Vogt-Koyanagi-Harada Disease with Onset in Elderly Patients Aged 68 to 89 Years

Background

We present the clinical case reports of elderly Vogt-Koyanagi-Harada (VKH) disease patients, including the oldest patient at onset to date.

Cases

Four patients with VKH disease, whose ages at onset were 68 to 89 years, were treated at Kochi Medical School Hospital between December 2002 and September 2004.

Observations

Four elderly patients were diagnosed with VKH disease according to the International Revised Diagnostic Criteria for VKH disease. Two were treated with corticosteroid pulse therapy, but the other two could not tolerate high-dose steroid therapy and were treated with only topical corticosteroids. All had recurrences, which were treated effectively. None of these patients experienced recurrence after sunset glow fundus was observed in the follow-up period.

Conclusions

VKH disease is thought to be more common in younger people, but it is not as uncommon in elderly people as is generally believed. Among elderly VKH disease patients, some cannot tolerate high-dose corticosteroid therapy, so we need to treat these patients with only topical corticosteroids.?Jpn J Ophthalmol 2007;51:60–63 © Japanese Ophthalmological Society 2007

     

The Impact of Visual Impairment on Completion of Cognitive Screening Assessments: A Post-Hoc Analysis from the IVIS Study

Aim:The aim of this study was to evaluate completed cognitive screens in stroke survivors with and without visual impairment to explore whether the presence of visual impairment impacts on completion of cognitive screening.Materials and methods:Cognitive screening assessment was undertaken using the Oxford Cognitive Screen (OCS). Data from visual function assessments (inclusive of visual acuity, visual fields, eye movements and visual perception evaluation) were analysed to determine whether presence and/or type of visual impairment impacted on cognitive screening scores achieved. Covariates, including glasses use, gender, age at stroke onset and stroke type, were used to assess confounding impacts on scores attained during cognitive screening.Results:1500 stroke admissions were recruited. One hundred ninety-seven who completed the OCS, were identified from the IVIS study database. Those who reported visual symptoms performed worse statistically on all cognitive tasks except the recall recognition (p = 0.232) and executive tasks (p = 0.967). Visual symptoms did not prevent participants from completing every section of the OCS (p = 0.095). In certain tasks, those not wearing their required glasses performed worse, including the executive function (p = 0.012), broken hearts and sentence reading tasks.Conclusions:Many tasks within cognitive screening assessment are impacted by presence of visual deficits, and adjustments, where possible (e.g. good lighting, large print) should be used to facilitate completion of cognitive screening. It is important to ensure required reading correction is worn during screening.     

Depressive Symptoms and Age-Related Macular Degeneration in Older People: The Cardiovascular Health Study

Purpose: To examine the association between age-related macular degeneration (AMD) and depressive symptoms. Methods: Population-based, cross-sectional study. A total of 2,194 persons aged 69–97 years were included in the current analyses. During the 1997–1998 examination, retinal photography from one randomly selected eye was graded for presence of early and late AMD using a modified Wisconsin AMD by Grading System. Depressive symptoms were assessed via a modified version of the Centers for Epidemiologic Studies Depression (CES-D) scale annually from 1989 through 1997–1998. Depressive symptoms were defined as a CES-D score of > 9 (top quartile of CES-D score) at the 1997–1998 examination. Results: There were 338 (15.6%) individuals with early AMD and 29 (1.3%) with late AMD. Among them, 368 (16.8%) persons had depressive symptoms at the 1997–1998 examination. Depressive symptoms were not associated with early AMD (multivariable adjusted odds ratio [OR]: 0.97; 95% confidence intervals [CI]: 0.69–1.36) or late AMD (OR: 1.15; 95% CI: 0.38–3.46). Including persons using anti-depressive medications did not alter these associations (OR: 0.98; 95% CI: 0.74–1.32 for early AMD and OR: 0.97; 95% CI: 0.35–2.67 for late AMD). There was no association in multinomial logistic regression models of increasing quartiles of the CES-D scores with early or late AMD status. Conclusions: Our study did not find an association between early AMD and depressive symptoms in older people.     

