Infantile strabismus inaugurates a constellation of dissociated eye movements that correspond to visuovestibular reflexes in lateral-eyed animals. These visual reflexes are generated by subcortical visual pathways that u...Infantile strabismus inaugurates a constellation of dissociated eye movements that correspond to visuovestibular reflexes in lateral-eyed animals. These visual reflexes are generated by subcortical visual pathways that use binocular visual input to modulate central vestibular tone. In this article, I present evidence that the accessory optic system is uniquely suited to provide an innervational substrate for visuovestibular eye movements in humans with infantile strabismus.
The Boston keratoprosthesis (KPro) has been used successfully in eyes with poor prognosis for conventional penetrating keratoplasty. However, postoperative changes in iris configuration after Boston KPro may occur, inclu...The Boston keratoprosthesis (KPro) has been used successfully in eyes with poor prognosis for conventional penetrating keratoplasty. However, postoperative changes in iris configuration after Boston KPro may occur, including iris obstruction of the Boston KPro, limiting visual potential in otherwise successful transplants. We describe our technique of argon laser iridoplasty after Boston KPro as a safe and effective procedure to treat visually significant optic obstruction and as a less-invasive alternative to surgical intervention.
A choroidal detachment may form during pars plana vitrectomy when the infusion line is partially disinserted and fluid is infused into the choroid or suprachoroidal space instead of into the vitreous cavity. We describe...A choroidal detachment may form during pars plana vitrectomy when the infusion line is partially disinserted and fluid is infused into the choroid or suprachoroidal space instead of into the vitreous cavity. We describe a new surgical technique that was used successfully in 4 patients who developed intraoperative choroidal detachments during 23-gauge vitrectomy after the infusion cannula was accidentally partially disinserted. During surgery, the infusion line was disconnected from the partially disinserted cannula and was reconnected to another fully inserted cannula. After resuming infusion into the vitreous cavity, the partially disinserted 23-gauge cannula was left in position and was used to immediately drain the choroidal detachment that had formed intraoperatively. In all 4 patients, the surgery then proceeded without complication.
Goldstein JE, Massof RW, Deremeik JT
… +6 more, Braudway S, Jackson ML, Kehler KB, Primo SA, Sunness JS, Low Vision Research Network Study Group
Arch Ophthalmol
· 2012 Aug · PMID 22893074
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OBJECTIVE: To characterize the traits of low vision patients who seek outpatient low vision rehabilitation (LVR) services in the United States. METHODS: In a prospective observational study, we enrolled 764 new low visio...OBJECTIVE: To characterize the traits of low vision patients who seek outpatient low vision rehabilitation (LVR) services in the United States. METHODS: In a prospective observational study, we enrolled 764 new low vision patients seeking outpatient LVR services from 28 clinical centers in the United States. Before their initial appointment, multiple questionnaires assessing daily living and vision, physical, psychological, and cognitive health states were administered by telephone. Baseline clinical visual impairment measures and disorder diagnoses were recorded. RESULTS: Patients had a median age of 77 years, were primarily female (66%), and had macular disease (55%), most of which was nonneovascular age-related macular degeneration. More than one-third of the patients (37%) had mild vision impairment with habitual visual acuity (VA) of 20/60 or greater. The VA correlated well with contrast sensitivity (r = -0.52) but poorly with self-reported vision quality. The intake survey revealed self-reported physical health limitations, including decreased endurance (68%) and mobility problems (52%). Many patients reported increased levels of frustration (42%) and depressed mood (22%); memory and cognitive impairment (11%) were less frequently endorsed. Patients relied on others for daily living support (87%), but many (31%) still drove. CONCLUSIONS: Most patients seeking LVR are geriatric and have macular disease with relatively preserved VA. The disparity between VA and subjective quality of vision suggests that LVR referrals are based on symptoms rather than on VA alone. Patients seen for LVR services have significant physical, psychological, and cognitive disorders that can amplify vision disabilities and decrease rehabilitation potential.
