Social, health and ocular factors associated with primary open-angle glaucoma amongst Chinese Singaporeans.

IMPORTANCE: There is limited literature on lifestyle and health factors related to primary open-angle glaucoma amongst Asians. BACKGROUND: This study evaluated the association of primary open-angle glaucoma with smoking, health and ocular factors amongst Chinese Singaporeans. DESIGN: Case-control study. PARTICIPANTS: The study used 711 primary open-angle glaucoma patients from a Singapore hospital and 2788 population-based controls. METHODS: Subjects underwent clinical examination and completed a questionnaire with details on family history of glaucoma, comorbidities, smoking and alcohol consumption. Glaucoma cases were subclassified as normal or high-tension glaucoma according to their untreated intraocular pressures. MAIN OUTCOME MEASURES: The association of various health and lifestyle factors, with normal-tension and high-tension glaucoma was evaluated. RESULTS: Using multiple logistic regression, primary open-angle glaucoma was associated with older age (odds ratio 1.12 per year older; 95% confidence interval 1.10-1.15; P < 0.001), family history of glaucoma (odds ratio 7.86; 95% confidence interval 4.48-13.79; P < 0.001), higher intraocular pressure (odds ratio 1.75 per 1 mmHg; 95% confidence interval 1.64-1.87; P < 0.001) and thinner central corneal thickness (odds ratio 1.01; 95% confidence interval 1.01-1.02; P < 0.001). Myopes were more likely to have primary open-angle glaucoma (P < 0.001). A current smoking habit was protective against normal-tension glaucoma (odds ratio 0.30; 95% confidence interval 0.10-0.92; P = 0.035). CONCLUSIONS AND RELEVANCE: Older age, family history of glaucoma, higher intraocular pressure, thinner central corneal thickness and myopia were significantly associated with primary open-angle glaucoma amongst Chinese Singaporeans.

Survey of common practices among oculofacial surgeons in the Asia-Pacific region: Graves' orbitopathy.

AIM: A web-based anonymous survey was performed to evaluate practice preferences in the management of Graves' orbitopathy amongst oculofacial surgeons in the Asia-Pacific region. METHODS: A questionnaire with contentious topics in Graves' orbitopathy was sent out via email to oculofacial surgeons in 14 countries within Asia-Pacific between May to December 2012. RESULTS: A response rate of 25.2% to 34.6% was achieved (32-44 of 127 participants). 61.0% of respondents encountered Graves' orbitopathy commonly in their practice. The more common causes of vision loss in Graves' orbitopathy included dysthyroid optic neuropathy (67.5%) and exposure keratopathy (15.0%). The clinical activity score was the most popular grading system for assessing Graves' orbitopathy. The preferred non-surgical therapeutic approaches included intravenous pulsed methylprednisolone (79.5%), oral steroids (56.4%), orbital radiation (12.8%), steroid-sparing immunosuppressants (10.3%) and watchful observation (7.7%). Thyroid orbital decompression was uncommonly or rarely performed by respondents. Orbital surgical decompression was most commonly performed via the two-wall technique (73.5%) and most respondents performed fat decompression (69.4%). Post-operatively, the most common complications include under correction (45.5%) and diplopia (42.4%). CONCLUSION: We report the results of the first survey on the management of Graves' orbitopathy amongst oculofacial surgeons in Asia-Pacific. Our respondents practice preferences reflected the Graves' orbitopathy management consensus statement by the European group on Graves' orbitopathy in 2008.

Centration and Stability of Small-Aperture Intraocular Lens in Aberrated Eyes.

