Klio Chatzistefanou

Posterior Capsule Opacification after Cataract Surgery in Patients with Uveitis

PURPOSE To compare the incidence rate of posterior capsule opacification (PCO) after phacoemulsification and standard extracapsular cataract extraction (P/ECCE) in eyes with antecedent uveitis with the incidence rate in eyes without any history of intraocular inflammation. DESIGN Review of records of 108 eyes of 78 patients with uveitis and 122 eyes of 106 patients with no uveitis who underwent P/ECCE. Rates of PCO were compared by the log-rank test of differences in the Kaplan-Meier survival curves. Proportional hazards regression models provided estimates of the relative risks of PCO among uveitic compared to nonuveitic eyes. MAIN OUTCOME MEASURES Performance of neodymium: YAG laser posterior capsulotomy was used as a proxy measure for the main outcome of visually significant PCO. RESULTS Study patients ranged in age from 6 to 81 years (median, 44.5 years) among those with uveitis and 27 to 96 years (median, 68.5 years) among those without uveitis (P = 0.0001). Crude incidence rates for visually significant PCO were 54% over a mean follow-up of 4.3 years in uveitic cases and 40% over a mean follow-up of 3.9 years among nonuveitic cases (P = 0.02). Estimates of PCO incidence (95% confidence interval) in uveitic eyes derived from the Kaplan-Meier models were 38.5% (range, 28.9%-48.2%) at 1 year and 56% (range, 45.8%-66.3%) at 3 years, and estimates among nonuveitic eyes were 11.5% (range, 6.2%-16.8%) at 1 year and 38.4% (range, 29%-47.8%) at 3 years. These rates of PCO among patients with uveitis and those patients without uveitis differed significantly by the log-rank test (P = 0.004). However, after adjusting for the younger age of patients with uveitis, the rates of PCO were no longer statistically different. CONCLUSIONS The apparent higher rate of PCO in patients with uveitis is primarily due to their younger age at the time of surgery. A moderately increased independent risk of PCO from uveitis cannot, however, be ruled out by this study.

The Ice Pack Test in the Differential Diagnosis of Myasthenic Diplopia

PURPOSE To investigate the diagnostic value and to establish threshold criteria for the ice pack test as an office preliminary test in the differential diagnosis of myasthenic diplopia in comparison with blepharoptosis. DESIGN Prospective, comparative cohort study. PARTICIPANTS Eighty-nine patients with a recent onset of diplopia, blepharoptosis, or both were evaluated with orbital cooling in a prospective manner. Forty-eight patients presented with diplopia, 25 patients with both blepharoptosis and ophthalmoplegia and 16 patients with blepharoptosis. TESTING All patients had the ice pack applied for 5 minutes on both eyelids at the initial orthoptic evaluation. Increasing the duration of cooling to 10 minutes was investigated in 36 diplopic patients. A complete diagnostic work-up was ordered and patients were followed up for a minimum of 6 months before diagnosis of myasthenia gravis was ascertained. MAIN OUTCOME MEASURES Difference in cover test measurements in primary position or marginal reflex distance before and after the application of the ice pack, specific cause for diplopia and blepharoptosis. RESULTS Fifteen patients were diagnosed as myasthenic. The optimal cutoff point for a positive response to the ice pack test proved to be a reduction in ocular deviation in primary position by 50% or by 10 prism diopters (PD) or more for presenting deviations larger than 20 PD. By this criterion, sensitivity for the detection of myasthenic diplopia was 76.9% (95% confidence interval [CI], 49.06%-92.50%) for the 5-minute application, compared with 92.3% (95% CI, 63.5%-98.9%) sensitivity demonstrated for blepharoptosis. Increasing the time of application to 10 minutes did not improve the diagnostic value of the test. Specificity was high (98.3%; 95% CI, 90.3%-99.9%) and was demonstrated even in patients with coexisting myasthenic and dysthyroid ophthalmopathy. Patients with oculomotor nerve paresis and Horner syndrome invariably were nonresponsive to the test. CONCLUSIONS The ice pack test demonstrated high specificity and an acceptable sensitivity in the differential diagnosis of myasthenic diplopia. Data from this series suggest that a partial rather than a complete response to the ice pack test may be expected for myasthenic diplopia. Standardization of the method of application of the ice pack is critical for the interpretation of its effect.

