American Journal of Ophthalmology - Articles in Press

Characterization of Diabetic Microaneurysms by Simultaneous Fluorescein Angiography and Spectral-Domain Optical Coherence Tomography - Corrected Proof

2012-02-02

Purpose: To correlate spectral-domain optical coherence tomography (SD-OCT) findings of perfused diabetic microaneurysms with leakage status on fluorescein angiography (FA) using simultaneous FA and SD-OCT. Design: Retrospective, observational case series. Methods: A total of 173 microaneurysms were analyzed in 50 eyes (14 mild nonproliferative diabetic retinopathy [NPDR]; 22 moderate NPDR; 9 severe NPDR; 5 proliferative diabetic retinopathy) of 40 diabetic patients using simultaneous FA and SD-OCT. The characteristics of microaneurysms were evaluated by 2 masked observers using SD-OCT and correlated with leakage status on FA. Results: External diameter of microaneurysms averaged 104 μm (range 43-266 μm). Some microaneurysm centers (15/173; 9%) and the outermost extent of microaneurysms (113/173; 68%) were localized to the outer half of the retina. Almost all microaneurysms spanned more than 1 retinal layer (157/173; 91%). Most microaneurysms had an internal lumen with homogeneous reflectivity (109/173; 63%) and moderate reflectivity (87/173; 50%). Retinal thickness through microaneurysms as well as the presence of adjacent hyporeflectivity on SD-OCT correlated with increasing leakage status seen on FA (P < .001). Microaneurysm dimensions, percent depth within the retina, retinal layer location, and internal reflectivity by SD-OCT did not correlate significantly with FA leakage status. Conclusions: Simultaneous FA and SD-OCT allows detailed characterization of perfused diabetic microaneurysms. Increased FA leakage of diabetic microaneurysms positively correlated with perianeurysm fluid and retinal thickness. Perfused microaneurysms seen by SD-OCT were localized deeper than the inner nuclear layer.

Changes in Health-Related Quality of Life 1 Year Following Strabismus Surgery - Corrected Proof

Sarah R. Hatt, David A. Leske, Laura Liebermann, Jonathan M. Holmes — 2012-01-27

Purpose: To report changes in health-related quality of life (HRQOL) 1 year following strabismus surgery. Design: Retrospective cohort study. Methods: Seventy-three adults undergoing strabismus surgery in a single clinical practice completed the Adult Strabismus-20 (AS-20) HRQOL questionnaire preoperatively and at 6 weeks and 1 year postoperatively. All included adults were successfully aligned at 6 weeks postoperatively. Success was defined based on clinical criteria. Change in AS-20 psychosocial and function scores was evaluated as: 1) difference in scores between 6 weeks and 1 year postoperatively and 2) proportions exceeding previously published limits of agreement at 6 weeks and 1 year. Results: For patients successfully aligned at both 6 weeks and 1 year (n = 51), further improvement in median scores was seen from 6 weeks to 1 year for both the psychosocial scale (83.8 vs 93.8; P < .0001) and the function scale (72.5 vs 77.5; P = .007). Also, a greater proportion exceeded limits of agreement at 1 year than at 6 weeks (psychosocial: 48% vs 30%; P = .007, function: 67% vs 51%; P = .01). For patients who became partial success (n = 18) or failure (n = 4) at 1 year there was a numerical decrease in scores at 1 year. Conclusions: Adult strabismus patients who remain successfully aligned show continued improvement in both psychosocial and function scores from 6 weeks to 1 year postoperatively, indicating that improvement in HRQOL is long-lasting. Evaluation of HRQOL should be considered when reporting strabismus surgery outcomes in clinical trials, and may prove helpful in assessing outcomes in clinical practice.

Causes of Glaucoma After Descemet Membrane Endothelial Keratoplasty - Corrected Proof

2012-01-27

Purpose: To describe the incidence and causes of glaucoma after Descemet membrane endothelial keratoplasty (DMEK). Design: Nonrandomized prospective cohort study at a tertiary referral center. Methods: The incidence of glaucoma was evaluated in the first 275 consecutive eyes that underwent DMEK for Fuchs endothelial dystrophy (260 eyes) or bullous keratopathy (15 eyes). Glaucoma was defined as a postoperative intraocular pressure (IOP) elevation of ≥24 mm Hg, or ≥10 mm Hg from the preoperative baseline. If possible, the cause of glaucoma was identified, and best-corrected visual acuity (BCVA), endothelial cell density (ECD), and postoperative course were documented, with a mean follow-up of 22 (± 13) months. Results: Overall, 18 eyes (6.5%) showed postoperative glaucoma after DMEK. Seven eyes (2.5%) had an exacerbation of a pre-existing glaucoma. Eleven eyes (4%) presented with a de novo IOP elevation, associated with air bubble–induced mechanical angle closure (2%), steroid response (0.7%), or peripheral anterior synechiae (0.4%), or without detectable cause (0.7%). Two eyes (0.7%) required glaucoma surgery after DMEK. At 6 months, all eyes had a BCVA of ≥20/40 (≥0.5), and 81% reached ≥20/25 (≥0.8) (n = 16); mean ECD was 1660 (± 554) cells/mm2 (n = 15) (P > .1). Conclusion: Glaucoma after DMEK may be a relatively frequent complication that could be avoided by reducing the residual postoperative air bubble to 30% in phakic eyes, applying a population-specific steroid regime, and avoiding decentration of the Descemet graft. Eyes with a history of glaucoma may need close IOP monitoring in the first postoperative months, especially in eyes with an angle-supported phakic intraocular lens.

Clinical Outcomes of Repeat Autologous Cultivated Limbal Epithelial Transplantation for Ocular Surface Burns - Corrected Proof

Sayan Basu, Hasnat Ali, Virender S. Sangwan — 2012-01-23

Purpose: To report the clinical outcomes of repeat autologous cultivated limbal epithelial transplantation in patients with recurrence of limbal stem cell deficiency after a failed primary procedure. Design: Retrospective case series. Methods: This study included 50 patients, above 8 years of age, with clinically diagnosed unilateral limbal stem cell deficiency following ocular surface burns, treated between 2001 and 2010. Following failure of primary surgery all patients underwent a repeat limbal biopsy from the unaffected eye. The limbal cells were expanded ex vivo on a human amniotic membrane substrate for 10 to 14 days using a completely xeno-free explant culture technique. The resulting cultured epithelial monolayer and amniotic membrane were transplanted onto the patient's affected eye. All patients underwent a comprehensive ophthalmic examination of both eyes at every follow-up visit. Postoperative corneal surface stability, change in visual acuity, and complications were objectively analyzed. Results: At a mean follow-up of 2.3 ± 1.4 (median: 1.96, range: 1 to 7.5) years, 33 of the 50 recipient eyes (66%) maintained a completely epithelialized, avascular, and clinically stable corneal surface. A 2-line improvement in visual acuity was seen in 38 of the 50 recipient eyes (76%). None of the donor eyes developed any clinical features of ocular surface disease, conjunctival overgrowth of the donor site, or decrease in vision throughout the follow-up period. Conclusions: Repeat autologous cultivated limbal epithelial transplantation successfully restores corneal epithelial stability and improves vision in eyes with recurrence of limbal stem cell deficiency, following failed primary surgery for ocular burns, without adversely affecting donor eyes.

The Effect of Alpha Antagonists on Pupil Dynamics: Implications for the Diagnosis of Intraoperative Floppy Iris Syndrome - Corrected Proof

2012-01-23

Purpose: To assess pupil dynamics quantitatively in relation to the use of α1-adrenoceptor antagonists, which contribute to the features of intraoperative floppy iris syndrome, using a new, hand-held, digital pupillometer. Design: Prospective case-control study. Methods: We studied 15 and 25 patients administered tamsulosin and alfuzosin, respectively, as well as 25 control patients. Resting pupil diameter and subsequent contraction, latency, constriction velocity, and dilation velocity were recorded using an electronic pupillometer. All pupil measurements were performed before and after pharmacologic dilation. Results: In predilation pupillary measurements, we detected a significant decrease in maximum pupillary diameter by 0.50 ± 0.19 mm (P = .011) and in the mean percentage of diameter reduction after stimulation (5.23 ± 2.42%, P = .035) in the tamsulosin group. Alfuzosin also induced a significant decrease in maximum pupillary diameter (0.49 ± 0.17 mm, P = .005). Constriction velocity was significantly reduced by 0.70 ± 0.20 m/s (P = .001) in the tamsulosin group and by 0.54 ± 0.18 m/s (P = .004) in the alfuzosin group. In terms of postdilation measurements, maximum and minimum pupil diameters were reduced significantly only in the tamsulosin group (by 1.09 ± 0.31 mm [P = .001] and by 0.89 ± 0.36 mm [P = .016], respectively). Conclusions: We describe a reliable, accurate, and rapid method to acquire quantitative pupil measurements and identify the tendency for intraoperative floppy iris syndrome before cataract surgery after the use of alfuzosin and tamsulosin. This investigation also analyzed the similarities and differences induced by the 2 drugs in predilation and postdilation pupil dynamics, demonstrating that tamsulosin is more potent than alfuzosin in inducing intraoperative floppy iris syndrome.

Correlation Between Plasma Pentosidine Concentrations and Retinal Hemodynamics in Patients With Type 2 Diabetes - Corrected Proof

Eiichi Sato, Taiji Nagaoka, Harumasa Yokota, Atsushi Takahashi, Akitoshi Yoshida — 2012-01-23

Purpose: To investigate whether plasma pentosidine, a well-defined advanced glycation end product, is associated with retinal hemodynamic abnormalities in patients with type 2 diabetes. Design: Prospective cross-sectional study. Methods: Forty-two eyes with type 2 diabetes mellitus were evaluated. The type 2 diabetic eyes were divided into 2 groups: 22 eyes (22 patients; mean age, 61 years) with nondiabetic retinopathy (NDR) and 20 eyes (20 patients; mean age, 61 years) with mild nonproliferative diabetic retinopathy (NPDR). We used a retinal laser Doppler system to measure the arterial diameter, velocity, and blood flow in the major temporal retinal arteries. The pulsatility ratio, a resistive index expressed as the peak systolic to the end diastolic velocity ratio, was calculated from the blood velocity traces. Plasma pentosidine was measured in 42 patients with diabetes using a commercially available competitive enzyme-linked immunosorbent assay. Results: The pulsatility ratio significantly increased in patients with NPDR (4.8 ± 1.5) compared with patients with NDR (3.7 ± 0.8) (P = .0061). No differences in velocity, diameter, or blood flow were seen between the 2 groups. Plasma pentosidine levels also increased significantly (P = .0085) in patients with NPDR (0.057 ± 0.015) compared to patients with NDR (0.047 ± 0.012). The pulsatility ratio was correlated positively with the plasma pentosidine levels in patients with NPDR (Pearson correlation, r = 0.45, P = .044). Multiple regression analysis showed that the plasma pentosidine level was significantly associated with the pulsatility ratio (standardized coefficient, 0.62; P = .009). Conclusions: The vascular rigidity of the retinal arteries may increase with increasing plasma pentosidine in patients with type 2 diabetes with retinopathy.

