Safety and Efficacy of Prostaglandin Analogues in the Immediate Postoperative Period after Uneventful Phacoemulsification

Prostaglandin analogues (PGAs) have been associated with the development of pseudophakic macular edema (PME) in complicated cataract cases, but evidence on their effects in uncomplicated phacoemulsification remains controversial. This two-arm, prospective, randomised study included patients with glaucoma or ocular hypertension under PGA monotherapy who were scheduled for cataract surgery. The first group continued PGA use (PGA-on), while the second discontinued PGAs for the first postoperative month and reinitiated use afterwards (PGA-off). Topical non-steroidal anti-inflammatory drugs (NSAIDs) were routinely administered to all patients during the first postoperative month. The patients were followed up for three months and the primary outcome was PME development. Secondary outcomes were corrected distance visual acuity (CDVA), central and average macular thickness (CMT and AMT), and intraocular pressure (IOP). The analysis included 22 eyes in the PGA-on group and 33 eyes in the PGA-off group. No patient developed PME. CDVA was not significantly different between the two groups (p = 0.83). CMT and AMT showed a small but statistically significant increase until the end of follow-up (p < 0.001). Mean IOP values had no significant differences between the groups at each visit (p > 0.05). At the end of follow-up, the IOP values were significantly lower than baseline in both groups (p < 0.001). In conclusion, PGA administration with concomitant topical NSAIDs appears to be a safe practice in the early postoperative period of uncomplicated phacoemulsification.

Comparison of two protocols of diode laser transscleral cyclophotocoagulation in refractory glaucoma

INTRODUCTION

Diode laser transscleral cyclophotocoagulation (DLTSCPC) remains the most commonly used cyclodestructive procedure. Nonetheless, there is no common consensus on a standardized technique.

METHODS

In this prospective randomized pilot study we compare the "pop"-titrated and "slow-burn" DLTSCPC techniques for a follow-up period of 3 months. The major outcomes of this study were intraocular pressure (IOP) before and after the procedure and the incidence of adverse events. Furthermore, postoperative pain, postoperative intraocular inflammation and corrected distance visual acuity (CDVA) were evaluated.

RESULTS

Mean baseline IOP decreased from 37.9 ± 12.7 mmHg in the pop group and 41.2 ± 9.6 mmHg in the slow-burn group to 20.3 ± 13.9 mmHg and 21.3 ± 13.4 mmHg at the final follow-up visit, corresponding to a 45.8 ± 31.7% and 46.3 ± 32.6% reduction respectively. 64.3% and 57.1% of patients had IOP ≥6 and≤ 21 mmHg in the pop and slow-burn groups respectively. The occurrence of adverse events was similar in both groups, with 1 case of hyphema in the pop group and 2 cases in the slow-burn group, and 1 case of hypotony in each group. Mean CDVA remained unchanged until the end of follow-up from 2.05 ± 0.84 to 2.04 ± 0.8 logMAR in the pop group and from 1.93 ± 0.78 to 1.89 ± 0.7 logMAR in the slow-burn group. Nonetheless, 4 eyes in each group encountered CDVA loss. Postoperative pain and inflammation were also similar between groups.

DISCUSSION

At the 3rd postoperative month, safety and efficacy was similar in the two techniques. The relative ease of the slow-burn technique may make its application more appealing to ophthalmic surgeons beyond glaucoma specialists.

Ocular Surface Disease Signs and Symptoms in Patients with Pseudoexfoliative Glaucoma: A Case—Control Study

Purpose: The present study evaluates the differences in the prevalence of the signs and symptoms of ocular surface disease (OSD) in patients with PEX glaucoma (PEXG), compared to other glaucoma types (non-PEXG). Methods: Patients with non-PEXG and PEXG were prospectively examined for the presence and severity of OSD signs and questioned for symptoms using the OSDI (ocular surface disease index) questionnaire. Results: 116 patients were prospectively enrolled (58 non-PEXG and 58 PEXG). PEXG subjects who were older, had lower central corneal thickness (CCT) values, at a more advanced glaucoma stage and required more IOP lowering drops. OSD signs were prevalent in both groups: conjunctival hyperemia (74.5% non-PEXG vs. 94.8% PEXG), eyelid redness (70.7% vs. 96.6%), conjunctival (74.1% vs. 93.1%) and corneal fluorescein staining (81% vs. 93.1%) and abnormal TFBUT (82.8% vs. 87.9%). When adjusted for potential confounders, (older age, thinner CCT, more advanced glaucoma in PEXG) eyelid redness remained the only parameter significantly associated with PEXG, being 11 times more likely to occur in this group (p = 0.037). Conclusion: Subjects with PEXG presented a higher frequency of signs of OSD compared to other glaucoma types. When accounting for confounding factors, the only difference between the groups was the significantly higher presence (11 times more likely) of eyelid redness in PEXG, suggesting, in addition to glaucoma treatment, the impact of PEX on ocular surface integrity.

Twelve-Year Incidence of Open-angle Glaucoma: The Thessaloniki Eye Study

OBJECTIVE

The objective of this study was to determine the 12-year incidence of open-angle glaucoma (OAG), with further classification into primary open-angle glaucoma (POAG) and pseudoexfoliative glaucoma (PEXG), in an elderly White population.

DESIGN

A longitudinal, population-based study in urban Northern Greece.

PARTICIPANT

Surviving cohort of the 2554 Thessaloniki Eye Study subjects 60 years and above who had the baseline examination.

METHODS

The surviving cohort was re-examined 12 years after baseline, using the same methodology and the same standard operating procedures as in the baseline examination. The definitions of glaucoma and pseudoexfoliation were consistent throughout the study. The 12-year incidences of OAG, POAG, and PEXG with corresponding 95% confidence intervals (CIs) were calculated for the whole study population, consisting of clinic-visit and home-visit participants. The population at risk was defined as those who did not meet the study criteria for the diagnosis of glaucoma in either eye at baseline.

MAIN OUTCOME MEASURES

Twelve-year incidence of OAG, with further classification into POAG and PEXG.

RESULTS

Of 1468 eligible subjects in the surviving cohort, 1092 were examined (participation rate 74%). Mean age at baseline was 68.9±4.6 years. Mean follow-up time was 11.6±1.6 years. The 12-year incidence of OAG was 4.4% (95% CI: 3.3-5.8); 0.37% per year. In the overall population the incidence of POAG and PEXG was 2.1% (95% CI: 1.3-3.2) and 2.3% (95% CI: 1.5-3.4), respectively. The corresponding incidence proportions were 2.9 (95% CI: 1.8-4.3) in those without PEX and 8.9 (95% CI: 5.8-12.9) in those with PEX at baseline and/or incidence. The latter was strongly associated with higher odds for incident glaucoma (odds ratio=3.34, 95% CI: 1.83-6.08, P<0.001). Of all incident OAG cases, 11.1% (95% CI: 4.4-24) had baseline intraocular pressure >21 mm Hg.

CONCLUSIONS

The incidence of OAG was similar or higher compared with other White populations. The incidence of glaucoma in those with PEX was higher compared with the incidence of glaucoma in those without PEX.

Peripapillary Choroidal Neovascular Membrane Secondary to Sarcoidosis-Related Panuveitis: Treatment with Aflibercept and Ranibizumab with a 50-month Follow-Up

A case of peripapillary choroidal neovascular membrane (PCNM) secondary to sarcoidosis-related panuveitis successfully treated with anti-vascular endothelial growth factor (anti-VEGF) agents and systemic immunomodulatory therapy is reported. Diagnosis and follow-up were based on fundoscopic, optical coherence tomography as well as fluorescein angiography findings. A 45-year-old female patient presented with sudden onset bilateral blurring of vision. Fundoscopy revealed bilateral granulomatous panuveitis with solitary peripheral granuloma in the right eye and PCNM in the left eye. Diagnostic work-up including conjunctival biopsy confirmed the diagnosis of sarcoidosis. Topical and systemic corticosteroids controlled the inflammation. Within 4 weeks, PCNM showed rapid enlargement (best-corrected visual acuity [BCVA]: 6/60) with foveal involvement. Monthly intravitreal aflibercept injections and systemic methotrexate were administered. After 5 aflibercept injections, anatomical and functional improvement was noted (BCVA: 6/6). Due to aflibercept unavailability, further treatment included ranibizumab injections. During a 50-month follow-up period, every anti-VEGF injection was followed by total NV regression and 6/6 BCVA. Both aflibercept and ranibizumab appear to be effective in the treatment of PCNM secondary to sarcoidosis.