Descemet membrane endothelial keratoplasty: learning curve of a single surgeon.

Purpose: To evaluate the learning curve of standardized “no-touch” Descemet membrane endothelial keratoplasty (DMEK) of a single surgeon in a clinic without an in-house eye bank facility. Methods: For 25 eyes of 22 patients, Descemet graft preparation and DMEK surgery were performed according to the protocols of the Netherlands Institute for Innovative Ocular Surgery with minor modifications. Best spectacle–corrected visual acuity, subjective refraction, Scheimpflug tomography, and endothelial cell density of the donor tissue were documented before and at 1, 3, and 6 months after the surgery; intraoperative and postoperative complications were recorded. Results: No donor tissue was lost owing to preparation failure of the Descemet graft allowing all surgeries to be completed as planned. At 6 months after the surgery, 83% of eyes reached ≥20/40 (≥0.5), 48% ≥20/28 (≥0.8), and 30% (7/23) ≥20/20 (≥1.0) (n = 23). The mean change in both spherical equivalent and refractive cylinder in the same interval was minimal (0.03 diopter). Mean donor endothelial cell density decreased from 2444 cells per square millimeter (±198 cells/mm2) before the surgery to 1331 cells per square millimeter (±491 cells/mm2) at 6 months after the surgery. Partial graft detachment requiring rebubbling occurred in 9 cases (36%). One eye developed primary graft failure. Conclusions: This case series shows that DMEK by a beginning surgeon can achieve good results without preparing the graft in an eye bank. Use of backup tissue can be avoided by strictly adhering to the Netherlands Institute for Innovative Ocular Surgery techniques and by harvesting the graft the day before surgery to avoid last-minute cancellation.

Optical coherence tomography findings in patients with retinitis pigmentosa and low visual acuity.

BACKGROUND AND OBJECTIVE To study the morphological features of the macula of patients with retinitis pigmentosa and visual acuities of 20/200 or less as examined by optical coherence tomography. PATIENTS AND METHODS In an observational case series study, 42 eyes (21 patients) with retinitis pigmentosa and visual acuities of 20/200 or less were evaluated by optical coherence tomography. RESULTS Thirty-four (81%) eyes had atrophic retina (group 1) and 8 (19%) eyes had cystoid macular edema (group 2). The mean visual acuity was 20/1000 in group 1 and 20/300 in group 2. Epiretinal membrane was identified in 27 (64.3%) eyes. CONCLUSION Optical coherence tomography is a more sensitive method in detecting macular pathology and can help in selecting cases where treatment may be applied.

Phaco-Trabeculectomy in Controlled, Advanced, Open-Angle Glaucoma and Cataract: Parallel, Randomized Clinical Study of Efficacy and Safety

Abstract Background: To examine the efficacy and safety of combined phaco-trabeculectomy in patients with cataract and controlled, open-angle advanced glaucoma and to identify preoperative predictive factors of postoperative glaucoma course. Setting: Departments of Ophthalmology, University of Athens, and General Hospital of Lamia, Greece. Methods: Prospective, interventional, parallel, cluster (units = examinations), randomized clinical study. 60 patients with visually significant cataract, visual field Mean Deviation (MD) worse than −15.0 dB, and preoperative intraocular pressure (IOP), controlled (consistently below 22 mmHg) on topical medications and with no previous ocular surgery, were randomly allocated (1:1) to phacoemulsification alone or phaco-trabeculectomy group. Intention-to-treat analysis was performed to compare the postoperative outcome and adjusted multivariate longitudinal linear regression analysis was performed to identify predictive factors of the main outcome measures, with postoperative visual field MD change up to two years postoperatively. Participant recruiters and data collectors were masked to group assignment. Results: 31 and 29 patients were randomized to phacoemulsification alone and phaco-trabeculectomy groups, respectively. Patients assigned to the phaco-trabeculectomy group experienced a 1.7 mmHg [95% CI:−3.1 to −0.23] reduction in IOP, a 1.4 dB [95% CI: −0.17 to 2.96] improvement in visual fields MD, a 0.6 [95% CI: −1.2 to −0.05] reduction in the number of glaucoma medications needed postoperatively, while the visual acuity improvement was similar between the two groups. Best predictors for visual field MD: degree of nuclear sclerosis, relative afferent pupilary defect (RAPD), preoperative MD deviation from −19.0dB and preoperative cup-disc ratio deviation from 0.9. The phacoemulsification group experienced more IOP spikes (>25 mmHg) with Odds Ratio (OR) of 0.34 [95% CI: 0.11–1.02]. No patient lost light perception. Conclusion: Phaco-trabeculectomy in advanced, controlled, open-angle glaucoma patients with cataract results in better postoperative visual field MD with no major adverse events.

