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Highlights from this issue

2017-10-25T02:51:05-07:00

Comparison of corneal endothelial cell density and morphology after posterior chamber phakic intraocular lens implantation with and without a central hole (see page 1461)

Phakic posterior chamber lens implantation using implants containing a central hole may be better than those without, but possibly only in terms of avoiding laser iridotomies and thereby minimising trauma to corneal endothelium.

The Malaysian cataract surgery registry: risk indicators for posterior capsular rupture (see page 1466)

The rate of posterior capsule rupture was observed to be higher with advancing age, male gender, presence of pseudoexfoliation, phacomorphic lens morphology, diabetes mellitus, renal failure, vitreo-retinal surgery and less experienced surgeons. Interestingly extracapsular cataract extraction and kinetic (topical or intracameral) anaesthesia were associated with lower posterior capsule rupture rates.

Predictive factors for the placebo effect in clinical trials for dry eye: a pooled analysis of three clinical trials...



Management of postoperative inflammation after cataract and complex ocular surgeries: a systematic review and Delphi survey

2017-10-25T02:51:05-07:00

Prevention and management of postoperative ocular inflammation with corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs) have been evaluated in several randomised controlled trials (RCTs). However, neither consensus regarding the efficacies of different regimens nor established guidelines are currently available. This has resulted in different practice patterns throughout the world. A systematic literature review found that for the management of postcataract inflammation nepafenac produced a positive outcome in three of three RCTs (3/3), as did ketorolac (1/1), bromfenac (7/7), loteprednol (3/3) and difluprednate (6/6), but not flurbiprofen (0/1). A single study found that betamethasone produced inconclusive results after retinal detachment (RD) surgery; ketorolac was effective (1/1) after vitrectomy, but triamcinolone was ineffective (0/1) after trabeculectomy. A two-round Delphi survey asked 28 international experts to rate both the inflammatory potential of different eye surgeries and their agreement with different treatment protocols. They rated trabeculectomy, RD surgery and combined phacovitrectomy as more inflammatory than cataract surgery. Vitrectomies for macular hole or epiretinal membrane were not deemed more inflammatory than cataract surgery. For trabeculectomy, they preferred to treat longer than for cataract surgery (NSAID + corticosteroid three times a day for 2 months vs 1 month). For vitrectomy alone, RD surgery and combined phacovitrectomy, the panel preferred the same treatment as for cataract surgery (NSAID + corticosteroid three times a day for 1 month). The discrepancy between preferred treatment and perception of the eye’s inflammatory status by the experts for RD and combined vitreoretinal surgeries highlights the need for RCTs to establish treatment guidelines.




KOH mount as an aid in the management of infectious keratitis at secondary eye care centre

2017-10-25T02:51:05-07:00

Aims

To report the clinical outcome of infectious keratitis managed after doing 10% KOH mount of corneal smears and reporting done by an ophthalmologist in the secondary eye care centre in South India.

Methods

103 consecutive cases of microbial keratitis were studied. Inclusion criteria were presence of corneal infiltrate on slit lamp biomicroscopy. An ophthalmologist carried out microbiological evaluation of 10% KOH mount of corneal scrapings. No cultures were done at secondary centres. Antifungal therapy with 5% Natamycin was initiated when 10% KOH mount was positive for fungal filaments. Else, the patients were started on combined topical ciprofloxacin (0.3%) and fortified cefazolin (5%).

Results

41/103 (39.8%) smears were positive for fungus and 62 (60.2%) were negative. 89 out of 103 patients (86.40%) healed with scarring at an average of 2.95±1.58 weeks. Healing was noted in 39/41 (95.12%) of patients at an average of 3.06±1.19 weeks in patients with KOH smear positive keratitis. 80.64% (50/62) healed with scarring at an average period of 2.86±1.86 weeks in KOH mount negative keratitis.

Conclusions

Initial smear examination of KOH mount by an ophthalmologist helped in diagnosis of infectious keratitis caused by fungi and its management and 95.12% of KOH positive patients healed with scarring. Reading of KOH mount by an ophthalmologist helped in initiation of specific therapy with improved clinical outcome.




Comparison of corneal endothelial cell density and morphology after posterior chamber phakic intraocular lens implantation with and without a central hole

2017-10-25T02:51:05-07:00

Aim

To compare the corneal endothelial cells after posterior chamber phakic intraocular lens with and without a central hole (hole implantable collamer lens (ICL) and conventional ICL) implantation for the correction of moderate to high myopia.

Methods

This retrospective study evaluated 34 eyes of 34 patients who underwent hole ICL implantation and 25 eyes of 25 patients who underwent conventional ICL implantation. Preoperatively and 3 months, and 1 and 2 years postoperatively, we compared the central corneal endothelial cell density (ECD), coefficient of variation in cell size (CV) and the percentage of hexagonal cells (HEX) between the two groups using a non-contact specular microscope (EM-3000, Tomey). Preoperatively and 2 years postoperatively, we also compared them in the peripheral regions.

Results

The mean central ECD loss was 0.3% and 1.1%, 2 years after hole ICL and conventional ICL implantation, respectively (Mann-Whitney U test, p=0.72). There were no significant changes in central ECD, CV or HEX at any time points either after hole ICL or conventional ICL implantation, and a significant decrease only in terms of ECD in the superior regions after conventional ICL implantation.

