We present a case of a macular hole formation and its spontaneous closure after vitrectomy for vitreomacular traction. To our knowledge, it is the first description of spontaneous closure of the macular hole after vitrectomy for vitreomacular traction.
A 78-year-old woman presented decreased visual acuity and metamorphopsia in the right eye due to vitreomacular traction. A vitrectomy with internal limiting membrane peeling and an air tamponade was performed in the right eye. Spectral-domain optical coherence tomography was obtained during all visits.
Seven days after the vitrectomy, the spectral-domain optical coherence tomography showed a resolved vitreomacular traction and a full-thickness macular hole. Examination after a further three weeks showed that the full-thickness macular hole had spontaneously closed. 5 months later spectral-domain optical coherence tomography showed a normal foveal contour without intraretinal microcystic spaces and a resolution of the photoreceptor and external limiting membrane elevation.
While performing a vitrectomy for vitreomacular traction posterior hyaloid membrane creates anterior-posterior traction on the fovea, and, during detachment, retinal layer damage occurs in the macular area and a full-thickness macular hole may develop. Removal of the anterio-posterior vitreous traction may play the main role and may help the spontaneous closure of the macular hole after vitrectomy for vitreomacular traction.
Vitreomacular traction; Full-thickness macular hole; Spectral-domain optical coherence tomography
The editors of BMC Ophthalmology would like to thank all of our reviewers who have contributed to the journal in Volume 13 (2013).
Graves’ disease (GD) and Graves’ ophthalmopathy (GO) are autoimmune disorders, which might be influenced by genetic factors. Copy number variation (CNV) is an important source of genomic diversity in humans, and influences disease susceptibility. This study investigated the association between CNV in the TSHR and TLR7 genes and the development of GD and GO in a Chinese population in Taiwan.
For this case-control study, sample from 196 healthy controls and 484 GD patients, including 203 patients with GO were studied. CNV was detected by real-time polymerase chain reaction (PCR) using TaqMan™ probes and the relative copy number (CN) was estimated by using the comparative Ct method.
The differences in the distribution of TSHR CNV in healthy controls and GD patients were statistically significant (p value = 0.01). However, the difference in the distribution of TSHR CNV in the control group and the GO group was not statistically significant (p value = 0.06). For TLR7 CNV, the results were not significantly different when we compared the distribution in healthy controls and GD patients and in healthy controls and GO patients (p values for Fisher’s exact test were 0.13 and 0.09, respectively). However, a lower than normal CNV for TLR7 (CNV < 2 for female and CNV < 1 for male) was found to have a protective effect against the development of GD (odds ratio (OR) = 0.24; 95% confidence interval (CI), 0.07-0.75) after adjusting for age and gender.
These results suggested that TSHR and TLR7 CNV might be associated with susceptibility to GD.
Graves’ disease; Graves’ ophthalmopathy; Copy number variation; TSHR; TLR7; Taiwan
The treatment of uveal melanoma has seen a shift towards eye conserving treatments. Efforts have been made towards the identification of patients at high risk of metastatic disease with the use of prognostic fine needle biopsy, Monosomy 3 a risk factor for metastatic death thought to occur early in the development of uveal melanoma.
We report a case in which an atypical optic nerve lesion was found to be a peripapillary primary uveal melanoma with distinct non-pigmented and pigmented halves on gross dissection and corresponding disomy 3 and monosomy 3 halves. The tumour demonstrated rapid growth with apparent transformation from disomy 3 to monosomy 3.
These are clinical features that challenge the current concepts of the cytogenetic pathogenesis of uveal melanoma and demonstrate the potential problems and limitations of prognostic fine needle biopsy and molecular classifications.
Uveal melanoma; Monosomy 3; Fine needle biopsy
Ochronosis/Alkaptonuria is a tyrosine metabolism disorder where accumulation of homogentisic acid, in eye, skin, cartilage and several other connective tissues leads to a black pigmentation of the affected tissues. It is autosomal-recessive inherited in men with a frequency of 1-9/1,000,000. While it is clear that pigment deposits lead to joint destruction, renal stone formation and cardiac valvulopathy respectively, the significance of ocular findings is still unclear. We therefore aim to evaluate the frequency and clinical significance of ocular findings in ochronosis and discuss possible therapeutic options.
Systematic review of literature via Medline and Web of Science. Only case reports in English, German, French, Spanish or Italian documenting detailed ophthalmologic examination were included.
