This Issue At A Glance

Article Outline

• Confocal Microscopy in Diagnosis of Meibomian Gland Dysfunction
• Rapid Visual Recovery with Boston Type I Keratoprosthesis for Corneal Disease
• Dyslipidemia in Diabetic Macular Edema
• Newer Treatment Strategies Don't Affect Outcome in Acute Retinal Necrosis
• Floppy Eyelid Syndrome Associated with Obstructive Sleep Apnea, Keratoconus

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Confocal Microscopy in Diagnosis of Meibomian Gland Dysfunction 

Ibrahim et al (p. 665) have found that confocal microscopy (CM) has the potential to diagnose meibomian gland dysfunction (MGD) with high sensitivity and specificity. The researchers conducted a prospective, controlled, single-center study involving 20 MGD patients and 26 age- and sex-matched control participants, evaluating a variety of CM parameters in the diagnosis of MGD. These included meibomian gland (MG) acinar longest diameter (MGALD), MG acinar shortest diameter (MGASD), inflammatory cell density (ICD) and MG acinar unit density (MGAUD). Results showed that with the CM parameters, the mean values of the MGALD, MGASD, ICD, and MGAUD in MGD patients were significantly worse than those in the controls. All CM parameters demonstrated significant correlation with tear functions, ocular surface vital stainings, MG expressibility, and MG dropout grades. The authors concluded that the CM-based diagnostic parameters correlated strongly with the status of the MGD and asserted that the study's cut-off parameters should prove valuable in helping clinicians diagnose this common ocular surface disease.

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Rapid Visual Recovery with Boston Type I Keratoprosthesis for Corneal Disease 

The Boston Type I keratoprosthesis device is an alternative for patients with corneal disease who have experienced multiple corneal graft failures due to immunologic rejection and other factors. In a retrospective, multicenter case series involving 122 patients (126 eyes) with corneal diseases who were not eligible to receive donor corneal transplants, Dunlap et al (p. 687) found that the Boston keratoprosthesis appears to provide rapid visual recovery with excellent uncorrected acuity after surgery. Results showed that 104 patients (82.5%) experienced improved vision within 6 months after surgery. About a quarter of the patients in this study (31 eyes of 126) achieved their best-corrected vision within 1 week of surgery. The vast majority of the study patients achieved a plano refractive error within 3 months postoperatively, and residual astigmatism was almost nonexistent. Although penetrating keratoplasty (PK) remains the surgery of choice for patients undergoing their first corneal surgeries, the researchers call for studies comparing PK with Boston keratoprothesis in eyes with a history of graft failure.

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Dyslipidemia in Diabetic Macular Edema 

Previously, the Early Treatment Diabetic Retinopathy Study clinically classified diabetic macular edema into 2 forms according to its prognostic value: clinically significant macular edema (CSME) and nonclinically significant macular edema (non-CSME). In this current population-based cross-sectional study in India involving 1414 participants, Raman et al (p. 766) addresses the influence of dyslipidemia on CSME vs. non-CSME–discovering different metabolic profiles in the 2 groups. Among those who showed evidence of diabetic retinopathy (255/1414), the prevalence of overall diabetic macular edema was 31.76%, with 25.49% showing non-CSME and 6.27% showing CSME. Three variables were associated with CSME: total serum cholesterol, glycosylated Hb of more than 8, and the presence of microalbuminuria. In contrast, serum low-density lipoprotein cholesterol, serum non–high-density lipoprotein cholesterol and cholesterol ratio were associated with non-CSME. The researchers call for further exploration of the role of different subclasses of lipoproteins in non-CSME and CSME, which may help identify the appropriate time to start lipid-lowering drugs in diabetic macular edema.

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Newer Treatment Strategies Don't Affect Outcome in Acute Retinal Necrosis 

Since the 1980s, the standard of care for acute retinal necrosis (ARN) has involved induction therapy with intravenous acyclovir (500 mg/m² 3 times per day) for 7–10 days followed by oral antiviral medications for 14 weeks. Over the past decade, newer intravitreal and oral antiviral alternatives have been introduced to treat this rare condition. Do these more recent therapies affect outcomes? According to a nonrandomized, retrospective series by Tibbetts et al (p. 818), there are no apparent differences in outcome between the newer antiviral era and the acyclovir-only era. In this study, 58 patients with ARN treated at 4 centers were divided into 2 subgroups: 36 patients treated with acyclovir only and 22 treated with newer antiviral medications. The investigators found a wide range of treatments with no single treatment strategy considered the standard of care. Visual outcomes in these patients were generally poor. The authors conclude that identifying more subtle differences in the outcomes of these treatment strategies will require a larger cohort or meta-analysis.

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Floppy Eyelid Syndrome Associated with Obstructive Sleep Apnea, Keratoconus 

First described in 1981, floppy eye syndrome (FES) is characterized by very elastic upper lids that become easily distorted and everted with minimal lateral traction. In a case-control study, Ezra et al (p. 839) have found that FES appears to be strongly associated with obstructive sleep apnea-hypopnea syndrome (OSAHS) and keratoconus. The study involved 102 FES patients and a control group of patients from a diabetic retinopathy clinic who were matched 1:1 in terms of age, body mass index (BMI), and sex. Not only did they find significant associations between FES and OSAHS and keratoconus, but between lash ptosis, dermatochalasis, upper lid medial canthal laxity, upper lid distraction, palpebral aperture, and levator function as well. In addition, while FES was more common in obese males in their 6th decade, the condition affected patients with a significant range of ages, BMI, and sex. The authors urge clinicians to keep in mind this strong association between FES and OSAHS and keratoconus when determining course of treatment.