Incidence of acute glaucoma in Finland from 1973 to 1982

Seasonal variations in anterior segment angle parameters in myopes and emmetropes

CLINICAL RELEVANCE

Seasonal variations are known to occur in a range of ocular parameters and in conditions including refractive error and glaucoma. It is of clinical importance to know if seasonal changes also occur in anterior segment angle parameters, given that they can influence these conditions.

BACKGROUND

The study aimed to examine the seasonal variations in anterior segment angle parameters in healthy young adults.

METHODS

Twenty-three emmetropic participants with a mean age of 26.17 ± 4.43 years and 22 myopic participants with a mean age of 27.27 ± 4.47 years completed four seasons of data collection. Anterior segment angle parameters were measured using swept-source anterior segment optical coherence tomography. Intraocular pressure (IOP) and objective refraction were also measured. Repeated-measures analysis of variance was used to determine the effect of season and refractive error on the various ocular parameters.

RESULTS

A significant main effect of season was found for the majority of anterior segment angle parameters, including the angle opening distance at 500 and 750 µm from the scleral spur (p = 0.02, p = 0.006, respectively), angle recess area at 500 and 750 µm from the scleral spur (both p = 0.002), and trabecular iris space area at 500 and 750 µm from the scleral (p = 0.02, p = 0.008, respectively). However, measures of anterior chamber depth and trabecular iris angle did not exhibit statistically significant seasonal variations (all p > 0.05). A significant main effect of season was also found for the changes in IOP (p = 0.004) and objective refraction (p < 0.001). There was no season by refractive group interaction for any anterior segment angle parameter or IOP (all p > 0.05).

CONCLUSION

There is a small but significant seasonal changes in the anterior segment angle parameters, refractive error, and IOP in healthy young adult males, in which the anterior segment angle dimensions are narrower, the IOP is higher, and the refraction is more myopic during winter.

Low ambient temperature and temperature drop as novel risk factors of acute glaucoma: a case-crossover study

The prevalence of glaucoma has seasonal variation in population, but the role of ambient temperature and its variation remains unclear in this seasonal trend. So, we conducted a time-stratified case-crossover study to examine the association of ambient temperature and temperature change between neighboring days (TCN) with the risk of acute glaucoma. Data on meteorological parameters and glaucoma outpatient visit between 2015 and 2021 covered all districts of Shanghai. Conditional logistic regression with distributed lag nonlinear model was applied to estimate the association of temperature or TCN with the risk of acute glaucoma. A total of 7,746 patients diagnosed with acute primary angle-closure glaucoma (APACG) were included in this analysis. We observed a significant increase in the risk of acute glaucoma with cold temperature and temperature drop. Compared with the referent temperature (32℃), moderate low (12 °C) and extreme low (4 °C) temperature exposures were associated with higher risk of acute glaucoma outpatient visit, with the highest cumulative OR of 1.46 (95% CI: 1.11, 1.91) and 1.50 (95% CI: 1.09, 2.06) over lag 0-2 days. Temperature drop (TCN =  - 4 °C) also increases the risk of acute glaucoma (OR = 1.34, 95% CI: 1.07, 1.67) over lag 0-7 days, comparing with no temperature change. Patients of female and above age 65 were more vulnerable to cold exposure and temperature drop. This case-crossover study provided novel and robust individual-level evidence that low ambient temperature and temperature drop significantly increase the acute glaucoma risk. The findings provide protective strategies for glaucoma patient, especially for female and the old, under cold exposure and sudden temperature decline.

Lens extraction versus laser peripheral iridotomy for acute primary angle closure

BACKGROUND

Acute primary angle closure (APAC) is a potentially blinding condition. It is one of the few ophthalmic emergencies and carries high rates of visual morbidity in the absence of timely intervention. Laser peripheral iridotomy (LPI) has been the standard of care thus far. However, LPI does not eliminate the long-term risk of chronic angle closure glaucoma and other associated sequelae. There has been increasing interest in lens extraction as the primary treatment for the spectrum of primary angle closure disease, and it is as yet unclear whether these results can be extrapolated to APAC, and whether lens extraction provides better long-term outcomes. We therefore sought to evaluate the effectiveness of lens extraction in APAC to help inform the decision-making process.  OBJECTIVES: To assess the effect of lens extraction compared to LPI in the treatment of APAC.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2022, Issue 1), Ovid MEDLINE, Ovid MEDLINE E-pub Ahead of Print, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily (January 1946 to 10 January 2022), Embase (January 1947 to 10 January 2022), PubMed (1946 to 10 January 2022), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to 10 January 2022), ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search. We last searched the electronic databases on 10 January 2022.

SELECTION CRITERIA

We included randomized controlled clinical trials comparing lens extraction against LPI in adult participants ( ≥ 35 years) with APAC in one or both eyes.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology and assessed the certainty of the body of evidence for prespecified outcomes using the GRADE approach.

