[Glaucoma and optic nerve drusen: Limitations of optic nerve head OCT]

INTRODUCTION

Optic nerve head drusen are congenital calcium deposits located in the prelaminar section of the optic nerve head. Their association with visual field defects has been classically described, but the diagnosis of glaucoma is not easy in these cases of altered optic nerve head anatomy.

CASE STUDY

We describe the case of a 67-year-old man with optic nerve head drusen complicated by glaucoma, which was confirmed by visual field and OCT examination of the peripapillary retinal nerve fiber layer (RNFL), but the measurement of the minimum distance between the Bruch membrane opening and the internal limiting membrane (minimum rim width, BMO-MRW) by OCT was normal.

DISCUSSION

OCT of the BMO-MRW is a new diagnostic tool for glaucoma. Superficial optic nerve head drusen, which are found between the internal limiting membrane and the Bruch's membrane opening, overestimate the value of this parameter.

CONCLUSION

BMO-MRW measurement is not adapted to cases of optic nerve head drusen and can cause false-negative results for this parameter, and the diagnosis of glaucoma in this case should be based on other parameters such as the presence of a fascicular defect in the retinal nerve fibers, RNFL or macular ganglion cell complex thinning, as well as visual field data.

[Regression of myelinated retinal nerve fibers in a case of primary open-angle glaucoma]

Myelinated retinal nerve fibers observed rarely on ocular fundus examination, usually adjacent to the optic disc, are known to be stable throughout life. However, the possibility of rarefaction, and even disappearance, of these myelinated fibers has been pointed out in very rare cases of ocular or neuro-ophthalmological pathologies. We report such a regression, identified after a six-year period, in one case of primary open-angle glaucoma.

[Genuine adult unilateral glaucomas: true or false]

The diagnosis of unilateral glaucoma essentially requires an etiologic investigation primarily to make sure that the deterioration is truly glaucomatous, thus specifically ruling out other optical neuropathies and papillary abnormality, such as tilted disc or drusen, which can mimic glaucomatous perimetric defects. Nonetheless, some apparent unilateral glaucomas can become bilateral later, as with primary open-angle glaucoma, though more frequently with primary closed-angle glaucoma in the absence of prophylaxis, and with exfoliative glaucoma. Genuine unilateral glaucomas concern the pigmentary glaucomas, the contusive glaucomas, the secondary closed-angle glaucomas, which encompass iridocorneoendothelial syndromes, ocular inflammations with opened angle, and glaucomas with an increase in the venous episcleral pressure.

Estimation of genetic parameters and genome scan for 15 semen characteristics traits of Holstein bulls

A QTL detection experiment was performed in French dairy cattle to search for QTL related to male fertility. Ten families, involving a total of 515 bulls, were phenotyped for ejaculated volume and sperm concentration, number of spermatozoa, motility, velocity, percentage of motile spermatozoa after thawing and abnormal spermatozoa. A set of 148 microsatellite markers were used to realize a genome scan. First, genetic parameters were estimated for all traits. Semen production traits were found to have moderate heritabilities (from 0.15 to 0.30) while some of the semen quality traits such as motility had high heritabilities (close to 0.60). Genetic correlations among traits showed negative relationships between volume and concentration and between volume and most quality traits such as motility or abnormal sperm while correlations between concentration and these traits were rather favourable. Percentages of abnormal sperm were negatively related to quality traits, especially with motility and velocity of spermatozoa. Three QTL related to abnormal sperm frequencies were significant at p < 0.01. In total, 11 QTL (p < 0.05) were detected. However, the number of QTL detected was within the range of expected false positives. Because of the lack of power to find QTL in this design further analyses are required to confirm these QTL.

[Satisfaction and compliance of ocular hypertensive and glaucoma patients topically treated with a combination therapy]

OBJECTIVES

To evaluate satisfaction and compliance in glaucoma and ocular hypertensive patients receiving a fixed combination treatment.

