American Journal of Ophthalmology

Evaluating Exaggerated, Prolonged, or Delayed Postoperative Intraocular Inflammation

Rishi R. Doshi, J. Fernando Arevalo, Harry W. Flynn, Emmett T. Cunningham — 2010-07-13

Purpose: To provide a diagnostic approach for the evaluation of patients with exaggerated, prolonged, or delayed postoperative intraocular inflammation.Design: Perspective.Methods: Selected articles on normal and abnormal postoperative intraocular inflammation were reviewed and interpreted in the context of the authors' clinical and research experience.Results: In addition to infectious endophthalmitis, a number of noninfectious conditions characterized by exaggerated, prolonged, or delayed postoperative inflammation have been described. Heuristically, increased postsurgical inflammation may be categorized by time from surgery to first recognition using the following general guidelines: as immediate and occurring within 2 days after surgery; as early and occurring after 2 days, but within the first 2 weeks, after surgery; and as delayed and occurring more than 2 weeks after surgery.Conclusions: Although infectious endophthalmitis always must be excluded as a cause of increased postoperative intraocular inflammation, potential noninfectious causes also exist. We review both infectious and noninfectious causes of increased postoperative inflammation and provide a diagnostic framework for evaluating such patients.

Causality in the Systems Era of Pediatric Ophthalmology: The Buddha's Smile

Michael C. Brodsky — 2010-06-25

Purpose: To identify the inherent complexities in assigning causation in the evolving systems era of pediatric ophthalmology.Design: Philosophical analysis of causality as it pertains to understanding the pathogenesis of pediatric strabismus and nystagmus.Methods: Review of general philosophical problems and profession-related differences in assigning causality as they apply to current controversies in pediatric ophthalmology.Results: Medicine is evolving into a systems era based on a complex network of interacting components including internal systems, gene expression, behavioral factors, and environmental factors. In this context, any definition of cause (epidemiologic, mechanical, physiologic, environmental, genetic, epigenetic, etc.) becomes a function of one's reference point. Thus, as medical science becomes more precise, causality seems to recede. Most current controversies in pediatric ophthalmology are reducible to simple questions of cause and effect. Strabismus and nystagmus often develop without apparent cause, providing a formidable challenge to deciphering disease pathogenesis and assigning causality. In these conditions, assigning causation is impeded by a tendency to confuse links and correlations with cause and effect, an inherent tendency to conflate form and function, the use of terminology that transposes cause and effect, and by our tendency to think linearly about problems that are fundamentally circular.Conclusions: Our tendency to think linearly creates a self-referential system that influences our understanding of cause and effect. Neural activity is characterized by feedback loops and bidirectionality. Understanding neurodevelopmental strabismus and nystagmus requires a dynamic, circular view of causality.

Efficacy of Ranibizumab in Patients With Macular Edema Secondary to Central Retinal Vein Occlusion: Results From the Sham-Controlled ROCC Study

2010-06-29

Purpose: The ROCC study (randomized study comparing ranibizumab to sham in patients with macular edema secondary to central Retinal vein OCClusion [CRVO]) evaluated the short-term effect of intravitreal ranibizumab injections on best-corrected visual acuity (BCVA) and macular edema.Design: Prospective, multicenter, randomized, double-masked, placebo-controlled trial.Methods: In this 6-month trial, 32 patients with macular edema secondary to CRVO were randomized to receive monthly intravitreal ranibizumab (0.5 mg/0.05 mL) or sham injections for 3 consecutive months. If macular edema persisted, patients received further monthly injections. Primary outcome measures were BCVA and central macular thickness (CMT) at 6 months.Results: Twenty-nine patients completed the study. After 3 months, BCVA improved by a mean ± standard deviation (SD) of 16 ± 14 Early Treatment Diabetic Retinopathy Study (ETDRS) letters in the ranibizumab group (n = 15), compared with a mean loss of 5 ± 15 ETDRS letters in the sham group (n = 14; P = .001). The mean ± SD change in CMT was −411 ± 200 μm in the ranibizumab group and −86 ± 165 μm with sham (P < .001). At 6 months, the mean ± SD change in BCVA was 12 ± 20 ETDRS letters in the ranibizumab group compared with −1 ± 17 ETDRS letters in the sham group (P = .067). The mean ± SD change in CMT was −304 ± 194 μm with ranibizumab and −151 ± 205 μm with sham (P = .05). Twelve patients (80%) in the ranibizumab group required more than 3 initial injections; mean ± SD number of injections was 4.3 ± 0.9 during the study.Conclusion: Monthly ranibizumab significantly increased BCVA and decreased macular edema, compared with sham, in patients with CRVO. Repeated consecutive injections are necessary to maintain initial positive results.

Randomized, Double-Masked, Sham-Controlled Trial of Ranibizumab for Neovascular Age-Related Macular Degeneration: PIER Study Year 2

Prema Abraham, Huibin Yue, Laura Wilson — 2010-07-02

Purpose: To evaluate efficacy and safety of quarterly (and then monthly) ranibizumab during the 2-year Phase IIIb, multicenter, randomized, double-masked, sham injection–controlled study of the efficacy and safety of ranibizumab in subjects with subfoveal CNV with or without classic CNV secondary to AMD (PIER) study.Design: Phase IIIb, multicenter, randomized, double-masked, sham injection–controlled trial in patients with choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD).Methods: Patients were randomized 1:1:1 to sham injection (n = 63) or 0.3 mg (n = 60) or 0.5 mg (n = 61) intravitreal ranibizumab monthly for 3 months and then quarterly. During study year 2, eligible sham-group patients crossed over to 0.5 mg ranibizumab quarterly. Later in year 2, all eligible randomized patients rolled over to 0.5 mg ranibizumab monthly. Key efficacy and safety outcomes of the 2-year trial are reported.Results: At month 24, visual acuity (VA) had decreased an average of 21.4, 2.2, and 2.3 letters from baseline in the sham, 0.3 mg, and 0.5 mg groups (P < .0001 for each ranibizumab group vs sham). VA of sham patients who crossed over (and subsequently rolled over) to ranibizumab decreased across time, with an average loss of 3.5 letters 10 months after crossover. VA of 0.3 mg and 0.5 mg group patients who rolled over to monthly ranibizumab increased for an average gain of 2.2 and 4.1 letters, respectively, 4 months after rollover. The ocular safety profile of ranibizumab was favorable and consistent with previous reports.Conclusions: Ranibizumab provided significant VA benefit in patients with AMD-related CNV compared with sham injection. Ranibizumab appeared to provide additional VA benefit to treated patients who rolled over to monthly dosing, but not to patients who began receiving ranibizumab after >14 months of sham injections.

