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    American Journal of Ophthalmology

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    Cataract Surgery Complicated by Anterior Capsule Tear

    March AJO

    Carifi et al. studied the results of phacoemulsification cataract surgery complicated by anterior capsule tear and found that tears often lead to additional intraoperative complications and a relatively high incidence of secondary interventions. Permanent visual loss and worsening refractive outcomes were also observed in cases where the lens was implanted outside the bag.

    This retrospective case series included 239 study eyes with intraoperative anterior capsule tears and 211 controls that underwent uneventful cataract surgery. Exclusion criteria included combined surgical procedures, planned manual extracapsular cataract extraction, and a history of previous intraocular surgery or eye trauma. The main outcome measures were intraoperative capsule complication rates, refractive and visual outcomes, and incidence of short-term postoperative complications.

    Among the 239 study eyes, planned phacoemulsification was converted to manual extraction in five eyes (2 percent). Concurrent posterior capsule ruptures occurred in 58 eyes (24 percent), with vitreous loss in 38 (16 percent) and dropped nuclear lens material in 11 (5 percent). In addition, 27 eyes (11 percent) underwent unplanned secondary surgical procedures, and permanent visual loss occurred in four (1.7 percent).

    Refractive analysis was based on 187 study eyes. Overall, 146 eyes (78.1 percent) were within 1.00 D of intended postoperative refraction, while only 79 (42.2 percent) were within 0.50 D of target; these results were significantly worse than the outcomes observed in the control group.

    Dry Eye Disease, Depression, and Anxiety

    March AJO

    In this retrospective case-control study, van der Vaart et al. investigated the relationship between dry eye disease and mental illness and found a significant association between dry eye disease and both depression and anxiety. Because treatment of coexisting depression has been shown to improve control of other chronic medical conditions, they suggested that similar improvement may also occur in patients with dry eye.

    The researchers performed a chart review of all individuals over the age of 18 years seen in University of North Carolina outpatient clinics between July 2008 and June 2013. Cases were defined according to ICD-9 diagnosis codes for dry eye disease, anxiety, and depression; and odds ratios were calculated between dry eye disease and each of the two mental illnesses. To validate their methodology, the investigators also calculated similar odds ratios between dry eye disease and rheumatoid arthritis, a systemic disease that has a known association with dry eye.

    Of the 460,611 patients screened, 7,207 were diagnosed with dry eye, 20,004 were diagnosed with anxiety, and 30,100 were diagnosed with depression. The estimated odds ratio was 2.9 for dry eye disease and depression and 2.8 for dry eye disease and anxiety. (The odds ratio for dry eye disease and rheumatoid arthritis was 3.2.)

    The authors concluded that ophthalmologists should be aware of this association and consider referral and treatment for coexisting depression and anxiety as an additional therapeutic measure. 

    Endogenous Endophthalmitis Among Hospitalized Patients

    March AJO

    Vaziri et al. identified potential risk factors associated with endogenous endophthalmitis among hospitalized patients with hematogenous infections. They found that while endogenous endophthalmitis is rare in this setting, children and middle-aged patients were at greater risk, as were those patients with longer hospital stays and those admitted to intensive care units.

    In this retrospective, cross-sectional study, the researchers reviewed Medicare Supplemental and Coordination of Benefit inpatient databases from the years 2007 to 2011. Using ICD-9 codes, the researchers calculated logistic regression to identify potential predictors and comorbidities for developing endophthalmitis.

    Among inpatients with hematogenous infections, the overall incidence rate of presumed endogenous endoph-thalmitis was between 0.05 percent and 0.4 percent for those with fungemia, and 0.04 percent for those with bacteremia. In addition, the following diseases and conditions were significantly associated with a diagnosis of endophthalmitis: HIV/AIDS, tuberculosis, endocarditis, bacterial meningitis, fungal meningitis, internal organ abscess, lymphoma/leukemia, skin abscess/cellulitis, pyogenic arthritis, diabetes with ophthalmic manifestations, and urinary tract infection. The researchers also found that patients younger than 17 years of age and those between the ages of 45 and 64 were more likely to be diagnosed with endogenous endophthalmitis, as were sicker patients (measured by length of hospital stay and admission to intensive care units).

    They concluded that these readily identifiable patient characteristics can help ophthalmologists predict patients’ risk of developing endogenous endophthalmitis from bacteremia or fungemia and may assist with triaging decisions in screening for patients with hematogenous infections.

    Morbidity and Mortality in AMD Patients Treated With Anti-VEGF

    March AJO

    In this population linkage study, Ng et al. described the rates of myocardial infarction (MI), stroke, and death in patients treated with intravitreal anti-VEGF for age-related macular degeneration (AMD). They found that the incidence rates were not significantly higher than age-adjusted rates in the general population.

    The researchers identified patients 40 years of age and older who received treatment with intravitreal anti-VEGF for AMD from Jan. 1, 2008, to Dec. 31, 2011, at the Singapore National Eye Centre. They then used a national record linkage database to identify those who either died or experienced MI or stroke after the first injection and compared these rates to those of the total Singapore population.

    A total of 1,182 patients were included in this analysis, with the majority receiving bevacizumab. Overall, there were 19 cases of MI, 16 cases of stroke, and 43 deaths, giving an age-adjusted incidence rate of 350.2 per 100,000 person-years for MI, 299.3 per 100,000 person-years for stroke, and 778.9 per 100,000 person-years for death. This was comparable to the weighted incidence rates of the Singapore population (427.1 per 100,000 person-years for MI, 340.4 per 100,000 person-years for stroke, and 921.3 per 100,000 person-years for death).

    The researchers noted that they were unable to include the prevalence of other known risk factors for MI and stroke, such as hypertension and smoking, in their study design.


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

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