Glaucoma-I Free Papers - aioseducation

ContentsGLAUCOMA – ITo find A Correlation between Gonioscopy and Anterior Segment OpticalCoherence Tomography (ASOCT) in Detecting Angle Closure in A South IndianPopulation...............................................................................................................279Dr. Arijit Mitra, Dr. Debarpita Chaudhury, Dr. Rama Krishnan R., Dr. Mohideen AbdulKadar P.M.T., Dr. Devendra MaheshwariComparison of Cup Disc Ratio Ophthalmoscopi-cally and Optical CoherenceTomography wise ..................................................................................................283Dr. Maragatham K., Dr. Vijay Krishnan B.Prevalence of Glaucoma in Patients Referred for Cataract Surgery from RuralScreening Camps...................................................................................................285Dr. Varada Gokhale, Dr. Sripriya Krishnamoorthy, Dr. Sandeep Mark Thirumalai,Dr. Ronnie Jacob GeorgeUltrasound Biomicroscopy Changes Before and after Laser Iridotomy inPrimary Angle Closure..........................................................................................289Dr. Savita Bhat, Dr. Anna Elias, Dr. A Giridhar, Dr. S.J. SaikumarImplications of Repeated Valsalva’s Manouver In High Resistance WindInstrument Ptayers................................................................................................296Dr. Lt. Col (Mrs.) Sagarika Patyal, Dr. (Brig) Ahluwalia T.S., Dr. (Lt. Col.) Partha SarthiMoulivk, Dr. Poninder Kumar DograClinical Effectiveness of Contrast Sensitivity Function in Patients with PrimaryOpen Angle Glaucoma and Ocular Hypertension.............................................306Dr. Vidya Chelerkar, Dr. Madan Deshpande, Dr. Mousami SaikiaStudy of Ocular Blood Flow in Primary Open Angle Glaucoma and PrimaryClosed Angle Glaucoma.......................................................................................309Dr. Mohan Shalini, Dr. Kanika Agrawal, Dr. Sneha M. Agrawal, Dr. Gupta RameshChandra, Dr. Perwej KhanPeripapillary Microperimetry Vs Retinal Sensitivity in Glaucoma..................312Dr. Ulka Srivastava, Dr. Pushpa Varma, Dr. Latika Khare, Dr. Mema JoshiRole of Dynamic Ultrasound Biomicroscopy in defining Laser Treatment inPigment Dispersion Syndrome/ Pigmentary Glaucoma ..................................315Dr. Atif Anwar, Dr. Tirupati Nath, Dr. Sourabh Kumar Soni, Dr. Jain B.K.Increased Test-retest Variability Typically Precedes Definite GlaucomatousField Defects in Early Glaucoma..........................................................................321Dr. Tutul Chakravarti153

Glaucoma Free PapersGLAUCOMA - IChairman: Dr. Krishnadas R.; Co-Chairman: Dr.Tiwari Uma Sharan;Convenor: Dr. Manish S. Shah; Moderator: Dr. Gowri Murthy J.To find A Correlation between Gonioscopyand Anterior Segment Optical CoherenceTomography (ASOCT) in Detecting AngleClosure in A South Indian PopulationDr. Arijit Mitra, Dr. Debarpita Chaudhury, Dr. Rama Krishnan R.,Dr. Mohideen Abdul Kadar P.M.T., Dr. Devendra MaheshwariThe current reference standard for evaluating the Anterior chamber angleconfiguration is gonioscopy, an examination that can be performed quicklybut that involves contact with the cornea and often is considered a cumbersomeexamination in a busy clinical practice. Furthermore, gonioscopic findings maybe affected by inadvertent pressure on the gonioscopy lens and by increasedillumination (which tends to open the ACA) during the examination. Previousstudies have shown that even experienced, cross-trained examiners have onlymoderate agreement in determining angle width. 1,2Anterior segment (AS) optical coherence tomography (OCT) uses a 1093-nmdiode laser to obtain real-time images of the Anterior chamber angle andprovides a rapid non-contact method for the detection of angle closure. 3-5 Theaim of this study was to compare the performance of gonioscopy and AS OCTin detecting angle closure in a cohort of patients attending a community clinicfor non-ophthalmic care and to investigate variations in findings between thetwo methods in the different quadrants of the Anterior chamber angle.MATERIALS AND METHODSThe first random 250 eyes of 250 patients presenting to the Glaucoma clinicsuspected of having occludable angles on primary slit lamp evaluation wereincluded in the study if they fulfilled the inclusion and exclusion criteria. Aftertaking the history to obtain previous medical and ophthalmic condition, eachsubject underwent the following examinations on the same day: Visual acuity,Anterior segment imaging by AS OCT (Visante; Carl Zeiss Meditec, DublinCA), Slit-lamp biomicroscopy, Goldmann applanation tonometry, and Indirectgonioscopy. Only subjects greater than 18 years were included. Subjects wereexcluded if they had a history of intraocular surgery or penetrating trauma ineither eye, previous anterior segment laser treatment, or a history of glaucoma.279

70th AIOC Proceedings, Cochin 2012patients. It uses low coherence near infrared light (850 nm) from a superluminescent diode and subsequent back scattering of the retina. It generatesposterior segment measurement with an axial resolution of 8–10 microns.We hereby compare the cup disc ratio with an ophthalmoscope and OCT tofind the usefulness of OCT in detecting glaucoma and the reliability of theophthalmoscopic examination.284MATERIALS AND METHODSThis is a prospective study. It includes 200 eyes of 100 patients referred toglaucoma services during the period of December 2010 to March 2011. Thepatients were divided into two groups namely glaucoma suspects (Group A)and established glaucomas (Group B).Group A had 96 eyes of 48 patients. Out of them 28 were male and 20 werefemale. Two eyes of Group A, OCT was not possible due to poor co-operation.Effectively 94 eyes were taken for comparison.104 eyes of 52 patients of Group B. Out of them 29 were male and 23 werefemale. In Group B, OCT was not possible in 19 eyes (poor vision) and 5 eyes(poor media clarity) respectively. Effectively 80 eyes were taken for comparisonThe difference of cup disc ratio between direct ophthalmoscope and OCTof values less than 0.1 is considered comparable and values more than 0.1 isconsidered increased.In Group A, 58 eyes showed increased cup disc ratio in OCT as compared towhen examined with an ophthalmoscope. In rest of the 36 eyes, the cup discratio was comparable to that of OCT. 42 eyes of Group B showed increased cupdisc ratio when compared to ophthalmoscopic examination. Rest of the 38 eyeswas similar to values obtained by OCT.OCT overestimates the cup disc ratio in 61% of the glaucoma suspects and52% of established glaucoma respectively. Thus clinical examination is moreimportant. So OCT can be used only as an adjunct in diagnosing glaucoma.In glaucoma screening, for mass population fundus can be examined withdirect ophthalmoscope. All the primary health centres can be provided withan ophthalmoscope and medical officers can be trained to identify increasedcup disc ratio so that the cases can be referred to higher centres for completeglaucoma evaluation.• If you diagnose glaucoma early you can treat it early,• If you treat it early you can slow the rate of progression,• If you slow the rate of progression you can prevent blindness• Prof. Weinreb

