Category: Peer-reviewed

Evaluation of Ocular Surface Disease in Patients with Glaucoma – Corrected Proof

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Purpose: To evaluate the subjective and objective measures of ocular surface disease in patients with glaucoma.Design: Cross-sectional study.Participants: Sixty-four glaucoma subjects with bilateral visual field (VF) loss and 59 glaucoma suspects with normal VFs.Methods: Consecutive patients were recruited prospectively from the Wilmer Eye Institute Glaucoma Clinic.Main Outcome Measures: Tear film breakup time (TBUT), corneal staining score (0–15), and Schirmer’s test results were included as objective metrics, whereas the Ocular Surface Disease Index (OSDI) questionnaire was administered to assess symptoms. Total OSDI score, vision-related subscore (derived from questions about vision and task performance), and discomfort-related subscore (derived from questions about ocular surface discomfort) were calculated for each subject.Results: Seventy-five percent (48/64) of glaucoma subjects and 41% (24/59) of glaucoma suspects were receiving topical medications. The corneal staining grade was greater in glaucoma subjects than in glaucoma suspects (6.4 vs. 4.1; P<0.001), but groups did not differ with regard to TBUT or Schirmer’s results (P>0.20 for both). Multivariate regression models showed that topical glaucoma therapy burden was associated with a significantly higher total corneal staining grade (β, +0.9 for each additional glaucoma drop; 95% confidence interval [CI], 0.5–1.3; P<0.001), but not with TBUT or Schirmer’s results (P>0.20 for both). Glaucoma subjects had significantly higher total OSDI scores than glaucoma suspects (16.7 vs. 7.9; P<0.001). This largely was the result of higher vision-related subscores in the glaucoma group (11.1 vs. 3.3; P<0.001). Ocular discomfort–related subscores, however, were similar in both groups (5.7 vs. 4.6; P = 0.30). In multivariate analyses, each 5-decibel decrement in better-eye VF mean deviation was associated with a 4.7-point increase in total OSDI score (95% CI, 1.9–7.5; P = 0.001) and a 3.7-point increase in the vision-related subscore (95% CI, 1.7–5.6; P<0.001) but did not predict a higher discomfort-related subscore (β, 1.1 point; P = 0.07). Topical glaucoma therapy burden was not associated with higher total OSDI score or vision- or discomfort-related subscore (P>0.20 for all).Conclusions: Glaucoma is associated with significant ocular surface disease, and topical glaucoma therapy burden seems predictive of corneal staining severity. However, OSDI is a poor metric for capturing ocular surface disease in glaucoma because symptoms seem to be related largely to VF loss.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

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Prevalence of Blindness and Outcomes of Cataract Surgery in Hainan Province in South China – Corrected Proof

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Objective: To define the prevalence of blindness and visual impairment (VI) in people in rural Hainan using the rapid assessment of avoidable blindness (RAAB) and to report the outcomes of cataract surgery among the residents.Design: Population-based, cross-sectional survey.Participants: A total of 6482 rural residents of the Hainan province.Methods: A total of 136 clusters, each of which consisted of 50 people aged ≥50 years, were selected through probability-proportionate-to-size sampling. Door-to-door visits were performed by 2 outreach teams. Visual acuity (VA) was measured on site, and those with VA <6/18 in either eye were examined by an ophthalmologist. Causes of blindness and VI were determined. The causes of poor visual outcome after cataract surgery were evaluated. Information regarding barriers to receiving surgery was collected by trained interviewers.Main Outcome Measures: Prevalence and causes of blindness (VA <3/60), severe VI (SVI) (VA <6/60 but ≥3/60), and VI (VA <6/18 but ≥6/60) based on presenting VA (PVA) were assessed. Outcomes of cataract surgery performed in public and private hospitals and charitable organizations were compared.Results: A total of 6482 subjects were examined (response rate, 95.3%). The sample prevalence of blindness was 4.4% (95% confidence interval [CI], 2.0–6.8). The prevalence of SVI and VI was 1.9% (95% CI, 0–4.3) and 9.9% (95% CI, 7.6–12.2), respectively. Age and sex were associated with increased prevalence of blindness, SVI, and VI. Overall, cataract accounted for approximately 60% of blindness and SVI. Of the 524 eyes that had received cataract surgery, 87.2% had intraocular lenses implanted, 21% had a poor visual outcome (PVA <6 /60), and 20% had a borderline visual outcome (PVA <6/18 but ≥6/60). Eyes that received surgery in charitable organizations had a higher rate of intraocular lens implantation and good visual outcome (VA ≥6/18) compared with eyes that were operated on elsewhere.Conclusions: The prevalence of blindness, SVI, and VI was high among rural residents in Hainan. Cataract remained the leading cause of avoidable blindness. Outcomes of cataract surgery performed in public hospitals were suboptimal. Quality-control initiatives should be introduced to improve cataract surgery outcomes.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Dexamethasone Intravitreal Implant in Combination with Laser Photocoagulation for the Treatment of Diffuse Diabetic Macular Edema – Corrected Proof

