Researchers Find High Levels of Undiagnosed Open-angle Glaucoma

Use Intraocular Suture Technique Rather Than Removing Luxated IOLs

Vitrectomy and Fluid Analysis Can Flush Out Inflammation's Causes

Botulinum Toxin Injection Effective for Graves' Ophthalmopathy

Early Onset Esotropia: Should You Wait or Operate?

Potential Dangers of Creating Monovision by Refractive Surgery

Slowing Myopia's Progress in Schoolkids

Topical Corticosteroids: A Superior Treatment for Bullous Pemphigoid

In a study of the five-year incidence of open-angle glaucoma, Mukesh et al. report two key findings: The incidence of OAG increased significantly with age, and a large percentage of participants with definite OAG were undiagnosed.

The Melbourne Visual Impairment Project-a population-based study of age-related eye diseases in the Australian state of Victoria-involved 3,271 individuals aged 40 years and older, who underwent a baseline and follow-up standardized ophthalmic examination. This included IOP, visual fields, cup-to-disc ratios and paired stereo photographs of the optic disc.

The researchers found that overall incidence of:

In addition, the amount of possible, probable and definite OAG increased significantly with age. The incidence, for instance, of definite OAG increased from none of the participants aged 40 to 49 years to 4.1 percent of participants aged 80 years and older.

The investigators also found that 50 percent of the definite OAG participants were undiagnosed and suggest that new community screening strategies for glaucoma need to be developed.

Hanemoto et al. contend that to maintain postoperative visual acuity it is better to suture a luxated IOL to the ciliary sulcus without extracting the IOL, as IOL removal and reimplantation may cause endothelial loss. In addition, a large scleral incision to extract the IOL may produce postoperative astigmatism.

To address this concern, the researchers describe a new technique for suturing a luxated IOL in the vitreous cavity to the ciliary sulcus using intraocular cow (girth) hitch knots without extraction.

For optimal results, the researchers recommend a subtotal vitrectomy including lens remnant for obtaining a good fixation to the ciliary sulcus. They also warn that hooking the IOL haptic with a cow hitch knot in the vitreous cavity is the most difficult part of this technique, but the surgeon can manage it with his or her better hand.

In a noncomparative interventional case series, five patients underwent this procedure. In all of these, the IOL fixated stably and remained well-positioned with no significant intra- or postoperative complications.

The researchers conclude that the intravitreal cow hitch knot technique provides a better grip of the IOL haptic than does a single knot and causes minimal damage to the ocular tissue. It also enables secure fixation to the ciliary sulcus of the luxated IOL in the vitreous.

In challenging cases where clinical examination and systemic laboratory workup fail to identify the cause of intraocular inflammation, diagnostic pars plana vitrectomy with directed fluid analysis may be helpful in establishing a diagnosis, report Mruthyunjaya et al.

In this noncomparative interventional case series, the researchers analyzed vitreous samples from 87 patients (90 eyes) who underwent diagnostic pars plana vitrectomy from 1989 through 1999.

The diagnostic tests performed most frequently included cytopathology (83 percent), microbiologic culture and sensitivity (43 percent), polymerase chain reaction (36 percent) and testing for intraocular antibody levels for Toxocara canis (14 percent). Intraocular antibody testing and PCR had the highest positive yield. Overall, the directed vitreous analysis identified a specific etiology in 35 eyes (39 percent).

The researchers conclude that this procedure may be a valuable adjunct in cases of intraocular inflammation that cannot be diagnosed by less-invasive methods. Indeed, by using pars plana vitrectomy with directed fluid analysis to rule out malignancy or infection, the clinician may proceed more confidently in treating those patients who present with a nonspecific inflammatory condition.

They predict that, with the continued improvement in detection methods in genomic amplification technology and cytopathology, the capacity to detect specific etiologies will further improve.

Botulinum toxin type A injections using a subconjunctival approach may be more effective than previously reported in the treatment of upper eyelid retraction associated with thyroid eye disease (Graves' ophthalmopathy), according to a study by Uddin and Davies.

Eleven patients with superior scleral exposure associated with thyroid eye disease underwent one or more treatments with injections of Botox into the subconjunctival space at the superior margin of the tarsal plate.

All patients developed some improvement in the amount of lid retraction after the injections, with the effect lasting from one to 40 months.

Results fell into three broad categories:

The researchers conclude that subconjunctival Botox injection is an effective treatment alternative for eyelid retraction associated with thyroid eye disease. It is easy to administer and well tolerated by patients, with few side effects.

American Journal of Ophthalmology 2002;133:109-118

When is an infant likely to experience spontaneous resolution of early onset esotropia? Findings from the Congenital Esotropia Observational Study may provide valuable guidelines for determining whether persistence of the esotropia is likely. This may help clinicians determine whether they should consider surgical correction for esotropia on infants at 3 to 4 months of age.

This prospective, multicenter cohort study by the Pediatric Eye Disease Investigator Group-conducted by 137 investigators at 104 clinical sites-involved 175 patients ranging from 4 to 19 weeks in age; the outcome examination was completed by 159 (91 percent) of the 175 patients.

Investigators found that esotropia with onset in early infancy frequently resolves in patients first examined at less than 20 weeks of age when the deviation is less than 40 prism diopters in size and is intermittent or variable.

On the other hand, cases with a constant deviation of at least 40 PD presenting after 10 weeks of age have a low likelihood of spontaneous resolution.

2001;5:342-347

The binocular visual system of adults may be susceptible to anomalous binocular experience, report Fawcett et al.

The researchers examined whether adults with long-standing surgical monovision demonstrated deficits in random-dot stereo acuity and foveal fusion even after anisometropic blur was corrected. Binocular function was evaluated in 32 adults with long-standing monovision produced by LASIK or PRK who underwent full binocular correction. An extra 20 age-matched control subjects also participated.

Analysis showed that long-standing surgical monovision had a significant effect on both random-dot stereo acuity and foveal fusion.

The researchers offer three conclusions:

Acta Ophthalmologica Scandinavica 2001;79:233-236

Can therapeutic interventions slow the progression of juvenile-onset myopia? Shih et al. studied 227 schoolchildren with myopia, aged 6 to 13, and randomly assigned them to three groups:

Each child was followed for at least 18 months, with 188 young people eventually included in the data analysis.

The researchers found that the ocular refraction and axial length showed less progression in the group given both multifocal glasses and atropine. In comparison, the multifocal lenses alone were not effective in controlling myopia progression.

The investigators hypothesize that the atropine may inhibit either the accommodation (which may exert force on the eye that leads to axial elongation) or the growth factors acting to elongate the eye. They call for further study to establish the true effectiveness of atropine.

The New England Journal of Medicine 2002;346:321-327

Highly potent topical corticosteroid therapy is an effective treatment alternative for

both moderate and severe bullous pemphigoid-the most common autoimmune blistering skin disease of the elderly-report Joly et al.

In addition, compared with the standard regimens of oral corticosteroids, topical corticosteroids are actually superior for extensive disease.

Among the 188 patients in the study with extensive bullous pemphigoid, topical corticosteroids proved superior to prednisone. There was a one-year survival rate of 76 percent in the topical-corticosteroid group and 58 percent in the oral-prednisone group.

Additionally, the disease was controlled in 92 of the 93 patients in the topical group (99 percent) and 86 of the 95 in the oral group (91 percent).

The 153 patients with moderate bullous pemphigoid did not demonstrate significant differences between the two treatment approaches in terms of overall survival or rate of control at three weeks.