Refractive lens exchange in high myopia: long term follow up

AIM: To establish long term outcomes and incidence of complications following refractive lens exchange (RLE) for the correction of high myopia. METHODS: Operative and postoperative records of 62 cases of small incision phacoemulsification RLE performed in 37 patients over an 11 year period, by a single surgeon, were reviewed. In addition, patients were recalled for a follow up examination, which included dilated retinal examination with scleral indentation. RESULTS: Two cases (3.2%) of retinal detachment occurred at intervals of 2 months and 5 months following uncomplicated RLE procedures. A posterior chamber intraocular lens was inserted in 46 eyes (74%). YAG laser posterior capsulotomy was performed in 38 of 62 eyes (61%) and did not represent a risk for retinal detachment. CONCLUSION: Refractive lens exchange results in rapid and predictable improvement in unaided vision in patients with high myopia. However, the risks of sight threatening complications inherent in any intraocular procedure underlie the need for appropriate patient selection.     

Accommodative function in school children with reading difficulties

Background  Prior findings suggest correlation between reading problems and accommodative function, but few studies have assessed accommodation in children with poor reading skills. Our aim was to characterize monocular accommodative amplitude, relative accommodation and binocular accommodative facility in a population of healthy, non-dyslexic primary school children with reading difficulties. Methods  We conducted a cross-sectional study on 87 poor readers and 32 control children (all between 8 and 13 years of age) in grades three to six recruited from 11 elementary schools in Madrid, Spain. In each subject with best spectacle correction, negative relative accommodation (NRA) and positive relative accommodation (PRA) were measured using a phoropter, monocular accommodative amplitude (MAA) was determined using the minus lenses method, and binocular accommodative facility (BAF) was measured using the Bernell Acuity Suppression Slide (VO/9) and a ± 2.00 D accommodative demand for a period of 1 minute. Results  Monocular accommodative amplitude was significantly lower (p < 0.001) in the group of poor readers (right eye 9.1 D ± 2.3, left eye 9.0 D ± 2.3) than in the control group (right eye 10.5 D ± 1.7, left eye 10.5 D ± 1.7). Binocular accommodative facility values were significantly lower (p < 0.05) in the poor readers (4.9 cpm ± 3.1) than controls (6.3 cpm ± 2.9). Negative and positive relative accommodation values were similar in both groups of children. Conclusions  This study provides data on the accommodative capacity of a population of children with reading difficulties. Our findings suggest a reduced monocular accommodative amplitude and binocular accommodative facility, such that this function should be assessed by an optometric clinician in children whose reading level is below average. Human subjects and informed consent  The authors confirm that this research was performed followed the tenets of the Declaration of Helsinki, and that informed consent was obtained from the subjects after having explained to them in detail the nature of the study. The study protocol was approved by the Clinical Research Ethics Committee of the School of Optometry.     

Relation among accommodative facility, lag, and amplitude in elementary school children

Normative data for accommodative lag, facility, and amplitude of children have been presented in the literature for each of the parameters separately. This paper delineates the relation among accommodative amplitude, lag, and flexibility for grade school children. Approximately 200 children were screened. Those who wore corrective lenses, had uncorrected acuity worse than 6/9 (20/30) in either eye, had strabismus, had a refractive error outside the range from 0.00 to +0.75 D; or astigmatism greater than 0.50 D were excluded from the study. Of the 123 who remained, 53% had a deficit in accommodative facility, 26% had a deficit in lag, and 25% had a deficit in amplitude from that which would be expected from their age. Sixteen percent had deficits in both facility and lag. Eighteen percent had deficits in both amplitude and lag. Twenty-four percent had deficits in both facility and amplitude. Only 4% had deficits in all three of the accommodative functions considered--amplitude, lag, and facility. Clinically, these results indicate that when a patient's accommodative dysfunction is examined all facets of accommodation--lag, facility, and amplitude--need to be evaluated.     

