Pregnancy and the eye: What do we need to watch out for? A review.

Pregnancy causes changes in all body systems, including the eye. The eye can undergo physiological and pathological changes in pregnancy. Some changes exacerbate pre-existing eye conditions while other conditions manifest for the first-time during pregnancy. Early recognition and management are essential to prevent sight threatening complications. In addition, some obstetric complications can be associated with ophthalmic signs. Prompt recognition of these eye findings may be life saving for both the mother and the foetus. The aim of this article is to present potential ocular complications in pregnancy and outline the appropriate management to preserve sight and maintain maternal and foetal safety. The safety of the use of common ophthalmological medications will also be discussed.

Successful treatment of fingolimod-associated macular edema with intravitreal triamcinolone with continued fingolimod use.

The occurrence of macular edema as an adverse effect of fingolimod is well documented. Treatment modalities used to manage fingolimod-associated macular edema (FAME) have included nonsteroidal anti-inflammatory agents and sub-tenon injection. We describe two cases where intravitreal injection is used to successfully treat FAME in patients who were previously unsuccessfully treated with topical nonsteroidal anti-inflammatories.

Orbital Varix Thrombosis and Review of Orbital Vascular Anomalies in Blue Rubber Bleb Nevus Syndrome.

A 57-year-old woman with cutaneous manifestations of (BRBNS) presented with acute left proptosis and venous congestion secondary to thrombosis within a superior ophthalmic vein varix. Multiple phleboliths were noted in the contralateral right orbit, and an incidental right middle cerebral artery aneurysm. Her symptoms spontaneously resolved within a few days. An English literature review found 7 reported cases of orbital vascular lesions in association with BRBNS from 1950 to 2012. All lesions showed contrast enhancement on CT or MRI: 4 had small orbital calcifications and 3 were distensible with raised venous pressure. The occurrence of a thrombosed orbital varix or cerebral artery aneurysm in BRBNS, to the best of the authors' knowledge, has not been previously reported. Although orbital vascular lesions in BRBNS have been described as hemangiomas, the biologic behavior and histology of most of the reported orbital lesions are most compatible with venous malformations.

Central retinal artery occlusion: a stroke of the eye.

Central retinal artery occlusion (CRAO), like a stroke in the brain, is a critical eye condition that requiring urgent medical attention. Patients with CRAO present with acute loss of vision and the visual prognosis is poor with low chance of spontaneous visual recovery. Moreover, the risk of developing ischaemic heart disease and cerebral stroke is increased due to the presence of underlying atherosclerotic risk factors. Currently, there is no officially recommended treatment for CRAO. This review will describe the anatomy, pathophysiology, clinical features of CRAO, as well as exploring existing and potential future approaches for managing the condition.

Risk of age-related macular degeneration 3 years after cataract surgery: paired eye comparisons.

OBJECTIVE: To clarify possible associations between cataract surgery and progression of age-related macular degeneration (AMD). DESIGN: Clinic-based cohort. PARTICIPANTS: We followed cataract surgical patients aged 65+ years in the Australian Cataract Surgery and Age-related Macular Degeneration (CSAMD) study. Patients who remained unilaterally phakic for at least 24 months after recruitment were included. METHODS: We performed annual examinations with retinal photography. We assessed AMD using side-by-side grading of images from all visits. Paired comparisons between operated and nonoperated fellow eyes (defined as nonoperated or operated <12 months previously) were made using generalized estimating equation models. MAIN OUTCOME MEASURES: Incident early AMD was defined as the new appearance of soft indistinct/reticular drusen or coexisting retinal pigmentary abnormality and soft distinct drusen in eyes at risk of early AMD. Incident late AMD was defined as the new appearance of neovascular AMD or geographic atrophy (GA) in eyes at risk of late AMD. RESULTS: Among 2029 recruited, eligible participants, 1851 had cataract surgery performed at Westmead Hospital, Sydney, and 1244 (70.7%) had 36-month postoperative visits. Of these participants, 1178 had gradable photographs at baseline and at least 1 follow-up visit. Of 308 unilaterally operated participants at risk of late AMD, this developed in 4 (1.3%) operated and 7 (2.3%) nonoperated fellow eyes (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.23-2.36) after adjusting for the presence of early AMD at baseline. Of 217 unilaterally operated participants at risk of early AMD, this developed in 23 (10.6%) operated and 21 (9.7%) nonoperated fellow eyes (OR, 1.07; 95% CI, 0.74-1.65). Incident retinal pigment abnormalities were more frequent in operated than nonoperated fellow eyes (15.3% vs. 9.9%; OR, 1.64; 95% CI, 1.07-2.52). There was no difference in the 3-year incidence of large soft indistinct or reticular drusen between the 2 eyes (8.8% vs. 7.9%; OR, 1.12; 95% CI, 0.79-1.60). CONCLUSIONS: Prospective follow-up data and paired eye comparisons of this older surgical cohort showed no increased risk of developing late AMD, early AMD, or soft/reticular drusen over 3 years. There was a 60% increased detection of retinal pigmentary changes in surgical eyes.