Glaucoma Free PapersREFERENCES1. Shields textbook of glaucoma – sixth edition 2011.2. Becker Shaffer’s diagnosis and therapy of glaucoma – eighth edition 2009.3. Glaucoma – Concepts and fundamentals - Tarek, M.E.D George l. Spaeth.4. Greaney M J, Hoffman CD, Garway DF et al. Comparison of optic nerve imagingmethods to distinguish nirmal eyes from those with glaucoma. Invest Ophthal VisSci. 2002;43:140-5.5. Morgan J. E, Waldock A, Jeffery G et al. Retinal nerve fibre layer polarimetry:historical and clinical comparison. Br J Ophthalmol 1998;82:684-90.6. Watkins R, Panchal L, Uddin J, Gunvant P Vertical cup-to-disc ratio: agreementbetween direct ophthalmoscopic estimation, fundus biomicroscopic estimation,and scanning laser ophthalmoscopic measurement.Prevalence of Glaucoma in Patients Referred forCataract Surgery from Rural Screening CampsDr. Varada Gokhale, Dr. Sripriya Krishnamoorthy, Dr. Sandeep MarkThirumalai, Dr. Ronnie Jacob GeorgeCataract and glaucoma are frequently coexisting ocular conditions in theelderly population. Both can be a natural part of the aging process. Manypeople over 60 may have both of these serious sight threatening conditions.Glaucoma is responsible for significant ocular morbidity in India. Primaryglaucoma accounts for 2/3rds of the morbidity. 1 A significant portion of thosewho had undergone cataract surgery from rural cohort of Chennai glaucomastudy had glaucoma. 2 There is a growing acceptance that the prevalence andpredominant type of glaucoma show racial variability. Population-basedsurveys in the age group 40 years and older in different races have shownlarge variations.Since rural India is comparatively underserved in terms of both availabilityand quality of ophthalmic care it is possible that the reported rate of glaucomais an exaggeration. 3We report our data on prevalence of glaucoma in patients referred for cataractsurgery from rural screening camps.MATERIALS AND METHODSA retrospective review was conducted of all patients diagnosed with cataractand referred from rural cataract screening camp for cataract surgery toJaslok community ophthalmic centre, a unit of Medical Research Foundation,Chennai.285

70th AIOC Proceedings, Cochin 2012The medical records of 624 consecutive patients referred for cataract surgeryin the month of August 2010 were reviewed.The following variables were collected: detailed history, demographics,detailed slit lamp examinations, ocular co morbidity, intraocular pressures,fundus examination, and if required gonioscopy, 90D examination, visualfields and ocular treatments.External examination and pupillary evaluation were done using a flashlight. Slitlamp biomicroscopy was done and any abnormalities in the anterior segmentwere noted. Using a narrow slit beam, peripheral anterior chamber depth wasgraded according to van Herick’s technique. Intraocular pressure (IOP) wasrecorded with a Goldmann applanation tonometer under topical anaesthesiausing 0.5% proparacaine and fluorescein staining of the tear film. The righteye was measured first and one reliable measurement was recorded for eacheye. Gonioscopy was performed if required, in dim ambient illuminationwith a shortened slit that did not fall on the pupil. A 4-mirror Posner lens(Volk Optical Inc, Mentor, Ohio) was used. The angle was graded accordingto the Shaffer system and the peripheral iris contour, the degree of trabecularmeshwork pigmentation, and other angle abnormalities were recorded. Anangle was considered occludable if the pigmented trabecular meshwork wasnot visible in more than 180° of the angle in dim illumination (primary angleclosuresuspects [PACS]). If the angle was occludable, indentation gonioscopywas performed and the presence or absence of peripheral anterior synechiaewas recorded.All subjects with open angles on gonioscopy underwent pupillary dilationusing 1% tropicamide and 5% phenylephrine hydrochloride (UnimedTechnologies, Halol, Gujarat, India). If phenylephrine was contraindicated, 1%homatropine (Warren PharmaceuticalsMumbai, India) was used. Subjects diagnosed as having PACS underwentpupillary dilatation after laser iridotomy.Stereoscopic evaluation of the optic nerve head was performed using a 90diopter (D) lens at slit lamp. The vertical and horizontal cup-disc ratios (CDRs)were measured and recorded.Presence of any notching, splinter haemorrhages, and peripapillary atrophywas documented. The detailed retinal examination was done with binocularindirect ophthalmoscope using the 20-D lens.Information was analysed.RESULTSA total of 624 subjects were examined (288 men 46.15%, 336 women 53.84%). Themean age was between 50-60 years. The mean IOP by Goldmann applanation286

70th AIOC Proceedings, Cochin 2012Cataract and glaucoma are frequently coexisting ocular conditions in theelderly population.Pre-existing glaucoma could remain undiagnosed if an inadequatepreoperative evaluation is performed. According to the Chennai glaucomastudy, 39% of the phakic subjects with glaucoma in urban population hadsignificant cataract. 7If the healthcare system could detect these cases when they present for cataractsurgery it would dramatically improve the detection rates for glaucoma inthe population (current detection rates are 7.8% for primary glaucoma in theurban cohort 4 and 1% for the rural sample). 7The prevalence of glaucoma in our study is 8.01% of those planned for cataractsurgery. If these numbers are similar for the rest of the country this approachwould result in detection of a large number of those with undiagnosedglaucoma.For many people in the country the only point of contact with the eye caresystem is when they seek or are “screened” for cataract surgery. Inadequateor inappropriate examination at this time is a lost opportunity to detect andtreat other non cataract ocular pathology. Unless people go for periodic eyecheckups that advocate a comprehensive eye examination at each visit, the rateof undiagnosed glaucoma in India will remain high.REFERENCES1. Foster A. Vision 2020: The Cataract Challenge. Community Eye Health. 2000;13:17-21.2882. World Health Organisation. Global initiative for the elimination of avoidableblindness: An informal consultation. Geneva: WHO; 1997.3. Foster A. Cataract and “Vision 2020- the right to sight” initiative. Br J Ophthalmol.2001;85:635-9.4. Vijaya L, George R, Baskaran M, Arvind H, Raju P, Ramesh SV, et al. Prevalenceof primary open-angle glaucoma in an urban south Indian population andcomparison with a rural population. The Chennai Glaucoma Study. Ophthalmology.2008;115:648–54.5. Arvind H, George R, Raju P, Ramesh SV, Baskaran M, Paul PG, et al. Glaucoma inaphakia and pseudophakia in the Chennai Glaucoma Study. Br J Ophthalmol. 2005;89:699–703.6. Murthy G, Gupta SK, John N, Vashist P. Current status of cataract blindness andVision 2020: the right to sight initiative in India. Indian J Ophthalmol. 2008;56:489–94.7. Ronnie George, Hemamalini Arvind, M Baskaran, S Ve Ramesh, Prema Raju andLingam Vijaya. The Chennai glaucoma study: Prevalence and risk factors forglaucoma in cataract operated eyes in urban Chennai. Indian J Ophthalmol. 2010;58:243–5.8. Vijaya L, George R, Rashima A, Raju P, Arvind H, Baskaran M, et al. Outcomes of

