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Purpose To compare rim area rates in patients with and without the visual field (VF) progression endpoint in the Canadian Glaucoma Study and determine whether intraocular pressure (IOP) reduction following the endpoint altered rim area rate. Design Prospective multicenter cohort study. Methods setting: University hospitals. patient population: Two hundred and six patients with open-angle glaucoma were examined at 4-month intervals with standard automated perimetry and confocal scanning laser tomography. intervention: After the endpoint, IOP was reduced by ≥20%. outcome measures: Univariate analysis for change in rim area rate and multivariable analysis to adjust for independent covariates (eg, age, sex, and IOP). Results Patients with an endpoint (n = 59) had a worse rim area rate prior to the endpoint compared to those without (n = 147; median [interquartile range]: −14 [−32, 11] × 10 −3 mm 2 /y and −5 [−14, 5] × 10 −3 mm 2 /y, respectively, P = .02). In univariate analysis, there was no difference in rim area rate before and after the endpoint (median difference [95% CI], 8 (−10, 24) × 10 −3 mm 2 /y), but the muItivariate analysis showed that IOP reduction >2 mm Hg after the endpoint was strongly linked to a reduction in rim area rate decline (8 × 10 −3 mm 2 /y for each additional 1 mm Hg reduction). Conclusions Patients with a VF endpoint had a median rim area rate that was nearly 3 times worse than those without an endpoint. Lower mean follow-up IOP was independently associated with a slower decline in rim area.

Background: Appropriate access to the best quality of vision care is enhanced when patients receive eye care services from the right professional, at the right time, and in the right place. In the preceding article the authors describe the development of two patient-centred vision care algorithms for the multidisciplinary management of diabetic retinopathy and red eye. Subsequently, a questionnaire survey was done to determine ophthalmologist, optometrist and general practitioner (GP) familiarity with and acceptance of the vision care algorithms. Methods: The survey was conducted in the summer of 2001 among all ophthalmologists, optometrists and GPs registered with their respective professional body in Nova Scotia to assess their knowledge and acceptance of the diabetes mellitus and red eye algorithms.They were also asked to indicate their preferred method(s) of education and dissemination regarding these and future algorithms. Results: Of the 740 practising GPs in Nova Scotia, 188 completed the questionnaire, for a response rate of 25.4%.The corresponding figures for optometrists and ophthalmologists were 73.6% (53/72) and 43.5% (20/46) respectively. Most of all three types of clinicians practise in Halifax County. More than 80% of the optometrists and ophthalmologists were aware of the algorithms, but less than 50% of the GPs were aware of them. A large majority of respondents in all three groups (77% to 98%) indicated that they were comfortable using the diabetes and red eye algorithms as presented. Interpretation: Ophthalmologists, optometrists and GPs indicated an understanding of and willingness to use the diabetes and red eye algorithms. However, they were not unanimous regarding the choice of implementation method. Therefore, six different strategies for implementing the vision care algorithms are currently being used and are described in the paper.

Background: Appropriate access to the best quality of vision care is enhanced when patients receive eye care services from the right professional, at the right time, and in the right place. This paper, the first in a two-part series, describes the development of an integrated framework for vision care delivery. Specifically, two patientcentred vision care algorithms for the multidisciplinary management of diabetic retinopathy and the red eye are outlined, and the process that resulted in their development is described. Methods: The method used relies on a description of a multidisciplinary collaboration that occurred among ophthalmologists, optometrists, general practitioners and representatives of the Nova Scotia Department of Health with the aim of developing an integrated patient-focused multidisciplinary framework for vision care delivery. Results: The process of collaborative negotiation among the four groups resulted in the development of multidisciplinary algorithms for the screening of patients with diabetes mellitus and the treatment of those presenting with a red eye. Interpretation: Professional scope of practice has always been a contentious issue among health care professions. However, where parties agree to work within an atmosphere of respect and to accept guidance in areas of disagreement from a third party respected by all, compromise is possible.The result was the development of two vision care algorithms and ongoing efforts on the development of other algorithms.

Objective To evaluate the incidence of visual field and optic disc progression in glaucoma patients with distinct patterns of optic disc damage. Design Prospective, observational case series. Participants One hundred five patients with open-angle glaucoma. Methods Baseline optic disc photographs of 105 study eyes of 105 patients were reviewed by 2 masked observers and classified according to patterns of disc damage into the following categories: focal, myopic, senile sclerotic, and generalized disc damage. Patients were followed up every 6 months with standard automated perimetry (SAP), high-pass resolution perimetry (HRP), and scanning laser tomography (SLT) with the Heidelberg Retina Tomograph. Main outcome measures Visual field (SAP and HRP) and optic disc (SLT) progression were determined according to predefined criteria. Results Twenty-four eyes were classified into the focal, 8 into the myopic, 12 into the senile sclerotic, and 28 into the generalized group. Eyes from 33 patients could not be classified by the observers into any of these groups and were excluded from further analysis. Although intraocular pressure during follow-up was similar among the four groups, some differences in frequency of progression were observed. Patients with senile sclerotic discs had the lowest rates of visual field progression (both with SAP and HRP) and optic disc progression, although the differences were significant only for optic disc progression ( P = 0.05). Conclusions Patients with senile sclerotic discs showed a tendency towards less visual field and optic disc progression when compared with patients with other types of disc damage.

