The Utility of Repeat Culture in Fungal Corneal Ulcer Management

Repeat, Culture, Fungal, Cornea, Corneal Ulcer, Clinical Trial
Am J Ophthalmol. 2017 Jun;178:157-162. doi: 10.1016/j.ajo.2017.03.032. Epub 2017 Apr 4.

The Utility of Repeat Culture in Fungal Corneal Ulcer Management: A Secondary Analysis of the MUTT-I Randomized Clinical Trial.

Abstract

PURPOSE:

To determine whether patients who had a positive repeated culture was predictive of worse clinical outcome than those who achieved microbiological cure at 6 days in the Mycotic Ulcer Treatment Trial I (MUTT-I).

DESIGN:

Secondary analysis from a multicenter, double-masked, randomized clinical trial.

METHODS:

setting: Multiple hospital sites of the Aravind Eye Care System, India.

STUDY POPULATION:

Patients with culture-positive filamentous fungal ulcers and visual acuity of 20/40 to 20/400 reexamined 6 days after initiation of treatment.

INTERVENTION:

Corneal scraping and cultures were obtained from study participants at day 6 after enrollment.

MAIN OUTCOME MEASURES:

We assessed 3-month best spectacle-corrected visual acuity (BSCVA), 3-month infiltrate/scar size, corneal perforation, and re-epithelialization rates stratified by culture positivity at day 6.

RESULTS:

Of the 323 patients with smear-positive ulcers enrolled in MUTT-I, 299 (92.6%) were scraped and cultured 6 days after enrollment. Repeat culture positivity was 31% (92/299). Among patients who tested positive at enrollment, those with positive 6-day cultures had significantly worse 3-month BSCVA (0.39 logMAR; 95% confidence interval [CI]: 0.24-0.44; P < .001), had larger 3-month scar size (0.39 mm; 95% CI: 0.06-0.73; P = .02), were more likely to perforate or require therapeutic penetrating keratoplasty (odds ratio: 6.27; 95% CI: 2.73-14.40; P < .001), and were slower to re-epithelialize (hazard ratio: 0.33; 95% CI: 0.21-0.50; P < .001) than those with a negative 6-day culture result.

CONCLUSIONS:

Early microbiological cure on culture is a predictor of clinical response to treatment.

PMID:
28385473
DOI:
10.1016/j.ajo.2017.03.032

Repeat, Culture, Fungal, Cornea, Corneal Ulcer, Clinical Trial

Collagen crosslinking with conventional and accelerated ultraviolet-A irradiation using riboflavin with hydroxypropyl methylcellulose

Collagen crosslinking,ultraviolet, irradiation,riboflavin,methylcellulose

J Cataract Refract Surg. 2017 Apr;43(4):511-517. doi: 10.1016/j.jcrs.2017.01.013.

Collagen crosslinking with conventional and accelerated ultraviolet-A irradiation using riboflavin with hydroxypropyl methylcellulose.

Abstract

PURPOSE:

To evaluate corneal collagen crosslinking (CXL) with conventional and accelerated ultraviolet-A (UVA) irradiation using riboflavin with methylcellulose.

SETTING:

Department of Ophthalmology, Oslo University Hospital, Oslo, Norway.

DESIGN:

Prospective randomized case series.

METHODS:

Patients with keratoconus were randomized to have CXL using conventional 3 mW/cm2 UVA irradiation for 30 minutes (CXL30) or accelerated 9 mW/cm2 UVA irradiation for 10 minutes (CXL10). In both groups, a solution of riboflavin 0.1% with hydroxypropyl methylcellulose 1.1% (methylcellulose-riboflavin) was used. The endothelial cell density (ECD), visual acuity, and tomography were measured at baseline and after 12 months. Anterior segment optical coherence tomography and in vivo confocal microscopy (IVCM) were performed after 1 month.

