American Journal of Ophthalmology

At the Frontier of Vision Research: The National Eye Institute Celebrates 40 Years

Paul A. Sieving — 2010-02-01

This year marks the fortieth anniversary of the National Eye Institute (NEI), during which we celebrate 4 decades of leadership in basic and clinical science of the eye and vision. The NEI emerged from the National Institute of Neurological Diseases and Blindness in 1968 as the first government organization solely dedicated to research on human visual diseases and disorders. Its establishment was the result of both a Congressional interest and urging by prominent ophthalmologists.

On the Nature of, and Response to, Medical Evidence

Alfred Sommer — 2010-02-01

When President Obama announced his support for “evidence-based” medicine, I became very concerned. Might patients think our past medical practices and recommendations were not based on evidence? Recent events have validated my concerns, but for entirely different reasons. Many politicians, patients, and even physicians it appears, completely oppose basing clinical practices on sound evidence!

Muscle Paths Matter in Strabismus Associated With Axial High Myopia

Joseph L. Demer — 2010-02-01

The relationship between high axial myopia and severe strabismus has long been recognized. Our understanding of the pathogenesis of this form of strabismus has, however, evolved tremendously, as illustrated by the paper in this issue by Yamaguchi and associates. Classical concepts of pathogenesis of severe myopic strabismus included supposition that the enlarged, highly myopic globe was gravitationally heavy and would physically sink to the orbital floor, or compress the lateral rectus muscle, causing ischemic paresis resulting in esotropia. These pathophysiologic suppositions provided ready explanations for the typical failure of standard recess/resect strabismus surgery to correct severe strabismus associated with high myopia. In retrospect, these formerly reasonable concepts now seem outdated.

Bayesian Methods for Data Analysis

Robert E. Weiss — 2010-02-01

The Bayesian approach to data analysis dates to the Reverend Thomas Bayes, who published the first Bayesian analysis (reprinted in Barnard 1958). Initially, Bayesian computations were difficult except for simple examples, and applications of Bayesian methods were uncommon until Adrian F. M. Smith began to spearhead applications of Bayesian methods to real data. Bayesian applications to science and medicine have exploded in the past 20 years (cf Berger 2000) because of the development of flexible and robust computational algorithms (Markov chain Monte Carlo).

HLA Typing in Uveitis: Use and Misuse

Katherine J. Zamecki, Douglas A. Jabs — 2010-02-01

Purpose: To evaluate the role of HLA typing as a diagnostic test in patients with uveitis.Design: Perspective derived from a literature review and analysis of reported results.Methods: Published data on the HLA associations of several uveitis entities and their prevalence among patients and the general population were used to calculate the positive predictive value of HLA testing as a diagnostic test for these disorders.Results: For nearly all diagnostic entities evaluated (including multiple sclerosis–associated intermediate uveitis, birdshot chorioretinitis, sympathetic ophthalmic, Behçet disease, and Vogt-Koyanagi-Harada disease), the positive predictive value was low (< 0.50), indicating the limited usefulness of routinely applied HLA typing as a diagnostic test. HLA-B27 testing may be of value in identifying a previously undiagnosed or misdiagnosed spondyloarthropathy among patients with recurrent acute anterior uveitis.Conclusions: In general, HLA typing has limited usefulness as a diagnostic test in patients with uveitis.

Unfolded Protein Response in Fuchs Endothelial Corneal Dystrophy: A Unifying Pathogenic Pathway?

2010-02-01

Purpose: To assess for activation of the unfolded protein response in corneal endothelium of Fuchs endothelial corneal dystrophy patients.Design: Retrospective, comparative case series of laboratory specimens.Methods: Corneal specimens of patients with Fuchs dystrophy and controls with corneal pathologic features other than Fuchs dystrophy were evaluated by transmission electron microscopy (TEM) to evaluate for structural changes of the rough endoplasmic reticulum in corneal endothelium. TEM images were evaluated for alterations of rough endoplasmic reticulum as a sign of unfolded protein response. Normal autopsy eyes, Fuchs dystrophy corneas, and keratoconus corneas were used for immunohistochemistry. Immunohistochemistry was performed on formalin-fixed, paraffin-embedded sections of patient corneas for 3 unfolded protein response markers (GRP78, the α subunit of eukaryotic initiation factor 2, C/EBP homologous protein) and 2 apoptosis markers (caspase 3 and 9). Immunohistochemistry signal quantitation of corneal endothelium for evaluation of marker expression was performed using automated software. Corneal sections were assessed quantitatively for levels of immunohistochemistry marker expression.Results: TEM showed enlargement of rough endoplasmic reticulum in corneal endothelium of all Fuchs dystrophy specimens. Immunohistochemistry quantitation demonstrated a significant increase in mean signal in corneal endothelium from Fuchs dystrophy patients for markers GRP78, the α subunit of eukaryotic initiation factor 2, C/EBP homologous protein, and caspase 9 compared with non-Fuchs dystrophy corneas (P < .05).Conclusions: Results of both TEM and immunohistochemistry indicate activation of unfolded protein response in Fuchs dystrophy. Unfolded protein response activation leads to endothelial cell apoptosis in Fuchs dystrophy and may play a central pathogenic role in this disease.

