Russell Pokroy

Single Intacs segment for post-laser in situ keratomileusis keratectasia

Purpose: To describe the visual outcome of implantation of a single Intacs® segment (Addition Technology Inc.) in eyes with keratectasia after myopic laser in situ keratomileusis (LASIK). Setting: Private refractive surgery center, Jerusalem, Israel. Methods: This retrospective, noncomparative, interventional, consecutive, small case series studied 5 eyes of 5 patients with post‐LASIK keratectasia from 3 refractive laser centers treated by Intacs implantation. Before and 9 months after Intacs implantation, the uncorrected visual acuity (UCVA), best spectacle‐corrected visual acuity (BSCVA), manifest refraction, keratometry, videokeratography, inferior−superior asymmetry, and patient questionnaires about visual function were assessed. Results: Intacs implantation was performed 17 to 32 months post LASIK with no intraoperative complications and no loss of visual acuity. After implantation, the UCVA improved 8, 4, 3, 0.5, and 5 lines and the BSCVA, 2, 2.5, 1, 0.5, and 2 lines. The mean manifest refraction spherical equivalent improved from −1.60 diopters (D) ± 1.67 (SD) to −0.80 ± 1.05 D. The mean manifest astigmatic correction decreased from −3.9 ± 2.96 to −2.46 ± 2.77 D. Corneal topography showed improved inferior steepening and less irregular astigmatism. The mean inferior−superior asymmetry improved from 7.88 ± 4.59 to 2.46 ± 2.77 D. Selfreported visual symptoms improved significantly in Cases 1, 2, and 5 and slightly in Cases 3 and 4. Conclusions: Implantation of a single Intacs segment inferiorly appeared to improve progressive myopia and regular and irregular astigmatism in eyes with corneal ectasia after LASIK. With further study, this technique may prove to be an effective, relatively noninvasive approach.

Intravitreal triamcinolone for diabetic macular edema: comparison of 1, 2, and 4 mg.

Purpose: To compare the efficacy and safety of different doses of intravitreal triamcinolone (IVTA) in treating eyes with refractory diffuse diabetic macular edema (DME) with cystic changes. Methods: Forty-five eyes of 45 patients with diffuse DME were randomized to receive 1, 2, or 4 mg IVTA. Patients were observed for 6 months and changes in best-corrected visual acuity (VA) in Early Treatment Diabetic Retinopathy Study (ETDRS) scores, retinal thickness analyzer (RTA) central macular thickness (CMT), intraocular pressure, and cataract progression were compared among the three groups. Results: Forty-two patients completed 6 months of follow-up and were included in the analysis. Following IVTA injection, the ETDRS score improved similarly, eight to nine letters, in all three groups at 4 weeks. The standardized CMT improved in all three groups at 4 weeks. This improvement was maintained through 12 and 24 weeks in the 1 and 2 mg groups, but not in the 4 mg group, which was significantly worse than the 1 and 2 mg groups at 12 and 24 weeks (P = 0.01, 0.03, 0.01, and 0.05). Conclusions: Regarding eyes with refractory diffuse DME with cystic changes, 4 mg IVTA does not appear to be more effective than 1 or 2 mg IVTA.

Intacs adjustment surgery for keratoconus

PURPOSE: To describe the visual outcome of keratoconic eyes managed with Intacs (Addition Technology, Inc.) that required additional Intacs surgery (defined as any combination of removal, exchange, addition, or shifting of an Intacs segment). SETTING: Private refractive surgery center, Jerusalem, Israel. METHODS: This retrospective noncomparative interventional consecutive small case series studied all eyes of a cohort of 58 keratoconic eyes managed with Intacs that had additional Intacs surgery. The uncorrected visual acuity (UCVA), best spectacle‐corrected visual acuity, manifest refraction, videokeratography, and patient questionnaires on visual function were assessed. These outcome measures were compared before Intacs implantation, before Intacs adjustment, and 1 year after the final Intacs adjustment. Eyes having any intervention other than Intacs surgery were excluded. RESULTS: Of 58 keratoconic eyes managed with Intacs, 7 had additional Intacs surgery. After the initial Intacs surgery, 6 of these eyes had UCVA ≤20/100 and 1 had UCVA of 20/50. After the final Intacs adjustment, 3 eyes achieved UCVA ≥20/40, 5 achieved UCVA ≥20/70, and 2 remained <20/200. The indications for Intacs adjustments were increased astigmatism in 4 eyes, induced hyperopia (overcorrection) in 3, and undercorrection in 1. One eye had both surgically induced astigmatism and hyperopia. Induced astigmatism and hyperopia were most often managed by removing the superior segment. The undercorrected eye, having initially received a single inferior segment, was treated by implanting a superior segment. CONCLUSIONS: Approximately 10% of keratoconic eyes managed with Intacs may require Intacs adjustment surgery, which often has a good outcome.

