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Lisa Nijm,1,2 Cynthia Matossian,3 Michelle K Rhee,4 John D Stephens,5 Maria E Rosselson,6 Parag A Majmudar,6 Subba Rao Gollamudi,7 Ravi H Patel,8 Aditi Bauskar,9 Alyssa Montieth,9 Srilatha Vantipalli,9 Andrea Gibson,9 Jamie Lynne Metzinger,9 Michael H Goldstein,9 Rabia Gurses Ozden9 1Warrenville EyeCare and LASIK, Warrenville, IL, USA; 2University of Illinois Eye and Ear Infirmary, Chicago, IL, USA; 3CM Associates, LLC, New Hope, PA, USA; 4Icahn School of Medicine at Mount Sinai, New York, NY, USA; 5Tyson Eye, Fort Myers, FL, USA; 6Chicago Cornea Consultants, Ltd, Chicago, IL, USA; 7Eye Specialty Group, Memphis, TN, USA; 8Eye Associates of Central Texas, Round Rock, TX, USA; 9Ocular Therapeutix, Inc, Bedford, MA, USACorrespondence: Aditi Bauskar, Ocular Therapeutix, Inc, 15 Crosby Drive, Bedford, MA, 01730, USA, Tel +1 210-452-8029, Email abauskar@ocutx.comPurpose: To evaluate both the early experience of real-world patients treated with dexamethasone ophthalmic insert (0.4 mg; DEXTENZA®), hereafter referred to as DEX, after cataract surgery as well as staff/practice integration of DEX relative to eyedrops.Patients and Methods: This was a cross-sectional survey study of 23 cataract practices in the United States. Respondents were patients and practice staff who had experience with DEX following cataract surgery. Both patients and practice staff completed an online survey. Descriptive statistics summarized the survey responses to portray the experience of the respondents.Results: Surveys were completed by 62 patients and 19 practice staff. Almost all patients (93%) were satisfied or extremely satisfied with DEX. Patients highly preferred DEX (93%) to topical steroid drops (7%) based on past experiences with topical steroid drops. Most practice staff (95%) were satisfied or highly satisfied with DEX, reporting a 45% reduction in time spent educating patients on postoperative drop use and a 46% decrease in time spent addressing calls from pharmacies regarding postoperative medications.Conclusion: Incorporating the DEX insert into clinical practice in cataract surgery practices can improve patient adherence, while potentially providing significant savings to practices in terms of time spent educating patients and responding to patient and pharmacy call-backs.Keywords: intracanalicular dexamethasone insert, phacoemulsification, hands-free therapy, ocular pain, ocular inflammation, sustained-release drug delivery

Purpose: Punctal occlusion using punctal plugs has been successfully used to treat the signs and symptoms of dry eye disease. However, the effects of punctal occlusion on the symptoms of allergic conjunctivitis (AC) have been less well documented. There is some concern among clinicians that punctal occlusion may make signs/symptoms of allergic conjunctivitis worse by trapping allergens on the eye. The objective of this post hoc analysis was to address this question and thus assess the effect of punctal occlusion alone on ocular itching and conjunctival redness associated with AC., Methods: This was a pooled post hoc analysis of three randomized, double-blind, placebo insert-controlled clinical trials in subjects with AC. Enrolled subjects were generally healthy adults with ocular allergies and a positive skin test reaction to perennial and/or seasonal allergens. The study used a modified version of the traditional conjunctival allergen challenge (CAC) model, which included multiple, repeated allergen challenges following placement of the intracanalicular insert. Subjects were rechallenged on Days 6, 7 and 8; Days 13, 14 and 15; and Days 26, 27 and 28., Results: The data set included 128 subjects that were administered placebo. Baseline mean (SD) ocular itching and conjunctival redness scores were 3.52 (0.44) and 2.97 (0.39), respectively. On post-insertion Days 7, 14 and 28, mean itching scores were 2.62, 2.26 and 1.91, respectively, representing 26%, 36% and 46% itching reductions, respectively ( p  < 0.001). On Days 7, 14 and 28, mean conjunctival redness scores were 1.98, 1.90, and 2.08, respectively, representing 33%, 36%, and 30% redness reductions, respectively ( p  < 0.001)., Conclusions: Based on this post hoc pooled analysis, punctal occlusion with a resorbable hydrogel intracanalicular insert did not worsen ocular itching or conjunctival redness in this patient population.

