European Journal of Ophthalmology

Both extraocular muscle (EOM) and orbital fat are involved in Graves’ orbitopathy (GO) but their enlargement might occur with a different temporal pattern. Two GO subtypes have been described, one with predominant EOM enlargement and the other with prevalent fat tissue involvement. We longitudinally investigated the EOM in patients with GO and their relationship with clinical activity.

By using commercial software with a segmentation technique, we calculated from computed tomography (CT) scan EOM coronal area (CA) and total orbit coronal area (TOA) in 23 control subjects and in 32 patients with GO. The latter were studied both at presentation and 18 months later. Superior, lateral, inferior, and medial EOM areas and TOA were selected by 3 different contiguous CT slices: A, B, and C, chosen at globe pole tangent and 2 and 4 mm backward. The Clinical Activity Score (CAS) was also measured.

Orbital EOM CA/TOA ratio (OM/TOA ratio) after 18 months decreased in most patients with GO, indicating that EOM area decrement contributed significantly to OM/TOA ratio reduction. Clinical Activity Score decrease was significantly correlated to the OM/TOA ratio decrease.

An easy method to measure CA of EOM and orbit allowed us to observe that in most patients with GO the OM/TOA ratio decreases with time, suggesting that macroscopic EOM involvement occurs initially and resolves as the other clinical signs and symptoms of the disease resolve, as indicated by the significant OM/TOA ratio correlation with CAS.

To evaluate aspiration cutter–assisted small-incision anterior orbitotomy.

Three patients with orbital adnexal tumors underwent orbital biopsy through a 3-mm incision in the eyelid skin (n=2) or conjunctival fornix (n=1). Standard aspiration cutters were introduced into anterior and posterior orbital tumors utilizing a bimanual technique. Multiple passes were made into the tumor. Fresh specimens were analyzed for adequacy prior to the end of surgery. Cytopathology, histopathology, and immunohistochemical analysis were performed.

Aspiration cutter technique biopsies were diagnostic in 2 of 3 cases. Diagnoses were orbital lymphoma, metastatic endometrial adenocarcinoma, and metastatic prostate cancer. The 20-G aspiration cutter yielded the most tissue. No sutures were required for the small incisions.

Sutureless, aspiration cutter biopsy offered benefits commonly associated with fine needle aspiration biopsy, controlled aspiration, and enclosed mechanical cutting.

To highlight the computed tomography (CT) and magnetic resonance imaging (MRI) characteristics of lacrimal gland adenoid cystic carcinoma.

We reviewed the clinical records and imaging findings of 17 patients who were histopathologically diagnosed with primary adenoid cystic carcinoma of the lacrimal gland between August 1998 and November 2010. Orbital CT scans were performed in 17 patients and MRI scans were obtained in 13 patients.

On the CT scans, out of 4 cases of adenoid cystic carcinoma, 3 showed characteristic features of a soft tissue mass with poorly enhancing areas representing cystic changes, and 4 of 17 cases had contiguous bony erosion. On the MRI scans, all cases had mixed signal intensity on T2-weighted images, and 6 cases showed poorly enhancing areas.

Enhanced CT and MRI (including T2-weighted) are helpful in the diagnosis of primary adenoid cystic carcinoma of the lacrimal gland.

To determine the outcome and safety of endoscopic dacryocystorhinostomy (EN-DCR) with the use of adjunctive mitomycin C (MMC) in nasolacrimal duct obstruction in adults.

In this retrospective, comparative case series, 54 consecutive adult patients underwent EN-DCR. We performed endonasal dacryocystorhinostomy with adjunctive MMC in 28 patients and endonasal dacryocystorhinostomy without MMC in 26 patients. All patients underwent a standardized procedure, with an endonasal approach to the lacrimal sac, surgical removal of nasal mucosa, lacrimal bone, and a fragment of the frontal process of the maxilla. The medial wall of the lacrimal sac was removed completely. In the study group (28 patients), a neurosurgical cottonoid soaked in MMC at 0.5 mg/mL was placed at the osteotomy site for 5 minutes (not using canalicular silicone intubation tube). In the other group (26 patients), standard endonasal dacryocystorhinostomy technique was used without MMC (not using canalicular silicone intubation tube). Main outcome measures were resolution of epiphora, absence of discharge, and patency of the ostium confirmed by irrigation at 6 months.

The EN-DCR procedure with adjunctive MMC was successful in 24 (85.71%) cases. The mean follow-up was 14.3 months (8–24 months). No significant complications were encountered. In the control group, the EN-DCR was successful in 19 patients (73.07%). The mean follow-up was 13.2 months (6-24 months).

Endoscopic dacryocystorhinostomy with MMC is a safe and successful procedure for the treatment of nasolacrimal duct obstruction in adults.

To assess the effect of mitomycin C on surgical success rate of dacryocystorhinostomy and silicone intubation in patients with improper flaps.

The study was a randomized clinical trial. The patients with indication for dacryocystorhinostomy surgery with silicone intubation (inappropriate lacrimal sac or nasal mucosal flaps during surgery and/or history of dacryocystitis in the past 3 months) were randomly assigned to application of mitomycin C (0.02%) on surgical flaps (group A) or a control group without mitomycin C application (group B). Main outcome measures were subjective symptomatic improvement and result of irrigation test at last follow-up visit.

The study enrolled 88 patients (88 eyes); there were 42 patients in group A and 46 patients in group B. There was an average follow-up of 10 months (range 6-15 months) following surgery. Significant improvement (no tearing with patent lacrimal system in irrigation) was observed in 31 patients (73.8%) in group A and 32 patients (69.6%) in group B. There was no statistically significant difference in no improvement (no change in tearing state and obstruction in irrigation test), relative improvement (decreased tearing and passage of fluid with force in irrigation test), and significant improvement rate between the 2 groups of study (p>0.05).

