To investigate the effect of astigmatism on near vision performance.
In a consecutive case series 23 eyes of 23 participants were fogged with 0 D, –0.75 D and –1.5 D of with-the-rule (WTR) and against-the-rule (ATR) astigmatism (cylindrical lenses without spherical compensation). All subjects were cyclopleged and distance corrected. Reading acuity (RAc) and speed (RS) were measured with standardised sentences, near visual acuity (NVA) was assessed using single optotypes (Snellen E), all presented on a thin film transistor display using the Salzburg Reading Desk (SRD). Data were analysed using Wilcoxon-matched-pairs test, regression analysis and Bland–Altman analysis.
An increasing amount of astigmatism resulted in a decreased NVA (p=0.16 for –0.75 D, p=0.005 for –1.5 D) and RAc (p=0.002 for –0.75 D, p=0.014 for –1.5 D). WTR astigmatism caused a reduced NVA, RAc and lower RS compared with ATR astigmatism (p<0.001). NVA was better than RAc with no astigmatism, –0.75 D WTR and –1.5 D WTR (p=0.03 for 0 D, p<0.001 for –0.75 D, p=0.03 for –1.5 D). There was no difference between NVA and RAc for –0.75 D ATR and –1.5 D ATR (p=0.06 for –0.75 D, p=0.5 for –1.5 D).
WTR astigmatism results in reduced reading parameters and NVA for –0.75 D and –1.5 D astigmatism compared with corresponding ATR astigmatism and no astigmatism added. No beneficial effect of astigmatism was detected.
We aimed to evaluate age-related cataract as a contributor to blindness and visual impairment (VI) in sub-Saharan Africa (SSA).
A systematic review of population-based studies published between 2000 and October 2012. Prevalence and proportions of blindness and VI due to cataract, cataract surgical coverage (CSC), per cent intraocular lens (IOL) implantation and visual outcomes of surgery in accordance with WHO criteria were ascertained.
Data from 17 surveys (subjects mostly aged ≥50-years-old) from 15 different countries in SSA were included, comprising 96 402 people. Prevalence of blindness (presenting visual acuity <3/60 in better eye) ranged from 0.1% in Uganda to 9.0% in Eritrea, and the proportion of total blindness due to cataract ranged between 21% and 67%. Cataract was the principal cause of blindness and VI in 15 and 14 studies, respectively. There was a strong positive correlation between good visual outcomes and IOL use (R=0.69, p=0.027). Considerable inter-study heterogeneity was evident in CSC and visual outcomes following surgery, and between 40% and 100% of operations had used IOL.
Cataract represents the principal cause of blindness and VI and should remain a priority objective for eye care in SSA. However, the prevalence of blindness and VI due to cataract was variable and may reflect differences in the availability of cataract surgical programmes and cataract incidence.
Macular pigment (MP) plays an important role in visual function and in the protection of the retina from oxidative damage. It is not known whether glaucoma, a progressive neurodegenerative disease of the optic nerve, is associated with alterations in MP. This study was designed to investigate the relationship, if any, between the optical density of MP optical density (MPOD) and glaucoma.
40 subjects (23 males, 17 females) with open angle glaucoma (mean age 69 ±11), and 54 normal controls (23 males, 31 females) without ocular disease (mean age 66 ±11), visual acuity (VA) >6/18, were recruited, and underwent a comprehensive eye examination including biomicroscopy, fundoscopy, Goldmann tonometry and visual field assessment, using the 24-2 SITA-fast algorithm on the Humphrey visual field analyser (II-i Series). MPOD, at 0.5° of retinal eccentricity was determined, for all subjects, using heterochromatic flicker photometry.
Median (IQR) MPOD for subjects with glaucoma was 0.23 (0.42) compared to 0.36 (0.44) for controls. The difference in MPOD between the glaucoma cases and controls was statistically significant (z=–2.158, p=0.031). There was no significant correlation (p>0.05) between MPOD and disease severity.
These findings suggest that MPOD is lower in patients with glaucoma. Further investigation is needed to determine the significance of MP in glaucoma, its relationship to glare symptoms in glaucoma and to assess what role therapeutic strategies aimed at increasing MP levels could have in the management of glaucoma.
Papillorenal syndrome is an autosomal-dominant syndrome involving optic nerve abnormalities and hypodysplastic kidneys (OMIM 120330).
Born with poor vision and right-beating nystagmus, our patient developed high myopia as an infant. Examination revealed excavated, dysplastic optic discs lacking central retinal vessels, with compensatory cilioretinal vessels at the rim (
To present the outcomes of a series of patients with choroidal neovascular membrane (CNV) secondary to a choroidal naevus and report the presence of outer retinal tubulation.
In this retrospective series, patients underwent a complete clinical and imaging assessment (fundus photo, fluorescein angiography and optical coherence tomography) and were observed or managed with intravitreal anti-VEGF injections dependent on whether visual acuity was affected.
Seventeen patients were included in this study. Of this, 46% (8/17) had classic or predominantly classic CNV and 53% (9/17) had occult or minimally classic CNV. Active treatment with intravitreal anti-VEGF injections was required in 35% (6/17). Visual acuity improved in three eyes by 2–4 Snellen lines, remained stable in one eye and worsened in two eyes by 2 Snellen lines. CNV partially regressed in five cases. In the observation group (65%, 11/17), visual acuity did not change during follow-up period. Outer retinal tubulation was found in 18% (3/17).
Anti-VEGF treatment is effective in the management of vision threatening CNV secondary to a choroidal naevus. Functional or anatomical improvement was obtained in 66% of treated eyes. Outer retinal tubulation, noted in 18%, showed the clinical importance of this sign in determining continuation of anti-VEGF treatment.
NIR transillumination photography may serve another essential clinical application as the first diagnostic technique described capable of detecting anterior uveal melanomas in patients implanted with black intraocular lenses (IOLs) who cannot undergo slit lamp examination.
Black IOLs are indicated in patients with intractable diplopia, visual confusion, unsightly leucocoria and a range of neuro-ophthalmic disorders.
To report the 12-month outcomes of the dexamethasone intravitreal implant in retinal vein occlusion (RVO), using an as-needed repeat injection protocol.
Retrospective consecutive case series of 51 eyes of 49 patients with macular oedema as a result of RVO that received an intravitreal dexamethasone implant and were followed up for at least 12 months.
70% of patients responded to dexamethasone implant injection with an improvement in visual acuity (VA) and macular oedema within 3 months of injection, but only 30% of eyes gained ≥15 letters. The mean change in VA letter score at 12 months compared with baseline for branch RVO (BRVO) and central RVO (CRVO) was 5.7±2.3 and 11.5±11.0 EDTRS letters, respectively. 56% of patients relapsed, with the median time to relapse being 17 weeks for patients with branch RVO and 18 weeks for patients with CRVO. Repeat injections achieved similar VA gains, but the duration of effect of repeat dexamethasone implants was much shorter at 10 weeks. 14 eyes (27%) developed a significant rise in intraocular pressure, and three of these required treatment with oral acetazolamide. Four eyes with CRVO developed neovascular glaucoma during the study.
The intravitreal dexamethasone implant does not last the 6 months implied by the retreatment protocol in the GENEVA trial, and improved results can be achieved with an as-needed retreatment protocol, particularly in CRVO. However, visual outcomes remain similar to those previously seen with triamcinolone in the SCORE study and neovascular complications remain a feature of CRVO.
It is common practice to routinely instruct patients not to drive after being administered mydriatics with the explanation that insurance companies may not pay out in the event of a motor vehicle accident. Although there is no objective evidence to suggest that driving performance is compromised by pupil dilation, a handful of papers have shown that dilatation has a small but significant effect on visual acuity, contrast sensitivity and glare sensitivity.
Keightley quoted personal communications with the Association of British Insurers (ABI) suggesting that insurers would have reservations supporting claims from drivers who were involved in accidents with dilated pupils even if he or she fulfilled the legal driving requirements.
To compare the 24-h intraocular pressure (IOP) control obtained with the bimatoprost–timolol fixed combination (BTFC) versus latanoprost in newly diagnosed, previously untreated exfoliation syndrome (XFS) or exfoliative glaucoma (XFG) patients with baseline morning IOP greater than 29 mm Hg.
One eye of 41 XFS/XFG patients who met inclusion criteria was included in this prospective, observer-masked, crossover, comparison protocol. All subjects underwent a 24-h untreated curve and were then randomised to either evening administered BTFC or latanoprost for 3 months and then switched to the opposite therapy. At the end of each treatment period, patients underwent a treated 24-h IOP assessment.
