Treatment of Inferior Oblique Muscle Overaction with Myectomy Or with Anterior Transposition

This paper presents a comparative study of the effectiveness of myectomy and anterior transposition in the treatment of inferior oblique muscle overaction. We operated 160 patients with overaction of the inferior oblique muscle. Eighty patients (148 eyes) were operated by myectomy at the insertion and 80 patients (151 eyes) by anterior transposition of the insertion of the inferior oblique near the temporal side of the insertion of the inferior rectus muscle. Comparison of the two methods, using the chi-squared test, showed that:

1) both surgical procedures were equally effective (χ2=0.26) for correcting overaction of the inferior oblique muscle and V-phenomenon;

2) weakening of the inferior oblique muscle of both eyes was almost always required (in 115 out of 116 cases) in cases with V-phenomenon and often (24 out of 44 cases) in cases of congenital paresis of the superior oblique muscle. We conclude that both procedures are equally effective and equally easy to perform.

Prevalence of Diplopia Related to Cataract Surgery among Cases of Diplopia

Purpose

To evaluate the prevalence of diplopia in Greece after cataract surgery among diplopia cases.

Methods

The authors retrospectively reviewed the medical records of 571 patients with diplopia over an 8-year period in order to evaluate the prevalence of diplopia related to cataract surgery. The surgical and anesthetic records were also reviewed. All patients had full orthoptic assessment including prisms with cover test in all gaze positions. The chi-square and cross-tabulation statistical tests were used for statistical analysis.

Results

Thirty-nine cases (6.8%) were having persistent diplopia related to cataract surgery. Type of anesthesia was peribulbar. Hyaluronidase was not used. Thirteen patients were men and 26 were women. Left eyes were involved in 22 cases (56.4%), right in 17 cases (43.6%). Mean age was 72.5 years. Patients were divided into four groups. Group 1 consisted of 29 patients related to surgical trauma due to anesthesia. Group 2 consisted of 7 patients related to pre-existing disorders. Group 3 consisted of 2 patients related to aniseikonia or anisometropia. Group 4 with 1 patient related to macular pathology. Vertical diplopia was mostly noted (28 cases). Twenty-nine patients were corrected with prisms, 9 needed strabismus surgery, and 1 needed both surgery and prisms.

Conclusions

Cataract surgery is not a common cause of persistent diplopia. However, this report highlights that prevalence of diplopia related to cataract is high among cases of diplopia in general, with diplopia being mostly vertical (p=0.001), affecting females (p=0.006), and being more common in left eyes, although results did not reach statistical significance (p=0.133).

Phaco-trabeculectomy in controlled, advanced, open-angle glaucoma and cataract: parallel, randomized clinical study of efficacy and safety

BACKGROUND

To examine the efficacy and safety of combined phaco-trabeculectomy in patients with cataract and controlled, open-angle advanced glaucoma and to identify preoperative predictive factors of postoperative glaucoma course.

SETTING

Departments of Ophthalmology, University of Athens, and General Hospital of Lamia, Greece.

METHODS

Prospective, interventional, parallel, cluster (units=examinations), randomized clinical study. 60 patients with visually significant cataract, visual field Mean Deviation (MD) worse than -15.0 dB, and preoperative intraocular pressure (IOP), controlled (consistently below 22 mmHg) on topical medications and with no previous ocular surgery, were randomly allocated (1:1) to phacoemulsification alone or phaco-trabeculectomy group. Intention-to-treat analysis was performed to compare the postoperative outcome and adjusted multivariate longitudinal linear regression analysis was performed to identify predictive factors of the main outcome measures, with postoperative visual field MD change up to two years postoperatively. Participant recruiters and data collectors were masked to group assignment.

RESULTS

31 and 29 patients were randomized to phacoemulsification alone and phaco-trabeculectomy groups, respectively. Patients assigned to the phaco-trabeculectomy group experienced a 1.7 mmHg [95% CI:-3.1 to -0.23] reduction in IOP, a 1.4 dB [95% CI: -0.17 to 2.96] improvement in visual fields MD, a 0.6 [95% CI: -1.2 to -0.05] reduction in the number of glaucoma medications needed postoperatively, while the visual acuity improvement was similar between the two groups. Best predictors for visual field MD: degree of nuclear sclerosis, relative afferent pupilary defect (RAPD), preoperative MD deviation from -19.0 dB and preoperative cup-disc ratio deviation from 0.9. The phacoemulsification group experienced more IOP spikes (>25 mmHg) with Odds Ratio (OR) of 0.34 [95% CI: 0.11-1.02]. No patient lost light perception.

