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Publisher: Elsevier   (Total: 3184 journals)

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Showing 1 - 200 of 3184 Journals sorted alphabetically
Academic Pediatrics     Hybrid Journal   (Followers: 37, SJR: 1.655, CiteScore: 2)
Academic Radiology     Hybrid Journal   (Followers: 26, SJR: 1.015, CiteScore: 2)
Accident Analysis & Prevention     Partially Free   (Followers: 100, SJR: 1.462, CiteScore: 3)
Accounting Forum     Hybrid Journal   (Followers: 28, SJR: 0.932, CiteScore: 2)
Accounting, Organizations and Society     Hybrid Journal   (Followers: 40, SJR: 1.771, CiteScore: 3)
Achievements in the Life Sciences     Open Access   (Followers: 6)
Acta Anaesthesiologica Taiwanica     Open Access   (Followers: 7)
Acta Astronautica     Hybrid Journal   (Followers: 435, SJR: 0.758, CiteScore: 2)
Acta Automatica Sinica     Full-text available via subscription   (Followers: 2)
Acta Biomaterialia     Hybrid Journal   (Followers: 28, SJR: 1.967, CiteScore: 7)
Acta Colombiana de Cuidado Intensivo     Full-text available via subscription   (Followers: 3)
Acta de Investigación Psicológica     Open Access   (Followers: 3)
Acta Ecologica Sinica     Open Access   (Followers: 11, SJR: 0.18, CiteScore: 1)
Acta Histochemica     Hybrid Journal   (Followers: 3, SJR: 0.661, CiteScore: 2)
Acta Materialia     Hybrid Journal   (Followers: 309, SJR: 3.263, CiteScore: 6)
Acta Mathematica Scientia     Full-text available via subscription   (Followers: 5, SJR: 0.504, CiteScore: 1)
Acta Mechanica Solida Sinica     Full-text available via subscription   (Followers: 9, SJR: 0.542, CiteScore: 1)
Acta Oecologica     Hybrid Journal   (Followers: 12, SJR: 0.834, CiteScore: 2)
Acta Otorrinolaringologica (English Edition)     Full-text available via subscription  
Acta Otorrinolaringológica Española     Full-text available via subscription   (Followers: 2, SJR: 0.307, CiteScore: 0)
Acta Pharmaceutica Sinica B     Open Access   (Followers: 1, SJR: 1.793, CiteScore: 6)
Acta Poética     Open Access   (Followers: 4, SJR: 0.101, CiteScore: 0)
Acta Psychologica     Hybrid Journal   (Followers: 25, SJR: 1.331, CiteScore: 2)
Acta Sociológica     Open Access   (Followers: 1)
Acta Tropica     Hybrid Journal   (Followers: 6, SJR: 1.052, CiteScore: 2)
Acta Urológica Portuguesa     Open Access  
Actas Dermo-Sifiliograficas     Full-text available via subscription   (Followers: 3, SJR: 0.374, CiteScore: 1)
Actas Dermo-Sifiliográficas (English Edition)     Full-text available via subscription   (Followers: 2)
Actas Urológicas Españolas     Full-text available via subscription   (Followers: 3, SJR: 0.344, CiteScore: 1)
Actas Urológicas Españolas (English Edition)     Full-text available via subscription   (Followers: 1)
Actualites Pharmaceutiques     Full-text available via subscription   (Followers: 7, SJR: 0.19, CiteScore: 0)
Actualites Pharmaceutiques Hospitalieres     Full-text available via subscription   (Followers: 3)
Acupuncture and Related Therapies     Hybrid Journal   (Followers: 8)
Acute Pain     Full-text available via subscription   (Followers: 15, SJR: 2.671, CiteScore: 5)
Ad Hoc Networks     Hybrid Journal   (Followers: 11, SJR: 0.53, CiteScore: 4)
Addictive Behaviors     Hybrid Journal   (Followers: 18, SJR: 1.29, CiteScore: 3)
Addictive Behaviors Reports     Open Access   (Followers: 9, SJR: 0.755, CiteScore: 2)
Additive Manufacturing     Hybrid Journal   (Followers: 11, SJR: 2.611, CiteScore: 8)
Additives for Polymers     Full-text available via subscription   (Followers: 23)
Advanced Drug Delivery Reviews     Hybrid Journal   (Followers: 184, SJR: 4.09, CiteScore: 13)
Advanced Engineering Informatics     Hybrid Journal   (Followers: 12, SJR: 1.167, CiteScore: 4)
Advanced Powder Technology     Hybrid Journal   (Followers: 17, SJR: 0.694, CiteScore: 3)
Advances in Accounting     Hybrid Journal   (Followers: 9, SJR: 0.277, CiteScore: 1)
Advances in Agronomy     Full-text available via subscription   (Followers: 17, SJR: 2.384, CiteScore: 5)
Advances in Anesthesia     Full-text available via subscription   (Followers: 29, SJR: 0.126, CiteScore: 0)
Advances in Antiviral Drug Design     Full-text available via subscription   (Followers: 2)
Advances in Applied Mathematics     Full-text available via subscription   (Followers: 11, SJR: 0.992, CiteScore: 1)
Advances in Applied Mechanics     Full-text available via subscription   (Followers: 11, SJR: 1.551, CiteScore: 4)
Advances in Applied Microbiology     Full-text available via subscription   (Followers: 24, SJR: 2.089, CiteScore: 5)
Advances In Atomic, Molecular, and Optical Physics     Full-text available via subscription   (Followers: 15, SJR: 0.572, CiteScore: 2)
Advances in Biological Regulation     Hybrid Journal   (Followers: 4, SJR: 2.61, CiteScore: 7)
Advances in Botanical Research     Full-text available via subscription   (Followers: 2, SJR: 0.686, CiteScore: 2)
Advances in Cancer Research     Full-text available via subscription   (Followers: 33, SJR: 3.043, CiteScore: 6)
Advances in Carbohydrate Chemistry and Biochemistry     Full-text available via subscription   (Followers: 9, SJR: 1.453, CiteScore: 2)
Advances in Catalysis     Full-text available via subscription   (Followers: 5, SJR: 1.992, CiteScore: 5)
Advances in Cell Aging and Gerontology     Full-text available via subscription   (Followers: 5)
Advances in Cellular and Molecular Biology of Membranes and Organelles     Full-text available via subscription   (Followers: 14)
Advances in Chemical Engineering     Full-text available via subscription   (Followers: 29, SJR: 0.156, CiteScore: 1)
Advances in Child Development and Behavior     Full-text available via subscription   (Followers: 10, SJR: 0.713, CiteScore: 1)
Advances in Chronic Kidney Disease     Full-text available via subscription   (Followers: 10, SJR: 1.316, CiteScore: 2)
Advances in Clinical Chemistry     Full-text available via subscription   (Followers: 26, SJR: 1.562, CiteScore: 3)
Advances in Colloid and Interface Science     Full-text available via subscription   (Followers: 20, SJR: 1.977, CiteScore: 8)
Advances in Computers     Full-text available via subscription   (Followers: 14, SJR: 0.205, CiteScore: 1)
Advances in Dermatology     Full-text available via subscription   (Followers: 15)
Advances in Developmental Biology     Full-text available via subscription   (Followers: 13)
Advances in Digestive Medicine     Open Access   (Followers: 12)
Advances in DNA Sequence-Specific Agents     Full-text available via subscription   (Followers: 7)
Advances in Drug Research     Full-text available via subscription   (Followers: 26)
Advances in Ecological Research     Full-text available via subscription   (Followers: 44, SJR: 2.524, CiteScore: 4)
Advances in Engineering Software     Hybrid Journal   (Followers: 29, SJR: 1.159, CiteScore: 4)
Advances in Experimental Biology     Full-text available via subscription   (Followers: 8)
Advances in Experimental Social Psychology     Full-text available via subscription   (Followers: 51, SJR: 5.39, CiteScore: 8)
Advances in Exploration Geophysics     Full-text available via subscription   (Followers: 1)
Advances in Fluorine Science     Full-text available via subscription   (Followers: 9)
Advances in Food and Nutrition Research     Full-text available via subscription   (Followers: 65, SJR: 0.591, CiteScore: 2)
Advances in Fuel Cells     Full-text available via subscription   (Followers: 17)
Advances in Genetics     Full-text available via subscription   (Followers: 21, SJR: 1.354, CiteScore: 4)
Advances in Genome Biology     Full-text available via subscription   (Followers: 10, SJR: 12.74, CiteScore: 13)
Advances in Geophysics     Full-text available via subscription   (Followers: 7, SJR: 1.193, CiteScore: 3)
Advances in Heat Transfer     Full-text available via subscription   (Followers: 26, SJR: 0.368, CiteScore: 1)
Advances in Heterocyclic Chemistry     Full-text available via subscription   (Followers: 11, SJR: 0.749, CiteScore: 3)
Advances in Human Factors/Ergonomics     Full-text available via subscription   (Followers: 24)
Advances in Imaging and Electron Physics     Full-text available via subscription   (Followers: 3, SJR: 0.193, CiteScore: 0)
Advances in Immunology     Full-text available via subscription   (Followers: 36, SJR: 4.433, CiteScore: 6)
Advances in Inorganic Chemistry     Full-text available via subscription   (Followers: 10, SJR: 1.163, CiteScore: 2)
Advances in Insect Physiology     Full-text available via subscription   (Followers: 2, SJR: 1.938, CiteScore: 3)
Advances in Integrative Medicine     Hybrid Journal   (Followers: 6, SJR: 0.176, CiteScore: 0)
Advances in Intl. Accounting     Full-text available via subscription   (Followers: 3)
Advances in Life Course Research     Hybrid Journal   (Followers: 9, SJR: 0.682, CiteScore: 2)
Advances in Lipobiology     Full-text available via subscription   (Followers: 1)
Advances in Magnetic and Optical Resonance     Full-text available via subscription   (Followers: 8)
Advances in Marine Biology     Full-text available via subscription   (Followers: 21, SJR: 0.88, CiteScore: 2)
Advances in Mathematics     Full-text available via subscription   (Followers: 12, SJR: 3.027, CiteScore: 2)
Advances in Medical Sciences     Hybrid Journal   (Followers: 8, SJR: 0.694, CiteScore: 2)
Advances in Medicinal Chemistry     Full-text available via subscription   (Followers: 6)
Advances in Microbial Physiology     Full-text available via subscription   (Followers: 5, SJR: 1.158, CiteScore: 3)
Advances in Molecular and Cell Biology     Full-text available via subscription   (Followers: 24)
Advances in Molecular and Cellular Endocrinology     Full-text available via subscription   (Followers: 8)
Advances in Molecular Toxicology     Full-text available via subscription   (Followers: 7, SJR: 0.182, CiteScore: 0)
Advances in Nanoporous Materials     Full-text available via subscription   (Followers: 5)
Advances in Oncobiology     Full-text available via subscription   (Followers: 2)
Advances in Organ Biology     Full-text available via subscription   (Followers: 2)
Advances in Organometallic Chemistry     Full-text available via subscription   (Followers: 18, SJR: 1.875, CiteScore: 4)
Advances in Parallel Computing     Full-text available via subscription   (Followers: 7, SJR: 0.174, CiteScore: 0)
Advances in Parasitology     Full-text available via subscription   (Followers: 5, SJR: 1.579, CiteScore: 4)
Advances in Pediatrics     Full-text available via subscription   (Followers: 27, SJR: 0.461, CiteScore: 1)
Advances in Pharmaceutical Sciences     Full-text available via subscription   (Followers: 18)
Advances in Pharmacology     Full-text available via subscription   (Followers: 17, SJR: 1.536, CiteScore: 3)
Advances in Physical Organic Chemistry     Full-text available via subscription   (Followers: 9, SJR: 0.574, CiteScore: 1)
Advances in Phytomedicine     Full-text available via subscription  
Advances in Planar Lipid Bilayers and Liposomes     Full-text available via subscription   (Followers: 3, SJR: 0.109, CiteScore: 1)
Advances in Plant Biochemistry and Molecular Biology     Full-text available via subscription   (Followers: 10)
Advances in Plant Pathology     Full-text available via subscription   (Followers: 6)
Advances in Porous Media     Full-text available via subscription   (Followers: 5)
Advances in Protein Chemistry     Full-text available via subscription   (Followers: 19)
Advances in Protein Chemistry and Structural Biology     Full-text available via subscription   (Followers: 20, SJR: 0.791, CiteScore: 2)
Advances in Psychology     Full-text available via subscription   (Followers: 66)
Advances in Quantum Chemistry     Full-text available via subscription   (Followers: 6, SJR: 0.371, CiteScore: 1)
Advances in Radiation Oncology     Open Access   (Followers: 1, SJR: 0.263, CiteScore: 1)
Advances in Small Animal Medicine and Surgery     Hybrid Journal   (Followers: 3, SJR: 0.101, CiteScore: 0)
Advances in Space Biology and Medicine     Full-text available via subscription   (Followers: 6)
Advances in Space Research     Full-text available via subscription   (Followers: 420, SJR: 0.569, CiteScore: 2)
Advances in Structural Biology     Full-text available via subscription   (Followers: 5)
Advances in Surgery     Full-text available via subscription   (Followers: 13, SJR: 0.555, CiteScore: 2)
Advances in the Study of Behavior     Full-text available via subscription   (Followers: 37, SJR: 2.208, CiteScore: 4)
Advances in Veterinary Medicine     Full-text available via subscription   (Followers: 20)
Advances in Veterinary Science and Comparative Medicine     Full-text available via subscription   (Followers: 15)
Advances in Virus Research     Full-text available via subscription   (Followers: 6, SJR: 2.262, CiteScore: 5)
Advances in Water Resources     Hybrid Journal   (Followers: 53, SJR: 1.551, CiteScore: 3)
Aeolian Research     Hybrid Journal   (Followers: 6, SJR: 1.117, CiteScore: 3)
Aerospace Science and Technology     Hybrid Journal   (Followers: 382, SJR: 0.796, CiteScore: 3)
AEU - Intl. J. of Electronics and Communications     Hybrid Journal   (Followers: 8, SJR: 0.42, CiteScore: 2)
African J. of Emergency Medicine     Open Access   (Followers: 6, SJR: 0.296, CiteScore: 0)
Ageing Research Reviews     Hybrid Journal   (Followers: 12, SJR: 3.671, CiteScore: 9)
Aggression and Violent Behavior     Hybrid Journal   (Followers: 474, SJR: 1.238, CiteScore: 3)
Agri Gene     Hybrid Journal   (Followers: 1, SJR: 0.13, CiteScore: 0)
Agricultural and Forest Meteorology     Hybrid Journal   (Followers: 18, SJR: 1.818, CiteScore: 5)
Agricultural Systems     Hybrid Journal   (Followers: 31, SJR: 1.156, CiteScore: 4)
Agricultural Water Management     Hybrid Journal   (Followers: 45, SJR: 1.272, CiteScore: 3)
Agriculture and Agricultural Science Procedia     Open Access   (Followers: 4)
Agriculture and Natural Resources     Open Access   (Followers: 3)
Agriculture, Ecosystems & Environment     Hybrid Journal   (Followers: 58, SJR: 1.747, CiteScore: 4)
Ain Shams Engineering J.     Open Access   (Followers: 5, SJR: 0.589, CiteScore: 3)
Air Medical J.     Hybrid Journal   (Followers: 7, SJR: 0.26, CiteScore: 0)
AKCE Intl. J. of Graphs and Combinatorics     Open Access   (SJR: 0.19, CiteScore: 0)
Alcohol     Hybrid Journal   (Followers: 12, SJR: 1.153, CiteScore: 3)
Alcoholism and Drug Addiction     Open Access   (Followers: 11)
Alergologia Polska : Polish J. of Allergology     Full-text available via subscription   (Followers: 1)
Alexandria Engineering J.     Open Access   (Followers: 2, SJR: 0.604, CiteScore: 3)
Alexandria J. of Medicine     Open Access   (Followers: 1, SJR: 0.191, CiteScore: 1)
Algal Research     Partially Free   (Followers: 11, SJR: 1.142, CiteScore: 4)
Alkaloids: Chemical and Biological Perspectives     Full-text available via subscription   (Followers: 2)
Allergologia et Immunopathologia     Full-text available via subscription   (Followers: 1, SJR: 0.504, CiteScore: 1)
Allergology Intl.     Open Access   (Followers: 5, SJR: 1.148, CiteScore: 2)
Alpha Omegan     Full-text available via subscription   (SJR: 3.521, CiteScore: 6)
ALTER - European J. of Disability Research / Revue Européenne de Recherche sur le Handicap     Full-text available via subscription   (Followers: 10, SJR: 0.201, CiteScore: 1)
Alzheimer's & Dementia     Hybrid Journal   (Followers: 54, SJR: 4.66, CiteScore: 10)
Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring     Open Access   (Followers: 6, SJR: 1.796, CiteScore: 4)
Alzheimer's & Dementia: Translational Research & Clinical Interventions     Open Access   (Followers: 6, SJR: 1.108, CiteScore: 3)
Ambulatory Pediatrics     Hybrid Journal   (Followers: 5)
American Heart J.     Hybrid Journal   (Followers: 58, SJR: 3.267, CiteScore: 4)
American J. of Cardiology     Hybrid Journal   (Followers: 63, SJR: 1.93, CiteScore: 3)
American J. of Emergency Medicine     Hybrid Journal   (Followers: 46, SJR: 0.604, CiteScore: 1)
American J. of Geriatric Pharmacotherapy     Full-text available via subscription   (Followers: 12)
American J. of Geriatric Psychiatry     Hybrid Journal   (Followers: 14, SJR: 1.524, CiteScore: 3)
American J. of Human Genetics     Hybrid Journal   (Followers: 37, SJR: 7.45, CiteScore: 8)
American J. of Infection Control     Hybrid Journal   (Followers: 29, SJR: 1.062, CiteScore: 2)
American J. of Kidney Diseases     Hybrid Journal   (Followers: 36, SJR: 2.973, CiteScore: 4)
American J. of Medicine     Hybrid Journal   (Followers: 50)
American J. of Medicine Supplements     Full-text available via subscription   (Followers: 3, SJR: 1.967, CiteScore: 2)
American J. of Obstetrics and Gynecology     Hybrid Journal   (Followers: 249, SJR: 2.7, CiteScore: 4)
American J. of Ophthalmology     Hybrid Journal   (Followers: 66, SJR: 3.184, CiteScore: 4)
American J. of Ophthalmology Case Reports     Open Access   (Followers: 5, SJR: 0.265, CiteScore: 0)
American J. of Orthodontics and Dentofacial Orthopedics     Full-text available via subscription   (Followers: 6, SJR: 1.289, CiteScore: 1)