PURPOSE: To investigate the visual outcomes and postoperative stability of IC-8 intraocular lens (AcuFocus, Inc) implantation following femtosecond laser-assisted cataract surgery. METHODS: In this prospective study, the IC-8 IOL was implanted in the non-dominant eye of 12 patients. Centration and uncorrected and corrected distance, intermediate, and near visual acuities (UDVA, UIVA, UNVA, CDVA, CIVA, CNVA) were evaluated up to postoperative month 3 (POM3). Means ± standard deviations are reported in logMAR units. RESULTS: There were no significant differences in absolute, vertical, and horizontal centration postoperatively versus intraoperatively. From intraoperative to POM3, mean displacement was 0.17 ± 0.09 and 0.14 ± 0.07 mm (P = .52) relative to the capsulorhexis and 0.28 ± 0.22 and 0.25 ± 0.14 mm relative to the limbus (P = .62), respectively. Centration remained within the 1.36-mm IC-8 aperture. Excluding patients with ocular comorbidities, from preoperatively to POM3, UDVA improved significantly from 0.52 ± 0.39 to 0.20 ± 0.11 logMAR (P = .024), with an efficacy index of 0.80 ± 0.31. The safety index was 1.30 ± 0.40, with no adverse events experienced. At POM3, CDVA, UIVA, and UNVA of 0.04 ± 0.05, 0.27 ± 0.11, and 0.22 ± 0.10 logMAR were achieved, respectively. Binocularly, all achieved UDVA of 20/25 or better and UIVA and UNVA of N6 and better. CONCLUSIONS: The IC-8 IOL can attain good centration and positional stability up to POM3. It enables both extended depth of focus and tolerance to aberration, making it capable of achieving spectacle independence after surgery. [J Refract Surg. 2022;38(2):98-105.].

Water Gonioscopy: A Technique for Intraoperative Visualization of the Anterior Chamber Angle.

AIM AND OBJECTIVE: To describe a technique of lens-free gonioscopy that allows the anterior chamber angle to be visualized intraoperatively, without the use of a gonioscopy lens. BACKGROUND: Minimally invasive glaucoma surgery (MIGS) is an increasingly popular treatment option for mild to moderate glaucoma. We describe a technique of lens-free gonioscopy that allows visualization of the anterior chamber angle without the use of a lens. This simple intraoperative technique may be used to inspect the placement of MIGS devices within the angle. TECHNIQUE: To perform a water gonioscopy, the surgeon sits temporal to the eye. The patient's head is turned 20-45° away from the surgeon, and the operating microscope is tilted 15-30° toward the surgeon. A reservoir of balanced salt solution is allowed to collect in the crater formed by the nose bridge and the bony orbital rim, external to the corneal surface. This body of liquid obliterates the cornea-air interface and hence allows visualization of the anterior chamber. In contrast to gonioscopy using a gonioscopy lens, water gonioscopy offers a lower magnification, ultra-wide field of view for angle visualization. CONCLUSION: Water gonioscopy is a useful technique that anterior segment surgeons might use for quick visualization of the anterior chamber angle without the need for additional equipment. CLINICAL SIGNIFICANCE: This is a simple technique that surgeons can use to visualize the anterior chamber angles intraoperatively. It is especially useful for MIGS that are placed within the anterior chamber angle, but this technique may also be used during other anterior segment surgeries, such as visualizing the haptics of an anterior chamber intraocular lens or checking for retained lens fragments in the anterior chamber angles. HOW TO CITE THIS ARTICLE: Chiam N, Perara S. Water Gonioscopy: A Technique for Intraoperative Visualization of the Anterior Chamber Angle. J Curr Glaucoma Pract 2021;15(3):106-108.

The Effects of Donor-Recipient Age and Sex Compatibility in the Outcomes of Deep Anterior Lamellar Keratoplasties.

