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An in-depth report on the causes, diagnosis, treatment, and prevention of glaucoma.
Glaucoma is one of the leading causes of blindness. Glaucoma can develop in anyone but people over age 60, those with a family history of glaucoma, and African-Americans are at especially high risk. Certain types of medical conditions, such as diabetes or extreme near-sightedness, can also increase the risk for glaucoma.
Glaucoma is a term used to describe several types of eye conditions that affect the optic nerve. In many cases, damage to the optic nerve is related to increased pressure in the eye, also known as intraocular pressure (IOP).
Primary Open-Angle Glaucoma
- Primary open-angle glaucoma is the most common type of glaucoma.
- In primary open-angle glaucoma, poorly functioning drainage channels prevent fluid from being released from the eye at a normal rate. This in turn causes a rise in intraocular pressure.
- People with primary open-angle glaucoma usually experience few or no symptoms until the later stages of the disease, when vision loss becomes apparent.
There is no cure for glaucoma, but treatment can help reduce intraocular pressure and prevent optic nerve damage and blindness. Glaucoma is usually treated with medications, although surgery may also be recommended for some patients.
Most glaucoma medications are usually given in the form of eye drops. Make sure your doctor or ophthalmologist explains to you the correct way to administer these drops.
A number of different medications are used to treat glaucoma. They include:
- Prostaglandins, such as latanoprost (Xalatan) and tafluprost (Zioptan)
- Beta-blockers, such as timolol (Timoptic, Betimol, generic)
- Carbonic anhydrase inhibitors, such as dorzolamide (Trusopt, generic) and brinzolamide (Azopt)
- Alpha agonists, such as apraclonidine (Iopidine, generic) and brimondidine (Alphagen, generic)
Glaucoma is a term used to describe several types of eye conditions that result in optic nerve damage.
In many cases, damage to the optic nerve isrelated toabnormally increased pressure in the eye, a condition known as high intraocular pressure (IOP) or ocular hypertension.
High intraocular pressure results from the buildup of aqueous humor, the clear fluid that circulates within and flows out of the front (anterior) chamber of the eye. Aqueous humor helps nourish the area around the colored iris and behind the cornea. To maintain normal eye pressure, the same amount of aqueous humor that is produced within the eye drains out from the eye.
Aqueous humor flows out through an open angle between the iris and cornea (the drainage angle.) It then passes through a sponge-like network of cells called the trabecular meshwork and exits the eye, eventually flowing into the bloodstream.
Excessive eye pressure occurs when problems arise with the drainage angle so that aqueous humor is trapped and builds up within the eye. Over time, high IOP can cause damage to the fibers of the optic nerve, resulting in the condition known as glaucoma. However, glaucoma can sometimes also develop in people who have normal eye pressure. Poor blood flow to the optic nerve may be another possible factor in causing optic nerve damage.
There are several types of glaucoma.
Open-Angle Glaucoma
Open-angle glaucoma (also called primary or chronic open-angle glaucoma) is the most common form of the disorder.
Open-angle glaucoma is essentially a plumbing problem. The drainage angle remains open, but tiny drainage channels in the trabecular meshwork pathway become clogged, causing the aqueous humor to flow out of the eye too slowly. The fluid continues to be produced but does not drain out efficiently. The result is increased ocular pressure. Open-angle glaucoma usually starts in one eye but eventually involves both eyes.
Normal-Tension Glaucoma. Eye pressure (intraocular pressure) is considered high when it is over 21 mm Hg (millimeters of mercury). Most people with glaucoma have a high IOP. However, some people develop optic nerve damage and vision loss even when their IOP is in a normal range (10 – 21 mm Hg). Until recently, this was called normal-tension, or low-tension, glaucoma. Now, it is not considered a separate type of glaucomabuta form of primary open angle glaucoma.
Closed-Angle Glaucoma
Closed-angle glaucoma (also called angle-closure or narrow-angle glaucoma) is less common than open-angle glaucoma in the U.S., but it constitutes about half of the world's glaucoma cases because of its higher prevalence among Asians.
Closed-angle glaucoma occurs when the iris is pushed against the lens closing off and blocking the drainage angle. The aqueous humor cannot drain out and eye pressure increases. The rise in pressure usually occurs very suddenly (a condition called acute closed-angle glaucoma). Less commonly, eye pressure can gradually increase over time (chronic closed-angle glaucoma).
Congenital Glaucoma
Congenital glaucoma, in which the eye's drainage canals fail to develop correctly, is present from birth. It is very rare, occurring in about 1 in 10,000 newborns. This is often an inherited condition and can usually be corrected with microsurgery.
Secondary Glaucoma
Secondary glaucoma is glaucoma caused by another disease or condition. Both open-angle glaucoma and closed-angle glaucoma can be secondary conditions.
Secondary glaucoma can result from medications, eye injuries or trauma, medical conditions such as diabetes, or inherited conditions. Two types of secondary glaucoma that have a genetic component are:
- Pseudoexfoliation (PEX) syndrome is marked by dandruff-like flakes that accumulate on the surface of the eye's lens. The material can clog the drainage angle of the eye and lead to build-up of intraocular pressure. PEX has a strong genetic component but other factors (possibly sunlight, an autoimmune response, or a slow virus) may be needed to trigger the disease.
- Pigmentary Glaucoma starts with a condition called pigment dispersion syndrome, an inherited condition in which granules of pigment (the substance that colors the iris) flake off into the intraocular fluid. These fragments clog the trabecular meshwork and can increase intraocular pressure.
Causes of Open-Angle Glaucoma
Doctors don't know exactly what causes the inefficient drainage process associated with primary open-angle glaucoma. The trapped aqueous humor builds up slowly over time, causing increased intraocular pressure and, eventually, damage to the optic nerve. But other factors, such as optic nerve bood supply and nutrition, may also produce optic nerve damage.
Research suggests that glaucoma in people with normal eye pressure (so-called "normal tension glaucoma) may also be due in part to poor nutrition and blood flow to the optic nerve. Normal-tension glaucoma is a form of open-angle glaucoma.
Causes of Closed-Angle Glaucoma
People with acute closed-angle glaucoma often have a structural defect that produces a narrow angle between the iris and cornea where the aqueous humor circulates. This structural defect makes them more susceptible to developing closed-angle glaucoma.
In acute closed-angle glaucoma, conditions that dilate (widen) the pupils may cause this shallow angle to suddenly close. Such conditions may include certain drugs (antihistamines, tricyclic antidepressants, some asthma and anti-seizure medications), darkness or dim light, and emotional stress.
Causes of Secondary Glaucoma
When glaucoma is caused by other diseases or conditions, it is known as secondary glaucoma.
Medical Conditions. A number of diseases can contribute to the development of secondary open-angle or closed-angle glaucoma:
- Diseases that affect blood flow to the optic nerve (such as diabetes, high blood pressure, and migraine)
- Hypothyroidism (underactive thyroid gland)
- Sleep apnea
- Physical injury to the eye or previous eye surgery
- Extreme nearsightedness (myopia)
- Other disorders, including leukemia, sickle cell anemia, and some forms of arthritis
Medications. Corticosteroids, commonly called steroids, are a type of drug that has multiple effects on the trabecular meshwork. Steroids come in eyedrop, pill, and inhaled forms. The risks for glaucoma are greatest with corticosteroid eyedrops. However, all types of corticosteroids can increase glaucoma risk when they are taken in high doses or for prolonged periods of time. Certain types of anti-seizure medications and sulfa drugs can cause temporary or permanent secondary glaucoma.
Risk Factors
About 4 million Americans have open-angle glaucoma, the most common type of glaucoma (accounting for about 90% of all glaucoma cases). Half of these people are unaware they have glaucoma because the condition causes no pain or visual changes in its early stages.
Risk factors for glaucoma include:
Increased Intraocular Pressure (IOP)
Elevated intraocular pressure is associated with increased risk of optic nerve damage and glaucoma.
The risk of developing glaucoma increases with age. Everyone over age 60 is at risk of developing glaucoma. People in certain racial or ethnic groups are at higher risk of developing glaucoma at younger ages.
Race and Ethnicity
Compared to Caucasians, African-Americans are 5 times more likely to develop glaucoma, and 4 times more likely to become blind because of it. African-Americans are also much more likely to develop glaucoma at younger ages. For African-Americans, the risk of developing glaucoma begins at age 40. Hispanic Americans are also at increased risk, especially after age 60.
People of Asian descent have a slightly greater risk than other racial groups of developing closed-angle glaucoma. Normal-tension glaucoma is very common in people of Japanese ancestry.
Family History
Glaucoma tends to run in families. This is especially true for primary open-angle glaucoma. People with family histories of glaucoma are also more likely to already have some vision loss when they are first diagnosed with glaucoma.
