Michael I. Seider

Cost of Selective Laser Trabeculoplasty vs Topical Medications for Glaucoma

46(2):91-110. 2. Heiden D, Ford N, Wilson D, et al. Cytomegalovirus retinitis: the neglected disease of the AIDS pandemic. PLoS Med. 2007;4(12):e334. 3. Ausayakhun S, Watananikorn S, Ittipunkul N, Chaidaroon W, Patikulsila P, Patikulsila D. Epidemiology of the ocular complications of HIV infection in Chiang Mai. J Med Assoc Thai. 2003;86(5):399-406. 4. Jabs DA, Ahuja A, Van Natta M, Lyon A, Srivastava S, Gangaputra S; Studies of the Ocular Complications of AIDS Research Group. Course of cytomegalovirus retinitis in the era of highly active antiretroviral therapy: five-year outcomes. Ophthalmology. 2010;117(11):2152-2161, e1-e2. 5. Ausayakhun S, Keenan JD, Ausayakhun S, et al. Clinical features of newly diagnosed cytomegalovirus retinitis in northern Thailand [published online January 19, 2012]. Am J Ophthalmol. doi:10.1016/j.ajo.2011.10.012.

Resident-performed Ex-PRESS shunt implantation versus trabeculectomy.

PurposeTo compare outcomes between resident-performed trabeculectomy and Ex-PRESS shunt implantation. MethodsA consecutive cohort of 36 Ex-PRESS shunt implantations and 57 trabeculectomies (1 eye/patient) performed by resident surgeons in their third year of ophthalmic training at the University of California, San Francisco and at the San Francisco Veterans Administration Hospital, under the supervision of a single glaucoma fellowship-trained surgeon were included in this study. Eyes with < 6 months of follow-up or previous glaucoma surgery were excluded. Preoperative and postoperative intraocular pressure (IOP), preoperative and postoperative number of ocular antihypertensive medications and complication rates were compared between the 2 procedures retrospectively. ResultsNo difference was found in postoperative IOP (all, P≥0.099) or proportional decrease in IOP (all, P≥0.092) between the trabeculectomy and Ex-PRESS shunt groups at all follow-up points. On average, the Ex-PRESS shunt group required significantly less ocular antihypertensive medication to control IOP at 3 months postoperative (P=0.01), but no difference was found at 6 months or 1 year (all, P≥0.28). A larger proportion of Ex-PRESS shunt patients had good IOP control without medication at 3 (P=0.057) and 6 months (P=0.076) postoperatively. No difference was found in the rates of sight-threatening complications between groups (all, P≥0.22). ConclusionsIn the hands of ophthalmology residents in their third year of training, the trabeculectomy and Ex-PRESS shunt implantation procedures perform comparably in terms of postoperative IOP control, reduction in patient dependence on ocular antihypertensive medications, and risk of complication in our population.

Optic disk size variability between African, Asian, white, Hispanic, and Filipino Americans using Heidelberg retinal tomography.

PurposeTo compare the optic disk size of African, Asian, white, Hispanic, and Filipino-American patients in a multiethnic glaucoma practice. Patients and MethodsFive hundred seventy-six eyes of 319 patients who had consecutively received Heidelberg retinal tomography 2 (HRT) from February 2006 to October 2007 in a glaucoma clinic that met inclusion criteria were included. The 5 ethnic groups represented were white (n=215, 37.3%), Asian (non-Filipino) (n=178, 30.8%), African (n=67, 11.6%), Hispanic (n=66, 11.4%), and Filipino-Americans (n=50, 8.7%). The relationship of optic disk size (global disk area) with race, age, sex, diagnosis, central corneal thickness (CCT), spherical equivalent refraction (SE), and cylindrical refraction was evaluated using multivariate regression analysis adjusting for confounders. ResultsMean optic disk size of white-Americans (2.15 mm2) was significantly smaller than that of African (2.55 mm2), Asian (2.38 mm2), Filipino (2.48 mm2), and Hispanic-Americans (2.57 mm2) (all, P≤0.0007). Global disk area was not statistically different between all other races (all, P≥0.054). Global disk area increased with SE (P=0.013), but was not found to vary with age, sex, diagnosis, CCT, or cylindrical refraction (all, P≥0.08). ConclusionsIn our glaucoma clinic-based population, white-Americans had smaller optic disks than all other races, and there were no optic disk size differences among the other races studied. Optic disk size had no significant relationship to age, sex, CCT, cylindrical refraction or diagnosis, and a small direct relationship to SE. Confirmation of these results in a population-based study is needed.