Our search revealed 36 case reports including 40 patients. Average age at the onset of ocular signs was 40.6 years. The most frequent sign was symmetric brown sclera pigmentation present in 82.5 percent of the patients. “Oil-drops”, brown pigment spots in the limbus are generally considered pathognomonic but were a little less frequent (75 percent). Vermiform pigment deposits at the level of the conjunctiva or increased conjunctival vessel diameter is also frequent. We found an increased incidence of central vein occlusion and elevated intraocular pressure going along with chamber angle hyperpigmentation. Another condition observed twice is rapid progressive astigmatism attributable to corneoscleral pigment accumulation.
Our observations suggest that ocular findings are of double relevance. First, characteristic ocular findings can anticipate the time of diagnosis and second, ocular findings may complicate to various conditions putting sight at risk. Opthalmologists and general physicians should be aware of both. Therapeutic options include protein restriction, administration of high dose vitamin C or nitisonone. Evidence for all of them is limited.
Hereditary ochronosis; Endogenous ochronosis; Alkaptonuria; Oil-drops; Eye; Opththalmology; Homogentisic acid; Ocular; Homogentisic acid oxidase deficiency
To evaluate the relationships between Reichert Ocular Response Analyzer (ORA) parameters corneal hysteresis (CH) and corneal response factor (CRF) and ocular dimensions, age and intraocular pressure.
Two hundred and twelve eyes of 212 participants with no ocular pathology had CH and CRF measured with the ORA. Intraocular pressure (IOP) was measured with the Dynamic Contour tonometer and central corneal thickness (CCT) was also evaluated. Partial least squares linear regression (PLSLR) analyses were performed to examine the relationships between each response variable, CH and CRF, and the predictor variables age, corneal curvature (CC), axial length (AL), CCT and IOP.
CH was positively associated with CCT and negatively associated with age (scaled coefficients: CCT 0.62, p < 0.0001; age -0.55, p <0.0001; r2 = 0.25). CRF was positively associated with CCT and DCT IOP and negatively associated with age and AL (scaled coefficients: CCT 0.89, p < 0.0001; DCT IOP 0.46, p < 0.01; age – 0.60, p < 0.0001; AL -0.37, p < 0.01; r2 = 0.43). There was no significant association between CC and CH or CRF.
The study suggests that age and CCT are strongly associated with CH and CRF, and that the latter is also influenced by AL and IOP. However, the variables studied could explain only 25% and 43% of the measured variation in CH and CRF, respectively, suggesting other factors also affect the values of these measurements.
Prior studies have shown age-related macular degeneration (AMD) to be associated with falls. The purpose of this study is to determine if (AMD) and AMD-related vision loss are associated with fear of falling, an important and distinct outcome.
Sixty-five persons with AMD with evidence of vision loss in one or both eyes and 60 glaucoma suspects with normal vision completed the University of Illinois at Chicago Fear of Falling questionnaire. Responses were Rasch analyzed. Scores were expressed in logit units, with lower scores demonstrating lesser ability and greater fear of falling.
Compared to glaucoma suspect controls, AMD subjects had worse visual acuity (VA) (median better-eye VA = 20/48 vs. 20/24, p < 0.001) and worse contrast sensitivity (CS) (binocular CS = 1.9 vs. 1.5 log units, p < 0.001). AMD subjects were also older, more likely to be Caucasian, and less likely to be employed (p < 0.05 for all), but were similar with regards to other demographic and health measures. In multivariable models controlling for age, gender, body habitus, strength, and comorbid illnesses, AMD subjects reported greater fear of falling as compared to controls (β = -0.77 logits, 95% CI = -1.5 to -0.002, p = 0.045). In separate multivariable models, fear of falling increased with worse VA (β = -0.15 logits/1 line decrement, 95% CI = -0.28 to -0.03, p = 0.02) and CS (β = -0.20 logits/0.1 log unit decrement, 95% CI = -0.31 to -0.09, p = 0.001). Greater fear of falling was also associated with higher BMI, weaker grip, and more comorbid illnesses (p < 0.05 for all).
AMD and AMD-related vision loss are associated with greater fear of falling in the elderly. Development, validation, and implementation of methods to address falls and fear of falling for individuals with vision loss from AMD are important goals for future work.
Fear of falling; Falls; Age-related macular degeneration; Disability; Older adults; Visual acuity; vision loss; Physical function; Safety
Presbyopia is the age-related decline in accommodation that diminishes the ability of the eye to focus on near objects. Presbyopia is common and easy to correct; however, many communities lack access to basic eye care. The purpose of this project was to assess the burden of uncorrected presbyopia in a rural Filipino population and to pilot an intervention aimed at increasing access to reading glasses in the community.
Individuals above the age of 40 who presented to a health outreach in the Philippines were invited to undergo a near vision exam to detect the presence of functional presbyopia and be fitted with ready-made, single-vision glasses. The change in stereoacuity was used as a surrogate measure of functional improvement after near vision correction. A questionnaire was administered to assess this population’s perceived barriers and benefits to correcting near vision.
