Birth Weight and Diabetic Retinopathy: Results From the Population-Based Gutenberg Health Study (GHS).

PURPOSE: This study investigates the relationship between diabetic retinopathy (DR) and birth weight (BW) in diabetic subjects sampled from the general population. METHODS: The Gutenberg Health Study (GHS) is a population-based, observational cohort study in participants aged from 35 to 74 years. Criteria for diabetes diagnosis were HbA1c ≥6.5% at study entry, a doctor-diagnosis of diabetes, or diabetes medication. The presence of DR was determined by evaluating fundus photographs. BW was assessed by self-reports. GHS participants were divided into three different BW groups (low: <2500 g; normal: 2500-4000 g; high:>4000 g). Logistic regression analysis was conducted as uni- and multivariable analysis with adjustment for age and sex. Effect mediators were separately investigated. RESULTS: A total of 1,124 GHS participants (7.5% of the cohort) had diabetes at study entry. Of these, 402 subjects (35.8%) had gradable fundus photographs, reported BW data and were included into this study. Overall, 91/402 subjects (23%) had DR. With regard to BW groups, DR was descriptively more frequent in subjects with low (28.1% [95%-CI: 14.4-47.0%; n = 32]) and high BW (30.8% [95%-CI: 19.1-45.3%; n = 52]) compared to normal BW (20.8% [95%-CI: 16.5-25.7%; n = 318]). Both high and low BW were associated with DR in multivariable analysis (high: OR = 1.68, p = .037; low: OR = 1.81, p = .05). The BW effect was mediated by duration of diabetes in both BW groups and by arterial hypertension in the low BW group. CONCLUSION: Low and high BW in persons with diabetes is related to higher risk of diabetic retinopathy. Longer duration of diabetes and higher prevalence of arterial hypertension are factors in these subjects explaining the elevated risk.

Association of ocular, cardiovascular, morphometric and lifestyle parameters with retinal nerve fibre layer thickness.

BACKGROUND: Glaucoma is a neurodegenerative disease, leading to thinning of the retinal nerve fibre layer (RNFL). The exact influence of ocular, cardiovascular, morphometric, lifestyle and cognitive factors on RNFL thickness (RNFLT) is unknown and was analysed in a subgroup of the Gutenberg Health Study (GHS). METHODS: Global peripapillary RNFLT was measured in 3224 eyes of 1973 subjects (49% female) using spectral-domain optical coherence tomography (SD-OCT). The association of age, sex, ocular, cardiovascular, morphometric, lifestyle and cognitive factors on RNFLT was analysed using Pearson correlation coefficient and fitting a linear mixed model. RESULTS: In the univariable analysis highest correlations were found for axial length (r = -0.27), spherical equivalent (r = 0.24), and glaucoma (r = -0.15) (p<0.0001, respectively). Other significant correlations with RNFLT were found for age, sex, intraocular pressure, systemic hypertension and systolic blood pressure, previous eye surgery, cholesterol, homocysteine, history of coronary artery disease, history of myocardial infarction, apnoea, diabetes and alcohol intake, p<0.05, respectively. Body length, body weight, BMI, diastolic blood pressure, blood glucose, HbA1c, history of apoplexy, cognitive function, peripheral artery disease, tinnitus, migraine, nicotine intake, central corneal thickness, and pseudophakia were not significantly correlated with RNFLT. The regression model revealed a significant relationship between RNFLT and age in decades (p<0.02), spherical equivalent (p<0.0001), axial length (p<0.0001), glaucoma (p<0.0001), tinnitus (p = 0.04), apnoea (p = 0.047), homocysteine (p = 0.05) and alcohol intake >10g/d for women and >20g/d for men (p = 0.02). Glaucoma, apnoea, higher homocysteine, higher alcohol intake and higher axial length as well as age were related to decreased RNFLT while higher spherical equivalent or history for tinnitus were related to thicker RNFL. CONCLUSION: RNFLT is related to age, ocular parameters and lifestyle factors. Considering these parameters in normative databases could improve the evaluation of peripapillary RNFLT. It is necessary to evaluate if a reduction of alcohol intake as well as the therapy of apnea or high homocysteine levels could positively influence RNFLT.

