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ObjectiveTo describe the development and implementation of a web-based high-quality data collection tool to track the outcomes of glaucoma treatments in routine practice.Methods and analysisThis is a prospective observational registry study. An international steering committee undertook an iterative structured process to define a minimum, patient-centred data set designed to track outcomes of glaucoma treatment. The outcomes were coded into a web-based programme allowing easy access for rapid data entry. Clinicians receive personal reports enabling instant audit of their outcomes. Analyses of aggregated anonymised data on real-world outcomes are analysed and periodically reported with the goal of improving patient care.ResultsThe minimum data set developed by the international steering committee includes the following: a baseline visit captures 13 mandatory fields in order to accurately phenotype each patient’s subtype of glaucoma and to allow comparison between services, and a follow-up visit includes only four mandatory fields to allow completion within 30 s.Currently, there are 157 surgeons in 158 ophthalmology practices across Australia and New Zealand who are registered. These surgeons are tracking 5570 eyes of 3001 patients and have recorded 67 074 visits. The median number of eyes per surgeon is 22 eyes with a range of 1–575. The most common glaucoma procedure, excluding cataract surgery, is iStent inject, with 2316 cases.ConclusionThis software tool effectively facilitates data collection on safety and efficacy outcomes of treatments for different subgroups of glaucoma within a real-world setting. It provides a template to evaluate new treatments as they are introduced into practice.

We present a novel method to image the vasculature of the anterior segment of the eye using a non-invasive optical coherence tomography angiography (OCTA) system with a modified lens system. This system utilises the Heidelberg Spectralis OCTA and a 3D printed lens mount holding a simple biconvex lens in place to allow capture of images in the anterior segment.

Background To examine unrecognized nasolacrimal duct obstruction as a risk factor for developing endophthalmitis post-cataract surgery in order to assess the value of preoperative lacrimal system screening. Design Prospective case-control study. Participants A random sample of patients undergoing phacoemulsification cataract surgery (control group) and a consecutive series of patients admitted to our hospital with post-cataract surgery endophthalmitis. Methods We compared the rate of nasolacrimal duct obstruction in the control group versus the endophthalmitis series. Both groups underwent nasolacrimal duct syringing with normal saline on the ipsilateral side to the surgery. A standard macro-dacryocystogram was performed to confirm for obstruction detected on syringing. Main Outcome Measures Nasolacrimal duct obstruction rate. Results Forty-four eyes from 39 patients were included in this study: 34 eyes from 29 patients formed the control group and 10 eyes from 10 patients formed the endophthalmitis group. A higher rate of nasolacrimal duct obstruction was found among patients who developed endophthalmitis post-cataract in comparison with the control group, on both nasolacrimal duct syringing (50.0% vs. 11.8%; P = 0.018) and macro-dacryocystogram (20.0% vs. 2.9%, P = 0.125). Two out of the three patients with radiologically confirmed nasolacrimal duct obstruction reported a long history of epiphora. Conclusion The higher rates of obstruction on nasolacrimal duct syringing and macro-dacryocystogram among patients who developed endophthalmitis suggest that nasolacrimal duct obstruction is a significant risk factor for postoperative endophthalmitis. We recommend routine screening for symptoms and examination of the lacrimal system prior to cataract surgery.

Fluorophotometry using the Metricon Model 120 slit-lamp fluorophotometer showed, at an anterior focus, two peaks which corresponded to the cornea and ciliary region--the latter predominantly due to the ciliary body but contributed to by the lens--and following this, at a posterior focus, a mid-vitreous minimum and a chorioretinal peak. Tracings made both before and after fluorescein injection were similar but the levels were higher post-injection, with increasing age and with non-pigmented irides. The change in fluorescein distribution with time after injection is described. Abnormally high fluorescein levels were found in the normal fellow eye in retinal vein occlusion, in diabetes, in senile macular degeneration with neovascular membrane, in active central serious retinopathy and in acute optic neuritis. It is of use in the differentiation of primary choroidal melanoma from naevus and metastases. There was no correlation between isolated measurements of the haemoglobin A1C level and leakage; plasma and ultrafiltrate fluorescein levels in diabetics did not differ from normal.

In surveying an extensive group of patients with unilateral pseudoexfoliation of the lens capsule certain interesting points emerged, particularly on the incidence of central retinal vein occlusion in this condition,and perhaps in glaucoma also. A total of 284 patients with unilateral pseudo-exfoliation of the lens capsule were examined clinically after an ophthalmic and general history were taken. Mean intraocular pressure (IOP) was 30.9 mmHg in the affected eye and 18.1 mmHg in the unaffected eye. Central retinal vein occlusion occurred in 10 affected eyes but no unaffected eyes and always in affected eyes with a rise in IOP. Average IOP in the affected eye with central retinal vein occlusion was 37.5 mmHg (range 26-54 mmHg);in the unaffected fellow eye it was 18.0 mmHg (range 11-28 mmHg). Although the process involved in producing pseudo-exfoliation of the lens capsule may contribute to the precipitation of central retinal vein occlusion, these findings suggest the rise in IOP is the more important cause. This may also be so in other forms of glaucoma.

