Ophthalmic Outcomes Research Articles

Geriatric Traumatic Open Globe Injuries

To characterize the pattern of ocular trauma in the geriatric population. Retrospective, comparative case series. Eight hundred forty-six consecutive patients comprising 848 open globe injuries, of which 166 injuries occurred in geriatric patients (defined as 65 years old or older at the time of injury), with the remaining patients serving as control subjects. Charts of open globe injuries (848 in total) treated surgically at the Massachusetts Eye and Ear Infirmary between January 2000 and April 2009 were retrospectively reviewed. Ocular Trauma Score, age, gender, mechanism of injury, zone of injury, site of injury, time of day, visual acuity at presentation, and best post-repair visual acuity were analyzed. Of 848 open globe injuries, 166 occurred in the geriatric population. The mean patient age in the geriatric group was 79.8 years. Females comprised most (58%) of this subpopulation. The most common mechanisms of injury were fall (65%), blunt trauma (16%), and motor vehicle accident (6%). The geriatric traumas tended to happen in late morning or late at night. There were no cases of endophthalmitis and fewer instances of enucleation in this group. The median raw Ocular Trauma Score was 47 in the geriatric population, compared with 70 in the younger subset (P < 0.0001). The injuries more often were in zones II and III in the geriatric population compared with the nongeriatric population (P < 0.0001). The geriatric patients were much more likely to have undergone previous intraocular surgery (P < 0.0001), which consisted of primarily cataract procedures. Visual acuity at presentation was significantly worse in the geriatric population than the nongeriatric population (P<0.0001). Similarly, the best postoperative visual acuity was worse in the elderly group than the younger group (P < 0.0001). The elderly represent a unique, yet neglected ocular trauma population. The pattern of ophthalmic injury and outcome differs greatly between the geriatric and nongeriatric populations. A better understanding of these injuries is necessary to improve prevention and treatment strategies for potentially devastating open globe injuries in this susceptible population.

Impact of a structured surgical curriculum on ophthalmic resident cataract surgery complication rates

To determine whether institution of a structured surgical curriculum for ophthalmology residents decreased the rate of sentinel surgical complications. Veterans Affairs Medical Center, Des Moines, Iowa, USA. A retrospective review was performed of third-year ophthalmic resident quality-assurance surgical outcomes data at a single residency-training site from 1998 to 2008. The primary outcome measure was defined as a sentinel event; that is, a posterior capsule tear (with or without vitreous loss) or vitreous loss (from any cause) occurring during a resident-performed case. The study population was divided into 2 groups. Group 1 comprised surgical cases of residents trained before the surgical curriculum change (academic years 1998 to 2003) and Group 2, surgical cases of residents trained with the enhanced curriculum (academic years 2004 to 2008). Data from 1 year (academic year 2003 to 2004) were excluded because the transition to the enhanced curriculum occurred during that period. The data were analyzed and adjusted for surgical experience. In Group 1 (before institution of surgical curriculum), there were 823 cases with 59 sentinel complications. In Group 2 (after institution of surgical curriculum), there were 1009 cases with 38 sentinel complications. There was a statistically significant reduction in the sentinel complication rate, from 7.17% before the curriculum changes to 3.77% with the enhanced curriculum (P = .001, unpaired 2-tailed t test). Implementation of a structured surgical curriculum resulted in a statistically significant reduction in sentinel event complications, even after adjusting for surgical experience.

Intravitreal bevacizumab (Avastin®) for neovascular age‐related macular degeneration in treatment‐naive patients

