Burden of Ocular Surface Disease in Patients With Glaucoma From Australia.

PURPOSE: In the Australian general population, the economic burden of ocular surface disease (OSD) severity and other dry eye-related diagnosis have been conducted; however, the glaucoma population has not been evaluated. We assessed the current OSD economic burden in Australian glaucoma patients. DESIGN: A cross-sectional, case-comparison study that quantified OSD signs and symptoms was conducted. METHODS: Patients with and without glaucoma from an Australian eye hospital participated. Patient-/physician-reported OSD assessment and literature-based cost-of-burden estimates were used to estimate burden of illness from the health care system (direct costs) and societal (indirect costs) perspectives. Ocular surface disease prevalence and costs were estimated. RESULTS: Significant OSD, defined as the presence of 2 or more signs plus 1 or more symptoms reported "often" or "always," was experienced by 39% of patients with glaucoma and 18% of a control group (P < 0.001); both populations had similar prevalence of mild OSD. Significant OSD cost estimates were Australian dollars (AU$) 1061.25 (direct costs) and AU$14078.40 (indirect costs); average (direct and indirect) was AU$6185.79 per patient per year. Based on 39% prevalence rate for significant OSD, estimated total cost to Australian society was AU$330.5 million per annum. CONCLUSIONS: The use of standard OSD definition across research would allow for comparisons between studies and for improved OSD prevalence estimates. In Australia, 39% of patients with glaucoma were found to have significant (moderate/severe) OSD, and the associated economic burden was AU$330.5 million per annum. Additional research evaluating quality of life and assessing actual direct/indirect OSD costs in the Australian population is warranted.

External analysis of the Randleman Ectasia Risk Factor Score System: a review of 36 cases of post LASIK ectasia.

BACKGROUND: To validate Randleman's model of ectasia risk factor scores using a large unbiased sample of unpublished cases. METHODS: Data were collected retrospectively on 36 eyes with ectasia post laser in situ keratomileusis treated by two surgeons at Vision Eye Institute. The data were then entered into Randleman's risk factor score system. Data were also collected about posterior maximum elevation (PME) and posterior maximum elevation position (PMEP); and these were compared with a control group of 50 eyes. RESULTS: Of the 36 eyes, 9 (25%) were classified as low risk, 7 (19%) as moderate risk and 20 (56%) as high risk. On average, the most points were scored in the topography and topography was abnormal in 69% of cases. Topography points also correlated the most strongly with the increasing risk scores (P < 0.0001).PME or PMEP was not significantly different between our ectasia group and the control group. CONCLUSION: Randleman's ectasia risk factor scale can miss a significant proportion of patients at risk of ectasia. Other factors must play a role in ectasia risk.Abnormal corneal topography appears to be the most important preoperative risk factor.

A comparison of CustomCornea myopia algorithms for wavefront-guided laser in situ keratomileusis.

OBJECTIVE: To determine whether the new CustomCornea M3 (myopic astigmatism) algorithm places additional pulses in the periphery to counter excimer laser peripheral ablation inefficiency. METHODS: Analysis of 25 myopic eyes of 18 patients that were within the approved indications for both the myopic astigmatism (M3) and myopic sphere (A7) algorithms. We analyzed ablation depth at peak and 4-mm, 6-mm, and 7-mm zone diameters for both the A7 and M3 algorithms. RESULTS: The M3 algorithm programmed for more of an ablation at the peak and peripheral zones than the A7 algorithm (P < .001). Even accounting for the additional peak ablation, there was significantly greater ablation in the periphery with the M3 algorithm compared with the A7 algorithm (P < .001). The mean (SD) manifest sphere was -4.09 (1.90) diopters (D), the mean (SD) manifest cylinder was -0.60 (0.52) D, and the mean (SD) manifest spherical equivalent was -4.39 (1.92) D. The manifest sphere ranged from -1.00 to -7.50 D, the manifest cylinder from 0.00 to -1.25 D, and the manifest spherical equivalent from -1.50 to -8.25 D. CONCLUSION: The new CustomCornea M3 algorithm is programmed to perform additional ablation in the periphery to counter decreased pulse efficacy and the potential for induced spherical aberration.

