Mean Increase In Visual Acuity Research Articles

Developmental characteristics and control effects of myopia and eye diseases in children and adolescents: a school-based retrospective cohort study in Southwest China

ObjectivesTo characterise the prevalence of myopia and eye diseases among school adolescents and children in Southwest China, and to evaluate the effectiveness of myopia control tools.DesignRetrospective cohort study.SettingAcross 95 basic...

UGH Syndrome Resolution after IOL Explantation and Concomitant Carlevale IOL Implantation

ABSTRACT Objective To examine the use of Carlevale IOL placement in patients with UGH, and to evaluate surgical outcomes. Design In this retrospective study, 28 patients with UGH syndrome that were subjected to IOL explantation and concomitant Carlevale IOL implantation were included in the study. Methods Information about VA, IOP, number of glaucoma medication, need for glaucoma surgery, presence of hemorrhage and inflammation were recorded up to 6 months after the procedure. Results We found a statistically significant increase in mean visual acuity and complete resolution of uveitis in all patients. Mean IOP and the mean number of glaucoma medications were significantly decreased postoperatively, while 14% of patients required additional glaucoma surgery. Conclusions IOL explantation and concomitant Carlevale IOL implantation may provide a viable solution for UGH syndrome resolution, increases visual acuity, and decreases the need for glaucoma medication.

THE EFFECT OF CORNEAL TRANSPLANTATION ON VISUAL FUNCTION AND VISION-RELATED QUALITY OF LIFE

Introduction: The success of corneal transplantation surgery is usually determined by graft clarity, absence of complications such as rejection, low astigmatism, and good visual acuity. However, patients are often more concerned about their visual function and its impact on their activities of daily living which are determinants of vision-related quality of life (QOL). Currently it is agreed upon that the real success of a medical intervention can be measured by its effect on the quality of life.[1] The patients’ expectations may not be met, and they may still experience poor functional outcome despite successful corneal transplantion.[2] National Eye Institute Visual Function Index 14 (NEI VF-14) was designed and validated to assess vision-related functioning in patients undergoing cataract surgery, but it has also been validated for use with other eye conditions such as glaucoma, retinal, and corneal diseases.[3][4][5][6] The aim of this study was to assess the QOL and satisfaction of patients who underwent corneal transplantation by using the NEI VF-14. Patients and Methods: Survey data using a modified version of the VFI were collected at the 3rd postoperative month from 38 patients who underwent corneal transplantation in 2018 at Baskent University Faculty of Medicine. The questionnaire was administered by a trained researcher (LA) in a face-to-face manner. The grading was performed as follows: 0, no difficulty; 1, a little difficulty; 2, moderate difficulty; 3, quite difficult; 4, impossible to perform. Sociodemographic and clinical data, including age, sex, initial and follow-up visual acuities, were collected. QOL survey measures were compared with patients’ clinical findings to assess the differences between objective and subjective visual functioning. Results: Mean age of the patients was 54.5±11.4 years. All patients underwent an uneventful surgery and had no complications during follow-up (Figure 1).Fig. 1. Mean best corrected Snellen visual acuity was 0.32±0.21 preoperatively and increased to 0.56±0.24 at the end of the 3rd month. The results of the NEI VF-14 questionnaire are shown in Figure 2.Fig. 2. The most difficult tasks to perform were reading small print, reading traffic signs, doing fine handwork and driving at night. Although there was almost a twofold increase in mean visual acuity, most patients reported difficulty in daily activities with mean scores between 1.07 and 3.82 for different tasks. Discussion: Corneal transplantation patients face difficulties in many daily activities at the 3rd postoperative month and report a low QOL despite increase in vision. Studies have shown that depression is common among adults with visual impairment.[7] This is of relevance to corneal graft recipients and might be the reason for the reported low QOL after corneal transplantation. Conclusion: Corneal graft recipients should receive preoperative counselling helping them to gain a realistic expectation of the outcome following corneal transplantation.

COMPARISON OF INTRAVITREAL DEXAMETHASONE IMPLANT AND AFLIBERCEPT IN PATIENTS WITH TREATMENT-NAIVE DIABETIC MACULAR EDEMA WITH SEROUS RETINAL DETACHMENT.