37 patients completed the trial. At baseline, mean untreated 24-h IOP was 31.1 mm Hg. Mean 24-h IOP with BTFC was significantly lower than with latanoprost (18.9 vs 21.2 mm Hg; p<0.001). Furthermore, BTFC reduced IOP significantly more than latanoprost at every time point, for the mean peak and trough 24-h IOP (p<0.001). There was no difference, however, in mean 24-h IOP fluctuation between the two medications (3.8 with BTFC vs 4.2 with latanoprost; p=0.161). Both treatments were well tolerated and there was no statistically significant difference for any adverse event between them.
As first choice therapy in high-pressure, at-risk exfoliation patients, BTFC controlled mean 24-h IOP significantly better than latanoprost monotherapy.
Vascular endothelial growth factor (VEGF) is a key factor in the pathogenesis of neovascular retinal diseases including age-related macular degeneration. VEGF inhibitors including ranibizumab, pegaptanib or bevacizumab improve retinal morphology and vision in many patients. The recently approved drug aflibercept (VEGF Trap-Eye/Eyelea, Regeneron, Tarrytown, New York, USA) offers a new therapy modality. We therefore tested for toxic and anti-proliferating effects of aflibercept.
The effects of aflibercept (0.125, 0.5, 2 mg), ranibizumab (0.125 mg) and bevacizumab (0.3125 mg) after 1, 24, 48 and 72 h on cell morphology via phase contrast pictures, cell viability via MTS assay, total cell amount via crystal violet staining, apoptosis induction via caspase 3/7 assay and proliferation via BrdU assay were investigated. Three ocular cell lines were chosen for toxicology testing: ARPE19 cells, RGC-5 cells and 661W cells.
Aflibercept did not cause changes in cell morphology, induce apoptosis or cause permanent decrease in cell viability, cell density or proliferation in any cell line or concentration investigated. In general, aflibercept had fewer effects (upregulation or downregulation) compared with controls than bevacizumab or ranibizumab.
In our experiments, aflibercept did not lead to any negative effects on retinal cell lines and might therefore be used safely in clinical applications.
Intraocular melanocytoma is a rare naevus variant that can be located at the optic disc or within the uvea, and belongs to the group of non-epithelial-associated melanocytic lesions. We wanted to gain an understanding of the role of GNAQ, GNA11 and BRAF V600E in the pathogenesis of uveal melanocytoma and in cases of transformation to uveal melanoma and also to perform a differential immunohistochemical study comparing melanocytoma with uveal melanoma.
Two patients were identified with melanocytoma, one of which had transformed to melanoma. In the latter case, the melanocytoma exhibited an immunophenotype that featured nuclear p27 and no HMB45 staining, with very low Cyclin D1 expression compared with the melanoma that featured little nuclear but more cytoplasmic p27 positivity, much higher Cyclin D1 expression and HMB45 positivity. The melanocytomas were negative for CD68 allowing distinction from melanophages. Both melanocytomas and the melanoma harboured mutations in GNAQ, with no mutations of GNA11 or BRAF V600E.
GNAQ mutations are present in uveal melanocytomas and in a case of transformation to melanoma, implicating GNAQ-dependent mitogen activation signals, in the pathogenesis of uveal melanocytoma. This assists in explaining why a proportion of uveal melanocytoma can transform to uveal melanoma, known to harbour high-frequency GNAQ mutations at exon 5, codon 209.
To compare the effect on contrast sensitivity (CS) measurements of panretinal photocoagulation (PRP) associated with intravitreal bevacizumab (IVB) injections versus PRP alone in high risk proliferative diabetic retinopathy (HR-PDR).
Prospective, randomised, masked, controlled trial.
42 patients with HR-PDR with visual acuity ≥20/200.
Eyes were randomised to one of two groups: one underwent PRP and IVB injections (study group) and the other PRP alone (control group). PRP was performed three times during the study and IVB injection was administered twice.
Mean change in CS threshold scores between and within groups, from baseline to 6 months.
Seven patients presented with vitreous haemorrhage and were removed from the study. Mean results for CS threshold (at 1.5, 3, 6, 12 and 18 cycles per degree (cpd) frequencies) for patients with and without diabetic macular oedema showed no significant differences (p>0.05 for all comparisons) between the two groups. In 35 eyes in the control group, compared with baseline values, there was significant worsening (p<0.05) of CS at 1.5, 12 and 18 cpd after 1 month, at 12 cpd after 3 months, and at 6 and 12 cpd after 6 months. In the study group, there was significant improvement in CS at 3 cpd, 3 months after treatment.
In eyes with HR-PDR, PRP treatment is associated with deterioration of CS while adjuvant use of bevacizumab prevents such deterioration. CS evaluation seems to support the adjuvant use of bevacizumab when using PRP for the treatment of HR-PDR.
ClinicalTrials.gov Identifier NCT 01389505.
To investigate longitudinal changes in anterior chamber depth (ACD) and axial length (AXL) over 5 years after trabeculectomy surgery in Asian patients with primary glaucoma, and to identify factors associated with these changes.
In this prospective cohort study, phakic subjects with primary glaucoma who underwent trabeculectomy had ACD and AXL measured over 5 years. The effect of intraocular pressure (IOP) on ACD and AXL was determined. Subjects were divided into two groups (high or low fluctuation of ACD/AXL) and factors were compared to determine if there were factors associated with greater fluctuation.
122 subjects were analysed. The majority of subjects were male (75.4%) and Chinese (77%). ACD and AXL were shallower/shorter compared with baseline at all postoperative visits, with a mean decrease of 0.11 mm (95% CI 0.07 to 0.15 mm, p<0.01) and 0.16 mm (95%CI 0.11 to 0.20 mm, p<0.01), respectively. Patients with primary open angle glaucoma (POAG) had higher odds of fluctuations in longitudinal measurements of ACD (OR=8.74, p<0.01) and AXL (OR=5.60, p<0.01) compared with patients with primary angle closure glaucoma. For every 1 mm Hg decrease in IOP, ACD and AXL decreased by 0.02 mm (p<0.01) and 0.01 mm (p=0.03), respectively, for POAG patients with emmetropia or mild myopia.
Trabeculectomy resulted in a decrease in both ACD and AXL, and these changes were persistent over a period of 5 years.
To identify a means to objectively measure corneal clouding in patients with mucopolysaccharidosis in a prospective controlled clinical trial.
Corneal haze was assessed by slit lamp examination and measured using the densitometry programme of the Pentacam, a rotating Scheimpflug camera in 33 mucopolysaccharidoses (MPS) patients and 32 controls.
Pentacam measurements were available in 31 right and 31 left eyes of 32 patients and in 32 left and right eyes of 32 subjects in the control group. Slit lamp findings correlated very well with corneal density measurements (Spearman correlation right eye (OD)/left eye (OS)=0.782/0.791). MPS patients had higher density units (median OD/OS=14.1/14.7) than control subjects (median OD/OS=6.7/6.9, p<0.001). In patients, the corneal centre density values (median OD/OS=13.8/14.0) did not differ from corneal periphery values (median OD/OS=14.3/14.7).
The densitometry programme of the Pentacam provides objective measurement of corneal haze in mucopolysaccharidosis patients.
To compare 24 h intraocular pressure (IOP) control obtained with preservative free (PF) tafluprost 0.0015% versus branded preservative containing latanoprost 0.005% administered as first choice monotherapy in patients with primary open angle glaucoma (POAG) or ocular hypertension (OHT).
This prospective, observer-masked, crossover study included consecutive newly diagnosed patients with POAG or OHT, and baseline IOP between 24 and 33 mm Hg. Qualifying patients underwent baseline untreated 24 h IOP monitoring in habitual positions, with Goldmann tonometry at times 10:00, 14:00, 18:00 and 22:00, and Perkins supine tonometry at times 02:00 and 06:00. They were then randomised to either latanoprost or tafluprost, administered in the evening, for 3 months and then switched to the opposite therapy for another 3 months. 24 h monitoring was repeated at the end of each treatment period.
38 patients completed the study. Mean untreated 24 h IOP (24.9 mm Hg) was significantly reduced with both prostaglandins (p<0.001). Tafluprost demonstrated similar mean 24 h efficacy compared with latanoprost (17.8 vs 17.7 mm Hg; p=0.417). Latanoprost demonstrated significantly better 24 h trough IOP (15.9 vs 16.3 mm Hg; p=0.041) whereas tafluprost provided significantly lower 24 h IOP fluctuation (3.2 vs 3.8 mm Hg; p=0.008). No significant difference existed between the two prostaglandins for any adverse event.
PF tafluprost achieved similar 24 h IOP reduction to branded latanoprost. The current study highlights the importance of complete assessment of efficacy over 24 h.
NCT01162603.
To compare efficacy of ‘split hours part-time patching’ and ‘continuous hours part-time patching’ for the treatment of anisometropic amblyopia.
We designed a prospective, interventional, non-randomised, comparative pilot study involving children between 4 and 11 years of age with anisometropic amblyopia who were treated with either continuous wear (Group A) or split hours part-time patching (Group B) as per parents wish, after appropriate discussion with the parents. Children were followed-up for the improvement in visual acuity and the compliance at each follow-up visit.