Glaucoma Free Papers4. Friedman DS. Who needs an iridotomy? Br J Ophthalmol. 2001;85:1019–21.5. Foster PJ, Buhrmann R, and Quigley HA, Johnson GJ. The definition andclassification of glaucoma in prevalence surveys. Br J Ophthalmol. 2002;86:238–42.6. Ramakrishnan R, Nirmalan PK, Krishnadas R, Thulasiraj RD, Tielsch JM, Katz J, etal. Glaucoma in a rural population in southern India. Ophthalmology 2003;110:1484-90.7. Dandona L, Dandona R, Mandal P et al. Angle closure glaucoma in an urbanpopulation in southern India. The Andhra Pradesh eye disease study. Ophthalmology2000;107:1710-6.8. Thomas R, George R, Parikh R, and Muliyal J, Jacob A. Five year risk of progressionof primary angle closure suspects to primary angle closure: A population basedstudy. Br J Ophthalmol 2003;87:450-9.9. L Vijaya, George R, Aravind H et al. Prevalence of Primary Angle-Closure Diseasein an n Urban South Indian Population and Comparison with a Rural Population:The Chennai Glaucoma Study. Ophthalmology 2008;115:655-60.e110. Saw SM, Gazzard G, Friedman DS. Interventions for angle-closure glaucoma: Anevidence-based update. Ophthalmology 2003;110:1869-79.11. Jin JC, Anderson DR. The effect of iridotomy on iris contour. Am J Ophthalmol. 1990;110:260–3.12. Nolan WP, Foster PJ, Devereux JG, et al. YAG laser iridotomy treatment for primaryangle-closure in East Asian eyes. Br J Ophthalmol. 2000;84:1255–9.13. Foster PJ, Buhrmann R, and Quigley HA et al. The definition and classification ofglaucoma in prevalence surveys. Br J Ophthalmol. 2002;86:238–42.14. Yao B, Wu L , Zhang C etal. Ultrasound Biomicroscopic Features Associatedwith Angle Closure in Fellow Eyes of Acute Primary Angle Closure after LaserIridotomy. Ophthalmology 2009;116:444-8.e2.15. He M, Friedman DS, Ge J.Laser Peripheral Iridotomy in Eyes with NarrowDrainage Angles: Ultrasound Biomicroscopy Outcomes. The Liwan Eye Study.Ophthalmology 2007;114:1513-9.16. He M, Friedman DS, Ge J Laser Peripheral Iridotomy in Primary Angle-Closure Suspects: Biometric and Gonioscopic Outcomes: The Liwan Eye Study.Ophthalmology 2007;114:494-500.17. T Dada, S Mohan, R Sihota, et al. Comparison of ultrasound biomicroscopicparameters after laser iridotomy in eyes with primary angle closure and primaryangle closure glaucoma. Eye 2007;21:956–61.18. Kaushik S, Jain R Pandav SS et al.. Evaluation of the anterior chamber angle in AsianIndian eyes by ultrasound biomicroscopy and gonioscopy. Indian J Ophthalmol2006;54:159-63.19. Gazzard G, Friedman DS, Devereux JG, et al. A prospective ultrasoundbiomicroscopy evaluation of changes in anterior segment morphology after laseriridotomy in Asian eyes. Ophthalmology. 2003;110:630–8.295

70th AIOC Proceedings, Cochin 2012Implications of Repeated Valsalva’s ManouverIn High Resistance Wind Instrument PtayersDr. Lt. Col (Mrs.) Sagarika Patyal, Dr. (Brig) Ahluwalia T.S., Dr. (Lt. Col.)Partha Sarthi Moulivk, Dr. Poninder Kumar DograValsalva’s maneuver is performed by moderately forceful attemptedexhalation against a closed glottis.It is known to significantly increase intraocular pressure by elevation ofepiscleral venous pressure and increase of orbicularis tone. 1,2 It occurs duringcoughing, lifting heavy weights and playing wind instruments. Comparisonof elevation of intraocular among bending, lifting of fifteen kg weight andperforming the valsalva manouver has shown maximum pressure elevationwith bending over and valsalva maneuver. 3This study was conducted to examine the intraocular pressure changesthat occurred during playing high resistance wind instruments and to do acomprehensive ocular examination of the wind instrument players for effectsthat may have occurred due to many years of playing such instruments.296Aim of this study is:1. To study intraocular pressure (IOP) changes that occurs while playingwind instruments.2. To evaluate ocular findings suggestive of transient iridocorneal contactthat may occur during repeated valsalva maneuver.MATERIALS AND METHODS22 members of a band were examined on two separate occasions while theywere playing music they used to regularly play. An baseline Intraocularpressure was measured before they started playing, IOP was repeated afterthey had played one musical piece lasting 5 minutes and then IOP was repeatedafter 10 minutes and again after 15 minutes after they had stopped playing. 22normals who played other instruments not involving valsalva manouvre, ofsame sex and age group were taken as controls.The entire experiment was repeated twice, after a gap of 2 months to ensurethat the readings of IOP were reproducible.The tonometer used for the procedure was a hand held; anesthetic freeRebound tonometer called iCare (Tiolat, Helsinki, Finland). This tonometerfeatures a small single use disposable probe of 0.9 mm radius held in positionby an electromagnetic field. The probe collides with the central cornea whilethe instrument is aligned 4–8 mm from the patient’s eye. The movement of

Glaucoma Free Papersthe probe induces a small induction current,allowing the impact duration to be measured.Measurements are taken within 0.1 secs. Theforce applied is so minimal that it does not evenelicit a blink reflex. Six consecutive readings aretaken to minimize deviation and to produce anaveraged measurement value. Good correlationhas been found between rebound tonometerand Goldmann applanation tonometer.Detailed history regarding number of hourseach member had played in his life, y riskfactors like family history of glaucoma andhistory of trauma was taken from every member. History of trauma wasparticularly enquired into because they were all young male individuals inthe army, therefore prone to trauma.Ocular examination was carried out consisting of visual acuity , slit lampexamination of anterior segments, gonioscopy, pachymetry, optic nervehead evaluation, IOP measurement by NCT and visual field examination byHumphrey ‘s visual field analyzer using the SITA – Standard algorithm .All individuals were re- examined after one year to evaluate any changes thatcould have occurred.RESULTS1. No of band members examined -222. No of controls-223. Sex – Males4. Age – 22 to 42 years5. Visual acuity- 6/6 unaided in both eyes in both the players and controls6. No family history of glaucoma in any individual7. No history of trauma in any individual8. Anterior segments of all members was normal with normal anteriorchamber depths by Van – Herrick’s method9. Baseline (taken before playing the instrument) Intraocular pressure –right eye 10-20 mmHg, left eye -21 mmHg in wind instrument players10. Baseline Intraocular pressure – right eye 10-20 mmHg, left eye 10 -20mmHg in controls11. Pachymetry– wind instrument players right eye varied from -451- 578µ,Left eye varied from – 444- 579µ.297

