American Journal of Ophthalmology

Changing Trends of Blindness: The Initial Harvest From Translational Public Health and Clinical Research in Ophthalmology

Ning Cheung, Tien Yin Wong — 2012-02-01

All ophthalmologists and vision researchers are aware of the profound adverse effects of blindness on our patients' health and quality of life. From a societal perspective, visual loss comes with an exorbitant price tag, with an estimated global cost of nearly $3 trillion for the 733 million people living with low vision and blindness worldwide. With unceasing population growth and aging demographics, these numbers are expected to spiral upward. In this issue of the Journal, however, contemporary surveillance data from 2 large population-based studies shed some light on our battle against blindness and offer hope that the tide may be turning because of new public health initiatives and novel clinical treatments that have been translated from research in recent years.

Avastin Doesn't Blind People, People Blind People

2012-02-01

Purpose: To review the appropriate preparation of bevacizumab for intravitreal injection by compounding pharmacies with specific recommendations designed to prevent microbial contamination. Design: Perspective. Methods: A review and discussion of compounding issues with supporting literature, clinical experience, illustrations, and expert opinion. Results: Closer examination of the events surrounding the recent clusters of infectious endophthalmitis cases occurring after the intravitreal injection of bevacizumab suggest that the vision loss is not the result of the drug or the injection technique, but rather of the compounding procedures used to prepare the syringes containing the bevacizumab. Noncompliance with recognized standards and poor aseptic technique are the most likely causes of these outbreaks. The key to preventing these catastrophic occurrences depends on the implementation of and strict adherence to United States Pharmacopoeia Chapter 797 requirements. Conclusions: Recommendations arising from a root cause analysis of infectious endophthalmitis outbreaks should focus on the procedures used by pharmacies to compound bevacizumab. Microbial contamination of bevacizumab-containing syringes prepared from the same vial of drug can be avoided by using a single vial of bevacizumab for each eye or by following strict adherence to United States Pharmacopoeia Chapter 797 requirements when compounding a single vial of bevacizumab into multiple syringes.

An Outbreak of Streptococcus Endophthalmitis After Intravitreal Injection of Bevacizumab

2012-02-01

Purpose: To report a series of patients with Streptococcus endophthalmitis after injection with intravitreal bevacizumab prepared by the same compounding pharmacy. Design: Noncomparative consecutive case series. Methods: Medical records and microbiology results of patients who presented with endophthalmitis after injection with intravitreal bevacizumab between July 5 and July 8, 2011, were reviewed. Results: Twelve patients were identified with endophthalmitis, presenting 1 to 6 days after receiving an intravitreal injection of bevacizumab. The injections occurred at 4 different locations in south Florida. All patients received bevacizumab prepared by the same compounding pharmacy. None of the infections originated at the Bascom Palmer Eye Institute, Miami, Florida, although 9 patients presented to its tertiary-care ophthalmic emergency room for treatment, and 3 additional patients were seen in consultation. All patients were treated initially with a vitreous tap and injection; 8 patients subsequently received a vitrectomy. Microbiology cultures for 10 patients were positive for Streptococcus mitis/oralis. Seven unused syringes of bevacizumab prepared by the compounding pharmacy at the same time as those prepared for the affected patients also were positive for S. mitis/oralis. After 4 months of follow-up, all but 1 patient had count fingers or worse visual acuity, and 3 required evisceration or enucleation. Local, state, and federal health department officials have been investigating the source of the contamination. Conclusions: In this outbreak of endophthalmitis after intravitreal bevacizumab injection, Streptococcus mitis/oralis was cultured from the majority of patients and from all unused syringes. Visual outcomes were generally poor. The most likely cause of this outbreak was contamination during syringe preparation by the compounding pharmacy.

Incidence of Legal Blindness From Age-Related Macular Degeneration in Denmark: Year 2000 to 2010

Sara Brandi Bloch, Michael Larsen, Inger Christine Munch — 2012-02-01

Purpose: To report incidence rates of legal blindness from age-related macular degeneration (AMD) and other causes in Denmark from years 2000 to 2010 in the age group at risk of AMD aged 50 years and older. Design: Population-based observational registry study. Methods: settings: Membership register of the Danish Association of the Blind, the primary admission criterion of which is best-corrected visual acuity 0.1 (20/200) or lower in a person's better-seeing eye. study population: A total of 11 848 incident cases of legal blindness from a population of citizens aged ≥50 years numbering 1.71 million in 2000 and 1.87 million in 2010 with free access to a single-payer public health care system. main outcome measures: Incidence rates of legal blindness from AMD from 2000 to 2010. Results: The incidence rate of legal blindness attributable to AMD in citizens aged ≥50 years decreased from 52.2 cases per year per 100 000 in 2000 to 25.7 cases per year per 100 000 in 2010, corresponding to a reduction of 50% (95% confidence interval [CI95]: 45%-56%, P < .0001, adjusted for age), the bulk of the reduction occurring after 2006. The incidence of legal blindness from causes other than AMD decreased by 33% (CI95: 21%-44%, P < .0001), most of the reduction occurring between 2000 and 2006. Conclusion: From 2000 to 2010 the incidence of legal blindness from AMD fell to half the baseline incidence. The bulk of the reduction occurred after the introduction of intravitreally injected inhibitors of vascular endothelial growth factor in 2006.

Time Trends in the Incidence and Causes of Blindness in Israel

2012-02-01

Purpose: To evaluate time trends in the incidence and causes of new cases of blindness in Israel between 1999 and 2008. Design: Descriptive, retrospective population-based study. Methods: During the decade of the study, 19 862 inhabitants of Israel were newly registered as legally blind. Data were retrieved from the 1999 to 2008 annual reports of the National Registry of the Blind in Israel and were reviewed retrospectively. Specific rates by age, gender, calendar year, and cause of blindness were calculated. Total and cause-specific annual age-standardized rates were calculated as well. Findings were evaluated by the use of Poisson regression models. Results: The age-standardized rate of incidence of newly registered legal blindness at the end of the studied decade was half of that at the beginning, declining from 33.8 per 100 000 in 1999 to 16.6 per 100 000 in 2008. The decline mainly was attributable to a decreased incidence of blindness resulting from age-related macular degeneration, glaucoma, diabetic retinopathy, and cataract. Conclusions: Contemporary interventions in ophthalmology combined with widely available universal free access to healthcare seem to be effective in causing a major reduction in the incidence of blindness.

Recent Statin Use and Cataract Surgery

Donald S. Fong, Kwun-Yee T. Poon — 2011-10-07

Purpose: To investigate whether the statin class of drugs reduces the risk of cataract extraction. Design: Case-control study. Method: setting: Kaiser Permanente Southern California, which provides prepaid healthcare for 3.2 million residents by 6000 physicians. patient population: Eligible patients were those who had 5+ years of continuous enrollment in 2009. Cases were 13 982 patients who underwent cataract surgery in their first eye in 2009. Controls were the 34 049 patients who had an eye examination, but did not undergo cataract surgery or have a diagnosis of cataract in their medical record. observation procedure: The primary source of data to assess cataract surgery, treatment with statins, and other risk factors is the electronic database of Kaiser Permanente. main outcome measure: Use of the statin class of drug. Results: Patients who had cataract surgery were older, were more likely to be white, and appeared to have more coronary artery disease but less diabetes. The proportion of statin users appeared to be greater among those with cataract surgery (64.3%) compared to those without a diagnosis of cataract or cataract surgery (55.5%). After adjustment for age, sex, race, smoking status, diabetes, and coronary artery disease, longer-term statin use was found to be protective against cataract extraction (OR: 0.93, P = .02), while shorter-term use was associated with cataract surgery (OR: 1.11, P < .0001). Age-stratified logistic regression analysis showed that statin use of 5 years or more was protective against cataract surgery in the younger age group (50-64 years), while shorter-term use (<5 years) was associated with an increased risk of surgery in both the younger and older age groups (60+ years). Conclusion: The current study finds that recent longer-tem statin use was protective against cataract surgery in younger patients (50-64 years of age), while shorter-term use was associated with an increased risk of surgery. One strength of the current study is information on the large number of incident cases of cataract extraction and the electronic database on drug use. Additional studies will be needed to understand the difference in effect between longer- and shorter-term users of statins.