Multimodal Fundus Imaging in Choroidal Osteoma - Corrected Proof

2012-01-23

Purpose: To describe the morphologic features of calcified and decalcified choroidal osteomas using multimodal imaging and correlate these findings with a previous histopathologic study. Design: Retrospective observational case series. Methods: Three patients with choroidal osteoma underwent complete ophthalmologic examination, fundus photography, and multimodal fundus imaging, including Fourier-domain optical coherence tomography (FD-OCT) and blue-light fundus autofluorescence (bAF). Results: FD-OCT imaging of calcified tumors revealed a distinctive latticework pattern of reflectivity resembling the spongy bone structure seen histopathologically. On bAF the fluorescence was relatively well preserved overlying calcified tumors. In decalcified areas 2 patterns of reflectivity were identified: the first consisted of areas of relative hyperreflectivity with a lamellar appearance while the second was characterized by heterogeneous, hyperreflective, mound-like irregular areas associated with some posterior optical shadowing. Decalcified tumor areas had reduced overall fluorescence on bAF. Conclusion: FD-OCT demonstrated different reflectivity patterns in both calcified and decalcified portions of the choroidal osteoma, which may correspond to different stages of tumor evolution. A distinctive latticework pattern of reflectivity similar to spongy bone was seen in calcified tumors. These observations improve our knowledge of the in vivo structure of choroidal osteomas and may have implications for the diagnosis and management of this tumor.

Surgical and Visual Outcomes of the Type I Boston Keratoprosthesis for the Management of Aniridic Fibrosis Syndrome in Congenital Aniridia - Corrected Proof

2012-01-23

Purpose: To report the clinical features and surgical management of aniridic fibrosis syndrome using the type I Boston Keratoprosthesis (KPro). Design: Interventional case series. Methods: Retrospective chart review of 9 eyes in 9 patients with congenital aniridia that developed aniridic fibrosis syndrome. Results: All patients had clinical diagnosis of congenital aniridia. Previously, all patients had undergone cataract surgery with posterior chamber intraocular lens (IOL) implantation and 7 patients had existing tube shunts. In all cases, fibrosis presented as progressive retrocorneal and retrolenticular membrane formation causing displacement of the IOL and secondary corneal decompensation. Two eyes had tractional folds in the retina with posterior extension of the membrane. The management included IOL explantation in 7 of 9 cases, removal of fibrosis with pars plana vitrectomy in all 9 patients, and implantation of a type I Boston KPro in all eyes. At a mean final follow-up of 26.1 months (range 6 to 48 months), vision remained improved in all patients. No patient had recurrence of the fibrotic membrane after KPro implantation. Conclusion: This study represents another case series describing aniridic fibrosis syndrome and the largest study to report utilization of the type I Boston KPro in such patients. As the fibrosis can cause IOL dislocation, corneal decompensation, hypotony, and retinal detachment, monitoring for aniridic fibrosis syndrome in congenital aniridia with early surgical intervention is recommended. Type I Boston KPro may be considered in the surgical treatment of this condition.

Evolution of Early Changes at the Vitreoretinal Interface After Cataract Surgery Determined by Optical Coherence Tomography and Ultrasonography - Corrected Proof

2012-01-20

Purpose: To evaluate the onset of posterior vitreous detachment (PVD) including early changes at the vitreoretinal interface after uneventful phacoemulsification in nonmyopic eyes using optical coherence tomography (OCT) and ultrasound. Design: Prospective consecutive study. Methods: Patients undergoing cataract surgery at our unit between January and October 2010 were recruited and examined with OCT and ultrasound preoperatively. Inclusion criteria were complete vitreoretinal attachment, no ocular pathology other than cataract, and no previous ocular surgery. All patients underwent phacoemulsification with intraocular lens implantation. Postoperatively, OCT and ultrasound were performed 1 month and 3 months after surgery. Exclusion criteria were axial length ≥25 mm, lattice degeneration, intraoperative complications, and incomplete follow-up. Results: Forty-nine eyes of 49 patients could be enrolled in the study. Some degree of PVD was noted in 29 eyes (59.2%) 1 month after surgery and in 35 eyes (71.4%) 3 months after surgery. Moreover, a significant decrease in prevalence of initial PVD and a corresponding increase of more advanced PVD stages throughout the duration of the study was observed. In patients older than 70 years some degree of PVD was diagnosed in 92.3% compared to 47.8% in patients younger than 70 years (P = .002). Conclusion: OCT facilitates the detection of early vitreoretinal separation that indicates initial PVD. After phacoemulsification the prevalence of some degree of PVD is consequently more frequent when supplementary OCT is used. Furthermore, OCT discloses a significant progression of PVD in the postoperative course. Patients older than 70 years are more likely to develop pseudophakic PVD.

Clinical Outcomes in Patients With Cytomegalovirus Retinitis Treated With Ganciclovir Implant - Corrected Proof

2012-01-20

Purpose: To describe the clinical outcomes of patients with cytomegalovirus (CMV) retinitis and AIDS treated with ganciclovir implant. Design: Retrospective cohort study. Methods: The charts of 115 patients (166 affected eyes) with CMV retinitis treated with ganciclovir implant in the Division of Ocular Immunology, Wilmer Eye Institute from April 1996 through November 2009 were reviewed. Ophthalmologic data collected included visual acuity, ocular complications, treatment, and presence of immune recovery. Kaplan-Meier analyses and Cox regression models were used to investigate relationships between potential risk factors and ocular outcomes. Results: At implantation, 55% of patients were prescribed highly active antiretroviral therapy (HAART), 21% were formerly on HAART, and 24% were HAART-naïve. One hundred sixty-six eyes received 257 ganciclovir implants. Fifty-seven of the implanted eyes were diagnosed with a total of 126 ocular complications after implant surgery (rate = 0.19/eye-year [EY]), the 3 most common being cataract, vitreous hemorrhage, and retinal detachment. Despite these ocular complications, the development of severe vision loss (≥6 lines lost) was low (0.005/EY). Patients with immune recovery during follow-up were less likely to have ocular complications after implant surgery; however, only the risk reduction for retinal detachment achieved statistical significance (hazard ratio = 0.29, 95% CI: 0.08, 0.98). Conclusions: Our data suggest that ocular complications after implant surgery, including cataract, vitreous hemorrhage, and retinal detachment, were relatively common after ganciclovir implantation but severe vision loss after surgery was low. Presence of immune recovery may lessen the risk of postoperative ocular complications.

Outcomes of 4-Snip Punctoplasty for Severe Punctal Stenosis: Measurement of Tear Meniscus Height by Optical Coherence Tomography - Corrected Proof

Sung Eun Kim, Sung Jun Lee, Sang Yeul Lee, Jin Sook Yoon — 2012-01-20

Purpose: To investigate the surgical outcome of rectangular 4-snip punctoplasty, a modification of rectangular 3-snip procedures, using objective measurements. Design: Noncomparative case series. Methods: The medical charts of patients who underwent rectangular 4-snip punctoplasty for severe punctal stenosis with at least 6 months follow-up were reviewed. Before surgery and at 1 and 6 months after surgery, subjective evaluation of tearing was assessed using Munk scores. The size of the punctum was graded based on slit-lamp examination, and measurement of tear meniscus height was done using Fourier-domain optical coherence tomography. Results: A total of 45 eyes (26 patients) were studied. The subjective epiphora score was significantly reduced after surgery and maintained until 6 months after the surgery (χ2 for trend test, P < .001). The grade of the punctum size was also significantly enlarged after surgery and the enlarged punctum was maintained until 6 months after the surgery (χ2 for trend test, P < .001). The mean preoperative tear height (452.4 ± 249.3 μm) was significantly reduced both at 1 month after surgery (341.6 ± 207.9 μm; P = .003, paired t test) and at 6 months after surgery (362.1 ± 212.6 μm; P = .004, paired t test). The functional success rate was 93.3% and anatomic success rate was 88.9% at 6 months after surgery. Conclusions: Rectangular 4-snip punctoplasty was an anatomically and functionally effective procedure for severe punctal stenosis patients, maintaining large puncta for fairly long periods.

Glued Intrascleral Fixation of Posterior Chamber Intraocular Lens in Children - Corrected Proof

2012-01-20

Purpose: To evaluate the short-term results of glued intrascleral fixation of posterior chamber intraocular lens (glued IOL) in children without adequate capsular support. Design: Noncomparative retrospective observational case series. Patients: Setting: Institutional practice. Methods: Forty-one eyes of 33 children who underwent glued IOL implantation were retrospectively evaluated. The indications were postsurgical aphakia, subluxated cataract, ectopia lentis, traumatic subluxation, and decentered IOL. Main outcome measures: Visual acuity (VA), endothelial cell changes, intraoperative and postoperative complications. Results: The mean age at the time of glued IOL was 10.7 ± 3.6 years (range 5−15). The mean duration of follow-up after surgery was 17.5 ± 8.5 months (range 12-36). The mean postoperative best spectacle-corrected visual acuity (BCVA in decimal equivalent) was 0.43 ± 0.33 and there was significant change noted (P < 0.001). Postoperatively, 20/20 and >20/60 BCVA was obtained in 17.1% and 46.3% of eyes respectively. BCVA improvement more than 1 line was seen in 22 eyes (53.6%). The mean postoperative refraction was myopic (−1.19 ± 0.7 diopters [D]) in 19 eyes and hyperopic (+1.02 ± 0.7 D) in 22 eyes. The mean endothelial loss was 4.13% (range 1.3%-5.94%). The 3 causes of reduced BCVA were the preexisting corneal, retinal pathology, and amblyopia. Postoperative complications included optic capture in 1 eye (2.4%), macular edema in 2 eyes (4.8%), and clinical decentration in 2 eyes (4.8%). There was no postoperative retinal detachment, IOL dislocation, endophthalmitis, or glaucoma. Conclusion: Short-term results in children after glued IOL were favorable, with a low rate of complications. However, regular follow-ups are required since long-term risks are unknown.

