This Issue At A Glance

Abstract

Current findings from the Ocular Hypertension Treatment Study indicate that careful review of optic disc photographs detects optic disc hemorrhages more frequently than does clinical examination. Budenz et al (p. 2137) also found an association between optic disc hemorrhage and an increased risk of developing a primary open-angle glaucoma (POAG) end point. However, most eyes (86.7%) that developed a disc hemorrhage had not developed a POAG end point to date. This cohort study involved 3236 eyes of 1618 participants who were studied to determine whether lowering intraocular pressure in ocular hypertension delayed or prevented POAG. In light of the current findings, the authors recommend that optic disc hemorrhage be included in the decision matrix about initiating treatment in a patient with ocular hypertension. Additionally, because optic disc hemorrhages represent a strong predictive factor for development of POAG in ocular hypertension, they suggest frequent monitoring for optic disc hemorrhages by careful examination of the optic disc and/or optic disc photography. Healthy People 2010 has made reduction of uncorrected visual impairment due to refractive errors a national priority. Vitale et al (p. 2163) used utilization data from the 1999 to 2000 National Health and Nutrition Examination Survey, along with data for 2000 from the Medical Expenditure Panel Survey and Centers for Medicare & Medicaid Services, to estimate the cost of providing refractive correction to all Americans who need eyeglasses or other corrective lenses to achieve normal levels of distance visual acuity. They found that more than 110 million Americans could or do achieve normal vision with refractive correction. The annual direct cost of correcting distance vision impairment is estimated to be between $3.9 billion and $7.2 billion. For the $3.9 billion figure, $2.94 billion represents costs of glasses already purchased for which recurrent costs will be incurred, and $967 million represents the new costs to provide an initial set of glasses. These cost estimates provide useful information in analyzing ophthalmic public health endeavors. A study by Klein et al (p. 2209) involving 2370 older cohort members (99% of whom were Caucasian) of the Beaver Dam (Wisconsin) Eye Study at the 10-year examination mark demonstrates an association between 3 common types of age-related cataract (nuclear, cortical, and posterior subcapsular) and some measures of frailty, independent of visual acuity (VA) and systemic comorbidities. The investigators found an association between nuclear cataract in men and slower gait time and poorer frailty index. Cortical cataract was associated with a lower peak expiratory flow rate in women and with weaker handgrip strength and poorer frailty index in men. Finally, posterior subcapsular cataract in women was associated significantly with a lower peak expiratory flow rate. The authors conclude that cataract may be considered an indicator of general decline in function in older adults—independent of VA. Consequently, physicians should keep in mind that older persons with cataract may benefit from general functional assessment and, possibly, assistance. In a small retrospective case series reported by Emerson et al (p. 2259), 4 patients (6 eyes) with indolent acute retinal necrosis (ARN) were treated successfully with oral rather than conventional intravenous (IV) antiviral therapy. Oral antiviral therapy included valacyclovir (1 g thrice daily) and oral famciclovir (500 mg thrice daily) for 5 weeks to 3 months. Patients also received topical and oral corticosteroids. With this treatment approach, symptoms and visual acuity improved within 2 weeks to 1 month in 3 of 4 patients treated with oral antiviral medication. These findings suggest that patients with peripheral indolent ARN may benefit from oral antiviral therapy. However, the authors recommend further study to determine whether valacyclovir or famciclovir is as rapid and effective as IV acyclovir for initial treatment of this condition. In the interim, the standard of care, IV antiviral therapy, should be used for patients with the typical presentation of ARN including rapidly progressive inflammation involving the peripheral retina. Although cerebral venous sinus thrombosis (CVST) is considered uncommon, the clinical presentation overlaps idiopathic intracranial hypertension (IIH). According to a report by Lin et al (p. 2281), it is crucial to differentiate the two conditions because CVST is typically treated with anticoagulation and IIH with diuretics. Additionally, apart from headache and visual loss, there are typically no neurologic complications of IIH, whereas CVST can cause stroke and death. For this study, researchers conducted a retrospective chart review of 131 patients with papilledema from 3 tertiary-care neuro-ophthalmology centers. They found that CVST occurred in 9.4% of patients with presumed IIH. These results suggest that it is prudent to perform magnetic resonance venography in combination with magnetic resonance imaging (MRI) on all patients with suspected IIH, as computed tomography or MRI alone is not adequate to exclude CVST. Due to the retrospective nature of the study, the authors also suggest a prospective study to confirm these findings.