board editorial

AAO Preferred Practice Pattern Guidelines recommend the monocular therapeutic trial to determine medication response to topical glaucoma medications. Bhorade et al (p. 2047) compared whether the monocular trial?in which one eye is treated and the untreated fellow eye serves as a control?is a better assessment of medication response than testing each eye independently. The authors used data from 206 participants, who placed a topical prostaglandin analogue (PGA) in one eye once daily and returned in 4 to 6 weeks to ascertain medication response. Intraocular pressure (IOP) response of the trial eye was determined by the IOP change between baseline and 1 month in the trial eye alone and by adjusting the IOP change in the fellow eye between the same visits. Both methods appeared equivalent. However, the authors found that neither method adequately determined medication response to topical PGAs. They call for further studies to elucidate factors that influence IOP measurement and assessment of medication response between visits. An accompanying editorial by Tony Realini, MD, ?Assessing the Effectiveness of Intraocular Pressure-Lowering Therapy,? (p. 2045), sheds further light onto the authors' findings.

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Las normas de Patrones de Práctica Preferidos de la AAO recomiendan una prueba terapéutica monocular para determinar la respuesta a los medicamentos tópicos para el glaucoma. Bhorade y otros (p. 2047) hicieron una comparación para determinar si la prueba monocular ?en la que se trata un ojo y el ojo no tratado sirve de control? es una mejor evaluación de la respuesta al medicamento que la prueba realizada independientemente en cada ojo. Los autores utilizaron datos de 206 participantes, que se aplicaron un análogo de prostaglandina (PGA) tópico en un ojo una vez al día y regresaron a las 4 o 6 semanas para determinar la respuesta al medicamento. La respuesta de la presión intraocular (PIO) del ojo tratado se determinó por el cambio en la PIO entre la medición de línea de base y la obtenida a 1 mes de iniciado el estudio, únicamente en el ojo tratado, y ajustando el cambio de la PIO en el otro ojo durante los intervalos entre las mismas citas de control. Ambos métodos parecieron ser equivalentes. Sin embargo, los autores vieron que ninguno de los dos determinaba adecuadamente la respuesta médica a los PGAs tópicos. Recomiendan realizar estudios adicionales para aclarar los factores que influyen en la medición de la PIO y en la evaluación de la respuesta al medicamento entre una y otra cita de control. Un editorial adjunto por el Dr. Tony Realini, ?Assessing the Effectiveness of Intraocular Pressure-Lowering Therapy,? (Evaluación de la efectividad de la terapia para reducir la presión intraocular) (p. 2045), vierte más luz en los hallazgos de los autores.

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The Ocular Hypertension Treatment Study (OHTS) was a landmark trial in ophthalmology, establishing clearly that prophylactic reduction of intraocular pressure (IOP) in ocular hypertensive individuals could forestall the development of glaucoma, as well as identifying the risk factors that predispose such individuals to develop glaucoma. When the first phase of OHTS ended, participants from the observation group were offered IOP-lowering therapy. Those accepting therapy underwent treatment initiation using the monocular drug trial. In this issue, Bhorade et al from the OHTS team report a post hoc analysis of the clinical utility of the monocular drug trial among 206 initially observed OHTS participants who were treated with a prostaglandin analogue at the completion of the first Ocular Hypertension Treatment Study.

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Objective: To determine whether adjusting the intraocular pressure (IOP) change of the trial eye for the IOP change of the fellow eye (i.e., monocular trial) is a better assessment of medication response than testing each eye independently.Design: Analysis of data from a prospective, randomized, clinical trial.Participants: Two hundred six participants with ocular hypertension randomized to the observation group and later started on a topical prostaglandin analog (PGA).Methods: Participants were started on a topical PGA in 1 eye and returned in approximately 1 month to determine medication response. The IOP response of the trial eye was determined by the IOP change between baseline and 1 month in the trial eye alone (unadjusted method) and by adjusting for the IOP change in the fellow eye between the same visits (adjusted method). Our ?gold standard? for medication response was the IOP change in the trial eye between up to 3 pre- and 3 posttreatment visits on the same medication. Pearson correlation was used to compare the gold standard with the unadjusted and adjusted methods. In addition, symmetry of IOP response between trial and fellow eyes to the same medication was determined by correlating the trial eye IOP change between up to 3 pre- and 3 posttreatment visits to the fellow eye IOP change between the same visits.Main Outcome Measures: Correlations of IOP change of the trial eye using the gold standard to the IOP change of the trial eye using the unadjusted and adjusted methods.Results: The correlations of IOP change using the gold standard to the IOP change using the unadjusted and adjusted methods were r = 0.40 and r = 0.41, respectively. The correlation of IOP change of both eyes between the same pre- and posttreatment visits was r = 0.81.Conclusions: The monocular trial (i.e., adjusted method) appears equivalent to testing each eye independently (i.e., unadjusted method); however, neither method is adequate to determine medication response to topical PGAs. Both eyes have a similar IOP response to the same PGA. Further studies to understand IOP fluctuation are necessary to improve current methods of assessing medication response.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

trial response medication between unadjust visits method methods adjust standard gold fellow posttreatment eyes topical monocular participants determine hypertension determin

Purpose: To describe the intraocular pressure (IOP) of the untreated fellow eye after unilateral trabeculectomy in the Collaborative Initial Glaucoma Treatment Study (CIGTS).Design: Data collected from a prospective, multicenter, randomized clinical trial.Participants: Three hundred patients with newly diagnosed open-angle glaucoma enrolled at 14 centers in the United States who were randomized to initial trabeculectomy.Methods: After baseline evaluation and randomization to initial trabeculectomy in the study eye, patients were evaluated at 3 and 6 months and at 6-month intervals thereafter. The IOP was measured by Goldmann applanation tonometry. All eyes included in the analysis were untreated fellow eyes, and the data were censored for potential IOP-lowering events in the fellow eye, including trabeculectomy, argon laser trabeculoplasty, or cataract extraction. Predictive factors for IOP response in the fellow eye to initial trabeculectomy in the study eye were analyzed using a linear mixed model.Main Outcome Measures: Intraocular pressure in the untreated fellow eye during follow-up.Results: Although the IOP in the fellow eye was lower than baseline at 3, 6, 12, 18, and 24 months after trabeculectomy in the study eye, this decrease was statistically significant only at month 12 (mean decrease from baseline, 0.73±3.37 mmHg; P = 0.0134). Predictive associations with higher IOP in the fellow eye during follow-up included higher baseline IOP (P

fellow trabeculectomy initial study baseline untreate glaucoma pressure intraocular decrease during follow months higher month randomize collaborative treatment data patients

