George Theodossiadis

Topical versus sub-Tenon’s anesthesia without sedation in cataract surgery

Purpose: To compare pain control using topical anesthesia with that using sub‐Tenons anesthesia for clear corneal phacoemulsification cataract surgery and foldable intraocular lens (IOL) implantation. Setting: Departments of Ophthalmology, General Hospital Asklepeion Voulas and General Hospital of Athens, University of Athens, Athens, Greece. Methods: One hundred consecutive patients scheduled for bilateral cataract surgery 1 to 2 months apart were prospectively randomized to receive topical anesthesia (100 eyes) or sub‐Tenons anesthesia (100 eyes). The randomization was stratified so that one half of first‐eye surgeries and one half of second‐eye surgeries were assigned to each anesthesia group, with each patient receiving each type of anesthesia once. All patients had clear corneal phacoemulsification with foldable IOL implantation. Patients were asked to rate their pain level on a 10‐point scale for 4 periods: during the administration of the anesthetic agent, during surgery, immediately after surgery, and 24 hours postoperatively. The surgeon recorded his subjective assessment of ease of surgery and surgical complications using a standardized template. Results: Eighty‐one percent of patients who received topical anesthesia and 8% of patients who received sub‐Tenons anesthesia reported no pain during delivery of the anesthetic agent. The mean pain score was 0.19 ± 0.39 (SD) in the topical group and 1.35 ± 0.63 in the sub‐Tenons group. The difference between groups was statistically significant (P < .001). Seventy‐two percent of patients in the topical anesthesia group and 86% in the sub‐Tenons anesthesia group reported no pain or slight discomfort during surgery (mean score 1.13 ± 1.57 and 0.57 ± 1.28, respectively) (P < .001). Ninety percent of topical anesthesia patients and 100% of sub‐Tenons anesthesia patients reported no pain or slight discomfort 30 minutes postoperatively (mean score 0.80 ± 0.93 and 0.12 ± 036, respectively) (P < .001). All patients in the topical anesthesia group and 77% in the sub‐Tenons group reported no pain 24 hours postoperatively (mean pain 0.00 ± 0.00 and 0.23 ± 0.40, respectively) (P < .001). Complications including prolonged akinesia of the globe, chemosis, and conjunctival hemorrhage occurred significantly more frequently in the sub‐Tenons than in the topical group (P < .001). Conclusions: Patients having cataract surgery under topical anesthesia had more intraoperative and postoperative discomfort than patients receiving sub‐Tenons anesthesia. However, patients having topical anesthesia reported less pain during its administration and had fewer complications. Both anesthesia methods provided high levels of pain control without additional sedation.

Risk factors in ocular hypertension.

The aim of the study was to determine whether certain factors are related to an increased risk of developing open-angle glaucoma. A total of 345 untreated glaucoma suspects with intraocular pressure (IOP) ≥ 21 mmHg, cup to disc ratio 0.4 or less and no visual field defects, were followed up for 6 to 8 years (mean 7.3). During the follow-up 71 patients developed established glaucoma and were compared to the remaining 274 patients. The following factors were analysed: age, family history of glaucoma, IOP, Humphrey 30-2 visual fields, optic disc appearance, myopia, exfoliation, arterial hypertension and diabetes. Analysis yielded statistically significant results regarding a number of these factors in the patients who subsequently developed open-angle glaucoma. A significant association with the subsequent development of field loss in ocular hypertension (OHT) included: heredity (p < 0.001), age ≥ 60 years (p = 0.013), axial myopia (0.001 < p < 0.01) and arterial hypertension (p = 0.05). About 20% of patients with ocular hypertension developed glaucoma over a period of seven years. Risk factors such as heredity, age, myopia and arterial hypertension, among others, must be considered in the follow-up of glaucoma suspects.

Assessing hydroxychloroquine toxicity by the multifocal ERG.

Twenty patients on Plaquenil treatment were evaluated for retinal toxicity using the (EOG) and the mfERG. Group 1 comprises 15 patients (30 eyes) with normal EOG. From these patients 11 (22 eyes) showed normal RRD of mfERG in area 1 and area 2. The rest four patients (8 eyes) the RRD were reduced. Six months after interruption of HC, the mfERG improved in three cases. Group 2 comprises 5 patients (10 eyes) with subnormal EOG. Four (8 eyes) of these showed a decrease of RRD of the mfERG in area 1 and 2. In the rest one (2 eyes) the RRD were normal. Six months after interruption of HC the mfERG and the EOG improved in 2 cases. These results postulate that the mfERG may be used as an alternative method, perhaps more sensitive, for the detection of the HC retinopathy and the follow up of the patients on hydroxychloroquine.

Evaluation of successful macular hole surgery by optical coherence tomography and multifocal electroretinography.

