Stanley C.C. Chi

Simvastatin and disease stabilization in normal tension glaucoma: a cohort study.

PURPOSE To investigate whether simvastatin use is associated with visual field (VF) stabilization in patients with normal tension glaucoma (NTG). DESIGN Prospective cohort study (ClinicalTrials.gov Identifier: NCT00321386). PARTICIPANTS A total of 256 eyes from 256 Chinese subjects with NTG. METHODS Patients were followed up at 4-month intervals for 36 months for VF progression per Andersons criteria. Clinical parameters were checked for association with progression in multivariate analysis. MAIN OUTCOME MEASURES The primary outcome was the association between simvastatin use and VF progression. RESULTS Thirty-one patients (12.1%) were taking simvastatin (statin+), and 225 patients (87.9%) were not taking simvastatin (statin-). Baseline age, gender, untreated intraocular pressure, VF indices, vertical cup-to-disc ratio, and central corneal thickness (CCT) were comparable between the 2 groups. There were significantly more patients with a history of hypercholesterolemia, systemic hypertension, and ischemic heart disease in the statin+ group. A total of 121 patients (47.3%) showed evidence of VF progression (mean rate of mean deviation loss was -0.30 decibel per year) during the 36 months of follow-up. Simvastatin use was among 8 of 121 patients (6.6%) who progressed compared with 23 of 135 patients (17.0%) who did not progress (P = 0.011). Logistic regression revealed that history of disc hemorrhage (relative risk [RR] 3.26; 95% confidence interval [CI], 1.21-8.76; P = 0.019), history of cerebrovascular accidents (RR 2.28; 95% CI, 1.03-5.06; P = 0.043), and baseline age (per 10 years older; RR 1.38; 95% CI, 1.08-1.76; P = 0.009) were significant risk factors for VF progression, whereas simvastatin use conferred a protective effect (RR 0.36; 95% CI, 0.14-0.91; P = 0.030). CONCLUSIONS Simvastatin use may be associated with VF stabilization in patients with NTG. A larger scale randomized controlled trial and cost-effectiveness analyses seem warranted.

Silent Cerebral Infarct and Visual Field Progression in Newly Diagnosed Normal-Tension Glaucoma: A Cohort Study

PURPOSE To investigate whether the presence of silent cerebral infarct (SCI) is related to field progression in patients with newly diagnosed normal-tension glaucoma (NTG). DESIGN Prospective cohort study. PARTICIPANTS A total of 286 eyes from 286 NTG patients: 64 with SCI (SCI+) and 222 without SCI (SCI-). METHODS Patients were assigned to the SCI+ or SCI- group depending on the presence of SCI as detected by cranial computed tomography scan at baseline. Patients were followed-up at 4-month intervals for 36 months for visual field progression as per Andersons criteria. MAIN OUTCOME MEASURES The primary outcome was the association between SCI and field progression. Secondary outcomes include the prevalence of SCI in NTG patients and other risk factors associated with progression. RESULTS There were no significant differences in the baseline intraocular pressures (IOPs), fluctuation amplitude of pretreatment IOP, baseline visual acuity, vertical cup-to-disc ratio, vertical disc diameter, presenting field indices, and central corneal thickness (CCT) between the 2 groups. Patients with SCI were significantly older compared with SCI- patients (72.4+/-10.7 vs. 63.2+/-14.2 years; P<0.001). Univariate analyses revealed age, fluctuation amplitude of pretreatment IOP, thinner CCT, presence of disc hemorrhage, systemic hypertension, arrhythmia, and SCI were significant for field progression. Silent cerebral infarct was present in 29.6% of field-progressed subjects versus 15.3% of field-stable subjects (P = 0.004). Kaplan-Meier survival analysis revealed that 65.6% of SCI+ versus 45.9% of SCI- patients had progressed (P = 0.003). Cox proportional hazards regression analysis showed disc hemorrhage (hazard ratio [HR], 2.28; 95% confidence interval [CI], 1.54-3.37; P<0.001), SCI (HR, 1.61; 95% CI, 1.09-2.36; P = 0.016), systemic hypertension (HR, 1.48; 95% CI, 1.04-2.10; P = 0.029), and CCT (per 30 mum of thinning; HR, 1.35; 95% CI, 1.16-1.75; P<0.001) were associated with field progression. Other variables significant in the univariate analysis were not significant in the regression model. The most common location of SCI was at the basal ganglia. CONCLUSIONS Presence of SCI may be an independent risk factor for visual field progression in patients with NTG.

