Risk of Sudden Visual Loss Following Filtration Surgery in End-Stage Glaucoma

FOTIS TOPOUZIS, MD, PARIS TRANOS, MD, ARCHIMIDIS KOSKOSAS, MD, THEOFANIS PAPPAS, MD, ELEFTHERIOS ANASTASOPOULOS, MD, STAVROS DIMITRAKOS, MD, AND M. ROY WILSON, MD, MS

To evaluate the effect of ltration surgery on visual acuity and visual elds in patients with endstage glaucoma during the immediate postoperative period and to assess the risk of sudden visual loss. DESIGN: Prospective interventional, consecutive caseseries. METHODS: The study prospectively included consecutive patients with end-stage glaucoma who underwent trabeculectomy with mitomycin-C. The inclusion criterion was a preoperative visual eld with Advanced Glaucoma Intervention Study score over 16. Main outcome measures included change in best corrected logMAR visual acuity, in mean deviation (MD) of visual eld test, in number of points among the four central visual eld points with a sensitivity less than 5 dB and in mean sensitivity of the four central visual eld points after surgery. The incidence of intraoperative and postoperative complications was also recorded. RESULTS: Twenty-one patients (21 eyes) were enrolled. Mean age was 64 years (range 31 to 78). Surgery resulted in a reduction of preoperative intraocular pressure (IOP) by 14.1 9.2 mm Hg (P < .001) and a decrease in postoperative antiglaucoma medication use (P < .001). Preoperatively the mean visual acuity was 0.77 0.78, and the mean value of the mean deviation at the visual eld test was 27.94 2.7 dB. Three months after surgery, there was no signicant difference in visual acuity (0.74 0.79, P .73) and mean deviation (27.50 2.6 dB, P .1). Similarly there was no signicant change in the visual eld parameters tested to assess central visual eld sensitivity. There were no intraoperative complications. Transient hypotony occurred in three eyes while one eye presented more
See accompanying editorial in this issue. Accepted for publication Apr 5, 2005. From the BDepartment of Ophthalmology, Aristotle University of Thessaloniki, Thessaloniki, Greece (F.T., P.T., A.K., T.P., E.A., S.D.); and Texas Tech University Health Sciences Center, Lubbock, Texas (M.R.W.). Inquiries to Fotis Topouzis, MD, Aristotle University of Thessaloniki, BDepartment of Ophthalmology, General Hospital Papageorgiou, Periferiaki Odos Thessalonikis N. Efkarpia 56403, Thessaloniki, Greece; fax: 302310839497; e-mail: ftopouzis@otenet.gr
0002-9394/05/$30.00 doi:10.1016/j.ajo.2005.04.016

PURPOSE:

extended hypotony. Three of these eyes experienced bleb leak (seidel). CONCLUSIONS: In our case-series of consecutive patients with end-stage glaucoma, followed for 3 months after ltration surgery IOP was reduced effectively and vision was preserved with no occurrences of wipe-out phenomenon. (Am J Ophthalmol 2005;140:661 666. 2005 by Elsevier Inc. All rights reserved.)

