Sudha Cugati

A review of central retinal artery occlusion: clinical presentation and management

Central retinal artery occlusion (CRAO) is an ophthalmic emergency and the ocular analogue of cerebral stroke. Best evidence reflects that over three-quarters of patients suffer profound acute visual loss with a visual acuity of 20/400 or worse. This results in a reduced functional capacity and quality of life. There is also an increased risk of subsequent cerebral stroke and ischaemic heart disease. There are no current guideline-endorsed therapies, although the use of tissue plasminogen activator (tPA) has been investigated in two randomized controlled trials. This review will describe the pathophysiology, epidemiology, and clinical features of CRAO, and discuss current and future treatments, including the use of tPA in further clinical trials.

Five-year incidence and progression of vascular retinopathy in persons without diabetes: the Blue Mountains Eye Study.

PurposeTo assess the 5-year incidence of vascular retinopathy and its associations in an older nondiabetic population.MethodsThe Blue Mountains Eye Study examined 3654 residents aged 49+ years (82.4% response rate) during 1992–1994, and re-examined 2335 (75.1% of survivors) during 1997–1999. Retinopathy lesions (microaneurysms, haemorrhages, hard or soft exudates) were assessed from 6-field retinal photographs in persons without diabetes. Incident retinopathy was assessed in those at risk. Hypertensive status was defined following the WHO/International Society of Hypertension guidelines.ResultsOf the 2335 re-examined, 195 had retinopathy lesions at baseline and 1725 were at risk of retinopathy after excluding subjects with diabetes (n=261), retinal vein occlusion (n=52) or missing/un-gradable photographs (n=102). The cumulative 5-year incidence was 9.7% (95% confidence intervals (CI) 8.3–11.1%). Age was the only factor significantly associated with incident retinopathy (Pfor trend=0.012). Neither fasting blood glucose (age–sex-adjusted P=0.147) nor hypertension (adjusted Pfor trend=0.43) was associated with incident retinopathy. Of the 195 with retinopathy lesions at baseline, 3.5% developed diabetes, 13.3% progressed, and 72.3% regressed/disappeared over 5 years. Progression was positively associated with elevated blood pressure (BP) (adjusted odds ratio (OR) 1.3, 95% CI 1.1–1.6 per 10 mmHg systolic BP) and inversely associated with fasting glucose level (OR 0.36, CI 0.14–0.92 per mmol/l increase). Aspirin use was weakly associated with regression (OR 2.4, CI 1.0–6.0).ConclusionsOver 5 years, retinopathy developed in 10% of older people without diabetes, while 72% of baseline lesions regressed. Age was significantly associated with the development of these lesions.

Retinal Arteriolar Emboli and Long-Term Mortality: Pooled Data Analysis From Two Older Populations

Background and Purpose— To assess the relationship between retinal arteriolar emboli and mortality in older people. Methods— Pooled data from 2 population-based cohort studies. At baseline, the Beaver Dam Eye Study (BDES) examined 4926 persons 43 to 86 years of age (1988 to 1990), and the Blue Mountains Eye Study (BMES) examined 3654 persons 49 to 97 years of age (1992 to 1994). Retinal arteriolar emboli were assessed by grading retinal photographs using standardized methods. Deaths and causes of death were determined from death certificates or Australian National Death Index. Cox regression models were used to estimate mortality hazard ratios (HRs) associated with emboli, adjusting for age, gender, body mass index, hypertension, diabetes, smoking, serum total cholesterol, high-density lipoprotein cholesterol, study site, and past histories of stroke, angina, and acute myocardial infarct. Results— Of 8580 baseline participants, 8384 (98%) had retinal photographs available, and 111 showed retinal arteriolar emboli (BDES n=61; BMES n=50). Over 10 to 12 years, 2506 participants (30%) died, including 344 (4%) from stroke-related and 1315 (16%) from cardiovascular causes. The cumulative mortality rates were higher in participants with than without emboli (all-cause 56% versus 30%; stroke-related 12% versus 4.0%; cardiovascular 30% versus 16%). The increased mortality risk associated with emboli was independent of age, gender, other vascular risk factors, and past histories of stroke or heart disease for all-cause (multivariate-adjusted HR, 1.3; CI, 1.0 to 1.8) and stroke-related mortality (HR, 2.0; CI, 1.1 to 3.8) but not for cardiovascular mortality (HR, 1.2; CI, 0.8 to 1.7). Conclusions— Our pooled data from 2 older populations suggest that retinal emboli predict a modest increase in all-cause and stroke-related mortality independent of cardiovascular risk factors.

Development and progression of diabetic retinopathy 12 months after phacoemulsification cataract surgery.

