Glaucoma - I Free Papers - aioseducation

Glaucoma Free Papers100% (32) as compared to 87.5% (28) in CT group.Table 1: IOP after TrabeculectomyTime Releasable suture Conventional techniqueDay 1 16.76±5.72 6.57±2.582 – 5 d 13.7±4.31 7.84±2.616 – 10 d 12.7±3.28 9.36±2.3914 – 21 d 12.34±2.45 12.24±1.471 mth 12.13±1.7 13.26±1.233 mth 11.56±2.33 13.72±3.4412 mth 11.42±2.17 13.56±3.82Table 2: Postoperative anterior chamber depthCondition of AC Releasable suture Conventional techniqueAC formed 28 15AC shallow 3 7AC collapsed 1 4AC>5 d to form 0 6Table 3: Postoperative Bleb scoreDescription of Bleb Time Releasable suture Conventional techniqueHigh (≥ 3) 2 – 5 days 25 51 month 30 18Low (2) 2 – 5 days 7 211 month 2 10Flat (1) 2 – 5 days 0 61 month 0 4DISCUSSIONThe advantages of a tightly sutured scleral flap with postoperative titration offiltration after trabeculectomy have led to the development of laser suturolysisand releasable suture techniques. In our study, it was observed that earlypostoperative IOP was significantly higher in the releasable suture groupthan in permanent suture group. Though, use of releasable sutures did notaffect the ultimate outcome of eyes with controlled IOP one year followingsurgery. The findings were comparable to those observed by Kolker and Kass.The blebs were scored according to Migdal and Hitchings classification. Thebleb score was better in the releasable suture group than in the permanentsuture group. Raina and Tuli observed similar results. Use of releasable suturecan significantly reduce the incidence of shallow AC postoperatively. Thereis however no consensus on timing and criterion for suture release. It shouldbe released within 3 weeks, preferably within first week to enhance filtration.307

69th AIOC Proceedings, Ahmedabad 2011Rebound Tonometry in A Clinical Setting,Comparison with Applanation TonometryDr. Jigisha Kiran Randeri, Dr. O P Billore, Dr. R Desai, Dr. F Mehta,Dr. K KhuranaThough glaucomatous optic atrophy has multifactorial origin, intraocularpressure (IOP) remains the only factor to be effectively acted upon.Goldmann applanation tonometry (GAT) is considered the international goldstandard for IOP measurements, although these measurements are affected bycorneal thickness and yield inaccurate results in certain pathologies affectingthe ocular surface. So several alternative methods have been proposed toovercome the disadvantages in GAT. These methods include new electronicapplanation tonometer, non contact tonometers and Rebound tonometry.Rebound tonometry, also called “impact: or “dynamic tonometry:, wasintroduced by Obbink more than 60 years ago and later modified by Dekkingand Coster in the sixties and by Kontiola in 1997. The method is based onmaking a moving object collide with the eye, and the motion parameters ofthe object are monitored following the contact. The instrument measures theimpact duration of a probe: the higher the IOP, the shorter is the duration ofthe impact. The main advantages are that it is quick, easy to use, the device isinexpensive and above all, local anesthesia is not required.Kontiola’s prototype tonometer had become available since 2003 under thename of iCare tonometer.Description and use of instrumentThe iCare tonometer is a hand held device made by Tiolat (Helsinki, Finland).It has a small disposable probe that makes contact with the eye very briefly,so that there is no need for a topical anaesthetic agent and new probe is usedfor each patient.The probe has a round tip of 0.9 mm radius and it weighs 26.5 mg. The other endof the probe is metallic and it is held in place in the tonometer by a magneticfield that is activated when the measurement button is pressed.The reading is performed by placing the adjustable rest on the patients forehead,so that the probe is 4-8 mm from the cornea. Once the measurement buttonis pressed, the tip of the probe hits the central cornea. The microprocessoranalyses the deceleration of the probe following the impact, deceleration isless at low than at high IOPs and consequently, the higher the IOP, the shorterthe duration of the impact. After six measurements, the IOP is shown on thedisplay preceded by a letter ‘P’, with an indication of reliability.308

Glaucoma Free PapersFigure 1The purpose of our study was to assess the usefulness of Rebound tonometry(RBT) in clinical settings, comparing the resulting measurements with an iCare tonometer with those obtained from Goldmann applanation tonometer(GAT), and the impact of CCT on IOP measurement.MATERIALS AND METHODSThis observational study included 100 eyes of 53 patients with mean age of 55± 14 yrs.All patients were of different types of glaucoma including primary openangle glaucoma, ocular hypertension, normal tension glaucoma, angle closureglaucoma; with or without cataract. Patients were being treated with eitherantiglaucoma medicines or surgery. Other than these pathology patients wereexcluded.All measurements were taken by the same examiner, central corneal thicknesswas measured with a central ultrasonic pachymetry the mean of three readingswere considered.IOP was measured with RBT without anesthesia, six measurements wererepeated. After ten minutes interval, three consecutive measurements wereperformed with GAT after instillation of one drops of 4% Xylocain, mean valueis considered. Readings were corrected according to central corneal thicknessvalue.RESULTS AND DISCUSSIONOut of 53 patients, 41 were male. The mean age of study group was 55 ± 14.0yrs.45 out of 100 eyes had POAG, 18 eyes had ACG, 4 eyes were of glaucomasuspect, 4 eyes of NTG and 28 eyes were of OHT, while one eye had secondaryopen angle glaucoma.15 eyes had cataract, 73 eyes were treated medically with antiglaucoma drugsand 7 with surgery. The average CCT in our sample was 510,SD34.70µm.In the whole series of 100 eyes, the mean IOP obtained through the RBT was20.36 mm Hg (with SD, 6.0 mmHg) and 20.47 mmHg with SD of 5.8 mmHgwith GAT (P

69th AIOC Proceedings, Ahmedabad 2011according to Pearson linear correlation test, r = 0.84, r2 =0.718 (p

Glaucoma Free PapersMean number of anti glaucoma medications pre operatively was 3.13 andreduced to a mean of 2.75(p=0.285).DISCUSSIONCampbell and Vela reported the procedure for synechial angle-closureglaucoma – GONIOSYNECHIALYSIS.¹² GSL has been performed alone¹ 0 orin combination with lens extraction,phacoemulsification,IOL implantation¹³,with diode laser iridoplasty 14 and has yielded successful results in thesestudies for control of IOP in PACG cases. A negative correlation was observedbetween duration of PAS and post op vision(r=-0.08) indicating that with PASof prolonged duration GSL was not as effective as in other cases in termsof improving VA . In our study a significant reduction in mean IOP wasobserved post operatively (p=0.027) in 6 cases, which was similar to studyby Tanihara et al 15 , Shingelton et al. 10 Among the remaining two cases, 1 casehad a marginal fall of 6mm Hg (post penetrating keratoplasty) and the othercase had increased inflammation post operatively (chronic uveitis) and bothunderwent trabeculectomy. In one case ,IOP remained uncontrolled even aftertrabeculectomy (chronic uveitis).However, all the cases required additional anti glaucoma medication post GSLfor control of IOP. A weak positive correlation was observed between durationof PAS and post op IOP (r=0.114) indicating that longer the duration of PASgreater was the post op IOP.In our study,early intervention for PAS resulted inbetter control of IOP post operatively.Mean number of anti glaucoma medications pre operatively was 3.13 andreduced to a mean of 2.75 (p=0.285) which was not statistically significant.This could be attributed to the fact that our study group included refractorysecondary glaucomas with uncontrolled IOP inspite of being on maximallytolerated medications and also the fact that most cases had broad areas of PAS.Though GSL was successful in anatomically opening the angles, functionalperformance of the angles could not be assessed.A statistically significant difference was noted in degree of PAS (p=0.003)following GSL. Angle closure was relieved in 7(87.5%) of the 8 patients whichwas similar to studies by Harasymowcyz et al¹, Lai et al¹. A good correlationwas observed between duration of PAS and post op PAS (r=0.84). In one patientthere was no change in PAS post GSL(chronic uveitis) and IOP remaineduncontrolled even after trabeculectomy .The duration (time lag) between theformation of PAS and performing GSL was longest(20 weeks) in this casewhich might have resulted in an ischemia and irreversible optic nerve damageAll the studies recruited patients of primary angle closure glaucoma. Howeverour study had only secondary angle closure glaucomas which would probablyaccount for the fact that 2 out of the 8 cases required filtration surgeries for the315