Medical Conditions
Diabetes and hypothyroidism (underactive thyroid) are the main medical conditions associated with increased glaucoma risk. High blood pressure and migraine headaches are also risk factors. Certain eye conditions, including nearsightedness (myopia), and previous eye surgery also boost risk.
Symptoms of Open-Angle Glaucoma
Open-angle glaucoma is a chronic condition that develops slowly over many years. In its earliest stages, it produces no pain, visual changes, or other symptoms. As the condition progresses and the optic nerve becomes damaged, the following symptoms appear in one or both eyes:
- Peripheral vision (vision from the side of the eyes) gradually decreases. Patients develop "tunnel vision," the ability to see only straight ahead.
- Eventually, straight-ahead vision decreases.
If left untreated, blindness results.
Symptoms of Closed-Angle Glaucoma
In acute closed-angle glaucoma, the pressure inside the eye increases quickly, and the symptoms are dramatic. Intense pain in the eyebrow area and blurred vision develop usually in one eye, and the patient often feels like the eye will burst (although it won't). The eyeoften reddens. A person may see rainbow-like halos around lights. Sometimes nausea and vomiting occur. These symptoms may occur on and off and not appear as a full attack. In either case, they indicate a medical emergency. In chronic closed-angle glaucoma, the process is gradual and painless.
Symptoms of Congenital Glaucoma
Although congenital glaucoma is usually present at birth, symptoms generally don't develop in the infant for a few months. If parents notice that an infant's eyes are enlarging, becoming cloudy, often watering, or tending to close in the presence of light, they should have an ophthalmologist examine the child's eyes. Port-wine stains on a baby's face could indicate Sturge-Weber syndrome, a disorder that occasionally causes glaucoma.
Early diagnosis is the key to successful treatment of glaucoma and prevention of blindness. Because chronic glaucoma has no warning symptoms, half of patients are unaware they have the condition.
Although pressure measurements are a necessary part of the complete eye exam, they are no longer considered sufficient to screen for glaucoma, because some people with glaucoma have low pressures and many with high pressure don't have glaucoma. As a result, doctors should always inspect the optic nerve through an ophthalmoscope. If the nerve is unusually indented, pale or asymmetric, glaucoma should be suspected even if the IOP is normal. A diagnosis of glaucoma requires both an abnormal appearance of the optic nerve and a visual field defect in at least one eye.
In other words, a diagnosis of glaucoma does not depend solely on the presence of increased pressure within the eye. Optic nerve damage or a strong indication of damage must also be present.
Recommendations for Glaucoma Screening
There has been debate about the relative benefits and risks of routine glaucoma screening in adults. Glaucoma screening can help identify signs of increased intraocular pressure (IOP) and the early stages of primary open-angle glaucoma (POAG). However, treatment of IOP and early POAG can potentially result in harmful effects, such as eye irritation and increased risk for cataracts. Because of this uncertainty, the United States Preventive Services Task Force has not found sufficient evidence to recommend for or against routine screening for glaucoma in adults.
In contrast, the American Academy of Ophthalmology strongly supports glaucoma screening, with the following recommendations:
- Everyone over age 65 and African-Americans over 40 years old should have periodic eye exams, including tests for glaucoma, every other year.
- African-Americans ages 20 - 39 should have eye examinations every 3 - 5 years.
- Other people at higher risk (people with diabetes, history of eye injuries, a family history of glaucoma, or those taking corticosteroid medications) should have eye examinations every year after age 35.
- People with known glaucoma should have frequent examinations to check peripheral vision and to be sure treatment is maintaining a safe eye pressure. After such examinations, the ophthalmologist will assess current treatment and make necessary adjustments.
Tonometry and Pressure Tests
Doctors determine IOP using a painless procedure called tonometry, which measures the force necessary to make an indentation in the eye. They may use a tonometer (small smooth instrument). There are several methods, and the doctor may apply anesthetic eye drops to first numb the eye:
- The applanation (Goldman) method uses a blue-light filter and slit-lamp, which is moved forward toward the patient's face.
- Electronic indentation tonometry uses an electronic pen with a digital read-out.
- The noncontact approach does not use a tonometer. It applies a puff of air to measure the force needed to indent the eye.
- In the Schiotz method, the doctor presses very lightly against the eye with the tonometer. IOP is measured by the weight needed to flatten the cornea. This method is not considered as accurate as the others.
In general, normal IOP is usually maintained at measurements of 10 - 21 mmHg. Intraocular pressure over 21 mmHg indicates a potential problem. The test is not completely accurate, however. Only about 10% of people with IOP levels of 21 - 30 mmHg will actually develop glaucoma and optic nerve damage. On the other hand, many people with glaucoma have normal pressure, at least for part of the time.
Measurement of Cornea Thickness (Pachymetry)
Corneal thickness is an important indicator of disease progression in patients with elevated IOP. Corneal pachymery is a test for measuring the thickness of the cornea. The doctor first applies numbing drops to the eye and then uses an ultrasonic wave instrument (pachymeter) to measure corneal thickness.
Tests for Optic Nerve Damage (Ophthalmoscopy)
To check for damage in the optic nerve, the doctor first uses eye drops to dilate (widen) the pupils and then examines the eyes with a magnifying lens instrument such as an ophthalmoscope, which has a light on one end.
Damaged nerve fibers may be indicated by:
- An asymmetrical or elongated cupped optic nerve. (The cup of the optic disc is the center portion, which enlarges as nerve damage progresses.)
- The optic nerve color may be pale or an unhealthy pink.
Visual Field Tests
The doctor will conduct tests of the visual fields (the areas that the patient can see). In most people with glaucoma, the first areas to become noticeably impaired are the peripheral visual fields (areas of sight that are not directly in front of a person but around the edges, or periphery).
Tests for Closed-Angle Glaucoma
Using an instrument called a gonioscope, ophthalmologists can inspect the front of the eyes and assess the drainage angle between the cornea and the iris and the channels in the trabecular meshwork. This test can help differentiate between closed- and open-angle glaucoma.
Glaucoma cannot be cured, but treatment may help delay disease progression. Most treatments for glaucoma aim to reduce ocular pressure and its fluctuations. Early treatment with medications, surgery, or both can nearly always maintain safe pressure of the aqueous humor, thus preventing optic nerve damage and blindness.
Decision to Start Treatment
Many people have high IOP but no sign of nerve damage. Over the course of 20 years, only 10 - 30% of these people will actually develop glaucoma. Nevertheless, once glaucoma has destroyed optic nerve fibers, no treatment can reverse the damage.
However, not allpeople with high eye pressuredevelop optic nerve damage and serious vision problems. Nor does treatment prevent progression in some patients. Medications used for glaucoma also can carry side effects and risks.
Some doctors recommend delaying treatment for people with borderline or early signs of glaucoma until they begin to show risk factors for progressive disease and vision loss (thinner corneas, larger cup to optic disc ratio, older age, and rising pressure).
Considerations for Drug Treatments
There are many different drugs for treating glaucoma. The drugs reduce pressure in the eye but all have a number of side effects that affect other parts of the body. Occasionally, some side effects can be severe.
Many of the drugs used for glaucoma can interact with common medications for other conditions. And, many patients require two or more drugs. If your doctor prescribes more than one medication, be sure you understand when you should take each drug and how long you should wait between applying each drop. Ask your doctor to write down a schedule for you. Let your doctor know if you experience any side effects. To prevent optic nerve damage, it is very important to take your medication on a regular basis and not skip doses.
Most glaucoma medications are given as eye drops. These drugs decrease eye pressure by reducing the production of aqueous humor or by helping the fluid drain more efficiently:
- Prostaglandin-like drugs are generally the first-line treatment for glaucoma. They include latanoprost (Xalantan), bimatroprost (Lumigan), travaprost (Travatan), and tafluprost (Zioptan).
- Beta-blockers such as timolol (Timoptic, generic) and other brands are a second choice.
- Alpha agonists, carbonic anhydrase inhibitors (CAIs), and miotics are other drug therapies.
- Some drugs are available are available as combination eye drops. For example, Cosopt combines the beta blocker timolol and CAI dorzolamide. Combigan combines timolol and the alpha agonist brimonidine.
Treating Pregnant Patients. Considerations for a pregnant woman with glaucoma can be complicated. All of the drugs used for glaucoma are absorbed by the body, cross the placenta, and are excreted in breast milk. Many have effects that can interfere with or adversely affect pregnancy.
Women should discuss going off medication, particularly during the first trimester, and be monitored during that time for increasing eye pressure. IOP tends to drop during pregnancy, although usually not to a significant degree. In addition, changes in IOP and visual loss vary greatly. Some women have no IOP change or visual loss during pregnancy, while others may experience an increase in IOP or worsening of visual loss. Your ophthalmologist must carefully consider your individual case and talk with you about the risks and benefits of continuing glaucoma medication during pregnancy. If women need to take medications, they should try to take the lowest effective dose possible.
