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Table of Contents

Efficacy of Different Excimer Laser Techniques in the Management of Recurrent Corneal Erosions

Werner W. Hütz, MD; Oliver Stachs, PhD; Fritz Hengerer, MD; Berthold Eckhardt, MD

Submitted 10/21/09; Accepted 7/20/10; Posted 8/30/10

BACKGROUND AND OBJECTIVE: To investigate the efficacy of two excimer laser techniques for recurrent corneal erosions (RCEs).

PATIENTS AND METHODS: Of 100 patients with RCEs not responding to common treatments, 50 received transepithelial (group 1) and 50 received subepithelial (group 2) treatment of 20 pulses of a 193-nm excimer laser (170 J/cm²). Postoperative follow-up occurred at 4 and 52 weeks. Outcome measures were frequency of RCEs, haze formation, and refractive changes.

RESULTS: At first follow-up, 7 patients (14%) in each group displayed recurrence. At second follow-up, 12 patients in group 1 (24%) and 10 patients in group 2 (20%) had RCE. Follow-up recurrence risk was 6% to 27% in both groups at 4 weeks and 13% to 38% in group 1 and 10% to 34% in group 2 at 52 weeks. The spherical equivalent remained unaffected in group 1, but a statistically significant change was observed in group 2.

CONCLUSION: Excimer laser treatment (transepithelial and subepithelial) of RCEs can be performed successfully on the intact epithelium without adjunct therapy or pain. The transepithelial technique is a simple and relatively painless way to reduce the rate of RCE and is equivalent to the well-established subepithelial treatment.

doi: 10.3928/15428877-20100830-01

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Long-Term Monitoring of Age-Related Macular Degeneration With Preferential Hyperacuity Perimetry

Michael Stur, MD; Yair Manor, PhD

Submitted 2/7/09; Accepted 7/6/10; Posted 8/30/10

BACKGROUND AND OBJECTIVE: To estimate the efficacy and usability of preferential hyperacuity perimetry (PHP) for monitoring patients with high-risk intermediate age-related macular degeneration (AMD).

PATIENTS AND METHODS: A long-term, observational, prospective case series of patients with intermediate AMD who underwent fluorescein angiography at recruitment. Eyes were examined every 3 months with PHP, visual acuity, and biomicroscopy. Optical coherence tomography (OCT) imaging was performed when PHP was outside normal limits. In case of suspected findings in OCT, fluorescein angiography was also performed. Patients diagnosed as having choroidal neovascularization (CNV) were offered anti-vascular endothelial growth factor therapy.

RESULTS: Twenty-six eyes (25 patients) were monitored for a mean follow-up period of 600 days. Of the 172 PHP tests done by these 26 eyes with intermediate AMD, 158 were within normal limits yielding a false-positive rate of 8.1%. Three of 4 eyes that converted to CNV had PHP test results outside normal limits before or on the day of diagnosis.

CONCLUSION: PHP is useful for detecting CNV in regularly monitored eyes with intermediate AMD while maintaining a low false-positive rate.

doi: 10.3928/15428877-20100830-05

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Retinal Layer Thickness Changes in Eyes With Preserved Visual Acuity and Diffuse Diabetic Macular Edema on Optical Coherence Tomography

Gábor Márk Somfai, MD, PhD; Erika Tátrai, MD; Mária Ferencz, MD, PhD; Carmen A. Puliafito, MD, MBA; Delia Cabrera DeBuc, PhD

Submitted 12/9/09; Accepted 6/16/10; Posted 8/30/10

BACKGROUND AND OBJECTIVE: Diabetic macular edema has several patterns on optical coherence tomography. This retrospective study aimed to assess which retinal layers show thickness changes in type 1 diffuse diabetic macular edema with preserved vision.

PATIENTS AND METHODS: Eleven eyes with diffuse diabetic macular edema on optical coherence tomography and eight control eyes with 20/20 best-corrected visual acuity were enrolled. Optical coherence tomography images were segmented using an algorithm of the authors’ design (OCTRIMA): regional thickness data in the central area, pericentral rings, and peripheral rings were obtained for the retinal cellular layers.