Punctal and Canalicular Anatomy: Implications for Canalicular Occlusion in Severe Dry Eye

2011-10-07

Purpose: To characterize the microscopic anatomy of the lacrimal punctum and canaliculi in relation to the tarsal plate, muscle of Riolan, and Horner muscle; and to report a novel technique to excise the horizontal canaliculus in severe dry eye patients. Design: Observational anatomic study and a retrospective case series. Methods: The microscopic anatomy was studied in 86 eyelids of 25 cadavers (age range: 45–96 years, mean: 79.5 years). Surgery was performed on 18 canaliculi of 7 patients with dry eyes (age range: 37–69 years, mean: 59.9 years). In the microscopic study, 32 eyelids were incised sagittally, 38 eyelids were incised horizontally (1 mm from the eyelid margin), and 16 eyelids were incised parallel to the tarsal plate. All specimens were stained with Masson trichrome. In the surgical group, probe-guided horizontal canalicular excision with incision of the Horner muscle to the lateral edge of the lacrimal caruncle was performed. Both canalicular stumps were cauterized. Results: In the microscopic anatomic study, the punctum and the vertical canaliculus were part of the tarsal plate with the muscle of Riolan, whereas the horizontal canaliculus was surrounded by the Horner muscle. In the surgical group, all the operated canaliculi were completely occluded without recanalization 12 months postoperatively. No complications were recorded. Conclusions: Based on microscopic anatomic findings that the lacrimal punctum and the vertical canaliculus are part of the tarsal plate, and that the horizontal canaliculus is surrounded by the Horner muscle, excision of the horizontal canaliculus may be an effective technique to treat patients with severe dry eyes.

Risk Factors for Orbital Exenteration in Periocular Basal Cell Carcinoma

2011-10-07

Purpose: To present the proportion of patients with periocular basal cell carcinoma (BCC) who underwent orbital exenteration and to evaluate the significance of the following risk factors: initial tumor site, pathologic features, and initial treatment. Design: Retrospective, comparative, interventional case series. Methods: Charts of all patients with BCC referred to Orbital Unit of the University of Naples “Federico II” between 1984 and 2003 were reviewed. Charts were reviewed for patient demographics, previous treatments, tumor site, clinical presentation, duration of symptoms, and histologic subtype. The main outcomes were recurrence rate, tumor-related deaths, orbital infiltration, and rate of exenteration. Results: Data (including follow-up) were available for 506 patients. Twenty-eight patients (5.5%) underwent orbital exenteration. For 8 patients (28.5%), orbital exenteration was the first procedure performed. In the exenterated group, the most common tumor site was the medial cantus, whereas in the overall group, it was the lower eyelid (P = .001). The proportion of patients initially treated without margin control was significantly higher in patients undergoing exenteration (P = .0001). Pathologic examination revealed a higher incidence of infiltrative subtype in the exenterated group (P = .00019). Conclusions: The need for exenteration for BCC may be significantly higher when the lesion involves a medial canthal location, initial management does not include margin-controlled excision, or pathologic analysis reveals an infiltrative subtype. Margin-controlled excision for periocular BCC and close follow-up after excision for medial canthal BCC may be indicated.

Clinicopathologic and Immunohistochemical Features of Pigmented Basal Cell Carcinomas of the Eyelids

Maria Kirzhner, Frederick A. Jakobiec — 2011-10-07

Purpose: To describe the clinical and microscopic features of pigmented basal cell carcinomas (pBCC) of the eyelid. Design: Retrospective observational case series collected at one institution. Methods: An analysis of clinical records, photographs, and histopathologic characteristics of 257 BCCs with a review of the literature. The frequencies of clinically pigmented, and of microscopically pigmented but clinically nonpigmented, BCCs were determined. Cytochemical stains (Fontana-Masson, Prussian blue) and immunohistochemical probes (S-100, microphthalmia-associated transcription factor [MiTF], HMB-45, MART-1, CK20, synaptophysin, chromogranin, CD1a, Ki-67) were then employed and the findings correlated with the degree of clinical pigmentation. Results: Histopathologically, 13 of 257 cases (5.06%) were found to have pigment; of these 13, 6 (all white patients) had clinically apparent pigmentation (2.33%), either focal or diffuse. Eight of 13 lesions developed on the lower eyelids. All stained positively for melanin but negatively for iron. MiTF highlighted numerous melanocytic nuclei in the tumor lobules, while MART-1 and HMB-45 revealed the dendritic shapes of the entrapped melanocytes. There was a subtotal blockage of melanin transfer to the surrounding basaloid cells. Intralobular S-100-positive cells included CD1a-positive Langerhans cells, while CK20 did not identify any Merkel cells. Conclusions: Only 1 of 6 lesions was uniformly clinically pigmented, whereas the other 5 were only focally brown-black. The clinical pigmentation was imparted by varying densities and distributions of melanocytes with arborizing dendrites, which were present in all BCCs. Melanophages within the stroma and basaloid cell melanization also contributed to pigmentation. No behavioral or biologic differences in pBCC were documented compared with clinically nonpigmented lesions.

Clinical Significance of Microbial Growth on the Surfaces of Silicone Tubes Removed From Dacryocystorhinostomy Patients

Sung Eun Kim, Sung Jun Lee, Sang Yeul Lee, Jin Sook Yoon — 2011-09-14

Purpose: To investigate the bacterial infection of silicone tubes removed from patients who underwent dacryocystorhinostomy (DCR) and assess the correlation between the culture results and postoperative clinical features. Design: Retrospective observational case series. Methods: Consecutive epiphora patients who underwent external or endoscopic DCR surgery were reviewed. The postoperatively removed silicone tubes were cultured. Preoperative canalicular stenosis and nasal septal hypertrophy, postoperative inflammation, membranous obstruction of nasal mucosa, and the duration of silicone intubation were reviewed. Correlations between the results of bacterial culture and clinical features were verified. Results: A total of 39 silicone tubes removed from 33 patients were cultured: 34 (87.2%) external DCR cases and 5 (12.8%) endoscopic DCR. Culture provided positive results in 37 cases (94.9%). A total of 52 isolates were identified: 73.1% gram-positive bacteria, 23.1% gram-negative bacteria, and 3.8% fungi. Of the gram-positive organisms, 73.9% were Staphylococcus aureus. Most of the gram-negative organisms were Pseudomonas aeruginosa, found in 5 eyes. The time of tube placement was significantly longer in cases with P. aeruginosa than in those with other bacteria (P = .001). The rate of pseudomonas infection was significantly higher in cases with revision than in those without revision (P = .001). Final surgical failure was significantly related with canalicular stenosis (P = .017), pus discharge at extubation (P < .001), history of endoscopic revision (P = .001), and pseudomonal infection (P = .010). Conclusions: Various bacterial species were cultured from removed silicone tubes. Although many of them were normal flora, P. aeruginosa infection showed significant relation with membranous obstruction of nasal mucosa, prolonged silicone intubation, and surgical failure.