Whole-Body 18F FDG Positron Emission Tomography/Computed Tomography Evaluation of Patients With Uveal Metastasis - Corrected Proof

Payal Patel, Paul T. Finger — 2012-01-20

Purpose: To investigate the value of whole-body positron emission tomography/computed tomography (PET/CT) as a screening tool for patients with uveal metastasis. Design: Retrospective observational case series. Methods: Setting: Clinical practice. Study population: Eighteen patients with uveal metastatic tumors were evaluated. Patients had no history of malignancy or a past medical history of malignancy without known active metastasis or known systemic cancer. Intervention: Whole-body PET/CT was used as a screening tool to evaluate the intraocular tumor, to evaluate for multi-organ metastatic disease, and for cancer staging. Main outcome measures: Detection and PET/CT uptake of primary tumors and metastatic disease. Results: PET/CT imaging uncovered previously occult primary nonocular cancers (11/18, 61%), revealed progression of known primary systemic cancer (7/18, 39%), and confirmed multi-organ metastases in all cases (18/18, 100%). PET/CT findings were used to direct nonocular, confirmatory biopsy in 67% of cases (12/18). No uveal biopsies were required. PET/CT revealed lymph nodes and bone as the most common metastatic sites. The intraocular tumor was detectable in 28% of cases. Small, non-avid tumors and those within the hypermetabolic, PET-avid brain were falsely negative. Conclusion: This study suggests that whole-body PET/CT can be useful for clinical evaluation of patients with uveal metastases. It allowed for screening of the entire body and directed extraocular biopsy. Commonly used for tumor staging, PET/CT aided in the detection of the primary cancer in patients with metastatic uveal tumors.

Graft Rejection Following Descemet Stripping Automated Endothelial Keratoplasty: Features, Risk Factors, and Outcomes - Corrected Proof

Elaine I. Wu, David C. Ritterband, Guopei Yu, Rebecca A. Shields, John A. Seedor — 2012-01-20

Purpose: To investigate the clinical features, risk factors, and treatment outcomes following immunologic graft rejection in eyes that have undergone Descemet stripping automated endothelial keratoplasty (DSAEK). Design: Retrospective case review. Methods: The charts for 353 DSAEK procedures performed at a single clinical practice at the New York Eye and Ear Infirmary from August 2006 to November 2010 were reviewed. Cases with at least 3 months follow-up were included. Outcome measures included rates of graft rejection, clinical findings, treatment outcomes, and risk factor analysis. Results: Thirty of 353 DSAEKs developed graft rejection (8.5%). Kaplan-Meier rate of rejection was 6.0% at 1 year (n = 175), 14.0% at 2 years (n = 79), and 22.0% at 3 years (n = 39). Rejection episodes occurred between 0.8 and 34 months. Clinical findings included anterior chamber cells, keratic precipitates, endothelial rejection line, and host-donor interface vascularization. Risk factors for development of graft rejection were cessation of postoperative steroid (hazard ratio 5.49, P < .0001) and black race (hazard ratio 2.71, P = .02). Recipient age, sex, surgical indication, glaucoma, postoperative steroid response, corneal neovascularization or peripheral anterior synechiae, graft size, prior keratoplasty in fellow eye, and concurrent or subsequent procedures were not associated with graft rejection. Twenty-two out of 30 rejection episodes (73.3%) resolved with steroid treatment. Conclusions: Graft rejection is an important complication following DSAEK. In contrast to penetrating keratoplasty, rejection following DSAEK is almost exclusively endothelial. Among risk factors traditionally associated with graft rejection, cessation of topical steroids was most significant. Prompt recognition and treatment of DSAEK rejection can lead to favorable outcomes.

Reduced-Fluence Photodynamic Therapy Combined With Intravitreal Bevacizumab for Polypoidal Choroidal Vasculopathy - Corrected Proof

Min Sagong, Suho Lim, Woohyok Chang — 2012-01-20

Purpose: To evaluate the efficacy and safety of reduced-fluence photodynamic therapy (PDT) combined with bevacizumab for polypoidal choroidal vasculopathy (PCV). Design: Prospective, noncomparative, interventional case series. Methods: Sixteen treatment-naïve patients with polypoidal choroidal vasculopathy were treated with reduced-fluence PDT combined with bevacizumab. All patients were followed up monthly for 12 months with measurements of best-corrected visual acuity (BCVA) and central foveal thickness by optical coherence tomography. Indocyanine green angiography and fluorescein angiography were performed every 3 months. Patients were re-treated with reduced-fluence PDT combined with bevacizumab or with sole injection of bevacizumab when indicated. Results: The mean logMAR BCVA showed significant improvement from 0.76 at baseline to 0.46 at 12 months (P = .002). At 12 months, the BCVA improved in 9 eyes (56.3%) by 3 lines or more, was stable in 6 eyes (37.5%), and decreased in 1 eye (6.3%) because of recurrence of polyps. During the study period, 3 patients (18.8%) had recurrence of polyps and 2 patients (12.5%) had persistent polyps. Mean episodes of reduced-fluence PDT and mean injections of intravitreal bevacizumab over 12 months were 1.44 and 2.44, respectively. Although 3 patients had mild choroidal nonperfusion—1 eye after 1 session of PDT and 2 eyes after 2 sessions—no severe complications, including endophthalmitis, uveitis, or subretinal hemorrhage, developed. Conclusion: Reduced-fluence PDT combined with bevacizumab for PCV seemed to be effective for improving vision and reducing complications. Further study to optimize the light dose of PDT in combination therapy is needed in order to achieve better treatment outcomes for PCV.

Succinate Increases in the Vitreous Fluid of Patients With Active Proliferative Diabetic Retinopathy - Corrected Proof

2012-01-20

Purpose: To examine vitreous succinate levels from proliferative diabetic retinopathy (PDR) patients and ascertain their association with PDR activity. Design: Comparative case series. Methods: A total of 81 eyes of 72 PDR patients were divided into active PDR (22 eyes), quiescent PDR (21 eyes), and active PDR with intravitreal bevacizumab injection (38 eyes). Twenty epiretinal membrane (ERM) patients (21 eyes) served as controls. Results: Mean vitreous succinate levels were 1.27 μM in ERM and 2.20 μM in PDR, with the differences statistically significant (P = .03). When comparing mean vitreous succinate levels (active PDR: 3.32 μM; quiescent PDR: 1.02 μM; active PDR with intravitreal bevacizumab injection: 1.20 μM), significant differences were found between active and quiescent PDR (P < .01) and between active PDR and active PDR with intravitreal bevacizumab injection (P < .01). Even though succinate levels were low, retinopathy activities were very high in patients with active PDR with intravitreal bevacizumab injection. Mean vitreous vascular endothelial growth factor (VEGF) levels (active PDR: 1696 pg/mL; quiescent PDR: 110 pg/mL; active PDR with intravitreal bevacizumab injection: n.d.) were similar to previous reports. Mean vitreous erythropoietin levels (active PDR: 703 mIU/mL; quiescent PDR: 305 mIU/mL; active PDR with intravitreal bevacizumab injection: 1562 mIU/mL) suggested very high retinopathy activities in patients with active PDR with intravitreal bevacizumab injection. Conclusions: Succinate, like VEGF, may be an angiogenic factor that is induced by ischemia in PDR. Although succinate is reported to promote VEGF expression, VEGF inhibition decreases succinate. Thus, VEGF, via a positive feedback mechanism, may regulate succinate.

Diagnostic Capability of Spectral-Domain Optical Coherence Tomography for Glaucoma - Corrected Proof

Huijuan Wu, Johannes F. de Boer, Teresa C. Chen — 2012-01-20

Purpose: To determine the diagnostic capability of spectral-domain optical coherence tomography in glaucoma patients with visual field defects. Design: Prospective, cross-sectional study. Methods: Settings: Participants were recruited from a university hospital clinic. Study population: One eye of 85 normal subjects and 61 glaucoma patients with average visual field mean deviation of −9.61 ± 8.76 dB was selected randomly for the study. A subgroup of the glaucoma patients with early visual field defects was calculated separately. Observation Procedures: Spectralis optical coherence tomography (Heidelberg Engineering, Inc) circular scans were performed to obtain peripapillary retinal nerve fiber layer (RNFL) thicknesses. The RNFL diagnostic parameters based on the normative database were used alone or in combination for identifying glaucomatous RNFL thinning. Main Outcome Measures: To evaluate diagnostic performance, calculations included areas under the receiver operating characteristic curve, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio. Results: Overall RNFL thickness had the highest area under the receiver operating characteristic curve values: 0.952 for all patients and 0.895 for the early glaucoma subgroup. For all patients, the highest sensitivity (98.4%; 95% confidence interval, 96.3% to 100%) was achieved by using 2 criteria: ≥ 1 RNFL sectors being abnormal at the < 5% level and overall classification of borderline or outside normal limits, with specificities of 88.9% (95% confidence interval, 84.0% to 94.0%) and 87.1% (95% confidence interval, 81.6% to 92.5%), respectively, for these 2 criteria. Conclusions: Statistical parameters for evaluating the diagnostic performance of the Spectralis spectral-domain optical coherence tomography were good for early perimetric glaucoma and were excellent for moderately advanced perimetric glaucoma.

Efficacy and Potential Complications of Difluprednate Use for Pediatric Uveitis - Corrected Proof

Mark A. Slabaugh, Erin Herlihy, Sharel Ongchin, Russell N. van Gelder — 2012-01-20

Purpose: To evaluate the clinical effect of topical difluprednate in pediatric patients for treatment of noninfectious uveitis. Design: Retrospective, observational case series. Methods: Twenty-six eyes of 14 pediatric patients with noninfectious uveitis who were treated with topical difluprednate were evaluated. Anterior and posterior cell grade, visual acuity, intraocular pressure (IOP), and cystoid macular edema (CME) were recorded at each visit. Main outcome measures were changes in anterior segment cell, CME, visual acuity, and IOP and development of a visually significant cataract. Results: A significant (≥ 2-grade decrease or decrease to 0 in anterior segment cell) reduction in anterior segment inflammation was observed during treatment with topical difluprednate in 88% of eyes (22/25) when used as an adjuvant to systemic immunomodulatory therapy. In addition, improvement in CME associated with uveitis was seen in response to topical therapy with difluprednate in 78% of eyes with CME (7/9). A significant IOP response (IOP increase of ≥ 10 mm Hg from baseline and IOP ≥ 24 mm Hg) was seen in 50% of eyes (13/26) and in 50% of patients (7/14); 3 eyes of 2 patients required glaucoma surgery. Cataract formation or progression was observed in 39% of eyes (10/26) and in 43% of patients (6/14); 5 eyes of 3 patients required cataract surgery. Conclusions: Difluprednate is an effective agent for both control of anterior segment inflammation and reduction of CME in pediatric patients with uveitis when used as an adjuvant to systemic immunomodulatory therapy. A high rate of steroid-induced IOP elevation and cataract formation is seen in this population. Close monitoring of pediatric patients receiving difluprednate is recommended.

