Purpose: To describe the incidence of canalicular closure with powered endonasal dacryocystorhinostomy (DCR) without canalicular intubation in primary acquired nasolacrimal duct obstruction (PANDO).Design: A single-surgeon, prospective, nonrandomized, noncomparative, interventional case series.Participants: Consecutive patients attending a specialist clinic of an oculoplastic surgeon (DS) with radiologically confirmed diagnosis of PANDO. Cases of canalicular disease were excluded.Methods: Patients with radiologically confirmed PANDO without canalicular involvement underwent endonasal DCR without intubation. The operation was performed by 1 surgeon (DS) and follow-up was at 4 weeks and 12 months.Main Outcome Measures: Outcomes were recorded as subjective symptomatic relief at 12 months and endoscopic evidence of ostium patency and canalicular patency.Results: There were 132 cases that fulfilled the inclusion criteria. Three cases were lost to follow-up. Preoperatively, 96.3% of cases had Munk scores of >2. Of the 129 cases, 127 (98.5%) had endoscopic evidence of a patent ostium with a positive endoscopic dye test at the 12-month follow-up. All cases had a patent canalicular system as demonstrated by syringing and probing. Of the 129 cases, 117 (90.7%) had subjective improvement of epiphora at 12 months with 88.4% of cases reporting Munk scores of ≤1.Conclusions: In this prospective series of nonintubation for PANDO, there were no cases of canalicular closure or stenosis at 12 months. Anatomic and functional success was similar to reported outcomes for DCR with intubation for PANDO. We advocate that routine intubation for the purpose of maintaining canalicular patency is not necessary when performing endonasal DCR in PANDO.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.
Category: Peer-reviewed
Cost-Effectiveness of Various Interventions for Newly Diagnosed Diabetic Macular Edema – Corrected Proof
Objective: Anti–vascular endothelial growth factor therapies have revolutionized the treatment of clinically significant diabetic macular edema (CSDME); yet these agents are expensive, and whether they are cost-effective is unclear. The purpose of this study is to determine the most cost-effective treatment option for patients with newly diagnosed CSDME: focal laser photocoagulation alone (L), focal laser plus intravitreal ranibizumab (L+R), focal laser plus intravitreal bevacizumab (L+B), or focal laser plus intravitreal triamcinolone (L+T) injections.Design: Cost-effectiveness analysis.Participants: Hypothetical cohort of 57-year-old patients with newly diagnosed CSDME.Methods: By using a Markov model with a 25-year time horizon, we compared the incremental cost-effectiveness of treating patients with newly diagnosed CSDME using L, L+R, L+B, or L+T. Data came from the DRCRnet randomized controlled trial, the Medicare fee schedule, and the medical literature.Main Outcome Measures: Costs, quality-adjusted life years (QALYs), and incremental costs per QALY gained.Results: Compared with L, the incremental cost-effectiveness of L+R and L+B was $89 903/QALY and $11 138/QALY, respectively. L+T was dominated by L. A probabilistic sensitivity analysis demonstrated that, at a willingness to pay (WTP) of $50 000/QALY, L was approximately 70% likely to be the preferred therapy over L+R and L+T. However, at a WTP of $100 000/QALY, more than 90% of the time, L+R therapy was the preferred therapy compared with L and L+T. In the probabilistic sensitivity analysis, L+B was found to be the preferred therapy over L and L+T for any WTP value >$10 000/QALY. Sensitivity analyses revealed that the annual risk of cerebrovascular accident would have to be at least 1.5% higher with L+B than with L+R for L+R to be the preferred treatment. In another sensitivity analysis, if patients require <8 injections per year over the remainder of the 25-year time horizon, L+B would cost <$100 000/QALY, whereas L+R would be cost-effective at a WTP of $100 000/QALY if patients require fewer than 0.45 injections per year after year 2.Conclusion: With bevacizumab and ranibizumab assumed to have equivalent effectiveness and similar safety profiles when used in the management of CSDME, bevacizumab therapy confers the greatest value among the different treatment options for CSDME.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.