The Effect of Standard and Transepithelial Ultraviolet Collagen Cross-Linking on Human Corneal Nerves: An Ex Vivo Study

2011-09-19

Purpose: To evaluate the early effect of standard and transepithelial collagen cross-linking on human corneal nerves in donor eyes by ex vivo confocal microscopy and acetylcholinesterase staining. Design: Experimental laboratory investigation. Methods: Eight human eye bank corneal buttons (mean age, 73.6 years) were included. Ultraviolet A collagen cross-linking was performed postmortem on 3 corneas with the standard protocol involving epithelial debridement and 4 corneas by the transepithelial approach. One cornea served as a control. Corneal nerves were evaluated using confocal microscopy and acetylcholinesterase histology. Results: Confocal microscopy demonstrated the absence of subbasal nerves in corneas treated by the standard technique. These nerves were preserved in corneas treated by the transepithelial approach. Stromal nerves were visible in both groups. Histology of corneas treated by the standard technique revealed localized swellings of the stromal nerves with disruption of axonal membrane and loss of axonal continuity within the treatment zone. These changes were absent in corneas treated by the transepithelial approach. Conclusions: This study highlights the immediate effects of collagen cross-linking on the corneal nerves in an ex vivo model. The absence of subbasal nerves in the early phase of treatment appears to be attributable mainly to mechanical removal of epithelium, rather than ultraviolet light–induced damage. Localized swelling of the stromal nerves was the main difference between the 2 treatment protocols. Further research on laboratory animals would be necessary to verify these changes over a specified time course without the super-addition of postmortem changes.

Prevalence, Progression, and Impact of Glaucoma on Vision After Boston Type 1 Keratoprosthesis Surgery

2011-10-10

Purpose: To report glaucoma outcomes after Boston type 1 keratoprosthesis (KPro) surgery, in particular, glaucoma prevalence, progression, and treatment. Design: Consecutive, retrospective, interventional case series. Methods: setting: Tertiary care institution. study population: Thirty-eight eyes in 38 patients. intervention: KPro surgery. main outcome measures: Visual acuity (VA), intraocular pressure, visual fields, optic nerve status, and glaucoma treatment. Results: Glaucoma diagnosis was known before surgery in 29 patients (76%; 14 had undergone previous surgery) and was diagnosed after surgery in 34 patients (89%) after a mean ± standard deviation of 16.5 ± 4.7 months of follow-up. The number of patients taking intraocular pressure-lowering medications increased from 19 (50%) before surgery to 28 (76%) after surgery (P = .017). Twenty-four patients (63%) were taking at least 1 additional glaucoma medication at their most recent postoperative visit. Eight patients (21%) had glaucoma progression (visual field progression, need for surgery, or both). Fifteen patients (40%) had a cup-to-disc ratio of 0.85 or more. Five patients required glaucoma surgery. VA was limited by glaucoma in 14 patients (37%), 11 of whom had a VA of 20/200 or worse. Five such patients (13%) had a dramatic improvement in VA, then progressed to end-stage glaucoma with fixation loss. Visual fields were limited by glaucoma in 25 patients (66%; mean Swedish Interactive Threshold Algorithm Fast mean defect, −20.3 ± 8.8 decibels; n = 18). Conclusions: Most KPro candidates have glaucoma, which may deteriorate in a subset of patients after surgery. Dramatic VA improvement after KPro surgery does not preclude the need for rigorous monitoring for glaucoma progression. A low threshold should be used to treat suspicion of even slightly elevated intraocular pressure.

Micrometer-Scale Contact Lens Movements Imaged by Ultrahigh-resolution Optical Coherence Tomography

Lele Cui, Meixiao Shen, Michael R. Wang, Jianhua Wang — 2011-09-14

Purpose: To dynamically evaluate contact lens movement and ocular surface shape using ultrahigh-resolution and ultralong-scan-depth optical coherence tomography (OCT). Design: Clinical research study of a laboratory technique. Methods: Four different types of soft contact lenses were tested on the left eye of 10 subjects (6 male and 4 female). Lens edges at primary gaze and temporal and nasal gazes were imaged by ultrahigh-resolution OCT. Excursion lag was obtained as the distance between the lens edge at primary gaze and immediately after the eye was quickly turned either nasally or temporally. The inferior lens edges were imaged continuously to track vertical movements during blinking. Ultralong-scan-depth OCT provided quantifiable images of the ocular surface, and the contour was acquired using custom software. Results: Excursion lag at the horizontal meridian was 366 ± 134 μm at temporal gaze and 320 ± 137 μm at nasal gaze (P > .05). The lens uplift at the vertical meridian was 342 ± 155 μm after blinking. There were significant differences in horizontal lags and vertical movements among different lenses (P < .05). Horizontal lags were correlated with radii of curvatures and sagittal heights at 6-mm and 14-mm horizontal meridian (P < .05). The blink-induced lens uplift first lowered by 104 ± 8 μm, and then lifted 342 ± 155 μm after the blink. Conclusions: Ultrahigh-resolution and ultralong-scan-depth OCT can assess micrometer-scale lens movements and ocular surface contours. Both lens design and ocular surface shape affected lens movements.

Reporting Visual Acuities

2012-02-01

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.

Characteristic Higher-Order Aberrations of the Anterior and Posterior Corneal Surfaces in 3 Corneal Transplantation Techniques

2011-10-07

Purpose: To investigate the corneal higher-order aberrations (HOAs) of the anterior and posterior corneal surfaces in eyes that underwent penetrating keratoplasty (PK), deep anterior lamellar keratoplasty (DALK), and Descemet stripping automated endothelial keratoplasty (DSAEK). Design: Retrospective, case-control study. Methods: study population: Twenty-four eyes underwent PK, 28 eyes underwent DALK, and 19 eyes underwent DSAEK; 29 normal eyes served as controls. observation procedures: The anterior and posterior corneal heights and pachymetric data were obtained with a Scheimpflug-based corneal topographer. Corneal HOAs for 4-mm pupils were calculated from the height data and were expanded with normalized Zernike polynomials. The HOAs resulting from the anterior and posterior corneal surfaces were compared among the procedures. main outcome measures: Anterior and posterior corneal HOAs (root mean square). Results: Control eyes had significantly lower total HOAs and Zernike vector terms of the anterior and posterior surfaces than the other groups, except for spherical aberration. The mean anterior corneal surface total HOAs in the PK, DALK, DSAEK, and control groups were 1.38 ± 0.67 μm, 1.19 ± 0.57 μm, 0.61 ± 0.33 μm, and 0.21 ± 0.07 μm, respectively. The anterior corneal HOAs in the DSAEK group were significantly less than those in the PK group (P < .001) and DALK group (P < .001). The mean posterior corneal surface total HOAs were, respectively, 0.20 ± 0.09 μm, 0.24 ± 0.11 μm, 0.27 ± 0.15 μm, and 0.07 ± 0.02 μm. There were no significant differences in the posterior corneal HOAs among the treatment groups. Conclusions: Because the refractive indices between the anterior and the posterior surfaces differed greatly, eyes that undergo DSAEK have lower anterior corneal HOAs compared with PK or DALK eyes. However, the anterior and posterior corneal HOAs in DSAEK eyes still were greater than those in control eyes.

Long-term Comparison of Full-Bed Deep Lamellar Keratoplasty With Penetrating Keratoplasty in Treating Corneal Leucoma Caused by Herpes Simplex Keratitis

