Park et al evaluated the prevalence of and risk factors for diabetic retinopathy (DR) in Koreans with type II diabetes (400 male, 296 female; aged 30–65 years) enrolled in the Seoul Metro-City Diabetes Prevention Program (SMC-DPP). The overall prevalence of any type of DR was 18.7%. In addition to traditional risk factors (duration of diabetes, serum HbA1c, mean arterial pressure, serum total cholesterol and serum triglycerides) insulin resistance was associated with an increased risk of DR. (see page
Gill et al compared the efficacy and safety of a two-quadrant technique that allows the use of a higher volume of local anaesthetic in 54 patients undergoing vitrectomy. Control group (27) received a standard 5 ml single inferonasal sub-Tenon injection of a 50:50 mixture of 2% lidocaine and 0.5% bupivacaine with 150 IU hyaluronidase and...]]>
To evaluate the prevalence of and risk factors for diabetic retinopathy (DR) in Koreans with type II diabetes.
Subjects (400 male, 296 female) aged 30–65 years (mean 55.3 years) with hyperglycaemia (fasting plasma glucose ≥7.0 mmol/ml) or known diabetes (mean±SD duration 6.36±5.73 years) were enrolled in the Seoul Metro-City Diabetes Prevention Program (SMC-DPP) from September 2008 to September 2009. The severity of DR was diagnosed by grading fundus photographs taken from five standard fields per eye and categorised following the Early Treatment of Diabetic Retinopathy Study grading protocol. All participants underwent routine clinical and laboratory examinations to evaluate risk factors for DR.
The overall prevalence of any type of DR was 18.7%. Logistic regression analyses showed that the following factors were significantly associated with DR after adjustment for age and gender, duration of diabetes, serum glycated haemoglobin A1c (HbA1c), mean arterial pressure, serum total cholesterol and serum triglycerides: duration of diabetes (OR 1.14, 95% CI 1.10 to 1.18, for 1 year increase), HbA1c (OR 1.49, 95% CI 1.20 to 1.85, for 1% increase), serum concentration of insulin (OR 0.87, 95% CI 0.81 to 0.94, for 1 μIU/ml increase), homoeostasis model assessment of insulin resistance (OR 0.06, 95% CI 0.01 to 0.29, for 10 unit increase), and presence of macroalbuminuria (OR 5.14, 95% CI 1.45 to 18.20, albumin to creatinine ratio >300 mg/g).
In addition to traditional risk factors, insulin resistance was associated with an increased risk of DR in Koreans with type 2 diabetes.
There are few published data on the prevalence of diabetic retinopathy in sub-Saharan Africa. We report the prevalence of all grades of retinopathy and associations with systemic parameters in patients attending a secondary care diabetes clinic in Blantyre, Malawi.
Cross-sectional study of all patients attending for diabetes care in a hospital setting. Clinical examination and biochemical testing was performed to assess visual acuity (VA), grade of retinopathy (slit lamp biomicroscopy), microvascular complications, glycaemic control, hypertension and HIV status. Sight-threatening diabetic retinopathy (STDR) was defined as moderate preproliferative retinopathy or worse, circinate maculopathy or exudates within one disc diameter of the foveal centre or clinically significant macular oedema.
In patients with type 2 diabetes (n=249) the prevalence (95% CI) of any retinopathy, STDR and proliferative diabetic retinopathy (PDR) was 32.5% (26.7 to 38.3%), 19.7% (14.7 to 24.6%) and 4.8% (2.2 to 7.5%), respectively. The presence of STDR was associated with albuminuria (OR 2.6; p=0.02), the presence of neuropathy (OR 3.4; p=0.005) and insulin use (OR 5.3; p=0.0004), but not with HIV status. In patients with type 1 diabetes (n= 32), the prevalence of any retinopathy, STDR and PDR was 28.1% (12.5 to 43.7%), 18.8% (5.2 to 32.2%) and 12.5% (1.0 to 24.0%), respectively. 12.1% of study subjects had VA worse than 6/18 (20/60).
This study provides baseline information on prevalence of all grades of retinopathy and STDR in consecutive cases attending an urban/semi-urban diabetes clinic in sub-Saharan Africa. Prevalence of STDR was high and in type 2 diabetes was associated with albuminuria, neuropathy and insulin use.
When King of Argos, Acrisius, visited the Oracle at Delphi, it was prophesised that he would die at the hands of his daughter's son. His daughter, Danae, was childless at the time and in order to ensure she did not bear a son, Acrisius imprisoned her. However, the Greek god Zeus, came to Danae as a ‘shower of golden rain’ in the prison and a son, Perseus was born to Danae.
Acrisius learnt of this and locked both the mother and son into...]]>
To determine the prevalence of glaucoma within the indigenous Australian population living in central Australia.
1884 individuals aged ≥20 years, living in one of 30 remote communities within the statistical local area of ‘Central Australia,’ were recruited for this study. This equated to 36% of those aged ≥20 years and 67% of those aged ≥40 years within this district. Slit-lamp examination of the anterior segment and intraocular pressure measurement, followed by stereoscopic slit-lamp funduscopy of the optic nerve, was performed. Selected patients underwent automated visual-field testing. The diagnosis of glaucoma was based on pre-existing definitions. Glaucoma prevalence data are presented.
