Exposure of the tube of an aqueous drainage device (ADD) through the conjunctiva is a serious complication of ADD surgery. Although placement of gamma-irradiated sterile cornea (GISC) as a patch ...graft over the tube is commonly performed, exposures still occur.
To measure GISC patch graft thickness as a function of time after surgery, estimate the rate of graft thinning, and determine risk factors for graft thinning.
Cross-sectional study of graft thickness using anterior segment optic coherence tomography (AS-OCT) was conducted at the Wilmer Eye Institute at Johns Hopkins Hospital. A total of 107 patients (120 eyes, 120 ADDs) 18 years or older who underwent ADD surgery at Johns Hopkins with GISC patch graft between July 1, 2010, and October 31, 2016, were enrolled.
Implantation of ADD with placement of GISC patch graft over the tube.
Graft thickness vs time after ADD surgery and risk factors for undetectable graft.
Of the 107 patients included in the analysis, the mean (SD) age of the cohort was 64 (16.2) years, 49 (45.8%) were male, and 43 (40.2%) were African American. The mean time of measurement after surgery was 1.7 years (range, 1 day to 6 years). Thinner grafts were observed as the time after surgery lengthened (β regression coefficient, -60 µm per year since surgery; 95% CI, -80 µm to -40 µm). The odds ratio of undetectable grafts per year after ADD surgery was 2.1 (95% CI, 1.5-3.0; P < .001). Age, sex, race, type of ADD, quadrant of ADD placement, diagnosis of uveitis or dry eye, and prior conjunctival surgery were not correlated with the presence or absence of the graft.
Gamma-irradiated sterile corneal patch grafts do not always retain their integrity after ADD surgery. Data from this cross-sectional study showed that on average, the longer the time after surgery, the thinner the graft. These findings suggest that placement of a GISC patch graft is no guarantee against tube exposure, and that better strategies are needed for preventing this complication.
To determine the impact of glaucoma on mobility in a population-based cohort.
Population-based observational study.
Persons examined as part of a population-based eye disease study.
Subjects ...performed a series of tasks, including walking an obstacle course, climbing stairs, performing tandem stands, and walking a 4-meter course. Persons with glaucoma were compared with those without glaucoma to identify differences in mobility.
Speed to complete an obstacle course, number of bumps, ability to perform tandem stands, and walking and stair climbing speed.
One thousand two hundred fifty subjects participated in the study. In an analysis adjusting for age, race, and gender, walking speed through the obstacle course was 2.4 m/minute slower for persons with bilateral glaucoma, and these individuals experienced 1.65 times the number of bumps when compared with persons without glaucoma (P<0.05 for both). None of the associations was statistically significant comparing persons with unilateral glaucoma with normals. This association remained after adjusting for other potentially confounding factors including visual acuity (VA), body mass index, height, Mini-Mental State Examination score, grip strength, arthritis, depressive symptoms, comorbidities, and use of mobility aids. Additional analyses indicate that visual field loss drives this association.
Bilateral glaucoma reduces mobility performance as measured in multiple ways in this population-based study of community-dwelling individuals. Persons with bilateral glaucoma completed the walking course more slowly and had more bumps even after adjusting for use of a mobility aid, comorbidities, and VA. After adjusting for all other factors, persons with bilateral glaucoma walked on average 2.4 m less per minute through the course than those without glaucoma.