The distribution of retinal nerve fiber layer thickness and associations with age, refraction, and axial length: the Gutenberg health study.

PURPOSE: To evaluate the distribution of peripapillary retinal nerve fiber layer thickness as measured by optical coherence tomography and its associations with ocular parameters in a population-based setting. METHODS: In the population-based Gutenberg Health Study, 1974 subjects from the Mainz-Bingen region were scheduled for ophthalmologic examinations, including visual acuity, refraction, tonometry, biometry, and measurements of peripapillary retinal nerve fiber layer thickness (pRNFL) by optical coherence tomography (SD-OCT, Spectralis®, Heidelberg Engineering, Germany). The associated factors in the global and sectoral pRNFL data were analyzed using multivariable linear mixed models related to age, sex, and ocular parameters. RESULTS: Advanced age and longer axial length were associated with a thinner pRNFL, whereas pRNFL thickness was independent of sex, intraocular pressure (IOP), and central corneal thickness (CCT). Spherical equivalent was positively associated with pRNFL thickness, except in the temporal pRNFL sector. CONCLUSIONS: In this large, population-based study, pRNFL thickness decreased with age. Longer eyes had thinner pRNFL thickness. Sex, IOP, and CCT showed no significant association with pRNFL thickness. These data may improve the interpretation of pRNFL data.

Results of an Adaptive Surgical Approach for Managing Late Onset Hypotony After Trabeculectomy With Mitomycin C.

OBJECTIVES: The objective of this study is to investigate the results of an adaptive approach of bleb revision surgery for late onset hypotony after trabeculectomy with mitomycin C because of bleb leakage and/or scleral melting. METHODS: A total of 29 eyes of 27 patients, aged 63.8±11.7 years with hypotony maculopathy [intraocular pressure (IOP), ≤6 mm Hg] because of late onset bleb leakage and/or scleral melting after trabeculectomy with mitomycin C in which minimally invasive transconjunctival suturing of the scleral flap was impossible were enrolled in this retrospective interventional case series. External bleb leakage was seen in 16 eyes, 11 eyes suffered from scleral melting. Because of the intraoperative findings regarding appearance of conjunctiva and sclera 4 different surgical approaches were used: (1) bleb excision (in case of external leakage) and conjunctival reapproximation, (2) bleb excision and free conjunctival autografting, (3) human donor scleral patch grafting (in case of scleral flap defect) with conjunctiva reapproximation and (4) combined conjunctival and scleral patch grafting. Outcome measures were IOP and visual acuity (VA) development over time. Data analysis comparing changes in the parameters (IOP and VA) before and after bleb revision surgery was carried out using the paired t test. RESULTS: Changes in IOP and VA were analyzed over 9.3±8.3 months (range, 1.1 to 36.5 mo). IOP increased from 4.0±1.8 mm Hg, (P<0.001) before revision surgery to 13.1±4.1 mm Hg at 3 months after revision and 12.6±3.8 mm Hg at last follow-up visit, showing no significant difference in IOP between 3 months post revision and at the last documented patients' follow-up visit (P=0.28). The VA before revision surgery (0.42±0.28 logMAR) significantly increased (P=0.05) 3 months after revision (0.32±0.23 logMAR) and remained stable (P=0.65) until the last follow-up visit (9.3±8.3 mo; range, 1.1 to 36.5) (0.35±0.32 logMAR). CONCLUSIONS: In patients with hypotony an adaptive approach of bleb management shows good results both in terms of IOP control and improvement in VA.

Bruch's Membrane Opening-Minimum Rim Width Assessment With Spectral-Domain Optical Coherence Tomography Performs Better Than Confocal Scanning Laser Ophthalmoscopy in Discriminating Early Glaucoma Patients From Control Subjects.

