[Causes of blindness in Israel].

Of the world population, 38 million are blind and another 110 million are visually impaired. Even in the developed countries there are 3.5 million who are blind. This study of blindness in Israel is based on the National Blind Registry. At the end of 1998, 15,937 were registered as blind, 0.3% of the total population; 776 (5%) of them were 18 years old or younger; 6,426 (40%) 18-65 years old; and 8,735 (55%) 65 years or older. The leading causes of blindness in Israel are glaucoma (2,074, 13%), macular degeneration (1,954, 12%) and diabetes mellitus (1,680, 11%). Since glaucoma and diabetes, and to a lesser extent glaucoma, respond to treatment, blindness could have been avoided in most cases. National screening programs for early diagnosis and treatment of these diseases would reduce prevalence of the newly blind.

Pterygium-induced corneal astigmatism.

BACKGROUND: Previous work has suggested an association between increasing size of pterygium and increasing degrees of induced corneal astigmatism. OBJECTIVES: To assess the quantitative relation between pterygium size and induced corneal astigmatism using a computerized corneal analysis system (TMS II) and slit-lamp beam evaluation of pterygium size, and to conclude whether corneal astigmatism is an early indication for surgical intervention. METHODS: We evaluated 94 eyes of 94 patients with unilateral primary pterygium of different sizes, using TMS II and slit-lamp beam measurements of the size of the pterygium (in millimeters) from the limbus to assess parameters of pterygium size with induced corneal astigmatism. Best corrected visual Snellen acuity was performed. RESULTS: Primary pterygium induced with-the-rule astigmatism. Pterygium extending > 16% of the corneal radius or 1.1 mm or less from the limbus produced increasing degrees of induced astigmatism of more than 1.0 diopter. Significant astigmatism was found in 16.16% of 24 eyes with pterygium of 0.2 up to 1.0 mm in size, in 45.45% of 22 eyes with pterygium of 1.1 up to 3.0 mm in size (P < or = 0.0004), and in 100% of 3 eyes with pterygium of 5.1 up to 6.7 mm in size (P = 0.0005). We found that visual acuity was decreased when topographic astigmatism was increased. CONCLUSIONS: When primary pterygium reaches more than 1.0 mm in size from the limbus it induces with-the-rule significant astigmatism (> or = 1.0 diopter). This significant astigmatism tends to increase with the increasing size of the lesion. Topographic astigmatism tends to be improved by successful removal of the pterygium. These findings suggest that early surgical intervention in the pterygium may be indicated when the lesion is more than 1.0 mm in size from the limbus.

Keratoconus and mitral valve prolapse.

PURPOSE: To investigate the prevalence of keratoconus in patients with mitral valve prolapse (MVP). METHODS: Videokeratography was performed in 36 patients (72 eyes) with an echocardiographic diagnosis of MVP, and were compared with 25 controls. All participants underwent slit-lamp examination and completed a medical questionnaire about joint hypermobility, arthralgia, asthma, and allergic reactions. RESULTS: Keratoconus was found in eight eyes (11. 1%) (P =.056) of eight patients (22.2%) (P =.049) in the MVP group and in one eye (2%) of one patient (4%) in the control group. The keratoconus was unilateral and asymptomatic in all cases. Conjunctival papillae were statistical significant higher in the MVP group (P =.015). A statistically significant intergroup difference existed in the presence of an allergic reaction (P =.001), but not in arthralgia, hypermobility of joints, or asthma. CONCLUSION: A borderline important association of MVP with keratoconus and with allergy exists. Patients with mitral valve prolapse complaining of poor vision should be suspected of having keratoconus.

Diclofenac sodium, 0.1% (Voltaren Ophtha), versus sodium chloride, 5%, in the treatment of filamentary keratitis.