The average age of the participants was 57 ± 11 years, with 87.6% of participants having an uncorrected near visual acuity of <20/50. Reading glasses improved near vision to 20/40 or better in 77.7% of participants having near-vision impairment (uncorrected near visual acuity of <20/40). Over 75% of participants also showed improvement in stereoacuity. Cost, rather than availability, was perceived to be the greater barrier to the procurement of glasses, and 84% of participants reported that the glasses dispensed would greatly improve their ability to earn a living.
Dispensing ready-made, single-vision glasses is a simple and cost-effective intervention to improve near vision and enhance depth perception. A greater understanding of the barriers and benefits to correcting near vision will inform the design and execution of a sustainable program to correct presbyopia in developing countries.
Presbyopia; Quality of life; Survey; Near vision; Stereoacuity; Reading glasses
Macular oedema secondary to retinal vein occlusion (RVO) can cause vision loss due to blockage of the central retinal vein (CRVO) or a branch retinal vein (BRVO). This systematic review assessed the efficacies of widely used treatments for macular oedema secondary to RVO and the feasibility of conducting indirect comparisons between these therapies.
A systematic review was undertaken in November 2010, including a literature search for trials in medical databases and relevant websites. Abstracts, conference presentations and unpublished studies were considered. Studies were data-extracted and quality assessed by two independent researchers. Outcome measures included the mean change in best corrected visual acuity (BCVA) from baseline in the study eye and/or number of patients gaining at least 10 letters from baseline to 6 months or the nearest equivalent time point.
Fourteen unique randomized controlled trials (RCTs) were identified. Ranibizumab 0.5 mg produced greater improvements in BCVA at 6 months than sham in BRVO (mean difference 11.0 letters, 95% confidence interval [CI] 7.83, 14.17) and CRVO (mean difference 14.10 letters, 95% CI 10.51, 17.69) in two double-blind sham-controlled RCTs. Pooled data from two double-blind, sham-controlled RCTs showed that improvements in BCVA were also significantly better for dexamethasone intravitreal (IVT) implant 0.7 mg compared with sham in patients with BRVO or CRVO (mean difference 2.5 letters, 95% CI 0.7, 4.3); the difference was significant for BRVO alone, but not CRVO alone. A significantly greater proportion of patients with BRVO gained ≥15 letters with laser therapy vs. no treatment at 36 months in a large prospective RCT (odds ratio 3.16, 95% CI 1.25, 8.00), whereas no difference was observed at 9 months in a smaller study. Three studies reported no benefit for laser therapy in CRVO. No indirect comparisons with ranibizumab were feasible due to differences in study design and baseline characteristics.
Data from RCTs for ranibizumab and dexamethasone IVT demonstrate that both new agents constitute significant improvements over the previously widely accepted standard of care (laser therapy) for the treatment of BRVO and CRVO. However, head-to-head studies are needed to assess the relative efficacies of licensed therapies for RVO.
Retinal vein occlusion; Ranibizumab; Dexamethasone intravitreal; Laser; Branch retinal vein occlusion; Central retinal vein occlusion
A new procedure to correct myopia that does not disturb the cornea in the optical zone and avoids injuring the corneal epithelium could be a key advance in corneal refractive surgery. The aim of this study is to observe the refractive change in the adult rabbits undergoing femtosecond laser-assisted multilayer intrastromal ablation in the mid-periphery of the cornea without injury of epithelium.
The right eyes of 8 New Zealand White adult rabbits were used for the experiments. A 60-kHz femtosecond laser delivery system was used, and three lamellar layers of laser pulses were focused starting at a corneal depth of 180 μm and ending at 90 μm from the surface, with each successive layer placed 45 μm anterior to the previous layer. In the interface of the applanation contact lens cone, a 6-mm diameter aluminum circle was placed at the center to block the laser, limiting ablation to the mid-periphery of the cornea. The laser settings were as follows: spot/line separation, 10 μm; diameter, 8.0 mm; energy for ablating the stroma, 1.3 μJ. An authorefractor was used to assess the manifest refraction.
Mean spherical equivalent (SE) (mean ± SD, SD: standard deviation) was significantly increased at postoperative week 1 (1.67 ± 0.26 D, p < 0.0001), month 1 (1.65 ± 0.23 D, p < 0.0001), and month 3 (1.60 ± 0.22 D, p < 0.0001) compared to baseline (0.68 ± 0.27 D). Mean spherical equivalent showed no significant change between postoperative week 1 and month 3 (p = 0.1168).
Femtosecond laser-assisted multilayer corneal intrastromal ablation in the mid-periphery may cause a consequent hyperopic shift with no refractive regression.