Considerations for Surgery
The goal of standard glaucoma surgery is to reduce pressure in the eye by increasing the outflow of the aqueous fluid. Two methods are commonly used:
- Filtration surgery (trabeculectomy). This uses standard surgical instruments to open a passage in the eye for draining fluid.
- Laser trabeculoplasty. This procedure uses a laser to burn tiny holes in the drainage area.
In general, surgery is used for patients who have not been helped by medications. However, in some cases doctors may recommend surgery before or in place of drug treatment. Surgery does not cure glaucoma, and over half of patients will need medication or a repeat surgical procedure within 2 - 5 years.
Nearly all glaucoma medications are prescribed to reduce eye pressure. They generally work by reducing the production of aqueous humor and increasing fluid outflow (drainage). In most cases, these drugs are taken as eye drops. If drops alone do not work, your doctor may also prescribe an oral medication (pill).
Prostaglandins are hormone-like substances that help widen blood vessels. Drugs that mimic natural prostaglandins increase the drainage of aqueous humor to help reduce intraocular pressure. Prostaglandin-like drugs are the first-line treatment for glaucoma.
Latanoprost (Xalatan, generic) is the standard brand. Latanoprost was the first prostaglandin to be approved as first-line treatment for elevated eye pressure. Three newer prostaglandins are travoprost (Travatan), bimatoprost (Lumigan),and tafluprost (Zioptan). These drugs are used to reduce eye pressure in patients with open-angle glaucoma and high ocular pressure.
Side effects include itching, burning, and eye redness. All of these drugs may permanently change eye color from blue or green to brown.
Topical beta-blockers lower the pressure inside the eye by inhibiting the production of aqueous humor.
Timolol (Timoptic, Betimol, generic) is the standard brand. Other examples of beta-blockers used for glaucoma treatment are levobunolol (Betagan, generic), carteolol (Ocupress, generic), metipranolol (OptiPranolol, generic), and betaxolol (Betoptic, generic).
After a beta-blocker is administered, only a tiny amount of the drug is absorbed by the cornea. Most of it enters in the bloodstream. These drugs, therefore, can cause side effects in parts of the body other than the eyes ("systemic" side effects). Beta-blockers may:
- Cause reduced sexual drive, fatigue, depression, anxiety, and breathing difficulties.
- Lower heart rate and reduce blood pressure.
- Worsen severe asthma or other lung diseases.
- Cause a sudden rise in eye pressure, particularly if a patient has switched to a beta-blocker from another type of glaucoma medication. It is important that IOP be checked shortly after the other drug has been withdrawn.
- When beta-blockers are used to treat one eye, the other (contralateral) eye also experiences a lesser, but still significant reduction in IOP.
Topical beta-blockers can interact with oral medications, such as other beta-blockers, calcium-channel blockers, or the antiarrhythmic drug quinidine. People with diabetes who take insulin or hypoglycemic medications should be aware that beta-blocker side effects may mask the symptoms of hypoglycemia (low blood sugar).
Carbonic Anhydrase Inhibitors
Carbonic anhydrase inhibitors (CAIs) are used for glaucoma when other drugs do not work. They may be combined with other medications.
In addition to reducing aqueous humor production, CAIs may improve blood flow in the retina and optic nerve (beta-blockers do not). Improving blood flow can keep the disease from getting worse.
CAIs are available in the following forms:
- Eye-drop CAIs include dorzolamide (Trusopt, generic) and brinzolamide (Azopt). Side effects may include stinging in the eye, watery or dry eyes, or bitter taste. Brinzolamide is a newer medication that may cause less stinging than dorzolamide.
- Oral forms include acetazolamide (Diamox, generic) and methazolamide (Neptazane, generic). Although pill forms are more effective than eye drops, they have significantly more side effects and are rarely used for long-term treatment. Unpleasant side effects include frequent urination, stomach problems, and tingling in fingers and toes. People who are allergic to sulfa drugs or who have a history of kidney stones should not use these drugs. CAIs can also produce a toxic reaction when taken with large doses of aspirin.
Alpha Agonists
Alpha agonists, also called adrenergic agonists, reduce the production of aqueous humor and increase drainage. They include apraclonidine (Iopidine, generic), brimonidine (Alphagan, generic), and dipivefrin (Propine).
The most common side effects are dry mouth, nose, and eyes, and blurred vision. Alpha agonists may also trigger an allergic reaction that causes red and itching eyes and lids.
Miotics, also called cholinergic agonists, narrow the iris muscles and constrict the pupil. This action pulls the iris away from the trabecular meshwork and allows the aqueous humor to flow out through the drainage channels, reducing the pressure inside the front of the eye.
Pilocarpine (Isoptocarpine, other brands, generic) was the most widely used anti-glaucoma drug before timolol was introduced. It is the preferred miotic. However, it has to be taken several times a day and many people have difficulty complying with this regimen. Carbachol (Isopto) is another miotic.
Miotics narrow the pupil and so decrease the amount of light that can enter the eye. This can cause dim vision and night blindness. Patients who take miotics often complain of difficulty seeing in darkened rooms or driving at night. Patients who have cataracts in addition to glaucoma may have particular problems with worsened vision.
Managing Drug Regimens
Many patients skip doses of their glaucoma medications, sometimes because of side effects and sometimes because of confusing or time-consuming regimens. Skipping even a few doses can greatly increase the risk of visual loss. It is essential that you inform your doctor ifyou are not regularly takingyour medication. Otherwise,your doctor may increase the dosage, thereby causing unwelcome side effects.
Patients who do not regularly take their glaucoma medication are at high risk for blindness. If you have problems taking your medications or sticking to the dosing regimen, talk with your doctor.
Hints for Managing a Regimen.
- Pharmaceutical manufacturers use colored tops, yellow for timolol, for example, and green for pilocarpine, to help prevent mix-ups. Creating a chart scheduling each drug by color can be helpful.
- Small electronic timers are available that will signal times for taking the medications. The timing of these combinations is important.
- Some patients may be candidates for single medications that combine two drugs, such as Cosopt, which contains both dorzolamide and timolol. This medication requires only one drop twice per day. Patients who need additional glaucoma drugs, however, will need to take these two drugs separately.
- When using any drug for a long period of time, side effects are a potential problem. If they become severe, ask yourdoctor about reducing the dosage or trying other drugs.
Administering Eye Drops. A common reason that glaucoma medicine does not work is that patients do not take it correctly. Patients should ask the ophthalmologist to watch while they place the drops in their own eyes to make sure they are doing it correctly. The following are some recommended steps:
- If you use both ointments and eye drops, take the eye drops first.
- Wash your hands before applying eye drops.
- Hold the bottle upside down.
- Tilt your head back and, with one hand, pull the lower eyelid down to form a pocket.
- With your other hand, hold the bottle as close as possible to your eye. Don't let the bottle directly touch your eye or eyelid.
- After you have placed the drop, close your eye or press your index finger against the corner of the eye near your nose. Gently move the lower lid upward until the eye is closed. Keep your eye closed for at least 1 minute. This prevents the drop from draining out.
- Wait at least 5 minutes before applying another drop or a different medication
Drug Therapy for Acute Closed-Angle Glaucoma
Acute closed-angle glaucoma is an emergency situation. Doctors may administer a combination of two or more medications to reduce eye pressure quickly before it can damage the optic nerve and cause visual loss. Apraclonidine (Iopidine, generic) is a powerful drug used before and after laser surgery to prevent an increase in fluid pressure and is more effective than other medications. In addition to standard drugs, doctors may also administer glycerin by mouth or mannitol or acetazolamide intravenously. Surgery is almost always performed once the pressure is reduced.
If medications do not control eye pressure, or if they create severe side effects, surgery may be necessary. The standard procedures are usually one of the following:
- Laser surgery (trabeculoplasty). This procedure partially opens the drainage area. It does not reduce pressure as much as filtering surgery (trabeculectomy) but it has fewer adverse effects.
- Filtration surgery (trabeculectomy). This conventional surgery procedure opens the full thickness of the drainage area.
- Newer surgical techniquesinclude canaloplasty but it is not yet clear how they compare to standard methods in terms of safety and long-term reduction of IOP.
Laser Surgery (Trabeculoplasty)
Laser trabeculoplasty is used to treat open-angle glaucoma. It involves the following steps:
- The procedure uses a laser to burn 80 - 100 tiny holes in the drainage area. The two main types of surgery are argon laser trabeculoplasty (ALT) and selective laser trabeculloplasty (SLT).
- A tiny scar forms, which increases fluid outflow.
