Download ijor shifts in corneal transplantation procedures in north China: 5316

Global issues
ijor shifts in corneal transplantation procedures in
north China: 5316
over 12 years
L Xie, F Qi, H Gao, T Wang, W Shi, J Zhao
State Key Laboratory
Cultivation Base, Shandong
Provincial Key Laboratory
of Ophthalmology,
Shandong Eye Institute,
Qingdao, PR China
Correspondence to:
Dr L Xie, Shandong Eye
Institute, 5 Yanerdao Road,
Qingdao 266071, PR
China;
[email protected]
Accepted 7 May 2009
Published Online First 24
June 200S
ABSTRACT
^
Aims: To investigate the major shifts in the ratio
of lamellar keratoplasty (LKP) to penetrating
keratoplasty (PKP) and in the preoperative
indications for each procedure.
Methods: Medical records of patients who
received LKP and/or PKP at Shandong Eye
Institute between 1996 and 2007 were
categorised and reviewed. The time period was
divided into intervals of 1996-8,1999-2001, 20024 and 2005-7.
Results: A total of 4346 patients (5316 eyes)
with integrated clinical records were included in
the study. LKPs and PKPs were performed on
1558 eyes (29.3%) and 3758 eyes (70.7%),
respectively. Within the first 3-year interval, the
top three indications for LKP were chemical
burns, keratoconus and corneal dermoid; the top
reasons for PKP were viral keratitis, suppurative
keratitis and corneal scarring. Within the last
interval, suppurative keratitis, keratoconus and
viral keratitis became most common indications
for LKP and suppurative keratitis, viral keratitis
and bullous keratopathy for PKP. The ratio of
LKP to PKP operations tended to increase.
Conclusion: Following proper indications, the
use of LKP has increased in number in north
China and has become particularly frequent in
the management of corneal infections,
keratoconus, corneal degeneration, and stro-mal
dystrophy.
Corneal transplantations are the main procedures performed
to treat corneal blindness. Traditionally, penetrating
keratoplasty (PKP) has been the procedure selected for
corneal diseases such as suppurative keratitis, keratoconus
and corneal stromal dystrophy. However, immune rejection,
which can lead to graft opacity, remains a major problem
after PKP. Even "normal" graft may have chronic corneal
allograft dysfunction.' With the accumulation of knowledge
on corneal diseases, corneal endothelia and corneal surgery
procedures, as well as the development of microsurgical
technology, lamellar keratoplasty (LKP) has become more
valued. Although today it is well accepted that LKP should
be preferred over PKP in as many cases without major
problems with the corneal endothelia as it is possible to
prevent endothelium-related problems such as immune
rejection and chronic corneal allograft dysfunction, we have
not yet seen a clinical report with a large number of cases to
support the existence of this shift. To track this spontaneous
change in procedure preference, we retrospectively reviewed
the corneal transplantation cases from Shandong Eye
Institute over 12 years and evaluated procedural shifts and
indications for each operative procedure.
fir J Ophthalmol 2009:93:1291-1295. doi:10.1136/bjo.2008.148981
METHODS
Medical records of patients who received corneal
transplantation at Shandong Eye Institute, including Qingdao
Eye Hospital and Shandong Eye Hospital, from January
1996 to December 2007 were reviewed. Shandong Eye
Institute is an important clinical centre for corneal diseases in
north China, with patients mainly from across the northern
provinces. The corneal diseases were categorised into
suppurative keratitis (fungal, bacterial and amoebic
infections), viral and other keratitis (viral infection, Mooren
ulcer and stromal keratitis), corneal degeneration, dystrophy
and congenital anomaly, keratoconus, corneal injury and
others.2
All data were divided into four time intervals according to
the admission date: January 1996 to December 1998, January
1999 to December 2001, January 2002 to December 2004
and January 2005 to December 2007. Clinical features of
patients, preoperative diagnosis and surgical procedure were
collected. Proportions of LKP versus PKP within each
interval and major preoperative diagnoses were analysed.
The f2 test was used for statistical analysis with SPSS10.0.
A p value of less than 0.05 was considered statistically
significant.
RESULTS
A total of 4346 patients (5316 eyes) were included. They
were 1312 women and 3034 men, aged from 6 months to 91
years. LKP and PKP were performed on 1558 eyes (29.3%)
and 3758 eyes (70.7%), respectively.
Changes in procedural preference
There were 982 corneal transplantations including 236 LKPs
(24.0%) and 746 PKPs (76.0%) during the period 1996-8,
1300 transplantations including 352 LKPs (27.1%,) and 948
PKPs (72.9%) during 1999 and 2001, 1641 transplantations
including 438 LKPs (26.7%) and 1203 PKPs (73.3%) during
2002 and 2004, and 1393 transplantations including 532
LKPs (38.2%) and 861 PKPs (61.8%) during 2005 and 2007
(x,2 = 74.79, p = 0.00). The proportions of LKP to PKP
increased (figs 1, 2).
Trends in major preoperative diagnoses
Over the 12 years, 1631 eyes with suppurative keratitis
underwent corneal transplantation, including 1046 eyes
(64.1%) with fungal keratitis, 563 (34.5%) with bacterial
keratitis and 22 (1.3%) with amoebic keratitis. Across the
four time intervals, LKP was given in 7.5%, 33.7%, 29.9%
and 36.9% of eyes with fungal infection (^=47.70, p<0.01),
7.6%, 32.3%, 30.8% and
1291
Clinica
Spectacle use after routine cataract surgery
M R Wilkins,1 B Allan,1 G Rubin,1'2 Moorfields IOL Study Group
' Moorfields Eye Hospital,
2
London, UK; UCL Institute
of Ophthalmology, NIHR
Faculty, Biomedical
Research Centre for
Ophthalmology, London,
UK
Correspondence to:
Or M Wilkins, Moorfields
Eye Hospital, 162 City
Road, London EC1V 2PD,
UK;
[email protected]
Accepted 13-March 2009
Published Online First 7 May
2009
ABSTRACT
Aims: To measure spectacle dependence
following bilateral monofocal intraocular lens
(IOL) implantation and assess how it is predicted
by postoperative refraction. Methods: 300
cataract patients had bilateral phacoemulsification surgery with monofocal IOL
implantation. A spherical equivalent of 0 to -0.5 D
was targeted. Three months after surgery,
patients answered a questionnaire and had a
spectacle refraction. Refractions were converted
into vector notation. Logistic regression was used
to evaluate whether spectacle dependence for
near and distance was related to overall
refractive error, spherical error, signed spherical
error and astigmatic error. Results: 169 patients
attended for assessment. 38 wore distance
glasses, and 160 wore reading glasses either
some or all of the time. The mean right spherical
equivalent was —0.03 D, and the mean right
cylinder was —0.64 D. Left outcomes were
similar. Patients were 34 times more likely to
always use distance glasses per dioptre of
astigmatic error in the better eye (p<0.003), but
there was no significant increase in the likelihood
of wearing distance glasses with spherical error
(odds ratio = 3,85, p>0.15). Similar effects were
seen for both the better and worse eyes. Nearspectacle use was not dependent on astigmatic
error (odds ratio = 0.22, p> 0.12). It was only
related to the signed spherical error in the worse
eye with hypermetropic patients 6.74 times more
likely to always wear spectacles per dioptre of
positive spherical error (p<0.005). Conclusions:
Following bilateral monofocal intraocular lens
implantation, small levels of overall refractive
error, in either eye, particularly astigmatism,
predict distance-spectacle dependence, whereas
spherical ammetropia in the range of +1.0 D
does not. Hypemnetropia in the worse eye, but
not astigmatism, predicts reading-spectacle
dependence.
The standard treatment tor patients undergoing routine
cataract surgery is to insert a monofocal or fixed focus
intraocular lens (IOL). When inserting such an IOL we
frequently select an IOL power that will leave the patient
with an emmetropic or low myopic prescription. Following
bilateral pha-coemulsification surgery where emmetropia has
been targeted, spectacle dependence for distance is at least
40%.'2
What is not clear is what factors in the postoperative
refraction predict whether a patient will be spectacledependent for near or distance. Knowledge of such factors
would allow the surgeon, by changing the IOL power
selected, or by managing preoperative astigmatism, to reduce
spectacle dependence.
routine bilateral sequential phacoemulsification. Three
hundred cataract patients were entered into a prospective
study of visual outcomes after bilateral cataract surgery.
