The large retrospective study comparing limbus-based and fornix-based trabeculectomy outcomes by Solus et al1Solus J.F. Jampel H.D. Tracey P.A. et al.Comparison of limbus-based and fornix-based trabeculectomy: success, bleb-related complications, and bleb morphology.Ophthalmology. 2012; 119: 703-711Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar together with the companion paper2Jampel H.D. Solus J.F. Tracey P.A. et al.Outcomes and bleb-related complications of trabeculectomy.Ophthalmology. 2012; 119: 712-722Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar from the same group looking at outcomes in general provide important data that can inform our practice. Although the companion paper describes baseline preoperative and demographic data, these are not shown in either paper individually for the 2 groups. This would have been extremely helpful, if not vital, particularly in the case of a retrospective, nonrandomized study, as it is possible that differences other than the conjunctival approach may contribute to the observed differences in outcomes. Another potential confounding factor relates to the area of mitomycin-C application. A larger area of MMC application may lead to more diffuse, less cystic blebs,3Jones E. Clarke J. Khaw P.T. Recent advances in trabeculectomy technique.Curr Opin Ophthalmol. 2005; 16: 107-113Crossref PubMed Scopus (131) Google Scholar and many surgeons have adopted the use of a larger area of application than used previously.4Rai P. Kotecha A. Kaltsos K. et al.Changing trends in the incidence of bleb-related infection in trabeculectomy.Br J Ophthalmol. 2012; 96: 971-975Crossref PubMed Scopus (34) Google Scholar This transition occurred at a similar time to the change from limbus to fornix-based conjunctival flaps, and may be facilitated by a fornix-based approach. It would be helpful to know if the study authors changed the size of area of application (although this may not be so easy to ascertain) as this could have a significant effect on outcomes. One of the main findings of the study is the lower infection risk with fornix-based procedures; could this be related to a change in MMC application technique rather than differences in conjunctival approach per se? Comparison of Limbus-Based and Fornix-Based Trabeculectomy: Success, Bleb-Related Complications, and Bleb MorphologyOphthalmologyVol. 119Issue 4PreviewTo compare the success and complications of trabeculectomy performed with limbus-based and fornix-based conjunctival approaches. Full-Text PDF Author replyOphthalmologyVol. 119Issue 10PreviewWe thank Drs. Gavin, Mahroo, and Lim for their thoughtful letter. We did not include a Table comparing the baseline preoperative and demographic data for limbus-based and fornix-based procedures because there were no differences in any important variables. For completeness here, the following variables were not significantly different between the limbus-based and fornix-based groups in our study: surgeon, age at surgery, sex, self-identified race, laterality of eye, glaucoma diagnosis type, history of prior laser treatment, number of previous incisional surgeries, number and type of preoperative glaucoma medications, highest untreated intraocular pressure (IOP), baseline mean IOP, visual acuity, or which antifibrosis agent was used (mitomycin used in 85% and 88% of limbus and fornix-based cases, respectively). Full-Text PDF

