American Journal of Ophthalmology - Articles in Press

Pharmacokinetics of Azithromycin and Moxifloxacin in Human Conjunctiva and Aqueous Humor During and After the Approved Dosing Regimens - Corrected Proof

2010-09-01

Purpose:: To evaluate the ocular pharmacokinetics of azithromycin and moxifloxacin in human conjunctiva and aqueous humor in subjects undergoing cataract surgery.Design:: Multicenter, open-label, randomized study.Methods:: Subjects scheduled for routine cataract surgery and with normal-appearing conjunctiva were eligible. One conjunctival biopsy sample and 1 aqueous humor sample were obtained from subjects randomly assigned to 1 of 10 prespecified time points (1 to 312 hours) after treatment initiation of azithromycin ophthalmic solution 1% or moxifloxacin ophthalmic solution 0.5%. Samples were assayed using liquid chromatography tandem mass spectrometry.Results:: Azithromycin 1% provided high concentrations (peak level, 559.7 μg/g) in human conjunctiva that were sustained at levels 1 to 2 orders of magnitude higher than those of moxifloxacin 0.5% throughout the 7-day dosing period and for at least 7 days thereafter. Azithromycin also showed an extended half-life (65.7 hours) in conjunctiva relative to that of moxifloxacin (28.6 hours). Accordingly, the concentration of azithromycin was maintained well above the minimum inhibitory concentration required for inhibition of growth of 90% of tested bacterial isolates for at least 7 days, whereas moxifloxacin conjunctival levels fell to levels at or less than the minimum inhibitory concentration required for inhibition of growth of 90% of tested bacterial isolates approximately 24 hours after the last dose. Peak aqueous humor concentration of moxifloxacin was higher (0.77 μg/mL) than that of azithromycin (0.053 μg/mL). No clinically relevant safety findings were observed.Conclusions:: Azithromycin 1% demonstrated high, therapeutic levels in the conjunctiva that were maintained up to 7 days after completion of a 1-week dosing regimen. Aqueous humor levels, however, were subtherapeutic with this dosing regimen. In comparison, moxifloxacin achieved lower conjunctival tissue levels, but higher aqueous humor levels.

Spontaneous Reattachment of Descemet Stripping Automated Endothelial Keratoplasty Lenticles: A Case Series of 12 Patients - Corrected Proof

2010-09-01

Purpose:: To review 12 cases of postoperative detachment and spontaneous reattachment of Descemet stripping automated endothelial keratoplasty (DSAEK) lenticles.Design:: Retrospective, observational case series.Methods:: This was a review of patients undergoing DSAEK at 7 institutions. Patients who had a significant detachment of their DSAEK lenticle during the postoperative period were identified and divided into 2 groups. Significant detachment was defined as either complete central interface fluid with bare peripheral attachment (group 1) or a free-floating lenticle in the anterior chamber (group 2). Patients who subsequently had a spontaneous reattachment of the lenticle were identified, with data regarding surgical technique and intraoperative and postoperative complications collected for analysis.Results:: Our cohort consisted of 12 eyes of 12 patients who met the definition of significant postoperative detachment with subsequent spontaneous reattachment. Four patients had complete central detachment with peripheral attachment (group 1), whereas 8 patients had a free-floating lenticle (group 2). Ten of the 12 patients had a successful outcome as defined as an attached and clear DSAEK lenticle. In our study, reattachment was seen as early as 5 days and as late as 7 months after surgery, with reattachment in 9 of 12 patients by day 25.Conclusions:: Spontaneous reattachment of detached DSAEK lenticles may occur during the postoperative period. The decision of when to bring the patient back for a rebubble ultimately must be made on a case-by-case basis.

Intravitreal Injection of Autologous Plasmin Enzyme for Macular Edema Associated with Branch Retinal Vein Occlusion - Corrected Proof

Toshiro Sakuma, Atsushi Mizota, Junji Inoue, Minoru Tanaka — 2010-08-31

Purpose: To investigate the effects of an intravitreal injection of autologous plasmin enzyme for macular edema associated with a branch retinal vein occlusion (BRVO).Design: Prospective, interventional case studies.Methods: Twenty-six eyes of 26 patients (14 men and 12 women) with macular edema resulting from a BRVO were studied. None of the eyes had a posterior vitreous detachment (PVD). The average age at the onset of BRVO was 58.7 ± 6.6 years. The interval between onset of the macular edema and injection of autologous plasmin enzyme was 4.2 months. One international unit of autologous plasmin enzyme in 0.1 mL was injected into each vitreous. The presence of a PVD was evaluated 1 week after the injection, and the visual acuity and macular thickness were measured before and 1 week and 1, 3, 6, and 12 months after the autologous plasmin enzyme injection.Results: After the autologous plasmin enzyme injection, a total PVD was observed in 23 eyes and no PVD was observed in 3 eyes. The visual acuity gradually recovered after the injection, improved by 2 lines or more in 23 eyes, and remained unchanged in the 3 eyes. The retinal thickness also recovered gradually at 1, 3, 6, and 12 months. The mean retinal thickness was reduced from 602.12 to 253.62 μm at 12 months after surgery. It was reduced significantly after 1, 3, 6, and 12 months (P < .0001).Conclusions: Intravitreal autologous plasmin enzyme may lead to an improvement of visual acuity and a reduction of macula edema in eyes with BRVO.

Magnetic Resonance Imaging of Tissues Compatible with Supernumerary Extraocular Muscles - Corrected Proof

Monica R. Khitri, Joseph L. Demer — 2010-08-31

Purpose:: To determine by magnetic resonance imaging (MRI) the prevalence and anatomy of anomalous extraocular muscle (EOM) bands.Design:: Prospective, observational case series.Methods:: High-resolution, multipositional, surface coil orbital MRI was performed using T1 or T2 fast spin echo weighting with target fixation control under a prospective protocol in normal adult subjects and a diverse group of strabismic patients between 1996 and 2009. Images demonstrating anomalous EOM bands were analyzed digitally to evaluate their sizes and paths, correlating findings with complete ophthalmic and motility examinations.Results:: Among 118 orthotropic and 453 strabismic subjects, 1 (0.8%) orthotropic and 11 (2.4%) strabismic subjects exhibited unilateral or bilateral orbital bands having MRI signal characteristics identical to EOM. Most bands occurred without other EOM dysplasia and coursed in the retrobulbar space between rectus EOMs such as the medial rectus to lateral rectus, from superior to inferior rectus, or from 1 EOM to the globe. In 2 cases, horizontal bands from the medial rectus to lateral rectus muscles immediately posterior to the globe apparently limited supraduction by collision with the optic nerve. All bands were too deep to be approached via conventional strabismus surgical approaches.Conclusions:: Approximately 2% of humans exhibit on MRI deep orbital bands consistent with supernumerary EOMs. Although band anatomy is nonoculorotary, some bands may cause restrictive strabismus.

Long-term Temporal Changes of Macular Thickness and Visual Outcome after Vitrectomy for Idiopathic Epiretinal Membrane - Corrected Proof

2010-08-18

Purpose:: To evaluate the long-term correlation of visual outcome and macular thickness after vitrectomy for idiopathic epiretinal membrane and to identify prognostic factors for good visual outcome.Design:: Retrospective, observational case series.Methods:: We reviewed the records of 52 patients with idiopathic epiretinal membrane who were treated with vitrectomy and could be followed up for more than 12 months. The main outcome measures were best-corrected visual acuity (BCVA) and central macular thickness at baseline; at 1, 3, 6, and 12 months after surgery; and at the final follow-up visit. The correlation between BCVA and central macular thickness was analyzed and the receiver operating characteristic curve analysis was performed to obtain cutoff values for visual prognosis.Results:: Most of the changes in BCVA and central macular thickness took place during the first 3 months and reached a plateau at 12 months after surgery. Despite the lack of changes in BCVA after 12 months of follow-up, significant reduction in central macular thickness could still be observed over 12 months after surgery. The final BCVA was correlated significantly with preoperative BCVA and central macular thickness and early postoperative central macular thickness. Among them, the postoperative central macular thickness at 1 month showed the largest area under the receiver operating characteristic curve.Conclusions:: Given the removal of the confounding effect of cataract, postoperative follow-up of 12 months may be sufficient to reach the final BCVA after surgery. However, more time is needed to achieve final central macular thickness. Because of the significant correlation between final BCVA and early postoperative central macular thickness, serial optical coherence tomography images in the early postoperative period were needed to predict visual outcome after epiretinal membrane removal.