44 and 24 children were recruited in Group A and Group B, respectively (mean±SD baseline BCVA of the amblyopic eye: 0.99±0.32 and 0.95±0.23 logMAR, respectively). BCVA (adjusted for baseline BCVA and age) at 3 months in Group A (0.59±0.24) was comparable (p=0.08) with that in Group B (0.71±0.24). This was same even at 6 months (0.51±0.25 in Group A and 0.59±0.25 in Group B, p=0.25). The improvement in BCVA at 3 months was also comparable (p=0.06) in Group A (0.39±0.23) and Group B (0.26±0.23). The improvement in BCVA at 6 months was also comparable (p=0.14) in Group A (0.47±0.26) and Group B (0.37±0.26).
Both patching regimens lead to significant and comparable improvement in BCVA in anisometropic amblyopia up to 6 months of follow-up.
To investigate in vivo optical coherence tomography (OCT) for imaging of periocular basal cell carcinoma (BCC).
Consecutive patients with periocular BCC were prospectively investigated with VivoSight OCT imaging prior to surgical excision. Histology sections were compared with OCT images with regard to lesion measurements (x, y and z dimensions) and histological features.
A total of 15 patients with biopsy proven BCC were recruited. The OCT horizontal margins correlated positively with histology (r=0.8 and 0.66, x and y axes) and could be identified in 3/15 (x axis) and 6/15 (y axis) cases. The vertical margin correlation was r=0.43 and BCC depth could be measured in 9/15 cases. The following histological features of BCC could be identified on OCT images: (1) lobular pattern (100%); (2) dilated blood vessels (80%); (3) reflective margins of tumour lobules (100%); and (4) epidermal thinning overlying BCC lobules (100%).
This study indicated a strong positive correlation between the margins of periocular BCCs measured using in vivo OCT and histology, and a weak positive correlation with depth of invasion. VivoSight OCT produced high resolution images of BCC morphology. The limitations in horizontal margin measurements could potentially be overcome by design modification of the scanning probe.
To evaluate the use of in vivo imaging of rabbit model of choroidal melanoma using high-frequency contrast-enhanced ultrasound (HF-CE-US) with two-dimensional (2D) or three-dimensional (3D) modes and to correlate the sonographic findings with histopathologic characteristics.
Five New Zealand white rabbits, which were immunosuppressed with daily cyclosporin A (CsA), were inoculated into their right eyes with aliquots of 1.5x106/50 μl of 92.1 human uveal melanoma cells cultured in RPMI. At week 4, the tumour-bearing eyes were imaged using high-frequency ultrasound (HF-US) with microbubble contrast agent to determine the 2D tumour size and relative blood volume and by 3D mode to determine tumour volume. Histologic tumour burden was quantified in enucleated eyes by ImageJ software, and mean vascular density (MVD) was determined by counting vascular channels in periodic acid Schiff (PAS) without haematoxylin sections.
Using HF-CE-US, melanomas were visualised as relatively hyperechoic regions in the images. The correlation coefficients of sonographic size and volume compared with histologic area were 0.72 and 0.70, respectively. The sonographic tumour relative blood volume correlated with the histologic tumour vascularity (r2=0.92, p=0.04).
There is a positive correlation between in vivo sonographic tumour volume/size and histologic tumour size in our rabbit choroidal melanoma model. HF-CE-US corresponds to MVD and blood volume.
To compare surgical outcome of bilateral lateral rectus recession (BLR-rec) and unilateral lateral rectus recession combined with medial rectus resection (R&R) for the basic type of intermittent exotropia (IXT) in children.
Eighty-five consecutive patients aged 3–15 years old with the basic type IXT who underwent surgery and had a minimum postoperative follow-up of 6 months were retrospectively reviewed. Thirty-eight patients underwent BLR-rec and 47 underwent R&R. Successful surgical alignment was defined as esophoria/tropia ≤5 PD (prism dioptres) to exophoria/tropia ≤8 PD in primary gaze while viewing distant or near targets.
After a mean follow-up of 14.8±9.5 months, the subjects who had undergone R&R surgery had a significantly higher success rate than those who had BLR-rec surgery (85.1% vs 65.8%, p=0.037). The undercorrection rate was significantly lower in the R&R group than in the BLR-rec group (6.4% vs 23.7%, p=0.023) and there was no significant difference in the overcorrection rate between the two groups (10.5% vs 8.5%, p=1.000).
R&R is more effective than BLR-rec surgery in the long term for the basic type IXT in children.
To investigate the effect of initial postoperative minimal overcorrection on the result of the surgical management of intermittent exotropia based on long-term follow-up results.
111 patients who underwent surgery for intermittent exotropia and were followed up for at least 5 years after surgery were retrospectively reviewed. The outcome was judged to be successful when there was 10 prism dioptres (PD) or less of exodeviation and less than 5 PD of esodeviation without any reoperation at the final follow-up visit. We evaluated the success, recurrence, overcorrection rate and the duration of diplopia according to their initial deviation.
We divided patients into four groups based on their initial deviation: orthophoria or undercorrection (Ortho group, 31 patients), minimally overcorrected at 5 PD or less (MO group, 20 patients), usually overcorrected between 6 PD and 10 PD (UO group, 35 patients), and highly overcorrected at more than 10 PD (HO group, 25 patients). The success rate was 43–60% between the four groups (p=0.52). The recurrence rate was 28–57% (p=0.105), but post hoc analysis showed borderline p values between the Ortho and HO group (p=0.024). No overcorrection was noted in the Ortho and MO groups (p=0.04). The duration of diplopia was 0–2.5 weeks, showing statistically significant difference among groups (p<0.001).
The amount of initial postoperative overcorrection may not predict the long-term success rate. However, the MO group showed a lower recurrence rate than the Ortho group and also showed no overcorrection and a shorter duration of postoperative diplopia than the UO and HO groups.
External examination revealed mild fullness of the temporal region. Normal upper and lower eyelids bilaterally without any erythema, oedema or lid retractions were noted. Conjunctiva was normal bilaterally. Visual acuity was at 20/25 in the right eye and 20/20 in the left eye. Anterior segment examination revealed axial proptosis of 6 mm...]]>
There are few high-quality studies describing the appearance and location of retinal haemorrhages in critically ill children not due to birth or abusive head trauma.
Prospective study from February 2008 to December 2009 of emergency admissions to a paediatric intensive care unit aged over 6 weeks. Children with a penetrating eye injury or suspected or proven abusive head injury were excluded. The children underwent either dilated funduscopy performed by a paediatric ophthalmologist or RetCam imaging.
Retinal haemorrhages were identified in 24/159 (15%) patients. 50% of the haemorrhages were bilateral. The severity was mild (<5 retinal haemorrhages) or moderate (5–20 retinal haemorrhages) in 75%. The location was in zone 1 in 45.8%, zones 1 and 2 in 33.3%, zone 2 alone in 8.3% and not described in 8.3%. Schisis cavities and perimacular folds were identified in two patients with one having a pseudohypopyon appearance; a further one patient had bilateral haemorrhagic retinal detachments. Three patients had exudates or scarring consistent with cytomegalovirus infection.
Retinal haemorrhages are seen in a proportion of critically ill children, however most retinal bleeding is not extensive as indicated by location within the retina or layer of bleeding. Higher numbers and extent of retinal haemorrhages were only observed in the presence of severe coagulopathy, leukaemia, one victim of a road traffic accident, and one child who sustained a fatal witnessed fall down the stairs; all circumstances that would be readily distinguished by history and laboratory testing from abusive head injury.
To investigate economic inequality and its determinants in near vision, in a middle-aged population.
In this population-based study, the presenting near vision in the better eye was investigated as the main outcome. If this vision revealed a value ≥1.6 M, the participant was considered to have presenting near vision impairment (PNVI). The effect of variables studied on PNVI was investigated using logistic regression. Economic inequality in PNVI was investigated using the Oaxaca–Blinder decomposition method.
PNVI in the better eye was observed in 18.2% (95% CI 16.8 to 19.6) of participants. The prevalence of PNVI in the high and low economic groups was 11.7% (95% CI 10.3 to 13.0) and 28.5% (95% CI 26.0 to 31.0), respectively. Age and education were observed as the main factors in the explained portion of this gap and were in favour of the high economic group. Gender and eye care utilisation were factors affecting the unexplained portion of this gap and were in favour of the low economic group.
Economic inequality plays a significant role in PNVI, while age and education are among the main factors affecting this gap. The effect caused by any change in these two factors was found to have a greater effect on women with low economic status.