Conclusions

Both ICLs do not induce a significant change in the density, polymegethism or polymorphism of corneal endothelial cells even 2 years postoperatively, except for the density in the superior regions after conventional ICL implantation. However, hole ICL implantation may have advantages over conventional ICL implantation only in terms of the density in the superior regions, possibly because preoperative laser iridotomies are unnecessary.




The Malaysian Cataract Surgery Registry: risk Indicators for posterior capsular rupture

2017-10-25T02:51:05-07:00

Aim

To identify the risk indicators for posterior capsular rupture (PCR) in the Malaysian Cataract Surgery Registry (CSR).

Methods

Data from the web-based CSR were collected for cataract surgery performed from 2008 to 2013. Data was contributed by 36 Malaysian Ministry of Health public hospitals. Information on patient's age, ethnicity, cause of cataract, ocular and systemic comorbidity, type of cataract surgery performed, local anaesthesia and surgeon's status was noted. Combined procedures and type of hospital admission were recorded. PCR risk indicators were identified using logistic regression analysis to produce adjusted OR for the variables of interest.

Results

A total of 150 213 cataract operations were registered with an overall PCR rate of 3.2%. Risk indicators for PCR from multiple logistic regression were advancing age, male gender (95% CI 1.04 to 1.17; OR 1.11), pseudoexfoliation (95% CI 1.02 to 1.82; OR 1.36), phacomorphic lens (95% CI 1.25 to 3.06; OR 1.96), diabetes mellitus (95% CI 1.13 to 1.29; OR 1.20) and renal failure (95% CI 1.09 to 1.55; OR 1.30). Surgical PCR risk factors were combined vitreoretinal surgery (95% CI 2.29 to 3.63; OR 2.88) and less experienced cataract surgeons. Extracapsular cataract extraction (95% CI 0.76 to 0.91; OR 0.83) and kinetic anaesthesia were associated with lower PCR rates.

Conclusions

This study was agreed with other studies for the risk factors of PCR with the exception of local anaesthesia given and type of cataract surgery. Better identification of high-risk patients for PCR decreases intraoperative complications and improves cataract surgical outcomes.




Predictive factors for the placebo effect in clinical trials for dry eye: a pooled analysis of three clinical trials

2017-10-25T02:51:05-07:00

Background

Placebo effect is one of the methodological difficulties in dry eye clinical trials. If we could elucidate the tendencies of the placebo response and find predictors, we could reduce the placebo response in clinical trials for dry eye. In this study, we investigated the predictive factors for the placebo effect in dry eye clinical trials.

Methods

A total of 205 patients with dry eye assigned to the placebo arms of three placebo-controlled randomised clinical trials were analysed by simple and multivariable regression analysis. The corneal fluorescein (FL) staining score and dry eye symptoms were studied at week 4. The variables of interest included gender, age, complications of Sjögren’s syndrome, Schirmer’s test I value, tear break-up time and conjunctival hyperaemia score. We also conducted a stratified analysis according to the patients’ age.

Results

Among all the studied endpoints, the baseline scores were significantly related to the corresponding placebo response. In addition, for the FL score and the dryness score, age was a significant predictor of the placebo response (p=0.04 and p<0.0001, respectively). Stratified analysis by age showed that patients more than 40 years of age are more likely to have a stronger placebo response in the FL and dryness scores.

Conclusion

The baseline scores and age were predictive factors of the placebo response in frequently used endpoints, such as FL score or dryness symptoms. These patient characteristics can be controlled by study design, and our findings enable the design of more efficient placebo-controlled studies with good statistical power.




Intereye asymmetry in bilateral keratoconus, keratoconus suspect and normal eyes and its relationship with disease severity

2017-10-25T02:51:05-07:00

Background/Aim

To describe the intereye asymmetry in patients with keratoconus (KC), keratoconus suspect (KCS) and normal participants, and to evaluate the relationship between asymmetry and disease severity.

Methods

In this prospective observational comparative study, 446 patients with bilateral KC, 68 patients with bilateral KCS and 306 normal participants underwent topographic, keratometric and pachymetric evaluations by Pentacam as well as refractive and visual acuity examinations. The intereye asymmetry in each parameter was calculated and compared between the groups.

Results

All parameters were significantly different between the worse and better eyes in the KC group (p<0.05), but not in the KCS and normal groups. No significant differences were observed in the measurements of the worse and better eyes of the normal group (p>0.05). There was a statistically significant greater intereye asymmetry in all parameters in the KC group compared with the KCS and normal groups (p<0.05). The intraclass correlations were poor in patients with KC, moderate to good in patients suspected with KC and strong in normal participants. There were statistically significant relationships between the intereye asymmetry in all parameters and KC severity in the worse eye in which intereye asymmetry significantly increased with an increase in disease severity, based on Keratoconus Severity Score classification (p<0.05). According to receiver operating characteristic analysis, the intereye asymmetry would effectively discriminate KC and KCS from normal eyes.

Conclusion

KC is an asymmetric disease, and the degree of asymmetry is associated with disease severity. The analysis of intereye asymmetry should be performed along with unilateral evaluation in the screening of KC.




