Author: Ophthalmology

Long-Term Trends in Glaucoma-Related Blindness in Olmsted County, Minnesota – Corrected Proof

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Objective: To determine the longitudinal trends in the probability of blindness due to open-angle glaucoma (OAG) in Olmsted County, Minnesota, from 1965 to 2009.Design: Retrospective, population-based cohort study.Participants: All residents of Olmsted County, Minnesota (aged ≥40 years) who were diagnosed with OAG between January 1, 1965, and December 31, 2000.Methods: All available medical records of every incident case of OAG were reviewed until December 31, 2009, to identify progression to blindness, defined as visual acuity ≤20/200 or visual field constriction to ≤20°. Kaplan–Meier analysis was used to estimate the cumulative probability of glaucoma-related blindness. Population incidence of blindness within 10 years of diagnosis was calculated using US Census data. Rates for subjects diagnosed in the period 1965–1980 were compared with rates for subjects diagnosed in the period 1981–2000 using log-rank tests and Poisson regression models.Main Outcome Measures: Cumulative probability of OAG-related blindness and population incidence of blindness within 10 years of diagnosis.Results: Probability of glaucoma-related blindness in at least 1 eye at 20 years decreased from 25.8% (95% confidence interval [CI], 18.5–32.5) for subjects diagnosed in 1965–1980 to 13.5% (95% CI, 8.8–17.9) for subjects diagnosed in 1981–2000 (P = 0.01). The population incidence of blindness within 10 years of the diagnosis decreased from 8.7 per 100 000 (95% CI, 5.9–11.5) for subjects diagnosed in 1965–1980 to 5.5 per 100 000 (95% CI, 3.9–7.2) for subjects diagnosed in 1981–2000 (P = 0.02). Higher age at diagnosis was associated with increased risk of progression to blindness (P < 0.001).Conclusions: The 20-year probability and the population incidence of blindness due to OAG in at least 1 eye have decreased over a 45-year period from 1965 to 2009. However, a significant proportion of patients still progress to blindness despite recent diagnostic and therapeutic advancements.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Circularity Index as a Risk Factor for Progression of Geographic Atrophy – Corrected Proof

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Objective: To develop a parameter that can assess the relative rate of progression of geographic atrophy (GA) based on the hypothesis that noncircular configuration of the atrophic lesion may be a risk factor for enlargement.Design: Cohort study.Participants: Digitized color photographs of 593 eyes with GA from the Age-Related Eye Disease Study (AREDS).Methods: A novel parameter called the “Geographic Atrophy Circularity Index” (GACI) was developed on the basis of area and perimeter measurements to categorize the irregularity of the shape of GA. The GACI ranges from 0.0 to 1.0 and is categorized into 3 groups: 0.25 (very irregular), 0.25 to <0.75 (partly irregular), and ≥0.75 (circular).Main Outcome Measures: Growth rate of GA.Results: The mean growth rate in the 3 categories was 0.40 (±0.18), 0.36 (±0.30), and 0.21 (±0.22) mm/year, respectively (P < 0.001). By adjusting for known confounders, baseline area, duration of GA, and configuration, GACI categories were significantly associated with increased growth rate of GA (P < 0.001).Conclusions: The GACI was associated with the progression rate of GA and may be a useful measure for clinical trial eligibility. The association also suggests that enlargement of GA may be related to the extent of the junctional zone of damaged retinal pigment epithelium, which increases with noncircularity for a given GA area.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Risk Factors for Amblyopia in the Vision in Preschoolers Study – Corrected Proof

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Objective: To evaluate risk factors for unilateral amblyopia and for bilateral amblyopia in the Vision in Preschoolers (VIP) study.Design: Multicenter, cross-sectional study.Participants: Three- to 5-year-old Head Start preschoolers from 5 clinical centers, overrepresenting children with vision disorders.Methods: All children underwent comprehensive eye examinations, including threshold visual acuity (VA), cover testing, and cycloplegic retinoscopy, performed by VIP-certified optometrists and ophthalmologists who were experienced in providing care to children. Monocular threshold VA was tested using a single-surround HOTV letter protocol without correction, and retested with full cycloplegic correction when retest criteria were met. Unilateral amblyopia was defined as an interocular difference in best-corrected VA of 2 lines or more. Bilateral amblyopia was defined as best-corrected VA in each eye worse than 20/50 for 3-year-olds and worse than 20/40 for 4- to 5-year-olds.Main Outcome Measures: Risk of amblyopia was summarized by the odds ratios and their 95% confidence intervals estimated from logistic regression models.Results: In this enriched sample of Head Start children (n = 3869), 296 children (7.7%) had unilateral amblyopia, and 144 children (3.7%) had bilateral amblyopia. Presence of strabismus (P < 0.0001) and greater magnitude of significant refractive errors (myopia, hyperopia, astigmatism, and anisometropia; P < 0.00001 for each) were associated independently with an increased risk of unilateral amblyopia. Presence of strabismus, hyperopia of 2.0 diopters (D) or more, astigmatism of 1.0 D or more, or anisometropia of 0.5 D or more were present in 91% of children with unilateral amblyopia. Greater magnitude of astigmatism (P < 0.0001) and bilateral hyperopia (P < 0.0001) were associated independently with increased risk of bilateral amblyopia. Bilateral hyperopia of 3.0 D or more or astigmatism of 1.0 D or more were present in 76% of children with bilateral amblyopia.Conclusions: Strabismus and significant refractive errors were risk factors for unilateral amblyopia. Bilateral astigmatism and bilateral hyperopia were risk factors for bilateral amblyopia. Despite differences in selection of the study population, these results validated the findings from the Multi-Ethnic Pediatric Eye Disease Study and Baltimore Pediatric Eye Disease Study.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Defects of the Lamina Cribrosa in Eyes with Localized Retinal Nerve Fiber Layer Loss – Corrected Proof

