Author: Ophthalmology

Role of Corneal Collagen Cross-Linking in Pseudophakic Bullous Keratopathy: A Clinicopathological Study – Corrected Proof

by  •  • 0 Comments

Objective: To evaluate the clinical and histopathologic changes induced by collagen cross-linking (CXL) in pseudophakic bullous keratopathy (PBK).Design: Randomized, prospective, interventional study.Participants: Twenty-four patients with PBK were included in the study.Methods: Twenty-four patients with PBK underwent CXL followed by keratoplasty at 1 or 3 months. Twelve patients underwent penetrating keratoplasty 1 month after CXL (group A) and the remaining 12 patients underwent penetrating keratoplasty 3 months after CXL (group B). The main outcome measures were assessed at 1 week and 1 month for all patients and at 3 months for 12 patients only. The corneal buttons underwent histopathologic and immunofluorescence evaluation.Main Outcome Measures: Visual acuity, ocular discomfort (tearing, redness, pain), corneal haze, central corneal thickness, histopathologic evaluation, and immunofluorescent microscopy.Results: Mean visual acuity showed a significant improvement after CXL, from 1.925±0.173 before surgery to 1.75±0.296 at 1 month after surgery (P = 0.010), but deteriorated to 1.81±0.23 at 3 months. Symptomatic relief after CXL was at a maximum at 1 month, with a worsening trend at 3 months. Eighteen patients showed a reduction in corneal haze 1 month after CXL. The effect was maintained in 9 of 12 patients at 3 months. The mean central corneal thickness decreased significantly from 846.46±88.741 to 781.0±98.788 μm at 1 month (P<0.01) after CXL, but increased to 805.08±136.06 μm at 3 months. Immunofluorescence microscopy revealed anterior stromal compaction in 7 of 12 patients (58.3%) in group A and in 5 of 12 patients (41.6%) in group B. Staining of keratocyte nuclei with 4′,6-diaminido-2-phenylindole dihydrochloride (Molecular Probes, Carlsband, CA) revealed a relative uniform distribution throughout the stroma.Conclusions: Collagen cross-linking causes symptomatic relief and a decrease in central corneal thickness and anterior stromal compaction in PBK. However, the effect decreases with time and depends on disease severity.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Read more →

Expanded Criteria for Pneumatic Retinopexy and Potential Cost Savings – Corrected Proof

by  •  • 0 Comments

Purpose: To provide insight into the preoperative factors that affect outcome after pneumatic retinopexy (PR) for treatment of primary rhegmatogenous retinal detachment repair. Additionally, we sought to analyze the cost of rhegmatogenous retinal detachment repair in the United States to determine potential cost savings with pneumatic retinopexy.Design: Single-center, retrospective, observational consecutive case series and third party payer-perspective comparative cost analysis.Participants: We included 141 eyes undergoing pneumatic retinopexy for the treatment of primary rhegmatogenous retinal detachment.Methods: Preoperative characteristics, anatomic outcomes, and best-available visual acuity were collected. Anatomic and visual outcomes were analyzed based on the presence of selected preoperative factors. The primary cohort was divided into 2 groups based on preoperative characteristics: (1) traditional pneumatic retinopexy and (2) nontraditional pneumatic retinopexy. Comparative cost analyses were performed between pneumatic retinopexy, scleral buckling, and vitrectomy.Main Outcome Measures: Anatomic and visual outcomes at 6 months.Results: Overall anatomic success was 78.7% and visual acuity improved significantly (logarithm of the minimum angle of resolution [logMAR] 0.48–0.25; P   0.05) and phakic versus pseudophakic groups (logMAR 0.23 vs 0.28; P > 0.05). Visual outcomes were better in macula-on detachments compared with those in which the macula was detached (logMAR 0.18 vs 0.42; P < 0.005). Annual health care cost savings in the United States ranging from $6 to $30 million are theoretically possible by increasing pneumatic retinopexy utilization from the current rate of 15% to 20%–35%.Conclusions: Pneumatic retinopexy is an effective treatment modality for primary rhegmatogenous retinal detachment. Anatomic and visual outcomes are similar for traditional and nontraditional preoperative inclusion criteria, as well as phakic and pseudophakic eyes. Inferior breaks and visible vitreous traction on a tear predicted failure. Increased utilization of pneumatic retinopexy would achieve significant cost savings while maintaining outcomes.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Read more →

