Faculty Bibliography

Purpose: To learn the long-term outcome of ciliary ablation with diode laser contact transscleral cyclophotocoagulation (TSCPC) in eyes with recalcitrant, severe glaucoma. Methods: Twenty-seven eyes of 27 patients with medically and surgically uncontrollable glaucoma and no previous ciliary ablation enrolled in this study. After baseline measurements and informed consent, the authors performed contact TSCPC. There were 14 pseudophakic, 7 aphakic, and 6 phakic eyes; 15 of these had primary open-angle glaucoma and the remainder had various secondary or open- or closed-angle glaucomas. Median follow-up was 19 months (range, 6 weeks to 27 months). initially after laser surgery, glaucoma medications were continued, except for a 2-week interruption of miotics; the ophthalmologist later adjusted medications in accordance with the patient's status. The authors define failure of TSCPC in two ways, based on IOP measurements during two consecutive study examinations 6 weeks or more after intervention or at the final examination: (1) less than 20% intraocular pressure (IOP) reduction from baseline, and (2) either less than 20% reduction of IOP from baseline or IOP greater than 22 mmHg. Results: For 27 eyes, the baseline IOP (mean +/- standard deviation) was 36.4 +/- 12.4 mmHg (range, 20-70 mmHg). The mean IOP at last examination was 20.3 +/- 8.7 mmHg. With failure definition 1, the cumulative probability of success was 84% at 1 year and 62% at 2 years. With failure definition 2 the cumulative probability of success was 72% at 1 year and 52% at 2 years. At the last examination, 19 eyes (70%) had visual acuity improved within one line of visual acuity at eligibility. One of these eyes, with light perception vision at entry, declined to no light perception. Three eyes (11%) lost two lines of vision and five (19%) lost three or more lines. Conclusions: Contact diode laser TSCPC yields long-term improvement of IOP and preservation of visual acuity in a substantial proportion of eyes with severe, medically uncontrolled glaucoma.

BACKGROUND: Primary juvenile glaucoma is a rare form of glaucoma that typically affects individuals between 3 and 20 years of ages and is inherited as an autosomal dominant trait. One gene responsible for this condition has been localized to the 1q21-q31 region of chromosome 1. To investigate the clinical features of this form of glaucoma, the authors have examined the affected members of five pedigrees demonstrating genetic linkage to the 1q21-q31 locus. METHODS: Clinical characterization of 23 affected patients was performed. Genetic linkage to the 1q21-q31 locus was confirmed by segregation of the disease trait in each pedigree with genetic markers located in the 1q21-q31 region. RESULTS: The clinical features of affected members of the five pedigrees presented are generally homogeneous. The average age of diagnosis was 18.5 years (range, 5-30 years), and the average initial intraocular pressure was 38.5 mmHg (range, 30-53 mmHg). Eighty-seven percent of affected individuals were myopic and 83% of affected individuals required surgical treatment for glaucoma. There were no uniformly associated systemic or ocular conditions. One possible nonpenetrant carrier was identified and a difference in phenotypic expression of the presumed disease gene was observed in a pair of affected monozygotic twins. We also identified two pedigrees with juvenile glaucoma and three pedigrees affected by the pigment dispersion syndrome that are not genetically linked to the 1q21-q31 region. CONCLUSION: The form of juvenile glaucoma caused by a gene located in the q21-q31 region of chromosome 1 is generally phenotypically homogeneous. The severe elevation of intraocular pressure typically seen in affected patients suggests the product of the predisposing gene may participate in the outflow function of the eye.

1. Three major items are needed for a visual field test to take place: a perimetrist, a patient, and a request for a certain type of test. All of these are subject to knowledge of certain information and the ability to perform certain tasks. 2. The purpose of visual field testing is to provide information that will assist in diagnosing ocular diseases, evaluating neurologic diseases, and monitoring progression in ocular diseases. 3. The assessment of the patient's visual field is vital to his or her complete ocular examination. This diagnostic tool is very important and needs to be administered with professional technique and responsibility.

