Author: Am J Ophthalmol

Purpose: To evaluate the accuracy of the visual field index (VFI) for the Humphrey Visual Field Analyzer in a population of patients with mild to moderate glaucoma.Design: Retrospective cohort study.Methods: The study included 42 patients (61 eyes) with at least 11 years of follow-up, and annual automated visual fields (VFs). Patients with mean deviations ≤−20 dB were excluded. All unreliable fields were omitted (fixation losses ≥20%, false-positive ≥15%, false-negative ≥33%). The VFs were divided into two 5-year series and the data were analyzed by the new Humphrey Visual Field Analyzer software. Projected VFIs from the first 5 years were compared with observed values obtained from the last 5 years. Unreliable fields initially excluded were reintroduced into the series (22 eyes) to create a comparison.Results: Predicted VFIs were accurate with a mean overestimation of VF deterioration of 1.37% (95% CI: −0.22%, 2.96%). Of the predicted values, 95% were between −4.5% and 5.2% of the observed values when the predicted VFI was ≥90%; and between −13.8% and 20.5% when the predicted VFI was <90%. No statistical difference was found between the reliable and unreliable series (mean difference of 0.09% [95% CI: −0.41%, 0.59%]).Conclusion: The new software for the Humphrey Visual Field Analyzer projects an accurate value for patients when the predicted VFI is ≥90%. Clinicians should consider the limitations of the software, especially for those patients with greater initial VF loss.

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Purpose: To analyze the outer retinal and retinal pigment epithelium (RPE) features of reticular pattern dystrophy of the retina using spectral-domain optical coherence tomography (SDOCT).Design: Retrospective observational case series.Methods: Consecu…

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Purpose: To determine the efficacy of 1 intravitreal bevacizumab injection followed by pro re nata (1 + PRN) injection in cases of subfoveal myopic choroidal neovascularization (CNV) and to identify CNV-recurrence–related prognostic factors.Design: Retrospective observational case series.Methods: In total, 103 eyes of 89 consecutive naive patients who had subfoveal myopic CNV and had been followed-up for at least 2 years were included. Of those eyes, 24 had recurrences. The remaining eyes were stable after the initial treatment.Results: The average patient age was 51.1 ± 15.2 years. The average follow-up duration was 44.1 ± 12.7 months. At baseline and at the 1-year, 2-year, and final visits, the average best corrected visual acuities (BCVAs) were 0.57 ± 0.45, 0.38 ± 0.51, 0.40 ± 0.52, and 0.41 ± 0.41 logMAR, respectively. The recurrence rate during follow-up was 23.3%. The BCVA improved by 0.2 logMAR after 2.7 injections in the eyes without recurrence but by only 0.08 logMAR after 6.9 injections in the eyes with recurrence. In univariate analysis, recurrence was associated with older age, more myopic refraction, thinner choroid, larger CNV lesions, and subfoveal hemorrhage at baseline. In multivariate analysis, only baseline CNV lesion size associated significantly with CNV recurrence (P = 0.002). Recurrence, baseline BCVA, choroidal thickness, and CNV size associated significantly with final BCVA (P = 0.026, <0.0001, 0.007, and 0.002, respectively). Baseline choroidal thickness, CNV size, age, and presence of lacquer cracks associated significantly with injection number (P < 0.0001, <0.0001, 0.026, and 0.035, respectively).Conclusions: 1 + PRN intravitreal bevacizumab monotherapy effectively stabilized subfoveal myopic CNV. The CNV size, the baseline BCVA, and the choroidal thickness were the main prognostic factors of subfoveal myopic CNV after 1 + PRN injection of bevacizumab.