PURPOSE To evaluate successful macular hole surgery using optical coherence tomography (OCT) and multifocal electroretinography (MFERG). DESIGN Interventional case series. METHODS In a prospective study, 20 eyes of 20 patients with successful surgery for stage II, III, or IV idiopathic macular hole were evaluated by best-corrected visual acuity (BCVA), ocular examination, OCT, and MFERG preoperatively and 1, 3, 6, and 12 months postoperatively. For statistical analysis, the paired t test and nonparametric methods were used, as well as the Spearman analysis. RESULTS Postoperatively, all 20 eyes of 20 patients had anatomic closure of the macular hole confirmed by OCT. The center of the fovea, measured by OCT from the retinal pigment epithelium to the inner retinal surface, had a mean +/- SD thickness of 116.5 +/- 30.9 microm (range, 68-175 microm) 1 year postoperatively. Best-corrected visual acuity significantly improved (preoperative mean +/- standard deviation [SD] value, 0.131 +/- 0.081 and 1 year postoperative mean +/- SD value, 0.407 +/- 0.193). Multifocal electroretinography values area 1 (0-2.8 degrees) and area 2 (2.8-9 degrees from the center of the fovea) significantly improved (preoperative mean +/- SD values 3.10 +/- 1.334 nV/deg(2) and 3.573 +/- 1.545 nV/deg(2), respectively, and 1 year postoperative +/- SD mean values, 5.53 +/- 1.208 nV/deg(2) and 4.748 +/- 1.404 nV/deg(2), respectively). The thickness of the fovea, measured by OCT, significantly correlated with the BCVA 1 year postoperatively. One year postoperative MFERG values areas 1 and 2 were not correlated with 12-month BCVA and OCT findings. CONCLUSIONS Twelve months postoperatively BCVA and MFERG values significantly improved in this series of eyes with successful macular hole surgery. Optical coherence tomography findings were correlated to BCVA, but MFERG values were not correlated to BCVA and OCT findings, 1 year postoperatively.

A missense mutation in GUCY2Dacts as a genetic modifier in RPE65-related Leber Congenital Amaurosis

Leber congenital amaurosis (LCA) is a clinically and genetically heterogeneous severe retinal dystrophy presenting in infancy. To explain the phenotypical variability observed in two affected siblings of a consanguineous pedigree diagnosed with LCA and establish a genotype-phenotype correlation, we screened GUCY2D, RPE65, CRX, AIPL1, and RPGRIP1for mutations. The more severely affected sibling carried a heterozygous missense mutation in the GUCY2Dgene (Ile539Val), which did not segregate with the disease phenotype. Subsequently, a homozygous nonsense mutation (Glu102STOP) in the RPE65gene was identified in both affected siblings, thus identifying the causative gene. This data provides evidence for the presence of genetic modulation in LCA. It appears that the heterozygous GUCY2D mutation further disrupts the already compromised photoreceptor function resulting in more severe retinal dysfunction in the older sibling. We suggest that the unusual phenotypic variability in these two siblings with LCA is caused by the modifying effect of a heterozygous GUCY2D mutation observed against the disease background of a homozygous RPE65mutation.

Preoperative and postoperative assessment by multifocal electroretinography in the management of optic disc pits with serous macular detachment

PURPOSE To evaluate the macular function by means of multifocal electroretinogram (MF ERG) in eyes with congenital optic disc pit and serous macular detachment. The evaluation was performed before and after the successful surgical intervention. DESIGN Nonrandomized, comparative (self-controlled), interventional trial. PARTICIPANTS Ten patients (10 eyes) with optic disc pit with serous macular detachment were treated with the macular buckling procedure and followed up from March 1999 through May 2001. METHODS In all patients included in the study, MF ERG was recorded before and after treatment. For recording, the VERIS III system (Visual Evoked Response Imaging System; Tomey, Nagoya, Japan) was used. MAIN OUTCOME MEASURES The retinal response densities were studied before and after treatment in areas 1 and 2 and were compared with visual acuity. RESULTS The MF ERG before treatment showed decreased retinal response densities in all 10 cases. Twelve months after the surgical intervention, the electrical response densities in areas 1 (foveal area) and 2 (parafoveal area) improved. Further improvement was noted in 3 of the 10 patients who completed a follow-up of 18 months after treatment. In 8 of the 10 patients, postoperative visual acuity also increased. In the remaining two patients, visual acuity did not change after treatment, despite improvement of the retinal response densities. CONCLUSIONS In eyes with congenital optic disc pit with serous macular detachment, the decrease in retinal electrophysiologic response before treatment was not limited to the fovea, but also involved the perifoveal area. In all 10 eyes 12 months after treatment, the electrical activities in areas 1 and 2 improved. This improvement was not always followed by an increase in visual acuity. In 2 of the 10 patients, visual acuity remained unchanged. The values of retinal response densities before treatment cannot be used alone as a prognostic factor for the postoperative functional retinal results. It should also be stressed that the results of this study cannot be compared with the results of studies where spontaneous resolution of the macular detachment occurred.

