Publications by authors named "Nathan M Radcliffe"

50 Publications

Comparison of Safety and Efficacy Between Ab Interno and Ab Externo Approaches to XEN Gel Stent Placement.

Clin Ophthalmol 2021 26;15:299-305. Epub 2021 Jan 26.

Department of Ophthalmology, Mount Sinai School of Medicine, New York, NY, USA.

Purpose: To compare the safety and efficacy of two different techniques for implantation of the XEN Gel Stent, a minimally invasive surgical device for the treatment of refractory glaucoma.

Methods: A retrospective chart review of eyes that received ab interno or ab externo XEN Gel Stent placement from February 2017 to October 2019 was conducted. A single surgeon (NMR) performed all operations. Eyes that received the XEN implant concomitant with a glaucoma drainage device insertion or that were lost to 6-month follow-up were excluded. Intraocular pressure (IOP) change, change in glaucoma medications, frequency of slit lamp revision procedures, and frequency of secondary glaucoma surgeries were the primary outcomes compared between groups.

Results: Fifty eyes that underwent ab interno placement and 30 eyes that underwent ab externo placement were studied. The ab interno cohort demonstrated a mean IOP reduction of 8.4 ± 1.7 mmHg (28.6% decrease) by 12 months, compared to a mean reduction of 12.8 ± 3.0 mmHg (40.1% decrease) in the ab externo group (p = 0.208). Mean reduction in medication use was 1.81 ± 0.29 medications in the ab interno group and 1.86 ± 0.37 in the ab externo group (p = 0.913). By 12 months, 58% of ab interno eyes had required 5-fluorouracil injection compared to 36.7% of ab externos (p = 0.105). Bleb needling was applied to 42% and 26.7% of the eyes, respectively (p = 0.231). A second glaucoma surgery was necessary for 20% of the ab interno cohort and 10% of the ab externo cohort (p = 0.351).

Conclusion: There were no differences in outcomes between ab interno and ab externo placement of the XEN Gel Stent. Both approaches are safe and effective for lowering IOP.
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http://dx.doi.org/10.2147/OPTH.S292007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7847364PMC
January 2021

Evaluation of the IOP-Lowering Effect of a Multi-Pressure Dial at Different Negative Pressure Settings.

Transl Vis Sci Technol 2020 11 13;9(12):19. Epub 2020 Nov 13.

Vance Thompson Vision, Sioux Falls, South Dakota, USA.

Purpose: To evaluate the intraocular pressure (IOP)-lowering effect of a multi-pressure dial (MPD) at targeted negative pressure settings.

Methods: Prospective, intrasubject controlled study of 65 healthy subjects randomized to receive no negative pressure for 60 minutes or negative pressure application at designated levels of 25%, 50%, and 75% of baseline IOP for 20 minutes each. The main outcome measure was mean IOP with application of negative pressure.

Results: In the study eye group, from a baseline IOP of 15.8 ± 3.6 mm Hg, the mean IOP was 13.5 ± 3.4, 11.5 ± 3.1, and 10.2 ± 2.7 mm Hg with negative pressure settings of 25%, 50% and 75%, respectively. In the control eye group, from a baseline IOP of 15.5 ± 3.0 mm Hg, the mean IOP values at the same time points, without negative pressure, were 15.6 ± 3.0, 15.5 ± 2.5 and 15.3 ± 2.4 mm Hg. The difference between the mean IOPs of the two groups was significantly different at all negative pressure settings ( < 0.001) in comparison with baseline. There was one minor adverse event, a corneal abrasion, that was unrelated to device wear.

Conclusions: Negative pressure application to the periocular space with a multi-pressure dial can produce titratable IOP reduction while the device is worn with active negative pressure. To our knowledge, this technology represents the first nonpharmacologic, nonlaser, nonsurgical method for IOP reduction.

Translational Relevance: This represents the first study demonstrating the IOP-lowering ability of the multi-pressure dial, a device that uses a novel IOP-lowering strategy by delivering negative pressure to the periocular region.
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http://dx.doi.org/10.1167/tvst.9.12.19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7673999PMC
November 2020

The Effects of Glaucoma and Glaucoma Therapies on Corneal Endothelial Cell Density.

J Glaucoma 2021 Mar;30(3):209-218

Sue Anschutz-Rodgers Eye Center, University of Colorado School of Medicine, Aurora, CO.

A healthy corneal endothelium is required for corneal clarity. Both the glaucoma disease state and its various forms of treatment can have adverse effects on the corneal endothelium. Both the presence of glaucoma and the magnitude of intraocular pressure elevation are related to endothelial cell loss (ECL). Topical medical therapy, laser procedures, and both traditional surgeries-trabeculectomy and tube-shunts-and newer minimally invasive glaucoma surgeries have variable effects on ECL. This review will summarize the reported effects of glaucoma and its treatment on ECL. Concerns for corneal endothelial cell health should be part of the decision-making process when planning glaucoma therapy for lowering intraocular pressure, with added caution in case of planned device implantation in eyes with preexisting ECL and low endothelial cell density at high risk for corneal endothelial decompensation.
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http://dx.doi.org/10.1097/IJG.0000000000001722DOI Listing
March 2021

Overnight Safety Evaluation of a Multi-Pressure Dial in Eyes with Glaucoma: Prospective, Open-Label, Randomized Study.

Clin Ophthalmol 2020 21;14:2739-2746. Epub 2020 Sep 21.

Vance Thompson Vision, Sioux Falls, SD, USA.

Purpose: To investigate the safety and tolerability of the multi-pressure dial (MPD) worn overnight for seven consecutive days.

Design: Prospective, open-label, randomized, single-site study.

Subjects: Twenty eyes of 10 subjects with open-angle glaucoma were fitted with an MPD and randomized to negative pressure application of -10 mmHg in one eye (study eye) worn overnight for 7 consecutive days.

Methods: Safety measures included best-corrected visual acuity (BCVA), intraocular pressure (IOP) changes from baseline during and after negative pressure application, slit lamp and dilated fundus exam findings, and rate of adverse events. Subjective assessments were completed daily by the subjects during the 7-day study period and immediately following the study period.