Evolving risk factors and antibiotic sensitivity patterns for microbial keratitis at a large county hospital

2017-10-25T02:51:05-07:00

Purpose: To identify the risk factors, causative organisms, antimicrobial susceptibility and outcomes of microbial keratitis in a large county hospital in Houston, Texas.

Design: Case series.

Methods

Setting: A large county hospital in Houston, Texas.

Study Population: Patients with known diagnosis of microbial keratitis from January 2011 to May 2015.

Observation Procedure: Retrospective chart review.

Main Outcomes: Epidemiology, risk factors, outcomes and antibiotic susceptibility of microbial keratitis.

Results

The most commonly identified risk factors were contact lens use (34.4%), ocular trauma (26.3%), diabetes mellitus (16.7%), ocular surgery (13.5%), ocular surface diseases (11.5%), previous keratitis (10.4%), glaucoma (6.3%), cocaine use (5.2%) and HIV-positive status (4.2%). Eyes with positive cultures (61.5%) were associated with worse visual outcomes (p=0.019) and a higher number of follow-up visits (p=0.007) than eyes with negative cultures (38.5%). Corneal perforation was the most common complication (11.5%). Gram-negative organisms (21.9%) were all susceptible to ceftazidime, tobramycin and fluoroquinolones. Gram-positive organisms (33.3%) had worse outcomes than Gram-negative organisms (21.9%) and exhibited a wide spectrum of antibiotic resistance, but all were susceptible to vancomycin. Twenty-seven per cent of the coagulase-negative Staphylococci were resistant to fluoroquinolones.

Conclusion

This study identified a recent shift in risk factors and antibiotic resistance patterns in microbial keratitis at a County Hospital in Houston, Texas. In our patient population, fluoroquinolone monotherapy is not recommended for severe corneal ulcers. On the basis of these results, vancomycin and tobramycin should be used for empirical therapy until microbial identity and sensitivity results are available.




Paediatric infectious keratitis: a case series of 107 children presenting to a tertiary referral centre

2017-10-25T02:51:05-07:00

Background/aims

Corneal ulcers can result in severe visual impairment in children. The recent trends of paediatric microbial ulcerative keratitis in the USA are unknown. The purpose of this study is to report the risk factors, microbiological profile and treatment outcomes of paediatric microbial keratitis in South Florida.

Methods

A university-based tertiary eye care centre retrospective case series between 1992 and 2015. Medical records of 107 paediatric patients (age <18 years) with the diagnosis of microbial ulcerative keratitis were analysed. Patient demographics, culture data, microbial susceptibility, management trends and patient outcomes were collected.

Results

Mean age of patients was 13±4.6 years (range 0.2–17 years). The most common associated risk factor was contact lens wear (77.6%), followed by ocular trauma (8.4%). Systemic factors were present in 4.7% of cases. Cultures were taken from 89 patients. A total of 74 organisms were isolated from the 52 corneal scrapings with growth, yielding a 58.4% positivity rate. Seventeen microbial species were identified, with a predominance of Pseudomonas aeruginosa (46.2%), followed by Stenotrophomonas maltophilia (19.2%) and Fusarium (13.5%). Combined fortified antibiotics were the most common treatment (51.4%). Mean follow-up time was 40.6±91.6 weeks (range: 0.3–480 weeks). The mean visual acuity improved from 20/160 to 20/50 (p<0.0001). No therapeutic penetrating keratoplasty was needed.

Conclusions

In this study, contact lens wear was the most frequent risk factor in infectious keratitis in children. P. aeruginosa was the most common microorganism present in our setting. The majority of the cases responded well to medical management.




Factors influencing intraocular pressure, corneal thickness and corneal biomechanics after congenital cataract surgery

2017-10-25T02:51:05-07:00

Aims

This study aims to compare intraocular pressure (IOP), central corneal thickness (CCT) and corneal biomechanics among patients with aphakia, patients with primary and secondary pseudophakia and matched controls following congenital cataract surgery and to investigate the factors influencing these variables.

Methods

This study included 36 aphakic eyes, 47 primary pseudophakic eyes and 30 secondary pseudophakic eyes. Thirty-four normal eyes of matched volunteers were recruited for comparisons. Postoperative IOP measured with a Goldmann applanation tonometer (IOPGAT), CCT, corneal hysteresis (CH), corneal resistance factor (CRF) and cornea-compensated IOP (IOPCC) were compared among the groups. Univariate analyses and multiple linear regression analyses were used to investigate the influences of independent factors on IOPGAT, CCT, CH, CRF and IOPCC, considering all the operated eyes as one group.

Results

IOPGAT was 12.5±0.92, 14.7±1.9, 13.4±2.3 and 15.7±2.0 mm Hg in normal, aphakic, primary pseudophakic and secondary pseudophakic eyes, respectively (p<0.001). CCT was 559.5±42.7, 628.0±61.7, 566.8±35.3 and 585.2±41.1 µm, respectively (p<0.001). CH was 10.87±2.47, 10.42±2.20, 11.84±2.13 and 9.74±1.94 mm Hg, respectively (p=0.019). IOPCC was 15.91±3.74, 18.40±4.35, 14.58±4.36 and 19.05±4.54 mm Hg, respectively (p<0.001). There was no significant difference in CRF among the groups (p=0.06). Regression analyses revealed that the type of operation was significantly associated with IOPGAT (p=0.04), CCT (p<0.001) and CH (p=0.006).

