The long-term outcome of glaucoma filtration surgery.

PURPOSE: To determine the long-term outcome of glaucoma filtration surgery in preserving vision. Visual loss from progressive glaucomatous damage and from complications of surgery, both short and long term, were included. METHODS: A retrospective, community-based, longitudinal study of residents of Olmsted County, Minnesota, who were newly diagnosed with open-angle glaucoma between 1965 and 1980 and underwent filtration surgery in these or subsequent years through 1998. Intraocular pressure (IOP), visual acuity, visual fields, and progression to legal blindness were monitored. Kaplan-Meier analysis was used to determine the cumulative probabilities of changes in these parameters. RESULTS: 73 eyes of 49 patients underwent conventional filtration surgery. Analysis of the first eye having surgery revealed a mean preoperative IOP of 27.6 +/- 8.5 mm dropping to 16.7 +/- 5.6 mm at year one, and remaining in this range throughout follow-up (14.7 +/- 3.0 mm at 10 years; with or without use of medications). The probability of progression to blindness was 46% at 10 years after surgery, as calculated by Kaplan-Meier analysis. Eyes going blind had a postoperative IOP equal to or lower than those not becoming blind (14.0 +/- 4.4 vs. 15.4 +/- 3.0 at postoperative year 10). Eyes going blind had more advanced field loss at the time of surgery, with scotomas above and below the horizontal axis, than eyes not going blind, which had scotomas in only one hemifield. Three patients developed late bleb leaks; two patients developed endophthalmitis. The probability of undergoing cataract surgery was 37% by 10 years postoperatively, which did not differ significantly from the cohort of patients not undergoing surgery at a comparable time point. CONCLUSIONS: Filtration surgery was associated with a 54% probability of preservation of vision from progression to legal blindness at 10 years after surgery. Patients becoming blind had more advanced field loss at the time of surgery; IOP was similar between those going blind and those retaining vision.

Estimated incidence of open-angle glaucoma in Olmsted County, Minnesota.

PURPOSE: To determine the incidence rates of open-angle glaucoma (OAG) in Olmsted County, MINNESOTA: DESIGN: Retrospective population-based estimate of incidence. PARTICIPANTS: From the medical histories of 60,666 residents of Olmsted County, Minnesota, who had ocular diagnoses during the study period, 114 subjects with newly diagnosed OAG were identified. METHODS: The database of the Rochester Epidemiology Project was used to identify all Olmsted County residents with a coded diagnosis of OAG, glaucoma suspect, or ocular hypertension during the period 1965 to 1980. Subjects newly diagnosed with and treated for OAG who also had documented clinical evidence of elevated intraocular pressure, optic nerve damage, and/or visual field loss consistent with glaucoma were included as incident cases. Population data for Olmsted County were drawn from United States Census data. Crude incidence data were adjusted to the age and gender distribution of the 1990 United States white population. MAIN OUTCOME MEASURES: Estimated incidence rates of OAG. RESULTS: The overall age- and gender-adjusted annual incidence rate of OAG in a predominantly Caucasian population is conservatively estimated to be 14.5 per 100,000 population. The rates increased with age from 1.6 in the fourth decade of life to 94.3 in the eighth decade. There was no significant difference in incidence by gender. The average annual rate of OAG in the last 2 years of the study was 27.7 compared with 12.3 before 1979. This difference is suggestive of the effect of the introduction of a new medical therapy (timolol) for OAG during the last 2 years. CONCLUSIONS: The incidence rates of OAG increase markedly with advancing age, and screening efforts should be targeted at both men and women in the older age groups. The advent of new diagnostic and therapeutic modalities can have an effect on incidence rates.

Cardiovascular and cerebrovascular mortality associated with ocular pseudoexfoliation.