Application of mitomycin C on surgical flaps during dacryocystorhinostomy surgery with silicone intubation in patients with improper flaps has no proven beneficial effect on success rate of surgery.

To study the frequency and severity of dry eye in patients with juvenile rheumatoid arthritis (JRA) and its relation to disease activity.

Evaluation for dry eye was done in 40 patients with juvenile rheumatoid arthritis referred for ocular assessment in the Ophthalmology Clinics, Faculty of Medicine, Ain Shams University. They were 28 girls and 12 boys with age range of 7–12 years. Medical history, clinical examination, and full ophthalmologic evaluation were performed for each patient. The dry eye tests included tear film break-up time, Schirmer-1 test, and corneal fluorescein staining. Dry eye severity grading was used. Twenty healthy, age- and sex-matched children were assessed for dry eye as a control group.

Thirty patients (75%) showed findings consistent with the diagnosis of dry eye. Twenty patients (50%) showed first-degree dryness, 8 (20%) showed second-degree, and 2 (5%) showed third-degree. The score of dry eye severity was significantly lower in remission compared to disease activity. Multiregression analysis showed the only factor affecting dry eye parameters was the duration of illness.

Dry eye is a common incident in children with JRA and should be screened for in all patients with this disease. Severity of eye dryness is highly correlated with the disease activity.

Blunt trauma after penetrating keratoplasty (PK) is a high risk for wound rupture at the donor-recipient interface. We present 6 cases of traumatic wound dehiscence after PK; we describe the morphologic and functional outcome after surgical intervention and provide a review of the current literature.

Six patients with a traumatic wound dehiscence after PK were analyzed retrospectively from the files of the University Eye Hospital Hamburg-Eppendorf (1998-2009). In addition, a comprehensive literature review was performed.

The indications for PK were keratoconus, corneal scars, and Fuchs endothelial dystrophy. The age range was 22-81 years; the time span between PK and globe rupture was 1 month to 27 years. The cause of the dislocation was a fall or blunt trauma, through a branch, airbag, fist, or finger. The corrected distance visual acuity (CDVA) pretrauma ranged between hand movement and 20/32. The CDVA after wound repair was 20/400 to 20/25 depending on the severity of the trauma. In 3 of the 6 cases, visual rehabilitation was superior to the pretrauma vision, whereas in 3 cases the pretrauma CDVA could not be reached.

If a timely and adequate treatment of the traumatically dislocated transplant can be given, it is likely that the transplant will survive. Nevertheless, severely reduced visual acuity (i.e., < hand movement) and lens damage at the time of trauma are the most reliable predictors for the final visual outcome. A permanent loss of visual acuity is related rather to the intraocular damage (vitreous loss, vitreous bleeding, retinal tears, and retinal detachment) than to the readapted transplant itself.

To present ultrasound biomicroscopic (UBM) findings and their clinical correlations in people with optically hazy media after injury at the Persian Wednesday Eve fireworks festival.

Ultrasound biomicroscopy was performed on a series of 32 eyes with severe closed-globe injuries by P40 ultrasound biomicroscope.

The median age of the participants was 19 years, and 81.3% were male. All but one had gross hyphema. Seventy-five percent had an extension of the injury (at least) to Birmingham Eye Trauma Terminology zone II. Ultrasound biomicroscopy detected 3 more iridodialyses and 10 more cyclodialyses in addition to the respective 5 and 3 that were diagnosed clinically. Ten cases of angle recession were observed, and 5 were suggestive of subluxation of the crystalline lens. Two cases were suspected for anterior segment intraocular foreign body on clinical examination, but UBM and computed tomography scanning together ruled out such a diagnosis.

Our study showed the value of UBM in the assessment of severely contused eyes and hyphema. It made possible evaluation for dialyses and recessions at presentation. Ultrasound biomicroscopy illustrated diverse subclinical disruptions in clinically invisible anterior segment structures.

To quantify the changes induced by cataract extraction (CE) in angle recess area (ARA), angle opening distance at 250 and 500 µm (AOD₂₅₀, AOD₅₀₀), and aqueous depth (AQD) in comparison with axial lens thickness (LT) and to reveal effects of LT and lens position (LP) on angle parameters and AQD using ultrasound biomicroscopy (UBM).

Thirty-five eyes of 35 patients (22 male; mean age 69.5±7.8 years) with senile or presenile cataract who consecutively underwent cataract surgery were enrolled in this institutional study. We performed UBM examinations before and 1 month after surgery under a standard protocol. Axial images of the anterior segment and radial sections of the angle at 4 quadrants were obtained. Aqueous depth and LT were measured in immersion A-scan mode and we used UBM Pro 2000^® software for the ARA, AOD₂₅₀, and AOD₅₀₀.

Aqueous depth and angle parameters at 4 quadrants were increased significantly after CE (p<0.05). The mean LT was 4.53±0.37 mm and LP was 4.96±0.25 mm preoperatively. There were statistically significant correlations between LT, LP, and AQD and angle parameters preoperatively. We also determined statistically significant correlations between LT, LP, and postoperative changes in AQD and angle parameters In comparison with LT, the mean increases in AQD, ARA, AOD₂₅₀, and AOD₅₀₀ were 0.21, 0.014, 0.012, and 0.017 times, respectively.

The results suggest that LT is as a significant factor as LPon the final dimensions of the anterior chamber and angle.

This study evaluated visual acuity, contrast sensitivity, and wavefront aberrations after refractive multifocal intraocular lens (IOL) implantation.