PURPOSE: To compare the efficacy and short-term safety of diclofenac sodium, 0.1% (Voltaren Ophtha; Ciba-Vision) and of sodium chloride, 5% ophthalmic solution, in the treatment of filamentary keratitis (FK) in patients with dry-eye syndrome due to secondary Sjögren's syndrome. METHODS: Thirty-two patients (64 eyes) with dry-eye syndrome due to secondary Sjögren' syndrome were enrolled in a randomized study (patients and authors were aware of which medication was being used). All patients had FK. Sixteen patients were treated with sodium chloride, 5% drops, and 16 patients received diclofenac sodium, 0.1% eyedrops. Treatment regimen included instillation of 1 drop, 4 times a day for 28 days, for both groups. Clinical assessment was performed once a week during the study period. Data on the efficacy and safety of the different therapeutic regimens were collected and compared. RESULTS: Both medications achieved disappearance of filaments at the end of the study. Treatment with diclofenac sodium, 0.1%, revealed a significantly more rapid improvement of the clinical symptoms as compared with sodium chloride, 5%. No significant adverse effects were observed in both groups. CONCLUSION: Diclofenac sodium, 0.1%, may be an effective and safe topical therapy in patients with FK caused by secondary Sjögren's disease.

Comparison of fluorescein angiography and indocyanine green angiography for imaging of choroidal neovascularization in hemorrhagic age-related macular degeneration.

PURPOSE: To compare fluorescein angiography and indocyanine green angiography for imaging of choroidal neovascularization located under subretinal hemorrhage, in age-related macular degeneration. METHODS: In a retrospective study, 30 eyes of 30 consecutive patients with hemorrhagic age-related macular degeneration were evaluated with fluorescein angiography and indocyanine green angiography. In each eye, areas of macular hemorrhage, choroidal neovascularization, and total lesion (hemorrhage plus choroidal neovascularization) were measured, and the choroidal neovascularization was categorized as classic, occult, or mixed on fluorescein angiography, and as hot spot, plaque, or combined lesion on indocyanine green angiography. Results of the two techniques were compared for the ability to identify a laser-treatable lesion. RESULTS: Fluorescein angiography showed fluorescence in most cases (28, 93.3%). In 23 cases (76.6%), the fluorescence pattern was compatible with occult choroidal neovascularization. Indocyanine green angiography revealed defined patterns of fluorescence in 27 cases (90%): 12 hot spots, seven plaques, and eight combined hot spots and plaques. Twenty lesions (66.6%) detected by indocyanine green angiography were considered eligible for laser therapy. Nine of them (45%) were extrafoveal. CONCLUSIONS: Indocyanine green angiography is beneficial for imaging choroidal neovascularization located under subretinal hemorrhage. Choroidal neovascularization demonstrated on indocyanine green angiography may be considered eligible for laser treatment. Therefore, indocyanine green angiography should be considered in cases of hemorrhagic age-related macular degeneration.

Analgesic effect of topical sodium diclofenac 0.1% drops during retinal laser photocoagulation.

AIMS: To evaluate the analgesic effect of topical sodium diclofenac 0.1% during retinal laser photocoagulation. METHODS: 87 patients, 45 with proliferative diabetic retinopathy treated with two sessions of panretinal photocoagulation (group A), and 42 patients with non-proliferative diabetic retinopathy who underwent grid treatment of the posterior pole (19 bilaterally) (group B). Sodium diclofenac 0.1% or sodium chloride 0.9% drops were topically applied 30-135 minutes before laser treatment in a masked fashion. Patients who had two sessions were given the alternate drug in the second one. Pain level was evaluated immediately after laser treatment with the visual analogue scale (VAS). The results were statistically analysed. RESULTS: Patients in group A reported pain in 85/90 sessions (94%). The average pain level was 44.2% with sodium diclofenac 0.1% drops and 53.1% with sodium chloride 0.9% drops (p = 0.011 by paired t test). Patients in group B reported pain in only 16/60 sessions (26. 7%), and the pain level ranged from 10% to 60% regardless of the kind of drops used. There was no correlation in either group between level of pain and time interval from application of the drops to laser treatment (30-135 minutes) or average energy level used (100-500 mW). CONCLUSION: Sodium diclofenac 0.1% is useful for pain reduction and should be applied before panretinal photocoagulation.

