American Academy of Ophthalmology Web Site: www.aao.org
New Findings from Ophthalmology, AJO and Archives
September’s American Journal of Ophthalmology:
August’s American Journal of Ophthalmology:
July’s Archives of Ophthalmology:
June’s Archives of Ophthalmology:
Roundup of Other Journals:
In a medical record review of 12 patients with posterior-pole toxoplasmic retinochoroiditis, Lasave et al. have found that intravitreal clindamycin and dexamethasone are associated with resolution of the condition.
Patients had one or more of the following indications for local therapy: intolerance to oral medication, contraindication to oral medication due to pregnancy, lack of response despite oral antimicrobial treatment, or were treated with concomitant oral and local therapy to avoid or limit foveal and/or optic disc involvement.
The patients included in the study were treated weekly with intravitreal injections of clindamycin (1.5 mg/0.1 ml) and dexamethasone (400 µg/0.1 ml) with an average of 3.6 injections. The treatment resolved inflammation and was associated with improvement of visual acuity and central macular thickness. At 24 months, no recurrences were reported in any of the patients.
The authors call for a controlled trial comparing intravitreal clindamycin and dexamethasone as an adjuvant to systemic therapy with standard oral systemic treatment.
Tesha et al. have found that subconjunctival 2 percent lidocaine significantly reduces pain in patients undergoing panretinal photocoagulation or peripheral laser retinopexy.
Thirty-two eyes of 32 patients received the anesthetic injection prior to laser treatment, and 33 eyes of 33 patients received a sham injection. These 65 patients were defined as the primary study group. Those patients who required a second laser treatment received in a masked fashion the opposite injection prior to laser treatment. They were defined as the crossover group. After treatment, all patients completed a pain questionnaire.
In the primary study group, 19 patients undergoing anesthetic treatment experienced pain compared with 32 undergoing sham treatment. Among the patients who did experience pain, the average pain score was 3.6 in the anesthetic treatment group and 4.1 in the sham treatment group.
In the crossover study group, 12 patients undergoing anesthetic treatment experienced pain compared with 28 undergoing sham treatment. In patients who did experience pain, the average pain score was 3.3 in the anesthetic treatment group and 4.6 in the sham treatment group. Seventy-one percent of crossover patients preferred anesthetic to sham treatments, 4 percent preferred sham over anesthetic and 25 percent felt both laser treatments were the same.
Zweifel et al. have demonstrated that both soft drusen and subretinal drusenoid deposits occur in patients with age-related macular degeneration and both are significantly associated with late AMD.
This prospective study included 153 AMD patients (of whom 131 had at least one eye with late AMD) and a control group of 101 patients who did not have AMD. The investigators used two evaluation methods—blue channel of color fundus photographs and SD-OCT—to identify subretinal drusenoid deposits in the participants. Results showed that subretinal drusenoid deposits were frequently found in eyes with AMD, but less frequently than soft drusen. In addition, subretinal drusenoid deposits were found much more frequently by SD-OCT than by examining the blue channel of the color photograph.
The authors recommend that detection and classification of drusen—and consequently assignment of risk—should be based on a methodology that includes SD-OCT. In addition, future studies on this subject should include SD-OCT imaging to help establish the drusen location.
Tamsulosin is the most commonly prescribed alpha-receptor blocker for benign prostatic hyperplasia. It has also been associated with the distinctive characteristics of intraoperative floppy iris syndrome.
Santaella et al. examined the human iris dilator smooth muscle and stroma using light microscopy. The study comprised a total of 51 postmortem eyes from 27 patients (14 with a history of tamsulosin use and 13 control patients) to determine if any differences in muscle size and iris architecture could be detected.
The authors found a statistically significant decreased mean iris dilator muscle thickness in the tamsulosin-treated group, which was on average 23.2 percent thinner than the mean iris dilator muscle of the control group. The authors did not detect any significant difference when comparing the mean iris stromal thickness between the two groups.