To study the effects of topical brimonidine tartrate 0.2%, an alpha(2)-agonist ocular hypotensive drug, on retinal capillary blood flow in patients with ocular hypertension.The study was a double-masked, randomized, placebo-controlled trial set in a tertiary eye center. Ocular hypertensive patients with repeatable intraocular pressures greater than 21 mm Hg and normal visual fields and optic disks were consecutively recruited. After an eye examination, baseline retinal blood flow measurements were made with confocal scanning laser Doppler flowmetry in one study eye. Patients were then randomly assigned to receive either brimonidine or placebo (saline) twice daily for 8 weeks. Blood flow and intraocular pressure measurements were then repeated after 4 and 8 weeks.Seventeen patients were randomly assigned to receive brimonidine, and 14 received placebo. One patient in each group failed to complete the study. The mean group differences in baseline age and intraocular pressure were not statistically significant (59. 23 [+/-10.24] and 52.23 [+/-16.46] years, respectively, and 24.84 [+/-2.08] and 24.56 [+/-2.85] mm Hg, respectively). Brimonidine reduced intraocular pressure by 17.90% and 16.17% at 4 and 8 weeks, respectively, with a significant difference in treatment effect compared with the placebo group (P.007). The group difference in treatment effect in any of the three hemodynamic parameters velocity, volume, and flow was within 8% and not significantly different at 4 or 8 weeks (P.360). Based on a type I error of 0.05, our study had a power greater than or equal to 75% to detect group differences in treatment effect of greater than or equal to 15% to 20%.Brimonidine reduces intraocular pressure without altering retinal capillary blood flow in patients with ocular hypertension.

Objective To compare the long-term safety and ocular-hypotensive efficacy of brimonidine tartrate 0.2% with timolol maleate 0.5% administered twice daily in patients with glaucoma or ocular hypertension. Design A double-masked, parallel-group, active-controlled, multicenter clinical trial of 12 months' duration. Participants Four hundred eighty-three patients with glaucoma or ocular hypertension were enrolled. Of these, 463 were evaluated according to the protocol criteria (280 in the brimonidine tartrate group and 183 in the timolol group). Interventions Brimonidine tartrate 0.2% or timolol maleate 0.5% was administered twice daily. Main outcome measures The primary efficacy variable was intraocular pressure (IOP). Results Brimonidine and timolol produced significant ( P P ≤ 0.007) were observed in patients treated with brimonidine as compared to timolol, whereas the mean decrease in IOP measured at trough was significantly greater in patients treated with timolol as compared to brimonidine ( P Conclusions Topically applied twice daily for 12 months, brimonidine tartrate 0.2% was safe and effective in lowering IOP in patients with glaucoma or ocular hypertension.

Noncardioselective beta-adrenoceptor antagonists are used for treatment of increased intraocular pressure. Because these agents may be absorbed systemically, their use is of concern in patients with restricted pulmonary function. We compared the efficacy of betaxolol, a cardioselective beta-adrenoceptor antagonist, and dipivefrin, an alpha/beta-adrenergic agonist. Seventy-six patients with open-angle glaucoma or ocular hypertension were randomly assigned to receive either betaxolol 0.5% or dipivefrin 0.1%. Patients were examined at two weeks, one month, two months, and three months. Intraocular pressure reductions were similar, with a mean decrease of 4.1 mm Hg in the betaxolol group and 3.5 mm Hg in the dipivefrin group. Both treatments caused similar minor increases in heart rate, typical with alpha-adrenergic agonists but atypical with beta-blockers. Stinging or burning in the betaxolol group was significantly (P = .008) greater than in the dipivefrin group. Our findings suggest that betaxolol and dipivefrin therapy are effective, equivalent ocular hypotensive agents.

The authors studied the effect of multiple threshold determinations on local and global (root-mean-square) short-term fluctuation in 30 subjects (10 controls, 10 glaucoma suspects, and 10 glaucoma patients) with a mean age of 56.70 years. Five custom programs were designed on the Octopus perimeter in which the total number of threshold determinations was equal but in which thresholds at 2 principal locations were determined between 2 and 15 times. One randomly selected eye of each subject was first tested with the standard Octopus programs G1 and 31 followed by the custom programs. Local fluctuation initially increased with the number of threshold determinations and then stabilized after five determinations. Global fluctuation was not influenced by the number of determinations and the values obtained by the shorter custom programs were not significantly different from those obtained by the standard programs. Programs that determine thresholds only twice at a given location may underestimate local fluctuation. Furthermore, local fluctuation is de-emphasized by the "watering-down" effect of estimating global fluctuation.

Objective To determine systemic and ocular risk factors for visual field progression in open-angle glaucoma. Methods In the Canadian Glaucoma Study, a multicenter prospective longitudinal study of 258 patients (131 men and 127 women; median age, 65.0 years), baseline systemic measures included assessment of peripheral vasospasm and markers for hematopathology, coagulopathy, and immunopathology. Patients were followed up at 4-month intervals with perimetry, optic disc imaging, and a standardized interventional protocol for intraocular pressure control. Univariate and proportional hazards models were used to identify factors that predicted progression. Main Outcome Measure Visual field progression with standard automated perimetry. Results Median follow-up was 5.3 years, with 167 patients (64.7%) completing 5 years or more and 67 patients (26.0%) completing 7 years or more. Abnormal baseline anticardiolipin antibody levels (hazard ratio [HR], 3.86; 95% confidence interval [CI], 1.60-9.31), higher baseline age (HR per year, 1.04; 95% CI, 1.01-1.07), female sex (HR, 1.94; 95% CI, 1.09-3.46), and higher mean follow-up intraocular pressure (HR per 1 mm Hg, 1.19; 95% CI, 1.05-1.36) before progression were associated with progression. Conclusions The Canadian Glaucoma Study identified 4 independent predictive factors for glaucomatous field progression. Application to Clinical Practice While confirming the importance of intraocular pressure in glaucoma progression, this study determined other risk factors that merit awareness. Trial Registration clinicaltrials.gov Identifier:NCT00262626

