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1.  A decade of clinical negligence in ophthalmology 
BMC Ophthalmology  2007;7:20.
Background
To present an overview of the clinical negligence claims for ophthalmology in the National Health Service (NHS) in England from 1995 to 2006. To compare ophthalmic subspecialties with respect to claim numbers and payments.
Methods
All the claims on the NHS Litigation Authority database for ophthalmology for the period 1995 to 2006 were analysed. Claims were categorised by ophthalmic subspecialty, and subspecialties were ranked according to numbers of claims, total damages paid, average level of damages and paid:closed ratio (a measure of the likelihood of a claim resulting in payment of damages).
Results
There were 848 claims, 651 of which were closed. 46% of closed claims resulted in payment of damages. The total cost of damages over the period was £11 million. The mean level of damages was £37,100. Cataract made up the largest share of claims (31%), paediatric ophthalmology had the highest mean damages (£170,000), and claims related to glaucoma were most likely to result in payment of damages (64%).
Conclusion
Clinical negligence claims in ophthalmology in England are infrequent, but most ophthalmologists will face at least one in their career. Ophthalmic subspecialties show marked differences with regard to their litigation profiles. From a medical protection perspective, these results suggest that indemnity premiums should be tailored according to the subspecialty areas an ophthalmologist is involved in.
doi:10.1186/1471-2415-7-20
PMCID: PMC2225389  PMID: 18096077
2.  Age-related compaction of lens fibers affects the structure and optical properties of rabbit lenses 
BMC Ophthalmology  2007;7:19.
Background
The goal of this investigation was to correlate particular age-related structural changes (compaction) to the amount of scatter in rabbit lenses and to determine if significant fiber compaction occurred in the nuclear and inner cortical regions.
Methods
New Zealand White rabbits at 16–20 months old (adult; n = 10) and at 3.5–4 years old (aged; n = 10) were utilized for this study. Immediately after euthanising, scatter was assessed in fresh lenses by low power helium-neon laser scan analysis. Scatter data was analyzed both for whole lenses and regionally, to facilitate correlation with morphometric data. After functional analysis, lenses were fixed and processed for scanning electron microcopy (SEM; right eyes) and light microscopy (LM; left eyes). Morphometric analysis of SEM images was utilized to evaluate compaction of nuclear fibers. Similarly, measurements from LM images were used to assess compaction of inner cortical fibers.
Results
Scatter was significantly greater in aged lenses as compared to adult lenses in all regions analyzed, however the difference in the mean was slightly more pronounced in the inner cortical region. The anterior and posterior elliptical angles at 1 mm (inner fetal nucleus) were significantly decreased in aged vs. adult lenses (anterior, p = 0.040; posterior, p = 0.036). However, the average elliptical angles at 2.5 mm (outer fetal nucleus) were not significantly different in adult and aged lenses since all lenses examined had comparable angles to inner fetal fibers of aged lenses, i.e. they were all compacted. In cortical fibers, measures of average cross-sectional fiber area were significantly different at diameters of both 6 and 7 mm as a function of age (p = 0.011 and p = 0.005, respectively). Accordingly, the estimated fiber volume was significantly decreased in aged as compared to adult lenses at both 6 mm diameter (p = 0.016) and 7 mm diameter (p = 0.010).
Conclusion
Morphometric data indicates that inner cortical fibers undergo a greater degree of age-related compaction than nuclear fibers. Increased scatter appears to be only tentatively correlated with regions of fiber compaction, suggesting that it is simply one of an array of factors that contribute to the overall decreased transparency in aged rabbit lenses.
doi:10.1186/1471-2415-7-19
PMCID: PMC2249566  PMID: 18096063
3.  Years of sunlight exposure and cataract: a case-control study in a Mediterranean population 
BMC Ophthalmology  2007;7:18.
Background
We aimed to investigate the relation between sunlight exposure and risk of cataract.
Methods
We carried out a frequency-matched case-control study of 343 cases and 334 controls attending an ophthalmology outpatient clinic at a primary health-care center in a small town near Valencia, Spain.
