Ophthalmology

Editorial Board

2012-02-01

This Issue at a Glance

Lori Baker Schena, John Kerrison — 2012-02-01

In vivo confocal microscopy (IVCM) has yielded insight into the morphologic diversity of the transparent cornea in the aging eye. Hillenaar et al (p. 241) identified 4 characteristic manifestations of normal corneal aging: stromal microdots, folds in the posterior stroma, opacification of Descemet's membrane, and corneal guttae. The observational cross-sectional study involved 300 corneas of 75 healthy men and 75 healthy women. In addition to the 4 characteristic manifestations of the aging cornea, the authors identified some features that were age-independent, including bright superficial epithelial cells, dendriform cells, and tortuous stromal nerves. The authors also found a novel corneal endothelium phenotype in 4 normal eyes of 2 participants, which they named “salt and pepper endothelium,” but could not determine if this was a morphologic variant of normal endothelium or a new condition. The authors maintain that understanding the effects of aging on corneal morphology is key when attempting to distinguish between the effects of normal aging and degenerative disorders in the cornea.

A Simple Vista en Este Número

Lori Baker Schena, John Kerrison — 2012-02-01

La microscopía confocal in vivo (IVCM) ha aclarado aún más la comprensión de la diversidad morfológica de la córnea transparente con el proceso de envejecimiento. Hillenaar y otros (p. 241) identificaron 4 manifestaciones características del envejecimiento normal de la córnea: micropuntos estromales, pliegues en el estroma posterior, opacificación de la membrana de Descemet y córnea gutatta. Este estudio de observación de corte transversal incluyó 300 córneas de 75 hombres y 75 mujeres sanos. Además de las 4 manifestaciones características de la córnea en el proceso de envejecimiento, los autores identificaron otras manifestaciones independientes de la edad, que incluyen células epiteliales superficiales brillantes, células dendriformes y nervios estromales tortuosos. Además, los autores encontraron un nuevo fenotipo de endotelio corneal en 4 ojos normales de 2 participantes, a los que dieron el nombre de “endotelio de sal y pimienta,” aunque no pudieron determinar si se trataba de una variante morfológica del endotelio normal o de una nueva condición. Los autores sostienen que la comprensión de los efectos del envejecimiento en la morfología de la córnea es clave cuando se trata de diferenciar entre los efectos del envejecimiento normal y los trastornos degenerativos de la córnea.

This Issue At A Glance

由Lori Baker Schena, 并且John Kerrison — 2012-02-01

活体共焦显微镜 (IVCM) 有助于我们了解翿年人透明角膜的形态多样性. Hillenaar et al (p. 241) 等确认正常角膜翿年性特征性改变: 基质微粒, 后基质皱褶, Descemet 膜混浊和角膜小滴. 这项横断面观察研究包括 75 例健康男性和 75 例健康女性的 300 只眼. 此外, 作者还发现了一些和年龄不相关的特征, 包括表层上皮发亮, 树枝状细胞和基质神经纤维弯曲. 在 2 例正常人 (4 只眼) 中, 作者发现一种新的角膜内皮表型, 他们称之为“椒盐样内皮”, 但目前还不能确定这是正常角膜内皮的形态学变异还是一种病理情况. 作者认为, 理解角膜形态学翿年性改变是鉴别角膜生理性翿化和退行性疾病的关键.

2012-02-01

Ergonomics: Back to the Future

Jeffrey L. Marx — 2012-02-01

The frequency of musculoskeletal disorders (MSD) has been reported in the ophthalmic literature over the last decade. Based upon different criteria, survey instruments, and populations studied, the prevalence of MSD symptoms in ophthalmologists varies. Kitzmann et al report the first study that compares MSD symptoms in ophthalmologists to family medicine doctors at 2 institutions using the same survey instrument. Ophthalmologists reported a statistically significant increased prevalence of neck, hand/wrist, and lower back pain in comparison to their family medicine doctor colleagues. Although the number of ophthalmologists surveyed was relatively low, and findings in practice settings as opposed to these 2 academic institutions may differ, the rates of symptoms among ophthalmologists were comparable to a survey done almost a decade ago in a larger cohort of subjects.

Erratum

2012-02-01

With apologies from the authors of “Randomized Comparison of Systemic Anti-inflammatory Therapy Versus Fluocinolone Acetonide Implant for Intermediate, Posterior, and Panuveitis: The Multicenter Uveitis Steroid Treatment Trial” (Ophthalmology 2011;118:1916-26), the paragraph on visual function (p.1919) stating “(median mean deviation = −5.7 vs −3.8 dB, respectively)” should be corrected to read “(median mean deviation −5.7 vs −4.8 dB, respectively).” An updated (online only figure) which relays the information noted above, has been posted online.

Erratum

2012-02-01

With apologies from the publisher, in the Letter to the Editor entitled, “Transmittance Curve of an IOL” (Ophthalmology 2011;118:2309), the authors' names should have appeared as follows: Christophe Pagnoulle, PhD, Dimitriya Bozukova, PhD, Laure Gobin, PhD.

A Survey Study of Musculoskeletal Disorders Among Eye Care Physicians Compared with Family Medicine Physicians

2011-09-19

Purpose: To evaluate the prevalence of musculoskeletal disorders among eye care physicians compared with family medicine physicians. Design: Case control study. Participants and Controls: Ophthalmologists and optometrists at the University of Iowa and Mayo Clinic (participants) and family medicine physicians at the University of Iowa and Mayo Clinic (controls). Methods: An electronic survey was e-mailed to all subjects. Main Outcome Measures: The prevalence of musculoskeletal symptoms between eye care providers and family medicine physicians (control group). Results: One hundred eight-six surveys were completed by 94 eye care physicians and 92 family medicine physicians with a response rate of 99% and 80%, respectively. There were no significant differences between the 2 groups with regard to mean age, gender, body mass index, years with current employer, or years in practice. Eye care providers, compared with their family medicine colleagues, reported a higher prevalence of neck (46% vs 21%; P<0.01), hand/wrist pain (17% vs 7%; P = 0.03), and lower back pain (26% vs 9%; P<0.01). A greater proportion of eye care physicians classified their job as a high-strain job (high demand, low control; 31% vs 20%) and a lower proportion classified their job as an active job (high demand, high control; 24% vs 47%; p = 0.01). Several job factors reported by eye care providers to contribute to musculoskeletal symptoms included performing the same task repeatedly, working in awkward/cramped positions, working in the same position for long periods, and bending/twisting the back (all P<0.01). Conclusions: In this survey, the study group, composed of ophthalmologists and optometrists, had a higher prevalence of neck, hand/wrist, and lower back pain compared with family medicine physicians; repetitive tasks, prolonged or awkward/cramped positions, and bending/twisting were contributory factors. Given the ramifications of these findings, future efforts should concentrate on modifications to the eye care providers' work environment to prevent or alleviate musculoskeletal disorders and their personal and socioeconomic burden. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Burden and Depression in the Caregivers of Blind Patients in India

Puneet S. Braich, Vikram Lal, Simon Hollands, David R. Almeida — 2011-10-31

Purpose: Several studies have examined the rates of depression in caregivers of patients with debilitating neurologic diseases. This study describes the degree of burden and the prevalence of depression among individuals caring for legally blind patients. To the best of our knowledge, no prior studies in the ophthalmic literature have reported this relationship. Design: Clinic-based, cross-sectional study. Participants: We included 522 individuals in Rampur, India, providing care to their close family relatives who were legally blind. Visual acuities varied from 20/200 in the best eye, to no light perception (NLP) in each eye. Methods: Several surveys were completed by the caregivers of patients whose sole impairment was visual, allowing us to quantitatively and selectively assess burden and depression among caregivers of blind patients. Main Outcome Measures: The Burden Index of Caregivers (BIC) was used to measure care burden and the Center for Epidemiologic Studies Depression scale was applied to determine depression. Results: Caregivers of patients with NLP experience higher burden than caregivers of patients with lesser degrees of blindness. Daily hours spent on close supervision and the intensity of care-giving were the definitive factors linked to high BIC scores (P<0.01). The prevalence of caregiver depression increased with degree of visual impairment from 16% in the 20/200 group to 48% in the NLP cohort (P<0.01). Independently related variables for depression in caregivers were daily hours required for close supervision of the patient, intensity of care-giving, low household income, and the caregiver being the parent of a blind adult child (P<0.01). Conclusions: Severity of blindness in patients directly correlated with burden in caregivers. More severe forms of blindness meant patients require more help with their activities of daily living and additional hours of close supervision per day, both of which increase care burden. The same 2 factors also increase risk of caregiver depression along with low household income and the caregiver being the parent of a blind adult child. Awareness of the extent of burden and depression among caregivers of blind individuals is required by vision health personnel to identify at risk caregivers and implement effective interventions and support strategies. Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Randomized Trial of Pterygium Surgery with Mitomycin C Application Using Conjunctival Autograft versus Conjunctival-Limbal Autograft

2011-12-07

Purpose: To compare the outcomes of free conjunctival autograft (CAU) versus conjunctival–limbal autograft (CLAU) in the prevention of recurrence after pterygium surgery with adjunctive mitomycin C application in patients with primary or recurrent pterygia. Design: Prospective, randomized study. Participants and Controls: Eighty-seven eyes of 86 patients with primary or recurrent nasal pterygia were included. Methods: All eyes underwent pterygium excision followed by removal of subconjunctival fibrovascular tissue and application of 0.02% mitomycin C for 3 minutes. The eyes then were assigned randomly to receive either CAU (44 eyes) or CLAU (43 eyes). Main Outcome Measures: Rate of conjunctival or corneal recurrence of pterygium after surgery. Results: A follow-up of at least 12 months (mean, 14±2.2 months) was achieved in 78 eyes of 78 patients, including 39 eyes in the CAU group (31 primary and 8 recurrent pterygia) and 39 eyes in the CLAU group (33 primary and 6 recurrent pterygia). After surgery, no eye in the CLAU group developed pterygium recurrence; however, recurrence was seen in 2 eyes (5.1%) in the CAU group, including 1 of 31 patients (3.2%) with primary pterygia and 1 of 8 patients (12.5%) with recurrent pterygia. There was no statistically significant difference in recurrence rates between the 2 groups or in the primary and recurrent subgroups. In the CLAU group, a localized pannus formation at the donor site of the limbal graft was noted in 5 eyes (12.8%), with the appearance of pseudopterygium in 1 eye. Conclusions: There was no significant difference in recurrence rates of pterygium after surgery with mitomycin C application between the CAU and CLAU groups, more remarkably in primary cases. Limbal damage was seen in some eyes with CLAU. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Squamous Carcinoma and Dysplasia of the Conjunctiva and Cornea: An Analysis of 101 Cases