Conclusions

IOPGAT, CCT, CH and IOPCC were significantly different in treated eyes compared with normal eyes after congenital cataract surgery. These variables were primarily affected by the type of surgery. Primary intraocular lens implantation preserved corneal structure and function of the anterior chamber angle.




Trends in operating room-based glaucoma procedures in France from 2005 to 2014: a nationwide study

2017-10-25T02:51:05-07:00

Purpose

To report the trends in operating room-based glaucoma procedures from 2005 to 2014 in France.

Methods

We identified operating room-based glaucoma procedures (trabeculectomies, deep sclerectomies, aqueous shunts and ciliary body destructions) performed in France from 2005 to 2014 by means of billing codes from a national database. The annual rates and incidence of these procedures per 100 000 inhabitants were analysed globally and in three age groups: 0–14 years, 15–59 years and over 60 years.

Results

The annual rate of trabeculectomies decreased slightly during the study period, while the rate for other surgical techniques (deep sclerectomies, aqueous drainage procedures and ciliary body destructions) increased. The overall rate of glaucoma surgeries was higher in areas with populations of African descent than in areas predominantly composed of Caucasian populations: 1.60 (95% CI 1.51 to 1.70, p<0.0001).

Conclusions

Trabeculectomy was the most commonly performed operating room-based glaucoma procedure in France from 2005 to 2014. Other modalities such as deep sclerectomies, aqueous drainage procedures and ciliary body destruction gained greater acceptance among French ophthalmologists during this 10-year period.




Childhood-onset Leber hereditary optic neuropathy

2017-10-25T02:51:05-07:00

Background

The onset of Leber hereditary optic neuropathy (LHON) is relatively rare in childhood. This study describes the clinical and molecular genetic features observed in this specific LHON subgroup.

Methods

Our retrospective study consisted of a UK paediatric LHON cohort of 27 patients and 69 additional cases identified from a systematic review of the literature. Patients were included if visual loss occurred at the age of 12 years or younger with a confirmed pathogenic mitochondrial DNA mutation: m.3460G>A, m.11778G>A or m.14484T>C.

Results

In the UK paediatric LHON cohort, three patterns of visual loss and progression were observed: (1) classical acute (17/27, 63%); (2) slowly progressive (4/27, 15%); and (3) insidious or subclinical (6/27, 22%). Diagnostic delays of 3–15 years occurred in children with an insidious mode of onset. Spontaneous visual recovery was more common in patients carrying the m.3460G>A and m.14484T>C mutations compared with the m.11778G>A mutation. Based a meta-analysis of 67 patients with available visual acuity data, 26 (39%) patients achieved a final best-corrected visual acuity (BCVA) ≥0.5 Snellen decimal in at least one eye, whereas 13 (19%) patients had a final BCVA <0.05 in their better seeing eye.

Conclusions

Although childhood-onset LHON carries a relatively better visual prognosis, approximately 1 in 5 patients will remain within the visual acuity criteria for legal blindness in the UK. The clinical presentation can be insidious and LHON should be considered in the differential diagnosis when faced with a child with unexplained subnormal vision and optic disc pallor.




Propionibacterium acnes as a possible pathogen of granuloma in patients with ocular sarcoidosis

2017-10-25T02:51:05-07:00

Background/aims

To detect Propionibacterium acnes from intraocular granuloma in patients with ocular sarcoidosis.

Methods

Ten patients (10 eyes) with uveitis associated with sarcoidosis, who underwent vitrectomy to remove the epiretinal membrane were analysed. The patients were 70.4±7.6 (mean±SD) years of age, and the observation period from diagnosis of sarcoidosis until vitrectomy was 27.6±15.1 months. Histopathological examination of paraffin-embedded sections of the excised epiretinal membranes was conducted by H&E staining and immunohistochemical staining using PAB antibody, which is a monoclonal antibody against P. acnes. Four patients with idiopathic epiretinal membrane and four patients with epiretinal membrane caused by chronic uveitis other than sarcoidosis were included as control.

Results

Granuloma in the epiretinal membrane was observed in 4 of 10 patients with sarcoidosis, and all the granulomas were positive for PAB. In one patient without granuloma in the epiretinal membrane, PAB immunoreactivity was found in inflammatory cells, presumably macrophages. No granuloma and no PAB immunoreactivity were detected in all control patients, except one with chronic uveitis in whom faint PAB immunoreactivity was detected in inflammatory cells.

Conclusions

P. acnes was detected from granulomas formed in the epiretinal membrane of patients with sarcoidosis. The significance of P. acnes in the pathogenesis of uveitis associated with sarcoidosis remains to be determined.




Ultrasound biomicroscopic imaging in paediatric ocular toxocariasis

2017-10-25T02:51:05-07:00

Purpose

To determine the potential and usefulness of ultrasound biomicroscopy (UBM) as a diagnostic procedure on a larger cohort of paediatric patients with ocular toxocariasis.

Methods

UBM was performed on 41 eyes of 41 patients with ocular toxocariasis in order to determine configuration of peripheral retina, pars plana and vitreous. Location and range of peripheral pathology using ophthalmoscopy with scleral indentation, UBM and intraoperative confirmation were recorded and compared.

