Category: Peer-reviewed

Purpose:
To identify risk factors and outcome of scleral necrosis after plaque radiotherapy of uveal melanoma.

Design:
Case-control study.

Participants:
A total of 73 cases with scleral necrosis and 73 controls without necrosis after plaque radiotherapy. Controls were matched for anteroposterior tumor epicenter and follow-up duration.

Intervention:
Plaque radiotherapy with iodine-125, cobalt-60, iridium-192, or ruthenium-106.

Main Outcome Measures:
Scleral necrosis.

Results:
Of 5057 patients treated with plaque radiotherapy for uveal melanoma, 73 (1%) developed radiotherapy-induced scleral necrosis. Scleral necrosis occurred in <1% of patients (3/1140) when plaque radiotherapy was used for tumors <3 mm in thickness, 1% of patients (33/3155) with 3- to 8-mm tumor thickness, and 5% of patients (37/762) with >8-mm-thick tumors. On the basis of tumor location, scleral necrosis was detected after plaque radiotherapy of iris melanoma in 0% of patients (0/91), ciliary body melanoma in 29% of patients (67/235), and choroid melanoma in <1% of patients (6/4731). The mean time interval between plaque radiotherapy and scleral necrosis was 32 months (median, 23 months; range, 4–126 months). The mean basal dimension of scleral necrosis was 4 mm (median, 3 mm; range, 1–15 mm), equivalent to 29% of mean tumor base (median, 24%; range, 6%–100%) and 22% of mean plaque size (median, 19%; range, 5%–75%). Multivariate analysis of factors that predicted clinically evident scleral necrosis included ciliary body (P = 0.0001) and pars plana to ora serrata (P < 0.0001) locations of anterior tumor margin, tumor thickness ≥6 mm (P = 0.0001), and radiation dose ≥400 Gy to the outer sclera (P = 0.0455). Scleral necrosis remained stable in 48% of patients (35/73), increased in size/severity in 48% of patients (35/73), or progressed to scleral perforation in 4% of patients (3/73) over a mean follow-up of 79 months (median, 54 months; range, 5–351 months). Treatment of scleral necrosis included observation in 81% of patients (59/73), scleral patch graft in 14% of patients (10/73), and enucleation in 5% of patients (4/73).

Conclusions:
Scleral necrosis after plaque radiotherapy of uveal melanoma was detected in 1% of cases. Factors predictive of scleral necrosis included increasing tumor thickness, ciliary body and peripheral choroidal location, and higher radiation dose to sclera. Most patients (81%) did not require treatment, and 4% evolved to full-thickness perforation.

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

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Purpose:
To evaluate the effect of corneal collagen cross-linking (CXL) on corneal innervation, corneal sensitivity, and tear function in patients with keratoconus.

Design:
Prospective, interventional case series.

Participants:
Twenty-four patients with bilateral keratoconus (30 eyes) who presented to the Institute of Vision and Optics, University of Crete, from May 2008 to October 2008.

Methods:
Patients underwent CXL. Confocal microscopic analysis of corneal sub-basal nerve plexus (total nerve length per image), corneal sensitivity (assessed with the Cochet–Bonnet esthesiometer), basic tear secretion (assessed with Schirmer’s I test with anesthesia), and tear film stability (evaluated by means of tear film break-up time [TFBUT]) were assessed preoperatively and at 1, 3, 6, 9, 12, 18, and 24 months postoperatively.

Main Outcome Measures:
Comparisons between preoperative and each postoperative value of total nerve length per image, corneal sensitivity, Schirmer’s I test results, and TFBUT.

Results:
Total nerve length per image and corneal sensitivity were significantly decreased until postoperative month 6 (for both parameters: P<0.05 paired-samples t test at 1, 3, and 6 months postoperatively). Total nerve length per image tended to increase up to 2 years postoperatively, when it reached the preoperative level, but differences with the preoperative values after the sixth post-CXL month were insignificant. The results of Schirmer’s I test and TFBUT had no statistically significant difference at any time point.

