Outcomes of cytomegalovirus retinitis-related retinal detachment surgery in acquired immunodeficiency syndrome patients in an Asian population.

BACKGROUND: This study reports the surgical outcomes of acquired immunodeficiency syndrome (AIDS) patients with Cytomegalovirus retinitis (CMVR) -related retinal detachments(RD) in an Asian population. METHODS: Review of CMVR characteristics, surgical outcomes and complications in 19 eyes with CMVR-related RD that underwent surgery from January 2000 to June 2011. RESULTS: CMVR was inactive in 73.7% of the eyes at time of surgery. Anatomical success was achieved in 14 eyes. Seven eyes (36.8%) had improvement of two or more lines in visual acuity (VA) and 8 eyes (42.1%) maintained VA. Thirteen eyes presented with worse than 6/120 vision, with 30.8% of them achieving ambulatory vision or better. Five eyes had re-detachments. Median durations from CMVR and immune recovery uveitis (IRU) diagnoses to RD were 2.7 and 1.0 months respectively. CONCLUSIONS: Surgery for CMVR-related RD is associated with good anatomical outcomes with most eyes maintaining or having improved vision. CMVR lesion size of <50% retinal area is associated with better outcomes. Eyes with CMVR and IRU require close monitoring for RD.

Telemedicine screening for cytomegalovirus retinitis using digital fundus photography.

BACKGROUND: Screening for cytomegalovirus retinitis (CMVR) is important in patients with acquired immune deficiency syndrome and low CD4(+) counts. However, many human immunodeficiency virus (HIV) patients lack access to specialist ophthalmological care. Telemedicine screening is a cost-effective method for screening these patients. We aimed to report the use of composite nine-field digital fundus photography (DFP) images for CMVR screening. We report its sensitivity and specificity in detecting CMVR and the level of agreement with gold-standard binocular indirect ophthalmoscopy. MATERIALS AND METHODS: An audit was performed on our national CMVR screening program that screened all HIV patients referred to the Ophthalmology Department at Tan Tock Seng Hospital, Singapore. All patients underwent retinal screening with DFP. Images were categorized as CMVR-positive, CMVR-negative, suspicious, or unreadable by blinded retinal specialists. Patients subsequently underwent dilated gold-standard indirect ophthalmoscopy by a different retinal specialist. Diagnoses were categorized as CMVR-positive, CMVR-negative, or unreadable. Sensitivity and specificity of retinal findings on DFP and kappa values for level of agreement between the two screening methods were calculated. RESULTS: Three hundred seventy screenings on 188 patients were performed. Twenty-three eyes diagnosed with CMVR on indirect ophthalmoscopy were also identified on DFP (100% sensitivity). A 99.9% specificity was achieved. The fundus photograph of one eye without CMVR was read as CMVR-positive because of an artifact, accounting for a false-positive. Kappa values ranged from 0.739 to 0.987. CONCLUSIONS: DFP is a sensitive and specific method of screening HIV patients for CMVR and has a high level of agreement with indirect ophthalmoscopy.

Intraoperative centration during small incision lenticule extraction (SMILE).

To evaluate intraoperative decentration from pupil center and kappa intercept during small incision lenticule extraction (SMILE) and its impact on visual outcomes.This was a retrospective noncomparative case series. A total of 164 eyes that underwent SMILE at the Singapore National Eye Center were included. Screen captures of intraoperative videos were analyzed. Preoperative and 3 month postoperative vision and refractive data were analyzed against decentration.The mean preoperative spherical equivalent (SE) was -5.84 ±â€Š1.77. The mean decentration from the pupil center and from kappa intercept were 0.13 ±â€Š0.06 mm and 0.47mm ±â€Š0.25 mm, respectively. For efficacy and predictability, 69.6% and 95.0% of eyes achieved a visual acuity (VA) of 20/20 and 20/30, respectively, while 83.8% and 97.2% of eyes were within ±0.5D and ±1.0D of the targeted SE. When analyzed across 3 groups of decentration from the pupil center (<0.1 mm, 0.1-0.2 mm, and >0.2 mm), there was no statistically significant association between decentration, safety, efficacy, and predictability. When analyzed across 4 groups of decentration from kappa intercept (<0.2 mm, 0.2-<0.4 mm, 0.4-<0.6 mm, and ≥0.6 mm), there was a trend toward higher efficacy for eyes with decentration of kappa intercept between 0.4 and <0.6 mm (P = .097). A total of 85.4% of eyes in the 0.4 to <0.6 mm group had unaided distance VA of 20/20 or better, as compared to only 57.8% of eyes in ≥0.6 mm group.Decentration of 0.13 mm from the pupil center does not result in compromised visual outcomes. Decentration of greater than 0.6 mm from the kappa intercept may result in compromised visual outcomes. There was a trend toward better efficacy in eyes which had decentered treatment from 0.4 to <0.6 mm from the kappa intercept. Patients with a large kappa intercept (>0.6 mm) should have their lenticule created 0.4 to 0.6 mm from the kappa intercept and not close to the pupil.