All cases were diagnosed as having a cataract in at least one eye based on the Lens Opacification Classification system (LOCS II). Controls had no opacities in either eye. All cases and controls were interviewed for information on outdoor exposure, "usual" diet, history of severe episodes of diarrhea illness, life-style factors and medical and socio-demographic variables. Blood antioxidant vitamin levels were also analyzed. We used logistic regression models to estimate sex and age-adjusted odds ratios (ORs) by quintiles of years of occupational outdoor exposure, adjusting for potential confounders such as smoking, alcohol consumption, serum antioxidants and education.
Results
No association was found between years of outdoor exposure and risk of cataract. However, exploratory analyses suggested a positive association between years of outdoor exposure at younger ages and risk of nuclear cataract later in life.
Conclusion
Our study does not support an association with cataract and sunlight exposure over adult life.
doi:10.1186/1471-2415-7-18
PMCID: PMC2234085  PMID: 18039367
4.  Interpretation of uniocular and binocular trials of glaucoma medications: an observational case series 
BMC Ophthalmology  2007;7:17.
Background
To predict the effectiveness of topical glaucoma medications based on initial uniocular and binocular treatment. To test a traditional hypothesis that effectiveness following a uniocular trial is associated with the change in IOP in the initially treated eye minus the change in the initially untreated eye. To determine whether uniocular or binocular treatment trials are superior.
Methods
Based on a review of medical records, we identified 168 instances in 154 patients with bilateral primary open angle glaucoma of initial uniocular use of a topical glaucoma medication with well-documented intraocular pressure (IOP) readings at baseline (IOPA), during the trial (IOPB), and at follow-up (IOPC). Abstracted data included demographic data, IOP, and medication use. Predictors of the IOP following the trial (IOPC) in each eye were identified by multivariable linear regression. In 70 cases, the predictive ability of initial uniocular and binocular treatment could be directly compared.
Results
In a multivariable analysis, the follow-up pressure in the initially treated eye (IOP1C) was directly correlated with treated eye IOP during initial uniocular use (IOP1B, p < 0.001). In a multivariable analysis, the follow-up pressure in the initially untreated eye (IOP2C) was directly correlated with its baseline IOP2A (p < 0.001), and also tended to be associated with treated IOP1B (p = 0.07). The multivariable regression coefficient (b) for the IOP change in the initially untreated eye was generally not close to the value of -1 expected by the classic teaching (for eye 1, b = 0.04, p = 0.35; for eye 2, b = 0.07, p = 0.50). In 70 cases, the uniocular and binocular trials predicted a similar fraction of the variance in follow-up IOP1C (r2 = 0.56 and 0.57, respectively) and IOP2C (r2 = 0.39 and 0.38, respectively).
Conclusion
1) For uniocular trials, the IOP change in the untreated eye should not be subtracted from that in the treated eye. 2) Uniocular and binocular trials have similar predictive value when interpreted correctly. Either may be selected based on clinical circumstances.
doi:10.1186/1471-2415-7-17
PMCID: PMC2093925  PMID: 17916260
5.  Pharmacoeconomic analysis of prostaglandin and prostamide therapy for patients with glaucoma or ocular hypertension 
BMC Ophthalmology  2007;7:16.
Background
To determine monthly cost and cost effectiveness of bilateral prostaglandin/prostamide therapy for lowering intraocular pressure (IOP) in patients taking bimatoprost 0.03% (Lumigan®, Allergan, Inc.), latanoprost 0.005% (Xalatan®, Pfizer, Inc.), or travoprost 0.004% (Travatan®, Alcon Laboratories, Inc.).
Methods
Drops in five new 2.5-mL bottles were counted and then averaged for each drug. Average retail price was determined by surveys of pharmacies. Drop count, average retail price, average wholesale price, and IOP reduction data were used to compute annual cost, and cost effectiveness (annual cost-per-mm Hg of IOP reduction) of the three drugs.
Results
Drops per 2.5-mL bottle averaged 113 for bimatoprost 0.03%, 84 for latanoprost 0.005%, and 83 for travoprost 0.004%. Average retail cost (2005) per bottle was $69.99 for bimatoprost 0.03%, $61.69 for latanoprost 0.005%, and $66.37 for travoprost 0.004%. The monthly retail cost of bilateral therapy was $37.92 for bimatoprost 0.03%, $44.75 for latanoprost 0.005%, and $49.25 for travoprost 0.004%. Cost effectiveness ranges were $57 to $65 per mm Hg reduction in IOP per year for bimatoprost, 0.03%, $67 to $90 per mm Hg for latanoprost 0.005%, and $74 to $84 per mm Hg for travoprost 0.004%.