PURPOSE: To compare the diagnostic performance and evaluate diagnostic agreement for early glaucoma detection between a confocal scanning laser ophthalmoscope (CSLO) and a spectral-domain optical coherence tomography (SD-OCT). PATIENTS AND METHODS: Fifty-five eyes of 55 open-angle glaucoma patients and 42 eyes of 42 healthy control subjects were enrolled in this observational, cross-sectional study. All participants underwent comprehensive ophthalmic examination, visual field testing, and optic nerve head and retinal nerve fiber layer imaging by CSLO (HRT3) and SD-OCT (Spectralis OCT). The agreements of categorical classifications were evaluated (κ statistics). Area under receiver operating characteristic curves (AUROC) and sensitivity at 95% fixed specificity were computed. RESULTS: The agreements of HRT3 and Spectralis OCT categorical classifications were fair to moderate (κ ranged between 0.33 and 0.54), except for Moorfields regression analysis of the HRT3 and the OCT global Bruch's membrane opening-minimum rim width (BMO-MRW) (criterion 1 κ=0.63, criterion 2 κ=0.67). The AUROC of OCT global BMO-MRW (0.956) was greater than those of HRT3 cup-to-disc area ratio (0.877, P=0.0063), vertical cup-to-disc ratio (0.872, P=0.0072), and cup area (0.845, P=0.0005). At 95% specificity, Spectralis OCT global BMO-MRW attained a higher sensitivity than HRT3 cup-to-disc area ratio (P<0.001). CONCLUSIONS: The BMO-MRW assessment with SD-OCT performed well in discriminating early glaucoma patients from control subjects and had a better performance than CSLO. The diagnostic classifications of HRT3 and Spectralis OCT may reach good agreement.

Associations with intraocular pressure across Europe: The European Eye Epidemiology (E3) Consortium.

Raised intraocular pressure (IOP) is the most important risk factor for developing glaucoma, the second commonest cause of blindness globally. Understanding associations with IOP and variations in IOP between countries may teach us about mechanisms underlying glaucoma. We examined cross-sectional associations with IOP in 43,500 European adults from 12 cohort studies belonging to the European Eye Epidemiology (E3) consortium. Each study conducted multivariable linear regression with IOP as the outcome variable and results were pooled using random effects meta-analysis. The association of standardized study IOP with latitude was tested using meta-regression. Higher IOP was observed in men (0.18 mmHg; 95 % CI 0.06, 0.31; P = 0.004) and with higher body mass index (0.21 mmHg per 5 kg/m2; 95 % CI 0.14, 0.28; P < 0.001), shorter height (-0.17 mmHg per 10 cm; 95 % CI -0.25, -0.08; P < 0.001), higher systolic blood pressure (0.17 mmHg per 10 mmHg; 95 % CI 0.12, 0.22; P < 0.001) and more myopic refraction (0.06 mmHg per Dioptre; 95 % CI 0.03, 0.09; P < 0.001). An inverted U-shaped trend was observed between age and IOP, with IOP increasing up to the age of 60 and decreasing in participants older than 70 years. We found no significant association between standardized IOP and study location latitude (P = 0.76). Novel findings of our study include the association of lower IOP in taller people and an inverted-U shaped association of IOP with age. We found no evidence of significant variation in IOP across Europe. Despite the limited range of latitude amongst included studies, this finding is in favour of collaborative pooling of data from studies examining environmental and genetic determinants of IOP in Europeans.

Prevalence of diabetic retinopathy in screening-detected diabetes mellitus: results from the Gutenberg Health Study (GHS).

AIMS/HYPOTHESIS: Individuals with type 2 diabetes mellitus may experience an asymptomatic period of hyperglycaemia, and complications may already be present at the time of diagnosis. We aimed to determine the prevalence of diabetic retinopathy in patients with newly diagnosed (screening-detected) type 2 diabetes. METHODS: The Gutenberg Health Study is a population-based study with 15,010 participants aged between 35 and 74 years. We determined the weighted prevalence of diabetic retinopathy by assessing fundus photographs. Screening-detected type 2 diabetes was defined as an HbA1c concentration of 6.5% (47.5 mmol/mol) or more, no medical diagnosis of diabetes and no intake of insulin or oral glucose-lowering agents. RESULTS: Of 14,948 participants, 1377 (9.2%) had diabetes mellitus. Of these, 347 (25.2%) had newly diagnosed type 2 diabetes detected by the screening. Overall, the weighted prevalence of screening-detected type 2 diabetes was 2.1%. Fundus photos were evaluable for 285 (82.1%) participants with newly diagnosed diabetes. The weighted prevalence of diabetic retinopathy in screening-detected type 2 diabetes was 13.0%; 12% of participants had a mild non-proliferative diabetic retinopathy and 0.6% had a moderate non-proliferative diabetic retinopathy. Diabetic retinopathy was proliferative in 0.3%. No cases of severe non-proliferative diabetic retinopathy or diabetic maculopathy were found. Thirty (14.9%) of 202 and six (7.2%) of 83 individuals with and without concomitant arterial hypertension, respectively, had diabetic retinopathy (OR 2.54, 95% CI 1.06, 7.14). Visual acuity did not differ between individuals with and without diabetic retinopathy . CONCLUSIONS/INTERPRETATION: In this large European study, the prevalence of diabetic retinopathy in screening-detected type 2 diabetes was 13%. Only a very small proportion of participants with detected diabetic retinopathy needed treatment.