- The procedure is performed on an outpatient basis, takes 15 minutes, causes almost no discomfort, and has very few complications.
Laser surgery is not a cure. Although it reduces intraocular pressure, patients still need to take medications every day. Within 2 - 5 years eye pressure increases and most patients require either additional surgery or new medications.
Filtration Surgery (Trabeculectomy)
Filtration surgery has been used for more than 100 years with only minor modifications. It uses conventional surgical techniques known as full-thickness filtering surgery or guarded filtering surgery (trabeculectomy).
- The surgeon creates a sclerostomy, a passage in the sclera (the white part of the eye) for draining excess eye fluid.
- A flap is created that allows fluid to escape without deflating the eyeball.
- The surgeon may also remove a tiny piece of the iris (called an iridectomy) so that fluid can flow backward into the eye.
- A small bubble called a bleb nearly always forms over the opening, which is a sign that fluid is draining out. Although surgeons aim for a thick bleb, which poses less risk than a thin one for later leakage, the ideal operation would have no bleb at all.
- The procedure is usually performed on an outpatient basis but some patients may need to stay overnight in the hospital.
For many patients, trabeculectomy eliminates the need for medications. In some patients, eye pressure eventually increases again and patients may need to go back on medication or undergo a second trabeculectomy.
A newer instrument called a trabectome allows for a less invasive type of trabeculectomy surgery. The trabectome procedure uses an electrosurgical pulse to remove a small section of the trabecular meshwork.
Eye doctors are also developing other surgical approaches as alternatives to trabeculectomy. They include canaloplasty,a minimally invasive procedure that uses a small microcatheter tube to hold open the Schlemm's canal.
Side Effects. Many of the serious side effects or complications that occur with filtration surgery involve blebs (blister-like bumps).
- Bleb Leaks and Infections. Blebs, particularly thin ones, commonly leak. Leakage can occur early on or sometimes as late as months or years after surgery. Untreated, leaks can be serious and even cause blindness. Surgical repair is the most effective way of managing leaking blebs, although drug therapies, pressure patching, and other nonsurgical techniques may be tried first. Due to the dangers of leaking blebs, doctors recommend lifelong monitoring after surgery.
- Scarring. Insome cases, scars form around the incision, closing up the drainage channels and causing pressure to rebuild. Scarring is a particular problem in young patients, African-Americans, and patients who have taken multiple drugs, have had an inflammatory disease, or have had cataract surgery. Releasing the surgical stitches used in the procedure may help prevent scarring and pressure build-up. A second procedure called bleb needling can sometimes open up the scarred area and restore drainage. With this technique, the tip of a very fine hypodermic needle is used to carefully cut loose the particles closing off the drainage area. Drugs may also be used to prevent scarring.
- Cataracts. The procedure significantly increases the risk for the later development of cataracts.
Drainage Implants (Tube Shunts)
Drainage implants, also known as tube shunts or aqueous shunts, may be used to drain fluid if patients have not been helped by laser or filtration surgery. They are also used to treat children with glaucoma.
The procedure is performed in an operating room using a local anesthetic.The procedureinvolves:
- An implant, most commonly a 1/2 inch silicone tube, is inserted into the eye's front (anterior) chamber.
- The tube drains the fluid onto a tiny plate that is sewn to the side of the eye.
- Fluid collects on the plate and then is absorbed by the tissues in the eye.
- The patient wears an eye patch and shield until the first post-operative visit. Healing time takes about 6- 8 weeks.
Complications are uncommon but may include very low eye pressure (hypotony), drooping eyelid, double vision, and retinal detachment. Occasionally the tube falls out and needs to be replaced.
Surgery for Acute Closed-Angle Glaucoma
Acute closed-angle glaucoma is an emergency situation that requires immediate medical attention. Doctors will first try to quickly reduce eye pressure using medications, and then perform surgery.
Laser iridotomy is the standard procedure. It uses a laser to make a small hole in the iris to allow the aqueous humor to flow out more freely. In some cases, conventional surgery, called peripheral iridectomy, may be performed. It involves surgically removing a small piece of the iris.
Laser iridotomy almost never requires hospitalization, and postsurgical treatment includes only aspirin and eye drops. It has almost completely replaced conventional surgery, which requires anesthesia and hospitalization.
Vision will be blurred, and recovery can take 4 - 8 weeks. Following surgery, patients can usually safely use previously restricted anticholinergic medications, such as antihistamines and certain antidepressants. In many cases, doctors recommend performing an iridotomy on the other eye at a later date.
Treatment for Patients with both Glaucoma and Cataracts
There are various approaches to treating patients who have both cataracts and glaucoma. Your doctor will recommend an approach on your individual condition. Some options include:
- For patients who have mild glaucoma, the doctor may recommend performing only cataract surgery and controlling the glaucoma with medication.
- For patients who have moderate-to-severe glaucoma, the traditional approach has been combination cataract-glaucoma surgery (phacotrabeculectomy). This combination surgery involves performing both trabeculectomy (glaucoma filtration surgery) and phacomulsification (cataract extraction).
- New techniques are being developed. Approved in 2012, the iStent is a tiny tube that is implanted in the eye during cataract surgery. It is used in place of trabeculectomy. The stent helps improve the outflow of aqueous humor and lower intraocular pressure (IOP).
Lifestyle Changes
Some evidence suggests that regular exercise may modestly reduce eye pressure in patients with open-angle glaucoma. Exercise has no effect on closed-angle glaucoma.
Exercise can be dangerous for patients who have pigmentary glaucoma. Vigorous high-impact exercise causes pigment to be released from the iris, which increases eye pressure.
Glaucoma patients should avoid yoga and other exercises that involve head-down or inverted positions. Talk with your doctor about an appropriate exercise program.
Antioxidants in Foods and Supplements. Diet most likely plays very little role in glaucoma. There has been no definitive evidence for an association between important nutrients associated with protection against other eye disorders, including vitamins C, E, A, and carotenoids.
Caffeine. Some studies have shown that large amounts of caffeine drunk in a short period of time can elevate eye pressure for up to 3 hours.
Fluids. Drinking large amounts (a quart or more) of any liquid within a short time, about 30 minutes, appears to increase pressure. Patients with glaucoma should have plenty of fluids, but they should drink them in small amounts over throughout theday.
Glaucoma can cause the eyes to be very sensitive to light and glare and glaucoma medications can worsen this problem. Sunglasses help provide relief and can also block the harmful ultraviolet (UV) radiation that is damaging to eyes Look for sunglasses whose product labels state they block 99 – 100% of UV light (which is equivalent to UV absorption up to 400 nm).
Polarized and mirror-coated lenses do not offer any protection against UV radiation. Colored tints, such as blue light-blocking lenses (which are usually amber in color), do not provide UV protection.
Herbs and Supplements
Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.
A number of herbal and nontraditional remedies have been advertised as glaucoma remedies. A few studies have reported that the herbal remedy ginkgo biloba may have properties that offer benefits to patients with glaucoma, including increasing blood flow in the eye without altering overall blood pressure, heart rate, or intraocular pressure. More research is needed. There is no evidence that bilberry, another popular herbal remedy for eye disorders, is effective in preventing or treating glaucoma.
Marijuana can lower ocular pressure, but only for a few hours, and it is no more effective than prescription medications. Due to its lack of long-term effectiveness, and mood-altering side effects, marijuana is not recommended for glaucoma treatment.
- www.glaucoma.org -- Glaucoma Research Foundation
- www.nei.nih.gov -- National Eye Institute
- www.glaucomafoundation.org -- The Glaucoma Foundation
- www.aao.org -- American Academy of Ophthalmology
- www.americanglaucomasociety.net -- American Glaucoma Society
- www.lighthouse.org -- Lighthouse International
American Academy of Ophthalmology. Primary Angle Closure: Preferred Practice Pattern. Updated October 2010.
American Academy of Ophthalmology. Primary Open-Angle Glaucoma: Preferred Practice Pattern. Updated October 2010.
American Academy of Ophthalmology. Primary Open-Angle Glaucoma Suspect: Preferred Practice Pattern. Updated October 2010.
Aptel F, Cucherat M, Denis P. Efficacy and tolerability of prostaglandin analogs: a meta-analysis of randomized controlled clinical trials. J Glaucoma. 2008 Dec;17(8):667-73.
Boland MV, Ervin AM, Friedman DS, Jampel HD, Hawkins BS, Vollenweider D, et al. Comparative effectiveness of treatments for open-angle glaucoma: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2013 Feb 19;158(4):271-9.
Cheng JW, Cai JP, Li Y, Wei RL. A meta-analysis of topical prostaglandin analogs in the treatment of chronic angle-closure glaucoma. J Glaucoma. 2009 Dec;18(9):652-7.
