The Asia-Pacific Journal of Ophthalmology

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Articles appearing in this section have been peer-reviewed and accepted for publication and posted online before formal publication. Articles appearing here may contain statements, opinions, and information that have errors in facts, figures, or interpretation. Accordingly, the editors and authors and their respective employees are not responsible or liable for the use of any such inaccurate or misleading data, opinion or information contained the articles in this section.

Original Study - Clinical

Bilateral Symmetric and Asymmetric Superior Rectus Recession for Patients with Dissociated Vertical Deviation Tibrewal, Shailja; Nguyen, Phuong T.T.; Ganesh, Suma; Molinari, Andrea
Purpose: To evaluate the outcome of bilateral symmetric and asymmetric superior rectus (SR) recessions in patients with bilateral dissociated vertical deviation (DVD) without oblique dysfunction and determine factors that might influence the surgical outcome.
Design: Retrospective study.
Methods: All patients who underwent bilateral SR recession for bilateral DVD from January 2012 to December 2016 at an eye hospital in New Delhi, India were included. Indication for surgery was decompensated DVD in 1 or both eyes. Symmetric SR recession was performed for symmetric DVD and asymmetric SR recession was performed for asymmetric DVD of 10 prism diopters (PD) or more. Patients with a minimum follow-up of 6 months were included. Success was defined as absence of manifest DVD in both eyes at the final postoperative visit.
Results: Medical records of 27 patients were analyzed. Their median age at surgery was 8 years [interquartile range (IQR), 6–10 years] and mean follow-up was 16.3 months (range, 6–48 months). Symmetric and asymmetric surgeries were performed in 19 and 8 patients, respectively. The amount of SR recession performed ranged from 5 to 10 mm. The median DVD reduced from 9 PD (IQR, 6–14 PD) to 5 PD (IQR, 3–8 PD) in the right eye (P = 0.015) and 9 PD (IQR, 7–12 PD) to 6 PD (IQR, 3–10 PD) in the left eye (P = 0.016) after surgery. Successful outcome was seen in 63% of patients. There was no difference in successful outcome with respect to age, sex, preoperative horizontal deviation, preoperative vertical deviation, postoperative residual horizontal deviation, surgical technique, asymmetry of SR recession, and magnitude of preoperative DVD. Patients with a preference for fixation were more likely to have a successful outcome.
Conclusions: Bilateral SR recession resulted in a success rate of 63% after single operation for bilateral DVD without oblique dysfunction. We found that the probability of a successful outcome did not depend on age at surgery, sex, preoperative horizontal or vertical deviation, magnitude of preoperative DVD, symmetry of SR recession, or surgical technique.
Intra-Arterial Chemotherapy for Retinoblastoma: 8-Year Experience from a Tertiary Referral Institute in Thailand Rojanaporn, Duangnate; Chanthanaphak, Ekachat; Boonyaopas, Rawi; Sujirakul, Tharikarn ; Hongeng, Suradej; Ayudhaya, Sirintara Singhara Na
Purpose: To study the safety and efficacy of intra-arterial chemotherapy (IAC) as a treatment for intraocular retinoblastoma in Thailand.
Design: Retrospective, interventional case series.
Methods: In this study, IAC was performed as primary or secondary treatment for patients with intraocular retinoblastoma using melphalan with or without additional topotecan or carboplatin. Survival rate, globe salvage rate, and treatment complications were recorded and analyzed.
Results: Of 27 eyes of 26 patients with retinoblastoma, 7 (26%) had IAC as primary treatment and 20 (74%) had IAC as secondary treatment. The eyes were classified by International Classification of Retinoblastoma (ICRB) as group B (n = 3, 11%), group C (n = 1, 4%), group D (n = 12, 44%), and group E (n = 11, 41%). Catheterization was successful in 75 (94%) of 80 sessions. The median number of IAC sessions was 3 (range, 1–7). At a mean follow-up of 32 months (range, 3–95 months), the overall globe salvage rate was 52%, with 100% in groups B and C, 75% in group D, and 9% in group E. Complications of IAC included occlusive vasculopathy (n = 4, 15%), vitreous hemorrhage (n = 3, 11%), retinal artery precipitation (n = 2, 7%), strabismus (n = 2, 7%), and transient ischemic attack (n = 1, 4%). The overall survival rate was 96% (n = 25).
Conclusion: Our experience suggests that IAC is a safe and effective treatment for patients with ICRB group B, C, D, and some group E retinoblastoma. Careful patient selection and experienced surgeons are critical for achieving the best treatment outcome.
The Relationship Between Optic Disc Parameters and Female Reproductive Factors in Young Women Lee, Samantha S.Y.; Yazar, Seyhan; Pasquale, Louis R.; Sanfilippo, Paul G.; Hewitt, Alex W.; Hickey, Martha; Skinner, Rachel; Mackey, David A.
Purpose: It has been suggested that female sex steroids have neuroprotective properties that may reduce risk of glaucoma in premenopausal women. In this study, we explored the associations of optic disc measures with female reproductive factors in a population of young women. Design: Cohort study.
Methods: Young women (n = 494; age range, 18–22 years) were recruited as part of the Western Australian Pregnancy Cohort (Raine) Study. Information on age at menarche, parity, and use of hormonal contraceptives were obtained from questionnaires. Participants underwent an eye examination, including spectral-domain optical coherence tomography imaging, to obtain optic disc parameters.
Results: Women who had given birth at least once (parous women;n = 10) had larger vertical neuroretinal rim widths (P < 0.001) than nulliparous women (n = 484) after correcting for use of hormonal contraceptives, intraocular pressure, refractive error, and family history of glaucoma. Furthermore, vertical and horizontal cup-to-disc ratios, which are inherently related to neuroretinal rim width, were found to be smaller among parous women compared with nulliparous women (both P < 0.001). Age at menarche and use of hormonal contraceptives were not significantly associated with any optic disc parameters.
Conclusions: We found limited evidence that female reproductive factors were related with optic disc parameters during young adulthood. The association between parity and optic disc parameter, though significant, should be further investigated given the small number of parous women in the current sample. Future follow-ups of this cohort will allow us to explore for any associations of these factors with optic disc parameters and glaucoma risk at an older age.
Clinical Course and Treatment Response of Neuromyelitis Optica Spectrum Disease: An 8-Year Experience Lin, Chao-Wen; Lin, I-Hung; Chen, Ta-Ching; Jou, Jieh-Ren; Woung, Lin-Chung
Purpose: To report the clinical course and treatment response in a cohort of neuromyelitis optica spectrum disorder (NMOSD) patients from a single referral center.