Longitudinal data from the Rotterdam Study indicates that the 10-year risk of glaucomatous visual field loss (GVFL) in an elderly Caucasian population is highly dependent on age, with the risk increasing from 1.9 percent at age 55 to 59, to 6.4 percent at age 80 and older.
Czudowska et al. also found that the incidence of GVFL is significantly associated with higher baseline IOP (incidence increased by 11 percent per mmHg increase in IOP), high myopia (spherical equivalent –4 D and more), male biological sex and glaucomatous optic neuropathy.
The study involved 6,630 participants aged 55 and older at risk of developing GVFL. The researchers’ findings did not show a statistically significant association between a positive family history of glaucoma and incident GVFL. However, a positive family history was significantly associated with incident GVFL if IOP was removed from the model.
In an interventional study, Shome et al. demonstrated that myoconjunctival enucleation with a PMMA implant provides better implant and prosthesis movement than the traditional PMMA implant, and better prosthesis movement than the porous polyethylene implant.
The investigators randomized 150 patients to three equal groups: group 1 received a traditional PMMA implant following enucleation with muscle imbrication; group 2 received a PMMA implant following enucleation with myoconjunctival technique and group 3 received a porous polyethylene implant following enucleation by the scleral cap technique.
The authors found the movement of the myoconjunctival PMMA implant was better than the traditional PMMA implant, but similar to the porous polyethylene implant.
Androudi et al. have found that intravitreal adalimumab is not efficacious in improving BCVA or reducing central retinal thickness in patients with refractory uveitis-related macular edema.
In this interventional case series, intravitreal adalimumab injections were administered monthly for three months to eight patients with controlled uveitis and chronic refractory cystoid macular edema. While no significant ocular or systemic side effects were observed, no improvement in BCVA or reduction in central retinal thickness was noted either.
Although this study was limited by a small sample size and lack of a control group, the results suggest intravitreal adalimumab may not be a viable option for patients with chronic refractory uveitic cystoid macular edema.
Seddon et al. have found that high-sensitivity C-reactive protein (CRP) and the CFHY402H and LOC ARMS2 genotypes are independently associated with the risk of age-related macular degeneration—implying that both a biologic serum marker of inflammation and genetic factors in the inflammatory pathway are related to AMD.
Controlling for genotype and demographic and behavioral risk factors in 244 patients with AMD and 209 individuals with no or minimal maculopathy, the authors noted that higher CRP levels were associated with a higher risk of AMD. In addition, the presence of higher CRP levels, combined with risk genotypes for each gene, constituted the higher risk of AMD.
The authors conclude that while genetic factors strongly predispose individuals to AMD, environmental and biologic factors—as well as factors leading to higher CRP—can modify genetic susceptibility to AMD.
In a cohort study, Quintana et al. developed decision trees based on visual acuity to determine guidelines concerning the appropriateness of cataract extraction.
To create these decision trees, the researchers randomly assigned 3,691 patients to a derivation cohort and 2,416 patients to a validation cohort. The investigators gathered clinical data, including visual acuity and the Visual Function Index 14 questionnaire, before and after cataract extraction.
The decision trees developed from the derivation cohort were then validated in the validation cohort. For patients with simple cataract, preintervention visual acuity was a predictor of significant improvement in visual acuity; greater surgical complexity was a negative predictor.
In patients with cataract and other ocular pathology, two additional variables— expected postoperative visual acuity and preintervention patient visual function—also predicted change in visual acuity.
The authors conclude that these decision trees represent a simple tool for physicians to use in their daily clinical practice when identifying appropriate patients for cataract extraction.
Hayashi et al. conducted a retrospective study focusing on the long-term progression pattern of each type of fundus lesion found in eyes with myopic maculopathy.
The researchers reviewed medical records of 806 eyes of 429 consecutive patients with high myopia (refractive error greater than –8 D or axial length greater than 26.5 mm) followed for a mean of 12.5 years.