Conclusion
Bimatoprost 0.03% had the lowest monthly and annual costs and the greatest cost effectiveness for lowering IOP compared with latanoprost 0.005% and travoprost 0.004%.
doi:10.1186/1471-2415-7-16
PMCID: PMC2077860  PMID: 17900371
6.  Idiopathic intracranial hypertension: the association between weight loss and the requirement for systemic treatment 
BMC Ophthalmology  2007;7:15.
Background
To determine whether weight loss is significantly associated with a discontinuation of treatment for idiopathic intracranial hypertension
Methods
The notes of 36 patients with idiopathic intracranial hypertension under regular review for at least 12 months by a single neuro-ophthalmologist were retrospectively reviewed. Weight was recorded at each assessment and weight loss recommended. Treatment was adjusted according to symptoms, visual function including visual fields and optic disc appearance only. Patients were divided according to duration of continuous follow-up, and then sub-divided as to whether they were on or not on treatment at most recent review and whether weight loss had been achieved compared to presentation. Survival analysis was performed to assess the probability of remaining on treatment having lost weight.
Results
Considering the patients as 3 groups, those with at least 12 months follow-up (n = 36), those with at least 18 months follow-up (n = 24) and those with 24 months or more follow-up (n = 19), only the group with 24 months or more follow-up demonstrated a significant association between weight loss and stopping systemic treatment (Fisher's exact test, p = 0.04). Survival analysis demonstrated that the probability of being on treatment at 5 years having gained weight was 0.63 and having lost weight was 0.38 (log rank test, p = 0.04). The results suggest that final absolute body mass index is more important than the change in body mass index for patients who stop treatment (Mann Whitney U, p = 0.05).
Conclusion
This is the first study to demonstrate that weight loss is associated with discontinuation of treatment. Unlike previous studies, our results suggest that final absolute body mass index is more important for stopping treatment than a proportional reduction in weight.
doi:10.1186/1471-2415-7-15
PMCID: PMC2075484  PMID: 17888152
7.  Patients' experiences with quality of hospital care: the Consumer Quality Index Cataract Questionnaire 
BMC Ophthalmology  2007;7:14.
Background
Patients' feedback is of great importance in health care policy decisions. The Consumer Quality Index Cataract Questionnaire (CQI Cataract) was used to measure patients' experiences with quality of care after a cataract operation. This study aims to evaluate the reliability and the dimensional structure of this questionnaire and assesses its ability to measure differences between hospitals in patients' experiences with quality of care.
Methods
Survey data of 4,635 respondents were available. An exploratory factor analysis was performed to evaluate the construct validity of the questionnaire and item-correlations and inter-factor correlations were calculated. Secondly, Cronbach's alpha coefficients were calculated to assess the internal consistency of the scales. Thirdly, to evaluate the ability of the questionnaire to discriminate between hospitals, multilevel analyses were performed with patients hierarchically nested within hospitals.
Results
Exploratory factor analysis resulted in 14 quality of care items subdivided over three factors (i.e. communication with ophthalmologist, communication with nurses, and communication about medication). Cronbach's alpha coefficients of 0.89, 0.76 and 0.79 indicated good internal consistency. Multilevel analyses showed that the questionnaire was able to measure differences in patients' experiences with hospital care regarding communication with ophthalmologist and communication about medication. In addition, there was variation between hospitals regarding ophthalmologist ratings, hospital ratings and one dichotomous information item.
Conclusion
These findings suggest that the CQI Cataract is a reliable and valid instrument. This instrument can be used to measure patients' experiences with three domains of hospital care after a cataract operation and is able to assess differences in evaluated care between hospitals.
doi:10.1186/1471-2415-7-14
PMCID: PMC2093924  PMID: 17877840
8.  Glaucoma following congenital cataract surgery – the role of early surgery and posterior capsulotomy 
BMC Ophthalmology  2007;7:13.
Background
To determine the rate of glaucoma following congenital cataract surgery at Moorfields Eye Hospital (MEH), and to investigate potential risk factors for glaucoma in our case series.
