Category: Peer-reviewed

Clinic-Based Glaucoma Care in the Era of Surgical Subspecialization – Accepted Manuscript

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Abstract: Purpose: To evaluate the impact of surgeon practice profile on clinic-based glaucoma care.Design: Population-based study of glaucoma care patterns in Ontario, Canada from 2000 to 2010.Methods: Using comprehensive physician services data from the Ontario Health Insurance Plan database, ophthalmologists were divided into five surgical practice subgroups. The role of each subgroup in the provision of glaucoma care was evaluated. Consultations and office visits were used to assess non-surgical care, while laser trabeculoplasty procedures were used to assess clinic-based procedural care.Results: Between 2000 and 2010, the population rate of glaucoma consultations and follow up visits provided by ophthalmologists who do not perform incisional glaucoma surgery increased at average annual rates of 1.6% (p<0.0002) and 3.3% (p<0.0001), respectively. In contrast, no significant growth in the rate of glaucoma consultations or follow up visits provided by glaucoma surgeons was observed (0.8%/year [p=0.2] for consultations; 0.2%/year [p=0.6] for follow up visits). Between 2000 and 2010, the rate of laser trabeculoplasty procedures provided by ophthalmologists who do not perform incisional glaucoma surgery increased 19.3% annually (p<0.0001), while growth among glaucoma surgeons was more modest (annual growth of 9.2% [p=0.0002]).Conclusions: While subspecialization is a growing reality in most areas of medicine, we found that the provision of clinic-based glaucoma care remains dependent on ophthalmologists that do not perform incisional glaucoma surgery. With increasing focus on integrated care, these findings will have important implications for residency education programs and their accrediting bodies and will inform decisions of health care policy makers, hospitals and academic departments.

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Comparison of refractive stability after non-toric versus toric intraocular lens implantation during cataract surgery – Accepted Manuscript

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Abstract: Purpose: To compare refractive state changes in eyes implanted with toric intraocular lenses (IOLs) versus non-toric IOLs, after cataract extraction.Design: Retrospective, comparative.Methods: In a single-institution, 121 eyes underwent phacoemulsification and implantation with either non-toric IOLs (AcrySof® IQ SN60WF) or toric IOLs (AcrySof® Toric IOL). The spherical value, cylindrical value, spherical equivalent (SE) of refractive error, and visual acuity were measured preoperatively and 1, 3, and 6 months after surgery. Main outcome measures were the pattern of changes of spherical, cylindrical, and SE values based on postoperative time, between different IOL types.Results: The groups included patients who underwent surgery with SN60WF (Group I), SA6AT3 (Group II-3), SA6AT4 (Group II-4), and SA6AT5 lens (Group II-5) containing 37, 29, 23, and 32 eyes, respectively. The cylindrical value was significantly decreased in all groups (p<0.05). Before surgery, the SE of refractive errors was estimated as -0.21, -0.10, -0.20, and -0.22 in respective groups. The actual remaining SE values were -0.19, -0.24, -0.42, and -0.56 at 1 month; -0.17, -0.26, -0.57, and -0.64 at 3 months; and -0.17, -0.26, -0.70, and -0.74 at 6 months postoperatively, respectively. The follow-up SE values in groups I and II-3 were similar (p>0.05 in both groups); however, significant myopic changes were observed in Groups II-4 and II-5 after surgery, versus Group I (p<0.05).Conclusion: Selection of toric IOLs for cataract surgery requires a refined formula to precisely determine necessary IOL power, especially in cases with high levels of astigmatism, to reliably and accurately prevent myopic outcomes.

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Comparison of Wide-Field Fluorescein Angiography and Nine-Field Montage Angiography in Uveitis – Accepted Manuscript

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Abstract: Purpose: To qualitatively and quantitatively compare Optos© fundus camera fluorescein angiographic images of retinal vascular leakage with 9-field montage Topcon© fluorescein angiography (FA) images in patients with uveitis. We hypothesized that Optos images reveal more leakage in uveitis patients.Design: Retrospective, observational case series.Methods: Images of all uveitis patients imaged with same-sitting Optos FA and 9-field montage FA during a 9 month period at a single institution (52 eyes of 31 patients) were graded for the total area of retinal vascular leakage. The main outcome measure was area of fluorescein leakage.Results: The area of apparent FA leakage was greater in Optos images than in 9-field montage images (median 22.5 mm2 vs. 4.8 mm2, P<0.0001). Twenty-two of 49 (45%) eyes with gradable photos had at least 25% more leakage on the Optos image than on the montage image. Two (4.1%) had at least 25% less leakage on Optos, and 25 (51%) were similar between the two modalities. Two eyes had no apparent retinal vascular leakage on 9-field montage but were found to have apparent leakage on Optos images. Twenty-three of the 49 eyes had posterior pole leakage, and of these 17 (73.9%) showed more posterior pole leakage on the Optos image. A single 200 degree Optos FA image captured a mean 1.50x the area captured by montage photography.Conclusion: More retinal vascular pathology, both in the periphery and the posterior pole, is seen with Optos FA in uveitis patients when compared with 9-field montage. The clinical implications of Optos FA findings have yet to be determined.

