ABSTRACTBackground:  To identify the clinical ocular signs of uveitis associated with latent tuberculosis (TB).Design:  Retrospective case-control study.Participants:  Consecutive patients from Singapore National Eye Centre Uveitis over 9 years. We compared 62 patients with uveitis associated with latent TB (LTBU) to 72 matched controls diagnosed with other known uveitides.Methods:  Patients were categorized as: (A) predominantly anterior segment inflammation (anterior uveitides) and (B) predominantly posterior segment inflammation (intermediate, posterior or pan-uveitides). The diagnostic performance of combining these clinical signs with investigations such as interferon-gamma release assay (IGRA) positivity and chest X-ray results suggestive of pulmonary tuberculosis (TB) was done using area under the receiver operator characteristic curve (AUC).Main Outcome Measures:  Sensitivity, specificity and likelihood of association with TB of various clinical signs.Results:  Extensive posterior synechiae and concomitant anterior scleritis in group A; low-grade anterior chamber activity, retinal phlebitis and severe vitritis in Group B were significantly associated with LTBU. Combining these clinical signs with a positive IGRA and tuberculin skin test (TST) improved the diagnostic performance in both groups (AUC for group A = 0.779; group B = 0.789).Conclusions:  Patients with a combination of suggestive clinical signs with positive IGRA and TST are more likely to be accurately diagnosed with uveitis associated with latent TB, which responds to anti-TB therapy.© 2012 The Authors. Journal compilation © 2012 Royal Australian and New Zealand College of Ophthalmologists

© 2012 The Authors. Journal compilation © 2012 Royal Australian and New Zealand College of Ophthalmologists

ABSTRACTBackground:  Current knowledge of the phenotypic characteristics (e.g., clinical features, risk factors, natural history and treatment response) of age-related macular degeneration in Asians remains limited. This report summarizes the rationale and study design of a prospective observational study of Asian neovascular age-related macular degeneration, including polypoidal choroidovasculopathy variant.Design:  The Asian Age-related macular degeneration Phenotyping study is a prospective, observational clinical study of Asian patients with neovascular age-related macular degeneration or polypoidal choroidovasculopathy in three tertiary eye centres in Singapore.Participants:  The study aims to recruit 500 consecutive patients from the retinal clinics of three tertiary eye centres in Singapore.Methods:  Standardized examination procedures include interviews, a comprehensive eye examination, digital photography of the retina, fundus fluorescein and indocyanine green angiography and spectral domain optical coherence tomography using a standardized protocol. Blood samples are collected for biochemical analyses, and stored for genetic and proteomic studies.Main Outcome Measures:  The aim of the study is to build a comprehensive database of clinical, angiographic, functional and natural history data of Asian AMD over a 12-month follow-up period.Results:  This article discusses the methodology and design of this prospective multi-centred study.Conclusions:  This study will provide in-depth longitudinal data of the evolution of clinical features, risk factors, natural history and treatment pattern and response of Asian age-related macular degeneration and polypoidal choroidovasculopathy, allowing unique insights into pathogenesis and the design of new treatment strategies.© 2012 The Authors. Journal compilation © 2012 Royal Australian and New Zealand College of Ophthalmologists

ABSTRACTBackground:  To estimate the incidence and causes of visual impairment and blindness among indigenous Australians living in central Australia.Design:  Clinic-based cohort study.Participants:  1,884 individuals aged ≥ 20 years living in one of 30 remote communities within the statistical local area of ‘Central Australia’.Methods:  From those initially recruited, 608 (32%) participants were reviewed again between 6 months and 3 years (median 2 years). Patients underwent snellen visual acuity testing and subjective refraction. Following this, an assessment of their anterior and posterior segments was made. Baseline results were compared with those who were reviewed.Main Outcome Measures:  The annual incidence rates and causes of bilateral visual impairment (vision worse than snellen visual acuity 6/12 in the better eye) and bilateral blindness (snellen visual acuity worse than 6/60 in the better eye).Results:  The annual incidence of bilateral visual impairment and blindness was 6.82% (8.12% for those aged ≥ 40 years) per year and 0.50% (0.62% for those aged ≥ 40 years) per year respectively. Refractive error, followed by cataract and diabetic retinopathy were the main causes for incident bilateral visual impairment and blindness.Conclusions:  This study has demonstrated rates of incident bilateral blindness and visual impairment among the indigenous Australian population within central Australia which are substantially higher than those from the non-indigenous population. Services need to address the underlying causes of this incident vision loss to reduce visual morbidity in indigenous Australians living in central Australia.© 2012 The Authors. Journal compilation © 2012 Royal Australian and New Zealand College of Ophthalmologists

ABSTRACTBackground:  To measure choroidal thickness in normal eyes and in patients with normal-tension glaucoma using enhanced depth imaging optical coherence tomography and evaluate the association between choroidal thickness and progression of visual field damage.Design:  Cross-sectional comparative study.Participants:  A total of 62 eyes of 62 normal subjects and 45 eyes of 45 normal-tension glaucoma patients were examined.Methods:  The choroid was measured at the fovea and 3 mm nasal and temporal from the fovea. In a separate analysis, we examined both eyes of normal-tension glaucoma patients. After measuring the visual fields using automated perimetry, we then calculated the changes in the mean deviation per year (dB/year), i.e., the mean deviation slope.Main Outcome Measures:  Outcome measures included the differences in the choroidal thickness between normal subjects and patients with normal-tension glaucoma, and the relationship between the mean deviation slope and the choroidal thickness in normal-tension glaucoma eyes.Results:  As compared to normal eyes, the choroidal thickness was significantly thinner at 3 mm nasal from the fovea in the normal-tension glaucoma eyes (P = 0.02). Subsequent analysis indicated there was a significant correlation between this choroidal thinning and the mean deviation slope (Pearson r = 0.413; P < 0.001).Conclusions:  The decrease in the thickness of the choroid at 3 mm nasal from the fovea in normal-tension glaucoma eyes may be associated with a progressive visual field loss. Thus, these findings suggest that choroidal abnormalities may play a role in the pathogenesis of normal-tension glaucoma.© 2012 The Authors. Journal compilation © 2012 Royal Australian and New Zealand College of Ophthalmologists

ABSTRACTBackground:  To describe the rationale and study design of a follow-up epidemiological eye study among Singaporean Malay adults.Design:  Follow-up prospective population-based study.Participants:  Participants of the Singapore Malay Eye Study (SiMES-1), which was conducted from August 2004 to June 2006.Methods:  This is a follow up study of the 3280 participants who participated in the SiMES-1 and are residing in Singapore. All participants of this follow-up study will undergo various standardized validated questionnaires on socio-demographics, quality of life and impact of visual impairment. Participants will undergo assessment of blood pressure, anthropometry, presenting and best-corrected visual acuity, subjective refraction, ocular biometry, slit-lamp and dilated eye examination, Goldmann tonometry, optic disc imaging, digital lens and retinal photography. Retinal tomography, retinal optical coherence topography and fundus autofluorescence will also be performed. Gonioscopy and visual fields examination will be performed on selected individuals.Main Outcome Measures:  Incidence, risk factors and impact of visual impairment and major eye diseases.Results:  A total of 3280 people who participated in the SiMES-1 will be contacted and invited to participate in this follow-up study. It is estimated that 12.8% of the participants will be deceased and there will be an 80% participation rate for the survivors of SiMES-1 (approximately 2288 participants).Conclusions:  SiMES-2 will be one of the few follow-up epidemiological eye studies among Asians and will determine the cumulative 6-year incidence, progression, risk factors and impact of major eye diseases in Singaporean Malay adults.© 2012 The Authors. Journal compilation © 2012 Royal Australian and New Zealand College of Ophthalmologists

ABSTRACTBackground:  To determine the normative data for lens thickness and its associated factors in a population-based study.Design:  Population-based study.Participants:  The Central India Eye and Medical Study included 4711 subjects (aged 30+ years).Methods:  The subjects underwent a detailed ophthalmologic examination including measurement of the lens thickness by sonography.Main Outcome Measures:  Sonographic lens thickness measurement.Results:  After excluding pseudophakic or aphakic eyes, lens thickness measurements were available for 9046 eyes of 4610 (97.9%) subjects with a mean age of 49.1 ± 13.2 years (range:30-100 years) and a mean refractive error of -0.11 ± 1.77 diopters (median, 0 diopters; range, -21.75 to + 7.75 diopters). Mean lens thickness was 3.95 ± 0.49 mm. In multivariate analysis, a thick lens was significantly associated with higher age (P < 0.001), male gender (P < 0.001), higher body stature (P = 0.02), higher body mass index (P = 0.003), thicker central cornea (P = 0.008), shallower anterior chamber depth (P < 0.001), and hyperopic refractive error (P < 0.001). After adjustment for ocular and systemic parameters, lens thickness decreased with higher degree of nuclear cataract.Conclusions:  In the rural Central Indian population, a thick lens was associated with higher age, male gender, high body stature, high body mass index, hyperopia, thick central cornea, shallow anterior chamber depth, and nuclear cataract. The data may be helpful to explain anatomic relationships of the anterior segment of the eye and to elucidate risk factors of diseases associated with ocular dimensions.© 2012 The Authors. Journal compilation © 2012 Royal Australian and New Zealand College of Ophthalmologists

© 2012 The Authors. Journal compilation © 2012 Royal Australian and New Zealand College of Ophthalmologists

ABSTRACTBackground:  It is unclear whether differences exist in surgical complication rates and long-term visual acuity (VA) outcomes between patients whose phacoemulsification cataract surgery was performed by ophthalmological trainees and those performed by consultants.Design:  Prospective clinical cohort study.Participants:  1851 participants of the Cataract Surgery and Age-related Macular Degeneration study, aged ≥ 64 years, had cataract surgery performed at Westmead Hospital, Sydney.Methods:  Surgical complication rates and VA at 24-month postoperative visits were compared between patients who were operated on by trainees and those operated on by consultants.Main Outcome Measures:  Surgical outcomes included operative complications recorded in surgical audit forms and 24-month postoperative VA.Results:  Of 1851 patients, 1274 (68.8%) were reviewed 24 months post-surgery. Of these, 976 had data on the type of surgeon who performed the operation. After excluding 152 challenging cases and three cases operated on by first-year trainees at the beginning of their training, 821 patients were included in this study, of those 498 operated on by trainees and 323 by consultants. Habitual VA ≥ 6/12 was achieved in 77.3% (385/498) and 74.3% (n = 240/323), respectively, of the two groups of patients 24-months postoperatively. Of 514 patients who had surgical audit data, the major complication rate was numerically greater, but not significantly different for the 330 trainee-operated (6.1%), compared with the 184 consultant-operated patients (2.7%, p = 0.091).Conclusions:  We found relatively comparable complication rates and visual outcomes after 2 years between patients operated on by ophthalmological trainees and those by consultants, in a cataract surgical cohort at Westmead Hospital.© 2012 The Authors. Journal compilation © 2012 Royal Australian and New Zealand College of Ophthalmologists

ABSTRACTBackground:  General adoption of the ocular surface (OS) concept has advanced the therapy of the external eye. Fresh physical findings have prompted new concepts, Examples, taken from each section of the text are: (1) Ever-present lipid sealant bridges the palpebral fissure, capping the three-dimensional ‘ocular surface’ sac. The muco-aqueous pool is thus enclosed, secluded from atmosphere, evaporation mitigated. Hence, the OS is conceptually, a compartment. The term ‘dacruon’ (otherwise ‘tear film’) has been coined for the combined fluids of the ocular surface, viz: lipid film and muco-aqueous pool. (MAP). (2) Investigative techniques of physics yield data on (say) surface tension and viscosity, and on functions such as: anchorage of dacruon base to the varied mucosae of the ocular surface; lubrication; renovation of inter-marginal fluid layers as the eye opens after each blink; and refinement of optics and vision by the fluids attached to the cornea. (3) Physical events in the opening eye produce the unique ‘black line’ phenomenon, in which capillary force induces sub-surface flows into thirsty menisci, bringing about para-meniscal dark grooves, pupilward of each meniscus. Attenuation of fluorescein in the shallowed fluid gaps behind each groove makes the dye appear un-illuminated (‘black lines’) relative to adjacent full-thickness MAP fluid glowing under cobalt-blue illumination. Isolated from cornea by grooves and gaps, the meniscal fluid cannot pass freely over the cornea. It therefore streams through the menisci to naso-lacrimal outflow.© 2012 The Authors. Journal compilation © 2012 Royal Australian and New Zealand College of Ophthalmologists

ABSTRACTBackground:  To determine the predictors of long-term visual outcome after chemoreduction for management of intraocular retinoblastoma.Design:  Retrospective case series.Participants:  140 eyes of 96 new retinoblastoma patients.Methods:  The clinical records were reviewed for demographic profile, tumor characteristics, treatment methods, treatment side effects, and final visual outcome. Multivariate analysis was used to evaluate factors predictive of final visual acuity.Main Outcome Measures:  The clinical data were analyzed for main outcome measures of good vision (visual acuity ≥ 20/40) or ambulatory vision (visual acuity> 20/200). The correlation among predictor variables was determined using Pearson product moment correlation for continuous variables and ‘T’ test and ANOVA test for categorical baseline variables.Results:  Follow-up ranged from 2 years to 14 years (median: 75 months). The final mean logMAR visual acuity (VA) was 0.79. Ambulatory vision (> 20/200) was achieved in 100 of 140 (71%) eyes and vision of > 20/40 was seen in 52 eyes (37%). Extrafoveolar tumor and greater number of tumors in the eye were the only predictors of VA> 20/40. Greater number of tumors correlated with smaller mean basal tumor diameter. The mean basal tumor diameter was 9.8mm in eyes with multiple tumors and 12.2 mm in eyes with single tumors (p = 0.03).Conclusions:  Long-term ambulatory vision (> 20/200) was achieved in the majority (71%) of retinoblastoma containing eyes not requiring enucleation after treatment with chemoreduction and adjunctive therapy. Absence of foveolar involvement and greater number of tumors were the predictor of long- term visual outcome of 20/40 or better.© 2012 The Authors. Journal compilation © 2012 Royal Australian and New Zealand College of Ophthalmologists

