Mohsin H. Ali

Evaluation of Risk Factors for Glaucoma Drainage Device-related Erosions: A Retrospective Case-Control Study.

Purpose:To identify risk factors for glaucoma drainage device (GDD) erosions. Patients and Methods:In a retrospective comparative case series, medical records of 1013 patients who underwent GDD surgery performed by 5 surgeons between 2006 and 2011 were reviewed. The outcome measures assessed included age, race, sex, contact lens wear, seasonal allergies, medical comorbidities, glaucoma diagnosis, preoperative oral and topical medications, type and number of preoperative surgeries and lasers, concomitant surgeries, tube type and position, patch graft material, and intraoperative use of Avastin, mitomycin-C, or Triescence. The association of variables with erosion status was evaluated using the Fisher exact test for categorical variables and the exact Wilcoxon rank-sum test for continuous variables. Results:Charts were included from 339 eyes that had complete data sets and at least 6 months of follow-up. Twenty-eight eyes (8.3%) developed conjunctival erosions. The median follow-up time was 2.03 years for the erosion group and 1.71 years for nonerosion group. Erosion was only associated with the presence of concomitant surgical procedures at the time of GDD implantation (35.7% erosion group vs. 17.4% nonerosion group, P=0.02, OR=2.64). The majority of concomitant surgeries were composed of pars plana vitrectomy (35.0%) and cataract surgery (32.0%). Variables that were suggestive of association with erosion (P<0.20) included smoking (OR=2.14), pseudoexfoliation glaucoma (OR=2.71), and history of dry eye syndrome (OR=2.22). Conclusion:History of concomitant intraocular surgery with GDD implantation may be a potential risk factor for future erosions.

EVALUATING CONTRAST SENSITIVITY IN AGE-RELATED MACULAR DEGENERATION USING A NOVEL COMPUTER-BASED TEST, THE SPAETH/RICHMAN CONTRAST SENSITIVITY TEST.

Background: Contrast sensitivity (CS) is a valuable measure of visual function in patients with age-related macular degeneration (AMD). The authors aimed to compare a novel computer-based test (the Spaeth/Richman Contrast Sensitivity test) with Pelli–Robson test for evaluating CS in patients with AMD. Methods: In this prospective cross-sectional study, CS was evaluated in patients with various stages of AMD and healthy controls using Spaeth/Richman Contrast Sensitivity test and Pelli–Robson test. Spaeth/Richman Contrast Sensitivity test determined CS scores for 5 areas of vision for each eye (central, superonasal, superotemporal, inferonasal, and inferotemporal) and the total score. Test scores between the two methods were compared using mixed-effects linear regression. Spearmans rank correlation coefficient was used to determine correlations. Test–retest reliability was determined using the intraclass correlation coefficient. Results: Of 35 participants with AMD (54 eyes) and 34 controls (66 eyes), 51% were female and 93% were of European descent. The mean Spaeth/Richman Contrast Sensitivity test score for the central area and each of the 4 peripheral quadrants was significantly lower for patients with AMD versus controls (P < 0.001 for all). The mean Pelli–Robson score was also significantly lower in patients with AMD versus controls (P < 0.001). The intraclass correlation coefficient for Spaeth/Richman Contrast Sensitivity test total score and Pelli–Robson score was 0.87 and 0.92, respectively. Conclusion: Spaeth/Richman Contrast Sensitivity test, a novel Internet-based method of testing CS, had significantly lower scores for patients with AMD compared with controls for central and peripheral vision. This test is a valuable tool for assessing CS in AMD.

Comparing Gonioscopy With Visante and Cirrus Optical Coherence Tomography for Anterior Chamber Angle Assessment in Glaucoma Patients.

