Search

We report a unique case of acute retinal necrosis with early macular involvement. Multimodal imaging demonstrated hyperreflectivity of both the inner and outer retina on optical coherence tomography and a choriocapillaris flow void on optical coherence tomography angiography. Purpose: To report an unusual case of early macular necrosis in acute retinal necrosis and its features on multimodal imaging. Methods: Findings on fundus examination, laboratory workup, fluorescein angiography, autofluorescence, optical coherence tomography, and optical coherence tomography angiography. Results: A 31-year-old healthy woman presented with 1 week of photophobia and central scotoma of the right eye. Initial examination revealed vitritis, hyperemia of the optic disc, and a yellow-white macular lesion without any peripheral findings. Peripheral involvement was first noted only 4 days later. The patient was diagnosed with acute retinal necrosis secondary to varicella zoster virus and was successfully treated with intravitreal and oral antiviral medications. Optical coherence tomography imaging of the macular lesion showed involvement of both the inner and outer retina. Optical coherence tomography angiography revealed a large flow void in the choriocapillaris, which has not been previously demonstrated. Conclusion: Multimodal imaging offers valuable information in the evaluation of patients with acute retinal necrosis. [ABSTRACT FROM AUTHOR]

Purpose: To use optical modeling to compare a 6.0 mm and 7.0 mm intraocular lens (IOL) optic diameters on peripheral retinal illumination with implications for negative dysphotopsia. Setting: Mayo Clinic, Rochester, Minnesota, and Simpson Optics LLC, Arlington, Texas. Design: Model eye. Methods: Ray-tracing software was used to simulate retinal illumination from an extended light source for a pseudophakic eye with in-the-bag biconvex IOLs (refractive index [n] = 1.46 and 1.55) and a 2.5 mm pupil. Ray-tracing diagrams and simulated retina illumination profiles were compared using the 6.0 mm and 7.0 mm optic diameter IOLs. Retinal locations were scaled to relative visual angles from 70 to 110 degrees horizontally. Results: A 7.0 mm optic (n = 1.46) expands the image field by 2.8 degrees compared with a 6.0 mm optic. High-angle input light misses a 7.0 mmoptic at a larger visual angle than a 6.0 mm optic, shifting illumination of the peripheral retina by this light anteriorly by 5.6 degrees. Consequently, a region of nonilluminated peripheral nasal retina is enlarged and shifted peripherally using a 7.0 mm optic (visual angle, 86.3 to 96.3 degrees) compared with a 6.0 mm optic (visual angle, 83.5 to 90.7 degrees). Similar illumination changes were seen modeling a 1.55 n IOL. Conclusions: A narrow dark region in the nasal retina when using a 6.0 mm optic is changed to a broader, more peripheral dark region when using a 7.0 mm optic. An extended, more peripheral dark nasal region may make a temporal shadow less bothersome and explain lower negative dysphotopsia rates using a 7.0 mm optic. [ABSTRACT FROM AUTHOR]

Overactivity of the sympathetic nervous system and high blood pressure are implicated in the development and progression of chronic kidney disease (CKD) and independently predict cardiovascular events in end-stage renal disease. To assess the role of renal nerves, we determined whether renal denervation (RDN) altered the hypertension and sympathoexcitation associated with a rabbit model of CKD. The model involves glomerular layer lesioning and uninephrectomy, resulting in renal function reduced by one-third and diuresis. After 3-week CKD, blood pressure was 13±2 mm Hg higher than at baseline (P<0.001), and compared with sham control rabbits, renal sympathetic nerve activity was 1.2±0.5 normalized units greater (P=0.01). The depressor response to ganglion blockade was also +8.0±3 mm Hg greater, but total norepinephrine spillover was 8.7±3.7 ng/min lower (both P<0.05). RDN CKD rabbits only increased blood pressure by 8.0±1.5 mm Hg. Renal sympathetic activity, the response to ganglion blockade and diuresis were similar to sham denervated rabbits (non-CKD). CKD rabbits had intact renal sympathetic baroreflex gain and range, as well as normal sympathetic responses to airjet stress. However, hypoxia-induced sympathoexcitation was reduced by -9±0.4 normalized units. RDN did not alter the sympathetic response to hypoxia or airjet stress. CKD increased oxidative stress markers Nox5 and MCP-1 (monocyte chemoattractant protein-1) in the kidney, but RDN had no effect on these measures. Thus, RDN is an effective treatment for hypertension in this model of CKD without further impairing renal function or altering the normal sympathetic reflex responses to various environmental stimuli. [ABSTRACT FROM AUTHOR]