Ostium Shrinkage after Endoscopic Dacryocystorhinostomy – Corrected Proof
Objective: Ostium closure after endoscopic dacryocystorhinostomy (DCR) is the commonest cause for anatomic failure. We aimed to determine the changes in size of the DCR ostium over time and investigate the correlation of ostium size and surgical outcom…
Macular Morphology and Visual Acuity in the Comparison of Age-related Macular Degeneration Treatments Trials – Corrected Proof
Objective: To describe the effects of treatment for 1 year with ranibizumab or bevacizumab on macular morphology and the association of macular morphology with visual acuity (VA) in eyes with neovascular age-related macular degeneration (AMD).Design: Prospective cohort study within a randomized clinical trial.Participants: Participants in the Comparison of Age-related Macular Degeneration Treatments Trials.Methods: Participants were assigned randomly to treatment with ranibizumab or bevacizumab on a monthly or as-needed schedule. Optical coherence tomography (OCT), fluorescein angiography (FA), color fundus photography (FP), and VA testing were performed periodically throughout 52 weeks. Masked readers graded images. General linear models were applied to evaluate effects of time and treatment on outcomes.Main Outcome Measures: Fluid type and location and thickness by OCT, size, and lesion composition on FP, FA, and VA.Results: Intraretinal fluid (IRF), subretinal fluid (SRF), subretinal pigment epithelium fluid, and retinal, subretinal, and subretinal tissue complex thickness decreased in all treatment groups. A higher proportion of eyes treated monthly with ranibizumab had fluid resolution at 4 weeks, and the difference persisted through 52 weeks. At 52 weeks, there was little association between the presence of fluid of any type (without regard to fluid location) and the mean VA. However, at all time points, eyes with residual IRF, especially foveal IRF, had worse mean VA (9 letters) than those without IRF. Eyes with abnormally thin (<120 μm) or thick (>212 μm) retinas had worse VA than those with normal thickness (120–212 μm). At week 52, eyes with larger neovascular lesions or with foveal scar had worse VA than eyes without these features.Conclusions: Anti–vascular endothelial growth factor (VEGF) therapy reduced lesion activity and improved VA in all treatment groups. At all time points, eyes with residual IRF had worse VA than those without. Eyes with abnormally thin or thick retinas, residual large lesions, and scar also had worse VA. Monthly ranibizumab dosing yielded more eyes with no fluid and an abnormally thin retina, although the long-term significance is unknown. These results have important treatment implications in eyes undergoing anti-VEGF therapy for neovascular AMD.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.
Molecular Diagnosis and Ocular Imaging of West Nile Virus Retinitis and Neuroretinitis – Corrected Proof
Purpose: To describe the ocular features of West Nile virus (WNV) infection proven by serology and molecular diagnostic techniques.Design: Prospective case series.Participants: Fifty-two patients who presented to the uveitis clinic with ocular inflamma…
Short-term Consumption of Oral Omega-3 and Dry Eye Syndrome – Corrected Proof
Purpose: To assess the effect of oral omega-3 fatty acids on tear break-up time (TBUT), Schirmer’s score, and Ocular Surface Disease Index (OSDI) through a double-blind clinical trial.Design: Randomized, double-blind clinical trial.Participants: Sixty-four patients with dry eye symptoms between the ages of 45 and 90 years were randomized into 2 groups: 33 persons in the treatment group and 31 persons in the placebo group.Methods: The treatment group received 2 capsules of omega-3 (each containing 180 mg eicosapentaenoic acid [EPA] and 120 mg docosahexaenoic acid [DHA]) daily for 30 days, and the placebo group received 2 medium-chain triglyceride oil capsules daily for 1 month. The outcomes were measured 1 month after the intervention.Main Outcome Measures: The primary outcome measure was an increase from baseline in TBUT at day 30. Secondary outcome measures were a decrease from baseline in the OSDI score and an increase in the Schirmer’s score at day 30.Results: In the placebo group, before the intervention, the mean TBUT, OSDI, and Schirmer’s scores were 4.5 ± 2.1 seconds, 36.4 ± 13.8, and 6.0 ± 2.6 mm, respectively, and 1 month later were 4.7 ± 2.6 seconds, 37.6 ± 13.5, and 6.2 ± 2.5 mm, respectively. In the treatment group, these values were 3.9 ± 1.7 seconds, 38.7 ± 16.5, and 5.8 ± 2.5 mm before the intervention and 5.67 ± 2.6 seconds, 29.3 ± 15.9, and 6.8 ± 2.8 mm after the intervention, respectively. Repeated-measures analysis of variance showed that improvements in TBUT, OSDI, and Schirmer’s scores were significantly better in the treatment group than in the placebo group. The changes in the treatment and placebo groups were 71% and 3.3% for TBUT (P < 0.001), 26% and 4% (P=0.004) for dry eye symptoms, and 22.3% and 5.1% for Schirmer’s score (P=0.033), respectively.Conclusions: This study demonstrated that oral consumption of omega-3 fatty acids (180 mg EPA and 120 mg DHA twice daily for 30 days) is associated with a decrease in the rate of tear evaporation, an improvement in dry eye symptoms, and an increase in tear secretion.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.