American J. of Otolaryngology     Hybrid Journal   (Followers: 25, SJR: 0.59, CiteScore: 1)
American J. of Pathology     Hybrid Journal   (Followers: 32, SJR: 2.139, CiteScore: 4)
American J. of Preventive Medicine     Hybrid Journal   (Followers: 28, SJR: 2.164, CiteScore: 4)
American J. of Surgery     Hybrid Journal   (Followers: 39, SJR: 1.141, CiteScore: 2)
American J. of the Medical Sciences     Hybrid Journal   (Followers: 12, SJR: 0.767, CiteScore: 1)
Ampersand : An Intl. J. of General and Applied Linguistics     Open Access   (Followers: 7)
Anaerobe     Hybrid Journal   (Followers: 4, SJR: 1.144, CiteScore: 3)
Anaesthesia & Intensive Care Medicine     Full-text available via subscription   (Followers: 66, SJR: 0.138, CiteScore: 0)
Anaesthesia Critical Care & Pain Medicine     Full-text available via subscription   (Followers: 24, SJR: 0.411, CiteScore: 1)
Anales de Cirugia Vascular     Full-text available via subscription   (Followers: 1)
Anales de Pediatría     Full-text available via subscription   (Followers: 3, SJR: 0.277, CiteScore: 0)
Anales de Pediatría (English Edition)     Full-text available via subscription  
Anales de Pediatría Continuada     Full-text available via subscription  
Analytic Methods in Accident Research     Hybrid Journal   (Followers: 5, SJR: 4.849, CiteScore: 10)
Analytica Chimica Acta     Hybrid Journal   (Followers: 44, SJR: 1.512, CiteScore: 5)
Analytica Chimica Acta : X     Open Access  
Analytical Biochemistry     Hybrid Journal   (Followers: 210, SJR: 0.633, CiteScore: 2)
Analytical Chemistry Research     Open Access   (Followers: 13, SJR: 0.411, CiteScore: 2)
Analytical Spectroscopy Library     Full-text available via subscription   (Followers: 14)
Anesthésie & Réanimation     Full-text available via subscription   (Followers: 2)
Anesthesiology Clinics     Full-text available via subscription   (Followers: 25, SJR: 0.683, CiteScore: 2)
Angiología     Full-text available via subscription   (SJR: 0.121, CiteScore: 0)
Angiologia e Cirurgia Vascular     Open Access   (Followers: 1, SJR: 0.111, CiteScore: 0)
Animal Behaviour     Hybrid Journal   (Followers: 218, SJR: 1.58, CiteScore: 3)
Animal Feed Science and Technology     Hybrid Journal   (Followers: 6, SJR: 0.937, CiteScore: 2)
Animal Reproduction Science     Hybrid Journal   (Followers: 7, SJR: 0.704, CiteScore: 2)

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Similar Journals
Journal Cover
American Journal of Ophthalmology
Journal Prestige (SJR): 3.184
Citation Impact (citeScore): 4
Number of Followers: 66  
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0002-9394
Published by Elsevier Homepage  [3184 journals]
  • Age and Gender Related Characteristics of Corneal Refractive Parameters in
           A Large Cohort Study
    • Abstract: Publication date: Available online 14 September 2019Source: American Journal of OphthalmologyAuthor(s): Igor Vainer, Michael Mimouni, Gilad Rabina, Oriel Spierer, Arie Y. Nemet, Yinon Shapira, Tzahi Sela, Igor KaisermanABSTRACTPurposeTo characterize age and gender related changes in corneal refractive parameters in myopic and hyperopic patients attending a refractive surgery.DesignA retrospective cross-sectional study.MethodsAnalysis of demographic and refractive parameters of myopic and hyperopic patients who underwent laser in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK) between January 2000 and December 2014 at the Care-Vision Laser Centers, Tel-Aviv, Israel.ResultsA total of 62,422 eyes of 31,211 patients were included. With advancing age, refractive surgery was performed for lower magnitudes of myopia and hyperopia. The magnitude of cylinder was higher in men compared to women in both myopic and hyperopic patients. In comparison to that, women were significantly more myopic than men (spherical equivalent of -3.73 D versus -4.07 D, p
  • Detection of reduced retinal vessel density in eyes with geographic
           atrophy secondary to age-related macular degeneration using
           projection-resolved optical coherence tomography angiography
    • Abstract: Publication date: Available online 14 September 2019Source: American Journal of OphthalmologyAuthor(s): Qi Sheng You, Jie Wang, Yukun Guo, Christina J. Flaxel, Thomas S. Hwang, David Huang, Yali Jia, Steven T. BaileyPurposeTo compare retinal vessel density in eyes with geographic atrophy (GA) secondary to age-related macular degeneration (AMD) to age-matched healthy eyes using projection-resolved optical coherence tomography angiography (PR-OCTA).DesignProspective cross-sectional study.MethodsStudy participants underwent macular 3×3-mm OCTA scans with spectral domain OCTA. Reflectance-compensated retinal vessel densities were calculated on projection-resolved superficial vascular complex (SVC), intermediate capillary plexus (ICP), and deep capillary plexus (DCP). Quantitative analysis using normalized deviation compared the retinal vessel density in GA regions, 500 μm GA rim regions, and non-GA regions to similar macular locations in control eyes.ResultsTen eyes with GA and 10 control eyes were studied. Eyes with GA had significantly lower vessel density in the SVC (54.8±2.4% vs. 60.8±3.1%, P
  • Evaluation of Hydroxychloroquine Retinopathy Using Ultra-widefield Fundus
           Autofluorescence: Peripheral Findings in the Retinopathy
    • Abstract: Publication date: Available online 14 September 2019Source: American Journal of OphthalmologyAuthor(s): Seong Joon Ahn, Jooyoung Joung, Byung Ro LeeABSTRACTObjectiveTo investigate the application of ultra-widefield fundus autofluorescence (UWF-FAF; Optos®) imaging in evaluating hydroxychloroquine (HCQ) retinopathy and to report peripheral autofluorescence findings in Asian patients with this condition.DesignRetrospective case seriesMethods: SettingInstitutionalPatient PopulationFifty-eight eyes of 29 patients with HCQ retinopathy.Observation ProceduresUWF-FAF imaging was performed using Optos 200 Tx (Optos PLC, Dunfermline, the United Kingdom), and the images were compared to conventional fundus autofluorescence (FAF) images obtained using a confocal digital ophthalmoscope (F-10; Nidek Co., Japan). The sensitivity of detecting retinopathy using the two modalities was compared. Peripheral autofluorescence findings in the eyes with HCQ retinopathy were assessed and their association with the Humphrey visual field test results obtained using the 30-2 and full-field 120 (FF-120) protocols was analyzed.Main Outcome MeasuresAbnormal FAF findingsResultsIn 41 of 58 eyes (70.7%) with HCQ retinopathy, abnormal FAF findings were noted in the retinal periphery outside the field of view of conventional FAF as hypoautofluorescent (23 eyes, 39.7%) and hyperautofluorescent (38, 65.5%) lesions. In five eyes (8.6%), differences were revealed between conventional FAF and UWF-FAF in detecting retinopathy. Most of the eyes with severe retinopathy showed most extensive hypoautofluorescence in the nasal peripheral retina. The areas with abnormal FAF findings were significantly correlated with the number of unseen spots on FF120 results and mean deviation and pattern standard deviation of the 30-2 test results. (all P
  • Functional and Morphological Evaluation of Meibomian Glands in the
           Assessment of Meibomian Gland Dysfunction Subtype and Severity
    • Abstract: Publication date: Available online 14 September 2019Source: American Journal of OphthalmologyAuthor(s): Jiaxin Xiao, Muhammed Yasin Adil, Xiangjun Chen, Øygunn A. Utheim, Sten Ræder, Kim Alexander Tønseth, Neil S. Lagali, Darlene A. Dartt, Tor P. UtheimABSTRACTPurposeTo classify subtypes of meibomian gland dysfunction (MGD) and evaluate dependency of dry eye signs, symptoms and parameters with MGD subtype.DesignCross-sectional studyStudy PopulationThe right eyes of 447 patients with MGD of various subtypes and 20 healthy volunteers.MethodsPatients were classified into four subtypes of MGD based on meibum expression, meibum quality, and MG loss on meibography images (meibograde of 0 to 6). Subtypes were those with high meibum delivery (hypersecretory- and non-obvious MGD) and those with low meibum delivery (hyposecretory- and obstructive MGD). Additional clinical tests included tear film break-up time (TFBUT), ocular staining, osmolarity, Schirmer I, blink interval timing and Ocular Surface Disease Index (OSDI) questionnaire.Results78 eyes had hypersecretory MGD, 49 eyes had non-obvious MGD, 66 eyes had hyposecretory MGD and 254 eyes had obstructive MGD. Increased tear film osmolarity and lower TFBUT was found in the low delivery groups; hyposecretory (P=0.006, P=0.016) and obstructive MGD (P=0.008, P=0.006) relative to high-delivery MGD (hypersecretory and non-obvious groups, respectively). Worse ocular symptoms and ocular staining were also found in low delivery MGD groups than the high delivery MGD groups (P
  • Residency Program Directors of United States Ophthalmology Programs: A
           Descriptive Analysis
    • Abstract: Publication date: Available online 13 September 2019Source: American Journal of OphthalmologyAuthor(s): Amy Kloosterboer, Nicolas A. Yannuzzi, Steven J. Gedde, Jayanth Sridhar PurposeTo analyze the academic background, scholarly achievements, and demographic characteristics of all US ophthalmology residency program directors (PDs).DesignCross-sectional study.MethodsSetting: Online search of publicly available resources conducted from February 16, 2019 to February 26, 2019.Study PopulationOne hundred and sixteen ophthalmology residency PDs.Main Outcome MeasuresDemographic and academic data.ResultsOne hundred and sixteen program directors were analyzed. Eighty-four of 116 (72%) PDs were male. The average age was 50.0 years. The mean age at appointment was 42.9 years. Ninety-three percent graduated from an American medical school, and 97% received an MD degree. Twenty percent of PDs completed an additional graduate degree, most commonly a master’s degree (7 of 23) and Doctor of Philosophy (7 of 23). Seventy-eight percent completed a fellowship, with the most frequent glaucoma (24%), cornea & external diseases (22%), and neuro-ophthalmology (21%). The mean number of publications as per PubMed was 17.6 (range of 0-92). There was no significant difference between the average number of publications between male and female PDs (19.2 ± 20.5 vs. 13.5 ± 23.1, P=0.21). On average, the Hirsch index was 8.7 (range of 0-35) and was higher in male than female PDs (9.8 ± 8.3 vs 5.4 ± 4.0, P=0.01).ConclusionsOphthalmology program directors are predominantly male with fellowship training in glaucoma, cornea, or neuro-ophthalmology. Women remain underrepresented and future efforts should be aimed at addressing this disparity.
  • Beyond Intraocular Pressure: Visual Functioning and Quality of Life in
           Primary Congenital Glaucoma and Secondary Childhood Glaucoma
    • Abstract: Publication date: Available online 13 September 2019Source: American Journal of OphthalmologyAuthor(s): Vijaya K. Gothwal, Sujata Sharma, Anil K. Mandal PurposeTo compare the visual functioning (VF) and vision-related QoL (VRQoL) of children aged 8-18 years treated for primary congenital glaucoma (PCG) and secondary childhood glaucoma.DesignCross-sectional study.Methods309 children aged 8-18 years treated for PCG and secondary childhood glaucoma between 2000 and 2010 by a single pediatric glaucoma specialist were prospectively enrolled at L V Prasad Eye Institute, Hyderabad, India. Children completed two questionnaires, the L V Prasad Functional Vision Questionnaire –II (LVP-FVQ-II), and Impact of Vision Impairment- Children (IVI-C) questionnaire. Rasch-calibrated scores from both these questionnaires were used to compare the VF and VFQoL between the two groups.RESULTSMean age of the children was 12.2 and 12.6 years in the PCG (53%, median age at diagnosis = 5 months) and secondary glaucoma groups (47%, median age at diagnosis =3 years), respectively. Majority (80%) of children had bilateral glaucoma and underwent filtering surgery (83%). Mean better eye logMAR visual acuity (VA) was comparable between PCG and secondary childhood glaucoma groups (0.49 vs 0.52; p=0.59).Children with PCG reported significantly better VF and VRQoL than secondary childhood glaucoma. Unadjusted and adjusted childhood glaucoma group comparisons revealed secondary childhood glaucoma to be associated with worse VF and VRQoL as compared to PCG (difference for VF, -0.83; 95% CI, -1.34 to 0.31, p=0.002; 0.39; 95% CI, 0.16 to 0.62, p=0.001 for VRQoL).ConclusionsOur results show that children with treated PCG experience significantly better VF and VRQoL than those with secondary childhood glaucoma, despite comparable VA and IOP.
  • Fluctuations of the Intraocular Pressure in Medically Versus Surgically
           Treated Glaucoma Patients by a Contact Lens Sensor
    • Abstract: Publication date: Available online 12 September 2019Source: American Journal of OphthalmologyAuthor(s): Mandabi Sengupta, Chengchira A. Sangma, Mayuri Borgohain, Prafulla Sarma, Shahinur Tayab, Shyam Sundar Das Mohapatra
  • A Randomized Clinical Trial of Immediate Versus Delayed Glasses for
           Moderate Hyperopia in Children 3 to 5 Years of Age
    • Abstract: Publication date: December 2019Source: American Journal of Ophthalmology, Volume 208Author(s): Jonathan M. Holmes, Marjean T. Kulp, Trevano W. Dean, Donny W. Suh, Raymond T. Kraker, David K. Wallace, David B. Petersen, Susan A. Cotter, Earl R. Crouch, Ingryd J. Lorenzana, Benjamin H. Ticho, Lisa C. Verderber, Katherine K. Weise, Pediatric Eye Disease Investigator GroupPurposeTo compare visual acuity (VA) and binocularity outcomes in moderately hyperopic children with normal VA and binocularity assigned to glasses versus observation.DesignProspective randomized clinical trial (RCT).MethodsOne hundred nineteen 3- to 5-year-old children with hyperopia between +3.00D and +6.00D spherical equivalent were randomly assigned to glasses versus observation (with glasses prescribed if deteriorated for subnormal distance VA or near stereoacuity, or manifest strabismus). Follow-up occurred every 6 months. At 3 years, the treatment strategy was classified as “failed” if any of the following were met, both with and without correction: subnormal distance VA or stereoacuity; manifest strabismus; or strabismus surgery during follow-up.ResultsOf 84 (71%) children who completed the primary outcome examination, failure occurred in five (12%; 95% confidence interval [CI]: 4%–26%) of 41 assigned to glasses and four (9%; 95% CI: 3%–22%) of 43 assigned to observation (difference = 3%; 95% CI: -12%–18%; P = .72). Deterioration prior to 3 years (requiring glasses per protocol) occurred in 29% (95% CI: 19%–43%) assigned to glasses and 27% (95% CI: 17%–42%) assigned to observation.ConclusionsIn an RCT comparing glasses to observation for moderately hyperopic 3- to 5-year-old children with normal VA and binocularity, failure for VA or binocularity was not common. With insufficient enrollment and retention, our study was unable to determine whether immediate glasses prescription reduces failure rate, but low failure rates suggest that immediate glasses prescription for these children may not be needed to prevent failure for VA and/or binocularity.
  • Impact of slab selection on quantification of choriocapillaris flow
           deficits by optical coherence tomography angiography
    • Abstract: Publication date: Available online 5 September 2019Source: American Journal of OphthalmologyAuthor(s): Iksoo Byon, Marco Nassisi, Enrico Borrelli, Srinivas R. Sadda PurposeTo assess the impact of slab selection on quantitative measurements of choriocapillaris (CC) flow deficits (FDs) using optical coherence tomography angiography (OCTA).DesignCross-sectional studyMethodsUsing a swept-source OCTA device, en face slabs to isolate the CC were first generated using the manufacturer’s default setting: a 20 μm-thick slab starting 29 μm posterior to the centerline of the automatically segmented retinal pigment epithelium (RPE) band. The inner and or outer borders were then adjusted by 2 μm increments to generate CC slabs with a range of offsets relative to the center of the RPE band. FDs of the modified slabs were compared to that of the default slab.ResultsTwenty-seven eyes of healthy subjects (mean age; 42.0 years) were prospectively enrolled. FD% increased when the slab was shifted outward by ≥4μm and inward by 20μm (P < .05). Fifteen eyes (55.6%) showed large hypointense regions precluding quantification when the slab was shifted inward by 20μm. Those without hypointensity demonstrated a decrease in FD% when the slab was shifted inward by 10 to 18 μm (P < .05). When modulating slab thickness, CC FD% increased and decreased when the slab thickness became thinner or thicker by ≥8μm, respectively (P < .05).ConclusionsQuantitative CC parameters may be significantly influenced by small differences in the slab selection. Slab close to the RPE can be susceptible to segmentation errors. These findings highlight the importance of accurate, precise, and consistent slab definition to reliably generate quantitative CC metrics from OCTA.
