Abhishek R. Payal

The global burden of cataract.

Purpose of review To review the previous years literature related to prevalence of blindness in general, blindness due to cataract, cataract surgical coverage (CSC) and cataract surgical rates (CSRs). Recent findings Cataracts are the major cause of blindness and visual impairment in developing countries and contributes to more than 90% of the total disability adjusted life years. This review shows that coverage continues to be a problem in many countries, especially for the female population, those residing in rural areas and those who are illiterate. Although CSR is an indicator of the availability and acceptability of services, for measuring the impact of the program, we should look at combining CSR with CSC. This strategy would also enable us achieve our goal of eliminating avoidable blindness due to cataracts by the year 2020. Summary Cataracts still continue- to be a major cause of blindness globally and with the rapidly aging population, it is a challenge to tackle. We need to plan a comprehensive strategy addressing issues related to availability, affordability, accessibility and acceptability of eye-care services.

Infliximab Treatment of Patients with Birdshot Retinochoroidopathy

PURPOSE To report the outcomes of infliximab treatment of birdshot retinochoroidopathy (BSRC) refractory to conventional immunomodulatory therapy. DESIGN Retrospective case series. PARTICIPANTS Twenty-two refractory birdshot retinochoroidopathy patients (44 eyes) who received infliximab between July 2005 and June 2012 were identified by retrospective chart review. METHODS All patients received 4 to 5 mg/kg infliximab at 4- to 8-week intervals. Data regarding patient demographics, use of immunosuppressive drugs, biologic agents, and reason for conventional therapy discontinuation were gathered. Disease activity markers, including signs of ocular inflammation, fluorescein angiography evidence of retinal vasculitis or papillitis, indocyanine green angiography evidence of active choroiditis, electroretinography parameters indicative of stable or worsening of retinal functions, and optical coherence tomography findings indicative of static or worsening macular edema were recorded. MAIN OUTCOME MEASURES Abolition of all evidence of active inflammation, visual acuity (VA), presence of cystoid macular edema at 6 months and 1 year, and adverse responses to infliximab. RESULTS Mean duration of disease before starting infliximab was 58.6 months. Before infliximab therapy, all patients received and failed conventional immunosuppressive therapy. Ten patients had received another biologic agent. After initiating infliximab, control of inflammation was achieved in 81.8% at 6 months and in 88.9% at the 1-year follow-up. Three patients had active inflammation during therapy. The rate of cystoid macular edema decreased from 22.7% at baseline to 13.9% at 6 months and 6.7% at 1 year after receiving the drug. Initial VA of 20/40 or better was found in 34 eyes (84.1%). At 6 months and 1 year, 91.7% and 94.4% of eyes, respectively, had VA of 20/40 or better. Six patients had adverse events; infliximab therapy was discontinued in these patients because of neuropathy, drug-induced lupus, allergic reaction, or fungal infection. CONCLUSIONS The data suggest that infliximab is effective for controlling inflammation in otherwise treatment-refractory cases of BSRC.

Interobserver Agreement in Clinical Grading of Vitreous Haze Using Alternative Grading Scales

PURPOSE To evaluate the reliability of clinical grading of vitreous haze using a new 9-step ordinal scale versus the existing 6-step ordinal scale. DESIGN Evaluation of diagnostic test (interobserver agreement study). PARTICIPANTS A total of 119 consecutive patients (204 uveitic eyes) presenting for uveitis subspecialty care on the study day at 1 of 3 large uveitis centers. METHODS Five pairs of uveitis specialists clinically graded vitreous haze in the same eyes, one after the other using the same equipment, using the 6- and 9-step scales. MAIN OUTCOME MEASURES Agreement in vitreous haze grade between each pair of specialists was evaluated by the κ statistic (exact agreement and agreement within 1 or 2 grades). RESULTS The scales correlated well (Spearmans ρ = 0.84). Exact agreement was modest using both the 6-step and 9-step scales: average κ = 0.46 (range, 0.28-0.81) and κ = 0.40 (range, 0.15-0.63), respectively. Within 1-grade agreement was slightly more favorable for the scale with fewer steps, but values were excellent for both scales: κ = 0.75 (range, 0.66-0.96) and κ = 0.62 (range, 0.38-0.87), respectively. Within 2-grade agreement for the 9-step scale also was excellent (κ = 0.85; range, 0.79-0.92). Two-fold more cases were potentially clinical trial eligible on the basis of the 9-step than the 6-step scale (P<0.001). CONCLUSIONS Both scales are sufficiently reproducible using clinical grading for clinical and research use with the appropriate threshold (≥ 2- and ≥ 3-step differences for the 6- and 9-step scales, respectively). The results suggest that more eyes are likely to meet eligibility criteria for trials using the 9-step scale. The 9-step scale appears to have higher reproducibility with Reading Center grading than clinical grading, suggesting that Reading Center grading may be preferable for clinical trials.