MAIN RESULTS

We included two studies conducted in Hong Kong and Singapore, comprising 99 eyes (99 participants) of predominantly Chinese origin. The two studies compared LPI with phacoemulsification performed by experienced surgeons. We assessed that both studies were at high risk of bias. There were no studies evaluating other types of lens extraction procedures.  Phacoemulsification may result in an increased proportion of participants with intraocular pressure (IOP) control compared with LPI at 18 to 24 months (risk ratio (RR) 1.66, 95% confidence interval (CI) 1.28 to 2.15; 2 studies, n = 97; low certainty evidence) and may reduce the need for further IOP-lowering surgery within 24 months (RR 0.07, 96% CI 0.01 to 0.51; 2 studies, n = 99; very low certainty evidence). Phacoemulsification may result in a lower mean IOP at 12 months compared to LPI (mean difference (MD) -3.20, 95% CI -4.79 to -1.61; 1 study, n = 62; low certainty evidence) and a slightly lower mean number of IOP-lowering medications at 18 months (MD -0.87, 95% CI -1.28 to -0.46; 1 study, n = 60; low certainty evidence), but this may not be clinically significant. Phacoemulsification may have little to no effect on the proportion of participants with one or more recurrent APAC episodes in the same eye (RR 0.32, 95% CI 0.01 to 7.30; 1 study, n = 37; very low certainty evidence). Phacoemulsification may result in a wider iridocorneal angle assessed by Shaffer grading at six months (MD 1.15, 95% CI 0.83 to 1.47; 1 study, n = 62; very low certainty evidence). Phacoemulsification may have little to no effect on logMAR best-corrected visual acuity (BCVA) at six months (MD -0.09, 95% CI -0.20 to 0.02; 2 studies, n = 94; very low certainty evidence). There was no evidence of a difference in the extent of peripheral anterior synechiae (PAS) (clock hours) between intervention arms at 6 months (MD -1.86, 95% CI -7.03 to 3.32; 2 studies, n = 94; very low certainty evidence), although the phacoemulsification group may have less PAS (degrees) at 12 months (MD -94.20, 95% CI -140.37 to -48.03; 1 study, n = 62) and 18 months (MD -127.30, 95% CI -168.91 to -85.69; 1 study, n = 60).  In one study, there were 26 adverse events in the phacoemulsification group: intraoperative corneal edema (n = 12), posterior capsular rupture (n = 1), intraoperative bleeding from iris root (n = 1), postoperative fibrinous anterior chamber reaction (n = 7), and visually significant posterior capsular opacification (n = 5), and no cases of suprachoroidal hemorrhage or endophthalmitis. There were four adverse events in the LPI group: closed iridotomy (n = 1) and small iridotomies that required supplementary laser (n = 3). In the other study, there was one adverse event in the phacoemulsification group (IOP > 30 mmHg on day 1 postoperatively (n = 1)), and no intraoperative complications. There were five adverse events in the LPI group: transient hemorrhage (n = 1), corneal burn (n = 1), and repeated LPI because of non-patency (n = 3).  Neither study reported health- or vision-related quality of life measures.

AUTHORS' CONCLUSIONS

Low certainty evidence suggests that early lens extraction may produce more favorable outcomes compared to initial LPI in terms of IOP control. Evidence for other outcomes is less clear. Future high-quality and longer-term studies evaluating the effects of either intervention on the development of glaucomatous damage and visual field changes as well as health-related quality of life measures would be helpful.

Acute Closed-Angle Glaucoma-an Ophthalmological Emergency

BACKGROUND

Acute closed-angle glaucoma has an incidence of 2.2-4.1 cases per 100 000 persons per year in Europe. It is an ophthalmological emergency in which markedly elevated intraocular pressure can damage vision permanently. Because the acute symptoms are not always clearly referable to the eyes, patients often present to physicians who are not ophthalmologists.

METHODS

This review is based on pertinent articles retrieved by a selective search in PubMed.

RESULTS

The diverse symptoms of acute closed-angle glaucoma include eye redness, worsening of vision and other visual disturbances, headache, and nausea. Acute closed-angle glaucoma has multiple causes. Not all predisposing factors have been definitively identified; above all, there are certain anatomical configurations of the eye that make it more likely to arise. The goals of treatment are to reduce the elevated intraocular pressure rapidly, which usually leads to marked symptom relief, as well as to eliminate the situation that led to closed-angle glaucoma. For proper treatment, the patient should be seen by an ophthalmologist without delay, on the day of symptom onset if possible.

CONCLUSION

Primary prevention of acute closed-angle glaucoma is not always possible. Even physicians who are not ophthalmologists can diagnose markedly elevated intraocular pressure by palpation of the globe. Proper, specific treatment can help patients rapidly and lastingly.

Seasonal variations and climatic factors on acute primary angle-closure admission in southern China: a 5-year hospital-based retrospective study

PURPOSE

To delineate the seasonality of acute primary angle-closure (APAC) admission in a coastal city of southern China and its association with climatic factors.

METHODS

A total of 1155 Chinese subjects with principal diagnosis of APAC attack were recruited from 2012 to 2016, and their medical records were retrieved. Monthly climatic factors were obtained from the Meteorological Bureau of Shantou. Monthly and seasonal APAC admissions were compared, and its correlation with climatic factors was evaluated.

RESULTS

APAC admission was higher in female subjects (75.9%) with an overall mean age of 64.7 ± 9.3 years. APAC admission was highest in summer with the peak onset in June. The peak of APAC admission for female subjects aged ≤ 65 years was in June, and that for> 65 years was in July. The peak of APAC admission for male subjects aged > 65 years was in August. Precipitation was positively correlated with APAC admission rate for both aged ≤ 65 (β = 0.415, p = 0.001) and > 65 years old (β = 0.364, p = 0.004) female subjects. In contrast, surface temperature was positively correlated with APAC admission rate for male subjects aged > 65 years (β = 0.441, p < 0.001). No climatic factor was correlated with APAC admission rate for male subjects ≤ 65 years.