To compare the efficacy and safety of intravitreal dexamethasone (DEX) implant versus aflibercept in patients with treatment-naive diabetic macular edema with inflammatory biomarkers. Ninety-eight eyes of 62 treatment-naive patients with diabetic macular edema with serous retinal detachment and hyperreflective foci were enrolled. Each patient was randomized to receive either aflibercept or DEX implant treatment. The treatment protocol included 3 monthly injections of 2 mg of aflibercept as a loading phase in the anti-vascular endothelial growth factor group and 0.7 mg of DEX implant in the DEX group and then pro re nata treatment. Primary outcome measures were mean changes in visual acuity and central retinal thickness at the end of the 12-month follow-up. Forty-eight eyes of 29 patients were received DEX implant, and 50 eyes of 33 patients received the aflibercept injection. Mean central retinal thickness decreased from 615.2 µm at baseline to 297.7 µm at 12 months in the DEX group (P < 0.001) and from 576.5 µm to 367.4 µm in the aflibercept group (P < 0.001). Except for the first month, mean central retinal thickness reduction was significantly higher in the DEX group (P < 0.05, Mann-Whitney U Test). Visual acuity improved significantly at the end of the follow-ups (46.3-52.7 Early Treatment Diabetic Retinopathy Study letters in the DEX group and 47.5-56.8 Early Treatment Diabetic Retinopathy Study letters in the aflibercept group at 12 months, P < 0.001, paired-sample t-test). Adjusting by baseline values, the increase in mean visual acuity during the 12-month follow-ups favored the aflibercept group (P < 0.01), 25% of the DEX-treated eyes and 42% of the aflibercept treated eyes experienced 10 or more Early Treatment Diabetic Retinopathy Study letters visual gain (P: 0.058). The DEX group received significantly fewer (2.6 vs. 7.2) injections (P: 0.001). It was observed that the both of DEX implant and aflibercept were effective and safe in treatment-naive diabetic macular edema patients with inflammatory phenotype. Anatomical results were found to be better in the DEX group, and functional results were found to be better in the aflibercept group. In pseudophakic eyes, the functional superiority of aflibercept ceased to exist, and the low number of injections in the DEX implant group was seen as an advantage.

Clinical impact of the 0.2 µg/day fluocinolone acetonide intravitreal implant: outcomes from the ILUVIEN® clinical evidence study in Portugal.

Introduction:The ILUVIEN® (fluocinolone acetonide) Clinical Evidence in Portugal (ICE-PT) study is a retrospective, multicenter, observational study evaluating the effectiveness and safety of the FAc implant in patients with diabetic macular edema.Methods:Patients included in this study had received the 0.2 µg/day fluocinolone acetonide implant for the treatment of diabetic macular edema and had measurements of visual acuity and retinal thickness assessed by optical coherence tomography for at least 12 months pre- and post-fluocinolone acetonide implant administration, with ⩾2 follow-up visits. Outcomes measured included visual acuity, central foveal thickness, and intraocular pressure.Results:There was a significant increase in mean visual acuity compared with baseline at 3, 6, 9, and 12 months post-fluocinolone acetonide in both the overall study population and the pseudophakic subgroup (p < 0.05 at all time points in both groups). A significant reduction in mean central foveal thickness compared with baseline was seen in the overall study population at 3, 6, 9, and 12 months post-fluocinolone acetonide (p < 0.05 at all time points). At 12-month post-fluocinolone acetonide, a small but significant intraocular pressure increase of 1.0 mmHg was seen in the overall study population.Conclusion:The results of this analysis show that switching from the current standard of care to the fluocinolone acetonide implant leads to beneficial effects in terms of vision and retinal structure in patients with diabetic macular edema and that patients benefited from FAc implant administration, regardless of lens status.

Bean-shaped Ring Segments as a Capsule Enhancement Tool in Complex Bag-in-the-Lens Intraocular Lens Implantation.