Results: Prior to the 7-day testing period, application of 10 mmHg negative pressure reduced mean IOP from 18.2 ± 3.8 mmHg to 14.0 ± 2.1 mmHg (p<0.01), a 22% reduction. After 7 days of consecutive nightly wear, repeat IOP measurements with the application of negative pressure showed a decrease in mean IOP from 16.9 ± 4.3 mmHg to 13.5 ± 3.7 mmHg. The observed IOP reduction was in addition to the subjects' current treatment regimen. There were no statistically significant changes in IOP, BCVA from baseline following the 7-day period of nightly wear with the application of negative pressure. The patient-reported outcomes were favorable.

Conclusion: The MPD can safely and comfortably be worn overnight. The decrease in IOP of >20% in addition to current therapy is both clinically and statistically significant. The MPD shows promise as a potential new treatment option for nocturnal IOP control.
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http://dx.doi.org/10.2147/OPTH.S256891DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7518782PMC
September 2020

The association between corneal hysteresis and surgical outcomes from trabecular meshwork microinvasive glaucoma surgery.

Graefes Arch Clin Exp Ophthalmol 2021 Feb 12;259(2):475-481. Epub 2020 Sep 12.

Mount Sinai Health System, New York, NY, USA.

Purpose: To assess whether an association exists between pretreatment corneal hysteresis (CH) and the magnitude of intraocular pressure (IOP) and medication burden reduction following microinvasive glaucoma surgery (MIGS).

Methods: Retrospective chart review of 84 eyes from 57 patients with CH measurements who underwent trabecular meshwork MIGS in a glaucoma practice in New York City with follow-up visits at 3-6 and 9-12 months. MIGS included canaloplasty, goniotomy, microbypass stents, or a combination thereof.

Results: The lowest and middle CH tertiles experienced significantly reduced mean IOP at 3-6-month follow-ups (p = .007, < .001), whereas the highest tertile did not (p = .06). At 9-12-month follow-ups, a significant mean IOP reduction only persisted in the middle tertile (p = .001). For medication burden reduction, only the highest CH tertile experienced significant mean reductions at both 3-6- and 9-12-month follow-ups (p = .015, .028). Notably, 7 patients in the lowest CH tertile failed MIGS and required an additional surgical or laser procedure within 24 months of MIGS, whereas only 3 patients failed in the other tertiles (likelihood ratio < .05). Multivariate analysis excluding MIGS failures demonstrated an inverse association between CH and the magnitude of post-operative IOP reduction at both 3-6- and 9-12-month follow-ups when controlling for baseline IOP and medication changes (p = .002, .026).

Conclusion: There was an inverse association between pretreatment CH and the magnitude of IOP reduction following surgery. There is also evidence of an increased need for repeat surgery or other intervention in patients with lower CH who undergo MIGS.
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http://dx.doi.org/10.1007/s00417-020-04921-3DOI Listing
February 2021

Circumferential Viscodilation Ab Interno Combined with Phacoemulsification for Treatment of Open-Angle Glaucoma: 12-Month Outcomes.

Clin Ophthalmol 2020 20;14:1357-1364. Epub 2020 May 20.

Mt Sinai School of Medicine, New York, NY, USA.

Purpose: To evaluate reduction in intraocular pressure (IOP) and medications for open-angle glaucoma (OAG) patients 12 months post-ab-interno circumferential viscodilation (VISCO360, Sight Sciences, Menlo Park, CA) in conjunction with cataract surgery.

Setting: Surgical center (New York, United States).

Design: Retrospective study of all OAG patients treated with 360-degree ab-interno viscodilation with cataract surgery by a single surgeon (NR) having 12 months of follow-up. Eyes were stratified by baseline IOP. Group 1: ≥18 mmHg (n=111). Group 2: <18 mmHg (n=69).

Methods: IOP was measured using Goldmann applanation tonometry. Medications, the number of medication-free eyes in each group at 12 months, and adverse events (AE) are reported. Analysis includes descriptive statistics and t-tests evaluating change from baseline.

Results: Groups 1 and 2 had mean baseline IOP of 22 and 14.3 mmHg. Medication use was 0.9 and 1.1 for Groups 1 and 2. At 12 months IOP for Group 1 was reduced 22% to 17.2 mmHg (p<0.0001) on 1.0 medications (p=0.7). IOP for Group 2 was similar to baseline (15.4 mmHg) but with a reduction in medications to 0.6 (p<0.05). The proportion medication free at 12 months was 32% and 47% for Groups 1 and 2 versus 34% and 26% at baseline, respectively. There were few AE (hyphema 1.7%, IOP elevation >10 mmHg >30 days post-op 1.1%, mild inflammation <1%) and no secondary surgical interventions excepting a single paracentesis, one-day postoperative.

Discussion: Treatment goals for the two groups differed. Pressure reduction (Group 1) or medication reduction (Group 2). Viscodilation achieved significant IOP reduction in Group 1 and medication reduction in Group 2 with many patients (both groups) medication free at 12 months. AE were infrequent and transient.

Conclusion: Circumferential ab-interno viscodilation can be combined with cataract surgery and provide an IOP lowering and medication reduction benefit sustained for at least 12 months, for many patients with OAG.
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http://dx.doi.org/10.2147/OPTH.S252965DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7246311PMC
May 2020

Relationship between optic disc hemorrhage and corneal hysteresis.

Can J Ophthalmol 2020 06 24;55(3):239-244. Epub 2019 Dec 24.

Einhorn Clinical Research Center, New York Eye and Ear Infirmary, New York, NY.

Objective: To determine the relationship between optic disc hemorrhage (DH) and corneal hysteresis (CH).

Methods: Consecutive patients with prior or current photographic evidence of unilateral DH who had undergone CH measurement with the Ocular Response Analyzer (ORA; Reichert, Buffalo, NY) were enrolled. Eyes with a history of corneal disease, refractive surgery, or bilateral DH were excluded. Central corneal thickness (CCT), visual field data, 5 consecutive previous intraocular pressures (IOPs), and maximum documented peak IOP were obtained by chart review. Vertical cup-to-disc ratio (VCDR), the presence of neuroretinal rim notching, number of clock hours of beta zone parapapillary atrophy (ßPPA), and eye with greater ßPPA width were determined from photographs by 2 masked expert examiners.