A prospective study comprising 174 eyes of 87 patients who had bilateral implantation of a multifocal IOL was carried out. A control group of 100 eyes of 50 age-matched patients with a monofocal IOL was used for comparison. Uncorrected and corrected distance and near visual acuity, contrast sensitivity (CS), and wavefront analysis (Hartmann-Shack) was performed 6 months after surgery. Contrast sensitivity was tested for distance and near under mesopic (2 cd/m²) and photopic conditions (90 cd/m²).

Distance photopic CS was not significantly different from the monofocal group, while distant mesopic CS and near photopic and mesopic CS were significantly lower. Mean aberration root mean square (RMS) values for the multifocal IOL group were 0.229±0.103 µm for coma, 0.137±0.067 µm for spherical aberration (SA), and 0.301±0.133 µm for higher order aberrations (HOAs). Strehl ratio averaged 0.096±0.045.

Distant visual performance with the multifocal IOL was excellent under photopic conditions, but was reduced under mesopic levels. Near vision showed suboptimal results in both photopic and mesopic conditions. Coma, SA, and HOAs with the multifocal IOL were higher than those reported previously, with a lower Strehl ratio.

To report cases of late onset spontaneous in-the-bag dislocation of the intraocular lens (IOL) and to compare these results with past reports.

We retrospectively studied 21 eyes of 18 patients with dislocation of the entire capsular bag containing the IOL. Gender, age, interval between original surgery and IOL dislocation, and the predisposing factors were examined. Cases occurring after trauma were excluded.

The mean ± SD age of the 12 men (57.1%) and 9 women included in the study was 67.8±8.6 years at the time of the IOL removal procedure. The interval between the original surgery and the IOL dislocation was 7.9±8.6. Associated clinical conditions included vitrectomy in 8 eyes (40.0%) of 7 patients, high myopia in 3 eyes (14%) of 2 patients, uveitis in 2 eyes (9.5%) of 2 patients, retinitis pigmentosa in 2 eyes (9.5%) of 1 patient, and pseudoexfoliation in 1 eye (4.8%) of 1 patient. There was no identifiable associated condition in 2 eyes (9.5%) of 2 patients, who were comparatively younger than the other cases. This result differs from previously published reports that have found a higher frequency of pseudoexfoliation and lower frequency of prior vitrectomy.

In-the-bag IOL dislocation was frequently associated with prior vitrectomy and sometimes occurred without specific conditions.

To evaluate the effect of immunosuppressive therapy on best-corrected visual acuity (BCVA), fixation stability, and central retinal sensitivity in patients with Vogt-Koyanagi-Harada (VKH) disease in the acute uveitic phase.

In this prospective study, 14 patients (28 eyes) were evaluated. Best-corrected visual acuity and MP-1 microperimetric evaluation of retinal sensitivity in the central 12 degrees and fixation stability were assessed at baseline and at 1, 3, 6, 9, and 12 months after treatment.

At baseline, logarithm of the minimum angle of resolution (logMAR) BCVA, fixation stability, and mean retinal sensitivity levels were 0.685±0.6 (Snellen equivalent, 20/100), 61.2%±29.0%, and 2.75±3.8 dB, respectively. At 3 months, logMAR BCVA (0.11±0.2, Snellen equivalent 20/25) and fixation stability (86.4%±13.4%) were almost maximum (p<0.001 for both comparisons), and thereafter remained almost unchanged. Mean retinal sensitivity continued to improve up to 12 months (12.0±2.3 dB, p<0.001); however, it was still significantly decreased. There were significant correlations between logMAR BCVA and mean retinal sensitivity at all time points. The percentages of BCVA improvement were significantly higher than the percentages of mean retinal sensitivity improvement at all time points (p<0.001 for all comparisons).

Compared with microperimetry, BCVA significantly underestimates macular dysfunction in VKH disease.

To describe the use of 3 prostaglandin/timolol fixed combinations (FCs) in UK primary care, to summarize characteristics of recipients, and to assess 12-month persistence.

This retrospective cohort study included first-time recipients of latanoprost/timolol FC, bimatoprost/timolol FC, or travoprost/timolol FC treated between April 1, 2007, and November 30, 2008, identified in The Health Improvement Network database, a large database of anonymized longitudinal electronic medical records of patients treated in UK primary care. Eligible patients were ≥18 years old at the index date (date of first prescription). Persistence, defined as a gap ≤60 days between consecutive prescriptions, was assessed through 12 months post-index for each cohort (Cox proportional hazards models).

A total of 2,015 patients were included: latanoprost/timolol FC, n=898 (44.6%); bimatoprost/timolol FC, n=733 (36.4%); travoprost/timolol FC, n=384 (19.1%). The mean age was approximately 72 years across cohorts (p=0.792). Glaucoma was the diagnosis for >90% of patients in each cohort. Twelve-month persistence was similar across treatments: latanoprost/timolol FC: 38.2%; bimatoprost/timolol FC: 38.6%; travoprost/timolol FC: 38.3% (p=0.985). Mean time to therapy change for nonpersistent patients was also similar: 143.3±89.8, 151.0±87.9, and 151.8±87.7 days, respectively (p=0.095). Among persistent patients, additional therapy was prescribed for 36.2%, 41.7%, and 41.5% of patients, respectively. Among nonpersistent patients, 64.0%, 70.4%, and 69.2%, respectively, restarted the index therapy.

The largest proportion of first-time recipients of prostaglandin/beta-blocker FC products treated in UK primary care was prescribed latanoprost/timolol FC. Twelve-month persistence was similar (<40%) across the 3 FCs evaluated.