Working-Age Cataract Patients: Visual Results, Reading Performance, and Quality of Life with Three Diffractive Multifocal Intraocular Lenses – Corrected Proof

by  •  • 0 Comments

Purpose: To compare the visual outcomes, reading performance, and quality of life (QoL) of working-age cataractous patients bilaterally implanted with 3 different diffractive multifocal intraocular lenses (MIOLs).Design: Two-center, randomized, prospective, double-masked study.Participants: Sixty-three consecutive patients (126 eyes) seen at Ophthalmology Section, Palermo and Florence University, Italy, randomized to receive the ReSTOR SN6AD3 (Alcon Laboratories, Inc, Irvine, CA) (20 patients, group A), ReSTOR SN6AD1 (Alcon Laboratories, Inc) (21 patients, group B), or TECNIS ZMA00 (Abbott Medical Optics, Santa Ana, CA) (22 patients, group C) MIOL.Intervention: Phacoemulsification.Main Outcome Measures: One-year follow-up differences among the 3 MIOL groups in visual acuity, reading performance by MNREAD (Minnesota Laboratory for Low-Vision Research, University of Minnesota, Minneapolis, MN) reading acuity (RA), critical print size (CPS), and maximum reading speed (MRS) under mesopic and photopic conditions.Secondary Outcome Measures: Photopic and mesopic contrast sensitivity (CS) by Pelli–Robson test and patient satisfaction by National Eye Institute Refractive Error Quality of Life Instrument-42 (NEI RQL-42) questionnaire.Results: Mean photopic uncorrected near visual acuity (UNVA), distance-corrected near visual acuity (DCNVA), and corrected near visual acuity (CNVA) did not differ among groups, with a preferred reading distance greater in group B (P < 0.0005). Photopic distance-corrected intermediate visual acuity (DCIVA) was best in group B (P = 0.001) and better in group C than in group A. Mesopic UNVA and DCNVA were worse in groups A and B compared with group C (P < 0.0005 in both cases), with better DCNVA in group B than in group A (P = 0.031). Mesopic uncorrected intermediate visual acuity (UIVA) and DCIVA were worst in group A, with better results in group C (P < 0.0005 and P = 0.001, respectively). Mesopic MNREAD RA was better in group C (P = 0.02), and mesopic MRS was higher in groups B and C than in group A (P = 0.002). The QoL scores by the NEI RQL-42 test exhibited no differences among groups in 9 over 13 scales. “Near vision” (P = 0.005), “symptoms” (P = 0.001), and “satisfaction with correction” scale scores (P = 0.030) were lowest in group A, and “appearance” scale score was lowest in group B (P = 0.045).Conclusions: Newer-generation aspheric diffractive MIOLs, especially low-add hybrid apodized or full diffractive, are highly suited for working-age cataractous patients in terms of visual outcomes, reading performance, and QoL. Intrinsic optical differences, such as optimization for computer or dim-light working, or night driving, could be useful tools to customize the IOL in each single case.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Read more →

Demographic and Clinical Profile of Ocular Chemical Injuries in the Pediatric Age Group – Corrected Proof

by  •  • 0 Comments

Objective: To review the risk factors, management, and visual outcomes of pediatric chemical eye injuries in a tertiary care hospital in North India.Design: Retrospective hospital-based study.Participants: Patients aged <16 years with ocular chemical burns.Methods: Case records of patients with ocular chemical injury who presented to the Dr. Rajendra Prasad Centre for Ophthalmic Sciences were reviewed over a 5-year period.Main Outcome Measures: Demographic profile, nature of chemical injury, complications, and visual outcomes after chemical injury.Results: A total of 134 pediatric patients with a history of ocular chemical burns were seen between March 2006 and March 2011. The mean age of patients at the time of injury was 8.95±4.89 years (range, 1.2–15.5 years); 63.4% were male. Sixty-nine patients (51.4%) belonged to the preschool (0–5 years) age group. Bilateral chemical injuries were seen in 24 patients (17.9%). Lime (“chuna”) was the most commonly involved chemical (88, 65.6%) followed by toilet cleaner (20, 14.9%). The mean time between injury and presentation was 68.3 days (range, 1–365 days). Severe (grade 3 and 4) ocular chemical injury was seen in 94 patients (70.1%). Surgical intervention was performed in 114 eyes (85%) in the form of amniotic membrane grafting (n = 78), symblepharon release (n = 56), limbal stem cell transplantation (n = 26), and lamellar keratoplasty (n = 14). The average number of surgeries conducted per patient was 2.3 (range, 1–4). Median visual acuity at final follow-up (mean, 537±354 days) was 3/60.Conclusions: Chemical injuries in pediatric patients are more commonly encountered in the preschool age group and are associated with severe visual loss. Alkali injury from bursting of chuna packets was the most common mode of injury in pediatric patients in our study.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Read more →