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HLA-DR, DQ Class II DNA Typing in Pediatric Panuveitis and Tubulointerstitial Nephritis and Uveitis (TINU) – Accepted Manuscript

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Abstract: Purpose: To describe chorioretinal lesions in pediatric uveitis that are strongly associated with the HLA-DR,DQ Class II type associated with tubulointerstitial nephritis and uveitis (TINU).Design: Retrospective, observational case series.Methods: Results: Fourteen of the 15 patients (93%) with otherwise unexplained pediatric panuveitis typed HLA-DRB1*01-HLA-DQB1*05. Eleven of 15 (73.3%) had bilateral sharply demarcated, usually inferior, 200-300 micron spots of chorioretinal atrophy, and 4 of 15 (27.7%) had bilateral clusters of 500-750 micron poorly defined orange choroidal lesions without overlying atrophy of the retinal pigment epithelium. None had interstitial nephritis. Four of the 6 definite TINU cases had Class II typing and TINU risk alleles; all 6 had bilateral panuveitis. The frequency of risk alleles was statistically higher in pediatric panuveitis than in the North American population, and in non-panuveitis pediatric uveitis patients assumed to have the North American HLA distribution (P<.0001, Fischer’s Exact). Positive likelihood ratios were 9.92 to 5.18 depending on assumptions regarding pre-test probability of disease.Conclusions: Recognition of characteristic chorioretinal lesions in otherwise unexplained pediatric panuveitis, supported by selective HLA Class II DNA typing, is useful in narrowing diagnostic possibilities and directing further evaluations. Panuveitis is under appreciated as a manifestation of TINU.

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Lateral Rectus Superior Compartment Palsy – Corrected Proof

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Purpose: To employ magnetic resonance imaging (MRI) to seek evidence of compartmental lateral rectus atrophy consistent with a lesion involving selective denervation of only 1 of the 2 neuromuscular compartments of the lateral rectus.Design: Prospective observational case-control series.Methods: At a single institution, surface coil coronal MRI was obtained at 312 μm resolution in quasi-coronal planes 2 mm thick throughout the orbit in 20 normal volunteers and 18 patients with unilateral lateral rectus palsy fixated monocularly on a target placed in central gaze. Maximum cross sections and posterior volumes of the superior and inferior lateral rectus compartments were computed and correlated with clinical findings.Results: Twelve patients with lateral rectus palsy demonstrated symmetric, highly significant 40% reductions in maximum cross sections and 50% reductions in posterior volumes from normal for both compartments (P < 10−6 for all comparisons). Six patients with lateral rectus palsy had similar significant but asymmetric reductions in those measures only for the superior compartment of the affected lateral rectus (P < 10−4 for all comparisons), with insignificant 20%-30% reductions for the inferior compartment (P > 0.2 for all comparisons).Conclusions: A subset of patients with clinical lateral rectus palsy may have palsy limited to the superior compartment. Paralytic esotropia may be caused by lateral rectus superior compartment palsy despite an intact lateral rectus inferior compartment. This finding is consistent with evidence supporting independent innervation of the 2 lateral rectus neuromuscular compartments.

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Author Reply – Corrected Proof

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Dr Fellman’s thoughtful comments allow for an opportunity to provide clarification with regard to the message conveyed in the editorial, “Things Go Better With Cataract Surgery.” First and foremost, I agree with Dr Fellman that blebless surgery is …

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Distribution of Retinal Layer Atrophy in Patients With Parkinson Disease and Association With Disease Severity and Duration – Corrected Proof