Specific cross-reacting autoimmunity against recoverin or collapsin response mediator protein (CRMP)-5 is known to cause cancer-associated retinopathy or paraneoplastic optic neuropathy, respectively. We report a rare case with small cell lung carcinoma developing bilateral neuroretinitis and unilateral focal outer retinitis positive for these antibodies.
A 67-year-old man developed bilateral neuroretinitis and foveal exudation in the right eye. Optical coherence tomography showed a dome-shaped hyperreflective lesion extending from inner nuclear layer to the photoreceptor layer at the fovea in the right eye. Single-flash electroretinography showed normal a-waves in both eyes and slightly reduced b-wave in the left eye. Results of serological screening tests for infection were within normal limits. The patient’s optic disc swelling and macular exudation rapidly improved after oral administration of prednisolone. Systemic screening detected lung small cell carcinoma and systemic chemotherapy was initiated. Immunoblot analyses using the patient’s serum detected autoantibodies against recoverin, CRMP-5, and α-enolase, but not carbonic anhydrase II. Neuroretinitis once resolved after almost remission of carcinoma on imaging but it recurred following the recurrence of carcinoma.
The development of neuroretinitis in this cancer patient with anti-retinal and anti-optic nerve antibodies depended largely on the cancer activity, suggesting the possible involvement of paraneoplastic mechanisms. Patients with paraneoplastic optic neuropathy and retinopathy are likely to develop autoimmune responses against several antigens, thus leading to various ophthalmic involvements.
Neuroretinitis; Recoverin; Cancer-associated retinopathy; Collapsin response mediator protein-5; Outer retinitis
The cataract surgery rate (CSR) is a critical index used to show that cataract blindness is being eliminated. It is considered to be tightly connected to social economic development; however, it is still extremely low in developing countries such as China. Although Shanghai is the most economically developed city in China, its CSR and the obstacles for increasing its CSR have not been previously evaluated.
A retrospective cross-sectional study was conducted. By analyzing the data in the “Shanghai Cataract Operations Database” from 2006 to 2009, the CSR in Shanghai was calculated. The numbers of cataract surgeries between urban and suburban districts as well as among various medical institutions were compared.
The CSR in Shanghai increased from 1741 in 2006 to 2210 in 2009, reflecting a 26.94% improvement. Phacoemulsification was the most frequent surgical choice for cataract removal, accounting for 94.93% of total cataract surgeries by 2009. In addition, by 2009, the CSR in urban districts had reached 5468, but only 532 in the suburbs. During 2009, cataract surgery records in 68 district hospitals, 23 medical centers, and 6 private hospitals comprised 32.05%, 52.33%, and 15.62%, respectively, of the total. There was a nearly 3.3-fold increase in the number of surgeries performed in private hospitals in the past four years. Furthermore, the average number of cataract surgeries per doctor that took place in private hospitals per year reached 207, which exceeded the average of 145 that took place in medical centers.
Until 2009, the CSR in Shanghai remained below the rates of social development and fell short of targets suggested by the World Health Organization (WHO). Furthermore, increasing the CSR in the suburbs as well as in district hospitals is an important issue that needs to be addressed.
Cataract surgery rate; Districts; Medical institutions; Restricting factors; Shanghai
To assess the socio-demographic and health-related risk factors associated with cataract subtypes in Korea.
A total of 11,591 participants (aged ≥40 years) were selected from the Korean National Health and Nutrition Examination Survey between 2008 and 2010. The Korean Ophthalmologic Society conducted detailed ophthalmologic examinations on these participants based on the Lens Opacity Classification System III. Risk factors for developing any type of cataract, and its subtypes (nuclear, cortical, posterior subcapsular and mixed), were identified from univariate and multivariate logistic regression analysis.
The prevalence of cataracts was 40.1% (95% CI, 37.8 − 42.3%) in participants over 40 years old. Older age, lower monthly household income, lower education, hypercholesterolemia, hypertension, and diabetes mellitus (DM) were independent risk factors for development of any cataract. Older age, lower monthly household income, lower education, hypercholesterolemia, and DM were independent risk factors for development of pure cortical cataracts. Older age, lower education, metabolic syndrome, and DM were independent risk factors for development of pure nuclear cataracts. Older age and DM were independent risk factors for development of pure posterior subcapsular cataracts. Older age, lower monthly household income, lower education, and DM were independent risk factors for development of mixed cataracts.
Although socioeconomic disparities are related to cataract development, this study identified several “modifiable” risk factors that may help to lower the incidence of cataracts and associated vision loss. Improved control of blood pressure, blood, glucose, and cholesterol may help to reduce the incidence of cataracts in the general Korean population.