Clinical Features of Newly Diagnosed Cytomegalovirus Retinitis in Northern Thailand - Corrected Proof

2012-01-20

Purpose: To characterize the clinical manifestations of cytomegalovirus (CMV) retinitis in northern Thailand. Design: Prospective, observational, cross-sectional study. Methods: We recorded characteristics of 52 consecutive patients newly diagnosed with CMV retinitis at a tertiary university-based medical center in northern Thailand. Indirect ophthalmoscopy by experienced ophthalmologists was supplemented with fundus photography to determine the proportion of eyes with various clinical features of CMV retinitis. Results: Of the 52 patients with CMV retinitis, 55.8% were female. All were HIV-positive. The vast majority (90.4%) had started antiretroviral therapy. CMV retinitis was bilateral in 46.2% of patients. Bilateral visual acuity worse than 20/60 was observed in 23.1% of patients. Of 76 eyes with CMV retinitis, 61.8% had zone I disease and 21.6% had lesions involving the fovea. Lesions larger than 25% of the retinal area were observed in 57.5% of affected eyes. CMV retinitis lesions commonly had marked or severe border opacity (47.4% of eyes). Vitreous haze often was present (46.1% of eyes). Visual impairment was more common in eyes with larger retinitis lesions. Retinitis lesion size, used as a proxy for duration of disease, was associated with fulminant appearance (odds ratio, 1.24; 95% confidence interval, 1.01 to 1.51) and marked or severe border opacity (odds ratio, 1.36; 95% confidence interval, 1.11 to 1.67). Based on lesion size, retinitis preceded antiretroviral treatment in each patient. Conclusions: Patients seeking treatment at a tertiary medical center in northern Thailand had advanced CMV retinitis, possibly because of delayed diagnosis. Earlier screening and treatment of CMV retinitis may limit progression of disease and may prevent visual impairment in this population.

Surgical Rehabilitation of the Open Globe Injury Patient - Corrected Proof

Michael T. Andreoli, Christopher M. Andreoli — 2012-01-20

Purpose: To describe the long-term surgical course of patients with open globe injury. Design: Retrospective case series. Methods: Patients with open globe injuries (848 in total) treated surgically at the Massachusetts Eye and Ear Infirmary between 2000 and 2009 were retrospectively reviewed. Data from presentation, initial repair, and follow-up surgery were analyzed. Results: Among 848 injuries, 1415 surgical procedures were performed. The mean follow-up time was 19.7 months, including 6017 visits. On average, patients required 1.7 surgeries and 7.1 follow-up visits. Factors predicting follow-up surgery included more severe ocular trauma score, worse prerepair visual acuity, retinal hemorrhage, anterior vitrectomy at primary repair, pars plana vitrectomy at primary repair, and lensectomy at primary repair. Patients with zone II injury, hemorrhagic choroidal detachment, and a history of previous ocular surgery tended to require follow-up surgery less frequently. Patients requiring a second surgery tended to have worse visual acuity at presentation and postrepair. Postoperative visual outcomes were worse for patients who underwent vitreoretinal follow-up surgery, likely because of mechanism of injury. Variables associated with inferior visual outcome were worse prerepair visual acuity, postoperative afferent pupillary defect (APD), old age, scleral laceration, and retinal detachment. Conclusion: Open globe injuries require significant surgical follow-up. Patients requiring multiple operations tended to have worse postoperative visual acuity. Patients who underwent vitreoretinal surgery had overall worse visual outcomes. While the first year of surveillance appears to be pivotal in the course of an open globe injury, these patients can expect long-term care from comprehensive and subspecialty ophthalmologists.

Sequential Topical Riboflavin With or Without Ultraviolet A Radiation With Delayed Intracorneal Ring Segment Insertion for Keratoconus - Corrected Proof

2012-01-20

Purpose: To report refractive, topographic, pachymetric, tonometric, and corneal biomechanical outcomes 24 months after corneal cross-linking (CXL), followed by insertion of intrastromal corneal ring segments (ICRS) in keratoconic eyes. Design: Prospective randomized clinical trial. Methods: settings: Institutional. Study population: Thirty-nine eyes of 31 patients, allocated into 2 groups. Intervention: Patients in the CXL group underwent corneal CXL with riboflavin and ultraviolet A (UVA) light. Patients in the riboflavin eyedrops group received riboflavin 0.1% (w/v) eyedrops – 20% dextran solution for 1 month. After 3 months, all patients underwent insertion of ICRS. Main outcome measures: Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), and topography were evaluated at baseline, at 1 month and 3 months after CXL or riboflavin eyedrops, and again at 1-, 3-, 6-, 12-, and 24-month intervals after ICRS insertion. Results: Mean (standard deviation [SD]) baseline UCVA and BSCVA in the CXL group and the riboflavin eyedrops group were 1.12 (0.59) and 0.84 (0.49), and 0.68 (0.43) and 0.45 (0.23), respectively; 24-month mean (SD) UCVA and BSCVA in the CXL group and the riboflavin eyedrops group were 0.79 (0.50) and 0.62 (0.28), and 0.52 (0.45) and 0.32 (0.21), respectively, with no statistically significant difference between groups (P = .70 and P = .78).There were no statistical differences between groups postoperatively at 24 months for all 3 topographic parameters, flattest-K1 (P = .81), steepest-K2 (P = .68), and average keratometry (mean power; P = .52). Conclusions: ICRS insertion, with or without prior CXL, showed no difference between groups in terms of refractive, topographic, pachymetric, tonometric, and corneal biomechanical results at 24 months.

Use of Topiramate and Risk of Glaucoma: A Case-Control Study - Corrected Proof

Mahyar Etminan, David Maberley, Frederick S. Mikelberg — 2012-01-20

Purpose: To examine the possible link of acute-onset glaucoma with topiramate. Design: Case-control study. Methods: A case-control study was conducted among a cohort of subjects who had visited an ophthalmologist in the Province of British Columbia, Canada from 2000 to 2007. Cases were identified as those newly diagnosed with glaucoma (ICD-9 360). For each case, 5 controls were selected and matched to the cases by age and calendar time using density-based sampling. Crude and adjusted rate ratios (RRs) for current and past use of topiramate were computed. As a sensitivity analysis, the risk of glaucoma with a positive control drug (an oral steroid) and a negative control drug (inhaled albuterol) was also assessed. Results: From the initial cohort of 989 591 subjects, 178 264 cases of glaucoma and 891 320 controls were identified. There was a slight increase in the risk of glaucoma among current users of topiramate (RR = 1.23 [95% confidence interval (CI), 1.09-1.40]). This risk was further elevated among new users of the drug (RR = 1.54 [95% CI, 1.09-2.17]). No increase in the risk of glaucoma requiring drug therapy was observed among current topiramate users (RR = 1.09 [95% CI, 0.80-1.61]). Conclusion: We found an increase in the risk of glaucoma with first-time users of topiramate. Future studies are needed to confirm these findings.

Optimization of an Implantable Collamer Lens Sizing Method Using High-Frequency Ultrasound Biomicroscopy - Corrected Proof

2012-01-16

Purpose: To develop and evaluate a new implantable collamer lens (ICL) sizing method that uses high-frequency ultrasound biomicroscopy (UBM). Design: Interventional case series. Methods: ICL were implanted in 47 eyes of 25 patients (8 male, 17 female, mean age 34.7 ± 6.8 years). At 3 months after ICL surgery, the vault (distance between ICL and crystalline lens) was measured using anterior optical coherence tomography (OCT). Stepwise multiple regression analysis was performed in order to determine the optimal ICL size that will be expected to achieve a 0.5-mm vault, and the regression equation was calculated. Mean keratometric power, axial length, anterior chamber depth, sulcus-to-sulcus (STS) diameter, and distance between STS plane and crystalline lens were applied as candidates for explanatory variables. Subsequently, the equation was applied to a new group of patients (81 eyes of 43 patients, 20 male and 23 female, mean age 35.6 ± 7.2 years) in order to decide the ICL size. Postoperative vault was evaluated at 3 months after surgery. Main outcome measures were mean postoperative vault and percentages of eyes that achieved moderate vault. Results: The regression equation was determined using 3 explanatory variables: anterior chamber depth (ACD), STS diameter, and distance between STS plane and anterior crystalline lens surface (STSL). The mean vault error (postoperative vault – predicted vault) was −0.06 ± 0.29 mm. Of the total number of eyes, 88.9% had a vault between 0.15 and 1.0 mm. None of the eyes had a low vault (<0.15 mm). Nine eyes (11.1%) had a high vault (>1.0 mm). Conclusion: A novel ICL sizing equation was developed and shown to be an effective method for calculation of the optimal ICL size in order to achieve an appropriate vault.

The Significance of Cone Outer Segment Tips as a Prognostic Factor in Epiretinal Membrane Surgery - Corrected Proof

2012-01-16

Purpose: To evaluate the prognostic value of the cone outer segment tips (COST) and other features using spectral-domain optical coherence tomography (SD-OCT) in patients undergoing epiretinal membrane (ERM) surgery. Design: Retrospective observational case series. Methods: Fifty eyes of 49 patients that underwent vitrectomy for idiopathic ERM were studied. Best-corrected visual acuity (BCVA) and SD-OCT images were examined preoperatively and at 1 and 6 months postoperatively. The SD-OCT features evaluated included central foveal thickness (CFT) and the status and defect diameter of the external limiting membrane (ELM), the photoreceptor inner/outer segment (IS/OS) junction, and the COST line. The associations between SD-OCT parameters and BCVA were analyzed. Results: There was no ELM disruption found, and thus the eyes were categorized into 3 groups: Group A, with a continuous IS/OS and COST line; Group B, with a continuous IS/OS but disrupted COST line; and Group C, with a disrupted IS/OS and COST line. At 6 months, Group A showed a significantly better BCVA than Group B (P < .005), and poorer BCVA was noted in Group C (P = .034). Defect diameters of IS/OS and COST line were also significantly correlated with BCVA postoperatively. The BCVA at 6 months was better in order of Group A, B, and C as assigned at baseline (P < .05) or 1 month (P < .001). There was no significant correlation between CFT and BCVA. Conclusions: The status of the COST line, in conjunction with the IS/OS junction, is a useful prognostic factor after ERM surgery.

