ORIGINAL STUDY
Is Episcleritis Associated to Glaucoma? Joseph Pikkel, MD,*w Otzem Chassid, MD,* Ward Srour, MD,* Yumna Busool, MD,* Larisa Vainer, MD,* Irena Epstein, MD,* and Itzchak Beiran, MDz
Objective: The aim of this study was to show possible connection between episcleritis and open-angle glaucoma. Design: This was a retrospective study. Materials and Methods: Data on 21 patients who suffered from episcleritis and had no previous attack of episcleritis or glaucoma were collected for a period of 8 years (from 2004 to 2011). Results: Six of the 21 patients of the study group (28.6%) were diagnosed as suffering from glaucoma. Four patients had a diffuse conjunctival congestion, 1 had sectoral congestion, and for 1 patient there was no record of conjunctival congestion. Two of the 6 patients with episcleritis and glaucoma experienced recurrent episcleritis events during the follow-up period. Conclusions: This study suggests an association between episcleritis and open-angle glaucoma. Key Words: episcleral venous pressure, intraocular pressure, inflammation, conjunctival congestion
(J Glaucoma 2015;24:669–671)
E
piscleral venous pressure (EVP) is recognized as one of the factors influencing intraocular pressure (IOP). High EVP is a possible cause of ocular hypertension and glaucoma.1 Episcleritis is a benign inflammation of the episclera. In a recently published series of 85 patients with episcleritis,2 ocular complications presented in 19.0%, including decreased vision in 2.3%, anterior uveitis in 16.5%, and ocular hypertension in 3.5%; connective tissue or vasculitic diseases presented in 15.3% of patients. We present a clinical observation of a possible link between episcleritis and open-angle glaucoma, probably due to increased EVP that occurs in episcleritis. Although some reports suggested such a link, to the best of our knowledge episcleritis has not been recognized to be associated with glaucoma.
MATERIALS AND METHODS This retrospective study included all patients who were diagnosed as suffering from episcleritis in a hospital-affiliated clinic between January 1, 2004 and December 31, 2011 (8 y). Diagnosis of episcleritis was based upon history and physical examination. Symptoms included mild eye pain, Received for publication April 30, 2013; accepted March 12, 2014. From the *Ziv Medical Center, Safed; wBar Ilan University Faculty of Medicine, Ramat Gan; and zRambam Medical Center, Haifa, Israel. Disclosure: The authors declare no conflict of interest. Reprints: Otzem Chassid, MD, Ziv Medical Center, Harambam st, 1 Safed, 13100 Israel (e-mail: [email protected]). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/IJG.0000000000000070
J Glaucoma
Volume 24, Number 9, December 2015
redness, and watery discharge and in some cases small nodules were present within the episclera. Episcleritis was differentiated from scleritis by the use of phenylephrine. Data regarding episcleritis characteristics and glaucoma work-up were retrospectively collected and analyzed. Exclusion criteria were previously diagnosed glaucoma, a previous event of steroid responding, and incomplete medical records. A diagnosis of glaucoma was based on the presence of at least 2 of the following 3 characteristics: cup/ disc ratio >2 SDs above the mean for the population under the affected eye, disc asymmetry of at least 0.2 between eyes, IOP of at least 23 mm Hg in the affected eye, and glaucomatous visual field defects in the affected eye. In all patients visual field defects were reproducible. Visual fields were considered abnormal if the defect was found in at least 2 examinations performed within 1 to 2 months in between examinations.
RESULTS During the study period, 28 patients were treated for episcleritis. Four were excluded from the study: 2 for previously diagnosed glaucoma and 2 for incomplete medical records. Three patients were previously diagnosed as suffering from episcleritis but were not recorded at any time as responding to steroids treatment in an elevated IOP and were therefore included in the study. There were 24 patients diagnosed as suffering from episcleritis. The mean age was 26.6 (range, 17 to 57) years; 6 were male and 18 were female patients. Five of the 21 patients of the study group (20.8%) were diagnosed as suffering from glaucoma. One of them had a narrow angle and was drawn out of the study. Relevant diagnostic data for these patients are presented in Table 1. All other 5 patients had an open angle on gonioscopy. Four patients had a diffuse conjunctival congestion, 1 had sectoral congestion, and in 1 patient there was no record of conjunctival congestion (Table 2). One of the 5 patients with episcleritis and glaucoma experienced recurrent episcleritis events during the follow-up period (Table 2). None of the patients who developed glaucoma had any anterior chamber inflammation or trabeculitis.