Results: We identified and analyzed 49 patients with photographically documented unilateral DH. Compared to fellow non-DH eyes, eyes with DH had lower CH (8.7 ± 1.9 vs 9.2 ± 1.7; p = 0.002), higher IOP (15.6 ± 3.6 vs 14.3 ± 4.1; p = 0.017), and greater VCDR (0.79 ± 0.13 vs 0.68 ± 0.23; p < 0.001), but were similar with respect to CCT, ßPPA extent, rim notching, peak IOP, and visual field damage (all p > 0.05). Using multivariate conditional logistic regression analysis, only CH (p = 0.012) and VCDR (p = 0.004) predicted the laterality of the DH.

Conclusions: Lower CH and greater VCDR are independently associated with DH. This suggests that CH may be a structural biomarker for an abnormality of the optic nerve complex that may be associated with progressive glaucoma. Eyes in which DH were detected had lower CH.
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http://dx.doi.org/10.1016/j.jcjo.2019.10.007DOI Listing
June 2020

8 hrs Safety Evaluation Of A Multi-Pressure Dial In Eyes With Glaucoma: Prospective, Open-Label, Randomized Study.

Clin Ophthalmol 2019 2;13:1947-1953. Epub 2019 Oct 2.

Vance Thompson Vision, Sioux Falls, SD, USA.

Purpose: To investigate the safety and tolerability of the multi-pressure dial with a continuous 8-hr duration in subjects with open-angle glaucoma.

Design: Prospective, controlled open-label, randomized, single site study.

Subjects: Twenty eyes of 10 subjects with open-angle glaucoma were fitted with a multi-pressure dial and randomized to negative pressure application of -10 mmHg in one eye for 8 (continuous) hours and ambient atmospheric pressure in the contralateral eye.

Methods: Main safety outcome measures include best-corrected visual acuity (BCVA), intraocular pressure (IOP) changes from baseline after negative pressure application, slit lamp and dilated fundus exam findings, and rate of adverse events. Subjective assessments were administered both hourly during the 8-hr study period and immediately following the study period.

Results: There were no statistically significant changes in IOP, BCVA or TBUT immediately following the 8-hr study period or at the 1-week follow-up visit. Patient-reported tolerability was favorable with a mean response of 1.8 ± 0.4 (scale → 1=best, 10 = worst). Subjects also reported positive interest in the MPD as a glaucoma therapy with a mean response of 1.8 ± 0.5 (scale → 1=best, 10 = worst). One adverse event was reported (headache) and resolved at conclusion of the Day 0 visit.

Conclusion: The MPD demonstrated favorable safety with key parameters remaining stable after an 8-hr wear with negative pressure. Negative pressure application through the MPD was well tolerated by subjects enrolled in the study. The favorable findings demonstrate the safety of sustained delivery of negative pressure over a continuous, uninterrupted 8-hr duration.
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http://dx.doi.org/10.2147/OPTH.S217736DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6778771PMC
October 2019

Consultation Section: Glaucoma. July consultation #9.

J Cataract Refract Surg 2019 07;45(7):1051-1052

New York, New York, USA.

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http://dx.doi.org/10.1016/j.jcrs.2019.05.013DOI Listing
July 2019

Micropulse Transscleral Cyclophotocoagulation: A Look at Long-Term Effectiveness and Outcomes.

Ophthalmol Glaucoma 2019 May - Jun;2(3):167-171. Epub 2019 Feb 8.

New York Eye and Ear Infirmary of Mount Sinai, Department of Ophthalmology, New York, New York; Consultant for Iridex Corporation, Mountain View, California. Electronic address:

Purpose: To investigate the long-term effectiveness of intraocular pressure (IOP) and medication reduction in patients who have undergone micropulse transscleral cyclophotocoagulation (mTS-CPC).

Design: Retrospective chart review.

Participants: A total of 73 eyes of 62 patients treated no more than 1 time with mTS-CPC in a practice in New York City with at least 1 year of follow-up.

Methods: Treatment was 100 seconds of mTS-CPC with energy titrated on the basis of visual acuity. Paired t test and multivariable analysis were performed with SAS (SAS Institute Inc, Cary, NC).

Main Outcome Measures: Visual acuity, IOP, medication burden, phthisis, and development of macular edema were followed.

Results: Average initial IOP was 25.5±9.4, and average number of initial medications was 3.1±1.1. At 1 year, average IOP was 13.8±7.0 (46% reduction) and average number of medications was 2.5±1.0 (19% reduction). A total of 11 of 15 patients (73.3%) initially taking an oral carbonic anhydrase inhibitor before CPC did not require the oral carbonic anhydrase inhibitor 1 year after treatment. Seventy-six percent of patients obtained at least 20% IOP reduction. Multivariate analysis found IOP reduction was associated with power used and preoperative IOP, whereas medication reduction was associated with initial medication burden. Notably, there was a 57% reduction in IOP at 2500 mW power and a 30% reduction at 2000 mW power. No patients developed macular edema or phthisis from the procedure. Some 18.8% of patients with 20/400 vision or better experienced persistent vision loss of ≥2 lines after the procedure, and 10% of patients with light perception to count finger vision progressed to no light perception (NLP) after the procedure. Of patients with 20/400 vision or better, 12.5% gained ≥2 lines of visual acuity on the Snellen chart at the postoperative year 1 visit. In addition, 15.4% of patients with count fingers to NLP vision improved at the postoperative year 1 visit after treatment. One of 6 patients (16.7%) with NLP gained vision at the postoperative year 1 visit.

Conclusions: This study provides evidence that mTS-CPC is a clinically useful procedure associated with good long-term medication burden reduction and IOP reduction that follows a dose-response pattern related to power used.
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http://dx.doi.org/10.1016/j.ogla.2019.02.002DOI Listing
February 2019

Surgical outcomes associated with a sutureless drainage valve implantation procedure in patients with refractory glaucoma.

Clin Ophthalmol 2018 12;12:2607-2615. Epub 2018 Dec 12.

Weill Cornell Medical College, New York, NY, USA,

Purpose: To evaluate the safety and efficacy profile of a sutureless procedure for drainage valve implantation with combined cataract removal and/or endoscopic cyclophotocoagulation (ECP).