Shuang-Qing Wu, Ping Zhou, Bei Zhang, Wen-Ya Qiu, Yu-Feng Yao — 2011-10-13

Purpose: To compare long-term outcomes of full-bed deep lamellar keratoplasty (DLK) with penetrating keratoplasty (PK) for treating corneal leucoma caused by herpes simplex keratitis (HSK). Design: Retrospective, comparative, interventional case series. Methods: setting: Institutional. patients: Inclusion criteria were patients with corneal scarring induced exclusively by HSK who underwent primary graft of full-bed DLK or PK and completed a minimum of 12 months postoperative follow-up. There was no significant difference of corneal scarring and vascularization between the 2 groups before surgery. Choosing PK or full-bed DLK depended on the patient's own willingness, except those patients with a preoperative endothelial cell count of less than 700 cells/mm2 or whose endothelial cell count was undetectable were encouraged to undergo only PK. Exclusion criteria were patients with a past history of corneal perforation, nonprimary graft, non–HSK-related corneal scars, and failure to complete a minimum of 12 months of postoperative follow-up. Fifty-eight eyes of 58 patients in the full-bed DLK group and 63 eyes of 63 patients in the PK group met the inclusion criteria. main outcome measures: Postoperative managements, recurrence of HSK, graft rejection, graft survival rate, visual acuity, and corneal endothelial density. Results: The mean postoperative follow-up duration was 45.8 ± 30.9 months in the full-bed DLK group and 47.9 ± 27.2 months in the PK group (P = .70). As compared with the PK group, the full-bed DLK group experienced earlier suture removal (P = .01), needed fewer postoperative visits (P < .001), and had a higher proportion of eyes with full withdrawal of oral acyclovir (P < .001) and topical corticosteroid (P < .001). There were a total of 21 episodes of recurrent HSK in the PK group, more frequent than the 7 episodes in the full-bed DLK group, among which recurrent epithelial keratitis amounted to 13 episodes in the PK group, remarkably more frequent than the 1 episode in the full-bed DLK group. Twenty-six eyes (41.3%) encountered rejection episodes in the PK group, but no rejection episode was found in the full-bed DLK group (P < .001). In 14 eyes in the PK group, graft failure developed because of graft rejection, recurrence of HSK, or both, whereas only in 1 eye in the full-bed DLK group did graft failure develop because of recurrence of HSK (P = .001). The clear graft survival rate in the full-bed DLK group was significantly higher than that in the PK group (P = .01). Corneal endothelial cell density was stable from 1 month through 5 years in the full-bed DLK group, but 51.3% cell loss was found in the PK group at 5 years after surgery. At the last visit, 66.1% of eyes with full-bed DLK grafts and 50.9% of eyes with PK grafts achieved a best-correct visual acuity of 0.5 or better (P = .10). Conclusions: Advantages of full-bed DLK over PK are no allograft rejection, longer graft survival, earlier drug withdrawal of topical steroid and oral acyclovir, less recurrence of HSK, and fewer follow-up visits. Full-bed DLK is preferable for treating HSK-induced corneal scarring with relatively healthy endothelium and with no history of perforation.

Intravitreal Bevacizumab for Treatment of Subfoveal Idiopathic Choroidal Neovascularization: Results of a 1-Year Prospective Trial

Han Zhang, Zhe-Li Liu, Peng Sun, Feng Gu — 2011-10-07

Purpose: To evaluate the visual and anatomic outcomes of intravitreal bevacizumab in patients with subfoveal idiopathic choroidal neovascularization (CNV). Design: Prospective, nonrandomized, interventional case series. Methods: Forty patients with subfoveal idiopathic CNV were included in this clinical trial. Their eyes were treated with a single intravitreal injection of 1.25 mg bevacizumab followed by as-needed dosing indicated by the presence and recurrence of intraretinal edema, subretinal fluid (SRF), or pigment epithelial detachment (PED), based on optical coherence tomography (OCT) performed monthly. Visual, clinical, angiographic, and anatomic changes were observed over a 12-month follow-up period. Results: After 12 months of follow-up, the mean logarithm of minimal angle of resolution (logMAR) best-corrected visual acuity (BCVA) improved from 0.53 (20/68 in Snellen equivalent) at baseline to 0.29 (20/39 in Snellen equivalent; P < .001). Mean central retinal thickness determined by OCT decreased from 321 μm to 237 μm (P < .001). All eyes (100%) had stable or improved vision, and 28 eyes (70%) showed an improvement of 2 lines or more. All lesions were in the cicatricial stage of CNV at 12 months of follow-up, with no leakage of fluorescein in the late phase of fluorescein angiography and no intraretinal edema, SRF, and/or PED detected by OCT. No drug-related systemic or ocular side effects were observed. Conclusions: Intravitreal bevacizumab is generally well tolerated and improves BCVA in eyes with subfoveal idiopathic CNV over a period of 12 months. Large, randomized, controlled, long-term clinical trials are required to further evaluate the efficacy and optimal strategy of this treatment modality.

Vascular Endothelial Growth Factor in Plasma and Vitreous Fluid of Patients with Proliferative Diabetic Retinopathy Patients after Intravitreal Injection of Bevacizumab

Yan Ma, Yan Zhang, Tong Zhao, Yan-rong Jiang — 2011-10-10

Purpose: To investigate plasma and vitreous vascular endothelial growth factor (VEGF) levels after intravitreal bevacizumab (IVB) injection into eyes with proliferative diabetic retinopathy (PDR). Design: Retrospective, interventional, nonrandomized, comparative study. Methods: Fifty-six eyes of 56 patients with PDR and 13 eyes of 13 patients with nondiabetic ocular diseases were enrolled. Analysis included evaluation of basic clinical conditions and measurement of vitreous and plasma VEGF concentrations using enzyme-linked immunosorbent assays. Results: PDR eyes without IVB had the highest vitreous VEGF levels; the levels were significant compared with those in the recent IVB group (previous injection within 1 week), the prolonged IVB group (injection more than 1 week previously), and the nondiabetic control group (P = .001, P = .035, P < .001, respectively). The vitreous VEGF level in the recent IVB group was higher than that in prolonged IVB group (P = .035). PDR eyes without IVB had the highest plasma VEGF level, and the level was significant compared with those in the recent IVB group, the prolonged IVB group, and the nondiabetic control group (P < .001, P = .003, P < .001, respectively). The plasma VEGF level in the recent IVB group was lower than that in the prolonged IVB group (P = .003). The vitreous VEGF level was associated significantly with the plasma VEGF level (P = .002). Conclusions: Vitreous and plasma VEGF levels were increased markedly in patients with PDR. VEGF concentrations in vitreous and plasma were decreased significantly after IVB into PDR eyes, and the effect lasted from 4.4 ± 2.2 days to 34.8 ± 33.7 days after injection.

Near-Infrared Autofluorescence in Patients With Idiopathic Submacular Choroidal Neovascularization

2011-10-10

Purpose: To investigate near-infrared autofluorescence (IR-AF) patterns and related changes in patients with idiopathic choroidal neovascularization (CNV) treated with intravitreal bevacizumab (IVB). Design: Retrospective observational consecutive case series. Methods: Bevacizumab was intravitreally injected into 12 eyes of 12 patients with idiopathic CNV as the primary treatment. Color fundus photographs, optical coherence tomography (OCT), fluorescein angiography and indocyanine green angiography (ICGA), and autofluorescence imaging short-wavelength and near-infrared autofluorescence (SW-AF and IR-AF) were performed at baseline. Changes in the autofluorescence patterns were evaluated after IVB. Results: All 12 eyes had classic CNV on fluorescein angiography at baseline. OCT showed CNV above the retinal pigment epithelium (RPE) in all eyes. After treatment, the final best-corrected visual acuity improved significantly (P < .001) compared with baseline. IR-AF showed ring-shaped hyperautofluorescence surrounding the CNV corresponding to the dark rim on ICGA in 6 of the 12 eyes on IR-AF at baseline. During the follow-up period after IVB, all 12 eyes had ring-shaped hyperautofluorescence. The intensity of the ring-shaped autofluorescence and its contrast increased as the CNV regressed. The contrast of the ring-shaped autofluorescence partially decreased in all 3 eyes with a recurrence. Conclusions: Ring-shaped hyperautofluorescence on IR-AF in the eyes with idiopathic CNV may indicate an involutional process of CNV enveloped by the RPE because its area corresponded to the dark rim on ICGA that reflects regression of idiopathic CNV. IR-AF can be a useful noninvasive adjunctive examination to evaluate the involution of CNV.