Prevalence of diplopia related to cataract surgery among cases of diplopia

Purpose To evaluate the prevalence of diplopia in Greece after cataract surgery among diplopia cases. Methods The authors retrospectively reviewed the medical records of 571 patients with diplopia over an 8-year period in order to evaluate the prevalence of diplopia related to cataract surgery. The surgical and anesthetic records were also reviewed. All patients had full orthoptic assessment including prisms with cover test in all gaze positions. The chi-square and cross-tabulation statistical tests were used for statistical analysis. Results Thirty-nine cases (6.8%) were having persistent diplopia related to cataract surgery. Type of anesthesia was peribulbar. Hyaluronidase was not used. Thirteen patients were men and 26 were women. Left eyes were involved in 22 cases (56.4%), right in 17 cases (43.6%). Mean age was 72.5 years. Patients were divided into four groups. Group 1 consisted of 29 patients related to surgical trauma due to anesthesia. Group 2 consisted of 7 patients related to pre-existing disorders. Group 3 consisted of 2 patients related to aniseikonia or anisometropia. Group 4 with 1 patient related to macular pathology. Vertical diplopia was mostly noted (28 cases). Twenty-nine patients were corrected with prisms, 9 needed strabismus surgery, and 1 needed both surgery and prisms. Conclusions Cataract surgery is not a common cause of persistent diplopia. However, this report highlights that prevalence of diplopia related to cataract is high among cases of diplopia in general, with diplopia being mostly vertical (p=0.001), affecting females (p=0.006), and being more common in left eyes, although results did not reach statistical significance (p=0.133).

Infectious Uveitis in Children

Dear Editor: Uveitis affecting children presents special challenges to the clinician. Most published series on pediatric uveitis focused on noninfectious uveitis entities including juvenile idiopathic arthritis associated uveitis, a common cause of ocular morbidity in the Western world. Uveitis caused by infectious agents has drawn limited attention in the literature so far. The type and relative frequency of infectious agents is strongly influenced by the patient demographics including age of affliction and may evolve in time with the recognition of new entities and the eradication of certain diseases. We sought to outline epidemiologic characteristics, specific causes, and visual outcome of children diagnosed with infectious uveitis through a retrospective study of the charts of patients younger than 16 years of age presenting from 1995 to 2007 at the Ocular Immunology and Inflammation Service, Athens, Greece. Institutional Review Board approval was obtained from the Athens General Hospital Scientific Committee for reviewing the charts. Among 237 pediatric uveitis cases, 55 patients had an identifiable infectious cause for uveitis. Infectious uveitis affected children and adults at a similar rate, 23.2% and 24.9% respectively, in our cohort. Mean age at onset of uveitis was 11.8 years (range, 2–15.9 years) and mean follow-up time was 19 months (range, 2–107 months). Only cases of confirmed infectious etiology based on extensive diagnostic work-up and/or confirmed by response to specific therapeutic regimen were included in this series. Confirmation by polymerase chain reaction was available for 20 patients (toxoplasmosis, 8 patients; herpes simplex virus [HSV], 9 patients; cytomegalovirus [CMV], 3 patients). An associated systemic infection (infectious mononucleosis, measles, and chickenpox) was confirmed in 4 patients, systemic immunosuppression in all 4 cases with CMV retinitis and congenital heart disease in the single patient with Staphylococcal endogenous endophthalmitis. Most common symptoms at presentation, specific diagnostic entities, and their distribution according to location of uveitis are shown in Tables 1, 2, and 3 respectively (available at http://www.aaojournal.org). Both eyes were involved in 18 patients (32.6%). Toxoplasma gondii was the most prevalent offending agent, followed by HSV, Bartonella henselae, CMV, and EpsteinBarr virus (EBV). When we compared the relative incidence of infectious agents affecting children as opposed to adults (Table 2, available online at http://www.aaojournal.org), we found that cat-scratch disease neuroretinitis was overrepresented among kids most likely due to careless exposure of children to pets. Among 5 patients with EBV associated uveitis, 2 were children. Toxoplasmosis expectedly was encountered more frequently among children (11.8%) than adults (6.5%). Varicella zoster virus (VZV) uveitic infections have been reported to predominate in the elderly4 and HSV-2 virus affecting more commonly patients younger than 25 years of