OBJECTIVE To assess whether phacoemulsification cataract surgery exacerbates the development and progression of diabetic retinopathy (DR) in a cataract surgical cohort. DESIGN Clinic-based cohort study. PARTICIPANTS Patients aged 65+ years undergoing cataract surgery at an eye clinic in Sydney, Australia, between 2004 and 2006. METHODS Digital retinal photography was performed after pupil dilation preoperatively and at 1-, 6-, and 12-month postoperative visits. DR was assessed using the modified Early Treatment Diabetic Retinopathy Study (ETDRS) classification. Preoperative and 1-month postoperative (baseline) photographs were compared side-by-side with 12-month postoperative photographs. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for DR progression in operated (pseudophakic) compared with nonoperated (phakic) eyes, adjusted for age, sex, diabetes duration, and preoperative glycosylated hemoglobin level. MAIN OUTCOME MEASURES Incident DR was defined in eyes without DR at baseline in which DR was detected at 12-month postoperative visits. DR progression was defined as an increase of 1 or more ETDRS steps during the same period, including incident cases. RESULTS Of 1994 surgical patients recruited, 190 (9.53%) with diabetes and complete data and thus were included. There were 56 patients with unilateral surgery performed before baseline (mean postoperative duration 3.3+/-3.3 years). The prevalence of DR at baseline was higher in these 56 pseudophakic eyes than in 324 phakic eyes (71.4% vs. 48.2%, respectively, adjusted OR 2.16; 95% CI, 1.16-4.03). Of the 190 patients, 169 were followed for 12+ months postoperatively; 278 eyes were pseudophakic, and 60 eyes remained phakic at 12 months. During the 12-month postoperative period, incident DR developed in 28.2% of pseudophakic eyes and 13.8% of phakic eyes (adjusted OR 2.65; 95% CI, 1.06-6.61). In a paired-eye comparison of 45 patients who remained unilaterally pseudophakic at 12 months and were at risk of DR progression, 35.6% of pseudophakic eyes exhibited DR progression compared with 20.0% of the fellow phakic eyes (adjusted OR 2.21; 95% CI, 0.85-5.71). CONCLUSIONS Diabetic patients undergoing phacoemulsification cataract surgery appear to have a doubling of DR progression rates 12 months after surgery. This outcome, however, represents less progression than was previously documented with intracapsular and extracapsular cataract surgical techniques.

Retinal Vascular Caliber and the Long‐Term Risk of Diabetes and Impaired Fasting Glucose: The Blue Mountains Eye Study

Objective: To assess the associations of retinal vessel caliber with the 10‐year incidence of diabetes and impaired fasting glucose (IFG). Methods: The Blue Mountains Eye Study is a population based cohort study of Australian residents aged at least 49 years, with baseline examinations conducted during 1992–4. Retinal arteriolar and venular calibers were measured and summarized from baseline digitized images in 3368 participants. Diabetes was defined as a physician‐diagnosis of diabetes or fasting blood glucose ≥ 126 mg/dL and IFG as fasting blood glucose 109 to 125 mg/dL. Ten year incidence of diabetes and IFG was defined from 5‐ and 10‐year follow up data. Results: After adjusting for age and gender, wider retinal venular caliber was associated with an increased incidence of diabetes and IFG. These associations were not significant after controlling for baseline glucose, body mass index and other factors. In persons 49–70 years of age at baseline, however, the association of wider retinal venular caliber and incident IFG persisted after further controlling for other factors (OR, 1.53, 95% CI, 1.11–2.12). Retinal arteriolar caliber was not associated with incident diabetes or IFG. Conclusions: This study suggests that wider retinal venular caliber was associated with higher risk of IFG in middle‐aged persons.

Risk of Age-related Macular Degeneration 3 Years after Cataract Surgery: Paired Eye Comparisons

OBJECTIVE To clarify possible associations between cataract surgery and progression of age-related macular degeneration (AMD). DESIGN Clinic-based cohort. PARTICIPANTS We followed cataract surgical patients aged 65+ years in the Australian Cataract Surgery and Age-related Macular Degeneration (CSAMD) study. Patients who remained unilaterally phakic for at least 24 months after recruitment were included. METHODS We performed annual examinations with retinal photography. We assessed AMD using side-by-side grading of images from all visits. Paired comparisons between operated and nonoperated fellow eyes (defined as nonoperated or operated <12 months previously) were made using generalized estimating equation models. MAIN OUTCOME MEASURES Incident early AMD was defined as the new appearance of soft indistinct/reticular drusen or coexisting retinal pigmentary abnormality and soft distinct drusen in eyes at risk of early AMD. Incident late AMD was defined as the new appearance of neovascular AMD or geographic atrophy (GA) in eyes at risk of late AMD. RESULTS Among 2029 recruited, eligible participants, 1851 had cataract surgery performed at Westmead Hospital, Sydney, and 1244 (70.7%) had 36-month postoperative visits. Of these participants, 1178 had gradable photographs at baseline and at least 1 follow-up visit. Of 308 unilaterally operated participants at risk of late AMD, this developed in 4 (1.3%) operated and 7 (2.3%) nonoperated fellow eyes (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.23-2.36) after adjusting for the presence of early AMD at baseline. Of 217 unilaterally operated participants at risk of early AMD, this developed in 23 (10.6%) operated and 21 (9.7%) nonoperated fellow eyes (OR, 1.07; 95% CI, 0.74-1.65). Incident retinal pigment abnormalities were more frequent in operated than nonoperated fellow eyes (15.3% vs. 9.9%; OR, 1.64; 95% CI, 1.07-2.52). There was no difference in the 3-year incidence of large soft indistinct or reticular drusen between the 2 eyes (8.8% vs. 7.9%; OR, 1.12; 95% CI, 0.79-1.60). CONCLUSIONS Prospective follow-up data and paired eye comparisons of this older surgical cohort showed no increased risk of developing late AMD, early AMD, or soft/reticular drusen over 3 years. There was a 60% increased detection of retinal pigmentary changes in surgical eyes.

