We are grateful to Dr. Hwang for providing lucid remarks on the potential instability of Bruch’s membrane opening (BMO) in myopic eyes. We have argued that the BMO is a true anatomic border from which neuroretinal rim measurements can be made; howeve…
Category: Peer-reviewed
Detection of Glaucoma with an Optical Coherence Tomography-derived Neuroretinal Rim Parameter
I have read with great interest the article entitled “Enhanced detection of open-angle glaucoma with an anatomically accurate optical coherence tomography-derived neuroretinal rim parameter” by Chauhan et al, and I congratulate the authors for the…
Reporting Visual Acuities
The AJO encourages authors to report the visual acuity in the manuscript using the same nomenclature that was used in gathering the data provided they were recorded in one of the methods listed here. This table of equivalent visual acuities is provided…
The Effect of Prior Trabeculectomy on Refractive Outcomes of Cataract Surgery
We read with great interest the article titled The Effect of Prior Trabeculectomy on Refractive Outcomes of Cataract Surgery by Zhang and associates. We applaud the authors for highlighting the issue of refractive surprises following cataract surgery i…
Inadvertent Trypan Blue Posterior Capsule Staining during Cataract Surgery
The article by Burkholder and associates is a useful addition to the literature in that it highlights the relatively uncommon complication of inadvertent trypan blue staining of the posterior capsule and adds to the list of risk factors (that includes …
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We appreciate the interest of Shah and colleagues in our recent article. They have made some excellent suggestions regarding our study and its application in clinical practice. They point out, as we did in our original study, that contact ultrasonic me…
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We thank Dr Coroneo for the comments and interest in our article. We agree that if the posterior capsule is stained with trypan blue, completion of the surgery, although more difficult, can still be performed successfully, and we believe it is importan…
Pterygium: Techniques and Technologies for Surgical Succes
Media Type: Textbook Synopsis: This textbook provides a comprehensive, yet concise, review of the current understanding of pterygia and existing treatment options. It is a clear, well-written account, highlighted with excellent figures that help illu…
The Effect of Phacoemulsification on Intraocular Pressure in Medically Controlled Open-Angle Glaucoma Patients – Corrected Proof
Purpose: To evaluate intraocular pressure (IOP) after phacoemulsification in patients with medically controlled open-angle glaucoma (OAG), and examine the association of biometric variables to IOP changes.Design: Retrospective case series.Methods: Open-angle glaucoma patients without prior incisional glaucoma surgery undergoing phacoemulsification by a single surgeon between January 1997 and October 2011 were evaluated. Patient charts were reviewed to obtain demographic information, preoperative glaucoma medications, severity and treatment measures, and preoperative and postoperative IOP.Results: A total of 157 eyes (157 patients) were included in the study. The average preoperative IOP of 16.3 ± 3.6 mm Hg decreased to 14.5 ± 3.4 mm Hg at 1 year (P < .001). Sixty eyes (38%) required additional medications or laser for IOP control within the first year postoperatively, or had a higher IOP at postoperative year 1 without medication change. Among eyes without postoperative medication changes (n = 102), higher preoperative IOP (P < .001), older age (P = .006), and deeper anterior chamber depth (P = .015) were associated with lower postoperative IOP.Conclusions: Phacoemulsification resulted in a small average decrease in IOP in patients with OAG. A sizeable proportion of medically controlled glaucoma patients with open angles undergoing phacoemulsification experienced an increase in IOP or required more aggressive treatment to control IOP postoperatively.