Cataract; Cataract subtype; Cataract risk factors; KNHANES
Poor health literacy is often a key cause of lack of or delayed uptake of health care services. The aim of this study was to assess the health literacy of common ocular diseases, namely cataract, glaucoma, night blindness, trachoma and diabetic retinopathy in Nepal.
A cross sectional study of 1741 participants randomly selected from non-triaged attendants in the outpatient queue at Tilganga Institute of Ophthalmology, a semi urban general population of Bhaktapur district of Kathmandu Valley and patients attending rural outreach clinics. Participants responded to trained enumerators using verbally administered, semi structured questionnaires on their awareness and knowledge of cataract, glaucoma, diabetic retinopathy, night blindness, and trachoma.
The awareness of cataract across the entire sample was 49.6%, night blindness was 48.3%, diabetic retinopathy was 29%, glaucoma was 21.3% and trachoma was 6.1%. Patients presenting to rural outreach clinics had poorer awareness of cataract, glaucoma, diabetic retinopathy, night blindness and trachoma compared to those from a semi-urban community and an urban eye hospital (p<0.05), Old age was directly associated with poorer awareness of cataract, glaucoma, night blindness, trachoma and diabetic retinopathy (p<0.05). Female gender was associated with lower awareness of cataract, glaucoma, night blindness and trachoma (p<0.05). Literacy was associated with greater awareness of cataract, glaucoma, diabetic retinopathy, night blindness and trachoma (p<0.05). Higher education was significantly associated with greater awareness of cataract, night blindness and trachoma (p<0.05). Multivariate analysis found that the awareness of common ocular diseases was significantly associated with level of education (p<0.05). Similarly, awareness of cataract, glaucoma, trachoma and night blindness was associated with female gender (p<0.05) whereas awareness of cataract, night blindness, trachoma and diabetic retinopathy was associated with age (p<0.05) but the awareness glaucoma and diabetic retinopathy was associated with camps.
Low awareness of common ocular conditions is associated with factors such as female gender, old age, lower levels of education and rural habitation. A would be successful health promotion programs should specifically target health determinants to promote health literacy and to ensure timely utilization of eye care services.
Cataract; Diabetic retinopathy; Glaucoma; Health literacy; Nepal; Night blindness; Trachoma
This study examined the refractive and visual outcome of wavefront-optimized laser in situ keratomileusis (LASIK) in eyes with low myopia and compound myopic astigmatism ≤ 0.75 diopter (D).
153 eyes from 153 consecutive myopic patients (74 male, 79 female; mean age at surgery 40.4 ± 10.4 years) who had a preoperative refractive cylinder ≤ 0.75 D and a manifest sphere between -0.25 D and -2.75 D, and who had completed 4-month follow-up. Three subgroups defined by the magnitude of preoperative manifest refractive cylinder (0.25, 0.50, and 0.75 D) were formed. Manifest refraction, uncorrected and corrected visual acuity were assessed pre- and postoperatively. The astigmatic changes achieved were determined using the Alpins vector analysis.
After 4 months (120.0 ± 27.6 days) of follow-up, a mean uncorrected distant visual acuity of 0.07 ± 0.11 logMAR and a mean manifest refraction spherical equivalent of -0.06 ± 0.56 D were found. There was no statistically significant difference in efficacy and safety between the preoperative cylinder groups. Astigmatic overcorrection for preoperative cylinder of ≤ 0.50 D was suggested by the correction index, the magnitude of error, the index of success, and the flattening index.
Low myopic eyes with a preoperative cylinder of ≤ 0.50 D were significantly overcorrected with regard to cylinder correction when combined with low myopic LASIK. Accordingly, we are cautious in recommending full astigmatic correction for eyes with low myopia and manifest cylinder of ≤ 0.50 D.
Alpins vector method; Cylinder axis; Induced astigmatism; Laser in situ keratomileusis; Low astigmatism; Low myopia
To identify risk factors for being a “reduced responder” to ranibizumab treatment in a clinical setting in patients with neovascular age-related macular degeneration.
This retrospective study included 165 eyes of 165 consecutive patients with choroidal neovascularisation secondary to neovascular, age-related macular degeneration. Eyes were treated with three intravitreal injections of ranibizumab, followed by PRN (pro re nata) dosing thereafter. All patients were reevaluated every four weeks and then followed for six months. Reduced responders were defined as patients with a loss in visual acuity of at least 1 visual acuity line at the last follow-up and/or persistent intraretinal or subretinal fluid or detectable choroidal neovascularisation at the last follow-up, compared to baseline.
