Endothelial keratoplasty with anterior chamber intraocular lens versus secondary posterior chamber intraocular lens.

AIM: To describe the long-term outcomes of Descemet stripping automated endothelial keratoplasty (DSAEK) with an anterior chamber intraocular lens (ACIOL) compared to secondary posterior chamber (PC) IOL. METHODS: This was a retrospective comparative cohort study. The clinical data of 82 eyes from 82 consecutive patients with pseudophakic (PBK) or aphakic bullous keratopathy (ABK) who either underwent DSAEK with retained or secondary ACIOL (n=23) or DSAEK with IOL exchange and/or secondary PCIOL (retropupillary iris-claw IOL, n=25; intrascleral-fixated IOL, n=29; or sulcus IOL, n=5) were analysed. The main outcome measures were graft survival and complications up to 5 years. RESULTS: The graft survival in the secondary PCIOL group was superior than the ACIOL group over 5 years (year 1, 100.0% vs 100.0%; year 3, 94.7% vs 75.0%; year 5, 91.1% vs 60.6%, p=0.022). The presence of an ACIOL was a significant risk factor associated with graft failure (HR, 4.801; 95% CI, 1.406 to 16.396, p=0.012) compared to a secondary PCIOL. There was no significant difference in the rate of graft detachment and elevated intraocular pressure between the groups. There were five cases (9.3%) of IOL subluxation or dislocation in the retropupillary iris-claw and intrascleral-fixated IOL groups. CONCLUSIONS: Eyes that underwent DSAEK with ACIOL in situ had poorer long-term graft survival compared with those with secondary PCIOL. Intraocular lens exchange was not associated with a higher complication rate. In ABK or PBK eyes with ACIOL, we recommend performing IOL exchange and/or secondary PCIOL implantation combined with endothelial keratoplasty.

Long-Term Review of Penetrating Keratoplasty: A 20-Year Review in Asian Eyes.

PURPOSE: To review the long-term outcomes of optical, therapeutic and tectonic forms of penetrating keratoplasty over a 20-year period in Asian eyes. DESIGN: Prospective cohort study involving the Singapore Corneal Transplant Study (SCTS). METHODS: All penetrating keratoplasties (PK) performed at the Singapore National Eye Centre (SNEC) from January 1991 to December 2010 were analyzed using records from the computerized database of the SCTS. This database includes preoperative, intraoperative, and postoperative patient data and donor cornea data. Only primary grafts were included. Patient demographics, donor cornea source, indications for grafting, complications, graft survival rate, and causes of graft failure were analyzed. RESULTS: A total of 1,206 primary PKs were performed. The mean age of the patients was 55 years (range: <1-101 years). The overall corneal graft survival rates at 1, 5, 10, 15, and 20 years were 91%, 66.8%, 55.4%, 52%, and 44%, respectively. For optical grafts, pseudophakic bullous keratopathy, postinfectious corneal scarring and thinning and keratoconus were the most common diagnoses. Graft survival for optical grafts was significantly better than therapeutic and tectonic grafts at all time points. Multivariate analysis suggested that a younger donor cornea age and higher donor endothelial cell count are associated with better long-term graft survival for optical grafts. Irreversible allograft rejection and late endothelial failure accounted for more than 60% of graft failures. CONCLUSIONS: Graft survival decreased over time from 91% at 1 year to 44% at 20 years' follow-up. Allograft rejection and late endothelial failure accounted for more than 60% of graft failures.

Prevalence and factors associated with secondhand smoke exposure among Malaysian adolescents.

INTRODUCTION: Exposure to secondhand smoke (SHS) has been proven to be detrimental to health. However, there is little information on SHS exposure among Malaysian adolescents. This study aims to assess the magnitude of and factors associated with SHS exposure among school-going adolescents in Malaysia. METHODS: We performed secondary analysis on data from 25461 respondents of the Global School Health Survey in Malaysia. Descriptive analyses and multivariable logistic regression were performed to determine factors associated with SHS exposure. RESULTS: Respondents were adolescents of mean age 14.84 (SD=1.45) years, 50.2% of which were male and 49.8% female. Approximately four in ten respondents were exposed to SHS in the past week (41.5%). SHS exposure was significantly higher among respondents who smoked than among non-smokers (85.8% vs 35.7%, p<0.001). The likelihood of exposure to SHS was higher among smoking adolescents (Adjusted OR=1.66, 95% CI: 1.07-2.56) and non-smoking adolescents (AOR=3.15, 95% CI: 1.48-4.71) who had at least one smoking parent/guardian regardless of their own smoking status. Male adolescents had higher risk of SHS exposure compared to their female counterparts (current smoker AOR=1.66, 95% CI: 1.07-2.56; non-smoker AOR=1.50, 95% CI: 1.12-2.00) and increased with age, regardless of their smoking status. CONCLUSIONS: Our findings suggest that prevalence of exposure to SHS among school-going adolescents in Malaysia is high. Parents should be advised to stop smoking or abstain from smoking in the presence of their children. Education programmes are recommended to increase awareness on avoidance of SHS as well as smoking cessation interventions for both adolescents and their parents.