Purpose: Prospective evaluation of patients with X-linked retinoschisis (XLRS)., Methods: Fifty-six males XLRS patients, age ≥7 years, had retinal structure and function tests performed every 6 months during an 18-month period., Results: Best corrected visual acuity (BCVA) was abnormal (mean ± SD logMAR 0.57 ± 0.32 OD and 0.50 ± 0.27 OS), with weak correlation between visual acuity and age (R = -0.24, P = 0.0095). Mean cyst cavity volume (CCV) determined on optical coherence tomography showed weak correlation with age (R = -0.33, P = 0.0009) and no correlation with visual acuity. Subjects had modest reduction in mean kinetic and static perimetry results, reduced b-wave amplitude on electroretinography, abnormal reading speed results, and decreased visual function quality of life scores. Contrast sensitivity results were normal in 85 of 99 eyes tested. Most subjects had no meaningful change in BCVA during follow-up. Subjects who started carbonic anhydrase inhibitor (CAI) treatment at enrollment had improved BCVA (mean ± SD change 3.15 ± 7.8 ETDRS letters, with increase of ≥15 ETDRS letters at 8 of 110 visits [in 3 subjects]). There were no significant changes in other parameters tested., Conclusions: Structural and functional results were stable during the 18-month follow-up period. Some patients starting CAI treatment at the baseline visit showed improvement in BCVA that was not correlated with changes in CCV. Natural history data such as these will be important for comparisons to the changes in measures of retinal structure and function following gene replacement therapy in patients with XLRS.

Spinal fusion is among the most frequently applied spinal surgical procedures. The goal of the present study was to evaluate whether the local administration of boric acid (BA) improves spinal fusion in an experimental spinal fusion model in rats. Currently, there is no published data that evaluates the possible positive effects if the local administration of BA on posterolateral spinal fusion. Thirty-two rats were randomly divided into four independent groups: no material was added at the fusion area for group 1; an autogenous morselized corticocancellous bone graft was used for group 2; an autogenous morselized corticocancellous bone graft with boric acid (8.7 mg/kg) for group 3; and only boric acid was placed into the fusion area for group 4. The L4-L6 spinal segments were collected at week 6, and the assessments included radiography, manual palpation, and histomorphometry. A statistically significant difference was determined between the groups with regard to the mean histopathological scores (p = 0.002), and a paired comparison was made with the Mann-Whitney U test to detect the group/groups from which the difference originated. It was determined that only the graft + BA practice increased the histopathological score significantly with regard to the control group (p = 0.002). Whereas, there was no statistically significant difference between the groups in terms of the manual assessment of fusion and radiographic analysis (respectively p = 0.328 and p = 0.196). This preliminary study suggests that BA may clearly be useful as a therapeutic agent in spinal fusion. However, further research is required to show the most effective dosage of BA on spinal fusion, and should indicate whether BA effects spinal fusion in the human body.

Snakebites are relatively rare medical emergency cases that might lead to serious consequences. This study aims to evaluate snakebite cases in terms of medical follow-up, antivenom therapy and antivenom reactions. Medical records of patients admitted to emergency department between January 1, 2006 and December 31, 2010 were retrospectively investigated. Snakebite-related cases of a total of 125 patients were included in the scope of the study. Of the total 125 cases, 54.4% were male and 45.6% were female. Most of cases (n: 65, 52%) were aged over 30 years, while the mean age was 34.87 ± 19.29 years. Snakebite-related applications to the emergency department were mostly seen in June with 27 cases. Upon admitting, all patients were recorded to be conscious and showing good general conditions; however, they suffered from pain and edema at the site of bite. Of all, 25 patients only suffered from bite injury and ecchymosis due to snakebite. The site of bite was upper extremities in 66 patients (52.8%), whereas it was lower extremities in 58 (46.4%). Of all, antivenom was unnecessary in 25 (20%) patients, while four antivenoms were administered to each of the 23 (18.4%) patients. Furthermore, six (4.8%) patients needed nine antivenom administrations for each. Anaphylaxis (n: 2, 1.6%), compartment syndrome (n: 2, 1.6%) and serum sickness (n: 1, 0.8%) encountered in remaining cases. Of all, 86 (68.8%) patients were hospitalized in the emergency department, while 25 (20.0%) patients were followed up by observation in emergency service. Only one patient was treated and followed up in intensive care unit. Implementation of antivenom therapy is considered unnecessary for the treatment of all snakebite cases. Antivenom reactions and number of related cases might be reduced by continuous close monitoring, appropriate prophylaxis and controlled slow infusion administration of medications., (© The Author(s) 2012.)