Choroidal Thickness in Normal Eyes Measured Using Cirrus HD Optical Coherence Tomography

Varsha Manjunath, Mohammad Taha, James G. Fujimoto, Jay S. Duker — 2010-06-29

Purpose: To examine choroidal thickness and area in healthy eyes using spectral-domain optical coherence tomography (SD-OCT).Design: Retrospective, observational case series.Methods: Thirty-four eyes (34 subjects), with no retinal or choroidal disease, underwent high-definition raster scanning using SD-OCT with frame enhancement software. Choroidal thickness was measured from the posterior edge of the retinal pigment epithelium to the choroid/sclera junction at 500-μm intervals up to 2500 μm temporal and nasal to the fovea. The central 1-mm area of the choroid was also measured, along with foveal thickness of the retina. All measurements were performed by 2 independent observers. Statistical analysis was used to correlate inter-observer findings, choroidal thickness and area measurements with age, and choroidal thickness with retinal foveal thickness.Results: The 34 subjects had a mean age of 51.1 years. Reliable measurements of choroidal thickness were obtainable in 74% of eyes examined. Choroidal thickness and area measurements had strong inter-observer correlation (r = 0.92, P < .0001 and r = 0.93, P < .0001 respectively). Area had a moderate negative correlation with age (r = −0.62, P < .0001) that was comparable to the correlation between mean subfoveal choroidal thickness and age (r = −0.61, P < .0001). Retinal and choroidal thickness were found to be poorly correlated (r = −0.23, P = .18). Mean choroidal thickness showed a pattern of thinnest choroid nasally, thickening in the subfoveal region, and then thinning again temporally. Mean subfoveal choroidal thickness was found to be 272 μm (SD, ± 81 μm).Conclusions: Choroidal thickness can be measured using SD-OCT high-definition raster scans in the majority of eyes. Choroidal thickness across the macula demonstrates a thin choroid nasally, thickest subfoveally, and again thinner temporally, and a trend toward decreasing choroidal thickness with age.

Analysis of Retinal Flecks in Fundus Flavimaculatus Using High-Definition Spectral-Domain Optical Coherence Tomography

2010-06-24

Purpose: To assess morphologic changes associated with retinal flecks in fundus flavimaculatus using spectral-domain optical coherence tomography (SD-OCT).Design: Observational case series.Methods: Simultaneous recordings of SD-OCT and confocal scanning laser ophthalmoscope (cSLO) fundus autofluorescence images were obtained in fundus flavimaculatus patients. Morphologic aspects of the retinal flecks were analyzed and classified.Results: Thirty-one eyes of 17 consecutive patients (8 male, 9 female; mean age 47.9 ± 17.1 years) were included for analysis. SD-OCT revealed 5 distinct types of lesions. Group A lesions were limited to the outer segment (OS) of the photoreceptors, the retinal pigment epithelium (RPE) interdigitations, and the RPE/Bruch membrane complex. Group B showed a protrusion of the hyper-reflective material through the interface of inner segment (IS)/OS of the photoreceptors up to the external limiting membrane. A further protrusion of the hyper-reflective material into the outer nuclear layer was seen in group C lesions. Group D lesions were characterized by an accumulation of the hyper-reflective material limited to the outer nuclear layer. Type E lesions can be described as drusen-like retinal pigment detachments. No significant correlation between the different types of flecks and visual acuity was observed (P > .05).Conclusions: SD-OCT allows one to distinguish at least 5 different types of lesions associated with retinal flecks in fundus flavimaculatus. The ability to characterize the different types of flecks and to analyze the photoreceptor layers surrounding these lesions suggests that SD-OCT might have a potential clinical role in the evaluation and follow-up of the structural changes in fundus flavimaculatus.

AJO History of Ophthalmology Series: The End of the Tether

2010-09-01

One of the less known works of Joseph Conrad is the novella, The End of the Tether, published in 1902. It depicts the struggle of an English ship captain to continue navigating the coastal waterways of the Malay Archipelago despite his increasing blindness. The conflict is between different responsibilities: the old captain's wish to provide for his only daughter and his sense of honor as a ship's captain. And like most of Conrad's stories, it all comes out badly.

