JAMA Ophthalmology Current Issue

“PhacoTracking” An Evolving Paradigm in Ophthalmic Surgical Training “PhacoTracking”

Smith P, Tang L, Balntas V, et al. — Wed, 01 May 2013 00:00:00 GMT

Motion analysis has been validated as a tool to evaluate surgical skill. We investigated a novel computer vision–based tool for the evaluation of surgical movements during cataract surgery. A prospective cohort analysis of 2 groups was performed. Ten videos of junior surgeons (ie, those with <200 cases) and 10 videos of senior surgeons (ie, those with >1000 cases) were analyzed. Movement parameters were measured over an entire procedure. Significant statistical differences were found between novice and expert surgeons for total path length (P = .002), number of movements (P = .05), and total time (P = .004). Our study has shown that computer vision–based motion analysis can be successfully applied to video recordings of cataract surgery to provide robust measurements of instrument motion. Further work needs to be done to evaluate its usefulness in training and feedback.

About This Journal

Wed, 01 May 2013 00:00:00 GMT

Accelerated In Vitro Degradation of Optically Clear Low–β Sheet Silk Films by Enzyme-Mediated Pretreatment Developing a Tissue-Engineered Corneal Stroma

Zarbin MA. — Wed, 01 May 2013 00:00:00 GMT

The cornea is the most frequently transplanted tissue in the United States. Worldwide, the demand for donor tissue exceeds supply. Manufacture of such tissue would address an important unmet clinical need. To manufacture transplantable corneal tissue, one must understand the design principles underlying cornea anatomy. Human cornea is a pentalaminar structure that includes the epithelium, Bowman layer, stroma, Descemet membrane, and endothelium. Several features give rise to corneal transparency including avascularity, active dehydration, and stromal fine structure. The optical properties of the cornea arise not only from its uniform refractive index but also from its surface curvature.

Anterior Chamber Bleeding After Laser Peripheral Iridotomy Anterior Chamber Bleeding

Golan S, Levkovitch-Verbin H, Shemesh G, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

To our knowledge, this is the first study to describe the correlation of anterior chamber bleeding after laser peripheral iridotomy (LPI) and antiplatelet therapy.

Objective

To determine the incidence and amount of anterior chamber bleeding after laser peripheral iridotomy in patients whose condition is suggestive of primary angle-closure glaucoma (PACS) who continued their antiplatelet or anticoagulant treatment before undergoing LPI compared with when they discontinued treatment.

Design and Setting

A prospective controlled trial.

Patients

Patients with suspected bilateral primary angle-closure and no other ocular disease who take antiplatelet or anticoagulant medications regularly (from January 2010-October 2011) were enrolled.

Main Outcome and Measure

The incidence of anterior chamber bleeding with and without antiplatelet and anticoagulant therapy.

Results

A total of 104 patients (208 eyes) participated in the study. Thirty-six eyes (34.6%) in the treated and untreated arms bled. The amount of bleeding did not differ significantly when the patient was on or off antiplatelet or anticoagulant treatment, nor did the immediate postprocedure mean intraocular pressure (P = .13). The type of antiplatelet or anticoagulant, total laser energy, age, sex, or color of irides were not risk factors for increased bleeding (P = .156 for all parameters).

Conclusions

No indication was noted for discontinuing these medications before a high-powered pulsed laser peripheral iridotomy.

Association Between Depression and Functional Vision Loss in Persons 20 Years of Age or Older in the United States, NHANES 2005-2008 Depression and Functional Vision Loss

Zhang X, Bullard K, Cotch M, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

This study provides further evidence from a national sample to generalize the relationship between depression and vision loss to adults across the age spectrum. Better recognition of depression among people reporting reduced ability to perform routine activities of daily living due to vision loss is warranted.

Objectives

To estimate, in a national survey of US adults 20 years of age or older, the prevalence of depression among adults reporting visual function loss and among those with visual acuity impairment. The relationship between depression and vision loss has not been reported in a nationally representative sample of US adults. Previous studies have been limited to specific cohorts and predominantly focused on the older population.

Design

The National Health and Nutrition Examination Survey (NHANES) 2005-2008.

Setting

A cross-sectional, nationally representative sample of adults, with prevalence estimates weighted to represent the civilian, noninstitutionalized US population.

Participants

A total of 10 480 US adults 20 years of age or older.

Main Outcome Measures

Depression, as measured by the 9-item Patient Health Questionnaire depression scale, and vision loss, as measured by visual function using a questionnaire and by visual acuity at examination.

