• Journal Highlights

    A Review of the Literature


    American Journal of Ophthalmology
    JAMA Ophthalmology
    Roundup of Other Journals


    Characteristics of Medically Reversible Limbal Stem Cell Disease

    October Ophthalmology

    Kim et al. assessed the clinical features of—and management strategies used in—patients who had limbal stem cell (LSC) disease that was reversed with medical therapy. They also described a stepwise approach to treatment.

    For this retrospective case series, the researchers reviewed the records of 15 patients (22 eyes) seen at three tertiary referral centers between 2007 and 2011. At presentation, the patients’ mean age was 39 years (range, 22-57 years). Symptoms included ocular irritation, contact lens intolerance, and blurred or decreased vision. One clinical sign seen in all patients was progressive epitheliopathy with hazy, translucent epithelium extending centrally from the limbus. In addition, all patients had mild to moderate tear film dysfunction, reduced tear film breakup time, or both. The extent of limbal involvement varied from 60 to 360 degrees, and the superior quadrant of the limbus was the most common site of involvement.

    Presumed causes for LSC disease in these patients included contact lens wear (13 eyes), contact lens wear in the setting of ocular rosacea (three eyes), and surface toxicity resulting from use of glaucoma medications (two eyes). No causes were identified in the remaining four eyes.

    Conservative management alone was enough to resolve the disease in four eyes. (This involved discontinuing contact lens wear and using preservativefree artificial tears.) Additional treatment was needed in the remaining 18 eyes, ranging from topical vitamin A, topical corticosteroids, topical cyclosporine, and punctal occlusion to oral doxycycline. All eyes achieved a stable ocular surface over a mean followup of 15 months (range, 4-60 months).


    Rituximab Effective for Refractory Scleritis

    October Ophthalmology

    In a prospective phase 1/2 clinical trial, Suhler et al. evaluated the use of rituximab in the treatment of refractory noninfectious scleritis. They found that the drug was moderately effective and well tolerated.

    The trial enrolled 12 patients who had noninfectious scleritis that did not respond to treatment with systemic corticosteroids and one or more additional systemic immunosuppressants. The patients were randomly assigned to receive 500 or 1,000 mg of rituximab on the first and 15th day of the study. Those who initially responded but had breakthrough inflammation after study week 24 were offered two additional infusions of
    1,000 mg rituximab.

    Primary outcomes were reduction of inflammation and reduction in corticosteroid dose by 50 percent or more. Secondary outcomes included improvement in visual acuity and reduction in pain.

    Of the 12 patients, nine met the inflammation endpoint before week 24, and four were able to reduce their corticosteroid dose. However, seven of the nine initial responders required a second cycle of infusions. Seven of the 12 patients noted a significant reduction in pain and/or analgesic use.

    Overall, treatment was well tolerated, with minimal side effects. However, three patients were classified as study failures; one of the three withdrew after the first infusion due to a severe uveitis flare.

    This is the first prospective interventional study of rituximab in the treatment of scleritis, the researchers noted. They added that although conclusions are limited by the study’s small size, there were no notable differences in efficacy, duration of effect, Bcell depletion, or toxicity between treatment groups.


    Topical NSAIDs for Macular Edema Prophylaxis

    October Ophthalmology

    In a meta-analysis of 15 randomized trials, Kessel et al. compared the effectiveness of topical steroids and topical nonsteroidal anti-inflammatory drugs (NSAIDs) in preventing cystoid macular edema (CME) after uncomplicated cataract surgery. They found that topical NSAIDs were more effective than even potent topical steroids for CME prophylaxis.

    When patients were evaluated by fluorescein angiography or optical coherence tomography at four to five weeks after cataract surgery, CME was six to seven times more prevalent in patients randomized to topical steroids, the researchers found. There was no statistically significant difference in the number of adverse events and no significant difference in visual acuity between the steroid and NSAID groups at the end of treatment.

    Five different NSAIDs were used in the included studies (diclofenac, ketorolac, bromfenac, nepafenac, and indomethacin); this meta-analysis was not designed to determine which NSAID was most effective. In addition, although this study did not evaluate the timing of treatment, it appeared that the risk of CME was lower if NSAIDs were administered before cataract surgery. Thus, it seems advisable to start NSAIDs one to three days before surgery, the researchers concluded.


