• Journal Highlights

    American Journal of Ophthalmology

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    Fine Needle Aspiration Biopsy in Uveal Melanoma

    February 2016

    Sellam et al. reported the technical aspects, complications, and outcomes of fine needle aspiration biopsy (FNAB) in uveal melanoma by means of a retrospective cohort study.

    FNAB was performed at an ocular oncology clinic if the tumor was more than 5 mm in thickness. Array comparative genomic hybridization analysis was conducted on biopsy samples with sufficient tissue. The main outcome measures were success rates (that is, samples that gave a successful result for biomarker analysis), complications, liver metastasis, and overall survival. The study included 217 consecutive patients with a mean age of 57 years; mean tumor thickness was 8.4 mm. The mean follow-up period was 31 months.

    The procedure was successful in 169 patients (78%). Thirty-one patients (14%) experienced intravitreal hemorrhage, 9 of whom required vitreal surgery. There were no cases of endophthalmitis, orbital dissemination, local recurrence, or rhegmatogenous retinal detachment. Thirty-two patients (15%) developed metastasis during the study, and 20 of them died. Of the 169 successful samples, 53 patients (31%) were classified as low risk, 41 (24%) as intermediate risk, and 54 (32%) as high risk. Fifteen patients (9%) did not have any detectable chromosomal abnormality, and 6 (4%) could not be classified.

    The authors concluded that FNAB is a relatively safe procedure that can be routinely used to obtain tissue biopsy samples for molecular genomic analysis. Further, they noted that such analysis helps determine the frequency of metastases and prognosis in uveal melanoma.

    Dry Eye Patients With Chronic Pain Syndromes

    February 2016

    Vehof et al. conducted a cross-sectional study to investigate clinical characteristics of dry eye disease (DED) patients with a chronic pain syndrome. The study compared ocular signs and symptoms in DED patients with and without a chronic pain syndrome in 2 cohorts. In both cohorts, patients with a chronic pain syndrome had increased severity of all dry eye symptoms, even though the objective signs were similar or less severe compared with those in patients without a chronic pain syndrome.

    One cohort included 425 DED patients at a tertiary care center in the Netherlands. Chronic pain syndromes of irritable bowel syndrome, chronic pelvic pain, and fibromyalgia were assessed by questionnaires. Outcome variables were Ocular Surface Disease Index (OSDI) symptom questionnaire, tear osmolarity, Schirmer test, tear breakup time, conjunctival hyperemia, corneal and conjunctival staining, and amount of mucus. Outcomes were cross-sectionally compared between DED patients with or without a chronic pain syndrome.

    Among the 425 DED patients, 74 (17%) reported at least 1 chronic pain syndrome. The total OSDI symptom score was significantly higher in DED patients with a chronic pain syndrome than in those without (46 vs. 34, p < .0005). Moreover, patients with a chronic pain syndrome scored higher on every single subscale of the 12-item symptom questionnaire. However, ocular signs were similar or even less severe in these patients than in those without a chronic pain syndrome.

    In addition, the researchers looked at a cohort of 64 DED patients from a population-based cohort, the TwinsUK Adult Twin Registry, which had a lower risk of ascertainment bias than the tertiary care clinic population. Similar to the Netherlands cohort, DED patients with a chronic pain syndrome in this UK cohort had higher subscale and total symptom scores.

    In DED patients, chronic pain syndromes seem to be common and are associated with increased severity of DED symptoms across all domains of the OSDI, even though objective ocular surface signs are no worse. Greater awareness of chronic pain syndromes might aid clinicians in understanding the discrepancy between signs and symptoms in DED.

    Reoperation and Binocularity After Strabismus Surgery in Children

    February 2016

    Leffler et al. used a retrospective cross-sectional study to determine the predictors of reoperation and abnormal binocularity outcomes (including amblyopia and diplopia) following pediatric strabismus surgery.

    The authors reviewed a national insurance database to identify children under the age of 18 years who had strabismus procedures between 2007 and 2013. Interventions included adjustable- or fixed-suture strabismus surgery and botulinum toxin injection. The main outcome measure was reoperation or diagnosis of abnormal binocularity in the first postoperative year.

    Of 11,115 children who had strabismus procedures, 851 (8%) underwent reoperation. The reoperation rate was 7% for fixed-suture surgeries, 10% for adjustable-suture surgeries, and 45% for botulinum injections. Age under 2 years was associated with higher reoperation and abnormal binocularity rates. For horizontal strabismus, the postoperative abnormal binocularity rate was 13% for fixed-suture surgery and 26% for botulinum injection.

    Reoperation rates tended to be higher with adjustable sutures or botulinum toxin injection and lower with 3- or 4-muscle surgery. Esotropia, hyperopia, and botulinum injection were independently associated with higher rates of postoperative abnormal binocularity. For vertical surgeries, predictors of reoperation were adjustable suture use and superior oblique surgery.

    Although previous studies conducted among adults found a lower rate of reoperation with use of adjustable sutures, our study found that in children, adjustable sutures were not associated with a lower reoperation rate. Younger age, esotropia, hyperopia, and botulinum injection were associated with postoperative abnormal binocularity. Superior oblique surgery and botulinum injection were associated with higher rates of reoperation.

    Peripheral Cryoablation for Pars Planitis

    February 2016

    Sohn et al. compared the long-term outcomes of peripheral retinal cryoablation to conventional treatment for active pars planitis. They found cryoablation to be effective in resolving the inflammation, possibly performing better than conventional corticosteroid therapy.

    In a retrospective interventional comparative case series conducted at a single institution among eyes with pars planitis, the authors compared the effect of cryotherapy to that of conventional therapy (topical, regionally injected, or oral corticosteroid therapy). Best-corrected visual acuity (VA), complications, resolution of cystoid macular edema (CME), and anterior chamber and vitreous inflammation were assessed.

    Of the study population of 186 eyes, 136 were treated conventionally (control group), and 50 were treated with cryotherapy. Median follow-up was 60.8 months in the cryotherapy group and 45.0 months in the control group. There were no significant differences between the groups in baseline VA, anterior chamber and vitreous inflammation, presence of CME, and prior use of regional corticosteroid injections.

    VA improved over time in the cryotherapy group but declined in the controls (p = .023). Kaplan-Meier survival estimates demonstrated faster times to resolution of anterior chamber cells, vitreous cells, and CME in the cryotherapy-treated eyes. Hazard ratios of remission for vitreous cells and CME for those treated with cryotherapy compared with controls were 4.73 and 6.85 (p = .044), respectively. No ocular complications were identified in the cryotherapy group.

    The authors concluded that peripheral retinal cryoablation therapy is an effective treatment for active pars planitis and may be better than conventional regional corticosteroid injections and oral corticosteroid therapy for induction of remission. They also noted that cryotherapy appears to have a low risk of side effects. However, they acknowledged that, because of study limitations, these results need to be evaluated in a randomized clinical trial.

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    American Journal of Ophthalmology summaries are edited by Thomas J. Liesegang, MD.

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