Voraporn Chaikitmongkol

Early detection of choroidal neovascularization facilitated with a home monitoring program in age-related macular degeneration.

PURPOSE To describe clinical and imaging findings in two eyes with new onset subtle neovascular age-related macular degeneration that was detected by the regular use of a home monitoring device based on preferential hyperacuity visual field testing. METHODS Interventional case report. RESULTS Case 1, an 82-year-old man with the intermediate stage of age-related macular degeneration in both eyes, had been using the ForeseeHome device for 2 years when a change in test scores prompted an examination (an alert visit) to search for choroidal neovascularization (CNV) in his right eye. He denied any vision changes, and visual acuity remained 20/20 in the right eye. Fundus examination showed large drusen without any signs of CNV. The late phase of a fluorescein angiogram showed a small juxtafoveal area of subretinal leakage which corresponded to an intraretinal cystoid abnormality on optical coherence tomography. Intravitreal ranibizumab therapy was initiated, and the patient has maintained excellent visual acuity for at least 1 year. Case 2, a 67-year-old woman, had been using the home device for 3 months when an alert notification was prompted in the left eye. On notification, she recognized that she had had a subtle change in her vision in that eye with new distortion. Visual acuity decreased to 20/32 in the left eye. Fundus examination revealed stable confluent drusen without any apparent fluid, blood, or lipid. No definite fluorescein angiogram leakage was identified among the hyperfluorescent staining of extensive drusen. However, optical coherence tomography showed a cystoid abnormality in the inner plexiform layer prompting the initiation of intravitreal ranibizumab under the assumption that the changes represented CNV. CONCLUSION The home monitoring device has been proven to facilitate early detection of CNV associated with age-related macular degeneration. These two cases highlight early diagnosis of CNV heralded by the device. Visual acuity remained 20/32 or better, minimal or no fluorescein angiogram leakage was found, and subtle cystoid abnormalities appeared on optical coherence tomography.

Repeatability and Agreement of Visual Acuity Using the ETDRS Number Chart, Landolt C Chart, or ETDRS Alphabet Chart in Eyes With or Without Sight-Threatening Diseases

Importance The Early Treatment Diabetic Retinopathy Study (ETDRS) alphabet chart is not feasible for measuring best-corrected visual acuity (BCVA) for individuals who are unfamiliar with the Roman alphabet. The ETDRS Landolt C chart is an alternative, but it may not reflect true BCVA among those with confusion between left and right. The ETDRS number chart might overcome these limitations, but little is known regarding its reliability. Objective To evaluate repeatability and agreement of BCVA using the ETDRS number chart or Landolt C chart compared with ETDRS alphabet charts in healthy and diseased eyes. Design, Setting, and Participants A cross-sectional study was conducted in Thailand from July 1, 2015, to June 30, 2016, among 154 adult Thai individuals. Those who could read Roman alphabets were classified into the following 4 groups, using 1 eye per participant: group A, which comprised 60 healthy eyes (BCVA, 20/20-20/25); group B, which comprised 40 eyes with age-related cataract, diabetic macular edema, or age-related macular degeneration (BCVA, 20/20-20/40); group C, which comprised 40 eyes with age-related cataract, diabetic macular edema, or age-related macular degeneration (BCVA, 20/50-20/100); and group D, which comprised 14 eyes with age-related cataract, diabetic macular edema, or age-related macular degeneration (BCVA, 20/125-20/200). Interventions Two standardized 4-m BCVA measurements with 3 different Precision Vision ETDRS charts (PV number, Landolt C, and alphabet), in random sequence, performed 30 minutes apart. Main Outcomes and Measures Repeatability, agreement, and testing duration of BCVA. Results Of 154 Thai participants (82 women and 72 men; mean [SD] age, 52.9 [18.2] years), the ETDRS number chart had strong repeatability coefficients (group A, 0.61 [95% CI, 0.42-0.75]; group B, 0.87 [95% CI, 0.78-0.93]; group C, 0.81 [95% CI, 0.67-0.90]; and group D, 0.81 [95% CI, 0.49-0.94]). Concordance correlation coefficients between the number and alphabet charts were also strong (group A, 0.89 [95% CI, 0.82-0.93]; group B, 0.97 [95% CI, 0.94-0.98]; group C, 0.92 [95% CI, 0.86-0.96]; and group D, 0.96 [95% CI, 0.87-0.99]), while the concordance correlation coefficients between the Landolt C and alphabet charts were lower (group A, 0.72 [95% CI, 0.52-0.83]; group B, 0.83 [95% CI, 0.68-0.91]; group C, 0.79 [95% CI, 0.61-0.89]; and group D, 0.89 [95% CI, 0.66-0.97]). The mean letter score difference between the number and alphabet charts was 1 (95% limits of agreement, −4 to +6) compared with −7 (95% limits of agreement, −18 to +5; P < .001) between the Landolt C and alphabet charts. Conclusions and Relevance The repeatability coefficients and concordance correlation coefficients suggest that ETDRS number charts are viable for measuring BCVA in clinical practice and trials for individuals who are unfamiliar with the Roman alphabet.

