Transactions of the American Ophthalmological Society最新文献

Purpose: To evaluate the diagnostic yield and concordance of color duplex ultrasound (CDU) of the superficial temporal artery (STA), temporal artery biopsy (TAB), and American College of Rheumatology (ACR) criteria in the diagnosis of giant cell arteritis (GCA).

Methods: Prospective, masked study of all patients evaluated in one institution suspected of having GCA. All patients with a suspected diagnosis of GCA were admitted for pulsed intravenous corticosteroids. Patients underwent serologic work-up and ACR criteria were documented. All patients had a CDU and TAB performed within 3 days of initiation of systemic corticosteroid therapy. Main outcome measure: Concordance of CDU and TAB. Secondary outcome measures: Concordance between unilateral and bilateral CDU and TAB by side and segment, concordance between TAB and ACR criteria, and statistical analysis of serologic markers for GCA.

Results: The diagnosis of biopsy-proven GCA was found in 14 of 71 (19.7%) patients. The sensitivity of CDU compared to the reference standard of TAB ranged between 5.1% and 30.8% depending on the signs studied on CDU and correlation of specific TAB parameters. Of the serologic studies, a platelet count threshold of 400,000μL had the highest positive (18.32) and lowest negative (0.37) likelihood ratios for a diagnosis of GCA.

Conclusions: In this study, CDU showed minimal value in diagnosing GCA compared to TAB. There was poor correlation between CDU results and ACR criteria for GCA. The threshold platelet count had higher positive and negative predictive values for GCA than CDU and is a useful serologic marker for GCA.

Purpose: To elicit and evaluate opinions in the diagnosis and management of nonparaneoplastic autoimmune retinopathy (npAIR) among members of the American Uveitis Society (AUS) and to further the development of consensus and criteria in the diagnosis and management of npAIR. We hypothesize that despite lack of any clear guidelines, a general consensus in the clinical diagnosis and treatment of npAIR exists among uveitis experts.

Methods: A literature review was performed and a panel of uveitis experts was consulted to formulate a survey regarding the diagnosis and management of npAIR. An online survey of 10 questions was developed, and a link was distributed through the AUS membership discussion list. We defined "general consensus" as meaning that a majority (>50%) of the respondents provided the same answer to a question.

Results: Fifty-four members of the AUS responded to the survey. Thirty-eight members (70.4%) see one to three AIR patients per year. Greater than 50% consensus was reached on most items, particularly items relating to diagnostic features and tests (up to 96% consensus).

Conclusions: The diagnosis and management of npAIR is challenging, as standardized clinical and laboratory diagnostic criteria have yet to be established. The results of this study support the presence of consensus regarding certain aspects of npAIR, but also indicate the need for developing clear clinical diagnostic criteria and treatment guidelines.

Purpose: To evaluate associations between sensations of ocular itch and dry eye (DE) symptoms, including ocular pain, and DE signs.

Methods: A cross-sectional study of 324 patients seen in the Miami Veterans Affairs eye clinic was performed. The evaluation consisted of questionnaires regarding ocular itch, DE symptoms, descriptors of neuropathic-like ocular pain (NOP), and evoked pain sensitivity testing on the forehead and forearm, followed by a comprehensive ocular surface examination including corneal mechanical sensitivity testing. Analyses were performed to examine for differences between those with and without subjective complaints of ocular itch.

Results: The mean age was 62 years with 92% being male. Symptoms of DE and NOP were more frequent in patients with moderate-severe ocular itch compared to those with no or mild ocular itch symptoms. With the exception of ocular surface inflammation (abnormal matrix metalloproteinase 9 testing) which was less common in those with moderate-severe ocular itch symptoms, DE signs were not related to ocular itch. Individuals with moderate-severe ocular itch also demonstrated greater sensitivity to evoked pain on the forearm and had higher non-ocular pain, depression, and post-traumatic stress disorders scores, compared to those with no or mild itch symptoms.

Conclusions: Subjects with moderate-severe ocular itch symptoms have more severe symptoms of DE, NOP, non-ocular pain and demonstrate abnormal somatosensory testing in the form of increased sensitivity to evoked pain at a site remote from the eye, consistent with generalized hypersensitivity.

[This corrects the article on p. T6 in vol. 115, PMID: 29147104.].

Purpose: To investigate the clinical, anatomical, and patient-reported outcomes of phacoemulsification (PE) with intraocular lens implantation performed to treat primary angle closure (PAC) and primary angle-closure glaucoma (PACG).

