Lifetime visual prognosis of patients with glaucoma.

BACKGROUND: To investigate the visual outcome of glaucoma patients. DESIGN: This is a retrospective study of case notes of patients who died while under follow up in a glaucoma clinic of a University Hospital in Scotland between 2006 and 2009. PARTICIPANTS: Seventy-seven patients were identified. METHODS: Data collected included type of glaucoma, coexisting pathology and best-corrected visual acuity in Snellen (converted to decimal values) for the first and final clinic visit. The final visual status was evaluated based on the best-corrected visual acuity of the better seeing eye at the last glaucoma clinic visit. Patients who had best-corrected visual acuity of less than Snellen decimal 0.5 were considered not to meet the standards for driving. MAIN OUTCOME MEASURES: Snellen decimal best-corrected visual acuity, fulfilment of driving standards, and eligibility for partial sight and blind registration at the last clinic visit. RESULTS: The mean ages at presentation and death were 71.8 ± 10.3 years and 82.2 ± 8.7 years respectively. The mean Snellen decimal best-corrected visual acuity of the better eye at presentation was 0.78, and at the final clinic visit was 0.61. At the final clinic visit, no patients were partial sight registrable, four (5.2%) were blind registrable, and 27 (35.1%) did not fulfil UK driving criteria. Glaucoma patients with other ocular pathologies were more likely to fail UK driving criteria at presentation (P = 0.02) and at last clinic visit (P = 0.03). CONCLUSION: The majority of glaucoma patients maintained good visual function at the end of their lifetime.

Prospective Clinical Study of Keratoconus Progression in Patients Awaiting Corneal Cross-linking.

PURPOSE: Keratoconus progression should be treated with corneal cross-linking (CXL) in a timely manner. This study aimed to investigate patient factors associated with keratoconus progression between time of listing and at time of CXL. METHODS: Prospective observational study at a tertiary center. Ninety-six eyes of 96 patients with keratoconus. Demographic, clinical, and tomographic parameters were analyzed to determine the risk factors for keratoconus progression. Analyzed tomographic indices included steepest keratometry, average keratometry, cornea thinnest point, index of surface variance, index of vertical asymmetry, keratoconus index, center keratoconus index, index of height asymmetry, and index of height decentration. RESULTS: A total of 38 eyes (39.6%) were found to have keratoconus progression during an average waiting time of 153 ± 101 days. There were significant differences in preoperative tomographic parameters such as index of surface variance (111.3 ± 36.6 vs. 88.3 ± 31.8; P = 0.002), index of vertical asymmetry (1.1 ± 0.4 vs. 0.9 ± 0.4; P = 0.005), keratoconus index (1.31 ± 0.12 vs. 1.22 ± 0.11; P < 0.001), and index of height decentration (0.16 ± 0.07 vs. 0.11 ± 0.06; P = 0.015) between eyes that progressed and those that remained stable. There were no significant differences in steepest keratometry, average keratometry, cornea thinnest point, and center keratoconus index. Multivariate analysis did not reveal age, presence of atopy/atopic keratoconjunctivitis, eye rubbing, or waiting time to be a significant risk factor for progression; however, Maori ethnicity was a risk factor (odds ratio = 3.89; P = 0.02). CONCLUSIONS: A significant proportion of eyes were found to be progressing while waiting for CXL. A risk stratification score for patients awaiting CXL may reduce the risk of progression.

The incidence of retinal breaks in the presenting and fellow eyes in patients with acute symptomatic posterior vitreous detachment and their associated risk factors.

PURPOSE: To determine the incidence of retinal breaks in presenting and fellow eyes in patients with acute symptomatic posterior vitreous detachment (PVD) and their associated risk factors. DESIGN: A prospective study of 101 consecutive patients presenting with acute symptomatic PVD. METHODS: The PVD status and other relevant ophthalmic findings were noted for both presenting and fellow eyes at initial presentation. Patients with PVD in the fellow eye were followed up appropriately whereas those without were invited to return for a further examination 4 years later. Data analysis was performed using general linear model and logistic regression. RESULTS: The mean age was 62 years. Seventy-six eyes had PVD in the presenting eyes, which were more myopic than their fellow eyes. Increased myopia and the presence of vitreous and/or retinal hemorrhage were associated with the presence of retinal tear(s) (P = 0.03 and P < 0.0001, respectively) at presentation. Twenty-three of the presenting eyes and 2 of the fellow eyes had have retinal break(s) at the first clinic visit. Of those, 14 eyes were found not to have a visible Weiss ring. Only 5.9% of the eyes (3 presenting eyes and 3 fellow eyes) developed delayed retinal break(s). CONCLUSIONS: Acute symptomatic PVD is a common presentation. It is essential to perform thorough examination to both presenting eye and fellow eye at initial presentation and follow-up appointments to prevent delay of treatment to retinal break(s).