Risk Factors Associated With Night Vision Disturbances After Phakic Intraocular Lens Implantation – Corrected Proof
Purpose: To investigate the incidence and severity of night vision disturbances after implantable collamer lens surgery and to analyze the risk factors.Design: Retrospective, noncomparative study.Methods: Medical charts from 50 eyes of 25 patients who …
A 5-Year Audit of Cataract Surgery Outcomes After Posterior Capsule Rupture and Risk Factors Affecting Visual Acuity – Corrected Proof
Purpose: To describe the posterior capsule rupture rates and visual outcomes after phacoemulsification, analyze risk factors for poor vision, and compare results of faculty (F) and residents (R).Design: Retrospective audit study.Methods: Visual success of all capsule ruptures (2006-2010) was analyzed and compared to uneventful cases. Rupture rates of faculty and residents were compared (χ², P < .05). Success was defined as % best-corrected visual acuity (BCVA) ≥20/40 at 3 months (excluding poor-prognosis eyes) and studied in relation to age, sex, surgeon type, stage of surgery, vitreous loss, dropped nucleus, and other complications (eg, retinal detachment, corneal decompensation, dislocated intraocular lens [IOL]). Final risk factors were identified using multivariate logistic regression analysis.Results: From 2006 to 2010, there were 887 capsule ruptures in 48 377 phacoemulsification cases (rate 1.8%). Uneventful cases had significantly better visual outcomes than capsule ruptures (98.5% vs 93.9%; P < .01). Faculty rupture rates were lower (F = 1.4%) than residents’ (R = 3.4%; P < .01), but visual outcomes were similar (F = 93.8%, R = 93.7%; P > .05). Ruptures most frequently occurred during phacoemulsification (59.6%) and irrigation and aspiration (24.8%) stages. Risk factors for poor outcomes included age >65 years, dropped nuclei, and other complications.Conclusion: The overall capsule rupture rate was 1.8%. Although residents had higher rates, visual success matched faculty’s, possibly attributable to case mix and close supervision. Associated risk factors for poor vision included age >65 years, dropped nuclei, and postoperative retinal, corneal, and IOL complications.
Indications and Outcomes of Intraocular Lens Exchange During a Recent 5-Year Period – Corrected Proof
Purpose: To analyze and classify the indications, clinical presentations, and surgical outcomes of intraocular lens (IOL) exchange performed in a recent 5-year period.Design: Retrospective, interventional case series.Methods: setting: Private clinical practice. study population: Chart records of 57 eyes of 53 consecutive patients who had undergone IOL exchange between May 2007 and December 2011 were reviewed. observation procedures and main outcome measures: The preoperative clinical characteristics, treatment parameters, intraoperative and postoperative complications, and pre- and postoperative logarithm of the minimal angle of resolution (logMAR) best-corrected visual acuity (BCVA) were recorded and analyzed.Results: IOL dislocation (46%), incorrect IOL power (23%), patient dissatisfaction (21%), and optic opacification (7%) were the most common indications for IOL exchange. In the IOL dislocation group, posterior capsule opening presented in 57% of eyes (8/14) with in-the-bag dislocation. Of the dissatisfaction patients, 42% (5/11) had undesired visual acuity without symptoms of glare/optical aberrations. Surface calcification of silicone lenses associated with asteroid hyalosis accounted for the most cases (3/4) of optic opacification. Overall, the mean logMAR BCVA improved significantly (P < .001) and 88% of all eyes were 20/40 or better, including 73% in the IOL dislocation group and 100% in all other groups. No vision-threatening complications occurred in this series.Conclusions: The request for IOL exchange owing to patient dissatisfaction is increasing, especially for those with undesired visual acuity in the absence of photic symptoms. Surface calcification of silicone lenses suggests that this type of lens is not appropriate in the presence of asteroid hyalosis. Optimal visual results with a low rate of complications can be achieved in each category of indication. The findings of the study may stimulate discussion of a question: Does in-the-bag IOL dislocation occur only in eyes with an intact posterior capsule?
The Diurnal and Nocturnal Effect of Travoprost With SofZia on Intraocular Pressure and Ocular Perfusion Pressure – Corrected Proof
Purpose: To determine the 24-hour effects of travoprost with sofZia on intraocular pressure (IOP) and ocular perfusion pressure as well as the endurance of IOP lowering after last dosing.Design: Prospective, open-label study.Methods: Forty subjects with open-angle glaucoma or ocular hypertension were admitted to our sleep laboratory for three 24-hour sessions monitoring IOP, blood pressure (BP), and heart rate. The first baseline session occurred after medication washout or immediately after enrollment for treatment-naïve patients. A second 24-hour monitoring session was performed after 4 weeks of once-nightly treatment of travoprost with sofZia. The medication was then discontinued and a third 24-hour session was completed 60-84 hours after the last dose taken. IOP measurements were taken using a pneumotonometer every 2 hours in the sitting position during the 16-hour diurnal period and in the supine position during the 8-hour nocturnal period. Ocular perfusion pressure was defined as 2/3[diastolic BP + 1/3(systolic BP − diastolic BP)] − IOP.Results: Treatment with travoprost with sofZia significantly lowered mean diurnal and nocturnal IOP levels from baseline (diurnal 18.1 ± 3.9 to 15.3 ± 3.3 mm Hg; nocturnal 20.6 ± 3.6 to 19.4 ± 3.4 mm Hg, P < .01 for both). Once treatment was discontinued, mean IOP remained at levels significantly less than baseline during both the diurnal (16.6 ± 3.8 mm Hg) and nocturnal periods (19.4 ± 3.5 mm Hg). Mean baseline ocular perfusion pressure was significantly increased during the diurnal but not the nocturnal period (diurnal 73.7 ± 11.4 to 76.5 ± 10.3 mm Hg, P = .01; nocturnal 64.4 ± 12.6 to 64.2 ± 11.1 mm Hg, P = .67).Conclusion: Travoprost with sofZia significantly lowers IOP throughout the diurnal and nocturnal periods, and increases ocular perfusion pressure in the diurnal, but not the nocturnal, period in open-angle glaucoma and ocular hypertension. The treatment effect on IOP endures for at least 84 hours after the last dose.