Yacoub A. Yousef, Paul T. Finger — 2011-12-21

Objective: To evaluate clinical and histopathologic factors of squamous conjunctival neoplasia associated with recurrence. Design: Retrospective, clinical case series. Participants: One hundred one eyes of 99 patients with squamous conjunctival dysplasia, carcinoma in situ, or squamous cell carcinoma. Methods: Review of the medical records, pathology reports, and color photographs. Main Outcome Measures: Demographic information, laterality, tumor size, extension, pathologic diagnosis, seventh edition of the American Joint Committee on Cancer Classification (AJCC) staging system stage, treatment methods, recurrence, and duration of follow-up. Results: Malignant squamous conjunctival neoplasia was seen most commonly in males at a median age of 71 years. Recurrences were seen in 12.9% (n = 13/101), with 92.3% occurring 6 to 12 months after primary treatment. Recurrence was not correlated significantly to age, gender, laterality, clinical appearance or focality of the tumor at presentation. However, tumors larger than 5 mm in diameter, tumors extending more than 2 mm onto the cornea, and tumors with local invasion (corneal, scleral, intraocular or orbital invasion) were associated with a higher risk of recurrence. Increasing AJCC T-stage was correlated strongly to the incidence of recurrence (P = 0.0006). Rates were 1.7% for Tis-staged tumors, 0% for T1- and T2-staged tumors, 34.3% for T3-staged tumors, and 50% for T4-staged tumors. Histopathologic diagnosis was correlated to recurrence (P = 0.037). None of the tumors defined histologically as dysplasia showed recurrence, whereas 12.8% of carcinoma in situ tumors and 22.2% of squamous cell carcinoma tumors recurred. Although the overall recurrence rate was 12.9%, the rate for tumors treated primarily at the authors' center was 4%, significantly less than the recurrence rate in previously operated tumors (P = 0.0003). Lymph nodes demonstrated positive results in 1%, and in no patient did distant metastasis develop. Conclusions: Advanced AJCC T-stage, locally invasive tumors, and more pathologically aggressive tumors were at higher risk for recurrence. Inadequate initial therapy also was an important risk factor for recurrence. Treatment strategies should be affected by tumor staging at presentation. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

How Normal Is the Transparent Cornea? Effects of Aging on Corneal Morphology

Toine Hillenaar, Hugo van Cleynenbreugel, Lies Remeijer — 2011-10-31

Purpose: To ascertain the effects of aging on corneal morphology and to illustrate the morphologic diversity of the different layers in the normal cornea as seen by in vivo confocal microscopy (IVCM). Design: Observational cross-sectional study. Participants: A total of 150 healthy subjects, evenly distributed over 5 age categories, comprising 75 men and 75 women. Methods: Both transparent corneas (n = 300) of all subjects were examined in duplicate by white light IVCM (Confoscan 4, NIDEK Technologies, Albignasego, Padova, Italy). After reviewing the IVCM examinations for morphologic variations of the corneal layers, we selected the 8 most common features to illustrate the morphologic diversity. Subsequently, all 600 IVCM examinations were assessed for the presence of these features. We used binary logistic regression analyses to assess the age-relatedness of each feature. Main Outcome Measures: Age distribution of bright superficial epithelial cells, dendriform cells, alterations characteristic of epithelial basement membrane dystrophy (EBMD), tortuous stromal nerves, stromal microdots in the anterior stroma, folds in the posterior stroma, opacification of Descemet's membrane, and corneal guttae. Results: Four features were found characteristic of the aging cornea: stromal microdots in the anterior stroma (P<0.0001), folds in the posterior stroma (P<0.0001), opacification of Descemet's membrane (P<0.0001), and corneal guttae (P<0.0001). Alterations characteristic of EBMD were found in 3% of all eyes and only detected in subjects aged ≥40 years, suggesting age-relatedness (P = 0.09). Other features, such as bright superficial epithelial cells (n = 38, 13%), dendriform cells (n = 42, 14%), and tortuous stromal nerves (n = 115, 38%), were age-independent. We also found a novel phenotype of corneal endothelium in 4 normal eyes of 2 subjects, which we coined “salt and pepper endothelium.” We could not establish whether this novel phenotype represented a morphologic variant of normal endothelium, an early stage of a known corneal endothelial disorder, or a completely new disease entity. Conclusions: Knowledge of the common morphologic variations of the corneal layers and the effects of aging on corneal morphology as seen by IVCM increases our understanding of corneal degenerative disorders and is essential to detect corneal pathology. Our finding of a novel phenotype of corneal endothelium emphasizes the morphologic diversity of this optically transparent tissue. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Long-term Results of Deep Anterior Lamellar versus Penetrating Keratoplasty

2011-11-07

Objective: To compare deep anterior lamellar keratoplasty (DALK) with penetrating keratoplasty (PK) in eyes with corneal diseases not involving the corneal endothelium (keratoconus, scars after infectious keratitis, stromal dystrophies, and trauma). Design: Retrospective, comparative case series. Participants: One hundred forty-two consecutive DALK (DALK group; big-bubble technique or manual lamellar dissection using a slitlamp) and 142 matched PK (PK group). Methods: Three models were used to describe the postoperative outcomes of the endothelial cell density. A joint regression model was used to predict long-term graft survival. Visual acuity, ultrasound pachymetry, specular microscopy, and optical coherence tomography (OCT) findings were recorded. Main Outcome Measures: Postoperative endothelial cell loss and long-term predicted graft survival. Results: The average 5-year postoperative endothelial cell loss was −22.3% in the DALK group and −50.1% in the PK group (P<0.0001). The early- and late-phase annual rates of endothelial cell loss were −8.3% and −3.9% per year, respectively, in the DALK group and −15.2% and −7.8% per year in the PK group (P<0.001; biphasic linear model). The median predicted graft survival was 49.0 years in the DALK group and 17.3 years in the PK group (P<0.0001). The average visual acuity was lower in the manual dissection subgroup compared with the PK group (average difference, 1.0 to 1.8 line) and with the big-bubble subgroup (average difference, 2.2 to 2.5 lines). The average central corneal thickness at 12 months was 536 μm in the PK group, 523 μm in the big-bubble subgroup, and 562 μm in the manual dissection subgroup (P<0.001). The average thickness of the residual recipient stroma measured by OCT was 87±26 μm in the manual dissection subgroup. No correlation was found between this figure and logarithm of the minimal angle of resolution at any postoperative time point (P>0.05). Conclusions: Long-term, model-predicted graft survival and endothelial densities are higher after DALK than after PK. The big-bubble technique gives better results than manual dissection and PK. Compared with PK, manual dissection provides higher survival of both the corneal endothelium and graft, but lower visual acuity. Financial Disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article.

Spontaneous Corneal Clearing after Descemet's Stripping without Endothelial Replacement

Rupa D. Shah, J. Bradley Randleman, Hans E. Grossniklaus — 2011-10-10

Purpose: To report spontaneous corneal clearing with improved visual acuity and central endothelial cell repopulation after Descemet's stripping without endothelial replacement. Design: Interventional case report. Methods: A 34-year-old woman with bilateral decreased vision secondary to corneal edema from endothelial dysfunction underwent Descemet's stripping endothelial keratoplasty (DSEK) in the right eye and Descemet's stripping only in the left eye. Histopathologic evaluation confirmed a dual diagnosis of Fuchs' endothelial dystrophy and posterior polymorphous membrane dystrophy from Descemet's membrane specimens removed from each eye. After primary graft failure with regraft in the right eye, the second posterior corneal lenticule detached and was removed and not replaced. The cornea cleared, and central endothelial cell repopulation was documented by confocal microscopy. Therefore, Descemet's stripping without endothelial replacement was performed in the left eye. The left cornea also cleared with central endothelial cell repopulation. Main Outcome Measures: Postoperative visual acuity and central endothelial cell repopulation. Results: Endothelial migration after Descemet's stripping alone in the left eye, with probable host endothelial cell repopulation in the right eye. Conclusions: Endothelial cell migration after Descemet's stripping procedure without insertion of endothelial graft can occur, resulting from host endothelial cell repopulation with corneal clearing and improved visual acuity. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Improved Refractive Outcome for Ciliary Sulcus-Implanted Intraocular Lenses

Rahul Dubey, Wayne Birchall, John Grigg — 2011-12-26

Objective: To investigate the ideal correction of intraocular lens (IOL) power for sulcus implantation. Design: Retrospective, comparative case series. Participants: The records of 679 patients undergoing cataract surgery from June 2007 to June 2008 were reviewed. Intervention: Eyes in this series underwent phacoemulsification and IOL implantation with local anesthesia. Patients in our study population had their IOL power reduced by 0.5 or 1 diopter (D) from that calculated by the SRK-T formula for in-the-bag implantation. The IOL implanted was the foldable 3-piece acrylic Acrysof MA60AC (Alcon Laboratories Inc., Fort Worth, TX). Main Outcome Measures: In each case, the difference between actual spherical equivalent (SE) refraction and that predicted by biometry using the SRK-T formula was calculated. Results: Posterior capsule tears requiring implantation of IOL in the ciliary sulcus occurred in 36 eyes. When comparing eyes in which the power was reduced by 0.5 D with those in which the reduction was 1.0 D, those with a power reduction of 1.0 D had significantly less unexpected error (0.49 vs. 1.01 D SE). After stratifying eyes by axial length (AL), we found higher unexpected refractive error in short eyes (<22 mm AL). Likewise, eyes with a predicted IOL power >25 D had a greater postoperative refractive error. Conclusions: This is the first comparative clinical review examining adjustment of power of the sulcus-implanted IOL. We found that the IOL power should be adjusted according to the measured AL and predicted IOL power. For patients with a predicted IOL power from 18 to 25 D, power should be reduced by at least 1 D; for lenses >25 D, power should be reduced by 1.5 to 2 D. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

In-the-Bag Capsular Tension Ring and Intraocular Lens Subluxation or Dislocation: A Series of 23 Cases

Liliana Werner, Brian Zaugg, Tobias Neuhann, Michael Burrow, Manfred Tetz — 2011-12-09