Optical Coherence Tomography Findings in Autoimmune Retinopathy - Corrected Proof

Azin Abazari, Souha S. Allam, Grazyna Adamus, Nicola G. Ghazi — 2012-01-16

Purpose: To report optical coherence tomography (OCT) features of patients with autoimmune retinopathy. Design: Consecutive case series. Method: Eight patients who presented with unexplained loss of central vision, visual field defects, and/or photopsia were diagnosed with autoimmune retinopathy based on clinical features, electroretinogram (ERG) findings, and serum antiretinal antibody analysis. All patients underwent OCT testing of the macula and nerve fiber layer (NFL). Results: Outer retinal abnormalities and/or decreased macular thickness on OCT were seen in all patients. Macular OCT showed reduced central macular and foveal thicknesses in 6 patients (mean thickness 143 ± 30 μm and 131 ± 29 μm respectively). In all but 1 patient, loss of the photoreceptor layer or disruption of the photoreceptor outer and inner segment junction was noted. Three patients showed only mild to moderate focal NFL loss. Conclusions: Retinal atrophy and reduced macular thickness on OCT are predominant features in patients with autoimmune retinopathy. OCT provides objective measures of retinal damage and may offer clues toward understanding the mechanism of visual dysfunction and the diagnosis of autoimmune retinopathy.

Delay to Treatment and Visual Outcomes in Patients Treated With Anti-Vascular Endothelial Growth Factor for Age-Related Macular Degeneration - Corrected Proof

2012-01-16

Purpose: To investigate the potential influences that affect visual acuity (VA) outcome in a clinic-based cohort of age-related macular degeneration (AMD) patients undergoing anti–vascular endothelial growth factor (anti-VEGF) treatment for choroidal neovascularization. Design: Prospective interventional case series. Methods: Patients with subfoveal choroidal neovascularization (CNV) secondary to AMD were prospectively recruited. A detailed questionnaire was given to patients at time of enrollment, to collect information relating to demographics, history of visual symptoms, visual acuity (VA), and treatment scheduling. Delay from symptoms to treatment (“Treatment delay”) was measured in terms of weeks and analyzed in tertiles. Information pertaining to treatment outcomes was collected over a 6-month period. Results: One hundred eighty-five eyes of 185 patients were recruited into the study. Longer delay from first symptoms suggestive of CNV to first injection was a significant predictor (P = .015) of poorer treatment outcome, when controlling for age, sex, and baseline VA. Patients with a delay in treatment of 21 weeks or more compared to a delay of 7 weeks or less had an odds ratio of 2.62 (1.20, 5.68) for worsening vision after treatment. Conclusions: Patients experiencing a longer delay between their first symptoms of CNV and their first anti-VEGF treatment have a significantly lower chance of improving vision at 6 months following anti-VEGF therapy. It is critical that this information reach those at potential vision loss from AMD, in order that prompt treatment may be instituted, to maximize the benefits of anti-VEGF treatment.

The Effect of General Anesthesia and Strabismus Surgery on the Intellectual Abilities of Children: A Pilot Study - Corrected Proof

Hee Kyung Yang, Dong Sun Chungh, Jeong-Min Hwang — 2012-01-16

Purpose: To determine the influence of general anesthesia and strabismus surgery on children's intellectual abilities. Design: Prospective, observational study. Methods: Settings: Institutional. Patients: Children 5 to 10 years of age receiving general anesthesia with sevoflurane and undergoing strabismus surgery were included. Intellectual abilities were examined before and 4 weeks after surgery using the Kaufman Assessment Battery for Children. Four subtests representing intellectual abilities related to complex cortical function were examined: identification of objects in a partially completed picture, reproduction of a presented design by using rubber triangles, selecting a picture that completes or is similar to another picture, and memory for location of pictures presented on a page. Main Outcome Measures: Preoperative and postoperative age-adjusted scores of the 4 subtests of the Kaufman Assessment Battery for Children. Results: The study group consisted of 21 children who underwent strabismus surgery under general anesthesia (mean duration, 51.3 minutes). The mean preoperative total score of the 4 subtests was 49.4 ± 6.2. The mean postoperative total score adjusted for potential learning effects and test–retest reliability was 48.1 ± 7.7. There was no significant postoperative change in the total score (P = .108). However, the triangle test score decreased significantly after operation (P = .019), particularly in patients with decreased stereoacuity after surgery. Conclusions: General anesthesia with sevoflurane and strabismus surgery generally do not affect the intellectual abilities of complex cortical function in children 5 to 10 years of age at 4 weeks after surgery. Cortical functions related to hand–eye coordination may be affected by transient changes in postoperative stereoacuity.

Clinical Features of 121 Patients With Diffuse Unilateral Subacute Neuroretinitis - Corrected Proof

2012-01-16

Purpose: To describe the determinant clinical signs to diagnose diffuse unilateral subacute neuroretinitis (DUSN) and the main features related to identification of the live worm. Design: Retrospective study performed at the Federal University of Rio Grande do Norte, Rio Grande do Norte, Brazil, between 2003 and 2008. Methods: Patients with early- or late-stage diffuse unilateral subacute neuroretinitis were included. All patients underwent complete ophthalmologic examination and had a minimum of 6 months of follow-up. Results: A total of 121 patients were included. Most patients were younger than 20 years (69.42%). Visual acuity was 20/400 or worse in 86 patients (71.7%). Nine patients (7.43%) presented in the early stage and 112 (92.57%) patients presented in the late stage. Subretinal tracks (91.7%), focal alterations of the retinal pigment epithelium (89.3%), small white spots (80.2%), and optic nerve atrophy (76.9%) were the most frequent clinical features. The subretinal worm was identified in 48 patients (39.66%), and laser treatment to destroy it was performed in all cases. The most common location of the nematode was the posterior pole (21 patients). It was observed that the younger the age, the higher the indices of larvae identification (P = .022). Multifocal yellow-white lesions and vitritis were correlated with identification of the worm (P = .001). Mean logarithm of the minimal angle of resolution visual acuity was 1.466 (20/600) and 1.281 (20/400) before and after laser treatment, respectively (P < .005). Conclusions: Identification of clinical signs and diagnosis of diffuse unilateral subacute neuroretinitis in its early stage, followed by prompt location and destruction of the worm by photocoagulation, may improve the vision of affected patients.

Long-term Outcome of Macular Microstructure Assessed by Optical Coherence Tomography in Eyes With Spontaneous Resolution of Macular Hole - Corrected Proof

Maiko Inoue, Akira Arakawa, Shin Yamane, Yoichiro Watanabe, Kazuaki Kadonosono — 2012-01-16

Purpose: To evaluate the long-term anatomic features as assessed by optical coherence tomography (OCT) in patients with spontaneously closed full-thickness macular hole (MH). Design: Retrospective, noncomparative, observational case series. Methods: Six eyes of 6 patients who eventually showed spontaneous resolution of idiopathic MH were studied. The best-corrected visual acuity (BCVA) and OCT images of the fovea were examined before and until at least 3 years after spontaneous resolution. Results: The MH closed spontaneously 1 to 4 months after the initial examination. There were 2 distinct macular abnormalities in the early period after spontaneous closure: 4 eyes showed outer foveal defects and the remaining 2 eyes showed persistent foveal detachment. However, the fovea regained its normal configuration and the photoreceptor inner segment/outer segment (IS/OS) junction recovered completely in all eyes. Although all 6 eyes showed visual improvement after the hole closure, the BCVA in the 4 eyes that showed delayed recovery of the IS/OS junction and foveal detachment was limited to 20/25 or worse. Conclusion: Spontaneous closure of MH could acquire complete anatomic reconstruction. However, delayed restoration of the IS/OS junction and persistent foveal detachment after spontaneous closure might influence the functional outcomes.

Association Between Retinal Nerve Fiber Layer Thickness and Abnormalities of Vision in People With Human Immunodeficiency Virus Infection - Corrected Proof

2012-01-16

Purpose: To investigate relationships between contrast sensitivity (CS), color vision, and retinal nerve fiber layer (RNFL) among people with human immunodeficiency virus (HIV) infection; to evaluate the effect of time since diagnosis of HIV infection on RNFL thickness. Design: Noninterventional cross-sectional study. Methods: We evaluated 102 eyes of 57 HIV-infected individuals without ocular opportunistic infections. Peripapillary RNFL thickness was determined with spectral-domain optical coherence tomography in 4 quadrants. CS was measured with the Pelli-Robson technique (expressed as logCS); color vision was measured with the Lanthony desaturated 15-hue technique (expressed as color confusion index [C-index], with higher scores indicating worse color vision). Correlations between values were assessed using Spearman correlation coefficients. Results: Median RNFL thickness (average of 4 quadrants) was 102.9 μm (range, 75.0–134.7 μm). Median logCS was 1.90 (range, 1.25–1.95). Median C-index was 1.58 (range, 0.96–4.07). Temporal RNFL thickness was correlated with logCS (r = 0.295, P = .003) and C-index (r = −0.338, P = .0005). Time since diagnosis of HIV infection was shorter for those with thick average RNFL than for those with thin average RNFL (P = .18). Conclusions: Both worse CS and worse color vision are correlated with thinning of the temporal RNFL, with possible threshold effects. Increased prevalences of abnormal CS and abnormal color vision in this population are therefore likely attributable to neuroretinal compromise. This pattern of structural and functional losses may reflect preferential damage to small-caliber axons in the maculopapillary bundle, possibly associated with mitochondrial dysfunction, providing a potential disease mechanism for HIV-associated “neuroretinal disorder.”

Postoperative Complications in the Tube Versus Trabeculectomy (TVT) Study During Five Years of Follow-up - Corrected Proof

2012-01-16

Purpose: To describe postoperative complications encountered in the Tube Versus Trabeculectomy (TVT) Study during 5 years of follow-up. Design: Multicenter randomized clinical trial. Methods: settings: Seventeen clinical centers. Study population: Patients 18 to 85 years of age who had previous trabeculectomy and/or cataract extraction with intraocular lens implantation and uncontrolled glaucoma with intraocular pressure (IOP) ≥18 mm Hg and ≤40 mm Hg on maximum tolerated medical therapy. Interventions: Tube shunt (350-mm2 Baerveldt glaucoma implant) or trabeculectomy with mitomycin C (MMC 0.4 mg/mL for 4 minutes). Main outcome measures: Surgical complications, reoperations for complications, visual acuity, and cataract progression. Results: Early postoperative complications occurred in 22 patients (21%) in the tube group and 39 patients (37%) in the trabeculectomy group (P = .012). Late postoperative complications developed in 36 patients (34%) in the tube group and 38 patients (36%) in the trabeculectomy group during 5 years of follow-up (P = .81). The rate of reoperation for complications was 22% in the tube group and 18% in the trabeculectomy group (P = .29). Cataract extraction was performed in 13 phakic eyes (54%) in the tube group and 9 phakic eyes (43%) in the trabeculectomy group (P = .43). Conclusions: A large number of surgical complications were observed in the TVT Study, but most were transient and self-limited. The incidence of early postoperative complications was higher following trabeculectomy with MMC than tube shunt surgery. The rates of late postoperative complications, reoperation for complications, and cataract extraction were similar with both surgical procedures after 5 years of follow-up.

