Leonard W. Yip

Ocular manifestations and complications of Stevens–Johnson syndrome and toxic epidermal necrolysis: an Asian series*

Background:  To describe the acute and late ocular manifestations and complications in toxic epidermal necrosis (TEN) and Stevens–Johnson syndrome (SJS), and identify predictors for development of late complications.

High-dose intravenous immunoglobulins in the treatment of toxic epidermal necrolysis: an Asian series.

Toxic epidermal necrolysis (TEN) is a severe, immune‐mediated, mucocutaneous reaction resulting in extensive keratinocyte apoptosis. High‐dose human intravenous immunoglobulins (IVIG) have been proposed as an effective treatment for TEN. Retrospective data from 8 patients with TEN and 4 patients with Stevens‐Johnson syndrome‐toxic epidermal necrolysis (SJS‐TEN) overlap treated with high‐dose IVIG were analysed. The total dose of IVIG administered was 2 g/kg body weight, with the exception of 2 patients who received a total dose of 1.5 g/kg body weight. Their mean age was 49.9 ± 18.8 years (range, 19 to 70 years). The mean time from the first sign of skin lesion or mucosal or epidermal detachment to commencement of IVIG was 8.7 ± 5.5 days (range, 3 to 22 days). Of the 11 patients who survived, the mean time to objective response was 3.6 ± 1.9 days (range, 2 to 8 days). The length of stay (LOS) in hospital was 20.4 ± 8.0 days (range, 10 to 37 days). The survival rate was 91.6%. One patient developed permanent mucocutaneous sequelae following TEN. There were no adverse reactions to IVIG. We conclude that high‐dose IVIG may be a safe and effective therapy for Asian patients with TEN.

Comparison of retinal nerve fiber layer measurement between 2 spectral domain OCT instruments.

PurposeTo determine the repeatability of retinal nerve fiber layer (RNFL) measurement from 2 spectral domain optical coherence tomography (OCT) instruments and assess the level of agreement. A secondary objective was to assess if pupillary dilatation affected the repeatability of RNFL measurement. DesignProspective, observational study. ParticipantsFifty normal participants were recruited after being screened for exclusion criteria, which included preexisting glaucoma and significant cataract. MethodsPeripapillary RNFL thickness was measured from either eye of the 50 participants using both the Cirrus and Spectralis OCTs. Three scans were performed consecutively for each instrument and the process was repeated after pupillary dilatation. Main Outcome MeasuresTest-retest variability, coefficient of variation, and intraclass correlation coefficient (ICC) for repeatability of RNFL measurement. ICC and Bland-Altman plots for agreement between both devices. ResultsTest-retest variability for the Cirrus and Spectralis OCTs were 4.89 &mgr;m and 4.95 &mgr;m, respectively. RNFL measurements were less repeatable in the 4 quadrants, ranging from 5.02 to 15.00 &mgr;m. The temporal quadrant was the most repeatable quadrant for the Cirrus OCT with a variability of 7.81 &mgr;m, whereas the nasal quadrant was the most repeatable for Spectralis OCT with 5.02 &mgr;m. Test-retest variability was poorer for the Cirrus OCT in the nasal, inferior, and superior quadrants. Pupillary dilatation increased repeatability of RNFL measurement for Cirrus OCT, particularly in the superior quadrant, whereas not affecting measurements from Spectralis OCT. ICC values for agreement between both instruments were good. For average RNFL as well as RNFL in the superior, inferior, and temporal quadrants, ICC ranged from 0.859 to 0.908. The nasal quadrant had a lower ICC of 0.663. Bland-Altman plots showed that the Spectralis OCT provided the thicker RNFL measurement in general, except in the nasal quadrant when RNFL was thin. ConclusionsThe repeatability of RNFL thickness measurement in normal participants was excellent for both the Cirrus and Spectralis OCTs. Agreement of RNFL measurement between both the devices was generally good, with the exception of the nasal quadrant in which a linear relationship exists. Pupillary dilatation improved the repeatability of RNFL measurement for Cirrus while having minimal influence on Spectralis OCT. More studies will be required to ascertain the relationships of RNFL measurement between the different spectral domain OCT instruments in normal and glaucomatous patients.

Comparison of the influence of cataract and pupil size on retinal nerve fibre layer thickness measurements with time-domain and spectral-domain optical coherence tomography.

Background:  To investigate and compare the effect of cataract and pupil size on retinal nerve fibre layer (RNFL) thickness measurements using spectral‐domain optical coherence tomography (Cirrus OCT) and time‐domain OCT (Stratus OCT).

Endoscopic cyclophotocoagulation for the treatment of glaucoma: an Asian experience.

Background:  To describe the efficacy and safety of endoscopic cyclophotocoagulation in Asian patients with glaucoma.

