructive sleep apnoea/hypopnoea syndrome with normally appearing optic disc. DESIGN: This is an observational case-control study. PARTICIPANTS: One hundred and eight consecutive patients with moderate or severe obstructive sleep apnoea/hypopnoea syndrome (OSAHS) as determined by overnight polysomnography and normal looking discs and 108 age-matched healthy controls were included in the study. METHODS: All patients underwent RNFL examinations by optical coherence tomography using fast retinal nerve fibre layer thickness scan. MAIN OUTCOME MEASURES: The main outcome measure was RNFL thickness. RESULTS: Multivariate regression analysis results showed that the RNFL was thinner for a patient with OSAHS than that of a normal control in the average by 4.20 µm (P < 0.003), in the superior quadrant by 4.83 µm (P = 0.028) and in the inferior quadrant by 5.19 µm (P = 0.016). RNFL thickness did not correlate with the severity of the disease. CONCLUSIONS: RNFL thinning was detected in normal-looking discs of patients with advanced OSAHS, but the extent of this thinning did not correlate with the severity of the disease. Longitudinal follow-up is needed to clarify whether RNFL thinning in OSAHS patients with normal clinically appearing optic nerves will eventually lead to glaucoma.

Sustained elevation of intraocular pressure after intravitreal injections of bevacizumab in eyes with neovascular age-related macular degeneration.

BACKGROUND: The use of intravitreal anti-VEGF agents in general, and of bevacizumab (Avastin) in particular, has become the common first-line treatment of neovascular age-related macular degeneration (AMD). Several reports addressed the possible elevation of intraocular pressure (IOP) following intravitreal injection of anti-VEGF. The aim of this study was to determine the prevalence of sustained IOP elevation following intravitreal bevacizumab injections for neovascular AMD and identify possible risk factors for the development of increased IOP. METHODS: This retrospective cohort study included 174 consecutive patients (201 eyes) receiving intravitreal bevacizumab (1.25 mg/0.05 ml) as treatment for neovascular AMD. The records of the study patients were reviewed for age, gender, history of glaucoma, phakic status, IOP levels, length of follow-up, total number of injections, intervals between injections, and IOP management in eyes that exhibited IOP elevation. Sustained IOP elevation was defined as IOP ≥22 mmHg and a change from baseline of ≥6 mmHg recorded on at least two consecutive visits and lasting ≥30 days. Risk factors for an IOP increase were identified from the association between the studied variables and IOP elevations. RESULTS: Sustained IOP elevation was found in 22 of 201 eyes (11%). The increased IOP was controlled with topical medications in all eyes. Among the variables studied, only male gender [OR = 3.1, 95% CI (1.1, 8.5) p = 0.029] and length of interval between injections <8 weeks [OR = 3.0, 95%CI (1.1, 7.9), p = 0.028] emerged as risk factors for IOP elevation in a multivariable model. The prevalence of IOP elevation was significantly higher when the interval between injections was <8 weeks than ≥8 weeks (17.6 and 6%, respectively, p = 0.009). Pre-existing glaucoma was not associated with IOP elevation (p = 0.9). CONCLUSIONS: Sustained IOP elevations can occur in normotensive eyes undergoing intravitreal bevacizumab treatment for neovascular AMD. This phenomenon was related to shorter intervals between injections, with 8 weeks being taken as the cut-off point. AMD eyes that receive intravitreal bevacizumab injections need to be monitored for IOP changes, especially those in which the intervals between injections are <8 weeks.

Selective laser trabeculoplasty in uncontrolled pseudoexfoliation glaucoma.

BACKGROUND AND OBJECTIVE: To assess the efficacy and safety of selective laser trabeculoplasty (SLT) in uncontrolled pseudoexfoliation glaucoma (PEXG). PATIENTS AND METHODS: Fifty-seven eyes (57 patients) with uncontrolled PEXG and intra-ocular pressure (IOP) greater than 23 mm Hg underwent SLT. All received ophthalmic evaluation preoperatively and at intervals postoperatively. IOP was measured at 1 hour, 1 day, 1 week, and 1, 3, 6, and 12 months postoperatively. During follow-up, patients were treated with topical anti-glaucoma medications as necessary. RESULTS: One year postoperatively, mean IOP in all patients decreased from 26.01 ± 2.5 to 17.8 ± 2.8 mm Hg (31.5%; P < .001). Mean medications per patient decreased from 2.8 to 2.3. Complications included conjunctival redness and infection within 1 day postoperatively in 30 eyes (67%). One hour after SLT treatment, an increase in IOP greater than 5 mm Hg was detected in two eyes (3.5%) and resolved within 24 hours with topical medication. CONCLUSION: SLT is safe and effective in patients with PEXG.

