Search

Purpose: To determine the association of single nucleotide polymorphisms (SNPs) of the thrombospondin 1 (THBS1) gene with development of chronic ocular surface inflammation (keratoconjunctivitis) after refractive surgery., Design: Retrospective cohort study., Participants: Active duty U.S. Army soldiers (n = 143) who opted for refractive surgery., Methods: Conjunctival impression cytology samples collected from participants before the surgery were used to harvest DNA for genotyping 5 THBS1 SNPs (rs1478604, rs2228262, rs2292305, rs2228262, and rs3743125) using the Sequenom iPLEX Gold platform (Sequenom, San Diego, CA). Samples collected after surgery were used to harvest RNA for gene expression analysis by real-time polymerase chain reaction (PCR). Participants were followed for 1 year after surgery to monitor the status of keratoconjunctivitis., Main Outcome Measures: Genetic basis of the development of chronic keratoconjunctivitis after refractive surgery., Results: Carriers of minor alleles of 3 SNPs each were found to be more susceptible to developing chronic keratoconjunctivitis (rs1478604: odds ratio [OR], 2.5; 95% confidence interval [CI], 1.41-4.47; P = 2.5 × 10(-3); rs2228262 and rs2292305: OR, 1.9; 95% CI, 1.05-3.51; P = 4.8 × 10(-2)). Carriers of the rs1478604 minor allele expressed significantly reduced levels of thrombospondin 1 (TSP1) (P = 0.042) and increased levels of an inflammatory cytokine associated with keratoconjunctivitis, interleukin-1β (P = 0.025), in their ocular surface epithelial cells compared with homozygous major allele controls., Conclusions: Genetic variation in the THBS1 gene that results in decreased expression of the encoded glycoprotein TSP1 in ocular surface epithelial cells significantly increases the susceptibility to develop chronic ocular surface inflammation after refractive surgery. Further investigation of THBS1 SNPs in a larger sample size is warranted., (Copyright © 2014 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Objective: To report the visual and anatomic outcomes as well as to predict the visual prognosis of combat ocular trauma (COT) during Operations Iraqi and Enduring Freedom., Design: Retrospective, noncomparative, interventional, consecutive case series., Participants: Five hundred twenty-three consecutive globe or adnexal combat injuries, or both, sustained by 387 United States soldiers treated at Walter Reed Army Medical Center between March 2003 and October 2006., Methods: Two hundred one ocular trauma variables were collected on each injured soldier. Best-corrected visual acuity (BCVA) was categorized using the ocular trauma score (OTS) grading system and was analyzed by comparing initial and 6-month postinjury BCVA., Main Outcome Measures: Best-corrected visual acuity, OTS, and globe, oculoplastic, neuro-ophthalmic, and associated nonocular injuries., Results: The median age was 25+/-7 years (range, 18-57 years), with the median baseline OTS of 70+/-25 (range, 12-100). The types of COT included closed-globe (n = 234; zone 1+2, n = 103; zone 3, n = 131), open-globe (n = 198; intraocular foreign body, n = 86; perforating, n = 61; penetrating, n = 32; and rupture, n = 19), oculoplastic (n = 324), and neuro-ophthalmic (n = 135) injuries. Globe trauma was present in 432 eyes, with 253 eyes used for visual acuity analysis. Comparing initial versus 6-month BCVA, 42% of eyes achieved a BCVA of 20/40 or better, whereas 32% of eyes had a BCVA of no light perception. Closed-globe injuries accounted for 65% of BCVA of 20/40 or better, whereas 75% of open-globe injuries had a BCVA of 20/200 or worse. The ocular injuries with the worst visual outcomes included choroidal hemorrhage, globe perforation or rupture, retinal detachment, submacular hemorrhage, and traumatic optic neuropathy. Additionally, COT that combined globe injury with oculoplastic or neuro-ophthalmologic injury resulted in the highest risk of final BCVA worse than 20/200 (odds ratio, 11.8; 95% confidence interval, 4.0-34.7; P<0.0005). Nonocular injuries occurred in 85% of cases and included traumatic brain injury (66%) and facial injury (58%). Extremity injuries were 44% (170 of 387 soldiers). Amputation is a subset of extremity injury with 12% (46 of 387) having sustained a severe extremity injury causing amputation., Conclusions: Combat ocular trauma has high rates of nonocular injuries with better visual outcomes in closed-globe compared with open-globe trauma. The OTS is a valid classification scheme for COT and correlates the severity of injury with the final visual acuity and prognosis. Globe combined with oculoplastic or neuroophthalmologic injuries have the worst visual prognosis., Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Objective: To report the injury patterns associated with perforating (through-and-through) injuries