Purpose To assess depression and mood indicators in subjects newly diagnosed with chronic open-angle glaucoma. Design Cross-sectional study of data from a randomized clinical trial. Methods ...Newly-diagnosed glaucoma patients enrolled in the Collaborative Initial Glaucoma Treatment Study (CIGTS) responded at baseline to quality-of-life (QOL) telephone interviews. We studied responses to the 33-item Visual Activities Questionnaire (VAQ), six items from a disease-specific Health Perceptions Index (HPI), and eight questions from the Center for Epidemiological Studies Depression Scale (CES-D). We correlated the responses to the HPI and the CES-D with visual acuity (VA) and CIGTS visual field (VF) as well as to the responses to the VAQ. Results VAQ score was correlated ( P < .01 in all cases) with better VA ( P = −0.181), better VF ( P = 0.139), worse VA ( P = −0.128), and worse VF ( P = .120). There were also correlations ( P ranging from .24 to .38, all P values ≤ .001) between patients’ perception of their vision (total VAQ score) and each item on the HPI and CES-D. None of the clinical vision measures were associated with any of the CES-D items. The strongest correlation between a clinical measure and an item from the HPI was between worse VF and worry about the possibility of blindness ( P = −0.114, P = .005). The odds ratio of reporting mood indicators and symptoms of depression increased with patients’ perceptions of worsening visual function but not worsening VA or VF. Conclusions In these newly diagnosed glaucoma patients, symptoms of depression and altered mood were related to worse self-reported visual function as assessed by the VAQ, but not to monocular clinical measures of visual function.
Endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) may be compromised by postoperative inflammation, polyposis, and adhesions, often requiring subsequent intervention. To address this ...issue, the authors investigated the safety and effectiveness of controlled delivery of mometasone furoate to the sinus mucosa via bioabsorbable implants deployed at the time of ESS.
Prospective, multicenter, randomized, controlled, double-blind trial using an intrapatient control design.
Otolaryngology-head and neck surgery centers; both academic and private practices.
The study enrolled 105 patients with CRS undergoing bilateral ethmoidectomy to compare the effect of drug-releasing to non-drug-releasing implants using an intrapatient control design. Postoperative interventions, polyposis, and adhesions were assessed postoperatively. Efficacy was determined through independent analysis of randomized video-endoscopies by 3 blinded sinus surgeons. Safety assessments included ocular examinations.
Implants were successfully deployed in all 210 ethmoid sinuses. Compared with control sinuses with non-drug-releasing implants, the drug-releasing implant provided a 29.0% relative reduction in postoperative interventions (P = .028) and a 52% (P = .005) decrease in lysis of adhesions. The relative reduction in frank polyposis was 44.9% (P = .002). Similar reductions were observed in real-time grading performed by the clinical investigators. No clinically significant changes from baseline in intraocular pressure or cataracts were observed.
This study provides a high level of evidence that use of steroid-releasing implants that apply a sustained release of corticosteroid improves surgical outcomes by reducing synechiae formation, polyposis, and the need for postoperative interventions, with no observable ocular safety risk.
To determine the prevalence of diagnosed glaucoma in the Medicare population and to assess regional variations and trends.
Retrospective, cross-sectional study.
A 5% random sample of Medicare ...beneficiaries aged ≥ 65 years, excluding those in health maintenance organizations.
All claims with a glaucoma diagnosis code submitted by ophthalmologists, optometrists, or ambulatory surgery centers were used to estimate prevalence of the diagnosis of glaucoma for each year from 2002 to 2008. Regional variation in diagnosed glaucoma was examined in 9 large geographic regions and in 179 smaller subregions, controlling for patient characteristics and provider supply.
The prevalence of diagnosed open-angle glaucoma suspect (OAG-s), open-angle glaucoma (OAG), angle-closure glaucoma suspect (ACG-s), and angle-closure glaucoma (ACG), trends over time, and regional variations in prevalence.
