Spinal fluid evacuation may provide temporary relief for patients with unexplained widespread pain and fibromyalgia.

Fibromyalgia (FM) exhibits characteristics of a neurological disorder, and similarities have been identified between FM and idiopathic intracranial hypertension (IICH). When intracranial pressure rises, the drainage of excess cerebrospinal fluid (CSF) through the subarachnoid space of the cranial and spinal nerves increases. Higher CSF pressure irritates nerve fibers inside nerve root sheaths and may consequently cause radicular pain, as was reported in patients with IICH. Moreover, the cut-off of 20-25 cm H20 used to define IICH may be too high, as has been suggested in patients with chronic fatigue syndrome. We hypothesize that the neurological symptoms of FM are caused by the dysregulation of cerebrospinal pressure (CSP) and that spinal fluid drainage can relieve this pain. Exploring the processes underlying increased CSP may provide an alternative explanation for the generation of unexplained widespread pain (WSP) and FM as opposed to central sensitization. Additionally, when performing a lumbar puncture for diagnostic reasons, it is useful to measure opening pressure in patients with chronic WSP.

Fibromyalgia and unexplained widespread pain: The idiopathic cerebrospinal pressure dysregulation hypothesis.

Fibromyalgia (FM) is a debilitating, widespread pain disorder that is assumed to originate from inappropriate pain processing in the central nervous system. Psychological and behavioral factors are both believed to underlie the pathogenesis and complicate the treatment. This hypothesis, however, has not yet been sufficiently supported by scientific evidence and accumulating evidence supports a peripheral neurological origin of the symptoms. We postulate that FM and several unexplained widespread pain syndromes are caused by chronic postural idiopathic cerebrospinal hypertension. Thus, the symptoms originate from the filling of nerve root sleeves under high pressure with subsequent polyradiculopathy from the compression of the nerve root fibers (axons) inside the sleeves. Associated symptoms, such as bladder and bowel dysfunction, result from compression of the sacral nerve root fibers, and facial pain and paresthesia result from compression of the cranial nerve root fibers. Idiopathic Intracranial Hypertension, Normal Pressure Hydrocephalus and the clinical entity of symptomatic Tarlov cysts share similar central and peripheral neurological symptoms and are likely other manifestations of the same condition. The hypothesis presented in this article links the characteristics of fibromyalgia and unexplained widespread pain to cerebrospinal pressure dysregulation with support from scientific evidence and provides a conclusive explanation for the multitude of symptoms associated with fibromyalgia.

Long term IOP lowering efficacy of bimatoprost/timolol fixed combination: a 12 month prospective study.

PURPOSE: To evaluate the long-term IOP-lowering effect of an initially successful switch from prostaglandine-analog (PGA) monotherapy to bimatoprosttimolol fixed combination (BTFC) METHODS: Prospective, monocentric, open-labeled clinical trial. 30 patients with insufficient intraocular pressure (lOP) control under PGA monotherapy were screened. Following a one month run-in period of BTFC, patients who presented an effective IOP-lowering response were prospectively studied for an additional 11-month period. IOP, tolerability and safety (adverse reactions, slit lamp biomicroscopy) were further assessed at month 6 and month 12 after initiating BTFC. RESULTS: BTFC therapy significantly decreased IOP when compared to PGA monotherapy (PGA monotherapy: 17.3+/-3.8 mmHg; BTFC 1 month 13.2+/-3.3mmHg; p<0.05). This decrease from PGA-monotherapy IOP was sustained throughout the time-frame (6-month: 13.5+/-3.6mmHg; 12-month: 13.9+/-2.4mmHg; p<0.05 in pairwise comparison). There was no statistical difference in IOP between BTFC study visits (p>0.05). Of the 27 patients who had a satisfactory lOP-lowering response to BTFC after one month, 18 (66.7%) still had sufficient IOP control at the 12 month study visit. Therapy was discontinued at 1 month in 3 patients (2 due to intolerance to medication and 1 failing to achieve IOP control). No intolerability was reported beyond the 1 month of BTFC therapy. CONCLUSION: In the majority of patients, the initial lOP lowering effect of replacing PGA monotherapy by BTFC seems to predict a long term response to the new treatment strategy.

