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Prospective randomized contralateral eye evaluation of subjective quality of vision after wavefront-guided or wavefront- optimized photorefractive keratectomy.

PURPOSE To compare the effect of wavefront-guided (WFG) and wavefront-optimized (WFO) photorefractive keratectomy (PRK) on patient perceived quality of vision. METHODS Seventy-one patients (142 eyes) were enrolled in this prospective, randomized, fellow eye controlled study. One eye was randomized to undergo WFG PRK treatment by the AMO Visx CustomVue S4 IR excimer laser system (Abbott Medical Optics, Inc., Santa Clara, CA) and the fellow eye received WFO PRK treatment by the Alcon Allegretto Wave Eye-Q 400 Hz excimer laser system (Alcon Laboratories, Inc., Fort Worth, TX). Patients answered questionnaires on their visual symptoms and quality of vision preoperatively and at 1, 3, 6, and 12 months after surgery. RESULTS Patients in both groups reported better vision compared to baseline from 3 months onward (mean change in score of 1.56 to 2.51 in the WFO group and 1.54 to 2.28 in the WFG group, P ⩽ .003). Both groups experienced less nighttime glare from 6 months onward (P ⩽ .030). Halos, double vision, and visual clarity were initially worse (P ⩽ .025) but not significantly different after 1 month. Haze and fluctuating vision resolved after 3 months. Visual symptoms were similar between the two groups at all times (P ⩾ .059) except at 6 months, when patients felt their WFG eyes had more excellent vision (P = .029). A composite of all symptoms was also similar between the groups until 12 months when patients had fewer symptoms in their WFO eye (P = .044). CONCLUSIONS One year after surgery, patient self-reported visual symptoms were not significantly different in eyes receiving WFG or WFO PRK. However, the average of all symptoms was lower in eyes receiving wavefront-optimized treatment.

Wavefront-Guided Versus Wavefront-Optimized Laser in situ Keratomileusis for Patients With Myopia: A Prospective Randomized Contralateral Eye Study

PURPOSE To compare the clinical outcomes of wavefront-guided and wavefront-optimized laser in situ keratomileusis (LASIK). DESIGN Prospective, randomized, fellow-eye-controlled study. METHODS The setting was a single academic institution. The study population included 110 eyes of 55 patients with myopia with and without astigmatism. One eye of each patient was randomized to undergo wavefront-guided LASIK by the AMO Visx CustomVue S4 IR excimer laser system; the fellow eye received wavefront-optimized LASIK by the Alcon Allegretto Wave Eye-Q 400 Hz excimer laser system. Corneal flaps were constructed using the Intralase FS 60 Hz femtosecond laser. Patients were followed at postoperative months 1, 3, 6, and 12. The studys main outcome measures were uncorrected visual acuity, stability of refractive correction, contrast sensitivity, and wavefront aberrometry. RESULTS After 12 months, LASIK eyes had achieved visual acuity of 20/12.5 or better (30 eyes, 56%) in the wavefront-guided group compared to those receiving wavefront-optimized treatment (22 eyes, 41%) (P = 0.016). Average spherical equivalent refractions were -0.13 ± 0.46 diopters in wavefront-guided eyes whereas in wavefront-optimized eyes the refractions were -0.41 ± 0.38 diopters at 12 months. Wavefront-guided eyes also achieved better best-corrected visual acuity at both the 5% and 25% contrast levels (P = 0.022 and P = 0.004, respectively). There were no differences in levels of residual astigmatism (P = 0.798) or in higher order aberrations (P = 0.869). CONCLUSIONS Both wavefront-guided and wavefront-optimized treatments are able to correct myopia safely and effectively in eyes with and without astigmatism. However, wavefront-guided treatment platforms appear to offer significant advantages in terms of residual refractive error, uncorrected distance acuity and contrast sensitivity.

Contralateral Eye-to-Eye Comparison of Wavefront-Guided and Wavefront-Optimized Photorefractive Keratectomy: A Randomized Clinical Trial