tial visual loss, after ltration surgery in patients with end-stage glaucoma. It has been reported that ltering procedures in advanced glaucoma may be associated with a risk of immediate unexplained postoperative visual eld loss, which includes xation with an accompanying change in central visual acuity (wipe-out phenomenon).1 4 The visual compromise after glaucoma surgery in patients with advanced glaucoma may be attributable to readily identiable complications including cataract, cystoid macular edema, suprachoroidal or vitreous hemorrhage, retinal detachment, endophthalmitis and uveitis.1 However, in a number of cases, loss of central visual eld can accompany an otherwise successful operation with none of the complications mentioned above being present.1 4 There are conicting reports, with some identifying the risk of wipe-out phenomenon, as high as 14% in patients with advanced eld defects,2 whereas others regard this phenomenon as extremely rare.5 The existing body of clinical evidence is based predominantly on retrospective studies that have several limitations and that fail to provide solid evidence and practice guidelines for the optimal management of patients with end-stage glaucoma.19 The current study was undertaken to prospectively evaluate the effect of ltration surgery on visual acuity and visual elds in patients with end-stage glaucoma during the immediate postoperative period and to assess the risk of sudden visual loss. It also aims to address determinants that could potentially be associated with increased risk of postoperative visual loss in those patients.
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TABLE 1. Baseline Clinical Characteristics of 21 Eyes of 21 Patients With End-stage Glaucoma Undergoing Filtration Surgery
Age (yrs) Range Mean SD Gender Males Females Lens status Phakic Pseudophakic Type of glaucoma Primary open angle Chronic angle closure Pseudoexfoliative Uveitic LogMAR visual acuity Range Mean SD IOP (mm Hg) Range Mean SD C/D ratio Range Mean SD Visual elds AGIS score Range Mean SD Visual elds mean deviation (dB) Range Mean SD Number of antiglaucoma agents Range Mean SD Interval between diagnosis of glaucoma and trabeculectomy (months) Range Mean SD

3178 64 13 14 (67%) 7 (33%) 17 (81%) 4 (19%) 6 3 11 1 (29%) (14%) (52%) (5%)

(0)(2.7) 0.8 0.8 1543 27 9 0.71.0 0.9 0.06 1720 19.2 0.56 2332 28 3 24 31

137 10 12

SD Standard Deviation; IOP Intraocular Pressure; C/D ratio Cup-Disc ratio; AGIS Advanced Glaucoma Intervention Study; dB decibel.

PATIENTS AND METHODS

THIS PROSPECTIVE, INTERVENTIONAL, CONSECUTIVE CASE

series study enrolled subjects with end-stage glaucoma who were due to undergo ltration surgery between March 2001 and April 2004 at the AHEPA Hospital, Aristotle University of Thessaloniki, Greece. End-stage glaucoma was dened on the basis of visual eld results. Patients with high risk for wipe-out phenomenon were selected. Specically, these patients had a visual eld score in the operated eye greater than 16 according to the Advanced Glaucoma Intervention Study (AGIS) grading system.10 In visual elds with AGIS score greater than 16, only a 661.e2 AMERICAN JOURNAL
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central island of vision is present while most of the visual eld points have no sensitivity at all (0 dB). The study was approved by the local Ethics Committee and written informed consent was obtained from each participant. Preoperatively, a structured interview was conducted by research staff and included questions on use of antiglaucoma medications, coexisting systemic or ocular disease, use of systemic medication, and previous intraocular surgical procedures. A baseline ophthalmic examination was performed within 2 days before surgery. Best-corrected visual acuity for distance was measured with standard ambient lighting by a retroilluminated ETDRS chart, placed at 4 m. Visual acuity was recorded as the number of letters read correctly from 0 (20/250) to 70 (20/10).11 Subsequently, a 30-2 full threshold visual eld test (Humphrey Field Analyzer 750-A10.1) and baseline slit-lamp examination were performed. Additionally, Goldmann applanation tonometry, gonioscopy, and dilated fundoscopy with assessment of the vertical cup/ disk ratio were performed. The type of glaucoma, the type and number of preoperative antiglaucoma medications used, and the lens status were documented. The surgical technique was standard in all subjects and all the operations were performed by the same surgeon (F.T). The technique involved a fornix-based conjunctival ap and a partial thickness 4 mm 4 mm rectangular scleral ap. In all patients antimetabolites were used as adjuncts to the ltration surgery with 0.3 mg/mL of mitomycin-C being applied with a sponge under conjunctival ap for 3 minutes intraoperatively after the scleral ap was made. This area was then irrigated with balanced salt solution (BSS). A paracentesis tract was created in the peripheral cornea. The sclerostomy was made with a surgical knife and a Vannas scissors (Carl Teufel, GMBH & CO, Liptingen, Germany) followed by an iridectomy. The scleral ap was sutured with three interrupted 10.0 nylon sutures. After injection of BSS into anterior chamber through the paracentesis tract, the anterior chamber remained formed with a visible leak present around the scleral ap at equilibrium. The conjunctival ap was closed with 8.0 Vicryl suture (Ethicon Inc, Somersville, NJ). Patients were examined 1 day, 1 week, 1 month, and 3 months postoperatively with documentation of visual acuity, IOP, optic disk status, and number of antiglaucoma agents that were required to achieve optimal levels of IOP. Optic disk assessment involved evaluation of cup to disk ratio, and the presence of rim thinning, notching, or disk hemorrhages. Additional visits were scheduled as clinically warranted. The incidence of intraoperative and postoperative complications such as at anterior chamber, hypotony, macular edema, choroidal detachment, and bleb leaking (seidel) were recorded at each visit. Hypotony was dened as an IOP of less than 5 mm Hg, and it was considered to be transient when the duration was less than 15 days. Visual elds were repeated at 3 months after surgery. OPHTHALMOLOGY OCTOBER 2005