Combined resection and anterior transposition of the inferior oblique muscle for asymmetric double dissociated vertical deviation.

OBJECTIVE: To evaluate the efficacy of combined monocular resection and bilateral anterior transposition of the inferior oblique (IO) muscle for asymmetric double dissociated vertical deviation (DVD). DESIGN: Nonrandomized, comparative clinical trial. PARTICIPANTS: Twelve patients with asymmetric DVD and coexisting unequal IO overaction (IOOA). INTERVENTION: Six consecutive patients underwent combined graded monocular resection and bilateral anterior transposition of the IO muscle and six consecutive historical control patients underwent equal anteriorization of the IO muscle. MAIN OUTCOME MEASURES: Between-group comparison of the postoperative vertical deviation and reduction in IOOA. RESULTS: The mean difference of the asymmetric DVD in the primary position was reduced from 13.3 +/- 4.8 prism diopters (PD) to 2.2 +/- 1.8 PD in the study group (P = 0.001) and from 13.3 +/- 4.0 PD to 10.2 +/- 3.1 PD in the control group (P = 0.003). The difference in improvement between the groups was statistically significant (P = 0.004). The IOOA was significantly reduced in both groups. CONCLUSIONS: Bilateral IO anteriorization with monocular-graded IO resection should be considered as the treatment of choice in patients with asymmetric DVD with IOOA.

Simultaneous indocyanine green and fluorescein angiography in retinal pigment epithelium tear using the confocal scanning laser ophthalmoscope.

PURPOSE: To describe the indocyanine green angiographic pattern of retinal pigment epithelium tears in the setting of age-related macular degeneration compared with the fluorescein angiographic features. METHODS: Twelve consecutive patients (12 eyes) with a retinal pigment epithelium tear underwent simultaneous indocyanine green angiography and fluorescein angiography with the confocal scanning laser ophthalmoscope. The findings for the two modes were compared. RESULTS: Choroidal neovascular membrane was evident beneath the rolled retinal pigment epithelium on indocyanine green angiograms in 11(92%) of 12 eyes: a focal neovascular membrane was apparent in five (42%) of 12 eyes, whereas a plaque neovascular membrane was seen in six (50%) of 12 eyes. In comparison, fluorescein angiography demonstrated late leakage as a result of occult choroidal neovascular membrane in nine (82%) of 11 eyes but no well-defined choroidal neovascular membrane. CONCLUSIONS: Indocyanine green angiography is superior to fluorescein angiography for imaging choroidal neovascularization in cases of retinal pigment epithelium tear and may serve as an important adjunct to indocyanine green-guided laser treatment in selected cases.

Cystoid macular edema after cataract surgery with intraocular vancomycin.

OBJECTIVE: To determine whether the use of supplemental prophylactic vancomycin in the irrigating solution during extracapsular lens extraction is associated with increased incidence of cystoid macular edema. DESIGN: Prospective, randomized, double-masked clinical study. PARTICIPANTS: Consecutive series of 118 patients 60 years of age or older undergoing cataract surgery. INTERVENTION: The study group received an irrigating balanced salt solution supplemented with vancomycin (10 microg/ml), and the control group received the salt solution only. Fluorescein angiography was performed 1 and 4 months after surgery. MAIN OUTCOME MEASURES: Evidence of angiographic and clinical cystoid macular edema, and visual acuity at 1 and 4 months after surgery. RESULTS: The rate of postoperative angiographic cystoid macular edema was significantly higher in the study patients than in the control group at 1 month (55% vs. 19%, P = 0.0006) and 4 months (26% vs. 4%, P = 0.0099). The rates of clinical macular edema were 23% and 7%, respectively, at 1 month (P = 0.011) and 20% versus 0% at 4 months (P = 0.006). Visual acuity of 20/30 or better was noted at 4 months after surgery in 76% of the study group compared to 95.5% of the control group. CONCLUSIONS: The role of preventive intracameral vancomycin during intraocular surgery should be reassessed in view of the associated increase in the incidence of angiographic cystoid macular edema.