In Vivo Confocal Microscopy Analyses of Corneal Microstructural Changes in a Prospective Study of Collagen Cross-linking in Keratoconus – Corrected Proof
Purpose: To use in vivo confocal microscopy (IVCM) to quantitatively analyze microstructural changes over time, after corneal collagen cross-linking for keratoconus.Design: Prospective cohort study.Participants: A total of 38 eyes of 38 patients undergoing collagen cross-linking for keratoconus.Methods: Prospective, clinical cohort study of corneal collagen cross-linking in progressive keratoconus. Laser scanning IVCM performed preoperatively and at 1, 3, 6, and 12 months postoperatively.Main Outcome Measures: Density of corneal sub-basal nerves, anterior and posterior keratocytes, and corneal endothelium.Results: Compared with baseline values, the mean sub-basal nerve density decreased significantly at 1, 3, and 6 months postoperatively (P < 0.01); however, this returned to preoperative values at 12 months (P = 0.57). One month postoperatively, there was complete absence of keratocyte nuclei in 86% of corneas. Anterior stromal edema with hyper-reflective cytoplasm and extracellular lacunae in a honeycomb-like appearance was observed and persisted at 3 months postoperatively. Scattered, presumed fragmented keratocyte nuclei, were observed at 1 and 3 months, but by 6 months, keratocyte repopulation of the anterior stroma was apparent. Quantitative analysis confirmed a significant decrease in the mean anterior keratocyte density 1, 3, and 6 months postoperatively (P ≤ 0.01) with return to baseline values at 12 months postoperatively (P = 0.57). The demarcation between treated and untreated corneal stroma appeared as a region where normal keratocytes transitioned into elongated, hyper-reflective, needle-like structures and then into large hyper-reflective stromal bands. There was no significant change in posterior keratocyte density or endothelial density at any postoperative time point.Conclusions: This prospective IVCM study revealed complete loss of the sub-basal nerve plexus and loss of anterior stromal keratocytes in the early postoperative period, with complete regeneration of the sub-basal nerve plexus and keratocyte repopulation by 12 months postoperatively. The posterior stroma and corneal endothelium were unaffected.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.
Assessing the Cone Photoreceptor Mosaic in Eyes with Pseudodrusen and Soft Drusen In Vivo Using Adaptive Optics Imaging – Corrected Proof
Purpose: To investigate the cone photoreceptor mosaic in eyes with pseudodrusen as evidenced by the presence of subretinal drusenoid deposits (SDD) and conventional drusen using adaptive optics (AO) imaging integrated into a multimodal imaging approach.Design: Observational case series.Participants: Eleven patients (11 eyes) with pseudodrusen and 6 patients (11 eyes) with conventional drusen.Methods: Consecutive patients were examined using near-infrared reflectance (IR) confocal scanning laser ophthalmoscopy (SLO) and eye-tracked spectral-domain optical coherence tomography (SD-OCT) and flood-illuminated retinal AO camera of nonconfluent pseudodrusen or conventional drusen. Correlations were made between the IR-SLO, SD-OCT, and AO images. Cone density analysis was performed on AO images within 50 × 50-μm windows in 5 regions of interest overlying and in 5 located between SDD or conventional drusen with the same retinal eccentricity.Main Outcome Measures: Cone densities in the regions of interest.Results: The pseudodrusen correlated with subretinal accumulations of material in SD-OCT imaging and this was confirmed in the AO images. Defects in the overlying ellipsoid zone band as seen by SD-OCT were associated with SDD but not conventional drusen. The mean ± standard deviation cone density was 8964±2793 cones/mm² between the SDD and 863±388 cones/mm² over the SDD, a 90.4% numerical reduction. By comparison the mean cone packing density was 9838±3723 cones/mm² on conventional drusen and 12 595±3323) cones/mm² between them, a 21.9% numerical reduction. The difference in cone density reduction between the two lesion types was highly significant (P < 0.001).Conclusions: The pseudodrusen in these eyes correlated with subretinal deposition of material in multiple imaging modalities. Reduced visibility of cones overlying SDD in the AO images can be because of several possible causes, including a change in their orientation, an alteration of their cellular architecture, or absence of the cones themselves. All of these explanations imply that decreased cone photoreceptor function is possible, suggesting that eyes with pseudodrusen appearance may experience decreased retinal function in age-related macular degeneration independent of choroidal neovascularization or retinal pigment epithelial atrophy.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.
