Differences of frequency in administration of ranibizumab and bevacizumab in patients with neovascular AMD.

PURPOSE: Intravitreal ranibizumab or bevacizumab are the most used drugs for treatment of neovascular age-related macular degeneration (nAMD). Repeated intravitreal injections represent an economic burden and may be associated with serious complications. The aim of this study is to evaluate the number of needed injections within 1 year of treatment. METHODS: 55 patients over 50 years of age with nAMD and visual acuity (VA) between 20/40 and 20/320 were included. Scheduled visits and treatment were performed monthly for 1 year. After a loading dose of three intravitreal injections (either ranibizumab = group 1 or bevacizumab = group 2), an "as needed" regimen was performed. Primary endpoint was a difference in the injection frequencies of ranibizumab and bevacizumab. Secondary endpoints were best corrected visual acuity (BCVA) and central retinal thickness (CRT). RESULTS: Difference in number of injections was not significant (5.00 ± 1.67 (ranibizumab group) vs. 5.80 ± 2.28 (bevacizumab group), p = 0.084). Mean BCVA was 59.12 ± 16.64 letters after 12 months if patients received ranibizumab (p = 0.001) and 64.75 ± 17.03 letters if patients received bevacizumab (p = 0.037). There was no statistical significance between the two groups (p = 0.631). The mean CRT did not differ significantly between groups after 12 months (315.67 ± 65.86 µm for ranibizumab, 350.47 ± 102.84 µm for bevacizumab, p = 0.088). CONCLUSION: There was no difference in number of treatment, BCVA and CRT after 1 year between ranibizumab and bevacizumab in patients with nAMD.

Encircling band, laser retinopexy and lens removal as standard procedure in complicated retinal detachment shows a good clinical outcome.

PURPOSE: To evaluate vitrectomy in conjunction with the use of perfluorocarbon, cerclage, laser retinopexy, lens removal and silicone oil as surgical treatment of proliferative vitreoretinopathy associated with retinal detachment. METHODS: Sixty-two eyes of 62 patients were treated for complicated retinal detachment following failed prior scleral buckling. Outcome measures were; retinal reattachment rate 6 months after silicone oil removal, status of the retina, visual acuity (VA), duration of silicone tamponade and frequency of reoperations. RESULTS: The final reattachment rate was 95%. Reoperations had to be performed in 25% of patients. Eighty-one per cent of these patients received one and 19% two or more operations following silicone oil implantation. The mean time to reoperation was 1.8 ± 1.4 months. Silicone oil was removed after 5.6 ± 4.1 months following the last vitreoretinal procedure in 90%, respectively, 95% with attached retina. Five per cent experienced retinal detachment after silicone oil removal. At the end of follow-up, the mean VA was 0.13 ± 0.26 Snellen. Seventy per cent of patients achieved a vision of 20/200 or better (mean 0.25 ± 0.27). CONCLUSION: Our study demonstrates good final outcomes when a rigorous surgical approach was used. Furthermore, this standard procedure reduces the need for reoperations and consequently improves the functional outcome.

Which factors influence patients' maximum acceptable waiting time for cataract surgery? - a questionnaire survey.

PURPOSE: To evaluate patients' maximum acceptable waiting time (MAWT) and to assess the determinants of patient perceptions of MAWT. METHODS: A total of 500 consecutive patients with cataract were asked to fill out a preoperative questionnaire, addressing patients' MAWT to undergo cataract surgery. Patients' visual impairment (VF-14 score), education, profession and social status were evaluated, and an ophthalmologic examination was performed. Univariate analysis included Spearman's correlation test, unpaired Student's t-test and the Mann­Whitney U test. Univariate and multivariate associations were calculated using unconditional logistic regression. RESULTS: The mean MAWT was 3.17 ± 2.12 months. The mean VF-14 score was 72.10 ± 22.54. Between VF-14 score and MAWT, there was a significant correlation (r = 0.180, p = 0.004). Patients with higher education (high school, university) accepted significantly longer MAWT (3.92 ± 2.38 months versus 3.02 ± 2.00 months, p = 0.009). Patients who had self-noticed visual impairment were nearly four times (OR: 3.88, 95% CI = 2.07­7.28, p < 0.001) more likely to accept only MAWT of <3 months. CONCLUSIONS: Patients with low tolerance for waiting had greater self-reported difficulty with vision. Patients' acceptance of waiting was not associated with clinical visual acuity measures. Education, ability to work, living independently and taking care of dependents were also strong predictors from patients' perspective. Considering the implementation of standards for waiting lists, these facts should be taken into account.