  • Clinical Course and Risk Factors for Visual Field Progression in
           Normal-Tension Glaucoma with Myopia without Glaucoma Medications
    • Abstract: Publication date: Available online 5 September 2019Source: American Journal of OphthalmologyAuthor(s): Jong Chul Han, Sun Hyup Han, Young Park, Eun Jung Lee, Changwon Kee PurposeTo investigate the natural clinical course and the risk factors of visual field (VF) progression in untreated normal-tension glaucoma (NTG) with myopia with a minimum three-year follow-up.DesignRetrospective cohort studyMethodsKaplan-Meier survival analysis and log-rank test were used to compare survival experiences between the groups. The hazard ratios (HRs) for the associations between potential risk factors and glaucomatous progression were determined using Cox proportional hazards model.ResultsThe average follow-up period for the included 97 patients was 71.1 ± 29.7 months and 32 eyes showed progression during the observation period. In NTG with myopia, Kaplan-Meier survival curve showed progression cases in 10.3% at 36 months and 24.8% at 60 months. When age and disc tilt direction were classified into two groups, a higher cumulative probability of progression was observed in those age ≤ 50 years than age> 50 years (P = .001) and in those with disc tilt direction < 45° than disc tilt direction ≥ 45° (P = .002). In Cox proportional hazards model, younger age, presence of disc hemorrhage and more temporally tilted disc or parapapillary atrophy (PPA) were associated with progression.ConclusionsNTG with myopia seems to have a slow progression rate even without glaucoma medications. Only 10.3% and 24.8% of patients showed VF progression at three years and five years of follow-up in untreated NTG with myopia. To predict VF progression in untreated NTG with myopia, it seems that age and disc morphology should be considered.
  • Diffuse Macular Damage in Mild to Moderate Glaucoma is Associated with
           Decreased Visual Function Scores under Low Luminance Conditions
    • Abstract: Publication date: Available online 5 September 2019Source: American Journal of OphthalmologyAuthor(s): Dana M. Blumberg, Jeffrey M. Liebmann, Sitara H. Hiriji, Donald C. Hood ImportanceGlaucoma patients commonly report increasing visual problems under low luminance or glare conditions yet there is limited understanding of the structural basis of visual functional losses.ObjectiveThis report examines the relationship between glaucomatous macular damage, assessed using structure-function correlation, and visual difficulty under low luminance conditions, as measured by Low Luminance Questionnaire (LLQ).Designobservational cohort studySettingtertiary care referral centerParticipants252 eyes of 126 participants with mild or moderate open angle glaucoma [24-2 mean deviation (MD) better than -12dB] selected from a consecutive sample.PredictorFocal and diffuse macular defects were identified based on corresponding abnormal regions on probability maps from spectral domain optical coherence tomography (SD-OCT) optic disc and macular cube scans, and 10-2 and 24-2 visual fields (VF).Main Outcome MeasureLLQ scoresResults82 (65%) of the 126 better eyes (defined by 24-2 VF MD) had evidence of macular damage, while the remaining 44 did not have macular damage. Of the 82 with damage, 33 (40%) had diffuse damage and 49 (60%) had focal damage. After adjusting for 24-2 MD and age in the multivariable regression, diffuse macular damage remained a significant predictor of the LLQ subscales ‘difficulty with extreme lighting’ (p=0.0024), ‘‘difficulty with low lighting’ (p=0.037), and ‘diminished mobility’; (p=0.042). In contrast, there was no significant difference in LLQ scores in any subscale between participants with focal macular damage and those without macular damage.Conclusion and RelevanceMild diffuse glaucomatous macular damage, as detected by abnormal topographical regions on measures of structure and function, is associated with decreased LLQ scores.
  • Relationship Between Retinal Fractal Dimension and Non-perfusion in
           Diabetic Retinopathy on Ultra-Wide Field Fluorescein Angiography
    • Abstract: Publication date: Available online 29 August 2019Source: American Journal of OphthalmologyAuthor(s): Wenying Fan, Muneeswar Gupta Nittala, Alan Fleming, Gavin Robertson, Akihito Uji, Charles C. Wykoff, David M. Brown, Jano van Hemert, Michael Ip, Kang Wang, Khalil Ghasemi Falavarjani, Michael Singer, Min Sagong, SriniVas R. SaddaPurposeTo correlate fractal dimension (FD) of the retinal vasculature with the extent of retinal non-perfusion area (NPA) in diabetic retinopathy (DR) on ultra-wide field (UWF) fluorescein angiography (FA).DesignCross-sectional study.MethodsBaseline Optos 200Tx UWF FA images of 80 eyes with DR from the DAVE (NCT01552408) and RECOVERY (NCT02863354) studies were stereographically projected at the Doheny Image Reading Center. The retinal vasculature was extracted from an early-phase FA frame by exploiting the elongated nature of the vessels and then skeletonized for calculation of FD using a box-counting method. NPA was delineated by two independent, masked reading center-certified graders using a standardized protocol and then computed in mm2.ResultsWhile no difference in FD was observed for the entire retina in DR compared to normal controls, a significantly smaller FD was found in the far-periphery of the DR eyes (P < 0.001). FD for the entire retina was negatively associated with global NPA (R = -0.44; P < 0.001) and this relationship was also present within the three concentric retinal zones (Posterior: R = -0.31, P = 0.016; Mid-periphery: R = -0.35, P = 0.007; Far-periphery: R = -0.31, P = 0.015).ConclusionsPeripheral FD on UWF FA is reduced in DR eyes compared to normal eyes and is correlated with the severity of retinal non-perfusion. As FD can be calculated automatically without need for correction of peripheral distortion, it may prove to be a useful surrogate biomarker when precise quantification of non-perfusion is not feasible.
  • Age-dependent Deformation of the Optic Nerve Head and Peripapillary Retina
           by Horizontal Duction
    • Abstract: Publication date: Available online 29 August 2019Source: American Journal of OphthalmologyAuthor(s): Alan Le, Jessica Chen, Michael Lesgart, Bola A. Gawargious, Soh Youn Suh, Joseph L. Demer PurposeWe studied effects of age and horizontal duction on deformation of the optic nerve (ON) head and peripapillary retina as reflected by displacement of vascular landmarks to explore the influence of adduction tethering.DesignCross-sectional study.MethodsSetting: University.Study Population: Single eyes of 20 healthy young adults (average age 23.9±3.9 SD) years were compared to 20 older subjects (average age 61.4±9.3) years. Observational Procedure: The disc and peripapillary retina were imaged by scanning laser ophthalmoscopy in central gaze, and 35° abd- and adduction.Main Outcome Measure: Deformations of the disc and adjacent PPR were measured by comparing positions of epipapillary and epiretinal blood vessels.ResultsVessels within the ONH of younger subjects shifted temporally during adduction and nasally during abduction. Displacement of the nasal hemi-disc in adduction was greater at 38.5±1.7μm (SEM) than the temporal half at 4.1±2.1μm (P
  • Reply to a Comment: Clinical Outcomes of Descemet Membrane Endothelial
           Keratoplasty in Eyes With a Glaucoma Drainage Device
    • Abstract: Publication date: Available online 27 August 2019Source: American Journal of OphthalmologyAuthor(s): Rénuka S. Birbal, C. Maya Tong, Isabel Dapena, John S. Parker, Jack S. Parker, Silke Oellerich, Gerrit R.J. Melles
  • Modelling changes in corneal parameters with age: implications for corneal
           disease detection
    • Abstract: Publication date: Available online 27 August 2019Source: American Journal of OphthalmologyAuthor(s): Janelle Tong, Jack Phu, Michael Kalloniatis, Barbara ZangerlABSTRACTPurposeTo apply computational methods to model normal age-related changes in corneal parameters and establish their association with demographic factors, thereby providing a framework for improved detection of subclinical corneal ectasia (SCE).DesignCross-sectional studyMethods117 healthy participants were enrolled from Centre for Eye Health (Sydney, Australia). Corneal thickness (CT), front surface sagittal curvature (FSSC) and back surface sagittal curvature (BSSC) measurements were extracted from 57 corneal locations using the Pentacam HR from one eye per participant. Cluster analyses were performed to identify locations demonstrating similar variations with age. Age-related changes were modeled using polynomial regression with sliding window methods, and model accuracy was verified with Bland-Altman comparisons. Pearson’s correlations were applied to examine the impacts of demographic factors.ResultsConcentric cluster patterns were observed for CT and FSSC, but not BSSC. Sliding window analyses were best fit with quartic and cubic regression models for CT and FSSC/BSSC respectively. CT and FSSC sliding window models had narrower 95% limits of agreement compared to decade-based models (0.015 mm versus 0.017mm and 0.14mm versus 0.27mm respectively), but were wider for BSSC than decade-based models (0.73mm versus 0.54mm). Significant correlations were observed between CT and astigmatism (p = 0.02-0.049) and FSSC and BSSC and gender (p =
  • Clinical evaluation of SITA-Faster compared to SITA-Standard in normal
           subjects, glaucoma suspects and glaucoma patients
    • Abstract: Publication date: Available online 27 August 2019Source: American Journal of OphthalmologyAuthor(s): Jack Phu, Sieu K. Khuu, Ashish Agar, Michael Kalloniatis PurposeTo compare the visual fields results obtained using the Swedish interactive thresholding algorithm (SITA) Standard (SS) and Faster (SFR), in normal subjects, glaucoma suspects and glaucoma patients, and to quantify potential time-saving benefits of the SFR algorithm.DesignProspective, cross-sectional study.MethodsOne randomly selected eye from 364 patients (77 normal, 178 glaucoma suspect and 109 glaucoma) seen in a single institution underwent testing using both SS and SFR on the Humphrey Field Analyzer (HFA3). Cumulative test time using each algorithm was compared after accounting for different rates of test reliability. Pointwise and cluster analysis was performed to determine whether there were systematic differences between algorithms.ResultsUsing SFR had a greater rate of unreliable results (29.3%) compared to SS (7.7%, p < 0.0001). This was mainly due to high false positive rates and seeding point errors. However, modelled test times showed that using SFR could obtain a greater number of reliable results within a shorter period of time. SFR resulted in higher sensitivity values (on average 0.5 dB for glaucoma patients), which was greater under conditions of field loss (
  • Effect of Keratoconus Severity on Clinical Outcomes After Deep Anterior
           Lamellar Keratoplasty
    • Abstract: Publication date: Available online 27 August 2019Source: American Journal of OphthalmologyAuthor(s): Sepehr Feizi, Mohammad Ali Javadi, Bahareh Kheiri
  • Outer retinal alterations associated with visual outcomes in Best
           vitelliform macular dystrophy
    • Abstract: Publication date: Available online 26 August 2019Source: American Journal of OphthalmologyAuthor(s): Edouard Augstburger, Raphaëlle Orès, Saddek Mohand-Said, Sarah Mrejen, Chafik Keilani, Aline Antonio, Christel Condroyer, Camille Andrieu, José-Alain Sahel, Christina Zeitz, Isabelle AudoPurposeTo describe outer retinal structure in Best vitelliform macular dystrophy (BVMD) patients using spectral-domain optical coherence tomography (SD-OCT) and correlate these RESULTS with best corrected visual acuity (BCVA) and patient age.DesignRetrospective cross-sectional study.MethodsPatients with molecularly confirmed BVMD were compared to normal control subjects (NC). Complete clinical evaluation was performed including BCVA, fundus photography, SD-OCT and fundus auto-fluorescence. SD-OCT images were analyzed to determine the stage of the lesion, the central macular thickness (CMT), the foveal outer nuclear layer (ONL) thickness, and tomographic structural changes.ResultsForty-two BVMD patients (42 eyes) with a molecular diagnosis and 42 NC (42 eyes) were included. Clinical stages (Gass clinical classification) were distributed as follow: 4.8% for stage 1, 23.8% for stage 2, 16.6% for stage 3, 45.2% for stage 4 and 9.5% for stage 5. The presence of subretinal fluid and vitelliform material was noted in 76% and 79% of the BVMD eyes examined, and was not associated with BCVA modification (P=0.758 and P=0.968, respectively). The median ONL thickness was significantly lower compared to the control group (P
  • Near vision impairment and Frailty: Evidence of an association
    • Abstract: Publication date: Available online 26 August 2019Source: American Journal of OphthalmologyAuthor(s): Varshini Varadaraj, Moon Jeong Lee, Jing Tian, Pradeep Y. Ramulu, Karen Bandeen-Roche, Bonnielin K. Swenor PurposeTo examine associations between near vision impairment (NVI) and frailtyDesignCross-sectional studyMethodsSettingNationally representative sample of non-institutionalized United States civiliansStudy Population2,705 older adults ≥60 years from National Health and Nutrition Examination Survey (1999-2002)ObservationPresenting NVI (PNVI)-near acuity worse than 20/40. Self-reported NVI (SNVI)-self-reported difficulty with near vision tasksMain Outcome Measure(s)5-item physical frailty; participants classified as frail (≥3 criteria) and pre-frail (1 or 2 criteria). Propensity score adjusted, and probability-weighted multinomial multivariable logistic regression was used to examine associations of PNVI and SNVI with frailty.ResultsOf 2,705 participants, 10%, 5%, and 3% had PNVI only, SNVI only, and PNVI+SNVI, respectively. In fully adjusted models, as compared to those without PNVI, participants with PNVI were more likely to be prefrail (OR=1.6; 95% CI=1.1,2.3) and frail (OR=2.5; 95% CI=1.4,4.3). As compared to those without SNVI, participants with SNVI were more likely to be prefrail (OR=2.9; 95% CI=1.8,4.7) and frail (OR=4.3; 95% CI=2.2,8.3). As compared to those without PNVI or SNVI, participants with PNVI+SNVI were more likely to be prefrail and frail (prefrail: OR=4.0; 95% CI=2.2,7.2 and frail: OR=4.5; 95% CI=1.7,12.7).ConclusionsOlder adults with PNVI and SNVI were more likely to be pre-frail and frail than those without respective NVI, suggesting that NVI is associated with frailty.
  • Incidence and Risk Factors for Glaucoma development after Bilateral
           Congenital Cataract Surgery in Microphthalmic eyes
    • Abstract: Publication date: Available online 23 August 2019Source: American Journal of OphthalmologyAuthor(s): Jeong-Ah Kim, Sang-yoon Lee, Ki Ho Park, Young Suk Yu, Jin Wook Jeoung PurposeTo evaluate the long-term incidence and risk of glaucoma after bilateral congenital cataract surgery in microphthalmic eyes.DesignRetrospective, observational case series.SubjectsChildren with microphthalmic eyes who had undergone surgery for bilateral congenital cataract within 6 months of birth and been followed up for at least 5 years.MethodsReview of medical records at our institution.Main Outcome MeasuresProbability of an eye’s developing glaucoma after bilateral congenital cataract surgery and associated risk factors.ResultsThirty-eight eyes of 19 children with bilateral congenital cataract were included. The mean age at surgery was 3.2 ± 1.7 months, and the mean follow-up duration was 7.79 ± 2.61 years. After cataract surgery, 11 eyes (29.0%) developed glaucoma at the age of 4.0 ± 1.4 years. Three of these eyes underwent Ahmed glaucoma valve implantation surgery. The probability of an eye’s developing glaucoma was estimated to be 32.0% by 10 years after surgery. In a multivariate analysis, axial length was significantly associated with glaucoma development (odds ratio = 0.364, P = .025). Age at the time of cataract surgery, corneal diameter, and aphakia did not affect the risk of glaucoma (P> .10). Eyes without glaucoma had a better final visual outcome than those with glaucoma (0.75 ± 0.60 and 1.47 ± 1.10 logMAR, respectively, P = .049).ConclusionsThe long-term cumulative risk of post-operative glaucoma development was 32.0% by 10 years after bilateral congenital cataract surgery. Because the risk of developing glaucoma persists for several years after surgery, careful monitoring and control of intraocular pressure is needed to preserve vision in such patients.
  • Anterior Segment Optical Coherence Tomography Angiography in Patients
           Following Cultivated Oral Mucosal Epithelial Transplantation
    • Abstract: Publication date: Available online 23 August 2019Source: American Journal of OphthalmologyAuthor(s): Shoko Kiritoshi, Yoshinori Oie, Kanako Nampei, Shinnosuke Sato, Misa Morota, Kohji Nishida PurposeTo analyze corneal neovascularization using anterior segment optical coherence tomography angiography (AS-OCTA) in patients following cultivated oral mucosal epithelial sheet transplantation (COMET).DesignObservational case series.MethodsNine eyes in 7 patients were analyzed. Four images of corneal quadrant were obtained by AS-OCTA from each patient during follow-up post-COMET in the Department of Ophthalmology at Osaka University Hospital. The depth of corneal neovascularization was evaluated using en face and B-scan images. Each quadrant image was classified as one of the following five types: stromal, predominantly stromal, epithelial, predominantly epithelial, or avascular. The image quality of slit-lamp photography and AS-OCTA was graded from 0 to 4. Manually segmented images of the epithelial and stromal vessels were obtained.Main Outcome MeasuresDepth and image quality of corneal neovascularization following COMET.ResultsSix patients were male and 1 was female. The mean patient age was 61.3 ± 19.1 years. Thirty-six quadrant images were obtained, of which 4 (11.1%) were stromal, 16 (44.4%) were predominantly stromal, 3 (8.3%) were epithelial, 11 (30.6%) were predominantly epithelial, and 2 (5.6%) were avascular. The image quality obtained by AS-OCTA was significantly better than that obtained by slit-lamp photography (2.38±0.94 vs 2.03±0.90; P = 0.021). Segmentation images clearly demonstrated both epithelial and stromal vasculatures individually.ConclusionsAS-OCTA is useful for evaluation of depth of corneal neovascularization and has the potential to distinguish between conjunctivalization and stromal neovascularization following COMET. Findings on AS-OCTA could contribute to clinical decision-making, given that retreatment is required for conjunctivalization after COMET.
  • Acute retinal necrosis: virological features using quantitative PCR,
           therapeutic management, and clinical outcomes
    • Abstract: Publication date: Available online 23 August 2019Source: American Journal of OphthalmologyAuthor(s): Meriem Hafidi, Hélène Janin-Manificat, Philippe Denis, Bruce Charleux, Muriel Rabilloud, Andre Boibieux, Carole Burillon, Laurent Kodjikian, Emilie Frobert PurposeTo evaluate outcomes of patients treated with intensive intravitreal therapy and to describe the evolution of quantitative real-time polymerase chain reaction (qPCR) in patients treated for acute retinal necrosis (ARN) syndrome.DesignRetrospective observational case series.MethodsThis study included 25 eyes of 24 patients with ARN who were treated and followed-up in two departments of ophthalmology in Lyon (France). Assessed outcomes included qPCR viral load profile during treatment, number of antiviral intravitreal injections (IVT), retinal detachment rate, and best-corrected visual acuity (BCVA).ResultsFinal visual acuity was 20/200 or less in 20% of cases; the rate of retinal detachment was 16%. Viral load kinetics changed in three phases: a first plateau period that was not consistent, a logarithmic decrease phase, and a negativation phase. Mean decay of the logarithm of the viral load was estimated at 0.076 per day; mean time of negativation was 56.1 days. Median IVT number was 9 (range, 0–28). Ten patients were treated with injections until the viral load was undetectable. Resistance to acyclovir was observed in a patient with a prolonged initial plateau of the viral load.ConclusionsNumerous and prolonged IVTs, used as ajdunctive therapy, could improve the prognosis of treated patients by decreasing the risk of retinal detachment and improving visual acuity. QPCR enables monitoring of the response to treatment and can provided evidence for resistance to antiviral treatment by enabling the detection of cases with a prolonged initial plateau of viral load.