Overall, 58 out of 165 eyes (35.2%) were considered to be reduced responders to treatment at the end of follow-up. The initial CNV size at baseline was correlated with the risk of being a reduced responder at the end of follow-up (p = 0.017).
We identified the initial lesion size as a predictor for a reduced response to treatment in this study. Patients with a large initial lesion size should be thoroughly informed about the possible poorer response to the intravitreal treatment.
Ranibizumab; Lucentis; Age-related macular degeneration; Response to treatment
Herein we report a case of bilateral anterior ischemic optic neuropathy (AION) showing histopathologic evidence of AL-amyloidosis of the temporal arteries. It is known that light-chain (AL) amyloidosis may rarely affect the temporal arteries, mimicking giant cell arteritis, while, to our knowledge, the association between AL-amyloidosis and AION was not previously described.
A 64 year-old woman with AL-amyloidosis secondary to a monoclonal gammopathy of undetermined significance (MGUS) referred to our hospital for acute painless drop of vision due to bilateral AION. Age greater than 50 years, high erythrocyte sedimentation rate (ESR), and bilateral AION were suggestive of giant cell arteritis (GCA). However, a temporal artery biopsy excluded GCA, showing segmental stenosis of the lumen caused by amyloidosis of the artery wall.
The present case shows that AL-amyloidosis may present with AION, high ESR, and temporal artery involvement, mimicking GCA. In patients with monoclonal gammopathies, C-reactive protein may be a more specific index of GCA compared with the ESR. Patient medical history and pathology are crucial for a correct diagnosis.
Ischemic optic neuropathy; Giant cell arteritis; Horton’s disease; Amyloidosis; Light-chain; Monoclonal gammopathy
A strong association exists between the use of tamsulosin and the occurance of intraoperative floppy iris syndrome. Several methods were advocated to overcome the progressive intraopertive miosis.
Our purpose was to investigate the effect of a mydriatic-cocktail soaked cellulose sponge on perioperative pupil diameter in tamsulosin-treated patients undergoing elective cataract surgery.
Patients using tamsulosin were dilated either with mydriatic-cocktail soaked sponge (group 1) or with conventional eyedrop regimen (group 2). Control patients not taking any α1 adrenergic receptor inhibtors were also dilated with mydriatic sponge (group 3).
In all groups oxybuprocain 0.4%, cocain 4%, tropicamide 1%, phenylephrine 10%, diclophenac 0.1% along with chloramphenicol 0.5% were used preoperatively.
Pupil diameter (mm) was measured preoperatively, after nucleus delivery, and before IOL implantation. Adverse effects associated with the use of sponge, minor and major intraoperative complications, the use of iris retractors and operation time were recorded.
Differences in general between groups were analyzed with a one way analysis of variance (ANOVA); differences between groups in proportions were assessed by Fisher’s exact test.
Mean pupil diameter (mm) was preopertively: 7.52 ± 1.21, 7.30 ± 1.55 and 7.99 ± 0.96 (ANOVA: p = 0.079); after nucleus delivery: 6 ± 1.20, 6.29 ± 1.12 and 6.52 ± 0.81 (ANOVA: p = 0.123); before IOL implantation: 5.46 ± 1.06, 5.83 ± 1.09 and 6.17 ± 0.89 (ANOVA: p = 0.0291).
No adverse effect related to sponge use was detected. Frequency of minor complications, and iris hook use was similar in the two tamsulosin treated group. Operation time did not differ significantly in the three groups.
We have found that using a mydriatic cocktail-soaked wick – an alternative way to achieve intraoperative mydriasis for cataract surgery – was as effective and safe as the conventional repeated eyedrops regiment for tamsulosin treated patients.
Current Controlled Trials ISRCTN37834752
Pupil dilation; Intraoperative floppy iris syndrome; Tamsulosin
Mooren’s ulcer is a severe ulcerative inflammation of the cornea. The exact pathogenesis remains unclear. Therefore many therapies of Mooren’s ulcer are recommended in literature. To shed more light on the ongoing question of optimal treatment of severe progressive Mooren’s ulcer, we here report on a retrospective case series of patients treated with systemic immunosuppressive therapy and additional amniotic membrane transplantation.
Medical records from seven patients (eleven eyes), 4 male and 3 female, with severe progressive Mooren’s ulcer were analysed retrospectively. The mean follow up was 88.4 ± 80.8 months (range 12–232 month). A HLA-typing was performed in all patients. A systemic immunosuppressive therapy was administered in all patients. The amniotic membrane was transplanted after the base of the ulcer was resected.
Multiple amniotic membrane transplantations were necessary in six patients. The visual outcome of all patients was poor. No patient achieved a visual acuity better than 20/630 Snellen chart. Five patients were positive for HLA-DQ2 and four patients were positive for HLA-DR17(3).
