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Vogt-Koyanagi-Harada-like Syndrome Induced by Checkpoint Inhibitor Cemiplimab. J Immunother 2023; 46:295-298. [PMID: 37315200 PMCID: PMC10473029 DOI: 10.1097/cji.0000000000000476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 04/13/2023] [Indexed: 06/16/2023]
Abstract
Checkpoint inhibition targeting programmed cell-death protein 1 has demonstrated efficacy for a wide range of indications including cutaneous malignancy. However, immune-related adverse events (irAEs), including infrequent but visually impactful ocular irAEs, require careful consideration of treatment options, including medication withdrawal, local corticosteroids, or rarely immunomodulation. This case presents a 53-year-old woman who developed uveitis and mucous membrane ulcers after treatment for numerous cutaneous neoplasms, primarily squamous cell carcinoma, with the programmed cell-death protein 1 inhibitor cemiplimab. Ophthalmic examination revealed diffuse choroidal depigmentation consistent with a Vogt-Koyanagi-Harada-like syndrome. Topical and periocular steroids were used to treat the intraocular inflammation, and cemiplimab was discontinued. Because of ongoing severe uveitis, systemic corticosteroids and corticosteroid-sparing immunosuppression were initiated. Specifically, azathioprine and methotrexate were introduced, but each was stopped due to side effects, prompting the initiation of adalimumab (ADA) treatment. While ADA controlled intraocular inflammation, the squamous cell carcinomas were noted to progress, resulting in the discontinuation of ADA. However, a uveitis recurrence was observed. After a discussion of risks and benefits of biologic immunosuppressive therapy, including the risk of vision loss, ADA was restarted with successful disease quiescence at a 16-month follow-up. The cutaneous neoplasms were managed with topical and intralesional therapies, such as 5-fluorouracil. Recent dermatologic examinations suggested no new cutaneous lesions. This scenario presents the effective use of ADA in an ocular irAE that balances the management of sight-threatening ocular inflammation with the risk of promoting recurrent or de novo neoplastic disease.
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Four-Year Visual Outcomes in the Protocol W Randomized Trial of Intravitreous Aflibercept for Prevention of Vision-Threatening Complications of Diabetic Retinopathy. JAMA 2023; 329:376-385. [PMID: 36749332 PMCID: PMC10408259 DOI: 10.1001/jama.2022.25029] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/28/2022] [Indexed: 02/08/2023]
Abstract
Importance Anti-vascular endothelial growth factor (VEGF) injections in eyes with nonproliferative diabetic retinopathy (NPDR) without center-involved diabetic macular edema (CI-DME) reduce development of vision-threatening complications from diabetes over at least 2 years, but whether this treatment has a longer-term benefit on visual acuity is unknown. Objective To compare the primary 4-year outcomes of visual acuity and rates of vision-threatening complications in eyes with moderate to severe NPDR treated with intravitreal aflibercept compared with sham. The primary 2-year analysis of this study has been reported. Design, Setting, and Participants Randomized clinical trial conducted at 64 clinical sites in the US and Canada from January 2016 to March 2018, enrolling 328 adults (399 eyes) with moderate to severe NPDR (Early Treatment Diabetic Retinopathy Study [ETDRS] severity level 43-53; range, 0 [worst] to 100 [best]) without CI-DME. Interventions Eyes were randomly assigned to 2.0 mg aflibercept (n = 200) or sham (n = 199). Eight injections were administered at defined intervals through 2 years, continuing quarterly through 4 years unless the eye improved to mild NPDR or better. Aflibercept was given in both groups to treat development of high-risk proliferative diabetic retinopathy (PDR) or CI-DME with vision loss. Main Outcomes and Measures Development of PDR or CI-DME with vision loss (≥10 letters at 1 visit or ≥5 letters at 2 consecutive visits) and change in visual acuity (best corrected ETDRS letter score) from baseline to 4 years. Results Among participants (mean age 56 years; 42.4% female; 5% Asian, 15% Black, 32% Hispanic, 45% White), the 4-year cumulative probability of developing PDR or CI-DME with vision loss was 33.9% with aflibercept vs 56.9% with sham (adjusted hazard ratio, 0.40 [97.5% CI, 0.28 to 0.57]; P < .001). The mean (SD) change in visual acuity from baseline to 4 years was -2.7 (6.5) letters with aflibercept and -2.4 (5.8) letters with sham (adjusted mean difference, -0.5 letters [97.5% CI, -2.3 to 1.3]; P = .52). Antiplatelet Trialists' Collaboration cardiovascular/cerebrovascular event rates were 9.9% (7 of 71) in bilateral participants, 10.9% (14 of 129) in unilateral aflibercept participants, and 7.8% (10 of 128) in unilateral sham participants. Conclusions and Relevance Among patients with NPDR but without CI-DME at 4 years treatment with aflibercept vs sham, initiating aflibercept treatment only if vision-threatening complications developed, resulted in statistically significant anatomic improvement but no improvement in visual acuity. Aflibercept as a preventive strategy, as used in this trial, may not be generally warranted for patients with NPDR without CI-DME. Trial Registration ClinicalTrials.gov Identifier: NCT02634333.