70th AIOC Proceedings, Cochin 2012This leads to vascular engorgement, increased choroidal volume, and a rise inintraocular pressure.This experiment studied change of intraocular pressure recorded by a handheld Rebound tonometer of 22 male members of a band while playing varietyof wind instruments. A definite rise of intraocular pressure was noted whichwas statistically significant. This rise of IOP while playing wind instrumentshas also been substantiated by other workers. 2,3 The Rebound tonometer can beused while the individual plays the instrument in sitting or standing positionand does not require any anaesthetic agent for recording intraocular pressure.Six readings are taken and the final record of intraocular pressure is shown onthe display preceded by the letter “P”. If the “P” reading is static, the readingis of greatest reliability.In this study, clumps of pigment were found in the angle of the anterior chambersignifying transient angle closure, possibly during the repeated episodes of300Pigment clumps in gonioscopy

Glaucoma Free Papersvalsalva manouvre during playing of wind instruments. This finding was seenin individuals playing these instruments for many years and not in individualswho had been playing only for 2 to 5 years. In a study done by Dada et al., itwas seen that there was significant elevation of intraocular pressure, narrowingof anterior chamber angle recess, thickening of ciliary body and increase iniris thickness during valsalva maneuver. The authors concluded that valsalvamaneuver may lead to angle closure in eyes anatomically predisposed to angleclosure. In another study by Sihota et. al. That transient iridocorneal contactdoes occur in valsalva manouvre has been seen.This is an important finding because in India the ratio of angle closure to openangles if 1:1 and the APEDS from India has suggested that chronic primaryangle closure glaucoma is commoner than thought; 0.7% of the populationover the age of 30 years had primary angle closure glaucoma; 1.4% over theage of 30 years had occludable angles at risk for angle closure. 5 In this studynone of the patients had narrow or occludable angles but in spite of widelyopen angles they had evidence of angle closure by the clumps of pigment inthe angles in all the members playing a variety of instruments which occurredwhen the IOP rose while playing..The visual fields did not show any changes nor were there any changes in theoptic nerve heads in any of the band members.However since chronic primary angle closure glaucoma is present in India inlarger numbers, examination of eyes prior to playing wind instruments and aperiodic review of band members would prevent any glaucomatous damageDescriptive StatisticsEye 1 N Minimum Maximum Mean Std. DeviationL D1 21 1 8 2.86 2.104Base1 22 10 21 14.73 2.711During1 22 13 28 18.68 4.571After101 22 9 23 14.91 3.650Base2 22 11 25 15.82 3.261During2 22 13 28 19.32 4.379After102 22 10 28 15.91 3.689Avg_base 22 11 22 15.27 2.802Avg_during 22 13 28 19.00 4.318Avg_after 10 22 11 21 15.41 2.797Valid n (listwise) 21R D1 22 1 8 2.86 2.054Base1 22 11 22 15.41 3.034During1 22 11 30 18.95 5.376After101 22 10 21 15.59 2.823301

70th AIOC Proceedings, Cochin 2012302Base2 22 12 22 15.77 2.877During2 22 11 31 19.50 5.387After102 22 10 21 15.55 2.857Avg_base 22 12 22 15.59 2.910Avg_during 22 11 30 19.23 5.250Avg_after10 22 10 21 15.57 2.838Valid n (listwise) 22D1 - left eye- data of intraocular pressure before playing wind instruments,during playing wind instruments and after playing followed by right eyereadings.Base 1- intraocular pressure before playing the instrument during firstexperiment,During 1- intraocular pressure during playing the instrument during firstexperiment ,After 10- intraocular pressure 10 minutes after stopping playing the instrumentduring first experimentBase 2- pressure before playing the instrument during second experimentDuring 1- intraocular pressure during playing the instrument during secondexperimentAfter 10- intraocular pressure 10 minutes after finishing playing the instrumentduring second experimentLeft eye ( first experiment)Mean intraocular pressure before playing instruments - 14.73 Mmhg (sd-2.711).Mean intraocular pressure during playing instruments- 18.68 Mmhg (sd 4.571).Mean intraocular pressure 10 minutes after finishing playing instruments-14.91(Sd-3.650).Left eye ( second experiment)Mean intraocular pressure before playing instruments - 15.82 Mmhg (sd-3.261).Mean intraocular pressure during playing instruments-19.32 Mmhg (sd- 4.379).Mean intraocular pressure 10 minutes after finishing playing instruments-15.91(Sd-4.379).Right eye ( first experiment)Mean intraocular pressure before playing instruments - 15.41 Mmhg (sd-3.034)Mean intraocular pressure during playing instruments- 18.95 Mmhg (sd 5.376)Mean intraocular pressure 10 minutes after finishing playing instruments-15.59Mmhg (sd-2.823)

70th AIOC Proceedings, Cochin 20123043. 32 Re – 15 Re - 543 2430 Hours In 9 YrsLe - 14 Le - 5434. 30 Re – 11 Re - 560 2700 Hours In 10 YrsLe - 12 Le - 5645. 30 Re - 11 Re - 560 2970 Hours In 11 YrsLe - 11 Le - 5646. 32 Re – 15 Re - 560 540 Hours In 2 YrsLe -13 Le - 5627. 25 Re – 15 Re - 512 540 Hours In 2 YrsLe - 15 Le – 5208. 25 Re – 12 Re - 529 2970 Hours In 11 YrsLe - 12 Le - 5259. 34 Re – 15 Re – 543 1350 Hours In 05 YrsLe - 14 Le - 54310. 35 Re – 11 Re – 451 2430 Hours In 9 YrsLe - 11 Le - 44411. 29 Re – 12 Re – 533 4050 Hours In 15 YrsLe - 14 Le - 54012. 42 Re – 14 Re – 548 4050 Hours In 15 YrsLe - 14 Le - 55913. 35 Re – 14 Re – 547 2700Hours In 10 YrsLe - 14 Le - 55614. 33 Re – 11 Re – 499 3240 Hours In 12 YrsLe - 11 Le - 50715. 36 Re – 20 Re – 576 2700 Hours In 10 YrsLe - 21 Le - 57916. 26 Re – 20 Re – 578 3240 Hours In 12 YrsLe - 20 Le - 57617. 32 Re –12 Re – 520 2610 Hours In 13YrsLe -12 Le - 53018. 34 Re –15 Re – 545 2700 Hours In 10 YrsLe - 15 Le - 54719. 28 Re –12 Re – 534 2700 Hours In 10 YrsLe - 13 Le - 53120. 28 Re –14 Re – 549 2220 Hours In 6YrsLe - 15 Le - 55821. 28 Re –10 Re – 546 2220 Hours In 6YrsLe - 10 Le – 53722. 30 Re –10 Re – 563 2220 Hours In 6YrsLe - 10 Le - 548