Cheng JW, Wei RL, Cai JP, Li Y. Efficacy and tolerability of nonpenetrating filtering surgery with and without implant in treatment of open angle glaucoma: a quantitative evaluation of the evidence. J Glaucoma. 2009 Mar;18(3):233-7.
Gedde SJ, Heuer DK, Parrish RK 2nd; Tube Versus Trabeculectomy Study Group. Review of results from the Tube Versus Trabeculectomy Study. Curr Opin Ophthalmol. 2010 Mar;21(2):123-8..
Hernández R, Rabindranath K, Fraser C, Vale L, Blanco AA, Burr JM; OAG Screening Project Group. Screening for open angle glaucoma: systematic review of cost-effectiveness studies. J Glaucoma. 2008 Apr-May;17(3):159-68.
Higginbotham EJ. Managing glaucoma during pregnancy. JAMA. 2006 Sep 13;296(10):1284-5.
Hollands H, Johnson D, Hollands S, Simel DL, Jinapriya D, Sharma S. Do findings on routine examination identify patients at risk for primary open-angle glaucoma? The rational clinical examination systematic review. JAMA. 2013 May 15;309(19):2035-42.
Jampel H. American glaucoma society position statement: marijuana and the treatment of glaucoma. J Glaucoma. 2010 Feb;19(2):75-6.
King A, Azuara-Blanco A, Tuulonen A. Glaucoma. BMJ. 2013 Jun 11;346:f3518.
Kwon YH, Fingert JH, Kuehn MH, Alward WL. Primary open-angle glaucoma. N Engl J Med. 2009 Mar 12;360(11):1113-24.
Leske MC, Heijl A, Hyman L, Bengtsson B, Dong L, Yang Z; EMGT Group. Predictors of long-term progression in the early manifest glaucoma trial. Ophthalmology. 2007 Nov;114(11):1965-72. Epub 2007 Jul 12.
Moyer, V.A., U.S. Preventive Services Task Force. Screening for Glaucoma: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013 Jul 9. [Epub ahead of print]
Pasquale LR, Kang JH. Lifestyle, nutrition, and glaucoma. J Glaucoma. 2009 Aug;18(6):423-8.
Quigley HA. Glaucoma. Lancet. 2011 Apr 16;377(9774):1367-77. Epub 2011 Mar 30.
Rivera JL, Bell NP, Feldman RM. Risk factors for primary open angle glaucoma progression: what we know and what we need to know. Curr Opin Ophthalmol. 2008 Mar;19(2):102-6.
Rolim de Moura C, Paranhos A Jr, Wormald R. Laser trabeculoplasty for open angle glaucoma. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD003919.
Stewart WC, Konstas AG, Nelson LA, Kruft B. Meta-analysis of 24-hour intraocular pressure studies evaluating the efficacy of glaucoma medicines. Ophthalmology. 2008 Jul;115(7):1117-1122.e1. Epub 2008 Feb 20.
Vizzeri G, Weinreb RN. Cataract surgery and glaucoma. Curr Opin Ophthalmol. 2010 Jan;21(1):20-4.
Review Date: 9/26/2013�
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.


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Iconology Classes Study Early Christian Artifacts at NYC Museums
March 23, 2012 • Off-campus Event • Faculty News • Deborah (Malacky) Belonick
Students enrolled in the Liturgical Arts course at St. Vladimir's took a field trip to New York City this past Friday to view two special exhibits of early Christian artifacts: "Transition to Christianity: Art of Late Antiquity, 3rd–7th Century AD" at the Onassis Cultural Center NY; and "Byzantium and Islam: Age of Transition" at The Metropolitan Museum of Art. There, under the tutelage of their teacher, Richard Schneider, visiting professor of Liturgical Arts at the seminary, they explored the early cultures in which Christianity grew, and they examined the stunning artifacts that emerged from them.
As they viewed coins, crosses, bracelets, earrings, statuary, dishware, fragments from Christian temples, and even household floor tiles, the students began to understand how early believers "interpreted" and "reinterpreted" common objects to proclaim their faith in Jesus Christ. Thus, they saw how the pagan statue of the Protective Shepherd began to be viewed instead as Jesus, the Good Shepherd (John 10:11) and how the icon of Christ usurped the place of the emperor's visage on Byzantine coins. In short, Christian began to "re-read" everyday objects around them in the light of Christ and to re-purpose material objects to exhibit their beliefs.
"St. Vladimir's Seminary is highly privileged to be in a location so near the great metropolis, where such outstanding special exhibitions are a relatively frequent occurrence," said Professor Schneider. "This outing allowed our community to have some contact with the 'real things' of our Christian material culture, and to understand the way we use that materiality to create powerful expressions of the faith.
" 'Understanding' means 'grasp,' and in many ways what we construct and the objects in whose midst we conduct our prayer have a lot to do with molding that grasp—our art tells us what we understand," he explained.
"Rather than the word 'transition' in the title of these exhibits," he concluded, "I would substitute the word 'interpretation' for the first exhibit, and 'interaction' for the second. Indeed, the material world is not evil, but is a goodly canvas which we must re-make through using our inventive minds, seeing through 'the eyes of our heart,' as it says in Ephesians 1:18, in order to be Orthodox co-creators with God."
Joining the group for a time was Dr. Helen C. Evans, the Mary and Michael Jaharis Curator of Byzantine Art, Department of Medieval Art and The Cloisters at The Metropolitan Museum of Art, New York. The group was privileged with her presence for a while in the "Byzantium and Islam" exhibit. Also joining the group were several members of the seminary campus community, and Dn. Evan Freeman, an alumnus ('09) currently enrolled in the seminary's Th.M. program, who has studied under Professor Schneider and who helped guide the group through the exhibits.
St. Vladimir's remains almost unique among major Orthodox seminaries in having a very full calendar of offerings in Orthodox "iconology," the field of study grounded in Christ's Incarnation and referring to the material world turned into theological vision. Besides students enrolled in the seminary degree programs, Professor Schneider's courses attract many people from surrounding areas.
Each year, the seminary offers a basic course—Liturgical Art—which introduces the fundamentals of iconological "visual reading," that is, how to acquire skills in seeing and interpreting with nuance and depth. Each year also, an advanced iconology course is offered; this spring the topic is "The Iconology of Orthodox Architecture: Designing Buildings and Iconography for Liturgy." In spring 2013 the advanced course will be "Orthodox Iconology in the Context of General Culture." In that course students will have the opportunity to evaluate many para-liturgical uses of Orthodox iconography in situations and contexts not limited to church and liturgy: placed in houses (and cars), worn on persons, kept as souvenirs of pilgrimage, even used in conjunction with state and military symbols (Byzantine coinage, for example); and a major topic will be the role(s) the church building plays in the total city-scape.
"As always, students will be encouraged to see Orthodox iconography as a living, creative art-language, which, upon observation, certainly has manifested itself in different ways in different cultures, instead of as a static, fossilized form," stated Professor Schneider.
View details about Professor Richard Schneider's courses in our 2011–2012 Academic Catalog, here.
View details about the "Transition to Christianity: Art of Late Antiquity, 3rd-7th Century AD" special exhibit at the Onassis Cultural Center NY, running December 7, 2011–May 14, 2012, here.
View details about the "Byzantium and Islam: Age of Transition" exhibit at The Metropolitan Museum of Art, running March 14–July 8, 2012, here.

subset: commoncrawl


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September 19 College Football Recap
Sunday, September 19, 2010
Here's a brief look at the highlights of the third week of the college football season - the Top-25 made a bid for no upsets, but if you stayed up late on Saturday, you saw Arizona and UCLA and Pac-10 pull off the only upsets (in the rankings) of the week. The rankings used in this recap are the AP rankings from prior to the games.
Andy Dalton, TCU (21-of-23, 267 yards, 2 TDs, 0 INT)
Colin Kaepernick, Nevada (10-of-15, 181 yards, 2 TDs, 0 INT)
Ryan Mallett, Arkansas (21-of-33, 380 yards, 3 TDs, 0 INT)
Kyle Padron, SMU (19-of-34, 280 yards, 4 TDs, 0 INT)
Russell Wilson, North Carolina State (26-of-40, 333 yards, 3 TDs, 0 INT)
Zac Dysert, Miami, Ohio (18-of-22, 231 yards, 3 TDs, 0 INT)
Bryan Ellis, UAB (23-of-37, 360 yards, 3 TDs, 2 INT)
Taylor Martinez, Nebraska (7-of-11, 150 yards, 1 TD, 0 INT)
Geno Smith, West Virginia (19-of-29, 268 yards, 4 TDs, 0 INT)
Brandon Weeden, Oklahoma State (23-of-32, 409 yards, 6 TDs, 0 INT)


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This better work this time :I
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There's BSing going on here?????????? I'm SHOCKED, SHOCKED!!!!!
