Pearls for successful cataract surgery with endothelial keratoplasty.

PURPOSE OF REVIEW: This article reviews the current methods of improving outcomes when cataract surgery and endothelial keratoplasty are performed together. RECENT FINDINGS: The refractive shift after endothelial keratoplasty is well known and can negatively affect achieving emmetropia after concomitant cataract surgery. Recent articles have described ways of achieving better refractive outcomes, including the use of nomograms and mathematical models. Specific operative techniques are recommended to minimize graft failure and dislocation when cataract surgery is also performed. There have been few recent reports on the use of 'premium' intraocular lenses in the setting of endothelial keratoplasty with variable results. SUMMARY: Surgeons are achieving better refractive outcomes without compromising graft clarity in combined endothelial keratoplasty and cataract surgery.

Optic nerve diffusion tensor imaging parameters and their correlation with optic disc topography and disease severity in adult glaucoma patients and controls.

PURPOSE: To evaluate optic nerve diffusion tensor imaging (DTI) parameters in glaucoma patients and controls, and to correlate DTI parameters with the rim area obtained with Heidelberg retina tomography (HRT) and with the severity of glaucomatous damage using the Glaucoma Staging System. DESIGN: Pilot study. METHODS: Twenty-seven patients with glaucoma and 12 control subjects underwent DTI and HRT imaging. Main outcome measures included: fractional anisotropy, mean diffusivity, axial diffusivity, radial diffusivity, HRT rim area, and Glaucoma Staging System stage. RESULTS: In group comparison, mean diffusivity (1.33 vs. 0.91 µm/ms, P=0.0002), axial diffusivity (1.70 vs. 1.43 µm/ms, P=0.036), and radial diffusivity (1.24 vs. 0.71 µm/ms, P<0.0001) were significantly higher and fractional anisotropy (0.21 vs. 0.44, P<0.0001) was significantly lower in the glaucoma compared with those of control subjects. In glaucoma patients, mean, axial, and radial diffusivities increased and fractional anisotropy decreased as rim area decreases and the Glaucoma stage increased (P<0.05). However, there were no statistically significant differences in the DTI parameters when adjacent pairs of stages were compared (P>0.05). CONCLUSIONS: DTI may be a useful technique for detection and evaluation of glaucomatous damage in the optic nerve, particularly for patients in whom conventional imaging and perimetry are not possible. Future studies are needed to evaluate how DTI parameters change longitudinally with glaucomatous damage within the visual pathways and address cerebrospinal fluid partial volume effects in diffusion tensor quantification, especially for patients with advanced glaucoma stage.

Differences in vision between clinic and home and the effect of lighting in older adults with and without glaucoma.

IMPORTANCE: Patients often report greater visual difficulties at home than expected from vision testing in the clinic. Such discordance may be owing to worse vision in the home than measured in clinic. OBJECTIVE: To compare vision measured between the clinic and home and evaluate factors, including lighting, associated with these differences. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study conducted from 2005-2009 involved 126 patients with glaucoma and 49 without glaucoma recruited from the Glaucoma and Comprehensive Eye Clinics at Washington University, St Louis, Missouri. Patients underwent clinic and home visits, were aged 55 to 90 years, were consecutively recruited, and met inclusion criteria for this study. A total of 166 eligible patients refused participation. EXPOSURE: Participants underwent clinic and home visits randomized to order of completion. At each visit, masked and certified examiners measured binocular distance visual acuity (DVA) with a nonbacklit chart, near visual acuity (NVA), contrast sensitivity (CS), CS with glare, and lighting. MAIN OUTCOMES AND MEASURES: Differences in vision between the clinic and home. RESULTS: The mean scores for all vision tests were significantly better in the clinic than home for participants with and without glaucoma (P < .05, matched-pair t tests). For DVA, 29% of participants with glaucoma read 2 or more lines better in the clinic than home and 39% with advanced glaucoma read 3 or more lines better. For the entire sample, 21% of participants read 2 or more lines better in the clinic than home for NVA and 49% read 2 or more triplets better in the clinic for CS with glare. Lighting was the most significant factor associated with differences in vision between the clinic and home for DVA, NVA, and CS with glare testing (P < .05, multiple regression model). Median home lighting was 4.3 times and 2.8 times lower than clinic lighting in areas tested for DVA and NVA, respectively. Home lighting was below that recommended in 85% or greater of participants. CONCLUSIONS AND RELEVANCE: Vision measured in the clinic is generally better than vision measured at home, with differences mainly owing to poor home lighting. Knowledge that vision discrepancies between patient report and clinical testing may be owing to home lighting may initiate clinician-patient discussions to optimize home lighting and improve the vision of older adults in their homes.

