Severe Visual Acuity Research Articles

Improved Visual Acuity after Frontalis Sling Surgery for Simple Congenital Ptosis

Congenital ptosis is malpositioning of the eyelids that, when moderate or severe, can negatively affect visual development during its critical period, resulting in amblyopia: diminished visual acuity with no apparent organic cause. Early diagnosis and timely treatment are essential for preventing amblyopia. Congenital ptosis is uncommon but poses a challenge to any ophthalmologist; the only treatment is surgical. Among these patients in Cuba, those with the most complex clinical characteristics are generally referred to the Ramón Pando Ferrer Ophthalmology Institute in Havana. Characterize visual acuity outcomes obtained in patients seen at this Institute who received surgery for simple congenital ptosis using the frontalis sling procedure. A descriptive prospective longitudinal study was conducted to describe visual acuity outcomes in 11 patients with a diagnosis of isolated congenital ptosis seen in the Oculoplastic Service of the Ramón Pando Ferrer Ophthalmology Institute between January and July 2009 and operated on using the frontalis sling procedure. The majority exhibited severe visual acuity impairment (0.1-0.5) prior to surgery. Variables employed were age, sex, degree of ptosis, degree of ptosis correction, visual acuity, and complications during surgery and postoperatively. Male patients aged 1-4 years predominated. Visual acuity improved in 100% of patients, to varying degrees. Prior to surgery, 72% had visual acuity of 0.1-0.5. Six months post-surgery, with visual rehabilitation, 90.9% exhibited visual acuity of >0.5. In 81.8% of patients, palpebral ptosis was fully corrected. Complications were minimal: injury to the palpebral tarsus and undercorrection were the most common and did not affect final surgical outcome or interfere with rehabilitation. Correction of congenital ptosis using the frontalis sling technique yielded satisfactory visual acuity outcomes, contributing to visual rehabilitation of the affected patients.

Ranibizumab Treatment for Choroidal Neovascularization from Causes Other than Age-Related Macular Degeneration and Pathological Myopia

Aim: Evaluation of safety and efficacy of intravitreal ranibizumab in the treatment of choroidal neovascularization (CNV) secondary to causes other than age-related macular degeneration (AMD) or pathological myopia (PM). Methods: Retrospective and multicentric analysis of 21 eyes with CNV. Nine eyes had angioid streaks, 5 inflammatory chorioretinal diseases, 3 central serous chorioretinopathy and 4 idiopathic CNV. Follow-ups lasted ≧3 months. Best-corrected visual acuity (BCVA), ocular coherence tomography (OCT) and fundus examination were assessed monthly. Results: Sixteen eyes (76%) completed 180 days of follow-up. Overall BCVA increased by +9.8 letters with treatment (p = 0.015). Visual acuity improvements ≧15 letters occurred in 43%. A significant reduction in OCT central thickness was observed. No cases of severe visual acuity loss, systemic or ocular side effects were registered. Conclusion: Short-term results of intravitreal ranibizumab for CNV unrelated to AMD or PM are encouraging. This treatment may constitute the only option for some of these patients.

Paranasal sinus mucoceles with visual disturbance

Objective Paranasal sinus mucoceles may cause visual disturbance in patients because of their close proximity to the orbit. We aimed to investigate visual prognosis to determine whether it is influenced by the interval before surgery and the severity of visual disturbance, and to heighten the physician's awareness of the occurrence of this disease. Methods We retrospectively reviewed eight surgically treated patients with paranasal sinus mucoceles accompanied by visual disturbances between March 2005 and January 2009, and examined the visual acuity outcome of the patients. Results Four patients with a mild visual acuity loss showed improvement after surgical drainage within 1 month after onset. Two patients with visual disturbances persisting for more than 1 year did not show postoperative improvements. Although two patient's preoperative visual acuity loss was worse than the ability to count fingers, they showed a remarkable improvement after surgery. Conclusions These results show the importance of diagnosing and treating paranasal sinus mucoceles with visual disturbance as soon as possible. In addition, the improvement of visual acuity can be expected if surgery is performed within 1 month after onset, and the patient's preoperative visual acuity loss is mild. However, if patients with severe visual acuity loss consult otolaryngologists at a later date, surgery may still be considered worthwhile.