Printable View
There's BSing going on here?????????? I'm SHOCKED, SHOCKED!!!!!
I think I sort of explained my reasons at the beginning, and I don't mind reiterating; I had a goal to overcome phobias of being in the ocean. This past summer I decided to face the fears and during time in Chincoteague this past summer I saw the young to old surfers having a blast on surfboards. I dove in and bought a board and fell in love right away. I think it was the empowerment I got from overcoming my worst fears about the ocean the first time I sat out in the line up. Then I caught a wave I was able to ride briefly. That feeling was something I never felt before and since that moment I want to experience it again and again. And the people I met in Chincoteague were really positive souls that stoked my stoke even more. I can't wait to see most of them this week! Great dudes and dudettes :)
Gruvi , surf lavalette tomorow.. Im seroiuse i wanna meet you and surf lol and take pics!!!
I don't read this site for like 3 days, and this is what happens? Thank god I was able to read a few pages from his initial thread before it got removed...
I mean, fu**, who needs the Jersey Shore when I can just log on and read this... I think I will wait another 24 hours, let the thread grow, pop some pop corn and enjoy myself....
This was seriously, pure magic... Welcome back my friend... Welcome back!
I hate to break it to everyone.....but im Gruvi....im a 40 year old albino virgin that saw the ocean for the first time this year...
Thanks for the welcome Zach :) Epic, I don't know where that break is. Plus I have a lesson to take on tomorrow at Belmar. I want a professional view of where I need to improve. A lot of my surfing to date has been with friendly critiquing and I feel a pros objective delegation will benefit me at this early stage...unless someone here that really knows what to teach will step up to take cash for real time with me?? Thanks :)
"Dudes and dudettes" is so awesome:confused:
the golf thread has zach sounding like gruvi


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'Mission Antarctic' Expedition Blog with Lucas Debari and Xavier De Le Rue
Xavier De le Rue and Lucas Debari are currently on expedition with The North Face to Antarctica. Follow along with the 'Mission Antarctic' expedition while the two share real-time dispatches as they ride some of the steepest and most beautiful lines at the bottom of the world. This Blog will be getting updated as the trip unfolds, and look out for the full feature in the March Issue of TransWorld SNOWboarding Magazine.
Photo Gallery from the trip
Xavier De Le Rue: Dispatch 5 (final blog entry)
Here I am sitting at this very brit looking like cafe place in Stanley Falklands just getting my head (and stomach) together after four days of delightful seasickness through the Drake Passage.
Coming back to the civilization, I'm getting all these flashbacks in my head.
The bays surrounding us, all the untouched faces, all the moments we shared with the crew through hell and heaven.
Beforehand I felt that this could be the trip of my life and I am certain now that it is indeed true.
I am so thankful to have had the chance to put the dream trip together and I can't wait to share it all with everyone.
There is a massive packing underway back at our boat the Golden Fleece. We are flying off tomorrow to hopefully make it on time for father Xmas.
We could feel all the way back on the peninsula all the stoke from our posts and it really helped us to carry on day after day with our exploration.
Thank you sooo much from the whole crew for all your cheers.
Stay tuned for more!
See the Full Feature and all the epic Photos in the March Issue of TransWorld SNOWboarding Magazine
(Print and iPad editions)
You can Follow the Story through the blog updates over the next pages


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Police searching for Domino's Pizza robbery suspect
From our News Partners at WCBD-TV:
On Tuesday, at approximately 8:20 PM, Charleston County Sheriff's Office deputies responded to Domino's Pizza located at 1041 Folly Road in Charleston to investigate a report of an armed robbery.
When deputies arrived they were advised that a black male suspect entered the restaurant brandishing a shot gun and demanding money from the clerk. The suspect opened the cash register and took $30 - $50.00 in cash.
According to witnesses, as the suspect was fleeing from the location, he also robbed another victim of $30.00, who had just pulled into the parking lot of Domino's Pizza.
The suspect fled the scene on foot and ran behind the BB&T Bank on Folly Road. The Charleston County Sheriff's K9 Unit responded to the scene in an attempt to track the suspect; however, the track ended near a fence behind the BB&T Bank.
According to the witnesses, the suspect is described as a black male, 5'04"- 5'07", stocky type build, wearing an olive color zip jump suit, black ski mask, and some type of ball cap under the ski mask.
Detectives are continuing to investigate the incident.
Anyone with information is asked to contact the Charleston County Sheriff's Office at 843-202-1700 or Crime Stoppers at 843-554-1111.
Photo Credit: Carl Ballou Shutterstock


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Canadian Corps Championship
The Film
Running Time
08 min 58 s
Canadian War Records Office, Ministry of Information
This footage was shot on July 1, 1918 in Deauville, France, and documents a large sporting and recreational event that brought together thousands of Canadian troops. Some of the activities take place on the beach of the coastal town, and the pier and its lighthouse are visible in some of the shots.
This Dominion Day gathering, organized under the direction of General Sir Arthur Currie, was perhaps the most important of such wartime events, and many veterans would later recall the occasion. In addition to boosting morale and providing a much-needed break for the troops, such gatherings played a vital role in cementing a sense of Canadian identity among the men.
As the war progressed, Canada would emerge as a player in its own right - still linked to the mother country but with a growing sense of its own national character. General Currie, who had successfully maintained the Canadian troops as a single coherent force, would have clearly understood how such recreational events helped to forge a sense of collective identity and competitive spirit. Since team competitions were organized by unit and sometimes by division, these events were also intended to instill a sense of pride at all levels within the army, and to help forge the identity of individual units.
The footage depicts various games and athletic activities. A sequence showing a small group parading in comic theatrical costumes suggests an attempt to establish an atmosphere of recreational fun. The men approaching a platform to receive trophies would be members of the 15th Battalion's soccer team, and can be identified by the number "15" on their jerseys. Most of them would be first-generation British immigrants from Toronto. Canadian-born soldiers tended to prefer baseball to soccer, and a baseball tournament, not depicted here, was apparently one of the day's highlights.
The nature of many of the activities - greasy pole competitions, wheelbarrow and sack races - once again underscore the organizers' intent to provide their troops with some light-hearted fun. The participants in the equestrian events would have been officers riding their personal mounts, and indicates how the military hierarchy mirrored class divisions within society at large. Most Canadian cavalry, with the exception of the Canadian Light Horse, fought with the British cavalry forces and would not have been present at this event.
These images were filmed by Walter Buckstone, one of several cameramen working for the Canadian War Records Office during the closing months of the war.
Pieces of History
Overseas Training in the Canadian Expeditionary Force
Andrew Iarocci
Postdoctoral Research Fellow, Wilfrid Laurier University, Waterloo
the sole object of training is to prepare our forces for war, success in battle being constantly held as the ultimate aim... It is the function of training to develop the mental, moral, and physical qualities as highly as possible in each individual, and also to inculcate by theory and practice the methods of employing the various arms in co-operation to the best advantage...1
As this passage demonstrates, military instruction consisted of two fundamental aspects: training of the individual soldier and training of formations. When new recruits joined the service, they first needed to learn the basic skills of soldiering—marching, drill and marksmanship. Once these were mastered, the soldier would continue to train for his specialized trade, whether it be infantry, artillery, engineering, signals, medical or supply. Then the individual would join a formation based on his trade, and training continued at the unit level on a regular basis. The ultimate objective was for each component of the army to function cooperatively as part of the whole; this was achieved through exercises at the battalion, brigade and divisional levels.
The first overseas contingent of Canadian troops was formed at Valcartier, Quebec, during August-September 1914. Much of the time at Valcartier was occupied with administrative details, and limited training was accomplished before the contingent—soon to be known as 1st Canadian Division—embarked for England in October. Upon arrival, the division was posted to Salisbury Plain, a large British training area, where it remained until February 1915.
The weather that winter was especially wet, and until recently, scholars have agreed that relatively little training was completed before the division moved to France. Recent research suggests, however, that despite inclement weather and other distractions, most elements of the division engaged in productive training on Salisbury Plain. The infantry learned to manoeuvre in conjunction with artillery and machine guns. Other divisional elements, such as engineers, artillery and signals, as well as mounted and transport troops carried out their own specialized programs. The engineers, for example, learned how to construct field fortifications, while the artillery brigades rehearsed their gun drills. The divisional transport and ammunition columns, meanwhile, discovered the intricacies of moving supplies around the battle zone.
