Purpose: To measure the maximum angle of ocular versions using photographs of the 9 cardinal positions and a modified limbus test.Design: An evaluation of diagnostic technology; a prospective observational study.Participants: We enrolled 104 healthy subjects, 20 to 40 years of age.Methods: Photographs were obtained in the 9 cardinal positions of gaze and the images were processed using Photoshop. The images were analyzed using the Image J program to measure the angle of version. The maximum angle of the 9 cardinal positions was quantified using a modified limbus test.Main Outcome Measures: We measured the maximum angle of ocular versions in the 9 cardinal positions of gaze. We also compared the results for males and females.Results: The mean angles of maximum version were adduction 47.4°, abduction 46.4°, elevation 31.8°, depression 47.8°, elevation in adduction 39.7°, elevation in abduction 40.7°, depression in adduction 52.7°, and depression in abduction 49.2°. The mean angle of maximum elevation was significantly smaller than that of depression (P < 0.001). There were no correlations between the angle of maximum version and age, spherical equivalents, or axial length. The angle of maximum version for males was significantly greater than that for females, except for inferior gaze.Conclusions: A modified limbus test using photographs of the 9 cardinal positions is an objective and reproducible tool for quantifying ocular movement. Considering its simplicity, ease of use, and low cost, it has clear applications in clinical practice.
Author: Ophthalmology
Surgical versus Medical Treatment of Ocular Surface Squamous Neoplasia: A Comparison of Recurrences and Complications – Corrected Proof
Purpose: Treatment for ocular surface squamous neoplasia (OSSN) has historically been surgery, but nonsurgical interventions are increasingly used. Treatment with interferon is efficacious, but evidence is needed regarding recurrence and complication r…
Gonioscopy-Assisted Transluminal Trabeculotomy, A Novel Ab Interno Trabeculotomy: Technique Report and Preliminary Results – Corrected Proof
Purpose: To introduce a novel, minimally invasive, ab interno approach to a circumferential 360-degree trabeculotomy and to report the preliminary results.Design: Retrospective, noncomparative cases series.Participants: Eighty-five eyes of 85 consecutive patients who sought treatment at Glaucoma Associates of Texas with uncontrolled open-angle glaucoma and underwent gonioscopy-assisted transluminal trabeculotomy (GATT) for whom there was at least 6 months of follow-up data.Methods: Retrospective chart review of patients who underwent GATT by 4 of the authors (D.S.G., D.G.G., O.S., R.L.F.) between October 2011 and October 2012. The surgery was performed in adults with various open-angle glaucomas.Main Outcome Measures: Intraocular pressure (IOP), glaucoma medications, visual acuity, and intraoperative as well as postoperative complications.Results: Eighty-five patients with an age range of 24 to 88 years underwent GATT with at least 6 months of follow-up. In 57 patients with primary open-angle glaucoma, the IOP decreased by 7.7 mmHg (standard deviation [SD], 6.2 mm Hg; 30.0% [SD, 22.7%]) with an average decrease in glaucoma medications of 0.9 (SD, 1.3) at 6 months. In this group, the IOP decreased by 11.1 mmHg (SD, 6.1 mmHg; 39.8% [SD, 16.0%]) with 1.1 fewer glaucoma medications at 12 months. In the secondary glaucoma group of 28 patients, IOP decreased by 17.2 mmHg (SD, 10.8 mmHg; 52.7% [SD, 15.8%]) with an average of 2.2 fewer glaucoma medications at 6 months. In this group, the IOP decreased by 19.9 mmHg (SD, 10.2 mmHg; 56.8% [SD, 17.4%]) with an average of 1.9 fewer medications (SD, 2.1) at 12 months. Treatment was considered to have failed in 9% (8/85) of patients because of the need for further glaucoma surgery. The cumulative proportion of failure at 1 year ranged from 0.1 to 0.32, depending on the group. Lens status or concurrent cataract surgery did not have a statistically significant effect on IOP in eyes that underwent GATT at either 6 or 12 months (P > 0.35). The most common complication was transient hyphema, seen in 30% of patients at the 1-week visit.Conclusions: The preliminary results and safety profile for GATT, a novel, minimally invasive circumferential trabeculotomy, are promising and at least equivalent to previously published results for ab externo trabeculotomy.