  • Deep Learning Classifiers for Automated Detection of Gonioscopic Angle
           Closure Based on Anterior Segment OCT Images
    • Abstract: Publication date: Available online 22 August 2019Source: American Journal of OphthalmologyAuthor(s): Benjamin Y. Xu, Michael Chiang, Shreyasi Chaudhary, Shraddha Kulkarni, Anmol A. Pardeshi, Rohit Varma PurposeTo develop and test deep learning classifiers that detect gonioscopic angle closure and primary angle closure disease (PACD) based on fully automated analysis of anterior segment OCT (AS-OCT) images.MethodsSubjects were recruited as part of the Chinese-American Eye Study (CHES), a population-based study of Chinese Americans in Los Angeles, CA. Each subject underwent a complete ocular examination including gonioscopy and AS-OCT imaging in each quadrant of the anterior chamber angle (ACA). Deep learning methods were used to develop three competing multi-class convolutional neural network (CNN) classifiers for modified Shaffer grades 0, 1, 2, 3, and 4. Binary probabilities for closed (grades 0 and 1) and open (grades 2, 3, and 4) angles were calculated by summing over the corresponding grades. Classifier performance was evaluated by five-fold cross validation and on an independent test dataset. Outcome measures included area under the receiver operating characteristic curve (AUC) for detecting gonioscopic angle closure and PACD, defined as either two or three quadrants of gonioscopic angle closure per eye.Results4036 AS-OCT images with corresponding gonioscopy grades (1943 open, 2093 closed) were obtained from 791 CHES subjects. Three competing CNN classifiers were developed with a cross-validation dataset of 3396 images (1632 open, 1764 closed) from 664 subjects. The remaining 640 images (311 open, 329 closed) from 127 subjects were segregated into a test dataset. The best-performing classifier was developed by applying transfer learning to the ResNet-18 architecture. For detecting gonioscopic angle closure, this classifier achieved an AUC of 0.933 (95% confidence interval, 0.925-0.941) on the cross-validation dataset and 0.928 on the test dataset. For detecting PACD based on two- and three-quadrant definitions, the ResNet-18 classifier achieved AUCs of 0.964 and 0.952, respectively, on the test dataset.ConclusionDeep learning classifiers effectively detect gonioscopic angle closure and PACD based on automated analysis of AS-OCT images. These methods could be used to automate clinical evaluations of the ACA and improve access to eyecare in high-risk populations.
  • Effect of Keratoconus Severity on Clinical Outcomes After Deep Anterior
           Lamellar Keratoplasty
    • Abstract: Publication date: Available online 19 August 2019Source: American Journal of OphthalmologyAuthor(s): Pranita Sahay, Prafulla K. Maharana
  • Schisis of the Retinal Nerve Fiber Layer in Epiretinal Membranes
    • Abstract: Publication date: November 2019Source: American Journal of Ophthalmology, Volume 207Author(s): S. Amal Hussnain, Tarun Sharma, Donald C. Hood, Stanley ChangPurposeTo describe schisis of the retinal nerve fiber layer (sRNFL) associated with epiretinal membranes (ERMs) seen on spectral-domain optical coherence tomography (OCT) prior to vitreoretinal surgery. Areas of sRNFL (size and location) were noted during preoperative planning. Spectral-domain OCT scans were obtained to study the inner retinal morphology postoperatively.DesignRetrospective observational consecutive case series.MethodsPre- and postoperative spectral-domain OCT and en face images of 41 eyes with ERMs that had undergone vitrectomy by a single surgeon were analyzed to record the presence of sRNFL. The extent of sRNFL was classified as focal or diffuse. Other characteristics such as involvement of the papillomacular bundle and areas of fibrillary protrusion of sRNFL above the internal limiting membrane (ILM) were documented. Color fundus photographs were reviewed to correlate with the spectral-domain OCT images.ResultsMean patient age and length of follow-up were 69.3 years (range 52-82 years) and 6.8 months (range 0.25-21 months), respectively. Mean preoperative and postoperative central thicknesses were 477 μm and 387 μm, respectively (P < .0001). sRNFL was observed in 51.2% (21/41 eyes), and was classified as diffuse (>1 disc diameter) in 90.5% (19/21 eyes). Protrusion of sRNFL through the ILM was present in 76.2% (16/21 eyes) and occurred in areas of dehiscence of the adjacent ILM. sRNFL was best visualized on spectral-domain OCT and en face imaging at the vitreoretinal interface and sometimes correlated with areas of retinal whitening. sRNFL resolved in all cases postoperatively.ConclusionssRNFL was a relatively common occurrence in ERMs, correlated frequently with areas of dehisced ILM intraoperatively, and resolved postoperatively in all cases.
  • Ophthalmic Clinical Trials: We've Come a Long Way, Baby
    • Abstract: Publication date: Available online 13 August 2019Source: American Journal of OphthalmologyAuthor(s): Alfred Sommer
  • Reply
    • Abstract: Publication date: Available online 13 August 2019Source: American Journal of OphthalmologyAuthor(s): Ken Hayashi, Motoaki Yoshida, Tatsuhiko Sato, Shin-Ichi manabe
  • Comment on: Refractive Laser-Assisted Cataract Surgery vs Conventional
           Manual Surgery: Comparing Efficacy and Safety in 3144 Eyes
    • Abstract: Publication date: Available online 13 August 2019Source: American Journal of OphthalmologyAuthor(s): Surbhi Agrawal, Ajit Kumar, Ashi Khurana
  • Reply
    • Abstract: Publication date: Available online 13 August 2019Source: American Journal of OphthalmologyAuthor(s): Ta Chen Chang, Justin Stoler
  • Envirotyping in Medical Schools: A Movement Toward Digital Health Literacy
    • Abstract: Publication date: Available online 13 August 2019Source: American Journal of OphthalmologyAuthor(s): Gabriella Schmuter
  • Reply to Correspondence: Impact of Binarization Thresholding and
           Brightness/Contrast Adjustment Methodology on Optical Coherence Tomography
           Angiography Image Quantification
    • Abstract: Publication date: Available online 13 August 2019Source: American Journal of OphthalmologyAuthor(s): Nihaal Mehta, Nadia K. Waheed
  • Improved diagnosis of retinal laser injuries using near-infrared
    • Abstract: Publication date: Available online 12 June 2019Source: American Journal of OphthalmologyAuthor(s): Samantha R. De Silva, James E. Neffendorf, Johannes Birtel, Philipp Herrmann, Susan M. Downes, Chetan K. Patel, Göran D. Hildebrand, Martin Gliem, Peter Charbel Issa PurposeTo assess whether near infrared autofluorescence (NIR-AF) imaging is a useful imaging modality in the diagnosis of handheld laser retinal injuries.DesignRetrospective observational case series.Methods12 patients identified to have handheld laser retinal injuries were included at two academic centers. Patients underwent ophthalmic assessment and retinal imaging including fundus photography, optical coherence tomography (OCT), conventional blue autofluorescence (B-AF) and NIR-AF imaging.ResultsIn all cases, lesions consistent with retinal laser injury were detected by NIR-AF imaging. The lesions showed a characteristic appearance with central hyperfluorescence and surrounding hypofluorescence although the number and extent of lesions varied between patients. Findings using other imaging modalities were variable: on color fundus photography these included localized pigmentary changes and on OCT imaging an ellipsoid zone interruption or outer nuclear layer changes. Only subtle changes were evident on B-AF imaging. Other macular conditions, such as poppers retinopathy or solar maculopathy, which may have similar findings on OCT imaging as laser damage, can be differentiated using NIR-AF imaging.ConclusionAn increased incidence of retinal injuries secondary to handheld lasers has been reported in recent years. We show that the diagnosis and full extent of retinal laser injuries is best demonstrated by NIR-AF, as other modalities give variable results. We propose that NIR-AF should be included when investigating patients suspected of macular injury secondary to exposure to handheld lasers.
  • Tilted disc syndrome associated with serous retinal detachment: long-term
           prognosis. A retrospective multicenter survey
    • Abstract: Publication date: Available online 4 June 2019Source: American Journal of OphthalmologyAuthor(s): Fumihiro Kubota, Tetsuyuki Suetsugu, Aki Kato, Fumi Gomi, Seiji Takagi, Takamasa Kinoshita, Hiroto Ishikawa, Yoshinori Mitamura, Mineo Kondo, Chiharu Iwahashi, Soichiro Kuwayama, Yasuo Kurimoto, Yuichiro Ogura, Tsutomu Yasukawa, Japanese Clinical Retina Study (J-CREST) Group PurposeWe evaluated the long-term visual prognosis of a serous retinal detachment (SRD) secondary to tilted disc syndrome with or without an SRD at a final visit and the interventions.DesignA retrospective, observational case seriesMethodsThis was a multicenter study with an enrollment of 48 eyes of 41 treatment-naïve patients (14 men, 27 women) diagnosed as tilted disc syndrome related SRDs at a first visit. Investigators at each institution decided whether to observe the patients without interventions or to treat with intravitreous injections of anti-vascular endothelial growth factor agents, photodynamic therapy, or combined therapies of both. The patients were followed up for at least 12 months. Main outcome measures were the changes of best-corrected visual acuity (BCVA) and central retinal thickness (CRT) from a baseline.ResultsAnalyses of all eyes showed improvement from a baseline when best BCVA was measured (p
  • Diurnal variation in corneal edema in Fuchs’ Endothelial Corneal
    • Abstract: Publication date: Available online 12 August 2019Source: American Journal of OphthalmologyAuthor(s): Marianne Fritz, Viviane Grewing, Philip Maier, Thabo Lapp, Daniel Böhringer, Thomas Reinhard, Katrin Wacker PurposeThe extent of diurnal variation in corneal edema in Fuchs’ dystrophy is unknown. We measured corneal thickness and posterior profile over the course of the day using Scheimpflug imaging.Design; Prospective cohort study.MethodsParticipants with clinically advanced Fuchs’ dystrophy eyes undergoing endothelial keratoplasty and participants with healthy corneas were assessed around noon the day before surgery and late afternoon, in presumed steady state. After controlled overnight patching to standardize eyelid closure, participants were assessed immediately upon eye opening in hospital the morning of surgery.ResultsDirectly upon awakening, mean corneal thickness was 663 μm (interquartile range [IQR], 625–707) in Fuchs’ dystrophy (n = 44) and 557 μm (IQR, 527–601) in 11 controls. In control corneas, there were no systematic changes with time. In Fuchs’ dystrophy eyes, corneal thickness decreased after awakening. 95% of patients can be expected to have a change in corneal thickness over the first four hours after awakening between -58 μm to -31 μm (95% prediction interval). Posterior Q decreased on average by 0.15 (95% confidence interval [CI], 0.07–0.23) and posterior radius of curvature decreased by 0.20 mm (95% CI, 0.14–0.27), indicating that edema resolution steepened the central posterior cornea. Beyond four hours after awakening, corneas no longer changed considerably in Fuchs’ dystrophy.ConclusionImpaired hydration control in clinically advanced Fuchs’ dystrophy makes measurements of key corneal parameters unreliable directly after eye opening. Beyond the first hours after eye opening, corneal thickness measurements are unlikely to vary more in Fuchs’ dystrophy eyes than in normal eyes.
  • Risk of Nonarteritic Anterior Ischemic Optic Neuropathy after Cataract
    • Abstract: Publication date: Available online 12 August 2019Source: American Journal of OphthalmologyAuthor(s): Hee Kyung Yang, Sang Jun Park, Seong Jun Byun, Kyu Hyung Park, Jeong-Min Hwang Background/aims: To determine whether the development of nonarteritic anterior ischemic optic neuropathy (NAION) is increased after receiving cataract surgery in a large general population.DesignNationwide, population-based, retrospective cohort studyMethods: SettingA 12-year nationwide, population-based, retrospective cohort study including 1,025,340 beneficiaries in the 2002–2013 Korean National Health Insurance Service database.PatientsWe identified 40,356 patients who had undergone cataract surgery and matched non-cataract surgery controls (1:2) using estimated propensity scores in reference to age, sex, demographics, comorbidities, and co-medications.ObservationsKaplan-Meier curves and Cox proportional hazard models were generated to determine the risk of developing NAION in the cataract surgery group compared to the non-cataract surgery group.Main Outcomes MeasuresEffect (hazard ratio [HR]) of cataract surgery on NAION development.ResultsThe 10-year incidence probability of NAION was 0.70% (95% CI, 0.55-0.86) in the cataract surgery group and 0.27% (95% CI, 0.25-0.29) in the non-cataract surgery group (p
  • Comment on: Effect of Topical Hypotensive Medications for Preventing
           Intraocular Pressure Increase after Cataract Surgery in Eyes with Glaucoma
    • Abstract: Publication date: Available online 2 August 2019Source: American Journal of OphthalmologyAuthor(s): Arij Daas, Henrietta Ho, Kin Sheng Lim
  • Optic nerve sheath diameter ultrasound: optic nerve growth curve and its
           application to detect intracranial hypertension in children
    • Abstract: Publication date: Available online 1 August 2019Source: American Journal of OphthalmologyAuthor(s): Fontanel Liviana, Pensiero Stefano, Ronfani Luca, Rosolen Valentina, Barbi EgidioPurpose(1) To create an optic nerve growth curve from the optic nerve sheath diameter (ONSD) normal values ​​measured with B-scan ultrasound in subjects aged 0-18. (2) To identify age-appropriate cut-offs of ONSD to be used in the diagnosis of intracranial hypertension (IHT).DesignProspective cross-sectional study.MethodsB-scan ocular ultrasound was performed on both eyes of 215 subjects aged 0-18, divided into 3 groups: 165 healthy children, 29 children with IHT (all>4 years of age) and 21 with optic disc drusen (ODD).ResultsThere were no statistically significant differences in ONSDs between healthy children and subjects with ODD.We created an optic nerve growth curve using ONSDs measured in healthy subjects aged 0-18: ONSD = ln (33.15) – [–0.18 * ln (children’s age)].Our curve shows a progressive increase of ONSD up to 10 years and then it remains constant until the age of 18. For this reason, we calculated two different cut-offs for age groups 4-10 and 11-18. They are 4.10 mm and 4.4 mm respectively, with a 100.0% sensitivity and a specificity ranged from 83.9% to 98.8%.We reached a sensitivity of 28.6%, applying to our population aged 4-18 the 5 mm threshold used in literature.ConclusionsThe ONSD continues to enlarge gradually until the age of 10. Therefore we calculated two different cut-offs for the age groups 4-10 and 11-18, considering the ONSDs of subjects aged 11-18 overlapping with those of adults.As we had no patients with IHT
  • Effects of immersive virtual reality headset viewing on young children:
           Visuomotor function, postural stability and motion sickness
    • Abstract: Publication date: Available online 1 August 2019Source: American Journal of OphthalmologyAuthor(s): Lawrence Tychsen, Paul Foeller PurposeTo assess the safety of VR 3D Headset (virtual reality three-dimensional binocular-stereoscopic near-eye display) use in young children. Product safety warnings that accompany VR Headsets ban their use in children under age 13 years.DesignProspective, interventional, before-and-after study.MethodsRecordings were obtained in 50 children (29 boys) age 4 -10 yr (mean 7.2 ± 1.8 yr). Minimum binocular corrected distance visual acuity (CDVA) was 20/50 (logMAR 0.4) and stereoacuity 800 arc sec or better. A Sony PlayStation VR Headset was worn for 2 sequential play sessions (each 30 min) of a first-person 3D flying game (Eagle Flight) requiring head movement to control flight direction (pitch, yaw and roll axes). Baseline testing preceded VR exposure and each VR session was followed by post-VR testing of: binocular CDVA; refractive error; binocular eye alignment (strabismus); stereoacuity; and postural stability (imbalance). Visually-induced motion sickness (VIMS) was probed using the simulator-sickness questionnaire modified for pediatric use (Peds SSQ). Visual-vestibulo-ocular reflex (V-VOR) adaptation was also tested pre- vs. post-trial in 5 of the children. Safety was gauged as a decline or change from baseline in any visuomotor measure.ResultsForty-six of 50 children (94%) completed both VR play sessions with no significant change from baseline in measures of: binocular CDVA (p = 0.89), refractive error (p = 0.36), binocular eye alignment (p = 0.90), or stereoacuity (p = .45). Postural stability degraded an average 9% from baseline after 60 min of VR exposure (p = .06). Peds SSQ scores increased a mean 4.7% – comparing pre-trial to post-trial – for each of 4 symptom categories: eye discomfort (p = .02); head/neck discomfort (p = .03); fatigue (p = .03) and motion sickness (p = .01). None of the children who finished both trial sessions (94%) asked to end the play and the majority were disappointed when play was halted. V-VOR gain remained unaltered in the 5 children tested. Three children (6% of participants) discontinued the trial during the first 10 min of the first session of VR play, two girls (age 5 and 6 yr) and one boy (age 7 yr). The girls reported discomfort consistent with mild motion sickness; the boy said he was bored and the Headset was uncomfortable. No child manifested after-effects (“flashbacks”) in the days following the VR exposure.ConclusionYoung children tolerate fully-immersive 3D virtual reality game play without noteworthy effects on visuomotor functions. VR play did not induce significant post-VR postural instability or maladaption of the vestibulo-ocular reflex. The prevalence of discomfort and after effects may be less than that reported for adults.