Association of Rare CYP39A1 Variants With Exfoliation Syndrome Involving the Anterior Chamber of the Eye

IMPORTANCE

Exfoliation syndrome is a systemic disorder characterized by progressive accumulation of abnormal fibrillar protein aggregates manifesting clinically in the anterior chamber of the eye. This disorder is the most commonly known cause of glaucoma and a major cause of irreversible blindness.

OBJECTIVE

To determine if exfoliation syndrome is associated with rare, protein-changing variants predicted to impair protein function.

DESIGN, SETTING, AND PARTICIPANTS

A 2-stage, case-control, whole-exome sequencing association study with a discovery cohort and 2 independently ascertained validation cohorts. Study participants from 14 countries were enrolled between February 1999 and December 2019. The date of last clinical follow-up was December 2019. Affected individuals had exfoliation material on anterior segment structures of at least 1 eye as visualized by slit lamp examination. Unaffected individuals had no signs of exfoliation syndrome.

EXPOSURES

Rare, coding-sequence genetic variants predicted to be damaging by bioinformatic algorithms trained to recognize alterations that impair protein function.

MAIN OUTCOMES AND MEASURES

The primary outcome was the presence of exfoliation syndrome. Exome-wide significance for detected variants was defined as P < 2.5 × 10-6. The secondary outcomes included biochemical enzymatic assays and gene expression analyses.

RESULTS

The discovery cohort included 4028 participants with exfoliation syndrome (median age, 78 years [interquartile range, 73-83 years]; 2377 [59.0%] women) and 5638 participants without exfoliation syndrome (median age, 72 years [interquartile range, 65-78 years]; 3159 [56.0%] women). In the discovery cohort, persons with exfoliation syndrome, compared with those without exfoliation syndrome, were significantly more likely to carry damaging CYP39A1 variants (1.3% vs 0.30%, respectively; odds ratio, 3.55 [95% CI, 2.07-6.10]; P = 6.1 × 10-7). This outcome was validated in 2 independent cohorts. The first validation cohort included 2337 individuals with exfoliation syndrome (median age, 74 years; 1132 women; n = 1934 with demographic data) and 2813 individuals without exfoliation syndrome (median age, 72 years; 1287 women; n = 2421 with demographic data). The second validation cohort included 1663 individuals with exfoliation syndrome (median age, 75 years; 587 women; n = 1064 with demographic data) and 3962 individuals without exfoliation syndrome (median age, 74 years; 951 women; n = 1555 with demographic data). Of the individuals from both validation cohorts, 5.2% with exfoliation syndrome carried CYP39A1 damaging alleles vs 3.1% without exfoliation syndrome (odds ratio, 1.82 [95% CI, 1.47-2.26]; P < .001). Biochemical assays classified 34 of 42 damaging CYP39A1 alleles as functionally deficient (median reduction in enzymatic activity compared with wild-type CYP39A1, 94.4% [interquartile range, 78.7%-98.2%] for the 34 deficient variants). CYP39A1 transcript expression was 47% lower (95% CI, 30%-64% lower; P < .001) in ciliary body tissues from individuals with exfoliation syndrome compared with individuals without exfoliation syndrome.

CONCLUSIONS AND RELEVANCE

In this whole-exome sequencing case-control study, presence of exfoliation syndrome was significantly associated with carriage of functionally deficient CYP39A1 sequence variants. Further research is needed to understand the clinical implications of these findings.

Factors associated with non-active retinal capillary density as measured with Confocal Scanning Laser Doppler Flowmetry in an elderly population: the Thessaloniki Eye Study (TES)

PURPOSE

To identify factors associated with retinal capillary density as measured with Confocal Scanning Laser Doppler Flowmetry (Heidelberg retina flowmeter (HRF)) in the Thessaloniki Eye Study (TES).

METHODS

Participants of the TES (age ≥60 years, cross-sectional population-based study) were assessed for active capillary density in the superior and inferior peripapillary retina using the HRF. Pixel-by-pixel analysis was performed to quantify the percentage of zero flow pixels (ZFPs; surrogate for % retinal area with non-active capillaries). Multivariable regression analyses were performed to assess the association of non-active vascular density with ophthalmic and systemic variables. Glaucoma, late age-related macular degeneration and diabetic retinopathy subjects were excluded.

RESULTS

1189 subjects were included in the analysis. Older age (per year) was associated with higher percentage of ZFP in both the superior (slope estimate (SE)=0.0020) and the inferior (SE=0.0019) peripapillary retina (p<0.0001). History of migraine was associated with lower percentage of ZFP (SE=-0.0166) compared with no history of migraine in the superior peripapillary retina only (p<0.05). Higher intraocular pressure ((IOP) per mm Hg) and height (per cm) were associated with higher percentage of ZFP in the inferior peripapillary retina only (SE=0.0012, p<0.05 and SE=0.0005, p<0.05, respectively). The group consuming vegetables one to three times per week compared with the group consuming vegetables at least once a day had higher percentage of ZFP only in the inferior peripapillary retina (SE=0.0080, p<0.05).

CONCLUSION

At a population level, our study revealed associations of older age, higher IOP and taller height with lower active retinal capillary density and of migraine with higher capillary density. Looking further into these associations may provide insight into disease mechanisms.

Factors Associated With Retinal Vessel Diameters in an Elderly Population: the Thessaloniki Eye Study

Purpose

To identify the factors associated with retinal vessel diameters in the population of the Thessaloniki Eye Study.

Methods

Cross-sectional population-based study (age ≥ 60 years). Subjects with glaucoma, late age-related macular degeneration, and diabetic retinopathy were excluded from the analyses. Retinal vessel diameters were measured using the IVAN software, and measurements were summarized to central retinal artery equivalent (CRAE), central retinal vein equivalent (CRVE), and arteriole to venule ratio (AVR).

Results

The analysis included 1614 subjects. The hypertensive group showed lower values of CRAE (P = 0.033) and AVR (P = 0.0351) compared to the normal blood pressure (BP) group. On the contrary, the group having normal BP under antihypertensive treatment did not have different values compared to the normal BP group. Diastolic BP (per mm Hg) was negatively associated with CRAE (P < 0.0001) and AVR (P < 0.0001), while systolic BP (per mm Hg) was positively associated with CRAE (P = 0.001) and AVR (P = 0.0096). Other factors significantly associated included age, sex, alcohol, smoking, cardiovascular disease history, ophthalmic medication, weight, and IOP; differences were observed in a stratified analysis based on BP medication use.

Conclusions

Our study confirms previous reports about the association of age and BP with vessel diameters. The negative correlation between BP and CRAE seems to be guided by the effect of diastolic BP as higher systolic BP is independently associated with higher values of CRAE. The association of BP status with retinal vessel diameters is determined by diastolic BP status in our population. Multiple other factors are also independently associated with retinal vessel diameters.

Treatment of spontaneous corneal perforation secondary to undiagnosed Sjögren's syndrome using regenerating agent and autologous serum eye drops

PURPOSE

The aim of this study was to report a case of sterile corneal ulcer leading to perforation, which was treated effectively with autologous serum eye drops, topical regenerative agent (poly-carboxymethylglucose sulfate), steroids, and systemic immunosuppression in a patient with undiagnosed primary Sjögren's syndrome.

METHODS

A 74-year-old female presented with a month's history of gradually worsening blurry vision in her left eye. Ophthalmic examination revealed a central descemetocele with excessive corneal stromal melting and absence of signs of infection. A bandage contact lens was applied for tectonic support along with topical corticosteroid and antibiotic drops. Autoimmune screen disclosed a diagnosis of Sjögren's syndrome, and the patient was commenced on systemic immunosuppression. Forty-eight hours after presentation, the patient developed a localized corneal perforation, presenting with a flat anterior chamber.

RESULTS

Urgent amniotic membrane transplantation was arranged while topical dexamethasone, moxifloxacin, and autologous serum eye drops were administered. After 24 h of intensive topical treatment, a significant reforming of the anterior chamber and subsequent gradual regeneration of the corneal stroma were noted, thus postponing amniotic grafting. The patient remained under close monitoring, showing progressive clinical improvement. Regenerating agent eye drops (Cacicol20^®) were also applied over the next month, with careful and slow tapering of topical dexamethasone. Further improvement of corneal thickness was observed, and visual acuity increased to 20/80.

CONCLUSION

This case report demonstrates the successful medical treatment of an autoimmune-related sterile corneal perforation without surgical intervention, highlighting the fact that early diagnosis and rigorous medical treatment with autologous serum and regenerating agent eye drops can effectively aid tissue regeneration and favorable visual rehabilitation.