PURPOSE: In recent years, several studies have shown the presence of vascular, cardiac, and other organ pseudoexfoliative material in patients with ocular pseudoexfoliation. The purpose of this study was to determine whether an association exists between ocular pseudoexfoliation and cardiovascular, cerebrovascular, or all-cause mortality. METHODS: This retrospective study included 472 residents of Olmsted County, Minnesota, who were diagnosed with pseudoexfoliation syndrome or pseudoexfoliative glaucoma at Mayo Clinic from 1976 through 1995. Of these 472 cases, 151 subsequently died from 1976 through 1997. Cause of death for these patients, as determined by the National Center for Health Statistics was compared with the entire Rochester, Minnesota, population using Kaplan-Meier analysis. RESULTS: Of the 472 patients with ocular pseudoexfoliation, 358 (76%) were female and 114 (24%) were male. The mean age at diagnosis was 74 years, with a SD of 10 years and a range from 39 to 106 years. Cardiovascular disease resulted in 40 deaths, with a 15-year cumulative probability of cardiovascular mortality of 22%, compared with an expected 20% (no significant difference with P = .19). Cerebrovascular disease resulted in 26 deaths with a 15-year cumulative probability of cerebrovascular mortality of 12%, compared with an expected 10% (no significant difference with P = .38). Finally, the 15-year observed all-cause cumulative mortality was 53% versus an expected rate of 59% (significant difference with P = .0002). CONCLUSIONS: No association was found between ocular pseudoexfoliation and cardiovascular or cerebrovascular mortality. All-cause mortality was significantly less in patients with ocular pseudoexfoliation.

Probability of filtration surgery in patients with open-angle glaucoma.

OBJECTIVE: To investigate the probability of undergoing filtration surgery in either 1 or both eyes in patients in whom open-angle glaucoma was newly diagnosed. METHODS AND DESIGN: A retrospective community-based study of 295 residents of Olmsted County, Minnesota, in whom open-angle glaucoma was newly diagnosed between January 1, 1965, and December 31, 1980, was performed. Kaplan-Meier methods were used to estimate the cumulative probability of undergoing filtration surgery during a 20-year period. RESULTS: At 20 years of follow-up, the Kaplan-Meier cumulative probability of undergoing filtration surgery in at least 1 eye was estimated to be 23% (95% confidence interval, 16%-30%), and in both eyes the estimate was 12% (95% confidence interval, 6%-17%). Patients with optic nerve damage at the time of diagnosis were more likely to undergo surgery than patients with elevated intraocular pressure but no damage (1 eye, 39% vs 15%; both eyes, 27% vs 5%). CONCLUSION: This retrospective study of a white population newly diagnosed as having and treated for open-angle glaucoma indicates that while most patients did not undergo filtration surgery in the course of glaucoma therapy, at least one third of those with glaucomatous damage at the time of diagnosis underwent filtration surgery.

Indiscriminate use of corticosteroid-containing eyedrops.

Ocular complications may occur with the use of corticosteroid-containing eyedrops. We describe two cases of corticosteroid-induced glaucoma and one case of corticosteroid-associated fungal keratitis. Corticosteroid-containing eyedrops should be avoided unless the practitioner is knowledgeable about tonometry, slit-lamp examination techniques, and ocular differential diagnosis and treatment. Alternative pharmacologic approaches to topical administration of corticosteroid-containing eyedrops are discussed.

The probability of blindness from open-angle glaucoma.

OBJECTIVE: This study aimed to determine the probability of a patient developing legal blindness in either one or both eyes from newly diagnosed and treated open-angle glaucoma (OAG) after starting medical or surgical therapy or both. DESIGN: The study design was a retrospective, community-based descriptive study. PARTICIPANTS: Two hundred ninety-five residents of Olmsted County, Minnesota, newly diagnosed with, and treated for, OAG between 1965 and 1980 with a mean follow-up of 15 years (standard deviation +/- 8 years) participated. INTERVENTION: Kaplan-Meier cumulative probability of blindness was estimated for patients treated and followed for OAG. MAIN OUTCOME MEASURES: Legal blindness, defined as a corrected visual acuity of 20/200 or worse, and/or visual field constricted to 20 degrees or less in its widest diameter with the Goldmann 1114e test object or its equivalent on automated perimetry, secondary to glaucomatous loss, was measured. RESULTS: At 20-years' follow-up, the Kaplan-Meier cumulative probability of glaucoma-related blindness in at least one eye was estimated to be 27% (95% confidence interval, 20%-33%), and for both eyes, it was estimated to be 9% (95% confidence interval, 5%-14%). At the time of diagnosis, 15 patients were blind in at least 1 eye from OAG. CONCLUSION: A retrospective study of a white population determined that the risk of blindness from newly diagnosed and treated OAG may be considerable.

