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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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Glaucoma de Ángulo Cerrado/cirugía , Iridectomía , Terapia por Láser , Implantación de Lentes Intraoculares , Facoemulsificación , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Recuento de Células , Endotelio Corneal/patología , Femenino , Glaucoma de Ángulo Cerrado/fisiopatología , Humanos , Presión Intraocular/fisiología , Iris/cirugía , Láseres de Estado Sólido/uso terapéutico , Masculino , Persona de Mediana Edad , Tonometría Ocular , Resultado del Tratamiento , Agudeza Visual/fisiologíaRESUMEN
OBJECTIVE: To determine whether the timing of cataract surgery after trabeculectomy has an effect on trabeculectomy function in terms of intraocular pressure control. METHODS: This was a cohort study nested within a randomized clinical trial. There were 235 participants with glaucoma who had a single previous trabeculectomy augmented with either intraoperative 5-fluorouracil or placebo. Cataract surgery with intraocular lens implantation was performed on participants judged to have significant lens opacity. Cox regression was performed to evaluate the effect of time between trabeculectomy and cataract surgery on the time to trabeculectomy failure, after adjusting for other relevant risk factors. The main outcome measure was time to failure of trabeculectomy, defined as an intraocular pressure of greater than 21 mm Hg. RESULTS: Of the 235 participants, 124 (52.7%) underwent subsequent cataract surgery. The median time from trabeculectomy to cataract surgery for these patients was 21.7 months (range, 4.6-81.9 months). The median follow-up period was 60 months (range, 28-84 months) for the cataract surgery group and 48 months (range, 12-84 months) for the non-cataract surgery group. Cox regression showed that the time from trabeculectomy to cataract surgery was significantly associated with time to trabeculectomy failure (hazard ratio, 1.73 [95% CI, 1.05-2.85]; P = .03). The adjusted declining hazard ratios for risk of subsequent trabeculectomy failure when cataract surgery was performed 6 months, 1 year, and 2 years after trabeculectomy were 3.00 (95% CI, 1.11-8.14), 1.73 (95% CI, 1.05-2.85), and 1.32 (95% CI, 1.02-1.69), respectively. CONCLUSIONS: Cataract surgery after trabeculectomy increases the risk of trabeculectomy failure, and this risk is increased if the time between trabeculectomy and cataract surgery is shorter.
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Glaucoma de Ángulo Cerrado/cirugía , Glaucoma de Ángulo Abierto/cirugía , Presión Intraocular/fisiología , Facoemulsificación , Trabeculectomía , Adulto , Anciano , Anciano de 80 o más Años , Alquilantes/administración & dosificación , Femenino , Fluorouracilo/administración & dosificación , Estudios de Seguimiento , Glaucoma de Ángulo Cerrado/fisiopatología , Glaucoma de Ángulo Abierto/fisiopatología , Gonioscopía , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Factores de Tiempo , Insuficiencia del Tratamiento , Resultado del Tratamiento , Agudeza Visual/fisiología , Campos Visuales/fisiologíaRESUMEN
PURPOSE: To examine the association between central corneal thickness (CCT) and glaucoma. METHODS: This was a nested case-control study using 1090 subjects from an eye disease population survey in Singapore and 243 participants from a hospital glaucoma surgery clinical trial in Singapore. RESULTS: Mean CCT in 938 community subjects was 539 µm ± 32 µm, and in 12 community subjects with primary open angle glaucoma (POAG) the mean CCT was 545 µm ± 38 µm. In the hospital cohort, mean CCT was 552 µm ± 38 µm in 138 patients with POAG and 551 µm ± 33 µm in 105 patients with primary angle closure glaucoma (PACG). No individuals had undergone previous intraocular surgery or had other significant ocular pathology. Regression models showed POAG diagnosis was not associated with CCT (P = 0.42) or age (P = 0.062) in community subjects but was associated with IOP (P = 0.005). Similar analyses for hospital cases showed CCT to be significantly higher in both POAG and PACG (both P = 0.001), but this became nonsignificant after controlling for IOP and age (P = 0.26, POAG; P = 0.08, PACG). Both age (P = 0.043) and IOP (P = 0.001) were highly associated with hospital POAG; only IOP (P = 0.001) was associated with hospital PACG. Further regression analyses for community subjects showed diabetic status and pseudophakia had no significant effect on CCT (P = 0.33 and P = 0.11, respectively). CONCLUSIONS: The authors found no evidence to support the previous observation that thinner corneas may be independently associated with POAG or PACG. Age and IOP are significantly associated with CCT, and this should be taken into account by future studies investigating CCT as an independent risk factor for glaucoma diagnosis.