RESULTS:

The study comprised 40 patients (40 eyes). A complete absence of keratocytes in all eyes at 100 μm depths was found on IVCM. At 300 μm, 400 μm, and preendothelial levels, the differences were 83.3% versus 31.3% (P = .02), 64.7% versus 20.0% (P = .01), and 42.1% versus 5.9% (P = .02) in the CXL30 and CXL10 groups. No statistically significant differences were found in the change in visual acuity or maximum keratometry between the groups after 12 months. There was no relationship between the depth of keratocyte absence and the ECD change after 12 months.

CONCLUSIONS:

Marked deep structural changes with an absence of keratocytes occurred when CXL was used with conventional or accelerated UVA irradiation; however, the changes were more pronounced with the use of conventional UVA irradiation. The use of methylcellulose-riboflavin might explain the deep alterations and raises a long-term safety concern.

PMID:
28532937
DOI:
10.1016/j.jcrs.2017.01.013

Guiding flying-spot laser transepithelial phototherapeutic keratectomy with optical coherence tomography

 flying spot, laser, transepithelial, phototherapeutic keratectomy, optical coherence tomography

J Cataract Refract Surg. 2017 Apr;43(4):525-536. doi: 10.1016/j.jcrs.2017.03.004.

Guiding flying-spot laser transepithelial phototherapeutic keratectomy with optical coherence tomography.

Abstract

PURPOSE:

To analyze transepithelial phototherapeutic keratectomy (PTK) results using optical coherence tomography (OCT) and develop a model to guide the laser dioptric and depth settings.

SETTING:

Casey Eye Institute, Portland, Oregon, USA.

DESIGN:

Prospective nonrandomized case series.

METHODS:

Patients with superficial corneal opacities and irregularities had transepithelial PTK with a flying-spot excimer laser by combining wide-zone myopic and hyperopic astigmatic ablations. Optical coherence tomography was used to calculate corneal epithelial lenticular masking effects, guide refractive laser settings, and measure opacity removal. The laser ablation efficiency and the refractive outcome were investigated using multivariate linear regression models.

RESULTS:

Twenty-six eyes of 20 patients received PTK to remove opacities and irregular astigmatism due to scar, dystrophy, radial keratotomy, or previous corneal surgeries. The uncorrected distance visual acuity and corrected distance visual acuity were significantly improved (P < .01) by 3.7 Snellen lines and 2.0 Snellen lines, respectively, to a mean of 20/41.2 and 20/22.0, respectively. Achieved laser ablation depths were 31.3% (myopic ablation) and 63.0% (hyperopic ablation) deeper than the manufacturer’s nomogram. The spherical equivalent of the corneal epithelial lenticular masking effect was 0.73 diopter ± 0.61 (SD). The refractive outcome highly correlated to the laser settings and epithelial lenticular masking effect (Pearson R = 0.96, P < .01). The ablation rate of granular dystrophy opacities appeared to be slower. Smoothing ablation under masking fluid was needed to prevent focal steep islands in these cases.

CONCLUSIONS:

The OCT-measured ablation depth efficiency could guide opacity removal. The corneal epithelial lenticular masking effect could refine the spherical refractive nomogram to achieve a better refractive outcome after transepithelial ablation.

Impact of First Eye versus Second Eye Cataract Surgery on Visual Function and Quality of Life

Cataract surgery, visual function, quality life
Ophthalmology. 2017 May 16. pii: S0161-6420(16)30787-4. doi: 10.1016/j.ophtha.2017.04.014. [Epub ahead of print]

Impact of First Eye versus Second Eye Cataract Surgery on Visual Function and Quality of Life.

Abstract

PURPOSE:

To compare the impact of first eye versus second eye cataract surgery on visual function and quality of life.

DESIGN:

Cohort study.

PARTICIPANTS:

A total of 328 patients undergoing separate first eye and second eye phacoemulsification cataract surgeries at 5 veterans affairs centers in the United States. Patients with previous ocular surgery, postoperative endophthalmitis, postoperative retinal detachment, reoperation within 30 days, dementia, anxiety disorder, hearing difficulty, or history of drug abuse were excluded.