Results

Pathological structures such as vitreous condensations or membranes of various configuration and extent were identified by UBM. UBM revealed peripheral granuloma and pseudocystic changes in the peripheral vitreous in 15 of 41 eyes. Compared with indirect ophthalmoscope, statistical analysis showed significant differences in the number of clock-hours of peripheral pathology detected by UBM (p=0.015), while statistical differences were not found between UBM and intraoperative peripheral examinations using scleral indentation (p=0.432).

Conclusions

UBM seems to be a valuable and reliable diagnostic technique for the evaluation of patients with ocular toxocariasis. Longitudinal studies will have to determine the relevance of UBM findings for the individual clinical course and their influence on therapeutic decisions.




Aqueous cytokine and growth factor levels indicate response to ranibizumab for diabetic macular oedema

2017-10-25T02:51:05-07:00

Background/Aims

To investigate the relations between aqueous humour levels of cytokines/growth factors and treatment response to intravitreal ranibizumab (IVR) for diabetic macular oedema (DME)

Methods

Sixty-eight eyes of 68 patients with treatment-naïve centre-involved DME, central macular thickness (CMT) greater than 400 μm and visual acuity (VA) worse than logMAR 0.3 were recruited. Each patient received monthly IVR injection (0.5 mg/0.05 mL) until CMT was reduced to below 300 μm. Additional IVR was given to maintain CMT below 300 μm during the clinical course of 6 months with monthly follow-up. Aqueous concentrations of cytokines/chemokines and growth factors were measured using samples obtained just before first IVR injection. CMT and VA were monitored monthly for up to 6 months. The number of monthly IVR injections given during the 6-month study period was also recorded.

Results

Twenty-four eyes showed CMT <300 μm soon after the first IVR injection (good responders), while 12 eyes did not reach the goal after six consecutive injections (poor responders). Baseline CMT and VA were not significantly different between the two groups. However, the good responders showed significant increases in baseline aqueous concentrations of vascular endothelial growth factor (VEGF), placenta growth factor, soluble VEGF receptor-1 (sVEGFR1), monocyte chemoattractant protein-1, intercellular adhesion molecule-1, interleukin 6 and inducible protein-10, but not of sVEGFR2, compared with poor responders.

Conclusions

Response to ranibizumab treatment for DME appears to be associated with aqueous concentrations of VEGFR1 family and certain inflammatory cytokines, but not with clinical parameters.




Features of the choriocapillaris in myopic maculopathy identified by optical coherence tomography angiography

2017-10-25T02:51:05-07:00

Aim

To describe the choriocapillaris features imaged by optical coherence tomography angiography (OCTA) in eyes with myopic maculopathy.

Methods

In this retrospective, non-invasive, observational case series, 26 eyes with myopic maculopathy and 12 age-matched healthy eyes underwent fluorescein angiography, indocyanine green angiography (ICGA) (highly myopic eyes only), OCT and OCTA, and the choriocapillaris features seen on OCTA and ICGA were compared.

Results

In all five (19%) eyes with patchy atrophy of the 26 highly myopic eyes, OCTA showed complete loss of the choriocapillaris and large choroidal vessels in the atrophic area. In nine (35%) eyes with diffuse atrophy in the atrophic area, OCTA showed low-density choriocapillaris in all eyes and medium and large choroidal vessels in seven (78%) eyes. In 23 eyes (88%) with lacquer cracks, OCTA showed partial loss of the choriocapillaris in 22 (96%) eyes in the area of the lacquer cracks. OCTA could not visualise the full length of the lacquer cracks in any eyes compared with ICGA.

Conclusions

OCTA visualised the choriocapillaris clearly. The choriocapillaris features differed depending to the category of myopic maculopathy. In eyes with lacquer cracks, choriocapillaris rupture might be less advanced than the breaks in Bruch's membrane and retinal pigment epithelium.




Poppers: legal highs with questionable contents? A case series of poppers maculopathy

2017-10-25T02:51:05-07:00

Background

Poppers are volatile alkyl nitrite compounds that are inhaled to enhance sexual experience and for their psychoactive effects. A less well-known side effect is foveal maculopathy, which has emerged following changes in their chemical composition. It is unclear if certain individuals are more susceptible to retinal damage or if there is a relationship between pattern of inhalation and brands used.

Methods

A case series of 12 patients presenting to Sussex Eye Hospital, Brighton, with poppers-related visual impairment. Follow-up data were available in 10 cases, at a median time interval of 5 months (range 0–31 months). Eight samples of poppers were analysed using proton nuclear magnetic resonance spectroscopy.

Results

Patients presented with disrupted central vision occurring soon after inhalation. All demonstrated disruption of the inner segment/outer segment junction on spectral domain optical coherence tomography. Six of the brands implicated in causing visual symptoms contained isopropyl nitrite, while Jungle Juice Plus varieties, used without side effects in one case, contained amyl nitrite, 2-methyl butyl nitrite and isobutyl alcohol. In general, symptomatic resolution, alongside partial, if not full, recovery of foveal architecture was observed following abstention.

