Author: Am J Ophthalmol

Angiographic and Optical Coherence Tomography Characteristics of Recent Myopic Choroidal Neovascularization – Corrected Proof

Purpose: To analyze the contribution of fluorescein angiography (FA) and spectral-domain optical coherence tomography (SD OCT) to the diagnosis of recent choroidal neovascularization (CNV) associated with high myopia.Design: Retrospective, observational case series.Methods: Ninety eyes of 73 highly myopic patients (refractive error ≥−6 diopters) with CNV in 1 or both eyes were included. Epidemiologic features, refractive error, fundus examination, fluorescein angiography, and SD OCT findings at onset of CNV were analyzed.Results: Mean age at onset of CNV was 54.4 ± 14 years. CNV was bilateral in 17 of 73 cases. Mean refractive error was −13.9 ± 5.2 diopters. Myopic CNV was associated more frequently with patchy or geographic atrophy (P = .019). CNV was associated with exudative features on fluorescein angiography in 82% of cases (64/78), and on SD OCT in 48.6% of cases (36/74). There was no agreement about signs of active CNV between these 2 imaging methods (κ = 25.7 ± 10%; P = .0044). CNV area was significantly smaller in younger patients (<55 years) than in older patients (0.57 mm2 vs 1.21 mm2, respectively; P = .023).Conclusions: Exudative features of myopic CNV are more obvious on FA than on SD OCT, suggesting that fluorescein angiography should be performed when new-onset myopic CNV is suspected. Myopic CNV occurring in older patients (≥55 years) is larger than those seen in younger patients and resembles CNV associated with age-related macular degeneration. This suggests an overlap between myopic CNV in older patients and age-related macular degeneration.

High-Resolution Imaging of Retinal Nerve Fiber Bundles in Glaucoma Using Adaptive Optics Scanning Laser Ophthalmoscopy – Corrected Proof

Purpose: To detect pathologic changes in retinal nerve fiber bundles in glaucomatous eyes seen on images obtained by adaptive optics (AO) scanning laser ophthalmoscopy (AO SLO).Design: Prospective cross-sectional study.Methods: Twenty-eight eyes of 28 patients with open-angle glaucoma and 21 normal eyes of 21 volunteer subjects underwent a full ophthalmologic examination, visual field testing using a Humphrey Field Analyzer, fundus photography, red-free SLO imaging, spectral-domain optical coherence tomography, and imaging with an original prototype AO SLO system.Results: The AO SLO images showed many hyperreflective bundles suggesting nerve fiber bundles. In glaucomatous eyes, the nerve fiber bundles were narrower than in normal eyes, and the nerve fiber layer thickness was correlated with the nerve fiber bundle widths on AO SLO (P < .001). In the nerve fiber layer defect area on fundus photography, the nerve fiber bundles on AO SLO were narrower compared with those in normal eyes (P < .001). At 60 degrees on the inferior temporal side of the optic disc, the nerve fiber bundle width was significantly lower, even in areas without nerve fiber layer defect, in eyes with glaucomatous eyes compared with normal eyes (P = .026). The mean deviations of each cluster in visual field testing were correlated with the corresponding nerve fiber bundle widths (P = .017).Conclusions: AO SLO images showed reduced nerve fiber bundle widths both in clinically normal and abnormal areas of glaucomatous eyes, and these abnormalities were associated with visual field defects, suggesting that AO SLO may be useful for detecting early nerve fiber bundle abnormalities associated with loss of visual function.

Comparison of Clinical Characteristics Between Korean and Western Normal-Tension Glaucoma Patients – Corrected Proof

