|Year : 2018 | Volume
| Issue : 2 | Page : 129-131
Atheek Shaik1, Murali Ariga2, Shruti Nishanth3
1 Department of Ophthalmology, Fathimah Eye Clinic, Chennai, Tamil Nadu, India
2 Department of Ophthalmology, Swamy Eye Clinic and Surgicentre; Department of Pediatric Ophthalmology, M.N. Eye Hospital Pvt. Ltd., Chennai, Tamil Nadu, India
3 Department of Pediatric Ophthalmology, M.N. Eye Hospital Pvt. Ltd., Chennai, Tamil Nadu, India
|Date of Web Publication||6-Aug-2018|
Dr. Atheek Shaik
Fathimah Eye Clinic, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shaik A, Ariga M, Nishanth S. Journal scan. TNOA J Ophthalmic Sci Res 2018;56:129-31
Odayappan A, Shivananda N, Ramakrishnan S, Krishnan T, Nachiappan S, Krishnamurthy S, et al. A retrospective study on the incidence of postcataract surgery Descemet's membrane detachment and outcome of air descemetopexy. Br J Ophthalmol 2018;102:182-6.
Retrospective analysis on 112 patients was done at Aravind Eye Hospital to analyze the anatomic and functional outcome of air descemetopexy in postcataract surgery Descemet's membrane detachment (DMD). All patients with moderate peripheral DMD (involving 25%—50% of the cornea and is peripheral) and severe DMD (involving >50% of the cornea or with central involvement) were advised air descemetopexy. Slit-lamp examination and anterior segment optical coherence tomography were done to diagnose it. All patients underwent re-surgery within 2 weeks of the primary surgery.
Corneal paracentesis was made in an area of clinically attached Descemet's membrane (DM), and using a 30-gauge hydrodissection cannula on a 2cc syringe, they have entered below the plane of the detached DM. The anterior chamber was completely filled with air and maintained a supine position for 15 min after which partial release of air was done. Postoperatively, supine posturing was advised.
Anatomical outcome was given by the reattachment of the detached DM after intervention, and the functional outcome was denoted by the best-corrected visual acuity (VA) at 1 month after intervention.
Results: One hundred and ten patients had minimum 1-month follow-up and were included for postintervention analysis.
The chances of DMD occurring after extracapsular cataract extraction and manual small incision cataract surgery were more than after phacoemulsification. The incidence of DMD was significantly more among surgical trainees (0.17%) than consultants (0.07%).
After air descemetopexy, the DM was attached in 78 of 110 patients (71%). There was no significant difference in the success rates between patients with moderate and severe DMD.
Twenty-four patients had persistent DMD (21.8%) among whom 15 underwent repeat air descemetopexy. Among them, 9 (60%) patients had successful reattachment of the DM. Of the 78 patients with attached DM after the first descemetopexy, 72 had improvement in VA by at least one Snellen line. Almost 75% of patients had a vision better than 6/18, 1 month after anatomically successful descemetopexy. There was no correlation between timing of the re-surgery and visual outcome.
Take home message
Air descemetopexy is a safe and efficient modality of treatment of DMD and should be tried even in patients with severe DMD before planning a major surgery like endothelial keratoplasty.
Knutsson KA, Paganoni G, Matuska S, Ambrosio O, Ferrari G, Zennato A, et al. Corneal collagen cross-linking in pediatric patients affected by keratoconus. Br J Ophthalmol 2018;102:248-52.
Prospective cohort study with 52 eyes of 43 pediatric patients with progressive keratoconus, corneal cross-linking (CXL) was performed.
Progression was defined as increase of K-max by at least 1.5D in two consecutive topographies performed within 1 year or by significant best spectacle-corrected VA (BSCVA) loss of one line or more.
Topography was performed every 3 months in patients under 14 years of age and every 6 months in patients aged over 14. Patients with thinnest corneal pachymetry <400 μm, corneal scarring, history of herpetic keratitis, severe dry eye, endothelial cell pathology, autoimmune disorders, or previous ocular surgery were excluded from the study.
Patients selected for the procedure underwent complete eye examination with recording of uncorrected VA (UCVA), BSCVA, keratometry, topography were performed every 3 months in patients under 14 years of age and every 6 months in patients aged over 14 and preoperative and postoperative pachymetry and specular biomicroscopy. Topography was done every 6 months in above 14 years and every 3 months in less than 14 years to closely monitor progression. Patients were examined postoperatively 1 day after the procedure, at 5 days for contact lens removal, and at 1 month, 6 months, and 1 year, and once yearly for the following follow-up examinations.
Most children received topical anesthesia alone, while general anesthesia was performed in seven eyes of four patients. The central 9 mm diameter of the corneal epithelium was removed, and instillation of 0.1% riboflavin solution containing dextran 20% was done for 30 min during the soaking phase and then 30 min ultraviolet A irradiation (3 mW/cm2) with reapplication of riboflavin solution every 2.5 min.