Purpose: To evaluate rates of visual field progression in eyes with optic disc hemorrhages and the effect of intraocular pressure (IOP) reduction on these rates.Design: Observational cohort study.Participants: The study included 510 eyes of 348 patients with glaucoma who were recruited from the Diagnostic Innovations in Glaucoma Study (DIGS) and followed for an average of 8.2 years.Methods: Eyes were followed annually with clinical examination, standard automated perimetry visual fields, and optic disc stereophotographs. The presence of optic disc hemorrhages was determined on the basis of masked evaluation of optic disc stereophotographs. Evaluation of rates of visual field change during follow-up was performed using the visual field index (VFI).Main Outcome Measures: The evaluation of the effect of optic disc hemorrhages on rates of visual field progression was performed using random coefficient models. Estimates of rates of change for individual eyes were obtained by best linear unbiased prediction (BLUP).Results: During follow-up, 97 (19%) of the eyes had at least 1 episode of disc hemorrhage. The overall rate of VFI change in eyes with hemorrhages was significantly faster than in eyes without hemorrhages (?0.88%/year vs. ?0.38%/year, respectively, P

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Objective: To estimate the intraocular pressure (IOP)-lowering effect of prostaglandin analogs (PGAs) when added to topical ?-blocker (BB) therapy.Design: Systematic review and meta-analyses of randomized clinical trials.Participants: Twenty-nine articles reporting on 33 study arms and 3 control arms.Methods: Articles published between January 1, 1990, and August 18, 2009, were identified in relevant databases. The pooled IOP-lowering effects at the 1- to 3-month follow-ups were calculated by performing random effects meta-analyses.Main Outcome Measures: Absolute and relative change in IOP for mean diurnal curve and highest and lowest IOP decrease on the diurnal IOP curve.Results: Adding 0.005% latanoprost in the evening to 0.5% timolol twice daily resulted in a pooled change of ?6.3 mmHg (95% CI, ?7.1 to ?5.5 mmHg, mean IOP curve); switching to the fixed combination of 0.5% timolol and 0.005% latanoprost in the morning resulted in a pooled change of ?2.8 mmHg (95% CI, ?3.3 to ?2.3 mmHg, mean IOP curve). Starting with any fixed combination of 0.5% timolol and a PGA in the morning resulted in a pooled change of ?8.4 mmHg (95% CI, ?9.1 to ?7.6 mmHg, mean IOP curve) and varied between ?9.1 mmHg (95% CI, ?9.9 to ?8.2 mmHg, highest) and ?7.9 mmHg (95% CI, ?8.5 to ?7.2 mmHg, lowest); starting with any fixed combination of 0.5% timolol and a PGA in the evening resulted in a pooled change of ?8.6 (95% CI, ?9.2 to ?8.0 mmHg, mean IOP curve) and varied between ?10.1 mmHg (95% CI, ?11.0 to ?9.2 mmHg, highest) and ?7.3 mmHg (95% CI, ?8.1 to ?6.4 mmHg, lowest).Conclusions: The concomitant use of latanoprost and timolol leads to a larger additional IOP reduction when compared with the fixed combination. There is no difference in mean IOP-lowering effect between evening and morning dosing of a fixed combination of timolol and a PGA, although the largest IOP decreases are seen with evening dosing. These findings are explained by differences in study design. When time points of IOP measurements close to the peak or trough moment of a drug are included, the IOP-lowering effect will be overestimated or underestimated, respectively.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

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Purpose: To investigate the effect of brimonidine monotherapy on intraocular pressure (IOP) during the nocturnal/sleep period.Design: Prospective, open-label experimental study.Participants: Fifteen patients with newly diagnosed open-angle glaucoma or ocular hypertension (ages, 46?72 years).Methods: Baseline data of 24-hour IOP in untreated patients were collected in a sleep laboratory. Measurements of IOP were taken using a pneumatonometer every 2 hours in the sitting and supine body positions during the 16-hour diurnal/wake period and in the supine position during the 8-hour nocturnal/sleep period. Patients were treated afterward with 0.1% brimonidine 3 times per day for 4 weeks, and 24-hour IOP data were collected under the same laboratory conditions.Main Outcome Measures: Diurnal and nocturnal IOP means under the brimonidine treatment were compared with the baseline.Results: The diurnal IOP mean was significantly lower under the brimonidine treatment than the baseline IOP in both the sitting and supine positions. There was no statistically significant change in IOP under the brimonidine treatment from the baseline during the nocturnal period.Conclusions: Although 0.1% brimonidine monotherapy significantly lowered IOP during the diurnal/wake period, it did not significantly lower IOP during the nocturnal/sleep period.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

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Purpose: To investigate the influence of timolol maleate 0.5% gel-forming solution and brinzolamide 1% ophthalmic suspension on contrast sensitivity, ocular higher-order aberration (HOA), and corneal surface light scattering.Design: Prospective, comparative study.Participants: Forty normal volunteers were enrolled in this study.Methods: We evaluated contrast sensitivity, ocular HOA, and corneal light scattering before and 2, 5, 10, and 15 minutes after instillation of antiglaucoma eyedrops. Contrast sensitivity function was assessed with the CSV-1000RN chart (Vector Vision Co., Greenville, OH). Higher-order aberration was measured for a 4-mm pupil using the Hartmann-Shack aberrometer (KR-9000PW; Topcon, Tokyo, Japan). Corneal surface light scattering was quantitatively evaluated by using the Scheimpflug camera (EAS-1000, Nidek, Aichi, Japan).Main Outcome Measures: Time course of changes in contrast sensitivity, ocular HOAs, and corneal light scattering.Results: Both timolol gel-forming solution and brinzolamide significantly decreased contrast sensitivity for at least 5 minutes after instillation (P

sensitivity contrast corneal scattering light instillation forming timolol ocular brinzolamide solution higher surface japan ophthalmic study evaluate maleate aberration order