PURPOSE:To determine rates of success and complications of trabeculectomy surgery. DESIGN:Case series. PARTICIPANTS:Consecutive patients undergoing trabeculectomy by 2 surgeons between May 2000 and October 2008. INTERVENTION:By using the Wilmer Institute's billing database, we identified all patients at least 12 years of age coded as having undergone trabeculectomy between May 2000 and October 2008 by 1 of 2 glaucoma surgeons and whose surgery was not combined with another operation. From the chart, we abstracted demographic information on the patients and clinical characteristics of the eyes. The Kaplan-Meier product-limit method and Cox proportional hazard models were used to look at success rates and characteristics associated with inadequate intraocular pressure (IOP) reduction. Complications were tabulated. MAIN OUTCOME MEASURES:(1) Success rate of trabeculectomy, as determined by the achievement of each of 4 different IOP goals, with or without IOP-lowering medications; and (2) incidence of surgical complications. RESULTS:During the study period, 797 eyes of 634 persons underwent trabeculectomy without concurrent surgery. The success rates 4 years after surgery, with or without the use of IOP-lowering eye drops, were 70%, 72%, 60%, and 44%, for achievement of target IOP, ≤18 mmHg and ≥20% IOP reduction, ≤15 mmHg and ≥25% reduction, and ≤12 mmHg and ≥30% reduction, respectively. Increased chance of success was associated with European-derived race; use of mitomycin C (MMC); higher concentrations of MMC, when used; and higher preoperative IOP. Age and previous intraocular surgery were not associated with surgical success. Complications included worsening lens opacity in 242 of 443 phakic eyes (55%), loss of ≥3 lines of acuity (Snellen) in 161 eyes (21%), surgery for bleb-related problems in 70 eyes (8.8%), and infection occurring >6 weeks after surgery in 27 eyes (3.4%). A total of 101 eyes of 94 patients had at least 1 subsequent operation for inadequate IOP control. CONCLUSIONS:Trabeculectomy surgery performed by 2 experienced glaucoma specialists achieved target IOP at 4 years in 70% of those operated and was associated with progressive cataract and small risks of bleb-related complications. These results are comparable to those reported in smaller series.

Purpose: To compare initial glaucoma therapy with medications and trabeculectomy in southern India. Methods: Patients aged ≥30 years newly diagnosed with glaucoma were randomized to trabeculectomy with 5-fluorouracil or medical therapy. Subjects with best-corrected vision <6/18 due to cataract underwent phacoemulsification (phaco/intraocular lens, IOL). Intraocular pressure (IOP), vision and visual function were assessed at 12 months. Results: Patients assigned to medications and surgery received the expected therapy in 86% (172/199) and 64% (126/199) of cases, respectively. Forty patients (20%) assigned to surgery refused any treatment and 33 (17%) received medications. Among 199 patients randomized to medications, 52 (26.1%) underwent phaco/IOL, as did 89/199 (43.7%) of patients randomized to trabeculectomy. Baseline parameters of the two groups did not differ, nor did 1-year follow-up rates (medication 65%, trabeculectomy 58%, P = 0.15). Final IOP was lower with randomization to trabeculectomy (16.3 ± 5.1 mmHg) than medication (18.8 ± 6.7 mmHg, P < 0.0001). In regression models, randomization to trabeculectomy (P < 0.0001) was associated with lower IOP, and simultaneous trabeculectomy and cataract surgery was associated with higher IOP (P = 0.008) than trabeculectomy alone. Subjects receiving Phaco/IOL had significantly better final acuity (P < 0.0001) and visual function (P = 0.035), despite concurrent glaucoma treatment. Final visual acuity was worse in those receiving trabeculectomy in addition to cataract surgery, but this was of borderline significance (P = 0.06). Conclusions: Trabeculectomy lowered IOP significantly more than medical treatment, but with slightly greater loss of visual acuity. Combined phaco/IOL and trabeculectomy improved visual acuity with substantial IOP lowering.

Purpose: To compare the success and complications of trabeculectomy performed with limbus-based and fornix-based conjunctival approaches.Design: Retrospective case series with some prospective data collection.Participants: Consecutive patients undergoing trabeculectomy by 2 surgeons between May 2000 and October 2008.Intervention: We performed limbus-based operations during the first 4 years and fornix-based operations during the last 4 years. We collected data by chart review and by examination at the most recent visit. For each follow-up visit, we defined success as undergoing no further glaucoma procedure and achieving one of our intraocular pressure (IOP) criteria. We used Kaplan-Meier survival analysis, Cox proportional hazards models, and generalized estimating equation (GEE) analysis. During 2009, 439 trabeculectomy sites of 347 patients were quantitatively assessed by the Indiana bleb grading system.Main Outcome Measures: (1) Success rate of trabeculectomy, as determined by the achievement of each of our different IOP goals, with or without IOP-lowering medications; and (2) incidence of surgical complications.Results: During the 4 years after surgery, the success rates of limbus-based and fornix-based trabeculectomy were not statistically different for any of our IOP criteria. Blebs after limbus-based surgery were more likely to be graded as higher and to be avascular (GEE model, both P < 0.0001). Four percent of eyes experienced late-onset bleb leaks within 4 years after both limbus- and fornix-based operations; however, limbus- based cases developed bleb leaks significantly later than did fornix-based cases (2.1 vs. 1.0 years; P = 0.002, GEE model). Late bleb-associated infection during the first 4 years after surgery occurred more often in limbus- based operations, although statistical significance was borderline (P = 0.054, Cox model). Symptomatic hypotony during all available follow-up was more common with fornix-based operations (P = 0.01, GEE model). Eyes undergoing the fornix-based operation had a greater risk of cataract surgery in the 4-year period after surgery (P = 0.02, Cox model), and fornix-based cases requiring cataract surgery had the operation earlier than limbus-based cases (P = 0.002, GEE model).Conclusions: Success rates are similar between limbus-based and fornix-based trabeculectomy. Limbus-based procedures produce higher, more avascular blebs, with a greater risk of infection. Fornix-based procedures have more symptomatic hypotony and more and earlier cataract development.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Ophthalmology 2012;119:703-711 (C) 2012 by the American Academy of Ophthalmology.