Hypertension is a risk factor for the vascular permeability and neovascularization that threatens vision in diabetic retinopathy. Excess reactive oxygen species derived from the Nox (NADPH oxidase) isoforms, Nox1 and Nox4, contributes to vasculopathy in diabetic retinopathy; however, if Nox1/4 inhibition is beneficial in hypertensive diabetic retinopathy is unknown. Here, we determined that diabetic spontaneously hypertensive rats had exacerbated retinal vascular permeability and expression of angiogenic and inflammatory factors, compared with normotensive diabetic Wistar Kyoto rats. GKT136901, a specific dual inhibitor of Nox1 and Nox4, prevented these events in diabetic Wistar Kyoto rats and spontaneously hypertensive rats. Retinal neovascularization does not develop in diabetic rodents, and therefore, the oxygen-induced retinopathy model is used to evaluate this pathology. We previously demonstrated that Nox1/4 inhibition reduced retinal neovascularization in oxygen-induced retinopathy. However, although Nox5 is expressed in human retina, its contribution to retinopathy has not been studied in vivo, largely due to its absence from the rodent genome. We generated transgenic mice with inducible human Nox5 expressed in endothelial cells (vascular endothelial-cadherin+Nox5+ mice). In vascular endothelial-cadherin+Nox5+ mice with oxygen-induced retinopathy, retinal vascular permeability and neovascularization, as well as the expression of angiogenic and inflammatory factors, were increased compared with wild-type littermates. In bovine retinal endothelial cells, which express Nox1, Nox4, and Nox5, Nox1/4 inhibition, as well as Nox5 silencing RNA, reduced the high glucose-induced upregulation of oxidative stress, angiogenic, and inflammatory factors. Collectively, these data indicate the potential of Nox1, Nox4, and Nox5 inhibition to reduce vision-threatening damage to the retinal vasculature. [ABSTRACT FROM AUTHOR]

Use optical modeling to evaluate the effect of the intraocular lens (IOL) optic–haptic junction on retinal illumination and negative dysphotopsia. Mayo Clinic, Rochester, Minnesota, USA. Schematic model eye. Ray-tracing software for an extended light source was used to simulate retina illumination in a pseudophakic eye with a biconvex high-index acrylic IOL and a 2.5 mm pupil. The haptic junction was modeled using an annular cone of haptic material of 0.75 mm width located between the optic and haptic. Ray-tracing diagrams and simulated retina illumination profiles were compared with and without the haptic junction. Retinal locations were scaled to visual angles from 70 to 110 degrees horizontally. Light incident on the peripheral optic creates a nonuniform retina illumination pattern consisting of a 5-degree band of nonilluminated retina bounded posteriorly by light refracted by the optic and anteriorly by light that missed the optic. Light incident on the haptic junction illuminates retina differently in that light that typically misses the optic (input angle 79 to 91 degrees) is instead refracted at a large angle or internally reflected by the haptic junction, which removes the illuminated peripheral retina that would otherwise delineate the shadow region. Further modification to the haptic junction region improved peripheral retina illumination and shifted the shadow region 10 degrees anteriorly. The haptic junction illuminated the peripheral retina differently than the peripheral optic, and this might explain why a horizontal haptic junction minimizes negative dysphotopsia. A modification to the optic–haptic junction redirected illumination and shifted the retina shadow anteriorly, possibly decreasing awareness. [ABSTRACT FROM AUTHOR]