Efficacy and safety of topical ganciclovir in the management of cytomegalovirus (CMV)-related anterior uveitis.

BACKGROUND: The aim of this study was to evaluate the efficacy and safety of topical ganciclovir 0.15 % gel in the management of patients with cytomegalovirus (CMV) anterior uveitis. RESULTS: This was a retrospective cohort study of the disease course of 31 patients (33 eyes) with aqueous polymerase chain reaction (PCR) positive for CMV. Data from a total of 160 episodes of anterior uveitis flare for 20 years, dating from December 1992 to December 2012, was collected. All patients were treated with concomitant topical anti-inflammatory medication. The disease course of each eye was analysed before and after the use of topical ganciclovir 0.15 %. The mean age at initial presentation of anterior uveitis was 57.5 ± 12.6 years. Twenty-eight (90.3 %) patients were Chinese. Patients on topical ganciclovir gel had a statistically significant fewer episodes of uveitis flare per person year (median -0.88 episodes/person years, p = 0.029). The time-to-quiescence was not significantly affected by topical ganciclovir use (median -1.25 days, p = 0.610). In the survival analysis using the Cox regression model, the use of topical ganciclovir was associated with a lower risk of recurrence, but this was not statistically significant (hazard ratio = 0.857, 95 % CI 0.543-1.36, p = 0.511). The overall median time-to-recurrence was 290 days (95 % CI 113 to 274 days) and 164 days (125 to 404 days) (p = 0.492), with and without topical ganciclovir, respectively. CONCLUSIONS: Topical ganciclovir may be beneficial in reducing the frequency of recurrence in patients with CMV anterior uveitis, but it was not statistically associated with prolonging the time-to-recurrence. The time-to-quiescence was also not significantly affected by topical ganciclovir. Prospective studies with a larger number of patients would be required to verify our findings.

Immune recovery uveitis in HIV patients with cytomegalovirus retinitis in the era of HAART therapy-a 5-year study from Singapore.

BACKGROUND: The aim of this study is to analyse the clinical features of HIV patients with cytomegalovirus retinitis (CMVR) developing immune recovery uveitis (IRU) while on highly active antiretroviral therapy (HAART) and to identify the risk factors, visual outcomes and complications of IRU. RESULTS: Majority (n = 26, 86.7 %) of patients were male, with 76.7 % (n = 23) of patients having bilateral disease. Twenty-seven eyes (50.9 %) had both anterior uveitis and vitritis. The median CD4 at IRU was 210 cells/µL (IQR 140-279), with 86.7 % having CD4 >100 cells/µL. The median duration from initiation of HAART to IRU was significantly different between those <50 years old (median 763 days, IQR 174-1872 days) and those ≥50 years old (median 161 days, IQR 84.5-278 days). Fourteen eyes (26.4 %) had loss of one or more Snellen lines visual acuity at 6 months while the rest maintained or improved vision. Complications developed in 21 eyes, with cataract (66.7 %), glaucoma and ocular hypertension (33.3 %) being the most common. The risk of complications was associated with the absolute difference in CD4 counts at IRU and at HAART commencement (p = 0.041). Age was also negatively associated with the duration from HAART to IRU (p = 0.005, Spearman's rho coefficient = -0.503). CONCLUSIONS: It is common to have both anterior uveitis and vitritis in IRU. There was a positive association between the increase in CD4 from HIV to IRU diagnoses and the risk of developing complications. Younger patients appeared to develop IRU later than older patients after HAART, suggesting that long-term follow-ups are essential for these patients.

Choroidal vascularity index - a novel optical coherence tomography parameter for disease monitoring in diabetes mellitus?