RESULTS: The retinal nerve fiber layer showed no changes, the ganglion cell and inner plexiform composite layer and the ganglion cell complex were thicker only in the pericentral regions, and all other layers were thicker in all regions in diffuse diabetic macular edema. Macular thickness was normal in the peripheral region.

CONCLUSION: The results show that the outer retina in the foveal area is the most affected in diffuse diabetic macular edema.

doi: 10.3928/15428877-20100830-04

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Comparison of Stereo Disc Photographs and Alternation Flicker Using a Novel Matching Technology for Detecting Glaucoma Progression

Nathan M. Radcliffe, MD; Mitra Sehi, PhD; Ira B. Wallace, MD; David S. Greenfield, MD; Theodore Krupin, MD; Robert Ritch, MD

Submitted 12/29/09; Accepted 6/9/10; Posted 8/30/10

BACKGROUND AND OBJECTIVE: To compare agreement of automated alternation flicker and serial stereophotograph inspection for detection of progressive glaucoma.

PATIENTS AND METHODS: Serial photographs of patients with glaucoma with at least 36 months of follow-up and perimetry every 4 months were assessed by four graders using predefined criteria with both flicker and stereophotography. The main outcome measure was progressive neuroretinal rim deterioration as identified by each technique.

RESULTS: Forty eyes (20 patients) were included and 12 eyes progressed with perimetry. Using stereophotography, the overall agreement (kappa ± standard error) was 0.19 ± 0.06 for rim change, 0.78 ± 0.06 for disc hemorrhage, and -0.04 ± 0.06 for vessel movement. Using flicker, the overall agreement was similar for rim change (0.28 ± 0.06; P = .29), worse for disc hemorrhage (0.43 ± 0.06; P < .001), and better for vessel movement (0.22 ± 0.06; P = .002). The agreement between perimetric and disc progression was similar using stereophotography (0.10 ± 0.05) and flicker (0.19 ± 0.05; P = .20).

CONCLUSION: Agreement between flicker and stereophotography was similar.

doi: 10.3928/15428877-20100830-02

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Bevacizumab for the Treatment of Pediatric Retinal and Choroidal Diseases

Robert A. Sisk, MD; Audina M. Berrocal, MD; Thomas A. Albini, MD; Timothy G. Murray, MD

Submitted 9/22/09; Accepted 6/9/10; Posted 8/30/10

BACKGROUND AND OBJECTIVE: To determine the efficacy of off-label intravitreal bevacizumab (IVB) for the treatment of pediatric retinal and choroidal vascular diseases.

PATIENTS AND METHODS: Retrospective, noncomparative, open-label, interventional, consecutive case series of all patients younger than 18 years old treated with off-label IVB at a single center from January 1, 2005, to January 1, 2008. Primary outcome measures with best-corrected visual acuity by age-appropriate testing and central macular thickness by time-domain optical coherence tomography.

RESULTS: Thirty-five eyes of 33 patients were treated with IVB alone or in combination with other treatments for choroidal neovascularization, Coats’ disease, familial exudative vitreoretinopathy, and various other indications. IVB was used in 24 eyes to reduce excess retinal fluid and exudation. Mean Snellen visual acuity improved from 20/170 at baseline to 20/100 at 1 month (P = .006), 20/80 at 3 months (P = .006), and 20/50 at 6 months (P = .023). Central macular thickness improved from 356 µm at baseline to 287 µm at 6 months (P = .028). IVB was used in 11 eyes to control peripheral retinal neovascularization and iris rubeosis. Although IVB reduced vascular engorgement, it did not prevent the progression of preretinal tractional forces. Mean visual acuity was maintained at each time point. No systemic or ocular adverse events were directly attributable to IVB in any patient.