Treatment and long term follow up of a capillary angioma of the optic disc

This case report describes the treatment of a capillary angioma involving the temporal aspect of the optic disc by photocoagulation therapy. It chronicles the effect of creating a retinal-choroidal adhesion at the temporal margin of the lesion in reducing exudation from the angioma spreading to involve the macula. The patient in question has been followed for sixteen years and vision in this eye has been maintained at 6/6 following the course of therapy described. Our experience suggests that direct laser treatment to capillary angiomas of the optic disc combined with photocoagulation barrier protection of the macula is beneficial and should be considered early when the lesion is relatively small.     

Accommodative dysfunction in children with cerebral palsy: a population-based study

PURPOSE: To determine the prevalence, nature, and degree of accommodative dysfunction among children with different types and severities of cerebral palsy (CP) in Northern Ireland. METHODS: Ninety subjects with CP (aged 4-15 years) were recruited through the Northern Ireland CP Register (NICPR). Modified Nott dynamic retinoscopy was used to measure lag and lead of accommodation at three test distances: 25 cm (4 D), 16.7 cm (6 D), and 10 cm (10 D) with the distance correction in place. Accommodative function was also assessed in an age-matched control group (n = 125) for comparison. Each subject's neurologic status was derived from the NICPR. RESULTS: Children with CP demonstrate significantly reduced accommodative responses compared with their neurologically normal peers. Of the subjects with CP, 57.6% demonstrated an accommodative lag outside normal limits at one or more distances. Reduced accommodative responses were significantly associated with more severe motor and intellectual impairments (ANOVA P = 0.001, P < 0.01, respectively). CONCLUSIONS: Brain injury such as that present in CP has a significant impact on accommodative function. These findings have implications for the optometric care of children with CP and inform our understanding of the impact of early brain injury on visual development.     

Ocular manifestations of familial amyloidotic polyneuropathy type I: long term follow up

AIMS—To obtain precise information on ocular manifestations of familial amyloidotic polyneuropathy (FAP) type I, the incidence of five main ocular manifestations—abnormal conjunctival vessels (ACV), keratoconjunctivitis sicca (KCS), pupillary abnormality, vitreous opacity, and glaucoma, were compared through long term follow up.
METHODS—Ocular examinations were performed in 37 FAP type I patients (Met30) from once to 12 times over a period of 1 to 12 years and 7 months.
RESULTS—The following incidences were observed on initial examination of each patient with FAP: ACV in 75.5%, pupillary abnormalities in 43.2%, KCS in 40.5%, glaucoma in 5.4%, and vitreous opacity in 5.4%. All ocular manifestations increased with the progression of FAP, and the incidence of ACV reached 100% during follow up: this may be helpful in the diagnosis of FAP.
CONCLUSION—Since no precise statistical ocular study on FAP with long term follow up has been performed, this report may provide important information to help elucidate the mechanism of the amyloid distributing process in the amyloid targeted organs of FAP and to provide the natural course of ocular manifestations of FAP.

     

Comparative study between deep sclerectomy with and without collagen implant: long term follow up

AIM: To identify the value of using collagen implant in deep sclerectomy. METHODS: A prospective randomised trial of 104 eyes (104 patients) with medically uncontrolled primary and secondary open angle glaucoma. All patients had deep sclerectomy (DS), half of them with and the other half without a collagen implant (CI) sutured in the scleral bed. The main outcome measures were intraocular pressure (IOP), visual acuity, number of treatments preoperative and postoperative, and Nd:YAG goniopunctures. RESULTS: Mean follow up period was 44.5 (SD 21) months for the DS group and 43.9 (SD 14) months for the deep sclerectomy with a collagen implant (DSCI) group. The mean preoperative IOP was 23.3 (SD 7.2) mm Hg for the DS group and 25.6 (SD 4.9) mm Hg for the DSCI group. The mean IOP at the first postoperative day was 6.1 (SD 4.21) mm Hg for the DS group and 5.1 (SD 3.3) mm Hg for the DSCI group. At 48 months IOP was reduced by 40% (14 versus 23.3 mm Hg) for the DS group and by 50% (12.7 versus 25.6 mm Hg) for the DSCI group. Complete success rate, defined as IOP lower than 21 mm Hg without medication, was 34.6% (18/52 patients) at 48 months for the DS group, and 63.4% (33/52 patients) for the DSCI group. Qualified success rate; patients who achieved IOP below 21 mm Hg with or without medication, was 78.8% (41/52 patients) at 48 months and 94% (49/52 patients) for the DSCI group. The mean number of medications was reduced from 2.1 (SD 0.8) to 1.0 (SD 1) after DS, and was reduced from 2.2 (SD 0.7) to 0.4 (SD 0.6) in the DSCI group (p = 0.001) CONCLUSION: The use of a collagen implant in DS enhances the success rates and lowers the need for postoperative medication.     