Comparison of Rebound Tonometry, Perkins Applanation Tonometry and Ocular Response Analyser in Mucopolysaccharidosis Patients.

AIMS: To investigate the feasibility and to compare three devices measuring intraocular pressure (IOP) in mucopolysaccharidosis patients (MPS): iCare rebound tonometer (RT), Perkins applanation tonometer (PAT) and ocular response analyzer (ORA). METHODS: MPS patients who underwent at least two examinations out of: RT, PAT and ORA at the same visit were identified and retrospectively analyzed in this study. RESULTS: 17 patients fulfilled the inclusion criterion. In all 17 patients IOP measurements were performed with RT (34 eyes) and ORA (33 eyes), while PAT measurement was possible in only 12 (24 eyes) patients. The RT, corneal-compensated intraocular pressure (IOPcc) and Goldmann-correlated intraocular pressure (IOPg) differed relevantly from IOP assessed with PAT. Corneal clouding in MPS patients correlated positively with PAT, RT and IOPg (r = 0.3, 0.5, and 0.5 respectively), but not with IOPcc (r = 0.07). The MPS-related corneal clouding correlated positively with biomechanical corneal parameters assessed with ORA: corneal hysteresis (r = 0.77) and corneal resistance factor (r = 0.77) either. CONCLUSIONS: RT and ORA measurements were tolerated better than applanation tonometry in MPS patients. IOP measurements assessed with RT and ORA differed relevantly from PAT. Corneal-compensated IOP assessed with ORA seems to be less affected by the MPS-related corneal clouding than applanation or rebound tonometry. RT and ORA measurements should be preferred for IOP assessment in patients with MPS.

The prevalence of amblyopia in Germany: data from the prospective, population-based Gutenberg Health Study.

BACKGROUND: Amblyopia is due to insufficient development of the visual system in early childhood and is a major source of lifelong impairment of visual acuity. Too little is known about the prevalence of amblyopia in Germany and the frequency of its various causes. METHODS: The Gutenberg Health Study of the University of Mainz Faculty of Medicine is an ongoing population-based, prospective, monocentric cohort study with 15 010 participants aged 35 to 74. All participants are examined for the presence of ocular, cardiovascular, neoplastic, metabolic, immunologic, and mental diseases. 3227 participants aged 35 to 44 underwent ophthalmological examination from 2007 to 2012. Amblyopia was defined as impaired visual acuity in the absence of any organic pathology capable of explaining the condition, and in the presence of a known risk factor for amblyopia. RESULTS: Amblyopia, when defined as a visual acuity less than or equal to 0.63, was present in 182 participants (5.6%, 95% confidence interval [CI] 4.9-6.5%), 120 of whom had a visual acuity less than or equal to 0.5 (3.7%, 95% CI 3.3-5.2%). A narrower definition of amblyopia requiring, in addition, an interocular difference in acuity of at least two lines yielded slightly lower prevalence figures: 5.0% (95% CI 4.2-5.8%) and 3.7% (95% CI 3.1-4.4%), respectively. The causes of amblyopia (visual acuity ≤ 0.63) were anisometropia (different refractive strengths of the two eyes) in 49% of participants, strabismus (a squint) in 23%, both of these factors in 17%, and visual deprivation in 2%. 3 patients (2%) had relative amblyopia due to a traumatic cataract sustained in early childhood. 7% of the participants with amblyopia had binocular amblyopia. CONCLUSION: This study yielded a prevalence figure of 5.6% for amblyopia in Germany-a higher figure than in other, comparable population-based studies, which have generally yielded figures of ca. 3% for visual acuity ≤ 0.63. The distribution of the causes of amblyopia is similar across studies.