MATERIALS AND METHODS

After instilling a fixed combination, patients were asked to fill out a questionnaire about their satisfaction and compliance at baseline and 15 days after the onset of new therapy.

RESULTS

1693 glaucoma patients (G) and 621 ocular hypertensive (OHT) patients were included. Mean age was 65.6+/-11.7 years. Onset of disease was 7.2+/-6.6 years and 5.2+/-4.9 years for G and OHT patients, respectively. Insufficient efficacy of the previous topical treatment (monotherapy in 55% of cases) was the main cause for shifting to a fixed combination in 70% of cases. Satisfaction was increased in 15% of the patients and compliance was increased in 25% of the patients.

DISCUSSION

Fixed combination provides an easier regimen and therefore encourages better compliance, a key issue in a chronic disease such as glaucoma.

[News in trabeculoplasty]

The main objection to argon laser trabeculoplasty is collateral tissular injury, requiring hazardous repeated sessions if tonometric efficacy decreases. Selective trabeculoplasty could allow reliably effective iterative sessions because it is relatively harmless to tissues. Two other physical methods are on the market, although they are still being investigated, which also allow repeated treatments with minimal trabecular impairment. Titanium:sapphire laser trabeculoplasty consists of a very short pulse duration, with a wavelength penetrating deeply into the trabecula meshwork; the first results indicate similar intraocular pressure reduction as that obtained with argon trabeculoplasty and selective trabeculoplasty, but point out a possible risk of a paradoxical pressure rise during the days following the procedure. Pneumotrabeculoplasty is a procedure that uses ocular stretching by suction, which could finally provide a long-lasting decrease in intraocular pressure, less than that obtained with lasers, but its harmlessness is proved and its cost much lower.

[Clinical key points. Optic disk]

Five points should be evaluated during optic disc examination: the size of the optic disc, the condition of the neuroretinal rim, the presence of optic disc hemorrhages, the appearance of the retinal nerve fiber layer, and the comparison between the two discs.

Transient adverse effects of an attenuated bluetongue virus vaccine on the quality of ram semen

This study investigated the effects of the vaccination of rams with a serotype 2 bluetongue virus vaccine on the quality of their semen. One group of 23 rams was vaccinated on days 0 and 47, and 23 rams were left unvaccinated. Samples of blood, serum and semen were collected regularly in order to detect the virus genome, and to compare the quality of the semen from the vaccinated and unvaccinated rams. Segment 10 of the genome of the vaccine strain was detected in the blood of the vaccinated animals by reverse transcriptase-PCR (RT-PCR) on days 7, 13 and 19 after the first vaccination, but no virus was isolated from the RT-PCR-positive blood or from any of the semen samples from the vaccinated animals. There was a significant decrease in the concentration and motility of the spermatozoa and an increase in the proportion of abnormal and dead spermatozoa after the first vaccination; however, after the second vaccination only smaller, non-significant changes were observed. On day 69, the quality of the semen of the vaccinated animals was not significantly different from that of the controls.

Prévalence et description du traitement par hypotonisants pour glaucome et hypertonie oculaire en France

PURPOSE

The first objective of the present study was to estimate the prevalence of patients treated for glaucoma or ocular hypertension (OHT) with an IOP (intraocular pressure) -lowering topical medication. Subjects were 40 years old and living in continental France. The second objective was to describe the type of therapy, compliance, and the quality of life of the subjects treated.

METHODS

This study was a telephone survey conducted in a general population on a representative sample of 5726 subjects in 2004. Subjects treated for glaucoma or OHT were defined as those declaring use of eye drops for more than 1 month and mentioning one of the 52 registered IOP-lowering topical medications and/or stating that they were taking eye drops for glaucoma or OHT. Quality of life was measured using the GlauQOL-17 questionnaire.