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Córnea/patología , Glaucoma de Ángulo Cerrado/diagnóstico , Glaucoma de Ángulo Abierto/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Envejecimiento/fisiología , Alquilantes/administración & dosificación , Pueblo Asiatico/etnología , Estudios de Casos y Controles , Femenino , Fluorouracilo/administración & dosificación , Glaucoma de Ángulo Cerrado/etnología , Glaucoma de Ángulo Cerrado/cirugía , Glaucoma de Ángulo Abierto/etnología , Glaucoma de Ángulo Abierto/cirugía , Humanos , Presión Intraocular/fisiología , Masculino , Persona de Mediana Edad , Factores de Riesgo , Singapur/epidemiología , Tonometría Ocular , Trabeculectomía , Pruebas del Campo VisualRESUMEN
PURPOSE: To report 3-year results of a randomized, controlled trial comparing the use of a single application of 5-fluorouracil (5-FU) with placebo in trabeculectomy surgery. DESIGN: Prospective, randomized, double-blinded treatment trial. PARTICIPANTS: Two hundred forty-three Asian patients with primary open-angle or primary angle-closure glaucoma undergoing primary trabeculectomy. METHODS: One eye of each patient was randomized to receive either intraoperative 5-FU or normal saline (placebo) during trabeculectomy. MAIN OUTCOME MEASURES: Primary outcome measure was the level of intraocular pressure (IOP). Secondary outcomes were progression of visual field loss, rates of adverse events, and interventions after surgery. RESULTS: Of the 288 eligible patients, 243 were enrolled and 228 completed 3 years follow-up; 120 patients received 5-FU and 123 received placebo. Trial failure, according to predefined IOP criteria, was lower in the 5-FU group compared with the placebo group, although the difference was only significant with a failure criterion of IOP >17 mmHg (P = 0.0154). There was no significant difference in progression of optic disc and/or visual field loss over 36 months between 5-FU and placebo (relative risk [RR], 0.67; 95% confidence interval [CI], 0.34-1.31; P = 0.239). Uveitis occurred more often in the 5-FU-treated group (14/115 [12%] vs 5/120 [4%]; P = 0.032). CONCLUSIONS: This is the first masked, prospective, randomized trial reporting the effect of adjunctive 5-FU in trabeculectomy surgery in an East Asian population. The trial shows that an increased success rate can be achieved for several years after a single intraoperative treatment with 5-FU. We conclude that 5-FU is relatively safe and can be routinely used in low-risk East Asian patients. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.
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Antimetabolitos Antineoplásicos/administración & dosificación , Fluorouracilo/administración & dosificación , Glaucoma de Ángulo Cerrado/terapia , Glaucoma de Ángulo Abierto/terapia , Presión Intraocular/fisiología , Trabeculectomía , Adulto , Anciano , Terapia Combinada , Progresión de la Enfermedad , Método Doble Ciego , Femenino , Estudios de Seguimiento , Glaucoma de Ángulo Cerrado/tratamiento farmacológico , Glaucoma de Ángulo Cerrado/fisiopatología , Glaucoma de Ángulo Cerrado/cirugía , Glaucoma de Ángulo Abierto/tratamiento farmacológico , Glaucoma de Ángulo Abierto/fisiopatología , Glaucoma de Ángulo Abierto/cirugía , Humanos , Cuidados Intraoperatorios , Masculino , Persona de Mediana Edad , Disco Óptico/patología , Estudios Prospectivos , Riesgo , Singapur , Campos VisualesRESUMEN
PURPOSE: Approximately 10% of Chinese people older than 50 years in Singapore have asymptomatic narrow angles [also termed primary angle closure suspects (PACS)]. The aim of this study was to determine the attitudes and practices of ophthalmologists in Singapore regarding the management of these patients. METHODS: A nation wide questionnaire-based survey was conducted on all registered, practicing ophthalmologists in Singapore by electronic mail and post. An ophthalmologist was defined as a doctor who had completed at least 3 years of specialist training in ophthalmology and had passed the Master's Degree in Ophthalmology or equivalent examinations. The survey asked the ophthalmologists about the methods and criteria used for the diagnosis of angle closure. It also inquired about the management of PACS and opinions on the effectiveness of prophylactic laser peripheral iridotomy (LPI) in preventing both acute and chronic angle closure. RESULTS: A total of 126 out of 158 ophthalmologists responded (79.7% response rate). Of the respondents, 84.9% would advise prophylactic LPI for asymptomatic PACS; 84.9% believed that prophylactic LPI would prevent acute angle closure but only 44% thought that it could prevent the development of glaucomatous optic nerve damage. The preferred method of prophylactic LPI was sequential argon-YAG LPI. In assessing patients for angle closure, 85.4% used gonioscopy, 92.9% assessed anterior chamber depth, and 17.5% performed provocative tests. CONCLUSIONS: Ophthalmologists in Singapore vary in the method of assessment of patients with angle closure. Most believe that prophylactic LPI should be performed for asymptomatic PACS.
