Category: Peer-reviewed

In Vivo Imaging of Cortical Vitreous Using 1050-nm Swept-Source Deep Range Imaging Optical Coherence Tomography

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Purpose: To image the cortical vitreous, determine the prevalence of the bursa premacularis and space of Martegiani, and measure the dimensions of the bursa using the new 1050-nm swept-source deep range imaging optical coherence tomography (DRI OCT-1 Atlantis).Design: Retrospective cross-sectional study.Methods: One hundred and nineteen consecutive patients (5-100 years) underwent an OCT scan using 1050-nm swept-source deep range imaging optical coherence tomography. Prevalence of the bursa premacularis and space of Martegiani and the stage of posterior vitreous detachment (PVD) were determined. The horizontal (width) and anteroposterior (depth) dimensions of the bursa were recorded along with the patient’s age.Results: A bursa was detected in 57.1% (136/238) of eyes. The bursa and space of Martegiani coexisted in 97.8% of eyes. Prevalence of detected bursa was 84.5% in eyes with either no PVD or perifoveal PVD only; the prevalence fell with further increases in the extent of PVD. Prevalence of detected bursa was 75.4% in patient group aged 0-60 years and 38% in the group aged 60-100 years. Mean width was 7001 μm (range: 3354-10 316 μm, SD: 1412 μm). Mean depth was 416 μm (range: 31-1189 μm, SD: 187 μm). Width and depth of the bursa did not correlate with age (R2 width = 0.0316; R2 depth = 0.0108). Bilateral bursa tended to be symmetrical in width but less so in depth (R2 width = 0.63, P < .001; R2 depth = 0.33, P < .001).Conclusion: Swept-source OCT has allowed us to demonstrate the almost invariable coexistence of the bursa premacularis and space of Martegiani. Swept-source OCT can image both in patients from as early as the first to as late as the tenth decade of life.

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In Vitro Susceptibility of Filamentous Fungal Isolates From a Corneal Ulcer Clinical Trial

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Purpose: To describe the minimum inhibitory concentration (MIC) of fungal isolates to natamycin and voriconazole, and to compare these MICs to previous ocular susceptibility studies.Design: Experimental laboratory study using isolates from a randomized clinical trial.Methods: The Mycotic Ulcer Treatment Trial I was a randomized, double-masked, multicenter trial comparing topical natamycin and voriconazole for fungal keratitis treatment. Susceptibility testing to natamycin and voriconazole were performed according to Clinical and Laboratory Standards Institute methods. The relationship between organism and MIC was assessed. A literature review was performed to compare results to previous ocular susceptibility studies.Results: Of the 323 patients enrolled in the trial, MICs were available for 221 (68%). Fusarium (n = 126) and Aspergillus species (n = 52) were the most commonly isolated organisms. MICs to natamycin and voriconazole were significantly different across all genera (P < .001). The MIC median (MIC50) and 90th percentile (MIC90) for natamycin were equal to or higher than voriconazole for all organisms except Curvularia species. Compared to other organisms, Fusarium species isolates had the highest MICs to voriconazole and Aspergillus flavus isolates had the highest MICs to natamycin. Our results were similar to previous reports except that the voriconazole MIC90 against Aspergillus species was 2-fold higher and the natamycin MIC90 against Aspergillus fumigatus was 4-fold higher in our study.Conclusion: In this large susceptibility study, Fusarium isolates were least susceptible to voriconazole and A flavus isolates were least susceptible to natamycin when compared to other filamentous fungi. In the future, susceptibility testing may help guide therapy if performed in a timely manner.

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Spinoza as an Optician

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Baruch Spinoza (1632-1677), famous as a philosopher and pillar of the rational Enlightenment, for many years actually earned his living as a maker of telescopic lenses. He was knowledgeable about all the contemporary ideas about the physics of light an…

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Outcomes of Macular Hole Surgery with Short-Duration Positioning in Highly Myopic Eyes: A Case-Control Study – Corrected Proof