TABLE 2. Visual Acuity and Visual Field Results Prior to and Three Months Following Filtration Surgery in the Cohort of 21 Patients With End-stage Glaucoma
Number of Central VF Points With Sensitivity Less Than 5 dB Exit Entry Exit

Gender

Age at Entry (years)

Eye

Glaucoma Type

Visual Acuity Entry Exit Entry

MD (dB)

Mean Sensitivity of 4 Central Points Entry Exit

1 2* 3 4 5 6 7 8 9* 10 11 12 13 14 15 16 17 18 19 20 21

M M F M F M M M M M F F M F M M M M F M F

73 63 74 78 45 55 74 75 74 31 67 75 71 53 65 73 76 68 60 67 35

OS OS OD OS OD OD OS OD OS OD OS OS OD OD OS OD OD OD OD OD OD

PXE PXE PXE CACG POAG CACG PXE-AC PXE PXE CHR. UV. POAG POAG PXE PXE PXE POAG PXE PXE POAG POAG POAG

20/40 20/80 20/60 20/200 LP 20/20 20/30 20/40 20/160 CF CF 20/40 20/25 20/100 20/160 20/200 20/60 CF 20/25 20/20 20/25

20/25 20/25 20/100 CF LP 20/25 20/30 20/50 20/25 20/200 CF 20/50 20/30 20/80 20/80 20/200 20/60 CF 20/30 20/20 20/40

29.23 26.04 24.93 25.65 32.12 31.42 22.95 25.72 28.53 31.36 26.89 30.15 29.47 30.89 29.94 23.88 29.02 29.09 28.29 24.20 27.11

27.57 26.71 23.24 27.66 32.12 30.93 23.16 26.99 28.14 29.29 26.72 29.14 29.08 30.88 29.76 25.90 28.58 26.83 27.60 24.04 23.33

4 1 1 4 4 4 2 3 3 3 4 3 3 3 3 2 3 4 2 1 2

2 1 1 4 4 3 2 2 2 2 3 4 3 2 3 4 3 2 2 2 1

0.00 11.75 10.75 1.75 0.00 0.00 11.75 2.25 5.00 2.00 0.00 1.25 4.50 1.75 1.75 7.00 4.50 0.00 9.25 10.25 7.75

10.75 10.50 13.00 0.00 0.00 1.50 7.75 4.00 7.00 7.50 1.25 1.00 6.50 4.75 2.50 0.25 3.50 5.75 12.25 13.75 9.00

dB Decibel; MD Mean Deviation. *Phaco-Trab. Secondary to Pseudoexfoliation Glaucoma. Chronic Angle Closure Glaucoma. Primary Open Angle Glaucoma. Pseudoexfoliation and Angle Closure. Secondary to Chronic Uveitis Glaucoma.