Conclusions:
A transient decrease in corneal innervation and corneal sensitivity can be observed up to 6 months after CXL. No significant effect of CXL could be detected on basic tear secretion and tear film stability in our group of patients.

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

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Purpose: To evaluate the effect of mechanical implantation of a continuous intrastromal ring in keratoconus.Design: Prospective, interventional, nonrandomized, case series.Methods: The MyoRing (Dioptex GmbH) was implanted after creation of an intrastro…

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Purpose:
To evaluate the pharmacogenetic relationship between genotypes of single nucleotide polymorphisms (SNPs) known to be associated with age-related macular degeneration (AMD) and response to treatment with ranibizumab (Lucentis; Genentech, Sout…

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Objective:
To develop a clinical classification system for age-related macular degeneration (AMD).

Design:
Evidence-based investigation, using a modified Delphi process.

Participants:
Twenty-six AMD experts, 1 neuro-ophthalmologist, 2 committee chairmen, and 1 methodologist.

Methods:
Each committee member completed an online assessment of statements summarizing current AMD classification criteria, indicating agreement or disagreement with each statement on a 9-step scale. The group met, reviewed the survey results, discussed the important components of a clinical classification system, and defined new data analyses needed to refine a classification system. After the meeting, additional data analyses from large studies were provided to the committee to provide risk estimates related to the presence of various AMD lesions.

Main Outcome Measures:
Delphi review of the 9-item set of statements resulting from the meeting.

Results:
Consensus was achieved in generating a basic clinical classification system based on fundus lesions assessed within 2 disc diameters of the fovea in persons older than 55 years. The committee agreed that a single term, age-related macular degeneration, should be used for the disease. Persons with no visible drusen or pigmentary abnormalities should be considered to have no signs of AMD. Persons with small drusen (<63 μm), also termed drupelets, should be considered to have normal aging changes with no clinically relevant increased risk of late AMD developing. Persons with medium drusen (≥63–<125 μm), but without pigmentary abnormalities thought to be related to AMD, should be considered to have early AMD. Persons with large drusen or with pigmentary abnormalities associated with at least medium drusen should be considered to have intermediate AMD. Persons with lesions associated with neovascular AMD or geographic atrophy should be considered to have late AMD. Five-year risks of progressing to late AMD are estimated to increase approximately 100 fold, ranging from a 0.5% 5-year risk for normal aging changes to a 50% risk for the highest intermediate AMD risk group.

Conclusions:
The proposed basic clinical classification scale seems to be of value in predicting the risk of late AMD. Incorporating consistent nomenclature into the practice patterns of all eye care providers may improve communication and patient care.

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

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Purpose: To compare nylon monofilament suture with polytetrafluoroethylene sheet for frontalis suspension surgery to treat eyes with congenital ptosis.Design: Retrospective, nonrandomized, comparative, interventional case series.Methods: We reviewed the medical records of 49 patients who had undergone 79 eyelid frontalis suspension surgeries to treat congenital ptosis. All of the patients were younger than 16 years and had congenital ptosis with poor levator muscle function. They were treated with frontalis suspension surgery with either a nylon suture or a polytetrafluoroethylene sheet and were followed up for at least 1 year. A single rhomboid loop sling was used for the nylon suture surgery. For the polytetrafluoroethylene sheet, an incision was made in the eyelid crease, and one end of the sheet was fixed to the tarsus and the other was fixed to the frontalis muscle. The main outcome measures were postoperative recurrences and complications.Results: We evaluated 37 eyelids of 25 patients after nylon suture surgery and 42 eyelids of 31 patients after polytetrafluoroethylene sheet surgery. Among these, 9 eyelids of 7 patients were included in both groups. The median postoperative follow-up period was 32 months in both groups. The recurrence rates were 62.2% for the nylon suture group and 0% for the polytetrafluoroethylene sheet group (P < .001). The postoperative complication rates were 0% for the nylon suture group and 7.1% for the polytetrafluoroethylene sheet group (P > .05).Conclusions: Frontalis suspension using a polytetrafluoroethylene sheet with direct tarsus and frontalis muscle fixation is a reasonable technique with low rates of recurrences and complications.