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Purpose: To evaluate Ozurdex (dexamethasone intravitreal implant [DEX implant]; Allergan, Inc, Irvine, CA) 0.7 mg combined with laser photocoagulation compared with laser alone for treatment of diffuse diabetic macular edema (DME).Design: Randomized, controlled, multicenter, double-masked, parallel-group, 12-month trial.Participants: Two hundred fifty-three patients with retinal thickening and impaired vision resulting from diffuse DME in at least 1 eye (the study eye) were enrolled.Intervention: Patients were randomized to treatment in the study eye with DEX implant at baseline plus laser at month 1 (combination treatment; n = 126) or sham implant at baseline and laser at month 1 (laser alone; n = 127) and could receive up to 3 additional laser treatments and 1 additional DEX implant or sham treatment as needed.Main Outcome Measures: The primary efficacy variable was the percentage of patients who had a 10-letter or more improvement in best-corrected visual acuity (BCVA) from baseline at month 12. Other key efficacy variables included the change in BCVA from baseline and the area of vessel leakage evaluated with fluorescein angiography. Safety variables included adverse events and intraocular pressure (IOP).Results: The percentage of patients who gained 10 letters or more in BCVA at month 12 did not differ between treatment groups, but the percentage of patients was significantly greater in the combination group at month 1 (P<0.001) and month 9 (P = 0.007). In patients with angiographically verified diffuse DME, the mean improvement in BCVA was significantly greater with DEX implant plus laser treatment than with laser treatment alone (up to 7.9 vs. 2.3 letters) at all time points through month 9 (P≤0.013). Decreases in the area of diffuse vascular leakage measured angiographically were significantly larger with DEX implant plus laser treatment through month 12 (P≤0.041). Increased IOP was more common with combination treatment. No surgeries for elevated IOP were required.Conclusions: There was no significant between-group difference at month 12. However, significantly greater improvement in BCVA, as demonstrated by changes from baseline at various time points up to 9 months and across time based on the area under the curve analysis, occurred in patients with diffuse DME treated with DEX implant plus laser than in patients treated with laser alone.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

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Incidence of Choroidal Neovascularization in the Fellow Eye in the Comparison of Age-Related Macular Degeneration Treatments Trials – Corrected Proof

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Objective: To assess the influence of drug; dosing regimen; and traditional, nontraditional, and genetic risk factors on the incidence of choroidal neovascularization (CNV) in the fellow eye of patients treated for CNV with ranibizumab or bevacizumab.Design: Cohort study of patients enrolled in a multicenter, randomized clinical trial.Participants: Patients with no CNV in the fellow eye at the time of enrollment in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT).Methods: Eligibility criteria for the clinical trial required that study eyes have evidence on fluorescein angiography and optical coherence tomography of CNV secondary to age-related macular degeneration (AMD) and visual acuity between 20/25 and 20/320. Treatment for the study eye was assigned randomly to either ranibizumab or bevacizumab and to 3 different regimens for dosing over a 2-year period. The genotypes for 4 single nucleotide polymorphisms (SNPs) associated with risk of AMD were determined. Only patients without CNV in the fellow eye at baseline were considered at risk. The CATT ophthalmologists examined patients every 4 weeks through 2 years and recorded treatment for CNV in the fellow eye.Main Outcome Measures: Development of CNV in the fellow eye.Results: Among 1185 CATT participants, 727 (61%) had no CNV in the fellow eye at enrollment. At 2 years, CNV had developed in 75 (20.6%) of 365 patients treated with ranibizumab and in 60 (16.6%) of 362 patients treated with bevacizumab (absolute difference, 4.0%; 95% confidence interval [CI], –1.7% to 9.6%; P = 0.17). The risk ratio for pro re nata dosing relative to monthly dosing was 1.1 (95% CI, 0.8–1.6). Greater elevation of the retinal pigment epithelium and fluid in the foveal center of the study eye were associated with increased incidence of CNV in the fellow eye. Incidence was not associated with genotype on rs1061170 (CFH), rs10490924 (ARMS2), rs11200638 (HTRA1), and rs2230199 (C3; P>0.35).Conclusions: Through 2 years, there was no statistically significant difference between ranibizumab and bevacizumab in incidence of CNV in the fellow eye. Genotype on 4 SNPs previously found to be associated with AMD did not affect the risk of CNV in the fellow eye among CATT patients.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