Comparison of different modes in optical coherence tomography and ultrasound biomicroscopy in anterior chamber angle assessment.

PurposeTo compare anterior chamber angle width measurements by low and high-resolution anterior segment optical coherence tomography (AS-OCT) and ultrasound biomicroscopy (UBM). Patients and MethodsThirty-six eyes of 32 patients with gonioscopically narrow angles from a university-based glaucoma clinic were recruited in the study. All subjects received AS-OCT {in “Anterior Segment Single” mode [low-resolution optical coherence tomography (LOCT)] and “High-resolution Cornea” mode [high-resolution optical coherence tomography (HOCT)]} and UBM examination in 1 or both eyes. Angle opening distance (AOD) and angle recess area of temporal (t) and nasal (n) quadrants were assessed using the customized software on each type of image. Angle measurements from UBM, LOCT, and HOCT images were compared; intraobserver and interobserver measurement reproducibility for each type of image was also evaluated. ResultsThirty-three eyes of 29 patients were available for analysis. No significant differences were found between LOCT and UBM in the measurement of t-AOD (P=0.350), n-AOD (P=0.106), and n-angle recess area (P=0.360). HOCT measurements were significantly larger than both LOCT and UBM for all parameters (all, P<0.05). HOCT images had better interobserver and intraobserver measurement reproducibility than UBM images. ConclusionsLOCT is similar to UBM for most of the studied angle measurements. HOCT tends to give larger measurements than both LOCT and UBM. AS-OCT measurements were more reproducible than those from UBM.

Adverse Medical Outcomes of Early Newborn Screening Programs for Phenylketonuria

OBJECTIVE. Despite the success of current newborn screening programs, some critics have argued that in the 1960s hundreds of children with false-positive results for phenylketonuria suffered death or disability from treatment with restrictive diets. Medically adverse outcomes after false-positive results may be a reason to be cautious when expanding current newborn screening programs. We sought to determine if newborn screening programs for phenylketonuria before 1980 led to adverse medical outcomes in children with false-positive results. PATIENTS AND METHODS. We examined the history of newborn screening programs for phenylketonuria in the United States. We reviewed the historical scholarship, conducted a systematic search for medical adverse outcomes, and interviewed key participants in the history of newborn screening programs. RESULTS. We found no population-based studies of early screening programs for phenylketonuria. One author reported 2 infants treated with restrictive diets after false-positive results for phenylketonuria who were developmentally delayed, and there is unpublished evidence of 4 additional cases of inappropriate treatment, although adverse outcomes were not documented. There were also 4 published reports of adverse medical outcomes after treating children with phenylketonuria variants, as screening for phenylketonuria revealed infants with intermediate or transiently high levels of phenylalanine. CONCLUSIONS. We found little evidence of death or disability that resulted from the inappropriate treatment of well children who were falsely identified by early newborn screening programs. Because the first decade of newborn screening typically reveals diagnostic and therapeutic complexity, systematic follow-up of screened populations and rapid dissemination of results may reduce morbidity/mortality rates.

High Prevalence of Narrow Angles Among Chinese-american Glaucoma and Glaucoma Suspect Patients

PurposeTo evaluate the prevalence of gonioscopically narrow angles in a Chinese-American population with glaucoma or glaucoma suspicion. Patients and MethodsCharts from all Chinese-American patients seen in a comprehensive ophthalmology clinic in the Chinatown district of San Francisco in 2002 were reviewed. One eye from each patient with glaucoma or glaucoma suspicion that met inclusion criteria was included (n=108). Data were collected for sex, age, race (self-declared), refraction (spherical equivalent), intraocular pressure, gonioscopy, and vertical cup-to-disk ratio. ResultsSixty percent (n=65) of Chinese-American eyes with glaucoma or glaucoma suspicion had gonioscopically narrow angles (Shaffer grade ≤2 in 3 or more quadrants). Those with narrow angles were significantly older (P=0.004) than their open angle counterparts, but the 2 groups did not differ in terms of sex, refraction, intraocular pressure, or cup-to-disk ratio (all, P≥0.071). In a multivariate model including age, sex, and refraction as predictors of angle grade (open or narrow), only age was a significant predictor of angle grade (P=0.004). ConclusionsA large proportion of Chinese-Americans in our study population with glaucoma or glaucoma suspicion had gonioscopically narrow angles. In multivariate analysis, patients with narrow angles were older than those with open angles but did not differ from them in terms of sex or refraction. Continued evaluation of angle closure glaucoma risk among Chinese-Americans is needed.

