Quantitative Fundus Autofluorescence in the Developing and Maturing Healthy Eye.

Purpose: Quantitative fundus autofluorescence (QAF) enables comparisons of autofluorescence intensities among participants. While clinical QAF reports mostly focused on the healthy and diseased adult retina, only very limited data of QAF in the maturing eye are available. Here, we report QAF in a large cohort of healthy children. Methods: In this prospective monocentric cross-sectional study, 70 healthy Caucasian children (5-18 years) were multimodal imaged, including QAF and spectral domain optical coherence tomography. QAF and retinal thicknesses were measured at predefined locations (along horizontal meridian; Early Treatment Diabetic Retinopathy Study [ETDRS] grid) and correlated using custom written Fiji plugins. Standard retinae for different age groups were generated. Results: Fifty-three participants were included. QAF was low in childhood but increased steadily (P < 0.001), also at the fovea (P < 0.001), with no gender differences (P = 0.61). The QAF distribution was similar to adults showing highest values superior-temporally. At individual points, retinal thickness remained stable, while using the ETDRS pattern, the retinal pigment epithelium (RPE) thickness increased significantly with aging. Standard QAF retinae of age groups also showed an increase with aging. Conclusions: QAF can be reliably performed in young children. Function-structure correlation showed a thickening of the RPE and an increasing QAF with aging, probably related to the histologic low number of RPE autofluorescent granules at a younger age but further deposition of these granules during maturation. Standard retinae help to distinguish abnormal QAF in the diseased retina of age-matched patients. Translational Relevance: Our data bridge the gap between preclinical QAF and clinical data application and structural OCT correlation in children.

Yokoyama procedure for esotropia associated with high myopia: real-world data from a large-scale multicentre analysis.

PURPOSE: High myopic patients may develop strabismus due to globe dislocation out of the normal extraocular muscle cone. Surgical correction of this strabismus type is possible by joining the superior and lateral rectus muscles without the need for a scleral suture called the Yokoyama procedure. Data from large patient samples and the evaluation of a potential effect of an additional medial rectus recession (MRR) have been lacking so far. METHODS: We pooled retrospective patient data of 14 departments of ophthalmology in Germany and Switzerland and analysed determinants of postoperative results using multivariable regression models. RESULTS: We included 133 patients (mean age: 59.7 ± 13.4 years, surgery between 2008 and 2017) with a mean preoperative esotropia (both Yokoyama with and without MRR) of 23.8°±4.6°. The angle of preoperative esotropia increased with age. The postoperative esotropia was 8.7° ± 9.9°, and six patients were overcorrected. While preoperative esotropia was highly associated with postoperative results, we found no association of additional MRR with any of our postoperative outcome measures. The Yokoyama procedure had a higher absolute effect in patients with higher preoperative esotropia. CONCLUSION: Our study confirms the positive effect of the Yokoyama procedure on strabismus due to high myopia in large-scale real-world data. In some cases, MRR may be needed because of muscle contracture, although additional MRR statistically did not affect the postoperative outcome. In patients with bilateral high myopic strabismus, correction of both eyes seems beneficial. The effect size of the Yokoyama procedure appears to be mainly driven by preoperative esotropia.

Methicillin resistance and biofilm production of Staphylococcus epidermidis isolates from infectious and normal flora conjunctiva.

PURPOSE: Coagulase-negative staphylococci have been reported to be the most frequent cause of bacterial postoperative endophthalmitis. Biofilm formation is the major virulence factor of Staphylococcus epidermidis and is often associated with methicillin resistance. This study aims at evaluating the presence of biofilm-producing and methicillin resistance genes (mecA) in S. epidermidis. METHODS: S. epidermidis isolated from clinically infected sites (group 1) and from normal human conjunctiva (group 2) were studied. All the isolates were tested for their ability to produce biofilm by the conventional Christensen´s method and the presence of mecA by PCR using the 22-mer oligonucleotides as primers. RESULTS: In total 20 isolates from group 1 and 22 from group 2 were studied. Biofilm and mecA were detected in 15 (75 %) and in 14 (70 %) in group 1 as compared to 8 (36.3 %) and 4 (18.2 %) in group 2 (p = 0.016). Simultaneously, biofilm production and presence of mecA genes were observed in 13/20 (65.0 %) in group 1, and 4/22 (18.2 %) in group 2 (p = 0.002). Multi-resistance was observed in 55 % in group 1 and 9 % in group 2 (p = 0.002); 57 % of the biofilm-producing strains was multi-resistant in contrast to none of the non-producing strains. In all multi-resistant strains, biofilm production was seen. CONCLUSIONS: Biofilm formation capacity was widely distributed, particularly among mecA (+) S. epidermidis strains, which also displayed a high diversity of antibiotic resistance profiles.