Cost-Effectiveness of Retinal Detachment Repair – Corrected Proof
Objective: To evaluate costs and treatment benefits of rhegmatogenous retinal detachment (RD) repair.Design: A Markov model of cost-effectiveness and utility.Participants: There were no participants.Methods: Published clinical trials (index studies) of…
Cost-Effectiveness of Bevacizumab and Ranibizumab for Newly Diagnosed Neovascular Macular Degeneration – Corrected Proof
Purpose: We sought to determine the most cost-effective treatment for patients with newly diagnosed neovascular macular degeneration: monthly or as-needed bevacizumab injections, or monthly or as-needed ranibizumab injections.Design: Cost-effectiveness analysis.Participants: Hypothetical cohort of 80-year-old patients with newly diagnosed neovascular macular degeneration.Methods: Using a mathematical model with a 20-year time horizon, we compared the incremental cost-effectiveness of treating a hypothetical cohort of 80-year-old patients with newly diagnosed neovascular macular degeneration using monthly bevacizumab, as-needed bevacizumab, monthly ranibizumab, or as-needed ranibizumab. Data came from the Comparison of Age-related macular degeneration Treatment Trial (CATT), the Medicare Fee Schedule, and the medical literature.Main Outcome Measures: Costs, quality-adjusted life-years (QALYs), and incremental costs per QALY gained.Results: Compared with as-needed bevacizumab, the incremental cost-effectiveness ratio of monthly bevacizumab is $242 357/QALY. Monthly ranibizumab gains an additional 0.02 QALYs versus monthly bevacizumab at an incremental cost-effectiveness ratio of >$10 million/QALY. As-needed ranibizumab was dominated by monthly bevacizumab, meaning it was more costly and less effective. In sensitivity analyses assuming a willingness to pay of $100 000/QALY, the annual risk of serious vascular events would have to be ≥2.5 times higher with bevacizumab than that observed in the CATT trial for as-needed ranibizumab to have an incremental cost-effectiveness ratio of <$100 000/QALY. In another sensitivity analysis, even if every patient receiving bevacizumab experienced declining vision by 1 category (e.g., from 20/25–20/40 to 20/50–20/80) after 2 years but every patient receiving ranibizumab retained their vision level, as-needed ranibizumab would have an incremental cost-effectiveness ratio of $97 340/QALY.Conclusions: Even after considering the potential for differences in risks of serious adverse events and therapeutic effectiveness, bevacizumab confers considerably greater value than ranibizumab for the treatment of neovascular macular degeneration.
Proton Therapy for Uveal Melanoma in 43 Juvenile Patients: Long-Term Results – Corrected Proof
Purpose: To examine the metastatic and survival rates, eye retention probability, and the visual outcomes of juvenile patients after proton beam radiotherapy (PBRT) for uveal melanoma (UM).Design: Retrospective case-factor matched control study.Participants and Controls: Forty-three patients younger than 21 years treated with PBRT for UM were compared with 129 matched adult control patients.Methods: Information on patient demographics and clinical characteristics were recorded before and after treatment from patients’ files. The control group was composed of adult patients (>21 years) matched for tumor size (largest tumor diameter, ±2 mm; height, ±2 mm) and anterior margin location (iris, ciliary body, pre-equatorial or postequatorial choroid). For each juvenile patient, 3 adults were selected.Main Outcome Measures: Comparing outcomes of juvenile and adult patients in terms of metastatic and eye retention rates using the log-rank statistic, relative survival using the Hakulinen method, as well as their visual outcomes.Results: Forty-three juvenile and 129 control cases were reviewed. The metastatic rate at 10 years was significantly lower in juvenile UM patients than in adult controls (11% vs. 34%; P < 0.01), with an associated relative survival rate of 93% versus 65% (P = 0.02). Six juvenile patients (14%) demonstrated metastases. One patient underwent enucleation because of a presumed local tumor recurrence and 4 additional patients underwent enucleation because of complications (9.3%). In the adult control group, 27% (n = 35) of matched patients demonstrated metastases, there were 2 cases of local recurrence, and 16% (n = 21) underwent enucleation because of complications. A visual acuity of more than 0.10 was maintained in most cases, without any significant differences before or after treatment observed between both groups.Conclusions: After PBRT, metastatic and survival rates are significantly better for juvenile than for adult patients with UM. Clinically, juvenile and adult eyes react similarly to PBRT, with patients having a comparable eye retention probability and maintaining a useful level of vision in most cases. This is the largest case-control study of proton therapy in juvenile eyes to date and further validates PBRT as an appropriate conservative treatment for UM in patients younger than 21 years.