69th AIOC Proceedings, Ahmedabad 2011uncontrolled IOP and all cases required anti glaucoma medications post GSLfor control of IOP.• GSL is an effective procedure in carefully selected cases of secondaryglaucoma with recent formation of PAS• Factors favouring success were early intervention following formation ofPAS and absence of perpetuating factors like uveitisREFERENCES1. Quigley HA. Number of people with glaucoma worldwide. Br J Ophthalmol1996;80:389–893.2. Foster PJ, et al. The prevalence of in Chinese residents of Singapore: a cross-sectionalpopulation survey of the Tanjong Pagar district. Arch Ophthalmol 2000;118:1105.3. Buhrmann RR, et al. Prevalence of glaucoma in a rural East African population.Invest Ophthalmol Vis Sci 2000;41:40.4. Dandona L, Dandona R, Mandal P, Srinivas M, John R K, McCarty C A, Rao G N.Angle-closure Glaucoma in an Urban Population in Southern India. The AndhraPradesh Eye Disease Study. Ophthalmology 2000;107:1710-6.5. R. R Allingham MD; Karim F Damji MD, FRCSC; Sharon Freedman MD; SayokoE. Moroi MD, PhD; George Shafranov MD; M. B Shields M D Shields textbook ofophthalmology. Fifth edition.6. Hsiao C H, Hsu C T, Shen S C, et al. Mid-term follow up of Nd: YAG laser iridotomyin Asian eyes. Ophthalmic Surg Lasers Imaging 2003;34:291-8.7. Ritch R. Argon Laser treatment for medically unresponsive attacks of angleclosureglaucoma. Am J Ophthalmol. 1982;94:ZS197-ZS204.8. Carnahan CM, Platt LW. Serial paracenteses in the management of acute elevationsof intraocular pressure. Ophthalmology 2002;109:1604-6.9. Jakobi PC, Dietlein TS, Luke C, et al. Primary phacoemulsification and intraocularlens implantation for acute angle-closure glaucoma. Ophthalmology 2002;109:1597-1603.10. Shingleton BJ, Chang MA, Bellows AR, et al. Surgical goniosynechialysis for angleclosureglaucoma. Ophthalmology 1990;97:551-6.11. Teekhasaenee C, Ritch R. Combined phacoemulsification and goniosynechialysisfor uncontrolled chronic angle-closure glaucoma after acute angle-closureglaucoma. Ophthalmology 1999;106:669-74.12. Campbell DG, Vela A. Modern goniosynechialysis for the treatment of synechialangle-closure glaucoma. Ophthalmology 1984;91:1052.13. Lai J S, Tham C C, Lam DS . The efficacy and safety of combined phacoemulsification,intraocular lens implantation, and limited goniosynechialysis, followed by diodelaser peripheral iridoplasty, in the treatment of cataract and chronic angle-closureglaucoma. J Glaucoma 2001;10:309-15.14. DG, Ahmed I, Assalian A, Lesk M, Al-Zafiri Y, Kranemann C, Hutnik C J .Phacoemulsification and goniosynechialysis in the management of unresponsiveprimary angle closure.Harasymowycz PJ, Papamatheakis. Glaucoma 2005;14:186-9.316

Glaucoma Free PapersDr. S SUJATA: MBBS (1990), Lady Hardinge Medical College, New Delhi,Delhi University, MD (1994), Dr. Rajendra Prasad Center for OphthalmicSciences, AIIMS, New Delhi. Presently, Prof & HOD, Glaucoma Services,Institute of Ophthalmology Joseph eye Hospital, Trichy, Tamil Nadu.E-mail: sujatasubbiah2@gmail.comComparison of UBM and UltrasonographicParameters in Phacomorphic Glaucoma andIntumescent CataractDr. S Sujata, Dr. Rameez Hussain, Dr. C A Nelson JesudasanUltrasound biomicroscopy (UBM) is a noninvasive imaging tool that hasbeen used to determine anterior chamber morphology, both qualitativelyand quantitatively.It allows for visualization of structures in the posteriorchamber that are otherwise hidden from clinical observation and can augmentgonioscopy in the qualitative and quantitative evaluation of pathologic changesleading to angle closure. Many biometric studies are available on primaryangle closure glaucoma eyes but no studies are available on phacomorphicglaucoma. Biometric studies of phacomorphic glaucoma may provide insightinto the pathophysiology and identify eyes at risk.To compare anatomical parameters and biometric findings of ocular structuresin phacomorphic glaucoma (PG), intumescent cataract (IC) and normal subjectsusing Ultrasound biomicroscopy (UBM) and conventional A Scan.MATERIALS AND METHODSA cross–sectional study was conducted wherein 40 consecutive eyes eachwith (PG), (IC) and normals underwent complete ophthalmic evaluationincluding IOP assessment and gonioscopy. Ocular biometry was done using(A&B) mode and UBM was done using 35MHz transducer. Radial and axialscans were performed in supine position. Anterior chamber depth (ACD),axial length (AL),lens thickness (LT),angle opening distance (AOD), Iris lenscontact distance (ILCD) trabecular ciliary process distance (TCPD) were doneand absolute lens position (ALP) and relative lens position (RLP) calculated.Statistical analysis was done using SPSS (version 10) and parameters in thethree group were compared.RESULTSOf 120 eyes studied 69 were males and 51 were females. The mean age was58.29 ±7.83yrs in the normal group, 62.87±9.56yrs in the (IC) group and 61.95±9.99 yrs in the (PG) group. The mean IOP was 47.71±13.85mmHg in (PG) eyes,16.27±3.45mmHg in the (IC) group and 16±2.55mmHg in normal eyes.317

Glaucoma Free Papersthe TIA averaged 11.7°±8.8°and 19.9°±9.8° and 31.3°±9.2° in patients with acute,intermittent and chronic ACG respectively.AOD quantifies iridotrabecular apposition and low values can predispose toPAS. In our study it was found to be less in patients with (IC) 0.23±0.06mm and(PG) 0.15±0.10mm than in normal eyes (0.40±0.06mm) which are comparable tothe findings of Pavlin 2 and Foster et al. In their study the mean AOD in PACGwas 0.11±34mm. Yoo 3 et al in a study on PAS in eyes with PACS stated thatAOD, TIA, ARA representing a relationship between the trabecular meshworkand the iris were narrower in the superior and inferior angles in PAS positivethan in PAS negative eyes. TPCD was smaller in superior quadrant in eyeswith PAS.Biometric and UBM parameters in (PG) showed shallow AC, reduced TIA,smaller AOD, increased ILCD and smaller IZD when compared to similarparameters in normal eyes. Moreover ALP was 4.57± 0.59 and RLP was 0.20±0.02. Biometric values in (IC) also showed shallow AC, reduced TIA, smallerAOD, increased ILCD and smaller IZD when compared to similar parametersin normal eyes but they were better than the parameters in (PG).ALP in (IC)was 4.08± 0.55 and RLP was 0.17±0.02.Studies show that eyes with ALP less than or equal to 4.79 had 3.3 times greaterrisk and eyes with RLP less than or equal to 0.21 had twice greater risk of PAS.Both (PG) and (IC) group had ALP and RLP within the range termed as riskvalues for PAS formation.Narayanaswamy4 etal in a study comparing anterior chamber assessment bygonioscopy and UBM states that UBM is essential for objective quantificationof angles and AOD 500 can be a reliable and standard parameter to gradeangle width.Conclusion: Our study shows that eyes with (PG) and (IC) had biometricparameters comparable to that in PNAG therefore suggesting that eyes thatdevelop (PG) have an anatomical predisposition.UBM proves multifactorial pathophysiological mechanism of phacomorphicglaucoma; crowding of anterior segment, increased iris lens contact and moreanterior shift of lens.REFERENCES1. Marchini.Ultrasound Biomicroscope and conventional ultrasonographicstudy of ocular dimensions in primary angle closure glaucoma. Ophthalmology1998;105:2091-8.2. Pavlin C J, Harasiewicz K, Foster F S. Ultrasound biomicroscopy of anterior segmentstructures in normal and glaucomatous eyes. Am J Ophthalmol 1992;112:381-9.3. Yoo C, Oh J H, Kim YY, Jung H R. Peripheral anterior synechiae and ultrasound319