PURPOSE: Corneal transplantations are the commonest allogenic transplant surgeries performed worldwide. Transplantable grade donor cornea is a finite resource. There is thus an impetus for eye banks to optimize the use of each harvested cornea, and clinicians to minimize the risks of graft rejection and failure. With better survival and lower rejection rates, anterior lamellar keratoplasty has gained popularity as an alternative technique to full-thickness penetrating keratoplasty, for the treatment of corneal stromal diseases. This study evaluated the effects of donor-recipient age- and sex-matching on the outcomes of eyes that had undergone deep anterior lamellar keratoplasty (DALK) surgeries. DESIGN: Observational cross-sectional study (national corneal graft registry data). SUBJECTS: All DALK surgeries performed in a tertiary ophthalmic hospital over an 11-year period. METHODS: To analyse the effects of donor-recipient sex-matching, transplantations were classified as "presumed H-Y incompatible" (male donor to female recipient) or "presumed H-Y compatible" (all other donor-recipient sex combinations). For age-matching, differences in donor and recipient ages were calculated. Cox proportional hazards regressions were used to evaluate the influence of donor-recipient sex-matching and age-matching on graft failure and rejection. MAIN OUTCOME MEASURES: Rates of graft failure and rejection within each group. RESULTS: 401 eyes were included. 271 (67.6%) transplants were presumed H-Y compatible. 29 (7.2%) grafts failed and 9 (2.2%) grafts rejected. There were trends of lower hazard ratios (HRs) in graft failure and rejection in the presumed H-Y compatible group [HRs: 0.59 (95% CI 0.20-1.77, p = 0.34) and 0.93 (95% CI 0.22-3.89, p = 0.926), respectively]. Median difference in age between recipients and donors was 15.0 years (IQR -2.8-34.3). The HRs of graft failure and rejection were not influenced by donor-recipient age [HRs per 1-year increase in age difference: 0.995 (95% CI 0.98-1.01, p = 0.483) and 1.01 (95% CI 0.99-1.03, p = 0.394), respectively]. CONCLUSION: In eyes that had undergone DALK surgeries, no significant influence of donor-recipient sex- or age-matching on graft rejection and failure was observed. Without strong evidence and the limitations of obtaining sample sizes required for an adequately powered study, the benefits of sex- and age-matching of donors and recipients during graft allocation for DALK surgeries is currently inconclusive.

Intravitreal Injection with a Conjunctival Injection Device: A Single-Center Experience.

Purpose: To evaluate the clinical performance of the intravitreal injection assistant device (InVitria) compared with the conventional freehand technique for delivering intravitreal injections. Methods: Seventy patients were randomized to receive intravitreal injections via the conventional freehand technique while 70 received injections using the InVitria. Half of all procedures in each group were performed by junior surgeons, while the rest were performed by senior surgeons. Results: Mean injections times were 90.0 ± 23.3 seconds and 64.9 ± 26.8 seconds for conventional versus InVitria (P < 0.001). Mean injection times with the conventional technique were 85.5 ± 23.0 seconds vs. 94.2 ± 23.0 seconds for senior versus junior surgeons (P = 0.120). Mean injection times with the InVitria were 56.1 ± 26.1 seconds vs. 66.3 ± 26.9 seconds (P = 0.211) for senior versus junior surgeons. There were no significant differences in pain scores regardless of technique (conventional versus In Vitria: 2.03 ± 1.73 vs. 2.13 ± 2.20, P = 0.770). Conclusions: In our experience, the InVitria is a comparable alternative to the conventional freehand technique of delivering intravitreal injections, with the potential for faster injection times and without compromising on patient comfort. Translational Relevance: The study provides evidence to suggest that the InVitria may be deployed effectively in clinical practice.

Comparing Patient-Reported Outcomes of Laser In Situ Keratomileusis and Small-Incision Lenticule Extraction: A Review.

PURPOSE: Laser in situ keratomileusis (LASIK) and small-incision lenticule extraction (SMILE) are popular refractive surgeries. The objective refractive outcomes of LASIK and SMILE have been studied extensively; both procedures have comparable safety, efficacy, and predictability. However, owing to various psychosocial factors, refractive patients may report dissatisfaction despite good postoperative vision. Hence the importance of studies on subjective patient-reported outcomes. This review discusses the role of psychometric-technique-based validated questionnaires when evaluating subjective outcomes. It also summarizes the literature on patient-reported outcomes for LASIK and SMILE. DESIGN: A literature search was performed on PubMed database to identify studies that have assessed patient-reported outcomes for LASIK and SMILE. RESULTS: Several studies have looked into patient-reported outcome measures for LASIK, but the number of equivalent studies for SMILE is limited. Questionnaires (validated and non-validated) are used to evaluate patient-reported outcomes. Validated questionnaires are designed based on psychometric techniques, such as Classic Test Theory, Item Response Theory, and Rasch analysis. The Quality of Life Impact of Refractive Correction (QIRC) questionnaire, a validated questionnaire administered to both LASIK and SMILE patients, suggests that both groups have comparable vision-related quality of life in the first few months postoperatively; but SMILE might confer a slight advantage in the later postoperative period (postoperative month 6). CONCLUSIONS: Future LASIK-SMILE comparative studies utilizing standardized validated questionnaires for patient-reported outcome measures with longer follow-up durations would be a welcome contribution to this important aspect of refractive surgery.