After surgery, topical levofloxacin 0.5% was instilled and a bandage contact lens was applied for 5 days. Postoperatively, the patients received topical levofloxacin (0.5%) six times daily for 5 days, sodium hyaluronate 0.15% four times daily for 30 days, and topical fluorometholone 0.1% four times daily for 21 days after contact lens removal.
Visual outcomes, topographic keratometry, maximum keratometry (K-max), refractive astigmatism, demarcation line, and endothelial cell density were measured postoperatively.
Results: Main outcomes were measured at the 2-year postoperative interval as all eyes had complete data compared with 36 eyes (69%) at 3 years. Mean age of the patients was 14.63 ± 2.33 years, 33 were males and 10 females. Average preoperative pachymetry of the thinnest point was 460 ± 63 μm. Keratoconus remained stable without signs of progression in 98% of eyes receiving CXL treatment. One patient showed signs of keratoconus progression with an increase of K-max by more than 1.5D after treatment. In this patient, cross-linking was repeated 9 months after the original treatment. At 1 year of follow-up after the retreatment, the patient showed clinical and topographical stability.
Mean K1 and K2 keratometry values were significantly reduced at 2 and 3 years compared with baseline. A significant decrease of K-max from 59.30 ± 7.08 to 57.07 ± 6.46 (P < 0.001) was observed at 2 years and was confirmed at 3 years. Average UCVA improved from 0.59 ± 0.41 logMAR to 0.46 ± 0.33 logMAR 2 years after the procedure, while BSCVA improved from 0.17 ± 0.11 logMAR to 0.15 ± 0.12 logMAR. These changes were not statistically significant.
One patient who became intolerant to contact lenses after the procedure and was unsatisfied with spectacle-corrected vision underwent deep anterior lamellar keratoplasty with a good outcome.
Take home message
This study highlights the efficaciousness of CXL in patients with advanced keratoconus characterized by elevated K-max values (>60D), which is known to be an important risk factor for keratoconus progression after CXL from studies performed on adults. It confirms the success of corneal CXL in stabilizing keratoconus in pediatric patients.
Atchison EA, Wood KM, Mattox CG, Barry CN, Lum F, MacCumber MW. The real-world effect of intravitreous antivascular endothelial growth factor drugs on intraocular pressure: An analysis using the IRIS registry. Ophthalmology 2018;125:676-82.
Database analysis in the American Academy of Ophthalmology Intelligent Research in Sight Registry of 23776 patients who received single type of anti-vascular endothelial growth factor (VEGF) medication (bevacizumab, aflibercept, or ranibizumab) was done to identify sustained differences in intraocular pressure (IOP) after intravitreous injections of anti-VEGF.
Analysis included patients who received an intravitreal injection with aflibercept, bevacizumab, or ranibizumab in the right eye for a diagnosis of age-related macular degeneration (AMD), macular edema resulting from a branch or central retinal vein occlusion, or diabetic macular edema (DME).
Patients who received more than one type of anti-VEGF drug or an intravitreous corticosteroid injection in the treated eye or receiving any intravitreal drug in the untreated fellow eye during the study period were excluded from the analysis.
Analysis included three primary groups: all patients, patients with a diagnosis of AMD, patients who were treatment naive for at least 1 year before the start of the study, and those who received at least 12, 18, and 25 injections during the study period were included in the study.
Mean change from baseline to the last IOP measurement at least 1 year after the first injection was noted.
For each group, they calculated the proportion of patients with a baseline IOP 21 mmHg who showed an IOP rise of at least 6 mmHg that resulted in an IOP of more than 21 mmHg (defined as a clinically significant IOP increase).
Results: Of the 23,776 patients, 14,333 (60%) were women and 9443 (40%) were men. The average age was 77 years. 13,349 patients (56%) received bevacizumab, 4548 patients (19%) received aflibercept, and 5879 patients (25%) received ranibizumab. Nearly 17,394 patients (73%) had neovascular AMD, 2873 patients (12%) had DME, 2658 patients (11%) had a vein occlusion with macular edema, and 851 patients (4%) had a combination of these diagnoses.
The mean number of intra vitreal injections given was 6.9 bevacizumabinjections, 9.3 aflibercept injections, and 9.0 ranibizumab.
Clinically, significant IOP rise was seen in 1.9% of aflibercept injections, 2.8% of ranibizumab injections, and 2.8% of bevacizumab injections. In patients who received 12—18 injections, the differences between treated and untreated eyes were statistically significant overall and for ranibizumab and bevacizumab, but there was no statistically significant difference between aflibercept and the fellow untreated eyes.
In patients receiving at least 25 injections, clinically significant IOP rise was seen in 1.9% of aflibercept, 2.2% of ranibizumab, and 3.2% of those receiving bevacizumab. However, the reliability of these data is low due to small sample size.