Oximetry: recent insights into retinal vasopathies and glaucoma.

This review will highlight a new technology and recent insights into measuring retinal oxygen saturation in several ophthalmic diseases. A growing body of evidence suggests that disturbances in retinal blood flow and oxygenation are related to several retinopathies and glaucoma, which can severely impair vision. The retinal oximeter may allow researchers and physicians to gain deeper insights into retinal physiology and clarify the impact of ischemia on retinal health and function. There are two commercially available systems to measure retinal oxygen saturation: the Oxymap retinal oximeter (Reykjavik, Iceland) and the Imedos Systems UG (Jena, Germany). In this review we will focus on the results obtained with Oxymap. Direct and non-invasive measurement of retinal oxygen saturation have potentially useful diagnostic and therapeutic indications in various eye diseases such as diabetic retinopathy, age-related macular degeneration, central retinal vein and artery occlusion, anterior ischemic optic neuropathy and retinopathy of prematurity. Despite several limitations, oxygen saturation assessment in the retinal vessels is a significant advancement in the understanding of ocular diseases. Nevertheless, further studies are needed to validate the use of oximetry in retinal vasopathies and glaucoma.

Laser-induced retinal injury following a recreational laser show: two case reports and a clinicopathological study.

BACKGROUND: Two patients who attended a dance festival with an audience-scanning laser show presented in our department with a decrease in visual acuity from a direct laser hit in one eye. Ophthalmoscopy showed a similarly sized retinochoroidal coagulation spot, which had led to a retinal hemorrhage in both patients. Because the organizers of the show concluded that the retinal injury was caused by powerful, handheld laser pointers in the crowd, we were interested in determining if these laser pointers could cause this kind of acute retinopathy. METHODS: A 44-year-old man with an extrafoveal, temporal choroidal melanoma was scheduled for enucleation. The eye (visual acuity 20/20) had a healthy-appearing macula. Prior to enucleation, the retina was exposed to eight different durations (0.5-64 seconds) of laser beam from a commercially available, handheld, class 3B green laser pointer (500 mW). RESULTS: Histologic analysis was unable to identify any abnormalities in the choriocapillaris, the photoreceptors or the retinal pigment epithelium (RPE). CONCLUSION: The use of powerful laser appliances (class 4 lasers) directed into the audience (audience-scanning laser show) can cause significant retinal injuries with lifelong visual consequences. It is unlikely that laser pointers, even those of class 3B, can cause these ocular injuries.

Patient-reported outcomes (PRO's) in glaucoma: a systematic review.

The aim of this review was to summarize literature in view of patient-reported outcome (PRO) instruments for glaucoma and provide guidance on how outcomes are best assessed based on evidence about their content and validity. A systematic literature review was performed on papers describing the developmental process and/or psychometric properties of glaucoma or vision-specific PRO-instruments. Each of them was assessed on their adherence to a framework of quality criteria. Fifty-three articles were identified addressing 27 PRO-instruments. In all, 18 PRO's were developed for glaucoma and 9 for diverse ophthalmologic conditions. Seven instruments addressed functional status, 11 instruments quality of life and 9 instruments disease and treatment-related factors. Most of the instruments demonstrated only partially adherence to predefined quality standards. The tools for assessing functional status were of poor quality, while the Glaucoma Quality of Life Questionnaire and the Vision Quality of Life Index were well-developed QoL measures, yet only validated using classical techniques. The Rasch-scaled QoL-tools, IVI and VCM1 need to improve their item-content for glaucoma patients. The questionnaires to measure adherence should improve their validity and the Treatment Satisfaction Survey for Intra Ocular Pressure pops out as the highest quality tool for measuring topical treatment side effects. This review revealed that most PRO-instruments demonstrated poor developmental quality, more specifically a lack of conceptual framework and item generation strategies not involving the patients' perspective. Psychometric characteristics were mostly tested using classical validation techniques.