Vitrectomy and Internal Limiting Membrane Peeling With and Without Gas Tamponade for Myopic Foveoschisis

Kyu Seop Kim, Seung Bum Lee, Won Ki Lee — 2011-10-10

Purpose: To compare clinical outcomes after vitrectomy and internal limiting membrane (ILM) peeling, with and without gas tamponade, for the treatment of myopic foveoschisis. Design: Retrospective, comparative, interventional case series. Methods: In this retrospective clinical study, 17 eyes of 17 consecutive patients underwent vitrectomy and ILM peeling for treatment of myopic foveoschisis. Eyes were divided into 2 groups, those with gas tamponade (n = 9) and those without (n = 8). Gas tamponade was chosen according to the period and surgeon's discretion. The changes of foveal anatomy on preoperative optical coherence tomography (OCT) were not considered in the decision. Main outcome measures were the rate of resolution of myopic foveoschisis measured by OCT, the time interval until resolution of myopic foveoschisis, central foveal thickness, and best-corrected visual acuity (BCVA). Results: After surgery, OCT showed a resolution of myopic foveoschisis in 8 eyes (88.9%) in the gas-treated group and in 6 eyes (75.0%) in the no-gas group. This difference between the groups was statistically insignificant (P = .576). The mean period until the resolution of myopic foveoschisis was 2.25 months in the gas-treated group and 4.50 months in the no-gas group (P = .011). The mean BCVA improved significantly in both the gas-treated and no-gas groups (P = .011 and P = .017, respectively). Conclusions: Vitrectomy and ILM peeling without gas tamponade appears to be as effective in the treatment of myopic foveoschisis as vitrectomy with gas tamponade. However, eyes treated with gas tamponade showed more rapid resolution of myopic foveoschisis.

Serum Concentrations of Bevacizumab (Avastin) and Vascular Endothelial Growth Factor in Infants With Retinopathy of Prematurity

2011-09-19

Purpose: To determine the serum concentrations of bevacizumab and vascular endothelial growth factor (VEGF) in infants with retinopathy of prematurity (ROP) who received intravitreal bevacizumab; and to determine whether the changes in the serum concentration of bevacizumab were significantly correlated with the serum concentration of VEGF after intravitreal bevacizumab. Design: Case series. Methods: Eleven infants (4 girls and 7 boys) with ROP were studied. They received 0.25 mg or 0.5 mg of intravitreal bevacizumab to either 1 eye (unilateral cases) or both eyes (bilateral cases) with vascularly active ROP. Serum samples were collected before and 1 day, 1 week, and 2 weeks after the intravitreal bevacizumab. The serum concentrations of bevacizumab and VEGF were measured by enzyme-linked immunosorbent assay, and the correlation in the serum levels between the 2 was determined. Results: The serum concentration of bevacizumab before and 1 day, 1week, and 2 weeks after a total of 0.5 mg of intravitreal bevacizumab was 0 ng/mL, 195 ± 324 ng/mL, 946 ± 680 ng/mL, and 1214 ± 351 ng/mL, respectively. The serum bevacizumab level before and 1 day and 1 week after a total 1.0 mg of intravitreal bevacizumab was 0 ng/mL, 248 ± 174 ng/mL, and 548 ± 89 ng/mL, respectively. The serum concentration of VEGF before and 1 day, 1 week, and 2 weeks after a total of 0.5 mg intravitreal bevacizumab was 1628 ± 929 pg/mL, 427 ± 140 pg/mL, 246 ± 110 pg/mL, and 269 ± 157 pg/mL, respectively. There was a significant negative correlation (r = −0.575, P = .0125) between the serum concentration of bevacizumab and VEGF when a total of 0.25 mg or 0.5 mg of bevacizumab was injected. Conclusions: These results indicate that bevacizumab can escape from the eye into the systemic circulation and reduce the serum level of VEGF in infants with ROP. Continued extensive evaluations of infants are warranted for possible effects after intravitreal bevacizumab in ROP patients.

Prediction of Postoperative Eyelid Height After Frontalis Suspension Using Autogenous Fascia Lata for Pediatric Congenital Ptosis

Chang Yeom Kim, Jin Sook Yoon, Jong-Myon Bae, Sang Yeul Lee — 2011-10-10

Purpose: To predict eyelid height after frontalis suspension using autogenous fascia lata for congenital ptosis. Design: Retrospective, observational case series. Methods: Eighty eyes of 54 children who underwent frontalis suspension using autogenous fascia lata were included. The amount of intraoperative eyelid lift and the postoperative change in eyelid height were assessed 6 months after surgery by reviews of photographs and medical records. The amount of operative eyelid lift was measured from 2 different baselines, and each amount was compared with the amount of real change in eyelid height after surgery. The difference between those was measured. Results: The postoperative eyelid height stabilized 3 months after surgery. The average amount of operative eyelid lift was 5.91 mm with anesthesia-induced lagophthalmos and 3.51 mm without. The amount of real change in eyelid height after surgery was 3.24 ± 1.14 mm. In less severe ptosis (< 3 mm of lift), an average operative lift of 2.03 mm resulted in 2.53 mm of elevation, whereas in more severe ptosis (≥ 4 mm of lift), an average operative lift of 3.98 mm resulted in only 3.72 mm of elevation 6 months after surgery. The preoperative palpebral fissure (P = .002) and anesthesia-induced lagophthalmos (P < .001) were significant factors influencing postoperative eyelid height. Conclusions: Postoperative eyelid height may predicted be more accurately by compensating for anesthesia-induced lagophthalmos and adjusting the palpebral fissure to be larger than the desired eyelid height for patients with more severe ptosis.

The Long-Term Survival Analysis of Bilateral Lateral Rectus Recession Versus Unilateral Recession-Resection for Intermittent Exotropia

Jin Choi, Ji Woong Chang, Seong-Joon Kim, Young Suk Yu — 2011-10-07

Purpose: To conduct a comparison of the long-term surgical outcomes of bilateral lateral rectus recession (BLR) vs unilateral lateral rectus recession–medial rectus resection (RR) in treatment of intermittent exotropia. Design: Nonrandomized, retrospective case series. Methods: Consecutive patients who underwent BLR or RR for treatment of intermittent exotropia between 2002 and 2006 and had ≥2 years' follow-up were recruited. Surgical outcomes were grouped according to postoperative angle of deviation as overcorrection (esophoria/tropia >5 Δ), success (esophoria/tropia ≤5 Δ to exophoria/tropia ≤10 Δ), or undercorrection/recurrence (exophoria/tropia >10 Δ), and were compared between the BLR group and the RR group at postoperative 1 day, 1 month, 6 months, 1 year, and 2 years, and at the final examination. Results: Of 128 patients, 55 underwent BLR and 73 underwent RR. The mean follow-up period was 44.2 months in the BLR group and 47.8 months in the RR group. At 1 day, 1 month, 6 months, 1 year, and 2 years after surgery, surgical outcomes in each group were not different (P > .05) However, the final outcome at a mean of 3.8 years was significantly different between the groups, demonstrating a higher success rate in the BLR group than in the RR group (58.2% vs 27.4%, P < .01). Cumulative probability of survival from recurrence was higher in the BLR group than in the RR group (P = .01, log-rank test). Recurrences were most common within 6 months from surgery; however, after that, recurrences occurred continuously in the RR group and rarely in the BLR group. Conclusion: Surgical outcomes by 2 years after surgery for intermittent exotropia were not different between the BLR and RR groups. However, final outcomes were better in the BLR group than in the RR group. This may be caused by the difference of recurrence rate over time: continuous recurrence of exotropia occurred in the RR group, while recurrence was low in the BLR group after postoperative 6 months.