of the globe and the visual impact of these injuries on patients with combat ocular trauma (COT) seen at Walter Reed Army Medical Center (WRAMC) from March 2003 through October 2006., Design: Retrospective, noncomparative, interventional case series., Participants: Sixty-five eyes of 61 United States military soldiers deployed during Operation Iraqi Freedom sustaining perforating globe injuries and treated subsequently at WRAMC., Intervention: Principal procedures included enucleation and 20-gauge 3-port pars plana vitrectomy with or without intraocular foreign body removal., Main Outcome Measures: Final visual acuity and rates of proliferative vitreoretinopathy, enucleation, and endophthalmitis., Results: Average patient age was 29 years, with an average of 200 days of postinjury follow-up (median, 97 days; range, 4-1023 days). Nineteen patients confirmed the use of eye protection at the time of injury, whereas 25 patients did not use eye protection. The median presenting visual acuity at WRAMC was no light perception (range, no light perception to hand movements). Twenty-five patients underwent primary enucleation, 1 was eviscerated, and 12 patients underwent secondary enucleation within 2 weeks of surgery. Of 19 patients undergoing pars plana vitrectomy, median visual acuity at presentation was light perception and the median final visual acuity was counting fingers, whereas 4 eyes (21%) achieved final visual acuity of better than 20/200, and in 11 (61%) of 17, proliferative vitreoretinopathy developed over a follow-up of at least 6 months. There were no cases of endophthalmitis or sympathetic ophthalmia. Neither mechanism of injury nor timing of surgery correlated with favorable outcomes. However, entry and exit wounds localized to the anterior half of the globe were associated with favorable anatomic outcome (P<0.005, Fisher exact test, 2-tailed) and visual outcome (P = 0.041, Fisher exact test, 2-tailed)., Conclusions: Perforating globe injuries associated with COT generally result in poor visual and anatomic outcomes despite surgical intervention. Prophylactic measures, such as eye protection, are helpful in reducing the likelihood of perforating injuries; however, novel surgical and pharmacologic therapies will be required to improve the functional and anatomic outcomes of these devastating injuries.

Objective: To report the long-term follow-up results of intraocular foreign body (IOFB) removal at Walter Reed Army Medical Center during Operation Iraqi Freedom and Operation Enduring Freedom from February 2003 through November 2005 and to determine the prognostic factors for visual outcome in this patient population., Design: Retrospective, noncomparative, interventional case series., Participants: Seventy-nine eyes of 70 United States military soldiers deployed in support of operations Iraqi Freedom and Enduring Freedom sustained IOFB injuries and subsequently were treated at the Walter Reed Army Medical Center with a minimum of 6 months of follow-up., Intervention: The principal procedure performed was 20-gauge 3-port vitrectomy with IOFB removal through limbal or pars plana incision., Main Outcome Measures: Final visual acuity, rate of proliferative vitreoretinopathy, rate of endophthalmitis., Results: Average patient age was 27 years, with an average of 331 days of postoperative follow-up. Average IOFB size was 3.7 mm (range, 0.1-20 mm). Median time to IOFB removal was 21 days (mean, 38 days; range, 2-661 days). Mean preoperative visual acuity was 20/400 (1.36 logarithm of mean angle of resolution [logMAR] units) and mean final visual acuity was 20/120 (0.75 logMAR). Of the patients, 53.4% achieved visual acuity of 20/40 or better, whereas 77.5% achieved visual acuity of better than 20/200. There were no cases of endophthalmitis (0/79 eyes; 95% confidence interval, 0%-3.1%), siderosis bulbi, or sympathetic ophthalmia. Among the eyes, 10.3% evolved to no light perception or had been enucleated by the 6-month follow-up visit. Poor visual outcome correlated with extensive intraocular injury (P<0.032). Seventeen of 79 eyes (21%) experienced proliferative vitreoretinopathy. Proliferative vitreoretinopathy correlated with poor initial vision (hand movements or worse; P = 0.035) and extensive intraocular injury (P<0.001). Timing of vitrectomy did not correlate with visual outcome. The most common systemic antibiotic administered was levofloxacin, whereas the most common topical antibiotic administered was moxifloxacin., Conclusions: Poor visual outcome and postoperative complication rates are related to extensive intraocular injury. Delayed IOFB removal with a combination of systemic and topical antibiotic coverage can result in good visual outcome without an apparent increased risk of endophthalmitis or other deleterious side effects.