The training of 1st Division did not cease after it crossed the English Channel in February 1915. Upon arrival at the front lines near the Franco-Belgian border, the Canadians were matched up with experienced British troops for orientation tours. The evidence suggests that this formative experience was overwhelmingly positive. As one soldier later recalled, "nothing could surpass the patience of" his British teachers "or their brotherly kindness to us as comrades in arms."2 The Canadians also learned about the costs of war, as they suffered their first casualties and witnessed the damage inflicted on the landscape.
In the summer of 1915, the 2nd Canadian Division arrived in England and began to train at Shorncliffe Camp. The open ground was ideal for company and battalion manoeuvres, and much of the instruction revolved around the challenges of trench warfare. Some of the officers attended British courses, while others went to France for short combat tours with 1st Division.3 With the expansion of the Canadian Corps to four divisions during 1915-16, additional training space was required for the new arrivals in England. A camp was opened at Bramshott in late 1915, and additional camps were added in 1916, including Crowborough, Hastings, New Shoreham, Seaford and Witley.4
As the war progressed, a broad selection of specialized schools was established—both in England and in France—covering everything from hand grenade training to field sanitation. Instructional programs were gradually standardized, while the British Army Printing and Stationery Depot produced a vast selection of training literature on every conceivable subject.
New technology appeared on the battlefield throughout the war and was reflected in training programs. In April 1915, for example, the German Army introduced chemical weapons to the Western Front. All soldiers were issued with respirators for the duration of the conflict and gas drill became an important component of basic training. Later in 1915, the .303 calibre Lewis gun, a portable automatic rifle, was issued to British and Dominion forces. Here again was a new piece of equipment to be mastered. In common with other types of military training, the correct procedure was subdivided into a simple series of component tasks.
Not all military instruction revolved around weapons systems and tactics. Sport and physical exercise were also important; peak fitness was vital if soldiers were to function under the strain of battle. As the British Army Manual of Physical Training explained:
a soldier should be well disciplined, a good marcher, intelligent, smart, active and quick, able to surmount obstacles in the field and capable of withstanding all the strains and hardships of active service...5
Fitness was achieved through physical drills, "Swedish" exercises and regular sporting events. Organized games and competitions not only fostered physical fitness, but also improved morale and encouraged teamwork. During the summer months, battalions, brigades and divisions organized their own sporting events in rear areas. After the war a veteran fondly recalled a sports day from the summer of 1918:
Who lives that does not remember the day of brigade sports at Izel-les-Hameaux? There were races and jumps and hurdles, something for everyone, a ring to box and wrestle in, baseball and football championships. The day was fine... everybody was there. It was a gay scene, the boys of four battalions and the airmen who joined us for the fun, all rollicking together...6
By late 1916 the Canadian Corps was a veteran formation, and had suffered heavy casualties in a series of costly battles, including Second Ypres, Festubert, St. Eloi Craters, Mount Sorrel and the Somme. In addition to formal training routines, this practical and bloody battle experience shaped the capabilities of the Corps. At the same time, the high casualty rates meant that large numbers of new recruits were constantly arriving in France and Belgium. Some Canadian commanders were dissatisfied with the level of basic training displayed by these reinforcements, and decided to establish their own courses at the battalion, brigade or divisional levels. These short refresher courses helped to ensure that new arrivals were familiar with the basics of soldiering before being thrust into the unforgiving front lines.
Training was an ongoing process throughout the First World War, as Canadian units were created, consumed in combat, reformed, and once again committed to battle. Under the challenging tactical and operational circumstances of 1914-18, nothing could have prevented high casualties, but effective training improved the chances that soldiers would succeed on the battlefield.
1Training and Manoeuvre Regulations, 1913. London: General Staff, War Office, 1913, p. 10-11.
2George Drillie Scott Fonds, LAC, MG 30, E 28.
3G.W.L. Nicholson. Canadian Expeditionary Force, 1914-1919. Ottawa: Queen's Printer, 1962, p. 113.
4David W. Love. "A Call to Arms": The Organization and Administration of Canada's Military in World War One. Winnipeg: Bunker to Bunker Books, 1999, p. 91.
5Manual of Physical Training, 1908. Rev. ed. London: His Majesty's Stationery Office, 1914, p. 7-8.
6James H. Pedley. Only This: A War Retrospect, 1917-1918. Ottawa: CEF Books, 1999, p. 175-176.


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Florida Georgia Line singer injured in dirt bike accident
Listen to Florida Georgia Line on iHeartRadio
Florida Georgia Line's Tyler Hubbard is recovering from a back injury.
TasteOfCountry.com says the country star's bandmate Brian Kelley discussed the incident at a Country Radio Seminar event Tuesday night, saying Tyler hurt his back on Sunday while attempting a jump on a dirt bike. He joked that Hubbard is "no Evel Knievel," but also admitted that his buddy has been in a lot of pain since the accident. Kelley added that Hubbard has sought treatment from doctors and chiropractors.
Thanks for all the prayers y'all. I'll be fine and back out there in no time. Love y'all. P.S. I may just have to wear the old man mask
— Tyler Hubbard (@THubbmusic) February 19, 2014
Hubbard's injury forced Florida Georgia Line to skip their performance at the event, which featured sets from Tim McGraw, Rascal Flatts, and others. But Brian said the duo still intends to open the show for Jason Aldean in Grand Rapids, Michigan Thursday night as scheduled.
Photo Credit Getty Images


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LONG BEACH - New procedures adopted by the Army Corps of Engineers could substantially cut the cost of a study on reconfiguring Long Beach's breakwater.
The "Three-Three-Three" system places a three-year limit for the study, sets the price tag at no more than $3 million and requires the creation of an informational binder no thicker than 3 inches, according to Tom Modica, Long Beach manager of government affairs.
That could cut the original $8 million price tag for the breakwater study to $3 million, officials said Friday.
"It changes the scope of the study substantially," Modica said. "But there are still a lot of unknowns."
Modica said he plans to meet with Army Corps officials in the near future and expects to be reporting to the City Council in August.
"This is a good thing for breakwater advocates," said 4th District Councilman Pat O'Donnell. "From what we can tell, this is positive for people who want cleaner water and waves."
The breakwater wall off the Long Beach coast was completed in 1949 and was designed to quiet the water to help protect the Port of Long Beach and local coastal areas.
Breakwater modification supporters seek to improve shoreline waves to reduce pollution and enhance recreational activities, while some beachfront residents have concerns that reconfiguration could increase beach erosion problems or allow flooding.
Originally, the Army Corps study could have cost $8 million - costs split between Long Beach and the federal government.
Modica said the city has $4 million in Tideland reserves set aside for its share of the study. He added, however, that the Army Corps has not yet identified funding for its share of the study.
A city report in July 2009 identified potential alternatives such as reconfiguring the Long Beach breakwater, changes in alignment of the Los Angeles River, creation of rocky reef habitat with kelp features and ways to deal with pollution issues. Alternatives will be developed in the feasibility study through a community outreach process, Army Corps planners said.
The city study listed constraints on the project, such as the port berths, Navy anchorage, Long Beach peninsula residences, THUMS islands, marinas and docks and navigational safety. The report made clear that these areas must not be adversely affected.
In the proposed study, the Army Corps will conduct an extensive analysis, including wave and water-quality modeling, economic and environmental factors, engineering and design, geotechnical studies, review of tidal elevations, sediment transport and other areas, according to Modica.
firstname.lastname@example.com, 562-714-2167, twitter.com/JoeSeguraPT


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A guest column by Richard Nelson
Every game has its rules, and politics are no different.
Here at the CKNJ, we have our own rules that we follow when it comes to politics and our coverage of political events. They are in place to help us be as fair as possible to each candidate.
When the political season rolls around, candidates begin by making an announcement of their intention to seek office. We welcome any candidate to do this, and we will publish one notice from each person declaring their candidacy.
If one Kentucky legislator has his way, many Kentuckians could lose access to public information related to their local governing bodies.
State Sen. Chris McDaniel, who represents District 23 covering a portion of Kenton County, filed Senate Bill 101 last Friday seeking to eliminate the requirement of public notices to be published in the newspaper.
"Welcome to the 1950s," he said, as he took my ticket and showed me to my seat.
For the following two hours, the comedy that was the extremely popular "I Love Lucy" show came alive, complete with actors who were dead ringers for Lucille Ball and Desi Arnaz.
I went with a friend to see "I Love Lucy Live" on Saturday. The theater was set as what I would imagine a television stage looked like in the 1950s.
How are those New Year's resolutions working for you? If you've already reneged on them, don't panic. You aren't alone.
According to a survey reported in Forbes magazine, 36 percent have broken their resolutions after one month, 54 percent have failed after 6 months and only 8 percent actually reach their New Year's goals.
British author and philosopher C.S. Lewis once observed, "Everyone thinks forgiveness is a lovely idea until he has something to forgive."