Corneal microstructural changes in nerve fiber, endothelial and epithelial density after cataract surgery in patients with diabetes mellitus.

PURPOSE: The aim of this study was to analyze microstructural corneal changes following phacoemulsification of cataract with intraocular lens insertion in diabetes mellitus (DM). METHODS: Prospective study of consecutive patients undergoing phacoemulsification with intraocular lens insertion, over a period of 6 months. Age, gender, serum glycosylated hemoglobin A1c levels, and effective phacoemulsification time were recorded. Anterior segment optical coherence tomography and corneal in vivo confocal microscopy were performed preoperatively and 1-month postoperatively. Subbasal nerve plexus (SBN) density, basal epithelial cell density, and endothelial cell density (ECD) were quantitatively analyzed. RESULTS: Twenty-eight patients with type 2 DM (71.2 ± 7.6 years) and 23 healthy controls (mean age, 74.4 ± 7.4 years) were recruited. Mean hemoglobin A1c level was 7.5% in patients with DM and 5.7% in the control group (P < 0.0001). A significant reduction in SBN density was noted postoperatively in both DM (P < 0.0001) and non-DM groups (P < 0.0001). Patients with DM had a lower mean SBN density compared with non-DM group, before (P < 0.0001) and after surgery (P < 0.0001). Longer effective phacoemulsification time correlated with a greater decrease in ECD postoperatively in the whole cohort (P < 0.0001), and in the control (P = 0.002) and DM (P = 0.039) groups independently. There was no significant difference in preoperative ECD between the DM group (2254 +/- 426 cells/mm(2)) and non-DM group (2384 +/- 438 cells/mm(2); P = 0.2). [corrected]. CONCLUSIONS: Subbasal nerve density is reduced after cataract surgery in patients with and without DM. However, lower initial SBN density in patients with DM may predispose them to develop diabetic keratopathy. DM does not predispose to greater endothelial loss following phacoemulsification.

Role of Concomitant Triamcinolone Acetonide Injection in Small-Gauge Vitrectomy for Idiopathic Epiretinal Membrane Peel.

PURPOSE: The concomitant use of triamcinolone acetonide (TA) at the completion of pars plana vitrectomy for the treatment of epiretinal membrane may speed up the anatomical and functional outcomes of surgery. We report the outcome of patients undergoing small-gauge vitrectomy for idiopathic epiretinal membrane peel with or without adjuvant TA therapy. DESIGN: This is a retrospective, single-center case series. METHODS: We included 75 eyes of 75 individual patients. Twenty-six patients (group A) had an adjuvant TA injection during surgery, whereas 49 patients (group B) were not injected. We assessed the patients for change in visual acuity (VA) and central macular thickness before and after surgery. RESULTS: Group A had a mean logarithm of the minimum angle of resolution VA of 0.63 ± 0.33 and 0.51 ± 0.31 preoperatively and 3 months after surgery, respectively. Group B had a mean logarithm of the minimum angle of resolution VA of 0.47 ± 0.17 and 0.36 ± 0.17 preoperatively and 3 months after surgery, respectively. No significant difference was found between the groups in change of VA. The mean central macular thickness for groups A and B patients before surgery was 474.12 ± 120 µm and 445 ± 85 µm, decreasing to 369 ± 70 µm and 386 ± 60 µm at the final visit, respectively. The difference in macular thickness reduction between the groups was statistically significant. CONCLUSIONS: Anatomical and functional improvement was found in both groups after surgery. Macular thickness was further reduced in the group of patients treated with adjuvant TA.

Clinical and demographic associations with optic nerve hypoplasia in New Zealand.

AIM: To identify the clinical features of optic nerve hypoplasia (ONH) and prevalence within a population of New Zealand children with severe visual impairment. METHODS: Retrospective review of medical records of children with severe visual impairment registered with Blind and Low Vision Educational Network New Zealand. RESULTS: Of 1500 children with severe visual impairment, 94 (6.3%) exhibited ONH, and 91 (97%) cases were bilateral. Of these 94 cases, 52 (55%) were males and ethnicities were European Caucasian (52%), Maori (40%), Pasifika (6%) and other (2%). Most children with ONH had poor vision, with 60% having ≤ 6/60 Snellen visual acuity equivalent. The median maternal age was 20.0 years old with 52% ≤ 20 years. There was a statistically significant over-representation of Maori ethnicity (40%) and young maternal age with age less than 20 years old (44%) in our cohort compared to the general population (14.6% and 7.4%, respectively; p<0.0001). Half had hypopituitarism, while neuroimaging abnormalities were detected in 60% cases. Cerebral neuroradiographic abnormalities were found to be associated with higher rate of developmental delay (OR 9.764 95% CI 3.246 to 29.373). CONCLUSIONS: This is the first major study of visual impairment in New Zealand children, and it demonstrates that ONH is an important cause of severe visual disability; with an over-representation of Maori children and younger maternal age.

