American Journal of Ophthalmology

Peer Review Should Continue After Publication

Thomas J. Liesegang — 2010-03-01

Most medical journals do not have a mechanism for producing well-written evidence-based medicine on a measured monthly basis. Some published articles are poorly written and some have few usable clinical tidbits. The temperament of different editors and editorial boards may vary from seeking sensational content that may be risky and shortly abandoned to publishing only methodical proven science. In fact, some view journals as a place to deposit only vetted and established work for posterity. The AJO, as do many journals, occasionally publishes controversial or novel topics and may provide an editorial to challenge the content, or offers readers the opportunity to challenge content through the correspondence section. In reality, most peer-reviewed journals seek more trust than debate and seek more science than sensationalism or entertainment, although we must sell subscriptions to continue our mission. We recognize that there are other current venues for less strict science reporting and more debating. Publication does not imply editorial support, as some articles in the same issue may have contradictory views. The medical literature, moreover, is a history of many ineffective and potentially dangerous treatments, which ultimately are supplanted by better science. At best, published articles represent provisional truth or a continuation of a hypothesis, and only a few articles survive as applicable information into the next decades.

Central Serous Chorioretinopathy: A Personal Perspective

Lawrence A. Yannuzzi — 2010-03-01

Although von Graefe described some of the clinical aspects of “relapsing idiopathic detachment of the macula” as early as 1866, it was more than 100 years later that Maumenee, using fluorescein angioscopy, noted that the detachment of the macula resulted from a leak at the level of the retinal pigment epithelium (RPE). The disorder at that time was commonly referred to as central serous retinopathy. Although numerous articles and name changes have been published in the ophthalmic literature, expanding our knowledge of its cause, clinical manifestations, natural course, and treatment, the pathogenesis of this condition remains poorly understood, little is known about the long-term natural course, and treatment is based on observational, uncontrolled studies.

Current Research in Biostatistics

Abdelmonem A. Afifi, Fei Yu — 2010-03-01

In the 1950s and '60s, a doctoral student in biostatistics could be reasonably expected to acquire a fairly sophisticated knowledge of the whole field before completing the doctoral dissertation. This knowledge would include the fundamentals of probability and mathematical theory of statistical inference, as well as biostatistics proper—that is, the theory and application of statistics to the life and health sciences. Today, biostatistics has grown to the point that no doctoral student in it can become an expert in all of it. Thus, our ambitious title notwithstanding, we can, in this limited space, only aspire to cover part of the current research in biostatistics.

Study Designs in Epidemiology and Levels of Evidence

Jie Jin Wang, John Attia — 2010-03-01

Facing an enormous influx of information from medical research, clinicians need to differentiate robust study findings from spurious ones and to decide which results they can use with high confidence and which they should be more skeptical about. Epidemiology provides guidelines for critical appraisal of the literature. This series aims to equip clinicians with the basic skills to analyze scientific evidence from the literature and wisely use high-quality evidence to guide their clinical practice while avoiding being misled.

Posterior Vitreous Detachment: Evolution and Complications of Its Early Stages

Mark W. Johnson — 2010-03-01

Purpose: To summarize emerging concepts regarding the onset and progression, traction effects, and complications of the early stages of age-related posterior vitreous detachment (PVD).Design: Interpretive essay.Methods: Review and synthesis of selected literature, with clinical illustrations, interpretation, and perspective.Results: Imaging of the vitreoretinal interface with optical coherence tomography has shown that PVD begins in the perifoveal macula. Recent longitudinal studies have demonstrated conclusively that early PVD stages persist chronically and progress slowly over months to years. Vitreous traction forces resulting from perifoveal PVD with a small vitreofoveolar adhesion (500 μm or less) may cause localized cystoid foveal thickening or one of several macular hole conditions. Traction associated with larger adhesion zones may cause or exacerbate a separate group of macular disorders. Ultrastructural studies suggest that epiretinal membrane develops from cortical vitreous remnants left on the retinal surface after PVD and plays an important role in traction vitreomaculopathies.Conclusions: Age-related PVD is an insidious, chronic event that begins in the perifoveal macula and evolves over a prolonged period before vitreopapillary separation. Although asymptomatic in most individuals, its early stages may be complicated by a variety of macular and optic disc pathologic features, determined in part by the size and strength of the residual vitreoretinal adhesion.

Wavefront Analysis, Contrast Sensitivity, and Depth of Focus After Cataract Surgery With Aspherical Intraocular Lens Implantation

2009-12-25

Purpose: To determine whether implantation of an aspherical intraocular lens (IOL) results in reduced ocular aberrations and improved contrast sensitivity after cataract surgery without critical reduction of depth of focus.Design: Double-blinded, randomized, prospective study.Methods: In an intraindividual study of 25 patients with bilateral cataract, an aspherical IOL (Akreos Advanced Optic [AO]; Bausch & Lomb, Inc., Rochester, New York, USA) was implanted in one eye and a spherical IOL (Akreos Fit; Bausch & Lomb, Inc) in the fellow eye. Higher-order aberrations with a 5- and 6-mm pupil were measured with a dynamic retinoscopy aberrometer at 1 and 3 months after surgery. Uncorrected and best-corrected visual acuity and contrast sensitivity under mesopic and photopic conditions also were measured. Distance-corrected near and intermediate visual acuity were studied as a measurement of depth of focus.Results: There was no statistically significant difference between eyes in uncorrected and best-corrected visual acuity at 1 and 3 months after surgery. There was a statistically significant between-group difference in contrast sensitivity under photopic conditions at 12 cycles per degree and under mesopic conditions at all spatial frequencies. The Akreos AO group obtained statistically significant lower values of higher-order aberrations and spherical aberration with 5- and 6-mm pupils compared with the Akreos Fit group (P < .05). There was no significant difference in distance-corrected near and intermediate visual acuity between both groups.Conclusions: Aspherical aberration-free Akreos AO IOL induced significantly less higher-order aberrations and spherical aberration than the Akreos Fit. Contrast sensitivity was better under mesopic conditions with the Akreos AO with similar results of depth of focus.

