Low cardiorespiratory fitness is associated with elevated intraocular pressure among apparently healthy adults

PURPOSE

To evaluate the association of cardiorespiratory fitness with elevated intraocular pressure (IOP) in healthy adults.

METHODS

In this cross-sectional study, we evaluated 17,990 asymptomatic self-referred adults free of diabetes or cardiovascular disease who were screened in a preventive healthcare setting. All subjects underwent measurement of IOP and completed a maximal exercise stress test according to the Bruce protocol. Fitness was categorized into age and sex-specific quintiles according to the treadmill time and dichotomized to low (lowest quintile) and non-low fitness groups. Elevated IOP was defined as ≥ 21 mmHg.

RESULTS

Median age was 45 (IQR 39-52) years and 12,073 (67%) were men. There were 3,351 (19%) subjects in the low fitness group. Median IOP was 14 mmHg (IQR 12-16) with elevated IOP documented in 188 (1%) subjects. Univariate binary logistic regression model demonstrated that compared with non-low fitness group, subjects in the low fitness group were 2.2 times more likely to have elevated IOP (95% CI 1.598-2.95, p<0.001). Multivariate binary logistic regression with adjustment to known cardiovascular risk factors (age, sex, hypertension, smoking, overweight, regular physical activity, low HDL cholesterol, high triglycerides, and fasting glucose levels) successfully demonstrated that lower fitness was independently and significantly associated with a 90% increased likelihood of elevated IOP (95% CI 1.37-2.61, p<0.001). Subgroup analysis revealed that the association was more pronounced among women compared with men (OR 3.8 vs. 1.6, p for interaction = 0.069).

CONCLUSIONS

Low cardiorespiratory fitness is independently associated with increased IOP among apparently healthy adults.

Effect of direct oral anticoagulants on bleeding during and after cataract surgery

PURPOSE

To assess the risk for intraoperative and postoperative ocular bleeding associated with direct oral anticoagulant treatment in patients undergoing phacoemulsification surgery.

METHODS

Consecutive patients had phacoemulsification and intraocular lens implantation while taking uninterrupted direct oral anticoagulants (dabigatran, rivaroxaban, or apixaban). Gender and age-matched patients without antithrombotic therapy were used as the control group. Patients were examined one week postoperatively. Intraoperative and postoperative hemorrhagic and non-hemorrhagic complications were assessed.

RESULTS

Forty patients (56 eyes) on direct oral anticoagulants and 120 patients (172 eyes) without anticoagulation, at a mean age of 77 years, had phacoemulsification. There was no significant difference between the groups in the rate of intraoperative and postoperative bleeding. One eye (1.8%) in the treatment group and 3 eyes (1.7%) in the control group had hyphema (p = 0.72). No patient had thromboembolic event during or after surgery.

CONCLUSIONS

Cataract surgery was safely performed while continuing direct oral anticoagulation.

Ocular blood flow biomarkers may predict long-term glaucoma progression

BACKGROUND/AIM

To examine the relationship between baseline blood flow biomarkers and long-term open-angle glaucoma (OAG) progression.

METHODS

112 patients with early to moderate OAG (mean age 64.9±11.0 years; 68 female) were evaluated at baseline and every 6 months from 2008 to 2013. Biomarkers of retinal capillary blood flow were assessed by Heidelberg retinal flowmetry. Functional disease progression was monitored via Humphrey visual field examinations, defined as two consecutive visits with a mean deviation decrease ≥2 decibels and/or Advanced Glaucoma Intervention Study score increase ≥2 compared with baseline. Structural progression was monitored with optical coherence tomography and Heidelberg retinal tomograph, defined as two consecutive visits with retinal nerve fibre layer thickness decrease ≥8% and/or horizontal or vertical cup/disk ratio increase ≥0.2 compared with baseline. Mixed-model analysis of covariance was used to test for significant change from baseline to 5-year follow-up. Times to functional and structural progression were analysed using Cox proportional hazards models.

RESULTS

Lower HRF retinal capillary blood flow in the superior retina was significantly associated with structural progression (p=0.0009).

CONCLUSION

In our OAG sample, baseline lower retinal capillary perfusion in the superior retina was predictive of structural progression after 5 years.

TRIAL REGISTRATION NUMBER

NCT01145911.

Association of Variants in TMEM45A With Keratoglobus

Importance

Keratoglobus is a rare corneal disorder characterized by generalized thinning and globular protrusion of the cornea. Affected individuals typically have significantly decreased vision and are at risk of corneal perforation. The genetic basis and inheritance pattern of isolated congenital keratoglobus are currently unknown.

Objective

To identify the genetic basis of isolated congenital keratoglobus.

Design, Setting, and Participants

This case series and molecular analysis studied 3 unrelated nonconsanguineous families with keratoglobus at a medical center in Israel. Data were collected from June 2019 to March 2021 and analyzed during the same period.