Purpose: The aim of the present study was to investigate the safety and potential efficacy of subconjunctival interferon-α2b (IFN-α), either alone or in combination with 5-fluorouracil (5-FU), in reducing the risk of failure of glaucoma surgery. Methods: A prospective, masked randomized phase II study was undertaken in which patients received three subconjunctival injections per week for 3–4 weeks postoperatively. Three treatments were compared: (i) IFN-α (1 × 106 IU per dose); (ii) 5-FU (5 mg per dose); and (iii) alternating IFN-α and 5-FU (BOTH). The primary outcome measures were: (i) rate of successful control of intra-ocular pressure without further surgery; and (ii) the incidence of side effects. Results: Fifty-seven patients undergoing glaucoma surgery with an increased risk of failure were evaluated, including 23 patients (40%) undergoing trabeculectomy combined with extracapsular cataract extraction as well as other conventional high-risk groups. With 53 patients (93%) completing 2 years follow up, there was no significant difference in success rates among the three groups. Intra-ocular pressure was controlled without further surgery in 79% of patients (95% confidence interval (CI): 61, 97%) receiving IFN-α, in 89% of patients (76, 100%) receiving 5-FU and in 89% of patients (76, 100%) receiving BOTH. Side effects were similar among the three groups. Conclusions: These results are consistent with a beneficial effect of IFN-α2b given either alone or in combination with 5-FU after glaucoma filtering surgery. However, the lack of a clear and substantial benefit over conventional anti-fibrotic therapy does not support the further clinical evaluation of these treatments.

To examine unrecognized nasolacrimal duct obstruction as a risk factor for developing endophthalmitis post-cataract surgery in order to assess the value of preoperative lacrimal system screening.Prospective case-control study.A random sample of patients undergoing phacoemulsification cataract surgery (control group) and a consecutive series of patients admitted to our hospital with post-cataract surgery endophthalmitis.We compared the rate of nasolacrimal duct obstruction in the control group versus the endophthalmitis series. Both groups underwent nasolacrimal duct syringing with normal saline on the ipsilateral side to the surgery. A standard macro-dacryocystogram was performed to confirm for obstruction detected on syringing.Nasolacrimal duct obstruction rate.Forty-four eyes from 39 patients were included in this study: 34 eyes from 29 patients formed the control group and 10 eyes from 10 patients formed the endophthalmitis group. A higher rate of nasolacrimal duct obstruction was found among patients who developed endophthalmitis post-cataract in comparison with the control group, on both nasolacrimal duct syringing (50.0% vs. 11.8%; P = 0.018) and macro-dacryocystogram (20.0% vs. 2.9%, P = 0.125). Two out of the three patients with radiologically confirmed nasolacrimal duct obstruction reported a long history of epiphora.The higher rates of obstruction on nasolacrimal duct syringing and macro-dacryocystogram among patients who developed endophthalmitis suggest that nasolacrimal duct obstruction is a significant risk factor for postoperative endophthalmitis. We recommend routine screening for symptoms and examination of the lacrimal system prior to cataract surgery.

* BACKGROUND AND OBJECTIVES: The authors noted an underestimation of the mean deviation for field testing using the Fastpak (Humphrey Instruments, San Leandro, CA) strategy, and set out to define the extent of this difference. * PATIENTS AND METHODS: Sixty-seven eyes of 35 glaucomatous patients were examined. Patients received full-threshold 24-2 tests before and after the Fastpak strategy was used, each test on a different day. For some patients, another full-threshold test was performed using a different birth date in order to obtain a result uninfluenced by prior data. * RESULTS: The mean deviation (MD) was significantly underestimated by Fastpak compared with the full-threshold tests. The time taken for Fastpak was almost identical to that taken for full-threshold tests. Short-term fluctuation (SF) appeared to have very little reliability statistically, and, consistent with this, there was a greater concordance among pattern standard deviation (PSD) data than among corrected pattern standard deviation (CPSD) data. * CONCLUSION: Fastpak was an effective method for charting the visual field, but did so with greater variation than full-threshold tests. It significantly underestimated the MD, and this was not a fatigue effect. Fastpak was no faster than full-threshold testing in advanced glaucoma. CPSD was a less consistent reading than PSD in these glaucomatous patients. [Ophthalmic Surg Lasers 1996;27:758-762.]