AS101 is a non-toxic organotellurium-IV compound with demonstrated immunomodulating activity in vitro and in vivo. Inflammatory responses are attributed to the pathophysiology of numerous ocular diseases. In this study, we wished to elucidate whether AS101 could mitigate pro-inflammatory activity in human retinal pigment epithelial (RPE) cells, which are heavily involved in ocular immune responses, induced by pro-inflammatory IL-β activity.
Primary and transformed RPE cells treated with varying concentrations of AS101 were used in this study. Real-time PCR and ELISA assays were used to detect cytokine/chemokine mRNA expression and protein production. Western blot was used to detect changes in the NFB pathway. Cell viability and proliferation were detected using a Vi-Cell XR cell counter. To measure the cytoprotective capacity of AS101, cell numbers were compared between cells treated with IL-1β or lipopolysaccharide (LPS) and cells treated with IL-1β or LPS in the presence of AS101.
AS101 inhibited IL-1β-induced mRNA expression and protein production of IL-6 and IL-8 in RPE cells. The viability of RPE cells treated with IL-1β and LPS was unaffected. AS101 slightly inhibited RPE cell growth in the presence of higher levels of IL-1β. Also, AS101 downregulated the IL-1β activity by inhibiting the phosphorylation of p65, an NFB subunit.
The results demonstrate that AS101 reduces IL-1β-induced inflammatory responses in the RPE. In previous studies, AS101 exhibited therapeutic effects in various disease models and was a safe profile in clinical trials. These results suggest that AS101 may have potent anti-inflammatory potential in the eye and confer the downregulation of RPE inflammatory responses in a pathological environment.
To evaluate the effect of ageing on the retinal vascular responsiveness to flicker light in glaucoma and ocular hypertension (OHT).
Retinal vascular response to flicker was measured with the retinal vessel analyser in 56 healthy subjects (59±9 years), 50 primary open-angle glaucoma (POAG) (60±10 years) and 46 OHT patients (62±9 years). In the glaucoma group, the less damaged eye; in the OHT group, the eye with the higher intraocular pressure; and in healthy controls, one randomly selected eye was considered. Parametric and non-parametric linear regression analysis, as well as a model of covariance analysis (ANCOVA) was used to evaluate the effect of age on the vascular response.
In all three groups (N=152) absolute (Pearson R: –0.19, p<0.019; Spearman R: –0.22, p<0.006) and relative change (Pearson R: –0.18, p<0.027; Spearman R: –0.21, p<0.010) were statistically associated with age. The ANCOVA showed no difference between the three groups in this regard (absolute change: p=0.43; relative change: p=0.51).
Vascular responsiveness to flicker light decreases with age in healthy individuals, in glaucoma patients and in OHT patients. This effect seems to be comparable between the tested groups, and age-related change in vascular responsiveness to flicker light seems an unlikely risk factor for glaucoma.
The purpose of this study was to determine the long-term efficacy and safety of valproic acid (VPA) treatment in patients with pigmentary retinal dystrophies.
A retrospective chart review was conducted on 31 patients with a diagnosis of pigmentary retinal dystrophy prescribed VPA at a single centre. Visual field (VF), visual acuity (VA), length of treatment, liver enzymes and side effects were analysed. VF areas were defined using Goldmann VF (GVF) tracings recorded before, during and after VPA treatment using the V4e isopter for each eye. Using custom software, planimetric areas of VF were calculated.
Five of the patients (10 eyes) had two Goldmann VF tracings, allowing comparison between baseline and follow-up VF. After 9.8 months of VPA, VF decreased by 0.145 cm2 (26.478%) (p=0.432). For 22 of the patients (41 eyes), VA data was available, and logarithm of the minimum angle of resolution (logMAR) score changed by 0.056 log units (representing a decline in VA) after 14.9 months on VPA (p=0.002). Twelve patients (38.7%) reported negative side effects related to VPA use.
VPA plays a complex role in patients with pigmentary retinal dystrophies and may be associated with VA and field decline as well as adverse side effects. Physicians should use caution with using VPA for pigmentary retinal dystrophies.
To describe a new technique of corneal stab incision with intracameral air injection for management of patients with acute corneal hydrops.
Five patients with acute corneal hydrops with large Descemet's membrane (DM) detachment and multiple stromal clefts underwent the procedure. The technique entailed anterior segment optical coherence tomography guided intrastromal fluid drainage through multiple corneal stromal venting incisions along with anterior chamber air tamponade. The time taken for the DM to reattach, resolution of corneal oedema and the best-corrected visual acuity (BCVA) were assessed postoperatively.
Five patients (age range, 10–25 years) with large DM detachment underwent the procedure. The presenting visual acuity varied from hand motions close to face to 1/60. No intraoperative complications were encountered. The DM attached on first postoperative day in four out of five cases. The corneal oedema resolved over 2–3 weeks in all cases. Repeat air injection was not required in any of the cases. All patients had a final BCVA of ≥3/60 with two of them achieving a BCVA of ≥6/24 at three months postoperatively.
The technique of intrastromal drainage of fluid combined with air tamponade can be effectively used as a treatment modality for the management of severe cases of acute corneal hydrops.
To compare effects of gabapentin premedication with diazepam in patients undergoing cataract surgery.
In a randomised double-blind study, the effects of gabapentin premedication as a sedative, anxiolytic, analgesic and oculohypotensive agent were studied in 56 elderly patients undergoing elective intraocular surgery.
There was significantly more sedation in the diazepam group than in the gabapentin group. However, there was less subjective anxiety in the gabapentin group than in the control group. There was a significant fall in intraocular pressure (IOP) and significant reduction in mean arterial pressure in the gabapentin group compared with the control group. Perioperatively, significantly more supplementation with intravenous midazolam was given in the control group than in the gabapentin group. A significantly larger number of patients in the gabapentin group scored a postanaesthesia recovery score of 10 compared with the control group. There was a statistically significant difference in the postoperative visual analogue scale scores for pain and number of analgesic requests with gabapentin scoring over diazepam in this regard.
Hence, premedication with oral gabapentin in these elderly patients undergoing elective intraocular surgery produced intraoperative anxiolysis, decreased sedation, a modest decrease in IOPs and improved postoperative recovery.
Spectral-domain (SD)- Optical Coherence Tomography (OCT) can track eye movements, has faster acquisition time and higher resolution than time-domain(TD)-OCT. The aim of the study was to assess the utility of SD-OCT in paediatric glaucoma and determine its agreement with TD-OCT.
Children who had SD-OCT(Spectralis, Heidelberg-Engineering,Germany) were retrospectively and prospectively identified from Duke paediatric glaucoma clinic. The peripapillary retinal nerve fibre layer (RNFL) and macular thickness and volume (MV) were compared amongst four groups: normal eyes, eyes with physiologic cupping (C:D >0.5 and <0.8, IOP <21), mild glaucomatous eyes (C:D <0.5, intra-ocular pressure (IOP) >21) and severe glaucoma (C:D>0.5, IOP>21). SD-OCT values were compared to TD-OCT(OCT-3, Carl-Zeiss-Meditec, Dublin, CA) values in a subset of subjects who had same day scans using both instruments. Children with neurologic disorders, refractive error >±5D, pseudophakia and prematurity were excluded.
Included were 83 eyes of 83 children, mean age 11.9±4.2 years. SD-OCT measurements of average RNFL thickness and MV differed among normals(n=24), physiologically cupped (n=31), mild (n=15) versus severe glaucoma (n=13): (RNFL:104±9, 99±6, 98±9 vs62±18 µm, respectively, p<0.05; MV: 8.7±0.3, 8.6±0.3, 8.8±0.4 vs8.0±0.6 mm³, respectively, p<0.05). Same-day SD-OCT and TD-OCT measures in 53 eyes correlated linearly (RNFL r2=0.88; MVr2=0.58). SD-OCT measured lower RNFL and higher macular thickness than TD-OCT. Among eyes with severe glaucoma, 4 of 13 (30%) had unreliable TD-OCT but reliable SD-OCT.
SD-OCT was easier to obtain than TD-OCT in children. SD-OCT and TD-OCT measurements correlated, but values were not interchangeable.
To analyse the relationship of clinically significant cystoid macular oedema (CME after phacoemulsification to blood–aqueous barrier breakdown as determined by aqueous flare, visual acuity and retinal thickness in optical coherence tomography (OCT).
30 eyes of 30 consecutive patients with clinically significant CME and vision loss were included. 46 pseudophakic and 45 phakic eyes without CME served as controls. Clinical data included age, gender, best-corrected visual acuity (BCVA) and spectral domain OCT volume scans. Retinal thickness measuring of the foveal central subfield was determined. Aqueous flare was measured quantitatively with the Kowa FM-500 Laser Flare-Cell Meter.
Patients with CME had significantly higher flare values compared with pseudophakic patients (p<0.0001). For patients with CME, aqueous flare values correlated significantly with BCVA (Spearman rs=0.4, p=0.041), while there was no correlation with retinal thickness. Using flare values to predict CME, receiver operating characteristic analysis returned an area under the curve of 0.976.