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Glaucoma de Ángulo Cerrado/diagnóstico , Glaucoma de Ángulo Cerrado/terapia , Conocimientos, Actitudes y Práctica en Salud , Oftalmología/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Pueblo Asiatico/etnología , Ceguera/prevención & control , Glaucoma de Ángulo Cerrado/etnología , Gonioscopía , Encuestas de Atención de la Salud , Humanos , Presión Intraocular , Iris/cirugía , Terapia por Láser , Programas Nacionales de Salud , Singapur/epidemiología , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
AIM: To determine the changes in peripapillary atrophy after episodes of acute primary angle closure (APAC). METHODS: Prospective observational study of 40 eyes in 38 patients of predominantly Chinese ethnicity. The mean (SD) intraocular pressure at the time of presentation was 51.7 (12) mm Hg (median, 55 mm Hg) and the mean duration of the symptoms was 37.7 (69.4) hours. A laser iridotomy was undertaken 3.2 (8.4) days after the APAC episode, leading to normalisation of intraocular pressure in all cases. Colour optic disc photographs taken at 2 and 16 weeks after APAC were examined morphometrically. Peripapillary atrophy was divided into alpha and beta zones. RESULTS: Comparing measurements at baseline with week 16, the minimum width of the alpha zone (0.013 (0.056) v 0.016 (0.001) arbitrary units; p = 0.23), the maximum width of the alpha zone (1.11 (1.31) v 1.31 (0.79) arbitrary units; p = 0.22), the minimum width of the beta zone (0.030 (0.122) v 0.033 (0.166) arbitrary units; p = 0.93), and the maximum width of the beta zone (0.62 (0.94) v 0.73 (0.98) arbitrary units; p = 0.42) did not vary significantly. The mean cup to disc ratio increased from 0.56 (0.05) to 0.62 (0.07) (p<0.0001) at the end of follow up. CONCLUSIONS: The alpha and beta zones of peripapillary atrophy did not enlarge markedly in patients after APAC, despite an enlargement of the optic cup during a follow up of four months.
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Glaucoma de Ángulo Cerrado/complicaciones , Atrofia Óptica/etiología , Disco Óptico/patología , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Presión Intraocular , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
PURPOSE: To determine the long-term outcome of the contralateral eye in Asian persons with a unilateral attack of acute primary angle closure (APAC). DESIGN: Cross-sectional observational case series. PARTICIPANTS: Seventy-nine individuals who were examined from 4 to 10 years after a unilateral episode of APAC at 2 Singapore hospitals. METHODS: All subjects underwent a complete eye examination. The optic discs were graded clinically and photographically for the presence of glaucomatous optic neuropathy, and automated visual field tests were assessed for damage. All visual fields and optic nerve photographs (when available) underwent a second evaluation by a masked glaucoma specialist, who assessed whether the changes were compatible with glaucoma. MAIN OUTCOME MEASURES: Glaucomatous optic neuropathy, intraocular pressure (IOP), and visual impairment (defined as best-corrected visual acuity of worse than 6/12). RESULTS: Ninety of 138 eligible patients (65.2%) with APAC were examined, 79 with unilateral attacks. Subjects were predominantly Chinese (n = 68; 86%). There were 54 females (68%), and mean age was 68.5+/-8.9 years (standard deviation) at the time of APAC, with a mean duration of 6.3+/-1.5 years from the time of the APAC episode to the study examination. The contralateral eyes of 7 patients (8.9%) had definite or probable glaucoma, 2 of whom were felt to have glaucoma in that eye at the time of the attack. Three eyes had markedly cupped optic discs (cup-to-disc ratio > or = 0.9). Thirteen eyes (16.9%) had best-corrected vision worse than 6/12, due to cataract in almost half the cases. Only 1 eye had vision < 6/60, the cause of which was corneal decompensation. One other patient had only a central island remaining with vision of 6/12. Mean IOP of the study participants was 15.7+/-4.7 mmHg, with 6 subjects (7.6%) having undergone trabeculectomy. CONCLUSIONS: Definite or probable glaucoma was present at the time of diagnosis in 2 (2.5%) fellow eyes and developed in an additional 5 (6.5%) with a mean follow-up of 6 years. More than 80% of this cohort retained good vision in the contralateral eye, in contrast to the eye that underwent APAC. Unoperated cataract accounted for most of the visual impairment in this group.