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Purpose: To investigate the repeatability of tear meniscus measurements using anterior segment swept-source optical coherence tomography (OCT) and the relationship of tear meniscus measurements with tear film breakup time and Schirmer test results.Design: Prospective, observational, cross-sectional study.Methods: We enrolled 26 healthy subjects (26 eyes; 20 men and 6 women; mean age, 36.5 ± 6.8 years) at the University of Tokyo School of Medicine, Tokyo, Japan, in this study. Examinations were conducted in the following sequence: anterior segment vertical raster scans by swept-source OCT, tear film breakup time, and Schirmer test. Each subject underwent OCT measurements twice by the same grader, and the central upper and lower tear menisci height and area and the lower tear meniscus volume were examined. Each OCT image was evaluated by 2 masked graders using the software calipers.Results: The average upper and lower tear meniscus heights were 231 ± 78 μm and 256 ± 57 μm, respectively, and the average upper and lower tear meniscus areas were 18 829 ± 7823 μm2 and 21 903 ± 8173 μm2, respectively. The average tear meniscus volume was 0.1327 ± 0.051 mm3. The intergrader intraclass correlations for all the parameters were more than 95%. The OCT tear meniscus measurements and the Schirmer test scores were correlated significantly (P < .05, Spearman nonparametric correlation analysis). However, tear film breakup time was not correlated significantly with any of the parameters of tear menisci (P > .05).Conclusions: Anterior segment swept-source OCT is a noninvasive and practical method that can be used for quantitative evaluation of tear fluid.

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Purpose: To assess the crystalline lens opacity level by measuring ocular light scattering with a double-pass system.Design: Prospective, single-center, cross-sectional study.Methods: Two hundred fifty-three eyes of 135 patients referred for cataract evaluation were enrolled. Patients with corneal or retinal anomalies potentially impairing ocular transparency were excluded. Lens opacification was assessed by the Lens opacities classification system III. Optical Quality Analysis System (Visiometrics SL) measurements provided ocular Modulation Transfer Function cutoff frequency and Objective Scatter Index. Best-corrected visual acuity and Quality of Vision questionnaire scores (Rasch-scaled) were recorded. We analyzed correlations between visual acuity, type and severity of cataract, Optical Quality Analysis System measurements, and discomfort level in each group.Results: In patients with best-corrected visual acuity better than 20/32, we found correlations between Objective Scatter Index, Modulation Transfer Function, and visual acuity (r = 0.4, P < .0001). The Objective Scatter Index, Modulation Transfer Function, and visual acuity were correlated with each type of cataract. In patients with good visual acuity and moderate functional symptoms, the Objective Scatter Index values also were correlated to the severity of posterior subcapsular cataract (r = 0.4, P = .0006).Conclusions: Patients with incipient cataract may report visual discomfort, despite minor lens opacity on slit-lamp examination, minor loss of best-corrected visual acuity, or both. The measurement of ocular scattering with the Optical Quality Analysis System device may be a useful tool in the preoperative evaluation of patients with early cataract.

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Purpose: To investigate the retention rate and complications of 2 different types of silicon lacrimal punctal plugs with the focus on the relationship to punctum size.Design: A prospective, nonrandomized, interventional, comparative study.Method: Forty-four patients with dry eye syndrome received lacrimal punctal plug insertion with the Punctal Plug F (FCI Ophthalmics) and 30 patients received plug insertion with the Super Flex plug (Eagle Vision; Softplug-Oasis Medical Inc). In total, 110 plug insertion regions were performed using the Punctal Plug F (group A) and 110 insertion regions were carried out using Super Flex plug (group B). The gauging system of Eagle Vision was used before the lacrimal punctal plug insertion in all subjects. Plug conditions (retention rates, spontaneous plug loss, and removal) and complications related to lacrimal punctal sizes were compared between the 2 groups.Results: Retention rates were 70.4% in group A and 30.1% in group B at 6 months. Spontaneous plug loss occurrence was significant with the larger lacrimal punctum size in group A (P < .05), whereas no significant differences were observed between lacrimal punctum sizes and spontaneous loss in group B. Spontaneous plug loss occurrence was significant in elderly patients in group B (P < .05). Granuloma and injector troubles were observed in 1 and 2 cases in group A, respectively.Conclusions: The Punctal Plug F seems to be more applicable for insertion into the smaller punctal sizes. Punctum size and age seem to be important factors in determining the appropriate types of lacrimal punctal plugs.

