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Introduction: To review the long-term outcome of photodynamic therapy (PDT) with verteporfin for inflammatory chorioretinal disease with subfoveal choroidal neovascularisation (CNV) over a 1-year period. Materials and Methods: Retrospective review of eyes with subfoveal CNV for associated choroiditis that were treated with PDT using verteporfin over a 1-year period. Main outcome measure: visual acuity. Results: Five eyes in 4 patients, with diagnoses including serpiginous choroiditis (2), ocular histoplasmosis syndrome (OHS, 1), and punctate inner choroidopathy (PIC, 2) underwent standard treatment procedure for PDT with verteporfin. Visual acuity, fluorescein angiography and treatment parameters were reviewed. Follow-up ranged from 12 months to 36 months (median, 36 months). Pre-PDT visual acuities ranged from 20/60 to 20/400 (median, 20/200). Post-PDT visual acuities ranged from 20/30 to 20/400 at 1 year (median, 20/300). Visual acuity was stabilised (within 1 line) or improved (greater than 1 line) in 3 eyes at 1 year and 4 of the 5 eyes at last follow-up. Conclusion: PDT for subfoveal CNV may stabilise, but rarely improves, visual acuity in eyes with choroidal neovascularisation secondary to inflammatory chorioretinal disease. Key words: Choroidal neovascularisation, Choroiditis, Photodynamic therapy, Verteporfin

PURPOSE To evaluate the safety and evidence of efficacy for oral 13-cis retinoic acid as a treatment for patients with subfoveal occult choroidal neovascularization (CNV) due to age-related macular degeneration (ARMD). METHODS Patients with active, subfoveal occult CNV with no prior treatment of the subfoveal component were eligible for inclusion. Patients received 40 mg of 13-cis retinoic acid twice daily for 5 months, stopped treatment for 2 months, and then resumed treatment for 5 months. Patients were observed monthly with Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity (VA), clinical examination, fluorescein angiography, and laboratory testing. RESULTS Eleven patients, aged 64 to 88 years, were enrolled and followed for 1 year. Initial VA ranged from 55 (20/40) to 5 (20/400) ETDRS letters (median 48 letters). Mild drug-related side effects (dry skin, chapped lips) occurred in all 11 patients. Three patients experienced more severe side effects (muscle aches, mood swings) and did not resume treatment after the drug holiday. Moderate VA loss occurred in 36% at both 6 and 12 months. CONCLUSIONS Oral 13-cis retinoic acid is too toxic to be useful in patients with ARMD. Oral 13-cis retinoic acid did not improve vision although it may have slowed visual acuity loss in patients with ARMD with occult subfoveal CNV.

Purpose: To evaluate the inhibitory effects of a urokinase-derived octapeptide, A˚6, on laser-induced choroidal neovascularization (CNV) in monkeys. Methods: Twenty female cynomolgus monkeys were randomly grouped into weekly or monthly A˚6 treatment groups, each consisting of 10 animals. CNV was induced in both eyes by perimacular laser treatment. In each right eye, a single 22.25-mg A˚6 dose (monthly group) or 4 22.25-mg A˚6 doses each week (weekly group) were given by intravitreal injections. Each left eye received phosphate buffer on the same schedule. Monkeys were observed for 4 weeks by ophthalmic examinations, color photography, and fluorescein angiography. Results: Weekly treated eyes had a 35% reduction of CNV compared with controls (P = 0.23). In contrast, monthly treated eye had a 71% reduction of CNV compared with controls (P = 0.0009). There was no evidence of toxicity at both clinical and pathologic examinations. Conclusions: Intravitreal A˚6 injections effectively inhibited CNV in cynomolgus monkeys without evidence of toxicity. The overall reduction in CNV was greater for monthly treated eyes than for weekly treated eyes. This study suggests that A˚6 has promise as a local antiangiogenic treatment of CNV. Further work is indicated to evaluate the potential role of A˚6 in therapy for human CNV associated with age-related macular degeneration.

Purpose To report the clinical outcome in 48 eyes of 48 children who received a Baerveldt glaucoma implant (BGI) for the management of pediatric glaucoma. Design Retrospective, noncomparative case series. Methods The medical records of all patients with pediatric glaucoma who underwent a BGI at two tertiary care referral centers in Los Angeles between 1990 and 1999 were reviewed. Intraocular pressure (IOP), intraoperative and postoperative complications, number of glaucoma medications, visual acuity, and pre- and postoperative corneal diameter and axial length were collected from patient records. Criteria for success were IOP between 6 and 21 mm Hg with or without glaucoma medications, no need for further glaucoma surgery, the absence of visually threatening complications, and some residual vision (minimum visual acuity of light perception). Results The study included 48 eyes from 48 patients aged 16 years and younger (mean age 4.1 years). Mean preoperative IOP was 31.2 ± 25.7 mm Hg, and mean postoperative IOP was 16.4 ± 4.9 mm Hg. Cumulative probability of success (based on the Kaplan-Meier survival curve) was 95% at 6 months, 90% at 1 year, 84% at 2 years, 74% at 36 months, and 58% at 48 months. On average, the BGIs were successful for a mean period of 5.6 years (67.7 months). Overall, 11 eyes failed, with the causes being uncontrolled IOP (eight eyes), retinal detachment (two eyes), and no light perception (one eye). Conclusions Baerveldt glaucoma implants can be a safe and effective treatment modality for the management of pediatric glaucoma refractive to medical therapy.

An epiretinal prosthesis, consisting of an extraocular microelectronic stimulator and an intraocular electrode array, was implanted in one eye of three blind and three sighted dogs. Three dogs (2 blind, 1 normal) were stimulated for 120 days, and two dogs (both normal) for 60 and 103 days respectively for 8-10 h/day at levels of 0.1 mC cm(-2) and 0.05 mC cm(-2), with each stimulus level presented to half of the array. One blind dog was kept as an inactive implant control. During the study period, electroretinograms (ERG) and fundus photographs were recorded. At the end of the study period, the dogs were sacrificed and histological and morphometric evaluation was made of the retina. No inflammatory reaction, neovascularization or hemorrhage was observed during the follow-up examinations. ERGs were unchanged. Stimulus levels used were of sufficient amplitude to elicit cortical evoked potentials. Histological evaluation showed no inflammatory infiltrates or changes in retina morphometry related to electrical stimulation when compared to the unstimulated control eye. Morphometric analysis revealed no consistent differences relating to electrical stimulation. In summary, chronic electrical stimulation of the dog retina at up to 0.1 mC cm(-2) with an epiretinal prosthesis does not appear to adversely affect the retina.