To report the effects of intravitreal bevacizumab (Avastin) in treatment-naive patients with exudative age-related macular degeneration (ARMD) assessed by visual acuity (VA), optical coherence tomography (OCT) and contrast sensitivity. A prospective, uncontrolled, pilot study of 26 eyes of 26 patients, all previously treatment-naive to photodynamic therapy, argon laser or anti-vascular endothelial growth factor (VEGF), were treated with one or more intravitreal injections of 1.25 mg bevacizumab. Of the 26 patients, 15 (57.7%) had occult choroidal neovascularization (CNV), 6 (23.1%) had predominantly classic CNV and 5 (19.2%) had minimally classic CNV. Ophthalmic outcome measures included changes in standardized Early Treatment Diabetic Research Study (ETDRS) VA, contrast sensitivity and OCT. The patients were examined at baseline and 1 week, 6 weeks, 3 months and 6 months after the first injection. Re-treatment was given on an 'as needed' basis. Twenty-four eyes of 24 patients completed 6 months of follow-up. Two patients chose to discontinue the study. Mean ETDRS VA score improved from 55 letters at baseline to 60 letters at 1 week (P < 0.01) and to 61 letters at 6 weeks (P < 0.01). No significant improvement in VA from baseline was found after 3 and 6 months. Patients with pigment epithelial detachment (PED) had a significantly worse outcome in VA at 6 months. Contrast sensitivity improved from baseline to 3 or 6 months, but this improvement was not statistically significant. Mean macular thickness decreased significantly from baseline to all follow-up examinations (P < 0.01). Mean ETDRS VA improved significantly after 1 and 6 weeks; thereafter, it remained stable throughout the study period. Macular thickness improved significantly at all time points. The results indicate that 1.25 mg intravitreal bevacizumab is associated with functional as well as morphological improvement among treatment-naive ARMD patients.

The relationship between ophthalmic deficits and functional ability in low birth weight children

Aim: To review the current literature on long-term ophthalmic deficits and behavioural and/or cognitive outcomes occurring in low birth weight (LBW) children and to determine whether there is any link between the ophthalmic deficits and functional out­come. Methods: A literature search was performed focusing mainly on publications from the past 10 years. Results: LBW children are at an increased risk of a large number of ophthalmic deficits, including reduced visual functions (acuity, visual field, colour vision, stereo-acuity and contrast sensitivity), increased prevalence of strabismus and all types of refractive error. These deficits are not restricted to the smallest children; they can occur with increased frequency in nil LBW children. As a group LBNV children have increased risk of cognitive and behavioural deficits, which can affect them through­out their education. There is evidence of an associa­tion between ophthalmic outcome and many aspects of functional ability (e.g. IQ, reading ability). Further research is required to discover whether there is a common aetiology. Conclusion: The evidence discussed supports the need for long-term ophthalmic monitoring, and treatment where necessary, due to the potential impact of LBW on education and development. Currently there is no standardised approach for this. Further discussion is required to optimise the long-term care of all LBW children.

A comparison of the concordance of ophthalmic outcome between low birth weight singletons and twins

Aim: To determine whether low birth weight twins have a similar outcome, and to compare the outcome of the twins with a matched comparison group of low birth weight singletons Methods: From a low birth weight (LBW) cohort ( Results: The twins showed a significant relationship with each other in terms of the presence or absence of retinopathy of prematurity (p = 0.001, concor­dance = 71%) but the matched singletons did not. The twins had a statistically significant relationship in terms of the level of visual acuity and refractive error. However, the relationship between the refrac­tive errors of the twins was weak (R2 = 0.14). The matched singleton group showed no statistically significant similarities on any measures of ophthalmic outcome. The level of concordance was higher between the pairs of twins for all measures of ophthalmic outcome compared with the matched singletons, but this increase did not reach statistical significance. Conclusion: There was a higher rate of concordance in the twin children on all measures of visual outcome, which suggests that when a deficit is detected in a low birth weight child from a multiple birth the sibling(s) should also be assessed. However, in this low birth weight cohort analysis, the degree of prematurity and the resultant systemic and ocular complications, have a greater impact, compared with genetic factors, on many measures of outcome.