Corneal topographic changes after retinal and vitreous surgery.

PURPOSE: To investigate the topographic changes in the cornea after retinal and vitreous operations. DESIGN: Observational prospective case series. PARTICIPANTS: The study population included 46 patients after vitreoretinal surgery: 11 underwent pneumatic retinopexy, 10 underwent vitrectomy, and 25 underwent scleral buckling procedure. METHODS: The corneal topography was measured by videokeratography with the absolute program and evaluated statistically by a quantitative comparative method, which was developed for this study, for the whole and the central cornea. MAIN OUTCOME MEASURES: The corneal topographic changes were measured in diopters (D), evaluating and comparing the preoperative and postoperative measurements. RESULTS: None of the operative procedures changed the shape of the whole cornea. Vitrectomy induced radial steepening of the central cornea 1.2 to 1.6 D, corresponding to the scleral sutures. Central steepening (average, 2.2 D) was also noted in the first week after circular buckling, but it flattened (average, 1.4 D) after 1 to 3 months. When an additional radial or circumferential buckling element was added to the circular buckle, steepening of the entire cornea and radial steepening of the central cornea (average, 0.6-0.8 D) occurred in the first week and flattened or returned to baseline after 1 to 3 months. There was no correlation between the location of the additional buckling element and the corneal topographic change. CONCLUSIONS: Corneal videokeratography is a useful tool for evaluating the postoperative corneal curvature. It showed that vitreoretinal surgery alters the shape of the cornea when buckling or scleral sutures are used, but pneumatic retinopexy does not.

Digital red-free photography for the evaluation of retinal blood vessel displacement in epiretinal membrane.

OBJECTIVE: To evaluate the displacement of retinal blood vessels during the natural course of epiretinal membrane (ERM) formation. DESIGN: Consecutive observational case series. PARTICIPANTS: Thirteen patients (13 eyes) diagnosed with unilateral idiopathic ERM and 10 normal fellow eyes of the same patients served as a control group and constituted the study group. TESTING: All eyes underwent digital red-free filter photography of the fundus using the Topcon Imagenet-1024 System. Photographs were taken on entry to the study and again after 8 to 13 months. Distances were measured between the major and minor blood vessel junctions at the upper and lower temporal arcades and between the disc margin and vessel junctions temporal to the macula on follow-up examinations. To clearly visualize vessel shift, both photographs of each patient were overlaid using the peripheral landmarks of major blood vessel crossings as reference points. MAIN OUTCOME MEASURES: The parameters measured were shifting of blood vessels caused by the ERM formation. The distances were measured in micrometers using the measurement feature of the Topcon Imagenet System. RESULTS: Blood vessel shift (range, 30 microm-434 microm) was noted in all 13 eyes, but in 15 measurements the shift was less than 30 microm and was considered as no shift. In four eyes (31%), the distances decreased in all directions, indicating contraction of the ERM. In four eyes (31%), the distances increased in all directions, indicating release of the ERMs. A mixed pattern of release and contraction of the ERM in the same eye was noted in five eyes (38%). No shift of blood vessels was noted in the control eyes. Findings on image overlay corresponded with the objective measurements. CONCLUSIONS: Noninvasive digital red-free photography is an informative tool for the objective measurement of the vessel displacement during ERM formation. Contraction and release of the ERM were noted.

Slanted lateral rectus recession for exotropia with convergence weakness.