Objective: To determine the prevalence of selected comorbidities in patients with open-angle glaucoma (OAG) and whether these comorbidities are more prevalent among individuals with OAG than those without OAG.Design: A retrospective, nationwide, case-control study using an administrative database.Participants: The study group comprised 76 673 OAG patients. The comparison group comprised 230 019 subjects matched to the study cohort.Methods: Data were collected retrospectively from the Taiwan National Health Insurance Research Database. The study cohort comprised all patients with a diagnosis of OAG (International Classification of Diseases, 9th Revision, Clinical Modification codes 365.1?365.11) in 2005 (n = 76 673). The comparison cohort comprised randomly selected patients (3 for every 1 OAG patient; n = 230 019) matched with the study group in terms of age, gender, urbanization level, and monthly income. In total, 31 medical comorbidities were selected based mainly on the Elixhauser Comorbidity Index. Separate conditional logistic regression analyses were used to estimate the adjusted odds ratio for each of the medical comorbidities between patients with and without OAG.Main Outcome Measures: The prevalences of selected comorbidities.Results: More than half (50.5%) of the OAG patients had hypertension, and more than 30% had hyperlipidemia or diabetes (30.5% and 30.2%, respectively). The prevalences of 28 of 31 comorbidities were significantly higher for OAG patients than subjects without glaucoma after adjusting for age, gender, urbanization level, and monthly income. The adjusted odds ratio was more than 1.50 for hypertension, hyperlipidemia, systemic lupus erythematosus, diabetes, hypothyroidism, fluid and electrolyte disorders, depression, and psychosis. Among the studied comorbidities, the prevalence difference of the OAG group minus the control group was 3% or higher for hypertension, hyperlipidemia, stroke, diabetes, liver disease, and peptic ulcer.Conclusions: Open-angle glaucoma patients are significantly more likely to have comorbidities, many of which can be life threatening or can affect the quality of life appreciably.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Objective: To compare the reliability and the agreement in measuring central corneal thickness (CCT) using the following technologies: RTVue Fourier-domain optical coherence tomography (Optovue, Inc., Fremont, CA), Pentacam (Oculus, Inc., Wetzlar, Germany), and ultrasonic pachymetry (USP; Pocket-II; Quantel Medical, Inc., Bozeman, MT).Design: Evaluation of diagnostic test.Participants: One hundred four eyes of 52 healthy subjects (mean age±standard deviation, 28.6±4.8 years).Methods: One eye from each subject was assigned randomly for a repeatability test in which a single operator performed 3 successive measurements. The other eye underwent an interoperator reproducibility test by 3 operators. Two centering methods of RTVue and 3 types of CCT from Pentacam were investigated. For USP, 1 drop of topical anesthetic was administered, and measurement was initiated 90 seconds later. Agreement among the instruments was evaluated using Bland-Altman plots.Main Outcome Measures: Various types of CCT were compared: central zone average and minimum thickness of RTVue centering on the vertex and the pupil; corneal thickness at the pupil center, apex, and thinnest location from Pentacam; and mean CCT of 5 repeated measurements of USP. The reliability of measurement was assessed using the repeatability or reproducibility coefficient (Rco), the coefficient of variation, and the intraclass correlation coefficient. The limit of agreement was used to analyze concordance.Results: The Rco of RTVue was 4 to 5 ?m, which was comparable with that of USP and better than that of Pentacam (10?11 ?m). The Rco was not dependent on centering methods (RTVue) or types of CCT (Pentacam). The location of minimum thickness found by RTVue was less reliable than that of the Pentacam. The central zone average of RTVue was approximately 7 ?m larger than the pupil center or apex thickness of Pentacam and approximately 13 ?m larger than the CCT measurement of USP. Those discrepancies could be as high as 20 and 23 ?m, respectively. The minimum thickness measured by the RTVue was similar to that of Pentacam.Conclusions: The RTVue is a rapid and reliable noncontact means of measuring CCT; however, the characteristics of CCT measured by RTVue must be understood when comparing the CCT obtained by the Pentacam or USP.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

rtvue pentacam thickness measurement central minimum methods types centering coefficient pupil corneal test agreement optical center tomography reliable pachymetry coherence

With apologies from the publisher, in the article entitled ?Genome-wide Association Study of Normal Tension Glaucoma: Common Variants in SRBD1 and ELOVL5 Contribute to Disease Susceptibility? (Ophthalmology 2010;117:1331-8), the author byline should have appeared as follows: The Writing Committee for the Normal Tension Glaucoma Genetic Study Group of Japan Glaucoma Society.

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Purpose: To compare the AcrySof Toric intraocular lens (IOL) and an AcrySof spherical control IOL and to investigate rotational stability of the AcrySof Toric IOL (Alcon Laboratories, Inc., Fort Worth, TX) in subjects with cataracts and preexisting corneal astigmatism.Design: Randomized, subject-masked, parallel-group, multicenter, 1-year study.Participants: We included 517 subjects (Toric IOL, n = 256; control IOL, n = 261).Methods: Unilateral implantation of an AcrySof Toric or AcrySof spherical control IOL (spherical powers, 12.00?25.00 diopters [D]; cylinder powers 1.50, 2.25, or 3.00 D for corneal astigmatism correction of 0.75 to

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Purpose: To examine the grading (interrater) reliability of the Age-Related Eye Disease Study (AREDS) Clinical Lens Grading System (ARLNS).Design: Evaluation of diagnostic test or technology.Participants: One hundred fifty volunteers (284 eyes).Methods: Participants with lens opacities of varying severity were independently graded at the slit lamp for cataract severity by 2 examiners (retinal or anterior segment specialists) using the ARLNS, which employs 3 standard photographs of increasing severity for classifying each of the 3 major types of opacity. Lens photographs were taken and graded at a reading center using the more detailed AREDS System for Classifying Cataracts from photographs.Main Outcome Measures: The Pearson correlation, weighted-kappa, and limits-of-agreement statistics were used to assess the interrater agreement of the gradings.Results: Examinations were performed on 284 lenses (150 participants). Tests of interrater reliability between pairs of clinicians showed substantial agreement between clinicians for cortical and posterior subcapsular opacities and moderate agreement for nuclear opacities. A similar pattern and strength of agreement was present when comparing scores of retinal versus anterior segment specialists. Interrater agreement between clinical and reading center gradings was not as great as inter-clinician agreement.Conclusions: Interrater agreements were in the moderate to substantial range for the clinical assessment of lens opacities. Inherent differences in cataract classification systems that rely on slit lamp vs photographic assessments of lens opacities may explain some of the disagreement noted between slit lamp and photographic gradings. Given the interrater reliability statistics for clinicians and the simplicity of the grading procedure, ARLNS is presented for use in studies requiring a simple, inexpensive method for detecting the presence and severity of the major types of lens opacities.Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