Assessment of Iris Surface Features and Their Relationship with Iris Thickness in Asian Eyes – Corrected Proof
Purpose: To assess iris surface features in Asian eyes and examine their associations with iris thickness measured by anterior segment optical coherence tomography (AS OCT).Design: Cross-sectional study.Participants: We recruited 250 subjects from the Singapore Malay Eye Study.Methods: We obtained standardized slit-lamp photographs and developed a grading system assessing iris crypts (by number and size), furrows (by number and circumferential extent), and color (higher grade denoting darker iris). Vertical and horizontal cross-sections of the anterior chamber were imaged using AS OCT. Intragrader and intergrader agreements in the grading of iris surface were assessed by weighted κ (κw) statistic. Associations of the average iris thickness with the grade of iris features were assessed using linear regression analysis.Main Outcome Measures: Frequency and size of iris crypts, furrows, and color; iris thickness at 750 μm (IT750) and 2000 μm (IT2000) from the scleral spur; and maximum iris thickness (ITM) averaged from the 4 quarters.Results: Three hundred sixty-four eyes had complete and gradable data for crypts and color; 330 eyes were graded for furrows. The grading scheme showed good intragrader (crypt κw = 0.919, furrow κw =0.901, color κw = 0.925) and intergrader (crypt κw = 0.775, furrow κw = 0.836, color κw = 0.718) agreements. Higher crypt grade was associated independently with thinner IT750 (β [change in iris thickness per grade higher] = −0.007; P = 0.029), IT2000 (β = −0.018; P < 0.001), and ITM (β = −0.012; P < 0.001). More extensive furrows were associated with thicker IT750 (β = 0.022; P < 0.001). Darker iris was also associated with thicker IT750 (β = 0.014; P = 0.001).Conclusions: Iris surface features, assessed and measured from slit-lamp photographs, correlate well with iris thickness. Irises with more crypts are thinner; irises with more extensive furrows and darker color are thicker peripherally. These findings may provide another means to assess angle closure risk based on iris features.
Intraocular Pressure in Eyes Receiving Monthly Ranibizumab in 2 Pivotal Age-Related Macular Degeneration Clinical Trials – Corrected Proof
Purpose: To characterize preinjection intraocular pressure (IOP) in eyes receiving monthly ranibizumab versus sham or verteporfin photodynamic therapy (PDT) for age-related macular degeneration (AMD).Design: Post hoc analysis of IOP data from 2 phase 3 clinical trials, the Minimally Classic/Occult Trial of the Anti-VEGF Antibody Ranibizumab in the Treatment of Neovascular AMD (MARINA) and the Anti-VEGF Antibody for the Treatment of Predominantly Classic Choroidal Neovascularization in AMD (ANCHOR) trial.Participants: All safety-evaluable patients who received 1 or more injections of sham or PDT or of ranibizumab and had 1 or more postbaseline IOP measurements recorded for the study eye.Methods: Preinjection IOP measurements for study eyes (n = 1125) and fellow eyes in MARINA and ANCHOR at baseline and at each monthly visit through month 24 were analyzed.Main Outcome Measures: End points evaluated were maximum preinjection IOP during the 24-month treatment period; any occurrence of absolute preinjection IOP of 21 mmHg or more, 25 mmHg or more, or 30 mmHg or more; any occurrence of IOP increase of 6 mmHg or more, 8 mmHg or more, or 10 mmHg or more from baseline; any combination of IOP increase of 6 mmHg or more or 8 mmHg or more from baseline with concurrent absolute preinjection IOP of 21 mmHg or more or 25 mmHg or more; glaucoma-related adverse events; new glaucoma medications used for 45 days or more; and glaucoma filtration or laser surgeries.Results: Across treatment groups, 60.1% to 70.9% of study eyes had a maximum preinjection IOP of less than 21 mmHg. Comparing ranibizumab 0.5 mg versus sham or PTD treatment, respectively: 39.9% versus 29.1% and 10.9% versus 5.1% had maximum preinjection IOPs of 21 mmHg or more or 25 mmHg or more, respectively; 44.1% versus 29.9% and 24.2% versus 13.6% had IOP increases from baseline of 6 mmHg or more or 8 mmHg or more, respectively; 26.1% versus 13.6% and 16.8% versus 9.0% had 1 or more IOP increase from baseline of 6 mmHg or more or 8 mmHg or more, respectively, with a concurrent IOP of 21 mmHg or more; 9.6% versus 3.7% and 7.5% versus 2.4% had 1 or more IOP increase from baseline of 6 mmHg or more or 8 mmHg or more, respectively, with a concurrent IOP of 25 mmHg or more. No differences were observed in fellow eyes.Conclusions: Most ranibizumab-treated eyes did not experience sustained preinjection IOP of 21 mmHg or more (>2 consecutive visits) over 24 months. When evaluating the combined IOP end point, more ranibizumab-treated eyes had 1 or more IOP increase from baseline of 6 mmHg or more or 8 mmHg or more, with concurrent highest IOPs of 21 mmHg or more and 25 mmHg or more versus sham or PDT. Intraocular pressure should be monitored in eyes receiving ranibizumab.