Design: Case series.

Methods: Ninety-six NMOSD patients who received treatment and follow-up checks at National Taiwan University Hospital for at least 2 years between 2008 and 2016 were recruited. Detailed characteristics of clinical course including acute episodes, maintenance therapies, and visual outcome were collected. Patients were examined every 6 months and during each episode of relapse. The study was approved by the institutional review board and informed consent was obtained.


Results: Among all patients, 68 (70.8%) had optic neuritis. Optic neuritis was the initial presentation of NMOSD in 44 patients. Among patients with optic neuritis, 32.4% had recurrent optic neuritis within 1 year from the first episode. Compared with the group without optic neuritis, the group with optic neuritis had a younger age of presentation (34.4 ± 15.9 versus 42.4 ± 14.7 years, P = 0.02) and a higher 1-year recurrence rate (64.7% versus 17.9%, P < 0.001). Among the patients with optic neuritis, 51.5% of patients had a final visual acuity of worse than 20/200. Multiple regression analysis showed that the presence of aquaporin-4-IgG antibodies and poor initial visual acuity were risk factors of worse visual outcome.

Conclusions: In this study, patients with optic neuritis were younger and had a higher 1-year recurrence rate. Despite using steroid therapy during the acute phase and immunosuppressive agents as long-term treatment, visual prognosis was poor. Aquaporin-4-IgG antibodies and initial visual acuity were associated with final visual outcome.
Delivery Characteristics of the Preloaded POB-MA 877PA Intraocular Lens System: Comparison of 2 Incision Sizes Yao, Anthony; Liu, Henry
Purpose: To obtain real-world data regarding the delivery characteristics of a preloaded delivery system, the Bi-Flex POB-MA 877PA, and to compare them in 2 main port incision sizes: 2.4 mm and 2.75 mm.
Design: Prospective multicenter observational cohort study.
Methods: Consecutive elective phacoemulsification and intraocular lens surgeries using the POB-MA 877PA implant were performed by a single experienced surgeon between December 2017 and April 2018. Patients were divided into 2 groups with group 1 and 2 underwent phacoemulsification through a main port size of 2.4 mm and 2.75 mm, respectively. Delivery characteristics were recorded, with a main outcome defined as lens delivery entirely into the capsular bag using the preloaded injector without additional manipulation. Other variances were classified as minor or major issues depending on lens or anatomical damage or requirement to replace device.
Results: A total of 110 total cases were included, with 59 cases in group 1 (2.4 mm) and 51 cases in group 2 (2.75 mm). Group 2 had a significantly lower proportion of cases that required secondary manipulation of the lens than group 1 [8 (15.7%) cases vs 24 (40.7%) cases; P < 0.05]. In groups 1 and 2, 3 (5.1%) and 3 (5.9%) cases had major issues, respectively.
Conclusions: The delivery characteristics of the POB-MA 877PA intraocular lens systems are different in the 2.4-mm and 2.75-mm main port incisions, with a lower proportion of cases requiring secondary manipulation in the 2.75-mm incision size. Despite its preloaded nature however, there are still delivery issues with these intraocular lens systems.

Review Article

How to Add Metacognition to Your Continuing Professional Development: Scoping Review and Recommendations Mack, Heather G.; Spivey, Bruce; Filipe, Helena P.
Participation in continuing professional development (CPD) is part of lifelong learning required by ophthalmologists. Metacognition is a new area of educational research. It is important because metacognitive skills are essential in medical education and likely to improve effectiveness of CPD activities. We systematically searched PubMed using the search terms ‘metacognition’ and ‘CPD’ or ‘continuing medical education (CME)’ and found only 5 articles. These articles were supplemented by a broad-based review of published literature including educational psychology, across the continuum of medical education. We summarize the techniques that may improve metacognition in CPD: awareness of and instruction in metacognition, awareness and mitigation of cognitive errors, appropriate needs analysis, and choosing appropriate activities. Metacognition and learning of new surgical techniques, the role of portfolios, and the role of the educator are described. The evidence is weak however, and it is usually extrapolated to CPD activities from other fields. Ophthalmologists may be able to improve their metacognitive skills in the CPD context, but the evidence supporting this is of low quality.
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