  • Integration of Genetic and Biometric Risk Factors for Detection of Primary
           Angle-Closure Glaucoma
    • Abstract: Publication date: Available online 1 August 2019Source: American Journal of OphthalmologyAuthor(s): Monisha E. Nongpiur, Chiea-Chuen Khor, Ching-Yu Cheng, Rahat Husain, Pui Yi Boey, Annabel Chew, Ching Lin Ho, Tina T. Wong, Shamira Perera, Tien Yin Wong, Eranga N. Vithana, Tin AungPurposeThe purpose of this study was to investigate whether the addition of primary angle closure glaucoma (PACG) associated genetic loci allows improved detection of PACG, compared to anterior segment parameters measured by imaging.DesignCase-control studyMethodsGenotype data of the 8 PACG SNPs (rs11024102 at PLEKHA7, rs3753841 at COL11A1, rs1015213 located between PCMTD1 and ST18 on Chromosome 8q, rs3816415 at EPDR1, rs1258267 at CHAT, rs736893 at GLIS3, rs7494379 at FERMT2, and rs3739821 mapping in between DPM2 and FAM102A) were available. Customized software was used to measure anterior segment optical coherence tomography (ASOCT) parameters, namely anterior chamber depth, width, and area (ACD, ACW, ACA) and lens vault (LV). Statistical analysis for positive predictive values was modelled using the Receiver operating characteristic curve (AUC). Statistical significance comparing predictive power of the different parameters was calculated using permutation.ResultsA total of 388 PACG subjects and 751 controls with both ASOCT and genetic data were available for analysis. Anterior segment parameters including ACD, ACA, and LV had excellent predictive value (AUC)>0.94), except ACW (AUC=0.65) for identifying PACG. The inclusion of genetic risk alleles (either singly or as a composite genetic risk score for 8 GWAS SNPs) to ACD only provided a +0.50% improvement in re-classifying PACG cases and controls over and above the discriminatory value of ACD. This +0.50% improvement was not statistically significant (P>0.05).ConclusionsAlthough significant on their own, the incorporation of genetic data in the context of anterior segment imaging parameters like ACD provided only a marginal improvement of PACG detection.
  • A New Era in the Treatment of Thyroid Eye Disease
    • Abstract: Publication date: Available online 1 August 2019Source: American Journal of OphthalmologyAuthor(s): Amy Patel, Huasheng Yang, Raymond S. Douglas PurposeImproved understanding of thyroid eye disease (TED) pathogenesis has facilitated identification of a targeted molecular approach for TED treatment offering the potential to halt or slow disease progression in a nonsurgical manner. Herein, we provide a summary of the current knowledge of TED management, followed by discussion of a novel insulin-like growth factor-1 receptor (IGF-1R) antagonist antibody and its potential to change the course of the disease.DesignPerspective.MethodsReview of the literature and authors’ experience.ResultsMany publications demonstrate IGF-1R overexpression in TED, and its activation as an autoantigen as a critical factor in TED pathogenesis. Several in vitro studies demonstrate that IGF-1R inhibition attenuates downstream molecular events including cytokine and hyaluronan production, and cellular differentiation. These observations led to the hypothesis that blocking the IGF-1R may abrogate the clinical progression of TED. The recent completion of phase 2 and 3, randomized, placebo-controlled trials demonstrate the efficacy and safety of teprotumumab, a fully human monoclonal IGF-1R antagonist antibody, in patients with moderate-to-severe active TED. Both the phase 2 and the recent phase 3 study results demonstrate that more patients with active TED receiving teprotumumab experienced a meaningful improvement in proptosis.ConclusionsCurrent TED treatment strategies target inflammation and symptoms, but do not modify the disease course. Therefore, proptosis as well as strabismus and its resulting diplopia often remain, impacting patient well-being and quality of life over the long-term. Targeted molecular therapy using teprotumumab demonstrates disease-modifying benefits with the potential to shift the paradigm for TED treatment.
  • Validation of the Pediatric Eye Questionnaire (PedEyeQ) in Children with
           Visual Impairment
    • Abstract: Publication date: Available online 1 August 2019Source: American Journal of OphthalmologyAuthor(s): David A. Leske, Sarah R. Hatt, Yolanda S. Castañeda, Suzanne M. Wernimont, Laura Liebermann, Christina S. Cheng-Patel, Eileen E. Birch, Jonathan M. Holmes PurposeTo evaluate the recently developed Pediatric Eye Questionnaire (PedEyeQ) in visually impaired and visually normal children, as an initial validation of the PedEyeQ.Design: Questionnaire validation studyMethods48 children with visual impairment (retinal, cortical, and corneal conditions) and 59 visually normal controls were enrolled at two centers. Five- to 17-year-old children completed the Child PedEyeQ (5-11 and 12-17 year-old versions), and parents completed the Proxy PedEyeQ (0-4, 5-11, 12-17 year-old versions) and the Parent PedEyeQ. Rasch scores were calculated, by age group, for each distinct domain within each age-specific PedEyeQ (converted to 0-100 for interpretation). Domains for the Child PedEyeQ are functional vision, bothered by eyes/vision, social, frustration/worry. Proxy PedEyeQ domains are: functional vision, bothered by eyes/vision, social, frustration/worry, eye-care. Parent PedEyeQ domains are: impact on parent and family, worry about child’s eye condition, worry about child’s self-perception/interactions, worry about child’s functional vision. For each domain, median PedEyeQ scores were compared between visually impaired and visually normal cohorts.ResultsChild 5-11 and 12-17 PedEyeQ scores were significantly lower (worse) for visually impaired children than for controls for each domain (P
  • Factors impacting outcomes and the time to recovery from malignant
    • Abstract: Publication date: Available online 1 August 2019Source: American Journal of OphthalmologyAuthor(s): Atalie C. Thompson, Daniel M. Vu, Eric A. Postel, Pratap ChallaABSTRACTPurposeTo identify factors associated with the successful management of malignant glaucoma (MG).DesignRetrospective case seriesMethodsSettingSingle institutionStudy population64 eyes (55 subjects) with MGObservation Procedure(s): Chart reviewMain Outcome MeasuresAnatomy, intraocular pressure (IOP), best visual acuity (BVA)Results87.5% (N=56/64) of eyes with MG required surgical intervention. Vitrectomy was more likely to be successful in eyes with a history of
  • Safety and Effectiveness of CyPass Supraciliary Micro-Stent in Primary
           Open-Angle Glaucoma: Five-Year Results from the COMPASS XT Study
    • Abstract: Publication date: Available online 1 August 2019Source: American Journal of OphthalmologyAuthor(s): George Reiss, Bill Clifford, Steven Vold, Jonathan He, Cody Hamilton, Jaime Dickerson, Stephen Lane PurposeTo characterize the long-term (up to five years) safety and effectiveness of the supraciliary micro-stent implanted at the time of phacoemulsification in eyes with coexisting open-angle glaucoma (OAG) and visually significant cataractDesignThree-year safety extension of a two-year randomized clinical trial.MethodsPatients from the multicenter COMPASS trial who underwent micro-stent implantation plus phacoemulsification (n=215) or phacoemulsification alone (n=67) were evaluated 36, 48, and 60 months postoperatively. The primary outcome measure was the occurrence of sight-threatening ocular serious adverse events. Evaluations at each time point included best-corrected visual acuity (BCVA), anterior and posterior segment examinations, tonometry, gonioscopy, pachymetry, perimetry, specular microscopy, and assessment of adverse events.ResultsThree sight-threatening ocular adverse events occurred, two in the micro-stent and one in the control group, but none of these events was related to the micro-stent device. Ocular adverse events were of similar frequencies in both groups, the most common of which were BCVA loss >2 lines compared with best BCVA in COMPASS and worsening of visual field mean defect (VFMD) >2.5 dB compared with Month 24. Changes from baseline in mean BCVA, clinical examinations, pachymetry and VFMD were similar in the two groups. At 60 months, a higher proportion of subjects in the micro-stent (46%; 95% CI 38.9% –53.2%) than in the control (32.1%; 95% CI 19.9%–46.3%) group achieved ≥ 20% IOP reduction without using hypotensive medication.ConclusionsFew sight-threatening serious ocular adverse events occurred following micro-stent implantation, and clinical evidence of corneal decompensation was minimal.
  • Racial, Ethnic, and Socioeconomic Disparities in Retinoblastoma
           Enucleation: A Population-Based Study, SEER 18 2000-2014
    • Abstract: Publication date: November 2019Source: American Journal of Ophthalmology, Volume 207Author(s): Nitya Rajeshuni, Alice S. Whittemore, Cassie A. Ludwig, Prithvi Mruthyunjaya, Darius M. MoshfeghiPurposeTo determine the effect of race, ethnicity, and census tract–level composite socioeconomic status (SES) on retinoblastoma enucleation. This study augments Truong and associates, providing multivariate analyses combining sociodemographic and clinical characteristics with more accurate SES measures. We hypothesized that children from nonwhite, Hispanic, and lower socioeconomic backgrounds would have increased adjusted odds of enucleation.DesignRetrospective cohort analysis.SettingMulticenter population-based study using the Surveillance, Epidemiology, and End Results (SEER) 18 Registries.Study PopulationChildren aged 18 years and younger diagnosed with retinoblastoma between 2000 and 2014. Subjects were identified using International Classification of Diseases–Oncology (ICD-O) site and morphology codes.Main Outcome MeasuresEnucleation odds ratios (ORs) and 95% confidence intervals (CIs).ResultsAnalysis of 959 retinoblastoma patients revealed that 70.8% were enucleated. Adjusted analyses showed associations between enucleation and Asian (OR 2.00, CI 1.08–3.71) or black (2.42, 1.41–4.16) race, Hispanic ethnicity (1.69, 1.16–2.46), and low SES (1.68, 1.09–2.58). Significantly increased enucleation risk was associated with older age at diagnosis (age 1-2 years 2.55, 1.80–3.61;>2 years 4.88, 2.57–9.25), unilateral disease (5.00, 3.45–7.14), and advanced stage (regional 4.71, 2.51–8.84; distant 3.15, 1.63–6.08). No interactions were observed between race, ethnicity, SES, and stage at diagnosis. Enucleation rates decreased over time across all racial, ethnic, and socioeconomic groups.ConclusionsChildren from nonwhite, Hispanic, and lower socioeconomic backgrounds are more likely to receive enucleation. These associations are independent of stage of diagnosis, suggesting larger systemic disparities in retinoblastoma care. The origin of these differences requires further study and attention by clinicians and policy makers.
  • Corneal Endothelial Cell Loss and Morphometric Changes 5 Years after
           Phacoemulsification With or Without CyPass Micro-Stent
    • Abstract: Publication date: Available online 1 August 2019Source: American Journal of OphthalmologyAuthor(s): Jonathan H. Lass, Beth Ann Benetz, Jonathan He, Cody Hamilton, Mark Von Tress, Jaime Dickerson, Stephen Lane PurposeTo characterize long-term corneal endothelial cell changes following phacoemulsification with or without supraciliary micro-stent (CyPass, Alcon, Ft. Worth, TX) implantation in eyes with open-angle glaucoma (OAG) and visually-significant cataract.DesignThree-year safety extension of a two-year randomized clinical trial.MethodsPatients from the multicenter COMPASS trial who underwent micro-stent implantation plus phacoemulsification (n=282) or phacoemulsification alone (n=67) were analyzed post-hoc. Specular microscopy was used to assess endothelial cell loss (ECL), including changes from baseline in endothelial cell density (ECD), coefficient of variation, and percentage of hexagonal cells,.ResultsPreoperative ECD was similar in the microstent (2432.6 cells/mm2 [95% CI: 2382.8, 2482.4]) and control (2434.5 cells/mm2 [95% CI: 2356.5, 2512.4]) groups. ECL at Months 48 and 60 was greater in the micro-stent than in the control group. At Month 60, mean percent changes in ECD were -20.4% (95% CI: -23.5%, -17.5%) in the micro-stent and -10.1% (95% CI: -13.9%, -6.3%) in the control group. No statistically significant between-group changes from baseline in cellular morphology were observed. Nine adverse events were possibly related to ECL, including three eyes with transient focal corneal edema and four eyes that required micro-stent trimming due to protrusion.ConclusionsIn eyes with OAG, ECL following phacoemulsification is acute and stabilizes after 3 months, whereas ECL following phacoemulsification plus micro-stent implantation proceeds for at least 5 years. Clinical findings associated with ECL in these eyes were uncommon (3.3% of implanted eyes), suggesting that ECL is generally a subclinical phenomenon.
  • Preoperative risk assessment for progression to DMEK following cataract
           surgery in Fuchs Endothelial Corneal Dystrophy.
    • Abstract: Publication date: Available online 29 July 2019Source: American Journal of OphthalmologyAuthor(s): Francisco Arnalich-Montiel, David Mingo-Botín, Pablo De Arriba-Palomero PurposeTo identify preoperative corneal tomographic features that predict progression to Endothelial Keratoplasty (EK) following cataract surgery in Fuchs Endothelial Corneal Dystrophy (FECD) and establish a regression model to identify high-risk patients.DesignProspective, observational cohort study.MethodsSettingHospital Universitario Ramón y Cajal, MadridStudy populationSixty-eight patients (84 eyes) with FECD who underwent phacoemulsification.Intervention We assessed preoperative best-corrected visual acuity; ultrasound central corneal thickness (CCT); pachymetric, anterior chamber depth and corneal backscatter variables using Scheimpflug imaging; and endothelial cell density.Main Outcome MeasuresProgression to EK.ResultsA total of 39.3 % (33 eyes) needed EK after phacoemulsification to rehabilitate vision. On multivariate analysis, Anterior-Layer (AL) corneal backscatter between 0 and 2 mm from the apex and relative increase in central corneal thickness from the “Relative Pachymetry Display” by the Pentacam were significant predictors of the risk of progression to EK. Using these two variables, a risk score (RISC score) was derived from the regression model (area under the curve (AUC) = 0.973; best cutoff point with a specificity of 95% representing a sensitivity of 96%). Excluding corneal backscatter data from the multivariate regression model, corneal thickness at the pupil center by the Pentacam, and relative increase in central corneal thickness were significant predictors and provided a modified risk score (RIPT score) with similar performance.ConclusionBoth scores demonstrated accuracy in predicting progression to EK using easily accessible preoperative data. This approach, which can be readily implemented by surgeons, allows for individualized risk assessment.
  • Influence of Bruch’s Membrane Opening Area in Diagnosing Glaucoma with
           Neuroretinal Parameters from Optical Coherence Tomography
    • Abstract: Publication date: Available online 24 July 2019Source: American Journal of OphthalmologyAuthor(s): Lucas A. Torres, Glen P. Sharpe, Donna M. Hutchison, Camila S. Zangalli, Reinhard O. Burk, Alexandre S.C. Reis, Vital P. Costa, Marcelo T. Nicolela, Balwantray C. Chauhan, Jayme R. Vianna PurposeTo determine whether the glaucoma diagnostic accuracy of age and Bruch’s membrane opening area (BMOA) adjusted normative classifications of minimum rim width (MRW) and retinal nerve fibre layer thickness (RNFLT) is dependent on BMOA, in a European descent population.DesignRetrospective, cross-sectional study.MethodsWe included 182 glaucoma patients and 166 healthy controls for the primary study, and 105 glaucoma patients in a second sample used for a replication study. Optical coherence tomography (Spectralis) measurements of BMOA, global MRW and RNFLT and normative classifications from the device software were exported for analysis. Sensitivity and specificity were calculated for a conservative criterion (abnormal = “outside normal limits” classification) and a liberal criterion (abnormal = “outside normal limits” or “borderline” classifications). The dependence of sensitivity and specificity on BMOA was analysed with comparison among subgroups divided by tertiles of BMOA, and with logistic regression.ResultsFor the conservative criterion, MRW sensitivity was independent of BMOA (p≥0.76), while RNFLT sensitivity increased in the large BMOA subgroup (p=0.04, odds ratio: 1.2 per mm2 [p=0.02]). For the liberal criterion, MRW and RNFLT sensitivities were independent of BMOA (p≥0.53). Specificities were independent of BMOA (p≥0.07). For the replication sample, which included younger patients, with larger BMOA, and worse visual field damage than the primary sample, sensitivities were independent of BMOA for both criteria (p≥0.10).ConclusionsRNFLT sensitivity was higher in eyes with larger BMOA, however, age and visual field damage may influence that association. MRW diagnostic accuracy was not dependent on BMOA.
  • Comparison between Methotrexate and Mycophenolate Mofetil monotherapy for
           the control of Non- Infectious Ocular Inflammatory Diseases
    • Abstract: Publication date: Available online 22 July 2019Source: American Journal of OphthalmologyAuthor(s): Sapna S. Gangaputra, Craig W. Newcomb, Marshall M. Joffe, Kurt Dreger, Hosne Begum, Pichaporn Artornsombudh, Siddharth S. Pujari, Ebenezer Daniel, H. Nida Sen, Eric B. Suhler, Jennifer E. Thorne, Nirali P. Bhatt, C. Stephen Foster, Douglas A. Jabs, Robert B. Nussenblatt, James T. Rosenbaum, Grace A. Levy-Clarke, John H. Kempen, SITE Cohort Research Group :PurposeTo compare mycophenolate mofetil (MMF) to methotrexate (MTX) as corticosteroid-sparing therapy for ocular inflammatory diseases.DesignRetrospective analysis of cohort study dataMethodsParticipants were identified from the Systemic Immunosuppressive Therapy for Eye Diseases Cohort Study. Demographic and clinical characteristics were obtained via medical record review. The study included 352 patients who were taking single agent immunosuppression with MTX or MMF at four tertiary uveitis clinics. Marginal structural models (MSM)-derived statistical weighting created a virtual population with covariates and censoring patterns balanced across alternative treatments. With this methodological approach, the results estimate what would have happened had none of the patients stopped their treatment. Survival analysis with stabilized MSM-derived weights simulated a clinical trial comparing MMF vs. MTX for non-infectious inflammatory eye disorders. The primary outcome was complete control of inflammation on prednisone ≤10 mg/day, sustained for ≥30 days.ResultsThe time-to-success was shorter (more favorable) for MMF than MTX (HR=0.68, 95% confidence interval: 0.46-0.99). Adjusting for covariates, the proportion achieving success was higher at every point in time for MMF than MTX from 2-8m then converges at 9 months. The onset of corticosteroid-sparing success took more than three months for most patients in both groups. Outcomes of treatment (MMF vs. MTX) were similar across all anatomic sites of inflammation. The incidence of stopping therapy for toxicity was similar in both groups.ConclusionsOur results suggest that, on average, MMF may be faster than MTX in achieving corticosteroid-sparing success in ocular inflammatory diseases.