Background: Spinal cord injury (SCI) is one of the most devastating conditions leading to neurological impairment and disabilities. The aim of the study was to investigate the potential neuroprotective effect of thymoquinone (TQ) histopathologically in an experimental model of traumatic spinal cord injury (SCI)., Methods: Twenty-four male Wistar albino rats were randomly divided into 4 groups: control group; SCI group; SCI-induced and 10 mg/kg/day TQ administered group; SCI-induced and 30 mg/kg/day TQ administered group. TQ was given as intraperitoneal for three days prior to injury and four days following injury. Spinal cord segment between T8 and T10 were taken for histopathologic examination. Hemorrhage, spongiosis and liquefactive necrosis were analyzed semiquantatively for histopathological changes., Results: Administration of TQ at a dose of 10 mg/kg did not cause any significant change on the histological features of neuronal degeneration as compared to the SCI group (p=0.269); however, 30 mg/kg TQ significantly decreased the histological features of spinal cord damage below that of the SCI group (p=0.011)., Conclusion: Data from this study suggest that TQ supplementation attenuates trauma induced spinal cord damage. Thus, TQ needs to be taken into consideration, for it may have a neuroprotective effect in trauma induced spinal cord damage.

Introduction: The side-to-side (SS) tenorrhaphy technique has been used in tendon transfer surgery. The mechanical properties of SS tendon suture have been studied previously. However, the histo-pathological healing of the SS tenorrhaphy of the tendons is unknown. The aim of this study was to assess the gross and histological effects of SS tenorrhaphy in a rabbit model., Materials and Methods: Twenty New Zealand rabbits were used. The extensor hallucis longus and tibialis anterior tendon were sewed SS at the level distal to the ankle joint. The patellar tendon (PT) at the same side was used as control group. A unilateral midline incision was made and repaired with a single suture. The animals were killed at the 12th week postoperatively. The histological sections were obtained from the side of surgery from each group. Each sample was stained with hematoxylene and eosin (H&E). Gross and microscopic healing was compared between the two groups., Results: Gross examination of the control group showed complete healing with a thin peri-tendinous sheath formation around the suture site, whereas in the study group, a thick peri-tendinous sheath was formed around the area of the tendon-tendon anastomosis. In the control group, at the 12th week after surgery, the healing was almost completed in all samples. In the study group, a thick fibro vascular sheath has formed around the side of anastomosis. In all specimens few inter-digitations were observed between the tendons;however, the trough was still present., Conclusion: The result of the current study showed that histological healing and union of SS tenorrhaphy differ from that in primary tendon injury and healing. Further studies are required to clarify the healing stages at the tenorrhaphy site.

Synovial fibrosis is one of the main outcomes of osteoarthritis. Some authors have reported that urotensin-II (U-II) may cause pathologic fibrosis in cardiovascular system, lung and liver. However there are no previous reports available in the literature about its relationship with the synovial fibrosis in osteoarthritis. The aim of this study was to compare the U-II levels in knee synovial fluids obtained from osteoarthritic and non-osteoarthritic patients. Two groups were created, the osteoarthritis group and non-osteoarthritic control group. The control group was consisted of patients who underwent arthroscopic surgery for other reasons than cartilage disorders. In the osteoarthritis group all patients had grade 4 primer degenerative osteoarthritis and were treated with total knee arthroplasty. Minimum 1 mL knee synovial fluids were obtained during operation. Levels of U-II were measured by using ELISA kit U-II levels were significantly higher in the osteoarthritic group than that in the control group. No correlation was found between U-II levels and age. In conclusion, the significantly high U-II levels in the knee synovial fluid of osteoarthritic patients supported our hypothesis that "U-II may be associated with the synovial fibrosis in osteoarthritis"., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to evaluate the treatment results of the application of nitric oxide (NO) in the form of topical glyceryl trinitrate (GTN) for the treatment of lateral epicondylitis (LE)., Methods: The study included 40 patients with LE randomized into 2 equal groups. Selection criteria included the presence of pain, tenderness, and positive pain stimulating maneuvers. Glyceryl trinitrate patches were applied to the area of maximal tenderness once a day in the treatment group and placebo patches in the control group. Outcomes in terms of pain relief was assessed using the visual analog scale (VAS) and were evaluated according to the criteria of Verhaar et al. Excellent or good results were considered successful. Differences in VAS scores between the two groups were calculated using the Mann-Whitney U-test and the chi-square test was used to investigate distributions of categorical variables (sex, affected side) and good and excellent results among groups., Results: There were no significant differences in any of the baseline clinical parameters between groups. At the 3rd week follow-up, there were statistically significant differences in the pain measured using VAS between groups (mean VAS score of the control and treatment groups were 6.45 and 3.15, respectively) (p=0.001). Patients in the GTN group and control group had lower VAS pain scores and reduced elbow pain at 3 weeks (3.15 vs 8.05 in the GTN and 6.45 vs 8.80 in the control group). In the control group, no patient had excellent or good results while 18 (90%) patients in treatment group reported successful treatment. There was statistically significant difference in the VAS measured at 6 months between groups (mean VAS score of the control and treatment groups were 4.85 and 0.70, respectively) (p=0.001)., Conclusion: The administration of NO directly over an area of tendinopathy through a GTN patch reduces pain and other symptoms in chronic LE.