METHODS:

Patients received complete preoperative and postoperative ophthalmic examinations for first eye and second eye cataract surgeries. Best-corrected visual acuity (BCVA) was measured 30 to 90 days preoperatively and postoperatively. Patients completed the National Eye Institute Visual Functioning Questionnaire (NEI-VFQ) 30 to 90 days preoperatively and postoperatively. The NEI-VFQ scores were calculated using a traditional subscale scoring algorithm and a Rasch-refined approach producing visual function and socioemotional subscale scores.

MAIN OUTCOME MEASURES:

Postoperative NEI-VFQ scores and improvement in NEI-VFQ scores comparing first eye versus second eye cataract surgery.

RESULTS:

Mean age was 70.4 years (±9.6 standard deviation [SD]). Compared with second eyes, first eyes had worse mean preoperative BCVA (0.55 vs. 0.36 logarithm of the minimum angle of resolution (logMAR), P < 0.001), greater mean BCVA improvement after surgery (-0.50 vs. -0.32 logMAR, P < 0.001), and slightly worse postoperative BCVA (0.06 vs. 0.03 logMAR, P = 0.039). Compared with first eye surgery, second eye surgery resulted in higher postoperative NEI-VFQ scores for nearly all traditional subscales (P < 0.001), visual function subscale (-3.85 vs. -2.91 logits, P < 0.001), and socioemotional subscale (-2.63 vs. -2.10 logits, P < 0.001). First eye surgery improved visual function scores more than second eye surgery (-2.99 vs. -2.67 logits, P = 0.021), but both first and second eye surgeries resulted in similar improvements in socioemotional scores (-1.62 vs. -1.51 logits, P = 0.255).

CONCLUSIONS:

Second eye cataract surgery improves visual function and quality of life well beyond levels achieved after first eye cataract surgery alone. For certain socioemotional aspects of quality of life, second eye cataract surgery results in comparable improvement to first eye cataract surgery.

Fundamental principles of an anti-VEGF treatment regimen: optimal application of intravitreal anti-vascular endothelial growth factor therapy of macular diseases.

anti-VEGF, treatment regimen,anti-vascular endothelial growth factor, therapy,macula

Graefes Arch Clin Exp Ophthalmol. 2017 May 19. doi: 10.1007/s00417-017-3647-4. [Epub ahead of print]

Fundamental principles of an anti-VEGF treatment regimen: optimal application of intravitreal anti-vascular endothelial growth factor therapy of macular diseases.

Abstract

BACKGROUND:

Intravitreal anti-vascular endothelial growth factor (VEGF) therapy is now considered the gold standard for the treatment of various retinal disorders. As therapy has evolved, so too have the treatment regimens employed by physicians in clinical practice; however, visual outcomes observed in the real world have typically not reflected those reported in clinical trials. Possible reasons for this include a lack of consensus on treatment regimens and a lack of clarity about what the aims of treatment should be.

METHODS:

The Vision Academy Steering Committee met to discuss the principles of an ideal treatment regimen, using evidence from the literature to substantiate each point. Literature searches were performed using the MEDLINE/PubMed database (cut-off date: March 2016) and restricted to English-language publications. Studies with fewer than ten patients were excluded from this review.

RESULTS:

The Steering Committee identified the following four key principles for the ideal treatment regimen for anti-VEGF management of retinal diseases: 1. Maximize and maintain visual acuity (VA) benefits for all patients 2. Decide when to treat next, rather than whether to treat now 3. Titrate the treatment intervals to match patients’ needs 4. Treat at each monitoring visit.

CONCLUSIONS:

It is proposed that the adoption of a proactive and more personalized approach in the clinic such as a treat-and-extend regimen will lead to benefits for both the patient and the physician, through a reduction in the associated treatment burden and better utilization of clinic resources. Implementation of the four principles should also lead to better VA outcomes for each patient, with a minimized risk of vision loss.

KEYWORDS:

Aflibercept; Anti–vascular endothelial growth factor; Retinal disease; Treat-and-extend; Treatment regimens; Visual acuity

Posturing of Patients Reduces Progression Toward the Fovea

Posture, Macula, Retina detachment, fovea
Ophthalmology. 2017 May 9. pii: S0161-6420(16)32438-1. doi: 10.1016/j.ophtha.2017.04.004. [Epub ahead of print]

Preoperative Posturing of Patients with Macula-On Retinal Detachment Reduces Progression Toward the Fovea.