One-Year Outcomes After Retinal Detachment Surgery Among Medicare Beneficiaries

2010-06-29

Purpose: To determine longitudinal rates of second retinal detachment operation and postoperative adverse outcomes after retinal detachment surgery in a nationally representative sample of older Americans.Design: Retrospective, longitudinal cohort analysis.Methods: A total of 9216 Medicare beneficiaries were identified from the Medicare 5% sample who were diagnosed with rhegmatogenous retinal detachment and underwent primary pars plana vitrectomy (PPV), scleral buckle, pneumatic retinopexy, or laser photocoagulation or cryotherapy alone. Rhegmatogenous retinal detachment, PPV, scleral buckle, pneumatic retinopexy, or laser photocoagulation/cryotherapy was ascertained from International Classification of Diseases and Current Procedural Terminology procedure codes. Rates of second retinal detachment operation and postoperative adverse outcomes were analyzed by cumulative incidence and logistic regression to control for prior adverse outcome measures and demographic factors.Results: At 1-year follow-up, the rate of receipt of a second retinal detachment operation for beneficiaries who had undergone primary pneumatic retinopexy was much higher (40.6%, P < .0001) relative to the scleral buckle (19.2%) group. After controlling for demographic variables and ocular comorbidities, pneumatic retinopexy individuals were nearly 3 times more likely to receive a second retinal detachment surgery than scleral buckle individuals. No significant differences exist in risk of second retinal detachment surgery for the PPV compared to the scleral buckle group. Individuals receiving PPV were 2 times more likely to suffer adverse outcomes than were those undergoing scleral buckle. Results were robust in sensitivity analysis.Conclusions: Rates of second operation were much higher after pneumatic retinopexy than PPV or scleral buckle, and rates of adverse outcomes were higher in PPV, even after controlling for risk factors and demographic variables.

Polyethylene Glycol Hydrogel Polymer Sealant for Closure of Sutureless Sclerotomies: A Histologic Study

Ajay Singh, Mojgan Hosseini, Seenu M. Hariprasad — 2010-06-24

Purpose: To evaluate a polyethylene glycol–based hydrogel bandage for its ability to secure sutureless pars plana vitrectomy sclerotomies.Design: Laboratory investigation.Methods: Twenty-gauge (20-G) and twenty-three gauge (23-G) sclerotomies were constructed in human cadaveric eyes. A total of 24 sclerotomies were constructed in 6 eyes. Four sclerotomies per eye were constructed. Two were straight 20-G incisions, of which 1 was sutured and 1 was covered with the bandage. The other 2 were 23-G beveled incisions, of which 1 was left bare and the other was closed with the hydrogel bandage. India ink was applied over the sclerotomy sites while the intraocular pressure (IOP) was varied. The presence of India ink particles along incisions was evaluated by histologic analysis.Results: The hydrogel bandage prevented the entry of ink particles in all covered incisions after IOP modulation and incision manipulation. One 20-G sutured incision showed partial ink ingress. Four uncovered 23-G incisions showed the presence of ink within the inner aspect of the incisions (P = .0455 relative to 23-G sealed incisions). Twenty-two out of 24 incisions were evaluated, as 2 incisions could not be identified on histologic analysis.Conclusions: The use of a hydrogel bandage to close sutureless sclerotomies is a practical alternative to sutures. Closure of sutureless sclerotomies may reduce the entry of ocular surface fluid into these incisions as well as prevent leakage of intraocular fluid in the immediate postoperative period. Incision closure may reduce the incidence of postoperative endophthalmitis and hypotony in sutureless vitreous surgery.

The Effect of Topical Autologous Serum on Graft Re-epithelialization After Penetrating Keratoplasty

2010-06-24

Purpose: To analyze factors influencing corneal graft re-epithelialization after penetrating keratoplasty (PK) and evaluate the effect of topical autologous serum in promoting graft re-epithelialization.Design: Prospective interventional study.Methods: We analyzed 165 eyes of 165 patients who underwent PK between January 1, 2005 and December 31, 2007. Patients were divided into 2 groups according to routine use or non-use of postoperative 20% topical autologous serum. Postoperative slit-lamp examination after fluorescein staining was performed, and graft re-epithelialization time was recorded. Recipient/donor characteristics, surgical variables, and topical use of autologous serum were analyzed for their effects on post-PK graft re-epithelialization. Statistical analysis was performed by univariate and multivariate regression analysis using the ordinal logistic fit model to assess the potential risk factors influencing graft re-epithelialization after PK.Results: In univariate analysis, diabetes mellitus (DM), longer death-to-storage time and death-to-surgery time of the donor, and larger recipient size significantly delayed graft re-epithelialization (P < .05). Use of autologous serum significantly expedited graft re-epithelialization (P = .004). In multiple regression analysis, only DM in the recipient (odds ratio [OR] = 5.10, P < .001), postoperative use of autologous serum (OR = 0.54, P = .046), and larger graft size (OR = 4.44, P < .001) influenced graft re-epithelialization. The beneficial and healing effect of autologous serum is particularly significant in diabetic recipients and larger grafts.Conclusions: Several factors may influence graft re-epithelialization after PK. Graft re-epithelialization time was longer in diabetic recipients and larger grafts. Use of autologous serum may be a beneficial strategy in these patients with potentially delayed epithelial healing.

Use of Intraoperative Fourier-Domain Anterior Segment Optical Coherence Tomography During Descemet Stripping Endothelial Keratoplasty

2010-06-29

Purpose: To evaluate the intraoperative use of handheld Fourier-domain optical coherence tomography (OCT) during Descemet stripping automated endothelial keratoplasty (DSAEK) to assess the donor-host interface.Design: Prospective, observational case series.Methods: Six patients undergoing DSAEK surgery were included. OCT scans of the cornea were performed intraoperatively after insertion of the donor disc, after instillation of air in the anterior chamber beneath the disc, after vent incisions in the host cornea in each quadrant, following air-fluid exchange at the end of operation, and on day 1 after surgery. The central 3 mm of each cornea was scanned. The broadest gap between donor and host cornea (interface space) was measured.Results: Adequate readings could be obtained from all patients without any complications. In 2 patients there was a decrease in the width of the interface space after each surgical step documented by the OCT scans. At the end of their operation, no interface space was detectable. In 2 patients, interface space disappeared after the vent incisions and did not reappear during the further course of the surgery. In further 2 patients the separation between the host and donor was still detectable at the end of the operation. All patients had no detectable interface gap on day 1.Conclusions: Handheld anterior segment OCT can be used to assess the host-donor interface in lamellar corneal transplantation surgery. Donor adherence can occur in spite of residual interface space at the end of surgery. Further studies should be conducted to answer the question of which surgical steps are useful in assisting with donor adhesion.

