Category: Peer-reviewed

Morphologic Characterization of Dome-Shaped Macula in Myopic Eyes With Serous Macular Detachment – Corrected Proof

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Purpose: To analyze dome-shaped maculas topographic features and related serous retinal detachment (SRD) in eyes with myopic staphyloma.Design: Retrospective, observational case series.Methods: We reviewed the records of 48 eyes in 33 patients with dome-shaped maculas who were referred because of decreased vision. Ophthalmologic examination included axial length measurement, spectral domain optical coherence tomography (OCT), and fluorescein and indocyanine green angiography. The height of the macular bulge was measured, and the choroidal thickness was mapped.Results: Patient mean age was 55.0 ± 13.6 years. Mean axial length was 27.49 ± 2.53 mm. Mean best-corrected visual acuity (BCVA) was 0.50 ± 0.33 logMAR. Three dome-shaped macula patterns were observed: round dome in 10/48 (20.8%) eyes; horizontal oval-shaped dome in 30/48 (62.5%) eyes; and vertical oval-shaped dome in 8/48 (16.7%) eyes. The mean macular bulge height was 407.7 ± 215.1 μm (120–1130) and was significantly greater in vertical oval-shaped domes. The mean central choroidal thickness (CCT) was 146.5 ± 56.0 μm, significantly greater than at 3 mm nasal and temporal to the fovea (P < 0.0001). The CCT was positively correlated to macular bulge height but not to BCVA. Foveal SRD was present in 25/48 eyes and significantly increased for macular bulge height greater than 350 μm (P = 0.0047). BCVA was significantly lower when SRD was present (P = 0.043).Conclusions: Most dome-shaped maculas did not display a round but a horizontal or vertical oval-shaped dome and could be missed on a single OCT scan. Chronic foveal SRD was associated with decreased vision and was more common when the macular bulge was highly elevated.

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Risk Factors, Microbiological Profile, and Treatment Outcomes of Pediatric Microbial Keratitis in a Tertiary Care Hospital in Hong Kong – Corrected Proof

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Purpose: To report the risk factors and microbiological profile of pediatric microbial keratitis cases in a tertiary care hospital in Hong Kong.Design: Retrospective study.Methods: Case records of patients <18 years old with microbial keratitis were reviewed over a period of 10 years, between January 2001 and December 2010. Risk factors, microbiological profile, and treatment outcomes were analyzed.Results: Overall, 18 patients (13 female, 5 male) with unilateral microbial keratitis were included. The mean age was 12.4 years (range: 3-17 years). The most commonly associated risk factor was contact lens wear (15, 83.3%). Seven cases (38.8%) were associated with orthokeratology lenses. Two cases (11.1%) were related to intrinsic keratopathy and 1 case (5.5%) was infected secondary to trauma. Microbiological culture was positive in 16 cases (88.8%). Overall, Pseudomonas sp. was the most commonly isolated organism (10/16, 62.5%), followed by coagulase-negative Staphylococcus (5/16, 31.2%) and Corynebacterium sp. (2/16, 12.5%). All cases responded to intensive medical management with topical antibiotics. One case with posttraumatic keratitis required stepped surgeries with initial tectonic penetrating keratoplasty followed by lens aspiration and retinal detachment repair. At the last follow-up, 13 out of 17 eyes (76.5%) had best-corrected visual acuity ≥20/40.Conclusions: Contact lens wear was the most commonly encountered risk factor for the occurrence of microbial keratitis in the pediatric age group in our setting. Orthokeratology remains one of the leading causes of contact lens–related infections. The majority of the cases responded to medical management.)