Optimising graft survival in endothelial keratoplasty for endothelial failure secondary to cytomegalovirus endotheliitis.

BACKGROUND: There is limited information regarding Descemet stripping automated endothelial keratoplasty (DSAEK) for endothelial failure secondary to cytomegalovirus (CMV) endotheliitis. Treatment is difficult with high recurrence rates. We describe a case when systemic valganciclovir therapy is directed by aqueous CMV-DNA levels, leading to good graft survival. FINDINGS: A 59-year-old male with bilateral CMV endotheliitis despite antiviral therapy developed endothelial failure and underwent DSAEK. Prior to surgery, aqueous polymerase chain reaction (PCR) for CMV was repeatedly performed, where CMV-positive episodes were treated with systemic valganciclovir. Monthly aqueous analysis was performed until CMV-DNA was undetectable before DSAEK was performed. Post-operative prophylactic systemic valganciclovir treatment was instituted and switched to topical valganciclovir treatment when aqueous samples were negative for CMV. CONCLUSION: Targeted aqueous sampling for CMV-DNA perioperatively guides antiviral therapy and ensures adequacy of treatment, minimising the duration of systemic valganciclovir therapy to reduce adverse effects of long-term treatment.

Support for smoke-free policy among Malaysian adults: findings from a population-based study.

OBJECTIVE: Public opinion and support can be powerful mandates for smoke-free policy. However, the scarcity of evidence on public opinion among Malaysians necessitates further investigation. Therefore, this study aimed to determine the level of support for smoke-free policy at various public domains and its associated factors among Malaysian adults. DESIGN: Data were derived from the Global Adult Tobacco Survey, Malaysia (GATS-M). GATS-M is a nationwide study that employed a multistage, proportionate-to-size sampling strategy to select a representative sample of 5112 Malaysian adults aged 15 years and above. Multiple logistic regression was used to identify factors associated with support for smoke-free policy in selected public domains that is, workplaces, restaurants, bars, hotels, casinos, karaoke centres, public transport terminals and shopping centres. RESULTS: The level of support for enactment of a smoke-free policy at selected public domains varied from 37.8% to 94.4%, with the highest support was for gazetted smoke-free domains, namely, shopping centres (94.4%, 95% CI: 93.2% to 95.3%) and public transport terminals (85.2%, 95% CI: 83.3% to 86.9%). Multiple logistic regression revealed that non-smokers were more likely to support smoke-free policy at all domains. In addition, respondents who worked in workplaces with total or partial smoking restrictions were more likely to support a smoke-free policy ((total restriction adjusted OR (AOR): 14.94 (6.44 to 34.64); partial restriction AOR: 2.96 (1.138 to 6.35); non-restriction was applied as a reference). CONCLUSION: A majority of the Malaysian adult population supported the smoke-free policy, especially at gazetted smoke-free domains. Therefore, expansion of a total smoking ban to workplaces, restaurants, bars, hotels, casinos and karaoke centres is strongly recommended to reduce exposure to secondhand smoke and to denormalise smoking behaviour.

Goniothalamin induces cell cycle arrest and apoptosis in H400 human oral squamous cell carcinoma: A caspase-dependent mitochondrial-mediated pathway with downregulation of NF-κß.

Goniothalamin is a natural occurring styryl-lactone compound isolated from Goniothalamus macrophyllus. It had been demonstrated to process promising anticancer activity on various cancer cell lines. However, little study has been carried out on oral cancer. The aim of this study was to determine the cytotoxic effects of goniothalamin against H400 oral cancer cells and its underlying molecular pathways. Results from MTT assay demonstrated that goniothalamin exhibited selective cytotoxicity as well as inhibited cells growth of H400 in dose and time-dependent manner. This was achieved primarily via apoptosis where apoptotic bodies and membrane blebbing were observed using AO/PI and DAPI/Annexin V-FITC fluorescence double staining. In order to understand the apoptosis mechanisms induced by goniothalamin, apoptosis assessment based on mitochondrial membrane potential assay and cytochrome c enzyme-linked immunosorbent assay were carried out. Results demonstrated that the depolarization of mitochondrial transmembrane potential facilitated the release of mitochondrial cytochrome c into cytosol. Caspases assays revealed the activation of initiator caspase-9 and executioner caspase-3/7 in dose-dependent manners. This form of apoptosis was closely associated with the regulation on Bcl-2 family proteins, cell cycle arrest at S phase and inhibition of NF-κß translocation from cytoplasm to nucleus. Conclusion, goniothalamin has the potential to act as an anticancer agent against human oral squamous cell carcinoma (H400 cells).

