Author: Ophthalmology

Objective:
To estimate the incidence and characteristics of rhegmatogenous retinal detachment (RRD) in The Netherlands in 2009.

Design:
Retrospective, observational case series.

Participants:
All patients with RRD in the Dutch population in 2009.

Methods:
By reviewing surgical logs, cases of primary RRD repair in 2009 were identified. Exclusion criteria included RRD before 2009 and exudative, tractional, or traumatic retinal detachments. Patient demographics, date of surgery, and lens status were documented. Incidence of RRD and 95% confidence intervals (CIs) were calculated based on the Poisson distribution. Age distribution, male-to-female ratio, and proportion of RRD patients with prior cataract extraction (CE) were determined. A Student t test was used to examine differences in the incidence of RRD between groups.

Main Outcome Measures:
Annual RRD incidence in the population and per gender-adjusted age category and proportion of RRD patients with prior CE.

Results:
The annual RRD incidence was 18.2 per 100 000 people (95% CI, 11.4–18.8), with a peak incidence of 52.5 per 100 000 people (95% CI, 29.4–56.8) between 55 and 59 years of age. The Bilateral RRD rate was 1.67%. Macula-off presentation occurred in 54.5% of all RRD patients. Prior CE was noted in 33.5% of RRD eyes. The male-to-female ratio was 1.3:1, and RRD incidence was statistically significantly more frequent in males (P<0.0001).

Conclusions:
Rhegmatogenous retinal detachment is predominantly a disease of the population older than 50 years, and males are more susceptible to RRD. The annual RRD incidence is highly dependent on demographic characteristics.

Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Purpose:
To compare aqueous levels of fluocinolone acetonide (FAc) after administration of FAc inserts or FAc implants (Retisert; Bausch & Lomb, Rochester, NY).

Design:
Comparison of pharmacokinetics from 2 prospective, interventional, clinical trials.

Participants:
Thirty-seven patients with diabetic macular edema (DME) (Fluocinolone Acetonide in Human Aqueous [FAMOUS] Study, C-01-06-002) and 7 patients with uveitis (NA-00019318).

Methods:
Aqueous FAc was measured after administration of FAc implants or 0.2 μg/day (low dose, ILUVIEN; Alimera Sciences Inc., Alpharetta, GA) or 0.5 μg/day (high dose) FAc inserts.

Main Outcome Measures:
The primary end point was aqueous levels of FAc.

Results:
At 1 month after administration for subjects who received 1 treatment, mean aqueous FAc levels were 2.17 (low dose) and 3.03 ng/ml (high dose) for FAc inserts and 6.12 ng/ml for FAc implants with maximum levels of 3.83, 6.66, and 13.50 ng/ml, respectively. At 3 months, mean FAc levels were 1.76, 2.15, and 6.12 ng/ml, respectively. Between 6 and 36 months after low-dose inserts, aqueous levels of FAc were remarkably stable, ranging from 1.18 to 0.45 ng/ml. After high-dose inserts, mean FAc levels were stable between 6 and 24 months, ranging from 1.50 to 0.84 ng/ml and then decreasing to 0.35 ng/ml at 30 months and 0.15 ng/ml at 36 months. In implant-containing eyes, mean FAc levels remained >6 ng/ml through 15 months, the last time point with measurements from at least 6 eyes.

Conclusions:
Low- and high-dose FAc inserts both provide stable long-term release of FAc with comparable peak levels in the aqueous: slightly >2 ng/ml for approximately 3 months followed by steady-state levels between 1.0 and 0.5 ng/ml through 36 months for low-dose inserts versus levels between 1.5 and 1.1 ng/ml through 24 months for high-dose inserts. Steady-state aqueous levels after FAc implants were >6 ng/ml. These results provide new insights that aid in the interpretation of efficacy trials and indicate that there is a dose effect for steroid-induced ocular hypertension. In susceptible patients, prolonged aqueous levels of FAc >1 ng/ml moderately increased the risk of glaucoma and levels >6 ng/ml posed a markedly increase risk.

Financial Disclosure(s):
Proprietary or commercial disclosure may be found after the references.