Overdiagnosis of open-angle glaucoma in the general population: the Thessaloniki Eye Study

PURPOSE

To assess the overdiagnosis of open-angle glaucoma (OAG) and to investigate associated factors.

METHODS

This was a cross-sectional, population-based study of an urban Caucasian population in northern Greece. Randomly selected subjects ≥60 years (n = 2554) participated in the Thessaloniki Eye Study. The definition of OAG required the presence of structural and functional damage, irrespective of intraocular pressure (IOP). Non-OAG subjects were classified as overdiagnosed with OAG if they had reported at least one of the following (self-reported glaucoma): (i) prior diagnosis of glaucoma, (ii) prior laser for glaucoma, (iii) prior glaucoma surgery. Factors associated with the overdiagnosis of OAG were investigated using a logistic regression model.

RESULTS

Of 57 (2.2%) subjects with self-reported glaucoma, 34 (60%) were overdiagnosed with OAG, corresponding to a prevalence of 1.3% (34/2554). In a logistic regression model among non-OAG subjects, worse visual acuity (VA) (20/200 or worse versus 20/25 or better; odds ratio (OR) = 4.30, 95% Confidence Intervals (CI), 1.13-16.35), family history of glaucoma (OR = 8.69, 95% CI, 2.83-26.67) and history of cataract surgery (OR = 11.50, 95% CI, 3.85-34.36) were statistically significantly associated with the overdiagnosis of OAG. Age, sex, higher IOP, higher vertical cup-to-disc ratio and pseudoexfoliation were not statistically significant.

CONCLUSION

The overdiagnosis of OAG was substantial in this elderly, Caucasian population. The overdiagnosis of glaucoma has not been previously addressed in population-based studies and needs to be further explored.

Risk factors for Age-related Macular Degeneration in a Greek population: The Thessaloniki Eye Study

PURPOSE

To assess the association of potential risk factors with early and late age-related macular degeneration (AMD) in the Thessaloniki Eye Study (TES) population Design: Population-based, cross-sectional study of subjects over age of 60 living in Thessaloniki, Greece Methods: Subjects without any AMD features and subjects with early and late AMD (neovascular AMD or geographic atrophy) were identified in the TES cohort using standardized procedures and masked grading of stereo color fundus photos. Demographic, lifestyle, systemic and other ophthalmic covariates were also collected during a detailed examination process. Their association with AMD was investigated using univariate and multivariate adjusted logistic regression models.

RESULTS

Among the 2108 participants with gradable photos, the grading process identified 1204 subjects with no AMD, 848 subjects with early AMD, and 56 subjects with late AMD (24 with geographic atrophy and 32 with neovascular AMD). In multivariate analysis, compared to no AMD, late AMD was positively associated with older age (OR:1.16; 95%CI:1.10-1.22 per year of age), current smoking (smoking vs. never smoking, OR:2.34; 95%CI:1.12-4.90), prior cataract surgery (cataract surgery vs. no cataract surgery OR:2.06; 95%CI:0.96-4.40), marital status (divorced/separated vs. married, OR:3.10; 95%CI:1.08-8.93) and with 60% lower odds when sleeping in the afternoon (yes vs. no, OR:0.40; 95%CI:0.22-0.72). Early AMD was positively associated with older age (OR: 1.03; 95%CI:1.01-1.05 per year of age) and negatively with higher pulse pressure (OR:0.99; 95%CI:0.98-0.99 per mmHg).

CONCLUSIONS

In TES, apart for well-known risk factors for AMD like age, smoking, and cataract surgery, two novel behavioral risk factors for prevalent late AMD were suggested. Sleeping in the afternoon was associated with 60% decreased odds for late AMD and 67% decreased odds for neovascular AMD. Being divorced/separated compared to married was associated with 3-fold higher odds for late AMD. Large longitudinal population-based studies will be necessary to further establish the potential late AMD risk effects of these two novel factors, to demonstrate potential implications of underlying pathogenetic mechanisms, and to explore preventive measures and therapeutic targets.

Investigational drugs targeting prostaglandin receptors for the treatment of glaucoma

INTRODUCTION

Prostaglandin F2α analogs were the first prostaglandin agonists introduced for glaucoma treatment. Thanks to their efficacy and favorable tolerability they set a high bar in competition, with a resultant paucity in new hypotensive drug development for many years. However, the scientific community has shown recently a new interest in exploring new options for glaucoma treatment, generating a remarkable incentive in the marketplace for new drugs.

AREAS COVERED

This article reviews agents targeting prostaglandin receptors that are currently being investigated for glaucoma treatment. We searched published literature for agonists targeting all subtypes of prostaglandin receptors found in ocular tissues. EP and FP receptor agonists are currently in the spotlight of clinical research, while less attention is paid in DP receptor agonists.

EXPERT OPINION

Prostaglandin analogs, targeting different and combinations of receptor subtypes and compounds that exhibit additivity to commonly prescribed medications seem to be highly promising options. New treatments need to be safe, more effective, superior to existing therapies, tolerable and cost-effective. New generation compounds with multiple mechanisms of action or multiagent formulations are vigorously being investigated and generated in laboratories around the world.

Tolerable rates of visual field progression in a population-based sample of patients with glaucoma

AIMS

To provide population-based data on the maximum tolerable rate of progression to avoid visual impairment (maxTRoP_VI) and blindness (maxTRoP_BL) from open-angle glaucoma (OAG).

METHODS

Participants with OAG in the Thessaloniki Eye Study (cross-sectional, population-based study in a European population) were included in the analysis. Visual impairment was defined as mean deviation (MD) equal to or worse than -12dB and blindness as MD equal to or worse than -24dB. Additional thresholds for visual impairment were tested. For each participant maxTRoP_VI was defined as the rate of progression which would not lead to visual impairment during expected lifetime. MaxTRoP_BL was defined accordingly. Both parameters were calculated for each OAG subject using age, sex, MD and life expectancy data. The eye with the better MD per subject was included in the analysis.

RESULTS

Among 135 subjects with OAG, 123 had reliable visual fields and were included in the analysis. The mean age was 73±6 years and the median MD was -3.65±5.28dB. Among those, 69.1% would have a maxTRoP_VI slower than -1dB/year and 18.7% would have a maxTRoP_VI between -1 and -2dB/year. Also, 72.4% would have a maxTRoP_BL slower than -2dB/year. For all tested thresholds for visual impairment, approximately 86% of the OAG study participants would not be able to tolerate a rate of progression equal to or faster than -2dB/year.

CONCLUSIONS

The majority of patients with glaucoma in our study would have a maximum tolerable rate of progression slower than -1dB/year in their better eye. Patient-tailored strategies to monitor the visual field are important, but raise the issue of feasibility with regard to the number of visual field tests needed.

Prevalence of Age-Related Macular Degeneration in Europe: The Past and the Future

Purpose

Age-related macular degeneration (AMD) is a frequent, complex disorder in elderly of European ancestry. Risk profiles and treatment options have changed considerably over the years, which may have affected disease prevalence and outcome. We determined the prevalence of early and late AMD in Europe from 1990 to 2013 using the European Eye Epidemiology (E3) consortium, and made projections for the future.

Design

Meta-analysis of prevalence data.

Participants

A total of 42 080 individuals 40 years of age and older participating in 14 population-based cohorts from 10 countries in Europe.

Methods

AMD was diagnosed based on fundus photographs using the Rotterdam Classification. Prevalence of early and late AMD was calculated using random-effects meta-analysis stratified for age, birth cohort, gender, geographic region, and time period of the study. Best-corrected visual acuity (BCVA) was compared between late AMD subtypes; geographic atrophy (GA) and choroidal neovascularization (CNV).

Main Outcome Measures

Prevalence of early and late AMD, BCVA, and number of AMD cases.

Results

Prevalence of early AMD increased from 3.5% (95% confidence interval [CI] 2.1%–5.0%) in those aged 55–59 years to 17.6% (95% CI 13.6%–21.5%) in those aged ≥85 years; for late AMD these figures were 0.1% (95% CI 0.04%–0.3%) and 9.8% (95% CI 6.3%–13.3%), respectively. We observed a decreasing prevalence of late AMD after 2006, which became most prominent after age 70. Prevalences were similar for gender across all age groups except for late AMD in the oldest age category, and a trend was found showing a higher prevalence of CNV in Northern Europe. After 2006, fewer eyes and fewer ≥80-year-old subjects with CNV were visually impaired (P = 0.016). Projections of AMD showed an almost doubling of affected persons despite a decreasing prevalence. By 2040, the number of individuals in Europe with early AMD will range between 14.9 and 21.5 million, and for late AMD between 3.9 and 4.8 million.

