EyeNet Magazine

Journal Highlights

New Findings from Ophthalmology, AJO and Archives

March’s Ophthalmology:
• Scleral Buckling Alone and With Pars Plana Vitrectomy Effective in Retinal Detachment Repair
• Alcohol Delamination of the Corneal Epithelium Helps Manage Recurrent Corneal Erosions
• Large Case Series Shows Most Orbital Metastatic Carcinoids Arise From Gastrointestinal Tract
• Intravitreal Bevacizumab in Neovascular AMD Shows Short-Term Visual Acuity Improvement

February’s American Journal of Ophthalmology:
• Laser Treatment Hastens Choroidal Neovascularization in Age-Related Maculopathy
• Changes in Corneal Surface Configuration After Penetrating Keratoplasty
• UV Fluorescence Photography to Detect Early Ocular Sun Damage in Children
• Visual Field Defects and Retinal Nerve Fiber Layer Defects in Eyes With Buried Optic Nerve Drusen

January’s Archives of Ophthalmology:
• Quality of Life and Psychosocial Characteristics of Patients With Blepharospasm
• Inflammatory Factors in Relation to Retinal Vessel Caliber
• Outcome of Eyes Developing Retinal Detachment During Early Treatment for ROP

Roundup of Other Journals:
• Corneal Thickness Changes After Topical Anesthetics
• Effect of Azathioprine on Multiple Sclerosis Lesions
• Adult Visual Cortex Plasticity May Be Affected by Prior Experience


Scleral Buckling Alone and With Pars Plana Vitrectomy Effective in Retinal Detachment Repair
March’s issue

Salicone et al. have found that scleral buckling is as effective in treating uncomplicated rhegmatogenous retinal detachments with undetected retinal breaks as surgery combining scleral buckling and pars plana vitrectomy (PPV).

The authors reviewed medical records of 44 patients with complicated macula-involving primary rhegmatogenous-appearing retinal detachments without retinal breaks detected preoperatively or intraoperatively. Twenty-six patients underwent scleral buckling and 18 underwent scleral buckling plus PPV, fluid-gas exchange and endolaser application. At the final two-month postoperative visit, the retina was attached in 15 of the 18 (83.3 percent) patients who underwent the combined treatment and 22 of 26 (84.6 percent) who underwent the scleral buckling procedure. Additionally, visual acuities at two months and best- and final best-corrected visual acuities were similar for both approaches, as were complication rates.

Given these findings, the authors conclude that surgeons should use their personal discretion when choosing surgical management options for individuals with uncomplicated rhegmatogenous retinal detachments when no breaks are found.

Alcohol Delamination of the Corneal Epithelium Helps Manage Recurrent Corneal Erosions
March’s issue

A prospective case series involving 12 patients with recurrent corneal erosions has demonstrated that alcohol delamination of the corneal epithelium is a viable alternative when conservative management fails.

Dua et al. described the procedure in which 20 percent alcohol was applied on the affected area of epithelium for 40 seconds under topical anesthesia. The patients were then treated with antibiotic, preservative-free artificial tear medication and a bandage contact lens until the epithelial healing was complete.

During the follow-up period, which ranged from six to 40 months, 11 of the 12 eyes experienced “dramatic relief” of symptoms. In addition, none of the patients experienced residual effects from the procedure. Interestingly, the epithelium could be removed as a sheet, providing an opportunity possibly to understand the pathology of the predisposing conditions.

The authors conclude that alcohol delamination appears to be a “novel, simple and inexpensive treatment” for recurrent corneal erosions, and they call for a larger, comparative study.

Large Case Series Shows Most Orbital Metastatic Carcinoids Arise From Gastrointestinal Tract
March’s issue

In a retrospective case series and literature review, Mehta et al. present the largest published series of orbital metastatic carcinoid tumors.

The average age at biopsy-proven diagnosis among the 13 patients (nine male) was 65.3 years. Eleven of the 13 orbital carcinoids were of gastrointestinal origin; one was from the lung and one from a primary breast tumor. Twelve patients had symptoms for an average of 6.3 months, and one patient was asymptomatic. Eleven of the 13 patients had noted a mass, eight had diplopia, three had reduced vision and only two of the 13 patients reported orbital pain.

Management techniques reflected advances in treatment techniques: four patients underwent exenteration prior to 1980 and nine underwent fractionated radiotherapy to the affected orbit. Two recent patients had local radiotherapy and receptor-targeted chemotherapy. At the time of the study, seven patients died from metastatic tumor. Kaplan-Meir analysis showed a five-year suvival rate of 72 percent and a 10-year survival rate of 38 percent.

