The Asia-Pacific Journal of Ophthalmology

Editorial

Endophthalmitis Prevention Das, Taraprasad; Sharma, Savitri
The current understanding of the pathobiology of endophthalmitis and the treatment strategy allow us to treat endophthalmitis more definitively than ever before. A seminal prospective randomized clinical trial has provided the evidence for treating endophthalmitis after cataract surgery with intravitreal antibiotics with or without vitrectomy. A single-port pars plana entry for vitreous biopsy and intravitreal antibiotic injection system (Intrector) is available for quick office-based treatment. There are also easy-to-use endophthalmitis treatment kits for emergency care that help reduce intravitreal antibiotic preparation (currently for ceftazidime, vancomycin, and voriconazole) dilution errors. New laboratory methods help in definite species identification and antibiotic susceptibility testing so as to institute appropriate antibiotic therapy. Despite all these measures, there is always limited visual recovery after treatment in the real world.

Perspectives

More Antisepsis, Less Antibiotics Whenever Possible Grzybowski, Andrzej; Turczynowska, Magdalena
Increasing bacterial resistance to antibiotics has recently become an important medical challenge. In ophthalmology antibiotics are widely used for treatment and prophylaxis of ocular infections. In many cases antiseptics may be a valuable adjunct and sometimes even an alternative to antibiotics for the prevention and treatment of infections, reducing the overuse of antibiotics. This review aims to highlight the available literature on the subject of antibiotic resistance in ophthalmology. Full understanding of this growing problem is necessary for tailoring effective pre-, intra-, and postoperative management to improve antibiotic stewardship programs.

Original Study - Clinical

Canine and Premolar Root Dimensions in Chinese. A Reference for Osteoodontokeratoprosthesis Surgery Sun, Stella Yue; Yeo, Woon Chee; Tay, Andrew Ban Guan; Tan, Donald Tiang Hwee; Tan, Danny Ben Poon
Purpose
Osteo-odonto-keratoprosthesis (OOKP) surgery is used to restore vision in end-stage corneal disorders, where an autogenous tooth supporting an optical cylinder is implanted through the cornea under a buccal mucosal graft. The ideal tooth for OOKP is a healthy single-rooted permanent tooth with sufficient bucco-lingual/palatal root diameter to accommodate an optical cylinder.

Aim of this study was to determine the bucco-lingual/palatal diameters of canine and premolar roots in Chinese, for selection of teeth for OOKP surgery.

Methods
Extracted canine and premolar teeth (excluding maxillary first premolars) were collected and the bucco-lingual/palatal and mesio-distal diameters of the root at the cervical line and at 2-mm intervals below the cervical line were measured with Vernier calipers. Other measurements included total tooth length, crown bucco-lingual/palatal diameter, and root length. Mean and minimum bucco-lingual/palatal root diameters were compiled for each 2-mm interval.

Results
415 extracted teeth (198 male, 217 female) were collected and measured. Recorded dimensions of keratoprostheses in 55 previous OOKP surgeries were used to establish acceptable lamina dimensions to ascertain root size adequacy.

Premolars in Chinese female patients were undersized in a small minority. Minimal dimensions of teeth were insufficient if at 6 mm root level, the bucco-lingual/palatal width was <5 mm, or the mesio-distal width was <3 mm. This was noted in female mandibular first premolars (5.6%), maxillary second premolars (4.5%), and mandibular second premolars (1.5%).