Tracking of coronary artery calcium (CAC) has been suggested for monitoring the effects of lipid control, but it is not known whether lipid control decreases progression of CAC. Seven hundred sixty-one subjects (mean age 64.5 +/- 7.3 years; 91% men; 69% positive for CAC) in an ongoing cohort study underwent baseline and follow-up (after 7.0 +/- 0.5 years) computed tomography for CAC. Subjects were stratified into low-risk (2 risk factors), intermediate-risk (or =2 risk factors but20% risk of coronary heart disease over 10 years), or high-risk (or =2 risk factors and20% risk of coronary heart disease in 10 years or diabetes) groups. Lipid control was defined according to criteria of the National Cholesterol Education Program. Two-way analysis of covariance was used to examine the relation of low-density lipoprotein (LDL) cholesterol and risk group to change in CAC volume score. Control of levels of high-density lipoprotein (HDL) cholesterol and triglycerides was also examined in relation to progression of CAC. After adjustment for other risk factors and baseline CAC volume, CAC progression was similar between those with adequate and those with inadequate control of LDL cholesterol (p = 0.68) and across categories of optimal, intermediate, and higher risk LDL cholesterol (p = 0.40). However, higher levels of HDL cholesterol (or =1.5 mmol/L [60 mg/dl]) were associated with less progression of CAC volume (151 vs 203 mm(3) in those with HDL cholesterol1.0 mmol/L [40 mg/dl], p = 0.03). There was no relation between triglycerides and CAC progression (p = 0.54). Our findings do not support the use of CAC assessment for monitoring the control of LDL cholesterol, but greater progression of CAC may occur in those in whom HDL cholesterol is not controlled.

PURPOSE. To evaluate the effect of viral IL-10 on the lacrimal gland immunopathologic response in the ocular surface disease, induced autoimmune dacryoadenitis. METHODS. Disease was induced in rabbits by injecting inferior lacrimal glands with peripheral blood lymphocytes activated by 5 days of coculture with autologous acinar cells in a mixed-cell reaction. In the treated group, an adenoviral vector carrying the vIL-10 gene was concurrently injected with activated lymphocytes. Tears were collected periodically for quantitation of IL-10 by ELISA. Two weeks after disease induction, tear production, tear film breakup time, and rose bengal staining score were determined. Sectioned glands were immunostained for expression of CD4, CD8, rabbit thymic lymphocyte antigen (RTLA), CD18 and major histocompatibility complex class II. RESULTS. The titer of vIL-10 in tears was at its maximum on day 3, started to decline by day 7, and was undetectable by day 14. In the diseased group, the tear production rate and tear film breakup time were significantly decreased, and rose bengal staining was significantly increased. Diseased glands had immune cell infiltrates containing CD4 + , RTLA + , and CD18 + cells, and major histocompatibility complex class II expression was increased. These changes were significantly ameliorated by expression of vIL-10. CONCLUSIONS. In vivo transduction of the lacrimal gland with AdvIL-10 resulted in the transient appearance of VIL-10 in tears. The presence of vIL-10 partially suppressed the appearance of Sjogren-syndrome-like features of reduced tear production, accelerated tear breakup, ocular surface disease, and immunopathologic response. Anti-inflammatory cytokine gene expression may offer a therapeutic modality for the treatment of autoimmune dacryoadenitis, once suitable vectors become available.

To evaluate intraocular pressure (IOP) control and the prevalence of complications associated with the two-stage insertion of the Baerveldt implant.Retrospective, noncomparative, interventional case series.We reviewed the medical records of all patients who underwent the two-stage Baerveldt implantation for advanced glaucoma between January 1995 and November 1998 at the Doheny Eye Institute, Los Angeles, California. All eyes with a minimum of 6 months of follow-up were included in the study. Eyes that failed before 6 months after stage II were also included in the study.The criterion for surgical success was postoperative IOP of 6 mmHg or more and 21 mmHg or less on two or more consecutive measurements with or without the use of glaucoma medications and without loss of light perception or further surgical intervention to lower IOP.Nineteen eyes from 19 patients were included. Median postoperative follow-up was 17 months (range, 3-56 months). The cumulative probability of success was 89% at both 12 and 24 months. The median preoperative IOP of 21 mmHg (range, 12-33 mmHg) was reduced to a median postoperative IOP of 12 mmHg (range, 1-17 mmHg; P0.0001). The median number of glaucoma medications before surgery was three and after surgery was one (P0.0001). Visual acuity remained the same or improved in 13 eyes (68%). One eye experienced hypotony (5%), and in two eyes (11%) suprachoroidal hemorrhages developed.The two-stage insertion of the Baerveldt implant effectively reduced IOP, produced few complications, and preserved visual acuity in more than two thirds of eyes with advanced glaucomatous damage.

Background— The South Bay Heart Watch is a prospective cohort study designed to appraise the value of coronary calcium and risk factors for predicting outcomes in asymptomatic adults. Two factors that may be related to subsequent cardiovascular events are coronary calcium (CAC, a manifestation of subclinical atherosclerosis) and high-sensitivity C-reactive protein (CRP, a measure of chronic inflammation). Methods and Results— Between December 1990 and December 1992, 1461 participants without coronary heart disease underwent baseline risk factor screening, computed tomography for CAC, and measurement of CRP. Participants were followed up for 6.4±1.3 years. Cox regression analyses were conducted for the 967 nondiabetics with CRP levels ≤10 mg/L to estimate the risk-factor–adjusted relative risks of CAC and CRP for the occurrence of (1) nonfatal myocardial infarction (MI) or coronary death and (2) any cardiovascular event (MI, coronary death, coronary revascularization, or stroke). CAC was a predictor of both end points ( P P =0.03). Risk group analysis defined by tertiles for CAC (142.1) and the 75th percentile for CRP (>4.05 mg/L) indicated that there was increasing risk with increasing calcium and CRP. Relative risks for the medium-calcium/low-CRP risk group to high-calcium/high-CRP risk group ranged from 1.8 to 6.1 for MI/coronary death ( P =0.003) and 2.8 to 7.5 for any cardiovascular event ( P Conclusions— Participants without diabetes and those at intermediate risk may benefit from risk stratification based on high-sensitivity CRP levels and CAC, because both factors contribute independently toward the incidence of cardiovascular events.

