Asaf Achiron

Photoreceptor Integrity Predicts Response to Anti-VEGF Treatment

Purpose: Assessing changes in foveal photoreceptor microstructure (FPM) following intravitreal anti-VEGF treatment may serve as a prognostic marker in patients with macular edema (ME). Methods: Sixteen eyes belonging to newly diagnosed patients with ME were included in this prospective longitudinal study. FPM integrity was evaluated at baseline and at the end of a series of anti-VEGF injections. Results: Treatment led to a significant improvement in mean visual acuity (VA) and central macular thickness. A larger FPM defect was associated with lower VA, both before and after treatment. Patients with larger FPM defects at baseline had smaller VA improvements, and the improvement in FPM integrity was associated with VA improvement (every 100-µm FPM recovery contributed to a gain of 0.04 logMAR). Conclusions: Recovery of FPM after anti-VEGF treatment was significantly associated with a VA improvement. Direct measurement of photoreceptor integrity might provide an additional tool for the assessment of retinal function and treatment response in patients newly diagnosed with ME.

Incision and Curettage Versus Steroid Injection for the Treatment of Chalazia: A Meta-analysis

Purpose: To compare the efficacy of the chalazia treatment modalities of incision and curettage (I&C) and intralesional steroid injections (SI). Methods: Full publications of randomized controlled trials that compared I&C with SI were identified. Aggregated success rate, weighted summary proportions, and weighted pooled relative risk for success were calculated for each method. Results: Data were extracted from 8 publications that met these criteria, between 1984 and 2013. There were 288 patients treated by SI with aggregate success rate of 60.4% with 1 injection and 72.5% with 1 or 2 injections. The range of the success rate was 8.7 to 86.7% for 1 injection. The success rate for the second SI was 19.0%, with a range of 0% to 53.8%. There were 264 patients treated by I&C with a larger aggregate success rate of 78.0% with 1 procedure and 86.7% with 1 or 2 procedures (p < 0.05 for both comparisons). The range of the success rates was 60.0% to 92.0% for 1 I&C. The success rate for the second I&C was 90.65%, with a range of 83.3% to 100%. Compared with I&C, the overall relative risk for SI with 1 procedure was 0.77 (p = 0.05), while the overall relative risk for 1 or 2 procedures was 0.89 (p = 0.002). Conclusions: This analysis shows that I&C is more effective than SI with 1 procedure. This benefit is reduced when comparing 1 or 2 attempts of I&C and SI. Studies failed to show a difference in the incidence of complications with either procedure.

Intraocular pressure measurement after DSAEK by iCare, Goldmann applanation and dynamic contour tonometry: A comparative study.

PURPOSE Corneal thickness inevitably increases following Descemets stripping automated endothelial keratoplasty (DSAEK), owing to the addition of a donor graft. The current study compares different devices in assessing post-DSAEK intraocular pressure (IOP). METHODS We compared IOP values measured by the Goldmann tonometry (GAT), iCare rebound tonometry (iCare) and Pascal dynamic contour tonometry (PDCT) in eyes following DSAEK. Agreement between measurements was calculated with correlation analysis and Bland-Altman plots. Effects of keratometry, central, thickness (CCT), endothelial cell density (ECD) and axial length on IOP measurements were assessed with Pearsons correlation. RESULTS Twenty eyes of 20 patients (mean age 74.3±14.4, 14 females) post-DSAEK were included in this study. There was a high concordance between the IOP readings obtained by the three devices: a strong and significant correlation was found between GAT and PDCT (r=0.94, P<0.001) GAT and iCare (r=0.86, P<0.001) and iCare with PDCT (r=0.81, P<0.001). However, the iCare measurements were significantly and consistently lower than that obtained with GAT (ΔIOP=1.68±2.0, P=0.002, 95% CI: 0.7-2.6) and with PDCT (ΔIOP=1.61±2.5, P=0.01, 95% CI: 0.4-2.8). CCT, ECD, CCT, AXL, corneal curvature or astigmatism did not influence IOP measurement by any instrument. CONCLUSIONS IOP measurement with three different techniques (applanation, rebound and dynamic contour) showed good correlations, despite an increased corneal thickness following DSAEK. However, the iCare, which is based on a rebound tonometry showed significant lower IOP then the two other methods. This should be taken into account when evaluating patients post DSAEK.