Objective: To describe clinical and pathologic findings from cases of in-the-bag capsular tension ring (CTR) and intraocular lens (IOL) subluxation or dislocation. Design: Retrospective case series with clinicopathologic correlation. Participants: Twenty-three explanted subluxated/dislocated capsular bags containing a CTR and an IOL explanted in Europe and submitted in fixative to the Berlin Eye Research Institute. Methods: Standard gross and light microscopy of specimens, complete histopathologic analyses of selected specimens done at the University of Utah, as well as questionnaire sent to explanting surgeons, and patient chart review, when available. Main Outcome Measures: Lens design, material, and abnormalities, capsular bag anomalies, patient demographic data, surgical dates, and presence or absence of known risk factors. Results: Patients were aged 76.31±8.24 years at explantation, which was performed 81.5±32.2 months after implantation. The IOLs in these cases were 3-piece hydrophobic acrylic (N = 11), 1-piece hydrophobic acrylic (n = 6), 3-piece silicone (n = 4), or 1-piece hydrophilic acrylic (n = 2) designs; all CTRs were made of poly(methyl methacrylate). Available information on associated ocular conditions included pseudoexfoliation (n = 17), glaucoma (n = 4), vitrectomy/retina surgery (n = 3), and trauma (n = 1). Complete histopathologic assessment in 3 specimens showed signs consistent with pseudoexfoliation, without available history related to this condition in one of the cases. Moderate/severe degrees of Soemmering's ring formation and capsulorhexis phimosis were observed or reported in 13 and 11 specimens, respectively. Fourteen eyes were implanted and explanted by the same surgeon, with an interval of 92.7±23.4 months between the procedures. His rate of explantation because of subluxation/dislocation was 0.76% of the CTRs implanted during the time considered. Conclusions: Explantation because of postoperative subluxation or dislocation of CTR–IOL–capsular bag complexes occurred approximately 6.8 years after implantation in this series, providing further evidence that a fine line exists between zonular insufficiency that can be stabilized with the CTR alone and that requiring further support. Analyses of large series may help to define common factors associated with this complication, as well as surgical planning and employment of various endocapsular support devices to enhance postoperative zonular stabilization. Financial Disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article.

Correlation between Preoperative Biometry and Posterior Chamber Phakic Visian Implantable Collamer Lens Vaulting

Dong-Hoon Lee, Sung-Ho Choi, Eui-Sang Chung, Tae-Young Chung — 2011-11-07

Objective: To evaluate (1) the effect of preoperative biometric factors on vault error and (2) the difference in achieved vault (AV) and expected vault (EV) after Visian Implantable Collamer Lens (ICL) implantation. Design: Retrospective, comparative, interventional case series. Participants: A total of 129 eyes of 75 myopic patients treated with ICL. Methods: On the basis of the hypothesis that ICL vaulting is due mainly to an inequality between ICL size and the horizontal sulcus-to-sulcus distance (STS) or horizontal white-to-white distance (WTW), we assumed that EV would linearly correlate with ICL horizontal compression, as demonstrated in an ex vivo experiment. Expected vault was defined as follows: EV(WTW[or STS]) = (ICL size – WTW[or STS]) × 1100 μm. With the use of preoperative data as independent variables (including age, anterior chamber depth measured from the central corneal endothelium to the anterior lens capsule, STS, WTW, ICL size, ICL size – STS, ICL size – WTW, STS – WTW, ICL diopter, and mean K-reading), a multiple regression analysis was performed to evaluate meaningful factors affecting AV. Main Outcome Measures: Preoperative ICL EV and postoperative ICL AV. Results: Mean AV was 518.6 (standard deviation [SD] 258.4 μm). The EV(WTW) was 626.6 (SD 220.9 μm), and EV was 242.8 (SD 364.2 μm). Higher ICL compression tended to result in a lower AV than EV, whereas lower ICL compression tended to result in a higher AV than EV. The ICL size – STS was more highly correlated with AV than the ICL size – WTW (Pearson correlation coefficient 0.425 vs. 0.247). Stepwise multivariate regression showed that, in order of the strength of the contribution, ICL size – STS, ICL size, age, and K-reading were significant factors associated with AV (adjusted R2=0.369), but ICL size – WTW was not. Among the meaningful factors, ICL size – STS, ICL size, and K-reading were positively correlated with AV, whereas age was negatively correlated. Conclusions: The ICL vaulting based on only the horizontal compression could not be quantitatively predicted. Additional factors, such as vertical compression by the iris, dampening effect of the ciliary sulcus structure, or innate ICL vault, should be considered to avoid unexpected vaulting after ICL implantation. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Determinants of Angle Width in Chinese Singaporeans

2011-11-25

Purpose: To investigate determinants of angle width and derive mathematic models to best predict angle width. Design: Population-based, cross-sectional study. Participants: A total of 1067 Chinese subjects aged ≥40 years. Methods: Participants underwent gonioscopy, A-scan biometry, and imaging by anterior segment optical coherence tomography (ASOCT, Carl Zeiss Meditec, Dublin, CA). Customized software (Zhongshan Angle Assessment Program, Guangzhou, China) was used to measure ASOCT parameters. Linear regression modeling was performed with trabecular–iris space area at 750 μm (TISA750) and angle opening distance at 750 μm (AOD750) from the scleral spur as the 2 dependent angle width variables. By using a combination of ASOCT and biometric parameters, an optimal model that was predictive of angle width was determined by a forward selection regression algorithm. Validation of the results was performed in a separate set of community-based clinic study of 1293 persons aged ≥50 years. Main Outcome Measures: Angle width and biometric parameters. Results: The mean age (standard deviation) of the population-based subjects was 56.9 (8.5) years, and 50.2% were male. For TISA750, the strongest determinants among ASOCT and A-scan independent variables were anterior chamber volume (ACV, R2=0.51), followed by anterior chamber area (ACA, R2=0.49) and lens vault (LV, R2=0.47); for AOD750, these were LV (R2=0.56), ACA (R2=0.55), and ACV (R2=0.54). The R2 values for anterior chamber depth and axial length were 0.39 and 0.27 for TISA750, respectively, and 0.46 and 0.30 for AOD750, respectively. An optimal model consisting of 6 variables (ACV, ACA, LV, anterior chamber width [ACW], iris thickness at 750 μm, and iris area) explained 81.4% of the variability in TISA750 and 85.5% of the variability in AOD750. The results of the population-based study were validated in the community-based clinic study, where the strongest determinants of angle width (ACA, ACV, and LV) and the optimal model with 6 variables were similar. Conclusions: Angle width is largely dependent on variations in ACA, ACV, and LV. A predictive model comprising 6 quantitative ASOCT parameters explained more than 80% of the variability of angle width and may have implications for screening for angle closure. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Immediate Changes in Intraocular Pressure after Laser Peripheral Iridotomy in Primary Angle-Closure Suspects

2011-10-31

Purpose: To determine the immediate changes in intraocular pressure (IOP) after laser peripheral iridotomy in primary angle-closure suspects. Design: Prospective, randomized controlled trial (split-body design). Participants: Seven hundred thirty-four Chinese people 50 to 70 years of age. Methods: Primary angle-closure suspects underwent iridotomy using a neodymium:yttrium–aluminum–garnet laser in 1 randomly selected eye, with the fellow eye serving as a control. Intraocular pressure was measured using Goldmann applanation tonometry before treatment and 1 hour and 2 weeks after treatment. Total energy used and complications were recorded. Risk factors for IOP rise after laser peripheral iridotomy were investigated. Main Outcome Measures: Intraocular pressure. Results: The proportion of treated eyes with an IOP spike (an elevation of ≥8 mmHg more than baseline) at 1 hour and 2 weeks after treatment was 9.8% (95% confidence interval [CI], 7.7–12.0) and 0.82% (95% CI, 0.2–1.5), respectively. Only 4 (0.54%) of 734 eyes (95% CI, 0.01–1.08) had an immediate posttreatment IOP of 30 mmHg or more and needed medical intervention. The average IOP 1 hour after treatment was 17.5±4.7 mmHg in the treated eyes, as compared with 15.2±2.6 mmHg in controls. At 2 weeks after treatment, these values were 15.6±3.4 mmHg in treated eyes and 15.1±2.7 mmHg in controls (P<0.001). No significant difference was detected in the baseline IOP of the treated and untreated eyes. Logistic regression showed that the incidence of IOP spike was associated with greater laser energy used and shallower central anterior chamber. Conclusions: Laser peripheral iridotomy in primary angle-closure suspects resulted in significant IOP rise in 9.8% and 0.82% of cases at 1 hour and 2 weeks, respectively. Eyes in which more laser energy and a higher number of laser pulses were used and those with shallower central anterior chambers were at increased risk for IOP spikes at 1 hour after laser peripheral iridotomy. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Open-Angle Glaucoma and the Risk of Erectile Dysfunction: A Population-based Case-control Study

2011-10-31

Purpose: Open-angle glaucoma (OAG) is associated with systemic metabolic and cardiovascular disorders, and both share common risk factors with erectile dysfunction (ED). However, few studies have investigated the association of ED with OAG. This study aimed to estimate the association of ED with prior OAG by using a nationwide, population-based data with a retrospective case-control cohort design in Taiwan. Design: Age-matched case-control study. Participants and Controls: We identified 4605 patients with ED as the cases and randomly selected 23 025 subjects as the controls (5 controls to 1 case). Methods: We used conditional logistic regression analysis to estimate the odds ratio and 95% confidence interval of having previously been diagnosed with OAG according to the presence/absence of ED after adjusting for patient's monthly income, geographical location, hypertension, diabetes, coronary heart disease, hyperlipidemia, obesity, and alcohol abuse. Main Outcome Measures: We identified OAG cases not only based on an International Classification of Diseases, Ninth Revision, Clinical Modification code, but also by the prescription of topical antiglaucoma medication. Results: In total, prior OAG was found among 137 subjects (0.5 %); 53 individuals (1.1% of the ED patients) from the cases and 84 individuals (0.4% of patients without ED) from the controls. Conditional logistic regression analysis demonstrated that, after adjusting for potential confounders, patients with ED were more likely to have prior OAG than controls (odds ratio, 2.85; 95% confidence interval, 2.10–4.07). Conclusions: This study identifies a novel association between ED and prior OAG. Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Rates of Change in the Visual Field and Optic Disc in Patients with Distinct Patterns of Glaucomatous Optic Disc Damage