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Glaucoma de Ángulo Cerrado/diagnóstico , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Pueblo Asiatico/etnología , Estudios Transversales , Femenino , Estudios de Seguimiento , Lateralidad Funcional , Glaucoma de Ángulo Cerrado/etnología , Humanos , Presión Intraocular , Masculino , Persona de Mediana Edad , Disco Óptico/patología , Enfermedades del Nervio Óptico/diagnóstico , Fotograbar , Pronóstico , Singapur/epidemiología , Trastornos de la Visión/diagnóstico , Agudeza Visual , Campos VisualesRESUMEN
OBJECTIVE: To examine the progression of lens opacity in Asian people after trabeculectomy and determine associated risk factors. METHODS: This was an observational case series of 243 people aged 36 to 82 years. Trabeculectomy was performed on 1 eye of each subject. Lens opacity was measured yearly using the Lens Opacification Classification System III. The main outcome measure was worsening of lens opacity defined as an increase of 2 or more Lens Opacification Classification System III units in any of the 3 lens regions, nuclear, cortical, and posterior subcapsular. Risk of progression was evaluated using logistic regression models. RESULTS: Data for 177 people were analyzed. One hundred seventeen (66%) of 177 subjects showed progression in opacity in any lens region at 3 years. Seventy-seven (66%) of 117 of those who progressed did so during the first year. Of these, 63 (82%) of 77 had lens opacity in the posterior subcapsular region. Factors associated with progression of posterior-subcapsular lens opacity at 1 year were diabetes (odds ratio, 2.4; 95% confidence interval, 1.0-5.4), use of antiglaucoma medication, dosage of topical steroid postoperatively, and being operated on by a trainee surgeon (odds ratio, 2.3; 95% confidence interval, 1.0-5.2). CONCLUSIONS: Trabeculectomy is associated with progression of lens opacity predominantly in the posterior subcapsular region. Modification of risk factors such as postoperative steroid use may delay progression.
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Antimetabolitos/uso terapéutico , Catarata/fisiopatología , Fluorouracilo/uso terapéutico , Glaucoma/terapia , Cristalino/fisiopatología , Complicaciones Posoperatorias , Trabeculectomía/métodos , Adulto , Anciano , Anciano de 80 o más Años , Terapia Combinada , Progresión de la Enfermedad , Femenino , Glaucoma/tratamiento farmacológico , Glaucoma/cirugía , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , SingapurRESUMEN
PURPOSE: To compare lens thickness (LT), lens position (LP), relative lens position (RLP), and degree and type of lens opacity between affected and fellow eyes of subjects with acute primary angle closure (APAC) to identify any differences in lens characteristics that may be contributory to the acute episode. In addition, axial length (AL) and anterior chamber depth (ACD) measurements were evaluated. METHODS: Seventy-three study subjects with unilateral APAC were treated with sequential laser iridotomy (LI) in both eyes. Two weeks after LI, ACD, LT, and AL measurements were made in both eyes using ultrasound pachymetry. LP was defined as ACD+1/2LT and RLP as LP/AL. The Lens Opacity Classification III (LOCS III) System was used for grading lens opacity. RESULTS: The subjects were 90% Chinese and 63% female. Mean age was 61.0+/-10.9 years. Significant differences between the affected and fellow eyes were found in the ACD (2.11+/-0.35 vs 2.18+/-0.23; P=0.02) and LP (4.61+/-0.47 vs 4.75+/-0.29; P=0.02). Cortical opacity was greater in fellow eyes (0.32+/-0.72 vs 0.53+/-0.95; P=0.02). There was no difference in LT, RLP, or degree of lens opacity in the nuclear and posterior subcapsular regions. CONCLUSIONS: Compared with fellow eyes, APAC-affected eyes have shallower ACD, more anterior LP, and less cortical opacity. These differences may be contributory to APAC.