Exposures

Whole-exome sequencing and direct Sanger sequencing, expression analysis by real-time polymerase chain reaction, splice-site variant analysis, immunohistochemical staining, and histological evaluation of a knockout mouse model.

Main Outcomes and Measure

Molecular characteristics associated with keratoglobus.

Results

Four pediatric patients (3 male individuals) from 3 families had clinical findings consistent with keratoglobus. These included globular protrusion, corneal thinning more prominent at the periphery, and high astigmatism. Truncating and splice site variants were identified in the TMEM45A gene, which fully segregate with the disorder. All affected individuals were homozygous or compound heterozygous for variants in the TMEM45A gene, while unaffected family members were heterozygous carriers. Expression analysis in healthy controls showed that TMEM45A was expressed 23 times higher in the human cornea compared with peripheral blood. Immunohistochemical staining of the TMEM45A protein in normal corneas confirmed its expression in the corneal stroma and epithelium. A TMEM45A knockout mouse model showed structural features consistent with keratoglobus.

Conclusions and Relevance

Expression of TMEM45A has been previously shown to result in upregulation of extracellular matrix components and fibrosis. These results suggest that isolated congenital keratoglobus is an autosomal recessively inherited disorder associated with variants in the TMEM45A gene.

Refractive outcomes of high-magnitude astigmatism correction using femtosecond LASIK versus transepithelial PRK

PURPOSE

To compare the outcomes of femtosecond laser assisted in situ keratomileusis (FS-LASIK) with transepithelial photorefractive keratectomy (T-PRK) for the correction of high-grade astigmatism.

METHODS

Medical records of patients with astigmatism of 2 diopters (D) or higher, who were treated with FS-LASIK or T-PRK in 2013 through 2014 at a private practice laser clinic, were retrospectively analyzed. Efficacy, safety, predictability and vector analysis of astigmatism correction were compared between the treatment groups.

RESULTS

The study included 93 eyes treated with FS-LASIK and 186 eyes treated with T-PRK. No significant differences in postoperative spherical equivalent (-0.10 ± 0.7 D and -0.11 ± 0.7 D, respectively, p = 0.958) and postoperative refractive astigmatism (0.79 ± 0.54 D and 0.82 ± 0.63 D, respectively, p = 0.685) were demonstrated. A significant advantage of FS-LASIK over T-PRK was seen for the efficacy (1.00 ± 0.18 and 0.86 ± 0.22, respectively, p < 0.001) and safety (1.03 ± 0.17 and 0.89 ± 0.21, respectively, p < 0.001) indices. Results remain statistically significant in a multivariate analysis model. Vector analysis for the astigmatism correction showed no significant difference between the surgery methods in the surgically induced astigmatism, difference vector, correction index and index of success.

CONCLUSION

Both procedures demonstrated desirable post-operative SE outcomes for high-grade astigmatism correction. However, FS-LASIK achieved better results than T-PRK in the efficacy and safety parameters.

Dynamic assessment of the tear film muco-aqueous and lipid layers using a novel tear film imager (TFI)

PURPOSE

The objective of the study was to assess a new technology, the tear film imager (TFI), which can dynamically image the muco-aqueous and lipid layers.

METHODS

Prospective pilot case series of individuals with and without dry eye (DE). Two sequential images were obtained with the TFI. Measurements were assessed for reproducibility and compared with clinically derived DE metrics. Individuals were grouped into DE categories based on signs of DE.

RESULTS

49 patients participated in the study with a mean age of 58.8 years (SD 15.9) and a female majority (69%). Reproducibility of the muco-aqueous layer thickness (MALT) was excellent (r=0.88). MALT measurements significantly correlated with the Schirmer score (r=0.31). Lipid break up time (LBUT) as measured by the TFI significantly correlated with the clinical measure of tear break up time (TBUT) (r=0.73). MALT and LBUT were significantly thinner and shorter, respectively, in the DE groups (mild-moderate and severe) compared with the control group. When comparing TFI parameters to clinically assessed signs, sensitivity of the device was 87% and specificity was 88%.

CONCLUSION

The TFI is the first machine capable of reproducibly measuring muco-aqueous thickness in human subjects which correlates with Schirmer score. In parallel, it assesses other important aspects of tear film function which correlate with clinician assessed DE metrics.

Modified Corneal Incisions for Cataract Surgery in Patients Treated with Tamsulosin: A Prospective Study

PURPOSE

To evaluate modified anterior elongated corneal incisions as a simple technique to reduce the incidence and severity of intraoperative floppy iris syndrome (IFIS), in patients taking tamsulosin (a selective α_1a-adrenergic receptor antagonist).

METHODS

This prospective case series was conducted at Meir Medical Center, a tertiary care facility in Israel. Included were 45 eyes of 39 male patients taking tamsulosin, and thus prone to IFIS. Patients underwent phacoemulsification cataract surgery with anterior elongated corneal incisions. The primary outcomes were the incidence and severity of IFIS, the complication rate and the need for additional IFIS management techniques. The secondary outcome was to quantify the surgically induced astigmatism, using Alpin's vector analysis. The tamsulosin treatment period and pupil diameter during five stages of the surgery were also noted.