2011-11-30

Purpose: To investigate the rate of visual field and optic disc change in patients with distinct patterns of glaucomatous optic disc damage. Design: Prospective longitudinal study. Participants: A total of 131 patients with open-angle glaucoma with focal (n = 45), diffuse (n = 42), and sclerotic (n = 44) optic disc damage. Methods: Patients were examined every 4 months with standard automated perimetry (SAP, SITA Standard, 24-2 test, Humphrey Field Analyzer, Carl Zeiss Meditec, Dublin, CA) and confocal scanning laser tomography (CSLT, Heidelberg Retina Tomograph, Heidelberg Engineering GmbH, Heidelberg, Germany) for a period of 4 years. During this time, patients were treated according to a predefined protocol to achieve a target intraocular pressure (IOP). Rates of change were estimated by robust linear regression of visual field mean deviation (MD) and global optic disc neuroretinal rim area with follow-up time. Main Outcome Measures: Rates of change in MD and rim area. Results: Rates of visual field change in patients with focal optic disc damage (mean −0.34, standard deviation [SD] 0.69 dB/year) were faster than in patients with sclerotic (mean −0.14, SD 0.77 dB/year) and diffuse (mean +0.01, SD 0.37 dB/year) optic disc damage (P = 0.003, Kruskal–Wallis). Rates of optic disc change in patients with focal optic disc damage (mean −11.70, SD 25.5 ×10−3 mm2/year) were faster than in patients with diffuse (mean −9.16, SD 14.9 ×10−3 mm2/year) and sclerotic (mean −0.45, SD 20.6 ×10−3 mm2/year) optic disc damage, although the differences were not statistically significant (P = 0.11). Absolute IOP reduction from untreated levels was similar among the groups (P = 0.59). Conclusions: Patients with focal optic disc damage had faster rates of visual field change and a tendency toward faster rates of optic disc deterioration when compared with patients with diffuse and sclerotic optic disc damage, despite similar IOP reductions during follow-up. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Reliability of Simultaneous Visual Field Testing

Benjamin C. Kramer, David C. Musch, Leslie M. Niziol, Jennifer S. Weizer — 2011-11-23

Objective: To test for differences in reliability and performance between traditional, isolated perimetry and simultaneous testing with 2 patients in the same room. Design: Comparative case series. Participants: A total of 471 eyes of 261 subjects. Methods: Consecutive patients undergoing Humphrey visual field (VF) testing in the Kellogg Eye Center glaucoma clinic were screened. Patients who underwent VF testing with another patient in the same room (“double field”) during the screening interval were included as subjects if a comparison isolated VF from the same patient (“single field”) was obtainable from the clinic's records. An individual subject's performance and reliability on his/her double and single fields were compared using a paired t test. In addition, the double fields were stratified by technician-to-patient ratio, and their VF indices were compared using an independent 2-sample t test. Main Outcome Measures: False negatives, false positives, fixation losses, mean deviation, pattern standard deviation, VF index, VF duration, and technician-to-patient ratio. Results: No significant differences between single and double fields were found in the reliability or performance parameters. Test duration was longer in double fields than in single fields (6.1 vs. 5.9 minutes, P < 0.001). There were no significant differences found in reliability or performance indices when the double-field data were stratified by technician-to-patient ratio (1:2 vs. 2:2). Conclusions: There is no decrement in VF performance or reliability when patients undergo simultaneous testing with another patient in the same room. Busy clinical practices may be able to minimize costs and maximize efficiency by having 1 technician simultaneously supervise more than 1 test-taker in the same space. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Progression Detection Capability of Macular Thickness in Advanced Glaucomatous Eyes

Kyung Rim Sung, Jae Hong Sun, Jung Hwa Na, Jin Young Lee, Youngrok Lee — 2011-12-19

Purpose: To evaluate the progression rate of macular and circumpapillary retinal nerve fiber layer (RNFL) thickness in advanced glaucomatous eyes using spectral domain optical coherence tomography (Cirrus HD-OCT, Carl Zeiss Meditec, Dublin, CA). Design: Longitudinal, observational study. Participants: A total of 98 eyes of 98 patients with advanced glaucoma (visual field [VF] mean deviation [MD] <−10 dB) with a mean follow-up time of 2.2 years. Methods: Three glaucoma experts independently reviewed optic disc and RNFL photographs and classified patients into 3 groups: progressed, stable, and undetermined (criterion 1). Patients in the undetermined group could not be evaluated because of advanced optic disc cupping. The eyes were also classified into 2 groups, progressed and stable, by serial VF data (criterion 2). Main Outcome Measures: Progression rates as determined by linear regression analysis against patient age using serial macular and RNFL thickness parameters were compared among different groups. Results: By criterion 1, 25 eyes (25.5%) were classified as stable, 13 eyes (13.3%) were classified as progressed, and 60 eyes (61.2%) were classified as undetermined. By criterion 2, 86 eyes (87.8%) were classified as stable, and 12 eyes (12.2%) were classified as progressed. By criterion 1, the mean progression rate of average macular thickness was significantly higher in the progressed group than in the stable and undetermined groups (−4.74±4.40, −0.53±1.44, and −2.72±4.75 μm/year, respectively; P = 0.01). The undetermined group showed a higher progression rate than the stable group (P = 0.045). However, the progression rate of average RNFL thickness did not differ significantly among the 3 groups (−1.19±2.62, −0.33±1.29, and −1.21±2.75 μm/year, respectively; P = 0.34). By criterion 2, the mean progression rate of average RNFL thickness did not differ significantly between the stable and progressed groups (−0.90±2.42 and −2.08±2.85 μm/year; P = 0.459). However, the progression rate as revealed by average macular thickness was significantly different between the 2 groups (−2.22±4.33 and −5.12±2.40 μm/year, respectively; P = 0.039). Conclusions: Exploration of changes over time in macular thickness may improve detection of progression in patients with advanced glaucoma. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Randomized, Controlled Trial of a Sustained Delivery Formulation of 5-Fluorouracil for the Treatment of Failing Blebs

2011-12-07

Purpose: To determine the efficacy of a subconjunctival injection of hyaluronic acid (HA) with 5-fluorouracil (5FU) formulation as an adjunct in reviving bleb function by needling. Design: Prospective, randomized, controlled trial. Participants: Fifty patients with previous trabeculectomy and scheduled by the managing physician for a needling intervention. Methods: One eye of each patient was randomized to receive needling with HA-5FU mixture or needling with subconjunctival injection of 5FU solution alone. Main Outcome Measures: The primary outcome was the percentage of subjects with an intraocular pressure (IOP) <15 mmHg without any medications at 3 months. Secondary outcomes included the need for additional needling procedures and changes in bleb morphology. Results: Forty-nine subjects (25 in the HA-5FU group and 24 in the 5FU group) completed 3 months of follow-up. At baseline, there was no significant difference between the groups in terms of demographic features, subtype of glaucoma, vertical cup-to-disc ratio, or visual field indices. The mean number of glaucoma medications at baseline was higher in the 5FU group (0.8±1.1 [mean ± standard deviation] vs. 0.2±0.6, P = 0.04). An IOP <15 mmHg without medications was reached in 48.0% of subjects in the HA-5FU group and in 33.3% of subjects in the 5FU group (P = 0.2). At 3 months, both groups demonstrated a significant decrease in IOP from baseline (HA-5FU: decrease of 5.9 mmHg [95% confidence interval, 3.4–8.4]; 5FU: decrease of 6.0 mmHg [95% confidence interval, 3.2–8.2]; P<0.001 for both). Intergroup comparisons for IOP change from baseline was not significant (P = 0.9). However, repeat needling was required more frequently in the 5FU group compared with the HA-5FU group (50.0% vs. 12.0%; P = 0.004). There were no significant differences in the number of reported adverse events, bleb vascularity, or morphology between the 2 groups. Conclusions: Subconjunctival injection of HA-5FU to revive bleb function after bleb needling is as effective as 5FU solution. Fewer repeat needlings were required after treatment with HA-5FU, suggesting that the use of a combined formulation of HA-5FU may improve the overall outcomes of bleb needlings. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Effect on Intraocular Pressure in Patients Receiving Unilateral Intravitreal Anti-Vascular Endothelial Growth Factor Injections

2011-11-07

Purpose: We assessed the frequency and predictive factors related to intraocular pressure (IOP) elevation in neovascular age-related macular degeneration (AMD) patients undergoing unilateral intravitreal ranibizumab and/or bevacizumab injections. Design: Retrospective cohort study. Participants: Charts of 207 patients with neovascular AMD who presented to a single physician at a retinal referral practice over a 6-month period were retrospectively reviewed. Methods: Data recorded included demographic information, clinical findings, total number of bevacizumab and ranibizumab injections received and IOP at each visit. Increases above baseline IOP of >5, >10, or >15 mmHg on ≥2 consecutive visits while under treatment were noted. Main Outcome Measures: The frequency of IOP elevation was compared between treated and untreated eyes. In addition, among treated eyes, frequency and odds ratio of experiencing IOP elevation >5 mmHg above baseline on ≥2 consecutive visits was stratified by number of injections. For the main regression analysis, the outcome variable was IOP elevation >5 mmHg on ≥2 consecutive visits and the main independent variable was total number of injections. Results: On ≥2 consecutive visits, 11.6% of treated versus 5.3% of untreated/control eyes experienced IOP elevation of >5 mmHg. The mean number of injections was higher in those with (24.4; 95% confidence interval [CI], 20.9–28.0; range, 9–39) than without IOP elevation of >5 mmHg (20.4; 95% CI, 18.9–21.8; range, 3–48) on ≥2 consecutive visits. There was an increased odds ratio (5.75; 95% CI, 1.19–27.8; P = 0.03) of experiencing IOP elevation >5 mmHg on ≥2 consecutive visits in patients receiving ≥29 injections compared with ≤12 injections. Of the factors considered, only the total number of injections showed a statistically significant association with IOP elevation >5 mmHg above baseline on ≥2 consecutive visits in treated eyes (P = 0.05). Conclusions: A greater number of intravitreal anti-vasular endothelial growth factor injections is associated with an increased risk for IOP elevation >5 mmHg on ≥2 consecutive visits in eyes with neovascular AMD receiving intravitreal ranbizumab and/or bevacizumab. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Analysis of Outcomes for Intravitreal Bevacizumab in the Treatment of Choroidal Neovascularization Secondary to Ocular Histoplasmosis