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Catarata/complicaciones , Glaucoma de Ángulo Cerrado/complicaciones , Cristalino/patología , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Cámara Anterior/diagnóstico por imagen , Cámara Anterior/patología , Biometría , Pesos y Medidas Corporales , Catarata/clasificación , Femenino , Glaucoma de Ángulo Cerrado/cirugía , Humanos , Iridectomía , Cristalino/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Estudios Prospectivos , UltrasonografíaRESUMEN
PURPOSE: To evaluate the changes in optic disc morphology in the first 4 months after an episode of acute primary angle closure (APAC) using stereoscopic optic disc photography and computer-assisted planimetry. DESIGN: Prospective observational case series. PARTICIPANTS: Forty-seven Asian subjects with unilateral APAC who were successfully treated with laser peripheral iridotomy (LPI). MAIN OUTCOME MEASURES: Cup-to-disc ratio (CDR) and optic cup and neuroretinal rim areas. METHODS: Stereoscopic optic disc photographs were taken 2 and 16 weeks after LPI, and the images were analyzed by computer-assisted planimetry. The overall, quadrantic, and 30 degrees sector areas of the optic disc, CDR, and neuroretinal rim area were analyzed by 2 independent masked graders, and the mean of the readings was used to calculate changes in optic disc parameters. RESULTS: The majority of the subjects were female (66%) and Chinese (90%), and the mean age was 67.6+/-11.2 years (range, 40-94). In APAC eyes from week 2 to week 16, the mean CDR increased from 0.56+/-0.05 to 0.59+/-0.03 (P<0.001), and the mean neuroretinal rim area decreased from 1.74+/-0.31 mm2 to 1.59+/-0.27 mm2 (P<0.001). Quadrantic and sector analysis showed preferential loss of neuroretinal rim area at the superotemporal and inferotemporal areas. There was no significant change in optic disc parameters in the fellow eyes over the study period. CONCLUSIONS: This study demonstrated changes in optic disc morphology from week 2 to week 16 after an episode of APAC. The pattern of optic nerve damage demonstrated in our study was comparable with that seen in primary open-angle glaucoma and experimental glaucoma models.
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Glaucoma de Ángulo Cerrado/diagnóstico , Disco Óptico/patología , Enfermedades del Nervio Óptico/diagnóstico , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Técnicas de Diagnóstico Oftalmológico , Femenino , Humanos , Presión Intraocular , Iridectomía , Terapia por Láser , Masculino , Persona de Mediana Edad , Fotograbar , Estudios ProspectivosRESUMEN
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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Miopía/complicaciones , Fibras Nerviosas , Disco Óptico/anatomía & histología , Nervio Óptico/anatomía & histología , Células Ganglionares de la Retina/citología , Adulto , Humanos , Presión Intraocular , Masculino , Estudios Prospectivos , Tomografía de Coherencia Óptica , Tonometría OcularRESUMEN
PURPOSE: To assess the performance of peripheral and central anterior chamber depth (ACD) measurements, and autorefraction, in identifying Chinese people with occludable drainage angles or established primary angle closure. DESIGN: Population-based cross-sectional analysis. METHODS: Subjects aged 40 years and older were drawn from a representative sample of Chinese Singaporean residents. Limbal chamber depth (LCD) was estimated and central ACD was measured using optical pachymetry and ultrasound. An autorefraction was taken for all subjects. Angle width and the presence of peripheral anterior synechiae were determined by gonioscopy. Receiver operating characteristic curves were generated to show the performance of these tests in detecting occludable angles. RESULTS: A total of 1090 subjects were examined. The prevalence of occludable angles was 6.5%. LCD measurement performed best in detecting occludable angles (area under the curve [AUC] 0.904, 95% confidence interval [CI] 0.870, 0.937). Optical pachymetry and ultrasound measurement of ACD performed less well (AUC 0.859 and 0.810, respectively), and autorefraction performed poorly in detecting occludable angles (AUC 0.632). LCD also gave the best performance in detecting primary angle closure (AUC 0.782, 95% CI 0.727, 0.837). CONCLUSIONS: Limbal LCD estimation outperforms other methods of measuring ACD as a screening tool for the detection of occludable drainage angles in the Chinese population of Singapore.