Evaluation of Progressive Neuroretinal Rim Loss as a Surrogate End Point for Development of Visual Field Loss in Glaucoma – Corrected Proof

by  •  • 0 Comments

Purpose: To evaluate the validity of using progressive loss of neuroretinal rim area as a surrogate end point for the development of visual field loss in glaucoma.Design: Prospective, observational cohort study.Participants: The study group included 492 eyes of 328 patients classified with suspected glaucoma at the baseline visit. These eyes had an average of 7.4±2.8 confocal scanning laser ophthalmoscopy (CSLO) images during a mean follow-up time of 6.6±1.6 years.Methods: Rim area measurements were acquired with CSLO during follow-up. The visual field end point was considered the development of 3 consecutive abnormal visual fields on standard automated perimetry. Strong predictive ability and large proportion of treatment effect (PTE) explained are requisites for a suitable surrogate end point. A joint longitudinal survival model was used to evaluate the ability of rates of rim area loss in predicting visual field development, adjusting for confounding variables (baseline age, race, and corneal thickness and follow-up measurements of intraocular pressure [IOP] and pattern standard deviation). The PTE was calculated by comparing the effect of IOP on the risk of development of visual field loss when incorporating rim area loss in the same model with the effect of IOP in the model excluding rim area measurements.Main Outcome Measures: Predictive strength was measured by survival-adapted R2 and PTE.Results: Sixty-two of 492 eyes (13%) developed visual field loss during follow-up. The mean rate of rim area change in eyes that developed visual field loss was −0.011 mm2/year versus −0.003 mm2/year in eyes that did not (P<0.001). In the multivariable model, each 0.01 mm2/year faster rate of rim area loss was associated with a 2.94 higher risk of visual field loss (hazard ratio, 2.94; 95% confidence interval, 1.38–6.23; P = 0.005). R2 values were 62% and 81% for univariable and multivariable models, respectively. The PTE was 65%.Conclusions: Progressive rim area loss was highly predictive of the development of visual field loss in glaucoma and explained a significant PTE on the clinically relevant outcome. These findings suggest that rim area measurements may be suitable surrogate end points in glaucoma clinical trials.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Read more →

Three-Dimensional Evaluation of Accommodating Intraocular Lens Shift and Alignment In Vivo – Corrected Proof

by  •  • 0 Comments

Objective: To quantify 3-dimensionally the anterior segment geometry, biometry, and lens position and alignment in patients before and after implantation of the Crystalens-AO (Bausch & Lomb, Rochester, NY) accommodating intraocular lens (A-IOL).Design: Prospective, observational study.Participants: Ten patients (20 eyes) with cataract before and after implantation of the Crystalens-AO A-IOL.Methods: Custom full anterior segment 3-dimensional (3-D) spectral optical coherence tomography (OCT) provided with quantification tools was used to image the cornea, iris, and natural lens preoperatively and intraocular lens postoperatively. Measurements were obtained under phenylephrine preoperatively and under natural viewing conditions and phenylephrine (for accommodative efforts ranging from 0 to 2.5 diopters [D]) and pilocarpine postoperatively.Main Outcome Measures: Three-dimensional quantitative anterior segment images, corneal geometry and power, anterior chamber depth (ACD), lens thickness, pupil diameter, A-IOL shift with accommodative effort or drug-induced accommodation, and A-IOL alignment.Results: Crystalline lens and IOLs were visualized and quantified 3-dimensionally. The average ACD were 2.64±0.24 and 3.65±0.35 mm preoperatively and postoperatively (relaxed state), respectively, and they were statistically significantly correlated (although their difference was not statistically correlated with lens thickness). The A-IOL did not shift systematically with accommodative effort, with 9 lenses moving forward and 11 lenses moving backward (under natural conditions). The average A-IOL shift under stimulated accommodation with pilocarpine was −0.02±0.20 mm. The greatest forward shift occurred bilaterally in 1 patient (−0.49 mm in the right eye and −0.52 mm in the left eye, under pilocarpine). The high right/left symmetry in the horizontal tilt of the crystalline lens is disrupted on IOL implantation. Accommodative IOLs tend to be slightly more vertically tilted than the crystalline lens, with increasing tendency with accommodative effort. Two subjects showed postoperative IOL tilts >9 degrees. Changes in pupillary diameter correlated with pilocarpine-induced A-IOL axial shift. Intermediate accommodative demands (1.25 D) elicited the greater shifts in axial A-IOL location and tilt and pupil diameter.Conclusions: Quantitative 3-D anterior segment OCT allows full evaluation of the geometry of eyes implanted with A-IOLs preoperatively and postoperatively. High-resolution OCT measurements of the Crystalens 3-D positioning revealed small (and in many patients backward) A-IOL axial shifts with both natural or drug-induced accommodation, as well as tilt changes with respect to natural lens and accommodative effort.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Read more →