Treatment of herpes zoster related corneal neovascularisation and lipid keratopathy by photodynamic therapy.

Traditionally, photodynamic therapy (PDT) has been used to treat choroidal neovascularisation. More recently, its use in corneal neovascularisation has provided promising clinical results. The major advantage of PDT is that it is minimally invasive, resulting in closure of the neovascular network without damaging the surrounding healthy tissue. This report describes the positive results of PDT, clinically and microstructurally, as imaged by in vivo confocal microscopy, for treating corneal neovascularisation with lipid keratopathy, secondary to herpes zoster infection.

Iatrogenic choroidal neovascularization following idiopathic epiretinal membrane peel.

Choroidal neovascularization is an uncommon complication of macular surgery. The functional outcome is poor despite various treatment options, including laser photocoagulation, photodynamic therapy, and a variety of surgical procedures. We report a case of iatrogenic choroidal neovascularization in a 69-year-old woman at the site of inadvertent retinal trauma 5 weeks after an epiretinal membrane peel. Visual acuity was 6/15 at the time of diagnosis. Four intravitreal bevacizumab injections were administered over a period of 6 months; treatment was discontinued when a disciform scar was noted. At last follow-up, 21 months after surgery, the patient's visual acuity was counting fingers.

Combining primary and piggyback intraocular lenses to treat extreme myopic astigmatism in stable keratoconus following cataract surgery.

The majority of those with keratoconus can maximise visual acuity with spectacle or contact lens correction as they age; however, as subjects enter their sixties, cataracts may supervene and contact lens tolerance diminishes with consequent reduction in visual acuity. Following cataract extraction, the complex refractive error associated with keratoconus may not be readily corrected by an intraocular lens alone. This report highlights the planned implantation of a primary posterior chamber toric intraocular lens with a secondary piggyback, sulcus-based, intraocular lens in advanced but stable keratoconus with extreme myopic astigmatism and cataract.

Retinal breaks in small-gauge pars plana vitrectomy.

PURPOSE: To determine the frequency of peripheral iatrogenic retinal breaks in eyes undergoing small-gauge pars plana vitrectomy. DESIGN: Prospective, single-center, noncomparative interventional case series. METHODS: A consecutive series of patients that underwent 23- or 25-gauge vitrectomy between July 2010 and the end of October 2010 were included in the study. We excluded patients with retinal detachment, dislocated crystalline lens from complicated cataract surgery, endophthalmitis, and previous history of eye trauma or vitrectomy. We recorded prospectively the frequency of all retinal breaks noted during surgery of patients undergoing 23- or 25-gauge vitrectomy. The indications for vitreoretinal surgery were recorded, as were the location of retinal breaks, the presence or absence of an intact posterior hyaloid, status of lens, method of retinopexy, and use of a tamponade, together with the onset of a rhegmatogenous retinal detachment during the 3-month follow-up interval. Main outcome was rate of entry site breaks in small-gauge vitrectomy. RESULTS: We included 184 patients in this study. The mean age was 65.6 years (SD 13.2) and 46% were male. Retinal breaks occurred in 29 patients (15.7%) but breaks in only 6 (3.2%) were deemed to be related to the sclerotomies. Entry site breaks were not linked to the gauge of the instruments, but retinal breaks were more common in 23-gauge surgeries, although this was not statistically significant. One rhegmatogenous retinal detachment occurred in the postoperative period. CONCLUSIONS: Entry site retinal breaks are not common in small-gauge vitrectomy.

Do Optic Disc Drusen Cause Unilateral Nyctalopia?

This is a case report of a patient with unilateral nyctalopia in whom ipsilateral optic disc drusen were the only finding despite extensive investigation.

Recurrent vitreous occlusion of glaucoma drainage device tube in a patient with glaucoma in aphakia: a case report.

Patients with spontaneous lens dislocation and glaucoma can be challenging to manage. We present a forty-six year old Caucasian lady who was referred with bilateral high intraocular pressure, and was subsequently diagnosed with glaucoma in association with lens dislocation and Marfan syndrome. Baerveldt glaucoma drainage device tubes were inserted in both eyes due to poor response to medical therapy. However, this was complicated by recurrent vitreous occlusion of both glaucoma drainage tubes requiring further multiple surgical interventions. There have not been any further recurrences of vitreous incarceration or posterior segment complications since, but the patient remains under close follow-up.