  • Effects of Hydrogen in Prevention of Corneal Endothelial Damage During
           Phacoemulsification: A Prospective Randomized Clinical Trial
    • Abstract: Publication date: November 2019Source: American Journal of Ophthalmology, Volume 207Author(s): Tsutomu Igarashi, Ikuroh Ohsawa, Maika Kobayashi, Yusuke Umemoto, Takeshi Arima, Hisaharu Suzuki, Toru Igarashi, Toshiaki Otsuka, Hiroshi TakahashiPurposeHydrogen (H2) has been reported to scavenge free radicals, particularly the hydroxyl radical (·OH). Ultrasound oscillation in an aqueous solution produces ·OH. Our recent study demonstrated that H2 dissolved in an irrigation solution prevented corneal endothelial damage during phacoemulsification in an animal model. We examined the effects of H2 during clinical phacoemulsification.DesignA single-center, prospective, randomized, double-masked clinical trial.MethodsThirty-two patients who had cataracts of similar nucleus hardness in both eyes (age: 75.4±7.68 years; 17 males, 15 females) were recruited. Phacoemulsification was performed using a solution of dissolved H2 in one eye, and a conventional solution in the contralateral eye. Endothelial cell density (ECD) at the center of the cornea was measured using noncontact specular microscopy preoperatively and at 1 day, 1 week, and 3 weeks postoperatively.ResultsReduction rates of ECD (mean ± standard deviation) were 16.0%±15.7% at 1 day, 15.4%±16.1% at 1 week, and 18.4%±14.9% at 3 weeks in the control group, compared to 6.5%±8.7% at 1 day (P = .003), 9.3%±11.0% at 1 week (P = .039), and 8.5%±10.5% at 3 weeks (P = .004) in the H2 groups. These rates were significantly smaller in the H2 group at all time points.ConclusionsH2 dissolved in irrigation solution reduced corneal endothelial damage during phacoemulsification. This suggests that a considerable part of the corneal endothelial damage during phacoemulsification is caused by oxidative stress, and that H2 is useful in clinical phacoemulsification.
  • Treatment for central-peripheral rivalry-type diplopia (“dragged-fovea
           diplopia syndrome”)
    • Abstract: Publication date: Available online 16 July 2019Source: American Journal of OphthalmologyAuthor(s): Sarah R. Hatt, David A. Leske, Lindsay D. Klaehn, Andrea M. Kramer, Raymond Iezzi, Jonathan M. HolmesABSTRACTPurposeTo report the effectiveness of treatments for central-peripheral rivalry (CPR)-type diplopia due to retinal misregistration.DesignRetrospective, interventional case seriesSettingAdult strabismus clinic at a tertiary medical centerPatient population50 adults with retinal misregistration and CPR-type diplopia (minimum frequency of “sometimes” at distance and/or for reading), caused by epiretinal membrane (n=44) or other retinal disorders (n=6).InterventionsIncluded treatments were: Bangerter filter, tape, Fresnel prism, clear prism (incorporated into glasses or loose prism in office), iseikonic manipulation (using iseikonic lenses or contact lenses), MIN lens, or epiretinal membrane peeling (alone or in any combination). Not all treatments were trialed on all patients.Main outcome measuresDiplopia frequency evaluated using the Diplopia Questionnaire. Success was defined as “never” or “rarely” diplopic for distance and reading using the Diplopia Questionnaire, at an outcome examination as close as possible to 6 months.ResultsOverall, 17 (34%, 95% CI 21% to 49%) of 50 patients were classified a success: Fresnel prism 4 (57%, 18% to 90%) of 7 patients; Bangerter filter 4 (14%, 4% to 33%) of 28, epiretinal membrane peeling 8 (44%, 22% to 69%) of 18 patients, and iseikonic manipulation (using a contact lens) 1 (4%, 0% to 22%) of 23 patients.Conclusionsand relevance: CPR-type diplopia may be relieved in some patients using non-surgical treatment options of Fresnel prism or Bangerter filter. ERM peeling was surprisingly successful and should be considered.
  • Glucocorticoid receptor α and MKP-1 as candidate biomarkers for treatment
           response and disease activity in Vogt-Koyanagi-Harada disease
    • Abstract: Publication date: Available online 16 July 2019Source: American Journal of OphthalmologyAuthor(s): Cristhian A. Urzua, Ping Chen, Benjamin Chaigne-Delalande, Baoying Liu, Rodrigo Anguita, Julia Guerrero, Pablo Sabat, Victor Velasquez, H. Nida Sen, Richard W.J. Lee, Annelise Goecke PurposeTo investigate the potential to utilize the expression of genes for glucocorticoid (GC) receptor and mitogen-activated protein kinase phosphatase-1 (MKP1) as biomarkers of corticosteroid (CS) refractoriness and disease activity in patients with Vogt-Koyanagi-Harada disease (VKH).DesignProspective cohort study.MethodsTwenty VKH patients receiving their first cycle of CS treatment, in the absence of additional systemic immunosuppressive therapy, and a control group of fifteen healthy volunteers were recruited from University of Chile (Santiago, Chile) and National Institutes of Health (Bethesda, United States). Intraocular inflammation was clinically quantified at enrolment and all follow-up visits. CS refractoriness was defined as an ocular reactivation of VKH on CS withdrawal at a daily oral prednisone dose of 10 mg or more. Quantitative RT-PCR was performed to measure the mRNA levels of the alpha (α) and beta (β) isoforms of GC receptor (GR) and MKP1 in peripheral blood mononuclear cells (PBMC) after in vitro stimulation with either anti-CD3/anti-CD28 antibodies, lipopolysaccharide (LPS) or phytohaemagglutinin (PHA), in the presence or absence of dexamethasone (Dex).ResultsAfter six hours of stimulation in the presence of Dex, PBMC from CS-refractory VKH patients had an impaired elevation in GRα expression (p=0.03). Furthermore, inactive patients showed a significant Dex-induced upregulation of MKP1 (p=0.005).ConclusionsIn this pilot study, the expression of GR isoforms and MKP1 corresponded with patients’ clinical response to systemic CS treatment and disease activity, respectively. Hence, these candidate biomarkers have potential clinical utility in the early identification of CS-refractoriness and sub-clinical inflammation in patients with VKH.
  • The effect of a spectral filter on visual quality in patients with an
           extended-depth-of-focus intraocular lens
    • Abstract: Publication date: Available online 16 July 2019Source: American Journal of OphthalmologyAuthor(s): Grzegorz Łabuz, Gerd U. Auffarth, Aydin Özen, Thomas JTP. van den Berg, Timur M. Yildirim, Hyeck-Soo Son, Ramin KhoramniaPurposeWavelength dependence of diffractive intraocular lenses (IOLs) was recognized in vitro but not yet assessed in vivo. By examining pseudophakic patients who had extended-depth-of-focus diffractive implants, we clinically measured this spectral effect on their vision. We also tested the lens in vitro.DesignCross-sectional study with laboratory investigation.MethodsTwelve patients (23 eyes), all pseudophakic with a Symfony lens, were measured monocularly in red and white light at far, intermediate and near. Corrected distance visual acuity (CDVA), distance corrected intermediate and near visual acuity (DCIVA and DCNVA) were assessed. Contrast sensitivity was examined at several spatial frequencies. The in-vitro lens modulation transfer function (MTF) was measured, under different spectral conditions, using an IOL metrology device.ResultsCDVA was comparable in red and white light. DCIVA and DCNVA were significantly better in white light by 0.06 and 0.09, respectively. Contrast sensitivity was slightly better with a red filter at far, but it was worse at intermediate, though differences were significant only at one frequency. Near contrast sensitivity was better in polychromatic than red light, which was significant at three frequencies. The in-vitro analysis confirmed Symfony's wavelength dependence: performance is improved at far, but is worse at intermediate and near.ConclusionsSymfony's spectral dependence was observed to affect visual acuity and contrast sensitivity. Although the red filter did not improve distance vision, it caused visual deterioration at near. One might take this effect into account when optimizing the reading performance of patients with diffractive IOLs.
  • Quantification of choriocapillaris with OCTA: a comparison study
    • Abstract: Publication date: Available online 16 July 2019Source: American Journal of OphthalmologyAuthor(s): Zhongdi Chu, Giovanni Gregori, Philip J. Rosenfeld, Ruikang K. Wang PurposeTo demonstrate the variation in quantitative choriocapillaris (CC) metrics with various binarization approaches using optical coherence tomography angiography (OCTA).DesignRetrospective, observational, cross-sectional case series.Methods3x3 mm and 6x6 mm macular OCTA scans were obtained from normal eyes and from eyes with drusen secondary to AMD. The CC slab was extracted and the CC flow deficits (FDs) were segmented with two previously published algorithms: fuzzy C-means approach (FCM method) and Phansalkar’s local thresholding (Phansalkar method). Four different values for the radius were used in order to investigate the effect on the FD segmentation when using the Phansalkar method. FD density (FDD), mean FD size (MFDS), FD number (FDN), FD area (FDA) and inter-capillary distance (ICD) were calculated for comparison. Repeatability was assessed as coefficient of variation (CV) and Pearson’s correlation analysis was conducted.ResultsSix eyes from 6 subjects with normal eyes and 6 eyes from 6 subjects with drusen secondary to AMD were scanned. 3x3 mm scans resulted in higher repeatability compared to 6x6 mm scans. For the Phansalkar method, larger values of the radius resulted in higher repeatability. ANOVA tests resulted in significant differences (p
  • Machine learning-based predictive modeling of surgical intervention in
           glaucoma using systemic data from electronic health records
    • Abstract: Publication date: Available online 16 July 2019Source: American Journal of OphthalmologyAuthor(s): Sally L. Baxter, Charles Marks, Tsung-Ting Kuo, Lucila Ohno-Machado, Robert N. Weinreb PurposeTo predict the need for surgical intervention in patients with primary open-angle glaucoma (POAG) using systemic data in electronic health records (EHR).DesignDevelopment and evaluation of machine learning models.MethodsStructured EHR data for 385 POAG patients from a single academic institution were incorporated into models using multivariable logistic regression, random forests, and artificial neural networks. Leave-one-out cross-validation was performed. Mean area under the receiver operating characteristic curve (AUC), sensitivity, specificity, accuracy, and Youden Index were calculated for each model to evaluate performance. Systemic variables driving predictions were identified and interpreted.ResultsMultivariable logistic regression was most effective at discriminating patients with progressive disease requiring surgery, with an AUC of 0.67. Higher mean systolic blood pressure was associated with significantly increased odds of needing glaucoma surgery (odds ratio [OR] 1.09, p
  • Retinal detachment: Patient perspective and Electronic Medical Records
    • Abstract: Publication date: Available online 16 July 2019Source: American Journal of OphthalmologyAuthor(s): Gary D. Novack, Michele C. LimTwo perspectives are provided on the retinal detachment suffered by one of the authors on a national holiday. One perspective is the personal one - a disturbing visual symptom, the surgery, the recovery and the worry about potential long lasting sequelae, and the need to reiterate detailed medical information several times during a stressful period. The other perspective is a national one regarding electronic health records. Current systems have been called “soul-sapping”, requiring physicians to direct their focus to the computer, rather than the patient. While electronic health records are a national mandate, the lack of intraoperability between different physician and hospital systems means that we are far from achieving meaningful digitization of records. For example, only forty-one percent of hospitals in the US that have electronically available medical information from outside providers or sources when treating a patient. Physicians in outpatient settings fare worse with only 14% of office-based physicians sharing data with providers outside of their organization. The case report outlined in our article provides a close look at how it may be difficult to receive care in a fragmented health care model in which physician and hospital do not share the same EHR. Information blocking, now prohibited by federal law, still remains as an obstacle to intraoperability. It will take continued effort and commitment from key stakeholders such as health care providers, patients, the federal government, and industry to bring this dream to fruition.
  • Performance Of The 2win Photoscreener With “Cr” Strabismus Estimation
           In High Risk Patients
    • Abstract: Publication date: Available online 9 May 2019Source: American Journal of OphthalmologyAuthor(s): Stephanie L. Arnold, Andrew W. Arnold, Jacob H. Sprano, Robert W. Arnold BackgroundAccurate estimation of refractive error and ocular alignment is critical for identifying amblyopia risk factors. The 2WIN photoscreener (Adaptica, Italy) uses a novel infrared-transmitting occluder wand to quickly estimate intermittent deviations.Design; Reliability analysis.Methods2WIN refraction was compared to dry and cycloplegic retinoscopy and Retinomax. 2WIN “CR” function with wand was compared to cover test.Results371 patients, 0.6-63 years, median age 6 years had refraction and 2WIN yielding high degrees of correlation (Pearson Product Moment) on linear regression for spherical equivalent (0.73-0.79), Cylinder power (0.78-0.79), J0 vector (0.79-0.83) and J45 vector (0.64-0.67) . Similar proportions of 2WIN and Retinomax were inside target refraction values for spherical equivalent (70% vs 69%), cylinder power (94% vs 90%) and cylinder axis (69% vs 71%). 2WIN CR above 10 PD correlated with cover test for constant and intermittent deviations (Pearson 0.64-0.71). 2WIN + CR screened for 2003 AAPOS amblyopia risk factors with 68% sensitivity and 84% specificity in preschool children with 56% prescreening probability and 31% developmental delays.ConclusionThe 2WIN correlated well with exam and Retinomax. The CR function reliably estimated constant and intermittent strabismus over 10 PD.
  • Clinical and molecular characterization of familial exudative
           vitreoretinopathy associated with microcephaly
    • Abstract: Publication date: Available online 8 May 2019Source: American Journal of OphthalmologyAuthor(s): Sarah Hull, Gavin Arno, Pia Ostergaard, Nikolas Pontikos, Anthony G. Robson, Andrew R. Webster, Chris R. Hogg, Genevieve A. Wright, Robert H.H. Henderson, Carol-Anne Martin, Andrew P. Jackson, Sahar Mansour, Anthony T. Moore, Michel Michaelides PurposeFamilial exudative vitreoretinopathy (FEVR) is a rare finding in patients with genetic forms of microcephaly. This study documents the detailed phenotype and expands the range of genetic heterogeneity.Design; Retrospective case-seriesMethodsTwelve patients (ten families) with a diagnosis of FEVR and microcephaly were ascertained from pediatric genetic eye clinics and underwent full clinical assessment including retinal imaging. Molecular investigations included candidate gene Sanger sequencing, whole-exome sequencing (WES) and whole-genome sequencing (WGS).ResultsAll patients had reduced vision and nystagmus. Six were legally blind. Two probands carried bi-allelic LRP5 variants, both presenting with bilateral retinal folds. A novel homozygous splice variant, and two missense variants were identified. Subsequent bone density measurement, identified osteoporosis in one proband.Four families had heterozygous KIF11 variants. Two probands had a retinal fold in one eye and chorioretinal atrophy in the other; the other two had bilateral retinal folds. Four heterozygous variants were found, including two large deletions not identified on Sanger sequencing or WES.Finally, a family of two children with learning difficulties, abnormal peripheral retinal vasculogenesis and rod-cone dystrophy were investigated. They were found to have bi-allelic splicing variants in TUBGCP6.Three families remain unsolved following WES and WGS.ConclusionsMolecular diagnosis has been achieved in seven of ten families investigated including a previously unrecognized association with LRP5. WGS enabled molecular diagnosis in three families after prior negative Sanger sequencing of the causative gene. This has enabled patient-specific care with targeted investigations and accurate family counseling.
  • Changes in Retinal Microcirculation Precede the Clinical Onset of Diabetic
           Retinopathy in Children with Type 1 Diabetes Mellitus
    • Abstract: Publication date: Available online 19 April 2019Source: American Journal of OphthalmologyAuthor(s): Merve Inanc, Kemal Tekin, Hasan Kiziltoprak, Servan Ozalkak, Sibel Doguizi, Zehra Aycan PurposeTo investigate whether abnormal glucose metabolism in diabetes mellitus (DM) affects the retinal microcirculation of children with well-controlled type 1 DM and to compare these results with those obtained from healthy children.DesignCross-sectional prospective study.MethodsThis study enrolled 60 patients with DM without clinically detectable diabetic retinopathy (DR) and who met 57 age-matched controls. Optical coherence tomography angiography (OCT-A) was performed using AngioVue (Avanti, Optivue). Foveal avascular zone (FAZ) area, non-flow area, superficial and deep vessel densities, FAZ perimeter, acircularity index of FAZ (AI; the ratio of the perimeter of FAZ and the perimeter of a circle with equal area), and foveal density (FD-300; vessel density in 300 microns around FAZ) were analyzed. Correlations between the investigated OCT-A parameters with DM duration and glycated hemoglobin (HbA1c) levels were evaluated among patients with type 1 DM.ResultsDifferences in the mean values for FAZ perimeter, AI, and FD-300 were statistically significant between DM group and control group (P
  • Optical Coherence Tomography Angiography for Evaluation of Reperfusion
           following Pterygium Surgery
    • Abstract: Publication date: Available online 6 April 2019Source: American Journal of OphthalmologyAuthor(s): Yu-Chi Liu, Kavya Devarajan, Tien-En Tan, Marcus Ang, Jodhbir S. Mehta PurposeTo describe the use of optical coherence tomography angiography (OCTA) to quantitatively monitor the conjunctival graft revascularization after pterygium excision and conjunctival autograft (CAG) transplantation.DesignProspective, interventional case series.MethodsTen patients undergoing pterygium excision and femtosecond laser-assisted CAG transplantation were included. OCTA was performed at 1 week, 1 and 3 months postoperatively at the CAG transplantation site and harvested area. The vessel density at three different depths: conjunctival epithelium or CAG epithelium, conjunctival stroma or CAG stroma, and episclera, was evaluated and quantified. The revascularization rate was assessed and correlated with the postoperative CAG thickness.ResultsNo intraoperative and postoperative complications occurred. Reperfusion of the CAGs was observed at 1 week, and early reperfusion within the first month accounted for more than half of graft revascularization. The vessel regrowth density was 9.6±2.6 % and 11.1±2.8 % between 1 week and 1 month, and was 9.8±1.8 % and 11.9±1.9 % between 1 and 3 months, at the CAG and underlying episcleral levels, respectively. All the CAGs were well-perfused at 3 months. The vessel regrowth density was significantly and strongly correlated with the changes of CAG thickness in a negative relationship (γ=-0.94, P=0.019). At the harvested site, the vascular network of episclera was not affected, and the conjunctival vascularization was restored at 1 month.ConclusionsOCTA is a promising tool to evaluate the vascularization or revascularization of conjunctiva, conjunctival graft and episclera, in a quantitative and serial manner, helping in diseases diagnosis and treatment monitoring. The graft revascularization rate was predictive of postoperative graft deswelling.
