Mladen Bušić

Intraobserver and interobserver repeatability of ocular components measurement in cataract eyes using a new optical low coherence reflectometer

BackgroundThe purpose of the study was to assess intraobserver and interobserver repeatability of eight ocular components measurement in cataract eyes using the optical low-coherence reflectometer Lenstar LS 900®.MethodsFive consecutive measurements of ocular components were taken by two examiners using the Lenstar. Components analyzed were: central corneal thickness, lens thickness, anterior chamber depth, axial length, retinal thickness, keratometry, white-to-white distance, and pupillometry. Within-subject standard deviation and the coefficient of variation were calculated for evaluation of intraobserver repeatability. Bland–Altman analysis was used for assessment of interobserver repeatability.ResultsThirty-two eyes of 22 patients were included. For both observers, the smallest intraobserver coefficient of variation was obtained for axial length, while the largest was found for corneal steepest meridian position. Interobserver repeatability demonstrated less repeatable results for white-to-white distance and corneal steepest meridian position. Considering axial length and anterior chamber depth values, predicted refractive error was 0 ± 0.05 D and 0.02 ± 0.19 D respectively in 95% of observations.ConclusionThe Lenstar LS 900® evidenced excellent repeatability and observers´ independent results of all components analyzed except white-to-white distance and corneal steepest meridian position measurements. To the best of our knowledge, this is the first study on interobserver repeatability of optical low-coherence reflectometry in cataract eyes.

Comparison of optical low-coherence reflectometry and applanation ultrasound biometry on intraocular lens power calculation

BackgroundThe aim of the study was to determine whether the innovative non-contact optical low-coherence reflectometry method utilized by the Lenstar LS 900® agrees sufficiently with applanation ultrasound A-scan technique in routine biometric measurement and intraocular lens power calculation to replace it.MethodsTwenty-two patients hospitalized at our eye clinic undergoing cataract surgery were assigned to have five consecutive measurements of axial length by two examiners in a single session using applanation ultrasound and the Lenstar. The applanation ultrasound intraocular lens power calculation was based on automated keratometry and applanation ultrasound axial length measurements. The Lenstar intraocular lens power calculation was based on its measurement of keratometry and axial length. Bland–Altman analysis was used to assess interobserver repeatability of applanation ultrasound and the Lenstar as well as agreement between the Lenstar and applanation ultrasound for axial length measurement and intraocular lens power calculation.ResultsThirty-two eyes of 22 patients were analyzed. In 95% of the observations, predicted refractive error corresponded to –0.26 ± 0.62 D and 0.01 ± 0.20 D obtained with applanation ultrasound and the Lenstar, respectively.ConclusionsBased on excellent repeatability of the Lenstar and acceptable repeatability of applanation ultrasound, two techniques may be used interchangeably. The predicted refractive error of ±0.20 D in 95% of the observations has never been achieved. Optical low-coherence reflectometry might become a new standard method for biometric measurement needed for intraocular lens-power calculation in patients with cataract.

Optical low-coherence reflectometry enables preoperative detection of zonular weakness in pseudoexfoliation syndrome

PurposeTo evaluate optical ocular components in patients with pseudoexfoliation syndrome using optical low-coherence reflectometry.MethodsA prospective cohort study of 224 eyes of patients planned for cataract surgery was conducted in the period from January 2009 until July 2009. Patients were divided in two groups: the first group of 47 eyes with cataract complicated with pseudoexfoliation syndrome and the control group of 177 eyes with uncomplicated cataract. Each group was further divided into two subgroups based on its refractive state: emmetropes and hypermetropes. The optical low-coherence reflectometry biometer LENSTAR® LS 900® was used to define ocular optical components.ResultsA statistically significant difference of ocular optical components was established between the two groups of patients and its matching subgroups: AL (t = 2.25; p < 0.05) and ACD (t = 2.24; p < 0.05) were significantly higher in the control group, PD was significantly higher in the control group hypermetropes than the PEX group hypermetropes (t = 2.21; p < 0.05) while LT (t = 3.01; p < 0.001), AST (t = 2.13; p < 0.05) and IOL (t = 3.06; p < 0.001) were higher in the PEX group of patients than in the control group.ConclusionsThe optical low-coherence reflectometry enabled preoperative detection of zonular weakness and subsequent lens instability documented as a significantly shallower anterior chamber, thicker lens, and smaller pupillary diameter in the pseudoexfoliation syndrome group in the studied population.

