Ophthalmology - Articles in Press

Prevalence of Myopia and Hyperopia in 6- to 72-Month-Old African American and Hispanic Children: The Multi-Ethnic Pediatric Eye Disease Study - Corrected Proof

Multi-Ethnic Pediatric Eye Disease Study Group — 2009-11-18

Purpose: To determine the age-, gender-, and ethnicity-specific prevalence of myopia and hyperopia in African American and Hispanic children aged 6 to 72 months.Design: Population-based cross-sectional study.Participants: The Multi-Ethnic Pediatric Eye Disease Study is a population-based evaluation of the prevalence of vision disorders in children aged 6 to 72 months in Los Angeles County, California. Seventy-seven percent of eligible children completed a comprehensive eye examination. This report focuses on results from 2994 African American and 3030 Hispanic children.Methods: Eligible children in 44 census tracts were identified during an in-home interview and scheduled for a comprehensive eye examination and in-clinic interview. Cycloplegic autorefraction was used to determine refractive error.Main Outcome Measures: The proportion of children with spherical equivalent (SE) myopia ≤ −1.00 diopter (D) and SE hyperopia ≥ +2.00 D in the worse eye. Prevalence of myopia and hyperopia is also reported using alternative threshold definitions.Results: Prevalence of myopia was higher in African American (6.6%) compared with Hispanic children (3.7%; P<0.001). Hispanics showed a higher prevalence of hyperopia than African American children (26.9% vs. 20.8% respectively, P<0.001). The prevalence of myopia showed a significant decreasing trend with age (P<0.001). Hyperopia prevalence reached a low point at approximately 24 months of age but increased and remained higher than that thereafter. No significant gender differences were found in the prevalence of refractive error for either ethnic group.Conclusions: We observed ethnicity-related differences in both hyperopia and myopia prevalence in preschool children. The age-related decrease in myopia prevalence in preschool children could reflect early emmetropization and contrasts with the increase in myopia prevalence known to occur in older school-aged children. The limits of emmetropization are evident, however, in the persistently elevated prevalence of hyperopia beyond 24 months of age.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Pupillographic Investigation of the Relative Afferent Pupillary Defect Associated with a Midbrain Lesion - Corrected Proof

Aki Kawasaki, Neil R. Miller, Randy Kardon — 2009-11-17

Objective: To identify clinical and pupillographic features of patients with a relative afferent pupillary defect (RAPD) without visual acuity or visual field loss caused by a lesion in the dorsal midbrain.Design: Experimental study.Participants and Controls: Four patients with a dorsal midbrain lesion who had normal visual fields and a clinically detectable RAPD.Methods: The pupil response from full-field and hemifield light stimulation over a range of light intensities was measured by computerized binocular pupillography.Main Outcome Measures: The mean of the direct and consensual pupil response to full-field and hemifield light stimulation was plotted as a function of stimulus light intensity.Results: All 4 subjects showed decreased pupillographic responses at all intensities to full-field light stimulation in the eye with the clinical RAPD. The pupillographic responses to hemifield stimulation showed a homonymous pattern of deficit on the side ipsilateral to the RAPD, similar to that observed in a previously reported patient with an optic tract lesion.Conclusions: The basis of a midbrain RAPD is the nasal-temporal asymmetry of pupillomotor input that becomes manifest when a unilateral postchiasmal lesion interrupts homonymously paired fibers traveling in the contralateral optic tract or midbrain pathway to the pupillomotor center, respectively. The pupillographic characteristics of an RAPD resulting from a dorsal midbrain lesion thus resemble those of an RAPD resulting from a unilateral optic tract lesion, but without the homonymous visual field defect.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Optical Coherence Tomography Quantitative Analysis of Iris Volume Changes after Pharmacologic Mydriasis - Corrected Proof

Florent Aptel, Philippe Denis — 2009-11-17

Purpose: To describe a method using anterior segment optical coherence tomography (AS OCT) for estimating iris volume. To quantify changes in iris volume induced by pharmacologic mydriasis in narrow-angle eyes predisposed to angle-closure compared with normal open-angle eyes.Design: Cross-sectional study.Participants: Thirty fellow eyes of 30 patients who had an episode of primary acute angle-closure and 30 eyes of 30 normal age- and gender-matched subjects with open angles. All fellow eyes had a patent laser peripheral iridotomy.Methods: Iris volume and all biometric measurements were performed before and after instillation of 1% tropicamide and at least 1 week later 10% phenylephrine. Iris volume was estimated using AS OCT radial sections of the iris and a customized image-processing software.Main Outcome Measures: Iris volume, pupil diameter, angle configuration including angle opening distance at 500 μm (AOD 500) and trabecular–iris space at 500 μm (TISA 500), AS OCT anterior chamber depth, and A-scan ultrasonography axial length before and after pupil dilation.Results: Iris volumes measured before dilation of the pupil were 44.94±2.1 mm3 and 44.29±3.9 mm3 in the fellow eyes and open-angle eyes, respectively, which was not significantly different (P>0.1). Thirty minutes after instillation of 1% tropicamide, mean iris volume increased significantly in the fellow eyes (from 44.94±2.1 mm3 to 49.92±2.9 mm3; P<0.01), whereas it decreased significantly in the open-angle eyes (from 44.29±3.9 mm3 to 37.88±2.2 mm3; P<0.01). Similar changes were observed after instillation of 10% phenylephrine. Based on multivariate analysis, significant predictors of increase in iris volume after pupil dilation were eyes predisposed to angle-closure compared with open-angle eyes (P = 0.008), larger pupil diameter (P = 0.02), and brown eyes (P = 0.01). Relative iris volume increase was correlated significantly with AOD 500 and TISA 500 relative decrease in the narrow-angle group (P<0.05).Conclusions: The iris volume may be estimated with AS OCT. The iris volume increases after pupil dilation in narrow-angle eyes predisposed to acute angle closure. In those patients, this biometric change is associated with a narrowing of the angle despite a patent laser peripheral iridotomy.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Idiopathic Intracranial Hypertension Is Associated with Lower Body Adiposity - Corrected Proof

Anat Kesler, Efrat Kliper, Galina Shenkerman, Naftali Stern — 2009-11-13

Objective: To characterize the obesity phenotype(s) in patients with idiopathic intracranial hypertension (IIH).Design: Database study.Participants: We studied 44 consecutive patients with IIH, in addition to 184 women attending the obesity clinic of the same medical center and 199 obese women participating in the first Israeli national survey on health and nutrition conducted in 1999 and 2000.Methods: Anthropometric parameters were compared with those of 2 control groups of the same age range.Main Outcome Measures: Weight, height, and waist and hip circumference were measured.Results: Forty subjects, comprising 91.0% of this cohort, were either overweight (body mass index, 25.0–29.9 kg/m2) or obese (body mass index ≥ 30 kg/m2). Mean waist circumference was 95.3 cm for IIH, 99.8 cm for the national survey, and 114.5 cm for the obesity clinic cohort (P<0.001), whereas hip circumference was 121 cm for IIH, 118.4 cm for the national survey, and 125.8 cm (P = not significant) for the obesity clinic cohorts. Waist-to-hip ratio, a descriptive measure of body fat distribution approximately reflecting upper to lower body fat ratio, was 0.79 in the patients with IIH, 0.84 in the national survey group, and 0.91 in the obesity clinic cohort (P<0.001; all comparisons were adjusted for age and body mass index).Conclusions: In IIH, fat tends to preferentially accumulate in the lower body relative to other obese women of the same range. Whereas most complications of obesity, such as hypertension, diabetes, dyslipidemia, and the metabolic syndrome, are linked to upper body adiposity, IIH may represent a unique condition potentially induced by nonvisceral fat-related mechanisms.Financial Disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article.

Micronutrients and Diabetic Retinopathy: A Systematic Review - Corrected Proof

2009-11-09

Background: We have evaluated the evidence for the association between intake and blood levels of micronutrients and diabetic retinopathy. Treatment for diabetic retinopathy requires significant clinical input and specialist ophthalmologic care. Micronutrients, including vitamin C, vitamin E, and magnesium, may interfere with pathologic mechanisms of diabetic retinopathy and potentially alter its risk.Methods: We conducted a search of epidemiologic literature in PubMed and Embase from 1988 to May 2008, using keywords for exposures, including magnesium, ascorbic acid, α-tocopherol and antioxidants, and outcomes, including diabetic retinopathy. Two authors independently extracted data and assessed the quality of the studies using the Newcastle-Ottawa Scale. The overall quality of evidence was graded as I (highest), II, or III (lowest).Results: Of the 766 studies identified, we reviewed 15 studies, comprising 4094 individuals. For vitamin C, hospital-based studies reported an inverse association between plasma levels with retinopathy, whereas population-based studies showed no association between dietary intake and retinopathy. For vitamin E, there was no association with dietary intake or plasma levels and retinopathy. For magnesium, a single prospective analysis showed an association between low levels in plasma and progression of retinopathy, but cross-sectional studies reported inconsistent results. In the assessment of quality, population-based studies had higher ratings than hospital-based studies.Conclusions: The evidence suggests that dietary intake or plasma levels of vitamins C and E and magnesium do not seem to be associated with diabetic retinopathy. Because of differences in study designs and measurement of micronutrients, incomplete ascertainment of retinopathy, and residual confounding, these findings require confirmation.Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Unintentional Displacement of the Retina after Standard Vitrectomy for Rhegmatogenous Retinal Detachment - Corrected Proof

2009-11-06

Objective: To study unintentional displacement of the retina after standard vitrectomy for rhegmatogenous retinal detachment (RRD).Design: Prospective interventional case series.Participants: Forty-three eyes of 43 consecutive patients with cystic RRD involving 1 or more quadrants underwent successful standard vitrectomy with 20% sulfur hexafluoride gas injection. Neither scleral buckling nor retinotomy was performed.Methods: Fundus autofluorescence (FAF) imaging was subsequently recorded to detect displacement of the retina using the Topcon TRC-50DX (Topcon, Tokyo, Japan) at 10 days and 1, 3, and 6 months postoperatively. Fluorescein angiography was also recorded using standard techniques for patients with abnormal FAF findings. Cyclotorsion and vertical deviation were measured postoperatively.Main Outcome Measures: The proportion of eyes with postoperative retinal displacement detected by FAF imaging.Results: The mean age of these 43 patients was 60 years with a range of 39 to 77 years. Of the 43 eyes, retinal detachment involved 1 quadrant in 2 eyes, 2 quadrants in 31 eyes, 3 quadrants in 8 eyes, and 4 quadrants in 2 eyes. After complete reattachment of the retina, FAF photography demonstrated hyperfluorescent lines superiorly parallel to retinal vessels within the vascular arcade in 27 of the 43 eyes (62.8%). Fluorescein angiography did not demonstrate any abnormalities corresponding to the linear autofluorescence. This autofluorescence was hypothesized to originate from increased metabolic activity of the retinal pigment epithelium that had been preoperatively located under the major retinal vessels and was postoperatively exposed to light because of downward displacement of the retina. Of the 27 eyes with retinal displacement, 1 to 5 degrees of extorsion were seen in 16 eyes (59.3%), and 1 to 4 degrees of vertical deviation were seen in 13 eyes (48.1%). None of the 27 patients had diplopia or slant. The extent of retinal detachment (P = 0.019) and the macular status (on or off) (P = 0.016) were significantly associated with postoperative displacement of the retina.Conclusions: In eyes with RRD treated with standard vitrectomy and gas injection, the retina may move downward after the surgery. If the extent of retinal detachment is large, or macular detachment is present, unintentional postoperative retinal translocation may easily occur.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Factors Affecting Rates of Visual Field Progression in Glaucoma Patients with Optic Disc Hemorrhage - Corrected Proof

