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BACKGROUND: To assess the efficacy and safety of collagen matrix implant (Ologen) in phacotrabeculectomy. DESIGN: Prospective, non-randomized, comparative study. PARTICIPANTS: Sixty-six Asian patients. METHODS: Thirty three consecutive patients underwent phacotrabeculectomy with Ologen implant and intraocular lens implantation, and 33 subjects recruited as controls underwent surgery with mitomycin C augmentation. MAIN OUTCOME MEASURES: The primary outcome measure was postoperative intraocular pressure at month 12. Additional postoperative treatments, such as bleb needling, and adverse events were secondary outcomes. RESULTS: The overall percentage reduction in intraocular pressure was 13% (95% confidence interval 6.7-19.2) in the Ologen group and 26% (95% confidence interval 14.8-37.9) in the mitomycin C group (P = 0.05). At 1 year after surgery (after adjusting for baseline differences), intraocular pressure decreased by 4.2 mmHg (95% confidence interval 2.8-5.6 mmHg) and 5.6 mmHg (95% confidence interval 4.2-7.0 mmHg), respectively (P = 0.16). Needling with 5-fluorouracil was required more often in the Ologen group (39% vs. 6%; P = 0.003). There was similar frequency (<10%) of adverse events in both groups, and there were no complications directly related to the Ologen implant. The blebs in the mitomycin C group had greater central area (P = 0.005), maximal area (P = 0.01) and height (P = 0.005), and were less vascular (P = 0.023) than the Ologen blebs. CONCLUSIONS: At 1 year, the overall performance of Ologen in combined phacotrabeculectomy was suboptimal compared with combined surgery with mitomycin C. Eyes in the Ologen group required more frequent bleb needling procedures.

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PURPOSE: To compare the 2-year efficacy of phacoemulsification and intraocular lens implant (phaco/IOL) with laser peripheral iridotomy (LPI) in the early management of acute primary angle closure (APAC) and coexisting cataract. DESIGN: Randomized, controlled trial. PARTICIPANTS: We included 37 subjects presenting with APAC who had responded to medical treatment such that intraocular pressure (IOP) was ≤30 mmHg within 24 hours, and had cataract with visual acuity of ≤6/15. MAIN OUTCOME MEASURES: The primary outcome measure was failure of IOP control defined as IOP between 22 to 24 mmHg on 2 occasions (readings taken within 1 month of each other) or IOP ≥25 mmHg on 1 occasion, either occurring after week 3. Secondary outcome measures were complications, degree of angle opening, amount of peripheral anterior synechiae, visual acuity, and corneal endothelial cell count (CECC). METHODS: Subjects were randomized to receive either LPI or phaco/IOL in the affected eye within 1 week of presentation and were examined at fixed intervals over 24 months. Patients underwent a standardized examination that included Goldmann applanation tonometry, gonioscopy, and CECC measurements. Logistic regression was used to estimate the effect of treatment on failure of IOP control. Time to failure was evaluated using the Kaplan-Meier technique and Cox regression was used to estimate the relative risk of failure. RESULTS: There were 18 patients randomized to LPI and 19 to phaco/IOL. The average age of subjects was 66.0±9.0 years and mean IOP after medical treatment was 14.5±6.9 mmHg. The 2-year cumulative survival was 61.1% and 89.5% for the LPI and phaco/IOL groups, respectively (P = 0.034). There was no change in CECC for either group from baseline to month 6. There was 1 postoperative complication in the phaco/IOL group compared with 4 in the LPI group (P = 0.180). CONCLUSIONS: Performed within 1 week in patients with APAC and coexisting cataract, phaco/IOL resulted in lower rate of IOP failure at 2 years compared with LPI.

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Postoperative fibrin pupillary-block glaucoma, an uncommon complication of intraocular surgery, develops when an inflammatory fibrin membrane occludes the pupil, resulting in peripheral angle closure. We present a series of 4 patients with this condition and describe the role of anterior segment optical coherence tomography and ultrasound biomicroscopy in distinguishing fibrin pupillary-block glaucoma from other forms of postoperative acute glaucoma. Specific to this condition is the presence of a fibrin membrane across the pupil and accumulation of aqueous in the posterior chamber, as would be expected in pupil block, but with a clear separation between the intraocular lens and the iris. The possible risk factors are discussed and various treatment modalities reviewed.