Nearly 2.1% of patients who had clinically significant IOP rise were patients with pre existing glaucoma. About 0.6% of treated eyes and 0.4% of untreated eyes underwent laser trabeculoplasty.
Take home message
Almost 2.6% of patients receiving anti-VEGF agents showed clinically significant sustained IOP elevations compared with the 1.5% rate for fellow untreated eyes. The rate of such an elevation was minimal for those receiving aflibercept (1.9%) compared with those receiving ranibizumab (2.8%) or bevacizumab (2.8%).
Lee S, Choi DY, Lim DH, Chung TY, Han JC, Kee C, et al. Lamina cribrosa changes after laser in situ keratomileusis in myopic eyes. Korean J Ophthalmol 2018;32:95-102.
Prospective observational study of forty eyes of forty patients underwent laser in situ keratomileusis (LASIK). All patients undergoing LASIK were included for the trial.
Exclusion critera — eyes in which lamina cribrosa (LC) margin was unclear, poor image quality due to cataracts and patients with other ocular diseases. Participants underwent slit-lamp biomicroscopy, Goldmann applanation tonometry, manifested refraction, dilated fundus photography, and enhanced depth imaging (EDI) spectral-domain optical coherence tomography (OCT).
Transient IOP elevation was induced between 15 and 20 s in the eye of each participant by a modified LASIK automated corneal shaper under local anesthesia.
The Heidelberg SPECTRALIS OCT, EDI mode was used for all images and was set to image a 10° ×15° rectangle for horizontal scans centered on the optic disc. Prelaminar thickness, LC thickness, and LC depth were measured in central, superior, and inferior midperiphery optic nerve head. Three B-scans in each portion were measured, and the average LC thickness and depth of nine images were used for analysis. All images were analyzed and measured twice by two examiners.
Results: Forty eyes in forty participants were included in this study. Thirteen of the participants were male (32.5%), and the average age of all participants was 28 years. The average CCT was 556 μm (range, 506—627 μm), and the average SE was −6 diopter (range, −10 to −3 diopter). The average IOP was 17 mmHg (range, 10—23 mmHg).
During follow-up, there was no significant difference in PL thickness or LC depth compared to those at preoperative examinations. LC thickness values at the superior, middle, and inferior portions were significantly increased at postoperative 1 day (all P < 0.001). However, no significant changes were observed at postoperative 1 week, 2 weeks, or 1 month compared to baseline LC thickness.
Take home message
LC thickness could increase at 1 day after LASIK surgery. However, the thickness eventually returns to the baseline morphology. The changes in LC thickness could be attributable to compensatory blood flow after temporary ischemia on LC.
Modjtahedi BS, Ferris FL 3rd, Hunter DG, Fong DS. Public health burden and potential interventions for myopia. Ophthalmology 2018;125:628-30.
Vitale et al. estimated the prevalence of myopia (defined as − 0.5D) using the National Health and Nutrition Examination Survey as 50.2% in individuals aged 20—39 years and 50.1% in 40—59 years. The prevalence of severe myopia (−5D) was 7.4% and 7.8% in these age groups, respectively.
An estimated 1.406 billion people in the world are myopic, and 163 million have high myopia. Based on certain assumptions, Holden et al. estimated that the number of individuals as well as the prevalence of both myopia and high myopia will increase by 2050 to 4.758 billion individuals and 938 million people. Uncorrectable visual impairment is seen in 4% of 75 years old with myopia and 39% with high myopia, and this risk is expected to increase 7—13 times by 2055 in high-risk areas.
The economic impact with a loss in global gross domestic product from uncorrected refractive error is estimated to be $202 billion annually.
Several strategies have been used to control myopia, of which orthokeratology, low-dose atropine, outdoor activity, and Bifocal Lenses in Nearsighted Kids can slow myopia progression. Orthokeratology requires high levels of patient compliance and carries considerable expense. Wu et al. demonstrated that low-dose atropine was well tolerated and resulted in less myopia progression compared with controls over a mean of 4.5 years.
Greater time spent outdoors has long been associated with a lower incidence of myopia. The probable mechanism responsible is likely secondary to light stimulation of retinal dopamine, which discourages axial growth.
More data are needed to clarify the level of benefit, parameters of exposure, and duration of benefit to develop more concrete recommendations. Arresting progression of myopia will require individualized patient care to identify and intervene in myopes at risk for significant progression. Ophthalmologists have to reach out and work with optometrists, pediatricians, and school administrators to develop the best research, reach the broadest population, and try to slow down progression of myopia.
Take home message
Myopia will be a major social and economic burden in future, in patients with progressive myopia the use of low dose atropine and encouraging outdoor activities can be advocated to reduce progression. Collaborative efforts with optometrists, parents, and school authorities are needed to achieve better results.
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Conflicts of interest
There are no conflicts of interest.