2009-11-06

Purpose: Optic disc hemorrhage (DH) is an important risk factor for glaucoma progression. We sought to investigated factors affecting the rate of visual field (VF) progression after DH in glaucomatous eyes.Design: Retrospective cohort study.Participants: Consecutive glaucoma patients from our Glaucoma Progression Study with ≥5 Swedish interactive threshold algorithm standard 24-2 VFs from 1999 through 2008.Methods: Disc photographs of all patients were evaluated for the presence of DH. Exclusion criteria were conditions other than glaucoma likely to affect the VF and insufficient number of VFs to create a slope after DH detection. Automated pointwise linear regression was used to determine the rate of VF loss after DH detection. Fast progression was defined as a global VF loss of ≥1.5 dB/year. Factors associated with a fast rate of VF loss after the detection of the DH were evaluated.Main Outcome Measures: Assessed variables included baseline (age, gender, intraocular pressure (IOP), central corneal thickness, VF mean deviation (MD), presence of migraine, Raynaud's phenomenon, low blood pressure, and exfoliation syndrome) and intercurrent data (DH recurrence, fellow eye involvement, glaucoma surgery, and IOP reduction). Odds ratios (ORs) and 95% confidence intervals (CIs) were determined for each variable.Results: Seventy-six eyes (76 patients; mean age, 68.3±10.9 years) were enrolled. Mean IOP and VF MD at the time of the DH detection were 16.6±3.8 mmHg and −5.6±5.7 dB, respectively. The mean global progression rate after DH was −1.1±1.3 dB/year (mean follow-up, 3.8±2.8 years). A rate of progression of ≥1.5 dB/year was found in 20 (26%) eyes. Multivariate logistic regression analysis revealed larger baseline MD (OR, 1.11; 95% CI, 1.01–1.20; P = 0.03) and older age (OR, 1.06; 95% CI, 1.01–1.13; P = 0.04) to be significant risk factors for fast progression after DH. Eyes with a baseline MD worse than −4.0 dB had a 270% increased risk of fast progression compared with those with an MD better than −4.0 dB.Conclusions: The presence of a DH in older subjects with a worse VF predicted further VF global MD deterioration by more than 5 dB within 4 years. These eyes should undergo careful and frequent disease surveillance and consideration should be given to more aggressive treatment.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Vascular Endothelial Growth Factor Gene Variation and the Response to Photodynamic Therapy in Age-Related Macular Degeneration - Corrected Proof

2009-11-06

Purpose: To evaluate the role of vascular endothelial growth factor (VEGF) gene polymorphisms in exudative age-related macular degeneration (AMD).Design: Retrospective, comparative case series.Participants: Patients with recent exudative AMD (n = 162) and age-matched subjects without AMD (n = 85).Methods: Fluorescein angiography (FA), clinical examination, and single nucleotide polymorphism (SNP) genotyping.Main Outcome Measures: The frequencies of 3 VEGF gene SNPs were analyzed, 1 at the promoter site (rs699947, A→C) and 2 intronic SNPs (rs2146323, A→C, and rs3025033, A→G), in relation to the risk of AMD, to choroidal neovascular (CNV) lesion size and configuration, and to the anatomic response to photodynamic therapy (PDT). These SNPs were chosen to cover all the haploblocks of the VEGF gene. The 86 patients who had undergone PDT were classified as either PDT responders or PDT nonresponders based on the outcome of PDT after the last treatment session. For the PDT responders, the treating physician had deemed the lesion to be clinically dry and without leakage from CNV in FA at a visit scheduled at least 12 weeks after the last PDT treatment. For the PDT nonresponders, the PDT sessions had been discontinued by the treating retina specialist because of an apparently poor response and a still exudative lesion after several PDT sessions.Results: The presence of exudative AMD or lesion size or configuration was not associated with the SNPs studied here. The frequencies of the rs699947 were significantly different in PDT nonresponders and PDT responders. The AA, AC, and CC genotypes were 14%, 39%, and 46%, respectively, in PDT nonresponders, compared with 40%, 48%, and 12%, respectively, in the PDT responders (P = 0.0008). The corresponding frequencies for the rs2146323 AA, AC, and CC genotypes were 4%, 32%, and 64%, respectively, in nonresponders and 24%, 38%, and 38%, respectively, in responders (P = 0.0369). The genotypes of the rs3025033 SNP were distributed evenly between the responders and nonresponders.Conclusions: The VEGF gene polymorphic SNPs at rs699947 and rs2146323 are strong determinants of the anatomic outcome after PDT, but the SNPs studied were not associated with the presence of exudative AMD or with the CNV lesion size or configuration.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Development and Initial Validation of Quality-of-Life Questionnaires for Intermittent Exotropia - Corrected Proof

2009-11-06

Purpose: The development and initial validation of patient-derived, health-related quality-of-life (HRQOL) questionnaires for intermittent exotropia (IXT).Design: Cross-sectional study.Participants: In a development phase, 27 children (age, range, 2–17 years) with IXT and 1 of their parents. In an initial validation phase, 33 children with IXT and 49 control children (age, 5–17 years), along with 1 parent for each child. Children in the control group had no strabismus or amblyopia.Methods: Individual patient interviews generated 35 items for child and proxy (parental assessment of child's HRQOL) questionnaires and 46 items for a parent questionnaire. To reduce to a feasible number of items, questionnaires were administered to 5- to 17-year-old children with IXT (n = 15) and parents of 2- to 17-year-old children with IXT (n = 27). Responses were analyzed using standard item reduction methodology. Three final derived IXT questionnaires (IXTQ): child, proxy, and parent (12, 12, and 17 items, respectively) were administered to children with IXT and control children and to parents of IXT and control children. Likert-type scales ranging from never (100, best HRQOL) to almost always (0, worst HRQOL) were used.Main Outcome Measures: Median scores for IXT and control groups, compared using Wilcoxon tests.Results: Median child scores were significantly lower (worse HRQOL) in the IXT group compared with the control group: 85 (quartiles, 73–92) versus 92 (quartiles, 79–96; P = 0.04). Median proxy IXTQ scores were significantly lower for IXT children than controls: 83 (quartiles, 75–94) versus 98 (quartiles, 92–100; P<0.0001). Median parent IXTQ scores also were significantly lower in the IXT group compared with the control group: 68 (quartiles, 56–79) versus 93 (quartiles, 87–99; P<0.0001).Conclusions: A new 3-part patient-derived HRQOL questionnaire for children with IXT and their parents has been developed and validated, comprising child, proxy, and parent questionnaires. These questionnaires detect reduced HRQOL in children with IXT as reported by the children themselves and perceived by their parents (proxy report). Childhood IXT also seems to affect parent HRQOL. The IXTQ HRQOL questionnaires may prove useful in the clinical assessment of IXT and for clinical trials.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Shifting of the Line of Sight in Keratoconus Measured by a Hartmann-Shack Sensor - Corrected Proof

2009-11-06

Purpose: To evaluate ocular wavefront aberrations owing to keratoconus compared with normal controls and to describe the changes in the axis of line of sight (LoS) among keratoconic patients.Design: Prospective case-control study.Participants: Fifty-five eyes of 30 patients with keratoconus and 100 eyes of 50 refractive surgery candidates with normal corneas.Methods: Ocular aberrations over a 4.5 mm (undilatated) pupil were measured with a Hartmann-Shack sensor. Corneal topographic measurement was performed with a Tomey corneal topographer. The axis of the displacement of LoS was calculated by vector analysis.Main Outcome Measures: Root mean square (RMS) and higher order RMS values, ocular aberrations up to the 6th Zernike order and the distance of the LoS from the pupillary center (x and y offset values) in keratoconic and normal eyes were measured with aberrometry. The steepest and average keratometric values and the axis of the steepest meridian were measured in keratoconic eyes with topography. Correlations were made between the size and the direction of the shift in the LoS and ocular aberrations.Results: The following parameters were significantly higher in the keratoconus group compared to the control group: higher order RMS (P<0.001), Z3−1 (P<0.001), Z3−3 (P<0.002), Z33 (P = 0.001), Z4−2 (P<0.001), Z42 (P<0.001), Z44 (P = 0.016), Z5−5 (P = 0.03), Z5−1 (P = 0.04), Z53 (P = 0.01), and y offset value (P<0.001). In keratoconic patients there was a significant correlation between the axis of the shift in the LoS and the steepest keratometric axis on topography (r = 0.59; P<0.001), the distance of the LoS from pupil center and vertical coma (r = −0.39; P = 0.004), and spherical aberration (SA; r = 0.29; P<0.04). There was also a significant correlation between the average keratometry value measured by topography and SA (r = −0.49; P<0.001). A factorial regression model testing the interactive effects of vertical coma and SA on the shift of LoS had a good fit on our data (r2 = 0.69; P<0.001).Conclusions: A significant displacement of the LoS is observed in keratoconus and relates to the position of the cone on topography and the induced vertical coma measured by aberrometry.Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

The Ability of Short-Wavelength Automated Perimetry to Predict Conversion to Glaucoma - Corrected Proof

Josine van der Schoot, Nicolaas J. Reus, Thomas P. Colen, Hans G. Lemij — 2009-11-06

Purpose: Short-wavelength automated perimetry (SWAP) has been claimed to predict conversion to glaucoma 3 to 4 years before standard automated perimetry (SAP) defects occur. This study compared the moment of glaucomatous conversion between SWAP and SAP.Design: Prospective, longitudinal follow-up study.Participants: Four hundred sixteen subjects with ocular hypertension (intraocular pressure ≥22 and ≤32 mmHg and normal visual fields).Methods: A Humphrey Field Analyzer (24-2 program; Carl Zeiss Meditec, Dublin, CA) was used to perform both SWAP and SAP. All participants were tested once every half year during 7 to 10 years or until the onset of conversion (study end point). The conversion to glaucoma was defined as a reproducible glaucomatous visual field defect in SAP.Main Outcome Measures: The moment of onset of a reproducible defect in SAP was compared with that in SWAP.Results: Of the 416 initial participants, 24 eyes of 21 subjects showed conversion in SAP. Of these eyes, 22 did not show earlier conversion in SWAP than in SAP. Standard automated perimetry even showed earlier conversion than SWAP in 15 cases. In only 2 eyes did SWAP show earlier conversion by up to 18 months.Conclusions: These results do not support the notion that SWAP generally predicts conversion to glaucoma in SAP. Instead, SAP appears to be at least as sensitive to conversion as SWAP in a large majority of eyes.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Moving the Goal Posts: Definitions of Success after Glaucoma Surgery and Their Effect on Reported Outcome - Corrected Proof

Alan P. Rotchford, Anthony J. King — 2009-11-05

Purpose: To determine (1) the extent to which the definition of success of glaucoma surgery varies in the literature and (2) the degree to which the reported outcome after trabeculectomy is affected by the criteria used to define success.Design: A systematic review of the literature and application of definitions to a retrospective cohort.Participants: A cohort of 100 patients who previously underwent trabeculectomy.Methods: A literature search was performed of PubMed using the search term trabeculectomy for a 5-year period. Studies presenting original data relating to longitudinal intraocular pressure (IOP) control after glaucoma surgery were included. The definitions of success and failure used were documented for each publication. Each IOP-related definition of success was applied to a cohort of patients who previously underwent trabeculectomy. Success rates were derived for each published definition up to 36 months after surgery.Main Outcome Measures: Intraocular pressure measured by Goldmann applanation tonometry.Results: From 100 publications meeting the inclusion criteria, 92 distinct IOP-related definitions of success were identified. Using these definitions, success rates for this series of 100 trabeculectomies varied between 36.0% and 98.0% after 3 years of follow-up.Conclusions: Over a recent 5-year period, there were nearly as many different definitions of success after glaucoma surgery as publications on the subject. The definition used markedly affects the quoted success rate after trabeculectomy, making interpretation of and comparison between published results extremely difficult. Standardization of published outcome parameters after glaucoma surgery is essential to allow meaningful comparisons between different study reports.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Conjunctival Nevi: Clinical Features and Therapeutic Outcomes - Corrected Proof

Laurent Levecq, Patrick De Potter, Jacques Jamart — 2009-11-05

Objective: To determine the epidemiology and the clinical and therapeutic outcomes of conjunctival nevi and to identify the clinical variables statistically associated with operative excision.Design: Prospective, observational, noncomparative case series.Participants: Two hundred fifty-five patients with the clinical diagnosis of conjunctival nevus.Methods: Consecutive cases of conjunctival nevi managed at a single institution were studied to identify the clinical risk factors for operative excision.Main Outcome Measures: Reasons for operative excision.Results: Of the 255 patients who were periodically observed for a mean of 5.3 years (range, 1–11), nevi were clinically diagnosed in 140 females and 115 males and modified operative excision was performed in 75 patients (29%). The decision of operative excision was made by the surgeon in 13 cases (17%) and by the patient in 62 cases (83%). In those 13 patients, the operative decision was prompted by our concern for possible malignant transformation based on suspicious biomicroscopic features in 10 patients (13%) and photographically documented tumor growth in 3 patients (4%). For the other 62 patients who elected to undergo surgery, their reasons for excision included patient's concern for cancer in 34 cases (45%), cosmetic arguments in 9 cases (12%), and patient's request owing to lesion-induced ocular surface irritation in 19 cases (25%). Comparison between groups showed that the clinical factors at initial visit that were statistically predictive of surgical excision were the older age of the patient (P = 0.001), the largest basal tumor diameter (P<0.001), tumor location (P = 0.023), and presence of clear cysts (P = 0.013), of intrinsic vasculature (P<0.001), of prominent feeder vessels (P<0.001), and of corneal involvement (P = 0.008). None of the excised lesions showed histopathologically malignant features.Conclusions: In our series, documented tumor growth of conjunctival nevus remained relatively a uncommon event with a incidence of 4%. Conjunctival nevi in older patients, associated with dilated feeder vessels, prominent intrinsic vasculature, and corneal involvement were more likely to be treated with operative excision.Financial Disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article.