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Purpose: To investigate the prevalence and morphologic changes of capsular bag distention syndrome after cataract surgery using the Pentacam and to analyze its clinical characteristics and influencing factors.Design: Retrospective, cross-sectional study.Methods: Clinical records of 239 consecutive patients who underwent cataract surgery were reviewed. Demographic data, use of intraoperative ophthalmic viscosurgical devices, type of intraocular lens implanted, axial length, and white-to-white corneal diameter were recorded. One month after surgery, dilated Scheimpflug imaging was performed. Prevalence, morphologic changes, and characteristic clinical findings of this syndrome were evaluated.Results: Using Scheimpflug imaging, the prevalence of capsular bag distention syndrome was high at 26.8% (64/239), and it was possible to classify its morphologic changes into 3 types. Patients with the syndrome had poorer best-corrected visual acuity and lower satisfaction scores than those without the syndrome (P = .041 and P = .008, respectively). Although there was no significant difference observed in rate of this syndrome between the 2 ophthalmic viscosurgical devices used in our study (P > .05), implantation of 4-haptic intraocular lenses was associated with a high prevalence of the syndrome (odds ratio, 2.07; 95% confidence interval, 1.05 to 4.07; P = .0346). Patients with this syndrome had significantly longer AL (26.26 ± 2.84 mm) and white-to-white diameter (12.02 ± 0.34 mm) than those without (AL, 24.63 ± 2.89 mm; white-to-white diameter, 11.81 ± 0.32 mm; P = .0002 and P < .0001, respectively).Conclusions: Scheimpflug imaging revealed the prevalence of capsular bag distention syndrome to be high, and these patients generally had poorer visual outcomes. Intraocular lens design and dimensions of the eyes significantly influenced the prevalence of this syndrome.

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Purpose: To report experience in the treatment of persistent corneal epithelial defect using overnight wear of a prosthetic device for the ocular surface.Design: Retrospective interventional case series.Methods: A clinical database of patients who underwent prosthetic replacement of the ocular surface ecosystem (PROSE) treatment from March 2003 to August 2008 was searched to identify patients treated for persistent corneal epithelial defect. In early 2003, overnight wear of a PROSE device and addition of commercially available, nonpreserved, topical ophthalmic moxifloxacin to the saline in the device reservoir became standard practice at this center when treating persistent corneal epithelial defect. Medical records were abstracted to obtain underlying diagnoses, previous treatments, days to re-epithelialization, and complications for subsequent analysis.Results: PROSE treatment incorporating overnight wear, with adjunctive use of moxifloxacin, was employed in 20 eyes of 19 patients for a total of 372 days. Re-epithelialization occurred in 17 of 20 eyes. Median duration of treatment incorporating overnight wear was 8.5 days (range = 2-76 days). Healing occurred in ≤7 days in 12 eyes, 8-14 days in 3 eyes, and >14 days in 2 eyes (range = 1-35 days). There were no cases of microbial keratitis.Conclusions: Overnight wear of a PROSE device is effective in promoting healing of persistent corneal epithelial defect. In comparison to an earlier series from this center, the rate of microbial keratitis as a complication of treatment has been reduced with the use of a nonpreserved topical fourth-generation fluoroquinolone in the device reservoir.

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Purpose: To evaluate the correlation between changes in tear osmolarity, symptoms, and corneal fluorescein staining in patients with dry eye disease (DED).Design: Retrospective, clinic-based cohort study.Methods: In this single-institution study, we reviewed the charts of 186 patients with DED from whom we had data on tear osmolarity, symptoms, and corneal fluorescein staining from 2 separate visits. Main outcomes included the correlation of the changes between the 2 visits for tear osmolarity (TearLab system), symptoms (Ocular Surface Disease Index), and corneal fluorescein staining (modified Oxford scheme). For tear osmolarity and corneal fluorescein staining the scores from the eye with highest readings were analyzed. The correlations were repeated on subgroups based on proposed cutoffs for DED severity and on patients’ treatment.Results: We found a modest, though statistically significant, correlation between changes in corneal fluorescein staining and symptoms of DED (R = 0.31; P < .001). However, there was no correlation between the recorded change in tear osmolarity and symptoms (R = −0.091; P = .38) or between changes in tear osmolarity and corneal fluorescein staining (R = −0.02; P = .80). This lack of correlation was consistent in all the subgroups studied. A multivariate analysis revealed that changes in corneal fluorescein staining had predictive value on symptom changes, whereas tear osmolarity changes did not.Conclusions: Changes in tear osmolarity do not correlate significantly with changes in patient symptoms or corneal fluorescein staining in dry eye disease.

