Sloan W. Rush

Systemic manifestations in response to mydriasis and physical examination during screening for retinopathy of prematurity.

Objective: To determine whether adverse effects manifested via vital sign changes during the screening examination for retinopathy of prematurity (ROP) are due to the pharmacologic properties of the eye drops or to physical manipulation of the eyes. The authors also investigated the relationship between distress during the screening process and the severity of prematurity of the infant. Design and Methods: A prospective observational study was designed that enrolled all infants either weighing ≤1500 g or who were ≤32 weeks gestational age at birth who were admitted to the neonatal intensive care unit (NICU) at Northwest Texas Hospital or Baptist St. Anthony’s Hospital from June 2002 to February 2003. Thirty participants were enrolled in this study. Blood pressure, pulse, temperature, respiratory rate, and O2 saturation were recorded at different time intervals during the examination. Infants were excluded from the study if they were on the ventilator, considered acutely ill, born with significant birth defects, or currently taking inotropic drugs, or had received albuterol 2 hours before the examination. Results: Oxygen saturation and pulse rate following physical manipulation of the eyes significantly varied from baseline values and the values obtained during the three instillations of topical mydriatics. No significant changes in blood pressure, temperature, or respiratory rate from their respective baseline values were observed throughout the ROP screening examination. Gestational age of the infant did not correlate with level of distress during the examination. Conclusion: Regardless of the severity of prematurity, infants seem to undergo significant distress during the eyelid speculum examination. Thus ophthalmologists should take into consideration the infant’s discomfort caused by physical manipulation of the eyes and attempt to perform the examination as swiftly, yet safely, as possible using topical anesthetic.

The Effects Of Comfort Care On The Pain Response In Preterm Infants Undergoing Screening For Retinopathy Of Prematurity

Objective: The aim of the study was to determine if pain and distress during the retinopathy of prematurity (ROP) screening examination could be ameliorated by providing comfort care. Study Design: This study was a prospective, randomized, controlled trial of 30 stable preterm infants who underwent initial ROP screening examinations. Fourteen study infants were swaddled, held, and given 24% sucrose solution during the examination. Sixteen controls were examined while lying in their cribs. Vital signs (i.e., pulse rate, respiratory rate, and oxygen saturation), crying time, and time for the vital signs to return to baseline values were recorded at different times during the examination. Results: The vital signs did not vary significantly between the two groups. The participants in the control group had a trend of longer crying time, but this trend did not reach a level of statistical significance. In addition, The time required for the vital signs to return to their baseline values did not vary significantly. Conclusion: ROP screening is very distressful for preterm infants. The routine use of comfort care to reduce pain during the examination could not be supported by this study.

Evaluation of Choroidal Neovascularization With Indocyanine Green Angiography in Neovascular Age-Related Macular Degeneration Subjects Undergoing Intravitreal Bevacizumab Therapy

PURPOSE To report the clinical implications of interval changes in choroidal neovascularization (CNV) size measured by indocyanine green (ICG) angiography in neovascular age-related macular degeneration (AMD) patients undergoing intravitreal bevacizumab therapy. DESIGN Retrospective, consecutive chart review. METHODS The charts of neovascular AMD patients who underwent intravitreal bevacizumab therapy using a treat-and-extend dosing schedule were reviewed. ICG angiographic CNV surface areas were measured at baseline, 2 months, 6 months, and 12 months in each subject. The primary outcome was change in CNV size. Secondary outcomes included the correlation of change in CNV surface area with change in best-corrected visual acuity (BCVA), change in central macular thickness on optical coherence tomography (OCT), and the number of injections delivered over the 12-month study interval. RESULTS A total of 123 subjects were included in the analysis. The baseline CNV size was 1.9 mm2±2.5 mm2. CNV size was 1.66 mm2±2.11 mm2 at 2 months, 1.60 mm2±2.23 mm2 at 6 months, and 1.50 mm2±2.12 mm2 at 12 months. The change in CNV size from baseline was not statistically significant at any of the follow-up intervals. A decrease in CNV size of 33% or more at 2 months was associated with a significant decrease in CNV size at 12 months (P=.0096), complete resolution of CNV at 12 months (P=.0013), and a decrease in the number of injections delivered over the study interval (P=.0165). Complete resolution of CNV at 12 months occurred in 7.3% of subjects. Subjects that had complete resolution of CNV at 12 months were significantly more likely to gain 3 more lines of BCVA at the end of the study interval (P=.0131). No significant correlation was found between CNV size and change in central macular thickness on OCT. CONCLUSIONS Our study suggests that change in CNV size on ICG angiography may help the clinician predict the clinical course of neovascular AMD subjects undergoing intravitreal bevacizumab therapy using a treat-and-extend dosing schedule.