Patients were randomised to sequential implantation with
either the Tecnis Z9000 or the Acrysof MA60AC monofocal
intraocular lenses. Computer-generated randomisation using
a non-blocked coin-toss protocol was used to allocate
patients to sequential bilateral implantation of the Z9000 IOL
or MA60AC IOL. A spherical equivalent from 0 to -0.5 D
was targeted in each eye. This study has been reported in
detail elsewhere.3
Inclusion criteria were: age 30 years and above and presence
of bilateral visually significant cataracts. Exclusion criteria
were: ocular co-pathology which might influence
postoperative vision, congenital cataracts or a history
indicative of amblyo-pia and preoperative astigmatism
greater than 1.5 D as measured by the lOLMaster
keratometer. Wherever cataract density permitted, biometry
was performed using the lOLMaster; otherwise A-scan
biometry was performed. Manufacturers' ultrasound A
constants were used throughout. Information on the biometry
technique used was retrospectively collected by examining
the notes.
Four months after the second eye was operated on, patients
were interviewed about whether they wore spectacles for
near and distance visual tasks and underwent a subjective
refraction. Patients were asked whether they wore distancespectacles "always," "tor driving/TV only" or "never." They
were also asked if they wore reading glasses "always," "for
fine print only," or "never."
Binocular uncorrected visual acuity (UCVA) and binocular
best spectacle corrected visual acuity (BSCVA) were tested
using Early Treatment of Diabetic Retinopathy Study
(ETDRS) log minimum angle of resolution (logMAR) letter
charts projected on a high-resolution liquid crystal display 4
m from the subject. Refractions were performed by two
trained ophthalmic technicians, using a precise protocol. The
duochrome technique was not used. All retractions were
recorded in minus cylinder format. Near acuities were not
recorded, as the original primary aim of the study was to
assess the effect of two IOL designs on distance visionrelated quality of life.
Spherocylindrical powers were converted to a threedimensional vector notation that included astigmatism and
sphere powers (M, Jo and ]^}.' The spherical error (M) refers
to the spherical equivalent; JO and J45 refer to Jackson
crossed cylinders with orientations of 0 and 45° respectively.
The values for M, Jo and ]4s specify a point in space, and the
distance of this point from the origin represents overall
refractive error (D). The astigmatic error (J) is half the
cylindrical power.
METHODS
T.-,i3 study is an analysis of data collected from a ;:^dv to
examine vision-related quality of life after
^•B-..-
1307
Ten years after photorefractive keratectomy (PRK)
and Saser in situ keratomileusis (LASIK) for
moderate to high myopia (control-matched study)
Institute Oftalmologico de
Alicante, Vissum
(Department of Refractive
Surgery) and Division of
Ophthalmology, Miguel
Hernandez University,
Medical School, Alicante,
Spain; Ankara University
School of Medicine, Ankara,
Turkey
Correspondence to:
Professor J L Alio, Institute
Oftalmologico de Alicante
Avda De Denia s/n,
|EdificioVISSUM) 03016,
Alicante, Spain;
[email protected]
Accepted 31 January 2008
Published Online First 3
December 2008
J L Alio,1 D Ortiz,1 0 Muftuoglu,2 M J Garcia1
threatening.6 7 Consequently, excimer laser superficial
ABSTRACT
keratectomy techniques such as photorefractive keratectomy
Objective: To compare the long(FRK), laser subepithelial keratectomy (LASEK) and
term outcomes of photorefractive
epithelial laser in situ keratomileusis (Epi-LASIK) have
gained popularity in recent years to correct myopia to refrain
keratectomy (PRK) and laser in situ
from possible complications of LASIK such as corneal
keratomilesis (LASIK) for myopia
ectasia.4 a 9
between -6 and -10 D.
Given that refractive surgery is mostly performed on
Methods: A retrospective, control- young and healthy eyes of patients with high expectations,
matched study including 68 eyes, 34 long-term safety and
which underwent PRK and 34
LASIK, with myopia between -6 and 10 D, operated using the VISX 20/20
excimer laser, was performed. Optical
zones of 5.5 to 6 mm were used. All
PRK-treated eyes were matched with
LASIK-treated eyes of the same age,
spherical equivalent within ±1.25 D,
sphere within ±1.5 D and cylinder
within ±2.5 D. All patients were
evaluated 3 months, 1 year, 2 years, 5
years and 10 years after surgery. The
main outcomes measures were
refractive predictability and stability,
safety, efficacy and re-treatment rate.
Results: At 10 years, 20 (71%) and 23
(88%) were within ± 1.00 D after PRK
and LASIK respectively. The retreatment rate was 35% and 18%
respectively. No eye lost more than
two lines of BSCVA in both groups.
The efficacy was 0.90 for PRK and
0.95 for LASIK. Conclusions: Both
PRK and LASIK were safe for
moderate myopia. LASIK
demonstrated slightly better efficacy,
predictability, and less rate of retreatment after 10 years. The
technical improvements should be
taken into account when comparing
these results with those obtained more
recently.
Photorefractive keratectomy (PRK) to correct myopia was
introduced in. the late 1980s.'2 Because of severe
postoperative pain and relatively slow recovery after FRK,
laser in situ keratomilesis (LASIK) was introduced in the
early 1990s and became the most performed refractive
surgery modality in the 2000s with claimed advantages over
PRK such as quick visual rehabilitation, higher
predictability, minimal postoperative discomfort and absence
of corneal haze." Although, studies with short-term followup reported that the risks associated with LASIK were
considered to be low, postoperative flap-related
complications and corneal
ectasia
can
be
sight-
efficacy are the greatest concerns.410 Despite millions of
procedures having been performec. there is a great lack of
data about the long-terr'-comparison of PRK and LASIK."
Previous studies comparing PRK and LASIK outcomes, up
to 1 year after surgery, found similar or slightly better safety
and efficacy outcomes for LASIK.""16 The aim of the present
study is to perform a comparative analysis of the evolution of
the corneal curvature and the refractive stability 10 years
after myopic PRK and LASIK for moderate myopia by
means of a control-matched retrospective study.
METHODS Patient
population
A total of 4800 charts of eyes that underwent PRK or LASIK
between April 1992 to December 1995 a:
the Institute Oftalmologico de Alicante (Spain;
were reviewed. Our database was compiled including 509
eyes of 356 patients treated with myopic PRK and 294 eyes
of 178 patients treated with myopic LASIK that returned for
follow-up at 3 months, 1 year, 2 years, 5 years and 10 years
after the initial procedure, either spontaneously or after
telephone calls (particularly at 10 years). Among this group,
34 (17 right, 17 left) PRK-treated eyes of 33 patients and 34
(15 right, 19 left) LASIK-treated eyes of 32 patients who had
Br J Ophthalmol 2009:93:1313-1318. doi:10.1136/bjo.2007:131748
a preoperative spherical equivalent between —6 and 10 D
were matched using the following criteria: (1) same age, (2)
preoperative spherical equivalent (SE) within ±1.25 D, (3)
preoperative sphere (S) wit;--;-. ±1.50 D and (4) preoperative
cylinder (C) wi;r_--±2.50D. Patient demographics,
refraction, mean optical zone and ablation depth at the time
c.f treatment are given in table 1. The study was approved by
the institutional review board (Ethical Committee of Clinical
Investigation of Institute Oftalmologico de Alicante) and
followed the tenets of Helsinki Declaration.
Surgical procedure
Inclusion criteria for surgery were: no contact lens wear 4
weeks before the surgery and stable refractive error for at
least 6 months before surgery, normal peripheral retina or
treated with photocoagulation when necessary, no previous
ocular surgery, and no corneal diseases, glance—.;
or history of ocular trauma. Exclusion criteria ::r surgery
were: evidence of keratoconus or kerato-conus suspect as
evidenced by corneal topography. active ocular or systemic
disease likely to affec:
corneal wound healing, pregnancy and nursing.
13-;
Use of Anterior Segment Optical Coherence
Tomography to Study Corneal Changes After
Collagen Cross-linking
MURIEL DOORS, NAYY1RIH G. TAHZIB,
FRED A. EGGINK, TOS T. J. M.