[Vascular endothelial growth factor (VEGF) and modulation of wound healing after glaucoma surgery]. / Vasculaire endotheliale groeifactor (VEGF) en modulatie van wondheling na glaucoomheelkunde.

Glaucoma is an important cause of blindness. Therefore, the optimalisation of glaucoma surgery might have an important impact on the visual prognosis and the quality of life of glaucoma patients. This project focuses on the development of antifibrotic strategies that would inhibit the scarring of the created fistula, and thus improve the outcome after glaucoma surgery. We found that the vascular growth factor VEGF that is mostly known for its role in blood vessel formation also plays a role in postoperative wound healing. Furthermore, we studied the potential of anti-VEGF therapy to inhibit excessive wound healing (scar formation) after glaucoma surgery. Indeed, both in vitro and in vivo, VEGF prove to be efficacious to reduce scar formation, and thus improve the prognosis after glaucoma surgery. This fundamental research translated into a prospective clinical study, in which anti-VEGF is administered during glaucoma surgery, to improve the outcome after the surgery. We therefore hope that this translational research will indeed result in a better prognosis and quality of life for our glaucoma patients.

Glaucoma medication during pregnancy and nursing.

Risks that glaucoma medications pose to the fetus and neonate must be balanced against the risk of vision loss in the mother. There is no high level evidence for harmful effects on the fetus and neonate of medications used to treat glaucoma. All topical and systemic glaucoma medication should be avoided during the first trimester of pregnancy. Systemic carbonic anhydrase inhibitors, topical prostaglandin analogues and antimetabolites during surgery should be avoided absolutely. Some topical medications are deemed compatible with lactation by the American Academy of Pediatrics, however, caution should still be practiced.

Conjunctival effects of a selective nasal pollen provocation.

BACKGROUND: Several clinical and experimental observations suggest that allergen deposition in the nose may partially be responsible for the induction of conjunctival symptoms in allergic rhinitis. The aims of this study were to evaluate the induction of conjunctival symptoms by selective nasal allergen provocation and to assess the feasibility of the different tools for evaluation of conjunctival allergic inflammation. METHODS: Grass pollen allergic subjects with rhinoconjunctivitis symptoms during the pollen season (n = 12) underwent a nasal sham and grass pollen provocation extra-seasonally. Nasal and conjunctival symptoms were scored using the Visual Analogue Scale (VAS) system at baseline, 15 min, 1 h and 24 h after provocation. In addition to Peak Nasal Inspiratory flow (PNIF) measurements, conjunctival inflammation and vascular congestion were evaluated and histamine and substance P levels in tear fluid were measured. RESULTS: Selective nasal grass pollen provocation induced ocular pruritus, lacrimation and conjunctival vascular congestion. PNIF values correlated inversely with lacrimation (r = -0.71, P < 0.001) and ocular pruritus (r = -0.41, P < 0.05). Four out of 11 patients showed a conjunctival eosinophilic inflammation and levels of histamine (r = 0.73, P < 0.05) and substance P (r = 0.67, P = 0.05) in tear fluid correlated with conjunctival symptoms. CONCLUSION: Selective nasal grass pollen provocation induced conjunctival inflammation, ocular pruritus and lacrimation, which correlated with histamine and substance P levels in tear fluid and inversely with the PNIF values. These data show a naso-ocular interaction in allergic rhinitis and offer objective tools for evaluation of conjunctival inflammation in allergic rhinoconjunctivitis.

Appraisal of optic disc stereo photos pre- and post-training session.

PURPOSE: To determine whether the diagnostic accuracy of judging serial optic disc color stereo photographs for glaucomatous change by non-expert ophthalmologists changed after a training session. METHODS: 24 ophthalmologists in training at the University Hospitals Leuven classified 50 eyes with varying severity of glaucoma as stable or progressing based on the appraisal of serial optic disc stereo photographs. A comparison between the diagnostic accuracy of residents (n=18) and trainees (n=6) was made before and after a training session. RESULTS: The mean agreement (kappa) with the reference standard before training was lower for the trainees than for the residents. The mean kappa before training was 0.37 for the residents and 0.29 for the trainees (p = 0.18). The mean agreement with the reference standard improved significantly after a training (from 0.29 to 0.56 [p = 0.031 for the trainees, and from 0.37 to 0.48 for the residents [p = 0.005]). The overall mean kappa was 0.35 pre-training and 0.50 post-training (p < 0.001). CONCLUSIONS: The agreement and diagnostic accuracy of residents in training in appraising serial optic disc photos improved significantly after a training session.