Purpose: To detect potential differences in the phenotypes between Western normal-tension glaucoma (NTG) and Korean NTG.Design: A retrospective, cross-sectional study.Methods: One hundred eighty-four NTG eyes of 71 patients of the Jules Stein Eye Institute, University of California, Los Angeles, and 113 patients of the Seoul National University Hospital, Seoul, Korea, were studied after reviewing medical charts retrospectively. All eligible patients from both institutions who were evaluated between July 2007 and June 2008 were included. The groups were matched for stage of glaucoma severity based on the visual field mean deviation value. All patients underwent a complete ophthalmic examination, Humphrey perimetry, Heidelberg Retina Tomography, Stratus optical coherence tomography, and pachymetry. Structural and functional parameters between the 2 groups were compared.Results: There were no statistically significant differences in the baseline intraocular pressure, disc area, frequency of disc hemorrhage, or peripapillary atrophy (P > .05). Cup-shape measure (by Heidelberg Retina Tomography), average RNFL thickness (by Stratus optical coherence tomography), and central corneal thickness were significantly different (P < .002). The eyes of Korean NTG patients showed higher values for cup-shape measure, higher average RNFL thicknesses, and thinner central corneal thicknesses than Western NTG patients. The difference was significant (P < .001) while controlling for age, sex, disc area, mean deviation, pattern standard deviation, and spherical equivalent with multivariate analysis.Conclusions: Korean NTG patients showed steeper cup shapes, thicker RNFL thickness, and thinner central corneal thickness compared with Western NTG patients with similar amounts of visual field loss. This result may help clinicians understand the clinical characteristics of NTG patients and points to the heterogeneous character of the glaucomas.

Comparison of Nylon Monofilament Suture and Polytetrafluoroethylene Sheet for Frontalis Suspension Surgery in Eyes With Congenital Ptosis

Purpose: To compare nylon monofilament suture with polytetrafluoroethylene sheet for frontalis suspension surgery to treat eyes with congenital ptosis.Design: Retrospective, nonrandomized, comparative, interventional case series.Methods: We reviewed the medical records of 49 patients who had undergone 79 eyelid frontalis suspension surgeries to treat congenital ptosis. All of the patients were younger than 16 years and had congenital ptosis with poor levator muscle function. They were treated with frontalis suspension surgery with either a nylon suture or a polytetrafluoroethylene sheet and were followed up for at least 1 year. A single rhomboid loop sling was used for the nylon suture surgery. For the polytetrafluoroethylene sheet, an incision was made in the eyelid crease, and one end of the sheet was fixed to the tarsus and the other was fixed to the frontalis muscle. The main outcome measures were postoperative recurrences and complications.Results: We evaluated 37 eyelids of 25 patients after nylon suture surgery and 42 eyelids of 31 patients after polytetrafluoroethylene sheet surgery. Among these, 9 eyelids of 7 patients were included in both groups. The median postoperative follow-up period was 32 months in both groups. The recurrence rates were 62.2% for the nylon suture group and 0% for the polytetrafluoroethylene sheet group (P < .001). The postoperative complication rates were 0% for the nylon suture group and 7.1% for the polytetrafluoroethylene sheet group (P > .05).Conclusions: Frontalis suspension using a polytetrafluoroethylene sheet with direct tarsus and frontalis muscle fixation is a reasonable technique with low rates of recurrences and complications.

Tear Meniscus Evaluation by Anterior Segment Swept-Source Optical Coherence Tomography

Purpose: To investigate the repeatability of tear meniscus measurements using anterior segment swept-source optical coherence tomography (OCT) and the relationship of tear meniscus measurements with tear film breakup time and Schirmer test results.Design: Prospective, observational, cross-sectional study.Methods: We enrolled 26 healthy subjects (26 eyes; 20 men and 6 women; mean age, 36.5 ± 6.8 years) at the University of Tokyo School of Medicine, Tokyo, Japan, in this study. Examinations were conducted in the following sequence: anterior segment vertical raster scans by swept-source OCT, tear film breakup time, and Schirmer test. Each subject underwent OCT measurements twice by the same grader, and the central upper and lower tear menisci height and area and the lower tear meniscus volume were examined. Each OCT image was evaluated by 2 masked graders using the software calipers.Results: The average upper and lower tear meniscus heights were 231 ± 78 μm and 256 ± 57 μm, respectively, and the average upper and lower tear meniscus areas were 18 829 ± 7823 μm2 and 21 903 ± 8173 μm2, respectively. The average tear meniscus volume was 0.1327 ± 0.051 mm3. The intergrader intraclass correlations for all the parameters were more than 95%. The OCT tear meniscus measurements and the Schirmer test scores were correlated significantly (P < .05, Spearman nonparametric correlation analysis). However, tear film breakup time was not correlated significantly with any of the parameters of tear menisci (P > .05).Conclusions: Anterior segment swept-source OCT is a noninvasive and practical method that can be used for quantitative evaluation of tear fluid.