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Purpose: To investigate the prevalence and visual acuity (VA) outcomes of cataract surgery in rural populations throughout China.Design: Population-based, cross-sectional study.Participants: Forty-five thousand seven hundred forty-seven adults 50 years of age and older.Methods: Geographically defined cluster sampling was used in randomly selecting a cross-section of residents from a representative rural county within each of 9 provinces in mainland China. Participants underwent VA measurements, refraction, and a slit-lamp examination at local examination sites; those with previous cataract surgery were queried as to the year and type of surgical facility. Surgical procedure and evidence of surgery complications were noted during the examination. The principal cause of visual impairment was identified for eyes with VA of 20/40 or worse.Main Outcome Measures: Cataract surgery procedure, presenting and best-corrected distance VA, and causes of visual impairment.Results: Of 50 395 enumerated eligible persons, 45 747 (90.8%) were examined and tested for VA. The overall prevalence of cataract surgery was 2.09%. Surgical coverage among those with VA worse than 20/200 in both eyes because of cataract was 35.7%. Unoperated cataract was associated with older age, female gender, lack of education, and geographic area (province). Among the 1174 cataract-operated eyes, 31.1% had presenting VA of 20/32 or better, 15.4% had presenting VA of 20/40 to 20/63, 30.0% had presenting VA worse than 20/63 to 20/200, and 23.5% had presenting VA worse than 20/200. With best correction, the percentages were 57.6%, 6.2%, 18.5%, and 17.7%, respectively. Posterior capsule opacification, refractive error, and retinal disorders were the main causes in cataract-operated eyes with VA worse than 20/63.Conclusions: Two thirds of those with bilateral visual impairment or blindness because of cataract remain in need of sight-restoring surgery. Posterior capsule opacification and refractive error, both readily amenable to treatment, were common in cataract-operated eyes. Sustained government efforts to provide access to affordable modern cataract surgery with a greater emphasis on postoperative follow-up and the quality of VA outcomes are needed.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

cataract surgery worse eyes presenting china visual rural prevalence impairment surgical operate examination outcomes participants procedure province refractive among cross

Objective: To introduce a new simple surgical approach with high-frequency radio-wave electrosurgery to reduce conjunctivochalasis (CCh).Design: Prospective, noncomparative, interventional case series analysis.Participants: Twelve patients (20 eyes) with CCh were recruited from the outpatient service of the Department of Ophthalmology, Kangbuk Samsung Hospital, Seoul, Korea.Methods: On the inferior bulbar conjunctiva, subconjunctival coagulation was performed with a fine-needle electrode using a high-frequency radio-wave electrosurgical unit (Ellman Surgitron; Ellman International, Inc., Hewlett, NY) in coagulation mode.Main Outcome Measures: Conjunctivochalasis grade; epiphora and dry eye symptoms (the Ocular Surface Disease Index [OSDI]; Allergan Inc., Irvine, CA, holds the copyright); and intraoperative and postoperative complications.Results: Eighteen eyes (90%) recovered a smooth, wet, and noninflamed conjunctival surface within 1 month and remained stable for a follow-up period of 3 months. At 3 months postoperatively, 18 eyes (90%) had grade 0 CCh. There was a statistically significant decrease of the OSDI score at 3 months postoperatively (P < 0.001).Conclusions: A surgical approach with high-frequency radio-wave electrosurgery produced a significant reduction in CCh and an improvement in symptoms. Radio-wave surgical techniques represent a favorable alternative to surgical treatment of CCh.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

high months radio wave frequency eyes surgical surface ellman postoperatively approach osdi coagulation grade simple electrosurgery holds period noninflam noncomparative

Purpose: To evaluate the visual outcome, number of injections, and direct medical cost of a ?treat and extend? regimen (TER) in managing neovascular age-related macular degeneration (nAMD) with intravitreal ranibizumab.Design: Retrospective, interventional, consecutive case series.Participants: Ninety-two eyes of 92 patients met the entry criteria from May 2006 to May 2008.Methods: All patients with treatment-naïve nAMD were treated monthly until no intraretinal or subretinal fluid was observed on optical coherence tomography (OCT). The treatment intervals were then sequentially lengthened by 2 weeks until signs of exudation recurred. The interval was individualized for each patient in an attempt to maintain an exudation-free macula.Main Outcome Measures: Change from baseline visual acuity, proportion of eyes losing

neovascular patients until namd outcome regimen relate macular treat treatment ranibizumab eyes extend visual degeneration exudation tomography patient case consecutive

Purpose: To determine the antibiotic susceptibility patterns of conjunctival flora in patients undergoing intravitreal (IVT) injection.Design: Prospective, observational study.Participants: Patients (n = 85) scheduled to undergo 136 IVT injections at California Vitreoretinal Center at Stanford University.Methods: Conjunctival cultures were obtained on the day of the IVT injection from the injection site bulbar conjunctiva before the application of povidone-iodine or antibiotics.Main Outcome Measures: Bacterial isolates were identified and tested for antibiotic susceptibility using either the Kirby-Bauer disc-diffusion technique or MicroScan-WalkAway system.Results: Our analysis included 136 samples collected from 90 eyes of 85 patients. Of those with positive cultures (n = 65), the most common bacterial isolates were coagulase-negative staphylococci (CNS), comprising 59 (83%) of the 71 bacterial strains. Among the CNS, all were susceptible to vancomycin and >80% were susceptible to gentamicin, chloramphenicol, tetracycline, and imipenem. Between 60% and 80% of the CNS were susceptible to the cephalosporins and newer generation fluoroquinolones. Fewer than 60% were susceptible to the penicillin analogs, erythromycin, and the earlier generation fluoroquinolones. Nearly half of the CNS (47%) were resistant to oxacillin/methicillin.Conclusions: Bacteria isolated from the injection site of patients undergoing IVT injections were mostly CNS. Most are sensitive to vancomycin, gentamicin, and chloramphenicol.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

patients susceptible injection bacterial antibiotic susceptibility undergoing conjunctival vancomycin isolates chloramphenicol injections flora gentamicin site cultures generation patterns disclosure intravitreal

Objectives: To determine the long-term effects of ranibizumab (RBZ) in patients with diabetic macular edema (DME).Design: Prospective, randomized, interventional, multicenter clinical trial.Participants: One hundred twenty-six patients with DME.Methods: Subjects were randomized 1:1:1 to receive 0.5 mg RBZ at baseline and months 1, 3, and 5 (group 1), focal or grid laser photocoagulation at baseline and month 3 if needed (group 2), or a combination of 0.5 mg RBZ and focal or grid laser at baseline and month 3 (group 3). Starting at month 6, if retreatment criteria were met, all subjects could be treated with RBZ.Main Outcome Measures: The mean change from baseline in best-corrected visual acuity (BCVA) at month 24.Results: After the primary end point at month 6, most patients in all groups were treated only with RBZ, and the mean number of injections was 5.3, 4.4, and 2.9 during the 18-month follow-up period in groups 1, 2, and 3, respectively. For the 33 patients in group 1, 34 patients in group 2, and 34 patients in group 3 who remained in the study through 24 months, the mean improvement in BCVA was 7.4, 0.5, and 3.8 letters at the 6-month primary end point, compared with 7.7, 5.1, and 6.8 letters at month 24, and the percentage of patients who gained 3 lines or more of BCVA was 21, 0, and 6 at month 6, compared with 24, 18, and 26 at month 24. The percentage of patients with 20/40 or better Snellen equivalent at month 24 was 45% in group 1, 44% in group 2, and 35% in group 3. Mean foveal thickness (FTH), defined as center subfield thickness, at month 24 was 340 ?m, 286 ?m, and 258 ?m for groups 1, 2, and 3, respectively, and the percentage of patients with center subfield thickness of 250 ?m or less was 36%, 47%, and 68%, respectively.Conclusions: Intraocular injections of RBZ provided benefit for patients with DME for at least 2 years, and when combined with focal or grid laser treatments, the amount of residual edema was reduced, as were the frequency of injections needed to control edema.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

month patients group edema mean baseline grid percentage focal thickness groups laser respectively bcva injections months primary treate subjects disclosure