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Effect of Intravitreous Anti-Vascular Endothelial Growth Factor vs Sham Treatment for Prevention of Vision-Threatening Complications of Diabetic Retinopathy: The Protocol W Randomized Clinical Trial. JAMA Ophthalmol 2021; 139:701-712. [PMID: 33784735 DOI: 10.1001/jamaophthalmol.2021.0606] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Importance The role of anti-vascular endothelial growth factor injections for the management of nonproliferative diabetic retinopathy (NPDR) without center-involved diabetic macular edema (CI-DME) has not been clearly established. Objective To determine the efficacy of intravitreous aflibercept injections compared with sham treatment in preventing potentially vision-threatening complications in eyes with moderate to severe NPDR. Design, Setting, and Participants Data for this study were collected between January 15, 2016, and May 28, 2020, from the ongoing DRCR Retina Network Protocol W randomized clinical trial, conducted at 64 US and Canadian sites among 328 adults (399 eyes) with moderate to severe NPDR (Early Treatment Diabetic Retinopathy Study severity level, 43-53), without CI-DME. Analyses followed the intent-to-treat principle. Interventions Eyes were randomly assigned to 2.0 mg of aflibercept injections (n = 200) or sham (n = 199) given at baseline; 1, 2, and 4 months; and every 4 months through 2 years. Between 2 and 4 years, treatment was deferred if the eye had mild NPDR or better. Aflibercept was administered in both groups if CI-DME with vision loss (≥10 letters at 1 visit or 5-9 letters at 2 consecutive visits) or high-risk proliferative diabetic retinopathy (PDR) developed. Main Outcomes and Measures Development of CI-DME with vision loss or PDR through May 2020, when the last 2-year visit was completed. Results Among the 328 participants (57.6% men [230 of 399 eyes]; mean [SD] age, 56 [11] years), the 2-year cumulative probability of developing CI-DME with vision loss or PDR was 16.3% with aflibercept vs 43.5% with sham. The overall hazard ratio for either outcome was 0.32 (97.5% CI, 0.21-0.50; P < .001), favoring aflibercept. The 2-year cumulative probability of developing PDR was 13.5% in the aflibercept group vs 33.2% in the sham group, and the 2-year cumulative probability of developing CI-DME with vision loss was 4.1% in the aflibercept group vs 14.8% in the sham group. The mean (SD) change in visual acuity from baseline to 2 years was -0.9 (5.8) letters with aflibercept and -2.0 (6.1) letters with sham (adjusted mean difference, 0.5 letters [97.5% CI, -1.0 to 1.9 letters]; P = .47). Conclusions and Relevance In this randomized clinical trial, among eyes with moderate to severe NPDR, the proportion of eyes that developed PDR or vision-reducing CI-DME was lower with periodic aflibercept compared with sham treatment. However, through 2 years, preventive treatment did not confer visual acuity benefit compared with observation plus treatment with aflibercept only after development of PDR or vision-reducing CI-DME. The 4-year results will be important to assess longer-term visual acuity outcomes. Trial Registration ClinicalTrials.gov Identifier: NCT02634333.
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Effect of Intravitreous Aflibercept vs Vitrectomy With Panretinal Photocoagulation on Visual Acuity in Patients With Vitreous Hemorrhage From Proliferative Diabetic Retinopathy: A Randomized Clinical Trial. JAMA 2020; 324:2383-2395. [PMID: 33320223 PMCID: PMC7739132 DOI: 10.1001/jama.2020.23027] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
IMPORTANCE Vitreous hemorrhage from proliferative diabetic retinopathy can cause loss of vision. The best management approach is unknown. OBJECTIVE To compare initial treatment with intravitreous aflibercept vs vitrectomy with panretinal photocoagulation for vitreous hemorrhage from proliferative diabetic retinopathy. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial at 39 DRCR Retina Network sites in the US and Canada including 205 adults with vison loss due to vitreous hemorrhage from proliferative diabetic retinopathy who were enrolled from November 2016 to December 2017. The final follow-up visit was completed in January 2020. INTERVENTIONS Random assignment of eyes (1 per participant) to aflibercept (100 participants) or vitrectomy with panretinal photocoagulation (105 participants). Participants whose eyes were assigned to aflibercept initially received 4 monthly injections. Both groups could receive aflibercept or vitrectomy during follow-up based on protocol criteria. MAIN OUTCOMES AND MEASURES The primary outcome was mean visual acuity letter score (range, 0-100; higher scores indicate better vision) over 24 weeks (area under the curve); the study was powered to detect a difference of 8 letters. Secondary outcomes included mean visual acuity at 4 weeks and 2 years. RESULTS Among 205 participants (205 eyes) who were randomized (mean [SD] age, 57 [11] years; 115 [56%] men; mean visual acuity letter score, 34.5 [Snellen equivalent, 20/200]), 95% (195 of 205) completed the 24-week visit and 90% (177 of 196, excluding 9 deaths) completed the 2-year visit. The mean visual acuity letter score over 24 weeks was 59.3 (Snellen equivalent, 20/63) (95% CI, 54.9 to 63.7) in the aflibercept group vs 63.0 (Snellen equivalent, 20/63) (95% CI, 58.6 to 67.3) in the vitrectomy group (adjusted difference, -5.0 [95% CI, -10.2 to 0.3], P = .06). Among 23 secondary outcomes, 15 showed no significant difference. The mean visual acuity letter score was 52.6 (Snellen equivalent, 20/100) in the aflibercept group vs 62.3 (Snellen equivalent, 20/63) in the vitrectomy group at 4 weeks (adjusted difference, -11.2 [95% CI, -18.5 to -3.9], P = .003) and 73.7 (Snellen equivalent, 20/40) vs 71.0 (Snellen equivalent, 20/40) at 2 years (adjusted difference, 2.7 [95% CI, -3.1 to 8.4], P = .36). Over 2 years, 33 eyes (33%) assigned to aflibercept received vitrectomy and 34 eyes (32%) assigned to vitrectomy received subsequent aflibercept. CONCLUSIONS AND RELEVANCE Among participants whose eyes had vitreous hemorrhage from proliferative diabetic retinopathy, there was no statistically significant difference in the primary outcome of mean visual acuity letter score over 24 weeks following initial treatment with intravitreous aflibercept vs vitrectomy with panretinal photocoagulation. However, the study may have been underpowered, considering the range of the 95% CI, to detect a clinically important benefit in favor of initial vitrectomy with panretinal photocoagulation. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02858076.
