The Asia-Pacific Journal of Ophthalmology

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More Antisepsis, Less Antibiotics Whenever Possible Grzybowski, Andrzej; Turczynowska, Magdalena
Increasing bacterial resistance to antibiotics has recently become an important medical challenge. In ophthalmology antibiotics are widely used for treatment and prophylaxis of ocular infections. In many cases antiseptics may be a valuable adjunct and sometimes even an alternative to antibiotics for the prevention and treatment of infections, reducing the overuse of antibiotics. This review aims to highlight the available literature on the subject of antibiotic resistance in ophthalmology. Full understanding of this growing problem is necessary for tailoring effective pre-, intra-, and postoperative management to improve antibiotic stewardship programs.

Original Study - Clinical

Outcomes of Infantile-Onset Glaucoma Associated With Port Wine Birthmarks and Other Periocular Cutaneous Vascular Malformations Reyes-Capó, Daniela; Cavuoto, Kara M.; Chang, Ta C.
Purpose: The incidence of infantile-onset secondary glaucoma associated with periocular cutaneous vascular malformations is high and the outcomes of these glaucomatous eyes have anecdotally been poor. The purpose of this study was to determine the anatomic and visual outcomes of affected eyes.

Design: Retrospective case series.

Methods: Consecutive patients with early-onset (younger than 36 months of age) glaucoma associated with cutaneous vascular malformations from 1995.2015 were included.

Results: Seventeen eyes of 13 patients with Sturge-Weber syndrome (SW, n = 10), Klippel-Trenaunay-Weber syndrome (KTW, n = 1), cutis marmorata telangiectatica congenita (CMTC, n = 1), and phakomatosis pigmentovascularis (PPV, n = 1) were included. Three SW and 1 KTW patient had bilateral glaucoma. At presentation, mean age was 6.5 ± 9.1 months and mean intraocular pressure was 27.2 ± 6.13 mm Hg. The average number of surgical procedures per eye increased from 1.0 ± 0.5 (range, 0.2) at less than 5 years’ follow-up (9 eyes) to 3.5 ± 2.3 (range, 1.7) with at least 5 years’ follow-up (8 eyes). Visual acuity was better than or equal to 20/70 in 2 of 6 eyes (33%) with less than 5 years’ follow-up and in 3 of 7 eyes (43%) with at least 5 years’ follow-up. Additionally, a higher number of baseline risk factors correlated with poorer visual outcome.

Conclusions: After a mean follow-up of 6.6 years, visual outcome in infantile-onset secondary glaucoma associated with cutaneous periocular vascular malformation is guarded. Increased numbers of baseline risk factors and procedures are associated with poorer vision.
Peripapillary Perfused Capillary Density in Exfoliation Syndrome and Exfoliation Glaucoma versus POAG and Healthy Controls: An OCTA Study Suwan, Yanin; Geyman, Lawrence S.; Fard, Masoud Aghsaei; Tantraworasin, Apichat; Chui, Toco Y.; Rosen, Richard B.; Ritch, Robert.
Purpose: To compare the peripapillary perfused capillary density (PCD) among eyes with exfoliation syndrome (XFS), exfoliation glaucoma (XFG), primary open-angle glaucoma (POAG), and controls.

Design: Observational, cross-sectional study.

Methods: Optical coherence tomography angiography (OCTA) images (4.5×4.5 mm) of the optic nerve head were obtained using a commercial spectral domain OCTA system (AngioVue Avanti RTVue-XR, OptoVue, Fremont, CA). Two concentric circles with 1.95-mm (inner) and 3.45-mm (outer) diameters were placed manually, producing an annulus of width 0.75 mm centered at the optic disc. PCD was calculated as the ratio of pixels associated with capillaries to the pixels in the annulus after large blood vessel removal. Continuous variables were assessed by analysis of variance and Tukey honest significant difference (HSD) test. Multiple linear regression analysis was performed to adjust for confounding factors.