Effect of antibiotic prophylaxis on Coagulase-negative Staphylococcus virulence factor profiles in patients undergoing cataract surgery.

PURPOSE: In this prospective study, multiplex polymerase chain reaction (PCR) was used to identify genes encoding virulence factors (ica, atlE and mecA) in Coagulase-negative Staphylococcus (CNS) isolates from the ocular microbiota of patients undergoing cataract surgery and to investigate possible changes in the CNS profile due to antibiotic prophylaxis. METHODS: Between 09/2011 and 08/2013, patients undergoing cataract surgery were recruited at the Department of Ophthalmology, National University of Asuncion, Paraguay. In the eye to be operated on, patients received moxifloxacin 0.5 % eye drops four times at the day before surgery and a last drop 1 hour before surgery (T1). The other eye remained as control (T0). Conjunctival swabs were taken from both eyes 1 hour after the last drop. The presence of genes encoding biofilm formation (ica and atlE) and methicillin resistance (mecA) was detected by a multiplex PCR. RESULTS: Of the 162 patients (162 study eyes, 162 fellow eye as control group), 87 (53.7 %) eyes were positive for CNS at T0 yielding 96 CNS isolates; 70 eyes (43.2 %) were positive at T1 yielding 77 CNS isolates. For this study, 43 CNS isolates (44.8 %) from T0 and 45 (64.3 %) from T1 were used. Of the total isolates, 81.8 % (72/88) had at least one virulence factor gene (37/43 from T0 and 35/45 from T1) (p = 0.314). Simultaneous detection of ica and atlE genes was higher in T0 (58.0 %) than T1 (46.7 %), but the difference was not significant (p = 0.28). CONCLUSION: A high frequency of genes encoding virulence factors was observed in the coagulase-negative Staphylococcus isolates. The use of moxifloxacin did not significantly modify the CNS virulence factor profiles.

Artificial iris implantation in a 9-year-old boy.

PURPOSE: To demonstrate the successful surgical treatment of congenital aniridia. METHODS: Development of sight-impairing cortical cataracts in a young boy with congenital aniridia led to the decision to perform phacoemulsification, intraocular lens implantation, and artificial iris implantation in each eye. RESULTS: Thorough examination showed that aniridia and cataract were the explanation for the patient's symptoms (sensitivity to glare and visual impairment). Combined surgery was performed without complication. A follow-up visit showed an improved corrected distance visual acuity of 8/20 (OU) and correctly centered implants. CONCLUSIONS: Artificial Iris® implantation combined with cataract surgery was successful in treating this child with congenital aniridia and lens opacification.

Diabetic retinopathy - ocular complications of diabetes mellitus.

In industrialized nations diabetic retinopathy is the most frequent microvascular complication of diabetes mellitus and the most common cause of blindness in the working-age population. In the next 15 years, the number of patients suffering from diabetes mellitus is expected to increase significantly. By the year 2030, about 440 million people in the age-group 20-79 years are estimated to be suffering from diabetes mellitus worldwide (prevalence 7.7%), while in 2010 there were 285 million people with diabetes mellitus (prevalence 6.4%). This accounts for an increase in patients with diabetes in industrialized nations by 20% and in developing countries by 69% until the year 2030. Due to the expected rise in diabetic patients, the need for ophthalmic care of patients (i.e., exams and treatments) will also increase and represents a challenge for eye-care providers. Development of optimized screening programs, which respect available resources of the ophthalmic infrastructure, will become even more important. Main reasons for loss of vision in patients with diabetes mellitus are diabetic macular edema and proliferative diabetic retinopathy. Incidence or progression of these potentially blinding complications can be greatly reduced by adequate control of blood glucose and blood pressure levels. Additionally, regular ophthalmic exams are mandatory for detecting ocular complications and initiating treatments such as laser photocoagulation in case of clinical significant diabetic macular edema or early proliferative diabetic retinopathy. In this way, the risk of blindness can considerably be reduced. In advanced stages of diabetic retinopathy, pars-plana vitrectomy is performed to treat vitreous hemorrhage and tractional retinal detachment. In recent years, the advent of intravitreal medication has improved therapeutic options for patients with advanced diabetic macular edema.

