Surgical options and clinical outcomes for high myopia.

PURPOSE OF REVIEW: Higher degrees of myopia are currently being treated with refractive surgery. However, there is limited characterization and outcomes data for this cohort. This article aims to review the literature on highly myopic patients who had refractive surgery and present a retrospective analysis of 149 patients (270 eyes) with high to extreme myopia (≤-5.0D SE) who underwent refractive surgery [laser-assisted subepithelial keratomileusis (LASIK), photorefractive keratectomy (PRK), or implantable collamer lense (ICL)] at a single practice. RECENT FINDINGS: There is substantial literature on the efficacy of LASIK, PRK, and phakic intraocular lenses for refractive error correction, but a dearth of studies on patients with high to extreme myopia undergoing different types of refractive surgery. Our study reveals that this cohort of patients has excellent outcomes with minimal complications. SUMMARY: Our study reveals that the average preoperative myopia was highest in ICL patients (-10.03D), followed by PRK (-7.21D), and LASIK (-7.04D) patients. Not surprisingly, eyes with high myopia and thin corneas were offered and elected ICLs for their procedure. Highly myopic patients achieved outcomes consistent with data reported in the literature- average postoperative uncorrected visual acuity was 20/20 for LASIK and ICL eyes and 20/25 for PRK eyes.

Refractive lens exchange - who is getting it, what are they getting, how are they doing?

PURPOSE OF REVIEW: The purpose of this article is to provide a review of the literature on refractive lens exchange and present a retrospective analysis of 55 patients who underwent refractive lens exchange at a single practice. RECENT FINDINGS: Our study substantiates refractive lens exchange as an important option for presbyopic patients, hyperopic patients or patients with extremely high refractive error who desire spectacle independence. SUMMARY: Our study reveals that the refractive lens exchange population is younger than the average cataract population and their primary motivations are to resolve hyperopic or myopic refractive errors, gain spectacle independence, and address near vision loss. A variety of presbyopia-addressing intraocular lens options are available and we present our experience with multifocal, extended depth-of-focus, light-adjustable, and monofocal lenses.

Topography-guided excimer laser ablation.

PURPOSE OF REVIEW: Currently, the most commonly performed corneal refractive surgery is laser-assisted in-situ keratomileusis (LASIK). Customized forms of LASIK have been developed, which have allowed for improved outcomes and the enhanced correction of higher order aberrations (HOAs). This review discusses one form of custom LASIK, topography-guided LASIK, including factors involved in preoperative planning, and advantages and disadvantages compared with other forms of keratorefractive surgery. RECENT FINDINGS: Various treatment-planning approaches addressing discrepancies between the refractive and topographic astigmatic magnitude and axis have been used successfully, although there is debate regarding a superior method in the literature. SUMMARY: There are many forms of custom LASIK, which provide excellent outcomes. Topography-guided LASIK may be of particular use in highly aberrated corneas and may also provide outstanding outcomes in healthy eyes given its emphasis on treating the primary refractive surface of the eye.

Acquired unilateral scotoma.

A 54-year-old white man presented with a "blind spot" temporally in his left eye. Best-corrected visual acuity in the affected eye was 20/20, and Humphrey visual field revealed an enlarged blind spot. Funduscopic examination revealed subtle peripapillary pigmentary changes corresponding to a well-demarcated peripapillary region of hyperautofluorescence and hypoautofluorescence on fundus autofluorescence. Outer retinal degenerative changes were detected on spectral-domain optical coherence tomography. A diagnosis of acute zonal occult outer retinopathy was made based on clinical history and imaging studies.

Work Related Ocular Injury: Nepal.

INTRODUCTION: Occupational eye injuries comprise a major source of ocular trauma. Knowledge of the epidemiology of occupational eye injuries is essential to formulate viable safety strategies. OBJECTIVES: To evaluate the demographics, patterns of protective eye wear use, and patterns of occupational eye injury among workers in Hetauda, Nepal. MATERIALS AND METHODS: Community based cross-sectional prospective survey was carried out from September 2010 to July 2011. Survey included all workers irrespective of their age and those who are willing to participate in survey by filling details on structured questioners and comprehensive eye examination at community level. RESULTS: 1236 surveys were collected. 38.3% (473) of workers surveyed reported experiencing a work-related eye injury. Over two-thirds [68.3% (844)] of workers surveyed reported never wearing safety eyewear while at work. There was a positive correlation between male sex (P<0.001), reported previous work-related injury (P<0.001), and attending school (P=0.016) and use of personal protective equipment (PPE). CONCLUSIONS: The population studied demonstrates a significant level of work related injury. There are potentially modifiable factors that could lead to increased use of eye protection.