RESULTS

237 subjects (4.1%) corresponded to this definition. The prevalence increased with age, from 0.7% in subjects aged 40-44 years to 10.6% in those aged 80 years or more. The age-standardized prevalence was higher in the Paris area (5.3%), the Mediterranean (4.5%), and the Southwest (4.7%), and lower in rural areas (3.2%), and in subjects with less than high school education (2.9%). Beta-blockers (49.5%) and prostaglandins (37.4%) were the most frequent treatments, followed by carbonic anhydrase inhibitors (15.3%), sympathomimetics (5.7%), and myotics (1.3%). Compliance was not total in 39% of the patients (22% of those treated with once-a-day dosage).

DISCUSSION

The results of the present study are in line with French health authority data and with the results of the French "Glaucoma and intraocular high pressure, one day" study results. Moreover, the lower prevalence in regions with low medical density, low socioeconomic level, and rural areas, suggest that glaucoma or OHT might be underdiagnosed.

CONCLUSION

On the basis of this first nationwide study, it can be estimated that the prevalence of subjects treated with IOP-lowering topical medications is about 1.2 million in France. The number of daily doses appears to influence compliance.

[Practical measures. When ocular hypertension is unilateral]

Certain causes of unilateral ocular hypertension (including glaucoma) are relatively frequent and/or can be problematic at the time of etiological diagnosis. Although the pseudo-exfoliative syndrome is often easily identified by the presence of typical whitish formations on the anterior crystalloid and by the atrophy of the pupillary margin of the iris, it can at times be difficult to recognize (use high magnification, pupillary dilatation, and gonioscopy). The diagnosis of pigmentary dispersion is classically based on the discovery of a Krükenberg spindle and iris transillumination, but these signs may be missing, and the diagnosis can only be made by observation of the anterior hyaloid angle. Questioning the patient can lead to the suspicion of an old ocular contusion, usually confirmed by thorough bilateral gonioscopic observation. Outside of crisis periods, Posner-Schlossman syndrome can only be strongly suspected by the persistence of very fine and rare retrocorneal precipitates visible on high magnification. Iridocorneal endothelial syndromes (causes of unilateral glaucoma by evolutive goniosynechia) affects women from 25 to 50 years of age with no notable antecedent; they evolve more or less rapidly and are expressed in three ways: essential atrophy of the iris and Cogan-Reese disease, with the anatomical features easily identified on the iris, while Chandler disease can only be confirmed by gonioscopy, high-magnification observation of the cornea, and corneal endothelial cell count and analysis.

[Practical assessment. Early-stage or advanced glaucoma]

In the case of early-stage or advanced glaucoma, the major problem is no longer diagnostic, but evaluating its response to treatment. Other than questioning the patient, assessment includes measuring visual acuity and intraocular pressure, examining the anterior segment and the optic disc, and finally an analysis of the visual field. This latter examination remains the least contestable, although subjective, in evaluating how a confirmed case of glaucoma is evolving. Examination of the optic disc using stereoscopy should include a drawing or, at best, a photograph. Finally, three recent analyzers are available and being evaluated: HRT II, GDx, OCT-3. Depending on the results (of intraocular pressure, the visual field and the optic disk), treatment can be modified and/or the assessment completed.

Long term effect on IOP of a stainless steel glaucoma drainage implant (Ex-PRESS) in combined surgery with phacoemulsification

AIM

To evaluate the efficacy and safety of a stainless steel miniature glaucoma drainage device (Ex-PRESS R50) for the surgical treatment of primary open angle glaucoma (POAG) and cataract when combined with phacoemulsification.

METHODS

Clinical, prospective, multicentre, single treatment arm, non-randomised, non-masked study. The Ex-PRESS device was implanted at the limbus under a conjunctival flap. Phacoemulsification cataract extraction and in the bag IOL implantation were performed through clear cornea temporally.

PRIMARY OUTCOME

IOP change; secondary outcomes: side effects and VA changes.