Use of ultrasonic dissection in the early surgical management of periorbital haemangiomas

To evaluate the efficacy and safety of the early surgical excision of periorbital haemangiomas with an ultrasonic scalpel in infants at risk of visual impairment. A retrospective analysis of 67 infants diagnosed to be at risk of amblyopia from periorbital haemangiomas, treated consecutively with the Dissectron between 1994 and 2005. Ophthalmic outcome parameters included the pre- and postoperative measurement of visual axis occlusion, strabismus, astigmatism, and degree of amblyopia. Visual performance showed an overall improvement of 30% following treatment. Seventy-six patients were found to have abnormal ophthalmic examinations preoperatively, compared to 46 following surgery. After surgery, visual axis occlusion decreased from 73 to 6%; amblyopia decreased from 67 to 22%, strabismus decreased from 26 to 18% and astigmatism (>onedioptre) decreased from 66 to 31%. Mean astigmatism values decreased from 3.5 to 1.9 dioptres. No new cases of astigmatism, strabismus or amblyopia were diagnosed postoperatively. Three minor complications resolved with conservative treatment. All patients were satisfied with the outcome of their surgery. Early surgical excision of periorbital haemangiomas using the Dissectron in infants with an established risk of visual impairment is a safe and effective alternative to pharmacological therapy. The use of the Dissectron is associated with reduced operative times and a shorter hospital stay.

Retinal detachment in horses: 40 cases (1998–2005)

To determine clinical features, ophthalmic examination findings, etiology, treatment, and outcome of horses diagnosed with retinal detachment (RD). Forty horses, presented to the North Carolina State University and The Ohio State University Veterinary Teaching Hospitals from 1998 to 2005 that were diagnosed with RD. PROCEDURE(S): Horses with documented RD, confirmed either on ophthalmic examination or by ultrasonography, and with a complete medical record were included. Information retrieved from the medical records included signalment, presenting complaint, duration of clinical signs, ophthalmologic examination findings, diagnostics performed, identified cause of the retinal detachment, treatment given, and outcome. Forty horses (46 eyes) were diagnosed with RD. Mean +/- SD duration of clinical signs of ocular disease was 10.5 +/- 14.7 months. Thirty-four horses presented with unilateral involvement, 6 with bilateral, 14 with partial and 32 with complete RD. Ultrasonography was used to make the diagnosis in 26 eyes, while RD was diagnosed on routine ocular examination in 20 eyes. Bullous RD was the only type of RD observed, although small vitreal traction bands were considered secondary to the underlying inflammation or trauma. RD caused by equine recurrent uveitis (ERU) was diagnosed in 27 of 40 (67.5%) horses. Trauma-induced RD involved 10 of the 40 horses (25%). Presenting problems included known ERU (n = 16), acute or progressive vision loss (n = 9), known ocular trauma (n = 6), cataract (n = 6), and a cloudy cornea (n = 3). No horses regained vision after RD despite therapy. Many eyes were enucleated or eviscerated, or the horses were euthanized. Seven eyes with complete RD were noted to be unchanged and comfortable with medical therapy. The visual prognosis of RD in horses is grave; however, horses with nontraumatic RD (most commonly ERU) may be able to maintain a comfortable but blind globe with anti-inflammatory medical therapy.

Severe, unilateral, unresponsive keratoconjunctivitis sicca in 16 juvenile Yorkshire Terriers

To present ophthalmic findings, clinical data, and treatment outcomes of 16 juvenile Yorkshire Terriers with severe unilateral keratoconjunctivitis sicca. Each of the 16 dogs exhibited extreme unilateral dryness associated with blepharospasm, mucoid discharge, and corneal vascularization. Ages of affected dogs at presentation ranged from 5 months to 4 years. Mean Schirmer tear test (STT) result for affected eyes was 1 mm/min. Topical application of 0.2% cyclosporine to the affected eye was not associated with improvement in STT values in any dog. Clinical signs subjectively improved with topical application of 20% chondroitin sulfate ophthalmic solution in some dogs, and transposition of the parotid duct was performed in three dogs. Histopathologic examination in one dog failed to show evidence of orbital lacrimal gland tissue. Clinical signs, age of presentation, disease severity, and lack of response to treatment are consistent with breed-related unilateral aplasia or hypoplasia of the lacrimal gland. Lacrimal gland aplasia or hypoplasia should be considered in young dogs with severe unilateral ocular dryness, especially female Yorkshire Terriers.