To use ray-tracing analysis and simulated retinal illumination profiles to design an intraocular lens (IOL) that prevents or reduces negative dysphotopsia after cataract surgery. Mayo Clinic, Rochester, Minnesota, and Simpson Optics LLC, Arlington, Texas, USA. Experimental study. Ray-tracing software was used to simulate peripheral retina illumination from an extended light source for a pseudophakic eye with a biconvex high refractive index IOL. Ray intensities were adjusted to include the effects of the surface reflections and the energy reduction caused by pupil obliquity at high incident angles. The results were compared with similar optical modeling of a modified IOL design with a concave region on the peripheral posterior surface. For a standard biconvex high refractive index IOL, simulated retina illumination profiles showed an area of nonilluminated peripheral nasal retina at a relative visual angle of approximately 85 degrees to 93 degrees. Using a modified IOL optic with a peripheral concave posterior surface, ray-tracing diagrams showed that peripheral input rays were redirected anteriorly into the nonilluminated dark area of the peripheral retina. Simulated retina illumination images confirmed that the redirected input rays improved illumination to the peripheral retina, including the dark area. Optical modeling showed that the new IOL design provides more uniform illumination of the peripheral nasal retina and specifically illuminates the dark region of the nasal retina associated with negative dysphotopsia. This modified IOL design could prevent or reduce negative dysphotopsia after cataract surgery. [ABSTRACT FROM AUTHOR]

Purpose To use optical modeling to demonstrate how a sulcus-fixated piggyback intraocular lens (IOL) affects negative dysphotopsia. Setting Mayo Clinic, Rochester, Minnesota, USA. Design Retrospective case series. Methods Optical modeling was performed on 3 patients with negative dysphotopsia who were treated with a sulcus-fixated piggyback IOL. Ray-tracing software was used to simulate peripheral retina illumination preoperatively and postoperatively. Biometric data and ultrasound biomicroscopy images were used to construct eye models. Ray intensities were adjusted for surface reflections and normalized by cosine function to compensate for pupil obliquity at high incident angles. Results Preoperatively, retinal illumination profiles showed a region of dim or nonilluminated peripheral nasal retina at visual angles of approximately 83 to 95 degrees. A piggyback IOL shifted the iris anteriorly (mean 0.41 mm; range 0.37 to 0.47 mm) and the primary IOL posteriorly (mean 0.10 mm; range 0.05 to 0.19 mm) and increased the mean distance between the iris and primary IOL from 0.46 mm preoperatively to 0.75 mm postoperatively. This increased distance allowed input rays to begin missing the primary IOL at lower incident angles (≥76 degrees) compared with preoperatively (≥84 degrees), resulting in increased illumination of the peripheral retina. Illumination of the peripheral retina, including the preoperative dark area, was increased in 2 patients. The negative dysphotopsia shadow resolved in 2 eyes and was unchanged in 1 eye. Conclusions In negative dysphotopsia patients, a secondary piggyback IOL allowed additional light to miss the primary IOL and illuminate larger areas of peripheral retina. Increased illumination of the peripheral retina that included the preoperative dark region was associated with improved negative dysphotopsia postoperatively. [ABSTRACT FROM AUTHOR]

BACKGROUND: Hyperbaric oxygen therapy (HBOT) markedly increases tissue oxygen delivery. Case series suggest it may have a potential therapeutic benefit in ulcerative colitis (UC). We investigated the therapeutic potential of HBOT as an adjunct to steroids for UC flares requiring hospitalization.METHODS: The study was terminated early due to poor recruitment with 18 of the planned 70 patients enrolled. UC patients hospitalized for moderate-severe flares (Mayo score ≥6, endoscopic sub-score ≥2) were block randomized to steroids + daily HBOT (n = 10) or steroids + daily sham hyperbaric air (n = 8). Patients were blinded to study assignment, and assessments were performed by a blinded gastroenterologist. Primary outcome was the clinical remission rate at study day 5 (partial Mayo score ≤2 with no sub-score >1). Key secondary outcomes were: clinical response (reduction in partial Mayo score ≥2, rectal bleeding sub-score of 0-1) and progression to second-line therapy (colectomy or biologic therapy) during the hospitalization.RESULTS: A significantly higher proportion of HBOT-treated patients achieved clinical remission at study day 5 and 10 (50 vs. 0%, p = 0.04). HBOT-treated patients less often required progression to second-line therapy during the hospitalization (10 vs. 63%, p = 0.04). The proportion requiring in-hospital colectomy specifically as second-line therapy for medically refractory UC was lower in the HBOT group compared to sham (0 vs. 38%, p = 0.07). There were no serious adverse events.CONCLUSION: In this small, proof-of-concept, phase 2A trial, the use of HBOT as an adjunctive therapy to steroids for UC patients hospitalized for moderate-severe flares resulted in higher rates of clinical remission, and a reduction in rates of progression to second-line therapy during the hospitalization. Larger well-powered trials are needed, however, to provided definitive evidence of therapeutic benefit. [ABSTRACT FROM AUTHOR]