Upper gastrointestinal bleeding in an end-stage renal disease patient treated with fluoxetine.

The defective platelets of end-stage renal disease patients might be further incapacitated by the antiplatelet effect of selective serotonin reuptake inhibitor, and bleeding tendency in these patients could be aggravated. Here we demonstrate an end-stage renal disease patient who was admitted for duodenal ulcer bleeding during the treatment with fluoxetine, and the bleeding did not stop by various active treatments until the cessation of fluoxetine.

Effect of measurement order between right and left eyes on intraocular pressure measurement.

OBJECTIVE: To determine whether the order of intraocular pressure (IOP) measurement between right and left eyes affects IOP measurement. METHODS: A total of 105 healthy volunteers from the eye clinics and staff at Washington University were randomized into 2 groups. Group 1 underwent 3 sets of 2 IOP measurements per eye, starting with the right eye (right eye twice, left eye twice, right eye twice). Group 2 underwent similar measurements starting with the left eye. After 2 weeks the order of IOP measurements were reversed between groups. A mixed-model repeated-measures analysis of variance analyzed the association of IOP measurement with the order measured (1) between first and second eyes, (2) between first and second visits, (3) between right and left eyes, and (4) with ocular squeezing. RESULTS: Intraocular pressure measured higher in first eyes compared with fellow eyes regardless of whether right or left eyes were measured first (P = .002). Intraocular pressure measurements decreased between the first and second visits (P < .001). No difference was found in IOP measurements between right and left eyes (P = .41). Moderate and severe ocular squeezing were associated with higher IOP measurements (P < .001) and occurred more during earlier than later IOP measurements within a set (P < .001) and between sets (P < .001 to P = .03). CONCLUSIONS: Intraocular pressure measured in the first eye, whether right or left, is higher than IOP measured in the fellow eye; this may be partially because of ocular squeezing. Measurements of IOP decrease between first and second visits. Multiple IOP measurements at multiple visits are necessary to accurately diagnose and treat patients with glaucoma and ocular hypertension.

Non-Invasive Couching Technique to Treat a Morgagnian Cataract Causing Bullous Keratopathy.

A case is described in which a non-invasive couching technique was used to relieve bullous keratopathy caused by a dislocated Morgagnian cataract. This technique involved applying digital pressure to the inferior cornea to push the dislocated nucleus through the pupil and into the posterior segment. This technique may be useful in cases where relief or prevention of eye pain is the primary goal.

Outcome following initial external beam radiotherapy in patients with Reese-Ellsworth group Vb retinoblastoma.

OBJECTIVE: To describe patient and ocular outcomes following initial treatment with external beam radiotherapy (EBT) in eyes with Reese-Ellsworth group Vb retinoblastoma. METHODS: Retrospective case series (from January 1, 1979, to February 28, 2002). The Kaplan-Meier method was used to analyze survival (ocular and patient) and incidence (second cancer) data. RESULTS: Two hundred forty-three patients with 1 or more Reese-Ellsworth group Vb eyes were identified. Of 284 group Vb eyes, 63 (22.2%) initially received EBT, vs 172 (60.6%) that were initially enucleated. Of the 63 radiated group Vb eyes, 31 (49.2%) had no further tumor growth, 26 (41.3%) developed a recurrence, and 8 (12.7%) developed a new tumor. Of the 63 radiated group Vb eyes, 33 (52.4%) developed ocular complications. The ocular survival rate of radiated group Vb eyes was 81.4% at 1 year and 53.4% at 10 years. Twenty-eight radiated group Vb eyes survived to the last follow-up with visual acuity information. Thirteen patients developed second cancers, 11 in the field of radiation. The probability of developing a second cancer following initial EBT for group Vb disease in patients with bilateral disease was 29.7% by 10 years after diagnosis. Survival from second cancers in patients with bilateral disease initially receiving EBT for group Vb disease was 93.6% at 5 years and 52.6% at 18(1/4) years. No patient with unilateral disease developed a second cancer. Deaths due to metastatic retinoblastoma were uncommon. CONCLUSIONS: To our knowledge, this is the first study focusing exclusively on group Vb eyes treated initially with EBT, most of which were salvaged with vision. Outcome data provided herein are clinically relevant when choosing treatment options for advanced intraocular retinoblastoma.