PURPOSE: To propose the use of choroidal vascularity index (CVI) as a novel tool to assess vascular status of the choroid using image binarization of enhanced depth imaging (EDI) optical coherence tomography (OCT) scans in diabetes mellitus (DM). METHODS: A prospective cross-sectional study was performed at a tertiary referral eye care centre in Singapore. Age and gender matched EDI-OCT scans of 38 eyes of 19 patients with DM were compared with eyes of healthy controls (n = 19). The choroidal images were binarized into luminal areas (LA) and stromal areas (SA). Choroidal vascularity index (CVI) was defined as the proportion of LA to total circumscribed subfoveal choroid area (TCA). Mean choroidal thickness, mean retinal thickness and mean CVI between patients and controls were compared using student's t-test. RESULTS: There were no significant differences in TCA (p = 0.78), LA (p = 0.90), SA (p = 0.33), average choroidal (p = 0.40) or retinal thickness (p = 0.70) between patients with DM and controls. However, there was a significantly lower CVI in patients with DM as compared to controls (65.10 ± 0.20 versus 67.20 ± 0.16, p < 0.0001). CONCLUSION: Eyes of patients with DM showed decreased CVI with no corresponding change in choroidal thickness. Image binarization may be potentially useful as a tool to assess choroidal structures and vasculature.

Assessment of Depression, Anxiety, and Quality of Life in Singaporean Patients With Glaucoma.

PURPOSE: To determine the prevalence and risk factors for anxiety disorder and depression among glaucoma patients in Singapore, and to assess the relationship between quality of life (QOL) and depression/anxiety. METHODS: In this cross-sectional study, glaucoma patients aged 21 and above with a known diagnosis of primary open-angle glaucoma or primary angle-closure glaucoma were recruited from a tertiary care hospital. Patients with other types of glaucoma, and coexisting ocular or psychiatric disorders were excluded.Ophthalmic examination was carried out on all participants, which included best-corrected visual acuity (BCVA), intraocular pressure (IOP), gonioscopy, standard automated perimetry, and optic disc evaluation. Sociodemographic information and treatment histories were also collected.The Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), and Visual Function Questionnaire (VFQ25) were administered to evaluate for depression, anxiety, and impact on QOL, respectively. RESULTS: A total of 100 patients were included in this study. The mean age was 67.1±12.0 years (range, 24 to 90 y). The frequency of depression and anxiety among our patients was 30% and 64%, respectively. The mean HAM-D score was 4.37±4.17 (range, 0 to 17), whereas the mean HAM-A score was 2.38±2.80 (range, 0 to 13). The mean VFQ25 score was 78.8±16.0 (range, 42.4 to 97.0). The poorest subscale on the VFQ25 was driving, with a mean score of 42.4±42.6 (range, 0.0 to 100.0).We did not find any significant difference between the presence of depression/anxiety between patients with primary open-angle glaucoma (P=0.263) and primary angle-closure glaucoma (P=0.830). Risk factors for depression included: female sex (P=0.020), higher logMAR BCVA in the worse eye (P=0.004), higher cup-disc ratio (P=0.016), lower MD in the better and worse eye (P=0.022 and 0.001, respectively), and lower mean VFQ25 score (P<0.001). Risk factors for anxiety included: lower MD in the worse eye (P=0.004) and lower mean VFQ25 score (P=0.004). There was also no significant association between the use of topical ß-blockers/carbonic anhydrase inhibitors with depression (P=0.793) or anxiety (P=0.282). CONCLUSIONS: There is a relatively high prevalence of depression (30%) and anxiety disorders (64%) among glaucoma patients in Singapore. Female glaucoma patients are more likely to suffer from depression. Other risk factors for depression include higher cup-disc ratio, higher logMAR BCVA, lower MD, and a lower mean VFQ25 score. Risk factors for anxiety disorder include lower MD and lower mean VFQ25 score. Ophthalmologists could consider use of the VFQ25 as an assessment for impairments in QOL in a glaucoma patient. If a glaucoma patient is at high risk of depression or anxiety disorder, a multidisciplinary management approach involving ophthalmology and psychiatry may be required.

A Cytomegalovirus Retinitis Screening Program: Evaluation of Enrollment Criteria for HIV Patients in Singapore.

