Quality of Life in Patients with Noninfectious Uveitis Treated with or without Systemic Anti-inflammatory Therapy.

PURPOSE: To compare vision-related (VR-QOL) and health-related quality of life (HR-QOL) in patients with noninfectious uveitis treated with systemic anti-inflammatory therapy versus nonsystemic therapy. METHODS: A prospective, cross-sectional study design was employed. VR-QOL and HR-QOL were assessed by the 25-Item Visual Function Questionnaire (VFQ-25) and the Short Form 12-Item Health Survey (SF-12), respectively. Multivariate regression analysis was performed to assess the VR-QOL and HR-QOL based on treatment. RESULTS: Among the 80 patients, the median age was 51 years with 28 males (35%). The adjusted effect of treatment modality on VR-QOL or HR-QOL showed no statistically significant difference in all subscores of VFQ-25 or physical component score (PCS) and mental component score (MCS) of SF-12. Systemic therapy did not compromise VR-QOL or HR-QOL compared to nonsystemic therapy. CONCLUSIONS: Systemic therapy can be effectively used to control serious cases of noninfectious uveitis without significant relative adverse impact on quality of life.

The effect of repeated measurements and the use of topical anesthetic on rebound tonometry values in children.

Measurement of intraocular pressure (IOP) in children is important in the management of pediatric glaucoma. Availability of the Icare rebound tonometer has greatly facilitated our ability to obtain awake IOP in infants and children, but little has been reported on either the effect of repeated sequential IOP measurements with Icare or the effect of topical anesthetic on subsequent Icare tonometry. This prospective study of 20 eyes of 10 cooperative children (12 normal eyes, 8 with suspected or known glaucoma) found that neither 8 sequential Icare measurements nor application of topical anesthetic produced a statistically or clinically signficant change in measured IOP by rebound tonometry.

Intraocular pressure in children: the effect of body position as assessed by Icare and Tono-Pen tonometers.

PURPOSE: To explore the effect of body position (sitting vs supine) on intraocular pressure (IOP) in children, as assessed by the Icare PRO and the Tono-Pen. DESIGN: Prospective clinical study. METHODS: Children with known or suspected glaucoma and those without glaucoma were recruited from the Duke Eye Center pediatric clinic. Subjects underwent tonometry in both eyes while upright (sitting), after instillation of topical anesthetic, with either the Icare PRO or the Tono-Pen first, and then the second instrument (order randomized). Goldmann applanation tonometry (GAT) was then performed by a clinician masked to the previous measurements. The subjects were then placed in the supine position for 5 minutes, and tonometry using the Icare PRO and the Tono-Pen was obtained, in the same order used when they were the sitting position. RESULTS: Enrolled were 47 children (94 eyes). Mean seated IOP for GAT, Icare PRO and Tono-Pen were 16.4 ± 4.2, 17.5 ± 3.5, and 18.0 ± 3.9 mm Hg, respectively. The mean supine IOP for the Icare PRO and Tono-Pen were 18.4 ± 4.5 and 18.8 ± 4.2 mm Hg, respectively. This rise was +0.9 ± 2.3 mm Hg for Icare PRO (P = 0.01) and +0.7 ± 1.8 mm Hg for Tono-Pen (P = 0.009), respectively. CONCLUSION: In children, Icare PRO tonometry correlates well with GAT in the sitting position, and with the Tono-Pen in both the sitting and supine positions. IOP rises when a child changes position from sitting to supine when measured by the Icare PRO or the Tono-Pen. However, the increase, which is less than 1 mm Hg, seems clinically insignificant and is unlikely to alter glaucoma management in children.

Second glaucoma drainage devices in refractory pediatric glaucoma: failure by fibrovascular ingrowth.

PURPOSE: To evaluate initial glaucoma drainage device failure and subsequent glaucoma drainage device placement for refractory pediatric glaucoma. DESIGN: Retrospective interventional case series. METHODS: The Duke University surgical records from a single surgeon from 1997 to 2012 were reviewed for patients having at least 2 glaucoma drainage devices for refractory pediatric glaucoma. Data collected included glaucoma diagnosis, age at surgery, surgical interventions, preoperative/postoperative IOP and medications, and complications. Failure was defined as having an IOP >21 mm Hg (or clinically inadequate), and/or IOP-reducing surgery/devastating complication. RESULTS: Forty-three eyes (37 patients) had 2 or more glaucoma drainage devices. Mean age at second glaucoma drainage device implantation was 9.2 ± 7.1 years, with mean IOP 30 ± 11 mm Hg, on 3 ± 1 IOP-lowering medications. Fibrovascular ingrowth was documented during second glaucoma drainage device surgery in 12 of 43 eyes (28%), occurring only in Ahmed devices, at a mean of 70 months (range 11-153) after initial implantation. Failure of the second glaucoma drainage device surgery occurred in 18 of 43 eyes (42%) at mean 26.1 ± 32.2 months (median 19.3 months). Surgical success of second glaucoma drainage devices (Kaplan-Meier analysis) at 1 year, 2 years, and 3 years was 81%, 62%, and 50%, respectively. CONCLUSIONS: Single glaucoma drainage device surgery fails to control IOP in some eyes with refractory pediatric glaucoma. Second glaucoma drainage device implantation offers a treatment option with modest success over time. Fibrovascular ingrowth should be suspected as a relatively common cause of IOP elevation and failure after Ahmed device implantation.