Operative treatment of large periocular xanthelasma.

Purpose: To present our experience in operative treatment of large periocular xanthelasma. Methods: Sixty-three patients with large periocular xanthelasma were operatively treated in our department. Ipsilateral and/or contralateral lid skin grafts harvested by blepharoplasty, alone or in combination with local flaps, were used. Forty patients (64%) had enough skin to graft the defect after primary xanthelasma removal. In 10 patients, additional local flaps were used: modified rhomboid flap in six patients, local advancement flap in two, and bi-lobed flap in two patients. In three patients (5%), a sequential approach was applied since xanthelasma were too large to be completely removed in a single-step excision. No serious complications were shown. Results: Patients were followed from 6 months to 8 years. Five patients (8%) returned with recurrences 3–8 years after primary excision. Conclusions: In lack of the setting for xanthelasma laser treatment, operative approach of a single-step or sequential excision using lid skin graft combined with local flaps proved its value for large periocular xanthelasma.

Zagreb Amblyopia Preschool Screening Study: near and distance visual acuity testing increase the diagnostic accuracy of screening for amblyopia.

Aim To present and evaluate a new screening protocol for amblyopia in preschool children. Methods Zagreb Amblyopia Preschool Screening (ZAPS) study protocol performed screening for amblyopia by near and distance visual acuity (VA) testing of 15 648 children aged 48-54 months attending kindergartens in the City of Zagreb County between September 2011 and June 2014 using Lea Symbols in lines test. If VA in either eye was >0.1 logMAR, the child was re-tested, if failed at re-test, the child was referred to comprehensive eye examination at the Eye Clinic. Results 78.04% of children passed the screening test. Estimated prevalence of amblyopia was 8.08%. Testability, sensitivity, and specificity of the ZAPS study protocol were 99.19%, 100.00%, and 96.68% respectively. Conclusion The ZAPS study used the most discriminative VA test with optotypes in lines as they do not underestimate amblyopia. The estimated prevalence of amblyopia was considerably higher than reported elsewhere. To the best of our knowledge, the ZAPS study protocol reached the highest sensitivity and specificity when evaluating diagnostic accuracy of VA tests for screening. The pass level defined at ≤0.1 logMAR for 4-year-old children, using Lea Symbols in lines missed no amblyopia cases, advocating that both near and distance VA testing should be performed when screening for amblyopia.

Our experience with dermofat graft in reconstruction of anophthalmic socket.

Purpose: To present our experience with dermofat graft in reconstruction of anophthalmic socket. Material and methods: In period from September 2005 until June 2009, eight patients have undergone orbital surgery of transplantation of dermofat graft. In six patients the dermofat graft was used as the secondary orbital implant after extrusion of hydroxyapatite orbital implant with major defect of bulbar conjunctiva. The other indication for the dermofat graft was correction of deep superior sulcus of the upper lid in anophthalmic socket in two patients. The graft was harvested from the left side of the belly. The size of the graft purposely exceeded the size of the defect to account for the expected tissue resorption. Results: We experienced no major complication. Approximately 20–40% of dermofat graft reduction was noticed in 3-months period postoperatively. It took 6–8 weeks for the graft to fully epithelize from the conjunctival edge. Silicone conformer was introduced for that period of time. Subsequently, in two out of six patients with dermofat graft as the secondary implant, fornix had to be reconstructed later on with oral mucosa graft. Conclusion: Dermofat graft is a valuable material in orbital reconstruction especially in anophthalmic socket.

Amblyopia screening: a new screening protocol implemented in Croatia.

