Author: Am J Ophthalmol

Correlation Between Quantitative Measurements of Tear Film Lipid Layer Thickness and Meibomian Gland Loss in Patients With Obstructive Meibomian Gland Dysfunction and Normal Controls – Corrected Proof

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Purpose: To evaluate the correlation between tear film lipid layer thickness and other objective measurements such as tear film break-up time (TBUT), upper and lower meibomian gland losses, and Schirmer 1 test in patients with obstructive meibomian gland dysfunction (MGD) and normal controls.Design: Cross-sectional study.Methods: Thirty eyes of 30 patients with obstructive MGD and 25 eyes of 25 normal controls were enrolled. Lipid layer thickness was measured using an interferometer. Tear film stability and tear production were evaluated by TBUT and Schirmer 1 test. Upper and lower meibomian gland losses were evaluated using noncontact meibography. The correlations among variables were evaluated in the obstructive MGD group and the control group.Results: TBUT was significantly shorter in the obstructive MGD group than in the control group (P < .001). Upper and lower meibomian gland losses were higher in the obstructive MGD group than in the control group (P < .001 and P < .001, respectively), and lipid layer thickness was significantly thicker in the control group than in the obstructive MGD group (P = .028). Lipid layer thickness was significantly negatively correlated with upper and lower meibomian gland losses in both groups.Conclusions: Lipid layer thickness objectively measured with the interferometer was significantly thicker in the control group than in the obstructive MGD group. Lipid layer thickness was negatively correlated with upper and lower meibomian gland losses in the control group as well as in the obstructive MGD group.

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Comparison of Cone Pathologic Changes in Idiopathic Macular Telangiectasia Types 1 and 2 Using Adaptive Optics Scanning Laser Ophthalmoscopy – Corrected Proof

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Purpose: To compare pathologic changes in the photoreceptors of eyes with idiopathic macular telangiectasia types 1 and 2 using adaptive optics scanning laser ophthalmoscopy (AO-SLO).Design: Prospective cross-sectional study.Methods: Eleven eyes with idiopathic macular telangiectasia type 1, 14 eyes with type 2, and 10 normal eyes underwent a full ophthalmologic examination, spectral-domain optical coherence tomography (SD-OCT), and imaging with an original prototype AO-SLO system. All eyes with idiopathic macular telangiectasia were examined with fluorescein angiography (FA), confocal blue reflectance, and microperimetry.Results: Compared with normal eyes (29 017 ± 5507 cones/mm2), those with idiopathic macular telangiectasia type 1 had significantly lower cone density on the temporal side (18 427 ± 4908 cones/mm2, P = .010). The FA leakage area (5.90 ± 3.23 mm2) was larger than the dark regions (2.45 ± 2.40 mm2) on AO-SLO (P = .003)—which were observed only in the FA leakage area. Compared with normal eyes, those with idiopathic macular telangiectasia type 2 had significantly lower cone density in all areas (P < .05 for all). Patchy dark regions were also seen in areas without FA abnormalities in 12 eyes. Higher mean retinal sensitivity correlated with greater mean cone density 0.5 mm from the center of the fovea (type 1: P = .010; type 2: P < .001).Conclusions: Idiopathic macular telangiectasia type-specific differences in the distribution of photoreceptor abnormalities were shown in the AO-SLO images. For both idiopathic macular telangiectasia types 1 and 2, visual impairment was associated with cone damage.

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Agreement of Flicker Chronoscopy for Structural Glaucomatous Progression Detection and Factors Associated With Progression – Corrected Proof

