Category: Peer-reviewed

Obstructive Sleep Apnea and Increased Risk of Glaucoma: A Population-Based Matched-Cohort Study – Corrected Proof

by  •  • 0 Comments

Purpose: Previous studies had reported an increased prevalence of glaucoma in patients with obstructive sleep apnea (OSA). However, the risk of open-angle glaucoma (OAG) among patients with OSA remains unclear. Using a nationwide, population-based dataset in Taiwan, this study aimed to examine the prevalence and risk of OAG among patients with OSA during a 5-year follow-up period after a diagnosis of OSA.Design: A retrospective, matched-cohort study.Participants and Controls: This study used data sourced from the Longitudinal Health Insurance Database 2000. We included 1012 subjects with OSA in the study cohort and randomly selected 6072 subjects in the comparison group.Methods: Each subject in this study was individually traced for a 5-year period to identify those subjects who subsequently received a diagnosis of OAG. Cox proportional hazards regression was performed to calculate the 5-year risk of OAG between the study and comparison cohorts.Main Outcome Measures: The incidence and risk of OAG between the study and comparison groups.Results: During the 5-year follow-up period, the incidence rate per 1000 person-years was 11.26 (95% confidence interval [CI], 8.61–14.49) and 6.76 (95% CI, 5.80–7.83) for subjects with and without OSA, respectively. After adjusting for monthly income, geographic region, diabetes, hypertension, coronary heart disease, obesity, hyperlipidemia, renal disease, hypothyroidism, and the number of outpatient visits for ophthalmologic care during the follow-up period, stratified Cox proportional hazards regression revealed that the hazard ratio for OAG within the 5-year period for subjects with OSA was 1.67 (95% CI, 1.30–2.17; P<0.001) that of comparison subjects.Conclusions: Our results suggest that OSA is associated with an increased risk of subsequent OAG diagnosis during a 5-year follow-up period.Financial Disclosures(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Read more →

Risk of Elevated Intraocular Pressure and Glaucoma in Patients with Uveitis: Results of the Multicenter Uveitis Steroid Treatment Trial – Corrected Proof

by  •  • 0 Comments

Objective: To report the 2-year incidence of raised intraocular pressure (IOP) and glaucomatous optic nerve damage in patients with uveitis randomized to either fluocinolone acetonide (FA) implants or systemic therapy. Secondarily, we sought to explore patient and eye characteristics associated with IOP elevation or nerve damage.Design: A randomized, partially masked trial in which patients were randomized to either FA implants or systemic therapy.Participants: Patients aged ≥13 years with noninfectious intermediate, posterior, or panuveitis active within the prior 60 days for which systemic corticosteroids were indicated were eligible.Methods: Visual fields were obtained at baseline and every 12 months using the Humphrey 24-2 Swedish interactive threshold algorithm fast protocol. Stereoscopic optic nerve photos were taken at baseline and at 3-, 6-, 12-, and 24-month follow-up visits. Masked examiners measured IOP at every study visit.Main Outcome Measures: Glaucoma was diagnosed based on an increase in optic nerve cup-to-disc ratio with visual field worsening or increased cup-to-disc ratio alone, for cases where visual field change was not evaluable, because of missing data or severe visual field loss at baseline.Results: Most patients were treated as assigned; among those evaluated for glaucoma, 97% and 10% of patients assigned to implant and systemic treatment, respectively, received implants. More patients (65%) assigned to implants experienced an IOP elevation of ≥10 mmHg versus 24% assigned to systemic treatment (P<0.001). Similarly, 69% of patients assigned to the implant required IOP-lowering therapy versus 26% in the systemic group (P<0.001). Glaucomatous optic nerve damage developed in 23% versus 6% (P<0.001) of implant and systemic patients, respectively. In addition to treatment assignment, black race, use of IOP-lowering medications, and uveitis activity at baseline were associated with incident glaucoma (P<0.05).Conclusions: Implant-assigned eyes had about a 4-fold risk of developing IOP elevation of ≥10 mmHg and incident glaucomatous optic neuropathy over the first 2 years compared with those assigned to systemic therapy. Central visual acuity was unaffected. Aggressive IOP monitoring with early treatment (often including early filtration surgery) is needed to avoid glaucoma when vision-threatening inflammation requires implant therapy.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