Treatment Outcomes in the Tube Versus Trabeculectomy (TVT) Study After Five Years of Follow-up - Corrected Proof

2012-01-16

Purpose: To report 5-year treatment outcomes in the Tube Versus Trabeculectomy (TVT) Study. Design: Multicenter randomized clinical trial. Methods: settings: Seventeen clinical centers. Study population: Patients 18 to 85 years of age who had previous trabeculectomy and/or cataract extraction with intraocular lens implantation and uncontrolled glaucoma with intraocular pressure (IOP) ≥18 mm Hg and ≤40 mm Hg on maximum tolerated medical therapy. Interventions: Tube shunt (350-mm2 Baerveldt glaucoma implant) or trabeculectomy with mitomycin C (MMC; 0.4 mg/mL for 4 minutes). Main outcome measures: IOP, visual acuity, use of supplemental medical therapy, and failure (IOP >21 mm Hg or not reduced by 20%, IOP ≤5 mm Hg, reoperation for glaucoma, or loss of light perception vision). Results: A total of 212 eyes of 212 patients were enrolled, including 107 in the tube group and 105 in the trabeculectomy group. At 5 years, IOP (mean ± SD) was 14.4 ± 6.9 mm Hg in the tube group and 12.6 ± 5.9 mm Hg in the trabeculectomy group (P = .12). The number of glaucoma medications (mean ± SD) was 1.4 ± 1.3 in the tube group and 1.2 ± 1.5 in the trabeculectomy group (P = .23). The cumulative probability of failure during 5 years of follow-up was 29.8% in the tube group and 46.9% in the trabeculectomy group (P = .002; hazard ratio = 2.15; 95% confidence interval = 1.30 to 3.56). The rate of reoperation for glaucoma was 9% in the tube group and 29% in the trabeculectomy group (P = .025). Conclusions: Tube shunt surgery had a higher success rate compared to trabeculectomy with MMC during 5 years of follow-up in the TVT Study. Both procedures were associated with similar IOP reduction and use of supplemental medical therapy at 5 years. Additional glaucoma surgery was needed more frequently after trabeculectomy with MMC than tube shunt placement.

Long-term Outcomes of Undercorrection Versus Full Correction After Unilateral Intraocular Lens Implantation in Children - Corrected Proof

2011-12-29

Purpose: To evaluate the impact of full correction vs undercorrection on the magnitude of the myopic shift and postoperative visual acuity after unilateral intraocular lens (IOL) implantation in children. Design: Retrospective case control study. Methods: The medical records of 24 children who underwent unilateral cataract surgery and IOL implantation at 2 to <6 years of age were reviewed. The patients were divided into 2 groups based on their 1-month-postoperative refraction: Group 1 (full correction) −1.0 to +1.0 diopter (D) and Group 2 (undercorrection) ≥+2.0 D. The main outcome measures included the change in refractive error per year and visual acuity for the pseudophakic eyes at last follow-up visit. The groups were compared using the independent groups t test and Wilcoxon rank sum test. Results: The mean age at surgery (Group 1, 4.2 ± 0.9 years, n = 12; Group 2, 4.5 ± 1.0 years, n = 12; P = .45) and mean follow-up (Group 1, 5.8 ± 3.7 years; Group 2, 6.1 ± 3.5 years; P = .69) were similar for the 2 groups. The change in refractive error (Group 1, −0.4 ± 0.5 D/y; Group 2, −0.3 ± 0.2 D/y; P = .70) and last median logMAR acuity (Group 1, 0.4; Group 2, 0.4; P = .54) were not significantly different between the 2 groups. Conclusions: We did not find a significant difference in the myopic shift or the postoperative visual acuity in children aged 2 to <6 years of age following unilateral cataract surgery and IOL implantation if the initial postoperative refractive error was near emmetropia or undercorrected by 2 diopters or more.

Association Between Hyperreflective Foci in the Outer Retina, Status of Photoreceptor Layer, and Visual Acuity in Diabetic Macular Edema - Corrected Proof

2011-12-05

Purpose: To determine if hyperreflective foci in the outer retina are associated with photoreceptor integrity and the logarithm of minimal angle of resolution (logMAR) visual acuity (VA) in patients with diabetic macular edema (DME).Design: Retrospective, observational, cross-sectional study.Methods: Patients (n = 76; 108 eyes) with clinically relevant macular edema and no serous retinal detachment were analyzed retrospectively. Spectral-domain optical coherence tomography (SD-OCT) images were obtained for all patients. We investigated the relationship between the hyperreflective foci in the outer retinal layers of the external limiting membrane (ELM) at the fovea and the photoreceptor integrity and VA.Results: SD-OCT showed that 58 eyes (53.7%) had hyperreflective foci in the outer retinal layers, and 107 eyes (99.1%) had hyperreflective foci in the inner retinal layers. The logMAR VA was significantly (P < .0001) worse in eyes with hyperreflective foci in the outer retinal layers than in eyes without them (0.463 ± 0.382 vs 0.127 ± 0.206, respectively). Disruption of the ELM line on OCT was significantly (P < .0001, for both comparisons) associated with both hyperreflective foci in the outer retinal layers and poor logMAR VA. Disruption of the junction of the inner and outer segment line (IS/OS) also was related to hyperreflective foci in the outer retinal layers and poor logMAR VA (P < .0001 for both comparisons).Conclusions: The presence of hyperreflective foci in the outer retina is closely associated with a disrupted ELM and IS/OS line on SD-OCT images and decreased VA in DME.

Retinal Adherence and Fibrillary Surface Changes Correlate With Surgical Difficulty of Epiretinal Membrane Removal - Corrected Proof

2011-12-05

Purpose: To correlate surgical difficulty of epiretinal membrane (ERM) removal with characteristics of ERM adherence seen by spectral-domain optical coherence tomography (SD-OCT).Design: Prospective observational case series.Methods: Surgical difficulty was correlated with extent of ERM adherence by SD-OCT using masked observers in consecutive eyes undergoing ERM removal (N = 31). Surgical videos were analyzed and difficulty of ERM removal (grade 1-3) was determined in 4 quadrants as well as the fovea by consensus of observers masked to SD-OCT findings. Extent of ERM adhesion was categorized (focal, broad, or complete) by masked observers using SD-OCT. The presence of fibrillary changes between the ERM and retinal nerve fiber layer (RNFL) was also evaluated. Surgical difficulty of ERM removal for each quadrant and fovea was compared to extent of ERM adherence and presence of fibrillary changes.Results: Assessment of ERM adherence using SD-OCT between masked observers was highly concordant (kappa = 0.9178). Surgical difficulty of ERM removal was strongly associated with more extensive ERM adherence to the retina observed by SD-OCT. Complete ERM adherence correlated with an 8.6-fold increased surgical difficulty of ERM removal compared to focal adherence (P < .0001). The presence of fibrillary changes between the ERM and RNFL also correlated with a 25.5-fold increased difficulty of surgical removal compared to the absence of fibrillary changes (P < .0001).Conclusion: Extent of ERM-retinal adhesion and presence of fibrillary changes determined by SD-OCT provide reliable preoperative assessment of surgical difficulty. Furthermore, SD-OCT analysis may help localize surgically advantageous coordinates to initiate ERM removal.

Progressive Constriction of the Hyperautofluorescent Ring in Retinitis Pigmentosa - Corrected Proof

2011-12-05

Purpose: To evaluate the constriction of the hyperautofluorescent ring over time in patients with retinitis pigmentosa (RP).Design: Prospective study.Methods: Fourteen eyes of 14 RP patients with a hyperautofluorescent ring were studied. Ring constriction was evaluated by measurements of its external and internal boundaries along the vertical and horizontal axes at baseline and at 12-, 24-, 36-, and 48-month follow-ups. Repeat fundus autofluorescence was obtained at 12, 24, 36, and 48 months in 13, 7, 5, and 1 eyes respectively. Spectral-domain optical coherence tomography (SD-OCT) images were obtained on 8 eyes and the horizontal extent of the inner segment/outer segment (IS/OS) junction was measured. SD-OCT was repeated at 12 and 24 months in 6 and 4 eyes respectively.Results: The external boundaries of the ring were identified along the horizontal axis in 12 eyes and along the vertical axis in 13. Internal boundaries were identified in 7 eyes. Constriction was demonstrated in all patients except 1 who demonstrated minimal expansion of the internal boundary along the horizontal axis. SD-OCT measurements showed a decrease in the IS/OS junction length.Conclusion: Progressive constriction of the hyperautofluorescent ring and a concordant decrease in IS/OS junction length were observed over time.

Dislocation of the Donor Graft to the Posterior Segment in Descemet Stripping Automated Endothelial Keratoplasty - Corrected Proof

2011-11-21

Purpose: To report a series of dislocations of the donor graft into the posterior segment associated with Descemet stripping endothelial keratoplasty (DSAEK) and to identify possible risk factors for dislocation and clinical outcomes.Design: Retrospective case series.Methods: Cases of donor graft dislocation into the posterior segment associated with endothelial keratoplasty were identified from the clinical experience of 7 surgeons. Observations included the preoperative surgical history of each eye, preoperative and postoperative visual acuity, management of the complication, and the postoperative clinical course. No identified cases were excluded from this series.Results: Eight posterior graft dislocations were associated with DSAEK surgery. Each eye had a history of vitrectomy. Five eyes had sutured posterior chamber intraocular lenses, 1 eye had a sulcus intraocular lens, and 2 eyes were aphakic. Each eye required repeat grafting, and in 6 of 8 eyes, pars plana vitrectomy was used to remove the dislocated graft. Final visual acuities ranged from 20/30 to no light perception.Conclusions: Graft dislocation into the posterior segment is a rare complication of DSAEK surgery that can lead to permanent vision loss. It has occurred in eyes that have undergone previous vitrectomy and complicated intraocular lens placement or were aphakic. As is the case with a dropped lens nucleus during cataract extraction, visual acuities after a dropped DSAEK graft range from very good to no light perception. Better postoperative results seem to be associated with prompt removal of the posteriorly dislocated graft.