ABSTRACTPurpose:  To assess the efficacy of a new nanopulse laser, Retinal Regeneration Therapy, (2RT) for the treatment of diabetic macular oedema (DMO).Design:  Randomized, non-inferiority, trial.Participants:  Subjects had DMO; 20 eyes of 17 subjects in the 2RT group, and 18 eyes of 14 subjects in the conventional group were analysed.Methods:  The treatment group received 2RT laser and the control group received conventional photocoagulation.Main Outcome Measures:  The primary outcome was the change in central retinal thickness at 6 months. A secondary outcome was the change in logMAR visual acuity at 6 months. Non-inferiority required the one-sided 95% confidence interval (C.I.) of the mean retinal thickness reduction (the ΔOCT) after 2RT to be within 35µm of the reduction after control laser. For the visual acuity, non-inferiority required the one-sided 95% C.I. of the mean 2RT group visual acuity (ΔVA) to be within 0.06 (3 letters) of the control group.Results:  When outliers were included in the dataset, the difference in retinal thickness reduction by ANCOVA was 10.9 (SD 17.6)µm in favour of the control laser. The ΔOCT was 40.8 µm. If two extreme outliers were excluded, the difference was 5.6 (SD 14.2)µm in favour of the 2RT laser, and the ΔOCT was 18.5 µm. The ΔVA was.059, meeting non-inferiority requirements.Conclusions:  Although retinal thickness reduction was not unambiguously non-inferior, in the short-term, 2RT approximates the clinical efficacy of conventional photocoagulation, stabilizing visual acuity and providing motivation for larger trials assessing 2RT.© 2012 The Authors. Journal compilation © 2012 Royal Australian and New Zealand College of Ophthalmologists

ABSTRACTBackground:  No study to date has examined gender differences in crash risk after cataract surgery. Therefore, this study aimed to determine gender-related differences in the effectiveness of first eye cataract surgery in reducing crash risk for older drivers.Design:  This retrospective before and after study used whole population linked data to compare the frequency of police reported crashes one year before and one year after first eye cataract surgery for the years 1997 to 2006.Participants:  All patients aged 60 to 85 years who had first eye cataract surgery between 1997 and 2006 in Western Australia and were involved in a motor vehicle crash 12 months before and/ or after surgery.Methods:  Two separate generalised estimating equation (GEE) Poisson models were undertaken for males and females to compare crash frequency before and after surgery.Main Outcome Measures:  Police-reported crashes before and after cataract surgery.Results:  A large proportion of the cohort involved in a crash either one year before or one year after first eye cataract surgery were male (n = 1091, 63.6%) compared to female (n = 624, 36.3%). Results from the GEE Poisson models showed a significant reduction of 15.3% (p = 0.040) in all police reported crash frequency for males one year after cataract surgery. However, there was no significant change in crash frequency after surgery for females.Conclusions:  The results of this study suggest that clinicians may need to take gender into account when advising patients on driving safety before and after cataract surgery.

ABSTRACTBackground:  Evaluation of outcomes of big bubble deep anterior lamellar keratoplasty (DALK) in cases with post-keratitis and post-traumatic corneal scars.Design:  Interventional case seriesParticipants:  Patients with corneal stromal scarring secondary to healed infectious keratitis or trauma were recruited from the Corneal Clinic of the M. M. Joshi Eye Institute, Karnataka, India between August 2007 and December 2009.Methods:  All patients underwent big bubble DALK surgery.Main outcome measures:  Best-corrected visual acuity (BCVA), as well as intra- and postoperative complications.Results:  Big bubble DALK was performed in 36 patients (25 males, 11 females) with post-infectious keratitis (n = 22) and post-traumatic (n = 14) corneal stromal scars sparing the Descemet's membrane (DM) and endothelium. Mean age was 39.7 ± 11.3 years (range: 22 to 58 years). Although a big bubble was achieved in all eyes (100%), intraoperative perforation of the DM occurred in 6 eyes (16%) during stromal dissection. Two cases required conversion to penetrating keratoplasty. A double anterior chamber occurred in the immediate postoperative period in 3 cases (8.3%). Raised intraocular pressure was seen in 1 eye. Mean preoperative BCVA (0.03 ± 0.04) improved significantly at the end of 6 months follow-up postoperatively (0.43 ± 0.20; p < 0.01, Wilcoxan signed-ranks test). Corneal stromal graft rejection was noted in 2 cases (5.5%) during the first 3 months after surgery. Graft failure occurred in 2 cases (5.5%).Conclusions:  DALK using the big bubble technique is a viable option in cases with post-infectious keratitis and post-traumatic corneal stromal scarring with normal DM and endothelium.

ABSTRACTBackground:  To estimate the prevalence and causes of blindness and low vision among adults aged ≥40 years in Fiji.Design:  Population-based cross-sectional study.Participants:  Adults aged ≥40 years in Viti Levu, Fiji.Method:  A population-based cross-sectional survey used multistage cluster random sampling to identify 34 clusters of 40 people. A cause of vision loss was determined for each eye with presenting vision worse than 6/18.Main Outcome Measures:  Blindness (better eye presenting vision worse than 6/60), low vision (better eye presenting vision worse than 6/18, but 6/60 or better).Results:  Of 1892 people enumerated, 1381 participated (73.0%). Adjusting sample data for ethnicity, gender, age and domicile, the prevalence of blindness was 2.6% (95%CI 1.7, 3.4) and low vision was 7.2% (95%CI 5.9, 8.6) among adults aged ≥40 years. On multivariate analysis, being ≥70 years was a risk factor for blindness, but ethnicity, gender and urban/rural domicile were not. Being Indo-Fijian, female and older were risk factors for vision impairment (better eye presenting vision worse than 6/18). Cataract was the most common cause of bilateral blindness (71.1%). Among participants with low vision, uncorrected refractive error caused 63.3% and cataract was responsible for 25.0%.Conclusion:  Strategies that provide accessible cataract and refractive error services producing good quality outcomes will likely have the greatest impact on reducing vision impairment.

ABSTRACTBackground:  To investigate the normative data of anterior chamber depth and its associations in adults in rural Central India.Design:  Population-based studyParticipants:  The Central India Eye and Medical Study included 4711 subjects aged 30+ years (response rate, 80.1%).Methods:  The subjects underwent an ophthalmologic examination including measurement of the anterior chamber depth by sonography.Main Outcome Measure:  Anterior chamber depthResults:  Mean anterior chamber depth (ACD) was 3.22 ± 0.34 mm. In multivariate analysis, a shallow chamber depth was significantly associated with higher age (P < 0.001), female gender (P < 0.001), shorter body stature (P= 0.003), hyperopic refractive error (P < 0.001), higher lens thickness (P < 0.001), and shorter axial length (P < 0.001).Conclusions:  In the rural Central Indian population, a shallow anterior chamber was associated with higher age, female gender, short body stature, hyperopia, thick lens, and shorter axial length. Compared with population-based data from East Asia (China), the anterior chamber was markedly deeper in India. The data may be helpful to explain anatomic relationships of the anterior segment of the eye, to elucidate risk factors of angle-closure glaucoma, and to explain ethnic differences in the prevalence of angle-closure glaucoma.

ABSTRACTBackground:  To investigate the role of inflammation in age-related macular degeneration (AMD) by measuring the levels of cytokines in the aqueous humor.Methods:  Samples of aqueous humor were collected from 34 patients with AMD and 16 age-matched control subjects undergoing cataract surgery. AMD stage (AREDS) was determined clinically, before surgery. Levels of cytokines were measured using Luminex X-MAP technology, and positive results were verified by Western blot.Results:  AMD was moderate in 18 patients and advanced in 16. The advanced-AMD group was further divided into patients with active choroidal neovascularization (CNV) (n = 7), disciform scar (n = 7), or central geographic atrophy (n = 2). Higher-than-normal levels of monocyte chemoattractant protein-1 (MCP-1) in the aqueous humor were associated with advanced AMD (200 ± 140 pg/ml vs 100 ± 61 pg/ml; p = 0.03), especially active CNV (255 ± 155 pg/ml; p = 0.02), Western blot analysis verified the MCP-1 findings. Patients with disciform scar showed a trend of abnormally high levels of IL-12 (p70) (1.7 ± 2.4 pg/ml vs 0.2 ± 1 pg/ml; p = 0.07), tumor necrosis factor (TNF)-α (1.8 ± 2.4 pg/ml vs 0.3 ± 1 pg/ml; p = 0.06), and IL-8 (4.7 ± 6.4 pg/ml vs 1.2 ± 2.1 pg/ml; p = 0.08).Conclusion:  Elevated levels of inflammation-related cytokines in the aqueous humor in various stages of AMD may suggest a pathogenic role of inflammation. MCP-1 may be indicative of the angiogenic phase. Further corroborative studies are required.

ABSTRACTBackground:  To compare the anterior segment biometric parameters amongst adult American Caucasians, American Chinese and mainland Chinese, in order to determine parameters that may contribute to increased risk for angle closure in Chinese.Design:  Cross-sectional clinic-based studyParticipants:  Four gender- and age-matched cohorts included Caucasians, American Chinese, Southern and Northern mainland Chinese.Methods:  Anterior segment optical coherence tomography (ASOCT) was utilized to image the anterior chamber. Customized software was used to calculate the anterior segment parameters.Main Outcome Measures:  Anterior chamber depth (ACD), anterior chamber width (ACW), lens vault (LV), and corneal arc depth (CAD).Results:  Data from 121, 124, 121, and 120 subjects were available for American Caucasian, American Chinese, and Southern and Northern Mainland Chinese subjects, respectively. Caucasians had significantly greater ACD, ACW, and CAD than all Chinese groups even after adjustment for refractive status and axial length. In multiple regression analysis, predictors of greater LV were female gender, older age, and more hyperopic/less myopic status for both racial groups. It was found only in Chinese that female and older subjects tended to have smaller ACD, ACW, and CAD.Conclusion:  The shallower anterior chamber in Chinese than Caucasians is likely attributable to the shorter corneal arc depth in the former group. Moreover, the smaller anterior chamber width contributes to more crowded anterior chambers in Chinese than in Caucasians. The more anteriorly located lens under a less vaulted cornea in Chinese females compared with Chinese males may account for the higher risk of angle closure in this subpopulation.

ABSTRACTIntroduction:  The microscopic and macroscopic anatomy of the anterior and posterior Tenon's capsule is described.Methods:  An observational anatomic study of twelve orbits of 6 cadavers (mean age, 79.5 years) were examined microscopically and 8 orbits of 4 cadavers (mean age, 76.8 years) were examined macroscopically. After orbital exenteration, an X-shaped incision was made in the specimens to include the posterior part of the globe. The sections were divided into 4 parts: superomedial, inferomedial, superolateral and inferolateral. In the macroscopically examined specimens, the eyelids and globes were removed from the exenterated tissues and the appearance of Tenon's capsule was studied.Results:  In the microscopic study, Tenon's capsule covered the sclera beneath the conjunctiva and contained smooth muscle fibers in the anterior area. This anterior fascia, which had a thick appearance, reached the globe equator. From there, the capsule of the orbital fat, which contained no smooth muscle fibers, enveloped the sclera and reached the optic nerve. This was defined as the posterior capsule. In the macroscopic specimens, Tenon's capsule had a thick and fibrous white appearance in the anterior area. More posteriorly, the capsule was thinner and more translucent. This thin capsular part was generally larger in the lateral area than in the medial area.Conclusions:  Tenon's capsule is composed of an anterior thick fibrous tissue comprising the orbital smooth muscle network and the posterior thin fibrous capsule of the orbital fat.

ABSTRACTGenome-wide association studies are a powerful tool for the identification of genetic risk factors for complex disease. This methodology has been successfully applied to primary open-angle glaucoma through the analysis of POAG itself as well as specific subgroups of patients including those with Normal Tension Glaucoma and Advanced Glaucoma. In addition, the analysis of quantitative traits important in POAG, including optic disc area and vertical cup-to-disc ratio has also identified genes important in POAG development. This review explores findings of genome-wide association studies for POAG and related traits.

ABSTRACTBackground:  Glaucoma is a sight threatening disease affecting 2-3% of the population over the age of 40. Glaucoma is treatable, and severe vision loss can usually be prevented if diagnosis is made at an early stage. Genetic factors play a major role in the pathogenesis of the condition, and therefore genetic testing to identify asymptomatic at risk individuals is a promising strategy to reduce the prevalence of glaucoma blindness. Furthermore, unravelling genetic risk factors for glaucoma would also allow a better understanding of the pathogenesis of the condition, and the development of new treatments.Design:  The Australian and New Zealand Registry of Advanced Glaucoma is a prospective study which aims to develop a large cohort of glaucoma cases with severe visual field loss to identify novel genetic risk factors for glaucoma blindness.Methods:  Clinical information and blood are collected from participants after referral by eye practitioners. Samples are collected across Australia and New Zealand using postage kits.Participants:  Our registry has recruited just over 2000 participants with advanced glaucoma, as well as secondary and developmental glaucomas.Results:  A positive family history of glaucoma is present in more than half of the advanced glaucoma cases and the age at diagnosis is significantly younger for participants with affected relatives, which reinforces the involvement of genetic factors in glaucoma.Conclusions:  With the collection of glaucoma cases recruited so far, our registry aims to identify novel glaucoma genetic risk factors to establish risk profiling of the population and protocols for genetic testing.