Purpose: To describe the 5-year outcomes of patients with cytomegalovirus (CMV) retinitis and AIDS in the era of highly active antiretroviral therapy (HAART).Design: Prospective, multicenter, observational study.Participants: A total of 503 patients with AIDS and CMV retinitis.Methods: Follow-up every 3 months with medical history, ophthalmologic examination, laboratory testing, and retinal photographs. Participants were classified as having previously diagnosed CMV retinitis and immune recovery (CD4+ T cells ?100 cells/?l), previously diagnosed retinitis and immune compromise, and newly diagnosed CMV retinitis (diagnosis

retinitis diagnos immune highly antiretroviral patients active cells year cytomegalovirus aids participants previously therapy describe recovery methods outcomes history newly

Purpose: To analyze focal hyperreflective morphologic alterations in outer retinal layers in patients with type 2 idiopathic macular telangiectasia (MacTel type 2) using spectral-domain optical coherence tomography (SD OCT).Design: Cross-sectional case-control study.Participants: Forty-one patients with MacTel type 2.Methods: Anatomic layers were evaluated and compared with those of controls of similar age. Simultaneous SD OCT scans were obtained with a combined confocal scanning laser ophthalmoscope for simultaneous tomographic and topographic in vivo imaging (Spectralis HRA+OCT; Heidelberg Engineering, Heidelberg, Germany).Main Outcome Measures: Morphologic alterations in the retinal layers secondary to MacTel type 2.Results: Hyperreflective spots in the outer retina of MacTel type 2 patients were detected in all stages of disease using the SD OCT. Their presence was confined to the foveolar and parafoveolar region. The phenomenon also was detected in a monozygotic twin in an eye with no typical angiographic sign of the disease. A hyperreflective haze was detected in the vicinity of a disruption of the hyperreflective OCT line that is assumed to represent the line between the photoreceptor inner and outer segments and interdigitation of the outer segments and the retinal pigment epithelium. No corresponding pathologic features could be identified by biomicroscopy, time-domain OCT, or confocal scanning laser ophthalmoscope imaging. Crystalline deposits and intraretinal migration of pigmented cells were distinguishable because of differences in shape, reflectivity, and location.Conclusions: Hyperreflective spots were identified in outer retinal layers of patients with MacTel type 2 in all disease stages. It is suggested that this phenomenon represents an early sign of a neurodegenerative process. Secondary assumptions include extravasated deposits or vascular abnormalities. The pathologic features are indicative of an active disease process before the disease manifests by typical fluorescein angiographic signs.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

type outer hyperreflective mactel disease retinal patients layers domain spots detect segments line pigment secondary sign scanning disclosure process alterations

Purpose: Retinitis pigmentosa (RP) causes hereditary blindness in adults (prevalence, approximately 1 in 4000). Each of the more than 30 causative genes identified to date are responsible for only a small percentage of cases. Genetic diagnosis via traditional methods is problematic, and a single test with a higher probability of detecting the causative mutation would be very beneficial for the clinician. The goal of this study therefore was to develop a high-throughput screen capable of detecting both known mutations and novel mutations within all genes implicated in autosomal recessive or simplex RP.Design: Evaluation of diagnostic technology.Participants and Controls: Participants were 56 simplex and autosomal recessive RP patients, with 360 population controls unscreened for ophthalmic disease.Methods: A custom genechip capable of resequencing all exons containing known mutations in 19 disease-associated genes was developed (RP genechip). A second, commercially available arrayed primer extension (APEX) system was used to screen 501 individual previously reported variants. The ability of these high-throughput approaches to identify pathogenic variants was assessed in a cohort of simplex and autosomal recessive RP patients.Main Outcome Measures: Number of mutations and potentially pathogenic variants identified.Results: The RP genechip identified 44 sequence variants: 5 previously reported mutations; 22 known single nucleotide polymorphisms (SNPs); 11 novel, potentially pathogenic variants; and 6 novel SNPs. There was strong concordance with the APEX array, but only the RP genechip detected novel variants. For example, identification of a novel mutation in CRB1 revealed a patient, who also had a single previously known CRB1 mutation, to be a compound heterozygote. In some individuals, potentially pathogenic variants were discovered in more than one gene, consistent with the existence of disease modifier effects resulting from mutations at a second locus.Conclusions: The RP genechip provides the significant advantage of detecting novel variants and could be expected to detect at least one pathogenic variant in more than 50% of patients. The APEX array provides a reliable method to detect known pathogenic variants in autosomal recessive RP and simplex RP patients and is commercially available. High-throughput genotyping for RP is evolving into a clinically useful genetic diagnostic tool.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

variants pathogenic mutations novel known recessive autosomal genechip simplex patients apex diagnostic array potentially identified throughput detecting genes high detect

Purpose: To determine visual and anatomic outcomes for patients with persistent fetal vasculature (PFV) observed or treated with surgery.Design: Retrospective interventional consecutive case series.Participants: A total of 165 eyes of 150 patients diagnosed with PFV between January 1, 1983, and December 31, 2006, at the Bascom Palmer Eye Institute.Intervention: Patients with media opacity, progressive glaucoma, or retinal detachment who were deemed to have visual potential underwent lensectomy, 3-port vitrectomy, or both, through a limbal or pars plicata/plana approach.Main Outcome Measures: Vision, postsurgical retinal attachment, lens status, need for eye removal, and rate of complications.Results: Of the 81 eyes that underwent surgical repair, 70 had at least 6 months of follow-up (median 47 months) and 49 (70.0%) had form vision, defined as finger counting, fix-and-follow, or better. Twenty (95.2%) of 21 eyes without form vision had a significant posterior component of PFV (P < 0.001). Forty eyes had limbal incisions, and 30 eyes had pars plicata incisions. The choice of surgical approach did not have a statistically significant effect on final visual acuity or rate of complications (P=0.43). Postoperative events occurred in 28 eyes (40.0%). Retinal attachment was achieved in 54 eyes (77.1%), and 61 eyes (87.1%) were left aphakic. Eighty-four eyes were not offered surgery, of which 78 eyes (92.9%) had a posterior component of PFV. The median age at diagnosis was greater compared with the surgical group (197 vs. 67.5 days, P=0.00545). Fifty-eight eyes (69.0%) lacked form vision, and 39 eyes (46.4%) had no light perception. Posterior manifestations of PFV, bilaterality, and microphthalmia were associated with poorer visual outcomes (P < 0.001, 0.041, and 0.002, respectively).Conclusions: The majority of patients receiving surgical intervention for PFV achieved form vision. Posterior disease, microphthalmia, glaucoma, and amblyopia limited visual acuity outcomes even after aggressive intervention. The choice of limbal versus pars plicata approach produced similar visual and anatomic outcomes without a significant difference in rate of complications.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

vision eyes visual patients outcomes surgery follow persistent fetal form months without anatomic retinal underwent glaucoma attachment december opacity counting