CONCLUSIONS

This study revealed the peak season of APAC admission in summer, and surface temperature and precipitation are the associated factors. Close monitoring of climate changes could help to reduce the incidence of APAC attack.

Ten-Year Clinical Outcomes of Acute Primary Angle Closure Randomized to Receive Early Phacoemulsification Versus Laser Peripheral Iridotomy

PURPOSE

To compare the 10-year clinical outcomes of eyes with acute primary angle closure (APAC) randomized to receive either early phacoemulsification or laser peripheral iridotomy (LPI).

METHODS

Sixty-two APAC patients, who underwent either early phacoemulsification (phaco group) or laser peripheral iridotomy (LPI group) in a previous randomized controlled trial, were invited for assessment 10 years after the interventions. The results of the 2 groups were compared.

RESULTS

Forty of 62 patients (64.5%; 19 in phaco group and 21 from LPI group) were examined. None of them underwent additional glaucoma procedure but 15 (71.4%) patients in the LPI group received lens extraction before this assessment. The mean follow-up duration was 10.7±0.7 years. The phaco group used less medication (0.16±0.37 vs. 0.76±1.09 bottle per eye, P=0.028), had less extensive anterior synechiae (120.0±116.12 vs. 244.3±139.8 degree, P=0.010), and greater mean Shaffer gonioscopy grading (1.79±0.84 vs. 1.40±0.87; P=0.021) than the LPI group. Five eyes had persistent intraocular pressure elevation of >21 mm Hg in 2 consecutive visits and 4 eyes had blindness (best-corrected visual acuity worse than 6/60 and/or central visual field of <20 degree) in the LPI group, compared with none in the phaco group (P=0.022 and 0.045, respectively). There was no significant difference in the mean intraocular pressure, best-corrected visual acuity, and the number of eyes with visual field progression.

CONCLUSION

At 10 years, APAC eyes that underwent early phacoemulsification required less medication, less peripheral anterior synechiae, lower incidence of intraocular pressure elevation and a lower incidence of blindness compared with APAC eyes that underwent initial LPI.

[Acute angle closure : An ophthalmological emergency in the emergency room]

Hintergrund

Die Symptome des akuten Winkelblocks, ein Notfallereignis, das ohne rechtzeitige Therapie zur irreversiblen Erblindung führen kann, sind vielfältig. Diese können initial als internistische oder neurologische Erkrankungen gedeutet werden, wenn Kopfschmerzen, Pupillenstarre oder Übelkeit im Vordergrund stehen. Ziel unserer Studie war es, die Rate belastender und invasiver Diagnostik durch primäre Vorstellung bei Nichtophthalmologen bei akutem primären Winkelblock zu erfassen.

Methode

Retrospektive Single-Center-Studie von Patienten mit akutem primärem Winkelblock. Zur Identifizierung dieser wurden alle Patienten erfasst, bei denen im Universitätsklinikum Freiburg, Klinik für Augenheilkunde im Zeitraum 2014–2018 eine chirurgische Iridektomie (5-133.0) oder Iridotomie durch Laser (5-136.1) durchgeführt wurde. Anschließend erfolgte durch Akteneinsicht die Datenanalyse zur Prüfung der Ein- und Ausschlusskriterien sowie des Krankheitsverlaufs.

Ergebnisse

Eingeschlossen wurden 91 Patienten mit akutem primären Winkelblock. Davon stellten sich 28 % (n = 25) initial bei nichtophthalmologischen Fachdisziplinen vor. In dieser Patientengruppe erhielten 56 % (n = 11) eine nichtzielführende Diagnostik, wobei bei 32 % (n = 8) eine kraniale Bildgebung und bei 8 % (n = 2) eine Lumbalpunktion durchgeführt wurde.

Schlussfolgerung

Bei akutem primären Winkelblock zeigt sich eine hohe Rate an nicht wegweisender Diagnostik durch Nichtophthalmologen, weshalb dieses Krankheitsbild fächerübergreifend präsent sein sollte. Bei unspezifischen Symptomen, wie Kopfschmerzen, Übelkeit und Erbrechen sowie Pupillenstarre, muss an die Möglichkeit eines akuten Augeninnendruckanstiegs durch einen akuten Winkelblock gedacht und das frühzeitige Hinzuziehen eines Ophthalmologen erwogen werden.

Nationwide Incidence of Acute Angle Closure Glaucoma in Korea from 2011 to 2015

BACKGROUND

Despite the significant disease burden, there is a paucity of data addressing the population-based incidence of acute angle closure glaucoma (AACG). Therefore, we estimated the nationwide, population-based standardized incidence rate of AACG in Korea.

METHODS

We conducted a nationwide, population-based, retrospective study using the database of National Health Insurance (NHI) system, which includes the entire Korean population (approximately 50 million people) from 2009 to 2015. We identified patients with incident AACG during the 5-year study period from 2011 to 2015 based on their diagnosis and AACG-related treatments (laser iridotomy and cataract surgery), and estimated age- and gender-standardized incidence rate of AACG during the study period.

RESULTS

We identified 11,049 patients (8,022 women, 72.6%) with incident AACG during the 5-year study period. Of these, after excluding 6 patients under 20 years old, 11,043 patients (8,020 women, 72.6%) aged ≥ 20 years were included in the analysis. The average standardized incidence rate during the 5-year study period was 59.95 (95% confidence interval [CI], 58.87-61.03) per 1,000,000 person-years. The incidence rates increased sharply with age and peaked at individuals aged 75-79 years; in men, those peaked at the same age group, however, in women, those peaked at individuals aged 70-74 years. Women has a 2.56 folds higher incidence rate (85.84 [95% CI, 84.03-87.66] per 1,000,000 person-years) than men (33.48 [95% CI, 32.33-34.62] per 1,000,000 person-years).

