Treatment of Diabetic Macular Edema with Intravitreal Antivascular Endothelial Growth Factor and Prompt versus Deferred Focal Laser during Long-Term Follow-Up and Identification of Prognostic Retinal Markers.

PURPOSE: Long-term follow-up of patients with diabetic macular edema (DME) treated with intravitreal antivascular endothelial growth factor (anti-VEGF) combined focal laser and identification of prognostic morphological characteristics. METHODS: Prospective clinical trial (50 treatment-naive eyes) with DME randomized 1 : 1 receiving intravitreal ranibizumab (0.5 mg/0.05 ml) and prompt grid laser compared with ranibizumab and deferred laser. Morphological characteristics potentially relevant for prognosis were assessed at baseline, month 6, month 9, and years 1, 2, 3, 4, and 5 of follow-up. RESULTS: Although functional results were slightly higher in the prompt group at week 12 (0.5; 20/40 Snellen (SD = 0.04, 0.3 logMAR) versus 0.4; 20/50 Snellen (SD = 0.04, logMAR: 0.4), p=0.4) and month 9 (prompt group: 0.5; 20/40 Snellen (SD = 0.03, 0.3 logMAR) versus deferred group: 0.4; 20/50 Snellen (SD = 0.04, 0.4 logMAR), p=0.4), these were statistically insignificant. There was no significant benefit regarding functionality during long-term follow-up in the prompt group compared to the deferred group. BCVA in the eyes with clusters of hyperreflective foci in the central macular region was inferior compared with the eyes without these alterations at year 5 (0.39; 20/50 Snellen, (SD = 0.25, 0.4 logMAR) versus 0.63; 20/80 Snellen (SD = 0.22, 0.2 logMAR), p < 0.01). CONCLUSION: Grid laser and ranibizumab therapy are effective in DME management during the long-term follow-up. Intraretinal hyperreflective material in SD-OCT is negatively related to BCVA.

Patients' maximum acceptable waiting time for cataract surgery: a comparison at two time-points 7 years apart.

PURPOSE: To evaluate the maximum acceptable waiting time (MAWT) of cataract patients and assess the determinants of their perception of MAWT at two time-points 7 years apart. METHODS: In 2007 (prior to the transformation of our cataract service to a day case unit) and 2014, 500 consecutive patients with cataract were asked to fill in a preoperative questionnaire addressing their MAWT to undergo cataract surgery. The patients' visual impairment (VF-14 score), education and social status were evaluated. RESULTS: The mean MAWT was 3.2 months in both periods, whereas the actual waiting time decreased significantly by 1.7 months (p < 0.001). Patients who had self-noted visual impairment were nearly four times (p < 0.001) more likely to accept only an MAWT of <3 months in 2007. In both periods, patients with a VF-14 score lower than the mean were more likely to accept a shorter MAWT (p = 0.002 and p = 0.034). Living together with children or having relatives close by was associated with a greater acceptance of an MAWT longer than 3 months (p = 0.002 and p = 0.023). CONCLUSION: Reducing the actual mean waiting time had no impact on the mean MAWT. Patients with poor tolerance of waiting had greater self-reported difficulty with vision. Social support was also a strong predictor from the patients' perspective. The VF-14 score had a greater impact than clinical visual acuity (VA) testing. Considering the implementation of standards for waiting lists, objective criteria to guarantee a transparent system should be taken into account.

Intraoperative floppy iris syndrome and its association with various concurrent medications, bulbus length, patient age and gender.

PURPOSE: To evaluate the association between intraoperative floppy iris syndrome (IFIS) and concurrent medications containing selective alpha1A receptor antagonists as well as nonselective alpha1-adrenergic receptor antagonists, bulbus length, patient age and gender. METHODS: We performed a prospective data acquisition of IFIS occurrence and grading, and retrospective evaluation of concurrent medications, bulbus length, patient age and gender of all patients undergoing cataract surgery over a 6-month period. RESULTS: IFIS was observed in 119 of 947 cases (12.6 %). 31 of those 119 patients (26.1 %) had a concurrent medication with a drug that is associated with a higher risk of causing IFIS. Tamsulosin was the drug most commonly associated with IFIS (n = 11), followed by a combination of drugs (n = 7), doxazosin (n = 4), quetiapine (n = 4), finasterid (n = 2), prothipendyl (n = 2), and mianserin (n = 1). Bulbus length and age did not show any significant association with occurrence or grade of IFIS. Gender distribution among IFIS cases was 57.1 % males (n = 68) and 42.9 % (n = 51) females. CONCLUSIONS: The occurrence of IFIS has to be expected with a variety of concurrent medications. The number of IFIS cases and the percentage of females in this series are higher compared to previous reports. The observations might be due to a rising awareness of surgeons or to an increasing number of causative medications on the market.