Glaucoma Free PapersTable 2: Rsults of Visual Fields 24 – 2 Sita Standard in WindInstrument Players1. Md Re+ 0.61 Db Le + 1.70 Db Psd Re 3.69 Db Psd Le 1.42Db2. Md Re + 1.62 Db Le + 2.55 Db Psd Re 2.55 Db Psd Le 1.99 Db3. Md Re + 1.15 Db Le + 1.80 Db Psd Re 2.36 Db Psd Le 2.50 Db4. Md Re + 1.79 Db Le + 2.48 Db Psd Re 1.39 Db Psd Le 1.51 Db5. Md Re + 1.15 Db Le + 1.80 Db Psd Re 2.36 Db Psd Le 2.50 Db6. Md Re + 1.79 Db Le + 2.48 Db Psd Re 1.39 Db Psd Le 1.51 Db7. Md Re + 1.98 Db Le +3.30 Db Psd Re 1.74 Db Psd Le 1.57 Db8. Md Re + 1.79 Db Le + 1.90 Db Psd Re 2.29 Db Psd Le 1.61 Db9. Md Re + 1.55 Db Le + 3.44 Db Psd Re 1.63 Db Psd Le 1.05 Db10. Md Re -0.09 Db Le + 1.07 Db Psd Re 3.49 Db Psd Le 1.97 Db11. Md Re +1.98 Db Le +3.30 Db Psd Re 1.74 Db Psd Le 1.57 Db12. Md Re +1.62 Db Le +1.70 Db Psd Re 1.56 Db Psd Le 1.34 Db13. Md Re +0.42 Db Le +1.76 Db Psd Re 1.59 Db Psd Le 1.50 Db14. Md Re -1.30 Db Le -2.53 Db Psd Re 2.70 Db Psd Le 2.16 Db15. Md Re +2.41 Db Le +2.36 Db Psd Re 1.40 Db Psd Le 1.92 Db16. Md Re +2.70 Db Le +2.58 Db Psd Re 1.18 Db Psd Le 1.23 Db17. Md Re -2.42 Db Le+ 4.62 Db Psd Re 7.72 Db Psd Le 6.12 Db18. Md Re +0.50 Db Le+ 1.69 Db Psd Re 1.77 Db Psd Le 1.77 Db19. Md Re +0.42 Db Le +1.76 Db Psd Re 1.59 Db Psd Le 1.50 Db20. Md Re -2.42 Db Le+ 4.62 Db Psd Re 7.72 Db Psd Le 6.12 Db21. Md Re +0.42 Db Le +1.76 Db Psd Re 1.59 Db Psd Le 1.50 Db22. Md Re +0.42 Db Le +1.76 Db Psd Re 1.59 Db Psd Le 1.50 dBREFERENCES1. Shield’s Textbook of Ophthalmology, Lippincott Williams and Wilkins, FifthEdition, Page 39.2. Intraocular pressure changes: the influence of psychological stress and theValsalva maneuver. Brody S, Erb C, Veit R, Rau H. Biol Psychol 1999;51;43-57.3. MS Lawrence. Effects of Bending, Lifting and Valsalva maneuver on intraocularpressure. Invest Ophthalmol Vis. Sci. 2003;44.4. Dawn EC Roberts. Comparison of iCare tonometer with Pulsair and Tonopen indomiciliary work. Optometry in practice, 2005;6:33-9.5. J Schuman, Massicotte EC, Connolly S, Hertzmark E, Mukerji B, Kunen MZ.Increased intraocular pressure and visual field defects in high resistance windinstrument players. Ophthalmology 107:127-33.6. Avdin P, Oran O, Akman A , Dursan D. Effect of wind instrument playing onintraocular pressure. Glaucoma 2000;9:322-4.7. R Thomas , R George, R Parikh , J Muliyil , A Jacob. Five year risk of progressionof primary angle closure suspects to primary angle closure: A population basedstudy. Br. J. Ophthalmol 2003;87:450-4.305

Glaucoma Free Papersdeviation with contrast sensitivity. The effect of glaucoma on both types ofcontrast sensitivity have been studied with use of a large number of tests. ThePelli- Robson chart represents a low – tech, reasonably available method ofmeasuring spatial contrast sensitivity that is compatible with clinical practice.We found a very strong correlation of mean deviation of visual field in relationto contrast sensitivity in both the group POAG( r= 0.939) and OHT( r= 0.794)with p value

70th AIOC Proceedings, Cochin 2012blood cell velocity and resistivity index) laser Doppler /Heidelberg retinaflowmeter 4 (superficial retinal blood flow), fluorescein angiography 5 (retinalfill time), indocyanine green angiography (choroidal fill time) etc.The CDI6 measures the peak systolic velocities (PSV) and end diastolicvelocities (EDV) can be determined, as well as the average velocity. Anotherparameter calculated from CDI is Resistive index (RI) or Pourcelot’s ratio:RI = [peak systolic velocity (PSV) - end diastolic velocity (EDV)]/peak systolicvelocity( PSV).These ratios are reported from 0 to 1 or from 0% to 100%, with 0 denoting noresistance and 1 or 100% meaning maximum resistance to blood flow.The aim of the study was to measure and compare PSV, EDV and RI in patientsof POAG, PACG and normal.MATERIALS AND METHODSThe total of 82 eyes of 50 patients attending glaucoma clinic of a tertiary carehospital were included; their IOPs was controlled on antiglaucoma medicationsor/and laser iridotomy with no history of any surgical intervention. Thepatients were divided in three groups based on standard definition in PACG,POAG and normal. Informed consent was taken from all patients includedin the study. All the patients underwent IOP measurement by Goldmannapplanation tonometry. Central corneal thickness (CCT) of all patients wasdone by pachymeter (Sonomed 300 AP 10 MHz pacscan). Corrected IOP wasmeasured by the formula 50 mm increase in the CCT will lead to falsely highIOP by 2.5mm Hg.Ocular blood flow (OBF) was measured by CDI technique using Dopplertechnique to measure the PSV , EDV , RI in Central retinal artery (CRA) byM- Turbo USG System (Sonosite, Inc. Bothell, WA , US) using a linear arraytransduser (L-25x/13-6 MHz) having a scanning depth of 9 cm. It uses thethe M-mode for HR calculation for distance/ time measurement and Dopplermode for velocity measurements.RESULTSThere were 50 subjects in the study of which 22 were females and 28 weremales.PACG group had 13 subjects having 7 females and 6 males. Mean age was55.18± 10.02years with a median of 55(range- 40-70).POAG group had 15 subjects out of which 5 were females and 10 were males.Mean age was 59.2±13.56 years with a median of 58(range 20-75).Normal controls (NC) were 32 out of which there were 12 males and 10 females.They had mean age of 50.36±13.66 years, median – 52 , and range 25 -74.310