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Purpose: To analyze the uncorrected binocular performance after biaspheric multifocal central presbyopic laser in situ keratomileusis treatments.Design: Retrospective, interventional case series.Methods: setting. Private clinical practice. patient or …

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Purpose: To determine whether pretreatment (baseline) optical coherence tomography (OCT) features can be used as predictors of visual acuity outcome at 12 months in eyes with neovascular age-related macular degeneration treated with intravitreal ranibizumab and to assess whether baseline OCT features can predict a change in visual acuity from baseline to 12 months.Design: Retrospective, observational study.Methods: We retrospectively evaluated the serial cross-sectional images of the macula obtained using the Spectralis OCT (HRA+OCT; Heidelberg Engineering) in 100 eyes of 94 patients attending a single center and undergoing treatment with intravitreal ranibizumab for neovascular age-related macular degeneration. The baseline OCT characteristics and visual acuity were correlated to the final visual acuity (Early Treatment Diabetic Retinopathy Study letters) and change in visual acuity after 12 months of monitoring and treatment. Univariate and multivariate analyses were carried out to correlate these morphologic features with the final visual acuity and the change in visual acuity.Results: Intact ellipsoid zone (P = .0001) and external limiting membrane in the subfoveal area (P < .0001) at baseline were the only 2 independent good prognostic indicators of final visual acuity at 12 months. However, none of the morphologic features at baseline could predict the change in visual acuity by 12 months.Conclusions: The results suggest that integrity of the outer retinal layers at baseline is crucial for determining final visual acuity at 12 months in eyes undergoing treatment with ranibizumab for neovascular age-related macular degeneration.

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Purpose: To report the frequency of postoperative vitreous hemorrhage (VH) in eyes that underwent primary 23-gauge pars plana vitrectomy (PPV) for nonclearing VH resulting from proliferative diabetic retinopathy, as well as associated risk factors.Design: Retrospective, consecutive, interventional case series.Methods: setting: Institutional (Retina Service of Wills Eye Institute). study population: One hundred seventy-three eyes of 157 patients. intervention: Twenty-three–gauge PPV for nonclearing diabetic VH. main outcome measures: Percentage of eyes in which postoperative VH developed, categorized as early, delayed, or severe persistent, as well as percentage requiring reoperation.Results: During a mean follow-up of 32 weeks, 56 (32%) of 173 eyes demonstrated postoperative VH, categorized as early (8 eyes; 5%), delayed (13 eyes; 8%), or severe persistent (35 eyes; 20%). Twenty-two (13%) of 173 eyes required reoperation: 4 (50%) of 8 in the early group, 8 (62%) of 13 in the delayed group, and 10 (29%) of 35 in the severe persistent group. Mean preoperative logarithm of the minimum angle of resolution visual acuity was 1.5 (Snellen equivalent, approximately 20/600); mean postoperative VA was 0.65 (Snellen equivalent, approximately 20/90), a gain of 0.85 (P < .0001). Thirty-four (27%) of 127 eyes with complete scatter photocoagulation before undergoing PPV compared with 22 (48%) of 46 eyes with incomplete scatter photocoagulation before undergoing PPV demonstrated postoperative VH (P = .002). Other factors associated with postoperative VH included younger age (P = .022) and phakia (P = .036).Conclusions: Postoperative VH was not uncommon after initial 23-gauge PPV for diabetic VH and was associated with incomplete scatter photocoagulation, younger age, and phakia before PPV. However, only a minority of patients required reoperation.