MMP expression in leaking filtering blebs and tears after glaucoma filtering surgery.

OBJECTIVE: Glaucoma filtering surgery may be compromised by cystic blebs which develop more frequently when anti-metabolites are used to arrest wound healing. Matrix metalloproteinases (MMPs) and the naturally occurring tissue inhibitors of metalloproteinases (TIMPs) are essential in connective tissue remodeling and wound healing. This study aimed to determine whether filtering blebs display increased expression of MMP-2, MMP-9, TIMP-1 and TIMP-2, and whether it is reflected in tear fluid. METHODS: Tissue samples from leaking blebs (n = 5) and control conjunctiva (n = 5) were evaluated by immunohistochemistry for MMP-2, MMP-9, TIMP-1 and TIMP-2. Tear fluid was collected from 12 patients (12 eyes) with cystic blebs and ten patients (ten eyes) with flat blebs following trabeculectomy with Mitomycin C applied and 16 controls. MMP levels were evaluated by zymography and TIMP levels by Western blot analysis. RESULTS: Conjunctival tissue was obtained from five eyes with cystic leaking blebs and five control eyes undergoing cataract surgery. More extensive MMP-2 and MMP-9 expression was found in the epithelial and stromal layers of blebs than in control conjunctiva. TIMP-1and TIMP-2 were expressed in all layers of the blebs, but only in the epithelium of control conjunctiva. MMP-2 and proMMP-2 activity in tears from eyes with flat blebs was significantly higher than that of controls, while activity in tears of eyes with cystic blebs was significantly higher than in those with flat blebs. There was no difference in MMP-9 activity between tears of control and post-filtering surgery eyes. CONCLUSIONS: Increased MMPs and TIMPs expression is associated with the formation of filtering blebs, suggesting involvement of MMPs in bleb remodeling. MMP-2 and ProMMP-2 levels in tear fluid may be markers for bleb configuration.

Genotype/phenotype correlation in primary congenital glaucoma patients from different ethnic groups of the Israeli population.

PURPOSE: To investigate the roles of CYP1B1 and MYOC mutations and characterize the phenotype of primary congenital glaucoma in Israeli patients from 3 different ethnic backgrounds. DESIGN: Interventional case series. METHODS: This institutional study included 34 Israeli primary congenital glaucoma patients (26 families) comprising 9 Jews (9 families), 17 non-Bedouin Muslim Arabs (10 families), and 8 Druze (7 families). The patients and their relatives (n = 99) were screened for CYP1B1 and MYOC mutations. RESULTS: Mutations in the CYP1B1 gene were detected in 12 of 26 families (46%) with primary congenital glaucoma (5 Muslim Arab, 5 Druze, and 2 Jewish). The Jewish families had compound heterozygous mutations and digenic mutations (ie, an Ashkenazi family had mutations in the CYP1B1 gene [Arg368His, R48G, A119S, and L432V haplotypes] and an Ashkenazi-Sephardic family had a mutation on the CYP1B1 gene [1908delA, Sephardic] with a second missense mutation on the MYOC gene [R76K, Ashkenazi]). The Muslim Arabs and Druze tended to have a more severe phenotype than that of the Jews. CONCLUSION: The phenotype and spectrum of the CYP1B1 and MYOC mutation roles in the clinical characteristics of primary congenital glaucoma varied according to ethnicity. The rarity of mutations in the CYP1B1 gene among Ashkenazi primary congenital glaucoma patients indicates that a different locus may be involved in the phenotype.

Lowering of IOP by echothiophate iodide in pseudophakic eyes with glaucoma.