CONCLUSION: IVB reduced vascular leakage and temporarily regressed pathologic neovascularization of the choroid, retina, and iris in this series of pediatric patients. Further prospective studies are warranted.

doi: 10.3928/15428877-20100830-03

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Sclerochorioretinal Abnormalities in Hypercholesterolemic Rabbits Treated With Rosiglitazone

Rogil José de Almeida Torres, MD; Cristina Muccioli, MD; Maurício Maia, MD, PhD; Lucia Noronha, MD; Andréa Luchini, MD; Alexandre Alessi, MD; Márcia Olandoski, PhD; Michel Eid Farah, MD; Dalton Bertolin Précoma, MD

Submitted 4/28/09; Accetped 5/20/10; Posted 7/29/10

BACKGROUND AND OBJECTIVE: To evaluate early retinal, choroidal, and scleral abnormalities induced by a hypercholesterolemic diet and the prevention of these abnormalities after oral administration of rosiglitazone in rabbits.

MATERIALS AND METHODS: Fifty-four New Zealand rabbits were divided into four study groups: control group, normal diet; group 1, hypercholesterolemic diet; group 2, hypercholesterolemic diet associated with daily administration of 3 mg of rosiglitazone from day 14 after beginning the diet; and group 3, hypercholesterolemic diet associated with daily administration of 3 mg of rosiglitazone since the beginning of the experiment. Sclera and choroid underwent histologic and histomorphometric analyses. Retina underwent immunohistochemical analysis with anti-calretinin and anti-glial fibrillary acidic protein (GFAP) antibodies.

RESULTS: No abnormalities were observed in the control group. Group 1 had significant increases in scleral and choroidal thicknesses compared with the control group (P < .01) and group 3 (P < .05). Group 1 presented significant increases in immunoreactivity (P < .001) to the anti-calretinin antibody compared with the other groups. Groups 2 and 3 had significant (P < .002) increases in calretinin immunoreactivity compared with the control group. GFAP was negative in all groups.

CONCLUSION: The hypercholesterolemic diet induced early retinal, choroidal, and scleral abnormalities. Rosiglitazone preserved the structural anatomy.

doi: 10.3928/15428877-20100726-05

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Comparison of 20- and 25-Gauge Vitrectomy for Primary Repair of Rhegmatogenous Retinal Detachment

Satoshi Kobayashi, MD; Shimpei Sato, MD; Maiko Inoue, MD; Shin Yamane, MD; Yoichiro Watanabe, MD; Akira Arakawa, MD; Eiichi Uchio, MD; Kazuaki Kadonosono, MD

Submitted 6/25/09; Accepted 5/20/10; Posted 7/29/10

BACKGROUND AND OBJECTIVE: To evaluate the outcome of 25-gauge transconjunctival pars plana vitrectomy and compare it with that of 20-gauge pars plana vitrectomy for primary repair of rhegmatogenous retinal detachment.

PATIENTS AND METHODS: A retrospective study of a consecutive series of 166 eyes of 164 patients who underwent pars plana vitrectomy for primary rhegmatogenous retinal detachment was performed. One hundred nineteen eyes underwent 25-gauge vitrectomy and 47 eyes underwent 20-gauge vitrectomy.

RESULTS: The anatomic success rates after the initial surgery in the 25-gauge vitrectomy and 20-gauge vitrectomy groups were 93.3% and 91.5%, respectively. The median visual acuity improved significantly from 20/80 preoperatively to 20/30 postoperatively in the 25-gauge group, and from 20/90 to 20/30 in the 20-gauge group.

CONCLUSION: Good anatomic and functional results were achieved with 25-gauge vitrectomy and the outcomes compared favorably with those of 20-gauge vitrectomy for the treatment of rhegmatogenous retinal detachment.

doi: 10.3928/15428877-20100726-03

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Reproducibility of an Analysis Software for Qualitative Observation of Elschnig Pearls

Nino Hirnschall, MD; Thomas Neumayer, MD; Wolf Buehl, MD; Oliver Findl, MD, MBA

Submitted 7/16/09; Accepted 5/20/10; Posted 7/29/10

BACKGROUND AND OBJECTIVE: To determine the reproducibility of a semi-objective analysis software for the morphological analysis of single Elschnig pearls from retroillumination images of posterior capsule opacification.