Panphotocoagulation reduces the risk of vision loss in proliferative diabetic retinopathy. However, not many patients tolerate this treatment well due to pain. Therefore, we evaluated the analgesic effect of etoricoxib during photocoagulation in patients with proliferative diabetic retinopathy.

A prospective, randomized, double-blind study was conducted on 44 consecutive patients eligible for panphotocoagulation due to proliferative diabetic retinopathy. During the first panphotocoagulation session, both groups were treated without medication. During the following session, the control group received a placebo pill while the other group received etoricoxib 120 mg. Both groups took the medicines 1 hour before the treatment. After each session, the patients quantified the level of pain on a subjective visual scale.

A total of 52 patients were selected for the study and the data of 44 patients were analyzed. In the control group, the average level of pain in the first session was 7.68 (standard deviation 1.70), dropping to an average of 7.32 (standard deviation 1.39) after ingestion of placebo. Therefore, there was no statistical difference (p=0.1187). In contrast, the average level of pain without the drug in the group taking etoricoxib 120 mg was 7.95 (standard deviation 1.46) vs 5.18 (standard deviation 1.65) with the drug, a significant statistical difference (p<0.001).

Etoricoxib 120 mg reduces pain and can be used before panphotocoagulation. Data show that the medication is more effective against pain during photocoagulation than placebo.

The aim of this study was to determine the prevalence of diabetic retinopathy among diabetic patients in Iran and its association with some predisposing factors.

All diabetic patients who attended the diabetes clinic underwent ocular examination, including slit-lamp biomicroscopy. The blood pressure and blood biochemical parameters were then measured.

The prevalence of diabetic retinopathy among 1022 diabetic participants was 23.6% (241 cases). This study showed that there is a statistically significant relation between diabetic retinopathy and mean blood pressure, fasting blood sugar, blood urea nitrogen, and level of HbA₁c. There was no difference in lipid profile between patients with and without retinopathy. The duration of diabetes was a predicting factor for retinopathy as well as presence of renal and cardiovascular diseases and fasting glucose >126 as independent variables.

The duration of diabetes was the most important risk factor for progression of retinopathy.

To describe fundus autofluorescence (FAF) patterns in patients with type 2A idiopathic juxtafoveolar retinal telangiectasia (IJRT).

We reviewed FAF images, color photographs, and fluorescein angiography (FA) images of 30 eyes from 16 patients with type 2A IJRT. Eyes with presence of subretinal neovascularization or any other retinal pathology were excluded. All the imaging modalities were obtained with a Heidelberg Retina Angiograph (HRA) confocal laser scanning system.

The mean age of the patients was 50.7 years, 68.5% female. At baseline, the median best-corrected visual acuity was 20/50. Loss of normal foveal hypoautofluorescence was noted in 93.3% of eyes. All the eyes showed hypoautofluorescence corresponding to intraretinal crystals and pigment clumps. Increased FAF around the pigments was noted in 93.3% of eyes. Increased FAF corresponding to the angiographic leakage from telangiectatic and nontelangiectatic areas was noted in 86.6% of eyes and 80% of eyes, respectively.

Loss of foveal hypoautofluorescence and increased FAF corresponding to the nontelangiectatic angiographic leakage areas were predominant features. Fundus autofluorescence patterns corresponding to color photography and FA findings may further add to the understanding of morphologic alterations in type 2A nonproliferative IJRT at early stages.

Cardiovascular disease and its risk factors may have a significant role in the development of neovascular age-related macular degeneration (NV-AMD). This study aims to assess the impact of these factors in this population and define their level of cardiovascular risk according to the Framingham model.

This was a cross-sectional, observational, multicenter study that included patients aged 50 years or older who attended ophthalmic centers for the diagnosis or follow-up of NV-AMD. Information collected included demographic and AMD data, a complete history of cardiovascular disease and its risk factors, lipid profile, blood pressure, and treatment history.

The study population consisted of 901 patients, predominantly Caucasian, with a mean age of 75.7 years, receiving anti–vascular endothelial growth factor therapy for their NV-AMD in 77.7% of the cases. Blood pressure measurement during the study visit and lipid analyses revealed poor control in 67.7% and 93.3% of the patients, respectively. Hypertension was the most prevalent cardiovascular risk factor (77.7%), followed by a history of cardiac disease or other forms of atherosclerotic disease (53.8%). Diabetes was present in 28% of the subjects. The study population was considered a high-risk population according to the National Cholesterol Education Program Expert Panel Clinical Guidelines (NCEP ATP III), with a probability of a cardiovascular event in 10 years of 19.3% according to the Framingham model.

This NV-AMD population is associated with a significant cardiovascular risk, and the Framingham model can help us identify those subjects with higher risk levels in order to improve their overall management.

To evaluate multifocal electroretinograms (mfERG) and macular retinal thickness before and after photodynamic therapy (PDT) for predominantly classic choroidal neovascularization (CNV) (classic type) and occult with no classic CNV (occult type).

Recording of mfERG and measurement of macular retinal thickness were performed before and after PDT in 19 patients (19 eyes) with the classic type and 24 (26 eyes) with the occult type. The evaluation items were the amplitude of the first negative wave (N1), the amplitude from the peak of the negative wave to that of the following positive wave (P1), and the peak latencies of the negative and positive waves.

Compared with mfERG before PDT, that after PDT showed a significant decrease in the P1 latency in the central area (31.1±1.9 ms before and 29.6±1.6 ms after PDT) for the classic type and significant decreases in both the central (32.0±2.0 ms before and 30.5±2.4 ms after PDT) and peripheral (30.2±2.0 ms before and 29.5±2.0 ms after PDT) areas for the occult type. Optical coherence tomography showed significant decreases in macular retinal thickness in both groups (464 and 314 μm before and after PDT, respectively, for the classic type and 516 and 340 μm for the occult type).

