Transepithelial versus Epithelium-off Corneal Collagen Cross-linking for Corneal Ectasia: A Systematic Review and Meta-analysis.

TOPIC: To evaluate the safety and efficacy of transepithelial corneal cross-linking in comparison with the established epithelium-off technique for corneal ectasia. CLINICAL RELEVANCE: Considerable debate exists regarding whether transepithelial and epithelium-off cross-linking are comparable in their safety and efficacy. METHODS: We searched 16 electronic databases, including Medline, Embase, Web of Science, and the grey literature, current to July 8, 2020, for randomized controlled trials comparing transepithelial and epithelium-off cross-linking for corneal ectasia. We excluded studies evaluating cross-linking for nonectatic indications, as well as non-randomized controlled trials. Our primary outcome was the change in maximal keratometry (Kmax) at 12 months after cross-linking, and we considered additional topographic, visual, and safety outcomes. We summarized our analyses by calculating weighted mean differences (MDs) with associated 95% confidence intervals (CIs) for continuous outcomes and relative risks (RRs) with corresponding 95% CIs for dichotomous outcomes. We conducted trial sequential analysis to determine whether the required information size was met for each outcome. The quality of individual trials was evaluated using the Cochrane Collaboration's risk of bias assessment tool, and the evidence was assessed at an outcome level using the Grading of Recommendations Assessment, Development, and Evaluation methodology. RESULTS: Twelve studies totaling 966 eyes were eligible. A significant difference was found between transepithelial and epithelium-off cross-linking groups in the change in Kmax at 12 months (MD, 0.75; 95% CI, 0.23-1.28; P = 0.004; primary outcome) and at longest follow-up (MD, 1.20; 95% CI, 0.62-1.77; P < 0.001; secondary outcome) after treatment. No significant difference was found between the 2 groups when examining uncorrected distance visual acuity (MD, 0.04; 95% CI, -0.06 to 0.14; P = 0.386) or corrected distance visual acuity (MD, 0.01; 95% CI, -0.06 to 0.09; P = 0.732). Transepithelial cross-linking was associated with significantly fewer complications than the epithelium-off approach (RR, 0.22; 95% CI, 0.06-0.79; P = 0.020), although it was associated with an increased rate of disease progression at 12 months after treatment (RR, 4.49; 95% CI, 1.24-16.25; P = 0.022). The required information size was met for our primary outcome and trial sequential analysis supported the conventional meta-analysis. The quality of evidence was rated as moderate using the Grading of Recommendations Assessment, Development, and Evaluation methodology. DISCUSSION: The efficacy of transepithelial cross-linking remains inferior to the epithelium-off approach, although it is significantly safer.

Biometric characteristics of eyes with exfoliation syndrome and occludable as well as open angles and eyes with primary open-angle glaucoma.

OBJECTIVE: To describe differences in axial length scan (A-scan) and ultrasound biomicroscopy (UBM) parameters in eyes with exfoliation syndrome (XFS) and occludable angles (XFSOc), XFS and open angles (XFSOp), and eyes with primary open-angle glaucoma (POAG). DESIGN: Cross-sectional descriptive study. PARTICIPANTS: Seventy-two eyes of 72 patients (mostly Caucasians) were identified through glaucoma clinics at the University of Ottawa;19 eyes had XFSOc, 31 eyes XFSOp, and 22 eyes POAG. METHODS: After a detailed ophthalmic history and examination, A-scan biometry and UBM were done to assess anterior segment parameters: central anterior chamber depth (ACD), lens thickness, trabecular meshwork-iris angle, and angle opening distance (AOD). Lens/axial length factor and the relative lens position were calculated. The above measurements were compared across the 3 groups. RESULTS: We found statistically significant differences in measurements among the groups. ACD was shallowest in eyes with XFSOc (1.88 [SD 0.07] mm), followed by XFSOp (2.37 [SD 0.05] mm), and POAG (2.64 [SD 0.08] mm). XFSOc had thicker lenses (5.28 [SD 0.09] mm) compared with the other groups: XFSOp (5.03 [SD 0.06] mm) and POAG (4.84 [SD 0.09] mm). Lens/axial length factor was highest in XFSOc (2.34 [SD 0.05] mm) versus XFSOp (2.12 [SD 0.03] mm) and POAG (2.02 [SD 0.05] mm); relative lens position was lowest in XFSOc (2.27 [SD 0.03] mm) versus XFSOp (2.31 [SD 0.02] mm) and POAG (2.36 [SD 0.03] mm). CONCLUSIONS: Eyes with XFSOc in our study demonstrated lens thickening and shallow central ACD versus eyes with XFSOp and eyes with POAG. This suggests the possibility that cataract formation and (or) zonular weakness may contribute to the development of an occludable angle in eyes with XFS.