Subconjunctival Bevacizumab Versus Mitomycin C Adjunctive to Trabeculectomy

Naveed Nilforushan, Maryam Yadgari, Shahin Khosh Kish, Nariman Nassiri — 2011-10-10

Purpose: To compare the outcome of trabeculectomy with subconjunctival bevacizumab with that of trabeculectomy with mitomycin C (MMC). Design: Prospective, randomized, comparative study. Methods: Thirty-six eyes from 34 patients with uncontrolled glaucoma were enrolled. Eighteen eyes underwent trabeculectomy with subconjunctival bevacizumab injection (2.5 mg/0.1 mL), and 18 eyes underwent trabeculectomy with MMC (0.02% for 3 minutes). The outcome measures were the best-corrected visual acuity, intraocular pressure (IOP), number of IOP-lowering medications, complications, and bleb morphologic features (based on the Indiana Bleb Appearance Grading Scale). Results: The mean follow-up times for the MMC and bevacizumab groups were 7.8 ± 2.2 months and 7.4 ± 24 months, respectively (P = .62). The mean preoperative IOP in the bevacizumab group improved from 21.9 ± 7.9 mm Hg with 2.7 ± 0.8 antiglaucoma medications to 13.6 ± 3.2 mm Hg with 0.2 ± 0.5 antiglaucoma medications at the last visit (P < .001 and P < .001, respectively). The mean preoperative IOP in the MMC group improved from 23.3 ± 4.9 mm Hg with 2.6 ± 0.7 antiglaucoma medications to 9.6 ± 2.7 mm Hg with no antiglaucoma medications at the final visit (P < .001 and P < .001, respectively). There was a statistically significant difference in the IOP between the 2 groups at the last visit (P < .001). The cumulative probabilities of total success at the last follow-up according to Kaplan-Meier analysis were 100% and 94.4% in bevacizumab and MMC groups, respectively (P = .32, log-rank test). Conclusions: Adjunctive subconjunctival bevacizumab with trabeculectomy is effective in controlling the IOP profile; however, its effect is less prominent than that of MMC.

Corneal Hysteresis and Beta-Zone Parapapillary Atrophy

2011-09-14

Purpose: To evaluate the relationship between β-zone parapapillary atrophy (βPPA) and corneal hysteresis (CH) in patients with glaucoma. Design: Prospective, cross-sectional study. Methods: Glaucoma patients aged 18 to 90 years with disc photographs within 12 months of the study visit were consecutively enrolled. Exclusion criteria included ocular surgery other than clear corneal phacoemulsification, myopia >6 diopters, contact lens use, and corneal abnormality. CH was measured using the Ocular Response Analyzer (ORA). Disc photographs were evaluated in a masked fashion for βPPA. Results: We enrolled 99 patients (mean age 67.6 years; 45 men, 54 women). Univariate analysis showed no significant difference in CH between eyes with and without βPPA (8.72 ± 0.23 vs 8.15 ± 0.27 mm Hg, P = .11). There were no differences in corneal resistance factor (CRF) (P = .47), central corneal thickness (CCT) (P = .11), ORA wave score (P = .23), age (P = .23), sex (P = .40), IOP (P = .86), or visual field mean deviation (VFMD) (P = .45). Eyes with βPPA were more myopic (−1.49 ± 0.27 vs −0.22 ± 0.31 diopters, P = .003). Multivariate analysis showed no significant difference in CH between eyes with and without βPPA (P = .38). Eyes with asymmetric βPPA also showed no significant difference in CH (8.97 ± 0.22 vs 9.10 ± 0.22 mm Hg, P = .69). Conclusions: We found no significant differences in CH between eyes with and without βPPA or between fellow eyes with asymmetric βPPA.

Ocular Complications of Human Immunodeficiency Virus Infection in Eastern China

2011-10-07

Purpose: To investigate ocular complications in patients with HIV/AIDS in eastern China during the time of highly active antiretroviral therapy (HAART). Design: Prospective study. Methods: This study was carried out from August 1, 2009 to July 31, 2010. Recruited HIV/AIDS patients underwent a series of surveys and ophthalmologic and laboratory examinations (including CD4 level) at enrollment. Results: In this study, all 787 HIV/AIDS patients (1574 eyes) had a history of HAART. Of these patients, 28.72% (95% CI = 0.26–0.32) had a history of systemic disease and 26.30% (95% CI = 0.23–0.29) had ocular complications. Of these ocular complications, cytomegalovirus retinitis (CMVR) had the highest prevalence (10.6%, 83/787) and ocular microangiopathy had the second-highest prevalence (9.4%, 74/787). Among the patients with CMVR, 16.9% (14/83) suffered from immune recovery uveitis (IRU). Furthermore, 3.4% (27/787) of the recruited AIDS patients had neuro-ophthalmologic disorders. The mean logMAR visual acuity of the group with ocular complications was 0.47 ± 0.64, which was significantly different from the asymptomatic group (0.17 ± 0.39, P < .001). The median CD4 T-cell count of the group with ocular complications is 43 cells/μL, which was significantly different from the asymptomatic group (116.5 cells/μL, P < .001). Conclusions: The study shows a high rate of treatable ocular complications among patients with HIV/AIDS in eastern China. HIV/AIDS treatment programs in China must be prepared to identify ocular complications and refer patients to the correct treatment facilities.

Depression and Visual Functioning in Patients With Ocular Inflammatory Disease

Ying Qian, Tanya Glaser, Elizabeth Esterberg, Nisha R. Acharya — 2011-09-15

Purpose: To characterize the level of depression in patients with ocular inflammatory disease and to determine predictors of depression in this population. Design: Prospective cross-sectional survey and medical record review. Methods: Participants were consecutive patients with noninfectious ocular inflammatory disease in a university-based tertiary referral center. Subjects were given the self-administered Beck Depression Inventory-II (BDI-II), National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25), and additional supplemental questions. Medical records were reviewed for clinical characteristics. Univariate analyses were conducted to compare clinical characteristics between patients with and without a positive screen for depression, and a multivariate regression model was performed to determine the most significant predictors of depression. Results: Of the 104 participants, 26.9% screened positive for depression with the BDI-II. Of these subjects, only 39.3% had been previously diagnosed with depression. NEI VFQ-25 scores were significantly lower in depressed patients in all subscales except driving and color vision. Predictors of depression were inadequate emotional support, lower visual functioning (VFQ composite score), history of changing immunomodulatory treatment, and current oral corticosteroid use. Conclusions: Depression may be a significant but underrecognized comorbid condition in patients with ocular inflammatory disease. Worse visual function was associated with depression. The authors recommend heightened awareness of potential depression in patients with ocular inflammatory disease.

In Vivo Analysis of Stromal Integration of Multilayer Amniotic Membrane Transplantation in Corneal Ulcers

Zisis Gatzioufas, Marlies Sauter, Andrea Hasenfus, Sigrun Smola, Berthold Seitz — 2012-02-01

Nubile and associates recently published an interesting study evaluating the integration of amniotic membrane into the corneal stroma after amniotic membrane transplantation for persistent noninfectious corneal ulcers. The authors investigated the integration patterns of amniotic membrane using laser scanning in vivo confocal microscopy and anterior segment optical coherence tomography. They documented that integration of amniotic membrane into the corneal stroma is preceded by epithelialization over the amniotic membrane covering the ulcer and that the integrated amniotic membrane undergoes progressive modifications characterized by early loss of amniotic epithelial cells, changes in fibrillar structure, and repopulation by corneal stroma-derived cells. Moreover, a stable increase in corneal thickness was achieved in all patients. These findings confirm that stromal integration of amniotic membrane provides corneal biomechanical stability, which is extremely important especially in cases of marked stromal thinning.

Reply

2012-02-01

We appreciate the interest and comments of Gatzioufas and associates concerning our article, “In Vivo Analysis of Stromal Integration of Multilayer Amniotic Membrane Transplantation in Corneal Ulcers,” and for bringing the important point of amniotic membrane transplantation in manifest or suspect herpetic keratitis to the readers' attention. As correctly pointed out by the authors, persistent corneal epithelial defects and sterile corneal ulcers and melting often may be related to the protean clinical expression of herpetic infection of the eye.

Quality of Life in a German Graves Orbitopathy Population

Renelle Pointdujour, Justin Gutman, Roman Shinder — 2012-02-01

We read with great interest the recent report by Ponto and associates describing the quality of life of patients with thyroid orbitopathy in a German population. We would like to point out to the readership our belief that the term Graves orbitopathy, as used in this article and throughout the medical literature, is misleading. The authors describe all patients as having Graves orbitopathy, when in fact 94% of the patients had true Graves disease, and the remaining 6% had either euthyroid orbitopathy or Hashimoto-related orbitopathy. This terminology is widespread in the literature and leads to confusion and misdiagnosis among many medical specialties.