    American Journal of Ophthalmology

    Anti-VEGF Treatment Patterns Among Medicare Beneficiaries

    September AJO

    Lad et al. examined the use of anti–vascular endothelial growth factor (VEGF) therapy in clinical practice among patients with neovascular age-related macular degeneration (AMD) in a retrospective cohort study. The authors found that, among Medicare fee-for-service beneficiaries initiating treatment between 2006 and 2010, real-world U.S. practice patterns in anti-VEGF therapy for patients with neovascular AMD do not reflect optimal treatment strategies suggested by recent clinical trial evidence.

    From the records of 459,237 Medicare beneficiaries, the authors identified anti-VEGF treatment using claims for intravitreal injections of anti-VEGF medications with a supporting diagnosis of neovascular AMD. They used the cumulative incidence function to calculate the frequency of anti-VEGF treatments and treatment visits for neovascular AMD per treated eye in the first and second year after the initial anti-VEGF injection. The mean number of injections was 4.3 in the first year, with 58 percent of patients receiving 1 to 4 injections, 20 percent receiving 5 to 6 injections, and 22 percent receiving 7 or more injections. Of patients who received 1 to 4 injections during the first year, 70 percent received no injections, and 24 percent received 1 to 4 injections, during the second year. Among patients who received 7 or more injections during the first year, 31 percent received a comparable number during the second year, and 12 percent received no injections. Rates of anti-VEGF discontinuation were 57 percent within 12 months and 71 percent within 24 months.


    Bleb Revision for Hypotony Maculopathy Following Trabeculectomy

    September AJO

    In a noncomparative retrospective case series, Bitrian et al. examined a surgical method of bleb revision for hypotony maculopathy following trabeculectomy. The aims of the study were to evaluate the long-term efficacy of this method and to define the relationship between the duration of hypotony maculopathy and visual acuity (VA) outcomes.

    Medical records of 33 patients with hypotony maculopathy who underwent primary bleb revision between June 1999 and September 2012 by a single surgeon were reviewed. Hypotony maculopathy was characterized by reduced VA and the presence of retinal striae and macular edema in the setting of decreased IOP after glaucoma filtering surgery. Thirty-three eyes of 33 patients were followed for 4.68 ± 3.56 years. Mean duration of hypotony maculopathy was 4.98 ± 8.93 months. LogMAR VA improved from 0.78 ± 0.40 at baseline to 0.34 ± 0.34 six months after bleb revision, and was 0.45 ± 0.55 12 months after bleb revision. Mean IOP increased from 3.51 ± 2.27 mmHg to 12.06 ± 4.06 mmHg at 12 months. Fifty-two percent of patients were not using any antiglaucoma medications at last follow-up. Five eyes (15 percent) required a second bleb revision to correct persistent hypotony maculopathy.

    Surgical repair for hypotony maculopathy provided a significant improvement in VA at six and 12 months. Surgical bleb revision was associated with good long-term control of IOP and improved VA in eyes with hypotony maculopathy after previous glaucoma filtering surgery.


    Evaluation of 3 Presbyopia-Correcting IOLs After Cataract Extraction

    September AJO

    Pepose et al. conducted a prospective randomized multicenter clinical trial to compare contrast sensitivity, visual acuity (VA), and halos in subjects bilaterally implanted with one of three FDA-approved presbyopia-correcting intraocular lenses (IOLs). The results demonstrated that each IOL has attributes that should be considered when selecting lenses for implantation.

    Seventy-eight patients were randomized sequentially for bilateral implantation with the Crystalens AO (Bausch + Lomb Surgical), AcrySof IQ ReSTOR + 3.0 D (Alcon), or Tecnis Multifocal (Abbott Medical Optics) lenses. Subjects were evaluated at four postoperative visits, the last occurring four to six months after surgery. At each visit, the following monocular and binocular assessments were performed: high- and low-contrast VA; contrast sensitivity without glare; halos or starbursts; defocus curves; optical scatter; retinal point spread function; and safety.

    The Crystalens and ReSTOR demonstrated better monocular and binocular contrast sensitivity without glare at low to mid-spatial frequencies compared with the Tecnis lens. The Crystalens had significantly better binocular low-contrast distance-corrected VA than the ReSTOR and better mean monocular low-contrast distance-corrected VA than the Tecnis lens. The Crystalens demonstrated significantly better monocular and binocular uncorrected and distance-corrected intermediate VA than the ReSTOR or Tecnis lens. The Crystalens caused significantly fewer halos than the Tecnis lens and less optical scatter than the ReSTOR or Tecnis. The ReSTOR lens had significantly better monocular and binocular uncorrected and distance-corrected near VA tested at 40 cm compared with Crystalens and Tecnis. Binocular uncorrected distance VA was not significantly different among the three lenses.