Management of Acute Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Utilizing Amniotic Membrane and Topical Corticosteroids

2009-12-11

Purpose: To describe the results of a novel treatment approach to the acute ophthalmic management of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN).Design: Retrospective interventional case series.Methods: setting: Institutional. study population: Sixteen eyes of 8 patients with acute, biopsy-proven SJS or TEN and significant ophthalmic involvement. interventional procedure(s): Application of amniotic membrane to the ocular surface, either in the operating room or at the bedside, and short-term use of intensive topical corticosteroid medication. main outcome measures: Visual acuity, slit-lamp appearance of the ocular surface, and patients' subjective impression of ocular comfort.Results: Two patients expired during the hospitalization. Mean follow-up time for the surviving patients was 7.7 months. Four surviving patients in whom the entire ocular surface (ie, the cornea, bulbar and palpebral conjunctiva, and eyelid margins) was treated with amniotic membrane retained visual acuities of 20/40 or better and an intact ocular surface. In contrast, the initial 2 patients in the study who were treated with only a Prokera device or unsutured amniotic membrane sheets, leaving the palpebral conjunctiva and eyelid margins uncovered, developed more significant ocular surface abnormalities, and 1 developed a corneal perforation.Conclusions: Amniotic membrane coverage of the ocular surface in its entirety coupled with the use of intensive short-term topical corticosteroids during the acute phase of SJS and TEN is associated with the preservation of good visual acuity and an intact ocular surface. Partial amniotic membrane coverage of the ocular surface may not serve to minimize the cicatrizing ocular sequelae of SJS and TEN as effectively as complete coverage.

Late Varicella-Zoster Virus Dendriform Keratitis in Patients With Histories of Herpes Zoster Ophthalmicus

2009-11-11

Purpose: To describe the characteristics and course of late varicella-zoster virus (VZV) dendriform keratitis in patients with histories of herpes zoster ophthalmicus (HZO); to describe responses of corneal lesions to antiviral treatment; and to investigate risk factors for recurrence.Design: Retrospective case series.Methods: Included were patients known to have 1 or more episodes of dendriform lesions beginning at least 2 weeks after HZO in 2 academic practices. Epithelial lesions were evaluated for the presence of VZV DNA by a polymerase chain reaction assay. Demographic, medical, and ophthalmic data were collected for each episode. Responses to treatment with antiviral medications were evaluated. Cumulative risk of recurrence was determined using Kaplan-Meier analysis; potential risk factors for recurrence (age, systemic disease, lesion characteristics, corticosteroids) were evaluated using univariate Cox proportional hazard models.Results: We identified 20 patients (14 women; median age, 65 years) who met inclusion criteria. Dendriform lesions were pleomorphic with thickened, opaque epithelium. Seven patients had systemic diseases characterized by altered immune function. VZV DNA was identified in 15 of 16 cases tested, and all lesions responded to antiviral therapy. The 1-year incidence of first recurrence was 95.8 lesions per 100 person-years of follow-up. Patients had multiple recurrences, but risk of recurrence appeared to decrease over time. No statistically significant risk factors for recurrence were identified.Conclusions: Late dendriform lesions associated with HZO are foci of productive VZV infection. Lesions can be treated effectively with topical or systemic antiviral agents. Patients can have multiple recurrences of dendriform lesions despite treatment.

Cost-Effectiveness of the Boston Keratoprosthesis

2009-11-24

Purpose: To conduct a cost-utility analysis and determine the cost-effectiveness of the Boston Keratoprosthesis (Boston Kpro).Design: Retrospective cohort study.Methods: setting: The Massachusetts Eye and Ear Infirmary corneal service. patients: Inclusion required a minimum 2-year follow-up. Patients with autoimmune diseases and chemical burns were excluded. Eighty-two patients were included with various indications for surgery. intervention: The keratoprosthesis is a collar button–shaped polymethylmethacrylate (PMMA) device consisting of 2 curved plates sandwiched around a corneal donor (allo)graft. The device is assembled intraoperatively and sutured to a patient's eye after removing the diseased cornea. main outcome measures: Average cost-effectiveness of the keratoprosthesis was determined by cost-utility analysis, using expected-value calculations and time-tradeoff utilities. The comparative effectiveness, or gain in quality-adjusted life years (QALYs), was also sought. Cost-effectiveness was compared to recently published data on penetrating keratoplasty (PK).Results: A total discounted incremental QALY gain for the Boston Kpro of 0.763 correlated with a conferred QALY gain of 20.3% for the average patient. The average cost-effectiveness of the keratoprosthesis was $16 140 per QALY.Conclusions: Comparable to corneal transplantation, with a cost-effectiveness between $12 000 and $16 000 per QALY, the keratoprosthesis can be considered highly cost-effective.

Predictive Factor Analysis for Successful Performance of Iris Recognition-Assisted Dynamic Rotational Eye Tracking during Laser In Situ Keratomileusis

2009-11-06

Purpose: To analyze the predictive factors associated with success of iris recognition and dynamic rotational eye tracking on a laser in situ keratomileusis (LASIK) platform with active assessment and correction of intraoperative cyclotorsion.Design: Interventional case series.Methods: Two hundred seventy-five eyes of 142 consecutive candidates underwent LASIK with attempted iris recognition and dynamic rotational tracking on the Technolas 217z100 platform (Techolas Perfect Vision, St Louis, Missouri, USA) at a tertiary care ophthalmic hospital. The main outcome measures were age, gender, flap creation method (femtosecond, microkeratome, epi-LASIK), success of static rotational tracking, ablation algorithm, pulses, and depth; preablation and intraablation rotational activity were analyzed and evaluated using regression models.Results: Preablation static iris recognition was successful in 247 eyes, without difference in flap creation methods (P = .6). Age (partial correlation, −0.16; P = .014), amount of pulses (partial correlation, 0.39; P = 1.6 × 10−8), and gender (P = .02) were significant predictive factors for the amount of intraoperative cyclodeviation. Tracking difficulties leading to linking the ablation with a new intraoperatively acquired iris image were more with femtosecond-assisted flaps (P = 2.8 × 10−7) and the amount of intraoperative cyclotorsion (P = .02). However, the number of cases having nonresolvable failure of intraoperative rotational tracking was similar in the 3 flap creation methods (P = .22).Conclusions: Intraoperative cyclotorsional activity depends on the age, gender, and duration of ablation (pulses delivered). Femtosecond flaps do not seem to have a disadvantage over microkeratome flaps as far as iris recognition and success of intraoperative dynamic rotational tracking is concerned.