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PURPOSE: To report diagnostic modalities and treatment options for glaucoma in eyes with osteo-odonto keratoprosthesis (OOKP). METHODS: Eyes that underwent OOKP were evaluated for glaucoma at the time of the first postoperative visit, then at 1 and 3 months after the procedure, and thereafter every 6 months. All eyes underwent stereo-biomicroscopic optic nerve head (ONH) assessment, kinetic (Goldmann perimetry) and automated static visual field testing, ONH photography, Heidelberg retina tomograph, scanning laser polarimetery (GDx), and optical coherence tomography. Treatment of glaucoma was also reviewed. RESULTS: Average follow-up period was 19.1 (range: 5 to 31) months. Of the 15 eyes that underwent OOKP, 5 eyes had preexisting glaucoma. None of the other 10 eyes developed glaucoma after OOKP. ONH photography and visual field testing were the most reliable methods to assess status of the disease, whereas Heidelberg retina tomograph and optical coherence tomography could be performed with reasonable reproducibility and quality; GDx imaging was poor. All patients with glaucoma were treated with oral acetazolamide 500 mg twice a day. Transscleral cyclophotocoagulation was performed in 3 eyes at stage 2 of OOKP surgery. Progression of glaucoma was noted in 2 eyes on the basis of optic disc photographs and automated perimetry. CONCLUSIONS: Visual field testing and optic disc assessment with optic disc photographs seem to be effective methods to monitor eyes with OOKP for glaucoma. Treatment strategies include oral medications to lower intraocular pressure and cyclophotocoagulation.

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PURPOSE: To assess the efficacy and safety of systematically switching a large number of hospital-based glaucoma patients from latanoprost to travoprost therapy. MATERIALS AND METHODS: In this prospective observational study, patients on latanoprost were systematically switched to travoprost without washout and followed-up for 12 weeks. The main outcome measures were control of intraocular pressure (IOP), rate of switching back, and tolerability. IOP was measured at baseline (while on latanoprost), and at weeks 6 and 12 after switching to travoprost. Adverse effects were assessed and conjunctival hyperemia was graded using a standardized scale. RESULTS: Ninety-three consecutive patients (mean age 63.3 +/- 12.1 y) were enrolled. Nine patients were lost to follow-up. Four patients (4.3%) were switched back to latanoprost after 6 weeks due to travoprost intolerance. There was no significant difference between mean IOP at baseline [16.4 +/- 3.4 mm Hg, 95% confidence interval (CI) 15.6-17.2] and that at week 6 (15.9 +/- 4.2 mm Hg, 95% CI 14.9-16.8) (P=0.2) and week 12 (16.4 +/- 5.7 mm Hg, 95% CI 15.1-17.7) (P=0.99). There was no significant difference in the mean hyperemia score at week 12 compared with baseline (P=0.09). The majority of patients (86.9%) felt that both medications were comparable in terms of degree of comfort; 5 felt that travoprost caused more redness. CONCLUSIONS: In this study, when glaucoma patients were systematically switched from latanoprost to travoprost, the efficacy and safety of the 2 medications were found to be comparable. A high switch rate (95.2%) was achieved with average hyperemia scores being comparable.

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INTRODUCTION: For many years, ophthalmologists have looked at the optic nerve head to evaluate the status of glaucoma. Clinical examination of the optic nerve head and retinal nerve fibre layer (RNFL) is however, subjective and sometimes variable. Recent developments in computer-based imaging technologies have provided a means of obtaining quantitative measurements of the optic nerve head topography and peripapillary retinal nerve fibre layer thickness. METHODS: Multiple searches using Medline were carried out. Additional searches were made using reference lists of published papers and book chapters. RESULTS: Studies involving three imaging technologies namely, confocal scanning laser ophthalmoscopy, scanning laser polarimetry and optical coherence tomography were reviewed. Overall, these technologies were reproducible and demonstrate good sensitivity and specificity in the range of 70 to 80%. Inclusion of age and ethnicity normative database will make these technologies more effective in screening and diagnosis. Quantitative measurements provide useful parameters for monitoring of patients. CONCLUSION: There is no consensus on the best technology for assessing structural damage in glaucomatous optic neuropathy. Therefore, as with any investigation, the clinician should exercise clinical correlation and judgment before instituting the appropriate treatment.