Ranibizumab versus Bevacizumab for Neovascular Age-related Macular Degeneration: Results from the GEFAL Noninferiority Randomized Trial – Corrected Proof

by  •  • 0 Comments

Objective: To evaluate the relative efficacy and safety profile of bevacizumab versus ranibizumab intravitreal injections for the treatment of neovascular age-related macular degeneration (AMD).Design: Multicenter, prospective, noninferiority, double-masked, randomized clinical trial performed in 38 French ophthalmology centers. The noninferiority limit was 5 letters.Participants: Patients aged ≥50 years were eligible if they presented with subfoveal neovascular AMD, with best-corrected visual acuity (BVCA) in the study eye of between 20/32 and 20/320 measured on the Early Treatment of Diabetic Retinopathy Study chart and a lesion area of less than 12 optic disc areas (DA).Methods: Patients were randomly assigned to intravitreal administration of bevacizumab (1.25 mg) or ranibizumab (0.50 mg). Hospital pharmacies were responsible for preparing, blinding, and dispensing treatments. Patients were followed for 1 year, with a loading dose of 3 monthly intravitreal injections, followed by an as-needed regimen (1 injection in case of active disease) for the remaining 9 months with monthly follow-up.Main Outcome Measures: Mean change in visual acuity at 1 year.Results: Between June 2009 and November 2011, 501 patients were randomized. In the per protocol analysis, bevacizumab was noninferior to ranibizumab (bevacizumab minus ranibizumab +1.89 letters; 95% confidence interval [CI], −1.16 to +4.93, P < 0.0001). The intention-to-treat analysis was concordant. The mean number of injections was 6.8 in the bevacizumab group and 6.5 in the ranibizumab group (P = 0.39). Both drugs reduced the central subfield macular thickness, with a mean decrease of 95 μm for bevacizumab and 107 μm for ranibizumab (P = 0.27). There were no significant differences in the presence of subretinal or intraretinal fluid at final evaluation, dye leakage on angiogram, or change in choroidal neovascular area. The proportion of patients with serious adverse events was 12.6% in the bevacizumab group and 12.1% in the ranibizumab group (P = 0.88). The proportion of patients with serious systemic or ocular adverse events was similar in both groups.Conclusions: Bevacizumab was noninferior to ranibizumab for visual acuity at 1 year with similar safety profiles. Ranibizumab tended to have a better anatomic outcome. The results are similar to those of previous head-to-head studies.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Read more →

Resident Compliance with the American Academy of Ophthalmology Preferred Practice Pattern Guidelines for Primary Open-Angle Glaucoma – Corrected Proof

by  •  • 0 Comments

Purpose: To examine resident adherence to preferred practice pattern (PPP) guidelines set up by the American Academy of Ophthalmology for follow-up care of primary open-angle glaucoma (POAG) patients.Design: Retrospective chart review.Participants: One hundred three charts were selected for analysis from all patients with an International Classification of Diseases, Ninth Revision, code of open-angle glaucoma or its related entities who underwent a follow-up evaluation between July 2, 2003, and December 15, 2004, at the resident ophthalmology clinic in the Durham Veteran Affairs Medical Center.Methods: Follow-up visits of POAG patients were evaluated for documentation of 19 elements in accordance to PPP guidelines.Main Outcome Measures: Compliance rates for the 19 elements of PPP guidelines first were averaged in all charts, and then were averaged per resident and were compared among 8 residents between their first and second years of residency.Results: The overall mean compliance rate for all 19 elements was 82.6% for all charts (n = 103), 78.8% for first-year residents, and 81.7% for second-year residents. The increase from first to second year of residency was not significant (P > 0.05). Documentation rates were high (>90%) for 14 elements, including all components of the physical examination and follow-up as well as most components of the examination history and management plan. Residents documented adjusting target intraocular pressure downward, local or systemic problems with medications, and impact of visual function on daily living approximately 50% to 80% of the time. Documentation rates for components of patient education were the lowest, between 5% and 16% in all charts.Conclusions: Residents’ compliance with PPP guidelines for a POAG follow-up visit was very high for most elements, but documentation rates for components of patient education were poor. Adherence rates to PPP guidelines can be used as a tool to evaluate and improve resident performance during training. However, further studies are needed to establish the advantages of using PPP guidelines for resident education and to determine if such assessments can lead to improved patient care.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Read more →

Author reply

by  •  • 0 Comments

We thank Dr Huevra for his interest and thoughtful comments on our paper and largely agree with his views on managing this problematic condition. We did not set out to compare topical with subconjunctival delivery of interferon—this was beyond the sc…

Read more →

Author reply

by  •  • 0 Comments

We thank Saad and Gatinel for their interesting observation. We agree that a quantitative definition might have been useful for both suspect keratoconus and forme fruste keratoconus (FFKC). Unfortunately, these definitions, such as those by Rabinowitz …

Read more →