Background: We have investigated the vascular perfusion of a wide variety of conditions of the anterior segment using fluorescein angiography. Methods: The conditions were classified and findings reported according to the system set out below. Patients underwent full ocular examination. Fluorescein angiography of the anterior segment was carried out when indicated to investigate iris atrophy and neovascularisation. Specular microscopy of the corneal endothelium was used to detect changes in this tissue. Results: The hypoperfusion was variable in degree and accompanied by varying degrees of iris hypoplasia and atrophy with neovascularisation. The degree of neovascularisation depended upon its rapidity of development, the pre-existing state of vascular perfusion and the underlying pathological condition. Conclusions: Hypoperfusion with resultant ischaemia and neovascularisation is common in conditions of the anterior segment. An understanding of the changes is valuable in treating many conditions affecting the anterior segment. The changes observed may also occur elsewhere in the physical system and may be a significant part of the ageing process, either as scattered, disparate processes or as part of a general disease process.

Background: Since the introduction of carbonic anhydrase inhibitors, a topical preparation has been sought to avoid the complications of systemic medication while retaining the effect of lowering intraocular pressure. Recently, a topical carbonic anhydrase inhibitor, MK-507, has been found superior to others and introduced for multicentre clinical trial. Patients and methods: As part of an international rnulticentre trial, we compared MK-507 with beta blockers for one year in 20 patients with raised intraocular pressure, both as monotherapy and in combination. Results: Twelve patients with a mean peak pressure of 31.9 ± 6.8 mmHg (range, 22 to 49 mmHg) off all medication received MK-507. After two weeks, mean peak pressure was 24.7 ± 6.1 mmHg (range, 14 to 41 mmHg) — a 22.6% fall in pressure. Six of these patients had a mean peak pressure of 27.8 ± 6.4 mmHg (range, 21 to 41 mmHg), a fall of 19.2% from day one and were given timolol as add-on therapy. This resulted in a fall to 19.1 ± 2.8 (range, 15 to 24 mmHg) at year one, a fall of 31.3% after add-on. Four patients on timolol and four on betaxolol gave similar falls in pressure with an additional fall when MK-507 was used as add-on therapy. Conclusions: MK-507 demonstrated its effectiveness as an ocular hypotensive agent in this trial of patients with an unusually high rise in pressure. It showed a hypotensive effect roughly equivalent to beta blockers. It is likely that either a topical carbonic anhydrase inhibitor or a cardioselective beta blocker will be the medication of first choice in newly diagnosed glaucoma.

Background: The authors studied a family with a form of congenital fibrosis of the extraocular muscles different from any group previously reported. Methods: A careful examination was done of all affected and all, except one, unaffected members of a family of 15 members extending over three generations. The authors performed computed tomography on five affected and four unaffected family members. Results: All affected family members showed complete loss of vertical ocular movement but largely free horizontal movement except for variable restriction of adduction in some members. A variable degree of ptosis was present, ranging from gross to nil, but with poor levator function and an absent Bell phenomenon in all affected members. All affected members showed superficial keratopathy, many with corneal scarring. Ocular alignment showed considerable variation. Refractive error and amblyopia also were variable. Computed tomographic scan indicated reduction in size of the extraocular muscles, particularly the superior recti with intracranial ventricular asymmetry in three of five patients examined, and abnormality in shape of the eye globes in two patients. Conclusions: The findings indicate a new group best described as dominantly inherited congenital fibrosis of the vertical-acting extraocular muscles, which is part of the syndrome of congenital ocular fibrosis. Computed tomographic scanning suggested that the clinical picture was produced by changes present in the orbit, but intracranial ventricular asymmetry also was present in some patients and asymmetry of the eye globes in others.

Purpose In order to remove precisely scleral tissue overlying Schlemm's canal with minimal trauma as an outpatient procedure under local anesthetic, we used a VisX Twenty/Twenty excimer laser. Methods We performed excimer laser filtration in three enucleated pig eyes, seven enucleated human eyes, and seven eyes of seven patients with severe glaucoma. Precise ablation to Schlemm's canal was confirmed by scanning electron microscopy in the enucleated eyes. For the patients, a local anesthetic was used, and a custom-made holder was used to mobilize the conjunctiva and fix the eye. Results A functional sclerostomy was obtained with 1,780 to 5,965 pulses, using a 2 × 1–mm slit. In our mean follow-up of nine months (range, six to 12 months) the excimer laser filtration technique achieved controlled filtration in five of seven patients and minimized conjunctival trauma. One patient subsequently underwent cataract extraction. Conclusions This study indicates that excimer laser filtration is an effective technique for achieving filtration in glaucoma. It may reduce the complications of glaucoma filtration surgery, particularly the incidence of shallow anterior chamber postoperatively, as it leaves the trabecular meshwork intact.

The effects of changes in iris perfusion in anterior segment pigment dispersal syndrome (ASPDS) were examined by iris fluorescein angiography in 29 patients (20 men and 9 women; mean age, 49 ± 14 years; range, 29 to 77 years). All showed hypoperfusion, with mild to moderate microneovascularization. There was a significant relationship between the degree of hypoperfusion and pigment scatter (P < .05), and between the level of intraocular pressure (IOP) and angle pigmentation (P < .01). No statistically significant relation was found between hypoperfusion and iris leak, nor between the level of IOP and iris hypoplasia, hypoperfusion, leakage of dye, pigment scatter, or iris processes. These findings suggest that iris hypoplasia and hypoperfusion are the underlying causes of ASPDS with a congenital etiology.