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Purpose: To evaluate the thickness of the 10 retinal layers in the paramacular area of Parkinson disease patients using a new segmentation technology of optical coherence tomography (OCT) to examine whether the thickness of specific layers predicts neurodegeneration or Parkinson disease severity.Design: Observational prospective study.Methods: Parkinson disease patients (n = 129) and age-matched healthy subjects (n = 129) were enrolled. The Spectralis OCT system was used to automatically segment all retinal layers in a parafoveal scan using the new segmentation application prototype. Mean thickness of each layer was calculated and compared between Parkinson disease patients and healthy subjects, and between Parkinson disease patients with disease durations of less than or at least 10 years. A correlation analysis was performed to evaluate the association between retinal layer thickness, duration of disease, and Parkinson disease severity. Logistic regression analysis was performed to determine the most sensitive layer for predicting axonal atrophy.Results: Parkinson disease patients showed statistically significant reduced thickness in the retinal nerve fiber, ganglion cell, inner plexiform, and outer plexiform layers and increased thickness in the inner nuclear layer compared with healthy subjects (P < .05). The inner retinal layers were more affected in Parkinson disease patients with long disease duration. The ganglion cell layer thickness was inversely correlated with disease duration and Parkinson disease severity, and was predictive of axonal damage in Parkinson disease patients.Conclusions: The segmentation application of the Spectralis OCT revealed retinal layer atrophy in Parkinson disease patients, especially in the inner layers of patients with long disease duration. Ganglion cell layer reduction was associated with increased axonal damage.

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Atropine for the Treatment of Childhood Myopia: Changes after Stopping Atropine 0.01%, 0.1% and 0.5% – Corrected Proof

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Purpose: To study the change in spherical equivalent and other ocular parameters 1 year after stopping the administration of atropine.Design: Prospective randomized double-masked clinical trial.Methods: We assigned 400 myopic children, 6 to 12 years of age, to receive atropine 0.5%, 0.1% or 0.01% for 24 months, after which medication was stopped. Parents and children gave informed consent to participate in the research. Children were reviewed at 26, 32 and 36 months, and changes in cycloplegic spherical equivalent (SE), axial length (AL), visual acuity, pupil size, and accommodation were assessed.Results: Of the children, 356 (89%) entered into the washout phase. At entry, there was no significant difference in age, gender, SE, or AL among the children in the various atropine groups. Over the following 12 months, myopic progression was greater in the 0.5% eyes (−0.87 ± 0.52 D), compared to the 0.1% (−0.68 ± 0.45 D) and 0.01% eyes (−0.28 ± 0.33 D, P < 0.001). AL growth was also greater in the 0.5% (0.35 ± 0.20 mm) and 0.1% (0.33 ± 0.18 mm) eyes, compared to the 0.01% eyes (0.19 ± 0.13 mm, P < 0.001). Pupil size and near visual acuity returned to pre-atropine levels in all groups, but accommodation at 36 months was less in the 0.5% eyes (13.24 ± 2.72 D) compared to the 0.1% (14.45 ± 2.61 D) and 0.01% eyes (14.04 ± 2.90 D, P < 0.001). The overall increase in SE over the entire 36 months in the 0.5%, 0.1% and 0.01% groups was −1.15 ± 0.81 D, −1.04 ± 0.83 D and −0.72 ± 0.72 D, respectively (P < 0.001).Conclusion: There was a myopic rebound after atropine was stopped, and it was greater in eyes that had received 0.5% and 0.1% atropine. The 0.01% atropine effect, however, was more modulated and sustained.

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Tear Meniscus Dimensions in Tear Dysfunction and Their Correlation With Clinical Parameters – Corrected Proof

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Purpose: To evaluate relationships between tear meniscus dimensions and parameters of ocular surface disease in a variety of tear dysfunction conditions.Design: Single-institution prospective observational study.Methods: This study from the Baylor College of Medicine included 128 eyes of 64 subjects. Cross-sectional lower tear meniscus height and tear meniscus area were measured using optical coherence tomography and were compared with tear break-up time (TBUT), corneal staining, conjunctival staining, and an irritation symptom questionnaire (Ocular Surface Disease Index). Study groups included meibomian gland disease (MGD), aqueous tear deficiency (ATD), Sjögren syndrome, non–Sjögren syndrome ATD, and control subjects. Statistical analyses were performed using the Pearson correlation and Student’s t test.Results: When compared with mean tear meniscus height in controls (345 μm), mean tear meniscus height was lower in all tear dysfunction (234 μm; P = .0057), ATD (210 μm; P = .0016), and Sjögren syndrome groups (171 μm; P = .0054). For tear meniscus height ≤210 μm, relative risk ratio for developing corneal staining ≥10 was 4.65. Tear meniscus height correlated with corneal staining for all subjects (R = −0.32; P = .0008), MGD (R = +0.40; P = .059), and ATD (R = −0.36; P = .04). Tear meniscus area showed similar trends in MGD (R = +0.55; P = .006) and ATD (R = −0.40; P = .018). Tear meniscus height correlated with TBUT for all subjects (R = +0.39; P < .0001) and ATD (R = +0.37; P = .018).Conclusions: In tear dysfunction conditions, lower tear volume correlates with worse corneal epithelial disease in ATD and Sjögren syndrome, conditions with lacrimal gland dysfunction. In contrast, higher tear volume is associated with corneal epithelial disease in MGD. These findings may improve the ability to identify patients at risk for corneal epithelial disease.