Methods
A retrospective case notes review was undertaken of all congenital cataract lensectomies performed at MEH between 1994 and 2000. The following parameters were ascertained: age at surgery, unilateral or bilateral cataract, whether a posterior capsulotomy (PC) was performed at the time of surgery, whether an intraocular lens (IOL) was inserted, duration of follow-up, and if aphakic glaucoma (AG) developed. All lensectomies were performed through a limbal incision by a single consultant surgeon.
Results
A total of 47 subjects were identified – 40 patients with bilateral cataracts and 7 with unilateral. Of the 40 bilateral cataract patients, 76 eyes had lensectomies; with 37 of these patients (71 lensectomies) having at least 5 year follow-up. Based on patient count, the 5 year risk of AG in at least one eye following surgery was 21.6%. Based on eye count, the 5 year risk of AG after lensectomy was 15.5%. The average age at surgery of patients who did not develop AG, and had at least 5 years follow-up, was 28.7 months (range 2 weeks to 6 years), with 20% having surgery within the first month of life. In comparison, the average age at surgery of patients with at least 5 years follow-up, who developed AG was 1.6 months (range 2 weeks to 7 months), with 60% having surgery within the first month of life. In subjects with at least 5 years follow-up, a PC rate of 100% was identified in the eyes that developed AG, compared to 61% in eyes that did not develop AG. An IOL was inserted in O% of eyes with AG, compared to 57% in eyes that did not develop AG. Onset of AG ranged from one month post surgery to 7 years, with an average yearly incidence of 5.3%.
Conclusion
Early surgery in patients with bilateral cataracts is associated with a marked increase in risk of AG. Our data suggest that an intact posterior capsule may be associated with a lower rate of AG.
doi:10.1186/1471-2415-7-13
PMCID: PMC2040130  PMID: 17848200
9.  The epidemiology of low vision and blindness associated with trichiasis in southern Sudan 
BMC Ophthalmology  2007;7:12.
Background
We investigated vision status associated with trachomatous trichiasis (TT) and explored age-sex patterns of low vision and blindness associated with trichiasis in Mankien district of southern Sudan where trachoma prevention and trichiasis surgery were absent.
Methods
A population based survey was undertaken and eligible persons underwent eye examination. Visual acuity (VA) was tested using Snellen E chart and persons with TT identified. Vision status was defined using the WHO categories of visual impairment based on presenting VA: normal vision (VA ≥ 6/18 in better eye); low vision (VA < 6/18 but ≥ 3/60 in better eye); and blindness (VA < 3/60 in better eye). An ordinal logistic regression model was fitted and age/sex specific distribution of vision status predicted.
Results
Overall 341/3,567 persons examined had any TT. Analysis was based on 319 persons, 22 persons were excluded: 20 had both TT and cataract; and 2 had missing VA data. Of the 319 persons: 158(49.5%) had trichiasis-related corneal opacity (CO); bilateral TT and bilateral CO were found in 251(78.7%) and 110 (34.5%), respectively; 146 (45.8%) had low vision or blindness; the ratio of low vision to blindness was 3.2:1; and no sex differences were observed. In our model the predicted distribution of vision status was: normal vision, 53.9% (95% CI 50.9–56.9); low vision, 35.3% (95% CI 33.3–37.2); and blindness, 10.9% (95% CI 9.7–12.0).
Conclusion
We have reported severe trichiasis and high prevalence of vision loss among persons with trichiasis. Our survey showed that almost 1 in 20 of the entire population suffered low vision or blindness associated with trachoma. The need for trichiasis surgery, trachoma prevention services, and rehabilitation of the blind is acute.
doi:10.1186/1471-2415-7-12
PMCID: PMC2077329  PMID: 17725828
10.  Prevalence of diabetic retinopathy in the United Arab Emirates: a cross-sectional survey 
BMC Ophthalmology  2007;7:11.
Background
Diabetic retinopathy (DR) is one of the leading causes of blindness. The aim of this study was to estimate the prevalence and determinants of retinopathy among diabetics in Al-Ain city, United Arab Emirates (UAE).
Methods
The study was part of a general cross-sectional survey carried out to assess the prevalence of diabetes (DM) complications including retinopathy among known diabetic patients in Al-Ain District, UAE. Patients were randomly selected during 2003/2004. Patients completed an interviewer-administered questionnaire carried out by treating doctors and underwent a complete medical assessment. All patients were examined for evidence of diabetic retinopathy by ophthalmologist and their fundi were examined using slit lamp examination and fundus photography of each eye through dilated pupils.