Prevalence and factors associated with smoking intentions among non-smoking and smoking adolescents in Kota Tinggi, Johor, Malaysia.

Intention to smoke is a valid and reliable factor for predicting future smoking habits among adolescents. This factor, however, has received inadequate attention in Malaysia. The present paper elaborates the prevalence and factors associated with intent to initiate or to cease smoking, among adolescent nonsmokers and smokers in Kota Tinggi, Johor, Malaysia. A total of 2,300 secondary school students aged 13-16 years were selected through a two-stage stratified sampling method. A set of standardized questionnaires was used to assess the smoking behavior among adolescents and the inter-personal and intra-personal factors associated with smoking intention (intention to initiate smoking or to cease smoking). Multivariable logistic regression was used to identify factors related to smoking intention. The prevalence of intention to smoke in the future or to cease smoking among non- smoking adolescents and current smokers were 10.7% and 61.7% respectively. Having friends who smoke, social influence, and poor knowledge about the ill effects on health due to smoking showed significant relationships with intention to smoke in the future among non-smokers. Conversely, perceived lower prevalence of smoking among peers, weak contributory social influence, and greater awareness of the ill effects of smoking are factors associated with the intention to cease smoking sometime in the future. The study found that prevalence of intention to initiate smoking is low among non-smokers while the majority of current smokers intended to cease smoking in the future. Existing anti-smoking programmes that integrate the factors that have been identified in the current study should be put in motion to reduce the prevalence of intention to initiate smoking and increase the intention to cease smoking among adolescents.

Visual outcomes comparison of 2 femtosecond laser platforms for laser in situ keratomileusis.

PURPOSE: To compare the efficacy, predictability, and safety outcomes of 2 femtosecond laser platforms for flap creation during laser in situ keratomileusis (LASIK) for myopia and myopic astigmatism. SETTING: Singapore National Eye Centre, Singapore. DESIGN: Retrospective case review. METHODS: In this single-center multisurgeon study, patients had LASIK with flaps created using a Visumax 500 kHz or Intralase 60 kHz femtosecond laser system. Ablation was performed with the Wavelight Allegretto Eye-Q 400 Hz excimer laser in all patients. Preoperative and 3-month postoperative manifest refraction, attempted treatment spherical equivalent (SE), visual acuity, and complications were compared. RESULTS: The 500 kHz femtosecond laser group comprised 381 patients (381 eyes) and the 60 kHz femtosecond laser group, 362 patients (362 eyes). Three months postoperatively, the uncorrected distance visual acuity was 20/40 or better in 99.1% of eyes in the 60 kHz laser group and 99.4% of eyes in the 500 kHz laser group (P=.678). Regarding predictability, 98.6% of eyes and 97.4% of eyes, respectively, were within ± 1.0 diopter of the attempted SE correction postoperatively (P=.228). The safety index was similar in the 60 kHz laser group and the 500 kHz laser group (mean 1.06 ± 0.16 [SD] versus 1.05 ± 0.14) (P=.321). CONCLUSION: The safety, predictability, and efficacy profiles of the 500 kHz femtosecond platform for LASIK were excellent and comparable to those of the 60 kHz platform.

Correlates of susceptibility to smoking among secondary school students in Kota Tinggi district, Johor, Malaysia.

BACKGROUND: Smoking among adolescents has been linked to a variety of adverse and long term health consequences. "Susceptibility to smoking" or the lack of cognitive commitment to abstain from smoking is an important predictor of adolescent smoking. In 2008, we conducted a study to determine the psycho-sociological factors associated with susceptibility to smoking among secondary school students in the district of Kota Tinggi, Johor. MATERIALS AND METHODS: Two thousand seven hundred students were randomly selected by proportional stratified sampling. Analyses on 1,736 non-smoking students revealed that prevalence of adolescents susceptible to smoking was 16.3%. RESULTS: Male gender (aOR=2.05, 95%CI= 1.23-3.39), poor academic achievement (aOR 1.60, 95%CI 1.05-2.44), ever-smoker (aOR 2.17, 95%CI 1.37-3.44) and having a smoking friend (aOR 1.76, 95%CI 1.10-2.83) were associated with susceptibility to smoking, while having the perception that smoking prohibition in school was strictly enforced (aOR 0.55, 95%CI 0.32-0.94), and had never seen friends smoking in a school compound (aOR 0.59, 95%CI 0.37-0.96) were considered protective factors CONCLUSIONS: These results indicate that follow-up programmes need to capitalise on the modifiable factors related to susceptibility to smoking by getting all stakeholders to be actively involved to stamp out smoking initiation among adolescents.