The Posterior Limb in the Medial Canthal Tendon in Asians: Does It Exist? - Corrected Proof

2010-08-18

Purpose: To analyze the medial canthal tendon and to clarify the true anatomic nature of the posterior limb of this tendon.Design: Observational anatomic study.Methods: Eleven postmortem eyelids of 9 Asian cadavers (6 right and 5 left eyes; age average, 77.2 years) were analyzed. Axial sections in parallel to the eyelid margin starting at 1 mm above the upper eyelid margin were made. The sliced specimens were dehydrated and embedded in paraffin, cut into 7-μm thickness sections, and stained with Masson trichrome. To demonstrate the hardness felt when the Horner muscle is pulled, 3 additional postmortem eyelids of 2 Asians (2 right and 1 left eyes; age, 70 and 75 years at death) were analyzed. The pulling process was documented with a video camera.Results: The posterior limb of the medial canthal tendon was not detected in any of the specimens. The Horner muscle originated via its tendon from the posterior lacrimal crest and the anterior area of the medial orbital wall. The lacrimal diaphragm around the posterior lacrimal crest ran almost parallel to the Horner muscle and usually was difficult to distinguish from the tendon of the Horner muscle. The medial check ligament supported the posterior aspect of the Horner muscle and was inserted into the medial orbital wall. The hard sensation that was felt when the Horner muscle was pulled was demonstrated in the video.Conclusions: The posterior limb of the medial canthal tendon was not detected in any of the specimens. This anatomic structure seems to be a part of the Horner muscle.

Inner Segment/Outer Segment Junction Assessed by Spectral-Domain Optical Coherence Tomography in Patients with Idiopathic Epiretinal Membrane - Corrected Proof

2010-08-18

Purpose:: To evaluate the anatomic features of the photoreceptor inner/outer segment (IS/OS) junction before and after surgery by spectral-domain optical coherence tomography in patients undergoing idiopathic epiretinal membrane (ERM) surgery and to correlate these features with the functional outcomes.Design:: Prospective, cohort study.Methods:: We prospectively studied 45 eyes of 45 patients with idiopathic epiretinal membrane who had a preoperative visual acuity of 20/32 or less and were scheduled to undergo transconjunctival 25-gauge vitrectomy. The patients were divided into 2 groups based on the preoperative structural integrity of the IS/OS junction: the intact IS/OS junction group and the disrupted IS/OS junction group. Changes in the IS/OS junction and best-corrected visual acuity were compared between 2 groups before and at 3, 6, and 12 months after surgery.Results:: A total of 45 patients were recruited for this study. There were 34 eyes with an intact IS/OS junction (group 1) and 11 eyes with a disrupted or irregular IS/OS junction (group 2), as determined before surgery. Significantly better postoperative best-corrected visual acuity was seen in group 1 as compared with that in group 2 at 3, 6, and 12 months after the surgery (P < .001). Significant improvement of visual acuity was also seen in group 1 when compared to group 2 (P < .05). Of the 34 eyes in group 1, 17 (50%) showed disruption of the IS/OS junction at 3 months after surgery, although this disruption was only transient and resolved completely by 12 months after the surgery. However, none of the eyes from group 2 showed a normal appearance of the IS/OS junction at any time point during the study period of 1 year.Conclusions:: The IS/OS junction can recover in eyes with preoperative intact IS/OS junction as assessed over a follow-up period of 1 year after surgery. Preoperative integrity of the IS/OS junction may be an important prognostic factor for better visual recovery and better improvement of the postoperative best-corrected visual acuity after epiretinal membrane surgery.

Polypoidal Choroidal Vasculopathy Masquerading as Neovascular Age-Related Macular Degeneration Refractory to Ranibizumab - Corrected Proof

2010-08-17

Purpose: To report a neovascular age-related macular degeneration pattern refractory to ranibizumab.Design: Retrospective, observational case series.Methods: Between March and May 2009, cases with neovascular age-related macular degeneration refractory to ranibizumab were investigated with indocyanine green angiography. We identified 12 eyes of 12 patients with polypoidal choroidal vasculopathy. Refractory to treatment were defined cases with persistent subretinal or intraretinal fluid, or both, after 3 or more consecutive monthly ranibizumab injections regardless of best-corrected visual acuity.Results: All patients identified were white, of whom 6 were male. Mean age ± standard deviation at presentation was 75 ± 5.6 years (range, 64 to 81 years); diagnosis, based on fluorescein angiography, comprised occult choroidal neovascularization (CNV) in 8 eyes, and 1 case each of classic-no-occult CNV, minimally classic CNV, predominantly classic CNV, and retinal angiomatous proliferation. Eight cases had switched from courses of other therapy (5 pegaptanib, 1 photodynamic therapy, 1 photodynamic therapy then pegaptanib, 1 bevacizumab). After a mean follow-up of 10.2 ± 4.8 months (range, 3 to 18 months) and 7.6 ± 3.9 ranibizumab injections (range, 3 to 14 injections), indocyanine green angiography revealed polypoidal choroidal vasculopathy lesions in all cases.Conclusions: Neovascular age-related macular degeneration refractory to a course of ranibizumab injections may harbor polypoidal choroidal vasculopathy. In such cases, indocyanine green angiography is a valuable tool for revealing polypoidal lesions.

Multicenter Survey with a Systematic Overview of Acute-Onset Endophthalmitis after Transconjunctival Microincision Vitrectomy Surgery - Corrected Proof

2010-08-17

Purpose: To explore the incidence and visual outcomes of acute-onset endophthalmitis after transconjunctival microincision vitrectomy surgery (MIVS).Design: Retrospective, interventional, multicenter survey with a systematic review.Methods: A clinical database search was performed at 27 institutions involving 43 868 consecutive patients who underwent vitrectomy between November 2003 and October 2008 to identify all patients with endophthalmitis after vitrectomy. A systematic review of studies reporting the endophthalmitis rates after MIVS versus 20-gauge vitrectomy was conducted to assess the pooled incidence rates of postvitrectomy endophthalmitis.Results: The endophthalmitis rates from the multicenter survey were 0.034% (10 cases per 29 030 eyes) after 20-gauge vitrectomy and 0.054% (8 cases per 14 838 eyes) after MIVS, with no significant (P = .603) differences between groups. Although the incidence in 25-gauge cases (6 per 8238 eyes; 0.073%) was greater than in 23-gauge cases (2 per 6600 eyes; 0.030%), the difference was not significant (P = 0.451). Of 8 eyes in which endophthalmitis developed after MIVS, 6 eyes (75%) had a final visual acuity of 0.5 or better, and none lost light perception. By combining the results of 7 studies, including the current multicenter survey, meta-analyses from a total of 77 956 cases at the baseline showed that the pooled endophthalmitis rates after MIVS (0.08%; 95% confidence interval, 0.030% to 0.164%) and after 20-gauge vitrectomy (0.030%; 95% confidence interval, 0.012% to 0.048%) did not differ significantly (P = .207, pooled risk difference; 0.0005 [95% confidence interval, −0.0002 to 0.0012]).Conclusions: The incidence of postvitrectomy endophthalmitis was low with no significant differences between MIVS and 20-gauge vitrectomy.

A Randomized Intraindividual Comparison of the Accommodative Performance of the Bag-in-the-Lens Intraocular Lens in Presbyopic Eyes - Corrected Proof

Georgia Cleary, David J. Spalton, Kavita B. Gala — 2010-08-17

Purpose: To compare the accommodative performance of the Morcher BioComFold Type 89A bag-in-the-lens intraocular lens (IOL) with a conventional in-the-bag control IOL in presbyopic eyes.Design: Prospective, randomized clinical trial with intraindividual comparison.Methods: Setting: Department of Ophthalmology, St. Thomas' Hospital, London, United Kingdom. Study population: Fifty-two eyes of 26 patients with bilateral age-related cataracts. Intervention: Phacoemulsification cataract extraction with implantation of a bag-in-the-Lens and a control IOL, the Alcon AcrySof SA60AT (Alcon Laboratories, Fort Worth, Texas, USA), randomized to either eye. Main outcome measures: Axial IOL shift stimulated by physiologic (near visual effort) and pharmacologic (pilocarpine and cyclopentolate) accommodative stimulation was measured objectively with partial coherence interferometry. Other outcome measures were objective and subjective accommodation, logarithm of the minimal angle of resolution distance-corrected near visual acuity, and defocus curves.Results: Three months after surgery, axial IOL shift stimulated by near visual effort measured −5.9 ± 10.3 μm in bag-in-the-lens eyes versus −8.4 ± 12.8 μm in control eyes (P = .37), that stimulated by pilocarpine measured 20.2 ± 165.6 μm versus 50.4 ± 164.4 μm (P = .36), and that stimulated by cyclopentolate measured −65.8 ± 64.3 μm versus −54.0 ± 37.5 μm (P = .34), respectively (n = 25). Objective accommodation measured 0.03 ± 0.18 diopters (D) in bag-in-the-lens eyes versus 0.08 ± 0.21 D in control eyes (P = .40), whereas subjective accommodation measured 2.48 ± 0.72 D versus 2.45 ± 0.80 D (P = .75), respectively. Distance-corrected near visual acuity and defocus curves showed no difference between IOLs.Conclusions: The bag-in-the-lens IOL demonstrated negligible axial shift and objective accommodation with physiologic near visual stimulation. The IOL shift demonstrated with pilocarpine also was clinically insignificant. The bag-in-the-lens IOL showed no accommodative or near visual advantage over a conventional in-the-bag IOL, despite its unique capsular fixation method. This provides further evidence that the focus-shift principle fails to produce clinically significant IOL movement.