Vision-related quality-of-life in children with albinism from 0 to 10 years of age

Introduction: Individuals with albinism show mild to severe visual acuity (VA) deficits from an early age. Compromised visual functioning beyond the VA deficit results from poor foveal development, cortical changes, nystagmus and photosensitivity. Because these effects on functioning are difficult to assess in children, we evaluated vision-related quality-of-life (VR-QOL).

Ophthalmological findings in children and young adults with genetically verified mitochondrial disease

Aim:To describe ophthalmological phenotypes in patients with mitochondrial disease and known genotypes.Methods:A retrospective study was performed on 59 patients (29 male, 30 female) with a mean age of 11.8 years...

Diabetic macular oedema and visual loss: relationship to location, severity and duration

To assess the relationship between visual acuity (VA) and diabetic macular oedema (DMO) in relation to the location of retinal thickening and the severity and duration of central macular thickening. Data from 584 eyes in 340 placebo-treated patients in the 3-years-long Protein Kinase C Diabetic Retinopathy Study (PKC-DRS2) trial were used to investigate the relationship between VA and DMO. Eligible eyes had moderately severe to very severe non-proliferative diabetic retinopathy and VA of at least 45 letters on Early Treatment Diabetic Retinopathy Study (ETDRS) charts (Snellen equivalent = 20/125). Diabetic retinopathy and DMO status were assessed using stereo photographs. Nearly one third of study eyes had foveal centre-involving DMO at the start of the trial. Sustained moderate visual loss was found in 36 eyes, most commonly associated with DMO at the centre of the fovea in 73% of eyes. There was a strong relationship (p < 0.001) between foveal centre involvement with DMO and mean VA. Mean VA decreased with increasing retinal thickness at the centre (p < 0.001) and increasing duration of centre-involving DMO (p < 0.001). This study documents the relationship between duration of DMO and progressive vision loss, and the key role of central foveal involvement in patients with diabetic retinopathy. These data will help to develop future strategies to prevent vision loss.

Verteporfin PDT for subfoveal occult CNV in AMD: two-year results of a randomized trial

ABSTRACTObjective: To determine whether verteporfin photodynamic therapy (PDT) can safely reduce the risk of vision loss in patients with subfoveal occult with no classic choroidal neovascularization (CNV) due to age-related macular degeneration.Research design and methods: Eligible patients were ≥50 years of age with lesion size ≤6 disc areas and best-corrected vision 20/40–20/200. A total of 364 patients with occult with no classic CNV were randomly assigned 2 : 1 to verteporfin PDT (n = 244) or placebo (n = 120). The primary outcome measures were loss of ≥15 and ≥30 letters of visual acuity (VA) from baseline at 12 and 24 months.Results: A total of 37% and 47% of verteporfin-treated patients versus 45% and 53% of placebo recipients lost ≥15 letters of VA at month 12 and month 24, respectively; 16% and 23% of verteporfin-treated patients versus 17% and 25% of placebo recipients lost ≥30 letters at month 12 and month 24, respectively. These differences were not statistically significant. Four (1.6%) verteporfin-treated patients and one placebo patient (who received verteporfin in error) experienced an acute severe VA decrease; all five patients recovered some degree of vision. No unexpected ocular or systemic adverse events were identified.Conclusions: Verteporfin PDT in the treatment of occult with no classic CNV was safe and well-tolerated. The differences between the two groups in the primary efficacy variables were not significant. Baseline characteristics and patient selection methods may have contributed to the small treatment effect.Trial registration: ClinicalTrials.gov identifier: NCT00121407.