OBJECTIVE: To evaluate the efficacy of slanted recession of the lateral rectus (LR) muscle for exotropia (XT) with convergence weakness. DESIGN: Predesigned, nonrandomized, comparative trial. PARTICIPANTS: Twelve study patients and six control subjects with XT greater at near than at distance by > or =10 prism diopters (PD). INTERVENTION: Twelve consecutive patients underwent slanted LR recession, and six consecutive control subjects underwent standard LR recession. MAIN OUTCOME MEASURES: Between-groups comparison of the postoperative ocular alignment at distance and near, and the difference between them, as well as the stereopsis. RESULTS: Slanted LR recession reduced the XT to <8 PD in all patients at distance and in 11/12 patients at near. Additionally, the mean difference between the distance and near exodeviation was reduced from 14+/-4.5 PD preoperatively to 2.9+/-2.4 PD postoperatively. All patients in the control group demonstrated postoperative deviations of <8 PD at distance, but all had residual exodeviations >8 PD at near. Three of the study patients gained gross stereopsis postoperatively. CONCLUSIONS: Slanted recession of the LR is superior to standard recession in reducing both distance and near XT and in collapsing the difference between them. This technique may also have a positive impact on gross stereopsis.

Intraocular pressure fluctuations during strabismus operations and the postoperative period.

PURPOSE: To evaluate the intraocular pressure (IOP) variations which occur during and after strabismus surgery. METHOD: We measured the IOP in 34 eyes of 20 pediatric patients undergoing primary strabismus surgery under general anesthesia. Measurements were performed by the Tono-Pen (Mentor O&Q Inc. Norwell, MA) prior to surgery, immediately after suturing of the conjunctive, and 1 week and 4 weeks after surgery. All patients received the same local antibiotics and steroid solutions postoperatively. RESULTS: IOP decreased from baseline to the end of surgery by a mean of 8.26 +/- 1.8 mmHg and increased from baseline to 4 weeks after surgery by a mean of 3.6 +/- 1.8 mmHg. Thirty-eight percent of the eyes had an IOP of 21 mmHg or more during the postoperative period. CONCLUSION: IOP variations are prevalent during and after strabismus surgery. Careful postoperative measurements are recommended in order to identify individuals who may be prone to iatrogenically increased IOP.

The combination of topical ceftazidime and aminoglycosides in the treatment of refractory pseudomonal keratitis.

BACKGROUND: Pseudomonal keratitis is a serious and potentially blinding infection. METHODS: We treated 12 patients with culture-positive fulminant pseudomonal keratitis with a topical combination of ceftazidime ophthalmic solution (50 mg/ml) and aminoglycosides (14 mg/ml). None of these patients had responded to the standard initial therapy with topical fortified gentamicin or tobramycin (14 mg/ml) combined with cefazolin (50 mg/ml). RESULTS: Substitution of cefazolin by ceftazidime achieved a remarkable clinical improvement during the first 24-48 h of administration in all cases. The average time of healing after initiation of the combination of ceftazidime and fortified aminoglycosides was 21+/-15 days. No serious side effects accompanied ceftazidime administration. In vitro susceptibility testing showed resistance to gentamicin or tobramycin in 33% of cases (4/12) and sensitivity to ceftazidime in all cases. CONCLUSIONS: The combination of ceftazidime, in a 5% solution, and fortified aminoglycosides (1.4%) may be a useful, safe and effective topical therapy for the treatment of pseudomonal keratitis resistant to aminoglycosides.

Intravitreal gas injection for hypotony after cataract surgery.

PURPOSE: To evaluate the efficacy and safety of intravitreal perfluoropropane gas injection to treat hypotony after cataract surgery. SETTING: The ophthalmology department of a major tertiary medical center. METHODS: After uneventful cataract extraction, 5 patients with hypotony due to iridocyclitis, choroidal detachment, and serous retinal detachment were treated with an intravitreal injection of 1.0 cc of perfluoropropane gas. RESULTS: The hypotony, choroidal detachment, and exudative retinal detachment resolved in all 5 patients, and visual acuity improved. No complications were observed. CONCLUSION: Intravitreal gas injection can be used to treat hypotony after cataract surgery in selected patients.