In 1968 Wilson and Jungner defined 10 criteria for a screening program, which have been only slightly changed in the past forty years (1). These criteria were confirmed and expanded by a bulletin of World Health Organization (WHO) published in April 2008 (2). Every screening protocol proposed to be introduced as a policy is not just a matter of medicine and science, but there are political, economic, and ethical issues that need to be addressed before adopting these methods. Human genome sequencing has raised many concerns – in medical and scientific aspect it has enabled screening for various diseases and syndromes, but ethically and economically these methods may prove to be questionable or unfeasible (2). Wilson and Jungner defined screening as “a cross-sectional, short-term operation on a population at risk” (1). Hence, it is necessary to differentiate between examining and treating a single patient from trying to “examine and treat” a community (3), the latter being in some way the goal of screening. Sacket et al (3) claim that an introduction of “untested community screening” may cause irreversible damage to the society and cause a permanent loss of “profession’s credibility.” The implementation of any population method must be guided by public needs and values (4), but established on medical and scientific evidence and measures. In Croatia, three National Preventive Programs were set up – for early detection of breast cancer in 2006, for colorectal cancer in 2007, and for cervical cancer in 2010 (5). However, some problems in conducting and implementing these screening strategies have been reported (5-7), mainly related to compliance, lack of population education, and organizational issues. For example, in colorectal cancer program, 84% of population at risk received the test package to their home address and only 19% returned the test sample, while the population from islands had difficulties in reaching a center were colonoscopy was performed (6). Another important question was raised concerning the organization and quality of the entire health care system, disclosing some of its weak points, like unequal quality of colonoscopy performance and unwillingness of some physicians to participate in such programs (6). The breast cancer screening program had a response rate of 49%. It proved its major benefit in diagnosing breast cancer of lower stages compared to unscreened population (7). Expectations from cervical cancer screening program are high as Croatia has well-organized infrastructure for this kind of screening and a long tradition of education of cytologists and primary gynecologists (8). For pediatric population, three screening programs were approved as national health policy in Croatia by June 1, 2015. These included screening for phenylketonuria, conducted in 1978, for congenital hypothyroidism in 1985, and for hearing disorders in 2002. Phenylketonuria screening program in Croatia discovers 5-6 patients per year (9). Although this number does not seem high, early detection of phenylketonuria has a substantial impact not only on affected individuals` lives, but also on society, economy, and labor productivity (10). The neighboring countries have similar national preventive policies for newborns (11). Children’s screening programs have a major sociological significance because they may bring about a lifetime benefit. Community is very sensitive to the child population, but it has little or no awareness of the disorders. In conclusion, screening programs in childhood that are to be introduced need a thorough medical, scientific, ethic, economic, and sociologic evaluation. Amblyopia, subnormal visual acuity, is a disorder that meets all the WHO criteria for a screening program (12,13). The gold standard to diagnose amblyopia is a complete ophthalmological examination, however, being an elaborate procedure it cannot be used as a screening method. Several simple and effective screening programs have been introduced since the Wilson and Jungner’s work. However, there is no consensus on the preferred, validated, and effective amblyopia screening protocol. Zagreb Amblyopia Preschool Screening (ZAPS) study aimed at validation and testing of a highly structured protocol, designed to be both highly sensitive and specific, for measuring near and distance visual acuity and raising a threshold value of visual acuity for referral (14). The protocol was conducted and tested in Zagreb, Croatia, on 15 648 children aged 48-54 months attending Zagreb kindergartens. ZAPS study protocol proved to have a high testability rate, sensitivity of 100%, and specificity of 96.68%. By testing visual acuity using optotypes in lines, the prevalence of amblyopia was found to be 8.08%, substantially higher than documented in the current literature. Founded on the evidence that amblyopia screening meets all the WHO criteria for screening program and having ZAPS study protocol as a valid screening tool, the Croatian Ministry of Health in June 2015 adopted a new screening program as an obligatory national health policy addressing all ethical, economic, and political issues, along with social community priorities (15). Pediatricians now refer all four-year-old children to the ophthalmologist, who performs screening examination in accordance with ZAPS study protocol. As stated by Wilson and Jungner, vision screening programs are the hallmark of a country’s development, which places Croatia among the most responsible societies in terms of promotion and enhancement of the quality of children’s health care (1).