Germline Mosaicism for KIF21A Mutation (p.R954L) Mimicking Recessive Inheritance for Congenital Fibrosis of the Extraocular Muscles - Corrected Proof

2009-11-05

Objective: To document the genotype for familial congenital fibrosis of the extraocular muscles (CFEOM) with apparent autosomal recessive inheritance.Design: Interventional family study.Participants: Two affected siblings, 3 asymptomatic siblings, and their 2 asymptomatic parents.Methods: Ophthalmologic examination and candidate gene analysis (KIF21A and PHOX2A from venous blood samples) of the 2 affected siblings and their parents; confirmatory testing for 3 available asymptomatic siblings.Main Outcome Measures: Significant clinical observations and results of gene testing.Results: The 2 affected siblings had large-angle exotropia, moderate bilateral hypotropia, moderate bilateral ptosis, sluggish pupils, and almost complete ophthalmoloplegia with some abnormal synkinesis. The asymptomatic parents were not related and had unremarkable ophthalmic examinations. Four other siblings were normal by history; 3 underwent venous blood sampling for confirmatory testing. Candidate gene testing of PHOX2A, the gene for recessive CFEOM (CFEOM2), did not reveal mutation in the 2 patients or their parents. Sequencing of KIF21A, the gene for dominant CFEOM (CFEOM1), revealed heterozygous p.R954L in both affected individuals but in not in their parents or 3 asymptomatic siblings, consistent with parental germline mosaicism. Haplotype analysis suggested paternal inheritance but was not conclusive.Conclusions: Parental germline mosaicism can mimic recessive inheritance in CFEOM and likely is underrecognized. Ophthalmologists should be aware of this phenomenon when counseling parents of children with apparent recessive (or de novo) hereditary eye disease. Unlike other reported KIF21A mutations that cause CFEOM1, the p.R954L variant seems to be associated with abnormal pupils.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Clinical and Histopathologic Evaluation of Six Human Eyes Implanted with the Bag-in-the-Lens - Corrected Proof

Liliana Werner, Marie-José Tassignon, Brian E. Zaugg, Veva De Groot, Jos Rozema — 2009-11-05

Purpose: To describe the clinical and histopathologic features of eyes implanted with the bag-in-the-lens (BIL), which involves the use of a twin capsulorhexis lens design, and performance of anterior and posterior capsulorhexes.Design: Case series with clinicopathologic correlation.Participants: Six eyes implanted with the foldable, hydrophilic acrylic BIL, obtained postmortem at different postoperative times, from 4 patients were studied.Methods: On the patients' death, the eyes were enucleated, immersed in fixative, and submitted for analyses under a high-frequency ultrasound unit (Artemis, Ultralink, St. Petersburg, FL; 50 MHz), gross analyses, and histopathologic analyses. Clinical data in each case were obtained by chart review.Main Outcome Measures: Clinical data obtained included patient demographics, preoperative evaluation, description of surgical implantation procedure, and postoperative outcomes. The postmortem evaluation included analyses of lens fixation and centration, as well as gross and histopathologic analyses of postoperative capsular bag opacification.Results: The patients were aged 74.6±12.6 years at implantation. The postoperative time in this series ranged from 4 to 39 months. In all eyes for which the surgical implantation was uneventful (N = 5), postoperative BIL decentration was insignificant. In 1 eye, the anterior capsulorhexis was torn off, and although BIL implantation was still possible, a relative lens decentration was observed postoperatively, but without clinical significance. Although progressively larger amounts of Soemmering's ring formation were observed in the specimens with larger follow-up, the central area delimitated by the rhexis openings remained perfectly clear in all 6 eyes.Conclusions: This is the first series of human eyes implanted with the BIL, obtained postmortem at different postoperative times. BIL centration depends on the performance of centered capsulorhexes of appropriate size. The results confirm the concept of the lens design in that any proliferative/regenerative material remains confined to the intercapsular space of the capsular bag remnant outside the optic rim.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Amblyopia Therapy in Children Identified by Photoscreening - Corrected Proof

2009-11-05

Purpose: To determine the efficacy of amblyopia treatment in children identified through a community photoscreening program.Design: Case series.Participants: We included 125 children diagnosed with amblyopia after referral from a photoscreening program.Methods: Retrospective chart review of 125 amblyopic children identified by photoscreening and treated in a single academic pediatric ophthalmology group practice. Treatment regimens included spectacles, patching, and/or atropine penalization. Successful treatment was defined as ≥3 Snellen line equivalent improvement in visual acuity and/or 20/30 visual acuity in the amblyopic eye in literate children. Successful treatment in initially preliterate children was defined as 20/30 or better visual acuity in the amblyopic eye.Main Outcome Measures: Percentage of successfully treated amblyopic children.Results: Of 901 children evaluated after being referred from photoscreening, 551 had amblyopiogenic risk factors without amblyopia, 185 were diagnosed with amblyopia, and 165 were false positives. Of 185 children with amblyopia, 125 met inclusion criteria for analysis and 78% (97 of 125) were successfully treated.Conclusions: The success rate of amblyopia treatment in children identified through our photoscreening program is high. This study supports the role of photoscreening programs in the prevention of amblyopia-related vision loss. Such early screening may translate to true visual acuity improvement.Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Epiblepharon in East Asian Patients: The Singapore Experience - Corrected Proof

2009-11-05

Purpose: To describe the demographics, presenting symptoms, indications for surgery, and surgical outcomes of epiblepharon correction in a tertiary care hospital in Singapore.Design: Retrospective review of patients who underwent surgery by 2 surgeons in a referral oculoplastic practice at the National University Health System, Singapore, from 2001 to 2007.Participants: A total of 108 patients who underwent surgery for clinically significant epiblepharon.Intervention: Modified Hotz procedure or suture correction for patients in whom conservative treatment failed.Main Outcome Measures: Comparison of symptoms, keratopathy, and recurrence on follow-up between the 2 procedures.Results: The mean age of the patients was 9.0 years, with an age range of 0.5 to 68 years. Of the patients, 51.9% were male. The majority were Chinese (n = 102). Seventy-four (68.5%) patients were symptomatic. Eighty-nine patients (82.4%) had keratopathy. In 98 patients (90.7%) both eyes were affected, and the majority of patients (75.0%) had epiblepharon of the lower lids. Initial treatment for the majority was lubricants (n = 71, 65.7%). The main indications for surgery were symptoms and keratopathy, with 37.9% of patients having both, and 44.4% and 15.7% of patients having either keratopathy or symptoms alone, respectively. Surgical correction consisted mostly of a modified Hotz procedure (n = 88, 81.5%), lid-everting sutures (n = 9, 8.3%), and others, including upper lid blepharoplasty with lid crease formation (n = 11, 10.2%). Outcomes were good, with the majority (n = 88, 81.5%) of lids being well corrected. Complications included undercorrection, overcorrection, wound dehiscence, and wound infections.Conclusions: Symptomatic epiblepharon, usually associated with keratopathy and commonly seen in children of East Asian descent, often requires surgical intervention with good surgical outcome. Increased awareness among ophthalmologists and pediatricians dealing with this ethnic group and age is emphasized. Contrary to the current practice of expectant observation, definitive surgical management should be considered when symptoms or keratopathy is present.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Intraocular Tumor-Associated Lymphangiogenesis: A Novel Prognostic Factor for Ciliary Body Melanomas with Extraocular Extension? - Corrected Proof

2009-11-04

Purpose: To evaluate whether intraocular tumor-associated lymphangiogenesis contributes to prognosis of ciliary body melanomas with extraocular extension and to study its association with other tumor characteristics.Design: Nonrandomized, retrospective case series.Participants: Twenty consecutive patients enucleated for a malignant melanoma of the ciliary body with extraocular extension.Methods: Lymphatic vessels were identified using lymphatic vascular endothelial-specific hyaluronic acid receptor-1 (LYVE-1) and podoplanin as specific immunohistochemical markers for lymphatic vascular endothelium. Baseline tumor characteristics included intra- and extraocular tumor size, 2009 tumor, node, metastasis (TNM) classification, route of extraocular spread, tumor cell type, mitotic rate, Ki-67 proliferation-index, microvascular patterns and density, tumor-infiltrating lymphocytes and macrophages, and expression of human leukocyte antigen (HLA) class I and insulin-like growth factor-1 receptor. Kaplan-Meier and Cox regression analyses of melanoma-specific survival were performed.Main Outcome Measures: Prevalence of intraocular LYVE-1+/podoplanin+ lymphatic vessels and association with intraocular tumor characteristics and metastasis-free survival.Results: Intraocular LYVE-1+ and podoplanin+ lymphatic vessels could be detected in 12 (60%) of 20 ciliary body melanomas with extraocular extension. Presence of intraocular LYVE-1+/podoplanin+ lymphatic vessels was significantly associated with larger intra- (P = 0.002) and extraocular tumor size (P<0.001), higher TNM categories (P = 0.004), epithelioid cellularity (P = 0.016), higher mitotic rate (P = 0.003), higher Ki-67 proliferation-index (P = 0.049), microvascular networks (P = 0.005), higher microvascular density (P = 0.003), more tumor-infiltrating macrophages (P = 0.002), higher expression of HLA class I (P = 0.046), and insulin-like growth factor-1 receptor (P = 0.033), but not significantly with route of extraocular spread (P = 0.803), and tumor-infiltrating lymphocytes (P = 0.069). Melanoma-specific mortality rates increased significantly with the presence of intraocular LYVE-1+/podoplanin+ lymphatic vessels (P = 0.008). By multivariate Cox regression, tumor size (hazard ratio, 14.40; P = 0.002) and presence of intraocular lymphatic vessels (hazard ratio, 8.09; P = 0.04) were strong prognostic predictors of mortality.Conclusions: Intraocular peritumoral lymphangiogenesis seems to be associated with an increased mortality risk in patients with ciliary body melanomas and extraocular extension. This association may be primarily because of an association of intraocular lymphangiogenesis with greater tumor size and increased malignancy.Financial Disclosure(s): The authors have no commercial or proprietary interest in any of the materials discussed in this article.