Complications and Clinical Outcomes of Descemet Stripping Automated Endothelial Keratoplasty With Intraocular Lens Exchange

2010-03-01

Purpose: To evaluate complications and clinical outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) with intraocular lens (IOL) exchange compared with DSAEK alone.Design: Retrospective, interventional case series.Methods: DSAEK was performed in 19 eyes in which the anterior chamber IOL was exchanged for a posterior chamber IOL (study group) and in 188 eyes in which the posterior chamber IOL was left in place (comparison group). The complications of graft dislocations, primary graft failure episodes, and pupillary block were recorded for all eyes. Six-month best spectacle-corrected visual acuity and mean central endothelial cell density were measured prospectively and then compared with preoperative values for all eyes.Results: Dislocations occurred in 0 (0%) of 19 eyes in the study group and in 5 (3%) of 188 eyes in the comparison group (P = .47), with 0 primary graft failures and 0 pupillary block episodes in either group. Preoperative mean best spectacle-corrected visual acuity for those eyes without any underlying ocular comorbidities was 20/205 and 20/100 in the study and comparison groups, respectively (P = .18). Mean best spectacle-corrected visual acuity at 6 months improved to 20/48 in the study group and to 20/34 in the comparison group, a statistically significant difference (P = .01). Mean donor cell loss at 6 months was 33% in the study group and 26% in the comparison group (P = .18).Conclusions: Concurrent IOL exchange with DSAEK surgery does not increase the dislocation, primary graft failure, or pupillary block rates in the immediate postoperative period. Donor endothelial cell loss in DSAEK was not increased significantly by IOL exchange. Visual acuity was slightly worse after combined surgery than after DSAEK alone.

Non-Syndromic Supernumerary Caruncles Causing Ocular Irritation After Cataract Surgery: A Critical Review of Caruncular Dysgeneses

Frederick A. Jakobiec, Helene Lam, Pooja Bhat, Roberto Pineda — 2010-03-01

Purpose: To describe a patient with 2 ipsilateral supernumerary caruncles and to determine if they are predictive of associated abnormalities.Design: Retrospective and interventional clinicopathologic study with a critical review of the literature over the past 100 years.Methods: Assessment of clinical features and histopathologic findings in paraffin-embedded tissue sections stained with hematoxylin and eosin, Masson trichrome, periodic acid–Schiff (PAS) reaction with and without diastase, and Ziehl-Neelsen method.Results: Two placoid lesions causing ocular irritation after routine phacoemulsification were discovered in the inferomedial palpebral conjunctiva. They were totally separate from a normal caruncle. Their surface was studded with yellowish micronodules with projecting white vellus hairs. There were no associated local ophthalmic or systemic abnormalities. Microscopically, they were covered by a goblet cell–rich, nonkeratinizing squamous epithelium with subadjacent pilosebaceous units, the hairs of which were highlighted by the Masson trichrome and Ziehl-Neelsen stains, and small lobules of lacrimal gland tissue. The ocular irritation has not returned after surgery.Conclusions: A literature review confirms that supernumerary (extra) caruncles coexisting with a normal caruncle are always unilateral and unassociated with any other ocular anomalies, as in the current case. They may, however, cause ocular irritation. They must be distinguished from ectopic (topographically displaced) or dysplastic caruncles that are generally bilateral and often associated with ocular adnexal abnormalities or Goldenhar syndrome. Ectopic or dysplastic caruncles, but not supernumerary ones, are characteristically accompanied by plical abnormalities or its absence. Well-documented supernumerary and ectopic caruncles have always been located in the inferior palpebral conjunctiva.

A Simplified Quantitative Method for Assessing Keratoconjunctivitis Sicca From the Sjögren's Syndrome International Registry

2009-12-25

Purpose: To describe, apply, and test a new ocular grading system for assessing keratoconjunctivitis sicca (KCS) using lissamine green and fluorescein.Design: Prospective, observational, multicenter cohort study.Methods: The National Institutes of Health-funded Sjögren's Syndrome International Registry (called Sjögren's International Collaborative Clinical Alliance [SICCA]) is developing standardized classification criteria for Sjögren syndrome (SS) and is creating a biospecimen bank for future research. Eight SICCA ophthalmologists developed a new quantitative ocular grading system (SICCA ocular staining score [OSS]), and we analyzed OSS distribution among the SICCA cohort and its association with other phenotypic characteristics of SS. The SICCA cohort includes participants ranging from possibly early SS to advanced disease. Procedures include sequenced unanesthetized Schirmer test, tear break-up time, ocular surface staining, and external eye examination at the slit lamp. Using statistical analyses and proportional Venn diagrams, we examined interrelationships between abnormal OSS (≥3) and other characteristics of SS (labial salivary gland [LSG] biopsy with focal lymphocytic sialadenitis and focus score >1 positive anti-SS A antibodies, anti-SS B antibodies, or both).Results: Among 1208 participants, we found strong associations between abnormal OSS, positive serologic results, and positive LSG focus scores (P < .0001). Analysis of the overlapping relationships of these 3 measures defined a large group of participants who had KCS without other components of SS, representing a clinical entity distinct from the KCS associated with SS.Conclusions: This new method for assessing KCS will become the means for diagnosing the ocular component of SS in future classification criteria. We find 2 forms of KCS whose causes may differ.

Quality of Life in Keratoconus Patients After Penetrating Keratoplasty

2010-03-01

Purpose: To determine vision-related quality of life (QoL) measured with the National Eye Institute Visual Function Questionnaire (NEI-VFQ) in keratoconus (KCN) patients who have undergone penetrating keratoplasty (PK) in 1 or both eyes and to compare the results of our study to those of historical controls.Design: Clinical-based, cross-sectional study.Methods: setting: Wills Eye Institute, Cornea Service, Thomas Jefferson University, Philadelphia, Pennsylvania. study population: This study included 149 consecutive patients who had undergone PK for KCN. intervention: Between June 1, 2008 and December 31, 2008, the NEI-VFQ was administered to 149 patients. The relationship between demographic and clinical factors and NEI-VFQ subscale scores was evaluated. main outcome measure: Vision-related quality of life.Results: Eighty-three of 149 patients (55.7%) were male. Approximately half of the patients (76/149; 51.0%) had PK in both eyes. Visual acuity with current correction in the better eye was better than 20/40 in 80% of patients (119/149). Our sample had significantly lower (worse) NEI-VFQ scores compared to Collaborative Longitudinal Evaluation of Keratoconus (CLEK) historical control group for the subscales of role difficulties, dependency, driving, and peripheral vision. In general, scores of our sample were between scores of patients with age-related macular degeneration (AMD) category 3 and 4. Patients with visual acuity better than 20/40 (in the better eye) showed significantly higher scores in all subscales except color vision. There was a significant relationship between minimum time since the graft of 5 years or greater and NEI-VFQ overall score better than AMD category 3 (P = .004).Conclusion: Despite satisfactory results on visual outcome measures obtained after PK, vision-related QoL in KCN patients remains impaired.