The Relative Odds of Progressing by Structural and Functional Tests in Glaucoma.

PURPOSE: The purpose of this study was to evaluate the effect of disease severity and number of tests acquired during follow-up on the relative odds of identifying progression by structural or functional tests in glaucoma. METHODS: This was an observational cohort study involving 462 eyes of 305 patients with glaucoma and 62 eyes of 49 healthy subjects. Glaucoma patients and healthy subjects were followed for an average of 3.6 ± 0.9 and 3.8 ± 0.9 years, with a median (interquantile range) of 8 (6-9) and 7 (6-8) visits, respectively. At each visit, subjects underwent visual field assessment with standard automated perimetry (SAP) and retinal nerve fiber layer (RNFL) evaluation by spectral-domain optical coherence tomography (SD-OCT). Slopes of change in SAP mean sensitivity and OCT RNFL thickness over time were estimated by linear regression using progressively cumulative visits over time. Cutoff values for age-related expected rates of change for each test were obtained from the healthy group. Progression by SD-OCT and/or SAP was determined if the slope of change was statistically significant and also lower (faster) than the fifth percentile cutoff calculated from the healthy group. A generalized estimating equation logistic regression model was used to evaluate the relative odds of progressing by OCT versus SAP in glaucoma eyes. RESULTS: Eyes with less severe disease at baseline had a higher chance of being detected as progressing by SD-OCT but not by SAP, whereas an increase in disease severity at baseline increased the chance that the eye would be detected as progressing by SAP but not SD-OCT. Each 1 dB higher MD was associated with a 5% increase in the odds of detecting progression by SD-OCT versus SAP (odds ratio = 1.05 per 1 dB; 95% confidence interval: 1.01-1.09; P = 0.005). CONCLUSIONS: The ability to detect glaucoma progression by SAP versus SD-OCT is significantly influenced by the stage of disease. Our results may provide useful information for guiding clinicians on the relative utility of these tests for detecting change throughout the disease continuum.

Anterior Segment Scleral Fluorescein Angiography in the Evaluation of Ciliary Body Neoplasm: Two Case Reports.

INTRODUCTION: Anterior segment tumors can be difficult to detect until tumor growth is substantial enough to cause local signs or symptoms. Earlier detection may result in improved outcomes, particularly the ability to option for globe-conserving therapy. Multiple diagnostic modalities such as ultrasound or optical coherence tomography exist to aid for earlier detection of ciliary body tumors, but they also have limitations. Here we describe the potential for scleral angiography as an adjunctive modality to assist in evaluating anterior segment ciliary body tumors. CASE PRESENTATIONS: A 61-year-old Caucasian male and a 57-year-old Hispanic female presented for ciliary body tumor evaluation. The Caucasian male notably had abnormal scleral, episcleral, and conjunctival vessels in the affected eye. Scleral angiography was performed in both cases with the abnormal vasculature highlighted in the Caucasian male. The Hispanic female did not demonstrate abnormal scleral angiographic patterns. Notably, the Caucasian male also had regions of abnormal scleral angiography arising in locations of otherwise normal appearing sclera. Both patients had the affected eyes enucleated. Histology of the enucleated eyes demonstrated a ciliary body melanoma in the Caucasian male associated with abnormal vascular and tumor infiltration of the scleral bed. The Hispanic female had a pigmented ciliary body adenoma without involvement of the scleral bed. CONCLUSION: With limited sample size, scleral angiography has the potential to detect abnormal scleral vascular patterns in otherwise normal appearing sclera in cases of ciliary body tumor with scleral vascular invasion.

REAL-TIME FULL-DEPTH VISUALIZATION OF POSTERIOR OCULAR STRUCTURES: Comparison Between Full-Depth Imaging Spectral Domain Optical Coherence Tomography and Swept-Source Optical Coherence Tomography.