Ten-Year Longitudinal Visual Function and Nd: YAG Laser Capsulotomy Rates in Patients Less Than 65 Years at Cataract Surgery

Britta Lundqvist, Eva Mönestam — 2009-11-18

Purpose: To investigate the longitudinal subjective and objective visual functional results in adult cataract patients younger than 65 years at surgery. To evaluate the 10-year cumulative incidence of neodymium–yttrium-aluminum-garnet (Nd:YAG) laser treatment.Design: A prospective, longitudinal, population-based cohort study.Methods: The study comprised 116 patients younger than 65 years who had cataract surgery during 1 year at Norrlands University Hospital, Umeå, Sweden. Most patients (94%) had received implantation with a hydrophobic acrylic intraocular lens. Evaluated were visual acuity (VA) and visual function questionnaire (VF-14) results before and after surgery. A comparison with patients 65 years or older at surgery was made. Ten years later, 102 survivors were offered eye examinations and again asked to fill out the questionnaire. Past Nd:YAG laser treatment, as well as high- and low-contrast VA results, were analyzed.Results: Ten years postoperatively, 37% of the patients under 65 at surgery had been treated with Nd:YAG in comparison to 20% of the older patients. The cumulative incidence for not having Nd:YAG over 10 years was 72% for those under 65 and 85% for the patients 65 years or more at surgery. Eighteen percent of the younger patients had lost more than 0.1 logarithm of the minimal angle of resolution (logMAR) units of the operated eye, compared with 37% of the older (P = .00003). A reduction in VF-14 score of 10 points or more was found in 9% of the younger and 28% of the older cataract surgery patients (P = .00004).Conclusion: Ten years after surgery, subjective and objective visual function remained stable in most patients younger than 65 years at surgery. More than one-third had received a posterior capsulotomy. Only a few patients with posterior capsular opacification requiring Nd:YAG were untreated at the 10-year follow-up.

Ultrasound Biomicroscopic Analysis of Iris-Sutured Foldable Posterior Chamber Intraocular Lenses

2009-11-06

Purpose: To report ultrasound biomicroscopic (UBM) findings of iris-sutured foldable posterior chamber intraocular lenses (PCIOLs).Design: Prospective, noninterventional consecutive case series.Methods: Fifteen eyes with foldable acrylic IOL implantation using peripheral iris suture fixation in the absence of capsular support were included. UBM was used to determinate the haptic position in relation to the ciliary sulcus and ciliary body in these eyes. Additionally, anterior chamber depth, lens tilt, site of suture fixation, focal iris or angle abnormalities, and relationship of iris to lens were determined. Main outcome measures were haptic position, anterior chamber depth, and iris anatomic changes.Results: Of the 30 haptics imaged, 16 (53.3%) were positioned in the ciliary sulcus. Nine (30%) haptics were found over the ciliary processes, and 5 (16.7%) were over pars plana. No patients were found to have peripheral anterior synechiae present at the haptic position. The mean (± standard deviation) depth of the anterior chamber was 3.84 ± 0.36 mm. The iris profile was altered in all patients at the iris–haptic suture fixation site. No angle abnormalities or tilted lenses were found.Conclusions: Iris-sutured PCIOL haptics were found to be in the ciliary sulcus or over the ciliary body with no significant tilt on UBM analysis. The procedure respects the angle anatomy, and no evidence of angle closure was found. The anterior chamber was deeper than has been reported previously for scleral sutured PCIOLs and was similar to that of pseudophakic eyes. This may have implications for surgical technique, IOL power calculations, and postoperative complications.

Rotational Stability of a Single-Piece Hydrophobic Acrylic Intraocular Lens During Removal of Ophthalmic Viscosurgical Devices

Joon Young Hyon, Hwan Eok Yeo — 2009-11-06

Purpose: To compare the effect of cohesive and dispersive ophthalmic viscosurgical device (OVD) on intraoperative rotational stability of the intraocular lens (IOL) with single-piece hydrophobic acrylate platform.Design: Prospective, comparative study.Methods: This institutional clinical study included 60 eyes of 60 patients who underwent phacoemulsifcation. The patients were equally divided into cohesive OVD (Healon GV; Abbott Medical Optics, Abbott Park, Illinois, USA) group and dispersive OVD (Viscoat; Alcon Laboratories, Fort Worth, Texas, USA) group. Image analysis from the captured digital image was used to measure intraoperative rotation of single-piece hydrophobic acrylate IOL (SA60AT or SA60NT) during OVD removal.Results: Mean intraoperative rotation was 7.42 degrees ± 4.16 (standard deviation) in dispersive OVD group and 13.08 degrees ± 5.25 (standard deviation) in cohesive OVD group (P < .001). Twenty-one cases (70%) maintained the alignment within 10 degrees during removal of OVD with dispersive OVD, while only 9 cases (30%) did so with cohesive OVD (P = .005). Counterclockwise rotation was observed in 33% of the all cases.Conclusions: This study showed that a significant amount of IOL rotation occurred during OVD removal. Intraoperative rotational stability of IOL was greater with Viscoat than with Healon GV.

