Shmuel Levartovsky

Factors affecting long term results of successfully treated amblyopia: initial visual acuity and type of amblyopia.

AIMS--The study aimed to assess the effect of initial visual acuity and type of amblyopia on the long term results of successfully treated amblyopia. METHODS--The visual acuity of 94 patients, who had been successfully treated for unilateral amblyopia by occlusion of the good eye and followed up to the age of 9 years, was examined 6.4 years, on average, after cessation of treatment. Patients were divided into two groups according to the depth of amblyopia before occlusion therapy was started: those with visual acuity between 20/60 and 20/100 and those with visual acuity of 20/100 or worse. RESULTS--Deterioration of visual acuity was observed in 42% of patients in the first group and in 63% of patients in the second group. Their average deterioration, as measured by the Snellen chart, was 0.58 and 1.54 lines, respectively. The results were also assessed by the division of patients into three groups according to the type of amblyopia: strabismic, strabismic anisometropic, and anisometropic. Deterioration of visual acuity occurred in 46%, 79%, and 36% of patients in these three groups, with an average deterioration on the Snellen chart of 0.70, 2.04, and 0.64 lines, respectively. CONCLUSION--It is concluded that low initial visual acuity and strabismic anisometropic amblyopia are risk factors for deterioration of visual acuity in the long term, following the successful earlier treatment of eyes with amblyopia.

Bacterial keratitis following laser in situ keratomileusis

Abstract Purpose The development of bacterial keratitis after laser in situ keratomileusis (LASIK) has been described in only a few isolated cases. We report the development of bacterial keratitis as a postoperative complication of LASIK in three subjects. Design A retrospective interventional small case series. Participants Three patients who underwent LASIK for correction of myopia during July and August 1998 and had bacterial keratitis develop after surgery. Methods Bacterial keratitis was encountered in the operated eyes between 1 and 22 days after surgery. Topical antibiotic therapy was administered. In one eye, which had significant opacification and irregularity of the flap was developed, lamellar keratoplasty was performed. Main outcome measures Postoperative inflammation was followed clinically and photographically until it resolved. Visual acuity was measured at intervals throughout the follow-up period. Results Keratitis resolved within 3 to 16 days of starting antibiotic therapy. The final best-corrected visual acuities were 20/30, 20/15, and 20/25. Conclusions Although infectious keratitis after LASIK is an infrequently reported event, it should be discussed preoperatively with patients as a possible complication.

Long-term follow-up of occlusion therapy in amblyopia.

OBJECTIVE To determine whether the results of occlusion therapy for amblyopia are maintained into adulthood. DESIGN Prospective, observational case series. PARTICIPANTS Fifty-four patients, who were successfully treated in childhood for unilateral amblyopia by occlusion, were followed up to the age of 9 years, were evaluated in 1984 for long-term results 6.4 years on average after cessation of treatment, and accepted our invitation for reevaluation in 1999. METHODS All patients were given a complete eye examination. The visual acuity (VA) was measured. RESULTS The average period of follow-up was 21.5 years (range, 17.2-25.1 years). The mean age at the most recent examination was 29.0 +/- 2.1 years (range, 25.1-34). At this examination, a best-corrected visual acuity (BCVA) of 20/40 or better was achieved by 72.3% of the patients. The mean BCVA was 20/35 (20/25-20/70) at the end of occlusion therapy, 20/45 (20/20-20/300) in 1984, and 20/34 (20/15-20/100) at the present examination. Relative to the results at the end of therapy, BCVA at the present examination was maintained or improved in 66.7% of the patients. Relative to 1984, the BCVA in 1999 was maintained or improved in 87% of the patients. MAIN OUTCOME MEASURE Visual acuity. CONCLUSION Comparative evaluation of BCVA at a long-term follow-up examination, performed 21.5 years on average after cessation of occlusion therapy, showed that VA was maintained or improved in two thirds of patients who had been successfully treated by occlusion for unilateral amblyopia in childhood.

