The Asia-Pacific Journal of Ophthalmology

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Original Study - Clinical

Corneal Biomechanics Using a Scheimpflug-Based Noncontact Device in Normal-Tension Glaucoma and Healthy Controls Hong, Karen; Wong, Ian Y.H.; Singh, Kuldev; Chang, Robert T.
Purpose: To determine if a novel biomechanical parameter, corneal applanation velocity, as measured by the Corvis ST, is associated with a diagnosis of normal-tension glaucoma (NTG).
Design: Prospective, cross-sectional study.
Methods: Study and control subjects were recruited from the ophthalmology clinic of a university teaching hospital in Hong Kong over an 8-week period in 2013. A total of 80 eyes with NTG diagnosis and 155 healthy eyes randomly selected to be in the control group were included in the final analysis. All subjects underwent corneal biomechanical testing with the Oculus Corvis ST non-contact tonometer. Logistic regression analysis adjusted for age and central corneal thickness was conducted to assess the relationship between inward and outward applanation velocity and the risk of NTG. Secondary outcome variables included corneal applanation time, length, amplitude, and highest concavity.
Results: Inward applanation velocity was faster in the NTG eyes (0.15 ± 0.02 m/s) than in the control eyes (0.14 ± 0.02 m/s) (P = 0.016). The odds ratio for a 0.01 m/s increase in inward applanation velocity when comparing NTG eyes with control eyes adjusted for age and central corneal thickness was 1.15 (95% confidence interval, 1.03–1.30) (P = 0.016). There was no evidence that outward applanation velocity or any secondary corneal biomechanical variable differed between the NTG and control eyes.
Conclusion: Normal-tension glaucoma eyes demonstrated a small, statistically significant faster corneal inward applanation velocity than normal control eyes.
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.
Early Pars Plana Vitrectomy for Treatment of Acute Infective Endophthalmitis Ho, I-Van; Fernandez-Sanz, Guillermo; Levasseur, Steve; Ting, Eugene; Liew, Gerald; Playfair, Justin; Downie, John; Gorbatov, Mark; Hunyor, Alex P; Chang, Andrew A
Purpose: To evaluate the efficacy and safety of early pars plana vitrectomy (PPV) for the treatment of acute infective endophthalmitis, and identify prognostic factors for better visual outcome.
Design: Retrospective cohort study.
Methods: Consecutive patients who underwent early PPV within 72 hours of presentation for the treatment of acute infective bacterial endophthalmitis and presented to a large tertiary referral center in New South Wales, Australia, between January 2009 and December 2013 were included. Changes in best-corrected visual acuity (VA) from baseline to 1 year were examined.
Results: A total of 64 patients were included. The inciting events were cataract surgery (53%), intravitreal injection (36%), trabeculectomy (3%), and endogenous (3%). The mean VA improved from 3.1 logMAR (hand motion) at baseline to 1.02 (approximately 20/200) at 1 year, with 42% achieving final VA equal to or better than 0.477 logMAR (20/60) following early PPV. Positive prognostic factors were negative microbial cultures (P < 0.01) and etiology of post–cataract surgery (P < 0.01). In multivariable analyses adjusting for age and prognostic factors, patients with baseline VA of light perception and hand motion achieved greater visual gains than those with counting fingers, with gains of logMAR of -2.68, -2.09, and -0.85, respectively (P <
0.0001).
Conclusion: Most patients who undergo early PPV experience substantial VA improvement. Negative microbial cultures and endophthalmitis after cataract surgery were associated with better final visual outcome. Patients with presenting VA of light perception or hand motion achieved higher visual gains than those with counting fingers, suggesting the possibility that early PPV may be beneficial in both groups.
Postoperative Adverse Events, Interventions, and the Utility of Routine Follow-Up After 23-, 25-, and 27-Gauge Pars Plana Vitrectomy Shields, Ryan A.; Ludwig, Cassie A.; Powers, Matthew A.; Tran, Elaine M.T.; Smith, Stephen J.; Moshfeghi, Darius M.
Purpose: To evaluate the utility of standard postoperative visit (POV) intervals in pars plana vitrectomy (PPV) as a function of adverse events (AEs) identified.
Design: Retrospective case review.
Methods: The medical records of all patients undergoing 23-, 25-, and 27-gauge PPV from January 1, 2016 to December 31, 2016 were reviewed. Each POV was assessed as a standard (s-POV), physicianadjusted (a-POV), or patient-initiated visit (p-POV). Preoperative features, diagnoses, and surgical procedures were evaluated to determine
protective and risk factors for AEs.
Results: A total of 256 patients (310 PPVs) were included in this study. The most common cumulative postoperative AEs were elevated intraocular pressure (>30 mm Hg) (12.3%), cystoid macular edema (6.1%), and retinal detachment (5.8%). Patients with the diagnosis of macular hole or epiretinal membrane had the lowest relative risk of AEs [0.30; 95% confidence interval (CI), 0.12−0.75 and 0.36; 95% CI, 0.21−0.63, respectively]. There was no difference in time to AE among different vitrectomy gauge sizes (P = 0.733). Patients in a-POV and p-POV groups had a statistically significant higher incidence of AEs in the POV day 5–10 window (P = 0.004).
Conclusions: The utility of standard POVs in detecting AEs is dependent on the indication for PPV. Specifically patients undergoing isolated macular surgery (epiretinal membrane peel or macular hole repair) had the lowest relative risk of postoperative AEs and may warrant a less-intensive follow-up regimen.
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.
Plaque Radiotherapy for Medulloepithelioma in 6 Cases From a Single Center Ang, Su Mae; Dalvin, Lauren A.; Emrich, Jacqueline; Komarnicky, Lydia; Shields, Jerry A.; Shields, Carol L.
Purpose: To describe outcomes of 6 patients treated with plaque radiotherapy for medulloepithelioma.