Scale for Photographic Grading of Vitreous Haze in Uveitis - Corrected Proof

2010-08-17

Purpose: To validate a scale for grading vitreous haze in uveitis using digitized photographs and standardized scoring.Design: Evaluation of clinical research methodology.Methods: Calibrated Bangerter diffusion filters inducing incremental decrements of spatial contrast were placed in front of the camera lens while photographing a normal eye to simulate vitreous haze. The photographs were digitized and an ordinal scale was created from 0 (none) to 8 (highest level of opacification at which fundus details could be seen). The scale steps correspond approximately to decimal Snellen visual acuities of 1.0, 0.8, 0.4, 0.2, 0.1, 0.04, 0.02, 0.01, and 0.002, with approximately 0.3 log step between each step. For validation, digitized fundus photographs of uveitis patients were displayed on a computer monitor for comparison with the standard photos. Three observers graded the test set twice under standard conditions. Interobserver and intraobserver variability and κ values for agreement greater than chance were calculated.Results: Variance component analysis determined that 87.7% of the variance in grades was attributable to the test item rather than to grader or session. The intraclass correlation between graders and grading sessions varied from 0.84 to 0.91. Simple agreement within 1 grade between graders and sessions occurred in 90 ± 5.5% of gradings. κ values averaged 0.91, which is considered near perfect.Conclusions: A 9-step photographic scale was designed to standardize the grading of vitreous haze in uveitis patients using fundus photographs. The scale is potentially adaptable to clinical trials in uveitis.

Intravitreal Ranibizumab for Choroidal Neovascularization in Angioid Streaks - Corrected Proof

2010-08-17

Purpose: To analyze retrospectively the efficacy of intravitreal ranibizumab injections for the management of choroidal neovascularization (CNV) in patients with angioid streaks.Design: Nonrandomized, double-center, retrospective, interventional case series.Methods: A consecutive series of patients affected with CNV associated with angioid streaks were treated with intravitreal ranibizumab injections (0.5 mg/0.05 mL). Best-corrected visual acuity, fundus photography results, optical coherence tomography (OCT) results, and fluorescein angiography results were examined before and after treatment. The primary end point was the percentage of eyes with stable or improved visual acuity at the end of follow-up. Secondary end points were the percentage of eyes with stable or decreased macular thickness on optical coherence tomography and the percentage of eyes with persistent leakage on fluorescein angiography at the last follow-up examination.Results: Thirty-five eyes of 27 patients were treated with repeated intravitreal ranibizumab injections (mean, 5.7 injections; range, 2 to 14 injections) for a mean of 24.1 months (range, 6 to 37 months). At the end of follow-up, visual acuity was stabilized or improved in 30 (85.7%) of 35 eyes. Macular thickness had stabilized or decreased in 18 (51.5%) of 35 eyes. At the last follow-up examination, on fluorescein angiography, no further leakage was observed in 23 (65.7%) of 35 eyes.Conclusions: In this large series of angioid streaks-associated CNV, ranibizumab injections allowed stabilization of visual acuity. Ranibizumab seems to be a safe therapeutic option in CNV associated with angioid streaks.

Photodynamic Therapy for Symptomatic Circumscribed Macular Choroidal Hemangioma in Chinese Patients - Corrected Proof

2010-08-16

Purpose: To evaluate the efficacy and safety of photodynamic therapy (PDT) for macular circumscribed choroidal hemangioma in Chinese patients.Design: Retrospective, consecutive, noncomparative case series.Methods: Twenty-five eyes (25 patients) with macular circumscribed choroidal hemangioma, 18 subfoveal and 7 perifoveal, with vision impairment attributable to subfoveal fluid and retinal detachment underwent visual acuity testing, fundus fluorescein angiography, ultrasonography, and optical coherence tomography (OCT) examinations to evaluate the efficacy and safety of PDT treatment. PDT was performed with a standard concentration of verteporfin and intravenous injection time. Laser was used at 50 J/cm2 for 83 seconds on subfoveal and 75 J/cm2 for 125 seconds on perifoveal lesions. More than 1 spot was used for large lesions and spots overlapped only outside the fovea.Results: The mean follow-up time was 35.5 ± 15 months. All patients were treated with 1 session except in 2 subfoveal cases. The mean best-corrected visual acuity (BCVA) increased from 0.09 ± 0.11 to 0.31 ± 0.37 (P < .01) and 11 patients (44%) had their vision improve over 4 lines. The remaining 14 patients (56%) had stabilized vision with the retina reattached. The mean thickness of the hemangioma before the treatment was 3.2 ± 0.9 mm and decreased to 1.3 ± 1.0 mm post treatment (P < .01), with complete regression of tumor in 7 cases (28%).Conclusions: PDT with individualized laser parameters for macular circumscribed choroidal hemangioma is effective and safe, leading to improved or stabilized BCVA as a result of tumor shrinkage and the resolution of the subretinal fluid.

Contact Lens–Induced Subconjunctival Hemorrhage - Corrected Proof

2010-08-16

Purpose: To present the first detailed assessment of the clinical features of CL-induced subconjunctival hemorrhage and associated risk factors.Design: Cross-sectional and case-control study of age-matched randomized groups.Methods: A total of 45 CL wearers with subconjunctival hemorrhage aged 18 to 45 years (CL-Hemorrhage group), 200 age-matched healthy control subjects (non-CL group), and 200 age-matched CL wearers (CL group) were enrolled. The conjunctiva was divided into the following 8 equal areas: superior, superior/nasal, nasal, inferior/nasal, inferior, inferior/temporal, temporal, and superior/temporal. The site of hemorrhage, the grade, and other parameters of conjunctivochalasis at 3 locations (nasal, middle, and temporal), and the grade of pinguecula on the nasal or temporal conjunctiva were determined in all subjects.Results: Typically, subconjunctival hemorrhage affected 1 or 2 regions of the temporal conjunctiva. The grade of conjunctivochalasis and pinguecula was higher in both the affected and unaffected eyes of the CL-Hemorrhage group than the non-CL and CL groups (all P < .00001). The effect of downward gaze or digital pressure on the extent of conjunctivochalasis was more marked in the CL-Hemorrhage group and superficial punctate keratitis was more common (all P < .00001). Multivariate logistic regression analysis of variables revealed that the presence of conjunctivochalasis and pinguecula were associated with an increased risk of CL-induced subconjunctival hemorrhage (all P < .05).Conclusions: These results suggest that the major risk factors for CL-induced subconjunctival hemorrhage are conjunctivochalasis and pinguecula.

Topography-Guided Conductive Keratoplasty: Treatment for Advanced Keratoconus - Corrected Proof

Naoko Kato, Ikuko Toda, Tetsuya Kawakita, Chikako Sakai, Kazuo Tsubota — 2010-08-09

Purpose: To evaluate the use of topography-guided conductive keratoplasty in eyes with keratoconus.Design: Interventional case series.Methods: We examined 21 eyes in 21 patients with advanced keratoconus. Topography-guided conductive keratoplasty was performed with intraoperative monitoring of corneal astigmatism using a surgical keratometer. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), corneal topography, manifest refraction, intraocular pressure (IOP), corneal endothelial cell counts, complications, and eventual outcomes were evaluated.Results: UCVA (logarithm of the minimal angle of resolution [logMAR]), which was 1.65 ± 0.49 preoperatively, improved to 1.04 ± 0.64 at 1 week (P < .001) and 1.12 ± 0.61 at 1 month after surgery (P < .001). BSCVA, which was 1.02 ± 0.56 preoperatively, improved to 0.76 ± 0.65 at 1 week (P = .026) and 0.76 ± 0.60 at 1 month after surgery (P = .003). Manifest refraction, which was −15.13 ± 6.66 diopters (D) before surgery, declined to −9.97 ± 6.71 D at 1 month after surgery (P = .002). Although corneal topography reverted to the preoperative pattern and UCVA and BSCVA also regressed toward preoperative values, 12 of 21 eyes were better able to tolerate and conduct normal daily activities using contact lenses. Five subjects have undergone or are considering corneal transplantation after unsatisfactory postoperative results. No serious perioperative complication was observed.Conclusions: Topography-guided conductive keratoplasty may be effective in reshaping corneal configuration in eyes with keratoconus, without serious complications, and possibly contributed to avoiding or delaying corneal transplantation.