PATIENTS AND METHODS: In this prospective study, images of eyes with varying degrees of regeneratory posterior capsule opacification and the presence of Elschnig pearls were taken. The size and morphology of single Elschnig pearls was evaluated from consecutive images using an analysis method called PearlTracer using three different modes: snake selection, where a few points detected the pearl border automatically; diameter circle selection, a circle function; and polygon selection, where several points were connected by straight lines. The interobserver and intraobserver reproducibility and the limits of the different modes concerning contrast were assessed.

RESULTS: One hundred fifty-eight retroillumination images of 55 eyes of 50 patients were included with a total of 857 pearls being analyzed. A high interobserver reproducibility was found, as well as a high intraobserver reproducibility. Furthermore, a significant difference in the pearl size and the pearl morphology between the three analysis features of the software was found.

CONCLUSION: For the observation of single Elschnig pearls and their morphological changes, the semi-objective PearlTracer analysis software was found to be a highly reproducible and useful method.

doi: 10.3928/15428877-20100726-02

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Bleb Morphology Characteristics and Effect on Positional Intraocular Pressure Variation

Jennifer S. Weizer, MD; Anju Goyal, MD; Patricia Ple-Plakon, BA; Agnieszka Trzcinka, MD; Bradley D. Strong, MD; Christina A. Bruno, MD; Justin Junn, BA; Irene Tseng, BA; Leslie M. Niziol, MS; David C. Musch, PhD; Sayoko E. Moroi, MD, PhD

Submitted 8/03/09; Accepted 5/20/10; Posted 7/29/10

BACKGROUND AND OBJECTIVE: To study bleb morphology and positional intraocular pressure (IOP) change (IOP supine to IOP sitting).

PATIENTS AND METHODS: In this observational case series, blebs were graded for height, extent, vascularity, microcysts, and “ring of steel.” Positional IOP change was analyzed using the paired t test. Associations between IOP change and bleb morphologies were evaluated by regression adjusting for inter-eye dependency.

RESULTS: Ninety-five eyes of 68 subjects were included. Decreased bleb height (P = .05), absence of microcysts (P = .02), and increased bleb vascularity (P = .02) were associated with larger positional IOP change. Twenty patients with a filter in one eye and a medically treated fellow eye had larger positional IOP change in the medically treated eye (6.1 vs 4.6 mm Hg, respectively; P = .01).

CONCLUSION: Successful filtration surgery results in both lower IOP and less positional IOP change compared with medically treated eyes. Bleb features associated with smaller positional IOP change include higher elevation, microcysts, and less vascularity.

doi: 10.3928/15428877-20100726-06

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Clinical Course of Choroidal Neovascularization Secondary to Angioid Streaks Treated With Intravitreal Bevacizumab

Anderson Teixeira, MD; Tessa Mattos, MD; Roberta Velletri, MD; Rafael Teixeira; Juliana Freire, MD; Nilva Moares, MD, PhD; Pedro Paulo Bonomo, MD, PhD

Submitted 5/11/09; Accepted 5/20/10; Posted 7/29/10

BACKGROUND AND OBJECTIVE: To evaluate visual acuity and anatomical outcomes of choroidal neovascularization (CNV) associated with angioid streaks after treatment with intravitreal bevacizumab injections.

PATIENTS AND METHODS: Best-corrected visual acuity, optical coherence tomography measurements (OCT), fluorescein and indocyanine green angiography, and ophthalmoscope examination at baseline and at each follow-up visit were performed. Five patients with CNV associated with angioid streaks were treated with injections of intravitreal bevacizumab (1.25 mg/0.05 mL). Re-treatment was recommended with symptomatic lesions, new subretinal hemorrhages, leakage on fluorescein and indocyanine green angiography, and/or fluid documented by OCT. Follow-up ranged between 18 and 32 months.

RESULTS: All eyes showed an improvement of visual acuity and were treated with at least four injections of intravitreal bevacizumab. Reduction of the leakage shown by fluorescein angiography and OCT was noted in all patients.

CONCLUSION: Intravitreal bevacizumab appears to be effective in stabilizing and recovering visual acuity in eyes with CNV associated with angioid streaks. Patients with early symptoms might benefit more.

doi: 10.3928/15428877-20100726-04

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Resident Physician Operative Times During Cataract Surgery

Michael N. Wiggins, MD; David B. Warner, MD

Submitted 09/09/2009; Accepted 5/20/10; Posted 7/29/10

BACKGROUND AND OBJECTIVE: To determine resident physician operative times surrounding their 45th, 86th, and 121st cataract surgery.