Objective: To evaluate optic disc topography changes after intraocular pressure (IOP) modulation in patients with glaucoma. Methods: Twenty-three patients with glaucoma were studied. Three mean optic disc topography images were obtained with the Heidelberg Retina Tomograph II at baseline and weeks 1, 2, 4, and 8 (visits 1, 2, 3, 4, and 5, respectively). Topical medications were discontinued in the study eye after visit 1 and resumed after visit 4 but maintained in the contralateral control eye. Central corneal thickness was measured at the last visit. Topographic changes were determined by stereometric parameters (rim area and mean cup depth) and at discrete topographic locations using the Topographic Change Analysis program (from the Heidelberg Retina Tomograph II). Results: In the study eyes, IOP increased significantly (5.4 mm Hg at visit 4; P

PURPOSE. To compare visual field progression with total and pattern deviation analyses in a prospective longitudinal study of patients with glaucoma and healthy control subjects. METHODS. A group of 101 patients with glaucoma (168 eyes) with early to moderately advanced visual field loss at baseline (average mean deviation [MD], -3.9 dB) and no clinical evidence of media opacity were selected from a prospective longitudinal study on visual field progression in glaucoma. Patients were examined with static automated perimetry at 6-month intervals for a median follow-up of 9 years. At each test location, change was established with event and trend analyses of total and pattern deviation. The event analyses compared each follow-up test to a baseline obtained from averaging the first two tests, and visual field progression was defined as deterioration beyond the 5th percentile of test-retest variability at three test locations, observed on three consecutive tests. The trend analyses were based on point-wise linear regression, and visual field progression was defined as statistically significant deterioration (P < 5%) worse than - 1 dB/year at three locations, confirmed by independently omitting the last and the penultimate observation. The incidence and the time-to-progression were compared between total and pattern deviation analyses. To estimate the specificity of the progression analyses, identical criteria were applied to visual fields obtained in 102 healthy control subjects, and the rate of visual field improvement was established in the patients with glaucoma and the healthy control subjects. RESULTS. With both event and trend methods, pattern deviation analyses classified approximately 15% fewer eyes as having progressed than did the total deviation analyses. In eyes classified as progressing by both the total and pattern deviation methods, total deviation analyses tended to detect progression earlier than the pattern deviation analyses. A comparison of the changes observed in MD and the visual fields' general height (estimated by the 85th percentile of the total deviation values) confirmed that change in the glaucomatous eyes almost always comprised a diffuse component. Pattern deviation analyses of progression may therefore underestimate the true amount of glaucomatous visual field progression. CONCLUSIONS. Pattern deviation analyses of visual field progression may underestimate visual field progression in glaucoma, particularly when there is no clinical evidence of increasing media opacity. Clinicians should have access to both total and pattern deviation analyses to make informed decisions on visual field progression in glaucoma.

Aims: To determine whether central corneal thickness (CCT) is a significant predictor of visual field and optic disc progression in open angle glaucoma. Methods: Data were obtained from a prospective study of glaucoma patients tested with static automated perimetry and confocal scanning laser tomography every 6 months. Progression was determined using a trend based approach called evidence of change (EOC) analysis in which sectoral ordinal scores based on the significance of regression coefficients of visual field pattern deviation and neuroretinal rim area over time are summed. Visual field progression was also determined using the event based glaucoma change probability (GCP) analysis using both total and pattern deviation. Results: The sample contained 101 eyes of 54 patients (mean (SD) age 56.5 (9.8) years) with a mean follow up of 9.2 (0.7) years and 20.7 (2.3) sets of examinations every 6 months. Lower CCT was associated with worse baseline visual fields and lower mean IOP in the follow up. In the longitudinal analysis CCT was not correlated with the EOC scores for visual field or optic disc change. In the GCP analyses, there was a tendency for groups classified as progressing to have lower CCT compared to non-progressing groups. In a multivariate analyses accounting for IOP, the opposite was found, whereby higher CCT was associated with visual field progression. None of the independent factors were predictive of optic disc progression. Conclusions: In this cohort of patients with established glaucoma, CCT was not a useful index in the risk assessment of visual field and optic disc progression.

To investigate the effect of cataract extraction on the visual fields of patients with open-angle glaucoma.Patients in a prospective cohort study in a tertiary center underwent standard automated perimetry every 6 months. We compared the mean results of the 2 examinations immediately before and 2 examinations immediately after phacoemulsification cataract extraction and intraocular lens implant (effect analysis) and the mean results of the first 2 and last 2 examinations from 4 consecutive examinations obtained more than 1 year after the cataract surgery (control analysis).Our sample contained 34 eyes of 26 patients (mean +/- SD age, 69.2 +/- 10.8 years). While the mean logMAR best-corrected visual acuity improved significantly by approximately 2 Snellen lines after surgery (P.001), the average change in mean deviation in both the effect and control analyses was less than 0.1 dB and not statistically significant (P = .85). There was a strong correlation between change in foveal sensitivity and change in mean deviation in the effect analysis but not in the control analysis (r = 0.76 [P.001] and r = 0.30 [P = .08], respectively). There was no relationship between change in visual acuity or initial mean deviation and change in mean deviation in either analysis. Change in pointwise total deviation was not systematically related to the respective baseline value in either analysis; however, the variance of the distribution of change in total deviation was significantly higher in the effect analysis (P.001).While there was an improvement in best-corrected visual acuity after cataract surgery, the changes in the visual field as a group were negligible.