Improving Function in Age-Related Macular Degeneration: A Randomized Clinical Trial – Corrected Proof
Purpose: To compare the efficacy of problem-solving therapy (PST) with supportive therapy (ST) to improve targeted vision function (TVF) in age-related macular degeneration (AMD).Design: Single-masked, attention-controlled, randomized clinical trial wi…
Gene Expression Profiling versus TNM Classification
We respectfully wish to draw attention to the way in which the Tumor, Node, Metastasis (TNM) classification of the American Joint Committee on Cancer (AJCC) was applied by Onken et al in their validation of a multigene prognostic assay in patients with…
Cognitive Impairment in AMD
Woo et al’s study examining the close association of senile neurodegenerative diseases age-related macular degeneration (AMD) and Alzheimer disease concludes that individuals with AMD are at greater risk for cognitive impairment. This assertion merits …
Tuberculosis of Eyelid Presenting as a Chalazion
Inflammatory and neoplastic lesions of the eyelid may present clinically as a primary or recurrent chalazion. We present a case of isolated unilateral tuberculosis of the eyelid masquerading as a partially prolapsed chalazion, missed initially because …
Caregiver Burden in Ocular Disease
Braich et al report a correlation between the degree of visual impairment and caregiver depression, in the context of a large scale study and use of quantitative methods. They describe intensity of care, number of hours spent providing care, low househ…
Editorial Board
Erratum
With apologies from the editorial office, in the Report entitled, “Intraocular Pressure in Pediatric Eyes” (Ophthalmology 2013;120:212), the title should have appeared as “IOL Position in Pediatric Eyes.”
C-Reactive Protein Levels and Tear Function Parameters
Dry eye syndrome (DES) is a common condition that affects patients’ everyday functioning. In a previous study, we found that 50% of patients with severe ocular surface symptoms did not have their symptoms addressed during their eye care visit. In busy …
This Issue At A Glance
Vinciguerra et al (p. 908) evaluated the 4-year outcomes of corneal cross-linking (CXL) for progressive keratoconus, focusing on results according to age. They found that CXL was effective in stabilizing ectatic disease progression in all age groups, w…
Author reply
We would like to thank Chow et al for sharing their interesting case report. Epidermal growth factor (EGF) receptor plays an important role in corneal remodeling. As they mentioned, ophthalmic complications secondary to the use of EGF receptor inhibito…
In Praise of Ignorance (Seriously!), Epistemology (Sort of …), and the Circle of Least Confusion
“Facts are stubborn things, whatever may be our wishes, our inclinations, or the dictates of our passion,” so said John Adams in his successful defense of British soldiers charged with murder in the Boston Massacre. At face value, his declaration e…
Aflibercept-Related Sterile Inflammation
Within the first 3 months after approval of aflibercept (Eylea; Regeneron, Inc., Tarrytown, NY) by the US Food and Drug Administration on November 18, 2011, a cluster of injection-related sterile intraocular inflammation was reported, raising safety co…
A Simple Vista en Este Número
Vinciguerra y otros (p. 908) evaluaron los resultados a 4 años del enlace cruzado de córnea (CXL) para queratocono progresivo, centrándose en los resultados según la edad. Determinaron que el CXL era efectivo para estabilizar la progresión de la e…
Transiency of Fleischer’s Rings in Forme-Fruste Keratoconus
Keratoconus has characteristic biomicroscopic signs that increase in prevalence as the disease progresses. Vögt striae and Fleischer’s ring are considered pathognomonic; however, no comment has been made regarding their relative permanency. This repor…