Prevalence and Cardiovascular Associations of Diabetic Retinopathy and Maculopathy: Results from the Gutenberg Health Study.

OBJECTIVE: Diabetic retinopathy (DR) is the leading cause of blindness in people of working age. The purpose of this paper is to report the prevalence and cardiovascular associations of diabetic retinopathy and maculopathy (DMac) in Germany. RESEARCH DESIGN AND METHODS: The Gutenberg Health Study (GHS) is a population-based study with 15,010 participants aged between 35 at 74 years from the city of Mainz and the district of Mainz-Bingen. We determined the weighted prevalence of DR and DMac by assessing fundus photographs of persons with diabetes from the GHS data base. Diabetes was defined as HbA1c ≥ 6.5%, known diagnosis diabetes mellitus or known diabetes medication. Furthermore, we analysed the association between DR and cardiovascular risk factors and diseases. RESULTS: Overall, 7.5% (1,124/15,010) of the GHS cohort had diabetes. Of these, 27.7% were unaware of their disease and thus were newly diagnosed by their participation in the GHS. The prevalence of DR and DMac was 21.7% and 2.3%, respectively among patients with diabetes. Vision-threatening disease was present in 5% of the diabetic cohort. In the multivariable analysis DR (all types) was associated with age (Odds Ratio [95% confidence interval]: 0.97 [0.955-0.992]; p = 0.006) arterial hypertension (1.90 [1.190-3.044]; p = 0.0072) and vision-threatening DR with obesity (3.29 [1.504-7.206]; p = 0.0029). DR (all stages) and vision-threatening DR were associated with duration of diabetes (1.09 [1.068-1.114]; p<0.0001 and 1.18 [1.137-1.222]; p<0.0001, respectively). CONCLUSIONS: Our calculations suggest that approximately 142 000 persons aged between 35 and 74 years have vision threatening diabetic retinal disease in Germany [corrected].Prevalence of DR was lower in the GHS compared to East-Asian studies. Associations were found with age, arterial hypertension, obesity, and duration of diabetes mellitus.

Flicker defined form perimetry in glaucoma suspects with normal achromatic visual fields.

BACKGROUND: To evaluate if repeated flicker-defined form (FDF) perimetry can detect visual field (VF) defects in glaucoma suspects with normal findings in achromatic standard automated perimetry (SAP). METHODS: Patients with optic nerve heads (ONHs) or retinal nerve fiber layer (RNFL) findings clinically suspicious for glaucoma and normal SAP were enrolled. Patients underwent VF testing with FDF perimetry (Heidelberg Edge Perimetry, HEP) at two consecutive visits (HEP I and HEP II) and confocal scanning laser ophthalmoscopy with the Heidelberg Retina Tomograph (HRT). Abnormal HEP was defined by cluster-point analysis (CPA) and by the HEP specific glaucoma hemi-field test (GHT). Results were compared with an age-matched control group of healthy individuals. RESULTS: In 65 eyes of 36 glaucoma suspects, the mean deviation (MD) in SAP was -0.9 ± 1.3 dB. In HEP I and HEP II, mean MD was -3.6 ± 3.0 and -3.3 ± 3.7 dB, respectively (p = 0.276). The HRT assessed CDR was significantly correlated with the MD in HEP II (r = -0.281, p = 0.04). In HEP I, VF defects on CPA testing were found in 38 study eyes (58.5%). In HEP II, 34 eyes (51.8%) had VF defects on CPA testing. In 46 eyes of 46 age-matched healthy individuals in the control group, the mean MD was -0.2 ± 1.1 and -1.6 ± 2.3 dB in SAP and HEP testing, respectively. The FDF was abnormal in 21.7% in the control group compared to 58.5% in the glaucoma suspect group in HEP I. CONCLUSIONS: In more than half of the patients with ONHs or RNFLs clinically suspicious for glaucoma and normal SAP second FDF perimetry depicts VF defects.

The size of subconjunctival preparation does not influence the outcome of trabeculectomy with mitomycin C.