After PDT, retinal function evaluated by mfERG improved for both the classic and occult types, and the recovery of P1 latency may be due to improvement in retinal edema.

To report long-term functional and anatomic results of safety-enhanced photodynamic therapy (PDT) with half-dose verteporfin for chronic central serous chorioretinopathy (CSC).

A retrospective analysis of 29 eyes of 27 patients with chronic CSC was performed. All eyes received half-dose PDT. Visual acuity, central foveal thickness, and angiographic features were evaluated.

Mean follow-up time was 20 months (range 12-40). Mean best-corrected visual acuity improved from 0.45±0.23 logMAR to 0.08±0.08 logMAR. Twenty-five eyes (86%) had a complete resolution of the subretinal fluid after only one session and 4 eyes had recurrences, 3 of them at the same leaking area observed at baseline. At the end of the follow-up all eyes (100%) showed resolution of the subretinal fluid. There was no visual loss secondary to exaggerated response to the PDT, nor any other adverse events.

The long-term results of this study further support the safety and effectiveness of safety-enhanced PDT with half dose of verteporfin for the treatment of chronic CSC.

To study the short-term effects of intravitreal bevacizumab (Avastin) on retinal blood flow velocity and compare them to clinical outcomes assessed by optical coherence tomography (OCT) and tests of visual acuity.

The Retinal Function Imager (RFI) was used noninvasively and quantitatively to measure retinal blood flow velocity. Eight patients receiving intravitreal injection of Avastin for choroidal neovascularization (CNV) were included in this study. All were imaged by the RFI preinjection and 1 and 7 days postinjection. Visual acuity (VA) and OCT were recorded preinjection and 1 month postinjection. Comparisons were performed using paired Student t test and correlation using Spearman rank test.

A good correlation was found between the 1-month change in VA and OCT measurements and the short-term change induced in blood flow velocity. Arterial and venous velocity changes 1 day after the injection correlated with the VA change (p<0.05). The 1-day arterial velocity changes correlated with total macular volume (p=0.02) and venous velocity changes correlated to central macular thickness (p=0.04).

The RFI provides a noninvasive technique to assess early hemodynamic responses to intravitreal injection of Avastin. These early changes may prove important for better understanding of the mechanism underlying this treatment and serve as a quantitative marker for treatment optimization.

To investigate whether genetic polymorphisms of GSTZ1 contribute to the development of exudative age-related macular degeneration (AMD).

The present case-control study consisted of 112 patients (44 female, 68 male) with exudative AMD and 112 sex frequency-matched healthy controls were randomly selected from unrelated volunteers in the same clinic. Genotypes were determined by polymerase chain reaction–restriction fragment length polymorphism–based method.

There was no significant association between study polymorphisms and susceptibility to exudative AMD. Considering the significant difference in age distribution between cases and controls, age was used as a covariate in further analysis. After odds ratio adjustment for age, the same results were observed. The study polymorphisms showed linkage disequilibrium. Analysis revealed that there was no difference between cases and controls for the prevalence of the haplotypes of GSTZ1.

Our study did not support any association between susceptibility to exudative AMD and polymorphisms of GSTZ1.

To use the continuous glucose monitoring system (CGMS) in very low birthweight (VLBW) infants to further explore the association between elevated glucose levels and retinopathy of prematurity (ROP) and to find new preventive strategies for ROP.

A secondary analysis of risk factors for ROP in VLBW infants was performed in the neonatal intensive care units of University Hospital Leuven and ZOL Genk, Belgium. The subjects were part of the NIRTURE trial (ISRCTN78428828). Only control subjects with conclusive ROP assessments who received standard clinical care were included in this analysis. A total of 100 VLBW infants (birthweight ≤ 1500 g) were included. Twenty-three (23%) infants developed ROP; 77 (77%) did not.

Development of ROP was linked to the known classic risk factors. In addition, ROP was associated with higher glycemia levels across the first week (p between 0.01 and <0.0001). Across the first week, glycemia predicted ROP with receiver operating characteristic (ROC) scores between 0.67 and 0.80, and with a median glycemia cutoff of 6.7 mmol/L. Comparison of ROC curves revealed first-week glycemia as an important variable in the development of ROP with a predictive power as high as the classic risk factors.

Moderately elevated glucose levels in the first week of life are associated with the development of ROP. They contribute to this multifactorial disease in a way equal to the known classical risk factors for ROP. Therefore, careful monitoring of glucose levels by CGMS can be helpful in the prevention of ROP.

As it is not always possible to use corneal electrodes for recording electroretinograms (ERG) in children, it is necessary to check the feasibility of performing ERG with skin electrodes and to try to establish normative data.

Fifty-one healthy children (aged 7-11 years) were recruited. Cone ERG and 30-Hz flicker ERG were recorded with one active skin electrode positioned over the lower eyelid and a reference electrode at the outer canthus of the eye. Responses were recorded to full-field stimuli. Correlations between results of both eyes were studied. Results were compared to normative data obtained with corneal electrodes.

Cone ERG response was obtained in 100/102 eyes. Flicker ERG was obtained in 88/102 eyes. No correlation between eyes was found for the a-wave latency, the a-wave amplitude, and the latency of the flicker. Mean b-wave implicit time of the cone ERG was 38.71±1.6 ms; the median of its amplitude was 10.0 µV. The median of the amplitude of the flicker ERG was 12.55 µV.