PURPOSE: Identification of optimal enrollment criteria for a CMVR screening program suitable for a resource-limited environment. METHODS: A prospective audit was performed on newly diagnosed HIV patients referred for CMVR screening with any of the following four criteria: (1) visual symptoms, (2) low CD4(+) counts (<50 cells/µL), (3) AIDS-defining illnesses (ADI), and/or (4) opportunistic infections (OI). Odds ratios for each of the demographic factors and enrollment criteria were calculated. Sensitivities, specificities, and workload reduction for the various combinations were determined. RESULTS: A total of 348 screening visits for 176 HIV patients were performed. While individually only ADI was statistically significant for increased CMVR risk, the combination of CD4(+) counts <50 cells/µL with either ADI or visual symptoms or all 3 criteria were also statistically significant. Two enrollment criteria, ADI and ADI with CD4(+) <50 cells/µL, demonstrated good sensitivities, specificities, and workload reduction. CONCLUSION: We propose ADI and possibly CD4(+) counts <50 cells/µL as enrollment criteria for CMVR screening.

Trends in patterns of intermediate uveitis in a tertiary institution in Singapore.

PURPOSE: The study aims to describe the characteristics and etiologic causes of intermediate uveitis (IU) patients seen by a tertiary eye center in Singapore over 8 years. METHODS: This was a retrospective analysis of the clinical records of consecutive new cases of IU that presented to the uveitis subspecialty clinic from 2004-2011 at Tan Tock Seng Hospital. Data collected included demographics, clinical and laboratory findings. Diagnoses were based on standardized clinical history, ophthalmological examination and investigations. RESULTS: There were 66 new cases of IU, comprising 5.7% of 1168 new uveitis patients. The median age of diagnosis was 40 years (mean 39.4±15.9), with largest subgroup of the patients in the age group of 41-60 years (36.4%). The majority was Chinese (57.6%), followed by Asian Indians (18.2%) and Malays (16.7%). The ethnicity distribution was dissimilar to our ethnic distribution in Singapore (p<0.001) with an increased incidence of IU in the Asian Indian population. Most were idiopathic (59.1%) in etiology, followed by tuberculosis (TB) (15.2%). Ocular complications developed in 21 patients (31.8%), with cystoid macular edema (CME) being the commonest (28.8%). Severe vitritis occurred in 9.1% of patients, and was significantly associated with TB-associated IU (p<0.001). There was a downward trend for the incidence of the proportion of IU patients over the total uveitis patients (p = 0.021), with Spearman's rho of -0.786. CONCLUSIONS: Despite the downward trend, TB-associated IU was still of higher prevalence compared to less endemic areas, emphasizing the need for increased TB surveillance. A high index of suspicion for TB-associated IU is required in patients with severe vitritis. Comparisons with other countries revealed disparities in the IU etiologies, indicating possible geographical differences. Prevalence of known immune-mediated etiologies of IU is less compared to the western population. Our study also suggests a probable predisposition of the Singapore local Indian population for IU.

The epidemiology and incidence of cytomegalovirus retinitis in the HIV population in Singapore over 6 years.

PURPOSE: We report the epidemiologic trend of cytomegalovirus (CMV) retinitis among human immunodeficiency virus (HIV) patients in Singapore. METHODS: Our study included a retrospective case series of HIV patients with newly diagnosed CMV retinitis (CMVR) at the Singapore CDC between 2005 and 2010. Demographics, symptoms, signs, and laboratory results, including CD4 counts, were collected. Prevalence and disease trends over time were measured. RESULTS: Of 224 new patients, 92.9% were male and 96.0% were on antiretroviral therapy (ART). Median age was 43.0 years, with a median CD4 count of 38.0 cells/µL at HIV diagnosis. There was a decline in CD4 counts at diagnosis, and median duration of ART initiation from HIV diagnosis generally was earlier. Overall incidence rate was 10.4 cases per 1000 person-years (PY) and the mortality rate was 19.4 per 1000 PY. Mean survival time was 160.2 months (95% confidence interval [CI] 150.3-170.2). The 25 patients who died during the study period were older at the time of CMVR diagnosis (P = 0.003) and had lower CD4 counts (P = 0.030). Worse prognoses were associated with older age (hazard ratio [HR] 1.06, 95% CI 1.02-1.10) and shorter time lag from HIV to CMVR diagnosis (HR 0.97, 95% CI 0.95-0.99). Patients who did not receive highly active antiretroviral treatment (HAART) had a higher mortality risk (HR 4.70, 95% CI 1.54-14.33). CONCLUSIONS: The incidence rate of CMVR was decreasing with earlier initiation of ART and lower CD4 counts at HIV diagnosis. Poor prognostic factors included older age, shorter time lag from HIV to CMVR diagnosis, and the absence of HAART. Constant ophthalmologic surveillance until immune reconstitution is recommended.