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Assessment of the DRCR Retina Network Approach to Management With Initial Observation for Eyes With Center-Involved Diabetic Macular Edema and Good Visual Acuity: A Secondary Analysis of a Randomized Clinical Trial. JAMA Ophthalmol 2020; 138:341-349. [PMID: 32077907 DOI: 10.1001/jamaophthalmol.2019.6035] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Among eyes with center-involved diabetic macular edema (CI-DME) and good visual acuity (VA), randomized clinical trial results showed no difference in VA loss between initial observation plus aflibercept only if VA decreased, initial focal/grid laser plus aflibercept only if VA decreased, or prompt aflibercept. Understanding the initial observation approach is relevant to patient management. Objective To assess the DRCR Retina Network protocol-defined approach and outcomes of initial observation with aflibercept only if VA worsened. Design, Setting, and Participants This was a post hoc secondary analyses of a randomized clinical trial of the DRCR Retina Network Protocol V that included 91 US and Canadian sites from November 2013 to September 2018. Participants were adults (n = 236) with type 1 or 2 diabetes, 1 study eye with CI-DME, and VA letter score at least 79 (Snellen equivalent, 20/25 or better) assigned to initial observation. Data were analyzed from March 2019 to November 2019. Interventions Initial observation and follow-up with aflibercept only for VA loss of at least 10 letters from baseline at 1 visit or 5 to 9 letters at 2 consecutive visits. Follow-up occurred at 8 weeks and then every 16 weeks unless VA or optical coherence tomography central subfield thickness worsened. Main Outcomes and Measures Whether individuals received aflibercept. Results Among 236 eyes in 236 individuals (149 [63%] male; median age, 60 years [interquartile range, 53-67 years]) randomly assigned to initial observation, 80 (34%) were treated with aflibercept during 2 years of follow-up. At 2 years, the median VA letter score was 86.0 (interquartile range, 89.0-81.0; median Snellen equivalent, 20/20 [20/16-20/25]). Receipt of aflibercept was more likely in eyes with baseline central subfield thickness at least 300 μm (Zeiss-Stratus equivalent) vs less than 300 μm (45% vs 26%; hazard ratio [HR], 1.98 [95% CI, 1.26-3.13], continuous P = .005), moderately severe nonproliferative diabetic retinopathy (Early Treatment Diabetic Retinopathy Study retinopathy severity level 47) and above vs moderate nonproliferative diabetic retinopathy (retinopathy severity level 43) and below (51% vs 27%; HR, 2.22 [95% CI, 1.42-3.47], ordinal P < .001), and among participants whose nonstudy eye received DME treatment within 4 months of randomization vs not (52% vs 25%; HR, 2.55 [95% CI, 1.64-3.99], P < .001). Conclusions and Relevance Most eyes managed with initial observation plus aflibercept only if VA worsened maintained good vision at 2 years and did not require aflibercept for VA loss. However, the eyes in the trial were approximately twice as likely to receive aflibercept for VA loss if they had greater baseline central subfield thickness, worse diabetic retinopathy severity level, or a nonstudy eye receiving treatment for DME. Trial Registration ClinicalTrials.gov Identifier: NCT01909791.