Effect of posterior capsule opacification on macular sensitivity.

PURPOSE: To evaluate the effect of posterior capsule opacification (PCO) on macular sensitivity. SETTING: Department of Ophthalmology, Medical University of Vienna, Vienna, Austria. METHODS: Macular sensitivity, best corrected visual acuity (BCVA), and PCO intensity were evaluated before and after neodymium:YAG (Nd:YAG) laser capsulotomy in pseudophakic eyes with clinically significant PCO that had a healthy macula or dry age-related macular degeneration (ARMD). Macular sensitivity was determined using the fundus-related Microperimeter 1 (Nidek) in a central field of 10 degrees. The intensity of the PCO was assessed objectively in the central 3.0 mm area (score 0 to 10) using quantification software. RESULTS: After Nd:YAG capsulotomy, both groups had a significant improvement in BCVA and mean macular sensitivity; the change in the mean logMAR value was -0.26 in the healthy macula group and -0.23 in the dry ARMD group and the change in mean macular sensitivity, 2.5 dB and 2.0 dB, respectively. Before Nd:YAG capsulotomy, significant correlations were observed between PCO values, BCVA, and macular sensitivity in the healthy macula group only (P<.01). CONCLUSIONS: Neodymium:YAG laser capsulotomy improved BCVA and macular sensitivity. The PCO scores correlated well with the PCO-induced decrease in BCVA and with PCO-induced loss of macular sensitivity. Functional macular mapping indicated an overall loss of macular sensitivity in patients with dry ARMD. There was no significant association between PCO values and macular sensitivity in eyes with dry ARMD.

Is day-case cataract surgery an attractive alternative from the patients' point of view? A questionnaire survey.

Cataract surgery is the most common elective surgical procedure undertaken in elderly people. In many European countries and in the USA cataract surgery is normally a day-case procedure without an overnight stay in hospital, unlike the situation in Austria where fewer than 2% of patients are day cases. However, there is a lack of prospective studies on patients' need for and acceptance of day-case surgery. The aim of our study was therefore to evaluate patients' demand and suitability for outpatient surgery, based on analysis of preoperative questionnaires on availability of family and/or social support and on preoperative ophthalmologic examination. Among 500 consecutive patients with cataract, 154 (41.8%) chose a day-case procedure and 256 (58.2%) preferred inpatient admission. Patients preferring full admission were older (mean age 76.4+/-8.1 vs. 72.73+/-9.5 years, P<0.001), had worse visual acuity (0.55+/-0.20 vs. 0.66+/-0.23, P<0.001), were more likely to be female (63.9% vs. 47.0%, P=0.001), to live more than one hour away from the hospital (26.5% vs. 12.5%, P<0.001) and have no carer at home (43.0% vs. 6.5%, P<0.001). Patients favoring day-case surgery were more likely to be able to attend an ophthalmologic check-up 24 h after surgery (96.7% vs. 59.6%, p<0.001). The majority of patients indicated a preference for inpatient care, but this may be a reflection of their previous hospital experience and a matter of custom in the elderly population. Information, education and better organization of after-surgery services could help increase the attractiveness of cataract surgery as an outpatient procedure in Austria. Our findings could also be relevant to day-case services in medical care in general.

Uveal and capsular biocompatibility after implantation of sharp-edged hydrophilic acrylic, hydrophobic acrylic, and silicone intraocular lenses in eyes with pseudoexfoliation syndrome.