    In summary, the Crystalens had statistically better uncorrected intermediate VA and distance-corrected intermediate VA than the ReSTOR or Tecnis Multifocal lens, and fewer photic phenomena than the Tecnis. Both multifocals had better distance-corrected near VA and uncorrected near VA than the Crystalens. The authors suggest that the findings may guide IOL selection for individual patients depending on their visual needs.


    JAMA Ophthalmology

    Combined Intravitreal Melphalan and Topotecan for Vitreous Seeding From Retinoblastoma

    August JAMA Ophthalmology

    Ghassemi et al. conducted a retrospective study to evaluate the efficacy and safety of combined intravitreal chemotherapy (melphalan hydrochloride and topotecan hydrochloride) for viable vitreous seeding from retinoblastoma. In this study, trans–pars plana intravitreal injection of melphalan hydrochloride (40 µg in 0.04 mL of diluent) combined with topotecan hydrochloride (820 µg in 0.04 mL of balanced salt solution), followed by injectionsite cryotherapy, was administered to nine eyes initially categorized as group D (n = 6) or E (n = 3) according to the International Classification of Retinoblastoma.

    This treatment produced complete control of vitreous seeds in all nine eyes following a mean of 1.9 injections (median, 2; range, 13 injections). In three cases, tumor control was achieved with a single injection, whereas in six cases, two or three injections were necessary. Three patients subsequently underwent enucleation because of recurrent tumor and persistent anterior chamber lesions. During a mean 15.2 months of followup (median, 16; range, 725 months), there was no recurrence of new tumor or vitreous seeds in the six remaining eyes.

    Complications included temporary hypotony of two weeks or less in two eyes, temporary epithelial defect in one eye, and vitreous hemorrhage in one eye. No episcleral or orbital retinoblastoma extension or remote retinoblastoma metastasis occurred among the six eyes that were not enucleated. There was no change in the a and bwaves of brightflash electroretinograms.


    Alteration of Tear Mucin 5AC in Office Workers Using VDTs

    August JAMA Ophthalmology

    Uchino et al. evaluated the relationship between mucin 5AC (MUC5AC) concentrations in tears, working hours, and the frequency of ocular symptoms among visual display terminal (VDT) users, including patients with dry eye disease (DED) and controls without DED.

    In an institutional cross-sectional study, participants included 96 Japanese office workers; both eyes of each individual were studied. Participants completed questionnaires about their hours working at a VDT and the frequency of ocular symptoms. DED was diagnosed as either definite or probable, or it was not present.

    Tear fluid was collected from the inferior fornix after instillation of 50 µL of sterile saline. The MUC5AC concentration was normalized to tear protein content and expressed as MUC5AC (nanograms) per tear protein (milligrams). The differences in MUC5AC concentration between DED groups, between VDT working hours (short, intermediate, or long), and between symptomatic and asymptomatic groups were evaluated at a 95 percent confidence interval (CI) based on nonparametric Hodges-Lehmann determination. The prevalence of definite and probable DED was 9 percent (n = 9) and 57 percent (n = 55), respectively.

    The mean MUC5AC concentration was lower in the tears of VDT users with definite DED than in those with no DED (estimated difference, –2.17; p = .02; CI, –4.67 to –0.30). The mean MUC5AC concentration in tears was lower in the group that worked longer hours than in the group that worked shorter hours (estimated difference, –1.65; p = .049; CI, –3.12 to 0.00). Also, MUC5AC concentration was lower in participants with symptomatic eye strain than in asymptomatic individuals (estimated difference, –1.71; p = .001; CI, –2.86 to –0.63).


    Methicillin-Resistant Staphylococcus aureus Dacryoadenitis

    August JAMA Ophthalmology

    Although methicillin-resistant Staphylococcus aureus (MRSA) is often thought to be chiefly a nosocomial infection, the incidence of community-acquired MRSA is rising, as highlighted in a case series by Liu et al. involving three adult patients presenting with community-acquired MRSA acute dacryoadenitis within a three-week period. All of the patients presented with pain and periocular erythema increasing over approximately one week. An S-shaped lid deformity was evident, and two of the three patients had multiple pustules/abscesses in the region of the lacrimal gland that were expressing purulent fluid into the superior fornix. Eye cultures yielded MRSA. Each patient had complete clinical resolution with two to four days of intravenous vancomycin followed by one week of oral trimethoprim-sulfamethoxazole combination therapy.