Seventeen individuals had glaucoma (0.90%). Causes of secondary glaucoma were found in four with neovascular glaucoma, two with uveitic glaucoma and four who had developed glaucoma subsequent to trauma or surgery. The remaining seven had no identifiable cause for their glaucoma and were thus classified as open-angle glaucoma equating to a prevalence of 0.52% (95% CI 0.14% to 0.90%) for those aged ≥40 years. Of these, four had an intraocular pressure ≤21 mm Hg, and three had an intraocular pressure >21 mm Hg.
The prevalence of open-angle glaucoma among indigenous Australians within central Australia was 0.52% for those aged ≥40 years. After adjustment for the age distribution of our sample, this is one-third the prevalence seen among the non-indigenous Australian population and is despite a higher prevalence of ocular parameters considered to be associated with glaucoma.
The authors address the question of whether vascular endothelial growth factor inhibitors (anti-VEGF) lead to better clinical outcomes than current treatments in patients with clinically manifest diabetic macular oedema (DMO), which is the leading cause of vision loss in the working age population in developed countries.
The authors performed a systematic literature search in common databases and compiled the evidence according to the GRADE methodology. The authors analysed clinically relevant improvement of visual acuity, vision-related quality of life and local or systemic adverse events.
In a proportion of patients (on average 25%), VEGF inhibitors result in better visual acuity (≥15 ETDRS letters or equivalent) than in patients treated with laser photocoagulation or sham injection. The number of injections required for long-term improvement as well as the general long-term efficacy is unknown. The evidence is not sufficient to confirm safety of the products in patients with DMO and does not suggest superiority of a single product.
For some patients with DMO, VEGF inhibitors seem to be more effective as a short-term treatment option than alternative therapies. The evidence is not of sufficient quality to confirm safety. Decisions on financing should take into account the high price difference between the products and ongoing research.
To compare the outcomes of non-posturing macular-hole surgery using sulfur hexafluoride (SF6) gas versus perfluoroethane (C2F6) for idiopathic macular hole repair.
Interventional, comparative cohort study.
39 eyes of 38 patients undergoing macular-hole surgery with SF6 were compared with another consecutive group of 39 eyes (39 patients) in whom C2F6 was used. All patients were operated on by a single surgeon and underwent 23G transconjunctival phakovitrectomy with no prone posturing in the postoperative period. The best-corrected Snellen's visual acuity (VA) was converted to the logarithm of minimal angle of resolution (logmar) visual acuity for analysis. Optical coherence tomography documentation of anatomical closure and complications of surgery were recorded.
Primary hole closure was achieved in 89.75% in the C2F6 group and 87.2% in the SF6 group. Secondary closure after non-posturing redo surgery with heavy oil (Oxane-HD) was 100% in both groups. The mean preoperative VA in the C2F6 group and SF6 group was 0.81 logMAR and 0.78 respectively. 2 weeks after surgey, SF6 was completely absorbed in all cases, and the mean VA improved to 0.5 logMAR; however, it remained 1.9 logMAR in the C2F6 group. The final mean VA at 6 months was 0.44 (range 0–0.78) and 0.38 (range 0–1) in the C2F6 and SF6 group respectively. There were no instances of pupillary capture in the SF6 group, whereas there were four in the C2F6 group.
Macular-hole surgery with SF6 gas achieves similar results to C2F6 and is absorbed faster, allowing quicker visual rehabilitation for the patient.
Total volume using a standard single inferonasal injection for sub-Tenon's anaesthesia is limited by an increase in intraocular pressure (IOP) and commonly requires the operating surgeon to top-up the block intraoperatively. This study compares the efficacy and safety of a two-quadrant technique that allows the use of a higher volume of local anaesthetic.
54 patients undergoing vitrectomy were randomised into two groups. The control group (n=27) received a standard 5 ml single inferonasal sub-Tenon injection of a 50:50 mixture of 2% lidocaine and 0.5% bupivacaine with 150 IU hyaluronidase. The study group (n=27) received a 5 ml inferonasal and 5 ml superotemporal injection of the same mixture (10 ml total). The primary outcome measure was the number of intraoperative top-ups required. Secondary outcome measures were intraoperative and postoperative pain scores, IOP, block onset time, ocular akinesia, eyelid akinesia and chemosis.
24 patients required a top-up in the control group. No patients required a top-up in the study group (p<0.001). IOP measurements were similar in both groups. Block onset was shorter, eyelid akinesia was improved and pain scores were also reduced in the study group intraoperatively and at 0–2 h, 4–6 h, 10–14 h and 20–24 h postoperatively.
Two-quadrant sub-Tenon's anaesthesia using 10 ml of a 50:50 mixture of 2% lidocaine and 0.5% bupivacaine with 150 IU hyaluronidase seems to be more effective than a single-quadrant technique at reducing intraoperative and postoperative pain during vitrectomy.
To describe a novel technique of sclerotomy construction to facilitate 20-gauge transconjunctical sutureless vitrectomy (TSV) along with the evaluation of the wound integrity.