Mycophenolate Mofetil for Ocular Inflammation

2009-12-30

Purpose: To evaluate mycophenolate mofetil as a single noncorticosteroid immunosuppressive treatment for noninfectious ocular inflammatory diseases.Design: Retrospective cohort study.Methods: Characteristics of patients with noninfectious ocular inflammation treated with mycophenolate mofetil at 4 subspecialty clinics from 1995 to 2007 were abstracted by expert reviewers in a standardized chart review of every eye at every visit. Main outcomes measured were control of inflammation, corticosteroid-sparing effects, and discontinuation of mycophenolate mofetil (including the reasons for discontinuation). Survival analysis was used to estimate the incidence of outcomes, and to identify risk factors for each.Results: Among 236 patients (397 eyes) treated with mycophenolate mofetil monotherapy, 20.3%, 11.9%, and 39.8% had anterior uveitis, intermediate uveitis, and posterior uveitis or panuveitis respectively; 14% had scleritis; 7.6% had mucous membrane pemphigoid; and 6.4% had other ocular inflammatory diseases. By Kaplan-Meier estimation, complete control of inflammation—sustained over consecutive visits spanning at least 28 days—was achieved in 53% and 73% of patients within 6 months and 1 year respectively. Systemic corticosteroid dosage was reduced to 10 mg of prednisone or less, while maintaining sustained control of inflammation, in 41% and 55% of patients in 6 months and 1 year respectively. Twelve percent of patients discontinued mycophenolate mofetil within the first year because of side effects of therapy.Conclusions: Given sufficient time, mycophenolate mofetil was effective in managing ocular inflammation in approximately half of the treated patients. Treatment-limiting side effects were observed in 12% of patients and typically were reversible.

Viral Retinitis After Intravitreal Triamcinolone Injection in Patients With Predisposing Medical Comorbidities

Ankur M. Shah, Stephen F. Oster, William R. Freeman — 2010-03-01

Purpose: To review the cases of viral retinitis after intravitreal steroid administration at a single center, to estimate the incidence, and to propose risk factors for its occurrence.Design: Retrospective, observational case series.Methods: Seven hundred thirty-six intravitreal triamcinolone (IVTA) injections were administered in the clinic and operating room by 3 retina specialists at a single academic medical center between September 2002 and November 2008. Inclusion criteria were simply a history of 1 or more IVTA injections during the period. The overall incidence of viral retinitis after IVTA injection was calculated. Subsequently, a chart audit was performed to estimate the number of patients with immune-altering conditions who had received IVTA during the period, and the incidence within this subgroup was calculated.Results: Viral retinitis developed after IVTA injection in 3 patients, yielding an overall incidence of 3 in 736 or 0.41%. An estimated 334 injections were administered to patients with an immune-altering condition, including diabetes. All 3 of the patients in whom viral retinitis developed after IVTA injection possessed abnormal immune systems, yielding an incidence rate of 3 in 334 or 0.90% within this subgroup.Conclusions: Our high reported incidence for this potentially devastating complication can be attributed to multiple factors, including coexisting medical immunocompromising comorbidities, a higher dose with a longer duration of local immunosuppression in the vitreous, multiple injections, as well as previous viral retinitis. Caution with a high index of clinical suspicion and frequent follow-up is advised in patients receiving IVTA injection with potentially immune-altering conditions, even after apparent immune recovery.

Association Between the Efficacy of Photodynamic Therapy and Indocyanine Green Angiography Findings for Central Serous Chorioretinopathy

Ryo Inoue, Miki Sawa, Motokazu Tsujikawa, Fumi Gomi — 2010-03-01

Purpose: To determine the efficacy of photodynamic therapy (PDT) and indocyanine green angiography (ICGA) findings for treating chronic central serous chorioretinopathy (CSC).Design: Observational case series.Methods: Thirty-two eyes of 27 patients with chronic CSC and symptoms for at least 6 months were recruited. The minimum follow-up was 1 year. The total PDT energy was reduced to about 36 to 42 mJ/cm2. The baseline middle-phase ICGA findings were classified as intense, intermediate, or no hyperfluorescence depending on the degree of hyperfluorescence. The resolution of the subretinal fluid and recurrence rates were assessed in relation to each ICGA finding at baseline.Results: ICGA before PDT showed intense hyperfluorescence in 23 eyes (72%), intermediate hyperfluorescence in 6 eyes (19%), and no hyperfluorescence in 3 eyes (9%). The subretinal fluid resolved completely 3 months after 1 application of PDT in 23 eyes (100%) with intense hyperfluorescence, 6 eyes (100%) with intermediate hyperfluorescence, and no eyes (0%) with no hyperfluorescence. In the last group, the subretinal fluid did not resolve throughout the follow-up period despite additional applications of PDT. The subretinal fluid recurred in 7 of 29 eyes (24%) in which the subretinal fluid resolved at 3 months; recurrence was frequent in eyes with intermediate hyperfluorescence (5 eyes; 83%).Conclusion: The PDT success rate in eyes with chronic CSC depends on the degree of hyperpermeability on ICGA. PDT is not effective or the recurrence rate is predicted to be high in eyes without intense hyperfluorescence.