Higher order aberrations and relative risk of symptoms after LASIK.

PURPOSE: To understand what level of higher order aberrations increases the relative risk of visual symptoms in patients after myopic LASIK. METHODS: This study was a retrospective comparative analysis of 103 eyes of 62 patients divided in two groups, matched for age, gender, pupil size, and spherical equivalent refraction. The symptomatic group comprised 36 eyes of 24 patients after conventional LASIK with different laser systems evaluated in our referral clinic and the asymptomatic control group consisted of 67 eyes of 38 patients following LADARVision CustomCornea wavefront LASIK. Comparative analysis was performed for uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), contrast sensitivity, refractive cylinder, and higher order aberrations. Wavefront analysis was performed with the LADARWave aberrometer at 6.5-mm analysis for all eyes. RESULTS: Blurring of vision was the most common symptom (41.6%) followed by double image (19.4%), halo (16.7%), and fluctuation in vision (13.9%) in symptomatic patients. A statistically significant difference was noted in UCVA (P = .001), BSCVA (P = .001), contrast sensitivity (P < .001), and manifest cylinder (P = .001) in the two groups. The percentage difference between the symptomatic and control group mean root-mean-square (RMS) values ranged from 157% to 206% or 1.57 to 2.06 times greater. CONCLUSIONS: Patients with visual symptoms after LASIK have significantly lower visual acuity and contrast sensitivity and higher mean RMS values for higher order aberrations than patients without symptoms. Root-mean-square values of greater than two times the normal after-LASIK population for any given laser platform may increase the relative risk of symptoms.

Reduced best spectacle-corrected visual acuity from inserting a thicker Intacs above and thinner Intacs below in keratoconus.

PURPOSE: To report a case of decreased best spectacle-corrected visual acuity (BSCVA) 2 months after Intacs implantation. METHODS: A 33-year-old woman with keratoconus and contact lens intolerance underwent Intacs surgery in the left eye at another institution. Two segments were used--a thinner one (0.25 mm) below the cone and a thicker one (0.35 mm) above the cone. RESULTS: Two months postoperatively, the patient presented to our practice with BSCVA reduced from 20/20 to 20/30. The superior Intacs segment was explanted, the inferior segment was exchanged for a thicker one (0.35 mm), and collagen cross-linking with riboflavin treatment was performed. This resulted in visual, topographic, and refractive improvement with BSCVA returning to 20/20. CONCLUSIONS: Single inferior segment Intacs may be more appropriate for paracentral and peripheral cones. Collagen cross-linking may help cause further flattening. Using asymmetrical segments, with the thicker segment above the cone, may increase distortions and result in loss of BSCVA.

Comparison of the effects of LASIK retreatment techniques on epithelial ingrowth rates.

PURPOSE: To compare the incidence of postoperative epithelial ingrowth using 3 different surgical LASIK retreatment techniques. DESIGN: Retrospective consecutive case series. PARTICIPANTS AND CONTROLS: Thirty consecutive eyes that underwent LASIK retreatments by a single surgeon. METHODS: The first 10 eyes underwent LASIK retreatment using the surgeon's routine surgical technique (forceps lift group), the next 10 retreated eyes had a bandage contact lens placed after surgery and removed the following day (contact lens group), and the next 10 patients had retreatment performed using a Pinelli spatula to cleave the circumference of the flap edge before lifting the flap and no contact lens placed after surgery (spatula cleaving group). The retreatment technique did not vary apart from these modifications. MAIN OUTCOME MEASURES: Incidence of postoperative epithelial ingrowth. RESULTS: The incidence of epithelial ingrowth was 40% in the contact lens group, 20% in the forceps lift group, and 10% in the spatula cleaving group. There was a trend toward a significant difference between the contact lens and spatula cleaving groups (P = 0.12). The patients with epithelial ingrowth showed a trend toward being older, with a mean age of 53+/-8.5 years compared with a mean age of 44+/-13 years for the patients without epithelial ingrowth (P = 0.07). Incidence of ingrowth was not related to the preoperative spherical equivalent. CONCLUSIONS: There was an increased incidence of epithelial ingrowth with use of an overnight bandage contact lens in our series. The Pinelli spatula may reduce trauma to the epithelium at the flap edge. The incidence of epithelial ingrowth was not related to the preoperative spherical equivalent. Increasing age may be a risk factor for epithelial ingrowth, but further study is warranted.