Conclusion

We observed a decreasing prevalence of AMD and an improvement in visual acuity in CNV occuring over the past 2 decades in Europe. Healthier lifestyles and implementation of anti–vascular endothelial growth factor treatment are the most likely explanations. Nevertheless, the numbers of affected subjects will increase considerably in the next 2 decades. AMD continues to remain a significant public health problem among Europeans.

Genetic association study of exfoliation syndrome identifies a protective rare variant at LOXL1 and five new susceptibility loci

Exfoliation syndrome (XFS) is the most common known risk factor for secondary glaucoma and a major cause of blindness worldwide. Variants in two genes, LOXL1 and CACNA1A, have previously been associated with XFS. To further elucidate the genetic basis of XFS, we collected a global sample of XFS cases to refine the association at LOXL1, which previously showed inconsistent results across populations, and to identify new variants associated with XFS. We identified a rare protective allele at LOXL1 (p.Phe407, odds ratio (OR) = 25, P = 2.9 × 10^-14) through deep resequencing of XFS cases and controls from nine countries. A genome-wide association study (GWAS) of XFS cases and controls from 24 countries followed by replication in 18 countries identified seven genome-wide significant loci (P < 5 × 10^-8). We identified association signals at 13q12 (POMP), 11q23.3 (TMEM136), 6p21 (AGPAT1), 3p24 (RBMS3) and 5q23 (near SEMA6A). These findings provide biological insights into the pathology of XFS and highlight a potential role for naturally occurring rare LOXL1 variants in disease biology.

Achievements and Limits of Current Medical Therapy of Glaucoma

Prescribing medical therapy for the treatment of glaucoma can be a complex process since many parameters should be taken into consideration regarding its achievements and limits. Today, a variety of options, including multiple drug classes and multiple agents within classes, are available to the clinician, but caution should be given to their side effects and contraindications. Glaucoma patients with preexisting ocular surface disease should be treated with caution, and preferably with preservative-free formulations, as there is an increased risk for symptom deterioration. The development and use of fixed-combination therapies has reduced the preservative-related side effects that threaten patient adherence and has minimized the washout effect of multiple instillations. Adherence to medical treatment is not only crucial to its efficacy but also to its cost-effectiveness. Further factors to consider are that there are patients who are nonresponders to treatment, and also that the target intraocular pressure (IOP) cannot be reached in all patients, regardless of the response to treatment. The progression of damage can occur even under maximum medical treatment or maximally tolerated medical treatment, and regardless of whether low IOP levels are reached. Furthermore, there is some conflict between medical treatment and quality of life due to long-term everyday use and to side effects of treatment. New molecules and new delivery systems are being investigated to open new horizons in glaucoma management. Although the general rule is to initiate glaucoma management with medical treatment, the limits of medical therapy should be considered to identify those patients in need of surgical management.

Bilateral intermediate uveitis with appearance of frosted branch angiitis and association with Mycoplasma pneumoniae infection: case report and review of the literature

A 12-year-old girl presented with acute bilateral visual loss following a mild upper respiratory tract infection. Clinical examination revealed bilateral severe peripheral retinal vasculitis with an appearance of frosted branch angiitis and cystoid macular edema. All tests for etiological diagnosis were negative, apart from positive IgM and IgG antibodies for Mycoplasma pneumoniae. She was treated with broad-spectrum antibiotics and intravenous corticosteroids. She responded to treatment, with dramatic improvement of her visual acuity, remission of angiitis, and a residual macular star formation. This is the first reported case of bilateral intermediate uveitis possibly associated with Mycoplasma pneumoniae infection.

Ethnicity-Based Differences in the Association of LOXL1 Polymorphisms with Pseudoexfoliation/Pseudoexfoliative Glaucoma: A Meta-Analysis

Pseudoexfoliation (PEX) is an age-related disorder of the extracellular matrix; it is strongly associated with glaucoma, the leading cause of irreversible blindness worldwide. We conducted an ethnic-based meta-analysis of the association of LOXL1 polymorphisms with PEX/pseudoexfoliative glaucoma (PEXG). Association studies were retrieved systematically from PubMed, EMBASE, and Web of Knowledge. Allelic and genotype frequencies of rs3825942, rs1048661, and rs2165241 were compared between PEX/PEXG and controls. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using a random effects model. Overall, 39 independent cohorts were included. Rs3825942 (G) was an at risk allele for PEX/PEXG in Caucasians, Japanese, Koreans, Chinese, South Asians, and Middle Easterners, but protective in Black South Africans (OR = 0.10, 95%CI:0.06-0.16). Rs1048661 (G) was an at risk allele for PEX/PEXG in Caucasians, South Asians, Middle Easterners and Black South Africans, but was protective in Japanese (OR = 0.03, 95%CI:0.02-0.06) and Koreans (OR = 0.10, 95%CI:0.05-0.22). These associations we-re confirmed for the genotypic recessive models. Rs2165241 (C) was a protective allele for PEX/PEXG in Caucasians, but was an at risk allele in Japanese (OR = 7.49, 95%CI:3.22-17.41) and Koreans (OR = 6.63, 95%CI:2.60-16.90). This was confirmed for the genotypic dominant model. Other genetic and/or environmental factors may modify the effect of LOXL1 polymorphisms in certain ethnic groups.

Increasing Prevalence of Myopia in Europe and the Impact of Education

Purpose

To investigate whether myopia is becoming more common across Europe and explore whether increasing education levels, an important environmental risk factor for myopia, might explain any temporal trend.

Design

Meta-analysis of population-based, cross-sectional studies from the European Eye Epidemiology (E³) Consortium.

Participants

The E³ Consortium is a collaborative network of epidemiological studies of common eye diseases in adults across Europe. Refractive data were available for 61 946 participants from 15 population-based studies performed between 1990 and 2013; participants had a range of median ages from 44 to 78 years.

Methods

Noncycloplegic refraction, year of birth, and highest educational level achieved were obtained for all participants. Myopia was defined as a mean spherical equivalent ≤−0.75 diopters. A random-effects meta-analysis of age-specific myopia prevalence was performed, with sequential analyses stratified by year of birth and highest level of educational attainment.

Main Outcome Measures

Variation in age-specific myopia prevalence for differing years of birth and educational level.

Results

There was a significant cohort effect for increasing myopia prevalence across more recent birth decades; age-standardized myopia prevalence increased from 17.8% (95% confidence interval [CI], 17.6–18.1) to 23.5% (95% CI, 23.2–23.7) in those born between 1910 and 1939 compared with 1940 and 1979 (P = 0.03). Education was significantly associated with myopia; for those completing primary, secondary, and higher education, the age-standardized prevalences were 25.4% (CI, 25.0–25.8), 29.1% (CI, 28.8–29.5), and 36.6% (CI, 36.1–37.2), respectively. Although more recent birth cohorts were more educated, this did not fully explain the cohort effect. Compared with the reference risk of participants born in the 1920s with only primary education, higher education or being born in the 1960s doubled the myopia prevalence ratio–2.43 (CI, 1.26–4.17) and 2.62 (CI, 1.31–5.00), respectively—whereas individuals born in the 1960s and completing higher education had approximately 4 times the reference risk: a prevalence ratio of 3.76 (CI, 2.21–6.57).

Conclusions

Myopia is becoming more common in Europe; although education levels have increased and are associated with myopia, higher education seems to be an additive rather than explanatory factor. Increasing levels of myopia carry significant clinical and economic implications, with more people at risk of the sight-threatening complications associated with high myopia.

Prevalence of refractive error in Europe: the European Eye Epidemiology (E(3)) Consortium

To estimate the prevalence of refractive error in adults across Europe. Refractive data (mean spherical equivalent) collected between 1990 and 2013 from fifteen population-based cohort and cross-sectional studies of the European Eye Epidemiology (E(3)) Consortium were combined in a random effects meta-analysis stratified by 5-year age intervals and gender. Participants were excluded if they were identified as having had cataract surgery, retinal detachment, refractive surgery or other factors that might influence refraction. Estimates of refractive error prevalence were obtained including the following classifications: myopia ≤-0.75 diopters (D), high myopia ≤-6D, hyperopia ≥1D and astigmatism ≥1D. Meta-analysis of refractive error was performed for 61,946 individuals from fifteen studies with median age ranging from 44 to 81 and minimal ethnic variation (98 % European ancestry). The age-standardised prevalences (using the 2010 European Standard Population, limited to those ≥25 and <90 years old) were: myopia 30.6 % [95 % confidence interval (CI) 30.4-30.9], high myopia 2.7 % (95 % CI 2.69-2.73), hyperopia 25.2 % (95 % CI 25.0-25.4) and astigmatism 23.9 % (95 % CI 23.7-24.1). Age-specific estimates revealed a high prevalence of myopia in younger participants [47.2 % (CI 41.8-52.5) in 25-29 years-olds]. Refractive error affects just over a half of European adults. The greatest burden of refractive error is due to myopia, with high prevalence rates in young adults. Using the 2010 European population estimates, we estimate there are 227.2 million people with myopia across Europe.

