Abstract: PURPOSE: To evaluate the outcome of modified deep sclerectomy [D-lectomy mitomycin C (MMC)] for medically refractory glaucoma patients. METHODS: In a retrospective comparative study, the surgical outcome in 1 eye each of 31 patients who underwent D-lectomy MMC was compared with that of 91 eyes of 91 patients who underwent trabeculectomy with adjunctive MMC. These eyes had a diagnosis of primary open-angle glaucoma or pseudoexfoliation glaucoma, a record of high intraocular pressure (IOP) exceeding 25 mm Hg, and planned for surgical intervention. In the D-lectomy MMC cases, a slit incision at the trabecular meshwork and peripheral iridectomy were created. The "lake" and trabeculo-Descemet membrane ("window") were examined by ultrasound biomicroscope, gonioscopy, and time-domain optical coherence tomography. RESULTS: Postsurgical IOP at 1, 3, 6, and 12 months after the D-lectomy MMC and trabeculectomy MMC were comparable (P=0.63-0.97). The filtering bleb was noted in 14 (45%) of the 31 D-lectomy MMC eyes at 3 months, and their survival was significantly less than trabeculectomy MMC subjects in which 81 of 91 eyes had the bleb at 3 months (P<0.0001). The lake was noted in 29 of 31 D-lectomy MMC eyes. The sealing of the once penetrated trabecular meshwork was complete at 3 months in 23 of 29 eyes by ultrasound biomicroscopic and/or gonioscopic examinations, whereas that was incomplete in 6 eyes. CONCLUSIONS: Addition of a slit incision to the trabecular meshwork and peripheral iridectomy (D-lectomy MMC) improved postsurgical IOP of the deep sclerectomy to the level comparable with trabeculectomy MMC, with a less frequency of the bleb formation.

Abstract: BACKGROUND: The high prevalence of normal tension glaucoma (NTG) in the Japanese requires special screening tests other than measurements of only the intraocular pressure (IOP). This study was carried out to determine whether there is a significant association between the axial length of the eye and the presence of NTG. METHODS: We reviewed the medical records of all patients who were scheduled to undergo cataract surgery alone or combined with glaucoma surgery at the same time. There were 87 patients with NTG, 137 with POAG, and 978 non-glaucomatous control cases. The axial length, IOP, curvature of the anterior corneal surface, age, and gender were determined at the time of the operation. If both eyes had surgery, data from only the right eyes were analyzed. An association of these parameters with NTG and POAG was analyzed by logistic regression analysis. The three groups were analyzed for differences in the axial length using the Kruskal-Wallis test followed by the Mann-Whitney U test. RESULTS: The axial length was significantly associated with NTG (odds = 1.24, P = 0.002) and POAG (odds = 1.28, P = 0.001). The incidence of either POAG or NTG was significantly higher in patients with axial lengths >or=25.0 mm (odds = 2.29, P < 0.001, Fisher's exact test). The age at the time of cataract surgery was weakly but significantly correlated negatively with the axial length (r = -0.24, P < 0.001, Pearson's correlation coefficient test). Men had significantly longer axial lengths than women. CONCLUSIONS: Long axial lengths can be considered a risk factor for NTG and POAG, and patients with long axial lengths need to be carefully examined for glaucoma.

Abstract: PURPOSE: To determine factors affecting the outcome of phacoviscocanalostomy in patients with cataract and primary open-angle glaucoma. METHODS: Factors for controlling intraocular pressure (IOP) were investigated in 180 patients using Cox multivariate proportional hazards survival regression. RESULTS: The mean preoperative IOP of 20.2+/-3.8 mm Hg decreased significantly (P<0.0001) to 15.3+/-2.6 mm Hg for 5 years postoperatively. The success probabilities defined as an IOP of 17 mm Hg or less or a 20% or greater reduction were 47.2% with or without medications and 31.4% without medications at 5 years. Preoperative IOP level [P=0.0013; odds ratio (OR), 1.14] and age (P=0.037; OR, 0.97) were risk factors in the success probability with or without medications. In the analysis without medications, the preoperative IOP (P<0.001; OR, 1.12), the preoperative number of antiglaucoma medications (P=0.033; OR, 1.27), age (P=0.003; OR, 0.96), and IOP spikes (P=0.028; OR, 1.22) were associated with failure. Sex, peeling of juxtacanalicular tissue, ruptured Descemet membrane, fibrin formation, and hyphema did not affect surgical outcomes. CONCLUSIONS: High preoperative IOP, the number of preoperative medications, postoperative IOP spikes (>30 mm Hg) increased the risk of failed IOP control after phacoviscocanalostomy. Increasing patient age decreased the risk of failure.