69th AIOC Proceedings, Ahmedabad 2011biomicroscopic parameters in ACG suspects. Korean J Ophthalmol 2007;21:106-10.4. Narayanaswamy A,Vijaya L, Shantha B,Baskaran M,Sathidevi AV.Anteriorchamber angle assessment using gonioscopy and ultrasound biomicroscopy. Jpn JOphthalmol 2004;48:44-9.Risk of Wipe-out Phenomenon afterTrabeculectomy with Releasable Suture andMitomycin–C in Advanced Glaucoma withTubular Fields and Split FixationDr Jyoti Shetty S, Dr. Janvi JhamnaniTo study the risk of wipe out phenomenon after trabeculectomy with reliablesuture and mitomycin–C in advanced glaucoma with tubular fields andsplit fixation.In advanced glaucomatous optic nerve damage leading to tubular fields withsplit fixation, it is imperative to have an aggressive control on intraocularpressure (IOP) to prevent further progression. If this target IOP is notachievable by medical therapy, then filtration surgery is the only option. Alsoa lower diurnal IOP variation in addition to a perfect compliance is convincingto prefer surgical reduction in IOP. However due to controversy of associatedrisk of immediate unexplained visual field (VF) loss including fixationcausing an accompanying change in the central visual acuity (VA) (Wipe outphenomenon), surgeons are hesitant to advice surgery. There are conflictingreports in the literature, identifying the risk of wipe out phenomenon to beanywhere between 0% to 14%. Also these studies are few, predominantlyretrospective and few have patients with split fixation recruited in the study.The current prospective study was undertaken to analyze the IOP control,maintenance of central visual acuity , preservation of VF, incidence of wipe outphenomenon after trabeculectomy with absorbable sutures and mitomycin-Cin advanced glaucoma with tubular fields and split fixation.MATERIALS AND METHODSThis is a prospective study of 50 eyes at the Bangalore West Lions Eye Hospitaland Cornea Grafting center. Inclusion criteria for the study were – patientswith un controlled IOP with maximum medical management and poorcompliance, advanced glaucomatous disc damage, showing tubular fields andsplit fixation on macular threshold.Exclusion Criteria: patients were excluded if they had uveitic glaucoma,neovascular glaucoma, corneal or retinal disease or if they had concurrentprocedure with trabeculectomy.320

Glaucoma Free Papers1. Data analysis included pre and post operative best spectacle correctedvisual acuity (BSCVA), pre and post operative IOP by applanationtanometery. All these were recorded from the closest visit before surgery,post operatively on day 1, 1st week, 1 monthand 3 months. The pointsunderwent a full threshold 30-2 test and macular threshold program forthe central 5 degree field on the Humphrey field analyzer (model 750).Patients with split fixation were identified on the basis of retinal sensitivitybeing ‘0’ in atleast one quadrant of macular threshold program. Wipe outwas defined as unexplained severe loss of best corrected post op centralvisual acuity by atleast 4 lines or counting fingers or less if preoperativevision was 20/200, associated with severe loss of threshold values inthe 4 quadrant of the macular threshold test. The parameters analyzedincluded change in BSCVA, control of IOP, change in total sensitivity ofthe 4 quadrant and each quadrant separately of the macular thresholdtest at the end of 3 months. The surgical technique was standard in allpatients and performed by same surgeon.2. Preoperatively all the patients were put on oral acetazolamide for 2days. Mannitol in dosages of 1mg/kg body weight was given 1 hourpreoperatively. Peribulbar anesthesia using ligocaine without adrenalinewas given.3. Surgical technique involved fornix based conjuctival flap and a partialthickness (1/2 to 1/3rd) triangular scleral flap 0.4 mg/dl of mitomycin – Cwas used for all patients. Controlled decompression of anterior chamberwas done by creating a paracentesis tract in peripheral cornea beforesclerostomy to prevent sudden hypotomy. Scleral flap was closed withinterrupted sutures at apex and 2 releasable sutures at the sides. Titratedclosureof scleral flap was done. Water tight closure of the conjunctiva wasensured.RESULT50 eyes of patients which fulfilled the inclusion criteria were included in thestudy. Of these 44 eyes were male patients while 6 were that of female patients.The mean age of the patients was 52.32 ± 16.71 years with a range from 35.49 to69.03 years. The average sum of all the quadratic add of macular fields in thepreop group was 354.72 ± 105.28 decibels.Demographic baseline clinical characteristics of 50 patients:ParameterAgeValues• Mean +- SD 52.32 +- 16.71Gender321

69th AIOC Proceedings, Ahmedabad 2011• Male 44• Female 6Type of Glaucoma• POAG 30• PACG 14• PXF 6dB total of MF• Range 68 to 477• Mean +_ SD 354.72 +-105.281. Range of BSCVALoss of BSCVA at 3 months41 eyes maintained their preop BSCVA. 7 eyes had a drop by 1 snellens line.3 eyes had a decrease by 2 snellens line. No case of wipe out (severe loss ofcentral visual acuity) seen. This loss of vision was not statistically significant(t= 1.705, p=0.094). The drop in BSCVA in these points were due to lenticularchanges.2. Surgical reduction of IOPThe average preop IOP with maximum medical management was 24.46 withstandard deviation of ±5.54 and average post op IOP was 10.36 with standarddeviation of ± 1.94. The mean reduction in IOP at the end of 3 months was 14.12which was statistically significant (t=19.49; p