A common variant mapping to CACNA1A is associated with susceptibility to exfoliation syndrome

Exfoliation syndrome (XFS) is the most common recognizable cause of open-angle glaucoma worldwide. To better understand the etiology of XFS, we conducted a genome-wide association study (GWAS) of 1,484 cases and 1,188 controls from Japan and followed up the most significant findings in a further 6,901 cases and 20,727 controls from 17 countries across 6 continents. We discovered a genome-wide significant association between a new locus (CACNA1A rs4926244) and increased susceptibility to XFS (odds ratio (OR) = 1.16, P = 3.36 × 10(-11)). Although we also confirmed overwhelming association at the LOXL1 locus, the key SNP marker (LOXL1 rs4886776) demonstrated allelic reversal depending on the ancestry group (Japanese: OR(A allele) = 9.87, P = 2.13 × 10(-217); non-Japanese: OR(A allele) = 0.49, P = 2.35 × 10(-31)). Our findings represent the first genetic locus outside of LOXL1 surpassing genome-wide significance for XFS and provide insight into the biology and pathogenesis of the disease.

Association of LOXL1 polymorphisms with pseudoexfoliation, glaucoma, intraocular pressure, and systemic diseases in a Greek population. The Thessaloniki eye study

PURPOSE

To investigate the association of the two single-nucleotide polymorphisms (SNPs) in the lysyl oxidase-like 1 (LOXL1) gene with pseudoexfoliation syndrome (PEX), pseudoexfoliative glaucoma (PEXG), and primary open-angle glaucoma (POAG) in a Greek population-based setting, from the Thessaloniki Eye study.

METHODS

A total of 233 subjects with successful DNA extraction, PCR amplification, and genotyping were included in the genetic analysis of G153D and R141L SNPs of LOXL1 gene and classified into four groups: controls (n = 93); subjects with PEX (n = 40); POAG (n = 66); and PEXG (n = 34). Multinomial logistic regression was used to test their association with LOXL1 SNPs with adjustment for covariates. The association of LOXL1 with IOP (in untreated subjects) and with systemic diseases was explored.

RESULTS

Both LOXL1 SNPs were present in high frequencies in controls and cases. The G153D was strongly associated with both PEX (odds ratio [OR] = 23.2, P = 0.003 for allele G) and PEXG (OR = 24.75, P = 0.003 for allele G) and was not associated with POAG (P = 0.451). In contrast, the R141L was not associated with PEX (P = 0.81), PEXG (P = 0.063), or POAG (P = 0.113). No association of the G153D with either intraocular pressure (IOP) or systemic diseases was found.

CONCLUSIONS

In the Thessaloniki Eye Study, the G153D SNP of LOXL1 gene was strongly associated with both PEX and PEXG, whereas the R141L was not associated. No association of the LOXL1 with IOP or with systemic diseases was found. These findings further support the hypothesis that the LOXL1 gene contributes to onset of PEXG through PEX. Gene variants of LOXL1 do not help to identify those with PEX at increased risk for glaucoma development.

Association of open-angle glaucoma with perfusion pressure status in the Thessaloniki Eye Study

PURPOSE

To investigate the association of open-angle glaucoma (OAG), primary open-angle glaucoma (POAG), and pseudoexfoliative glaucoma (PEXG) with ocular perfusion pressure status (ocular perfusion pressure with or without antihypertensive treatment).

DESIGN

Cross-sectional, population-based study.

METHODS

A total of 2554 randomly selected, ≥ 60-year old subjects participated in the Thessaloniki Eye Study. Only clinic-visit participants (n = 2261), who had uniformly collected data, were included in the analyses. A logistic regression model was run for OAG in all clinic-visit participants; covariates included age, sex, diastolic ocular perfusion pressure, antihypertensive treatment, intraocular pressure (IOP), IOP-lowering treatment, pseudoexfoliation, and vascular factors identified as risk factors for glaucoma in a previous analysis. Similar logistic regression models were run separately for POAG and PEXG. In addition, logistic regression models were run for OAG, POAG, and PEXG in subjects with and without antihypertensive treatment. Also, logistic regression models were run to assess the role of systolic ocular perfusion pressure in OAG, POAG, and PEXG.

RESULTS

Among clinic-visits, 1212 subjects (53.7%) were using antihypertensive treatment. An association of borderline significance was found between low diastolic ocular perfusion pressure and POAG (OR = 0.84 per 10 mm Hg, 95% CI = 0.70-1.01, P = .059). The effect of antihypertensive treatment on POAG was not statistically significant (OR = 1.20, 95% CI = 0.75-1.91, P = .45). In subgroup analyses, diastolic ocular perfusion pressure was significantly associated with POAG in subjects using antihypertensive treatment (OR = 0.78 per 10 mm Hg, 95% CI = 0.62-0.97, P = .028). No association was found between diastolic ocular perfusion pressure and PEXG, regardless of the use of antihypertensive treatment. No associations were found between systolic ocular perfusion pressure and OAG, POAG, or PEXG, regardless of the use of antihypertensive treatment.

CONCLUSIONS

Low diastolic ocular perfusion pressure may be associated with increased risk for POAG. This association was confirmed in subjects treated for systemic hypertension in subgroup analysis. This may support the hypothesis that the concept of ocular perfusion pressure status may be more relevant to glaucoma pathogenesis than ocular perfusion pressure alone.

Association of sequence variation in the CX3CR1 gene with geographic atrophy age-related macular degeneration in a Greek population

PURPOSE

To explore the association of two single nucleotide polymorphisms (SNPs) in the CX3CR1 gene with grades of age-related macular degeneration (AMD) in a population-based setting.

METHODS

The Thessaloniki Eye study is a cross-sectional population-based epidemiologic study of chronic eye diseases in Thessaloniki, Greece. A total of 371 subjects were included and classified according to their AMD status. Subjects with AMD Grades 0-1 (n = 188) were compared to those with AMD Grades 2-3 (n = 138), to those with AMD Grade 4 (geographic atrophy) (n = 20) and to those with AMD Grade 5 (neovascular AMD) (n = 25) with regard to the presence of CX3CR1 polymorphisms (V249I and T280M). Polychotomous logistic regression analysis adjusted for age, gender, and smoking was conducted and the log-additive allelic model was preferred.

RESULTS

Participants with AMD Grade 4 were approximately three times more likely to carry the VI249 and nine times more likely to carry the II249 alleles, compared to those with AMD Grades 0-1, whereas those with AMD Grades 2-3 or Grade 5 did not differ. The T280M polymorphism was not associated with either AMD Grades 2-3 or AMD Grades 4 or 5.

CONCLUSION

In this Greek population, after adjusting for known risk factors, increased risk of geographic atrophy (GA) AMD among the carriers of the V249I polymorphism in the CX3CR1 gene was found. Our study failed to reveal any association with the T280M polymorphism reported in previous studies. Additional studies in different ethnic populations using standardized methodology are needed in order to confirm this association.

Agreement among three examiners of colour Doppler imaging retrobulbar blood flow velocity measurements

PURPOSE

To assess the agreement among three masked examiners on central retinal artery (CRA) and ophthalmic artery (OA) blood flow velocity measurements performed with colour Doppler imaging (CDI) in healthy volunteers.

METHODS

The study included 30 eyes of 15 healthy volunteers. Prior to the study, all examiners underwent intensive CDI training by an expert to facilitate uniformity in performing measurements according to a specific protocol. Following the eligibility visit, three masked examiners performed CDI measurements assessing the CRA and OA in both eyes of all subjects. All CDI images were analysed by a masked grader. Intraclass correlation coefficients (ICC) were calculated for peak systolic velocity (PSV) and end diastolic velocity (EDV) in the CRA and OA among the examiners. p-values < 0.05 were considered statistically significant.