Objective Assessment of Crystalline Lens Opacity Level by Measuring Ocular Light Scattering With a Double-Pass System

Purpose: To assess the crystalline lens opacity level by measuring ocular light scattering with a double-pass system.Design: Prospective, single-center, cross-sectional study.Methods: Two hundred fifty-three eyes of 135 patients referred for cataract evaluation were enrolled. Patients with corneal or retinal anomalies potentially impairing ocular transparency were excluded. Lens opacification was assessed by the Lens opacities classification system III. Optical Quality Analysis System (Visiometrics SL) measurements provided ocular Modulation Transfer Function cutoff frequency and Objective Scatter Index. Best-corrected visual acuity and Quality of Vision questionnaire scores (Rasch-scaled) were recorded. We analyzed correlations between visual acuity, type and severity of cataract, Optical Quality Analysis System measurements, and discomfort level in each group.Results: In patients with best-corrected visual acuity better than 20/32, we found correlations between Objective Scatter Index, Modulation Transfer Function, and visual acuity (r = 0.4, P < .0001). The Objective Scatter Index, Modulation Transfer Function, and visual acuity were correlated with each type of cataract. In patients with good visual acuity and moderate functional symptoms, the Objective Scatter Index values also were correlated to the severity of posterior subcapsular cataract (r = 0.4, P = .0006).Conclusions: Patients with incipient cataract may report visual discomfort, despite minor lens opacity on slit-lamp examination, minor loss of best-corrected visual acuity, or both. The measurement of ocular scattering with the Optical Quality Analysis System device may be a useful tool in the preoperative evaluation of patients with early cataract.

Comparison of Retention Rates and Complications of 2 Different Types of Silicon Lacrimal Punctal Plugs in the Treatment of Dry Eye Disease

Purpose: To investigate the retention rate and complications of 2 different types of silicon lacrimal punctal plugs with the focus on the relationship to punctum size.Design: A prospective, nonrandomized, interventional, comparative study.Method: Forty-four patients with dry eye syndrome received lacrimal punctal plug insertion with the Punctal Plug F (FCI Ophthalmics) and 30 patients received plug insertion with the Super Flex plug (Eagle Vision; Softplug-Oasis Medical Inc). In total, 110 plug insertion regions were performed using the Punctal Plug F (group A) and 110 insertion regions were carried out using Super Flex plug (group B). The gauging system of Eagle Vision was used before the lacrimal punctal plug insertion in all subjects. Plug conditions (retention rates, spontaneous plug loss, and removal) and complications related to lacrimal punctal sizes were compared between the 2 groups.Results: Retention rates were 70.4% in group A and 30.1% in group B at 6 months. Spontaneous plug loss occurrence was significant with the larger lacrimal punctum size in group A (P < .05), whereas no significant differences were observed between lacrimal punctum sizes and spontaneous loss in group B. Spontaneous plug loss occurrence was significant in elderly patients in group B (P < .05). Granuloma and injector troubles were observed in 1 and 2 cases in group A, respectively.Conclusions: The Punctal Plug F seems to be more applicable for insertion into the smaller punctal sizes. Punctum size and age seem to be important factors in determining the appropriate types of lacrimal punctal plugs.