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Mechanism of Retinal Pigment Epithelium Tear Formation Following Intravitreal Anti–Vascular Endothelial Growth Factor Therapy Revealed by Spectral-Domain Optical Coherence Tomography – Corrected Proof

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Purpose: To demonstrate the mechanism by which retinal pigment epithelium (RPE) tears occur in eyes with neovascular age-related macular degeneration (AMD) treated with intravitreal anti–vascular endothelial growth factor (VEGF) agents using spectral…

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Optical Coherence Tomography Morphologic Grading of Macular Commotio Retinae and its Association With Anatomic and Visual Outcomes – Corrected Proof

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Purpose: To investigate the morphologic characteristics of macular commotio retinae using spectral-domain optical coherence tomography (SDOCT) and develop a grading system for traumatic photoreceptor damage.Design: Retrospective, observational case series.Methods: setting: Seoul National University Bundang Hospital. patients: Forty-nine patients with macular commotio retinae, examined by SDOCT within 7 days of the initial traumatic event. observations: A 4-step grading system was based on the morphology revealed by SDOCT. Best-corrected visual acuity (BCVA) and structural integrity of the 3 photoreceptor layers (cone outer segment tips [COST], inner/outer segment [IS-OS] junction, external limiting membrane [ELM]) were evaluated at baseline, at 1 month, and at the final visit. Visual and anatomic outcomes at 1 month and at the final visit were compared among subgroups. main outcome measures: The severity of photoreceptor damage as revealed by SDOCT and BCVA.Results: The following 4 distinct photoreceptor morphologic features were observed: increase in IS-OS junction reflectivity with the disappearance of the thin hyporeflective optical space (n = 8, grade 1), COST defect only (n = 5, grade 2), COST and IS-OS junction defects (n = 16, grade 3), and COST, IS-OS junction, and ELM defects (n = 20, grade 4). Eyes with higher grades at baseline had significantly worse visual (final BCVA, P = .002) and anatomic outcomes (complete photoreceptor recovery, P < .001).Conclusions: The number of disrupted photoreceptor layers, as determined using SDOCT images, can be used to grade macular commotio retinae. This system may be useful in documenting the baseline severity of photoreceptor damage and in predicting visual and anatomic outcomes.

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Identification of Persons With Incident Ocular Diseases Using Health Care Claims Databases – Corrected Proof

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Purpose: To assess the extent to which incidence rates calculated for common ocular diseases by using claims data may be overestimated according to the length of the disease-free look-back period used in the analysis.Design: Retrospective longitudinal cohort analysis.Methods: Billing records of 2457 persons continuously enrolled for 11 years in a managed-care network were searched for International Classification of Diseases (ICD-9-CM) diagnoses of cataract, open-angle glaucoma (OAG), nonexudative age-related macular degeneration (ARMD), and nonproliferative diabetic retinopathy (NPDR) at eye-care visits in the first half of 2001, the second half of 2010, and 2011. For each condition, incidence rates calculated by using “look-back” periods ranging from 0.5-9 years were compared with best estimates from a gold-standard period of 9.5 years.Results: With a 1-year disease-free look-back period, incidence was overestimated by 260% for cataract, 135% for OAG, 209% for ARMD, and 300% for NPDR. Expanding the disease-free look-back period to 3 years resulted in a reduction of incidence overestimation to 40% for cataract, 14% for OAG, 45% for ARMD, and 100% for NPDR. A 5-year look-back period yielded incidence rates that were overestimated by <30% for all 4 conditions.Conclusions: In our claims-data analysis of 4 common ocular conditions, a disease-free interval ≤1 year insufficiently distinguished newly diagnosed from pre-existing disease, resulting in grossly overestimated incidence rates. Using look-back periods of 3-5 years, depending on the specific diagnosis, yielded considerably more accurate estimates of disease incidence.