RESULTS

The study included seven men and eight women (mean age 30.9 ± 4.5 years). In right eyes, ICCs for PSV and EDV in the CRA ranged from 0.917 to 0.961 and from 0.937 to 0.980, respectively. ICCs for PSV and EDV in the OA ranged from 0.802 to 0.926 and from 0.611 to 0.891, respectively. In left eyes, all ICCs for PSV and EDV were >0.9, both in the CRA and the OA. All p-values calculated for ICCs were statistically significant.

CONCLUSION

Expert training and execution of a specific protocol for CDI of ocular blood flow velocity measurements provide highly reproducible results in healthy volunteers. This is important for long-term studies assessing ocular hemodynamics, where multiple examiners may be involved.

Risk factors for primary open-angle glaucoma and pseudoexfoliative glaucoma in the Thessaloniki eye study

PURPOSE

To investigate risk factors for primary open-angle glaucoma (POAG) and pseudoexfoliative glaucoma (PEXG) in the Thessaloniki Eye Study.

DESIGN

Cross-sectional, population-based study.

METHODS

Randomly selected subjects 60 years of age and older (n=2554) participated in the Thessaloniki Eye Study. Glaucomatous damage and presence of pseudoexfoliation (PEX) were defined according to specific criteria. Open-angle glaucoma (OAG) subjects were compared with nonglaucoma subjects (controls), POAG subjects were compared with controls without PEX, and PEXG subjects were compared with controls with PEX for demographic, lifestyle, ophthalmic, and systemic factors. Factors with P < .2 in the univariate analysis were retained for multivariate analyses.

RESULTS

In multivariate analysis restricted to persons who participated in clinic visits and who had at least 1 phakic eye (n=2078), intraocular pressure (odds ratio [OR], 1.21 per 1 mm Hg; P<.001), PEX (OR, 2.81; P<.001), history of coronary artery bypass or vascular surgery (OR, 1.95; P=.017), and moderate-to-high myopia (≥ -3 diopters; OR, 2.40; P=.009) were associated with higher odds for OAG. In analysis including all clinic visits (n=2261), age became significantly associated (OR, 1.05; P=.004). In multivariate analysis for POAG (n=1840), associations were found for age (OR, 1.04 per year; P=.048), IOP (OR, 1.19 per 1 mm Hg; P<.001), history of coronary artery bypass or vascular surgery (OR, 2.09; P=.01), and history of diabetes treated with insulin (OR, 3.05; P=.045). In multivariate analysis for PEXG (n=238), the latter was associated with increased IOP (OR, 1.25 per 1 mm Hg; P<.001).

CONCLUSIONS

IOP was the only factor associated with both POAG and PEXG, whereas moderate-to-high myopia showed borderline significance in both. Vascular systemic diseases and their treatment were associated only with POAG. The implications of these differences for the pathogenesis between the 2 common types of OAG should be explored further.

Increased likelihood of glaucoma at the same screening intraocular pressure in subjects with pseudoexfoliation: the Thessaloniki Eye Study

PURPOSE

To compare the clinical characteristics of primary open-angle glaucoma (POAG) and pseudoexfoliative glaucoma (PEXG) identified in the Thessaloniki Eye Study and to evaluate the proportion of subjects with and without pseudoexfoliation (PEX) who have glaucoma by screening intraocular pressure (IOP).

DESIGN

Cross-sectional, population-based study.

METHODS

Randomly selected subjects > or =60 years (n = 2,554) participated in the Thessaloniki Eye Study. Subjects were classified as having POAG or PEXG according to specific criteria. POAG and PEXG cases were compared for various clinical characteristics. The proportion with glaucoma among subjects with PEX and the proportion with glaucoma among subjects without PEX were estimated by IOP levels.

RESULTS

Among the clinic-visit participants (n = 2,261), 94 subjects (4.2%) had POAG and 41 (1.8%) had PEXG. The prevalence of glaucoma among subjects with PEX was 15.2% and the prevalence of glaucoma among subjects without PEX was 4.7%. In subjects without treatment, the mean IOPs were 19.8 mm Hg and 24.3 mm Hg for POAG and PEXG, respectively. For IOP level >20 mm Hg, the proportion with glaucoma among subjects with PEX was higher than that for glaucoma among subjects without PEX (37% vs 15%; P = .004), while no statistically significant difference was found for IOP level < or =20 mm Hg (2.1% vs 2.1%; P = .999), Fisher exact test.

CONCLUSIONS

In the Thessaloniki Eye Study, for screening IOP </=20 mm Hg the proportion with glaucoma was similar in subjects with and without PEX. For IOP level >20 mm Hg, the proportion with glaucoma increased highly in subjects both with and without PEX, while it was much higher among those with PEX at the same screening IOP.

Association of diabetes with age-related macular degeneration in the EUREYE study

OBJECTIVE

To examine the association between self-reported diabetes history and early or late age-related macular degeneration (AMD) in the European population.

METHODS

Participants aged 65 years and over in the cross-sectional population-based EUREYE study underwent an eye examination including digital retinal photography. The images were graded at a single centre. A structured questionnaire was administered by trained field workers for putative risk factors for AMD including history of diabetes mellitus. Logistic regression models were used to examine the association between diabetes and stages of AMD, taking account of potential demographic, behavioural, dietary and medical (history of cardiovascular disease) confounders.

MAIN OUTCOME MEASURES

Photographic images were graded according to the modified International Classification System for AMD and stratified into five exclusive stages from no signs of AMD (AMD stage 0), early AMD (Stages 1-3) and late AMD (Stage 4). Late AMD was subdivided in neovascular AMD (NV-AMD) or geographic atrophy (GA).

RESULTS

Data on diabetes history and potential confounders were available in 2117 control subjects without AMD, 2182 with early AMD, 49 with GA and 101 with NV-AMD. Of all participants, 13.1% reported a history of diabetes. After adjusting for potential confounders, subjects with neovascular AMD compared with controls had increased odds for diabetes (odds ratio 1.81; 95% confidence interval, 1.10 to 2.98, p = 0.02). Subjects with AMD grades 1 to 3 or GA had no increased odds for diabetes compared with those without AMD.

CONCLUSIONS

In the EUREYE study, after multiple adjustments, positive association of diabetes mellitus with neovascular AMD was found. The hypothesis that diabetes is associated with neovascular AMD but not with geographic atrophy may suggest a different pathogenesis of the two advanced forms of the disease and needs to be further evaluated.

Reproducibility of pixel-by-pixel analysis of Heidelberg retinal flowmetry images: the Thessaloniki Eye Study

PURPOSE

To identify the investigator effect in the analysis results of Heidelberg retinal flowmetry (HRF) images when pixel-by-pixel analysis is performed.

METHODS

Thirty-two of 732 HRF images were randomly selected from a population-based study. Pixel-by-pixel analysis was performed by two trained masked graders in the following way: a square window of 40 x 40 pixels or two windows of 30 x 30 pixels or four windows of 20 x 20 pixels free from blood vessels at the peripapillary retina were identified. Using a 1 x 1-pixel window, the grader performed pointwise analysis according to a specific protocol. The analysis process was performed by each observer three times (A, B, C) at 1-week intervals. The percentage of pixels with < 1 arbitrary unit of flow (zero flow), the 10th, 25th, 50th, 75th and 90th percentiles and mean flow values were calculated. The difference between the results of analyses B-A and C-A for all HRF parameters was estimated using the Wilcoxon signed rank test. Mixed-effect regression models were also used after controlling for grader effect and correlation within subjects.

RESULTS

There was no statistically significant difference between the results of analyses B-A and C-A or for any parameter in the mixed-effect regression models. Intraclass correlation was 0.9665 for the percentage of zero flow pixels.

CONCLUSIONS

Pixel-by-pixel analysis of HRF images by trained graders remains a highly reproducible method. No grader effect was found. If a precise protocol is followed, the results are independent of the exact placement of the analysis windows and the pointwise analysis of the identified and mapped retinal tissue.

Prevalence of open-angle glaucoma in Greece: the Thessaloniki Eye Study

PURPOSE

To estimate the prevalence of open-angle glaucoma (OAG) in a population-based sample of subjects 60 years of age or older in Thessaloniki, Greece.

DESIGN

Cross-sectional population-based study.

METHODS

Subjects randomly identified from municipality registers in Thessaloniki underwent a complete ophthalmologic examination. Glaucoma was defined in two ways. Definition 1 was based on the presence of both glaucomatous optic disk and confirmed glaucomatous visual field defect. Subjects also were classified as having glaucoma when the clinical judgment was strongly in favor of the presence of glaucoma even though the strict criteria were not fulfilled (definition 2).