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Purpose: To evaluate agreement of flicker chronoscopy for structural glaucomatous progression detection and factors associated with progression.Design: Retrospective cohort study.Methods: Two glaucoma fellowship–trained ophthalmologists, masked to temporal sequence, independently graded serial flicker chronoscopy images from 1 eye of a cohort of glaucoma patients for features of structural progression. Agreement between graders was determined, as was accuracy for determining the temporal order of images. After adjudication, simple and multiple logistic models were constructed to determine baseline variables associated with increased odds of progression.Results: Fifty of 103 included eyes/patients (48.5%) had at least 1 sign of structural progression. Temporal sequence was incorrectly determined in 14 of 206 cases (6.4%). Interobserver agreements for identifying baseline photographs (κ = 0.9), global progression (κ = 0.7), parapapillary atrophy (PPA) progression (κ = 0.7), disc hemorrhages (κ = 0.7), neuroretinal rim loss (κ = 0.5), and retinal nerve fiber layer (RNFL) loss (κ = 0.2) were calculated. Age was significantly associated with global (1.8; 1.3-2.6, P < .001) (odds ratio; 95% confidence interval, significance) and PPA progression (1.7; 1.2-2.4, P = .002). Lower corneal hysteresis was associated with global progression (0.78; 0.56-0.99, P = .049) and RNFL loss (0.5; 0.3-0.9, P = .02). Goldmann-correlated intraocular pressure (1.0, 0.7-1.4, P = .9), visual field mean deviation (1.0, 0.9-1.0, P = .2), and central corneal thickness (0.9, 0.8-1.0, P = .1) were not significantly associated with progression. On multivariable analysis, only age was associated with global progression (1.8; 1.2-2.5, P = .002).Conclusion: Flicker chronoscopy demonstrated acceptable interobserver agreement in structural progression detection. Corneal hysteresis and age were both associated with progression, but age was the only significant factor on multivariable analysis.

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The Effect of Prior Trabeculectomy on Refractive Outcomes of Cataract Surgery – Corrected Proof

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Purpose: To examine surgical and refractive outcomes of phacoemulsification with intraocular lens (IOL) implant in eyes with prior trabeculectomy.Design: Retrospective observational case-control study.Methods: The study compared eyes that underwent phacoemulsification with IOL implant at least 3 months post-trabeculectomy (n = 77) with eyes with either medically controlled glaucoma (n = 43) or no glaucoma (n = 50) at an academic institution. The main outcome measure was the difference between the expected and the actual postoperative refraction.Results: Mean intraocular pressure (IOP) increased in trabeculectomy eyes from 8.7 ± 4.2 mm Hg to 10.7 ± 4.0 mm Hg (P < .0001), whereas it decreased in glaucoma control and normal control groups by 2.0 mm Hg (P = .003) and 2.1 mm Hg (P < .00001), respectively, with concurrent decrease in drops in the glaucoma control group (0.76 to 0.23, P < .0001). The difference from expected refractive outcome was −0.36 (more myopic) in trabeculectomy eyes compared with +0.23 (more hyperopic) in nonglaucoma controls and +0.40 in glaucoma controls (P < .0001). The correlation between change in IOP vs extent of refractive surprise was statistically significant (P = .01, r = −0.20). Final visual acuity was not affected by the difference in refractive error.Conclusions: The refractive surprise correlated to IOP change, with 2 mm Hg rise resulting in a −0.36 diopter shift between predicted and actual refraction. After cataract extraction, IOP decreased in controls and fewer drops were required, but IOP increased in the study group. Factors affecting refractive surprise in cataract surgery after trabeculectomy, especially IOP change and axial length, require further investigation.

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Color-Code Agreement Among Stratus, Cirrus, and Spectralis Optical Coherence Tomography in Relapsing-Remitting Multiple Sclerosis With and Without Prior Optic Neuritis – Corrected Proof

