Author: Am J Ophthalmol

Macular Surgery, Second Edition

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Media Type: Textbook with On-line text and image bank (requires activation) Synopsis: The second edition of Macular Surgery is a well-written, comprehensive, and current review of macular diseases as well as their clinical and surgical management. Th…

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We thank Caimi and associates for their interest in our article regarding serous macular detachment in Waldenström macroglobulinemia. They describe 1 patient in whom cystoid macular edema and serous macular detachment was present without outer retinal…

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Reporting Visual Acuities

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The AJO encourages authors to report the visual acuity in the manuscript using the same nomenclature that was used in gathering the data provided they were recorded in one of the methods listed here. This table of equivalent visual acuities is provided…

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Incidence and Progression of Epiretinal Membranes in Eyes After Cataract Surgery – Corrected Proof

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Purpose: To assess eye-specific epiretinal membrane (ERM) incidence 3 years after phacoemulsification surgery, and ERM detection bias attributable to cataract.Design: Cohort study.Methods: We recruited 1932 cataract surgical patients aged ≥64 years at Westmead Hospital (2004-2007). The surgical eye of each patient was assessed for presence of cellophane reflex or preretinal fibrosis at preoperative and 1-month-postoperative visits, and annually thereafter, using retinal image grading. Agreement on ERM detection between preoperative and 1-month-postoperative visits was assessed using kappa statistics. Cumulative incidence of ERM from 1 month to 3 years postoperatively was estimated using Kaplan-Meier methods and compared to the 5-year incidence of idiopathic ERM in right eyes of age-matched Blue Mountains Eye Study (BMES) participants.Results: ERM prevalence was 13.9% among 1394 participants with retinal photographs taken 1 month postoperatively. Of 1040 participants with retinal photographs from both preoperative and 1-month-postoperative visits, ERM was detected in 3.1% and 14.8%, respectively, with low diagnostic agreement (kappa = 0.17). Of 1119 subjects without ERM 1 month post surgery, the 3-year cumulative incidence of ERM was 11.2% (95% confidence interval [CI], 9.4%-13.4%; cellophane reflex 6.6%; preretinal fibrosis 4.2%). The age-standardized 3-year incidence of ERM in the surgical cohort (12.1%, 95% CI 8.6%-16.9%) was higher than the 5-year incidence of the BMES subsample (4.4%, 95% CI 3.0%-6.0%).Conclusions: A substantial under-detection of ERM in eyes before cataract surgery could incorrectly contribute to ERM incidence after surgery. Over 3 years, ERM developed in >10%, including preretinal fibrosis in 4%, of surgical eyes free of ERM 1 month post surgery.

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Comparisons of Outcomes With Different Intervals Between Adjunctive Ranibizumab and Photodynamic Therapy for Polypoidal Choroidal Vasculopathy – Corrected Proof

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Purpose: To determine the optimal time for administration of intravitreal ranibizumab injections before photodynamic therapy (PDT) as combined therapy to treat polypoidal choroidal vasculopathy (PCV).Design: Retrospective, comparative, interventional case series.Methods: The study included 99 eyes (98 patients) with treatment-naïve subfoveal PCV treated with an intravitreal ranibizumab injection followed by PDT. The combination therapy included 1 ranibizumab injection administered 7 days before PDT (7-day group) or 2 days before PDT (2-day group). All eyes were followed for over 12 months.Results: Intravitreal ranibizumab was administered 7 days before PDT in 59 eyes and 2 days before PDT in 40 eyes. In the 7-day group, the best-corrected visual acuity (BCVA) did not improve significantly at 3 months (P = .086) or 12 months (P = .259) compared with baseline. In the 2-day group, BCVA improved significantly at 3 months (P < .001) and 12 months (P < .001). The polypoidal lesions regressed completely in 46 eyes (78.0%) in the 7-day group and in 34 eyes (85.0%) in the 2-day group; 38 eyes (64.4%) and 35 eyes (87.5%), respectively, did not require additional treatment, which differed significantly (P = .008) between the 2 groups. Subretinal hemorrhages did not develop in either group within 1 month after the combined therapy.Conclusions: Administration of an intravitreal ranibizumab injection 2 days before PDT achieves significantly better visual outcomes and requires fewer additional treatments compared with administration of the injection 7 days before PDT.