Outer Retinal Structure in Patients With Acute Zonal Occult Outer Retinopathy - Corrected Proof

2011-11-21

Purpose: To correlate visual function with high-resolution images of retinal structure using adaptive optics scanning laser ophthalmoscopy (AOSLO) in 4 patients with acute zonal occult outer retinopathy (AZOOR).Design: Observational case series.Methods: Four women, aged 18 to 51, with acute focal loss of visual field or visual acuity, photopsia, and minimal funduscopic changes were studied with best-corrected visual acuity (BCVA), Goldmann kinetic and automated perimetry and fundus-guided microperimetry, full-field and multifocal electroretinography (ffERG and mfERG), spectral-domain optical coherence tomography (SD-OCT), and AOSLO imaging. Cone spacing was measured in 4 eyes and compared with 27 age-similar normal eyes. Additional functional testing in 1 patient suggested that cones were absent but rods remained. Serum from all patients was analyzed for anti-retinal antibody activity.Results: In all patients vision loss was initially progressive, then stable. Symptoms were unilateral in 2 and bilateral but asymmetric in 2 patients. In each patient, loss of retinal function correlated with structural changes in the outer retina. AOSLO showed focal cone loss in most patients, although in 1 patient with central vision loss such change was absent. In another patient, structural and functional analyses suggested that cones had degenerated but rods remained. Anti-retinal antibody activity against a ∼45 kd antigen was detected in 1 of the patients; the other 3 patients showed no evidence of abnormal anti-retinal antibodies.Conclusions: Focal abnormalities of retinal structure correlated with vision loss in patients with AZOOR. High-resolution imaging can localize and demonstrate the extent of outer retinal abnormality in AZOOR patients.

Randomized Double-Masked Controlled Trial Comparing Pain Scores With and Without the Use of Supplementary 2% Lidocaine Gel in LASIK - Corrected Proof

2011-11-21

Purpose: To compare pain scores with and without supplementary topical 2% lidocaine gel in patients undergoing simultaneous bilateral laser-assisted in situ keratomileusis (LASIK) under topical anesthesia using 0.5% proparacaine eye drops.Design: Randomized double-masked placebo-controlled trial.Methods: Fifty-one Chinese subjects (102 eyes, with 51 eyes in each arm) were included. One eye was randomly allocated to have supplementary 2% lidocaine gel while the other eye received carbomer gel as control, in addition to topical 0.5% proparacaine. The pain scores for each eye during microkeratome flap creation, during laser ablation, and at 15, 30, and 45 minutes after LASIK were assessed. An overall pain score of the LASIK procedure was also obtained. Primary outcome measures were pain scores during and after LASIK. Secondary outcomes included need for additional topical anesthesia, patient cooperation score, and duration and complications of surgery.Results: In the 2% lidocaine gel–treated group, the pain scores were significantly lower during microkeratome flap creation and laser ablation, and postoperatively at 30 and 45 minutes (P < .05 for all). Patients in the lidocaine gel group required less additional topical anesthesia (P = .0004) and were more cooperative (P = .019) as compared to the carbomer gel group. No surgical or postoperative complications were observed.Conclusions: The use of supplementary 2% lidocaine gel in LASIK is effective in lowering the pain experienced during and up to 45 minutes after LASIK.

Reading Performance After Implantation of a Modified Corneal Inlay Design for the Surgical Correction of Presbyopia: 1-Year Follow-up - Corrected Proof

2011-11-21

Purpose: To evaluate change in different reading performance parameters after monocular ACI7000PDT corneal inlay implantation for the improvement of near and intermediate vision.Design: Prospective, interventional case series.Methods: Twenty-four patients were scheduled for corneal inlay implantation in the nondominant eye in a university outpatient surgery center. Naturally emmetropic and presbyopic patients between 45 and 60 years of age, with uncorrected distance visual acuity of at least 20/20 in both eyes, without any additional ocular pathology were eligible for inclusion. Bilateral uncorrected reading acuity, reading distance, mean and maximum reading speed, and smallest log-scaled print size (lowercase letter of a Radner reading chart) were evaluated in a standardized testing procedure using the Salzburg Reading Desk. Minimum postoperative follow-up was 12 months.Results: The reading desk results showed significant changes in each parameter tested. After 12 months the mean reading distance changed from the preoperative value of 46.7 cm (95% CI: 44.1–49.3) to 42.8 cm (95% CI: 40.3–45.3, P < .004), and the mean reading acuity “at best distance” improved from 0.33 logRAD (95% CI: 0.27–0.39) to 0.24 logRAD (95% CI: 0.20–0.28, P < .005). Mean reading speed increased from 141 words per minute (wpm, 95% CI: 133–150) to 156 wpm (95% CI: 145–167, P < .003), maximum reading speed increased from 171 wpm (95% CI: 159–183) to 196 wpm (95% CI: 180–212, P = .001), and the smallest print size improved from 1.50 mm (95% CI: 1.32–1.67) to 1.12 mm (95% CI: 1.03–1.22, P < .001).Conclusions: After ACI7000PDT implantation, there were significant changes in all tested reading performance parameters in emmetropic presbyopic patients. These 1-year results indicate that the inlay seems to be an effective treatment for presbyopia.

Choice of Analytic Approach for Eye-Specific Outcomes: One Eye or Two? - Corrected Proof

2011-11-11

Purpose: To investigate the use of analytic approaches for eye-specific outcomes in ophthalmology publications.Design: A review of analytic approaches used in original research articles published in ophthalmology journals.Methods: All 161 research articles published in 5 ophthalmology journals in the first 2 months of 2008 were considered. Publications were categorized according to analytic approach: 1 eye selected, both eyes contribute, or per-individual outcome. Studies were considered suboptimal when criteria for eye selection were not provided or when measurements from both eyes were included without interocular correlation being considered. Visual impairment prevalence data were used to illustrate analytic approach choices.Results: Measurements from both eyes were included in 38% of the 112 studies that used statistical inferential techniques. In 31 (74%), there was no mention of possible correlation. Only 7% used statistical methods appropriate for correlated outcomes. In 35 studies (31%), measurements from 1 eye were selected; 31% of these did not provide selection criteria. In 67%, only univariate tests were used. A review of 47 articles published in 2011 produced similar findings. Characteristics of studies were not found to differ according whether the studies were suboptimal. Using a test appropriate for correlated outcomes resulted in a P value 3.5 times that obtained ignoring the correlation.Conclusions: Between-eye correlation seems not to be assessed commonly in ophthalmology publications, although its knowledge aids the choice of analytic approach when eye-specific variables are of interest. Statistical methods appropriate for correlated ocular outcome data are not being applied widely.

Combined Intravitreal Ranibizumab and Photodynamic Therapy for Retinal Angiomatous Proliferation - Corrected Proof

Masaaki Saito, Tomohiro Iida, Mariko Kano — 2011-11-11

Purpose: To clarify the efficacy of combined therapy with intravitreal ranibizumab injections and photodynamic therapy (PDT) in patients with symptomatic retinal angiomatous proliferation.Design: Retrospective, interventional, consecutive case series.Methods: We retrospectively reviewed 20 treatment-naïve eyes of 16 patients (8 men, 8 women; age range, 79 to 92 years; mean age, 84.8 years) treated with 3 consecutive monthly intravitreal injections of ranibizumab (0.5 mg/0.05 mL) and PDT and followed up for at least 12 months. PDT was applied 1 or 2 days after the initial injection. Retreatment was performed as a combined therapy of a single intravitreal ranibizumab injection and PDT.Results: The mean best-corrected visual acuity (BCVA) levels significantly improved from 0.24 at baseline to 0.43 at 12 months (P < .001). The mean improvement in BCVA at 12 months from baseline was 2.51 lines. The BCVA at 12 months improved in 10 eyes (improved by 3 lines or more) and was stable (defined as a loss of less than 3 lines of vision) in 10 eyes. No patient had a decrease in the BCVA of 3 lines or more during any 12 months. The central retinal thickness decreased significantly from 444 μm at baseline to 143 μm at 12 months (P < .0001). Complete occlusion of the retinal–retinal anastomosis was achieved in 17 of the 19 eyes at 12 months. The mean numbers of PDT treatments and injections during 12 months, including the treatments in the initial regimen, were 1.8 and 3.8, respectively. No complications or systemic adverse events developed.Conclusions: Combined intravitreal ranibizumab and PDT for patients with retinal angiomatous proliferation effectively maintained or improved visual acuity and reduced the exudation without adverse events.

Determinants of Fixation in Eyes with Neovascular Age-Related Macular Degeneration Treated with Intravitreal Ranibizumab - Corrected Proof

Raeba Mathew, Elizabeth Pearce, Sobha Sivaprasad — 2011-11-09

Purpose: To correlate the anatomic features of the macula with functional parameters like location and stability of fixation in patients with neovascular age-related macular degeneration treated with intravitreal ranibizumab injections.Design: Retrospective analysis.Methods: The location and stability of fixation were determined in 41 eyes of 41 patients treated with ranibizumab for neovascular age-related macular degeneration for at least 12 months. All patients underwent 3 injections of ranibizumab 1 month apart and were retreated according to predefined criteria. The fixation parameters measured with microperimetry were correlated to visual acuity, qualitative measures on optical coherence tomography, and patterns of autofluorescence.Results: The location of fixation was predominantly central in 68.29%, poor central in 2.4%, and predominantly eccentric in 29.27%. The fixation was stable in 80.5%, relatively unstable in 7.3%, and unstable in 12.2%. The factors that determined central and stable location of fixation were better visual acuity (P = .004), absence of subretinal thickening (P = .003), intact subfoveal third hyperreflective band (P = .006), and intact external limiting membrane (P = .036). Autofluorescence pattern within the 4-degree circle of fovea did not correlate with fixation characteristics. However, complete absence of autofluorescence in this area was a poor prognostic indicator for central fixation.Conclusions: Anatomic characteristics of the macula determine fixation patterns in patients with neovascular age-related macular degeneration treated with intravitreal ranibizumab injections. Further studies focused on eyes with complete absence of autofluorescence in the central 4-degree circle of fovea may help to define the disease characteristics in this group.

Incomplete Posterior Vitreous Detachment: Prevalence and Clinical Relevance - Corrected Proof

José Lorenzo Carrero — 2011-11-09

Purpose: To investigate the prevalence and clinical relevance of incomplete posterior vitreous detachment (PVD).Design: Prospective, observational cohort study.Methods: setting: Institutional. patients: Consecutive patients without previous ocular history who were diagnosed with acute uncomplicated PVD. observations: Baseline kinetic ultrasound evaluation differentiated posterior vitreous separation as complete or incomplete. Prospective follow-up searched for complications related to PVD. Multivariate analysis evaluated associations of baseline demographic and clinical characteristics to incomplete PVD. A Kaplan-Meier analysis evaluated the probability and its standard error of experiencing an adverse outcome. The log-rank test determined whether incomplete PVD modifies the natural history of PVD. main outcome measures: Prevalence of incomplete PVD and the estimated incidence of late adverse outcomes such as new retinal tears, epimacular membranes, or both.Results: A total of 54 of 207 patients had incomplete PVD (prevalence, 26.1%). Younger age and lattice degeneration were associated independently with incomplete PVD. After a mean follow-up of 5 years (range, 4 to 8 years), 16 patients (9.7%) experienced some adverse outcome. In 5 patients (2.7%), new retinal tears and 1 retinal detachment developed. In 12 patients (7.6%), epimacular membranes developed. Patients with incomplete PVD at baseline experienced significantly more adverse outcomes than patients with complete PVD (Kaplan-Meier estimated probability and standard error, 19.2% and 0.061 vs 5.4% and 0.02; P = .01, log-rank test).Conclusions: Up to one fourth of symptomatic, acute, and uncomplicated PVDs show incomplete posterior vitreous separation. Delayed complications related to PVD, like retinal tears and epimacular membranes, develop more frequently in patients showing incomplete PVD.