RESULTS

The overall rate of IFIS was 33.33% (n = 15). The IFIS severity was rated as mild in 22.22% and moderate in 11.11% of the study eyes. No IFIS was noted in 66.67% of the eyes. There were no cases of severe IFIS, and no need for other IFIS management strategies. The complications rate was 2.22% (n = 1). Patients who developed IFIS had a significantly smaller pupil at the beginning of surgery (p < 0.05). There was no significant difference in tamsulosin treatment period between patients with and without IFIS (p = 0.19). The centroid - the mean SIA vector was 0.51 D @ 18° ±1.5 D (SD).

CONCLUSIONS

In tamsulosin treated patients, using modified corneal incisions may be feasible in order to reduce the incidence and severity of IFIS during cataract surgery. Future randomized studies are warranted.

Orthokeratology Associated Microbial Keratitis

Purpose

To report the clinical course, microbiologic findings, treatment, and outcomes of overnight orthokeratology associated microbial keratitis.

Methods

Four cases of overnight orthokeratology associated microbial keratitis are reported.

Results

Four patients aged 14–23 years (mean 18 years) who had central or paracentral corneal ulcers were included. Visual acuity at presentation ranged from 20/30 to hand motion. In all cases Pseudomonas aeruginosa was cultured from corneal scrapings or storage solution. In all patients the infection resolved with intensive topical antimicrobial treatment. Final best-corrected visual acuity ranged from 20/25 to 20/200 according to the location, size, and density of the corneal scar, which complicated all cases.

Conclusions

Infectious keratitis is a significant, visual threatening complication of overnight orthokeratology. Eye care practitioners should be aware of this complication and educate their patients of the importance of lens hygiene and prompt medical care when symptoms or signs of keratitis appear.

Modified corneal incisions in intraoperative floppy iris syndrome (IFIS)-prone patients

BACKGROUND

We aimed to report a simple technique that involves modified anterior (to the limbus) elongated corneal incisions in order to reduce the incidence and severity of intraoperative floppy iris syndrome (IFIS) and related complications.

METHODS

This was a retrospective study of phacoemulsification cataract surgeries performed by a single surgeon on patients receiving tamsulosin or alfuzosin between 1 January 2009 and 31 July 2012 at Meir Medical Center, Kfar-Sava, Israel. We recorded preoperative gender, age, α-antagonist medication, coexisting pseudoexfoliation (PXF), and intraoperative use of ophthalmic viscosurgical devices (OVDs), pupil size, complications, IFIS grading and the need for additional operative strategies to manage IFIS. Elongated corneal incisions were performed approximately 1 mm anterior to the limbus.

RESULTS

Ninety-three eyes of 81 men were included. Mean age was 76.5 years (range 55 to 96 years). Forty-seven eyes (40 patients) had documented use of alfuzosin and 45 eyes (40 patients) of tamsulosin. One patient received both. The overall rate of IFIS was 22.6 % (n = 21). Eyes of patients who were treated with alfuzosin had a milder grading (p < 0.001) and an overall lower percentage of IFIS compared to tamsulosin (4.26 % versus 42.22 % respectively, p < 0.001). No additional strategies were used to manage IFIS during surgery. No intraoperative complications occurred.

CONCLUSION

Anterior elongated incisions are simple and efficient in preventing IFIS, exempting the surgeon from the use of additional expensive devices or materials in most cases. They do not limit the surgeon to one strategy, and therefore, if necessary, another may be applied at any given time.

Conclusiveness of the Cochrane Eye and Vision Group Reviews

BACKGROUND

To assess the conclusiveness of Cochrane Eye and Vision Group Reviews (EVGRs). We tested the hypotheses that: (1) the majority of EVGRs are inconclusive; (2) most reviews state the need for further and better studies; (3) the conclusiveness of a given review is affected by the number of randomized controlled trials (RCTs) included and the cumulative number of patients and eyes studied.

METHODS

A retrospective study of all EVGRs available in the Cochrane Library in June 2013. For each EVGR we recorded the number of RCTs found by the reviewers, the number of RCTs included for final analysis as fulfilling inclusion criteria, the total cumulative number of patients and eyes studied, the stated need for further and better studies, the reason stated for further studies and the type of conclusion reached by the reviewer(s). We used the Kruskal-Wallis test to determine differences between ''conclusive'' and ''inconclusive'' studies in terms of the outcome variables studied. The correlation between the number of included studies and cumulative sample size was studied using regression analysis.

RESULTS

Out of 106 EVGRs, 52.8% were conclusive. In 83.9% of the conclusive EVGRs one treatment/strategy/drug was found to be better than the alternative. The average number of available and included RCTs was significantly higher in conclusive EVGRs (P = 0.007 and P = 0.003 respectively). The total cumulative number of patients and number of eyes studied was approximately ten times higher in the conclusive EVGRs (P < 0.001 and P < 0.015 respectively). A similar percentage of RCTs was included in both conclusive and inconclusive reviews (76 vs. 73%). The vast majority of EVGRs, whether conclusive (84%) or inconclusive (96%), stated the need for further and better studies (P = 0.042). Fifty eight percent of the EVGRs justified the need for further studies for at least two reasons. The reason that was stated the most was a need for a larger amount of RCTs (67%).