Aqueous flare as a marker for inflammation and breakdown of the blood–retinal barrier is increased in patients with CME after cataract surgery.
To report the surgical outcomes of Descemet's stripping endothelial keratoplasty (DSEK) in cases of congenital hereditary endothelial dystrophy (CHED) cohort and compare it with penetrating keratoplasty (PK) in a paired-eye setting.
Ours is a retrospective, comparative, consecutive and interventional clinical case series. All patients less than 14 years of age who underwent PK in one eye and DSEK in the contralateral eye at a single centre from January 2006 and February 2011 were analysed. Main outcome measures were graft clarity, visual outcome and complications.
The mean age of the patients was 6.6±2.19 years at the time of presentation. The outcomes of two surgeries were compared with 1 year of follow-up at the corresponding follow time. At 1 year, all grafts were clear. There was no significant difference in the spherical component of the refraction; the astigmatism was significantly lower after EK. The refraction stabilised in patients with EK as early as 3 months, while it continued to change up to 1 year after PK. Complications included graft dislocation in two cases of DSEK, which were managed by rebubbling, and a graft dehiscence in one case of PK, which was managed by resuturing. The final visual acuity improved in all the patients.
Endothelial keratoplasty is a viable option to conventional PK in cases of CHED. It offers an advantage of early visual stabilisation compared with PK.
The allergic reaction taking place in the nasal mucosa can induce a secondary ocular (keratoconjunctival) response of an immediate (SIOR), late (SLOR) or delayed (SDYOR) type in some patients with keratoconjunctivitis (KC).
To investigate the concentration changes of histamine, tryptase, eosinophil-derived neurotoxin (EDN), eosinophil cationic protein (ECP), eosinophilic peroxidase (EPO), leucotrienes (LTB4, LTC4, LTE4), prostaglandins (PGD2, PGE2 and PGF2α), thromboxane B2 (TXB2), myeloperoxidase (MPO), interferon- (IFN-) and interleukins (IL-2, IL-4 and IL-5) in tears during the SIOR, SLOR and SDYOR.
19 SIORs (p<0.001), 28 SLORs (p<0.001) and 10 SDYORs (p<0.05) recorded in 57 KC patients following nasal challenges with allergens (NPT) and 57 phosphate-buffered saline (PBS) control tests were repeated and supplemented with determination of the mediators in tears.
The ocular response types were associated with significant changes (p<0.05) of mediators in tears as follows: (1) SIORs: histamine, tryptase, ECP, LTC4, PGD2, PGF2α, IL-4 and IL-5; (2) SLORs: histamine, ECP, EDN, LTB4, LTC4, PGE2, MPO, IL-4 and IL-5; (3) SDYORs: LTB4, TXB2, MPO, IFN- and IL-2. No significant changes of these factors were measured in tears during the 57 PBS controls (p>0.1).
These results demonstrate a causal involvement of nasal allergy in some KC patients, inducing a secondary keratoconjunctival response of an immediate (SIOR), late (SLOR) or delayed (SDYOR) type, associated with different inflammatory mediator profiles in the tears, suggesting participation of different hypersensitivity mechanisms. These results also emphasise the diagnostic value of nasal challenge with allergen combined with monitoring of ocular response in KC patients, responding insufficiently to the usual ophthalmologic therapy.
Ocular surface squamous neoplasia (OSSN) is the most common cause of malignancy of the conjunctiva. Variable clinical presentation means that invasive malignant OSSN is often difficult to discriminate from other similarly presenting differential diagnoses which can be managed more conservatively.
Identification of clinical factors associated with a histopathological diagnosis of conjunctival squamous cell carcinoma (SCC).
Prospective consecutive case series of suspected OSSN cases presenting at two hospitals in Central Malawi over a 1 year period. A pro forma was completed assessing preidentified clinical variables. Suspected lesions underwent excisional biopsy followed by histopathological investigation.
Fifty-eight patients were recruited. Mean age was 35.8 (range 22–62). 51 cases of histopathologically confirmed OSSN were found. 30 (50%) patients were confirmed HIV seropositive which rose to 86.67% in invasive SCC. Larger size of tumour (p=0.008), male gender (p=0.025) and HIV seropositivity (p=0.010) were associated with invasive SCC pathology.
A clinicopathological study of OSSN has not previously been performed in Malawi. The association of HIV with SCC corresponds to previous reports from sub-Saharan Africa. A new finding in our study is a relationship between larger tumour size and invasive lesions confirmed by histopathology. When integrated into a clinical decision-making model, tumour area provides a simple clinical measure for ophthalmic practitioners to use in order to differentiate higher risk OSSN from more benign pathology. The higher risk lesions can subsequently be treated with greater surgical care and undergo closer follow-up.
A 7-year-old African-American girl was found to have reduced vision in the right eye on routine screening. Visual acuity was hand motions in the right eye and 20/20 in the left eye. Intraocular pressure was 17 mm Hg in each eye. Slit-lamp examination of the right eye showed a normal anterior segment, but immediately posterior to the lens was an opaque vascularised cyclitic membrane that blocked the visualisation of the vitreous and retina (
Four years prior to visual symptoms, the patient experienced respiratory distress and facial swelling...]]>
To determine the age and ethnicity-specific prevalence of anisometropia in Australian preschool-aged children and to assess in this population-based study the risk of anisometropia with increasing ametropia levels and risk of amblyopia with increasing anisometropia.
A total 2090 children (aged 6–72 months) completed detailed eye examinations in the Sydney Paediatric Eye Disease Study, including cycloplegic refraction, and were included. Refraction was measured using a Canon RK-F1 autorefractor, streak retinoscopy and/or the Retinomax K-Plus 2 autorefractor. Anisometropia was defined by the spherical equivalent (SE) difference, and plus cylinder difference for any cylindrical axis between eyes.
The overall prevalence of SE and cylindrical anisometropia ≥1.0 D were 2.7% and 3.0%, for the overall sample and in children of European-Caucasian ethnicity, 3.2%, 1.9%; East-Asian 1.7%, 5.2%; South-Asian 2.5%, 3.6%; Middle-Eastern ethnicities 2.2%, 3.3%, respectively. Anisometropia prevalence was lower or similar to that in the Baltimore Pediatric Eye Disease Study, Multi-Ethnic Pediatric Eye Disease Study and the Strabismus, Amblyopia and Refractive error in Singapore study. Risk (OR) of anisometropic amblyopia with ≥1.0 D of SE and cylindrical anisometropia was 12.4 (CI 4.0 to 38.4) and 6.5 (CI 2.3 to 18.7), respectively. We found an increasing risk of anisometropia with higher myopia ≥–1.0 D, OR 61.6 (CI 21.3 to 308), hyperopia > +2.0 D, OR 13.6 (CI 2.9 to 63.6) and astigmatism ≥1.5 D, OR 30.0 (CI 14.5 to 58.1).
In this preschool-age population-based sample, anisometropia was uncommon with inter-ethnic differences in cylindrical anisometropia prevalence. We also quantified the rising risk of amblyopia with increasing SE and cylindrical anisometropia, and present the specific levels of refractive error and associated increasing risk of anisometropia.
A 39-year-old obese woman presented with bilateral blurred vision worsening over 2 days. She also complained of lower back pain for the previous 3 weeks. Her ocular history revealed no abnormalities. Her medical history was significant for HELLP (Haemolysis, Elevated Liver enzyme levels, Low Platelet count) syndrome 12 years ago during her first pregnancy.
On examination, best-corrected visual acuity (BCVA) was 20/100 in the right and 20/400 in the left eye. Intraocular pressure, motility and anterior segments of both eyes were normal. Ophthalmoscopy revealed bilateral central serous retinal detachment and several cotton wool spots (
How will you approach a patient presenting with secondary retinal detachment in both eyes of acute origin. What further investigations...]]>
To estimate current clinical practice for frequency of visual field (VF) monitoring in glaucoma in England.
A cross-sectional review of all patients with chronic open angle glaucoma (COAG) attending specialist glaucoma clinics at six hospitals in England was performed. The number of VF tests undertaken prior to the study date and during the first 2 years since diagnosis were recorded and compared with European Glaucoma Society (EGS) guidelines for newly-diagnosed patients. Clinician-requested monitoring intervals were compared with intervals from the National Institute of Clinical Excellence (NICE) guidelines, and the relationships with disease severity, intraocular pressure (IOP) and glaucoma progression status were reviewed.
One-hundred and four patients with COAG were included. 73 patients had at least 2 years of follow-up. Median (IQR) total number of VF tests and in the first 2 years of diagnosis were 4 (2–7) and 2 (2–3), respectively. No patients met EGS guidelines, but 87% of patients had their monitoring intervals requested in accordance with NICE guidelines. These intervals were not related to disease severity or VF stability (Kruskal–Wallis test, p=0.25) but shortened significantly when IOP control was inadequate or when the overall clinical impression was disease progression (p<0.001).