Glaucoma Free PapersTable 1: Mean ± SD of PSV, EDV and RI in the different groupsPACG POAG ControlsPeak systolic velocity 11.46 ± 3.7 9.61 ± 2.2 13.99 ± 4.7End diastolic velocity 3.57 ± 1.23 3.22 ± 5.9 4.34 ± 1.3Resistivity index 0.68 ± 0.6 0.66 ±0 .6 0.68 ± 0.6Independent‘t’ test showed that difference of mean PSV was significant inPACG ( p = 0.032). and POAG ( p= 0.0001) in comparison to controls. Similarlydifference of EDV was significantly difference in PACG (p=0.027) and inPOAG (p=0.0001) when compared with controls. Although, resistivity indexwas not different significantly. The comparison between PACG and PAOGshowed that PSV(p=0.04) and EDV were more in PACG although EDV was notsignificantly different (p=0.13).DISCUSSIONMost of the IOP measurement techniques are discontinuous so the effectof blood flow (or more specifically, blood volume) on IOP generally goesunnoticed. However, continuous IOP measurement by direct cannulationshows that ocular blood volume contributes to IOP. 7 The peak systolic and enddiastolic flow velocities of both the open and closed angle glaucoma cases wassignificantly lower (p>0.05) than that of controls. Only PSV was significantlylower (p>0.05) in POAG than PACG. So we can say that flow velocity measuredby CDI shows least velocity in the order of POAG< PACG

70th AIOC Proceedings, Cochin 2012We conclude from present study that PSV is better in PACG than POAG. OnceIOP is controlled then following up these patients through OBF might indicatethat a patient is likely to progress and subsequently there is a need for furtherintervention.REFERENCES1. Kerr J, Nelson P, O’Brien C. A comparison of ocular blood flow in untreated primaryopen-angle glaucoma and ocular hypertension. Am J Ophthalmol. 1998;126:42–51.2. Flammer J, Orgul S, Costa VP, et al.The impact of ocular blood flow in glaucoma.Prog Retin Eye Res 2002;21:359-93.3. Butt Z, O’Brien C, McKillop G, Aspinall P, Allan P. Color Doppler imagingin untreated high- and normal-pressure glaucoma. Invest Ophthalmol Vis Sci.1997;38:690–6.4. Nicolela MT, Hnik P, Drance SM. Scanning laser Doppler flowmeter study of retinaland optic disc blood flow in glaucomatous patients. Am J Ophthalmol 1996;122:775–83.5. Schwartz B, Rieser JC, Fishbein SL. Fluorescein angiographic defects of the opticdisc in glaucoma. Arch Ophthalmol 1977;95:1961–74.6. Cioffi GA, Alm A. Measurement of ocular blood flow. J Glaucoma 2001;10:S62–4.7. Januleviˇciene I, Ehrlich R, Siesky B, Nedzelskien˙e I, Harris A. Evaluation ofhemodynamic Parameters as Predictors of Glaucoma Progression. J Ophthalmol2011;12:1-9.8. Kaiser HJ, Schoetzau A, Stumpfig D, Flammer J. Blood flow velocities of theextraocular vessels in patients with high tension and normal tension primaryopen angle glaucoma. Am J Ophthalmol. 1997;123:320-7.9. Hafez AS, Bizzarro RLG, Lesk MR, “Evaluation of optic nerve head andperipapillary retinal blood flow in glaucoma patients, ocular hypertensives, andnormal subjects,” Am J Ophthalmol 2003;136:1031.Peripapillary Microperimetry Vs Retinal Sensitivityin GlaucomaDr. Ulka Srivastava, Dr. Pushpa Varma, Dr. Latika Khare, Dr. Mema JoshiGlaucoma is an optic neuropathy characterized by a specific andprogressive injury to the optic nerve head (ONH) and retinal nerve fiberlayer (RNFL), resulting in progressive loss of vision. Conventional automatedperimetry is generally an accepted method for the diagnosis and follow-up ofa patient with glaucoma. It is probable that conventional visual field tests candetect abnormalities only after a substantial number of nerve fibers have beendefinitely lost.312

Glaucoma Free PapersMicroperimetry is a procedure in which retinal sensitivity is assessed whilethe fundus of the eye is directly examined and it enables an exact correlationbetween pathology and corresponding functional defects.OCT is a non contact, non invasive diagnostic technique that allows themeasurement of RNFL (retinal nerve fiber layer) thickness with goodreproducibility. Early detection and prevention of RNFL glaucomatousdamage is essential because RNFL injury is largely irreversible. OCT computesRNFL thickness measurements from high-resolution cross-sectional images ofthe retina and is able to identify diffuse and focal RNFL defects that occur inglaucoma. Both macular and peripapillary NFL thicknesses, as measured byOCT, show statistically significant correlation with glaucoma, the peripapillaryRNFL thickness turns out to be the best marker in glaucoma assessment.Purpose of the study is to determine peripapillary threshold sensitivity usingmicroperimetry and correlate it with retinal nerve fiber layer thicknessmeasured by OCT.MATERIALS AND METHODSTotal 45 eyes including 10 POAG (gp-1), 23 glaucoma suspects (gp-2) and 10age match control (gp 3) were enrolled in this prospective case control study.All attended the OPD of upgraded dept. of ophthalmology, MGMMC andMYH, Indore. Subjects with glaucoma were diagnosed on the basis of raisedintraocular pressure, optic disc changes and visual field changes and openangle in gonioscopy. Glaucoma suspects were the patients with optic nervehead changes suggestive of glaucoma but without a raised IOP or visual fieldchanges. Controls were patients without any history of ocular or systemicdiseases, other than refractive error.Exclusion criteria: myopia>5D, any corneal, retinal, optic nerve (other thanglaucoma), or neurologic pathology associated with visual field defects andany other optic disc abnormality (tilted disc, optic disc drusen, optic discpit,optic disc coloboma) that would affect the evaluation of optic disc. Allstudy subjects underwent complete ophthalmic examination including bestcorrected visual acuity, slit lamp biomicroscopy, intraocular pressure check,fundoscopy, perimetry with SLO –MP using standard peripapillary grid andRNFL thickness measeared with OCT using fast RNFL thickness protocol (3.4mm).The testing protocol included Goldmann IV stimuli, fixation target: cross 1*, astimulus presentation time of 200 ms, background illumination (1.27 cd/m2)with attenuation of stimulus intensity 16 db. A 4-2-1 staircase strategy wasused. The MP tested 12 locations with peripapillary grid. Test was performedwith pupillary semidilatation.313

