The normal optic nerve variations in an optometric population:Possible ocular and systemic influences

Early detection of glaucoma relies on a detailed knowledge of how the normal optic nerve (ONH) varies within the population. The purpose of this study focused on two main areas; 1. To explore the optic nerve head appearance in the normal optometric population and compare the south Asian (principally Pakistani) with the European white population, correcting for possible ocular and non-ocular influences in a multiple regression model. The main findings were: • The optic discs of the South Asian (SA) and White European (WE) populations were not statistically different in size. The SA group possessed discs with increased cupping and thinner neuro-retinal rims (NRR) compared with the WE group. The SA group also demonstrated a more vertically oval shape than the WE population. These differences were significant at the p<0.01 level. • The upper limits of inter-eye asymmetry were: ≤0.2 for cup to disc area ratio, and 3mmHg for intra-ocular pressure (IOP) for both ethnic groups and this did not increase with age. IOP asymmetry did not vary with gender, ethnicity or a family history of glaucoma and was independent of ONH asymmetry. ONH and IOP asymmetry are therefore independent risk factors when screening for glaucoma for both ethnic groups. 2. To investigate the validity of the ISNT rule: inferior> superior> nasal> temporal NRR thickness in the optometric population. The main findings were: • As disc size increased the disc become rounder and less vertically oval in shape. Vertically oval discs had thicker superior and inferior NRRs and thinner nasal and temporal NRRs compared with rounder disc shapes due to cup shape being independent of disc shape. Vertically oval discs were therefore more likely to obey the ISNT rule than larger rounder discs. • The ISNT rule has a low adherence in our sample of normal eyes (5.7%). However, by removing the nasal sector to become the IST rule, 74.5% of normal eyes obeyed. SA eyes and female gender were more likely to obey the ISNT rule due to increased disc ovality. The IST rule is independent of disc shape and therefore more suitable for assessing discs from both ethnic backgrounds. Obeying the ISNT rule or IST rule was not related to disc or cup size.

Cling film as a barrier against CJD in Goldmann-type applanation tonometry

Purpose: To determine the feasibility of taking intra-ocular pressure (IOP) readings with Goldmann-type applanation tonometer probe covered with cling film to avoid transmission of Creutzfeldt-Jakob disease (CJD). Methods: Data were collected on two occasions from the right eyes of 30 healthy subjects using a Perkins applanation tonometer. On each occasion, a single tonometry measurement was made with and without cling film covering. Results: Cling film covering brought about a statistically significant IOP bias (-0.8 mmHg on first occasion and -1.17 mmHg on second occasion). The 95% limits of agreement, between readings made with and without cling film covering, were ±3.4 mmHg on first occasion; ±2.5 mmHg on second occasion. A statistically significant reduction of inter-sessional repeatability was observed for readings taken with cling film (±5.2 mmHg) compared to those made without (±3.9 mmHg). Conclusions: Even if the above findings are found to be acceptable, given the known intra-subject variations of this type of tonometry (±4 mmHg), ethical and legal considerations relating to the barrier properties of cling film are likely to prevent its routine use by optometrists. © 2004 The College of Optometrists.

Design and synthesis of proteoglycan analogues for tissue repair and regeneration

This thesis is concerned with the design and synthesis of a novel, injectable proteoglycan analogue for tissue repair. This is of particular relevance to the restoration of disc height to a degraded nucleus pulposus of the intervertebral disc. The focus is on the use of sulfonate monomers as proteoglycan analogues, in particular sodium 2-acrylamido-2-methylpropane sulfonic acid and the potassium salt of 3-sulfopropyl acrylate. For most biomedical applications, synthetic hydrogels need to show dimensional stability to changes in pH, osmolarity, and temperature. This is readily achieved by neutral structures however ionic sulfonate containing hydrogels are responsive to environmental change which renders them difficult to manage in most tissue replacement applications. In this case osmotic responsiveness rather than stability is desirable. Therefore sulfonate based materials possess advantageous properties. This is a result of the sulfonate becoming an ideal surrogate for the sulfate group present within the structure of natural proteoglycans. This thesis reports polymerisation studies based on the production of a redox initiated copolymer system capable of polymerising in situ within a timescale of circa. 5-7 minutes. The rheological properties, osmotic drive, and residual monomer content of successful compositions is analysed. Properties are adapted to mimic those of the target natural tissue. The adaptation of the material for use as an injectable intra-ocular lens, with hyaluronic acid as an interpenetrate is reported. The synthesis of a radiopaque macromer to allow visibility of the repair system once in situ is investigated and discussed. The results presented in this thesis describe a suitable proteoglycan tissue analogue which is injectable, biomimetic, osmotically responsive and mechanically stable in its desired application.