CONCLUSIONS

In approximately half of the cases, EVGRs allow the reader to reach a clinically applicable conclusion. Larger total cumulative participants, total cumulative number of eyes studied and number of RCTs performed all increase the likelihood of an EVGR to be conclusive.

The effects of the frequency of the initial treatment with intravitreal bevacizumab on macular volume and visual acuity

PURPOSE

The ideal notion of monthly intravitreal injections is difficult to achieve when it comes to real-life scenarios. In reality, patients often are treated with larger intervals due to circumstances. The purpose of this study was to compare the results of intravitreal bevacizumab injections with shorter intervals versus longer intervals for the treatment of choroidal neovascularization (CNV) in age-related macular degeneration (AMD) in a real-life clinic.

METHODS

A retrospective, consecutive cohort study of naive eyes of patients with CNV secondary to AMD treated with intravitreal bevacizumab. Patients included underwent at least 3 consecutive injections with intervals <45 days in between them (Group A) or >45 days (Group B). Best corrected visual acuity (BCVA) and optical coherence tomography were performed before the initial intravitreal injections and after the last injection.

RESULTS

Group A consisted of 24 eyes of 18 patients and Group B 30 eyes of 25 patients. There was a significantly larger mean of consecutive (5.0 vs. 3.78, P = 0.013) and total (9.44 vs. 7.2, P = 0.021) injections in Group B. There was a significant improvement in average BCVA in Group A only (0.65-0.52, P=0.006). However, a significant and similar improvement in retinal volume was found in both groups (P < 0.05).

CONCLUSION

This study emphasizes the importance of achieving consecutive injections with short intervals. Practitioners and decision makers should be mindful that providing additional resources to accomplish proper frequency may be more effective (visual outcome), cost effective (less injections), and safer (less exposure) for the patient.

A 10-year survey: prevalence of ocular surface squamous neoplasia in clinically benign pterygium specimens

PURPOSE

It is essential to assess the yield of routine histopathological examination of pterygium specimens excised from clinically benign pterygium. The purpose of this study was to determine the rate of histopathologically identified ocular surface squamous neoplasia (OSSN) in clinically benign pterygium specimens.

MATERIALS AND METHODS

This retrospective consecutive study consisted of patients from the cornea services of the ophthalmology departments of Meir Medical Center, Kfar Sava, and Rabin Medical Center, Petah Tikva, Israel. Included patients were those with clinically benign pterygium who underwent pterygium excision between January 2002 and December 2011. The pterygium specimens were sent for histopathological examination and the pathology reports were reviewed for evidence of OSSN.

RESULTS

Overall, pathology reports of 682 eyes of 585 sequential patients were included in the study. There was a male predominance of cases (59%). Patients' age ranged from 16 to 87 years with an average age of 56 years. Six hundred and forty-three cases were primary (94%) and 39 cases were recurrent (6%).

CONCLUSIONS

Cases of clinically benign pterygium diagnosed and excised by an experienced corneal expert are less likely to harbor OSSN. The yield of routine histopathological examination of such specimens may be low.

Safety and efficacy of intrastromal injection of 5% natamycin in experimental fusarium keratitis

PURPOSE

To compare the efficacy of combined intrastromal injection and topical natamycin 5% to standard topical therapy alone in an experimental rabbit model of Fusarium keratitis.

METHODS

Fungal keratitis was induced in the right eyes of 12 New Zealand rabbits by stromal injection of Fusarium solani spore suspension into the cornea. Four days after inoculation, animals were randomly assigned to 2 different treatment groups (n=6 in each group). The study group received intrastromal injections of natamycin 5% on treatment day 1 and 4, combined with topical natamycin 5% eye drops given hourly between 8:00 and 20:00 for the first 2 days, followed by 4 times daily on days 3-11. The control group received only topical natamycin 5% at identical intervals. Eyes were examined clinically on days 1, 4, 7, and 11 for status of corneal healing, corneal vascularization, and hypopyon. Animals were sacrificed on day 11, and corneas were subjected to histopathological examination.

RESULTS

Both groups showed significant improvement in terms of conjunctival hyperemia, size and density of corneal infiltrate, corneal edema, and total clinical score. In the study group, there was a significant improvement in the height of hypopyon in the anterior chamber, while there was also an increased amount of vascularization.

CONCLUSIONS

This study showed that intrastromal injection of natamycin 5% combined with topical treatment has little beneficial effect over topical therapy in a Fusarium keratitis rabbit model. The addition of intrastromal injection should be reserved to the most severe or recalcitrant cases.