69th AIOC Proceedings, Ahmedabad 2011no incidence of wipe out at the end of 3 months in all the 50 patients withadvanced glaucoma with tubular fields and split fixation. We used the quadratictotal and difference in dB values in each quadrant of macular threshold test forevaluation. Use of lignocaine without adrenaline for anesthesia, preoperativeIV mannitol, oral hypotensive agents, paracentesis to prevent suddenhypotomy after sclerostomy, judicious intraoperative adjustment of sclerel flapresistance by use of releasable sutures, prevention of post operative spikes bymaintaining on oral hypotensive agents in our surgical technique could havecontributed to this.In view of our results, we conclude that sudden unexplained post operativeloss of vision in patients with end stage glaucoma undergoing filteringsurgery is at most a rare complication and that early surgical intervention withappropriate surgical technique can prevent further progression.REFERENCE1. Topouzis F, Tranos P, Koskosas A; etal. Risk of sudden visual loss followingfiltering surgery in end stage glaucoma. Am J Opthalmol 2005;140:661-6.2. Kolker AE,. Visual prognosis in advanced glaucoma: a comparison of medical andsurgical therapy for retention of vision in 101 eyes with advanced glaucoma. TransAM J Opthalmol. Soc 1977;75:539-55.3. Costa VP, Smith M, Spaeth GL, Gandham S, markovitz B. Loss of visual acuityafter trabeculatetomy. Ophthalmology 1993;100:599-612.4. Aggarwal SP, hendeles S. Risk of sudden visual loss following trabeculectomy inadvanced primary open angle glaucoma. BR J Opththalmol 1986;70:97-9.5. Licther PR, Raving JG. Risk of sudden visual loss after glaucoma surgery. Am JOphthalmol. 1974;78:1009-13.6. Levene RZ. Central visual field, visual acuity and sudden loss after glaucomasurgery. Ophthalmic Surg 1992;23:388-94.7. Langerhorst CT, de Clercq B, van den Berg TJ. Visual filed behavior after intraocularsurgery in glaucoma patients with advanced defects. Doc Ophthalmol 19 9 0;75:2 81-9.Retrospective Study of Pre-Operative FactorsAffecting TrabeculectomyDr. Kalyani Vijaya Kumari, Dr. Padmawati Bhattacharya, Dr. VidyaCherlekar, Col. M DeshpandeSince the original description by Cairns in 1968, trabeculectomy has goneon to become the surgery of choice for control of glaucoma. It is the goldstandard against which all other procedures are compared.324

Glaucoma Free PapersTabeculectomy has been operation of choice for improving aqueous outflow inglaucomatous eyes in which IOP lowers by providing limbal fistula throughwhich aqueous drains into subconjunctival space.The indication for surgery is, in general, progressive disease with maximalmedical treatment or intolerance to medication or both. It is also theprimary treatment modality in certain glaucomas. However, the resultsof trabeculectomy are quite variable, with success rates of 48% - 83% beingreported for POAG.This study was designed to retrospectively evaluate the influence of variouspre-operative factors on the outcome of trabeculectomy.MATERIALS AND METHODSOur study was a retrospective review of case records of primarytrabeculectomies done at a tertiary care eye hospital, between May 2004and January 2009. Indication for surgery was controlled IOP with maximummedical treatment initial high IOP which will be threat to the visual fields.Preoperative data collected included age ,gender, type of glaucoma,preoperative medication and its duration, dates of all surgical interventionsincluding laser operations, best corrected visual acuity (BCVA), refraction, IOP,anterior segment status, posterior pole abnormalities, optic disc appearance,and results of visual field examinations. The preoperative IOP, was consideredto be the value measured by Goldmann applanation tonometry at the visitimmediately prior to trabeculectomy.Postoperative IOP values measured on the first postoperative day aftertrabeculectomy and at one week, one month, and one year postoperativelywere collected.Repeat trabeculectomies and trabeculectomy done in pediatric patients wereexcluded from the study. A total of 200 trabeculectomies done in 174 patients(both eyes were operated in 26 patients) were included in the study.Complete success is defined as post operative IOP between 6-21 mm Hgwithout additional topical or systemic medications, IOP control requiring useof single medications defined as qualified success. Failure defined as unable toachieve complete or qualified success and requring further surgical or otherproceduresRESULTSOf the 174 patients included, 78 (44.9 %) were females and 96 (55.1 %) males. Themean age of the patients was 67.2 years (range 22 to 78 years). Trabeculectomywas combined with cataract surgery in 22 cases. Intraoperative mitomycin Cwas used in 29 cases.325

69th AIOC Proceedings, Ahmedabad 2011Table 1: Distribution of Cases According to Type of GlaucomaPrimary Open Angle Glaucoma 86Primary Angle Closure Glaucoma 24Pseudo Exfoliation Glaucoma 57Normal Tension Glaucoma 13Uveitic Glaucoma 11Traumatic Glaucoma 9Total 200Table 2: IOP Levels In Various Glaucomas – Preoperative and 1yr Post-OperativeType of Glaucoma Pre- Op Post – OpMean IOP Mean IOPPrimary Open Angle Glaucoma 27.2 15.2Primary Angle Closure Glaucoma 33.4 17.7Pseudo Exfoliation Glaucoma 30 17.1Normal Tension Glaucoma 17.6 12.4Uveitic Glaucoma 29.3 19.4Traumatic Glaucoma 32 20.8Table 3: No. of Successful Trabeculectomies in Different Types ofGlaucomaTypeNo.POAG 53PACG 13PXFG 31NTG 7Uveitic 6Traumatic 4Successful trabeculectomy, as defined by IOP reduction by two-third of preoperativevalues, was obtained in 114 patients. Qualified success was achievedin 19 cases with addition of single topical medication. Of these, 11 cases wereof POAG, 7 of PXFG and 1 was uveitic glaucoma.Relationship with Pre-Operative IOPThe operated eyes were divided into two groups on the basis of pre-operativeIOP less or more than equal to 35 mm of Hg.326

Glaucoma Free PapersTable 4: Outcome of trabeculectomy 1mth post operatively, in relationto pre-operative IOPPre-op IOP /= 35 MmComplete Success 69 45Qualified Success 13 6Failure 34 33Total 116 84Completely successful surgical outcome was achieved in 59% when pre-op IOPwas /= 35 mm of Hg .Relationship with Duration of Medical TreatmentOf the 200 eyes that underwent trabeculectomy, 109 had received medicaltreatment primarily and were uncontrolled by it. 70 of these eyes were ofPOAG, 25 of PXFG, 11 of NTG and 3 of uveitic glaucoma. The eyes with PACGand traumatic glaucoma had received medical treatment only as a short termmeasure, prior to laser or surgery.A total of 63 eyes had been on medical treatment for more than a year. Meanpre-op IOP in this group was 28.2 mm of Hg. The eyes on medical treatment ofless than a year had a mean pre-op IOP of 27.1 mm of Hg.Table 5: Pre-op and 1 yr. post –op IOP, in two groups made on thebasis of duration of medical treatmentMean Pre-Op IOPMean Post-Op IOP1 YR 28.2 19.6Table 6: Outcome of trabeculectomy in relation to duration of preoperativemedical treatment< 1YR > 1YRComplete Success 29 35Qualified Success 7 12Failure 10 16TOTAL 46 63DISCUSSIONThe principle aim of the study was to determine the success rate for longterm IOP control after primary conventional trabecvlectomy and need forfurther antiglacomatous treatment either medical, or surgical based on the327

69th AIOC Proceedings, Ahmedabad 2011clinical experience and on the literature , in high risk cases including youngpatients , eyes with previous ocular surgery, trauma, Aphakia, active Uveitis,neovascular glaucoma. In these cases Anti, metabolites together withconventional filtering surgery is indicated.The present study our results demonstration success rate depends on theage of the patient, the older the age better the result as the fibrous tissueprofilration is less. In young there was need of medication or second surgerywas indicated to reach the target IOP.Outcome of Trabeculectomy in terms of IOPNo standard definition exists for the success of glaucoma surgery with regardto IOP because no single target IOP can be regarded as a safe limit for diseasecontrol in all individuals. We use the limit of 21 mm Hg. In some studiesreducation of IOP at least 20% to 33% from the pre surgical level has consideredsuccess. In this study success rate depends on initial IOP in cases with highIOP the IOP reducation is less thn compare to less initial pre operative IOP.Type of GlaucomaIn terms of type of glaucoma success rate in more common in POAG, PACGthen PXF glaucoma IOP reduction was more in PXF glaucoma because ofshort term of use of preoperative glaucoma medications. In the present studycomplete success was significant in POAG , PACG, PXF glaucoma.Best outcomes of trabeculectomy are obtained with low initial IOP, shortduration of medical treatment and primary open angle glaucoma.REFERENCES1. The AGIS Investigators. The Advanced Glaucoma Intervention Study (AGIS): 11.Risk factors for failure of trabeculectomy and argon laser trabeculoplasty. Am JOphthalmol 2002;134:481–98.2. Borisuth NSC, Phillips B, Krupin T. The risk profi le of glaucoma fi ltration surgery.Curr Opin Ophthalmol 1999;10:112–6.3. Broadway DC, Chang LP. Trabeculectomy, risk factors for failure and thepreoperative state of conjunctiva. J Glaucoma 2001;10:237–49.4. Cairns JE. Trabeculectomy: preliminary report of a new method. Am J Ophthalmol1968;66:673–9.5. Chen TC, Wilensky JT, Viana MAG. Long-term follow-up of initially successfulltrabeculectomy. Ophthalmology 1997;104:1120–5.6. D‘Ermo F, Bonomi L, Doro D. A critical analysis of the long-term results oftrabeculectomy. Am J Ophthalmol 1979;88:829–35.7. Diestelhorst M, Khalili MA, Krieglstein GK. Trabeculectomy: a retrospectivefollow-up of 700 eyes. International Ophthalmology 1999;22:211–20.328