Author information

Posture, Macula, Retina detachment, fovea

Abstract

PURPOSE:

Traditionally, preoperative posturing consisting of bed rest and positioning is prescribed to patients with macula-on retinal detachment (RD) to prevent RD progression and detachment of the fovea. Execution of such advice can be cumbersome and expensive. This study aimed to investigate if preoperative posturing affects the progression of RD.

DESIGN:

Prospective cohort study.

PARTICIPANTS:

Ninety-eight patients with macula-on RD were included. Inclusion criteria were volume optical coherence tomography (OCT) scans could be obtained with sufficient quality; and the smallest distance from the fovea to the detachment border was 1.25 mm or more.

METHODS:

Patients were admitted to the ward for bed rest in anticipation of surgery and were positioned on the side where the RD was mainly located. At baseline and before and after each interruption for meals or toilet visits, a 37°×45° OCT volume scan was performed using a wide-angle Spectralis OCT (Heidelberg Engineering, Heidelberg, Germany). The distance between the nearest point of the RD border and fovea was measured using a custom-built measuring tool.

MAIN OUTCOME MEASURES:

The RD border displacement and the average RD border displacement velocity moving toward (negative) or away (positive) from the fovea were determined for intervals of posturing and interruptions.

RESULTS:

The median duration of intervals of posturing was 3.0 hours (interquartile range [IQR], 1.8-14.0 hours; n = 202) and of interruptions 0.37 hours (IQR, 0.26-0.50 hours; n = 197). The median RD border displacement was 2 μm (IQR, -65 to +251 μm) during posturing and -61 μm (IQR, -140 to 0 μm) during interruptions, a statistically significant difference (P < 0.001, Mann-Whitney U test). The median RD border displacement velocity was +1 μm/hour (IQR, -21 to +49 μm/hour) during posturing and -149 μm/hour (IQR, -406 to +1 μm/hour) during interruptions, a statistically significant difference (P < 0.001).

CONCLUSIONS:

By making use of usual interruptions of preoperative posturing we were able to show, in a prospective and ethically acceptable manner, that RD stabilizes during posturing and progresses during interruptions in patients with macula-on RD. Preoperative posturing is effective in reducing progression of RD.

Rates of Local Retinal Nerve Fiber Layer Thinning before and after Disc Hemorrhage in Glaucoma

Retina, Nerve fiber layer, Thinning, Disc hemorrhage, glaucoma
Ophthalmology. 2017 May 9. pii: S0161-6420(16)32367-3. doi: 10.1016/j.ophtha.2017.03.059. [Epub ahead of print]

Rates of Local Retinal Nerve Fiber Layer Thinning before and after Disc Hemorrhage in Glaucoma.

Abstract

Retina, Nerve fiber layer, Thinning, Disc hemorrhage, glaucoma

PURPOSE:

To investigate longitudinal temporal and spatial associations between disc hemorrhage (DH) and rates of local retinal nerve fiber layer (RNFL) thinning before and after DHs.

DESIGN:

Longitudinal, observational cohort study.

PARTICIPANTS:

Forty eyes of 37 participants (23 with glaucoma and 17 with suspect glaucoma at baseline) with DH episodes during follow-up from the Diagnostic Innovations in Glaucoma Study and the African Descent and Glaucoma Evaluation Study.

METHODS:

All subjects underwent optic disc photography annually and spectral-domain optical coherence tomography (OCT) RNFL thickness measurements every 6 months. The rates of RNFL thinning were calculated using multivariate linear mixed-effects models before and after DH.

MAIN OUTCOME MEASURES:

Rates of global and local RNFL thinning.