Amplitudes are significantly reduced, with a scaling factor of 8.75 for the b-wave amplitude of the cone ERG compared to corneal electrodes (9.6 for the a-wave amplitude and 8.87 for the flicker amplitude). Our study contributes to the establishment of normative data for skin electrode ERG. It emphasizes the feasibility and accuracy of this method. It is very useful to assess the normality of the ERG in many clinical situations, such as nystagmus and suspicion of delayed visual maturation.

To describe the clinical presentation of primary macular hole retinal detachment (MHRD) secondary to high myopia and to evaluate the surgical outcomes.

Nine eyes of 9 patients with primary myopic MHRD (axial length ≥26.5 mm) were enrolled. A standardized surgical protocol was performed using vitrectomy with preservative-free triamcinolone acetonide–assisted internal limiting membrane (ILM) peeling and silicone oil tamponade and were followed for at least 6 months from the first surgery.

There were 6 women and 3 men with a median age of 52 years. Six (66.6%) patients presented with inferior bullous configuration and 3 had subtotal retinal detachment. The mean preoperative refractive error (spherical equivalent) and mean axial length was 12±3.553 D (range 8.50-19.50) and 28.13±1.65 mm (range 26.50-31.50), respectively. The patients were followed up for a period of at least 6 months. The retina was attached and macular hole closed in all the eyes. There was significant visual acuity improvement from mean preoperative visual acuity of logMAR 1.85±0.11 (range 1.76-1.93) to postoperative visual acuity of logMAR 0.95±0.14 (range 0.84-1.06) (p<0.001).

Retinal detachment in highly myopic eyes can often be secondary to a macular hole with predominance of inferior bullous configuration and primary vitrectomy with ILM peeling with silicone oil tamponade results in good anatomic and functional outcomes.

To evaluate the role of postoperative prone posturing for a single night in the outcome of trans pars plana vitrectomy (TPPV) with internal limiting membrane (ILM) peel and 20% perfluoroethane (C₂F₆) internal tamponade for idiopathic macular hole.

This prospective trial enrolled 14 eyes in 14 consecutive patients with idiopathic macular hole. All eyes underwent TPPV with vision blue assisted ILM peeling with and without phacoemulsification and intraocular lens (IOL) for macular hole. Intraocular gas tamponade (20% C₂F₆) was used in all cases with postoperative face-down posturing overnight and without specific posturing afterwards. LogMAR visual acuity, appearance by slit-lamp biomicroscopy, and ocular coherence tomography (OCT) scans were compared preoperatively and postoperatively to assess outcome.

Among 14 eyes recruited, all eyes were phakic; 50% of patients underwent concurrent phacoemulsification with IOL. The macular holes were categorized preoperatively by OCT appearance, 4 (28.57%) were stage 2, 7 (50%) were stage 3, and 3 (21.43%) were stage 4. Mean macular hole size was 0.35 disk diameters. Symptoms of macular hole had been present for an average of 6.5 months. All holes (100%) were closed 3 and 6 months postoperatively. Mean visual acuity (logMAR) was improved to 0.61 at 3 months and was stable at 6 months after the surgery. None of the eyes had worse vision postoperatively.

Vitrectomy with ILM peeling and 20% C₂F₆ gas with a brief postoperative 1 night prone posturing regimen is a reasonable approach to achieve anatomic closure in idiopathic macular hole. Concurrent cataract extraction did not alter outcomes and was not associated with any additional complications.

A meta-analysis was conducted to estimate the prevalence of patients with molecularly confirmed Leber hereditary optic neuropathy (LHON) carrying any of the 3 primary mtDNA mutations (m.11778G>A, m.14484T>C, m.3460G>A) which cause this inherited form of blindness.

A literature search was conducted to identify primary reports with LHON prevalence data reported for Europe. The overall prevalence of LHON with molecularly confirmed diagnosis was evaluated by weighting the prevalence estimates of the individual studies by the inverse of their variance.

Based on this meta-analysis of 5 European studies providing appropriate information, the estimated prevalence of LHON disease associated with the combined m.11778G>A, m.14484T>C, m.3460G>A mutations was ∼1:45,000 (2.23×10^-5; 95% confidence interval [CI] 2.01-2.44×10^–5). Patients with LHON carrying either the m.11778G>A or the m.3460G>A mutation have a more severe clinical presentation and a much lower chance of spontaneous recovery from vision loss compared to patients with the m.14484T>C mutation. The estimated prevalence for patients with LHON in Europe carrying either of these severe mutations (m.11778G>A or m.3460G>A) was ∼1:65,000 (1.54×10^–5; 95% CI 1.33-1.74×10^–5).

Although this meta-analysis summarizes the existing prevalence data for the primary, disease-causing mitochondrial DNA mutations of LHON in Europe, there is still a clear lack of reliable primary epidemiologic data for this devastating ophthalmologic disease.

To evaluate the psychometric properties of the Greek National Eye Institute Refractive Error Quality of Life Questionnaire (NEI-RQL-42).

We developed the Greek version of the instrument using forward and backward translation. To examine reliability, Cronbach alpha for each subscale was used as an index of internal consistency. Test-retest reliability was evaluated with intraclass correlation coefficients (ICC). Regarding construct validity, both convergent and discriminant validities were calculated by means of multi-trait analysis. Furthermore, the instrument was evaluated by Rasch analysis, as well.