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PURPOSE: To compare the performance of the scanning peripheral anterior chamber depth analyzer (SPAC) and the modified van Herick grading system in the assessment of angle closure, using gonioscopy as the reference standard. DESIGN: Prospective comparative study. PARTICIPANTS: One hundred twenty phakic subjects (53 with primary angle closure and 67 with open angles) with no history of laser or intraocular surgery. METHODS: The modified van Herick grading system was used to grade the peripheral anterior chamber depth (ACD) clinically. The SPAC was used to assess ACD, and this was graded categorically as S (suspect angle closure), P (potential angle closure), or N (normal) and numerically from 1 to 12. One randomly selected eye of each subject underwent examination with the modified van Herick grading, SPAC, Goldmann applanation tonometry, optic disc examination, and gonioscopy. The SPAC measurements, modified van Herick grades (0%, 5%, 15%, 25%, 40%, 75%, and > or =100% of corneal thickness), and gonioscopy (graded as narrow or open) were correlated using the Spearman correlation coefficient. The receiver operating characteristics of the 2 methods to detect angle closure also were compared. MAIN OUTCOME MEASURES: Grading of ACD by the SPAC, the modified van Herick system, and gonioscopic grading of the angle. RESULTS: The SPAC results correlated well with the modified van Herick grading system (categorical grade, r = 0.527; numerical grade, r = 0.542; P<0.0001). For eyes graded as having narrow angles by gonioscopy, the area under the curve (AUC) for SPAC categorical grade S or P was 0.790; sensitivity and specificity were 84.9% and 73.1%, respectively. For the modified van Herick grading system, using a cutoff of peripheral ACD < or = 25% corneal thickness, the AUC was 0.872 and sensitivity and specificity were 84.9% and 89.6%. Compared with gonioscopy that found 53 of 120 cases of narrow angles, the SPAC graded more eyes as having narrow angles (63/120) than the modified van Herick system (52/120). CONCLUSIONS: The SPAC correlated well with the modified van Herick system in grading peripheral ACD. However, the SPAC appeared to overestimate the proportion of eyes with narrow angles relative to gonioscopy and the modified van Herick grading system.

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PURPOSE: The purpose of this study was to evaluate the associations between macular volume and thickness, as assessed by optic coherence tomography (OCT), with refraction and axial length (AL) in children. METHODS: A total of 104 Chinese school children (51 girls and 53 boys) 11 to 12 years of age were randomly selected from one school during the 2005 examination in the Singapore Cohort Study of the Risk Factors for Myopia (SCORM). Cycloplegic autorefraction was performed to obtain refraction (defined as spherical equivalent [SE]) and ultrasound biometry performed to obtain the AL. Macular volume and thickness were then measured (StratusOCT3; Carl Zeiss Meditec, Dublin, CA). RESULTS: Children with moderate myopia (SE at least -3.0 D) tended to have smaller total macular volume and thinner quadrant-specific macular thickness (except in the inferior and superior inner quadrants), followed by children with low myopia (-0.5-0.5 D). Total macular volume was positively associated with SE (beta=1.58, 95% CI, 0.84 to 2.32, standardized beta=0.14, P<0.001) and negatively associated with AL (beta=-1.20, 95% CI, -1.62 to -0.79, standardized beta=0.45, P<0.001) in multiple linear regression models controlling for age and gender. CONCLUSIONS: In children, increasing axial myopia was associated with reduced macular volume and thickness. These findings suggest that early anatomic changes may be present in the retinas of children with axial myopia.