Effect of Macular Ischemia on Intravitreal Ranibizumab Treatment for Diabetic Macular Edema

Purpose: To evaluate the impact of macular ischemia on the functional and anatomical outcome after intravitreal injections of ranibizumab for the treatment of diabetic macular edema (DME). Procedures: Participants were 49 patients with diabetes mellitus, divided into two groups based on the presence of ischemia on fluorescein angiography: (i) nonischemic group (n = 32) and (ii) ischemic group (n = 17). All patients were treated with intravitreal ranibizumab and were followed up for 6 months. The main outcome measures were changes in visual acuity (VA) and central foveal thickness (CFT). Results: There was a statistically significant improvement in VA and CFT between baseline and the end of the follow-up in the nonischemic group, while in the ischemic group there was no significant difference in VA but CFT differed significantly at the 6-month follow-up. Conclusions: Macular ischemia may have a negative impact on functional outcomes 6 months after intravitreal ranibizumab treatment in patients with DME but has no effect on anatomical outcomes.

Treatment of inferior oblique muscle overaction with myectomy or with anterior transposition

This paper presents a comparative study of the effectiveness of myectomy and anterior transposition in the treatment of inferior oblique muscle overaction. We operated 160 patients with overaction of the inferior oblique muscle. Eighty patients (148 eyes) were operated by myectomy at the insertion and 80 patients (151 eyes) by anterior transposition of the insertion of the inferior oblique near the temporal side of the insertion of the inferior rectus muscle. Comparison of the two methods, using the chi-squared test, showed that: 1) both surgical procedures were equally effective (χ2=0.26) for correcting overaction of the inferior oblique muscle and V-phenomenon; 2) weakening of the inferior oblique muscle of both eyes was almost always required (in 115 out of 116 cases) in cases with V-phenomenon and often (24 out of 44 cases) in cases of congenital paresis of the superior oblique muscle. We conclude that both procedures are equally effective and equally easy to perform.

Electrophysiological assessment for early detection of retinal dysfunction in β-thalassemia major patients

PurposeThe purpose of this study was to assess the role of various diagnostic tests in early detection of retinal changes in β-thalassemia major patients.MethodsThirty-eight visually asymptomatic β-thalassemia major patients receiving regular blood transfusions and iron-chelation therapy with deferoxamine (group A, n = 13), deferasirox (group B, n = 11) or deferoxamine with deferiprone (group C, n = 14) and fourteen age- and sex- matched healthy individuals were included in the study. All participants underwent ophthalmoscopy, full-field electroretinography (ERG), visual evoked potentials (VEP), multifocal electroretinography (mfERG), fundus autofluorescence (FAF) imaging and optical coherence tomography (OCT) scans.ResultsRetinal pigment epithelium changes were present in two cases. Scotopic ERG demonstrated decreased a-wave amplitude in groups A, B and C (p = 0.03, p = 0.002 and p = 0.002, respectively) and decreased b-wave amplitude in groups B and C (p = 0.002 and p = 0.01, respectively) compared to controls. Photopic ERG showed delayed b-wave latency in groups A and C (p = 0.03 and p = 0.03, respectively) ERG maximal combined response and VEP response did not differ between groups. MfERG showed reduced retinal response density in ring 1 in groups A, B, C (p < 0.001, p < 0.001, p = 0.001, respectively) and ring 2 in group B (p = 0.02) and delayed latency in ring 5 in groups A and B (p = 0.04 and p = 0.04, respectively). Abnormal FAF images appeared in three cases and OCT abnormalities in one case, whereas no changes were observed in controls (p = 0.55 and p = 1.00, respectively).ConclusionsFull-field ERG and mfERG are more sensitive tools for detecting early retinal changes in β-thalassemia patients compared with ophthalmoscopy, VEP, FAF imaging and OCT scans.