Primary Retinectomy in Proliferative Vitreoretinopathy

H. Stevie Tan, Marco Mura, Sarit Y. Lesnik Oberstein, Marc D. de Smet — 2010-03-01

Purpose: To describe the functional and anatomic results of retinectomy without scleral buckling for anterior proliferative vitreoretinopathy in eyes that did not undergo previous buckling surgery.Design: Retrospective, nonrandomized, interventional case series.Methods: We reviewed the results of 123 consecutive cases of retinectomy for rhegmatogenous retinal detachment complicated by anterior proliferative vitreoretinopathy. The primary outcome measure was anatomic success, defined as complete retinal reattachment. Secondary outcome measures were final anatomic success, final visual acuity outcome, number of operations required for retinal reattachment, baseline extent of proliferative vitreoretinopathy, ocular pressure at final follow-up, extent of retinectomy, and occurrence of complications.Results: The anatomic success rate was 77.2%. Final attachment rate was 95.9%, reached after 1 rhegmatogenous retinal detachment reoperation in 21 cases and after 2 rhegmatogenous retinal detachment reoperations in 4 cases. We had a low rate of postoperative hypotony (4.1%). Visual acuity was significantly improved from 2.10 to 1.44 logarithm of the minimal angle of resolution units (P < .001). Improvement was related significantly to retinectomy extent and primary anatomic success.Conclusions: Our results show that primary retinectomy without scleral buckling has good anatomic and functional results.

Long-term Follow-up of Full Macular Translocation for Choroidal Neovascularization

Yoshihisa Yamada, Noritake Miyamura, Kiyoshi Suzuma, Takashi Kitaoka — 2009-12-25

Purpose: To report the long-term (>5 years) results of full macular translocation in patients with choroidal neovascularization (CNV).Design: Retrospective, interventional case series.Methods: This study involved 32 eyes of 32 patients who had undergone full macular translocation for CNV. The median follow-up was 6.5 years (range, 5.2 to 7.7 years). We evaluated the best-corrected visual acuity, fundus examination results obtained before and 1 and 5 years after operation, and postoperative complications.Results: At the 1-year follow-up, foveal retinal pigment epithelium atrophy was observed in only 3 eyes (12%), and the mean logarithm of the minimal angle of resolution (logMAR) visual acuity (VA) at that time (1.39 ± 0.67) was not significantly changed from that before surgery (logMAR, 1.31 ± 0.66) in 25 eyes with age-related macular degeneration (AMD). However, at 5-year follow-up, foveal retinal pigment epithelium atrophy increased (18 eyes; 72%), and final mean logMAR VA (1.88 ± 0.76) was significantly lower (P < .01). Five eyes with myopic CNV maintained their VA from before operation (mean logMAR, 0.88 ± 0.35) until final follow-up (mean logMAR, 0.73 ± 0.31). The final VA was significantly better in myopic CNV than in exudative age-related macular degeneration on multiple regression analysis (P = .019).Conclusions: Long-term follow-up of full macular translocation showed that the final VA was poor in age-related macular degeneration, but relatively better in myopic CNV.

Choroidal Neovascularization in Pathologic Myopia: Intravitreal Ranibizumab Versus Bevacizumab—A Randomized Controlled Trial

2010-03-01

Purpose: To compare the short-term efficacy and safety of intravitreal ranibizumab versus bevacizumab in treating myopic choroidal neovascularization (CNV).Design: Prospective, comparative, randomized, interventional study.Methods: Thirty-two eyes from 32 patients with myopic CNV were consecutively enrolled and randomly treated, in a 1:1 ratio, with intravitreal ranibizumab (0.5 mg) or bevacizumab (1.25 mg) as needed, after the first injection. ETDRS best-corrected visual acuity (BCVA), foveal center thickness (FCT) on optical coherence tomography (OCT), and fluorescein angiographic findings were examined before and after treatment. Patients were followed up for 6 months.Results: No statistically significant difference in the BCVA improvement, as well as in the FCT reduction, was found between groups during follow-up (P value at 1, 3, 6 months > .05). Complete resolution of fluorescein leakage was observed in all 16 bevacizumab-treated eyes and in 15 out of 16 (93.7%) ranibizumab-treated eyes. No ocular or systemic adverse effects from treatment were encountered.Conclusion: This randomized clinical study cannot determine a statistically significant difference in anti-VEGF treatment effect between ranibizumab and bevacizumab for the treatment of CNV secondary to pathologic myopia. A larger study is required to determine the relative efficacy and duration of action of these drugs.

One-Year Results of Reduced-Fluence Photodynamic Therapy for Polypoidal Choroidal Vasculopathy

Ayana Yamashita, Fumio Shiraga, Chieko Shiragami, Aoi Ono, Kaori Tenkumo — 2009-12-30

Purpose: To report 1-year results of reduced-fluence photodynamic therapy (PDT) for polypoidal choroidal vasculopathy (PCV) in Japanese patients.Design: Prospective interventional case series.Methods: In the present study, 28 treatment-naïve eyes of 28 consecutive patients underwent PDT with a reduced laser fluence of 25 J/cm2. Patients were followed up at baseline and 1 week and 3, 6, 9, and 12 months after PDT. Choroidal perfusion changes were evaluated by indocyanine green angiography (ICGA) and leakage from PCV lesions and exudative changes by fluorescein angiography and optical coherence tomography. Treatment safety was assessed according to visual acuity (VA) and adverse events. The best-corrected VA (BCVA) obtained by Landolt ring tests was converted into the logarithm of the minimal angle of resolution (logMAR).Results: At baseline, the mean logMAR BCVA was 0.45 (geometric mean: 7/20). At 12 months, the mean logMAR BCVA significantly improved to 0.29 (geometric mean: 10/20) (P = 0.0001). The logMAR BCVA was stable or improved by ≥0.2 in 26 eyes (93%) at 1-year follow-up. In 10 eyes with VA better than 20/40 at baseline, the mean logMAR BCVA was significantly improved compared with baseline at 12 months. Although 16 of 28 eyes (57%) showed mild to moderate nonperfusion of choriocapillaris in early ICGA at 1 week, 27 eyes (96%) showed recovery to pretreatment levels at 3 months. Mean number of treatment sessions during the 12 months was 1.3. No severe side effects related to treatment were encountered.Conclusions: Reduced-fluence PDT is an effective treatment for PCV and could improve vision even in eyes with VA better than 20/40.