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Incidence and Progression of Geographic Atrophy: Observations from a Population-based Cohort – Corrected Proof

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Purpose: To examine early age-related macular degeneration (AMD) lesion characteristics and risk factors associated with the long-term development and progression of geographic atrophy (GA).Design: Population-based cohort.Participants: Of 3654 participants aged ≥49 years in the Blue Mountains Eye Study, 75.8%, 76.7%, and 56.1% of survivors attended the 5-, 10-, and 15-year follow-up examinations, respectively.Methods: Retinal photographs were taken at each visit. Incident GA was confirmed using a side-by-side grading method. Computer planimetry was used to measure the area involved by GA. Fast and slow/normal progression rates were defined as GA area enlargement by ≥2 and <2 mm2/year, respectively. Incident GA was estimated using the Kaplan–Meier product-limit method. Early AMD lesion characteristics were assessed for association with GA incidence using eye-specific data and generalized estimating equation models adjusting for age, current smoking, and presence of risk alleles of the complement factor H (CFH) or age-related maculopathy susceptibility 2 (ARMS2) genes, genotyped or imputed using genome-wide scan data.Main Outcome Measures: Incidence and progression of GA.Results: By excluding 41 subjects with GA at baseline, of 2503 participants at risk of GA, incident pure GA (without coexisting neovascular AMD lesions) was confirmed in 57 participants, with a 15-year incidence of 3.6%. Baseline early AMD lesion characteristics associated with GA incidence included drusen type (soft indistinct: odds ratio [OR], 59.0; 95% confidence interval [CI], 20.4–171.0; reticular drusen: OR, 13.9; 95% CI, 4.0–47.6); drusen location within a 500-μm radius of the fovea (OR, 15.1; 95% CI, 7.4–30.8); drusen area greater than 375 μm in diameter (OR, 10.1; 95% CI, 4.0–25.6); presence of retinal pigment epithelial depigmentation (OR, 9.0; 95% CI, 4.1–19.8); or hyperpigmentation (OR, 12.0; 95% CI, 6.1–23.5), referenced to subjects with no or hard drusen only. Fast progression was more frequent among current smokers at baseline, subjects with the CFH or ARMS2 risk genotypes, and pseudophakic eyes.Conclusions: Early AMD lesion characteristics (type, location, area involved) were strongly associated with higher long-term risk of developing GA independent of age, smoking, and AMD genetic susceptibility from the CFH or ARMS2 genes. Known AMD risk factors also were more frequently present among quickly progressing GA cases.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

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The Impact of Dry Eye Disease on Visual Performance While Driving – Corrected Proof

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Purpose: A specific simulator was used to assess the driving visual performance in patients with dry eye disease (DED) and to determine clinical predictors of visual impairments while driving.Design: Prospective case-control study.Methods: The study was conducted in the Center for Clinical Investigation of Quinze-Vingts National Ophthalmology Hospital, Paris, France. Twenty dry eye patients and 20 age- and sex-matched control subjects were included. Vision-related driving ability was assessed using a specific driving simulator displaying randomly located targets with a progressive increase in contrast to be identified. Other examinations included clinical examinations, serial measurements of corneal higher-order aberrations (HOAs), and vision-related quality-of-life questionnaire (Ocular Surface Disease Index [OSDI]). Data collected during driving test (ie, the number of targets seen, their position, and the response time) were compared between groups and analyzed according to clinical data, aberration dynamics, and quality-of-life index.Results: The percentage of targets missed as well as average response time were significantly increased in DED patients as compared with controls (P < .01). More specifically, the visual function of DED patients was more impaired in specific situations, such as crossroad or roundabout approaches. In DED patients, the response time was found to positively correlate with the progression index for HOAs (P < .01) and with the OSDI “symptoms” subscale (P < .05).Conclusions: Degradation of ocular optical qualities related to DED is associated with visual impairments during driving. This study objectively has demonstrated the impact of tear film–related aberration changes on activities of daily living in DED.