Klein R, Myers CE, Knudtson MD
… +4 more, Lee KE, Gangnon R, Wong TY, Klein BE
Arch Ophthalmol
· 2012 Aug · PMID 22893073
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OBJECTIVE: To describe the relationship of blood pressure (BP), antihypertensive medication use, and other factors to serial measurements of retinal arteriolar diameters over time in the Beaver Dam Eye Study. METHODS: Re...OBJECTIVE: To describe the relationship of blood pressure (BP), antihypertensive medication use, and other factors to serial measurements of retinal arteriolar diameters over time in the Beaver Dam Eye Study. METHODS: Retinal arteriolar diameter was measured by computer-assisted methods and summarized as central retinal arteriolar equivalent (CRAE) in 4573 persons aged 43 to 99 years at 4 examinations (each separated by 5 years) during a 15-year period. Associations of CRAE with risk factors measured concurrently and 5 years previously were determined using multivariate analyses. RESULTS: While adjusting for image quality, refraction, and lens status, age (per 10 years: β estimate, -0.73; P < .001), systolic BP (per 10 mm Hg: concurrent examination, -2.74; P < .001; previous examination, -1.75; P < .001), smoking status (smoker vs nonsmoker: concurrent examination, 4.29; P < .001; previous examination, 1.63; P = .004), body mass index (per category: concurrent examination, -0.51; P = .05; previous examination, -0.22; P = .44), and heavy alcohol consumption (drinking) (current vs past/never heavy drinker: concurrent examination, -2.54; P = .03; previous examination, -2.42; P = .02) were associated with CRAE. In the same model, there were significant interactions between concurrent and previous systolic BP (0.11; P = .003) and between concurrent and previous body mass index (0.12; P = .04). Use of calcium channel blockers at both the concurrent and past examination (vs neither examination, 1.59; P = .01), but not other classes of antihypertensive drugs, was associated with CRAE. CONCLUSIONS: Retinal arteriolar diameter is independently associated with past and current systolic BP, calcium channel blocker use, smoking status, body mass index, and heavy drinking during 5-year intervals. The relationships with CRAE are stronger for concurrent than for past measures of these variables.
OBJECTIVES: To test the hypotheses that lipopolysaccharide (LPS) stimulates leukotriene B4 (LTB4) production in human ocular surface and adenexal cells, arachidonic acid duplicates the stimulatory effect of LPS, LPS-bind...OBJECTIVES: To test the hypotheses that lipopolysaccharide (LPS) stimulates leukotriene B4 (LTB4) production in human ocular surface and adenexal cells, arachidonic acid duplicates the stimulatory effect of LPS, LPS-binding protein potentiates LPS-induced LTB4 secretion, and dihydrotestosterone attenuates the immune effect of LPS. METHODS: Immortalized human corneal, conjunctival, and meibomian gland epithelial cells were cultured in the presence or absence of fetal bovine serum and were exposed to vehicle, LPS, LPS plus LPS-binding protein, arachidonic acid, or dihydrotestosterone. Culture media were processed for the LTB4 analysis. RESULTS: Lipopolysaccharide stimulates time-dependent secretion of LTB4 by human corneal, conjunctival, and meibomian gland epithelial cells. This effect, which we could not detect with arachidonic acid, is potentiated by exposure to LPS-binding protein. This potentiation, in turn, is significantly reduced by cellular treatment with dihydrotestosterone. CONCLUSIONS: Ocular epithelial cells have the ability to generate LTB4 in response to LPS exposure. This proinflammatory process is modulated by LPS-binding protein and by dihydrotestosterone. CLINICAL RELEVANCE: When induced by appropriate stimuli, LTB4 production may have a role in the generation of inflammation in ocular surface disease.