Comparative Efficacy and Tolerability of Topical Prostaglandin Analogues for Primary Open-Angle Glaucoma and Ocular Hypertension

Objective: To systematically review the efficacy and tolerability of 4 prostaglandin analogues (PGAs) as first-line monotherapies for intraocular pressure (IOP) lowering in adult patients with primary open-angle glaucoma or ocular hypertension. Data Sources: A literature search was performed in PubMed (1965-June 2013) and the Cochrane Library (1980-June 2013) using the search terms ocular hypertension, open-angle glaucoma, prostaglandin analogues, bimatoprost, latanoprost, tafluprost, and travoprost. Additional studies were searched from the reference lists of identified publications. Study Selection and Data Extraction: In all, 32 randomized controlled trials comparing between PGAs (bimatoprost 0.03%, latanoprost 0.005%, tafluprost 0.0015%, and travoprost 0.004%) or PGA with timolol were selected. Data Synthesis: A network meta-analysis was conducted. Using timolol as reference, the relative risks (RRs) of achieving treatment success, defined as the proportion of patients achieving at least 30% IOP reduction, with 95% CIs, were as follows: bimatoprost, 1.59 (1.28-1.98); latanoprost, 1.32 (1.00-1.74); travoprost, 1.33 (1.03-1.72); and tafluprost, 1.10 (0.85-1.42). The mean IOP reductions after 1 month were 1.98 (1.50-2.47), 1.01 (0.55-1.46), 1.08 (0.59-1.57), and 0.46 (−0.41 to 1.33) mm Hg, respectively, and the results were sustained at 3 months. Bimatoprost was associated with the highest risk of developing hyperemia, whereas latanoprost had the lowest risk, with RRs (95% CI) of 4.66 (3.49-6.23) and 2.30 (1.76-3.00), respectively. Conclusions: Bimatoprost achieved the highest efficacy in terms of IOP reduction, whereas latanoprost had the most favorable tolerability profile. This review serves to guide selection of the optimal PGA agent for individual patient care in clinical practice.

A comparison of the glaucoma probability score to earlier heidelberg retina tomograph data analysis tools in classifying normal and glaucoma patients.

PurposeTo compare the performance of the Glaucoma Probability Score (GPS), Mikelberg linear discriminant function (LDF), Burk LDF, and Moorfield regression analysis (MRA) in classifying optic disc images acquired from normals and glaucoma patients with the Heidelberg Retina Tomograph (HRT). Patients and MethodsThis is a retrospective comparative study of 110 eyes of 110 subjects clinically categorized as glaucoma or normal. Topographic images of the optic nerve head were obtained from HRT. Data analysis of the HRT images were carried out using GPS, Mikelberg LDF, Burk LDF, and MRA. Diagnostic performances and agreement in classification between the data analysis tools were calculated and compared for GPS, Mikelberg LDF, Burk LDF, and MRA. ResultsThe highest specificity but lowest sensitivity value was obtained using the Burk LDF. The highest sensitivity but lowest specificity was obtained using the GPS. The GPS and MRA were however similar in performance. Sensitivity and specificity values of the GPS and other LDFs were affected by disc size. ConclusionsThe GPS compared similarly with the MRA without the need of additional contour line placements. Disc size is still an important factor in classification by the GPS and the other LDFs.

A comparison of interocular differences in patients with pigment dispersion syndrome.

PurposePigment dispersion syndrome (PDS) and pigmentary glaucoma (PG) are characterized by loss of iris pigment because of reverse pupillary block. The loss of iris pigment is manifested as transillumination defects. Differences in ocular anatomy have been found between subjects with PDS and controls. Our study aims to see if differences in interocular anatomic features are also related to differences in the quantity of transillumination defects between eyes. Patients and MethodsThis is an observational case series of 30 eyes of 15 subjects with PDS/PG in at least 1 eye. Patients underwent refraction, exophthalmometry, corneal and anterior chamber analysis by Pentacam, biometry, A-scan, ultrasound biomicroscopy, and anterior segment digital photography. ResultsThe Pentacam mean central radii of the posterior corneal surface (cornea back Rm), vertical central radius of curvature of the posterior corneal surface (cornea back Rv), and keratometric power deviation (influence of the posterior surface of the cornea on refractive power) were statistically different between eyes with greater pigment loss and eyes with lesser pigment loss. Eyes with greater pigment loss had a larger back radius of corneal curvature and a correspondingly numerically smaller keratometric power deviation. Other measurements of ocular anatomy were not statistically significant. ConclusionsA flatter curvature of the posterior corneal surface of the eye is associated with increased pigment loss in PDS and PG. The authors postulate that this could result in a difference in the biomechanical properties of the cornea, increased deformation with blinking, and a pumping action resulting in the reverse pupil block of PDS.