A 17-year-old girl presented with unilateral retrobulbar optic neuritis as well as bilateral funduscopic findings and outer retinal dysfunction suggestive of acute zonal occult outer retinopathy (AZOOR). Fundus autofluorescence abnormalities, visual field loss, and electroretinographic changes were supportive of bilateral AZOOR. MRI was consistent with the diagnosis of clinically isolated syndrome (CIS), which is defined as a central nervous system demyelinating event that may herald the onset of multiple sclerosis (MS). While AZOOR previously has been linked to MS and demyelinating white matter lesions in the brain, our case seems unique due to concurrent development of AZOOR and retrobulbar optic neuritis as a CIS. [ABSTRACT FROM AUTHOR]

Purpose: To compare a binocular free-viewing autorefractor pupillometer (WAM 5500 Binocular Accommodation Instrument) and a monocular occlusion pupillometer (Neuroptics pupillometer). Setting: Department of Ophthalmology and Visual Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA. Design: Evaluation of diagnostic test or technology. Methods: Normal subjects were tested under 1 lux and 7 lux ambient illumination with controlled distance fixation. The monocular occlusion pupillometer and free-viewing autorefractor pupillometer test order and eye test order were randomized. Devices were compared using Bland-Altman plots. Effects of eye test order and device test order were analyzed. The number of outliers (ie, difference ≥0.5 mm between devices) was tabulated. Results: The mean device difference (monocular pupillometer minus binocular pupillometer) was +0.51 mm ± 0.36 (SD) (range −0.20 to +1.50 mm) in right eyes and +0.27 ± 0.31 mm (SD) (range −0.30 to +1.00 mm) in left eyes at 1 lux and +0.26 ± 0.28 mm (range −0.30 to +0.90 mm) and +0.21 ± 0.24 mm (range −0.80 to +0.40 mm), respectively, at 7 lux. The outlier frequency (N = 49) at 1 lux was 23 (47%) in right eyes and 7 (14%) in left eyes and at 7 lux, 11 (22%) and 10 (20%), respectively. At all age decades, the free-viewing autorefractor underestimated dark-adapted pupil diameter. Eye test order and device order did not cause unidirectional bias. Conclusions: The free-viewing pupillometer frequently disagreed with the monocular occlusion pupillometer by more than 0.5 mm. Testing the first eye with the monocular pupillometer did not induce sustained pupillary constriction that might bias results in the second eye. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. [ABSTRACT FROM AUTHOR]

Purpose: To compare the performance of the Marco Nidek ARK-530A autorefractor pupillometer function and the Keeler PupilScan II pupillometer (study pupillometer) against the clinical standard NeurOptics PLR-200 pupillometer (standard pupillometer) for measurement of the dark-adapted pupil diameter. Setting: Department of Ophthalmology and Visual Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA. Design: Evaluation of diagnostic test or technology. Methods: Subjects aged 20 to 60 years were dark-adapted for 2 minutes at 1 lux ambient illumination. Accommodation was controlled through distance fixation. The dark-adapted pupil diameter was measured with the standard pupillometer, then the study pupillometer, then the autorefractor. Results were compared using Bland-Altman graphs. Results: The autorefractor underestimated the dark-adapted pupil diameter by a mean of 1.03 mm (range 0.0 to 2.3 mm). Thirty-four (85%) measurements were at least 0.5 mm smaller than the corresponding standard pupillometer values, and 16 (40%) were more than 1.0 mm smaller. Observer experience did not improve accuracy. The study pupillometer underestimated the dark-adapted pupil diameter by a mean of 0.31 mm (range 0.0 to 0.9 mm). Ten (25%) measurements were at least 0.5 mm smaller than the standard pupillometer values. Accuracy improved in the final 10 subjects (study pupillometer smaller; mean difference 0.16 mm; range 0.0 to 0.4 mm). Conclusions: The autorefractor pupillometry function had an unpredictable negative bias (variable underestimation of dark-adapted pupil diameter). The study pupillometer had a slight negative bias but required significant examiner skill and knowledge of normal pupil movement to obtain a valid result. Neither device was sufficiently accurate for confident surgical planning or clinical diagnosis. Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned. [ABSTRACT FROM AUTHOR]