Intravitreal Bevacizumab in Neovascular AMD Shows Short-Term Visual Acuity Improvement
March's issue

A study by Avery et al. looking at the short-term safety, biologic effect and possible mechanisms of action of intravitreal bevacizumab (Avastin) in patients with neovascular AMD suggests the medication is well-tolerated and associated with improvement in visual acuity, decreased retinal thickness by optical coherence tomography, and reduction in angiographic leakage in most patients. The interventional, consecutive, retrospective case series involved 81 eyes of 79 patients, most of whom had undergone previous treatment with photodynamic therapy and/or pegaptanib (Macugen). They received intra-vitreal bevacizumab (1.25 milligrams) on a monthly basis until macular edema, subretinal fluid and/or pigment epithelial detachment resolved. The authors acknowledge that while the study had several limitations, the study constitutes “proof of concept” that intravitreally administered bevacizumab demonstrated short-term anatomic improvements that were often associated with concomitant increases in visual acuity.


Laser Treatment Hastens Choroidal Neovascularization in Age-Related Maculopathy
American Journal of Ophthalmology
February’s issue

The role of laser treatment in age-related maculopathy (ARM) has been a matter of debate for years. The Drusen Laser Study Group evaluated use of macular laser to prevent choroidal neovascularization (CNV) and vision loss in high-risk ARM in a prospective, interventional, randomized, controlled clinical trial in five hospital centers.

Patients in the unilateral group had neovascular ARM and drusen in the study eye. Study eyes were randomized to laser-treated or no-laser groups. For patients in the bilateral drusen group, eyes were randomized to right eye, laser or no laser; and left eye, alternative. Laser treatment consisted of 12 argon spots. Outcome was best-corrected visual acuity and CNV signs, which were monitored for three years.

In the unilateral group, vision loss occurred in 21 (28.8 percent) of 73 patients in laser vs. 13 (19.7 percent) of 66 no-laser patients (P = 0.214). Incidence of CNV was 27 (29.7 percent) of 91 in laser vs. 15 (17.65 percent) of 85 no-laser patients (P = 0.061). CNV onset was approximately six months earlier in laser-treated compared with no-laser patients (P = 0.05). In the bilateral group, vision loss occurred in six (8.3 percent) of 72 laser-treated vs. 10 (13.9 percent) of 72 fellow eyes (P = 0.387). CNV incidence was 12 (11.6 percent) of 103 in laser-treated vs. seven (6.8 percent) of 103 fellow eyes (P = 0.225). There was no difference in onset of CNV.

The results of this study do not support prophylactic laser of the fellow eye of patients with neovascular ARM. Its role in patients with bilateral drusen remains unclear.

Changes in Corneal Surface Configuration After Penetrating Keratoplasty
American Journal of Ophthalmology
February’s issue

Vision after penetrating keratoplasty (PK) is frequently governed by the corneal configuration after the surgery. Hayashi and Hayashi examined the long-term longitudinal changes in corneal surface configuration as determined by Fourier series harmonic analysis of videokeratography data and refraction after PK in an interventional case series.

The study included 130 eyes of 130 consecutive patients who were scheduled for PK using 16 interrupted 10-0 nylon sutures. The spherical equivalent power, regular astigmatism component, irregular astigmatism (asymmetry and higher-order irregularity) component of the central cornea as determined by Fourier analysis of videokeratographic data, spectacle-corrected visual acuity and spherical equivalent were evaluated at one week, and again at one, three, six, nine, 12, 18 and 24 months after PK.

Spherical equivalent power increased considerably for up to one month after PK, but thereafter showed no further appreciable change up to the final follow-up at 24 months. The regular astigmatism component decreased markedly for up to six months after PK, while the total irregular astigmatism (sum of the asymmetry and higher-order irregularity) component decreased considerably up to approximately three months, and then these showed no further relevant change for up to 24 months. Spectacle-corrected visual acuity also improved markedly until approximately three months after PK, after which it was virtually stable. Correlations were found between regular and irregular astigmatism and the spectacle-corrected visual acuity.

Corneal surface configuration after PK appears to be stable by approximately six months after PK, concurrent with postkeratoplasty stabilization of visual acuity.

UV Fluorescence Photography to Detect Early Ocular Sun Damage in Children
American Journal of Ophthalmology
February’s issue

Studies have confirmed the adverse effects of ultraviolet light on the eye. Ooi et al. in Australia developed a method to detect precursors of ocular sun damage using ultraviolet fluorescence photography (UVFP) and applied the technique in an observational cross-sectional study of 71 schoolchildren, ages 3 to 15, in Sydney.