Results
A sample of 513 diabetic patients was selected with a mean age of 53 years (SD ± 13.01). Retinopathy was present in 19% (95% CI: 15.1–23.5%) of the study population. Most patients (74%) were not aware of their condition. The disease was more common among males (24.2 vs. 13.9%; p = 0.016), increased with increasing age (p = 0.004) and disease duration (p = 0.0001). Type I DM was a highly significantly contributing risk factor (38.3% for type 1, vs. 16.4% for type 2; p < 0.0001). Retinopathy was higher among patients with hypertension, microalbuminuria, peripheral vascular disease, coronary artery disease and neuropathy.
Conclusion
The prevalence of DR in the UAE was (19%) and significantly affected elderly males. Regular screening to detect DR is highly recommended as with the early detection of proliferative retinopathy and timely laser photocoagulation which are known to prevent most of the diabetes related blindness.
doi:10.1186/1471-2415-7-11
PMCID: PMC1913498  PMID: 17572909
11.  Single-session photodynamic therapy combined with intravitreal bevacizumab and triamcinolone for neovascular age-related macular degeneration 
BMC Ophthalmology  2007;7:10.
Background
To evaluate the efficacy of triple therapy consisting of single-session photodynamic therapy (PDT), intravitreal bevacizumab (IVB) and intravitreal triamcinolone (IVT) as initial pulse therapy followed by repeat intravitreal bevacizumab injections for maintenance treatment in neovascular age-related macular degeneration (AMD).
Methods
In a prospective interventional case series, patients with subfoveal choroidal neovascularization (CNV) secondary to AMD underwent pulse therapy with single-session PDT according to the standard protocol followed by 1.25 mg IVB and 2 mg IVT 48 hours later. Best corrected visual acuity (BCVA) was assessed and optical coherence tomography (OCT) and fluorescein angiography (FA) were performed prior to treatment. BCVA and OCT measurements were repeated at 6 week intervals and FA was obtained after 12 weeks and when necessary thereafter. Repeat injections of IVB were performed based on fluorescein angiographic evidence of CNV leakage.
Results
This series included 17 eyes of 17 patients with mean age of 67.6 ± 7.2 years. Mean follow up duration was 50.4 ± 15.5 weeks. Mean BCVA prior to treatment was 0.74 ± 0.33 logMAR which improved to 0.52 ± 0.36 logMAR after 12 weeks (P = 0.012) and 0.41 ± 0.38 logMAR after 24 weeks (P = 0.001). Mean pretreatment central macular thickness (CMT) was 395 ± 181μ which was significantly reduced to 217 ± 69μ (P = 0.005), 231 ± 79μ (P = 0.028) and 221 ± 87μ (P = 0.05) six, twelve and twenty-four weeks after initial treatment respectively. Visual acuity improvement and CMT reduction was maintained during the follow-up period. IVB injections were repeated once, twice and three times in 10, 7 and 2 eyes at a mean interval of 20.2 ± 10.1, 19 ± 13.7 and 15 ± 1.4 weeks after initial therapy, respectively.
Conclusion
Initial pulse triple therapy consisting of single-session PDT combined with IVB and IVT improves vision and reduces CMT in neovascular AMD. Repeat IVB injections maintain the visual gain from the initial combination therapy.
doi:10.1186/1471-2415-7-10
PMCID: PMC1904176  PMID: 17555600
12.  Corneal topographic changes in premenopausal and postmenopausal women 
BMC Ophthalmology  2007;7:9.
Background
To asses the effect of menopause on the corneal curvature changes using corneal computerized videokeratography (CVK) in premenopausal and postmenopausal healthy women.
Methods
Thirty-six postmenopausal women with mean ages of 49.2 (range 39 to 57) were enrolled in this randomized, prospective study, comparing with 26 healthy controls with mean ages of 38.5 +/- 4.9 (range 32 to 49). Subjects were determined to be postmenopausal, by the Gynecology and Obstetrics Department, based on blood Follicular Stimulating Hormone (FSH), Luteinizing Hormone (LH), Estradiol, Progesterone levels and clinical complaints. Complete ophthalmic examination and CVK using Haag-Streit System was performed in both premenopausal and postmenopausal women.
