Correlates of cognitive function scores in elderly outpatients

OBJECTIVE

To determine medical, ophthalmologic, and demographic predictors of cognitive function scores as measured by the Telephone Interview for Cognitive Status (TICS), an adaptation of the Folstein Mini-Mental Status Exam. A secondary objective was to perform an item-by-item analysis of the TICS scores to determine which items correlated most highly with the overall scores.

DESIGN

Cross-sectional cohort study.

SETTING

The Glaucoma Consultation Service of the Massachusetts Eye and Ear Infirmary.

SUBJECTS

472 of 565 consecutive patients age 65 and older who were seen at the Glaucoma Consultation Service between November 1, 1987 and October 31, 1988.

MEASUREMENTS

Each subject had a standard visual examination and review of medical history at entry, followed by a telephone interview that collected information on demographic characteristics, cognitive status, health status, accidents, falls, symptoms of depression, and alcohol intake.

RESULTS

A multivariate linear regression model of correlates of TICS score found the strongest correlates to be education, age, occupation, and the presence of depressive symptoms. The only significant ocular condition that correlated with lower TICS score was the presence of surgical aphakia (model R2 = .46). Forty-six percent (216/472) of patients fell below the established definition of normal on the mental status scale. In a logistic regression analysis, the strongest correlates of an abnormal cognitive function score were age, diabetes, educational status, and occupational status. An item analysis using step-wise linear regression showed that 85 percent of the variance in the TICS score was explained by the ability to perform serial sevens and to repeat 10 items immediately after hearing them. Educational status correlated most highly with both of these items (Kendall Tau R = .43 and Kendall Tau R = .30, respectively).

CONCLUSION

Education, occupation, depression, and age were the strongest correlates of the score on this new screening test for assessing cognitive status. These factors were stronger correlates of the TICS score than chronic medical conditions, visual loss, or medications. The Telephone Interview for Cognitive Status is a useful instrument, but it may overestimate the prevalence of dementia in studies with a high prevalence of persons with less than a high school education.

Early treatment study of elevated intraocular pressure (2)

A randomized, long-term clinical trial was conducted to determine whether topical timolol therapy was effective in delaying or preventing the onset of glaucomatous damage in ocular hypertensive subjects. This study was designed to help clinicians make decisions concerning the management of patients with elevated intraocular pressure and apparently normal optic discs and visual fields.

Ophthalmologic effects of psychotropic medications

This article reviews the effects of psychotropic medications on the eye. Although some of these effects have been known for years, they have been largely ignored by psychiatrists. The ophthalmologic effects of antidepressants, neuroleptics, benzodiazepines, carbamazepine, and lithium in therapeutic doses and overdose are reviewed and their implications discussed. Recommendations are made for appropriate monitoring, treatment, and ophthalmologic referral of patients on these medications.

Falls in elderly patients with glaucoma

We analyzed the determinants of serious falls among 489 ambulatory elders aged 65 years and older who received a comprehensive examination at a glaucoma consultation service. For the previous year, at least one fall requiring medical attention or restricted activity was reported by 9.6% (95% confidence interval [CI], 7.0% to 12.2%) of participants. Using logistic regression to adjust for potential confounding variables, the greatest single risk factor for falls was the use of nonmiotic topical eye medications (odds ratio [OR], 5.4; 95% Cl, 1.8 to 16.4). Additional risk factors for falls were female sex (OR, 2.3; 95% Cl, 1.1 to 4.7) and use of cardiac medications (OR, 2.5; 95% Cl, 1.1 to 5.6). Three other characteristics were also associated with the risk of falls: use of miotic eye medications (OR, 3.2; 95% Cl, 1.0 to 10.1); visual field impairment of 40% or greater (OR, 3.0; 95% Cl, 0.94 to 9.8); and use of sedatives (OR, 2.4; 95% Cl, 0.89 to 6.7). These findings suggest that ocular and systemic medications are the major predictors of falls even in this elderly population seeking ophthalmologic care for glaucoma. Medications appear to pose a greater risk for falls than even major visual impairment.