PATIENTS AND METHODS: Retrospective chart review of 375 surgical records of 25 ophthalmology residents. Groups were compared with each other and to a published surgeon.

RESULTS: The mean operative times of surgeries 43 to 47, 84 to 88, and 119 to 123 were 39.9, 30.0, and 27.2 minutes, respectively. Surgical time decreased 25% from the 45th to the 86th case (P = .0002) and 9% from the 86th to the 121st case (P = .2049). Compared with a published surgeon’s time of 26.8 minutes, residents’ times were significantly longer around their 45th (P = .0001) and 86th surgery (P = .0012), but nearly identical around the 121st surgery (P = .7022).

CONCLUSION: Significant decreases in operative time occurred between the 45th and 86th case. Smaller decreases occurred after the 86th case. Residents’ operative times approach that of a published ophthalmologist around the 121st case.

doi: 10.3928/15428877-20100726-07

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A Modified Technique for Extracting a Dislocated Lens With Perfluorocarbon Liquids and Viscoelastics

José Dalma-Weiszhausz, MD; Valentina Franco-Cardenas, MD; Alejandro Dalma, MD

Submitted 11/03/09; Accepted 5/7/10; Posted 7/29/10

The authors describe a modified technique for extraction of a dislocated crystalline lens or large and hard lens fragments displaced into the vitreous cavity. An ophthalmic viscosurgical device was used around and on top of the heavy liquid bubble to keep the lens centered and less mobile for easier phacofragmentation or removal by the cutting-suction probe. This technique was used in 10 eyes, including cases of traumatic dislocation and Marfan syndrome, with excellent anatomical results and no complications that could be attributed to the surgical technique. The technique has also been used to retrieve and reposition dislocated intraocular lenses.

doi: 10.3928/15428877-20100726-01

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Descemet’s Membrane Detachment Following Phacoemulsification

Jaspreet Sukhija, MD; Jagat Ram, MD; Sushmita Kaushik, MD; Amod Gupta, MD

Submitted 3/1/09; Accepted 4/22/10; Posted 6/30/10

BACKGROUND AND OBJECTIVE: To determine the management options and the indications for surgical intervention in Descemet’s membrane detachment (DMD) after phacoemulsification.

PATIENTS AND METHODS: Clinical records of 11 consecutive eyes (11 patients) with DMD were reviewed. All cases had undergone phacoemulsification with posterior chamber intraocular lens implantation. Patients with DMD involving one-third or more of the cornea were analyzed.

RESULTS: All patients underwent clear corneal phacoemulsification. In three cases where the detachment was recognized intraoperatively, perfluoropropane gas was injected. Eight eyes (8 cases) had unexpected corneal edema detected as DMD postoperatively and managed by injecting perfluoropropane gas into the anterior chamber. Three eyes that required repeated surgical intervention postoperatively had more than 50% corneal involvement with significant separation of the membrane from the stroma and curling or folding of the membrane. At last follow-up, 10 eyes retained clear corneas and one had residual DMD not involving visual axis. All 11 eyes had best-corrected visual acuity of better than 6/12.

CONCLUSION: DMD should be suspected in patients showing unexpected corneal edema postoperatively who have undergone uneventful phacoemulsification and be treated in a timely manner. Surgical intervention is recommended in cases with significant separation of the membrane from stroma and curling or folding of the Descemet’s membrane.

doi: 10.3928/15428877-20100625-02

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Trainee Glaucoma Surgery: Experience With Trabeculectomy and Glaucoma Drainage Devices

Michael A. Connor, MD; Robert M. Knape, MD; Matthew H. Oltmanns, MD; Mary Fran Smith, MD

Submitted 7/27/09; Accepted 4/14/10; Posted 6/30/10

BACKGROUND AND OBJECTIVE: To examine outcomes of trabeculectomy with mitomycin C and glaucoma drainage device placement for uncontrolled glaucoma when performed by resident surgeons.