Large cell carcinoma of the lung and squamous cell carcinoma of the oropharynx presenting as uveitis.

Ocular manifestations of systemic malignancy may precede the diagnosis of cancer; some intraocular lymphomas can present initially as chronic uveitis. The two cases described were found to have underlying carcinomas of the lung and oropharynx. Both presented with chronic uveitis and decreased visual acuity that were not responding to antiinflammatory therapy.

Transepithelial versus epithelium-off corneal collagen cross-linking for corneal ectasia: protocol for a systematic review, meta-analysis and trial sequential analysis of randomised controlled trials.

INTRODUCTION: Corneal ectasias are progressive, degenerative ocular diseases defined by abnormal structural changes in the cornea, leading to distortion of vision and substantial reduction in quality of life. Corneal collagen cross-linking (CXL) increases the biomechanical rigidity of the cornea and has been shown to halt ectatic processes. The established CXL protocol requires removal of the corneal epithelium. However, some surgeons have proposed transepithelial approaches to enhance patient recovery and minimise adverse events. Whether novel transepithelial approaches are as effective in arresting ectasia as the established epithelium-off protocol remains unclear. This study will systematically review the evidence on transepithelial CXL approaches and compare it to the epithelium-off protocol. METHODS AND ANALYSIS: We will include randomised controlled trials (RCTs) comparing transepithelial and epithelium-off CXL for any corneal ectasia. We will search 16 electronic databases including MEDLINE and Embase, as well as the grey literature. Two reviewers will independently screen search results to identify eligible studies, complete data abstraction and conduct quality assessment. We will assess the quality of individual RCTs using the Cochrane risk of bias assessment tool. Our primary outcome will be the change in maximal keratometry at 12 months after treatment, and we will examine 11 additional outcomes. We will summarise our analyses by measures of association (relative risk or odds ratio) and corresponding 95% confidence intervals (CIs) for dichotomous outcomes and weighted mean differences with 95% CIs for continuous outcomes. Prespecified subgroup analyses will be conducted to explore heterogeneity. The overall quality of evidence will be rated using the Grading of Recommendations Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION: Ethics approval is not required for this systematic review as it draws from previously published data. Results of the study will be submitted to a peer-reviewed journal for publication and discussed at conferences and seminars. PROSPERO REGISTRATION NUMBER: CRD42018102069.

Generalized posterior keratoconus: clinical pathologic correlations.

CASE REPORT: A 73-year-old woman presented with bilateral generalized posterior keratoconus. The corneal thickness measured 0.320 mm paracentrally and 0.440 mm toward the periphery. The corneal specimen revealed absence of Bowman's layer and focal homogeneous oval stromal deposits that stained for amyloid. COMMENTS: Our case of generalized posterior keratoconus shows absence of Bowman's layer. The amyloid deposits, which also were noted clinically in the cornea of the fellow right eye, were most consistent with a diagnosis of polymorphous amyloid degeneration. To our knowledge, this is the first histopathological report of generalized posterior keratoconus.

Tranexamic acid in the treatment of pediatric traumatic hyphema.