Reply

Katharina A. Ponto, George J. Kahaly — 2012-02-01

Pointdujour and associates argue that the term Graves orbitopathy (GO) “leads to confusion and misdiagnoses among many medical specialists.” We agree that there are several reasons why the term Graves orbitopathy is not ideal for describing this orbital pathologic condition. GO is the most common extrathyroidal manifestation of Graves disease, and therefore, most patients with GO have associated hyperthyroidism. Experts agree that the prevalence of GO in Graves disease depends on the sensitivity of the testing methodology. Although clinically overt GO is present in 30% of Graves disease patients, extraocular muscle involvement is observed in 91% of these patients when assessed by CT. When patients with euthyroid orbitopathy are evaluated extensively, they often are found to have morphologic changes in the thyroid, positive thyroid stimulating hormone (TSH)-receptor autoantibodies, or a positive family history of thyroid disease. In total, 89% of these patients have some type of thyroid abnormality. It also should be noted that GO may occur before, simultaneously, or after the onset of Graves disease. Therefore, patients with euthyroid orbitopathy may demonstrate thyroid dysfunction during the course of GO. Because GO is commonly associated with Graves disease, it also occurs in patients with Hashimoto thyroiditis or in patients without thyroid dysfunction. For example, of the 310 GO patients seen at our multidisciplinary orbital center, 13 had autoimmune thyroiditis, and 7 did not have any thyroid disease at the time of data acquisition. The signs and symptoms of orbitopathy as well as the relationship between orbitopathy and the thyroid differ in every patient, and this is likely one reason why both clinicians and scientists have investigated GO for decades.

Blindness and Long-term Progression of Visual Field Defects in Chinese Patients With Primary Angle-Closure Glaucoma

Aparna Rao — 2012-02-01

I read with interest the article by Quek and associates regarding the long-term progression of primary angle-closure glaucoma in Chinese patients. For some time there has been a need for long-term studies of the progression in primary angle-closure glaucoma in the Asian population, where primary angle-closure glaucoma accounts for more than 50% of all cases of glaucoma. This study assumes greater importance in trying to identify risk factors for progression in primary angle-closure glaucoma.

Reply

Desmond T.L. Quek, Shamira A. Perera, Tin Aung — 2012-02-01

We thank Dr Rao for the interest in our article. Dr Rao found it surprising that the mean intraocular pressure (IOP) and range of IOP were not significant risk factors for visual field progression in the primary angle-closure glaucoma subgroup without acute angle closure. Our article actually stated that mean overall IOP was found to be a risk factor for visual field progression, both in univariate and multivariate analyses. We agree that the mean overall IOP in eyes with prior attacks of acute angle closure were probably higher because of acute spikes of IOP. We believed that it would be artificial to disregard the initial IOP and consider only the average and range of the rest of the IOP measurements in the assessment of risk for visual field progression in primary angle-closure glaucoma. It also was difficult to define the end of an acute episode in patients with a variety of presentations. Unfortunately, because of the limited sample size and retrospective nature of our study, we were unable to ascertain other IOP-related risk factors in primary angle-closure glaucoma eyes that progressed.

Corneal Thickness Change in Eyes Undergoing Corneal Cross-Linking

Zhen-Yong Zhang — 2012-02-01

I read with interest the recent work by Holopainen and Krootila and would like to ask the authors to clarify some points about their study and offer comments on their findings. The authors stated in the Methods that the central corneal thickness was recorded. However, the documented results in the Results was the corneal thickness at the thinnest point. The authors should not have neglected this disagreement because the central corneal thickness does not always represent the least value of the corneal thickness in keratoconus. I also note that the population in this study consisted of those with keratoconus and keratectasia and other patients. They might have different responses to corneal cross-linking (CXL), as evidenced by a previous study in which a significant difference in the change in pachymetry measurement between keratoconus patients and ectasia patients was found after CXL. Therefore, interdisease variability in postoperative main outcome measures, that is, corneal thickness measurements, should be considered. Also, the cornea per se in progressive keratoconus or ectasia may thin during 6 months of follow-up. This necessitates a control group in which no intervention is performed and serial corneal thickness measurements are obtained.

Reply

Juha M. Holopainen, Kari Krootila — 2012-02-01

We thank Dr Zhang for his interest in our article. We agree that especially in keratoconic corneas, the thickness of the cornea may be very different on different areas of the cornea, and that is why measurements based on handheld instruments may be demanding. Perhaps optical methods to explore the entire cornea could be better. Yet, during corneal cross-linking (CXL), this is not feasible. Accordingly, we state in the Methods, “Corneal thickness was evaluated preoperatively and postoperatively and during the CXL treatment using an ultrasound pachymeter by measuring the corneal thickness at its thinnest point (based on topography) 5 times and calculating the average of these readings.” Naturally, we are not able to measure the thickness at exactly the thinnest point, but we aimed to do this as well as possible using topography to guide our measurements. Obviously, this will cause some fluctuation in the results. However, it does not jeopardize our results because the trend in decreasing corneal thickness can be seen easily. Importantly, we included in our study the first 30 patients treated in our department with CXL who had keratoconus (24 patients), pellucid marginal degeneration (2 patients), ectasia after laser in situ keratomileusis (3 patients), and bullous keratopathy (1 patient). In all cases, a marked decrease in the corneal thickness during CXL was seen.

Use of Infliximab in the Treatment of Peripheral Ulcerative Keratitis in Crohn Disease

Archana Singh, Virender S. Sangwan — 2012-02-01

We read with great interest the article “Use of Infliximab in the Treatment of Peripheral Ulcerative Keratitis in Crohn Disease,” published in August 2011 issue of the Journal. We appreciate the authors for highlighting the importance of biologics and the newer immunosuppressives in the management of peripheral ulcerative keratitis in Crohn disease refractory to conventional immunosuppressive therapy. We also agree with the authors' comments that infliximab similarly may be effective in diseases with similar mechanisms of action like rheumatoid arthritis.

Reply

Elmer Y. Tu, Mary Pham, Clement C. Chow, David Badawi — 2012-02-01

We thank Drs Singh and Sangwan for their interest in our article, “Use of Infliximab in the Treatment of Peripheral Ulcerative Keratitis in Crohn Disease,” and are heartened that they have found a similar effect of this class of biologic agents for peripheral ulcerative keratitis (PUK) resulting from other causes.

Oral Mucosal Graft to Correct Lid Margin Pathologic Features in Cicatricial Ocular Surface Diseases

Saurabh Kamal, Sushil Kumar — 2012-02-01

The article by Fu and associates evaluating the oral mucosal graft in cicatricial ocular surface reconstruction is very interesting. The lamellar division of the eyelid at the grey line with repositioning is used for corrections of entropion and lid margin keratinization. We also have found the technique very useful for such cases. In addition to the correction of lid margin deformity, the procedure also corrects lid retraction and lagophthalmos. However, the technique at our center differs from that of Fu and associates in the following respects. We carry out the splitting of anterior and posterior lamella just short of superior fornix along with the passage of 3 mattress sutures from the conjunctiva toward the skin. These sutures prevent retraction of the posterior lamella in the postoperative period and are removed at the third week. Second, in the presence of lid retraction, we perform the recession of the Müller muscle by freeing it from the superior tarsus border and conjunctiva. This produces slight ptosis and corrects retraction as well as lagophthalmos. In the present series, for eyes with incomplete closure, the oral mucosal graft was obtained intentionally with more stromal fat so that the tarsal height could be lengthened. In 3 of 12 cases, the residual incomplete closure could be attributed to fat resorption that required oral mucosal graft to both the upper and lower lid. For such cases with severe scarring, our technique may be used.