Glaucoma Surgery Decreases the Rates of Localized and Global Visual Field Progression

2010-02-01

Purpose: Incisional glaucoma surgical procedures produce greater intraocular pressure (IOP) reduction and less IOP variability than medical treatment. We sought to determine the efficacy of glaucoma surgery in decreasing localized and global rates of visual field (VF) progression.Design: Retrospective, interventional case series.Methods: Subjects in the New York Glaucoma Progression Study with glaucomatous optic neuropathy, repeatable VF loss, and 10 or more Swedish interactive threshold algorithm standard VF examinations were assessed for eligibility. Patients who underwent successful glaucoma surgery (not requiring further surgical intervention and IOP < 18 mm Hg) in either eye and who were followed up for at least 2 years before and after surgery were enrolled. Automated pointwise linear regression analysis was used to calculate global and localized rates of progression before and after surgery. Eyes with other ocular conditions likely to affect the VF and an insufficient number of VF to create a slope before and after surgery were excluded. Comparisons were performed within the same eyes before and after surgery (Student paired t test).Results: We enrolled 28 eyes of 28 patients (mean age, 61.2 ± 14.5 years). The mean number ± standard deviation of VF was 13.4 ± 2.3, spanning 7.1 ± 1.2 years (range, 4 to 9 years). Mean IOP ± standard deviation decreased from 19.0 ± 3.9 mm Hg before surgery to 11.3 ± 3.7 mm Hg after surgery (40% reduction; P < .01). Mean global progression rates decreased from −1.48 ± 1.4 dB/year before surgery to −0.43 ± 0.8 dB/year after surgery (70% reduction; P = .01). Twelve eyes (42.8%) had at least 1 significantly progressing point before surgery, whereas only 2 (7.1%) had at least 1 progressing point after surgery. Each 1 mm Hg of IOP reduction after surgery resulted in a 0.1 dB/year decrease in the global rate of progression.Conclusions: Successful IOP reduction after glaucoma surgery greatly reduces both the number of progressing points and the localized and general rates of VF progression.

Ability of New Vital Dyes to Stain Intraocular Membranes and Tissues in Ocular Surgery

2009-11-06

Purpose: To evaluate the ability of novel dyes to stain lens capsule (LC), internal limiting membrane (ILM), epiretinal membrane (ERM), and vitreous.Design: Experimental study in animal and human donor eyes.Methods: Thirteen dyes, methyl violet, crystal violet, eosin Y, sudan black B, methylene blue, toluidine blue, light green, indigo carmine, fast green, congo red, evans blue, brilliant blue, and bromophenol blue, were injected onto the LC and ILM of enucleated porcine eyes. The vitreous was stained with 2 mL of dyes for 1 minute. Six dyes (indigo carmine, evans blue, fast green, light green, bromophenol blue, and brilliant blue) were selected for experiments in human donor eyes and freshly removed ERM.Results: In the porcine eyes, ILM staining with methylene blue, toluidine blue, indigo carmine, evans blue, bromophenol blue, and fast green was moderate, and methyl violet, crystal violet, brilliant blue, or sudan black resulted in strong staining. Methyl violet, crystal violet, sudan black, toluidine blue, and methylene blue caused histologic damage in porcine retinas. Vitreous examination revealed moderate staining with congo red, crystal violet, fast green, eosin Y, methylene blue, toluidine blue, brilliant blue, bromophenol blue, and methyl violet and strong staining with light green and evans blue. ERMs showed strong staining with 0.5% evans blue and moderate staining with 0.5% light green, fast green, brilliant blue, and bromophenol blue. Evaluation of donor eyes disclosed moderate staining with evans blue, light green, and bromophenol blue and strong staining with 0.5% brilliant blue. Moderate or strong staining of the vitreous occurred with most dyes. LC evaluation showed moderate staining with 0.5% evans blue, fast green, and brilliant blue, whereas 0.5% light green produced strong LC staining.Conclusions: Brilliant blue shows the best ILM staining, whereas bromophenol blue, evans blue, and light green also stain ILM. Most dyes bind well to LC, vitreous, and ERM.

Staphylococcus aureus Endophthalmitis: Antibiotic Susceptibilities, Methicillin Resistance, and Clinical Outcomes

2009-11-18

Purpose: To investigate the antibiotic susceptibility and clinical outcomes of endophthalmitis caused by methicillin-sensitive Staphylococcus aureus (MSSA) versus methicillin-resistant (MRSA) S. aureus.Design: Retrospective, consecutive case series.Methods: Charts of 32 patients with culture-proven S. aureus endophthalmitis seen at the Bascom Palmer Eye Institute from January 1, 1995, through January 1, 2008, were reviewed. Antibiotic susceptibility profiles, identified using standard microbiologic protocols, and visual acuity at 1 and 3 months were the main outcome measures.Results: MSSA was recovered from 19 (59%) of 32 patients and MRSA was recovered from 13 (41%) of 32 patients. Causes included cataract surgery in 18 (56%) of 32 patients, endogenous in 5 (16%) of 32 patients, bleb association in 4 (13%) of 32 patients, pars plana vitrectomy and ganciclovir implantation in 3 (9%) of 32 patients, and trauma in 2 (6%) of 32 patients. All isolates were sensitive to vancomycin. MSSA isolates were sensitive to all tested antibiotics, except one that exhibited fluoroquinolone resistance. In the MRSA group, frequent resistance occurred with the fourth-generation fluoroquinolones (moxifloxacin, 5 of 13 patients [38%]; gatifloxacin, 5 of 13 patients [38%]). The median presenting visual acuity was approximately hand movements for both MSSA and MRSA eyes. All eyes received intravitreal antibiotics. Pars plana vitrectomy was performed on 47% of MSSA and 61% of MRSA patients. A final visual acuity of 20/400 or better at 3 months was achieved in 59% of MSSA and 36% of MRSA patients (P = .5).Conclusions: Although all MSSA and MRSA isolates were sensitive to vancomycin, fewer than half of MRSA isolates were sensitive to the fourth-generation fluoroquinolones. Visual acuity outcomes between MRSA and MSSA eyes were not significantly different.