Periorbital Contact Sensitization

Lilla Landeck, Peter C. Schalock, Lynn A. Baden, Ernesto Gonzalez — 2010-06-11

Purpose: To identify frequency and pattern of contact sensitization among patients with periorbital dermatitis.Design: Cross-sectional retrospective investigation of 1247 patients referred for patch testing over a 17-year period.Methods: Data were collected for patients undergoing patch testing to the standard and customized trays between January 1990 and December 2006 at the Massachusetts General Hospital, Contact Dermatitis Clinic. Our study group consisted of 266 patients affected by periorbital dermatitis. Findings were compared to 981 referrals without periorbital dermatitis (controls). Patch test results were read after 48 and 72 hours and classified as allergic, questionable, irritant, or negative. Statistical analyses were carried out by using χ2 test and Fisher exact test.Results: General epidemiologic data among periorbital dermatitis patients showed significant predominance of female gender (87.6%) and of individuals aged 40 to 59 years (45.9%). Nickel (16.5%) and fragrance mix (13.2%) were the top-ranking sensitizers. Ingredients of topical ophthalmologic products did not result in significant sensitization. Comparison of the periorbital dermatitis group to the controls did not reveal significant differences in sensitization pattern. Patch testing confirmed the likelihood of allergic contact dermatitis in 50.8% of the periorbital dermatitis patients tested.Conclusions: Allergic contact dermatitis is a common cause of periorbital dermatitis. Patch testing should be considered in all patients with periorbital dermatitis when suspecting contact allergy in order to identify and avoid offending allergens.

Association of Dyslipidemia in Moderate to Severe Meibomian Gland Dysfunction

2010-07-08

Purpose: To determine whether meibomian gland disease, a major contributor to dry eye syndrome, is associated with dyslipidemia.Design: Retrospective case-control study.Methods: setting: Clinical practice. patient or study population: Sixty-six patients from January 2008 to July 2009 with moderate to severe meibomian gland disease whose serum lipid levels were obtained. We excluded patients who were already taking lipid-altering substances and patients with rheumatologic disease. We analyzed several parameters in prevalence of dyslipidemia (total cholesterol > 200 mg/dL, low-density lipoprotein [LDL] > 130 mg/dL, high-density lipoprotein [HDL] < 40 mg/dL, and triglycerides >150 mg/dL) in MGD patients and compared these patients to the general population as reported by data from the National Health and Nutrition Examination Survey (NHANES). main outcome measure: The prevalence of dyslipidemia (elevated total cholesterol, elevated LDL, decreased HDL, or elevated triglycerides) in patients with moderate to severe MGD.Results: Patients with moderate to severe MGD had a higher incidence of dyslipidemia with respect to elevated total cholesterol (>200 mg/dL), 67.4% to 45.1% (P = .0012) when compared to population controls. There was a smaller number of MGD patients with low HDL (HDL < 40 mg/dL), 6.5%, when compared to controls, 15.7% (P = .045). The incidence of increased LDL was not statistically significant (P = .184). There was a statistically smaller number of MGD patients with high triglycerides (TG > 150 mg/dL), 15.2%, when compared to controls, 33.1% (P = .0049).Conclusions: Patients with moderate to severe MGD have a higher incidence of dyslipidemia with respect to elevated total cholesterol than the general population. Surprisingly, the component of total cholesterol that contributed most to this increase in total cholesterol came from elevated serum HDL levels. To our knowledge, elevated HDL has not been associated with any pathologic state. Patients with MGD had a statistically significant lower incidence of hypoalphalipoproteinemia (low HDL) than the general population. Patients with MGD also had a lower incidence of hypertriglyceridemia than the general population.

Efficacy of Surface Ablation Retreatments Using Mitomycin C

Laura de Benito-Llopis, Miguel A. Teus — 2010-06-07

Purpose: To evaluate the visual and refractive results and the incidence of complications after laser subepithelial keratectomy (LASEK) enhancement using mitomycin C (MMC) after a previous LASEK procedure with MMC.Design: Retrospective, noncomparative, interventional case series.Methods: Setting was Vissum Santa Hortensia, Madrid, Spain. We performed a retrospective study of LASEK-treated eyes that received intraoperative MMC for 30 seconds and that needed an enhancement procedure. LASEK retreatment with MMC 0.02%, applied for 60 seconds, was performed 3 to 6 months after the initial surgery. We measured the visual and refractive results 3 months after the enhancement and the incidence of complications.Results: Eighty-two eyes were included in the study. The preoperative data were best spectacle-corrected visual acuity (BSCVA) 1.08 ± 0.19, sphere −4.68 ± 2.8 diopters (D), and cylinder −1.30 ± 1.20 D. Three to 6 months postoperatively, before enhancement, the uncorrected VA (UCVA) was 0.59 ± 0.2; the BSCVA, 0.976 ± 0.2; the residual sphere, +0.17 ± 0.7 D, and the cylinder, −0.39 ± 0.5 D. Three months after retreatment, the UCVA was 0.93 ± 0.1; the BSCVA, 0.977 ± 0.1; the residual sphere, 0.09 ± 0.3 D; and the residual cylinder, −0.2 ± 0.3 D. The safety index after retreatment was 1.01 ± 0.1, and the efficacy index was 0.96 ± 0.1. No haze, no delay in epithelial healing, and no case of endothelial decompensation were detected.Conclusion: Surface ablation retreatment using MMC seems to be effective to correct residual refractive errors after an initial surgery with MMC.