BERENDSCHOT, CARROLL A. B. WEBERS,
AND RUDY M. M. A. NUIJTS
• PURPOSE: To investigate the stromal demarcation line after corneal
KERATOCONUS IS A BILATERAL, PROGRESSIVE COR-neal
cross-linking using anterior segment optical coherence tomography (AS-
disease with a multifactorial cause and a classical onset at puberty.1 It is
OCT) and its influence on the short-term results of cross-linking in
characterized by corneal collagen structure changes, decreased corneal
patients with progressive keratoconus.
rigidity, and corneal thinning, leading to a progressive corneal defor-
• DESIGN: Prospective, nonrandomized study.
• METHODS: Twenty-nine eyes of 29 patients with progressive
mation (conical protrusion) and decreased vision.2 Early treatment
options are correction of the refractive error by spectacles or contact
keratoconus (n = 28) or after laser in situ keratomileusis ectasia (n =1)
lenses (such as soft, rigid, or scleral lenses).3 In contact lens-intolerant
were included and treated with comeal cross-linking at our institution.
patients with mild to moderate keratoconus, the implantation of
Measurements at 1, 3, 6, and 12 months after comeal cross-linking were:
intracorneal ring segments can be considered because they lead to a
refraction, best-corrected visual acuity (BCVA), tonome-try, corneal
flattening effect of the cornea and can increase contact lens tolerance.4
topography,
aberrometry.
However, these treatment options do not interfere with the progression of
Demarcation line depth was measured centrally, 2 mm temporally, and 2
AS-OCT,
specular
microscopy,
and
the disease and therefore are insufficient in cases of progressive
mm nasally by two independent observers using AS-OCT and was
keratoconus. In advanced cases of keratoconus (eg, with corneal scars,
correlated with clinical parameters.
thin, bulging corneas, or both), penetrating or lamellar keratoplasty
• RESULTS: The stromal demarcation line was visible with AS-OCT at
procedures are the only solution. Until now, keratoconus remains one of
1 month after surgery in 28 of 29 eyes. Pairwise comparisons between
the leading indications for keratoplasty.5 For progressive, nonadvanced
the two observers of the AS-OCT measurements did not show a
cases, corneal collagen cross-linking has become available, leading to a
statistically significant difference. After an initial steepening of maximal
mechanical strengthening of the cornea and thereby achieving a
keratometry values and a decrease in BCVA at 1 month after surgery
stabilization of the disease. This may delay the need for keratoplasty in
(both with P < .012), no significant changes were found at 3, 6, and 12
this young, nonadvanced patient group.
months after surgery compared with before surgery. Refractive cylinder,
Comeal cross-linking, which combines riboflavin eye-drops and
topographic astigmatism, aberration values, endothelial cell density, and
ultraviolet A (UVA) radiation, was first described by Spoeri and
intraocular pressure remained stable during all postoperative visits. A
associates in 1998.6 UVA radiation in combination with riboflavin
deeper demarcation line depth was associated with a larger decrease in
generates reactive oxygen species, leading to the formation of cross-links
corneal thickness (r = -0.506; P = .012).
between the corneal collagen fibers. The primary goal of corneal cross-
• CONCLUSIONS: AS-OCT is a useful device to detect the stromal
linking is to increase corneal rigidity by increasing the mechanical
demarcation line after corneal cross-linking. At 3 to 12 months follow-
stability of the corneal stroma. Wollensak and associates reported a 4.5-
up, all clinical parameters remained stable, indicating stabilization of the
times increase in biomechanical rigidity in human corneas after corneal
keratoconic disease. (Am J Ophthalmol 2009;148:844-851. © 2009 by
cross-linking, with a primary treatment effect in the anterior 300 (Jim of
Elsevier Inc. All rights reserved.)
the comeal stroma.7 In current practice, patients with progressive
keratoconus or post-laser in situ keratomileusis (LASIK) ectasia may be
eligible for corneal cross-linking, provided that their corneas are clear
Accepted for publication Jim 28, 2009.
From the Department of Ophthalmology, University Medical Center
Maastricht, Maastricht, The Netherlands.
Inquiries to Rudy M. M. A. Nuijts, Department of Ophthalmology,
University Medical Center Maastricht, P. Debyelaan 25, 6229 HX,
Maastricht, The Netherlands; e-mail: [email protected]
844
and not too thin.8"10
In 2003, Wollensak and associates reported the first clinical shortterm results of corneal cross-linking in patients with progressive
keratoconus.9 They found that the progressive nature of keratoconus was
at least stopped in all
' 2.009 BY ELSEVIER INC. ALL RIGHTS RESERVED.
Endothelial Growth
Factor as a
Thickening Following
Cataract "-' With
Diabetes Mellitus
Aqueous ¥.
Predictor of
Surgery &
1»K3it3»LA5 TnSKHAM, LAUREN PAYNTER, PETE GEISEN,
CATt KOCH, AND KENNETH L. COHEN
M. ELLZH
CYSTOID MACULAR EDEMA (CME) AND EXACER-bated diabetic
PURPOSE: To
aqueous vascular ;-- 1
/•••TflirffcilBBIl^1'1111'**''^ insulin-like
11 1
grow-th -i---' 1
" •wE.'-sh. measured with ;~; . -BeaBigim;
following phacc=~- 1 - Lair1 ilEli
• DESIGN; Cohc" •-..
• METHODS: A :-_ -
macular edema (DME) can adversely affect visual outcomes following
cataract ^rgery in patients with diabetes mellitus (DM).1"5 With :e;hnical
improvements in cataract surgery, better glyce-mic control in patients
with diabetes, and preoperative la5er treatment for clinically significant
macular edema (CSME), long-lasting macular edema (ME) following
IOL in 1 eye bv i:1^11; -ii.cpai.a: !
•1 •
111
li
lliii 11
~A Carolina conser-'er -
cataract surgery is reported less often now than in the past, but the
.-gis'iti1 -
problem of postoperative ME still exists.3'6 A 30% increase in the center
. Four patients
point thickness as measured by optical coherence tomography (OCT) was
<—:, •aHWW^^'ws OCT central '•_-"- _ ,
T
•sr.si'.-rr-'s'—^'a. and aqueous ar-i : .
'•'•^." (CSME) receive correlations we-e :
reported in 22% of patients with diabetes at 1 month postcataract
mean CSF or & ;
CSF (>11% c: T-months
extraction. More than half had resolution at 3 months in this study.
postope-;:
However, delay in treatment of macular edema has been shown to reduce
1
visual improvement following cataract extraction in some patients.8'9
• RESULTS: Th^-;
cases of CSME -:
"gBiiir Tm iir r ciaa
in patients with : r increased with :~ .:•
preoperative C''1-,~Z
and the greatest OK
erative correlatic-^?
more severe rer^:---3«
absent (r = 0.41-: ? =
VEGF and C?},^ - =
postoperative, a;-:1 .
n'anii" Twainawith >11% chanCSME status '- = associations ex:—• CONCLUSION' - . _ia—, •» tively associate J -- . in diabetic pat^r:
Therefore, preoperative measurements that identify patients at risk for
J'y ••«i««»——r:i;iaiiff
Accounting for pre.:B-ther study is in^^i-sn*-1 895-901. © 2C03 ^ E
ME after cataract surgery may be beneficial to initiate treatment early and
reduce vision loss from ME.
Vascular endothelial growth factor (VEGF) and insulin-like growth
factor-1 (IGF-1) have been implicated in the pathogenesis of ME and
diabetic retinopathy (DR). VEGF is a vasopermeability factor10 and has
been associated with DME.11 Intravitreous injections of agents that
neutralize the bioactivity of VEGF have stabilized or improved visual
acuity (VA) and reduced central subfield thickness (CSF) as measured by
OCT in phakic patients with DME12 and have had mixed reports in
nondiabetic pseudophakic patients with CME.13'14 Another study reported
that elevated aqueous levels of VEGF, IL-6, and protein were associated
with exacerbated fluorescein leakage in the maculas of diabetic patients 6
months following cataract surgery.
A recent report showed that 8
patients with diabetes who had had intravitreous bevacizumab (Avastin;
Accepted for pu't-":: From
the
Dep.—
K.L.C.) and BK--- Chapel Hill, Nc^ ^
Inquiries to M. ^._ JI North Carolina.
27599; e-me:: -
Genentech Inc, South San Francisco, California, USA) for CSME prior to
cataract surgery had reduced aqueous VEGF levels at the time of surgery
2 months later, but only a transient reduction in CSF.16 The efficacy of
:
. NC
-mi—fcsaEBl?" -•:•»-
: B C-'T
•"T^-"^,
ALL RIGHTS
RESERVED.