A 27–Gauge Instrument System for Transconjunctival Sutureless Microincision Vitrectomy Surgery - Corrected Proof

Yusuke Oshima, Taku Wakabayashi, Tatsuhiko Sato, Masahito Ohji, Yasuo Tano — 2009-11-02

Objectives: To evaluate the efficiency, preliminary safety, and feasibility of a 27-gauge instrument system for transconjunctival microincision vitrectomy surgery (MIVS) in a variety of vitreoretinal diseases.Design: Experimental, interventional case series.Participants: Thirty-one eyes (31 patients) underwent a variety of vitreoretinal procedures using the 27-gauge transconjunctival MIVS system to treat epiretinal membrane (n = 10), idiopathic macular holes (n = 7), diabetic vitreous hemorrhage (n = 5), vitreous opacity with suspicion of intraocular lymphoma (n = 4), focal diabetic traction retinal detachment (n = 3), macular traction syndrome (n = 1), and macular edema secondary to central retinal vein occlusion (n = 1).Methods: We developed a 27-gauge instrument system that includes an infusion line, a high-speed vitreous cutter, an illumination system, and a variety of vitreoretinal instruments, such as membrane forceps and sharp-tipped endophotocoagulation probes. The duty cycle of the 27- and 25-gauge cutters was measured for several cut rates using a high-speed imaging camera. Infusion and aspiration rates were measured using balanced saline solution (BSS) and porcine vitreous with different aspiration levels. Surgical outcomes, including anatomic success, visual outcomes, operating times, and intraoperative and postoperative complications, were evaluated.Main Outcome Measures: Duty cycle of cutters, infusion and aspiration rates, and surgical results of 27-gauge vitrectomy.Results: Although the infusion and aspiration rates of the 27-gauge system measured in BSS were reduced to an average of 62% and 80%, respectively, compared with those of the 25-gauge system, the duty cycle of the 27-gauge cutter, 61% at 1000 cpm and 38% at 1500 cpm, was equal to or better than those of the 25-gauge cutter (62% and 28%, respectively). Analysis of the fluid dynamics showed that vented gas-forced infusion can be set to range from 20 to 30 mmHg to control intraocular pressure (IOP) during 27-gauge vitrectomy. Anatomic success was achieved in all study eyes (100%); 20 eyes (65%) had visual improvement of 3 lines or more. No eyes required conversion to larger gauge instrument. All sclerotomies self-sealed without hypotony (IOP ≤ 7 mmHg) from 1 day postoperatively.Conclusions: Although the fluid dynamics and cutting efficiency of 27-gauge instruments are lower compared with 25-gauge MIVS, the 27-gauge system is feasible and may reduce concerns about wound sealing-related complications in selected cases.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

The 25-Year Incidence of Visual Impairment in Type 1 Diabetes Mellitus: The Wisconsin Epidemiologic Study of Diabetic Retinopathy - Corrected Proof

Ronald Klein, Kristine E. Lee, Ronald E. Gangnon, Barbara E.K. Klein — 2009-11-02

Objective: To examine the 25-year cumulative incidence of visual impairment (VI) and its relation to various risk factors.Design: Population-based study.Participants: Nine hundred fifty-five insulin-taking persons living in an 11-county area in southern Wisconsin with type 1 diabetes diagnosed before age 30 years who participated in a baseline (1980–1982) and at least 1 of 4 follow-up (4-, 10-, 14-, and 25-year) examinations or who died before the first follow-up examination (n = 64).Methods: Best-corrected visual acuity (VA) was measured using a modification of the Early Treatment Diabetic Retinopathy Study protocol. Visual impairment and severe VI were defined as best-corrected VA in the better eye of 20/40 or worse and 20/200 or worse, respectively.Main Outcome Measures: Incidence of VI.Results: The 25-year cumulative incidences of any VI and severe VI (accounting for competing risk of death) were 13% and 3%, respectively. Multivariate models showed increased risk of VI was associated (hazard ratio, 95% confidence interval, and P value) with more severe baseline retinopathy (1.14 per 1-step increase in retinopathy level; 1.03–1.27; P = 0.01), presence of cataract (2.49 versus absence; 1.53–4.04; P<0.001), higher glycosylated hemoglobin (1.28 per 1%; 1.16–1.42; P<0.001), presence of hypertension (1.72 versus absence; 1.05–2.83; P = 0.03), and currently smoking (vs. never smoked, 1.63; 1.01–2.61; P = 0.04), but not proteinuria.Conclusions: These data show that the 25-year cumulative incidence of VI is related to modifiable risk factors and, therefore, that VI may be reduced by better glycemic and blood pressure control and avoidance of smoking.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Anterior Chamber Depth Is Significantly Decreased after Scleral Buckling Surgery - Corrected Proof

2009-10-28

Objective: Myopic patients have an increased risk for the development of a rhegmatogenous retinal detachment (RRD). Currently, myopic patients have the choice to undergo correction of their refractive error by the implantation of a phakic intraocular lens (pIOL). After pIOL implantation, progressive endothelial cell loss may result if the anterior chamber is too shallow. Because scleral buckling (SB) surgery for treatment of an RRD may in itself result in a decreased anterior chamber depth (ACD), this may become an important issue not only for the retinal surgeon who is faced with a patient who has both an RRD and a pIOL, but also for the refractive surgeon who should consider the potential problems of the implantation of pIOL in an eye that has previously undergone SB surgery. The goal of this study was to evaluate how long changes in ACD persist after SB procedures in patients with RRD.Design: Prospective case series.Participants: Thirty-eight eyes with a primary RRD treated by SB using an encircling element and a radial or segmental buckle; 31 fellow eyes served as controls.Methods: Anterior chamber depth (in the horizontal meridian) and axial length were measured preoperatively and at 1 week and 1, 3, 6, 9, and 12 months postoperatively with an anterior optical coherence tomography method and an IOLMaster (Carl Zeiss Meditec, Jena, Germany), respectively.Main Outcome Measures: In all 38 eyes, ACD was significantly reduced compared with preoperative levels up to 9 months after SB surgery.Results: Anterior chamber depth returned to normal at 1 year after surgery. Axial length was significantly enlarged during the whole follow-up period. No significant differences were found between the use of radial or segmental buckles.Conclusions: Anterior chamber depth may remain decreased after SB for a longer time period than previously reported.Financial Disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article.

Double Lacrimal Puncta: Clinical Presentation and Potential Mechanisms of Epiphora - Corrected Proof

Khami Satchi, Alan A. McNab — 2009-10-28

Purpose: Congenital supernumerary lacrimal puncta and canaliculi are rarely reported. Our purpose is to present the largest series of patients with supernumerary puncta and to describe the clinical presentation and associated lacrimal anomalies.Design: Observational retrospective case series.Participants: All patients diagnosed with supernumerary puncta by a single surgeon between 1988 and 2008.Methods: Retrospective case note review.Main Outcome Measures: Patient demographics, clinical presentation, lacrimal and systemic examination findings, management, and surgical outcomes.Results: Twenty-three patients (12 female, 11 male) with a median presenting age of 54 years (range, 1–88 years) had unilateral double lower lid puncta. In 5 patients the presence of a double punctum was an incidental examination finding. Eighteen patients had unilateral tearing on the same side as the double punctum. In 6 children presenting with tearing, associated congenital lacrimal anomalies included nasolacrimal duct obstruction, a lacrimal fistula, a lacrimal sac diverticulum, and absence of the upper canaliculus. Associated systemic findings in 3 children included Down syndrome (1 patient) and preauricular sinuses (2 patients). Of 12 adult patients presenting with ipsilateral tearing, 5 had complete nasolacrimal duct obstruction and 6 had either partial nasolacrimal duct obstruction or functional epiphora. Dacryocystorhinostomy was performed in 12 patients and resulted in improvement or resolution of symptoms in 11 patients (92%).Conclusions: Double lower lacrimal puncta may be associated with epiphora. In younger patients, tearing may be due to associated congenital anomalies of the nasolacrimal system. A proportion of patients presenting with onset of tearing in adulthood have patent lacrimal systems and otherwise normal adnexal examination results, suggesting that the presence of double puncta may be associated with compromised canalicular function. Reflux of tears through the accessory canaliculus is a potential mechanism and would be consistent with a recently proposed 2-compartment model of lacrimal canalicular drainage.Financial Disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article.

A Randomized Controlled Trial Comparing Everting Sutures with Everting Sutures and a Lateral Tarsal Strip for Involutional Entropion - Corrected Proof

2009-10-28

Objective: To determine whether there is a statistically significant difference in the surgical outcome of everting sutures (ES) alone versus everting sutures with a lateral tarsal strip (ES+LTS) in the treatment of involutional entropion.Design: Prospective randomized comparative trial.Participants: Sixty-three patients with primary involutional lower eyelid entropion were enrolled in the study. The age range was 54 to 94 years, with a mean age of 77 years. Baseline characteristics of the comparative groups were similar.Methods: Patients requiring primary surgical repair for involutional entropion were selected, and those providing informed consent were randomized for surgery. Thirty-six patients were randomized to ES alone, and 27 patients were randomized to ES+LTS. Patients were evaluated at 3 weeks and 6, 12, and 18 months postoperatively.Main Outcome Measures: Successful surgery was defined as a normal eyelid position at rest and inability to induce entropion on tetracaine provocation testing at or before the 18-month follow-up visit.Results: Eight patients were lost to follow-up (7 had ES alone). Of the 55 patients with complete follow-up data, there were 6 failed procedures in the patients who underwent ES alone and no failed procedures in the patients who underwent ES+LTS (P = 0.02).Conclusions: These data provide strong evidence that success rates at 18 months are higher in patients treated with ES+LTS procedure compared with ES alone.Financial Disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article.

Descemet's Membrane Endothelial Keratoplasty: Prospective Multicenter Study of Visual and Refractive Outcomes and Endothelial Survival - Corrected Proof

Marianne O. Price, Arthur W. Giebel, Kelly M. Fairchild, Francis W. Price — 2009-10-28

Purpose: To describe Descemet's membrane endothelial keratoplasty (DMEK) techniques, perioperative challenges, management, and visual and refractive outcomes.Design: Prospective, multicenter, consecutive case series.Participants: Sixty eyes of 56 patients with Fuchs' endothelial dystrophy, pseudophakic bullous keratopathy, or failed previous graft.Intervention: Descemet's membrane (DM) and endothelium were stripped from donor corneas submerged in corneal storage solution in a corneal viewing chamber. Donor DM diameters were 8.5 or 9.0 mm. The central 7 mm of DM was stripped from the recipient cornea. After staining with trypan blue to improve visualization, donor DM was inserted through a 2.8-mm incision. Descemet's membrane endothelial keratoplasty was performed alone (n = 48) or was combined with phacoemulsification and lens implantation (n = 11), pars plana vitrectomy (n = 2), or both.Main Outcome Measures: Best spectacle-corrected visual acuity (BSCVA), manifest refraction, and endothelial cell density.Results: Median BSCVA was 20/30 at 1 month (range, 20/20–20/60), improving from 20/50 (range, 20/25–hand movements) before DMEK, excluding 4 eyes (7%) with preexisting ocular pathologic features that limited visual potential. At 3 months, 26% had 20/20 vision, 63% saw 20/25 or better, and 94% saw 20/40 or better. Refractive cylinder remained unchanged at 0.9 diopters (D; P = 0.93), and a hyperopic shift of 0.49±0.63 D (P = 0.0091) was noted in DMEK single procedures. Endothelial cell loss was 30%±20% at 3 months and 32%±20% in 38 eyes that reached the 6-month examination. Median pachymetry decreased from 660 μm before surgery to 530 μm. Descemet's membrane stripped successfully from 60 of 72 donor corneas; 6 were converted successfully to Descemet's stripping automated endothelial keratoplasty (DSAEK) and 6 (8%) were discarded. Only 1 graft detached completely, but air was reinjected in 38 eyes (63%), mainly for partial detachments. Five DMEK corneas (8%) failed to clear and were replaced successfully with DMEK or DSAEK. All remained clear at last follow-up.Conclusions: Compared with DSAEK, DMEK provided a significantly higher rate of 20/20 and 20/25 vision, with comparable endothelial cell loss. Descemet's membrane endothelial keratoplasty restored physiologic pachymetry, but donor preparation and attachment currently are more challenging than with DSAEK.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Natural History of Open-Angle Glaucoma - Corrected Proof

2009-10-26

Objective: This article, based on the Early Manifest Glaucoma Trial (EMGT), provides prospective natural history data on progression of glaucomatous field defects in 3 of the most common glaucoma types.Design: Cohort of EMGT patients randomized to the untreated control group and followed up to the time of progression, when treatment could be initiated.Participants: We evaluated 118 control patients: 46 with high-tension glaucoma (HTG), 57 with normal-tension glaucoma (NTG), and 15 with pseudoexfoliation glaucoma (PEXG).Methods: Visual fields were tested every 3 months with the Humphrey 30-2 Full Threshold test program.Main Outcome Measures: Linear regression analyses of the perimetric mean deviation (MD) values were performed, and the rate of progression was defined as the regression coefficient in decibels per year. Percentages of progressed eyes and time to progression were determined using EMGT event-based predetermined progression criteria derived from Glaucoma Change Probability Maps.Results: The median and interquartile rates of visual function loss were −0.40 (1.05) dB/year overall and −0.46 (1.61) in HTG, −0.22 (0.65) in NTG, and −1.13 (6.13) in PEXG. Thus, interpatient variability was large. Mean rates were considerably higher than medians: −1.08 dB/year overall, −1.31 in HTG, −0.36 in NTG, and −3.13 in PEXG. Differences in median visual function progression rates among groups were statistically significant (NTG vs. HTG, P = 0.003; PEXG vs. non-PEXG, P<0.001). Progression was considerably and significantly faster in older than in younger patients (P = 0.002). By 6 years, 68% of patients had progressed overall, 74% of those with HTG, 56% of those with NTG, and 93% of those with PEXG (P = 0.012). Median time to progression also differed considerably among groups: 19.5 months in PEXG, 44.8 months in HTG, and particularly 61.1 months in NTG (P<0.0001).Conclusions: In this 6-year follow-up study, the median untreated rate of progression corresponded to advancing from normal visual function to blindness in approximately 70 years, whereas on the basis of the mean rate, visual function would show the same deterioration in approximately 25 years. Large differences existed among patients and different glaucoma types, with PEXG progressing considerably faster than HTG, and NTG progressing at the lowest rate.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Diurnal Intraocular Pressure Fluctuation and Associated Risk Factors in Eyes with Angle Closure - Corrected Proof