PURPOSE: To compare the real-time visualization of vitreoretino-choroidal structures using full-depth imaging (FDI) spectral domain optical coherence tomography (SD-OCT) and swept-source (SS)-OCT. METHODS: Foveal scans using both FDI SD-OCT (Heidelberg Spectralis) and SS-OCT (Topcon Deep Range Imaging-OCT-1) were obtained in 40 normal eyes, 40 eyes with macular pathologies, and 40 eyes with glaucoma. Full-depth imaging SD-OCT images were obtained by manually enhancing the vitreoretinal interface first and then the choroid while averaging each OCT B-scan 100 times. Swept-source-OCT images were obtained by averaging each B-scan 96 times. After masking and randomly mixing the original OCT images, two independent physicians graded visualization of the premacular bursa, interdigitation zone line, and chorioscleral boundary, and also sharpness of choroidal structures. RESULTS: A real-time full-depth image of vitreoretino-choroidal structures was successfully achieved with FDI SD-OCT in 118 cases (98.3%) and with SS-OCT in 45 cases (37.5%, P < 0.001). Full-depth imaging SD-OCT imaging was superior to SS-OCT imaging in visualizing the anterior border of the premacular bursa in 109 eyes (90.8%), with average grading of 1.63 ± 0.53 for the FDI SD-OCT and 0.39 ± 0.52 for the SS-OCT (P < 0.001). Swept-source-OCT was similar to FDI SD-OCT in visualizing the chorioscleral boundary in 108 eyes (90.0%), with average grading of 1.81 ± 0.39 for the SS-OCT and 1.78 ± 0.38 for the FDI-OCT (P = 0.566). The visualization of the interdigitation zone line was identical in the 2 imaging instruments (P = 1.000). The sharpness of the choroidal structures was greater with SS-OCT than with FDI-OCT (P < 0.001). CONCLUSION: Manual double-enhancing FDI technique using SD-OCT provided a good compromise between vitreous and retinochoroidal structures visualization in real time during scanning procedure. In contrast, SS-OCT imaged well details of choroidal sublayers. Appropriate OCT technology and software should be selected according to its application in clinical settings.

A Portable Platform for Evaluation of Visual Performance in Glaucoma Patients.

PURPOSE: To propose a new tablet-enabled test for evaluation of visual performance in glaucoma, the PERformance CEntered Portable Test (PERCEPT), and to evaluate its ability to predict history of falls and motor vehicle crashes. DESIGN: Cross-sectional study. METHODS: The study involved 71 patients with glaucomatous visual field defects on standard automated perimetry (SAP) and 59 control subjects. The PERCEPT was based on the concept of increasing visual task difficulty to improve detection of central visual field losses in glaucoma patients. Subjects had to perform a foveal 8-alternative-forced-choice orientation discrimination task, while detecting a simultaneously presented peripheral stimulus within a limited presentation time. Subjects also underwent testing with the Useful Field of View (UFOV) divided attention test. The ability to predict history of motor vehicle crashes and falls was investigated by odds ratios and incident-rate ratios, respectively. RESULTS: When adjusted for age, only the PERCEPT processing speed parameter showed significantly larger values in glaucoma compared to controls (difference: 243ms; P<0.001). PERCEPT results had a stronger association with history of motor vehicle crashes and falls than UFOV. Each 1 standard deviation increase in PERCEPT processing speed was associated with an odds ratio of 2.69 (P = 0.003) for predicting history of motor vehicle crashes and with an incident-rate ratio of 1.95 (P = 0.003) for predicting history of falls. CONCLUSION: A portable platform for testing visual function was able to detect functional deficits in glaucoma, and its results were significantly associated with history of involvement in motor vehicle crashes and history of falls.

Use of statistical analyses in the ophthalmic literature.

PURPOSE: To identify the most commonly used statistical analyses in the ophthalmic literature and to determine the likely gain in comprehension of the literature that readers could expect if they were to add knowledge of more advanced techniques sequentially to their statistical repertoire. DESIGN: Cross-sectional study. METHODS: All articles published from January 2012 through December 2012 in Ophthalmology, the American Journal of Ophthalmology, and Archives of Ophthalmology were reviewed. A total of 780 peer-reviewed articles were included. Two reviewers examined each article and assigned categories to each one depending on the type of statistical analyses used. Discrepancies between reviewers were resolved by consensus. MAIN OUTCOME MEASURES: Total number and percentage of articles containing each category of statistical analysis were obtained. Additionally, we estimated the accumulated number and percentage of articles that a reader would be expected to be able to interpret depending on their statistical repertoire. RESULTS: Readers with little or no statistical knowledge would be expected to be able to interpret the statistical methods presented in only 20.8% of articles. To understand more than half (51.4%) of the articles published, readers would be expected to be familiar with at least 15 different statistical methods. Knowledge of 21 categories of statistical methods was necessary to comprehend 70.9% of articles, whereas knowledge of more than 29 categories was necessary to comprehend more than 90% of articles. Articles related to retina and glaucoma subspecialties showed a tendency for using more complex analysis when compared with articles from the cornea subspecialty. CONCLUSIONS: Readers of clinical journals in ophthalmology need to have substantial knowledge of statistical methodology to understand the results of studies published in the literature. The frequency of the use of complex statistical analyses also indicates that those involved in the editorial peer-review process must have sound statistical knowledge to appraise critically the articles submitted for publication. The results of this study could provide guidance to direct the statistical learning of clinical ophthalmologists, researchers, and educators involved in the design of courses for residents and medical students.