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Selection of an Initial Contact Lens Power for Infantile Cataract Surgery without Primary Intraocular Lens Implantation – Corrected Proof

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Purpose: To provide guidelines for the selection of an initial contact lens (CL) power based on the preoperative characteristics of the patient in eyes undergoing infantile cataract surgery without primary intraocular lens (IOL) implantation.Design: Cohort study.Participants: Eyes were included if cataract surgery was performed without primary IOL implantation before 1 year of age, a SilSoft CL (Bausch & Lomb, Rochester, NY) was placed immediately after surgery, and postoperative refraction data were available within 1 month after surgery.Methods: The target CL power was calculated by using the postoperative refraction at the corneal plane for each eye. A regression formula was derived using the targeted CL power and the axial length (AL). The CL power also was estimated using various formulas. An A-constant was derived to estimate CL power using IOL power calculation formula.Main Outcome Measures: Contact lens power.Results: Fifty eyes of 50 patients were analyzed. Age at the time of cataract surgery was 2.4±1.7 months. Refraction at the corneal plane was 29.6±4.4 diopters (D). Regression analysis revealed that CL power = 84.4 – 3.2 × AL (R2 = 0.82; P<0.001). Contact lens power can be estimated using an A-constant of 112.176 in the IOL power calculation formula. If a CL power of 32 D had been used, 22 (44%) of 50 eyes would have needed a replacement of CL.Conclusions: We devised guidelines on selecting the initial CL power based on preoperative AL. The IOL power calculator also can help to estimate CL power. Refraction at the conclusion of surgery in infants may be difficult, and preoperative biometry can be used to estimate CL power.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Subfoveal Choroidal Thickness in Diabetes and Diabetic Retinopathy – Corrected Proof

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Purpose: To examine subfoveal choroidal thickness (SFCT) in patients with diabetes mellitus and patients with diabetic retinopathy.Design: Population-based, cross-sectional study.Participants: The population-based Beijing Eye Study 2011 included 3468 individuals with a mean age of 64.6±9.8 years (range, 50–93 years).Methods: A detailed ophthalmic examination was performed including spectral-domain optical coherence tomography (OCT) with enhanced depth imaging for measurement of SFCT and fundus photography for the assessment of diabetic retinopathy.Main Outcome Measures: Subfoveal choroidal thickness.Results: Fasting blood samples, fundus photographs, and choroidal OCT images were available for 2041 subjects (58.8%), with 246 subjects (12.1±0.7%) fulfilling the diagnosis of diabetes mellitus and 23 subjects having diabetic retinopathy. Mean SFCT did not differ significantly between patients with diabetes mellitus and nondiabetic subjects (266±108 vs. 261±103 μm; P = 0.43) nor between patients with diabetic retinopathy and subjects without retinopathy (249±86 vs. 262±104 μm; P = 0.56). After adjustment for age, sex, axial length, lens thickness, anterior chamber depth, corneal curvature radius, and best-corrected visual acuity, SFCT was associated with a higher glycosylated hemoglobin (HbA1c) value (P<0.001; regression coefficient B, 8.18; 95% confidence interval [CI], 4.02–12.3); standardized coefficient β, 0.08) or with the presence of diabetes mellitus (P = 0.001; B, 21.3; 95% CI, 9.12–33.5) but not with presence of diabetic retinopathy (P = 0.61) or stage of diabetic retinopathy (P = 0.14). As a corollary, after adjusting for age, region of habitation, body mass index, systolic and diastolic blood pressure, and level of education, diabetes mellitus was associated with a thicker SFCT (P<0.001). In contrast, neither presence of diabetic retinopathy (P = 0.61) nor stage of diabetic retinopathy (P = 0.09) were associated significantly with SFCT after adjusting for body mass index, diastolic and systolic blood pressure, and level of education and after adjusting for blood glucose concentrations, HbA1c value, diagnosis of diabetes mellitus, and systolic and diastolic blood pressure, respectively.Conclusions: Patients with diabetes mellitus had a slightly, but statistically significantly, thicker subfoveal choroid, whereas presence and stage of diabetic retinopathy were not associated additionally with an abnormal SFCT. Whereas diabetes mellitus as a systemic disease leads to a slight thickening of the choroid, diabetic retinopathy as an ocular disorder was not associated with choroidal thickness abnormalities after adjusting for the presence of diabetes mellitus.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Parafoveal Scotoma Progression in Glaucoma: Humphrey 10-2 versus 24-2 Visual Field Analysis – Corrected Proof