Reply

Scheffer C.G. Tseng — 2012-02-01

I thank Drs Kamal and Kumar for their interest in our recently published article. I am pleased to learn that they also found our surgical technique useful in correcting lid margin deformity, lid retraction, and lagophthalmos. Although the proposed surgery starts from lamellar division of the involved eyelid at the grey line and ends with posterior repositioning of the anterior lamella, our splitting of anterior and posterior lamella does not reach the level that they stated, that is, just short of superior fornix. As a matter of fact, ours only reaches the level that is sufficient to allow the anterior lamella to be recessed from the tarsal margin, that is, approximately 3 to 5 mm. They found it beneficial to pass 3 mattress sutures from the conjunctiva toward the skin, presumably in a manner similar to the Quickert procedure, which is known to prevent retraction of the posterior lamella and to correct entropion. They also performed the recession of the Müller muscle to create slight ptosis and to correct retraction as well as lagophthalmos. Notwithstanding the fact these steps have their own merits, however, we did not do so and have not noted such a shortcoming in our patients. We suspect that our patients may have different underlying causes from theirs because the main pathologic features reside at the lid margin, exhibiting keratinization, distichiasis, scarring, and contour deficit, instead of entropion or retraction. Because topical steroids had been used before the lid margin reconstruction in most patients, the main reason leading to improvement of all persistent corneal epithelial defects more likely is the result of the correction of the aforementioned lid margin deficits, but not topical steroids.

Possible Short-term Changes of Aqueous Inflammatory Cytokines After Intravitreal Bevacizumab for Diabetic Macular Edema

Won June Lee, Hee Yoon Cho — 2012-02-01

We read with great interest the article by Sohn and associates, “Changes in Aqueous Concentrations of Various Cytokines after Intravitreal Triamcinolone versus Bevacizumb for Diabetic Macular Edema.” They reported that only aqueous vascular endothelial growth factor (VEGF) was decreased significantly after intravitreal bevacizumab (IVB) treatment, but that aqueous levels of interleukin (IL)-6, IL-8, interferon-induced protein-10, monocyte chemotactic protein (MCP)-1, and platelet-derived growth factor-AA were not affected by IVB treatment. Previously, Funk and associates also reported that IVB resulted in a significant decrease of VEGF and that all other cytokines, including IL-8 and MCP-1, were not affected in patients with diabetic macular edema (DME).

Reply

2012-02-01

We appreciate the comments of Lee and Cho regarding short-term changes of aqueous inflammatory cytokines after intravitreal bevacizumab (IVB) for diabetic macular edema, and their remarks about possible acute alteration of associated cytokines after IVB are worth considering.

Natural Course of Adult-Onset Foveomacular Vitelliform Dystrophy: A Spectral-Domain Optical Coherence Tomography Analysis

Rosa Dolz-Marco, Roberto Gallego-Pinazo, Manuel Díaz-Llopis — 2012-02-01

We read with great interest the article by Querques and associates describing progressive stages in patients with presumed adult-onset foveomacular vitelliform dystrophy (AOFVD): vitelliform, pseudohypopyon, vitelliruptive, and atrophic. The authors also noted a significant decrease in visual acuity in eyes showing progression through these stages.

Reply

Giuseppe Querques, Lea Querques, Eric H. Souied — 2012-02-01

We thank Dolz-Marco and associates for their interest in and comments on our recent article on the natural course of adult-onset foveomacular vitelliform dystrophy (AOFVD) by spectral-domain optical coherence tomography. The clinical features of AOFVD were described first by Gass in 1974. The disease then was characterized by a late-onset (between 30 and 50 years of age) solitary, round or oval, elevated, yellow, subretinal lesion of the fovea, ranging from one-third to 1 disk diameter in size and often accompanied by a central pigmented spot. Since 1974, several cases of AOFVD have been reported in multiple clinical series. These series revealed high variability in the appearance and progression of AOFVD, and unfortunately, have generated a number of different terms and abbreviations for this disease and have supported the idea that it may represent a heterogeneous group of disorders with variable clinical features. These undefined features may have led Dolz-Marco and associates to misdiagnose as AOFVD the series of 25 eyes investigated by spectral-domain optical coherence tomography to whom they refer. In fact, it should be noted that, as recently reported by Meunier and associates, age of onset is the only major criterion to distinguish juvenile vitelliform macular dystrophy from AOFVD (2 diseases otherwise clinically indistinguishable). Thus, it is not surprising that a similar progression, through different stages, may account for both vitelliform macular dystrophy and AOFVD, as described in our article.

2012-02-01

American Journal of Ophthalmology

Changing Trends of Blindness: The Initial Harvest From Translational Public Health and Clinical Research in Ophthalmology

Avastin Doesn't Blind People, People Blind People

An Outbreak of Streptococcus Endophthalmitis After Intravitreal Injection of Bevacizumab

Incidence of Legal Blindness From Age-Related Macular Degeneration in Denmark: Year 2000 to 2010

Time Trends in the Incidence and Causes of Blindness in Israel

Recent Statin Use and Cataract Surgery

Punctal and Canalicular Anatomy: Implications for Canalicular Occlusion in Severe Dry Eye

Risk Factors for Orbital Exenteration in Periocular Basal Cell Carcinoma

Clinicopathologic and Immunohistochemical Features of Pigmented Basal Cell Carcinomas of the Eyelids

Clinical Significance of Microbial Growth on the Surfaces of Silicone Tubes Removed From Dacryocystorhinostomy Patients

The Effect of Standard and Transepithelial Ultraviolet Collagen Cross-Linking on Human Corneal Nerves: An Ex Vivo Study

Prevalence, Progression, and Impact of Glaucoma on Vision After Boston Type 1 Keratoprosthesis Surgery

Micrometer-Scale Contact Lens Movements Imaged by Ultrahigh-resolution Optical Coherence Tomography

Reporting Visual Acuities

Characteristic Higher-Order Aberrations of the Anterior and Posterior Corneal Surfaces in 3 Corneal Transplantation Techniques

Long-term Comparison of Full-Bed Deep Lamellar Keratoplasty With Penetrating Keratoplasty in Treating Corneal Leucoma Caused by Herpes Simplex Keratitis

Intravitreal Bevacizumab for Treatment of Subfoveal Idiopathic Choroidal Neovascularization: Results of a 1-Year Prospective Trial

Vascular Endothelial Growth Factor in Plasma and Vitreous Fluid of Patients with Proliferative Diabetic Retinopathy Patients after Intravitreal Injection of Bevacizumab

Near-Infrared Autofluorescence in Patients With Idiopathic Submacular Choroidal Neovascularization

Vitrectomy and Internal Limiting Membrane Peeling With and Without Gas Tamponade for Myopic Foveoschisis

Serum Concentrations of Bevacizumab (Avastin) and Vascular Endothelial Growth Factor in Infants With Retinopathy of Prematurity

Prediction of Postoperative Eyelid Height After Frontalis Suspension Using Autogenous Fascia Lata for Pediatric Congenital Ptosis

The Long-Term Survival Analysis of Bilateral Lateral Rectus Recession Versus Unilateral Recession-Resection for Intermittent Exotropia

Subconjunctival Bevacizumab Versus Mitomycin C Adjunctive to Trabeculectomy

Corneal Hysteresis and Beta-Zone Parapapillary Atrophy

Ocular Complications of Human Immunodeficiency Virus Infection in Eastern China

Depression and Visual Functioning in Patients With Ocular Inflammatory Disease

In Vivo Analysis of Stromal Integration of Multilayer Amniotic Membrane Transplantation in Corneal Ulcers

Reply

Quality of Life in a German Graves Orbitopathy Population

Reply

Blindness and Long-term Progression of Visual Field Defects in Chinese Patients With Primary Angle-Closure Glaucoma

Reply

Corneal Thickness Change in Eyes Undergoing Corneal Cross-Linking

Reply

Use of Infliximab in the Treatment of Peripheral Ulcerative Keratitis in Crohn Disease

Reply

Oral Mucosal Graft to Correct Lid Margin Pathologic Features in Cicatricial Ocular Surface Diseases

Reply

Possible Short-term Changes of Aqueous Inflammatory Cytokines After Intravitreal Bevacizumab for Diabetic Macular Edema

Reply

Natural Course of Adult-Onset Foveomacular Vitelliform Dystrophy: A Spectral-Domain Optical Coherence Tomography Analysis

Reply

Contents