OBJECTIVE: To highlight a case series of patients manifesting epiphora and misdirection of tears laterally or along the upper-eyelid skin crease. This association has been termed upper-eyelid wick syndrome. We describe t...OBJECTIVE: To highlight a case series of patients manifesting epiphora and misdirection of tears laterally or along the upper-eyelid skin crease. This association has been termed upper-eyelid wick syndrome. We describe the clinical features and outcomes of management of these patients. METHODS: A retrospective review of patients referred to 2 oculoplastic centers during a 6-year period for epiphora, who were considered to have misdirection of tears related in some way to upper-eyelid dermatochalasis. RESULTS: Nine patients (7 women and 2 men; mean [SD] age, 61.2 [11.3] years, range, 41-76 years) with bilateral epiphora and lateral spillover (100%), occasionally combined with upper-eyelid wetting (n = 2). All patients had upper-eyelid dermatochalasis. Five patients had upper-eyelid skin obscuring and in contact with the lateral canthus (type 1), and in 4 the lateral canthus was only partially obscured by upper-eyelid skin (type 2). Five patients (56%) had linear excoriation of skin in the lateral canthus. All patients underwent upper-eyelid blepharoplasty, 3 combined with ptosis repair and 3 combined with eyebrow-lift. All patients achieved 80% to 100% improvement in epiphora following surgical intervention to the upper eyelid. The mean (range) follow-up was 2.8 (1-6) years. CONCLUSIONS: We defined upper-eyelid wick syndrome as the misdirection of tears laterally or along the upper-eyelid skin crease causing epiphora, related in some way to upper-eyelid dermatochalasis. In all cases, epiphora improved with treatment of upper-eyelid dermatochalasis. Although recognized among physicians, this has never been formally described in the ophthalmic literature, to our knowledge.
OBJECTIVE: To evaluate if adult-onset foveomacular vitelliform dystrophy (AOFVD) and butterfly-shaped pigment dystrophy (BSPD) are associated with risk single-nucleotide polymorphisms (SNPs) for age-related macular degen...OBJECTIVE: To evaluate if adult-onset foveomacular vitelliform dystrophy (AOFVD) and butterfly-shaped pigment dystrophy (BSPD) are associated with risk single-nucleotide polymorphisms (SNPs) for age-related macular degeneration (AMD). METHODS: This was a tertiary referral center-based cross-sectional study including 35 consecutive patients with BSPD and AOFVD, 317 patients with AMD, and 159 unaffected individuals. Demographics, clinical information, and ophthalmic imaging studies were collected. Sequencing was performed for the peripherin/RDS and BEST1 genes, and genotyping was performed for SNPs in the genes for complement factor H (CFH) (rs1061170), HTRA1 (rs11200638), and complement component 3 (C3) (rs2231099). RESULTS: Adult-onset foveomacular vitelliform dystrophy and BSPD were diagnosed in 24 (68.6%) and 11 (31.4%) of the 35 patients, respectively. The mean (SD) age of patients with pattern dystrophy (PD) was 75.3 (10) years and median visual acuity was 0.7. Pattern dystrophy was associated with the HTRA1 risk allele compared with unaffected individuals (odds ratio, 1.72; 95% CI, 1.11-2.66; P = .03). The HTRA1 SNP showed similar prevalence in patients with AMD and PD. The CFH risk allele was significantly less common in patients with PD compared with patients with AMD (odds ratio, 0.47; 95% CI, 0.28-0.76; P = .002). No mutations in peripherin/RDS or BEST1 were detected. CONCLUSIONS: The AOFVD and BSPD phenotypes are associated with an HTRA1 risk SNP. These phenotypes often present in elderly individuals who do not carry peripherin/RDS gene mutations and are associated with retinal pigment epithelium alterations and increased risk for choroidal neovascularization. Further research is required to evaluate if AOFVD and BSPD phenotypes in aged individuals are associated with AMD.