They found that 40 percent of these eyes experienced progression during the follow-up period. Only 13.4 percent of eyes with a tessellated fundus showed a progression of myopic maculopathy, while progression of myopic maculopathy was seen in 69.3 percent of eyes with lacquer cracks, 49.2 percent of eyes with diffuse atrophy, 70.3 percent of eyes with patchy atrophy and 90.1 percent of eyes with choroidal neovascularization. During the follow-up period, the authors observed posterior staphyloma more frequently in eyes that showed any progression pattern than in those eyes without progression.
The authors conclude that myopic maculopathy tends to progress in approximately 40 percent of highly myopic eyes and the pattern of progression affects the visual prognosis. Preventive therapy targeting posterior staphyloma should therefore be considered to prevent the visual impairment caused by the progression of myopic maculopathy.
American Journal of Ophthalmology
Garcia-Gonzalez et al. evaluated binocular visual acuity, contrast sensitivity and stereopsis in myopic patients after LASIK-induced monovision.
Thirty-seven consecutive patients older than 45 years underwent bilateral myopic LASIK with planned monovision. At the six-month postoperative visit, the authors evaluated distance and near binocular visual acuity, contrast sensitivity and stereopsis. Binocular tests were done without spectacles (in monovision condition). These tests were compared with the results obtained by repeating the same binocular tests with the same patients after spectacle correction of the residual myopic defect in the nondominant eye for distance tests and after spectacle correction of the presbyopia bilaterally for near tests.
By inducing a mean residual spherical equivalent defect of –0.97 D in the nondominant eye, the patients achieved a mean near binocular uncorrected visual acuity (UCVA) of 0.74, a mean reading test binocular UCVA of 0.88 using an acceptable spontaneous reading distance and a mean distance binocular UCVA of 1.08. A slight decrease in contrast sensitivity and stereopsis was observed in monovision compared with full distance correction.
Kinge et al. evaluated the short-term effect of intravitreal ranibizumab injections on BCVA and macular edema in patients with central retinal vein occlusion.
In this six-month trial, 32 patients with macular edema secondary to central retinal vein occlusion were randomized to receive monthly intravitreal ranibizumab (0.5 mg/0.05 ml) or sham injections for three consecutive months. If macular edema persisted, patients received further monthly injections. Primary outcome measures were BCVA and central macular thickness (CMT) at six months. Twenty-nine patients completed the study.
After three months, BCVA improved by a mean ± standard deviation (SD) of 16 ± 14 Early Treatment Diabetic Retinopathy Study (ETDRS) letters in the ranibizumab group, compared with a mean loss of 5 ± 15 ETDRS letters in the sham group. The mean ± SD change in CMT was –411 ± 200 µm in the ranibizumab group and –86 ± 165 µm with sham.
At six months, the mean ± SD change in BCVA was 12 ± 20 ETDRS letters in the ranibizumab group compared with –1 ± 17 ETDRS letters in the sham group. The mean ± SD change in CMT was –304 ± 194 µm with ranibizumab and –151 ± 205 µm with sham.
Twelve patients in the ranibizumab group required more than three initial injections; mean ± SD number of injections was 4.3 ± 0.9 during the study.
Muselier et al. compared the functional and the anatomic outcomes of combined surgery and consecutive surgery for macular hole and cataract extraction.
One hundred and twenty patients (120 eyes) with an idiopathic macular hole and cataract underwent surgery in one or two sessions in two academic centers. Combined surgery and consecutive surgery were performed between 2006 and 2007. All patients underwent pars plana vitrectomy with internal limiting membrane peeling and gas tamponade. Cataract extraction was performed with phacoemulsification followed by a posterior chamber IOL implantation. The main outcome measures were near and far visual acuity at six and 12 months. The rate of closure of macular hole was evaluated with OCT.