ABSTRACTBackground:  Full axon counting of optic nerve cross-sections represents the most accurate method to quantify axonal damage, but such analysis is very labor intensive. Recently, a new method has been developed, termed targeted sampling, which combines the salient features of a grading scheme with axon counting. Preliminary findings revealed the method compared favorably with random sampling. The aim of the current study was to advance our understanding of the effect of sampling patterns on axon counts by comparing estimated axon counts from targeted sampling with those obtained from fixed-pattern sampling in a large collection of optic nerves with different severities of axonal injury.Methods:  Chronic ocular hypertension was induced in adult Sprague-Dawley rats for 1 to 7 weeks by translimbal laser photocoagulation of the trabecular meshwork. Axonal damage on resin embedded cross sections was estimated using three different methods: (1) semi-quantitative damage grading; (2) semi-quantitative, automated axon counting using targeted sampling; (3) semi-quantitative, automated axon counting using fixed-pattern sampling.Results:  Estimated axon counts, as generated by targeted sampling and fixed-pattern sampling correlated equally well with the semi-quantitative grading scheme. Estimated counts obtained with targeted sampling were not statistically different from those yielded by fixed-pattern sampling. Bland-Altman analysis showed a good agreement between the two methods.Conclusions:  The results of our study validate the use of both fixed-pattern sampling and targeted sampling for estimation of axonal damage, but do not indicate that the latter method is superior for detection of axon loss in animals with minor damage.

ABSTRACTBackground:  To evaluate the reproducibility of a new system for grading pupil ruff changes and associated findingsDesign:  Observational comparative studyParticipants:  47 photograph sets including iris, pupil edge and ruff, and inferior anterior chamber drainage angleMethods:  A novel system for recording pupillary ruff changes was developed, along with reference iris, pupil and gonioscopy images. A prospective masked agreement study was undertaken using two observers who graded the photograph sets using this new system. Parameters included pupillary ruff absence and abnormality, pupil edge pigment, trabecular meshwork pigment; Sampaolesi line pigment, iris root pigment and pigment “lumps” and “piles”.Main Outcome Measures:  Intraobserver and interobserver agreement for the parameters of the grading system, assessed with the intraclass correlation coefficient (ICC) and Bland-Altman plots.Results:  Photographs of 47 eyes of 47 glaucoma suspect and glaucoma patients were evaluated. Agreement percentages of ≥95% (average 96%) and ≥60% (average 70%) were obtained for intraobserver and interobserver agreement respectively. The average interobserver single measure ICC and repeat measures ICC was 0.75 (range 0.54-0.88) and 0.85 (range 0.70-0.94) respectively. There was a non-significant trend towards interobserver systematic bias on one of the nine parameters (iris stroma pigment at the pupil edge).Conclusions:  This grading system provides a reliable and reproducible system for encoding of clinical signs of pupil ruff atrophy for clinical research.

ABSTRACTBackground:  To evaluate the clinical safety and efficacy of implanted Ferrara intrastromal corneal ring segments (ICRS) in a large sample of patients with ectatic corneal disease.Design:  Retrospective, consecutive case series.Sample:  A total of 1073 eyes of 810 patients consecutively operated from January 2006 to July 2008 were evaluated.Methods:  Two groups were created according to the type of ring implanted: Group I – patients implanted with the 160-degree of arc ring and Group II – patients implanted with the 210-degree of arc ring.Main Outcome Measures:  Uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), keratometry (K), asphericity (Q) and pachymetry at the thinnest point (PTP) of the cornea. All patients were evaluated using a corneal tomography (Oculus Pentacam,USA)Results:  For Group 1 patients, UCVA increased to 20/80, BCVA increased to 20/40, asphericity decreased to -0.35, spherical equivalent decreased to -2.26 D, and keratometry decreased to 45.72 D (p < 0.001 for each compared to preoperative values). For Group 2 patients, UCVA increased to 20/130, BCVA increased to 20/60, asphericity decreased to -0.56, spherical equivalent decreased to -4.14 D, and keratometry decreased to 48.10 D (p < 0.001 for each compared to preoperative values). The 210o ICRS reduced keratometry and asphericity more than did the 160o ICRS. The complication rate was 3.82%.Conclusions:  Ferrara ICRS implantation is safe and effective and has a low complication rate. It can effectively reduce the corneal steepening and improve UCVA and BCVA in patients with keratoconus.

ABSTRACTPurpose:  To study the potential use of human donor anterior lens capsule (AC) as a descemet membrane substrate.Methods:  AC's were recovered from the lenses of 30 cornea donors. Human corneal endothelial cells (HCE) were recovered from the remaining corneal sclera rims of 15 donor corneas used for penetrating keratoplasty. Samples were sorted into 3 groups. Group 1 consisted of 10 samples in which the endothelial cells were allowed to grow on AC's. In Group 2 HCE grew on a collagen membrane and in Group 3 on polystyrene culture plates. Cell density, morphology, and adherence of the cell–capsule complex were evaluated at 1, 4, 7 and 14 days with a phase-contrast microscope, a scanning electron microscope and by histology. Cell viability was quantified by a microscopic live–dead assay. Expression of zonula occludens-1, Na+/K+-adenosine triphosphatase, tissue transglutaminase and vimentin were investigated by immunohistochemistry.Results:  A mean diameter of 10,05 ± 0,13 mm of anterior capsule was obtained as a substrate for cell culture. Endothelial cell density of group 1 was measured at 2455.4 ± 283.8 cells/mm2, which was also comparable to the cell density of the control group. Cell viability was 95% or superior in all groups and multiple cellular interconnections developed between growing cells. Immunohistochemical analysis demonstrated strongly positive staining for all investigated proteins. Electron microscopy confirmed the adherence and monolayer growth of the endothelial cells.Conclusion:  Human donor anterior lens capsule might therefore be a potential scaffold for the ex vivo expansion of human corneal endothelial cells.

ABSTRACTBackground:  To evaluate the level of agreement between intended and measured ablation of the WFO profile corrected by the Wellington nomogram in myopic spherocylindrical corrections and assess its impact on refractive outcomes.Design:  Prospective, university-institute settingParticipants:  86 participants (86 eyes for PRK group) and 86 participants (86 eyes for LASIK group) recruited in a consecutive-if –eligible basis.Methods:  Differences between intended and measured ablation were evaluated with Scheimpflug camera. Refractive outcomes were evaluated by means of postoperative spherical equivalent (postSE), postoperative defocus equivalent (postDE), contrast sensitivity, correction index (CI), difference vector (DV) and index of success (IOS).Main outcome measures:  Correlation of visual outcomes with intended ablationResults:  Both PRK and LASIK groups demonstrated significant over-ablations (16.7 ± 8.5, p < 0.001 & 11.8 ± 18.5, p < 0.001, respectively). Intended ablation was the primary determinant of the measured difference (r-square 0.769 & 0.765, respectively). PRK spherocylindrical corrections over 100µ had significant impact on postSE, postDE, CI, DV and IOS (p:0.044, p:0.05, p:0.019, p:0.016, p:0.006, respectively), while LASIK spherocylindrical corrections over 100µ had significant impact only on postDE, DV and IOS (p:0.04, p:0.05). Measured differences had no impact on the number of re-treatments or ectasias (none observed) or contrast sensitivity.Conclusions:  The results suggest that the WFO profile seems to over-ablate corneal tissue both in PRK and LASIK. Over-ablation exerts significant impact on refractive outcomes only in high spherocylindrical corrections that require a significant amount of tissue to be ablated.

ABSTRACTPurpose:  To evaluate the efficacy and tolerance of two different foldable anterior chamber phakic intraocular lenses (IOL) for high myopia.Design:  A prospective interventional case series at the Eye Clinic, Kartal Training and Research Hospital, Istanbul, Turkey.Participants:  Sixty-two eyes of 31 patients received iris-claw lens (group 1) (Artiflex AC 401, Ophtec), and 43 eyes of 22 patients received angle-supported lens (group 2) (I-Care, Corneal).Methods:  The mean preoperative spherical equivalents (SE) for group 1 and group 2 were -12.13 diopter and -18.95 diopter, respectively. Endothelial cell density (ECD) was measured at day 1 and at 1, 3, 6, 12 and 18 months for follow-ups.Main outcome measures:  Percentage change in ECD and improvement in visual acuity (VA).Results:  Mean age of group 1 and 2 were 29.2 ± 7.6 (range, 16 to 45) and 31.6 ± 5.2 (range, 20 to 40), respectively. At the eighteen-months follow-up, uncorrected VA improved to logMAR 0.37 ± 0.23 from 1.60 ± 0.10 in group 1, and logMAR 0.47 ± 0.14 from 0.70 ± 0.20 in group 2, best spectacle corrected VA improved to logMAR 0.23 ± 0.22 from logMAR 0.36 ± 0.14) in group 1, and logMAR 0.29 ± 0.18 from logMAR 0.50 ± 0.20) in group 2 (p < 0.001, in both groups). Mean decreased ECD was 241 cells/mm2(8.61%) and 223 cells/mm2 (8.42%) at eighteen months follow up in group 1 and 2, respectively (p = 0.17) but significant in comparison to preoperative values for both groups (p < 0.001).Conclusions:  Although both iris-claw and angle-supported lenses offer good refractive outcomes significant ECD was observed at eighteen months follow-up.

ABSTRACTBackground:  The present study compared the effects of adjuvant bevacizumab and 5-fluorouracil (5-FU) on the efficacy and safety of trabeculectomy.Design:  A nonrandomized, prospective, interventional case study.Participants:  62 patients in 2 groups undergoing primary trabeculectomy.Methods:  In Group 1 (21 POAG, 9 PEXG), trabeculectomy was performed with an adjuvant 5% solution of 5-FU administered for 4 min. intraoperatively. In Group 2 (21 POAG, 11 PEXG), trabeculectomy was enhanced with 1.25 mg of bevacizumab applied subconjunctivally immediately before and after surgery and again 1 and 7 days after surgery.Main outcome measures:  IOP, BCVA, VFI, bleb morphology, cornel endothelial cell count.Results.  Mean IOP was 28.0 ± 8.0 mmHg before 5-FU-augmented trabeculectomy and 27.8 ± 9.5 mmHg before bevacizumab-augmented trabeculectomy. After 6 months, mean IOP was 13.4 ± 4.6 mmHg in the 5-FU group and 13.7 ± 5.2 mmHg in the bevacizumab group. After 12 months, mean IOP was 13.6 ± 4.4 mmHg in the 5-FU group and 14.7 ± 4.7 mmHg in the bevacizumab group. A 30% reduction of initial IOP was attained in 86.7% of patients in the 5-FU group and 78.1% of patients in the bevacizumab group at the end of follow-up. No significant differences were noted between the 2 studied groups with respect to corneal endothelial density, visual field indices and postoperative complications.Conclusions.  The twelve-month IOP results showed no significant differences between the 2 groups of patients after bevacizumab or 5-FU to augment trabeculectomy. However, to obtain successful IOP control more patients in bevacizumab group needed medical therapy.

ABSTRACTBackground: To investigate the effect of adding Indocyanine Green (ICG) to Mitomycin C (MMC) in augmented trabeculectomyDesign: A prospective, non-comparative interventional case seriesParticipants: 37 eyes of 37 patients followed up for one yearMethods: A solution containing 12.5 mg/mL of ICG was added to MMC, resulting in an MMC concentration of 0.2-0.4 mg/mL, which was applied to bare sclera and Tenon's capsule for 3 minutes during trabeculectomy.Main outcome measures: Visual acuity, intraocular pressure (IOP), bleb morphology, Moorfields Bleb Grading System (MBGS) scores, complicationsResults: ICG could be visualised on clinical examination for all eyes on the first postoperative day. Mean IOP decreased from 22.9 ± 6.2 mm Hg to 12.1 ± 4.4 mm Hg postoperatively (P < 0.001) at one year. 34 eyes (91.9%) achieved an IOP of less than 21 mmHg at final visit without additional topical IOP-lowering medications. 3 eyes (8.1%) developed bleb failure and required Baerveldt device implantation. There were no cases of blebitis or late bleb leak. No adverse effects attributable to ICG could be identified postoperatively.Conclusion: The addition of ICG during trabeculectomy improves the visibility of antimetabolites intraoperatively and allows for the estimation of antimetabolite treatment area intraoperatively and postoperatively. It appears to have no adverse effect on surgical outcomes and complication rates, while improving safety of antimetabolite use.

AbstractAlthough considerable recent work on hereditary eye diseases in Tasmanian families has been published, much of this depended on a century of meticulous pedigree collection by earlier clinical researchers. This article reviews some of the historical papers and the importance they have played in gene discovery and understanding of ophthalmic genetics. Tasmanian families have contributed to the identification of genes for X-linked megalocornea, Leber's hereditary optic neuropathy, retinitis pigmentosa, congenital cataract, ptosis, keratoconus, glaucoma and myopia. The true value of the Tasmanian pedigrees will be realized with the translation of genetic discoveries into early diagnosis and treatment for these eye diseases.