A method of combined cataract extraction with posterior chamber intraocular lens and trabeculectomy using separate incisions was tested in 44 operations on 38 patients. The mean preoperative intraocular pressure (IOP) of 28.1 +/- 11.7 (range 12 to 56) mmHg on maximum medication was lowered to 13.9 +/- 3.4 (9 to 23) mmHg at one year, with half the eyes still requiring topical medication. The IOP was 40 mmHg or more preoperatively in eight eyes and 20 mmHg or more in only two patients at one year. There were no rises in IOP above 20 mmHg in the early postoperative period (days 1 and 2). Visual acuity was 6/9 or better in 27 and 6/12 in three eyes. There was an expulsive haemorrhage in one case, rupture of the posterior capsule in two eyes and a choroidal detachment in one eye, but no flat anterior chambers. The two-incision method allowed placement of an intraocular lens with good post-operative pressure control.

We revised our trabeculectomy technique in an effort to minimize the complications associated with the use of 5-fluorouracil (5-FU) in these procedures and then compared the results obtained with this procedure both with (25 patients) and without (25 patients) the use of 5-FU. There was no significant difference between the two groups in terms of mean postoperative IOP at 1 year, number of patients that required needling of the bleb to control postoperative IOP, and number of patients requiring postoperative topical medications to control IOP. Since more (although not significantly more) patients who did not receive 5-FU required needling of the bleb to maintain filtration, and since we were able to achieve satisfactory results in the great majority of cases using only a small total dose of 5-FU, we suggest that it may be simpler to use low doses of 5-FU in all trabeculectomy procedures.

Recently, new techniques have been introduced for performing glaucoma surgery without opening into the anterior chamber, thus avoiding the complications which are commonly associated with penetrating glaucoma surgery. These methods involve exposure of the canal of Schlemm under a deep scleral flap without actually entering the anterior chamber and sometimes insertion of a collagen sponge under the scleral flap.1-4 Essentially these methods stem from the seminal work of Grant who demonstrated that in normal enucleated human eyes 75% of the resistance to aqueous outflow was located in the trabecular meshwork.5 Following Grant's work, various attempts were made to redesign glaucoma surgery to remove resistance at the trabecular meshwork thus lowering intraocular pressure. It is instructive now to reappraise these attempts. Redmond Smith6 introduced the concept of trabeculotomy as surgery for open angle glaucoma and this was further developed by Harms and Dannheim.7 Soon after Grant's work Dvorak-Theobald and Kirk8 pointed out that some cases of open angle glaucoma were due to obstruction of the scleral collectors and Krasnov introduced sinusotomy for use in glaucoma when trabecular function appeared adequate.9 Sinusotomy and trabeculotomy were even combined to produced a filtering bleb with an intact anterior chamber.10 In 1968 John Cairns introduced trabeculectomy having noted the lack of acceptance of trabeculotomy.11 Essentially this functions as a guarded full thickness sclerectomy, although Cairns originally postulated that removal of trabecular meshwork would allow free flow of fluid into the open lumen of the canal of Schlemm bypassing trabecular resistance. There is now little doubt that trabeculectomy has supplanted all other forms of …

To assess the effect of acute angle closure glaucoma (AACG) and related surgical intervention on the corneal endothelium, specular microscopy was performed following surgery in a series of 69 patients: 27 for AACG, 9 for incipient angle closure, 17 for chronic angle closure glaucoma (CACG), and 16 for chronic open angle glaucoma (COAG). Peripheral iridectomy for incipient angle closure glaucoma caused no significant effect on the corneal endothelium, but, following peripheral iridectomy or drainage operation for AACG, significant lowering of the endothelial cell count was present in the affected eye (p less than 0.05) with 1,000 cells/mm2 in 7 cases. This was related to the presence of segmental iris atrophy (p less than 0.01). Peripheral iridectomy for CACG or incipient angle closure glaucoma was not accompanied by a significant effect, but drainage operation for CACG or COAG was associated with a significant fall in count (p less than 0.01). Thus, both AACG and drainage operation significantly affect the corneal endothelium, and this should be assessed before undertaking further surgery.

The deposits of cornea guttata, which often precede Fuchs' endothelial dystrophy, represent a risk factor in patients undergoing intraocular surgery, rendering a cornea unsuitable for use as donor material. These corneal guttae clinically resemble subendothelial blebs that accompany various corneal and anterior segment inflammatory conditions so that confusion between the two groups is possible. In differentiating the two groups it is noted that (a) guttae are more elevated and usually appear in the relief mode; (b) the endothelial mosaic, if present, is usually relatively normal around the guttae; (c) both guttae and blebs may be contiguous and even confluent; (d) guttae are more regular and endothelial cells are often arranged regularly around them; (e) although small guttae may occur, if guttae are at all numerous, large ones are also usually present; and (f) inflammatory cells are rarely present in the relief mode with guttae but are always present with blebs associated with uveitis.