DISCUSSION IOP is dependent on the rate of aqueous production, facility of outflow, and EVP. The role of episcleral venous flow was already described more than 70 years ago.3,4 The Goldmann equation describes the link between IOP and EVP as IOP = F/C + EVP. F represents aqueous humor inflow and C represents outflow facility.5 Although there is not a well-established mathematical correlation between IOP and EVP, it has been proposed that every 1 mm Hg rise in EVP will cause a rise of Z1 mm Hg in IOP.6 www.glaucomajournal.com |
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
669
Pikkel et al
J Glaucoma
TABLE 1. Relevant Glaucoma Signs in the Patients Diagnosed With Episcleritis and Glaucoma
Patient No.
IOP IOP C/D Ratio C/D Ratio Diseased Healthy Diseased Healthy Eye Eye Eye Eye
6
25
17
0.6
0.3
9
22
15
0.7
0.4
13
25
16
0.6
0.3
15
27
12
0.5
0.3
19
26
14
0.6
0.2
21
23
16
0.6
0.3
Lower nasal Para central Para central Nasal step Nasal step Upper arcuate
Three main causes of elevated EVP1 are: venous obstruction, arteriovenous anomalies, and idiopathic (Table 3). In episcleritis, episcleral vessels are engorged. In affected patients, anterior segment fluorescence angiography reveals a normal vasculature pattern but a rapid flow rate, which may lead to increased EVP.6 Elevated EVP may cause a rise in IOP, which, if of long duration, may cause cupping of the optic nerve head and loss of visual field. Nineteen cases of idiopathic-elevated EVP as a cause of open-angle glaucoma have been documented in the English language literature.7 Lammer8 suggested sinusotomy as the surgical procedure of choice in these patients. Kollarits et al9 found that orbital varices may cause elevated EVP that leads to open-angle glaucoma. Glaucoma, which had not been previously diagnosed, was detected in the diseased eye of 5 of 24 (20.8%) patients who suffered from episcleritis in the current study. All 5 patients presumed to have met all 3 criteria for glaucoma, and there was a significant C:D asymmetry between the diseased eye and the other one. Although using the contralateral eye as an internal control might be in dispute, the eye with episcleritis had a much larger C:D in every case. This is another strong indicator of a possible link between episcleritis and glaucoma. The high incidence of glaucoma in our study compares with 7.8% reported by Akpek et al.10 In light of the 2% incidence of glaucoma in the general population, these findings suggest an association between episcleritis and glaucoma. High incidence of glaucoma in our study group
TABLE 3. Causes to Elevated EVP Venous obstruction
Arteriovenous anomalies
15 19 21
Diffuse Sectoral Not recorded Diffuse Diffuse Diffuse
Gonioscopy Right Eye
Gonioscopy Left Eye
Recurrent Attacks
Open Shallow Open
Open Shallow Open
Yes No No
Open Open Open
Open Open Open
No Yes No
670 | www.glaucomajournal.com
Thyroid ophthalmopathy Retrobulbar tumor Cavernous sinus/orbital thrombosis Episcleral/orbital vein vasculitis Obstruction of superior vena cava Carotid artery-cavernous sinus fistula Orbital varices Dural shunts Sturge-Weber syndrome
Idiopathic EVP indicates episcleral venous pressure.
