Histologic assessment of dermatochalasis: elastolysis and lymphostasis are fundamental and interrelated findings.

OBJECTIVE: To determine the presence, degree, and extent of lymphatic, elastic, and collagen fiber alterations in dermatochalasis (DC) specimens. DESIGN: Case control study of patients with DC compared with age-, gender-, and site-matched controls. PARTICIPANTS: A total of 25 eyelid specimens were studied; 15 of these were blepharoplasty specimens (experimental) and 10 were entropion/ectropion specimens of patients without DC (controls). METHODS: The number and maximal dilation of lymphangiectasia was measured by light microscopy, immunohistochemistry with lymphatic marker D2-40, and elastic tissue content by Verhoeff-van Gieson histochemistry. The number of macrophages was compared between patients with DC and controls in CD68 immunostained specimens. MAIN OUTCOME MEASURES: Lymphatic density, edema, and inflammation. RESULTS: Dermatochalasis eyelid specimens showed increased lymphangiectasia density (5.6 vs. 2.4 lymphatics/high power field; P<0.05), maximal lymphatic dilation (127 vs. 51.5 µm; P<0.05), loss of elastic fibers (2.2 vs. 8.9 fibers/high power field; P<0.05), and greater disruption of collagen networks and edema compared with controls (increased stromal collagen bed of 752 vs. 269 µm; P<0.05; increased intercollagen space of 32.5 vs. 11.8 µm; P<0.05). Macrophages were present in greater quantities in DC specimens (28.6 vs. 11.9 macrophages/high power field; P<0.05). CONCLUSIONS: Patients with DC show an increase in number and maximal dilation of lymphatic vessels in conjunction with widely spaced collagen bundles. This finding coexists with loss of elastic fibers, components known to be essential to the structure and function of the lymphatic system. Governed by macrophages, the pathogenesis of DC may begin with subclinical inflammation leading to elastolysis and secondary lymphostasis. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Utilization patterns for diagnostic imaging in the evaluation of epiphora due to lacrimal obstruction: a national survey.

PURPOSE: To evaluate current physician patterns for diagnostic lacrimal imaging in patients with epiphora related to lacrimal obstruction. METHODS: An invitation was sent to members of the American Society of Ophthalmic Plastic and Reconstruction Surgeons in September 2008 to participate in a short web-based questionnaire. The survey focused on basic demographic information and the use and indications for various types of diagnostic imaging modalities in the evaluation of epiphora. Specific imaging modalities queried included facial x-ray, lacrimal ultrasound, CT, MRI, contrast dacryocystography, and radionuclide dacyroscintigraphy. Responses were analyzed using standard statistical methods. RESULTS: Less than 5% of respondents use lacrimal imaging of any type for the majority of their patients with epiphora thought due to lacrimal obstruction. When lacrimal imaging was used, CT was the most common type overall. CT was the preferred modality for all indications surveyed when an imaging modality was elected, except when confirming the site or type of obstruction in which case dacryocystography was preferred. Excluding CT, a majority of respondents indicated that they "never" (0%) used any of the specific lacrimal imaging studies surveyed, including dacyroscintigraphy, which was never used by over 75% of respondents. CONCLUSIONS: The low overall imaging rate suggests that most lacrimal problems are diagnosed with office testing alone. For most specific indications, respondents indicated a preference for CT. No difference in imaging frequency was found for the majority of our respondents when considering external versus endonasal dacryocystorhinostomy. Most respondents favored external approach dacryocystorhinostomy.

MRI Study of the Posterior Visual Pathways in Primary Open Angle Glaucoma.

PURPOSE OF THE STUDY: The purpose of the study was to evaluate neurodegeneration along brain visual pathways in primary open angle glaucoma (POAG) using improved analysis methods of volumetric and diffusion tensor magnetic resonance imaging (MRI) data. METHODS: Eleven POAG patients (60.0±9.2 y) with primarily mild to moderate POAG and 11 age-matched controls (55.9±7.5 y) were studied using structural and diffusion tensor MRI. Surface-based segmentation was applied to structural MRI to obtain visual cortical area and volume. Fiber tracking was applied to diffusion tensor data to obtain diffusion parameters along the optic tract and optic radiation. MRI parameters in glaucoma patients were compared with the corresponding left and right visual fields and retinal nerve fiber layer thicknesses, instead of with the left and right eye. RESULTS: Area and volume of the primary visual cortex were significantly reduced in POAG patients compared with controls (P<0.05) but did not correlate with visual field loss. Fractional anisotropy was reduced at multiple locations along the optic tracts and optic radiations in POAG patients compared with controls. Axial and radial diffusivity along the fiber tracts showed trends but were not significantly different between POAG patients and controls when averaged over the whole structures. Only fractional anisotropy (P<0.05) of the optic radiations was significantly correlated with visual field loss. No MRI parameters were correlated with retinal nerve fiber layer thickness. CONCLUSIONS: Improved analysis techniques of MRI data improves delineation of degeneration in the brain visual pathways and further supports the notion that neurodegeneration is involved with glaucoma pathogenesis.