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Effect of Adding Dexamethasone to Continued Ranibizumab Treatment in Patients With Persistent Diabetic Macular Edema: A DRCR Network Phase 2 Randomized Clinical Trial. JAMA Ophthalmol 2019; 136:29-38. [PMID: 29127949 DOI: 10.1001/jamaophthalmol.2017.4914] [Citation(s) in RCA: 146] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Some eyes have persistent diabetic macular edema (DME) following anti-vascular endothelial growth factor (anti-VEGF) therapy for DME. Subsequently adding intravitreous corticosteroids to the treatment regimen might result in better outcomes than continued anti-VEGF therapy alone. Objective To compare continued intravitreous ranibizumab alone with ranibizumab plus intravitreous dexamethasone implant in eyes with persistent DME. Design, Setting, and Participants Phase 2 multicenter randomized clinical trial conducted at 40 US sites in 129 eyes from 116 adults with diabetes between February 2014 and December 2016. Eyes had persistent DME, with visual acuity of 20/32 to 20/320 after at least 3 anti-VEGF injections before a run-in phase, which included an additional 3 monthly 0.3-mg ranibizumab injections. Data analysis was according to intent to treat. Interventions Following the run-in phase, study eyes that had persistent DME and were otherwise eligible were randomly assigned to receive 700 μg of dexamethasone (combination group, 65 eyes) or sham treatment (ranibizumab group, 64 eyes) in addition to continued 0.3-mg ranibizumab in both treatment arms as often as every 4 weeks based on a structured re-treatment protocol. Main Outcomes and Measures The primary outcome was change in mean visual acuity letter score at 24 weeks as measured by the electronic Early Treatment Diabetic Retinopathy Study (E-ETDRS). The principal secondary outcome was change in mean central subfield thickness as measured with the use of optical coherence tomography. Results Of the 116 randomized patients, median age was 65 years (interquartile range [IQR], 58-71 years); 50.9% were female and 60.3% were white. Mean (SD) improvement in visual acuity from randomization was 2.7 (9.8) letters in the combination group and 3.0 (7.1) letters in the ranibizumab group, with the adjusted treatment group difference (combination minus ranibizumab) of -0.5 letters (95% CI, -3.6 to 2.5; 2-sided P = .73). Mean (SD) change in central subfield thickness in the combination group was -110 (86) μm compared with -62 (97) μm for the ranibizumab group (adjusted difference, -52; 95% CI, -82 to -22; 2-sided P < .001). Nineteen eyes (29%) in the combination group experienced increased intraocular pressure or initiated treatment with antihypertensive eyedrops compared with 0 in the ranibizumab group (2-sided P < .001). Conclusions and Relevance Although its use is more likely to reduce retinal thickness and increase intraocular pressure, the addition of intravitreous dexamethasone to continued ranibizumab therapy does not improve visual acuity at 24 weeks more than continued ranibizumab therapy alone among eyes with persistent DME following anti-VEGF therapy. Trial Registration clinicaltrials.gov Identifier: NCT01945866.
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“Pacman” invasion of the retina: Two cases of ophthalmomyiasis interna posterior. Am J Ophthalmol Case Rep 2019; 15:100491. [PMID: 31249904 PMCID: PMC6584607 DOI: 10.1016/j.ajoc.2019.100491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 05/30/2019] [Accepted: 06/03/2019] [Indexed: 11/24/2022] Open
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Effect of Adding Dexamethasone to Continued Ranibizumab Treatment in Patients With Persistent Diabetic Macular Edema: A DRCR Network Phase 2 Randomized Clinical Trial. JAMA Ophthalmol 2018. [PMID: 29127949 DOI: 10.1001/jamaophthalmol.2017.4914.4914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
IMPORTANCE Some eyes have persistent diabetic macular edema (DME) following anti-vascular endothelial growth factor (anti-VEGF) therapy for DME. Subsequently adding intravitreous corticosteroids to the treatment regimen might result in better outcomes than continued anti-VEGF therapy alone. OBJECTIVE To compare continued intravitreous ranibizumab alone with ranibizumab plus intravitreous dexamethasone implant in eyes with persistent DME. DESIGN, SETTING, AND PARTICIPANTS Phase 2 multicenter randomized clinical trial conducted at 40 US sites in 129 eyes from 116 adults with diabetes between February 2014 and December 2016. Eyes had persistent DME, with visual acuity of 20/32 to 20/320 after at least 3 anti-VEGF injections before a run-in phase, which included an additional 3 monthly 0.3-mg ranibizumab injections. Data analysis was according to intent to treat. INTERVENTIONS Following the run-in phase, study eyes that had persistent DME and were otherwise eligible were randomly assigned to receive 700 μg of dexamethasone (combination group, 65 eyes) or sham treatment (ranibizumab group, 64 eyes) in addition to continued 0.3-mg ranibizumab in both treatment arms as often as every 4 weeks based on a structured re-treatment protocol. MAIN OUTCOMES AND MEASURES The primary outcome was change in mean visual acuity letter score at 24 weeks as measured by the electronic Early Treatment Diabetic Retinopathy Study (E-ETDRS). The principal secondary outcome was change in mean central subfield thickness as measured with the use of optical coherence tomography. RESULTS Of the 116 randomized patients, median age was 65 years (interquartile range [IQR], 58-71 years); 50.9% were female and 60.3% were white. Mean (SD) improvement in visual acuity from randomization was 2.7 (9.8) letters in the combination group and 3.0 (7.1) letters in the ranibizumab group, with the adjusted treatment group difference (combination minus ranibizumab) of -0.5 letters (95% CI, -3.6 to 2.5; 2-sided P = .73). Mean (SD) change in central subfield thickness in the combination group was -110 (86) μm compared with -62 (97) μm for the ranibizumab group (adjusted difference, -52; 95% CI, -82 to -22; 2-sided P < .001). Nineteen eyes (29%) in the combination group experienced increased intraocular pressure or initiated treatment with antihypertensive eyedrops compared with 0 in the ranibizumab group (2-sided P < .001). CONCLUSIONS AND RELEVANCE Although its use is more likely to reduce retinal thickness and increase intraocular pressure, the addition of intravitreous dexamethasone to continued ranibizumab therapy does not improve visual acuity at 24 weeks more than continued ranibizumab therapy alone among eyes with persistent DME following anti-VEGF therapy. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01945866.