Results

In 2005-2008, the estimated crude prevalence of depression (9-item Patient Health Questionnaire score of ≥10) was 11.3% (95% CI, 9.7%-13.2%) among adults with self-reported visual function loss and 4.8% (95% CI, 4.0%-5.7%) among adults without. The estimated prevalence of depression was 10.7% (95% CI, 8.0%-14.3%) among adults with presenting visual acuity impairment (visual acuity worse than 20/40 in the better-seeing eye) compared with 6.8% (95% CI, 5.8%-7.8%) among adults with normal visual acuity. After controlling for age, sex, race/ethnicity, marital status, living alone or not, education, income, employment status, health insurance, body mass index, smoking, binge drinking, general health status, eyesight worry, and major chronic conditions, self-reported visual function loss remained significantly associated with depression (overall odds ratio, 1.9 [95% CI, 1.6-2.3]), whereas the association between presenting visual acuity impairment and depression was no longer statistically significant.

Conclusions and Relevance

Self-reported visual function loss, rather than loss of visual acuity, is significantly associated with depression. Health professionals should be aware of the risk of depression among persons reporting visual function loss.

Clinical Manifestations of Cytomegalovirus-Associated Posterior Uveitis and Panuveitis in Patients Without Human Immunodeficiency Virus Infection CMV-Associated Posterior Uveitis and Panuveitis

Pathanapitoon K, Tesavibul N, Choopong P, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Little attention has been paid to clinical features of cytomegalovirus (CMV) infections in individuals without human immunodeficiency virus (HIV).

Objective

To describe the clinical manifestations and comorbidities of patients without HIV infection who have CMV-associated posterior uveitis or panuveitis.

Design and Setting

Retrospective observational case series in an academic research setting.

Participants

The medical records were reviewed of 18 patients (22 affected eyes) diagnosed as having posterior uveitis or panuveitis who had aqueous positive for CMV by polymerase chain reaction techniques.

Main Outcome Measures

Demographic data, clinical manifestations, and associated systemic diseases were recorded.

Results

Ocular features included focal hemorrhagic retinitis (n = 13) and peripheral retinal necrosis (n = 7). Two eyes had no focal retinal lesions but manifested vasculitis and vitritis. All patients exhibited vitreous inflammation. Inflammatory reactions in anterior segments developed in 14 of 22 eyes (64%). Retinal vasculitis was observed in 16 of 22 eyes (73%) and included mostly arteries (in 13 of 16 eyes [81%]). Eleven of 18 patients were taking immunosuppressive medications (5 for hematologic malignant diseases, 4 for systemic autoimmune diseases, and 2 following organ transplants). One additional patient was diagnosed as having non-Hodgkin lymphoma 3 months after the onset of CMV-associated panuveitis, and another patient had primary immunodeficiency disorder. Of the remaining 5 patients, 2 had diabetes mellitus, and 3 had no associated systemic diseases and exhibited no evidence of immune deficiency.

Conclusions and Relevance

Cytomegalovirus-associated infections of posterior eye segments can develop in patients without HIV infection who have compromised immune function of variable severity but may occur also in individuals who have no evidence of immune insufficiency. Cytomegalovirus infections located in posterior eye segments in patients without HIV infection caused intraocular inflammatory reaction in all cases and demonstrated more variable clinical presentation than classic CMV retinitis observed in patients with HIV infection.

Conjunctival Papilloma Features and Outcomes Based on Age at Initial Examination Conjunctival Papilloma

Kaliki S, Arepalli S, Shields CL, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Conjunctival papilloma is a benign epithelial tumor occurring in both children and adults with varying clinical features and outcomes. In this article, we describe our experience regarding the difference in the clinical features and outcomes of conjunctival papilloma based on age at initial examination.

Objective

To evaluate the clinical features, treatment, and outcomes in patients with conjunctival papilloma based on age at initial examination.

Design

Retrospective study.

Setting

Ocular Oncology Service, Wills Eye Hospital, Philadelphia, Pennsylvania.

Participants

Ten children and adolescents (aged ≤20 years) and 63 adults (aged >20 years) with conjunctival papilloma.

Interventions

Excisional biopsy, cryotherapy, oral cimetidine, topical or injection interferon alfa-2b, and photodynamic therapy.

Main Outcome Measure

Tumor response.

Results

A comparison of conjunctival papillomas between age groups revealed significant differences in the mean number of tumors per eye (children and adolescents vs adults, 2 vs 1; P = .05), tumor basal dimension (8 vs 6 mm; P = .05), and associated feeder vessels (20% vs 47%; P = .05). Primary treatment included sole treatment with oral cimetidine (15% vs 5%), topical interferon alfa-2b (0% vs 1%), cryotherapy (0% vs 3%), photodynamic therapy (0% vs 1%), excisional biopsy and cryotherapy (38% vs 65%), excisional biopsy and cryotherapy with adjuvant oral cimetidine (8% vs 9%), and excisional biopsy and cryotherapy with adjuvant topical or injection interferon alfa-2b (38% vs 15%). Significant differences in age groups in treatment outcome during the follow-up period (mean, 24 vs 38 months) included complete regression with single treatment (38% vs 95%; P < .01) and tumor recurrence (15% vs 1%; P = .05).

Conclusions and Relevance

Conjunctival papillomas are larger and more likely to be multiple in children and adolescents than in adults. Excisional biopsy and cryotherapy with or without adjuvant oral cimetidine and/or topical interferon alfa-2b provide satisfactory tumor control. Papilloma recurrence is more common in children and adolescents than in adults.