PURPOSE: To evaluate the uveal and capsular biocompatibility of 3 types of sharp-edged foldable intraocular lenses (IOLs) in eyes with pseudoexfoliation syndrome (PEX). SETTING: Department of Ophthalmology, Medical University of Vienna, Vienna, Austria. METHODS: Eighty-five eyes with PEX had implantation of 1 of the following sharp-edged 3-piece IOLs: hydrophilic acrylic (Injectacryl F3000, OphthalMed), hydrophobic acrylic (AcrySof MA60MB, Alcon), or silicone (CeeOn 911, AMO). Postoperative evaluation (flare, cellular reaction, and capsular reaction) was performed at 1, 3, and 7 days as well as 1, 3, 6, and 12 to 18 months. RESULTS: One year after surgery, flare was comparable between the IOLs. In terms of uveal biocompatibility, whereas the Injectacryl had the highest deposition of debris on the IOL surface (P = .04), the CeeOn 911 had significantly more small round cells in the first 6 months (P<.03). The AcrySof had the highest number of foreign-body giant cells (P = .01). In terms of capsular biocompatibility, lens epithelial cell outgrowth was highest in the AcrySof group (P<.02). Anterior capsule opacification was comparable between the 3 groups. Posterior capsule opacification was mild in all groups but was significantly greater in the Injectacryl group (P<.05). There were no cases of clinically significant IOL decentration or capsule contraction. CONCLUSIONS: In general, inflammatory cells accumulated more easily on hydrophobic IOLs than on hydrophilic IOLs; the AcrySof IOL had the highest prevalence of foreign-body giant cells. All 3 IOLs had good biocompatibility, although the AcrySof group had increased inflammatory signs.

Functional macular mapping in patients with vitreomacular pathologic features before and after surgery.

PURPOSE: To evaluate the potential benefit of microperimetry and preferential hyperacuity perimeter (PHP) to document visual performance objectively in patients with macular hole and macular pucker undergoing macular surgery. DESIGN: Observational case series. METHODS: In 19 patients with macular hole and 18 with macular pucker, best-corrected visual acuity (BCVA; in logarithm of the minimum angle of resolution units), central retinal sensitivity, and presence and extent of metamorphopsia were documented before and four and 12 weeks after surgery. Macular sensitivity (mean sensitivity decibel [dB], stability of fixation) was determined using MP1 microperimetry (Nidek, Padova, Italy). The PreView-PHP (Carl Zeiss Meditec, Dublin, California, USA) was used to quantify metamorphopsia. RESULTS: Before surgery, mean BCVA was 0.68 +/- 0.25 (macular holes) and 0.58 +/- 0.25 (macular pucker). Microperimetry demonstrated a mean retinal sensitivity of 11.3 +/- 2.5 dB (macular holes) and 10.7 +/- 2.8 dB (macular pucker). Twelve weeks after surgery, mean BCVA improved to 0.53 +/- 0.26 (macular holes) and 0.33 +/- 0.26 (macular pucker; P = .042 and P = .004). Accordingly, retinal sensitivity increased significantly with 12.8 +/- 1.9 dB (macular holes) and 12.7 +/- 2.5 dB (macular pucker; P = .04 and P = .02) as well as stability of fixation. At 12 weeks, 47.3% of macular hole eyes and 66.7% of macular pucker eyes improved in BCVA, but a significantly higher number (68.4% [macular holes] and 77.8% [macular pucker]) demonstrated improvement in microperimetry results. PHP results showed no significant change of scotomas, patient reliability, or presence of metamorphopsia at any interval. CONCLUSIONS: A higher number of patients improved in microperimetry than in visual acuity testing. Therefore, microperimetry highlights the value of functional macular mapping for these patients and indicates that BCVA may underestimate functional benefit of surgery.

Reading performance of patients with uveitis-associated cystoid macular edema.