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Purpose:
To study macular hole (MH) surgery in terms of baseline demographics, intraoperative complications, post-vitrectomy cataract, reoperation, and visual outcome.

Design:
National Ophthalmology Database study.

Participants:
A total of 1078 e…

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Purpose:
To examine which prognostic factors are associated with glaucomatous visual field progression.

Design:
Knowledge of prognostic factors helps clinicians to select patients at risk of glaucomatous visual field progression and intensify their…

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Purpose:
To provide a population-based estimate of the incidence of herpes zoster ophthalmicus (HZO) with comparisons across racial, sex, and age groups, as well as to estimate the frequency of postherpetic neuralgia (PHN).

Design:
Retrospective, population-based cohort study.

Participants:
All patients enrolled in the Kaiser Permanente Hawaii health plan during the study period (N = 217 061).

Methods:
All patient encounters between January 1, 2006, and December 31, 2007, in the electronic medical record of Kaiser Permanente Hawaii were queried for International Classification of Diseases, 9th edition (ICD-9) codes corresponding to HZO. Charts were reviewed to confirm a diagnosis of HZO and to collect information about specific ocular manifestations. Demographic data and information on PHN were collected electronically. Incidence rates were calculated per 100 000 person-years for the entire population and for age-, sex-, and race-specific subgroups.

Main Outcome Measures:
Clinical diagnosis of HZO during the study period.

Results:
A total of 134 cases of HZO were identified in this population of 217 061 people. The overall incidence was 30.9 per 100 000 person-years (95% confidence interval [CI], 25.9–36.6). The incidence rate for the population aged ≥65 years was 104.6 per 100 000 person-years (95% CI, 79.0–135.9), approximately 5 times the remainder of the population (P < 0.001). The most common manifestation of HZO was dermatitis, followed by keratitis and conjunctivitis. The incidence of HZO for Pacific Islanders was 19.0 per 100 000 person-years (95% CI, 12.4–28.3), which was significantly lower than the rate for non–Pacific Islanders (P = 0.007). Twenty-one percent of patients with HZO developed PHN. Older age and HZO with keratitis, conjunctivitis, or uveitis were found to be risk factors for PHN.

Conclusions:
This study provides a population-based estimate of HZO and highlights differences across various age and racial groups. It also suggests that demographic characteristics may be useful in determining the risk of developing HZO.

Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Purpose:
To assess the cost-effectiveness of a telemedicine diabetic retinopathy (DR) screening program in rural Southern India that conducts 1-off screening camps (i.e., screening offered once) in villages and to assess the incremental cost-effectiveness ratios of different screening intervals.

Design:
A cost–utility analysis using a Markov model.

Participants:
A hypothetical cohort of 1000 rural diabetic patients aged 40 years who had not been previously screened for DR and who were followed over a 25-year period in Chennai, India.

Methods:
We interviewed 249 people with diabetes using the time trade-off method to estimate utility values associated with DR. Patient and provider costs of telemedicine screening and hospital-based DR treatment were estimated through interviews with 100 diabetic patients, sampled when attending screening in rural camps (n = 50) or treatment at the base hospital in Chennai (n = 50), and with program and hospital managers. The sensitivity and specificity of the DR screening test were assessed in comparison with diagnosis using a gold standard method for 346 diabetic patients. Other model parameters were derived from the literature. A Markov model was developed in TreeAge Pro 2009 (TreeAge Software Inc, Williamstown, MA) using these data.

Main Outcome Measures:
Cost per quality-adjusted life-year (QALY) gained from the current teleophthalmology program of 1-off screening in comparison with no screening program and the cost–utility of this program at different screening intervals.

Results:
By using the World Health Organization threshold of cost-effectiveness, the current rural teleophthalmology program was cost-effective ($1320 per QALY) compared with no screening from a health provider perspective. Screening intervals of up to a frequency of screening every 2 years also were cost-effective, but annual screening was not (>$3183 per QALY). From a societal perspective, telescreening up to a frequency of once every 5 years was cost-effective, but not more frequently.