Results: Forty-three XFG eyes, 31 POAG eyes matched for visual field mean deviation, 33 XFS eyes, and 45 control eyes were analyzed. PCD demonstrated a progressive decrease from controls to XFS to POAG to XFG. Pairwise comparisons revealed significant differences in PCD between each pair of groups (all P<0.01) except for PCD between XFS and POAG (P = 0.08). A multivariable model adjusting for age and stage showed a more significant decrease in PCD in XFG compared with POAG (P = 0.001).

Conclusions: PCD was more significantly decreased in XFG compared with POAG eyes and in XFS compared with control eyes. OCTA provides the first quantitative evidence of the microvascular disturbance that accompanies XFS.
First Rapid Assessment of Avoidable Blindness Survey in the Maldives: Prevalence and Causes of Blindness and Cataract Surgery Thoufeeq, Ubeydulla; Das, Taraprasad; Limburg, Hans; Maitra; Maharshi; Panda, Lapam; Sil, Asim; Trevelyan John; Sapkota, Yuddha
Purpose: A nationwide rapid assessment of avoidable blindness survey was undertaken in the Maldives among people aged 50 years or more to assess the prevalence and causes of blindness and visual impairment, cataract surgical coverage, cataract surgery outcome, and barriers to uptake of cataract surgical services.

Design: Prospective population-based study.

Methods: In the cluster sampling probability proportionate to size method, 3100 participants in 62 clusters across all 20 atolls were enrolled through house-to-house visits. They were examined in clusters by an ophthalmologist-led team. Data was recorded in mRAAB version 1.25 software on a smartphone.

Results: The age-sex standardized prevalence of blindness was 2.0% [95% confidence interval (CI), 1.5-2.6]. Cataract was the leading cause of blindness (51.4%) and uncorrected refractive error was the leading cause of visual impairment (50.9%). Blindness was more prevalent in higher age groups and women (16.3%). Cataract surgical coverage was 86% in cataract blind eyes and 93.5% in cataract blind persons. Good visual outcome in cataract operated eyes was 67.9% (presenting) and 76.6% (best corrected visual acuity). In this study, 48.1% of people had received cataract surgery in neighboring countries. Important barriers for not using the services were “did not feel the need” (29.7%) and “treatment deferred” (33.3%).

Conclusions: Cataract surgical coverage is good, though nearly half the people received surgery outside the Maldives. Cataract surgery outcomes are below World Health Organization standards. Some barriers could be overcome with additional human resources and training to improve cataract surgical outcomes, which could encourage greater uptake of services within the country.
Predictive Value of Baseline Biochemical Parameters for Clinical Response of Macular Edema to Bevacizumab in Eyes With Central Retinal Vein Occlusion: A Retrospective Analysis Madanagopalan, V.G.; Kumari, Bibha
Purpose: To evaluate the influence of baseline biochemical parameters on the improvement in best corrected visual acuity (BCVA) and reduction in central foveal thickness (CFT) in patients treated with intravitreal bevacizumab (IVB; Avastin, Genentech, Inc) for macular edema (ME) secondary to central retinal vein occlusion (CRVO).

Design: A retrospective study.

Methods: Seventy eyes of 70 participants with CRVO who underwent IVB for ME and had at least 1 month of follow-up after the last injection were studied. Demographic variables, systolic and diastolic blood pressure (SBP and DBP), BCVA, CFT measured by optical coherence tomography (OCT), and biochemical investigations [hemoglobin, fasting and postprandial blood sugar (FBS and PPBS), lipid profile, blood urea (BU), serum creatinine (SC), glycosylated hemoglobin (HbA1c)] at baseline were noted. IVB need at every visit was based on clinical and OCT parameters. Changes in BCVA (ΔBCVA) and CFT (ΔCFT) from baseline to last injection were estimated.

Results: After IVB, there was a statistically significant reduction in mean CFT (P < 0.01). The group of patients with normal BU and SC had more than 2 lines of improvement compared with those with elevated values (P = 0.043 and 0.009, respectively). Other parameters like FBS, PPBS, hemoglobin, HbA1c, and serum lipids were not associated with improvement of BCVA and reduction of CFT.

Conclusions: Normal baseline renal parameters (BU and SC) predict better visual outcome after treatment for ME in CRVO and offer additional benefit over and above that obtained with ME reduction.