BACKGROUND: This study was undertaken to determine whether a difference exists in treatment outcome between patients treated with tranexamic acid (TEA) plus topical steroids and those treated with topical steroids alone. METHODS: A retrospective cohort study was conducted to compare treatment results for children with traumatic hyphema treated with TEA and topical steroids versus topical steroids alone. Patients were identified from a chart review of the Children's Hospital of Eastern Ontario eye clinic and the Queen's Department of Ophthalmology emergency eye clinic for charts coded "traumatic hyphema." The primary outcomes measured included visual acuity, rebleed rate, intraocular pressure, and time to hyphema resolution. Covariates were hyphema grade, the need for medications to lower intraocular pressure, and the presence of associated ocular traumatic complications. Analysis was performed with both bivariate analysis and multivariate models. RESULTS: Two hundred and fifteen patients with traumatic hyphema were included in our study. One hundred and thirty-seven patients (63.1%) received TEA plus topical steroids, and the remaining 78 patients received topical steroids alone. There was no significant difference in rebleed rate between the TEA plus topical steroid group (1.6%) and the steroid-alone group (2.6%, p = 0.60). INTERPRETATION: Patients with traumatic hyphema treated with TEA plus topical steroids did not have a significantly lower incidence of rebleed than those treated with topical steroids alone.

Prostaglandin analogues for ophthalmic use: a cost-effectiveness analysis.

BACKGROUND: The objective of this study was to perform an economic analysis of the cost-effectiveness of prostaglandin analogues for the treatment of increased intraocular pressure (IOP). Prostaglandin analogues for ophthalmic use are more costly than alternative agents for the lowering of IOP. An important policy decision is whether to support continued open listing of these agents or to restrict them to limited use status. METHODS: The cost-effectiveness of prostaglandin analogues was assessed using a decision analytic model. Latanoprost was compared with timolol, dorzolamide, and brimonidine, and travoprost was compared with timolol separately. The effectiveness data used for this economic analysis were the number of millilitres of mercury of IOP reduction compared with baseline and the incidence of adverse events resulting in a withdrawal of the patient from the study. Sensitivity analyses were conducted to assess the robustness of the study results. RESULTS: Compared with latanoprost, dorzolamide was not a cost-effective strategy. Compared with brimonidine, latanoprost provided a higher IOP reduction with an incremental cost-effectiveness ratio of $16.17 (base case), but the additional IOP reduction with latanoprost was obtained at a cost higher than the average cost per millimetre of mercury reduction obtained with brimonidine. Compared with timolol, latanoprost and travoprost had a positive incremental cost-effectiveness ratio of $34.48 and $39.06, respectively. INTERPRETATION: For the first-line treatment of glaucoma and elevated IOP, latanoprost is a more cost-effective strategy than dorzolamide and brimonidine. Latanoprost and travoprost are more effective than timolol but also more expensive. For those for whom timolol is not contraindicated, it would be preferable, from a cost-effectiveness standpoint, to initiate treatment with timolol and reserve the prostaglandin analogues as an alternative treatment or as add-on therapy for patients not achieving a clinical response with timolol. Better treatment compliance associated with these analogues improves their cost-effectiveness.

The value of corneoscleral rim cultures in keratoplasty: a systematic review and cost-effectiveness analysis.