Purpose:The aim of this study was to compare gonioscopy with Visante and Cirrus optical coherence tomography (OCT) for identifying angle structures and the presence of angle closure in patients with glaucoma. A secondary objective was to assess interrater agreement for gonioscopy grading among 3 independent examiners. Methods:Gonioscopy grading using Spaeth Classification and determination of angle-closure risk was performed on 1 randomly selected eye for 50 phakic patients. Images of the same eye using both Visante and Cirrus OCT were obtained in both light and dark conditions. Agreement of angle closure among 3 devices and interrater agreement for gonioscopy were determined using Cohen’s &kgr; (K) or Kendall’s coefficient of concordance (W). Results:Of the 50 patients, 60% were female, 64% were white, and the mean age was 62 years. Angle closure was detected in 18%, 16%, and 48% of quadrants with Visante, Cirrus, and gonioscopy, respectively. The scleral spur was identified in 56% and 50% of quadrants with Visante and Cirrus OCT, respectively. Visante and Cirrus OCT showed moderate agreement in detecting angle closure (K=0.42 light, K=0.53 dark) but slight-to-fair agreement with gonioscopy (Visante K=0.25, Cirrus K=0.15). Gonioscopy demonstrated substantial agreement in angle closure (K=0.65 to 0.68) and angle-closure risk assessment (W=0.83) among 3 examiners. Conclusions:Visante and Cirrus OCT imaging may have limited ability to identify angle closure because of difficulty identifying angle structures. Gonioscopy by well-trained clinicians had remarkably consistent agreement for identifying angle-closure risk.PURPOSE The aim of this study was to compare gonioscopy with Visante and Cirrus optical coherence tomography (OCT) for identifying angle structures and the presence of angle closure in patients with glaucoma. A secondary objective was to assess interrater agreement for gonioscopy grading among 3 independent examiners. METHODS Gonioscopy grading using Spaeth Classification and determination of angle-closure risk was performed on 1 randomly selected eye for 50 phakic patients. Images of the same eye using both Visante and Cirrus OCT were obtained in both light and dark conditions. Agreement of angle closure among 3 devices and interrater agreement for gonioscopy were determined using Cohens κ (K) or Kendalls coefficient of concordance (W). RESULTS Of the 50 patients, 60% were female, 64% were white, and the mean age was 62 years. Angle closure was detected in 18%, 16%, and 48% of quadrants with Visante, Cirrus, and gonioscopy, respectively. The scleral spur was identified in 56% and 50% of quadrants with Visante and Cirrus OCT, respectively. Visante and Cirrus OCT showed moderate agreement in detecting angle closure (K=0.42 light, K=0.53 dark) but slight-to-fair agreement with gonioscopy (Visante K=0.25, Cirrus K=0.15). Gonioscopy demonstrated substantial agreement in angle closure (K=0.65 to 0.68) and angle-closure risk assessment (W=0.83) among 3 examiners. CONCLUSIONS Visante and Cirrus OCT imaging may have limited ability to identify angle closure because of difficulty identifying angle structures. Gonioscopy by well-trained clinicians had remarkably consistent agreement for identifying angle-closure risk.

Detection of asymmetric glaucomatous damage using automated pupillography, the swinging flashlight method and the magnified-assisted swinging flashlight method

PurposeTo determine the sensitivity and specificity of various methods of detecting a relative afferent pupillary defect (RAPD) in patients with glaucoma-related diagnoses.Patients and methodsPatients underwent RAPD evaluation using the swinging flashlight method (SFM), the magnifier-assisted SFM, and pupillography using the Konan RAPDx. Main outcome measures were sensitivity and specificity of three methods of RAPD evaluation in detecting visual field mean deviation (MD), cup to disc ratio (CDR), disc damage likelihood scale (DDLS), and retinal nerve fiber layer (RNFL) asymmetry.ResultsEighty-one consecutive patients from the Wills Eye Hospital glaucoma service were enrolled, 60 with glaucoma and 21 with ocular hypertension or glaucoma suspect. Thirty-one percent of subjects had MD asymmetry>5 dB, 19.7% had CDR asymmetry≥0.20, 26.7% had DDLS asymmetry≥2, and 38.2% had RNFL asymmetry>10 microns. Sensitivity values for pupillography were 93.3% (95% CI, 68.1–99.8) for detecting MD asymmetry, 80.0% (95% CI, 51.9–95.7) for CDR asymmetry, 100.0% (95% CI, 73.5–100.0) for DDLS asymmetry, and 69.2% (95% CI, 38.6–90.9) for RNFL asymmetry. Specificity values were 41.2% (95% CI, 24.7–59.3) for detecting MD asymmetry, 32.8% (95% CI, 21.3–46.0) for CDR asymmetry, 33.3% (95% CI, 18.0–51.8) for DDLS asymmetry, and 42.9% (95% CI, 21.8–66.0) for RNFL asymmetry. Pupillography amplitude score was correlated with MD asymmetry (r2=0.41, P<0.001) and area under the curve was 0.84.ConclusionAutomated pupillography had higher sensitivity and lower specificity in detecting MD, CDR, DDLS, and RNFL asymmetry. Within the bounds of the cohort tested, this method had limited case-finding ability.

Congenital cavitary optic disc anomaly and Axenfeld’s anomaly in Wolf-Hirschhorn syndrome: A case report and review of the literature

ABSTRACT Background: Wolf-Hirschhorn syndrome is a rare genetic syndrome caused by a heterozygous deletion on chromosome 4p16.3 and is characterized by a “Greek warrior helmet” facies, hypotonia, developmental delay, seizures, structural central nervous system defects, intrauterine growth restriction, sketelal anomalies, cardiac defects, abnormal tooth development, and hearing loss. A variety of ocular manifestations may occur in up to 40% of patients. Materials/methods: We report the genetic testing results, systemic findings, and complete ophthalmologic examination findings in a patient with Wolf-Hirschhorn syndrome, including external photography, RetCam3 (Clarity Medical Systems, Pleasonton, CA) goniography, and fundus photography. In addition, we review the literature on ocular manifestations of Wolf-Hirschhorn syndrome. Results: Microarray analysis revealed an unbalanced translocation between 4p16.3–15.3 and Xp22.33-p22.2. Systemic findings included “Greek warrior helmet” facies, hypotonia, cleft palate, neonatal tooth eruption, talipes equinovarus, bilateral clinodactyly, clitoromegaly, partial agenesis of the corpus callosum, bilateral renal hypoplasia, and two atrial septal defects. Ocular findings included normal intraocular pressures and corneal diameters, large-angle exotropia, downward slanting of the palpebral fissures, absent eyelid creases, upper and lower eyelid retraction with shortage of the anterior eyelid lamellae, euryblepharon, lagophthalmos with poor Bell’s reflex and exposure keratopathy, hypertelorism, Axenfeld’s anomaly, megalopapillae, and cavitary optic disc anomaly. Conclusions: We describe the ocular phenotype of a patient with Wolf-Hirschhorn syndrome, including the rare descriptions and photographs of Axenfeld’s anomaly, megalopapilla, and cavitary optic disc anomaly in this condition.