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Reduction of Retinal Sensitivity in Eyes With Reticular Pseudodrusen – Corrected Proof

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Purpose: To evaluate the effect of macular reticular pseudodrusen on retinal function using multiple imaging methods.Design: Prospective cross-sectional study.Methods: Thirteen eyes with reticular pseudodrusen, but without any other macular abnormality or glaucoma, and 20 normal eyes were evaluated. All subjects underwent color fundus photography, infrared reflectance (IR), fundus autofluorescence (FAF), and microperimetry.Results: The similarity in the number of reticular pseudodrusen was evaluated through inter-observer intraclass correlation coefficients, which ranged from 0.852-0.944. IR could detect reticular pseudodrusen within the center circle area in 12 eyes, whereas blue-channel fundus photography and FAF could only detect these lesions in 1 and 3 eyes, respectively. The number of reticular pseudodrusen correlated among the different imaging modalities (P < .001 for all) for all areas of the macula, except the center. The mean retinal sensitivity in eyes with reticular pseudodrusen was lower in all areas of the macula, compared with normal eyes (P < .001 for all). The number of reticular pseudodrusen correlated with retinal sensitivity in all areas by IR imaging (P = .003, P < .001, P = .003 for center, inner ring, outer ring, respectively), in the inner and outer rings by blue-channel fundus photography (P < .001 for both), and in the inner and outer rings by FAF (P < .001 and P = .001, respectively).Conclusions: Although multiple imaging modalities are capable of quantifying reticular pseudodrusen, IR appears to have the best ability to do so as compared to blue-channel photography and FAF. The distribution and number of reticular pseudodrusen lesions are closely associated with retinal sensitivity.

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Accomodative Tone in Children Under General Anesthesia – Corrected Proof

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Purpose: To determine the effect of general anesthesia on the accommodative tone in children.Design: Cohort study in an academic practice.Methods: In children under 12 years of age who were undergoing general anesthesia, cycloplegic refraction was measured using streak retinoscopy during an office visit. Within 6 months, streak retinoscopy without cycloplegia was performed under general anesthesia. The main outcome measure was the difference between retinoscopy under anesthesia and cycloplegic retinoscopy in children.Results: In 41 children with an average age of 3.7 years (range, 0.8 to 11 years) retinoscopy under anesthesia yielded significantly more myopic measurements than cycloplegic retinoscopy for the sphere and spherical equivalent (P < 0.0001 for both) but was in good agreement with cycloplegic retinoscopy for cylinder power and axis. The average difference between retinoscopy under anesthesia and cycloplegic retinoscopy was −0.98 diopters (D) (95% limit of agreement, −3.08 D to +1.10 D) for the sphere, 0.08 D (95% limit of agreement, −0.67 D to +0.82 D) for the cylinder, and −0.94 D (95% limit of agreement, −3.01 D to +1.13 D) for the spherical equivalent. Retinoscopy under anesthesia was within 1 D of cycloplegic retinoscopy in 25 subjects (61%) for the sphere, in all subjects for the cylinder, and in 28 subjects (68.3%) for the spherical equivalent.Conclusions: Although general anesthesia reduced the accommodative tone in most children, it was still significant in some as compared to the tone found in cycloplegic retinoscopy. If an accurate measurement is essential, cycloplegia is recommended when measuring refraction in children under general anesthesia.

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Neutrophil Collagenase, Gelatinase, and Myeloperoxidase in Tears of Patients with Stevens-Johnson Syndrome and Ocular Cicatricial Pemphigoid – Corrected Proof