may be due to the relatively small number of patients, which may explain the high incidence of glaucoma found by us. Every patient diagnosed was about 4% of the study group; however, although the study group was small, it does show a higher incidence of glaucoma in patients suffering from episcleritis. In this study, a higher proportion of patients with episcleritis were females than males (18/24 = 76%), similar to the proportion reported by Akpek et al (69%).10 The recurrence of episcleritis detected in one of the patients (1/5) in the current study is also similar to their documentation of 28%. An association between elevated EVP and glaucoma has been demonstrated previously.11,12 EVP was found to be higher in eyes with untreated primary open-angle glaucoma than in eyes with untreated normal-tension glaucoma, and EVP in both was higher than in control eyes.13 Further, evidence exists regarding the role of elevated EVP in glaucoma associated with the Sturge-Weber syndrome.14 Increased EVP may occur in episcleritis.15,16 Although glaucoma is a chronic slowly progressing disease, and episcleritis is an acute condition, we suspect that subclinical disease (“silent” episcleritis) may cause a chronic increase in EVP, leading to increased IOP, hence resulting in glaucoma. This is in contrast to a report in which a low facility of outflow in 2 patients with episcleritis and secondary open-angle glaucoma led to the conclusion that EVP was not the mechanism of glaucoma.17
CONCLUSIONS This study suggests an association between episcleritis and open-angle glaucoma. Because of the small number of patients in the present report, further large-scale prospective studies are needed to affirm and characterize the exact nature of this association.
TABLE 2. Relevant Episcleritis Signs in Patients Diagnosed With Episcleritis and Glaucoma
6 9 13
Volume 24, Number 9, December 2015
VF Defect
C/D ratio indicates cup-to-disc ratio; IOP, intraocular pressure; VF, visual field.
Patient No. Congestion
REFERENCES 1. Moster M, Ichhpujani P. Episcleral venous pressure and glaucoma. J Cur Glaucoma Pract. 2009;3:5–8. 2. Sainz de la Maza M, Molina N, Gonzalez-Gonzalez LA, et al. Clinical characteristics of a large cohort of patients with scleritis and episcleritis. Ophthalmology. 2012;119:43–50. 3. Ascher KW. The aqueous veins: physiological importance of the visible elimination of fluid. Am J Ophthalmol. 1942; 25:1147. 4. Ascher KW. Aqueous veins. Am J Ophthalmol. 1942;25:31. 5. Brubaker RF. Goldmanns’ equation and clinical measures of aqueous dynamics. Exp Eye Res. 2004;78:633–637.
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Glaucoma
Volume 24, Number 9, December 2015
6. Watson P. Diseases of the sclera and episclera. In: Tasman W, Jaeger EA, eds. Duane’s Ophthalmology. 15th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:30–31. Chapter 23. 7. Rhee DJ, Gupta M, Moncavage MB, et al. Idiopathic elevated episcleral venous pressure and open-angle glaucoma. Br J Ophthalmol. 2009;93:231–234. 8. Lammer R. Secondary open angle glaucoma with idiopathic episcleral venous pressure (Radius Maumenee syndrome): sinusotomy as a procedure of choice. Ophthalmologe. 2007;104:515–516. 9. Kollarits CR, Gaasterland D, Di Chiro G, et al. Management of patient with orbital varices, visual loss and ipsilateral glaucoma. Ophthalmic Surg. 1977;8:54–62. 10. Akpek EK, Uy HS, Christen W, et al. Severity of episcleritis and systemic disease association. Ophthalmology. 1999;106:729–731. 11. Minas TF, Podos SM. Familial glaucoma associated with elevated episcleral venous pressure. Arch Ophthalmol. 1968;80:202–208.
Copyright
r
Is Episcleritis Associated to Glaucoma?
12. Talusan ED, Fishbein SL, Schwartz B. Increased pressure of dilated episcleral veins with open-angle glaucoma without exophthalmos. Ophthalmology. 1983;90:257–265. 13. Selbach JM, Posielek K, Steuhl KP, et al. Episcleral venous pressure in untreated primary open-angle and normal-tension glaucoma. Ophthalmologica. 2005;219:357–361. 14. Shiau T, Armogan N, Yan DB, et al. The role of episcleral venous pressure in glaucoma associated with Sturge-Weber syndrome. JAAPOS. 2012;16:61–64. 15. Jorgensen JS, Payer H. Increased episcleral venous pressure in uveal effusion. Klin Mond Augenhelikd. 1989;195:14–16. 16. Jorgensen JS, Guthoff R. The role of episcleral venous pressure in the development of secondary glaucoma. Klin Mond Augenhelikd. 1988;193:471– 475. 17. Harbin TS Jr, Pollack IP. Glaucoma in episcleritis. Arch Ophthalmol. 1975;93:948–950.