PURPOSE . To compare frequency-doubling technology (FDT) perimetry with standard automated perimetry (SAP) for detecting glaucomatous visual field progression in a longitudinal prospective study. METHODS . One eye of patients with open-angle glaucoma was tested every 6 months with both FDT and SAP. A minimum of 6 examinations with each perimetric technique was required for inclusion. Visual field progression was determined by two methods: glaucoma change probability (GCP) analysis and linear regression analysis (LRA). For GCP, several criteria for progression were used. The number of locations required to classify progression with FDT compared with SAP, respectively, was 1:2 (least conservative), 1:3, 2:3, 2:4, 2:6, 2:7, 3:6, 3:7, and 3:10 (most conservative). The number of consecutive examinations required to confirm progression was 2-of-3, 2-of-2, and 3-of-3. For LRA, the progression criterion was any significant decline in mean threshold sensitivity over time in each of the following three visual field subdivisions: (1) all test locations, (2) locations in the central 10° and the superior and inferior hemifields, and (3) locations in each quadrant. Using these criteria, the proportion of patients classified as showing progression with each perimetric technique was calculated and, in the case of progression with both, the differences in time to progression were determined. RESULTS . Sixty-five patients were followed for a median of 3.5 years (median number of examinations, 9). For the least conservative GCP criterion, 32 (49%) patients were found to have progressing visual fields with FDT and 32 (49%) patients with SAP. Only 16 (25%) patients showed progression with both methods, and in most of those patients, FDT identified progression before SAP (median, 12 months earlier). The majority of GCP progression criteria (15/27), classified more patients as showing progression with FDT than with SAP. Contrary to this, more patients showed progression with SAP than FDT, when analysed with LRA; e.g., using quadrant LRA 20 (31%) patients showed progression with FDT, 23 (35%) with SAP, and only 10 (15%) with both. CONCLUSIONS . FDT perimetry detected glaucomatous visual field progression. However, the proportion of patients who showed progression with both FDT and SAP was small, possibly indicating that the two techniques identify different subgroups of patients. Using GCP, more patients showed progression with FDT than with SAP, yet the opposite occurred using LRA. As there is no independent qualifier of progression, FDT and SAP progression rates vary depending on the method of analysis and the criterion used.

Purpose To evaluate factors associated with optic disc hemorrhages (ODHs) in patients with open-angle glaucoma. Design Cohort study. Participants One hundred thirty-seven patients with open-angle glaucoma, with an initial mean age of 60.0 years (standard deviation [SD], 11.0 years) followed up for a mean of 9.5 years (SD, 5.0 years). Methods The association between ODHs and various patient-related variables (diabetes, systemic hypertension, heart disease, hypercholesterolemia, migraine, hypothyroidism, use of platelet antiaggregant agents) and eye-related variables (mean and range of intraocular pressure, refractive error, and severity of disease) was investigated using multivariate time-to-event analyses in patients with open-angle glaucoma. To determine the influence of the level of intraocular pressure (IOP) on the occurrence of ODHs, we compared the IOP at the time the first ODH was noted with the mean IOP of the previous 3 visits. As a control, a similar analysis was performed on the same eyes using a randomly selected visit before the occurrence of the first ODH. Main outcome measurements Patient-related and eye-related variables associated with ODHs and the comparative level of IOP in which these ODHs were observed. Results Fifty eyes of 38 patients (28%) had 1 or more ODHs during the follow-up period. The ODHs were associated with presence of diabetes (hazard ratio, 4.43; 95% confidence interval [CI], 1.8–10.50; P = 0.001) and use of aspirin (hazard ratio, 2.30; 95% CI, 1.2–4.6; P = 0.019). The IOP at the time of the first ODH was, on average, 1.4 mmHg lower than the mean IOP of the 3 previous visits (95% CI, −2.2 to −0.6 mmHg; P P = 0.410). Conclusions Optic disc hemorrhages were associated with diabetes and aspirin use and were observed at relatively lower IOP during follow-up.