Purpose: To report the prevalence and distribution of eye conditions and visual impairment and associations with early social and biological factors using parental report of diagnosed eye conditions and additional chronic illnesses.Design: Population-based, cross-sectional study.Participants: We included 14 981 children, aged 3 years, participating in the United Kingdom Millennium Cohort Study.Methods: Data on demographic, socioeconomic, and maternal and child health factors were obtained by maternal report through structured interview and verbatim reports of diagnosed eye problems and additional chronic illnesses were recorded. Multinomial regression analyses were used to calculate risk ratios of the association of eye disease (with or without associated visual impairment), with socioeconomic and early life factors.Main Outcome Measures: Parental report of diagnosed eye conditions and other chronic illnesses.Results: Overall, at 3 years, 5.7% (95% confidence interval, 5.2?6.3%; n = 881) of children had ?1 eye condition with 0.24% (0.15?0.3%; n = 45) reported to have associated visual impairment. In the majority, time of onset was reported to be the first year of life. Eye disorders without report of visual impairment were independently associated with lower socioeconomic status, decreasing birth weight, and prematurity. Visual impairment was more likely in those of low birthweight for gestational age and from an ethnic minority group. Maternal illnesses during pregnancy were associated with eye disease without reported visual impairment, as was white ethnicity.Conclusions: Good research opportunities exist within the context of population-based general health surveys to use parental report to estimate minimum prevalence, investigate associations of eye disease with a broad range of environmental factors, and as a mechanism for ?flagging? individuals with eye disease in a population sample for further study. Our findings regarding the association of parentally reported childhood eye disease with early life factors such as modest degrees of prematurity, ethnicity and maternal ill-health warrant further investigation.Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

report visual disease impairment factors associate maternal illness early conditions diagnos chronic parental life health without population socioeconomic prevalence study

Purpose: To report our experience of deep anterior lamellar keratoplasty (DALK) in children.Design: Retrospective case note review.Participants: Nine patients (13 eyes) aged from 13 weeks to 14 years, 11 months at the Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children National Health Service (NHS) Trust, London, United Kingdom.Methods: A study of all pediatric patients undergoing DALK from February 2002 to October 2008 was undertaken. Deep anterior lamellar keratoplasty was attempted in 9 children (13 eyes); the procedure was successful in 11 eyes, and 2 eyes progressed to penetrating keratoplasty (PKP). One eye underwent repeat DALK. Preoperative examination included electrophysiology, ultrasound biomicroscopy (UBM), and slit-lamp biomicroscopy.Main Outcome Measures: Complications and visual acuity at last follow-up.Results: Five patients had mucopolysaccharidoses (MPS), 3 patients had scarring presumed to be infectious, and 1 patient had keratoconus. Because of the failure of follow-up and loose sutures, 1 child with MPS had an epithelial rejection and the operation was repeated successfully. All grafts showed good graft clarity 10 to 80 months after grafting with visual acuities ranging from 0.28 to 1.0 logarithm of the minimum angle of resolution. Two children with nonspecific causes of scarring showed good visual acuities 24 to 51 months post-DALK. Two children who had conversion to PKP were lost to follow-up because they had moved abroad. In 4 of the 5 children with MPS, established techniques of DALK could not be performed because of excessive glycosaminoglycans (GAGs) in the stroma. Ultrasound biomicroscopy was used to guide trephination depth in the first instance. In 1 child with MPS, viscodissection was successfully used. All clinically diagnosed scars were histologically confirmed, and electron microscopy of corneal buttons confirmed the diagnosis in patients with MPS.Conclusions: Deep anterior lamellar keratoplasty should be considered in children with MPS and partial-thickness scars. In MPS, viscodissection and the ?big bubble? technique may not be useful if there are excessive GAGs in the stroma.Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references.

children patients keratoplasty dalk anterior lamellar eyes deep visual biomicroscopy months follow acuity ultrasound successfully stroma viscodissection confirm disclosure scars

Purpose: To evaluate changes in the spherical equivalent (SE) refractive error and astigmatism in Korean patients with accommodative esotropia.Design: Retrospective cases series.Participants: A total of 111 patients with accommodative esotropia who received at least 2 years of follow-up after receiving prescription spectacles.Methods: Patients were divided into groups according to the age at which spectacles were prescribed (youngest, middle, and oldest age groups), initial degree of SE refractive error (lowest, moderate, and highest SE group), initial degree of astigmatism (least, moderate, and most astigmatic group), and presence of amblyopia (amblyopic or nonamblyopic). Changes in SE refractive error and astigmatism were compared between groups. Factors that significantly influenced changes in refractive error were analyzed using mixed linear models.Main Outcome Measures: Changes in SE refractive error and changes in astigmatism according to the duration of time after the initiation of wearing spectacles.Results: Patients were followed up for a mean of 7.55±3.59 years. Although an initial increase in SE was noted in the youngest-age group, an overall decreasing tendency in SE refractive error during the follow-up period was noted in the youngest (P < 0.01, mixed linear model), the middle (P < 0.01), and the oldest (P < 0.01) age groups. Amblyopic eyes showed greater decreases in SE compared with nonamblyopic eyes (P=0.01). The most hyperopic group showed the greatest decrease in hyperopia over time (P=0.01). The initial degree of hyperopia (P < 0.01) and amblyopia (P < 0.01) showed significant associations with changes in SE refractive error. The initial degree of astigmatism (P < 0.01) showed a significant association with changes in astigmatism.Conclusions: Patients with accommodative esotropia showed a continuous decrease in SE refractive error over time. Changes in refractive error in patients with accommodative esotropia may be influenced by both spectacle wearing and amblyopia.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

error refractive changes patients astigmatism initial accommodative groups group youngest spectacles follow note years degree esotropia least according moderate prescription