Most newly-diagnosed COAG patients receive less than three VFs in the first 2 years following diagnosis and an average of 0.7 VF per year over the duration of follow-up.
To analyse the refractive implications of single-step, transepithelial photorefractive keratectomy (TransPRK) ablations.
A simulation for quantifying the refractive implications of TransPRK ablations has been developed. The simulation includes a simple modelling of corneal epithelial profiles, epithelial ablation profiles as well as refractive ablation profiles, and allows the analytical quantification of the refractive implications of TransPRK in terms of wasted tissue, achieved optical zone (OZ) and induced refractive error.
Wasted tissue occurs whenever the actual corneal epithelial profile is thinner than the applied epithelial ablation profile, achieved OZ is reduced whenever the actual corneal epithelial profile is thicker than the applied epithelial ablation profile and additional refractive errors are induced whenever the actual difference centre-to-periphery in the corneal epithelial profile deviates from the difference in the applied epithelial ablation profile.
The refractive implications of TransPRK ablations can be quantified using simple theoretical simulations. These implications can be wasted tissue (~14 µm, if the corneal epithelial profile is thinner than the ablated one), reduced OZ (if the corneal epithelial profile is thicker than ablated one, very severe for low corrections) and additional refractive errors (~0.66 D, if the centre-to-periphery progression of the corneal epithelial profile deviates from the progression of the ablated one). When TransPRK profiles are applied to normal, not previously treated, non-pathologic corneas, no specific refractive implications associated to the transepithelial profile can be anticipated; TransPRK would provide refractive outcomes equal to those of standard PRK. Adjustments for the planned OZ and, in the event of retreatments, for the target sphere can be easily derived.
To evaluate the mid-term efficacy and safety of the GTS-400-iStent combined with phacoemulsification in patients with cataract and open-angle glaucoma (OAG) or ocular hypertension (OHT).
Prospective, non-comparative, uncontrolled, interventional case series study. Subjects underwent phacoemulsification and two GTS-400 implantation. Efficacy outcomes: intraocular pressure (IOP) and antiglaucoma medications. Safety outcomes: complications, best-corrected visual acuity and endothelial cell count (ECC). Follow-up was 1 year.
20 patients were enrolled (mean age: 75.1±8.6 years). Mean medicated baseline IOP was 19.95±3.71 mm Hg and 26±3.11 mm Hg without medication. Mean final IOP was 16.75±2.24, determining a final IOP decrease of 35.68% (9.42±3 mm Hg; p<0.001), from baseline washout IOP. Mean number of medications fell from 1.3±0.66 to 0.3±0.57 (P<0.001). 75% of patients were off medications at one year. Mean ECC decreased from 2289.64±393.5 cells/mm2 to 1986.95±520.58 cells/mm2.
Combined cataract surgery with implantation of GTS-400-iStent seems to be an effective and safe procedure.
To evaluate the technical feasibility and surgical outcome of microincision vitrectomy surgery (MIVS) in patients with myopic foveoschisis (MF).
In total, 33 eyes of 29 patients who underwent surgical intervention due to MF were included. The patients were diagnosed with MF by spectral-domain optical coherence tomography (SD-OCT) and followed up for 6 months after MIVS that included internal limiting membrane (ILM) peeling with or without intraocular gas tamponade. To identify factors affecting visual outcome, the best-corrected visual acuity, axial length, and SD-OCT findings were analysed.
After surgery, the mean BCVA improved from 1.01±0.46 logMAR to 0.76±0.64 logMAR (p=0.004). Central subfield thickness in SD-OCT decreased from 431±256 μm to 231±72 μm after surgery (p<0.001). SD-OCT showed complete resolution of MF with complete foveal reattachment in 96% of patients (27/28). The accompanying macular hole was successfully closed in all four cases. Hypotony <6 mm Hg was seen in one eye only. At the end of surgery, eight of 24 eyes (33.3%) undergoing 25-gauge MIVS and four of nine eyes (44.4%) undergoing 23-gauge MIVS required sutures to close at least one sclerotomy site. Postoperative development of a macular hole was seen in one patient. It was successfully treated by reoperation using silicone oil tamponade.
MIVS with ILM peeling appeared to yield favourable visual and anatomical outcomes for MF in highly myopic eyes.
Ectopia lentis (EL) can be caused by trauma or associated with ophthalmic and systemic disorders such as Marfan syndrome (OMIM154700), pseudoexfoliation or isolated EL (OMIM129600). It is therefore managed and researched by a wide range of physicians and scientists. To date, there is no validated method of classifying the clinical features of this condition.
A novel grading in ectopia lentis (GEL) classification system was created to encompass the possibilities of lens movement. This was assessed on anterior segment images from our hospital database of patients with EL of any aetiology. All pupils were pharmacologically dilated with a combination of tropicamide (1%) and phenylephrine (2.5%) drops. Primarily, subluxation (Sub) was defined as movement of the lens within coronal plane behind the iris, while dislocation (D) was defined as complete movement either anteriorly (DA) into the anterior chamber or posteriorly (DP) into the vitreous cavity. Subluxation was categorised by direction and...]]>
A 38-year-old man was referred to our retinal department following a diagnosis of central retinal vein occlusion (CRVO) in his right eye 3 days previously. His referring physician had started anti-aggregant therapy. Best-corrected visual acuity (BCVA) was 20/40. No afferent pupillary defect was detected. Slit lamp examination revealed a normal ocular anterior segment and clear media. The intraocular pressure was 15 mm Hg in both eyes. Funduscopic examination showed alterations consistent with the diagnosis of CRVO such as dilated and tortuous retinal veins and diffuse spotty and flame-shaped intraretinal haemorrhages. However, an unusual perivenular whitening was detectable at the posterior pole. This finding, associated with the scanty haemorrhage number and the absence of clinically visible macular oedema, prompted further analysis to rule out an arterial ischaemic event.
As a result of the multi-imaging approach, the typical fern-like perivenular changes that characterise impending CRVO became clearly detectable, allowing the clinicians to reach the...]]>
Disruption of corneal epithelial barrier function by inflammation may contribute to the development of dry eye. The effects of rebamipide, a drug used for the treatment of dry eye, on barrier function and cytokine expression in a human corneal epithelial (HCE) cell line were examined.
Barrier function of HCE cells was evaluated by measurement of transepithelial electrical resistance (TER). The subcellular localisation of the tight junction protein zonula occludens (ZO)-1 was examined by immunofluorescence analysis. The release of cytokines was determined with ELISAs, and the intracellular abundance of cytokine mRNAs was quantitated by reverse transcription and real-time PCR analysis. Degradation of the nuclear factor-B inhibitor IBα was detected by immunoblot analysis.
Rebamipide increased TER of HCE cells in a concentration-dependent manner as well as attenuating the loss of TER and the disappearance of ZO-1 from the cell surface induced by tumour necrosis factor α (TNFα). Rebamipide also suppressed TNFα-induced expression of interleukin-6 and interleukin-8 at the mRNA and protein levels and inhibited the TNFα-induced degradation of IBα.
The upregulation of barrier function and the anti-inflammatory effects of rebamipide, together with its mucin secretagogue activity, may contribute to the effectiveness of this drug for the treatment of dry eye.
To determine the causes of severe visual impairment and blindness (SVI/BL) in children in Suriname (Dutch Guyana) and to identify preventable and treatable causes.
4643 children under 16 years of age were recruited from two locations: 33 children attending the only school for the blind were examined and 4610 medical records were analysed at an eye clinic. Data have been collected using the WHO Prevention of Blindness Programme eye examination record for children.
65 children were identified with SVI/BL, 58.5% were blind and 41.5% were severely visually impaired (SVI). The major anatomical site of SVI/BL was the retina in 33.8%, lens in 15.4% and normal appearing globe in 15.4%. The major underlying aetiology of SVI/BL was undetermined in 56.9% (mainly cataract and abnormality since birth) and perinatal factors 21.5% (mainly retinopathy of prematurity (ROP)). Avoidable causes of SVI/BL accounted for 40% of cases; 7.7% were preventable and 32.3% were treatable with cataracts and ROP the most common causes (15.4% and 12.3%, respectively).
More than a third of the SVI/BL causes are potentially avoidable, with childhood cataract and ROP the leading causes. Corneal scarring from vitamin A deficiency does not seem to be a continuing issue in Suriname.
Going into hospital? A booklet written by Dr Rami Seth. Produced by Cross Publishing Services. ISBN: 978-0-9572680-0-5.
