Automated refraction is stable 1 week after uncomplicated cataract surgery.

PURPOSE: To compare automated refraction 1 week and 1 month after uncomplicated cataract surgery. METHODS: In this prospective cohort study, we recruited patients in a 2-month period and included consecutive patients scheduled for bilateral small-incision phacoemulsification cataract surgery. The exclusion criteria were (i) corneal and/or retinal pathology that could lead to automated refraction miscalculation and (ii) surgery complications. Automated refraction was measured 1 week and 1 month after surgery. RESULTS: Ninety-five patients met the in- and exclusion criteria and completed follow-up. The mean refractive shift in spherical equivalent was -0.02 dioptre (D) between 1 week and 1 month after surgery and not statistical significant (p = 0.78, paired t-test). The magnitude of refractive shift in either myopic or hyperopic direction was neither correlated to age, preoperative corneal astigmatism, axial length nor phacoemulsification energy used during surgery (p > 0.05 for all variables, regression analysis). The refractive target was missed with 1.0 D or more in 11 (12%) patients. In this subgroup, the mean refractive shift in spherical equivalent was 0.49 D between 1 week and 1 month after surgery with a trend towards statistical significance (p = 0.07, paired t-test). There was no difference in age, preoperative corneal astigmatism, axial length or phacoemulsification energy used during surgery compared to the remainder of the patients (p > 0.05 for all variables, unpaired t-test). CONCLUSION: Automated refraction is stabile 1 week after uncomplicated cataract surgery, but there is a trend towards instability, if the refractive target is missed with 1.0 D or more.

Intravitreal ranibizumab for diabetic macular oedema in previously vitrectomized eyes.

PURPOSE: There is little information about the efficacy of intravitreal vascular endothelial growth factor (VEGF) inhibition in vitrectomized eyes. This study aimed to evaluate the efficacy of anti-VEGF (ranibizumab) on diabetic macular oedema in previously vitrectomized eyes. METHODS: A nationwide retrospective review of medical records from 2010 to 2013. RESULTS: We identified 33 previously vitrectomized eyes in 28 patients treated with ranibizumab injections for diabetic macular oedema. Median follow-up was 323 days (interquartile range 72-1404 days). Baseline mean visual acuity was 0.57 logMAR (95% CI 0.13-1.01) before injections. After an average of 4.7 injections (range 1-15), mean visual acuity remained stable at 0.54 logMAR (95% CI 0.13-0.95) with a mean improvement of 0.03 (p = 0. 45, 95% CI -0.12 to 0.06). In 12 eyes (36%), visual acuity improved 0.1 logMAR or more, in 12 eyes (36%), vision was unchanged (gain or loss of 0-0.05 logMAR), and in nine eyes (27%), vision decreased 0.1 logMAR or more. Mean central foveal thickness (CFT) on optical coherence tomography (OCT) scan was 412 µm (95% CI 390-434 µm) before injections. After injections, the mean CFT decreased to 352 µm (95% CI 334-370 µm). The mean reduction in CFT was 14% (95% CI 4-24%, p = 0.01). Sixteen eyes (48.5%) became devoid of oedema on the last OCT scan. Despite the significant reduction in CFT, the visual acuity remained unchanged. CONCLUSION: Intravitreal ranibizumab can be effective in previously vitrectomized eyes with diabetic macular oedema. However, the response is variable and should be carefully monitored.

[White pupil in an infant]. / Hvid pupil hos børn kan være tegn påalvorlig øjensygdom.

A whitish pupillary reflex (leukocoria) indicates abnormal reflection from intraocular pathology. In a child, leukocoria may be a sign of serious and even life-threatening eye disease (retinoblastoma), but the most common cause is congenital cataract. Both diagnoses require immediate referral to an ophthalmologist. Leukocoria is best detected by evaluating the reflex from the pupil with a handheld ophthalmoscope. We here present a case story of an infant with leukocoria that proved to be caused by unilateral congenital cataract.

Intraocular surgery in a large diabetes patient population: risk factors and surgical results.