M02-9394/09/S3^ :•:
Fsr-
doi:10.1016/j.ajo._:C-
--.. T3L,
..3BCMEa-
anti-VEGF treatment for prevention or treatment of postoperative CME
or exacerbation of CSME from cataract surgery in patients with diabetes
remains indeterminate and may require further study.
895
A simple and evolutional approach proven to
recanalise the nasolacrimai duct obstruction
D Chen,1 J Ge,2 L Wang,2 Q Gao,2 P Ma,2 N Li,2 D-Q Li,3 Z Wang2
10
See Editorial, p 1416
ABSTRACT Aini: To evaluate a new created in 1994. Since then, this approach has been widely
adopted
by
many
in China for its simplicity,
' Department of ENT, First
approach of recanalisation of safety, efficacy andophthalmologists
minimal invasion.""15 In the present study,
Affiliated Hospital, Sun Yatnasolacrimai duct obstruction (RC- we report the long-term follow-up results of RC-NLDO in the
sen University, Guangzhou,
PR China; 2 State Key
NLDO) in the treatment of the clinical treatment for 506 cases of NLDO and chronic
Laboratory of
nasolacrimai duct obstruction (NLDO) dacryocystitis, as well as the histopathological evidence from
Ophthalmology, Zhongshan
animal experiments. The relative indication, contraindication,
and chronic dacryocystitis. surgical technique, postoperative care, complications,
Ophthalmic Center, Sun
Yat-sen University,
Methods: 583 patients with 641 eyes advantages and disadvantages of the RC-NLDO are discussed.
Guangzhou, PR China;
suffering from NLDO and chronic
Sullen Eye Institute,
MATERIALS AND
dacryocystitis were enrolled in this
Department of
Ophthalmology, Baylor
METHODS Patients
study. The RC-NLDO was performed
College of Medicine,
This study adhered to the tenets of the Declaration of Helsinki
in
506
eyes,
with
135
eyes
undergoing
Houston, Texas, USA
and was approved by the Institutional Review
Board
external
dacryocystorhinostomy
(EX(IEJB)/Ethics
Committee
of
Zhongshan
Ophthalmic
Center,
Correspondence to:
DCR) as controls. Patient follow-up for Sun Yat-sen University. All cases were chosen from
Dr Z Wang, Zhongshan
Ophthalmic Center, Sun
54 months was evaluated by symptoms, outpatients who were diagnosed as having NLDO and/or
Yat-sen University, No 54 S
dacryocystitis. Every patient underwent preoperatively
dye disappearance test, lacrimal chronic
Xianlie Road, Guangzhou
comprehensive ophthalmic and intranasal examination.
irrigation and digital subtraction Dacryocystogram or digital subtraction dacryocystogram was
510060, PR China;
[email protected]
dacryocystogram. The RC-NLDO was performed in some cases.
also performed in 12 rhesus monkeys A total of 641 eyes of 583 consecutive patients were
Accepted 20 February 2009
from July 2003 to June 2006 with their signed
for histopathological examination. recruited
Published Online First 4
informed consent forms, including 135 eyes of 126 patients
May 2009
Results: The clinical success rates were undergoing the EX-DCR and 506 eyes of 457 patients
93.1% in 506 cases of RC-NLDO and undergoing the RC-NLDO. There were no statistical
91.11% in 135 cases of EX-DCR, The differences in patient demographics between these two groups.
male-to-female ratio was approximately 1:3, and the
success rates for second surgery were The
average age was 50 years. The duration of symptoms ranged
achieved in 85.19% on RC-NLDO and from 6 months to 26 years (mean 5.1 years) in the RC-NLDO
40.0% on EX-DCR. No major intra- or group and from 6 months to 17 years (mean 4.7 years) in the
postoperative complications were EX-DCR group.
Nasolacrimai duct obstruction (NLDO) and chronic
dacryocystitis are common ophthalmic diseases. The external
dacryocystorhinostomy (EX-DCR) has been the most effective
and standard surgery in treating these conditions since 1904
when it was reported by Toti.' However, EX-DCR is an
invasive, relatively complex and time-consuming procedure
that causes a facial cutaneous scar. Many patients prefer to
suffer tearing rather than undergo this surgery.2 3 The improvement on DCR has been made recently, such as the endonasal
DCR and endocanalicular laser DCR. These approaches were
promising but still necessitate bone removal and require costly
equipment. These surgical procedures were reported to have
less effective results than EX-DCR and involve a marked
learning curve.^9 The approach of the EX-DCR and these new
procedures is to create a bypass draining system, rather than to
restore the obstructed nasolacrimai duct.
Recanalisation of nasolacrimai duct obstruction (RC-NLDO)
was an evolutionally developed surgical approach for treating
these conditions to restore the native nasolacrimai duct, using a
simple instrument, the lacrimal canaliser, which we
This paper is freely
available online under the
BMJ Journals unlocked
scheme, see http://
bjo.bmj.com/site/abouV
unlocked.xhtml
instrument used for RC-NLDO
The instrument used for recanalisation of nasolacrimai duct
obstruction was the lacrimal canaliser consisting of a console
and its accessories (fig 1). The console can discharge a power
current (50-150 W) with 500kHz frequency. The high-frequent
lacrimal (HFL) probe is made of copper-silver alloy 1.2 mm in
diameter and 140 mm in length. Its tip is 2.0 mm long, smooth,
blunt and naked (without an insulating coat on the surface),
features allowing it to cauterise blocked tissue in a
nasolacrimai duct.
Surgicai procedures
EX-DCR was performed under local anaesthesia in a
standardised fashion.9 The RC-NLDO was
1438
Ctiiteal SsBr
Macular thickness decreases with age in normal
eyes: a
on the macuSar thickness map protocol in
the Stratus OCT
U Eriksson, A Aim
Department of
Neuroscience,
Ophthalmology, University
Hospital, Uppsala, Sweden
Correspondence to:
Dr U Eriksson, Akademiska
sjukhuset,
Ogonmottagningen, ing 70,
University Hospital, S-701
85 Uppsala, Sweden;
urban.eriksson@akademisk
a.se
Accepted 11 June 2008
Published Online First
19 November 2008
ABSTRACT
Background/aim: Retinal and retinal
nerve fibre layer (RNFL) thinning
with age have been described in
histological studies. In vivo techniques
like optical coherence tomography
(OCT) have shown thinning of optic
nerve RNFL and the retina in specific
areas. One would expect thinning of
the total macula, but so far, no
correlation with the quantitative OCT
macular map tool and age has been
found.
Methods: Sixty-seven healthy
individuals underwent three repeated
scans in both eyes with the macular
thickness map protocol in the Stratus
OCT. That protocol divides the
macula area into nine ETDRS fields.
The RNFL was measured in one
specific location close to the optic disc.
Correlations between retinal, RNFL
thickness, macular volume and age
were determined. Results: We found a
statistically significant negative
relationship between retinal thickness
and age for all ETDRS areas, total
macular volume and RNFL thickness.
Retina] thickness decreased by 0.260.46 urn, macula volume 0.01 mm3
and RNFL 0.09 u.m per year.
Conclusion: Retinal thickness within
the area covered by the macular map
significantly decreases with age. In the
area examined in the papillomacular
bundle, 20% of the retinal thinning is
due to the RNFL, and 80% is due to
thinning of other layers of the retina.
Histological studies of the human retina and optic nerve have
shown a decreased density of photo-receptors, ganglion cells,
retinal pigmentepithelium and optic nerve fibres with age.*"3
With optical coherence tomography (OCT), both qualitative
and quantitative measurements of the retina can be made.^7 A
macular mapping technique that has shown a good
reproducibility is implemented into the OCT 2000 and OCT3
scanners, which are in clinical use today.8"13 Observations
based on single scan measurements have shown a decrease in
retinal and RNFL thickness with age. In a pilot study,
Schuman et al reported that the peripapillary retinal nerve
fibre layer (RNFL) decreases with age using OCT I.14
Poinoosawmy and coworkers also demonstrated a
progressive reduction in the nerve fibre layer thickness with
age using scanning laser polarime-try (GDx).15 In an OCT
study by Alamouti and Funk, both retinal and RNFL
thickness decreased slightly with age.16 Finally, Kanai and
coworkers
also found that retinal thickness decreases with age.17 None
of these investigators, however, used the OCT mapping
technique. Based on the findings in postmortem and in vivo
studies, one would expect a slight thinning of the total retina.