After a 12-month follow-up, postoperative BCVA significantly improved in both the combined and the consecutive surgery groups (near and far vision in both groups). However, the improvement of far visual acuity was not significant in the consecutive surgery group at six months, while such an improvement was observed in the combined surgery group. The one-month closure rates—100 percent and 96 percent in the combined and the consecutive groups, respectively—and postoperative complications did not differ significantly between groups.
The researchers conclude that both combined and consecutive surgeries are safe and effective methods to treat macular hole and cataract with equivalent functional and anatomic results in both procedures.
In a prospective, observational study, Pierro et al. evaluated macular thickness measurement reproducibility using six spectral-domain OCT devices and one time-domain OCT device. Macular thickness was assessed in 18 randomly chosen consecutive eyes of 18 healthy volunteers by two masked operators. The main outcome measure was intraoperator and interoperator reproducibility of OCT-measured central macular thickness.
Mean macular thickness ranged from 172.77 to 272.87 µm. Intraobserver intraclass coefficient correlation ranged from 0.75 to 0.96. Intraobserver coefficient of variation ranged from 0.44 to 2.75. In Bland-Altman analysis, interoperator mean difference ranged from 0.22 to 9.69. An analysis of variance used for repeated measurement was statistically significant for instruments and operators.
The seven OCT devices presented differing macular thickness measurement values; the lowest value was with the SOCT Copernicus (Reichert) and the highest was with the Spectralis HRA+OCT (Heidelberg Engineering). The new generation of spectral-domain OCT devices had good intraoperator reproducibility, but the Spectralis presented the highest reproducibility together with the best interoperator agreement.
The software and, in particular, the algorithm used was the most important factor regarding reproducibility differences in macular thickness measurement.
Jang et al. investigated the effect of yellow-tinted IOLs on short-wavelength automated perimetry (SWAP).
Twenty-two patients who had implantation of yellow-tinted IOLs in one eye and nontinted IOLs in the other eye were included in this cross-sectional observation study. The patients did not have any coexisting ocular disease known to affect the visual field, such as optic nerve disease, glaucoma or diabetic retinopathy.
Standard automated perimetry (SAP) and SWAP were performed and the results for the mean deviation, pattern standard deviation and glaucoma hemifield test results were compared.
There was no statistically significant difference between the IOLs on the SAP. However, a significant difference was observed between the IOLs on the SWAP.
The glaucoma hemifield test did not show significant differences in the SAP. However, the SWAP showed significant differences.
Archives of Ophthalmology
Carvounis et al. reported on the refractive outcomes of anatomically successful lens-sparing vitrectomy (LSV) for stage 4A retinal detachments due to retinopathy of prematurity.
The researchers evaluated the refractive outcomes of eyes of nine infants with ROP who had received bilateral complete ablative laser for threshold ROP but then developed a unilateral stage 4A retinal detachment that was successfully repaired with LSV.
The eyes that underwent LSV had significantly less myopia compared with control eyes (mean spherical equivalent, –6.78 D vs. –10.33 D) at an average age of four years. This was predominantly due to increased anterior chamber depth (mean, 3.8 mm vs. 2.96 mm) and more posterior lens position (mean, 5.58 mm vs. 4.63 mm) with a minor contribution from reduced corneal power in LSV eyes (43.9 D vs. 44.2 D).
The authors conclude that infant eyes undergoing LSV for stage 4A ROP develop less myopia than fellow eyes treated with laser alone mainly due to posterior displacement of the crystalline lens. Such a reduction in myopia may explain the encouraging functional outcomes previously reported for LSV for stage 4A ROP.
The Singapore Malay Eye Study is a population-based cross-sectional survey that examined 3,280 people aged 40 to 80 years to determine the relationship between refractive error, ocular biometry and primary open-angle glaucoma (POAG) in the Malay population.