2015 Wolters Kluwer Health, Inc. All rights reserved.
www.glaucomajournal.com |
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
671
Is Episcleritis Associated to Glaucoma? Joseph Pikkel, MD,*w Otzem Chassid, MD,* Ward Srour, MD,* Yumna Busool, MD,* Larisa Vainer, MD,* Irena Epstein, MD,* and Itzchak Beiran, MDz
Objective: The aim of this study was to show possible connection between episcleritis and open-angle glaucoma. Design: This was a retrospective study. Materials and Methods: Data on 21 patients who suffered from episcleritis and had no previous attack of episcleritis or glaucoma were collected for a period of 8 years (from 2004 to 2011). Results: Six of the 21 patients of the study group (28.6%) were diagnosed as suffering from glaucoma. Four patients had a diffuse conjunctival congestion, 1 had sectoral congestion, and for 1 patient there was no record of conjunctival congestion. Two of the 6 patients with episcleritis and glaucoma experienced recurrent episcleritis events during the follow-up period. Conclusions: This study suggests an association between episcleritis and open-angle glaucoma. Key Words: episcleral venous pressure, intraocular pressure, inflammation, conjunctival congestion
(J Glaucoma 2015;24:669–671)
E
piscleral venous pressure (EVP) is recognized as one of the factors influencing intraocular pressure (IOP). High EVP is a possible cause of ocular hypertension and glaucoma.1 Episcleritis is a benign inflammation of the episclera. In a recently published series of 85 patients with episcleritis,2 ocular complications presented in 19.0%, including decreased vision in 2.3%, anterior uveitis in 16.5%, and ocular hypertension in 3.5%; connective tissue or vasculitic diseases presented in 15.3% of patients. We present a clinical observation of a possible link between episcleritis and open-angle glaucoma, probably due to increased EVP that occurs in episcleritis. Although some reports suggested such a link, to the best of our knowledge episcleritis has not been recognized to be associated with glaucoma.
MATERIALS AND METHODS This retrospective study included all patients who were diagnosed as suffering from episcleritis in a hospital-affiliated clinic between January 1, 2004 and December 31, 2011 (8 y). Diagnosis of episcleritis was based upon history and physical examination. Symptoms included mild eye pain, Received for publication April 30, 2013; accepted March 12, 2014. From the *Ziv Medical Center, Safed; wBar Ilan University Faculty of Medicine, Ramat Gan; and zRambam Medical Center, Haifa, Israel. Disclosure: The authors declare no conflict of interest. Reprints: Otzem Chassid, MD, Ziv Medical Center, Harambam st, 1 Safed, 13100 Israel (e-mail: [email protected]). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/IJG.0000000000000070
J Glaucoma
Volume 24, Number 9, December 2015
redness, and watery discharge and in some cases small nodules were present within the episclera. Episcleritis was differentiated from scleritis by the use of phenylephrine. Data regarding episcleritis characteristics and glaucoma work-up were retrospectively collected and analyzed. Exclusion criteria were previously diagnosed glaucoma, a previous event of steroid responding, and incomplete medical records. A diagnosis of glaucoma was based on the presence of at least 2 of the following 3 characteristics: cup/ disc ratio >2 SDs above the mean for the population under the affected eye, disc asymmetry of at least 0.2 between eyes, IOP of at least 23 mm Hg in the affected eye, and glaucomatous visual field defects in the affected eye. In all patients visual field defects were reproducible. Visual fields were considered abnormal if the defect was found in at least 2 examinations performed within 1 to 2 months in between examinations.
RESULTS During the study period, 28 patients were treated for episcleritis. Four were excluded from the study: 2 for previously diagnosed glaucoma and 2 for incomplete medical records. Three patients were previously diagnosed as suffering from episcleritis but were not recorded at any time as responding to steroids treatment in an elevated IOP and were therefore included in the study. There were 24 patients diagnosed as suffering from episcleritis. The mean age was 26.6 (range, 17 to 57) years; 6 were male and 18 were female patients. Five of the 21 patients of the study group (20.8%) were diagnosed as suffering from glaucoma. One of them had a narrow angle and was drawn out of the study. Relevant diagnostic data for these patients are presented in Table 1. All other 5 patients had an open angle on gonioscopy. Four patients had a diffuse conjunctival congestion, 1 had sectoral congestion, and in 1 patient there was no record of conjunctival congestion (Table 2). One of the 5 patients with episcleritis and glaucoma experienced recurrent episcleritis events during the follow-up period (Table 2). None of the patients who developed glaucoma had any anterior chamber inflammation or trabeculitis.