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Assessment of ischemia in acute central retinal vein occlusion from inner retinal reflectivity on spectral domain optical coherence tomography. Clin Ophthalmol 2016; 11:71-79. [PMID: 28053503 PMCID: PMC5189968 DOI: 10.2147/opth.s122683] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Purpose To determine the relationship between different spectral domain optical coherence tomography (SD-OCT) signs of retinal ischemia in acute central retinal vein occlusion (CRVO) and whether they predict anterior segment neovascularization (ASNV). Design Retrospective, observational study. Subjects Thirty-nine consecutive patients with acute CRVO and 12 months of follow-up. Methods We graded baseline SD-OCTs for increased reflectivity of the inner retina, loss of definition of inner retinal layers, presence of a prominent middle-limiting membrane (p-MLM) sign, and presence of paracentral acute middle maculopathy (PAMM). Graders were masked with respect to all clinical information. Results The intraclass correlation coefficients (ICCs) of grading–regrading by graders 1 and 2 were 0.8104, 95% confidence interval (CI) (0.6686, 0.8956), and 0.7986, 95% CI (0.6475, 0.8892), respectively. The intragrader coefficients of repeatability (COR) for graders 1 and 2 were 0.94 and 0.92, respectively. The ICC of graders 1 compared with 2 was 0.8039, 95% CI (0.6544, 0.8916). The intergrader COR was 0.80. SD-OCT grades of baseline ischemia were not associated with baseline visual acuity (VA), central subfield mean thickness (CSMT), or relative afferent pupillary defect; 12-month VA, CSMT, change in VA, change in CSMT, number of antivascular endothelial growth factor injections or corticosteroid injections, or proportion of eyes developing ASNV. SD-OCT grades of ischemia did not correlate with the proportion of eyes having the p-MLM sign or PAMM. PAMM and p-MLM are milder signs of ischemia than increased reflectivity of the inner retinal layers. Eyes with PAMM can evolve, losing PAMM and gaining the p-MLM sign. Conclusion Grading of ischemia from SD-OCT in acute CRVO was repeatable within graders and reproducible across graders for the graders in this study. SD-OCT signs of ischemia are not correlated with each other and do not reliably predict subsequent ASNV. Close monitoring of eyes with acute CRVO continues to be the safest method to avoid missing ASNV and neovascular glaucoma.
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Frequency of vitreomacular interface disease in patients presenting to a tertiary care institution. Ophthalmic Surg Lasers Imaging Retina 2014; 45:517-20. [PMID: 25423630 DOI: 10.3928/23258160-20141118-05] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 07/18/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE To evaluate the frequency of vitreomacular interface disease using a recently published optical coherence tomography (OCT) classification and assess which of these patients would qualify for ocriplasmin. PATIENTS AND METHODS A retrospective, consecutive case series of patients with macular cyst, hole, or pseudohole (ICD-9 code 362.54) and concurrent OCT imaging was performed. Eyes were classified using OCT as pseudohole, lamellar hole, vitreomacular adhesion (VMA), vitreomacular traction (VMT), and full-thickness macular hole (FTMH). Minimum diameter (MD) of FTMH was measured. RESULTS The study included 399 eyes of 331 patients. Of these, 61 eyes (15.3%) had VMA or VMT, 120 (30.0%) had a lamellar hole or pseudohole, and 218 (54.6%) had FTMH. Of eyes with FTMH, 73 were small (< 250 µm MD), 48 were medium (250 to 400 µm MD), and 97 were large (> 400 µm MD). Overall, 68 eyes (17.0%) would be candidates for ocriplasmin therapy. CONCLUSION Most patients had FTMH, and 17% would qualify as candidates for ocriplasmin therapy.
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Imaging characteristics of neovascular pigment epithelial detachments and their response to anti-vascular endothelial growth factor therapy. Br J Ophthalmol 2013; 97:1024-31. [DOI: 10.1136/bjophthalmol-2013-303155] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Rate of Hypotony Following 25-Gauge Pars Plana Vitrectomy. Ophthalmic Surg Lasers Imaging Retina 2013; 44:155-9. [DOI: 10.3928/23258160-20130215-01] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 01/02/2012] [Indexed: 11/20/2022]
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Triamcinolone Acetonide as an Adjuvant to Membrane Peeling Surgery: A Pilot Study. Ophthalmic Surg Lasers Imaging Retina 2013; 44:41-5. [DOI: 10.3928/23258160-20121221-11] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Accepted: 06/21/2012] [Indexed: 11/20/2022]
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Melanocytoma of the optic disc associated with visual field defects: clinical features and imaging characteristics. Ophthalmic Surg Lasers Imaging Retina 2011; 42 Online:e75-80. [PMID: 21830749 DOI: 10.3928/15428877-20110804-06] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2010] [Accepted: 06/20/2011] [Indexed: 11/20/2022]
Abstract
The authors studied the clinical features, visual field, and spectral-domain optical coherence tomography (SD-OCT) characteristics of peripapillary melanocytoma associated with visual field defects in two eyes of two patients. Both eyes had hyperreflective anterior surface and posterior optical shadowing in the region of peripapillary melanocytoma on SD-OCT imaging. The retinal nerve fiber layer was thin adjacent to these lesions, and this corresponded to the opposite hemifield defect on Humphrey Visual Field testing. Three-dimensional imaging of the melanocytoma revealed an irregular elevation in the peripapillary region. SD-OCT, when used in conjunction with clinical examination and Humphrey Visual Field testing, provided useful information that may assist clinicians in treating patients with peripapillary melanocytoma, particularly when observing them over time.