Surprisingly, studies on normal retinal thickness with the
mapping protocol have so far not shown any significant
correlation between retinal thickness and age.8"" Therefore,
we wanted to examine the relation between retinal thickness
and age with the macular map technique.
SUBJECTS
The study was conducted in accordance with the guidelines
of the Declaration of Helsinki, and the protocol was approved
by the ethics committee of Uppsala University. A total of 134
eyes from 67 healthy Caucasian subjects (43 women (64%)
and 24 men (36%), median age 34.4 years (range 12-74)),
recruited among the staff and their families at the department
of ophthalmology, University Hospital, Uppsala, were
included. All subjects underwent three measurements with
the map protocol in both eyes. Before inclusion, a thorough
medical history was obtained, and all subjects underwent a
routine ophthalmological examination including visual
acuity, slit-lamp examination and dilated fundus examination
with the 60-dioptre lens in the slit lamp. Subjects with a
history of any ophthalmological condition or positive
findings on a routine eye examination were excluded. A
visual acuity below 1.0 (20/20) and a refractive error of more
than 6 dioptres spherical and/or more than 3 dioptres
cylindrical were exclusion criteria.
METHODS
The pupils were dilated with 0.5% tropicamide, and all
subjects underwent a dilated slit-lamp examination. The
latest commercially available OCT model, Stratus OCT 3
(Carl Zeiss Meditec. Dublin, California) with software 4.0.1,
was used. In Stratus OCT, there are three different map
protocols. The macular thickness map protocol was used in
this study.
OCT is a non-invasive, non-contact technique by which to
obtain high-resolution images from the anterior and posterior
segments of the eye.4"6 Utilising the principles of ultrasound,
OCT measures backscattered low-coherent light from intraocular structures as an A-scan. Cross-sectional tomographic
images (B-scans) are constructed from repetitive axial Ascans while the probe beam scans across the retina. The
retinal thickness is defined as
Br J Ophthalmol 2009;93:1448-1452. doi:10.1136/bjo.2007.131094
1448
EDITOR'S
CHOICE
Intravitreal injection of
pegaptanib sodium for
proliferative diabetic
retinopathy
V H Gonzalez, G P Giuliari. R M Banda, D A Guel
Valley Retina Institute, PA,
McAllen, Texas, USA
Correspondence to:
Or V H Gonzalez, Valley
Retina Institute, PA, 1309
East Ridge Road, Suite 1,
McAllen, TX 78503, USA;
[email protected]
Received 5 December 2008
Published Online First 18
August 2009
ABSTRACT
Background: To compare the efficacy of intravitreal pegaptanib (IVP) with panretinal laser photocoagulation
(PRP) in the treatment of active proliferative diabetic retinopathy (PDR).
Methods: A prospective, randomised, controlled, open-label, exploratory study. Twenty subjects with active
PDR were randomly assigned at a 1:1 ratio to receive treatment in one eye either with IVP (0.3 mg) every 6
weeks for 30 weeks or with PRP laser. Efficacy endpoints included regression of retinal neovascularisation
(IW), changes from baseline in best-corrected visual acuity (BCVA) and foveal thickness. Safety outcomes
included observed and reported adverse events. Results: In 90% of randomised eyes to IVP, retinal IW showed
regression by week 3. By week 12, all IVP eyes were completely regressed and maintained through week 36. In
the PRP-treated group, at week 36, two eyes demonstrated complete regression, two showed partial regression,
and four showed persistent active PDR. The mean change in BCVA at 36 weeks was +5.8 letters in pegaptanibtreated eyes and -6.0 letters in PRP-treated eyes. Only mild to moderate transient ocular adverse events were
reported with pegaptanib. Conclusions: IVP produces short-term marked and rapid regression of diabetic retinal
IW. Regression of NV was maintained throughout the study and at the final visit.
Diabetic retinopathy (DR) is a major cause of blindness in the Western world.'2 Research into the aetiology of ocular
neovascular diseases such as DR has identified a pivotal role for vascular endothelial growth factor (VECE) in promoting both
angiogenesis and increased vascular permeability.3 4
Intravitreal injection of VECP induces many of the pathological changes characteristic of DR, including intraretinal and
preretinal neovascularisation, microaneurysm formation, intraretinal haemorrhage, macular oedema and areas of capillary
non-perfusion with endothelial cell hyperpla-sia.5 Elevated intraocular levels of VEGF have been reported in patients with
DR. Moreover, this elevation is more pronounced in PDR than in non-proliferative diabetic retinopathy (NPDR)/ 7
The Isoform.165 of VECF-A (VECFi®) is particularly potent in promoting ocular neovascularisation and breakdown of the
blood-retinal barrier (BRB) through a leucocyte-dependent mechanism.8 " Pegaptanib sodium is a selective anti-VECF
aptamer that binds to VECE^.10 Preclinical studies demonstrated that intravitreal injections of pegaptanib (IVP) can inhibit
pathological ocular neovascularisation while leaving physiological vascularisation unimpaired.8 In a recent Phase II
study of pegaptanib for the treatment of diabet::
macular oedema (DME), findings suggested ths-IVP may be capable of halting and even reversing pathological retinal
neovascularisation (NV)." " |
We hypothesised that in patients with active ' PDR, IVP would cause marked reduction ir vitreous levels of VECFi® with
regression or pathological NV, thereby hindering the progressior. of PDR. In this report we present the final results from our
pilot, study to test this hypothesis.
METHODS
Study design
This study was a randomised, prospective, open-label direct comparison of pegaptanib alone to PRP alone in patients with
PDR. It was approved by the Sterling Institutional Review Board, and conducted in conformity to the principles of the
Declaration of Helsinki.
Subject selection
Eligible subjects had active FDR, in one or both eyes, with at least one of the following high-risk characteristics as defined by
the Diabetic Retinopathy Study (DRS): (1) new vessels within one disc diameter of the optic nerve head that are larger than a
third of the disc area and/or (2) vitreous or preretinal haemorrhage associated with either less extensive new vessels at the
optic disc, or with new vessels elsewhere half the disc area or larger.13 In addition, at the screening visit, the best-corrected
visual acuity (BCVA; measured by the Early Treatment Diabetic Retinopathy Study (ETDRS) chart) was s'24 letters
(approximately 20/320) and <85 letters (approximately 20/20). Eyes with mild preretinal haemorrhage or vitreous
haemorrhage (VH) that did not interfere with visualisation of the macula and optic disc were eligible for inclusion. Subjects
could participate in the study only if, in the opinion of the evaluating physician, PRP could be safely withheld for 4 weeks.
Exclusion criteria included the following:
haemorrhage or media opacity obscuring visualisation of the macula and optic nerve; significant epiretinal membranes (ERM)
involving the macula;
proliferative diabetic membranes along the major retinal arcades sufficiently extensive to cause either significant
vitreomacular traction or significant impairment in BCVA; any tractional retinal detachment; severe ischaemia involving the
foveal avascular zone; neovascular glaucoma; study eye treated with intravitreal steroid injections within 6 months prior to
baseline and/or PRP treatment within 90 days of baseline.
tWmlcal science]
Predicting visual success in macular
hole surgery
B Gupta; D A H Laidlaw,1 T H Williamson,1 S P Shah,2 R Wong,1 S Wren1
predicting restoration of good visual acuity (VA) (better than
ABSTRACT
' Department of
20/40; 6/12 UK Snellen) and to present these data in a
Aim: Data on the outcome of surgery facilitate
Ophthalmology, St
clinically usable format for use in preoperative counselling.
Thomas's Hospital, London, informed preoperative patient counselling. Most
2
studies on the outcome of surgery for idiopathic
UK; International Centre
As surgical techniques are known to differ widely,7"9 in
for Eye Health, Clinical
full thickness macular hole surgery have
building the cohort we only included patients that had the
Research Unit, London
concentrated on rates of anatomical closure. The same surgical technique and postoperative instructions, so that
School of Hygiene and
aim of this study was to identify factors predicting this study had one of the largest cohorts of patients
Tropical Medicine, London, visual success (better than 20/40; 6/12 Snellen)
undergoing standardised macular hole surgery.