A long term follow up of ocular siderosis: Quantitative assessment of the electroretinogram

Siderosis oculi is a severe sequel of retained, iron made, intraocular foreign body. Iron atoms or ions, dissolved from the foreign body, may diffuse to the retina and produce irreversible cellular damage. Therefore, early extraction of an iron foreign body is recommended. When the risks of surgical intervention outweigh the danger of siderosis, the patient is periodically examined in order to detect the initial signs of siderosis. The most commonly used test for quantitative and objective assessment of retinal function is the electroretinogram (ERG). We report here a long term ERG follow-up (about 8 years) of a patient suffering from a unilateral iron intraocular foreign body. The development of siderosis was detected by any of the ERG responses; cone-dominated, rod-dominated or mixed cone-rod responses. However, the degree of the assessed damage varied and strongly depended upon the flash intensity used to elicit the ERG response and upon the ERG wave chosen to assess retinal function. The relationship between the ERG b- and a-waves showed a profound deterioration reflecting a reduction in signal transmission from the photoreceptors to the inner nuclear layer. These findings suggested that iron toxicity produced more damage to the inner retina than to the outer retina.     

Prognostic value of carotid ultrasound lesion morphology in retinal ischaemia: result of a long term follow up.

The importance of carotid plaque morphology in the prognosis of retinal ischaemia was investigated in a group of 165 patients followed for 2-7 years (mean 3.3 years). All patients had an initial carotid duplex ultrasound examination, with the results expressed in terms of the degree of stenosis caused by the lesion, and the lesion morphology. Lesions were divided into two groups, (a) combined homogeneous and simple heterogeneous structures, and (b) complex heterogeneous plaques. Complex heterogeneous plaques had a low echo pool within the lesion and/or an irregular surface pattern. A total of 144 (87%) patients were successfully followed, and of these 37 (26%) had cerebrovascular, cardiovascular, or retinal ischaemic events in the follow up period; 14 (10%) cerebrovascular accidents (eight fatal), 17 (12%) myocardial infarctions (10 fatal), two episodes of amaurosis fugax, and one of tunnel vision caused by a retinal embolus were recorded. There was no report of subsequent blindness. The percentage stenosis caused by the carotid lesions, although more severe in the vascular event group, was not significantly different between the groups. However, a significant difference (p < 0.1) was found in the morphological characteristics of the carotid lesions between the groups. Patients who suffered a vascular event in the follow up period had significantly more complex heterogeneous lesions compared with simple heterogeneous/homogeneous lesions, than those patients who remained alive and well. Carotid endarterectomy and antiplatelet therapy were equally distributed between the event and non-event groups. This suggests that the criteria for selection for treatment should be based on the lesion morphology as well as the degree of stenosis.     