Visual Outcomes of LASIK-Induced Monovision in Myopic Patients With Presbyopia

Montserrat Garcia-Gonzalez, Miguel A. Teus, José L. Hernandez-Verdejo — 2010-06-08

Purpose: To evaluate binocular visual acuity (VA), contrast sensitivity, and stereopsis in myopic patients after laser in situ keratomileusis (LASIK)-induced monovision.Design: Prospective, observational study.Methods: We performed a prospective study of 37 consecutive patients older than 45 years who underwent bilateral myopic LASIK with planned monovision. At the 6-month postoperative visit, we evaluated distance and near binocular visual acuity, contrast sensitivity, and stereopsis. Binocular tests were done without spectacles (in monovision condition) and compared with the results obtained by repeating the same binocular tests with the same patients (serving as a control group) after spectacle correction of the residual myopic defect in the nondominant eye for distance tests (reverting monovision) and after spectacle correction of the presbyopia bilaterally for near tests (near best spectacle-corrected VA).Results: By inducing a mean residual spherical equivalent defect of -0.97 diopter in the nondominant eye, the patients achieved a mean near binocular uncorrected visual acuity (UCVA) of 0.74, a mean reading test binocular UCVA of 0.88 using an acceptable spontaneous reading distance (48 cm), and a mean distance binocular UCVA of 1.08. A slight decrease in contrast sensitivity and stereopsis was observed in monovision compared to full distance correction.Conclusions: Monovision is a valid option for myopic patients with presbyopia who are considering LASIK. Good distance and near UCVAs can be obtained with this procedure.

Macular Hole Surgery and Cataract Extraction: Combined vs Consecutive Surgery

2010-07-07

Purpose: To compare the functional and the anatomic outcomes of a combined surgery and consecutive surgery for macular hole and cataract extraction.Design: Multicenter, retrospective, comparative case series.Patients: One hundred twenty patients (120 eyes) with an idiopathic macular hole and cataract were operated on in 1 or 2 sessions in 2 academic centers, Dijon University Hospital and Nancy University Hospital. Combined surgery (n = 64) and consecutive surgery (n = 56) were performed between 2006 and 2007. All patients underwent pars plana vitrectomy with internal limiting membrane peeling and gas tamponade. Cataract extraction was performed with phacoemulsification followed by a posterior chamber intraocular lens implantation. The main outcome measures were near and far visual acuity at 6 and 12 months, and the rate of closure of macular hole evaluated with optical coherence tomography.Results: After a 12-month follow-up, the postoperative best-corrected visual acuities significantly improved in both the combined and the consecutive surgery groups (near and far vision in both groups, P < .0001). However the improvement of far visual acuity was not significant in the consecutive surgery group at 6 months (P = .06) while such an improvement was observed in the combined surgery group (P < .0001). The rates of closure, 100% and 96% in the combined and the consecutive groups respectively, and the complications did not differ significantly between groups.Conclusion: Both combined and consecutive surgeries are safe and effective methods to treat macular hole and cataract with equivalent functional and anatomic results in both procedures. However, combined surgery shortened the delay for visual recovery.

Nosocomial Acute-Onset Postoperative Endophthalmitis at a University Teaching Hospital (2002–2009)

2010-07-08

Purpose: To evaluate acute-onset postoperative endophthalmitis occurring at an academic medical center and to compare rates over the last 25 years at a single institution.Design: Retrospective, consecutive case series.Methods: Medical records were reviewed for all patients diagnosed with acute-onset postoperative nosocomial endophthalmitis from 2002 through 2009 associated with surgery at Bascom Palmer Eye Institute.Results: The 8-year frequency of acute-onset postoperative endophthalmitis was 0.025% (14 of 56 672 intraocular surgeries). The rate was 0.028% (8/28 568) for cataract surgery and 0.011% (2/18 492) for pars plana vitrectomy (PPV). Both PPV endophthalmitis cases followed 20-gauge surgery and no cases followed small-gauge, transconjunctival PPV (n = 2262). Three cases occurred following penetrating keratoplasty (3/2788, 0.108%). The most common bacterial isolate was Staphylococcus (n = 7, 50%). Initial treatment involved ocular paracentesis (n = 8, 57%) or vitrectomy (n = 5, 36%), in combination with injection of intraocular antibiotics (n = 14, 100%). Vancomycin and ceftazidime were used in 13 eyes (93%) and intraocular steroids were given initially to 9 eyes (64%). Final visual acuity was ≥20/200 in 9 eyes (64%) and 2 eyes (14%) were no light perception. At this institution since 1984, there has been a statistically significant trend for a decreasing rate of acute-onset postoperative endophthalmitis (1984–1994: 0.09%; 1995–2001: 0.05%; 2002–2009: 0.025%; P < .001).Conclusion: At a university teaching hospital involving resident, fellow, and faculty surgeons, the frequency of acute-onset postoperative nosocomial endophthalmitis is low, has not increased in the era of sutureless clear corneal cataract surgery, and has steadily decreased when compared to prior time periods from the same institution.

Bleb Morphology and Vascularity After Trabeculectomy With Intravitreal Ranibizumab: A Pilot Study

Malik Y. Kahook — 2010-06-07

Purpose: To investigate outcomes after trabeculectomy using intraoperative intravitreal ranibizumab and topical mitomycin C (MMC) vs MMC alone.Design: Prospective randomized single-site pilot study.Methods: Patients diagnosed with primary open-angle glaucoma were randomized 1:1 to either combination intravitreal ranibizumab 0.5 mg and topically applied MMC (0.4 mg/mL for 2 min) or MMC (0.4 mg/mL for 2 min) therapy alone at time of trabeculectomy surgery. The primary endpoint measured was bleb morphology and vascularity using the Moorfields Bleb Grading System. Unqualified success was defined as postoperative intraocular pressure (IOP) of >5 and <22 mm Hg and a 30% decrease from baseline without use of postoperative hypotensive drops. Qualified success was defined as postoperative IOP of >5 and <22 mm Hg and a 30% decrease from baseline with use of postoperative hypotensive drops.Results: Ten patients were randomized to either standard trabeculectomy with MMC (Group A) or trabeculectomy with intravitreal ranibizumab and MMC (Group B). All patients completed the study and were classified as unqualified successes. There were statistically significant differences in peripheral bleb area (P = .02), peripheral bleb vascularity (P = .02), and non-bleb-related peripheral conjunctiva vascularity (P = .0003), with Group B exhibiting more diffuse blebs with a lower degree of vascularity.Conclusions: Combination intravitreal ranibizumab and topical MMC at time of trabeculectomy resulted in more diffuse blebs with less vascularity when compared to use of topical MMC alone. Further studies are planned to better understand the utility of anti–vascular endothelial growth factor agents as modulators of wound healing post trabeculectomy.