Survey of Common Practices among Oculofacial Surgeons in the Asia-Pacific Region: Management of Orbital Floor Blowout Fractures.

A web-based anonymous survey was performed to assess common practices of oculofacial surgeons in the management of traumatic orbital floor blowout fractures. A questionnaire which contained questions on several controversial topics in the management of orbital floor fractures was sent out via e-mail to 131 oculofacial surgeons in 14 countries in the Asia-Pacific region. A total response rate of 58.3% was achieved from May to December 2012. The preferred time for surgical intervention was within 2 weeks for adult patients, porous polyethylene implant was the most popular choice, and most surgeons preferred the transconjunctival approach. Postoperatively, diplopia was the most commonly encountered complication and most oculofacial surgeons reviewed their patients regularly for up to 12 months. We report the results of the first survey of oculofacial surgeons within the Asia-Pacific region on the management of orbital floor blowout fractures. Compared with previous surveys (from year 2000 to 2004), the duration to surgical intervention was comparable but there was a contrasting change in preferred surgical approach and choice of orbital implant.

Uveitis and gender: the course of uveitis in pregnancy.

The hormonal and immunological changes in pregnancy have a key role in maintaining maternal tolerance of the semiallogeneic foetus. These pregnancy-associated changes may also influence the course of maternal autoimmune diseases. Noninfectious uveitis tends to improve during pregnancy. Specifically, uveitis activity tends to ameliorate from the second trimester onwards, with the third trimester being associated with the lowest disease activity. The mechanism behind this phenomenon is likely to be multifactorial and complex. Possible mechanisms include Th1/Th2 immunomodulation, regulatory T-cell phenotype plasticity, and immunosuppressive cytokines. This clearly has management implications for patients with chronic sight threatening disease requiring systemic treatment, as most medications are not recommended during pregnancy due to lack of safety data or proven teratogenicity. Given that uveitis activity is expected to decrease in pregnancy, systemic immunosuppressants could be tapered during pregnancy in these patients, with flare-ups being managed with local corticosteroids till delivery. In the postpartum period, as uveitis activity is expected to rebound, patients should be reviewed closely and systemic medications recommenced, depending on uveitis activity and the patient's breastfeeding status. This review highlights the current understanding of the course of uveitis in pregnancy and its management to help guide clinicians in managing their uveitis patients during this special time in life.

Scedosporium prolificans endogenous endophthalmitis.

Scedosporium prolificans is an opportunistic fungus with a predilection for sepsis and endophthalmitis in immunocompromised patients. We report a case of endogenous S. prolificans endophthalmitis in a 9-year-old girl following chemotherapy for acute myeloid leukemia. She achieved an excellent visual outcome following intensive antifungal therapy.

The course of uveitis in pregnancy and postpartum.

AIM: To examine the course of non-infectious uveitis during pregnancy. METHODS: This is a retrospective case series. The medical records of 47 subjects with a previous history of non-infectious uveitis pre-dating their pregnancy were reviewed. Uveitis activity during the periods 1 year before pregnancy, during pregnancy and 1 year postpartum, were recorded. Information on patient demographics, type of uveitis, medication use, sex of child and breastfeeding status were also collected. The main outcome measures were the events of flare-ups during the prepregnancy, pregnancy and postpartum periods. RESULTS: The rate of flare-up was 1.188 per person year prior to pregnancy, 0.540 per person year during pregnancy and 0.972 per person year in postpartum (p<0.001 for comparison between prepregnancy and pregnancy; p=0.009 for comparison between pregnancy and postpartum). Rates of flare-up only began to decrease in the second trimester. After delivery, rates of flare-up rebounded and within 6 months postpartum, flare-up rates were not significantly different from prepregnancy levels (p=0.306). Even so, 40% of subjects were found to have remained inactive within 1 year postpartum. CONCLUSIONS: Uveitis activity decreased by mid-pregnancy, but returned to prepregnancy levels within 6 months postpartum. These findings may be used to adjust uveitis management during pregnancy and the postpartum period.