2011-11-30

Purpose: To assess the long-term outcomes of intravitreal bevacizumab (IVB) in the treatment of choroidal neovascularization (CNV) secondary to presumed ocular histoplasmosis syndrome (POHS). Design: Retrospective, comparative case series. Participants: Interventional series of 150 eyes in 140 patients treated for subfoveal or juxtafoveal CNV secondary to POHS from January 2006 to January 2010. Intervention: Intravitreal bevacizumab monotherapy or combination IVB and verteporfin photodynamic therapy (IVB/PDT). Main Outcome Measures: Visual acuity (VA) at 12 and 24 months was analyzed. Secondary outcome measures included the number of injections per year and treatment-free intervals. Results: A total of 117 eyes received IVB monotherapy, and 34 eyes underwent combination IVB/PDT treatment. For all patients, the average pretreatment logarithm of minimum angle of resolution (logMAR) was 0.63 (Snellen equivalent 20/86) with a 12-month logMAR VA of 0.45 (Snellen equivalent 20/56) and a 24-month logMAR VA of 0.44 (Snellen equivalent 20/55). The mean follow-up was 21.1 months with an average of 4.24 IVB injections per year. There was no significant difference in initial VA, VA at 12 months, VA at 24 months, or number of eyes with a 3-line gain between the IVB monotherapy and IVB/PDT groups. Thirty-eight percent (39/104) of eyes gained 3 lines or more, and 81.2% (84/104) of subjects had maintained or improved their starting VA at 1 year. The proportion of subjects maintaining a 3-line gain in VA was relatively preserved at 2 years (29.8%, 17/57) and 3 years (30.3%, 10/32) follow-up. There was no increase in the proportion of subjects losing 3 lines or more over 3 years of follow-up. Conclusions: There is no significant difference in VA outcomes between IVB monotherapy versus IVB/PDT combination therapy. The use of IVB alone or in combination with PDT results in significant visual stabilization in the majority of patients with CNV secondary to POHS. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Smoking as a Risk Factor for Choroidal Neovascularization Secondary to Presumed Ocular Histoplasmosis Syndrome

2011-10-31

Purpose: To investigate the relationship of smoking to choroidal neovascularization (CNV) secondary to presumed ocular histoplasmosis syndrome (POHS). Design: Retrospective, case-control study. Participants: A total of 568 patients 18 to 50 years of age, 142 of whom were diagnosed with CNV secondary to POHS in a private retina practice between July 1, 2000, and August 1, 2010. Four hundred twenty-six were controls selected from a private comprehensive ophthalmology practice at the same location. Methods: A retrospective medical record review was performed for all participants. Age, gender, zip code, CNV diagnosis date, insurance status, and smoking status at CNV diagnosis date were collected first for the POHS patients. For each of these 142 patients, 3 randomly selected comprehensive clinic patients, whose visit date fell within 3 months of the corresponding POHS patient's CNV diagnosis date, served as controls. Age, gender, zip code, visit date, reason for visit, insurance type, and smoking status were recorded. Descriptive statistics were calculated for cases and controls. Main Outcome Measures: Logistic regression analyses were performed for both univariate and multivariate models, with CNV secondary to POHS as the main outcome variable and smoking as the main predictor variable, while adjusting for age, gender, insurance type, median household income, and education level. Results: The mean age of patients with CNV secondary to POHS was 39.0±7.1 years, whereas that of the control patients was 35.7±9.1 years. Of the patients with CNV secondary to POHS, 47.2% were current or former smokers (42.3% current, 4.9% former). Of the control patients, 22.5% were current or former smokers (21.8% current, 0.7% former). Age, insurance type, median income, educational attainment, and smoking status were significant in the univariate models. In the final adjusted logistic regression model, only age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02–1.07; P = 0.001), level of educational attainment by zip code (OR, 0.95; 95% CI, 0.92–0.98; P = 0.001) and smoking status (OR, 2.83; 95% CI, 1.86–4.31; P<0.0001) were significant. Conclusions: The odds of a smoker having CNV secondary to POHS are almost 3 times that of a nonsmoker. In this study, the odds of having CNV secondary to POHS increased with age and decreased with increasing level of educational attainment. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Risk Alleles in CFH and ARMS2 Are Independently Associated with Systemic Complement Activation in Age-related Macular Degeneration

2011-11-30

Purpose: Systemic complement activation is associated with age-related macular degeneration (AMD) and has mainly been attributed to a risk allele in the complement factor H (CFH) gene. Whether other important AMD genes also influence complement activation is unclear. In the present case-control study, complement activity and concentrations of complement components and their activation products are measured in AMD patients and in unaffected controls and correlated with genetic variants in the CFH, ARMS2, C3, CFI, and CFB genes. Design: Case-control study. Participants: A cohort of 197 confirmed AMD patients and 150 unaffected age-matched controls were recruited prospectively for the study. Methods: Hemolytic complement assays (AP50, CP50, and LP50), complement components (C3, CFB, CFI, and CFH), and the activation products (C3d, C5a, and SC5b-9) were analyzed in serum or plasma. The DNA samples were genotyped for 5 single nucleotide polymorphisms (SNPs) previously associated with AMD in the CFH, ARMS2, C3, CFB, and CFI genes. Main Outcome Measures: Complement concentrations and their associations with SNPs in the CFH, ARMS2, C3, CFB, and CFI genes. Results: The AMD patients had increased activation of the alternative complement pathway (P = 0.003) and elevated levels of complement activation components C3d (P<0.0001) and C5a (P<0.0001), CFB (P<0.0001), and an increased C3d/C3 ratio (P<0.0001) calculated as a measure of C3 activation. While the CFH risk genotype was significantly associated with the elevated C3d/C3 ratios obtained, in the absence of CFH risk alleles the ARMS2 risk genotype also showed significantly increased levels of complement activation (P = 0.013). Furthermore, the carriers of the CFB protective allele had lower CFB concentrations. Conclusions: The current study found evidence showing that in AMD risk alleles in CFH and ARMS2 are independently associated with complement activation. Especially the C3d/C3 ratio seems to be a strong marker for AMD. The findings suggest that CFH and ARMS2 share a common pathway in the pathogenesis of AMD. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Atropine for the Treatment of Childhood Myopia: Safety and Efficacy of 0.5%, 0.1%, and 0.01% Doses (Atropine for the Treatment of Myopia 2)

2011-10-03

Purpose: Our previous study, Atropine for the Treatment of Myopia 1 (ATOM1), showed that atropine 1% eyedrops were effective in controlling myopic progression but with visual side effects resulting from cycloplegia and mydriasis. The aim of this study was to compare efficacy and visual side effects of 3 lower doses of atropine: 0.5%, 0.1%, and 0.01%. Design: Single-center, double-masked, randomized study. Participants: A total of 400 children aged 6–12 years with myopia of at least −2.0 diopters (D) and astigmatism of −1.50 D or less. Intervention: Children were randomly assigned in a 2:2:1 ratio to 0.5%, 0.1%, and 0.01% atropine to be administered once nightly to both eyes for 2 years. Cycloplegic refraction, axial length, accommodation amplitude, pupil diameter, and visual acuity were noted at baseline, 2 weeks, and then every 4 months for 2 years. Main Outcome Measures: Myopia progression at 2 years. Changes were noted and differences between groups were compared using the Huber–White robust standard error to allow for data clustering of 2 eyes per person. Results: The mean myopia progression at 2 years was −0.30±0.60, −0.38±0.60, and −0.49±0.63 D in the atropine 0.5%, 0.1%, and 0.01% groups, respectively (P=0.02 between the 0.01% and 0.5% groups; between other concentrations P > 0.05). In comparison, myopia progression in ATOM1 was −1.20±0.69 D in the placebo group and −0.28±0.92 D in the atropine 1% group. The mean increase in axial length was 0.27±0.25, 0.28±0.28, and 0.41±0.32 mm in the 0.5%, 0.1%, and 0.01% groups, respectively (P < 0.01 between the 0.01% and 0.1% groups and between the 0.01% and 0.5% groups). However, differences in myopia progression (0.19 D) and axial length change (0.14 mm) between groups were small and clinically insignificant. Atropine 0.01% had a negligible effect on accommodation and pupil size, and no effect on near visual acuity. Allergic conjunctivitis and dermatitis were the most common adverse effect noted, with 16 cases in the 0.1% and 0.5% atropine groups, and no cases in the 0.01% group. Conclusions: Atropine 0.01% has minimal side effects compared with atropine at 0.1% and 0.5%, and retains comparable efficacy in controlling myopia progression. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Prevalence and Causes of Blindness in Children in Vietnam

Hans Limburg, Clare Gilbert, Do Nhu Hon, Nguyen Chi Dung, Tran Huy Hoang — 2011-10-31

Objective: To estimate the prevalence of blindness in children in Vietnam and to assess the major causes. Design: A population-based study sampled children from 16 provinces across Vietnam. The second study examined children attending all blind schools in Vietnam. Participants: In 16 provinces, 28 800 children aged 0-15 were sampled. In 28 blind schools, 569 children aged 0-15 were examined. Intervention: In children not seeing well according to the parents, presenting visual acuity (PVA) was assessed. If PVA was <3/60 in one or both eyes, the child was examined by an ophthalmologist. All children in blind schools were examined by a pediatric ophthalmologist. Main Outcome Measures: Blindness was defined as PVA <3/60 in the better eye. Causes of visual loss were classified using the World Health Organization classification. Results: In the population-based study, 22 children had a PVA <3/60 in the better eye, a prevalence of 7.6/10 000 children (95% confidence interval [CI], 4.9–11.8/10 000). Fourteen children had a pinhole visual acuity <3/60 in the better eye, a prevalence of 4.9/10 000 (95% CI, 2.8–8.4/10 000). An estimated 16 400 (95% CI, 10 500–25 300), children were blind from all causes, with 36.4% from uncorrected refractive errors. In the blind schools, 411 children had a PVA <3/60 in the better eye and 55.5% were male. Conditions of the retina (24.6%) and cornea (24.0%) predominated. Retinopathy of prematurity (ROP) caused blindness in 32.6% of children younger than 10 years, but in only 6% of older children. The converse was true for corneal scarring and phthisis (14.0% and 27.3%, respectively). All other causes were similar between age groups (53.5% and 66.7%, respectively). More than half of all causes were avoidable. Conclusions: Vietnam is developing very rapidly, and this is impacting health indices. The mortality rate of those younger than 5 years declined from 65/100 live births in 1980 to 14/100 in 2008. The findings of this study show these changes, because the childhood blindness prevalence was relatively low, and the causes show improved control of measles and vitamin A deficiency, as well as increased services for premature babies. Eye care services for children should now focus on refractive errors, cataract, and control of ROP. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Anophthalmos, Microphthalmos, and Coloboma in the United Kingdom: Clinical Features, Results of Investigations, and Early Management