OBJECTIVES: To evaluate the cost-effectiveness of a 9-month preventive occupational therapy (OT) program in the Well-Elderly Study: a randomized trial in independent-living older adults that found significant health, function, and quality of life benefits attributable to preventive OT. DESIGN: A randomized trial. SETTING: Two government-subsidized apartment complexes. PARTICIPANTS: One hundred sixty-three culturally diverse volunteers aged 60 and older. INTERVENTION: An OT group, a social activity group (active control), and a nontreatment group (passive control). MEASUREMENTS: Use of healthcare services was determined by telephone interview during and after the treatment phase. A conversion algorithm was applied to the RAND 36-item Short Form Health Survey to derive a preference-based health-related quality of life index, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio for preventive OT relative to the combined control group. RESULTS: Costs for the 9-month OT program averaged $548 per subject. Postintervention healthcare costs were lower for the OT group ($967) than for the active control group ($1,726), the passive control group ($3,334), or a combination of the control groups ($2,593). The quality of life index showed a 4.5% QALY differential (OT vs combined control), P < .001. The cost per QALY estimates for the OT group was $10,666 (95% confidence interval = $6,747–$25,430). For the passive and active control groups, the corresponding costs per QALY were $13,784 and $7,820, respectively. CONCLUSION: In this study, preventive OT demonstrated cost-effectiveness in conjunction with a trend toward decreased medical expenditures.

The purpose of this study was to compare nonmydriatic digitized images obtained using a digital imaging system (resolution of 640 x 480 pixels) with 35-mm slide images for detecting specific findings of age-related macular degeneration (AMD) and to evaluate its usefulness as a screening tool in detecting signs of AMD.Seventeen consecutive patients (33 eyes) underwent digital color imaging (with a nonmydriatic, 45-degree, fundus camera attached to a digital back) and standard 35-mm, 30-degree retinal color photography of the fundus: posterior pole, nasal retina, and temporal retina. The images were later reviewed for the presence or absence of specific retinal findings. The images were not compressed. Primary outcome measures included the presence or absence of drusen, hard exudate, choroidal neovascularization (CNV), subretinal hemorrhage, retinal pigment epithelial (RPE) changes, subretinal fibrosis, pigment epithelial detachment (PED), and subretinal fluid. Presence of drusen, with or without any one of the other findings, and presence of disciform scar or geographic atrophy were positive indications in screening for AMD.Agreement between image type was highest for PED (97%), CNV (91%), and subretinal fibrosis (91%); and lowest for RPE changes (63%). Sensitivity, specificity, positive predictive value, and negative predictive values were determined using the 35 mm-slide images as the reference for comparison. Sensitivity ranged from 40% (hard exudates) to 75% (subretinal hemorrhage). Specificity ranged from 88% (drusen) to 100% (hard exudate, CNV, RPE changes, PED). Positive predictive value ranged from 67% (subretinal hemorrhage) to 100% (hard exudate, CNV, RPE changes, PED). Negative predictive value ranged from 44% (drusen) to 97% (PED). For the purposes of screening for any evidence of AMD, the system was 70% sensitive.This digital fundus imaging system with 640 x 480 pixel resolution has low sensitivity and high specificity, as compared with 35-mm slide images, for detection of early AMD, but higher sensitivity for late findings (CNV, scar, atrophy) of AMD. Because of sensitivity for detecting any AMD coupled with the low sensitivity for detecting CNV, the system is not useful for evaluating AMD patients who require close follow-up and who are at risk for more severe visual loss.

Objective To study the incidence of biopsy-proven giant cell arteritis (GCA) in a Hispanic population with clinical features suggestive of GCA. Design Retrospective review. Participants Records of 121 consecutive patients who underwent temporal artery biopsy at the Doheny Eye Institute and the Los Angeles County/University of Southern California Hospital from January 1986 through April 1998 were reviewed. Main outcome measures The incidence of biopsy-proven GCA was determined, and the biopsy-positive group was compared with the biopsy-negative group. Study variables included age at diagnosis, gender, erythrocyte sedimentation rate (ESR), and ethnic background. Results Among these 121 patients who underwent temporal artery biopsy, the mean age of those in the biopsy-positive group (75.2 ± 5.0 years) was higher than that of those in the biopsy-negative group (69.1 ± 9.2 years; P P Conclusions Giant cell arteritis occurs primarily in the white population. None of the Hispanic patients in our study was found to have positive biopsy results. Hispanic persons may have unknown factors that protect them from this disease. Further study is necessary to examine the genetic predisposition.

PURPOSE: To identify associations between complications of disease and final visual acuity in patients with Vogt-Koyanagi-Harada disease and to identify prognostic factors for disease outcome. METHODS: All patients diagnosed with Vogt-Koyanagi-Harada disease at the Doheny Eye Institute or the Los Angeles County/University of Southern California Medical Center between 1983 and 1997 were reviewed. Data extracted included initial and final visual acuities, age, gender, ethnicity, complications, treatment, duration of disease, and number of recurrences. RESULTS: One hundred one patients with Vogt-Koyanagi-Harada disease were identified, 68 (67%) of which were female. Mean age was 34 ± 14 years (range, 8 to 75 years). Asians presented at a significantly older age than all other groups. One hundred three eyes (51%) developed at least one complication, including cataract in 84 eyes (42%), glaucoma in 54 eyes (27%), choroidal neovascular membranes in 22 eyes (11%), and subretinal fibrosis in 13 eyes (6%). Patients who developed at least one complication had a significantly longer median duration of disease and number of recurrent episodes of inflammation ( P = .0001 for each) than did those patients who developed no complications. Statistically significant associations existed between poor final visual acuity and greater numbers of complications ( P = .001), greater age at onset ( P = .03), a longer median duration of disease ( P = .03), and greater number of recurrent episodes of inflammation ( P = .0004). Eyes possessing a better visual acuity at presentation were more likely to have a better visual acuity at final follow-up ( P = .001). CONCLUSIONS: Factors associated with a worse final acuity included increasing numbers of complications, greater age at onset, and worse acuity at presentation.