Main outcome measures included the best-corrected visual acuity and the mean deviation (MD) of the visual eld 3 months after surgery compared with preoperative values. In addition, the four central visual eld points were considered in two ways in the analysis. First, the number of points among the four central visual eld points with a sensitivity of less than 5 dB was included as a main outcome measure. We wanted a cut-off point in sensitivity that would be considered by clinical consensus to be very low and 5 dB was arbitrarily selected. Additionally, the mean sensitivity of the four central points was used to provide a different approach to evaluating the status of the four central points. Box-and-whisker plots and histograms were used to summarize distributions. Relationships of outcome measures with baseline characteristics and possible explanatory variables were evaluated with independent t test for normally distributed variables. Mann-Whitney U, Spearman rank correlation test, and Wilcoxon signed-rank test were used for VOL. 140, NO. 4 RISK
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variables that showed nonnormality. Relationships between categorical variables were evaluated by the 2 test. All tests of association were considered to be statistically signicant if P .05. Analyses were carried out by the use of SPSS (version 10.0, SPSS Inc, Chicago. Illinois, USA).

RESULTS
TWENTY-ONE CONSECUTIVE EYES OF 21 PATIENTS (14 MALES

and 7 females) fullled the inclusion criteria and were recruited into the study. The mean AGIS score of these eyes was 19.24 0.56 (range 17 to 20). Demographic and baseline clinical characteristics of all patients are summarized in Table 1. Mean age of the subjects was 64 13 years (range 31 to 78 years), and the mean interval between the diagnosis of glaucoma and ltration surgery was 10 12 months (range 1 to 37 months). Trabeculectomy alone was performed in 19 eyes (91%) whereas in two
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TABLE 3. Mean Change in Visual Acuity and Visual Fields 3 Months Following Glaucoma Filtration Surgery in 21 Patients With End-stage Glaucoma
N Mean at Baseline (SD) Mean at Final Follow up (SD) P Value

Visual acuity (logMAR) Number of central visual eld points with sensitivity less than 5 dB Mean sensitivity of 4 central visual eld points (dB) Mean deviation (dB)

21 19* 21 19* 21 19* 21 19*

0.77 (0.78) 0.77 (0.82) 2.81 (1.03) 2.89 (0.99) 4.44 (4.26) 4.03 (4.12) 27.94 (2.7) 28.01 (2.8)

0.74 (0.79) 0.79 (0.80) 2.48 (0.98) 2.58 (0.96) 5.83 (4.49) 5.53 (4.58) 27.50 (2.6) 27.52 (2.7)

.73 .66 .16 .19 .05 .06 .10 .08

SD Standard Deviation; dB decibel. *Patients who underwent ltration surgery only (two cases with combined surgery are excluded).