CONCLUSION

Phaco-trabeculectomy in advanced, controlled, open-angle glaucoma patients with cataract results in better postoperative visual field MD with no major adverse events.

Characteristics of uveitis presenting for the first time in the elderly

OBJECTIVE

This study aimed to describe the clinical characteristics of uveitis presenting de novo in the elderly.

DESIGN

The study design was a description of a retrospectively identified case series.

PARTICIPANTS

A population of 138 patients (209 eyes) with uveitis beginning after age 60 was analyzed.

RESULTS

Uveitis in the elderly accounted for 10.4% of the authors' uveitis population. The localization of uveitis was anterior in 56.5% of patients, intermediate uveitis was diagnosed in two patients (1.4%), posterior uveitis was found in 25.4%, while 16.7% of patients presented with panuveitis. Idiopathic uveitis accounted for the majority of cases (31.2%), whereas herpes zoster ophthalmicus (11.6%), herpes simplex virus (6.5%), presumed sarcoidosis (5.8%), syphilis (4.3%) ankylosing spondylitis (4.3%), and birdshot chorioretinopathy (3.6%) were the most frequent specific diagnostic entities. Secondary elevation of intraocular pressure was common (67 eyes, or 32%). The development of macular edema complicated 28.7% of cases (60 eyes). Two cases of intraocular lymphoma were identified in 19 diagnostic vitreous biopsy specimens. Fifty-two percent of eyes retained visual acuity of 20/40 or more; 32.6% had final visual acuity worse than 20/100.

CONCLUSIONS

Uveitis presenting for the first time in the elderly is not uncommon. Idiopathic uveitis accounts for the majority of cases, and herpes zoster ophthalmicus and herpes simplex virus are particularly prevalent. Intraocular lymphoma does not predominate in this age group. With adequate control of intraocular inflammation and its sequelae, the visual prognosis in patients in this age group with uveitis is relatively good.

Posterior capsule opacification after cataract surgery in patients with uveitis

PURPOSE

To compare the incidence rate of posterior capsule opacification (PCO) after phacoemulsification and standard extracapsular cataract extraction (P/ECCE) in eyes with antecedent uveitis with the incidence rate in eyes without any history of intraocular inflammation.

DESIGN

Review of records of 108 eyes of 78 patients with uveitis and 122 eyes of 106 patients with no uveitis who underwent P/ECCE. Rates of PCO were compared by the log-rank test of differences in the Kaplan-Meier survival curves. Proportional hazards regression models provided estimates of the relative risks of PCO among uveitic compared to nonuveitic eyes.

MAIN OUTCOME MEASURES

Performance of neodymium: YAG laser posterior capsulotomy was used as a proxy measure for the main outcome of visually significant PCO.

RESULTS

Study patients ranged in age from 6 to 81 years (median, 44.5 years) among those with uveitis and 27 to 96 years (median, 68.5 years) among those without uveitis (P = 0.0001). Crude incidence rates for visually significant PCO were 54% over a mean follow-up of 4.3 years in uveitic cases and 40% over a mean follow-up of 3.9 years among nonuveitic cases (P = 0.02). Estimates of PCO incidence (95% confidence interval) in uveitic eyes derived from the Kaplan-Meier models were 38.5% (range, 28.9%-48.2%) at 1 year and 56% (range, 45.8%-66.3%) at 3 years, and estimates among nonuveitic eyes were 11.5% (range, 6.2%-16.8%) at 1 year and 38.4% (range, 29%-47.8%) at 3 years. These rates of PCO among patients with uveitis and those patients without uveitis differed significantly by the log-rank test (P = 0.004). However, after adjusting for the younger age of patients with uveitis, the rates of PCO were no longer statistically different.

CONCLUSIONS

The apparent higher rate of PCO in patients with uveitis is primarily due to their younger age at the time of surgery. A moderately increased independent risk of PCO from uveitis cannot, however, be ruled out by this study.

Intravitreous injections of vascular endothelial growth factor produce retinal ischemia and microangiopathy in an adult primate

PURPOSE

The purpose of the study is to determine the effect of exogenous vascular endothelial growth factor (VEGF) on the primate retina and its vasculature.

METHODS

Ten eyes of five animals were studied. Physiologically relevant amounts of the 165 amino acid isoform of human recombinant VEGF were injected into the vitreous of six healthy cynomolgus monkey eyes. Inactivated human recombinant VEGF or vehicle was injected into four contralateral control subject eyes. Eyes were assessed by slit-lamp biomicroscopy, tonometry, fundus color photography, fundus fluorescein angiography, light microscopy, and immunostaining with antibodies against proliferating cell nuclear antigen and factor VIII antigen.