The surgical technique is described. One hundred consecutive patients who underwent TSV were evaluated for wound leaks, postoperative hypotony, endophthalmitis and any other complication related to surgery. The sclerotomies of eight patients (24 ports) were analysed by imaging with anterior segment optical coherence tomography immediately after surgery, and on the first postoperative day and after the first postoperative month.
104 eyes of 100 patients were evaluated with a mean follow-up of 9.6 months. All cases underwent surgery with standard 20-gauge instrumentation and vitrectomy techniques. Five sclerotomies were found to leak at the end of surgery, requiring a suture. Anterior segment optical coherence tomography images were obtained from eight eyes with good apposition of the tunnel noted in all the cases. Mean intraocular pressure was 18.7 mm Hg on the first postoperative day. One patient had hypotony without leak and this patient had pre-existing hypotony due to chronic panuveitis. There was no instance of postoperative endophthalmitis.
This technique of 20-gauge TSV achieves good wound apposition with a low incidence of complications while using standard 20-gauge instrumentation and vitrectomy techniques.
To explore the factors affecting surgical outcomes of highly myopic macular holes (HMMHs).
This is a retrospective cross-sectional study. Twenty-two eyes that underwent vitrectomy for HMMHs were included. The eyes were studied retrospectively and divided into two groups by preoperative optical coherence tomography (OCT): 10 eyes with retinoschisis around HMMH and 12 without. Preoperative status including age and posterior staphyloma height measured by OCT, and surgical outcome including postoperative final best-corrected visual acuity and reoperation rate, were evaluated and compared.
The schisis group was significantly older (p<0.01) with a worse visual acuity (p<0.05) and greater posterior staphyloma height (p<0.05). The preoperative best-corrected visual acuity and the presence or absence of retinoschisis were significantly (p<0.01 and p=0.01, respectively) associated with the postoperative best-corrected visual acuity; age was borderline (p=0.06).
There are two types of macular holes (MHs) in highly myopic eyes with distinctly different prognoses. Preoperative OCT images must be interpreted carefully to determine the precise surgical results. Retinoschisis negatively impacts vitrectomy for HMMHs.
To characterise the extension and progression of alteration of neurosensory layers following acute and chronic branch retinal artery occlusion (BRAO) in vivo using spectral-domain optical coherence tomography.
In this observational case series, eight eyes with acute BRAO and nine eyes with chronic BRAO were analysed using a Spectralis Heidelberg Retina Angiograph (HRA)+optical coherence tomography system including eye tracking. Patients with acute BRAO were examined within 36±5 h after primary event and at weekly/monthly intervals thereafter. Segmentation measurements of all individual neurosensory layers were performed on single A-scans at six locations in affected and corresponding non-affected areas. The thickness values of the retinal nerve fibre layer together with the ganglion cell layer (NFL/GCL), inner plexiform layer (IPL), inner nuclear layer together with outer plexiform layer (INL/OPL), outer nuclear layer (ONL), and photoreceptor layers together with the retinal pigment epithelium (PR/RPE) were measured and analysed.
Segmentation evaluation revealed a distinct increase in thickness of inner neurosensory layers including the NFL/GCL (35%), IPL (80%), INL/OPL (48%) and mildly the ONL by 21% in acute ischaemia compared with corresponding layers in non-ischaemic areas. Regression of intraretinal oedema was followed by persistent retinal atrophy with loss of differentiation between IPL and INL/OPL at month 2. In contrast, the ONL and subjacent PR/RPE retained their physiological thickness in patients with chronic BRAO.
In vivo assessment of retinal layer morphology allows a precise identification of the pathophysiology in retinal ischaemia.
To investigate an association between genotype for three single nucleotide polymorphisms strongly associated with the development of age-related macular degeneration (AMD) and the early response to treatment with intravitreal ranibizumab for neovascular AMD.
Best corrected visual acuity letter score was recorded at baseline and each subsequent visit. Age, sex, smoking history, lesion type and the number of injections were also recorded. Genotypes were obtained for rs11200638 in HTRA1, rs1061170 in CFH and rs1413711 in VEGF. Data were analysed with treatment response at month 6 as both a binary (>5 letter improvement vs ≤5 letter gain) and a linear trait.
This initial study cohort consisted of 104 Caucasian neovascular AMD patients treated with intravitreal ranibizumab. Trends towards a more favourable outcome were seen with the higher AMD risk genotypes in CFH and VEGF in both the linear and binary models and in HTRA1 in the linear model alone. For CFH, mean letter score change after 6 months was +1.6, +5.9 and +7.2 letters for the TT, TC and CC genotypes and a >5 letter gain was seen in 34.6%, 56.6% and 56%, respectively. For VEGF, mean letter score change after 6 months was +1.3, +5.8 and +7.4 letters for the TT, TC and CC genotypes and a >5 letter gain was seen in 40%, 55.8% and 51.9%, respectively. For HTRA1, mean letter score change was +2.2, +7.5 and +2.9 letters for the GG, GA and AA genotypes.