Optic Nerve Head Haemorrhages Associated with Posterior Vitreous Detachment Polkinghorne, Philip J.
Purpose: To report and evaluate the clinical and optical coherence tomography (OCT) features of optic nerve hemorrhages (ONH) associated with spontaneous posterior vitreous detachment (PVD).

Design: A prospective case series conducted at a private ophthalmic practice in Auckland, New Zealand. Methods: A consecutive series of patients presenting at a private multispecialty practice in Auckland, New Zealand, with symptoms of PVD with ONH underwent imaging of the optic nerve with digital retinal photography and OCT. The number and location of each hemorrhage were recorded, together with relevant ophthalmic and demographic data.

Results: Twenty of 30 eyes with ONH had evidence of persistent vitreopapillary adhesion. Three patterns of adhesion were identified: central, peripheral, and combined. In all, 52 hemorrhages were identified, of which the majority were flame-shaped, although other types were seen including dot and blot hemorrhages. One subretinal hemorrhage occurred in a patient with a central vitreopapillary adhesion.

Conclusions: ONH hemorrhages associated with PVD are commonly found with persistent vitreopapillary adhesions as evidenced on OCT. The clinical features of ONH together with OCT imaging may help to distinguish ONH associated with PVD from other hemorrhages found on or adjacent to the optic nerve.
Submacular Hemorrhage: Visual Outcomes and Prognostic Factors Kunavisarut, Paradee; Thithuan, Tipparut; Patikulsila, Direk; Choovuthayakorn, Janejit; Watanachai, Nawat; Chaikitmongkol, Voraporn; Pathanapitoon, Kessara; Rothova, Aniki
Purpose: To describe causes, visual outcomes, and prognostic factors in patients with submacular hemorrhage (SMH).

Design: Retrospective case review.

Methods: We performed a retrospective review of SMH with a size of at least 1 disc diameter. SMH causes were classified into 3 groups: 1) neovascular age-related macular degeneration (nAMD), 2) polypoidal choroidal vasculopathy (PCV), and 3) other miscellaneous causes.

Results: Ninety-eight eyes of 98 patients were included. Based on clinical presentation and indocyanine green angiography (ICGA ), the diagnoses of PCV (59%), nAMD (31%), and miscellaneous other causes (10%) were made. PCV patients were younger (P = 0.005) and had larger SMH size than nAMD patients (P = 0.008). Poor visual outcome [>1.0 logarithm of the minimum angle of resolution (logMAR )] at 6 months was associated with low initial visual acuity (VA; >1.0 logMAR ; P = 0.002) and with the diagnosis of nAMD (P = 0.02). In addition, limited visual outcomes were noted for patients older than 65 years and those with persistent SMH for at least 2 months.

Conclusions: PCV was the most common cause of SMH in Thailand. ICGA represented a valuable tool for the diagnosis. Visual outcomes were limited for patients with nAMD and for patients who presented with poor initial VA.

Visual Acuity Improves in Children and Adolescents With Idiopathic Infantile Nystagmus Balzer, Ben W.R.; Catt, Caroline J.; Bou-Abdou, Milia; Martin, Frank J.
PURPOSE: Idiopathic infantile nystagmus is associated with reduced visual acuity. Recent work has linked extraocular muscle surgery to improvements in visual acuity through childhood but no work has reported long-term secular trends in visual acuity in infantile nystagmus. Our aim is to describe visual acuity changes for children and adolescents with idiopathic infantile nystagmus to allow comparison for future interventional studies.

DESIGN: Retrospective chart review.

METHODS: Review of patients attending our center up to the age of 18 with a diagnosis of idiopathic infantile nystagmus and visual acuity measured using Snellen visual acuity. Patients provided informed consent.

RESULTS: We observed improvements in best corrected visual acuity in 43 children and adolescents with idiopathic infantile nystagmus. Binocular best corrected visual acuity improved at a rate of -0.16 logarithm of the minimum angle of resolution (logMAR)/log year of age (P < 0.001), an improvement of 0.05 logMAR (half a Snellen line) as the age doubles. Intraclass correlation was 0.95 and interindividual correlation between visual acuity and age was significant (r = -0.24, P < 0.001).