Purpose: To study willingness to pay for cataract surgery, and its associations, in Southern China.Design: Cross-sectional willingness-to-pay interview incorporating elements of the open-ended and bidding formats.Participants: Three-hundred thirty-nine persons presenting for cataract screening in Yangjiang, China, with presenting visual acuity (VA) <= 6/60 in either eye due to cataract. Methods: Subjects underwent measurement of their VA and a willingness-to-pay interview. Age, gender, literacy, education, and annual income also were recorded.Main Outcome Measures: Maximum amount that the subjects would be willing to pay for cataract surgery.Results: Among 325 (95.9%) subjects completing the interview, 169 (52.0%) were 70 years or older, 213 (65.5%) were women, and 217 (66.8%) had an annual income of < 5000 renminbi (5000 = US $625). Eighty percent (n = 257) of participants were willing to pay something for surgery (mean, 442 444 renminbi [US $55 +/- 55]). In regression models, older subjects were willing to pay less (8 renminbi [US $1] per year of age; P = 0.01). Blind subjects were significantly more likely (odds ratio, 5.7; 95% confidence interval, 1.7-19.3) to pay anything for surgery, but would pay on average 255 renminbi (US $32) less (P = 0.004). Persons at the highest annual income level (> 1 0 000 renminbi [US $1250]) would pay $50 more for surgery than those at the lowest level (< 5000 renminbi) (P = 0.0003). The current cost of surgery in this program is 500 renminbi (US $63).Conclusions: Sustainable programs will need to attract younger, more well-to-do persons with better vision, while still providing access to the neediest patients.

center dot PURPOSE: We studied the effects on intraocular pressure (IOP) of anesthesia administered during examination under anesthesia (EUA) in children.center dot DESIGN: Randomized clinical trial.center dot METHODS: This randomized trial compared IOP after inhaled sevoflurane gas to that after intramuscular ketamine hydrochloride in children undergoing EUA. IOP was measured in 30 eyes with TonoPen XL (Mentor, Inc, Norwell, Massachusetts, USA) as soon as possible after anesthesia induction (T1) and two, four, six, and eight minutes thereafter. At the same times, we recorded systolic and diastolic blood pressure (SBP, DBP) and heart rate (HR).center dot RESULTS: Compared with the mean IOP at T1, IOP in the sevoflurane group was significantly lower for all measurements from two to eight minutes thereafter (mean decrease in IOP: two minutes = 12%, four minutes = 19%; six minutes = 19%; eight minutes = 17%, all P <= .01). In the ketamine group, mean IOP was not significantly changed from T1 through six minutes, whereas at eight minutes, it was 7% lower (P = .03). SBP and DBP were significantly lower for sevoflurane than for ketamine at all measurements from two minutes onward, and HR was lower for sevoflurane than for ketamine at two, four, and six minutes.center dot CONCLUSIONS: IOP measured after ketamine sedation is more likely to represent the awake IOP than that after sevoflurane anesthesia. Changes in SBP, DBP, and HR caused by sevoflurane suggest that hemodynamic alterations may underlie its effects on IOP.