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Purpose: To evaluate the outcomes of macular hole (MH) surgery with 3-day prone positioning in highly myopic eyes and to compare them with those from non–highly myopic eyes.Design: Retrospective nested case-control study from a cohort of 496 consecutive patients (496 eyes) who underwent surgery for MH.Participants: Forty-seven highly myopic eyes (with axial length >26 mm) were included in the study group and were matched for MH size and duration of symptoms with 47 non–highly myopic control eyes selected from the same cohort.Methods: All patients underwent pars plana vitrectomy, internal limiting membrane peeling, and 17% hexafluoroethane gas filling. Patients then were advised to maintain strict face-down positioning for 3 days only and to avoid the supine position during the night for a minimum of 1 week.Main Outcome Measures: The MH closure rate, the relationship between axial length and closure rate, the best-corrected visual acuity (BCVA), and the surgical complications were analyzed.Results: The mean axial length was 28.5±2.2 mm in highly myopic eyes and 23.3±1.1 mm in controls (P < 0.001). Closure of the MH was achieved in 39 of 47 eyes (83%) in the study group and in 45 of 47 eyes (95.7%) in the control group (P = 0.045). Anatomic outcomes tended to decrease when axial length increased (P = 0.066). Mean BCVA improved in both groups (0.41±0.39 logarithm of the minimal angle of resolution [logMAR] vs. 0.68±0.34 logMAR) but was significantly lower in highly myopic eyes (P < 0.001). Retinal detachment occurred in 8.5% of highly myopic patients versus 2.1% of controls, but the difference was not significant.Conclusions: Macular hole surgery with 3-day postoperative positioning in highly myopic eyes resulted in satisfactory anatomic and functional outcomes. However, the MH closure rate and mean improvement of visual acuity were less favorable than those in control eyes. Longer axial length may increase the risk of anatomic failure.

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The Use of Bowman’s Layer Vertical Topographic Thickness Map in the Diagnosis of Keratoconus – Corrected Proof

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Purpose: To evaluate the use of Bowman’s layer (BL) vertical topographic thickness maps in diagnosing keratoconus (KC).Design: Prospective, case control, interventional case series.Participants: A total of 42 eyes: 22 eyes of 15 normal subjects and 20 eyes of 15 patients with KC.Intervention: Bowman’s layer 2-dimensional 9-mm vertical topographic thickness maps were created using custom-made ultra high-resolution optical coherence tomography.Main Outcome Measures: Bowman’s layer average and minimum thicknesses of the inferior half of the cornea, Bowman’s ectasia index (BEI; defined as BL minimum thickness of the inferior half of the cornea divided by BL average thickness of the superior half of the cornea multiplied by 100), BEI-Max (defined as BL minimum thickness of the inferior half of the cornea divided by BL maximum thickness of the superior half of the cornea multiplied by 100), keratometric astigmatism (Ast-K) of patients with KC, and average keratometric (Avg-K) readings.Results: In patients with KC, BL vertical thickness maps disclosed localized relative inferior thinning of the BL. Inferior BL average thickness (normal = 15±2, KC = 12±3 μm), inferior BL minimum thickness (normal = 13±2, KC = 7±3 μm), BEI (normal = 91±7, KC = 48±14), and BEI-Max (normal = 75±8; KC = 40±13) all showed highly significant differences in KC compared with normal subjects (P < 0.001). Receiver operating characteristic (ROC) curve analysis showed excellent predictive accuracy for BEI and BEI-Max with 100% sensitivity and specificity (area under the curve [AUC] of 1) with cutoff values of 80 and 60, respectively. The AUC of inferior BL average thickness and minimum thickness were 0.87 and 0.96 with a sensitivity of 80% and 93%, respectively, and a specificity of 93% and 93%, respectively. Inferior BL average thickness, inferior BL minimum thickness, BEI, and BEI-Max correlated highly to Ast-K (R = −0.72, −0.82, −0.84, and −0.82, respectively; P < 0.001) and to Avg-K (R = −0.62, P < 0.001; R = −0.59, P = 0.001; R = −0.60, P < 0.001; and R = −0.59, P = 0.001, respectively).Conclusions: Bowman’s layer vertical topographic thickness maps of patients with KC disclose characteristic localized relative inferior thinning. Inferior BL average thickness, inferior BL minimum thickness, BEI, and BEI-Max are qualitative and quantitative indices for the diagnosis of KC that accurately correlate with the severity of KC. In our pilot study, BEI and BEI-Max showed excellent accuracy, sensitivity, and specificity in the diagnosis of KC.