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Cámara Anterior/patología , Pueblo Asiatico/etnología , Técnicas de Diagnóstico Oftalmológico , Glaucoma de Ángulo Cerrado/diagnóstico , Glaucoma de Ángulo Cerrado/etnología , Adulto , Anciano , Cámara Anterior/diagnóstico por imagen , Área Bajo la Curva , Estudios Transversales , Reacciones Falso Positivas , Femenino , Gonioscopía , Humanos , Limbo de la Córnea/diagnóstico por imagen , Limbo de la Córnea/patología , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Prevalencia , Refracción Ocular , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Singapur/epidemiología , UltrasonografíaRESUMEN
BACKGROUND: Ischaemic changes in the iris occur frequently after an episode of acute primary angle closure (APAC). The aim of this study was to investigate the significance of such changes with regards to visual outcome. METHODS: Acute primary angle closure cases were treated with medical therapy followed by laser peripheral iridotomy after resolution of the acute episode. Subjects were examined at 1, 4, 8, 12 and 16 weeks post laser peripheral iridotomy. Eyes were examined for signs of iris ischaemic changes (IIC), defined as the presence of iris whorling or stromal atrophy. Iris photographs were also taken at weeks 1, 8 and 16. Subjects requiring glaucoma medication or filtering surgery during the follow-up period were excluded. The visual acuity and visual field (using automated white-on-white threshold perimetry) at week 16 were used in the assessment of visual outcome. RESULTS: Sixty-one subjects with APAC completed the study. The majority of subjects were female (82%) and Chinese (92%), and the mean age was 59 +/- 8.8 years. More than half the subjects (52.5%) were found to have developed IIC during the study, 65% of whom already had signs of IIC by the first week. Only 13 subjects (41%) with IIC and 6 subjects (21%) without IIC had an abnormal visual field defect at week 16 (P = 0.09). There was also no difference in visual acuity at week 16, the majority of subjects in both groups having visual acuity of 6/12 or better. CONCLUSIONS: The development of iris ischaemic changes after a single episode of APAC may not be associated with an adverse visual outcome.
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Glaucoma de Ángulo Cerrado/complicaciones , Iris/irrigación sanguínea , Isquemia/etiología , Agudeza Visual , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Antihipertensivos/uso terapéutico , Femenino , Glaucoma de Ángulo Cerrado/tratamiento farmacológico , Glaucoma de Ángulo Cerrado/cirugía , Humanos , Presión Intraocular/efectos de los fármacos , Iridectomía , Iris/cirugía , Isquemia/cirugía , Terapia por Láser , Masculino , Persona de Mediana Edad , Campos VisualesRESUMEN
PURPOSE: To evaluate changes in lens opacity in the first year after prophylactic laser peripheral iridotomy (LPI) performed in fellow eyes of subjects with acute primary angle closure (APAC). DESIGN: Prospective observational case series. PARTICIPANTS: Sixty Asian subjects with unilateral APAC. METHODS: All fellow eyes underwent prophylactic LPI within the first week of presentation, followed by 1 week of topical steroids. The degree of lens opacity was graded at the slit-lamp examination using the Lens Opacity Classification System III (LOCS III) with standard color photographs as the reference for grading of lens opacity. This was performed 2 weeks, 4 months, and 12 months after LPI. Progression in lens opacity was defined as an increase in LOCS III grade by 2 or more units in any lens region. MAIN OUTCOME MEASURES: Lens Opacity Classification Sytem III grades in nuclear, cortical, and posterior subcapsular (PSC) regions. RESULTS: Most patients were Chinese (85%) and female (63.3%), with an average age of 61.5 +/- 10.6 years. The mean baseline LOCS grades in the nuclear, cortical, and PSC regions were 3.58 +/- 0.74, 0.57 +/- 1.08, and 0.23 +/- 0.72, respectively. With 12 months of follow-up, 14 of the 60 eyes (23.3%; 95% confidence interval, 16.9-29.7%) showed significant progression in any lens region. Progression in the nuclear, cortical, and PSC regions was documented in 5%, 6.7%, and 16.7% of cases, respectively. By use of logistic regression, the following factors were not found to be significant for cataract progression in any lens region: age, race, gender, history of hypertension or diabetes, presence of peripheral anterior synechiae or angle width at baseline, and total laser energy delivered. CONCLUSIONS: In fellow eyes of APAC, prophylactic LPI is complicated by significant cataract progression, mainly in the posterior subcapsular region. These findings may have implications for the role of prophylactic LPI in the prevention of angle-closure blindness.
