Many diseases have distinct patterns of behavior or progression among different ethic groups. Wong et al. from the Multi-Ethnic Study of Atherosclerosis (MESA) group described the prevalence and risk factors of diabetic retinopathy in a multiethnic U.S. population of whites, blacks, Hispanics and Chinese with a cross-sectional study of 778 individuals, aged 45 to 85 years, with diabetes.
Retinal photographs were obtained with a 45-degree nonmydriatic digital fundus camera. Presence and severity of diabetic retinopathy were graded at a central reading center on the basis of a modification of the Airlie House classification system. All participants underwent a standardized interview, examination and laboratory investigation.
In this population, the prevalence of any retinopathy was 33.2 percent and macular edema 9 percent. The prevalence of any diabetic retinopathy and macular edema was significantly higher in blacks (36.7 percent and 11.1 percent, respectively) and Hispanics (37.4 percent and 10.7 percent) than in whites (24.8 percent and 2.7 percent) and Chinese (25.7 percent and 8.9 percent) (P = 0.01 and P = 0.007, comparing racial/ethnic differences for retinopathy and macular edema, respectively). Significant independent predictors of any retinopathy were longer duration of diabetes, higher fasting serum glucose, use of diabetic oral medication or insulin, and greater waist-hip ratio. Race was not an independent predictor of any retinopathy.
Effect of Optic Material and Haptic Design on ACO and Capsulorhexis Contraction
American Journal of Ophthalmology
There is ongoing debate on the influence of IOL properties on subsequent need for additional postcataract surgery. Sacu et al. examined the influence of the optic material (silicone and hydrophobic acrylic) and the haptic design (one-piece and three-piece) of sharp-optic-edged IOLs on anterior capsular opacification (ACO) and capsulorhexis contraction. The researchers conducted a randomized, controlled, double-blind trial with intraindividual comparison.
The study comprised 210 eyes of 105 patients with bilateral age-related cataract. In group 1 (n = 53 patients), a three-piece acrylic IOL was compared with a three-piece silicone IOL. In group 2 (n = 52 patients), the three-piece acrylic IOL was compared with the one-piece acrylic IOL. One year after the operation, standardized digital slit-lamp images of ACO were taken; one week and one year after the operation, digital retroillumination images were taken to assess capsulorhexis size. The intensity of ACO was graded objectively (score, 0 percent to 100 percent) and the capsulorhexis area (square millimeters) was determined objectively.
One year after surgery, the mean ACO score in group 1 was 21 percent for the acrylic and 20 percent for the silicone IOL (P = 0.4). In group 2, it was 18 percent for both the three-piece and one-piece acrylic IOLs (P = 0.87). There was no significant difference between the IOL types in the amount of capsulorhexis contraction.
The authors conclude that, in the hydrophobic sharp-optic-edged IOLs that were examined, neither the optic material nor the haptic design had an influence on the amount of ACO or capsulorhexis contraction.
Quality of Life After Iodine-125 Brachytherapy vs. Enucleation for Choroidal Melanoma
Archives of Ophthalmology
This study described health- and vision-targeted quality of life following treatment with I125 brachytherapy vs. enucleation for choroidal melanoma.
Two hundred nine patients who enrolled in the Collaborative Ocular Melanoma Study trial for medium-sized tumors participated in this ancillary study of quality of life and were randomly assigned to treatment with I125 brachytherapy or enucleation. Patients were interviewed by telephone using a battery of standard quality-of-life questions prior to study randomization, again at six months, and on annual anniversaries of study enrollment.
There was a significant increase in both treatment groups in levels of reported difficulty for most vision-oriented activities, and in bodily and ocular pain, at six months following treatment. Differences in visual function between treatment groups were relatively small, but at one year follow-up brachytherapy patients reported fewer problems with driving than those in the enucleation group. And at two years, they reported fewer problems with peripheral vision than did the enucleation patients.
Anxiety levels in both the groups decreased significantly following treatment, but patients treated with brachytherapy with symptoms of anxiety were less likely to report later resolution of those symptoms than patients who were treated with enucleation. No treatment-related differences were found at two years or later follow-up times.
Given that no significant differences in survival between enucleation and brachytherapy were found, patients and physicians can make treatment choices based on a patient’s preferences.
Age-Related Eye Disease, Visual Impairment and Survival: The Beaver Dam Eye Study
Archives of Ophthalmology
Knudtson et al. investigated the long-term relationship of age-related maculopathy, cataract, glaucoma, visual impairment and diabetic retinopathy to survival over a 14-year period.
Persons ranging in age from 43 to 84 years from 1987 to 1988 participated in the baseline examination of the population-based Beaver Dam Eye Study (n = 4,926). Standardized protocols, including photography, were used to determine the presence of ocular disease. Survival was followed using standardized protocols.
As of Dec. 31, 2002, 32 percent of the baseline population had died (median follow-up of 13.2 years). After adjusting for age, gender, systemic and lifestyle factors, poorer survival was associated with cortical cataract (hazard ratio [HR] 95 percent confidence interval [CI]: 1.21 (1.06,1.37)), any cataract (HR, CI: 1.16 (1.03,1.32)), diabetic retinopathy (HR, CI: 1.36 (1.14,1.63) per 1-step increase in 4-level severity), and visual impairment (HR, CI: 1.24 (1.04,1.48)). Poor survival was marginally associated with increasing severity of nuclear sclerosis (HR, CI: 1.07 (0.99, 1.16)). Age-related maculopathy and glaucoma were not associated with poorer survival. Associations tended to be slightly stronger in men than in women.