Discussion

On the basis of the products tested here, it seems that isopropyl nitrite is toxic to the fovea and can cause significant visual disturbance. The production of poppers is unregulated and their popularity is concerning, particularly given their exemption from the Psychoactive Substances Act 2016, which might suggest that they are harmless chemicals.




Internal limiting membrane peeling or not: a systematic review and meta-analysis of idiopathic macular pucker surgery

2017-10-25T02:51:05-07:00

Purpose

To determine whether internal limiting membrane (ILM) peeling improves anatomical and functional outcomes in idiopathic macular pucker (IMP)/epiretinal membrane (ERM) surgery in this systematic review and meta-analysis.

Methods

We searched the PubMed, Medline, Web of Science, Cochrane, Ovid MEDLINE, ClinicalTrials.gov and CNKI databases for studies published before 15 September 2016. The eligibility criteria included studies comparing ILM peeling versus no-peeling for IMP surgery.

Results

Thirteen articles (10 retrospective cohort studies, 1 prospective cohort study and 2 randomised controlled trials (RCTs)) were included in the review. Primary outcomes: no differences were observed in the best-corrected visual acuity (BCVA) or central macular thickness (CMT) at 12 months; however, lower ERM recurrence (OR, 0.13; 95% CI 0.04 to 0.41; p=0.0004) and reoperation rates (OR, 0.10; 95% CI 0.02 to 0.49; p=0.004) that favoured ILM peeling were observed at the final follow-up. Secondary outcomes: no difference was observed in BCVA at 3, 6 months, the final follow-up or in CMT at 3, 6 months, the final follow-up. Significantly increased CMT, which favoured ILM peeling, was observed at the final follow-up (p=0.002) in the RCTs.

Conclusions

ILM peeling yielded greater anatomical success, but no improvement in functional outcomes as the treatment of choice for patients undergoing IMP surgery.




Interchangeability and reliability of macular perfusion parameter measurements using optical coherence tomography angiography

2017-10-25T02:51:05-07:00

Aim

The aim of the study was to investigate the interchangeability and reliability of macular perfusion measurements using optical coherence tomography angiography.

Methods

A prospective cross-sectional observational study. Healthy adult Chinese subjects were recruited. Macular perfusion parameters were automatically analysed by software included in a spectral-domain optical coherence tomography system. The vessel density (VD) of the whole, parafovea, superior-hemi, inferior-hemi, fovea, temporal, superior, nasal and inferior quadrants as well as the foveal avascular zone (FAZ) and choroidal capillary VD (CCVD) were quantified.

Results

A total of 51 eyes in 27 subjects were included (8 men and 19 women, mean age 24±4 years). Significant differences in VD of all quadrants (all p<0.001) was detected between the 3x3 mm and 6x6 mm macular scan size. The biggest difference of VD between the two scan size was 5.14±4.03, which was not clinically meaningful. No statistically significant differences were found in FAZ or CCVD between the two different scan sizes. The mean intraclass correlation coefficient (ICC) between two measurements from the inter-rater of 20 eyes was from 0.560 to 0.893 for VD and 0.845 for FAZ. The mean ICC between two measurements from the intrarater of 20 eyes was from 0.497 to 0.870 for VD and 0.780 for FAZ.

Conclusions

FAZ and CCVD are interchangeable between the 3x3 mm and 6x6 mm macular scan sizes. The VD differences between the two different scan sizes are not clinically meaningful. The macular perfusion parameters presented good but not perfect reliability, which should be acknowledged in clinical practice.




Retinopathy in an obesity WHO III cohort: prevalence and risk factors

2017-10-25T02:51:05-07:00

Objective

To assess retinopathy and its risk factors in an obesity WHO III cohort.

Methods

In the Mannheim Obesity Study, 277 subjects with obesity WHO III aged 18–64 years were examined in a cross-sectional approach. Screening for retinopathy was performed using 3-field retinal photography. Endothelial function was assessed using arteriole-to-venule ratio and flicker light analysis. Subjects with and without retinopathy were analysed for anthropometry, metabolic, vascular and renal parameters.

Results

Retinopathy was found in 18 of the 277 subjects (6.5%). Prevalence of retinopathy was 16.7% in subjects with and 3.4% in subjects without diabetes mellitus. Between subjects with and without retinopathy there were significant differences in diabetes prevalence (61.1% vs 21.7%, p<0.001), systolic blood pressure (145.56 vs 131.73 mm Hg, p=0.005), intima-media thickness (0.7 vs 0.59 mm, p=0.034), dilatation of retinal veins in response to flicker light (2.24% vs 4.28%, p=0.004) and creatinine (0.92 vs 0.83 mg/dL, p=0.011). Stepwise logistic regression analysis revealed that the presence of diabetes mellitus led to an 8.3-fold increased risk for retinopathy (OR 8.3, p=0.049, 95% CI 1.01 to 67.49), whereas risk for retinopathy decreased by nearly 50% (OR 0.54, p=0.032, 95% CI 0.30 to 0.95) with each percentage increase in venous dilatation in response to flicker light.

Conclusions

Retinopathy prevalence in our obesity WHO III cohort is low. Presence of diabetes mellitus is the most important risk factor for retinopathy. Preserved venular function indicates protection from retinopathy.

Trial registration number

NCT00770276, Results.