Materials And Methods: A retrospective case series study of consecutive surgeries for Ahmed glaucoma valve (AGV; New World Medical) implantation in a 1-year period was analyzed. The surgery was performed using a Tisseel fibrin sealant (Baxter Healthcare Corporation) in place of sutures. Some subsets within the case series also included a cataract extraction with intraocular lens (CEIOL) insertion and/or ECP (Endo Optiks) within the same procedure. Primary outcomes for this study including efficacy (IOP change, reduction in medications) and safety (complications and reoperations) were measured out to 3 years. Comparisons between subsets were made using ANOVA with post hoc Tukey's pairwise tests.

Results: One hundred twenty-two eyes of 99 patients underwent sutureless AGV implantation surgery. Of the 122, 18 had an AGV implantation only, 46 had an AGV + CEIOL, 35 had an AGV + ECP, and 23 had an AGV + CEIOL + ECP. In total, there was a significant decrease in IOP (<0.0001) and number of glaucoma medications (≤0.0054) at each postoperative visit. In a one-way ANOVA, there were no significant differences in mean IOP between the different subsets of surgeries (>0.05); 10.7% and 14.8% of eyes required a reoperation either for a complication or for uncontrolled glaucoma, respectively.

Conclusion: Sutureless valve implantation is associated with a significant reduction in IOP percentage and medication use after the procedure with a safety profile comparable with other glaucoma surgeries.
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http://dx.doi.org/10.2147/OPTH.S186369DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6296183PMC
December 2018

12-Month Outcomes of Goniotomy Performed Using the Kahook Dual Blade Combined with Cataract Surgery in Eyes with Medically Treated Glaucoma.

Adv Ther 2018 09 4;35(9):1460-1469. Epub 2018 Aug 4.

Vance Thompson Vision, Sioux Falls, SD, USA.

Introduction: To describe the 12-month efficacy and safety of goniotomy performed using the Kahook Dual Blade (KDB) in combination with cataract surgery in eyes with medically treated open-angle glaucoma (OAG).

Methods: This was a prospective, interventional case series conducted at seven centers in North America. Consecutive patients with medically treated OAG and visually significant cataract underwent phacoemulsification combined with goniotomy (PE + goniotomy) using KDB. Indications for glaucoma surgery included reduction of intraocular pressure (IOP) and reduction of IOP-lowering medications. De-identified data were collected and included pre-, intra-, and postoperative data on IOP, the use of IOP-lowering medications, and adverse events through 12 months of follow-up.

Results: Among 52 eyes undergoing surgery, mean IOP was reduced from 16.8 ± 0.6 mmHg at baseline to 12.4 ± 0.3 mmHg at month 12 (P < 0.001), a 26.2% reduction. Mean IOP across time points ranged from 12.4-13.3 mmHg during follow-up. The mean number of topical IOP-lowering medications was reduced from 1.6 ± 0.2 at baseline to 0.8 ± 0.1 at month 12 (P < 0.05), a 50.0% reduction. At month 12, 57.7% of eyes had IOP reduction ≥ 20% from baseline, and 63.5% were on ≥ 1 fewer IOP-lowering medications. In subgroup analysis, 84.6% of eyes with lower mean baseline IOP were using ≥ 1 fewer medications at month 12, and 100% of eyes with higher mean baseline IOP had IOP reductions ≥ 20%. The most common postoperative adverse events were pain/irritation (n = 4, 7.7%), opacification of the posterior lens capsule (n = 2, 3.8%), and IOP spike > 10 mmHg (n = 2, 3.8%).

Conclusion: PE + goniotomy using the KDB significantly lowers both IOP and dependence on IOP-lowering medications in eyes with OAG. Adverse events were not sight-threatening and typically resolved spontaneously.

Funding: New World Medical, Inc.
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http://dx.doi.org/10.1007/s12325-018-0755-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6133141PMC
September 2018

Goniotomy with a single-use dual blade: Short-term results.

J Cataract Refract Surg 2017 09;43(9):1197-1201

From Vance Thompson Vision (Greenwood, Berdahl), Sioux Falls, South Dakota, the University of Colorado School of Medicine (Seibold), Aurora, Colorado, the New York Eye Surgery Center (Radcliffe), New York, New York, the Mayo Clinic (Dorairaj), Jacksonville and the Eye Institute (Darlington), Melbourne, Florida, the University of Illinois (Aref, Román), Chicago, Illinois, New World Medical, Inc. (Abdullah, Bahjri), Rancho Cucamonga, California, and B Through C, LLC (Jasek), Burleson, Texas, USA; Asociación para Evitar la Ceguera (Lazcano-Gomez), Mexico City, Mexico.

Purpose: To evaluate the intraocular pressure (IOP)-lowering efficacy and safety of a single-use dual blade (Kahook) in patients with mild to end-stage glaucoma.

Setting: International multicenter ophthalmic care centers.

Design: Prospective interventional case series.

Methods: Consecutive patients with glaucoma who had phacoemulsification plus goniotomy with the single-use dual blade were enrolled in this study. Each center collected deidentified clinical data, including preoperative and postoperative IOP, medication use, adverse events, and whether additional surgery was required during a 6-month follow-up.

Results: Of the 71 eyes included in this study, 70% had primary open-angle glaucoma. Other diagnoses included angle-closure, pigmentary, pseudoexfoliative, and normal-tension glaucoma. Sixty-five percent of eyes were classified as having mild to moderate glaucoma and 35%, severe glaucoma. The mean baseline IOP decreased from 17.4 mm Hg ± 5.2 (SD) to 12.8 ± 2.6 mm Hg 6 months postoperatively and the hypotensive medication use decreased from 1.6 ± 1.3 to 0.9 ± 1.0, respectively (P < .001 and P = .005, respectively). The most common observation was blood reflux during surgery (39.4%).

Conclusion: Single-use dual blade goniotomy plus phacoemulsification resulted in a significant and sustained reduction in IOP and a decrease in glaucoma medications after 6 months of follow-up.
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http://dx.doi.org/10.1016/j.jcrs.2017.06.046DOI Listing
September 2017

Combined endocyclophotocoagulation and phacoemulsification in the management of moderate glaucoma.

Surv Ophthalmol 2017 Sep - Oct;62(5):712-715. Epub 2017 Mar 3.