The Use of Titanium T-Plate as Platform for Globe Alignment in Severe Paralytic and Restrictive Strabismus

2010-06-08

Purpose: To evaluate the long-term effectiveness of improved ocular alignment using a suture/T-plate anchoring platform system.Design: Retrospective, noncomparative, interventional case series.Methods: setting: Institutional. study population: Seven consecutive patients with large angle deviations attributable to paralytic and/or restrictive strabismus managed jointly by orbital and strabismus surgeons. intervention procedure: The T-plate base is anchored to the orbital rim with the shaft projecting toward the orbital apex to simulate the origin of the affected muscle. A nonabsorbable suture serves as the coupling element linking the muscle insertion to the tip of the T-plate such that the suture coincides with the axis of the dysfunctional muscle and yields a pull vector to simulate the passive tensile force of the muscle. Information analyzed included patient demographics, etiology of strabismus and characteristics, prior muscle surgeries, secondary interventions, subjective appraisal of diplopia, and final ocular alignment measurements. main outcome measures: Subjective appraisal of diplopia, final ocular alignment in primary gaze, and late stability.Results: All 7 patients showed marked reduction in ocular deviation with a median change of 33 prism diopters (PD) and a range of 7 to 72 PD. For the 6 patients with medial rectus dysfunction, the final ocular alignment ranged from 6 to 18 PD of residual exotropia in primary gaze. The patient with sixth nerve palsy had 5 PD of residual esotropia. There were no failures after an average of 59.4 months of follow-up.Conclusions: A globe tethering technique using a suture/titanium T-plate anchoring platform system effectively treats refractory cases of paralytic and restrictive strabismus with large angles of deviation.

Unifocal and Multifocal Reactive Lymphoid Hyperplasia vs Follicular Lymphoma of the Ocular Adnexa

Rebecca C. Stacy, Frederick A. Jakobiec, Lynn Schoenfield, Arun D. Singh — 2010-07-05

Purpose: To characterize the differentiating histopathologic and immunophenotypic features of reactive lymphoid hyperplasia (RLH) and follicular lymphoma of the ocular adnexa.Design: Retrospective case study with clinical follow-up and review of the literature.Methods: Clinical records of 9 cases of RLH and 6 cases of follicular lymphoma from 2 institutions were reviewed. Light microscopic evaluation and immunohistochemical stains including CD20, CD3, CD5, CD21, CD23, BCL-2, BCL-6, CD10, kappa, lambda, and Ki67 were used to distinguish the 2 categories.Results: RLH preferentially involved the conjunctiva, whereas follicular lymphoma had a propensity to involve the lacrimal gland. Microscopic analysis with immunohistochemical staining distinguished RLH from follicular lymphoma. BCL-2 was positive in follicular centers of follicular lymphoma but not in RLH. CD10 identified follicular center cells and Ki67 quantified cells in S-phase. CD21 and CD23 detected dendritic cell scaffoldings of indistinct germinal centers. None of the patients with RLH developed lymphoma during their clinical courses (up to 18 years). However, 3 patients with orbital, but not conjunctival, RLH developed immunohistochemically proven multifocal nonophthalmic supradiaphragmatic adnexal RLH (sites included lung, parotid, axillary nodes, and uvea). All 6 patients with follicular lymphoma had disseminated disease.Conclusions: A correct diagnosis of RLH vs follicular lymphoma can be reliably established employing immunohistochemical methods. A heretofore undescribed “multifocal RLH” syndrome must be distinguished from follicular lymphoma. Conjunctival RLH can usually be managed surgically without radiotherapy, but “multifocal RLH” required systemic treatment in 2 of 3 patients. Follicular lymphoma requires systemic chemotherapy if discovered beyond stage 1E.

Comparison of In Situ Excision and Whole-Globe Recovery of Corneal Tissue in a Large, Single Eye Bank Series

2010-06-07

Purpose: To compare the quality of corneal tissue after 2 different procurement techniques, whole-globe enucleation and in situ excision.Design: Cross-sectional study.Methods: Data in the interval 2005 to 2008 were collected from the Lions Eye Bank of Oregon. A total of 3618 eyes underwent whole-globe enucleation (enucleation group) and 2048 eyes were subject to in situ excision (in situ group). Endothelial cell density (ECD) and death-to-preservation time (D-to-P) were analyzed. Grading scores ranging from 0 (excellent) to 4 (unacceptable for transplantation) were used to evaluate the epithelium, stroma, Descemet fold, and overall endothelium. The incidences of ECD less than 2000 cells/mm2 (ECD <2000), primary graft failure (PGF), and postoperative infection were investigated.Results: ECD was 2726 ± 419 cells/mm2 in the enucleation and 2645 ± 395 cells/mm2 in the in situ group (P < .001). D-to-P was 9.81 ± 3.56 hours and 8.90 ± 3.65 hours, respectively (P < .001). The mean grade of the stroma was 1.44 ± 0.51 in the enucleation group and 1.50 ± 0.56 in the in situ group (P = .001). The mean grades of overall endothelium were 1.51 ± 0.72 and 1.58 ± 0.69, respectively (P < .001). The incidence of ECD <2000 was 2.38% in the enucleation group and 2.39% in the in situ group (P > .999), PGF rates were 0.72% and 0.68% (P > .999), and postoperative infection levels were 0.14% and 0.39% (P = .080).Conclusion: Although there were minor differences in parameters related to the endothelium, in situ excision seemed equivalent to whole-globe enucleation when various parameters were evaluated.