Purpose: The aim of this study was to test a simple technique to augment the pullout resistance of an anchor in an over-drilled sheep humerus model., Methods: Sixty-four paired sheep humeri were harvested from 32 male sheep aged 18 months. Specimens were divided into an augmented group and non-augmented group. FASTIN RC 5-mm titanium screw anchors (DePuy Mitek, Raynham, MA) double loaded with suture material (braided polyester, nonabsorbable USP No. 2) were used in both groups. Osteoporosis was simulated by over-drilling with a 4.5-mm drill. Augmentation was performed by fixing 1 of the sutures 1.5 cm inferior to the anchor insertion site with a washer screw. This was followed by a pull-to-failure test at 50 mm/min. The ultimate load (the highest value of strength before anchor pullout) was recorded. A paired t test was used to compare the biomechanical properties of the augmented and non-augmented groups., Results: In all specimens the failure mode was pullout of the anchor. The ultimate failure loads were statistically significantly higher in the augmented group (P < .0001). The mean pullout strength was 121.1 ± 10.17 N in the non-augmented group and 176.1 ± 10.34 N in the augmented group., Conclusions: The described augmentation technique, which is achieved by inferior-lateral fixation of 1 of the sutures of the double-loaded anchor to a fully threaded 6.5-mm cancellous screw with a washer, significantly increases the ultimate failure loads in the over-drilled sheep humerus model., Clinical Relevance: Our technique is simple, safe, and inexpensive. It can be easily used in all osteoporotic patients and will contribute to the reduction of anchor failure. This technique might be difficult to apply arthroscopically. Cannulated smaller screws would probably be more practical for arthroscopic use. Further clinical studies are needed., (Copyright © 2014 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to ascertain the effect of gender and cultural habits on hip, knee and ankle range of motion (ROM) and to determine the differences between the ROM of right and left side symmetric joints of the lower extremities., Methods: The study included 987 (513 males and 474 females) healthy volunteers. Individuals with a history of illness, prior surgery or trauma involving any joint of either lower extremity were excluded from the study. The terminology and techniques of measurements used were those suggested by the American Academy of Orthopedic Surgeons., Results: Left side passive hip flexion and active internal rotation was higher than the right side. Passive flexion of the hip joint was higher in male subjects and internal and external rotation was higher in female subjects. In the knee joint, passive extension was higher in males. Plantarflexion and inversion of the ankle joint were higher in male subjects and dorsiflexion and eversion were higher in female subjects. The differences were considered insignificant in clinical terms as all were less than 3 degrees., Conclusion: There is no clinically significantly difference between right and left side hip, knee and ankle joints ROM. Gender and cultural habits do not appear to have clinically significantly effects on lower extremity joint ROM.