Design: Retrospective review.

Methods: Computerized medical records were reviewed for cytopathologically confirmed medulloepithelioma treated with plaque radiotherapy from 1970 to 2017. Clinical and radiotherapy parameters along with outcomes of tumor regression, globe salvage, and metastatic disease were recorded.


Results: Of 6 patients with medulloepithelioma, plaque radiotherapy was primary (n = 5) or secondary (n = 1) treatment. The median patient age at diagnosis was 41 months (mean, 145; range, 10–624 months). Patient demographics included white race (n = 6) and female sex (n = 5). Patients presented with strabismus (n = 1), decreased vision (n = 1), ocular pain (n = 1), hyphema (n = 1), corectopia (n = 1), and visible iris lesion (n = 1). Mean tumor basal diameter was 11.2 mm (median, 10.0; range, 7.0–16.0 mm), and mean tumor thickness was 6.8 mm (median, 6.4; range, 3.1–11.0 mm). Related findings included cataract (n = 4), iris neovascularization (n = 5), secondary glaucoma (n = 2), and ectropion uveae (n = 2). Mean radiation dose to tumor apex was 44 Gy (median, 38; range, 35–70 Gy). At mean follow-up of 59 months, tumor control was achieved in 5 (83%) eyes with globe salvage in 4 (67%) eyes. No patient had evidence of metastases or death at last follow-up visit (mean, 59 months; range, 12–210 months).