The first prototype of chromatic pupillometer for objective perimetry in retinal degeneration patients

We recently demonstrated the feasibility of quantifying pupil responses (PR) to multifocal chromatic light stimuli for objectively assessing visual field (VF). Here we assessed a second-generation chromatic multifocal pupillometer device with 76 LEDs of 18 degree visual field and a smaller spot size (2mm diameter), aimed of achieving better perimetric resolution. A computerized infrared pupillometer was used to record PR to short- and long-wavelength stimuli (peak 485 nm and 640 nm, respectively) presented by 76 LEDs, 1.8mm spot size, at light intensities of 10-1000 cd/m2 at different points of the 18 degree VF. PR amplitude was measured in 11 retinitis pigmentosa (RP) patients and 20 normal agedmatched controls. RP patients demonstrated statistically significant reduced pupil contraction amplitude in majority of perimetric locations under testing conditions that emphasized rod contribution (short-wavelength stimuli at 200 cd/m2) in peripheral locations (p<0.05). By contrast, the amplitude of pupillary responses under testing conditions that emphasized cone cell contribution (long-wavelength stimuli at 1000 cd/m2) were not significantly different between the groups in majority of perimetric locations, particularly in central locations. Minimal pupil contraction was recorded in areas that were non-detected by chromatic Goldmann. This study demonstrates the feasibility of using pupillometerbased chromatic perimetry for objectively assessing VF defects and retinal function in patients with retinal degeneration. This method may be used to distinguish between the damaged cells underlying the VF defect.

Quantification of metamorphopsia using the MacuFlow test before and after vitreoretinal surgery.

Background and Objective: This pilot study evaluated the clinical utility of the MacuFlow software in measuring metamorphopsia prior to and following surgery in patients with vitreoretinal diseases. Patients and Methods: Four patients with vitreoretinal disorders causing metamorphopsia were included in this pilot study. Visual acuity (VA), optical coherence tomography and MacuFlow scores were recorded prior to and following surgical intervention. Results: The mean preoperative VA was 0.59 ± 0.09 logMAR, central macular thickness 491.2 ± 41.3 µm and calculated macular volume 8.99 ±1.47 mm3. These parameters improved postoperatively to a mean VA of 0.30 ± 0.22 logMAR, central macular thickness of 372.8 ± 85.4 µm and macular volume of 7.94 ± 1.34 mm3 but did not reach statistical significance. The mean preoperative MacuFlow score was 14.02 ± 8.21, which significantly improved postoperatively to 5.4 ± 3.13 (p = 0.045). Conclusions: This is the first study to demonstrate the clinical utility of MacuFlow for the quantification of metamorphopsia and its improvement or resolution following surgery. This simple method may be a valuable addition for the clinical assessment and monitoring of patients with retinal diseases causing metamorphopsia.