Visual Loss After Transscleral Diode Laser Cyclophotocoagulation for Primary Open-Angle and Neovascular Glaucoma

BACKGROUND AND OBJECTIVE Varying incidences of visual loss after transscleral diode laser cyclophotocoagulation for uncontrolled intraocular pressure (IOP) have been reported. This study compared the treatment response in primary open-angle (POAG) and neovascular (NVG) glaucoma, particularly regarding vision loss. PATIENTS AND METHODS Case notes of consecutive patients who underwent transscleral diode laser cyclophotocoagulation between March 2001 and September 2005 were retrospectively reviewed. A diagnosis of POAG or NVG and at least 6 months of follow-up were required for inclusion. Conservative laser parameters were used. The treatment response of the POAG and NVG groups was compared. RESULTS Twenty-five eyes of23 patients with POAG and 14 eyes of 14 patients with NVG were studied. Mean follow-up was 22.4 and 12.9 months in the POAG and NVG groups, respectively. Post-treatment, both groups had significant reduction in mean IOP of 7.3 (29.2%) and 13.2 (36.6%) mm Hg, respectively (between group P = .18). One eye in each group had mild hypotony of 4 mm Hg, and no eyes became phthisical. Oral acetazolamide treatment was significantly reduced in both groups. Visual acuity post-treatment decreased in both groups; the POAG eyes had better initial visual acuity and lost more visual acuity. Nine of 25 (36%) POAG and 4 of 8 (50%) NVG eyes lost 2 or more LogMAR lines. CONCLUSIONS Transscleral diode laser cyclophotocoagulation reduced IOP and medication requirements in POAG and NVG. Patients should be warned that visual loss may occur, especially in endstage glaucoma.

Retinal detachment in eyes with vitreous loss and an anterior chamber or a posterior chamber intraocular lens: comparison of the incidence

Purpose: To compare the incidence of retinal detachment within 6 months of cataract surgery complicated by vitreous loss in eyes with a posterior chamber intraocular lens (PC IOL) or an anterior chamber IOL (AC IOL). Setting: Department of Ophthalmology, Kaplan Medical Center, Rehovot, Israel. Methods: In this retrospective consecutive nonrandomized comparative case series, all cases of cataract surgery complicated by vitreous loss between January 1991 and March 1998 were reviewed. Included were patients who had thorough anterior vitrectomy and primary IOL implantation and at least 6 months follow‐up. Exclusion criteria were congenital and traumatic cataract, previous intraocular surgery, and previous retinal detachment. Patients receiving an unsutured single‐piece poly(methyl methacrylate) (PMMA) PC IOL formed the PC group, while those receiving flexible open‐loop single‐piece PMMA AC IOLs formed the AC group. The incidence of postoperative retinal detachment in the 2 groups was compared. Results: Of the 151 eyes of 149 patients, 66 received a PC IOL and 85 received an AC IOL. Two eyes (3.0%) in the PC group and 2 (2.4%) in the AC group developed retinal detachment; the difference between groups was not statistically significant (P = 1.00, Fisher exact test). Conclusions: In eyes that have vitreous loss and thorough anterior vitrectomy, AC IOL implantation did not appear to increase the incidence of retinal detachment.

Monovision surgery in myopic presbyopes: visual function and satisfaction.