To describe the outcome of a novel capsular or sulcular device to support the bag-in-the-lens (BIL) implant in cases of capsular or zonular instability. Bean-shaped ring segments or 'beans' (Morcher GmbH, Stuttgart, Germany) are designed to fit the groove of the BIL and may be placed in either the capsule or the ciliary sulcus in cataract cases with loose zonules or unstable capsule. This was a retrospective single center observational study of all consecutive cases of bean implantation between May 2011 and April 2015. Sixty-four eyes of 57 patients were included in this study. Beans were used to support the BIL implant in all cases. Surgical technique, positioning, visual outcomes, refractive outcomes, and complications were evaluated in all cases. The beans were implanted in 23 eyes after IOL exchange, 14 eyes with crystalline lens dislocation, 12 eyes presenting with traumatic cataract, 8 eyes presenting with unstable capsules, and 7 eyes with postoperative visual complaints due to an unstable BIL implant. The mean increase in visual acuity was 0.35 decimal Snellen for the total cohort. Visual gain was highest in the crystalline lens dislocation (0.43 decimal Snellen) and traumatic cataract (0.41 decimal Snellen) groups. Best refractive outcomes were achieved in the traumatic cataract and intraocular lens exchange groups (0.73 and 0.80 diopters mean deviation from target refraction, respectively). Bean-shaped ring segments are a useful tool to augment the stability of the capsule/zonular complex, expanding the indications of patients who can be treated with the BIL implant. [J Refract Surg. 2017;33(7):454-459.].

Safety and Effectiveness of Cataract Surgery with Simultaneous Intravitreal Anti-VEGF in Patients with Previously Treated Exudative Age-Related Macular Degeneration.

To evaluate the safety and impact on visual acuity, retinal and choroidal morphology of simultaneous cataract surgeryand intravitreal anti-vascular endothelial growth factor on patients with visually significant cataracts and previously treated exudativeage-related macular degeneration. Prospective study, which included 21 eyes of 20 patients with exudative age-related macular degenerationsubmitted to simultaneous phacoemulsification and intravitreal ranibizumab or bevacizumab. The patients were followed for 12 monthsafter surgery using a pro re nata strategy. Visual acuity, foveal and choroidal thickness changes were evaluated 1, 6 and 12 monthspost-operatively. There was a statistically significant increase in mean visual acuity at one (13.4 letters, p < 0.05), six (11.5 letters, p < 0.05) andtwelve months (11.3 letters, p < 0.05) without significant changes in retinal or choroidal morphology. At 12 months, 86% of eyes wereable to maintain visual acuity improvement. There were no significant differences between the two anti-vascular endothelial growthfactor drugs and no complications developed during follow-up. Simultaneous phacoemulsification and intravitreal anti- vascular endothelial growth factor is safe and allows improvementin visual acuity in patients with visually significant cataracts and exudative age-related macular degeneration. Visual acuity gains weremaintained with a pro re nata strategy showing that in this subset of patients, phacoemulsification may be beneficial. Cataract surgery and simultaneous anti-vascular endothelial growth factor therapy improves visual acuity in patients withexudative age-related macular degeneration.

Morphological and Functional Retinal Assessment in Epiretinal Membrane Surgery

ABSTRACTPurpose: To analyze functional and morphological findings after surgery for idiopathic epiretinal macular membrane (IEMM). Materials and Methods: Twenty eyes of 20 patients affected by IEMM underwent 23-Gauge surgery. Morphological and functional examinations were assessed at baseline and at 30, 90, and 180 days after surgery. SD-OCT evaluated foveal morphology and thickness, photoreceptor inner/outer segment junction, and external limiting membrane. Functional assessment evaluated visual acuity, retinal sensitivity, and fixation patterns. Statistical analysis was performed with the Student’s t test and Pearson correlation test. Results: Mean central retinal thickness (CRT), visual acuity (VA), and retinal sensitivity (RS) at baseline were respectively 494.90 ± 38.73 µm, 0.55 ± 0.08 LogMAR, and 11.13±1.02; after surgery, at day 180, we observed a significant decrease in mean CRT to 326.90±32.68 µm, an increase in mean VA to 0.33 ± 0.05 LogMAR (p < 0.05), and in mean RS to 13.25 ± 0.73 dB (p < 0.05). A stable fixation increased from 40% of patients at baseline to 75% of patients at day 180 (p < 0.05). Discussion: IEMM surgery results in continuous improvement in visual function, not only at month one but also beyond month six, due to the progressive reduction of residual intraretinal edema and recomposition of retinal layers.