Objective: Congenital cranial dysinnervation disorders (CCDDs) are developmental abnormalities involving the hypoplasia or aplasia of the cranial nerves with muscle dysinnervation. This study aimed to determine if congenital superior oblique palsy with superior oblique hypoplasia also can be classified as a CCDD.Design: Observational case series.Participants: Ten patients with superior oblique hypoplasia.Methods: Ophthalmologic examination and thin-section magnetic resonance imaging (MRI) at the brainstem level as well as across the orbit were performed in 10 patients with superior oblique hypoplasia. To confirm the accuracy of the procedure, the results obtained were compared with those of a control group comprising 12 children by using the same technique.Main Outcome Measures: Examination of ductions and versions, 3-step test, angle of deviation, and presence of the trochlear nerve and superior oblique hypoplasia on MRI.Results: Trochlear nerve was absent on the affected side in 10 patients with confirmed hypoplastic superior oblique muscles. The trochlear nerves as well as normal-sized superior oblique muscles were observed in 24 (100%) of 24 eyes screened as controls.Conclusions: Congenital superior oblique palsy with superior oblique hypoplasia also can be classified as a CCDD by the MRI documentation of congenital aplasia of the trochlear nerve.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

oblique superior hypoplasia trochlear nerve congenital patients dysinnervation examination cranial classified muscles ccdd aplasia nerves confirm palsy main materials absent

Objective: The pathogenesis of diabetic papillopathy largely is unknown, but case reports suggest that it may follow rapidly improved metabolic control. The present study was designed to investigate this hypothesis.Design: Retrospective case-control study.Participants: Two thousand sixty-six patients with type 1 diabetes.Methods: Review of clinical, photographic, and clinical chemistry records from a large diabetology and ophthalmology unit between 2001 and 2008.Main Outcome Measures: Simultaneous, bilateral diabetic papillopathy.Results: The mean follow-up was 4.9 years. During 10 020 patient-years of observation, bilateral diabetic papillopathy developed in 5 patients. During the year preceding this incident, all 5 patients had experienced a decrease in glycosylated hemoglobin A1c (HbA1C) at a maximum rate of ?2.5 (mean) percentage points per quarter year, which was significantly different from the changes in HbA1C observed in the remainder of the study population (P

diabetic papillopathy study bilateral patients years follow metabolic design mean case during clinical year main patient observ sixty hypothesis points

Purpose: To review the findings of dilated fundus examinations (DFEs) in patients with the diagnosis of corneal metal foreign body (CMFB) and to assess the likelihood of concomitant intraocular foreign body (IOFB) in this clinical setting.Design: Retrospective, case review series.Participants: All 288 cases with a new diagnosis of CMFB that had a documented DFE in the emergency department at Massachusetts Eye and Ear Infirmary from January 1, 2008, to December 31, 2008. In addition, all 9 separate cases of metal IOFB seen in the same time period were also reviewed.Methods: The medical records of all patients were individually reviewed.Main Outcome Measures: The DFE findings of each visit were analyzed in addition to mechanism of injury, visual acuity and anterior segment abnormalities.Results: Of the 288 CMFB cases, all but 1 presented without corneal or conjunctival laceration. The etiologies of the injuries included low- and high-velocity impact. Best-corrected visual acuity ranged between 20/15 and 20/150. The anterior chamber (AC) reaction ranged from quiet to 4+ cells. None of the DFEs revealed an IOFB. Only 1 case had a posterior segment abnormality related to the injury?commotion retinae in the setting of an explosion. There were 14 cases with unrelated DFE findings. Among the separate 9 cases of metal IOFB reviewed, all had a history of high-velocity injury and evidence of corneal or conjunctival laceration. In 1 of the 9 cases, the IOFB was protruding from the cornea; in 2 cases, IOFBs were seen on DFE. Six cases were diagnosed by computed tomography. All documented AC examinations for this group of patients had significant findings such as 4+ cells, hyphema, or lens fragments.Conclusions: The finding of IOFB on a DFE for patients with a CMFB without clinical evidence of penetrating injury is very rare.Financial Disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

cases iofb review injury patients findings foreign metal corneal cmfb intraocular body examinations conjunctival velocity separate without visual setting dfes

Purpose: To describe a case series of patients with anterior orbital invasion by medial canthal basal cell carcinoma (BCC) managed with non-exenterating surgery.Design: International, multicenter, retrospective, noncomparative, consecutive case series.Participants: Twenty patients identified from the individual institutions' databases with histologically confirmed orbital invasion by periocular BCC.Methods: Examination of charts, relevant imaging, and histopathologic data.Main Outcome Measures: Demographics; clinical characteristics and radiologic features; histopathologic features; surgical techniques for excision, reconstruction, and subsequent procedures; complications; visual acuity; and recurrence.Results: Twenty patients were identified. Twelve of 20 patients (60%) had recurrent BCCs, with 1 patient having had prior radiotherapy for previously incomplete excision. Eighteen of 20 patients (90%) had a palpable mass, 16 of 20 patients (80%) had clinical involvement of the nasolacrimal system, and 1 of 20 patients (5%) had limited extraocular movements. Preoperative radiologic evidence of orbital invasion was found in 10 of 20 patients (50%). Histologic evidence of orbital invasion was present in every patient, the subtypes being infiltrative (9/20, 45%), nodular (4/20, 20%), micronodular (2/20, 10%), multifocal (1/20, 5%), and mixed (4/20, 20%); extratumoral perineural invasion was present in 1 patient (5%). Final margins were clear in 18 of 20 patients (90%), positive in 1 of 20 patients (5%), and unclear in 1 of 20 patients (5%). Reconstruction was by direct closure in 1 patient and by a variety of standard oculoplastic flaps and grafts in 19 of 20 patients (95%). Twelve of 20 patients (60%) had postoperative extraocular muscle movement restriction, and 15 of 20 patients (75%) had epiphora. Subsequent revision procedures were needed in 12 of 20 patients (60%), including insertion of a lacrimal bypass tube and revision of medial canthal position. At a mean follow-up of 38 months, 18 of 20 patients (90%) were still alive (2 deaths due to other causes) with 1 recurrence (exenterated). Postoperative visual acuity was within 2 Snellen lines of preoperative visual acuity in 17 of 20 patients (85%).Conclusions: With careful planning and margin control, conservative surgery in this highly selected group proved possible with a low rate of disease recurrence, albeit with a relatively short follow-up. Postoperative complications, such as epiphora and ophthalmoplegia, were largely expected; most patients underwent subsequent revision procedures to address these and other complications.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

patients orbital invasion patient visual canthal revision subsequent complications surgery acuity medial procedures recurrence postoperative identified features cell present epiphora