PURPOSE: To evaluate the extent of the visual impairment caused by uveitis-associated cystoid macular edema (CME) and compare the results with lesion size. DESIGN: Observational case series. METHODS: setting: Uveitis outpatient clinic of the Department of Ophthalmology and Optometry, Medical University of Vienna. patient population: CME was verified in 30 eyes of 30 consecutive uveitis patients with optical coherence tomography and lesion size was assessed with retinal thickness analyzer. main outcome measures: Distance visual acuity (VA) (measured with Early Treatment Diabetic Retinopathy Study charts), reading acuity, and reading speed (tested with Radner Reading Charts). Results were compared with nonaffected partner eyes. RESULTS: Distance VA was logMAR 0.22 +/- 0.15 in CME eyes vs -0.02 +/- 0.17 in healthy controls. Reading acuity was 75% of logMAR in CME eyes vs 92% of logMAR in control eyes (P = .01). The mean reading speed was 148.4 +/- 36.6 words per minute in patients with CME vs 168.9 +/- 36.3 in patients without CME (P = .04). Reading acuity correlated with both lesion size and distance VA (r = 0.61; P = .01 and r = 0.53; P = .028, respectively). Neither anatomical classification of uveitis nor gender or age had a significant influence on the evaluated parameters. CONCLUSIONS: Reading acuity and reading speed were considerably more impaired than distance visual acuity. The assessed parameters showed a better correlation to lesion size and seem to be a better reflection of macular dysfunction. Analyzing reading function is an important factor when following patients with CME and evaluating success of treatment modalities.

Differences in reading performance of patients with Drusen maculopathy and subretinal fibrosis after CNV.

PURPOSE: To evaluate differences in reading performance and contrast sensitivity on patients with drusen maculopathy and subretinal fibrosis after CNV (choroidal neovascularisation). METHODS: 136 patients (60 with drusen (D), 76 with fibrosis (F)) were studied. Patients were classified according to type of maculopathy and best-corrected visual acuity into groups D1 and F1 (LogMAR 0.2-0.4), groups D2 and F2 (LogMAR>0.4-0.7), and group F3 (LogMAR>0.7-1.3). Reading acuity (in LogRAD) and speed were examined with the Radner Reading charts and compared to the reading speed measured with the long paragraphs of the Zuercher Reading Test. Contrast sensitivity was measured with Pelli-Robson charts. RESULTS: The patients' distance visual acuity was comparable between the drusen and fibrotic CNV groups (D1 versus F1, D2 versus F2). The reading acuity of the corresponding groups D1 and F1 was also comparable, but F2 patients showed a statistically lower reading acuity than D2 patients (P=0.03). All reading speed measurements of the groups F1 and F2 were significantly worse than those of the corresponding groups D1 and D2 (P-values: 0.0005-0.02). The correlation of reading speed between the Radner and Zuercher texts was very high (r=0.73-0.94). The contrast sensitivity was significantly lower in all groups compared with group D1 (P<0.001), but comparable for groups F1, F2, and F3. CONCLUSIONS: Despite comparable results in distance visual acuity, patients with subretinal fibrosis after CNV had a greater reduction in reading ability than the patients with drusen. The distance visual acuity measurements alone, therefore, underestimate the real-life conditions and impact of AMD.

Influence of laser in situ keratomileusis and laser epithelial keratectomy on patients' reading performance.