Long-term outcomes of phacoemulsification cataract surgery performed by trainees and consultants in an Australian cohort.

BACKGROUND: It is unclear whether differences exist in surgical complication rates and long-term visual acuity outcomes between patients whose phacoemulsification cataract surgery was performed by ophthalmological trainees and those performed by consultants. DESIGN: Prospective clinical cohort study. PARTICIPANTS: 1851 participants of the Cataract Surgery and Age-related Macular Degeneration study, aged ≥64 years, had cataract surgery performed at Westmead Hospital, Sydney. METHODS: Surgical complication rates and visual acuity at 24-month postoperative visits were compared between patients who were operated on by trainees and those operated on by consultants. MAIN OUTCOME MEASURES: Surgical outcomes included operative complications recorded in surgical audit forms and 24-month postoperative visual acuity. RESULTS: Of 1851 patients, 1274 (68.8%) were reviewed 24 months after surgery. Of these, 976 had data on the type of surgeon who performed the operation. After excluding 152 challenging cases and three cases operated on by first-year trainees at the beginning of their training, 821 patients were included in this study, of those, 498 were operated on by trainees and 323 by consultants. Habitual visual acuity ≥6/12 was achieved in 77.3% (n = 385/498) and 74.3% (n = 240/323), respectively, of the two groups of patients 24 months postoperatively. Of 514 patients who had surgical audit data, the major complication rate was numerically greater, but not significantly different for the 330 trainee-operated (6.1%) patients, compared with the 184 consultant-operated patients (2.7%, P = 0.091). CONCLUSIONS: We found relatively comparable complication rates and visual outcomes after 2 years between patients operated on by ophthalmological trainees and those by consultants, in a cataract surgical cohort at Westmead Hospital.

A review of the management of central retinal artery occlusion.

Central retinal artery occlusion (CRAO), the ocular analog of a cerebral stroke, is an ophthalmic emergency. The visual prognosis for overall spontaneous visual recovery in CRAO is low. Furthermore, the risk of future ischemic heart disease and cerebral stroke is increased due to the underlying atherosclerotic risk factors. There is currently no guideline-endorsed treatment for CRAO. This review will describe the anatomy, pathophysiology, epidemiology, and clinical features of CRAO, and investigate the current and future management strategies.

Ophthalmic associations in pregnancy.

BACKGROUND: A range of ocular pathology exists during pregnancy. Some pre-existing eye conditions, such as diabetic retinopathy, can be exacerbated during pregnancy. Other conditions manifest for the first time during pregnancy as a result of complications such as pre-eclampsia and eclampsia. Early recognition and understanding of the management of ophthalmic conditions is crucial. OBJECTIVE: The aim of this article is to discuss the physiological and pathological changes in the eyes of pregnant women. Pathological changes are sub-divided into: 1) pre-existing eye conditions modified during pregnancy, 2) pathological conditions occurring for the first time and 3) ophthalmic associations due to complications in pregnancy. DISCUSSION: This article reviews the ophthalmic conditions that can manifest during pregnancy and discusses their pathophysiology and clinical implications. Recognition, history and examination of ophthalmic conditions and a diagnostic framework for referral are provided. Fundamental multidisciplinary care principles involving the primary care physician, ophthalmologist, rheumatologist or haematologist and obstetrician in the care of the pregnant patient are discussed.