CONCLUSION

The present study provides detailed estimates for AACG incidence according to all age groups and gender through the 5-year study period.

Has the EAGLE landed for the use of clear lens extraction in angle-closure glaucoma? And how should primary angle-closure suspects be treated?

Angle-closure glaucoma is an aggressive condition that causes millions to become blind worldwide. This review explores the use of prophylactic laser peripheral iridotomy (PI) in patients classified as primary angle-closure suspects (PACS), and additionally, the use of clear lens exchange as a primary treatment option in established angle-closure disease with or without glaucoma. As PI has a strong prophylactic effect in fellow eyes of patients who have had an acute attack, its use has been widely adopted in those patients classified as PACS, but with limited evidence to support this. A large randomised trial conducted in China has demonstrated that although PI reduces the risk of incident angle-closure disease, the incidence of disease that would threaten vision was much lower than anticipated. This suggests that the benefit of prophylactic PI is very limited. Health services data shows an association between rising cataract surgical rates and of decreasing rates of acute angle-closure. Age-related growth of the lens is a major component of angle-closure disease. Several studies have shown that clear lens extraction (CLE) effectively lowers IOP in angle-closure. The use of CLE as a primary treatment option has been tested against LPI in the EAGLE study, a large RCT that enroled people with angle-closure and an IOP > 30 mmHg, and those with angle-closure glaucoma. The trial showed CLE to be superior to PI both for IOP control and patient reported quality of life. On these grounds, CLE should be considered for first-line treatment of more advanced angle-closure disease.

Acute primary angle closure-treatment strategies, evidences and economical considerations

Acute primary angle closure requires emergency management that involves a rapid lowering of the intraocular pressure and resolution of relative pupil block - the most common mechanism of angle closure. Emergency strategies for lowering intraocular pressure include medical treatment and argon laser peripheral iridoplasty. Anterior chamber paracentesis and diode laser transcleral cyclophotocoagulation may be considered in special situations. Relative pupil block can be relieved by peripheral laser iridotomy and primary lens extraction; the latter is a more effective treatment according to the results of clinical trials. However, primary lens extraction can be technically demanding in the acute setting. Peripheral laser iridotomy has a role in relieving pupil block and should also be considered in most cases. Lens extraction may be combined with procedures such as goniosynechialysis, trabeculectomy or endoscopic cyclophotocoagulation. In this review, we aim to discuss the available evidence regarding the different treatment modalities. We also discuss the economic consideration, including cost-effectiveness and life expectancy, in the management of acute primary angle closure.

The Seasonality of Acute Attack of Primary Angle-Closure Glaucoma in Beijing, China

In this study, the seasonality of acute attack of primary angle-closure glaucoma (PACG) was analysed. This retrospective case series included 283 patients (200 women, 83 men; mean age, 68.2 ± 10.3 years; range, 37–96 years) with acute attack of PACG from a university-based clinic over 4 years. Patients’ age and sex, and the date and season of onset of PACG attack, were analysed. Descriptive analysis and von Mises distribution were used for statistical analysis. The highest incidence of acute attack of PACG was observed in those aged 60–69 years (34.6%). Descriptive analysis showed that the incidence was greater in June and July for men, November for women, and November for the entire sample. An angular plot (using von Mises distribution) of the individual dates of onset revealed the estimated peak onset on September 11, November 8, and October 28 for men, women, and both, respectively. Integration of the results from the two analyses revealed the incidence to be higher in the summer and winter for men, and in the winter for women and for the entire sample. More females than males were affected. Monthly and seasonal variations in onset were observed, which might be related to weather changes.

The incidence of acute angle closure in Scotland: a prospective surveillance study

PURPOSE

To estimate the incidence, and describe the clinical features and short-term clinical outcomes of acute angle closure (AAC).

METHODS

Patients with newly diagnosed AAC were identified prospectively over a 12-month period (November 2011 to October 2012) by active surveillance through the Scottish Ophthalmic Surveillance Unit reporting system. Data were collected at case identification and at 6 months follow-up.

RESULTS

There were 114 cases (108 patients) reported, giving an annual incidence of 2.2 cases (95% CI 1.8 to 2.6) or 2 patients (95% CI 1.7 to 2.4) per 1 00 000 in the whole population in Scotland. Precipitating factors were identified in 40% of cases. Almost one in five cases was associated with topical dilating drops. Best-corrected visual acuity (BCVA) at presentation ranged from 6/6 to perception of light. The mean presenting intraocular pressure (IOP) was 52 mm Hg (SD 11). Almost 30% cases had a delayed presentation of 3 or more days. At 6 months follow-up, 75% had BCVA of 6/12 or better and 30% were found to have glaucoma at follow-up. Delayed presentation (≥3 days) was associated with higher rate of glaucoma at follow-up (22.6% vs 60.8%, p<0.001), worse VA (0.34 vs 0.74 LogMAR, p<0.0001) and need for more topical medication (0.52 vs 1.2, p=0.003) to control IOP.

CONCLUSION

The incidence of AAC in Scotland is relatively low compared with the Far East countries, but in line with previous European data. Almost one in five cases were associated with pupil dilation for retinal examination.