Severity of Pediatric Blepharokeratoconjunctivitis in Asian Eyes - Corrected Proof

Livia Teo, Jodhbir S. Mehta, Hla M. Htoon, Donald T.H. Tan — 2011-11-09

Purpose: To describe and evaluate the severity of pediatric blepharokeratoconjunctivitis in Asia.Design: Retrospective case series.Methods: Clinical records of patients diagnosed with pediatric blepharokeratoconjunctivitis at a tertiary referral center in Singapore from 1991 through 2010 were reviewed. Patients were graded as having mild (corneal involvement without scarring), moderate (corneal scarring), or severe (corneal scarring with thinning or perforation) disease based on recorded clinical findings.Results: Fifty-one patients were diagnosed with pediatric blepharokeratoconjunctivitis. The mean age at presentation was 10.2 ± 3.6 years, most patients were female (80.4%), and the mean duration of follow-up was 58.9 ± 44.0 months. Chinese (56.9%) subjects made up most of the cases. Most subjects had moderate (56.9%), followed by severe (37.4%) and mild (5.9%), disease. Four patients (7.9%) had an associated dermatologic disease. All patients were treated with topical antibiotics, and 98% were treated with topical steroids. Nineteen (37.3%) patients received systemic antibiotic therapy, and 1 received systemic steroid therapy. Three patients required deep lamellar keratoplasty (2 tectonic and 1 optical), and 2 underwent cornea gluing alone; all 5 of them were Chinese. Patients graded as having severe disease were more likely to undergo surgical intervention (26.3%) than patients who were graded as having moderate (0%) and mild (0%) disease (P < .05). The main complication of treatment was raised intraocular pressure in 7 (13.7%) patients requiring medical therapy. Overall, best-corrected visual acuity improved by 0.10 logarithm of the minimal angle of resolution units (P < .001) after appropriate medical and surgical intervention.Conclusions: Pediatric blepharokeratoconjunctivitis patients in Asia seem to have a more severe clinical presentation and course. Early and adequate management can arrest the disease process and can minimize visual morbidity.

Classification of Early Dry-Type Myopic Maculopathy with Macular Choroidal Thickness - Corrected Proof

2011-11-09

Purpose: To compare the macular choroidal thickness in 2 types of early dry-type myopic maculopathy.Design: Prospective, observational, comparative study.Methods: Patients with a refractive error of less than −8 diopters were included and were classified into 2 groups. Group 1 consisted of 24 eyes with a tessellated fundus, and group 2 consisted of 33 eyes with diffuse chorioretinal atrophy, but not to the extent of patchy chorioretinal atrophy. These 2 groups were compared with regard to their clinical characteristics, refractive error, axial length, macular choroidal thickness, and best-corrected visual acuity (BCVA). Linear regression was used to evaluate the explanatory variables in terms of macular choroidal thickness and BCVA.Results: Patients in group 1 were significantly younger and had better BCVA, less myopia, shorter axial length, and less staphyloma than those in group 2. Refractive error, axial length, and BCVA correlated significantly with macular choroidal thickness in group 2. However, no such significant correlations were observed in group 1. Multiple linear regression analysis showed that age and macular choroidal thickness were the variables that associated most strongly with BCVA, whereas neither refractive error nor axial length was a significant predictor of BCVA. In group 2, eyes with lacquer cracks showed worse BCVA and thinner macular choroidal thickness than eyes without lacquer cracks.Conclusions: Macular choroidal thickness is an important factor in myopic maculopathy and can be a better indicator of its severity. These findings suggest that BCVA reduction in eyes with dry-type myopic maculopathy can be related to a thinner macular choroidal thickness and to the development of lacquer cracks.

Plasma Biomarkers of Oxidative Stress and Genetic Variants in Age-Related Macular Degeneration - Corrected Proof

2011-10-31

Purpose: To compare plasma levels of oxidative stress biomarkers in patients with age-related macular degeneration (AMD) and controls and to evaluate a potential relationship between biochemical markers of oxidative stress and AMD susceptibility genotypes.Design: Prospective case-control study.Methods: Plasma levels of oxidative stress biomarkers were determined in 77 AMD patients and 75 controls recruited from a clinical practice. Cysteine, cystine (CySS), glutathione, isoprostane, and isofuran were measured, and participants were genotyped for polymorphisms in the complement factor H (CFH) and age-related maculopathy susceptibility 2 (ARMS2) genes.Results: CySS was elevated in cases compared with controls (P = .013). After adjustment for age, sex, and smoking, this association was not significant. In all participants, CySS levels were associated with the CFH polymorphism rs3753394 (P = .028) as well as an 8-allele CFH haplotype (P = .029) after correction for age, gender, and smoking. None of the other plasma markers was related to AMD status in our cohort.Conclusions: Our investigation of the gene–environment interaction involved in AMD revealed a relationship between a plasma biomarker of oxidative stress, CySS, and CFH genotype. These data suggest a potential association between inflammatory regulators and redox status in AMD pathogenesis.

Clinical Significance of Owl Eye Morphologic Features by In Vivo Laser Confocal Microscopy in Patients with Cytomegalovirus Corneal Endotheliitis - Corrected Proof

2011-10-26

Objective: To demonstrate the clinical significance of owl eye morphologic features observed by in vivo laser confocal microscopy in patients with cytomegalovirus (CMV) corneal endotheliitis.Design: Observational case series.Methods: Participants: Six eyes of 6 patients (6 men; mean age, 73.3 years) with cytomegalovirus corneal endotheliitis diagnosed by clinical manifestations together with polymerase chain reaction from aqueous humor samples. Intervention: All patients were examined by slit-lamp biomicroscopy and in vivo laser confocal microscopy. Main Outcome Measures: Clinical manifestations were summarized by reviewing medical records. Selected confocal images of corneal layers were evaluated qualitatively for shape and degree of light reflection of abnormal cells and deposits.Results: All patients had long histories of anterior uveitis with intraocular pressure elevation, corneal edema with keratic precipitates, and decrease of endothelial cell densities. Coin-shaped lesions were observed by slit lamp only in 1 patient at the first visit and in 2 additional patients at subsequent follow-up. In all patients, confocal microscopy demonstrated reduced subepithelial nerves, subepithelial opacity, increased reflectivity of keratocytes, highly reflective dots, and needle-shaped bodies. Owl eye morphologic features were observed consistently in all patients at the initial visit, and highly reflective round bodies were detected in 5 patients; most notably, these confocal features were reversible after resolution of endotheliitis.Conclusions: Owl eye morphologic features and highly reflective round bodies observed by confocal microscopy may be useful as an adjunct for the noninvasive diagnosis of cytomegalovirus corneal endotheliitis. Reversibility of these features after resolution of endotheliitis may be useful for monitoring the therapeutic effects without multiple anterior chamber tap.

Delayed- Versus Acute-Onset Endophthalmitis After Cataract Surgery - Corrected Proof

2011-10-26

Purpose: To report a large consecutive case series of patients who developed delayed-onset and acute-onset endophthalmitis after cataract surgery.Design: Retrospective consecutive case series.Methods: The current study is a retrospective consecutive case series of patients treated between January 2000 and December 2009 for culture-proven endophthalmitis after cataract surgery. The study defined 2 groups after cataract surgery: acute-onset endophthalmitis (≤6 weeks after surgery) and delayed-onset endophthalmitis (>6 weeks after surgery).Results: A total of 118 patients met study criteria; cases included 26 delayed-onset cases and 92 acute-onset cases. The following clinical features and outcomes occurred in delayed- vs acute-onset cases: 1) the presenting visual acuity was ≤5/200 in 31% vs 89%; 2) hypopyon was found in 46% vs 80%; 3) the most frequent isolate was Propionibacterium acnes (11/26) vs coagulase-negative Staphylococcus (57/92); and 4) patients with the most frequent isolate achieved a visual outcome of ≥20/100 in 91% vs 56%. In delayed-onset cases, the intraocular lens was removed or exchanged in 19 of 26 cases (73%). Of these 19 cases, 13 achieved a visual outcome of ≥20/100.Conclusions: Patients with delayed-onset endophthalmitis generally presented with better initial visual acuities, had a lower frequency of hypopyon, and had better visual outcomes compared to acute-onset patients. Propionibacterium acnes and coagulase-negative Staphylococcus species were the most common organisms cultured in delayed- and acute-onset categories, respectively, and were associated with the best visual acuity outcomes in each group.

Quantitative Imaging of Retinal Pigment Epithelial Detachments Using Spectral-Domain Optical Coherence Tomography - Corrected Proof

2011-10-26

Purpose: To evaluate the reproducibility of area and volume measurements of retinal pigment epithelium detachments (PEDs) in eyes of patients with age-related macular degeneration using spectral-domain optical coherence tomography imaging and a novel automated, quantitative algorithm.Design: Prospective study to evaluate a diagnostic technology.Methods: Patients with PEDs associated with age-related macular degeneration underwent spectral-domain optical coherence tomography imaging. Each eye was imaged 5 times, and each scan consisted of a raster pattern comprising 40 000 uniformly spaced A-scans organized as a 200 × 200 A-scan array. Each raster scan covered a retinal area of 6 × 6 mm encompassing the entire PED. A novel algorithm was used to create PED maps that permitted both qualitative and quantitative assessment of PED area and volume. Test–retest standard deviations of PED area and volume measurements were calculated for each eye.Results: Sixty-three eyes of 58 patients were enrolled in this study. The qualitative appearance and the quantitative measurements of PED area and volume were highly reproducible over the 5 different datasets obtained from each eye. The intraclass correlation coefficient was more than 0.99 for both area and volume measurements obtained using the entire dataset.Conclusions: A novel algorithm for the qualitative and quantitative assessment of PEDs imaged using spectral-domain optical coherence tomography was shown to be highly reproducible. The ability to measure PED area and volume reliably represents a novel strategy for following disease progression, especially when assessing the response of vascularized PEDs to antiangiogenic therapy.