Evaluation of patient suitability for a retinal prosthesis using structural and functional tests of inner retinal integrity

The purpose of this study was to assess inner retinal structure and function in patients with retinitis pigmentosa (RP) using optical coherence tomography (OCT) imaging of the retina, and electrical stimulation of the retina with a contact lens electrode. OCT images of 17 RP patients were acquired at the macula and at four quadrants of the peripheral retina in both eyes. Analysis was made of the residual inner retinal thickness and nerve fibre layer thickness in RP patients, and this was compared to normal controls. Eight of these patients further underwent contact lens electrical stimulation of one eye and thresholds for phosphene perception were obtained. OCT imaging showed a significant amount of inner retinal preservation in the peripheral retina and the macula of RP patients despite severe visual acuity and visual field loss. Phosphene thresholds were obtained across the range of pulse durations tested but were much higher than those obtained in normal controls. Phosphene thresholds in RP patients moderately correlated with inner retinal thicknesses as measured by OCT. Preservation of inner retinal structure in patients with RP and the responsiveness of these eyes to electrical stimulation suggest adequate inner retinal preservation for a retinal prosthesis to be successful.

Late Onset Optic Neuropathy in Methylmalonic and Propionic Acidemia

To describe 3 cases of late-onset bilateral optic neuropathy with visual dysfunction in patients with organic acidemia. Retrospective case series. A total of 3 subjects, a 16-year-old male with methylmalonic acidemia (MMA), a 21-year-old male with MMA, and a 20-year-old female with propionic acidemia (PA), are included in this series. Comparison of the patients' clinical course, ophthalmologic exam, and testing are discussed. The outcome measures include visual acuity (VA), fundus appearance, visual fields, brain imaging, and genetic testing. All 3 subjects had late-onset severe bilateral VA loss with bilateral optic nerve pallor, central or cecocentral scotomas on visual field testing, and negative diagnostic workups for other causes of bilateral optic neuropathy. Patients with organic acidemia may develop late-onset bilateral optic neuropathy with visual dysfunction despite lifelong propiogenic amino acid restriction and dietary supplementation.

Disparities in awareness and use of low-vision rehabilitation

Objective: To describe the demographic, visual, health, and psychological variables associated with awareness and use of low-vision rehabilitation services in Montreal, Que. Study Design: Hospital-based cross-sectional study. Participants: Four hundred forty-eight patients with best-corrected visual acuity worse than 20/70 in their better eye recruited from 4 ophthalmology departments. Methods: Patients answered questions about their awareness and use of low-vision services. Visual acuity was recorded and patients answered the Brief Cope and Center for Epidemiologic Studies - Depression Scale questionnaires and provided information on demographics and health status. Multiple logistic regression was used to identify independent predictors of awareness and use of low-vision rehabilitation services. Results: A majority of patients in the sample (71%) were aware of low-vision rehabilitation. Of those who were aware, 81% reported participating in low-vision rehabilitation. Black patients, those whose first language was French, those with less severe visual acuity loss, and those who reported less acceptance on the Brief Cope questionnaire were less likely to know about low-vision services ( p < 0.05). Of those who knew about low-vision services, those with less severe visual acuity loss were less likely to have participated in low-vision services ( p < 0.05). Conclusions: It is important that all those who qualify for low-vision rehabilitation services can access them. Although the patients in this Montreal area study showed a high rate of awareness and use of low-vision rehabilitation, awareness and use could be improved in certain demographic populations and in those with less severe vision loss.

SHORT-TERM EFFICACY AND SAFETY OF INTRAVITREAL RANIBIZUMAB FOR MYOPIC CHOROIDAL NEOVASCULARIZATION

To evaluate the safety and efficacy of intravitreal ranibizumab in the treatment of choroidal neovascularization (CNV) secondary to pathologic myopia (PM). Retrospective, multicenter, consecutive, nonrandomized, interventional case series. Twenty-six eyes of 26 patients with CNV secondary to pathologic myopia; 11 eyes with previous photodynamic therapy; and 15 eyes with no previous treatment. 3 or more months. Best-corrected visual acuity (BCVA), ocular coherence tomography, and the presence of metamorphopsia were assessed monthly. At 1 month, 31% of the eyes had an improvement in visual acuity of 3 or more lines. Twenty-six eyes completed 3 months of follow-up, and nine eyes completed 6 months of follow-up. Visual acuity improved significantly from 20/100 at baseline to 20/80 at 1 month (P = 0.003) to 20/63 at 3 months (P < 0.001), and 20/50 at 6 months (P = 0.01). A significant reduction in ocular coherence tomography central thickness was observed at 1, 3, and 6 months. No cases of severe visual acuity loss occurred, and no systemic or ocular side effects were registered during the follow-up. Short-term results of intravitreal ranibizumab for myopic CNV are encouraging. Further prospective long-term studies are necessary to evaluate safety and efficacy of intravitreal ranibizumab in the treatment of myopic CNV.