RESULTS

Of the 3,617 eligible subjects, 2,554 (71%) participated. The prevalence of OAG was 3.8% and 5.5% by definitions 1 and 2, respectively. The prevalence of primary OAG was 2.7% and 3.8% by definitions 1 and 2, respectively, and the prevalence of pseudoexfoliation glaucoma (PEXG) was 1.1% and 1.7% by definitions 1 and 2, respectively. Pseudoexfoliation was present in 11.9% of participants, whereas 15.2% among those with pseudoexfoliation had PEXG.

CONCLUSIONS

The prevalence of OAG in the Thessaloniki Eye Study (TES) is similar or slightly higher compared with other population-based studies in White persons. The overall slightly higher prevalence of OAG in the TES compared with other studies may be attributed to the high prevalence of PEXG in the TES.

Foveomacular Retinitis and Associated Optical Coherence Tomography Findings

A 45-year-old man presented with clinical manifestations of foveomacular retinitis, including visual symptoms and foveal lesions characteristic of solar retinopathy, but repeated questions failed to elicit a history of sun gazing. Cross-sectional retinal images produced by optical coherence tomography revealed localized loss of retinal pigment epithelium cells in both eyes. A different pattern of reflectivity at the level of the photoreceptor layer was observed between the right and left eye, reflecting asymmetry in tissue damage. This case is described to provide additional evidence that solar retinopathy and foveomacular retinitis are the same entity and may also have common optical coherence tomography findings.

Age-related macular degeneration is associated with an increased risk of hip fractures in the Medicare database

PURPOSE

To explore the relationship between age-related macular degeneration (AMD) and incident hip fractures in the Medicare population.

DESIGN

Prospective cohort study.

METHODS

With a 5% random sample of Medicare beneficiaries in 1995, 8596 cases were coded with exudative AMD; 26,942 cases were coded with atrophic AMD, and 1,013,748 cases were coded without AMD. The Medicare claims from 1996 to 1999 were evaluated for hip fracture codes. The relationship between AMD and incident hip fractures was analyzed with multiple logistic regression models, with adjustment for baseline, ocular, and systemic covariates.

RESULTS

In adjusted analyses, the risk of hip fractures was similar in cases that were coded with exudative AMD (odds ratio, 1.03; 95% confidence interval (CI), 0.95, 1.12) compared with cases with no AMD but was significantly higher in cases that were coded with atrophic AMD (odds ratio, 1.11; 95% CI, 1.06, 1.16).

CONCLUSION

Medicare patients with a code for atrophic AMD had an 11% greater risk of hip fractures than did patients without a code for AMD over a four-year follow-up period.

Prevalence of age-related macular degeneration in Greece: the Thessaloniki Eye Study

PURPOSE

To estimate the age- and gender-specific prevalence of age-related macular degeneration (AMD) in a population-based sample of subjects 60 years of age or older in Thessaloniki, Greece.

DESIGN

Cross-sectional population-based study.

METHODS

A total of 2554 subjects randomly identified from municipality registers in Thessaloniki underwent a complete ophthalmologic examination.

RESULTS

Of the 3617 eligible subjects, 2554 (71%) participants completed a clinical examination. The prevalence was 2.5% for AMD, 1.4% for neovascular (NV) AMD, and 1.3% for geographic atrophy (GA). Bilateral AMD was present in 40% of AMD cases. The prevalence of AMD, NV, GA, and bilateral AMD increased with increasing age (P< .0001). No gender-specific statistically significant differences were noted. Of all participants with AMD, 67% were unaware of the diagnosis.

CONCLUSIONS

The prevalence of AMD in Greece is comparable to that in other Caucasian populations. A dramatic increase in prevalence in people older than 80 years of age was observed.

Association of blood pressure status with the optic disk structure in non-glaucoma subjects: the Thessaloniki eye study

PURPOSE

To study the association of blood pressure (BP) status on the optic disk structure as measured with the Heidelberg Retina Tomograph (HRT) in people without glaucoma.

DESIGN

Cross-sectional population-based setting study.

METHODS

Consecutive participants in the Thessaloniki Eye Study were included in this study. HRT images of the optic disk and BP measurements were taken. Hypertension was defined as a systolic BP (SBP) > or =140 mm Hg, diastolic BP (DBP) >/=90 mm Hg, or both. Subjects were classified in three groups by SBP and DBP. The Kruskal-Wallis test was used to compare the three groups with respect to the HRT parameters. Regression models adjusted for age, gender, height, disk size, intraocular pressure, cardiovascular disease, diabetes, and duration of antihypertensive treatment were used for each HRT parameter to compare values among the different groups. The P value was considered significant at <.05.

RESULTS

A total of 232 subjects were included in the analysis. Rim area was significantly different among groups when DBP was considered as the criterion to classify subjects (P = .005). In regression models, cup area, and cup-to-disk (c/d) ratio were increased in subjects with normal DBP that was the result of treatment, as compared with both the high DBP and untreated normal DBP groups.

CONCLUSIONS

In patients without glaucoma, the DBP <90 mm Hg that results from antihypertensive treatment is associated with increased cupping and decreased rim area of the optic disk. This information should be considered in research aiming to define the role of the BP status as an independent factor initiating optic disk changes and/or as a contributing factor to glaucoma damage.

Risk of sudden visual loss following filtration surgery in end-stage glaucoma

PURPOSE

To evaluate the effect of filtration surgery on visual acuity and visual fields in patients with end-stage glaucoma during the immediate postoperative period and to assess the risk of sudden visual loss.

DESIGN

Prospective interventional, consecutive case-series.

METHODS

The study prospectively included consecutive patients with end-stage glaucoma who underwent trabeculectomy with mitomycin-C. The inclusion criterion was a preoperative visual field with Advanced Glaucoma Intervention Study score over 16. Main outcome measures included change in best corrected logMAR visual acuity, in mean deviation (MD) of visual field test, in number of points among the four central visual field points with a sensitivity less than 5 dB and in mean sensitivity of the four central visual field points after surgery. The incidence of intraoperative and postoperative complications was also recorded.

RESULTS

Twenty-one patients (21 eyes) were enrolled. Mean age was 64 years (range 31 to 78). Surgery resulted in a reduction of preoperative intraocular pressure (IOP) by 14.1 +/- 9.2 mm Hg (P < .001) and a decrease in postoperative antiglaucoma medication use (P < .001). Preoperatively the mean visual acuity was 0.77 +/- 0.78, and the mean value of the mean deviation at the visual field test was -27.94 +/- 2.7 dB. Three months after surgery, there was no significant difference in visual acuity (0.74 +/- 0.79, P = .73) and mean deviation (-27.50 +/- 2.6 dB, P = .1). Similarly there was no significant change in the visual field parameters tested to assess central visual field sensitivity. There were no intraoperative complications. Transient hypotony occurred in three eyes while one eye presented more extended hypotony. Three of these eyes experienced bleb leak (seidel).

CONCLUSIONS

In our case-series of consecutive patients with end-stage glaucoma, followed for 3 months after filtration surgery IOP was reduced effectively and vision was preserved with no occurrences of "wipe-out" phenomenon.

Sensitivity and specificity of the 76-suprathreshold visual field test to detect eyes with visual field defect by Humphrey threshold testing in a population-based setting: the Thessaloniki eye study

PURPOSE

To evaluate the screening performance of the 76-Suprathreshold (76-STHR) visual field test to detect eyes with visual field defect (VFD) as measured by Humphrey threshold testing in a population-based setting.

DESIGN

Cross-sectional study.

METHODS

All 88 subjects who agreed to participate in the pilot phase of the Thessaloniki Eye Study were included. Participants underwent a 76-STHR visual field test followed by a 30-full threshold (30-2 FTHR) test (Humphrey field analyzer). One eye/subject was randomly selected and included in the analysis. Sensitivity and specificity rates of the 76-STHR to detect eyes with VFD by the 30 to 2 FTHR test were calculated.

RESULTS

When eyes with borderline results in the 30 to 2 FTHR test were classified as having a VFD, sensitivity rates of the 76-STHR to detect eyes with VFD by the 30 to 2 FTHR were 85.2%, 77.8%, and 74.1%, whereas specificity rates were 70%, 78%, and 86%, depending on the cutoff used for the 76-STHR.

CONCLUSIONS

The 76-STHR test showed high sensitivity and low false-negative results at the "at least one point missed" cutoff level criterion to detect eyes with visual field defect by Humphrey threshold testing in a population-based setting. This criterion should be used when screening in a population-based study setting. By contrast, the 76-STHR would not be the appropriate screening test in a primary care setting with limited resources.