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Purpose: To determine medical student preferences for learning the ocular fundus examination and to assess their accuracy using different examination modalities.Design: Prospective, randomized study of medical student education approaches.Methods: First-year medical students received training in direct ophthalmoscopy using simulators and human volunteers. Students were randomized to receive vs not receive specific training on interpreting fundus photographs prior to accuracy assessments. Students’ preferences for each of the 3 methods (direct ophthalmoscopy on simulators or human volunteers, or use of fundus photographs) and recognition of normal and abnormal fundus features were assessed.Results: Of 138 first-year medical students, 119 (86%) completed all required elements. For learning ophthalmoscopy, 85 (71%) preferred humans to simulators. For learning relevant features of the ocular fundus, 92 (77%) preferred photographs to ophthalmoscopy on simulators or humans. Accuracy of answers was better when interpreting fundus photographs than when performing ophthalmoscopy on simulators (P < .001). Performance improved after specific teaching about assessing fundus photographs before testing (P = .02). Examination of the ocular fundus was found easier and less frustrating when using photographs than when using ophthalmoscopy on simulators or humans. Eighty-four students (70%) said they would prefer to have fundus photographs instead of using the ophthalmoscope during upcoming clinical rotations.Conclusions: Students preferred fundus photographs for both learning and examining the ocular fundus. Identification of ocular fundus features was more accurate on photographs compared to examination by direct ophthalmoscopy. In the future, the increasing availability of nonmydriatic ocular fundus photography may allow replacement of direct ophthalmoscopy in many clinical settings for non-ophthalmologists.

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Purpose: To investigate the frequency and types of systemic findings in patients with apparently isolated uveal coloboma.Design: Cross-sectional observational study.Methods: setting: Single-center ophthalmic genetics clinic. study population: Ninety-nine patients with uveal coloboma seen at the National Eye Institute. observational procedure: Results of audiology testing, echocardiogram, brain magnetic resonance imaging, renal ultrasound, and total spine radiographs. main outcome measure: Prevalence of abnormal findings on systemic testing.Results: Uveal coloboma affected only the anterior segment in 8 patients, only the posterior segment in 23 patients, and both anterior and posterior segments in 68 patients. Best-corrected visual acuity (BCVA) of eyes with coloboma was ≥20/40 in 45% of eyes; 23% of eyes had BCVA of ≤20/400. The majority of patients (74%) had good vision (>20/60) in at least 1 eye. Ten of the 19 patients (53%) who underwent echocardiography had abnormalities, with ventral septal defects being the most prevalent. Abnormal findings were observed in 5 of 72 patients (7%) who had a renal ultrasound and in 5 of 29 patients (17%) who underwent a brain MRI. Audiology testing revealed abnormalities in 13 of 75 patients (17%), and spine radiographs showed anomalies in 10 of 77 patients (13%). Most findings required no acute intervention.Conclusions: Although some patients with coloboma had evidence of extraocular abnormalities, the majority of findings on routine clinical examination did not require acute intervention, but some warranted follow-up. Results from the systemic evaluation of patients with coloboma should be interpreted with caution and in view of their clinical context.

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Purpose: To develop and validate an associative model using pupillography that best discriminates those with and without glaucoma.Design: A prospective case-control study.Methods: We enrolled 148 patients with glaucoma (mean age 67 ± 11) and 71 controls (mean age 60 ± 10) in a clinical setting. This prototype pupillometer is designed to record and analyze pupillary responses at multiple, controlled stimulus intensities while using varied stimulus patterns and colors. We evaluated three approaches: (1) comparing the responses between the two eyes; (2) comparing responses to stimuli between the superonasal and inferonasal fields within each eye; and (3) calculating the absolute pupil response of each individual eye. Associative models were developed using stepwise regression or forward selection with Akaike information criterion and validated by fivefold cross-validation. We assessed the associative model using sensitivity, specificity and the area-under-the-receiver operating characteristic curve.Results: Persons with glaucoma had more asymmetric pupil responses in the two eyes (P < 0.001); between superonasal and inferonasal visual field within the same eye (P = 0.014); and smaller amplitudes, slower velocities and longer latencies of pupil responses compared to controls (all P < 0.001). A model including age and these three components resulted in an area-under-the-receiver operating characteristic curve of 0.87 (95% CI 0.83 to 0.92) with 80% sensitivity and specificity in detecting glaucoma. This result remained robust after cross-validation.Conclusions: Using pupillography, we were able to discriminate among persons with glaucoma and those with normal eye examinations. With refinement, pupil testing may provide a simple approach for glaucoma screening.