Corneal Graft Alterations After Descemet Stripping: Implications for Split Cornea Transplantation

Heindl LM, Riss S, Adler W, et al. — Wed, 01 May 2013 00:00:00 GMT

In recent years, there has been tremendous progress in improving lamellar keratoplasty techniques such as deep anterior lamellar keratoplasty and Descemet membrane endothelial keratoplasty. Splitting of a single donor cornea into an anterior part (including epithelium, its basement membrane, Bowman layer, and stroma) for use in a deep anterior lamellar keratoplasty procedure in a patient with anterior stromal disease (eg, keratoconus) and into a posterior part (endothelium–Descemet membrane layer) for use in a Descemet membrane endothelial keratoplasty procedure in a patient with endothelial disease (eg, Fuchs endothelial dystrophy) can reduce the need and cost for corneal donor tissue by up to 47%. Since it is thus far unclear what time limits are acceptable for storing anterior and posterior grafts in split cornea transplantation, we investigated split corneal tissue for temporal morphologic alterations after Descemet stripping.

Delayed Presentation of Emulsified Subretinal Silicone Oil Appearing as an Inverse Macular Pseudohypopyon

Gosse E, Lochhead J. — Wed, 01 May 2013 00:00:00 GMT

The use of silicone oil is well established in complex retinal detachment surgery, and it is still the most frequently used internal tamponade in the management of giant retinal tear. The common complications associated with silicone oil have been extensively described. Subretinal silicone oil is an infrequent but serious complication. The delayed presentation of subretinal silicone oil is uncommon and has previously been described in cases of retinal detachment associated with optic disc pit. We describe an unusual late complication of subretinal silicone oil presenting as an inverse macular pseudohypopyon in a patient successfully treated for giant retinal tear 25 years previously.

Effect of Intravitreous Anti–Vascular Endothelial Growth Factor Therapy on Choroidal Thickness in Neovascular Age-Related Macular Degeneration Using Spectral-Domain Optical Coherence Tomography

Branchini L, Regatieri C, Adhi M, et al. — Wed, 01 May 2013 00:00:00 GMT

A critical method of monitoring patients with neovascular age-related macular degeneration (AMD) being treated with anti–vascular endothelial growth factor (anti-VEGF) is optical coherence tomography (OCT), which uses low-coherence interferometry of light to examine the retina in vivo on a micrometer scale.

Effect of Low Concentrations of Benzalkonium Chloride on Acanthamoebal Survival and Its Potential Impact on Empirical Therapy of Infectious Keratitis Benzalkonium Chloride and Acanthamoebal Survival

Tu EY, Shoff ME, Gao W, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

The significant antiacanthamoebal effect of benzalkonium chloride, at or below concentrations used for preservation of common ophthalmic preparations, should be understood both when choosing empiric antibiotic therapy for infectious keratitis and when assessing the persistent rise in Acanthamoeba cases in the United States since 2003.

Objective

To characterize the antiacanthamoebal efficacy of low concentrations of benzalkonium chloride (BAK) for drug preservation and therapeutic effect against Acanthamoeba.

Design

Experimental study with a review of the literature.

Setting

Laboratory.

Exposures

A concentration of 10⁴ trophozoites of 3 well-characterized clinical strains of Acanthamoeba were exposed at 0.5, 2.0, 3.5, 5.0, and 6.5 hours to BAK (0.001%, 0.002%, and 0.003%), moxifloxacin hydrochloride (0.5%), and moxifloxacin (0.5%) + BAK (0.001% and 0.003%) with hydrogen peroxide (3%) and amoeba saline controls.

Main Outcomes and Measures

Amoeba survival was calculated using the most probable number method recorded as log kill values. The relationship of BAK concentration and exposure time as well as the relative effect of BAK and moxifloxacin on acanthamoebal survival were analyzed.

Results

Amoebicidal activity of BAK is both time dependent and concentration dependent in pooled and strain-stratified analyses (P < .001). Moxifloxacin demonstrated no significant independent inhibitory effect or additive effect to BAK efficacy on acanthamoebal survival. The profound antiacanthamoebal effect of BAK, 0.003%, was similar to that of hydrogen peroxide for certain strains.

Conclusions and Relevance

Low concentrations of BAK, previously demonstrated to concentrate and persist in ocular surface epithelium, exhibit significant antiacanthamoebal activity in vitro at or below concentrations found in commercially available ophthalmic anti-infectives. The unexplained persistence of the Acanthamoeba keratitis outbreak in the United States, clusters abroad, and clinical studies reporting resolution or modification of Acanthamoeba keratitis without specific antiacanthamoebal therapy suggests that other contributing factors should be considered, including changes in the formulations used for empirical therapy of presumed infectious keratitis occurring in the same period.