The Role of Multisystem Disease in Composition of Autologous Serum tears and ocular surface symptom improvement

PurposeAutologous serum tears (AST) contain growth factors and vitamins similar to those in healthy tears and are an effective treatment option for ocular surface disease. This study determined the differences in composition of AST in patients with systemic diseases versus patients with localized ocular surface diseases and the effects on ocular surface symptom improvement.MethodAn observational study was performed on 53 patients with either systemic diseases (Group I) or localized ocular surface diseases (Group II) who were prescribed AST. Concentrations of epidermal growth factor (EGF), interleukin 8 (IL-8), fibronectin, vitamin A, and tumor necrosis factor-α (TNF-α) were determined through ELISA assays from patients in both groups. The Ocular Surface Disease Index (OSDI) scores were calculated prior to and 6 weeks after initiation of treatment with AST for new patients.ResultsThe average concentration of EGF in Group I (29.39 pg/ml ± 52.85 pg/ml) was significantly lower than in Group II (88.04 pg/ml ±113.75 pg/ml) (p < 0.05). Levels of fibronectin, IL-8, and vitamin A were similar in both groups. There was a 24% reduction in OSDI score 6 weeks after initiation in Group I compared to a 36% reduction reported in Group II (p = 0.065). The OSDI score was reduced significantly after the treatment in all subjects (p = 0.002).ConclusionSerum tears are a promising therapy for management of ocular surface disease and associated symptoms. The differences between levels of EGF in patients with localized ocular surface disease and systemic inflammatory disease may account for differences in therapeutic outcome.     

Equal Exodeviations: Characteristics and Results of Treatment with Orthoptics

A retrospective study of 49 patients (22 males and 27 females) has been completed. The mean age of the group was 20.1 years. Diplopia, headaches, asthenopia and blur as a result of binocular visual dysfunction were the most frequently reported symptoms. Sixty-five per cent of the group were found to have either intermittent or constant deviations of the eyes. Over the mean course of treatment of 7.6 weeks, the distance and near angles of deviation, the positive vergences at distance and near, the near point of convergence and the binocular amplitude of accommodation were found to have changed significantly. Constant deviations were strongly related to longer necessary treatment durations. Further results of the treatment are presented and the implications of this data with regard to the treatment of these patients is briefly discussed.     

Monovision: the patient's perspective

We surveyed a group of 60 presbyopic subjects following eight weeks of monovision contact lens wear. The questions focussed on satisfaction with various aspects of visual performance, performance when driving, and general questions related to contact lens wear such as lens handling, care and maintenance and lens comfort. The subjects reported relatively high levels of satisfaction with visual performance, except in low light levels. Driving with monovision was also considered to be significantly worse at night than during daylight. Relatively few of the subjects had difficulties with lens handling, care and maintenance or lens comfort.     

The effect of letter-stroke boldness on reading speed in central and peripheral vision

People with central vision loss often prefer boldface print over normal print for reading. However, little is known about how reading speed is influenced by the letter-stroke boldness of font. In this study, we examined the reliance of reading speed on stroke boldness, and determined whether this reliance differs between the normal central and peripheral vision. Reading speed was measured using the rapid serial visual presentation paradigm, where observers with normal vision read aloud short single sentences presented on a computer monitor, one word at a time. Text was rendered in Courier at six levels of boldness, defined as the stroke-width normalized to that of the standard Courier font: 0.27, 0.72, 1, 1.48, 1.89 and 3.04× the standard. Testings were conducted at the fovea and 10° in the inferior visual field. Print sizes used were 0.8× and 1.4× the critical print size (smallest print size that can be read at the maximum reading speed). At the fovea, reading speed was invariant for the middle four levels of boldness, but dropped by 23.3% for the least and the most bold text. At 10° eccentricity, reading speed was virtually the same for all boldness <1, but showed a poorer tolerance to bolder text, dropping by 21.5% for 1.89× boldness and 51% for the most bold (3.04×) text. These results could not be accounted for by the changes in print size or the RMS contrast of text associated with changes in stroke boldness. Our results suggest that contrary to the popular belief, reading speed does not benefit from bold text in the normal fovea and periphery. Excessive increase in stroke boldness may even impair reading speed, especially in the periphery.     

The Management of Posterior Polar Cataract: The Role of Patching and Grading

The outcome of bilateral medial rectus posterior fixation sutures +/– central tenotomy was assessed as a secondary procedure for residual convergence excess esotropia in 11 patients. Ten had previously undergone bilateral medial rectus recessions. One had recess/resect surgery on the deviating eye. The average preoperative near angle was 30 prism diopters with a range of 16 to 45 prism diopters. Eight patients underwent bilateral medial rectus posterior fixation sutures with central tenotomy. Two had bilateral medial rectus posterior fixation sutures only, and one had bilateral medial rectus posterior fixation suture, a lateral rectus resection, and an inferior oblique disinsertion. The postoperative near angle ranged from 4-30 prism diopters, with mean of 12 prism diopters. Five patients demonstrated some stereopsis preoperatively, all needing bifocals. Postoperatively, nine patients demonstrated an improvement in stereopsis, none needing bifocals. Two showed smaller near angles and better control without bifocals. Final stereopsis ranged from 30 seconds of arc to 800 seconds of arc. We feel that bilateral medial rectus posterior fixation sutures with or without central tenotomy is a viable secondary procedure for residual convergence excess esotropia.     