2011-11-07

Purpose: To describe the clinical features of children with anophthalmos, microphthalmos, and typical coloboma (AMC). Design: Descriptive, observational, cross-sectional study of the United Kingdom. Participants: A total of 135 children with AMC newly diagnosed over an 18-month period beginning in October 2006. Methods: Cases were identified using active surveillance through an established ophthalmic surveillance system. Eligible cases were followed up 6 months after first notification. Main Outcome Measures: Phenotypic characteristics, both ocular and systemic, clinical investigations, causes, and interventions. Results: A total of 210 eyes (of 135 children) were affected by AMC, of which 153 had isolated coloboma or coloboma with microphthalmos. The most common colobomatous anomaly was a chorioretinal defect present in 109 eyes (71.2%). Some 44% of children were bilaterally visually impaired. Systemic abnormalities were present in 59.7% of children, with craniofacial anomalies being the most common. Children with bilateral disease had a 2.7 times higher odds (95% confidence interval, 1.3–5.5, P = 0.006) of having systemic involvement than unilaterally affected children. Neurologic imaging was the most frequent investigation (58.5%) performed. Less than one third (30.3%) of the children with microphthalmos had ocular axial lengths measured. Eight children had confirmed genetic mutations. Approximately half (49.2%) of the children required ocular intervention. Conclusions: Colobomatous defects were the most common phenotype within this spectrum of anomalies in the United Kingdom. The high frequency of posterior segment colobomatous involvement means that a dilated fundal examination should be made in all cases. The significant visual and systemic morbidity in affected children underlines the importance of a multidisciplinary approach to management. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Choroidal Abnormalities Detected by Near-Infrared Reflectance Imaging as a New Diagnostic Criterion for Neurofibromatosis 1

2011-10-03

Objective: To investigate in a large sample of consecutive patients with neurofibromatosis type 1 (NF1) the possibility of including the presence of choroidal abnormalities detected by near-infrared reflectance (NIR) as a new diagnostic criterion for NF1. Design: Cross-sectional evaluation of a diagnostic test. Participants and Controls: Ninety-five consecutive adult and pediatric patients (190 eyes) with NF1, diagnosed based on the National Institutes of Health (NIH) criteria. Controls included 100 healthy age- and gender-matched control subjects. Methods: Confocal scanning laser ophthalmoscopy was performed for each subject, investigating the presence and the number of choroidal abnormalities. Main Outcome Measures: Sensitivity, specificity, and diagnostic accuracy for the different cutoff values of the criterion choroidal nodules detected by NIR compared with the NIH criteria. Results: Choroidal nodules detected by NIR imaging were present in 79 (82%) of 95 of the NF1 patients, including 15 (71%) of the 21 NF1 pediatric patients. Similar abnormalities were present in 7 (7%) of 100 healthy subjects, including 2 (8%) of the 25 healthy pediatric subjects. The highest accuracy was obtained at the cutoff value of 1.5 choroidal nodules detected by NIR imagery. Sensitivity and specificity of the examination at the optimal cutoff point were 83% and 96%, respectively. Diagnostic accuracy was 90% in the overall population and 83% in the pediatric population. Both of these values were in line with the most common NIH diagnostic criteria. Conclusions: Choroidal abnormalities appearing as bright patchy nodules detected by NIR imaging frequently occurred in NF1 patients. The present study shows that NIR examination to detect choroidal involvement should be considered as a new diagnostic criterion for NF1. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Surgical Outcomes in Patients with Bilateral Ptosis and Hering's Dependence

Altug Cetinkaya, Robert C. Kersten — 2011-10-07

Purpose: To assess whether sequential or simultaneous ptosis repair yields a better postoperative outcome in patients with documented preoperative Hering's dependency. Design: Retrospective, case-control study. Participants and Controls: Of the 216 patients who underwent bilateral ptosis surgery, 109 patients with documented Hering's dependency constituted the study group and the 107 patients with no Hering's dependency constituted the control group. Methods: The charts of patients who underwent levator advancement ptosis surgery between April 2002 and December 2004 by the same surgeon (R.C.K.) were reviewed retrospectively. Data regarding patient demographics, preoperative and postoperative margin-reflex distance values, levator function, presence of Hering's dependency, side of the initial operation, and reoperation status were collected from the charts. Patients demonstrating preoperative Hering's dependency of eyelid position operated simultaneously and sequentially were compared for postoperative symmetry and reoperation rates. Postoperative asymmetry was defined as a more than 1-mm difference between upper eyelid heights. Main Outcome Measures: Postoperative asymmetry and reoperation rates. Results: In the Hering's dependency group (n = 109), 64 sequential surgeries that yielded 15 asymmetric results (23.4%) and 7 reoperations (10.9%) compared with the 45 simultaneous operations, which revealed 1 case of asymmetry (2.2%; P = 0.002) and 1 case of reoperation (2.2%; P = 0.137). Compared with the control group, sequentially operated Hering's dependency patients still showed higher postoperative asymmetry (P = 0.011), and the reoperation rate was similar (P = 0.134). Hering's dependency patients who had the initial operation on the left side demonstrated a significantly higher rate of postoperative asymmetry (42.3% vs. 10.5%; P = 0.006). Conclusions: Bilateral ptosis cases with documented Hering's dependency yield better results when both eyes are operated in the same session, rather than delaying surgery for the second eyelid. Ocular dominance probably has a significant impact on Hering's dependency and postoperative outcome after unilateral operations. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Reliability of Estimating Ductions in Thyroid Eye Disease: An International Thyroid Eye Disease Society Multicenter Study

2011-09-29

Purpose: To determine intraobserver and interobserver reliability of 3 clinical techniques for measuring ocular ductions in patients with thyroid eye disease and to compare these with an established method using a Goldmann perimeter. Our secondary goals were to compare the clinical methods for test duration, ease of learning and performance, and whether these differed between novices and experts. Design: Multicenter, prospective, comparative trial. Participants: We recruited 38 patients with thyroid orbitopathy and reduced ocular motility from 7 academic centers. Methods: At each center, 2 novices and 2 experts measured the ocular ductions of each eye of each patient in 4 directions (0°, 90°, 180°, and 270°) using 3 techniques (best guess [BG], light reflex [LR], and a ruler measuring [RU] technique). Test duration and clinicians' feedback were recorded. A subjective and objective measurement for ocular ductions using a Goldmann perimeter was performed for each subject by a trained technician. The 3 clinical measurements and the perimetry measurements were performed twice, separated by ≥1 hour. Main Outcome Measures: We measured the intraobserver and interobserver reliability of the 3 clinical techniques and intraobserver reliability of Goldmann perimeter. Clinical testing reliability was compared between experts and novices. We also examined test duration and clinician feedback. Results: The LR technique had significantly better intraobserver and interobserver repeatability compared with the BG or RU clinical measurements and statistically was equivalent to the gold-standard perimetric technique. Reliability was constant regardless of the amount of restriction in ocular movement. There was no difference between reliability values for experts and novices. The LR and BG techniques were significantly faster than the RU or perimetry techniques and were considered easiest to learn and perform, but clinicians had most confidence in the LR technique results. Conclusions: The LR technique for measuring ocular ductions in thyroid orbitopathy is more reliable than other clinical techniques and as reliable as the established technique using the perimeter. However, unlike the latter method, it is easier to learn and perform by both novices and experts, is significantly faster, and can be performed by the clinician without machinery or a trained technician. Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Acquired Lower Eyelid Epiblepharon in Thyroid-Associated Ophthalmopathy of Koreans

Sung Wook Park, Sang In Khwarg, Namju Kim, Min Joung Lee, Ho-Kyung Choung — 2011-10-07

Purpose: To investigate the prevalence and clinical features of acquired lower eyelid epiblepharon in Korean patients with thyroid-associated ophthalmopathy (TAO) and compare the pathogenic features of acquired and congenital epiblepharon. Design: Retrospective, nonrandomized, comparative case series, cross-sectional study. Participants: A total of 494 Korean patients with TAO and 845 Korean patients with congenital lower eyelid epiblepharon. Methods: The medical records were reviewed, and the presence, location, and extent of epiblepharon were identified. Clinical features of TAO (lower eyelid retraction, exophthalmos, and elevation limitation) were compared between patients with TAO with and without epiblepharon. Acquired epiblepharon was classified into 3 types according to the location and extent. The prevalence of epiblepharon types was determined and evaluated for associations with TAO clinical features. Comparisons were made between the prevalence of epiblepharon types in acquired and congenital epiblepharon. Main Outcome Measures: Prevalence, location, and extent of epiblepharon; association with clinical features of TAO; and difference from congenital epiblepharon. Results: An acquired lower eyelid epiblepharon was found in 42 (8.5%) of 494 patients with TAO. The mean age of patients with TAO with epiblepharon (34.2±13.5 years) was significantly lower than that of patients with TAO without epiblepharon (46.5±14.1 years) (P = 0.000). Lower eyelid retraction (0.78±1.11 mm) was more severe in patients with TAO with epiblepharon than in patients without epiblepharon (0.30±0.73 mm) (P = 0.000). Lower eyelid retraction was more severe in diffuse-type acquired epiblepharon than in central-type epiblepharon (P = 0.012). Elevation limitation was more severe in central-type acquired epiblepharon than in medial-type epiblepharon (P = 0.001). The occurrence of central-type epiblepharon was higher in TAO-associated acquired epiblepharon (20 eyelids, 30.8%) than in congenital epiblepharon (27 eyelids, 1.9%, P = 0.000). Conclusions: Acquired lower eyelid epiblepharon is one of the clinical features of patients with TAO. The association between lower eyelid retraction and acquired epiblepharon may lead to a better understanding of the cause of acquired epiblepharon in patients with TAO. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Improved Ocular Alignment with Adjustable Sutures in Adults Undergoing Strabismus Surgery