Development and progression of diabetic retinopathy 12 months after phacoemulsification cataract surgery.

OBJECTIVE: To assess whether phacoemulsification cataract surgery exacerbates the development and progression of diabetic retinopathy (DR) in a cataract surgical cohort. DESIGN: Clinic-based cohort study. PARTICIPANTS: Patients aged 65+ years undergoing cataract surgery at an eye clinic in Sydney, Australia, between 2004 and 2006. METHODS: Digital retinal photography was performed after pupil dilation preoperatively and at 1-, 6-, and 12-month postoperative visits. DR was assessed using the modified Early Treatment Diabetic Retinopathy Study (ETDRS) classification. Preoperative and 1-month postoperative (baseline) photographs were compared side-by-side with 12-month postoperative photographs. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for DR progression in operated (pseudophakic) compared with nonoperated (phakic) eyes, adjusted for age, sex, diabetes duration, and preoperative glycosylated hemoglobin level. MAIN OUTCOME MEASURES: Incident DR was defined in eyes without DR at baseline in which DR was detected at 12-month postoperative visits. DR progression was defined as an increase of 1 or more ETDRS steps during the same period, including incident cases. RESULTS: Of 1994 surgical patients recruited, 190 (9.53%) with diabetes and complete data and thus were included. There were 56 patients with unilateral surgery performed before baseline (mean postoperative duration 3.3+/-3.3 years). The prevalence of DR at baseline was higher in these 56 pseudophakic eyes than in 324 phakic eyes (71.4% vs. 48.2%, respectively, adjusted OR 2.16; 95% CI, 1.16-4.03). Of the 190 patients, 169 were followed for 12+ months postoperatively; 278 eyes were pseudophakic, and 60 eyes remained phakic at 12 months. During the 12-month postoperative period, incident DR developed in 28.2% of pseudophakic eyes and 13.8% of phakic eyes (adjusted OR 2.65; 95% CI, 1.06-6.61). In a paired-eye comparison of 45 patients who remained unilaterally pseudophakic at 12 months and were at risk of DR progression, 35.6% of pseudophakic eyes exhibited DR progression compared with 20.0% of the fellow phakic eyes (adjusted OR 2.21; 95% CI, 0.85-5.71). CONCLUSIONS: Diabetic patients undergoing phacoemulsification cataract surgery appear to have a doubling of DR progression rates 12 months after surgery. This outcome, however, represents less progression than was previously documented with intracapsular and extracapsular cataract surgical techniques.

Retinal vascular caliber and the long-term risk of diabetes and impaired fasting glucose: the Blue Mountains Eye Study.

OBJECTIVE: To assess the associations of retinal vessel caliber with the 10-year incidence of diabetes and impaired fasting glucose (IFG). METHODS: The Blue Mountains Eye Study is a population based cohort study of Australian residents aged at least 49 years, with baseline examinations conducted during 1992-4. Retinal arteriolar and venular calibers were measured and summarized from baseline digitized images in 3368 participants. Diabetes was defined as a physician-diagnosis of diabetes or fasting blood glucose >or= 126 mg/dL and IFG as fasting blood glucose 109 to 125 mg/dL. Ten year incidence of diabetes and IFG was defined from 5- and 10-year follow up data. RESULTS: After adjusting for age and gender, wider retinal venular caliber was associated with an increased incidence of diabetes and IFG. These associations were not significant after controlling for baseline glucose, body mass index and other factors. In persons 49-70 years of age at baseline, however, the association of wider retinal venular caliber and incident IFG persisted after further controlling for other factors (OR, 1.53, 95% CI, 1.11-2.12). Retinal arteriolar caliber was not associated with incident diabetes or IFG. CONCLUSIONS: This study suggests that wider retinal venular caliber was associated with higher risk of IFG in middle-aged persons.

