Direk Patikulsila

Predictive factors and outcomes of posterior segment intraocular foreign bodies

PurposeTo identify the predictive factors for anatomical and visual outcomes in posterior segment intraocular foreign body (IOFB) patients managed by pars plana vitrectomy (PPV).MethodsA retrospective chart review was performed for 77 patients, who had PPV for IOFBs removal between January 2001 and July 2007. Univariate and multivariate analyses were conducted to evaluate the predictive factors.ResultsThe mean age of the patients was 33.4 years. The nature of IOFBs was mainly metal, with injuries most commonly caused by an electric grass trimmer. The mean time interval between injury and IOFBs removal was 30.7 days. The mean preoperative visual acuity (VA) was 1.82 logarithm of the minimal angle of resolution (logMAR), and mean final was VA 1.10 logMAR. From multivariate analysis, good visual outcome was correlated with the corneoscleral entry site, and poor visual outcome was correlated with the presence of relative afferent pupillary defect.ConclusionsIn noncombat IOFBs, most cases were work-related. Delayed IOFBs removal was acceptable when primary wounds were repaired appropriately and extensive antibiotics administered. Even though advancement in vitreoretinal surgery can reduce the frequency of blindness, further promotion and education on eye protection during work are needed.

Telemedicine Screening for Cytomegalovirus Retinitis at the Point of Care for Human Immunodeficiency Virus Infection

IMPORTANCE Cytomegalovirus (CMV) retinitis is a leading cause of blindness in many developing countries, likely the result of inadequate screening. Telemedicine screening for CMV retinitis instituted at the point of care for human immunodeficiency virus (HIV) infection may allow for earlier detection. OBJECTIVES To determine the diagnostic accuracy of retinal photography in detecting CMV retinitis at the point of HIV care and to characterize the clinical manifestations of CMV retinitis detected through the screening program. DESIGN, SETTING, AND PARTICIPANTS We enrolled 103 participants from a population of 258 patients with HIV and a CD4 level of less than 100/μL treated at an HIV clinic in Thailand from June 2010 through June 2012. We captured mosaic fundus photographs through a dilated pupil using a digital fundus camera. An experienced on-site ophthalmologist masked to the results of the fundus images subsequently examined each eye with indirect ophthalmoscopy and recorded the clinical findings on a standardized form. Three remote graders evaluated each image for CMV retinitis. INTERVENTION Fundus photography and indirect ophthalmoscopy. MAIN OUTCOMES AND MEASURES Sensitivity and specificity of telemedicine relative to indirect ophthalmoscopy for diagnosis of CMV retinitis and clinical features of CMV retinitis lesions. RESULTS Sixteen patients (15.5%) were diagnosed as having CMV retinitis, of whom 5 (31%) had bilateral disease. Of the 21 eyes (10.2%) with CMV retinitis, 7 (33%) had visual symptoms. Retinitis lesions occupied less than 10% of the total retinal surface area in 13 of 21 eyes (62%) and did not involve the posterior pole (ie, zone 1) in 15 of 21 eyes (71%). Mean logMAR visual acuity in affected eyes was 0.41 (95% CI, 0.11-0.71; Snellen equivalent, 20/50 [95% CI, 20/25-20/100]). The mean sensitivity for the 3 remote graders in detecting CMV retinitis on fundus photography was 30.2% (95% CI, 10.5%-52.4%), and mean specificity was 99.1% (95% CI, 97.8%-100.0%). The CMV retinitis lesions missed by the remote graders (false-negative findings) were more likely to be small (P = .001) and located in the peripheral retina (P = .04). CONCLUSIONS AND RELEVANCE Patients undergoing screening at a clinic for HIV treatment had less extensive retinitis than patients in recent reports from an ophthalmology clinic. Retinal photography with the camera used in this study was not highly sensitive in detecting CMV retinitis but may identify disease with an immediate threat to vision. Improved accuracy will require a camera that can more easily image the peripheral retina.