RESULTS:

Thirty-six eyes of 33 participants with inferior or superior DHs were analyzed. The rates of RNFL thinning were significantly faster in DH quadrants than in non-DH quadrants after DH (-2.25 and -0.69 μm/year; P < 0.001). In the 18 eyes with intensified treatment after DH, the mean rate of RNFL thinning significantly slowed after treatment compared with before treatment in the non-DH quadrants (-2.89 and -0.31 μm/year; P < 0.001), but not in the DH quadrants (-2.64 and -2.12 μm/year; P = 0.19). In 18 eyes with unchanged treatment, the rate of RNFL thinning in the DH quadrant was faster after DH than before DH (P = 0.008). Moreover, compared with eyes without a treatment change, intensification of glaucoma treatment after DH significantly reduced the global, non-DH quadrants, and DH quadrant rates of RNFL thinning after DH compared with before DH (global, P = 0.004; non-DH quadrant, P < 0.001; DH quadrant, P = 0.005). In the multiple linear regression analysis, treatment intensification (β, 1.007; P = 0.005), visual field mean deviation (β, 0.066; P = 0.049), and difference in intraocular pressure before and after DH (β, -0.176; P = 0.034) were associated significantly with the difference of global RNFL slope values before and after DH.

CONCLUSIONS:

Although the rate of RNFL thinning worsened in a DH quadrant after DH, glaucoma treatment intensification may have a beneficial effect in reducing this rate of thinning.

Central Bright Spot Sign: A Potential New MR Imaging Sign for the Early Diagnosis of Anterior Ischemic Optic Neuropathy due to Giant Cell Arteritis.

Central Bright Spot Sign,MRI,Ischemic Optic Neuropathy,Giant Cell Arteritis

AJNR Am J Neuroradiol. 2017 May 11. doi: 10.3174/ajnr.A5205. [Epub ahead of print]

The Central Bright Spot Sign: A Potential New MR Imaging Sign for the Early Diagnosis of Anterior Ischemic Optic Neuropathy due to Giant Cell Arteritis.

Abstract

BACKGROUND AND PURPOSE:

A rapid identification of the etiology of anterior ischemic optic neuropathy is crucial because it determines therapeutic management. Our aim was to assess MR imaging to study the optic nerve head in patients referred with anterior ischemic optic neuropathy, due to either giant cell arteritis or the nonarteritic form of the disease, compared with healthy subjects.

MATERIALS AND METHODS:

Fifteen patients with giant cell arteritis-related anterior ischemic optic neuropathy and 15 patients with nonarteritic anterior ischemic optic neuropathy from 2 medical centers were prospectively included in our study between August 2015 and May 2016. Fifteen healthy subjects and patients had undergone contrast-enhanced, flow-compensated, 3D T1-weighted MR imaging. The bright spot sign was defined as optic nerve head enhancement with a 3-grade ranking system. Two radiologists and 1 ophthalmologist independently performed blinded evaluations of MR imaging sequences with this scale. Statistical analysis included interobserver agreement.

RESULTS:

MR imaging scores were significantly higher in patients with giant cell arteritis-related anterior ischemic optic neuropathy than in patients with nonarteritic anterior ischemic optic neuropathy (P ≤ .05). All patients with giant cell arteritis-related anterior ischemic optic neuropathy (15/15) and 7/15 patients with nonarteritic anterior ischemic optic neuropathy presented with the bright spot sign. No healthy subjects exhibited enhancement of the anterior part of the optic nerve. There was a significant relationship between the side of the bright spot and the side of the anterior ischemic optic neuropathy (P ≤ .001). Interreader agreement was good for observers (κ = 0.815).

CONCLUSIONS:

Here, we provide evidence of a new MR imaging sign that identifies the acute stage of giant cell arteritis-related anterior ischemic optic neuropathy; patients without this central bright spot sign always had a nonarteritic pathophysiology and therefore did not require emergency corticosteroid therapy.

Ranibizumab pretreatment in diabetic vitrectomy: a pilot randomised controlled trial (the RaDiVit study

Ranibizumab,pretreatment, diabetic vitrectomy, trial,RaDiVit study

Eye (Lond). 2017 May 12. doi: 10.1038/eye.2017.75. [Epub ahead of print]

Ranibizumab pretreatment in diabetic vitrectomy: a pilot randomised controlled trial (the RaDiVit study).