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Purpose: To evaluate the agreement of retinal nerve fiber layer (RNFL) color codes among Stratus, Cirrus, and Spectralis optical coherence tomography (OCT) in patients with relapsing-remitting multiple sclerosis.Design: Prospective cohort study.Methods: In 140 eyes from 70 patients having relapsing-remitting multiple sclerosis from January 2011 to September 2011, peripapillary RNFL thickness was measured using the fast RNFL program by Stratus, the optic disc cube protocol by Cirrus, and the N-site axonal analysis by Spectralis.Results: Overall, a moderate to good RNFL color code agreement was found (0.435-0.884), except for the nasal quadrant. The temporal quadrant was the most abnormal color coding by both Cirrus (64.7%) and Spectralis (61.7%) in both the optic neuritis (ON) and non-ON group and by Stratus (58.8%) in the ON group. Abnormal temporal RNFL color-code rate was significantly higher in ON eyes than non-ON eyes by Cirrus (P < .001), Stratus (P < .001), and Spectralis (P = .030). Overall, Cirrus significantly displayed abnormal findings while both Stratus and Spectralis displayed normal results for the inferior quadrant (P < .05). On the other hand, Spectralis OCT showed a significantly higher rate of abnormal findings while Cirrus displayed normal results for the temporal quadrant in non-ON eyes (P < .001).Conclusions: We found a substantial color-code disagreement among devices in patients with relapsing-remitting multiple sclerosis regarding the ON antecedent. In non-ON eyes, Spectralis yielded a significantly higher thinning for temporal quadrant than Cirrus, suggesting that N-site axonal analysis could define axonal damage in relapsing-remitting multiple sclerosis patients earlier than conventional RNFL analysis.

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Argon Laser Photoablation of Superficial Conjunctival Nevus: Results of a 3-Year Study – Corrected Proof

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Purpose: To evaluate and report the results of a 3-year study investigating argon laser photoablation of superficial conjunctival nevus.Design: Retrospective, interventional case series.Methods: The medical charts of patients referred to our clinic for the removal of a conjunctival nevus were reviewed. Argon laser photoablation of superficial conjunctival nevi was performed for 230 patients during the period from March 2006 to February 2009. The clinical course, complications, and recurrence rates were evaluated.Results: The mean follow-up period was 71.29 ± 19.51 months (range, 36-100 months). The horizontal and vertical diameters of conjunctival nevi were 4.53 ± 1.85 mm and 3.41 ± 1.62 mm, respectively. Most nevi were faintly pigmented and located on the nasal bulbar conjunctiva. The argon laser spot size was 200 μm; its duration was 0.1 second; and the power was 321.50 ± 9.23 mW. One session was required to completely remove the nevus in 212 eyes (81%). The total number of laser spots that were required to remove 1 nevus was 107.83 ± 33.68 (range, 53-172) for cases in which the horizontal and vertical diameters were <4 mm. In all cases, the laser procedure resulted in complete removal of the conjunctival nevus. There were no significant complications, such as infection, corneal damage, or permanent injection.Conclusions: Argon laser photoablation could be a safe and effective treatment for benign superficial conjunctival pigmentation. This method is especially helpful for large conjunctival nevi, for which surgical excision would be impossible.

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Characterization of Microaneurysm Closure After Focal Laser Photocoagulation in Diabetic Macular Edema – Corrected Proof

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Purpose: To characterize microaneurysm closure following focal laser photocoagulation in diabetic macular edema (DME) using simultaneous fluorescein angiography (FA) and spectral-domain optical coherence tomography (SD-OCT).Design: Retrospective observational case series.Methods: Leaking microaneurysms (n = 123) were analyzed in eyes (n = 29) with nonproliferative diabetic retinopathy (NPDR) that underwent navigated focal laser photocoagulation in DME and were followed at 3, 6, and 12 months. Closure of diabetic microaneurysms was characterized in detail following focal laser using SD-OCT.Results: Closure rate of microaneurysms by both FA and SD-OCT was 69.9% (84/123), 79.7% (98/123), and 82.9% (102/123) at 3, 6, and 12 months, respectively. Microaneurysm closure rate increased at 6 and 12 months compared to 3 months (P < .003, P < .001). Over half of closed microaneurysms (45/86, 52.3%) left hyperreflective spots while the remaining half (41/86, 47.7%) disappeared without any hyperreflectivity by SD-OCT at 3 months. Hyperreflective spots decreased at 6 (36/99, 36.4%) and 12 months (17/102, 16.7%) with a concomitant increase in complete loss of reflectivity at 6 (63/99, 63.6%) and 12 months (85/102, 83.3%). Smaller outer and inner diameters and heterogeneous lumen reflectivity were positively associated with microaneurysm closure at 12 months (P < .0001, P < .001, P < .03).Conclusions: Characterization of microaneurysms following focal laser photocoagulation resulted in hyperreflective spots and complete resolution of all reflectivity using SD-OCT. Smaller microaneurysms and those with heterogeneous lumen were positively associated with microaneurysm closure. These findings provide greater understanding of localized retinal changes following focal laser photocoagulation in DME treatment.