The prevalence of diabetes is on the increase in developed countries. Accordingly, the prevention and treatment of vision-threatening diabetic eye complications is assuming greater importance. The overall aim of this thesis is to analyse risk factors for intraocular surgery in a large diabetes population and to report surgical results. The specific objectives are to (1) estimate the incidence of diabetic vitrectomy and analyse risk factors (Study I), (2) report long-term results, prognostic factors and incidence of cataract surgery after diabetic vitrectomy (Study II), (3) report results and prognostic factors after cataract surgery in diabetes patients (Study III) and (4) analyse risk factors for diabetic papillopathy with emphasis on metabolic control variability (Study IV). All studies are based on a close-to-complete national surgery register and a large, closely followed diabetic retinopathy screening population. Study I (cohort study, 3980 type 1 diabetes patients) illustrates that diabetic vitrectomy is rarely required in a diabetes patient population with varying degrees of diabetic retinopathy. The risk of reaching diabetic vitrectomy increases fourfold with poor metabolic control, defined as glycosylated haemoglobin A1c > 75 mmol/mol (~9%), which points to good metabolic control as an important preventive measure. Study II (cohort study, 167 diabetes patients) shows that most diabetic vitrectomy patients stand to gain visual acuity ≥0.3 after surgery. Visual acuity is stable after 1 year, and the stability is maintained through 10 years of follow-up. The use of silicone oil for endotamponade is a consistent long-term predictor of low vision after surgery. The risk of requiring cataract surgery after diabetic vitrectomy is substantial, and the risk increases if silicone oil is used. Study III (cohort study, 285 diabetes patients) shows, on the other hand, that diabetes patients can expect a significant improvement in visual acuity after cataract surgery, regardless of the degree of diabetic retinopathy. Poor preoperative visual acuity, a high degree of diabetic retinopathy and advanced age are predictors of a poor visual acuity after surgery. The risk of diabetic macular oedema after surgery is 4%. Finally, Study IV (case-control study, 2066 type 1 diabetes patients) demonstrates that diabetic papillopathy shares characteristics with diabetic retinopathy. The risk of experiencing diabetic papillopathy increases markedly with a drastic, recent reduction in glycosylated haemoglobin A1c and a small optic disc. This lends support to the theory that diabetic eye complications may occur in anatomically predisposed patients in response to metabolic control variability. Overall, results after intraocular surgery in diabetes patients are favourable. Surgery, however, is associated with costs to society, patient discomfort and risk of complications. This thesis provides an analysis of risk factors for intraocular surgery and identifies prognostic factors for visual acuity after surgery, which can be used for preventive purposes, surgical decision-making and patient counselling.

Profound bilateral visual loss after hysterectomy indicated for severe postpartum haemorrhage.

We present a case of a patient with bilateral posterior ischaemic optic neuropathy in the previously unreported setting of hysterectomy indicated for severe postpartum haemorrhage. The diagnosis was based on clinical and paraclinical examinations, including MRI of the head, electroretinography (ERG) and visual evoked potentials (VEP) testing. During 1 year of follow-up, repeated optical coherence tomography (OCT) scans demonstrated optic disc atrophy, which was interpreted as a sign of direct retrograde ganglion cell degeneration after ischaemic damage to the retrolaminar part of the optic nerves. The diagnosis of perioperative posterior ischaemic optic neuropathy is mostly a clinical diagnosis. However, MRI plays a major role in excluding other causes of visual loss, and VEP, ERG and OCT are valuable supplemental diagnostic tools.

Diabetic vitrectomy in a large type 1 diabetes patient population: long-term incidence and risk factors.