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Objective: To determine whether focal abnormalities of the lamina cribrosa (LC) are present in glaucomatous eyes with localized retinal nerve fiber layer (RNFL) defects.Design: Cross-sectional, observational study.Participants: We analyzed 20 eyes of 14 subjects with localized RNFL defects detected by masked grading of stereophotographs and 40 eyes of 25 age-matched healthy subjects recruited from the Diagnostic Innovations in Glaucoma Study at the University of California, San Diego.Methods: All eyes had stereoscopic optic disc photography and in vivo LC imaging using enhanced depth imaging optical coherence tomography (EDI-OCT). Two masked graders identified focal LC defects defined by a standardized protocol using 48 radial scan EDI-OCT images. The kappa coefficient was calculated as a measure of the reliability of interobserver agreement.Main Outcome Measures: The number of focal LC defects and the relationship between the location of LC defects and the location of localized RNFL defects.Results: Of 20 eyes with a localized RNFL defect, 15 (75%) had ≥1 LC defect compared with only 1 of 40 healthy eyes (3%). There were 13 eyes with localized RNFL defects that had 1 LC defect, 1 eye with 2 LC defects, and 1eye with 3 LC defects. The largest area LC defect was present in a radial line EDI-OCT scan corresponding with a localized RNFL defect in 13 of 15 eyes (87%). There was good agreement between graders as to whether an eye had an LC defect (kappa = 0.87; 95% confidence interval [CI], 0.73–1.00; P<0.001) and the location of the largest defect (kappa = 0.72; 95% CI, 0.44–1.00; P<0.001).Conclusions: Focal defects of the LC were frequently visible in glaucomatous eyes with localized RNFL defects. Focal abnormalities of the LC may be associated with focal retinal nerve fiber damage.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

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Intravitreal Aflibercept for Treatment-Resistant Neovascular Age-Related Macular Degeneration – Corrected Proof

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Objective: To assess the effectiveness of intravitreal aflibercept in patients with neovascular age-related macular degeneration (AMD) previously resistant to treatment with other anti–vascular endothelial growth factor agents.Design: Prospective, open-label, noncontrolled, registered clinical trial.Participants: Forty-nine patients with treatment-resistant neovascular AMD.Intervention: A dose of 2 mg intravitreal aflibercept was administered as 3 initial loading doses every 4 weeks (week 0, week 4, and week 8), followed by further injections every 8 weeks (weeks 16 and 24) across a 24-week period in total. All patients underwent a complete ophthalmic examination, including measurement of Early Treatment Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity (BCVA), intraocular pressure assessment, adverse event monitoring, and spectral-domain optical coherence tomography at every visit. Baseline fluorescein angiography and indocyanine green angiography also were performed.Main Outcome Measures: Outcomes assessed included proportions of patients with a gain or loss of more than 5 ETDRS letters and a decrease or increase in central retinal thickness (CRT) of more than 150 μm at week 24 compared with baseline, change in mean BCVA and CRT between baseline and week 24, and descriptive safety data.Results: The BCVA improved and CRT was reduced significantly at all follow-up visits compared with baseline (P < 0.001), with a mean improvement of 6.9 letters of BCVA and a decrease of 89.4 μm in CRT at week 24. Spacing of injections from every 4 weeks to 8 weeks resulted in an increase of 37.4 μm in CRT (P < 0.001); however, this was not correlated with a significant change in vision. There was 1 (2%) patient who lost more than 5 ETDRS letters, and 27 (55%) patients who gained more than 5 letters. Two (4%) patients had a more than 150 μm increase in CRT at week 24, and 10 (20%) patients showed a decrease in CRT of more than 150 μm.Conclusions: Intravitreal aflibercept is effective in previously treatment-resistant neovascular AMD. Further follow-up is required to determine whether these improvements can be maintained.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