Conclusions: Plaque radiotherapy is a reasonable alternative treatment for localized, small to medium-size medulloepithelioma. Tumors larger than 11.0 mm, with retrolental cyclitic membrane or extrascelral extension, might still require enucleation.
Bilateral Implantation of a Single-Piece Bifocal Diffractive Intraocular Lens in Presbyopic Patients: A Prospective Case Series Chang, John S.M.
Purpose: To report visual outcomes and quality after bilateral implantation of a single-piece diffractive multifocal intraocular lens (MIOL) with a bifocal design.Design: Prospective, observational case series.Methods: All presbyopic subjects were implanted with the ZMB00 MIOL (Abbott Medical Optics) at the Hong Kong Sanatorium and Hospital. We evaluated the distance, intermediate, and near visual acuity (VA) under photopic and mesopic conditions; contrast sensitivity with and without glare under photopic and mesopic conditions; quality of vision; and rate of spectacle independence. The current study was conducted in accordance with the Declaration of Helsinki and the ethics committee of our hospital approved the study.Results: Thirty-six subjects were included. No intraoperative complications developed. At the 6-month visit, the mean monocular uncorrected VAs at distance, intermediate, and near were 0.01 ± 0.12 (standard deviation), 0.26 ± 0.17, and 0.09 ± 0.08, respectively. The mean binocular uncorrected VAs were −0.05 ± 0.09, 0.12 ± 0.13, and 0.04 ± 0.06, respectively. No eyes lost any corrected distance VA. The binocular contrast sensitivity was significantly better without glare than with glare under photopic and mesopic conditions (P < 0.05 for all spatial frequencies under both conditions). Twenty-one (58%) and 21 subjects (58%) reported halo and glare, respectively. Thirty subjects (83%) reported complete spectacle independence.Conclusions: Bilateral implantation of the bifocal MIOL in presbyopic patients with or without cataract was safe and resulted in satisfactory vision and a high rate of spectacle independence. Halos and glare were common.
Asia-Pacific Technology and Trend Survey 2016–2017 Chhablani, Jay; Shaikh, Adnan; Goud, Abhilash; Kawasaki, Ryo; Kwon, Oh W.; Chang, Andrew; Lam, Dennis; Das, Taraprasad
Purpose: To report the results of a survey conducted among retina specialists in the Asia-Pacific region on real-life practice patterns in the management of vitreoretinal diseases.
Design: Prospective questionnaire-based study.
Methods: In 2016 and 2017, a link was sent to 1400 retinal specialists across the Asia-Pacific region by e-mail, which directed to a web-based questionnaire (Google forms or Survey Monkey) with secure confidential access. Answers to some of the common questions were compared with the domestic and global trends results of the 2016 American Society of Retina Specialists Preferences and Trends survey.
Results: Of 1400 retinal specialists who received the email broadcast, 539 (38.5%) and 200 (14.3%) completed the survey in 2016 and 2017, respectively. Among those who completed the survey, approximately 85% practiced combined medical and surgical retina. In the management of wet age-related macular degeneration, ranibizumab was the drug of choice (41% of respondents) in 2016, and bevacizumab (48%) in 2017. In the management of polypoidal choroidal vasculopathy, both combination of verteporfin photodynamic therapy and anti–vascular endothelial growth factor (VEGF) (59% of respondents) and intravitreal aflibercept monotherapy (53%) were preferred. Anti-VEGF treatment remained the first choice for center-involving diabetic macular edema (DME) (78% in 2016 and 87% in 2017) and switching to dexamethasone implant in nonresponding DME was preferred after 6 anti-VEGF injections (42% in 2016 and 53% in 2017).
Conclusions: The survey revealed information that may be close to real-world practices in the Asia-Pacific region and could be of help to understand the transformation of global trends and practices due to evolving evidence and technologies.
Anesthesia Considerations in Modified Osteo-Odonto-Keratoprosthesis Raman, Sonali; Singh, Sumeer; Jagdish, V.
Purpose: To elucidate anesthesia-related challenges in patients who underwent modified osteo-odonto-keratoprosthesis (MOOKP).
Design: Retrospective cohort study.
Methods: Medical records of consecutive patients who underwent MOOKP surgery between January 2007 and January 2015 were reviewed. Data including demographic details, systemic comorbidities, indications for MOOKP, and anesthesia techniques at various stages of MOOKP were collected and analyzed.
Results: A total of 74 patients (47 men, 27 women) were included in this study. The mean age of the patients was 29.7 ± 9.1 years. The most common indication for MOOKP was Stevens–Johnson syndrome (53%), followed by chemical burn (38%). In all stages of the MOOKP procedure, 94.6% of patients were American Society of Anesthesiologists (ASA) grade II, whereas 5.4% were ASA grade III. Mallampati score 1 was found in 79.7% of patients in stage 1, 82.4% of patients in stage 1B + 1C, and 81.1% of patients in stage 2. Recovery grade of 10 was noted in all patients at all stages of the MOOKP procedure. Intubation in the second attempt was carried out in 8 patients and oral intubation in stage 1B + 1C was performed in 4 patients. Difficulty in intubation was noted in 3 patients in stage 1A, 4 patients in stage 1B + 1C, and 1 patient in stage 2.
Conclusions: In patients undergoing MOOKP, a good preoperative anesthetic evaluation and intraoperative anesthesia plan before each stage could help in successful administration of anesthesia in these patients.