The overall prevalence increased from 10.4% in 2002 to 11.9% by 2008, largely owing to increase in diagnosed OAG-s (from 3.2% to 4.5%; P<0.001). The relative prevalence of diagnosed OAG compared with diagnosed ACG was 32:1. In 2008, multivariable models showed that the New England and Mid-Atlantic regions had 1.7 times more diagnosed OAG-s than the reference region (East South Central; New England: odds ratio OR, 1.66; 95% confidence interval CI, 1.58-1.75; Mid-Atlantic: OR, 1.66; 95% CI, 1.59-1.73). The odds of diagnosed OAG was 36% higher in New England (OR, 1.36; 95% CI, 1.30-1.42) and 31% higher in the Mid-Atlantic (OR, 1.31; 95% CI, 1.26-1.36) than in the reference region. The New England and Mid-Atlantic regions had the highest odds of diagnosed ACG-s and the Mid-Atlantic region had the highest odds of diagnosed ACG. Among 179 subregions, the New York area had high diagnosis rates of all glaucoma types.
The relative prevalence of diagnosed ACG compared with diagnosed OAG was lower than expected from population-based data, possibly owing to failure to perform gonioscopy. Substantial regional differences in diagnosed rates existed for all types of glaucoma, even after adjusting for patient characteristics and provider concentration, suggesting possible overdiagnosis in some areas and/or underdiagnosis in other areas. Regionally higher diagnosis rates in the New York area deserve further study.
To estimate the change in iris cross-sectional (CS) area with pupil dilation using anterior segment optical coherence tomography comparing eyes with angle closure (AC) to open angle glaucoma (OAG).
...Sixty-five patients from the Wilmer Glaucoma service, 36 with definite or suspected OAG and 29 with definite or suspected AC, underwent anterior segment optical coherence tomography imaging under 3 conditions (pupil constriction to light, physiologic dilation in the dark, and after pharmacologic dilation). The nasal and temporal iris CS areas were measured with custom software, 3 times in each of 4 meridians. The principal outcome variables were iris CS area and change in iris CS area/mm pupil diameter change. The relation of these parameters to potential variables that would influence iris area was estimated by multivariate regression.
CS area was smaller in eyes with larger pupil diameter, those that had undergone trabeculectomy, and those of European-derived persons (P<0.05 for all in a univariate analysis). In a multivariate model with CS area as the dependent variable, larger pupil diameter (with a 0.19 mm decrease in CS area for each 1 mm of pupil enlargement, P=0.0002), and trabeculectomy remained significant factors. In a second multivariate model, AC irides had less change in CS area/mm pupil enlargement than OAG or OAG suspects (P=0.01). Change in iris CS area was essentially complete in 5 seconds (n=10 eyes).
The iris loses nearly half its volume from a pupil diameter of 3 to 7 mm, probably by eliminating extracellular fluid. Smaller iris CS area change with physiologic pupil dilation is a potential risk factor for AC. Dynamic iris CS area change deserves testing as a prospective indicator of AC.
With the recent development of enhanced depth imaging spectral-domain optical coherence tomography (SD-OCT), it is now possible to measure choroidal thickness in patients with Sturge-Weber syndrome ...and detect abnormalities that are not visible as part of the fundus examination.
We were successful in imaging at least 1 eye in 12 individuals with Sturge-Weber syndrome using enhanced depth imaging SD-OCT. Eyes were defined as affected if they manifested at least one of the following: darkened choroid, glaucomatous optic nerve damage, or conjunctival hyperemia. None of the participants had a clinically visible choroidal hemangioma. The affected eyes had over twice the choroidal thickness of the unaffected eyes (mean SD, 697 337 μm vs 331 94 μm; P = .004, determined by use of an unpaired t test). For the 6 unilaterally affected participants who had both eyes imaged, the choroidal thickness was greater in the affected eyes than in the unaffected eyes of 5 participants (mean SD, 672 311 μm vs 329 88 μm; P = .01, determined by use of a paired t test).
The advent of enhanced depth imaging SD-OCT has allowed us to quantify choroidal thickness in the posterior pole, even in eyes with a markedly thickened choroid, such as those found in individuals with Sturge-Weber syndrome. Spectral-domain OCT has a much higher resolution (5-10 μm) than B-scan ultrasonography (150 μm) and can be used to distinguish between the retina and the choroid. Furthermore, enhanced depth imaging SD-OCT can detect choroidal thickness in eyes without clinically apparent choroidal abnormalities.