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Ceguera/prevención & control , Catarata/etiología , Glaucoma de Ángulo Cerrado/cirugía , Iridectomía/efectos adversos , Iris/cirugía , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Ceguera/etiología , Catarata/clasificación , Catarata/fisiopatología , Extracción de Catarata , Progresión de la Enfermedad , Femenino , Glaucoma de Ángulo Cerrado/complicaciones , Humanos , Presión Intraocular , Iridectomía/métodos , Terapia por Láser , Masculino , Persona de Mediana Edad , Fotograbar , Estudios Prospectivos , Factores de Riesgo , Agudeza VisualRESUMEN
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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Dexametasona/administración & dosificación , Sistemas de Liberación de Medicamentos , Glaucoma de Ángulo Abierto/cirugía , Glucocorticoides/administración & dosificación , Facoemulsificación/métodos , Trabeculectomía/métodos , Segmento Anterior del Ojo/efectos de los fármacos , Fluorouracilo/administración & dosificación , Estudios de Seguimiento , Humanos , Presión Intraocular , Complicaciones Posoperatorias , Estudios Prospectivos , Colgajos QuirúrgicosRESUMEN
OBJECTIVE: To evaluate the risk of peripheral anterior synechiae (PAS) and glaucomatous optic neuropathy attributable to primary angle closure at varying anterior chamber depths (ACDs) in two East Asian populations. METHODS: Participants 40 years and older were from 2 population-based glaucoma surveys in Mongolia and Singapore. Central ACD was measured by optical pachymetry. Presence of PAS was determined by dynamic gonioscopy. Cases with secondary PAS were excluded. Glaucomatous optic neuropathy was diagnosed in subjects with structural and functional evidence of glaucoma. RESULTS: A total of 2032 subjects, consisting of 942 Mongolians and 1090 Chinese Singaporeans, were included in this study. A logistic model of the relationship between ACD and PAS among Singaporeans showed a consistent, incremental increase in PAS across the entire range of ACD. In deeper anterior chambers the rate of PAS exceeded that seen in Mongolians. In Mongolians, there was a clear threshold for ACD (2.4 mm) at or above which PAS were very uncommon. With ACD less than 2.4 mm, the rate of PAS rose rapidly to overtake that seen in Singaporeans. CONCLUSIONS: Shallow anterior chambers are a significant risk factor for angle closure in East Asians, although the nature of the association is specific to the individual population. There was a trend toward higher rates of glaucomatous optic neuropathy in people with the shallowest anterior chambers.
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Cámara Anterior/patología , Glaucoma de Ángulo Cerrado/diagnóstico , Glaucoma de Ángulo Cerrado/etnología , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Pueblo Asiatico/etnología , Femenino , Gonioscopía , Humanos , Masculino , Persona de Mediana Edad , Mongolia/epidemiología , Enfermedades del Nervio Óptico/diagnóstico , Enfermedades del Nervio Óptico/etnología , Factores de Riesgo , Distribución por Sexo , Singapur/epidemiologíaRESUMEN
PURPOSE: Mutations in the myocilin (MYOC) gene have been implicated in juvenile as well as late-onset primary open-angle glaucoma (POAG). Overall, MYOC mutations account for 3% to 5% of cases of POAG worldwide, making it the most significant gene identified so far in glaucoma. Although there are some similarities in the phenotype of POAG and in particular chronic primary angle-closure glaucoma (PACG), little is known about the role of MYOC in the causation of PACG. To address this, the MYOC gene was screened in a cohort of 106 patients with chronic PACG. METHODS: Genomic DNA was extracted from leukocytes of the peripheral blood and exons 1 to 3 of the MYOC gene were PCR amplified and subjected to bidirectional sequencing and analysis. RESULTS: One hundred six patients with chronic PACG of Chinese ethnicity were studied. Sequencing of the MYOC gene in these patients revealed eight sequence variants. Of these, one was a nonsense change, three were missense changes, two were synonymous codon changes, and two were changes in noncoding sequences. These included the Arg46Stop and Thr353Ile mutations, which have been reported in individuals with POAG. However, all the sequence alterations identified have been found in normal Chinese subjects. CONCLUSIONS: The results of this study do not support a role for MYOC mutations in the pathogenesis of chronic PACG in the Chinese.