Comparison of Intravitreal Triamcinolone Acetonide With Photodynamic Therapy and Intravitreal Bevacizumab with Photodynamic Therapy for Retinal Angiomatous Proliferation

Masaaki Saito, Chieko Shiragami, Fumio Shiraga, Mariko Kano, Tomohiro Iida — 2010-01-05

Purpose: To compare the efficacy of combined therapy with intravitreal triamcinolone (IVTA) and photodynamic therapy (PDT; IVTA plus PDT) with intravitreal bevacizumab (IVB) and PDT (IVB plus PDT) for patients with retinal angiomatous proliferation (RAP).Design: Retrospective, observational case series.Methods: We retrospectively reviewed 25 treatment-naïve eyes of 22 Japanese patients (11 men, 11 women) with retinal angiomatous proliferation. Twelve eyes of 11 patients were treated with combined therapy of IVTA plus PDT from September 1, 2004, through July 31, 2006. Thirteen eyes of 11 patients were treated with combined therapy of IVB plus PDT from February 1, 2007, through January 31, 2008.Results: In 12 eyes treated with IVTA plus PDT, the mean best-corrected visual acuity (BCVA) levels at baseline and 12 months were 0.29 and 0.13, respectively. A significant (P < .05) decline in the mean BCVA from baseline was observed at 12 months. In 13 eyes treated with IVB plus PDT, the mean BCVA levels at baseline and 12 months were 0.25 and 0.37. A significant (P < .05) improvement in the mean BCVA from baseline was observed. At 12 months, the difference in BCVA between the 2 groups was significant (P < .05). The mean numbers of treatments at 12 months in the IVTA plus PDT group and the IVB plus PDT group were 2.7 and 1.6, respectively. The difference between the 2 treatments reached significance (P < .05). No complications developed.Conclusions: Compared with IVTA plus PDT, IVB plus PDT was significantly more effective in maintaining and improving visual acuity and in reducing the number of treatment for patients with retinal angiomatous proliferation.

Acute Endophthalmitis After Cataract Surgery: 250 Consecutive Cases Treated at a Tertiary Referral Center in the Netherlands

2010-01-05

Purpose: To evaluate the clinical characteristics, bacterial culture, and visual outcome of patients with acute endophthalmitis after cataract surgery.Design: Retrospective consecutive interventional case series.Methods: Clinical notes from patients treated for acute endophthalmitis after cataract surgery in a single center from 1996 to 2006 were reviewed. Patients with less than 1 month of follow-up and missing bacterial cultures were excluded. Vitreous biopsy or primary vitrectomy followed by intravitreal injection of vancomycin and ceftazidime (± prednisolone) was performed. Main outcome measures were bacterial culture and final visual acuity.Results: Bacterial cultures (total 250 cases) showed bacterial growth in 166 cases (66.4%). From these 166 cultures, 89 (53.6%) revealed gram-positive coagulase-negative, 63 (38.0%) other gram-positive, 10 (6.0%) gram-negative, and 4 (2.4%) polymicrobial cultures. Vitreous biopsy with intravitreal antibiotics injection was performed in 225 (90.0%) of cases. Primary vitrectomy with intravitreal antibiotics was performed in 25 eyes (10.0%). Final visual acuity ≥0.5 was achieved in 129 (51.6%) of all cases, 54 (60.7%) of the 89 gram-positive coagulase-negative cultures, 20 (31.7%) of the 63 other gram-positive cultures, 5 (50.0%) of the 10 gram-negative cultures, and 9 (45.0%) of the 20 Staphylococcus aureus cultures. There was no additional effect for treatment by primary vitrectomy or intravitreal prednisolone.Conclusions: Treatment outcome after endophthalmitis is highly dependent on the causative organism. Treatment outcomes for gram-negative bacteria and S. aureus may be better than previously reported. Prompt treatment of endophthalmitis remains essential and the role of complete primary vitrectomy remains subject to debate.

Pattern Electroretinogram and Psychophysical Tests of Visual Function for Discriminating Between Healthy and Glaucoma Eyes

2010-03-01

Purpose: To compare the diagnostic accuracy of the pattern electroretinogram (pattern ERG) to that of standard automated perimetry (SAP), short-wavelength automated perimetry (SWAP), and frequency-doubling technology (FDT) perimetry for discriminating between healthy and glaucomatous eyes.Design: Cross-sectional study.Methods: Eighty-three eyes of 42 healthy recruits and 92 eyes of 54 glaucoma patients (based on optic disc appearance) from the University of California, San Diego, Diagnostic Innovations in Glaucoma Study were tested with pattern ERG for glaucoma detection (PERGLA; Lace Elettronica, Pisa, Italy), SAP, SWAP, and FDT within 9 months. Receiver operating characteristic (ROC) curves were generated and compared for pattern ERG amplitude and SAP, SWAP, and FDT mean deviation and pattern standard deviation (PSD). Sensitivities and specificities were compared and agreement among tests was described.Results: The area under the ROC curve for pattern ERG amplitude was 0.744 (95% confidence interval = 0.670, 0.818). The ROC curve area was 0.786 (0.720, 0.853) for SAP PSD, 0.732 (0.659, 0.806) for SWAP PSD, and 0.818 (0.758, 0.879) for FDT PSD. At 95% specificity, sensitivities of SAP and FDT PSD were significantly higher than that of pattern ERG amplitude; at 80% specificity, similar sensitivities were observed among tests. Agreement among tests was slight to moderate.Conclusion: The diagnostic accuracy of the pattern ERG amplitude was similar to that of SAP and SWAP, but somewhat worse than that of FDT. Nevertheless, the pattern ERG may hold some advantage over psychophysical testing because of its largely objective nature.

Retinal Thickness Analysis by Race, Gender, and Age Using Stratus OCT

2009-12-30

Purpose: To detect differences in retinal thickness among patients of different race, gender, and age using Stratus OCT.Design: Cross-sectional study.Methods: In a multicenter, university-based study, 126 patients with no history of ocular disease were enrolled (78 diabetics without retinopathy and 48 nondiabetics). Optical coherence tomography measurements were performed using Stratus OCT. Statistical comparisons of center point foveal thickness and mean foveal thickness were made using generalized estimating equations adjusting for diabetic status, race, age, and gender.Results: The study population consisted of 36% male subjects, 39% Caucasian, 33% African-American, and 28% Hispanic. Mean foveal thickness was 191.6 ± 2.7 μm and 194.5 ± 2.7 μm for diabetics and nondiabetics, respectively (P = .49). Mean foveal thickness in male subjects was significantly larger than in female (201.8 ± 2.7 μm and 186.9 ± 2.6 μm, respectively; P < .001). Mean foveal thickness was 200.2 ± 2.7 μm for Caucasian, 181.0 ± 3.7 μm for African-American, and 194.7 ± 3.9 μm for Hispanic subjects. Mean foveal thickness was significantly less for African-American than Caucasian (P < .0001) or Hispanic subjects (P = .005). Center point foveal thickness and mean foveal thickness showed a significant increase with age.Conclusions: There are statistically significant differences in retinal thickness between subjects of different race, gender, and age. When compared to Caucasian and Hispanic subjects, African-American race is a predictor of decreased mean foveal thickness; and male sex (regardless of race) is a significant predictor of increased mean foveal thickness. Mean foveal thickness is similar among diabetics and nondiabetics when data are controlled for age, race, and sex. These results suggest that studies comparing OCT measurements should carefully control for age-based, race-based, and gender-based variations in retinal thickness.