Conclusions:
From a health provider perspective, a 1-off DR telescreening program is cost-effective compared with no screening in this rural Indian setting. Increasing the frequency of screening up to 2 years also is cost-effective. The results are dependent on the administrative costs of establishing and maintaining screening at regular intervals and on achieving sufficient coverage.

Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Objective:
To investigate whether a topographic correlation exists between β-zone parapapillary atrophy (PPA) and retinal nerve fiber layer (RNFL) defect. The location and extent of the β-zone were examined.

Design:
Retrospective, cross-sectional study.

Participants:
One hundred twenty-eight eyes from 128 consecutive patients with primary open-angle glaucoma (POAG) and a single localized RNFL defect were included.

Methods:
Digital optic disc photographs of the enrolled eyes were reviewed and eyes with β-zone PPA were identified. The topographic parameters of β-zone PPA and RNFL defect were measured on optic disc photographs and digital red-free RNFL photographs. The association between these parameters was examined statistically.

Main Outcome Measures:
Angular location and angular extent of β-zone PPA and RNFL defect, angular location of point of maximum radial extent (PMRE) of β-zone PPA, and β-zone PPA-to-disc area ratio.

Results:
Eighty-two (64.1%) of the 128 eyes with a single localized RNFL defect had β-zone PPA. Patients with β-zone PPA were younger (by 6.6 years) than those without β-zone PPA (P = 0.001). β-Zone PPA was located most commonly inferotemporally (65.9%). The RNFL defect was located in the same hemifield as the β-zone PPA in 76% of eyes and was located in the same hemifield as PMRE in 88% of eyes. The angular location of the RNFL defect showed a linear correlation with those of β-zone PPA (r = 0.390; P<0.001) and PMRE (r = 0.558; P<0.001). The angular extent of RNFL defect was not correlated significantly with that of β-zone PPA (P = 0.106), but it was associated weakly with β-zone PPA-to-disc area ratio (r = 0.197; P = 0.026). The angular extent of the RNFL defect also was correlated with the cup-to-disc ratio (r = 0.322; P<0.001) and the cup-to-disc area ratio (r = 0.337; P = 0.002).

Conclusions:
In POAG, a localized RNFL defect is correlated spatially with β-zone PPA.

Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Purpose:
To compare the distribution of a p53 gene polymorphism among European subjects undergoing primary retinal detachment (RD) surgery in relation to the development of proliferative vitreoretinopathy (PVR).

Design:
Case-controlled gene association study conducted as a component of the Retina 4 Project (a European multicenter study).

Participants and Controls:
Five hundred fifty DNA samples, 134 with PVR secondary to primary RD and 416 with RD without PVR.

Methods:
The p53 codon 72 polymorphism (rs1042522) was analyzed using allele-specific primer polymerase chain reaction. Proportions of genotypes and the proline (Pro-P) homozygote groups between subsamples from different countries were analyzed in 2 phases. In the first, subsamples from Spain and Portugal were analyzed. After significant results were found, samples from the United Kingdom (UK) and The Netherlands were analyzed (second phase). Genotypic and allelic frequencies were compared between cases and controls in the global sample.

Main Outcome Measures:
Single significant associations with PVR.

Results:
A significant difference (P<0.05, Fisher exact test) was observed regarding the p53 genotype frequencies at codon 72 between the PVR cases and the non-PVR controls in Spain and Portugal (phase I), but not in the UK or The Netherlands (phase II). Analysis of Pro homozygote carriers between cases and controls revealed differences in Spain (29.01–42.18 and 2.29–10.20, respectively), Portugal (10.49–29.50 and 1.35–8.89, respectively), and The Netherlands (16.49–31.70 and 4.51–15.09, respectively), but no differences in the UK (7.68–18.1 and 4.85–13.94, respectively). The odds ratio of Pro carriers from Spain and Portugal together was 8.12 (95% confidence interval [CI], 3.72–17.69; P<0.05), whereas the odds ratio of Pro carriers from the UK and The Netherlands was 2.12 (95% CI, 0.96–4.68; P = 0.07). All control samples were in Hardy-Weinberg equilibrium. Considering the entire sample, significant differences were found in genotype frequencies between cases (RR, 30.59%; RP, 43.28%; PP, 26.11% [R = Arg; P = Pro]) and controls (RR, 39.66%; RP, 52.64%; PP, 7.69%) and in Pro homozygote carriers between controls (Pro homozygote 95% CI, 18.67–33.52) and cases (Pro homozygote 95% CI, 5.1–10.2).