Verteporfin therapy in occult with no classic CNV due to AMD: results of the Photodynamic Therapy in Occult-Only Lesions study

To provide further information on verteporfin photodynamic therapy in occult with no classic choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). Verteporfin therapy was administered at baseline and then at months 3, 6, and 9, if fluorescein leakage from CNV was evident on angiography. Of 202 patients enrolled, 184 completed 12 months. Each patient was treated in one eye only. All study eyes received verteporfin therapy at baseline, with a progressive decrease in the number treated at subsequent visits (mean 2.5 treatments during 12 months). The mean change in visual acuity letter score from baseline to month 12 was -11.9. At month 12, 164 eyes (82.4%) had lost <30 letters of visual acuity, 123 eyes (61.8%) had lost <15 letters, 78 eyes (39.2%) had lost <5 letters, 31 (15.6%) had >5-letter increase, and 7 (3.5%) had >15-letter improvement. The percentage of eyes with fluorescein leakage from CNV decreased from 75.5% at month 3 to 25.1% at month 12. Adverse events were documented for 54% patients. Few patients had treatment-associated adverse events (7%). Acute severe visual acuity decrease occurred in two eyes (1%), one of which had visual acuity that returned to baseline by the next follow-up visit. This study provides additional evidence that over 12 months, verteporfin is generally well tolerated and maintains or improves visual acuity in over one-third of eyes containing occult-only CNV. Verteporfin also improved anatomical outcomes by reducing leakage from CNV in at least two-thirds of eyes.

Severe Bilateral Hypertensive Retinopathy and Optic Neuropathy in a Patient with Pheochromocytoma

We present a case of severe bilateral hypertensive retinopathy and optic neuropathy due to pheochromocytoma. A 31-year-old woman presented with severe bilateral visual acuity loss associated with headaches and photophobia. Ophthalmoscopy showed bilateral optic disc edema, soft exudates, macular star, flame-shaped hemorrhages and arterial narrowing. The situation was more severe in the right eye. Fluorescein angiography confirmed the diagnosis of hypertensive retinopathy. Arterial blood pressure was 220/145 mmHg. A thorough systemic control revealed a right adrenal gland mass. Catecholamine secretion was normal. After ablation, the tumor proved to be a pheochromocytoma, and immunohistochemistry showed dopamine secretion. Postoperative evolution was uncomplicated. Antihypertensive treatment lasted only a few months. Visual acuity was restored and the retinal alterations disappeared 8 months after surgery. Severe hypertensive retinopathy with optic neuropathy may be a consequence of malignant hypertension due to a pheochromocytoma. It is reversible after ablation of the tumor. Early diagnosis is of vital importance and relies on hormonal investigation and immunohistochemistry.

Loss of vision associated with angioid streaks in β-thalassemia intermedia

An acquired diffuse elastic tissue defect that resembles inherited pseudoxanthoma elasticum (PXE) has been noticed with a significant age-related frequency in hemoglobin disorders, especially beta-thalassemia and has been held responsible for a number of complications observed in these cases, some of which are quite severe. We report here two patients with beta-thalassemia intermedia, who presented with severe visual acuity impairment associated with angioid streaks, the typical ocular manifestation of PXE.

Central retinal artery occlusion associated with traumatic carotid cavernous fistula: case report

Carotid cavernous fistulas are a rare entity occurring as result of head trauma and also spontaneously. The authors report a rare case of central retinal artery occlusion complicating traumatic carotid-cavernous fistula, resulting in severe visual acuity loss. Spontaneous closure of the fistula was observed. The possible mechanisms responsible for this complication are discussed.