  • Evaluating the Impact of Uveitis on Visual Field Progression Using Large
           Scale Real-World Data
    • Abstract: Publication date: Available online 26 June 2019Source: American Journal of OphthalmologyAuthor(s): Xiaoxuan Liu, Stephen R. Kelly, Giovanni Montesano, Susan R. Bryan, Robert J. Barry, Pearse A. Keane, Alastair K. Denniston, David P. Crabb PurposeTo compare rates of visual field (VF) loss in uveitis patients with glaucoma against patients with primary open angle glaucoma (POAG) and explores the association between intraocular pressures (IOP) and rate of VF loss.Design; Retrospective cohort study.MethodsAnonymized VFs and IOP measurements extracted from the EMR of 5 regionally different glaucoma clinics in England. A total of 205 eyes with diagnosis of “uveitis” plus “glaucoma” were compared with 4600 eyes with “POAG” only. Minimum inclusion criteria was ≥4 visits within a 4-year window. Relative risk (RR) of being a “rapid progressor” (mean deviation (MD) loss ≥1.5 dB/year) was calculated. A mixed-effects model (MEM) and a pointwise VF progression analysis of pattern deviation was used to confirm differences between the groups. Longitudinal IOP mean, range and variability were compared with rate of VF progression.ResultsMedian (IQR) baseline MD in the uveitis and POAG groups was –3.8 (-8.7, -1.5) dB and –3.1 (-6.6, -1.2) dB respectively. The uveitis and POAG groups had 23/205 (11%) and 331/4600 (7%) “rapidly progressing” eyes respectively. Age-adjusted RR for “rapid progression” in uveitic versus POAG eyes was 1.9 (95% CI:1.8-2.0). The MEM confirmed that uveitic eyes (-0.49 dB/year) showed higher rates of VF progression than the POAG group (-0.37 dB/year; p
  • Prediction of Glaucoma Progression with Structural Parameters: Comparison
           of Optical Coherence Tomography and Clinical Disc Parameters
    • Abstract: Publication date: Available online 25 June 2019Source: American Journal of OphthalmologyAuthor(s): Ramin Daneshvar, Adeleh Yarmohammadi, Reza Alizadeh, Sharon Henry, Simon K. Law, Joseph Caprioli, Kouros Nouri-Mahdavi PurposeTo test the hypothesis that baseline optical coherence tomography (OCT) measures predict visual field (VF) progression in a cohort of patients with suspected or established glaucoma and compare their performance to semiquantitative optic disc measures.DesignObservational cohort study.MethodsSetting: Academic institution.Study PopulationOne-hundred seventy-one eyes of 95 patients with good-quality baseline retinal nerve fiber layer (RNFL) and macular OCT images and disc photographs with>2 years of follow-up and ≥5 VFs.Observation ProceduresBaseline macular and RNFL OCT measures and cup-to-disc ratio and disc damage likelihood score.Main Outcome MeasuresPrediction of glaucomatous visual field deterioration according to trend and event analyses.ResultsMedian (IQR) baseline mean deviation and follow-up were –2.9 (–6.4 to –1.1) dB and 54 (44-65) months, respectively. Seventeen and 25 eyes progressed by final visit based on pointwise event analysis and trend analysis of Visual Field Index (VFI), respectively. Thinner CCT (p =0.005), female gender (p =0.015), and thinner average pRNFL (p =0.001) predicted VF progression on proportional hazard models. Thinner RNFL at baseline (p =0.006) or thinner average GCIPL (p =0.028) along with higher baseline VFI (p =0.018 and 0.048, respectively) predicted VFI progression. Neither optic disc measures predicted VF progression in any of the explored models.ConclusionsBaseline structural OCT measures predicted subsequent VF progression in contrast to semiquantitative optic disc measures. OCT-based structural measures should be included in prognostic models of glaucomatous VF deterioration.
  • Glaucoma Management in Patients with Aniridia and Boston Type 1
    • Abstract: Publication date: Available online 24 June 2019Source: American Journal of OphthalmologyAuthor(s): Rafaella Nascimento e Silva, Lucy Q. Shen, Carolina A. Chiou, Swapna S. Shanbhag, Eleftherios I. Paschalis, Louis R. Pasquale, Kathryn A. Colby, Claes H. Dohlman, James Chodosh, Milton R. Alves PurposeTo assess outcomes and glaucoma management in eyes with aniridia following Boston type 1 Keratoprosthesis (KPro) implantation.DesignRetrospective, interventional comparative case series.Methods:PopulationPatients with aniridia and patients with other preoperative diagnoses (excluding Stevens-Johnson syndrome, mucous membrane pemphigoid, and congenital disorders) who underwent KPro implantation at Massachusetts Eye and Ear with at least 2 years of follow-up. One eye per patient was selected based on the longer follow-up time.Main OutcomeIntermediate and long-term outcomes related to glaucoma.ResultsThe aniridia (n=22) and comparison (n=61) groups had similar preoperative visual acuity (VA, mean ± standard deviation, 1.86±0.52 LogMAR, p=0.33) and follow-up time (65.6±26.3 months, p=0.25). Prior to KPro implantation, eyes with aniridia had more glaucoma (76.2%) and glaucoma surgery (57.1%) than comparison eyes (51.8%, p=0.053; 23.2%, p=0.005, respectively). More Ahmed valves were co-implanted with KPro in aniridia (47.6%) versus comparison eyes (17.9%, p=0.008). At final follow-up, more aniridia eyes had glaucoma (90.5%) than comparison eyes (64.3%, p=0.02), but the two groups had similar percentages of eyes with cup-to-disc ratio (CDR)>0.8 (23.8% vs. 30.4%, p=0.57) or CDR progression of ≥0.2 (42.9% vs. 44.6%, p=0.89, respectively). None of the eyes with prophylactic tube implantation developed glaucoma. Eyes with and without aniridia did not differ in post-KPro VA improvement (72.7%, 72.1%, p=0.96), and final VA (1.28±0.79 LogMAR, 1.23±0.98 LogMAR, p=0.51).ConclusionDespite a higher glaucoma prevalence, eyes with aniridia achieved similar VA as comparison eyes with more than 5 years of mean follow-up time. Boston KPro offers satisfactory visual rehabilitation in aniridia when glaucoma is managed aggressively.
  • Risk Factors For Fast Visual Field Progression In Glaucoma
    • Abstract: Publication date: Available online 22 June 2019Source: American Journal of OphthalmologyAuthor(s): Ji Hyun Kim, Alessandro Rabiolo, Esteban Morales, Fei Yu, Abdelmonem A. Afifi, Kouros Nouri-Mahdavi, Joseph Caprioli PurposeTo identify baseline and longitudinal risk factors for fast visual field decay in open angle glaucoma patients.DesignRetrospective cohort study.MethodsOpen-angle glaucoma patients with ≥6 visual fields (VF) and ≥4 years of follow-up were included. Visual field decay rates were measured with the following methods: mean deviation (MD) rate, visual field index (VFI) rate, and the Glaucoma Rate Index (GRI). The relationship between visual field rates and clinical variables were investigated with linear mixed models. Logistic regression analysis was performed to determine which factors were associated with fast progression.Results1,317 eyes of 745 patients with a mean (± SD) age of 63.3 (±10.9) years and a median (IQR) MD −2.4 (-0.7 to -5.6) dB at baseline were analyzed. The median (IQR) number of VFs was 12 (9 to 16), and mean follow-up duration was 11.5 (±3.7) years. Older age (p
  • Handheld Optical Coherence Tomography Normative Inner Retinal Layer
           Measurements for Children
    • Abstract: Publication date: Available online 21 June 2019Source: American Journal of OphthalmologyAuthor(s): Maria E. Lim, Kim Jiramongkolchai, Limin Xu, Sharon F. Freedman, Vincent Tai, Cynthia A. Toth, Mays A. El-Dairi PurposeMeasurements of the ganglion cell complex (GCC), comprising the retinal nerve fiber (RNFL), ganglion cell, and inner plexiform layers, can be correlated with vision loss caused by optic nerve disease. Handheld optical coherence tomography (HH-OCT) can be used with sedation in children not amenable to traditional imaging. Purpose: to report GCC and RNFL measurements in normal children using HH-OCT.DesignProspective observational study of normal children ≤ 5-years of age.MethodsHealthy, full-term children ≤5 years-old undergoing sedation or anesthesia were enrolled. Exclusion criteria: prematurity, pre-existing neurologic, genetic, metabolic or intraocular pathology. Demographic data, axial length (Master-Vu Sonomed Escalon, NY), and HH-OCT macular and optic nerve volume scans at 0 degrees (Bioptigen, Inc., NC) were obtained. Retinal segmentation was completed with DOCTRAP software, creating average volume thickness maps.ResultsSixty-seven children (67 eyes, 31 male, age range 3.4-70.9 months) were enrolled. Average axial length was 21.2±1.0 mm with mean spherical equivalent +1.49±1.34 diopters (range: -2.25 to +4.25). Average GCC volume for the total retina was 0.28±0.04 mm3. Forty-seven of these eyes had RNFL analysis. Average RNFL thickness of the papillomacular bundle was 38.2±9.5 μm. There was no correlation between GCC volume, RNFL thickness, patient age, or axial length.ConclusionAverage GCC volume and RNFL thickness was stable from 6-months to 5-years of age. This study provides normative data for GCC and RNFL obtained by HH-OCT in healthy eyes of young children, to serve in evaluating those with optic neuropathies.
  • Netarsudil/Latanoprost Fixed-Dose Combination for Elevated Intraocular
           Pressure: 3-Month Data From a Randomized Phase 3 Trial
    • Abstract: Publication date: Available online 21 June 2019Source: American Journal of OphthalmologyAuthor(s): Sanjay Asrani, Alan L. Robin, Janet B. Serle, Richard A. Lewis, Dale W. Usner, Casey C. Kopczynski, Theresa Heah, Mercury-1 Study Group PurposeTo compare the ocular hypotensive efficacy and safety of a fixed-dose combination (FDC) of the Rho kinase inhibitor netarsudil and latanoprost vs monotherapy with netarsudil or latanoprost.DesignThree-month primary endpoint analysis of a randomized, double-masked, phase 3 clinical trial.MethodsAdults with open-angle glaucoma or ocular hypertension (unmedicated intraocular pressure [IOP]>20 and
  • Systemic Determinants of Peripapillary Vessel Density in Healthy African
           Americans: the African American Eye Disease Study
    • Abstract: Publication date: Available online 21 June 2019Source: American Journal of OphthalmologyAuthor(s): Ryuna Chang, Andrew J. Nelson, Vivian LeTran, Brian Vu, Bruce Burkemper, Zhongdi Chu, Ali Fard, Amir H. Kashani, Benjamin Y. Xu, Ruikang K. Wang, Rohit Varma, Grace M. Richter, African American Eye Disease Study Group PurposeTo determine the relationship between systemic factors and radial peripapillary capillary (RPC) vessel density (VD) in healthy African American (AA) participants of the African American Eye Disease Study.DesignA population-based, cross-sectional study.Methods4135 eyes from 2127 AA participants aged 40 years and older in Inglewood, California, were imaged for 6x6mm optic disc scans on a spectral-domain optical coherence tomography angiography (OCTA) device. Of these, 1029 eyes from 1029 participants who met the inclusion and exclusion criteria were analyzed, including only one eye per participant. Custom software was used to quantify RPC VD. Multivariate linear regression was used to identify systemic factors associated with RPC VD with a significance level set at 0.05. The contribution of each variable to the final model was estimated with the magnitude of standardized regression coefficients (SRC). The fit of the final model was measured by the R2.ResultsAverage RPC VD was 0.346±0.045. Controlling for signal strength, the systemic variables in the final multivariate model associated with reduced RPC VD were older age (β=-0.0123 per decade; SRC=-0.2733; p=
  • Descemet Membrane Endothelial Keratoplasty versus Descemet Stripping
           Automated Endothelial Keratoplasty and Penetrating Keratoplasty
    • Abstract: Publication date: Available online 19 June 2019Source: American Journal of OphthalmologyAuthor(s): J.H. Woo, Marcus Ang, H.M. Htoon, D.T. Tan PurposeTo compare the long-term graft survival outcomes and complications of patients who underwent Descemet Membrane Endothelial Keratoplasty (DMEK), Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) and Penetrating Keratoplasty (PK) for Fuchs corneal endothelial dystrophy (FECD) and bullous keratopathy (BK).DesignRetrospective comparative cohort studyMethodsPatients with FECD and BK who underwent DMEK (121 eyes), DSAEK (423 eyes) or PK (405 eyes) from the prospective cohort from the Singapore Corneal Transplant Registry were included. A Kaplan-Meier survival analysis was conducted to compare the survival probabilities of the 3 groups. The main outcome measure was graft survival.ResultsThe DMEK group had the best overall cumulative graft survival of 97.4%, compared to DSAEK (78.4%) and PK (54.6%). (P
  • Adalimumab in juvenile-idiopathic arthritis-associated uveitis (JIA-U):
           5-year follow-up of the Bristol participants of the SYCAMORE trial
    • Abstract: Publication date: Available online 13 June 2019Source: American Journal of OphthalmologyAuthor(s): S. Horton, A.P. Jones, C.M. Guly, B. Hardwick, M.W. Beresford, R.W.J. Lee, A.D. Dick, A.V. Ramanan PurposeTo determine longer-term outcomes of participants enrolled from a single center in the SYCAMORE trial, a randomized placebo-controlled trial of adalimumab versus placebo in children with juvenile idiopathic arthritis-associated uveitis (JIA-U) uncontrolled on methotrexate.DesignRetrospective interventional case series.MethodsMedical records of all 28 SYCAMORE participants recruited at the Bristol Eye Hospital were reviewed at approximately 3-monthly intervals up to 5 years from the trial randomization date. Uveitis activity, treatment course, visual outcomes, ocular complications and adverse events were recorded. Data are presented using summary statistics.ResultsFollowing withdrawal of the investigational medicinal product (IMP), 25 of the 28 participants were started on adalimumab for active juvenile idiopathic arthritis-associated uveitis (JIA-U). Of the 12 participants in the active treatment arm of the SYCAMORE study, 11 (92%) were restarted on adalimumab after withdrawal of the IMP for active JIA-U (median time to flare 188 days (range 42-413)). Two participants stopped adalimumab for uncontrolled JIA-U. One participant had a reduction in vision to 0.3 due to cataract. Mean visual acuity for the remaining 27 participants was -0.04 (right eye) and -0.05 (left eye).ConclusionsDrug-induced remission of JIA-U did not persist when adalimumab was withdrawn after 1-2 years treatment. Adalimumab was well tolerated and visual acuity outcomes were excellent.
  • Long-term outcomes after surgery of late in-the-bag intraocular lens
           dislocation: a randomized clinical trial
    • Abstract: Publication date: Available online 10 June 2019Source: American Journal of OphthalmologyAuthor(s): Marius Dalby, Olav Kristianslund, Liv Drolsum PurposeTo compare the long-term efficacy and safety of two operation methods for late in-the-bag intraocular lens (IOL) dislocation.DesignProspective, randomized, parallel-group surgical clinical trial.MethodsDuring a 3-year period, we randomly assigned 104 patients (104 eyes) to one group for IOL repositioning by scleral suturing (n = 54) or one for IOL exchange by retropupillary fixation of an iris-claw IOL (n = 50). A single surgeon performed all operations with an anterior approach. Patients were examined before surgery and 6 months, 1 year, and 2 years after surgery. The present study included the 66 patients (63%) who completed the 2-year follow-up, and the main outcome measure was corrected distance visual acuity (CDVA) 2 years after surgery.ResultsAfter 2 years, the mean CDVA was 0.20 ± 0.29 logarithm of the minimum angle of resolution (logMAR) units (range, -0.18 to 1.10) in the repositioning group and 0.22 ± 0.30 logMAR (range, -0.10 to 1.22) in the exchange group (P = .69). A CDVA of 20/40 or better was achieved by 76% of all patients. Four eyes (12%) had cystoid macular edema in the repositioning group compared with five eyes (15%) in the exchange group. Two eyes had re-dislocation (one in each group). There were no cases of endophthalmitis or retinal detachment.ConclusionsThere were no significant differences in visual acuity between IOL repositioning and IOL exchange 2 years after surgery. The two methods were equally efficient and safe from a long-term perspective and are both considered acceptable treatments.