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Purpose: To evaluate the effect of choroidal vascular hyperpermeability, as determined using indocyanine green angiography (ICGA), on the outcome of anti–vascular endothelial growth factor (VEGF) treatment for polypoidal choroidal vasculopathy (PCV).Design: Retrospective comparative series.Methods: Based on the presence of choroidal vascular hyperpermeability on ICGA, 103 eyes (101 patients) with PCV were categorized into 2 subgroups: choroidal vascular hyperpermeability (+) group (41 eyes) and choroidal vascular hyperpermeability (−) group (62 eyes). All subjects were treatment naïve and treated by anti-VEGF with initial 3 loading injections per month, followed by an as-needed reinjection. Best-corrected visual acuity (BCVA) and central macular thickness after treatment were compared between the 2 groups at baseline and at 3, 6, 9, and 12 months.Results: At 12 months after treatment, mean BCVA was significantly improved from 0.68 logarithm of the minimal angle of resolution (logMAR) (20/95 Snellen equivalent) to 0.50 logMAR (20/63 Snellen equivalent) in the choroidal vascular hyperpermeability (−) group (P = .01); however, there was no significant improvement, from 0.79 logMAR (20/123 Snellen equivalent) to 0.74 logMAR (20/109 Snellen equivalent), in the choroidal vascular hyperpermeability (+) group. In paired comparisons of BCVA between baseline and each follow-up visit, the choroidal vascular hyperpermeability (−) group showed significant improvement of BCVA at every follow-up visit (P < .05); however, the choroidal vascular hyperpermeability (+) group did not show significant visual improvement after 9 months (P > .05).Conclusions: The therapeutic response to anti-VEGF treatment for PCV in patients with choroidal vascular hyperpermeability decreased over time. Choroidal vascular hyperpermeability was associated with an inferior visual outcome after intravitreal anti-VEGF treatment for PCV.

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Purpose: To compare accuracy of intraocular lens (IOL) power calculation formulae in infantile eyes with primary IOL implantation.Design: Comparative case series.Methods: The Hoffer Q, Holladay 1, Holladay 2, Sanders-Retzlaff-Kraff (SRK) II, and Sanders-Retzlaff-Kraff theoretic (SRK/T) formulae were used to calculate predicted postoperative refraction for eyes that received primary IOL implantation in the Infant Aphakia Treatment Study. The protocol targeted postoperative hyperopia of +6.0 or +8.0 diopters (D). Eyes were excluded for invalid biometry, lack of refractive data at the specified postoperative visit, diagnosis of glaucoma or suspected glaucoma, or sulcus IOL placement. Actual refraction 1 month after surgery was converted to spherical equivalent and prediction error (predicted refraction − actual refraction) was calculated. Baseline characteristics were analyzed for effect on prediction error for each formula. The main outcome measure was absolute prediction error.Results: Forty-three eyes were studied; mean axial length was 18.1 ± 1.1 mm (in 23 eyes, it was <18.0 mm). Average age at surgery was 2.5 ± 1.5 months. Holladay 1 showed the lowest median absolute prediction error (1.2 D); a paired comparison of medians showed clinically similar results using the Holladay 1 and SRK/T formulae (median difference, 0.3 D). Comparison of the mean absolute prediction error showed the lowest values using the SRK/T formula (1.4 ± 1.1 D), followed by the Holladay 1 formula (1.7 ± 1.3 D). Calculations with an optimized constant showed the lowest values and no significant difference between the Holladay 1 and SRK/T formulae (median difference, 0.3 D). Eyes with globe AL of less than 18 mm had the largest mean and median prediction error and absolute prediction error, regardless of the formula used.Conclusions: The Holladay 1 and SRK/T formulae gave equally good results and had the best predictive value for infant eyes.

