The Value of Diagnostic Work-Up in the Evaluation of White Dot Syndromes.

BACKGROUND AND OBJECTIVE: To determine the diagnostic yield of systemic work-up in white dot syndromes. PATIENTS AND METHODS: A retrospective chart review. RESULTS: Eighty-six consecutive patients with a diagnosis of a white dot syndrome were identified. Forty-three had a diagnosis of birdshot chorioretinopathy. Overall, 395 diagnostic tests were performed with a diagnostic yield of 11.9%. The test with the greatest diagnostic yield was HLA-A29 typing (89%). Four patients had abnormal angiotensin converting enzyme levels. No patients had a positive rapid plasma reagin or fluorescent treponemal antibody absorption test. Four patients had positive tuberculosis testing and required treatment. The mean number of tests performed per diagnosis group ranged from 0.3 in multiple evanescent white dot syndrome to 5.6 in multifocal choroiditis and panuveitis. Diagnostic testing was found to be the most expensive in birdshot chorioretinopathy, with a mean cost of $504.82. CONCLUSIONS: Diagnostic yield of systemic work-up was low in this patient population. Rather than performing an exhaustive work-up, the authors advocate for a limited work-up tailored to pretest clinical suspicion. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:540-545.].

Incidence of Cystoid Macular Edema After Descemet Membrane Endothelial Keratoplasty as a Staged and Solitary Procedure.

PURPOSE: To compare the incidence of visually significant postoperative cystoid macular edema (CME) in pseudophakic eyes after Descemet membrane endothelial keratoplasty (DMEK) performed after recent versus remote cataract surgery. METHODS: A retrospective chart review was performed of all consecutive eyes that underwent DMEK without concurrent cataract surgery at the University of Iowa between October 2012 and December 2014. The DMEK procedures were classified as staged if performed between 2 weeks and 6 months after cataract surgery and solitary if performed more than 6 months after cataract surgery. Possible confounders, including a history of diabetes in the recipient, were tracked. Macular optical coherence tomography was performed to detect CME 1 month after DMEK if the best-corrected visual acuity was ≤20/30 with a clear cornea with no other reason for visual compromise. RESULTS: A total of 173 eyes from 140 patients were included in the statistical analysis. Staged DMEK was performed in 88 eyes (50.8%) and solitary DMEK in 85 eyes (49.2%). The incidence of CME was 8.0% (7 of 88 eyes) in the staged DMEK group and 7.1% (6 of 85 eyes) in the solitary DMEK group (P = 0.823). The incidence of CME did not differ significantly between the staged and solitary DMEK groups regardless of the recipient diabetic status. All cases of CME resolved within 6 months on topical therapy. CONCLUSIONS: The incidence of postoperative CME after DMEK is similar in the setting of recent or remote cataract surgery.

Endothelial image quality after descemet stripping with endothelial keratoplasty: a comparison of three microscopy techniques.

PURPOSE: To determine corneal endothelial image quality after descemet stripping with endothelial keratoplasty (DSEK) as recorded by three different microscopy techniques: noncontact specular microscopy, noncontact confocal microscopy, and contact confocal microscopy. METHODS: The corneal endothelium of 52 eyes after DSEK and 20 normal eyes was photographed by the three microscopy techniques during a single encounter. Image quality was graded by two masked observers according to the proportion of countable contiguous cells visible in the image; disagreements in grading were adjudicated by a third observer. Endothelial cell density was compared among the three techniques. RESULTS: After DSEK, image quality was better with contact confocal microscopy than with noncontact confocal microscopy (P = 0.01) and better with noncontact confocal microscopy than with noncontact specular microscopy (P < 0.001). With noncontact specular microscopy, 42% of images after DSEK were uncountable. In normal corneas, all images were countable, and although image quality was better with contact confocal microscopy than with noncontact confocal (P = 0.03) and noncontact specular (P < 0.001) microscopy, the difference was not clinically important. For countable images, the mean differences in endothelial cell density between microscopy methods were close to zero after DSEK and in normal corneas. CONCLUSIONS: Confocal optics enable better image quality of the corneal endothelium in corneas with high backscatter, such as those after DSEK. When images were countable, there was a good agreement for endothelial cell density measured by the three microscopy techniques.

Long-term keratometric changes after penetrating keratoplasty for keratoconus and Fuchs Endothelial dystrophy.

PURPOSE: To compare long-term keratometric changes after penetrating keratoplasty (PK) for keratoconus and Fuchs endothelial dystrophy. DESIGN: Retrospective, comparative case series. METHODS: We retrospectively analyzed 168 corneas after PK for keratoconus (85 eyes of 63 subjects) and Fuchs dystrophy (83 eyes of 60 subjects). Patients were examined after final suture removal at 12 months after PK to 30 years after surgery. Operations were performed by one surgeon (W.M.B.) using the same suturing technique in all cases. Eyes were excluded from further analysis after regrafting or after relaxing incisions. Mean keratometric corneal power and astigmatism were measured by manual keratometry. Data were assessed by using generalized estimating equation models to determine change over time. RESULTS: Mean keratometric corneal power and astigmatism increased through 30 years after PK for keratoconus (P < .001 and P < .001), but did not change through 20 years after PK for Fuchs dystrophy (P = .55 and P = .55) The change in keratometric corneal power and astigmatism after PK in keratoconus patients only differed from the change in Fuchs dystrophy patients 10 or more years after PK (P = .002 and P = .003). CONCLUSIONS: Corneal curvature and regular astigmatism increase progressively after PK for keratoconus, but remain stable after PK for Fuchs dystrophy. Our data suggest that keratometric instability after PK for keratoconus is attributable to delayed, progressive ectasia in the host corneal rim.