Identification of New Pathogens in the Intraocular Fluid of Patients With Uveitis - Corrected Proof

2010-08-05

Purpose: To determine infectious causes in patients with uveitis of unknown origin by intraocular fluids analysis.Design: Case-control study.Methods: Ocular fluids from 139 patients suspected of infectious uveitis, but negative for herpes simplex virus, varicella-zoster virus, cytomegalovirus, and Toxoplasma gondii by polymerase chain reaction and/or antibody analysis in intraocular fluids, were assessed for the presence of 18 viruses and 3 bacteria by real-time polymerase chain reaction (PCR). The ocular fluids from 48 patients with uveitis of known etiology or with cataract were included as controls.Results: Positive PCR results were found for Epstein-Barr virus, for rubella virus, and for human herpesvirus 6 each in 1 patient and for human parechovirus in 4 patients. Of the human parechovirus–positive patients, 1 was immunocompromised and had panuveitis. The other 3 patients were immunocompetent and had anterior uveitis, all with corneal involvement.Conclusions: Human parechovirus might be associated with infectious (kerato)uveitis.

Visual Performances With Monofocal, Accommodating, and Multifocal Intraocular Lenses in Patients With Unilateral Cataract - Corrected Proof

Cem Mesci, Hasan Hasbi Erbil, Ali Olgun, Sevil Ari Yaylali — 2010-08-05

Purpose: To compare the visual performance of patients with unilateral cataract following implantation of monofocal, accommodating, refractive, and diffractive multifocal intraocular lenses (IOL).Design: Prospective nonrandomized clinical trial.Methods: Eighty-seven patients with unilateral cataract were enrolled in 4 groups for phacoemulsification and IOL implantation. Twenty-four patients had monofocal (Alcon Acrysof) (group 1), 21 patients had accommodating (Human Optics 1CU) (group 2), 22 patients had diffractive multifocal (Tecnis ZM900) (group 3), and 20 patients had refractive multifocal (AMO Rezoom) (group 4) IOL implantations. Ages of patients were between 40 and 70. Parameters analyzed at the 18th postoperative month were subjective refractions, monocular and binocular distance, intermediate and near uncorrected visual acuities, monocular distance and near best-corrected visual acuities, monocular distance-corrected intermediate and near visual acuities, stereopsis, visual complaints, and spectacle dependency.Results: No significant difference was observed between distance and near best-corrected visual acuities of IOL groups, and between intermediate visual acuities of groups 2, 3, and 4. Groups 3 and 4 had statistically better near vision than the other groups (P < .05). No significant difference was observed between near visual acuities of groups 3 and 4. Number of patients with better stereoscopic function, spectacle independence, and complaints of halo in groups 3 and 4 was significantly higher than in other groups (P < .05).Conclusions: Multifocal IOLs provide better stereopsis, higher spectacle independence rates, and satisfactory functional vision over a broad range of distances in presbyopic patients with unilateral cataract compared with the monofocal and accommodating IOLs.

Patients With an Acute Zonal Occult Outer Retinopathy–like Illness Rapidly Improve With Valacyclovir Treatment - Corrected Proof

Vinit B. Mahajan, Edwin M. Stone — 2010-08-05

Purpose: To describe 3 cases of an acute zonal occult outer retinopathy–like illness responsive to valacyclovir hydrochloride.Design: Retrospective, interventional case series.Methods: Three patients were treated with valacyclovir and monitored by clinical examination, Goldmann visual field testing, and electroretinography.Results: Patients with an acute zonal occult outer retinopathy–like illness presented following progressive vision loss. This course was immediately reversed by treatment with oral valacyclovir, and visual acuity and visual field improved significantly at 1 week and 1 month. Patients remained stable without treatment during a follow-up period ranging from 1 to 3 years.Conclusions: Some conditions with features of acute zonal occult outer retinopathy may be attributable to a subacute herpetic viral infection that is responsive to oral antiviral medication.

In Vivo Confocal Microscopic Evaluation of Morphologic Changes and Dendritic Cell Distribution in Pterygium - Corrected Proof

Yan Wang, Feng Zhao, Wenqing Zhu, Jianjiang Xu, Tianyu Zheng, Xinghuai Sun — 2010-08-05

Purpose: To observe morphologic changes and the distribution of dendritic cells in pterygium using in vivo laser scanning confocal microscopy (LSCM).Design: Prospective comparative study.Methods: Twenty-six eyes of 26 patients with pterygium and 17 eyes of 17 healthy subjects were recruited. Using LSCM, in vivo images of the pterygium and adjacent clear cornea were captured. The density of basal corneal epithelial cells and keratocytes in the anterior and posterior stroma and the density of dendritic cells in the pterygium and adjacent clear cornea were determined. In the controls, the central cornea and nasal bulbar conjunctiva were imaged. The density of basal corneal epithelial cells, keratocytes, and dendritic cells was evaluated.Results: Morphologic alterations of the sub-basal nerve plexus were observed in pterygium. The density of basal corneal epithelial cells and anterior keratocytes in pterygium was 5359.0 ± 543.1 cells/mm2 and 407.4 ± 188.7 cells/mm2 respectively, which was significantly lower than that in the controls (P < .001). The density of dendritic cells in the clear corneas of pterygia was 60.3 ± 25.5 cells/mm2, which was significantly higher than the 23.6 ± 11.1 cells/mm2 in the central corneas of controls (P < .001). The dendritic cell density in the pterygium was significantly higher than the density in the nasal bulbar conjunctiva of controls (P < .001).Conclusions: Histopathologic alterations and increased dendritic cells were evident in pterygium and the adjacent clear cornea by in vivo LSCM. In vivo LSCM was found to be an effective method of observing the morphologic alterations of pterygium.

Improvement of Angiographic Findings of Polypoidal Choroidal Vasculopathy After Intravitreal Injection of Ranibizumab Monthly for 3 Months - Corrected Proof

2010-08-05

Purpose: To evaluate the efficacy of 1 intravitreal injection of ranibizumab monthly for 3 months in eyes with polypoidal choroidal vasculopathy (PCV), with attention to changes on indocyanine green angiography (ICGA) with confocal scanning laser ophthalmoscopy (cSLO).Design: Prospective, consecutive case series.Methods: Fifty consecutive eyes of 50 patients with symptomatic PCV who had not been treated previously received 1 intravitreal injection of 0.5 mg ranibizumab monthly for 3 months. Changes in ICGA findings with cSLO 3 months after the primary injection were evaluated.Results: The mean visual acuity (VA) at baseline (0.25; range, 0.1-0.8) improved to 0.38 (P = .001) 3 months after the primary injection. Nineteen eyes (38%) had an improvement in VA of 0.3 or more logMAR unit, and 5 eyes (10%) had a decrease in VA of 0.3 or more logMAR unit. Polypoidal lesions disappeared on ICGA in 13 eyes (26%) and the number of lesions decreased but did not disappear in 26 eyes (52%), with absorption of the accompanying fluid on optical coherence tomography. The remaining 11 eyes (22%) had unchanged or worsened polypoidal lesions. A branching vascular network remained in all 48 eyes in which the network was detected at baseline. Although resolution of the branching vascular networks or decreased diameter of the branching vascular network occurred in 11 eyes (23%), the branching vascular network was unchanged or worse in 37 eyes (77%).Conclusion: Although a limitation of this study is the short-term follow-up, polypoidal lesions tended to respond to ranibizumab therapy, but the branching vascular network responded poorly.

Pain Perception at Laser Treatment of Peripheral Retinal Degenerations With Green and Infrared Wavelengths - Corrected Proof

2010-08-05

Purpose: To compare the pain perception at laser treatment of peripheral retinal degenerations with green (532-nm) and infrared (810-nm) wavelengths.Design: Prospective randomized clinical trial.Methods: Sequential patients with indications for photocoagulation of bilateral peripheral retinal degenerations were invited to participate in the study. Thirty patients (60 eyes) were enrolled in the study. Each patient had 1 eye treated with infrared laser (diode, 810-nm wavelength) and the other eye treated with green laser (frequency-doubled solid-state laser, diode-pumped, with 532-nm wavelength). The eyes were randomized to infrared or green wavelengths. The right eye was the first treated in all cases regardless of the wavelength arrangement. Immediately after photocoagulation of each eye, the patient was asked to grade pain perception according to an 11-point (ie, 0–10) numerical rating scale (NRS), with 0 meaning “No pain” and 10 meaning “Pain as bad as you can imagine.” The primary outcome was the assessment of pain.Results: The mean grading of pain perception was 2.80 (SD 1.27; mode and median = 2) to green wavelengths and 5.07 (SD 1.36; mode = 4 and median = 5) to infrared wavelengths (P < .001).Conclusions: The results showed a statistically and clinically significant difference of pain perception between the 2 groups, with advantage to the green laser group.