Vision Preference Value Scale and Patient Preferences in Choosing Therapy for Symptomatic Vitreomacular Interface Abnormality

Importance While symptomatic vitreomacular interface abnormalities (VIAs) are common, assessment of vision preference values and treatment preferences of these may guide treatment recommendations by physicians and influence third-party payers. Objective To determine preference values that individuals with VIA assign to their visual state and preferences of potential treatments. Design, Setting, and Participants In this cross-sectional one-time questionnaire study conducted between December 2015 and January 2017, 213 patients from tertiary care referral centers in Thailand, the United Kingdom, and the United States were studied. Patients with symptomatic VIA diagnosed within 1 year of data collection, visual acuity less than 20/20 OU, and symptoms ascribed to VIAs were included. Data were analyzed from January 2017 to November 2017. Main Outcomes and Measures The primary end points were overall mean preference value that individuals with VIA assigned to their visual state and patients’ preferences for potential treatments. Preference values were graded on a scale from 0 to 1, with 0 indicating death and 1 indicating perfect health with perfect vision. Results Of the 213 included patients, 139 (65.3%) were women, and the mean (SD) age was 65.6 (7.7) years. Diagnoses included epiretinal membrane (n = 100 [46.9%]), macular hole (n = 99 [46.5%]), and vitreomacular traction (n = 14 [6.6%]). The mean (SD) vision preference value was 0.76 (0.15), without differences identified among the 3 VIA types. More participants were enthusiastic about vitrectomy (150 [71.1%]) compared with intravitreal injection (120 [56.9%]) (difference, 14.2%; 95% CI, 5.16-23.3; P = .002). Adjusted analyses showed enthusiasm for vitrectomy was associated with fellow eye visual acuity (odds ratio, 10.99; 95% CI, 2.01-59.97; P = .006) and better-seeing eye visual acuity (odds ratio, 0.03; 95% CI, 0.001-0.66; P = .03). Overall enthusiasm for treatment was associated with fellow eye visual acuity (odds ratio, 7.22; 95% CI, 1.29-40.40; P = .02). Overall, most participants (171 [81.0%]) were enthusiastic about surgery, injection, or both. Conclusions and Relevance Study participants reported similar preference values among 3 types of VIAs. The data suggest that most patients with these conditions would be enthusiastic about undergoing vitrectomy or an injection to treat it, likely because of the condition’s effect on visual functioning, although there may be a slight preference for vitrectomy at this time.

Predictive factors of open globe injury in patients requiring vitrectomy

BACKGROUND To determine the outcomes and predictive factors of patients with open globe injury requiring pars plana vitrectomy (PPV). METHODS The medical records of 114 patients age 10 years or older who had undergone PPV due to ocular trauma, with at least 6 months follow up, were retrospectively reviewed. RESULTS The mean age of the patients was 42 (SD14) years, with males accounting for 89% of the cases. Penetrating eye injury was the most common injury mechanism (43%) with most injuries occurring secondary to work related incidents (54%). After surgical interventions, 78% of the patients had visual improvement of one or more Snellen lines, while no light perception occurred in 10%. Anatomical attachment was achieved in 87% of eyes at the final follow up. Logistic regression analysis showed that the presence of a relative afferent pupillary defect (RAPD) was a significant predictive factor of visual outcome, while initial retinal detachment was a significant predictor of anatomical outcome. CONCLUSIONS Pupillary reaction is an important presenting ocular sign in estimating the post-vitrectomy poor visual outcome for open globe injury. Vision was restored and improved in more than half of the patients in this study; however, long-term sequelae should be monitored.

Risk Factors for Development of Rhegmatogenous Retinal Detachment in Patients with Uveitis

ABSTRACT Purpose: To describe risk factors for development of rhegmatogenous retinal detachment (RRD) in patients with uveitis. Methods: We performed a retrospective review of 411 consecutive human immunodeficiency virus-negative patients with uveitis (571 affected eyes) and report on prevalence, risk factors and visual outcomes of patients with RRD. Results: Prevalence of RRD was 7% of all patients with uveitis. Multivariate analysis revealed that posterior uveitis and panuveitis were associated with RRD (P = 0.001). Strong association between RRD development and infectious uveitis was also observed (P = 0.009). Acute retinal necrosis (ARN) was firmly associated with RRD development (P = 0.016). Although anatomical success was obtained, functional outcome was poor. Poor visual outcomes at 6-month and 1-year follow-up were associated with initial VA < counting fingers (P = 0.05, P = 0.044). Conclusions: Prevalence of RRD in uveitis was 7% and development of RRD was encountered in posterior and panuveitis. Infectious uveitis (specifically ARN) formed a high risk for RRD.