The purpose of this study was to investigate the mechanisms of the leukemic glaucoma. We established a cell culture from leukemic cells collected from the aqueous humor of a living patient with chronic lymphocytic leukemia (CLL) and glaucoma secondary to the leukemia. We then perfused 16 pairs of fresh cadaver normal human eyes at a constant pressure of 10 mmHg at 37 degrees C. We delivered as a bolus either cultured CLL cells or cultured normal lymphocytes, using 3 x 10(2), 3 x 10(3), 3 x 10(4) or 3 x 10(5) cells in Bárány's solution, into one eye of each pair. The other eye of the pair served as a control, receiving a sham bolus of Bárány's solution alone. In addition, CLL and normal lymphocytes were perfused through 0.2, 0.6, 2, and 3 microns millipore filters. Following perfusion, the tissue and the filters were examined histopathologically by light, transmission and scanning electron microscopy. Cultured leukemic lymphocytes perfused into normal cadaver eyes caused a significantly more profound reduction in outflow facility than normal lymphocytes (P < 0.05); however, there was no significant difference in the effect on outflow facility between leukemic and normal lymphocytes when they were perfused through the millipore filters. Histopathology confirmed the presence of lymphocytes in the trabecular meshwork and Schlemm's canal, deforming on passage through the inner wall. Our results suggest that leukemic lymphocytes in CLL may reduce outflow facility by means of a biological interaction with the tissues of the outflow pathways, rather than by mechanical obstruction due to a lack of distensibility. Questions remain as to the nature of this biological interaction.

OBJECTIVE: To evaluate optical coherence tomography, a new technique for high-resolution cross-sectional imaging of the retina, for quantitative assessment of retinal thickness in patients with macular edema. DESIGN: Survey examination with optical coherence tomography of patients with macular edema. SETTING: Referral eye center. PATIENTS: Forty-nine patients with the clinical diagnosis of diabetes or diabetic retinopathy and 25 patients with macular edema secondary to retinal vein occlusion, uveitis, epiretinal membrane formation, or cataract extraction. MAIN OUTCOME MEASURES: Correlation of optical coherence tomograms with slit-lamp biomicroscopy, fluorescein angiography, and visual acuity. RESULTS: Optical coherence tomograms of cystoid macular edema closely corresponded to known histopathologic characteristics. Quantitative measurement of retinal thickness is possible because of the well-defined boundaries in optical reflectivity at the inner and outer margins of the neurosensory retina. Serial optical coherence tomographic examinations allowed tracking of both the longitudinal progression of macular thickening and the resolution of macular edema after laser photocoagulation. In patients with diabetic retinopathy, measurements of central macular thickness with optical coherence tomography correlated with visual acuity, and optical coherence tomography was more sensitive than slit-lamp biomicroscopy to small changes in retinal thickness. CONCLUSIONS: Optical coherence tomography appears useful for objectively monitoring retinal thickness with high resolution in patients with macular edema. It may eventually prove to be a sensitive diagnostic test for the early detection of macular thickening in patients with diabetic retinopathy.

PURPOSE: To assess the potential of a new imaging technique, optical coherence tomography, for the diagnosis and monitoring of central serous chorioretinopathy. Optical coherence tomography is a novel noninvasive, noncontact imaging modality that produces high longitudinal resolution, cross-sectional tomographs of ocular tissue. METHODS: Optical coherence tomography is analogous to ultrasound, except that it uses light rather than sound to obtain higher image resolution in the retina. Cross-sectional tomographs of optical reflectivity within the retina are produced with longitudinal resolution of 10 microns. Optical coherence tomography was used to examine 16 patients at a referral eye center whose initial examination disclosed the clinical diagnosis of central serous chorioretinopathy. The optical coherence tomography results were correlated with slit-lamp biomicroscopy, fundus photography, and fluorescein angiography. RESULTS: The cross-sectional view produced by optical coherence tomography was effective in objectively quantifying the amount of serous retinal detachment in the disease. Optical coherence tomography disclosed detachments that were undetected by slit-lamp biomicroscopy. Longitudinal measurements with optical coherence tomography were successfully able to track the resolution of subretinal fluid accumulation. CONCLUSION: Optical coherence tomography is potentially useful as a new, noninvasive diagnostic technique for quantitative examination of patients with central serous chorioretinopathy and objectively monitoring the clinical course of the serous retinal detachment in this disease.