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Objective: To investigate the levels of matrix metalloproteinases (MMPs), myeloperoxidase (MPO), and tissue inhibitor of metalloproteinase-1 (TIMP-1) in tears of patients with Stevens-Johnson syndrome (SJS) and ocular cicatricial pemphigoid (OCP).Design: Prospective, noninterventional cohort study.Participants: Four SJS patients (7 eyes), 19 OCP patients (37 eyes), and 20 healthy controls who underwent phacoemulsification (40 eyes).Methods: Tear washes were collected from all patients and were analyzed for levels of MMP-2, MMP-3, MMP-7, MMP-8, MMP-9, MMP-12, MPO, and TIMP-1 using multianalyte bead-based enzyme-linked immunosorbent assays. Total MMP activity was determined using a fluorometric assay. Correlation studies were performed between the various analytes within study groups.Main Outcome Measures: Levels of MMP-2, MMP-3, MMP-7, MMP-8, MMP-9, MMP-12, MPO, and TIMP-1 (in nanograms per microgram of protein) and total MMP activity (in relative fluorescent units per minute per microgram of protein) in tears; MMP-8–to–TIMP-1 ratio; MMP-9–to–TIMP-1 ratio; and the correlations between MMP-8 and MMP-9 and both MMP and MPO.Results: MMP-8, MMP-9, and MPO levels were elevated significantly in SJS and OCP tears (SJS>OCP) when compared with controls. The MMP activity was highest in SJS patients, whereas OCP patients and controls showed lower and similar activities. The TIMP-1 levels were decreased in SJS and OCP patients when compared with those in controls, with levels in OCP patients reaching significance. The MMP-8–to–TIMP-1 and MMP-9–to–TIMP-1 ratios were markedly elevated in SJS and OCP tears (SJS>OCP) when compared with those of controls. Across all study groups, MMP-9 levels correlated strongly with MMP-8 and MPO levels, and MMP-8 correlated with MPO, but it did not reach significance in SJS patients. There was no relationship between MMP-7 and MPO.Conclusions: Because MMP-8 and MPO are produced by inflammatory cells, particularly neutrophils, the correlation data indicate that they may be the common source of elevated enzymes, including MMP-9, in SJS and OCP tears. Elevated MMP-to-TIMP ratios and MMP activity suggest an imbalance in tear MMP regulation that may explain the predisposition of these patients to demonstrate corneal melting and chronic complications associated with persistent inflammation. Myeloperoxidase in tears may be a sensitive and specific marker for the quantification of ocular inflammation.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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A Comparison of Treatment Approaches for Bilateral Congenital Nasolacrimal Duct Obstruction – Corrected Proof

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Purpose: To compare the clinical outcomes of two treatment approaches for bilateral nasolacrimal duct obstruction (NLDO) in infancy.Design: Multicenter, randomized clinical trial.Methods: We studied 57 infants between the ages of 6 and <10 months who had bilateral NLDO. Participants were randomized to receive either (1) immediate office-based probing within two weeks (n = 31) or (2) 6 months of observation and nonsurgical management followed by surgical facility-based probing for unresolved cases (n = 26). Treatment success was defined as the absence of clinical signs of NLDO (epiphora, increased tear lake, mucous discharge) in both eyes on masked examination at 18 months of age.Results: In the observation and deferred facility probing group, resolution without surgery occurred by 6 months after randomization in both eyes for 14 participants (56%), in one eye for 5 (20%), and in neither eye for 6 (24%). Eight participants in the observation and deferred facility probing group underwent facility probing (one of whom later had a second facility probing). Four participants in the immediate office probing group later underwent an additional procedure in a surgical facility. In the immediate office probing group, treatment success at 18 months of age occurred in both eyes for 19 of 29 (66%) participants and in one eye for 3 (10%); in the observation and deferred facility probing group, treatment success occurred in both eyes for 19 of 25 (76%) participants and in one eye for 3 (12%) (difference in success = −10%; 95% CI = −35% to 14%).Conclusions: Both the immediate office probing approach and the observation and deferred facility probing approach are successful and reasonable treatment options for infants with bilateral NLDO.