Mutational spectrum of the ZEB1 gene in corneal dystrophies supports a genotype-phenotype correlation

PURPOSE

Mutations in ZEB1 have been reported in posterior polymorphous corneal dystrophy (PPCD3; MIM #609141) and Fuchs' endothelial corneal dystrophy (FECD6; MIM #613270). Although PPCD and keratoconus are clinically and pathologically distinct, PPCD has been associated with keratoconus, suggesting a common genetic basis. The purpose of our study was to perform mutational screening of the ZEB1 gene in patients affected with keratoconus or PPCD.

METHODS

Sanger sequencing of ZEB1 was performed in 70 unrelated patients with keratoconus and 18 unrelated patients with PPCD. Real-time quantitative PCR (RT-qPCR) was performed on RNA from cultured corneal keratocytes obtained from a keratoconic patient harboring a missense ZEB1 mutation (p.Gln640His) undergoing corneal transplantation.

RESULTS

Mutational analysis of ZEB1 in PPCD identified a previously reported frameshift mutation (C.1578_1579INSG) and a novel nonsense mutation (C.2249C A) in exon 7 of ZEB1 causing the insertion of a stop codon: p.Ser750X. In the keratoconus cohort, a novel heterozygous pathogenic mutation in exon 7 (c.1920G > T; p.Gln640His) of ZEB1 was identified in a family affected with keratoconus and Fuchs' endothelial corneal dystrophy. RT-qPCR performed on cultured corneal keratocytes harboring the missense ZEB1 mutation (p.Gln640His) demonstrated that COL4A1 and COL4A2 were markedly downregulated, and COL4A3, COL4A4, and COL8A2 were moderately downregulated.

CONCLUSIONS

Our data combined with the previously reported mutational spectrum of ZEB1 support a genotypephenotype correlation: missense substitutions in the ZEB1 protein are associated with FECD6 and keratoconus, whereas protein truncating ZEB1 mutations result in PPCD3. The dysregulation of α-type IV collagens represents a common link between ZEB1 mutation and the clinical phenotypes (PPCD3, FECD, and keratoconus).

Giant cobblestone-like papillae during isotretinoin therapy

PURPOSE

To report a case of giant cobblestone-like papillae that appeared during oral isotretinoin therapy.

DESIGN

Case report.

METHODS

A 14-year-old boy presented with bilateral eye itching for 1 week. Bilateral upper palpebral conjunctival cobblestone-like papillae, superficial punctate keratitis, and shield ulcer in the left cornea were seen. At the time, he was treated with oral isotretinoin for 6 months.

RESULTS

Following cessation of isotretinoin, the ulcer and SPK healed, and the papillae disappeared completely after an 8-week course.

CONCLUSION

Giant cobblestone-like papillae and corneal shield ulcer may be considered as a probable isotretinoin-induced ocular adverse event.

Deep Anterior Lamellar Keratoplasty for Post-LASIK Ectasia

PURPOSE

To describe 2 cases of post-laser in situ keratomileusis (LASIK) ectasia managed with deep anterior lamellar keratoplasty (DALK).

METHODS

Clinical findings, surgical interventions, and outcomes are reported. The surgical technique of DALK is described.

RESULTS

Two patients developed progressive loss of vision after LASIK surgery with enhancement procedure(s). Corneal ectasia was diagnosed on the basis of clinical findings, progressive central corneal thinning on pachymetry, and topographical changes with irregular astigmatism and inferior corneal steepening. Both patients underwent uneventful DALK surgery, in which the anterior 80% of the central corneal stroma was replaced by a donor button and sutured in place. The postoperative recovery was uneventful, except for mild interface haze in 1 case, which resolved within 2 weeks of surgery. However, 1 patient underwent additional surgery, including clear lens extraction with intraocular lens placement, astigmatic keratotomies, and photorefractive keratectomy (PRK) to achieve good unaided visual acuity. At last follow-up, at least 2 years after DALK, both patients were satisfied with their vision. Their uncorrected visual acuity (UCVA) was 20/60+ and 20/40- in their operated eyes, improving to 20/40+ and 20/30- with minimal refractive corrections. The grafts and lamellar interfaces were clear.

CONCLUSIONS

We believe that DALK should be considered as an alternative to penetrating keratoplasty for the surgical management of post-LASIK ectasia.

Corneal laceration by sharp objects in children seven years of age and younger

PURPOSE

Young children are prone to develop amblyopia after penetrating injury. We sought to evaluate the management of penetrating corneal injury without intraocular foreign body (IOFB) in children <or=7 years old and to assess the long-term visual acuity results.

METHODS

A retrospective chart review was performed in 2 ophthalmology departments to identify children <or=7 years old with penetrating corneal injury from sharp objects that had follow-up of >18 months. Data retrieved included all details from the initial examination, surgical procedures, amblyopia prevention measures, and final visual acuity.