Retinal vein occlusion and vascular mortality: pooled data analysis of 2 population-based cohorts.

PURPOSE: To assess the association of retinal vein occlusion (RVO) with cardiovascular and cerebrovascular mortality. DESIGN: Pooled data from 2 population-based cohort studies. PARTICIPANTS: At baseline, the Beaver Dam Eye Study (BDES) examined 4926 persons aged 43 to 86 years (from 1988-1990) and the Blue Mountains Eye Study (BMES) examined 3654 persons aged 49 to 97 years (from 1992 to 1994). METHODS: Retinal vein occlusion was assessed from retinal photographs. Vascular deaths were determined using either death certificates (BDES) or the Australian National Death Index (BMES). Cox regression analysis was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). MAIN OUTCOME MEASURE: Vascular (cardiovascular and cerebrovascular) mortality was determined. RESULTS: Of 8384 baseline participants, 96 (1.14%) had RVO at baseline (BDES, n = 38; BMES, n = 58). Over 12 years, 1312 (15.7%) died of cardiovascular-related conditions and 341 (4.1%) died of cerebrovascular-related conditions. Age-standardized vascular mortality rates were 26.0% and 5.3%, respectively, in persons with RVO and 17.1% and 4.5%, respectively, in those without RVO. After adjusting for age, gender, body mass index, hypertension, diabetes, smoking, glaucoma, and study site, RVO was not associated with cardiovascular-related mortality (HR, 1.2; 95% CI, 0.8-1.8) or cerebrovascular-related mortality (HR, 0.9; 95% CI, 0.4-2.1) among participants of all ages. However, in persons aged less than 70 years, baseline RVO was associated with higher cardiovascular mortality (combined BDES and BMES: HR, 2.5; 95% CI, 1.2-5.2; BDES: HR, 2.5; 95% CI, 0.9-6.9; BMES: HR, 2.1; 95% CI, 0.7-6.8). CONCLUSIONS: Retinal vein occlusion in persons aged 43 to 69 years may signal a doubling of the risk of cardiovascular mortality.

Visual impairment, age-related macular degeneration, cataract, and long-term mortality: the Blue Mountains Eye Study.

OBJECTIVE: To assess the association of visual impairment, age-related macular degeneration (ARMD), and cataract with long-term mortality. METHODS: At baseline, 3654 persons 49 years and older were examined in the Blue Mountains Eye Study (1992-1994). Standardized photographic grading was used to assess ARMD and cataract. Mortality and causes of death occurring between baseline and December 31, 2003, were obtained via data linkage with the Australian National Death Index. Age-standardized mortality rates were calculated. Hazard ratios (HRs) and 95% confidence intervals (CIs) were assessed using Cox models. Result Age-standardized mortality was higher in persons with vs without visual impairment (54.0% vs 34.0%), ARMD (45.8% vs 33.7%), and cataract (39.2% vs 29.5%). After adjusting for factors that predict mortality, neither visual impairment (HR, 1.3; 95% CI, 0.98-1.7) nor ARMD (HR, 1.0; 95% CI, 0.8-1.3) was significantly associated with all-cause mortality in all ages. Among persons younger than 75 years, however, ARMD predicted higher all-cause mortality (HR, 1.6; 95% CI, 1.0-2.4). Any cataract (HR, 1.3; 95% CI, 1.0-1.5) and cortical (HR, 1.2; 95% CI, 0.97-1.4), nuclear (HR, 1.2; 95% CI, 0.98-1.5), and posterior subcapsular (HR, 1.3; 95% CI, 1.0-1.7) cataract were also associated with higher all-cause mortality. CONCLUSION: Cataract predicted increased mortality in persons 49 years and older, and ARMD predicted mortality in persons aged 49 to 74 years.

Retinal vascular caliber, diabetes, and retinopathy.