2009-10-22

Objective: To investigate diurnal intraocular pressure (IOP) fluctuation in eyes with angle closure in comparison with normal subjects and to look for associated risk factors for IOP fluctuation.Design: Prospective, cross-sectional study.Participants: Ninety-eight eyes of 98 Asian subjects with angle closure (consisting of 32 primary angle-closure suspects [PACS], 34 subjects with primary angle closure [PAC], and 32 subjects with primary angle-closure glaucoma [PACG]) and 21 eyes of 21 normal control subjects.Methods: All angle-closure subjects were enrolled after laser peripheral iridotomy but before commencement of any medical or surgical treatment. Ophthalmic examination, including dynamic gonioscopy and automated perimetry, were performed, and diurnal IOP measurements were obtained using noncontact air-puff tonometry at hourly intervals between 8:00 am and 5:00 pm. Mean diurnal IOP, peak diurnal IOP, trough IOP, and IOP fluctuation (peak IOP–trough IOP) were compared between groups. Multiple linear regression analysis was performed to study the association of IOP fluctuation with clinical variables such as age, extent of peripheral anterior synechiae (PAS), central corneal thickness, vertical cup-to-disc ratio, and pattern standard deviation (PSD) on automated perimetry.Main Outcome Measures: Mean diurnal IOP, peak IOP, and IOP fluctuation.Results: Most subjects were Chinese (89.1%) and female (61.3%). Intraocular pressure fluctuation was significantly higher in PACG (5.4±2.4 mmHg) and PAC (4.5±2.3 mmHg) subjects compared with PACS subjects (3.7±1.2 mmHg) and normal controls (3.8±1.1 mmHg; P = 0.005), with highest IOP found in the early morning. The combined PACG and PAC group had more than twice the risk (odds ratio, 2.38; 95% confidence interval, 1.1–5.1; P = 0.025) of having IOP fluctuation of more than 3 mmHg compared with the combined PACS and normal group. Extent of PAS (Pearson's correlation coefficient, r = 0.37; P = 0.0001) and visual field PSD (r = 0.34; P = 0.0002) were found to be associated with greater IOP fluctuation.Conclusions: The PACG and PAC eyes showed diurnal IOP fluctuation of 4 to 5 mmHg, and this fluctuation was higher than in PACS subjects and normal controls. The degree of PAS and visual field loss were associated with IOP fluctuation in PAC and PACG eyes.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Statin Use and the Incidence of Advanced Age-Related Macular Degeneration in the Complications of Age-Related Macular Degeneration Prevention Trial - Corrected Proof

2009-10-22

Objective: To evaluate the impact of statin use on the incidence of advanced age-related macular degeneration (AMD) and its components, choroidal neovascularization (CNV) and geographic atrophy (GA), among patients with bilateral large drusen.Design: Cohort study within a multicenter, randomized, clinical trial.Participants: Patients enrolled in the Complications of Age-related Macular Degeneration Prevention Trial (CAPT).Methods: Eligibility criteria for the clinical trial required that participants have ≥10 large (>125 μm) drusen and visual acuity ≥20/40 in each eye. Patients scheduled for their final CAPT visit after May 2005 were interviewed on their history of use of cholesterol-lowering medications, including statins. Trained readers identified CNV and end point GA (>1 Macular Photocoagulation Study disc area of GA) based on review of fluorescein angiograms and fundus photographs taken at annual follow-up visits and when patients reported symptoms. The risk ratio for participants developing CNV or developing GA associated with statin use was estimated with time-dependent Cox proportional hazards models.Main Outcome Measures: Development of advanced AMD, CNV, and end point GA.Results: Among 764 patients eligible for the interview, 744 (97.4%) patients completed the interview on medication use. Statin use was reported by 296 (39.8%) of those interviewed, with the majority, 187 (63.2%) of the 296, beginning use after enrollment in CAPT. Among 744 patients, advanced AMD developed in 332 (22.5%) eyes of 242 (32.5%) patients, CNV in 222 (15%) eyes of 176 (23.7%) patients, and GA in 114 (7.7%) eyes of 80 (10.8%) patients. With adjustment for other risk factors, the estimated risk ratio for eyes (95% confidence interval) associated with statin use was 1.15 (0.87–1.52) for advanced AMD, 1.35 (0.99–1.83) for CNV, and 0.80 (0.46–1.39) for GA.Conclusions: The CAPT data are not consistent with a strong protective effect (risk ratio, ≤0.85) of statins on the development of advanced AMD among patients with bilateral large drusen.Financial Disclosures: The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Intraoperative Pachymetric Measurements during Corneal Collagen Cross-Linking with Riboflavin and Ultraviolet A Irradiation - Corrected Proof

2009-10-22

Objective: To study central corneal pachymetric variations during corneal collagen cross-linking (CXL) treatment with the use of riboflavin and ultraviolet A irradiation (UVA).Design: Prospective, noncomparative, interventional clinical study.Participants: Fifteen keratoconic patients (19 eyes) were enrolled.Methods: All patients underwent riboflavin-UVA–induced corneal CXL. Intraoperative central corneal thickness (CCT) measurements using ultrasound pachymetry were performed during the procedure. Measurements were obtained after epithelial removal, after riboflavin drop instillation, and every 5 minutes (6 interval times) during UVA irradiation (30 minutes).Main Outcome Measurements: Central corneal thickness measurements.Results: Mean patient age was 26.9±6.5 years (range, 17–40 years). Ten were male and 5 were female. Mean preoperative CCT was 458.5±21.5 μm (range, 427–494 μm; 95% confidence interval [CI], 448–467 μm) and 415.7±20.6 μm (range, 400–468 μm; 95% CI, 406–426 μm) before and after epithelial removal, respectively. There was a statistically significant decrease (mean, 75 μm) of CCT between the epithelial removal interval (415.7±20.6 μm; range, 400–468 μm) and at the end of riboflavin solution instillation (340.7±22.9 μm; range, 292–386 μm; P<0.001). There was no statistically significant change in CCT during irradiation (P>0.05). There was no statistically significant difference between preoperative and 1-month postoperative endothelial cell count (preoperative, 2780±197 to 1-month postoperative, 2713±116; P = 0.14). No intraoperative, early postoperative, or late postoperative complications were observed in this patient series.Conclusions: During corneal CXL with the use of riboflavin and UVA irradiation, a statistically significant decrease of CCT was demonstrated.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Effect of Early Vitreous Surgery for Aggressive Posterior Retinopathy of Prematurity Detected by Fundus Fluorescein Angiography - Corrected Proof

2009-10-08

Objective: To assess the effect of early vitrectomy for aggressive posterior retinopathy of prematurity (APROP) using fundus fluorescein angiography.Design: Retrospective, observational case series.Participants: Eleven eyes of 7 patients with APROP that underwent early vitreous surgery.Methods: All eyes underwent vitrectomy with lensectomy that removed the vitreous gel around the fibrovascular proliferative tissue, but not the proliferative tissue when fibrovascular proliferation and retinal detachment occurred despite retinal photocoagulation. Fundus fluorescein angiography was performed before and after the early vitreous surgery.Main Outcome Measures: Dye leakage from the fibrovascular tissue, dilation and tortuosity of the retinal vasculature, and shunt vessels were evaluated by fundus fluorescein angiography. The status of the retinal reattachment was assessed postoperatively.Results: Nine eyes had severe dye leakage from the fibrovascular tissue and 2 eyes had moderate leakage seen by preoperative fluorescein angiography. Severe dilation and tortuosity of the retinal vessels were detected in 10 eyes and shunt vessels in 7 eyes. Six to 12 days after successful surgery, the retina reattached and dilation and tortuosity of the retinal vessels decreased substantially. Dye leakage diminished markedly in all eyes, resolved completely in 7 eyes, and was still apparent slightly in 4. At the final examination, fibrovascular proliferation and retinal detachment did not progress in any eyes; however, 2 eyes had a dragged or folded retina. Follow-up ranged from 6 to 19 months (mean, 9.2).Conclusions: Early vitrectomy that removes vitreous gel from around the proliferative tissue promptly reduces vascular activity and may limit progression of retinal detachment in APROP.Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Rituximab Treatment of Patients with Severe, Corticosteroid-Resistant Thyroid-Associated Ophthalmopathy - Corrected Proof

2009-10-08

Purpose: To study the effectiveness of anti-CD20 (rituximab [RTX]; Rituxan; Genentech, Inc., South San Francisco, CA) therapy in patients with severe, corticosteroid (CS)-resistant thyroid-associated ophthalmopathy (TAO).Design: Retrospective, interventional case series.Participants: Six consecutive subjects with severe, progressive TAO unresponsive to CS.Methods: Electronic medical record review of consecutive patients receiving RTX during the previous 18 months. Responses to therapy were graded using standard clinical assessment and flow cytometric analysis of peripheral lymphocytes.Main Outcome Measures: Clinical activity score (CAS), proptosis, strabismus, treatment side effects, and quantification of regulatory T cells.Results: Six patients were studied. Systemic CS failed to alter clinical activity in all patients (mean CAS±standard deviation, 5.3±1.0 before vs. 5.5±0.8 during therapy for 7.5±6.4 months; P = 1.0). However, after RTX treatment, CAS improved from 5.5±0.8 to 1.3±0.5 at 2 months after treatment (P<0.03) and remained quiescent in all patients (CAS, 0.7±0.8; P<0.0001) at a mean follow-up of 6.2±4.5 months. Vision improved bilaterally in all 4 patients with dysthyroid optic neuropathy (DON). None of the 6 patients experienced disease relapse after RTX infusion, and proptosis remained stable (Hertel measurement, 24±3.7 mm before therapy and 23.6±3.7 mm after therapy; P = 0.17). The abundance of T regulatory cells, assessed in 1 patient, increased within 1 week of RTX and remained elevated at 18 months of follow-up.Conclusions: In progressive, CS-resistant TAO, rapid and sustained resolution of orbital inflammation and DON followed treatment with RTX.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Anisometropia in Hispanic and African American Infants and Young Children: The Multi-Ethnic Pediatric Eye Disease Study - Corrected Proof

2009-10-08

Purpose: To determine anisometropia prevalence and associated risk factors in Hispanic and African American preschoolers.Design: Population-based, cross-sectional study.Participants: We included 3030 Hispanic and 2994 African American children aged 6 to 72 months from Inglewood, California.Methods: Retinomax autorefraction was performed on all participants after cycloplegia. Anisometropia was defined by difference in spherical equivalent (SE), by difference in plus cylinder in any axis (cylindrical), and by difference in cylinder axis vectors (vertical Jackson cross cylinder vector [J0] and oblique Jackson cross cylinder vector [J45] between the eyes. Strabismus was determined by prism-cover testing. A parental questionnaire explored potential risk factors including developmental delay, prematurity, prenatal exposure, and family history.Main Outcome Measures: Anisometropia prevalence stratified by age, gender, and ethnicity. The association of anisometropia with strabismus and other biological risk factors was assessed.Results: The prevalence of SE anisometropia ≥1.0 diopter (D) was 4.3% for Hispanics and 4.2% for African Americans. Prevalence of cylindrical anisometropia ≥1.0 D was 5.6% and 4.5%, respectively. Prevalence of cylindrical or SE anisometropia ≥3.0 D was ≤0.4% for both ethnic groups. Cylinder vector anisometropia ≥0.5 was twice as common as cylindrical anisometropia ≥1.0 D. The SE anisometropia decreased at age 1 year in Hispanics (P = 0.0016) but not African Americans. Cylindrical anisometropia decreased in the first year of life in both ethnic groups (P ≤ 0.001). There was no trend in SE or cylindrical anisometropia beyond 1 year of age, but cylinder vector anisometropia steadily decreased beyond 1 year of age in both ethnic groups. Cylinder vector anisometropia was more prevalent among African Americans, but there was no difference in other measurements of anisometropia between ethnic groups. Anisometropia did not vary by gender. Strabismus was associated with all types of anisometropia. No association of anisometropia with gestational age, birth weight, cerebral palsy, family history, or prenatal exposure could be identified.Conclusions: Spherical and cylindrical anisometropia (≥1.0 D) each affect 4% to 6% of Hispanic and African American preschoolers. Anisometropia ≥3.0 D is rare. Except for cylinder axis vector, the prevalence of anisometropia does not diminish beyond 1 year of age. Strabismus is associated with all forms of anisometropia.Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Novel Mutations and Electrophysiologic Findings in RGS9- andR9AP-Associated Retinal Dysfunction (Bradyopsia) - Corrected Proof