Endothelial Morphometric Measures to Predict Endothelial Graft Failure After Penetrating Keratoplasty Morphometric Measures and Endothelial Graft Failure

Benetz B, Lass JH, Gal RL, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Endothelial morphometric measures have potential value in predicting graft failure after penetrating keratoplasty.

Objective

To determine whether preoperative and/or postoperative central morphometric measures (endothelial cell density [ECD], coefficient of variation [CV], and percentage of hexagonality [HEX]) and their postoperative changes are predictive of graft failure caused by endothelial decompensation after penetrating keratoplasty to treat a moderate-risk condition, principally Fuchs dystrophy or pseudophakic corneal edema.

Design

In a subset of Cornea Donor Study participants with graft failure, a central reading center determined preoperative and postoperative ECD, CV, and HEX from available central endothelial specular images.

Setting

Cornea Image Analysis Reading Center of the Specular Microscopy Ancillary Study.

Participants

Eighteen patients with graft failure due to endothelial decompensation and 54 individuals matched for most donor and recipient measures at baseline whose grafts did not fail.

Main Outcome Measure

Change in ECD, CV, and HEX values.

Results

Preoperative ECD was not associated with graft failure (P = .43); however, a lower ECD at 6 months was predictive of subsequent failure (P = .004). Coefficient of variation at 6 months was not associated with graft failure in univariate (P = .91) or multivariate (P = .79) analyses. We found a suggestive trend of higher graft failure with lower HEX values at 6 months (P = .02) but not at the established statistical significance (P < .01). The most recent CV or HEX values, as time-dependent variables, were not associated with graft failure (P = .26 and P = .81, respectively). Endothelial cell density values decreased during follow-up, whereas CV and HEX appear to fluctuate without an apparent trend.

Conclusions and Relevance

Endothelial cell density at 6 months after penetrating keratoplasty is predictive of graft failure, whereas CV and HEX appear to fluctuate postoperatively, possibly indicating an unstable endothelial population in clear and failing grafts.

Trial Registration

clinicaltrials.gov Identifier:NCT00006411

Failure of Systemic Propranolol Therapy for Choroidal Hemangioma of Sturge-Weber Syndrome A Report of 2 Cases

Krema H, Yousef YA, Durairaj P, et al. — Wed, 01 May 2013 00:00:00 GMT

Propranolol was incidentally discovered to induce accelerated involution of infantile cutaneous hemangioma. Thereafter, reports have demonstrated a favorable response to propranolol as a first-line treatment for cutaneous, orbital, and ocular hemangioma in different ages. We report the outcome of oral propranolol therapy in 2 cases with choroidal hemangioma of Sturge-Weber syndrome (SWS).

Forniceal Conjunctival Pedicle Flap for the Treatment of Complex Glaucoma Drainage Device Tube Erosion Forniceal Conjunctival Flap for GDD Erosion

Grover DS, Merritt J, Godfrey DG, et al. — Wed, 01 May 2013 00:00:00 GMT

This retrospective study evaluated the safety and efficacy of the forniceal conjunctival pedicle flap for repair of conjunctival-deficient tube erosions. Additionally, we report the split-lid technique, a procedural improvement if fornix access is difficult. We identified 15 eyes of 14 consecutive patients with complex tube erosions. The mean age was 72.8 years and 33.3% had diabetes mellitus. Most patients were functionally monocular and 80% had undergone 4 or more prior ocular surgical procedures. There was no difference between the following preoperative and postoperative values: visual acuity, intraocular pressure, or number of glaucoma medications. The mean follow-up time after pedicle flap repair was 49 months. There were no recurrent erosions allowing for preservation of the drainage implant with excellent intraocular pressure control. This study demonstrates the relative long-term safety and success of this novel technique.

In Vivo Confocal Microscopy of Fuchs Endothelial Dystrophy Before and After Endothelial Keratoplasty Confocal Microscopy of Fuchs Endothelial Dystrophy

Patel SV, McLaren JW. — Wed, 01 May 2013 00:00:00 GMT

Importance

This study reveals significant changes of the anterior cornea in Fuchs endothelial dystrophy that probably affect the visual outcomes of endothelial keratoplasty for the disease.

Objective

To determine whether abnormalities of corneal stromal and subepithelial cells in Fuchs endothelial dystrophy resolve after Descemet stripping endothelial keratoplasty (DSEK).

Design

Prospective observational study of 49 corneas of 42 patients with Fuchs dystrophy before DSEK and during 3 years of postoperative follow-up. None of the preoperative corneas were vascularized or had pronounced subepithelial fibrosis on results of slitlamp examination. Corneas were examined using in vivo confocal microscopy to determine stromal cell density and the presence of abnormal subepithelial cells (presumed fibroblasts).

Setting

The cornea service at Mayo Clinic, Rochester, Minnesota.

Participants

Forty-nine corneas of 42 patients.

Intervention

Descemet stripping endothelial keratoplasty.

Main Outcome Measures

Stromal cell density and presence of subepithelial cells.