Prospective analysis of outcomes and economic factors of same-day bilateral cataract surgery in the United States

Purpose To evaluate the visual and economic benefits of same‐day bilateral cataract surgery versus separate‐day bilateral cataract surgery in the United States. Setting Private practice, Amarillo, Texas, USA. Design Prospective controlled nonrandomized clinical trial. Methods A cohort of patients having same‐day bilateral cataract surgery was age‐matched with a cohort of control patients who had standard separate‐day bilateral cataract surgery. The primary outcome was a comparison of the direct cost for the patient, physician, ambulatory surgery center (ASC), and third‐party payer. Results The same‐day cohort (42 patients, 84 eyes) had similar baseline characteristics and postoperative outcomes as the control cohort (42 patients, 84 eyes). The same‐day cohort had less total distance traveled for care (P = .0039 and P < .0001 for in‐town and out‐of‐town residents, respectively), less total time spent traveling for care (P = .0008 and P < .0001 for in‐town and out‐of‐town residents, respectively), less total number of visits required for care (P < .0001), and less total time for vision recovery (P < .0001) than the control cohort. The physician and ASC reimbursements were lower in the same‐day cohort (P = .0028 and P = .0016, respectively), whereas the total physician time spent caring for the patient in surgery was not different between the 2 groups (P = .7310). The total ASC expenses were higher in the same‐day cohort (P < .0001). The total third‐party payer cost was significantly less in the same‐day cohort (P < .0001). Conclusion Visual and economic benefits for the patient can be achieved with same‐day bilateral cataract surgery in the U.S. at the present time. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

The Safety and Efficacy of Routine Administration of Intracameral Vancomycin during Cataract Surgery.

Purpose. To evaluate the safety and efficacy of intracameral vancomycin during cataract surgery using a standardized dosage and delivery technique. Methods. The charts of 20,719 consecutive eyes that underwent phacoemulsification with intraocular lens implantation in a single ambulatory surgery center were retrospectively reviewed over a 5-year period. Results. The first 11,333 consecutive cases did not receive intracameral vancomycin, whereas the next 9,386 consecutive cases all received intracameral vancomycin. There were no significant differences in the baseline characteristics between the cohort of subjects who received intracameral vancomycin and the cohort of subjects that did not. There were a total of 11 subjects (0.97 cases per 1,000) that developed postoperative endophthalmitis in the group that did not receive intracameral vancomycin, whereas there were no cases of postoperative endophthalmitis in the group that received intracameral vancomycin (p = 0.0015). The overall rate of intraoperative and postoperative complications and the final postoperative visual acuities were similar among cohorts. There were no cases of toxic anterior segment syndrome occurring in either group during the study period. Conclusions. Routine administration of intracameral vancomycin during cataract surgery significantly decreased the incidence of postoperative endophthalmitis and was not associated with an increased incidence of postoperative adverse events.

Epithelium-off versus transepithelial corneal collagen crosslinking for progressive corneal ectasia: a randomised and controlled trial

Aim To compare the outcomes of corneal collagen crosslinking (CXL) for the treatment of progressive corneal ectasia using a standard epithelium-off technique versus a transepithelial technique with enhanced riboflavin solution. Methods One hundred and forty-four eyes with progressive corneal ectasia were prospectively randomised into a transepithelial CXL study arm or an epithelium-off CXL control arm. Follow-up examinations were set at 3, 6, 12 and 24 months. The primary outcome measure was change in the maximum simulated keratometry value (Ksteep) after 24 months of follow-up. The secondary outcome measure was change in the best spectacle-corrected visual acuity (BSCVA) after 24 months follow-up. Results One hundred and thirty-one eyes completed the 24-month follow-up interval. Change in Ksteep was −1.52±0.66 dioptres (D) for the control group versus −0.54±0.58 D for the study group at 24 months of follow-up (p=0.0320). Change in BSCVA was −0.18±0.09 logMAR for the control group versus −0.14±0.08 logMAR for the study group at 24 months of follow-up (p=0.4978). Two eyes in the control group had minor postoperative complications that did not affect the final visual acuity, and one eye in the control group underwent keratoplasty during the study interval. Conclusions At 24 months of follow-up, subjects in the epithelium-off CXL group demonstrated a greater improvement in Ksteep compared with subjects in the transepithelial CXL group, but no statistically significant difference in BSCVA was found between groups. Trial registration number NCT01708538; pre-results.

Ranibizumab Versus Bevacizumab for Neovascular Age-Related Macular Degeneration With an Incomplete Posterior Vitreous Detachment.