PURPOSE: We retrospectively investigated the intraocular pressure (IOP)-lowering effects of echothiophate iodide (EI) as adjunctive treatment for pseudophakic glaucoma patients who were receiving maximal medical therapy (MMT), including the newer class of medications, i.e., prostaglandin analogs, alpha-2 agonists, and topical carbonic anhydrase inhibitors. METHODS: The medical records of all pseudophakic glaucoma patients (24 eyes) under MMT who received supplementary EI 0.125% between January 2002 and December 2003 were reviewed. IOP data and number of medications before, during and after EI treatment were collected. RESULTS: Adding EI to MMT further reduced IOP in 23 of 24 eyes. Three eyes (12.5%) showed some lowering of IOP, but not enough to be considered controlled (IOP above the target pressure). The mean baseline IOP of 30.4 +/- 8.2 mmHg (median 29 mmHg) dropped at final follow-up (11.2 +/- 3.9 months) to 16.6 +/- 4.2 mmHg (median 17 mmHg, p < 0.0001) in all eyes that had showed effective pressure reduction upon the addition of EI. Their IOP rose to 27.7 +/- 8.0 mmHg (median 28 mmHg, p < 0.001) when EI was discontinued because of commercial non-availability. IOP reduction was > or =20% in 18 (75%) eyes and > or =30% (a mean decrease of 16.7 +/- 8.3mmHg) in 15 eyes (63%). Four eyes (16.6%) required a trabeculectomy despite EI supplement. Five eyes were re-challenged with EI when a small amount was released for sale: their IOP of 26.6 +/- 7.1 mmHg after the first EI discontinuation had dropped to 16.4 +/- 4.3 mmHg (p < 0.0001) and rose to 29.6 +/- 7.1 mmHg when EI was again discontinued. The recorded EI-associated side effects were increased miosis in all eyes and headache (8/24 patients), neither of which were reasons for discontinuation of the drug in any patient. CONCLUSION: EI substantially decreased the IOPs in pseudophakic glaucoma eyes receiving maximal medical therapy, including the newer class of medications. This drug may be the last resort for post-cataract advanced glaucoma patients and may obviate the need for filtering surgery among the very elderly.

Comparison of optic nerve head topography findings in eyes with non-arteritic anterior ischemic optic neuropathy and eyes with glaucoma.

BACKGROUND: To compare the peripapillary retinal nerve fiber layer (RNFL) thickness in eyes affected by non-arteritic ischemic optic neuropathy (NAION) or glaucoma as determined by optical coherence tomography (OCT). METHODS: This cross-sectional institutional study included 18 eyes with NAION (at least 6 months since the acute event) and 29 eyes with glaucoma, both having localized visual field (VF) defects confined to one hemifield. Twenty-nine normal subjects served as controls. The fast RNFL thickness protocol (3.4) of the Stratus OCT (Carl Zeiss Meditec, Dublin, CA, USA) was used. The RNFL thickness and inferior maximum/temporal average (Imax/Tavg) and superior maximum/temporal average (Smax/Tavg) data corresponding to the hemifield with and without visual sensitivity loss were compared between NAION and glaucomatous eyes and with corresponding quadrants in normal eyes. The area under the receiver operating characteristic curve (AUC), sensitivities, and specificities were used to determine the OCT parameters that differ most in the two groups. RESULTS: The mean RNFL thickness in the quadrants corresponding to the affected hemifield in the NAION and glaucomatous eyes was not significantly different (P > 0.9), but the values for both were decreased compared to the control eyes (P < 0.0001). The mean RNFL thickness in the quadrant corresponding to the unaffected hemifield was significantly lower in the glaucomatous eyes (73.8 +/- 20.04 micro) than in the NAION eyes (96.6 +/- 23.32 micro, P = 0.023), and in both study groups compared to the controls (117.2 +/- 13.44 micro, P < 0.0001 for glaucomatous vs control eyes, and P < 0.025 for NAION vs control eyes). Smax/Tavg and Imax/Tavg of the quadrant corresponding to the unaffected hemifield had the strongest power to differentiate the two diseases (an AUC of 0.92). CONCLUSIONS: Stratus OCT detected significant quantitative differences in RNFL thickness between glaucomatous and NAION eyes, both conditions with hemifield defects. These differences might hold a clue in understanding the processes involved in optic nerve injury.

Refractive surgery in Israel Defense Forces recruits.

PURPOSE: To determine the prevalence of refractive surgery history in recruits for military service in the Israel Defense Forces (IDF) between 1998 to 2005 and to evaluate the effect of surgery on the recruits' fitness to serve in combat units. SETTING: Surgeon General's HQ, Medical Corps, Israel Defense Forces. METHODS: The computerized medical records of all ametropic Israeli army inductees were reviewed. They included spectacle-wearing, contact lens-wearing, and post refractive-surgery individuals who were examined in the recruitment office before their compulsory military service. The extracted data from the personal files consisted of the assignment to combat units of those who had refractive surgery and those who wore corrective eyewear and the first and last military position of all ametropic recruits who were assigned to combat units. RESULTS: Five hundred ninety-seven inductees (513 men, 84 women) had refractive surgery before their military service during the study period. The prevalence of recruits who had refractive surgery increased from 0.8/1000 ametropes in 1998 to 4.9/1000 ametropes in 2005. Significantly more recruits who had surgery (73.5%) than recruits who wore corrective eyewear were assigned to combat units (P<.001). The dropout rate from combat units of the former was significantly lower than that of the latter (13.1% versus 29.2%) (P<.001). CONCLUSIONS: More corrective eyewear users had refractive surgery before their IDF military service, and relatively more of them applied for combat duty. The high percentage of recruits who had refractive surgery who serve uninterruptedly in combat units indicates that the procedure has no deleterious effect on the recruits' fitness.