Keratocyte Density after Laser-Assisted Subepithelial Keratectomy with Mitomycin C - Corrected Proof

2010-08-05

Purpose: To study the effects of laser-assisted subepithelial keratectomy (LASEK) with mitomycin C (MMC) on the keratocyte population.Design: Prospective, nonrandomized, interventional, comparative case series.Methods: Fifty-six eyes treated at Vissum Santa Hortensia, Madrid, Spain, were included in the study. We compared 28 eyes treated with LASEK with intraoperative 0.02% MMC versus 28 non-treated eyes. Keratocyte density was measured 3 months after the surgery in the anterior, mid, and posterior stroma and was compared with the corresponding layers in the control eyes. The anterior layer in the LASEK group was compared with 2 layers in the control group: the most anterior stromal layer and the 80 μm-deep layer, because that was the mean ablation depth performed in eyes that underwent LASEK.Results: We found a statistically significantly lower keratocyte population in the most anterior stromal layer after LASEK with MMC compared with both the most anterior stromal layer and the 80 μm-deep layer in controls. On the contrary, the treated group showed a significantly higher keratocyte density in both the mid stroma and the deep stroma. The comparison between the average densities through the entire cornea showed a significantly higher keratocyte population in the LASEK with MMC group.Conclusions: LASEK with MMC seems to cause a decrease in the anterior stromal cells 3 months after the surgery compared with nonoperated corneas. There seems to be a compensating proliferation of keratocytes in the deeper corneal layers, suggesting that the ability of keratocytes to repopulate the cornea is maintained after the surgical procedure.

Impact of Age-Related Macular Degeneration on Vision-Specific Quality of Life: Follow-up from the 10-Year and 15-Year Visits of The Study of Osteoporotic Fractures - Corrected Proof

2010-08-05

Purpose: To assess vision-specific quality of life (QOL), based on abbreviated surveys derived from the National Eye Institute Visual Function Questionnaire (NEI-VFQ), in a cohort of United States women who participated in the Study of Osteoporotic Fractures.Design: Prospective, observational cohort study.Methods: Age-related macular degeneration (AMD) status, based on a 3-level classification (no AMD, early AMD, late AMD), and vision-specific QOL, based on abbreviated NEI-VFQ surveys, were calculated for 1674 women enrolled in the Study of Osteoporotic Fractures at 4 centers within the United States who had gradable fundus photographs at both the 10-year and 15-year follow-up visits. The associations among 5-year changes in NEI-VFQ composite scores, change in AMD status, and distance visual acuity were examined.Results: Compared with study participants without AMD at both visits, study participants with late AMD at both visits and those who progressed from early AMD to late AMD demonstrated the greatest declines in adjusted NEI-VFQ composite scores, up to a mean decrease of 16.2 from a scale of 100. Visual acuity declines also were most prominent for patients with late AMD at both visits and for those who progressed from early AMD to late AMD. Change in visual acuity was found to correlate significantly with change in vision-specific QOL.Conclusions: The abbreviated NEI-VFQ surveys provide reliable assessments of vision-specific QOL in AMD patients. The decline in vision-specific QOL associated with the progression of AMD is clinically meaningful.

Educational Levels in Patients with Stargardt Disease - Corrected Proof

Anastasios Anastasakis, Azzrah Thobani, Gerald A. Fishman, J. Jason McAnany — 2010-08-05

Purpose: To assess the highest educational level attained by patients with Stargardt disease and clinically significant visual impairment.Design: Cross-sectional assessment.Methods: Patients with Stargardt disease and clinically significant visual impairment (documented best-corrected visual acuity of 20/70 or worse in each eye either before or up to the age of 22 years) were included in the study. Information concerning the highest level of education attained was obtained for all participants by an interview.Results: Of the 33 participants, 32 completed high school. Either an associate's or bachelor's degree was attained by 21 patients (63.6%), whereas 3 patients (9.1%) were enrolled in college at the time of the interview. Further, a postgraduate degree (master's or doctorate) was attained by 7 patients (21.2%).Conclusions: Our findings document that the potential for attaining a higher degree of academic education beyond high school does not seem to be precluded by clinically significant visual impairment in Stargardt patients. This information can be useful for visual practitioners when counseling these patients and their families.

Ophthalmomyiasis with a Singular Subretinal Track - Corrected Proof

2010-08-05

Purpose: To report 3 cases of myiasis with a singular subretinal track in the Northeastern part of United States.Design: Noninterventional case series.Methods: Three patients from Pennsylvania were referred for evaluation of a linear and serpiginous retinal scar. Funduscopic examination and fluorescein angiography were performed to assess the referred retinal lesion.Results: Funduscopic examination showed a singular subretinal track from the superior periphery to either the posterior pole or inferior midperiphery in the study cases. Fluorescein angiography showed exudative retinal detachment in all 3 cases. Laser photocoagulation of the subretinal worm was performed in all reported cases.Conclusions: Our case series represents a report of singular subretinal tracks presumably caused by the warble fly larva in the Northeastern part of United States.

Comparison of Travoprost and Bimatoprost plus Timolol Fixed Combinations in Open-Angle Glaucoma Patients Previously Treated with Latanoprost plus Timolol Fixed Combination - Corrected Proof

2010-08-04

Purpose: To compare the ocular hypotensive effect of bimatoprost plus timolol and travoprost plus timolol fixed combinations in glaucoma patients whose disease was controlled but had not reached their target intraocular pressure (IOP) with the fixed combination of latanoprost plus timolol.Design: A 2 × 3-month, multicenter, prospective, randomized, double-masked, cross-over clinical trial.Methods: Eighty-nine open-angle glaucoma (OAG) patients were included. After a 6-week run-in period with latanoprost plus timolol, patients were randomized to either travoprost plus timolol or bimatoprost plus timolol for 3 months. Patients then switched to the opposite therapy for 3 additional months. The primary end point was the comparison of mean daily IOP after 3 months of each treatment.Results: At baseline, mean IOP was 16.5 mm Hg (95% confidence interval, 16.0 to 17.0 mm Hg) with treatment with latanoprost plus timolol. Both bimatoprost plus timolol and travoprost plus timolol statistically significantly reduced the mean IOP from baseline (P < .0001). Mean IOP at month 3 was statistically significantly lower in the bimatoprost plus timolol group compared with the travoprost plus timolol group (14.7 mm Hg [95% confidence interval, 14.3 to 15.3 mm Hg] vs 15.4 mm Hg [95% confidence interval, 15.0 to 15.9 mm Hg]; P = .0041). IOP was lower during bimatoprost plus timolol treatment at all time points and statistical significance was reached at 8 am, 11 am, and 5 pm, but not at 2 pm and 8 pm. Both treatments showed similar tolerability profile.Conclusions: Bimatoprost plus timolol and travoprost plus timolol can provide additional IOP-lowering effect in patients not fully controlled with latanoprost plus timolol. The observed additional IOP reduction was greater with bimatoprost plus timolol with a similar tolerability profile.

Long-Term Changes in Axial Length in Adult Eyes with Pathologic Myopia - Corrected Proof

2010-08-04

Objective: To examine the long-term changes of the axial length in adults with high myopia.Design: Open-label, consecutive, retrospective case series.Methods: The medical records of 101 patients (184 eyes) with high myopia (myopia ≥−6 diopters or axial length ≥26.5 mm) were studied. The axial length of the eye was measured by A-scan ultrasonography. The significance of the changes in the axial length during follow-up was determined. The effects of the age, axial length, and the presence of a posterior staphyloma at the initial examination on the axial length elongation were determined.Results: The mean follow-up period was 8.2 years. The median axial length increased significantly from 28.6 mm at the initial examination to 29.4 mm at the final examination in the 184 eyes. The axial length remained stable (≤1-mm difference) in 69%, whereas the axial length increased by more than 1 mm in 31% of the eyes. For these 31%, the median axial length increased by 1.55 mm. An increase of the axial length per year was significantly greater in older patients than their younger cohorts, and the increase in eyes with a posterior staphyloma was significantly greater than in eyes without a staphyloma. Multiple regression analyses showed that the axial length elongation was positively and significantly correlated with patient age at the initial examination.Conclusions: In highly myopic adult patients, the axial length continued to increase. Older individuals with posterior staphyloma were more susceptible to having a larger increase in the axial length. A progression of posterior staphyloma with increasing age is considered a key factor for the continuous increase of axial length in adults with high myopia.