UK
following macular hole surgery. Methods: A
retrospective study of 133 patients undergoing
Correspondence to:
standardised macular hole surgery with at least 3 METHODS
Mr D A H Laidlaw,
months of postoperative follow-up. All patients
A retrospective case note review of all phakic patients
Department of
underwent preoperative measurement of the
undergoing surgery for IFTMH under one consultant-led
Ophthalmology, St
maximum macular hole diameter using optical
surgical team from March 2004 until October 2007 was
Thomas's Hospital,
coherence tomography. Results: Multivariable
performed. Only the first operation on the first operated eye of
Lambeth Palace Road,
regression analysis identified that age,
each patient was included in the analysis. Exclusion criteria
London SE1 7EH, UK;
preoperative visual acuity and macular hole size
included macular holes in association with trauma, any
Alistair.
were significant predictors of visual success. The previous intraocular surgery and a history of other [email protected]
resulting model correctly classified the visual
limiting eye conditions such as age-related macular
outcome
of 80% of cases. Predicted rates of
degeneration, glaucoma and amblyopia.
Accepted 7 May 2009
visual success varied from 93% in patients <60
Published Online First
Data collected included: age, sex, laterality, duration of
years
old
with
visual
acuity
better
than
6/24
and
26 July 2009
visual symptoms, preoperative VA, preoperative maximum
a hole diameter of <350 u.m, to 2% in patients
linear dimension (MLD),
those >79 years old with visual acuity of 6/60 or
worse and hole diameter of >500 urn.
Conclusion: The results provide a simple and
clinically useful model to employ when
counselling patients on macular hole surgery.
Data on the outcome of surgery facilitate informed
grade of operating surgeon, intra- and postopera-1 tive
complications, postoperative anatomical do- j sure and VA at
3 months (table 1).
!
Preoperative MLD of the IFTMH was measured :
using optical coherence tomography (OCT) (Stratus OCT,
Zeiss (Carl Zeiss Meditec, Inc., Dublin, California, USA)
and Topcon 3D OCT-1000 (Topcon Medical Systems,
Paramus, New Jersey, USA)) and was defined as the greatest
linear distance along the smallest hole aperture (fig 1).
All cases underwent phacoemulsification and intraocular
lens implantation followed by 20-gauge three-port pars plana
vitrectomy with induction of a posterior vitreous detachment
when not already present. Indocyanine green (ICC)-assisted
internal limiting membrane peeling was performed in all
cases, using 0.5 ml of 0.5 mg/ml (0.05%) ICG and minimal
retinal exposure time followed by fluid to air to 16% CgFg
gas exchange. All patients were instructed to maintain an
upright postoperative posture during the day and to strictly
avoid sleeping in a supine position. Follow-up was
performed at day 1, 2 weeks and 3 months. Anatomical
closure was determined at 3 months after surgery using
indirect slit lamp biomicro-scopy.
Statistical analysis
Snellen acuities were converted to logMAR units for
analysis. LogMAR values of 2.0 and 3.0 were used for vision
of counting finger and hand movement, respectively.
Distribution analysis revealed postoperative vision and MLD
to be non-normally distributed. In order to make prediction
probabilities easier for application in a clinical setting a
binary outcome variable "visual success" was defined,
consistent with previous literature,10 as postoperative VA of
<0.3 logMAR (better than 6/12) at 3 months. MLD was
categorised into quartiles (<350, s'350 to <400, 3=400 to
<500, 3=500 urn), age into decades, and preoperative VA as
ss0.3 to <0.6, ss0.6 to <0.9 and &0.9 logMAR. Logistic
regression analysis was used to determine which explanatory
variables were to be included in the predictor for visual
success. The multivariable model was built using a forward
manual stepwise method by adding the most significant
variable first. The significance level for removal from the
model was p=0.1. Odds ratios (ORs) and 95% confidence
intervals (CIs) were derived from this model. All p values
were two-sided. Prediction models using logistic regression
were evaluated by establishing a cut-off point; predicted
probabilities below the cut-off point were treated as
predictors of no event and predictions at or above the cut-off
point were considered to be predictors of the event." A cutoff point of 0.50 was usually chosen. Using the 0.5
prediction cut-off points, we
fir J Ophthalmol 2009:93:1488-1491. doi:10.1136/bjo.2008.153189
^^.^.^^.^^..^.......MsVSKU
Cataract surgery and primary intraocuiar lens
implantation in children <2 years old in the UK and
Ireland: finding of national surveys
A L Solebo,1'2 I Russell-Eggitt,2'3 K K Nischal,2-3 A T Moore,™ P Cumberland,1-2 J S Rani,1'2'3'4'5
on behalf of the British Isles Congenital Cataract Interest Group
' MRC Centre of
Epidemiology for Child
Health, UCL Institute of
Child Health, London, UK:
2
Ulverscmft Vision
Research Group, UGL
Institute of Child Health,
London, UK; clinical and
Academic Department of
Ophthalmology, Great
Ormond Street Hospital for
Children, London, UK;
''Moorfields Eye Hospital,
5
London, UK: UCL Institute
of Ophthalmology, London,
UK
ABSTRACT
Background: Current patterns of practice relating
to primary intraocular lens (IOL) implantation in
children <2 years old in the UK and Ireland are
investigated. Methods: National postal
questionnaire surveys of consultant
ophthalmologists in the UK and Ireland. Results:
76% of 928 surveyed ophthalmologists replied. 47
(7%) of the respondents operated on children aged
< 2 with cataract. 41 (87%) of respondents
performed primary IOL implantation, but 25%
would not implant an IOL in a child under 1 year
old. 88% of surgeons used limbal wounds, 80%
manual capsulotomies, 98% posterior
capsulotomies and 100% hydrophobic acrylic
lenses. The SRK/T formula was most commonly
used (70%). Exclusion criteria for primary IOL
torrespondence to:
implantation varied considerably and included
Or J Rahi, MRC Centre of
microphthalmos (64% of respondents), anterior
Epidemiology for Child
and posterior segment anomalies (53%, 58%), and
Health, UCL Institute of
glaucoma (19%). Discussion: Primary IOL
Child Health, 30 Guilford
Street, London WG1N 1EH, implantation in children <2 has been widely
adopted in the UK and Ireland. There is
UK; [email protected]
concordance of practice with regards to surgical
technique and choice of IOL model. However,
Accepted 7 May 2009
there is some variation in eligibility criteria for
Published Online First
primary lOLs: this may reflect a lack of consensus
16 June 2009
on which children are most likely to benefit. Thus,
there is a need for systematic studies of the
outcomes of primary IOL implantation in younger
children.
Primary intraocular (IOL) implantation has become accepted
practice for older children with cataract.'2 While primary IOL
implantation is being increasingly undertaken in children in the
first 2 years of life,3 4 the long-term benefits and the factors
associated with positive and negative outcomes are unclear.'2 5-9
The British Isles Congenital Cataract Interest Croup
(BCCIG), a research network comprising British and Irish
ophthalmic consultants, was established in 1995 in order to
study the incidence, detection, causes, management and
outcomes of congenital and infantile cataract.10-14 A national
epidemiological study to investigate outcomes following
primary IOL implantation in children < 2 years old with
congenital and infantile cataract is now being undertaken
through the BCCIG. As a foundation for this research, we have
investigated the surgical management of .cataract in younger
children in the UK and Ireland, with a focus on primary IOL
implantation.
the Royal College of Ophthalmologists and Irish consultant
ophthalmologists with a known interest in congenital cataract,
were contacted using postal questionnaires accompanied by
hand-addressed cover letters and postage-paid reply envelopes.
Members of the BCCIG who did not respond to the mailing
were sent reminders.
We sought to discover the number of children < 2 years old
with congenital or infantile cataract managed over the previous
year, the number undergoing surgery with and without primary
IOL implantation and the details of surgical management.
Respondents were asked to estimate the number of children
managed over the preceding year. Exclusion criteria for
primary implantation in children <2 were requested, as were
preferred IOL model and IOL power calculation formulae
together with details of surgical technique including lens
aspiration and vitrectomy approaches and capsulotomy
practices. The postoperative measurement of axial length was
also investigated.
Statistical analysis
Free text answers on exclusion criteria were coded. A
descriptive analysis of the responses was undertaken.