Purpose: Colour Doppler imaging provides an estimate of the velocity of blood flow in vessels supplying the eye. Methods: To assess changes in orbital blood flow with age, we used a method to study peak systolic velocity in 20 young normal patients, mean age 25.2 ± 2.4 years and 30 elderly normal patients, mean age 69.5 ± 7.9 years. Results: Peak systolic velocity was significantly higher in the central retinal artery and the temporal division of the posterior ciliary artery in elderly patients. There was greater variation in the peak systolic velocity readings in the distal part of the ophthalmic artery in the elderly than in the younger group. There was greater variation in the pulsatility index in the central retinal artery in young subjects. Conclusions: Though not large, these differences suggest changes in the orbital blood vessels with age which could affect the development of disease processes in elderly patients. These changes should be taken into account when assessing blood flow in elderly patients.

In surveying an extensive group of patients with unilateral pseudoexfoliation of the lens capsule certain interesting points emerged, particularly on the incidence of central retinal vein occlusion in this condition,and perhaps in glaucoma also. A total of 284 patients with unilateral pseudo-exfoliation of the lens capsule were examined clinically after an ophthalmic and general history were taken. Mean intraocular pressure (IOP) was 30.9 mmHg in the affected eye and 18.1 mmHg in the unaffected eye. Central retinal vein occlusion occurred in 10 affected eyes but no unaffected eyes and always in affected eyes with a rise in IOP. Average IOP in the affected eye with central retinal vein occlusion was 37.5 mmHg (range 26-54 mmHg);in the unaffected fellow eye it was 18.0 mmHg (range 11-28 mmHg). Although the process involved in producing pseudo-exfoliation of the lens capsule may contribute to the precipitation of central retinal vein occlusion, these findings suggest the rise in IOP is the more important cause. This may also be so in other forms of glaucoma.

The diagnosis of congenital fibrosis of the extraocular muscles (CFEOM) encompasses several different inherited strabismus syndromes characterized by congenital restrictive ophthalmoplegia affecting extraocular muscles innervated by the oculomotor and/or trochlear nerves. The OMIM database (http://www.ncbi.nlm.nih.gov/Omim/) currently contains four familial CFEOM phenotypes: CFEOM1-3, which map to the FEOM1-3 loci (MIM 135600, 602078, 604361), respectively, and congenital fibrosis of the vertically acting extraocular muscles (MIM 600638), reported in a single family without a corresponding genotype. We have had the opportunity to study the reported family with this fourth phenotype and now demonstrate that their phenotype can be reclassified as CFEOM3 and that it maps to FEOM3, flanked by D16S498 to 16qter, with a maximum lod score of 6.0.

One hundred and twenty patients with anterior segment pigment dispersion syndrome were reviewed in order to ascertain the features of the condition and form some idea of their significance. Patients were regarded as having pigment dispersion syndrome on the basis of heavy trabecular mesh pigmentation with at least one other feature of the condition. Although common in men, 44 patients, or a little over one-third, were women. Average age at presentation was 47.8 years with women presenting 10 years later than men. Intraocular pressure was very variable at presentation being less than 20 mmHg in 23 patients. Some patients with elevated pressure had no field loss. Variable myopia was recorded in 38 patients: 30 patients were not myopic. Anterior chamber depth was also variable, the average being 3.0 mm, but six patients had a depth of 2.2 mm or less. The syndrome is extremely variable in its features at presentation. The mild hypoplasia and the hypoperfusion of the iris previously described is consistent with the laxity of the iris noted by Ritch and colleagues.

Purpose We followed, for a long term, end-stage glaucoma patients as defined by the level of legal blindness. Methods Follow up was for 7.7+/-1.8 years (range 2-9) for 22 patients (13 men and nine women) having 32 eyes with functional vision. Age at exit was 74.6+/-15.5 years (range 33-89). Humphrey computerized perimetry and applanation tonometry were used throughout. We attempted to hold intraocular pressure below 15 mmHg using as much medical therapy as required. Results All visual fields were less than 10 degrees diameter at exit, but at entry seven eyes of six patients still had a field between 10 degrees and 20 degrees, the rest were all less than 10 degrees. Corrected visual acuity at entry was 6/9 to 6/6 in 21 eyes of 6 patients and none had less than 6/60. At exit 16 eyes had 6/9 to 6/6 and five eyes had less than 6/60, but no patient had complete loss of vision. Mean intraocular pressure (IOP) throughout was below 15 mmHg in all but four patients, whose (IOP) were less than 20 mmHg, using multiple medications if necessary. All patients had undergone prior surgery and/or laser trabeculoplasty. Conclusions Even though visual loss slowly progressed, most patients with end-stage glaucoma retained functional vision for a long period when intraocular pressure was held below 15 mmHg. More stringent early control of intraocular pressure may avoid the development of end-stage glaucoma.