Comparison of 1-day versus 1-hour application of topical neomycin/polymyxin-B before cataract surgery.

PURPOSE: To compare the efficacy of 2 prophylaxis regimens before cataract surgery using topical antibiotics (1 hour before surgery versus the day before), both with povidone-iodine, with regard to reducing the preoperative conjunctival bacterial load. SETTING: Tertiary ophthalmic referral center, Munich, Germany. DESIGN: Prospective comparative case series. METHODS: Eyes were treated with topical antibiotics and their conjunctival sac flush irrigated using 10 mL of povidone-iodine 1.0%. All eyes were randomized to receive either 4 applications of topical 3500 IU/mL neomycin sulfate/6000 IU/mL polymyxin-B sulfate within 1 hour preoperatively (Group 1) or on the day before surgery (Group 2). Conjunctival specimens were obtained at 4 timepoints: T0C untreated fellow eye (control), T0 surgery eye (after antibiotic prophylaxis but before povidone-iodine irrigation), T1 after povidone-iodine, and T2 at the conclusion of surgery. All specimens were inoculated onto blood and chocolate-blood agar and into thioglycollate broth. RESULTS: One hundred thirty-three eyes of 133 consecutive patients were included (Group 1, 64 eyes; Group 2, 69 eyes). The antibiotic regimens were equally effective in reducing the aerobic and microaerophilic conjunctival flora (Group 1, P=.028; Group 2, P=.000), but had no significant effect on anaerobic bacteria (Group 1, P=.201; Group 2, P=.117). Flush irrigation of the conjunctival sac using 10.0 mL povidone-iodine 1.0% significantly decreased the conjunctival bacterial load in both groups. CONCLUSION: Topical neomycin/polymyxin-B was equally effective in reducing the conjunctival bacterial load whether given 1 day or 1 hour before surgery. The greatest effect was achieved by irrigating the conjunctival sac using povidone-iodine. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Clinical and epidemiological characteristics of infectious keratitis in Paraguay.

To describe the clinical and epidemiological characteristics of patients with severe infectious keratitis in Asunción, Paraguay between April 2009 and September 2011. All patients with the clinical diagnosis of severe keratitis (ulcer ≥2 mm in size and/or central location) were included. Empiric treatment consisted of topical antibiotics and antimycotics; in cases of advanced keratitis, fortified antibiotics were used. After microbiological analysis, treatment was changed if indicated. In total 48 patients (62.5 % males, 25 % farmers) were included in the analysis. A central ulcer was found in 81.3 % (n = 39). The median delay between onset of symptoms and time of first presentation at our institution was 7 days (range 1-30 days). Fungal keratitis was diagnosed in 64.5 % (n = 31) of patients, of which Fusarium sp. (n = 17) was the most common. Twenty-one patients (43.8 %) reported previous trauma to the eye. The globe could be preserved in all cases. While topical therapy only was sufficient in most patients, a conjunctival flap was necessary in six patients suffering from fungal keratitis. The high rate of fungal keratitis in this series is remarkable, and microbiological analysis provided valuable information for the appropriate treatment. In this setting, one has to be highly suspicious of fungal causes of infectious keratitis.

Incidence of postoperative endophthalmitis from 1990 to 2009 using povidone-iodine but no intracameral antibiotics at a single academic institution.