Photodynamic therapy for neovascular age-related macular degeneration

In neovascular age-related macular degeneration (AMD) new vessels grow under the retina distorting vision and leading to scarring. This is exacerbated if the blood vessels leak. Photodynamic therapy (PDT) has been investigated as a way to treat the neovascular membranes without affecting the retina. The aim of this review was to examine the effects of PDT in the treatment of neovascular AMD. We searched CENTRAL (Issue 1, 2007), MEDLINE (1966 to March 2007), EMBASE (1980 to March 2007). We contacted experts in the field and searched the reference lists of relevant studies. We included randomised trials of PDT in people with choroidal neovascularisation due to AMD. Two authors independently extracted the data. Risk ratios were combined using a fixed-effect model after testing for heterogeneity. Three published trials were identified that randomised 1022 participants to verteporfin therapy compared to 5% dextrose in water. The TAP and VIP trials were performed by the same investigators using largely the same clinical centres and funded by manufacturers of verteporfin. Outcome data were available at 12 and 24 months after the first treatment. Participants received on average five treatments over two years. The risk ratio of losing three or more lines of visual acuity at 24 months comparing the intervention with the control group was 0.77 (95% confidence interval 0.69 to 0.87). The risk ratio of losing six or more lines of visual acuity at 24 months comparing the intervention with the control group was 0.62 (95% confidence interval 0.50 to 0.76). The results at 12 months were similar to those at 24 months. The most serious adverse outcome, acute (within seven days of treatment) severe visual acuity decrease, occurs in about one in 50 patients. Some outcomes from the more recent VIM trial could be included in the meta-analysis but have not greatly altered the findings. Photodynamic therapy in people with choroidal neovascularisation due to AMD is probably effective in preventing visual loss though there is doubt about the size of the effect. Outcomes and potential adverse effects of this treatment should be monitored closely. Further independent trials of verteporfin are required to establish that the effects seen in this study are consistent and to examine important issues not yet addressed, particularly relating to quality of life and cost. However, the advent of new interventions for AMD make this unlikely.

Mild visual acuity disturbances are associated with performance on tests of complex visual attention in MS

Because MS patients frequently report visual acuity disturbances, neuropsychologists often screen patients for severe visual acuity disturbances and tailor test batteries that minimize the need for intact vision. Less is known about how mild visual acuity disturbances may influence neuropsychological test performance. This study examined the extent to which mild visual acuity disturbances influence performance on visually-based tests of complex attention. Relapsing-remitting and secondary progressive MS patients who reported adequate vision were recruited for this study. A battery was administered that included the oral version of the Symbol Digit Modalities Test (SDMT), the Visual Elevator (VE) subtest from the Test of Everyday Attention, and a reduced near vision eye chart. Results suggested that, in addition to measuring higher order cognitive processes, visual tests of attention are sensitive to mild primary visual disturbances in MS.

OCT-3 Study of Serous Retinal Detachment in a Preeclamptic Patient

We report optical coherence tomography-3 (OCT-3) of retinal disorders in acute preeclampsia. A 33-year-old woman developed mind hypertension (170/90 mm Hg) and proteinuria in the 28th week of pregnancy. The patient complained of sudden and severe visual acuity decrease. Fundus exam showed bilateral serous retinal detachment at the macula area. OCT-3 exam demonstrated subretinal and intraretinal fluid. Bilateral serous retinal detachment is an unusual finding of preeclampsia of unknown aetiology. Intense arteriolar vasospasm has been implicated in the pathogenesis of the serous retinal detachment. OCT-3 showed the presence of both subretinal and intraretinal fluid during the acute phase of preeclampsia.