DISCUSSION IOP is dependent on the rate of aqueous production, facility of outflow, and EVP. The role of episcleral venous flow was already described more than 70 years ago.3,4 The Goldmann equation describes the link between IOP and EVP as IOP = F/C + EVP. F represents aqueous humor inflow and C represents outflow facility.5 Although there is not a well-established mathematical correlation between IOP and EVP, it has been proposed that every 1 mm Hg rise in EVP will cause a rise of Z1 mm Hg in IOP.6 www.glaucomajournal.com |
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
669
Pikkel et al
J Glaucoma
TABLE 1. Relevant Glaucoma Signs in the Patients Diagnosed With Episcleritis and Glaucoma
Patient No.
IOP IOP C/D Ratio C/D Ratio Diseased Healthy Diseased Healthy Eye Eye Eye Eye
6
25
17
0.6
0.3
9
22
15
0.7
0.4
13
25
16
0.6
0.3
15
27
12
0.5
0.3
19
26
14
0.6
0.2
21
23
16
0.6
0.3
Lower nasal Para central Para central Nasal step Nasal step Upper arcuate
Three main causes of elevated EVP1 are: venous obstruction, arteriovenous anomalies, and idiopathic (Table 3). In episcleritis, episcleral vessels are engorged. In affected patients, anterior segment fluorescence angiography reveals a normal vasculature pattern but a rapid flow rate, which may lead to increased EVP.6 Elevated EVP may cause a rise in IOP, which, if of long duration, may cause cupping of the optic nerve head and loss of visual field. Nineteen cases of idiopathic-elevated EVP as a cause of open-angle glaucoma have been documented in the English language literature.7 Lammer8 suggested sinusotomy as the surgical procedure of choice in these patients. Kollarits et al9 found that orbital varices may cause elevated EVP that leads to open-angle glaucoma. Glaucoma, which had not been previously diagnosed, was detected in the diseased eye of 5 of 24 (20.8%) patients who suffered from episcleritis in the current study. All 5 patients presumed to have met all 3 criteria for glaucoma, and there was a significant C:D asymmetry between the diseased eye and the other one. Although using the contralateral eye as an internal control might be in dispute, the eye with episcleritis had a much larger C:D in every case. This is another strong indicator of a possible link between episcleritis and glaucoma. The high incidence of glaucoma in our study compares with 7.8% reported by Akpek et al.10 In light of the 2% incidence of glaucoma in the general population, these findings suggest an association between episcleritis and glaucoma. High incidence of glaucoma in our study group
TABLE 3. Causes to Elevated EVP Venous obstruction
Arteriovenous anomalies
15 19 21
Diffuse Sectoral Not recorded Diffuse Diffuse Diffuse
Gonioscopy Right Eye
Gonioscopy Left Eye
Recurrent Attacks
Open Shallow Open
Open Shallow Open
Yes No No
Open Open Open
Open Open Open
No Yes No
670 | www.glaucomajournal.com
Thyroid ophthalmopathy Retrobulbar tumor Cavernous sinus/orbital thrombosis Episcleral/orbital vein vasculitis Obstruction of superior vena cava Carotid artery-cavernous sinus fistula Orbital varices Dural shunts Sturge-Weber syndrome
Idiopathic EVP indicates episcleral venous pressure.