Conclusions:
Results indicate that the Pro variant of p53 codon 72 polymorphism is associated with a higher risk of PVR developing after a primary RD. Further studies are necessary to understand the role of this polymorphism in the development of PVR.

Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Purpose:
To compare the outcomes of 2 intraocular lenses (IOLs) for the treatment of age-related cataracts.

Design:
Prospective, randomized trial.

Participants:
Patients with age-related cataracts were recruited and randomized to receive phacoemulsification and implantation of either the AcrySof SA60AT lens (Alcon, Inc, Fort Worth, TX) or the low-cost Tecsoft Flex lens (Fred Hollows Foundation, Tilganga, Nepal). A total of 300 patients were available for description and analysis (148 in the AcrySof group and 152 in the Tecsoft group).

Methods:
Patients underwent phacoemulsification and implantation of the AcrySof SA60AT lens or the Tecsoft Flex lens. They were followed up and examined at baseline, 1 week, 1 month, 6 months, and 12 months after cataract surgery.

Main Outcome Measures:
Uncorrected distance visual acuity (UDVA), best-corrected distance visual acuity (BDVA), incidence of posterior capsule opacification (PCO), Visual Function Index questionnaire results, and safety of the implanted IOLs.

Results:
No significant difference (P>0.05) was found in UDVA and BDVA after surgery between the 2 groups. The equivalence test of the 95% confidence intervals showed that both lenses had an equal improvement of UDVA and BDVA as well as similar rates of PCO after cataract surgery. There was no significant difference between the 2 groups with regard to visual functioning or the incidence of adverse surgical events during (P>0.05) or after (P>0.05) the surgery.

Conclusions:
The Tecsoft Flex IOL is a low-cost suitable alternative that is similar to the AcrySof IOL in terms of safety and visual outcomes.

Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Purpose:
To evaluate the clinical features of peripapillary choroidal cavitation (PCC) detected by optical coherence tomography (OCT).

Design:
Retrospective, observational case series.

Participants:
One hundred twenty-two eyes from 83 patients diagnosed with PCC by OCT database review were included in this study.

Methods:
Stereoscopic color fundus photographs from eyes with PCC were reviewed by 2 independent ophthalmologists. They were masked to the refractive error, axial length, and OCT findings.

Main Outcome Measures:
Chart review and data analysis included gender, age, best-corrected visual acuity (BCVA), refractive error, axial length, clinical appearance of the peripapillary area, and associated funduscopic abnormalities.

Results:
One hundred twenty-two eyes with PCC from 83 patients were analyzed. Among the patients, 41.8% were men and 58.2% were women. The mean age was 48.2±12.6 years and mean BCVA in logarithm of the minimum angle of resolution units was 0.23±0.43. The mean refractive error in spherical equivalent was −9.03±5.11 diopters (D) and mean axial length (AL) was 27.36±2.09 mm. With respect to refractive error, 90 eyes (73.8%) were highly myopic (≥–6.00 D), 24 eyes (19.7%) had low myopia ( 1.00 D). Forty eyes (32.8%) with PCC had AL of less than 26.50 mm (mean, 25.11±1.07 mm; range, 22.51–26.42 mm). Patients with eyes with PCC that had low myopia, were emmetropic, and were hyperopic also were significantly older than patients with highly myopic eyes (P<0.05). Stereoscopic fundus photographs demonstrated a yellow-orange, localized, well-circumscribed peripapillary lesion in 57 (46.7%) eyes with PCC. A PCC with opening was observed in 14 (26.4%) of 53 eyes with excavated myopic conus and in 5 (7.2%) of 69 eyes without excavated myopic conus (P<0.05).