I thought of Lewis' statement after the University of Louisville hired Bobby Petrino as its head football coach for the second time. Not being a Cardinal fan, forgiving the coach for his past mistakes was easy for me.
They say those big nostrils can sense the fear in you. Given my fluttery disposition and general wariness of any animal that I have to look up to, I've always kept my distance from horses.
But take a drive around Taylor County and you are sure to see several breeds and colors of horses living here. Local horse enthusiasts take great pride in their horses' training, bloodlines that go back several decades or more and even the distinctive coloring that sets each one apart.
Everybody wants to make more money, and people making minimum wage are certainly at the top of that list.
Some Democrats in the Kentucky legislature are also looking to help those in the Bluegrass state making minimum wage receive a pay raise, and they hope to see it climb from the current rate of $7.25 per hour to $10.10 per hour over a three-year period.
It's easy to say that the minimum wage should go up (it hasn't increased since 2009), but it's another thing to look at what it will do to those who make more than minimum wage.
A new year is a chance to start over.
We can start that diet again, begin watching our checkbooks a bit more closely, spend more time with family and friends and set ourselves on what we believe is our right path.
The first day of the year marks a moment where we can become the people we think we want to be.
I'm not really one to make resolutions as Jan. 1 rolls around. But this year, I'll make some personal ones and some for our community. And I'll also tell you what I hope happens this year.
News Enterprise
Landmark News Service
When "Duck Dynasty" patriarch Phil Robertson expressed his views on a variety of topics that included statements regarding homosexuality, executives of the A&E network acted surprised. It was as if they had no idea that Robertson felt the way he did.
A&E would like us to believe that Robertson's views were not representative of the network nor the "Duck Dynasty" show.
Copyright © 2017
The Central Kentucky News-Journal is your source for local news, sports, events, and information in Campbellsville, KY and the surrounding area.


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Andrew Johnston, MDiv, MA, LPCI
710 Pettigru St, Greenville, South Carolina 29601
While anger is a natural response to certain situations, it can also become overwhelming. As with all emotions, it arises for a reason. In our response to persistent anger, we will explore short-term techniques for self-calming and composure, as well as look for the source of this emotion. Long-term relief often requires looking below the surface, where we can find out together what the deeper causes might be.


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Developed only for Hammacher Schlemmer, this is the elegant wooden tower that neatly stores up to 25 pairs of shoes and rotates a full 360° for easy access to all footwear. Its five levels are each subdivided into five cubbyholes large enough for storing men's or women's dress and casual shoes of all sizes and types. A spin of the smoothly turning tower quickly locates the pair you want. The turntower provides simpler retrieval than storing shoes in a stack of boxes, and its compact design ensures that mates remain in tidy, orderly pairs, rather than in a messy jumble on a closet floor. Unlike lesser shoe storage systems, the turntower is as attractive as it is practical, with furniture-quality birch veneer construction and a rich walnut stain. Assembly required. 30" H x 23 3/4" Diam. (53 1/4 lbs.)
Lifetime Guarantee
The 25 Pair Shoe Turntower comes with The Hammacher Schlemmer Lifetime Guarantee. If this product ever disappoints you, for any reason, you may return your Hammacher Schlemmer purchase for exchange, credit, or refund.
Should you have any questions, we are available seven days a week (8:00 am – midnight EST). Please call 1-800-321-1484 to speak with a specialist or email us at email@example.com to receive a response within three business hours or less.
May we recommend:
(based on 84 reviews)
Ratings Distribution
5 Stars
4 Stars
3 Stars
2 Stars
1 Stars
of respondents would recommend this to a friend.
Best Uses
Reviewed by 84 customers
Displaying reviews 1-10
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(39 of 40 customers found this review helpful)
Somewhat disappointed
By none
from St. Charles, IL
The design is clever. Product is durable. However, the individual compartments are too small to accommodate an adult woman's shoes (size 7-8). They would not fit a man's shoe size. The shoes tend to catch on things (because they partially hang out)--the wall or on clothing located nearby, as the unit is turned to locate stored shoes. It would work best for children's shoes or other small articles.
Bottom Line No, I would not recommend this to a friend
Hammacher Schlemmer Response: Thank you for your feedback. Average size adult shoes should fit into the compartments. Taller shoes/high heels may sometimes need to be turned sideways to fit into the compartments on the turntower.
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(18 of 19 customers found this review helpful)
Used as a bed side table
By KC
from Portland, Oregon
It arrived promptly and was fairly easy to assemble. I've used it for a swivel bed side table and it's perfect with good storage
Bottom Line Yes, I would recommend this to a friend
(17 of 18 customers found this review helpful)
Small spaces; not good for mens shoes
By BB
from Odenton, MD
This looked like a great idea for shoe storage. And it is, if you're not a guy with size 11 shoes. The cubby holes are all too small to just set shoes my size them easily; they must be crammed and creatively placed (and I figure the same would go for men's sizes down to 8 or 9, too). This seems ideal for women's shoes, especially flats. Likely, when we further redisign our bedroom, I'll turn this over to the wife. Very sturdy, good looking, just not good for average men's shoes.
(13 of 13 customers found this review helpful)
It's a Great Product!
By llawson
from MS
Beautiful piece. Not for tall, tall heels!
(12 of 12 customers found this review helpful)
25 Pair Shoe Turntower
By Omi
from Texas
I Realy like the Turntower. Use it in my Bedroom, closet is to full. It looks very attractive more like a piece of furniture.
(10 of 10 customers found this review helpful)
this was easy to put together. It doesn't take up much room.
By Bert Zach
from Philadelphia, Pa
This is perfect for our bedroom. Holds most of my shoes. May not fit all sizes. I wear a size 7it just makes it. Otherwise it would be short.But I really love it.
By LRRH
from Houston, Tx
I am very pleased with the 25 Shoe Turntower. It was easy to assemble and the parts were all there. The turning assembly, however, is held on to the main tower by very small, short screws...so when you are "righting" the tower be careful when you place the tower to handle the turning part carefully.
Classy Shoe Tower
By TerryW
from Sandy UT
I had all my shoes in a pile at the bottom of my closet, and it always looked messy - so now with my new shoe tower, my closet is clean and my shoes are easy find and the turnstile is easy to select any shoes I want without messing up the rest of the shoes! Thanks whoever invented this!
(8 of 9 customers found this review helpful)
It works!
By n/a
from Alberta Canada
Seems like a good product - bought 2. Easy to put together, but easier if the cam locks are hammered in with a rubber hammer before setting the board on the cam pin. Well made and designed.
(5 of 6 customers found this review helpful)
By XXX
from CORONA, NY
COPYRIGHT © 2016 HAMMACHER SCHLEMMER & COMPANY, INC. ALL RIGHTS RESERVED. W105147 E. 57th ST • NEW YORK, NY • 10022 • 1-800-_321-1484


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A type of sex policing based on the idea that a lesbian- identified person is of a higher ranking if they've never had sexual contact with a "man". This reinforces the oppressive idea that a person must have been born with a biological penis in order to be a man, and discriminates against FtM (Female to Male) Transgendered people. It also reinforces the transphobic thought that a person who was born with a biological penis cannot legitimately be considered a womyn (and discriminates against MtF- Male to Female- individuals.) Sex Policing like this is dangerous to our communities because it supports destructive sexist ideals, and encourages the creation of rules and regulations about sexuality & gender rather than encouraging to challenge & break those rules.
"Stacey's a gold star cuz she's never fucked a boy."
"Oh, you're a gold star dyke, too? Let's ride off into the rainbow sunset together on a unicorn made of misogynist shit!"
"Oh, you're a gold star dyke, too? Let's ride off into the rainbow sunset together on a unicorn made of misogynist shit!"
by trannyfagwitchfucker! March 27, 2011
The Urban Dictionary Mug
One side has the word, one side has the definition. Microwave and dishwasher safe. Lotsa space for your liquids.Buy the mug


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Thread: Epidural
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10th June 2014 04:32 PM #1
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- Jun 2014
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What are the long-term effects of an epidural?
13th June 2014 11:39 AM #2
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- 931
Their are many negatives and positives to the epidural. However each woman must do her own research and make a informed decision before she goes into labor with her baby.
I chose to not ask for epidurals in 4 of my 5 pregnancies. I love to know that my body works and can handle the birth of my own baby.
Here is a very infomative article of the risks to mother and baby when using a epidural in labor.
Please do take the time to read it throughly as you will find quite a bit of great researched based information on epidurals.
14th June 2014 01:25 AM #3
- Join Date
- Jun 2014
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Thanks, sunnymumof5!
I actually chose an epidural because I wanted a pain-free labor. But, it was harder for me to push during the delivery. Also, I noticed some low back pains a few days after.
Now that I've read the article, I think it's also possible that my milk supply decreased because of that.