Long-term keratometric changes after penetrating keratoplasty for keratoconus and Fuchs endothelial dystrophy.

PURPOSE: To compare long-term keratometric changes after penetrating keratoplasty (PK) for keratoconus and Fuchs endothelial dystrophy. METHODS: We retrospectively analyzed 168 corneas after PK for keratoconus (85 eyes of 63 subjects) and Fuchs dystrophy (83 eyes of 60 subjects). Patients were examined after final suture removal at 12 months after PK to 30 years after surgery. Operations were performed by one surgeon using the same suturing technique in all cases. Eyes were excluded from further analysis after regrafting or after relaxing incisions. Mean keratometric corneal power and astigmatism were measured by manual keratometry. Data were assessed by using generalized estimating equation models to determine change over time. RESULTS: Mean keratometric corneal power and keratometric astigmatism increased through 30 years after PK for keratoconus (P < .001 and P < .001) but did not change through 20 years after PK for Fuchs dystrophy (P = .55 and P = .55). The change in keratometric corneal power and astigmatism after PK in keratoconus patients differed from the change in Fuchs dystrophy patients only at 10 or more years after PK (P = .002 and P = .003). CONCLUSIONS: Corneal curvature and regular astigmatism increase progressively after PK for keratoconus but remain stable after PK for Fuchs dystrophy. This keratometric instability after PK for keratoconus may lead to delayed corneal ectasia.

Risk of retinal detachment after cataract extraction, 1980-2004: a population-based study.

PURPOSE: To estimate the long-term cumulative risk of retinal detachment (RD) after cataract extraction (CE). DESIGN: Retrospective cohort study and nested case-control study. PARTICIPANTS: All residents of Olmsted County, Minnesota who had CE from 1980 through 2004 (10 256 CEs in 7137 residents) and were diagnosed subsequently with RD in the same period. Two controls chosen from the primary cataract surgery cohort were matched to each RD case by age, gender, and duration of follow-up. METHODS: Cases were identified through the Rochester Epidemiology Project databases. Records were reviewed to confirm case status and ascertain risk factor information. The observed probability of RD after CE was estimated using the Kaplan-Meier method. A cumulative probability ratio of RD after CE was determined by comparing the observed probability of RD and the expected probability of RD in residents without CE. Logistic regression models assessed differences between cases and controls. MAIN OUTCOME MEASURES: Probability of and risk factors associated with RD after CE. RESULTS: Eighty-two cases of RD were identified. The cumulative probability of RD increased in a nearly linear manner over the 25-year study period. At 1, 5, 10, 15, and 20 years after extracapsular CE (ECCE) and phacoemulsification, cumulative probabilities of RD were 0.27%, 0.71%, 1.23%, 1.58%, and 1.79%, respectively. There was no significant difference in the probability of RD after ECCE when compared with phacoemulsification (P = 0.13). The cumulative probability ratio of RD at 20 years after ECCE and phacoemulsification remained 4.0-fold (95% confidence interval, 2.6-5.4) higher than would be expected in a similar group of residents not undergoing CE (P<0.001). Male gender, younger age, myopia, increased axial length, and posterior capsular tear were associated significantly with RD (P<0.01). CONCLUSIONS: The cumulative risk of RD after ECCE and phacoemulsification is increased for up to 20 years after surgery.

Risk of retinal detachment after cataract extraction, 1980-2004: a population-based study.

PURPOSE: To estimate the long-term cumulative risk of retinal detachment (RD) after cataract extraction. METHODS: Using the resources of the Rochester Epidemiology Project, we retrospectively identified all residents of Olmsted County, Minnesota, who had cataract extraction from 1980 through 2004 (10,256 cataract extractions in 7,137 residents) and were diagnosed with RD. The observed probability of RD after cataract extraction was estimated using the Kaplan-Meier method. A cumulative probability ratio of RD after cataract extraction was determined by comparing the observed probability of RD with the expected probability of RD in residents without cataract extraction. Two controls chosen from the primary cataract surgery cohort were matched to each RD case by age, sex, and duration of follow-up. Logistic regression models assessed differences between cases and controls. RESULTS: Eighty-two cases of RD after cataract extraction were identified. The cumulative probability of RD after extracapsular cataract extraction (ECCE) and phacoemulsification was 0.27%, 0.71%, 1.23%, 1.58%, and 1.79% at 1, 5, 10, 15, and 20 years after surgery. There was no significant difference in the probability of RD after ECCE when compared to phacoemulsification (P =.13). The cumulative probability ratio of RD at 20 years after ECCE and phacoemulsification was four times (95% CI, 2.6-5.4) higher than would be expected in a similar group of residents not undergoing cataract extraction (P <.001). Males, younger age, myopia, and increased axial length were significantly associated with RD (P <.001). CONCLUSIONS: The cumulative risk of RD after ECCE and phacoemulsification is increased for up to 20 years after surgery.