Department of Ophthalmology, New York University Langone Medical Center, New York, New York, USA. Electronic address:

Cataract and glaucoma are the leading causes of blindness worldwide and commonly coexist in elderly patients. Endocyclophotocoagulation is a minimally invasive approach for glaucoma management that is amenable to combination with cataract surgery. We review the literature on endocyclophotocoagulation and evaluate intraocular pressure reduction efficacy when combined with phacoemulsification. Several studies demonstrate that phacoemulsification and endocyclophotocoagulation successfully reduces intraocular pressure and decreases medication burden. Phacoemulsification and endocyclophotocoagulation has a minimal side effect profile, and risks are limited to those usual postphacoemulsification. Most importantly, phacoemulsification and endocyclophotocoagulation allow for all future procedures, including trabeculectomy or tube implantation if necessary.
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http://dx.doi.org/10.1016/j.survophthal.2017.01.011DOI Listing
September 2017

One Year of Glaucoma Research in Review-2013 to 2014.

Asia Pac J Ophthalmol (Phila) 2015 Jul-Aug;4(4):228-35

From the *Department of Ophthalmology, Weill Cornell Medical College; and †Department of Ophthalmology, NYU School of Medicine, New York, NY.

Purpose: The purpose of this study was to provide the practicing clinical ophthalmologist with an update on relevant glaucoma literature published from 2013 to 2014.

Design: This study is a literature review.

Methods: The authors conducted a 1-year (October 1, 2013, to September 30, 2014) English-language glaucoma literature search on PubMed of articles containing "glaucoma" or "glaucomatous" with title/abstract as a filter. Medical subject headings filtered searching was not performed because of the newness of the reviewed material.

Results: Literature search yielded 2314 articles, after which we excluded reviews and letters to the editor. We highlighted articles featuring new or updated approaches to the pathophysiology, diagnosis, or treatment of glaucoma and gave preference to human research.

Conclusions: This review features literature that is of interest to ophthalmologists in practice and also highlights studies that may provide insight on future developments applicable to clinical ophthalmology.
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http://dx.doi.org/10.1097/APO.0000000000000133DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4520779PMC
April 2016

Association between corneal hysteresis and the magnitude of intraocular pressure decrease after cataract surgery.

J Cataract Refract Surg 2015 Jun 19;41(6):1176-81. Epub 2015 Jun 19.

From the Departments of Ophthalmology, Weill Medical College, Cornell University, and New York University School of Medicine, New York, and New York Medical College, Valhalla, New York, and the Wills Eye Institute, Philadelphia, Pennsylvania, USA. Electronic address:

Purpose: To evaluate the relationship between baseline corneal hysteresis (CH) and the change in intraocular pressure (IOP) before and after cataract extraction in patients without glaucoma.

Setting: Private practice, New York City, New York, USA.

Design: Retrospective cohort study.

Methods: Charts of consecutive patients who had phacoemulsification cataract extraction with posterior chamber intraocular lens implantation were analyzed. All included patients had preoperative and postoperative measurements with the Ocular Response Analyzer 2 to 4 months and 10 to 12 months postoperatively. Data collected included age, baseline CH, baseline central corneal thickness (CCT), and IOP.

Results: Thirty nine (65 eyes) of the 230 patients met the inclusion criteria. The mean patient age was 70.8 years ± 8.6 (SD). The mean preoperative, 2- to 4-month and 10- to 12- month postoperative IOP values were 14.8 ± 3.5 mm Hg, 11.9 ± 3.4 mm Hg, and 12.6 ± 3.1 mm Hg, respectively (P < .05 for comparisons with preoperative IOP). The baseline CH was not predictive of the IOP reduction at 2 to 4 months (β = -0.3; 95% confidence interval [CI], -0.7 to 0.01; P = .06). However, the baseline CH (but not the baseline CCT) was statistically associated with the magnitude of IOP reduction at 10 to 12 months when controlling for patient age (β = -0.5; 95% CI, -0.8 to -0.1; P = .01).

Conclusion: A low baseline CH was associated with a larger magnitude of IOP reduction after cataract extraction.

Financial Disclosure: Dr. Radcliffe is a consultant to Reichert Technologies and Glaukos Corp.; a consultant to and speaker for Allergan, Inc., Alcon Laboratories, Inc., Iridex Corp., Merge Healthcare, Carl Zeiss Meditec AG; and a speaker for Merck Pharmaceuticals. No other author has a financial or proprietary interest in any material or method mentioned.
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http://dx.doi.org/10.1016/j.jcrs.2014.09.040DOI Listing
June 2015

Change in corneal hysteresis over time in normal, glaucomatous and diabetic eyes.

Acta Ophthalmol 2015 Dec 28;93(8):e627-30. Epub 2015 Apr 28.

Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA.

Purpose: Corneal hysteresis (CH) is lower in glaucomatous eyes. The aim of this study was to determine and compare the change in CH over time between normal, open angle glaucoma (POAG) and diabetic subjects.

Methods: We retrospectively analysed records of patients undergoing assessment with the Ocular Response Analyzer (Reichert, Corp., New York, NY, USA). Right eyes with at least 7 measurements were included. Patients with ocular pathology other than POAG were excluded. Two-sample t-tests, chi-squared and logistic regression were used to analyse data.

Results: A total of 1418 normal and 322 POAG patients were included. Patients with POAG were significantly older (70.73 ± 11.33 vs. 61.59 ± 16.56 years; p < 0.001), had a longer follow-up (4.14 ± 1.34 vs. 2.72 ± 1.49 years; p < 0.001) and had lower CH (9.58 ± 2.17 vs. 9.95 ± 2.19 mmHg p = 0.01), but there were no gender differences between groups (61.5 vs. 57.7% female; p = 0.21). We observed a significantly greater decrease in CH among patients with POAG (-0.11 ± 0.73 vs. 0.07 ± 2.31 mm Hg/year; p = 0.02). The relation between ∆CH/year and diagnosis persisted after adjusting for age and follow-up time (OR 0.90; 95% CI 0.82, 0.99; p = 0.03). We found CH to be higher in diabetics vs. non-diabetics (10.34 ± 2.04 vs. 9.88 ± 2.19; p = 0.02), but ∆CH/year was not different (0.07 ± 1.27 vs. 0.03 ± 2.10; p = 0.77).