The aggressive and highly inflammatory form of Mooren’s ulcer is difficult to treat and the progression of the disease is hard to influence positively even under systemic immunosuppressive therapy. Therefore, the main intention of therapy is to achieve a stable epithelialized corneal surface without the risk of perforation. Amniotic membrane transplantation is not able to cure severe forms of Mooren’s ulcer. However it supports the immunosuppressive therapy in acute situations as in critical corneal thinning.
Cornea; Mooren’s ulcer; Amniotic membrane; Autoimmune disease; Immunosuppressive therapy
National guidelines on MRSA (methicillin-resistant Staphylococcus aureus) screening policy in England have changed on a number of occasions, but there is limited data on its influence at a local level. The aim of this study was to determine if changes in National policy influenced preoperative screening of cataract patients for MRSA.
A structured telephone survey was conducted on all 133 ophthalmology units in England in 2004 and again in 2007 for the initial responders, after a change in national policy.
A total of 74 units (56%) responded in 2004 and 71 units (96% of initial respondents) in 2007. In 2004, 57% of units screened for MRSA. They screened groups at high risk of carriage, including patients with previous MRSA (93%) and patients from Nursing homes (21%). Swab sites included the nose (100%), eyes (31%) and perineum (62%). In 2007, there was no significant change in the number of units that screened for MRSA (57% vs 66%; p = 0.118; McNemar test). However, more units screened for MRSA in patients from nursing/residential homes (21% vs 51%; p = 0.004, McNemar test), and in patients who had recent admission to hospital (12% vs 36%; p = 0.003). In the second survey, 3 units (6%) now screened patients who were close relatives of MRSA carriers.
This survey has highlighted inconsistences in MRSA screening practice of day-case cataract surgery patients across England after 2 major national policy changes. A change in DoH policy only led to more units screening patients for MRSA from high risk groups.
Healthcare surveys; Meticillin-resistant Staphylococcus aureus; Phacoemulsification; Screening
Major academic ophthalmology departments have been expanding by opening multi-office locations (“satellites”). This paper offers a first glimpse into satellites of academic ophthalmology departments.
Leaders of seven medium to large, geographically diverse departments agreed to participate. One- to two-hour phone interviews were conducted to assess the features of their satellite practices.
Success as clinical entities, profitability, and access to patients were stated goals for most satellites. In approximate descending order, refractive surgery, retina, oculoplastics, and pediatric ophthalmology were the most common subspecialties offered. Faculty staffing ranged from recruitment specifically for satellites to rotation of existing faculty. Except for a department with only one academic track, satellite doctors were a mix of tenure and mostly non-tenure track faculty. According to these department leaders, scholarly productivity of satellite faculty was similar to that of colleagues at the main campus, though research was more community-based and clinical in nature. Fellowship but little resident education occurred at satellites. Though it was agreed that satellite practices were integral to department finances, they accounted for a smaller percentage of revenues than of total departmental visits.
Satellite offices have offered access to a better payor mix and have boosted the finances of academic ophthalmology departments. Challenges include maintaining collegiality with referring community physicians, integrating faculty despite geographic distance, preserving the department’s academic “brand name,” and ensuring consistent standards and operating procedures. Satellite clinics will likely help departments meet some of the challenges of health care reform.
The association of inflammatory factors and the aqueous flare value with macular edema in central retinal vein occlusion (CRVO) patients remains unclear. We investigated the relations between the aqueous flare value and vitreous levels of vascular endothelial growth factor (VEGF), soluble intercellular adhesion molecule-1 (sICAM-1), and interleukin-6 (IL-6) in patients with CRVO and macular edema or patients with idiopathic macular hole (MH).
In 38 patients who underwent unilateral vitrectomy (21 CRVO patients and 17 MH patients), vitreous samples were obtained during vitrectomy to measure VEGF, sICAM-1, and IL-6. Retinal ischemia was evaluated from capillary non-perfusion on fluorescein angiography, and the CRVO patients were classified into nonischemic or ischemic groups. Aqueous flare values were measured with a laser flare meter and macular edema was examined by optical coherence tomography.
The median aqueous flare value increased significantly across the three groups (MH group < nonischemic CRVO group < ischemic CRVO group). There was a significant correlation between the flare value and vitreous levels of VEGF, sICAM-1, and IL-6 in the CRVO group. The flare value was also significantly correlated with the severity of macular edema in the CRVO group.
Inflammation and/or ischemia may increase vascular permeability and disrupt the blood-aqueous barrier by increasing levels of inflammatory factors in patients with CRVO and macular edema.