    These cases underscore the changing profile of MRSA infections, especially in the community-based setting. MRSA dacryoadenitis can be difficult to treat with standard therapeutic approaches and may progress to orbital cellulitis. The authors recommend consideration of a short hospital admission for intravenous antibiotic therapy while bacterial sensitivities are being determined before transitioning to a dual-targeted oral antibiotic regimen.


    Ophthalmology summaries are written by Jean Shaw and edited by Susan M. MacDonald, MD. American Journal of Ophthalmology summaries are edited by Thomas J. Liesegang, MD. JAMA Ophthalmology summaries are based on authors’ abstracts as edited by senior editor(s).


    Roundup of Other Journals

    Novel Method for Lacrimal Duct Reconstruction

    British Journal of Ophthalmology
    Published online June 11, 2014

    Chen et al. evaluated a new method of lacrimal duct reconstruction that combines a histoengineered material with the patient’s conjunctival tissue to form a new tear duct.

    For this study, the researchers recruited five patients (five eyes) with partial or total absence of the lacrimal duct as a result of trauma (four eyes) or of congenital abnormality (one eye).

    For the new duct, the researchers used a xenogeneic acellular dermal matrix and a patch of conjunctival tissue, from the conjunctival fornix area, which served as a free graft. The biofilm was immersed in normal saline so that the conjunctival tissue could adhere to it, and this reconstructed complex was rolled and fixed by suture into a tubelike structure, with the epithelium forming the inner wall and the biofilm forming the outer wall.

    Average duration of follow-up was 7.2 months (range, 6-12 months). All five reconstructed tear ducts proved to be effective, as assessed by irrigation testing and alleviation of epiphora.


    Modified Suturing Technique Effective in Treating Hypotony

    Journal of Glaucoma

    Richman et al. used full-thickness hypotony sutures to treat posttrabeculectomy hypotony and found the technique to be effective.

    For this prospective case series, the researchers treated 15 patients with hypotony from an overfiltering trabeculectomy with a modified full-thickness suturing technique. Several radial sutures were placed in the area of the prior trabeculectomy, and the suture pass started at the limbus and traveled through the conjunctiva and full-thickness sclera for a long pass before exiting the conjunctiva. The sutures were tied using slipknots, and the knots were rotated away from the limbus.

    Patients were evaluated one day, one week, four to six weeks, three months, six months, and one year after surgery; and, over the postoperative course, sutures were removed on a selective basis to titrate intraocular pressure (IOP).

    Before surgery, the mean IOP was 3.3 mmHg (range, 0-6 mmHg) and visual acuity (VA) was 20/150. One day after surgery, mean IOP was 23.5 mmHg; it dropped to 12.9 mmHg three months after surgery and to 10.4 mmHg one year after surgery (range, 5-19 mmHg). Hypotony was resolved in all patients; 13 (87 percent) achieved a target IOP; and VA improved to 20/30.


    Phakic IOLs Outperform Laser for Moderate Myopia

    Cochrane Database of Systematic Reviews

    In a meta-analysis, Barsam and Allan compared excimer laser refractive surgery and phakic intraocular lenses (IOLs) for the correction of moderate to high myopia. They found that phakic IOLs outperform laser surgery on several outcome measures, including best spectacle-corrected visual acuity (BSCVA) and contrast sensitivity.

    For this review, the authors identified 221 relevant clinical studies; of these, three randomized controlled trials met the criteria for inclusion. The three studies included a total of 228 eyes of 132 consecutive patients who had myopia ranging from –6 D to –20 D and up to 4 D of myopic astigmatism. Two of the studies compared LASIK with an iris claw–fixated anterior chamber IOL; the third compared PRK with a toric IOL.

    With regard to treatment outcomes, the percentage of eyes with uncorrected visual acuity (UCVA) of 20/20 or better at 12 months did not differ significantly between those who had received a phakic IOL and those who had been treated with laser. In addition, phakic IOL surgery resulted in less final loss of BSCVA, appeared to result in better contrast sensitivity, and scored higher on patient satisfaction/preference questionnaires. However, it slightly increased the risk of developing early cataract.

    Studies looking at more up-to-date technology with longer follow-up are needed to determine the optimal range of myopia for phakic IOLs and to fully address long-term safety issues, the authors noted.


    Roundup of Other Journals is written by Jean Shaw and edited by Deepak P. Edward, MD.

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