Climate and season: the effects on ophthalmic diseases

Seasonal changes and climate have a significant impact on human health. Diseases influenced by temperature and climate conditions are likely to undergo dynamic pattern shifts with consequent impact on human health. A number of infectious and non-infectious ophthalmic diseases are influenced by temperature and seasonality. Awareness of this is important from public and global health perspective in addition to resource allocation strategies. We examine the evidence for a seasonal pattern to ophthalmic diseases and assess the possible impact of climate change.

Prevalence of pectinate ligament dysplasia and associations with age, sex and intraocular pressure in the Basset hound, Flatcoated retriever and Dandie Dinmont terrier

Background

The aims of this study were to: determine the prevalence of pectinate ligament dysplasia (PLD) in populations of Basset hounds (BH), Flatcoated retrievers (FCR) and Dandie Dinmont terriers (DDT) resident in the UK; investigate possible associations between the degree of PLD and age, sex and intraocular pressure (IOP) and; investigate possible associations between IOP and age and sex. Gonioscopy was performed in both eyes of 198 BH, 170 FCR and 95 DDT and the percentage of iridocorneal angle affected by PLD was estimated and classified as unaffected (0 %), mildly affected (<20 %), moderately affected (20–90 %) or severely affected (>90 %). Rebound tonometry was performed bilaterally in the majority of enrolled dogs.

Results

Seventy-six of 198 (38.4 %) BH, 36/170 (21.2 %) FCR and 21/95 (22.1 %) DDT were moderately or severely affected by PLD. The prevalence of PLD was significantly higher in BH than both FCR and DDT. In all breeds there was a significant positive correlation between PLD and age. In the BH only there was a significant association between PLD and sex. In the DDT only there was a weak negative correlation between PLD and IOP and a moderately strong negative correlation between IOP and age.

Conclusions

PLD is prevalent and significantly associated with age in all three breeds we investigated. The linear relationship between PLD and age can be explained by the progression of PLD over time which would contribute to the high prevalence of PLD despite widespread screening.

Pharmacotherapy and Adherence Issues in Treating Elderly Patients with Glaucoma

Glaucoma is a leading cause of visual morbidity throughout the world and is an age-related condition, the prevalence of which rises significantly with increasing age. Glaucoma, a condition affecting the optic nerve, has a variety of subtypes with multiple aetiological factors, the most important of which are intraocular pressure (IOP) and increasing age. Treatment by lowering of IOP is the only current method, for which there is evidence, by which the rate of progressive visual deterioration can be slowed or halted. Although there are surgical and laser treatments that are efficacious in lowering IOP, the most common manner in which patients with glaucoma control their IOP is with administration of daily topical ocular hypotensive drugs (eye drops). The variety of topical drugs utilised in the management of glaucoma all have the potential to have adverse effects and/or interactions with concomitant medications, many of which may be used for other age-related conditions. Adherence with appropriate medicines has a major effect on the outcome of medical conditions and this aspect applies to the management of glaucoma. There are certain specific issues that relate to the administration of topical agents, with respect to both adverse effects and adherence. Although many suspect poor adherence in elderly patients with glaucoma, relative to younger patients, adequate evidence for this is lacking. Furthermore, the manner by which adherence issues could be improved remains inadequately understood and poorly addressed. The aims of this article were to review, from a clinical perspective, the medical therapies currently used for glaucoma and discuss adherence issues with respect to the population of patients with glaucoma, who tend to be relatively elderly.

Diurnal intraocular pressure changes in eyes affected with acute primary angle closure and fellow eyes after laser peripheral iridotomy

PURPOSE

To evaluate diurnal curves of intraocular pressure (IOP) in eyes affected with unilateral acute primary angle closure (APAC) after laser peripheral iridotomy (LPI), and fellow eyes.

METHODS

The medical records of 22 female patients (44 eyes) with unilateral APAC and LPI performed OU were reviewed along with those of 48 normal control subjects (48 eyes). None of the subjects used glaucoma medications after LPI. IOP was measured with a Goldman applanation tonometer during waking hours and in a sitting position every 2 h between 09:00 and 23:00. IOP profiles were compared including the means, peaks, trough IOPs, and IOP fluctuations of the affected, fellow, and normal eyes.

RESULTS

The IOPs of the affected eyes were significantly higher than those of normal eyes at every time point measured, including peak and trough IOPs. The diurnal IOPs of fellow eyes were higher than those of normal eyes, though not significantly. There were no significant differences in IOP fluctuation between the affected, fellow, and normal eyes. IOP diurnal curves for APAC affected, fellow, and normal eyes were not statistically different (repeated measures ANOVA, p = 0.865). The mean coefficient of IOP in affected and fellow eyes ranged from 0.486 to 0.604.

CONCLUSIONS

There were no clinically significant differences among the three groups in terms of IOP diurnal curves, and thus LPI did not have a significant effect on diurnal patterns of IOP. Though the diurnal IOPs of affected eyes after LPI was significantly higher than those of normal eyes, the IOP range was not acute.

ReGAE 10: long-term visual acuity outcomes after acute primary angle closure

PURPOSE

The aim of this study was to identify the long-term visual acuity (VA) outcomes of eyes following an attack of acute primary angle closure in an urban UK population.