PURPOSE: This study evaluated the performance of donor corneoscleral rim cultures for predicting infection after corneal transplantation, and determines if there is a correlation between positive corneoscleral rim cultures and postkeratoplasty infection. DESIGN AND DATA SOURCES: This was a systematic review, prognostic accuracy analysis, and cost-effectiveness analysis. Databases searched were: Medline (Ovid), Embase (Ovid), CINAHL, Cochrane Library, Web of Science, and BioSis Previews. Grey literature was also explored. MATERIALS AND METHODS: A systematic review was conducted to locate published and unpublished studies. All studies examining corneal button contamination and its association with endophthalmitis and keratitis posttransplantation were included. Extracted data were used to calculate sensitivity, specificity, positive predictive value, and negative predictive value. Cost data from the London Laboratory Services Group in London, ON were used to calculate the cost-effectiveness of culturing donor rim cultures. RESULTS: Of 7,870 grafts, 954 had a positive rim culture (12.1%), with 12 patients going on to develop keratitis or endophthalmitis (1.3%). The prevalence of keratitis and endophthalmitis in this study was 0.15%, and the positive predictive value 1.5%. Of the 12 infections, nine were fungal and three bacterial. The estimated cost of a positive and negative test result was CAD$45.99 and $14.15, respectively. The cost to run all 7,870 tests was estimated to be $141,735.86, with an incremental cost-effectiveness ratio of $40,215.70. CONCLUSION: There was a significant divergence between bacterial and fungal rim-culture results. Bacterial cultures predicted clinical infection poorly, did not change management, and were expensive. Fungal cultures predicted clinical infection in over 10% of patients, had the potential to change management, and were 40% less expensive than full rim culturing (bacterial and fungal tests). Fungal rim cultures may be considered in areas where fungal infection rates are high.

A simple, cross-linked collagen tissue substitute for corneal implantation.

PURPOSE: To develop a simple corneal substitute from cross-linked collagen. METHODS: Porcine type I collagen (10%; pH 5), was mixed with 1-ethyl-3-(3-dimethylaminopropyl)carbodiimide (EDC) and N-hydroxysuccinimide (NHS). The final homogenous solution was molded to corneal dimensions, cured, and then implanted into rabbits and minipigs by lamellar keratoplasty. The implants were followed for up to 6 months after surgery. Clinical examinations of the cornea included detailed slit lamp biomicroscopy, in vivo confocal microscopy, topography and esthesiometry for nerve function. Histopathologic examinations were also performed on rabbit corneas harvested after 6 months. RESULTS: Cross-linked collagen (refractive index, 1.35) had optical clarity superior to human corneas. Implanted into rabbit and porcine corneas, only 1 of 24 of the surgical corneas showed a slight haze at 6 months after surgery. All other implants showed no adverse reactions and remained optically clear. Topography showed a smooth surface and a profile similar to that of the contralateral nonsurgical eye. The implanted matrices promoted regeneration of corneal cells, tear film, and nerves. Touch sensitivity was restored, indicating some restoration of function. The corneas with implants showed no significant loss of thickness and demonstrated stable host-graft integration. CONCLUSIONS: Collagen can be adequately stabilized, using water soluble carbodiimides as protein cross-linking reagents, in the fabrication of corneal matrix substitutes for implantation. The simple cross-linking methodology would allow for easy fabrication of matrices for transplantation in centers where there is a shortage of corneas, or where there is need for temporary patches to repair perforations in emergency situations.

Conjunctival T-cell lymphoma: a clinicopathologic case report.

OBJECTIVE: To report a patient with conjunctival T-cell lymphoma, an extremely rare entity. DESIGN: Single case report. METHODS: Based on clinical examination, an excisional biopsy and immunostaining were performed on the conjunctival lesion. For management, we excised and performed triple freeze-thaw cryotherapy to the involved area, and we consulted the oncology service. MAIN OUTCOME MEASURES: T-cell and B-cell markers, and clinical examination of the lesion. RESULTS: Both examination and laboratory assessment revealed no evidence of systemic involvement. Conjunctival biopsy showed expansion of the substantia propria with an infiltrate of chronic inflammatory cells (including lymphocytes, plasma cells, and eosinophils), and prominent lymphocyte exocytosis with reactive epithelial changes. The CD-45 RO (T-cell marker) was strongly positive, whereas the CD-20 (B-cell marker) was negative. The T-cell receptor gene rearrangement was positive with beta clonality, confirming the diagnosis of T-cell lymphoma. CONCLUSIONS: T-cell lymphoma is a rare but possible diagnosis of gelatinous conjunctival lesions. The oncology consultants were reluctant to treat the patient with systemic chemotherapy or radiation because extraconjunctival extension could never be documented. The answer to the question of what is the most appropriate treatment for conjunctival T-cell lymphoma remains unknown.