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Author reply – Corrected Proof

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First, We really appreciate Huisingh and McGwin’s interest in our recent publication regarding the study of suppression in patients with anisometropic amblyopia. However, the concerns they raise in their recent correspondence are not directly relevant to our study. The aim of our study was not to measure suppression before and after occlusion therapy. Rather, measurements of suppression, stereopsis, and visual acuity were made in observers with amblyopia (cases) and age-matched observers without amblyopia (controls). For a number of measurements, visual acuity was decreased in the nondominant eye of each control using optical defocus so that it matched the amblyopic eye visual acuity of the case with whom they were paired. In addition, suppression was simulated in controls using neutral density filters. We also examined the relationships between acuity, stereopsis, and suppression in observers with amblyopia and explored the acute effects of spectacle and rigid gas-permeable contact lens correction on suppression in a specified subset of 19 cases (Figure 4 in our original paper). Once the case-control phase of the study was complete, 26 cases had subsequently received occlusion therapy combined with spectacle correction as part of their standard clinical care. Measurements of amblyopic eye visual acuity made at the first follow-up visit after treatment initiation were available for these cases. It has previously been reported that pretreatment measurements of suppression may be related to the outcomes of occlusion therapy, whereby stronger pretherapy suppression is associated with a poorer response to therapy. We therefore investigated whether a similar effect was present in the subset of our cases who had received treatment. We found that cases whose treatment had resulted in an amblyopic eye visual acuity improvement of <0.2 logarithm of the minimum angle of resolution had significantly stronger pretreatment suppression than those whose treatment was considered successful (>0.2 logarithm of the minimum angle of resolution acuity improvement). Detailed descriptions of the experimental design and analyses outlined are provided in our original manuscript.

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Refractive Changes after Pharmacologic Resolution of Diabetic Macular Edema – Corrected Proof

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Purpose: To determine precisely the mean change in refractive power induced by treatment in patients with diabetic macular edema (DME).Design: Prospective, randomized study.Participants: Fifty eyes of 50 consecutive patients with clinically significant macular edema receiving all 3 types of current state-of-the-art treatment with intravitreal antiedematous substances (ranibizumab, bevacizumab, or triamcinolone).Methods: Patients were followed up at monthly intervals and were treated following a standardized pro re nata regimen according to protocol. Best-corrected visual acuity (BCVA) was determined by certified visual acuity examiners. The refractive power of the treated eyes was determined using a push-plus technique. The change in refraction between baseline and the visit when the macula was completely dry or when the central subfield thickness (CST) measured by optical coherence tomography had reached the thinnest level was analyzed.Main Outcome Measures: Spherical equivalent refraction (SER) and CST.Results: Fifty eyes of 50 patients received intravitreal therapy using ranibizumab (n = 11), bevacizumab (n = 20), or triamcinolone (n = 19). Mean BCVA was 0.33±0.23 logarithm of the minimum angle of resolution (logMAR) and mean CST was 492±130 μm. The mean SER was 0.41±2.06 diopters (D) at baseline. The BCVA at the time of optimal retinal morphologic features was 0.24±0.2 logMAR, mean CST was 300±78 μm, and mean change in SER was −0.01±0.46 D. Changes is BCVA and CST were statistically significant (P < 0.0001), but the SER change was not (P = 0.824).Conclusions: Appropriate spectacle correction can be prescribed to patients with DME any time during ongoing therapy using antiedematous substances because resolution of retinal thickening is not associated with an increased risk of a myopic shift.

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Spontaneous resolution of vitreomacular traction demonstrated by spectral-domain optical coherence tomography – Accepted Manuscript

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Abstract: Purpose: To evaluate the natural course of idiopathic vitreomacular traction (VMT) with spectral-domain optical coherence tomography (SDOCT) from the vitreomacular adhesion (VMA) stage to the spontaneous resolution of VMT.Design: Prospective observational case series.Methods: We studied the natural course of idiopathic VMT in 46 eyes (46 patients) divided into those that proceeded to spontaneous VMT resolution (12 cases) and those that remained at the VMT stage (34 cases). All patients were examined with SDOCT at regular three-monthly intervals. We recorded the vitreomacular angle of VMA nasally and temporally, the horizontal diameter of VMA, macular thickness, visual acuity, photoreceptor layer, and external limiting membrane.Results: In the 12 eyes that proceeded to spontaneous resolution, the vitreous adhesion angle had a mean increase of 38° at VMT, compared to the angle at the VMA stage. In the 34 eyes that remained at the VMT stage, the mean angle of traction increased by only 1° throughout follow-up. In all 46 patients, the angle at the VMT stage was significantly associated with traction resolution (nasally P = 0.001, temporally P < 0.001). The likelihood of resolution was more than 99% lower for patients with a VMT diameter > 400 μm compared with that of eyes with a VMT diameter < 400 μm. Patients with broad-type VMT remained at the same stage, whereas patients with V-type VMT had 80% probability of resolution.Conclusions: Spontaneous VMT resolution is negatively associated with the horizontal adhesion diameter. The strength of the traction exerted by the vitreous on the fovea seems to be positively related to the size of the vitreomacular angle.