The Development of Myopia Among Children With Intermittent Exotropia

Noha S. Ekdawi, Kevin J. Nusz, Nancy N. Diehl, Brian G. Mohney — 2010-03-01

Purpose: To describe the long-term refractive error changes in children diagnosed with intermittent exotropia (IXT) in a defined population.Design: Retrospective, population-based observational study.Methods: Using the resources of the Rochester Epidemiology Project, the medical records of all children (<19 years) diagnosed with IXT as residents of Olmsted County, Minnesota, from January 1, 1975 through December 31, 1994 were retrospectively reviewed for any change in refractive error over time.Results: One hundred eighty-four children were diagnosed with IXT during the 20-year study period; 135 (73.4%) had 2 or more refractions separated by a mean of 10 years (range, 1–27 years). The Kaplan-Meier rate of developing myopia in this population was 7.4% by 5 years of age, 46.5% by 10 years, and 91.1% by 20 years. There were 106 patients with 2 or more refractions separated by at least 1 year through 21 years of age, of which 43 underwent surgery and 63 were observed. The annual overall progression was −0.26 diopters (SD ± 0.24) without a statistically significant difference between the observed and surgical groups (P = .59).Conclusion: In this population-based study of children with intermittent exotropia, myopia was calculated to occur in more than 90% of patients by 20 years of age. Observation versus surgical correction did not alter the refractive outcome.

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

Eriko Uchiyama, Toshihiko Matsuo, Sayuri Imai, Emi Itoshima — 2009-12-30

Purpose: To search for a new definition of muscle hypoplasia in congenital or idiopathic superior oblique muscle palsy.Design: Retrospective case-control study.Methods: Cross-sectional areas of the superior oblique and 4 rectus muscles near the eye globe–optic nerve junction were measured by an image analysis software on magnetic resonance images of 50 patients with congenital or idiopathic superior oblique muscle palsy and 45 patients with other disease conditions serving as a control. The paretic side/contralateral normal side ratios of the cross-sectional areas and the left side/right side ratios were calculated for the superior oblique muscle palsy patients and the control patients, respectively.Results: The 95% confidence intervals in paretic side/contralateral side ratios of cross-sectional areas of the superior oblique muscle were 0.55 to 0.80 in the right-side superior oblique muscle palsy, and 0.48 to 0.75 in the left-side palsy, while the 95% confidence interval in the left side/right side ratios was 0.99 to 1.00 in the control. The 95% confidence intervals in the left side/right side ratios of the 4 rectus muscles were 1.00, both in the superior oblique muscle palsy and in the control.Conclusions: The muscle hypoplasia could be defined as such when the paretic side/contralateral side ratios of cross-sectional areas of the superior oblique muscle on magnetic resonance images fell outside the 95% confidence interval of the ratios in normal controls.

Protective Effect of Paraoxonase 1 Gene Variant Gln192Arg in Age-Related Macular Degeneration

2009-12-30

Purpose: Age-related macular degeneration (AMD) is the leading cause of blindness among older adults, in which oxidative damage may play a pivotal role. Paraoxonase 1 (PON1) protects against oxidative damage and has been evaluated for its involvement in aging diseases including AMD. This study investigated whether PON1 gene polymorphisms associate with AMD.Design: Case-control association study.Methods: We studied 1037 individuals with AMD subcategorized using AREDS criteria and 370 control subjects without retinal disease. Participants were primarily Caucasian of European descent. All exons of PON1 were evaluated by single-strand conformation polymorphism and direct sequence analysis.Results: Six missense changes (Leu55Met, Met127Arg, His155Arg, Gln192Arg, Gln192Glu, Ala252Gly) were identified in PON1. We observed a weak association of Leu55Met with an increased risk of wet AMD (P = .02), but not with dry AMD or when combining all patient categories. A significantly higher allele frequency for Gln192Arg was detected in controls than in the combined AMD patient population (P < .0001), and when category 2, 3, and 4 patients were separately considered (P = .004, P = .002, and P < .0001, respectively). For category 4 AMD, the Arg192 allele was significantly less prevalent in the wet form (P < .0001), but not in the dry form (P = .377).Conclusion: We report a weak association of PON1 Leu55Met with an increased risk of wet AMD, replicating previous reports. Our findings indicate a protective role for Gln192Arg, particularly for patients with the wet form. Gln192Glu warrants consideration, as this variant alters the same amino acid as Gln192Arg and was identified only in category 4 AMD patients. We believe that Met127Arg, His155Arg, and Ala252Gly play minor roles in AMD susceptibility because of their limited frequency and/or location within the PON1 gene. The functional and biological mechanism by which Gln192Arg is acting to decrease AMD susceptibility remains to be determined.

Testability of Vision and Refraction in Preschoolers

Amy Pai, Chameen Samarawickrama, George Burlutsky, Jody Leone, Paul Mitchell — 2010-03-01

Trager and associates recently reported interesting findings from the Strabismus, Amblyopia and Refractive Error Study (STARS) on the testability of vision and refraction in a Singaporean sample of Chinese preschool children, aged 6 to 72 months. The authors correctly indicated that there was a paucity of studies in the literature on the testability of different vision screening modalities in preschool children internationally, and that most publications were based on relatively small sample sizes. This makes it difficult to evaluate the sensitivity, the specificity, and the practical values of some vision testing methods in preschool populations.