A New Fitting Approach for Providing Adequate Comfort and Visual Performance in Keratoconus: Soft HydroCone (Toris K) Lenses

To evaluate the comfort and visual performance of soft HydroCone (Toris K) silicone hydrogel lenses in keratoconus patients. Fifty eyes of 50 keratoconic patients who were fitted with the Toris K lens were included in the study. All patients were evaluated at baseline and after 2 weeks of lens wear. Uncorrected and best-corrected visual acuities were measured. Corneal topography, ocular aberrations, and point spread function (PSF) were obtained using NIDEK-OPD Scan. Comfort level and visual performance in daytime and nighttime conditions were scored from 0 to 5 after 2 weeks of lens wear. Best-corrected visual acuity was significantly better with the Toris K lens (P<0.001). Mean increase in visual acuity with the lens was 4.5 lines. Mean K1, K2, and Kmax values significantly decreased with the lens (P<0.001). Both total and higher-order root-mean-square errors were significantly corrected with the Toris K lens (P<0.001 and P=0.038, respectively). A significant correction of total coma and trefoil aberrations was achieved with the lens. Also, PSF values were significantly increased with the lens (P<0.001). Although comfort scores in 46 eyes (92.0%) were classified as good/excellent, only 4 eyes (8.0%) had moderate comfort scores. Visual acuity was classified as good/excellent in 46 eyes (92.0%) in daytime and in 38 eyes (76%) in nighttime conditions. Soft HydroCone silicone hydrogel keratoconus lenses should be considered as alternative visual correction for keratoconus patients. The soft and full-custom design provides optimal comfort and visual performance for the patients' daily requirements.

Perspective on the role of Ozurdex (dexamethasone intravitreal implant) in the management of diabetic macular oedema.

Diabetic macular oedema (DMO) is the most common cause of visual loss in the working age population. Intravitreal therapy has superseded macular laser as the first-line treatment for the management of centre-involving DMO in most patients. As well as the proven efficacy of intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents, phase II and III clinical trials of Ozurdex intravitreal dexamethasone implants for DMO have also demonstrated a mean increase in visual acuity and corresponding mean reduction in central macular thickness, particularly in pseudophakic eyes. Because of the risk of visual loss from cataract, glaucoma and intraocular infection with the use of intravitreal steroids, Ozurdex tends to be reserved for use in patients unresponsive to anti-VEGF therapy for centre-involving DMO. Situations where Ozurdex may be considered a first-line treatment option for eyes with centre-involving DMO include pseudophakia, impending cataract surgery, or in the context of a recent arterial thromboembolic event. Because of their stable pharmacokinetics, Ozurdex slow-release implants may also be considered in vitrectomized eyes.

Polymorphisms in Vascular Endothelial Growth Factor Receptor 2 Are Associated with Better Response Rates to Ranibizumab Treatment in Age-related Macular Degeneration

Intravitreal anti-vascular endothelial growth factor (VEGF) injections are currently the standard treatment for neovascular age-related macular degeneration (AMD), but a broad range of response rates has been observed. We evaluated the association of single nucleotide polymorphisms (SNPs) in VEGF genes and their receptors (VEGFR) with the response rate to ranibizumab in 366 patients with neovascular AMD. Case series study. A total of 366 eyes of 366 patients with neovascular AMD. Visual acuity (VA) was determined at baseline, after 3 monthly ranibizumab injections, and after 1 year of treatment. Genotyping of 126 SNPs in the genes encoding VEGF family members VEGFA, VEGFB, VEGFC, VEGFD (FIGF), and placental growth factor (PGF); VEGF receptors VEGFR1 (FLT1), VEGFR2 (KDR), and VEGFR3 (FLT4); and the gene encoding pigment epithelium-derived factor (PEDF) (SERPINF1) was performed. The changes in VA after 3 injections and after 1 year of treatment and their association with VEGF and VEGFR genotypes. Univariate analyses of variance (ANOVAs) revealed a significant effect of SNP rs4576072 in the VEGFR2 gene on VA change after 12 months (F[1,235]= 14.05; P= 0.02). A stepwise linear regression analysis returned a model (P= 0.01) with SNPs rs4576072 and rs6828477 in the VEGFR2 gene as independent predictors for VA change after 12 months, with a mean increase in VA of 0.26 on the logarithm of the minimum angle of resolution (logMAR) scale in patients with 3 contributing minor alleles compared with a loss of 0.03 logMAR in patients with no minor allele. Polymorphisms in the VEGFR2/KDR gene significantly influence visual outcome in patients receiving ranibizumab treatment for neovascular AMD. This study shows that genetic variation partially explains the wide range of response to ranibizumab treatment, which in the future might help clinicians tailoring medicalinterventions to individual needs.