Purpose: To analyze intraocular lens (IOL) surface abnormalities seen after folding using a forceps insertion technique. Setting: Mayo Clinic, Rochester, Minnesota, USA. Methods: Acrylic AcrySof MA60AC IOLs were examined using an Axio Imager microscope before and after they were folded using a forceps insertion technique. Differential interference contrast, brightfield reflected light, and darkfield reflected light imaging techniques were used as necessary. The effects of temperature, time, and ophthalmic viscosurgical device (OVD) on optic surface abnormalities after folding were studied. Results: All 17 IOLs examined had smooth, defect-free optic surfaces before folding. After folding, anterior optic surface depressions were observed in all IOLs; the depressions corresponded to the contact area of the titanium insertion forceps. Surface depressions were present up to 72 hours after folding, were more pronounced when an insertion forceps with a high degree of wear was used, and were greater when the IOL was warmed to 98°F before folding. Coating the IOL surface with OVD before grasping it with the insertion forceps prevented formation of depressions. Conclusions: The anterior optic surface of the acrylic IOL was vulnerable to forceps-induced surface depressions. Surface abnormalities were prevented by coating the anterior optic surface with OVD before grasping it with a metal insertion forceps. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. [Copyright &y& Elsevier]

Purpose: To compare the accuracy of a handheld infrared digital pupillometer and digital infrared photography for measurement of the dark-adapted pupil diameter. Setting: Department of Ophthalmology and Visual Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA. Methods: The right horizontal pupil diameter in healthy volunteers was measured using a NeurOptics PLR-200 pupillometer and then videographed using the infrared function of a CyberShot video camera after 2 minutes and 5 minutes dark adaptation at 1 lux ambient illumination. The best still image was extracted from the video file, and the horizontal pupil diameter was determined by comparison against an internal photographic length standard using digital image software. Accommodation and alertness were controlled during testing. Results: The mean horizontal pupil diameter by infrared photography after 2 minutes of dark adaptation by subject age was 7.71 mm for ages 20 to 29 years, 6.80 mm for ages 30 to 39 years, 6.53 mm for ages 40 to 49 years, 5.94 mm for ages 50 to 59 years, and 6.01 mm for ages 60 to 69 years. The mean difference (infrared photography minus pupillometer) was +0.09 mm (range +0.30 to −0.14 mm) at 2 minutes of adaptation and +0.07 mm (range +0.25 to −0.13 mm) at 5 minutes. Conclusions: The pupillometer accurately measured the horizontal pupil diameter at 1 lux, with no measurement more than 0.3 mm different from infrared photography measurements. The pupillometer had a slight negative bias that is unlikely to introduce an error greater than 0.5 mm in clinical measurements. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. [Copyright &y& Elsevier]

Purpose: To estimate sex- and age-specific incidence rates of cataract surgery in a defined United States population and evaluate the change in incidence over time. Setting: Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA. Methods: Rochester Epidemiology Project databases were used to identify all incident cataract surgeries in Olmsted County, Minnesota, residents during the 25-year period from January 1, 1980, through December 31, 2004. Annual incidence rates for each sex and 10-year age group were calculated and adjusted to the 2000 U.S. white population. Change in incidence over time was assessed by fitting generalized linear models assuming a Poisson error structure. Results: During the study period, 10 245 cataract extractions were performed in 7141 residents of all ages. Overall, the age-adjusted cataract surgery incident rate per 100000 residents was 548 (95% confidence interval [CI], 534-561) for women, 462 (95% CI, 447-478) for men, and 511 (95% CI, 501-521) for all residents. The incidence of cataract surgery increased 500% among women and 467% among men during the study period (P<.001). Overall, the incidence of cataract surgery was highest in residents 70 years and older (3538 surgeries [95% CI, 3322-3764] per 100000 residents). Conclusions: This population-based study found a substantial increase in incident cataract surgery among Olmsted County residents during the 25-year study period. The rate of cataract surgery increased in a nearly linear fashion during a period when phacoemulsification replaced extracapsular cataract extraction in the community. [Copyright &y& Elsevier]