The Sivaganga Eye Survey: I. Blindness and cataract surgery

PURPOSE To assess the prevalence of visual acuity impairment, blindness, and cataract surgery among older adults in rural southern India. METHODS Random selection of village- and urban-based clusters was used to identify a cross-sectional sample of persons 50 years of age or older from the Sivaganga district of Tamil Nadu. Subjects in 25 selected clusters were enumerated through a door-to-door survey and invited to examination sites for measurement of uncorrected, presenting, and best-corrected visual acuity and ocular examination in 1999. The principal cause was identified for eyes with presenting visual acuity worse than 6/18. Quality assurance monitoring of visual acuity measurements took place in five of the study clusters. RESULTS A total of 5081 persons in 3517 households were enumerated, and 4642 (91.4%) were examined. Thirty-six percent presented with visual acuity worse than 6/18 in the better eye. The prevalence of blindness, based on visual acuity worse than 6/60 in both eyes, was 6.0% (95% confidence interval [CI]: 5.1% to 6.9%) with presenting vision, and 2.5% (95% CI: 1.8% to 3.1%) with best correction. Blindness with presenting visual acuity was associated with older age and illiteracy. Cataract was the principal cause of blindness in one or both eyes in 69.4% of those presenting blind, and uncorrected aphakia and other refractive error affected 35.6% in at least one eye. The prevalence of cataract surgery was 14.7% (95% CI: 13.0% to 16.4%); low surgical coverage among the cataract blind was associated with illiteracy. CONCLUSION It appears that much has been done in the prevention of blindness in Sivaganga. Nevertheless, blindness remains an important public health problem, mainly because of cataract and refractive error. Prevention of blindness programs in the area should target these two causes, with special emphasis on the elderly and the illiterate.     

A Survey of Cases in Sydney Optometric Practices: AGE and SEX DISTRIBUTIONS; SYMPTOMS and REASONS for CONSULTATION.

ABSTRACT: Nineteen thousand seven hundred and-fifty three case records from 22 optometric practices in Sydney were surveyed to obtain data on age and sex distributions and on the symptoms, complaints and reasons for consultation presented by patients. Contact lens wearers were excluded. The age distribution was bimodal, with a major peak in the age group 45–54 years and a second peak in the age group 25–34. The median age was 47.3 years. Males comprised 46.3% of the cases, which was statistically different from the Australian population estimate of 48%. There was wide variation in age and sex distributions amongst individual practices. The most frequently presented reasons for consultation were “near problems” (29%) and “check-up” (no specific symptoms) (26.1%). Of the cases presented symptoms relating to clarity, to vision at distance and/or near were found in 46.2%. A further 36.4% either had no specific problems or complaints, or sought a consultation because of lost or broken spectacles. “Headache/migraine” was presented by 12.6% of females, and by only 6.9% of males. Other symptoms of visual or ocular discomfort were also presented more frequently by females than by males, and by young rather than old people.     

The Mallett Fixation Disparity Test: influence of test instructions and relationship with symptoms

Fixation disparity is a minute ocular misalignment under conditions of binocular single vision and is typically detected in primary eye care practices in the UK using the Mallett Unit Fixation Disparity Test. This instrument creates natural viewing conditions, when the patient's binocular system is fused using both central and peripheral fusion locks. This allows the examiner to determine the minimum prism power that eliminates the fixation disparity: the associated phoria or aligning prism. The spherical power that eliminates the fixation disparity, the aligning sphere, can also be determined. The near Mallett Unit Fixation Disparity Test has been shown to have good sensitivity and specificity for detecting symptomatic heterophoria. Cases of decompensated heterophoria tend to have a fixation disparity and the aligning prism or aligning sphere is a good indicator of the correction that will render the heterophoria compensated. The purpose of this study was, for the first time, to investigate the effect of test instructions on the results of the Mallett Unit Fixation Disparity Test. In study 1, we surveyed and observed practitioners to determine the instructions that are typically used. In study 2, we compared results obtained with this "standard" method of questioning with a more "specific" form of questioning that has been suggested in the literature. The participants for study 2 were 105 patients aged 7-70 years who were randomly selected from those attending a community optometric practice. Significantly different results were obtained with the two sets of instructions. The specific form of questioning revealed more cases of fixation disparity and the results with this method showed a better correlation with symptoms. This only held for near vision: for distance vision, symptoms were not significantly correlated with the presence of fixation disparity. This agrees with previous work with the Mallett unit, which showed a significant relationship with symptoms only at near. We also found that patients with more severe symptoms had greater degrees of aligning prism. Our study supports previous work indicating that the Mallett unit is a useful tool for detecting symptomatic heterophoria at near. However, we found that the testing method is important: patients need to be asked not just whether the nonius strips are aligned but also whether one or both of the strips ever moves. More research is needed to investigate the significance of precise test instructions in other optometric and orthoptic tests.     