To determine the risk factors for low intraocular pressure (IOP) and its detrimental consequences after trabeculectomy.
We performed a retrospective chart review of consecutive patients aged 12 years ...and above undergoing trabeculectomy alone by 1 of 2 surgeons between May 2000 and October 2008 at the Wilmer Institute.
Among 753 eyes of 596 patients, 112 eyes (14.9%) of 103 patients had an IOP of ≤5 mm Hg at ≥3 months postoperatively (late low IOP). Physical signs related to low IOP occurred in 61 eyes of 58 patients, and 40 eyes of 37 patients had revision surgery for low IOP. Physical signs of low IOP included 34 eyes with choroidal detachment or shallow anterior chamber, 10 with hypotony maculopathy, and 7 with both. Compared with 187 control eyes of 165 patients, risk factors for late low IOP included: surgeon 2 (P=0.0003), left eyes (P=0.03), and secondary glaucoma (P=0.05). Physical signs of low IOP were more common in phakic eyes (P=0.03), whereas need for revision surgery was associated with younger age (P=0.01). The presence of hypotony maculopathy significantly decreased the risk of choroidal detachment/shallow anterior chamber (P=0.003). Hypotony maculopathy was associated with younger age (P=0.02).
Late low IOP was more common with techniques used by 1 of 2 surgeons and in eyes with secondary glaucoma. Clinical signs of low IOP were more common in phakic eyes. Younger age was a risk factor for hypotony maculopathy. Hypotony maculopathy and choroidal detachment tend to occur in different eyes.
Discrepancies between information in conference abstracts and full publications describing the same randomized controlled trial have been reported. The association between author conflicts of ...interest and the publication of randomized controlled trials is unclear. The objective of this study was to use randomized controlled trials in ophthalmology to evaluate (1) the agreement in the reported main outcome results by comparing abstracts and corresponding publications and (2) the association between the author conflicts of interest and publication of the results presented in the abstracts.
We considered abstracts describing results of randomized controlled trials presented at the 2001-2004 Association for Research in Vision and Ophthalmology conferences as eligible for our study. Through electronic searching and by emailing abstract authors, we identified the earliest publication (journal article) containing results of each abstract's main outcome through November 2013. We categorized the discordance between the main outcome results in the abstract and its paired publication as qualitative (a difference in the direction of the estimated effect) or as quantitative. We used the Association for Research in Vision and Ophthalmology categories for conflicts of interest: financial interest, employee of business with interest, consultant to business with interest, inventor/developer with patent, and receiving ≥ 1 gift from industry in the past year. We calculated the relative risks (RRs) of publication associated with the categories of conflicts of interest for abstracts with results that were statistically significant, not statistically significant, or not reported.
We included 513 abstracts, 230 (44.8 %) of which reached publication. Among the 86 pairs with the same main outcome domain at the same time point, 47 pairs (54.7 %) had discordant results: qualitative discordance in 7 pairs and quantitative discordance in 40 pairs. Quantitative discordance was indicated as < 10, 10-20, > 20 %, and unclear in 14, 5, 14, and 7 pairs, respectively. First authors reporting of one or more conflicts of interest was associated with a greater likelihood of publication (RR = 1.31; 95 % CI = 1.04 to 1.64) and a shorter time-to-publication (log-rank p = 0.026). First author conflicts of interests that were associated with publication were financial support (RR = 1.50; 95 % CI = 1.19 to 1.90) and one or more gifts (RR = 1.42; 95 % CI = 1.05 to 1.92). The association between conflicts of interest and publication remained, irrespective of the statistical significance of the results.
More than half the abstract/publication pairs exhibited some amount of discordance in the main outcome results, calling into question the dependability of conference abstracts. Regardless of the main outcome results, the conflicts of interests of the abstract's first author were associated with publication.
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