  • Tomographic and Refractive Characteristics of Pediatric First-Degree
           Relatives of Keratoconus Patients
    • Abstract: Publication date: Available online 10 June 2019Source: American Journal of OphthalmologyAuthor(s): Shady T. Awwad, Madeleine Yehia, Carl-Joe Mehanna, Maamoun Abdul Fattah, Alain Saad, Ahmad Hatoum, Christiane Al-Haddad PurposeTo evaluate the tomographic and refractive characteristics of pediatric first-degree relatives of patients with keratoconus.DesignCross-sectional studyMethodsSetting: Department of Ophthalmology at the American University of Beirut Medical, Beirut, Lebanon.Study PopulationPediatric first-degree relatives of patients with keratoconus. Both eyes of all participants aged between 6 and 18 years were included and studied.Exclusion criteriasoft contact lens use in the past 2 weeks or rigid gas-permeable lens wear within 4 weeks, history of prior ocular surgery or infectious keratitis, and unreliable corneal tomography.Masking and randomizationTwo masked cornea and refractive surgeons of different training backgrounds independently evaluated the participants’ tomographical outputs. Additionally, the tomographic data was analyzed using Smadja’s decision tree.Observation proceduresScheimpflug tomography, manifest refraction, and slit-lamp examination.Main outcome measuresAnterior curvature indices, posterior elevation values, thinnest pachymetry, and subjective and objective tomographical interpretation.ResultsOne hundred eighty-three subjects were recruited. Tomographic evaluation after Cohen’s kappa coefficient analysis revealed 32 patients as having keratoconus (17.5%), while 35 patients (19.1%) were labelled as keratoconus by objective analysis. 11.5%-15.5% of patients with keratoconus aged less than 11 years, 18.0% aged 12-15 years, and 25.5% aged 16-18 years. Their respective steepest anterior curvature and thinnest pachymetry are 44.8±6.5D and 515.9±39.2μm, 47.34±3.4D and 496.1±37.9μm, and 49.7±6.1D and 486.0±66.5μm. 37.5% of the keratoconus patients were unilateral as evaluated by tomography alone.ConclusionsThe prevalence of keratoconus in pediatric first-degree relatives of diagnosed keratoconus patients is high. Screening in this high-risk group is warranted.
  • Distribution of Diabetic Neovascularization on Ultra-Widefield Fluorescein
           Angiography and on Simulated Widefield OCT Angiography
    • Abstract: Publication date: Available online 10 June 2019Source: American Journal of OphthalmologyAuthor(s): Jonathan F. Russell, Harry W. Flynn, Jayanth Sridhar, Justin H. Townsend, Yingying Shi, Kenneth C. Fan, Nathan L. Scott, John W. Hinkle, Cancan Lyu, Giovanni Gregori, Stephen R. Russell, Philip J. RosenfeldABSTRACTPurposeAreas of neovascularization (NV) in proliferative diabetic retinopathy (PDR) on ultrawide-field (UWF) fluorescein angiography (FA) were identified and compared with a simulated wide field (WF) swept-source OCT angiography (SS-OCTA) field of view (FOV) to determine whether the WF SS-OCTA FOV was sufficient for detection of NV in PDR.DesignRetrospective, consecutive case seriesMethodsAll patients with PDR and UWF FA imaging at the Bascom Palmer Eye Institute over a period of 5.5 years were identified. UWF FA images were reviewed and sites of NV were identified either as NV of the disc (NVD) or NV elsewhere (NVE). Sites of NVE were classified by disc-centered retinal quadrants. A simulated WF SS-OCTA montage FOV was overlaid on the UWF FA images to determine whether sites of NV would have been identified by this simulated WF SS-OCTA FOV.ResultsA total of 651 eyes with PDR from 433 patients had at least one UWF FA with NV. Of the 651 eyes, 50% were treatment-naïve, 9.8% had NVD only, 41.8% had NVE only, and 48.4% had both NVD and NVE. NVE was most prevalent in the superotemporal quadrant and least prevalent in the nasal quadrants. When the simulated WF SS-OCTA FOV was overlaid on the UWF FA, 98.3% of all eyes, 99.4% of treatment-naive eyes, and 97.2% of previously-treated eyes had NV within the WF SS-OCTA FOV. In those eyes with a repeat UWF FA within 6 to 18 months of the first FA, the distribution of NV did not change in either the treatment-naive or previously-treated eyes.ConclusionsNVE in PDR was most prevalent superotemporally, and 99.4% of treatment-naïve eyes had NV within the simulated WF SS-OCTA FOV. Combined with previous research using WF SS-OCTA to identify NV in PDR, these findings suggest that WF SS-OCTA may be the only imaging modality needed for the diagnosis and longitudinal management of PDR.
  • Spectrum of Disease Severity and Phenotype in Choroideremia Carriers
    • Abstract: Publication date: Available online 8 June 2019Source: American Journal of OphthalmologyAuthor(s): Ruben Jauregui, Karen Sophia Park, Akemi J. Tanaka, Ahra Cho, Maarjaliis Paavo, Jana Zernant, Jasmine H. Francis, Rando Allikmets, Janet R. Sparrow, Stephen H. Tsang PurposeTo characterize and bring awareness to the disease spectrum of female choroideremia patients, as severity can vary from mild, to severe disease comparable to that observed in males.DesignRetrospective cohort study.Methods12 female carriers of disease-causing variants in the CHM gene confirmed by molecular genetic sequencing were characterized clinically and imaged with short-wave fundus autofluorescence (SW-FAF), spectral-domain optical coherence tomography (SD-OCT), and color fundus imaging.ResultsTwelve unrelated female patients with a clinical and genetic diagnosis of choroideremia carriers were included in this study. Disease severity among these phenotypes ranged from mild to severe resembling the typical presentation of choroideremia in males. Mild disease presented with retinal pigment epithelium mottling, a patchy pattern of hypoautofluorescent speckles on SW-FAF, and intact retinal layers on SD-OCT. Severe disease presented with widespread chorioretinal atrophy as shown by SW-FAF and SD-OCT. Each of the identified genetic variants in CHM was predicted to be disease-causing according to in silico prediction software. Disease progression analysis of four patients with follow-up showed a decline in visual acuity for two patients, with progression observed on SD-OCT in one of the patients. No significant disease progression on SW-FAF was observed for any of the patients.ConclusionsFemale carriers of choroideremia can present with a wide range of clinical phenotypes and disease severity, from mild to severe disease similar to males. Symptomatic females should be considered for current and upcoming gene replacement therapy clinical trials.
  • Prolonged cone b-wave on electroretinography is associated with severity
           of inflammation in non-infectious uveitis.
    • Abstract: Publication date: Available online 4 June 2019Source: American Journal of OphthalmologyAuthor(s): Anna H. Brouwer, Gerard C. de Wit, Ninette H. ten Dam, Ralph Wijnhoven, Maria M. van Genderen, Joke H. de Boer PurposeTo investigate retinal function of non-infectious uveitis patients using full-field electroretinography (ERG) and correlate the ERG to disease duration and severity of inflammation.DesignProspective cohort study.MethodsPatients (n=200) with non-infectious uveitis and a disease duration of 5 years (group B, n=120) were included. ERGs of the total 355 uveitis eyes were measured according to an extended ISCEV protocol. ERG abnormalities were related to demographics and uveitis characteristics, including anatomical classification, the duration of uveitis, severity of inflammation, best corrected visual acuity (BCVA), cystoid macular edema (CME), and the highest fluorescein angiography (FA) score during the course of the disease.ResultsThe ERG showed abnormalities in 235 eyes (66.2%). The most frequent and pronounced ERG abnormality was a prolonged implicit time of the cone b-wave (151 eyes, 42.5%), which was associated with vitritis (p=.005), cells in the anterior chamber (p=.007), highest FA score (p=.011), age (p
  • Indications for Fine Needle Aspiration Biopsy of Posterior Segment
           Intraocular Tumors
    • Abstract: Publication date: Available online 3 June 2019Source: American Journal of OphthalmologyAuthor(s): Zélia Maria Corrêa, James Jay Augsburger PurposeTo define four indication categories of fine needle aspiration biopsies (FNABs) of solid intraocular tumors and describe the differences among the patients, tumors, and results of biopsy in these four indication categories.MethodsRetrospective descriptive analysis of 880 FNABs of a solid intraocular tumor of the posterior ocular segment performed by in the authors’ ocular oncology practice during the period July 1980 through July 2014.ResultsFNABs were performed as a separate procedure in 372 cases (42.3%), at plaque implantation in 279 (31.7%), post-enucleation in 225 (25.6%), and post-resection/pre-laser in 4 (0.4%). FNABs were categorized as diagnostic in 292 (33.2%), confirmatory in 121 (13.8%), investigational in 187 (21.3%), and prognostic in 280 (31.8%). Prior to the biopsy, all patients who underwent diagnostic FNAB had a tumor of uncertain pathological type, while all patients who underwent confirmatory FNAB had a clinically diagnosed malignant intraocular neoplasm. In contrast, all patients who underwent a prognostic FNAB had an unequivocal primary posterior uveal melanoma clinically, while patients who underwent an investigational biopsy all had an unequivocal or probable malignant intraocular tumor of a specific type. Most diagnostic FNABs were performed transvitreous (n=255, 87.3%) compared to prognostic FNABs (n=143, 51.1%) (p < 0.001). Overall, 733 FNABs (83.3%) yielded a sufficient specimen for cytological diagnosis. Diagnostic and confirmatory FNABs were the most likely to yield an insufficient aspirate (28.4% and 20.7% respectively), while investigational and prognostic FNABs were most likely to yield sufficient specimens (94.7% and 90.0% respectively) (p < 0.001). Mean post-FNAB follow-up of the entire group was 62.7 months (SD = 59.8, 95% CI = 58.7-66.6). Mean post-treatment follow-up or total follow-up of untreated patients was 53.7 months (SD = 58.7, 95% CI = 49.8-57.6).ConclusionsBecause of the substantial differences shown among FNAB cases performed for different indications, it seems appropriate to report results of FNAB or other biopsy methods according to the category (indication) of the biopsy.
  • Trends and Disparities in Inpatient Costs for Eye Trauma in the United
           States (2001-2014)
    • Abstract: Publication date: Available online 3 June 2019Source: American Journal of OphthalmologyAuthor(s): Mustafa Iftikhar, Asad Latif, Bushra Usmani, Joseph K. Canner, Syed M.A. ShahABSTRACTPurposeTo determine the trends and disparities in inpatient costs for eye trauma in the United States (US) from 2001 through 2014.DesignRetrospective population-based cross-sectional study.MethodsNational Inpatient Sample, a representative sample of US hospital discharges, was used to determine costs of eye trauma hospitalizations. Linear regression was used to estimate changes in mean inflation-adjusted cost per admission. Multivariable logistic regression was used to evaluate factors associated with a cost in the highest quartile (>$13,000) including age, sex, race, income quartile, primary payer, hospital location, size, and type. The model was adjusted for year of admission, length of stay, type of trauma, comorbidities, and the type and number of procedures performed.ResultsThe inpatient costs for eye trauma from 2001 through 2014 totaled $1.72 billion. The mean cost (95% CI) per stay remained relatively constant: $12,000 ($11,000–13,000) in 2001 to $11,000 ($10,000–12,000) in 2014 (p=0.643). A cost in the highest quartile was more likely in African-Americans compared to Whites (adjusted odds ratio [aOR], 1.3; 95% CI, 1.2-1.5), patients in the highest income quartile compared to those in the lowest (1.3; 1.2-1.5), uninsured patients compared to publicly insured patients (1.2; 1.1-1.4), teaching hospitals compared to non-teaching ones (1.5; 1.2-1.8), and the West compared to the South (2.4; 2.0-2.8).ConclusionsInpatient costs of eye trauma have remained steady and can be potentially reduced by addressing associated disparities. Further research including outpatient costs and eye trauma in vulnerable populations will be key to optimizing care and advancing healthcare equity.
  • Projection-Resolved Optical Coherence Tomography Angiography of the
           Peripapillary Retina in Glaucoma
    • Abstract: Publication date: Available online 3 June 2019Source: American Journal of OphthalmologyAuthor(s): Liang Liu, Beth Edmunds, Hana Takusagawa, Shandiz Tehrani, Lorinna Lombardi, John C. Morrison, Yali Jia, David HuangPurposeTo detect plexus-specific peripapillary retinal perfusion defects in glaucoma using projection-resolved optical coherence tomography angiography (PR-OCTA).DesignProspective cross-sectional study.MethodsOne eye each of 45 perimetric glaucoma participants and 37 age-matched normal participants were scanned using 4.5-mm OCTA scans centered on the disc. The PR-OCTA algorithm removed flow projection artifacts in OCT angiograms. Five en face OCTA slabs were analyzed: nerve fiber layer plexus (NFLP), ganglion cell layer plexus (GCLP), superficial vascular complex (SVC = NFLP + GCLP), deep vascular complex (DVC), and all plexuses combined. Peripapillary retinal capillary density (CD) and vessel density (VD) were calculated using a reflectance-compensated algorithm.ResultsFocal capillary dropout could be visualized more clearly in the NFLP than the other slabs. The NFLP, SVC and all-plexus CD in the glaucoma group were significantly lower (P
  • Depression, Anxiety, and Stress in Parents of Patients with Retinoblastoma
    • Abstract: Publication date: Available online 1 June 2019Source: American Journal of OphthalmologyAuthor(s): Mary Louise Z. Collins, Jana Bregman, Jennifer S. Ford, Carol L. ShieldsABSTRACTPurposeTo assess depression, anxiety, and stress in parents of patients with retinoblastoma and to evaluate the impact of unifocal versus multifocal retinoblastoma.MethodsA cross-sectional, self-reported psychological assessment of parents of patients with retinoblastoma at a tertiary care ocular oncology center was performed. The Beck Depression Inventory–II (BDI), Beck Anxiety Inventory (BAI), The Parental Stress Index 4–Short Form (PSI 4-SF) and retinoblastoma Knowledge Assessment questionnaire were administered. Descriptive statistics for outcomes and comparative analyses were made.ResultsThere were 138 parents of children with retinoblastoma (unifocal: n = 77, multifocal: n=61). Overall, parents displayed mild, moderate or severe depression (BDI) (n=37, 26,7%), mild, moderate, or severe anxiety (BAI) (n=49, 35.8%), and stress scores within normal limits (n=138, 100%). A comparison (unifocal vs. multifocal) revealed parents of children with multifocal retinoblastoma with severe depression (1.4% vs. 10.2%, p
  • Expanded phenotypic spectrum of retinopathies associated with autosomal
           recessive and dominant mutations in PROM1
    • Abstract: Publication date: Available online 24 May 2019Source: American Journal of OphthalmologyAuthor(s): Marta Del Pozo-Valero, Inmaculada Martin-Merida, Belen Jimenez-Rolando, Ana Arteche, Almudena Avila-Fernandez, Fiona Blanco-Kelly, Rosa Riveiro-Alvarez, Caroline Van Cauwenbergh, Elfride De Baere, Carlo Rivolta, Blanca Garcia-Sandoval, Marta Corton, Carmen Ayuso PurposeTo describe the genetic and phenotypic characteristics of a cohort of patients with PROM1 variants.DesignCase-case study.MethodWe screened a cohort of 2216 families with inherited retinal dystrophies using classical molecular techniques and next-generation sequencing approaches. The clinical histories of 25 patients were reviewed to determine age of onset of symptoms, and the results of ophthalmoscopy, best corrected visual acuity, full-field electroretinography, and visual field studies. Fundus autofluorescence and spectral-domain optical coherence tomography were further assessed in 7 patients.ResultsPROM1 variants were identified in 32 families. Disease-causing variants were found in 18 autosomal recessive and 4 autosomal dominant families. Monoallelic pathogenic variants or variants of unknown significance were identified in the remaining 10 families. Comprehensive phenotyping of 25 patients from 22 families carrying likely disease-causing variants revealed clinical heterogeneity associated with the PROM1 gene. Most of these patients presented cone-rod dystrophy and some exhibited macular dystrophy or retinitis pigmentosa, while all presented macular damage. Phenotypic association of a dominant splicing variant with late-onset mild maculopathy was established. This variant is one of the 3 likely founder variants identified in our Spanish cohort.ConclusionsWe report the largest cohort of patients with PROM1 variants, describing in detail the phenotype in 25 of them. Interestingly, within the variability of phenotypes due to this gene, macular involvement is a common feature in all patients.
  • Optic disc pit maculopathy: new perspectives on the natural history
    • Abstract: Publication date: Available online 13 May 2019Source: American Journal of OphthalmologyAuthor(s): Edward Bloch, Odysseas Georgiadis, Marko Lukic, Lyndon da Cruz PurposeTo investigate the natural history of optic disc pit maculopathy and explore associations between demographic, anatomical and functional characteristics.Design: Retrospective, comparative case series.MethodsA single-center medical record review of previously untreated optic disc pit maculopathy. Baseline data of visual function, demography and pit physiognomy were collected and further subgroup analysis was undertaken on patients with long-term follow-up, according to whether they were monitored or received surgical intervention. LogMAR visual acuity was the primary outcome measure and anatomical characteristics were reported, where available.Results87 patients were identified with a new presentation of optic disc pit maculopathy. No demographic or pit features were correlated with vision at baseline. In 51 patients with available OCT data, only the presence of subretinal fluid at baseline was associated with poorer visual acuity (p
  • Longitudinal Macular Structure-Function Relationships in Glaucoma and
           Their Sources of Variability
    • Abstract: Publication date: Available online 10 May 2019Source: American Journal of OphthalmologyAuthor(s): Kouros Nouri-Mahdavi, Nima Fatehi, Joseph CaprioliABSTRACTPurpose1) Review central structure-function (SF) relationships in glaucoma; 2) compare contributions of within-session and between-session variability to total variability of macular optical coherence tomography (OCT) thickness measurements; and 3) test the hypothesis that longitudinal within-eye variability of central SF relationships is smaller than between-individual variability.MethodsWe reviewed the pertinent literature on central SF relationships in glaucoma. Thirty-eight eyes (20 normal or glaucoma subjects) had ×3 macular images per session over 3 sessions and superpixels thickness measurements for ganglion cell layer (GCL), ganglion cell/inner plexiform layer (GCIPL), ganglion cell complex (GCC) and full macular thickness (FMT) were exported. Linear mixed models were used for estimating contributions of between- and within-session variability to total thickness variability. 120 eyes with ≥3 10° visual fields (VFs)/OCT images were enrolled for the longitudinal study. We investigated within-eye longitudinal SF relationships (GCIPL thickness vs. VF test locations) with a change-point regression model and compared within-eye with between-individual variabilities with components-of-variance models.ResultsIn the cross-sectional study, between-session component contributed 8%, 11%, 11%, and 36% of total variability for GCL, GCIPL, GCC, and FMT. In the longitudinal study, between-individual variability explained 78%, 77%, and 67% of total SF variability at 3.4°, 5.6°, and 6.8° eccentricities (P
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