Histopathological changes in involutional lower eyelid entropion: the tarsus is thickened!

OBJECTIVE Evaluation of histopathological changes in lower eyelid involutional entropion. DESIGN Case-control, comparative study at a single institution. PARTICIPANTS A total of 20 consecutive patients with previously untreated involutional lower eyelid entropion and 20 matching patients with lateral lower eyelid basal cell carcinoma (BCC). METHODS Patients with involutional entropion were operated using our modified surgical method, and patients with BCC underwent full-thickness pentagonal excision with 3-mm surgical margins. Histopathological analysis of the full-thickness eyelid specimens of both groups included measurements of tarsal thickness and height, thickness of the pretarsal orbicularis oculi muscle, diameter of muscle fibres, and qualitative changes in lower eyelid retractor attachment. RESULTS The tarsus was significantly thicker in the entropion group (p = 0.006). The mean tarsal thickness was 1.40 ± 0.32 mm, whereas in the BCC group it was 1.16 ± 0.19 mm. There was no statistically significant difference in the tarsal height and the thickness of the pretarsal orbicularis oculi muscle between the 2 groups. In the entropion group, 60% of the lids had total and 35% partial dehiscence of the retractor, whereas in the BCC group, dehiscence was found in only 45% of the lids. The difference was statistically significant (p = 0.002). CONCLUSIONS To the best of our knowledge, this is the first histopathological study documenting thickening of the tarsus in involutional lower eyelid entropion. Moreover, dehiscence of the lower eyelid retractor was proven histopathologically in 95% of the entropic lids. With this in mind, correction of vertical instability should be mandatory in involutional lower eyelid entropion repair.

Early satellite Metastatic Uveal Melanoma to The Lower Eyelid – The First Report

Purpose: To present a unique case of an early satellite metastatic uveal melanoma to the ipsilateral lower eyelid. Methods: Retrospective review of the medical records of a single patient. Results: A 71-year-old white male developed a fast growing, painless, solitary, subcutaneous, nodular mass in the medial half of his right lower eyelid 13 months after enucleation of the right eye for inferonasaly located uveal melanoma of the spindle cell type. Microscopically excised eyelid tumor proved to be malignant melanoma of the epitheloid type. The patient underwent complete systemic examination including positron emission tomography that ruled out the primary cutaneous or visceral melanoma. Conclusion: The paper is, according to our knowledge, the first documented case of an early satellite metastatic uveal melanoma to the lower eyelid in the patient with no evidence of further metastases.

Scleral Thinning Documented by Ultrasound Biomicroscopy after Plaque Therapy for Anterior Ciliary Melanoma

ABSTRACT Purpose: To evaluate, by ultrasound biomicroscopy (UBM), changes in scleral thickness after ruthenium-106 CCB and CCC plaque (Eckert & Ziegler BE-BIG GmbH, Berlin, Germany) therapy for anterior ciliary melanoma. Methods: Eleven patients with anterior ciliary melanoma underwent ruthenium-106 CCB and CCC plaque radiation with a radiation dose at the tumor apex of 80–100 Gy. UBM measurements performed prior to and after treatment were as follows: the largest prominence of the tumor perpendicular to the sclera and scleral thickness at scleral spur, 1.0 mm, and 2.0 mm posteriorly. Results: The article presents one year follow-up results for each of the 11 patients. The mean regression of the tumor of 24.3±9.31% was observed. The thinning of the sclera was statistically significant at the scleral spur (t=1.80, p ≤ 0.05) and at maximal tumor thickness (t=1.35, P=0.05). Conclusion: UBM documented significant thinning of the sclera at the scleral spur and overlying the maximal tumor thickness after Ru-106 CCB and CCC plaque radiation. Taking into consideration the shortcomings of the study—small sample size, insufficient probe resolution, and subjectively determined anatomic landmarks—observed minimal thickness change of the sclera does not necessarily mean its necrosis. However, thinning of the sclera documented at one year follow-up associated with very slow regression of the tumor indicates the need for the introduction of the CIA plaque treatment in our patients with anterior ciliary melanoma.