Efficacy of omega-3 fatty acids in preventing age-related macular degeneration: a systematic review.

TOPIC: What is the evidence for efficacy of dietary and/or supplemental omega-3 fatty acids in preventing age-related macular degeneration (AMD)? CLINICAL RELEVANCE: Age-related macular degeneraion is the leading cause of blindness and vision impairment in persons older than 50 years living in North America. There is no cure for AMD, and treatment does not usually restore vision but only prevents disease progression to a modest degree. omega-3 fatty acids are considered potentially important antioxidants and are being considered as an arm of the Age-Related Eye Disease Study II clinical trial. METHODS/LITERATURE REVIEWED: Keywords were searched in Medline, Pre-Medline, Embase, and the Cochrane Library on Ovid. There was no restriction on the year or language of publication. RESULTS: There were 6 observational studies found, but the specific outcomes, exposures, and covariates studied all varied greatly. CONCLUSION: There is some clinical evidence for protection of AMD from omega-3 fatty acids. However, the results are not consistent. Hence, our conclusion is that this issue is neither clearly supported nor refuted by the present world literature. This is an intriguing and extremely important question but needs further study first with prospective cohort designs and, if positive, randomized clinical trials.

Conjunctival mucoepidermoid carcinoma in a patient with ocular cicatricial pemphigoid and a review of the literature.

Invasive mucoepidermoid carcinoma of the conjunctiva of the left lower eyelid was diagnosed in an orbital exenteration specimen of a 57-year-old woman, after a biopsy of the same lesion was originally diagnosed as invasive squamous cell carcinoma. The woman was undergoing mitomycin C injections for ocular cicatricial pemphigoid, diagnosed in the same eye 2 years prior to identification of the neoplasm. The tumor invaded the cornea, sclera, lacrimal gland, regional small nerves, and lymphatics, but did not show intraocular involvement. The original biopsy specimen was reassessed with stains for mucin and found to be mucoepidermoid carcinoma of the conjunctiva. We reviewed 21 cases of mucoepidermoid carcinoma of the conjunctiva described to date in the English literature. We believe this number underestimates the true incidence of this condition, as it is frequently misdiagnosed both clinically and histopathologically. Evaluating suspected aggressive squamous cell carcinoma with special stains for mucin generally helps to identify mucoepidermoid carcinoma of the conjunctiva. More extensive surgical excision than that used for squamous cell carcinoma should be implemented in the management of mucoepidermoid carcinoma of the conjunctiva to prevent recurrence.

Bilateral acanthamoeba keratitis and treatment strategy based on lesion depth.

CASE REPORT: This report summarizes a case of bilateral acanthamoeba keratitis in an 18-year-old male contact-lens wearer. Early diagnosis is important and combination treatment is recommended, tailored to the depth of the lesions. COMMENTS: Treatment can be difficult, particularly since amoebic cysts are especially resistant. Surgery may be required for advanced cases. Suggestions for reducing corneal toxicity to antiamoebic therapy are included.

Perspectives on low vision service in Canada: a pilot study.

BACKGROUND: A review of the literature and current practice patterns for vision rehabilitation care in Canada provide a basis for this pilot study, which was undertaken to explore related issues from the perspectives of older adults and low vision service providers. The pilot study was overseen by a number of collaborators whose names are listed at the end of this paper. METHODS: Thirty people aged 60 years or older who had vision impairments and were clients of the Canadian National Institute for the Blind were surveyed by telephone. Ophthalmologists, optometrists, and opticians completed a mail questionnaire. Vision rehabilitation practitioners and nurses, ophthalmic technicians, and service providers for low vision technical aids were surveyed by e-mail. RESULTS: Ophthalmologists are a primary source of referrals to low vision services, but low functional vision does not always trigger such referrals, nor are referrals always timely. Optometrists are primary providers of low vision services, including dispensing of low vision aids, but such aids are expensive, and inadequate training in their use may contribute to noncompliance. Costs associated with providing low vision assessments and services are higher than compensation to vision service providers, whose capacity to meet increasing demand is limited. In addition, there are disparities between rural and urban areas and among provinces in the availability of, and funding for, services and aids. INTERPRETATION: On the basis of the findings, an emergent theory is proposed on the consequences resulting from lack of planning and standards for vision rehabilitation care. The implications of this study form the basis for further research.