PURPOSE: Diabetic vitrectomy represents an end-point of diabetic retinopathy progression. This study was designed to estimate long-term incidence of diabetic vitrectomy and associated risk factors. METHODS: Retrospective review of prospectively collected data from a large diabetes centre between 1996 and 2010. Surgical history was obtained from The Danish National Patient Register. RESULTS: The population consisted of 3980 patients with type 1 diabetes. Median follow-up was 10.0 years. In total, 106 patients underwent diabetic vitrectomy in the observation period. Surgery indications were nonclearing vitreous haemorrhage (43%) or tractional retinal detachment (57%). The cumulative incidence rates of diabetic vitrectomy were 1.6% after 5 years and 2.9% after 10 years. When excluding patients with no or mild diabetic retinopathy, the corresponding rates were higher; 3.7% and 6.4%, respectively (p < 0.001, log-rank test). The risk of reaching diabetic vitrectomy increased in patients experiencing glycosylated haemoglobin A1c > 75 mmol/mol in the observation period (p < 0.001, hazard ratio: 3.9, Cox regression analysis). Systolic blood pressure ≥ 140 mmHg, diastolic blood pressure ≥ 90 mmHg, diabetes duration, age, gender and nephropathy were not associated with an increased risk of reaching diabetic vitrectomy (p > 0.05 for all variables). CONCLUSIONS: Diabetic vitrectomy is rarely required in a type 1 diabetes population with varying degrees of retinopathy, but the risk increases markedly with poor metabolic control.

Long-term results, prognostic factors and cataract surgery after diabetic vitrectomy: a 10-year follow-up study.

PURPOSE: To report long-term results, prognostic factors and cataract surgery after diabetic vitrectomy. METHODS: Retrospective review of patient files from a large diabetes centre between 1996 and 2010. Surgical history was obtained from the Danish National Patient Register. Follow-up intervals were 3 months and 1, 3, 5 and 10 years after surgery. RESULTS: In total, 167 patients had diabetic vitrectomy indicated for non-clearing vitreous haemorrhage (47%) and tractional retinal detachment (53%). The proportion of patients with visual acuity ≥0.3 increased from 29% before surgery to 60% after 3 months (p < 0.001, chi-square test). Median visual acuity increased from 0.06 before surgery to 0.3 after 3 months (p < 0.001, paired signed-rank test) and 0.4 after 1 year (p = 0.009) before stabilizing. No significant long-term prognostic factors were identified for non-clearing vitreous haemorrhage patients. For tractional retinal detachment patients, use of silicone oil was associated with low vision (visual acuity<0.3) after 3 months and 1, 3 and 5 years (all odds ratios >4 and p-values ≤ 0.03, logistic regression). Of the 134 patients who were phakic after surgery, 43% and 29% were phakic after 5 and 10 years, respectively. Use of silicone oil increased the risk of cataract surgery (p = 0.009, log-rank test). CONCLUSIONS: Most diabetic vitrectomy patients stand to gain visual acuity ≥0.3 after surgery and a stable long-term visual acuity after 1 year. The only consistent long-term predictor of low vision after surgery is use of silicone oil for endotamponade. About 2/3 of phakic patients will subsequently have cataract surgery the first 10 years after diabetic vitrectomy.

Phacoemulsification cataract surgery in a large cohort of diabetes patients: visual acuity outcomes and prognostic factors.

PURPOSE: To assess visual acuity outcomes after phacoemulsification cataract surgery in a large population of diabetic patients with all degrees of diabetic retinopathy. SETTING: Diabetology and ophthalmology unit, Copenhagen, Denmark. DESIGN: Cohort study. METHODS: This review of prospectively collected data comprised patients who had small-incision phacoemulsification cataract surgery between 1999 and 2008 (10 years) according to the Danish National Patient Registry. RESULTS: Data of 7323 diabetic patients were reviewed. Of these patients, 285 had cataract surgery. The corrected distance visual acuity (CDVA) increased significantly after cataract surgery (P<.001; P<.05 in all diabetic retinopathy categories). The postoperative CDVA outcome was positively correlated with preoperative CDVA and negatively correlated with the degree of diabetic retinopathy and age (P<.001). Patients with a history of focal laser treatment for clinically significant macular edema had a higher risk for not gaining from cataract surgery (P=.04; relative risk, 1.6). In post hoc analysis, the proportion of patients in the cohort without diabetic retinopathy appeared to increase the year before cataract surgery (P=.03) and decrease the year after cataract surgery (P<.001). CONCLUSIONS: The CDVA increased significantly after phacoemulsification cataract surgery in diabetic patients regardless of the degree of diabetic retinopathy. The apparent progression in diabetic retinopathy after modern cataract surgery seems to reflect the masking of low grades of diabetic retinopathy by preoperative lens opacities. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Bilateral diabetic papillopathy and metabolic control.