Diamond burr polishing for recurrent corneal erosions: results from a prospective randomized controlled trial.

Purpose: To evaluate the use of diamond burr polishing as an in-office treatment for recurrent corneal erosion (RCE). Methods: A double-masked randomized controlled trial was conducted. Patients with RCE secondary to trauma or anterior basement membrane dystrophy underwent epithelial debridement (ED) or diamond burr superficial keratectomy (DBSK) at the slit lamp. Patients were followed up for 6 months, and the recurrence rates of RCE and visual outcomes were compared. Results: Forty-eight eyes of 48 patients were recruited. The mean ± SD age was 38.3 ± 12.9 years. Twenty-five patients underwent DBSK, and 23 patients received ED alone. There was no significant difference in the baseline demographics between the 2 groups. Kaplan-Meier survival analysis showed significantly less major and minor recurrences and less need for repeated surgical interventions in the DBSK group compared with the ED group (P < 0.001). Eyes in the DBSK group also had significantly lower mean magnitude of astigmatism after treatment compared to the ED group (P = 0.021). Conclusion: Diamond burr polishing is a safe, convenient, and inexpensive treatment option for the management of RCE and resulted in better outcomes compared to simple epithelial debridement.

Pediatric ocular surface infections: a 5-year review of demographics, clinical features, risk factors, microbiological results, and treatment.

Purpose: To evaluate the clinical and microbiological profiles of pediatric patients with ocular surface infections requiring corneal or conjunctival scraping for diagnosis. Methods: The medical records of 138 consecutive patients aged 18 years or younger who had undergone corneal or conjunctival scraping over a 5-year-period in a tertiary ophthalmic center were reviewed. Demographics, clinical features, risk factors, microbiological results, and treatment were recorded. Results: Ocular surface infections were classified into 4 groups: infectious keratitis (group 1); blepharokeratoconjunctivitis (group 2); conjunctivitis (group 3); and congenital nasolacrimal duct obstruction or dacryocystitis (group 4). The groups had different mean ages of presentation, with group 4 presenting the youngest at 2 years and group 1 presenting the oldest at 14 years. Contact lens wear and blepharitis were the major risk factors. The positive culture rate was 60.9%, of which 65.5% were Gram-positive organisms. Coagulase-negative staphylococci were the most common organisms (23.2%), followed by Pseudomonas aeruginosa (9.4%) and Staphylococcus aureus (8.0%). Microbial yield was highest in group 1 (86%) and lowest in group 3 (38.6%). There were 9 orthokeratology-related infectious keratitis cases (18%) and 9 chlamydial ophthalmia neonatorum cases isolated. Conclusions: With increasing contact lens wear in the pediatric and adolescent populations and the common occurrence of blepharokeratoconjunctivitis and staphylococcal ocular surface infections, parents and children should be highly vigilant with eyelid hygiene and contact lens practice.

The use of postoperative topical mitomycin C in the treatment of recurrent conjunctival papilloma.

Purpose. To describe the use of postoperative topical mitomycin C (MMC) in the treatment of recurrent conjunctival papilloma. Methods. Case report. Results. We report a 26-year-old man with recurrent conjunctival papilloma despite repeated surgical excision, cauterization, and cryotherapy. He was then treated with excision by cryotherapy, followed by a 2-week course of topical MMC eyedrops prescribed at postoperative day 7 (0.02 mg/mL, four times daily). No recurrence was observed 24 months postoperatively, and no complication was observed during the follow-up period. Conclusion. Postoperative topical MMC may be a useful adjunct in the management of recurrent conjunctival papilloma.