PURPOSE: To assess the potential of a new diagnostic technique called optical coherence tomography (OCT) for diagnosing and monitoring macular holes. This technique is a novel noninvasive, noncontact imaging modality that produces high longitudinal resolution (10-micron) cross-sectional tomographs of ocular tissue. METHODS: Optical coherence tomography is analogous to ultrasound except that optical rather than acoustic reflectivity is measured. Cross-sectional tomographs of the retina profiling optical reflectivity in a thin, optical slice of tissue are obtained with a longitudinal resolution of 10 microns. Optical coherence tomography was used to examine 49 patients with the clinical diagnosis of idiopathic full-thickness macular hole, impending macular hole, epimacular membrane with macular pseudohole, or partial-thickness hole. The resulting OCTs were correlated with contact lens and slit-lamp biomicroscopy, fundus photography, and fluorescein angiography. RESULTS: The cross-sectional view produced by OCT was effective in distinguishing full-thickness macular holes from partial-thickness holes, macular pseudoholes, and cysts. Optical coherence tomography was successful in staging macular holes and provided a quantitative measure of hole diameter and the amount of surrounding macular edema. Optical coherence tomography also was used to evaluate the vitreoretinal interface in patients' fellow eyes and was able to detect small separations of the posterior hyaloid from the retina. CONCLUSION: Optical coherence tomography appears potentially useful as a new, noninvasive, diagnostic technique for visualizing and quantitatively characterizing macular holes and assessing fellow eyes of patients with a macular hole. The tomographic information provided by OCT eventually may lead to a better understanding of the pathogenesis of macular hole formation.

Optical coherence tomography (OCT) is a novel technique that allows cross-sectional imaging of the anterior and posterior eye. OCT has a resolution of approximately 10 microns, with extremely high sensitivity (approximately 10(-10) of incident light). OCT is analogous to computed tomography, which uses x-rays, magnetic resonance imaging, which uses spin resonance, or B-scan ultrasound, which uses sound waves, but OCT uses only light to derive its image. OCT is a noncontact, noninvasive system by which retinal substructure may be analyzed in vivo. OCT is useful in the evaluation of retinal pathologies and glaucoma. In retinal disease, entities such as macular holes, macular edema, central serous chorioretinopathy, retinal vascular occlusion and other factors have been examined. Separation between the posterior vitreous and retina, or lack thereof, are seen and quantitated. In glaucoma, retinal nerve fiber layer (NFL) thickness is measured at standardized locations around the optic nerve head. A circular scan produces a cylindrical cross-section of the retina, from which the NFL can be analyzed. In addition, radial scans through the optic nerve head are used to evaluate cupping and juxtapapillary NFL thickness. OCT, a new imaging technology by which the anterior and posterior segment are seen in cross-section, may permit the early diagnosis of glaucoma, and the early detection of glaucomatous progression.

OBJECTIVE: To demonstrate optical coherence tomography for high-resolution, noninvasive imaging of the human retina. Optical coherence tomography is a new imaging technique analogous to ultrasound B scan that can provide cross-sectional images of the retina with micrometer-scale resolution. DESIGN: Survey optical coherence tomographic examination of the retina, including the macula and optic nerve head in normal human subjects. SETTING: Research laboratory. PARTICIPANTS: Convenience sample of normal human subjects. MAIN OUTCOME MEASURES: Correlation of optical coherence retinal tomographs with known normal retinal anatomy. RESULTS: Optical coherence tomographs can discriminate the cross-sectional morphologic features of the fovea and optic disc, the layered structure of the retina, and normal anatomic variations in retinal and retinal nerve fiber layer thicknesses with 10-microns depth resolution. CONCLUSION: Optical coherence tomography is a potentially useful technique for high depth resolution, cross-sectional examination of the fundus.