Genes in the High-Density Lipoprotein Metabolic Pathway in Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy – Corrected Proof
Purpose: To investigate the associations of genetic variants in the high-density lipoprotein (HDL) metabolism pathway with neovascular age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV).Design: Cross-sectional, case-cont…
Diagnostic Performance of Optical Coherence Tomography Ganglion Cell–Inner Plexiform Layer Thickness Measurements in Early Glaucoma – Corrected Proof
Purpose: To evaluate the glaucoma diagnostic performance of ganglion cell inner–plexiform layer (GCIPL) parameters used individually and in combination with retinal nerve fiber layer (RNFL) or optic nerve head (ONH) parameters measured with Cirrus HD…
A Randomized, Controlled Trial of Corneal Collagen Cross-Linking in Progressive Keratoconus: Three-Year Results – Corrected Proof
Purpose: To report the refractive, topographic, and clinical outcomes 3 years after corneal collagen cross-linking (CXL) in eyes with progressive keratoconus.Design: Prospective, randomized controlled trial.Participants: One hundred eyes with progressive keratoconus were randomized into the CXL treatment or control groups.Methods: Cross-linking was performed by instilling riboflavin 0.1% solution containing 20% dextran for 15 minutes before and during the 30 minutes of ultraviolet A irradiation (3 mW/cm2). Follow-up examinations were arranged at 3, 6, 12, 24, and 36 months.Main Outcome Measures: The primary outcome measure was the maximum simulated keratometry value (Kmax). Other outcome measures were uncorrected visual acuity (UCVA; measured in logarithm of the minimum angle of resolution [logMAR] units), best spectacle-corrected visual acuity (BSCVA; measured in logMAR units), sphere and cylinder on subjective refraction, spherical equivalent, minimum simulated keratometry value, corneal thickness at the thinnest point, endothelial cell density, and intraocular pressure.Results: The results from 48 control and 46 treated eyes are reported. In control eyes, Kmax increased by a mean of 1.20±0.28 diopters (D), 1.70±0.36 D, and 1.75±0.38 D at 12, 24, and 36 months, respectively (all P < 0.001). In treated eyes, Kmax flattened by −0.72±0.15 D, −0.96±0.16 D, and −1.03±0.19 D at 12, 24, and 36 months, respectively (all P < 0.001). The mean change in UCVA in the control group was +0.10±0.04 logMAR (P = 0.034) at 36 months. In the treatment group, both UCVA (−0.15±0.06 logMAR; P = 0.009) and BSCVA (−0.09±0.03 logMAR; P = 0.006) improved at 36 months. There was a significant reduction in corneal thickness measured using computerized videokeratography in both groups at 36 months (control group: −17.01±3.63 μm, P < 0.001; treatment group: −19.52±5.06 μm, P < 0.001) that was not observed in the treatment group using the manual pachymeter (treatment group: +5.86±4.30 μm, P = 0.181). The manifest cylinder increased by 1.17±0.49 D (P = 0.020) in the control group at 36 months. There were 2 eyes with minor complications that did not affect the final visual acuity.Conclusions: At 36 months, there was a sustained improvement in Kmax, UCVA, and BSCVA after CXL, whereas eyes in the control group demonstrated further progression.
期刊一览
Shah (p. 352) 等人分析了肺癌葡萄膜转移患者的临床特征、治疗及预后。 他们发现，44%葡萄膜转移癌患者在转移灶发现时并未诊断出肺癌。另外，他们还发现，尽管现阶段的眼部治疗方案可以尽…
Rising Cataract Surgery Rates: Demand and Supply
Cataract surgery is the most frequently performed surgical procedure in many developed countries, providing significant, long-term, and cost-effective improvements in the quality of life for patients of all ages. Advances in cataract surgery techniques…
Editorial Board
A Simple Vista en Este Número
Shah y otros (p. 352) evaluaron las características, el tratamiento y el pronóstico clínico de pacientes con metástasis uveal por cáncer de pulmón. Encontraron que 44% de los pacientes con metástasis uveal no habían sido diagnosticados con cán…
Things Go Better with Cataract Surgery
In 1965, the largest beverage company in the world came up with the slogan: “Things go better with Coke.” Although very little has changed regarding the choice of, and techniques pertaining to, stand-alone glaucoma surgery, the past few years have …
This Issue At A Glance
Shah et al (p. 352) assessed the clinical features, treatment, and prognosis of patients with uveal metastasis from lung cancer. They found that 44% of patients with uveal metastasis had not been diagnosed with lung cancer at the time the metastasis w…
Contents
Corrigendum
With apologies from the authors of “Preterm Birth and Later Retinal Detachment: A Population-Based Cohort Study of More than 3 Million Children and Young Adults” (Ophthalmology 2013;120:2278-2285), the 6th paragraph on the 2nd column (p. 2280) shou…
Polymorphisms in Vascular Endothelial Growth Factor Receptor 2 Are Associated with Better Response Rates to Ranibizumab Treatment in Age-related Macular Degeneration – Corrected Proof
Purpose: Intravitreal anti–vascular endothelial growth factor (VEGF) injections are currently the standard treatment for neovascular age-related macular degeneration (AMD), but a broad range of response rates has been observed. We evaluated the assoc…