eyes (9%), ltration surgery was combined with phacoemulsication and intraocular lens implantation. Glaucoma was of the primary open angle type in seven patients (33%), two patients (10%) had chronic angle closure glaucoma, 11 patients (52%) had pseudoexfoliation glaucoma, and one patient (5%) had glaucoma attributable to chronic uveitis. The latter case had history of chronic idiopathic iritis with no posterior segment involvement, which was quiescent for at least 6 months preoperatively. One pseudoexfoliative patient presented with angle closure (Tables 1 and 2). Six of the patients were blind in the fellow eye at presentation. In ve of these patients, blindness was attributable to glaucoma. Five patients had previous ltration surgery in the study eye. There were no intraoperative complications. Transient hypotony occurred in three eyes while one eye presented with more extended hypotony. Three of these eyes experienced bleb leak (seidel). In all cases bleb leaking (seidel) was considered to be mild. There were no cases of at anterior chamber, macular edema, or choroidal detachment. Ten patients (48%) required Argon laser suturelysis. One of those patients developed subsequent hypotony for a period longer than 15 days that was managed successfully with autologous blood injection in the bleb. Additionally, injection of 5-uoruracil (5-FU) was carried out in nine patients (43%) during the postoperative period. We obtained a signicant reduction of IOP from 27 9 mm Hg preoperatively to 12 7 mm Hg, 3 months after surgery (Wilcoxon signed-rank test, P .001). Sixteen patients (76%) had IOP less than 16 mm Hg at the end of the study period whereas IOP was greater than 21 mm Hg in three patients (14%). In two of these patients, antiglaucoma treatment was prescribed before the 3-month visit whereas the third patient received treatment during this visit. The reduction in IOP resulted in a decreased need for postoperative antiglaucoma agents from 3.1 0.7 at baseline to 0.5 1.1 at the end of the follow-up (P .001). Sixteen patients (76%) achieved an optimal IOP with no need for postoperative topical or systemic medi661.e4 AMERICAN JOURNAL
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cation and only two patients (10%) required two or more antiglaucoma agents. Preoperative visual acuity was 20/40 or better in nine eyes (43%) whereas ve eyes (29%) had visual acuity of 20/200 or worse. There was no signicant change in mean logMAR visual acuity (Wilcoxon signed-rank test, P .73) 3 months after ltration surgery (Table 3). All eyes had advanced glaucomatous visual eld defects at baseline. The preoperative mean deviation was less than 26 dB in six eyes (29%), 10 eyes (48%) had a mean deviation between 26 and 30 dB, and ve eyes (23%) had a mean deviation greater than 30 dB. Minimal change (decrease by 0.4 1.4 dB) was observed in the mean deviation (MD) 3 months after surgery but this change failed to reach statistically signicant levels (Wilcoxon signed-rank test, P .159) (Table 3). Similarly, the mean number of the central visual eld points with sensitivity less than 5 dB remained at preoperative levels (2.8 1.0 and 2.5 1.0 before and after surgery, respectively, P .14). When the change in mean sensitivity of the four central visual eld points was tested, results showed improvement by 1.4 3.6 dB (P .05). This improvement was greater in patients with higher baseline AGIS score (P .031). However the above results lost statistical signicance (Wilcoxon signed-rank test, P .061 and P .073, respectively) when the two patients with combined cataract and glaucoma surgery were excluded from the analysis (Table 3). None of the participants developed wipe-out phenomenon. Minimal changes in visual acuity and visual eld were observed in some cases. In two patients (Table 2, patients 3 and 21), visual acuity changed by more than one line 3 months after surgery. In patient 3, this was believed to be because of cataract development. Six months after surgery, and after cataract extraction, visual acuity was 20/20. In patient 21, a transient visual acuity decrease to 20/80 was observed attributable to hypotony after Argon laser suturelysis one week after surgery. At the 3-month visit, and after successful management of the hypotony OPHTHALMOLOGY OCTOBER 2005

with autologous blood injection, the visual acuity was improved to 20/40 (Table 2). At 6 months after surgery, further improvement was observed and the visual acuity returned to preoperative values. Further analysis showed that change in visual acuity or visual elds after trabeculectomy was not associated with age, gender, type of surgery (trabeculectomy alone or combined with cataract extraction), type of glaucoma, coexisting systemic disease, use of systemic medications, use of 5-FU application, or change in IOP (Spearman rank correlation test, P .05).