Proliferative vitreoretinopathy in human immunodeficiency virus-infected patients in the era of highly active antiretroviral therapy

PURPOSE To assess the prevalence of proliferative vitreoretinopathy (PVR) and prognosis of cytomegalovirus (CMV) retinitis-related retinal detachment (RD) surgery in the era of highly active antiretroviral therapy (HAART). DESIGN Retrospective interventional cohort study. METHODS Thirty-five human immunodeficiency virus (HIV)-positive patients with CMV retinitis-related RD who underwent surgical repair were assessed for PVR, CD4-positive T cell counts, and use of HAART. Main outcome measures included anatomic and functional outcomes of RD surgery as well as the presence of PVR and CD4-positive T cell counts. RESULTS PVR was present in 10 of 35 patients (29%) at the time of the first surgery. The presence of PVR was associated with worse preoperative and postoperative visual acuity (P = .017 and P = .009, respectively), with the CD4-positive T cell counts above 200 cells/microL (P = .054), and with a longer interval between the diagnosis of RD and surgery (P = .025). The odds ratio for development of PVR in patients with CD4-positive T cells above 200 cells/microL was 11.3 (95% confidence interval 1.01-125). PVR was not associated with age, gender, or duration of HIV infection. Anatomic reattachment was obtained in 31 patients (89%), though the functional outcomes were limited. The central location of CMV retinitis was associated with postoperative visual acuity (VA) of less than 0.1 (P = .000). Postoperative logMAR VA was associated with preoperative logMAR VA (P < .001) and development of PVR (P = .009). CONCLUSION PVR was present in 29% of CMV retinitis-related RD and was associated with higher CD4-positive T cell counts and longer interval between the diagnosis of RD and surgery.

Repeatability and Agreement of Visual Acuity Using the ETDRS Number Chart, Landolt C Chart, or ETDRS Alphabet Chart in Eyes With or Without Sight-Threatening Diseases

Importance The Early Treatment Diabetic Retinopathy Study (ETDRS) alphabet chart is not feasible for measuring best-corrected visual acuity (BCVA) for individuals who are unfamiliar with the Roman alphabet. The ETDRS Landolt C chart is an alternative, but it may not reflect true BCVA among those with confusion between left and right. The ETDRS number chart might overcome these limitations, but little is known regarding its reliability. Objective To evaluate repeatability and agreement of BCVA using the ETDRS number chart or Landolt C chart compared with ETDRS alphabet charts in healthy and diseased eyes. Design, Setting, and Participants A cross-sectional study was conducted in Thailand from July 1, 2015, to June 30, 2016, among 154 adult Thai individuals. Those who could read Roman alphabets were classified into the following 4 groups, using 1 eye per participant: group A, which comprised 60 healthy eyes (BCVA, 20/20-20/25); group B, which comprised 40 eyes with age-related cataract, diabetic macular edema, or age-related macular degeneration (BCVA, 20/20-20/40); group C, which comprised 40 eyes with age-related cataract, diabetic macular edema, or age-related macular degeneration (BCVA, 20/50-20/100); and group D, which comprised 14 eyes with age-related cataract, diabetic macular edema, or age-related macular degeneration (BCVA, 20/125-20/200). Interventions Two standardized 4-m BCVA measurements with 3 different Precision Vision ETDRS charts (PV number, Landolt C, and alphabet), in random sequence, performed 30 minutes apart. Main Outcomes and Measures Repeatability, agreement, and testing duration of BCVA. Results Of 154 Thai participants (82 women and 72 men; mean [SD] age, 52.9 [18.2] years), the ETDRS number chart had strong repeatability coefficients (group A, 0.61 [95% CI, 0.42-0.75]; group B, 0.87 [95% CI, 0.78-0.93]; group C, 0.81 [95% CI, 0.67-0.90]; and group D, 0.81 [95% CI, 0.49-0.94]). Concordance correlation coefficients between the number and alphabet charts were also strong (group A, 0.89 [95% CI, 0.82-0.93]; group B, 0.97 [95% CI, 0.94-0.98]; group C, 0.92 [95% CI, 0.86-0.96]; and group D, 0.96 [95% CI, 0.87-0.99]), while the concordance correlation coefficients between the Landolt C and alphabet charts were lower (group A, 0.72 [95% CI, 0.52-0.83]; group B, 0.83 [95% CI, 0.68-0.91]; group C, 0.79 [95% CI, 0.61-0.89]; and group D, 0.89 [95% CI, 0.66-0.97]). The mean letter score difference between the number and alphabet charts was 1 (95% limits of agreement, −4 to +6) compared with −7 (95% limits of agreement, −18 to +5; P < .001) between the Landolt C and alphabet charts. Conclusions and Relevance The repeatability coefficients and concordance correlation coefficients suggest that ETDRS number charts are viable for measuring BCVA in clinical practice and trials for individuals who are unfamiliar with the Roman alphabet.