OBJECTIVE To describe an optical coherence tomographic finding of layered hyperreflective bands beneath the retinal pigment epithelium (RPE), the so-called onion sign believed to represent lipid within a vascularized pig...OBJECTIVE To describe an optical coherence tomographic finding of layered hyperreflective bands beneath the retinal pigment epithelium (RPE), the so-called onion sign believed to represent lipid within a vascularized pigment epithelial detachment. METHODS This retrospective observational case series involved reviewing clinical histories of patients with the onion sign. Imaging studies analyzed included spectral-domain optical coherence tomography, color and red-free photographs, near infrared reflectance, fundus autofluorescence, and blue-light fundus autofluorescence. RESULTS A total of 22 eyes of 20 patients with sub-RPE hyperreflective bands were identified. There were 15 women and 5 men with a mean patient age of 76 years (range, 60-92 years). Snellen best-corrected visual acuities ranged from 20/25 to counting fingers, with a median of 20/80. Two patients had bilateral involvement, and 3 of 17 eyes had multifocal onion signs in the same eye. All eyes had neovascular age-related macular degeneration, with type 1 (sub-RPE) neovascularization. In all patients, the onion sign correlated with areas of yellow-gray exudates seen clinically that appeared bright on red-free and near infrared reflectance imaging. No specific fundus autofluorescence or blue-light fundus autofluorescence pattern was identified. CONCLUSIONS The onion sign refers to layered hyperreflective bands in the sub-RPE space usually associated with chronic exudation from type 1 neovascularization in patients with age-related macular degeneration. With an associated bright near infrared reflectance, these bands may correspond to lipid, collagen, or fibrin. Because the onion sign colocalizes to areas of exudation that are known to consist of lipoprotein, we propose that this finding may represent layers of precipitated lipid in the sub-RPE space. To our knowledge, this is the first report of lipid detected in the sub-RPE space on clinical examination.
Arch Ophthalmol
· 2012 Dec · PMID 22892888
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OBJECTIVE To examine the safety, tolerability, and reproducibility of intraocular pressure (IOP) patterns during repeated continuous 24-hour IOP monitoring with a contact lens sensor. METHODS Forty patients suspected of...OBJECTIVE To examine the safety, tolerability, and reproducibility of intraocular pressure (IOP) patterns during repeated continuous 24-hour IOP monitoring with a contact lens sensor. METHODS Forty patients suspected of having glaucoma (n = 21) or with established glaucoma (n = 19) were studied. Patients participated in two 24-hour IOP monitoring sessions (S1 and S2) at a 1-week interval (SENSIMED Triggerfish CLS; Sensimed AG). Patients pursued daily activities, and sleep behavior was not controlled. Incidence of adverse events and tolerability (visual analog scale score) were assessed. Reproducibility of signal patterns was assessed using Pearson correlations. RESULTS The mean (SD) age of the patients was 55.5 (15.7) years, and 60% were male. Main adverse events were blurred vision (82%), conjunctival hyperemia (80%), and superficial punctate keratitis (15%). The mean (SD) visual analog scale score was 27.2 (18.5) mm in S1 and 23.8 (18.7) mm in S2 (P = .22). Overall correlation between the 2 sessions was 0.59 (0.51 for no glaucoma medication and 0.63 for glaucoma medication) (P = .12). Mean (SD) positive linear slopes of the sensor signal from wake to 2 hours into sleep were detected in both sessions for the no glaucoma medication group (S1: 0.40 [0.34], P < .001; S2: 0.33 [0.30], P < .01) but not for the glaucoma medication group (S1: 0.24 [0.60], P = .06; S2: 0.40 [0.40], P < .001). CONCLUSIONS Repeated use of the contact lens sensor demonstrated good safety and tolerability. The recorded IOP patterns showed fair to good reproducibility, suggesting that data from continuous 24-hour IOP monitoring may be useful in the management of patients with glaucoma. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01319617.
OBJECTIVE To estimate and compare the incidence of operable cataract and the desired cataract surgery rates required to eliminate cataract-related visual impairment in several Latin American settings. METHODS We obtained...OBJECTIVE To estimate and compare the incidence of operable cataract and the desired cataract surgery rates required to eliminate cataract-related visual impairment in several Latin American settings. METHODS We obtained raw data on age-specific cataract prevalence from standardized population-based surveys. We used the data in a previously described model to estimate the incidence of operable cataract at 11 sites in 10 countries across Latin America. Age-specific incidence rates were then multiplied by corresponding population data to calculate the desired cataract surgery rates needed to eliminate cataract-related visual impairment in eyes in each country. Age-standardized incidence was also calculated to explore potential non-age-related differences in incidence among the countries. RESULTS The desired cataract surgery rates ranged from 3441 to 8935 in the 11 sites. Much of the variation was owing to differing age structures, but there may be important variation in age-specific incidence rates as well. CONCLUSIONS Age structure has a major effect on the number of cataract surgeries needed in different countries of Latin America, and it is essential to consider this when planning cataract surgical services. Potential differences in non-age-related risk factors for cataract among different populations also deserve further study.