Restoration of Photoreceptor Outer Segment after Vitrectomy for Retinal Detachment

2009-11-25

Purpose: To report photoreceptor restoration and visual outcomes after vitrectomy for retinal detachment.Design: Retrospective, observational case series.Methods: We prospectively studied the tomographic features of reattached retinas in 20 eyes with a macula-off rhegmatogenous retinal detachment using spectral-domain optical coherence tomography 1, 3, and 6 months after 3-port vitrectomy with SF6 gas tamponade. All eyes were examined more than 3 months after surgery.Results: The optical coherence tomography foveal findings were classified as a disrupted inner segment and outer segment (IS/OS) line, a residual foveal detachment, and a continuous IS/OS line. A disrupted IS/OS line was seen in 11 eyes (55%) at 1 month and in 8 eyes (40%) at 3 months, a foveal detachment was seen in 8 eyes (40%) at 1 month and in 7 eyes (35%) at 3 months, and a continuous IS/OS line was seen in 1 eye (5%) at 1 month and in 5 eyes (25%) at 3 months. In 18 eyes followed up for 6 months, optical coherence tomography showed a disrupted IS/OS line in 3 eyes (17%), a foveal detachment in 6 eyes (33%), and a continuous IS/OS line in 9 eyes (50%). The mean best-corrected visual acuities at 1 and 6 months were 0.26 and 0.16 with a disrupted IS/OS line, 0.60 and 0.95 with a foveal detachment, and 0.8 and 0.95 with a continuous IS/OS line. The mean best-corrected visual acuity was significantly (P < .0001) lower with a disrupted IS/OS line compared with the other formations at 6 months.Conclusions: The IS/OS line at the fovea recovered gradually after surgery. The postoperative visual acuity was correlated with a restored IS/OS line.

Serous Retinal Detachment Associated With Retinal Vein Occlusion

2010-02-01

Purpose: To study the pathomorphology of serous retinal detachment (RD) associated with retinal vein occlusion by optical coherence tomography (OCT).Design: Retrospective chart review.Methods: Ninety-one eyes of 91 patients with macular edema associated with retinal vein occlusion had undergone a comprehensive ophthalmologic examination, including measurement by spectral-domain OCT.Results: Eyes with macular edema associated with retinal vein occlusion typically showed foveal cystoid spaces and marked retinal swelling, especially in the outer retina. In addition, 76 eyes (83.5%) showed serous RD involving the fovea, which ranged in thickness from 64 μm to 871 μm (219.2 ± 161.6 μm). Fifty-two eyes showed a small pointed RD, with a small base. The point of the RD was always located beneath the fovea, where the outer surface of the swollen neurosensory retina seemed to be contracted inward, resulting in development of the pointed RD. Two eyes with no RD at the initial visit developed such a pointed RD during follow-up. In contrast, 24 eyes showed a more dome-shaped RD, with a large base, and in 18 eyes, a pointed RD seen at the initial visit changed into a dome-shaped RD during follow-up. In some cases, small outer retinal discontinuity was seen on the external surface of the swollen neurosensory retina.Conclusions: In eyes with retinal vein occlusion, a small pointed RD initially developed just beneath the fovea, but subsequently changed into a dome-shaped RD. Based on the findings by OCT, we hypothesize that the foveal architecture, especially that of the Müller cell cone, is involved in the formation of serous RD.

Idiopathic Epiretinal Macular Membrane and Cataract Extraction: Combined versus Consecutive Surgery

2010-02-01

Purpose: To assess the functional and anatomic outcomes of cataract and idiopathic epiretinal macular membrane extraction in combined and consecutive surgeries.Design: Multicenter, retrospective, comparative case series.Methods: One hundred seventy-four patients (174 eyes) with an epiretinal macular membrane (ERM) and cataract were operated on in 1 or 2 sessions in 2 academic centers, Dijon University Hospital and Nancy University Hospital. Combined surgery (n = 109) and consecutive surgery (n = 65) were performed between 2005 and 2006. All patients underwent ERM and internal limiting membrane removal. Cataract extraction was performed with phacoemulsification followed by a posterior chamber intraocular lens implantation. The main outcome measures were near and far visual acuity and central macular thickness 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). Similarly, the postoperative macular thickness significantly decreased in both groups (P < .0001). We noted no statistical differences between the visual acuity improvement in both groups (near vision, P= .54; far vision, P = .38). However, visual acuity recovery was quicker in the combined surgery group.Conclusions: Combined and consecutive surgeries are effective procedures to treat idiopathic ERM. The functional and anatomic results are equivalent in both procedures.

Reporting Visual Acuities

2010-02-01

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.