The Well Elderly Study was a randomized trial in independent-living older adults that found significant health, function, and quality of life benefits attributable to a 9-month program in preventive occupational therapy (OT). All participants completing the trial were followed for an additional 6 months without further intervention and then reevaluated using the same battery of instruments. Long-term benefit attributable to preventive OT was found for the quality of interaction scale of the Functional Status Questionnaire and for six of eight scales on the RAND SF-36: physical functioning, role functioning, vitality, social functioning, role emotional, and general mental health (p

PURPOSE: To create a model of Staphylococcus aureus keratitis after lamellar keratectomy; to assess the toxicity of an antibiotic irrigating solution on the corneal stromal bed; and to test the chemotherapeutic effectiveness of a topical antibiotic, both alone and with an antibiotic-containing irrigating solution in preventing S. aureus keratitis after lamellar keratectomy. METHODS: The right eye of each of 38 rabbits were used in this study. In 18 eyes, a lamellar flap was created with a microkeratome, and an inoculum of S. aureus (either 1,000, 5,000, or 50,000 CFUs) was instilled under each flap; the eyes were examined for signs of infection and inflammation at 24 and 48 hours. In another five eyes, a lamellar flap was created in the same manner and the stromal bed was irrigated with 0.3% ofloxacin; the eyes were assessed for ocular inflammatory changes and evidence of crystalline deposits. Finally, in each of 15 additional eyes, 1,000 CFUs of S. aureus were instilled under a lamellar flap to create experimental infectious keratitis. The keratitis was treated according to three regimens: irrigation of the stromal bed with sterile balanced salt solution; irrigation of the stromal bed with 0.3% ofloxacin, followed by application of topical ofloxacin four times a day; application of topical ofloxacin only, four times a day. Eyes were examined for infection and ocular inflammatory changes at 24 and 48 hours. RESULTS: Staphylococcus aureus keratitis can consistently be produced under the stromal flap by inoculation of relatively few organisms. Irrigation of the stromal bed with commercial-strength topical ofloxacin does not appear to be toxic to the stromal bed, with no evidence of crystalline precipitates of the antibiotic. In our model of infectious keratitis after lamellar keratectomy, both topical ofloxacin alone and the combination of topical ofloxacin and irrigation of the stromal bed with 0.3% ofloxacin were effective at preventing S. aureus keratitis. However, the combined treatment of antibiotic irrigation plus topical antibiotic was more effective at preventing inflammation than topical ofloxacin alone. CONCLUSIONS: In this model of S. aureus keratitis after lamellar keratectomy, irrigation of the stromal bed with antibiotic plus topical antibiotic appears to be both safe and effective for preventing infection.

Few studies have examined the correlation between change in carotid artery intima-media thickness (IMT) and change in coronary artery disease. In the Cholesterol Lowering Atherosclerosis Study, current nonsmoking men with coronary artery disease were randomized to colestipol-niacin or placebo. Among 133 subjects with baseline and on-trial coronary angiography and carotid ultrasonography, colestipol-niacin treatment significantly reduced progression of atherosclerosis by both end point measures (2-year average change in percent diameter stenosis by coronary angiography and rate of change in carotid IMT). Significant correlations between change in common carotid artery IMT and quantitative coronary angiographic measures of change were evident over all coronary artery lesions, and in mild:moderate (B 50% diameter stenosis), but not severe (] 50% diameter stenosis) coronary artery lesions. In mild:moderate lesions, correlations with change in common carotid IMT were: percent diameter stenosis (r0.28, P0.002), minimum lumen diameter (r 0.28, P 0.002), and vessel edge roughness (r0.25, P0.003). While measures obtained by carotid ultrasonography and coronary angiography are correlated, they each assess different aspects of atherosclerosis change. © 2000 Elsevier Science Ireland Ltd. All rights reserved.

As the percentage of older adults of diverse ethnicities increases in the United States, the call for culturally sensitive health care service strategies that target the special needs of older people grows. The present report describes methods used to adapt a health care program so that it would better meet the needs of a group of well, older Mandarin-speaking Chinese residents of Los Angeles. The specific qualitative research procedures that we used to adapt the treatment program are described, along with the particular adaptations that emerged. Additionally, outcomes from a randomized pilot experiment are presented that are consistent with the notion that the adapted program was effective in reducing health-related declines among older Mandarin-speaking men and women. The overall outcome of this project is in agreement with other reports in the health care literature that address the importance of providing culturally sensitive health care service for elders.

BACKGROUND: The purpose of the present study is to quantify the in vitro antiproliferative and cytotoxic effects of mitomycin-C on human keratocytes for their potential to modulate corneal stromal wound healing. METHODS: Cultured human keratocytes were exposed to various concentrations of mitomycin-C for periods of 5 minutes and 1 hour. Keratocyte proliferation and viability were assessed by phase-contrast microscopy, 3H-thymidine uptake, and electronic cell counting. RESULTS: Cytotoxic changes and inhibition of keratocyte proliferation exhibited after exposure to mitomycin-C were both dose- and time-dependent. The lowest concentrations to significantly (>50%) inhibit keratocyte proliferation after 5minute exposures were 0.05 mg/ml (P50 ) and median lethal dose (LD50) after 1 hour of exposure differed by a magnitude of 50 (0.0048 vs. 0.28 mg/ml). CONCLUSIONS: Mitomycin-C has antiproliferative effects at concentrations below those cytotoxic to human keratocytes. If used after photorefractive keratectomy, the drug should be administered at antiproliferative rather than cytotoxic concentrations. [J Refract Surg 1998;14:534-540]