Results

Subnormal cell density in the most anterior 10% of the host stroma in Fuchs dystrophy before DSEK (mean [SD], 22 030 [6479] cells/mm³ [n = 41]) remained unchanged at 2 (20 433 [4993] cells/mm³ [n = 35]; P = .36) and 3 years (20 925 [5433] cells/mm³ [n = 23]; P = .99) after DSEK. Abnormal subepithelial cells, which formed reticular networks deep to the basal epithelial cells, were visible in 33 eyes (67%) and remained present at 3 years after DSEK. Mean preoperative central corneal thicknesses when these subepithelial cells were and were not visible were 652 (45) and 668 (56) μm, respectively (P = .75).

Conclusions and Relevance

The reduced cellularity of the anterior stroma in Fuchs dystrophy does not recover 3 years after restoring endothelial function. Abnormal subepithelial cells, presumably fibroblasts, are present in most corneas with Fuchs dystrophy requiring DSEK, even in cases with mild edema and in the absence of clinically obvious preoperative subepithelial fibrosis. Anterior corneal structural abnormalities might be related to visual outcomes after DSEK.

Macular Xanthophylls and ω-3 Long-Chain Polyunsaturated Fatty Acids in Age-Related Macular Degeneration A Randomized Trial Macular Xanthophylls and LC-PUFAs in AMD

Arnold C, Winter L, Fröhlich K, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

It has been shown that the functionality of the macula lutea depends on the nutritional uptake of lutein and zeaxanthin and that it is inversely associated with the risk of age-related macular degeneration (AMD). Additionally, ω-3 long-chain polyunsaturated fatty acids (LC-PUFAs) may also be protective.

Objective

To investigate the effect of a 12-month intervention with macular xanthophylls and ω-3 LC-PUFAs on xanthophylls and fatty acids in plasma, antioxidant capacity, and optical density of the macular pigment of patients with nonexudative AMD.

Design

The LUTEGA study was a randomized, double-blind, placebo-controlled, parallel clinical trial that was conducted for 12 months.

Setting

University Eye Hospital and Institute of Nutrition, Friedrich Schiller University Jena, Germany.

Participants

A total of 172 individuals with nonexudative AMD.

Intervention

Individuals were enrolled and randomly divided as follows: placebo group, group 1 (a capsule containing 10 mg of lutein, 1 mg of zeaxanthin, 100 mg of docosahexaenoic acid, and 30 mg of eicosapentaenoic acid administered each day), and group 2 (same substances but twice the dose used in group 1). One hundred forty-five participants completed the study successfully.

Main Outcome Measures

Plasma xanthophyll concentrations and fatty acid profiles, optical density of the macular pigment, and antioxidant capacity in plasma (6-hydroxy-2,5,7,8-tetramethylchroman-2-carboxylic acid [Trolox] equivalent antioxidant capacity and photochemiluminescence).

Results

The concentrations of the administered carotenoids in plasma as well as the optical density of the macular pigment increased significantly in the groups randomized to receive supplementary macular xanthophylls and ω-3 LC-PUFAs after 1 month of intervention and remained at this level through the end of the study. Use of the double dose resulted in a beneficial alteration of the fatty acid profile in the plasma of patients with AMD in comparison with the dose in group 1. The lipophilic antioxidant capacity in plasma was significantly elevated with the intervention.

Conclusions and Relevance

A supplement containing a fixed combination of lutein, zeaxanthin, and ω-3 LC-PUFAs during 12 months significantly improved plasma antioxidant capacity, circulating macular xanthophyll levels, and the optical density of the macular pigment.

Trial Registration

clinicaltrials.gov Identifier: NCT00763659

Management of Fingolimod-Associated Macular Edema

Chui J, Herkes GK, Chang A. — Wed, 01 May 2013 00:00:00 GMT

Fingolimod is the first orally active drug approved for the management of relapsing-remitting multiple sclerosis (MS). Its immunosuppressive action is related to downregulation of sphingosine 1–phosphate receptor 1 on lymphocytes, which inhibits their egress from lymphoid tissues. Macular edema (ME) is an infrequent adverse effect of fingolimod, usually occurring within 3 months of initiation of treatment and resolving on cessation of fingolimod. We report a case of ME in a patient with MS receiving fingolimod and its successful management by topical anti-inflammatory drugs.

Minocycline-Induced Scleral and Dermal Pigmentation

Kovach JL, Kovach BT. — Wed, 01 May 2013 00:00:00 GMT

Morphogenetic Model for Radial Streaking in the Fundus of the Carrier State of X-Linked Albinism

Moshiri A, Scholl HN, Canto-Soler M, et al. — Wed, 01 May 2013 00:00:00 GMT

Ocular albinism is an X-linked disease characterized in affected males by poor vision, nystagmus, iris transillumination, hypopigmented fundus, foveal hypoplasia, and a decreased proportion of ipsilateral ganglion cell fibers at the optic chiasm. Mutation of the OA1/GPR143 gene on the X chromosome is responsible for this condition. The skin and hair pigmentation appears clinically normal, but skin histologic analysis reveals macromelanosomes in melanocytes. Carriers of the condition are rarely symptomatic but often have signs of their carrier status. Female carriers have macromelanosomes in the skin, although they are fewer in number than in affected males. The eyes of carriers often show iris transillumination (80%) and a mud-splattered appearance of the posterior pole with typical pigmentary streaks in the peripheral fundus (92%). The pathogenesis of these streaks has not been understood.