Age-related maculopathy and cataract surgery outcomes: visual acuity and health-related quality of life

PurposeTo assess visual acuity (VA) and health-related quality of life (HRQoL) outcomes in patients with and without age-related maculopathy (ARM) after cataract surgery.MethodsPatients aged 60+ years who had undergone cataract surgery at the Westmead Hospital during 2001–2003 were re-examined 1–3 years after surgery. Tests included VA and assessment of visual- and HRQoL using standardised questionnaires (VF-14, SF-12). Preoperative comorbidity data were collected from medical records. Poor surgical outcomes (VA<6/12; no VA improvement; lowest quintile of VF-14, SF-12 scores) were compared in patients with and without ARM, adjusting for age, sex, preoperative systemic comorbidities, ocular comorbidities and surgical or postoperative complications.ResultsOf 622 surviving patients, 454 (73%) were followed up for a mean period of 2.8 years. Similar proportions with VA≥6/12 were observed in patients with (80.2%) and without (88.8%) pre-existing ARM. Preoperative early ARM was only associated with slightly lower mean VF-14 scores (87.64 with vs92.58 without ARM, P=0.01). Increasing age and preoperative ocular comorbidities were associated with all poor outcomes measured. Low SF-12 scores were associated with preoperative systemic comorbidities.ConclusionOur study documents favourable cataract surgical outcomes 1–3 years after cataract surgery in patients with preoperative ARM.

Australian Prospective Study of Cataract Surgery and Age-Related Macular Degeneration: Rationale and Methodology

Background: Cataract surgery is the most frequently performed ophthalmic procedure worldwide. While benefits gained from cataract surgery outweigh surgical risks, there have been concerns that older persons may have an increased risk of developing age-related macular degeneration (AMD) after cataract surgery. Objective: The Australian Prospective Study of Cataract Surgery and Age-Related Macular Degeneration Study aims to assess the risk of AMD in a large cohort of older patients following cataract surgery. The current report describes the study rationale, design and methodology. Design: Longitudinal studyParticipants: Approximately 2000 cataract surgical patients aged 65 years or older are being recruited from both public and private sources in western Sydney, Australia.Methods: At study visits, participants are interviewed using standardized questionnaires to obtain information on demographic, medical, and ocular conditions and AMD risk factors, together with data on general health and vision-related quality of life. Eye examinations include visual acuity, intraocular pressure, keratometry and A-scan measurements, plus lens and retinal photography, following pupil dilatation. Retinal photographs taken before cataract surgery, and at 1, 6, 12, and 24 months after surgery are graded for early and late AMD lesions, using the Wisconsin age-related maculopathy grading system. The 1-month post-operative retinal photographs supplement the baseline macular assessment for cases in which cataract occludes a clear view of the macula pre-operatively. It is intended that study participants will be followed for up to five years post-operatively to clarify the question of whether aphakic or pseudophakic, compared to phakic eyes, have a greater risk of developing AMD.

Ten-Year Incidence of Retinal Emboli in an Older Population

Background and Purpose— To assess 10-year incidence of retinal emboli and its predictors in an older population. Methods— Survivors of 3654 Blue Mountains Eye Study participants ≥49 years of age were re-examined 5 and 10 years later. Incident emboli were assessed from retinal photographs. Results— Cumulative 10-year incidence was 2.9% (95% CI, 2.1% to 3.6%) among 2361 at risk. Age was associated with incident emboli (Ptrend=0.0001). After multivariate adjustment, hypertension (odds ratio [OR], 1.8; CI, 1.0 to 3.1), hypercholesterolemia (OR, 1.3; CI, 1.0 to 1.6), overweight (OR, 3.3; CI, 1.6 to 6.9), current smoking (OR, 2.5; CI, 1.1 to 5.9), increasing fibrinogen level (OR per mg/dL, 1.1; CI, 1.0 to 1.2), and retinal vascular signs (arteriovenous nicking OR, 2.0; CI, 1.2 to 3.6; arteriolar wall opacification OR, 2.3; CI, 1.1 to 5.0; retinal vein occlusion OR, 3.2; CI, 1.0 to 9.9) were significantly associated with incident emboli. Conclusions— The 3% incidence of retinal arteriolar emboli found in this older population is likely to be an underestimate attributable to the transient nature of emboli and differential loss to follow-up. Most cardiovascular risk factors predict retinal embolism.

Long-term outcomes of phacoemulsification cataract surgery performed by trainees and consultants in an Australian cohort

Background:  It is unclear whether differences exist in surgical complication rates and long‐term visual acuity outcomes between patients whose phacoemulsification cataract surgery was performed by ophthalmological trainees and those performed by consultants.