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Objective: To compare the performance of 10-2 versus 24-2 visual fields (VFs) in detecting progression of initial parafoveal scotoma (IPFS) in glaucomatous eyes.Design: Retrospective, observational study.Participants: Glaucoma patients with the following criteria: (1) an IPFS (≥3 adjacent points with P<0.05 within the central 10° degrees of fixation, 1 point or more with P<0.01 lying at the innermost paracentral points, and no scotoma outside the central 10°) in either hemifield based on 2 reliable Humphrey 24-2 Swedish interactive threshold algorithm standard VFs, and (2) 5 or more 10-2 and 24-2 VFs.Methods: Based on threshold map sensitivities, VF progression, defined as having 1 or more significantly progressing point(s) with a slope of sensitivity of less than –1.0 dB/year at P<0.01, was evaluated using pointwise linear regression.Main Outcome Measures: The number of progressing eyes in 10-2 and 24-2 VF analyses.Results: Fifty eyes (50 patients) were included (mean age ± standard deviation, 62±9 years). Mean follow-up period (5.7 vs. 5.6 years) and number of VFs (7.6 vs. 7.8) were similar between 10-2 and 24-2 analyses (all P>0.3). Significantly more progressing eyes were detected in 10-2 than in 24-2 analyses (24 vs. 11 eyes; P = 0.007). This difference became greater within the central 10° (24 vs. 4 eyes; P<0.001). Four of the 11 progressing eyes in 24-2 analysis were missed in 10-2 analysis, whereas 17 of the 24 progressing eyes in 10-2 analysis were missed in 24-2 analysis. The 4 progressing eyes missed in 10-2 analysis had progressing point(s) only outside the central 10° in 24-2 analysis. The other 3 eyes with progressing point(s) only outside the central 10° in 24-2 analysis were detected as progressing in 10-2 analysis. Similar results were obtained when more stringent criteria (at least 2 significantly progressing points within the same hemifield) were used for VF progression.Conclusions: The 10-2 VF detects more progressing eyes than the 24-2 VF in glaucoma patients with IPFS, suggesting that closer surveillance of the central VF using testing algorithms with closely spaced grids is warranted in eyes with parafoveal scotomas.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

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The Posterior Pole and Papillomacular Fold in Posterior Microphthalmos: Novel Spectral-Domain Optical Coherence Tomography Findings – Corrected Proof

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Purpose: To report and analyze the spectral-domain optical coherence tomography (SD-OCT) features of the posterior pole and papillomacular fold (PMF) in posterior microphthalmos (PM) in relation to axial length of the globe and corneal power.Design: Comparative case series.Participants: Forty eyes of 20 PM patients and 70 eyes of 35 age-matched controls.Methods: All PM and control eyes underwent a full biometric evaluation, including axial length and corneal power measurements, and macular SD-OCT. In addition, a novel SD-OCT marker of the posterior pole curvature, termed the posterior pole curvature index (PPCI), was measured along both the vertical and horizontal meridians. The OCT characteristics of the PMF were analyzed and the PPCIs were compared and correlated with the axial length and corneal power in both groups of eyes, and with the PMF severity in PM eyes.Main Outcome Measures: We considered the SD-OCT features of the PMF, the PPCI in PM eyes and controls, and the correlations between PPCI and PMF severity and axial length.Results: All PMFs were predominantly horizontal and partial thickness, sparing the outer retina except the outer plexiform layer. The PPCI in PM eyes (mean ± standard deviation, 145±40.3 microns; median, 144) was significantly larger than that of controls (14±12.8 microns; median, 14; P<0.0001). In addition, the vertical PPCI in PM eyes, but not in controls, was notably larger than the horizontal PPCI (mean difference, 55±30.4 microns; P<0.0001). In PM eyes, the PPCI strongly correlated with PMF height (R = 0.68; P<0.0001), inverse axial length (R = –0.71; P<0.0001), and corneal power (R = 0.49; P = 0.002), and the PMF height correlated strongly and inversely with the axial length (R = –0.62; P<0.0001).Conclusions: The PMF in PM eyes has characteristic morphologic SD-OCT features. The increased posterior pole curvature in PM and its significant correlation with the axial length, the PMF severity and keratometry established in this study suggest that PM eyes are not only shorter than normal, but seem to be abnormally shaped posteriorly, particularly along the vertical meridian. This factor may play a role in the pathogenesis and morphology of the PMF.Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

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