Adjunctive use of delayed and adjustable low-dose 5-fluorouracil in refractory glaucoma

We used delayed 5-mg subconjunctival injections of 5-fluorouracil as an adjunct to filtering surgery in ten eyes with refractory glaucoma. The first 5-fluorouracil injection was made three to 15 days postoperatively and was used only when clinical signs suggested an impending bleb failure. These signs included flattening and localization of bleb, increased vascularity, early subconjunctival scarring, loss of microcystic conjunctival changes, and increased intraocular pressure. After a follow-up of ten to 17 months (mean, 13.7 months), an intraocular pressure of less than 21 mm Hg was attained in five eyes without medication and in four eyes with medication. The treatment failed in one eye. The average dose of 5-fluorouracil was 28 +/- 12 mg per eye. There were no conjunctival wound leaks. Six eyes developed transient corneal epithelial defects. The modified administration of 5-fluorouracil can result in fewer conjunctival wound leaks. Its use can be limited to those patients who show evidence of impending bleb failure.

Anterior segment evaluation of infants with retinopathy of prematurity

To understand the mechanisms of glaucoma in retinopathy of prematurity (ROP), anterior segment evaluation is essential. The authors prospectively examined the anterior segment of 27 eyes of 17 premature infants with stages IV and V ROP. Twenty-six eyes received no previous surgery or treatment. Schiøtz and applanation tonometry were performed. Structural evaluation of each anterior segment was conducted by biomicroscopy and Koeppe gonioscopy. In the 26 eyes, angle closure of greater than 180 degrees was noted in 3 (12%). The authors noted prominent Schwalbe's line in 4 eyes (15%), high iris convexity in 15 (58%), hypopigmentation of the iris root in 19 (73%), translucent matrix in the angles ("Barkan's-type" membrane) in 18 (69%), posterior synechiae in 16 (62%), visible iris or angle vessels in 12 (46%), and pigment clumping in the angle recess in 12 (46%). This study identified structural abnormalities in the anterior segment of ROP infants, including pathologic changes and anatomic features that could have a developmental origin.

A long-term clinical trial of timolol therapy versus no treatment in the management of glaucoma suspects

One hundred seven patients with intraocular pressures (IOPs) between 22 and 28 mmHg with normal visual fields on Goldmann perimetry and without evidence of optic nerve damage were randomly assigned to either a timolol treatment (TT) or a no treatment (NT) arm in a prospective clinical trial. The patients were followed for an average of 56 and 51 months, respectively. Criteria for failure were a confirmed IOP of greater than 32 mmHg, stereophotographically documented optic nerve progression, or development of glaucomatous visual field loss by Goldmann or Octopus perimetry. Nine patients failed in the TT group and 17 in the NT group (P = 0.07). Of the nine TT group failures, six had discontinued timolol before failure (4 for greater than 6 months). In a Cox proportional hazards analysis controlling for confounding variables, timolol was found to be significantly protective with an adjusted risk ratio of 0.38 (95% confidence interval = 0.16-0.89, P = 0.03). When only field and disc failure criteria were considered, timolol treatment was found to be significantly protective in an analysis considering patients who stopped timolol as being lost to follow-up (P = 0.05). A higher tonographic facility of outflow was protective in all analyses. A trend toward a substantial loss of effectiveness of timolol on IOP was not observed. Seasonal fluctuations in IOP were observed (P = 0.0007), with higher IOP occurring in the winter. The results demonstrate a favorable influence of timolol therapy on the clinical course of patients with mildly elevated IOP.(ABSTRACT TRUNCATED AT 250 WORDS)

Focal scleral thinning after transscleral Nd:YAG cyclophotocoagulation

Transscleral neodymium (Nd):YAG cyclophotocoagulation, a new cyclodestructive procedure for controlling intraocular pressure in patients with refractory glaucoma, is designed to penetrate the sclera and selectively destroy the ciliary body and processes without damaging the overlying tissue. Complications include conjunctival edema, corneal edema, iritis, gas in the anterior chamber, pain, hyphema, hypopyon, vitreous hemorrhage, and cataract. We present a case in which a patient developed focal areas of scleral thinning 6 weeks after transscleral Nd:YAG cyclophotocoagulation. The possibility of scleral damage or thinning should be kept in mind when performing the procedure.

Trabeculectomy with resection of ciliary processes in glaucoma following scleral buckling

We report a case of glaucoma following scleral buckling that required filtering trabeculectomy. Despite anterior entry to the anterior chamber, swollen ciliary processes were incarcerated in the sclerostomy site, blocking aqueous flow. Resection of the occluding ciliary processes resulted in restoration of aqueous flow through the sclerostomy. This case demonstrates that anterior rotation of the ciliary body and processes plays an important role in the pathogenesis of glaucoma following scleral buckling operation.