PATIENTS AND METHODS: This study included any patient who underwent a trabeculectomy with mitomycin C (n = 93) or a glaucoma drainage device (n = 60) by a resident surgeon between 2001 and 2006. Outcome measures at 3, 6, and 12 months included failure of treatment, number of follow-up appointments, complications, number of medications, and need for further surgery.

RESULTS: One year postoperatively, intraocular pressure averaged 12.1 ± 5.1 mm Hg in the trabeculectomy group and 13.0 ± 5.1 mm Hg in the glaucoma drainage device group (P = .31). Complications occurred in 30% of eyes with trabeculectomy and 10% of eyes with a glaucoma drainage device.

CONCLUSION: During the first postoperative year, glaucoma drainage device surgery may have fewer complications and less morbidity than a trabeculectomy with mitomycin C when these surgeries are performed by resident surgeons. Final intraocular pressures were similar between the two groups.

doi: 10.3928/15428877-20100625-01

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In Vivo Laser Confocal Microscopic Analysis of Corneal K-Structures After Keratorefractive Surgery (LASIK and Epi-LASIK)

Hideaki Yokogawa, MD; Akira Kobayashi, MD, PhD; Kosaku Tagawa, MD, PhD; Kazuhisa Sugiyama, MD, PhD

Submitted 5/25/10; Accepted 3/26/10; Posted 6/30/10

BACKGROUND AND OBJECTIVE: To demonstrate alterations of corneal K-structures (sub-Bowman’s fibrous structures) after keratorefractive surgery by in vivo laser confocal microscopy and to look for association of K-structures with fluorescein-stained anterior corneal mosaic (ACM).

PATIENTS AND METHODS: Five patients (nine eyes) participated in this study. For four patients, one eye was evaluated after laser in situ keratomileusis (LASIK) and the other after epipolis-laser in situ keratomileusis (epi-LASIK). For one patient, the left eye was evaluated after epithelial debridement. A photograph of the ACM was obtained. Central corneal regions were scanned by Heidelberg Retina Tomograph 2 Rostock Cornea Module (Heidelberg Engineering GmbH, Heidelberg, Germany).

RESULTS: The ACM and K-structures disappeared in all corneas after epi-LASIK, but not after LASIK and epithelial debridement cornea.

CONCLUSION: The presence of K-structures and ACM may be an index to identify eyes that had a previous refractive surgical procedure (surface ablation or LASIK) and be a health index of Bowman layer and adjacent anterior stroma.

doi: 10.3928/15428877-20100625-03

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Repeatability of Retinal Thickness Measurements Between Spectral-Domain and Time-Domain Optical Coherence Tomography Images in Macular Disease

Amitha Domalpally, MD; Sapna Gangaputra, MD, MPH; Qian Peng, MS; Ronald P. Danis, MD

Submitted 4/16/09; Accepted 11/30/09; Posted 3/30/10

BACKGROUND AND OBJECTIVE: To evaluate and compare the intra-session repeatability of retinal thickness measurements from the Topcon 3D OCT 1000 (Topcon Medical Systems; Paramus, NJ), a spectral-domain optical coherence tomography (SD-OCT) system, with the Stratus (Carl Zeiss Meditec, Inc., Dublin, CA), a time-domain OCT (TD-OCT) system, in eyes with retinal diseases.

PATIENTS AND METHODS: Repeated scans with both SD-OCT and TD-OCT were taken. Thickness measurements from high-quality scans were used to assess repeatability and compare measurements between the two instruments.

RESULTS: Paired scans from 127 eyes were evaluated, of which 63 pairs were of high quality. Coefficients of repeatability and variation for the central subfield were 20.1 µm (2.6%) with SD-OCT and 27.4 µm (4%) with TD-OCT (P = .38). The mean difference in central subfield thickness between the two instruments was 24.5 µm (standard deviation = 20.9).

CONCLUSION: Repeatability of retinal thickness measurements with the Topcon 3D OCT 1000 is comparable to the Stratus. The measurements of the two machines differ significantly and cannot be used interchangeably.

doi: 10.3928/15428877-20100325-01

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