Reply

2010-03-01

We thank Dr Pai and associates for their helpful insights regarding testability of visual function tests in preschool-aged children. The Sydney Pediatric Eye Disease Study (SPEDS) corroborates with the testability results from our Strabismus, Amblyopia, and Refractive Error Study (STARS) in many respects, with a few notable small differences. For example, the Singaporean cohort had better logMAR visual acuity (VA) and IOL Master testabilities than the Sydney cohort. In contrast, children in Sydney had better Randot stereoacuity testability than Singaporean children. We agree that these differences can be explained by variability in examiners between the 2 study centers as well as differences in testing protocols and population characteristics. When children in the SPEDS used the electronic visual acuity (EVA) instrument, testabilities were very similar to the STARS logMAR chart. The EVA tester was also utilized in the Multi-Ethnic Pediatric Eye Disease Study (MEPEDS), again leading to similar visual acuity testabilities to that of Singapore, substantiating the Sydney results. Furthermore, the fact that the SPEDS found no differences in testability between Caucasians and East Asians and the MEPEDS found no difference in testability between African Americans and Hispanics supports the lack of a substantial influence of ethnic differences on variability in testability.

Recovery of Corneal Hysteresis After Reduction of Intraocular Pressure in Chronic Primary Angle-Closure Glaucoma

Ali Poostchi, Simon Nicholas, Anthony P. Wells — 2010-03-01

We read with interest the paper by Sun and associates, which corroborates prior reports of rises in corneal hysteresis following reductions in intraocular pressure (IOP), but were surprised that they did not consider that the association they found could be related to their method of measurement.

Reply

Lei Sun, Meixiao Shen, Jianhua Wang, Aiwu Fang, Aiqin Xu, Haizhen Fang, Fan Lu — 2010-03-01

In this letter, we reply to the issues presented by Dr Ali Poostchi and associates in their correspondence to the Editor regarding our article. We thank Dr Poostchi and his associates for sharing their findings on the associations between the corneal hysteresis and intraocular pressure. We are in agreement with their explanations that the associations may be related to the measurement of the ocular response analyzer (ORA), which was not considered in our article. We hope this exchange will stimulate further research.

Outcome of Raised Intraocular Pressure in Uveitic Eyes With and Without a Corticosteroid-Induced Hypertensive Response

Nazneen Nazm, Suneeta Dubey, Monica Gandhi, Julie Pegu — 2010-03-01

We read with great interest the recently published article “Outcome of raised intraocular pressure in uveitic eyes with and without a corticosteroid-induced hypertensive response” by Sallam and associates. We would like to highlight the following points.

Reply

Ahmed Sallam, Susan Lightman — 2010-03-01

We appreciate the comments by Dr Nazm and associates about our article, which looked at the outcome of raised intraocular pressure in uveitic eyes with and without a corticosteroid-induced hypertensive response.

Increased Likelihood of Glaucoma at the Same Intraocular Pressure in Subjects With Pseudoexfoliation

Miguel A. Teus — 2010-03-01

We read, with great interest, the paper by Topouzis and associates. The authors should be congratulated for their work, because population-based studies are needed to provide accurate information about the prevalence of any disease in the general population. In this sense, the conclusions the authors reach about the prevalence of pseudoexfoliation (PEX), pseudoexfoliative glaucoma (PEXG), and primary open-angle glaucoma (POAG) in the Greek population are sound. Nevertheless, Topouzis and associates also analyze the influence of IOP in the development of glaucoma. For this kind of analysis, it is mandatory to evaluate the untreated IOP of the population studied. In fact, this is what the authors do, but as the prevalence of both PEXG and POAG in the general population is relatively low, and because some of their patients were already under therapy, the number of untreated PEXG eyes they analyzed was low (17 eyes).

Reply

2010-03-01

We would like to thank Dr Teus for his interest in and comments on our article, entitled “Increased likelihood of glaucoma at the same screening intraocular pressure in subjects with pseudoexfoliation: the Thessaloniki Eye Study.” We agree with Dr Teus that population-based data on pseudoexfoliation (PEX) and pseudoexfoliative glaucoma (PEXG) are limited and therefore needed. In our opinion, the considerably high prevalence of PEX and PEXG found in the Thessaloniki Eye Study (TES) provides a dataset suitable for comparison of clinical characteristics between primary open-angle glaucoma (POAG) and PEXG. In the present manuscript we reported that for intraocular pressure (IOP) level > 20 mm Hg, the proportion with glaucoma increased highly in subjects both with and without PEX, while it was much higher among those with PEX at the same screening IOP. This may be attributable to the reported higher IOP fluctuations in eyes with PEX or to greater susceptibility to high IOP in the optic nerves of eyes with PEX.

Stratus OCT Signal Strength and Reliability of Retinal Nerve Fiber Layer Measurements

Ying Liu, Chameen Samarawickrama, Amy Pai, Yasser Tariq, Paul Mitchell — 2010-03-01

The recent article by Vizzeri and associates makes an interesting contribution to the emerging literature examining the roles of signal strength and scan misalignment on the reliability of retinal nerve fibre layer (RNFL) measurements using optical coherence tomography (OCT). In this retrospective study, the authors assessed the relationship between signal strength and RNFL measurements by comparing repeat and baseline Stratus OCT (Carl Zeiss Meditec, Dublin, California, USA) scans. Influences from vertical and horizontal scan alignment on RNFL measurements also was assessed. The authors reported a larger variation in RNFL measurements between scans at different visits than on repeat scans at the same visit, and also reported significant differences (from baseline) in quadrant-specific RNFL measurements with signal strength. A positive association between signal strength and average RNFL measurements at signal strength 7 or more was noted. Also, signal strength influenced the nasal minus temporal RNFL quadrant measurements but not superior minus inferior RNFL quadrant measurements, suggesting that RNFL measurement variability was associated more strongly with horizontal than with vertical misalignment.

Reply

2010-03-01

Imaging instruments are a powerful tool to assist clinicians in the diagnosis and management of glaucoma. However, image quality is an important variance component that can affect the outcomes of any imaging device, including Stratus OCT (Carl Zeiss Meditec, Dublin, California, USA). Based on our findings and the findings from other groups, signal strength can influence measurements' accuracy and reliability. Therefore, scan quality should always be assessed before interpreting Stratus OCT results for clinical management decisions.