Predictive Value of Spectral-Domain Optical Coherence Tomography Features in Assessment of Visual Prognosis in Eyes With Neovascular Age-Related Macular Degeneration Treated With Ranibizumab

Purpose: To determine whether pretreatment (baseline) optical coherence tomography (OCT) features can be used as predictors of visual acuity outcome at 12 months in eyes with neovascular age-related macular degeneration treated with intravitreal ranibizumab and to assess whether baseline OCT features can predict a change in visual acuity from baseline to 12 months.Design: Retrospective, observational study.Methods: We retrospectively evaluated the serial cross-sectional images of the macula obtained using the Spectralis OCT (HRA+OCT; Heidelberg Engineering) in 100 eyes of 94 patients attending a single center and undergoing treatment with intravitreal ranibizumab for neovascular age-related macular degeneration. The baseline OCT characteristics and visual acuity were correlated to the final visual acuity (Early Treatment Diabetic Retinopathy Study letters) and change in visual acuity after 12 months of monitoring and treatment. Univariate and multivariate analyses were carried out to correlate these morphologic features with the final visual acuity and the change in visual acuity.Results: Intact ellipsoid zone (P = .0001) and external limiting membrane in the subfoveal area (P < .0001) at baseline were the only 2 independent good prognostic indicators of final visual acuity at 12 months. However, none of the morphologic features at baseline could predict the change in visual acuity by 12 months.Conclusions: The results suggest that integrity of the outer retinal layers at baseline is crucial for determining final visual acuity at 12 months in eyes undergoing treatment with ranibizumab for neovascular age-related macular degeneration.

Postoperative Vitreous Hemorrhage After Diabetic 23-Gauge Pars Plana Vitrectomy

Purpose: To report the frequency of postoperative vitreous hemorrhage (VH) in eyes that underwent primary 23-gauge pars plana vitrectomy (PPV) for nonclearing VH resulting from proliferative diabetic retinopathy, as well as associated risk factors.Design: Retrospective, consecutive, interventional case series.Methods: setting: Institutional (Retina Service of Wills Eye Institute). study population: One hundred seventy-three eyes of 157 patients. intervention: Twenty-three–gauge PPV for nonclearing diabetic VH. main outcome measures: Percentage of eyes in which postoperative VH developed, categorized as early, delayed, or severe persistent, as well as percentage requiring reoperation.Results: During a mean follow-up of 32 weeks, 56 (32%) of 173 eyes demonstrated postoperative VH, categorized as early (8 eyes; 5%), delayed (13 eyes; 8%), or severe persistent (35 eyes; 20%). Twenty-two (13%) of 173 eyes required reoperation: 4 (50%) of 8 in the early group, 8 (62%) of 13 in the delayed group, and 10 (29%) of 35 in the severe persistent group. Mean preoperative logarithm of the minimum angle of resolution visual acuity was 1.5 (Snellen equivalent, approximately 20/600); mean postoperative VA was 0.65 (Snellen equivalent, approximately 20/90), a gain of 0.85 (P < .0001). Thirty-four (27%) of 127 eyes with complete scatter photocoagulation before undergoing PPV compared with 22 (48%) of 46 eyes with incomplete scatter photocoagulation before undergoing PPV demonstrated postoperative VH (P = .002). Other factors associated with postoperative VH included younger age (P = .022) and phakia (P = .036).Conclusions: Postoperative VH was not uncommon after initial 23-gauge PPV for diabetic VH and was associated with incomplete scatter photocoagulation, younger age, and phakia before PPV. However, only a minority of patients required reoperation.

Short-Term External Buckling With Pneumatic Retinopexy for Retinal Detachment With Inferior Retinal Breaks

Purpose: To introduce a new approach for short-term external scleral buckling with pneumatic retinopexy for the management of rhegmatogenous retinal detachment with inferior retinal breaks.Design: Retrospective, noncomparative, interventional case series.Methods: A review of 33 consecutive eyes of 31 patients who underwent external buckling with pneumatic retinopexy for uncomplicated rhegmatogenous retinal detachment with inferior retinal breaks from December 2006 through December 2010. An external buckle was made of a 505 sponge sutured along the blunt side of a 279 tyre (MIRA Inc). The buckle was inserted deeply into the inferior fornix without suture after pneumatic retinopexy and was kept in place for 3 days. Primary and final anatomic outcomes, visual acuity, and adverse events were recorded.Results: All patients tolerated the procedure. The mean follow-up period was 24.0 months (range, 9 to 61 months). Primary success, defined as successful retinal reattachment within 6 months without further treatment, was achieved in 29 (87.9%) eyes. All patients attained final retinal reattachment (100%). Overall, the mean best-corrected visual acuity improved significantly at the end of follow-up (0.30 logarithm of the minimal angle of resolution units; Snellen equivalent, 6/12), compared with the preoperative best-corrected visual acuity (0.82 logarithm of the minimal angle of resolution units; Snellen equivalent, 6/38; P < .001).Conclusions: Short-term external buckling with pneumatic retinopexy is a novel and effective treatment for rhegmatogenous retinal detachment with inferior retinal breaks, with a comparable success rate with other treatment methods. This approach also can avoid complications of long-term buckle implantation. Further comparative cohort studies may be necessary to compare the clinical efficacy with other conventional operations.