2011-10-31

Objective: To assess whether outcomes of strabismus surgery are improved by using the adjustable suture technique and to determine which subgroups of strabismus patients benefit most from the adjustable suture technique. Design: A retrospective chart review. Participants: A total of 535 adults who underwent strabismus surgery between 1989 and 2010. Methods: Success was defined as ≤10 prism diopters (PD) for horizontal deviations and ≤2 PD for vertical deviations. Differences in the proportion of successful strabismus surgery were analyzed using a chi-square test with an alpha of 0.05. Main Outcome Measures: Ocular alignment in primary position at a 7-day to 12-week follow-up examination. Results: A total of 491 patients met the inclusion criteria (nonadjustable suture, n = 186; adjustable suture, n = 305). The success rates for the nonadjustable and adjustable groups were 61.3% and 74.8%, respectively (χ2=9.91, P=0.0016). Adjustable suture use was particularly beneficial for patients undergoing a reoperation for childhood strabismus (success rate: nonadjustable, 42.4%; adjustable, 65.7%; P=0.0268; n = 100). The differences in outcomes were not statistically significant for patients with childhood strabismus undergoing a primary surgery (nonadjustable, 65.0%; adjustable, 81.4%; P=0.1354; n = 90) or with thyroid orbitopathy (nonadjustable, 76.7%; adjustable, 74.1%; P=0.8204; n = 57). Conclusions: Strabismus surgery using adjustable sutures was associated with improved short-term ocular alignment compared with strabismus surgery without the use of adjustable sutures. Adjustable sutures were most beneficial for patients undergoing reoperations for childhood strabismus. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Abducens Nerve Is Present in Patients with Type 2 Duane's Retraction Syndrome

Jae Hyoung Kim, Jeong-Min Hwang — 2011-10-31

Objective: To determine whether the abducens nerve is present in patients with type 2 Duane's retraction syndrome (DRS). Design: Retrospective, observational case series. Participants: Twelve consecutive patients diagnosed with type 2 DRS. Methods: A retrospective review of medical records of ophthalmologic examination and thin-sectioned magnetic resonance imaging (MRI) at the brainstem level and the orbit was performed on 12 patients who showed the typical signs of type 2 DRS, including adduction deficit; globe retraction; narrowing of fissure on adduction; and upshoot, downshoot, or both. Main Outcome Measures: Presence of the abducens nerve and any other extraocular muscle abnormalities discovered by MRI scan. Results: Magnetic resonance imaging revealed the presence of the abducens nerve in all the affected eyes (n = 13) of 12 patients with type 2 DRS. Conclusions: The abducens nerve is present on the affected side in type 2 Duane's retraction syndrome. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Clinical Survey of 3680 Iris Tumors Based on Patient Age at Presentation

2011-10-31

Objective: To report the spectrum of iris lesions based on patient age at presentation. Design: Retrospective, nonrandomized, single-center case series. Participants: We included 3680 iris tumors in 3451 patients. Methods: Chart review. Main Outcome Measures: Diagnostic category based on age. Results: The mean age at presentation was 48 years and there were 449 (12%) tumors in children (≤20 years), 788 (21%) in young adults (21–40 years), 1308 (36%) in mid adults (41–60 years), and 1135 (31%) in senior adults (>60 years). Of 3680 tumors, the diagnostic category was cystic (n = 768; 21%) or solid (n = 2912; 79%). The cystic tumors originated from iris pigment epithelium (IPE; n = 672; 18%) or iris stroma (n = 96; 3%). The solid tumors included melanocytic (n = 2510; 68%) and nonmelanocytic (n = 402; 11%). The melanocytic tumors comprised nevus (n = 1503; 60%), melanocytoma (n = 68; 3%), melanoma (n = 645; 26%), and melanocytosis (n = 64; 3%). Of 2510 melanocytic tumors, the first and second most common diagnoses by age (children, young adult, mid adult, senior adult) were nevus (53%, 57%, 63%, and 63%, respectively) and melanoma (17%, 27%, 26%, and 27%, respectively). The nonmelanocytic tumors included categories of choristomatous (n = 4; <1%), vascular (n = 57; 2%), fibrous (n = 2; <1%), neural (n = 3; <1%), myogenic (n = 2;, <1%), epithelial (n = 35; 1%), xanthomatous (n = 8; <1%), metastasis (n = 67; 2%), lymphoid (n = 12; <1%), leukemic (n = 2; <1%), secondary (n = 12; <1%), and nonneoplastic simulators (n = 198; 5%). The median age (in years) at diagnosis included cystic (39), melanocytic (52), choristomatous (0.7), vascular (56), fibrous (53), neural (8), myogenic (42), epithelial (63), xanthomatous (1.9), metastasis (60), lymphoid (57), leukemic (25.5), secondary (59), and nonneoplastic simulators (49). Overall, the 3 most common specific diagnoses (children, young adult, mid adult, senior adult) were nevus (25%, 36%, 47%, and 47%, respectively), IPE cyst (28%, 30%, 15%, and 14%, respectively), and melanoma (8%, 16%, 20%, and 19%, respectively). Conclusions: In an ocular oncology practice, the spectrum of iris tumors includes cystic (21%) and solid (79%) tumors. The solid tumors were melanocytic (68%) or nonmelanocytic (11%). At all ages, the most common specific diagnoses were nevus (42%), IPE cyst (19%), and melanoma (17%). Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

A Five-Year Study of Slotted Eye Plaque Radiation Therapy for Choroidal Melanoma: Near, Touching, or Surrounding the Optic Nerve

Paul T. Finger, Kimberly J. Chin, Lawrence B. Tena — 2011-11-30

Objective: To evaluate slotted eye plaque radiation therapy for choroidal melanomas near the optic disc. Design: A clinical case series. Participants: Twenty-four consecutive patients with uveal melanomas that were near, touching, or surrounding the optic disc. Intervention: Slotted eye plaque radiation therapy. Main Outcome Measures: Recorded characteristics were related to patient, clinical, and ophthalmic imaging. Data included change in visual acuity, tumor size, recurrence, eye retention, and metastasis. Results: From 2005 to 2010, 24 consecutive patients were treated with custom-sized plaques with 8-mm–wide, variable-depth slots. Radiation doses ranged from 69.3 to 163.8 Gy (mean, 85.0 Gy) based on delivering a minimum tumor dose of 85 Gy. All treatments were continuously delivered over 5 to 7 days. Mean patient age at presentation was 57 years. Tumors were within 1.5 mm of the optic nerve (n = 3, 13%), juxtapapillary (n = 6, 25%), touching ≥180 degrees (n = 7, 29%), or circumpapillary (n = 8, 33%). Ultrasound revealed dome-shaped tumors in 79% of patients, collar-button tumors in 17% of patients, irregular tumor in 1 patient (4%), and intraneural invasion in 2 patients. Mean initial largest basal dimension was 11.0 mm (standard deviation [SD] ± 3.5 mm; median, 11.4 mm; range, 5.9–16.4 mm). Mean initial tumor thickness was 3.5 mm (SD ± 1.7 mm; median, 3.0 mm; range, 1.4–6.9 mm). Initial visual acuities were a median 20/25 (range, 20/20 to hand motions) and decreased to a median 20/40 (range, 20/20 to no light perception). At a mean follow-up of 23 months, 12 patients required periodic intravitreal bevacizumab to suppress radiation optic neuropathy (RON) or maculopathy. To date, there has been a 100% local control rate. No patients have required secondary enucleation for recurrence or neovascular glaucoma. No patients have developed metastasis. Conclusions: Slotted plaque radiation therapy allows peripapillary, juxtapapilary, and circumpapillary choroidal melanomas (and a safety margin) to be included in the radiation targeted zone. Normalization of the plaque position beneath the tumor appears to increase RON and improve local control. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Aspheric Multifocal Intraocular Lens

Cheng Peng, Jiang Yue Zhao, Jin Song Zhang — 2012-02-01

Although many studies have demonstrated that the AcrySof ReSTOR SN6AD1 intraocular lenses (IOLs) with a near add of +3.00 diopter (D) can yield a full range of visual outcomes, especially intermediate visual outcomes, it is still of interest to evaluate visual function and possible adverse effects of the +3D IOL. Thus, we sought to investigate the optical quality of eyes implanted with the +3D IOL compared with a standard aspheric monofocal IOL, and analyzed specific indicators of optical quality—intraocular straylight, wavefront aberration, and contrast sensitivity (CS).

Paradoxical Embolus and Endophthalmitis

2012-02-01

Endogenous endophthalmitis (EE) accounts for 2%–15% of infectious endophthalmitis presentations. We describe a young, otherwise healthy Australian woman with unilateral metastatic panophthalmitis and blindness associated with congenital cardiac anomalies.

Streptococcal Orbital Abscesses

2012-02-01

Orbital cellulitis with abscess formation can be both sight and life threatening. Orbital infection with streptococcal organisms belonging to the Streptococcus Milleri Group (SMG) are particularly virulent, requiring rapid intervention to preserve vision and life. Three specific organisms in this group include Streptoccocus anginosus, Streptococcus intermedius, and Streptoccocus constellatus. The SMG are unique among streptococcal species in their propensity toward rapid and unremitting infection, and have only infrequently been reported to cause frank orbital abscess formation. We report the clinical features and management in 6 cases of SMG orbital abscess.

Residency Interview Video Conferencing

2012-02-01

The ophthalmology residency matching has been used in the United States for over 30 years. Each institution reviews applications, and selected applicants are invited for Face-to-Face Interviews (FFIs). However, total interviewing expenses can be costly for applicants, and interview schedules among different institutions may conflict.

Resident Cataract Surgery

2012-02-01

We are writing regarding the recent report by Woodfield et al about resident cataract surgery complication rates. We definitely agree that it provides useful information that we might apply to our Ophthalmology Residency Training Program. However, it is also true that the results provided in this article are rather controversial.

Author reply

Alonzo S. Woodfield, Emily W. Gower, Sandra D. Cassard, Saraswathy Ramanathan — 2012-02-01

We would like to begin by thanking Zabalza et al for their thoughtful questions and comments. In our article, we describe complication rates by year of residency. We certainly think that correlating complications with surgical experience on a resident-by-resident basis is an interesting topic, however, we feel it is a separate question. We are not seeking to elucidate the mechanisms of the resident learning curve for phacoemulsification. Rather, we are trying to draw conclusions about the overall complication rate for residents of a particular level. Since residents have varying levels of exposure to particular surgeries and natural ability (and since we as teachers can control neither), studies are needed that examine the issue in aggregate in order to inform teaching policy. The concern with such an aggregation of data, as Zabalza et al point out, is the possibility of bias. We believe that a 5-year study helps us in this regard as the effect individual differences among residents skill and experience levels are reduced by the number of residents involved. Furthermore, because the data is longitudinal (the same residents contribute data to the second- and third-year datasets), residents are in effect being compared with themselves.

Glaucoma Clinical Guidelines

Jennifer L.Y. Yip, John Sparrow — 2012-02-01

We read with interest the article by Ou et al article appraising 3 primary open angle glaucoma (POAG) clinical practice guidelines. Evaluation using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument showed poor scores in the domains of stakeholder involvement, applicability, and editorial independence. Good clinical guidelines aim to improve the quality of healthcare, with the potential to change the process of health care and improve clinical outcomes.