Long term follow up of nasolacrimal intubation in adults

BACKGROUND/AIMS: The authors have previously reported a short term mean 15 month follow up of nasolacrimal intubation in adults. The effectiveness of this procedure for long term (mean 78 months) control of epiphoria is assessed here. METHODS: 65 eyes from 40 patients who underwent nasolacrimal intubation were followed. Mean age at intubation was 59.2 years. The mean follow up period was 6.2 years. The results were based on long term symptomatic improvement. RESULTS: Complete long term resolution of symptoms was reported in 50.7%. A partial improvement was reported in 38.5%, and no improvement in 10.7%. A better outcome was associated with a canalicular than nasolacrimal duct obstruction. On long term follow up 16.9% required dacrocysto-rhinostomy (DCR). CONCLUSION: Nasolacrimal intubation, a minimally invasive procedure is successful in the long term control of epiphora. Selection of patients with canalicular duct obstruction gives higher success rates with fewer patients subsequently requiring the DCR procedure.     

The effects of accommodative facility training on a group of children with impaired relative accommodation—a comparison between dioptric treatment and sham treatment

The effects of accommodative facility training were evaluated by comparing training with plano lenses and +/-2.00 D lens flipper sets. Thirteen children with symptoms and signs of accommodative dysfunction were included in the study. Seven started with 2 weeks of plano lens training before proceeding to traditional dioptric flipper training; later, one patient from this group was lost to follow-up. The remaining six children used powered flipper training from the start. The positive (PRA) and negative relative accommodation (NRA) were examined every second week. During the initial training period both the PRA and the NRA decreased in the sham treatment group (P = 0.010 and P= 0.102, respectively), while the PRA and the NRA increased during the dioptric training in both groups (P = 0.102 and P = 0.033, respectively). The result of this study indicates that accommodative facility training has a real effect on the amplitude of relative accommodation in patients with impaired relative accommodation.     

Changes in dynamics of accommodation after accommodative facility training in myopes and emmetropes

This study evaluates the effect of accommodative facility training in myopes and emmetropes. Monocular accommodative facility was measured in nine myopes and nine emmetropes for distance and near. Subjective facility was recorded with automated flippers and objective measurements were simultaneously taken with a PowerRefractor. Accommodative facility training (a sequence of 5 min monocular right eye, 5 min monocular left eye, 5 min binocular) was given on three consecutive days and facility was re-assessed on the fifth day. The results showed that training improved the facility rate in both groups. The improvement in facility rates were linked to the time constants and peak velocity of accommodation. Some changes in amplitude seen in emmetropes indicate an improvement in facility rate at the expense of an accurate accommodation response.     

Controlled Cyclophotocoagulation with diode laser in refractory glaucoma and long term follow up at King Abdulaziz University Hospital,Riyadh

Purpose

To evaluate the clinical efficacy and safety of controlled contact transscleral diode laser Cyclophotocoagulation (COCO) procedure in reducing the Intraocular Pressure (IOP) among patients with refractory glaucoma.

Methods

Thirty two patients (35 eyes) with refractory glaucoma in prospective clinical studies were treated with trans-sclera diode laser in a controlled manner. The energy power used was 5 W in adults and 3 W in children, exposure time was 0.5 s, a total of 16 shots were applied over ciliary body and four shots in each quadrant. Pre and postoperative IOP were measured at different postoperative visits. Snellen visual acuity, the number of anti-glaucoma medications and associated complications were also recorded. Student T test was used to compare the pre and post intervention IOPs, while Wilcoxon Signed Ranks test was used, to detect significance change in medication dependency.

Results

The mean (SD) follow up time was 80.2(±9.6) months, range (36–84) m, where the mean IOP was significantly reduced from 35.1 mm Hg (±10.7) before intervention to 18.8 mm Hg (±7.3) after intervention, in the final visit (P < 0.0001). Complete success was achieved in seven eyes (20%), 22 eyes (62.8%) showed qualified successes and complete failure was reported in six eyes (17.1%). The overall success rate was 82.8% (95% CI: 70.4–95.3). Visual acuity improved in three eyes (8.5%), no change took place in 27 eyes (77.1%) and decreased in five eyes (14.2%). The number of anti-glaucoma medications has significantly changed between pre and post intervention (P < 0.0001). No cases of hypotony, phthisis bulbi or sympathetic ophthalmia were reported.