This study reports preliminary evidence suggesting that the higher AMD risk genotypes in CFH, VEGF and HTRA1 may influence the short-term response to treatment with ranibizumab for neovascular AMD.
To report novel spectral domain optical coherence tomography (SD-OCT) findings and new mutational data in patients with ‘cone dystrophy with supernormal rod electroretinogram’, a recessive childhood onset retinal dystrophy consequent upon mutation in the KCNV2 gene.
This was a comparative case series study of 12 patients with clinical and/or electrophysiological findings in keeping with KCNV2 mutation. Clinical examination and electrophysiological testing results were reviewed. Fundus photography and autofluorescence imaging were performed. Retinal layer appearance and thickness were evaluated using SD-OCT. The coding region and intron–exon boundaries of KCNV2 were screened by direct sequencing.
Mutations in KCNV2 were detected in all families; five of these changes were novel. Pattern electroretinograms were undetectable and full-field electroretinograms showed findings specific for the disorder. SD-OCT demonstrated bilateral morphological changes, usually confined to the fovea. Four foveal SD-OCT phenotypes were observed: (i) discontinuous inner and outer segment (IS/OS) junction reflectivity (6 patients), (ii) loss of IS/OS line and an optical gap in the foveola (2 patients); (iii) IS/OS junction disruption and profound foveal depth reduction, without optical gap and with preserved retinal pigment epithelium (RPE) complex (2 patients); and (iv) outer retina and RPE complex abnormalities (2 patients). Thinning of the neurosensory retina was observed in all eyes.
In KCNV2 retinopathy foveal morphological changes are evident on SD-OCT even in the early stages of disease. However, there appears to be a window of opportunity, before marked structural damage has occurred, during which novel therapeutic intervention, such as gene replacement therapy, may rescue retinal function.
To automatically classify abnormal retinal images from four different categories using artificial neural networks with a high degree of accuracy in minimal time to assist the ophthalmologist in subsequent treatment planning.
We used 420 abnormal retinal images from four different categories (non-proliferative diabetic retinopathy, central retinal vein occlusion, central serous retinopathy and central neo-vascularisation membrane). Green channel extraction, histogram equalisation and median filtering were used as image pre-processing techniques, followed by texture-based feature extraction. The application of Kohonen neural networks for pathology identification was also explored.
The approach described yielded an average classification accuracy of 97.7% with ±0.8% deviation for individual categories. The average sensitivity and the specificity values are 96% and 98%, respectively. The time taken by the Kohonen neural network to achieve these accurate results was 300±40 s for the 420 images.
This study suggests that the approach described can act as a diagnostic tool for retinal disease identification. Simultaneous multi-level classification of abnormal images is possible with high accuracy using artificial neural networks. The results also suggest that the approach is time-efficient, which is essential for ophthalmologic applications.
To assess spectral domain-optical coherence tomography (SD-OCT) contribution to choroidal osteoma characterisation.
A retrospective chart review of a series of patients diagnosed with choroidal osteoma, which included patient, clinical, ultrasonographic, photographic and SD-OCT imaging.
11 patients were included in this series. Their mean age was 42.5 years (median=43.0; range, 14–73). Using statistical analysis, the mean basal diameters of tumours as derived from fundus photographs (5.2 mm) and ultrasound images (6.4 mm) were significantly different (paired t-test, p=0.03). Tumours were SD-OCT hyporeflective in two cases, isoreflective in seven cases and hyper-reflective in two cases. Intrinsic reflectivity of the tumour was inhomogeneous in four cases. The overlying choroid was compressed by the tumour in eight cases and the retina exhibited degenerative changes in five cases.
This study revealed that SD-OCT provided deeper and higher resolution images of choroidal osteoma when compared with previous studies using time domain-OCT. These findings offer new insights into the pathophysiology and diagnosis of choroidal osteoma.
To increase sensitivity of impression cytology (IC) for the diagnosis of conjunctival intraepithelial neoplasia (CIN) by three repeated applications of IC.
This study included 35 eyes with a clinical diagnosis of CIN and 6 eyes with pinguecula as control. All eyes received IC by three consecutive applications of the cellulose acetate filter paper. All eyes in the CIN group had subsequent surgical excision with histopathological evaluation. The sensitivity of each application of IC for the diagnosis of CIN was determined.
In the control group, all IC specimens were negative for CIN. In the CIN group, with positive histopathology in all cases, the first IC was positive in 17 eyes (56.7%), showed atypical squamous cells indefinite for dysplasia (ASCID) in 8 (26.7%) and was negative in 5 (16.6%). The second application was positive in 25 eyes (83.3%), showed ASCID in 3 (10%) and was negative in 2 (6.7%). The third application was positive in 26 eyes (87.7%), showed ASCID in 3 (10%) and was negative in 1 (3.3%). The second application resulted in a statistically significant higher positive yield than the first application (p=0.009), with no significant difference between the second and the third applications (p=0.12).
Consecutive repeated applications of filter paper significantly increased the diagnostic sensitivity of IC for the diagnosis of CIN.
To evaluate minor salivary glands and labial mucous membrane graft in patients with severe symblepharon and dry eye secondary to Stevens–Johnson syndrome (SJS).