OBJECTIVE: The pathogenesis of diabetic papillopathy largely is unknown, but case reports suggest that it may follow rapidly improved metabolic control. The present study was designed to investigate this hypothesis. DESIGN: Retrospective case-control study. PARTICIPANTS: Two thousand sixty-six patients with type 1 diabetes. METHODS: Review of clinical, photographic, and clinical chemistry records from a large diabetology and ophthalmology unit between 2001 and 2008. MAIN OUTCOME MEASURES: Simultaneous, bilateral diabetic papillopathy. RESULTS: The mean follow-up was 4.9 years. During 10,020 patient-years of observation, bilateral diabetic papillopathy developed in 5 patients. During the year preceding this incident, all 5 patients had experienced a decrease in glycosylated hemoglobin A1(c) (HbA1(C)) at a maximum rate of -2.5 (mean) percentage points per quarter year, which was significantly different from the changes in HbA1(C) observed in the remainder of the study population (P<0.001). Photographs recorded before the onset of bilateral diabetic papillopathy showed that all 5 patients had small cup-to-disc diameter ratios in both eyes (P<0.001). CONCLUSIONS: Diabetic papillopathy was associated markedly with a drastic recent reduction in glycemia and a small cup-to-disc diameter ratio. This supports the hypothesis that diabetic papillopathy may be an early worsening phenomenon occurring in anatomically predisposed patients in response to a recent rapid decrease in glycemia. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Sclerosing Wegener's granulomatosis in the orbit.

PURPOSE: To report three cases of sclerosing Wegener's granulomatosis in the orbit and to compare the histopathological morphology with those of other types of sclerosing orbital inflammation. METHODS: We analysed the clinical data along with histopathological specimens from orbital biopsies and from two enucleated eyes. RESULTS: All three patients had longstanding inflammation in the orbit and involvement of the paranasal sinuses. Proptosis, impaired ocular motility and reduced visual acuity dominated the clinical picture. All histopathological specimens featured granulomatous inflammation, tissue necrosis, vasculitis and widespread dense fibrosis. In certain areas of all specimens the fibrous tissue was arranged in characteristic concentric, onionskin-like whorls of collagen around obliterated small blood vessels. CONCLUSIONS: Wegener's granulomatosis may lead to orbital fibrosis and sclerosis. The stromal changes and cellular infiltrate resemble the non-specific orbital inflammation previously termed orbital pseudotumour. We present the first 'onionskin' lesions in association with Wegener's granulomatosis in the orbit. This latter morphology may represent an abnormal fibrotic reaction in inflammatory tissue.

[Subintimal angioplasty of long femoropopliteal artery occlusions]. / Subintimal angioplastik af lange femoropopliteale arterieokklusioner.

INTRODUCTION: Subintimal angioplasty is a newer method in the treatment of lower extremity atherosclersosis. This paper reports the results of our first experiences with long (>10 cm) femoropopliteal artery occlusions. MATERIALS AND METHODS: In the period from July 1999 to July 2003, 28 patients were treated with subintimal angioplasty. The indication was intermittent claudication or critical ischaemia. The patients were followed clinically to evaluate the patency. The results are reported retrospectively. RESULTS: The technical success rate was 25/28 (89%). Patients with intermittent claudication experienced relief of symptoms after the intervention, and their median ankle-brachial index increased significantly. The primary patency rate for patients with intermittent claudication treated successfully was 53% after one year. Critical ischaemia was associated with a lower patency rate. CONCLUSION: Subintimal angioplasty can be used in the treatment of long (>10 cm) femoropopliteal artery occlusions with a high technical success rate. Our patency rates are comparable with those recorded in the literature but are still lower than those after distal bypass surgery. Thus, subintimal angioplasty may be used in treatment of patients for whom open vascular surgery is impossible or as a bridge to open vascular surgery in young patients with severe intermittent claudication.