An Extension of the Early Treatment Diabetic Retinopathy Study (ETDRS) System for Grading of Diabetic Macular Edema in the Astemizole Retinopathy Trial

Purpose: To compare the effects of astemizole, an antihistamine, versus placebo on the 1-year course of diabetic macular edema (DME) and to illustrate use of a modified ETDRS system for grading areas of retinal thickening and hard exudates that may be useful in clinical trials of treatments for this disorder. Methods: Between June 1994 and September 1997, at 2 clinics, 63 patients who had, in at least one eye (the study eye), DME that had not previously been treated with macular photocoagulation, and for which photocoagulation was not currently recommended by the investigator, were enrolled and randomly assigned to astemizole or placebo. Fifty-four of the 63 patients (86%, 26 in Clinic 1 and 28 in Clinic 2) completed 1 year of followup and had adequate 7-field stereoscopic film-based color fundus photographs of the study eye at the baseline and 1-year visits. DME was > 0.33 disc diameters (DD) from the center of the macula in 48% of study eyes and involved the center in 13%. Photographs were graded using the ETDRS protocol modified to allow estimates of areas of retinal thickening (RT) and hard exudate (HE) to be made on continuous scales in disc area (DA) units. Principal outcome measures were mean change in the square root of RT area (the average diameter of the area in DD), mean change in area of HE, and change in the degree to which RT involved or threatened the center of the macula. Results: At baseline, RT area in the 54 study eyes ranged from 0.09 to 4.0 DA (median 1.1). At the 1-year visit the square root of RT area (RTdd) had decreased by ≥ 0.3 DD in 10 eyes, increased by ≥ 0.3 DD in 19 and was about the same in 25. Mean change at 1 year was +0.09 DD (SD 0.57) for astemizole versus +0.19 DD (SD 0.48) for placebo, for a difference of −0.10 DD (95% CI −0.38, +0.19; p = 0.51). Adjustments for baseline and time-dependent risk factors did not change this result appreciably, although there was a trend towards a difference in favor of astemizole in the subgroup of patients with more severe retinopathy. Other morphologic outcomes paralleled change in RTdd. Change in RTdd did vary by clinic: −0.03 DD in Clinic 2, versus + 0.32 DD in Clinic 1, for a difference of −0.35 DD (95% CI −0.62, −0.07; p = 0.014). Clinic 1 is a tertiary retinal referral center in Pennsylvania and Clinic 2 a retinal clinic closely affiliated with a large diabetes clinic in Copenhagen. The unexpected clinic difference in outcome provided an opportunity for further analyses using the modified ETDRS system. In comparison to Clinic 1, Clinic 2 patients were more often male, were younger at diagnosis of diabetes, and had less severe retinopathy and better visual acuity, but these differences did not appear to explain the trend for lesser increase in RTdd. Conclusion: No effect of astemizole was found, but the confidence interval for the principal outcome, mean change in RTdd, included both a modest beneficial effect and a small harmful effect. This outcome measure did demonstrate a small difference in outcome by clinic, which could not be explained by baseline characteristics but may reflect differences in access to and/or continuity of care or other unmeasured differences associated with different referral patterns. Although optical coherence tomography may supplant photography as a measure of central RT, photographic assessments of change in RT and HE areas analyzed with the methods described herein may be useful outcomes in trials assessing treatment of early stages of DME. Application of these methods to other data sets is needed to confirm this conclusion.

NEOVASCULAR AGE-RELATED MACULAR DEGENERATION

This review summarizes the data reported in peer-reviewed literature and presents current knowledge on differentiation, natural history, and therapeutic outcomes of neovascular age-related macular degeneration (AMD). The MEDLINE database was searched to review natural history of neovascular AMD and therapeutic effects of available treatments. The search produced>7,000 articles. Research suggests that fluorescein angiographic characterization of location, composition, and size of neovascular lesions may be important in prognosis and should be considered for evaluation of treatment benefits in conjunction with evidence of recent disease progression for lesions not composed of predominantly classic choroidal neovascularization (CNV). Laser photocoagulation, photodynamic therapy with verteporfin, and administration of pegaptanib sodium reduce the risk of vision loss in selected cases of neovascular AMD, while submacular surgery can reduce the risk of severe visual acuity loss in selected cases of predominantly hemorrhagic CNV; further approaches are under investigation. Visual prognosis of neovascular AMD is variable according to lesion location, composition, and size. Often, lesions have a poor prognosis, resulting in rapid and progressive loss of visual acuity and contrast sensitivity. Such losses have a profound effect on patients' quality of life and ability to perform everyday tasks. Reducing the risk of further loss of visual acuity and contrast sensitivity might enable patients with neovascular AMD to maintain better functional abilities.