Conclusions: Patients with POAG in this study had a significantly greater rate of CH decline compared to normal. There was no significant difference in rate of CH change in diabetic and non-diabetic patients.
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http://dx.doi.org/10.1111/aos.12726DOI Listing
December 2015

Corneal hysteresis and its relevance to glaucoma.

Curr Opin Ophthalmol 2015 Mar;26(2):96-102

aWeill Medical College, Cornell University bReichert Inc., Depew cDepartment of Ophthalmology, NYU School of Medicine, New York, USA.

Purpose Of Review: Glaucoma is a leading cause of irreversible blindness worldwide. It is estimated that roughly 60.5 million people had glaucoma in 2010 and that this number is increasing. Many patients continue to lose vision despite apparent disease control according to traditional risk factors. The purpose of this review is to discuss the recent findings with regard to corneal hysteresis, a variable that is thought to be associated with the risk and progression of glaucoma.

Recent Findings: Low corneal hysteresis is associated with optic nerve and visual field damage in glaucoma and the risk of structural and functional glaucoma progression. In addition, hysteresis may enhance intraocular pressure (IOP) interpretation: low corneal hysteresis is associated with a larger magnitude of IOP reduction following various glaucoma therapies. Corneal hysteresis is dynamic and may increase in eyes after IOP-lowering interventions are implemented.

Summary: It is widely accepted that central corneal thickness is a predictive factor for the risk of glaucoma progression. Recent evidence shows that corneal hysteresis also provides valuable information for several aspects of glaucoma management. In fact, corneal hysteresis may be more strongly associated with glaucoma presence, risk of progression, and effectiveness of glaucoma treatments than central corneal thickness.
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http://dx.doi.org/10.1097/ICU.0000000000000130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4323574PMC
March 2015

The impact of timolol maleate on the ocular tolerability of fixed-combination glaucoma therapies.

Clin Ophthalmol 2014 12;8:2541-9. Epub 2014 Dec 12.

Ophthalmology, New York University, New York, NY, USA.

Glaucomatous optic atrophy is the second most common cause of blindness worldwide, and lowering intraocular pressure (IOP) is the only proven method to slow or stop the progression of the disease. Approximately 40% of patients with elevated IOP will require more than one medication to obtain a modest 20% reduction in IOP, and as a result, some patients may require two medications, provided in either two separate bottles or in one bottle with the use of fixed-combination therapies. Each therapy has its own unique safety and efficacy profile. Topical beta-blockers have a particularly favorable ocular-tolerability profile, and several studies of fixed-combination medications containing the beta-blocker timolol maleate have shown a lower prevalence of some ocular adverse events for the fixed-combination therapy compared to the non-beta-blocker individual component. In this review, we examined clinical data pertaining to the ocular surface tolerability of fixed-combination medications containing timolol maleate in comparison to the individual components. In particular, preference was given to prospective, randomized, multicenter trials of 3 months in duration or longer that compared a fixed-combination therapy to monotherapy with the individual components. A review of the literature revealed that some fixed-combination therapies can provide a reduced risk of common side effects compared to their individual components, with conjunctival hyperemia and ocular allergy being less frequent in some timolol-containing fixed-combination therapies. This effect appears to be most significant for latanoprost 0.005%, bimatoprost 0.03%, and brimonidine 0.2%.
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http://dx.doi.org/10.2147/OPTH.S76053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4270356PMC
December 2014

December consultation #10.

J Cataract Refract Surg 2015 Jan;41(1):245; discussion 246

New York, New York, USA.

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http://dx.doi.org/10.1016/j.jcrs.2014.11.028DOI Listing
January 2015

Minimally invasive glaucoma surgery: current implants and future innovations.

Can J Ophthalmol 2014 Dec;49(6):528-33

Department of Ophthalmology, University of Colorado School of Medicine, Aurora, Colo.. Electronic address:

Traditionally, invasive surgical management of glaucoma is recommended when medication and/or laser trabeculoplasty fail to control intraocular pressure (IOP). Filtering procedures, such as trabeculectomy and glaucoma drainage devices, are effective in lowering IOP, but they have significant associated adverse events and rates of failure. For these reasons, a new group of surgical procedures has emerged that seeks to decrease IOP with lower associated rates of complications. The acronym MIGS, usually described as minimally invasive glaucoma surgery, has been coined to describe this group of procedures. As new devices become available, MIGS procedures will help to fill the gap between conservative medical and laser therapy and invasive surgical treatment of glaucoma to offer patients an earlier and safer transition to surgical management of their disease. In this review, we define the characteristics of an ideal MIGS procedure and discuss implants currently in use or under investigation.
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http://dx.doi.org/10.1016/j.jcjo.2014.09.002DOI Listing
December 2014

One Year of Glaucoma Research in Review: 2012 to 2013.

Asia Pac J Ophthalmol (Phila) 2014 Jan-Feb;3(1):48-55

Department of Ophthalmology, Weill Cornell Medical College, New York, NY.

Purpose: The objective of this study was to provide the practicing clinical ophthalmologist with an update of pertinent glaucoma literature published from 2012 to 2013.

Design: Literature review.

Methods: The authors conducted a 1-year (July 1, 2012, to September 30, 2013) English-language glaucoma literature search on PubMed using the following terms: glaucoma, automated perimetry, optic nerve imaging, optical coherence tomography, glaucoma structure and function, intraocular pressure, central corneal thickness, glaucoma medical therapy, neuroprotection, glaucoma laser treatment, secondary glaucoma, glaucoma surgery, and miscellaneous topics in glaucoma.

Results: Of 2659 articles on glaucoma published during our time frame, this review selected original and review articles that reflect novel aspects and updates in the field of glaucoma, while excluding letters to the editor, unpublished works, and abstracts. Preference was given to human research.

Conclusions: This review focuses on literature that is applicable to ophthalmologists in practice and also highlights studies that may enhance the diagnosis and management of glaucoma.
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http://dx.doi.org/10.1097/APO.0000000000000041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4148017PMC
August 2015

Ab interno stenting procedures.

