Effect of posterior juxtascleral triamcinolone acetonide on choroidal neovascular growth after photodynamic therapy with verteporfin.

OBJECTIVE: To assess if posterior juxtascleral application of 40 mg triamcinolone acetonide (TA), given at the same time as initial photodynamic therapy (PDT) for predominantly classic choroidal neovascularization (CNV) related to age-related macular degeneration affects lesion growth at 3 and 6 months. DESIGN: Comparative (nonrandomized) interventional study. PARTICIPANTS: The study group consists of 38 eyes of 38 patients. The control group consists of 73 eyes of 73 patients. METHODS: Comparison of 2 consecutive case series collected at different times. The study group had a posterior juxtascleral TA with their initial PDT treatment. The controls were treated with PDT alone. All patients were reviewed at 1, 3, and 6 months. MAIN OUTCOME MEASURES: Change in total lesion size; secondary outcomes: area of leak, best-corrected visual acuity, number of treatments, and intraocular pressure. RESULTS: There was significantly less growth of total lesion at 3 months (mean difference = 2.47 mm2; 95% confidence interval (CI): +1.22 to +3.72 mm2; P = 0.0002) and 6 months (mean difference = 2.88 mm2; 95% CI: +0.61 to +5.15 mm2; P = 0.0134) in patients given TA with PDT compared with PDT alone. There was also a significantly smaller residual area of leak at 3 months in the study group (mean difference = 1.07 mm2; 95% CI: +0.16 to +1.97 mm2; P = 0.02). At 6 months, the residual area of leak between the 2 groups became comparable (mean difference = 0.13 mm2; 95% CI = -1.59 to +1.33 mm2; P = 0.86). Mean number of letters lost on the logarithm of the minimum angle of resolution chart at 6 months was 9.1 letters (standard error of the mean [SEM] = 2.21) in the study group compared with 12.4 letters (SEM = 1.91) in the control group (P = 0.30). At 6 months, 10 of 36 eyes (27.8%) in the study group showed > or =15 letters loss, compared with 29 of 73 eyes (39.7%) in the control group. Intraocular pressure was raised in 4 of 38 eyes (10.5%). Fewer retreatments were required in the TA with PDT group (2.03 compared with 2.47 [P = 0.006]). CONCLUSIONS: Posterior juxtascleral placement of TA with PDT at baseline significantly reduces CNV growth at 3 and 6 months. Fewer retreatments were required. Visual outcome may be improved, although we did not show a statistically significant improvement with this sample size. A larger, randomized trial with longer follow-up is justified.

A modified method for measuring uniocular fields of fixation: reliability in healthy subjects and in patients with Graves orbitopathy.

OBJECTIVE: To assess the intraobserver and interobserver reliability of recording uniocular fields of fixation using a modified perimeter technique in healthy subjects and patients with Graves orbitopathy (GO). Patients with restrictive myopathies, particularly GO, require accurate measurement of monocular excursions. These ductions are recorded in 4 to 12 directions of gaze using a perimeter, producing a plot known as a uniocular field of fixation. While 4 direction plots give limited information on vertical muscles, recording 12 directions is time consuming and uncomfortable. This modified technique uses the 6 directions of gaze corresponding to the primary field of action of each muscle. METHODS: A single observer measured modified uniocular fields of fixation in 35 healthy subjects aged 20 to 60 years to establish normal and age-related ranges for all ductions. Fifteen subjects underwent measurement on 5 separate occasions by the same observer to establish intraobserver reproducibility. A second observer independently performed measurements in 10 of the subjects to determine interobserver reproducibility. Reliability was compared with that measured in 29 patients with GO. RESULTS: The technique was reproducible to within 4 degrees for healthy subjects undergoing assessment by a single observer. When results of 2 observers were compared, the coefficient of repeatability was 7.9 degrees . For subjects with GO, however, maximal variability was 7.8 degrees . For clinical purposes, only a change of 8 degrees or more can be assumed to be significant. CONCLUSIONS: This technique offers advantages for assessing any restrictive myopathy, including GO to within 8 degrees . This level of accuracy is likely to be similar in other centers, and has implications for interpreting GO outcome measures, where 5 degrees was previously taken to represent significant change.

The effect of contrast reduction on pattern-reversal VEPs in suspected multiple sclerosis and optic neuritis.

A retrospective study was conducted to investigate whether the use of low-contrast stimuli in addition to the standard high-contrast stimuli would increase the sensitivity of the pattern-reversal P100 when testing for multiple sclerosis (MS) and optic neuritis (ON). We found that there was a statistically significant increase in the number of abnormal results when using 25' checks, but not for 50' checks. Examination of patient records showed that VEP abnormalities to low-contrast stimuli only was not prognostic for subsequent development of multiple sclerosis.

Improved illumination for the Perkins applanation tonometer.

AIMS: To improve the Perkins tonometer measurements by using an augmented, monochromatic solid-state light source of 470 nm wavelength. METHODS: This prospective study comprised 44 patients of our ophthalmic department who were split into two groups of 21 and 23 patients, and were tested by two independent ophthalmologists. Intraocular pressure (IOP) was measured in both eyes, comparing the instrument with augmented source against the standard Perkins for both observers. A set of three consecutive IOP measurements was recorded on each patient's eye and the time required to make each of them was recorded. The mean of the three IOP values was used in the analyses. RESULTS: For Observer 1, higher values of IOP with our augmented illumination against the standard were recorded, the mean difference of +0.59 mmHg being statistically significant (95% CI, 0.0 to +1.18 mmHg). For Observer 2, the mean difference of -0.22 mmHg was not significant (95% CI, -0.70 to +0.26 mmHg). Measurement times for observers were shorter when using the augmented illumination (Observer 1: mean difference = -2.0 s, S.E. = 1.4 s, CI, +0.8 to -4.9 s; Observer 2: mean difference = -5.0 s, S.E. = 1.3 s, CI, -2.5 to -7.5 s). CONCLUSION: The monochromatic blue light source may improve the performance of IOP measurements with the Perkins instrument under bright room conditions, making them faster and more convenient.