Factors Affecting Long-Term Results of Successfully Treated Amblyopia: Age at Beginning of Treatment and Age at Cessation of Monitoring

The visual acuity of 104 patients who had previously been successfully treated for unilateral amblyopia by occlusion of the good eye was examined 6.4 years, on average, after cessation of treatment. Three age groups were defined, according to the age at which treatment was started: younger (2 to 5.5 years), middle (5.5 to 8 years) and older (above 8 years). In 55% of the patients, the long-term follow-up examination revealed deterioration of the visual acuity. In patients in whom amblyopia had been monitored at least up to the age of 9 years, the age at which treatment was started did not significantly affect the mean amount of deterioration or the mean visual acuity noted at the long-term follow-up examination.

Long term effect of hypermetropic anisometropia on the visual acuity of treated amblyopic eyes

AIM To evaluate the effect of the extent of hypermetropic anisometropia on the long term visual acuity results in amblyopic eyes following their treatment by occlusion. METHODS The visual acuity of 86 patients, who had been treated for unilateral amblyopia by occlusion of the fellow eye and followed up at least to the age of 9 years, was examined 6.4 years, on average, after cessation of treatment. Patients were divided into two groups—those with a small amount of hypermetropic anisometropia, where the spherical equivalent difference between the eyes ranged between 0 and +1.50 dioptres, and those with a large amount of hypermetropic anisometropia, where the difference was +1.75 dioptres or greater. RESULTS Deterioration of visual acuity after cessation of occlusion treatment occurred in 51% of the patients in the group with a small amount of anisometropia and in 75% of the patients in the group with a large amount. At cessation of treatment, the average visual acuity in both groups was 20/40+. At the long term follow up examination, however, the average visual acuity was 20/40− and 20/70, respectively. This difference was statistically significant. CONCLUSIONS Hypermetropic anisometropia greater than 1.50 dioptres appears to be a risk factor for deterioration of visual acuity in the long term, following treatment of amblyopic eyes by occlusion of the fellow eye.

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.

Factors Predicting the Need for Retreatment After Laser Refractive Surgery.

Purpose: To identify the potential risk factors that increase the likelihood of requiring retreatment after refractive surgery. Methods: This retrospective study included patients who underwent laser in situ keratomileusis or photorefractive keratectomy between January 2005 and December 2012 at the Care-Vision Laser Centers, Tel-Aviv, Israel. Patients were divided into 2 groups according to whether they underwent additional refractive surgery (retreatment) during the study period. Results: Overall, 41,504 eyes (n = 21,313) were included in the final analysis of this study. Throughout the study period, there was a significant reduction in the 2-year annual retreatment rates with a decline from 4.52% for primary surgeries done in 2005 to 0.18% for surgeries performed in 2012 (quadratic R2 = 0.96, P < 0.001). The retreatment group had significantly higher preoperative age, maximum keratometric power, sphere, cylinder, and better best-corrected visual acuity. They were more likely to have preoperative hyperopia, photorefractive keratectomy as opposed to laser in situ keratomileusis, intraoperative higher humidity conditions and lower temperature, and higher ablation depths. Significant differences in retreatment rates were found between the 5 high-volume surgeons (>1500 procedures performed) ranging from 0.48 to 3.14% (P < 0.0001). Multiple logistic regression analysis demonstrated that age, astigmatism, hyperopia, temperature, and surgeons experience all significantly affected the need for retreatment. Conclusions: The following factors significantly increase the need for refractive retreatment: older preoperative age, higher degrees of astigmatism, hyperopia, colder operating room temperature, and less surgeon experience. Some of these factors may be incorporated into nomograms to reduce future retreatment rates.

Homologous scleral graft for corneal perforation in a child.