PURPOSE: To evaluate the influence of laser in situ keratomileusis (LASIK) and laser-assisted subepithelial keratectomy (LASEK) on reading performance regarding reading acuity, reading speed based on print size, maximum reading speed, and critical print size. SETTING: Department of Ophthalmology, University of Vienna, Vienna, and Auge-und-Laser, Medicent Baden, Austria. METHODS: Fifty-two eyes of 34 patients (26 eyes per group) were studied. Best corrected LogMAR visual acuity (Early Treatment Diabetic Retinopathy Study charts), reading acuity, and reading speed were tested monocularly before LASIK or LASEK and 3 weeks after surgery. Reading acuity (LogRAD) and reading speed were determined with the standardized Radner reading charts. RESULTS: Preoperatively, the distance visual acuity and reading acuity were comparable between the LASIK and LASEK patients. Reading speed measurements also showed no statistical difference. Three weeks after refractive surgery, no statistically significant differences in the preoperative measures and between the 2 surgical procedures could be found in any tested parameters. The mean distance visual acuity was LogMAR -0.02 +/- 0.06 (SD) (LASIK) and LogMAR -0.05 +/- 0.07 (LASEK). The mean reading acuity was LogRAD 0.00 +/- 0.12 (97.7% of LogMAR) (LASIK) and LogRAD 0.04 +/- 0.16 (93.7% of LogMAR) (LASEK). The mean maximum reading speed was 235 +/- 35 words per minute (LASIK) and 240 +/- 37 words per minute (LASEK), and the mean critical print size was at LogRAD 0.48 +/- 0.19 (LASIK) and 0.49 +/- 0.17 (LASEK). CONCLUSIONS: In a standardized reading test setting, no significant effects of LASIK and LASEK on individual reading performance could be evaluated. This indicates that patients can expect to retain their normal visual function after refractive surgery with these 2 procedures under full light conditions.

Proliferative vitreoretinopathy--at what risk is the fellow eye?

PURPOSE: To find out if patients with proliferative vitreoretinopathy (PVR) due to complicated retinal detachment are at risk to acquire the same disease or other vision-threatening retinal abnormalities in the fellow eye. To furthermore assess in what time-period they appear and if subgroups of patients have special risks. METHODS: 100 consecutive PVR-patients were studied retrospectively. 21 patients with PVR graded lower than C3, traumatic PVR, diabetic retinopathy or congenital vitreoretinal diseases were excluded. Age, gender, best-corrected visual acuity at the first and last visit, refraction, ocular disease in both eyes and observation-time were recorded. RESULTS: After a mean follow-up of 8.5 years, 42 of 79 patients (53.4%) showed vision-threatening abnormalities in their fellow eyes: among them, 9 patients (11.4%) had PVR, 13 (16%) simple retinal detachments and 14 (17.3%) retinal breaks. Abnormalities in the fellow eye did not develop after a certain time following surgery of the primary eye; 71.4% appeared within 5 years. Aphakic and pseudophakic patients had retinal breaks significantly more often (p = 0.011) than phakic patients. Myopia did not increase the risk for any abnormality. Men developed retinal detachment (p = 0.037) and PVR (p = 0.025) significantly more often than women. CONCLUSION: Patients with PVR have a greater than 50% risk of developing vision-threatening retinal abnormalities in their fellow eye. Because of this increased risk, these patients need regularly-scheduled long-term follow-up. SUMMARY STATEMENT: Patients with PVR have a greater than 50% risk of developing vision-threatening retinal abnormalities in their fellow eye and a 37% risk to develop PVR from rhegmatogenous retinal detachment. More than two thirds of abnormalities in the fellow eye developed within five years of surgery of the primary eye.

Informed consent and decision making by cataract patients.

OBJECTIVES: To investigate decision making by patients on the day before cataract surgery and to evaluate to what extent the informed consent process influences the patients' decision regarding consent. METHODS: On the day before surgery, 70 patients (mean +/- SD age, 70.3 +/- 10.3 years) underwent a standardized informed consent procedure. They were also invited to answer 15 questions established in interdisciplinary cooperation among clinical psychologists, lawyers, and ophthalmologists. MAIN OUTCOME MEASURES: We assessed presurgical information and personal estimation of risks in cataract surgery; the patient-physician relationship regarding surgery-related decisions; and evaluations of the informed consent procedure and the patients' decision. RESULTS: Questionnaire answers indicated that 28 (40%) of the 70 participating patients arrived for surgery without any information; 16 (23%) believed that there were surgical procedures without risks; and 53 (76%) estimated that there were no risks for their cataract surgery. A physician-dominated decision for surgery was preferred by 31 patients (44%); 16 (26%) wanted to decide together with their ophthalmologist. Possible risks of a sight-threatening complication did not influence 54 patients' (77%) decisions, and 55 patients (78%) said the informed consent process did not influence their decision. The remaining 15 (22%) stated that the informed consent process positively confirmed their decision. CONCLUSIONS: Informed consent 1 day preoperatively does not seem to influence the decision for cataract surgery. Cognitive dissonance as part of a decision-making process makes changes in an already chosen option unlikely. The resulting limited decisive potential is very important for credibility in a trial and has to be considered in ophthalmologic surgery.