Host and Graft Thickness after Descemet Stripping Endothelial Keratoplasty for Fuchs Endothelial Dystrophy - Corrected Proof

2010-08-04

Purpose: To determine relationships between vision, forward scatter, and total corneal and graft thicknesses after Descemet stripping endothelial keratoplasty (DSEK).Design: Prospective, cohort study.Methods: Forty-four eyes with Fuchs endothelial dystrophy were examined before and at 1, 3, 6, and 12 months after DSEK; all eyes were pseudophakic after surgery. Central total corneal and graft thicknesses were measured using confocal microscopy. Best-corrected high-contrast visual acuity (BCVA) was measured using the electronic Early Treatment Diabetic Retinopathy Study protocol, and forward light scatter was measured using a straylight meter.Results: Total corneal thickness was 610 ± 50 μm (mean ± standard deviation) before DSEK, increased to 680 ± 74 μm by 1 month after DSEK (P < .001), and stabilized at 660 ± 68 μm by 3 months after DSEK (P = .03 vs 1 month). Graft thickness was 170 ± 57 μm at 1 month, decreased to 157 ± 49 μm by 3 months (P = .004), and then remained stable through 12 months (156 ± 51 μm; P = .99 vs 3 months). BCVA was 0.44 ± 0.21 logarithm of the minimal angle of resolution (logMAR) units (Snellen equivalent, 20/55) before DSEK, improved to 0.26 ± 0.20 logMAR units (Snellen equivalent, 20/36) by 3 months (P < .001), and improved to 0.16 ± 0.16 logMAR units (Snellen equivalent, 20/29) at 12 months (P < .001 vs 3 months). BCVA and forward light scatter did not correlate with corneal or graft thickness after DSEK.Conclusions: Stromal edema resolves by 3 months after DSEK for Fuchs dystrophy, whereas visual acuity continues to improve through 12 months. Thicker corneas and grafts are not associated with worse visual acuity or increased forward scatter.

Inflammatory Disorders of the Orbit in Childhood: A Case Series - Corrected Proof

2010-08-04

Purpose: To describe a series of cases of orbital inflammatory disorders in children.Design: Retrospective case series.Methods: The medical records of pediatric patients diagnosed with orbital inflammation between September 1, 2002, and December 31, 2008, at Texas Children's Hospital were reviewed. Data collected included age at presentation, final diagnosis, treatment, workup and evaluation, need for biopsy and biopsy results, and involvement of lacrimal gland and muscles.Results: Twelve cases were identified. Six cases were males and 6 were females with age at presentation ranging from 1.3 to 16.2 years (mean, 11.9 years). The most common presentation was lacrimal gland enlargement, which was bilateral in 3 cases. Other common presenting signs were proptosis, extraocular motility limitation, and pain on eye movement. Half of our patients had systemic complaints at presentation, the most common of which was fever. Four patients were diagnosed as having a systemic cause and 2 of these patients had systemic symptoms.Conclusions: Idiopathic orbital inflammatory conditions in children are uncommon, but can be associated with systemic conditions. Patients typically have lacrimal gland involvement, pain with eye movement, proptosis, and motility deficits at presentation. Bilateral cases may have a higher incidence of systemic disease.

Ischemic Diabetic Retinopathy May Protect against Nuclear Sclerotic Cataract - Corrected Proof

Nancy M. Holekamp, Fang Bai, Ying-Bo Shui, Arghavan Almony, David C. Beebe — 2010-08-04

Purpose: To determine whether diabetes mellitus is protective for nuclear sclerotic cataract at baseline and 6 and 12 months after vitrectomy surgery.Design: Prospective, interventional cohort study.Methods: Phakic diabetic and nondiabetic patients undergoing vitrectomy surgery for a variety of retinal conditions underwent Scheimpflug lens photography in the operated and fellow eye at baseline and at 6 and 12 months after vitrectomy surgery.Results: Of 52 eyes included in the analysis, 23 eyes were from diabetic patients, 14 of which had surgery for ischemic retinopathy. At baseline, eyes with ischemic diabetic retinopathy had less nuclear sclerotic cataract than nonischemic diabetic and nondiabetic eyes. This was true for eyes undergoing vitrectomy surgery (P = .0001) and for fellow eyes (P = .003). Nuclear sclerotic cataract developed after vitrectomy surgery in nonischemic diabetic eyes and nondiabetic eyes at the same rate. Diabetic eyes with ischemic retinopathy showed no significant progression of nuclear opacification, and therefore had significantly less postvitrectomy nuclear cataract at 6 months (P < 1 × 10−6) and at 12 months (P < .001) than nondiabetic or nonischemic diabetic eyes. Normalizing to baseline opacity and adjusting for age and other comorbidities did not alter this result.Conclusions: Ischemic diabetic retinopathy, not just systemic diabetes mellitus, protected against nuclear sclerotic cataract at baseline and after vitrectomy surgery. These findings are consistent with the hypothesis that increased exposure to oxygen is responsible for nuclear cataract formation.

Visual and Systemic Outcomes in Pediatric Ocular Myasthenia Gravis - Corrected Proof

2010-08-02

Purpose: To evaluate visual and systemic outcomes in pediatric patients with purely ocular myasthenia gravis (OMG) treated at the Children's Hospital of Philadelphia.Design: Retrospective chart review.Methods: Pediatric patients with OMG seen at a single institution over a 16-year period with a minimum follow-up of 1 year were reviewed. Associations of demographic and clinical characteristics with disease resolution, amblyopia, and development of generalized symptoms of myasthenia gravis were analyzed.Results: Thirty-nine patients were identified, with a mean age of 5.4 ± 4.8 years and mean follow-up of 4.8 ± 4.3 years. Fifteen patients were treated with pyridostigmine only, 19 (49%) also received steroids, and 15 (38%) underwent thymectomy. Four patients (10%) received steroid-sparing immunosuppressive therapy. Resolution occurred in 10 patients, and generalized symptoms eventually occurred in 9 patients. Although 10 patients were treated for amblyopia, only 1 had amblyopia at the final visit. There was no correlation between sex or age with amblyopia or development of generalized symptoms. Thymectomy, when performed before the onset of generalized symptoms, showed a trend toward protection from the development of generalized symptoms (P = .07).Conclusions: In our series, 24% of patients had disease resolution and 23% had generalized symptoms. Our larger cohort confirms previous findings that treated and untreated pediatric patients with OMG have a relatively low risk of developing generalized symptoms and that related amblyopia is readily reversible. Although our treatments were more aggressive than those previously reported, our rates of amblyopia and development of generalized symptoms are comparable.

Clinical Features and the Risk Factors of Infantile Exotropia Recurrence - Corrected Proof

Ji-Hye Park, Seung-Hyun Kim — 2010-08-02

Purpose: To evaluate the clinical features and the risk factors of recurrence in infantile exotropia.Design: Retrospective, observational case series.Methods: The clinical records of 20 infantile exotropia patients who underwent exotropia surgery were reviewed retrospectively. Patients were divided into 2 groups according to the amount of exodeviation present at 1 year after surgery. Preoperative patient characteristics and postoperative alignments were evaluated at 1 day and 1, 3, 6, and 12 months after surgery.Results: The successful group was composed of 12 patients with an alignment of less than 10 prism diopters (PD) of exodeviation, and the recurrent group was composed of 8 patients with an alignment of 10 PD or more of exodeviation (range, 10 to 18 PD) at 1 year after surgery. The incidences of dissociated vertical deviation, inferior oblique overaction, and rates of constancy before operation were not significantly different in the 2 groups (P = .603, P = .158, and P = .347, respectively), and postoperative deviations were not significantly different at 1 day after surgery. However, postoperative deviations were significantly different in the 2 groups at 1 month (P = .069) and 3 months (P < .001) after surgery, and this difference was maintained at 12 months after surgery. Furthermore, correlation between initial alignments at 1 month after surgery and final alignments was significant in successful group (P = .012).Conclusions: No single factor affecting the surgical outcome was identified in infantile exotropia, but the recurrence of infantile exotropia was apparent from the first postoperative month.

Use of Glaucoma Medications: State of the Science and Directions for Observational Research - Corrected Proof

Vicky H. Lu, Ivan Goldberg, Christine Y. Lu — 2010-08-02

Purpose: To summarize observational studies that focus on the use of glaucoma medications and to identify gaps in knowledge to guide future investigation.Design: Literature study.Methods: We searched the electronic databases MEDLINE, EMBASE, and PubMed for English language articles published through December 2009 using the search terms physician's practice patterns, drug prescriptions, pharmaceutical services, medication adherence, ophthalmology, glaucoma, and ophthalmic solutions. We categorized studies by areas of focus and extracted and summarized key features: study population, data sources, and main findings.Results: We identified 2224 articles by the search. Fifty-five described glaucoma medication use using large databases. Predominant areas of focus were: trends in prescription choices (n = 13); adherence, persistence, or both (n = 31); rational use of medications (n = 9); and policy-related issues (n = 2). Over the last decade, use of β-blockers and miotics has decreased substantially, whereas new agents, particularly prostaglandin analogs, have become more popular. Nonadherence was an issue in more than 25% of patients. A significant proportion of patients with comorbidities, contraindications, or both had received topical β-blockers.Conclusions: To date, most studies have focused on adherence to glaucoma medications and changes in treatment choices. Major gaps in knowledge include prescribing patterns by prescriber specialty (ophthalmologists, primary care physicians, and optometrists), medication-related problems, and subsequent adverse health outcomes. Well-designed longitudinal observational studies addressing these gaps are warranted to improve patient safety.