Estimation of retinal ganglion cell loss in glaucomatous eyes with a relative afferent pupillary defect.

PURPOSE: To estimate retinal ganglion cell (RGC) losses associated with a relative afferent pupillary defect (RAPD) in glaucoma. METHODS: A cross-sectional study was conducted including both eyes of 103 participants from the Diagnostic Innovations in Glaucoma Study. A total of 77 subjects had glaucoma in at least one eye and 26 were healthy. Pupil responses were assessed using an automated pupillometer that records the magnitude of RAPD as an "RAPD score." Standard automated perimetry (SAP) and optical coherence tomography (OCT) also were performed. Retinal ganglion cell counts were estimated using empirical formulas that combine estimates from SAP and OCT. The estimated percentage RGC loss was calculated using the combined structure function index (CSFI). RESULTS: There was good correlation between RAPD magnitude and intereye differences in estimated RGCs (R(2) = 0.492, P < 0.001), mean deviation (R(2) = 0.546, P < 0.001), retinal nerve fiber layer thickness (R(2) = 0.362, P < 0.001), and CSFI (R(2) = 0.484, P < 0.001). Therefore, a high RAPD score is likely to indicate large asymmetric RGC losses. The relationship between intereye difference in RGC counts and RAPD score was described best by the formula; RGC difference = 21,896 + 353,272 * RAPD score. No healthy subjects had an absolute RAPD score > 0.3, which was associated with asymmetry of 105,982 cells (or 12%). CONCLUSIONS: Good correlation between the magnitude of RAPD and intereye differences in mean deviation and estimated RGC counts suggests pupillometry may be useful for quantifying asymmetric damage in glaucoma. (ClinicalTrials.gov number, NCT00221897.).

Heidelberg edge perimetry for the detection of early glaucomatous damage: a case report.

PURPOSE: To illustrate the potential role for Heidelberg edge perimetry (HEP) in the assessment of early functional loss in glaucoma. CASE REPORT: A 46-year-old male presented with raised intraocular pressure but healthy optic discs and normal standard automated perimetry (SAP). He was diagnosed with ocular hypertension, but after 16 years, he developed glaucomatous changes to the right optic disc and inferior retinal nerve fiber layer thinning. Despite the evidence of progressive structural damage, functional testing using SAP was repeatedly normal, based on conventional criteria. HEP, on the other hand, revealed an extensive superior visual field damage in agreement with the structural changes. Additionally, and in contrast to SAP, the HEP indices of Glaucoma Hemifield Test, mean deviation and pattern standard deviation were all outside normal limits. CONCLUSION: This case illustrates that HEP may have an important role in the early detection of functional damage in glaucoma, with potential advantages over SAP.

The relationship between visual field index and estimated number of retinal ganglion cells in glaucoma.

PURPOSE: To evaluate the relationship between visual field index (VFI) and the estimated number of retinal ganglion cells (RGCs) in glaucoma. METHODS: A multicenter study of 1,245 healthy, glaucomatous and suspected glaucomatous eyes of 1,245 subjects recruited from the Diagnostic Innovations in Glaucoma Study (DIGS) and African Descent and Glaucoma Evaluation Study (ADAGES). All eyes underwent standard automated perimetry (SAP) and time-domain optical coherence tomography (TD-OCT). Estimates of RGC count and percentage of RGCs remaining, compared to age-matched healthy eyes, were calculated from TD-OCT using a previously described formula. Smoothing spline curves were fitted to examine the relationship between VFI and the percent remaining RGCs. The first derivative (i.e., slopes) of these curves was used to explore the relationship between changes in these measures. RESULTS: The relationships between the VFI and both estimated RGC counts and the percent remaining RGCs were nonlinear. A unit number of VFI loss corresponded to substantially greater loss of estimated RGCs and estimated percentage of RGCs remaining in early compared to late disease. CONCLUSIONS: The relationship between VFI and estimated RGC counts is nonlinear and the index substantially underestimates the amount of neural loss early in the disease. Disease severity should be taken into account when interpreting rates of VFI change over time.