PurposeThe aim of this study was to compare the effects of ranibizumab to those of bevacizumab during the treatment of neovascular age-related macular degeneration (AMD) with an incomplete posterior vitreous detachment. DesignA retrospective chart review. MethodsA retrospective chart review was performed on treatment-naive neovascular AMD subjects with an incomplete posterior vitreous detachment treated with either ranibizumab or bevacizumab over a 12-month period. ResultsOne hundred thirty subjects were analyzed. There were 49 subjects determined to have vitreous attachment to the fovea. Subjects with vitreous attachment to the fovea required a significantly greater number of injections during the study interval compared with those without (10.2 ± 0.75 vs 7.8 ± 0.62) (P < 0.0001). In subjects with vitreous attachment to the fovea, the ranibizumab cohort had a greater improvement in visual acuity (0.18 ± 0.1 vs 0.04 ± 0.11 logMAR) (P = 0.0176) and a greater reduction in macular thickness (93.4 ± 32.2 &mgr;m vs 30.3 ± 28.3 &mgr;m) (P = 0.0064) compared with the bevacizumab cohort. ConclusionsNeovascular AMD patients with vitreous attachment to the fovea may have better visual and anatomic outcomes when treated with ranibizumab compared with bevacizumab.

Incidence and Outcomes of Anterior Chamber Gas Bubble during Femtosecond Flap Creation for Laser-Assisted In Situ Keratomileusis

Purpose. To report the incidence and outcomes of anterior chamber gas bubble formation during femtosecond laser flap creation for laser-assisted in situ keratomileusis (LASIK). Methods. The charts of 2,886 consecutive eyes that underwent femtosecond LASIK from May 2011 through August 2014 were retrospectively reviewed. The incidence, preoperative characteristics, intraoperative details, and postoperative outcomes were analyzed in subjects developing anterior chamber gas bubble formation during the procedure. Results. A total of 4 cases (0.14%) developed anterior chamber gas bubble formation during femtosecond laser flap creation. In all four cases, the excimer laser was unable to successfully track the pupil immediately following the anterior chamber bubble formation, temporarily postponing the completion of the procedure. There was an ethnicity predilection of anterior chamber gas formation toward Asians (p = 0.0055). An uncorrected visual acuity of 20/20 was ultimately achieved in all four cases without further complications. Conclusions. Anterior chamber gas bubble formation during femtosecond laser flap creation for LASIK is an uncommon event that typically results in a delay in treatment completion; nevertheless, it does influence final positive visual outcome.

One-Year Outcomes of Femtosecond Laser-Assisted LASIK Following Previous Radial Keratotomy.

PURPOSE To report the 1-year outcomes of LASIK in patients with previous radial keratotomy using a novel femtosecond laser platform. METHODS The charts of 27 eyes of 18 patients who underwent femtosecond laser-assisted LASIK with the WaveLight FS200 laser (Alcon Laboratories, Inc., Fort Worth, TX) for consecutive hyperopia following previous radial keratotomy were retrospectively reviewed at a single private practice location. The preoperative characteristics, intraoperative details, and postoperative results were evaluated. RESULTS All 27 eyes had successful femtosecond laser flap creation without significant intraoperative or postoperative complications. Uncorrected visual acuity significantly improved postoperatively to 0.13 ± 0.13 logMAR at 12 months of follow-up (P < .0001). Postoperative spherical equivalent averaged 0.11 ± 0.53 diopters. None of the patients lost any lines of corrected distance visual acuity during the postoperative period. CONCLUSIONS The femtosecond laser technique described by this study resulted in a safe and effective way to deliver LASIK following previous radial keratotomy. Future investigations are needed to further validate the outcomes of this study.

Outcomes of Infectious versus Sterile Perforated Corneal Ulcers after Therapeutic Penetrating Keratoplasty in the United States.

Purpose. To compare the long-term outcomes of infectious versus sterile perforated corneal ulcers after therapeutic penetrating keratoplasty in the United States. Methods. The charts of 45 consecutive eyes that underwent primary therapeutic penetrating keratoplasty for a perforated corneal ulcer at a single center were retrospectively reviewed. The perforated ulcers were classified as infectious or sterile and the underlying demographics, clinical features, and 36-month outcomes were compared among the two groups. Results. Mean follow-up among subjects was 38.6 (±6.9) months. Patients presenting with sterile perforated ulcers were more likely to have a peripheral perforation location (p = 0.0333) and recurrence of the underlying disease condition (p = 0.0321), require adjunctive surgical measures in the immediate postoperative period (p < 0.0001), have reperforation after keratoplasty (p = 0.0079), have worse best corrected visual acuity (p = 0.0130), develop no light perception vision (p = 0.0053), and require enucleation/evisceration (p = 0.0252) when compared to the infectious perforated ulcer group. Conclusions. Sterile perforated corneal ulcers have a worse prognosis and may be more frequent than those caused by infectious disease in the United States compared to the developing world.