PURPOSE. Vasospasm has been associated with glaucoma, but its mechanisms have not been elucidated. The present study was designed to evaluate the role of endothelin (ET)-1, a potent endogenous vasoconstrictor, in the genesis of vasospasm in glaucoma. METHODS. Our sample contained patients with open-angle glaucoma (n 43) and subjects with normal nonglaucomatous eyes and without acral vasospasm (n 27). After the eligibility visit, all subjects underwent a provocative cooling test, consisting of wearing for 30 minutes a head-vest cooling garment containing coolant fluid. Blood was collected before and after cooling, and plasma ET-1 was determined by immunoassay. In addition, visual fields and retinal blood flow, measured with a confocal scanning laser and Doppler flowmeter, were measured before and after cooling. Peripheral finger flow, skin temperature, and blood pressure were monitored during the experiment. A recovery visit was performed within 1 month, when visual field and retinal blood flow measurements were repeated. RESULTS. Baseline plasma ET-1 levels were similar between patients with glaucoma and control subjects (mean SD: 2.81 1.29 and 2.56 1.36 pg/mL, respectively, P 0.465). Patients with glaucoma, however, had a significant increase in plasma ET-1 after cooling (mean SD increase of 34% 52%, P 0.001), not observed in control subjects (mean SD increase of 7% 43%, P 0.750). No significant change in visual fields or retinal blood flow was observed after cooling in either group. Patients with glaucoma who had evidence of acral vasospasm, however, were more likely to show deterioration in visual fields after cooling than patients without acral vasospasm (P 0.007). CONCLUSIONS. Patients with glaucoma have an abnormal increase in plasma ET-1 after the body cools. It is possible that at least in some patients, increased levels of ET-1 in response to vasospastic stimuli may be involved in the pathogenesis of glaucomatous damage. (Invest Ophthalmol Vis Sci. 2003;44: 2565‐2572) DOI:10.1167/iovs.02-0913

PURPOSE: To determine the interobserver and intraobserver agreement in the recognition of different patterns of glaucomatous optic disk damage and evaluate if these patterns changed over time in patients followed for a number of years. METHODS: Patients with early to moderate glaucoma (n = 105) were consecutively enrolled to participate in a prospective observational study. In the first part of the present study, optic disk photographs obtained closest to patient’s entry date in the prospective study were classified in a masked fashion by three observers according to the pattern of optic disk damage into one of the following: (1) focal, (2) myopic, (3) senile sclerotic, (4) concentric cup enlargement, (5) normal appearance, or (6) miscellaneous (those disks that did not qualify for any of the other groups). The observers were also asked to assign a confidence score for each classification, ranging from 1 (low confidence) to 5 (highest confidence). The three observers reclassified the photographs after a minimal period of 2 months, in order to assess intraobserver agreement. In a second part of the study, one observer reviewed, in a masked fashion, all the optic disk photographs that had been taken during the routine follow-up of the 105 patients in order to evaluate whether the classification of disk pattern changed over time. RESULTS: Intraobserver agreement yielded kappa values (95% confidence interval [CI]) from 0.51 (CI, 0.40 to 0.62) to 0.85 (CI, 0.77 to 0.93) depending on the observer. Interobserver agreement kappa values between all three observers was 0.40 (CI, 0.35 to 0.46), but it improved if photographs classified with moderate or higher degrees of confidence were included (0.52 [CI, 0.44 to 0.60]). During a mean follow-up period of 8.2 ± 4.8 years, 41.6% of the eyes were always classified into the same group and 23.6% of the eyes were classified at least once into two or more of the four patterns of damage (groups 1 to 4) CONCLUSIONS: Intraobserver agreement on the pattern of optic disk damage was generally very good, with some variation among the observers. Interobserver agreement was reasonable and increased proportionally with the confidence in the classification. During long-term follow-up, the pattern of optic disk damage usually did not change. This type of classification can probably be used accurately in clinical practice.

PURPOSE: To evaluate the ability of scanning laser polarimetry to discriminate between subjects with glaucoma with specific patterns of visual field defect and normal controls. METHODS: This cross-sectional, prospective study in a glaucoma practice, focused on subjects with glaucoma with predefined types of visual field defect, including advanced (group A, n = 14), localized (group L, n = 46), or mixed (diffuse and localized) defects (group M, n = 22) and normal controls (n = 32). Scanning laser polarimetry was performed in one study eye per subject. Two methods of analysis were used: a subjective analysis, in which examination printouts with the image of the optic disk manually blocked were classified by two observers masked to the diagnosis, and a logistic regression analysis of the retardation parameters included in the printouts. RESULTS: The observers correctly identified 97% of the controls and 68% of subjects with glaucoma (overall correct classification of 77%), with 93%, 70%, and 47% of patients from groups A, L, and M, respectively, being correctly identified. The best discrimination obtained with the logistic regression correctly identified 69% of controls and 94% of glaucoma subjects (overall correct classification of 87%). The performance was only slightly better for cases from group A compared with L and M. CONCLUSIONS: Subjective assessment of the scanning laser polarimetry standard printout of single eyes might not be sensitive enough to detect cases of glaucoma with localized or milder mixed types of visual field defect. The discriminating ability of scanning laser polarimetry improves slightly when logistic regression analysis is employed.

Objective To investigate the relationship between optic disc changes measured with scanning laser tomography and those measured with conventional perimetry and optic disc photography. Methods In a prospective longitudinal study, we followed up 77 patients with early glaucomatous visual field damage. Scanning laser tomography (using the Heidelberg Retina Tomograph) and conventional perimetry (using the Humphrey Field Analyzer) were carried out every 6 months. Disc progression was determined by a procedure recently described by us for scanning laser tomography, with confirmed progression requiring repeatable changes based on probability limits for both the depth (using individual test-retest variability values) and size of change (determined in a group of 37 healthy individuals also followed up prospectively). Field progression was determined with the Statpac Glaucoma Change Probability Analysis. The agreement between scanning laser tomography and conventional disc photography was determined in a subgroup of patients. Results Patients were followed up for a median of 5.5 years, with a median of 12 sets of examinations with scanning laser tomography and conventional perimetry. Twenty-one patients (27%) showed no progression with either technique. Thirty-one patients (40%) progressed with scanning laser tomography only, while 3 (4%) progressed with conventional perimetry only. Of the 22 patients (29%) who progressed with both techniques, 10 (45%) progressed with scanning laser tomography first (median, 18 month earlier) and 9 (41%) with conventional perimetry first(median, 12 months earlier), while 3 (14%) progressed at the same time. Of the 16 patients with disc photographs that closely overlapped the follow-up, there was concordance between scanning laser tomography and disc photography in 13 patients (81%). Conclusions Glaucomatous disc changes determined with scanning laser tomography occur more frequently than field changes. Most patients with field changes also had disc changes; however, less than half of those with disc changes had field changes.