Clinical evaluation of the Grand Seiko Auto Ref/Keratometer WAM-5500

Purpose: A clinical evaluation of the Grand Seiko Auto Ref/Keratometer WAM-5500 (Japan) was performed to evaluate validity and repeatability compared with non-cycloplegic subjective refraction and Javal–Schiotz keratometry. An investigation into the dynamic recording capabilities of the instrument was also conducted. Methods: Refractive error measurements were obtained from 150 eyes of 75 subjects (aged 25.12 ± 9.03 years), subjectively by a masked optometrist, and objectively with the WAM-5500 at a second session. Keratometry measurements from the WAM-5500 were compared to Javal–Schiotz readings. Intratest variability was examined on all subjects, whilst intertest variability was assessed on a subgroup of 44 eyes 7–14 days after the initial objective measures. The accuracy of the dynamic recording mode of the instrument and its tolerance to longitudinal movement was evaluated using a model eye. An additional evaluation of the dynamic mode was performed using a human eye in relaxed and accommodated states. Results: Refractive error determined by the WAM-5500 was found to be very similar (p = 0.77) to subjective refraction (difference, -0.01 ± 0.38 D). The instrument was accurate and reliable over a wide range of refractive errors (-6.38 to +4.88 D). WAM-5500 keratometry values were steeper by approximately 0.05 mm in both the vertical and horizontal meridians. High intertest repeatability was demonstrated for all parameters measured: for sphere, cylinder power and MSE, over 90% of retest values fell within ±0.50 D of initial testing. In dynamic (high-speed) mode, the root-mean-square of the fluctuations was 0.005 ± 0.0005 D and a high level of recording accuracy was maintained when the measurement ring was significantly blurred by longitudinal movement of the instrument head. Conclusion: The WAM-5500 Auto Ref/Keratometer represents a reliable and valid objective refraction tool for general optometric practice, with important additional features allowing pupil size determination and easy conversion into high-speed mode, increasing its usefulness post-surgically following accommodating intra-ocular lens implantation, and as a research tool in the study of accommodation.

Regional differences in oxygen saturation in retinal arterioles and venules

BACKGROUND: Retinal vessel oxygenation saturation measurements have been the focus of much attention in recent years as a potential diagnostic parameter in a number of ocular and systemic pathologies. This interest has been heightened by the ability to measure oxygen saturation in vivo using a photographic technique. METHODS: Retinal vessel oxygenation in venules and arterioles of 279 retinal vessels of 12 healthy Caucasian participants (mean age: 30 SD (+/- 6) years) were measured consecutively three times to evaluate short-term variation in oxygen saturation and regional variability of retinal vessel oxygen saturation using dual-wavelength technology (Oxymetry Modul, Imedos, Germany). All subjects underwent standard optometric assessment including non-contact intra-ocular pressure assessment as well as having their systemic blood pressure measured. RESULTS: Vessels were grouped as either near-macula or peripheral, depending on their location. Peripheral arterioles and venules exhibited significantly lower oxygen saturation compared to their near-macula counterparts (arterioles: 94.7% (SD 3.9) vs. 99.7% (SD 3.2); venules: 65.1% (SD 7.2) vs. 90.3% (SD 6.7)). Both arterioles and venules, main branches, and those feeding and draining the retina near the macula and periphery showed low short-term variability of oxygen saturation (arterioles: COV 1.2-1.8%; venules: COV 2.9-4.9%). CONCLUSIONS: Retinal arterioles and venules exhibit low short-term variation of oxygen saturation in healthy subjects. Regional differences in oxygen saturation could be a potential useful marker for risk stratification and diagnostic purposes of area-specific retinal pathology such as age-related macula degeneration and diabetic maculopathy.

Reliability of retinal vessel calibre measurements using a retinal oximeter

Background: Summarised retinal vessel diameters are linked to systemic vascular pathology. Monochromatic images provide best contrast to measure vessel calibres. However, when obtaining images with a dual wavelength oximeter the red-free image can be extracted as the green channel information only which in turn will reduce the number of photographs taken at a given time. This will reduce patient exposure to the camera flash and could provide sufficient quality images to reliably measure vessel calibres. Methods: We obtained retinal images of one eye of 45 healthy participants. Central retinal arteriolar and central retinal venular equivalents (CRAE and CRVE, respectively) were measured using semi-automated software from two monochromatic images: one taken with a red-free filter and one extracted from the green channel of a dual wavelength oximetry image. Results: Participants were aged between 21 and 62 years, all were normotensive (SBP: 115 (12) mmHg; DBP: 72 (10) mmHg) and had normal intra-ocular pressures (12 (3) mmHg). Bland-Altman analysis revealed good agreement of CRAE and CRVE as obtained from both images (mean bias CRAE = 0.88; CRVE = 2.82). Conclusions: Summarised retinal vessel calibre measurements obtained from oximetry images are in good agreement to those obtained using red-free photographs.

The influence of simulated cataract on retinal vessel oximetry measurements

PURPOSE: To assess the impact of human crystalline lens opacification and yellowing, similar to that observed in patients with cataracts, on retinal vessel blood oxygen saturation measurements using custom manufactured soft contact lenses. METHODS: Ten healthy, non-smoking individuals were enrolled for this study. All subjects underwent digital blood pressure measurements, assessment of non-contact intra-ocular pressure, pupil dilation and retinal vessel oximetry using dual-wavelength photography (Oximetry Module, Imedos Systems). To simulate lens changes, three different contact lenses were inserted, one to simulate opacities followed by two more lenses to simulate different levels of lens yellowing (Cantor & Nissel). RESULTS: The measurements obtained showed an opposite change in arterial and venous oxygen saturation and optical density ratio across conditions, resulting in a statistically significant difference in arterial minus venous oxygen saturation value (p = 0.003). However, this difference was only significant for the 'opacity' condition but not for the 'yellowing' conditions. CONCLUSION: Lenticular changes such as cataracts can impact on spectrophotometric analysis in particular dual-wavelength retinal vessel oximetry. Hence, lenticular assessment and cataract grading should be considered when assessing elderly individuals and patient groups developing cataract earlier in life such as those suffering from diabetes mellitus.