Trabeculectomy and phacotrabeculectomy, with mitomycin-C, show similar two-year target IOP outcomes.

BACKGROUND: To determine the efficacy and safety of trabeculectomy with mitomycin-C (trabMMC) compared with that of single-site phacotrabeculectomy with mitomycin-C (phacotrabMMC) in glaucoma patients at increased risk for filtering surgery failure. METHODS: Eighty-five consecutive eyes that underwent trabMMC and 105 consecutive eyes that underwent phacotrabMMC were retrospectively compared up to 2 years postoperatively with respect to intraocular pressure (IOP), number of glaucoma medications, and surgical complication rates. The primary outcome was the difference in the cumulative proportion of patients meeting the target IOP range at 2 years. Secondary outcomes included mean postoperative IOP, mean IOP drop from baseline, mean number of glaucoma medications, and surgical complication rates. RESULTS: Baseline characteristics were similar in the 2 groups and most patients had advanced glaucoma with a similar upper limit of the target IOP range (15.5 +/- 2.6 mm Hg for trabMMC vs. 15.3 +/- 2.1 mm Hg for phacotrabMMC, p = 0.56). Loss to follow-up was significant in both groups (almost 50% over 2 years). A statistically similar proportion of patients achieved their target IOP range at 1 and 2 years in both groups: the cumulative success rate at 2 years was 29.04% and 22.91% (p = 0.44) without add-on glaucoma therapy, 25.38% and 25.22% (p = 0.60) with the use of up to 2 glaucoma medications, and 30.01% and 25.17% (p = 0.81) with the use of any number of glaucoma medications, in the trabMMC and phacotrabMMC groups, respectively. Mean postoperative IOP was also similar between the 2 groups at almost all follow-up times up to 2 years (13.56 +/- 4.92 mm Hg in trabMMC vs. 13.98 +/- 4.74 mm Hg in phacotrabMMC at 2 years, p = 0.67). The mean IOP drop from baseline was significantly greater in the trabMMC group throughout the study period (-10.87 +/- 8.33 mm Hg in trabMMC vs. -6.15 +/- 7.01 mm Hg in phacotrabMMC at 2 years, p = 0.003); however, baseline IOP was also higher in the trabMMC group (26.1 mm Hg vs. 20.3 mm Hg, p < 0.0001). Serious postoperative complication rates were similarly low between the 2 groups. INTERPRETATION: TrabMMC and phacotrabMMC may be equally safe and effective in bringing IOP to within an acceptable target range over 2 years in advanced glaucoma patients at increased risk for filtering surgery failure, although trabMMC appears to be associated with greater IOP lowering from baseline.

The evidence for efficacy of omega-3 fatty acids in preventing or slowing the progression of retinitis pigmentosa: a systematic review.

BACKGROUND: Studies in preterm and term human infants have suggested that a dietary supply of omega-3 fatty acids is essential for optimal visual development. Several basic science studies support the hypothesis that omega-3 fatty acids may be useful therapeutic agents for pathologies of the retina and lens. As part of a systematic review of the effect of omega-3 fatty acids on eye health, the purpose of this study was to conduct a systematic review of the scientific-medical literature to appraise and synthesize the evidence for the effects of omega-3 fatty acids in preventing the development or progression of retinitis pigmentosa. METHODS: A comprehensive search was undertaken in MEDLINE, PREMEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Global Health, and Dissertation Abstracts. Unpublished literature was sought through manual searches of reference lists of included studies and key review articles and from the files of content experts. Searches were not restricted by language of publication, publication type, or study design. Eligibility criteria were applied to screen eligible studies on two levels. Data extraction and quality assessment were performed. RESULTS: Six studies published between 1995 and 2004 met eligibility criteria in investigating the question of the possible value of omega-3 fatty acids in slowing the progression of retinitis pigmentosa. Meta-analysis was not performed because there was not enough available information for formal quantitative analysis. INTERPRETATION: There are trends in improvement of some retinitis pigmentosa outcomes with omega-3 fatty acids in the higher quality studies. Clinical research is preliminary in this field, however. Accordingly, definitive answers will require significantly more observational and interventional clinical research.