DISCUSSION
THE POTENTIAL RISK OF POSTOPERATIVE VISUAL LOSS AF-

ter ltration surgery in advanced glaucoma has been the concern of many ophthalmologists since the introduction of drainage procedures. Wipe-out phenomenon has been described as sudden reduction of visual acuity after ltration surgery in end-stage glaucoma, with no apparent ocular pathology to account for this decline.1 Only a limited number of predominantly retrospective studies exists, and these fail to provide conclusive data on the visual prognosis of patients with advanced visual eld defects who undergo glaucoma procedures.19 Kolker and associates reported an incidence of 13.6% (3/22) of central vision loss in the immediate postoperative period.2 In each instance, visual acuity decreased to 20/ 200 on all subsequent visits. One of those patients had persisting postoperative hypotony and another developed severe, brinous uveitis and cataract after surgery. Additionally, the authors stated that in all three patients, the preoperative visual eld defect involved xation, thus suggesting that this complication is very rare when central vision is spared. More recent reports showed that the risk of unexplained postoperative loss of central visual eld does exist but is lower than 1% and is more likely to occur in older patients with macular splitting in the preoperative visual eld.1 Aggarwal and associates, in a prospective study, reported three cases of central visual eld loss after trabeculectomy out of nine patients with very small visual eld (100) because of advanced glaucoma.3 However, two of those cases had developed postoperative cystoid macular edema or persisting hypotony with only the third patient having no identiable cause of this visual loss. Otto also reported on loss of xation after cyclodialysis and trephining operations.4 He suggested that the incidence of this complication was very low and was mainly caused by cardiovascular insufciency and nutritional disturbance. Although the exact mechanism of the wipe-out phenomenon remains elusive, it has been suggested that it may be associated with the occurrence of sudden, intraoperative ocular hypotony during glaucoma surgery. This may result in optic nerve hemorrhage and decreased perfusion pressure to an already compromised optic nerve blood VOL. 140, NO. 4 RISK
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supply. It may also induce a microembolic episode that could damage the remaining nerve bers.5,7 Conversely, other investigators suggested that surgical intervention in advanced glaucoma is seldom, if ever, associated with reduction of central visual elds.6 Chandler and associates stated that he had never seen a case of sudden unexplained postoperative loss of vision regardless of the smallness of the preoperative visual eld.12 Lichter and Ravin in a retrospective study of 52 eyes with glaucomatous visual eld defects, with or without involvement of the xation, reported no cases of sudden visual acuity loss, concluding that this is, at most, a rare complication of ltering surgery.5 Similar results have also been reported by OConnell and associates, and more recently by Martinez and associates in retrospective studies which showed that in patients with advanced glaucoma, sudden postoperative reduction of visual acuity irrespective of the underlying cause (macular edema, hypotony maculopathy, or keratopathy) was extremely uncommon.6,7 This diversity of reports on the incidence of unexplained visual loss after ltration surgery may lead to confusion among clinicians. It is probably attributable to its indistinct denition, since several studies have considered cases with obvious macular pathology including postoperative macular edema and central retinal folds as wipe-out phenomenon. Even in eyes without preoperative macular damage, the use of intraoperative mitomycin-C may affect the macula and cause vision loss. In addition, the lack of systematic evaluation of visual eld loss by means of a standardized grading score for staging glaucoma damage, lack of dened patient eligibility criteria, and the inherent limitations associated with the retrospective nature of the previous studies have contributed to the inconsistency noted in the existing literature. Our study prospectively investigated the effect of glaucoma surgery on visual acuity and visual elds in a series of consecutively enrolled patients. The use of the AGIS scoring system ensured recruitment of a homogenous group of patients with end-stage glaucoma. The use of the four central visual eld points in addition to mean deviation (MD) allowed accurate quantication of postoperative visual eld change. In end-stage glaucoma where most of the visual elds points have no sensitivity at all (0 dB), the mean deviation (MD) representing all visual elds points may be less sensitive to small changes, which could occur in the central remaining island of vision. By the use of the four central visual eld points as an outcome measure, we were able to quantify small changes that could occur in the remaining central visual eld. Additionally, visual acuity measurements were performed by a standardized method (ETDRS charts at standard ambient light). Results showed that none of the participants developed wipe-out phenomenon within the 3 months postoperative follow-up period. Our study included patients with high risk of wipe-out phenomenon according to previous reports.1,3 Most of our
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patients were in the older age group while all of them had very small visual elds (100) at baseline. The lack of visual loss or other signicant perioperative complications was accompanied by a substantial reduction of the IOP after ltration surgery. This resulted in more optimal control of the IOP and a considerable decrease of the postoperative medication use, with almost 80% of the subjects requiring no treatment after the drainage procedure. In conclusion, our series shows that glaucoma surgery has a benecial effect in the vast majority of patients with severely compromised visual elds and intractable IOP. Since we did not identify any cases of unexplained visual eld loss subserving macular function, and as the latter has also been described after other types of intraocular surgery, we speculate that this rare occurrence should not be considered peculiar only to glaucoma surgery.6,13 We should point out that although our sample size was small, it did achieve sufcient statistical power with traditional -value of 0.05. However, the latter may not be low enough to identify wipe-out cases that occur on very rare instances. Conversely, the prospective design, the homogenous study population with patients at high risk for wipe-out phenomenon, the standardization of surgery performed by a single surgeon, and the thorough follow-up of all participants with systematic evaluation of logMAR visual acuity and central visual elds, provide a high level of accuracy and reliability in the information obtained. In view of our results, we conclude that sudden unexplained postoperative loss of vision in patients with endstage glaucoma undergoing ltrating surgery is, at most, a rare complication. Therefore we recommend early surgical intervention despite the presence of advanced visual eld defects when medical control of IOP has failed, and there is evidence of progressive glaucomatous damage to the optic nerve. Further prospective studies, with a larger number of patients, would be required to conrm our