RESULTS

26 eyes of 25 patients were implanted with the device. The mean (SD) follow up was 23.9 (10.4) months and the mean age was 75.1 (7.1) years. 17/26 eyes have more than 3 years of follow up. One case was discontinued because of device removal, one because of death, and three were lost to follow up.

EFFICACY

preoperative IOP was 21 (4) mm Hg; at 1, 2, and 3 years IOP was 15.3 (3.1) mm Hg (35% reduction), 16.6 (2.7) mm Hg (29% reduction), and 16 (2.6) mm Hg (22% reduction) respectively. Kaplan-Meyer determined overall success rate (IOP < or = 21 mm Hg at the last visit with or without medications) as 76.9%. The number of antiglaucoma medications was reduced by 95% at year 1. Only six patients (23%) were taking IOP lowering treatment at their last visit, five with one medication and one with two medications. Side effects: early postoperative complications were clinically mild and included six cases of hypotony (IOP <5 mm Hg), three cases of hyphaema (<2 mm) with no clinically significant further effects. Long term complications were two cases (7.7%) of device rotation (one treated by reposition) and three cases (11.5%) of conjunctival erosion at 2 and 3 years.

CONCLUSIONS

The Ex-PRESS implant, combined with phacoemulsification cataract extraction, is clinically safe and effective, maintaining in the long term a large reduction in IOP and in the number of antiglaucoma medications.

Les mécanismes des glaucomes par fermeture de l’angle

Glaucoma caused by primary closure of the iridocorneal angle accounts for half of the glaucoma cases in the world, 9 out of 10 in patients of Sino-Mongolian origin. The most frequent mechanism involved is anterior chamber angle blockage, but glaucoma can also be the result of a plateau iris structure, ciliary blockage, and exceptionally microphthalmos. Other than these forms, closure of the iridocorneal angle can be secondary to acquired iridopathies, or caused by crystallin anomalies or therapeutic interventions.

[Pigmentary dispersion: is iridectomy useful?]

Several clinical reasons induced Campbell to propose an iridotomy in cases of pigmentary dispersion: removing the inverse pupillary block, balancing pressures through the iris, and finally stopping the posterior erosion of the iris leading to pigmentary release. It is likely that certain failures in this method stem from an erroneous evaluation of the cases that could benefit from iridal perforation. Three conditions are required for this procedure to be successful: established ocular hypertension, an abnormally concave iris base, and absence of patent glaucoma.

[Glaucoma and quality of life]

Glaucoma is a serious ocular disorder potentially leading to blindness. Measuring the quality of life of patients with glaucoma is important because it makes it possible to evaluate the impact of the disease and its treatment on the patient's everyday life. Hitherto, this was done using generic scales, or those developed for other diseases; but no scale suitable for glaucoma was available. The recently developed GlauQOL scale is now available. We present the short version of this questionnaire adapted to individual use within an ophthalmology consultation setting.

[Creating a specific quality-of-life questionnaire in patients with glaucoma: item generation]