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Crystalline retinopathy in primary hyperoxaluria. J AAPOS 2011; 15:214-6. [PMID: 21596303 DOI: 10.1016/j.jaapos.2010.12.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2010] [Revised: 12/20/2010] [Accepted: 12/21/2010] [Indexed: 12/28/2022]
Abstract
We present the case of a 2.5-month-old boy with type 1 primary hyperoxaluria and severe systemic oxalosis resulting in massive retinal crystalline deposition. Maculopathy was demonstrated by optical coherence tomography, and nystagmus was present. Electroretinography demonstrated retinal dysfunction, unusual in oxalosis.
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Spectral domain optical coherence tomography for proliferative diabetic retinopathy with subhyaloid hemorrhage. Ophthalmic Surg Lasers Imaging Retina 2009; 39:494-6. [PMID: 19065981 DOI: 10.3928/15428877-20081101-14] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A prototype 6-microm axial resolution spectral domain optical coherence tomography (SD-OCT) device was used to image the retina of a patient with uncontrolled diabetes mellitus who had proliferative diabetic retinopathy with subhyaloid hemorrhage. A raster scan pattern with 128 B-scans covering a 6 X 6 X 2-mm volume of the retina was obtained. SD-OCT showed the presence of blood localized between the internal limiting membrane and the posterior hyaloid face and allowed visualization of the cross sectional retinal architecture and the vitreoretinal interface at different horizontal levels that could be registered with the color fundus photograph. SD-OCT provided useful information about the relationship of the hemorrhage to the posterior hyaloid and the retina.
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Repeatability of the multifocal visual evoked potentials in a clinical glaucoma setting. Can J Ophthalmol 2008; 43:435-40. [PMID: 18711458 DOI: 10.3129/i08-078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND To determine the reproducibility of the multifocal visual evoked potentials (mfVEP) test results in a clinical glaucoma setting, and the factors that affect variability. METHODS This was an observational case series study. The monocular mfVEP test, having a 58-sector, pattern-reversal dartboard array, was performed twice within 4 weeks in both eyes of 29 adult open-angle glaucoma (OAG) patients and suspects, using AccuMap Opera Software (ObjectiVision Pty Ltd, Sydney, Australia). The AccuMap severity index (ASI), the mean amplitude, and the individual amplitudes in each sector were compared between the 2 tests using intraclass correlations (ICCs). The effects of the severity of mfVEP field defects and signal-to-noise ratio (SNR) on the reproducibility of these variables were determined using the McNemar test and the Spearman rank correlation, respectively. RESULTS The average ICCs of the ASI and amplitudes in the 2 tests were 0.84 and 0.87, respectively. Two sectors in the right eye and 6 in the left eye had significant differences between the 2 tests (Wilcoxon signed-rank p < 0.05). Larger differences were observed in patients having lower SNR (Spearman p = 0.022). Forty-six of the 58 eyes stayed within the same diagnosis category on repeating the test (i.e., within normal limits or outside normal limits). INTERPRETATION Although there were some isolated examples of clinically significant differences on repeating the mfVEP test in our patients, our results suggest overall good repeat reliability. The variability of the test was higher in patients having high noise levels during the test.
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Macular thickness measurements in normal eyes using spectral domain optical coherence tomography. Ophthalmic Surg Lasers Imaging Retina 2008; 39:S43-9. [PMID: 18777876 DOI: 10.3928/15428877-20080715-02] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVE Knowledge of the macular thickness in a normal population is important for the evaluation of pathological macular change. The purpose of this study was to define and measure macular thickness in normal eyes using spectral domain optical coherence tomography (OCT). PATIENTS AND METHODS Fifty eyes from 50 normal subjects (29 men and 21 women, aged 22 to 68 years) were scanned with a prototype Cirrus HD-OCT system (5 microm axial resolution) (Carl Zeiss Meditec, Inc.). The proprietary Cirrus segmentation algorithm was used to produce retinal thickness maps, which were then averaged over 9 regions defined by a circular target centered at the true fovea location. The macular thickness of 13 subjects scanned with both HD-OCT and StratusOCT were compared. RESULTS After centering the fovea, the mean and standard deviation values for retinal thickness measurements were calculated point wise and averaged on standard regions. For patients scanned with both systems, the thickness measurements from HD-OCT were approximately 50 microm larger than those from StratusOCT. The difference between the two measurements decreased somewhat with eccentricity. CONCLUSION Using HD-OCT, it is possible to acquire retinal data sets containing an unprecedented number of data points. Furthermore, it is possible to use OCT fundus images to evaluate the scan quality and to center the measurement at the fovea. These advantages, together with good automated segmentation, can produce more accurate retinal thickness measurements. Incorporation of the photoreceptor layer in the measurements is anatomically meaningful and may be significant in evaluating various retinal pathologies and visual acuity outcomes.