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Clinical Results of Ab Interno Trabeculotomy Using the Trabectome for Open-Angle Glaucoma: The Mayo Clinic Series – Corrected Proof

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Purpose: To determine outcomes of ab interno trabeculotomy for treatment of open-angle glaucoma (OAG).Design: Retrospective interventional single-surgeon, single-center case series.Methods: Data were collected from 246 patients undergoing ab interno trabeculotomy between September 1, 2006, and December 1, 2010, with 3 months’ follow-up or longer. Kaplan-Meier analysis was performed using Criteria A (postoperative intraocular pressure [IOP] ≤21 mm Hg or ≥20% reduction from preoperative IOP) and Criteria B (IOP ≤18 mm Hg and ≥20% reduction in IOP). Failure included increased glaucoma medications or subsequent surgery. Failure risk factors were identified using Cox proportional hazards ratio (HR).Results: Of 88 cases of ab interno trabeculotomy-only and 158 cases of ab interno trabeculotomy with cataract extraction, the retention rate was 70% for 1 year and 62% for 2 years. Preoperative mean IOP was 21.6 ± 8.6 mm Hg; the number of glaucoma medications was 3.1 ± 1.1. At 24 months postoperatively, mean IOP was reduced 29% to 15.3 ± 4.6 mm Hg (P < 0.001) and the number of glaucoma medications was reduced 38% to 1.9 ± 1.3 (P < 0.001) with a success rate of 62% (95% CI, 56%–68%) using Criteria A and 22% (95% CI, 16%–29%) using Criteria B. Failure risk factors using Criteria A included primary OAG (HR 3.14, P < 0.01, 95% CI, 1.91–5.17) and past argon laser trabeculoplasty (HR 1.81, P < 0.01, 95% CI, 1.18–2.77). Using Criteria B, the HR for pseudoexfoliative glaucoma was 0.43 (P < 0.01, 95% CI 0.27–0.67). Of the cases, 66 (26.8%) required subsequent surgery on an average of 10 months (2 days to 3.2 years) after ab interno trabeculotomy.Conclusions: For criteria involving IOP ≤18 mm Hg, the 24-month survival of ab interno trabeculotomy is low. This surgery is appropriate for patients requiring a target IOP of 21 mm Hg or above.

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Expanded Criteria for Pneumatic Retinopexy and Potential Cost Savings – Corrected Proof

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Purpose: To provide insight into the preoperative factors that affect outcome after pneumatic retinopexy (PR) for treatment of primary rhegmatogenous retinal detachment repair. Additionally, we sought to analyze the cost of rhegmatogenous retinal detachment repair in the United States to determine potential cost savings with pneumatic retinopexy.Design: Single-center, retrospective, observational consecutive case series and third party payer-perspective comparative cost analysis.Participants: We included 141 eyes undergoing pneumatic retinopexy for the treatment of primary rhegmatogenous retinal detachment.Methods: Preoperative characteristics, anatomic outcomes, and best-available visual acuity were collected. Anatomic and visual outcomes were analyzed based on the presence of selected preoperative factors. The primary cohort was divided into 2 groups based on preoperative characteristics: (1) traditional pneumatic retinopexy and (2) nontraditional pneumatic retinopexy. Comparative cost analyses were performed between pneumatic retinopexy, scleral buckling, and vitrectomy.Main Outcome Measures: Anatomic and visual outcomes at 6 months.Results: Overall anatomic success was 78.7% and visual acuity improved significantly (logarithm of the minimum angle of resolution [logMAR] 0.48–0.25; P   0.05) and phakic versus pseudophakic groups (logMAR 0.23 vs 0.28; P > 0.05). Visual outcomes were better in macula-on detachments compared with those in which the macula was detached (logMAR 0.18 vs 0.42; P < 0.005). Annual health care cost savings in the United States ranging from $6 to $30 million are theoretically possible by increasing pneumatic retinopexy utilization from the current rate of 15% to 20%–35%.Conclusions: Pneumatic retinopexy is an effective treatment modality for primary rhegmatogenous retinal detachment. Anatomic and visual outcomes are similar for traditional and nontraditional preoperative inclusion criteria, as well as phakic and pseudophakic eyes. Inferior breaks and visible vitreous traction on a tear predicted failure. Increased utilization of pneumatic retinopexy would achieve significant cost savings while maintaining outcomes.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

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