Optic Pathway Gliomas Neoplasms, Not Hamartomas Optic Pathway Gliomas as Neoplasms

Liu GT, Katowitz JA, Rorke-Adams LB, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Optic pathway gliomas are an important neuro-ophthalmic cause of vision loss in children. Their management depends on whether they are considered neoplasms or hamartomas.

Objective

To outline the evidence that optic pathway gliomas are slowly growing neoplasms and not hamartomas.

Design

Review of relevant studies in the literature.

Setting

The authors are from a pediatric tertiary referral center.

Results

The growth patterns and histopathology of optic pathway gliomas are more consistent with those of neoplasms. Spontaneous regression, thought to be a characteristic of hamartomas, can be seen in neoplasms of other types as well as in optic pathway gliomas. Chemotherapy used in low-grade gliomas has been shown to halt or improve vision loss in optic pathway gliomas in many cases.

Conclusions and Relevance

Optic pathway gliomas are not hamartomas but truly are neoplasms. Thus, patients should be followed up closely, and chemotherapies should be used when clinical progression occurs. Other more directed therapies will certainly be used in the future.

Pars Plana Vitrectomy for Primary Retinal Detachment Persistent Anterior Peripheral Retinal Detachment Pars Plana Vitrectomy for Retinal Detachment

Silva RA, Flynn HW, Ryan EH, et al. — Wed, 01 May 2013 00:00:00 GMT

In the century since rhegmatogenous retinal detachment was first repaired by Jules Gonin, a variety of surgical techniques have been successfully used. From the introduction of the scleral buckle by Ernst Custodis, MD, in 1949 to the development of the pars plana vitrectomy (PPV) by Robert Machemer, MD, in 1971, the principles of retinal reattachment remain consistent: identify the retinal breaks, treat the retinal breaks, and relieve vitreoretinal traction. Contemporary techniques provide unparalleled opportunities to address a variety of complex retinal detachments, but these techniques should not steer vitreoretinal surgeons away from these basic principles.

Posterior Segment Worm Infestation

Sawant S, Shah J, Shah S, et al. — Wed, 01 May 2013 00:00:00 GMT

Prevalence of Glaucoma in an Urban West African Population The Tema Eye Survey Glaucoma in West Africa

Budenz DL, Barton K, Whiteside-de Vos J, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Multiple studies have found an increased prevalence, younger age at onset, and more severe course of glaucoma in people of African descent, but these findings are based on studies conducted outside Africa.

Objective

To determine the prevalence of glaucoma in an urban West African population of adults.

Design and Setting

A population-based, cross-sectional study of adults 40 years and older conducted from September 1, 2006, through December 31, 2008, from 5 communities in Tema, Ghana.

Participants

Participants from randomly selected clusters underwent a screening examination that consisted of visual acuity, frequency doubling perimetry, applanation tonometry, and optic disc photography. Participants who failed any of these tests were referred for complete examination, including gonioscopy, standard automated perimetry, and stereoscopic optic disc photography.

Results

A total of 6806 eligible participants were identified, and 5603 (82.3%) were enrolled in the study. The field examination referred 1869 participants (33.3%) to the clinic examination, and 1538 (82.2%) came for complete examination. A total of 362 participants were identified as having glaucoma of any type and category. Primary open-angle glaucoma was the underlying diagnosis in 342 participants (94.5%). The prevalence of primary open-angle glaucoma was 6.8% overall, increasing from 3.7% among those 40 to 49 years old to 14.6% among those 80 years and older, and was higher in men than in women in all age groups, with an overall male-female prevalence ratio of 1.5. Of the participants with glaucoma, 9 (2.5%) were blind using World Health Organization criteria, and only 12 (3.3%) were aware that they had glaucoma.

Conclusions and Relevance

The prevalence of glaucoma is higher in this urban West African population than in previous studies of people of East or South African and of non-African descent. Strategies to identify affected persons and effectively manage the burden of glaucoma are needed in West Africa.

Reducing the Risk of Endophthalmitis After Intravitreous Injection Endophthalmitis After Intravitreous Injection

Kim SJ, Chomsky AS, Sternberg P. — Wed, 01 May 2013 00:00:00 GMT

Intravitreous (IVT) injection is the fastest growing procedure in ophthalmology. The number of IVT injections performed in the United States, estimated from Medicare procedure codes, increased from fewer than 3000 injections per year in 1999 to more than 1 million injections in 2008, and the number of injections will continue to increase given the aging population and the expanding indications.