Colour Doppler imaging (CDI) of orbital vessels is non- invasive but may be fallacious, while computed tomography (CT) angiography displays a visual outline of orbital vessels. We compared clinical findings of the two methods in 33 patients with a wide variety of clinical conditions. It was not possible to visualize the central retinal arteries with CT angiography, but it was possible to show the intracranial carotid, which CDI could not. Changes in the ophthalmic arteries on CDI usually showed changes in calibre on CT angiography. Patients with unexplained or gross visual loss often showed marked abnormalities on CT scanning, not entirely consistent with the clinical picture. Several patients showed marked ectasia of the intracranial carotid along with variable clinical findings. Findings on CT angiography complement and augment those on CDI, and are likely to be more clinically valuable in the future.

We present a procedure whereby the confocal laser scanning ophthalmoscope can be used to extract information about the three-dimensional structure of the central excavated area or the cup of the optic nerve head of the eye. The data are analyzed in terms of spherical harmonics. It is hypothesized that the shape of the cup of the optic nerve head for a normal eye can be parameterized by a specific set of spherical harmonic coefficients and is different from the set of coefficients describing a glaucomatous eye. The sets of coefficients are analyzed by using multivariate statistics and can in turn be used to classify new observations. Preliminary results indicate that there are significant differences in the coefficients and that the procedure might have potential as a diagnostic aid for the detection or the screening of glaucoma.

Purpose: The aim of the present study was to test the hypothesis that the three-dimensional (3-D) topography of the optic disc contains sufficient information to diagnose glaucoma with a high degree of reliability. Methods: The Zeiss ‘Confocal Laser Scanning Ophthalmoscope’ (CLSO) was used to obtain digitized samples of 3-D images of optic nerve heads from the following three groups of patients: (i) 40 normals with normal optic discs, normal Humphrey 24–2 full threshold visual fields and an intraocular pressure (IOP) ≤ 21 mmHg; (ii) 20 established glaucoma patients with cupping, glaucomatous field loss and an IOP > 21 mmHg; and (iii) 20 early glaucoma patients with early cupping, field loss with a mean defect less than –10 dB and IOP > 21 mmHg. The cupping in these patients was paramaterized by spherical harmonics and was classified by multivariate statistical analysis. Results: Of 40 glaucoma patients, 39 were correctly classified. Of 40 normal patients one was classified as glaucoma. Conclusions: This study demonstrates that the CLSO, with the use of spherical harmonics, can differentiate glaucomatous from normal optic discs in this selected group of patients without the need for a skilled observer. This constitutes a promising technique to be tested on a large, unselected body of patients as a screening tool.

It is sometimes claimed that a relationship exists between Fuchs' dystrophy and angle closure glaucoma and that this is an indication for the simultaneous performance of keratoplasty and cataract extraction in patients with Fuchs' dystrophy. If such a relationship exists, then the anterior chamber depth in Fuchs' dystrophy should resemble that in angle closure glaucoma and a significant degree of cornea guttata might be expected to be common in angle closure glaucoma. In 88 patients with angle closure glaucoma we found that the anterior chamber depth was significantly shallower than in cornea guttata or Fuchs' dystrophy for acute (p < 0.001), chronic (p < 0.002) or incipient angle closure glaucoma (p < 0.001). Cornea guttata and Fuchs' dystrophy were very infrequent in these patients with angle closure, only two having cornea guttata and one Fuchs' dystrophy. These results do not support a relationship between angle closure glaucoma and Fuchs' dystrophy or cornea guttata and do not justify performing combined cataract surgery and keratoplasty in all cases of cornea guttata or Fuchs' dystrophy undergoing keratoplasty. Each case should be assessed on its merits and combined surgery should be reserved for patients shown to have a shallow anterior chamber or significant cataract.

The reversal of optic disc cupping following pressure reduction by medical or surgical means has long been recognised, particularly in congenital and juvenile glaucoma. Less clear cut is whether this reversal is accompanied by any improvement in visual function. The matter is, obviously, an important one and there are some reports suggesting that an improvement may occur. If so this presumably is due to recovery of neuronal function which has …

A 52-year-old Caucasian woman with pigmentary glaucoma underwent a left cyclodiathermy procedure for raised intraocular pressure (IOP) in 1962 and right sclerectomy the following year. Over 25 years later a low IOP was still maintained though pilocarpine was needed in the left eye. After a left cataract extraction with insertion of a posterior chamber lens, field loss had not progressed very much in either eye though the visual acuity was reduced in the more affected eye. Both drainage operation and a cyclodestructive procedure controlled IOP over a long period of time in this patient and were associated with only a very gradual progression of field loss.