Participants underwent a standardized clinical examination including slit-lamp biomicroscopy, Goldmann applanation tonometry, refraction, dilated optic disc assessment, and axial length and central corneal thickness measurements. The study’s strengths centered on having a high participation rate and making a diagnosis of glaucoma based on optic nerve changes and perimetric findings that coincided with the International Society for Geographical and Epidemiological Ophthalmology’s criteria.
The main finding was that persons with moderate or higher myopia (–4 D or worse) had an almost three times higher risk of POAG compared with emmetropes. An association between increasing axial length and POAG was also demonstrated. Furthermore, the association of moderate or higher myopia and POAG was no longer significant after controlling for axial length, suggesting that axial myopia rather than other factors may be the main biometric constituent underlying risk for POAG.
Vasconcelos-Santos et al. investigated distinctive clinical features of patients with tuberculous serpiginouslike choroiditis (Tb-SLC) compared with classic serpiginous choroiditis (SC) in a region that is nonendemic for tuberculosis.
A retrospective review of medical records was conducted to compare five cases of presumed Tb-SLC with five cases of classic SC. The diagnosis of Tb-SLC was based on fundus examination, positive tuberculin skin test results and response to antituberculosis treatment. The diagnosis of classic SC was made based on typical fundus and angiographic findings and exclusion of other uveitis entities.
All patients with recurrent Tb-SLC primarily emigrated from areas highly endemic for tuberculosis and had been unsuccessfully treated with steroids and immunosuppressive agents. These patients received oral tuberculostatic drugs without recurrences. The ocular involvement in Tb-SLC was mostly unilateral with multiple irregular serpiginoid lesions involving the posterior pole and periphery but usually sparing the juxtapapillary area. All five cases had inflammatory cells in the vitreous.
Patients with SC were from areas nonendemic for tuberculosis, had negative uveitis workup findings and were successfully managed with steroids and immunosuppressive agents with no recurrence. Ocular involvement in SC was usually bilateral, rarely multifocal and primarily involved the posterior pole, especially around the optic disc, and extending contiguously to the macula. No patient with SC presented with vitritis.
The authors conclude that in areas nonendemic for tuberculosis, SC can be clinically differentiated from Tb-SLC. Patients with Tb-SLC come from highly endemic regions, show significant vitritis and often present with multifocal chorioretinal lesions in the posterior pole and periphery. Cases of SC, in contrast, reveal minimal or no vitritis with larger solitary chorioretinal lesions extending primarily from the juxtapapillary area and sparing the periphery.
Klein et al. examined the prevalence of age-related macular degeneration and its association with age, sex and other risk factors in a cohort of 2,810 people aged 21 to 84 years.
The presence and severity of various characteristics of drusen and other lesions typical of AMD were determined by grading digital color fundus images using the Wisconsin Age-Related Maculopathy Grading System. The authors reported early AMD to be present in 3.4 percent of the cohort. The frequency of early AMD varied from 2.4 percent in those aged 21 to 34 years to 9.8 percent in those aged 65 years or older. The prevalence estimates reported in the study were lower than those of previous studies.
The researchers found that other risk factors associated with early AMD were older age, male biological sex, cigarette smoking, higher serum high-density lipoprotein cholesterol level and presence of a hearing impairment. There were no early AMD associations with blood pressure level, body mass index, physical activity level, history of heavy drinking, white blood cell count, hematocrit level, platelet count, serum total cholesterol level or carotid intimal-medial thickness.
Sarraf et al. described the findings of a new crystalline maculopathy exclusively affecting individuals who have previously received intravitreal triamcinolone acetonide injections.
In a retrospective case series, 21 eyes of 13 patients referred over a nine-year period were identified as having a characteristic crystalline maculopathy. Each patient underwent detailed historical questioning and comprehensive ocular evaluation, including formal retinal examination, fundus photography, fluorescein angiography and OCT.
Each of the 21 eyes had been treated with intravitreal triamcinolone for macular edema (18 eyes due to diabetes, two due to pseudophakic cystoid macular edema and one due to a vein occlusion).