Nine-month results of intravitreal bevacizumab versus triamcinolone for the treatment of diffuse diabetic macular oedema: a retrospective analysis

To compare efficacy of intravitreal bevacizumab versus triamcinolone in the treatment of diffuse diabetic macular oedema (DME). This retrospective nonrandomized study includes 60 patients with diffuse DME treated with at least one intravitreal triamcinolone injection (ITA) or intravitreal bevacizumab injection (IBe). Regression analysis was performed for pretreatment, glycosylated haemoglobin level, visual acuity (VA) at baseline and central macular thickness (CMT) at baseline. After 1-, 3-, 6- and 9-month follow-up, there was no significant change in either VA or CMT treatment in the ITA and IBe groups. There was no statistically significant difference between the two treatment groups. Changes in CMT and VA in the subgroups were not significant. Only predictive factor independent of HbA1c level and VA was CMT at baseline in both treatment groups. The thicker CMT at baseline, the higher was reduction in CMT. After 1 month, the IBe group had a significantly higher decrement than the ITA group. In our study collective, neither IBe nor ITA treatment was able to improve VA during follow-up, significantly. CMT was reduced in both treatment groups, however not significantly. Our data demonstrates that reduction in CMT with either IBe or ITA treatment was significantly influenced by degree of CMT at baseline.

A Phase I Study of Intravitreal Vascular Endothelial Growth Factor Trap-Eye in Patients with Neovascular Age-Related Macular Degeneration

To determine the safety, tolerability, maximum tolerated dose, and bioactivity of an intravitreal injection of vascular endothelial growth factor (VEGF) Trap-Eye, a fusion protein of binding domains from human VEGF receptors 1 and 2 with human immunoglobulin-G Fc that binds VEGF family members, in patients with neovascular age-related macular degeneration (AMD). Dose-escalation, multicenter, interventional clinical trial. Twenty-one patients (13 female, 8 male) with neovascular AMD (NVAMD) and lesions <or=12 disc areas in size and >or=50% active choroidal neovascularization (CNV) with best-corrected visual acuity (BCVA) <or=20/40 received a single intraocular injection of 0.05 mg (n = 3), 0.15 mg (n = 3), 0.5 mg (n = 3), 1 mg (n = 6), 2 mg (n = 3), or 4 mg (n = 3) of VEGF Trap-Eye. Safety assessments included eye examinations, vital signs, and laboratory tests. Measures of bioactivity included changes from baseline in BCVA, optical coherence tomography (OCT), and fluorescein angiography. The primary end point was 6 weeks and patients were followed up for 12 weeks. Safety assessments. There were no serious adverse events and no identifiable intraocular inflammation. The mean decrease in excess foveal thickness for all patients was 104.5 mum at 6 weeks, and the mean increase in visual acuity was 4.43 letters. In the 2 highest dose groups combined (2 and 4 mg), the mean increase in BCVA was 13.5 letters, with 3 of 6 patients demonstrating improvement of >or=3 lines and 3 patients requiring no adjunctive treatment of any type for 12 weeks. Some showed elimination of fluorescein leakage and reduction in area of CNV. Intravitreal injection of up to 4 mg of VEGF Trap-Eye in patients with NVAMD was well tolerated with no evidence of ocular inflammation. Although the number of patients in each cohort was small, there was evidence of bioactivity, because several patients, especially those receiving 2 or 4 mg of VEGF Trap-Eye, showed substantial improvement in BCVA associated with reductions in foveal thickness. Phase III trials to investigate the efficacy of intraocular VEGF Trap-Eye in patients with NVAMD are under way.

Findings in Fluorescein Angiography and Optical Coherence Tomography after Intravitreal Bevacizumab in Type 2 Idiopathic Macular Telangiectasia