Comparison of eye-tracking success in laser in situ keratomileusis after flap creation with 2 femtosecond laser models.

PURPOSE: To determine the efficiency of an eye tracker after laser in situ keratomileusis (LASIK) flap creation with 1 of 2 femtosecond laser models. SETTING: Tertiary referral center, Singapore National Eye Center, Singapore. DESIGN: Randomized clinical trial. METHODS: The LASIK flap was created with an IntraLase (Group A) or a VisuMax (Group B) femtosecond laser. An Advanced Control Eye Tracker was initiated 3 times to obtain iris recognition. Eye tracking was considered successful if the eye movements could be followed despite the presence or absence of an opaque bubble layer (OBL). Univariate-multivariate logistic regression analysis was performed. RESULTS: Preoperatively, the mean values (ranges) of the 87 eyes were sphere, -5.64 diopters (D) ± 2.17 (SD) (-9.75 to -0.25 D); cylinder 1.65 ± 1.63 D (-3.75 to 0.00 D); optical zone, 6.34 ± 0.20 mm (5.6 to 7.0 mm); keratometry, 43.48 ± 1.32 D (40.1 to 42.8 D); flap thickness, 109.30 + 5.21 µm (90 to 115 µm). Eye tracking was successful in 38 (90.5%) of 42 eyes in Group A and 43 (95.6%) of 45 eyes in Group B. No specific type of OBL was seen in either group. The LASIK was completed in all eyes. There was a statistically significant association between positive tracking and a smaller optical zone (P=.03). There were no statistically significant differences in eye tracking between the 2 femtosecond lasers. CONCLUSIONS: Eye tracking was achieved in more than 90% of cases after LASIK flap creation with 1 of 2 femtosecond laser models, even in the presence of an OBL.

Fungal endophthalmitis after descemet stripping automated endothelial keratoplasty--a case report.

BACKGROUND/AIMS: Descemet stripping automated endothelial keratoplasty (DSAEK) is increasingly gaining popularity as an effective alternative to traditional penetrating keratoplasty for the treatment of endothelial diseases. However, new complications such as donor graft dislocation are seen after DSAEK. Surface venting incisions have been advocated to reduce rates of graft dislocation. We report a case of post-DSAEK fungal endophthalmitis in which the clinical course may have been influenced by the presence of surface venting incisions. METHOD: A retrospective case report. RESULTS: A 72-year-old woman, who developed primary/iatrogenic graft failure after DSAEK, underwent a repeat DSAEK. Corneal venting incisions were reopened at the original sites as her first operation. Early postoperatively, she developed intrastromal opacities, which were thought to be epithelial downgrowth, but progression and increasing stromal and intraocular inflammation required anterior chamber and vitreous tap, which confirmed the presence of Candida parapsilosis, confirming the diagnosis of fungal endophthalmitis. Penetrating keratoplasty, removal of the posterior lamellar graft, removal of the posterior chamber intraocular lens implant (PCIOL) and capsular bag, and anterior vitrectomy were performed after failure of conservative antifungal therapy. Postoperatively, no recurrence of infection occurred, and the graft has remained clear at her most recent follow-up at 6 months, with a best-corrected visual acuity of 20/40. CONCLUSIONS: Corneal venting incisions in DSAEK surgery may be a portal of entry for microorganisms, leading to corneal and intraocular infection, and a high index of suspicion is warranted in the presence of stromal infiltrates or inflammation at venting sites.

Juvenile xanthogranuloma of the corneoscleral limbus.

PURPOSE: To report an 11-year-old Chinese girl with juvenile xanthogranuloma of the limbus, occurring in isolation without dermatologic involvement, and to discuss the clinical and histologic features, pathogenesis, and treatment of juvenile xanthogranuloma. METHODS: Case report and review of medical literature. RESULTS: A total excision and biopsy of the limbal lesion with lamellar graft was performed. Histologic examination showed a xanthogranuloma. At 12-month follow-up, there was no recurrence of tumor. CONCLUSION: The diagnosis of juvenile xanthogranuloma may be straightforward in cases that have concomitant cutaneous manifestations. However, in isolated ocular forms, histopathological examination is necessary. Unlike the more common iris lesions that are preferably treated nonsurgically, limbal lesions require surgical excision.