Orbital injuries in trauma patients: Prevalence and outcome

Purpose: Eye injuries in patients with multiple trauma are overlooked or missed as special attention is primarily given to their life-threatening injuries. The aim of this study is to present the incidence of eye injuries in polytrauma patients and give the insight of their complexity and outcome. Patients and methods: All polytrauma patients admitted to our institution during the period 1991—2001 were considered eligible to participate in this study. Inclusion criteria were multiple trauma (ISS > 16) and presence of eye and/or orbital injury. Exclusion criteria included early transfer of patients to other centers and loss of patients’ to follow-up. The records of patients who fulfilled the inclusion criteria were retrospectively reviewed and specific characteristics were documented including age, sex, mechanism of injury, type of eye injury, type of ophthalmic surgical interventions and outcome. Results: In total out of 2985 polytrauma patients 222 (7.5%) had sustained eye and orbital injuries forming the study group. The records of 181 (31 females) patients were available at the final follow up. The mean age was 33 years (range 3—84). The most common causes of eye injuries were road traffic accidents (56%), falls from heights (28%), assaults (9%) and work related accidents (4%). The most frequently encountered types of eye injury were orbital wall fractures (61%), periorbital swelling or hematoma (46%), sub-conjunctival hemorrhage (23%), periorbital lacerations (22%), optic o ( w p l Abstracts

Children born weighing less than 1701 g: visual and cognitive outcomes at 11–14 years

Background and objective: Few studies of low birthweight children have explored the relationship between later visual morbidity and neuropsychological function. This study evaluated these outcomes using a geographically defined cohort....

Treatment-Resistant Severe, Active Graves' Ophthalmopathy Successfully Treated with B Lymphocyte Depletion

Treatment-Resistant Severe, Active Graves' Ophthalmopathy Successfully Treated with B Lymphocyte Depletion

A Call for Empirical Research on Best Practices for Economic Evaluation in Ophthalmic Outcomes Research

A Call for Empirical Research on Best Practices for Economic Evaluation in Ophthalmic Outcomes Research

Neuroblastoma with orbital metastasis: ophthalmic presentation and role of ophthalmologists

Neuroblastoma is predominantly a tumour of early childhood, which metastasises to the orbits. In such cases, ophthalmologists are involved in the multidisciplinary management. This unique series from a tertiary referral centre is used to elaborate the ophthalmic associations and the ophthalmologist's role in this rare condition. A review of case notes was performed on six patients who presented to the paediatric ophthalmology - oncology liaison service at the Leeds teaching hospitals between 1998 and 2003. The ophthalmic outcome and role of the ophthalmologist were assessed. Average age of presentation was 29.8 months (range 15-69 months). Average duration of follow-up was 19.5 months (range 2-58 months). One child died during treatment. Two have completed treatment and are under follow-up. Presenting features of the six children were proptosis in four, periorbital ecchymosis in two, ocular motility restriction in two, and subconjunctival haemorrhage in one. Only one case developed blindness. The role of the ophthalmologist in patients with metastatic orbital neuroblastoma can vary from a supportive role to one of active intervention and management of ophthalmic complications. The ophthalmologist is involved in diagnosis and staging as well as monitoring response to treatment of both the primary disease and secondary ophthalmic complications.

Taser penetrating ocular injury

To describe the presentation and treatment of a Taser penetrating ocular injury. Case report. A 50-year-old man with a Taser injury 1.5 cm below the right lower eyelid margin was admitted to the emergency department of a tertiary hospital. The case report describes the ophthalmic assessment, investigation, treatment, and outcome of the Taser barb penetrating ocular injury. The Taser has a fish hook barb that caused a full-thickness wound adequately large for vitreous to escape when the Taser was removed. Consequently, the scleral wound was repaired and cryopexy was performed. The affected eye made a satisfactory recovery, and the visual acuity was 6/9 with a pinhole 1 week after operation. Any Taser injury around the orbits should raise the suspicion of a penetrating ocular injury. In likely cases, removal of the Taser should be performed in an operating theater under general anesthesia.

