Previews

Amblyopia—Atropine or Patch?
August’s Ophthalmology

The Pediatric Eye Disease Investigator Group conducted a multicenter, randomized clinical trial of children with amblyopia to evaluate the relative treatment benefit of atropine vs. patching based on such patient characteristics as age, cause of amblyopia and depth of amblyopia.

The trial involved 419 children with amblyopia in the range of 20/40 to 20/100. The children were at least 3 years old but younger than 7. The investigators found that visual acuity improved with both treatment approaches, irrespective of the factors being studied. Patients with acuity of 20/80 to 20/100 improved faster when a greater number of hours of patching were prescribed. However, after six months, the improvement was not significantly greater than that seen with either a lesser number of patching hours or atropine.

Given that both patching and atropine were effective for children in this age and acuity range, regardless of the depth or cause of amblyopia, the authors conclude that the clinician may want to take into consideration parent or child preference when deciding which treatment to prescribe.

Large Spot Size Transpupillary Thermotherapy for Occult CNV Associated With AMD
Archives of Ophthalmology
2003;121:821–820

Since 1999, several small studies have described a mild visual benefit from the use of transpupillary thermotherapy in the treatment of occult choroidal neovascularization in the setting of age-related macular degeneration. While there are numerous ongoing clinical trials checking into a variety of treatment options for occult CNV, there remains no treatment of proven visual benefit at the present time.

Thach et al. report a prospective, nonrandomized series of 69 patients treated with transpupillary thermotherapy. All patients had at least six months follow-up, and at that time, 71 percent of patients had stable or improved visual function.

The results of this prospective, single center study are encouraging in that the majority of patients had stabilization of their visual acuity.

A multicenter, prospective TTT4CNV clinical trial, which is expected to release preliminary data later this year, should further clarify the full extent of transpupillary thermotherapy’s benefits.

The Academy has published Preferred Practice Patterns for approximately 20 commonly encountered problems in ophthalmology, including primary open-angle glaucoma.¹ Each PPP is based on evidence-based data, when such data exist, or else represents a consensus-based approach.

This current study assesses the rate of performance when dealing with POAG in the setting of managed care. Fremont et al. conclude that patient visit and visual field test intervals were consistent with the PPP recommendations.

However, an area that was lacking was in the realm of adjustments in therapy when there was elevation of IOP.

The authors conclude that POAG patients seem to be receiving care consistent with the PPP guidelines, with the exception of being undertreated relative to standards for IOP control based on recent clinical trials.

Round-Up of Other Journals

Plaque Radiotherapy Treatment for Orbital Malignancies
Ophthalmic, Plastic and Reconstructive Surgery
2003;19:91–95

Orbital exenteration has been the traditional treatment for certain orbital malignancies, such as malignant epithelial tumors of the lacrimal gland and orbital extension of eyelid basal cell carcinoma or conjunctival melanoma.

However, with some patients, minimal residual tumor may exist after the excision—yet the vision of the eye remains excellent. Orbital exenteration may not necessarily be appropriate for these patients.

One option, according to Shields et al., may be plaque radiotherapy.

The investigators treated eight patients who had malignant orbital tumors with an iodine 125 plaque, custom designed to deliver a target dose of 50 Gray—surgically placing it in the region where the orbital malignancy was partially resected. In contrast to external beam irradiation, this approach was completed in four days rather than four to five weeks. Most of the patients achieved subsequent tumor control in follow-up ranging from two to 10 years. No patient had radiation cataract, retinopathy, papillopathy or dry eye syndrome.

The authors conclude that while plaque radiotherapy may be a reasonable alternative for these patients, the true efficacy of this approach will not be known until many years of follow-up.

While endogenous endophthalmitis was first recognized as a major cause of visual loss in 1856, it remains a challenging condition to both detect and treat.

Binder et al. present an 18-year chart review of all patients (27 with 34 affected eyes) seen at a tertiary care center with infectious endogenous endophthalmitis between 1982 and 2000.

Almost half of the cases were initially misdiagnosed or missed.

The investigators found an equal incidence of bacterial and fungal endophthalmitis. Among the fungal etiologic agents, Candida albicans was predominate. All patients received intravenous antibiotics, 18 patients received intravitreous antibiotics and 21 eyes underwent pars plana vitrectomy surgery. A good visual outcome was associated with a visual acuity at diagnosis of 20/200 or better and no hypopyon. Vitrectomy was not associated with improved final visual acuity.

The investigators noted that the diagnosis of endogenous endophthalmitis requires a detailed ophthalmic examination performed by an ophthalmologist familiar with the disease and often requires extensive follow-up exams.