Vision Preference Value Scale and Patient Preferences in Choosing Therapy for Symptomatic Vitreomacular Interface Abnormality

Importance While symptomatic vitreomacular interface abnormalities (VIAs) are common, assessment of vision preference values and treatment preferences of these may guide treatment recommendations by physicians and influence third-party payers. Objective To determine preference values that individuals with VIA assign to their visual state and preferences of potential treatments. Design, Setting, and Participants In this cross-sectional one-time questionnaire study conducted between December 2015 and January 2017, 213 patients from tertiary care referral centers in Thailand, the United Kingdom, and the United States were studied. Patients with symptomatic VIA diagnosed within 1 year of data collection, visual acuity less than 20/20 OU, and symptoms ascribed to VIAs were included. Data were analyzed from January 2017 to November 2017. Main Outcomes and Measures The primary end points were overall mean preference value that individuals with VIA assigned to their visual state and patients’ preferences for potential treatments. Preference values were graded on a scale from 0 to 1, with 0 indicating death and 1 indicating perfect health with perfect vision. Results Of the 213 included patients, 139 (65.3%) were women, and the mean (SD) age was 65.6 (7.7) years. Diagnoses included epiretinal membrane (n = 100 [46.9%]), macular hole (n = 99 [46.5%]), and vitreomacular traction (n = 14 [6.6%]). The mean (SD) vision preference value was 0.76 (0.15), without differences identified among the 3 VIA types. More participants were enthusiastic about vitrectomy (150 [71.1%]) compared with intravitreal injection (120 [56.9%]) (difference, 14.2%; 95% CI, 5.16-23.3; P = .002). Adjusted analyses showed enthusiasm for vitrectomy was associated with fellow eye visual acuity (odds ratio, 10.99; 95% CI, 2.01-59.97; P = .006) and better-seeing eye visual acuity (odds ratio, 0.03; 95% CI, 0.001-0.66; P = .03). Overall enthusiasm for treatment was associated with fellow eye visual acuity (odds ratio, 7.22; 95% CI, 1.29-40.40; P = .02). Overall, most participants (171 [81.0%]) were enthusiastic about surgery, injection, or both. Conclusions and Relevance Study participants reported similar preference values among 3 types of VIAs. The data suggest that most patients with these conditions would be enthusiastic about undergoing vitrectomy or an injection to treat it, likely because of the condition’s effect on visual functioning, although there may be a slight preference for vitrectomy at this time.

Changes in Central Macular Thickness following Single Session Multispot Panretinal Photocoagulation

Purpose. To determine changes in central subfield (CSF) macular thickness and best corrected visual acuity (BCVA) following single session, multispot panretinal photocoagulation (PRP). Methods. Forty eyes of 33 patients with newly diagnosed proliferative diabetic retinopathy were treated with single session, 20-millisecond, multispot PRP. Changes in central macular thickness and BCVA at 4- and 12-week follow-up were compared to baseline measurements. Results. Each eye received a mean (SD) of 2,750 (686.7) laser spots. At 4-week follow-up, there was a statistically significant 24.0 μm increase in mean CSF thickness (P = 0.001), with a 17.4 μm increase from baseline at 12-week follow-up (P = 0.002). Mean logMAR BCVA increased by 0.05 logMAR units (P = 0.03) at 4-week follow-up. At 12-week follow-up, BCVA had almost returned to normal with only an increase of 0.02 logMAR units compared to baseline (P = 0.39). Macular edema occurred in 2 eyes (5%) at 12-week follow-up. Conclusions. Macular thickening occurs following single session, 20-millisecond, multispot PRP, with a corresponding, mild change in BCVA. However, the incidence of macular edema appears to be low in these patients. Single session, 20-millisecond, multispot PRP appears to be a safe treatment for patients with proliferative diabetic retinopathy.

Predictive factors of open globe injury in patients requiring vitrectomy

BACKGROUND To determine the outcomes and predictive factors of patients with open globe injury requiring pars plana vitrectomy (PPV). METHODS The medical records of 114 patients age 10 years or older who had undergone PPV due to ocular trauma, with at least 6 months follow up, were retrospectively reviewed. RESULTS The mean age of the patients was 42 (SD14) years, with males accounting for 89% of the cases. Penetrating eye injury was the most common injury mechanism (43%) with most injuries occurring secondary to work related incidents (54%). After surgical interventions, 78% of the patients had visual improvement of one or more Snellen lines, while no light perception occurred in 10%. Anatomical attachment was achieved in 87% of eyes at the final follow up. Logistic regression analysis showed that the presence of a relative afferent pupillary defect (RAPD) was a significant predictive factor of visual outcome, while initial retinal detachment was a significant predictor of anatomical outcome. CONCLUSIONS Pupillary reaction is an important presenting ocular sign in estimating the post-vitrectomy poor visual outcome for open globe injury. Vision was restored and improved in more than half of the patients in this study; however, long-term sequelae should be monitored.