Optical Coherence Tomography for Retinal Surgery: Perioperative Analysis to Real-Time Four-Dimensional Image-Guided Surgery

Magnification of the surgical field using the operating microscope facilitated profound innovations in retinal surgery in the 1970s, such as pars plana vitrectomy. Although surgical instrumentation and illumination techniques are continually developing, the operating microscope for vitreoretinal procedures has remained essentially unchanged and currently limits the surgeons depth perception and assessment of subtle microanatomy. Optical coherence tomography (OCT) has revolutionized clinical management of retinal pathology, and its introduction into the operating suite may have a similar impact on surgical visualization and treatment. In this article, we review the evolution of OCT for retinal surgery, from perioperative analysis to live volumetric (four-dimensional, 4D) image-guided surgery. We begin by briefly addressing the benefits and limitations of the operating microscope, the progression of OCT technology, and OCT applications in clinical/perioperative retinal imaging. Next, we review intraoperative OCT (iOCT) applications using handheld probes during surgical pauses, two-dimensional (2D) microscope-integrated OCT (MIOCT) of live surgery, and volumetric MIOCT of live surgery. The iOCT discussion focuses on technological advancements, applications during human retinal surgery, translational difficulties and limitations, and future directions.

The Association Between Compliance With Recommended Follow-up and Glaucomatous Disease Severity in a County Hospital Population

PURPOSE To assess the association between insufficient follow-up and clinical parameters such as disease severity and medication use among glaucoma patients at a metropolitan county hospital. DESIGN Cross-sectional study. METHODS Two-hundred and six patients with established glaucoma were recruited from San Francisco General Hospital. Subjects were classified based on compliance with recommended follow-up examination intervals over the year preceding commencement of the study, as determined by patient medical records. Glaucoma severity was determined based on the American Academy of Ophthalmology Preferred Practice Patterns guidelines. Multivariate logistic regression analysis was used to assess the relationship between adherence with follow-up visits and disease severity. RESULTS After adjustment for the impact of potential confounding variables, subjects with severe glaucomatous disease were found to have been less adherent to their recommended follow-up than those patients with mild or moderate glaucomatous disease (adjusted OR 1.89, 95% CI 1.21-2.94; P = .01). Subjects who were on glaucoma medications were found to be less adherent to follow-up recommendations (adjusted OR 3.29, 95% CI 1.41-7.65, P = .01). CONCLUSION Subjects with poor follow-up adherence were significantly more likely to have severe glaucomatous disease, suggesting that poor follow-up may contribute to disease worsening or, alternatively, those with more severe disease are less inclined to follow up at appropriate intervals.

The Effect of Procedure Room Temperature and Humidity on LASIK Outcomes

OBJECTIVE To determine whether procedure room temperature or humidity during LASIK affect refractive outcomes in a large patient sample. DESIGN Retrospective cohort study. PARTICIPANTS A total of 202 394 eyes of 105 712 patients aged 18 to 75 years who underwent LASIK at an Optical Express, Inc., location in their United Kingdom and Ireland centers from January 1, 2008, to June 30, 2011, who met inclusion criteria. METHODS Patient age, gender, flap creation technique, pre- and 1-month post-LASIK manifest refraction, and ambient temperature and humidity during LASIK were recorded. Effect size determination and univariate and multivariate analyses were performed to characterize the relationships between LASIK procedure room temperature and humidity and postoperative refractive outcome. MAIN OUTCOME MEASURES One month post-LASIK manifest refraction. RESULTS No clinically significant effect of procedure room temperature or humidity was found on LASIK refractive outcomes. When considering all eyes in our population, an increase of 1°C during LASIK was associated with a 0.003 diopter (D) more hyperopic refraction 1 month postoperatively, and an increase in 1% humidity was associated with a 0.0004 more myopic refraction. These effect sizes were the same or similar when considering only myopic eyes, only hyperopic eyes, and subgroups of eyes stratified by age and preoperative refractive error. CONCLUSIONS Neither procedure room temperature nor humidity during LASIK were found to have a clinically significant relationship with postoperative manifest refraction in our population.

Ultra-High Resolution Spectral Domain Optical Coherence Tomography of Traumatic Maculopathy

The authors describe a patient who suffered traumatic maculopathy following blunt trauma to the eye with commotio retinae, subretinal and preretinal hemorrhage, traumatic macular hole, and outer retinal and retinal pigment epithelium disruption. Serial imaging with commercially available and ultra-high resolution spectral domain optical coherence tomography characterized the evolution of the injury.