AbstractIntroduction:  Orbicularis oculi (OO) muscle has recently proposed as a suitable muscle for biopsy to diagnose mitochondrial cyopathy:Methods:  Enzyme histochemical and immunohistochemical studies were performed on OO muscle obtained from 18 patients aged 37–87 years (median 64 years), 6 males, 12 females, who were undergoing routine upper blepharoplasty surgery.Results:  We confirmed the marked type II fibre (fast myosin heavy chain) predominance (89%) but also noted a different proportion and distribution of mitochondria in these fibres with occasional pseudo-‘ragged-red’ fibres with prominent subsarcolemmal and cytoplasmic aggregation of mitochondria. Cytochrome oxidase-negative fibres and true ‘ragged-red’ fibres were found at all ages over 40 years at levels that approach those used for diagnosis of mitochondrial cytopathy in peripheral or limb skeletal muscles.Conclusion:  We would therefore urge caution in the use of OO as muscle biopsy for diagnosis of mitochondrial cytopathy and advise concomitant biopsy of limb skeletal muscle and/or supplementary genetic studies.

AbstractBackground:  To report the prevalence of current and previous uveitis within the indigenous population living within Central Australia.Design:  Population-based cross-sectional study in Central Australia.Participants:  One thousand eight hundred and eighty-four subjects who identified themselves as indigenous Australians, presenting to the remote clinics during the 36-month period between July 2005 and June 2008.Methods:  Clinical assessments for active or previous uveitis were performed. Data were collected using a standardized form.Main Outcome Measures:  Prevalence of various types of uveitis.Results:  Four of 1881 subjects had evidence of previous or current anterior uveitis, giving a prevalence for anterior uveitis of 0.21% (95% confidence interval, 0.01–0.42%). Eleven of 1854 patients had signs of previous posterior uveitis, giving a prevalence for posterior uveitis of 0.59% (95% confidence inteval 0.24–0.94%). Nine of the 11 patients with posterior uveitis cases (82%) had presumed toxoplasma retinochoroiditis. There were no cases of intermediate uveitis or panuveitis observed in this study. There were no observed cases consistent with well-recognized clinical uveitic syndromes, such as Behçet's disease or Vogt–Koyanagi–Harada syndrome.Conclusions:  A distinct pattern of uveitis appears to be present among indigenous population of remote Central Australia. Posterior uveitis was commoner than anterior uveitis with a predominance of toxoplasma retinochoroiditis. Environmental factors appeared to be more important in this genetically distinct population, with infective causes and ocular trauma being the most common aetiologies of uveitis.

AbstractCataract extraction in primary open angle glaucoma has not been thought to provide a clinically useful or predictable decrease in IOP. This concept has now been challenged, with the opposite belief being promulgated: namely, that lens exchange should be considered as treatment for glaucoma. This revelation could bring a significant change in the glaucoma treatment paradigm.There are no randomised controlled trials to guide the role of lens extraction in primary open angle glaucoma. The available evidence suggests at most a modest reduction in IOP from cataract extraction – greater in the presence of pseudoexfoliation – which is likely to be of marginal benefit, and only in milder forms of open angle glaucoma. There is currently no evidence of any quality to suggest that lens extraction routinely represents a clinically useful treatment for primary open angle glaucoma.

AbstractBackground:  To determine if gender inequities exist in Latin America in regard to cataract surgery.Design:  Meta-analysis.Participants:  Total of 38 992 subjects participating in epidemiological surveys; summary measures were used (not patient-level data).Methods:  A literature search and knowledge of rapid assessment of cataract surgical services/rapid assessment of avoidable blindness studies carried out in Latin America found 11 studies with complete cataract surgical coverage (CSC) data. Using summary original study data, a meta-analysis (random effects model) was conducted to analyse the differences in CSC between males and females. Results were adjusted for design effect.Main Outcome Measures:  Odds ratio (OR) of receiving cataract surgery comparing women with men.Results:  CSC with a visual acuity (VA) <3/60 on an eye basis showed a non-statistically significant OR of 1.01 (95% confidence intervals [CI]: 0.86–1.18) for women receiving cataract surgery in comparison with men. For VA < 6/18, a non-statistically significant OR of 0.94 (95% CI: 0.83–1.07) was obtained for women receiving cataract surgery. On a person basis at a VA of <3/60 and <6/18, non-statistically significant ORs of 1.12 (95% CI: 0.78–1.63) and 0.94 (95% CI: 0.77–1.15) were obtained for women receiving cataract surgery, respectively. Statistical heterogeneity was 0% (I2 statistic), except for results at a VA of <3/60 on a person basis (I2 = 30%).Conclusions:  In the Latin American countries in which CSC was assessed, gender does not appear to be a significant factor in receiving cataract surgery. However, more data are required to confirm these results.

AbstractOne of the key responsibilities of professional bodies, such as the Royal Australian and New Zealand College of Ophthalmologists, is to determine, teach and assess the competencies required for trainees to reach an expert level. Vocational training programs (VTP) need to incorporate advances in educational research and reflect changes in generational thinking and learning styles to provide the most optimal learning environment to meet the desired educational outcomes. This paper seeks to introduce some of the important concepts of adult educational theory and to explain how they connect to four strategic areas in the development and implementation of the VTP:1 What are the learning needs of trainees?2 What educational methods best address these needs?3 What assessment methods best test the acquisition of the desired learning outcomes?4 What are the needs of supervisors and teachers?

AbstractBackground:  Despite increasing knowledge of the genetic pathophysiology of glaucoma, mutations in known genes account for less than 15% of disease. Gene screening predominantly remains a research tool rather than an essential part of the clinical work-up. We aimed to determine the mutational spectrum and frequency in the genes implicated in glaucoma, in a range of glaucoma and ‘glaucoma suspect’ (GS) participants, with a positive family history.Methods:  Observational large case series. One hundred fifteen patients recruited from public hospital and private clinics had diagnoses of GS, ocular hypertension, pseudoexfoliative glaucoma (PXG) or primary open-angle glaucoma (POAG), and at least one affected family member. In a university laboratory, DNA samples were screened for mutations in all coding exons of MYOC and CYP1B1, and OPTN (exons 4, 5 and 16). WDR36 (exons 1, 4, 5, 8, 11, 13 and 17) was screened in those with CYP1B1 changes. LOXL1 risk variants were screened in PXG pedigrees. Cascade screening of family members was undertaken.Results:  Seven out of one hundred fifteen (6.1%) individuals had at least one pathogenic or hypomorphic CYP1B1 allele associated with GS, POAG (5) and PXG phenotypes, including two novel sequence variations (p.Ser6Gly, p.Val243Leu). No pathogenic MYOC change was detected. Five individuals (4.3%) carried an OPTN sequence variation. Three of the seven with CYP1B1 changes had polygenic changes.Conclusions:  Mutational analysis of known glaucoma genes in a mixed glaucoma population replicates the reported frequency of pathogenic CYP1B1 changes. Heterozygous CYP1B1 changes occurred at a greater frequency than other genes. Glaucoma pathogenesis in the clinic setting is genetically heterogeneous and may be polygenic.

AbstractThe purpose of this paper was to analyse the causes, pathogenesis, diagnostic modalities and treatment outcomes of microsporidial keratoconjunctivitis (MKC). Microsporidia are increasingly recognized as opportunistic infectious pathogens in immunocompromized patients causing keratoconjunctivitis. In the recent years, there has been a surge in reports of MKC in immunocompetent individuals presenting with stromal keratitis. A detailed literature search was done using Medline, OVID, Cochrane Library, UptoDate and Google Scholar databases with the terms microsporidia, keratitis, conjunctivitis, immunocompromized and immunocompetent. The articles were reviewed to determine the spectrum of clinical presentation, disease course, investigations, treatment modalities and outcome. Thirty-six publications were reviewed, and 151 cases of MKC were included for this review. The main presenting features included pain, redness, photophobia, epiphora and blurring of vision. Duration of the symptoms lasted between 4 days and 18 months. Light microscopy with modified trichrome stain was most commonly used to diagnose MKC. Resolution of symptoms was most commonly achieved with oral albendazole and/or topical fumidil B. Topical fluoroquinolones are also effective as a monotherapy as suggested by recent studies. Clinical outcome was good (visual acuity ≤ 6/12) for the patients who presented earlier (≤1 month) (75% of cases with documented final best-corrected visual acuity). MKC occurs more commonly in immunocompetent individuals than expected and can be diagnosed in earlier stages. From our review, we conclude that the patients, who were diagnosed early and treated, had complete resolution of symptoms with a better clinical outcome.

AbstractBackground:  The prevalence of blind individuals in the north of China is unknown. The study aimed to investigate the prevalence and causes of blindness and low vision in rural areas in Heilongjiang province of China in 2008–2009.Design:  Cross-sectional study.Participants or Samples:  A cluster random sampling method was used to recruit participants of all ages in rural areas of Heilongjiang.Methods:  Trained professionals performed interviews and clinical examinations to measure visual acuity. The relationships between blindness or low vision and age, gender and education level were analysed.Main Outcome Measures:  The main outcome measure was prevalence rates of bilateral blindness and bilateral low vision.Results:  Of the 11 787 subjects, 10 384 (88.1%) were surveyed. The overall age-adjusted prevalence rates were 0.7% (95% confidence interval: 0.5–0.8%) for bilateral blindness and 1.7% (95% confidence interval: 1.4–1.9%) for bilateral low vision. The prevalence rates of blindness and low vision were higher in the elderly and uneducated population (P < 0.05). The main causes for blindness and low vision were cataracts (44.1 and 46.0%, respectively) and refractive errors (17.7 and 42.5%, respectively).Conclusion:  Blindness and low vision are highly prevalent among people with cataracts and refractive errors. Eye care planning must focus on treating the avoidable and curable forms of blindness.

AbstractBackground:  Pseudoexfoliation syndrome (XFS) has been found to occur more commonly among indigenous Australians. This paper was designed to determine the prevalence of XFS within the indigenous Australian population living in central Australia.Design:  Clinic-based cross-sectional study.Participants:  One thousand eight hundred eighty-four individuals living in one of 30 remote communities within the statistical local area of ‘Central Australia’ were recruited. This equated to 36% of those aged 20 years or older and 67% of those aged 40 years or older within this district.Methods:  Participants aged 20 years or over were recruited as they presented to the eye clinic at each remote community. Slit-lamp examination was performed, and the presence of XFS in each eye was recorded and presented.Main Outcome Measure:  Prevalence and associations of XFS.Results:  XFS was present in one or both eyes of 4.7% of the individuals recruited into the study. Prevalence increased with age (5.9% of those ≥40 years and 12.7% ≥ 60 years). There was a significant association between the presence of XFS and climatic keratopathy (χ2 = 240.13; P < 0.00001). Notably, none of those with XFS had ocular hypertension or glaucoma.Conclusion:  XFS was present in a significantly higher proportion of indigenous Australians compared with previously reported prevalence estimates among non-indigenous Australians. The association found between XFS and climatic keratopathy may represent a common causal link between the two conditions. The lack of association of XFS with ocular hypertension and glaucoma appears to be a unique feature of the indigenous Australian population, and this merits further investigation.

AbstractObjective:  To clarify the role of IGF-2 on the development of myopia, the dynamic expression of IGF-2 was investigated in the FD eyes’ retina, and the effects of intravitreous injection with IGF-2 ASON was studied on the diopter and axial eye length of FD eyes.Methods:  64 guinea pigs were divided into 2 groups. In group A (n = 24), the right eyes were covered. On days 7, 14 and 21, the diopter, axial eye length and level of IGF-2 of both eyes were measured in every 8 guinea pigs. In group B (n = 40), the right eyes were covered. On day 1, the right eyes were received intravitreal injection with 40 µg IGF-2SON, 10 µg, 20 µg or 40 µg IGF-2 ASON. The diopter, axial eye length and level of IGF-2 were measured on day 14.Results:  FD eyes showed myopic shift, axial length enlongation, and up-regulation in retinal IGF-2 from day 7 to day 21. The level of retinal IGF-2 in FD eyes was higher than that in non-FD eyes. Compare with FD eyes without injection, the myopia diopter of FD eyes decreased in received intravitreous injection with IGF-2 ASON, axial length shortened, and down-regulated with retinal IGF-2. With the increase dose of IGF-2 ASON, the change of myopic diopter, axial length, and level of retinal IGF-2 were showed more and more significant.Conclusions:  FD is effective to up-regulate the level of retinal IGF-2 expression in guinea pig. Intravitreous injection with IGF-2 ASON can inhibit the development of myopia.