Purpose: To measure the effects of commercially prepared topical fluoroquinolones on the healing rate of epithelial defects in the rabbit cornea after excimer laser keratectomy. Setting: The Doheny Eye Institute and the Department of Ophthalmology, University of Southern California School of Medicine, Los Angeles, California, USA. Methods: Twenty-four New Zealand white rabbits had unilateral excimer laser superficial keratectomy to create a circular, central corneal epithelial defect. Following keratectomy, each rabbit was randomly assigned to one of three treatment groups, each consisting of eight rabbits. Each rabbit was treated with one drop of the assigned medication, each hour until epithelialization was complete; Group 1 received ciprofloxacin, Group 2, ofloxacin, and Group 3, preservative-free artificial tears as a control. The epithelial defect was stained with fluorescein and photographed every 12 hours with a cobalt blue filtered light. Planimetric measurements of the wound area were made with an image analysis system. Results: The control group eyes were re-epithelialized within 84 hours. The fluoroquinolone-treated eyes required 144 hours for complete healing. Both ciprofloxacin and ofloxacin significantly delayed corneal epithelial healing ( P = .0055) compared with the control. Two animals treated with topical ciprofloxacin developed a white precipitate in the area of the epithelial defect; however, the precipitate did not prevent closure of the epithelial defect. No such precipitate was seen with ofloxacin. Conclusion: These data suggest that both ofloxacin and ciprofloxacin influence corneal wound healing in rabbits after laser keratectomy and that their healing rates did not differ. A white precipitate that appeared in the epithelial defect area in some rabbits treated with ciprofloxacin did not prevent closure of the defect.

Purpose: The purpose of the study was to characterize the clinical development of proliferative vitreoretinopathy (PVR) after trauma in the human eye. Methods: A chart review was performed on the records of 1564 patients with ocular trauma seen at a large metropolitan hospital. The frequency, type of ocular trauma, time to onset, potential risk factors, and visual outcome for PVR were evaluated. Results: Proliferative vitreoretinopathy occurred in 71 (4%) of 1654 injured eyes. Of these 71 injured eyes, 30 (42%) resulted from rupture, 15 (21 %) from penetration, 13 (18%) from perforation, and 7 (10%) from contusion. Six (9%) were associated with an intraocular foreign body (IOFB). The frequency of PVR following perforation, rupture, penetration, IOFB, and contusion was 43%, 21%, 15%, 11 %, and 1 %, respectively. Overall, those eyes that developed PVR had a poorer visual outcome, with PVR being the primary reason for visual loss. The time from injury to onset of PVR was shortest after perforation (median, 1.3 months), followed by rupture (2.1 months), IOFB (3.1 months), penetration (3.2 months), and contusion (5.7 months). Vitreous hemorrhage was the strongest independent predictive factor for the development of PVR. A long, posteriorly located wound and persistent intraocular inflammation were also important risk factors for PVR. Conclusions: These results suggest that PVR is a common complication following a variety of ocular injuries, and that it is associated with a poor visual outcome. Its frequency, onset, and outcome are strongly dependent on the nature of the trauma. Specific high-risk groups are identified as candidates for more aggressive therapy.

Study objectives To update our database, reporting changes in the results of weaning attempts and profile of patients transferred to us after prolonged mechanical ventilation (PMV) in the ICU. Design Retrospective record review, with prospective recording of physiologic measurements on admission from mid-1994. Setting Regional weaning center (RWC). Patients We studied 1,123 consecutive ventilator-dependent patients transferred for attempted weaning over an 8-year period. Measurements and results Median (range) time of mechanical ventilation prior to transfer to the RWC declined from 37 (1 to 249) days in 1988 to 29 (1 to 120) days in 1996 (p Conclusions Patients are being transferred from the ICU to our RWC for attempted weaning sooner in their course of PMV. Although more severely ill on arrival than in past years, mortality is unchanged, more than half of the patients continue to be successfully weaned, and survival after RWC discharge is improved.

Non-mydriatic digital fundus cameras constitute the key component for diabetic retinopathy tele-screening. This study investigated whether image capture skills acquired by non-professional photographers in a 1-day seminar and applied in a community setting may be reinforced and strengthened over time using an online continuous quality improvement (CQI) protocol. Approximately 20 amateur photographers from 13 independent sites were trained to capture images according to the recommended protocol: one 45 degrees image per eye, centered between the macula and the optic nerve, without dilation. In total, over the 19-month project period, 58 non-professional photographers captured and submitted 2,917 images. A professional photographer evaluated each image online assigning a CQI score. CQI scores indicated acquisition, and maintenance of skills was sustained over the study period. Over 93% of the images were scored as sufficient for clinical grading. Exposure and focus proved to be the most difficult skills. Skills needed to operate the digital cameras were acquired with relative ease. The online CQI protocol reinforced photographer skills over a significant period of time even when considerable turnover was experienced. The use of digital fundus cameras is easy to learn for the non-professional photographer. Their use saves the cost of a professional photographer. An online CQI protocol is also an effective tool for reinforcing and ensuring skill transfer, especially when considerable turnover in photographers can be expected.

Purpose: To assess four commonly available visual function tests to detect visually disabling or vision-threatening eye conditions among new patients of a large, urban, public, general ophthalmology clinic. Methods: Three hundred seventeen patients were tested for contrast sensitivity, Amsler grid abnormalities, and visual acuity at near and at distance. A complete eye evaluation found the prevalence of serious eye diseases, allowing determination of the sensitivity (Sn), specificity (Sp), likelihood ratio (LR), and other characteristics of each test. Results: Of 317 patients, most were Hispanic (77%), women (60%), and middle-aged (44 ± 17 years). Normal findings were reported in 18%; refractive error in 43%; cataracts in 16%; glaucoma in 7.3%; and macular degeneration in 4.1%. Near visual acuity of 20/40 or worse (Sn = 0.75; Sp=0.74; LR=2.8); and distance visual acuity testing of 20/30 or worse (Sn = 0.74; Sp=0.73; LR=2.7) correlated significantly with ocular disease, whereas contrast sensitivity testing (Sn = 0.62; Sp=0.41; LR=1.1) and Amsler grid test (Sn = 0.19; Sp=0.92; LR=2.4) did not. Test performance decreased when refractive errors were excluded and among those younger than 40 years of age relative to those 40 years of age or older. Conclusion: Of the four screening tests studied, distance and near threshold visual acuities as defined above were judged to have the best correlations of an abnormal result with ocular disease, both including or excluding refractive error. Different combinations of tests did not result in more accurate detection of ocular disease. More efficient screening tools for detecting ocular disease need to be developed.

Computed tomographic image slices between 2.5 and 3.0 mm are commonly used for coronary calcium scanning. To evaluate the comparative accuracy of thicker image slices (5 to 6 mm) for predicting coronary events, we acquired both types of scans in 280 research participants and clinically followed them up for 7 years. We found that thick-slice image scanning and image assessment ranked calcium scores similarly and that measurements from both scanning methods predicted coronary heart disease events equally.