UV and standard control photographs were taken of the nasal and temporal interpalpebral regions bilaterally. Outcome measures were the presence of areas of increased fluorescence detected by UVFP, or presence of pingueculae detected by standard photography.

Established pingueculae, on standard photography, were seen in seven of 71 (10 percent) children, all 13 years of age or older. On UVFP, all of these pinguecu-lae demonstrated fluorescence. In total, 23 of 71 (32 percent) had increased fluorescence detected on UVFP, including the seven of 23 (30 percent) with pinguec-ulae. Of the remaining 16 of 23 (70 percent), the changes were only detectable using UVFP. Fluorescence on UVFP was seen only in children aged 9 years and above, with prevalence increasing with age. The presence of fluorescence (in at least one region of the eye) was found in six of 23 children (26 percent) aged 9 to 11; and 17 of 21 children (81 percent) aged 12 to 15. The areas seen to fluoresce on UVFP but which were not detectable on control photography represent precursors for ophthalmohelioses. The preliminary data suggest that UVFP is a sensitive method for detecting early ocular sun damage occurring many years before clinical manifestations.

Visual Field Defects and Retinal Nerve Fiber Layer Defects in Eyes With Buried Optic Nerve Drusen
American Journal of Ophthalmology
February’s issue

Visible optic nerve drusen can be associated with visual field defects. Katz et al. evaluated the visual field with the use of automated perimetry and evaluated the retinal nerve fiber layer (RNFL) with optical coherence tomography (OCT) in patients with buried optic nerve drusen (OND) in an observational case control study.

Eyes with buried OND were defined as eyes with ultrasound-proved drusen that were not visible with indirect slit-lamp biomicroscopy. Automated perimetry was performed with the Humphrey visual field analyzer. OCT was performed with the Zeiss Stratus 3000 OCT.

Fifty-eight eyes of 41 patients with buried OND were evaluated. Three eyes (5 percent) had inferior arcuate scotomas. The other 55 eyes did not have visual field defects. Twenty-one of the eyes without visual field defects underwent RNFL analysis with OCT. All 21 eyes had normal RNFL thickness. Some eyes had focal RNFL defects, but it is not clear whether these defects were clinically significant.

Visual field defects seem to be uncommon in eyes with buried OND. Eyes with buried OND may have focal RNFL defects but have normal average RNFL thickness. In patients with buried OND and a visual field defect, consideration should be given to searching for other causes of the defect, especially if it is substantial.

Quality of Life and Psychosocial Characteristics of Patients With Blepharospasm
Archives of Ophthalmology
January’s issue

Hall et al. examined vision-targeted, health-related quality of life and psychosocial characteristics in patients with benign essential blepharo-spasm (BEB) and compared them with patients with hemifacial spasm (HFS).

Persons with BEB (159) or HFS (91) were identified based on ICD-9 codes with subsequent verification by chart abstraction. Information regarding demographics, health characteristics, disease characteristics and vision-targeted, health-related quality of life were obtained through a telephone interview.

For both BEB and HFS patients, the National Eye Institute Visual Function Questionnaire (VFQ-25) composite scores and subscale scores were low. But compared with persons with HFS, patients with BEB reported more depressive symptoms (P = 0.03), met the criteria for generalized anxiety disorder (P = 0.007), had lower VFQ-25 composite scores and had lower VFQ-25 subscale scores regarding general vision (P = 0.03), ocular pain (P < 0.0001), distance activities (P = 0.001), driving (P < 0.0001) and all vision-specific subscales addressing psychosocial issues.

The authors conclude that compared with those with HFS, patients with BEB experience a greater reduction in vision-targeted, health-related quality of life and are more prone to symptoms of depression and anxiety. This underscores the inadequacy of current treatment options for BEB in light of the fact that these patients had been receiving standard of care treatment for some time.

Inflammatory Factors in Relation to Retinal Vessel Caliber
Archives of Ophthalmology
January’s Issue

Klein et al. examined the relationship of systemic markers of inflammation and endothelial dysfunction to retinal vessel diameter.

Cross-sectional analyses were completed on a random sample of 396 persons aged 50 to 86 years who had under-gone a baseline examination from 1988 to 1990 as part of the Beaver Dam Eye Study. Diameters of arterioles and venules were measured from digitized fundus photographs.

While controlling for age, smoking status, diabetes status, serum HDL-cholesterol and hematocrit, the researchers found that wider retinal venules were associated with higher serum levels of high-sensitivity C-reactive protein, interleukin-6 and amyloid A, all markers of inflammation. While controlling for age, blood pressure, smoking status, HDL cholesterol and gout, the researchers found that smaller arteriolar diameters were associated with higher serum amyloid A and lower serum albumin, but not with high-sensitivity C-reactive protein or interleukin-6 levels.