may be due to the relatively small number of patients, which may explain the high incidence of glaucoma found by us. Every patient diagnosed was about 4% of the study group; however, although the study group was small, it does show a higher incidence of glaucoma in patients suffering from episcleritis. In this study, a higher proportion of patients with episcleritis were females than males (18/24 = 76%), similar to the proportion reported by Akpek et al (69%).10 The recurrence of episcleritis detected in one of the patients (1/5) in the current study is also similar to their documentation of 28%. An association between elevated EVP and glaucoma has been demonstrated previously.11,12 EVP was found to be higher in eyes with untreated primary open-angle glaucoma than in eyes with untreated normal-tension glaucoma, and EVP in both was higher than in control eyes.13 Further, evidence exists regarding the role of elevated EVP in glaucoma associated with the Sturge-Weber syndrome.14 Increased EVP may occur in episcleritis.15,16 Although glaucoma is a chronic slowly progressing disease, and episcleritis is an acute condition, we suspect that subclinical disease (“silent” episcleritis) may cause a chronic increase in EVP, leading to increased IOP, hence resulting in glaucoma. This is in contrast to a report in which a low facility of outflow in 2 patients with episcleritis and secondary open-angle glaucoma led to the conclusion that EVP was not the mechanism of glaucoma.17
CONCLUSIONS This study suggests an association between episcleritis and open-angle glaucoma. Because of the small number of patients in the present report, further large-scale prospective studies are needed to affirm and characterize the exact nature of this association.
TABLE 2. Relevant Episcleritis Signs in Patients Diagnosed With Episcleritis and Glaucoma
6 9 13
Volume 24, Number 9, December 2015
VF Defect
C/D ratio indicates cup-to-disc ratio; IOP, intraocular pressure; VF, visual field.
Patient No. Congestion
REFERENCES 1. Moster M, Ichhpujani P. Episcleral venous pressure and glaucoma. J Cur Glaucoma Pract. 2009;3:5–8. 2. Sainz de la Maza M, Molina N, Gonzalez-Gonzalez LA, et al. Clinical characteristics of a large cohort of patients with scleritis and episcleritis. Ophthalmology. 2012;119:43–50. 3. Ascher KW. The aqueous veins: physiological importance of the visible elimination of fluid. Am J Ophthalmol. 1942; 25:1147. 4. Ascher KW. Aqueous veins. Am J Ophthalmol. 1942;25:31. 5. Brubaker RF. Goldmanns’ equation and clinical measures of aqueous dynamics. Exp Eye Res. 2004;78:633–637.
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Glaucoma
Volume 24, Number 9, December 2015
6. Watson P. Diseases of the sclera and episclera. In: Tasman W, Jaeger EA, eds. Duane’s Ophthalmology. 15th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:30–31. Chapter 23. 7. Rhee DJ, Gupta M, Moncavage MB, et al. Idiopathic elevated episcleral venous pressure and open-angle glaucoma. Br J Ophthalmol. 2009;93:231–234. 8. Lammer R. Secondary open angle glaucoma with idiopathic episcleral venous pressure (Radius Maumenee syndrome): sinusotomy as a procedure of choice. Ophthalmologe. 2007;104:515–516. 9. Kollarits CR, Gaasterland D, Di Chiro G, et al. Management of patient with orbital varices, visual loss and ipsilateral glaucoma. Ophthalmic Surg. 1977;8:54–62. 10. Akpek EK, Uy HS, Christen W, et al. Severity of episcleritis and systemic disease association. Ophthalmology. 1999;106:729–731. 11. Minas TF, Podos SM. Familial glaucoma associated with elevated episcleral venous pressure. Arch Ophthalmol. 1968;80:202–208.
Copyright
r
Is Episcleritis Associated to Glaucoma?
12. Talusan ED, Fishbein SL, Schwartz B. Increased pressure of dilated episcleral veins with open-angle glaucoma without exophthalmos. Ophthalmology. 1983;90:257–265. 13. Selbach JM, Posielek K, Steuhl KP, et al. Episcleral venous pressure in untreated primary open-angle and normal-tension glaucoma. Ophthalmologica. 2005;219:357–361. 14. Shiau T, Armogan N, Yan DB, et al. The role of episcleral venous pressure in glaucoma associated with Sturge-Weber syndrome. JAAPOS. 2012;16:61–64. 15. Jorgensen JS, Payer H. Increased episcleral venous pressure in uveal effusion. Klin Mond Augenhelikd. 1989;195:14–16. 16. Jorgensen JS, Guthoff R. The role of episcleral venous pressure in the development of secondary glaucoma. Klin Mond Augenhelikd. 1988;193:471– 475. 17. Harbin TS Jr, Pollack IP. Glaucoma in episcleritis. Arch Ophthalmol. 1975;93:948–950.
2015 Wolters Kluwer Health, Inc. All rights reserved.
www.glaucomajournal.com |
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
671