Effect of inferior-segment Intacs with and without C3-R on keratoconus.

PURPOSE: To determine whether corneal collagen cross-linking with riboflavin (C3-R) augments the effect of inferior-segment Intacs (Addition Technology) in the treatment of keratoconus. SETTING: Private practice, Beverly Hills, California, USA. METHODS: A retrospective nonrandomized comparative case series comprised 12 eyes of 9 patients who had inferior-segment Intacs placement without C3-R (Intacs-only group) and 13 eyes of 12 patients who had inferior-segment Intacs placement combined with C3-R (Intacs with C3-R group). The 2 groups were matched preoperatively. All patients had inferior-segment Intacs placed with the incision in the steep axis of manifest refraction. Corneal collagen cross-linking with riboflavin was performed after the Intacs segments were inserted. Outcome measures were topographic keratometry values and the lower-upper (L-U) ratio, which is a topographic measure of the degree of keratoconus. Preoperative data were compared to results 1 day postoperatively and measurements at the last postoperative visit. RESULTS: The Intacs with C3-R group had a significantly greater reduction in cylinder than the Intacs-only group (P<.05). Steep and average keratometry were reduced significantly more in the Intacs with C3-R group (P<.05). There was a greater reduction in L-U ratio in the Intacs with C3-R group (P<.05). CONCLUSION: The addition of C3-R to the Intacs procedure resulted in greater keratoconus improvements than Intacs insertion alone.

Calculation of intraocular lens power after corneal refractive surgery.

PURPOSE: Underestimation of required intraocular lens (IOL) power with resultant hyperopia is common in post-corneal refractive surgery eyes. A number of methods to minimize error have been proposed but most studies have been small and theoretical. METHODS: We retrospectively reviewed 34 eyes that had undergone routine phacoemulsification and IOL implantation after photorefractive keratectomy or laser in situ keratomileusis. Sixteen eyes were included in the final analysis. Using known pre- and postoperative data, four methods were used to obtain keratometric values combined with three common IOL formulae (Holladay 2, SRK/T and Hoffer Q) and Koch's published Double-K nomogram. The Double-K method was also used in conjunction with the Holladay 2 formula. Target refractions were calculated and then compared to actual postoperative results. RESULTS: The Clinical History method at the spectacle plane produced the lowest mean K-values. Shammas adjustment formula combined with the Holladay 2 and Hoffer Q produced results closest to emmetropia. The Double-K methods produced the least number of hyperopic results. Overall, all methods would have resulted in unacceptably high rates of hyperopia and deviation from target refraction. CONCLUSIONS: No method produces acceptably consistent results because modern IOL formulae were designed for presurgical eyes. Accuracy will only be improved when new IOL formulae based on the anatomy of postrefractive eyes become available. Shammas adjustment formula and regression formulae are viable alternatives especially when there is a lack of preoperative data. The Double-K methods are best suited to avoiding a hyperopic surprise.

Centration analysis of ablation over the coaxial corneal light reflex for hyperopic LASIK.

PURPOSE: To analyze postoperative topographic centration when the coaxially sighted corneal light reflex was used for laser centration in hyperopic LASIK. METHODS: Centration photographs of 21 eyes (12 patients) that underwent hyperopic LASIK with centration over the coaxially sighted corneal light reflex were reviewed to determine the distance from the entrance pupil center to the coaxially sighted corneal light reflex. Postoperative ablation centration was determined topographically at day 1 and 3 months by four different methods. The difference between the actual decentration and the decentration that would have occurred had the ablation been centered over the entrance pupil center was calculated. RESULTS: The mean deviation of the coaxially sighted corneal light reflex from the entrance pupil center preoperatively was 0.34 +/- 0.24 mm nasal or 4.5 +/- 3.0 degrees. At 1 day, the average decentration was 0.10 mm or 1.3 degrees temporal. The mean decentration that would have occurred if the ablation had been centered over the entrance pupil center was 0.44 mm or 5.5 degrees temporal. At 3 months, the average decentration was 0.07 mm or 0.25 degrees temporal. The mean decentration that would have occurred if the ablation had been centered over the entrance pupil center was 0.45 mm or 5.6 degrees temporal. Mean uncorrected visual acuity (logMAR) improved 3 lines from 0.54 +/- 0.14 (20/70) to 0.22 +/- 0.17 (20/32). No eye lost >2 lines of best spectacle-corrected visual acuity (BSCVA); 2 (10%) eyes lost 1 line of BSCVA at 3-month follow-up. CONCLUSIONS: Excellent centration in hyperopic ablation is possible even in eyes with positive angle kappa when the ablation is centered over the corneal light reflex.