Glaucoma Free Papers8. Downes SM, Misson GP, Jones HS, O’Neill EC. The predictive value of postoperativeintraocular pressures following trabeculectomy. Eye 1994;8:394–7.9. Jacobi PC, Dietlein TS , Krieglstein GK. Primary trabeculectomy in young adults:Longterm clinical results and factors infl uencing the outcome. Ophthalmic SurgLasers 1999;30:637–46.10. Jerndal T , Lundström M. 330 Trabeculectomies: A long time study (3–5½ years).Acta Ophthalmol 1980;58:947–56.11. Lavin MJ, Wormald RPL, Migdal CS, Hitchings RA. The infl uence of prior therapyon the success of trabeculectomy. Arch Ophthalmol 1990;108:1543–8.12. Mills KB. Trabeculectomy: a retrospective long term follow-up of 444 cases. Br JOphthalmol 1981;65:790–5.13. Nouri-Mahdavi K, Brigatti L, Weitzman M , Caprioli J. Outcomes of trabeculectomyfor primary open-angle glaucoma. Ophthalmology 1995;102:1760−9.14. Popovic V, Sjöstrand J. Long-term outcome following trabeculectomy: I.Retrospective analysis of intraocular pressure regulation and cataract formation.Acta Ophthalmol 1991;69:299–304.15. Levene R Z; Glaucoma filtering surgery factors that determine pressure controlled.16. Sturmer, J Broadway, D C Hitching, young patient trabeculectomy, assessment ofrisk factors for failure.17. D’Ermo, F L, Doro D; A Critical analysis of long term results of trabeculectomy.Dr. REKHA S BAINCHINCHOLEMATH: MBBS: Mahadevappa Rampure,Medical College, Gulbarga, Gulbarga University, Karnataka; DOMS (2007),Jawaharlal Nehru Medical College, Belgaum, Karnataka, Rajiv GandhiUniversity, Karnataka; DNB (2010), Medical research foundation, SankaraNethralaya, Chennai, Tamil Nadu. Presently, Viteroretinal fellowship,Sankara Nethralaya, Chennai, Tamilnadu.Association of Ocular Hypertension, PrimaryOpen Angle Glaucoma and Angle ClosureDisease with Retinal Vein OcclusionDr. Rekha S Bainchincholemat , Dr. Ronnie Jackob George, Dr. L VijayaTo assess the prevalence of ocular hypertension (OHT), primary open angleglaucoma (POAG) and angle closure disease in subjects presenting withretinal vein occlusion to a tertiary eye care center.MATERIALS AND METHODSStudy population : 1000 consecutive patients who presented with retinal veinocclusion disease who fulfilled the inclusion and exclusion criteria betweenJune 2006-June 2008.329

69th AIOC Proceedings, Ahmedabad 2011Inclusion criteria: Central retinal vein occlusion (CRVO), branch retinal veinocclusion (BRVO) or Hemi-central retinal vein occlusion.Exclusion criteria: Vasculitis, Secondary vessel occlusion, Secondary glaucoma(Neovascular and uveitic), Pseudoexfoliation, Steroid induced glaucoma.In addition to an ocular and medical history, ocular examination includeddocumentation of visual acuity, slit lamp biomicroscopy for the presence orabsence of neovascularisation of iris, intraocular pressure measurement withgoldmann applanation tonometer, gonioscopy with four mirror for presenceor absence of neovascularisation of angles, to differentiate open, narrow andclosed angles and also to know about the presence or absence of peripheralanterior synechiae, disc evaluation using 90 D lens.RESULTS AND DISCUSSIONThe study included 1000 patients (1000 eyes) with retinal vein occlusion. Therewere 673(67.3%) men and 327(32.7%) women. The mean age was 56.94 ± 11.74(standard deviation) with minimum age of 15years to maximum of 89 years. Inwhich there were 542(54.2%) right eyes and 458(45.8%)with left eye involvement,CRVO were 41.3%(18.4% ischaemic, 22.9% nonischaemic), HCRVO were 2.5%(0.6% superior, 1.9% inferior) and BRVO were 56.2%(29.9% superotemporal,19.7% inferotemporal, 6.3% macular, 0.2% superonasal, 0.1% inferonasal).Three hundred and eighty eyes were considered to be glaucomatous of which227(22.7%) were on topical antiglaucoma medications.The prevalence of POAG was 20.5% in RVO, 23.48% in CRVO, 48% in HCRVOand 17.08% in BRVO. OHT was seen in 2.7% of eyes. The prevalence of PACSwas 6.5%,PAC was 1.3% and PACG was 7% in RVO. The prevalence of PACD inCRVO was 17.19%, in BRVO was 13.35% and in HCRVO was 8%. The prevalenceof glaucoma was significantly higher in RVO cases compared to the generalpopulation (p

Glaucoma Free PapersThe prevalence of glaucoma in CRVO was 44.3%,HCRVO was 56% ,BRVO was32.56% and prevalence of CRVO ,BRVO in glaucoma was 48.16% while HCRVOwas 3.68%.Previous studies have shown variable risk factors for both central and branchretinal vein occlusion and found that glaucoma was significantly associatedwith CRVO, while hypertension and smoking were significantly associatedwith BRVO. Our study shows similar results of increased association ofglaucoma in CRVO and hypertension in BRVO.History of hypercholesterolemia had a significantly greater among thosewithout glaucoma (p