Results
Mean horizontal curvature and vertical curvature of central corneal power in premenopausal women were 43.5 +/- 1.25 Diopter (D), and 44.1 +/- 1.53 D. Mean horizontal curvature and vertical curvature of central corneal power in postmenopausal women were 43.9 +/- 1.4 D, and 44.6 +/- 1.3 D. The mean keratometric astigmatisms of premenopausal and postmenopausal women were 0.81 +/- 0.57 D (4–179 degrees), 0.74 degrees +/- 0.5 D (1–180 degrees) respectively. No significant corneal curvature changes were detected between premenopausal and postmenopausal groups (P > 0.05). On the other hand, we only found negative but significant correlation between horizontal corneal curvature and estrogen level of postmenopausal women (r = -0.346, p = 0.038).
Conclusion
Menopause is physiologic process and may also affect corneal topographic changes. In postmenopausal women, corneal steeping was observed minimally compared to premenopausal women. The results suggest that changes in estrogen level of women with menopause are associated with slightly alteration of horizontal curvature of cornea.
doi:10.1186/1471-2415-7-9
PMCID: PMC1877796  PMID: 17501998
13.  Thiazolidinedione induced thyroid associated orbitopathy 
BMC Ophthalmology  2007;7:8.
Background
To describe an episode of thyroid associated orbitopathy (TAO) following the initiation of thiazolidinedione (TZD).
Case presentation
We report a female patient with a history of Graves' disease and stabilised thyroid associated orbitopathy for 2.5 years, who experienced rapid progression of TAO after the initiation of thiazolidinedione for glycemic control. Following the discontinuation of TZD, the patient experienced subsequent stabilisation of disease and normalization of vision. The medical history, ophthalmic findings, and clinical course are discussed.
Conclusion
Thiazolidinediones may exacerbate TAO, and this should be taken into consideration when selecting treatment for diabetic patients with a history of autoimmune thyroid disorders.
doi:10.1186/1471-2415-7-8
PMCID: PMC1876204  PMID: 17462097
14.  Unilateral external ophthalmoplegia in Miller Fisher syndrome: case report 
BMC Ophthalmology  2007;7:7.
Background
A description of the diagnostic features of Miller Fisher syndrome.
Case presentation
The clinical presentation, investigation, and subsequent progress of our patient with clinical unilateral external ophthalmoplegia.
Conclusion
Our case demonstrates the presentation of clinical unilateral external ophthalmoplegia as part of the full triad of Miller Fisher syndrome.
doi:10.1186/1471-2415-7-7
PMCID: PMC1863413  PMID: 17439660
15.  Radiation Retinopathy: Case report and review 
BMC Ophthalmology  2007;7:6.
Background
Ocular damage from radiation treatment is a well established phenomenon. Many factors are now known to influence the incidence of radiation retinopathy, including total dosage and daily fraction size. Patients who are diabetic, hypertensive or received previous chemotherapy are more susceptible to radiation retinopathy.
Case Presentation
A 55 year old male was referred from the oncology department with epiphora. His medical history included Type 2 Insulin treated Diabetes Mellitus and hypertension. One year prior to presentation he had undergone a total rhinectomy with a 4 week course of post-operative radiotherapy for an aggressive sqaumous cell carcinoma of the nose. On examination the visual acuity was noted to be 6/36 left eye and 6/9 right eye. Posterior segment examination revealed marked retinal ischaemia present in the posterior pole and macular region of both eyes. The appearance was not thought to be typical of diabetic changes, radiation retinopathy being the more likely diagnosis especially in view of his history. Over the next four months the vision in both eyes rapidly deteriorated to 3/60 left eye and 1/60 right eye. Bilateral pan retinal photocoagulation was thought to be appropriate treatment at this point.
