Stuart I. Brown

Depression, visual acuity, comorbidity, and disability associated with age-related macular degeneration

OBJECTIVE To examine (1) the prevalence of depressive disorders in community-dwelling adults with advanced age-related macular degeneration (AMD) and (2) the relationship in this population between depression, visual acuity, the number of comorbid medical conditions, disability caused by vision loss as measured by the National Eye Institute-Vision Function Questionnaire (NEI-VFQ) and the vision-specific Sickness Impact Profile (SIPV), and disability caused by overall health status as measured by the Sickness Impact Profile-68 (SIP). DESIGN Analysis of cross-sectional baseline data from a randomized clinical trial. PARTICIPANTS Participants were 151 adults aged 60 and older (mean age, 80 years) with advanced macular degeneration whose vision was 20/60 or worse in their better eye. METHODS Subjects were interviewed using measures of depression, disability, and chronic medical conditions. Visual acuity was obtained. Nonparametric correlation analyses and linear regression analyses were performed. MAIN OUTCOME MEASURES Structured Clinical Interview for DSM-IV (SCID-IV), Geriatric Depression Scale (GDS), NEI-VFQ, SIPV, and SIP. RESULTS Of the participants, 32.5% (n = 49) met SCID-IV criteria for depressive disorder, twice the rate observed in previous studies of community-dwelling elderly. Over and above depression (GDS), visual acuity aided in prediction of the level of vision-specific disability (NEI-VFQ and SIPV). CONCLUSIONS Depressive disorder is a significant problem for the elderly afflicted with advanced macular degeneration. Further research on psychopharmacologic and psychotherapeutic interventions for depressed AMD patients is warranted to improve depression and enhance functioning. Over and above depression, visual acuity aided in predicting vision-specific disability. Treatment strategies that teach patients to cope with vision loss should be developed and evaluated.

Immunosuppressive therapy in ocular cicatricial pemphigoid.

To evaluate the efficacy of systemic immunosuppressive drugs, including corticosteroids, in the long-term treatment of ocular cicatricial pemphigoid, we conducted a prospective clinical trial in 57 patients (34 women and 23 men ranging in age from 46 to 94 years). Each patient was assigned to one of five groups. Group 1 (26 patients) served as the control group (four patients in this group who showed progression were later switched to treatment groups). Group 2 (eight patients) received combination therapy with cyclophosphamide and prednisone; Group 3 (13 patients) received cyclophosphamide alone: Group 4 (nine patients) received azathioprine; and Group 5 (five patients) received prednisone alone. We found that untreated ocular cicatricial pemphigoid has a variable course and does not necessarily progress. Further, the disease may be asymmetric in severity and progression; progression is more likely in advanced stages than in the earlier stages. Although immunosuppressive therapy inhibited conjunctival shrinking in all four treatment groups, some eyes in each group progressed despite treatment. Serious complications included hemorrhagic cystitis, dermatitis, anorexia and weight loss, gastrointestinal bleeding, and leukopenia.

Bacterial Endophthalmitis Associated with Exposed Monofilament Sutures Following Corneal Transplantation

Three cases of bacterial endophthalmitis following corneal transplantation resulted from suture abscesses that were initiated by loose or broken exposed sutures. Histopathologic examination clearly demonstrated that the infection gained access to the anterior chamber by following a deeply placed suture that traversed the posterior wound gap at the donor-host interface. We believe that exposed sutures may lead to significant postoperative complications and must be carefully observed.

Therapy of Mooren's ulcer.

In 37 eyes of 23 patients with Moorens ulcer initial treatment with topical corticosteroids healed 12 ulcers. Conjunctival excision, used if the corticosteroids failed, healed eight ulcers. Patients failing to respond to topical corticosteroids and conjunctival excision were treated with immunosuppression. This resulted in healing of four of 13 ulcers. Overall, 24 of 37 ulcers (65%) were healed. Eight of nine unilateral ulcers and six of six bilateral nonsimultaneous ulcers (ulcer began in one eye after healing in the other) healed after treatment with topical corticosteroids and conjunctival excision. However, only ten of 22 bilateral simultaneous ulcers responded to topical corticosteroids, conjunctival excision, and immunosuppression. Bilateral, simultaneously active Moorens ulcer is a severe, relentlessly destructive condition for which no completely satisfactory treatment exists.