PATIENTS AND METHODS

This was a retrospective observational case series of 134 consecutive eyes of 123 subjects presenting with acute primary angle closure to a supraregional tertiary referral unit in the United Kingdom over a period of 60 months. The VA in the affected eye was recorded at presentation 6 months after the acute event and at the final follow-up. In addition, causes of poor vision were documented as sociodemographic variables and surgical interventions. The main outcome measure was severe visual impairment (SVI). SVI was classified as VA<6/60 in the affected eye.

RESULTS

A total of 134 eyes of 123 subjects were assessed, 89 (72%) female and 34 (28%) male patients. The majority of the individuals were White Caucasians (78%), followed by Indian and Pakistani (14%), African Caribbean (4%), and Chinese (2.4%). The mean age was 67.3±11.9 years.During the period of follow-up, 44 (33%) eyes needed a cataract surgery, whereas 13 (10%) eyes underwent filtration surgery. Eight (6%) eyes had combined cataract and filtration surgery. The mean final follow-up period was 31.4±18.1 months. At this stage, 16 (12%) of the affected eyes had SVI. Glaucomatous optic neuropathy was responsible for SVI in 5/16 eyes, 1 eye had corneal decompensation, whereas 2/16 eyes were affected by central retinal vein occlusion. Other SVI causes were age-related macular degeneration (5/16) and cataract (3/16).

CONCLUSIONS

Sixteen (12%) eyes had SVI at the final follow-up. One third of SVI was secondary to GON.

Early lens extraction compared to standard treatment in acute primary angle closure

This is the protocol for a review and there is no abstract. The objectives are as follows: To compare the efficacy as well as harms of early lens extraction versus standard treatment in patients with acute primary angle closure.

Retrospective analysis of the risk factors for developing phacomorphic glaucoma

AIM

To determine the risk factors for developing phacomorphic glaucoma in eyes with mature cataracts.

MATERIALS AND METHODS

This is a case-control study comprising of 90 eyes with phacomorphic glaucoma and 90 age- and sex-matched control eyes with mature cataracts without phacomorphic glaucoma. Patients with pre-existing glaucoma, previous intraocular surgery and /or absence of documented axial lengths were excluded from this study. Binary logistic regression analysis of the variables, axial length and anterior chamber depth, was performed. Anterior chamber depth of the contralateral eye was used as a proxy measure of the pre-phacomorphic state in the eye with phacomorphic glaucoma as majority of them first presented to our center during the phacomorphic attack without prior measurements of the pre-phacomorphic ACD or lens thickness; therefore, their anterior chamber depth would not be representative of their pre-phacomorphic state. Axial length of 23.7 mm was selected as a cut-off for dichotomized logistic regression based on the local population mean from published demographic data.

RESULTS

The mean age was 73.1 ± 10.2 years. All phacomorphic and control eyes were ethnic Chinese. The mean presenting intraocular pressures were 49.5 ± 11.8 mmHg and 16.7 ± 1.7 mmHg in the phacomorphic and control eyes respectively (P< 0.0001), whilst the median Snellen best corrected visual acuity were light perception and hand movement in the phacomorphic and control eyes respectively. Eyes with phacomorphic glaucoma had shorter axial length of 23.1 ± 0.9 mm median when compared with that of control eyes, 23.7 ± 1.5 mm (P = 0.0006). Eyes with AL ≤ 23.7 mm were 4.3 times as likely to develop phacomorphic glaucoma when compared with AL > 23.7 mm (P = 0.003).

CONCLUSION

Axial length less than ≤ 23.7 mm was a risk factor for developing phacomorphic glaucoma. Eyes with AL shorter than the population mean were 4.3 times as likely to develop phacomorphic glaucoma compared with eyes with longer than average AL. In an area where phacomorphic glaucoma is prevalent and medical resources are limited, patients with AL shorter than their population mean may be considered for earlier elective cataract extraction as a preventive measure.

Gender and glaucoma: what we know and what we need to know

PURPOSE OF REVIEW

With growing aging populations and an increase in cases of glaucoma and glaucoma blindness worldwide, aging populations are particularly at higher risk of glaucoma and glaucoma blindness. Awareness of the gender differences might increase attention toward populations at risk.

RECENT FINDINGS

Women not only outlive men, but also outnumber men in glaucoma cases worldwide. Women are at higher risks for angle closure glaucoma, but there is no clear gender predilection for open angle glaucoma. Of interest, there is some evidence suggesting that female sex hormones might be protective of the optic nerve. In addition, it is hypothesized that decreased estrogen exposure is associated with increased risk for open angle glaucoma, yet population-based studies present inconsistent results. Presently, there is insufficient evidence to support hormonal replacement therapy use in glaucoma prevention. In addition, it appears that women carry a larger burden of glaucoma blindness due to longevity and disadvantages in socioeconomic/health beliefs.

SUMMARY

Current evidence suggests that older women are at risk for glaucoma and glaucoma blindness. Further interdisciplinary research involving investigators, specialized in glaucoma, women's health and health disparities, will lead to better understanding of gender health disparities in glaucoma and better targeting populations at risk.

Pharmacological and environmental factors in primary angle-closure glaucoma

INTRODUCTION OR BACKGROUND

A large number of drug classes have now been reported to provoke angle closure in high-risk individuals. The mechanism of action can be generalized into three main categories: sympathomimetic, parasympatholytic and idiosyndratic reactions.

SOURCES OF DATA

This review of the ophthalmic literature provides a clinical summary of primary angle-closure glaucoma (PACG) and its management.

AREAS OF AGREEMENT

External stimuli (pharmacological and environmental) may induce acute, and more often, asymptomatic angle closure, which carries a significant risk of glaucoma.