Aim: The risk factors and epidemiological data for Graves’ ophthalmopathy with and without abnormal circulating thyroid levels were examined to determine the relation of thyroid dysfunction to ophthalmopathy. Methods: The authors retrospectively evaluated 482 patients seen with Graves’ ophthalmopathy. Of these, 413 were classified as having abnormal levels of circulating thyroid hormone (ALTH) and 69 as having normal levels of circulating thyroid hormone (NLTH). Results: Patients in the NLTH group, compared to the ALTH group, were older on average (56 (SD 13.5) v 52 (15.4)) and had a higher age adjusted body mass index (26.1 (0.8) v 23.4 (0.3)). In addition, a higher percentage of NLTH patients had hypercholesterolaemia. Those in the ALTH group were more likely to be female (76% v 51%), to have a family history of thyroid problems, and to have had eye surgery. Conclusion: NLTH and ALTH appear to differ from each other in terms of risk factors and epidemiological characteristics. Additionally, thyroid dysfunction seems to be associated with a more severe ophthalmopathy compared to the euthyroid state.

Purpose: The authors present a retrospective study designed to assess the effectiveness of the Baerveldt glaucoma implant in controlling intraocular pressure (10P) and maintaining visual function in eyes with neovascular glaucoma. Methods: The medical records of all 36 patients (36 eyes) who underwent Baerveldt glaucoma implantation for medically uncontrolled neovascular glaucoma between February 1991 and December 1992 were reviewed. Results: Eighteen patients received Model 350 implants, 16 received Model 500 implants, and 2 received Model 200 implants. The 12- and 18-month life-table success rates (success defined as 6 mmHg ≤ final IOP ≤ 21 mmHg without additional "glaucoma surgery or devastating complication) were 79% and 56%, respectively. Visual acuity remained stable or improved in 10 (31 %) patients. Postoperative complications included flat anterior chamber, serous choroidal detachment, and obstruction of the proximal tube tip with fibrovascular tissue, each of which occurred in four (11 %) patients. Eleven (31 %) patients lost light perception. There were no significant differences between the groups receiving the Model 350 and Model 500 implants with respect to life-table success rates, percentage of postoperative IOP reduction, or complication rates. Patients in the Model 500 implant group required significantly fewer antiglaucoma medications postoperatively, but also demonstrated a significantly greater mean visual acuity reduction. Better preoperative visual acuity and increased patient age were positively correlated with a successful outcome. Conclusions: Baerveldt implantation is effective in controlling IOP elevation associated with neovascular glaucoma. Postoperative visual loss, despite adequate IOP control, is common. Young patient age and poorer preoperative visual acuity are significant predictors of surgical failure.

Experimental animal virus replication models make it possible to study the role of viral gene products in adenovirus (Ad)-induced ocular disease. This study tested the hypothesis that the early region 3 (E3) of the human Ad genome plays an important role in the pathogenesis of Ad-induced ocular disease. Both Ad5 wt300, a genetically defined E3+ parent, and Ad5 dl327, a deletion mutant without E3 (E3-), replicated in ocular-derived cell cultures. Ad5 E3+ and Ad8 replicated more efficiently than did Ad5 E3- in cornea and conjunctival cell cultures. Lacrimal gland-derived cell cultures supported human Ad8 replication significantly more efficiently than did either Ad5 E3+ or Ad5 E3-. After intrastromal and topical inoculation of rabbits with either Ad wt300 or Ad dl327, a specific immune response was elicited that coincided with the appearance of subepithelial opacities that mimicked human disease both clinically and histologically. The clinical features (i.e., conjunctivitis, iritis, and corneal edema) were not significantly different for Ad5 E3(+)- and Ad5 E3(-)-induced ocular infection. Ad5 E3(+)- and Ad5 E3(-)-inoculated eyes shed virus for up to 7 and 5 days, respectively, and occasionally established persistent and/or latent infections in corneal, conjunctival, and, infrequently, lacrimal gland cells. Both Ad5 E3+ and Ad5 E3- spread from virus-inoculated animals to the cornea and conjunctiva of normal animals. Under current experimental conditions, expression of the E3 gene does not appear to affect the degree of virulence in ocular disease induced by Ad5 in the rabbit eye model. Deletion of the E3 gene from Ad5 does not make the model more like human disease.

Study objective To identify variables associated with weaning outcome in long-term ventilator-dependent patients. Using those variables, to construct models to predict weaning success and to test the accuracy of those models. Design Retrospective medical record review. Setting Regional weaning center (RWC). Patients An initial group of 421 and a subsequent group of 170 consecutive patients referred for attempted weaning after 6 weeks of mechanical ventilation. Measurements and results Data obtained on admission to our facility were analyzed for correlation with weaning outcome. In the initial patient group, selected variables which correlated with weaning success were alveolar-arterial oxygen pressure difference (P[A—a] O 2 ), BUN, BUN/creatinine ratio (each with p≤0.001), and female gender (p=0.04). We used these variables in logistic regression models to predict weaning success in this population. We then tested the models in the 170-patient validation group using both standard and receiver operating characteristic (ROC) curve analysis. The ROC analysis indicated 59% accuracy using P(A—a)O 2 alone and 68% accuracy using all previously mentioned variables. We used data from all 565 patients with known outcome and omitted BUN/creatinine ratio to fashion a simple scoring system to predict weaning success with 70% accuracy using P(A—a)O 2 , BUN, and Gender—the A+B+G score. Conclusion In patients suffering prolonged mechanical ventilation, models incorporating simple measurements allowed construction of a score to predict weaning success at our RWC.