Anterior segment photography in pediatric eyes using the Lytro light field handheld noncontact camera.

PURPOSE: To compare anterior segment findings identified in young children using digital photographic images from the Lytro light field camera to those observed clinically. METHODS: This was a prospective study of children <9 years of age with an anterior segment abnormality. Clinically observed anterior segment examination findings for each child were recorded and several digital images of the anterior segment of each eye captured with the Lytro camera. The images were later reviewed by a masked examiner. Sensitivity of abnormal examination findings on Lytro imaging was calculated and compared to the clinical examination as the gold standard. RESULTS: A total of 157 eyes of 80 children (mean age, 4.4 years; range, 0.1-8.9) were included. Clinical examination revealed 206 anterior segment abnormalities altogether: lids/lashes (n = 21 eyes), conjunctiva/sclera (n = 28 eyes), cornea (n = 71 eyes), anterior chamber (n = 14 eyes), iris (n = 43 eyes), and lens (n = 29 eyes). Review of Lytro photographs of eyes with clinically diagnosed anterior segment abnormality correctly identified 133 of 206 (65%) of all abnormalities. Additionally, 185 abnormalities in 50 children were documented at examination under anesthesia. CONCLUSIONS: The Lytro camera was able to document most abnormal anterior segment findings in un-sedated young children. Its unique ability to allow focus change after image capture is a significant improvement on prior technology.

Accomodative tone in children under general anesthesia.

PURPOSE: To determine the effect of general anesthesia on the accommodative tone in children. DESIGN: Cohort study in an academic practice. METHODS: In children under 12 years of age who were undergoing general anesthesia, cycloplegic refraction was measured using streak retinoscopy during an office visit. Within 6 months, streak retinoscopy without cycloplegia was performed under general anesthesia. The main outcome measure was the difference between retinoscopy under anesthesia and cycloplegic retinoscopy in children. RESULTS: In 41 children with an average age of 3.7 years (range, 0.8 to 11 years) retinoscopy under anesthesia yielded significantly more myopic measurements than cycloplegic retinoscopy for the sphere and spherical equivalent (P < 0.0001 for both) but was in good agreement with cycloplegic retinoscopy for cylinder power and axis. The average difference between retinoscopy under anesthesia and cycloplegic retinoscopy was -0.98 diopters (D) (95% limit of agreement, -3.08 D to +1.10 D) for the sphere, 0.08 D (95% limit of agreement, -0.67 D to +0.82 D) for the cylinder, and -0.94 D (95% limit of agreement, -3.01 D to +1.13 D) for the spherical equivalent. Retinoscopy under anesthesia was within 1 D of cycloplegic retinoscopy in 25 subjects (61%) for the sphere, in all subjects for the cylinder, and in 28 subjects (68.3%) for the spherical equivalent. CONCLUSIONS: Although general anesthesia reduced the accommodative tone in most children, it was still significant in some as compared to the tone found in cycloplegic retinoscopy. If an accurate measurement is essential, cycloplegia is recommended when measuring refraction in children under general anesthesia.

An ROP screening dilemma: hereditary cataracts developing in a premature infant after birth.

A female infant born prematurely at 23 weeks' gestational age developed bilateral hereditary cataracts at post-menstrual age 33 weeks, which precluded retinopathy of prematurity screening. The infant underwent right cataract extraction 1 week later, and retinopathy of prematurity was monitored by examining the right eye. In the seventeenth week of life (post-menstrual age 40 weeks), the cataract was removed from the left eye. Visual outcome at 19 months of age was good in both eyes. Very early cataract extraction may be necessary in premature infants to allow ROP evaluations.

Macular hemorrhage in neovascular age-related macular degeneration after stabilization with antiangiogenic therapy.

PURPOSE: To study patients with neovascular age-related macular degeneration (AMD) who experienced a macular hemorrhage after stabilization with intravitreal antivascular endothelial growth factor (anti-VEGF) agents to improve current treatment regimens and prevent disease progression. METHODS: Retrospective chart review of six patients. The main outcome measures included time between last intravitreal anti-VEGF treatment and date of hemorrhage, time between last office visit and date of hemorrhage, and visual acuity before and after hemorrhage. RESULTS: Three of 6 eyes had a macular hemorrhage within 4 weeks of a stable examination. One eye had optical coherence tomography (OCT) that demonstrated no fluid 1 day before the macular hemorrhage. The average time between the date of the last injection and macular hemorrhage was 16.8 weeks (range, 7.3-28.9 weeks). The average time between the last stable examination and an event was 4.2 weeks (range, 1 day to 7.3 weeks). Three of six patients had a persistent decline in vision after the hemorrhage. Among the 4 patients, who had better than 20/200 vision before the macular hemorrhage, 2 dropped to 20/200 or worse. CONCLUSION: Sight-threatening macular hemorrhages from AMD can occur within days to weeks after a stable examination and absence of fluid on OCT. Regimens that treat "as needed" based on clinical findings and OCT may not be appropriate for certain patients.