Methods: Patients were evaluated at baseline and at 6 months after PE. The examination included visual acuity, intraocular pressure (IOP), visual field, optic nerve head, endothelial cell count (ECC), aqueous depth, and ocular biometric parameters. Patient-reported visual function and health status were assessed. Coprimary outcome measures were IOP changes, angle widening, and patient-reported visual function; secondary outcome measures were visual acuity changes, use of IOP-lowering medications, and complications. Univariate and multivariate analyses were performed to determine the predictors of IOP change.

Results: Thirty-nine cases were identified, and postoperative data were analyzed for 59 eyes, 39 with PACG and 20 with PAC. Globally, PE resulted in a mean reduction in IOP of -6.33 mm Hg (95% CI, -8.64 to -4.01, P<.001). Aqueous depth and angle measurements improved (P<.01), whereas ECC significantly decreased (P<.001). Both corrected and uncorrected visual acuity improved (P<.01). The EQ visual analog scale did not change (P=.16), but VFQ-25 improved (P<.01). The IOP-lowering effect of PE was greater in the PACG compared to the PAC group (P=.04). In both groups, preoperative IOP was the most significant predictor of IOP change (P<.01). No sight-threatening complications were recorded.

Conclusions: Our data support the usefulness of PE in lowering the IOP in patients with PAC and PACG. Although PE resulted in several anatomical and patient-reported visual improvements, we observe that a marked decrease in ECC should be carefully weighed before surgery.

Purpose: To assess if narrower-angle status and anterior segment optical coherence tomography (AS-OCT) parameters can predict intraocular pressure (IOP) drop in primary open-angle glaucoma (POAG) patients after cataract surgery.

Methods: This was a prospective case series of consecutive cataract surgery patients with POAG and no peripheral anterior synechiae (PAS) using a standardized postoperative management protocol. Preoperatively, patients underwent gonioscopy and AS-OCT. The same glaucoma medication regimen was resumed by 1 month. Potential predictors of IOP reduction included narrower-angle status by gonioscopy and angle-opening distance (AOD500) as well as other AS-OCT parameters. Mixed-effects regression adjusted for use of both eyes and other potential confounders.

Results: We enrolled 66 eyes of 40 glaucoma patients. The IOP reduction at 1 year was 4.2±3 mm Hg (26%, P<.001) in the narrower-angle group vs 2.2±3 mm Hg (14%, P<.001) in the wide-angle group (P=.027 for difference), as classified by gonioscopy. By AOD500 classification, the narrower-angle group had 3.4±3 mm Hg (21%, P<.001) reduction vs 2.5±3 mm Hg (16%, P<.001) in the wide-angle group (P=.031 for difference). When the entire cohort was assessed, iris thickness, iris area, and lens vault were correlated with increasing IOP reduction at 1 year (P<.05 for all).

Conclusions: In POAG eyes, cataract surgery lowered IOP to a greater degree in the narrower-angle group than in the wide-angle group, and parameters relating to iris thickness and area, as well as lens vault, were correlated with IOP reduction. These findings can guide ophthalmologists in their selection of cataract surgery as a potential management option.

Purpose: To evaluate the ability of various visual field (VF) analysis methods to discriminate treatment groups in glaucoma clinical trials and establish the value of time-domain optical coherence tomography (TD OCT) imaging as an additional outcome.

Methods: VFs and retinal nerve fibre layer thickness (RNFLT) measurements (acquired by TD OCT) from 373 glaucoma patients in the UK Glaucoma Treatment Study (UKGTS) at up to 11 scheduled visits over a 2 year interval formed the cohort to assess the sensitivity of progression analysis methods. Specificity was assessed in 78 glaucoma patients with up to 11 repeated VF and OCT RNFLT measurements over a 3 month interval. Growth curve models assessed the difference in VF and RNFLT rate of change between treatment groups. Incident progression was identified by 3 VF-based methods: Guided Progression Analysis (GPA), 'ANSWERS' and 'PoPLR', and one based on VFs and RNFLT: 'sANSWERS'. Sensitivity, specificity and discrimination between treatment groups were evaluated.

Results: The rate of VF change was significantly faster in the placebo, compared to active treatment, group (-0.29 vs +0.03 dB/year, P<.001); the rate of RNFLT change was not different (-1.7 vs -1.1 dB/year, P=.14). After 18 months and at 95% specificity, the sensitivity of ANSWERS and PoPLR was similar (35%); sANSWERS achieved a sensitivity of 70%. GPA, ANSWERS and PoPLR discriminated treatment groups with similar statistical significance; sANSWERS did not discriminate treatment groups.

Conclusions: Although the VF progression-detection method including VF and RNFLT measurements is more sensitive, it does not improve discrimination between treatment arms.