AbstractBackground:  To investigate the indications for corneal transplantation and the distribution of donor corneal tissue in New Zealand.Design:  Analysis of the prospective database of the New Zealand National Eye Bank.Participants:  A total of 2205 corneal transplants were assessed.Methods:  New Zealand National Eye Bank records were analysed for the decade 2000–2009.Main Outcome Measures:  Variables analysed included donor corneal tissue distribution (including public and private sectors), indications for transplantation, donor corneal tissue recipient demographics (age and gender) and corneal transplantation type.Results:  An average of 220 corneal transplants were performed each year over the 10-year period (n = 2205). The median recipient age was 45 years (range 3 to 102 years) and 54.0% of recipients were male. In total 71.8% of transplants were performed in the public health sector. Surgeons in the Auckland metropolitan area performed 47.2% of all corneal transplants. The most common indications for corneal transplantation were: keratoconus (41.1%), repeat transplant (17.0%), aphakic/pseudophakic bullous keratopathy (13.9%), corneal dystrophy (10.7%), keratitis (7.9%) and trauma (3.7%). Overall, penetrating keratoplasty accounted for 90.7% of all corneal transplants, however, during the latter half of the study there was a progressive shift in transplantation type, with deep anterior lamellar keratoplasty and Descemet's stripping endothelial keratoplasty combined accounting for 32.3% of all transplants in the final year of the study period.Conclusions:  This New Zealand National Eye Bank study provides valuable data regarding the indications for corneal transplantation, transplant recipient demographics and changes in transplantation type in New Zealand over the past decade.

AbstractBackground:  We aimed to investigate the performance of five different trend analysis criteria for the detection of glaucomatous progression and to determine the most frequently and rapidly progressing locations of the visual field.Design:  Retrospective cohort.Participants or Samples:  Treated glaucoma patients with ≥8 Swedish Interactive Thresholding Algorithm (SITA)-standard 24-2 visual field tests.Methods:  Progression was determined using trend analysis. Five different criteria were used: (A) ≥1 significantly progressing point; (B) ≥2 significantly progressing points; (C) ≥2 progressing points located in the same hemifield; (D) at least two adjacent progressing points located in the same hemifield; (E) ≥2 progressing points in the same Garway-Heath map sector.Main Outcome Measures:  Number of progressing eyes and false-positive results.Results:  We included 587 patients. The number of eyes reaching a progression end–point using each criterion was: A = 300 (51%); B = 212 (36%); C = 194 (33%); D = 170 (29%); and E = 186 (31%) (P ≤ 0.03). The numbers of eyes with positive slopes were: A = 13 (4.3%); B = 3 (1.4%); C = 3 (1.5%); D = 2 (1.1%); and E = 3 (1.6%) (P = 0.06). The global slopes for progressing eyes were more negative in Groups B, C and D than in Group A (P = 0.004). The visual field locations that progressed more often were those in the nasal field adjacent to the horizontal midline.Conclusions:  Pointwise linear regression criteria that take into account the retinal nerve fibre layer anatomy enhances the specificity of trend analysis for the detection glaucomatous visual field progression.

AbstractBackground:  To provide an update on the frequency, distribution, risk factors and in vitro susceptibility of ocular infections caused by non-tuberculous mycobacteria.Design:  Retrospective study of university clinic patients.Participants:  One hundred thirty-nine patients with culture confirmed non-tuberculous mycobacteria infections seen at Bascom Palmer Eye Institute from January 1980 to July 2007.Methods:  Chart review of data collected included patients' demographics, risk factors, microbiological profiles and clinical outcomes.Main Outcome Measures:  Frequency, distribution, risk factors and in vitro susceptibility of ocular infections caused by non-tuberculous mycobacteria.Results:  A total of 183 non-tuberculous mycobacteria isolates from 142 eyes were identified, with a fourfold increase in the number of eyes infected with non-tuberculous mycobacteria from 1980–1989 (13.4%) to 2000–2007 (56.3%). Eighty-three percent of non-tuberculous mycobacteria isolates were identified as M. abscessus/chelonae. The majority (91%) of isolates were recovered within 10 days. Common diagnoses included keratitis (36.6%), scleral buckle infections (14.8%) and socket/implant infections (14.8%). Identifiable risk factors were presence of biomaterials (63.1%), ocular surgery (24.1%) and steroid exposure (77%). The median time from diagnosis of culture positive non-tuberculous mycobacteria infection to resolution was 13 to 24 weeks. Combination therapy was used to treat 80% of infected eyes. In vitro susceptibility of non-tuberculous mycobacteria isolates were: amikacin, 81%; clarithromycin, 93%; and moxifloxacin, 21%.Conclusions:  The incidence of ocular infections caused by non-tuberculous mycobacteria has increased within the last 8 years, with a high number of biomaterial associated infections among this group. Clinical diagnosis and microbiological confirmation of non-tuberculous mycobacteria infections remains challenging. Patient outcomes may be improved by early diagnosis, appropriate therapy and removal of biomaterials.

AbstractBackground:  To evaluate efficacy, safety and predictability of apodized, diffractive multifocal intraocular lenses.Design:  Prospective, observational study.Participants or Sample:  Two hundred three patients (363 eyes) underwent surgery for cataract (54.8%) or clear lens extraction (45.2%).Methods:  A study of consecutive patients undergoing lens extraction with insertion of the AcrySof Natural ReSTOR intraocular lens (SN60D3). Assessment included: refraction, corneal topography, biometry, monocular and binocular uncorrected and best spectacle corrected distance and near visual acuity.Main Outcome Measures:  Visual acuity, spectacle dependence.Results:  Mean preoperative best corrected visual acuity was 6/12 (cataract) and 6/6 (clear lens extraction). One hundred sixty-one (98.2%) of the clear lens extraction group were hyperopic and presbyopic (mean spherical equivalent +4.25±3.5D). Postoperatively uncorrected visual acuity was ≥6/12 in 96.5% of eyes (51.9% ≥6/6) and ≥ N5 in 95% of eyes. At 6 months, 182 eyes (91.4%) (cataract) and 137 eyes (83.5%) (clear lens extraction) were ≤0.50 D of target spherical equivalent. Spectacle independence was reported in 81.9% (n = 168). Minor halos or other visual phenomena were reported in 10.2%. No subjects required intraocular lens exchange. Safety index at 6 months was 2.5 and 1.17 for cataract and clear lens extraction, respectively.Conclusions:  The apodized, diffractive multifocal intraocular lens predictably provided excellent near uncorrected visual acuity and good distance uncorrected visual acuity following cataract and clear lens extraction surgery with a high rate of spectacle independence. A minority of subjects note halos and other visual phenomena that may be related to intraocular lens design.

AbstractBackground:  To determine the change in the prevalence in active trachoma in children in a remote Aboriginal community over a 32-year period.Design:  Data used from two cross-sectional studies repeated in the same community 32 years apart.Participants or Samples:  Children aged 5–13 years living in the community.Methods:  Thirty-five mm photographs of the everted upper lid taken in 1975 and digital photographs taken in 2007 were graded using a fine trachoma-grading scheme.Main Outcome Measure:  The age-specific prevalence and severity of trachoma was compared at the two time points.Results:  Images were available from 82 children in 1975 and from 92 children in 2007. The overall prevalence of active trachoma (trachomatous inflammation follicular and or trachomatous inflammation intense) was 59% in 1975 and in 2007 was significantly lower at 23% (P < 0.001). The overall severity grades of active trachoma had also decreased significantly for each sign from 1975 to 2007 (all P values from the rank-sum test were less than 0.001). However, in 2007, there were still some children with severe active trachoma and severe scarring still occurred.Conclusion:  Although the prevalence and severity of active trachoma in children have decreased significantly over the last 30 years in this community, trachoma still remains a significant public health problem. One third of the children have active trachoma, a figure in excess of the threshold set as a public health problem by the World Health Organization.

AbstractBackground:  To compare the intraocular pressure readings obtained with the iCare rebound tonometer and the 7CR non-contact tonometer with those measured by Goldmann applanation tonometry in treated glaucoma patients.Design:  A prospective, cross-sectional study was conducted in a private tertiary glaucoma clinic.Participants or Samples:  One hundred nine (54 males : 55 females) patients including only eyes under medical treatment for glaucoma.Methods:  Measurement by Goldmann applanation tonometry, iCare rebound tonometry and 7CR non-contact tonometry.Main Outcome Measures:  Intraocular pressure.Results:  There were strong correlations between the intraocular pressure measurements obtained with Goldmann and both the rebound and non-contact tonometers (Spearman r-values ≥ 0.79, P < 0.001). However, there were small, statistically significant differences between the average readings for each tonometer. For the rebound tonometer, the mean intraocular pressure was slightly higher compared with the Goldmann applanation tonometer in the right eyes (P = 0.02), and similar in the left eyes (P = 0.93); however, these differences did not reach statistical significance. The Goldmann correlated measurements from the non-contact tonometer were lower than the average Goldmann reading for both right (P < 0.001) and left (P > 0.01) eyes. The corneal compensated measurements from the non-contact tonometer were significantly higher compared with the other tonometers (P ≤ 0.001).Conclusions:  The iCare rebound tonometer and the 7CR non-contact tonometer measure intraocular pressure in fundamentally different ways to the Goldmann applanation tonometer. The resulting intraocular pressure values vary between the instruments and will need to be considered when comparing clinical versus home acquired measurements.

AbstractBackground:  To find out the relationship between laminar displacement and age between patients with primary open-angle glaucoma and normal tension glaucoma.Design:  Retrospective study conducted at a tertiary university hospitalParticipants or Samples:  Twenty-six eyes of 26 primary open-angle glaucoma patients and 52 eyes of 52 normal tension glaucoma patients.Methods:  Patients were scanned with a Stratus optical coherence tomography apparatus to measure the retinal nerve fibre layer thickness and to visualize the cross-sectional laminar displacement of 12 clock-hour segments, 30 degrees each. Depth1 was defined as the longest distance between the retinal pigment epithelium and the anterior laminar cribrosa surface, which represents the amount of laminar displacement.Main Outcome Measure:  Partial correlation coefficients adjusted by mean deviation and intraocular pressure between (i) retinal nerve fibre layer thickness and age, and (ii) Depth1 and age.Results:  In the primary open-angle glaucoma group, strong negative correlations (approximately −0.343 ∼ −0.738) were found between Depth1 and age. Eight of 12 clock-hour segments' correlations were significant after Bonferroni correction (α = 0.0021; 24 comparisons). However, no significant correlations were found between Depth1 and age in the normal tension glaucoma group. When the correlation coefficients were compared between the two groups, eight clock-hour segments showed significant differences after Bonferroni correction.Conclusions:  The significantly different correlation between laminar displacement and age between primary open-angle glaucoma and normal tension glaucoma patients may suggest a different role of the lamina cribrosa to the disease.

AbstractBackground:  This study sought to inhibit herpes simplex virus type 1 replication using small interfering RNA which targeting infected-cell polypeptide 4 genes to mediate transcription of early and late viral genes in herpes simplex virus type 1 lytic (productive) infection in retina epithelial cells.Methods:  After pre- or post-infecting with herpes simplex virus type 1, small interfering RNAs were transfected into retina epithelial cells. The antiviral effects of small interfering RNA were evaluated by Western blot, plaque assays, indirect immunofluorescence and reverse transcription polymerase chain reaction. The viral titre was detected by the 50% tissue culture infective dose method.Results:  Small interfering RNA decreased infected-cell polypeptide 4 expression in retina epithelial cells that were infected with herpes simplex virus type 1 before or after small interfering RNA transfection. Compared with herpes simplex virus type 1 infection alone or transfection with negative control small interfering RNA, the viral titre and the retina epithelial cell cytopathic effect were significantly decreased in retina epithelial cells transfected with infected-cell polypeptide 4-targeting small interfering RNA (50 and 100 nM) (P < 0.05). The small interfering RNA effectively silenced herpes simplex virus type 1 infected-cell polypeptide 4 expression on both mRNA and the protein levels (P < 0.05). The inhibition of infected-cell polypeptide 4-targeting small interfering RNA on infected-cell polypeptide 4 protein expression was also verified by Western blot in herpes simplex virus type 1 infected human cornea epithelial cell, human trabecular meshwork cells and Vero cells.Conclusions:  Infected-cell polypeptide 4-targeting small interfering RNA can inhibit herpes simplex virus type 1 replication in retina epithelial cells, providing a foundation for development of RNA interference as an antiviral therapy.

AbstractBackground:  The accuracy and impact on service uptake of early examination after cataract surgery is not known.Design:  Prospective cohort study.Participants:  Cataract patients in rural IndonesiaMethods:  Visual acuity was measured preoperatively, 1 day, 1–3, 4–6 and >12 weeks after surgery, and 6–8 months postoperatively at an outreach examination. Acceptance of second-eye surgery and spectacles was evaluated.Main outcome measure:  Presenting visual acuity in the operated eye.Results:  Among 241 subjects (extracapsular surgery 84%), examinations at 1 day, 1–3, 4–6 and >12 weeks and 6–8 months were completed for 100% (241), 90.9% (219), 67.6% (163), 22.0% (53) and 80.0% (193), respectively. Among subjects at the final examination (mean age 65.8 ± 10.6 years, 51.8% male), 73.6% had bilateral preoperative presenting visual acuity ≤ 6/60. By 4–6 weeks, the proportion with good (≥6/18) or poor (≤6/60) visual acuity did not differ significantly from the final examination. Among 49 persons accepting free second-eye surgery, 69.4% (34) and 16.3% (8) returned to clinic at 4–6 and >12 weeks, respectively. Among 131 patients (67.9%) paying US$7 for glasses, 94 (71.8%) and 30 (22.9%) attended 4- to 6- and >12-week examinations, respectively.Conclusion:  Even with large-incision surgery, early assessment of postoperative vision is representative of final vision, and may help deliver postoperative services to more of those needing them.