Introduction: In locking intramedullary nails, the most important problem is to put the distal interlocking screw accurately and quickly with minimum radiation exposure. The purpose of this clinical study was to compare the fluoroscopic time and surgical time required for distal locking with either free-hand fluoroscopic guidance or with an electromagnetic navigation system., Materials and Methods: The study comprised 54 patients with 58 fractures of the lower extremity. The patients were divided in two groups: distal locking with freehand fluoroscopic guidance (group I) and distal locking with electromagnetic navigation (group II). The primary outcome in this study was fluoroscopy time. The secondary outcome was the operative time in distal interlocking., Results: In group I, the mean operation time was 108 (81-135) min, the mean time for distal interlocking was 18.35 (9-27) min, the total fluoroscopy time was 47.77 (19-74) s, the mean fluoroscopy time during distal interlocking was 18.29 (2-29) s and the mean attempt at number of distal locking for two screws was 9.96 (2-18) times. In group II, the mean operation time was 80.96 (63-100) min, the mean time for distal interlocking was 7.85 (6.5-10) min, the total fluoroscopy time was 22.59 (15-32) s, the mean fluoroscopy time during distal interlocking was 1.62 (0-2) s and the mean attempt number of distal interlocking was 2 (2-2)., Conclusion: Fluoroscopy time to achieve equivalent precision is significantly reduced with electromagnetism-based surgical navigation compared with free hand fluoroscopic guidance. Also the operative time is significantly reduced with electromagnetic based navigation., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Purpose: To assess the reproducibility of retinal nerve fiber layer thickness and macular thickness measurements using OCT-3., Methods: Randomly chosen eyes of healthy individuals were scanned following pupillary dilation by two trained operators (RGO, RV) using OCT-3 (software version A1.1, Carl Zeiss Meditec, Inc., Dublin, CA), three times on separate days within a one-month period. Fast and regular macula (128 A-scans), and fast and regular RNFL (256 A-scans) scanning protocols were performed. Intra- and interoperator measurement reproducibility was evaluated., Results: Ten eyes of 10 subjects (6 females, 4 males) were enrolled. Mean age was 32 +/- 11.2 years (range, 21 to 52 years). Intraoperator reproducibility was high for both macular and RNFL thickness measurements. Mean coefficients of variation (CV) for mean total RNFL thickness measurements ranged from 6.9 +/- 6.4% to 8.0 +/- 3.5% for operators 1 and 2 in fast and regular RNFL protocols. Mean CV for mean macular thickness measurements ranged from 4.7 +/- 2.6% to 6.4 +/- 5.5% for operator 1 and 2 in fast and regular macula protocols. There was no difference in mean total RNFL and mean foveal thickness measurements performed on different days (P > 0.05 for all measurements in all protocols, for operators 1 and 2, ANOVA). Interoperator reproducibility was high for both macular and RNFL thickness measurements (P > 0.05 for all measurements in all protocols, paired t test)., Conclusion: OCT-3 RNFL and macular thickness measurements are reproducible in normal eyes. These results should be validated in ocular hypertensive and glaucomatous eyes.

Purpose: To determine the optimal OCT-3 scanning protocol., Methods: Normal subjects, ocular hypertensive, and open-angle glaucoma patients were enrolled. The "fast" RNFL scan protocol consists of 3 consecutive circular scans, each containing 256 A-scans obtained in a single 1.92 second session. The "regular" RNFL scan protocol contains 3 separate circular scans, each of which consists of 512 A-scans and is obtained in 1.28 seconds (total 3.84 seconds). A customized 256-point scan was created from the 512-point "regular" RNFL scan by extracting the RNFL measurements from every second point. Mean RNFL thickness measurements and mean coefficients of variation (CV) were calculated for each of the scan types., Results: Thirty-one eyes with visual field defects (31 glaucoma eyes) and 30 eyes with normal fields (10 normal and 20 ocular hypertensive eyes) were enrolled. There was no difference in RNFL thickness or CV between fast, regular, or customized RNFL scans in the eyes with VF defects (P > 0.05 for all comparisons). Although eyes with normal fields showed no difference in CV between fast, regular, and customized RNFL scans (P > 0.05 for all comparisons), there was a thicker RNFL measurement using the fast RNFL scan (P = 0.01)., Conclusions: Optimal sampling density for OCT-3 assessment of parapapillary RNFL thickness is not more than 256 axial determinations. Although both scanning protocols have good reproducibility, the scanning protocol should remain constant during serial OCT-3 evaluation.