Evolution of idiopathic epiretinal membrane studied by optical coherence tomography

Purpose To study the evolution of idiopathic epiretinal membrane (IERM) as examined by optical coherence tomography (OCT) in the 1-mm-diameter circle centered on the fovea. Methods In a case series study 71 subjects (71 eyes) with idiopathic epiretinal membrane and macular thickness greater than 220±10 μm were evaluated by OCT. The fellow healthy eye of 52 patients was used as the control group. The mean follow-up was 36 months. Measurements of macular thickness at baseline and at the final examination were performed. Best-corrected visual acuity was expressed as the number of letters read on the Early Treatment Diabetic Retinopathy Study chart. Results Within the inner macular central circle of 1 mm diameter the thickness of the fovea increased by an average of 12.29% (p<0.001) during follow-up in the study group while in the control group the foveal thickness decreased by −0.44% (p=0.43). The mean increase of the fovea thickness was accompanied by a modest decrease of best-corrected visual acuity from a mean 43.26 letters at baseline to a mean 39.20 letters at the last examination (p<0.001). Conclusions In the study group the macular thickness increased during a mean follow-up period of 36 months. The average increase between the baseline and the final examination at the inner central circle of 1 mm diameter was 12.29%. Decrease of the macular thickness was not observed in any of the studied cases. The mean decrease of visual acuity was 9.4%. OCT also depicted with accuracy the changing morphology of the affected macula during the study period.

Coloboma of the Optic Disk Associated With Retinal Vascular Abnormalities

PURPOSE We studied a case of congenital optic disk pit and coloboma with associated malformations of the retinal vessels. METHODS Slit-lamp biomicroscopy and fluorescein angiography were performed. RESULTS Multiple retinal venous anastomoses associated with a congenital coloboma and pit of the optic disk were observed. The retinal vascular anomalies extended from the optic disk to the temporal periphery. CONCLUSIONS We consider the coexistence of retinal venous anastomoses with optic disk coloboma and pit to be an extremely rare congenital retinal anomaly.

Arcuate Relaxing Incisions with a 5.00-mm Optical Zone for the Correction of High Postcataract Astigmatism

The purpose of this study was to investigate the efficacy and safety of arcuate cuts with a 5-mm optical zone to correct high postoperative astigmatism after extracapsular cataract extraction. We performed 5-mm optical zone arcuate cuts on 23 eyes of 23 patients with high postoperative astigmatism. Ophthalmic examination included uncorrected visual acuity (UCVA), best spectacle corrected visual acuity (BSCVA) and the amount of the refractive and keratometric cylinder before and 9 months after operation. Surgically induced refractive change was calculated in all cases. A significant reduction in astigmatism was achieved in all cases with minimal axis deviation. No case developed clinically significant irregular astigmatism. The mean magnitude of astigmatism of the surgically induced refractive change calculated from standard keratometry and refractive data was 3.73 ± 0.72 and 3.70 ± 0.77 dptr, respectively. The mean axis deviation calculated from the keratometric and refractive data was 1.18 ± 2.33 and 1.32 ± 3.62°, respectively. At the last examination, 78.2% of the eyes had UCVA of 20/40 or better. No eye lost more than two lines of vision, 6 eyes lost one line, 2 eyes gained one and 1 eye gained two lines of BSCVA. The above data show that the 5-mm optical zone arcuate astigmatic keratotomy is an effective and safe method of correcting high postoperative astigmatism.

New optical coherence tomography fundus findings in a case of beta-thalassemia

Patients with beta-thalassemia may present with an acquired diffuse elastic tissue defect due to degeneration of elastic tissue along with vaso-occlusive findings in the retinal microvasculature. Here we report the case of a patient with granular-like accumulation presenting as black sunburst lesions detected by optical coherence tomography (OCT). A 38-year-old man with beta-thalassemia intermedia associated with angioid streaks complained of deterioration of vision in both eyes. Funduscopic examination revealed small, round, hyperpigmented lesions bilaterally. During the early and late phases of fluorescein angiography, granular hyperfluoresence was present, associated with pigment decompensation and mottled-like hypofluorescence. The main OCT finding was the presence of granuloid-like accumulations at the retinal pigment epithelium level. Granule penetration was also noticed at the photoreceptor layer, while isolated granuloid-like accumulations were found in the inner layers of the macula and choroid. In this case, the new OCT finding was the granular-like hyperpigmented accumulations in the macula located at the level of the retinal pigment epithelium. To the best of our knowledge, our OCT findings show for the first time granuloid-like accumulations representing black sunburst lesions.