Purpose: To determine the validity, test-retest reliability and repeatability of the UFOV test in healthy controls and glaucoma patients. Methods: Three substudies with the UFOV test were conducted: (1) validity was evaluated in 77 older controls (mean age 64 [SD, 7] years) and 53 glaucoma patients (mean age 69 [SD, 8] years); (2) test-retest reliability was evaluated in 13 young controls (mean age 28 [SD, 4] years), 21 older controls (mean age 66 [SD, 9] years), and 22 glaucoma patients (mean age 68 [SD, 8] years) who performed the test twice within approximately two weeks; (3) repeatability was evaluated in 17 young controls (mean age 33 [SD, 8] years) who performed the test five times on the same day. Results: In the validity substudy, mean total processing time was significantly less for older controls (358.3 ms [SD, 226.8 ms]), than glaucoma patients (580.2 ms [SD, 324.5 ms]), with moderate correlations (rho ≥ 0.40) between total processing time and age, and visual field impairment. In the reliability substudy, mean total processing time was significantly less on retest (P ≤ 0.02), with glaucoma patients showing the largest mean test-retest difference (144.7 ms [SD, 168.9 ms]) compared with young (31.5 ms [SD, 43.7 ms]) and older controls (56.2 ms [SD, 74.8 ms]). The 95% limits of agreement were significantly wider for glaucoma patients (−186.3 and +475.7 ms) compared with young (−54.1 and +117.1 ms) and older controls (−90.5 and +202.9 ms), (P < 0.01). In the repeatability substudy, performance remained constant after the second of five tests (differences in mean total processing time

The first two visual field examinations of each of 16 glaucoma suspects and 16 glaucoma patients, who were followed up for a median of 7.46 years with seven examinations, were averaged. Three-dimensional color-coded images of the visual field were then generated. After correcting for test-retest variability, the images, as well as additional interpolated images, were aligned and presented in rapid succession to create an animation sequence. Five glaucoma specialists trained themselves to classify the visual fields as either progressing or not progressing. The interobserver and intraobserver agreement rates were then calculated. Perfect agreement (100% concordance) between the observers was obtained for 18 (56.3%) subjects, and at least 80% concordance was obtained for 27 (84.4%) subjects. Of the eight sequences that were repeated to test intraobserver agreement, four of the five observers had a value of at least 87.5%.

To complement results from individual test locations, clinicians also evaluate indices, as they give a succinct overview of the visual field. This, however, requires exact knowledge of their variability. The present study was designed to determine normal interindividual variability of global visual field indices and incorporates a data base of a multicenter study performed with Octopus 201 perimeters using Program G1. The 824 fields thus obtained included 139 fields of 139 healthy volunteers who had undergone two previous visual fields and completed all three phases of program G1. The index mean sensitivity showed a significant and linear decrease with increasing age, 0.064 dB/year of life. The indices loss variance, corrected loss variance, and short-term fluctuation did not correlate significantly with age. Percentiles are given for these visual field indices. While within the limits of normal values provided by the manufacturer for these indices, these results suggest that visual fields with “borderline” values require further clinical investigation in reliable, experienced subjects. The results may help clinicians to better evaluate global visual field indices and, therefore, to detect loss of visual function earlier.

Using confocal scanning laser tomography, we studied the test-retest variability of topographic measurements of the optic nerve head and parapapillary retina in 30 patients with glaucoma and 30 normal control subjects. We obtained three independent images, separated by between one and six hours, centered on the optic nerve head. We condensed each original 256 x 256-pixel image to a 64 x 64-pixel image, thereby allowing a realistic estimate of the empiric 90% confidence interval of testretest variability at each condensed pixel. Confidence interval maps generated for each subject showed highest measurement variability along the cup border and blood vessels. The mean standard deviation equivalents of test-retest variability in the patients and controls were 31.20 and 25.94 microns, respectively. These differences were statistically significant (P = .010). Variability increased with age (P.001). When the analysis was repeated for discrete parapapillary areas, the group differences were not statistically significant (P = .100).

Objectives To determine rates of visual field change associated with risk factors for progression in the Canadian Glaucoma Study (abnormal anticardiolipin antibody level, age, female sex, and mean follow-up intraocular pressure [IOP]), and to evaluate the effect of IOP reduction on subsequent rates of visual field change in progressing patients. Methods Two hundred sixteen patients (median age, 65.2 years) were followed up at 4-month intervals with perimetry and were monitored for progression. Patients reaching an end point based on total deviation analysis underwent 20% or greater reduction in IOP. Rates of mean deviation (MD) change were calculated. Results Patients with 0, 1, and 2 end points had a median of 18, 23, and 25 examinations, respectively. The median MD rate in progressing patients prior to the first end point was significantly worse compared with those with no progression (-0.35 and 0.05 dB/y, respectively). An abnormal anticardiolipin antibody level was associated with a significantly worse MD rate compared with a normal anticardiolipin antibody level (-0.57 and -0.03 dB/y, respectively). Increasing age was associated with a worse MD rate, but female sex and mean follow-up IOP were not. After the first end point, the median IOP decreased from 18.0 to 14.8 mm Hg (20% in individual patients), resulting in a significant MD rate change from -0.36 to -0.11 dB/y. Conclusions Patients with abnormal anticardiolipin antibody levels and increasing age had faster visual field change. Modest IOP reduction in progressing patients significantly ameliorated the rate of visual field decline. Trial registration clinicaltrials.gov Identifier: NCT00262626.