Acute angle closure glaucoma precipitated by olanzapine

A 78-year-old female patient with Alzheimer-type dementia arrived to our ophthalmic emergency department. Her care provider noticed that for the past 3 days, the patient has irritated left eye and has difficulties in her vision-dependent daily living tasks (e.g. reaching food on her plate and locating her eyeglass). The patient herself was not able to describe her subjective complaints due to her cognitive condition. There was no history of head injury or trauma. Her surgical history was vitrectomy with lensectomy after lens dislocation on her right eye, 5 years earlier. Past medical history, other than Alzheimer’s disease, included hyperlipidemia and gastric ulcer. Her regular medications included simvastatin 40mg, lansoprazole 30mg, memantine 10mg, donepezil 10mg and citalopram 10mg. Her husband noted that the patients started olanzapine 5mg per day 7days prior to the onset of symptoms. Ophthalmological examination revealed left eye visual acuity of hand motion, intraocular pressure (IOP) of 42mmHg, hyperemic conjunctiva, corneal edema, shallow anterior chamber with mid-dilated non-responsive pupil and a mature brunescent cataract (Figure 1A). The right eye visual acuity was 6/12; there was an anterior chamber intraocular lens with peripheral iridotomy (Figure 1B. On admission, she immediately started topical IOP lowering agents (timolol maleate 0.5, brimonidine tartrate, and latanoprost) and systemic acetazolamide tablets. She also received topical pilocarpine 2% and topical steroids. Laser iridotomy was subsequently conducted. This clinical presentation, following new administration of a drug with known low risk rate of anti-cholinergic effect, led to the diagnosis of drug-induced angle closure glaucoma (AACG). In consultation with her psychogeriatrician, olanzapine admission stopped. The mechanism suspected was pupillary block. Ultrasound biomicroscopy ruled out anterior choroidal effusion as an alternative mechanism for the AACG. The visual acuity improved to counting fingers, the IOP normalized to 10mmHg, conjunctival injection reduced, and the anterior chamber deepened, but the corneas were still edematous. We believe that the right eye was spared from the acute attack because of the existence of a previous iridotomy. AAGC is an important cause of visual loss. Delayed recognition and treatment may lead to permanent visual loss due to corneal decompression, optic nerve ischemia, and retinal vein thrombosis due to persistent high IOP (Achiron et al., 2014). Drugs that have sympathomimetic or parasympatholytic properties can cause pupillary block, where a contact is formed between the pupillary margins and the lens, thus preventing flow of aqueous humor from the posterior chamber to the anterior via the pupil, resulting in increased pressure gradient between the chambers. The high pressure in the posterior chamber that exacerbates the bowing of the lens-iris diaphragm leads to narrowing of the irido-corneal angle and to increased IOP. Patients with anatomical risk factors such as narrow anterior chamber angle, shallow anterior chamber, and hypermetropia with short axial length are more susceptible to develop AACG, mainly in dark when the pupil are in semi-dilated position. Pupillary dilation, a precipitant of AACG, can be induced by sympathetic stimulation or parasympathetic inhibition. Several typical antipsychotics were previously reported to induce AACG, yet no previous reports of AACG induced by the atypical antipsychotics olanzapine was documented (Razeghinejad, 2010). Olanzapine, a thienobenzodiazepine derivative, is a second-generation antipsychotic agent with higher affinity for serotonin 5-HT2A than for dopamine D2 receptors and a weak anti-cholinergic effect (Muench and Hamer, 2010). Olanzapine-treated patients have increased serum anti-cholinergic levels and do experience anti-cholinergic side effect as salivation, constipation, urinary disturbances, and tachycardia/palpitations, although lesser than as compared with other atypical antipsychotic drug, as clozapine (Chengappa et al., 2000). However, the low anti-cholinergic effect of olanzapine was sufficient enough to induce AACG event in our patient, which was anatomically predisposed because of shot axial length (22.3mm), thick brunescent lens (3.46mm) and pseudoexfoliation. In conclusions, AACG is an ocular emergency, and clinical signs should be recognized, especially in the demented population, where a communication barrier often exists (McCormick et al., 1994). Presenting symptoms include conjunctival hyperemia, acute

Frequency, comprehension and attitudes of physicians towards abbreviations in the medical record

Aims Abbreviations are common in the medical record. Their inappropriate use may ultimately lead to patient harm, yet little is known regarding the extent of their use and their comprehension. Our aim was to assess the extent of their use, their comprehension and physicians’ attitudes towards them, using ophthalmology consults in a tertiary hospital as a model. Methods We first mapped the frequency with which English abbreviations were used in the departments’ computerised databases. We then used the most frequently used abbreviations as part of a cross-sectional survey designed to assess the attitudes of non-ophthalmologist physicians towards the abbreviations and their comprehension of them. Finally, we tested whether an online lecture would improve comprehension. Results 4375 records were screened, and 235 physicians responded to the survey. Only 42.5% knew at least 10% of the abbreviations, and no one knew them all. Ninety-two per cent of respondents admitted to searching online for the meanings of abbreviations, and 59.1% believe abbreviations should be prohibited in medical records. A short online lecture improved the number of respondents answering correctly at least 50% of the time from 1.2% to 42% (P<0.001). Conclusions Abbreviations are common in medical records and are frequently misinterpreted. Online teaching is a valuable tool for physician education. The majority of respondents believed that misinterpreting abbreviations could negatively impact patient care, and that the use of abbreviations should be prohibited in medical records. Due to low rates of comprehension and negative attitudes towards abbreviations in medical communications, we believe their use should be discouraged.