Abstract: PURPOSE: To evaluate the effect of pars plana implantation of the Ahmed glaucoma valve on refractory glaucoma. METHOD: Five patients (5 eyes) (3 men, 2 women) were fitted with the Ahmed glaucoma valve. Mean age was 51.8 21.3 years, and mean follow-up was 9.4 +/- 2.6 months. Among the 5 eyes studied, 4 eyes were in neovascular glaucoma patients. Of these 4 eyes, 2 eyes were in diabetic retinopathy patients and 2 eyes were in a patient with central retinal vein occlusion. The remaining eye was in a developmental glaucoma patient. As a surgical procedure after pars plana vitrectomy, the inlet tube of the Ahmed glaucoma valve was placed in the posterior chamber. RESULT: The mean preoperative IOP of 46.8 +/- 15.7 mmHg (30-64 mmHg) under maximum tolerable medication was reduced to 16.0 +/- 2.0 mmHg (14-19 mmHg) after surgery. Postoperative visual acuity improved in 3 eyes, and the mean visual acuity in these eyes improved from 0.05 +/- 0.09 (sl.-0.07) to 0.17 +/- 0.3(0-0.7). A reduction in visual acuity was observed in 2 eyes; in one, due to retinal detachment, and in the other, due to transient high IOP and vitreous hemorrhage. The visual acuity improved in 60% of patients and the IOP controlled in 80% of patients. CONCLUSION: The implantation of the Ahmed glaucoma valve for refractory glaucoma was effective in our study.

Abstract: PurposeTo better understand the reference values and adequate discrimination values of colour vision function with described quantitative systems for the Lanthony desaturated D-15 panel (D-15DS).MethodsA total of 1042 Japanese male officials were interviewed and underwent testing using Ishihara pseudoisochromatic plates, standard pseudoisochromatic plates part 2, and the D-15DS. The Farnsworth-Munsell (F-M) 100-hue test and the criteria of Verriest et al were used as definitive tests. Outcomes of the D-15DS were calculated using Bowman's Colour Confusion Index (CCI). The study design included two criteria. In criterion A, subjects with current or past ocular disease and a best-corrected visual acuity less than 0.7 on a decimal visual acuity chart were excluded. In criterion B, among subjects who satisfied criterion A, those who had a congenital colour sense anomaly were excluded.ResultsOverall, the 90th percentile (95th percentile) CCI values for criteria A and B in the worse eye were 1.70 (1.95) and 1.59 (1.73), respectively. In subjects satisfying criterion B, the area under the receiver operating characteristic curve was 0.951 (95% confidence interval, 0.931-0.971). The CCI discrimination values of 1.52 or 1.63 showed 90.3% sensitivity and 90% specificity, or 71.5% sensitivity and 95% specificity, respectively, for discriminating acquired colour vision impairment (ACVI).ConclusionWe provided the 90th and 95th percentiles in a young to middle-aged healthy population. The CCI is in good agreement with the diagnosis of ACVI. Our results could be helpful for using D-15DS for screening purposes.Eye advance online publication, 3 October 2008; doi:10.1038/eye.2008.292.

Abstract: PURPOSE: To identify factors that affect corneal birefringence, such as the corneal polarization axis (CPA) and corneal polarization magnitude (CPM), after laser in situ keratomileusis (LASIK) using scanning laser polarimetry with a variable corneal polarization compensator. METHODS: The CPA and CPM from 42 patients (42 eyes) who underwent LASIK and 24 normal untreated subjects (24 eyes) were measured 1 week before and 1 week after LASIK. Changes in the CPA and CPM after LASIK were studied using Student t test and Pearson correlation coefficient. RESULTS: In the LASIK group, the post-LASIK CPA and CPM significantly changed, whereas both values did not change in normal subjects. Among 5 candidate factors [preoperative CPA (pre-CPA), preoperative CPM (pre-CPM), age, change in corneal curvature, and ablation depth], the change in CPA was significantly correlated with the pre-CPA (r=-0.793) and pre-CPM (r=0.339). The change in CPM was correlated with the pre-CPA (r=-0.455) and pre-CPM (r=-0.411). Over 83% case of postoperative corneal birefringence can be explained by only 2 parameters with regression analysis. CONCLUSIONS: The pre-CPA and pre-CPM are strongly associated with LASIK-induced changes in CPA and CPM. Variations in age, changes in corneal curvature, and ablation depth do not contribute to changes in either parameter.