Purpose: To examine Müller's muscle's horizontal extensions in relation to the peribulbar smooth muscle network.Design: Observational anatomic study.Participants: Twenty postmortem orbits (10 right, 10 left) of 15 Asians (8 males, 7 females; age range at death, 61?93 years; mean age, 78.4 years) fixed in 10% buffered formalin.Methods: After performing a full-thickness 360° incision of the periosteum around the circumference of the orbit, the periosteum was elevated and finally detached near to the orbital apex. Nerves, blood vessels, and the nasolacrimal duct arising from the orbital wall were cut. The lateral orbital wall then was removed at approximately 3 cm posterior to the orbital rim and the retrobulbar content was incised with a sharp scalpel in a coronal plane. The removed orbital content was incised at a plane passing from a point located 15 mm superior to the upper eyelid margin and the globe equator at 3- and 9-o'clock areas. The sliced specimens were dehydrated and embedded in paraffin, cut into 7-?m thickness sections, and then stained with Masson trichrome.Main Outcome Measures: The medial and lateral extensions of Müller's muscle in relation to the peribulbar smooth muscle network.Results: In all specimens, Müller's muscle extended medially and laterally. The medial extension reached the medial rectus muscle pulley, which is rich in smooth muscle fibers. The lateral extension reached the lateral rectus muscle pulley by passing through the lacrimal gland fascia of the palpebral lobe, in which 12 specimens also showed a direct extension to the lateral rectus muscle pulley in the posterior part.Conclusions: Müller's muscle has a medial and a lateral extension to the peribulbar smooth muscle network. These new findings indicated that Müller's muscle is not an independent structure in the upper eyelid, but rather a component of the peribulbar smooth muscle network.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

muscle smooth mller lateral peribulbar orbital network extension medial pulley specimens rectus periosteum wall relation posterior eyelid extensions upper plane

Diabetic macular edema (DME) is the most common cause of decreased visual acuity among diabetic subjects. Traditional methods of evaluating the macula area including slit-lamp biomicroscopy, fluorescein angiography, and stereo fundus photography are relatively insensitive to small changes in retinal thickness. Substantial differences also exist between experienced retinal specialists in defining the extent and location of retinal thickening in a given patient.

retinal edema diabetic thickening angiography changes fluorescein between subjects location indexdiabetic common patient methods acuity traditional insensitive biomicroscopy laser slit

Inferior detachments occurring after cataract surgery have peculiar findings such as multiple and tiny retinal breaks (RB), far peripheral location of breaks, unclear break morphology, inadequate view of the fundus, greater extent, and higher incidence of macular detachment.

retinal breaks surgery break pseudophakic fundus morphology occurring extent detachments cataract detachment peculiar multiple unclear tiny incidence greater macular location

Previous investigations have shown an association between myopia and a reduced prevalence of exudative age-related macular degeneration and proliferative diabetic retinopathy. Other studies have revealed that intraocular neovascularization is associated with vascular endothelial growth factor (VEGF), while other cytokines such as monocyte chemoattractant protein-1 (MCP-1), intercellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-1 (VCAM-1) indirectly contribute to the neovascular process. Since the reasons for the association between myopia and a reduced prevalence of neovascular age-related macular degeneration and diabetic retinopathy remain uncertain, we conducted the present study to examine whether the concentrations of cytokines associated with intraocular neovascularization were associated with the refractive error in normal eyes.

associate vegf adhesion molecule degeneration study vascular association diabetic cytokines reduc retinopathy macular neovascular prevalence between myopia relate intraocular refractive

The recent report from the DRCR.net provides further important clinical information about the potential role of surgical management for diabetic macular edema in the presence of vitreomacular traction. The study showed that after vitrectomy, while 1 in 3 patients had improved vision, a significant proportion (1 in 4) had poorer vision. The key questions, however, remain unanswered?who would most likely benefit from surgery and who would be at risk of more vision loss after surgery?

vision surgery vitrectomy diabetic macular loss patients unanswer presence management study drcr significant surgical information poorer risk show further likely

Different systemic and local factors are thought to influence an individual's intraocular pressure (IOP). There can be a clinically significant IOP rise when going from an upright to a horizontal body position, and the magnitude of the IOP change is greater in glaucomatous eyes. As patients usually spend a significant portion of their lives in the horizontal position (mainly during sleep) this is highly relevant. In an elegant study, Buys et al investigated the effects of a 30-degree head-up sleeping position on nocturnal IOP in patients with features of progressive glaucoma despite good IOP control during office hours. The authors reported a significant IOP reduction (mean difference of 3.2 mmHg) in the head-up position when compared with the horizontal position (lying flat).

position significant horizontal head patients during pressure local highly factors lying mean buys influence systemic mmhg greater investigate magnitude flat

We thank Drs Prata and Kanadani for their interest in our article and support of our findings. We would also like to thank them for pointing out the previous publication of Jain et al., which compared the Mackay-Marg tonometer with the pneumatonograph in measuring intraocular pressure (IOP) in various postures in normal and glaucoma eyes. Although this paper only assessed IOP at limited time points (sitting, 2 and 5 minutes after lying flat and 2 minutes after lying with head elevated 15 degrees) they reported a reduced IOP in the 15 degree head-up position compared with 5 minutes supine, which in the glaucoma population was 0.64 mmHg with the pneumatonograph and 0.86 mmHg with the Mackay-Marg (statistics were not provided for this comparison). These results are consistent with our study which reported a 3.18 mmHg (95% confidence interval 0.25-6.1 mmHg) decrease in mean IOP during the whole sleep period (2400-0800) in the 30 degree head-up position compared with flat position.

mmhg position head minutes compar lying flat glaucoma degree pneumatonograph marg mackay report thank author prata publication period assess decrease

We read with interest the recent article by Ezra et al concerning the associations of floppy eyelid syndrome (FES). FES is not uncommon in our own clinical practice and, as previously reported, many cases we encounter were previously misdiagnosed or considered unspecified chronic ocular surface inflammations. Taking into account the important systemic associations of FES, such as the obstructive sleep-apnea syndrome and the risks they carry, the early recognition of the condition is of high clinical value. Accordingly, we would like to add a comment concerning a clinical association of FES we observe frequently, which we believe may assist clinicians in recognizing this condition.

clinical previously associations syndrome condition concerning floppy interest chronic apnea association misdiagnos blepharoptosis ocular eyelidwe report important comment assist recognizing

We would like to thank Detorakis et al for their points regarding the observation of lateral ptosis and lateral canthal laxity in patients with floppy eyelid syndrome (FES). In our case control study, we did indeed find that medial canthal laxity was significantly associated with FES when compared with the control group. The presence of lateral canthal laxity was not found to be significantly associated, although it must be noted that the study was not powered to discern these parameters. Concurrent lateral canthal laxity and ptosis may indeed be a feature of FES as the lateral canthal tendon accepts insertions from the lateral levator aponeurosis. However, the specificity and sensitivity of this feature are questionable as ptosis is a common sequela of mechanical trauma to the upper lid and is present in a range of conditions.

lateral canthal laxity ptosis indee feature associate study significantly aponeurosis syndrome presence patients medial points eyelid specificity however trauma author