Lens-Sparing Vitrectomy for ROP
Nudelman et al. evaluated long-term lens clarity after lens-sparing vitrectomy (LSV) surgery was performed in patients with advanced retinopathy of prematurity (ROP). The researchers confirmed previous findings that LSV for ROP has a high success rate, particularly when intervention takes place at the earliest stage. They also found that cataract formation is a rare complication in the first decade of a child’s life—and, if present, most often occurs within one year after LSV.
This study was a retrospective chart review of ROP patients who underwent LSV between 1992 and 2013 at a single tertiary referral pediatric vitreoretinal practice. Patients were excluded if any surgery had been performed elsewhere before referral or if a scleral buckle had been placed. In addition, eyes were excluded if they had a concurrent anatomic abnormality, such as coloboma, or a known history of familial exudative vitreoretinopathy.
A total of 496 eyes (351 patients) met inclusion criteria. Of these, 280 eyes had stage 4A detachments, 177 had stage 4B detachments, and 39 had stage 5 detachments. Main outcome measures were retinal reattachment after LSV, lensectomy after LSV, lens opacity at the time of lensectomy, and lens clarity at last follow-up.
The rate of reattachment after a single LSV surgery was 82.1 percent for stage 4A, 69.5 percent for stage 4B, and 42.6 percent for stage 5. A total of 19.8 percent of eyes required a subsequent retinal surgery; of these, 88.7 percent included a lensectomy. The majority—75 percent—of lensectomies occurred within the first year after LSV surgery.
Choice of Local Anesthetic for Vitreoretinal Surgery
Lidocaine and bupivacaine may be used separately or in combination for peribulbar anesthesia in patients undergoing vitreoretinal surgery. Jaichandran et al. investigated whether there are clinical advantages in terms of onset of effect or duration of action associated with these different anesthetic choices. In this study, bupivacaine appeared to be the best choice, and mixing the drugs did not provide any advantages.
For this cross-sectional study, the researchers randomized 90 patients evenly into three groups: 0.5 percent bupivacaine, 0.2 percent lidocaine, or a combination of the two. Main outcome measures included time of onset of analgesia, akinesia, and intraoperative pain. The efficacy of the block was graded from 0 to 5 depending on the adequacy of anesthesia and akinesia and the need for anesthetic supplementation.
No significant difference was noted in the time of onset for either analgesia or akinesia among the three treatment groups. However, during surgery, 10 patients (33.3 percent) in the bupivacaine group and 19 patients (63.3 percent) each in the lidocaine and combination groups required peribulbar supplementation because of pain. In the postoperative period, seven patients (23.3 percent) in the bupivacaine group, 19 (63.3 percent) in the lidocaine group, and 15 (50 percent) in the combination group needed intramuscular ketorolac for pain relief. In addition, 17 patients in the bupivacaine group (56.7 percent) attained grade 5 block, versus seven (23.3 percent) in the lidocaine group and nine (30 percent) in the combination group.
HIV Neuroretinal Disorder in AIDS Patients
Jabs et al. set out to determine the prevalence, incidence, risk factors, and outcomes of HIV neuroretinal disorder in patients who have AIDS. They reported that the disorder—which is typically characterized by decreased contrast sensitivity and may include abnormal color vision and visual field loss—is a common finding among patients with AIDS and is associated with an increased mortality rate and an increased risk of visual impairment. They also found that successful antiretroviral therapy decreases but does not eliminate the risk of the disorder.
For this prospective cohort study, the researchers evaluated 1,822 patients enrolled in the Longitudinal Study of the Ocular Complications of AIDS. None of the patients had either ocular opportunistic infection or media opacity.
Although the researchers found that 294 of the patients (16 percent) had HIV neuroretinal disorder, they estimated that cumulative incidence may be as high as 50 percent of patients with AIDS by 20 years after the initial AIDS diagnosis. Female and African-American patients are at increased risk; other risk factors include hepatitis C infection, low CD4+ T-cell count, and elevated HIV load. Despite presenting with good visual acuity, patients with HIV neuroretinal disorder were more likely to develop bilateral visual impairment and blindness—and had a substantially higher mortality rate—than those without.
Combination antiretroviral therapy may reduce the risk of the disorder, but it does not eliminate it, the researchers found.
Baseline Demographics of Pioneering POAG Genetics Study
Charlson et al. described the baseline characteristics of patients participating in the Primary Open-Angle African American Glaucoma Genetics Study, the largest African-American population with POAG recruited at a single institution to date. Of the 2,520 African-Americans recruited thus far, 2,067 have met all inclusion criteria and completed the clinical examination. Of these, 1,260 participants have POAG and 807 are serving as controls. All participants were recruited from five low-income ZIP codes adjacent to the sponsoring institution.
Baseline demographics indicate that patients with POAG are more likely to have a lower body mass index (BMI) and to report a history of blindness, while controls are more likely to have diabetes, to have nonproliferative diabetic retinopathy, to use systemic diabetes medications, and to be female, the researchers said.
With regard to recruitment, the researchers said that the following strategies have proved successful in achieving a high participation rate: 1) cultural tailoring of recruitment procedures, 2) strong doctor-patient relationships, and 3) sensitivity to the participants’ socioeconomic needs.
The goal of the study is to construct a risk model of POAG in African-Americans. As part of that endeavor, the researchers intend to perform a comprehensive genetic analysis of POAG, including a genome-wide association study, as well as whole-genome sequencing and functional studies of variants, along with deep endophenotyping.
Ophthalmology summaries are written by Jean Shaw and edited by Susan M. MacDonald, MD.
More from this month's Journal Highlights
American Journal of Ophthalmology
Roundup of Other Journals