PURPOSE. To study the prevalence and determinants of compliance with spectacle wear among school-age children in Oax-aca, Mexico, who were provided spectacles free of charge.METHODS. A cohort of 493 children aged 5 to 18 years chosen by random cluster sampling from primary and secondary schools in Oaxaca, Mexico, all of whom had received free spectacles through a local program, underwent unannounced, direct examination to determine compliance with spectacle wear within 18 months after initial provision of spectacles. Potential determinants of spectacle wear including age, gender, urban versus rural residence, presenting visual acuity, refractive error, and time since dispensing of the spectacles were examined in univariate and multivariate regression models. Children not currently wearing their spectacles were asked to select the reason from a list of possibilities, and reasons for noncompliance were analyzed within different demographic groups.RESULTS. Among this sample of children with a mean age of 10.4 +/- 2.6 years, the majority (74.5%) of whom were myopic (spherical equivalent [SE] <= -0.50 D), 13.4% (66/493) were wearing their spectacles at the time of examination. An additional 34% (169/493) had the spectacles with them but were not wearing them. In regression models, the odds of spectacle wear were significantly higher among younger (OR = 1.19 per year of age; 95% CI, 1.05-1.33) rural (OR = 10.6; 95% CI, 5.3-21.0) children and those with myopia <= -1.25 D (OR = 3.97; 95% CI, 1.98-7.94). The oldest children and children in urban-suburban areas were significantly more likely to list concerns about the appearance of the glasses or about being teased than were younger, rurally resident children.CONCLUSIONS. Compliance with spectacle wear may be very low, even when spectacles are provided free of charge, particularly among older, urban children, who have been shown in many populations to have the highest prevalence of myopia. As screening programs for refractive error become increasingly common throughout the world, new strategies are needed to improve compliance if program resources are to be maximized.

purpose. To study the prevalence and determinants of compliance with spectacle wear among school-age children in Oaxaca, Mexico, who were provided spectacles free of charge. methods. A cohort of 493 children aged 5 to 18 years chosen by random cluster sampling from primary and secondary schools in Oaxaca, Mexico, all of whom had received free spectacles through a local program, underwent unannounced, direct examination to determine compliance with spectacle wear within 18 months after initial provision of spectacles. Potential determinants of spectacle wear including age, gender, urban versus rural residence, presenting visual acuity, refractive error, and time since dispensing of the spectacles were examined in univariate and multivariate regression models. Children not currently wearing their spectacles were asked to select the reason from a list of possibilities, and reasons for noncompliance were analyzed within different demographic groups. results. Among this sample of children with a mean age of 10.4 ± 2.6 years, the majority (74.5%) of whom were myopic (spherical equivalent [SE] ≤ −0.50 D), 13.4% (66/493) were wearing their spectacles at the time of examination. An additional 34% (169/493) had the spectacles with them but were not wearing them. In regression models, the odds of spectacle wear were significantly higher among younger (OR = 1.19 per year of age; 95% CI, 1.05–1.33) rural (OR = 10.6; 95% CI, 5.3–21.0) children and those with myopia ≤ −1.25 D (OR = 3.97; 95% CI, 1.98–7.94). The oldest children and children in urban–suburban areas were significantly more likely to list concerns about the appearance of the glasses or about being teased than were younger, rurally resident children. conclusions. Compliance with spectacle wear may be very low, even when spectacles are provided free of charge, particularly among older, urban children, who have been shown in many populations to have the highest prevalence of myopia. As screening programs for refractive error become increasingly common throughout the world, new strategies are needed to improve compliance if program resources are to be maximized.