Characterization of lymphoproliferative lesions of the conjunctiva: immunohistochemical and molecular genetic studies.

BACKGROUND: Conjunctival lymphoproliferative lesions have not been selected for independent analysis with newer immunohistochemical and molecular genetic techniques to highlight their unique profile. METHODS: Retrospective case series examined biopsies from 16 consecutive patients with conjunctival lymphoproliferative lesions. The histopathologic, immunohistochemical, and molecular genetic features were characterized, as well as the frequency of tumour type, prognostic implications, clinical features, and treatments offered. RESULTS: The diagnosis was lymphoma in 12 cases, atypical lymphoid hyperplasia (ALH) in 1 case, and reactive lymphoid hyperplasia (RLH) in 3 cases. The primary lymphomas consisted of 4 mucosa-associated lymphoid tissue lymphomas (MALTL), 1 follicular lymphoma (FL), 2 diffuse large B-cell lymphomas (DLBCLs), 1 lymphoplasmacytic lymphoma, and 1 T-cell lymphoma. Primary lymphomas were treated with radiation (n = 7), surgery (n = 1), and topical chemotherapy (n = 1). Complete remission was achieved in 8 of 9 primary lymphomas. Two cases of recurrence to the other conjunctiva were treated with radiation and both remained disease free. Secondary lymphomas included 2 DLBCL and 1 MALTL. Complete remission was seen in 2 patients after radiation plus chemotherapy, while the patient treated with chemotherapy alone was lost to follow-up. The 1 case of ALH presented bilaterally and achieved complete remission after topical chemotherapy treatments. The 3 RLH cases were surgically managed and 2 of the 3 recurred and were subsequently excised. Eleven lymphomas were of B-cell lineage by immunophenotyping. Molecular genetic studies of immunoglobulin heavy chain (IgH) gene rearrangement by polymerase chain reaction (PCR) showed clonal bands in 6 of 12 lymphomas, 1 of 3 RLH (polyclonal by immunophenotyping) and 1 ALH. BCL2-IgH [t(14;18)] rearrangement was seen in 8 of 12 cases (1 FL, 3 DLBCLs, 4 MALTLs) by real-time quantitative PCR. INTERPRETATION: Conjunctival lymphomas are predominantly B-cell type with a high prevalence of MALTL. An unexpected finding was the BCL2-IgH rearrangement seen in 4 of 5 MALTL cases in our series. The significance of this remains unclear.

The Effects of Low-Vision Rehabilitation on Reading Speed and Depression in Age Related Macular Degeneration: A Meta-Analysis.