A prospective, non-comparative, interventional case series of 19 patients with severe symblepharon and dry eye secondary to SJS who underwent labial mucous membrane and minor salivary glands transplantation. A complete ophthalmic examination including the Schirmer I test was performed prior to and following surgery. All patients had a preoperative Schirmer I test value of zero.
Nineteen patients with severe symblepharon and dry eye secondary to SJS were included in the study. There was a statistically significant improvement in the best spectacle-corrected visual acuity in eight patients (t test; p=0.0070). Values obtained in the Schirmer I test improved significantly in 14 eyes (73.7%) 6 months following surgery (2 test; p=0.0094). A statistically significant increase in tear production (Schirmer I test) was found in eyes that received more than 10 glands per graft compared with eyes that received fewer glands (2 test; p=0.0096). Corneal transparency improved significantly in 11 (72.2%) eyes and corneal neovascularisation improved significantly in five eyes (29.4%) (McNemar test; p=0.001 and p=0.0005). The symptoms questionnaire revealed improvement in foreign body sensation in 53.6% of the patients, in photophobia in 50.2% and in pain in 54.8% (Kruskal–Wallis test; p=0.0167).
Labial mucous membrane and minor salivary glands transplantation were found to constitute a good option for the treatment of severe symblepharon and dry eye secondary to SJS. This may be considered as a step prior to limbal stem cell and corneal transplantation in these patients.
To determine whether prognostic immunological profiles predict the severity of keratoconjunctivitis sicca (KCS) in patients with Sjögren's syndrome (SS).
121 patients diagnosed with SS and followed for at least 1 year were enrolled in this study. Patients were allocated to either a mild KCS group (Mi-KCS; n=65) or to a moderate to severe KCS group (MS-KCS; n=56) based on the Oxford scheme and response to treatment. These groups were each sub-divided into two groups based on the clinical severity of KCS and the presence of associated rheumatic disease (primary SS vs secondary SS). Anti-Ro/anti-La antibody, rheumatoid factor and tear interleukin (IL)-17 levels and Schirmer test results were compared between each group.
Anti-Ro/SSA antibody and anti-La/SSB antibody concentrations were significantly higher in the MS-KCS group than in the Mi-KCS group for total and primary SS. The presence of anti-La/SSB antibody was significantly higher in the MS-KCS than the Mi-KCS group for total and primary SS. The mean tear IL-17 concentration in the MS-KCS group was significantly higher than in the Mi-KCS group for both total SS and primary SS patients.
Serum anti-La/SSB antibody, serum anti-Ro/SSA antibody and tear IL-17 are likely to be strongly involved in the clinical severity of KCS in patients with primary SS.
To evaluate the relationship, over time, between central graft thickness and visual acuity following Descemet's stripping endothelial keratoplasty (DSEK).
A retrospective analysis of 70 consecutive cases of DSEK. All donor lenticules were dissected manually. Serial postoperative measurements of central graft and total corneal thicknesses were made using anterior segment optical coherence tomography. Visual acuity, refraction and patient demographics were collected from case notes. The correlation between central graft thickness and visual acuity at serial time points was calculated.
The median age at surgery was 75 years (lower quartile (LQ) 66, upper quartile (UQ) 83, range 36–90 years). Nineteen eyes were excluded from statistical analysis, leaving 51 eyes of 46 patients remaining. Last follow-up occurred a median of 12 months postoperatively (LQ 6, UQ 23, range 4–38 months). The median preoperative visual acuity was 0.71 logarithm of the minimum angle of resolution (logMAR), improving to 0.34 logMAR postoperatively (p<0.001, n=43). Median graft thickness decreased from 209 μm at day 1 to 142 μm at last follow-up (p<0.001). No statistically significant correlation was found between central total corneal thickness and visual acuity at any time point. Except for a single time point, no statistically significant correlation was found between central graft thickness and visual acuity.
There is no clear association between central graft, or total corneal, thickness and visual acuity following DSEK.
To determine if eyelid closure (ELC) after topical prostaglandin instillation provides greater intraocular pressure (IOP) reduction than prostaglandin instillation without ELC.
Patients receiving chronic bilateral prostaglandin monotherapy were enrolled in this study. The study intervention, ELC, was randomly assigned to one eye, while the fellow eye served as control. ELC was performed for either 1 min or 3 min. After a 1-day washout, the IOP was measured in a masked fashion at baseline, 1 h and 24 h, and at a final visit that took place 7–14 days after enrolment. All visits were scheduled during the morning, and every individual patient's visits occurred at similar times during the day. The main outcome was difference between intervention eye and control eye in IOP-lowering from baseline.
51 patients meeting eligibility criteria were enrolled: 25 were randomised to ELC for 1 min and 26 to ELC for 3 min in the intervention eye. The pooled IOP-lowering difference (95% CI, p value) in intervention versus control eyes was 0.24 mm Hg (–0.5 to 0.9, p=0.50), 0.24 mm Hg (–0.7 to 1.2, p=0.61) and 0.24 mm Hg (–0.7 to 1.2, p=0.61) in the overall group, 1 min ELC subgroup and 3 min ELC subgroup, respectively. The effect of ELC did not change significantly across visits.