Glycemic Control and Quality of Life Following Cataract Surgery in Patients with Type 2 Diabetes and without Maculopathy

ABSTRACT Objective: To assess whether cataract removal surgery will improve glycemic control and quality of life in patients with diabetes. Methods: A prospective longitudinal study of 28 patients with type 2 diabetes and without diabetic retinopathy scheduled for cataract removal surgery. During the 4 months of follow-up, measurements of glycated hemoglobin (HbA1c) were obtained and assessment of quality of life was performed using two questionnaires: The EuroQoL 5-Dimension (EQ-5D®) and the Multidimensional Diabetes Questionnaire (MDQ). Results: HbA1c values decreased by approximately 0.45% following surgery (7.24% to 6.78%, P = 0.009). Younger patients reduced HbA1c significantly more than older patients (0.73% vs. 0.03%, respectively, P = 0.043). Younger age also correlated with better visual acuity improvement (R = −0.44, P = 0.02). Poor glycemic control prior to surgery correlated with better HbA1c reductions, with a 42% chance for reduction of at least 0.5% HbA1c in patients with preoperative HbA1c values of 7.5% and a 72% chance for reduction in patients with preoperative HbA1c values of 8.5%. Quality of life was improved by 14% following surgery, as noted in the MDQ results (33.9–38.7, P = 0.034) only. Conclusions: Cataract removal surgery may positively influence glycemic control and quality of life in type 2 diabetic patients without maculopathy. Younger patients achieved superior improvement in visual and glycemic outcomes. The results of this study highlight the need for frequent inquiry regarding eyesight deterioration in patients with diabetes.

Reduction of intraocular pressure after bariatric surgery

To investigate the effects of bariatric surgery on intraocular pressure (IOP).

TOPICAL APRACLONIDINE REDUCES PAIN AFTER INTRAVITREAL INJECTIONS: A Double-Blind Randomized Controlled Trial.

Purpose: To evaluate the efficacy of topical apraclonidine in reducing pain and subconjunctival hemorrhage (SCH) after intravitreal injections (IViT). Methods: A prospective, randomized, double-blinded study. Thirty-nine patients were examined twice, at each monthly IViT of 1.25 mg/0.05 mL bevacizumab. Patients were randomly assigned to receive either topical apraclonidine 0.5% or placebo to the treated eye, 30 minutes before the first IViT. At their second IViT, the intervention was switched. Thirty minutes after the injection, SCH size was measured by a slit lamp, and pain was assessed by the numerical rating scale (NRS-11). Results: Mean pain score was 1.69 (SD ±1.44) in the apraclonidine group and 3.28 (SD ±2.27) in the control group (P < 0.001). Phakic patients had a greater pain reduction after topical apraclonidine (P < 0.001). Subconjunctival hemorrhage incidence was 41% in the apraclonidine group and 51.3% in the control group (P = 0.503). Mean SCH size was 1.71 mm2 (SD ±5.83) in the apraclonidine group and 3.25 mm2 (SD ±6.41) in the control group (P = 0.253). After topical apraclonidine, there was a smaller reduction in SCH size in patients with choroidal neovascularization or hypertension (P = 0.003 and 0.044, respectively), and a greater reduction in phakic patients (P = 0.048). Conclusion: Topical apraclonidine 0.5%, administered 30 minutes before IViT, significantly decreased pain by a factor of 1.94. It did not decrease the incidence or size of SCH in the entire cohort, but only in several subpopulations.