Reversal of optic disc cupping with improvement of visual field and stereometric parameters after trabeculectomy in young adult patients (two case reports).

The authors report two cases of mid- to long-term reversal of optic disc cupping after trabeculectomy with mitomycine-C in young adult patients suffering from secondary glaucoma. The cup to disc ratio reversed from 0.80 and 0.60 to 0.65 and 0.40 respectively and remained unchanged until the last follow-up visit at 6 and 36 months respectively. Concomitantly, there was an improvement of the visual field and of the optic disc stereometric parameters on the Heidelberg Retina Tomograph.

The iStent trabecular micro-bypass stent: a case series.

PURPOSE: To evaluate the safety and effectiveness of a trabecular micro-bypass stent, the iStent (Glaukos, USA), for reduction of intraocular pressure in patients with open angle glaucoma. METHODS: In this prospective case series, ten eyes of eight patients underwent a gonioscopically-guided implantation of an iStent. Six eyes underwent combined surgery: cataract surgery followed by iStent implantation, and the remaining four eyes underwent iStent implantation only. The primary outcome measure was intraocular pressure and the secondary outcome measures were the reduction in number of glaucoma medications, and the number of complications. RESULTS: Mean intraocular pressure dropped from 19.6 mmHg preoperatively to 16.3 mmHg (range 12-27) after one month (p = 0.04), to 15.4 mmHg (range 8-23) after six months (p = 0.03) and 15.8 mmHg (range 9-25 mmHg) after one year (p = 0.03). There was a significant reduction in number of hypotensive medications between baseline and 12 months postoperatively from 2.7 to 1.7 medications. No vision-threatening complications were observed. CONCLUSIONS: The Glaukos iStent trabecular micro-bypass implantation is a safe procedure that is not associated with complications traditionally associated with filtering surgery. This trabecular bypass results in significant mid-term reduction of intraocular pressure as well as the number of medications.

Ahmed and Baerveldt glaucoma drainage implants: long-term results and factors influencing outcome.

PURPOSE: To evaluate the clinical outcome of patients who received an Ahmed or Baerveldt implant for refractory glaucoma at the University Hospitals Leuven and to identify the factors which may influence the outcome. METHODS: Retrospective study including 62 eyes with uncontrolled glaucoma, who underwent the implantation of a drainage device between January 2002 and December 2008. Criteria for complete success were an intraocular pressure (IOP) < or = 21 mmHg and > 5 mmHg, and a minimum 20% decrease in IOP compared to baseline, without additional medications at 2 consecutive visits after 3 months. Qualified success was defined as the same criteria with additional medications. If these criteria were not met, if additional glaucoma surgery was needed, or if the eye became phtitic, the case was classified as failure. Other outcome measurements were IOP reduction, additional glaucoma medications at the last follow-up, visual acuity, visual field, and complications. RESULTS: Over a mean follow-up period of 25 +/- 21,91 months, the mean intraocular pressure decreased from 27,98 +/- 6,5 mmHg to 15,2 +/- 5,87 mmHg (mean drop of 45%) at the last visit. Overall success (i.e. with or without medication) was 67.3%. Visual acuity improved or remained unchanged in 52/62 (83,9%) of patients. Eight patients (12,9%) had complications with significant visual loss (at least two Snellen lines worse) and five patients (8,1%) needed further surgery due to complications. No significant outcome predictors could be established. CONCLUSION: Ahmed and Baerveldt implants are a safe and effective procedure for lowering the IOP in the management of refractory glaucoma.

Allergic reaction to hyaluronidase after retrobulbar anaesthesia: a case series and review.