Webster's defines leadership as the "capacity to lead." Tennyson's poem Oenone refers to the "trinity of excellence": self-reverence, self-knowledge and self-control. Many refer to this triad as the essence of leadership. Sir Graham Day, a Canadian who has demonstrated leadership and vision, refers to strong leadership as a combination of vision, commitment and strategic ability. He also refers to the Harvard view of substance, humanity and morality. Although there is an extensive literature on the matter, with a wide range of views, consensus defines leadership as: • coping with change • setting the direction • directing change • creating vision • developing strategies. Note that there is no reference to political leadership, which appears to adopt a very different set of values. Several major political figures have indeed been great leaders, but perhaps not as great as we have needed in the past and, some would say, more desperately need today.

PURPOSE: To compare confocal scanning laser tomography (CSLT) to optic disc photography for detecting progressive glaucomatous disc changes. METHODS: Four expert observers first examined a training set of 40 pairs of monoscopic disc photographs to help set a criterion for change. They then classified 44 pairs of monoscopic photographs of patients followed prospectively as having either definitely no change, probably no change, probably change, or definitely change (score, 0, 1, 2, or 3, respectively). Observers were unaware that 10 pairs were photographs of fellow eyes obtained the same day to measure specificity. These patients were imaged with the Heidelberg Retina Tomograph every 6 months. Topographic change analysis (TCA) software with three criteria (yielding specificity of 81%, 94%, or 97%) was used. Comparisons between the TCA results and those of observers were made for a range of liberal to conservative criteria and for individual and combined observer scores. RESULTS: The median follow-up was 9.0 years with 18 CSLT images. Observer specificity varied from 50% to 90% (using score 0) and 60% to 100% (using score 0 or 1). Interobserver kappa ranged from 0.22 to 0.38 from the most liberal to conservative criterion and was generally higher than corresponding TCA-observer agreement. For most criteria, observers had either a high hit rate with low specificity or high specificity with a low hit rate compared with the TCA. Similar results were obtained when observer scores were combined to derive a broader range of criteria. CONCLUSIONS: The results indicate that the TCA performs at least as well as either the individual or best combination of observer classifications of disc photographs.

To investigate the on-road driving performance of patients with glaucoma.The sample comprised 20 patients with glaucoma and 20 subjects with normal vision, all licensed drivers, matched for age and sex. Driving performance was tested over a 10-km route incorporating 55 standardized maneuvers and skills through residential and business districts of Halifax, Nova Scotia, Canada. Testing was conducted by a professional driving instructor and assessed by an occupational therapist certified in driver rehabilitation, masked to participant group membership and level of vision. Main outcome measures were total number of satisfactory maneuvers and skills, overall rating, and incidence of at-fault critical interventions (application of the dual brake and/or steering override by the driving instructor to prevent a potentially unsafe maneuver). Measures of visual function included visual acuity, contrast sensitivity, and visual fields (Humphrey Field Analyzer; Carl Zeiss Meditec, Inc., Dublin, CA; mean deviation [MD] and binocular Esterman points).There was no significant difference between patients with glaucoma (mean MD = -1.7 dB [SD 2.2] and -6.5 dB [SD 4.9], better and worse eyes, respectively) and control subjects in total satisfactory maneuvers and skills (P = 0.65), or overall rating (P = 0.60). However, 12 (60%) patients with glaucoma had one or more at-fault critical interventions, compared with 4 (20%) control subjects (odds ratio = 6.00, 95% CI, 1.46-24.69; higher still after adjustment for age, sex, medications and driving exposure), the predominant reason being failure to see and yield to a pedestrian. In the glaucoma group, worse-eye MD was associated with the overall rating of driving (r = 0.66, P = 0.002).This sample of patients with glaucoma with slight to moderate visual field impairment performed many real-world driving maneuvers safely. However, they were six times as likely as subjects with normal vision to have a driving instructor intervene for reasons suggesting difficulty with detection of peripheral obstacles and hazards and reaction to unexpected events.

PURPOSE: To compare the reliability, validity, and responsiveness of the Mars Letter Contrast Sensitivity (CS) Test to the Pelli-Robson CS Chart. METHODS: One eye of 47 normal control subjects, 27 patients with open-angle glaucoma, and 17 with age-related macular degeneration (AMD) was tested twice with the Mars test and twice with the Pelli-Robson test, in random order on separate days. In addition, 17 patients undergoing cataract surgery were tested, once before and once after surgery. RESULTS: The mean Mars CS was 1.62 log CS (0.06 SD) for normal subjects aged 22 to 77 years, with significantly lower values in patients with glaucoma or AMD (P