AbstractBackground:  To assess the distribution of iris structural measurements among American Caucasians, American Chinese and mainland Chinese aged 40 years and over, in order to determine associated factors of increased risk for angle closure in Chinese.Design:  Prospective multicentre cross-sectional study.Participants:  Four gender- and age-matched cohorts: Caucasians, American Chinese, Southern Chinese from Guangzhou and Northern Chinese from Beijing were enrolled in this study.Methods:  Anterior segment optical coherence tomography was utilized to image the anterior chamber. Customized software was used to calculate the related parameters from anterior segment optical coherence tomography images.Main Outcome Measures:  Iris thickness at 750 µm from the scleral spur, iris curvature, iris area, pupil diameter.Results:  Data from 121, 124, 121 and 120 subjects were available for American Caucasian, American Chinese, Southern and Northern Mainland Chinese subjects, respectively. The Chinese cohorts did not differ with regard to any of the parameters. Multiple linear regressions indicated that Caucasians had thinner iris thickness at 750 µm from the scleral spur and smaller iris area than Chinese after controlling for potential confounders. Female Caucasians had thinner irides (P = 0.015) and smaller iris area (P = 0.001) than male Caucasians. Female Chinese tended to have more convex irides (P = 0.021) than male Chinese. Pupil size was inversely associated with age (P < 0.001) in both ethnicities.Conclusions:  In dark conditions, Chinese have thicker irides and greater iris area than Caucasians independent of pupil size. Among Chinese, more convex irides in women may account for the higher rate of narrow angles identified in this segment of the Chinese population.

AbstractBackground:  To analyse the anatomy of the medial canthal tendon in Caucasians and to clarify the true anatomical nature of its posterior limb.Methods:  This was an experimental anatomic study. Seven Caucasian cadavers (11 eyelids; age range: 78–101 years at death). Anatomical dissection and histological examination of cadaveric eyelids fixed in 10% buffered formalin was performed. The axial sections were made in parallel with the eyelid margin at 1 mm superior or inferior to the upper or lower eyelid margins, respectively. The histological specimens were first dehydrated and embedded in paraffin and then divided into 7 µm thickness sections and stained with Masson's trichrome. Microscopic photographs were taken with a digital camera system attached to the microscope.Results:  The posterior limb of the medial canthal tendon was not detected in any of the specimens. The medial check ligament supported the posterior aspect of Horner's muscle and inserted into the medial orbital wall through the periosteum. The lacrimal diaphragm around the posterior lacrimal crest ran almost parallel to Horner's muscle and was usually difficult to distinguish from the tendon of Horner's muscle.Conclusions:  The posterior limb of the medial canthal tendon was not detected in any of the studied specimens. This anatomical structure appears to be Horner's muscle, and the lacrimal diaphragm.

AbstractBackground:  To evaluate long-term outcomes and complication rates following trabeculectomy with mitomycin C in a case series of African Caribbean patients.Design:  A prospective, observational and non-comparative case series.Participants:  Forty-seven consecutive African Caribbean patients (47 eyes) with glaucoma.Methods:  All patients underwent augmented trabeculectomy with mitomycin C for uncontrolled intraocular pressure (IOP). Survival analysis was performed with a minimum of 12 months' follow up.Main Outcome Measures:  Surgical success was based upon IOP reduction to ≤21 mmHg, ≤18 mmHg and ≤15 mmHg without glaucoma medication (complete); or IOP reduction to ≤21 mmHg, ≤18 mmHg and ≤15 mmHg with or without glaucoma medication (qualified).Results:  The mean follow-up period was 48.6 months. At 3 years post-trabeculectomy 92.6% achieved a qualified success and 59.3% a complete success for an IOP ≤21 mmHg. At final follow up the mean IOP reduced from 33.7 mmHg to 13.1 mmHg (P < 0.0001). Survival rates were 96%, 90% and 86% at 12, 24 and 36 months, respectively, with a mean survival time of 97.4 months (95% confidence interval, 86.0–108.8) for an IOP ≤21 mmHg. Early postoperative hypotony requiring surgical intervention occurred in four (8.5%) patients. There were no cases of blebitis, endophthalmitis, suprachoroidal haemorrhage, malignant glaucoma or hypotony maculopathy.Conclusions:  Good long-term stable IOP can be achieved with low complication rates and high success rates amongst African Caribbean patients following trabeculectomy with mitomycin C. A proactive postoperative management regime is needed to ensure trabeculectomy survival in high-risk populations.

AbstractBackground:  Descement Stripping Endothelial Keratoplasty has been associated with a steep learning curve. Angle closure post Descement Stripping Endothelial Keratoplasty has been reported, either because of air posterior to the iris causing iridocorneal adhesions, or by air anterior to the iris causing pupillary block. The mechanics of floppy iris syndrome and pupil block have not been discussed.Methods:  We evaluated the various forces competing within the anterior chamber via mathematical modelling and computational simulation, and considered the influence of floppy iris on pupil block glaucoma.Results:  Energy formulae suggest a critical pressure value will maintain normal anterior chamber relationships, above which abnormal iris buckling may occur. This mechanical instability can be influenced intraoperatively by abnormal iris properties and intracameral forces (such as air). This critical value is lowered if the patient has a floppy iris (because of a lower elastic modulus, a mechanical measure of iris rigidity). To demonstrate this mathematical concept, a 3-D computational model was built. Simulations show that, as intracameral pressure increases, the iris ring can buckle into predictable modes of shapes.Conclusion:  This model shows how iris buckling could occur with an intracameral air bubble leading to posterior iris displacement and mechanical pupil block. It also shows that abnormal iris behaviour in IFIS is consistent with the expected predicted buckling of an elastic disc.

AbstractBackground:  The mouse corneal stroma varies in thickness across its diameter. The purpose of the present study was to explain this variation and to advance our understanding of stromal lamellar architecture in the mammalian cornea.Methods:  Eight C57BL/6 mice were killed, eyes enucleated, immersed in 2% glutaraldehyde fixative, processed and sectioned transversely for light and transmission electron microscopy. Transmission electron micrographs were assembled into montages and printed at 5000× magnification and used for lamellar counts and thickness assessments.Results:  The mouse cornea had an average of 49.8 ± 2.4 lamellae centrally averaging 2.1 µm in thickness versus 35.5 ± 3.0 lamellae, averaging 1.9 µm in thickness peripherally. The central to peripheral decrease in number lamellae and lamellar thickness measured utilizing the transmission electron microscope was statistically significant (P < 0.005).Conclusions:  This study demonstrated that the thickness difference between the thicker central and thinner peripheral mouse cornea is explained primarily by the number of lamellae present and that the peripheral lamellar dropout occurred in the anterior 2/3 of stroma. The decreased lamellar count towards the periphery suggested that not all lamellae cross the cornea limbus to limbus. These findings may be relevant to the thickness variation of the human cornea.

AbstractBackground:  To evaluate the intra-test variability of ARK-30 handheld autorefractor and the agreement with subjective refraction and retinoscopy after uneventful cataract surgery.Design:  Prospective and non-randomized study that included 6 visits by patients undergoing uneventful cataract surgery at IOBA (Instituto de Oftalmobiología Aplicada) Eye Institute (University of Valladolid).Participants:  The mean age of the 79 patients was 66.5 years (range 23–90 years). For the 124 eyes, the mean spherical equivalent of the sample at baseline visit was −3.59 ± 6.28 D (range −21.00 D to +4.44 D).Methods:  Automated refraction was performed on follow-up visits 1 day and weekly for 4 weeks. Retinoscopy and subjective refraction were conducted at the Week 4 follow up.Main Outcome Measures:  Automated refraction.Results:  Sphere, cylinder and mean spherical equivalent, J0 and J45 coefficient variabilities were low in all visits. Standard deviations and the limits of agreement were smallest for the last visit. Subjective refraction sphere and cylinder values were more positive than autorefraction by 0.12 ± 0.53 D (P = 0.031) and 0.23 ± 0.42 D (P < 0.001), respectively. Comparison between autorefraction and retinoscopy showed a similar trend with the sphere and cylinder differences, 0.32 ± 0.77 D and 0.38 ± 0.43 D (P < 0.05), respectively.Conclusions:  The ARK-30 is sufficiently accurate and repeatable for automated refraction after uneventful cataract surgery. This instrument may be useful for monitoring refractive outcome in these patients.

AbstractThis paper aims to review the current methods available for the measurement of intraocular pressure after myopic laser in situ keratomileusis for the correction of myopia. Searches were performed for studies that assessed or compared various methods of intraocular pressure assessment. There were 20 eligible studies that explored the use of pneumotonometry, pressure phosphene tonometry, rebound tonometry, dynamic contour tonometry, statistical modeling, mathematical formulae, ocular response analyzer and even measuring intraocular pressure on the nasal cornea. Our review shows that an ideal method would be one that is independent of corneal factors. Dynamic contour tonometry and pressure phosphene tonometry held promise in research settings. More studies need to be done to validate the new methods of intraocular pressure assessment, especially in glaucoma patients. It is important to empower laser in situ keratomileusis patients with knowledge of these difficulties and potential implications for the future.

AbstractBackground:  Postoperative cystoid macular oedema is a complication of uneventful cataract surgery. Whereas improved surgical techniques have decreased the incidence of cystoid macular oedema, it remains a cause of unfavourable visual outcome following surgery. Fundus fluorescein angiography has been the ‘gold standard’ for diagnosing subclinical cystoid macular oedema; however, non-invasive cross-sectional imaging of the retina with optical coherence tomography may be equally effective at detecting the condition and offers the ability to quantify and repeat results over time.Design:  Prospective pre–post case series of patients undergoing routine phaco-emulsification surgery.Participants:  Eighty consecutive patients (100 eyes) with cataracts and an age range of 40 to 90 years (mean 76.18).Methods:  Macular thickness of participants was determined using time-domain optical coherence tomography preoperatively and after surgery at 1 day, 1 week, 4 weeks and 6 months. Optical coherence tomography was used to diagnose postoperative cystoid macular oedema.Main Outcome Measures:  Presence of cysts at the macula, identified by optical coherence tomography, in addition to foveal and macular thickness (µm).Results:  Cystoid macular oedema was present in 5% of eyes. Macular thickness increased after surgery and central foveal thickness increased by almost 7% but returned to preoperative levels after 6 months. Findings also indicate that patients who developed postoperative cystoid macular oedema had significantly thicker central foveal thickness of approximately 5% compared with those that did not.Conclusions:  Optical coherence tomography is a useful, non-invasive diagnostic tool in determining subclinical cystoid macular oedema in uncomplicated cataract surgery patients and detects the presence of retinal thickening and intra-retinal cysts very soon after surgery, thereby facilitating earlier diagnosis and treatment of postoperative cystoid macular oedema.

AbstractBackground:  To assess agreement between the Diaton, a new transpalpebral tonometer, and Goldmann applanation tonometry, the accepted gold standard.Design:  Comparative study of two devices in a hospital setting.Participants:  Two hundred and fifty-one patients attending the eye casualty and general ophthalmology clinics at St James' University Hospital, Leeds between February and December 2009.Methods:  Intraocular pressure was measured using Goldmann applanation tonometry and Diaton tonometry by one examining ophthalmologist. Patient preference for either technique was also recorded.Main Outcome Measures:  Intraocular pressure measured by Diaton was compared with intraocular pressure measured by Goldmann applanation tonometry. Limits of agreement were determined using the Bland-Altman method.Results:  Two hundred and fifty right eyes underwent both Goldmann applanation tonometry and Diaton tonometry. Mean intraocular pressure was 13.8 ± 3.6 mmHg using Goldmann applanation tonometry and 13.2 ± 4.3 mmHg using Diaton tonometry. Upper and lower limits of agreement were +8.4 mmHg and −9.6 mmHg, respectively. Order of intraocular pressure measurement and positioning did not influence limits of agreement in a clinically significant manner. Overall, more patients expressed preference for Diaton tonometry (40.2%) than Goldmann applanation tonometry (30.3%). Those aged 50 or less were more likely to prefer Diaton tonometry.Conclusions:  The Diaton tonometer is portable, lightweight, user-friendly and well tolerated by patients. However, it shows poor agreement with Goldmann applanation tonometry, thereby precluding it from being regarded as a substitute in routine clinical practice.

AbstractBackground:  The prevalence of astigmatism, its axis and determinants were determined in the 40- to 64-year-old population of Shahroud, Iran.Design:  Population-based cross sectional study.Participants:  Using random cluster sampling, 6311 subjects were invited for eye examinations. Of 5190 participants (response rate = 82.2%), data of 5020 were eligible for analysis.Methods:  Participants received visual acuity measurement, manifest refraction and eye examinations.Main Outcome Measures:  The prevalence of astigmatism based on cylinder powers of more than 0.5, 1 and 3 D were studied.Results:  The prevalence (and 95% confidence interval) of astigmatism based on a cylinder power worse than 0.5, 1, and 3 D was 49.1% (47.6–50.5), 24.1% (22.9–25.3), and 3.4% (2.9–3.9), respectively. In a multiple logistic regression model, the prevalence of astigmatism was higher in men (odds ratio = 1.25) and increased with age (odds ratio for each 5 years = 1.21). Higher education was found to be inversely correlated to astigmatism (P < 0.001). The prevalence of with-the-rule, against-the-rule and oblique astigmatism was 12.6%, 25.9% and 10.6%, respectively. Oblique astigmatism was significantly higher in women and the older age groups (P < 0.001). Against-the-rule astigmatism increased with age from 19.9% in the age group of 40–44 to 37.0% in the age group of 60–64 (P < 0.001).Conclusions:  In comparison with those studies conducted in Iran and other countries, the prevalence of astigmatism was higher in this study. Astigmatism was higher in men and age had an important role in astigmatism and its axis. The prevalence of against-the-rule and oblique astigmatism increased with age.