Purpose We studied events leading to the development of posttraumatic endophthalmitis by examining the significance of 15 factors on microbial contamination of injured eyes. Methods A prospective study was done of 30 ruptured globes in patients admitted to an urban medical center. Cultures were taken from the conjunctiva before and after preoperative disinfection and from the anterior chamber at the beginning and end of wound repair. Twenty-five of 30 patients received a three-day regimen of intravenous antibiotics that were begun before surgery. Results Anterior chamber samples grew microorganisms in ten (33%) of 30 eyes, with positive cultures recovered from specimens taken at the beginning of wound repair in eight eyes and at the end of wound repair in six eyes. Contamination with indigenous flora may have occurred at the time of injury in one eye and during repair in another eye. Microbes recovered included Staphylococcus, Corynebacterium , and Aspergillus species. No patient developed endophthalmitis. Of the 15 factors studied, only intravenous antibiotics significantly decreased the incidence of positive anterior chamber cultures in eyes treated before wound repair compared with eyes not receiving such therapy (P = .002). Conclusions Despite the frequency of anterior chamber microbial contamination during injury or repair of the wound, with our treatment protocol and the presence of physiologic mechanisms to reduce intraocular microbes, no eyes developed clinical endophthalmitis. With our limited sample size only intravenous antibiotic therapy was found significantly to reduce anterior chamber microorganisms at the time of surgical repair, supporting their prophylactic use against the development of posttraumatic endophthalmitis.

Trabeculectomy outcome in Pseudophakie glaucoma patients treated with mitomycin C (MMC) or 5fluorouracil (5-FU) was analyzed retrospectively in 46 cases (46 eyes). Thirty patients received intraoperative MMC; 16, 5-FU. There were no significant differences between the two groups in terms of preoperative data (demographics, number of previous filtering procedures, visual acuity, and intraocular pressure [1OP]). After a mean follow up of 13.4 ± 8.1 and 11.5 ± 5.8 months for the 5-FU and MMC groups, respectively, 12 5-FU eyes (75%) and 21 MMC eyes (70%) were deemed at least qualified successes (IOP =s 21 mm Hg with or without antiglaucoma medications). Six (37.5%) of the 5-FU eyes and 13 (43.3%) of the MMC eyes were complete successes (IOP « 21 mm Hg without antiglaucoma medications). There were no significant differences between the two groups in terms of duration of follow up, number of qualified successes, and number of complete successes (P s .35, .9, and .7, respectively). Nor were there any significant differences in the mean final IOPs and visual acuities. Excluding transient corneal effects associated with 5-FU therapy, there were no significant differences in the frequency of postoperative complications. These results suggest that 5-FU and MMC antiproliferative therapy are associated with similar shortterm success rates and postoperative complications.

Objective To examine the association of atherosclerosis burden in the survivors of an asymptomatic elderly cohort study and its relationship to other coronary risk factors (specifically, age) by evaluating aortic atherosclerotic wall burden by magnetic resonance imaging (MRI). Methods A total of 312 participants in an ongoing observational cohort study underwent cardiac and descending thoracic aorta imaging by MRI. Maximum wall thickness was measured and the mean wall thickness calculated. Wall/outer wall ratio was used as a normalized wall index (NWI) adjusted for artery size difference among participants. Percent wall volume (PWV) was calculated as NWI × 100. Results In this asymptomatic cohort (mean age: 76 years), the mean (SD) aortic wall area and wall thickness were 222 ± 45 mm2 and 2.7 ± 0.4 mm, respectively. Maximum wall thickness was 3.4 ± 0.6 mm, and PWV was 32% ± 4%. Women appeared to have smaller wall area, but after correcting for their smaller artery size, had significantly higher PWV than men (P = 0.03). Older age was associated with larger wall area (P = 0.04 for trend) with similar PWVs. However, there were no statistically significant associations between standard risk factors, Framingham global risk, or metabolic syndrome status, therapy for cholesterol or hypertension, coronary or aortic calcium score, and the aortic wall burden. Aortic calcification was associated with coronary calcification. Conclusions Asymptomatic elderly in this cohort had a greater descending thoracic aortic wall volume that correlated with age, and women had a significantly increased PWV compared to men. In these survivors, the atherosclerotic aortic wall burden was not significantly associated with traditional risk factors or with coronary or aortic calcium scores or coronary calcium progression. Results suggest that age, or as yet unidentified risk factor(s), may be responsible for the increase in atherosclerosis.

Objective. To identify which specific parenting behaviors are associated with the onset of alcohol and tobacco use and how they are associated. Design. Prospective cohort study of two groups of preadolescents surveyed annually, the first group for 4 years, the second for 3 years. Setting. Two public school districts in Southern California. Subjects. 1034 fifth graders and 1266 seventh graders began the study after obtaining parental consent to complete surveys in a classroom setting. By the last measurement, attrition was 37 and 38% for the two cohorts, respectively. Main outcome measures. The onset of tobacco or alcohol use in the last month. Results. Children who reported that parents spent more time with them and communicated with them more frequently had lower onset rates of using alcohol and tobacco in the last month. These parental interactions lead to more positive relationships with their children. Parental monitoring and positive relations were protective factors for disruptive behavior and the selection of substance-using friends. Disruptive behavior increased the odds of adolescents drinking in the last month approximately twofold and of smoking in the last month two to fourfold. Conclusions. This study provides further evidence that parenting behaviors are significant precursors to adolescent disruptive behavior, vulnerability to peer pressure, and subsequent substance use. Parents should be targeted in future substance use prevention programs, before their children reach adolescence.

Background: The Baerveldt glaucoma implant is a large equatorial aqueous shunting device that is installed through a single-quadrant conjunctival incision. The intermediateterm results of a randomized study comparing the 350- and 500-mm 2 Baerveldt implants are reported. Methods: Seventy-three patients with medically uncontrollable, nonneovascular glaucomas associated with aphakia, pseudophakia, or failed filters were enrolled in a randomized, prospective study comparing 350- and 500-mm 2 Baerveldt implants. Surgical success was defined as 6 mmHg ≤ final intraocular pressure ≤ 21 mmHg without glaucoma reoperation or devastating complication. Results: Of patients with 350- and 500-mm 2 implants, 93% and 88%, respectively, achieved surgical success (18-month life-table analysis, P = 0.93). The 500-mm 2 implants afforded intraocular pressure control with significantly fewer medications (0.7 versus 1.3; P = 0.006). The postoperative visual acuities remained within one line of the preoperative visual acuities or improved in 62% and 66% of patients in the 350- and 500mm 2 groups, respectively (P = 0.93). Complication rates were statistically similar. The most frequent ones in the 350- and 500-mm 2 groups, respectively, were serous choroidal effusion (16% and 32%), strabismus (16% and 19%), anterior uveitis (14% and 11 %), and corneal or corneal graft edema (11 % each). Conclusion: The intermediate-term results of the 350- and 500-mm 2 Baerveldt implants were statistically comparable with respect to surgical and visual outcomes, as well as complications, although the larger implant was associated with a higher rate of some complications. However, the 500-mm 2 Baerveldt implant afforded intraocular pressure control with fewer medications than the 350-mm 2 implant.