Author reply

Yvonne Ou, Ivan Goldberg, Clive Migdal, Paul P. Lee — 2012-02-01

We would like to thank Dr. Yip and Dr. Sparrow for their thoughtful comments on our paper entitled, “A Critical Appraisal and Comparison of the Quality and Recommendations of Glaucoma Practice Guidelines.”

Confocal Microscopy

Samrat Chatterjee, Deesphikha Agrawal — 2012-02-01

We have read with interest the article by Vaddavalli et al on the role of confocal microscopy in the diagnosis of infectious keratitis due to fungi and acanthamoeba. The authors found that about 10% of fungal keratitis could not be diagnosed with confocal microscopy, but do not suggest reasons for this. A possible explanation for false-negative results has been provided in another series published after Vaddavalli's article had been submitted, where it was suggested that hazy images and lack of patient cooperation may be possible causes of not detecting fungal filaments. Were the scans in this false-negative group of patients in the present study re-examined after microbiological confirmation to detect filaments that may have been missed or were additional scans performed? This might not have been in the study protocol, but could be important as detection of fungal filaments in fresh scans would imply limitation of the instrument and examination procedure, while their detection on reexamination of the previous scans would mean limitation in the interpretation process. The authors mention a learning curve in the interpretations of the scans, and this would be supported if the negative results were obtained in the initial phases of the study.

Author reply

2012-02-01

We thank Chatterjee et al for their observations regarding the role of confocal microscopy in the diagnosis of infective keratitis. We would like to reiterate that our study was designed as a double-masked protocol with confocal microscopy performed first followed by microbiology evaluation, with both the evaluator studying the confocal scans and the microbiologist processing the slides and cultures masked to the results of the other's results. Only following the completion of the study and tabulation of the results, did the false positives and negatives emerge. Since the primary purpose of the study was to evaluate the sensitivity and specificity of the confocal microscope in diagnosing fungal and Acanthamoeba keratitis, we did not reexamine the scans from the false positives and false-negative patients nor were the false-negative patients subjected to a repeat scan. The article referred to by Chatterjee et al, by Kanavi et al does describe one case of a false-negative scan that has been attributed to an uncooperative patient. Similarly, a previous study by Parmer et al assessing the role of the tandem scanning confocal microscope in Acanthamoeba keratitis have alluded to uncooperative patients as the reason for false-negative results. In our study, as stated in the results section, 2 cases were excluded as they were uncooperative and were not part of the final analysis. We have also mentioned that no scans were excluded on the basis of poor scan quality.

Photoreceptor Imaging

Susanna S. Park, Stacey S. Choi, Robert J. Zawadzki, John S. Werner — 2012-02-01

We read with interest the recent article by Ooto et al entitled, “High-resolution imaging of photoreceptor layer in epiretinal membrane using adaptive optics scanning laser ophthalmoscopy,” published in May 2011. The article describes foveal microfolds in eyes with epiretinal membrane and metamorphopsia visualized using adaptive optics scanning laser ophthalmoscopy (AO-SLO), a finding not noted in normal eyes. They describe this finding as an “abnormality…not reported in previous studies of normal eyes or eyes with various other retinal diseases examined by AO imaging systems.”

Author reply

Sotaro Ooto, Masanori Hangai, Nagahisa Yoshimura — 2012-02-01

We would like to thank Dr. Park et al for their interest and their comments on our article, “High-resolution imaging of photoreceptor layer in epiretinal membrane using adaptive optics scanning laser ophthalmoscopy.”

Bevacizumab for ROP

Michael Blair, Michael J. Shapiro — 2012-02-01

We read with interest the editorial by Moshfeghi and Berrocal regarding the Bevacizumab Eliminates the Angiogenic Threat of Retinopathy of Prematurity (BEAT-ROP) study which reported the first randomized trial of anti-vascular endothelial growth factor (VEGF) treatment for ROP. The BEAT-ROP study reported a statistically significant reduction, by 54 weeks postmenstrual age (PMA), in treatment requiring recurrence of ROP in eyes treated with bevacizumab injection as compared with laser ablation. In their editorial, Moshfeghi and Berrocal note the eyes in the bevacizumab group had later mean onset of recurrence with large standard deviation and state concern for recurrence after the 54-week study endpoint. For zone 1 disease, this interval was 6.4±6.7 weeks after laser treatment but 19.2±8.6 weeks after bevacizumab. Deriving a first approximation of the high-risk period for recurrence from the limited data in zone 1 disease presented in the BEAT-ROP suggests a mean age at recurrence of 53.7 weeks PMA. Thus, approximately 71 weeks PMA, for 2 standard deviations above the mean, would provide around 97% inclusion of recurrences. These data indicate a major change in the behavior of the disease.

Author reply

Darius M. Moshfeghi, Audina M. Berrocal — 2012-02-01

We have carefully reviewed the commentary by Drs. Blair and Shapiro regarding the need for a change in retinopathy of prematurity (ROP) screening behavior both with respect to its duration and frequency following off-label administration of bevacizumab for zone I, stage 3+ ROP as advocated by the BEAT-ROP Study Group, and note that it highlights our own specific concerns outlined in our editorial. Specifically, we wrote, “Treatment with bevacizumab is not a one-and-done therapy.”

Smartphone Fundoscopy

Andrew Bastawrous — 2012-02-01

More ophthalmologists than ever carry a smartphone with them on a daily basis. There are many ophthalmic applications (apps) and reference texts available on a variety of platforms.

Author reply

Vinay A. Shah, Ron K. Lord, Rohit Krishna — 2012-02-01

We would like to congratulate Dr. Bastawrous on his innovative and well-documented technique of “Smartphone Fundoscopy.” We agree with him that our method of viewing the fundus with the smartphone, 20 diopter lens and flash light is not as easy as his technique using the flash light feature of the newly available smartphones. We would like to clarify that when we wrote our article, we were not aware of a smartphone with a flashlight that was commonly available. However, with the availability of this new feature, flashlight technology and higher-resolution camera fundus documentation with the smartphones has become easier. This technique may lead to more widespread use of this modality for fundus documentation. As Dr. Bastawrous mentioned, with this technique it is very important to be careful about protecting patient information on both our smartphone and internet devices as we store and share pictures. We also suggest physicians should consider obtaining a media consent from the patient allowing them to share and/or publish these pictures. We congratulate Dr. Bastawrous on his innovative and user-friendly technique.

Ophthalmology

Editorial Board

This Issue at a Glance

A Simple Vista en Este Número

This Issue At A Glance

Contents

Ergonomics: Back to the Future

Erratum

Erratum

A Survey Study of Musculoskeletal Disorders Among Eye Care Physicians Compared with Family Medicine Physicians

Burden and Depression in the Caregivers of Blind Patients in India

Randomized Trial of Pterygium Surgery with Mitomycin C Application Using Conjunctival Autograft versus Conjunctival-Limbal Autograft

Squamous Carcinoma and Dysplasia of the Conjunctiva and Cornea: An Analysis of 101 Cases

How Normal Is the Transparent Cornea? Effects of Aging on Corneal Morphology

Long-term Results of Deep Anterior Lamellar versus Penetrating Keratoplasty

Spontaneous Corneal Clearing after Descemet's Stripping without Endothelial Replacement

Improved Refractive Outcome for Ciliary Sulcus-Implanted Intraocular Lenses

In-the-Bag Capsular Tension Ring and Intraocular Lens Subluxation or Dislocation: A Series of 23 Cases

Correlation between Preoperative Biometry and Posterior Chamber Phakic Visian Implantable Collamer Lens Vaulting

Determinants of Angle Width in Chinese Singaporeans

Immediate Changes in Intraocular Pressure after Laser Peripheral Iridotomy in Primary Angle-Closure Suspects

Open-Angle Glaucoma and the Risk of Erectile Dysfunction: A Population-based Case-control Study

Rates of Change in the Visual Field and Optic Disc in Patients with Distinct Patterns of Glaucomatous Optic Disc Damage

Reliability of Simultaneous Visual Field Testing

Progression Detection Capability of Macular Thickness in Advanced Glaucomatous Eyes

Randomized, Controlled Trial of a Sustained Delivery Formulation of 5-Fluorouracil for the Treatment of Failing Blebs

Effect on Intraocular Pressure in Patients Receiving Unilateral Intravitreal Anti-Vascular Endothelial Growth Factor Injections

Analysis of Outcomes for Intravitreal Bevacizumab in the Treatment of Choroidal Neovascularization Secondary to Ocular Histoplasmosis

Smoking as a Risk Factor for Choroidal Neovascularization Secondary to Presumed Ocular Histoplasmosis Syndrome

Risk Alleles in CFH and ARMS2 Are Independently Associated with Systemic Complement Activation in Age-related Macular Degeneration

Atropine for the Treatment of Childhood Myopia: Safety and Efficacy of 0.5%, 0.1%, and 0.01% Doses (Atropine for the Treatment of Myopia 2)

Prevalence and Causes of Blindness in Children in Vietnam

Anophthalmos, Microphthalmos, and Coloboma in the United Kingdom: Clinical Features, Results of Investigations, and Early Management

Choroidal Abnormalities Detected by Near-Infrared Reflectance Imaging as a New Diagnostic Criterion for Neurofibromatosis 1

Surgical Outcomes in Patients with Bilateral Ptosis and Hering's Dependence

Reliability of Estimating Ductions in Thyroid Eye Disease: An International Thyroid Eye Disease Society Multicenter Study

Acquired Lower Eyelid Epiblepharon in Thyroid-Associated Ophthalmopathy of Koreans

Improved Ocular Alignment with Adjustable Sutures in Adults Undergoing Strabismus Surgery

Abducens Nerve Is Present in Patients with Type 2 Duane's Retraction Syndrome

Clinical Survey of 3680 Iris Tumors Based on Patient Age at Presentation

A Five-Year Study of Slotted Eye Plaque Radiation Therapy for Choroidal Melanoma: Near, Touching, or Surrounding the Optic Nerve

Aspheric Multifocal Intraocular Lens

Paradoxical Embolus and Endophthalmitis

Streptococcal Orbital Abscesses

Residency Interview Video Conferencing

Resident Cataract Surgery

Author reply

Glaucoma Clinical Guidelines

Author reply

Confocal Microscopy

Author reply

Photoreceptor Imaging

Author reply

Bevacizumab for ROP

Author reply

Smartphone Fundoscopy

Author reply