PURPOSE: To correlate the incidence of postoperative endophthalmitis with changes in the preoperative prophylaxis over a 20-year period. SETTING: Department of Ophthalmology, Ludwig-Maximilians-University, Munich, Germany. DESIGN: Retrospective chart review. METHODS: Patients diagnosed with postoperative endophthalmitis from 1990 to 2009 after intraocular surgery performed at the same institution were included. Because of changes in the preoperative prophylaxis during the study period, 3 groups were formed for data analysis: Period 1 (1990 to 1992), no standardized prophylaxis regimen; period 2 (1993 to 1998), preoperative topical medication, povidone-iodine 10.0% periorbitally, and 1 drop of povidone-iodine 1.0% in the conjunctiva sac; and period 3 (1999 to 2009), similar to period 2 except with irrigation of the conjunctival sac with 10 mL of povidone-iodine 1.0%. RESULTS: The overall rate of postoperative endophthalmitis was 0.113% (77/68,323) for all intraocular surgeries. It decreased significantly from 0.291% (16/5505) in period 1 to 0.170% (33/19,413) in period 2 to 0.065% (28/43,405) in period 3 (P < .001). In cataract surgery, the overall rate of postoperative endophthalmitis was 0.125% (30/24,034). It decreased in each subsequent period, from 0.338% (9/2662) in period 1 to 0.224% (15/6696) in period 2 to 0.041% (6/14,676) in period 3 (P < .001). Coagulase-negative Staphylococcus was the most commonly isolated organism (47.4%). CONCLUSIONS: The rate of postoperative endophthalmitis decreased over a 20-year period at a single academic institution. Although multiple factors might have contributed to this decline, implementation of a preoperative prophylaxis protocol using copious povidone-iodine might have been the most important contributor. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Reasons reported by African ophthalmologists for staying in Africa and for considering migrating.

In sub-Sahara Africa, the shortage of ophthalmologists is a major obstacle in the struggle of fighting preventable blindness. Migration of well-trained ophthalmologists has an additional negative effect on the low number of caregivers. However, to date, the reasons affecting migration of ophthalmologists have not been completely understood. The present study evaluates reasons reported by ophthalmologists for staying in their current work setting/country and potential reasons why they might consider migrating. In the years 2009-2011, after approval was obtained from the Institutional Review Board, a questionnaire evaluating reasons for and against migration of ophthalmologists was distributed to the participants of 2-week courses in Ethiopia, Cameroon and Kenya providing continuing medical education in the field of ophthalmology. A total of 84 ophthalmologists participated in this survey. The main reasons for staying in their current region/country were good working conditions, commitment to help, possibility of further training, familial ties and general feeling of satisfaction. Professional development elsewhere and better income abroad were named as the main reasons for considering migration. Almost half of the survey participants reported good infrastructure, equipment, and consumables, which is encouraging. Programs aimed at continuing medical education of ophthalmologists to enable professional development may have an appropriate role in the establishment of an ophthalmic infrastructure which can meet patients' needs.

Endophthalmitis after intravitreal injection: decreasing incidence and clinical outcome-8-year results from a tertiary ophthalmic referral center.

PURPOSE: To report the incidence, clinical features, microbiologic culture results, management and visual outcome of patients with endophthalmitis after intravitreal injections (IVTs). METHODS: This retrospective chart review included all patients receiving IVTs between January 2005 and July 2012. Cases of suspected and confirmed endophthalmitis after IVT were identified and reviewed. RESULTS: A total of 20,179 IVTs were perfomed during the study period. Six cases of supected endophthalmitis were identified clinically (0.03%), of which 3 were culture positive (0.015%). The risk of culture-positive post-IVT endophthalmitis was 2/8,882 (0.023%) in the 2005 to 2008 period and 1/11,297 (0.009%) in the period 2009 to 2012. Symptoms developed within the first 3 days after IVT in 4 of the 6 patients and visual acuity was reduced to hand motion in 4 of the 6 patients. Microbiologic specimens were positive on 3 of the 6 cases (coagulase-negative Staphylococcus, n = 2; Staphylococcus aureus, n = 1). Mean visual acuity before patients with endophthalmitis was 20/100, whereas mean final visual acuity at last follow-up was 20/200. CONCLUSION: The incidence of endophthalmitis after IVT was low with no cases because of Streptococcus species in the present setting using povidone-iodine in the preoperative disinfection of the conjunctival sac. Therefore, adherence to standardized protocols including the use of povidone-iodine when performing IVTs is recommended.

Dermis fat grafts as primary and secondary orbital implants.