RESULTS

Twenty children eligible for the study were identified. The mean age was 4.3 years, and mean follow-up time was 58 months. The corneal wound size range was 1-10 mm, with 8 eyes having wounds >or=6 mm. All patients required primary surgical management. Traumatic cataract extraction was performed at the primary operation in 6 eyes, with intraocular lens (IOL) implantation in 4 eyes. Additional surgical procedures were performed in 12 eyes. Yttrium-Aluminum-Garnet (YAG) capsulotomy was performed in 3 eyes with secondary cataract. Twelve patients required spectacle or contact lens correction, and 11 patients had patching for amblyopia prevention. At the end of follow-up, visual acuity was 20/40 or better in 14 eyes, 20/50 to 20/100 in 4 eyes, no light perception (NLP) in 1 eye, and unknown in 1 eye.

CONCLUSIONS

Proper management of penetrating corneal injury in young children can result in excellent visual rehabilitation. Major measures include prompt traumatic cataract extraction with either primary or secondary IOL implantation, opening of posterior capsular opacification with YAG laser, correction of refractive errors, and patching for amblyopia prevention.

Structural abnormalities of the cornea and lid resulting from collagen V mutations

PURPOSE

Type V collagen forms heterotypic fibrils with type I collagen and accounts for 10% to 20% of corneal collagen. The purpose of this study was to define the ocular phenotype resulting from mutations in the type V collagen genes COL5A1 and COL5A2 and to study the pathogenesis of anomalies in a Col5a1-deficient mouse.

METHODS

Seven patients with classic Ehlers-Danlos syndrome (EDS) due to COL5A1 haploinsufficiency and one with an exon-skipping mutation in COL5A2 underwent an ocular examination, corneal topography, pachymetry, and specular microscopy. A Col5a1-haploinsufficient mouse model of classic EDS was used for biochemical and immunochemical analyses of corneas. Light and electron microscopy were used to quantify stromal thickness, fibril density, fibril structure, and diameter.

RESULTS

Five males and three females (mean age, 26 +/- 13.57 years; range, 11-52) were studied. All patients had "floppy eyelids." The corneas of all eyes were thinner (mean corneal thickness: 435.75 +/- 12.51 microm) when compared with control corneas (568.89 +/- 28.46 microm; P < 0.0001). In the Col5a1+/- mouse cornea, type V collagen content was reduced by approximately 49%, and stromal thickness was reduced by approximately 26%. Total collagen deposition in Col5a1(+/-) corneas also was reduced. Collagen fibril diameters were increased, but fibril density was decreased throughout the stroma at all developmental stages.

CONCLUSIONS

In the eye, COL5A1 and COL5A2 mutations manifest as abnormally thin and steep corneas with floppy eyelids. Mechanisms involved in producing the latter anomalies probably involve altered regulation of collagen fibrillogenesis due to abnormalities in heterotypic type I/V collagen interactions similar to those observed in the Col5a1+/- mouse cornea.

Downregulation of gene expression in the ageing lens: a possible contributory factor in senile cataract

PURPOSE

To study the molecular characteristics of lens epithelial cells from patients with senile cataract by cDNA microarray technique.

METHODS

Lens epithelial cells adhering to anterior capsules taken during cataract surgery collected from 108 patients, aged 56-92 years (senile cataract group), were pooled. Pooled epithelial cells of normal, noncataractous lenses from one patient with ocular trauma, one patient with lens subluxation, and 25 cadaveric eyes, all under the age of 55 years, served as a control. Total RNA was extracted by conventional methods from the two groups of cells, and a fluorescent probe was prepared for each group. The probes were hybridized on 9700 known human cDNA clones. Hybridized clones were analysed using a scanning laser and the results were processed by GEMTools (Incyte Genomics) software.

RESULTS

A total of 1827 clones hybridized with the two probes. Of these, 400 showed differences of more than two-fold in gene expression between the two probes. Relative to controls, gene expression in the senile cataract lenses was upregulated in 318 clones and downregulated in 82. Three genes-filensin, inwardly rectifying potassium channel (IRPC), and pigment epithelium-derived factor (PEDF) were strongly downregulated (by 41.3-, 6.8-, and 5.9-fold, respectively) in senile cataract.

CONCLUSIONS

Cataractogenesis is associated with numerous changes in the genetic profile of the lens epithelial cells. Since filensin, IRPC, and PEDF genes are known to have important roles in the physiology and morphology of the transparent lens, substantial downregulation of their expression might contribute to the formation of senile cataract.

Outcome of Penetrating Keratoplasty Performed by Cornea Fellows Compared With That of an Experienced Staff Surgeon

PURPOSE

To compare the outcome of penetrating keratoplasty performed by supervised cornea fellows and an experienced staff surgeon.

METHODS

Retrospective review of cases of penetrating keratoplasty performed over a 4-year period with corneal topography performed on a clear graft. Overall, 202 cases from 184 patients were included: 108 performed by an experienced staff surgeon and 94 cases by 9 cornea fellows. Charts were reviewed for topographic astigmatism, other topographic indices, refractive astigmatism and best-corrected visual acuity (BCVA), all recorded after removal of the 10-0 sutures while the 11-0 suture remained in place. Graft clarity was assessed at final follow-up.