AbstractBackground:  To assess the indications for and graft outcomes of penetrating keratoplasty (PK) in a tertiary hospital in China.Design:  A retrospective analysis of hospital records of patients, who had undergone PK at the First Affiliated Hospital of Zhejiang University in China over a 10-year period, was performed.Participants:  A total of 203 eyes met the inclusion criteria for this study.Methods:  All PKs were performed with a standard technique throughout.Main Outcome Measures:  Outcome measures included best corrected visual acuity at last follow-up, and overall graft survival. Data were assessed by Kaplan–Meier survival methods, univariate analysis and multivariate cox proportional hazards regression modelling.Results:  Among 203 eyes included in this study, the most common indications for PK in this study group were corneal scar caused by herpes simplex keratitis (24.1%) and trauma (mechanical and chemical) (21.2%). At the last follow-up, significantly more patients (35.0%) achieved 20/40 or better after PK compared with preoperation (P < 0.05). Overall, the 2-year graft survival rate was 79.9 ± 3.6%. In a univariate analysis, gender, indications for PK, type of operative procedure, rejection episode, postoperative glaucoma and postoperative herpetic recurrence were shown to be significantly associated with graft survival. In a multivariate analysis, three independent predictors of graft failure were identified including indications, gender and rejection episode.Conclusions:  PK is effectively performed to improve visual function in southeast China. The outcomes of this study concur with other published studies and can be used as prognostic guidelines for any tertiary hospital in developing world.

AbstractOphthalmic population-based studies have been used to establish the frequency of eye disease and the associated environmental and genetic factors that cause vision impairment and blindness. Most of these studies have concentrated on the diseases of ageing: cataract, age-related macular degeneration, glaucoma and diabetic retinopathy. Other studies have identified eye diseases in children but few studies of young adult eye disease exist. We conducted a systematic review of the ophthalmic literature to identify potential population-based eye studies and then note the age of participants in the studies. We then summarized the disease specific to young adults to show there is a need for further research to identify eye disease in this important and often-neglected group in the community. Eighty-four large population-based studies have been conducted worldwide: 9 in North America, 2 in South America, 17 in Africa, 35 in Asia, 11 in Australia and the Pacific, 6 in Europe, 4 in the Middle East and 1 that covered 3 continents. No studies specifically examined young adults. Twenty-six per cent of studies included young adults as part of all ages examined but none of these examined a large number of young adults.

AbstractBackground:  To compare the clinical outcomes in Marfan's with subluxated lens having phaco-emulsification with simultaneous scleral-fixated posterior chamber intraocular lens or iris-fixated anterior chamber intraocular lens implantation.Design:  Randomized case series in the State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China.Participants:  Seventy-one eyes of 49 patients with Marfan's syndrome with subluxated lens.Methods:  This is a randomized case series of patients with Marfan's syndrome and subluxated lenses who underwent phaco-emulsification combined with scleral-fixated posterior chamber intraocular lens or iris-fixated anterior chamber intraocular lens implantation.Main Outcome Measures:  The evaluation indexes included the surgery time, best corrected visual acuity, intraocular pressure, aqueous flare and cells counts, corneal endothelium counts and complications.Results:  Increase in best corrected visual acuity in both groups was not significant. The aqueous flare and cells rose in both groups postoperatively. Significant difference between the two groups at 1 week postoperatively was found, whereas no statistically significant difference was found later. The loss rate of corneal endothelium cells in the scleral-fixated posterior chamber intraocular lens group was 13.2% and 19.5% at 3 months and 1 year postoperatively, which in the iris-fixated anterior chamber intraocular lens group was 13.3% and 19.3% (P > 0.05). Prolapse of vitreous was found in 21 cases intraoperatively. The posterior capsule opacification rate was 32% and 15%, respectively. The decentration of the intraocular lens was found in 19 eyes (48.7%) in the scleral-fixated posterior chamber intraocular lens group 1 year postoperatively, whereas none was found in the iris-fixated anterior chamber intraocular lens group.Conclusions:  Iris-fixated anterior chamber intraocular lens after phaco-emulsification presented a safe, simple and efficient approach for managing subluxated lens in Marfan's syndrome.

AbstractBackground:  To analyse the magnitude of cylindrical corrections over which cyclotorsion compensation with iris recognition (IR) technology is beneficial during wavefront laser-assisted in situ keratomileusis.Design:  A retrospectively comparative case series.Participants or Samples:  Fifty-four eyes that underwent wavefront laser-assisted in situ keratomileusis without IR (non-IR group) and 53 eyes that underwent wavefront laser-assisted in situ keratomileusis with IR (IR group) were recruited.Methods:  Subgroup analysis based on baseline astigmatism were: a low degree of astigmatism (≥1.00 D to <2.00 D), a moderate degree of astigmatism (≥2.00 D to <3.00 D) and a high degree of astigmatism (≥3.00 D).Main Outcome Measures:  Vector and non-vector analyses were used for comparison.Results:  The mean cylinder was −1.89 ± 0.76 D in the non-IR group and −2.00 ± 0.77 D in the IR group. Postoperatively, 38 eyes (74.50%) in the IR group and 31 eyes (57.50%) in the non-IR group were within ± 0.50 D of the target induced astigmatism vector (P = 0.063). The difference vector was 0.49 ± 0.28 in the IR group and 0.63 ± 0.40 in the non-IR group (P = 0.031). In the analysis of subgroups, the magnitude of error was significantly lower in the moderate IR subgroup than that of the moderate non-IR subgroup (P = 0.034). Furthermore, the moderate IR subgroup had a lower mean difference vector (P = 0.0078) and a greater surgically induced astigmatism (P = 0.036) than those of the moderate non-IR group.Conclusions:  Wavefront laser-assisted in situ keratomileusis for the treatment of astigmatism using IR technology was effective and accurate for the treatment of myopic astigmatism.

AbstractBackground:  To evaluate the long-term results following deep sclerectomy with mitomycin C-SKgel implant (DSMMC-SKgel), mitomycin C (DSMMC) and trabeculectomy.Design:  Comparative case series, Goztepe Training and Educational Hospital.Participants:  Ninety-one open-angle glaucoma patients.Methods:  DSMMC-SKgel, DSMMC and trabeculectomy operations were performed in 28, 30 and 33 eyes, respectively.Main Outcome Measures:  Intraocular pressures (IOP) and distance corrected visual acuities (DCVA) were measured preoperatively and postoperatively at days 1, 7 and months 1, 3, 6, 12, 18, 24, 30, 36, 48.Results:  At month 48, deep sclerectomy groups had better DCVAs, and in all groups mean IOPs and number of medications were significantly lower and DCVAs were worse than preoperative values. Mean IOPs in trabeculectomy group at week 1, months 1 and 3 were significantly lower than those in DSMMC group. Mean IOPs in DSMMC-SKgel group at week 1 and month 1 were significantly lower than those in DSMMC group. Mean preoperative IOPs, postoperative IOPs following 3rd month, complete (IOP ≤ 21 mmHg and ≤18 mmHg without medication) and qualified (IOP ≤ 21 mmHg and ≤18 mmHg with or without medication) success rates of all groups were not statistically different. Rate of complications such as hyphema, hypotony, shallow anterior chamber, bleb leak, bleb fibrosis, cataract, choroidal detachment and macular oedema were found to be significantly higher in trabeculectomy group (P < 0.05). No significant difference in the mean post-laser goniopuncture IOPs was found between the two deep sclerectomy groups during the follow up.Conclusions:  DSMMC, DSMMC-SKgel and trabeculectomy operations were almost equally effective in lowering IOP at long-term follow up, but complication rates were higher after trabeculectomy operations.

AbstractBackground:  Chemical burns cause depletion of limbal stem cells and eventually lead to corneal opacity and visual loss. We investigated the long-term effectiveness of autologous cultured limbal stem cell grafts in patients with limbal stem cell deficiency.Design:  Prospective, non-comparative interventional case series.Participants:  Sixteen eyes from 16 patients with severe, unilateral limbal stem cell deficiency caused by chemical burns.Methods:  Autologous ex vivo cultured limbal stem cells were grafted onto the recipient eye after superficial keratectomy.Main Outcome Measures:  Clinical parameters of limbal stem cell deficiency (stability/transparency of the corneal epithelium, superficial corneal vascularization and pain/photophobia), visual acuity, cytokeratin expression on impression cytology specimens and histology on excised corneal buttons.Results:  At 12 months post-surgery, evaluation of the 16 patients showed that 10 (62.6%) experienced complete restoration of a stable and clear epithelium and 3 (18.7%) had partially successful outcomes (re-appearance of conjunctiva in some sectors of the cornea and instable corneal surface). Graft failure (no change in corneal surface conditions) was seen in three (18.7%) patients. Penetrating keratoplasty was performed in seven patients, with visual acuity improving up to 0.8 (best result). For two patients, regeneration of the corneal epithelium was confirmed by molecular marker (p63, cytokeratin 3, 12 and 19, mucin 1) analysis. Follow-up times ranged from 12 to 50 months.Conclusions:  Grafts of autologous limbal stem cells cultured onto fibrin glue discs can successfully regenerate the corneal epithelium in patients with limbal stem cell deficiency, allowing to perform successful cornea transplantation and restore vision.

AbstractBackground:  To estimate the proportion of cataract surgery performed at various visual acuity and lens opacity thresholds that would coincidentally treat early angle-closure disease, and to estimate the effect of this surgery on the incidence of primary angle-closure glaucoma.Design:  Cross-sectional, population-based survey in Meiktila, Myanmar.Participants:  Total of 2076 inhabitants, 40 years of age and over were included.Methods:  Eyes with cataract-induced visual impairment, and primary angle-closure disease were identified. Analyses were stratified by various pinhole-corrected visual acuity and Lens Opacity Classification System III scores thresholds.Main Outcome Measures:  The dual role of cataract surgery in primary cataract treatment and primary angle-closure glaucoma prevention was estimated.Results:  Of 4153 eyes available for analysis, 261 eyes were either primary angle-closure suspect or primary angle closure; 975 eyes had a visual acuity of <6/18 and Lens Opacity Classification System III score ≥3 on the nuclear or cortical scales. Of these, 86 eyes had either primary angle-closure suspect or primary angle closure. If cataract surgery were performed on all 975 eyes, this would potentially prevent up to 86 cases of primary angle-closure glaucoma in this population; 8.82% (95% confidence interval 7.12–10.78%) of the cataract surgery would address the cataract and prevent primary angle-closure glaucoma. This would achieve a 38.46% (95% confidence interval 20.23–59.43%) relative reduction in the incidence of primary angle-closure glaucoma in the adult population.Conclusion:  In populations with a high prevalence of both visually significant cataract and angle-closure disease, quality cataract extraction can serve a dual role of visual restoration and reducing the incidence of angle-closure disease in the population: killing two birds with one stone.

AbstractAngle closure can recur following peripheral iridotomy in up to 58% of cases, due to plateau iris syndrome, lens disproportion or ciliary block. Ciliary block glaucoma is an important differential diagnosis of shallow anterior chamber, angle closure and high intraocular pressure, which may occur spontaneously or following laser or surgery. Some underlying mechanisms of ciliary block glaucoma remain poorly understood but lens-ciliary body apposition and anterior hyaloid changes with increased hydraulic resistance are major pathogenic factors. An understanding of the pathogenic factors facilitates early recognition of ciliary block glaucoma, and aids a logical sequence of intervention. We review the mechanisms of post-iridotomy angle closure and propose a stepwise treatment strategy for these conditions.

AbstractBackground:  Tumour necrosis factor-alpha (TNF-α) is an important proinflammatory cytokine driving axonal degeneration and retinal ganglion cell apoptosis in glaucoma. The aim of the study was to evaluate the association of TNF-α -308 G/A and -238 G/A polymorphisms with primary open-angle glaucoma (POAG).Design:  A prospective, case–control study, university hospital setting.Participants:  Eighty-six POAG patients and 193 healthy unrelated controls.Methods:  TNF-α polymorphisms were screened by using direct gene sequencing.Main Outcome Measures:  Frequency of TNF-α -308 G/A and TNF-α -238 G/A promoter polymorphisms in glaucoma and healthy subjects.Results:  The frequencies of TNF-α -308 GA genotype and ‘A’ allele were higher in patients with POAG (22.1% and 12.2%, respectively) in comparison with the control group (10.9% and 6%, respectively) (P = 0.046 and 0.02, respectively), with odds ratios of 2.45 (P = 0.01, 95% CI = 1.23–4.87) and 2.19 (P = 0.013, 95% CI = 1.18–4.08), respectively. Genotype distribution of the TNF-α -238 variants did not yield a statistically significant difference between the two groups (P = 0.87).Conclusion:  TNF-α -308 G/A polymorphism seems to be associated with POAG in Turkish population. However, population-based studies with large number of subjects and long-term follow-up are needed to verify the association of TNF-α -308 G/A polymorphism with glaucoma susceptibility.