ELC did not provide significant additional IOP reduction compared with no ELC in patients using chronic prostaglandin monotherapy.
To evaluate corneal hysteresis (CH) and intraocular pressure (IOP) before and after IOP lowering with prostaglandin analogue (PGA) therapy in medication-naïve eyes.
In this retrospective study, we included records from 57 consecutive patients with open angle glaucoma who were initiated on PGA. Patients underwent ocular response analyser measurement with IOP assessment at baseline (untreated) and at follow-up (treated).
Median follow-up time between IOP measurements was 1.4 (range 0.4–13.5) months. IOP was reduced by 3.2 mm Hg (18.8%) from 17.0 to 13.8 mm Hg (p<0.001). CH increased by 0.5 mm Hg (5.2%) from 9.7 to 10.2 mm Hg (p=0.02). Baseline CH (but not baseline central corneal thickness) was a significant predictor of the magnitude of IOP reduction, with patients in the lowest quartile of CH (mean 7.0 mm Hg) experiencing a 29.0% reduction in IOP while those in the highest CH quartile (mean 11.9 mm Hg) experienced a 7.6% reduction in IOP (p=0.006). A multivariate analysis controlling for baseline IOP demonstrated that baseline CH independently predicted the magnitude of IOP reduction with PGA therapy in both per cent (ß=3.5, p=0.01) and absolute (ß=0.6, p=0.02) terms.
Although CH is influenced by IOP, baseline CH is independently associated with the magnitude of IOP reduction with PGA therapy.
The aims of this study were: (1) to examine whether the original glaucoma medication adherence and eye drop technique self-efficacy scales could be shortened for easier use in practice settings; and (2) to validate these scales against objective medication adherence measures.
Prospective study conducted at a single private practice site. We measured subjects' adherence to glaucoma medications through Medication Event Monitoring System (MEMS) devices and assessed eye drop instillation technique by video-recording. Principal components factor analysis and logistic and linear regression were used to analyse the data.
Our results yielded a 10-item Glaucoma Medication Adherence Self-Efficacy Scale that was strongly associated with subject adherence measured using MEMS (β coefficient 8.52, 95% CI 1.94 to 15.1). In addition, the six-item Eye Drop Technique Self-Efficacy Scale was strongly associated with video-recorded subject eye drop installation technique (OR 10.47, 95% CI 1.78 to 61.63).
Eye care providers and researchers could use these shorter scales to identify subjects with either poor glaucoma medication adherence and/or eye drop instillation technique. This could help to identify those who may benefit most from education and training on both adherence and eye drop instillation.
To compare iridotomy outcomes in dark irides by 1064 nm pulsed Nd:YAG laser with and without 532 nm continuous-wave Nd:YAG (frequency-doubled) green laser pretreatment.
30 patients with occludable anterior chamber angles underwent bilateral standard pulsed 1064 nm Nd:YAG laser iridotomy with one eye randomly assigned to sequential pretreatment with 532 nm continuous-wave Nd:YAG laser. Outcome measures were iridotomy patency and complications including haemorrhage and elevated intraocular pressure (IOP).
Median pulsed YAG power in the standard treatment group was 37.5 mJ (IQR 25–77) and 22.5 mJ (IQR 14–32) in the sequential treatment group (p=0.0079). Iris haemorrhage occurred in 43% of the standard treatment group and 13% of the sequential treatment group (p=0.0126). All iridotomies were patent at the end of the procedure in the sequential treatment group, while 2/30 in the standard treatment group were abandoned due to significant haemorrhage. Mean IOP at 1 h was significantly lower than pre-laser values in both groups (with magnitude of reduction significantly more in the sequential treatment group). There was no significant change in IOP at 1 week. All iridotomies were patent at last follow-up of median 38.5 months (IQR 32.0–42.3).
This study provides evidence that iridotomy with pretreatment using a continuous-wave Nd:YAG laser is safer and more effective than pulsed Nd:YAG-only laser iridotomy for dark irides and should be considered as the preferred technique.
To determine the effects of pupil size on uncorrected visual acuity (UCVA) in astigmatic eyes.
The authors examined 20 normal eyes of 20 healthy volunteers (age 26.7±4.9 years (mean±SD); 8 men, 12 women). After fully correcting cycloplegic refraction, the authors created with-the-rule and against-the-rule astigmatism of 1, 2, and 3 dioptres (D) in each eye, and then assessed UCVA using artificial pupils (1 to 5 mm) in these astigmatic eyes. Measurements were performed three times, and the mean value was used for statistical analysis.
In eyes with with-the-rule astigmatism of 1, 2 and 3 D, logMAR UCVA was 0.04±0.08, 0.09±0.09 and 0.16±0.16 for 1 mm pupils, –0.01±0.09, 0.12±0.15 and 0.33±0.24 for 2 mm pupils, 0.02±0.09, 0.20±0.19 and 0.46±0.30 for 3 mm pupils, 0.02±0.08, 0.24±0.20 and 0.48±0.21 for 4 mm pupils, and 0.08±0.10, 0.33±0.18 and 0.53±0.22 for 5 mm pupils, respectively. The variance of the data was statistically significant (p=0.03 for 1 D, p<0.001 for 2 D, p<0.001 for 3 D, analysis of variance). Similar results were obtained in eyes with against-the-rule astigmatism.