Doctors make the worst patients. This statement encapsulates two truths. Yes, doctors continue to act like doctors when they are patients and try and tell their doctors what to do or ask too many questions but the more pertinent truth is that even doctors fall ill and become patients. The ultimate truth is that one day we will die, doctors and all. However, there are many things we can do to delay the inevitable and enjoy healthy lives or enjoy life within the limits permitted by the state of our health. This is the strong message that comes from this booklet written by Dr Rami Seth, a general practitioner and surgeon who developed cancer of the kidney, which spread to his liver and lungs, and was cured by surgery and medication.
Going into hospital?...]]>
To determine the prevalence of eyelid hyperlaxity and floppy eyelid syndrome (FES) in obstructive sleep apnoea (OSA), and the presence of OSA in FES.
One-hundred and fourteen patients who had been consecutively admitted for OSA evaluation and 45 patients with FES in which sleep studies were recorded.
Subjects underwent eyelid laxity measurement, slit-lamp examination and polysomnography.
Eighty-nine patients were diagnosed of OSA. Fourteen patients with OSA had FES (16%) and 54/89 (60.67%) had eyelid hyperlaxity. Two of the 25 non-OSA patients had FES (8%) and 8 of 25 (32%) had eyelid hyperlaxity. There was a significantly higher incidence of eyelid hyperlaxity in OSA than in non-OSA patients (p=0.004). Thirty-eight of the 45 patients with FES were diagnosed of OSA (85%) and 65% had severe OSA.
OSA might be an independent risk factor for eyelid hyperlaxity and severe OSA is common in patients with FES.
The avoidance of schematic approaches and the customisation of the therapy, modified according to the disease presentation, will be highly desirable and will open to a patient-oriented approach, granting a more prompt and stable improvement of the ocular surface with better-tolerated therapies.
]]>Editor,
With the growth in three-dimensional viewing of movies, we assessed whether visual fatigue or alertness differed between three-dimensional (3D) viewing versus two-dimensional (2D) viewing of movies. We used a camera-based analysis of eye movements to measure blinking, fixation and saccades as surrogates of visual fatigue.
Our observational crossover study included 28 subjects (age: 20–30 years) who watched a video (movie ‘Journey to the Center of the Earth’) presented for 40 min on a 3D display or 2D display. An eye tracking system (EYELINK 2000, Remote, SR Research, Mississauga, Ontario, Canada) was used to record the eye movements and pupil diameter. On one day, half the group watched a movie on a panel with a pattern-retard display technology for 3D viewing. On the next day, the participants watched the same movie on a 2D display. For the other half of the...]]>
To evaluate a step ladder approach for immunosuppressive regimen for Mooren's ulcer.
We retrospectively analysed patients of Mooren's ulcer presenting to a tertiary care centre in south India from 1987 to 2010. Patients were analysed for the age, disease severity at time of presentation in terms of the quadrants of peripheral corneal involvement and amount of peripheral corneal thinning. According to the disease severity, patients were instituted either topical steroids (prednisolone acetate 1%) single agent or in combination with oral steroids (prednisolone 1–1.5 mg/kg/day), oral immunomodulators (methotrexate 7.5–12.5 mg/week), intravenous pulsed methyl prednisolone 1 g or pulsed cyclophosphamide 1 g. The main outcome measure was control of disease activity.
Topical steroids as a single therapy had a disease resolution rate in 76% of the cases. Cases that required oral steroids, oral methotrexate, intravenous pulsed methyl prednisolone and combination of pulsed methyl prednisolone and cyclophosphamide had a resolution rate of 86%, 78.5%, 71.4% and 73.3%, respectively. The most common complication was secondary infection. Most of the cases that failed therapy had perforation of the cornea and required corneal transplantation.
An aggressive immunosuppressive regimen that is tailor made based on disease severity as a first line of therapy improves the chances of disease control even in cases of aggressive Mooren's ulcer.
To present a technique for near-infrared transillumination imaging of intraocular tumours based on the modifications of a conventional digital slit lamp camera system.
The Haag-Streit Photo-Slit Lamp BX 900 (Haag-Streit AG) was used for transillumination photography by gently pressing the tip of the background illumination cable against the surface of the patient's eye. Thus the light from the flash unit was transmitted into the eye, leading to improved illumination and image resolution. The modification for near-infrared photography was done by replacing the original camera with a Canon EOS 30D (Canon Inc) converted by Advanced Camera Services Ltd. In this camera, the infrared blocking filter was exchanged for a 720 nm long-pass filter, so that the near-infrared part of the spectrum was recorded by the sensor.
The technique was applied in eight patients: three with anterior choroidal melanoma, three with ciliary body melanoma and two with ocular pigment alterations. The good diagnostic quality of the photographs made it possible to evaluate the exact location and extent of the lesions in relation to pigmented intraocular landmarks such as the ora serrata and ciliary body. The photographic procedure did not lead to any complications.
We recommend near-infrared transillumination photography as a supplementary diagnostic tool for the evaluation and documentation of anteriorly located intraocular tumours.
Macular telangiectasia (MacTel) type 2 is a bilateral disease of unknown origin exhibiting characteristic changes of the macular deep capillary network and neurosensory retina.
To perform Descemet stripping automated endothelial keratoplasty (DSAEK) using a novel technique to obtain very thin (<100 µm) posterior corneal disks.
Twenty five DSAEK grafts were prepared with two sequential cuts: the first cut, of variable thickness, was made with a femtosecond laser and the second with a 300 µm microkeratome head. Spectacle corrected visual acuity, endothelial cell density evaluation with specular microscopy and anterior segment optical coherence tomography to measure central and peripheral graft thickness was performed preoperatively and postoperatively at 1, 3 and 6 months.
There were no irregular cuts or perforations during tissue preparation. Central graft thickness was 79.6 µm (SD±14.5; range 54–98) and 69.3 µm (SD±14.2; range 49–96) at 3 and 6 months. Corrected distance visual acuity improved from 0.91 logMAR preoperatively to 0.11 logMAR at 6 months. Donor endothelial cells averaged 2675 cells/mm2 preoperatively and 1729 cells/mm2 at 6 months. There were no graft detachments.
This new technique consistently yielded very thin grafts (<100 µm), excellent visual acuity results and good endothelial cell counts. No donor tissue was wasted.
To evaluate blink rate effects by a novel light-emitting diode (LED) timer device (PISC) on non-dry eye (DE) subjects and DE patients during a reading task on liquid crystal display (LCD) screens, in different environmental conditions.
This was a case–control study that included 15 DE patients and 15 non-DE subjects as controls. Participants had their blink rates measured while they read an electronic format text. These tasks were performed in four different conditions: with and without a LED timer device in two visits, and with and without air conditioning. All participants completed the Ocular Surface Disease Index and were examined by best spectacle-corrected visual acuity exam, biomicroscopy, Schirmer test 1, fluorescein staining and break-up time and lissamine green staining (Oxford scale grading).
Outcomes between reading tasks conditions were compared independently for each group and blink rate frequency was higher in tasks with LED timer device, with and without air conditioning, for the DE group (p<0.0001), and with air conditioning for the control group (p<0.05).
An LED timer device increased blink frequency for DE and control groups. Further studies need to be carried out in order to evaluate long-term effects of this new device, as well as its assessment with different reading scenarios.
There are three relevant reviews on The Cochrane Library.
To evaluate the refractive outcomes, prediction error (PE) and factors affecting PE in children with aphakia following congenital cataract surgery undergoing secondary intraocular lens (IOL) implantation.
We analysed the records of children less than 16 years old who underwent secondary IOL implantation for aphakia following congenital cataract surgery. PE and absolute PE for each case calculated 3 months following secondary IOL implantation were analysed. Multiple regression analysis was performed to determine the relationship between age at secondary IOL implantation, axial length, keratometry readings and PE.
174 eyes of 104 children were analysed. Mean age at surgery was 6.08±3.75 years. The mean PE was 1.65±2.46 dioptres (D) (range –3.25 to 7.5 D) and mean absolute PE was 2.15±1.68 D (range 0–7.5 D) at 3 months. There was a statistically significant difference in absolute PE between eyes in which IOL calculation was performed using IOL master (1.80±1.40 D) versus IOL calculation under general anaesthesia with contact method (2.43±1.83 D), p=0.01. Multiple regression analysis revealed an inverse relationship between age at secondary IOL implantation and mean absolute PE (p=0.01).
IOL power calculation with SRK II formula with sulcus placement of IOL gives favourable refractive outcomes. Though age-based refraction is targeted, a significant PE may be expected.
To report the largest cluster of Urrets–Zavalia Syndrome (UZS), which occurred as a sequel of toxic anterior segment syndrome (TASS) after uneventful cataract surgery, and to evaluate the possible causes and risk factors to prevent additional cases.
Department of Ophthalmology, Liaquat University of Medical & Health Sciences, Hyderabad, Pakistan.
Prospective Case Series.