Standard-Fluence versus Low-Fluence Photodynamic Therapy in Chronic Central Serous Chorioretinopathy: A Nonrandomized Clinical Trial

2009-11-06

Purpose: To evaluate the efficacy of low-fluence compared with standard-fluence rate photodynamic therapy (PDT) for treating chronic central serous chorioretinopathy.Design: Prospective, multicenter, investigator-masked, nonrandomized clinical trial.Methods: Forty-two eyes (42 patients) with chronic central serous chorioretinopathy were enrolled; 19 eyes received indocyanine green angiography-guided standard-fluence PDT (50 J/cm2) and 23 eyes received indocyanine green angiography-guided low-fluence PDT (25 J/cm2). Primary outcome measures were the changes in mean logarithm of the minimal angle of resolution best-corrected visual acuity and the rate of eyes with complete subretinal fluid reabsorption. Secondary outcomes were the changes in central foveal thickness and choroidal perfusion.Results: Mean logarithm of the minimal angle of resolution best-corrected visual acuity improved significantly at all time points (P < .01), in the standard-fluence group from 0.43 to 0.24 at 12 months and in the low-fluence-group from 0.46 to 0.16, without significant difference between the 2 groups. At 12 months, a complete subretinal fluid reabsorption was seen in 15 standard-fluence–treated and 21 low-fluence–treated eyes (79% vs 91%; P = .5). In 1 standard-fluence eye, choroidal neovascularization developed at 3 months, and this eye received further PDT; in the other eyes, at 12 months, a moderate-significant choriocapillaris nonperfusion was seen in 8 standard-fluence–treated and 0 low-fluence–treated eyes (44% vs 0%; P = .002).Conclusions: In most of the eyes, both standard-fluence PDT and low-fluence PDT resulted in complete subretinal fluid reabsorption with visual acuity improvement. Choroidal hypoperfusion related to PDT could be reduced by low-fluence PDT.

Subretinal Hemorrhages Associated with Age-Related Macular Degeneration in Patients Receiving Anticoagulation or Antiplatelet Therapy

2009-11-24

Purpose: To evaluate the incidence of and risk factors for subretinal hemorrhages in age-related macular degeneration (AMD) patients on anticoagulation or antiplatelet therapy.Design: Retrospective, observational case series.Methods: We retrospectively reviewed the medical and photographic records of 71 consecutive patients who sought treatment at our institution with acute subretinal hemorrhages complicating age-related macular degeneration. The size of the subretinal hemorrhage was measured in standardized Macular Photocoagulation Study disc areas. Data on the use of medications and medical indications for anticoagulation and antiplatelet therapy were obtained.Results: Overall, patients receiving antithrombotic therapy had a significantly larger subretinal hemorrhage size (mean, 9.71 disc areas) than patients not receiving anticoagulant or antiplatelet therapy (mean, 2.99 disc areas). Subgroup analysis revealed that both antiplatelet (P < .0001) and anticoagulant therapy (P = .003) were associated with a significantly larger bleeding size. Moreover, subgroup analysis among patients with arterial hypertension revealed that individuals receiving antithrombotic therapy had a statistically significantly larger hemorrhage size than hypertensive patients who did not receive anticoagulants or antiplatelet agents (P < .0001).Conclusions: Our results indicate that anticoagulants and antiplatelet agents are strongly associated with the development of large subretinal hemorrhages in AMD patients. Moreover, arterial hypertension is a strong risk factor for large subretinal hemorrhages in AMD patients receiving anticoagulants or antiplatelet agents. Physicians should be aware of an increased risk of extensive subretinal hemorrhage in AMD patients when deciding on the initiation and duration of anticoagulant and antiplatelet therapy.

Prognostic Factors of Vitreous Hemorrhage Secondary to Exudative Age-Related Macular Degeneration

2010-02-01

Purpose: Vitreous hemorrhage (VH) is a rare but serious complication of the eyes with exudative age-related macular degeneration (AMD). This retrospective study was designed to evaluate various clinical factors that may affect the visual prognosis of patients with VH secondary to exudative AMD.Design: Retrospective case study.Methods: We intensively documented 31 cases of VH secondary to exudative AMD and retrospectively analyzed best-corrected visual acuity (BCVA). All eyes underwent standard pars plana vitrectomy (PPV) for treating VH. Three subgroups were created according to the clinical course and treatment history before the occurrence of VH: (1) gas group (7 eyes), pneumatic displacement with sulfur hexafluoride gas performed to treat massive submacular hemorrhage; (2) photodynamic therapy (PDT) group (9 eyes), PDT performed to treat exudative AMD; (3) untreated group (15 eyes), no treatment performed.Results: As a whole, BCVA before the occurrence of VH was 1.05 ± 0.59 (logarithm of the minimal angle of resolution). After the occurrence of VH, BCVA before PPV dropped to 2.61 ± 0.82. After the operation, final BCVA improved significantly to 1.25 ± 0.73 (P< 10−8). In a subgroup analysis, no statistically significant difference was seen among the 3 subgroups at any time point. We found that the eyes whose fellow eye had exudative AMD showed significantly poor final BCVA compared with the unilateral cases (0.92 ± 0.57 and 1.49 ± 0.72; P = .02).Conclusions: PPV can improve visual acuity in the eyes with VH secondary to AMD, although effectiveness is limited. Medical practitioners should be cautious of the visual prognosis, especially in the cases in which the fellow eye has exudative AMD.