2009-10-08

Purpose: To examine the phenotypes of 8 patients with evidence of cone dysfunction and normal color vision (characteristic features of both oligocone trichromacy and bradyopsia), and subsequently to screen RGS9 and R9AP for disease-causing mutations.Design: Retrospective case series.Participants: Eight affected individuals from 7 families.Methods: Ophthalmologic examination, color vision testing, fundus photography, and detailed electrophysiologic assessment were undertaken. Blood samples were taken for DNA extraction from affected subjects and, where possible, unaffected relatives. Mutation screening of RGS9 and R9AP was performed.Main Outcome Measures: Detailed clinical, electrophysiologic, and molecular genetic findings.Results: All 8 patients had normal ocular examination results, with visual acuity ranging from 6/12 to 6/18. Four subjects were found to harbor mutations in RGS9 or R9AP, with 3 of the identified sequence variants being novel. Three subjects, 2 Pakistani sisters and an Afghani female, had mutations in R9AP. A novel homozygous nonsense mutation, p.G205fs, was identified in the simplex case, and a second novel homozygous in-frame deletion, p.D32_Q34del, was found in the 2 sisters. The remaining patient, a British male, had a compound heterozygous mutation in RGS9 (p.R128X/p.W299R). The mutation p.R128X represents the first nonsense mutation reported in RGS9. The 4 mutation-positive subjects had concordant characteristic previously described electrophysiologic findings that were not present in the 4 individuals in whom mutations were not identified. Novel findings associated with these mutation-positive patients included that they all showed electroretinogram (ERG) evidence of severe cone system dysfunction under photopic conditions but normal cone function to a red flash under scotopic conditions. Such findings seem unique for the disorder.Conclusions: This is the first report describing a nonsense mutation in RGS9. We have established novel electrophysiologic observations associated with RGS9 and R9AP mutations, including those relating to dark-adapted cone function and S-cone function. Patients with either RGS9/R9AP mutations (bradyopsia) or oligocone trichromacy have very similar clinical phenotypes, characterized by stationary cone dysfunction, mild photophobia, normal color vision, lack of nystagmus, and normal fundi. The distinctive electrophysiologic features associated with RGS9 and R9AP mutations enable directed genetic screening.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Mortality Associated with Resistant Cytomegalovirus among Patients with Cytomegalovirus Retinitis and AIDS - Corrected Proof

2009-10-08

Objective: To evaluate the effect of drug-resistant cytomegalovirus (CMV) on survival among patients with CMV retinitis.Design: Prospective cohort study during 1993 to 2003.Participants: We included 266 patients with AIDS and newly diagnosed CMV retinitis treated with either ganciclovir or foscarnet.Methods: Data on ganciclovir and foscarnet resistance were obtained from blood and urine specimens collected at regular, predetermined intervals. The effect of resistant CMV on mortality was evaluated with a time-dependent Cox proportional hazard model.Main Outcome Measures: Mortality.Results: The median survival of the entire cohort was 12.6 months. Analysis of risk factors for mortality demonstrated that resistant CMV was associated with an increased mortality (hazard ratio, 1.65; 95% confidence interval, 1.05–2.56; P = 0.032). Among the other parameters tested, only time since AIDS diagnosis was associated significantly with mortality, with a hazard ratio of 1.10 per year since AIDS diagnosis (P = 0.001).Conclusions: Resistant CMV is associated with increased mortality among patients with AIDS being treated for CMV retinitis.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Emerging Prevalence of Microsporidial Keratitis in Singapore: Epidemiology, Clinical Features, and Management - Corrected Proof

2009-10-07

Objective: To investigate the incidence and epidemiologic factors involved in the development of microsporidial keratitis. The association of host immune status and clinical pattern, clinical features, and the role of fluoroquinolone monotherapy in treatment are also examined.Design: Retrospective, noncomparative case series.Participants: All cases (124 patients, 134 eyes) of microsporidial keratitis confirmed with modified trichrome stain positive of corneal scrape over a 4-year period.Methods: Epidemiologic factors were observed. Host immune status with human immunodeficiency virus (HIV) serology and CD4/CD8 analysis was performed when consent was obtained. Visual acuity (VA) and slit-lamp examination throughout the course of keratitis was recorded. Treatment used included topical fluoroquinolones (ciprofloxacin 0.3%, moxifloxacin 0.5%, gatifloxacin 0.5%, levofloxacin 0.5%, or norfloxacin 0.3%) as monotherapy or in combination with topical fumagillin and/or systemic albendazole. Where corneal edema developed, ultrasound corneal pachymetry was recorded.Main Outcome Measures: Demographic features and epidemiologic factors, including host immune status. Clinical features and disease course, including the response to different therapeutic regimes.Results: Patients ranged in age from 11 to 68 years (mean, 31.9; median, 30) with a male:female ratio of 8:1 (females n = 17 [13.7%]). We performed HIV serology and CD4/CD8 in 45.9% of cases (n = 57); all the cases tested were negative with normal T-cell indices. Epidemiologic factors included soil exposure (50%), contact lens wear (21.1%), and topical steroid treatment (17.1%). The VA on presentation ranged from 20/20 to 20/100 (median, 20/30) with no loss in lines of VA on resolution. Common features were follicular papillary conjunctivitis and coarse punctate epithelial lesions in 3 patterns—diffuse, peripheral, and paracentral—evolving into nummular keratitis before resolution. Resolution occurred in 99% of cases on topical fluoroquinolone monotherapy. Four patients had recurrent disease that resolved with repeat fluoroquinolone or fluoroquinolone/oral albendazole combination. Two new clinical features were identified—diffuse endotheliitis (19.4%) with corneal edema and limbitis.Conclusions: This study identifies an increasing incidence of microsporidial keratitis in Singapore with a strong correlation with prior soil exposure. Diffuse endotheliitis and limbitis have not been described and resolves with topical steroid therapy. Topical fluoroquinolone monotherapy is a valid treatment option.Financial Disclosure(s): Proprietary or commercial disclosure maybe found after the references.

Predicted Long-term Outcome of Corneal Transplantation - Corrected Proof

2009-10-07

Objective: To analyze graft survival and the outcome of the corneal endothelium after corneal transplantation in a single model to predict the long-term prognosis of these grafts. Design: Cohort study. Data were recorded prospectively and then analyzed retrospectively. Participants: One thousand one hundred forty-four consecutive eyes of 1144 patients who underwent corneal transplantation between 1992 and 2006. Interventions: Penetrating keratoplasty and deep anterior lamellar keratoplasty. Main Outcome Measures: Slit-lamp examination and wide-field specular microscopy results. A joint analysis of endothelial cell loss and time to graft failure was undertaken. From midterm simultaneous analysis of graft survival and endothelial cell loss, long-term graft survival was predicted. Results: The observed 5- and 10-year graft survival estimates were, respectively, 74% and 64%. The average endothelial cell density (cell loss) was 2270 cells/mm2 before surgery, 1058 cells/mm2 (–53%) during the sixth postoperative year, and 865 cells/mm2 (–61%) during the 10th postoperative year. Overall, the predicted graft survival estimate was 27% at 20 years and 2% at 30 years. Both observed and predicted graft survival were higher in patients who had undergone lamellar keratoplasty than in patients who had undergone penetrating keratoplasty and had normal recipient endothelium and higher in patients who had undergone penetrating keratoplasty and had normal recipient endothelium than in patients who had undergone penetrating keratoplasty and had impaired recipient endothelium. Conclusions: For corneal diseases involving the endothelium, penetrating keratoplasty seems to be a good therapeutic approach in elderly patients because the graft life-span may be similar to the patient life expectancy. Conversely, for younger patients, penetrating keratoplasty is only a midterm therapeutic approach. For corneal diseases not involving the endothelium, deep anterior lamellar keratoplasty seems to be a promising therapeutic approach with higher long-term expected survival. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Familial Asymptomatic Macular Telangiectasia Type 2 - Corrected Proof

2009-10-07

Objective: To report findings in asymptomatic family members of patients with macular telangiectasia type 2.Design: Prospective, observational, cross-sectional case series.Participants: Four patients with symptomatic macular telangiectasia type 2 (index patients) and 5 relatives, including 2 sets of monozygotic twins.Methods: Screening of family members of participants in a non-interventional natural history study of macular telangiectasia type 2. Ophthalmologic examination included best-corrected visual acuity testing, fundus biomicroscopy, fluorescein angiography (FA), optical coherence tomography (OCT), and fundus autofluorescence (FAF) imaging.Main Outcome Measures: Evidence for macular telangiectasia type 2 in any of the imaging methods used and visual function of the family members studied.Results: In the first family, 2 of 3 daughters of a severely affected 68-year-old woman had features of macular telangiectasia type 2. Although one of the daughters was diagnosed by biomicroscopic examination, the second daughter was diagnosed only by subtle changes on OCT and FAF imaging. Both affected daughters were asymptomatic and were unaware that they had the condition. In the second family, clinical examination showed that the 60-year-old brother of the 75-year-old index patient obviously was affected, despite a lack of any subjective visual dysfunction. The 65-year-old monozygotic twin of the third index patient showed a slight retinal thinning within a small area temporal to the foveola in both eyes as well as minor staining on FA and a subtle monocular loss of macular pigment. The 56-year-old asymptomatic monozygotic twin of the last proband had opacification of the retina with leakage on FA in the right eye. The fellow eye was unremarkable except for an abnormal FAF signal that was present in both eyes.Conclusions: Macular telangiectasia type 2 may be more common than previously assumed, but patients may not seek ophthalmic care if their visual function is normal. The study of these early, asymptomatic cases may yield valuable insights into the pathogenesis of the condition. Further research is warranted to determine whether there is an underlying, dominantly inherited genetic abnormality in macular telangiectasia type 2 of variable penetrance and expressivity.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Imaging of Long-term Retinal Damage after Resolved Cotton Wool Spots - Corrected Proof

Maria Laura Gomez, Francesca Mojana, Dirk-Uwe Bartsch, William R. Freeman — 2009-10-07

Purpose: Patients infected with the human immunodeficiency virus (HIV) develop noninfectious retinopathy characterized by retinal cotton wool spots (CWS) and microvascular abnormalities. Ophthalmoscopically, CWS fade with time. We hypothesized that structural changes should be permanent and possibly visible well after ophthalmoscopic resolution. We used simultaneous spectral domain optical coherence tomography (SD-OCT)/scanning laser ophthalmoscope (SLO) to allow colocalization of the lesions and determine the extent and location of residual damage after ophthalmoscopic resolution of the lesions.Design: Retrospective, noninterventional case series.Participants: Eight eyes of 7 HIV patients with 19 resolved retinal CWS.Methods: Nineteen retinal CWS were imaged between 2 and 16 years (median, 7.84) after the acute lesions using simultaneous SD-OCT and SLO examinations. The areas of the previous CWS were scanned by overlaying the color retinal image over the SLO image and scanning at high resolution in the horizontal plane through the resolved lesion. Each CWS lesion had a control area taken from the same eye within 2 disc diameters of the lesion. The thickness of each of the retinal layers was compared between lesions and control areas using a paired t-test with multitest correction.Main Outcome Measures: Thickness of the retinal nerve fiber layer (RNFL), ganglion cell layer (GCL), inner plexiform layer (IPL), inner nuclear layer (INL), outer plexiform layer (OPL), and outer nuclear layer (ONL).Results: The greatest loss of thickness was seen in the retinal GCL with a 43% reduction in thickness. There was a statistically significant thinning of the RNFL, GCL, IPL, INL, and OPL. The median thickness differences ranged from 5 to 7 microns. This difference was highly significant. Another striking finding was the displacement of the ONL toward the retinal surface resulting in an apparent increase in thickness of the ONL by >15% (median difference, 12 microns).Conclusions: Our data, using ultrahigh resolution and high-speed SD-OCT/SLO, show and quantify the presence of permanent retinal destruction associated with retinal CWS in HIV disease.Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Incidence of Dislocation of Intraocular Lenses and Pseudophakodonesis 10 Years after Cataract Surgery - Corrected Proof