Purpose: To review the incidence, culture results, clinical course, management, and visual outcomes of infectious keratitis after photorefractive keratectomy (PRK) at 6 Army and Navy refractive surgery centers., Design: Retrospective study., Participants: Twelve thousand six hundred sixty-eight Navy and Army sailors and service members., Methods: Army and Navy refractive surgery data banks were searched for cases of infectious keratitis. A retrospective chart review and query of the surgeons involved in the care of those patients thus identified provided data regarding preoperative preparation, perioperative medications, treatment, culture results, clinical course, and final visual acuity., Results: Between January 1995 and May 2004, we performed a total of 25337 PRK procedures at the 6 institutions. Culture proven or clinically suspected infectious keratitis developed in 5 eyes of 5 patients. All patients received topical antibiotics perioperatively. All cases presented 2 to 7 days postoperatively. Cultures from 4 cases grew Staphylococcus, including 2 methicillin-resistant S. aureus (MRSA). One case of presumed infectious keratitis was culture negative. There were no reported cases of mycobacterial or fungal keratitis. In addition, we identified 26 eyes with corneal infiltrates in the first postoperative week that were felt to be sterile, and which resolved upon removal of the bandage contact lens and increasing antibiotic coverage., Conclusions: Infectious keratitis is a rare but potentially vision-threatening complication after PRK. It is often caused by gram-positive organisms, including MRSA. Early diagnosis, appropriate laboratory testing, and aggressive antimicrobial therapy can result in good outcomes.

Purpose: To examine the history, current status, outcomes, and future direction of the Army Warfighter Refractive Eye Surgery Program (WRESP), which was established to reduce the limitations posed by corrective eyewear in combat arms soldiers., Design: Retrospective study., Participants: Sixteen thousand one hundred eleven Army service members who underwent refractive surgery between May 2000 and September 2003., Methods: Results were collected from monthly WRESP reports and from questionnaires administered to refractive surgery patients returning from deployments to southwest Asia. Soldiers rated the impact of refractive surgery on their ability to perform select operational tasks as well as their overall readiness., Main Outcome Measures: Visual acuity (VA) and patient satisfaction., Results: Between May 2000 and September 30, 2003, 32 068 eyes of 16 111 soldiers were treated. Postoperative uncorrected VA was better than or equal to 20/20 in 85.6%, 20/25 in 92.4%, and 20/40 in 98.2% of eyes with at least 3 months' follow-up, and 93.7% of 175 surveyed patients rated their overall readiness better or much better after surgery., Conclusions: This program has provided excellent outcomes and enhanced the overall readiness of over 16 000 Army service members. Reports of night vision difficulties, LASIK flap dislocation, and dry eye are infrequent, and do not seem to have a significant negative impact on military operations or individual readiness. This article contains additional online-only material available at http://www.ophsource.com/periodicals/ophtha.