GROWING POINTS

Whenever in doubt, patients at risk of PACG who are starting on drug therapy known to provoke angle closure or aggravate the condition should be referred for detailed gonioscopic examination of the anterior chamber by an ophthalmologist. AREAS FOR DEVELOPING RESEARCH: The use of new imaging methods such as anterior segment optical coherence tomography to assess the presence or risk of angle closure is gaining popularity, and may offer a more rapid method of identifying people who are at risk of sight loss from angle-closure glaucoma precipitated by non-ophthalmological medication.

Angle-closure: risk factors, diagnosis and treatment

INTRODUCTION

Primary angle-closure glaucoma (PACG) is the leading cause of blindness in East Asia. The disease can be classified into primary angle-closure suspect, primary angle closure (PAC), and PACG. Pupil-block, anterior nonpupil-block (plateau iris and peripheral iris crowding), lens related and retrolenticular mechanisms have been suggested as the four main mechanisms of angle closure.

RISK FACTORS

The risk factors for PAC are female gender, increasing age, Inuit or East Asian ethnicity, shallow anterior chamber, shorter axial length, and genetic factors.

DIAGNOSIS

The diagnosis of acute PAC is mainly clinical. Diagnosis can be made with careful slit lamp examination, including intraocular pressure (IOP) measurement and gonioscopy. The diagnosis of chronic PAC and chronic PACG also require a careful history to assess risk factors, slit lamp examination including IOP and gonioscopy. Further investigations may also be required including visual fields, ultrasound biomicroscopy, and other imaging methods.

MANAGEMENT

In acute PAC, rapid control of the IOP needs to be achieved to limit optic-nerve damage. This can be carried out medically, and/or by laser iridoplasty. Both the affected and fellow eye should undergo laser peripheral iridotomy (PI). The aim of treating chronic PAC is to eliminate the underlying pathophysiological mechanism and to reduce IOP. This can be done by carrying out laser PI, iridoplasty, medical therapy, or surgery (trabeculectomy, lens extraction, combined lens extraction with trabeculectomy and goniosynechialysis).

CONCLUSION

Angle-closure glaucoma is usually an aggressive, visually destructive disease. By assessing the risk factors and diagnosing the mechanism involved in a patient's condition, the management of that patient can be tailored appropriately.

Medication adherence in glaucoma: approaches for optimizing patient compliance

PURPOSE OF REVIEW

To summarize recent literature regarding medication adherence with a focus on the complexities inherent in glaucoma management.

RECENT FINDINGS

Adherence to medications can be enhanced by undertaking the following strategies: enhanced patient education; improved dosing schedules; increased accessibility to healthcare (including longer hours, evening hours, and shorter wait times), and improved provider-patient relationships (e.g. increased trust). Patients may be less likely to forgo medication use due to cost pressures if the physician trust level is high. Recent studies suggest a role for baseline screening for adherence predictors and focused interventions in addressing modifiable risk factors for poor adherence (such as depression, stress, and lower education).

SUMMARY

Many factors are associated with the lack of medication adherence in patients. The solution is likely to be multi-dimensional and employ combination strategy (must be individualized for the patient). Educational interventions involving patients, family members, or both can be effective in improving adherence.

On the application of the von Mises distribution and angular regression methods to investigate the seasonality of disease onset

This paper describes an approach to summarize the data arising from studies investigating the pattern of disease onset within a calendar year. Such data have been traditionally summarized into monthly counts summated over the complete years studied and patterns often examined by use of Pearson's chi(2) tests with 11 degrees of freedom. This test and others commonly used in practice are reviewed. As an alternative, we suggest that by first representing the date of onset for an individual as a point on a unit circle that the von Mises distribution with a single peak may provide a useful description of such data. Further an extension to angular regression including covariates, analogous to that used routinely in other areas of clinical research, potentially allows a more systematic and detailed investigation of possible seasonal patterns in patient subgroups. The methodology is applied to examples from the date of onset of primary angle-closure glaucoma and date of diagnosis of acute lymphoblastic leukaemia and examines in both situations how the peak onset varies with covariates. Difficulties associated with convergence to the maximum likelihood estimates of the associated parameters are described. Finally, we emphasize the need for individualized (rather than grouped) patient data to be available for study, a clear specification of the particular 'onset' time studied, and suggest that further case studies are required to evaluate the approach.

The epidemiology of primary angle closure and associated glaucomatous optic neuropathy

Angle closure glaucoma is emerging as a leading cause of blindness in the densely populated countries of Asia. It has a greater propensity to cause bilateral blindness than either primary open-angle glaucoma or secondary glaucoma. An estimated 9.4 million people in China aged 40 years and older have glaucomatous optic neuropathy. Approximately 5.2 million people (55%) would be blind in at least one eye. Around 1.7 million (18.1%) would be blind in both eyes. it is likely that PACG is responsible for the vast majority (91%) of bilateral glaucoma blindness in China. The number of Chinese people with an "occludable" drainage angle is in the region of 28.2 million, and of these 9.1 million have significant angle closure. There is a growing emphasis on a revised method of classifying the disease, which reserves the term "glaucoma" for cases with glaucomatous optic neuropathy. The term primary angle closure (PAC) is used in cases with a closed angle and peripheral anterior synechiae or raised intraocular pressure. Risk factors for PAC include older age, female gender, Chinese ethnicity, all of which are associated with anatomical risk factors of central and/or peripherally shallow anterior chambers (usually associated with a thicker, anteriorly-positioned lens), and a shorter axial length of the globe.