PURPOSE: To compare the outcome of fornix-based trabeculectomy with mitomycin C (MMC) using 2 different sizes of subconjunctival preparation (36 mm² compared with 72 mm²). METHODS: Prospective, randomized interventional case series. STUDY POPULATION: Patients 18 to 85 years of age with open-angle glaucoma and progressive visual field defects under maximum tolerated medical therapy were randomized to undergo initial fornix-based trabeculectomy with MMC (0.2 mg/mL for 5 min) with subconjunctival preparation of 6×6 mm (group A) or 8×9 mm (group B). Main outcome parameters were: intraocular pressure (IOP), best-corrected visual acuity (BCVA), number of 5-fluorouracil (5-FU) injections, and laser suturolyses (SL). RESULTS: Twenty-eight eyes of 26 patients were enrolled, including 14 eyes in group A and 14 in group B. At 12 months, IOP (mean±SD) was 9.69±2.5 mm Hg in group A and 9.93±3.2 mm Hg in group B (P=0.17) without glaucoma medication. Mean BCVA (logMAR) at month 12 was 0.29±0.26 in group A and 0.26±0.2 in group B (P=0.71). Patients required 3.0 5-FU in group A and 4.1±2.9 5-FU in group B (P=0.16); 1.3±1.1 SL and 1.8±1.1 SL, respectively (P=0.23). We noted 2 cases of intraocular hypotony in the 6×6 mm group (14.3%) and 1 in the 8×9 mm group (7.1%). CONCLUSIONS: There were no significant differences between study groups in mean IOP reduction, change in BCVA, or number of applied 5-FU and SL at 1-year follow-up. The area of subconjunctival preparation is only one of several factors playing a role in the outcome of trabeculectomy with MMC.

Comparison of Laser Scanning Diagnostic Devices for Early Glaucoma Detection.

BACKGROUND: To compare the diagnostic accuracy and to evaluate the correlation of optic nerve head and retinal nerve fiber layer thickness values between Fourier-Domain optical coherence tomography (FD-OCT), confocal scanning laser ophthalmoscopy (CSLO), and scanning laser polarimetry (SLP) for early glaucoma detection. PATIENTS AND METHODS: Ninety-three patients with early open-angle glaucoma, 58 patients with ocular hypertension, and 60 healthy control subjects were included in this observational, cross-sectional study. All study participants underwent FD-OCT (RTVue-100), CSLO (HRT3), and SLP (GDx VCC) imaging of the optic nerve head and the retinal nerve fiber layer. Area under the receiver operating characteristic curves (AUROC) and Bland-Altman analysis were performed. RESULTS: The parameters with the highest diagnostic accuracy were found for FD-OCT cup-to-disc ratio (AUROC=0.841), for SLP NFI (AUROC=0.835), and for CSLO cup-to-disc ratio (AUROC=0.789). Diagnostic accuracy of the best CSLO and SLP parameter was similar (P=0.259). There was a small statistically significant difference between the best CSLO and FD-OCT parameters for differentiating between glaucoma and healthy eyes (P=0.047). CONCLUSIONS: FD-OCT and SLP have a similarly good diagnostic ability to distinguish between early glaucoma and healthy subjects. The diagnostic accuracy of CSLO was comparable with SLP and marginally lower compared with FD-OCT.

Prevalence and associations of diabetic retinopathy in a large cohort of prediabetic subjects: the Gutenberg Health Study.

AIMS: To evaluate the prevalence of diabetic retinopathy/maculopathy (DR/DMac) and its associations with cardiovascular risk factors (CRF) in participants with prediabetes (PwPD) in a large European cohort within the population-based Gutenberg Health Study (GHS). METHODS: The study was based on a sub-cohort of the GHS (n=5,000, age: 35-74 y). Prediabetes was diagnosed according to HbA1c levels (5.7-6.4%). DR/DMac was graded from fundus photographs. Blood samples and comprehensive questionnaires served for evaluation of laboratory results and CRF. RESULTS: The prevalence of prediabetes was 22.4%, and of DR/DMac 8.1%/0.2%, respectively. The majority of participants had mild DR (7.2%). A percentage of 0.5 of PwPD presented with moderate and 0.3% with severe non-proliferative disease. None of the subjects had proliferative DR. No independent association was found between any of the analyzed CRF [hypertension, smoking, (family) history of myocardial infarction, congestive heart failure, coronary heart disease, stroke, obesity, dyslipidemia, chronic obstructive pulmonary disease, peripheral artery disease and chronic kidney disease] and DR. CONCLUSIONS: Although prevalences of prediabetes and DR in this Caucasian cohort are considerable, retinopathy findings are mainly mild, and no association was found for DR/DMac and CRF.