The methods for developing Health-Related Quality-of-Life (HRQoL) measures and their application in medical research have demonstrated their utility in various chronic, progressive, or life-threatening diseases. The efforts made to allow the patient's perspective to be included in the methodological framework of evidence-based medicine have been successful. The assumption of a strong relationship between clinical status and daily life is certainly valid in ophthalmology. However, there is a lack of specific HRQoL measures dedicated to ophthalmic diseases. Our work aimed at creating the first Glaucoma-specific Quality of Life scale - the Glau-QoL questionnaire - to provide researchers and physicians with a comprehensive, practical, and validated tool. This article describes the first stage of the process, which consisted in generating items and formatting them in order to create a questionnaire that exhaustively covers the relevant concepts. The whole process was conducted by an expert committee including clinicians and methodologists. The standard recommendations in the development of a HRQoL questionnaire were followed: we first identified existing tools and performed a preliminary collection of concepts from the published literature; we then designed an interview guide with the help of clinicians; a trained psychologist interviewed 22 patients at various disease severity stages (from isolated hypertonic to severely impaired); the interviews were tape-recorded and scripted; general domains and related detailed concepts were identified from the script; they were then analyzed and organized; the format of the questionnaire was set up; and questions were derived from the patient's verbatim to capture the identified detailed concepts. The test questionnaire was applied to seven patients for cognitive debriefing. We finally amended the test questionnaire and designed the pilot questionnaire according to the patients' tests and the clinician's review. The test questionnaire was well accepted by the patients, despite a completion duration ranging from 14 to 35 minutes. The pilot questionnaire contained 151 items, grouped into 5 sections: (1) vision problems, physicians, and daily treatment (49 items); (2) activities of daily living (37 items); (3) self-expression (37 items); (4) vision problems and mood (14 items); and (5) other questions (14 items). The next step of our work will be the item reduction process and the psychometric validation of the Glau-QoL questionnaire.

[Is trabeculoplasty still indicated?]

Trabeculoplasty was introduced in 1979 to decrease intra ocular pressure. Long-term results have been unsatisfactory compared to the first publications, because of the repeated relapse of initially successfully treated eyes. However, the technique may be particularly useful in numerous clinical conditions: pseudo exfoliation syndrome, pigmentary dispersion, slight cataract waiting for combined surgery, and in elderly patients. Developing new energy sources (i.e., selective laser trabeculoplasty) could extend the indications of this method, with longer-lasting results and/or completely harmless retreatments.

Additive IOP-reducing effect of latanoprost in patients insufficiently controlled on timolol

PURPOSE

To evaluate the effect on intraocular pressure (IOP) of switching from timolol to latanoprost or adding latanoprost to timolol in patients with open angle glaucoma or ocular hypertension where IOP is not adequately controlled with timolol.

METHODS

This was a 6-week, double-masked, randomised multi-centre study. 53 patients with primary open angle glaucoma, capsular glaucoma, or ocular hypertension with an IOP of at least 21 mmHg on current therapy were recruited. After a run-in period of at least 2 weeks on timolol, 5 mg/ml twice daily, patients were randomised to one of three groups. One group continued on timolol, one switched from timolol to latanoprost, 50 microg/ml once daily, and a third group received latanoprost in addition to timolol. The efficacy was evaluated by comparing IOP at 9 AM at baseline and after 6 weeks of treatment.

RESULTS

IOP at baseline and after 6 weeks of treatment (mean +/- SEM) were 24.2 +/- 0.9 and 23.8 +/- 1.0 mmHg (n = 16) for patients continuing on timolol, 26.3 +/- 1.2 and 19.6 +/- 1.1 mmHg (n = 17) for patients switching to latanoprost, and 23.2 +/- 1.0 and 17.5 +/- 0.8 mmHg (n = 17) for patients with combined treatment. Adding latanoprost to timolol reduced IOP with 5.9 +/- 0.9 mmHg (p < 0.001) and switching from timolol to latanoprost reduced IOP with 5.0 +/- 0.9 mmHg (p < 0.001), which caused in each group a significant IOP reduction of about 25%.

CONCLUSIONS

The effect of latanoprost was additive to that of timolol, and a good effect on IOP reduction was also achieved by switching from timolol to latanoprost, suggesting that a switch in many patients is an effective alternative to combination treatment.

[An observational, retrospective two-year cost study in primary open-angle glaucoma and ocular hypertension in newly diagnosed patients]

PURPOSE

To investigate the different treatment strategies in France and the direct costs for patients with newly diagnosed primary open-angle glaucoma or ocular hypertension who have started treatment with beta-blockers, and to estimate the total direct cost for two years of treat.

MATERIAL

and methods: We analyzed 225 medical charts retrospective in eleven academically and office-based centers in France over the first two years after diagnosis. Standard costs for each resource in current medical practice were determined from the French Social Security perspective.