Reliability and Validity of Abbreviated Surveys Derived from the National Eye Institute Visual Function Questionnaire: The Study of Osteoporotic Fractures

2010-02-01

Purpose: To test the reliability and validity of questionnaires shortened from the National Eye Institute 25-item Vision Function Questionnaire (NEI VFQ-25).Design: Cross-sectional, multicenter cohort study.Methods: Reliability was assessed by Cronbach α coefficients. Validity was evaluated by studying the association of vision-targeted quality-of-life composite scores with objective visual function measurements. A total of 5482 women between the ages of 65 and 100 years participated in the year-10 clinic visit in the Study of Osteoporotic Fractures (SOF). A total of 3631 women with complete data were included in the visual acuity (VA) and visual field (VF) analyses of the 9-item NEI VFQ (NEI VFQ-9), which is defined for those who care to drive, and a total of 5311 women with complete data were included in the VA and VF in the analyses of the 8-item NEI VFQ (NEI VFQ-8). To assess differences in prevalent eye diseases, which were ascertained for a random sample of SOF participants, 853 and 1237 women were included in the NEI VFQ-9 and the NEI VFQ-8 analyses, respectively.Results: The Cronbach α coefficient for the NEI VFQ-9 scale was 0.83, and that of the NEI VFQ-8 was 0.84. Using both questionnaires, women with VA worse than 20/40 had lower composite scores compared with those with VA of 20/40 or better (P < .001). Participants with mild, moderate, and severe binocular VF loss had lower composite scores compared with those with no binocular VF loss (P < .001). Compared with women without chronic eye diseases in both eyes, women with at least 1 chronic eye disease in at least 1 eye had lower composite scores.Conclusions: Both questionnaires showed high reliability across items and validity with respect to clinical markers of eye disease. Future research should compare the properties of these shortened surveys with those of the NEI VFQ-25.

Surgical Procedure for Correcting Globe Dislocation in Highly Myopic Strabismus

Makoto Yamaguchi, Tsuranu Yokoyama, Kunihiko Shiraki — 2009-11-24

Purpose: To design a surgical procedure for correcting globe dislocation in strabismus in high myopia (highly myopic strabismus).Design: Prospective, interventional case series.Methods: We examined 36 eyes of 21 patients with highly myopic strabismus and 27 eyes of 27 healthy volunteers as controls at Osaka City General Hospital between 2000 and 2006. Anatomic relationships between the muscle cone and globe were analyzed using magnetic resonance imaging. Ranges of globe movement and angles of ocular deviation were measured quantitatively as angles of maximum abduction and sursumduction and angles of ocular deviation, respectively, using the Goldmann perimeter and alternate prism cover tests. A surgical procedure involving muscle union of the superior rectus and lateral rectus muscles was performed in 23 eyes of 14 patients to restore the dislocated globe back to the muscle cone.Results: After surgery, the angle of dislocation of the globe, defined as the angle formed by a line connecting the area centroid of the superior rectus muscle and the globe and a line connecting area centroid of the lateral rectus muscle and globe against the supertemporal wall of the orbit, was significantly decreased (P < .001), and angles of maximum abduction and sursumduction and the angle of ocular deviation improved significantly (P < .001).Conclusions: This surgical procedure to restore the dislocated globe back into the muscle cone by uniting muscle bellies of the superior rectus and lateral rectus muscles is effective for highly myopic strabismus.

Height, Stunting, and Refractive Error Among Rural Chinese Schoolchildren: The See Well to Learn Well Project

2009-10-29

Purpose: To evaluate the hypothesis that changes in nutritional status could be partly responsible for observed increases in myopia prevalence among Chinese children.Design: Cross-sectional cohort study.Methods: Rural Chinese secondary school children participating in a study of interventions to promote spectacle use were randomly sampled (20% of children with uncorrected vision >6/12 bilaterally, and 100% of remaining children) and underwent cycloplegic refraction with subjective refinement and measurement of height and weight. Stunting was defined according to the World Health Organization standard population.Results: Among 3226 children in the sample, 2905 (90.0%) took part. Among 1477 children undergoing refraction, 1371 (92.8%) had height and weight measurements. These children had a mean age of 14.5 ± 1.4 years, 59.8% were girls, and mean spherical equivalent refraction was −1.93 ± 1.82 diopters. Stunting was present in 87 children (6.4%). While height was inversely associated with refractive error (RE) (taller children were more myopic) among boys (r = −0.147, P = .001), this disappeared when adjusting for age, and no such association was observed among girls. Neither girls nor boys with stunting differed significantly in refraction from children without stunting, and neither stunting nor height was associated with RE when adjusting for age, height, and parental education. The power of this study to have detected a 0.75 diopters difference in RE between children with and without stunting was 0.96.Conclusion: Results from this cross-sectional study are not consistent with the hypothesis that nutritional status is a determinant of RE in this setting.

Systemic and Local Management at the Onset of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis with Ocular Complications

Chie Sotozono, Mayumi Ueta, Shigeru Kinoshita — 2010-02-01

Stevens-Johnson Syndrome (SJS) and Toxic Epidermal necrolysis (TEN) are recognized as two of the most devastating ocular surface disorders and are extremely difficult to treat both at the acute and later stages. Massive inflammation on the ocular surface at the acute stage often is uncontrollable. Even after the acute-stage impairments subside, ocular complications such as serious visual impairment with dry eye and keratinization remain at the later stage. Recently, we reported in our retrospective analysis that visual outcomes at the later stage were significantly better in the group receiving topical steroids at the acute stage compared with the no-treatment group (P < .00001). Furthermore, using a prospective study, we confirmed the therapeutic importance of steroid therapy at disease onset for reducing the degree of ocular complications. Therefore, we read with great interest the editorial entitled “Acute Management of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis to Minimize Ocular Sequelae” by Scheffer C. G. Tseng, in which the author states that “systemic high-dose of glucocorticoids may heighten the risk of inciting (existing) infections in the wake of managing patients with life-threatening diseases.” In this editorial, the author suggests that amniotic membrane transplantation (AMT) may be a better strategy for reducing immunoreactions on the ocular surface. However, in some aspects, we are not in agreement with the author's comments.