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Alcohol Use and Positive Screening Results for Depression and Anxiety Are Highly Prevalent among Chinese Children with Strabismus – Accepted Manuscript

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Abstract: Purpose: To study associations between strabismus and alcohol use, anxiety and depression among 10-17-year-old children in Guangdong, southern China.Design: Cross-sectional, population-based studyMethods: Among 7537 children aged 6 to 17 years from 9 randomly-selected primary and middle schools, ocular alignment was assessed with the Hirschberg light reflex, cover-uncover testing, and alternate cover testing at distance (6 m) and near (40cm). Additionally, 4000 children (53.1%) aged 10+ years received self-administered questionnaires containing screening questions on alcohol use, anxiety and depression.Results: Examinations were completed on 7,464 of 7,537 subjects (99.0%), including 3,928 (52.6%) boys, with a mean age of 11.1±1.8 years. The prevalence of any strabismus, including exotropia (2.7%), esotropia (0.2%), and intermittent exotropia (3.9%), was 6.8%. Strabismus was more prevalent in urban students (7.3%) and females (7.4%) compared to rural students (6.0%) and males (6.2%) (all P < .05). In multivariate regression models, any strabismus was associated with older age and rural versus urban residence. Among 3903 (97.6%) children answering questionnaires, history of alcohol use (62.3% versus 36.3%) and positive screening responses for depression (26.0% versus 11.6%) and anxiety (10.3% versus 4.9%) were significantly (P < .01 for all) more common among children with strabismus.Conclusion: These Chinese children with strabismus had significantly higher prevalence of alcohol use and possible markers of emotional problems than children without strabismus. Further research should focus on the appropriateness of classifying surgical treatment for strabismus as "cosmetic" (ineligible for reimbursement) under China’s rural health insurance.

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Multiple subretinal fluid blebs after successful retinal detachment surgery: Incidence, risk factors, and presumed pathophysiology – Accepted Manuscript

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Abstract: Purpose: To investigate the incidence and the clinical factors associated with the occurrence of multiple subretinal fluid (SRF) blebs after successful rhegmatogenous retinal detachment (RD) repair.Design: Retrospective, observational case seriesMethods: We retrospectively investigated the medical records of 185 eyes of 184 patients who had undergone successful RD surgery either vitrectomy or scleral buckling. Each patient had undergone spectral domain optical coherence tomography (SD-OCT) combined with infrared reflectance (IR) imaging every 3 months postoperatively. We carefully examined postoperative SD-OCT and fundus IR images, in an effort to identify any SRF blebs present.Results: Multiple (≥3) SRF blebs were observed in 40 (21.6%) of 185 cases. SRF blebs were first detected 1.7 ± 1.8 months postoperatively. In 22 cases which could be fully followed up, SRF blebs were completely absorbed 13.1 ± 6.1 months postoperatively. Multiple logistic regression analysis showed that only young age (<30 years) was significantly associated with the occurrence of multiple SRF blebs (odds ratio, 5.1; 95% confidence interval, 1.5–17.6; p = 0.010). Serial measurements of SRF bleb size using SD-OCT showed that SRF bleb height was greatest at postoperative 2.9 ± 0.9 months, while SRF bleb width tended to decrease gradually over time. The SRF blebs typically spared large retinal vessels.Conclusions: Multiple SRF blebs are commonly found after successful RD surgery, especially in young patients. The serial morphological features evaluated in this study indicate that multiple SRF blebs may result from the active reattachment of retinal pigment epithelium and photoreceptors during the resolution of RD.