Conclusion

Controlled COCO is a simple procedure, safe with minimal complications and fewer side effects.     

Relationship of accommodative response and nearpoint phoria in a sample of myopic children.

Esophoria has been associated with onset and progression of myopia in children. The induction of myopia by optical defocus shown by animal models suggests that a high lag of accommodation during near work may contribute to myopia in children. This paper examines the relationship of nearpoint phoria and accommodative response in a sample of children with myopia. Accommodative response was measured under binocular conditions with the Canon Autoref R-1 autorefractor with a 40 cm viewing distance. Phorias were measured with the von Graefe method using a 40 cm test distance. In the statistical analysis exophoria was scored as a negative number and esophoria was scored as a positive number. The coefficient of correlation of accommodative response with phoria was -0.32 (n = 73; p<0.01), thus showing an association of a more positive (more convergent) near phoria with lower accommodative response. The correlation coefficient increased to -0.39 when an exponential function was used. When only esophores were considered, the correlation coefficient was -0.59 (n = 44; p<0.001). Lower accommodative response (higher lag of accommodation) was associated with greater esophoria.     

Ophthalmological long term follow up of preterm infants: a population based, prospective study of the refraction and its development

BACKGROUND—Numerous studies have reported an increased risk of refractive errors in prematurely born infants, but only few have been long term and strictly population based.
METHODS—A 3.5 year ophthalmological long term follow up of 248 preterm infants was performed. The infants had been included in a previous epidemiological study of retinopathy of prematurity (ROP) (birth weight  1500 grams). The incidence of refractive errors and development of refraction were studied, based on retinoscopies at 6 and 30 months of corrected age.
RESULTS—The overall incidence of myopia was 8% at 6 months, of which 35% was transient, and 10% at 30 months. Of the cryotreated infants, 30-40% were myopic at both retinoscopies. The incidence of astigmatism was 52% at 6 months and 26% at 30 months. Astigmatism was associated with ROP, but not with cryotreated ROP itself. Astigmatism "against the rule" was commoner than astigmatism "with the rule". Anisometropia occurred in 6.5% of the infants at 6 months and in 8.4% at 30 months. The incidence of anisometropia was higher in eyes with ROP, particularly in cryotreated eyes, which tended to have high and persistent anisometropia.
CONCLUSION—The risk of refractive errors is higher in preterm infants than in infants born at term, and also prematurely born infants without ROP do run an increased risk of having myopia and anisometropia. We recommend follow up examinations with retinoscopy for all infants included in screening programmes for ROP.

Keywords: prematurity; prospective study; retinopathy of prematurity; refraction     

Treatment of band keratopathy by excimer laser phototherapeutic keratectomy: surgical techniques and long term follow up.

A series of 122 eyes with band keratopathy was treated by excimer laser phototherapeutic keratectomy (PTK), with a mean follow up of over 12.3 months (range 3 to 60 months). A single photoablation zone was used to remove the opacity over the visual axis in smooth surfaced band deposition. In eyes with reduced vision, an improvement was reported in 88% and in a series of 66 eyes mean Snellen visual acuity increased significantly (p < 0.05, t = 2.27). A reduction in glare was reported in 88% and in a series of 17 patients, visual contrast sensitivity (p < 0.01) and measurements of disability glare (p < 0.01) improved postoperatively. The mean hyperopic shift in 32 eyes at 6 months was 1.4 D (range 0-4.25 D). Multiple overlapping ablation zones, with mechanical debulking of large calcium plaques, were used to smooth the irregular corneal surface in eyes with rough bands. Ocular discomfort was improved in 95%. Band keratopathy recurred in nine eyes (8%) within 2 to 30 months (mean 12 months) of surgery, with silicone oil responsible in five eyes. Reablation was necessary in three eyes and performed successfully in all cases. Excimer laser PTK is a safe and effective outpatient treatment for band keratopathy.     