15 consecutive TASS cases following uneventful cataract surgery were evaluated for potential causes and risk factors. Main outcome measures included visual acuity, anterior segment reaction, corneal oedema, intraocular pressure, pupillary reaction and response to topical and/or systemic steroid therapy at first day, first week and first month postoperatively.
The TASS incidence in this study was 0.08%. All cases presented with corneal oedema, anterior chamber reaction and fixed dilated pupils on first postoperative day. One month postoperatively, the anterior segment inflammation improved considerably in all patients. There was a statistically significant difference between the mean Best-corrected visual acuity (BCVA) at first postoperative day (2.32±0.93 LogMAR) and mean BCVA at 1 month (0.49±0.12 LogMAR) (p=0.0001). The rate of UZS in this study was 93%. Ringer lactate solution was found to be the offending agent of TASS, and replacing it brought a halt to this cluster.
Timely diagnosis, steroid therapy and close monitoring are the main keys for properly managing TASS. To our knowledge, we report, for the first time, the largest cluster of UZS occurring as a sequel of TASS.
During the last 10 years, considerable progress has been made in cancer genetics and many cancer diagnoses now rely on molecular biology. Chromosomal abnormalities have been first studied by karyotype analysis then fluorescence in situ hybridisation (FISH), and now new techniques are available, like comparative genomic hybridisation and single nucleotide polymorphism (SNP) arrays, that are becoming more and more affordable in molecular pathology labs. New technologies for genome-wide DNA sequencing are now revealing specific and unbiased information on cancer initiation and progression, and are paving the way for new targeted therapies that will allow more efficient treatment.
Tumours like breast cancer, sarcoma, paediatric round-cell tumours, etc, can be classified according to their genomic characteristics.
In uveal melanoma, the use of genome profiling or gene expression signatures leads to the classification of uveal melanoma into two major subtypes of tumours with very different prognosis. Research is still ongoing to find new targeted therapies...]]>
To investigate the expression levels of vascular endothelial growth factor (VEGF), vascular endothelial growth factor receptor 1 (VEGFR-1) and VEGFR-2 in pterygium and to clarify the prognostic significance of these expressions in pterygia.
A total of 40 surgically excised pterygia and 9 normal conjunctivae were immunohistochemically studied applying the streptavidin–biotin method in paraffin-embedded tissue sections. Monoclonal antibodies were targeted against VEGF, VEGFR-1 and VEGFR-2 proteins. At the sixth postoperative month, the recurrence rate was graded on a scale of 1–4.
The mean percentage of VEGF-positive epithelial cells was comparable in pterygium and normal conjunctivae. However, the pterygium group presented higher expression levels of VEGF in pterygia endothelial cells (p=0.05). In terms of VEGFR-1 expression in epithelial cells, no statistically significant difference was found between two groups (p=0.658). However, normal conjunctivae exhibited higher expression levels of VEGFR-1 in endothelial cells (p=0.002). Epithelial cells in pterygium presented higher combined scores of VEGFR-2 (87.5% and 22.2%, respectively) (p=0.013). While higher expression levels of VEGFR-2 were documented in pterygia endothelial cells, no VEGFR-2 immunoreactivity was observed in the endothelial cells of normal conjunctivae (p<0.001). Expression levels of VEGFR-2 in epithelial cells and endothelial cells were positively correlated with the postoperative recurrence grading system (p<0.001 and =0.627, p=0.001 and =0.508, respectively).
The results suggest that VEGF may play a key role through VEGFR-2 in the pathogenesis of pterygium. Moreover, overexpression of VEGFR-2 in pterygia may have a predictive value for a higher postoperative recurrence rate.
To compare postoperative visual acuity, higher-order aberrations (HOAs) and corneal asphericity after femtosecond lenticule extraction (FLEx) and after wavefront-guided laser-assisted in situ keratomileusis (wfg-LASIK) in myopic eyes.
We examined 43 eyes of 23 patients undergoing FLEx and 34 eyes of 19 patients undergoing wfg-LASIK to correct myopia. Ocular HOAs were measured by Hartmann-Shack aberrometry and corneal asphericity was measured by a rotating Scheimpflug imaging system before and 3 months after surgery.
There was no statistically significant difference in uncorrected (p=0.66 Mann–Whitney U-test) or corrected distance visual acuity (p=0.14) after two surgical procedures. For a 6-mm pupil, the changes in fourth-order aberrations after FLEx were statistically significantly less than those after wfg-LASIK (p<0.001). On the other hand, there were no statistically significant differences in the changes in third-order aberrations (p=0.24) and total HOAs (p=0.13). Similar results were obtained for a 4-mm pupil. The positive changes in the Q value after FLEx were statistically significantly less than those after wfg-LASIK (p=0.001).
In myopic eyes, FLEx induces significantly fewer ocular fourth-order aberrations than wfg-LASIK, possibly because it causes less oblation in the corneal shape, but there was no statistically significant difference in visual acuity or in the induction of third-order aberrations and total HOAs. It is suggested that FLEx is essentially equivalent to wfg-LASIK in terms of visual acuity and total HOA induction, although the characteristics of HOA induction are different.
To evaluate ocular outcome in premature infants treated with intravitreal ranibizumab injections for retinopathy of prematurity (ROP) over a period of 3 years.
An interventional case series. Premature infants with high-risk prethreshold or threshold ROP with plus disease received an off label monotherapy with intravitreal injections of ranibizumab. The primary outcome was treatment success defined as regression of neovascularisation (NV) and absence of recurrence. The secondary outcomes were ocular and systemic adverse events and visual acuity.
Six eyes were included in the study and treated with intravitreal injections of ranibizumab. All showed complete resolution of NV after a single injection. The anti-angiogenic intravitreal injections allowed for continued normal vessel growth into the peripheral retina, without any signs of disease recurrence or progression during the follow up period. No ocular or systemic adverse effects were observed.
Three years of follow up in a small series suggest that intravitreal ranibizumab injections for ROP result in apparently preserved ocular outcome. Further large scale studies are needed to address the long-term safety and efficacy.
Severe ocular inflammation is a blinding ophthalmological emergency. This study evaluates the efficacy and patient tolerance of a validated regime of pulsed intravenous cyclophosphamide and methylprednisolone (‘PICM protocol’) for these patients.
26 patients with severe inflammatory eye disease (43 eyes: 22 uveitis, 21 scleritis/sclerokeratitis; median age 52 years (IQR 40.25–62.25)) presenting to a regional tertiary referral centre were recruited over a 10-year period (January 2002–December 2011) into the PICM protocol, comprising intravenous cyclophosphamide 15 mg/kg, intravenous methylprednisolone 10 mg/kg, maximum nine pulses over 20 weeks supplemented with low-dose continuous oral prednisolone. Data were captured pretreatment and at 6 and 12 months follow-up. Primary outcome measures were control of inflammation according to standard criteria and reduction in systemic glucocorticoid to ≤10 mg prednisolone/day.
A median of six pulses (IQR 5–6) were administered over a median of 3 months (IQR 2.25–4). In the scleritis/sclerokeratitis group, 15/21(71%) achieved success or partial success at 6 and 12 months versus 9/22 (41%) for the same time points in the uveitis group (2=4.058, p=0.044). Two patients had adverse events requiring treatment withdrawal.
This PICM protocol is a well-tolerated regimen for managing severe ocular inflammation and appears particularly useful in patients with scleritis/sclerokeratitis.
Dry eye syndrome is an ubiquitous ophthalmic condition effecting as many as 80% of the population over the age of 80.
The novel immunochromatographic assay (ICGA) kit was recently developed to diagnose herpes simplex virus (HSV) infection. This multicentre study aimed to evaluate the value of the ICGA kit for the diagnosis of herpetic epithelial keratitis by comparing it with immunofluorescence assay (IFA) and real-time PCR.
Corneal scrapings were collected from 117 patients, including 77 with herpetic keratitis as their final clinical diagnosis as well as 40 others at 21 facilities. These samples were tested by the ICGA kit, IFA and real-time PCR.
The positive concordance between final clinical diagnosis and ICGA was 46.7% (35/75 cases) and the negative concordance was 100% (39/39). The positive and negative concordance between real-time PCR and ICGA were 57.4% (35/61 cases) and 100% (53/53), respectively. The positive and negative concordance between IFA and ICGA were 61.1% (22/36 cases) and 83.3% (55/66), respectively. In 92 cases where anti-HSV drugs were not prescribed prior to corneal scraping, the positive and negative concordance between final clinical diagnosis and ICGA were 55.0% (33/60 cases) and 100% (32/32), respectively.
The ICGA kit has moderate sensitivity and high specificity, indicating clinical utility in the diagnosis of herpetic epithelial keratitis.
The Beijing Eye Study 2011 is a population-based cross-sectional study in a rural region and an urban region of Greater Beijing.