IMPORTANCE: Age related macular degeneration (AMD) is a progressive eye disease that, as of 2015, has affected 11 million people in the U.S. and 1.5 million in Canada causing central vision blindness. By 2050, this number is expected to double to 22 million. Eccentric vision is the target of low-vision rehabilitation aids and programs for patients with AMD, which are thought to improve functional performance by improving reading speed and depression. OBJECTIVE: This study evaluates the effect of various low-vision rehabilitation strategies on reading speed and depression in patients 55 and older with AMD. DATA SOURCES: Computer databases including MEDLINE (OVID), EMBASE (OVID), BIOSIS Previews (Thomson-Reuters), CINAHL (EBSCO), Health Economic Evaluations Database (HEED), ISI Web of Science (Thomson-Reuters) and the Cochrane Library (Wiley) were searched from the year 2000 to January 2015. STUDY SELECTION: Included papers were research studies with a sample size of 20 eyes or greater focused on AMD in adults aged 55 or older with low vision (20/60 or lower). DATA EXTRACTION AND SYNTHESIS: Two independent reviewers screened and extracted relevant data from the included articles. Standardized mean difference (SMD) was chosen as an effect size to perform meta-analysis using STATA. Fixed- and random-effect models were developed based on heterogeneity. MAIN OUTCOMES: Reading Speed and Depression Scores. RESULTS: A total of 9 studies (885 subjects) were included. Overall, a significant improvement in reading speed was found with a SMD of 1.01 [95% CI: 0.05 to 1.97]. Low-vision rehabilitation strategies including micro-perimetric biofeedback, microscopes teaching program significantly improved reading speed. Eccentric viewing training showed the maximum improvement in reading speed. In addition, a non-significant improvement in depression scores was found with a SMD of -0.44 [95% CI: -0.96 to 0.09]. CONCLUSION: A considerable amount of research is required in the area of low-vision rehabilitation strategies for patients with AMD. Based on current research, low-vision rehabilitation aids improve reading speed. However, they do not have a significant effect on depression scores in those 55 and older with AMD.

Diabetic retinopathy screening with pharmacy-based teleophthalmology in a semiurban setting: a cost-effectiveness analysis.

BACKGROUND: Diabetic eye complications are the leading cause of visual loss among working-aged people. Pharmacy-based teleophthalmology has emerged as a possible alternative to in-person examination that may facilitate compliance with evidence-based recommendations and reduce barriers to specialized eye care. The objective of this study was to estimate the cost-effectiveness of mobile teleophthalmology screening compared with in-person examination (primary care) for the diabetic population residing in semiurban areas of southwestern Ontario. METHODS: A decision tree was constructed to compare in-person examination (comparator program) versus pharmacy-based teleophthalmology (intervention program). The economic model was designed to identify patients with more than minimal diabetic retinopathy, manifested by at least 1 microaneurysm at examination (modified Airlie House classification grade of ≥ 20). Cost-effectiveness was assessed as cost per case detected (true-positive result) and cost per case correctly diagnosed (including true-positive and true-negative results). RESULTS: The cost per case detected was $510 with in-person examination and $478 with teleophthalmology, and the cost per case correctly diagnosed was $107 and $102 respectively. The incremental cost-effectiveness ratio was $314 per additional case detected and $73 per additional case correctly diagnosed. Use of pharmacologic dilation and health care specialists' fees were the most important cost drivers. INTERPRETATION: The study showed that a compound teleophthalmology program in a semiurban community would be more effective but more costly than in-person examination. The findings raise the question of whether the benefits of pharmacy-based teleophthalmology in semiurban areas, where in-person examination is still available, are equivalent to those observed in remote communities. Further study is needed to investigate the impact of this program on the prevention of severe vision loss and quality of life in a semiurban setting.

Donor age as a predictor of cornea transplant success.

BACKGROUND: The purpose of this study was to examine the association between donor age and cornea transplant success. METHODS: This retrospective cohort study comprised 116 patients who had cornea transplants performed for the first time. The primary analysis was performed to evaluate the time to graft failure as a function of donor age. Donor age was divided into 3 categories: (1) continuous, (2) younger than 65 versus 65 years and older, and (3) younger than 60 versus older than 70 years. We controlled for other variables that may affect graft outcome by multivariate modeling. The primary outcome was graft failure. RESULTS: No statistically significant association was found between time to failure and donor age [adjusted hazard ratio: 1.004 (p = 0.68) for continuous age, 1.18 (p = 0.68) for age < 65 vs. > or = 65 years, and 2.10 (p = 0.089) for age < 60 vs. > 70 years]. However, with all model-building strategies, our results demonstrated that all hazard ratios calculated were greater than 1.00 for the older versus the younger aged groups. INTERPRETATION: The influence of donor age on success of cornea transplants remains unresolved. Large, multicentre prospective cohort studies and randomized trials are needed to decisively determine the impact of donor age on cornea transplant success.