Conclusion
This case highlights the importance for ophthalmologists and oncologists to be aware of the close relationship between diabetes and radiation treatment and the profound rapid impact this combination of factors may have on visual function. Radiation is being used with increasing frequency for ocular and orbital disease, because of this more cases of radiation retinopathy may become prevalent. Factors which may potentiate radiation retinopathy should be well known including, increased radiation dosage, increased fraction size, concomitant systemic vascular disease and use of chemotherapy. Counselling should be offered in all cases at risk of visual loss. As no effective treatment currently exists to restore visual function, monitoring of visual acuity in all cases and early referral to the ophthalmologist as appropriate is warranted.
doi:10.1186/1471-2415-7-6
PMCID: PMC1855313  PMID: 17411428
16.  Establishing the tolerability and performance of tamarind seed polysaccharide (TSP) in treating dry eye syndrome: results of a clinical study 
BMC Ophthalmology  2007;7:5.
Background
One of the problems arising from available preparations for dry eye syndrome is the limited residence time of products on the ocular surface. In this paper, we look at an innovative new treatment for dry eye, tamarind seed polysaccharide (TSP). TSP possesses mucomimetic, mucoadhesive and pseudoplastic properties. The 'mucin-like' molecular structure of TSP is similar to corneal and conjunctival mucin 1 (MUC1), a transmembrane glycoprotein thought to play an essential role in protecting and wetting the corneal surface and may explain its increased retention on the eye surface.
Methods
The activity of TSP and hyaluronic acid (HA) in the treatment of dry eye syndrome was compared in an open-label, randomised, single-centre clinical study. Thirty patients were randomised to receive three or more applications per day of either TSP 0.5%, TSP 1% or HA 0.2% (Hyalistil™) over a period of 90 days. The primary objective of tolerability was assessed by visual analogue scale (VAS), scoring of specific symptoms and the incidence of adverse events. Secondary objectives included improvement in stability of the precorneal tear film, subjective symptoms and corneal and conjunctival staining.
Results
TSP 0.5% and 1% were comparable to HA 0.2% with regard to both primary and secondary objective parameters.
TSP 1% showed benefits over HA 0.2% for the subjective symptoms; trouble blinking, ocular burning and foreign body sensation.
Conclusion
This study suggests that TSP 0.5% and 1% offer at least equivalent relief to HA 0.2% for dry eye syndrome. All treatments demonstrated optimal tolerability and are suitable for frequent use in the therapy of dry eye.
TSP 1% produced promising results in terms of improvements in certain patient symptoms and suggests benefits of the TSP formulation. This study paves the way for a larger study to further establish the performance and safety of TSP compared with HA and highlights the need to expand this therapeutic agent to a wider dry eye population.
doi:10.1186/1471-2415-7-5
PMCID: PMC1859988  PMID: 17394642
17.  Painful vertical diplopia as a presentation of a pituitary mass 
BMC Ophthalmology  2007;7:4.
Background
Pituitary tumours may present with a variety of neurological and endocrinological signs and symptoms. It is very rare however for them to present with sudden onset painful diplopia. The current literature and possible mechanisms for this are discussed.
Case presentation
We describe a case of a pituitary mass which presented with sudden onset painful diplopia with an associated restricted pattern on Lees Chart testing. This led to an initial working diagnosis of orbital myositis.
Conclusion
Awareness of different modes of presentation of pituitary lesions is important so that appropriate imaging may be requested and delay in diagnosis prevented.
doi:10.1186/1471-2415-7-4
PMCID: PMC1838406  PMID: 17362519
18.  TOZAL Study: An open case control study of an oral antioxidant and omega-3 supplement for dry AMD 
BMC Ophthalmology  2007;7:3.
Background
The primary objective of this prospective study was to measure the change from baseline in visual function – Best-Corrected Visual Acuity (BCVA) via the Early Treatment Diabetic Retinopathy Study (ETDRS) chart, contrast sensitivity, central 10 degree visual fields and retinal imaging (angiograms and photographs) at 6 months in subjects with atrophic (dry) age-related macular degeneration treated with a targeted nutritional supplement.
Methods
37 mixed gender patients with a mean age of 76.3 +/- 7.8 years were enrolled at 5 independent study sites and received standard of care with a novel formulation of a nutritional supplement. Results were compared to a placebo cohort constructed from the literature that was matched for inclusion and exclusion criteria. A paired t-test was used to test a null hypothesis and a two-sided alpha level of 0.05 was used to determine statistical significance.