Intraoperative Refractive Biometry for Predicting Intraocular Lens Power Calculation after Prior Myopic Refractive Surgery – Corrected Proof
Purpose: To evaluate a new method of intraoperative refractive biometry (IRB) for intraocular lens (IOL) power calculation in eyes undergoing cataract surgery after prior myopic LASIK or photorefractive keratectomy.Design: Retrospective consecutive cases series.Participants: We included 215 patients undergoing cataract surgery with a history of myopic LASIK or photorefractive keratectomy.Methods: Patients underwent IRB for IOL power estimation. The Optiwave Refractive Analysis (ORA) System wavefront aberrometer was used to obtain aphakic refractive measurements intraoperatively and then calculate the IOL power with a modified vergence formula obtained before refractive surgery. Comparative effectiveness analysis was done for IRB predictive accuracy of IOL power determination against 3 conventional clinical practice methods: surgeon best preoperative choice (determined by the surgeon using all available clinical data), the Haigis L, and the Shammas IOL formulas.Main Outcome Measures: Median absolute error of prediction and percentage of eyes within ±0.50 diopters (D) and ±1.00 D of refractive prediction error.Results: In 246 eyes (215 first eyes and 31 second eyes) IRB using ORA achieved the greatest predictive accuracy (P < 0.0001), with a median absolute error of 0.35 D and mean absolute error of 0.42 D. Sixty-seven percent of eyes were within ±0.5 D and 94% were within ±1.0 D of the IRB’s predicted outcome. This was significantly more accurate than the other preoperative methods: Median absolute error was 0.6, 0.53, and 0.51 D for surgeon best choice, Haigis L method, and Shammas method, respectively.Conclusions: The IOL power estimation in challenging eyes with prior LASIK/photorefractive keratectomy was most accurately predicted by IRB/ORA.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.
Corneal Topographic and Tomographic Analysis of Fellow Eyes in Unilateral Keratoconus Patients Using Pentacam – Corrected Proof
Purpose: To evaluate topographic and tomographic changes in fellow eyes in unilateral keratoconus (KCN) patients by comparing them with normal eyes.Design: Retrospective comparative case series.Methods: Fourteen eyes of 14 patients with unilateral KCN and 34 eyes of 34 refractive surgery candidates were divided into 3 diagnostic groups using a Pentacam rotating Scheimpflug camera: advanced KCN eyes of unilateral KCN (KCN group, 14 eyes), normal fellow eyes of unilateral KCN (fellow eye group, 14 eyes), and refractive surgery candidates (normal group, 34 eyes). Topographic and tomographic parameters, which were obtained from Pentacam using sagittal curvature, elevation, and corneal thickness maps, were compared among the 3 groups. Receiver operating characteristic (ROC) curves were used to identify cutoff points in discriminating between fellow and normal eyes.Results: Keratometric asymmetry, topometric indices, and elevation differences (maximum − minimum) on both the anterior and posterior surfaces were statistically different (P < .05). On ROC curve analysis, keratometric asymmetry and topometric index were best at discriminating fellow eyes from normal, followed by elevation differences (maximum − minimum) on the posterior and anterior cornea surface.Conclusions: Fellow eyes in unilateral KCN showed differences in several parameters that were not detectable with the Pentacam detection program, when compared with normal. However, each single parameter alone is not sufficient to detect early changes; thus, elevation indices as well as indices of anterior curvature should be considered together.
The Future of Uveitis Treatment – Corrected Proof
Purpose: Uveitis is a heterogeneous collection of diseases with polygenic and environmental influences. This heterogeneity presents challenges in trial design and selection of end points. Despite the multitude of causes, therapeutics targeting common i…
Long-Term Trends in Glaucoma-Related Blindness in Olmsted County, Minnesota – Corrected Proof
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.