RESULTS
Thirty-two of the 960 distributed questionnaires were returned
as undeliverable. Of the remaining 928 contacted consultants,
709 (76%) replied to the survey. Replies were received
between October 2008 and January 2009. Of the 709
respondents, 47 (7%) stated that they operated on children <2
years old, estimating that over the preceding year they had
operated on a total of 301 children. Six (13%) of the 47
surgeons did not perform primary IOL implantation in any
child <2. The 41 surgeons who did perform primary IOL
implantation estimated that in the preceding year they had
operated on 268 children (116 with unilateral, 152 with
bilateral cataract), undertaking primary IOL implantation in
65% (table 1).
Exclusion criteria
Exclusion criteria for primary IOL implantation in children <2
were provided by 36 of the 41 respondents. Six (17%)
surgeons did not mention any ocular anomaly among their
stated exclusion criteria. Twenty-three (64%) described
specific anomalies which would prevent them from
METHODS
In October 2008, 960 consultants comprising all members of
the BCCIG, all consultant members of
Br
5
J
Ophthalmol
2009:93:1495-1498.
doi:10.1136/bjo.2009.160069
149
Comparison of long-term surgica/ success of
Ahmed
Valve implant versus trabecu/ectomy in openangle glaucoma
D H Iran/ C Souza,1-2 M J Ang,' J Loman,1 S K Law/ A L Coleman,1 J Caprioli1
' Glaucoma Division, Jules
Stein Eve Institute, David
Geffen S^'^v of Medicine,
University of ;s -omia Los
Angeles, Los Angeles, USA; 2
Ophthalmology Dspartment,
Federal University v Sao
Paulo, Sao Paulo, Brazil
ABSTRACT
Aim: To compare the long-term intraocular pressure
(IOP) outcomes of Ahmed Glaucoma Valve (AGV)
implantation to trabeculectomy with mitomycin C
(MMC) in open-angle glaucoma fOAGj.
Methods: 78 OAG patients who underwent AGV
implantation were matched with respect to age,
preoperative surgery, preoperative IOP and preoperative
medicines to 88 OAG patients who underwent trabecu;-:"3saondence to:
lectomy with MMC with a minimum of 3 years' follow~-.~ - CaB'ioli, Glaucoma
up. The cumulative probability of success between the
Division, . - 55 S-sn Eye
two groups with different criteria was analysed: (1) an
Institute, 100 S:;' ^azs, Los
IOP<21 mm Hg and a reduction of IOP5s'15% from
Angeles, ^ 9:Ca5, USA;
baseline; and (2) an IOP < 18 mm Hg and a reduction of
:2:-: ^'ss'.ucla.edu
,^£C2a a Fsbruary 2009 IOPss20% from baseline. No loss of light perception, no
additional glaucoma surgery and no hypotony were also
Ptasres Offline Frst)
required.
July 2009
Results: The 5-year cumulative probability of success
was not statistically significant between eyes that had an
AGV or trabeculectomy with MMC when success was
defined as criteria A (p == 0.094). However, when
success was defined according to criteria B, eyes
undergoing trabeculectomy with MMC had a higher rate
of success (p = 0.024).
Conclusions: Trabeculectomy with MMC has a significantly higher 5-year cumulative probability of
success compared with AGV implants when greater
reduction IOP is necessary.
It is estimated that by 2010, 60 million people worldwide will
suffer from some type of glaucoma. Open-angle glaucoma
(OAG) accounts for 74% of these cases.' In OAG, the
intraocular pressure (IOF) is frequently controlled with
medications. However, when medications and lasers fail to
control IOP, surgical management is necessary. Two surgical
treatments with the longest success records are trabeculectomy
with mitomycin C (MMC) and glaucoma drainage devices
(GDD). Prior studies have reported 40-90% success rate with
trabeculectomy in OAC." However, the majority of the studies
with GDD include patients with neovascular, uveitic,
developmental and mixed glaucoma (referred to as refractory,
intractable or complicated glaucoma).7'17 furthermore, there are
fewer studies comparing the two surgical modalities, and only
one of them is in patients with OAC. Currently, there is an
ongoing prospective study comparing the 350 mm2 Baerveldt
glaucoma implant to trabeculectomy with MMC in patients
with OAG and chronic angle-closure •glaucoma (CACG).18
The treatment outcomes in the Tube Versus Trabeculectomy
study reported a
higher 1-year success rate in patients with the Baerveldt
compared with trabeculectomy with MMC. One study
comparing Ahmed Glaucoma Valve (AGV) implant with
trabeculectomy with MMC in patients with primary OAG,
secondary OAG and primary angle-closure glaucoma (PACG)
reported no difference between the two groups with follow-up
times of 6-13 months.8 Another study, by the same group, also
reported no difference between the two groups at 31 months in
patients with primary OAG and FACG.20 There is only one
prior study comparing cataract extraction combined with
Molteno implant or trabeculectomy in patients with OAG.21
Molteno and coauthors also reported no difference between the
two groups at 8 years. As far as we are aware, there is
currently no data comparing ACV with trabeculectomy with
MMC in patients with OAG beyond 3 years.
The purpose for this study is to compare the long-term
surgical success of ACV implantation with trabeculectomy in
OAG.
PATIENTS AND METHODS
This is a retrospective case-controlled study of patients with
OAC, which includes primary open-angle (POAG),
pseudoexfoliation glaucoma '(PXPG) and pigmentary
dispersion glaucoma (PDG), who underwent ACV
implantation (New World Medical, Rancho Cucamonga,
California) or trabeculectomy with MMC at the Jules Stein
Eye Institute, University of California, Los Angeles with a
minimum of 3 years' follow-up time. The surgery was
performed by three experienced surgeons (JC, ALC or SKL)
from 1994 to 2004. One hundred and eighty-eight eyes from
166 patients followed at the Jules Stein Eye Institute from
1994 to 2007 were identified. OAG eyes that had ACV
implantation were matched with OAC eyes who had
trabeculectomy with MMC with respect to age, preoperative
IOF, preoperative medicines and prior surgeries (no prior
surgery, cataract surgery and one or more glaucoma surgeries).
The study protocol was approved by the Human Subject
Protection Committee at the University of California, Los
Angeles, and all study procedures adhered to the
recommendations of the Declaration of Helsinki.
Data collection
Preoperative data collected were age at the time of the surgery,
gender, race, self-reported history of hypertension and
diabetes, best-corrected visual acuity (BCVA), mean
intraocular pressure (IOP)
Br J Ophthalmol 2009;93:1504-1509. doi; 10.1136/bJ0.2008.150870
Turnover rate of tear-film lipid layer determined by
fluorophotometry
1
Division for Vision
Research, National Institute
of Sensory Organs, National
Tokyo Medical Center,
Tokyo, Japan;
2
Department of
Ophthalmology, Keio
University School of
Medicine, Tokyo. Japan
Correspondence to:
Dr M Yamada, Division for
Vision Research, National
Institute of Sensory Organs,
National Tokyo Medical
Center, 2-5-1 Higashigaoka,
Meguro-ku, Tokyo 1528902, Japan;
yamadamasakazu@kankak
uki. go-IP
Accepted 1 July 2009
Published Online First 18
August 2009
H Mochizuki,1 M Ya.mada,1 S Hatou,1'2 K Tsubota2
16
Of these,
ABSTRACT of evaporation from the ocular surface."
observation of lipid layer characteristics by interferometric
Aim: This study was performed to methods has been well established."'17 In various pathological
conditions, such as meibomian gland dysfunction, the
independently assess
of the lipid layer can change. Lipid layer thickness,
the turnover rates of aqueous and lipid appearance
measured by interferometry, has been reported to correlate
layers of the tear
with tear-film evaporation, tear-tilm breakup time, and clinical
3
la
We have previously reported that the
film. symptoms.
concentration of lipocalin in tears from patients with
Methods: Two fluorescent dyes, meibomian gland dysfunction was significantly lower than in
fluorescein sodium and 5- normal controls.19 Thus, lipids in tears, both in the lipid layer
dodecanoylaminofluorescein (DAF), and in the aqueous layer held by lipocalin, are important when
the pathophysiology of evaporative dry eye, such
which is a free-fatty-acid conjugate of considering
as meibomian gland dysfunction. Until now, however, there
fluorescein, were applied to the right has been no information about the flow rate of tear-film lipid
eye of 12 healthy volunteers. layer.