Results
76.7% of subjects receiving the nutritional supplement demonstrated stabilization or improvement of BCVA at 6 months. Subjects gained an average of 0.0541 logMAR or one-half of a line of visual acuity (VA) over the 6-month period. There was a statistically significant improvement in VA from baseline with P = .045. The results provide strong evidence that the treatment being studied produces an improvement in VA.
Conclusion
Treatment with this unique nutritional supplement increased VA above the expected baseline decrease in the majority of patients in this population with dry macular degeneration. The results of the TOZAL study agree with the LAST and CARMIS studies and are predictive for positive visual acuity outcomes in the AREDS II trial. However, patients will likely require supplementation for longer than 6 months to effect changes in additional visual parameters.
doi:10.1186/1471-2415-7-3
PMCID: PMC1831760  PMID: 17324285
19.  Heavier molecular weight ocular viscoelastic devices and timing of post-operative review following cataract surgery 
BMC Ophthalmology  2007;7:2.
Background
To assess the safety of abandoning the next day post-operative review in preference for assessment only 2 hours post-surgery for both phacoemulsification and extracapsular surgery with heavier molecular weight ocular viscoelastic devices (OVD).
Methods
475 patients who underwent uncomplicated cataract surgery using heavier molecular weight ocular viscoelastic device (Healon GV) were studied. Of these 415 were phacoemulsification and 60 extracapsular and none received Intraocular pressure (IOP) lowering prophylaxis at the end of surgery. All were examined at 2 hours post-surgery and on the following day. Results were tabulated and analysed assessing wound stability, corneal clarity, anterior chamber reaction and IOP.
Results
In the time between the two assessments 44 (10.6%) patients developed a total of 53 new problems, with a majority being increases in IOP. Based on the lower threshold of IOP of 30 mmHg, the incidence of new problems at the next-day assessment was 9.8% (95% CI: 7.0 to 13.6) in the phacoemulsification group and 16.3% (7.3 to 29.7)in the extracapsular surgery group. At the higher threshold of IOP of 35 mmHg the corresponding figures were 6.6% and 16.3%.
Conclusion
There is a higher incidence of new problems at the next-day assessment than previous studies with conventional OVD. Therefore results from previous studies using standard OVDs cannot be simply extrapolated to heavier molecular weight OVDs. When these agents are used, routine use of an ocular hypotensive agent may be necessary to increase the safety of abandoning the review on the first post-operative day for phacoemulsification patients. This is to be studied.
doi:10.1186/1471-2415-7-2
PMCID: PMC1800901  PMID: 17291337
20.  Molecular characterization, biofilm analysis and experimental biofouling study of Fusarium isolates from recent cases of fungal keratitis in New York State 
BMC Ophthalmology  2007;7:1.
Background
To characterize Fusarium isolates from recent cases of fungal keratitis in contact lens wearers, and to investigate fungal association with MoistureLoc solution.
Methods
We studied six fungal isolates from recent cases of keratitis in New York State. The isolates were characterized by nucleotide sequencing and phylogenetic analyses of multiple genes, and then typed using minisatellite and microsatellite probes. Experimental fungal biofilm formation was tested by standard methods. MoistureLoc solutions were tested in biofouling studies for their efficacy in elimination of Fusarium contamination.
Results
Fusarium solani – corneal ulcers (2 isolates), lens case (1 isolate), and F. oxysporum – corneal ulcer (1 isolate), eye (1 isolate), were recovered from five patients. An opened bottle of MoistureLoc solution provided by a patient also yielded F. solani. Two distinct genotypes of F. solani as well as of F. oxysporum were present in the isolated strains. Remarkably, F. solani strains from the lens case and lens solution in one instance were similar, based on phylogenetic analyses and molecular typing. The solution isolate of F. solani formed biofilm on contact lenses in control conditions, but not when co-incubated with MoistureLoc solution. Both freshly opened and 3-month old MoistureLoc solutions effectively killed F. solani and F. oxysporum, when fungal contamination was simulated under recommended lens treatment regimen (4-hr). However, simulation of inappropriate use (15 – 60 min) led to the recovery of less than 1% of original inoculum of F. solani or F. oxysporum.
Conclusion
Temporary survival of F. solani and F. oxysporum in MoistureLoc suggested that improper lens cleaning regimen could be a possible contributing factor in recent infections.
doi:10.1186/1471-2415-7-1
PMCID: PMC1794232  PMID: 17263885

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