Retinal Vasculitis, Aneurysms, and Neovascularization in Blau Syndrome—Diagnosis

Wed, 01 May 2013 00:00:00 GMT

Retinal Vasculitis, Aneurysms, and Neovascularization in Blau Syndrome—Quiz Case

Amin SR, Pulido JS. — Wed, 01 May 2013 00:00:00 GMT

A 6-year-old white boy presented to our office for evaluation after failing 3 school vision screenings. On initial presentation, the patient's visual acuity was 20/800 OD and 20/20 OS with a right afferent pupillary defect. He saw 0/14 Ishihara color plates with his right eye and 13/13 with his left eye. A slitlamp examination was notable for rare cells in the anterior chamber of both eyes, in addition to 3+ cells and hemorrhage within the right vitreous, and rare vitreous cells were found in the left eye. A fundoscopic examination of the right eye revealed indistinct disc margins, neovascularization, extensive vascular sheathing, and obliteration of peripheral vessels. The left fundus had distinct disc margins, but there was marked disc neovascularization and arteriolar aneurysms.

Retrospective Evaluation of Patients With Uveal Melanoma Treated by Stereotactic Radiosurgery With and Without Tumor Resection Uveal Melanoma Treated by Stereotactic Radiosurgery

Suesskind D, Scheiderbauer J, Buchgeister M, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

The present study intended to analyze the suitability of single-dose stereotactic radiotherapy in the treatment of uveal melanoma that cannot be handled with ruthenium-brachytherapy and therefore is a challenge for ophthalmologists concerning local tumor control, as well as preservation of the eye and visual function.

Objectives

To evaluate local tumor control, eye preservation, visual course, radiation complications, metastases, and death after single-dose stereotactic radiotherapy (SDRT) applied exclusively or combined with tumor resection in uveal melanomas that are neither suitable nor favorably located for ruthenium brachytherapy.

Design

Retrospective, observational case series.

Setting

Primary care center.

Participants

Seventy-eight patients with uveal melanoma were treated.

Intervention

Between June 3, 2003, and March 18, 2008, patients with uveal melanoma received SDRT monotherapy (group 1, 60 patients) or SDRT combined with tumor resection (group 2, 18 patients). Radiotherapy was performed with a tumor-surrounding dose of 25 Gy on a linear accelerator.

Main Outcome Measures

Local tumor control, eye preservation, visual results, and radiation complications.

Results

Within a median follow-up of 33.7 months (range, 0.13-81.13 months), 6 recurrences occurred in group 1; none recurred in group 2. The Kaplan-Meier estimate for local control was 85% at 3 years in group 1 and 100% in group 2 (P = .22). Eye preservation rate was 77% vs 87% at 3 years (groups 1 and 2, respectively) (P = .82). Visual acuity decreased with a median loss of −18 Snellen lines (group 1) and −22 Snellen lines (group 2). More retinopathies (P = .07), opticopathies (P = .27), and rubeotic glaucomas (P = .10) occurred in group 1. No significant difference was observed in the development of metastases (P = .33). The groups differed in overall survival because of 2 deaths occurring shortly after surgery in group 2 for unexplained reasons (P = .06).

Conclusions and Relevance

Survival analysis suggested that SDRT with combined tumor resection might be associated with increased tumor control and fewer radiation complications than SDRT as monotherapy. Both groups had similar eye retention rates and were comparable concerning the decrease in visual function in most eyes. However, the protocol was stopped after 3 unexplainable deaths after surgery.

Sagging Eye Syndrome Connective Tissue Involution as a Cause of Horizontal and Vertical Strabismus in Older Patients Sagging Eye Syndrome

Chaudhuri Z, Demer JL. — Wed, 01 May 2013 00:00:00 GMT

Importance

Recognition of sagging eye syndrome (SES) as the cause of chronic or acute acquired diplopia may avert neurologic evaluation and imaging in most cases.

Objectives

To determine whether SES results from inferior shift of lateral rectus (LR) extraocular muscle (EOM) pulleys and to investigate anatomic correlates of strabismus in SES.

Design and Setting

We used magnetic resonance imaging to evaluate rectus EOMs, pulleys, and the LR–superior rectus (SR) band ligament at an eye institute.

Participants

Patients with acquired diplopia suspected of having SES. We studied 56 orbits of 11 men and 17 women (mean [SD] age of 69.4 [11.9] years) clinically diagnosed with SES. Data were obtained from 25 orbits of 14 control participants age-matched to SES and from 52 orbits of 28 younger controls (23 [4.6] years).

Main Outcome Measures

Rectus pulley locations compared with age-matched norms and lengths of the LR-SR band ligament and rectus EOMs. Data were correlated with facial features, binocular alignment, and fundus torsion.