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Clinical and Spectral-Domain Optical Coherence Tomography Findings in Patients with Focal Choroidal Excavation – Corrected Proof

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Objective: To describe the clinical and spectral-domain optical coherence tomography (SD-OCT) findings in patients with focal choroidal excavation (FCE).Design: Retrospective case series.Participants: Forty-one eyes of 38 patients with FCE identified in 2 tertiary medical centers in Korea.Methods: Clinical features, SD-OCT findings, and associated macular disorders of FCE were analyzed and detailed.Main Outcome Measures: Statistical associations among clinical features, including lesion type, size, and choroidal thickness, and frequency of association with central serous chorioretinopathy (CSC), choroidal neovascularization (CNV), and polypoidal choroidal vasculopathy (PCV).Results: Mean patient age was 50.1 years (range, 25–76 years). The mean spherical equivalent of refractive error was −3.7 diopters (range, −10.0 to +1.5 diopters). Three patients (8%) had bilateral lesions, and 1 patient (3%) had 2 distinct lesions in the same eye. The mean FCE width and depth were 757 μm and 107 μm, respectively, with a positive correlation between width and depth (P = 0.003). The mean subfoveal choroidal thickness of FCE eyes was 284 μm, which was not statistically different from that of age-, sex-, and refractive error–matched normal subjects. Choroidal thickness in FCE was less in eyes with hyperreflective choroidal tissue under the excavation that was present in 22 eyes (54%) versus eyes without excavation (128 vs. 190 μm, respectively; P = 0.009). Twelve FCEs (29%) were the nonconforming type, revealing separation between the photoreceptor tips and the retinal pigment epithelium on SD-OCT. Nonconforming FCE was associated with visual symptoms (P < 0.001) and the presence of concurrent CSC (P = 0.001). Ten eyes (24%) were associated with CSC, and 9 eyes (22%) were associated with CNV, including 1 eye with PCV features. One eye with FCE and type 1 CNV developed a new excavation, and the excavated area in 1 eye with PCV enlarged slightly during follow-up.Conclusions: Focal choroidal excavation is a relatively common entity and frequently associated with choroidal diseases, including CSC, CNV, and PCV. Although FCE is classically thought to be a congenital malformation, acquired FCE forms possibly exist.

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Qualitative and Quantitative Characteristics of Near-Infrared Autofluorescence in Diabetic Macular Edema – Corrected Proof

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Objective: To study the characteristics of near-infrared autofluorescence (NIR-AF) imaging and its association with spectral-domain optical coherence tomography (SD-OCT) findings and logarithm of the minimal angle of resolution (logMAR) visual acuity (VA) in diabetic macular edema (DME).Design: Retrospective, observational, cross-sectional study.Participants: One hundred twenty-one consecutive eyes of 87 patients with center-involved DME for whom NIR-AF and SD-OCT images of sufficient quality were obtained.Methods: The NIR-AF images were acquired using Heidelberg Retina Angiograph 2 (Heidelberg Engineering, Heidelberg, Germany), and sectional retinal images were obtained using Spectralis OCT (Heidelberg Engineering). The presence of a mosaic pattern and cystoid signs were determined qualitatively. We quantified the average fluorescence intensity in the central 1-mm subfield. The characteristics of the NIR-AF images were compared with the OCT findings and logMAR VA.Main Outcome Measures: Qualitative and quantitative characteristics of the NIR-AF images and their association with SD-OCT findings and logMAR VA.Results: Fifty-seven eyes with a mosaic pattern in the NIR-AF macular images had worse logMAR VA (0.355±0.239 vs. 0.212±0.235; P = 0.001), a thicker central subfield (CSF) (530±143 μm vs. 438±105 μm; P < 0.001), and disrupted external limiting membrane (ELM; P < 0.001) compared with 64 eyes without these findings. Forty-one eyes with a cystoid sign in the NIR-AF images had worse logMAR VA (0.393±0.233 vs. 0.221±0.234; P < 0.001) and a thicker CSF (557±155 μm vs. 443±100 μm; P < 0.001) than those without them; there were no significant differences in the ELM status. The relative fluorescence intensity in the central subfield in the NIR-AF images was correlated negatively with the CSF thickness and logMAR VA (R = 0.492, P < 0.001 and R = 0.377, P < 0.001, respectively). Eyes with foveal serous retinal detachment had lower levels of relative fluorescence intensity than those without it (0.751±0.191 vs. 0.877±0.154; P = 0.007); there was no association with the presence of foveal cystoid spaces, disrupted ELM, or hyperreflective foci in the outer retinal layers.Conclusions: Novel qualitative and quantitative NIR-AF characteristics in the macula indicated the clinical relevance and suggested the pathogenesis in DME.

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