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Increased Risk of Parkinson Disease Following a Diagnosis of Neovascular Age-Related Macular Degeneration: A Retrospective Cohort Study – Corrected Proof

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Purpose: To investigate the risk for Parkinson disease during a 3-year follow-up period after a diagnosis of neovascular age-related macular degeneration (AMD) using a nationwide population-based dataset in Taiwan.Design: A retrospective matched-cohort study.Methods: We identified 877subjects with neovascular AMD as the study cohort and randomly selected 8770 subjects for a comparison cohort. Each subject was individually followed for a 3-year period to identify those who subsequently developed Parkinson disease. Stratified Cox proportional hazard regressions were performed as a means of comparing the 3-year risk of subsequent Parkinson disease between the study and comparison cohorts.Results: The incidence rate of Parkinson disease was 5.32 (95% confidence interval [CI]: 3.03-8.72) per 1000 person-years in patients with neovascular AMD and 2.09 (95% CI: 1.59-2.70) per 1000 person-years in comparison patients. The log-rank test indicated that subjects with neovascular AMD had a significantly lower 3-year Parkinson disease–free survival rate than comparison subjects (P < .001). After censoring cases in which patients died during the follow-up period and adjusting for monthly income, geographic region, hypertension, diabetes, hyperlipidemia, and coronary heart disease, the hazard ratio of Parkinson disease during the 3-year follow-up period for subjects with neovascular AMD was 2.57 (95% CI: 1.42-4.64) that of comparison subjects.Conclusion: In this study, subjects with neovascular AMD were found to be at a significant risk of Parkinson disease during a 3-year follow-up period after their diagnosis among Taiwanese Chinese. Further study is needed to confirm our findings and explore the underlying pathomechanism.

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The Spectrum of Ocular Alterations in Patients with β-Thalassemia Syndromes Suggests a Pathology Similar to Pseudoxanthoma Elasticum – Corrected Proof

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Purpose: To determine the prevalence and spectrum of ocular fundus abnormalities in patients with β-thalassemia and to investigate risk factors for their development.Design: Cross-sectional, observational study.Participants: A total of 255 patients with β-thalassemia major (TM) and β-thalassemia intermedia (TI) were consecutively recruited and investigated.Methods: Patients underwent best correct visual acuity, indirect ophthalmoscopy, and fundus photography, including fundus autofluorescence (FAF) and near-infrared reflectance imaging using a confocal scanning laser ophthalmoscope (cSLO). Hematologic parameters were determined, including mean ferritin levels, aspartate amino transferase, alanine amino transferase, calcium, pre-transfusion hemoglobin, history of splenectomy, and liver iron concentration. Factors associated with the ocular phenotype were assessed using logistic regression.Main Outcome Measures: Ocular phenotype as determined by clinical examination and used multimodal imaging.Results: A total of 153 patients (60.0%) affected by TM and 102 patients (40.0%) affected by TI participated, of whom 216 (84.7%) were receiving iron-chelating therapy. Ocular fundus abnormalities characteristic of pseudoxanthoma elasticum (PXE) were detected by cSLO in 70 of 255 patients (27.8%) and included peau d’orange (19.6%), angioid streaks (12.9%), pattern dystrophy-like changes (7.5%), and optic disc drusen (2.0%). Pseudoxanthoma elasticum–like changes were more frequent in patients with TI (P < 0.001). Patients with PXE-like fundus changes were older than patients without these fundus changes (P < 0.001). In both patients with TI and TM, age (P = 0.001) and splenectomy (P = 0.001) had the strongest association with presence of PXE-like fundus changes in multivariate analyses. A total of 43 of 255 patients (16.9%) showed increased retinal vascular tortuosity independently of the PXE-like fundus changes, which was associated with aspartate amino transferase (P = 0.036), hemoglobin (P = 0.008), and ferritin levels (P = 0.005).Conclusions: Pseudoxanthoma elasticum–like fundus changes are a frequent finding in patients with β-thalassemia. In TI, these changes increase with duration or severity of the disease. This particular ocular phenotype suggests an ocular pathology similar to PXE. Retinal vascular tortuosity may be an additional disease manifestation independent of the PXE-like syndrome. Patients with long-standing disease requiring iron-chelating treatment and a history of splenectomy need regular ophthalmic checkups because they are at risk of developing PXE-like fundus changes and potentially of subsequent choroidal neovascularization.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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