Fluorescent intensity of the precorneal Aqueous tear flow is determined by several aspects of tear
including tear production, tear volume, tear
tear film was measured at the central dynamics
evaporation and tear outflow.20 Tear flow can be assessed by
cornea every minute for 10 min for introducing a dye or radioactive substance into the
fluorescein sodium, and every 5 min for conjunctival sac and measuring the decay in concentration
21
50 min for DAF. The turnover rate was over a certain period. Since the report of Mishima et al,
measurement using fluorescein sodium as a
calculated by plotting fluorescent fluorophotometric
tracer has been the gold standard to quantify tear flow.16 20 The
intensity against time in a semilog plot elimination rate of fluorescein sodium essentially represents
and expressed as %/min. Results: the bulk aqueous flow because the dye is hydrophilic;
Turnover rates of fluorescein sodium however, the turnover of a certain tear component may not
The precorneal tear film has traditionally been described as
consisting of an outer lipid layer, a middle aqueous layer and
an inner mucus layer. Although this remains valid, some
modifications have been proposed.''3 In the current model of
the tear film, the aqueous-mucin layer is covered by two thin
layers of lipids. Polar lipids such as phospholipids lie adjacent
to the aqueous-mucin layer, and non-polar lipids such as
cholesterol and wax ester are present at the tear-air interface. In
addition, tears contain proteins that possess lipid-binding
properties, such as tear lipocalin.4-" Although lipids in tears are
primarily located in the tear-film lipid layer, some lipids are
presumably bound by lipocalin in the aqueous layer. Tear
lipocalin is thought to have an important role in stabilising the
tear-film lipid layer by transferring lipids to it from the aqueous
layer.""6
Despite comprising a very small proportion of the overall
tear-film thickness, the lipid layer is important for retarding
evaporation and maintaining tear-film stability.2 3 Where the
lipid layer is absent or where the integrity of the lipid layer is
compromised, the evaporation rate of tears increases,
accompanied by tear-film instability.7 8 To assess the lipid layer
of tears, several techniques have been developed, including
observation of lipid layer characteristics by interferometric
methods,sl-n quantitative measurement of meibomian lipid on
the lid margin by meibometry12 13 and measurement
parallel the bulk aqueous flow. For example, we recently
reported differences between the bulk aqueous flow of
hyaluronic acid and the turnover of hyaluronic acid, suggesting
that hyaluronic acid remains on the ocular surface independent
of the bulk aqueous flow.22 Accordingly, we hypothesised that
the flow rate of the tear lipid layer might be different from that
of aqueous tear layer.
In this study, we tested this hypothesis using fluorescein
sodium and a free-fatty-acid conjugate of fluorescein.
Fluorescein was used to assess the aqueous flow, and the
conjugated dye was used as a tracer to determine the How rate
of the tear lipid layer.
METHODS Fluorescent dye and fluorophotometer
5-Dodecanoylaminofluorescein (DAF; Molecular Probes,
Eugene, Oregon) is a lipophilic and water-insoluble free-tattyacid conjugate of fluorescein. This dye has the longestwavelength absorption maximum at 495 nm, and an emission
spectrum that peaks at 518 nm. A DAF emulsion (50 mg/ml)
was prepared in sterile 0.067 M phosphate-buffered saline
(PBS), pH 7.4, with 1% Tween 80
This paper is freely
available online under the
BMJ Journals unlocked
scheme, see http;//
bjo.bmj.com/site/about/
unlocked.xhtrril
«
Br J Ophthalmol 2009:93:1535-1538. doi:10.1136/bjo.2008.156828
1535
Comparison of Outcomes of Lamellar
Keratoplasty ano Penetrating Keratoplasty in
Keratoconus
DAPHNE C. Y. HAN, JODHB1R S. MEHTA, YONG M1NG POR, HLA MYINT HTOON, AND DONALD T. H. TAN
• PURPOSE: To compare outcomes after penetrating ker-atoplasty (PK)
PENETRATING KERATOPLASTY (PK), THE FULL-THIC-ness
and two techniques of deep anterior lamellar keratoplasty (DALK) in
replacement of a diseased cornea with -r_ allograft donor cornea, has
patients with keratoco-
been a well-accepte-surgical treatment for keratoconus over the past few
nus.
decades.1"4 However, it can be complicated by allograr endothelial
• DESIGN: Retrospective cohort study.
• METHODS: One hundred and twenty-five corneal transplantations
subsequent risk of graft failure Deep anterior lamellar keratoplasty
comprising 100 PK and 25 DALK procedures for keratoconus at the
(DALK), which r.-volves replacing the anterior part of a diseased corner
Singapore National Eye Centre from. April 1992 through December 2006
while retaining the healthy deeper tissue, has the advantage of reducing
were included. DALK was performed with the modified An-war
the risks of graft rejection and intraocular complications. It is, however,
technique (descemetic or DALKa group) in 14 eyes and manual lamellar
more technically demanding and may result in suboptimal visual
keratoplasty (predescemetic or DALKm group) was performed in 11
outcomes because c:" interface and refractive irregularities.
eyes.
rejection, which will lead to concomitar--endothelial cell loss with
Over the past few decades, several techniques of anterior lamellar
• RESULTS: At 12 months, the DALKa and PK groups achieved a
keratoplasty (ALK) have been described.5' These include the earlier
logarithm of the minimum angle of resolution mean best spectacle-
predescemetic procedures in which some stromal tissue and Descemet
corrected visual acuity (BSCVA) of 0.15 and 0.27, respectively (P = .26),
membrane (DM) are left behind, such as in the manual forms of DALK in
whereas the mean BSCVA of the DALKm group was 0.41 compared
which manual lamellar surgical dissections were performed. A recent
with the PK group (P = .12). Significance level was achieved between the
innovation of predescemetic DALK is automated lamellar therapeutic
DALKa and DALKm groups (P = .013). There was no significant
keratoplasty, which uses microkera-tome instrumentation to perform
difference in the mean spherical equivalent (P = .72) and astigmatism (P
lamellar dissection. Most recently, descemetic lamellar keratoplasty
= .88) between the PK and DALK groups. The DALK group had a
procedures have been described in which total stromal removal is at-
significantly lower incidence of complications compared with PK cases,
tempted, leaving only the DM and endothelium behind, which includes
including allograft rejection and glaucoma. Graft survival rate of both the
the Anwar big-bubble technique.
PK and DALKa groups was 100%, whereas that of the DALKm group
This study aimed to compare the optical results of PK and two
was 73% at 3 years after surgery (P = .000 between PK and DALKm
subgroups of ALK in patients with keratoconus, that is, predescemetic
groups).
and descemetic techniques. In our population, keratoconus is the fourth
• CONCLUSIONS: Visual acuity outcomes of the DALKa technique are
most common indication for corneal grafting after pseudophakic and
comparable with those of PK for keratoconus, whereas DALK surgery
aphakic bullous keratopathy, postinfectious scarring, and regrafts.1
results in fewer postoperative complications than PK. DALKa is
Because keratoconus represents low-risk keratoplasty and patients
emerging as a preferred choice among the lamellar techniques for better
usually are young and free of other ocular pathologic features, they
optical outcome. Further studies are required to provide long-term
provide an ideal cohort to study success and visual outcomes between
analysis of these results. (Am J Ophthalmol 2009;148:744-751. © 2009
lamellar keratoplasty and PK.
by Elsevier Inc. All rights reserved.)
METHODS
A COMPARATIVE COHORT STUDY WAS PERFORMED IN which
See accompanying Editorial on page 629.
Accepted for publication May 20, 2009.
clinical data were retrieved from computerized database of the
From the Singapore National Eye Centre (D.C.Y.H., J.S.M., Y.M.P.,
prospective Singapore Corneal Transplant Study.1 A total of 168
D.T.H.T.); the Singapore Eye Research Institute, Singapore (j.S.M.,
keratoconus patients underwent
H.M.H., D.T.H.T.); and the Department of Ophthalmology (D.T.H.T.),
Yong Loo Lin School of Medicine, National University of Singapore,
Singapore, Republic of Singapore.
Inquiries to Donald T. H. Tan, Singapore National Eye Centre, 11
Third Hospital Avenue, Singapore 168751, Republic of Singapore;
e-mail: [email protected]
744
0002-9394/09/$36.00
2009 BY ELSEVIER INC. ALL RIGHTS
RESERVED.
doi:10.101
G/j.ajo.2009.05.028