CONCLUSIONS: We describe a natural history of gradual improvement in binocular visual acuity in infantile nystagmus and provide a baseline against which future interventional work can be compared.
Combined Cataract Extraction With Pars Plana Vitrectomy and Metallic Intraocular Foreign Body Removal Through Sclerocorneal Tunnel Using a Novel “Magnet Handshake” Technique Dhoble, Pankaja; Khodifad, Ashish
Purpose: To study the outcomes of combined cataract extraction with pars plana vitrectomy (PPV) and metallic intraocular foreign body (IOFB) removal through a sclerocorneal tunnel using the “magnetic handshake” technique.

Design: A retrospective review.

Methods: Retrospective review of case records of 14 patients from 2010 to 2016 with metallic IOFB and traumatic cataract was performed. Cataract extraction was combined with PPV. Two intraocular magnets (IOMs) introduced through 20-gauge vitrectomy port and sclerocorneal tunnel helped achieve safe delivery of IOFB outside the globe by the “magnetic handshake” technique.

Results: All patients were males with a mean age of 33.04 years. A final best corrected visual acuity (BCVA) of 20/60 or better was noted in 10 (71.42%) of 14 patients. Final reattachment with more than 1 surgery was achieved in 13 (92.85%) patients. Postoperative complications included retinal detachment (RD) and phthisis bulbi in 1 (14.28%) patient each.

Conclusions: Combined cataract extraction with PPV and metallic IOFB removal through sclerocorneal tunnel using the “magnet handshake” technique gives good visual and surgical outcomes.

Review Article

Retinal Vein Occlusion Review Ip, Michael; Hendrick, Andrew
Retinal vein occlusions are a very common condition with great importance in ophthalmology clinical practice. This article reviews the salient epidemiology, risk factors, clinical features, and treatments related to retinal vein occlusions.
Intravitreal Bevacizumab in Diabetic Retinopathy Recommendations from the Pan-American Collaborative Retina Study Group (PACORES): The 2016 Knobloch Lecture Arevalo, J. Fernando; Liu, T.Y. Alvin; Pan-American Collaborative Retina Study Group (PACORES)
The advent of intravitreal anti-vascular endothelial growth factor (anti-VEGF) medications has revolutionized the treatment of diabetic eye diseases. Herein, we report the outcomes of clinical studies carried out by the Pan-American Collaborative Retina Study Group (PACORES), with a specific focus on the efficacy of intravitreal bevacizumab in the management of diabetic macular edema and proliferative diabetic retinopathy. We will also discuss the use of intravitreal bevacizumab as a preoperative, adjuvant therapy before vitrectomy for proliferative diabetic retinopathy.
Paradigms for Pediatric Cataract Surgery Vasavada, Viraj
Pediatric cataract surgery has seen several advances in techniques, technologies, and conceptual practices. Pediatric cataract management heavily depends on a combined effort, not only from the ophthalmologist, but also the parents, the anesthetists, and the supporting staff members (eg, optometrists, orthoptists, patient coordinators). Surgical management, though critical, is not the only consideration for these children. Continuing visual rehabilitation and monitoring for complications remain key elements even after the surgery is done. Pediatric cataract surgery is a complex issue best left to surgeons who are familiar with the surgical paradigms and its long-term complications. Key components of surgery are management of posterior capsule and anterior vitreous and intraocular lens (IOL) implantation. It is a preferred practice today to perform a primary posterior capsulorhexis with anterior vitrectomy in younger children (up to 3 to 5 years old). Even in older children (up to the age of 8 years), performing a posterior capsulorhexis without anterior vitrectomy is the preferred approach. Above the age of 8 years, the posterior capsule can be left intact. In-the-bag IOL implantation is almost becoming a norm for children above the age of 1 year. Though there is no universal consensus regarding the earliest age for primary IOL implantation, many surgeons increasingly prefer primary IOL implantation even in infants. Alternate approaches that can avoid anterior vitrectomy like optic capture through the posterior capsulorhexis and bag-in-the-lens are also gaining more and more popularity.
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