To report the short-term effects of intravitreal bevacizumab in patients with type 2 idiopathic macular telangiectasia (IMT). Noncomparative, interventional, retrospective case series. Seven eyes of 6 patients with type 2 IMT were studied. Patients received 2 doses of intravitreal bevacizumab (1.5 mg) at 4-week intervals. Serial examinations included standardized Early Treatment of Diabetic Retinopathy Study (ETDRS) visual acuity (VA), fluorescein angiography, and optical coherence tomography (OCT). Assessments of OCT retinal thickness, angiographic characteristics, and VA were performed at baseline and at 4 and 8 weeks after the initial treatment. A mean increase in VA of 8 ETDRS letters at 8 weeks was found (P<0.05). Visual acuity improved by more than 15 letters in 1 patient and by 10 to 15 letters in 2 patients and remained stable (-1 to +10 letters) in another 4 patients compared with baseline. All patients showed a reduction in extension and intensity of late-stage parafoveal hyperfluorescence on fluorescein angiography. In OCT imaging, mean retinal thickness showed a reduction in the foveal and in the parafoveal zones (P<0.01). The most pronounced effect (mean decrease, 22 microm) was in the parafoveal temporal zone. No significant ocular or systemic side effects were observed. Short-term results indicate that inhibition of vascular endothelial growth factor by intravitreal bevacizumab is associated with a decrease in retinal thickness and a reduction in angiographic leakage in type 2 IMT. Furthermore, intravitreal bevacizumab may improve VA in affected patients.

TRIPLE THERAPY FOR CHOROIDAL NEOVASCULARIZATION DUE TO AGE-RELATED MACULAR DEGENERATION

To evaluate the efficacy and safety of triple therapy with verteporfin photodynamic therapy (PDT), dexamethasone, and bevacizumab in choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). This prospective, noncomparative, interventional case series included 104 patients. Verteporfin PDT was administered with a reduced light dose (42 J/cm, accomplished by light delivery time of 70 seconds). Approximately 16 hours after PDT, dexamethasone (800 microg) and bevacizumab (1.5 mg) were injected intravitreally. Patients attended follow-up visits every 6 weeks, undergoing visual acuity and intraocular pressure measurement, slit-lamp and ophthalmoscopic examination, and optical coherence tomography (OCT). Fluorescein angiography was performed every 3 months or earlier if OCT showed significant edema. All 104 patients received one triple therapy cycle (5 patients received a second triple treatment due to remaining CNV activity). The triple therapy was complemented in 18 patients (17.3%) by an additional intravitreal injection of bevacizumab. The mean follow-up period was 40 weeks (range, 22-60 weeks). Mean increase in visual acuity was 1.8 lines (P < 0.01). Mean decrease in retinal thickness was 182 microm (P < 0.01). No serious adverse events have been observed. In most patients with CNV due to AMD, triple therapy results in significant and sustained visual acuity improvement after only one cycle of treatment. In addition, the therapy offers a good safety profile, potentially lower cost compared with therapies that must be administered more frequently, and convenience for patients.

Combined Photodynamic Therapy and Intravitreal Triamcinolone Acetonide for the Treatment of Myopic Subfoveal Choroidal Neovascularization

To evaluate visual acuity changes and safety of combined treatment with photodynamic therapy (PDT) and intravitreal triamcinolone acetonide (IVTA) in myopic eyes with choroidal neovascularization (CNV). Prospective interventional case series. Twelve eyes of 12 patients with subfoveal myopic CNV were treated with PDT followed by IVTA within a week. Changes in visual acuity and possible complications related to the combined therapy were assessed in periodic visits. After combined therapy, a significant increase in mean visual acuity was observed at one, three, and six months. A significant increase of mean intraocular pressure was observed after seven days, one month, and three months. Ten patients (83%) required topical antiglaucomatous therapy during follow-up. The combination of PDT and IVTA may increase the possibility of improving or stabilizing visual acuity in patients with subfoveal myopic CNV, but further studies are needed to asses the effects of this treatment.