RESULTS

Mean postoperative topographic astigmatism was 4.60 +/- 2.7 diopters in the fellow group and 4.08 +/- 2.41 diopters in the staff group. The mean postoperative time at which corneal topography was obtained was 9.53 +/- 4.4 months in the fellow group and 9.22 +/- 4.6 months in the staff group. Mean refractive astigmatism was 3.77 +/- 1.97 diopters (fellows) and 3.49 +/- 1.93 diopters (staff). Mean surface asymmetry index (SAI) was 1.89 +/- 1.42 (fellows) and 1.61 +/- 1.08 (staff). Mean surface regularity index (SRI) was 1.43 +/- 0.72 (fellows) and 1.45 +/- 0.61 (staff). Mean BCVA was 0.49 logMAR (20/61) +/- 4.3 lines (fellows) and 0.47 logMAR (20/59) +/- 3.9 lines (staff). In the fellow group, 85 (90%) cases remained clear over a mean follow-up of 32 months and in the staff group 100 (93%) grafts remained clear over a mean follow-up of 38 months. Simple and multiple regression analyses indicated no difference between the 2 groups in all outcome measures.

CONCLUSIONS

Properly supervised cornea fellows in training achieved favorable penetrating keratoplasty results that were comparable to those of an experienced staff surgeon.

High prevalence of thrombophilia among young patients with myocardial infarction and few conventional risk factors

BACKGROUND

Thrombophilia refers to series of acquired and inherited conditions that confer a tendency to thrombus formation. The exact relationship between thrombophilia and MI is not well established.

OBJECTIVES

To determine the prevalence of thrombophilia in young patients with their first MI and few conventional risk factors.

METHODS

We evaluated the baseline characteristics and the thrombophilia profile, including anti-cardiolipin antibodies, activated protein C resistance (APCR) with the factor V Leiden mutation, prothrombin G20210A mutation, protein C, protein S, and antithrombin-III levels, among 85 consecutive patients (<50 year old) who were admitted to CCU with their first MI. Patients were divided into two groups: group A-patients with < or =1 risk factor and group B-patients with > or =2 risk factors.

RESULTS

92% were male and 55% with anterior wall MI. Overall, the risk factor profile was: smoking in 60%, hyperlipidemia in 42%, positive family history in 29%, hypertension in 18%, diabetes mellitus in 13%, and obesity in 8%. Forty-seven percent of patients had < or =1 risk factor (n=40, group A) and 53% had > or =2 risk factors (n=45, group B). The prevalence of the prothrombin mutation was 15% in group A compared to 7% in group B (p=0.12). APCR secondary to a heterozygous genotype of factor V Leiden mutation was found in 20% in group A compared to 2% in group B (p<0.01). Anti-cardiolipin antibodies were found in 16% in group A compared to 22% in group B (p=ns). Finally, we have found that the likelihood of identifying at least one thrombophilia marker was 50% in group A compared to 29% in group B (p=0.046).

CONCLUSIONS

The likelihood to detect at least one thrombophilia marker in young patients with MI and few conventional risk factors is significantly high. Thrombophilia may contribute to the development of MI in this specific group of young patients.

Combined Topical and Intracameral Anesthesia in Penetrating Keratoplasty

BACKGROUND

The standard of care for penetrating keratoplasty (PKP) is either retrobulbar or peribulbar anesthesia combined with seventh cranial nerve akinesia or general anesthesia. These methods are known to be associated with rare but potentially serious adverse ocular and systemic events.

PURPOSE

To determine the safety and efficacy of combined topical and intracameral anesthesia in addition to intravenous sedation for repeat penetrating keratoplasty (PKP).

SETTING

Tertiary-care university hospital.

METHODS

In this prospective study, combined topical tetracaine 0.5% and 0.2 cc intracameral 1% lidocaine along with i.v. sedation with midazolam and fentanyl were used for patients undergoing repeat PKP in 15 eyes of 15 selected patients. The indication for surgery was failed corneal graft. Verbal pain scale (VPS, 0-3) was recorded preoperatively, intraoperatively at 3 time-points (after trephination, after placing 8 interrupted sutures, and after placing the running suture), and postoperatively (1 hour postoperatively, overnight pain, and 1 day postoperatively). Patient and surgeon satisfaction were assessed postoperatively using a scale (1-5). After surgery patients were asked for their preferences comparing the current use of topical anesthesia compared with retrobulbar anesthesia used for their initial PKP.

RESULTS

The mean intraoperative VPS score was 0.51 +/- 0.32 (range 0-1.33), and the mean postoperative VPS score was 0.47 +/- 0.50 (range 0-1.67). There were no serious intraoperative or postoperative complications. All patients reported high mean satisfaction score of 4.67 +/- 0.49 (range 4-5). The mean satisfaction score reported by the surgeon was 4.47 +/- 0.63 (range 3-5). All patients but 1 (93.3%) preferred combined topical over retrobulbar anesthesia, which they had in their previous surgery.