To determine whether high-pass resolution perimetry detected glaucomatous visual field progression earlier than conventional perimetry.In a prospective longitudinal study, we observed 113 patients with open-angle glaucoma and with early to moderate visual field damage and 119 healthy control subjects. Each subject underwent testing at 6-month intervals using conventional and high-pass resolution perimetry (program 30-2 of the Humphrey Field Analyzer [Humphrey Instruments, Inc, San Leandro, Calif] and the Ring program of the Ophthimus perimeter [Hi-Tech Vision, Göteborg, Sweden], respectively). Our predetermined criterion for progression with conventional perimetry was the presence of at least 4 overlapping nonedge locations outside the fifth percentile for test-retest variability of threshold deviations (defined by the Glaucoma Change Probability Analysis of the Statpac 2 program) in 2 of 3 consecutive visual fields. We employed the identical criterion for progression with high-pass resolution perimetry using our own test-retest variability data. We repeated this procedure in the controls to measure the false-positive rate of progression.Patients were observed for a median of 4.5 years and 11 examinations with each technique. Fifty-seven patients (50.4%) did not show progression with either technique. Twenty-four patients (21.2%) showed progression with high-pass resolution perimetry alone, whereas 6 (5.3%) showed progression with conventional perimetry alone. Of the remaining 26 patients (23.0%) who showed progression with both techniques, 14 (54%) showed progression with high-pass resolution perimetry first (median, 12 months earlier); 5 (19%), with conventional perimetry first (median, 6 months earlier); and 7 (27%), with both techniques at the same time. Controls were observed for a median of 5 years and 11 examinations with each technique. One control (0.8%) showed progression with high-pass resolution perimetry.Our results suggest that high-pass resolution perimetry detects glaucomatous visual field progression earlier than conventional perimetry in most patients with progression.

PURPOSE To examine intra- and interrater agreement when analyzing cumulative defect curves. Cumulative defect (Bebie) curves provide a graphical representation of the visual field and allow a subjective classification of diffuse and localized loss. METHODS We used 75 Humphrey 30-2 visual field tests, randomly chosen from a database of 782 fields of 113 patients with open-angle glaucoma. Cumulative defect curves were generated and randomly arranged into five sets, with each set containing the 75 curves in a unique sequence. Five raters (two experienced and three inexperienced) rated each set and classified each curve as showing diffuse loss, localized loss, both diffuse and localized loss, or no loss. The intra- and interrater agreement in rating the curves was then analyzed. RESULTS Intrarater agreement ranged from 73.3-88.0% for perfect rater agreement, with 5 identical ratings. Agreement for experienced versus inexperienced raters gave similar results (means: 84.0% and 77.8%, respectively, for perfect agreement). Interrater agreement for each set, evaluated by the kappa statistic, was substantial for all 5 sets (0.65-0.71). Kappa values for each set were comparable for experienced and inexperienced raters (0.72-0.83 and 0.59-0.69 respectively). CONCLUSIONS Analyzing the nature of visual field loss using the cumulative defect curve is simple to learn and provides high intrarater agreement as well as substantial interrater agreement.

This collaborative study involves 39 investigators and shows the effects of timolol maleate when used short-term on large numbers of patients (418). Intraocular pressure response is excellent. Statistical analyses of pressure response are done using random sampling. patient complaints were monitored during the study and present interesting findings. Very few adverse reactions were reported.

• The visual fields of 30 patients (subjects) with glaucoma were sent to six experienced clinicians (observers). Each subject had at least four visual field examinations on the OCTOPUS 201 automated perimeter spanning at least one year. Each observer was asked to review the visual field data of each subject and determine whether the visual fields were stable, improved, or worse over time. The visual field data were then analyzed using six different statistical models. In only 15 of the 30 subjects did at least five of the six human observers agree on the behavior of the visual field. Agreement among the statistical models was better, with at least five of the six models agreeing on 22 of the 30 subjects. It was concluded that there is, at present, no validated technique for detecting progressive visual field loss in glaucoma using automated perimetry when relatively few visual fields are available for analysis.

Glucose tolerance tests were performed on 100 patients classified as high (gg) intraocular pressure responders (> 31 mm. Hg) to topical dexamethasone and compared with 100 matched patients classified as low (nn and ng) intraocular pressure responders. The sum of plasma glucose values at 0, 1, 2, and 3 hours was distributed in approximately Gaussian fashion for the poor intraocular pressure responders (mean 450 ± 70 (σ) mg./100 ml. Plasma glucose sums of 600 mg./100 ml. or more were found in 21 per cent of the gg patients but in only 3 per cent of the nnng group.

Visual field assessment using the Octopus Perimeter was carried out on 96 eyes with early P.O.A.G. The central visual field was assessed quantitatively using programmes 31 and 32 while the peripheral field was assessed using a two-step suprathreshold screening programme (07).

CATARACT formation with resultant reduction of vision is a frequent occurrence in patients receiving miotic therapy for glaucoma. This is especially true when using cholinesterase inhibitors which produce such intense miosis that the visual impairment from even minimal lens changes is greatly magnified. The development of proliferations of the pigment epithelium of the iris may cause further reduction of the pupillary opening in patients using these agents. In addition, individuals subjected to prolonged use of anticholinesterase drugs may develop central anterior subcapsular vacuoles and opacities. The necessity for cataract surgery, therefore, often arises in the long-term follow-up of glaucoma patients. Since the glaucoma patient will often require miotics postoperatively, it is advisable to create a permanent large pupillary opening at the time of cataract surgery. The advantages of the larger opening are twofold. First, during the operative procedure, the delivery of the lens is facilitated. Second, postoperatively, the fundus can