RESULTS

The vast majority of patients (90%) had a diagnosis of primary, open-angle glaucoma or ocular hypertension in both eyes. In 60% of the patients we found a moderate or severe defect in their visual field or optic nerve. Intraocular pressure before treatment was 23.9+4.7mmHg and 17.5+4.2mmHg after two years of treatment. Over the first two years, 25% of visits led to a change in therapy (medical or surgical), involving 64% of the patients. Two-thirds of the changes occurred during the first year of treatment and in around 80% of cases for low intraocular pressure at check-up. Laser surgery or surgical intervention was performed in 25% of the patients. Total direct costs for two years were 5698F.F. The intraocular pressure before treatment was positively correlated (p<0.01) with treatment costs, while the initial intraocular pressure-lowering effects of treatment were negatively correlated with two-year costs.

CONCLUSION

After two years of treatment, the mean intraocular pressure decreased from 24 to 17.5mmHg. The higher the basal intraocular pressures is, the more intensive the treatment and the higher the costs. The more efficient the treatment to decrease baseline intraocular pressure is, the earlier the costs will be reduced.

[Relevance of quality of life and treatment compliance measurement in patients with chronic open-angle glaucoma]

Chronic glaucoma is a severe disease that can induce blindness.Early diagnosis and symptomatic treatment reduce the risk of blindness. Treatment that will be started before the onset of clinical signs and will remain lifelong thereafter is troublesome, and therapeutic compliance is usually poor. Thus, quality of life (QOL) measurement in patients with chronic glaucoma has a particular purpose: to measure patients' perception of the disease and treatment in order to maintain good treatment compliance to ensure therapeutic management efficacy and to preserve visual function. No glaucoma-specific instrument is available in the medical and QOL literature. Various generic(SF-36, SF-20 and SIP) and specific(VAQ, VF-14, NEI-VFQ) QOL questionnaires,one glaucoma-specific symptomatic scale (GSS),and one treatment preference scale (COMTol) have been used to measure QOL in glaucoma patients. These instruments do not sufficiently measure the psychosocial dimension of the disease and the QOL impact of treatment. An instrument able to measure all dimensions needs to be developed in order to help ophthalmologists in the therapeutic management of their patients and to measure QOLin patients in the successive stages of the disease.

Migraine and glaucoma: an epidemiologic survey of French ophthalmologists

Glaucoma is a common ocular disorder; a high intraocular pressure is observed in the majority of glaucoma (HIOPG) cases, but some patients have low-tension glaucoma (LTG). In the literature, some works link LTG and migraine, which is speculative of a potential role of a vasospastic factor or diathesis common to migraine and LTG. Using a standardized questionnaire based on International Headache Society (IHS) criteria, we investigated 954 glaucoma patients; 320 (33.5%) described a headache (migraine or tension-type headache) and 240 (25.1%) presented the IHS criteria for migraine. Migraine prevalence was not significantly different between HIOPG and LTG patients (22.8% and 32%, respectively) in this study.

Variations of vitamin D-like reactivity in the crustacean Orchestia cavimana during the molt cycle

An investigation into vitamin D-like molecules has been performed on whole extracts of the terrestrial amphipod Orchestia cavimana, using a sensitive nonequilibrium assay employing 1,25-(OH)2 D receptor from calf thymus. Relatively large amounts of these secosteroid-like molecules were observed and they varied in concentration according to the stages of the molt cycle. The amplitude of these variations reaches a ratio of about 40 from the minimum in premolt to the intermolt sharp peak.

[Efficacy and tolerance of dipivephrin]

The effects and the tolerance of dipivephrin have been studying during 6 months, in 30 glaucomatous or ocular hypertensive patients. The pressure decrease was 29.4%. Three patients were excluded because of undesirable side effects. The tolerance was appreciate good or excellent in the 27 other patients.