PURPOSE: To assess the relationship of retinal vessel caliber with diabetes and diabetic retinopathy (DR). DESIGN: Population-based cross-sectional analysis of the Blue Mountains Eye Study, Australia (n = 3,654, age >or=49 years). METHODS: Diabetes was defined as physician-diagnosed or fasting blood glucose >or= 7.0 mmol/l; impaired fasting glucose as fasting glucose 6.1 to 6.9 mmol/l. DR was graded from retinal photographs. Retinal vessel caliber was measured from digitized images. RESULTS: After controlling for age, gender, blood pressure, and other factors, mean retinal venular caliber was significantly wider in participants with moderate-severe nonproliferative DR (severe 262.7 microm; moderate 236.7 microm) than in nondiabetic participants (221.9 microm) or participants with diabetes but no DR (221.2 microm) (P < .0001). Mean retinal arteriolar caliber was significantly wider in participants with diabetes (193.5 microm) than in nondiabetic participants (190.2 microm) (P < .01). CONCLUSIONS: Increasing severity of DR in persons with diabetes is associated with widening of retinal venular caliber.

Australian prospective study of cataract surgery and age-related macular degeneration: rationale and methodology.

BACKGROUND: Cataract surgery is the most frequently performed ophthalmic procedure worldwide. While benefits gained from cataract surgery outweigh surgical risks, there have been concerns that older persons may have an increased risk of developing age-related macular degeneration (AMD) after cataract surgery. OBJECTIVE: The Australian Prospective Study of Cataract Surgery and Age-Related Macular Degeneration Study aims to assess the risk of AMD in a large cohort of older patients following cataract surgery. The current report describes the study rationale, design and methodology. DESIGN: Longitudinal study. PARTICIPANTS: Approximately 2000 cataract surgical patients aged 65 years or older are being recruited from both public and private sources in western Sydney, Australia. METHODS: At study visits, participants are interviewed using standardized questionnaires to obtain information on demographic, medical, and ocular conditions and AMD risk factors, together with data on general health and vision-related quality of life. Eye examinations include visual acuity, intraocular pressure, keratometry and A-scan measurements, plus lens and retinal photography, following pupil dilatation. Retinal photographs taken before cataract surgery, and at 1, 6, 12, and 24 months after surgery are graded for early and late AMD lesions, using the Wisconsin age-related maculopathy grading system. The 1-month post-operative retinal photographs supplement the baseline macular assessment for cases in which cataract occludes a clear view of the macula pre-operatively. It is intended that study participants will be followed for up to five years post-operatively to clarify the question of whether aphakic or pseudophakic, compared to phakic eyes, have a greater risk of developing AMD.

Ten-year incidence of retinal emboli in an older population.

BACKGROUND AND PURPOSE: To assess 10-year incidence of retinal emboli and its predictors in an older population. METHODS: Survivors of 3654 Blue Mountains Eye Study participants > or =49 years of age were re-examined 5 and 10 years later. Incident emboli were assessed from retinal photographs. RESULTS: Cumulative 10-year incidence was 2.9% (95% CI, 2.1% to 3.6%) among 2361 at risk. Age was associated with incident emboli (Ptrend=0.0001). After multivariate adjustment, hypertension (odds ratio [OR], 1.8; CI, 1.0 to 3.1), hypercholesterolemia (OR, 1.3; CI, 1.0 to 1.6), overweight (OR, 3.3; CI, 1.6 to 6.9), current smoking (OR, 2.5; CI, 1.1 to 5.9), increasing fibrinogen level (OR per mg/dL, 1.1; CI, 1.0 to 1.2), and retinal vascular signs (arteriovenous nicking OR, 2.0; CI, 1.2 to 3.6; arteriolar wall opacification OR, 2.3; CI, 1.1 to 5.0; retinal vein occlusion OR, 3.2; CI, 1.0 to 9.9) were significantly associated with incident emboli. CONCLUSIONS: The 3% incidence of retinal arteriolar emboli found in this older population is likely to be an underestimate attributable to the transient nature of emboli and differential loss to follow-up. Most cardiovascular risk factors predict retinal embolism.