PURPOSE:To determine the heritability of refractive error and the familial aggregation of myopia in an older population. METHODS:Seven hundred fifty-nine siblings (mean age, 73.4 years) in 241 families were recruited from the Salisbury Eye Evaluation (SEE) Study in eastern Maryland. Refractive error was determined by noncycloplegic subjective refraction (if presenting distance visual acuity was < or =20/40) or lensometry (if best corrected visual acuity was >20/40 with spectacles). Participants were considered plano (refractive error of zero) if uncorrected visual acuity was >20/40. Preoperative refraction from medical records was used for pseudophakic subjects. Heritability of refractive error was calculated with multivariate linear regression and was estimated as twice the residual between-sibling correlation after adjusting for age, gender, and race. Logistic regression models were used to estimate the odds ratio (OR) of myopia, given a myopic sibling relative to having a nonmyopic sibling. RESULTS:The estimated heritability of refractive error was 61% (95% confidence interval [CI]: 34%-88%) in this population. The age-, race-, and sex-adjusted ORs of myopia were 2.65 (95% CI: 1.67-4.19), 2.25 (95% CI: 1.31-3.87), 3.00 (95% CI: 1.56-5.79), and 2.98 (95% CI: 1.51-5.87) for myopia thresholds of -0.50, -1.00, -1.50, and -2.00 D, respectively. Neither race nor gender was significantly associated with an increased risk of myopia. CONCLUSIONS:Refractive error and myopia are highly heritable in this elderly population.

Purpose: To determine whether hyperopia aggregates in families in an older mixed-race population.Design: Cross-sectional familial aggregation study using sibships.Methods: We recruited 759 subjects (mean age, 73.4 years) in 241 families through the population-based Salisbury Eye Evaluation study. Subjects underwent noncycloplegic refraction if best-corrected visual acuity (BCVA) was less than or equal to20/40, had lensometry to measure their currently worn spectacles if BCVA was >20/40 with spectacles, or were considered to be plano (refraction of zero) if the BCVA was >20/40 without spectacles. Preoperative refraction from medical records was used for bilaterally pseudophakic subjects.Results: Utilizing hyperopia cutoffs from 1.00 to 2.50 diopters, age-, race-, and gender-adjusted odds ratios for hyperopia with an affected sibling ranged from 2.72 (95% confidence interval [CI], 1.84-4.01) to 4.87 (95% CI, 2.54-9.30). The odds of hyperopia increased with age until 75 years, after which they remained relatively constant. Black men were significantly less likely to be hyperopic than white men, white women, or black women.Conclusions: Hyperopia appears to be under strong genetic control in this older population. (C) 2005 by the American Academy of Ophthalmology.

Objective: To determine the prevalence and causes of low vision in a large sample of nursing home residents.Methods: Twenty-eight nursing homes on the Eastern Shore of Maryland and Delaware were enrolled in a clinical trial to assess the impact of vision restoration/rehabilitation on nursing home residents. Visual acuity was measured using both recognition charts and preferential looking techniques. An ophthalmologist examined all residents with visual acuity worse than 20/40 in the better-seeing eye and determined the primary cause for decreased vision. Results are reported for the better-seeing eye.Results: Of 2544 eligible residents, 1591 (63%) participated, but 286 residents were unable to respond to visual acuity testing. Of the remaining 1307 residents, 496 (37%) had best-corrected visual acuity worse than 20/40 in the better-seeing eye. Causes were ascribed for 412 subjects. Rates of low vision were similar between African American subjects and white subjects (39% and 38%, respectively; age-adjusted P = .18). Cataract was the leading cause of low vision, responsible for 37% of low vision among white subjects and 54% of low vision among African American subjects. Macular degeneration was responsible for 29% of low vision among white subjects but only 7% among African American subjects. Glaucoma caused low vision in 4% of white subjects and 10% of African American subjects. Refractive error was not a frequent cause of low vision in nursing home residents.Conclusions: Low vision is highly prevalent among nursing home residents, with 37% having visual acuity worse than 20/40 in the better-seeing eye. Differences in causes of low vision between African American subjects and white subjects were noted, with African American subjects more likely to have vision loss on the basis of cataract, a readily treated condition. Appropriate interventions for nursing home residents, who face significant obstacles in accessing eye care services, have the potential to improve the quality of life of this at-risk older population.