AbstractBackground:  The present study aims to report the influence of dietary-fibre intake on diabetes and diabetic microangiopathies among subjects >40 years in Urban IndiaDesign:  Population-based cross-sectional study.Participants:  A total of 1383 patients were included in the study, 1261 diabetics and 122 controls.Methods:  All subjects underwent comprehensive eye examination including assessment of diabetic retinopathy using fundus photography. Dietary-fibre intake was assessed using a validated questionnaire. All questions were validated based on factor analysis (overall communalities value >0.5). The cut-off for low-fibre diet was calculated by the average of study scores (≤ 32 for low-fibre diet).Main Outcome Measures:  Prevalence of diabetes in subjects with low-fibre diet versus healthy diet and risk of microangiopathies.Results:  Subjects with low-fibre diet intake, had 1.51 times more risk of microalbuminuria than those with a healthy-fibre diet. Similarly, the odds of having diabetic retinopathy and sight-threatening diabetic retinopathy (odds ratio 1.41 [95% CI 1.02–1.94] and odds ratio 2.24 [95% CI 1.01–5.02], respectively) in low-fibre diet subjects were more. Low-fibre diet was consumed predominantly by lower socioeconomic status group (11.9 vs. 6.5, P = 0.002).Conclusions:  Subjects with type II diabetes had a lower dietary-fibre intake. The presence of diabetic retinopathy, sight-threatening diabetic retinopathy and microalbuminuria were also associated with lower dietary-fibre intake.

AbstractBackground:  To describe clinical features of severe vernal keratoconjunctivitis with steroid response in Asian children and risk factors for glaucoma filtration surgery.Design:  Retrospective non-controlled, comparative case series.Participants:  Patients with severe vernal keratoconjunctivitis seen at a single centre over 6 years.Methods:  Clinical features, symptoms and treatment modalities were recorded for patients (i) diagnosed with severe VKC (clinical grade ≥3); (ii) had >2 recordings of increased intraocular pressures of >21 mmHg; (iii) and a minimum follow-up period of 1 year post-presentation.Main Outcome Measure:  Corticosteroid-induced glaucoma requiring trabeculectomy with mitomycin-C.Results:  Six patients (eight eyes) of 36 patients required trabeculectomy/mitomycin-C. All were male. Mean age of disease onset was 9.3 ± 4.5 years for a mean duration of 6.08 ± 3.5 years. Mean intraocular pressures increase from baseline was 29.0 ± 8.2 mmHg and all required >2 anti-glaucoma medications. The main risk factor for trabeculectomy was a greater increase in intraocular pressures from baseline (odds ratio 1.3; 95% confidence interval, 1.0–1.5; P = 0.011), which was independent of potential confounders such as type and duration of corticosteroid use. Comparing eyes pre- and post-trabeculectomy, all improved in clinical severity of vernal keratoconjunctivitis (mean clinical grade improvement 2.1; 95% confidence interval, 1.3–3.0; P < 0.001) and reduced dependence on topical corticosteroids for mean duration of 22.5 ± 15.3 months.Conclusion:  In our study, patients with a ‘greater steroid response’, that is, higher increase in intraocular pressures from baseline are associated with a 30% higher risk toftrabeculectomy.

AbstractThe maintenance of vision, through prevention and attenuation of neuronal injury in glaucoma, forms the basis of current clinical practice. Currently, the reduction of intraocular pressure is the only proven method to achieve these goals. Although this strategy enjoys considerable success, some patients progress to blindness; hence, additional management options are highly desirable. Several terms describing treatment modalities of neuronal diseases with potential applicability to glaucoma are used in the literature, including neuroprotection, neurorecovery, neurorescue and neuroregeneration. These phenomena have not been defined within a coherent framework. Here, we suggest a set of definitions, postulates and principles to form a foundation for the successful translation of novel glaucoma therapies from the laboratory to the clinic.

AbstractPurpose:  To report the outcome of retinal detachment surgery following trauma treated with small-gauge vitrectomy.Design:  Retrospective chart review.Participants:  Adult patients presenting with a retinal detachment following severe trauma between 2007 and 2009 that underwent vitreoretinal surgery with either 25- or 23-gauge vitrectomy.Methods:  Data collected included; age, sex, eye, time interval between injury and diagnosis of retinal detachment, anatomical and functional success, complications, and length of follow up.Main Outcome Measures:  Anatomical and functional outcome.Results:  Nineteen consecutive adult patients with traumatic retinal detachment were included. The mean age was 51.4 ± 19.3 years; 68.5% were male. Thirteen patients (68.4%) presented with visual acuity of hand movement or worse including six patients with light perception only. Five eyes achieved 6/60 vision or better, and three eyes had visual acuity of 6/12 or better. During the period of follow up six eyes experienced a recurrent retinal detachment.Conclusion:  Traumatic retinal detachment can be successful managed with small-gauge vitrectomy.

AbstractVisual prostheses including artificial retinal devices are a novel and revolutionary approach to the treatment of profound visual loss. The development of the field of visual prosthesis began with cortical prosthetic devices but since then, a variety of devices which target different sites along the visual pathway have been developed with the retinal prosthesis being the most advanced. We present a review of the history of these devices, an update on the current state of play and future prospects of this field.

AbstractThe last decade has produced pivotal change in our understanding of the molecular mechanisms underlying age-related macular degeneration (AMD), a leading cause of global blindness. In this time, the complement system has featured as a unifying theme for several elements of new evidence: initially, the discovery of complement proteins within drusen and subsequently, the association between AMD and mutations in various complement pathway genes, most notably complement factor H. Increasingly, a wealth of data are pointing towards a role for chronic local inflammation and complement activation in the patho-aetiology of AMD. These findings have paved the way for the exploration of a new paradigm of therapy in AMD management; targeting of specific molecular constituents in the complement pathway thus producing dampening or inhibition of the inflammatory response. Such an approach has the potential to intervene earlier in the disease process and ideally before vision is compromised. In this review we discuss the role of the complement system in AMD, novel therapies in preclinical evaluation and clinical trial, and whether these have a part to play in reducing the burden of disease.

AbstractPeople with vision-threatening diabetic retinopathy are likely to experience enhanced social and emotional strain. Critically, those with both vision-threatening diabetic retinopathy and psychosocial problems may have significantly reduced levels of functioning compared with psychologically healthy counterparts. This can cause inadequate compliance, increased strain on family functioning, worse diabetes control, increased progression of diabetic retinopathy and, consequently, further psychosocial stress resulting in a number of concerning implications for disease management, clinical outcomes and healthcare costs. However, the emotional and social health consequences of diabetic retinopathy have not yet been systematically explored. This information is crucial as it allows for a targeted approach to treatment and prevention and avoidance of the potentially detrimental implications described above. Therefore, this paper reviews the current qualitative and quantitative evidence regarding the social and emotional impact of diabetic retinopathy and identifies directions for future research. Key search terms were applied to the electronic databases Pubmed, ISI Web of Science and Embase and the bibliographies of relevant papers were systematically reviewed for additional references. Overall, the evidence suggests that diabetic retinopathy and associated vision loss have several debilitating effects, including disruption of family functioning, relationships and roles; increased social isolation and dependence; and deterioration of work prospects resulting in increased financial strain. Adverse emotional responses include fear, anxiety, vulnerability, guilt, loss of confidence, anger, stress and self-perception issues. However, the research to date is largely qualitative in nature, with most quantitative studies being small, cross-sectional and somewhat outdated. Similarly, the outcome measures used in many studies to date are suboptimal in terms of content and validity. Therefore, this review identifies the need for improved outcome measures to provide valid, meaningful measurement of the social and emotional impact of diabetic retinopathy and discusses potential directions for future research such as item banking and computer adaptive testing.

AbstractIn the developed world, diseases of the retina are common causes of untreatable blindness. In many cases, a genetic component to the aetiology has been identified, making the development of gene-based treatments a logical long-term goal. The clinical strategy for retinal gene therapy broadly encompasses two distinct advantages over systemic drug delivery. First is that gene delivery can limit expression of a therapeutic protein to a specific target cell, which is rarely possible even with local drug delivery methods. Second, by delivering DNA that remains stable and non-degraded, gene expression and hence protein production could in theory be indefinite, obviating the need for repeated tablets or injections. Viruses have evolved distinct mechanisms, such as receptor mediated uptake and genomic integration, which efficiently encompass these two properties. For non-viral gene therapy approaches, however, nuclear localization and stable long-term transgene expression remain significant hurdles that need to be overcome. The challenge of non-viral gene therapy is therefore to harness current laboratory and molecular-based techniques to develop a man-made system that can approach the efficiency of a natural biological process. In the unique environment of the retina, this goal may not be insurmountable and would overcome the major limiting factor of adeno-associated viral vectors, which is the size of gene that can be delivered.

AbstractCentral retinal vein occlusion remains a common cause of unilateral visual loss. Until recently, our treatment options for this condition were limited only to laser photocoagulation for the devastating end sequelae of anterior segment neovascularization. Over the last 2 years, a number of randomized controlled trials have given us significant new treatment options to address not only visual loss from macular oedema but also the ability to create a bypass around the obstruction in the central retinal vein and to address the raised venous hydrostatic pressure. In the future, it is likely that combination approaches to the management of central retinal vein occlusion will develop using specific agents and techniques to address the components of macular oedema, retinal ischaemia and raised venous hydrostatic pressure, all of which combine to produce the clinical picture and the reduction in vision seen in this condition.

AbstractBackground:  To describe the changes in retinal vascular calibre in response to intravitreal ranibizumab injections in patients with neovascular age-related macular degeneration.Design:  Prospective interventional case series.Participants:  Treatment naïve patients with neovascular age-related macular degeneration were recruited over a 1-year period.Methods:  Each patient received three monthly intravitreal injections according to a ‘loading dose’. Retinal arteriolar and venular calibre was measured from digital fundus photographs and summarized as central retinal artery equivalent and central retinal vein equivalent at baseline and 3 months.Main Outcome Measure:  Central retinal artery equivalent and central retinal vein equivalent changes from baseline to 3 months.Results:  Seventy-four eyes of 71 patients had good quality images for grading vessel calibre at baseline and at 3 months in treated (study) eyes and 51 eyes of 51 patients had good quality images in fellow (control) eyes. Over 3 months, in study eyes treated with ranibizumab, there was a significant increase in central retinal vein equivalent over baseline (+6.20 µm, P = 0.005), but no significant change in central retinal artery equivalent (+0.86 µm, P = 0.55). In control eyes, there was no change in central retinal vein equivalent (−0.82 µm, P = 0.70) or central retinal artery equivalent (0.34 µm, P = 0.75).Conclusion:  Intravitreal ranibizumab has a significant vasodilational effect on retinal venular calibre in eyes treated for neovascular age-related macular degeneration. The reason for this change is unclear, but may relate to changes in blood flow or inflammatory changes within the retina.

AbstractBackground:  To investigate the efficacy of ranibizumab therapy for choroidal neovascular (CNV) membranes secondary to conditions other than macular degeneration.Design:  Prospective case series conducted at the Royal Victorian Eye and Ear Hospital.Participants:  Twelve-month follow-up data for 41 patients with CNV recruited from the outpatient clinic from May 2008 to April 2010 is presented. Fifteen patients had myopia, seven had multifocal choroiditis, and eight had other primary causes.Methods:  All patients had visual acuity, fluorescein angiogram and optical coherence tomography performed at the initial visit (baseline). Ranibizumab was injected with a standard sterile technique. Patients were reviewed after 1 month, and further injections were given at the treating doctors' discretion.Main Outcome Measures:  Change in visual acuity and central macular thickness at 12 months was compared with baseline for each of the groups. Local and systemic adverse outcomes were recorded.Results:  Analysis was stratified by primary pathology. On average, 40%, 43% and 25% of patients with myopia, multifocal choroiditis and ‘other’ pathologies, respectively, experienced a three or more line improvement in vision. The average number of injections in 12 months was 4.2 for the entire group. Central macular thickness significantly decreased in the 12-month period for the combined group (P = 0.03). No patient had an adverse systemic side-effect; however, there was one case of endophthalmitis.Conclusions:  Ranibizumab is an effective treatment for CNV secondary to non-age-related macular degeneration causes, with most patients gaining an improvement in the first 2 months following injection.

AbstractBackground:  The Diabetes Management Project is investigating the clinical, behavioural and psychosocial barriers to optimal diabetes care in individuals with and without diabetic retinopathy.Design:  Prospective cohort.Participants:  Two hundred and twenty-three and 374 patients without and with diabetic retinopathy, respectively.Methods:  All individuals underwent a comprehensive dilated eye test, anthropometric measurements, blood and urine samples, and psychosocial questionnaires.Main Outcome Measures:  Good glycaemic control was defined as glycosylated haemoglobin < 7%, good blood pressure control as systolic and diastolic values ≤130 and 80 mmHg, respectively, and good diabetes control as glycosylated haemoglobin < 7% and blood pressure values ≤130 and 80 mmHg.Results:  Four hundred and one males (65.4%) and 212 females (34.6%) aged 26–90 years (mean age ± standard deviation = 64.6 ± 11.6) were examined. The median glycosylated haemoglobin for all participants was 7.5% (interquartile range = 1.7%). Average systolic and diastolic blood pressure values were 139.7 mmHg (standard deviation = 18.8) and 92.7 mmHg (standard deviation = 30.9), respectively. Initial data analyses indicate that over two-thirds of participants with diabetes have poor glycaemic control, which was worse in those with diabetic retinopathy compared with those without (76.3% vs. 49.3%; P < 0.001). Blood pressure control was similar for those with and without diabetic retinopathy, with almost a third (28.5%) of the total sample having poor blood pressure control. Overall, those with diabetic retinopathy had poorer diabetes control than those without (24.3% vs. 13.7%; P = 0.002).Conclusions:  Our findings substantiate the implementation of the Diabetes Management Project, developed to assess factors associated with suboptimal diabetes care.