Reporting Visual Acuities

2010-09-01

The AJO encourages authors to report the visual acuity in the manuscript using the same nomenclature that was used in gathering the data provided they were recorded in one of the methods listed here. This table of equivalent visual acuities is provided to the readers as an aid to interpret visual acuity findings in familiar units.

Alcohol Consumption and the Long-Term Incidence of Cataract and Cataract Surgery: The Blue Mountains Eye Study

Gowri L. Kanthan, Paul Mitchell, George Burlutsky, Jie Jin Wang — 2010-07-08

Purpose: To assess whether alcohol consumption is associated with the long-term incidence of cataract or cataract surgery.Design: Population-based prospective cohort study.Methods: A total of 3654 persons aged 49+ years were examined at baseline and 2564 were re-examined after 5 and/or 10 years. Lens photographs were taken at each visit and assessed using the Wisconsin Cataract Grading System by masked graders. An interviewer-administered questionnaire was used to collect information on alcohol consumption.Results: No significant associations were observed between alcohol consumption and long-term risk of nuclear, cortical, and posterior subcapsular cataract. However, after adjusting for age, gender, smoking, diabetes, myopia, socioeconomic status, and steroid use, total alcohol consumption of over 2 standard drinks per day was associated with a significantly increased likelihood of cataract surgery, when compared to total daily alcohol consumption of 1 to 2 standard drinks (adjusted odds ratio [OR] 2.10, 95% confidence interval [CI] 1.16-3.81). Abstinence from alcohol was also associated with increased likelihood of cataract surgery when compared to a total alcohol consumption of 1 to 2 standard drinks per day (adjusted OR 2.36, 95% CI 1.25–4.46).Conclusion: A U-shaped association of alcohol consumption with the long-term risk of cataract surgery was found in this older cohort: moderate consumption was associated with 50% lower cataract surgery incidence, compared either to abstinence or heavy alcohol consumption.

Paretic Side/Normal Side Ratios of Cross-Sectional Areas of the Superior Oblique Muscle Vary Largely in Idiopathic Superior Oblique Palsy

Joseph L. Demer — 2010-09-01

I read with interest the recent report by Uchiyama and associates of their magnetic resonance imaging study of superior oblique (SO) muscle cross-section in patients with unilateral SO palsy. These authors compared coronal plane magnetic resonance imaging (MRI) in 50 cases, and in 45 control subjects. The authors calculated the ratio of SO cross-section between the paretic and normal sides. The figure provided by these authors shows a very impressive scatter of data for SO palsy, yet very small 95% confidence intervals are superimposed on the data. For SO palsy in total, the 95% confidence intervals for the ratio are stated as ranging from 0.66 to 0.80. Nevertheless, all but 3 of their 49 unilateral cases lie outside of the 95% confidence interval. Of course, such an occurrence is a statistical impossibility, because the idea of a 95% confidence interval is to encompass the great bulk of all observations. Readers will probably be confused by the data as presented. It appears that the authors are actually plotting 95% confidence intervals for the sample mean of the ratio for a group of patients, rather than 95% confidence interval for individual patient observations. That latter value, which is equal to the sample mean ±1.96 standard deviations, gives a confidence interval ranging from 0.01 through 1.31. Because clinicians make clinical decisions based on individual patient observations, such a wide confidence interval provides little insight in the absence of a wider perspective on current controversies concerning SO function. Uchiyama and associates' stated confidence intervals should not be used for diagnostic purposes.

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Toshihiko Matsuo — 2010-09-01

It is my pleasure to have discussion with Dr Demer regarding our article. What we revealed in the study was (1) that paretic side/normal side ratios of the cross-sectional areas of the superior oblique (SO) muscle in patients with idiopathic SO palsy showed a wide range of variation; (2) that left side/right side ratios of the cross-sectional areas of the SO in control subjects did not show any variation; and (3) that left side/right side ratios of the cross-sectional areas of the 4 rectus muscles in both SO palsy patients and control subjects did not show any variation. We did not state in our article that the 95% confidence interval of the paretic side-to-normal side ratios of the cross-sectional areas of the SO in the SO palsy patients should be used for diagnostic purpose of the SO muscle atrophy. Rather, we stated in the Conclusions of the Abstract that “the muscle hypoplasia could be defined as such when the paretic side/contralateral side ratios of cross sectional areas of the SO muscle on magnetic resonance images fall outside the 95% confidence interval of the ratios in normal controls.” We also suggested in the Discussion of the article that “another way of defining the muscle hypoplasia is to use the paretic side/contralateral side ratios which are located outside the range of the left side/right side ratios of cross sectional areas of the SO muscle in normal controls.”

Novel Dyes in Intraocular Surgery

2010-09-01

We read with great interest the article “Ability of New Vital Dyes to Stain Intraocular Membranes and Tissues in Ocular Surgery,” by Rodrigues and associates. We congratulate the authors for an excellent article highlighting various novel vital dyes that can be used to stain intraocular membranes.

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2010-09-01

We appreciate the comments of Ambatipudi and associates regarding our recently published work on chromovitrectomy. In this publication, we described a variety of dyes that may be suitable for intraocular surgery. We thank the authors for allowing us to clarify some important issues in this article.