The prognostic significance of immune changes in patients with renal cell carcinoma treated with interferon alfa-2b

PURPOSE

To evaluate the response rate and the immunorestorative properties of subcutaneously administered interferon alfa-2b (IFN-A2b) in patients with advanced renal cell carcinoma (RCC) and to correlate the immune status with the clinical responses.

PATIENTS AND METHODS

Twenty-six patients with advanced RCC were treated with recombinant IFN-A2b. The dose was increased progressively from 5 x 10(6) IU the first week to 10 x 10(6) IU the second week, and thereafter to 15 x 10(6) IU subcutaneously.

RESULTS

Four patients (15%) achieved partial responses (PRs), and five patients (19%) had stable disease (S), whereas 17 patients (65%) progressed. In all patients, blood was withdrawn before IFN treatment and monthly thereafter. T lymphocytes after isolation from peripheral blood were tested for proliferation in the autologous mixed lymphocyte reaction (autoMLR) and allogeneic mixed lymphocyte reaction (alloMLR), interleukin-2 (IL-2) production, expression of IL-2 receptors during the alloMLR, and the production of interleukin-1 (IL-1) by peripheral-blood monocytes. Twelve patients were assessable, four patients had a PR, one patient had S, and seven patients had progressive disease. Striking increases were demonstrated in all parameters 1 month after treatment with IFN-A2b in the four patients who responded and the patient with S. Namely, the autoMLR responses showed a mean increase of 250%, the IL-2 production 247%, the expression of IL-2-specific receptors 446%, the alloMLR responses 160%, and the production of IL-1 262%. On the contrary, the nonresponders did not show any change in their overall immune status, and in some, deterioration of the already depressed immunologic functions was observed.

CONCLUSIONS

Administration of IFN-A2b results in a marked potentiation of deficient cellular immune response in vitro in those patients with RCC who respond to the treatment. This may have prognostic significance, and certainly more patients are required to be studied for definite conclusions.

Prothymosin alpha enhances human and murine MHC class II surface antigen expression and messenger RNA accumulation

Prothymosin alpha (ProT alpha) is an acidic polypeptide with potentiating effects on HLA-DR-restricted in vitro cellular immune response systems such as T cell proliferative responses to soluble proteins and cellular auto- or alloantigens. Experiments were performed to investigate the effect of ProT alpha on MHC class II Ag expression in human monocytes, murine splenocytes, and tumor cell lines at both protein and molecular levels. RIA and immunofluorescence analysis revealed that ProT alpha enhances HLA-DR surface Ag expression whereas Northern blot analysis demonstrated that ProT alpha causes significant accumulation of MHC class II mRNA. The enhancing effect of ProT alpha was demonstrated convincingly using precultured human peripheral monocytes, which are known to express decreased amounts of surface HLA-DR Ag, and HLA-DR-positive human cell lines. Moreover, ProT alpha was shown to induce HLA-DR Ag expression in a priori HLA-DR-negative tumor cells. Furthermore, ProT alpha was shown to be active in vivo. Splenocytes from mice pretreated with ProT alpha expressed more surface Ilpha Ag and contained more I alpha-specific mRNA. These findings suggest that ProT alpha may be important in the regulation of the immune response by enhancing MHC class II Ag expression in APC.

Prothymosin alpha enhances human and murine MHC class II surface antigen expression and messenger RNA accumulation

Prothymosin alpha (ProT alpha) is an acidic polypeptide with potentiating effects on HLA-DR-restricted in vitro cellular immune response systems such as T cell proliferative responses to soluble proteins and cellular auto- or alloantigens. Experiments were performed to investigate the effect of ProT alpha on MHC class II Ag expression in human monocytes, murine splenocytes, and tumor cell lines at both protein and molecular levels. RIA and immunofluorescence analysis revealed that ProT alpha enhances HLA-DR surface Ag expression whereas Northern blot analysis demonstrated that ProT alpha causes significant accumulation of MHC class II mRNA. The enhancing effect of ProT alpha was demonstrated convincingly using precultured human peripheral monocytes, which are known to express decreased amounts of surface HLA-DR Ag, and HLA-DR-positive human cell lines. Moreover, ProT alpha was shown to induce HLA-DR Ag expression in a priori HLA-DR-negative tumor cells. Furthermore, ProT alpha was shown to be active in vivo. Splenocytes from mice pretreated with ProT alpha expressed more surface Ilpha Ag and contained more I alpha-specific mRNA. These findings suggest that ProT alpha may be important in the regulation of the immune response by enhancing MHC class II Ag expression in APC.

Monocyte disorders associated with T cell defects in patients with solid tumors

T cells proliferate in response to autologous monocytes in the autologous mixed lymphocyte reaction (AMLR). AMLR was found to be impaired in patients with advanced cancer (stages III and IV), whereas normal values were found in the early stages of the disease (stages I and II). Peripheral T lymphocytes from patients with advanced stages also exhibited a decreased ability to produce Interleukin-2 (IL-2) during an AMLR response, whereas production of IL-2 by T cells in stages I and II was comparable to that of normal donors. The impaired IL-2 production by T lymphocytes in the AMLR was associated with high concentrations of soluble interleukin-2 receptor (sIL-2R) in culture supernatants and reduced expression of membrane-bound interleukin-2 receptors (IL-2R) on the same AMLR-activated T lymphocytes. These abnormalities in T cells from cancer patients were demonstrated to be associated with dysfunctions of autologous monocytes. Thus monocytes from patients with advanced cancer exhibited diminished expression of HLA-DR antigens and produced low levels of Interleukin-1 beta (IL-1 beta) and Tumor Necrosis Factor a (TNFa). No changes were detected in the expression of HLA-A, -B, -C antigens. The results presented here demonstrate that decreased in vitro T cell responses may be attributed to monocyte dysfunctions in these patients and provide new information for a better understanding of the impaired T cell function in cancer patients.

Prothymosin-alpha enhances HLA-DR antigen expression on monocytes from patients with multiple sclerosis

Monocytes from patients with multiple sclerosis (MS) express decreased numbers of class II major histocompatibility complex (MHC) antigens in peripheral blood and are poor stimulators in the autologous mixed lymphocyte reaction (autoMLR). We assessed the effect of prothymosin-alpha (ProT alpha) on the expression of MHC class II antigens by monocytes. Immediately after isolation, monocytes were analyzed for MHC class II antigen expression using a radiolabelled monoclonal antibody specific for a monomorphic determinant on HLA-DR antigens. After incubation with ProT alpha we observed significant increases in HLA-DR antigens on MS monocytes (1.5- to 4-fold increase compared to freshly isolated monocytes). Kinetic analysis revealed that enhancement peaked after 2 days of incubation with ProT alpha. The increase in HLA-DR antigen on MS monocytes resulted in the restoration of the deficient autoMLR in MS patients. This is the first demonstration suggesting a link between HLA-DR antigen expression and cellular immune defects in MS. The significance of low autoMLR responses for T suppressor levels in MS patients is discussed.

Enhancement of human T lymphocyte function by prothymosin alpha: increased production of interleukin-2 and expression of interleukin-2 receptors in normal human peripheral blood T lymphocytes

The in vitro incubation of phytohemagglutinin (PHA)- or alloantigen-stimulated peripheral blood T cells with prothymosin alpha (ProT alpha) resulted in a marked and reproducible increase in the production of interleukin-2 (IL-2). Incubation of T cells with ProT alpha, in the absence of PHA or alloantigen, failed to induce any production of IL-2. ProT alpha by itself did not exert any IL-2 activity. Finally, ProT alpha was shown to increase the expression of IL-2 receptors on phytohemagglutinin- or alloantigen-activated T cells. These data provide the basis for understanding the in vitro immunoenhancing effects of ProT alpha in cellular immune systems.

Decreased expression of HLA-DR antigens on monocytes in patients with multiple sclerosis

Immunofluorescence, cell binding assays and enzyme immunoassays were used to investigate the expression of class II major histocompatibility antigens on peripheral blood monocytes in 67 patients with multiple sclerosis. Monocytes from patients with active disease expressed fewer HLA-DR molecules on their surface than normal monocytes; furthermore the percentage of cells which exhibited detectable amounts of surface HLA-DR antigens was decreased in patients with active multiple sclerosis. During the inactive stage of the disease both deficiencies were milder, probably representing secondary pathogenetic phenomena. Quantitation of monocyte surface HLA-DR antigen expression could be valuable in assessing the clinical disease activity. The demonstration of a molecular defect in patients with multiple sclerosis will improve our understanding of the pathogenesis of the disease.