Both the amount of astigmatism and the pupil size can affect UCVA in astigmatic eyes. It is suggested that not only the amount of astigmatism but also the pupil size should be taken into consideration for acquiring better visual performance in astigmatic eyes.
The accuracy of retinal thickness measurement in age-related macular degeneration by optical coherence tomography (OCT) is affected by threshold algorithm line errors. The reproducibility of error correction in Stratus and Cirrus OCT should be examined.
OCT examinations of a consecutive series of 104 patients with neovascular age-related macular degeneration included in another study were reviewed. 72 eyes exhibited failures in Stratus OCT and 32 eyes in Cirrus OCT and were included in this new study. Algorithm line failures of Stratus OCT (retinal thickness program) and Cirrus OCT (Macular Cube 512x128 program) were corrected independently twice by two ophthalmologists and two residents, respectively, using the Stratus and Cirrus OCT built-in software. Reproducibility was assessed by the interclass correlation coefficient (ICC).
The corrected values of central retinal thickness were significantly lower than the automated measured values in Stratus OCT for all examiners (p<0.001), while in Cirrus OCT the differences were not significant (p=0.06–0.09). For Stratus OCT, the ICC for central retinal thickness was 0.991 and 0.997 for the experienced ophthalmologists and 0.89 and 0.97 for the residents. For Cirrus OCT, the ICC was 1.0 and 1.0 for the experienced ophthalmologists and 0.99 and 0.95 for the residents.
The reproducibility of threshold algorithm line failure correction was good overall in Stratus and Cirrus OCT and can therefore be recommended to improve retinal thickness measurement, particularly when experienced examiners perform the corrections.
To present a case series of relapsing migratory idiopathic orbital inflammation.
Case series and review of the literature. The medical records of six patients with recurrent orbital myositis or idiopathic inflammation at different sites treated at the Goldschleger Eye Institute between April 2006 and December 2009 were collected and analysed; one patient treated at the orbital service in Priyamvada Birla Aravind Eye Hospital, Kolkata, India, was also included (June 2008 to August 2010). Orbital biopsy was performed in patients who failed to respond to steroids treatment.
A total of six patients with recurrent episodes of orbital myositis or inflammation were identified. Four patients had orbital myositis of one extraocular muscle at the initial episode and recurrent myositis of a different extraocular muscle on the contralateral orbit. One patient had recurrent myositis of a different extraocular muscle on the same orbit. Two patients had a third episode of recurrence on a different site, that is, an extraocular muscle or an eyelid. One patient had eyelid and soft tissue involvement on one orbit and recurrence of orbital myositis on the contralateral eyelid. Histological findings in the latter case showed small perivascular lymphocytic aggregates and scattered histiocytes. The mean time for recurrence was 7.2 months. All patients were treated successfully with oral steroids and/or intralesional triamcinolone injection.
Idiopathic orbital inflammation or orbital myositis can recur on a different extraocular muscle and on the contralateral orbit. These cases can be successfully treated with orally administered or intralesionally injected steroids.
Oculopharyngeal muscular dystrophy (OPMD) presents with progressive ptosis, dysphagia and limb girdle weakness, and is caused by expansion of a trinucleotide tandem repeat within the gene encoding poly-(A) binding protein 2.
To review the clinical manifestations of all genetically confirmed patients with OPMD in Scotland identified since 2002, and to estimate the delay between symptom onset and diagnosis.
Retrospective case note review.
The authors identified 17 patients. The commonest first symptom was ptosis at about the age of 60 years. Three to 20 years elapsed from the onset of ptosis to OPMD diagnosis. In 14 (82%) patients, dysphagia had developed by the time of diagnosis, and four (24%) out of these 14 patients with dysphagia had undergone a decade of investigation and treatment for pharyngeal problems. Thirteen patients (77%) also had symptoms of limb girdle muscle weakness. Every patient had a first-degree relative with ptosis.
OPMD could have been diagnosed earlier in every patient in this case series. Greater awareness of OPMD among ophthalmologists, gastroenterologists and otolaryngologists may lead to earlier diagnosis, improved management and avoidance of unnecessary investigations.
To identify clinical risk factors for obtaining an ‘equivocal’ T-SPOT.TB result in patients consistent with tuberculosis (TB)-associated uveitis (TAU).
Prospective cohort study of consecutive new patients, with ocular signs consistent with TAU at a single tertiary centre enrolled over 15 months. All subjects underwent ocular and systemic evaluation, and investigations to rule out underlying disease. Subjects with underlying disease and interdeterminate T-SPOT.TB results were excluded. Patients were followed up for 1 year from enrolment.