CONCLUSIONS

We found combined topical and intracameral anesthesia to be safe and effective in our selected group of patients undergoing repeat PKP, and it may provide a satisfactory alternative anesthetic modality for patients in whom general, retrobulbar, or peribulbar anesthesia may be contraindicated.

Combined mitomycin C application and free flap conjunctival autograft in pterygium surgery

PURPOSE

To evaluate the long-term postoperative outcome and complication rate of combined intraoperative low-dose mitomycin C application and free conjunctival autograft for the treatment of pterygium.

METHODS

In a prospective, consecutive, noncomparative case series, a series of 46 consecutive patients (50 eyes) with primary pterygium (43 eyes) or recurrent pterygium (7 eyes) were studied. The patients' ages ranged from 23.0 to 80.0 years (mean, 53.4 years). All patients underwent pterygium excision combined with intraoperative low-dose mitomycin C application (0.02% for 2 minutes) and free conjunctival autograft. The mean follow-up period was 29.2 months (range 12 to 41 months). The main outcome measures were recurrence of pterygium and postoperative complications.

RESULTS

Pterygium recurred to a small extent (0.5 mm) in one eye (2%) of a patient with recurrent pterygium. There were no intraoperative complications. Subconjunctival graft hematoma appeared soon after surgery and resolved spontaneously in five eyes (10%). One eye developed transient high intraocular pressure without optic nerve or visual field defect, and one eye developed mild symblepharon. There were no sight-threatening complications or serious side effects.

CONCLUSIONS

By applying a single low dose of mitomycin C combined with free conjunctival autograft during pterygium excision, the recurrence rate of pterygium can be markedly reduced.

Primary cataract extraction and intraocular lens implantation in penetrating ocular trauma

PURPOSE

To analyze the postoperative outcome and complication rate after cataract extraction or lensectomy with primary intraocular lens (IOL) implantation for penetrating traumatic cataract.

DESIGN

Retrospective, nonconsecutive, noncomparative case series.

METHODS

We retrospectively reviewed the files of 21 patients who were admitted to our departments because of traumatic cataract with corneal or scleral laceration caused by penetrating trauma with or without intraocular foreign body (IOFB) from 1992 through 1997. Lens aspiration or manual extracapsular cataract extraction with primary IOL implantation was performed in all patients. Removal of an IOFB was performed in eight patients.

MAIN OUTCOME MEASURES

Final visual acuity and deviation of actual refraction from emmetropia and from expected postoperative refraction.

RESULTS

The mean follow-up was 20.4 months. Fourteen eyes (67%) achieved final visual acuity of 20/40 or better, 95% obtained 20/60 or better final visual acuity, and all eyes achieved 20/100 or better final visual acuity. Major causes of limited visual acuity were central corneal scar and central retinal injury. Eleven eyes (57%) experienced secondary cataract and underwent neodymium:yytrium-aluminum-garnet capsulotomy.

CONCLUSIONS

Primary implantation of posterior chamber lenses after penetrating ocular trauma is associated with favorable visual outcome and a low rate of postoperative complications.

Acute eosinophilic interstitial nephritis and uveitis (TINU syndrome) associated with granulomatous hepatitis

A 23-year-old male presented with renal failure, cholestatic liver enzyme elevation and uveitis. Percutaneous renal biopsy revealed marked eosinophilic infiltration of the renal interstitium, which made the diagnosis of TINU syndrome (Tubulo-Interstitial Nephritis and Uveitis). Percutaneous liver biopsy showed granulomatous hepatitis, which was not described as a part of TINU syndrome. The diagnostic dilemma and the literature are discussed.

Effect of aspirin intake on bleeding during cataract surgery

PURPOSE

To study the association between chronic intake of aspirin and intraoperative bleeding during cataract surgery and the effect of discontinuing the medication before surgery.

SETTING

Department of Ophthalmology, Meir Hospital, Sapir Medical Center, Kfar-Saba, Israel.

METHODS

Sixty-one patients having cataract surgery and receiving aspirin to prevent thromboembolic events were divided into 3 groups: Group A, continuation of the medication; Group B, cessation of aspirin intake for 2 to 5 days before surgery; Group C, cessation of medication for 7 to 10 days before surgery. Blood tests of coagulation parameters, a detailed questionnaire, and 1 day and 1 week follow-up were evaluated.

RESULTS

There were no significant differences in blood tests and the amount and incidence of intraoperative bleeding among the 3 groups. Diathermy was used somewhat more in Group A; however, there was no difficulty stopping the bleeding in any case and discontinuation of the medication had no effect on the intraoperative course or postoperative outcome.

CONCLUSIONS

Aspirin intake was not associated with significant intraoperative bleeding; thus, discontinuation of aspirin is usually not indicated. Clear corneal phacoemulsification is advantageous in patients receiving antiplatelet therapy.