None of the biomarkers of endothelial dysfunction studied were associated with retinal arteriolar or venular diameters. The authors conclude that their data show an association of inflammatory markers with larger retinal venular diameter, suggesting that retinal venular caliber may be a marker of systemic inflammation. This is important because retinal vascular caliber changes have now been shown to predict a range of systemic vascular diseases such as coronary heart disease, diabetes, hypertension, renal disease and stroke in different populations.

Outcome of Eyes Developing Retinal Detachment During Early Treatment for ROP
Archives of Ophthalmology
January’s Issue

Repka et al. examined the structural and functional outcomes at nine months’ corrected age in 401 patients with high-risk prethreshold ROP who were enrolled in the Early Treatment for Retinopathy of Prematurity Study. All had retinal detachment associated with retinopathy of prematurity (ROP). Retinal detachments occurred in 89 eyes of 63 patients. Follow-up was available for 78 eyes of 56 patients. The detachments were classified as stage 4A in 30 eyes, stage 4B in 14 eyes, stage 5 in 16 eyes and not classified in 18 eyes.

Twelve eyes of 11 patients were observed, and 66 eyes of 52 patients underwent vitreoretinal surgery. Attachment of the macula at nine months persisted or was achieved in 17 of 56 eyes (30 percent) following vitrectomy with or without scleral buckle, in six of 10 (60 percent) following scleral buckle only, and in two of 12 eyes (17 percent) followed without surgery. Favorable visual acuity (1.85 cycles/ degree) was found in 13 of the 78 eyes (17 percent).

Eleven stage 5 eyes underwent vitreoretinal surgery resulting in six with no light perception, three with light perception only and two with detection of only the low vision card.

The authors conclude that vitreoretinal surgery for retinal detachment was associated with macular attachment in 16 of 48 eyes. Vitreoretinal surgery for stage 5 disease was associated with some structural successes, but poor functional outcomes.

Roundup of Other Journals

Corneal Thickness Changes After Topical Anesthetics

According to a report by Nam et al., the topical anesthetics oxybuprocaine and proparacaine both produce a transient increase in corneal thickness after application of the first drop. However, proparacaine produces a second increase five minutes later.

For this study, the authors recruited 18 healthy young participants and administered proparacaine to the right eye and oxybuprocaine to the left. They measured corneal thicknesses every 30 seconds for 10 minutes using a noncontact specular microscope. Corneal thickness increased by 8.6 micrometers after proparacaine and then returned to baseline within 80 seconds. Similarly, corneal thickness increased by 7.7 µm after oxybuprocaine and then returned to baseline within 80 seconds. However, a second brief increase in corneal thickness occurred after proparacaine at the four-minutes-and-40-seconds mark.

The authors conclude that ophthalmologists should measure central corneal thickness 80 seconds after oxybuprocaine in glaucoma or refractive surgery patients, and should keep in mind that corneal thickness may be unstable for five minutes after administering proparacaine.

Effect of Azathioprine on Multiple Sclerosis Lesions
Archives of Neurology

Azathioprine is a cytostatic agent that for years has been used to treat transplant rejections and autoimmune diseases. Several clinical trials have shown that azathioprine effectively modifies the course of multiple sclerosis (MS) and reduces the relapse rate, similar to beta interferon. However, its effect on suppressing new brain lesions had not been studied.

Massacesi et al. conducted an open-label treatment vs. baseline study involving 14 MS patients who had relapsing-remitting MS of short duration with at least three gadolinium-enhancing (Gd+) brain lesions six months prior to treatment. The participants received up to 3 milligrams/kilogram of azathioprine daily, and underwent MRI six months before and six months into the course of treatment. Results showed that the number of Gd+ lesions were reduced 50 percent or more in 12 of 14 patients, with an equivalent reduction in the number of new T2 lesions.

Adult Visual Cortex Plasticity May Be Affected by Prior Experience
Nature Neuroscience

A study by Hofer et al., which demon-strated that the ability of the brain to adapt to alterations in its sensory environment can be improved dramatically if the brain experienced a similar change in its sensory environment earlier in life.  For this study, the authors used the standard model for sensory plasticity in mouse visual cortex, ocular dominance plasticity, to determine the adult brain’s capacity for plasticity. They found that after one episode of monocular deprivation (MD) in juvenile mice, the effects of a second MD appeared faster and lasted longer in the same mice four to nine weeks later. The authors noted that a specific trace of MD was left in the visual cortex, which maintained a memory of its deprivation history. They conclude that plasticity in the mammalian cortex may be conditioned by past experience.

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 Journals is written by Lori Baker Schena and edited by Deepak P. Edward, MD.

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