Purpose: To evaluate the effect of pupillary dilation on retinal nerve fiber layer thickness (RNFL) measurements using optical coherence tomography (OCT-3)., Methods: Randomly chosen eyes of healthy individuals were scanned before and after pupillary dilation by two trained operators (R.G.O., R.V.) using OCT-3 (Carl Zeiss Meditec, Inc., Dublin, CA). Fast and regular RNFL (256 A-scans) OCT-3 protocols (software version A1.1) were used in each scanning session. RNFL thickness measurements before and after dilation were compared., Results: Ten eyes of 10 subjects (6 females, 4 males) were enrolled. Mean age was 32.0 +/- 11.2 years (range, 21 to 52 years). Mean pupillary diameter before and after dilation was 2.9 +/- 0.6 mm and 7.6 +/- 0.8 mm, respectively (P < 0.0001, paired t-test). There was no significant difference in RNFL thickness measurements before and after dilation using both fast and regular RNFL protocols (P > or = 0.05 for all comparisons, paired t-test). Mean coefficients of variation for mean RNFL thickness measurements were 15.3% before and 13.7% after dilation for operator 1; and 10.8% before and 12.7% after dilation for operator 2 for the fast RNFL protocol and 11.3% versus 10.4% and 12.9 versus 11.1%, respectively, for the regular RNFL protocol., Conclusion: Pupillary dilation is not necessary in all subjects to obtain reproducible RNFL thickness measurements using OCT-3.

Background and Objective: To investigate the effects of acute intraocular pressure (IOP) elevation on optic disc morphology., Patients and Methods: Ophthalmodynamometry was used to increase the IOP of normal, healthy eyes. Confocal scanning laser ophthalmoscopy of the optic nerve head using the Heidelberg Retinal Tomograph II (Heidelberg GmbH, Heidelberg, Germany) and IOP measurements were obtained before, during, and after IOP elevation., Results: Sixteen eyes of 16 normal volunteers (mean age, 32.8 +/- 11.9 years) were enrolled. Rim area, rim volume, cup area, cup volume, cup-to-disc ratio, mean cup depth, maximum cup depth, mean retinal nerve fiber layer (RNFL) thickness, and RNFL cross-sectional area showed significant changes during IOP elevation (all P < .05, paired t test). All measured parameters returned to their original values after pressure resolution (all P > .2) except mean RNFL thickness (P = .03)., Conclusion: Transient elevation of IOP results in measurable alterations in optic nerve head topography.

Purpose: To describe a new, highly accurate, tactile technique to increase accuracy in the self-administration of eye drops., Design: Interventional case series., Methods: Ten adult patients with loss of fixation (< or = 20/400) in one eye and ten adult patients with loss of fixation in both eyes instilled one drop of artificial tears in each eye using the technique normally employed at home. The time required to instill each drop, the number of drops squeezed from the bottle, and location of the drops' landing points on the face or eye were recorded. The patients were then instructed in a new technique for instillation, guided through the procedure once, and allowed to practice until comfortable with it. All measurements were then repeated., Results: In patients with loss of fixation in one eye, an additional 3.2 +/- 4.1 seconds were required to instill a drop using the new technique (P <.0001, paired t test; range, -7-18 seconds). The mean number of drops dispensed decreased by 0.1 +/- 0.6 drops (P =.60, paired t test; range, -2-1 drop). The accuracy of drop placement increased from 80.0% to 82.5% (P =.32, paired t test). In subjects with loss of fixation in both eyes, using the new technique increased the time needed to instill a drop by 3.8 +/- 3.8 seconds (P <.0001, paired t test; range, -3-13 seconds). The average number of drops dispensed decreased by 0.1 +/- 0.6 drops (P =.25, paired t test; range, -2-1 drop). The accuracy of placement increased from 63.0% to 85.0% (P =.001, paired t test)., Conclusions: This technique of drop instillation may be beneficial for patients with significant visual impairment in both eyes.