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PURPOSE: To determine the relationship between peripapillary retinal nerve fiber layer (RNFL) thickness and myopia using optical coherence tomography (OCT). DESIGN: Prospective observational case series. METHODS: One hundred thirty-two young males with myopia (spherical equivalent [SE], -0.50 to -14.25 diopters) underwent ophthalmic examination of one randomly selected eye. Optical coherence tomography (OCT-1, version 4.1) was performed by a single operator using circular scans concentric with the optic disc with scan diameters of 3.40 mm, 4.50 mm, and 1.75 x vertical disc diameter (VDD). For each scan diameter, mean peripapillary RNFL thickness was calculated. Statistical analysis comprised repeated-measurements analysis and Pearson correlation. RESULTS: Mean peripapillary RNFL thickness did not correlate with SE for the 3.40-mm (r = -0.11, P = 0.22), 4.50-mm (r = -0.103, P = 0.24), or 1.75xVDD (r = -0.08, P = 0.36) OCT scan diameters. Neither did mean peripapillary RNFL thickness correlate with axial length for the 3.40-mm (r = -0.04, P = 0.62), 4.50-mm (r = 0.03, P=0.75), or 1.75xVDD (r = -0.02, P = 0.78) scan diameters. Mean peripapillary RNFL thicknesses for the 3.40-mm, 4.50-mm, and 1.75xVDD scans were 101.1+/-8.2 microm (95% confidence interval [CI], 99.4-102.8), 78.9+/-8.2 microm (95% CI, 77.5-80.3), and 97.5+/-10.9 microm (95% CI, 95.6-99.4), respectively. CONCLUSIONS: Mean peripapillary RNFL thickness did not vary with myopic SE or axial length for any OCT scan diameter investigated. Retinal NFL thickness measurements may be a useful parameter to assess and monitor glaucoma damage in myopic subjects.

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PURPOSE: To evaluate the use of Surodex (Oculex Pharmaceuticals, Sunnyvale, California) a drug delivery system incorporating 60 micrograms of dexamethasone in a pellet, in phacotrabeculectomy surgery. DESIGN: Nonrandomized, prospective, interventional case series. METHODS: Phacotrabeculectomy was performed on 37 Asian subjects with primary open-angle glaucoma (POAG) using a standardized technique. All subjects received a Surodex pellet underneath the scleral flap. Results were compared with those of 31 POAG subjects who had undergone phacotrabeculectomy augmented with 50 mg/ml of intraoperative 5-fluorouracil (5-FU) during the same period. RESULTS: Mean follow-up in months was 19.7 +/- 7.9 and 22.1 +/- 6.2 for the Surodex and 5-FU groups, respectively (P = .29). There was a 20.1% decrease in intraocular pressure in the Surodex group compared with 28.5% decrease in the 5-FU group (P = .6). Postoperative complications occurred in three cases (8.1%) and six cases (19.3%), respectively (P = .04). CONCLUSIONS: Combined phacotrabeculectomy surgery augmented by intra-scleral placement of Surodex results in good control of IOP and a low incidence of complications.

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PURPOSE: To investigate the variation in macular retinal thickness in otherwise normal young Asian myopic subjects by using optical coherence tomography (OCT). METHODS: One hundred thirty ophthalmically normal men 19 to 24 years of age with myopia (spherical equivalent, -0.25 to -14.25 D) underwent examination of one randomly selected eye. Visual acuity, refraction, slit lamp examination, applanation tonometry, gonioscopy, A-scan ultrasound, fundus examination, visual field testing, and optic disc photography were performed. Exclusion criteria were visual acuity worse than 20/30, previous intraocular surgery, intraocular pressure >21 mm Hg, or other ocular diseases. Three horizontal transfixation and three vertical transfixation OCT scans (ver.4.1; Carl Zeiss Meditec, Dublin, CA) of 6 mm each were conducted on each eye by a single operator. Neurosensory retinal thicknesses at 100 points along each scan were measured, and the overall average, maximum, and minimum retinal thicknesses were analyzed by simple linear regression and analysis of variance. RESULTS: The average macular retinal thickness (overall) was 230.9 +/- 10.5 microm and was not significantly related to the degree of myopia. The mean maximum retinal thickness (at the parafovea) was 278.4 +/- 13.0 microm, and correlated negatively with axial length (P = 0.03). The mean minimum retinal thickness (at the foveola) was 141.1 +/- 19.1 microm, and this was positively correlated with axial length (P = 0.015) and spherical equivalent (P = 0.0002). The retina was thicker at the superior and nasal parafovea compared to the inferior or temporal parafovea. CONCLUSIONS: Average retinal thickness of the macula does not vary with myopia. However, the parafovea was thinner and the fovea thicker with myopia.