Results

Patients with SES commonly exhibited blepharoptosis and superior sulcus defect. Significant inferolateral LR pulley displacement was confirmed in SES, but the spectrum of abnormalities was extended to peripheral displacement of all other rectus pulleys and lateral displacement of the inferior rectus pulley, with elongation of rectus EOMs (P < .001). Symmetrical LR sag was associated with divergence paralysis esotropia and asymmetrical LR sag greater than 1 mm with cyclovertical strabismus. The LR-SR band was ruptured in 91% of patients with SES.

Conclusions and Relevance

Widespread rectus pulley displacement and EOM elongation, associated with LR-SR band rupture, causes acquired vertical and horizontal strabismus. Small-angle esotropia or hypertropia may result from common involutional changes in EOMs and orbital connective tissues that may be suspected from features evident on external examination.

The Richest Monetary Prize in Vision The Richest Monetary Prize in Vision

Sommer A. — Wed, 01 May 2013 00:00:00 GMT

Those seeking breakthrough discoveries in ophthalmology and vision, like those working to bring the benefits of such discoveries and modern ophthalmic care to poor people around the globe, are not doing it for the recognition or the money. Still, recognition and monetary awards, particularly those that advance their work, do not hurt. The António Champalimaud Vision Award, which is given annually, brings both recognition and funding to research and practice. At [euro]1 million ($1.32 million at recent exchange rates), it is also among the “richest” prizes in all of medicine and, by far, the largest prize for vision research and blindness prevention.

Transitional Cell Carcinoma of the Lacrimal Sac Presenting With Bloody Tears

Azari AA, Kanavi MR, Saipe N, et al. — Wed, 01 May 2013 00:00:00 GMT

Transitional cell carcinomas (TCCs) of the lacrimal sac are uncommon tumors that can have significant morbidity and mortality if not diagnosed and treated in a timely fashion. These tumors have variable clinical and histologic features. Bloody tears, also known as dacryohemorrhea, have been reported only once previously as a presenting sign of the tumor. We describe a case of lacrimal sac TCC manifesting with epiphora, dacryohemorrhea, and medial canthal mass.

Traumatic Airbag Maculopathy

Kung J, Leung LB, Leng T, et al. — Wed, 01 May 2013 00:00:00 GMT

With the prevalence of motor vehicle crashes, airbag deployment is a significant source of ocular trauma. We describe a case of traumatic airbag maculopathy in which imaging studies document a constellation of interesting findings, including subretinal fluid with impending macular hole and persistent paracentral scotoma with underlying electrophysiological disturbance despite anatomical recovery on optical coherence tomography (OCT).

Validity of the Results of a Contact Lens Sensor?

Faschinger C, Mossböck G. — Wed, 01 May 2013 00:00:00 GMT

We read with great interest the study by Mansouri et al titled “Continuous 24-Hour Monitoring of Intraocular Pressure Patterns With a Contact Lens Sensor: Safety, Tolerability, and Reproducibility in Patients With Glaucoma.”

Validity of the Results of a Contact Lens Sensor?—Reply

Mansouri K, Medeiros FA, Tafreshi A, et al. — Wed, 01 May 2013 00:00:00 GMT

In reply

Vision Function, Functional Vision, and Depression Vision Function, Functional Vision, and Depression

Morse AR. — Wed, 01 May 2013 00:00:00 GMT

Vision loss and depression have long been linked but their relationship has not been well understood. Each condition by itself can be life altering but, when combined, their deleterious effects may be compounded. In this issue of JAMA Ophthalmology, Zhang et al address the relationship between vision loss and depression, and they provide evidence that loss of functional vision (ie, actual task-related visual performance) is linked to depression. This finding underscores the importance of addressing not only the causes of vision loss but their consequences in everyday life. Their analysis of data from the National Health and Nutrition Examination Survey, which used a population-based probability sample, found an overall prevalence of depression of 4.8% in the general US population without vision loss but 11.3% among US adults with self-reported vision loss, which reflects a decline in vision that interferes with an individual's normal or desired functioning. Depression in the National Health and Nutrition Examination Survey sample was assessed using the 9-Item Patient Health Questionnaire, a brief, easily administered tool that identifies and grades the severity of depression. Among those with visual acuity of less than 20/40 in the better eye with correction, the prevalence of depression was 10.7% compared with 6.8% among adults with better visual acuity. Importantly, self-reported vision loss, an individual's perception about how their vision loss affects their performance in everyday activities, was significantly related to depression while acuity was not.

Errors in Text and Table in: Methanol Poisoning: Predictors of Visual Outcomes

Wed, 01 May 2013 00:00:00 GMT

Errors in Text and Table. In the Clinical Sciences article titled “Methanol Poisoning: Predictors of Visual Outcomes” by Desai et al, published online January 3, 2013, and in the March issue of JAMA Ophthalmology (2013;131[3]:358-364), errors occurred in the units given for methanol in the text and Table 1. On page 359, in the second line from the bottom of the left column, the units for blood methanol concentration should have been given as milligrams per deciliter weight per volume. Likewise, on page 361, in the first column of Table 1, the units for methanol levels also should have appeared as milligrams per deciliter weight per volume.