Surgical management of double-head pterygium by using a novel technique: conjunctival rotational autograft combined with conjunctival autograft.

Purpose: To describe a novel technique for the surgical management of double-head pterygium and to evaluate its safety and efficacy. Methods: A prospective noncomparative interventional case series was conducted. Patients with primary double-head pterygium underwent pterygium excision, followed by conjunctival rotational autograft (CRA) combined with conjunctival autograft (CA). CRA was harvested from the larger pterygium and placed over the bare scleral defect of the smaller pterygium with 180-degree rotation. The bare scleral defect of the larger pterygium was covered with CA harvested from the superior bulbar conjunctiva. Patients were followed up for 1 year, and the outcomes and recurrence rates were noted. Results: Twenty patients were recruited into the study, of which 7 (35%) were men and 13 (65%) were women. The mean age was 63.8 years. No intraoperative complication was encountered. Postoperatively, there was significant improvement in best-corrected visual acuity (P = 0.005) and reduction in magnitude of astigmatism (P = 0.016). At 1 year after operation, there were 7 cases of recurrence (35%), but 4 were 1 mm. The main postoperative complication was persistent CRA injection in 9 cases. Conclusions: CRA combined with CA is a safe alternative in the management of double-head pterygium. Further modifications of the surgical techniques are warranted to decrease prolonged hyperemia of the CRA.

Good Visual Outcome After Prompt Treatment of acanthamoeba Keratitis Associated With Overnight Orthokeratology Lens Wear

Purpose. To describe a patient with a good visual outcome after prompt treatment of Acanthamoeba keratitis as a complication of overnight orthokeratology lens wear. Methods. Interventional case report. Results. A 9-year-old boy experienced pain, photophobia, and redness in his right eye 3 days after visiting a swimming pool. He had been wearing overnight orthokeratology lenses for 5 months for the correction of moderate myopia in both eyes. On examination, best-corrected visual acuity in the right eye was 20/40. A diagnosis of Acanthamoeba keratitis with the presence of the classic feature of perineural infiltrates was made. The patient responded well to treatment with polyhexamethylene biguanide and propamidine isethionate (Brolene). Culture of corneal scrapings and contact lens solution showed heavy growth of Acanthamoeba. Treatment was tapered gradually during the next 4 months, and the final best-corrected visual acuity was 20/25. Conclusions. Acanthamoeba keratitis may be a vision-threatening complication associated with overnight orthokeratology lens wear. It is essential for eye care professionals to fully explain and warn parents of the potential downsides that may be associated with orthokeratology. Ophthalmologists should have a high level of suspicion of this complication because prompt diagnosis and treatment can result in good visual outcome.

Randomized clinical trial of the efficacy and safety of tropicamide and phenylephrine in preoperative mydriasis for phacoemulsification

Purpose: To compare the mydriatic effect and safety between different concentrations of tropicamide and phenylephrine in preoperative mydriasis for phacoemulsification.

Cost-effectiveness of treating normal tension glaucoma.

PURPOSE To assess the long-term cost-effectiveness of treating normal tension glaucoma (NTG). METHODS A Markov decision-analytic health model was developed to determine the cost-effectiveness of treating NTG with IOP lowering therapy to prevent progressive visual field loss. Transitional probabilities were derived from the Collaborative Normal Tension Glaucoma Study and cost data obtained from the literature and the Medicare fee schedule. Incremental cost-effectiveness ratios (ICER) of treating all patients with NTG and treating selected individuals with risk factors for disease progression were determined using Monte Carlo simulation. Sensitivity analyses were performed by varying the cost of consultations, medications, laser/surgery, and adjusting utility loss from progressed states. RESULTS The ICER of treating all patients with NTG over a 10-year period was United States (US)

Comparison of the clinical characteristics of normal tension glaucoma patients with pretreatment intraocular pressures in the high-teens and low-teens

34,225 per quality-adjusted life year (QALY). The ICER would be reduced when treatment was offered selectively to those with risk factors for disease progression. The ICER for treating NTG patients with disc hemorrhage, migraine, and those who were female were US