Purpose To describe our experience with monovision excimer laser correction in individuals with myopic presbyopia. Methods This prospective interventional case series was conducted in a private refractive surgery center on 40 patients with presbyopia aged 40 years and older, who were treated with monovision refractive surgery between 2010 and 2011. The dominant eye was corrected for distance vision and the nondominant eye was corrected for near vision, with anisometropia of ≥1.00 diopters (D). All patients underwent comprehensive objective and subjective visual assessments, including a questionnaire that was filled out preoperatively and at 6 and 12 months postoperatively. The primary outcomes were preoperative and postoperative refraction, binocular visual acuity, stereopsis, contrast sensitivity, glare, and questionnaire results. Results The 1-year follow-up was completed by 38 patients (95%). Preoperative and 1-year postoperative refraction of the distance eye spherical equivalent (SE), anisometropia SE, and uncorrected visual acuity were −4.05 ± 1.94 and −0.01 ± 0.22 D, 0.45 ± 0.50 and 1.73 ± 0.56 D, and 0.87 ± 0.2 and 0.09 ± 0.11 logMAR, respectively. Best-corrected visual acuity was unchanged. Both mean distance and near stereopsis decreased, from 52 to 142 seconds of arc and from 54 to 57 seconds of arc, respectively. Contrast sensitivity and glare decreased significantly. Patient satisfaction improved from 41.5 ± 30.4% to 85.2 ± 5.0% (range, 40 to 100%) at the 1-year follow-up. Conclusions Monovision excimer laser correction provides both effective and satisfactory results and should be considered as an option for individuals with myopic presbyopia suitable for, and interested in, refractive surgery.

Reversal of cystoid macular edema in gyrate atrophy patients

ABSTRACT Purpose: This study reports the presentation of two families with gyrate atrophy (GA). The aim of this study was to characterize the potential effect of therapeutic regimens on macular edema. Methods: Two unrelated patients with GA were studied for the potential effect of low protein diet (≤ 0.8 g/kg/d), and oral administration of pyridoxine (500 mg/day), on serum ornithine levels, best corrected visual acuity (BCVA), slit-lamp, OCT, and auto-fluorescence findings. Blood samples for DNA, mRNA, and exons of the OAT gene were screened for mutations and splicing effect when relevant. Results: At presentation, both patients manifested typical ophthalmic features of GA including cystoid macular edema (CME). One patient also exhibited optic nerve head hamartoma. Following treatment ornithine levels have lessened, BCVA improved, and central macular thickness (CMT) markedly decreased in all four studied eyes. The molecular pathologic features included a novel splice site mutation (c.900+1G>A). Conclusions: We have identified a novel mutation and two formerly described mutations in patients with GA. Of them, one patient comprised an unusual phenotype including bilateral astrocytic hamartomas. We have recognized for the first time improvement in CME following treatment with low protein intake and pyridoxine supplement. This finding may have significance in the understanding of treatment options for macular edema regardless of underlying etiology.

Bilateral optic pit-like maculopathy with normal optic nerve heads.

had improved slightly to 20/100. Upon OCT, the central macular thickness had decreased to 165 mm OD and 224 mm OS, indicative of a normalized central macular thickness. The cystic maculopathy and retinoschisis of the parafoveal area had also improved (Figs. 2C, D). OCT is a new imaging modality that provides highresolution, cross-sectional images of the macular region and is helpful in diagnosing and monitoring the clinical course of XLRS and determining the treatment response. Recently, treatments with carbonic anhydrase inhibitors and vitrectomy have been reported to improve or resolve foveal retinoschisis in patients with XLRS. Ghajania and Gorin administered acetazolamide orally to a patient with cystic maculopathy. There was nearly complete resolution of the cystoid spaces in both eyes evident onOCT after 9 months. Apushkin and Fishman and Bastos et al. used topical dorzolamide and confirmed the disappearance of foveal cysts upon OCT. These 2 studies, however, were short term and could not assess whether the lesions recurred over the long term. Recently, Ikeda et al. performed vitrectomies in 5 cases of XLRS. In 4 cases, retinoschisis improved after the initial surgery, whereas a second procedure was required in the remaining case. To our knowledge, this is the first case of spontaneous resolution of retinoschisis in XLRS as observed by OCT. We conclude that, although rare, foveal schisis may improve during the natural course of the illness, as shown in our case. Accordingly, the clinical course of such cases should be monitored with OCT before drug therapy or surgery is considered.

Surgical technique for removal of a capsular tension ring from the vitreous cavity.

PURPOSE To describe a surgical technique for removing a posteriorly dislocated capsular tension ring (CTR). METHODS Retrospective interventional case report. CASE REPORT A 68-year-old African American man underwent cataract surgery. Early in the procedure, a CTR was placed at the equator of the lens capsule. Subsequently, the posterior capsule ruptured. The CTR was left in place, and an intraocular lens was placed in the sulcus. On postoperative Day 6, the CTR subluxated into the vitreous cavity and was removed without complication by pars plana vitrectomy, using the CTR inserter. CONCLUSION The technique of using the CTR inserter to remove the CTR from the vitreous cavity appears to be safe and effective.