The crystals were superficial, refractile, white or yellow-green, asymmetric in distribution and deposited as a cluster in the central macula or in a perifoveal distribution. The crystals were benign and unassociated with visual deficit. Preretinal hyperreflective deposits were noted with OCT. Two eyes underwent vitrectomy with membrane peeling, and the crystals were no longer present postoperatively.
Sharma et al. reported a case of vancomycin-resistant enterococcal endophthalmitis following cataract surgery.
A 73-year-old woman presented with endophthalmitis seven weeks after phacoemulsification and IOL implantation. The patient was initially treated with a pars plana vitrectomy, lens exchange and intravitreous vancomycin and ceftazidime. However, vitreous culture grew Enterococcus faecium that was resistant to vancomycin, ampicillin, ciprofloxacin, levofloxacin, erythromycin, penicillin, streptomycin and tetracycline, but susceptible to chloramphenicol, linezolid and quinupristin/dalfopristin. The patient received topical chloramphenicol and fortified gentamicin sulfate eyedrops, as well as intravenous and oral linezolid, and experienced resolution of inflammation.
No adverse reaction to linezolid was reported.
Roundup of Other Journals
Kahook et al. conducted a study to determine if high-molecular-weight aggregates play a role in the occurrence of the sustained elevated IOP that has been reported after single or multiple injections of ranibizumab and bevacizumab. They focused on repackaged bevacizumab, which has been linked to a majority of cases involving IOP spikes.
They analyzed repackaged bevacizumab syringes from three outside compounding pharmacies and samples from the original vial using enzyme-linked immunosorbent assay, size exclusion chromatography and polyacrylamide gel electrophoresis. They also used microflow imaging to examine the size and number of particulate material within the samples.
The researchers found significant differences in the immunoglobulin concentration in the different repackaged bevacizumab syringes. The reasons for these differences require further studies, but a trend exists for an increase in micron-sized protein aggregates corresponding to a decrease in immunoglobin concentration.
The authors speculate that the presence of large particulate matter could potentially cause an obstruction of aqueous outflow with a subsequent elevation in IOP.
A study by Asrani et al. indicates that the ICare tonometer is accurate and reliable for use by patients.
In this study, a technician first measured IOP in the right eye of 100 consecutive glaucoma patients using the ICare tonometer. After receiving instruction from the technician, each patient then measured his or her own IOP using the device. Next, a different technician measured IOP by Goldmann applanation tonometry.
The findings showed that 82 of the patient ICare readings were within 3 mmHg of the technician ICare readings and 75 of the patient ICare measurements were within 3 mmHg of the Goldmann applanation tomometry measurements.
While the researchers conclude that IOP readings using the ICare tonometer were both reliable and reproducible, they pointed out some limitations to the possibility of home use.
First, the reliability of the patient measurements may not be the same when the patient is using the device without being supervised by a technician. Subsequent studies would be useful to evaluate this effect. Second, patients may not necessarily measure IOP from the central cornea if they use the device by themselves.
Glaucoma filtering surgery usually involves a transconjunctival traction suture through the superior rectus muscle placed at the 12 o’clock position, or a peripheral lamellar corneal suture placed at the same position. Recent studies show the former approach may be associated with a lower success rate compared with a corneal traction suture. Yet, a 12 o’clock corneal traction suture—combined with a fornix-based approach—may distort the scleral flap tissue.
To improve the success of this procedure, Grehn and Klink describe a new technique that places the corneal traction suture away from the surgical site at the 6 o’clock position. The technique involves a transcorneal suture at 6 o’clock passed underneath a notched solid-bladed lid speculum, which pushes the suture deep into the inferior fornix to rotate the eye downward.
Since May 7, 2007, 412 trabeculectomies were performed using this technique with no significant complications. In all cases, the exposure of the 12 o’clock position was adequate for fornix-based or limbus-based trabeculectomy and also for canaloplasty.