Risk Factors for Development of Rhegmatogenous Retinal Detachment in Patients with Uveitis

ABSTRACT Purpose: To describe risk factors for development of rhegmatogenous retinal detachment (RRD) in patients with uveitis. Methods: We performed a retrospective review of 411 consecutive human immunodeficiency virus-negative patients with uveitis (571 affected eyes) and report on prevalence, risk factors and visual outcomes of patients with RRD. Results: Prevalence of RRD was 7% of all patients with uveitis. Multivariate analysis revealed that posterior uveitis and panuveitis were associated with RRD (P = 0.001). Strong association between RRD development and infectious uveitis was also observed (P = 0.009). Acute retinal necrosis (ARN) was firmly associated with RRD development (P = 0.016). Although anatomical success was obtained, functional outcome was poor. Poor visual outcomes at 6-month and 1-year follow-up were associated with initial VA < counting fingers (P = 0.05, P = 0.044). Conclusions: Prevalence of RRD in uveitis was 7% and development of RRD was encountered in posterior and panuveitis. Infectious uveitis (specifically ARN) formed a high risk for RRD.

Post-injection endophthalmitis in eyes receiving vs. not receiving topical antibiotic prophylaxis in Northern Thailand

Endophthalmitis following intravitreous anti-vascular endothelial growth factor (VEGF) injection is a rare sight-threatening condition. Several Western references suggest lower rates of post-injection endophthalmitis can be achieved without topical antibiotic prophylaxis [1–3]. However, a majority of physicians in the Asia-Pacific region still prescribe antibiotic prophylaxis [4], anecdotally stating concern that differences in environmental factors (e.g., tropical climates) or patient factors in the region might cause higher risk of endophthalmitis, comparing to the Western settings, to warrant this prophylaxis, despite little scientific rationale supporting such use. To our knowledge, little is known regarding incidence of post-injection endophthalmitis without antibiotic prophylaxis in a developing countries in Asia or elsewhere. Therefore, this study determined incidence of postinjection endophthalmitis with vs. without topical antibiotic prophylaxis at a university-based practice in Northern Thailand.

Color Fundus Photography, Optical Coherence Tomography, and Fluorescein Angiography in Diagnosing Polypoidal Choroidal Vasculopathy

PURPOSE To determine sensitivity and specificity of polypoidal choroidal vasculopathy (PCV) diagnosis using color fundus photography (CFP), optical coherence tomography (OCT), and fundus fluorescein angiography (FFA) without indocyanine green angiography (ICGA). DESIGN Validity analysis. METHODS Treatment-naïve eyes with serous/serosanguinous maculopathy undergoing CFP, OCT, FFA, and ICGA imaging before treatment at a university hospital in Thailand (January 1, 2013 to June 30, 2015) were identified. Images of each subject were categorized into 4 sets (set A: CFP; set B: CFP+OCT; set C: CFP+FFA; set D: CFP+OCT+FFA). Six graders, 3 from Thailand (PCV endemic area) and 3 from the United States (nonendemic area), individually reviewed each set (without ICGA), and determined if the presumed diagnosis was PCV. In parallel, 2 other graders confirmed if each case had PCV or not using EVEREST criteria (including ICGA). Sensitivity and specificity of a PCV diagnosis with each set (without ICGA) were analyzed compared with diagnoses including ICGA. RESULTS Of 119 study eyes (113 subjects, 57% male, mean age ± SD 59.9 ± 13.8 years), definite PCV diagnosis was 40.3%. Sensitivity of sets A, B, C, D: 0.63 (95% confidence interval [CI]: 0.47-0.76), 0.83 (95% CI: 0.69-0.92), 0.54 (95% CI: 0.39-0.68), 0.67 (95% CI: 0.51-0.79); specificities: 0.93 (95% CI: 0.84-0.97), 0.83 (95% CI: 0.72-0.91), 0.97 (95% CI: 0.89-0.99), 0.92 (95% CI: 0.82-0.97); accuracies: 0.81 (95% CI: 0.73-0.88), 0.83 (95% CI: 0.76-0.90), 0.79 (95% CI: 0.73-0.87), 0.82 (95% CI: 0.74-0.88). Discrepancies between Thai and US graders existed through sets A, C, and D. CONCLUSIONS These data suggest that without ICGA, fundus photography combined with OCT provides high sensitivity and high specificity to diagnose PCV; adding FFA does not improve accuracy.