Abstract: PURPOSE: To compare the midterm efficacy and safety of phacoviscocanalostomy (viscocanalostomy, phacoemulsification, and intraocular lens [IOL] implantation) and cataract surgery (phacoemulsification and IOL implantation) in patients with normal-tension glaucoma (NTG) and cataract. SETTING: Sensho-kai Eye Institute, Kyoto, Japan. METHODS: Thirty-one eyes had phacoviscocanalostomy, and 35 eyes had uncomplicated cataract surgery only. The intraocular pressure (IOP), postoperative antiglaucoma medications, and visual outcomes were compared between groups. RESULTS: The mean follow-up was 34.9 months+/-19.8 (SD) (range 7 to 78 months). At 36 months, the mean preoperative IOP and postoperative IOP were 17.2+/-1.5 mm Hg and 14.1+/-1.6 mm Hg, respectively, in the phacoviscocanalostomy group and 16.7+/-1.4 mm Hg and 15.6+/-3.4 mm Hg, respectively, in the cataract surgery only group. The differences between groups were significant at all time points (P<.05). The success probabilities of the phacoviscocanalostomy group achieving 20% and 30% IOP reductions with (or without) medications were 78.5% (67.4%) and 35.5% (37.4%) at 24 months and 58.0% (44.2%) and 28.0% (26.6%) at 48 months, which were significantly better than the probabilities in the cataract surgery only group, which were 16.0% (9.5%) and 5.7% (2.9%) at 24 months (P<.001 for each comparison, Kaplan-Meier life-table analysis with log-rank test). Based on the modified Aulhorn-Greve classification, the visual acuity and visual fields did not deteriorate in the phacoviscocanalostomy group; the visual fields deteriorated in 6 eyes in the cataract surgery only group during the follow-up (P=.024). CONCLUSION: Phacoviscocanalostomy lowered IOP and maintained postoperative visual outcomes; it was safe and effective in elderly patients with coexisting NTG and cataract.

Abstract: PURPOSE: To evaluate retinal nerve fiber layer (RNFL) thickness in patients with diabetes mellitus compared with age-matched normal control subjects, to assess the correlation between the RNFL thickness and the severity of retinopathy, and to investigate whether diabetes mellitus is a potential source of abnormal results in glaucoma screening or evaluation with scanning laser polarimetry (SLP). DESIGN: Cross-sectional analysis of normal and diabetic eyes. METHODS: setting: Institutional clinical study. patients: One hundred twenty-eight subjects with type 2 diabetes mellitus and 50 age-matched normal control subjects without glaucoma or glaucoma-suspect. All patients underwent imaging with SLP and repeatable automated perimetry. Subjects with diabetes mellitus were classified into four stages on the basis of the severity of retinopathy that was assessed by dilated funduscopic examination, high-quality fundus color photography, and fluorescein angiography. MAIN OUTCOME MEASURES: The SLP (GDx VCC software, version 5.5.0) parameters. RESULTS: The RNFL thickness in patients with diabetes mellitus was reduced significantly compared with age-matched normal control eyes (P < .01). Moreover, all RNFL thickness parameters of the GDx VCC software decreased significantly as an exacerbation of diabetic retinopathy (P = .0019, P = .0045, P = .0010 for temporal-superior-nasal-inferior-temporal (TSNIT) average, superior average, inferior average, respectively). The nerve fiber indicator also increased significantly (P < .0001), despite an absence of glaucomatous optic nerve damages. CONCLUSION: The RNFL thickness in type 2 diabetes mellitus, which was measured by GDx VCC software, significantly decreased with the severity of diabetic retinopathy. The presence of diabetes mellitus can be a source of false-positive results and overestimation of glaucomatous optic neuropathy when eyes are screened with GDx VCC software.