Case series: Monocular visual loss associated with subarachnoid hemorrhage secondary to ruptured intracranial aneurysms

PurposeTo describe variations in the presentation of monocular visual loss associated with intracranial aneurysm rupture. The clinical course, possible etiologies and management of visual loss in three patients are described.Clinical featuresThe first patient developed Terson’s syndrome (vitreal hemorrhage associated with raised intracranial pressure secondary to subarachnoid hemorrhage). Following aneursymal clipping, her postoperative management was conservative and there was no improvement in visual acuity. The second patient underwent surgical clipping of internal carotid aneursysms and sustained visual loss subsequent to surgical dissection and temporary clipping around the optic nerve and anterior choroidal artery. The vessel subsequently thrombosed. Potential contributing factors to visual loss in this case included intraoperative hypotension and anemia. This patient received anti-platelet medications, and experienced subsequent improvement in visual acuity to 6/9. A third patient underwent a right orbito-frontal keyhole craniotomy with the cranial flap retracted across the orbit. Elevated intraocular pressure secondary to external orbital compression may have compromised retinal and choroidal perfusion. This patient also developed vasospasm of both anterior cerebral arteries which resolved partially with papaverine therapy. Hypertensionhypervolemia therapy was instituted, with subsequent partial recovery of visual acuity in her right eye.ConclusionPerioperative monocular visual loss associated with intracranial aneurysm repair is an infrequent occurrence, and clinical presentations may be quite variable. The primary pathophysiological mechanisms are intraocular hemorrhage and ischemia of ocular structures, including the optic nerve. Early detection, via regular fundoscopic examination and treatment aimed at decreasing intraocular pressure and augmenting ocular perfusion may improve outcomes.ObjectifLa perte visuelle monoculaire associée à la rupture anévrysmale intracrânienne peut se présenter de diverses façons. Le cas de trois patients est décrit selon le tableau clinique, les causes possibles et le traitement de la perte visuelle.Éléments cliniquesChez la première patiente un syndrome de Terson s’est développé (hémorragie vitréenne associée à une hypertension intracrânienne secondaire à une hémorragie sous-arachnoïdienne). Après la ligature anévrysmale, le traitement postopératoire conservateur administré n’a pas amélioré l’acuité visuelle. Le second patient a subi une ligature chirurgicale d’anévrysmes de la carotide interne et une perte visuelle permanente consécutive à la dissection chirurgicale et au clip temporaire autour du nerf optique et de l’artère choroïdienne antérieure. Une thrombose est survenue ensuite dans ce vaisseau. Dans ce cas, les facteurs potentiels de la perte visuelle comprennent l’hypotension et l’anémie peropératoires. Le patient a reçu des anti-plaquettaires qui ont amélioré l’acuité visuelle à 6/9. Un troisième patient a subi une craniotomie orbito-frontale à incision minimale où le lambeau crânien a été rabattu sur l’orbite. Ľélévation intra-oculaire de la pression, secondaire à la compression orbitale externe, peut avoir compromis la perfusion rétinienne et choroïdienne. Un vasospasme des deux artères cérébrales antérieures s’est aussi développé, résorbé partiellement avec la papavérine. Un traitement de l’hypertension-hypervolémie a été institué, suivi d’une récupération partielle de l’acuité visuelle de l’œil droit.ConclusionLa perte visuelle monoculaire périopératoire associée à la réparation d’un anévrysme intracrânien survient rarement et son tableau clinique peut varier. Les mécanismes physiopathologiques principaux en sont l’hémorragie intra-oculaire et l’ischémie des structures oculaires, dont le nerf optique. La détection précoce, par l’examen régulier du fond de l’œil, et le traitement visant à réduire la pression intra-oculaire et à augmenter la perfusion oculaire peuvent améliorer la situation.

Additive effect of unoprostone and latanoprost in patients with elevated intraocular pressure

Aims: To assess the additive effect of unoprostone and latanoprost in patients with primary open angle glaucoma (POAG) or ocular hypertension (OHT) Methods: 32 patients with POAG or OHT were randomised to receive either latanoprost once daily or unoprostone twice daily for 4 weeks. After 4 weeks, all patients received both latanoprost and unoprostone for another 4 weeks. The IOP was measured at 9 am and 5 pm on the baseline, day 28, and day 56 visits, and at 9 am on day 14 and day 42 visits. The medications were given to the patients in an open label fashion. The observer was masked to the treatment given. The mean of the measurements was calculated. Safety parameters were also recorded. The additive effect of the medications was assessed by the reduction in intraocular pressure (IOP) when both medications were used, compared with when one medication was used. Results: 28 patients completed both treatment periods and had IOP data available for evaluation. After 1 month of treatment, latanoprost significantly reduced IOP (mean by 6.1 (SEM 0.8) mm Hg (p<0.001) and unoprostone by 4.9 (1.0) mm Hg (p<0.001) from the baseline of 24.4 (0.6) mm Hg and 24.4 (1.1) mm Hg respectively (p = 0.18). When latanoprost once daily was given to patients treated with unoprostone, there was additional IOP lowering of 1.9 (0.6) mm Hg (p = 0.012). However, adding unoprostone to those being treated with latanoprost produced an IOP change of +0.4 (0.5) mm Hg (p = 0.42). Ocular symptoms and findings were mild and equally distributed between treatment groups, and after combined therapy. Hyperaemia and ocular irritation were the most frequently reported events. Over a third of patients experienced ocular irritation with the combination of medications. Conclusions: Latanoprost once daily causes additional IOP lowering in eyes which were being treated with unoprostone twice a day. However, there was no additional IOP lowering when unoprostone was added to eyes which were being treated with latanoprost. Both drugs were well tolerated together with few ocular adverse events.