69th AIOC Proceedings, Ahmedabad 2011332• Glaucoma is a significant risk factor in retinal vein occlusions but withoutany significant differences in presentation in primary open angle glaucomaand primary angle closure glaucoma.• Systemic vascular diseases are a risk factor for retinal vein occlusion butnot significantly associated with glaucoma as a additional risk factor.• Angle closure disease is also commonly associated with retinal veinocclusion and should be looked for in this at risk population.REFERENCES1. Sohan singh Hayreh, MD, DSc, M. Bridget Zimmerman, Meena Beri, MD, PatriciaPodhajshy, BSN. Intraocular pressure abnormalities associated with Central andHemicentral Retinal Vein Occlusion. Ophthalmology 2004;111:133-41 by Americanacademy of ophthalmology.2. David H.Orth,MD,and Arnall Patz,MD :Retinal branch vein occlusion. SurvOphthalmol 1978;22:357-76.3. Vijaya L, George R, Arvind H, Baskaran M, Paul PG, Ramesh SV, Raju P,Kumaramanickavel G, McCarty C. Prevalence of angle-closure disease in a urbansouthern Indian population. Glaucoma Project, Vision Research Foundation,Sankara Nethralaya, Chennai, India. Ophthalmology 2008;115:655-60.4. Vijaya L, George R, Paul PG, Baskaran M, Arvind H, Raju P, Ramesh SV,Kumaramanickavel G, McCarty C. Prevalence of open-angle glaucoma in a urbansouth Indian population. Glaucoma Project, Vision Research Foundation, SankaraNethralaya, Chennai,India. Ophthalmology 2008;115:648-54.5. Luntz MH,MD.and Schenker HI,MD. Retinal vascular accidents in glaucoma andocular hypertension. Surv Ophthalmol. 1980;25:163-7.6. Sonty S, Schwartz B. Vascular accidents in acute angle closure glaucoma.Ophthalmology 1981;88:225-8.7. Hitchings RA, Spaeth GL. Chronic retinal vein occlusion in glaucoma. Br JOphthalmol. 1976;60:694-9.8. Sohan singh Hayreh, M. Bridget Zimmerman, Meena Beri, Patricia Podhajshy:Incidence of various types of retinal vein occulsion and their recurrence anddemographic characteristics. Am J ophthalmol 1994;117:429-41.Comparison of Vertical Cup: Disc Ratioof Glaucomatous Indian Eyes by ClinicalEvaluation and Optical Coherence TomographyDr. Rupal Rathod, Dr. Suhas Haldipurkar, Dr. Rita DhamankarGlobally Glaucoma is the second leading cause of blindness affecting 67million documented cases and the leading cause of preventable blindness.It is characterized by progressive optic nerve damage associated with loss ofvisual function.

Glaucoma Free PapersAn examination of the optic nerve head along with its surrounding RNFL isbelieved to be essential in both detecting and monitoring glaucoma.Slit lamp biomicroscopic examination of the optic nerve head is one of thekey tests performed during the diagnosis and follow-up of a patient withglaucoma. New systems offering automatic analysis of the optic nerve headand the nerve fiber layer are increasingly being used. One of these instrumentsavailable is the optical coherence tomography (OCT) that is used as a usefulclinical support for both the diagnosis and follow-up of the disease.In this study, we compared the optic nerve head findings for vertical cup: discratio (VCDR) done with the slit lamp biomicroscopic examination of the opticnerve head(clinical method) and the OCT findings for vertical cup: disc ratio.MATERIALS AND METHODSThe study population involved patients diagnosed with glaucoma on variousmode of management in the period from February 2008 through March 2010.Inclusion Criteria: All diagnosed glaucomatous cases with significant clinicaloptic disc findings and in Optic nerve head (ONH) analysis using OCTimaging.Include all glaucomatous patients receiving various modes of management.Exclusion Criteria: Patients with media opacity like corneal opacity, maturecataract etc;• Patient with retinal diseases;• Other optic disc anomalies like optic disc pit, optic disc coloboma etc.• Patients having neurological diseases viz. those with visual field defectsdue to causes other than glaucoma (e.g., demyelinating disease, nonglaucomatousneuropathy or a central nervous system disorder).Study DesignA cross sectional study of 220 eyes of 112 patients with glaucoma was done.For the statistical analysis purpose median value for VCDR was calculated foreach eye examined by four observers clinically.The descriptive statistics for age showed mean age was 57.13.RESULTS• A significant difference was found for VCDR evaluation done by clinicalmethod and using OCT with p

69th AIOC Proceedings, Ahmedabad 2011by clinical method, using the Kappa test. It showed variable amount ofagreement between the observers.Paired DifferencesMean Std. Std. Error Mean 95%DeviationConfidence IntervalLower Upper of the Difference Sig.t df (2-tailed)Median -0.092532 0.116088 0.007827 0.107957 0.077107 11.823 219 .000VCDR (-ve) (-ve) (-ve) (-ve)OCT VCDRDISCUSSIONAssessment of the optic nerve is of paramount importance when evaluating apatient with suspected or diagnosed glaucoma and, in most cases; structuraldamage to the nerve head can be detected before any defects in the visual fieldappears. The development of new automatic diagnostic instruments basedon the structural analysis of the optic nerve head and nerve fiber layer hastherefore had a huge impact on managing the patient with glaucoma sincethese instruments provide objective morphometric data. OCT proceduresenable a complete analysis of papillary morphology and provide easilyunderstandable quantitative data that can be compared with normalitymeasurements from databases. Similar to our study results, a study done byArnalich-Montiel et al, determined the agreement between three observersand the OCT in estimating cup to disc ratios in glaucomatous and ocularhypertensivepatients, concluded that the OCT was found to overestimateratios and these overestimates were greater for smaller disc sizes.Also, Varma R et al through their study found that interobserver agreement inassessing glaucomatous damage was moderate.OCT values always were on higher side compared to clinical data for VCDR.Also we found variable agreement between the observers in the study.However, as with any investigation, clinical decisions should not be made onthe basis of an isolated test. The clinician should exercise clinical correlationand judgment before instituting the appropriate treatment.REFERENCES1. Arnalich-Montiel F, Muñoz-Negrete FJ, Rebolleda G, Salaes-Sanz M, Cabarga C.Cup-to-disc ratio: agreement between slit-lamp indirect ophthalmoscopic estimationand Stratus optical coherence tomography measurement. Eye 2007;21:1041-9.2. J M Martinez-DE-LA-Casa et al. Agreement between slit lamp examination and opticalcoherence tomography in estimating cup-disc ratios. Eur J Ophthalmol 2008; 18.3. Varma et al. Expert agreement in evaluating the optic disc for glaucoma.Ophthalmology 1992;99:215-21.334

69th AIOC Proceedings, Ahmedabad 2011Controlled IOP was defined as IOP ≤18 mmHg on two separate occasionstaken one week apart during office hours. Mean IOP value was recorded asoffice IOP.336Exclusion Criteria: 1) Post trabeculectomy and post NPDS patients of POAGwith IOP controlled with additional medications.2) Patients having undergone any other intraocular surgery in the eye underconsideration.3) Patients with ocular disease which can directly affect IOP or measurementof IOP (corneal opacity, uveitis, etc.).A written informed consent was taken from all the patients for inclusion inthe study. After detailed history and general physical examination to ruleout any gross systemic disease, patients were subjected to a detailed ocularexamination including, Visual acuity: unaided and best corrected, anteriorand posterior segment examination, gonioscopy, central corneal thickness,visual field charting and IOP measurement.Diurnal variation (DV): IOP was measured by Goldmann applanationtonometer. The diurnal tension curve DTC was obtained after getting 3 hourlyreadings beginning from10 a.m. in the morning onthe day of admission, andconsecutive readings weretaken at 1 p.m., 4 p.m., 7 p.m.10 p.m., 1 a.m., 4 a.m. and 7a.m. DV was calculated as:Maximum – minimum IOPreading.Water Drinking Test: Thistest was performed at 7 amafter taking the baseline IOPmeasurement. The patientwas asked to drink 1 litreof tap water in 10 minutesfollowed by IOP readingsevery 15 minutes for 1½ to2 hrs till the baseline IOPvalue was reached.The IOP fluctuation duringthe WDT was: Maximum IOP – Baseline IOPThe data was analyzed statistically by using one way ANOVA test.