Review Article

Diagnosis and Management of Cerebral Venous Diseases in Neuro-Ophthalmology: Ongoing Controversies Dinkin, Marc; Patsalides, Athos; Ertel, Monica
Diseases of the cerebral venous system frequently lead to neuro-ophthalmic complications. Cortical venous sinus thrombosis and dural arteriovenous fistulas may be complicated by elevation of intracranial pressure, with secondary papilledema or abducens palsies. There is increasing recognition that stenosis at the transverse sinus–sigmoid sinus junction plays a role in the pathophysiology of idiopathic intracranial hypertension and offers a new avenue of treatment in patients who fail medical therapy. Diseases of the cavernous sinus manifest with their own set of neuro-ophthalmic symptoms, reflecting the presence of all 3 ocular motor nerves and the oculosympathetic fibers within its walls, along with its role as the primary drainage pool of the globe and orbit. Numerous questions and controversies remain regarding the diagnosis and optimal treatment of cerebral venous disease, including the role of venous stenting in idiopathic intracranial hypertension, the role of anticoagulation in cavernous sinus thrombosis, and the risks and benefits of embolization of mild indirect cavernous carotid fistulas.
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.
The History of Exfoliation Syndrome Grzybowski, Andrzej; Kanclerz, Piotr; Ritch, Robert
The first description of exfoliation syndrome (XFS) was presented by John Gustaf Lindberg in his doctoral thesis 100 years ago. The syndrome is an age-related disorder in which abnormal fibrillar extracellular material is produced and accumulates in several ocular tissues. Once thought to be peculiar to Scandinavia, XFS is found in almost every race and ethnic group. Subsequent studies provided evidence for the systemic nature of XFS, which involves an aberrant connective tissue metabolism throughout the body. There is a prominent association with zonular instability. This study presents the developments in the understanding of the pathomechanism and clinical significance of XFS and explains the problem of terminology in the description of XFS and pseudoexfoliation.
Neurofibromatosis Type 1: Review and Update on Emerging Therapies Karaconji, Tanya; Whist, Eline; Jamieson, Robyn V.; Flaherty, Maree P.; Grigg, John R.B.
Neurofibromatosis type 1 (NF1) is an autosomal dominant neurocutaneous disorder affecting 1:3000 births. This familial tumor predisposition syndrome is diagnosed clinically and affects the skin, bones, and nervous system. Malignant tumors can arise in childhood or adulthood and are the commonest cause of mortality in this population. Early diagnosis and management led by a multidisciplinary team remains the standard of care, particularly in the management of optic pathway glioma. Emerging concepts in the genetic patterns of this condition have led to the introduction of new treatment modalities that target the mitogen activated protein kinase (MAPK) and the mammalian target of rapamycin (mTOR) pathways. The role of the ophthalmologist and approach to screening for optic pathway glioma is outlined based on previous recommendations. Updates on choroidal involvement, as a diagnostic criterion, will also be discussed, further highlighting the pivotal role of the ophthalmologist in the diagnosis and management of this complex condition.
Persistent Fetal Vasculature Chen, Chonglin; Xiao, Hu; Ding, Xiaoyan
During development, the fetal vasculature nourishes the developing lens and retina, subsequently regressing after the formation of the retinal vessels. Persistent fetal vasculature (PFV) occurs as a result of a failure of fetal ocular vasculature to undergo normal programmed involution, which leads to blindness or serious loss of vision. Persistent fetal vasculature is responsible for as much as 5% of childhood blindness in Western countries. The regulatory mechanisms responsible for fetal vascular regress remain obscure, as do the underlying causes of the failure of regression. Because of recent advancements in microinvasive surgical techniques, the early treatment of PFV has become safer and more effective, thus paving the way for the development of a future new treatment strategy. In this review, clinical and imaging manifestations of PFV and the progress in the treatment of PFV are highlighted.
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