Angle-Closure Glaucoma—Simpler Answers to Complex Mechanisms

Seshubabu Gosala — 2010-03-01

The article “Angle-closure glaucoma–Simpler answers to complex mechanisms: LXVI Edward Jackson Memorial Lecture” by Harry A Quigley introduces a new concept of dynamic physiological features precipitating acute angle closure in susceptible individuals with static anatomic factors. This answers many issues related to the pathogenesis of glaucoma in general and angle-closure glaucoma in particular.

Reply

Harry A. Quigley — 2010-03-01

I thank Dr Gosala for his letter. He first suggests that differences in iris stroma between angle-closure and other eyes might be an effect of acute high intraocular pressure (IOP) leading to “damage to the stroma” rather than a pre-existing risk factor. This is not compatible with our findings, since most of the angle-closure eyes in which we found lower iris volume loss with pupil dilation had never had an acute attack. The general level of IOP in the angle-closure eyes was similar to the open-angle glaucoma eyes in our studies—including adjustment for other features such as medical eyedrop treatment, length of disease, and surgery. To show that the feature of lower iris volume loss is truly predictive (hence, “causative”), we and others are carrying out prospective studies of angle-closure suspects.

Spontaneous Corneal Clearance Despite Graft Detachment in Descemet Membrane Endothelial Keratoplasty

Swee Ying Choo, Aida Zairani Mohd Zahidin, Kong Yong Then — 2010-03-01

We read with interest the article by Balachandran and associates reporting on 2 cases of spontaneous corneal clearance despite graft detachment in Descemet membrane endothelial keratoplasty. In our experience, we also had a case whereby an 86-year-old man with cataract and a distant uncorrected visual acuity (UCVA) of 6/60 in his right eye underwent extracapsular cataract extraction (ECCE) in June 2008. During the procedure, the surgeon accidentally removed almost the entire central Descemet membrane, leaving a 2-mm peripheral rim of Descemet membrane. Postoperatively, there was diffuse stromal edema with hand-movement vision. We managed him conservatively in view of the fact that his general health and age did not allow him to undergo further operation under general anesthesia.

Reporting Visual Acuities

2010-03-01

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

Petros E. Carvounis — 2010-03-01

Media Type: Textbook Synopsis: This book is an exquisitely well-written review of the pathogenesis, epidemiology, and natural history of retinal detachment, as well as the principles of retinal detachment repair. The authors offer a carefully considered synopsis of the literature enriched with pearls from their vast clinical and surgical experience. Particularly impressive is the concise, rational and impartial discussion of the several vantage points on methods of retinal detachment repair. Ophthalmology trainees and practicing ophthalmologists alike will enjoy and treasure this textbook.

Monique A. Anawis — 2010-03-01

Media Type: Textbook Target Audience: Ophthalmology Residents, Attending Ophthalmologists, and Emergency Room Physicians

Jane C. Edmond — 2010-03-01

Media Type: Textbook Target Audience: Neuro-ophthalmologist

Scientific Referees 2009

2010-03-01

The Editorial Board of the american journal of ophthalmology gratefully acknowledges the contributions of these scientific reviewers to the integrity, accuracy, and quality of the journal. These reviewers generously contributed their knowledge, expertise, and time to review and evaluate the suitability of manuscripts for publication in the journal during the year 2009.

2010-03-01

American Journal of Ophthalmology

Peer Review Should Continue After Publication

Central Serous Chorioretinopathy: A Personal Perspective

Current Research in Biostatistics

Study Designs in Epidemiology and Levels of Evidence

Posterior Vitreous Detachment: Evolution and Complications of Its Early Stages

Wavefront Analysis, Contrast Sensitivity, and Depth of Focus After Cataract Surgery With Aspherical Intraocular Lens Implantation

Complications and Clinical Outcomes of Descemet Stripping Automated Endothelial Keratoplasty With Intraocular Lens Exchange

Non-Syndromic Supernumerary Caruncles Causing Ocular Irritation After Cataract Surgery: A Critical Review of Caruncular Dysgeneses

A Simplified Quantitative Method for Assessing Keratoconjunctivitis Sicca From the Sjögren's Syndrome International Registry

Quality of Life in Keratoconus Patients After Penetrating Keratoplasty

Mycophenolate Mofetil for Ocular Inflammation

Viral Retinitis After Intravitreal Triamcinolone Injection in Patients With Predisposing Medical Comorbidities

Association Between the Efficacy of Photodynamic Therapy and Indocyanine Green Angiography Findings for Central Serous Chorioretinopathy

Primary Retinectomy in Proliferative Vitreoretinopathy

Long-term Follow-up of Full Macular Translocation for Choroidal Neovascularization

Choroidal Neovascularization in Pathologic Myopia: Intravitreal Ranibizumab Versus Bevacizumab—A Randomized Controlled Trial

One-Year Results of Reduced-Fluence Photodynamic Therapy for Polypoidal Choroidal Vasculopathy

Comparison of Intravitreal Triamcinolone Acetonide With Photodynamic Therapy and Intravitreal Bevacizumab with Photodynamic Therapy for Retinal Angiomatous Proliferation

Acute Endophthalmitis After Cataract Surgery: 250 Consecutive Cases Treated at a Tertiary Referral Center in the Netherlands

Pattern Electroretinogram and Psychophysical Tests of Visual Function for Discriminating Between Healthy and Glaucoma Eyes

Retinal Thickness Analysis by Race, Gender, and Age Using Stratus OCT

The Development of Myopia Among Children With Intermittent Exotropia

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

Protective Effect of Paraoxonase 1 Gene Variant Gln192Arg in Age-Related Macular Degeneration

Testability of Vision and Refraction in Preschoolers

Reply

Recovery of Corneal Hysteresis After Reduction of Intraocular Pressure in Chronic Primary Angle-Closure Glaucoma

Reply

Outcome of Raised Intraocular Pressure in Uveitic Eyes With and Without a Corticosteroid-Induced Hypertensive Response

Reply

Increased Likelihood of Glaucoma at the Same Intraocular Pressure in Subjects With Pseudoexfoliation

Reply

Stratus OCT Signal Strength and Reliability of Retinal Nerve Fiber Layer Measurements

Reply

Angle-Closure Glaucoma—Simpler Answers to Complex Mechanisms

Reply

Spontaneous Corneal Clearance Despite Graft Detachment in Descemet Membrane Endothelial Keratoplasty

Reporting Visual Acuities

Scientific Referees 2009

Contents