Surgical Removal vs Observation for Subfoveal Choroidal Neovascularization,Either Associated With the Ocular Histoplasmosis Syndrome or Idiopathic

To report findings regarding health-related quality-of-life outcomes by treatment arm, both overall and within subgroups defined by selected baseline characteristics, among patients who participated in the Submacular Surgery Trials (SST) randomized trial of observation vs surgical removal of subfoveal choroidal neovascular lesions that were either idiopathic or associated with ocular histoplasmosis (SST Group H Trial). Eligible patients were 18 years or older and had subfoveal choroidal neovascularization (including a classic component on fluorescein angiography) and visual acuity of 20/50 to 20/800 inclusive in the eye randomly assigned to surgery or observation. Trained interviewers, who were masked to treatment assignment, administered the National Eye Institute Visual Function Questionnaire (NEI-VFQ), the 36-Item Short-Form Health Survey (SF-36), and the Hospital Anxiety and Depression Scale (HADS) by telephone before enrollment and at 6, 12, and 24 months after enrollment; early enrollees also had interviews at 36 and 48 months. Baseline clinical examinations provided data regarding visual acuity, other aspects of vision, and presence of unilateral or bilateral choroidal neovascularization. Of 225 patients interviewed at baseline and enrolled, 201, 190, and 161 patients (respectively, 89%, 85%, and 88% of those eligible to be interviewed) were interviewed 12, 24, and 36 months later. The NEI-VFQ scores in both treatment arms improved from baseline (median score, 75) to the 24-month interview. Patients in the surgery arm had 4-point larger improvements, on average, than patients in the observation arm (95% confidence interval, 1-8 points). The largest differences between treatment arms for mean 24-month improvements from baseline were in the role difficulties subscale (9 points) and dependency subscale (8 points), with larger mean improvements in the surgery arm. Scores on the SF-36 worsened by approximately 1 point on the physical component summary and improved by 2 points or more on the mental component summary in both treatment arms by 24 months in comparison to baseline. The percentage of HADS-defined "definite cases" of both anxiety and depression declined from baseline in each treatment arm. Vision-targeted quality of life improved more after submacular surgery than with observation, supporting a possible small overall benefit of surgery suggested by the ophthalmic outcomes reported elsewhere. Ophthalmologists and patients similar to those who participated in the SST Group H Trial should be aware of the effects of submacular surgery on specific aspects of vision-targeted quality of life as well as on ophthalmic outcomes when considering this treatment approach.

Responsiveness of the SF-36 health survey to changes in visual acuity among patients with subfoveal choroidal neovascularization

*Other members of the subcommittee are: Carol M. Mangione, MD, MSPH (Chair); Eric B. Bass, MD, MPH (Co-Chair); Neil M. Bressler, MD; Li Ming Dong, PhD; Barbara S. Hawkins, PhD; Marta J. Marsh, MS; Päivi H. Miskala, PhD**A listing of all Submacular Surgery Trials Pilot Study investigators and personnel, as well as funding for the Submacular Surgery Trials Pilot Study, appears in: Submacular Surgery Trials Pilot Study Investigators. Submacular Surgery Trials (SST) randomized pilot trial of laser photocoagulation versus surgery for recurrent choroidal neovascularization secondary to age-related macular degeneration. I. Ophthalmic outcomes. SST Pilot Study Report Number 1. Am J Ophthalmol 2000;130:387–407. PurposeTo report the responsiveness of the SF-36 Health Survey to changes in visual acuity among patients with subfoveal choroidal neovascularization participating in the Submacular Surgery Trials pilot study. DesignCohort study. MethodsCorrelation analyses were used to explore relationships at each time point, and linear regression was used to determine the relation between the 2-year changes in SF-36 scores and visual acuity. ResultsA weak, but statistically significant, association was found between the 2-year changes in both the Physical Component Summary score and the Physical Functioning subscale with changes in visual acuity of the better eye. No association was found between changes in visual acuity and the Mental Component Summary score or the Mental Health subscale. ConclusionsThe SF-36 summary scales and the individual subscales were minimally responsive to 2-year changes in visual acuity in this subgroup of patients.

The Activities of Daily Vision Scale for cataract surgery outcomes: re-evaluating validity with Rasch analysis.