Outcomes of cataract surgery with residents as primary surgeons in the Veterans Affairs Healthcare System.

Purpose To explore visual outcomes, functional visual improvement, and events in resident‐operated cataract surgery cases. Setting Veterans Affairs Ophthalmic Surgery Outcomes Database Project across 5 Veterans Affairs Medical Centers. Design Retrospective data analysis of deidentified data. Methods Cataract surgery cases with residents as primary surgeons were analyzed for logMAR corrected distance visual acuity (CDVA) and vision‐related quality of life (VRQL) measured by the modified National Eye Institute Vision Function Questionnaire and 30 intraoperative and postoperative events. In some analyses, cases without events (Group A) were compared with cases with events (Group B). Results The study included 4221 cataract surgery cases. Preoperative to postoperative CDVA improved significantly in both groups (P < .0001), although the level of improvement was less in Group B (P = .03). A CDVA of 20/40 or better was achieved in 96.64% in Group A and 88.25% in Group B (P < .0001); however, Group B had a higher prevalence of preoperative ocular comorbidities (P < .0001). Cases with 1 or more events were associated with a higher likelihood of a postoperative CDVA worse than 20/40 (odds ratio, 3.82; 95% confidence interval, 2.92‐5.05; P < .0001) than those who did not experience an event. Both groups had a significant increase in VRQL from preoperative levels (both P < .0001); however, the level of preoperative to postoperative VRQL improvement was significantly less in Group B (P < .0001). Conclusion Resident‐operated cases with and without events had an overall significant improvement in visual acuity and visual function compared with preoperatively, although this improvement was less marked in those that had an event. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.

Effects of tear gases on the eye

Chemical agents that target the eyes have been a popular choice for law enforcement during riots and for military training for nearly a century. The most commonly used agents are chloroacetophenone (formerly sold as Mace), o-chlorobenzylidene malononitrile, and oleoresin capsicum (OC or pepper spray, current ingredient for Mace). Initially, most severe ocular injuries were caused by the explosive force rather than the chemical itself. The development of sprays reduced the mechanical severity of ocular injuries, but resulted in a variety of chemical injuries. The effects on eyes include conjunctival injection, complete corneal epithelial defects, pseudopterygium, corneal neovascularization, persistent conjunctivalization, corneal opacities, and reduced visual acuity. Current management, based on limited human studies, emphasizes decontamination and symptomatic treatment. We review the literature related to clinical and histopathologic effects of tear gas agents on the eye and their management.

Increased Submacular Choroidal Thickness in Active, Isolated, Extramacular Toxoplasmosis

origin of the blood circulation of the brain and choroid through the internal carotid artery may play a role. Taking into account that choroidal thickness depends on choroidal blood vessel filling and considering the choroidal blood circulation as an extracranial part of the cerebral blood system may make one infer that decreased cerebral blood circulation may have an effect on both a decreased cognitive function and a reduced choroidal thickness. Our results should be interpreted with limitations in mind; it is not fully clear how well the Mini Mental Status Examination test applied in our study to assess cognitive function. In conclusion, thicker SFCT (or a lesser degree of fundus tessellation) was associated with higher cognitive function and vice versa, after adjusting for ocular and systemic parameters. These results suggest that more research is needed to explore the association between a leptochoroid and a reduced cerebral function.

Outcomes after cataract surgery in eyes with pseudoexfoliation: Results from the Veterans Affairs Ophthalmic Surgery Outcomes Data Project

OBJECTIVE To compare clinical outcomes of cataract surgery in eyes with and without pseudoexfoliation (PXF). DESIGN Retrospective deidentified data analysis. PARTICIPANTS A total of 123 PXF and 4776 non-PXF eyes of patients who underwent cataract surgery. METHODS We compared data on visual acuity, Visual Function Questionnaire (VFQ)-based quality of life, and complications in PXF and non-PXF eyes from the Veterans Affairs (VA) Ophthalmic Surgery Outcomes Data Project across 5 VA medical centres. RESULTS Pupillary expansion devices were used in 31 (25.2%) PXF cases and 398 (8.4%) non-PXF cases (p < 0.0001). Capsular tension rings were used in 6 (4.9%) PXF cases and 55 (1.2%) non-PXF cases (p < 0.004). The following complications occurred more frequently in PXF cases: zonular dehiscence without vitrectomy (4 [3.3%] PXF cases vs 40 [0.8%] non-PXF cases p = 0.02), persistent inflammation (28 [24.1%] vs 668 [14.5%]; p = 0.007), and persistent intraocular pressure elevation (5 [4.3%] vs 68 [1.5%]; p = 0.03). Best corrected visual acuity (BCVA) improved in both groups after 1 month, but 87 (83.7%) PXF cases achieved postoperative BCVA better than or equal to 20/40 compared to 3991 (93.8%) non-PXF cases (p = 0.0003). There was no significant difference in the postoperative composite VFQ scores between PXF (82.1 ± 16.9) and non-PXF cases (84.2 ± 16.8, p = 0.09). CONCLUSIONS Several complications occurred more frequently in the PXF group compared to the non-PXF group, and fewer PXF cases achieved BCVA better than or equal to 20/40. Despite this, both groups experienced similar improvement in vision-related quality of life after cataract surgery.