J Cataract Refract Surg 2014 Aug;40(8):1273-80

From the Atlanta Ophthalmology Associates (Brown), Atlanta Veterans Medical Center, and Emory University Eye Center (Lynch), Atlanta, Georgia, and the Department of Ophthalmology (Radcliffe), Weill Cornell Medical College, New York, New York, USA.

Unlabelled: Trabecular bypass was first used as a surgical treatment for glaucoma more than 100 years ago and aims to circumvent the trabecular meshwork, thought to be the main site of aqueous humor outflow resistance. The emerging field of microinvasive glaucoma surgery has brought a new ab interno trabecular microbypass stent through the U.S. Food and Drug Administration-approval process, and data from long-term randomized prospective trials have shown the safety and intraocular pressure-lowering value of trabecular microbypass. This review discusses the historical evolution of trabecular microbypass and describes new and forthcoming surgical options along with available clinical safety and efficacy data.

Financial Disclosure: Proprietary or commercial disclosures are listed after the references.
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http://dx.doi.org/10.1016/j.jcrs.2014.01.033DOI Listing
August 2014

Structural glaucomatous progression before and after occurrence of an optic disc haemorrhage.

Br J Ophthalmol 2015 Jan 23;99(1):21-5. Epub 2014 Jul 23.

Department of Ophthalmology, Weill Cornell Medical College, New York, New York, USA.

Background: An optic disc haemorrhage (DH) has been associated with subsequent structural glaucoma progression, but it is unknown if there is structural progression prior to a DH. We evaluated a cohort of patients to determine whether structural progression occurs before a DH, after a DH or is simply associated with a DH.

Methods: Eyes meeting inclusion criteria were placed into two groups. Group 1 included eyes that each had a baseline photograph of the optic nerve and a photograph with a DH at follow-up. Group 2 included eyes that each had a photograph of the optic nerve with a DH at baseline and a photograph at follow-up. Flicker images were created and graded by two ophthalmologists for structural glaucomatous change. We compared the proportion of structural progressors between Groups 1 and 2. Patient characteristics were also compared between the two groups.

Results: 49 patients and 51 unique eyes were included. Groups 1 and 2 had 28 and 38 sets of photographs, respectively. The proportion of global progression in Groups 1 and 2 were 21.4% and 39.5%, respectively (p=0.12). No significant differences in any structural progression feature and patient characteristics (besides age at time of DH (p=0.04) between the two groups were found.

Conclusions: Patients show structural glaucomatous progression before and after the event of a disc haemorrhage without significant differences. This suggests that a DH is an ongoing structural progression in glaucoma and may not be a discrete event that leads to subsequent progression.
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http://dx.doi.org/10.1136/bjophthalmol-2014-305349DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4343035PMC
January 2015

A novel optic nerve photograph alignment and subtraction technique for the detection of structural progression in glaucoma.

Acta Ophthalmol 2014 Jun 25;92(4):e267-72. Epub 2014 Jan 25.

Ophthalmology, Weill Cornell Medical College, New York, New York, USA; New York University School of Medicine, New York, New York, USA.

Purpose: To highlight changing features over time within a single static image through the auto-alignment and subtraction of serial optic nerve photographs.

Methods: Subtraction maps were generated from auto-aligned (EyeIC, Narbeth, PA) baseline and follow-up images using Adobe Photoshop software. They demonstrated progressive retinal nerve fibre layer (RNFL) defects, optic disc haemorrhage (DH), neuroretinal rim loss (RL) and peripapillary atrophy (PPA). A masked glaucoma specialist identified features of progression on subtraction map first, then assessed feature strength by comparison with original images using alternation flicker. Control images with no progression and parallax-only images (as determined by flicker) were included.

Results: Eighty eyes of 67 patients were used to generate subtraction maps that detected glaucoma progression in 87% of DH (n = 28, sensitivity (Se) 82%, specificity (Sp) 98%) and 84% of PPA (n = 30, Se 80%, Sp 98%) cases. The lowest rate of detection was seen with RL at 67% (n = 31, Se 65%, Sp 100%). The subtraction technique was most sensitive for detecting parallax (n = 39, Se 98%, Sp 94%). Features of glaucoma progression appeared equally strong in flicker and subtraction images, but parallax was often enhanced on subtraction maps. Among control images selected for absence of features of glaucomatous change (n = 9) in original flicker images, no features were detected on subtraction maps.

Conclusions: Auto-alignment and subtraction of serial optic nerve photographs reliably detects features of glaucoma progression with a single static image. Parallax identification may also be facilitated. Auto-alignment and subtraction of serial optic nerve photographs may prove especially useful in education and printed publications when dynamic imaging is not feasible.
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http://dx.doi.org/10.1111/aos.12329DOI Listing
June 2014

Isolated foveal hypoplasia without nystagmus.

Int Ophthalmol 2014 Aug 19;34(4):877-80. Epub 2014 Jan 19.

Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA,

We report the case of a 23-year-old healthy Caucasian male with isolated foveal hypoplasia without nystagmus. Clinical examination and spectral-domain optical coherence tomography demonstrated the bilateral absence of a foveal depression and the patient was diagnosed with isolated foveal hypoplasia. This is a rare condition which is probably under-diagnosed since it can exist without nystagmus and low vision.
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http://dx.doi.org/10.1007/s10792-014-9900-5DOI Listing
August 2014

Retinal blood vessel positional shifts and glaucoma progression.

Ophthalmology 2014 Apr 15;121(4):842-8. Epub 2013 Dec 15.

Einhorn Clinical Research Center, New York Eye and Ear Infirmary, New York, New York; Department of Ophthalmology, The New York Medical College, Valhalla, New York.

Purpose: To determine the characteristics and significance of retinal blood vessel (RBV) positional shifts over time in a cohort of patients with progressive glaucoma.

Design: Retrospective cohort study.

Participants: Baseline and serial stereophotographs from 1 eye of 125 patients with open-angle glaucoma with ≥8 reliable Swedish interactive threshold algorithm standard visual fields (VFs) were included. On the basis of global rates of threshold sensitivity change, patients with glaucoma were divided into groups of minimal (<-0.02 decibels [dB]/year), moderate (-0.02 to -0.65 dB/year), or fast (≥-0.65 dB/year) progression. To determine whether graders' assessments of RBV positional shifts were false-positives, a control group consisting of 33 patients with glaucoma with 2 sets of photographs taken on the same day was included.