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Purpose: To introduce a new approach for short-term external scleral buckling with pneumatic retinopexy for the management of rhegmatogenous retinal detachment with inferior retinal breaks.Design: Retrospective, noncomparative, interventional case series.Methods: A review of 33 consecutive eyes of 31 patients who underwent external buckling with pneumatic retinopexy for uncomplicated rhegmatogenous retinal detachment with inferior retinal breaks from December 2006 through December 2010. An external buckle was made of a 505 sponge sutured along the blunt side of a 279 tyre (MIRA Inc). The buckle was inserted deeply into the inferior fornix without suture after pneumatic retinopexy and was kept in place for 3 days. Primary and final anatomic outcomes, visual acuity, and adverse events were recorded.Results: All patients tolerated the procedure. The mean follow-up period was 24.0 months (range, 9 to 61 months). Primary success, defined as successful retinal reattachment within 6 months without further treatment, was achieved in 29 (87.9%) eyes. All patients attained final retinal reattachment (100%). Overall, the mean best-corrected visual acuity improved significantly at the end of follow-up (0.30 logarithm of the minimal angle of resolution units; Snellen equivalent, 6/12), compared with the preoperative best-corrected visual acuity (0.82 logarithm of the minimal angle of resolution units; Snellen equivalent, 6/38; P < .001).Conclusions: Short-term external buckling with pneumatic retinopexy is a novel and effective treatment for rhegmatogenous retinal detachment with inferior retinal breaks, with a comparable success rate with other treatment methods. This approach also can avoid complications of long-term buckle implantation. Further comparative cohort studies may be necessary to compare the clinical efficacy with other conventional operations.

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Purpose: To compare choroidal thickness and extent and density of drusen between eyes with typical exudative age-related macular degeneration (AMD) and eyes with retinal angiomatous proliferation (RAP).Design: Observational case series.Methods: Twenty-four eyes with typical exudative AMD and 20 eyes with RAP were included. Subfoveal choroidal thickness was measured using enhanced depth imaging optical coherence tomography. Eyes were classified into 3 groups according to the extent of drusen distribution in the fundus photograph. Density of drusen was estimated based on optical coherence tomography images of the fellow eye. The proportion of the length beneath the drusen per the entire length of the Bruch membrane was defined as the density of drusen. Subfoveal choroidal thickness, extent of drusen distribution, and the density of drusen were compared between typical exudative AMD and RAP.Results: Mean ± standard deviation subfoveal choroidal thickness in eyes with typical exudative AMD and eyes with RAP was 184.9 ± 68.5 μm and 139.0 ± 65.5 μm, respectively (P = .035). The mean density of drusen was 0.06 ± 0.08 and 0.24 ± 0.12, respectively (P < .001). In the typical exudative AMD group, 19, 3, and 2 eyes were included in the small extent group ( two thirds), respectively. In the RAP group, 3, 14, and 3 eyes were included in each aforementioned group, respectively (P = .001).Conclusions: The thinner subfoveal choroidal thickness and greater extent and density of drusen in RAP than the typical exudative AMD may suggest compromised choroidal perfusion in the development of RAP.

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Purpose: To reappraise macular pseudohole characteristics using spectral-domain optical coherence tomography (OCT) and characteristics and postoperative outcomes of macular pseudoholes.Design: Retrospective, observational case series.Methods: In this i…

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Purpose:
To report the 4-year outcomes of corneal cross-linking (CXL) for progressive keratoconus in a population of different age groups.

Design:
Retrospective, single-center, nonrandomized clinical study.

Participants:
Four hundred consecutive …

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Objective:
To determine whether foveal swelling exists in patients with foveal sparing and geographic atrophy (GA) secondary to dry age-related macular degeneration (AMD) and to establish the contribution of different foveal layers to this condition …

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Objective:
To describe the clinical and genetic characteristics of patients with autosomal recessive bestrophinopathy (ARB).

Design:
Retrospective case series.

Participants:
Ten patients with ARB from 7 different families.

Methods:
All patients…

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Purpose:
To determine clinical features predictive of growth of iris nevus into melanoma.