Peripheral fundus findings in X-linked retinoschisis

2017-10-25T02:51:05-07:00

Background/aims

Vitreous haemorrhage (VH) and retinal detachment (RD) cause a precipitous decline in vision in a subset of patients with X-linked retinoschisis (XLRS), an otherwise a slowly progressive condition. This study aims to report the frequency of macular and peripheral retinal findings in a large cohort of patients with XLRS and to determine whether peripheral retinal findings are associated with VH and RD.

Methods

A retrospective observational case series was performed in 65 patients with XLRS with a pathogenic variant in retinoschisin 1. Chart review included examination notes, fundus photographs and optical coherence tomography (OCT). Fisher exact tests and univariable logistic regression analysis were used to determine the association between peripheral retinal findings (including retinoschisis, metallic sheen, vascular sheathing, pigmentary changes, white spiculations and vitreous veils) and complications (including VH and RD).

Results

Seven eyes (8%) showed normal macular structure on OCT. Peripheral retinoschisis was significantly associated with both VH and RD. Out of 10 eyes with complications, 9 (90%) had peripheral retinoschisis, compared with 33 out of 116 eyes (28%) without complications (p=0.0014). In addition, each additional peripheral finding increased the odds of RD by a factor of 4.06 (95% CI 1.58 to 10.39, p=0.028). There were no complications in the 28 eyes with a normal periphery (p=0.84) or in the 35 eyes with metallic sheen (p=0.42).

Conclusion

The data suggest that patients with peripheral retinoschisis are at increased risk for VH and RD. Furthermore, patients with additional peripheral retinal findings together with peripheral schisis may carry additional risk for RD.




Rectus muscle excyclorotation and V-pattern strabismus: a quantitative appraisal of clinical relevance in syndromic craniosynostosis

2017-10-25T02:51:05-07:00

Purpose

V-pattern strabismus observed with syndromic craniosynostosis has been attributed to disparate causes. We compared severity of V pattern with degree of excyclorotation of rectus muscles to appraise significance of this proposed aetiology.

Methods

43 patients with Apert, Crouzon or Pfeiffer syndrome referred to Boston Children's Hospital Department of Ophthalmology were identified. 28 met inclusion criteria for retrospective cohort study, specifically: (1) sensorimotor measurements in minimum of seven cardinal gazes, (2) quantified fundus torsion and (3) orbital CT imaging sufficient to measure rectus muscle cyclorotation in coronal and quasicoronal planes, posteriorly (near orbital apex) and anteriorly (near pulleys). Patients were placed in one of four V-pattern severity groups. The most severe group demonstrated inability to elevate abducted eye above midline with characteristic ‘seesaw’ misalignment during horizontal saccades. Rectus muscle cyclorotation was measured by paediatric neuroradiologist blinded to group placement. Primary outcome was correlation of severity of V pattern with degree of excyclorotation. Secondary outcome was correlation of severity with craniosynostosis syndrome.

Results

Increasing severity of V pattern correlated with greater excyclorotation in anterior coronal (p=0.009), anterior quasicoronal (p=0.021), posterior coronal (p=0.014) and posterior quasicoronal (p=0.040) planes for moderate-to-severe V pattern. Even greater excyclorotation was associated with seesaw V pattern in anterior quasicoronal (p=0.004) and posterior quasicoronal (p=0.001) views. Highly significant association was found between Apert syndrome and severity of V pattern (p=0.004).

Conclusions

Severity of V pattern is associated with magnitude of excyclorotation. More severe V pattern and seesaw strabismus noted with Apert syndrome may relate to distinctive orbital morphology.




Cancer-associated epiphora: a retrospective analysis of referrals to a tertiary oculoplastic practice

2017-10-25T02:51:05-07:00

Aim

To report the underlying causes and treatment outcome of lacrimal drainage obstruction in patients with cancer-associated epiphora.

Methods

A single-centre retrospective review was performed for consecutive referrals to an oculoplastic surgeon for cancer-associated epiphora between 2010 and 2016. Charts were reviewed for underlying neoplastic conditions, pharmacy records, radiotherapy records, levels of obstruction of the lacrimal drainage apparatus and treatment methods and outcome.

Results

Forty-three patients (70 eyes) were included in this study. The most common cause of epiphora was radiotherapy on the head and neck (35%), followed by oral S-1 (33%) and docetaxel (23%). The nasolacrimal duct was the most common obstruction site in patients who underwent radiotherapy (59%), whereas the punctum or canaliculus was mostly affected in patients treated with S-1 (94%) or docetaxel (100%). S-1-treated patients showed severe obstruction of the entire canaliculus (11/24 (46%)) with the lowest success rate at 58% (S-1 vs radiotherapy: p=0.012; S-1 vs docetaxel: p=0.002). Moreover, the patients treated within 1 year after the first symptom showed a significantly higher proportion of symptom improvement (85%) than did those treated after 1 year (27%) in the S-1 group (p=0.011).

Conclusions

Cancer-associated epiphora can have various causes. The level of obstruction and treatment outcome vary according to underlying causes, and S-1-associated epiphora and delayed treatment are related to unsatisfactory results. Given the importance of early intervention, oncologists should be alert to tearing symptoms and cooperate with ophthalmologists in the early stages to improve patients’ quality of life.