Reduced-Fluence Photodynamic Therapy for Polypoidal Choroidal Vasculopathy

Jay Chhablani — 2010-09-01

I read the article by Yamashita and associates with interest. The article described advantages of reduced-fluence photodynamic therapy (PDT) for polypoidal choroidal vasculopathy (PCV). I would like to comment about the application of PDT in PCV. PDT is associated with several disadvantages. First, PCV often presents as multiple widely distributed lesions, so it may be difficult to treat all lesions, including multiple polyps and interconnecting vessels, with a single beam of PDT. Treatment of leaking polypoidal dilations only, without treating the entire vascular complex, can result in persistence or worsening of exudation. Second, it can be difficult to treat nodules in the peripapillary area with a round PDT beam. Third, features commonly associated with PCV such as a large PED or a large submacular hemorrhage usually are not amenable to PDT treatment. Fourth, PCV tends to recur repeatedly, so multiple PDT treatments are often necessary, which can increase the risk of long-term choroidal atrophy. Cases of massive subretinal or suprachoroidal hemorrhage have been reported soon after PDT. Even 50% reduced light-fluence PDT can produce a retinal pigment epithelial tear in pigment epithelial detachment.

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Ayana Yamashita, Fumio Shiraga — 2010-09-01

We thank Dr Chhablani for his interest in and comments on our article. There seems to be a racial difference in clinical characteristics of polypoidalchoroidal vasculopathy (PCV) among East Asians, including patients of Japanese, Korean or Chinese, and Asian Indian origins. More than 50% of the Japanese patients who are diagnosed with neovascular age-related macular degeneration actually have PCV. Most PCV lesions are located within the macula (peripapillary lesions are rare), and their greatest linear dimension usually is less than 7000 μm. Therefore, PCV lesions in Japanese patients are superficially similar to typical AMD lesions.

M. Bowes Hamill — 2010-09-01

Media Type: Textbook with DVD-ROM Synopsis: The fourth edition has been substantially re-edited to include a broad spectrum of topics in corneal surgery complementing the Krachmer, Mannis, and Holland's Cornea textbook, as well as to appeal to an international readership. To this end Dr. Brightbill has been joined by Drs. Farjo, McDonnell, McGhee, and Serdarevic as co-editors. This textbook is authored by international experts in the field and is extremely well-illustrated with photographs as well as outstanding color and line drawings by Laurel Cook Lhowe. For the first time a DVD is included, the quality of which may be its only weak aspect.

Richard Alan Lewis — 2010-09-01

Media Type: Reference Textbook Synopsis: Edited by internationally renowned authorities on ophthalmic drugs and their toxicities, this comprehensive text covers both the principles of drug therapy, mechanisms of their action and toxicity, and relevant evaluation and monitoring, and also the full range of side-effects on the visual system. Agents are classed by region of primary action and each drug's effects are capsulized by a standard outline and brief text, complete with relevant citations. Although there are minor stylistic irregularities, this is the incomparable reference on all agents with proven or potential toxicities in the visual system.

Michael G. Hunt — 2010-09-01

Media Type: iPhone application Synopsis: Technological advances have been integrated into the study and practice of ophthalmology for many years. The Eye Handbook capitalizes on the versatility of the iPhone to provide multiple reference, diagnostic, and testing tools in one application. From a searchable coding database to differential diagnosis and ophthalmology mnemonics, the broad range of information contained in this application can be useful for both those beginning their study of ophthalmology as well as for the seasoned practitioner. The testing section provides a helpful resource for those seeing patients outside the office. Because of the ease of expanding the data in this format, future versions can incorporate new information easily.

2010-09-01

American Journal of Ophthalmology

Evaluating Exaggerated, Prolonged, or Delayed Postoperative Intraocular Inflammation

Causality in the Systems Era of Pediatric Ophthalmology: The Buddha's Smile

Efficacy of Ranibizumab in Patients With Macular Edema Secondary to Central Retinal Vein Occlusion: Results From the Sham-Controlled ROCC Study

Randomized, Double-Masked, Sham-Controlled Trial of Ranibizumab for Neovascular Age-Related Macular Degeneration: PIER Study Year 2

Choroidal Thickness in Normal Eyes Measured Using Cirrus HD Optical Coherence Tomography

Analysis of Retinal Flecks in Fundus Flavimaculatus Using High-Definition Spectral-Domain Optical Coherence Tomography

AJO History of Ophthalmology Series: The End of the Tether

One-Year Outcomes After Retinal Detachment Surgery Among Medicare Beneficiaries

Polyethylene Glycol Hydrogel Polymer Sealant for Closure of Sutureless Sclerotomies: A Histologic Study

The Effect of Topical Autologous Serum on Graft Re-epithelialization After Penetrating Keratoplasty

Use of Intraoperative Fourier-Domain Anterior Segment Optical Coherence Tomography During Descemet Stripping Endothelial Keratoplasty

Periorbital Contact Sensitization

Association of Dyslipidemia in Moderate to Severe Meibomian Gland Dysfunction

Efficacy of Surface Ablation Retreatments Using Mitomycin C

Visual Outcomes of LASIK-Induced Monovision in Myopic Patients With Presbyopia

Macular Hole Surgery and Cataract Extraction: Combined vs Consecutive Surgery

Nosocomial Acute-Onset Postoperative Endophthalmitis at a University Teaching Hospital (2002–2009)

Bleb Morphology and Vascularity After Trabeculectomy With Intravitreal Ranibizumab: A Pilot Study

The Use of Titanium T-Plate as Platform for Globe Alignment in Severe Paralytic and Restrictive Strabismus

Unifocal and Multifocal Reactive Lymphoid Hyperplasia vs Follicular Lymphoma of the Ocular Adnexa

Comparison of In Situ Excision and Whole-Globe Recovery of Corneal Tissue in a Large, Single Eye Bank Series

Reporting Visual Acuities

Alcohol Consumption and the Long-Term Incidence of Cataract and Cataract Surgery: The Blue Mountains Eye Study

Paretic Side/Normal Side Ratios of Cross-Sectional Areas of the Superior Oblique Muscle Vary Largely in Idiopathic Superior Oblique Palsy

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Novel Dyes in Intraocular Surgery

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Reduced-Fluence Photodynamic Therapy for Polypoidal Choroidal Vasculopathy

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Contents