Post-injection endophthalmitis in eyes receiving vs. not receiving topical antibiotic prophylaxis in Northern Thailand

Endophthalmitis following intravitreous anti-vascular endothelial growth factor (VEGF) injection is a rare sight-threatening condition. Several Western references suggest lower rates of post-injection endophthalmitis can be achieved without topical antibiotic prophylaxis [1–3]. However, a majority of physicians in the Asia-Pacific region still prescribe antibiotic prophylaxis [4], anecdotally stating concern that differences in environmental factors (e.g., tropical climates) or patient factors in the region might cause higher risk of endophthalmitis, comparing to the Western settings, to warrant this prophylaxis, despite little scientific rationale supporting such use. To our knowledge, little is known regarding incidence of post-injection endophthalmitis without antibiotic prophylaxis in a developing countries in Asia or elsewhere. Therefore, this study determined incidence of postinjection endophthalmitis with vs. without topical antibiotic prophylaxis at a university-based practice in Northern Thailand.

Color Fundus Photography, Optical Coherence Tomography, and Fluorescein Angiography in Diagnosing Polypoidal Choroidal Vasculopathy

PURPOSE To determine sensitivity and specificity of polypoidal choroidal vasculopathy (PCV) diagnosis using color fundus photography (CFP), optical coherence tomography (OCT), and fundus fluorescein angiography (FFA) without indocyanine green angiography (ICGA). DESIGN Validity analysis. METHODS Treatment-naïve eyes with serous/serosanguinous maculopathy undergoing CFP, OCT, FFA, and ICGA imaging before treatment at a university hospital in Thailand (January 1, 2013 to June 30, 2015) were identified. Images of each subject were categorized into 4 sets (set A: CFP; set B: CFP+OCT; set C: CFP+FFA; set D: CFP+OCT+FFA). Six graders, 3 from Thailand (PCV endemic area) and 3 from the United States (nonendemic area), individually reviewed each set (without ICGA), and determined if the presumed diagnosis was PCV. In parallel, 2 other graders confirmed if each case had PCV or not using EVEREST criteria (including ICGA). Sensitivity and specificity of a PCV diagnosis with each set (without ICGA) were analyzed compared with diagnoses including ICGA. RESULTS Of 119 study eyes (113 subjects, 57% male, mean age ± SD 59.9 ± 13.8 years), definite PCV diagnosis was 40.3%. Sensitivity of sets A, B, C, D: 0.63 (95% confidence interval [CI]: 0.47-0.76), 0.83 (95% CI: 0.69-0.92), 0.54 (95% CI: 0.39-0.68), 0.67 (95% CI: 0.51-0.79); specificities: 0.93 (95% CI: 0.84-0.97), 0.83 (95% CI: 0.72-0.91), 0.97 (95% CI: 0.89-0.99), 0.92 (95% CI: 0.82-0.97); accuracies: 0.81 (95% CI: 0.73-0.88), 0.83 (95% CI: 0.76-0.90), 0.79 (95% CI: 0.73-0.87), 0.82 (95% CI: 0.74-0.88). Discrepancies between Thai and US graders existed through sets A, C, and D. CONCLUSIONS These data suggest that without ICGA, fundus photography combined with OCT provides high sensitivity and high specificity to diagnose PCV; adding FFA does not improve accuracy.

Spontaneous Large Serous Retinal Pigment Epithelial Tear

Purpose: To report cases of spontaneous retinal pigment epithelial (RPE) tear complicating serous pigment epithelial detachment (PED). Methods: The records of 3 Asian patients with spontaneous giant RPE tear were reviewed retrospectively by including clinical presentation, angiography, optical coherence tomography, fundus autofluorescence imaging, and visual outcome. Results: Three patients (4 eyes) were included in this study, with a mean age of 48.3 (42–56) years, and a mean follow-up period of 7.75 (4–18) months. Fundus examination in all patients showed giant RPE tear associated with bullous PED. Two cases had a history of prior corticosteroid use, and 1 had no history of medication use. All 3 patients developed spontaneous resolution of subretinal fluid with no treatment. However, in patients who used corticosteroids, initial progression of the tear and subretinal fluid were observed despite ceasing medication. On subsequent follow-up, an incomplete RPE regeneration was demonstrated by fundus autofluorescence imaging, and choroidal neovascularization developed in 1 patient. Conclusion: Large PED with RPE tear is a rare manifestation. When the fovea is spared, visual prognosis is favorable. No specific treatment is required, but careful choroidal neovascularization monitoring should be performed.