70th AIOC Proceedings, Cochin 2012RNFL thickness measurement was performed with stratus OCT. The fastRNFL thickness protocol (3.4 mm) was used for peripapillary RNFL scans.The best quality, properly aligned scan were chosen for analysis. Superior,inferior and average RNFL thickness were measured.Analysis of perimetric results: Differential thresholds values were comparedfor 12 matching points in a peripapillary grid is compared with RNFLthickness divided in 12 sectors.RESULTSIn all 10 control (5 men, 5 women, mean age 53 years) 23 glaucoma suspects(17 men, 6 women, mean age 54 years) 10 glaucomatous eyes (6 men, 4 women,mean age 58 years) were included.Table 1: Retinal nerve fiber layer thickness in all groupsRNFL Glaucoma Suspects Controlsthickness(microns) (Group-1) (Group-2) (Group-3)Superior 72.77 123. 06 143.62Inferior 69.18 102.47 146.45Average 66.23 75.87 97.54Table 2: Peripapillary threshold retinal sensitivity in all groupsAverage retinalsensitivity (db) Group-1 Group-2 Group-39.2 14.6 18.12We found a progressive significant reduction of RNFL thickness andperipapillary retinal senstivity in glaucomatous eyes and suspect eyes ascompared to controls.On comparing RNFL thickness in 12 retinal sector among three groups wefound a double-hump pattern with peaks at sectors 7 (inferior sector) and12 (superotemporal sector), and troughs at sectors 3 (nasal sector) and 10(temporal sector).Similarly on comparing peripapillary retinal sensitivity in 12 retinal sectoramong 3 groups we found that in normal eyes it was markedly regular,whereas that in suspects and glaucomatous eyes shows a double hump patternwith troughs at sectors 1 (superior sector) and 7 (inferior sector) in the suspectsgroup, and at sectors 12 and 7 in the glaucomatous group.In our study, we found that there is positive correlation in RNFL thickness andperipapillary threshold sensitivity in all 12 sectors in POAG eyes. In suspecteyes this correlation was not seen in 3, 4, 11 o clock area.314

70th AIOC Proceedings, Cochin 2012the peripheral iris) that leads to recurrent contact of the iris pigment epitheliumand lens-zonular diaphragm, causing dispersion of iris pigments. 7,8 Bowing ofthe iris also occurs in conditions such as during blinking, accommodation orphysical exercise. But along with iris bowing the lens concavity also increases,creating a ‘reverse pupillary block’ under these conditions. 9,10Using ultrasound biomicroscopy (UBM), the presence of iris concavity (IC) andirido-zonular contact (IZC) in PDS eyes was first showed by Potash et al. 11 It wasalso proved that laser iridotomy could restore a normal iris configuration. 11,12This is a Case Series of PDS/PG patients evaluated with dynamic UBM.The term ‘dynamic’ here refers to the measurement of the various outcomemeasures in terms of darkness (closed dark room) and brightness (normalroom illumination). Here different parameters were assessed in these TWOstates to identify any significant differences between the two settings and todefine the utility of this dynamic UBM procedure and its relation with the PostLaser Iridotomy results for PDS/PG in terms of the outcome measures.To assess the utility of UBM, in light and dark room illumination, in decidingthe treatment of PDS/pigmentary glaucoma with Nd-YAG Laser Iridotomy.Outcome Measures1. Primary Outcome: [A]evidence of reverse pupillary block/Irido-Lenticular Contact/ Irido-Zonular Contact/ Irido-Ciliary Contact underdark illumination only, on UBM; [B]Reversal of reverse pupillary blockafter Nd-YAG peripheral iridotomy as documented on UBM.3162. Secondary Outcome: [A] IOP control.MATERIALS AND METHODSIt is a Prospective, Interventional Case Series study carried out at GlaucomaServices, Sadguru Netra Chikitsalaya, Chitrakoot. The period of study wasfrom Nov’ 2010- May’ 2011.Inclusion CriteriaPDS was identified by: (i) a positive phenylephrine test (i.e., noticeable pigmentdispersion into the anterior chamber after pupil dilatation) and/or midperipheralradial iris trans-illumination defects, and/or Krukernberg spindle(Fig-1) on Slit Lamp Examination, (ii) hyperpigmentation of TM on gonioscopy(Fig-2); and PG which was diagnosed in those patients presenting as abovewho also showed: (i) glaucomatous visual field (VF) defects in at least one eye(ii) optic disc cupping consistent with a glaucomatous optic neuropathy; and(iii) IOP may or may not be raised.Exclusion CriteriaEyes with (1) any previous intra-ocular surgery and/or laser application,

70th AIOC Proceedings, Cochin 2012318• Irido-ciliary contact (ICC):measured along the edge of theciliary body to a point where theiris contact was present.Above Figures:UBM showingFigure 3: Normal room illumination (with no IC) Figure 4: Dark illumination (IC picked up)On UBM, all PDS/PG eyes withconcave iris in normal roomillumination and also those thatwere picked up in dark illuminatedstate were advised to undergoNd:YAG laser peripheral iridotomy(PI). These parameters also gave usthe clue to the ‘reverse pupillary Figure 5: Post-treatment improvement seenblock’ before laser treatment and in iris configuration at 4 weeks(all taken at 3more importantly the reversal of the o’clock)‘reverse pupillary block’ after thetreatment when the patient was followed up in 1-4 weeks.Statistical AnalysisAll calculations of percentages, means and SD were done using SPSS software(SPSS Inc. version 16, Chicago, IL, USA).RESULTSIn the present study, 10 eyes of 6 patients with features of PDS/PG in the variousclinical examinations mentioned above were enrolled. UBM was conductedin all eyes. Group 1comprised of 4 eyes (40%) who had Iris Concavity undernormal room illumination with ILC. Group 2 comprised of the rest 6 eyes(60%).

Glaucoma Free PapersWhen UBM was repeated under dark illumination in the group 2 patients itwas able to pick up concavity of iris in 5 more eyes (50% of total eye takenfor the study). In group 2, 5 eyes had ILC among which 1 eye each had IZCand ICC. 9 eyes of the total 10 eyes were advised Nd-YAG PI, out of which 8underwent the procedure. At a mean follow up of 11.33 weeks, out of the 8eyes which underwent Nd-YAG PI, 6 eyes (75%) showed reversal of reversepupillary block or regaining of normal iris configuration.Table 1: IOP of patients before treatment and then after treatment(*with or without treatment on last follow up).Pt. Pre-Treatment Post-TreatmentNo. IOP (Mm Hg) IO (Mm Hg)*RE LE RE LE1. 14 14 15 62. 17 17 16 163. 18 23 12 164. 22 23 12 165. 12 12 10 106. 16 16 15 15On evaluating IOP (secondary outcome), the decrease in the IOP level wasevident in those eyes which had an initially raised levels, corroborating to thetreatment offered.DISCUSSIONIn this study we conducted UBM under different room illuminations toidentify the anatomical features capable of differentiating the active dispersionof pigments from the normal iris. In particular the most important feature wasrelated to the dynamics of the iris itself which has been proven by variousprevious studies. 13 Accommodation during UBM with a fixed target has pickedup fine details with relation to PDS/PG has also been studied. 13In our study we aimed at dealing with those eyes which had earlyanatomical changes of PDS/PG and also those patients who had difficulty inaccommodating or were unresponsive or uncooperative to the command of theoperator while conducting the UBM examination. As the clinical examinationand the UBM were conducted by an experienced single examiner (TN), therisk of errors in identifying the various ocular structures was minimized.So UBM under different room illuminations was found to be of great assistancein diagnosing various parameters of PDS/PG like ILC, IZC and ReversePupillary Block. It would help diagnose subtle findings in PDS/PG eyes, thoseunresponsive and uncooperative patients and also in those patients havingaccommodation insufficiency.319