The involvement of matrix metalloproteinases 2 and 9 in rat retinal ischemia.

BACKGROUND: The involvement of matrix metalloproteinases (MMPs) in ischemic tissue damage and remodeling has been reported by many investigators. Our study was designed to investigate the involvement of MMPs and of tissue inhibitors of metalloproteinases (TIMPs) in rat retinal ischemic injury, the effect of nitric oxide synthase (NOS) inhibitors on MMPs' activity in this model and whether minocycline (an MMP inhibitor) is protective in retinal ischemia. METHODS: Ninety-four rats were used in the study. Ischemia was induced by 90 min elevation of intraocular pressure. MMPs' activities and the effect of NOS inhibitors [aminoguanidine (AG) or N-nitro-L-arginine (NNA)] and minocycline on MMPs' activities were assessed by zymography and TIMPs expression by Western analysis. Morphological damage was quantified by morphometry of hematoxylin and eosin-stained retinal sections. RESULTS: Retinal extracts exhibited activities of proMMP-9 and proMMP-2. The activity of proMMP-9 increased immediately post ischemia (PI) and peaked to 4.6 times that of normal untreated controls in ischemic retinas and to 2.6 times that of controls in retinas of fellow sham-treated eyes at 24 h PI. The relative amount of TIMP-1 increased to 1.9-fold following ischemia and 2.5-fold in fellow sham-treated eyes at 24 h PI. ProMMP-2 activity increased more than two-fold immediately, at 24 h and at 48 h PI in ischemic retinas, and insignificantly in fellow sham-treated eyes. Treatment with 25 mg/kg AG or NNA caused a non-significant increase in proMMP-9 activity at 24 h PI (3.7- and 2.9-fold, respectively, p>0.6). There was no effect of AG or NNA on the activity of proMMP-2. Minocycline significantly attenuated the retinal ischemic damage, primarily by partially preserving ganglion cells and the inner plexiform layer. Minocyline (0.5 mg/ml or 5 mg/ml) inhibited MMPs' activities in ischemic retinal extracts in vitro. CONCLUSIONS: MMPs participated in morphological ischemic damage to rat retina. Treatment with minocycline dramatically attenuated damage to the retina.

[Binocular function and patient satisfaction after monovision induced by laser in situ keratomileusis (lasik)].

INTRODUCTION: Presbyopia is a problem in refraction attributed to loss of near vision. Monovision (MV) is a strategy to compensate for presbyopia whereby one eye is corrected for distance and the other eye corrected for near vision. The patient should be able to suppress the blurred image from one eye and see clearly at all distances without glasses. PURPOSE: To measure binocular function and patient satisfaction with MV induced by laser in situ keratomileusis (LASIK) in myopic and hyperopic presbyopic patients. METHODS: Patients 39 years or older who underwent MV LASIK and minimum 90 days follow-up were included in the study. The following parameters were used: distance and near corrected/uncorrected visual acuity, manifest refraction before and after surgery and near stereopsis postoperatively. Patient satisfaction was evaluated by a questionnaire. RESULTS: One hundred and fourteen patients (100 myopes, 14 hyperopes) were included. After surgery, 79% had distance binocular uncorrected visual acuity of 6/7.5 or better and 97% of the patients had near binocular uncorrected visual acuity of J2 or better. The median of the near steroacuity was 100 seconds of arc. A total of 80% of the patients were very satisfied. The surgical score was 85. An overall 89.5% of the patients felt that their main goal had been achieved and 89% would choose to have surgery if they had it to do over. Eight percent of the patients used glasses for distance and 24% used reading glasses after surgery. The quality of life while driving at night improved in 55% and deteriorated in 15% of the patients. The quality of life while driving during the day improved in 69% and deteriorated in 1%. CONCLUSIONS: Monovision induced by LASIK may be a valuable option for both myopic and hyperopic presbyopic individuals considering refractive surgery. However, due to the risk of decreased night vision and continued use of reading glasses during the day, this surgery may not be suitable for patients in whom night driving and/or reading are an essential part of their life.