Improved functional vision with a modified prolate IOL

Packer and coauthors1 present data to support the idea that an aspheric intraocular lens (IOL) (Tecnis Z9000, Pfizer) produces significantly better quality of vision than a traditional spherical-design IOL (AR40e, AMO). The improvement in quality of vision is theoretically mediated through a reduction in higher-order aberrations (HOAs), resulting in improved contrast sensitivity. Using the wavefront-guided design of IOLs to correct more than defocus is an intuitively appealing concept. Unfortunately, the data as presented do not support the study conclusions and do little to clarify the relationships between HOA, contrast sensitivity, and quality of vision. First, the sample size seems inadequate. A sample-size calculation reveals that 18 patients are needed for each IOL group for a 2-tailed analysis sensitive enough to detect a 0.15 log unit difference in contrast sensitivity with α = 0.05 and a study power of 80%. Insufficient sample sizes reduce the power of the study and potentially miss true differences, if they exist. Second, differences in contrast sensitivity may be due to a different index of refraction between IOLs, producing HOA profiles that cannot be attributed to the surface design alone. Third, comparability between the Tecnis and AR40e groups is unclear because there are no baseline data for contrast sensitivity for either group and the age disparity (contrast sensitivity declines with age2) between groups might be statistically significant. Fourth, there were no data (means and standard deviations) about improvement in contrast sensitivity between baseline and 3 months (endpoint) for either group, making it difficult to interpret contrast sensitivity differences for a single point in time (3 months). Head-to-head trials usually include comparisons of change scores over the same time period. Fifth, the magnitude of the contrast sensitivity difference is somewhat misleading. For example, the 44% contrast sensitivity difference between the 2 IOLs at 3 months is a relative percentage difference. At 6 cycles per degree, under photopic conditions, this represents a contrast sensitivity difference of 0.5%, illustrating that a large change in a small number is still a small number. Further, the clinical relevance of this type of change is unclear since there were no significant differences in contrast sensitivity at other spatial frequencies despite a marked mean increase in visual acuity in both groups. These observations are consistent with the authors' previous findings3 but are at odds with others,4 further clouding the issue. Finally, as the authors point out, there were no direct measurements of HOA in either group, so we are left to infer that contrast sensitivity differences were due to significant reductions in HOA. This conclusion is largely based on the assertion of the manufacturer of the Tecnis IOL, is not supported by the current evidence, and does not justify the conclusion that this IOL produces significantly improved quality of vision. As with refractive surgery, the full and precise meaning of reductions in various HOAs in terms of variation in contrast sensitivity, image clarity, or improved functioning in vision-dependent activities of daily living remains unclear. For example, Schallhorn reported that only 11% to 15% of the variation in HOA is explained by differences in contrast sensitivity (S. Schallhorn, MD, “Correlating Optical Aberrations to Quality of Vision After LASIK,” presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, Philadelphia, Pennsylvania, USA, June 2002). Furthermore, the Tecnis lens represents a “one size fits all” solution, with relatively little tolerance for tilt or decentration in patients with varying degrees of HOA, diminishing the likelihood that most patients would derive a clear benefit. Wavefront-guided IOL design may be an important advance for cataract patients, particularly if it becomes feasible to customize IOL design to the individual patient. However, further studies are needed to determine its ability to improve quality of vision in ways that translate to improved functioning. Peter N. Rosen MD Michael D. Twa OD aSan Diego, CA, USA bColumbus, OH, USA

Outcome of Rotational Keratoplasty

The nature of chronic endothelial cell loss in homologous corneal grafts is still unclear. Possible causes are cell migration to the recipient bed and chronic subclinical immune reaction. To compare endothelial cell loss after autologous rotational keratoplasty and homologous keratoplasty and present the clinical outcome of patients after rotational keratoplasty. In this open prospective study, we included 7 consecutive patients who underwent rotational keratoplasty between 1998 and 2000 in our hospital. Patients were examined clinically every 3 months, and visual acuity, astigmatism, and endothelial cell density were evaluated. Endothelial cell densities were compared with endothelial cell counts of 293 homologous keratoplasties. Mean follow-up for autologous grafts was 39 months. Mean increase in visual acuity was 3.5 lines. Mean astigmatism was 4.75 diopters in the autologous graft group. Mean preoperative endothelial cell density was 2058 (637 cells/mm(2)). Mean endothelial cell density after 1 year was 1865 (639 cells/mm(2)), which represents a mean +/- SD cell loss of 15% +/- 7.19%. At the end of follow-up, endothelial cell number after autologous grafting was 1630 +/- 622 cells/mm(2). Endothelial cell loss after 1 year in homologous grafts was 40% +/- 21.34%. There was 1 decompensation of autologous graft in the follow-up period. Main Outcome Measure Comparison of endothelial cell count at different postoperative time points using nonpaired t test. Endothelial cell loss in autologous grafts is significantly lower than in homologous grafts, which supports the hypothesis that chronic endothelial cell loss is due to chronic subclinical immune reactions in homologous grafts. Autologous keratoplasties can lead to good functional results and can be superior to homologous corneal grafting in suitable situations.