Methods: Masked graders reviewed serial photographs aligned with automated alternation flicker (EyeIC, Narbeth, PA) and assessed them for the presence of any discrete RBV positional shifts (2 graders) and for traditional measures of structural progression (2 graders), including neuroretinal rim loss, parapapillary atrophy progression, and disc hemorrhage (DH).

Main Outcome Measures: Presence or absence of RBV positional shifts, rates of VF progression, and presence or absence of traditional measures of structural progression.

Results: A total of 158 image sets (125 longitudinal and 33 same-day controls) from patients with glaucoma were included. Retinal blood vessel shifts were noted in 33 of 125 (26.4%) longitudinally followed glaucomatous eyes and 2 of 33 (6%) same-day control patients (P = 0.01). Agreement between graders I and II was 90.4% (kappa=0.77; P< 0.001). Eyes with RBV positional change progressed more rapidly than those without (-0.55 vs. -0.29 dB/year; 95% confidence interval [CI], 0.03-0.48); P = 0.03). Retinal blood vessel shift was present in 12.1% of minimal progressors versus 31.5% of moderate and fast progressors (P = 0.04). Rate of VF progression was statistically associated with RBV shift (odds ratio [OR], 2.2; 95% CI, 1.1-4.5; P = 0.03). Other variables significantly associated with RBV shift included neuroretinal rim loss (OR, 21.9; 95% CI, 5.7-83.6; P< 0.001) and DH (OR, 4.6; 95% CI, 1.5-15.5; P< 0.01). A multivariable model revealed that rim loss and DH, but not rate of functional change, were significantly associated with RBV shift.

Conclusions: Retinal blood vessel positional shifts occurred in eyes with functionally progressive glaucoma, neuroretinal rim loss, and DH. This is a novel clinical finding that could help identify glaucoma progression or individuals at higher risk for future progression.
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http://dx.doi.org/10.1016/j.ophtha.2013.11.002DOI Listing
April 2014

Association of blood and ocular perfusion pressure with structural glaucomatous progression by flicker chronoscopy.

Br J Ophthalmol 2013 Dec 24;97(12):1569-73. Epub 2013 Sep 24.

Department of Ophthalmology, Weill Cornell Medical College, , New York, NY, USA.

Background: Vascular risk factors have been associated with glaucomatous visual field progression.

Aim: We determined the relationship between vascular risk factors and structural glaucomatous progression using serial flicker chronoscopy images.

Methods: Two glaucoma fellowship-trained ophthalmologists, masked to temporal sequence, independently graded serial flicker chronoscopy images from one eye of a cohort of glaucoma patients for features of structural progression in this retrospective cohort study. After adjudication, simple and multiple logistic models were constructed to determine variables associated with increased odds of progression, including systolic blood pressure (BP), diastolic BP and mean ocular perfusion pressure.

Results: Seventy-two eyes of 72 patients were analysed. Patients with any form of structural progression (n=40) were older (67.0 vs 58.8 years; p=0.005) and had lower diastolic BP (71.8 vs 76.5 mm Hg; p=0.02) than patients without progression (n=32). In the univariable model, diastolic BP was associated with progressive retinal nerve fibre layer (RNFL) loss (OR=0.2 per 10 mm Hg, 95% CI 0.1 to 0.6, p<0.006) and neuroretinal rim loss (OR=0.4 per 10 mm Hg, 95% CI 0.2 to 0.8, p<0.01). Diastolic BP was also significant in the multivariable model for RNFL loss (p=0.009) and neuroretinal rim loss (p=0.003).

Conclusions: This study is the first to use structural progression and flicker chronoscopy to identify vascular glaucoma risk factors. Older age and lower diastolic BP were associated with progression. By multivariable analysis diastolic BP was associated with RNFL and neuroretinal rim loss. These findings suggest that diastolic BP is associated with structural glaucomatous progression which may have implications for management.
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http://dx.doi.org/10.1136/bjophthalmol-2013-303655DOI Listing
December 2013

August consultation #5.

J Cataract Refract Surg 2013 Aug;39(8):1278; discussion 1279

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http://dx.doi.org/10.1016/j.jcrs.2013.05.031DOI Listing
August 2013

Relationship between corneal hysteresis and optic nerve parameters measured with spectral domain optical coherence tomography.

Graefes Arch Clin Exp Ophthalmol 2013 Jul 22;251(7):1777-83. Epub 2013 Mar 22.

Department of Ophthalmology, Weill Cornell Medical College, 1305 York Avenue, 11th Floor, New York, NY 10021, USA.

Background: Corneal hysteresis (CH) has been associated with visual field damage in glaucoma and is related to the velocity of perimetric glaucoma progression. We undertook this investigation to determine whether CH is associated with structural markers of glaucoma damage on spectral domain optical coherence tomography (SD-OCT).

Methods: In this retrospective study, 131 patients under glaucoma evaluation were evaluated with SD-OCT (Cirrus; Carl Zeiss Meditec, Dublin, CA) and had CH measurements with the ocular response analyzer (Reichert, Inc., Buffalo, NY). Pearson and partial correlation adjusting for age were preformed to examine the association between CH and variables of interest. Generalized estimating equations were used to construct simple and multiple linear models.

Results: While Pearson correlations were modest overall, CH best correlated with mean deviation (MD; r = 0.19) followed by average retinal nerve fiber layer (RNFL) thickness (r = 0.18) and vertical cup to disc ratio (r = -0.11) in the open angle glaucoma group. In univariable models, CH varied as a function of MD (ß = 0.1, 95 % CI 0.03, 0.1; p < 0.001) and of average RNFL thickness (ß = 0.2, 95 % CI 0.1, 0.4; p = 0.001). In a multivariable analysis including MD, age, average RNFL thickness, and glaucoma status, MD (p = 0.001) and age (p < 0.001) retained significant associations with CH.

Conclusions: In patients under evaluation and treatment for glaucoma, CH was more closely related to visual field MD than to structural markers of glaucoma damage as measured by SD-OCT.
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http://dx.doi.org/10.1007/s00417-013-2311-xDOI Listing
July 2013