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Ocular Biometric Parameters Associated With Intraocular Pressure Reduction After Cataract Surgery in Normal Eyes – Corrected Proof

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Purpose: To evaluate the ocular biometric parameters associated with intraocular pressure (IOP) reduction after phacoemulsification.Design: Prospective, observational case series.Methods: The study included 999 patients who had undergone uncomplicated phacoemulsification. IOP and ocular biometric parameters were checked preoperatively and 3 months postoperatively using anterior segment optical coherence tomography, optical biometry, and ultrasonic biomicroscopy. The relationship between IOP change and the parameters, including preoperative IOP, anterior chamber depth, axial length, angle opening distance at 500 μm, anterior chamber area, corneal thickness, lens thickness, and iris thickness at 750 μm, was evaluated.Results: The mean patient age was 67.1 ± 4.3 years. The average change in IOP was −1.6 mm Hg (−11.8%). In univariate analysis, axial length, corneal thickness, and iris thickness were not significantly associated with IOP reduction. However, preoperative IOP, anterior chamber depth, angle opening distance, anterior chamber area, and lens thickness were significantly associated with IOP change (P < .05). Furthermore, changes in anterior chamber depth (standardized coefficient beta [B] = −0.082), angle opening distance (B = −0.095), and anterior chamber area (B = −0.380) were more strongly correlated with IOP change than were preoperative factors (B = −0.078, B = −0.071, and B = −0.067, respectively). In multivariate analysis, preoperative IOP, lens thickness, angle opening distance change, and anterior chamber area change were significantly associated with IOP change (P < .005).Conclusion: In addition to preoperative IOP and lens thickness, parameters such as changes in anterior chamber area and angle opening distance were significantly associated positively with reduced IOP after phacoemulsification.

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The Value of Combining Autofluorescence and Optical Coherence Tomography in Predicting the Visual Prognosis of Sealed Macular Holes – Corrected Proof

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Purpose: To investigate the autofluorescence patterns of sealed macular holes and determine the correlations of the postoperative changes in spectral-domain optical coherence tomography and fundus autofluorescence (FAF) with the best-corrected visual acuity (BCVA) of patients with sealed idiopathic macular holes.Design: Retrospective consecutive observational case series.Methods: Seventy-seven eyes from 75 consecutive patients who had undergone successful vitrectomies for idiopathic macular holes by a single surgeon with postoperative follow-ups for over 1 year were included. FAF imaging studies were performed 1 month and 6 months post surgery, and optical coherence tomography (OCT) was performed at regular intervals after surgery. The main outcome measures were macular hole size, FAF patterns, retina outer segment from OCT, and BCVA before and after operation.Results: The patients who had intact external limiting membranes (ELMs) at 1 month after surgery had better BCVAs than those without (P < .001), regardless of the photoreceptor inner segment/outer segment (IS/OS) condition. The FAF patterns were divided into 3 groups: homogenous hyperfluorescence, patchy hyperfluorescence, and normal hypofluorescence. No significant BCVA differences were noted (P = .28) among the 3 groups. However, significantly better BCVAs were noted in the patients who had both intact ELMs and normal hypofluorescence patterns (P = .011).Conclusions: In sealed macular holes, intact ELMs predicted good postoperative BCVA. In this subgroup, a hypofluorescence pattern on the FAF imaging predicted the best postoperative BCVA.

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Cataract Extraction Outcomes and the Prevalence of Zonular Insufficiency in Retinitis Pigmentosa – Corrected Proof

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Purpose: To examine surgical outcomes in patients with retinitis pigmentosa (RP) undergoing phacoemulsification cataract extraction.Design: Retrospective observational case series.Patients And Methods: In this single-institution study of consecutive RP patients who underwent phacoemulsification cataract extraction and intraocular lens implantation by a single surgeon between 2002 and 2012, preoperative, intraoperative, and postoperative records were analyzed with attention to best-corrected visual acuity (BCVA), lens and zonular status, capsular tension ring use, incidence of posterior capsular opacification and neodymium-doped yttrium-aluminum-garnet (YAG) laser capsulotomy, and surgical complications.Results: Eighty eyes of 47 RP patients (21 male) underwent cataract surgery during the study period at an average age of 48.9 years (range, 31-78 years). Mean follow-up time was 23.3 months (range, 1 day – 95 months). Posterior subcapsular cataracts were present in 97.5% of patients. Mean BCVA improved from 20/340 (logarithm of the minimal angle of resolution [logMAR] 1.23) to 20/129 (0.81) within 3 months of surgery, P < .0001. Eyes with a preoperative vision of 20/40 to 20/200 (47 eyes) improved from a mean of 20/81 (logMAR 0.61) preoperatively to 20/43 (0.33), P < .0001, postoperatively. Posterior capsule opacification occurred in 66 eyes (82.5%), and 42 eyes (52.5%) underwent a YAG laser capsulotomy at a mean of 10.8 months after surgery. Fifteen eyes (18.8%) of 10 patients (21.3%) had signs of phacodonesis (3 eyes noted preoperatively, 8 intraoperatively, and 4 postoperatively). One patient had bilateral dislocated in-the-bag intraocular lenses at 5.5 years and 6 years after surgery.Conclusion: Cataract surgery yields significantly improved Snellen visual acuity in a majority of RP patients with a preoperative vision of 20/200 or better. Conversely, patients with a preoperative visual acuity of 20/400 or worse generally have more limited objective improvements, likely because of macular involvement, but usually report noticeable subjective improvement. A high prevalence of zonular instability is seen in RP patients undergoing cataract extraction. It is therefore important to conduct a careful preoperative assessment of lens stability with preparation for adjunctive methods that augment intraoperative and postoperative lens stabilization.