Conclusions:
This study demonstrated that peripapillary choroidal cavitation is common and not exclusive to highly myopic eyes. The funduscopic finding of a yellow-orange peripapillary abnormality may not be evident in all eyes with demonstrable PCC by OCT. Although its pathogenesis and pathologic significance require further investigation, PCC may be a degenerative change in aging eyes.

Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Purpose:
To report an association of congenital optic nerve anomalies with peripheral retina nonperfusion and to describe the clinical manifestations and treatment.

Design:
Retrospective, observational case series.

Participants:
Fifteen patients …

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Purpose:
Selective endothelial transplantation in the form of Descemet’s stripping endothelial keratoplasty (DSEK) is rapidly replacing traditional full-thickness penetrating keratoplasty (PK) for endothelial disease. An incremental cost-effectiveness analysis was performed to determine whether the benefits of DSEK are worth the additional costs.

Design:
Retrospective cohort study.

Participants:
Patients at the Singapore National Eye Center, a tertiary eye center in Singapore, with Fuchs’ dystrophy or bullous keratopathy who underwent either PK or DSEK.

Intervention:
Patients underwent either PK (n = 171) or DSEK (n = 93) from January 2001 through December 2007. Data were collected from inpatient and outpatient notes corresponding to the time immediately before the procedure to up to 3 years after.

Main Outcome Measures:
Improvements in best spectacle-corrected visual acuity were used to calculate the increase in quality-adjusted life years (QALYs) 3 years after the procedure. This was combined with hospital charges (a proxy for costs) to determine incremental cost-effectiveness ratios (ICERs) comparing PK with no intervention and DSEK with PK.

Results:
Three-year charges for DSEK and PK were $7476 and $7236, respectively. The regression-adjusted improvement in visual acuity for PK relative to no intervention was −0.613 logarithm of the minimum angle of resolution (logMAR) units (P<0.001), and for DSEK relative to PK, it was −0.199 logMAR units (P = 0.045). The regression-adjusted marginal gain in utility for PK relative to no intervention was 0.128 QALYs (P<0.001) and for DSEK relative to PK was 0.046 QALYs (P = 0.031). This resulted in ICERs of $56 409 per QALY for PK relative to no intervention and $5209 per QALY for the more expensive DSEK relative to PK.

Conclusions:
If the goal is to maximize societal health gains given fixed resources, DSEK should be the preferred strategy. For a fixed budget, it is possible to achieve greater QALY gains by providing DSEK to as many patients as possible (and nothing to others), rather than providing PK.

Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Purpose:
To report the outcomes of infliximab treatment of birdshot retinochoroidopathy (BSRC) refractory to conventional immunomodulatory therapy.

Design:
Retrospective case series.

Participants:
Twenty-two refractory birdshot retinochoroidopath…

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Purpose:
To evaluate the feasibility of intraoperative anterior segment (AS) optical coherence tomography (OCT) for quantification of the corneal depth reached with the dissecting cannula used for deep anterior lamellar keratoplasty, as well as its c…

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Objective:
To describe the development of flash visual evoked potentials (FVEPs) in preterm infants from 1 to 18 months and to determine if the maturation of FVEPs is similar to that of term infants.

Design:
Longitudinal follow-up study.

Participa…

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Purpose:
To compare the central and peripheral pachymetry measurements determined using Orbscan IIz (Bausch & Lomb, Rochester, NY), Visante optical coherence tomography (OCT; Carl Zeiss Meditec, Dublin, CA), and RTVue OCT (Oculus Technologies, Wynwood, WA) with ultrasound pachymetry in eyes with established keratoconus and to evaluate the agreement between them.

Design:
Evaluation of diagnostic technologies.

Participants:
One hundred six eyes of 67 consecutive patients with a clinical diagnosis of keratoconus ranging in age from 12 to 40 years.

Methods:
Central corneal thickness (CCT) was determined by all the 4 techniques. Peripheral corneal thicknesses were determined using Orbscan IIz, Visante OCT, and RTVue at 8 points (superior, inferior, temporal, nasal, superior-temporal, inferior-temporal, superior-nasal, and inferior-nasal) all in the 5.0- to 7.0-mm arcuate zone.