Objective: The purpose of this case series was to present an overview of the nature and frequency of ocular complications in the Department of Defense (DoD) Smallpox Vaccination Program., Design: Retrospective, noncomparative case series., Participants: The authors retrospectively evaluated data collected on individuals with an ophthalmologic complaint after receiving smallpox vaccination or after contact with a recently immunized individual. The vaccinee and contact cases occurred secondary to inoculations given between December 13, 2002 and May 28, 2003 as part of the DoD Smallpox Vaccination Program., Methods: Data were collected primarily from reports to military headquarters or to the Vaccine Adverse Event Reporting System and individual medical records., Main Outcome Measures: The incidence, types, and timing of ocular complications were evaluated. Diagnostic and treatment considerations also were reviewed., Results: Between December 13, 2002 and May 28, 2003, 450,293 smallpox vaccinations were given. We identified 16 confirmed or probable cases of ocular vaccinia, with an incidence of 3.6 per 100,000 inoculations. Of these cases, 12 (75%) were seen in the vaccinees, and 4 (25%) in close contacts. Of the 12 self-inoculation cases, 7 (58.3%) were seen in individuals receiving the vaccine for the first time (primary vaccination), and 3 (25.0%) were seen in individuals previously vaccinated (revaccination); the vaccination status in 2 cases was unknown. Clinical manifestations included lid pustules, blepharitis, periorbital cellulitis, conjunctivitis, conjunctival ulcers, conjunctival membranes, limbal pustules, corneal infiltrates, and iritis, with onset of symptoms 3 to 24 days after inoculation or contact. Five of 9 tested cases were culture or polymerase chain reaction positive for vaccinia. Treatment for most cases was topical trifluridine 1% (Viroptic; King Pharmaceuticals, Inc., Bristol, TN). Vaccinia immune globulin was used in 1 case. In all patients, recovery occurred without significant visual sequelae., Conclusions: When compared with historical data on the ocular complications of smallpox vaccination, the incidence of ocular complications during the DoD Smallpox Vaccination program has been low. In addition, the severity of disease seems to be less than during other vaccination periods. These findings perhaps are the result of improved screening of vaccinees, prevaccination counseling, postvaccination wound care, and the suggested efficacy of trifluridine in the treatment of ocular vaccinia.

Objective: To evaluate visual performance and resolution through night vision goggles (NVG) before and after photorefractive keratectomy (PRK)., Design: Nonrandomized, comparative (self-controlled) trial., Participants: Nineteen patients (38 eyes) of active-duty US Army Special Forces soldiers., Intervention: PRK for myopia and astigmatism., Main Outcome Measures: Visual acuity with best optical correction was measured preoperatively and postoperatively (3 months) using acuity charts of various contrast (100%, 10%, 2.5%, 1.25%). Preoperative and postoperative (3 month) uncorrected and best-corrected visual resolutions through NVGs were assessed using a high contrast tribar chart presented at four light levels (3.44 x 10(-3), 1.08 x 10(-3), 1.04 x 10(-4), 1.09 x 10(-5) foot Lamberts) simulating a range of night sky conditions. Subjects were trained before testing., Results: Uncorrected visual acuity at the 3-month postoperative assessment was greater than or equal to 20/20 in 33 of 38 (86.8%) eyes. No eyes lost 2 or more lines of best spectacle-corrected visual acuity. Preoperative and 3-month postoperative best-corrected low-contrast acuity measurements showed no significant differences at all levels of resolution. Preoperative visual resolution through NVGs decreased systematically with decreasing night sky condition. Visual acuities before PRK were reduced without optical correction. Postoperative visual performance with NVGs (without optical correction) equaled or exceeded performance preoperatively with best correction., Conclusions: This prospective case series provides data on the safety and efficacy of PRK with respect to visual performance under night sky conditions using NVGs. There was no significant loss of visual acuity across a range of contrast levels 3 months postoperatively. There was no change in best-corrected NVG visual resolution postoperatively, whereas uncorrected visual resolution was significantly enhanced compared with preoperative levels. This improvement may translate into better function for soldiers who are unable to or choose not to use optical correction in operational environments.