Topical beta-blockers reduce the intraocular pressure (IOP) by blockade of sympathetic nerve endings in the ciliary epithelium causing a fall in aqueous humour production. Two types of topical beta-blockers are available for use in glaucoma: nonselective, which block both beta 1- and beta 2-adrenoceptors; and cardioselective, which block only beta 1-receptors. Of the beta-Blockers commercially available, timolol, levobunolol, metipranolol and carteolol are nonselective, and betaxolol is cardioselective. Twice-daily timolol is probably the most effective agent in lowering IOP, although levobunolol is equally effective and can be used once daily with little difference in effect. Carteolol is used twice daily and any theoretical advantage in diminished side effects conferred by its partial beta-agonist activity compared with timolol has not been fully substantiated. Metipranolol is effective twice daily and does not have partial beta-agonist activity. Betaxolol has an effect comparable to timolol in lowering IOP, but is less effective in some patients. beta-Blockers can be used with other antiglaucoma medications, but their combined action with epinephrine (adrenaline) is suspect, particularly in the case of the nonselective beta-blockers, and the effect should be assessed in patients on an individual basis. Local stinging can be a problem in some patients with betaxolol. The most serious side effects of beta-blockers are the exacerbation of chronic obstructive airways disease with nonselective agents and the precipitation of bronchospasm in some patients. Betaxolol seems relatively free of adverse respiratory effects, although this may be dose-related and extreme caution should still be exercised in patients with any history of respiratory illness. Because of the lower risk of precipitating side effects, betaxolol is probably the beta-blocker of first choice for use in glaucoma; timolol or levobunolol are reserved for patients who do not respond satisfactorily to betaxolol and are quite free of respiratory disease.

YAG cyclophotocoagulation is a non-invasive cyclodestructive procedure which may be used in a graduated dosage as an outpatient procedure in cases of refractory glaucoma. In a group of 60 patients treated there were 37 patients with absolute glaucoma and 23 patients with advanced glaucoma in most of whom drainage operation had failed to control the intraocular pressure (IOP). Following treatment IOP fell in all but one case with absolute glaucoma. In 21 cases with absolute glaucoma it fell to 22 mmHg or less, while in 21 cases with advanced glaucoma it was 22 mmHg or less. Treatment was graduated as mild, moderate or maximal. Reactions were more severe with maximal treatment. In advanced glaucoma mild treatment only was used and this was repeated if necessary. Hypotony only occurred with maximal therapy.

Corneal oedema and bullous keratopathy may occur following intraocular surgery or arise spontaneously in nonguttate eyes. In some patients the fellow eye shows a relatively normal endothelial cell count with abnormal pleomorphism and polymegathism of the endothelial cells, while in others it shows a markedly lowered endothelial cell count with no evidence of corneal guttae. A survey of 17 such patients suggested the following classification. 1. Nonguttate corneal endothelial dystrophy with irregular endothelial cell morphology but a relatively normal endothelial cell count occurring following surgery (eight patients) or spontaneously (four patients). 2. Nonguttate corneal endothelial dystrophy with grossly reduced endothelial cell count occurring spontaneously (two patients). Three additional post-surgical patients showed a relatively normal endothelial cell count and only mild changes in the morphology of the corneal endothelium. These findings support the presence of a nonguttate corneal endothelial dystrophy in both the spontaneous and some of the post-surgical cases.

The two main factors which define the limits of safe recession of a horizontal rectus muscle are: 1. The ability of the muscle to contract, and 2. Mechanical factors, particularly the mechanical torque exerted by the muscle upon the globe of the eye.

We compared the results of surgery designed on the basis of measurement of the dimensions of the eye by A scan with surgery based upon the use of conventional methods in operations on horizontal recti muscles only in eso and exo devation. A successful result in both groups was one with a residual deviation within 10Δ of 5Δ of postoperative esotropia. Of 55 patients undergoing surgery designed by A scan for esotropia 50 gave a successful result for a success rate of 91% while for 69 operations designed by conventional methods in 64 patients with esotropia there were 44 successful results for a success rate of 64%. Of 51 patients undergoing surgery designed by A scan for exotropia 39 gave a successful result for a success rate of 76%, while for 35 operations designed by conventional methods in 32 patients with exotropia there were 19 successful results for a success rate of 54%. The difference between the groups was statistically significant for esotropia pi 0.01,χ2= 11.4, 1 df and for exotropia p i0.02,ϯ2= 5.5, 1 df. Although the series were not strictly comparable, we believe that design of surgery by A scan will improve the results of squint surgery.

Although phacolytic glaucoma is well known and the clinical picture is well recognized, the nature of the polychromatic hyperrefringent granules is less well understood. A series of five cases was examined by specular microscopy, and the anterior chamber aspirate obtained at operation was subsequently examined by direct microscopy of the wet aspirate. Direct microscopy showed that the macrophages identified histologically in the aspirate corresponded to regular round cells about three times the size of an erythrocyte seen in the relief mode of specular microscopy. This finding aided in the interpretation of cellular deposits seen on specular microscopy. One hyperrefringent granule was seen on the posterior endothelium on specular microscopy, and results of subsequent examination of the aspirate showed this and the crystals in another patient to be morphologically identical with cholesterol crystals. The findings confirm that cholesterol crystals are present in the exudate in phacolytic glaucoma and are responsible for hyperrefringent granules.