Anatomical and visual outcome of macular hole surgery with infracyanine green-assisted peeling of the internal limiting membrane, endodrainage, and silicone oil tamponade

Purpose To evaluate the anatomical and visual outcome in macular hole patients who underwent surgery with infracyanine green-assisted internal limiting membrane peeling. Design A prospective case series with 51 consecutive eyes of 49 patients with idiopathic, iatrogenic, or traumatic Stage 2, 3, or 4 macular holes. Methods After removing the vitreous, in all eyes infracyanine green-assisted removal of the internal limiting membrane was performed. Patients older than 65 years of age underwent a simultaneous phacoemulsification. At the end of surgery, a silicone oil tamponade was used in all cases, and all patients were asked to position face down for 24 hours. Optical coherence tomography was performed preoperatively and postoperatively to determine the macular hole stage/size and the anatomical closure rate, respectively. Results The mean follow-up time was 9.8 months (range, 6–26 months). The overall median duration between the first symptoms and the surgery was 5 months. The overall anatomical success rate after one surgery was 92% (47 eyes), while that of chronic and nonchronic ones was 72.3% and 97.5%, respectively. The median preoperative visual acuity was 20/160 (range, 20/30 to counting fingers) and increased to 20/50 (range, 20/20 to 20/400) postoperatively. The mean increase in visual acuity was 3.7 lines (range, −4 to 10 lines). Of all 51 operated-on eyes, 26 (51%) eyes had a final visual acuity of 20/50 or better. Conclusions These findings indicate that infracyanine green-assisted removal of the retinal internal limiting membrane appears to induce a high incidence of anatomical closure, with good visual outcome.

A comparison of visual results and complications in eyes with posterior chamber intraocular lens dislocation treated with pars plana vitrectomy and lens repositioning or lens exchange

Purpose To compare the visual results and the postoperative complications in eyes with posterior chamber intraocular lens (PCIOL) dislocation that underwent pars plana vitrectomy with lens repositioning with eyes that underwent pars plana vitrectomy with lens exchange. Design Nonrandomized consecutive comparative case series. Participants Fifty-nine eyes (27 right eyes and 32 left eyes) of 56 subjects (28 women and 28 men) ranging in age from 59 to 90 years. Mean follow-up was 34 months. Methods A comparison of the best-corrected preoperative visual acuities, final visual acuities, and postoperative complications in subjects with dislocated PCIOLs that underwent pars plana vitrectomy. Logarithm of the minimum angle of resolution (LogMAR)–converted visual acuities were used for comparison. Categorical data were analyzed by Fisher’s exact test, and population means were compared by a pooled Student’s t test. Main outcome measures Final mean visual acuities, change in mean visual acuities, and postoperative complications. Results For all 59 eyes the mean preoperative visual acuity was 20/152, and the mean final visual acuity was 20/48. Final visual results were similar between the eyes that underwent lens repositioning (20/55) and the eyes that underwent lens exchange (20/43; P = 0.19). Final visual results were also similar between the eyes that underwent lens exchange with sutured PCIOL placement (20/51) and the eyes that underwent lens exchange with anterior chamber intraocular lens (ACIOL) placement (20/38; P = 0.26). Final mean visual acuity in eyes that received an ACIOL (20/38) was better than in eyes that underwent repositioning of the dislocated lens into the ciliary sulcus (20/65; P = 0.01). The mean increase in visual acuities was greater for eyes with ACIOL placement compared with eyes with sutured PCIOL placement ( P = 0.01). For all eyes, final visual results were unaffected by a concurrent diagnosis of age-related macular degeneration (20/52; P = 0.71), glaucoma (20/48; P = 0.95), or postoperative cystoid macular edema (20/55; P = 0.45). Final visual acuities were significantly worse in eyes with a detectable preoperative afferent pupillary defect (20/200; P < 0.0001). Postoperative retinal detachments developed in 4 of 29 eyes (14%) that underwent lens repositioning and in 2 of 30 eyes (7%) that had lens exchange ( P = 0.42). Postoperative lens subluxations occurred in 6 of 29 eyes (21%) that underwent lens repositioning and in 1 of 30 eyes (3%) that underwent lens exchange ( P = 0.05). Conclusions The final visual results in eyes with dislocated PCIOLs that underwent pars plana vitrectomy with lens repositioning were similar to the visual results obtained in eyes that underwent pars plana vitrectomy with lens exchange. For eyes that underwent lens exchange, final visual results in eyes that received an ACIOL were similar to the visual results obtained in eyes that received a PCIOL; however, eyes with an ACIOL showed a greater increase in mean visual acuity. Eyes with a preoperative afferent pupillary defect had worse final visual results.