Purpose: To evaluate the effect of attempted eyelid closure on intraocular pressure (IOP) measurements in normal-tension (NTG) and high-tension (HTG) open-angle glaucoma patients., Design: Prospective clinical trial., Methods: Forty randomly selected eyes of 40 patients underwent corneal pachymetry and IOP measurements using both Goldmann applanation tonometry and Tono-pen XL (Mentor, Inc., Norwell, Massachusetts, USA). Intraocular pressure was measured by the same examiner holding the eyelids open, both with and without the subject simultaneously attempting forced eyelid closure. Subjects were seated during all measurements and waited 5 minutes between measurements with each instrument; the order of measurement was randomized., Results: Twenty NTG and 20 HTG eyes were enrolled. The mean age was 63.0 +/- 13.0 years (range, 31-80 years). The average corneal thickness was 540 +/- 32 microm (range, 480-608 microm) in NTG patients and 552 +/- 40 microm (range, 449-610 microm) in HTG patients (P =.07, analysis of variance [ANOVA]). Using Goldmann applanation tonometry, IOP measurement in eyes with NTG increased by 3.9 +/- 2.0 mm Hg with attempted eyelid closure (P <.0001, paired t test; range, 2-11 mm Hg). With the Tono-pen XL, IOP measurements increased 4.2 +/- 2.7 mm Hg (P <.0001, paired t test; range, 1-14 mm Hg). With attempted forced eyelid closure, the Goldmann applanation measurement in eyes with HTG increased 4.1 +/- 2.1 mm Hg (P <.0001, paired t test; range, 1-9 mm Hg). Using the Tono-pen XL, measurements increased 4.5 +/- 2.0 mm Hg (P <.0001, paired t test; range, 2-11 mm Hg)., Conclusion: Attempted eyelid closure during tonometry is a significant and common source of error in eyes with glaucoma and may influence the clinical management and decision-making in the treatment of NTG and HTG.

Objective: To assess the internal reflectivity of the retinal nerve fiber layer in normal, ocular hypertensive, and glaucomatous eyes using optical coherence tomography., Methods: All patients underwent complete ophthalmic examination and achromatic automated perimetry. Intraocular pressure was 21 mm Hg or less for low-tension glaucoma and normal eyes and at least 25 mm Hg on 2 separate occasions in ocular hypertensive and high-tension glaucoma eyes. All glaucomatous eyes had characteristic glaucomatous optic neuropathy and associated achromatic automated perimetry defect. Relative retinal nerve fiber layer internal reflectivity was measured on optical coherence tomography images using a software program of our own design., Results: We enrolled 98 eyes (19 normal, 34 ocular hypertensive, 17 high-tension glaucoma, and 28 low-tension glaucoma). Relative internal reflectivity was less in eyes with glaucoma than in normal (P<.001, t test) and ocular hypertensive eyes (P<.001, t test). There was no difference in relative internal reflectivity between normal and ocular hypertensive eyes (P =.32) and between eyes with high-tension glaucoma and low-tension glaucoma (P =.43). Internal reflectivity correlated with mean deviation on achromated automatic perimetry (r(2) = 0.49, P<.001, quadratic regression analysis)., Conclusion: Relative retinal nerve fiber layer internal reflectivity may provide useful information about the extent of retinal nerve fiber layer injury in glaucoma. Arch Ophthalmol. 2000;118:1044-1047

Background and Objective: The commercially available optical coherence tomography (OCT) scanner displays images in a pre-set window regardless of the projected scan length on the retinal surface. The aim of this study was to demonstrate the true dimensions of proportion-corrected OCT images and the additional information present in grayscale images., Materials and Methods: OCT raw data were exported to an IBM-compatible PC and processed to show grayscale and proportion-corrected images using an automated software of our own design., Results: Eyes with cystoid macular edema and retinal pigment detachment were analyzed. Grayscale images showed a finer gradation of signal reflectance. Scan lengths of 2, 4, 6, and 8 mm on the retinal surface showed different qualitative appearances using proportion-corrected software from the printed or on-screen images., Conclusions: Grayscale OCT images can be used to demonstrate additional information not present in false-color images. The disparity between the standard OCT image format and proportion-corrected images emphasizes the need for quantitative rather than qualitative evaluation of retinal dimensions and internal reflectance.