Purpose: To show the emergency use of preserved homologous sclera for the repair of a perforated cornea in a young child. Methods: Our case was a 3.5-year-old boy who presented with an acute corneal ulcer and endophthalmitis, which was complicated by a developing corneal melting and perforation of 2.5-mm diameter during pars plana vitrectomy. Because no donor cornea was available, a full-thickness preserved donor sclera was used to close the corneal defect. Results: During the next 8 months, scar tissue formed underneath the scleral graft. The graft was removed, revealing mild opacification at the site of corneal perforation. Three years after surgery, best-corrected visual acuity was 20/60. Conclusions: In the absence of a corneal button for grafting, preserved homologous sclera may be used for closing a corneal defect.

Comparison of Three Epithelial Removal Techniques in PRK: Mechanical, Alcohol-assisted, and Transepithelial Laser.

PURPOSE To compare the visual and refractive results obtained after photorefractive keratectomy (PRK) in patients who underwent one of three different epithelial removal techniques. METHODS The authors reviewed the medical files of consecutive eyes with myopia and myopic astigmatism that were treated during a 10-year period by mechanical PRK, alcohol-assisted PRK, or transepithelial PRK (in the phototherapeutic keratectomy mode), and observed for more than 1 year. RESULTS A total of 3,417 patients (3,417 eyes) were included in this study. At 3 and 6 months postoperatively, the outcome of alcohol-assisted PRK was superior both in efficacy (P < .01) and safety (P < .001) to those of both mechanical PRK and transepithelial PRK, which were similar. At more than 1 year postoperatively, the mean efficacy index was still high for alcohol-assisted PRK, but low for the transepithelial PRK, corresponding to a mean uncorrected visual acuity of more than one Snellen line lower than those of the other two techniques (P < .0001). All three techniques showed a regression toward myopia more than 1 year postoperatively, with significant undercorrection obtained in eyes treated with transepithelial PRK (P < .0001). CONCLUSIONS Significant differences were detected in both the visual outcomes and the refractive results of the three epithelial removal techniques. The long-term outcomes were best for alcohol-assisted PRK.

Prevalence of Epilepsy among Cataract Patients.

Purpose: To evaluate the prevalence of epilepsy among patients undergoing cataract surgery. Design: A retrospective observational case control study. Methods: We calculated the prevalence of epilepsy among all the patients older than 50 years who underwent cataract surgery (years 2000–2007, n = 12,984) in a district of the largest health maintenance organization in Israel (the Central District of Clalit Health Services) and among 25,968 age and gender matched controls. The database was screened for epilepsy by integrating the clinical and ancillary work-up as well as the drug regimen. The use of anti-epileptic drugs (AEDs) was evaluated among the cataract patients and the controls. The main outcome measure was the prevalence of epilepsy and antiepileptic medical treatment among patients undergoing cataract surgery versus controls. Results: No difference was found in demographics among the groups including age, gender, marriage status, socioeconomic class and living place between the study and control groups (except for patients origin). Epilepsy was found to be significantly more prevalent in patients undergoing cataract surgery. The odds ratio (OR) was 1.3 (95% confidence interval (CI): 1.1–1.6): 1.4 in men (95% CI: 1.1–1.9) and 1.2 in women (95% CI: 1.0–1.6). AEDs, particularly clonazepam (OR = 1.5, 95% CI: 1.1–2.1) and carbamazepine (OR = 1.4, 95% CI: 1.05–1.8), were also used more by cataract patients. Multivariate logistic regression analysis revealed a significant association between cataract surgery and epilepsy (OR 1.26, p < 0.001) as well as diabetes (OR 1.38, p < 0.001), arterial hypertension (OR 1.26, p < 0.001), smoking (OR 1.22, p < 0.001), hyperlipidemia (OR 1.12, p < 0.001), and Ashkenazi origin (OR 0.85, p < 0.001). Conclusions: Epilepsy is associated with the presence of cataract. Various hypotheses may explain this finding, including a cataractogenic role of AEDs.