Three patient groups were studied (emmetropes (n=20), myopes (n=41), and hyperopes (n=18)). Emmetropes scored significantly better in the majority of subscales, while myopes scored better than hyperopes in clarity of vision (p=0.012), near vision (p<0.001), and satisfaction with correction (p=0.001). Cronbach alpha ranged from 0.490 (glare) to 0.948 (expectations), with most subscales having high internal consistency. The ICCs ranged from 0.76 to 0.93 for all subscales. All items passed the convergent and discriminant validity tests. Strong correlations were detected between uncorrected visual acuity and near vision, expectations, activity limitations, dependence on correction, worry, and suboptimal correction subscales. Rasch analysis revealed potential weaknesses of the instrument that are associated with the assumptions of the model itself. Specifically, 3 items and 17.5% of the participants fell outside the tolerance box. Moreover, principal component analysis indicated average unidimensionality for the instrument.

Traditional validation methods indicate that the Greek NEI-RQL-42 scale has adequate psychometric properties for comparative studies in local populations. Rasch analysis indicates significant misfits to the model that should be taken into consideration and evaluated in future studies. These misfits might reflect inherent weaknesses of the original NEI-RQL-42 and not of its adaptation to Greek norms.

To evaluate the efficacy of amniotic membrane transplantation in lamella melting after anterior lamellar keratoplasty (ALK) assisted by femtosecond laser in a pediatric patient.

An 11-year-old girl with progressive keratoconus underwent ALK assisted by femtosecond laser on the right eye. The surgical procedure was performed under general anesthesia. The 60-KHz IntraLase femtosecond laser (Abbott Medical Optics) created both the donor (thickness 350 µm; diameter 8.1 mm; side cut 70°) and recipient (thickness 260 µm; diameter 8.0 mm; side cut 70°) lamellae. The recipient lamella was then gently removed and donor was fitted into place and sutured using 4 interrupted sutures added to a running suture in nylon 10-0. The surgery was uneventful. Two months after surgery, a lamella melting was observed. One month after topical steroid treatment, amniotic membrane transplantation was performed.

When lamella melting was observed, the best-corrected visual acuity (BCVA) was 0.1 and 0.5 with foramen and no inflammatory reaction in the anterior chamber was reported. Eleven months after amniotic membrane transplantation, BCVA was 0.9 and no visual acuity increase was recorded with foramen.

Our findings show that amniotic membrane transplantation could be considered in lamella melting after ALK assisted by femtosecond laser in children.

Permanent immovability of phakic intraocular lenses (pIOLs) for the correction of high myopia is crucial in avoiding injury to the corneal endothelium and maintaining visual acuity. Unstable position of iris-fixated pIOLs due to traumatic or nontraumatic disenclavation of the haptic has been described previously.

We report a different mechanism of repeated excessive implant motility in both eyes of a young woman who developed late nontraumatic elongation of the iris fibers to which an iris-claw pIOL was fixated. This led to increased motility of the pIOLs with blinking causing mild iritis. Subsequent bilateral successful re-enclavation to other iris fibers ameliorated these symptoms. After 2.5 years, these iris fibers, too, were elongated, causing excessive movements of the pIOLs and consecutive endothelial cell loss necessitating removal of the pIOLs. The etiology of this iris fiber laxity remains unclear.

Surgeons should be aware of this rare potential complication.

To describe a case of ABCA4 gene mutation (G1961E) associated with bilateral choroidal neovascularization (CNV) treated with intravitreal ranibizumab injections.

A 52-year-old man with bilateral CNV associated with ABCA4 gene mutation underwent complete ophthalmologic examination over a 30-month follow-up and was treated with intravitreal ranibizumab injections on an as-needed basis.

Baseline best-corrected visual acuity (BCVA) was 20/32 in the right eye (RE) and 20/63 in the left eye (LE). Two small CNVs with juxtafoveal location were detectable in the RE, whereas a single subfoveal CNV was visible in the LE. Overall, 6 and 9 intravitreal ranibizumab injections were administered in RE and LE, respectively, during the 30-month follow-up. At the end of the follow-up, BCVA was 20/100 in the RE and 20/200 in the LE.

This case report reveals that ABCA4 gene mutation may be complicated by multiple and bilateral CNVs. Intravitreal injection of ranibizumab can achieve temporary CNV stabilization, but cannot guarantee complete quiescence over a long-term follow-up. Other therapeutic approaches could be necessary to accomplish visual acuity preservation.

Choroidal neovascularization (CNV) is a rare complication after laser photocoagulation for disorders such as central serous chorioretinopathy (CSC).

We report 2 patients who developed CNV after laser treatment for persistent CSC and were treated by 3 1.25-mg intravitreal injections of bevacizumab in 1-month intervals.

In both patients, best-corrected visual acuity improved from 20/120 to 20/80 and from counting fingers at 3 feet to 20/100 over 12 months of follow-up.

The favorable outcome suggests that intravitreal injection of bevacizumab may be beneficial for patients who develop CNV after laser photocoagulation. The favorable outcome may be related to the limited pathology.

To report the optical coherence tomography (OCT) findings of acute central retinal artery occlusion (CRAO) with cilioretinal sparing.

Optical coherence tomography findings in a 45-year-old man with CRAO with cilioretinal sparing were evaluated.

Optical coherence tomography disclosed diffuse thickening of the neurosensory retina in the perifoveolar area. Increased reflectivity was noted in the inner retinal layers. The hyporeflectivity is observed in the outer retina including the outer neurosensory retina. The photoreceptors are not seen because of the shadowing effect. A localized foveal detachment composed of a dome-shaped retinal elevation over a nonreflective cavity with minimal shadowing of the underlying tissues was seen.

The OCT findings showed that besides the usual OCT findings in acute CRAO, the presence of a cilioretinal artery might lead to the leakage of fluid into the subfoveal space leading to localized detachment.

To report a case in which a nonselective cyclooxygenase (COX) inhibitor improved an exudative lesion in age-related macular degeneration.