Periorbital mass refractory to outpatient management

A Hispanic woman in her 60s presented to the oculoplastics clinic with a 1-week history of pain, redness, and swelling in the medial aspect of the right periorbital region. Her medical history included sarcoidosis, type 2 diabetes, hypertension, and coronary artery disease. Her ocular history included pseudophakia and proliferative diabetic retinopathy in both eyes; she had also undergone pars plana vitrectomy and panretinal photocoagulation in both eyes. Seven days prior to presentation, an ophthalmologist prescribed the patient oral amoxicillin-clavulanate, 500 mg 3 times daily, and topical antibiotics. However, her symptoms persisted and eventually worsened. She reported increasing swelling and pain in the affected region. She denied changes in vision, eye pain, or pain with eye movements. The patient’s best-corrected visual acuity was 20/60 OD and 20/50 OS, her pupils were reactive, extraocular motility was full and painless, and intraocular pressures were 18 mm Hg in both eyes. External examination revealed an erythematous, tender, firm mass in the medial periorbital area (Figure, A). Results of anterior slitlamp examination and dilated fundus examination were unremarkable. Contrast-enhanced computed tomographic imaging of the maxillofacial region was performed and showed a peripherally enhancing mass in the affected area (Figure, B). Mass in medial periorbital area A Mass in medial aspect of right periorbital region B

Disc-damage Likelihood Scale (DDLS) as a Clinical Indicator of the Presence of a Relative Afferent Pupillary Defect (RAPD).

Purpose:To evaluate clinical parameters and their relationship to the presence of a relative afferent pupillary defect (RAPD). Materials and Methods:Retrospective chart review of 672 consecutive patients who presented to the Glaucoma Service at Wills Eye Hospital from January 1 through May 29, 2012. Swinging flashlight method (SFM) was used to test for RAPDs. Records of visual acuity, intraocular pressure (IOP), disc-damage likelihood scale (DDLS), cup/disc (C/D) ratio, visual field mean deviation (MD), optical coherence tomography (OCT), and Heidelberg retinal tomography (HRT) asymmetries were examined. We measured the prevalence of RAPDs as clinical asymmetries increase, calculated cut-off points for clinical asymmetries that optimized sensitivity and specificity in detecting RAPDs, and determined values of clinical asymmetries above which a RAPD always exists. Results:Upon exclusion, we studied 409 patients, 175 (42.8%) with RAPDs and 234 (57.2%) without. Age, visual acuity, IOP, DDLS, C/D ratio, MD, retina nerve fiber layer thickness by OCT, HRT C/D, and HRT rim area asymmetries all correlated with RAPD status (OCT and HRT parameters did not include enough patients for multivariable analysis or cut-off determination). Multivariable analysis indicated that IOP, DDLS, and MD asymmetries were significantly correlated with RAPD status (P-value<0.05). Although the optimal cut-off values for the variables retained in the final multivariable model had low sensitivity and moderate specificity, DDLS had the highest specificity of 0.86. Conclusions:IOP, DDLS, and MD asymmetries had the best correlation with RAPD status, and increased asymmetries in these parameters were associated with higher likelihood of RAPDs. DDLS score had the highest specificity in predicting a RAPD, and DDLS asymmetry scores ≥6 identified all cases of RAPDs.

Elevated Intraocular Pressure and Endothelial Cell Loss Following Iris Color Change

Amaninhis30spresentedwithcomplaintsofbilateralblurryvision,eye redness, andheadaches. His ocular history was significant for amotor vehicle crash resulting in likely left optic neuropathy (18 years ago), a procedure performed to change the color of his eyes from brown to blue (4 years ago), and bilateral laser in situ karatomileusis surgery (2 years ago). He was being treated by outside ophthalmologists with loteprednol, nepafenac, timolol, andartificial tears.Hedidnotwearcontact lenses.Hisbest-correctedvisualacuitywas20/20 OD and 20/30OS. Anterior slitlamp examination of both eyes revealed the finding shown in Figure 1. His anterior segment was deep and quiet, and his dilated fundus examination was unremarkable. His intraocular pressure (IOP) was reproducibly higher in the right eye on 3 separate visits, averaging 20mmHg OD and 13 mmHg OS. His central corneal thickness was 496 μm OD and 480 μm OS. His endothelial cell count was 1681 cells/mm2 OD and 2045 cells/mm2 OS. Figure 1. External photograph of patient’s right eye on presentation.