Spatial characteristics of cerebral polyopia: a case study

A 41-year-old woman showed bilateral monocular polyopia and an incomplete, right-sided homonymous hemianopia following bilateral cerebral strokes confirmed by neuroimaging. She was tested with briefly-presented visual stimuli to determine whether her polyopic images varied with visual field position of stimuli which evoked them. Stimuli close to her scotoma elicited polyopic images at shorter latency and higher probability than did stimuli more distant from it. RS could maintain stable fixation on small stimuli, suggesting that eye movements were not responsible for her polyopia. We discuss the possibility that cerebral polyopia is due to recoding of visual receptive fields in primary visual cortex and that bilateral occipital lesions are a causative factor in the genesis of the disorder.     

The Role of Complement Factor H in Age-related Macular Degeneration: A Review

Factor H is a 155 kDa sialic acid containing glycoprotein that plays an integral role in the regulation of the complement-mediated immune system that is involved in microbial defense, immune complex processing, and programmed cell death. These events take place primarily in fluid phase and on the cell surface and are particularly important in the context of distinguishing self from non-self. Activation of the complement system occurs within seconds and results in a proteolytic cascade eventually forming the membrane attack complex leading to cell lysis. Factor H protects host cells from injury resulting from unrestrained complement activation. Mutations and SNPs (single nucleotide polymorphisms) in Factor H have been implicated in a variety of human conditions including age-related macular degeneration (AMD), atypical hemolytic uremic syndrome, and membranoproliferative glomuleronephritis type II or dense deposit disease. It should not be surprising that these seemingly unrelated diseases involving mutations in Factor H may share common features. Because the immune process involves, in part, an inflammatory response and common or similar surface antigens, it is also not unexpected to observe features of inflammation, including deposition of bioactive complement fragments such as C3a and C5a, a cellular influx of immune related cells such as lymphocytes, and the potential for multiple organ involvement. We review recent developments in molecular genetics; SNPs, including Y402H; the three-dimensional structure; and mass spectroscopy of Factor H as it relates to the pathogenesis of eye disease. In addition, we discuss the concepts of molecular mimicry, sequestered or hidden antigens, and antigenic cross reactivity, and propose that AMD should not simply be considered to be an eye disease, but rather a systemic vascular disease where the eye has the ability to self regulate a local immune response. Identification of the initial event or inciting antigen has yet to be determined and will significantly advance the understanding of the pathogenesis of AMD.     

The optometric role in angle closure glaucoma

Primary angle closure glaucoma (PACG) is not a rare disease, nor is it always readily diagnosed. Patients having primary angle closure glaucoma present with a spectrum of severity from symptomless through to a very dramatic form. This review describes the pathophysiology of angle closure and details the signs and symptoms of the disease in its various forms. Optometric management strategies are suggested for the diagnosis and management of the disease and current ophthalmological treatment is also outlined.     

Correlations between commonly used objective signs and symptoms for the diagnosis of dry eye disease: clinical implications

Purpose: To evaluate the relationship between signs and symptoms of dry eye disease (DED) in a clinic‐based population. Methods: In a retrospective analysis, clinical signs and symptoms were evaluated for 344 subjects (n = 82, normal; n = 263, dry eye), across 11 sites from the EU and United States. Pearson correlations between signs and symptoms (r²) and an independent components analysis (ICA) mixing matrix were derived from the data set. Similar analysis was performed on an independent data set from 200 subjects in a previous study in Munich, Germany. Results: No correlations above r² = 0.17 were found between any signs and symptoms, except for corneal and conjunctival staining, which reported an r² = 0.36. In the multisite study, the average r² for osmolarity (0.07), tear breakup time (0.12), Schirmer test (0.09), corneal (0.16) and conjunctival staining (0.17), meibomian grading (0.11) and Ocular Surface Disease Index^® (0.11) were consistently low. Among patients who showed evidence of DED by consensus of clinical signs, only 57% reported symptoms consistent with a diagnosis of DED. Similar results were observed in the Munich‐based study data set. Each component of the ICA mixing matrix exhibited minimal residual information. Conclusions: No consistent relationship was found between common signs and symptoms of DED. Each type of measurement provides distinct information about the condition of the ocular surface. These results also demonstrate that symptoms alone are insufficient for the diagnosis and management of DED and argue for a consensus of clinical signs that better reflect all aspects of the disease.