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Purpose: To describe the clinical and molecular findings in ten unrelated African American patients with Stargardt disease.Design: Retrospective, observational case series.Methods: We reviewed the clinical histories, examinations, and genotypes of 85 patients with molecular diagnoses of Stargardt disease. Three ABCA4 sequence variations identified exclusively in African Americans were evaluated in 300 African American controls and by in silico analysis.Results: ABCA4 sequence changes were identified in 85 patients from 80 families, of which 11 patients identified themselves as African American. Of these 11 patients, 10 unrelated patients shared 1 of 3 ABCA4 sequence variations: c.3602T>G (p.L1201R); c.3899G>A (p.R1300Q); or c.6320G>A (p.R2107H). The minor allele frequencies in the African American control population for each variation were 7.5%, 6.3%, and 2%, respectively. This is comparable to the allele frequency in African Americans in the Exome Variant Server. In contrast, the allele frequency of all three of these variations was less than or equal to 0.05% in European Americans. Although both c.3602T>G and c.3899G>A have been reported as likely disease-causing variations, one of our control patients was homozygous for each variant, suggesting that these are nonpathogenic. In contrast, the absence of c.6320G>A in the control population in the homozygous state, combined with the results of bioinformatics analysis, support its pathogenicity.Conclusions: Three ABCA4 sequence variations were identified exclusively in 10 unrelated African American patients: p.L1201R and p.R1300Q likely represent nonpathogenic sequence variants, whereas the p.R2107H substitution appears to be pathogenic. Characterization of population-specific disease alleles may have important implications for the development of genetic screening algorithms.

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Purpose: To determine whether Descemet stripping automated endothelial keratoplasty (DSAEK) donor cornea graft thickness impacts measurements of best spectacle-corrected visual acuity (BSCVA), refractive error and intraocular pressure (IOP).Design: Retrospective chart review in a tertiary care center at Duke University Eye Center.Methods: We studied 460 eyes that had undergone DSAEK surgery. They were segregated into three groups based on the thickness of the donor graft: <100 μm (n = 67 eyes); 100–150 μm (n = 316 eyes); and >150 μm (n = 77 eyes). The three graft-thickness groups were assessed at about 6 months postoperatively for measurement of BSCVA, spherical equivalent, and IOP.Results: Baseline demographics were similar in the three groups. All groups experienced significant improvement in BSCVA (mean ± SD = −0.34 ± 0.50 logMAR); mild hyperopic shift (mean ± SD = 0.48 ± 1.7 D); and stability in IOP measurements (mean ± SD = 0.19 ± 4.8 mm Hg). There were no significant differences in groups according to donor graft thicknesses with respect to change in BSCVA (P = 0.8); hyperopic shift (P = 0.76); or IOP measurement (P = 0.56).Conclusions: DSAEK significantly improves BSCVA. DSAEK graft thickness may not play an important role in the final BSCVA, refractive error, or accuracy of IOP measurement. The ideal DSAEK graft thickness to minimize graft-related complications remains to be determined.