ndings and better dene the risk and the risk factors for the wipe-out phenomenon after ltration surgery.

REFERENCES
1. Costa VP, Smith M, Spaeth GL, Gandham S, Markovitz B. Loss of visual acuity after trabeculectomy. Ophthalmology 1993;100:599 612. 2. Kolker AE. Visual prognosis in advanced glaucoma: a comparison of medical and surgical therapy for retention of vision in 101 eyes with advanced glaucoma. Trans Am Ophthalmol Soc 1977;75:539 555. 3. Aggarwal SP, Hendeles S. Risk of sudden visual loss following trabeculectomy in advanced primary open-angle glaucoma. Br J Ophthalmol 1986;70:9799. 4. Otto J. Loss of point of xation after glaucoma surgery. Klin Monatsbl Augenheilkd 1957;131:178 195. 5. Lichter PR, Ravin JG. Risks of sudden visual loss after glaucoma surgery. Am J Ophthalmol 1974;78:1009 1013. 6. OConnell EJ, Karseras AG. Intraocular surgery in advanced glaucoma. Br J Ophthalmol 1976;60:124 131. 7. Martinez JA, Brown RH, Lynch MG, Caplan MB. Risk of postoperative visual loss in advanced glaucoma. Am J Ophthalmol 1993;115:332337. 8. Levene RZ. Central visual eld, visual acuity, and sudden visual loss after glaucoma surgery. Ophthalmic Surg 1992;23: 388 394. 9. Langerhorst CT, de Clercq B, van den Berg TJ. Visual eld behavior after intra-ocular surgery in glaucoma patients with advanced defects. Doc Ophthalmol 1990;75:281289. 10. The Advanced Glaucoma Intervention Study Investigators. Advance Glaucoma Intervention Study. Visual eld test scorring and reliability. Ophthalmology 1994;101:14451455. 11. Klein R, Klein BEK, Moss SE. Visual impairment in diabetes. Ophthalmology 1984;91:19. 12. Chandler PA, Grant WM. Lectures on glaucoma. Philadelphia: Lea and Febiger, 1965:136. 13. Newsom RSB, Johnston R, Sullivan PM, Aylward GB, Holder GE, Gregor ZJ. Sudden visual loss after removal of silicone oil. Retina 2004;24:871 877.

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Biosketch
Fotis Topouzis, MD, is assistant professor in the B Department of Ophthalmology, Aristotle University of Thessaloniki, Thessaloniki, Greece. Dr. Topouzis primary research interests include glaucoma epidemiology and risk factors, age-related macular degeneration epidemiology and risk factors, glaucoma medical treatment, glaucoma surgery, imaging of the optic nerve and the retina, markers for glaucoma progression, markers for age-related macular degeneration, quality of life in glaucoma and in age-related macular degeneration, psychophysics in glaucoma and in age-related macular degeneration, ocular blood ow, neuroprotection. In 1997 he was the recipient of the Shaffer International Fellowship Award, Glaucoma Research Foundation, San Francisco, CA and he was a glaucoma fellow in Jules Stein Eye Institute, UCLA, Los Angeles, CA.

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