Reading performance with a refractive multifocal and a diffractive bifocal intraocular lens.

PURPOSE: To evaluate the reading performance of a diffractive bifocal (811E, Pharmacia) and a refractive multifocal (SA40N, Allergan) intraocular lens (IOL) and compare it with that of a monofocal IOL (811C, Pharmacia) with respect to reading acuity, reading speed based on print size, maximum reading speed, reading distance, and critical print size. SETTING: Department of Ophthalmology, University of Vienna, Vienna, Austria. METHODS: This study comprised 120 pseudophakic eyes of 70 patients; each IOL group had 40 eyes. The patients' age, sex, and best corrected logMAR visual acuity were recorded. Reading acuity and speed were tested monocularly. Reading acuity was determined in logRAD (ie, the reading equivalent of logMAR). Patients with bifocal and multifocal IOLs read with best distance correction and patients with a monofocal IOL, with an addition of +3.0 diopters. RESULTS: The age, mean spherical equivalent, cylinder, and best corrected distance visual acuity were comparable among the 3 groups. The mean logRAD reading acuity was 0.17 +/- 0.18 (SD) in the 811E group (94.0% of logMAR), 0.31 +/- 0.13 in the SA40N group (73.2% of logMAR), and 0.24 +/- 0.22 in the 811C group (94.1% of logMAR). The reading acuity in the SA40N group was statistically significantly lower than in the 811E and 811C groups. The best reading distance was 30 cm in the 811E group and 40 cm in the SA40N group. The mean maximum reading speeds in words per minute were comparable: 187.5 +/- 26.1 (811E), 171.0 +/- 21.1 (SA40N), and 179.4 +/- 21.6 (811C). The reading speed, which ranged from logRAD 0.7 to 0.3, and the critical print size in the SA40N group were significantly worse than in the 811E and 811C groups. The mean critical print size in the 811E group was significantly worse than in the 811C group. CONCLUSIONS: Reading performance was acceptable in the bifocal and multifocal IOL patients, with the diffractive bifocal IOL performing best in a standardized reading test setting.

The validity and reliability of short German sentences for measuring reading speed.

PURPOSE: To investigate whether short German sentences that have been developed to be highly comparable in number and length of words, as well as in difficulty and construction, are reliable and valid test items for measuring reading speed in order to use them for measuring simultaneously reading acuity and speed with the "Radner Reading Charts". METHODS: Tests were performed in 198 persons: 99 university students (average age 23.6+/-2.8 years) and blue-collar apprentices (average age 18.4+/-2.5 years). Reading speed and the number of errors were determined first with 24 sentences for our recently developed German reading charts (14 words equal in difficulty, length and construction) and secondly with long paragraphs of the "Zuercher Reading Test" (ZRT; paragraphs 3-5, 261 words). RESULTS: The overall mean reading speed obtained with short sentences was 209.6+/-41.0 words per minute (wpm), compared with 169.2+/-35.0 wpm for the ZRT ( P<0.001). The correlation between the short sentences and the ZRT was high ( r=0.9). Students read faster and made fewer errors than did the apprentices. Reliability analyses yielded an overall Cronbach's alpha coefficient of 0.98. The coefficient of selectivity of the 24 sentences (test items) varied from 0.75 to 0.88. CONCLUSION: The present study indicates that the 24 short single sentences we have tested are highly comparable in terms of both lexical difficulty and reading length, and it has demonstrated the validity and reliability of such sentences as test items for determining reading speed.