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Composite spectral domain optical coherence tomography images of diabetic tractional retinal detachment. Ophthalmic Surg Lasers Imaging Retina 2008; 39:S99-103. [PMID: 18777880 DOI: 10.3928/15428877-20080715-06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This article describes the spectral domain optical coherence tomography (SD-OCT) findings in three patients with diabetic tractional retinal detachment. Three patients underwent fundus photography and SD-OCT imaging before and after pars plana vitrectomy, endola-ser, and membrane peel. On SD-OCT, all three patients exhibited significant improvement or resolution of subretinal fluid after the surgical release of traction. In this case series, a clinically useful method of visualizing SD-OCT images is demonstrated. Composite images were manually constructed with commercially available software by merging high-density B-scans from the macula and optic nerve. The composite image allowed simultaneous visualization of the effects of proliferative diabetic retinopathy on the macula and optic nerve and is particularly helpful in evaluating tractional macular detachment.
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Three-dimensional spectral-domain optical coherence tomography images of the retina in the presence of epiretinal membranes. Am J Ophthalmol 2008; 145:1023-1030. [PMID: 18342830 DOI: 10.1016/j.ajo.2008.01.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2007] [Revised: 01/06/2008] [Accepted: 01/08/2008] [Indexed: 02/02/2023]
Abstract
PURPOSE To study the inner surface of the retina in the presence of epiretinal membranes (ERMs) using a prototype spectral-domain optical coherence tomography (SD-OCT) device. DESIGN Small case series, performed in the Department of Ophthalmology, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, from August 2005 through December 2006. METHOD An 8-microm axial-resolution SD-OCT instrument was used to scan the eyes of patients diagnosed with ERM. The ERM and the internal limiting membrane (ILM) were segmented separately to evaluate the traction caused by the ERM on the retina. It was then possible to reconstruct the ILM and ERM surfaces in 3-dimensional space and to obtain corresponding retinal thickness maps. RESULTS SD-OCT B scans showed the points of attachment of the ERM to the ILM. Segmented surface maps of the ERM produced very smooth sheets, whereas those of the ILM presented wrinkles under and around the ERM. CONCLUSIONS SD-OCT revealed the geometry of retinal traction in eyes with ERM and may be useful in understanding further the pathologic features of these lesions.
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Imaging Serpiginous Choroidopathy With Spectral Domain Optical Coherence Tomography. Ophthalmic Surg Lasers Imaging Retina 2008; 39:S95-8. [DOI: 10.3928/15428877-20080715-05] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Effect of statin drugs and aspirin on progression in open-angle glaucoma suspects using confocal scanning laser ophthalmoscopy. Clin Exp Ophthalmol 2007; 35:506-13. [PMID: 17760631 DOI: 10.1111/j.1442-9071.2007.01529.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To determine the effect of statins and aspirin on the rate of progression of optic nerve parameters in open-angle glaucoma (OAG) suspects, as defined by confocal scanning laser ophthalmoscopy (CSLO). METHODS Data of OAG suspects who had undergone at least two CSLO tests at the Beckman Vision Center at UCSF from January 2001 to June 2006 was collected. We conducted a retrospective chart review of 149 eyes from 76 patients considered suspect for glaucoma based on a cup-to-disc ratio >0.5, but with normal intraocular pressures (IOP) and visual fields. Subjects included glaucoma suspects who took statin drugs or aspirin for greater than 23 months. The control group consisted of suspects who never used statins or aspirin. The data were analysed using mixed effects regression. RESULTS When comparing controls with the statin group there were significant differences in the progression of multiple CSLO parameters per year, including rim volume (-13.7% controls, +26.7% statin only; P = 0.0156), retinal nerve fibre layer cross-sectional area (-12.2% controls, +24.3% statin only; P = 0.0051), and mean global retinal nerve fibre layer thickness (-10.3% controls, +26.6% statin only; P = 0.0114), with adjustment for age, gender, race, IOP, central corneal thickness, refractive error and multiple systemic comorbidities. No significant differences were found when comparing subjects taking a statin plus aspirin or aspirin alone with the controls. CONCLUSIONS Statin drugs may be associated with slowed progression of optic nerve parameters in glaucoma suspects as measured by CSLO.
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New Investigations: Contour-Matching Tonometry in the World of Glaucoma Diagnostics. J Curr Glaucoma Pract 2007. [DOI: 10.5005/jp-journals-10008-1051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Abstract
PURPOSE To evaluate whether treatment of systemic hypertension has an effect on progression of optic nerve parameters in glaucoma suspects using confocal scanning laser ophthalmoscopy. METHODS Two hundred eyes of 103 glaucoma suspect patients were included in this retrospective cohort study. Thirty-one patients (of whom 59 eyes were included in the study) had systemic hypertension under treatment (based on medical history). The remaining 72 age-matched normotensive controls (of whom 141 eyes were included in the study) were not on blood-pressure-lowering medications. Each patient had a follow-up period of at least 4 years with a minimum of four Heidelberg retinal tomograph tests (one baseline and three follow-up scans). The slopes of progression of optic nerve head parameters with time were studied and compared between these two groups using mixed effects regression models. RESULTS Patients with systemic hypertension showed a statistically significant increase in cup area (slope 0.2, p = 0.03), cup-to-disk area ratio (slope 0.01, p = 0.007), and decrease in rim area (slope -0.4, p = 0.03), rim-to-disk area ratio (slope -0.01, p = 0.005), and global Retinal Nerve Fiber Layer (RNFL) thickness (p = 0.008) with time. The differences in slopes of progression of many parameters between hypertensives and normotensives were statistically significant. CONCLUSIONS Systemic hypertension treated with hypotensive medications may be a risk factor for increased progression of optic nerve parameters in glaucoma suspects compared with age-matched normotensive subjects.