Conclusion
Canines have adequate dimensions for OOKP surgery. However, premolars in Chinese females may be undersized in a small minority.
Peripapillary Perfused Capillary Density in Exfoliation Syndrome and Exfoliation Glaucoma versus POAG and Healthy Controls: An Optical Coherence Tomography Angiography Study Suwan, Yanin; Geyman, Lawrence S.; Fard, Masoud Aghsaei; Tantraworasin, Apichat; Rosen, Richard B.; Ritch, Robert
Purpose: To compare the peripapillary perfused capillary density (PCD) among eyes with exfoliation syndrome (XFS), exfoliation glaucoma (XFG), primary open-angle glaucoma (POAG), and controls.
Design: observational, cross-sectional study
Methods: 4.5x4.5 mm optical coherence tomography angiography (OCTA) images of the optic nerve head were obtained using a commercial spectral domain OCTA system (AngioVue Avanti RTVue-XR, OptoVue, Fremont, CA). Two concentric circles with 1.95-mm (inner) and 3.45-mm (outer) diameters were placed manually, producing an annulus of width 0.75 mm centered at the optic disc. PCD was calculated as the ratio of pixels associated with capillaries to the pixels in the annulus after large blood vessel removal. Continuous variables were assessed by analysis of variance and Tukey’s HSD test. Multiple linear regression analysis was performed to adjust for confounding factors.
Results: 43 XFG eyes, 31 POAG eyes matched for visual field mean deviation, 33 XFS eyes, and 45 control eyes were analyzed. PCD demonstrated a progressive decrease from controls to XFS to POAG, to XFG. Pairwise comparisons revealed significant differences in PCD between each group (all p<0.01) except for PCD between XFS vs POAG (p=0.08). A multivariable model adjusting for age and stage showed a more significant decrease in PCD in XFG compared to POAG (p=0.001).
Conclusions and Relevance: PCD was more significantly decreased in XFG compared to POAG eyes and in XFS compared to control eyes. OCTA provides the first quantitative evidence of the microvascular disturbance that accompanies XFS.
Long-Term Follow-up of Lateral Canthal Resuspension Ramesh, Sathyadeepak; Gupta, Adit; Rootman, Daniel Benson; Goldberg, Robert Alan
Purpose: To evaluate the long-term results of lateral canthal resuspension over time.
Design: A cohort study of adults (n = 25, 45 eyelids) undergoing lateral canthal resuspension.
Methods: Marginal reflex distance 2 (MRD2), inferior scleral show, lateral canthal height, lateral canthal angle, horizontal palpebral aperture, and lateral scleral triangle area were measured preoperatively and at postoperative week 1, month 3, and the final follow-up visit.
Results: Minimum follow-up time was 6 months (mean, 15.1 months). At the final follow-up visit, MRD2 decreased by 0.41 ± 0.14 mm, inferior scleral show decreased by 0.27 ± 0.05 mm, and lateral canthal height increased by 0.81 ± 0.15 mm. The overall function of time was found to be significant for change in MRD2 (P < 0.01). In multiple comparisons, all time point values were significantly different from one another (Bonferroni corrected, P < 0.05), except for 3 months and the final position, which were not. Similarly, the overall effect of time on lateral canthus position was also significant (P < 0.01). All time points were significantly different from one another (Bonferroni corrected, P < 0.05). The overall effect of time on inferior scleral show was also significant (P < 0.01). Differences were significant from preoperative to final postoperative position, although the other time points were not significant (Bonferroni corrected, P < 0.05). No complications were noted.
Conclusions: Minimally invasive lateral canthal resuspension provides durable, albeit modest, improvements in MRD2, inferior scleral show, and lateral canthal height without significantly changing lateral canthal angle, horizontal palpebral aperture, or lateral scleral triangle area.
Outcomes of Infantile-Onset Glaucoma Associated With Port Wine Birthmarks and Other Periocular Cutaneous Vascular Malformations Reyes-Capó, Daniela; Cavuoto, Kara M.; Chang, Ta C.
Purpose: The incidence of infantile-onset secondary glaucoma associated with periocular cutaneous vascular malformations is high and the outcomes of these glaucomatous eyes have anecdotally been poor. The purpose of this study was to determine the anatomic and visual outcomes of affected eyes.
Design: Retrospective case series.
Methods: Consecutive patients with early-onset (younger than 36 months of age) glaucoma associated with cutaneous vascular malformations from 1995.2015 were included.
Results: Seventeen eyes of 13 patients with Sturge-Weber syndrome (SW, n = 10), Klippel-Trenaunay-Weber syndrome (KTW, n = 1), cutis marmorata telangiectatica congenita (CMTC, n = 1), and phakomatosis pigmentovascularis (PPV, n = 1) were included. Three SW and 1 KTW patient had bilateral glaucoma. At presentation, mean age was 6.5 ± 9.1 months and mean intraocular pressure was 27.2 ± 6.13 mm Hg. The average number of surgical procedures per eye increased from 1.0 ± 0.5 (range, 0.2) at less than 5 years’ follow-up (9 eyes) to 3.5 ± 2.3 (range, 1.7) with at least 5 years’ follow-up (8 eyes). Visual acuity was better than or equal to 20/70 in 2 of 6 eyes (33%) with less than 5 years’ follow-up and in 3 of 7 eyes (43%) with at least 5 years’ follow-up. Additionally, a higher number of baseline risk factors correlated with poorer visual outcome.
Conclusions: After a mean follow-up of 6.6 years, visual outcome in infantile-onset secondary glaucoma associated with cutaneous periocular vascular malformation is guarded. Increased numbers of baseline risk factors and procedures are associated with poorer vision.
Visual Acuity Improves in Children and Adolescents With Idiopathic Infantile Nystagmus Balzer, Ben W.R.; Catt, Caroline J.; Bou-Abdou, Milia; Martin, Frank J.
PURPOSE: Idiopathic infantile nystagmus is associated with reduced visual acuity. Recent work has linked extraocular muscle surgery to improvements in visual acuity through childhood but no work has reported long-term secular trends in visual acuity in infantile nystagmus. Our aim is to describe visual acuity changes for children and adolescents with idiopathic infantile nystagmus to allow comparison for future interventional studies.
DESIGN: Retrospective chart review.
METHODS: Review of patients attending our center up to the age of 18 with a diagnosis of idiopathic infantile nystagmus and visual acuity measured using Snellen visual acuity. Patients provided informed consent.