Thinner Choroid and Greater Drusen Extent in Retinal Angiomatous Proliferation Than in Typical Exudative Age-Related Macular Degeneration

Purpose: To compare choroidal thickness and extent and density of drusen between eyes with typical exudative age-related macular degeneration (AMD) and eyes with retinal angiomatous proliferation (RAP).Design: Observational case series.Methods: Twenty-four eyes with typical exudative AMD and 20 eyes with RAP were included. Subfoveal choroidal thickness was measured using enhanced depth imaging optical coherence tomography. Eyes were classified into 3 groups according to the extent of drusen distribution in the fundus photograph. Density of drusen was estimated based on optical coherence tomography images of the fellow eye. The proportion of the length beneath the drusen per the entire length of the Bruch membrane was defined as the density of drusen. Subfoveal choroidal thickness, extent of drusen distribution, and the density of drusen were compared between typical exudative AMD and RAP.Results: Mean ± standard deviation subfoveal choroidal thickness in eyes with typical exudative AMD and eyes with RAP was 184.9 ± 68.5 μm and 139.0 ± 65.5 μm, respectively (P = .035). The mean density of drusen was 0.06 ± 0.08 and 0.24 ± 0.12, respectively (P < .001). In the typical exudative AMD group, 19, 3, and 2 eyes were included in the small extent group ( two thirds), respectively. In the RAP group, 3, 14, and 3 eyes were included in each aforementioned group, respectively (P = .001).Conclusions: The thinner subfoveal choroidal thickness and greater extent and density of drusen in RAP than the typical exudative AMD may suggest compromised choroidal perfusion in the development of RAP.

Combined Depth Imaging Technique on Spectral-Domain Optical Coherence Tomography

Purpose: To describe a technique to obtain combined images of vitreoretinal and choroidal structures using spectral-domain (SD) optical coherence tomography (OCT) and to evaluate applicability in normal eyes and limitations in eyes with cataract.Design: Prospective, observational case series.Methods: Three different foveal scans, including conventional SD OCT, enhanced depth imaging OCT and the novel method called combined depth imaging (CDI) OCT, were obtained in 42 eyes of healthy volunteers and in 26 eyes with cataract using the Heidelberg Spectralis HRA (Heidelberg Engineering). The CDI OCT images were obtained manually using an image modification process that enhances the vitreoretinal interface first and then the choroid, while averaging 100 separate OCT scans. The visualization of the inner border of the preretinal pocket and the outer border of the choroid was graded by independent masked observers for each OCT scan method.Results: The CDI technique was able to create a good-quality combined image of the posterior structures in all the eyes, including eyes with cataract. The agreement between the grading performed by the independent observers was high for both the inner border of the vitreal pocket (κ, 0.86; P < .001) and the outer choroidal border (κ, 0.90; P < .001). CDI OCT was equivalent to conventional SD OCT in visualizing the vitreal pocket (P = .445 for normal eyes, P = .162 for eyes with cataract) and was equivalent to enhanced depth imaging OCT in visualizing the outer choroidal border (P = .660 for normal eyes, P = .329 for eyes with cataract). CDI OCT was superior to conventional SD OCT and enhanced depth imaging OCT in visualizing both of the structures (P < .001).Conclusions: The manual technique of CDI OCT is highly sensitive to visualize posterior vitreoretinal and choroidal structures into a single full-depth image and is not affected by mild to moderate cataract.