Health state utility values (HSUVs) are important in the assessment of the cost effectiveness of new interventions. In the case of visual conditions, models generally tend have tended to be built around a set of health states defined by visual acuity (VA). The aim of this review was to assess the impact of VA on HSUVs in patients with diabetic retinopathy, diabetic macular oedema or age-related macular degeneration.
A systematic literature search was undertaken in major bibliographic databases to identify articles reporting on the relationship between HSUVs and vision. Data were extracted for population characteristics, visual levels and estimated utilities. Evidence from reported statistical models, where available, was considered in the evaluation of vision in the better-seeing eye and the worse-seeing eye. Due to the heterogeneity of included studies, a narrative synthesis was undertaken.
Of the 17 relevant studies, 9 studies had data that could be used in the analysis of the impact of vision on HSUVs. Visual loss was associated with a marked impact on health utilities. However, the relationship was not comparable between conditions or by measure of HSUVs. Key results included the finding that overall, self-rated time-trade off estimates were more likely to discriminate between different VA levels than EQ-5D values. Additionally, a stronger correlation was observed between HSUVs and better-seeing eye VA compared to worse-seeing eye VA.
Visual acuity has a significant impact on HSUVs. Nevertheless, care must be taken in the interpretation and use of estimates in cost-effectiveness models due to differences in measures and population diversity.
Health utility; Visual acuity; Diabetic retinopathy; Age-related macular degeneration
Endophthalmitis is a severe complication of cataract surgery which leads to high ocular morbidity and visual loss even with antibiotic treatment. Bacterial ocular floras are the implicated causative agents. This study was undertaken to evaluate the external ocular surface bacterial isolates and their antimicrobial susceptibility patterns among pre-operative cataract patients at Mulago National Hospital.
This cross sectional study enrolled consecutively 131 patients scheduled for routine cataract surgery in the Department of Ophthalmology at Mulago National Hospital in Kampala, Uganda. Eyelid margin and conjunctival swabs were collected and processed using standard microbiological procedures to identify bacterial isolates and their respective antimicrobial susceptibility patterns.
Of 131 patients involved (mean age 63.3 ± 14.5 years), 54.2% (71/131) were females. The eyelid margin and conjunctival samples were culture positive in 59.5% (78/138) and 45.8% (60/138) respectively. The most common organisms identified were Coagulase-negative Staphylococci (CoNS) [65.9% (91/138)] and Staphylococcus aureus [21.0% (29/138)]. CoNS showed the highest resistance to tetracycline (58.2%, 53/91) and erythromycin (38.5%, 35/91), whereas in S. aureus the resistance to tetracycline and erythromycin were 55.2% (16/29) and 31.0% (9/29) respectively. Methicillin resistant CoNS (MRS) and Methicillin resistance S. aureus (MRSA) were 31.9% (29/91) and 27.6% (8/29) respectively. There were low resistance rates for CoNS, S. aureus and other bacterial isolates to ciprofloxacin (11.1%-24.2%), gentamicin (5.6-31.0%), tobramycin (17.2% -25.3%) and vancomycin (0.0%).
CoNS and S. aureus are the most common bacterial isolates found on the external ocular surface of the pre-operative cataract patients. Ciprofloxacin, gentamicin, tobramycin and vancomycin showed the lowest resistance rates to all bacterial isolates, therefore may be used to reduce bacteria load in the conjunctiva sac among cataract patients prior to surgery.
Antimicrobial susceptibility; Cataract patients; Uganda
Noonan syndrome is an autosomal, dominantly inherited disease; it is physically characterized by short stature, short neck, webbed neck, abnormal auricles, high arched palate, and cardiovascular malformation. Its pathological condition is thought to be due to a gain-of-function mutation in the Ras-mitogen-activated protein kinase (MAPK) signal transduction pathway. Eyelid abnormalities such as ocular hypertelorism and blepharoptosis are the most commonly observed eye complications.
We report a case of Noonan syndrome associated with mature cataract that required operation. A 42-year-old man was diagnosed with Noonan syndrome at the age of 1 year. He underwent an eye examination after complaining of decreased visual acuity in the right eye and was diagnosed with mature cataract, which was treated by cataract surgery. There were no intraoperative complications, and the postoperative course was uneventful. Protein analysis of lens capsule and epithelium at capsulorhexis showed MAPK cascade proteins such as ERK and p38MAPK were upregulated. An abnormality in the PTPN11 gene was also observed; a potential mechanism of cataract onset may be that opacity of the lens rapidly progressed due to abnormal activation of the Ras-MAPK signal transduction pathway.
This case highlights the possible association of cataract formation with MAPK cascade protein upregulation in Noonan syndrome.
Noonan syndrome; Ocular manifestation; Mitogen-activated protein kinase (MAPK); Cataract