RESULTS: We observed improvements in best corrected visual acuity in 43 children and adolescents with idiopathic infantile nystagmus. Binocular best corrected visual acuity improved at a rate of -0.16 logarithm of the minimum angle of resolution (logMAR)/log year of age (P < 0.001), an improvement of 0.05 logMAR (half a Snellen line) as the age doubles. Intraclass correlation was 0.95 and interindividual correlation between visual acuity and age was significant (r = -0.24, P < 0.001).
CONCLUSIONS: We describe a natural history of gradual improvement in binocular visual acuity in infantile nystagmus and provide a baseline against which future interventional work can be compared.
Sleep Duration in Infants Was Not Associated With Myopia at 3 Years Sensaki, Sonoko; Sabanayagam, Charumati; Chua, Sharon; Htoon, Hla Myint; Broekman, Brit F.P.; Thiam, Daniel Goh Yam; Ngo, Cheryl; Saw, Seang Mei
Purpose: To investigate the association of sleep duration and quality at 12 months and myopia at 3 years.
Design: Cohort study.
Methods: The Growing Up in Singapore Towards Healthy Outcomes (GUSTO GUSTO) birth cohort recruited pregnant women at 2 major public maternity hospitals (n = 1236). We included 376 children of Chinese, Malay, and Indian ethnicity who had completed caregiver questionnaires on the child’s sleep at 12 months of age [Brief Infant Sleep Questionnaire (BIS Q)] and also completed cycloplegic autorefraction and eye axial length (AL ) measurement at 3 years of age. Data on total sleep duration and number of night wakings were collected by BIS Q. Univariable and multivariable regression models adjusting for potential confounders (age, sex, ethnicity, parental myopia, maternal education level, outdoor time, near work, and height) were used.
Results: Thirteen (3.5%) participants were myopic and mean spherical equivalent (SE) was 0.89 diopters (D) (SD 0.88) at 3 years. Total sleep duration and number of night wakings at 12 months were not associated with SE at 3 years (P > 0.05). The total sleep duration (P = 0.07) and number of night wakings (P = 0.49) were not associated with AL in the multivariate model. Total sleep duration in tertile 2 was not associated with AL (P = 0.11) compared with tertile 1. Only total sleep duration in tertile 3 was associated with longer AL (P = 0.006), but there was no association with SE.
Conclusions: Sleep duration and quality at 12 months of age were not associated with refractive error at 3 years.
Submacular Hemorrhage: Visual Outcomes and Prognostic Factors Kunavisarut, Paradee; Thithuan, Tipparut; Patikulsila, Direk; Choovuthayakorn, Janejit; Watanachai, Nawat; Chaikitmongkol, Voraporn; Pathanapitoon, Kessara; Rothova, Aniki
Purpose: To describe causes, visual outcomes, and prognostic factors in patients with submacular hemorrhage (SMH).
Design: Retrospective case review.
Methods: We performed a retrospective review of SMH with a size of at least 1 disc diameter. SMH causes were classified into 3 groups: 1) neovascular age-related macular degeneration (nAMD), 2) polypoidal choroidal vasculopathy (PCV), and 3) other miscellaneous causes.
Results: Ninety-eight eyes of 98 patients were included. Based on clinical presentation and indocyanine green angiography (ICGA ), the diagnoses of PCV (59%), nAMD (31%), and miscellaneous other causes (10%) were made. PCV patients were younger (P = 0.005) and had larger SMH size than nAMD patients (P = 0.008). Poor visual outcome [>1.0 logarithm of the minimum angle of resolution (logMAR )] at 6 months was associated with low initial visual acuity (VA; >1.0 logMAR ; P = 0.002) and with the diagnosis of nAMD (P = 0.02). In addition, limited visual outcomes were noted for patients older than 65 years and those with persistent SMH for at least 2 months.
Conclusions: PCV was the most common cause of SMH in Thailand. ICGA represented a valuable tool for the diagnosis. Visual outcomes were limited for patients with nAMD and for patients who presented with poor initial VA.
Combined Cataract Extraction With Pars Plana Vitrectomy and Metallic Intraocular Foreign Body Removal Through Sclerocorneal Tunnel Using a Novel “Magnet Handshake” Technique Dhoble, Pankaja; Khodifad, Ashish
Purpose: To study the outcomes of combined cataract extraction with pars plana vitrectomy (PPV) and metallic intraocular foreign body (IOFB) removal through a sclerocorneal tunnel using the “magnetic handshake” technique.
Design: A retrospective review.
Methods: Retrospective review of case records of 14 patients from 2010 to 2016 with metallic IOFB and traumatic cataract was performed. Cataract extraction was combined with PPV. Two intraocular magnets (IOMs) introduced through 20-gauge vitrectomy port and sclerocorneal tunnel helped achieve safe delivery of IOFB outside the globe by the “magnetic handshake” technique.
Results: All patients were males with a mean age of 33.04 years. A final best corrected visual acuity (BCVA) of 20/60 or better was noted in 10 (71.42%) of 14 patients. Final reattachment with more than 1 surgery was achieved in 13 (92.85%) patients. Postoperative complications included retinal detachment (RD) and phthisis bulbi in 1 (14.28%) patient each.
Conclusions: Combined cataract extraction with PPV and metallic IOFB removal through sclerocorneal tunnel using the “magnet handshake” technique gives good visual and surgical outcomes.
Optic Nerve Head Haemorrhages Associated with Posterior Vitreous Detachment Polkinghorne, Philip J.
Purpose: To report and evaluate the clinical and optical coherence tomography (OCT) features of optic nerve hemorrhages (ONH) associated with spontaneous posterior vitreous detachment (PVD).
Design: A prospective case series conducted at a private ophthalmic practice in Auckland, New Zealand. Methods: A consecutive series of patients presenting at a private multispecialty practice in Auckland, New Zealand, with symptoms of PVD with ONH underwent imaging of the optic nerve with digital retinal photography and OCT. The number and location of each hemorrhage were recorded, together with relevant ophthalmic and demographic data.
Results: Twenty of 30 eyes with ONH had evidence of persistent vitreopapillary adhesion. Three patterns of adhesion were identified: central, peripheral, and combined. In all, 52 hemorrhages were identified, of which the majority were flame-shaped, although other types were seen including dot and blot hemorrhages. One subretinal hemorrhage occurred in a patient with a central vitreopapillary adhesion.
Conclusions: ONH hemorrhages associated with PVD are commonly found with persistent vitreopapillary adhesions as evidenced on OCT. The clinical features of ONH together with OCT imaging may help to distinguish ONH associated with PVD from other hemorrhages found on or adjacent to the optic nerve.