Retinotopic fMRI Reveals Visual Dysfunction and Functional Reorganization in the Visual Cortex of Mild to Moderate Glaucoma Patients.

PURPOSE: To investigate retinotopic functional representation in the visual cortex of mild to moderate primary open-angle glaucoma (POAG) participants and age-matched normal volunteers using high-resolution retinotopic blood oxygenation level dependent (BOLD) functional magnetic resonance imaging (fMRI). METHODS: fMRI was performed on 9 POAG participants (61±11 y old) and 9 age-matched controls (58±5 y old) were studied. A wide-view visual presentation (±55 degrees) was used to evaluate central and peripheral vision. Cortical magnification factors and BOLD% changes as a function of eccentricity. Correlation analysis between BOLD% changes and visual field scores, and between BOLD% changes and retinal nerve fiber layer thicknesses was performed. Comparison of BOLD% changes for individual visual field quadrants between POAG subgroups and normal group was performed. RESULTS: BOLD% changes of POAG participants in peripheral visual regions were reduced compared to normals but similar in central visual regions, consistent with the notion of peripheral vision being affected first and more compared to central vision. fMRI retinotopic mapping revealed enlarged representation of the parafovea in the visual cortex of POAG participants compared to normals. Cortical magnification of the central, but not peripheral, visual representation in the visual cortex was larger in POAG participants, suggesting functional remapping. BOLD% changes of individual visual field quadrants were significantly correlated with visual field scores and with retinal nerve fiber layer thickness in the corresponding quadrants. CONCLUSIONS: These results support the hypothesis that there are functional alteration and remapping in the topographic representation of the visual cortex in POAG participants, and these changes are correlated with disease severity.

Clostridium septicum endophalmitis associated with colon adenocarcinoma.

Endogenous Clostridium septicum endophthalmitis is a rare, devastating infection that has been shown to be associated with colonic and hematologic malignancies. We present a case of clostridial endophthalmitis that resulted in expedient identification of colon adenocarcinoma.

Age and positional effect on the anterior chamber angle: assessment by ultrasound biomicroscopy.

Purpose. To investigate age- and position-related changes of anterior chamber angle anatomy in normal, healthy eyes. Patients and Methods. Thirty subjects were separated into a younger and older cohort. The superior and inferior anterior chamber angles of the eyes were measured in supine and sitting positions by ultrasound biomicroscopy (UBM) with bag/balloon technology. Statistical analysis was used to evaluate positional and age-related changes in angle morphology. Results. In the younger cohort, no location or positional differences in angle anatomy were observed. In the older cohort, the inferior quadrant was significantly narrower than the superior quadrant (P = 0.0186) in the supine position. This cohort also demonstrated an interaction effect between position and location. In the older cohort, the angle was deeper inferiorly while the subject was sitting but was deeper superiorly while the subject was supine. Conclusion. Comparison of positional variations in anterior chamber angle anatomy as measured by UBM has recently become possible. This study found that age-related positional changes in the anterior chamber angle anatomy exist in normal healthy eyes.

Clinical outcomes of peripheral iridotomy in patients with the spectrum of chronic primary angle closure.