An Anterior Chamber Toxicity Study Evaluating Besivance, AzaSite, and Ciprofloxacin - Corrected Proof

2010-08-02

Purpose: We determined whether Besivance (Bausch & Lomb), AzaSite (Inspire Pharmaceuticals, Inc; both with DuraSite bioadhesive [InSite Vision, Inc]) and ciprofloxacin are toxic inside the anterior chamber.Design: Randomized, masked, placebo-controlled animal study.Methods: Twenty New Zealand white rabbits (40 eyes) were randomized to 1 of 4 study groups: Besivance, AzaSite, ciprofloxacin, and balanced salt solution. Each eye was injected with 0.1 mL of the study medication. Clinical slit-lamp examinations were conducted at 24 and 48 hours after injection. All rabbits then were killed and all eyes were enucleated. We randomized eyes to either corneal vital staining or histopathologic examination. The main outcome measures were clinical and pathologic signs of toxicity.Results: The 2 DuraSite-based study groups (Besivance and AzaSite) showed clinically and pathologically significant differences when compared with the ciprofloxacin and balanced salt solution groups. Besivance and AzaSite eyes exhibited significantly similar and severe clinical damage, including severe corneal edema. Ciprofloxacin and balanced salt solution eyes appeared very similar and had only mild conjunctival injection and limbal vascularity. Vital staining and histopathologic evaluation revealed glaucomatous and toxic damage in eyes given DuraSite-based medications, whereas non-DuraSite groups showed minimal changes.Conclusions: DuraSite blocks the trabecular meshwork and may be additionally toxic when introduced as a large bolus. Until the safety of these medications is established with further studies using smaller injected volumes, we recommend placement of a suture over a clear corneal wound if DuraSite-based medications are used.

Plus Disease in Retinopathy of Prematurity: Quantitative Analysis of Vascular Change - Corrected Proof

2010-07-20

Purpose: To examine the relationship between rate of vascular change and plus disease diagnosis.Design: Retrospective observational case-control study.Methods: Wide-angle images were taken bilaterally from 37 infants at 31 to 33 weeks and 35 to 37 weeks postmenstrual age (PMA). The semi-automated Retinal Image multiScale Analysis system was used to measure parameters for all arteries and veins: integrated curvature, diameter, and tortuosity index. A reference standard diagnosis (plus vs not plus) was defined for each eye by consensus of 5 experts at 35 to 37 weeks PMA. Weekly rate of change in parameters was compared in eyes with plus vs not plus disease. Receiver operating characteristic area under the curve (AUC) was calculated for plus disease detection based on 1) weekly rates of parameter change between 31 to 33 weeks and 35 to 37 weeks PMA and 2) parameter values at 35 to 37 weeks only.Results: Weekly rates of change in all venous parameters were significantly different in eyes with plus vs not plus disease, particularly for tortuosity index (P < .0004) and diameter (P = .018). Using weekly rate of change, AUC for plus disease detection was highest for venous tortuosity index (0.819) and venous diameter (0.712). Using the 35 to 37-week PMA image only, AUC was highest for venous integrated curvature (0.952) and diameter (0.789).Conclusion: Rate of change in venous, but not arterial, parameters is correlated with plus disease development in this data set. This did not appear to contribute information beyond analysis of an image at 35 to 37 weeks PMA only.

Retinal Nerve Fiber Layer Thickness in Patients Receiving Chronic Anti–Vascular Endothelial Growth Factor Therapy - Corrected Proof

Michael B. Horsley, Naresh Mandava, Marco A. Maycotte, Malik Y. Kahook — 2010-07-20

Purpose: To evaluate the effects of multiple intravitreal injections of anti–vascular endothelial growth factor (VEGF) agents on the thickness of the retinal nerve fiber layer (RNFL) in patients with wet age-related macular degeneration (ARMD).Design: Retrospective, observational, consecutive case series of patients diagnosed with wet ARMD.Methods: Forty-one eyes of 37 consecutive patients (25 female and 12 male; mean age 79.2 ± 8.7 years) who underwent treatment with pegaptanib, bevacizumab, and/or ranibizumab for ARMD followed by sequential RNFL thickness measurement by optical coherence tomography (OCT) were studied. Patients were included in the analyses if they had greater than 10 total anti-VEGF injections, RNFL measurements prior to the first injection, and at least 12 months of follow-up. Patients were divided into 3 groups depending on which anti-VEGF agent(s) they received. The OCT RNFL measurements at the initial and final follow-up were used for analyses.Results: Average follow-up for all patients was 27.0 ± 9.7 months and they received an average of 16.0 ± 5.5 intravitreal injections. The average RNFL thickness at presentation was 92.4 ± 15.2 μm and at last follow-up was 93.8 ± 15.2 μm (P = .68). There were no statistically significant differences in RNFL measurements when comparing between individual anti-VEGF treatment groups.Conclusion: Long-term treatment with anti-VEGF agents did not lead to significant changes in RNFL thickness in a patient population with wet ARMD. Despite the possibility of repeated intraocular pressure (IOP) fluctuations after intravitreal injections and known neurotrophic properties of VEGF in the eye, chronic therapy with intravitreal anti-VEGF agents does not appear to adversely affect RNFL thickness. Further prospective studies with longer follow-up are needed to corroborate the findings of this study.

Outer Foveolar Defect After Surgery for Idiopathic Macular Hole - Corrected Proof

Se Woong Kang, Ji Won Lim, Song Ee Chung, Chan-Hui Yi — 2010-07-20

Purpose: To describe the clinical implications of outer foveolar defects on optical coherence tomography (OCT) in eyes treated surgically for macular hole (MH).Design: Retrospective observational case series.Methods: Ninety-six eyes of 93 subjects who had undergone surgery for the treatment of idiopathic MH were included. Clinical data, including OCT prior to and at follow-up visits ranging from 3 to 32 months after surgery, were analyzed. Incidence, risk factors, and clinical outcomes of outer foveolar defect were evaluated.Results: Outer foveolar defects were noted on postoperative OCT in 44 of the 96 eyes (45.8%). The mean preoperative diameter of MH in the eyes (333.5 ± 126.3 μm) evidencing outer foveolar defects was significantly smaller than those that did not (504.2 ± 155.6 μm) (P < .0001). The mean disappearance time of the defect was estimated to be 182 days after surgery. The mean postoperative visual acuity (logMAR) improved to 0.40 ± 0.26 from 0.58 ± 0.23 after the disappearance of outer foveolar defects.Conclusions: Outer foveolar defects were detected predominantly after surgery for small MHs. The defect decreases gradually in size and eventually disappears completely approximately 6 months after surgery.

Incidence Rates and Risk Factors for Ocular Complications and Vision Loss in HLA-B27-Associated Uveitis - Corrected Proof

Allison R. Loh, Nisha R. Acharya — 2010-07-20

Purpose: To calculate the incidence rates of ocular complications and vision loss in HLA-B27-associated uveitis and to explore the effect of chronic inflammation on clinical outcomes.Design: Retrospective longitudinal cohort study.Methods: The clinical records of 99 patients (148 uveitis-affected eyes) with HLA-B27-associated uveitis seen at a tertiary care center were included. The main outcome measures were ocular complications (posterior iris synechiae, band keratopathy, posterior subcapsular [PSC] cataracts, ocular hypertension, hypotony, cystoid macular edema, and epiretinal membrane) and vision loss. Anterior chamber inflammation was defined as ≥1+ grade inflammation. Chronic uveitis was defined as persistent inflammation with relapse in <3 months after discontinuing treatment or requiring medications to suppress inflammation for >3 months after reviewing the patient's entire clinical course.Results: The clinical course was most commonly acute/recurrent (75%) or chronic (20%). The most common complications to develop during follow-up were ocular hypertension (0.10/eye-year) and PSC cataracts (0.09/eye-year). In multivariate analysis, the presence of posterior synechiae at presentation, inflammation, corticosteroid-sparing therapy, corticosteroid injections, chronic disease, and male gender were associated with a statistically significant increased risk of developing vision loss (20/50 or worse). Chronic disease course was associated with a 7-fold increased risk of visual impairment (hazard ratio [HR] = 6.8, P < .0001). The presence of inflammation during follow-up was associated with an increased risk of developing visual impairment (HR = 6.2, P < .0001). In multivariate analysis, chronic disease course and topical corticosteroids were associated with an increased risk of developing any incident ocular complication (HR = 2.2, P = .04 and HR = 3.3, P = .01, respectively).Conclusions: Poorly controlled inflammation was associated with the development of ocular complications including vision loss. Patients with chronic inflammation were also at greater risk of complications.