Read more →

Analysis of a Novel Protocol of Pulsed Intravenous Cyclophosphamide for Recalcitrant or Severe Ocular Inflammatory Disease – Corrected Proof

by  •  • 0 Comments

Purpose: To analyze the success rate of pulsed intravenous (IV) cyclophosphamide (CyP) for noninfectious ocular inflammatory disease and to identify risk factors for failure of therapy.Design: Retrospective, interventional, noncomparative cohort study.Participants: One hundred ten eyes of 65 patients.Methods: Through a computer search of the Massachusetts Eye Research and Surgery Institution’s database, we identified patients who were treated with IV CyP between May 2005 and April 2012. We obtained demographic and clinical information through review of the electronic health record of each patient.Main Outcomes Measures: Clinical response, corticosteroid-sparing effect, recurrence rate, calculated “risk factors” for failure, visual acuity, and adverse reactions.Results: Pulsed IV CyP achieved complete remission of inflammation (for ≥2 visits) in 54 patients (84.4%). Sustained remission of inflammation occurred in 70% of patients within 3 months, 86.6% of patients within 6 months, and 91.7% within 9 months. The mean time to achieving quiescence was 3.5 months. The success rate in reducing corticosteroid to prednisone ≤10 mg/d within 6 months, while maintaining control of ocular inflammation, was 89.7% (95% confidence interval [CI], 81.1–93.5%). The mean duration of clinical remission for those patients who had a positive response to CyP was 32.67 months (95% CI, 25.91–39.43). Relapse of vasculitis was observed in 1 patient (1.5%) after completing the course of therapy. Early initiation of therapy during the course of the disease was correlated with a lesser rate of recurrence (P = 0.028). The most common adverse effects were nausea (29%) and transient lymphopenia (26%). The mean best-corrected visual acuity (BCVA) improved from 0.59±0.66 at baseline to 0.30±0.54 at 6 months of follow-up (P<0.001). The mean follow-up period was 31.61±20.47 months.Conclusions: Pulsed IV CyP employing our protocol results in an extremely high rate of sustained complete remission in patients with recalcitrant and fulminant, vision-threatening ocular inflammatory disorders, with an excellent safety profile in the hands of physicians trained and skilled in the art of this therapy. It also allows tapering and discontinuing corticosteroids in most patients. Early initiation of therapy may decrease the risk of relapses.Financial Disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article.

Read more →

Screening for Diabetic Retinopathy with or without a Copayment in a Randomized Controlled Trial: Influence of the Inverse Care Law – Corrected Proof

by  •  • 0 Comments

Objective:
To examine whether the inverse care law operates in a screening program for diabetic retinopathy (DR) based on fee for service in Hong Kong.

Design:
Randomized controlled trial.

Participants:
All those with type 1 or 2 diabetes from 2 clinics were recruited.

Intervention:
Diabetic retinopathy screening with a small copayment versus free access in a publicly funded family medicine service.

Main Outcome Measures:
Uptake of screening and severity of DR detected. Association between these outcome variables and independent variables were determined using multivariate logistic regression models and reported as odds ratios (ORs).

Results:
After randomization, 1387 subjects in the free group and 1379 subjects in the pay group were eligible for screening, and 94.9% (1316/1387) and 92.6% (1277/1379), respectively, agreed to participate in the study. The offer of screening was accepted by 94.8% (1247/1316) in the free group and 91.2% (1164/1277) in the pay group, and the final uptake ratios were 88.5% (1165/1316) and 82.4% (1052/1277), respectively (Pearson chi = 19.74, P<0.001). Being in the pay group was associated with a lower uptake of screening than being in the free group (OR, 0.59; confidence interval [CI], 0.47–0.74) and a lower detection rate of DR (OR, 0.73; CI, 0.60–0.90) after adjustment for potential confounding factors. Subjects with higher socioeconomic status were more likely to attend screening and had a lower prevalence of DR detected.

Conclusions:
The inverse care law seems to operate in a preventive intervention when a relatively small copayment is applied. There is a case for making effective preventive services free of charge.

Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Read more →

Long-Term Effects of Vitamins C and E, β-Carotene, and Zinc on Age-Related Macular Degeneration: AREDS Report No. 35 – Corrected Proof

by  •  • 0 Comments

Objective: To describe the long-term effects (10 years) of the Age-Related Eye Disease Study (AREDS) formulation of high-dose antioxidants and zinc supplement on progression of age-related macular degeneration (AMD).Design: Multicenter, randomized, controlled, clinical trial followed by an epidemiologic follow-up study.Participants: We enrolled 4757 participants with varying severity of AMD in the clinical trial; 3549 surviving participants consented to the follow-up study.Methods: Participants were randomly assigned to antioxidants C, E, and β-carotene and/or zinc versus placebo during the clinical trial. For participants with intermediate or advanced AMD in 1 eye, the AREDS formulation delayed the progression to advanced AMD. Participants were then enrolled in a follow-up study. Eye examinations were conducted with annual fundus photographs and best-corrected visual acuity assessments. Medical histories and mortality were obtained for safety monitoring. Repeated measures logistic regression was used in the primary analyses.Main Outcome Measures: Photographic assessment of progression to, or history of treatment for, advanced AMD (neovascular [NV] or central geographic atrophy [CGA]), and moderate visual acuity loss from baseline (≥15 letters).Results: Comparison of the participants originally assigned to placebo in AREDS categories 3 and 4 at baseline with those originally assigned to AREDS formulation at 10 years demonstrated a significant (P<0.001) odds reduction in the risk of developing advanced AMD or the development of NV AMD (odds ratio [OR], 0.66, 99% confidence interval [CI], 0.53–0.83 and OR, 0.60; 99% CI, 0.47–0. 78, respectively). No significant reduction (P = 0.93) was seen for the CGA (OR, 1.02; 99% CI, 0.71–1.45). A significant reduction (P = 0.002) for the development of moderate vision loss was seen (OR 0.71; 99% CI, 0.57–0.88). No adverse effects were associated with the AREDS formulation. Mortality was reduced in participants assigned to zinc, especially death from circulatory diseases.Conclusions: Five years after the clinical trial ended, the beneficial effects of the AREDS formulation persisted for development of NV AMD but not for CGA. These results are consistent with the original recommendations that persons with intermediate or advanced AMD in 1 eye should consider taking the AREDS formulation.Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Read more →

Corneal Collagen Cross-Linking for Ectasia after LASIK and Photorefractive Keratectomy: Long-Term Results – Corrected Proof

by  •  • 0 Comments

Purpose:
To report the long-term results of corneal collagen cross-linking (CXL) in ectasia after LASIK and photorefractive keratectomy (PRK).

Design:
Retrospective, interventional cases series.

Participants:
Twenty-six eyes of 26 patients (18 male, 8 female) with postoperative ectasia after LASIK (23 eyes) and PRK (3 eyes) were included with a mean age of 35±9 years at the time of treatment and a mean follow-up of 25 months (range, 12–62 months).

Methods:
All consecutive patients treated with CXL for progressive ectasia after LASIK or PRK at the Institute for Refractive and Ophthalmic Surgery, Zurich, Switzerland between 2004 and 2010 were included.

Main Outcome Measures:
Corrected distance visual acuity (CDVA), maximum keratometry readings (Kmax), minimum radius of curvature (Rmin), and 6 corneal topography indices were assessed in this study.

Results:
Mean CDVA before CXL was 0.5 logarithm of the minimum angle of resolution (logMAR) units, which improved to a mean of 0.3 logMAR units (P<0.001). Corrected distance visual acuity improved 1 line or more in 19 cases and remained unchanged in 7 patients. Mean Kmax after CXL of 50.9±4.9 diopters (D) was significantly lower (P<0.001) than mean pre-CXL Kmax of 52.8±5 D. The Rmin after CXL was increased significantly (P = 0.006), whereas the index of surface variance (P = 0.03), the index of vertical asymmetry (P = 0.04), the keratoconus index (P = 0.03), and the central keratoconus index (P = 0.016) were reduced significantly.

Conclusions:
Ectasia after LASIK and PRK was arrested by CXL with stabilization or improvement of CDVA and Kmax after a mean follow-up of 25 months. There were improvements in 4 topography indices, suggesting a more regular corneal surface.

Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Read more →

Genetic Influences on the Outcome of Anti-Vascular Endothelial Growth Factor Treatment in Neovascular Age-related Macular Degeneration – Corrected Proof

by  •  • 0 Comments

Purpose: To determine the association of genetic variants in known age-related macular degeneration (AMD) risk-associated genes with outcome of anti-vascular endothelial growth factor (VEGF) treatment in neovascular AMD.Design: Prospective cohort study.Participants: We enrolled 224 consecutive patients with neovascular AMD at the Royal Victorian Eye and Ear Hospital, Australia.Methods: Patients were treated with 3 initial monthly ranibizumab or bevacizumab injections followed by 9 months of “as required” injections based on clinician’s decision at each follow-up visit according to retreatment criteria. Seventeen single nucleotide polymorphisms (SNPs) in known AMD risk-associated genes including CFH (rs800292, rs3766404, rs1061170, rs2274700 and rs393955), HTRA1 (rs11200638), CFHR1-5 (rs10922153, rs16840639, rs6667243, and rs1853883), LOC387715/ARMS2 (rs3793917 and rs10490924), C3 (rs2230199 and rs1047286), C2 (rs547154), CFB (rs641153) and F13B (rs6003) were examined. Multivariate analysis was used to determine the role of each SNP in treatment outcome.Main Outcome Measures: The influence of selected SNPs on mean change in visual acuity (VA) at 12 months.Results: Mean baseline VA was 51±16.8 Early Treatment Diabetic Retinopathy Study letters. Overall, the mean change in VA from baseline was +3.2±14.9 letters at 12 months. The AA (homozygote risk) genotype at rs11200638 – HTRA1 promoter SNP (P = 0.001) and GG (homozygote risk) genotype at rs10490924 (A69S) in LOC387715/ARMS2 (P = 0.002) were each significantly associated with poorer VA outcome at 12 months after multiple correction. Mean ± standard deviation change in VA from baseline in patients with AA genotype at rs11200638 was –2.9±15.2 letters after 12 months compared with +5.1±14.1 letters in patients with AG or GG genotypes at this SNP. Patients with either of these genotypes were also significantly more likely to lose >15 letters after 12 months. SNPs rs11200638 and rs10490924 were in high linkage disequilibrium (r2 = 0.92). None of the other examined SNPs was associated with outcome.Conclusions: The HTRA1 promoter SNP (rs11200638) and A69S at LOC387715/ARMS2 were associated with a poorer visual outcome for ranibizumab or bevacizumab treatment in neovascular AMD, suggesting strong pharmacogenetic associations with anti-VEGF treatment. This finding could aid in applying more individualized treatment regimens based on patients’ genotype to achieve optimal treatment response in AMD.Financial Disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article.

Read more →

Long-Term Outcomes of Neoadjuvant Intra-arterial Cytoreductive Chemotherapy for Lacrimal Gland Adenoid Cystic Carcinoma – Corrected Proof

by  •  • 0 Comments

Purpose: To compare the long-term outcomes after intra-arterial cytoreductive chemotherapy (IACC) with conventional treatment for lacrimal gland adenoid cystic carcinoma (ACC).Design: Retrospective case series.Participants: Nineteen consecutive patients treated with IACC, followed by orbital exenteration, chemoradiotherapy, and intravenous chemotherapy.Interventions: Analyses of the histologic characteristics of biopsy specimens, extent of disease at the time of diagnosis, diagnostic surgical procedures, incidence of locoregional recurrences or distant metastases, disease-free survival time, response to IACC, tumor margins at definitive surgery, and toxicity and complications.Main Outcome Measures: Disease relapse, disease-free survival, and chemotherapeutic complications.Results: Eight patients with an intact lacrimal artery had significantly better outcomes for survival (100% vs. 28.6% at 10 years), cause-specific mortality, and recurrences (all P = 0.002, log-rank test) than conventionally treated patients from the University of Miami Miller School of Medicine. These 8 patients (group 1) had cumulative 10-year disease-free survival of 100% compared with 50% for 11 patients (group 2) who had an absence of the lacrimal artery or deviated from the treatment protocol (P = 0.035) and 14.3% for conventionally treated patients (P<0.001). Likewise, group 2 was associated with lower cause-specific mortality than the institutional comparator group (P = 0.038). Prior tumor resection with lateral wall osteotomy, delay in IACC implementation or exenteration, and failure to adhere to protocol are risk factors for suboptimal outcomes.Conclusions: Neoadjuvant IACC seems to improve overall survival and decrease disease recurrence. An intact lacrimal artery, no disruption of bone barrier or tumor manipulation other than incisional biopsy, and protocol compliance are factors responsible for favorable outcomes. The chemotoxicity complication rate is limited and manageable.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Read more →