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Proteínas del Ojo/genética , Glaucoma de Ángulo Cerrado/genética , Glicoproteínas/genética , Anciano , Anciano de 80 o más Años , Pueblo Asiatico/etnología , Enfermedad Crónica , Proteínas del Citoesqueleto , ADN/aislamiento & purificación , Femenino , Glaucoma de Ángulo Cerrado/etnología , Humanos , Masculino , Persona de Mediana Edad , Biología Molecular , Mutación , Reacción en Cadena de la Polimerasa , Singapur/epidemiologíaRESUMEN
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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Técnicas de Diagnóstico Oftalmológico , Mácula Lútea/patología , Miopía/complicaciones , Tomografía de Coherencia Óptica/métodos , Adulto , Pesos y Medidas Corporales , Gonioscopía , Humanos , Masculino , Refracción Ocular , Tonometría Ocular , Agudeza Visual , Campos VisualesRESUMEN
PURPOSE: To determine the long-term outcome of Asian eyes with an acute attack of primary angle closure (APAC) and to identify risk factors at presentation associated with the development of glaucomatous optic nerve damage. DESIGN: Cross-sectional observational case series. PARTICIPANTS: Ninety individuals who were initially seen with APAC 4 to 10 years previously at 2 Singapore hospitals. METHODS: All subjects underwent a complete eye examination, including visual acuity, visual field testing, dilated eye examination, and optic nerve head photography. The optic discs were judged clinically and photographically as to whether there was glaucomatous optic neuropathy present, and visual fields were assessed for corresponding visual field loss. All visual fields and optic nerve photographs underwent a second evaluation by an experienced, but masked, glaucoma specialist, who assessed whether the changes were compatible with glaucoma. MAIN OUTCOME MEASURES: The main outcome measures were blindness (defined as best-corrected visual acuity worse than 6/60 and/or central visual field of less than 20 degrees in the attack eye) and glaucomatous optic neuropathy (GON). RESULTS: A total of 90 of 170 eligible subjects (65.2%) were examined. All subjects were Asian and were predominantly Chinese (78 subjects [86.7%]). There were 61 females (67.8%), and the age of the subjects was 62.0+/-9.0 years (mean +/- standard deviation) at the time of APAC, with a mean duration of 6.3+/-1.5 years from the time of the APAC episode to the study examination. Sixteen (17.8%) subjects were blind in the attack eye; half of the cases of blindness were caused by glaucoma. Forty-three subjects (47.8%) had GON, with 13 eyes (15.5%) having markedly cupped optic discs (cup-to-disc ratio >0.9). Thirty-eight eyes (58%) had best-corrected vision worse than 6/9, with cataract responsible for close to half the cases of poor vision. There were no identifiable risk factors related to the APAC episode that were significantly associated with the presence of GON. CONCLUSIONS: Several years after being seen with APAC, 17.8% of subjects examined were blind in the attack eye, and almost half had glaucomatous optic nerve damage. Vision was also reduced in a large number of individuals, largely from unoperated cataract. Subjects with APAC would benefit from regular follow-up to monitor for visual field decline and glaucoma development.
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Ceguera/etiología , Glaucoma de Ángulo Cerrado/complicaciones , Enfermedades del Nervio Óptico/etiología , Agudeza Visual , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Asia/epidemiología , Estudios Transversales , Femenino , Glaucoma de Ángulo Cerrado/etnología , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Disco Óptico/patología , Pronóstico , Factores de Riesgo , Campos VisualesRESUMEN
PURPOSE: To evaluate the changes in the configuration of the drainage angle in the first year after acute primary angle closure (APAC). DESIGN: Prospective observational case series. PARTICIPANTS: Forty-four Asian subjects with APAC. METHODS: Acute primary angle closure cases were treated with medical therapy followed by laser peripheral iridotomy (LPI). Static and dynamic gonioscopies were performed in APAC-affected and fellow eyes before LPI (baseline) and then at 2 weeks, 4 months, and 12 months after presentation. The angles were graded in each quadrant according to the Shaffer scheme, and the number of clock hours of peripheral anterior synechiae (PAS) was recorded. Patients who underwent intraocular surgery at any point during follow-up were excluded from the study. Intraocular pressure (IOP) and medical treatment were documented at each visit, and gonioscopic changes were correlated with the development of elevation in IOP requiring medical treatment. MAIN OUTCOME MEASURES: Average Shaffer grade and the number of clock hours of PAS. RESULTS: The majority of subjects were Chinese (84%) and female (64%), and the mean age was 60.2+/-10.7 years. At presentation, 73% of both affected and fellow eyes had very narrow angles (average Shaffer grade < or = 1), with affected eyes having more extensive PAS (P<0.001), a third of whom had > or =8 clock hours of PAS. In APAC eyes, there was a significant increase in angle width from baseline to 2 weeks after LPI (P = 0.045), but no change in angle width subsequently. Fellow eyes showed a widening of the angle between baseline and week 2 (P = 0.01) and from week 2 to month 4 (P = 0.001). There was no significant change in PAS in either affected or fellow eyes over the 12 months of follow-up. Of the 44 subjects, 19 (41.3%) subsequently developed IOP elevation during follow-up that required treatment. However, there was no difference in angle width or amount of PAS between eyes with and without a subsequent rise in IOP, and the angle configuration did not change significantly in either group over 1 year. CONCLUSION: In Asian eyes with APAC, the angle widened in the first 2 weeks after LPI, but did not change thereafter over 1 year, and the amount of PAS remained stable throughout. The results indicate the effectiveness of LPI in preventing progressive closure of the angle in the first year after APAC.