Eva I. Mönestam — 2009-10-07

Purpose: To estimate the incidence of early and late intraocular lens (IOL) dislocation and the frequency of pseudophakodonesis in a population-based cohort of cataract surgery cases. The patients were followed up from before to 10 years after surgery.Design: Cohort study.Participants: Eight hundred ten cataract surgery patients.Methods: A prospective population-based cohort of 810 cataract surgery patients with presenile or senile cataracts was examined before surgery. Ten years later, 289 (73%) of 395 survivors agreed to participate in an eye examination. In addition to a routine eye examination of the anterior and posterior segment, all eyes were assessed for pseudophakodonesis and significant dislocation of the IOL. The medical records were studied and information concerning previous postoperative surgical interventions such as IOL exchange or repositioning was noted. This information was also obtained from the records of the deceased patients and those unable or unwilling to participate. The material was analyzed statistically.Main Outcome Measures: Previous IOL exchange or repositioning surgery, significant IOL dislocation, and degree of pseudophakodonesis.Results: Most patients (n = 795/810; 98%) underwent sutureless clear corneal phacoemulsification surgery with a 3.2-mm temporal incision. A foldable IOL was implanted, 95% of which were an Alcon MA60BM AcrySof, (Alcon Inc, Fort Worth, TX). Approximately 40% of the patients had pseudoexfoliations (PEX). After a 10-year follow-up, 5 (0.6%) of the 800 patients at risk required surgery for a dislocated IOL. All of these patients were male, and in all cases, the dislocation was late and within the capsular bag. The cumulative incidence over 10 years was 1%. At the examination 10 years after surgery, 2 (0.7%) of 287 patients at risk had pronounced pseudophakodonesis and 4 (1.4%) had moderate pseudophakodonesis.Conclusions: The 10-year cumulative incidence of dislocated IOLs needing surgical attention was low in this population-based cohort with a high frequency of PEX. Early dislocation did not occur in any of the patients. The risk of this complication in an individual patient seems to be low. Because of the large number of people with previous cataract surgery, dislocated IOLs may cause a relatively large public health care burden.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Uveitis in a Patient Treated with Bacille-Calmette-Guérin: Possible Antigenic Mimicry of Mycobacterial and Retinal Antigens - Corrected Proof

2009-10-07

Purpose: To investigate the cellular immune response in uveitis developing after intravesical Bacille-Calmette-Guérin (BCG) applications.Design: Experimental study.Participants: A 72-year-old HLA-B27–negative patient with bilateral granulomatous anterior uveitis that developed during the third cycle of intravesical BCG applications she was receiving for treatment of bladder carcinoma.Methods: The patient's peripheral T cell reactivity to ocular autoantigens was compared with the response to purified protein derivative (PPD) from Mycobacterium tuberculosis. T-cell proliferation and cytokine and chemokine secretion were measured in vitro.Main Outcome Measures: Anterior uveitis was treated successfully with topical corticosteroids and cycloplegics.Results: The following were demonstrated: proliferation to PPD, interphotoreceptor retinoid-binding protein (IRBP), and IRBP-peptide R16, as well as secretion of proinflammatory cytokines in response to PPD, retinal soluble antigen (S-Ag), IRBP, cellular retinal-binding protein (CRALBP), and some S-Ag and IRBP peptides.Conclusions: These data indicate the generation of a polyclonal autoimmune reaction elicited by BCG. Amino acid sequence alignments revealed homologies between proteins from M. tuberculosis, BCG, and retinal antigens, suggesting antigenic mimicry as a potential cause of uveitis in this patient.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Interventions Improve Poor Adherence with Once Daily Glaucoma Medications in Electronically Monitored Patients - Corrected Proof

2009-10-07

Purpose: To investigate the impact of an intervention program to improve adherence with topical, once daily therapy for glaucoma.Design: Randomized controlled clinical trial.Participants: Sixty-six patients with glaucoma being treated with a prostaglandin analog in 1 or both eyes at the Scheie Eye Institute or Wilmer Eye Institute between November 2006 and June 2007.Methods: In an observational study, participants who took 75% or fewer doses (as measured using the travoprost Dosing Aid [DA]) during an initial 3-month period were randomized into 2 groups. The intervention group watched an educational video, reviewed current barriers to drop-taking and possible solutions with a study coordinator, received regular phone call reminders, and had audible and visible reminders activated on their DA devices. The control group was told to take drops as prescribed and received no additional intervention.Main Outcome Measures: Change in drop use adherence as determined by the DA device.Results: In the 3-month observation period before randomization, intervention group patients had used a mean of 54±17% of scheduled doses, and this increased to 73±22% during the following 3-month period (P<0.001, n = 35). The control mean adherence rate of 46±23% at baseline was statistically unchanged during the follow-up observation period (51±30%, P = 0.16, n = 31). In a multivariate analysis, intervention, baseline compliance rate of <50%, and white ethnicity were predictors of improved adherence during the 3 months of intervention. The intraocular pressure (IOP) of the intervention and control groups did not change between months 3 and 6 after intervention (P = 0.96, 0.34, respectively), and there was no correlation of IOP change with adherence rate change between both groups (Pearson correlation r = 0.06, P = 0.51).Conclusions: A multifaceted intervention significantly increased adherence with glaucoma medications. Those with improved adherence were in the intervention group, had very low adherence rates at baseline, and were white. IOP did not correlate with adherence. Further research is needed to determine which components of this intervention were most effective.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Low-Dose Aspirin and Medical Record–Confirmed Age-Related Macular Degeneration in a Randomized Trial of Women - Corrected Proof

William G. Christen, Robert J. Glynn, Emily Y. Chew, Julie E. Buring — 2009-10-07

Objective: To test whether alternate-day low-dose aspirin affects incidence of age-related macular degeneration (AMD) in a large-scale randomized trial of women.Design: Randomized, double-masked, placebo-controlled trial.Participants: Thirty-nine thousand eight hundred seventy-six healthy female health professionals aged 45 years or older.Intervention: Participants were assigned randomly to receive either 100 mg aspirin on alternate days or placebo and were followed up for the presence of AMD for an average of 10 years.Main Outcome Measures: Incident AMD responsible for a reduction in best-corrected visual acuity to 20/30 or worse based on self-report confirmed by medical record review.Results: After 10 years of treatment and follow-up, there were 111 cases of AMD in the aspirin group and 134 cases in the placebo group (hazard ratio, 0.82; 95% confidence interval, 0.64–1.06).Conclusions: In a large-scale randomized trial of female health professionals with 10 years of treatment and follow-up, low-dose aspirin had no large beneficial or harmful effect on risk of AMD.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Neovascular Age-related Macular Degeneration: Intraocular Cytokines and Growth Factors and the Influence of Therapy with Ranibizumab - Corrected Proof

2009-10-07

Purpose: To investigate concentrations of growth factors and inflammatory cytokines in eyes with neovascular age-related macular degeneration (AMD) before and during therapy with intravitreal ranibizumab and to identify associations with disease activity.Design: Prospective clinical trial.Participants and Controls: Twenty-eight eyes of patients with neovascular AMD were compared with 28 eyes of age-matched patients with cataract as control.Methods: Ranibizumab was administered intravitreously once at baseline, and retreatments were given at monthly visits if optical coherence tomography (OCT) revealed macular edema or vision loss had occurred. Aqueous humor samples were taken each time intravitreal interventions were performed. Follow-up was 12 months. Luminex (Luminex Inc., Austin, TX) multiplex assays were used for measurement of 29 different growth factors and cytokines, including vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF).Main Outcome Measures: Differences in the concentrations of growth factors and inflammatory cytokines in eyes with neovascular AMD compared with control eyes and the influence of therapy with intravitreal ranibizumab.Results: A significantly increased expression of VEGF (P = 0.033) and a significantly decreased expression of PDGF (P = 0.038) were measured in the aqueous humor of eyes with neovascular AMD. Furthermore, a significant decrease of VEGF (P<0.001) was observed after intravitreal injection of ranibizumab along with significant changes in visual acuity and central retinal thickness (P = 0.039 and P<0.001). During follow-up with a flexible regimen, a correlation was identified between increased VEGF levels and persistent or recurrent macular edema. Changes in PDGF levels were strongly associated with alterations in VEGF concentration.Conclusions: Vascular endothelial growth factor and PDGF-AA seemed to be associated with disease activity of neovascular AMD. Intravitreal anti-angiogenic treatment with ranibizumab resulted in significantly decreased intraocular VEGF expression below physiologic levels compared with controls. This effect was measurable as long as 4 weeks after each injection and was prolonged by consecutive retreatment. With recurrence after discontinuation of treatment, VEGF levels increased again.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Prevalence of Visually Significant Cataract and Factors Associated with Unmet Need for Cataract Surgery: Los Angeles Latino Eye Study - Corrected Proof

2009-10-07

Purpose: To estimate the prevalence of visually significant cataract in a US Latino population and to report predisposing, enabling, need, and health behavior characteristics associated with the unmet need for cataract surgery (UNCS).Design: Population-based, cross-sectional study.Participants: A total of 6142 Latinos 40 years and older from 6 census tracts in Los Angeles County, California.Methods: Participants completed an in-home interview and a comprehensive eye examination that included assessment of lens opacification, using the slit lamp-based Lens Opacities Classification System II (LOCS II), and best-corrected visual acuity. Visually significant cataract was defined by any LOCS II grading ≥2, best-corrected visual acuity <20/40, cataract as the primary cause of vision impairment, and self-reported vision of fair or worse. Because cataract surgery is not needed in all persons, participants with a visually significant cataract or prior cataract surgery in at least 1 eye composed the at-risk cohort needing cataract surgery. Unmet need for cataract surgery was defined as any person in the at-risk cohort who had at least 1 eye with a visually significant cataract. Univariate and stepwise logistic regression analyses were used to identify predisposing, enabling, need, and health behavior characteristics associated with UNCS.Main Outcome Measure: Prevalence of visually significant cataract and odds ratios (ORs) for factors associated with UNCS.Results: Of 6142 participants who completed the interview and clinical examination, 118 (1.92%) had visually significant cataract in at least 1 eye. Of the 344 participants who have needed cataract surgery, 118 (34.3%) had UNCS. Independent factors associated with UNCS included health behavior: having last eye examination ≥5 years ago compared with <1 year ago (OR, 3.76; 95% confidence interval [CI], 1.71–8.25), and enabling factors: being uninsured (OR, 2.79; CI, 1.30–5.19), income less than $20,000 (OR, 2.60; CI, 1.40–5.56), and self-reported barriers to eye care (OR, 2.41; CI, 1.14–5.13).Conclusions: Latinos in our study had a substantial UNCS. Because Latinos with specific health behavior and enabling characteristics were more likely to have UNCS, interventions aimed at modifying these characteristics may be beneficial in reducing the unmet need and thus reducing the burden of visual impairment related to cataract in the United States.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Major Eye Diseases and Risk Factors Associated with Systemic Hypertension in an Adult Chinese Population: The Beijing Eye Study - Corrected Proof

2009-10-07

Purpose: To assess the relationship of hypertension with major eye diseases and other ocular parameters.Design: Population-based study.Participants: The Beijing Eye Study is a population-based study that included 4439 Chinese subjects examined at the baseline examination in 2001; there was a follow-up examination in 2006, in which 3251 subjects participated, of whom 3222 had blood pressure measurements.Methods: All participants underwent an ophthalmic examination, anthropometric measurements, and blood pressure measurement. Hypertension was defined as a systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg, and/or self-reported current treatment for hypertension with antihypertensive medication.Main Outcome Measures: Blood pressure and ocular parameters, including intraocular pressure and prevalence of major ophthalmic diseases.Results: Mean age of participants in the present study was 60.4±10.0 years. Hypertension was present in 1500 (46.6%) of the 3222 subjects who had their blood pressure measured. In multiple regression analysis, hypertension was associated with higher intraocular pressure (β = 0.39; 95% confidence interval [CI], 0.12–0.66; P = 0.005), focal arteriolar narrowing (odds ratio [OR], 1.78; 95% CI, 1.34–2.36; P<0.001), arteriovenous nicking (OR, 1.50; 95% CI, 1.11–2.04; P = 0.009), generalized retinal arteriolar narrowing (OR, 1.65; 95% CI, 1.30–2.09; P<0.001), retinal vein occlusions (OR, 2.86; 95% CI, 1.21–6.80; P = 0.02), and diabetic retinopathy (OR, 1.90; 95% CI, 1.08–3.31; P = 0.02). Hypertension was not significantly associated with the prevalence of open-angle glaucoma (P = 0.19), angle-closure glaucoma (P = 0.15), age-related macular degeneration (AMD) (P = 0.73), nuclear cataract (P = 0.88), posterior subcapsular cataract (P = 0.30), cortical cataract (P = 0.10), or area of alpha zone (P = 0.05) or beta zone of parapapillary atrophy (P = 0.95).Conclusions: In Chinese persons, while controlling for other systemic parameters, hypertension was associated with increased intraocular pressure, retinal microvascular abnormalities, and prevalence of retinal vein occlusion and diabetic retinopathy. Hypertension was not associated significantly with AMD, age-related cataract, or glaucoma.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