Prognosis of Upper Eyelid Epiblepharon Repair in Down Syndrome - Corrected Proof

2010-07-20

Objective: To evaluate the recurrence rate after upper eyelid epiblepharon repair in patients with Down syndrome.Design: Retrospective, observational study.Methods: Total of 578 Korean children (21 with Down syndrome patients, 557 with non-Down syndrome patients), who had undergone epiblepharon repair and were followed up for more than 2 months, were included in this study. The recurrence rate was compared between two groups at 2, 6 months after surgery. Recurrence was defined as the re-appearance of cilia touching to cornea. The recurrence rate was also analyzed according to whether patients had undergone concomitant z-medial epicanthoplasty or not.Results: Lower eyelid epiblepharon repair was performed on 22 eyelids of Down syndrome patients, and 1072 eyelids of non-Down syndrome patients. At 3 months after surgery, the recurrence rate was not significantly different between two groups (P = 1.00). Upper eyelid epiblepharon was repaired on 40 eyelids of Down syndrome patients, and 204 eyelids in non-Down syndrome patients. At 2 and 6 months after surgery, the recurrence rate was significantly higher in Down syndrome patients (27.5% and 29.4%) than non-Down syndrome patients (3.4% and 4.6%) (P = 0.000, P = 0.004, respectively). The recurrence rate of upper eyelid epiblepharon repair was not affected in both groups whether Z-epicanthoplasty was combined or not (P = 1.00 in both groups).Conclusions: In Down syndrome patients, the recurrence rate after upper eyelid epiblepharon repair was higher than non-Down syndrome patients. The effect of combined Z-medial epicanthoplasty was limited in both groups.

Cardiovascular Risk Factors, Inflammation, and Corneal Arcus: The Singapore Malay Eye Study - Corrected Proof

Renyi Wu, Jie Jin Wang, E. Shyong Tai, Tien Yin Wong — 2010-07-13

Purpose: To examine the relationship of corneal arcus with cardiovascular risk factors and inflammation in Malay adults living in Singapore.Design: Population-based cross-sectional study.Methods: A total of 3280 Malays aged 40-80 years (out of 4168 eligible participants; 78.7% response rate) had a standardized interview, systemic and ocular examinations, and laboratory investigations, including measurement of C-reactive protein (CRP), chronic kidney disease, and peripheral artery disease. Corneal arcus was defined from anterior segment images taken with a slit-lamp camera.Results: Corneal arcus was seen in 2345 out of 3260 participants who had anterior segment images (73.2%). After adjustment for age, gender, total cholesterol, serum glucose, and current smoking, many cardiovascular risk factors significantly associated with corneal arcus, including male gender (odds ratio [OR] 1.65, 95% confidence interval [CI] 1.27–2.03), older age (per 10 years, OR 4.49, 95% CI 3.91–5.15), higher body mass index (per kg/m2, OR 1.02, 95% CI 1.00–1.04), higher levels of CRP (per 10 mg/L, OR 1.36, 95% CI 1.13–1.64), total cholesterol (per mmol/L, OR 1.21, 95% CI 1.11–1.32), low-density lipoprotein cholesterol (per mmol/L, OR 1.94, 95% CI 1.38–2.74), presence of peripheral artery disease (OR 3.85, 95% CI 1.29–11.5), chronic kidney disease (OR 1.14, 95% CI 1.03–1.38), and current smoking (OR 1.29, 95% CI 1.02–1.69).Conclusions: This study confirms known associations of traditional cardiovascular risk factors with corneal arcus in an Asian population. Additionally, corneal arcus may be associated with systemic inflammatory markers, peripheral artery disease, and chronic kidney disease.

Ophthalmic Manifestations of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis and Relation to SCORTEN - Corrected Proof

2010-07-08

Purpose: To evaluate the severity of ocular involvement of patients with Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS/TEN overlap, and to investigate the relationship of the SCORTEN (a severity-of-illness score for SJS and TEN based on a minimal set of well-defined variables calculated within 24 hours of admission) with eye disease in this patient population.Design: Retrospective observational case series.Methods: Charts of all patients admitted to the Parkland Memorial Hospital Burn Center with a preliminary diagnosis of SJS, SJS/TEN overlap, or TEN between 1998 and 2008 were reviewed. Patients were included for study if they met clinical criteria, had positive diagnostic skin biopsy, and had dermatologic and ophthalmologic consultations. Eighty-two patients with a diagnosis of SJS, SJS/TEN overlap, or TEN met inclusion criteria. Ocular manifestations were classified as mild, moderate, or severe. Admission data were used to calculate the SCORTEN. Main outcome measure was the severity of ocular involvement with respect to diagnosis and SCORTEN.Results: Overall, 84% of patients had ocular involvement (71% SJS, 90% TEN, 100% SJS/TEN overlap). There was no difference in the severity of acute ocular complications among groups. While the SCORTEN value did correlate well with mortality rate (correlation coefficient 0.97, P = .005), there was no correlation between the SCORTEN value and severity of eye involvement in the acute setting. There was also no association of any individual diagnosis of SJS/overlap/TEN with the severity of eye involvement, although eye findings are more common in TEN (P = .03).Conclusions: Ocular damage in the acute setting was more frequent in patients with epidermal detachment >10% of the total body surface area. The SCORTEN value did not correlate with the severity of eye involvement in the acute setting.

Inhibition of Corneal Neovascularization by Topical Bevacizumab (Anti-VEGF) and Sunitinib (Anti-VEGF and Anti-PDGF) in an Animal Model - Corrected Proof

2010-06-29

Purpose: To evaluate the effects of topically applied bevacizumab and sunitinib on experimentally induced corneal neovascularization.Design: Experimental animal study.Methods: Thirty-six New Zealand rabbits were involved. One eye per rabbit was used. Corneal neovascularization was induced by placing 5 silk sutures in the upper cornea. Rabbits were randomized to 1 of 3 groups (12 rabbits each): Group 1 received saline 0.9%, Group 2 bevacizumab 5 mg/mL, and Group 3 sunitinib 0.5 mg/mL. All treatments were administered 3 times daily for 14 days. Photographs were taken on a slit lamp on days 7 and 14, and angiographic photographs were taken on day 14. The area of neovascularization was measured in mm2, percentage of the total corneal area, and percentage of the corneal surface covered by sutures.Results: On day 14, corneal neovascularization area in Group 1 (25.92 ± 5.08 mm2, 18.78% ± 3.5% of corneal surface, 105.59% ± 18.9% of corneal surface with sutures) was larger than in Groups 2 (18.52 ± 7.94 mm2, 13.67% ± 5.8%, 76.35% ± 33.2%) (1-way analysis of variance, P = .041) and 3 (4.57 ± 2.32 mm2, 3.40% ± 1.7%, 18.94% ± 9.2%)(P < .001). Neovascularization in Group 2 was larger than in Group 3 (P < .001). Compared to saline, corneal neovascularization was inhibited 28.5% by bevacizumab and 82.3% by sunitinib. Sunitinib settled on the iris.Conclusions: Topical administration of both bevacizumab and sunitinib inhibits corneal neovascularization in rabbits. But vascular endothelial growth factor (VEGF) pathway blockade by bevacizumab was not sufficient for a profound inhibition. Blocking both VEGF and platelet-derived growth factor pathways using sunitinib was 3-fold more effective.

Early Vitrectomy for Vitreous Hemorrhage Associated With Retinal Tears - Corrected Proof

H. Stevie Tan, Marco Mura, Heico M. Bijl — 2010-06-24

Purpose: To evaluate outcome of early surgery in vitreous hemorrhage, presumably associated with retinal tears.Design: Retrospective, noncomparative interventional case series.Methods: We included 40 consecutive cases in 39 patients treated with early vitrectomy for vitreous hemorrhage. Main outcome measures were incidence of tears identified preoperatively and intraoperatively, visual acuity, and complications.Results: Vitrectomy took place after a mean delay of 2.7 days after presentation. A total of 69 tears were found in 40 eyes; 53.7% of tears were identified preoperatively by funduscopy or ultrasound (U/S) and the remaining 46.3% of tears were only identified during vitrectomy. Visual acuity improved significantly from 1/60 to 0.8. The sensitivity of U/S tear detection was 55.9%. A history of predisposing factors was not related to the risk of presence of unsupported tears. In 2 cases a retinal detachment developed between the U/S evaluation and vitrectomy. Postoperative complications were cataract (30%), macular pucker (2.5%), and retinal detachment (5.0%).Conclusions: Our findings illustrate the potential dangers of a conservative approach to vitreous hemorrhage and show that early vitrectomy has good outcome with acceptable complication rates. Prospective studies on optimal treatment of vitreous hemorrhage associated with tears are needed.