Systemic autonomic function in subjects with primary angle-closure glaucoma: a comparative study of symptomatic and asymptomatic disease presentation

BACKGROUND

Autonomic dysfunction is thought to be a contributory factor in primary angle-closure glaucoma (PACG) by precipitating pupil block in anatomically predisposed eyes. This study aimed to compare systemic autonomic function between subjects who had suffered a previous episode of acute angle closure (symptomatic PACG), those who had asymptomatic PACG, and age and sex-matched controls.

METHODS

Tests for systemic parasympathetic function included the heart-rate response to standing (30:15 ratio), heart-rate variation during deep breathing, and the ratio of the heart rate at phases IV and II of the Valsalva manoeuvre (Valsalva ratio). For assessment of the sympathetic nervous system, blood pressure was recorded supine and then after 2 and 5 min of standing. A modified sweat test, the sympathetic skin response, was recorded on the palm and sole.

RESULTS

A total of 30 subjects were examined: eight previous symptomatic PACG, eight asymptomatic PACG and 14 control subjects. The mean ages were similar, and all except one subject were Chinese. None of the subjects had evidence of systemic dysautonomia. There was no significant difference found between the groups for the 30:15 ratio, heart-rate variation during deep respiration and the Valsalva ratio. No significant orthostatic hypotension was detected in subjects with PACG. Abnormal sympathetic skin response was not more common in PACG subjects compared to control subjects.

CONCLUSIONS

This study identified no systemic autonomic dysfunction in people with PACG.

Issues in the epidemiology and population-based screening of primary angle-closure glaucoma

Among Caucasians, it is well known that 75-95% of primary glaucoma is due to open-angle glaucoma (POAG), with angle-closure (PACG) comprising only a very small minority of cases. These figures are reversed among other groups such as Asians and Eskimos, where PACG makes up 80-90% of primary glaucoma. Among Eskimos, the prevalence of PACG has been reported as 2-8%, as compared to 0.1% among Caucasians. It appears that a population tendency toward shallow anterior chambers may explain the excess burden of PACG morbidity. Among Asians, the prevalence of PACG is intermediate between Caucasians and Eskimos. Existing biometrical data do not show a clear tendency toward shallower anterior chambers among Asians. PACG may be screened for on a population basis by means of various techniques that estimate axial or limbal anterior chamber depth, measure intraocular pressure, or evaluate the optic disc or visual fields. Demographic information and medical and family history will also be of great importance in screening for PACG in large populations. Groups at increased risk for the disease include women, individuals over 50, first-degree relatives of PACG probands, and hyperopes.

Acute closed angle glaucoma and sunshine

STUDY OBJECTIVE

The aim was to examine a possible association of amount of sunshine and risk for acute closed angle glaucoma.

DESIGN

This was a retrospective analysis of hospital discharge registry data, linked to meteorological data for the same period.

SETTING

The study was a national survey using hospital discharge data for the whole of Finland over a 10 year period.

PARTICIPANTS

All subjects with the acute closed angle glaucoma diagnosis from the hospital discharge registry were collected for the years 1972 to 1982. A total of 1796 patients were found.

MEASUREMENTS AND MAIN RESULTS

Meteorological data from two cities in Finland, Helsinki and Oulu, were collected for the same years from the Finnish Meteorological Institute. A peak incidence of acute closed angle glaucoma was noted whenever the number of hours without sunshine increased. A regression analysis including incidence of acute closed angle glaucoma as a dependent variable, and sex, mean temperature, mean air pressure, mean humidity, total amount of rain per month, and mean sunshine hours as independent variables, was constructed. Sex and sunshine hours best explained the variation in incidence in a covariate model. No other meteorological variate could improve the model fit.

CONCLUSIONS

The result confirms that the number of hours without sunshine is positively associated with the incidence of acute closed angle glaucoma, when other meteorological variables are controlled for.

Epidemiologic data on adult glaucomas. Data from the Hospital Discharge Registry and the Registry of Right to Free Medication

The prevalence of glaucoma was studied using material from the Registry of Right to Free Medications, completed by the Social Insurance Institution of Finland in 1985. A total of 31,981 patients (10,022 males and 21,959 females) received free medication for glaucoma in 1985. Total crude glaucoma prevalence in Finland in 1985 was 0.67%, calculated for the total population (all glaucomas) according to data from this registry. The crude prevalence for those of 40 years of age and over, was 1.7% and for those of age 70 years and older, 6.1%. Age adjusted prevalence showed a female excess of cases with a male-female ratio of 1/1.3. The incidence of different types of glaucoma was studied using the Hospital Discharge Registry for the years 1973-1982. For this 10-year period, a total of 48,864 patients with glaucoma and 10,614 glaucoma suspects were found in a compilation based on an International Classification of Diseases (8th edn.) code number. Of all adult glaucomas, 67% were primary glaucomas, while 33% were secondary glaucomas. An increase in the incidence of glaucoma was noted during the 10-year period, especially for the chronic simple and capsular glaucoma groups. Females were at higher risk for chronic simple, acute angle-closure, capsular and chronic angle-closure glaucoma; whereas, males were at greater risk for other types of secondary glaucomas. The patients with secondary glaucoma were the youngest (mean age 53.5 years in males, and 60.3 years in females), while the patients with capsular glaucoma were the oldest (mean age 71.9 years in males, and 72.8 in females).