An Outbreak of Post-Cataract Surgery Endophthalmitis Caused by Pseudomonas aeruginosa - Corrected Proof

2009-10-07

Objective: Infectious endophthalmitis is among the most serious complications of cataract surgery. Gram-negative bacteria, including Pseudomonas aeruginosa, are responsible for less than 30% of cases; however, their rapidity of infection and virulence often results in poor visual outcome despite prompt antibiotic treatment. The purpose of this study was to investigate an outbreak of post-cataract surgery P. aeruginosa endophthalmitis in India.Design: Hospital-based case series.Participants: Twenty patients with acute postoperative endophthalmitis who underwent cataract surgery at one of the peripheral centers of Joseph Eye Hospital, Tiruchirapalli, Tamil Nadu, India, from February 23 to April 2, 2008.Interventions: Vitreous aspirates and environmental surveillance specimens were inoculated for culture. Antibiotic susceptibility testing was performed by agar diffusion method. Polymerase chain reaction (PCR) with enterobacterial repetitive intergenic consensus (ERIC) primers (ERIC-PCR) was used to establish the clonal relationship between clinical and environmental isolates.Main Outcome Measure: Post-cataract surgery P. aeruginosa endophthalmitis.Results: Pseudomonas aeruginosa was isolated from 20 eyes with postoperative endophthalmitis, the phacoemulsifier's internal tubes, the povidone-iodine solution, and the operating theater air-conditioning system. All strains were multidrug-resistant to cefazolin, chloramphenicol, tetracycline, aminoglycosides, and fluoroquinolones; conversely, most of them were susceptible to polymyxin B. Polymerase chain reaction with enterobacterial repetitive intergenic consensus primers disclosed 2 major clusters: six genetically identical clinical isolates shared 94% of similarity with the air-conditioning isolate; 11 other clinical isolates had 88% of similarity with the former strain. Despite the prompt use of intravitreal antibiotics, 10 patients had evisceration or phthisis of the affected eye.Conclusions: The outcome of cataract surgery-related P. aeruginosa endophthalmitis is poor. The detection of multidrug-resistant isolates is a serious problem, jeopardizing an appropriate choice of treatment. Polymerase chain reaction with enterobacterial repetitive intergenic consensus results strongly suggest that the main source of infection in this outbreak was the contaminated air-conditioning system. Polymerase chain reaction with enterobacterial repetitive intergenic consensus is an inexpensive, fast, reproducible, and discriminatory DNA typing tool for effective epidemiologic surveillance of clinical and environmental isolates of P. aeruginosa.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Long-term Topical Steroid Treatment after Penetrating Keratoplasty in Patients with Pseudophakic Bullous Keratopathy - Corrected Proof

2009-10-07

Purpose: To assess the use of long-term topical corticosteroid treatment in patients with pseudophakic bullous keratopathy (PBK) after penetrating keratoplasty (PK).Design: Retrospective cohort study.Participants: This study considered patients with PBK undergoing an initial PK procedure for visual reasons in the United Kingdom between April 1999 and March 2004. There were 1274 initial PK procedures for PBK reported to United Kingdom Transplant in this period, of which 1184 (91%) were grafted for visual reasons. Of these 1184 grafts, follow-up was reported in 1033 instances (87%).Methods: A Cox regression model was used to investigate the combined effects of all preoperative factors (recipient age, human leukocyte antigen [HLA] matching, trephine size, deep stromal vascularization, surgeon activity) on graft failure. The model was fitted using all preoperative factors first, and subsequently, factors associated with corticosteroid and other medications were included.Main Outcome Measures: Graft survival.Results: Three-year survival of grafts for PBK was 65% (95% confidence interval [CI], 59%–70%). Topical corticosteroids were still being used beyond 18 months after surgery in 378 (37%) of the 1033 corneal grafts included in this study. The grafts of patients not currently receiving steroids were 1.5 times as likely to fail (hazard ratio [HR], 1.5; 95% CI, 1.0–2.2; P<0.03). Lack of HLA matching (P = 0.006), trephine size ≤7.50 mm and ≥8.00 mm (P = 0.03), recipient age younger than 65 years (P = 0.003), and corneal vascularization (P = 0.04) all increased the risk of graft failure.Conclusions: The use of long-term postoperative corticosteroids improved graft survival after PK for PBK. Barring patient contraindications for long-term topical corticosteroid use, clinicians should consider maintaining patients with PBK on long-term postoperative corticosteroid maintenance.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Analysis of Diluted Vitreous Samples from Vitrectomy Is Useful in Eyes with Severe Acute Postoperative Endophthalmitis - Corrected Proof

2009-10-07

Purpose: This study was designed to compare the diagnostic yield of microbiological analysis performed on diluted and undiluted vitreous samples from pars plana vitrectomy (PPV) in patients with acute postcataract endophthalmitis.Design: Cohort study, evaluation of diagnostic test or technology.Participants: Patients with acute postcataract endophthalmitis (<6 weeks).Methods: Undiluted and diluted vitreous samples were taken from 34 consecutive patients at the beginning of PPV as part of the multicenter prospective study of the French Institutional Endophthalmitis Study (FRIENDS) group. Vitrectomy was performed after 1 (n = 12) or 2 (n = 22) intravitreous antibiotic injections. McNemar's nonparametric test was used to compare culture and polymerase chain reaction (PCR) results between diluted and undiluted samples.Main Outcome Measures: Rate of positivity of conventional culture (brain heart infusion broth) and eubacterial PCR tests from undiluted and diluted vitreous samples.Results: The microbiological analysis of both undiluted and diluted vitreous samples detected and identified a bacterial pathogen in 26 out of 34 cases (76.4%). The analysis of undiluted and diluted vitreous at the time of PPV, using eubacterial PCR and conventional culture, gave similar results (P = 0.99; McNemar test). However, eubacterial PCR was more sensitive than culture in detecting bacteria in vitreous at the time of PPV (76% vs 6%; P = 0.001; McNemar test). The difference in sensitivity between the 2 techniques was primarily associated with false-negative culture results for undiluted samples (2/3 of cases), mainly for coagulase-negative staphylococci.Conclusions: The microbiological results obtained combining PCR and culture techniques were similar for diluted vitreous and undiluted vitreous analysis. When eubacterial PCR is available, sampling diluted vitreous, an easier procedure, may replace sampling undiluted vitreous.Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Background Comparison of Typical Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy in Japanese Patients - Corrected Proof

2009-10-07

Objective: To compare background factors of the 2 most dominant subtypes of exudative age-related macular degeneration (AMD) in the Japanese population: typical AMD and polypoidal choroidal vasculopathy (PCV).Design: Cross-sectional comparison.Participants: Consecutive patients with typical AMD (n = 89) and PCV (n = 138) for the primary survey. For the secondary survey, the number of participants was extended to include 148 typical AMD and 170 PCV patients. All the patients included in the present study had been followed up at The University of Tokyo Hospital outpatient macular clinic.Methods: Background data on gender; age; body mass index; smoking; alcohol consumption; and histories of hypertension, diabetes mellitus (DM), hyperlipidemia, ischemic heart disease, stroke, intensive light exposure, central serous chorioretinopathy (CSC), cataract surgery, glaucoma, and steroid use were obtained mainly through interview. The interviewers were masked to the subtype diagnosis of AMD. Univariate and multivariate logistic regression analyses were performed to identify differences in the background factors between typical AMD and PCV. In the secondary survey, the association of a history of CSC and PCV was confirmed further, and funduscopic findings of an atrophic retinal pigment epithelial (RPE) tract and focal photocoagulation scars that could indicate a history of CSC were investigated.Main Outcome Measures: Frequency and mean of background factors in patients with typical AMD or PCV.Results: The 2 groups showed similar backgrounds with the exception of their histories of DM and CSC. A history of DM was more frequent in typical AMD (24.7% vs. 13.0% in the primary survey; P = 0.027), whereas a history of CSC was more prevalent in PCV (3.4% vs. 14.7% in the secondary survey; P = 0.0005). Funduscopic findings of an atrophic RPE tract or focal photocoagulation scars were found more frequently in PCV (0.7% vs. 7.6%; P = 0.002).Conclusions: Background factors of typical AMD and PCV are similar but not identical. A history of DM and CSC are more frequent in typical AMD and PCV, respectively.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Optical Coherence Tomography: Pathology Correlation of Optic Disc Melanocytoma - Corrected Proof

Paul T. Finger, Sribhargava Natesh, Tatyana Milman — 2009-10-07

Objective: To correlate combined optical coherence tomography (OCT) and scanning laser ophthalmoscope (SLO) imaging to clinical and histopathologic characteristics of optic disc melanocytoma (ODM).Design: Retrospective, consecutive clinical case analysis.Participants: Twenty patients with ODM were evaluated.Testing: All underwent ophthalmic examinations including a best-corrected visual acuity, slit-lamp examination, dilated ophthalmoscopy, fundus photography with angiography, B-scan ultrasonography, and combined OCT and SLO imaging.Main Outcome Measures: One eye, treated by enucleation, was evaluated by pathologic analysis and was correlated to its combined OCT and SLO images. These findings were correlated to clinical and OCT information from 19 patients with ODM.Results: Histopathologic and combined OCT and SLO features included: disruption of the internal limiting membrane, disorganization of the retina (overlying the tumor), and visualization of the tumor's subretinal surface. Compressive and infiltrative changes in the optic nerve, peripapillary choroid, and retina were correlated directly to combined OCT and SLO images. To varying degrees, these histopathologic findings were seen on combined OCT and SLO. However, the pigment of the ODMs blocked OCT reflectance deep to the tumor's surface.Conclusions: This study demonstrated that OCT and SLO findings could be correlated directly with histopathologic characteristics. Imaging with OCT can be used to diagnose and correlate secondary retinal, superficial, and subretinal tumor characteristics.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Quantitative Iris Parameters and Association with Narrow Angles - Corrected Proof

2009-10-07

Purpose: To investigate the relationship between quantitative iris parameters (iris curvature [I-Curv], iris area [I-Area], and iris thickness) and the presence of narrow angles.Design: Cross-sectional, community-based study.Participants: We recruited 2047 subjects >50 years old without ophthalmic symptoms from a community clinic in Singapore.Methods: All subjects underwent gonioscopy and anterior segment optical coherence tomography (AS-OCT) under dark conditions. An eye was considered to have narrow angles if the posterior pigmented trabecular meshwork was not visible for ≥180° on nonindentation gonioscopy with the eye in the primary position. Customized software was used on horizontal AS-OCT scans to measure I-Curv, I-Area, and iris thickness 750 μm (IT750) and 2000 μm (IT2000) from the scleral spur. The average of both temporal and nasal measured values of the right eye was used for analysis.Main Outcome Measures: The association between iris parameters and narrow angles on gonioscopy.Results: Iris parameters from 1465 eyes (71.6%) were available for analysis. Of these, 315 subjects (21.5%) had narrow angles. The mean I-Curv (0.366 vs 0.259 mm; P<0.020), IT750 (0.476 vs 0.453 mm; P<0.001), and IT2000 (0.491 vs 0.482 mm; P = 0.010) were greater in persons with than without narrow angles. After adjusting for age, gender, anterior chamber depth, axial length, and pupil size, the greater I-Curv, I-Area, IT750, and IT2000 were significantly associated with narrow angles (odds ratio [OR] 2.5 and 95% confidence interval [CI], 1.3–5.1; OR, 2.7 and 95% CI, 1.6–4.8; OR, 2.6 and 95% CI, 1.6–4.1; OR, 2.7 and 95% CI, 1.5–4.7, comparing 4th with 1st quartile for each parameter, respectively). In stratified analysis, women and subjects aged ≥60 years had stronger associations for most iris parameters with narrow angles than men and younger subjects.Conclusions: Quantitative iris parameters (I-Curv, I-Area, and iris thickness) are independently associated with narrow angles, particularly in women and older subjects. These data provide further insights into the pathogenesis of angle closure in Singaporeans.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.