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Long-term Results After Transconjunctival Resuturing of the Scleral Flap in Hypotony Following Trabeculectomy – Corrected Proof

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Purpose: To present the 4-year follow-up results in the surgical treatment of hypotony following trabeculectomy with mitomycin C in glaucoma patients with additional flap sutures.Design: Retrospective interventional case series.Methods: Since 2006, 53 patients with hypotony maculopathy attributable to overfiltration following glaucoma surgery (trabeculectomy with mitomycin C) were included in this institutional study. We were able to follow up intraocular pressure (IOP) and distance-corrected visual acuity in 33 (62%) over 4 years, whereas all were followed over 2 years. To elevate IOP, we placed tangential transconjunctival sutures through the scleral flap and connected them to the adjacent sclera in all 53 patients.Results: Mean IOP prior to surgery was 3.55 mm Hg (± 2.05; range 0-8 mm Hg), 20.08 mm Hg (± 12.48) on the first postoperative day, 10.69 mm Hg (± 4.73) after 1 month, 10.12 mm Hg (± 3.95) after 6 months, 10.42 mm Hg (± 4.17) after 2 years, and 9.5 mm Hg (± 3.93) after 4 years. Mean visual acuity (VA) improved from 0.8 logarithm of minimal angle of resolution (logMAR) preoperatively to 0.5 after 1 month, and remained stable after 6 months at 0.3. Macular folds resolved in all patients and choroidal detachment in 51 patients (96%) after 6 months. IOP increase and vision improvement were statistically significant (<.05).Conclusion: Even 4 years after resuturing of the scleral flap through the intact conjunctiva, there is evidence that this surgical method is an effective and simple technique to treat hypotony maculopathy after glaucoma surgery.

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Variants of Anterior Segment Dysgenesis and Cerebral Involvement in a Large Family With a Novel COL4A1 Mutation – Corrected Proof

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Purpose: To investigate the diverse ocular manifestations and identify the causative mutation in a large family with autosomal dominant anterior segment dysgenesis accompanied in some individuals by cerebral vascular disease.Design: Retrospective observational case series and laboratory investigation.Methods: Forty-five family members from 4 generations underwent ophthalmic examination. Molecular genetic investigation included analysis with single nucleotide polymorphism (SNP) markers and DNA sequencing. Whole exome sequencing was performed in 1 individual.Results: A broad range of ocular manifestations was observed. Typical cases presented with corneal clouding, anterior synechiae, and iris hypoplasia. Posterior embryotoxon, corectopia, and early cataract development were also seen. One obligate carrier and several other family members had minor ocular anomalies, thus confounding the scoring of affected and unaffected individuals. Cerebral hemorrhages had occurred in 4 individuals, in 3 at birth or during the first year of life. Seven patients with corneal clouding were considered “definitely affected” for linkage studies. Haplotype mapping revealed that they shared a 14 cM region in the terminal part of chromosome 13q that included the locus for COL4A1. The affected family members were heterozygous for a novel COL4A1 sequence variant c.4881C>G (p.Asn1627Lys) predicted to be damaging and not found among 185 local blood donors. Exome sequencing showed that this variant was the only one in the candidate region not found in dbSNP.Conclusion: Among the family members shown to carry the novel COL4A1 mutation, heterogenous presentations of anterior segment dysgenesis was seen. Testing family members for this mutation also made a definite diagnosis possible in patients with a clinical presentation difficult to classify. In families where anterior segment dysgenesis occurs together with cerebral hemorrhages, genetic analysis of COL4A1 should be considered.

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