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Purpose: To investigate whether peripapillary choroidal thickness in perimetrically affected eyes of primary open-angle glaucoma (POAG) patients differs from that in perimetrically unaffected fellow eyes and eyes of healthy controls.Design: Retrospective, comparative, cross-sectional study.Methods: Thirty-one POAG patients with unilateral visual field loss and 31 healthy controls were included. Eyes were divided into 3 groups: 31 eyes in group A (eyes with visual field loss), 31 eyes in group B (perimetrically unaffected fellow eyes), and 31 eyes in group C (age- and sex-matched controls). A 360-degree 3.4-mm diameter peripapillary circle scan was performed for retinal nerve fiber layer (RNFL) assessment using enhanced depth imaging optical coherence tomography. The observer used the manual segmentation function to delineate the posterior edge of the retinal pigment epithelium and the sclerochoroidal interface. The RNFL thickness algorithm function was used to generate the choroidal thickness automatically in corresponding sectors. Statistical analysis was conducted to compare mean choroidal thickness and RNFL thickness among 3 groups and to correlate choroidal thickness with age, RNFL thickness, and visual field mean deviation.Results: The global mean RNFL and choroidal thickness measurements were 62.3 ± 16.7 μm and 154.3 ± 69.7 μm in group A, 90.4 ± 12.2 μm and 154.7 ± 68.9 μm in group B, and 106.6 ± 9.2 μm and 154.2 ± 60.9 μm in group C. The RNFL thickness was significantly thinner in group A than in groups B and C globally and at all peripapillary locations (all P = .000). The RNFL thickness also was significantly thinner in group B than in group C (P = .000 to .021). However, choroidal thickness measurements did not differ among 3 groups globally or at any peripapillary location (P = .273 to .934, P = .757 to .994, and P = .808 to .975, respectively). Age was the only significant factor associated with peripapillary choroidal thickness in each group (r = −0.418 to −0.641, r = −0.569 to −0.690, and r = −0.689 to −0.827, respectively; all P < .05).Conclusions: There was no significant difference in peripapillary choroidal thickness of POAG eyes with visual field loss compared with that of perimetrically unaffected fellow eyes and eyes of healthy controls, which does not support using peripapillary choroidal thickness as a clinical parameter in POAG diagnosis or management.

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Purpose: To assess the effects of glasses for anisometropia on stereopsis and to determine the factors that affect the level of stereopsis.Design: Retrospective observational case series.Methods: One hundred six nonamblyopic patients who were wearing glasses for anisometropia and 56 who were wearing glasses for isoametropia were enrolled. The levels of stereopsis in the anisometropic patients were divided into normal (≤40 seconds of arc), equivocal (40 < – ≤ 100), and subnormal (100 < – ≤ 400) and compared with those in the isoametropic patients. It was evaluated whether the amount of interocular difference in the lens power of the glasses, the type of anisometropia, a history of amblyopia, and the age at the time of the prescription of the first glasses were related to the stereopsis.Results: In the anisometropia, the mean stereopsis (seconds of arc) was 77.52 (40-200) in the Titmus-fly test and 52.78 (40-100) in the Randot stereotest. The rate of normal and equivocal stereopsis was 87.7% in the Titmus-fly test and 96.9% in the Randot stereotest. The isoametropic patients demonstrated better stereopsis (52.86 and 39.20 in either test) than did the anisometropic patients (P < .05). The stereopsis was worse in the spherical hyperopic type of anisometropia than in the spherical myopic type (P < .05). The level of stereopsis was not related to the other factors that were investigated.Conclusions: The level of stereopsis with the wearing of anisometropic glasses was clinically near normal and the glasses did not seriously affect the binocular vision regardless of the severity of the anisometropia.

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Purpose: To determine the clinical outcomes after glued trans-scleral posterior chamber intraocular lens (IOL) exchange for anterior chamber (AC) IOL.Design: Retrospective case series.Methods: Eyes with AC IOL explantation with glued IOL implantation i…

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In their recent article, Constantinou and associates reported clinical outcomes in patients who experienced infectious keratitis after penetrating keratoplasty. Their principal conclusion was that “prolonged use of corticosteroid eye drops is a major…

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We appreciate the interest of Carifi and associates in our recent article. They have raised some excellent points regarding the limitations of our study, some of which we acknowledged in the article. Since our study was retrospective and included patie…

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Purpose: To describe a cohort of patients with Stargardt disease who show a foveal-sparing phenotype.Design: Retrospective case series.Methods: The foveal-sparing phenotype was defined as foveal preservation on autofluorescence imaging, despite a retin…

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The study by Cheng and associates one short-term external buckling with pneumatic retinopexy treating retinal detachment with inferior retinal breaks gives us new insight. Rhegmatogenous retinal detachment (RRD) with inferior breaks usually is a contr…

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