Main Outcome Measures:
Central and peripheral keratoconus thickness.

Results:
Ultrasound pachymetry determined significantly higher CCT values than Orbscan IIz (P<0.001), Visante (P<0.001), and RTVue (P = 0.037), with a mean ± standard deviation difference of 14±3 μm, 13±2 μm, and 5±3 μm, respectively. The mean CCT difference was minimal (1±3 μm; P = 0.69) between the Orbscan IIz and Visante. A strong correlation was found (r>0.80) between all the CCT measurement techniques. Orbscan IIz significantly overestimated the peripheral thickness compared with the rest, and the mean differences ranged between 21 and 60 μm. Mean peripheral thickness differences between RTVue and Visante OCT always remained less than 20 μm. Weak correlations and larger limits of agreement were found between the techniques in thinner and peripheral zones.

Conclusions:
Orbscan IIz, Visante, RTVue, and ultrasound pachymetry show high correlation, although Orbscan IIz and Visante significantly underestimated CCT measurements compared with ultrasound pachymetry in keratoconus. Orbscan IIz significantly overestimated peripheral corneal thickness compared with RTVue and Visante.

Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Objective:
To determine the incidence and timing of new intraocular tumor foci in genetic retinoblastoma cases after treatment with ophthalmic artery chemosurgery (OAC).

Design:
Single-center retrospective review of all genetic retinoblastoma cases…

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Objective:
To review the published literature to assess the safety, efficacy, and predictability of femtosecond lasers for the creation of corneal flaps for LASIK; to assess the reported outcomes of LASIK when femtosecond lasers are used to create co…

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Purpose:
To determine the long-term efficacy of prismatic correction in consecutive esotropia after a unilateral recession and resection (RR) procedure for primary exotropia.

Design:
Retrospective cohort study.

Participants:
A total of 110 patien…

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Purpose:
To evaluate the relationship of anisometropia with unilateral amblyopia, interocular acuity difference (IAD), and stereoacuity among Head Start preschoolers using both clinical notation and vector notation analyses.

Design:
Multicenter, cross-sectional study.

Participants:
Three- to 5-year-old participants in the Vision in Preschoolers (VIP) study (n = 4040).

Methods:
Secondary analysis of VIP data from participants who underwent comprehensive eye examinations, including monocular visual acuity testing, stereoacuity testing, and cycloplegic refraction. Visual acuity was retested with full cycloplegic correction when retest criteria were met. Unilateral amblyopia was defined as IAD of 2 lines or more in logarithm of the minimum angle of resolution (logMAR) units. Anisometropia was defined as a 0.25-diopter (D) or more difference in spherical equivalent (SE) or in cylinder power and 2 approaches using power vector notation. The percentage with unilateral amblyopia, mean IAD, and mean stereoacuity were compared between anisometropic and isometropic children.

Main Outcomes Measures:
The percentage with unilateral amblyopia, mean IAD, and mean stereoacuity.

Results:
Compared with isometropic children, anisometropic children had a higher percentage of unilateral amblyopia (8% vs. 2%), larger mean IAD (0.07 vs. 0.05 logMAR), and worse mean stereoacuity (145 vs. 117 arc sec; all P<0.0001). Larger amounts of anisometropia were associated with higher percentages of unilateral amblyopia, larger IAD, and worse stereoacuity (P<0.001 for trend). The percentage of unilateral amblyopia increased significantly with SE anisometropia of more than 0.5 D, cylindrical anisometropia of more than 0.25 D, vertical and horizontal meridian (J0) or oblique meridian (J45) of more than 0.125 D, or vector dioptric distance of more than 0.35 D (all P<0.001). Vector dioptric distance had greater ability to detect unilateral amblyopia than cylinder, SE, J0, or J45 (P<0.001).

Conclusions:
The presence and amount of anisometropia were associated with the presence of unilateral amblyopia, larger IAD, and worse stereoacuity. The threshold level of anisometropia at which unilateral amblyopia became significant was lower than current guidelines. Vector dioptric distance is more accurate than spherical equivalent anisometropia or cylindrical anisometropia in identifying preschoolers with unilateral amblyopia.

Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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