IMPORTANCE Wavefront-guided (WFG) and wavefront-optimized (WFO) platforms for refractive surgery are designed for improved visual outcomes. It is unclear which treatment profile is superior for patients undergoing photorefractive keratectomy (PRK). OBJECTIVE To compare the safety, efficacy, predictability, stability, and higher-order aberrations in eyes undergoing WFG and WFO PRK. DESIGN, SETTING, AND PARTICIPANTS A prospective, randomized, fellow-eye-controlled clinical trial was conducted at the Byers Eye Institute at Stanford with enrollment between April 2009 and March 2011; 1 year of follow-up was included. Of 90 patients screened, 71 patients (142 eyes) with less than 12.00 diopters (D) of spherical myopia and less than 3.00 D of astigmatism were enrolled consecutively. INTERVENTIONS One eye was randomized to undergo WFG PRK treatment (Visx CustomVue Star S4 IR excimer laser system; Abbott Medical Optics), and the fellow eye received WFO PRK treatment (WaveLight Allegretto Wave Eye-Q 400 Hz excimer laser system; Alcon Surgical). MAIN OUTCOMES AND MEASURES Data on the manifest refraction, uncorrected visual acuity, best-corrected visual acuity, 5% and 25% contrast best-corrected visual acuity, and higher-order aberrations were collected preoperatively and at the 1-, 3-, 6-, and 12-month follow-up visits. RESULTS Eyes undergoing both treatments had improved best-corrected visual acuity (WFG: mean, 0.05 [95% CI, 0.03-0.07]; WFO: mean, 0.04 [95% CI, 0.02-0.06]) and less sphere (WFG: mean, -4.79 [95% CI, -5.31 to -4.26]; WFO: mean, -4.61 [95% CI, -5.18 to -4.03]), cylinder (WFG: mean, 0.66 [95% CI, 0.49-0.82]; WFO: mean, 0.52 [95% CI, 0.35-0.69]), and spherical equivalents (WFG: mean, -4.45 [95% CI, -4.99 to -3.91]; WFO: mean, -4.34 [95% CI, -4.92 to -3.76]) (P < .001) but higher levels of spherical aberration (WFG: mean, -0.11 [95% CI, -0.15 to -0.06]; WFO: mean, -0.11 [95% CI, -0.14 to -0.07]) (P < .001) and higher-order root-mean-square aberrations (WFO: mean, -0.07 [95% CI, -0.12 to -0.02]; WFO: mean, -0.12 [95% CI, -0.17 to -0.70]) (P = .005 in WFG eyes and P < .001 in WFO eyes) at 12 months compared with preoperative measurements. A total of 93.0% of the eyes in the WFG group and 94.4% in the WFO had an uncorrected visual acuity of 20/20 or better at 12 months, with 56.3% in the WFG group and 43.7% in the WFO group gaining 1 or more lines of best-corrected visual acuity. The stability of the refractive correction was excellent for both groups. CONCLUSIONS AND RELEVANCE A difference in uncorrected visual acuity or contrast acuity between eyes undergoing WFG or WFO treatment at 3 months and beyond could not be identified. This lack of difference suggests that both systems can be used to provide excellent improvement in vision for persons with myopia. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01135719.

SMARTPHONE-BASED DILATED FUNDUS PHOTOGRAPHY AND NEAR VISUAL ACUITY TESTING AS INEXPENSIVE SCREENING TOOLS TO DETECT REFERRAL WARRANTED DIABETIC EYE DISEASE.

Purpose: To compare clinical assessment of diabetic eye disease by standard dilated examination with data gathered using a smartphone-based store-and-forward teleophthalmology platform. Methods: 100 eyes of 50 adult patients with diabetes from a health care safety-net ophthalmology clinic. All patients underwent comprehensive ophthalmic examination. Concurrently, a smartphone was used to estimate near visual acuity and capture anterior and dilated posterior segment photographs, which underwent masked, standardized review. Quantitative comparison of clinic and smartphone-based data using descriptive, kappa, Bland-Altman, and receiver operating characteristic analyses was performed. Results: Smartphone visual acuity was successfully measured in all eyes. Anterior and posterior segment photography was of sufficient quality to grade in 96 and 98 eyes, respectively. There was good correlation between clinical Snellen and smartphone visual acuity measurements (rho = 0.91). Smartphone-acquired fundus photographs demonstrated 91% sensitivity and 99% specificity to detect moderate nonproliferative and worse diabetic retinopathy, with good agreement between clinic and photograph grades (kappa = 0.91 ± 0.1, P < 0.001; AUROC = 0.97, 95% confidence interval, 0.93–1). Conclusion: The authors report a smartphone-based telemedicine system that demonstrated sensitivity and specificity to detect referral-warranted diabetic eye disease as a proof-of-concept. Additional studies are warranted to evaluate this approach to expanding screening for diabetic retinopathy.

Aflibercept For The Treatment Of Retinal Pigment Epithelial Detachments

Purpose: To compare anatomical and visual acuity outcomes of eyes with persistent pigment epithelial detachments (PEDs) secondary to exudative age-related macular degeneration despite ranibizumab or bevacizumab treatment. Methods: After institutional review board approval, 40 eyes with PEDs switched from ranibizumab or bevacizumab to intravitreal aflibercept were compared for logMAR visual acuity, central subfield thickness on spectral domain optical coherence tomography, and PED height. Using paired t-tests, these parameters at baseline, after 3 consecutive injections, and 1 year after the switch were compared. Results: Baseline visions of 20/61 ± 3.99 lines declined after 3 injections with aflibercept by 0.39 ± 2.43 lines (P = 0.32) and continued to fall after 1 year by 1.27 ± 3.48 lines (P = 0.03). Central subfield thickness was reduced after 3 injections (9.1 ± 52.0 &mgr;m, P = 0.27) and after 1 year (24.4 ± 55.3 &mgr;m, P = 0.01). The height of PEDs decreased by 31.7 ± 71.53 &mgr;m (P = 0.008) after 3 injections and by 47.81 ± 77.94 &mgr;m (P < 0.001) after 1 year. Conclusion: Switching to aflibercept from ranibizumab or bevacizumab resulted in a reduction in the height of PED and central subfield thickness, but a trend toward worse visual acuity 1 year after the switch.