RESULTS

All six bioactive VEGF-injected eyes developed dilated, tortuous retinal vessels that leaked fluorescein. Eyes receiving multiple injections of VEGF developed progressively dilated and tortuous vessels, venous beading, edema, microaneurysms, intraretinal hemorrhages and capillary closure with ischemia. The severity of the retinopathy correlated with the number of VEGF injections. None of the four control eyes exhibited any abnormal retinal vascular changes. The endothelial cells of retinal blood vessels were proliferating cell nuclear antigen positive only in the bioactive VEGF-injected eyes.

CONCLUSION

Vascular endothelial growth factor is sufficient to produce many of the vascular abnormalities common to diabetic retinopathy and other ischemic retinopathies, such as hemorrhage, edema, venous beading, capillary occlusion with ischemia, microaneurysm formation, and intraretinal vascular proliferation.

Experimental corneal neovascularisation using sucralfate and basic fibroblast growth factor

PURPOSE

To develop a non-inflammatory model of both acute and chronic angiogenesis in the rabbit cornea using a known directly angiogenic cytokine.

METHODS

Pellets made of the slow-release polymer Hydron (polyhydroxyethylmethacrylate) and containing sucralfate and/or basic fibroblast growth factor (basic-FGF) were implanted into rabbit corneas. The neovascular response to the implantation of pellets containing basic-FGF alone, sucralfate alone or a titration of basic-FGF in the presence of a constant amount of sucralfate was measured. The role of inflammation in the neovascular response was also investigated.

RESULTS

The addition of sucralfate to the pellets led to the sustained release of basic-FGF resulting in a predictable and aggressive neovascular response with a low dose of basic-FGF that by itself was unable to elicit neovascularisation. At a dose of 500 ng per pellet, approximately one-third of the surface area of the cornea was vascularised within eight days of implantation. Minimal or no vascularisation occurred with the same dose of basic-FGF without sucralfate. While this dose of basic-FGF induced corneal oedema, only minimal inflammation was observed and the response was unaffected by ionising radiation. A less aggressive though still robust neovascular response with no or only minimal oedema was observed when the dose was lowered to 50 ng of basic-FGF per pellet. Some induced vessels persisted for more than three months.

CONCLUSION

This is an inexpensive in vivo model of angiogenesis with the advantages of the neovascularisation being aggressive, predictable, persistent, unassociated with an obvious inflammatory response and induced by the sustained release of an agent known to have a direct stimulatory action on endothelial cells.

Vascular endothelial growth factor is sufficient to produce iris neovascularization and neovascular glaucoma in a nonhuman primate

OBJECTIVE

To determine whether the angiogenic peptide vascular endothelial growth factor (VEGF) is sufficient to produce iris neovascularization in a nonhuman primate (Macaca fascicularis).

METHODS

Eight eyes of 4 animals were studied. The 165-amino acid isoform of human recombinant VEGF (VEGF165) was injected into the vitreous of 5 cynomolgus monkey eyes (doses ranging from 0.25-2.5 micrograms per injection). Equal amounts of inactivated human recombinant VEGF (2 eyes) or vehicle (1 eye) were injected into contralateral control eyes. Eyes were assessed by slitlamp biomicroscopy, tonometry, iris color photography, fluorescein angiography, histopathologic examination, and immunostaining with antibodies against proliferating cell nuclear antigen.

RESULTS

All 5 bioactive VEGF-injected eyes developed neovascularization with dilated and tortuous iris vessels that leaked fluorescein. None of the 3 control eyes exhibited any iris vascular changes. Inflammation was absent in both treatment groups. A dose response to VEGF was observed in the single animal that received 2.5 micrograms and 0.25 microgram in the right and left eyes, respectively. Iris vessel endothelial cells were positive for proliferating cell nuclear antigen in the bioactive VEGF-injected eyes only. Injections of 1.25 micrograms of VEGF every 3 days during a 30-day period produced advanced iris neovascularization, ectropion uvea, and neovascular glaucoma.

CONCLUSIONS

Intravitreal injections of recombinant human VEGF165 in amounts comparable with those measured in eyes with active neovascularization are sufficient to produce noninflammatory iris neovascularization in a nonhuman primate. Prolonged exposure to VEGF165 can produce ectropion uveae and neovascular glaucoma.