INTRODUCTION: This study was performed to evaluate the outcome after autologous dermis-fat graft [DFG] orbital implants in a large sample. MATERIALS AND METHODS: A retrospective chart review of all primary and secondary DFGs in a 16-year period was done. Aesthetic and functional results, patients' satisfaction and postoperative complications were evaluated. RESULTS: In total 468 DFGs were performed in the study period (315 primary [I°] and 153 secondary [II°] DGFs). In the analysis, 173 DFG I° and 66 DFG II° were included as sufficient follow-up was available. Median follow-up after DFG I° was 21.5 months and 14 months after DFG II°. After DFG I°, in 76% of patients motility of the graft was possible in all directions; 81% had good fitting of the prosthesis and 83% were highly satisfied with the results. Mean width of palpebral apertures was 0.2 mm smaller and Hertel exophthalmometry revealed a mean enophthalmus of 1.6 mm on the operated side compared to the fellow-eye. After DFG II°, motility was possible in all directions in 34% of patients. Fitting of the prosthesis was good/reasonable in 49%/41% and patients were highly satisfied in 57%. On average, on the operated side palpebral apertures were 0.6 mm smaller and Hertel measurements showed an enophthalmus of 2.6 mm. Major complications were uncommon. Complete necrosis of the implant was more often observed after II° (6.1%) than after I° DFG (3.5%). DISCUSSION: In this large sample, DFG proved to be an effective and safe method for the reconstruction of anophthalmic sockets.

Quality of life in the follow-up of uveal melanoma patients after CyberKnife treatment.

To assess quality of life in uveal melanoma patients within the first and second year after CyberKnife radiosurgery. Overall, 91 uveal melanoma patients were evaluated for quality of life through the Short-form (SF-12) Health Survey at baseline and at every follow-up visit over 2 years after CyberKnife radiosurgery. Statistical analysis was carried out using SF Health Outcomes Scoring Software and included subgroup analysis of patients developing secondary glaucoma and of patients maintaining a best corrected visual acuity (BCVA) of the treated eye of 0.5 log(MAR) or better. Analysis of variance, Greenhouse-Geisser correction, Student's t-test, and Fisher's exact test were used to determine statistical significance. Physical Functioning (PF) and Role Physical (RP) showed a significant decrease after CyberKnife radiosurgery, whereas Mental Health (MH) improved (P=0.007, P<0.0001 and P=0.023). MH and Social Functioning (SF) increased significantly (P=0.0003 and 0.026) in the no glaucoma group, MH being higher compared with glaucoma patients (P=0.02). PF and RP were significantly higher in patients with higher BCVA at the second follow-up (P=0.02). RP decreased in patients with BCVA<0.5 log(MAR) (P=0.013). Vitality (VT) increased significantly in patients whose BCVA could be preserved (P=0.031). Neither tumor localization nor size influenced the development of secondary glaucoma or change in BCVA. Although PF and RP decreased over time, MH improved continuously. Prevention of secondary glaucoma has a significant influence on both SF and MH, whereas preservation of BCVA affects VT. Emotional stability throughout follow-up contributes positively toward overall quality of life. CyberKnife radiosurgery may contribute to attenuation of emotional distress in uveal melanoma patients.

Traumatic retinopathy presenting as acute macular neuroretinopathy.

AIM: Traumatic retinopathy presenting as acute macular neuroretinopathy (AMNR) is an uncommon disease causing paracentral scotomas after indirect trauma. METHODS: We report on five patients (six eyes) with AMNR with a temporary reduction of visual acuity and persistent paracentral scotomas after indirect trauma. The findings were documented using multimodal imaging and the follow-up was up to 32 months. RESULTS: Initially, fundoscopy was unremarkable in all patients while visual acuity (Snellen equivalents) varied between 0.03 and 1.0, and a paracentral scotoma was present in all patients. During follow-up, visual acuity recovered to 1.0 in all patients while the paracentral scotomas persisted. Spectral-domain optical coherence tomography revealed a disruption of the inner/outer segment junction within the macular lesion and changes in the outer nuclear layer, which slowly recovered partly during the follow-up. CONCLUSIONS: These findings suggest that indirect trauma can cause changes in the outer retina resembling those seen in AMNR, resulting in persisting paracentral scotomas.