Effect of a multimedia-assisted informed consent procedure on the information gain, satisfaction, and anxiety of cataract surgery patients.

PURPOSE: To assess whether a multimedia-assisted preoperative informed consent procedure has an effect on patients' knowledge concerning cataract surgery, satisfaction with the informed consent process, and reduction in anxiety levels. SETTING: Hietzing Hospital, Vienna, Austria. DESIGN: Prospective randomized controlled clinical trial. METHODS: Patients participated in an informed consent procedure for age-related cataract surgery that included the standard approach only (reading the information brochure and having a standardized face-to-face discussion) or supplemented with a computer-animated video. The main outcome was information retention assessed by a questionnaire. Further outcome measures used were the State-Trait Anxiety Inventory, the Visual Function-14 score, and an assessment of satisfaction. RESULTS: The study included 123 patients (64 in standard-only group; 59 in computer-animated video group). Both groups scored well on the questionnaire; however, patients who watched the video performed better (82% retention versus 72%) (P = .002). Scores tended to decrease with increasing age (r = -0.25, P = .005); however, this decrease was smaller in the group that watched the video. Both groups had elevated anxiety levels (means in video group: anxiety concerning the current situation [S-anxiety] = 63.8 ± 9.6 [SD], general tendency toward anxiety [T-anxiety] = 65.5 ± 7.9; means in control group: S-anxiety = 61.9 ± 10.3, T-anxiety = 66.2 ± 7.8). CONCLUSIONS: A high level of information retention was achieved using an informed consent procedure consisting of an information brochure and a standardized face-to-face discussion. A further increase in information retention was achieved, even with increasing patient age, by adding a multimedia presentation. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Acute anterior uveitis is associated with depression and reduction of general health.

AIMS: This study explored the association of active acute anterior uveitis (AAU) with depressive feelings and patients' general health. METHODS: This case-control study comprised 80 participants: 35 patients with an active case of AAU and 45 healthy peers were analysed to compare their depressive moods (Beck depression inventory (BDI), Zerssen Mood Scale (ZMS)) and general health (Short form-8 health survey (SF8)). Furthermore, patients were questioned regarding the presence of distress, occupational satisfaction and impairment in performing daily life tasks. RESULTS: During an acute attack, AAU patients were shown to suffer from depressive moods more often than their healthy peers (BDI 54% vs 9%, respectively; ZMS 2.7-fold shift in mood levels towards depression) and experienced a reduction in mental and physical scores (SF8). Patients felt impaired reading (94%), driving (69%) and working (69%). In all, 74% of the patients believed that distress was a probable trigger. Lack of occupational satisfaction was associated with a persistence of depressive feelings and a reduction in physical health. CONCLUSIONS: AAU patients exhibited a significant psychopathology towards depression, a reduction of general health and impairment of performing daily life tasks. Patients who were unsatisfied at work seemed to suffer even more. The results underline the importance of offering psychological support to the patients and providing information to patients and close social contacts.

Time to first treatment: The significance of early treatment of exudative age-related macular degeneration.

PURPOSE: To determine whether the time span between initial symptoms and treatment with ranibizumab in patients with neovascular age-related macular degeneration has an effect on visual outcome. METHOD: In this retrospective study, 45 patients with exudative age-related macular degeneration were split into 3 groups depending on the duration of visual symptoms--Group I: <1 month, Group II: 1 month to 6 months, and Group III: >6 months. Best-corrected visual acuity, clinical ophthalmologic examination, and central retinal thickness as measured by optical coherence tomography were recorded at baseline and 2 months later. Fluorescein angiography was performed at baseline. Treatment consisted of 2 intravitreal injections of 1.25 mg of ranibizumab at baseline and after 4 weeks. RESULTS: The mean time span between initial symptoms and treatment was 59 ± 62 days. In all groups, a reduction of retinal thickness was observed. Shorter disease duration, as estimated by persistence of visual symptoms, was correlated with a better visual outcome after treatment. Patients in Group I demonstrated a significant increase in best-corrected visual acuity (P = 0.007). Patients of Group II (P = 0.095) and Group III (P = 0.271) still achieved a visual improvement in best-corrected visual acuity, albeit not significant. The mean change in best-corrected visual acuity was 0.08 ± 0.1 in all patients and was not statistically significant between groups (P = 0.87). CONCLUSION: Duration of visual symptoms <1 month before treatment is associated with a better visual outcome. Treatment of new-onset wet age-related macular degeneration should be initiated as soon as possible.

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.

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.