Small incision guarded hydroaspiration of iris lesions

2017-10-25T02:51:05-07:00

Aim

To describe the technique and results of a minimally invasive surgical technique for resection of small iris lesions.

Methods

Consecutive case series of 22 patients with localised, small iris lesions that were resected using the described surgical technique that composed of multiple, small corneal incisions created to allow for internal iris resection with 23-gauge horizontal vitrectomy scissors, followed by guarded tumour aspiration through a clear plastic tubing (diameter 3.5 mm) primed with viscoelastic agent.

Results

The mean largest basal diameter was 3.0 mm (range 1.5–5.0 mm; median 3.0 mm) and mean thickness was 1.3 mm (range 0.5–2.5 mm; median 1.0 mm). Use of multiple (2–4) small corneal incisions (range 2.0–3.0 mm; mean 2.8 mm) allowed reduced postoperative morbidity (significant hyphema (0%), hypotony (0%), wound leak (0%), >2 line change in best corrected visual acuity at postoperative 1 week (4.5%) and mean corneal astigmatism of 1.0 D (range 0.14–2.99 D; median 0.8 D) at postoperative 4–12 weeks. The tumour could be resected with clear surgical margins in all neoplastic cases (benign (2), borderline (1) and malignant (16)). Local recurrence or metastases were not observed in any melanoma case over a mean follow-up of 33.0 months (range 1.0–90.0 months; median 33.5 months).

Conclusions

Small incision guarded hydroaspiration is a minimally invasive surgical technique for resection of select small iris lesions. Use of multiple small corneal incisions avoids morbidity associated with a single large corneoscleral incision, and use of guarded aspiration may eliminate the risk of wound contamination by the malignant tumour.




Serum IgG2 and tissue IgG2 plasma cell elevation in orbital IgG4-related disease (IgG4-RD): Potential use in IgG4-RD assessment.

2017-10-25T02:51:05-07:00

Aims

To determine the role of serum and tissue IgG2 in orbital biopsies with the histological features of IgG4-related disease (IgG4-RD) in comparison with non-IgG4-related orbital inflammatory disorders (OID), including autoimmune disorders.

Methods

This is an international (Sheffield, UK, and Singapore) collaborative, retrospective case review of 69 patients (38 from Singapore National Eye Centre and 31 from Royal Hallamshire Hospital, Sheffield) with orbital inflammatory biopsies between 2002 and 2016. Clinical information and histology were reviewed and cases were classified into three groups: Group 1: IgG4-RD orbital inflammation (n=43); Group 2: idiopathic OID (n=12) and Group 3: autoimmune OID (n=14). Serum IgG1, IgG2, IgG3 and IgG4 levels were collated where available and immunohistochemistry (IHC) for tissue IgG2 plasma cells was performed.

Results

Dual IHC showed IgG2 plasma cells as a distinct population from IgG4 plasma cells. Significant (twofold) serum IgG2 elevation was noted among IgG4-RD (group 1), idiopathic (group 2) and autoimmune OID (group 3). Similarly, significant elevation of tissue IgG2 plasma cells was also seen among IgG4-RD (group 1), idiopathic and autoimmune OID (groups 2 and 3).

Conclusions

Significant elevations of serum IgG2 and tissue IgG2 plasma cells are present in orbital IgG4-RD in comparison with non-IgG4 orbital inflammation (idiopathic and autoimmune OID), suggesting that IgG2 may play a role in IgG4-RD. A serum IgG2 cut-off >5.3 g/L was found to be 80% sensitive and 91.7% specific for orbital IgG4-RD, with an accuracy of 0.90. Tissue IgG2 and IgG4 subclass reporting may provide additional insight regarding the ‘IgG4-RD’ pathogenesis.




Paracrine effects of mesenchymal stem cells on the activation of keratocytes

2017-10-25T02:51:05-07:00

Aims

The purpose of this study is to investigate the impact of mesenchymal stem cell (MSC)-derived soluble factors on the function of keratocytes, with a particular focus on the processes involved in wound healing, including keratocyte activation, migration and proliferation as well as extracellular matrix (ECM) synthesis.

Methods

Primary cultured rabbit keratocytes were treated with MSC-conditioned medium (MSC-CM). The paracrine factors released by bone marrow MSCs were examined by ELISA. Time-lapse microscope was used to examine wound closure in vitro. Mouse model of corneal injury was made by epithelial scraping after ethanol injury.

Results

MSC-CM significantly increased the wound closure rate of corneal stromal cells in vitro. This enhancement of wound closure by MSC-CM was due to the promotion of cell migration. MSC-CM enhanced keratocyte survival following ethanol injury via inhibiting apoptosis. The expression of ECM component genes in keratocytes was upregulated by MSC-CM. In addition, MSC-CM promoted corneal epithelial wound healing following chemical injury. A number of wound healing mediators were detected in MSC-CM, including vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), hepatocyte growth factor (HGF), transforming growth factor beta 1 (TGFβ1), interleukin 8 (IL8), interleukin 6 (IL6) and monocyte chemoattractant protein 1 (MCP1).

Conclusion

MSC secretes certain factors that accelerate corneal re-epithelialisation. The paracrine effects of MSC on corneal wound healing including improvements in cell viability, migration and ECM formation.