A 64-year-old man had a complaint of metamorphopsia in the left eye. Visual acuity was 0.5 in the left eye. Fluorescein angiography and indocyanine angiography showed juxtafoveal occult choroidal neovascularization (CNV) in the left eye, and pegaptanib sodium 0.3 mg was administered once every 6 weeks. After 4 months, visual acuity improved to 0.8. After 8 months follow-up, optical coherence tomography (OCT) showed subretinal fluid (SRF) and retinal pigment epithelium (RPE) irregularity. Visual acuity was 0.4. We recommended further pegaptanib sodium injections, but the patient did not consent to the treatment. Onset of cellulitis of the left toe occurred 1 week before the scheduled visit after 9 months. The patient was treated with loxoprofen sodium (nonselective COX inhibitor) and cefdinir for 7 days. At 2 weeks after onset of cellulitis, SRF had disappeared and OCT showed improvement of RPE irregularity.

A COX inhibitor had an effect on vascular permeability in CNV and may have improved exudative changes.

To report imaging findings of unilateral acute idiopathic maculopathy (UAIM).

In this observational case report, the Spectralis acquisition system (Heidelberg Engineering, Germany), which includes spectral domain optical coherence tomography (OCT), multiple autofluorescence (AF), fluorescein angiography (FA), and indocyanine green (ICG) angiography, was used for monitoring onset and evolution of UAIM.

A well-defined, bullous macular lesion was evident on color pictures, infrared imaging (IR), and AF. Fluorescein angiography and ICG similarly showed early hypofluorescence of the lesion and, exclusively on FA, mild staining. Notably, the definition and limits of the detachment were clearly identifiable on late-phase ICG, and formed a hypocyanescent area. Spectral domain OCT disclosed severe retinal pigment epithelium (RPE) but not neurosensory detachment; the distinction between the photoreceptors inner/outer segment line was nonapparent for the entire length of the lesion. At 7-week follow-up, visual acuity improved to 20/20, with resolution of the exudative detachment. Autofluorescence and FA imaging indicated normalization, and only IR showed the boundaries of the lesion as still identifiable. Infrared imaging also showed a central granular feature, suggesting persistent choroid and pigment alteration. Indocyanine green angiography still evidenced the early hypofluorescent halo that became more evident in the late phases without any staining of the dye. Tomography depicted a reconstituted fovea, in which the outer limiting membrane and the inner/outer segment junction returned detectable.

Comprehensive evaluation of UAIM by AF, FA, ICG, and spectral domain OCT disclosed involvement of RPE, the neuroretina, and the choroid in the pathogenesis of the disease. Despite functional recovery, choroidal rather than retinal alteration could persist.

To report a case of choroidal neovascularization (CNV) associated with optic disk melanocytoma successfully treated with bevacizumab.

A 63-year-old man complained of visual impairment in his left eye. His visual acuity was 0.9 OS. Fundus examination showed optic disk melanocytoma associated with serous retinal detachment and mild hemorrhage. Fluorescein and indocyanine green angiography revealed CNV adjacent to the optic disc. Intravitreous bevacizumab (IVB) was performed 3 times.

Choroidal neovascularization and serous retinal detachment disappeared at 5 months after IVB. Visual acuity recovered to 1.5 OS and has been stable for 1 year follow-up. No adverse events were found related to IVB.

Intravitreous bevacizumab can be a beneficial treatment for CNV associated with optic disc melanocytoma.

To describe the diagnosis and management of an intraretinal cyst.

A 34-year-old man with a history of retinal detachment presented sudden loss of vision in the left eye. Visual acuity was hand movement. Examination revealed hematic vitreous haze and ultrasound showed a rounded mobile object in the vitreous cavity.

After differential diagnosis ruled out cysticercosis, pars plana vitrectomy revealed a neovascularized intraretinal macrocyst attached to a posterior flap of a 13-year-old retinal tear. Retinotomy and retinectomy were performed, removing this cyst located in the upper retina together with a portion of detached retina. At 1 year, the retina had adapted and the vitreous cavity was clear. Final visual acuity was 18/20.

Intraretinal cysts are usually asymptomatic and associated with long-standing retinal detachment, as seen in our clinical case. Periodic fundus examination is essential for their detection. Surgical treatment of the underlying condition usually leads to complete resolution.

We describe an atypical case of a patient with Coats disease that re-emerged after 30 years, illustrating a previously poorly understood long-term evolution of the disease.

A 20-year-old man consulted for visual acuity (VA) decrease in the left eye (LE) to 0.3. Fundus examination revealed an exudative lesion with telangiectasias in the superior peripheral retina compatible with the diagnosis of Coats disease.

The patient was treated with cryotherapy and argon laser. Visual acuity improved to 0.5 and remained stable during a 1-year follow-up. The patient did not seek further clinical follow-up. Thirty years later, he returned complaining of a progressive VA decrease in the LE. Snellen VA was measured to counting fingers. Fundus examination revealed stage 3A Coats disease with macular exudation and a serous retinal detachment in the inferior quadrants requiring the placement of an encircling band, external drainage, and cryotherapy of the vascular lesions. After 10 additional sessions of argon laser on the vascular malformations, exudation regressed further and best-corrected VA increased to 0.1 at the end of the follow-up period.

Coats disease must be considered as a chronic disease, which necessitates a very long-term follow-up even in the absence of subjective visual loss. The disease can reawaken and recur with force in previously unaffected areas of the retina several decades later. The gold standard treatment consists of cryotherapy and argon laser. However, in cases of very important retinal exudation, surgical management with subretinal drainage may be necessary.