Adverse side effects associated with latanoprost.

PURPOSE: To report three different adverse reactions after initiating treatment with latanoprost. METHOD: Serial clinical examinations of three patients were performed. RESULTS: Adverse reactions such as ocular hypotony and choroidal effusions, recurrent cystoid macular edema, and facial rash were noted to occur within 1 to 4 weeks after starting topical latanoprost for the treatment of primary open-angle glaucoma. CONCLUSION: Clinicians should be alerted to these possible complications of topical latanoprost therapy.

Incidence of nonarteritic anterior ischemic optic neuropathy.

PURPOSE: Nonarteritic anterior ischemic optic neuropathy is the most common acute optic nerve disease of adults over age 50 years. This study determined the incidence of acute nonarteritic anterior ischemic optic neuropathy in the circumscribed population of Olmsted County, Minnesota. METHODS: This was a retrospective study of the incidence of acute nonarteritic anterior ischemic optic neuropathy between 1981 and 1990. The Rochester Epidemiology Project medical records linkage system facilitates identification of the medical records of virtually all Olmsted County residents with a given diagnosis. All cases of acute nonarteritic anterior ischemic optic neuropathy that fulfilled certain inclusion and exclusion criteria were identified. RESULTS: Twenty-two cases in 21 patients (11 men and 10 women) were recorded. The crude annual incidence rate was 10.3 per 100,000 individuals (95% confidence interval [CI] = 5.1 to 18.4). When adjusted to the age and sex distribution of the 1990 United States white population, the incidence rate was 10.2 per 100,000 (95% CI = 6.5 to 15.6). At diagnosis, the median age was 72 years, mean visual acuity was 20/200 in the affected eye, and the most common visual field defect was an altitudinal deficit (10 cases). CONCLUSIONS: Although results of this small study should be interpreted cautiously, extrapolation of our findings to the United States white population indicates that nearly 5,700 new cases of acute nonarteritic anterior ischemic optic neuropathy may be expected to occur each year in this group.

Ocular lymphoma in a patient with chronic lymphocytic leukemia.

PURPOSE: To treat large-cell lymphoma in a patient with chronic lymphocytic leukemia and bilateral vitreous cells. METHODS: The patient underwent a diganostic vitrectomy. RESULTS: Biopsy of the vitreous specimen disclosed large B-cell lymphoma. Large B-cell lymphoma occurring in patients with chronic lymphocytic leukemia is referred to as Richter's syndrome. CONCLUSIONS: Large-cell lymphoma of Richter's syndrome can occur in the eye. This case expands the clinical spectrum of organ involvement in Richter's syndrome.

Electrolyte composition of lacrimal gland fluid and tears of normal and vitamin A-deficient rabbits.

Rabbit tears and lacrimal gland fluid were collected simultaneously during pilocarpine stimulation with the goal of comparing the ionic composition of these fluids at various flow rates. Ions measured were sodium, potassium, calcium, magnesium, zinc, chloride, and bicarbonate. Human tears were also analyzed for purposes of comparison. Generally, tears and lacrimal gland fluid do not differ in ionic composition except for zinc and bicarbonate, which are in higher concentration in tears than in lacrimal gland fluid. The ionic composition of tears and lacrimal gland fluid of vitamin A-deficient rabbits was also analyzed. The maximal flow rate of lacrimal gland fluid was decreased in vitamin A-deficient rabbits as were calcium levels in tears and lacrimal gland fluid, as compared with controls. Concentrations of other ions generally did not differ from normal levels, indicating that vitamin A deficiency has only moderate effects on lacrimal gland function in the rabbit.