BACKGROUND: The enzyme hyaluronidase (HA) is an adjunctive in retrobulbar anaesthesia (RA) that is used during ophthalmic surgery to improve the efficacy and speed of nerve blocks. Although uncommon, HA has been shown to be a potential cause of allergic responses. CASE REPORTS: We describe three patients who experienced an allergic reaction to HA following ocular surgery in our department and provide an extensive overview of the literature on HA in RA. CONCLUSIONS: Although rare and mostly benign, allergy to HA should be included in the differential diagnosis when chemosis, proptosis and restriction of eye movements occur after parabulbar or retrobulbar anaesthesia. The authors feel that the beneficial effect of HA in small volumes of RA warrants its use despite this potential complication.

Acute visual field constriction in optic disc drusen: report of an unusual case.

We describe a case of an acute symptomatic and non-progressive visual field constriction in one eye of a 19-year-old female with optic disc drusen. The fellow eye showed slowly progressive visual field defects. A limited or retrolaminar infarction of the optic nerve head seems a plausible cause of the acute visual field loss. The slow progression in the fellow eye is most probably due to mechanical compression by the drusen. The case is documented with Humphrey perimetry during a follow-up of 11 years and with Color Doppler Imaging (CDI) of the optic nerve.

Argon versus selective laser trabeculoplasty.

PURPOSE: To compare conventional argon laser trabeculoplasty (ALT) with selective laser trabeculoplasty (SLT) in terms of their efficiency in lowering the intra-ocular pressure. METHODS: In this retrospective study, 56 eyes from 44 patients with primary open angle glaucoma, ocular hypertension, pseudo-exfoliative (PXF) or pigment dispersion glaucoma (PDG) were included. Patients underwent either ALT (n=18) or SLT (n=38). The intraocular pressure (IOP) was measured immediately prior to and 3 to 5 weeks after the theraPY. RESULTS: At 3 to 5 weeks the lOP-reduction was 22.4% after ALT and 15.5% after SLT (p = 0.141). Of note, of the four patients with PDG 2 underwent ALT and 2 SLT. Remarkably, both patients who had had SLT showed a paradoxical rise in lOP after the procedure (+15.5%). When these patients were excluded from the analysis, a similar hypotensive efficacy was found between ALT (-19%) and SLT (-17.9%) (p = 0.836). A small additional study with lower energy levels (< 0.9 mJ) confirmed the paradoxical IOP rise in 6 patients with heavily pigmented angles (2 with PDG and 2 with PXF) (+19.2%). It occurred in the absence of steroid treatment and persisted until 12 weeks after treatment. CONCLUSIONS: The short term efficacy of ALT and SLT was similar. In this study, the patients with PDG who underwent SLT showed a paradoxical rise in IOR This finding may indicate that even lower energies (0.4 to 0.6 mJ) are required when performing SLT in patients with heavily pigmented trabeculae.

Safe trabeculectomy technique: long term outcome.

AIM: To assess the long term outcome of a new trabeculectomy technique. METHODS: Trabeculectomy was performed using a fornix based conjunctival flap, an anterior chamber maintainer, a standardised punch technique, and a combination of adjustable and releasable sutures in 56 eyes of 53 patients. The main outcome measures were the postoperative intraocular pressure (IOP) and the frequency of early postoperative complications. The mean follow up time was 15.7 (range 12-21) months. RESULTS: The mean preoperative and postoperative IOP at 12 months were 21.2 (SD 6) and 12.8 (3.0) mm Hg, respectively. All patients had an IOP of <21 mm Hg, 90.9% had an IOP <18 mm Hg, and 61.4% had an IOP <14 mm Hg. Postoperative complications were infrequent: flat anterior chamber (1.8%), bleb leakage (0%), or hypotony (1.5%) beyond 3 weeks, or choroidal detachment at any time point (8.9%). CONCLUSIONS: This novel trabeculectomy method offers the possibility to tailor the IOP postoperatively with a minimum of postoperative complications and excellent IOP control at the long term follow up.