Design:
Retrospective, comparative case series.

Participants:
A total of 1611 consecutive patients referred to an ocular oncology center with iris nevus.

Intervention:
Observation and photographic documentation.

Main Outcome Measures:
Growth into melanoma.

Results:
The mean age at referral for iris nevus was 51 years (median, 54; range, <1–94 years). At presentation, the mean tumor basal diameter was 3 mm (median, 3 mm; range, <1–12 mm) and mean tumor thickness was 0.8 mm (median, 0.5 mm; range, 0–5 mm). All patients were initially diagnosed with benign iris nevus. Growth of iris nevus to melanoma was confirmed in 2% of eyes (n = 27) over a mean follow-up of 68 months (median, 46 months; range, 3–465 months). By Kaplan–Meier estimates, iris nevus growth to melanoma occurred in <1%, 3%, 4%, 8%, and 11% at 1, 5, 10, 15, and 20 years, respectively. Factors predictive of iris nevus growth to melanoma by multivariable analysis included age ≤40 years at presentation (hazard ratio [HR], 3), episode of hyphema (HR, 9), 4:00 to 9:00 clock hour location of tumor (HR, 9), diffuse tumor (involving entire iris surface) (HR, 14), ectropion uveae (HR, 4), and feathery tumor margins (HR, 3). Additional important factors by univariable analysis included tumor seeding on the iris or in the anterior chamber angle, feeder vessels, and nodule formation. These factors can be remembered using the mnemonic ABCDEF, representing A = age young, B = blood, C = clock hour inferior, D = diffuse, E = ectropion, and F = feathery margin.

Conclusions:
In an analysis of 1611 cases of iris nevus referred for evaluation at an ocular oncology center, growth into melanoma occurred in 8% by 15 years. Risk factors for growth, identified by ABCDEF included Age young, Blood (hyphema), Clock hour inferior, Diffuse configuration, Ectropion uveae, and Feathery tumor margin.

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

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Purpose:
To investigate prognostic factors for visual improvement in patients undergoing vitrectomy for epiretinal membrane (ERM) using spectral domain (SD) optical coherence tomography (OCT).

Design:
Prospective cohort study.

Participants:
A total of 41 eyes of 38 patients.

Methods:
A total of 41 eyes of 38 patients with idiopathic ERM underwent ERM resection. Ophthalmic evaluations included best-corrected visual acuity (BCVA) and OCT parameters before and 1, 3, and 6 months after surgery. Correlations between OCT parameters and BCVA were assessed at each time point. Correlations between postoperative BCVA and preoperative factors were evaluated, including age, preoperative BCVA, photoreceptor outer segment (PROS) length, central foveal thickness (CFT), outer foveal thickness (OFT), and outer nuclear layer thickness (ONLT). The factors influencing postoperative BCVA were evaluated using multiple regression analysis.

Main Outcome Measures:
The BCVA at 6 months postoperatively.

Results:
The PROS length had the most significant correlation with BCVA at each time point (baseline: P = 0.0098, r = −0.409; 1 month: P = 0.0002, r = −0.586; 3 months: P < 0.0001, r = −0.642; 6 months: P = 0.0002, r = −0.577). The PROS length 1 month postoperatively was significantly decreased compared with that preoperatively (P = 0.0325), and the PROS length at 3 months recovered to the baseline length. Preoperative BCVA and PROS length were significantly correlated with postoperative BCVA at 6 months (P = 0.0055, r = 0.439 and P = 0.0089, r = −0.414, respectively). Other parameters, including age, CFT, OFT, and ONLT, were not significantly correlated with postoperative BCVA. Multiple regression analysis showed that preoperative PROS length yielded the highest regression coefficient with postoperative BCVA (P = 0.0363, standard regression coefficient = −0.335, overall R2 = 0.289).

Conclusions:
Imaging of PROS length with SD-OCT was found to be a good indicator of BCVA at each time point after surgery and a predictor of postoperative BCVA in patients with idiopathic ERM. The PROS length changes after surgery may indicate surgical injury and restoration of the macular outer layer.

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

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