The authors conclude that cataract, diabetic retinopathy and visual impairment were associated with poorer survival and not explained by traditional risk factors for mortality. These ocular conditions may serve as markers for mortality in the general population.
Iris Pigment Epithelial Translocation for Exudative Macular Degeneration
Archives of Ophthalmology
Aisenbrey et al. examined the long-term effect of subretinal transplantation of iris pigment epithelium (IPE) cell suspensions in age-related macular degeneration patients.
Autologous IPE cells were translocated to the subretinal space in 20 consecutive patients aged 33 to 85 years with subfoveal choroidal neovascularization. Nine patients had classic CNV secondary to AMD, seven patients had occult CNV secondary to AMD, two patients had idiopathic CNV, one patient had a CNV secondary to high myopia, and one patient had a CNV secondary to dominant drusen.
After three-port pars plana vitrectomy and extraction of the CNV, freshly isolated IPE cells in suspension were injected into the subretinal space.
A large iridectomy was performed through a peripheral corneal incision on the eyes undergoing vitrectomy. The tissue was placed in a glass well with a drop of balanced salt solution, and the IPE cells were mechanically isolated from the underlying stroma without enzymes. For injection, the cells were suspended in 20 microliters of BSS.
The site of translocation was evaluated by funduscopy and fluorescein angiography. Fixation behavior was tested by scanning laser ophthalmoscopic (SLO) microperimetry. Visual acuity was measured with Early Treatment Diabetic Retinopathy Study (ETDRS) charts at defined time intervals.
Seventeen patients were followed for a period of at least three years after IPE translocation. At three years, one patient showed improved visual acuity of more than two ETDRS lines, 13 patients retained stable visual acuity, and three patients had reduced visual acuity of more than two ETDRS lines compared with their preoperative visual acuity. SLO examination showed that central fixation was not regained or preserved in any of the patients. No macular edema or recurrent CNV was apparent by fluorescein angiography at any time during the three-year follow-up.
The authors conclude that autologous IPE cells transplanted to the subretinal space are well tolerated for three years and do not adversely affect photoreceptor function. However, visual function is not improved beyond what would be expected by membrane removal alone. CNV did not recur in any of these patients, suggesting that the value of IPE transplantation may be in preventing CNV recurrence following CNV removal in AMD patients.
Ophthalmology summaries are written by Lori Baker Schena and edited by John Kerrison, MD. American Journal of Ophthalmology summaries are edited by Thomas J. Liesegang, MD. Archives of Ophthalmology summaries are written by the lead authors.
Roundup of Other JournalsSolarScan for Diagnosis of Primary Melanoma
Archives of Dermatology
2005;141:1388–1396, 1444–1446 (editorial)
In a nine-center study covering three continents, Menzies et al. have found that SolarScan (Polartechnics Ltd.) shows promising results as an automated tool to diagnose primary melanoma. The study involved images from a data set of 2,430 pigmented skin lesions, in which 382 were melanomas with a median Breslow thickness of 0.36 millimeters.
These lesions were divided into a training set and an independent test set; high-quality clinical and dermascopy images with a detailed patient history for 78 lesions from the test set were given to various clinicians to compare their diagnostic accuracy with that of SolarScan.
SolarScan had comparable or superior sensitivity and specificity compared with those of experts, dermatologists, trainees and general practitioners. The researchers caution that this technology will never be 100 percent accurate.
Also an accompanying editorial by Rubegni et al. warns that all digital systems have inherent limits, “particularly automated systems designed to provide a clinical decision.” Consequently, these sophisticated instruments should only be used by experienced dermatologists.
Early Complications of Deep Lamellar Endothelial Keratoplasty
Results looking at early complications of deep lamellar endothelial keratoplasty (DLEK) show that complications from the surgery are relatively rare and easily resolved, but the authors warn that because it is so technically challenging surgeons must be highly proficient in the technique to obtain low complication rates.
The prospective study by Terry and Ousley involved the first 100 consecutive DLEK cases performed by a single surgeon. Of the 98 patients who had completed DLEK surgery (two were converted to penetrating keratoplasty), four experienced a dislocated disk on the first postoperative day, a problem resolved by repositioning the disk. One eye had primary graft failure caused by surgeon error, resulting in a disk dislocation that was successfully replaced with another disk the day after surgery. Four patients experienced graft rejection after stopping steroids, but all grafts cleared upon resumption of steroids. Additionally, there were no infections, ulcerations, healing defects or late dislocations.
The authors conclude that DLEK represents a viable alternative to standard penetrating keratoplasty surgery, and it eliminates need for sutures and provides a considerable “safety margin” not found in other forms of endothelial replacement surgery. However, they caution that surgeons should undergo extensive training with animal and cadaver models before attempting DLEK.
Surgical Monovision With LASIK for Presbyopia
Monovision represents a workable alternative for presbyopia in contact lens wearers, with success rates between 50 percent and 75 percent. Yet is this treatment strategy successful in LASIK patients?
A study by Reilly et al. indicates that surgical monovision can, in fact, help presbyopic patients reduce their dependence on glasses. The researchers analyzed 82 patients who underwent LASIK for monovision; 97 percent achieved success defined as those patients who elected not to have their monovision reversed and who had J2 near vision or better. None of the patients who underwent a contact lens trial of monovision prior to LASIK elected monovision reversal, whereas two patients who did not undergo this contact lens trial chose monovision reversal.
Roundup of Other Journals is written by Lori Baker Schena and edited by Deepak P. Edward, MD.