Purpose. To evaluate outcomes of peripheral iridotomy (PI) for initial management of primary angle closure suspects (PACS), chronic primary angle closure (CPAC), and chronic primary angle closure glaucoma (CPACG). Patients and Methods. Seventy-nine eyes with PACS, CPAC, or CPACG and better than 20/50 visual acuity that underwent PI as initial management were included. Eyes with previous acute angle closure attacks, laser trabeculoplasties, surgeries, or intraocular injections were excluded. Additional treatments, glaucomatous progression, intraocular pressure, visual acuity, and the number of medications were evaluated. Results. The mean followup was 57.1 ± 29.0 months (range 13.8-150.6 months). Sixty-eight eyes (86.1%) underwent additional medical, laser, or surgical treatment. Forty eyes (50.6%) underwent lens extraction due to reduced visual acuity. The mean 10× logMAR visual acuity score for all patients significantly declined from 0.94 ± 1.12 at baseline to 1.83 ± 3.49 (N = 79, P = 0.0261) at the last followup. Conclusions. Most patients who undergo PI for CPAC spectrum will require additional intervention for either IOP lowering or improvement of visual acuity. This suggests that a procedure that not only deepens the angle but also lowers IOP and improves visual acuity would be desirable as further intervention could be avoided. Evaluation of techniques that achieve all 3 goals is warranted.

Short-Term Outcomes of KeraSys Patch Graft for Glaucoma Drainage Devices: A Case Series.

Purpose. Tube-related exposure is a known complication of glaucoma drainage device (GDD) surgery. Our objective is to report the early (approximately 1 year) tube exposure rate of implants covered with a keraSys (IOP Inc., Costa Mesa, CA, USA) tissue reinforcement graft. Patients and Methods. A retrospective, noncomparative, consecutive case series of 42 eyes with GDD implantation with keraSys patch grafts was performed. Main outcome measurements included patch-related complications: patch exposure, tube exposure, wound dehiscence, and patch migration. Results. Forty-two eyes were followed for an average of 15.24 ± 10.44 months (range 1.0-32.3 months). Four (10%) eyes experienced patch-related complications: two with exposure 8 months postoperatively, one with exposure 13 months postoperatively, and one with exposure 4 weeks postoperatively. Conclusion. The effectiveness of the keraSys patch graft is limited by the higher than expected early exposure rate found in this case series. These results should be confirmed in other studies.

Age-related changes in trabecular meshwork imaging.

PURPOSE: To evaluate the normal aging effects on trabecular meshwork (TM) parameters using Fourier domain anterior segment optical coherence tomography (ASOCT) images. PATIENTS AND METHODS: One eye from 45 participants with open angles was imaged. Two independent readers measured TM area, TM length, and area and length of the TM interface shadow from 3 age groups (18-40, 41-60, and 61-80). Measurements were compared using stepwise regression analysis. RESULTS: The average TM parameters were 0.0487 (± 0.0092) mm(2) for TM area, 0.5502 (± 0.1033) mm for TM length, 0.1623 (± 0.341) mm(2) for TM interface shadow area, and 0.7755 (± 0.1574) mm for TM interface shadow length. Interobserver reproducibility coefficients ranged from 0.45 (TM length) to 0.82 (TM area). TM area and length were not correlated with age. While the TM interface shadow length did not correlate with age, the TM interface shadow area increased with age. Race, sex, intraocular pressure, and gonioscopy score were not correlated with any TM parameters. CONCLUSION: Although the TM measurements were not correlated with age, the TM interface shadow area increased with age. Further study is required to determine whether there is any relationship between the age-related ASOCT findings of the TM interface shadow area and physiologic function.

Reproducibility of scleral spur identification and angle measurements using fourier domain anterior segment optical coherence tomography.

Purpose. To evaluate intraobserver and interobserver agreement in locating the scleral spur landmark (SSL) and anterior chamber angle measurements obtained using Fourier Domain Anterior Segment Optical Coherence Tomography (ASOCT) images. Methods. Two independent, masked observers (SR and AZC) identified SSLs on ASOCT images from 31 eyes with open and nonopen angles. A third independent reader, NPB, adjudicated SSL placement if identifications differed by more than 80 µm. Nine months later, SR reidentified SSLs. Intraobserver and interobserver agreement in SSL placement, trabecular-iris space area (TISA750), and angle opening distance (AOD750) were calculated. Results. In 84% of quadrants, SR's SSL placements during 2 sessions were within 80 µm in both the X- and Y-axes, and in 77% of quadrants, SR and AZC were within 80 µm in both axes. In adjudicated images, 90% of all quadrants were within 80 µm, 88% in nonopen-angle eyes, and 92% in open-angle eyes. The intraobserver and interobserver correlation coefficients (with and without adjudication) were above 0.9 for TISA750 and AOD750 for all quadrants. Conclusions. Reproducible identification of the SSL from images obtained with FD-ASOCT is possible. The ability to identify the SSL allows reproducible measurement of the anterior chamber angle using TISA750 and AOD750.