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Scheffer C.G. Tseng — 2010-02-01

Inspired by the encouraging finding reported by his group based on pulse systemic steroid and topical betamethasone therapies, the author drafted the editorial entitled “Acute Management of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis to Minimize Ocular Sequelae” with a single purpose in mind, that is, to call consulting ophthalmologists' attention to take an active role in ameliorating potentially blinding complications during the acute care of patients inflicted with Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN; see the first and the last paragraph of the editorial). This effort is augmented by a new literature revelation indicating that SJS/TEN can be distinguished, clinically, from an often-confusing entity termed erythema multiforme and that promising therapies have emerged to avert ophthalmic sequelae.

Announcement

2010-02-01

Marco A. Zarbin, MD, is this year's recipient of the Heed Award. Dr. Zarbin, a previous Heed Fellow, received the award at the annual alumni luncheon of the Society of Heed Fellows during the 2009 American Academy of Ophthalmology Meeting in San Francisco, California.

Elizabeth Yeu — 2010-02-01

Media Type: Handbook/textbook Synopsis: Alastair Denniston and Philip Murray have followed up the first edition of the Oxford Handbook of Ophthalmology with an excellent, very thorough handbook that is useful for ophthalmologists at any stage in their training or career. The book has many contributing authors, all of whom are based in the UK.

Charles N.S. Soparkar — 2010-02-01

Media Type: Textbook Synopsis: The scope of oculoplastic cosmetic procedures continues to expand in both range and depth of understanding. Pearls and Pitfalls in Cosmetic Oculoplastic Surgery ambitiously reviews many of the most frequently performed oculoplastic, cosmetic procedures through a well-organized compilation of over a hundred and seventy contributions from nearly a hundred authors, detailing favored approaches and “tricks of the trade.” Novices and senior surgeons alike will benefit from the long string of pearls amassed to prevent the most common pitfalls. Although the material is densely presented, chapter brevity makes this an easy pick-up read.

Peter T. Chang — 2010-02-01

Media Type: Textbook Synopsis: This book is an 8th edition of the classic textbook originally published by Drs. Shaffer and Becker in 1961. The goal is “to provide, in one comprehensive volume, information from the clinician's viewpoint” for the management of glaucoma. In a departure from previous editions, several contributors in addition to the principal authors have assisted with 6 of the 39 chapters; nonetheless, the three principal authors succeed in preserving the cohesiveness of the text, sometimes missing in textbooks in which each chapter is authored by different contributors. Becker-Shaffer's Diagnosis and Therapy of the Glaucomas, 8th edition, is effectively illustrated without being overdone and provides an excellent update to the diagnosis and treatment of different glaucoma entities.

2010-02-01

American Journal of Ophthalmology

At the Frontier of Vision Research: The National Eye Institute Celebrates 40 Years

On the Nature of, and Response to, Medical Evidence

Muscle Paths Matter in Strabismus Associated With Axial High Myopia

Bayesian Methods for Data Analysis

HLA Typing in Uveitis: Use and Misuse

Unfolded Protein Response in Fuchs Endothelial Corneal Dystrophy: A Unifying Pathogenic Pathway?

Management of Acute Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Utilizing Amniotic Membrane and Topical Corticosteroids

Late Varicella-Zoster Virus Dendriform Keratitis in Patients With Histories of Herpes Zoster Ophthalmicus

Cost-Effectiveness of the Boston Keratoprosthesis

Predictive Factor Analysis for Successful Performance of Iris Recognition-Assisted Dynamic Rotational Eye Tracking during Laser In Situ Keratomileusis

Ten-Year Longitudinal Visual Function and Nd: YAG Laser Capsulotomy Rates in Patients Less Than 65 Years at Cataract Surgery

Ultrasound Biomicroscopic Analysis of Iris-Sutured Foldable Posterior Chamber Intraocular Lenses

Rotational Stability of a Single-Piece Hydrophobic Acrylic Intraocular Lens During Removal of Ophthalmic Viscosurgical Devices

Glaucoma Surgery Decreases the Rates of Localized and Global Visual Field Progression

Ability of New Vital Dyes to Stain Intraocular Membranes and Tissues in Ocular Surgery

Staphylococcus aureus Endophthalmitis: Antibiotic Susceptibilities, Methicillin Resistance, and Clinical Outcomes

Restoration of Photoreceptor Outer Segment after Vitrectomy for Retinal Detachment

Serous Retinal Detachment Associated With Retinal Vein Occlusion

Idiopathic Epiretinal Macular Membrane and Cataract Extraction: Combined versus Consecutive Surgery

Reporting Visual Acuities

Standard-Fluence versus Low-Fluence Photodynamic Therapy in Chronic Central Serous Chorioretinopathy: A Nonrandomized Clinical Trial

Subretinal Hemorrhages Associated with Age-Related Macular Degeneration in Patients Receiving Anticoagulation or Antiplatelet Therapy

Prognostic Factors of Vitreous Hemorrhage Secondary to Exudative Age-Related Macular Degeneration

Reliability and Validity of Abbreviated Surveys Derived from the National Eye Institute Visual Function Questionnaire: The Study of Osteoporotic Fractures

Surgical Procedure for Correcting Globe Dislocation in Highly Myopic Strabismus

Height, Stunting, and Refractive Error Among Rural Chinese Schoolchildren: The See Well to Learn Well Project

Systemic and Local Management at the Onset of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis with Ocular Complications

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