Distribution of central corneal thickness and its association with ocular parameters in a large central European cohort: the Gutenberg health study.

MAIN OBJECTIVE: To evaluate the distribution of central corneal thickness (CCT) in a large German cohort and to analyse its relationship with intraocular pressure and further ocular factors. DESIGN: Population-based, prospective, cohort study. METHODS: The Gutenberg Health Study (GHS) cohort included 4,698 eligible enrollees of 5,000 subjects (age range 35-74 years) who participated in the survey from 2007 to 2008. All participants underwent an ophthalmological examination including slitlamp biomicroscopy, intraocular pressure measurement, central corneal thickness measurement, fundus examination, and were given a questionnaire regarding glaucoma history. Furthermore, all subjects underwent fundus photography and visual field testing using frequency doubling perimetry. RESULTS: Mean CCT was 557.3 ± 34.3 µm (male) and 551.6±35.2 µm in female subjects (Mean CCT from right and left eyes). Younger male participants (35-44 years) presented slightly thicker CCT than those older. We noted a significant CCT difference of 4 µm between right and left eyes, but a high correlation between eyes (Wilcoxon test for related samples: p<0.0001). Univariable linear regression stratified by gender showed that IOP was correlated with CCT (p<0.0001). A 10 µm increase in CCT led to an increase in IOP between 0.35-0.38 mm Hg, depending on the eye and gender. Multivariable linear regression analysis revealed correlations between gender, spherical equivalent (right eyes), and CCT (p<.0001 and p=0.03, respectively). CONCLUSIONS: We observed positive correlations between CCT and IOP and gender. CCT was not correlated with age, contact lens wear, positive family history for glaucoma, lens status, or iris colour.

Neuroprotection of medical IOP-lowering therapy.

Intraocular pressure (IOP)-lowering therapy has been shown to arrest or retard the progression of optic neuropathy typical for glaucoma and can, thus, be described as neuroprotective. At present, six classes of medical therapy are employed, namely parasympathomimetics, alpha/beta-sympathomimetics, ß-blockers, carbonic anhydrase inhibitors, α2-adrenergic receptor agonists and prostaglandin analogues. For several of these substances, some experimental evidence exists of a possible neuroprotective mechanism, beyond their IOP-lowering activity. ß-Blockers are involved in the up-regulation of brain-derived neurotrophic factor (BDNF) and can decrease glutamate-mediated NMDA receptor activation. Not only systemic but also topical carbonic anhydrase inhibitors are able to increase retinal blood flow. α2-Adrenergic receptor agonists can up-regulate the formation of BDNF and anti-apoptotic factors. Prostaglandin analogues increase blood flow to the eye, possibly including the retina. To date, evidence for a neuroprotective effect independent of IOP regulation in human glaucoma is scarce and has only been shown to be likely for the α2-adrenergic receptor agonist, brimonidine.

The influence of intersubject variability in ocular anatomical variables on the mapping of retinal locations to the retinal nerve fiber layer and optic nerve head.

PURPOSE: To investigate the influence of intersubject variation in ocular parameters on the mapping of retinal locations to the retinal nerve fiber layer and optic nerve head. METHODS: One hundred retinal nerve fiber layer (RNFL) bundle photographs from 100 subjects were optimized digitally and single RNFL bundles manually traced back to the ONH where their entry point was noted. A 24-2 visual field (VF) grid pattern was superimposed onto the photographs in order to relate VF test points to intersecting RNFL bundles and their entry angles into the ONH. Axial length, spherical equivalent, the position of the ONH in relation to the fovea, size, orientation, tilt, and shape of the ONH were assessed. Multilevel linear models were generated for predicting the entry angle of RNFL bundles, based on ocular parameters. RESULTS: A total of 6388 RNFL bundles were traced. The influence of ocular parameters could be evaluated for 33 out of 52 VF locations. The position of the ONH in relation to the fovea was the most prominent predictor for variations in the mapping of retinal locations to the ONH, followed by disc area, axial length, spherical equivalent, disc shape, disc orientation, and disc tilt. CONCLUSIONS: Mapping of retinal locations to the optic nerve head varies between patients according to a given patient's ocular parameters. By considering these parameters, patient-tailored, structure-function maps can be built and structural and functional measurements can be correlated more accurately. Individualized maps may assist clinicians detecting glaucoma and monitoring glaucomatous progression.