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Deep Anterior Lamellar Keratoplasty versus Penetrating Keratoplasty for Macular Corneal Dystrophy: A Randomized Trial – Corrected Proof

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Purpose: To compare outcomes of big-bubble deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK) for macular corneal dystrophy.Design: Prospective, randomized, interventional case series.Methods: setting: Single hospital. patients: Eighty-two eyes of 54 patients requiring keratoplasty for the treatment of macular corneal dystrophy without endothelial involvement were included. main outcome measures: Operative complications, uncorrected visual acuity, best-corrected visual acuity, contrast sensitivity function, higher-order aberrations, and endothelial cell density were evaluated.Results: The DALK and PK group consisted of 35 and 41 eyes, respectively. Best-corrected visual acuity after surgery was 20/40 or better 68.5% and 70.7% of the eyes in the DALK and PK groups, respectively (P > .05). No statistically significant differences between groups were found in contrast sensitivity function with and without glare for any spatial frequency (P > .05). Significantly higher levels of higher-order aberrations were found in the DALK group (P < .01). In both groups, a progressive and statistically significant reduction in endothelial cell density was found (P < .01). At the last follow-up, the mean endothelial cell loss was 18.1% and 26.9% in DALK and PK groups, respectively (P = .03). Graft rejection episodes were seen in 5 eyes (12.1%) in the PK group, and regrafting was necessary in 3 eyes (7.3%). Recurrence of the disease was documented in 5.7% and 4.8% of the eyes in the DALK and PK groups, respectively.Conclusions: Deep anterior lamellar keratoplasty with the big-bubble technique provided comparable visual and optical results as PK and resulted in less endothelial damage, as well as eliminating endothelial rejection in macular corneal dystrophy. Deep anterior lamellar keratoplasty surgery is a viable option for macular corneal dystrophy without endothelial involvement.

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Role of Oral Corticosteroids in Orbital Cellulitis – Corrected Proof

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Purpose: To evaluate the role of oral corticosteroids as an anti-inflammatory adjunct in the treatment of orbital cellulitis.Design: Prospective, comparative, single-masked, interventional clinical study.Methods: setting: Tertiary eye care center (All India Institute of Medical Sciences). study population: Patients with acute onset (within 14 days) of orbital cellulitis with or without abscess. intervention: Patients were randomized into 2 groups in the ratio of 1:2. Both groups received initial intravenous antibiotics. In Group 2, oral steroids were added after an initial response to intravenous antibiotics. main outcome measures: Resolution of signs and symptoms, duration of intravenous antibiotics, length of hospital stay, and sequelae of disease (ptosis, proptosis, and movement restriction) were evaluated and compared between the 2 groups.Results: A total of 21 patients (age range, 11-59 years) with orbital cellulitis were studied. There were 7 patients in Group 1, who received standard intravenous antibiotics, and 14 in Group 2, who received adjuvant steroids. Patients in Group 2 showed an earlier resolution of inflammation in terms of periorbital edema (P = .002 at day 7), conjunctival chemosis (P < .001 at day 10), and pain (P = .012 at day 7). They also attained vision of 0.02 on logMAR earlier than Group 1 patients. Decrease in proptosis and improvement in extraocular movements were also significantly better with the use of steroids (P = .027 at day 10, P = .003 at day 14, respectively). While a significant number of patients in Group 1 had mild residual ptosis, proptosis, and movement restriction at 12 weeks, none of the patients treated with steroids had any residual changes (P = .023, P = .001, and P = .001, respectively). The durations of intravenous antibiotics and hospital stay were significantly less in Group 2.Conclusion: Use of oral steroids as an adjunct to intravenous antibiotic therapy for orbital cellulitis may hasten resolution of inflammation with a low risk of exacerbating infection.

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