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Assessment of the Quality of Glaucoma Referral Letters Based on a Survey of Glaucoma Specialists and a Glaucoma Guideline – Corrected Proof

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Objective: To assess the quality of glaucoma referral letters and to report on the results of a survey of glaucoma specialists about referral letter content.Design: Cross-sectional study.Participants: A survey of 135 glaucoma specialists and audit of 200 consecutive referral letters to a tertiary glaucoma unit.Methods: An online questionnaire was sent to members of the Canadian and American Glaucoma Societies asking what they considered the most important data to be included in a glaucoma referral. Consecutive referral letters to a tertiary glaucoma unit were assessed for legibility and content on the basis of the survey results and information items in current guidelines.Main Outcome Measures: Survey outcome and proportion of included content items in referral letters.Results: The survey revealed that the top 5 most important data that glaucoma specialists would like to be included in a referral letter for progressive glaucoma were serial visual fields (VFs), current glaucoma therapy, current intraocular pressure (IOP), maximum IOP, and serial disc imaging. These items often were omitted in the referral letters audited. A total of 200 referral letters were assessed, 46% from ophthalmologists, 42% from optometrists, 10% from family practitioners, and 2% from other sources. Reasons for referral were diagnosis of glaucoma (37%), unstable glaucoma (25%), angle assessment (17%), and others (21%). Some 26% of the referral letters were deemed illegible (18% from ophthalmologists vs. 6% from optometrists; P < 0.01). Degree of urgency was mentioned in 27% of referrals. Optometrists were more likely than ophthalmologists to provide visual acuity (VA), IOP, refraction, and VFs (P < 0.01 for each). Some 24% of referrals for progression included more than 10 of the 14 information points suggested by the Canadian glaucoma guidelines, and 34% included fewer than 8 of the 14 points.Conclusions: Referral letters frequently did not include important information, with 34% of referral letters deemed substandard. Optometrist referrals were better than ophthalmologist referrals in terms of content and legibility. A checklist of clinical details for referring physicians is suggested, which includes maximum and current IOP, disc evaluation, serial VFs, and serial disc imaging.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Prognostic Factor Analysis of Vitrectomy for Retinal Detachment Associated with Myopic Macular Holes – Corrected Proof

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Purpose: To describe the anatomic and functional outcomes in a cohort of subjects undergoing vitrectomy for retinal detachment (RD) resulting from myopic macular hole (MH) and to analyze the prognostic and surgical factors predicting retinal reattachment and MH closure.Design: Retrospective case series.Participants: All patients who underwent vitrectomy for RD resulting from myopic MH between 2000 and 2009 at our center.Methods: Case records were reviewed at 6 months after surgery. Retinal reattachment and complete anatomic success, defined as retinal reattachment with MH closure, were assessed. Multivariate logistic regression models, including age, gender, duration of symptoms, spherical equivalent refraction (SE), internal limiting membrane peeling, tamponade choice, and concurrent scleral buckling, were constructed to assess associations with covariates.Main Outcome Measures: Retinal reattachment and complete anatomic success (retinal reattachment with MH closure).Results: In total, 114 subjects were analyzed. Most were women (n = 79 [69.3%]), and the mean age was 57.5±13.3 years. The mean SE was −9.88±6.37 diopters. At 6 months, 98 subjects (86.0%) demonstrated retinal reattachment, of whom 93 subjects required only 1 operation. Complete anatomic success was achieved in 61 subjects (53.5%), of whom 55 needed only 1 operation. Subjects with retinal reattachment had better best-corrected visual acuity (BCVA; mean BCVA, 1.22±0.81 logarithm of the minimum angle of resolution [logMAR] units) than those without (mean BCVA, 1.98±1.26 logMAR units; P < 0.001), and subjects with complete anatomic success had better BCVA (mean BCVA, 1.05±0.87 logMAR units) than those without (mean BCVA, 1.62±0.87 logMAR units; P < 0.001). In multivariate analyses, increasing age and the use of perfluoropropane (C3F8) tamponade were predictive of anatomic success (per 1-year increase: odds ratio [OR], 1.049; 95% confidence interval [CI], 1.002–1.099; P = 0.04; and for tamponade: OR, 10.71; 95% CI, 1.08–106.29; P = 0.04).Conclusions: Vitrectomy is effective in the repair of RD resulting from MH in myopic eyes, with retinal reattachment achieved more frequently than MH closure. Retinal reattachment and MH closure are important for improving visual outcomes. Greater age at presentation and use of C3F8 are associated with a greater likelihood of anatomic success.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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