Purpose: Published series of peripapillary retinal nerve fiber layer (RNFL) measurements using optical coherence tomography (OCT) have sampled 100 evenly distributed points on a 360 degrees peripapillary circular scan. The goal of this study was to determine whether a four-fold increase in sampling density improves the reproducibility of OCT measurements., Methods: Complete ophthalmic examinations, achromatic automated perimetry, and OCT imaging were performed in all patients. The OCT scanning consisted of three superior and inferior quadrantic scans (100 sampling points/quadrant) and three circular scans (25 points/quadrant). The RNFL thickness measurements and coefficient of variation (CV) were calculated for the superior and inferior quadrants for each sampling density technique., Results: The study included 22 eyes of 22 patients (3 control subjects; 2 patients with ocular hypertension; and 17 patients with glaucoma). Quadrants with associated glaucomatous visual field loss on automated achromatic perimetry had thinner RNFLs than quadrants without functional defects for both the 25- and 100-points/quadrant scans. For quadrants associated with normal visual hemifields (n = 22), there was no difference between the 25- and 100-points/quadrant scans in mean RNFL thickness and CV. Among quadrants with visual field defects (n = 22), RNFL thickness measurements were thinner in the 25-points/quadrant scans than in the 100-points/quadrant scans. The CV for the 25-points/quadrant scans (25.9%) was significantly higher than that for the 100-points/quadrant scans (11.9%)., Conclusion: Increasing the sampling density of OCT scans provides less variable representation of RNFL thickness. The optimal sampling density to achieve maximal reliability of OCT scans remains to be determined.

Purpose: To report the case of a 53-year-old woman with a 2-year history of episodic upper eyelid swelling and nonspecific complaints, who was diagnosed as having allergic conjunctivitis., Methods: A complete ocular examination, orbital computerized tomographic (CT) scans followed by complete physical and systemic examinations., Results: The results of physical and systemic examinations were unremarkable for systemic lymphoma and a primary focus of cancer. The results of the ocular examination were normal. CT scans demonstrated well-defined lesions bilaterally with a homogeneous internal structure in the lacrimal gland fossa, which suggested a diagnosis of chronic dacryoadenitis. The differential diagnosis included lymphoma and orbital metastases. The patient refused a biopsy and was started on a tapering dose of 60 mg oral prednisolone daily. The follow-up CT scans 1 month after cessation of 6-week oral corticosteroid treatment showed near complete resolution of the orbital lesions., Conclusion: This case demonstrates that orbital inflammation can be misdiagnosed as refractory allergic conjunctivitis.

Purpose: This study investigated the effect of ophthalmic betaxolol, a beta, selective adrenoceptor antagonist, on ocular blood flow and visual function in patients with normotension glaucoma (NTG)., Methods: Thirty-six eyes of eighteen patients with NTG, but otherwise free of systemic disease, were included. Blood fibrinogen, sedimentation rates, Goldmann intraocular pressure, Humphrey automated perimetry, and color Doppler imaging were done at baseline and after one year of twice-daily bilateral topical ocular dosing with 0.5% betaxolol HCI., Results: After treatment, the resistivity index of the ophthalmic artery was significantly reduced, and visual fields were significantly improved. The resistivity indexes of the central retinal artery and posterior ciliary artery were also reduced but did not achieve statistical significance. Intraocular pressure was significantly reduced. There was no change in blood fibrinogen and sedimentation rates., Conclusions: These findings indicate that long-term treatment with ophthalmic betaxolol improves ocular hemodynamics by lowering the resistivity index of the ophthalmic artery and results in an improvement in the visual fields of patients with NTG. In view of this positive effect on blood flow and visual function, betaxolol is recommended in the management of patients with NTG.

A 60-year-old woman developed anterior segment ischemia 1 week after an uneventful pterygium excision in the left eye. Corrected visual acuity fell from 20/20 to 20/200. Ophthalmic examination found keratic precipitates on the corneal endothelium, ++ cells in the aqueous humor, and necrosis of the lower half of the iris with posterior synechiae resulting in a fixed and distorted pupil. On therapy of topical corticosteroid eyedrops hourly and atropine eyedrops three times a day, the iridocyclitis resolved in 2 weeks. At the final examination 3 months after the surgery, the corrected visual acuity was 20/20. The atrophy of the lower half of the iris and posterior synechiae in the lower half of the pupil, giving the fixed and distorted pupil, were noted as sequelae. Iris fluorescein angiography revealed filling defects in the lower half of the iris but no leakage from iris vessels. Systemic evaluation was unremarkable except for mild hypertension. Doppler studies of carotid, ophthalmic, and central retinal arteries were normal. Mitomycin C, beta-irradiation and rectus muscle fixation sutures were not used. Only conjunctival dissection or episcleral cauterization were seen as possible causes of interference with the anterior segment blood supply. We believe this is the first report of anterior segment ischemia following pterygium surgery.