Abstract

PurposeOur aim was to evaluate the impact of intravitreal ranibizumab pretreatment on the outcome of vitrectomy surgery for advanced proliferative diabetic retinopathy. The objective was to determine the feasibility of a subsequent definitive trial and estimate the effect size and variability of the outcome measure.Patients and methodsWe performed a pilot randomised double-masked single-centre clinical trial in 30 participants with tractional retinal detachment associated with proliferative diabetic retinopathy. Seven days prior to vitrectomy surgery, participants were randomly allocated to receive either intravitreal ranibizumab (Lucentis, Novartis Pharmaceuticals UK Ltd, Frimley, UK) or subconjunctival saline (control). The primary outcome was best-corrected visual acuity 12 weeks following surgery.ResultsAt 12 weeks, the mean (SD) visual acuity was 46.7 (25) ETDRS letters in the control group and 52.6 (21) letters in the ranibizumab group. Mean visual acuity improved by 14 (31) letters in the control group and by 24 (27) letters in the ranibizumab group. We found no difference in the progression of tractional retinal detachment prior to surgery, the duration of surgery, or its technical difficulty. Vitreous cavity haemorrhage persisted at 12 weeks in two of the control group but none of the ranibizumab group.ConclusionRanibizumab pretreatment may improve the outcome of vitrectomy surgery for advanced proliferative diabetic retinopathy by reducing the extent of post-operative vitreous cavity haemorrhage. However, the effect size appears to be modest; we calculate that a definitive study to establish a minimally important difference of 5.9 letters at a significance level of P<0.05 would require 348 subjects in each arm.Eye advance online publication, 12 May 2017; doi:10.1038/eye.2017.75.

Fundus Autofluorescence and Near Infrared Reflectance as Prognostic Biomarkers for Visual Acuity in Foveal-Sparing Geographic Atrophy

Fundus, Autofluorescence ,Infrared Reflectance ,Visual Acuity,Fovea, Geographic Atrophy
Invest Ophthalmol Vis Sci. 2017 May 1;58(6):BIO61-BIO67. doi: 10.1167/iovs.16-21210.

Combined Fundus Autofluorescence and Near Infrared Reflectance as Prognostic Biomarkers for Visual Acuity in Foveal-Sparing Geographic Atrophy.

Abstract

PURPOSE:

To identify predictors of best corrected visual acuity (BCVA) in eyes with foveal-sparing geographic atrophy (GA) secondary to age-related macular degeneration (AMD).

METHODS:

Best corrected visual acuity (Early Treatment Diabetic Retinopathy Study charts); serial fundus autofluorescence; and near-infrared reflectance images of patients participating in the FAM (NCT00393692) and DSGA (NCT02051998) studies were analyzed. The sizes of GA and spared fovea, and the minimal linear dimension of intact retinal pigment epithelium (“bridge”) between the residual foveal island and the surrounding retina were quantified and associations with BCVA were assessed by local regression curves and mixed effects models.

RESULTS:

A total of 65 eyes (51 patients, aged 75.68 ± 8.41 years) were included. Median time between baseline and last visit with detectable foveal sparing was 18 (quartiles: 12, 33) months. Median BCVA was 0.30 (0.20, 0.52) logMAR at baseline and 0.4 (0.3, 0.7) logMAR at follow-up. Local regression curves suggested no linear association of BCVA with GA size, sparing size or bridge size. Most contrasting values for BCVA were observed for >1.5 mm2 foveal-sparing size and for 400 μm bridge size. Employing these values as cutoff levels, mixed effects modeling revealed that both anatomic parameters, but not time, significantly impacted BCVA.

CONCLUSIONS:

Fundus, Autofluorescence ,Infrared Reflectance ,Visual Acuity,Fovea, Geographic Atrophy

RP – not from article

During the review period eyes with foveal-sparing GA were likely to maintain the baseline BCVA. There was no linear correlation of BCVA with foveal-sparing size. Yet, BCVA was worse if the spared foveal area was <1.5 mm2 or if the bridge was smaller than 400 μm in width. These findings add to the understanding of the natural history of foveal-sparing GA and may support future clinical trial designs.