Glaucoma Free PapersRESULTSThe Mean age was 61.70+3.92 years and 59.80+8.51 years in group I and IIrespectively. Males were 45% and 55% respectively in the 2 groups. Therewas no statistically significant difference in the visual acuity, lens changesand optic disc cupping in the 2 groups. The mean duration of surgery was34.15+47.10 months in Trabeculectomy and 39.85+39.71 months in NPDS group(p value- .681). Mean office IOP was lower in NPDS (13.02+3.731mm) thanTrabeculectomy group (14.50+3.19mm), but not significant(p=.321). 60% ofgroup I and 70% of NPDS group had office IOP < 16mm of Hg.On DVT, IOP fluctuation was lower in NPDS (4.90+2.36) as compared toTrabeculectomy group (5.15+1.63 mm)( NS) A rise of >8mm was seen in 10% inTrabeculectomy and 15% in NPDS groups. Morning rise was found in 65% and75% in group I and II (statistically not significant). On WDT, both fluctuation andmaximum IOP, though higher in trabeculectomy group (5.25+2.22, 21.35+4.72)were not significant different from NPDS group(5.15+2.11, 20.50+6.50).AnIOP >21mm was seen in 35 and 25% patients on DVT and 55&50%on WDT intrabeculectomy and NPDS group respectively.Table 1: DVT and WDT ResultsDVT GROUP I GROUP II P valueIOP MAX* (RANGE) 18.55±4.29 (12-26) 17.55±5.37 (10-28) .520IOP MIN* (RANGE) 13.40±3.37 (8-18) 12.65±3.49 (7-20) .495IOP Fl* (RANGE) 5.15±1.63 (2-8) 4.90±2.36 (2-12) .699WDTWbaseline (RANGE) 16.00±3.94 (10-24) 15.30±5.02 (8-28) .627W MAX* (RANGE) 21.35±4.72 (14-30) 20.50±6.50 (12-34) .639W Fl* (RANGE) 5.25±2.22 (2-10) 5.15±2.11 (1-8) .885*mean±SDTable 2: The distribution of IOP Fluctuation (IOP Fl) (in mmHg)IOP Fl GROUP B GROUP CDV WDT DV WDT

69th AIOC Proceedings, Ahmedabad 2011( p8mm Hg on Diurnal Variation as wellas Water Drinking Test. Such fluctuations may be responsible for progressionof glaucomatous damage in treated patients of POAG, as most studies rely onoffice IOP control to define success of glaucoma therapy. We also found thatthe mean IOP levels of NPDS group were lower than trabeculectomy groupin all the parameters, however the difference was not statistically significant.This is at variance with previous study 6 which reported significantly lowermean IOP on DV in trabeculectomy group compared to NPDS. However alltheir IOP recording was done during office hours only, while 65% and 75%of patients of group I and II in our study showed early morning rise of IOP.Also, all their patients of trabeculectomy had been given intra-operativemitomycin-C, which was not used for NPDS patients, hence the lower IOPlevels in that group. Mitomycin-C was not used in any of our cases duringsurgery Hence we conclude that long term efficacy of NPDS was found to becomparable to trabeculectomy.REFERENCES1 Drance SM. Diurnal variation of intraocular pressure in treated glaucoma. Am JOphthalmol 1963;70:302-11.2 O’Brien C, Schwartz B, Takamoto T, et al. Intraocular pressure and the rate ofvisual field loss in chronic open-angle glaucoma. Am J Ophthalmol 1991;111:491-500.3. Roth JA. Inadequate diagnostic value of the water-drinking test. Br J Ophthalmol1974;58:55-61.4. Geudes RA, Geudes VM, Chaoubah A. Use of water drinking after non-penetratingdeep-sclerectomy. J Fr Ophthalmol 2005;28:1076-80.5. Vetrugno M, Sisto D, Trabucco T, et al. Water-drinking test in patients withprimary open-angle glaucoma while treated with different topical medications. JOcul Pharmacol Ther 2005;45:250-7.6. Mansouri K, Orguel S, Mermoud A, et al. Quality of diurnal intraocular pressurecontrol in primary open-angle patients treated with latanoprost compared withsurgically treated glaucoma patients: a prospective trial. Br J Ophthalmol 2008;92:332-6.338

Glaucoma Free PapersTable 1: Table showing the gender distribution of the study patientsGender Number PercentageMale 34 82.93Female 7 17.07The gender distribution was skewed heavily in favour of the males.Table 2: Association of history of trauma with angle recessionNumberPercentageA 29 70.73B 5 12.20C 7 17.07A=Definitive single episode of Trauma; B=Multiple episodes of Trauma.The anglerecession and the eventual development of glaucoma cannot be attributed to one singleepisode.; C= Patients denying any history of ocular traumaThus in most of the patients either a single or multiple episodes of traumacould be attributed as the cause of the raised intraocular pressures.Table 3: Time from injury to surgeryTime from injury to surgery Number (n =29) Percentage< 6 months 4 13.796m – 2 yrs 7 24.142yrs – 5 yrs 11 37.935 yrs – 10 yrs 5 17.24>10 yrs 2 6.89The time frame from the occurrence of injury to the surgical intervention wasfrom less than 6 months to more than 10 years.Table 4: Indication for surgeryIndication for surgery Number PercentageMedically uncontrolled Glaucoma 21 51.22Documented progression of visual field changes 14 34.15Advanced cupping and uncontrolled IOP 6 14.63Table 5: Pre-operative Intraocular pressure rangeIOP mm of Hg Number Percentage20 – 30 18 43.9031-40 13 31.7141-50 6 14.6351-60 3 7.32>60 1 2.44341

69th AIOC Proceedings, Ahmedabad 2011Table 6: Degrees of Angle recessionDegrees of AR Number Percentage90-180 2 4.88180-270 7 17.07270-360 32 78.05Most of the patients 32/41(78.05%) had an angle recession in excess of 270º.Table 7: Time duration of application of 0.2 mg/ml of MMCTime duration Number Percentage4 mins 34 82.932 mins 7 17.07In all the case MMC was applied. In 34/41 eyes the antimetabolite applicationwas for 4 minutes while in 7 eyes it was applied for 2 minutes.Table 8: Comparison of Pre-operative and post operative IOPS Follow Mean SD Meanno up n Pre op Follow up Pre op Follow up diff d.f sig1 1w 41 31.1611 11.2416 9.72 5.66 19.92 40 P

Glaucoma Free PapersAll the complications were treated by medical means and there was no needfor any surgical intervention.DISCUSSIONThe association of blunt ocular trauma with subsequent development ofglaucoma has been well described. 1-2 Pathological changes have been seenin the trabecular meshwork and angle recession is not responsible for theobstruction to aqueous outflow. While recession of the irido-corneal angleis common after blunt trauma (60–94%), the late development of glaucoma israre (2– 10%). The rise in intraocular pressure that occurs immediately aftera nonpenetrating eye injury can be severe but usually lasts only days orweeks and, in most cases, can be controlled with glaucoma medication alone.Traumatic glaucoma with chronically raised intraocular pressure, optic nervecupping, and visual field damage usually occurs years or even decades afterblunt trauma. Late glaucoma is more frequent if the recession involves 180 0or more of the angle and in the present series 78.05%of the patients had anglerecession between 270-360º of AR.We did a retrospective analysis of 41 eyes of 41 patients who were subjectedto Trab with MMC for medically uncontrolled glaucoma or documentedprogression of Visual Field changes or for advanced cupping and uncontrolledIOP. Certain studies like the one done by A Mermoud et al 3 have shown thatthe use of antimetabolites in the primary procedure for these patients greatlyincreases the success rates. Thus MMC was used in all the patients selectedfor this study. The mean preoperative IOP was 31.1611±9.72 mm of Hg andat the last follow up post surgery the IOP was 15.6674±2.16 mm of Hg. TheIOP was successfully controlled without medical treatment in 78.05%(32/41eyes),9.76%(4/41 eyes) were designated as qualified success while 12.19%(5/41eyes) were designated as failiure.A study was done by Mermoud A, Salmon JF, Barron A, et al named Surgicalmanagement of post-traumatic angle recession glaucoma was publishedin Ophthalmology 1934. In that series the success of trabeculectomy usingKaplan-Meier life table analysis was 62 % after 2 years and 42 % after 4 years.In our study the success rates were significantly higher and the cumulativeprobability of success was 78% at 2 years and 65% at 4 years. The authors inthat study have attributed the low success rates to the young age,black raceand severe contusional injuries sustained by some of the eyes included in thestudy. In our study the severity of the contusional injuries was relatively lessand the age of the patients included were higher which may explain the bettersuccess rates.343