Intraconal superior ophthalmic vein embolisation for carotid cavernous fistula.

A 53-year-old man presented with a longstanding carotid cavernous fistula that could not be embolised completely via the femoral route. A superior ophthalmic vein approach was necessary; however, the vein was thrombosed anteriorly and only intraconal cannulation was possible. The vein was accessed via a superior lid crease approach and the fistula successfully embolised. Whilst utilising the superior ophthalmic vein is well described in the literature, to our knowledge, needing to access the intraconal portion of the vein has not previously been reported.

Dense membrane formation after combined phacoemulsification-trabeculectomy surgery.

A case is reported of formation of a dense intraocular membrane following combined phacoemulsification-trabeculectomy surgery. The membrane might have originated from a loose piece of pigment epithelium or might have resulted from dense pigment deposition on a postoperative pupillary membrane. Postoperative membranes have been reported particularly after combined procedures. A combination of intensive topical dexamethasone, homatropine and a Nd:YAG laser was used to speed resolution of the membrane.

Predictors of recurrent ischemic optic neuropathy in giant cell arteritis.

BACKGROUND: The competing interests of preventing recurrent ischemic optic neuropathy (ION) and minimizing medication side effects make corticosteroid dose reduction in giant cell arteritis (GCA) a difficult problem. The authors sought to determine whether any factors were predictive of recurrent ION. METHODS: Retrospective review of the records of 100 consecutive patients with biopsy-proven giant cell arteritis diagnosed in two Australian hospitals between 1988 and 1998. Among 67 patients who met inclusion criteria for ION in GCA, seven patients had recurrent ION. We compared the seven patients with recurrent ION to the 60 patients with nonrecurrent ION in terms of age, gender, mode of corticosteroid delivery, initial visual acuity in the affected eye, prevalence of bilateral ION, initial erythrocyte sedimentation rate (ESR) level, and rate of corticosteroid dose reduction. In the recurrent ION group, we documented the timing of the recurrence in relation to corticosteroid dose, elevation in acute phase reactants, and relapse of systemic symptoms. RESULTS: We found recurrent ION in GCA in 10% of our cohort, higher than has been previously reported. Recurrences, all of which were ipsilateral, occurred from 3 to 36 months (median 8 months) after the initial ION. None of the clinical indicators the authors examined differed between the two groups. Six of seven patients with recurrent ION had elevations in ESR or C-reactive protein or a new headache at the time of ION recurrence, but in only one of these patients were these features recognized as preceding the recurrent ION. One patient had neither an elevation in acute phase reactants nor a relapse in systemic symptoms of GCA at the time of ION recurrence. CONCLUSIONS: Recurrent ION in GCA is difficult to predict. Although elevated acute phase reactants or new systemic symptoms consistent with GCA were present in six (83%) of our patients with ION recurrence, in only one patient (17%) did these events occur with enough lead time to allow caregivers to act preemptively. Thus, even very close monitoring of GCA patients with ION may not predict ION recurrence.

Oral and intravenous steroids in giant cell arteritis.

Giant cell arteritis can result in devastating visual loss. Treatment with steroids does result in visual recovery in some patients but the exact percentage is unknown. Intravenous megadose steroids appear to offer some advantage over oral steroids presumably through non-genomic effects, which manifest at doses of 500 mg or more. Side-effects are more likely in the elderly especially those with renal and cardiac co-morbidities. The authors' current recommendation is that intravenous steroids should be given to patients with established visual loss or amaurosis fugax.