Standard automated perimetry versus matrix frequency doubling technology perimetry in subjects with ocular hypertension and healthy control subjects.

BACKGROUND: To evaluate the relationship and agreement between standard automated perimetry (SAP) and Matrix frequency doubling technology (Matrix-FDT) in subjects with ocular hypertension and healthy control subjects. METHODS: Forty-four eyes of 44 ocular hypertensive subjects and 29 eyes of 29 healthy age-matched control subjects were included in this prospective study. All participants underwent complete ophthalmic examination, including slit-lamp biomicroscopy, intraocular pressure measurement, pachymetry, and dilated fundus examination, and showed reliable visual field tests. One randomly selected eye of each participant was examined with SAP (Swedish Interactive Threshold Algorithm [SITA] Standard 24-2 test) and Matrix-FDT (24-2 threshold test), in random order. Correlations between global indices (MD, PSD), regions (2 hemifields, 4 quadrants, 6 sectors) and 52 single field positions were analyzed using Spearman's rank correlation coefficient. RESULTS: In both groups, mean deviation values of SAP and Matrix-FDT correlated significantly (OHT subjects: r = 0.47, p<0.005; healthy subjects: r = 0.68; p<0.001, respectively). Pattern standard deviation of SAP and Matrix-FDT showed no significant correlation in healthy subjects but correlated significantly in ocular hypertensive subjects (r = 0.45, p<0.005). In healthy subjects, a significant correlation between SAP and Matrix-FDT was shown in the supero-temporal and infero-temporal sectors of the disc (r = 0.40 and r = 0.38, p<0.05, respectively). In OHT subjects, supero-temporal, supero-nasal and nasal sectors correlated significantly (r = 0.49, 0.62 and 0.38, p≤0.01, respectively). The correlation pattern of individual visual field test locations appeared heterogeneous in both groups. CONCLUSIONS: In both, ocular hypertensive and healthy subjects SAP and Matrix-FDT correlate well. In ocular hypertensive subjects, both techniques showed good correlation in the supero-temporal, supero-nasal, and nasal sectors of the disc. Poor agreement was found in the temporal, infero-temporal and infero-nasal disc sectors. This missing correlation might be related to early retinal nerve fiber layer damage in these regions of the disc, recognized by one of the visual field instruments.

The international forum of ophthalmic simulation: developing a virtual reality training curriculum for ophthalmology.

BACKGROUND: To investigate the effect of a structured, supervised, cataract simulation programme on ophthalmic surgeons in their first year of training, and to evaluate the level of skill transfer. METHODS: Trainees with minimal intraocular and simulator experience in their first year of ophthalmology undertook a structured, sequential, customised, virtual reality (VR) cataract training programme developed through the International Forum of Ophthalmic Simulation. A set of one-handed, bimanual, static and dynamic tasks were evaluated before and after the course and scores obtained. Statistical significance was evaluated with the Wilcoxon sign-rank test. RESULTS: The median precourse score of 101.50/400 (IQR 58.75-145.75) was significantly improved after completing the training programme ((postcourse score: 302/400, range: 266.25-343), p<0.001). While improvement was evident and found to be statistically significant in all parameters, greatest improvements were found for capsulorhexis and antitremor training ((Capsulorhexis: precourse score=0/100, range 0-4.5; postcourse score=81/100, range 13-87.75; p=0.002), (antitremor training: precourse score=0/100, range 0-0; postcourse score=80/100, range 60.25-91.50; p=0.001)). CONCLUSIONS: Structured and supervised VR training can offer a significant level of skills transfer to novice ophthalmic surgeons. VR training at the earliest stage of ophthalmic surgical training may, therefore, be of benefit.