70th AIOC Proceedings, Cochin 2012In conclusion UBM evaluation in different room illuminations detected subtlefeatures of PDS/PG in 5 out of 6 eyes (83.33%)which did not have iris concavityor ILC in baseline conditions (normal room illuminations). Nd:YAG laseriridotomy was performed in 8 eyes, out of which normal iris configuration wasrestored in 6 (75%). Therefore conducting UBM in different room illuminationscan be of assistance in early diagnosis of PDS/PG and in deciding the LASERtreatment in PDS/PG to restore the normal iris configuration althoughprospective randomized studies are still required to prove this aspect.320REFERENCES1. Sugar HS. Pigmentary glaucoma: a 25-year review. Am J Ophthalmol 1966;62:499–507.2. Ritch R. Pigment dispersion syndrome. Am J Ophthalmol 1998;126:442–5.3. Migliazzo CV, Shaffer RN, Nykin R, et al. Long-term analysis of pigmentarydispersion syndrome and pigmentary glaucoma. Ophthalmology 1986;93:1528–36.4. Farrar SM, Shields MB,Miller KN, et al. Risk factors for the development andseverity of glaucoma in the pigment dispersion syndrome. Am J Ophthalmol1989;108:223–9.5. Siddiqui Y, Ten Hulzen RD, Cameron JD, et al. What is the risk of developingpigmentary glaucoma from pigment dispersion syndrome? Am J Ophthalmol 2003;135:794–9.6. P Mora, C Sangermani, S Ghirardini, A Carta, N Ungaro, SA Gandolfi; Ultrasoundbiomicroscopy and iris pigment dispersion: a case―control study; Br J Ophthalmol2010;94:428-32.7. Sokol J, Stegman Z, Liebmann JM, et al. Location of the iris insertion in pigmentdispersion syndrome. Ophthalmology 1996;103:289–93.8. Karickhoff JR. Reverse pupillary block in pigmentary glaucoma: follow up andnew developments. Ophthalmic Surg. 1993;24:562–3.9. Pavlin CJ, Harasiewicz K, Foster FS. Posterior iris bowing in pigmentary dispersionsyndrome caused by accommodation. Am J Ophthalmol. 1994;118;114–6.10. Strouthidis NG, Scott A, Peter NM, et al. Optic disc and visual field progressionin ocular hypertensive subjects: detection rate, specificity and agreement. InvestOphthalmol Vis Sci. 2006;47:2904–10.11. Potash SD, Tello C,Liebmann J, Ritch R. Ultrasound biomicroscopy in pigmentdispersion syndrome. Ophthalmology 1994;101:332–9.12. Karickhoff J R. Pigmentary dispersion syndrome and pigmentary glaucoma: anew mechanism concept, a new treatment and a new technique. Ophthalmic Surg.1992;23:269–77.13. Roberto G Carassa, Paolo Bettin, Marina Fiori, Rosario Brancato;Nd:YAG laseriridotomy in pigment dispersion syndrome: an ultrasound biomicroscopic study;Br J. Ophthalmol 1998;82:150-153 .

Glaucoma Free PapersIncreased Test-retest Variability TypicallyPrecedes Definite Glaucomatous Field Defectsin Early GlaucomaDr. Tutul ChakravartiEarly defects manifested as increased scatter/variable responses in affectedareas of 9 visual charts (29%) out of 31 converted charts (25 convertedpatients).Variability occurs mostly at pathological points in those converted 9charts even if the tests are administered within a short time period.In conclusion test-retest variability increases in the areas that finally becomedefinitely abnormal and may represent warning signs of impending absolutedefects.Early glaucomatous field loss may develop very gradually over a period ofseveral years. Local depressions of sensitivity frequently come and go forquite some time before finally resolving into stable and repeatable defects.Threshold values at individual test point locations frequently vary fromtest to test of the same eye, even if the tests are administered within a shorttime. Clinically significant defects can be identified in probability plots evenbefore they are clearly visible in grayscale representations. Such increasedtest-retest variability of glaucomatous field is bound by certain laws, however,and depends on test point defect depth, test point location, and overall visualfield status. Most of the variability occurs in pathological points rather thanin normal ones and variability tends to be higher farther away from fixationthan more centrally.MATERIALS AND METHODSIn a retrospective chart review, 129 cases, (256 visual field charts; 243 OHT +9 PAC + 4 glaucoma suspects) from Eye and Glaucoma Care, Kolkata, Indiawere included for this study. Group A:122 patients (243 field charts) with OHT(Intraocular Pressure > 22 and 22 and 19 and

70th AIOC Proceedings, Cochin 2012defined as a reproducible glaucomatous visual defect in Standard AutomatedPerimetry (SAP).In this study each field (total 256 visual field charts) was evaluated by Hoddap-Parrish-Anderson’s (H-P-A) criteria to detect early localized field defect dueto glaucoma. Three criteria for minimal abnormality to determine earlyglaucomatous nerve fiber bundle defect are:1) Three or more non – edge adjacent scotomas in pattern deviationprobability plot (PSD) s, Two points p < 5% And one point p < 1%;2) PSD p < 5%;3) G.H.T. abnormal.It is accepted that meeting any one of these 3 criteria is sufficient to make thetest result abnormal. Comparisons are based on more than three test resultsor visual charts to describe a visual field variable.322Table 1IOP Visual Field Gonioscopy Optic discmm of HgOHT >22&22&19 and

Glaucoma Free Papersgroups. In areas of the visual field initially found to have moderate loss ofsensitivity, GHT varies from Borderline to General reduction of sensitivity,even outside normal limits. Variation in follow-up measurements ranged fromnormal sensitivity to absolute defect, within a short period of time, with littledependence on distance from fixation. Variability occurs mostly at pathologicalpoints in those converted 9 charts even if the tests are administered in a shortperiod.List of participants from each group, (OHT, PAC, and Glaucoma Suspects);List of converted patients from each group;and list of variability from eachconverted group in Table 2.Table 2Number Number of Number Number Variabilityof Eyes/charts of ofPatients Converted ConvertedPatients chartsGroup A OHT 122 243 eyes/charts 20 patients 24 eyes/charts 5 out ofpatients24 chartsGroup B PAC 5 patients 9 eyes/charts 3 patients 5 eyes/ charts 3 out of5 chartsGroup C, 2 patients 4 eyes/charts 2 patients 2 eyes/charts 1 out ofGlaucoma2 chartsSuspectsTOTAL 129 256 charts/eyes 25 patients 31 eyes/charts 9 out of 31patientschartsTable 3: Maximum variability in a PAC patient out of these 9 charts,(under observation from 2004 to 2007)MD(dB) PSD (dB) GHT2004 -2.79 1.78 Borderline2005 -3.19 2.08 Borderline2006 -4.49 2.29 Outside Normal limit2007 (06-06-2007) -5.06 2.16 Borderline2007 (11-01-2007) -5.04 1.47 Generalized reduction of Sensitivity2007 (07-09-2007) -3.94 1.70 Outside Normal LimitTable 4: Variability in a OHT patient Converted to POAGYEAR MD PSD GHT2004 1.00 1.19 Borderline2006 +0.68 1.42 Within Normal Limit2007 -0.63 2.39 Outside Normal Limit2008 -0.09 1.83 Outside Normal Limit323