Running Nylon Suture Dissolution After Penetrating Keratoplasty

We attempted to evaluate whether the low degrees of astigmatism achieved early in the postkeratoplasty period with the combined interrupted/running suturing technique were maintained for long periods of time. For 13 to 70 months (mean, 30.2 months), we monitored a group of patients (25 eyes) who had previously undergone the combined interrupted/running suturing technique (12 interrupted 10-0 nylon sutures and one running 11-0 nylon suture). Nine running sutures broke spontaneously, causing a significant increase of the keratometric astigmatism of the entire population from 1.7 +/- 1.6 to 3.4 +/- 2.6 diopters (mean +/- standard deviation). The mean vector-corrected change in astigmatism after suture breakage was 4.9 +/- 2.6 diopters. Surgical procedures to reduce astigmatism were required in many of the eyes in which the 11-0 running nylon suture broke. Our results suggested that 11-0 nylon is not an ideal material for the running suture because its high rate of spontaneous disruption leads to undesired, statistically significant increases in postkeratoplasty astigmatism. Further, our results indicated that the selective suture technique can maintain low degrees of astigmatism only if the sutures remain intact. Studies of the effect of keratoplasty suturing techniques on astigmatism should probably include a follow-up that is sufficiently long to indicate its long-term value to the patient.

Refractive errors in low-income preschoolers

Purpose: To estimate the overall prevalence of refractive errors in a study population of low-income preschoolers in San Diego County. Methods: The study sample included 507 preschool children selected from a study population of all 3–5 year-old children in Head Start and San Diego Unified School District preschools (74% Latino). The sample was examined by optometrists in the mobile clinic of the University of California, San Diego, Department of Ophthalmology with retinoscopy under cycloplegia to assess the presence of refractive errors defined as myopia ≥2D in 3–4 year-olds and ≥1D in > 4 year-olds; hyperopia ≥4D in 3–4 year-olds and ≥3D in > 4 year-olds; and astigmatism ≥1.75D in 3–4 year-olds and ≥1.5D in > 4 year-olds. Anisometropia was defined as ≥1.25D difference between the eyes. Emmetropia was defined as refractive errors below these levels. Results: A total of 16% (n = 81 children) (95% confidence interval: 15.4–16.5) met study definitions of refractive errors in at least one eye. Myopia was found in 3%, (OD Mean Sphere = 2.4D); hyperopia in 7.5% (OD Mean Sphere = 3.8D); astigmatism in 5.5% (OD Mean Cylinder = 2.3D); and 84% were emmetropic (OD Mean Sphere = 1.3D). Conclusions: Hyperopia and astigmatism were the most frequent refractive errors in this sample of low-income preschoolers, most of whom were Latino.

A new objective digital computerized vision screening system.

PURPOSE Fewer than 40% of children in the crucial younger-than-4 age group are evaluated for visual problems by pediatricians. This is due to impracticality from either a clinical or practice efficiency standpoint. Current photoscreening methods require trained readers and suffer from significant subjectivity and interobserver variability. We report a cross-sectional, double-masked study using new digital imaging with objective, automated, computerized image analysis. METHODS Two-hundred six children aged 9 months to 16 years were prospectively studied in a University-based pediatric ophthalmology practice. Images were taken by volunteers with a modified digital camera which, when downloaded, were analyzed within 35 seconds by new image analysis software. The analysis was compared to a masked review of a complete pediatric ophthalmic exam. RESULTS Overall agreement between physician and the objective computerized analysis was 86.9%. Positive predictive value was 91%, sensitivity was 89%, and specificity was 83%. CONCLUSIONS This automated digital imaging screening system eliminates human bias and provides accurate and immediate results. The system requires no special expertise.

The Effect of Increased Intraocular Pressure on Visual Acuity and Corneal Curvature After Radial Keratotomy

To detect the effect of increased intraocular pressure on visual acuity and corneal curvature after radial keratotomy, we measured these variables in the sitting and inverted positions in 18 patients who underwent radial keratotomy (Group 1) and compared their results with those from the unoperated on eyes of seven patients (Group 2). We also compared the results before and after inversion within each group. Intraocular pressure increased to approximately two times normal in each group. Significant improvement in visual acuity and reduction in central keratometry were noted only in Group 1. By multiple regression analysis, visual improvement correlated with the number of incisions but not the time since surgery. Our study provides evidence that increased intraocular pressure may account for transient changes in vision and corneal curvature after radial keratotomy.

Transplantation of Congenitally Opaque Corneas from Eyes with Exaggerated Buphthalmos

We treated three eyes with marked buphthalmos and congenitally opaque corneas with cyclocryotherapy, one application in one eye and two applications in two eyes. The size of the eyes became rapidly smaller during the first two weeks postoperatively. Thereafter, corneal transplantation improved vision in each eye.

Corneal Transplantation in Microphthalmic Eyes

We performed corneal transplantation in nine microphthalmic eyes of five patients, who ranged in age from 1 to 63 months. The anteroposterior diameter of the eyes ranged from 12.5 to 16 mm. Complications from the surgery included superficial epithelial erosions in three eyes, leading to superficial scarring in one eye, glaucoma, and suture microabscesses. Despite these complications, seven of nine grafts have remained clear and vision developed in all eyes.