15 of 155 subjects (9.67%) obtained ‘equivocal’ T-SPOT.TB results. Mean age was 52.2 (range 12–77) years. Most of the subjects were Chinese (n=8, 53.3%) with no sex dominance (seven male, eight female). None were immunocompromised. Patients aged <13 or >55 years old were found to be more likely to have an ‘equivocal’ T-SPOT.TB result (OR 21.2; 95% CI 3.7 to 121.6; p=0.001), while adjusting for possible confounders including sex, race, history of diabetes mellitus, disease duration, type of uveitis and tuberculin skin test positivity. These patients are more likely to be QuantiFERON-TB Gold In-tube negative (OR 14.7; 95% CI 1.2 to 179.9; p=0.035).
An ‘equivocal’ T-SPOT.TB result is associated with patients aged >55 years. Such patients are likely to have a negative QuantiFERON-TB Gold In-tube result.
The receptor for advanced glycation end-products (RAGE) has been implicated in the pathogenesis of diabetic microvascular complications. The aim of this study was to investigate the association between 2245G/A gene polymorphism of the RAGE gene and retinopathy in Malaysian type 2 diabetic patients.
342 unrelated type 2 diabetic patients (171 with retinopathy (DR), 171 without retinopathy (DNR)) and 235 unrelated healthy subjects from all over Malaysia were recruited for this study. Genomic DNA was isolated from 3 ml samples of whole blood using a modified conventional DNA extraction method. The genotype and allele frequencies of 2245G/A were studied using the polymerase chain reaction–restriction fragment length polymorphism (PCR-RFLP) method.
A statistically significant difference in 2245A minor allele frequency was found between control (5.5%) and DR groups (15.2%) (p<0.001, OR=3.06, 95% CI 1.87 to 5.02) as well as between DNR (8.2%) and DR (15.2%) groups (p<0.01, OR=2.01, 95% CI 1.24 to 3.27). However, when the frequency was compared between control and DNR groups, there was no significant difference (p>0.05).
This is the first study that shows an association between the 2245A allele of the RAGE gene and development of diabetic retinopathy in the Malaysian population.
To determine whether cultured corneal endothelial (CE) cells suppress interleukin 17 (IL-17)-producing effector T cells in vitro.
CE cell lines established from a normal mouse were used. Target bystander T cells were established from normal splenic T cells with anti-CD3 antibodies. Production of IL-17 by target T cells was evaluated by ELISA, flow cytometry and quantitative PCR. To abolish the CE-inhibitory function, transforming growth factor β (TGFβ)-small interfering RNA-transfected CE cells or transwell membrane inserts, which block cell-to-cell contact, were used.
Cultured CE cells greatly suppressed the activation of bystander target cells (pan-T, CD4 T, CD8 T, and B cells) in vitro, particularly inflammatory cytokine production by CD4 cells. Cultured CE cells significantly suppressed IL-17-producing T cells and fully suppressed polarised T helper 17 (Th17) cell lines that are induced by Th17-associated differentiation factors. However, CE cells failed to suppress Th17 cells if the CE cell lines were pretreated with TGFβ small interfering RNA or if direct contact with T cells was blocked with transwell membrane inserts.
CE cells impair the effector functions and activation of IL-17-producing helper T cells in a cell-contact-dependent mechanism. Thus, corneal endothelium may contribute to the maintenance of the privileged immune status in the eye by inducing peripheral immune tolerance.
A 65-year-old Taiwanese female without previous ocular illness but arrhythmias and mitral valve prolapse history presented with progressive corneal oedema and decreased vision in the right eye in 1994. She was diagnosed as having bilateral Fuchs endothelial dystrophy, confirmed by slit-lamp biomicroscopy and specular microscopy (
Diabetic retinopathy (DR), branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO) are frequently complicated by macular oedema (MO), a condition that arises as a direct consequence of blood–retinal barrier (BRB) breakdown and the subsequent increase in vascular permeability. Accumulating evidence suggests that the upregulation of inflammatory factors or the downregulation of anti-inflammatory factors and a subsequent increase in leucocyte–endothelial interactions contribute to disruption of tight junctions and BRB breakdown.
Recently, clinical treatment has become available to reduce the ocular expression of inflammatory cytokines. Intravitreal injection of triamcinolone acetonide (TA) is effective for reducing macular thickness in patients with diabetic macular oedema (DMO) and those with MO due to BRVO or CRVO.
The authors have not mentioned if the per-operative measurements and IOL power calculation were performed by the same observer or different observers. This could lead to interobserver variation and inadvertently influence the study outcomes. The authors have implanted multiple types of IOL such as polymethyl methacrylate, foldable silicone and foldable acrylic IOLs. Silicone IOLs undergo a continuous forward movement
The authors stated that preoperative axial length measurements were performed using the Alcon Ocuscan. This system has both immersion and contact capability. The authors did not state which technique they employed. In a recent study comparing axial length measurements by contact and immersion techniques in paediatric cataractous eyes,
There were different types of intraocular lens implantation implanted. Stratification on lens type did not show statistically significant differences in rate of refractive change, nor in prediction error. However, the subgroups became relatively small to get reliable results. Therefore we did not stratify for the different intraocular lens implantation types in the paper.
Standard phacoemulsification was performed through a 3 mm corneoscleral incision. When a poly(methyl methacrylate) (PMMA) lens was inplanted, this incision was...]]>