Long-Term Drug-Free Remission and Visual Outcomes in Sympathetic Ophthalmia

ABSTRACT Purpose: To assess corticosteroid- and immunosuppressive therapy (IST)-free long-term remission in the treatment of patients with sympathetic ophthalmia (SO), a vision-robbing disease that can span a lifetime. Methods: The medical records of 19 patients with SO aged 16.1 to 94.95 years (median age 58.56 years) with median follow-up of 7.10 years (mean, 6.41; range, 2.5 to 8.63 years) were retrospectively examined. Results: All patients achieved control of inflammation, 13 of them for 2 years or more. Three (15.78%) of the 19 patients maintained remission without IST and corticosteroids for more than 5 years with vision of 20/25 or better in the sympathizing eye. Thirteen patients (68.42%) were inactive on IST or corticosteroids or in combination therapy. Eleven patients (57.9%) maintained visual acuity of 20/40 or better at the end of follow-up. Conclusion: Even with a devastating and possibly lifelong disease like sympathetic ophthalmia, long-term remission off all IST and corticosteroids, and perhaps even cure, is possible.

Outcome of Multiple Implants and Dissociation of Fluocinolone Acetonide Intravitreal Implant (Retisert) in a Series of 187 Consecutive Implants

Abstract Purpose: To evaluate outcomes of long-term follow-up of Retisert multiple implantation and dissociation in eyes with chronic noninfectious uveitis. Methods: Review of 187 consecutive Retisert implants. Outcomes of multiple implantation and spontaneous medication pellet-strut dissociation were evaluated. Results: A total of 187 consecutive Retisert implants were reviewed. Eight implants were removed. The prevalence of spontaneous dissociation was 2.6% (5/187). The rate of dissociation increased to 11.11% (2/18) in cases of multiple implants. The mean period between Retisert implantation and spontaneous dissociation was 65.05 months. The mean period between implants in the same eye was 55.25 months. In cases of multiple implantations the old implant was not removed and 17.64% (3/17) of eyes required glaucoma filtering surgery. Conclusion: The rate of spontaneous dissociation of Retisert medication pellet-strut in eyes with single implant for noninfectious uveitis is low, which tends to increase in eyes with multiple implants.

Cataract Surgery Outcomes in Glaucomatous Eyes: Results From the Veterans Affairs Ophthalmic Surgery Outcomes Data Project

PURPOSE To compare visual acuity outcomes, vision-related quality of life, and complications related to cataract surgery in eyes with and without glaucoma. DESIGN Retrospective cohort study. METHODS Cataract surgery outcomes in cases with and without glaucoma from the Veterans Affairs Ophthalmic Surgical Outcomes Data Project were compared. RESULTS We identified 608 glaucoma cases and 4306 controls undergoing planned cataract surgery alone. After adjusting for age, pseudoexfoliation, small pupil, prior ocular surgery, and anterior chamber depth, we found that glaucoma cases were more likely to have posterior capsular tear with vitrectomy (odds ratio [OR] 1.8, P = .03) and sulcus intraocular lens placement (OR 1.65, P = .03) during cataract surgery. Glaucoma cases were more likely to have postoperative inflammation (OR 1.73, P < .0001), prolonged elevated intraocular pressure (OR 2.96, P = .0003), and additional surgery within 30 days (OR 1.92, P = .03). Mean best-corrected visual acuity (BCVA) and Visual Function Questionnaire (VFQ) scores significantly improved after cataract surgery in both groups (P < .0001), but there were larger improvements in BCVA (P = .01) and VFQ composite scores (P < .0001) in the nonglaucoma vs the glaucoma group. A total of 3621 nonglaucoma cases (94.1%) had postoperative BCVA 20/40 or better, compared to 466 glaucoma cases (89.6%) (P = .0003). CONCLUSIONS Eyes with glaucoma are at increased risk for complications and have more modest visual outcomes after cataract surgery compared to eyes without glaucoma. Despite this, glaucoma patients still experience significant improvement in vision-related outcomes after cataract extraction. Further study is needed to explore potential factors that influence cataract surgery outcomes in glaucomatous eyes.