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PURPOSE: To evaluate the changes in retinal nerve fiber layer (RNFL) thickness in the first 16 weeks after acute primary angle closure (APAC) using scanning laser polarimetry (SLP). DESIGN: Prospective, observational case series. PARTICIPANTS: Thirty-seven Asian subjects with APAC. METHODS: For all cases, APAC had resolved after treatment, and the study was conducted during the follow-up period after the acute episode. Using the GDx Nerve Fiber Analyzer (Laser Diagnostic Technologies, San Diego, CA), the RNFL was assessed in both eyes 2 weeks after APAC, and again after 16 weeks. The SLP parameters were compared between week 2 and week 16 within affected and fellow eyes. A multiple logistic regression analysis was carried out to analyze factors likely to influence RNFL outcome. MAIN OUTCOME MEASURES: Superior and inferior average RNFL thickness. RESULTS: The mean age of study subjects was 60.1+/-10.3 years (range, 46-91 years), and most subjects were female (68%) and Chinese (86%). In APAC eyes, the superior average RNFL thickness decreased from 63.8+/-13.6 microm to 61.4+/-11.2 microm (P = 0.04) and the inferior average RNFL thickness decreased from 69.5+/-14.4 microm to 66.3+/-12.6 microm (P = 0.005). There was also a decrease in inferior ratio (P = 0.008) and ellipse modulation (P = 0.02). In the fellow eyes, there was no difference found between week 2 and week 16 for any of the SLP parameters studied. Logistic regression analysis showed no significant association between developing a 10% reduction in either superior or inferior RNFL thickness with age, gender, history of ischemic risk factors, duration of symptoms during APAC, the level of presenting intraocular pressure (IOP), or the development of a rise in IOP between study visits. CONCLUSIONS: After an episode of APAC, superior and inferior average RNFL thickness was found to decrease significantly from week 2 to week 16.

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PURPOSE: To compare optic disc topography and nerve fiber layer thickness in ocular hypertensive eyes and normal subjects. DESIGN: Prospective, case-controlled study. PARTICIPANTS AND CONTROLS: One eye in each of 20 normal and 27 ocular hypertensive patients was enrolled. METHODS: Consecutive normal and ocular hypertensive patients were enrolled. Each patient underwent complete ophthalmic examination, achromatic automated perimetry, short-wavelength automated perimetry, confocal scanning laser ophthalmoscopy, confocal scanning laser polarimetry, and optical coherence tomography. The intraocular pressure was 21 mmHg or less for normal subjects and at least 25 mmHg on two separate occasions in ocular hypertensive eyes. Structural parameters were compared between the two groups. Eyes with evidence of glaucomatous optic neuropathy, achromatic visual field loss, or evidence of focal visual field injury during short-wavelength automated perimetry were excluded. MAIN OUTCOME MEASURES: Optic nerve head topography and nerve fiber layer thickness. RESULTS: The three imaging technologies could not detect differences in optic disc or nerve fiber layer anatomy between the two groups. Ocular hypertensive eyes had a greater corrected pattern standard deviation than normal eyes during short-wavelength automated perimetry (P = 0.04). CONCLUSIONS: Ocular hypertensive eyes with normal achromatic automated perimetry and short-wavelength automated perimetry could not be distinguished from normal subjects with confocal scanning laser ophthalmoscopy, confocal scanning laser polarimetry, and optical coherence tomography.

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Management of angle closure glaucoma requires an understanding of the underlying pathophysiologic mechanisms. Treatment is aimed at eliminating pupillary block and other causes of angle closure, re-opening the angle, and preventing further damage to the optic nerve by lowering intraocular pressure. Medical therapy plays an important role in the successful management of this condition. This article describes commonly used pharmacologic agents, as well as newer classes of drugs such as topical carbonic anhydrase inhibitors, prostaglandin analogues and selective alpha2- adrenergic agonists. Use of these drugs in several clinically distinct angle closure syndromes and modes of presentation are discussed.

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