69th AIOC Proceedings, Ahmedabad 2011There were some post surgical complications like shallow anterior chambers,choroidal detachments, hyphaema etc but they resolved spontaneouslywithout any need for surgical intervention. In one case hypotony relatedmaculopathy occurred but the patient responded well to topical and oralmedication. One case of late bleb infection occurred but the aggressive useof topical medications was able to resolve the condition. 3 cases however lostvision subsequently over the follow up period but the cause of the loss ofvision was not due to the raised intraocular pressure but due to the damagesustained to the retina due to the contusional injury to the globe.The surgical management of post-traumatic angle recession glaucoma isdifficult because the patients are young, the disease is often advanced, and thefollow up and compliance are poor. Our results of surgical treatment of posttraumaticangle recession glaucoma using mitomycin C suggest that goodmid term control of intraocular pressure can be achieved without the need fortopical medication.REFERENCES1. 1 Salmon J F, Mermoud A, Ivey A, et al. The detection of post-traumatic anglerecession by gonioscopy in a population-based glaucoma. Ophthalmology1994;101:1844–50.2. Desai P, MacEwen CJ, Bains P, et al. Incidence of cases of ocular trauma admittedto hospital and incidence of blinding outcome. Br J Ophthalmol 1996;80:592–6.3. Mermoud A, Salmon JF, Straker C, et al. Post-traumatic angle recession glaucoma:a risk factor for bleb failure after trabeculectomy. Br J Ophthalmol 1993;77:631–4.4. Mermoud A, Salmon JF, Barron A, et al. Surgical management of post-traumaticangle recession glaucoma. Ophthalmology 1993;100:634–42.5. Shields MB, Scroggs MW, Sloop CM, et al. Clinical and histopathologic observationsconcerning hypotony after trabeculectomy with adjunctive mitomycin C. Am JOphthalmol 1993;116:673–83.6. Zacharia PT, Depperman SR, Schuman JS. Ocular hypotony after trabeculectomywith mitomycin C. Am J Ophthalmol 1993;116:314–26.7. Greenfield DS, Suner IJ, Miller MP, et al. Endophthalmitis after filtration surgerywith mitomycin. Arch Ophthalmol 1996;114:943–9.8. Higginbotham EJ, Stevens RK, Musch DC, et al. Bleb related endophthalmitis aftertrabeculectomy with mitomycin C. Ophthalmology 1996;103:650–6.9. Fukuchi T, Iwata K, Sawaguchi S, et al. Nd:YAG laser trabeculopuncture (YLT) forglaucoma with traumatic angle recession. Graefes Arch Ophthalmol 1993;231:571–6.10. Mermoud A, Salmon JF, Straker C, et al. Post-traumatic angle recession glaucoma:a risk factor for bleb failure after trabeculectomy. Br J Ophthalmol 1993;77:631–4.11. Mermoud A, Salmon JF, Barron A, et al. Surgical management of post-traumaticangle recession glaucoma. Ophthalmology 1993;100:634–42.344

Glaucoma Free PapersVisual Segmental Rim Assessment in PrimaryOpen Angle GlaucomaDr. Rajesh Gupta, Dr. Nangia Vinay B, Dr. Anshu Khare, Dr. Ajit KumarSinhaThe optic disc is an important site of glaucomatous damage. 1 In additionthis is accompanied by changes in the retinal nerve fiber layer andadjacent peripapillary tissues. Clinical examination of the optic nerve remainsan important tool in the day to day diagnosis and management of subjectswith optic neuropathy. Stereoscopic magnified evaluation of the optic nervehas become the norm of clinical optic disc examination. Clinical notesand drawings of the optic nerve has been followed for several decades.Optic nerve photography became adopted as a tool for documentation andcomparison of disc photographs which complimented the clinical stereoscopicevaluation and the disc drawings. Stereodisc photography using camerasspecially designed for it was also adopted though not universally. Subjectiveassessment both clinically and on photography is an important consideration.A shift in techniques and technology towards a more objective and accuratedocumentation system which allows for follow up over time was an importantgoal. This was the basis of the development of several objective and accurateimaging tools amongst which is the confocal scanning laser ophthalmoscopealso known as the Heidelberg Retina Tomograph. 2,3The early diagnosis of glaucoma is dependant on the diagnostic ability of thenewer imaging equipments and the clinical acumen of the glaucoma specialist.Early detection of progression of optic disc damage, and retinal nerve fiberlayer is more dependant on the imaging equipment and their validatedsoftware. The moorfields regression was derived on normal subjects. 4 Theregression has its basis the log of the rim area plotted against the disc area.Thus if for a particular disc, the rim area/disc area ratio is less than expectedin a normal population, then one may suspect that the patient has glaucoma.Similarly it may be calculated for different segments of the optic nerve asdefined on the HRT. It was the purpose of this study to clinically assessthe optic disc rim divided according to the St. Andrews Cross in glaucomapatients on digital photographs and to see if the clinical assessment correlatedwith Moorfields Regression Analysis (MRA) on the CSLO.MATERIALS AND METHODS95 eyes (47 right eye and 48 left eyes) of 67 POAG subjects, diagnosed on thebasis of the optic disc damage and visual field loss were included. The meanage was 57.27+10.73 yrs. All subjects underwent an ophthalmic evaluationincluding slit lamp biomicroscopy, applanation tonometry, gonioscopy, optic345

Glaucoma Free PapersThe optic disc was classified as abnormal by visual assessment for thewhole disc and for the segments with greater frequency than with MoorfieldsRegression analysis. The greatest difference in frequency was found for thetemporal segment and then for the superior segment and then for overall opticdisc, followed by inferior disc. The least difference was for the nasal discsegment.DISCUSSIONThe rim disc ratio is an important parameter in determining abnormality dueto loss of rim tissue. This has been implemented in the Moorfields regressionanalysis used in the CSLO. This may be taken as one method of identifyingabnormality of the optic disc, the presence of glaucoma or glaucoma likefeatures. The premise of the rim area depends on the contour line. Furtherthe initial MRA results are a one time assessment. The rim area is furtherdependant on the reference plane, which will identify the cup area. Everythingabove the cup is defined as the rim. The difference in identifying segmentaldamage on visual assessment on digital optic disc and retinal nerve fiber layerphotographs is clinically significant. Visual assessment takes into account notonly the anatomy of the optic disc and retinal nerve fiber layer, but many othercues, including, overall appearance, color, texture, vascular characteristics,beta zone presence. The findings suggest that clinical assessment of the opticdisc should be considered an important part of the optic disc assessment,in conjunction with imaging. Imaging has several advantages, includingobjectivity and measurements. Clinical skills may take a long time to developbut nevertheless should continue to be fostered to the greatest extent. Clinicalassessment and imaging together may help in enhancing detection and theexact role and importance of each in different patients may best be left to thetreating clinician.REFERENCES1. Jost B. Jonas and Wido M. Budde. Diagnosis and Pathogenesis of GlaucomatousOptic Neuropathy: Morphological Aspects. Progress in Retinal and Eye Research2000;19-1:1-402. The Essential HRT Primer. Editors: Murray Fingeret, John G. Flanagan, JeffreyM. Liebman. Jocoto Advertising Inc. San Ramon 94583. 2005. by HeidelbergEngineering.3. A.F. Scheuerle, E. Schmidt. Springer Verlag. Atlas of Laser ScanningOphthalmoscopy. Berlin Heidelberg 2004.4. Wollstein G, Garway-Heath DF, Hitchings RA: Identification of early glaucomacases with scanning laser ophthalmoscope. Ophthalmology 1998;105:1557-63.347