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Abstract
PURPOSE To compare the prevalence and severity of dry eye in patients with rheumatoid arthritis (RA) with that in age- and sex-matched controls in the Indian population. METHODS A cross-sectional study was performed on 84 randomly selected eyes of 84 adult patients with well-documented rheumatoid arthritis and 84 eyes of 84 age- and sex-matched controls in the Department of Ophthalmology, Seth G.S. Medical College and K.E.M. Hospital. McMonnie's dry eye questionnaire was used to classify the patients on the basis of their symptoms. Dry eye was diagnosed if the wetting on Schirmer filter paper test was < or =5 mm at 5 minutes and the tear film breakup time was < 10 seconds on slit-lamp examination after fluorescein staining. RESULTS Twenty three patients (27.3%) with rheumatoid arthritis had dry eyes based on the Schirmer test as compared to 10 (12%) age- and sex-matched controls; 19 (22.62%) patients with RA had a tear film breakup time of < 10 sec. on slit-lamp examination, compared to 8 (9.52%) patients without RA. The difference in the mean wetting (p = 0.003) and mean tear film breakup time (p < 0.001) between RA and non-RA patients was statistically significant. Ocular symptoms had a limited correlation with the results of these tests. CONCLUSIONS Patients with RA in the Indian population have a significantly higher prevalence and severity of dry eye when compared to age- and sex-matched controls.
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Documentation by Spectral Domain OCT of Spontaneous Closure of Idiopathic Macular Holes. Ophthalmic Surg Lasers Imaging Retina 2007; 38:330-2. [PMID: 17674926 DOI: 10.3928/15428877-20070701-11] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
An observational case series using an 8-microm axial resolution prototype spectral domain optical coherence tomography (OCT) system was performed in two patients with idiopathic macular holes. Spontaneous closure and visual acuity improvement occurred in both patients. Useful information about morphology and vitreoretinal relationship of the holes was provided by spectral domain OCT.
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Documentation of Optic Nerve Pit With Macular Schisis-like Cavity by Spectral Domain OCT. Ophthalmic Surg Lasers Imaging Retina 2007; 38:262-4. [PMID: 17552399 DOI: 10.3928/15428877-20070501-17] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The authors report using spectral domain optical coherence tomography (OCT) to observe a patient with an optic nerve pit and macular schisis-like spaces. An 8-microm axial resolution prototype spectral domain OCT and stereo fundus photography were used to observe the patient. A macular schisis-like cavity was present at baseline and additional cystic changes developed in the nerve fiber layer over a period of 16 months; however, the visual acuity remained stable at 20/20. Spectral domain OCT provides greater detail of the changes in morphology and structure of macular schisis and edema associated with an optic nerve pit.
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Abstract
Interindividual variability of central corneal thickness has been found to be a source of error for conventional Goldmann applanation tonometry. The dynamic contour tonometer represents a potentially new technology for non-invasive and direct intraocular pressure (IOP) measurement, and has been proposed to accurately measure the true IOP irrespective of the corneal thickness. It is based on the principle that when the tip of the device exactly matches the contour of the cornea, the pressure measured by a transducer placed on its tip is an accurate indicator of the true IOP. This device is also capable of measuring the ocular pulse amplitude, a variable that has controversial significance in the diagnosis and management of glaucoma. Even though this technique seems to be very promising, further studies are required to conclusively determine the effectiveness of the dynamic contour tonometer in patients having an abnormal or irregular corneal contour.
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Intraocular pressure and ocular pulse amplitude comparisons in different types of glaucoma using dynamic contour tonometry. Curr Eye Res 2006; 31:851-62. [PMID: 17050277 DOI: 10.1080/02713680600899887] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To compare the intraocular pressures (IOP) and ocular pulse amplitudes (OPA) in patients with different types of glaucoma, ocular hypertension (OHT), and normal controls (NC) using dynamic contour tonometry (DCT) and the goldmann applanation tonometry (GAT). METHODS 906 eyes of 501 adult patients in the following five groups were included in this cross-sectional study: primary open angle glaucoma (POAG), normal tension glaucoma (NTG), Pseudoexfoliative Glaucoma (PXG), OHT, and NC. The following tests were performed simultaneously during a single visit: IOP using DCT and GAT; OPA using DCT and central corneal thickness (CCT) using ultrasound pachymetry. Mixed effects regression models were used to compare the DCT and GAT IOP measurements in the five groups; the effect of CCT on IOP and the relationship between OPA and IOP within each group. RESULTS DCT consistently had higher IOP values than GAT in POAG, PXG, NTG, and controls (p < 0.001) but not in OHT (p = 0.84). DCT IOP did not change while GAT IOP showed a non-significant increase (p = 0.09) with increased corneal thickness in each group. OPA was found to be highest in OHT (3.61 mmHg) and lowest in the control group (2.86 mmHg) and significantly increased with IOP in all groups. CONCLUSIONS DCT measures an IOP that is significantly higher than GAT IOP in glaucoma and control subjects but not in ocular hypertensives. Furthermore, the DCT may measure an IOP that is independent of the CCT, which may not be true for the GAT, which increases with the CCT. OPA was highest in OHT and may be affected by the IOP.
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