The Activities of Daily Vision Scale (ADVS) has been extensively validated by traditional methodology. In the current study, Rasch analysis was used to explore further the validity of the ADVS and to determine whether improvements could be made. Forty-three patients with cataract underwent visual acuity (VA) and contrast sensitivity (CS) testing and completed the ADVS. The data were Rasch analyzed and the value of response scale and item reduction explored. A shortened version and the original ADVS were tested for criterion validity by determining correlations with VA and CS. The ADVS data contained abnormally distributed items and items with ceiling effects and empty response categories. Therefore, items benefited from shortening the response scale, the optimum length being three responses. There was poor targeting of item difficulty to patient ability, because many patients with cataract were sufficiently able that they had no difficulty with many activities. Items were eliminated if the task was too easy or did not fit with the overall concept of visual disability determined by the Rasch model. A reduced ADVS version was established that had adequate precision, equivalent criterion validity, and improved targeting of item difficulty to patient ability, but this version was still not ideal. Despite careful traditional validation, the ADVS data contained inadequacies exposed by Rasch analysis. Through Rasch scaling, particularly with response scale reduction, the ADVS can be improved, but additional questions seem to be needed to suit the more able, including patients undergoing second eye cataract surgery. There remains a need to develop Rasch-scaled measures of visual disability for use in ophthalmic outcomes research.

Ocular complications and visual outcome in juvenile chronic arthritis: a 25-year follow-up study.

Assessment of longterm ophthalmic outcome in juvenile chronic arthritis (JCA) with emphasis on visual acuity and identification of disease-related parameters associated with rheumatic eye affection. Sixty-five adults (52 females, 13 males) with a history of or still active JCA were assessed an average of 26.7 years after disease onset. Cross-sectional, longterm, follow-up study including complete ophthalmological and rheumatological examinations. Evidence of ocular complications was found in 13 subjects (20%): 10 had had recurrent iritis, two band keratopathy, and one diplopia due to rheumatoid eye muscle involvement. The three single eyes with poor sight (<0.1) were all in the complication subgroup. Binocularly, all but one patient scored at least 6/9 as best corrected visual acuity; one, however, had severe glaucoma-impaired visual fields. The refractive range was -8.12 to +6.0 D. There were no cases of keratoconjunctivitis sicca. Iritis was associated with early disease onset (p = 0.02), longer disease duration (p = 0.02) and a positive antinuclear antibodies (ANA) (p = 0.02). Ophthalmic complications were recorded in 20% of the study group, primarily in ANA positive patients with pauciarticular onset JCA. In addition to the two patients with severely affected bilateral visual status (3%), one of the 65 patients had acquired unilateral blindness. Half of the complications were late in that they were first recorded after the age of 16 years. Otherwise, the findings were in keeping with other studies of visual prognosis using non-selected series.

Ophthalmic outcomes after prenatal and postnatal treatment of congenital toxoplasmosis

Purpose To describe the ophthalmologic outcomes of cases of congenital toxoplasmosis treated prenatally and postnatally. Design Observational case series. Methods Follow-up ophthalmologic examinations of 18 children born to mothers who were infected before 25 weeks gestation were performed concurrently by two ophthalmologists. The infection in these children was first suspected when their mothers seroconverted during gestation. Toxoplasmic infection of the fetus was diagnosed by fetal blood or amniotic fluid analysis. Mothers were treated by a regimen of alternating pyrimethamine-sulfonamides and spiramycin during gestation. Pyrimethamine-sulfonamides treatment was continued from birth to 1 year of age. Results The median age of the children was 4.5 years (range 1–11), when the follow-up ophthalmologic examinations were performed. Visual acuity was decreased in only one child, who had extensive bilateral macular and peripheral lesions. A posterior pole scar was noted in four eyes (four children) for whom visual acuity remained normal. Peripheral lesions were observed in nine eyes (five children). Both eyes were normal in 11 of 18 (61%) of the children. Conclusions In these children at a high risk for congenital toxoplasmic retinochoroiditis, a favorable visual outcome was observed in all but one case.

Long-term ophthalmic outcome of low birth weight children with and without retinopathy of prematurity

Long-term ophthalmic outcome of low birth weight children with and without retinopathy of prematurity