Fibrin glue for prevention of recurrent epithelial ingrowth under a LASIK flap with a central buttonhole defect

A 61-year-old woman presented with a paracentral buttonhole flap defect associated with a linear tear, extensive epithelial ingrowth, and macrostriae in the right eye. A laser in situ keratomileusis enhancement had been performed 3 weeks earlier. The epithelial ingrowth was removed after careful lifting of the flap, and tissue adhesive was used postoperatively as a barrier to further ingrowth. Six months postoperatively, the patients corrected distance visual acuity had improved to 20/20 and the slitlamp examination showed no evidence of recurrent epithelial ingrowth. This case presents a novel approach to the management of a buttonhole defect.

One-day application of topical moxifloxacin 0.5% to select for fluoroquinolone-resistant coagulase-negative Staphylococcus

PURPOSE: To compare selection for fluoroquinolone‐resistant bacteria between 1‐day and 3‐day application of topical moxifloxacin 0.5%. SETTING: Department of Ophthalmology, Stanford University, Stanford, California, USA. METHODS: After investigative review board approval, patients scheduled for ocular surgery were randomized to receive topical moxifloxacin 0.5% drops 4 times a day for 1 day or 3 days preoperatively. Conjunctival cultures were obtained at baseline and after antibiotic application. Bacteria were identified and tested for resistance to a battery of antibiotic agents using the Kirby‐Bauer disk‐diffusion method. The differences in resistance distributions for the most commonly isolated bacteria between baseline (T0) and after antibiotic administration (T1) were compared between the 2 treatment groups. RESULTS: Coagulase‐negative Staphylococcus (CNS) were the most common bacteria isolated at T0 and T1. At T0, the proportion of CNS isolated in the 1‐day group (n = 63) that was resistant to fluoroquinolones ranged from 4% to 22% depending on the antibiotic agent tested. After 1‐day treatment with moxifloxacin, the percentage of resistant bacteria increased significantly (range 13% to 67%) for all fluoroquinolones except gatifloxacin (P<.05). Resistance to gentamicin and tobramycin also increased significantly. However, patients treated for 3 days (n = 57) showed no differences in bacterial resistance rates to any antibiotic agent tested. CONCLUSION: Prophylactic topical moxifloxacin 0.5% treatment starting 1 day before ocular surgery resulted in a significant increase in fluoroquinolone‐resistant bacteria, while a 3‐day antibiotic regimen did not select for resistant organisms.

Experience With Aflibercept for the Treatment of Neovascular Age-Related Macular Degeneration

BACKGROUND AND OBJECTIVE Describe visual and anatomic outcomes of eyes with exudative age- related macular degeneration (AMD) after treatment with aflibercept. PATIENTS AND METHODS Eyes treated with intravitreal injections of aflibercept for exudative AMD were retrospectively reviewed to compare visual acuity and central subfield thickness (CST) on optical coherence tomography. RESULTS A total of 142 eyes receiving aflibercept were previously treated with bevacizumab or ranibizumab intravitreal injections. Baseline vision was 20/73 ± 5.18 lines when switched to aflibercept. It improved by 0.2 ± 1.91 lines (P =.14) after three injections but decreased by 0.45 ± 2.9 lines (P = .06) after 1 year of follow-up. The reduction in CST was 9.9 ± 46.5 µm (P = .06) after three injections and grew to 19.3 ± 50.6 µm (P = .002), a statistically significant amount, after 1 year. CONCLUSION Switching to aflibercept resulted in no clinically significant differences in visual acuity after 1 year. There was a significant reduction in CST, but this may not be clinically significant.

Kinetics of central macular thickness reduction in patients with macular edema after intravitreal drug therapy

Background The purpose of this study was to characterize central macular thickness and retinal volume following intravitreal injections using time domain and spectral domain optical coherence tomography (TD-OCT and SD-OCT, respectively). Methods Nine patients with macular edema secondary to diabetes or retinal vein occlusion treated with intravitreal triamcinolone 4.0 mg and/or bevacizumab 1.25 mg were enrolled. Central macular thickness and volume was measured by SD-OCT and TD-OCT scan at baseline, and 1, 3, 6, 24, 48 hours, and 1 week postinjection. Results Equations were derived to describe central macular thickness and volume reduction in the hours following intravitreal injection. Measurements of central macular thickness by SD-OCT were significantly reduced by 3 hours (P = 0.03) and retinal volume by 6 hours (P = 0.03). Central macular thickness measured 40.9 (28.6–53.2) μm thicker on the SD-OCT instrument while volume measured 3.47 (3.27–3.66) mm3 higher. Conclusion Significant central macular thickness and volume reductions occur in the first hours after injection with triamcinolone and/or bevacizumab.

Perivascular Exudates in Frosted Branch Angiitis

Three cases of young, minimally symptomatic patients found to have vitritis and extensive perivenous vitreous exudates resembling frosted branch angiitis are presented. Optical coherence tomography showed that these exudates appear to be extravascated from the vasculature. The material persisted over 1 year on immunosuppressive therapy, suggesting that its resolution should not be a treatment end point. These cases add to our understanding of the spectrum of clinical findings in frosted branch angiitis.