Retained cilia in the eye following injury are rare. There are reports of long term tolerance to cilia in the anterior chamber but no information about the effect on the corneal endothelium. A 31-year-old man was seen with a 19-year history of a retained eyelash embedded in a corneal scar and extending across the anterior chamber to the chamber angle. The follicle was absent. There was no cellular inflammatory reaction, and the eye otherwise appeared normal on slit-lamp examination with normal vision. However, there was the appearance of an encrusted deposit on the surface of the lash and a markedly lowered endothelial cell count of 750 cells/mm2 compared with the fellow eye. The lash was not removed.

Two patients with deep corneal stromal opacities occurring after prolonged contact lens wear are described. The opacities were associated with folds or striae in Descemet's membrane which they overlay. Development of the opacities was associated with ocular discomfort, photophobia, reduced vision and a history of prolonged daily wearing times. Although the corneal endothelial cell counts were within the normal range, the count was reduced in the affected eye in the patient with the unilateral deep stromal opacity and there was mild polymegathism of the endothelial cells. It is possible that the long-term effects of subtle endothelial cell changes may cause a keratopathy with later scarring and opacification. Poor oxygen transmissibility, carbon dioxide build-up, or suction effects by the lens may all be aetiological factors. Early recognition and treatment, particularly with a better fitting lens of high oxygen transmissibility is important, as once developed the opacities regress only slowly and may result in permanent visual impairment.

The corneal endothelium was assessed following penetrating keratoplasty in a series of 50 patients and eight illustrative cases are described. Assessment disclosed a wide variation in the endothelial cell count and morphology following keratoplasty. In some patients the endothelial cell count was so low and the morphology so abnormal that long-term survival of the graft was doubtful. In cases with such a low count it is very doubtful, whether the graft will survive a secondary procedure such as cataract extraction or, intraocular lens implantation. Some donor material may carry corneal guttae and the use of such material should be avoided. If the material is good it will withstand inflammatory episodes including graft rejection if treatment is prompt and appropriate. Satisfactory material may be obtained from elderly donors while a young donor does not guarantee suitable material. It is desirable to assess the corneal endothelium of donor material carefully before use.

During the four-and-a-half year period from January 1982 to June 1986, 511 penetrating keratoplasty specimens were submitted to the Pathology Department of The Royal Victorian Eye and Ear Hospital Seventy per cent were from patients of the RMEH and the remainder were submitted from outside the Hospital The cases were classified both clinically and pathologically The most frequent diagnosis was keratoconus, followed by scarring, regrafts, bullous keratopathy, acute or chronic ulceration, corneal dystrophies and a small miscellaneous group Post-herpetic scarring was the most common cause of scarring Bullous keratopathy was usually aphakic in origin in 1982, but after 1983 pseudophakc bullous keratopathy (PBK) was the most common cause of bullous keratopathy Acute ulceration was usually bacterial in origin, not infrequently with hypopyon

Subendothelial blebs were seen in cases of superficial keratopathy of varied etiology: superficial punctate keratopathy (42 patients); keratoconjunctivitis sicca (11 patients); epithelial basement membrane dystrophy (9 patients); mild superficial keratopathy due to exposure (9 patients), trichiasis (6 patients), or chemical contact (4 patients); and in contact-lens wearers (29 patients). The blebs were probably due to intercellular edema, separating endothelial cells from Descemet's membrane, and were reversible after resolution of the keratopathy. If the condition is chronic, changes in endothelial morphology may occur, with pleomorphism and polymegathism of the endothelial cells. These cases show that conditions which cause fine disruption of the corneal epithelium affect the integrity of the corneal endothelium. Recognition of resulting long-term changes may be important before intraocular surgery or if the cornea is to be used for grafting.

One hundred and thirty-three eyes with raised intraocular pressure treated by argon laser trabeculoplasty were studied to determine the factors predicting a fall in pressure with treatment. The two main predictive factors were: (i) initial pressure--a higher initial pressure was associated with a greater fall in pressure (p less than 0.001); and (ii) diagnosis (type of glaucoma)--pseudoexfoliative glaucoma (PXFG) and chronic open-angle glaucoma (COAG) had the greatest fall (p less than 0.05). Aphakic glaucoma was associated with the worst results. Of the other factors studied, only the degree of pigmentation of the angle was a significant predictor: the greatest fall in pressure occurred in eyes with moderately pigmented angles (p = 0.05). Complications of treatment were pigment scatter in the angle with depigmentation (41% of eyes), peripheral anterior synechiae (7.5%), immediate postoperative rise in pressure of 10 mmHg or more (7%), moderately severe iritis (3%) and hyphaema (2%). Medication was able to be ceased in only five patients after laser trabeculoplasty; even if a small fall in pressure is achieved, a large fall to the bottom of the normal range is unlikely.