Review Article

Paradigms for Pediatric Cataract Surgery Vasavada, Viraj
Pediatric cataract surgery has seen several advances in techniques, technologies, and conceptual practices. Pediatric cataract management heavily depends on a combined effort, not only from the ophthalmologist, but also the parents, the anesthetists, and the supporting staff members (eg, optometrists, orthoptists, patient coordinators). Surgical management, though critical, is not the only consideration for these children. Continuing visual rehabilitation and monitoring for complications remain key elements even after the surgery is done. Pediatric cataract surgery is a complex issue best left to surgeons who are familiar with the surgical paradigms and its long-term complications. Key components of surgery are management of posterior capsule and anterior vitreous and intraocular lens (IOL) implantation. It is a preferred practice today to perform a primary posterior capsulorhexis with anterior vitrectomy in younger children (up to 3 to 5 years old). Even in older children (up to the age of 8 years), performing a posterior capsulorhexis without anterior vitrectomy is the preferred approach. Above the age of 8 years, the posterior capsule can be left intact. In-the-bag IOL implantation is almost becoming a norm for children above the age of 1 year. Though there is no universal consensus regarding the earliest age for primary IOL implantation, many surgeons increasingly prefer primary IOL implantation even in infants. Alternate approaches that can avoid anterior vitrectomy like optic capture through the posterior capsulorhexis and bag-in-the-lens are also gaining more and more popularity.
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