Purpose: To assess the specificity of simulation-based virtual reality ophthalmic cataract surgery training on the Eyesi ophthalmic virtual reality surgical simulator, and test the hypothesis that microsurgical motor learning is highly specific.

Methods: Retrospective educational interventional case series. The rates of vitreous loss and retained lens material, and vitreous loss and retained lens material associated with an errant continuous curvilinear capsulorhexis (CCC) were assessed among 1037 consecutive cataract surgeries performed during four consecutive academic years at a teaching hospital. The data were grouped by Eyesi use and capsulorhexis intensive training curriculum (CITC) completion. The main intervention was the completion of the CITC on the Eyesi.

Results: In the Eyesi simulator experience-based stratification, the vitreous loss rate was similar in each group (chi square p=0.95) and was not preceded by an errant CCC in 86.2% for "CITC done at least once", 57.1% for "CITC not done, but some Eyesi use", and 48.9% for "none" training groups (p=4×10-5). Retained lens material overall and occurring among the errant CCC cases was similar among training groups (p=0.82 and p=0.71, respectively).

Conclusions: Eyesi capsulorhexis training was not associated with lower vitreous loss rates overall. However, non-errant CCC associated vitreous loss was higher among those who underwent Eyesi capsulorhexis training. Training focused on the CCC portion of cataract surgery may not reduce vitreous loss unassociated with an errant CCC. It is likely that surgical training is highly specific to the task being trained. Residents may need to be trained for all surgical steps with adequate intensity to minimize overall complication rates.

Purpose: To test the hypothesis that delayed dark adaptation in patients with macular degeneration is due to an excess of free unliganded opsin (apo-opsin) and a deficiency of the visual chromophore, 11-cis retinal, in rod outer segments.

Methods: A total of 50 human autopsy eyes were harvested from donors with and without macular degeneration within 2-24 hrs. postmortem. Protocols were developed which permitted dark adaptation of normal human eyes after death and enucleation. Biochemical methods of purifying rod outer segments were optimized and the concentration of rhodopsin and apo-opsin was measured with UV-visible scanning spectroscopy. The presence of apo-opsin was calculated by measuring the difference in the rhodopsin absorption spectra before and after the addition of 11-cis retinal.

Results: A total of 20 normal eyes and 16 eyes from donors with early, intermediate and advanced stages of macular degeneration were included in the final analysis. Dark adaptation was achieved by harvesting whole globes in low light, transferring into dark (light-proof) canisters and dissecting the globes using infrared light and image converters for visualization. Apo-opsin was readily detected in positive controls after the addition of 11-cis retinal. Normal autopsy eyes showed no evidence of apo-opsin. Eyes with macular degeneration also showed no evidence of apo-opsin, regardless of the severity of disease.

Conclusions: Methods have been developed to study dark adaptation in human autopsy eyes. Eyes with age-related macular degeneration do not show a deficiency of 11-cis retinal or an excess of apo-opsin within rod outer segments.

Purpose: Understanding the apparent paradoxical role of zinc in the pathogenesis and prevention of age-related macular degeneration (AMD) has been limited by the lack of animal models for its detection in sub-retinal epithelial deposits (drusen), a definitive early hallmark of AMD. In-vitro studies using Zinpyr-1 showed drusen contained high levels of zinc, but the probe was not suitable for in-vivo studies. This study compares Zinpyr-1 to ZPP1, a new fluorescein-based probe for zinc, to assess the potential of ZPP1 for in-vivo detection of zinc in drusen.

Methods: Flat mounts of human sub-RPE tissue using the probes were analyzed by fluorescence and confocal microscopy. Flat mounts of sub-RPE tissue from mice deficient in superoxide dismutase isoform-1 (CuZn-SOD-KO) or isoform-2 (Mn-SOD-RPE-KO) were analyzed with sub-RPE deposits confirmed by histology.

Results: Drusen are detected in greater numbers and intensity with ZPP1 compared to Zinpyr-1. Using ZPP1, drusen was detected in a sample from a 46-year old human donor without ocular history, suggesting that ZPP1 might be sensitive enough to detect drusen at an early stage. With CuZn-SOD KO mice, ZPP1 detected sub-RPE deposits at 10 months of age, whereas Zinpyr-1 required 14 months.

Conclusion: Detection of sub-RPE deposits by ZPP1 was greatly enhanced compared to Zinpyr-1. This enhanced sensitivity will allow for more insightful analysis of zinc in AMD using human specimens and mouse models. This could result in the development of a sensitive in-vivo probe to enhance research on the role zinc in drusen formation and the early clinical diagnosis of AMD.