Purpose: To analyze the course of intraocular pressure (IOP) during lamellar microkeratotomy (LMK) in enucleated human eyes using 3 microkeratome systems. Setting: Department of Ophthalmology, Texas Tech University Health Sciences Center, Lubbock, Texas, U.S.A. Methods: Sixteen enucleated human globes were cannulated through the optic nerve, and IOP was recorded continuously while the eyes had standard LMK flap creation. Three microkeratomes were used: Carriazo-Barraquer (Moria Inc.), Innovatome (Innovative Optics Inc.), and Hansatome (Bausch & Lomb). Results: During the vacuum affixation phase, the IOP reached a mean plateau of 97.9 mm Hg with the Hansatome, 135.8 mm Hg with the Innovatome, and 150.0 mm Hg with the Carriazo-Barraquer. During applanation and cutting, the IOP rose to mean plateau of 154.7 mm Hg, 151.8 mm Hg, and 175.8 mm Hg, respectively. Statistical analysis using Kruskal-Wallis testing suggested a difference in mean IOP elevation between the 3 microkeratomes during the vacuum affixation phase (P = .0394) but no difference during the applanation and cutting phase (P = .506). Conclusion: The IOP during LMK was higher than previously reported, and this may increase the risk for complications in certain patient groups. [Copyright &y& Elsevier]

Purpose: To investigate the accuracy of pupil diameter measurement using the Colvard pupillometer and to determine the learning curve for inexperienced examiners. Setting: Texas Tech University Health Sciences Center, Lubbock, Texas, USA. Methods: In this population study, subjects with normal pupillary behavior were tested by 1 of 2 investigators (examiner A, examiner B). After 5 minutes of dark adaptation at 1 lux, digital infrared pupil photography of the right eye was performed, followed by measurement of the horizontal pupil diameter and vertical pupil diameter with the Colvard pupillometer. The photographs were digitally analyzed to determine the horizontal and vertical pupil diameters. During phase I of the study, examiners were masked to the results of infrared pupil photography; during phase II, they reviewed the infrared pupil photography results after each testing session. Bland-Altman plots were created to detect measurement bias; results were graphed by subject test sequence to assess learning. A test difference of less than ±0.5 mm was considered clinically acceptable. Results: Fifty-nine subjects were tested in phase I, of whom 39 had adequate infrared pupil photography for analysis; 40 were tested in phase II, of whom 34 were included. The mean age of the analyzed subjects was 27 years (range 18 to 44 years). For all subjects, the infrared pupil photography median horizontal pupil diameter was 7.09 mm ± 0.75 (SD) (range 5.44 to 8.79 mm); the median vertical pupil diameter was 7.22 ± 0.79 mm (range 5.45 to 9.10 mm). Examiner A initially had a negative bias (Colvard pupillometer value less than infrared pupil photography value) for both horizontal and vertical pupil diameter measurements, which resolved during phase I after 23 subjects were tested; 18 of the final 19 subjects tested (11 phase I, 8 phase II) showed a test difference of less than 0.5 mm for all readings. The pupil diameter did not affect the bias. Examiner B had a strong positive bias that persisted throughout the study. Testing 26 subjects in 5 sessions during phase II did not improve the accuracy. During the final testing session, 3 of 8 subjects had a test difference of 0.5 mm or more in at least 1 dimension. The pupil diameter did not affect the bias. Conclusion: The Colvard pupillometer is susceptible to user errors causing unidirectional bias and seems to have a steep and variable learning curve. [Copyright &y& Elsevier]