Diode laser cyclophotocoagulation: longer term follow up of a standardized treatment protocol

Background : Diode laser cyclophotocoagulation (cyclodiode) is gaining acceptance as a therapy for refractory or end‐stage glaucoma. The aim of the study was to establish whether a reproducible dose–effect relationship exists following a single standardized cyclodiode treatment to lower intraocular pressure (IOP). Methods : This paper reports results from a longer‐term follow up of a trial involving the study of 30 patients with uncontrolled IOP and advanced glaucoma who were treated with a single episode of either a half or a full standardized dose of laser depending on clinical risk of phthisis and monitored for IOP control, visual acuity, postoperative inflammation and phthisis. Results : A lowering of IOP at the final follow up was achieved in 83% of patients, with a mean follow‐up time of 21 months. For patients receiving a full standardized laser dose, preoperative IOP was 49.4 ± 11.2 mmHg (mean ± SD) and postoperative IOP was 28.5 ± 20.0 mmHg (42% reduction); 45% of patients achieved IOP < 22 mmHg and 68% gained an IOP reduction > 30%. For the half treatment cases, the preoperative IOP was 29.4 ± 4.3 mmHg (mean ± SD) and the postoperative IOP was 18.3 ± 10.0 mmHg (38% reduction); 63% of patients achieved IOP < 22 mmHg and 50% gained an IOP reduction of > 30%. Of 22 sighted eyes, nine (41%) recorded no change in vision; and nine (41%) lost and four (18%) gained vision. Hypotony was seen in 4/22 (18%) of full standardized laser dose cases. Conclusion : Longer follow‐up times confirm that diode laser cyclophotocoagulation is a convenient and useful therapy in the control of IOP in end‐stage glaucoma. Response of IOP to the laser therapy is highly variable, particularly in the neovascular glaucoma group, and it does not appear to be possible to predict an IOP outcome for an individual eye. Circumferential treatments in neovascular eyes should be avoided. Prospects for long‐term vision retention in end‐stage eyes are poor, perhaps due to progression of the underlying disease.     

Measuring ADHD behaviors in children with symptomatic accommodative dysfunction or convergence insufficiency: a preliminary study.

BACKGROUND: Accommodative dysfunction and convergence insufficiency (CI) are common pediatric vision problems that have been associated with an increase in frequency and severity of vision-specific symptoms that affect children when doing schoolwork. However, the relationship between accommodative dysfunction and CI and other learning problems, such as attention deficit hyperactivity disorder (ADHD), are not well understood. The purpose of this study was to evaluate the frequency of ADHD behaviors in school-aged children with symptomatic accommodative dysfunction or CI. METHODS: Children 8 to 15 years of age with symptomatic accommodative dysfunction or CI were recruited from the teaching clinic at the Southern California College of Optometry. Children with learning disabilities or ADHD were excluded. One parent of each child completed the Conners Parent Rating Scale-Revised Short Form (CPRS-R:S). The children's scores on the CPRS-R:S were compared with the normative sample. RESULTS: Twenty-four children (9 boys and 15 girls) participated in the study with a mean age of 10.93 years (SD = 1.75). On the CPRS-R:S, cognitive problem/inattention, hyperactivity, and ADHD index were significantly different from normative values (p < or = .001 for all tests). CONCLUSIONS: The results from this preliminary study suggest that school-aged children with symptomatic accommodative dysfunction or CI have a higher frequency of behaviors related to school performance and attention as measured by the CPRS-R:S.     

Variation and correlation of clinical tests of accommodative function in a sample of school-age children.

Accommodative facility, lag of accommodation, accommodative response, and relative accommodation were measured in 244 school-age (7.9 to 15.9 years of age) children. The tests studied included monocular estimate method (MEM) dynamic retinoscopy, Nott dynamic retinoscopy, low neutral dynamic retinoscopy, the binocular cross cylinder test, lens accommodative rock (facility), distance (near-far) accommodative rock, negative relative accommodation (NRA), and positive relative accommodation (PRA). The mean, standard deviation, and range of test findings of each test are presented. Coefficients of correlation among the various tests are presented.