Purpose: To determine if multifocal electroretinogram (mfERG) testing shows abnormalities that correspond to perimetric defects in HIV positive patients without infectious retinitis. Methods: We studied three groups of patients: HIV negative controls, HIV high CD4 nadir patients (lowest CD4 T cell count is over 100) and low CD4 nadir patients (below 100 for over 6 months). Twenty-six HIV positive eyes and 16 HIV negative control eyes were studied by mfERG. A subset of 10 eyes also underwent computerized perimetry for comparison. We analyzed mfERG by hexagons as well as by quadrants and rings. Results: Of 103 hexagon locations there was no significant difference in the amplitudes P1 and N1 (nV/degree2) between the three studied groups (p>0.05), similarly, the latencies were not different (p>0.05). All eyes with significant visual field defects at the 0.01 and 0.005 level (Humphrey pattern deviation; 24-2) were compared to mfERG amplitudes and latencies at those locations–there were no corresponding defects in mfERG data (p>0.2). Conclusion: In the era of HAART there are still demonstrable visual field defects and other evidence of damage to the retinal nerve fiber layer in HIV patients. Our mfERG studies show that the damage appears to affect the inner retina, the outer retina is spared. Further studies of inner retinal structure and function are indicated to elucidate this process.

To identify factors associated with variability in retinal nerve fiber layer (RNFL) thickness measurements obtained by optical coherence tomography (OCT).Retrospective observational case series.One hundred fifty consecutive patients with known or suspected glaucomatous optic nerve damage undergoing OCT imaging for RNFL thickness measurement.One eye with known or suspected glaucoma from each patient was scanned twice within the same visit using the Stratus OCT's fast nerve fiber layer thickness acquisition protocol. For each scan, the average RNFL thickness, signal strength (a measure of the amount of light reflecting back from the retina), and analysis confidence (AC, a measure of the quality of the data as reported by the OCT software) were recorded. Retinal nerve fiber layer thickness measurements of the initial and repeat scans for each case were compared, and the difference in thickness measurements was correlated with difference in signal strength, AC (either low or normal), and the average RNFL thickness.Difference in RNFL thickness.The mean difference in RNFL thickness between the initial and repeat scans was 10 microns (12.5%; range, 0.04-86.15 microns). Difference in signal strength between initial and repeat scans positively correlated with the difference in RNFL thickness (Spearman correlation coefficient = 0.44; P0.001), whereas the average nerve fiber layer thickness negatively correlated with the difference in RNFL thickness (Spearman correlation coefficient = -0.25; P = 0.002). The presence of a scan with low AC was associated with a lower average RNFL thickness and a greater difference in RNFL thickness between the initial and repeat scans.Signal strength variability, low AC, and low RNFL thickness are associated with variability in RNFL thickness measurements obtained by Stratus OCT. Comparability of RNFL thickness measurements between visits may be improved if scans of similar signal strengths without low AC are obtained. This is especially important for patients with moderate glaucomatous optic nerve damage and for patients from whom good quality scans are not obtainable.

Purpose To evaluate the use of intravitreal triamcinolone (IVTA) for the treatment of macular edema secondary to immune recovery uveitis (IRU) in patients with AIDS. Design Prospective, consecutive, interventional case series. Participants Eight eyes of 7 patients receiving 13 injections. Methods Prospective, consecutive, interventional case series of 13 injections involving 8 eyes in 7 patients who underwent an intravitreal injection of 20 mg decanted triamcinolone acetate for fluorescein angiographically proven IRU-related macular edema. Main Outcome Measures The primary outcome measure was vision (using the Early Treatment Diabetic Retinopathy Study chart). Other outcome measures included fluorescein angiography and optical coherence tomography. Results Visual acuity improved at all time points and was statistically significant at the 1-month and 3-month follow-up examinations. The average visual improvement was 3 lines at 3 months. Retinal volume and thickness improvement were statistically significant at all time points. All patients had a minimum follow-up of 9 months, and there were no cases of cytomegalovirus reactivation. Conclusions Previous studies showed that treatment with sub-Tenon repository steroids for the treatment of macular edema of IRU was only marginally effective. However, the current study shows that IVTA can be an effective short-term treatment for macular edema secondary to IRU in patients with AIDS. Longer follow-up is needed to assess the durability of the effect and to monitor for longer-term complications and outcomes.

Objective To report the frequency and severity of optical coherence tomography (OCT) retinal thickness measurement errors and to describe parameters that predict these errors. Design Observational case series. Participants Two hundred consecutive patients undergoing OCT imaging. Methods One eye (primary) from each of 200 consecutive patients undergoing Stratus OCT imaging (Carl Zeiss Meditec, Dublin, CA) with radial lines or fast macular thickness-based acquisition protocols was selected for review by 2 graders. On each of the line scans, graders evaluated the position of the automated retinal boundary lines (inner retinal surface and retinal pigment epithelium band) used by the OCT machine for thickness calculations and graded the positioning on a 6-point subjective, categorical error scale to generate an error score. The presence of thickness errors was correlated with various parameters, including the analysis confidence assessment reported by the OCT software, disease diagnosis, retinal morphologic features, the foveal center thickness standard deviation (FCTSD), and the FCTSD-to-foveal center thickness (FCT) ratio. Main Outcome Measure Average OCT retinal thickness error score. Results Errors of retinal boundary detection and thickness measurement were observed in 92% of eyes, but were severe in only 13.5% of eyes. The identification of an error or low analysis confidence by the OCT software was strongly associated with the severity of the retinal thickness errors. A higher FCTSD-to-FCT ratio and presence of subretinal fluid also were associated with more severe errors. Retinal cysts and a diagnosis of retinal vascular disease such as diabetic macular edema were less likely to be associated with significant errors. Conclusions Retinal thickness measurement errors occur frequently with current OCT segmentation and analysis algorithms. Severe errors are more frequent in eyes with subretinal pathologic features, but generally are detected by the OCT software. A high FCTSD-to-FCT ratio (>0.1) also may alert the clinician to the possibility of thickness errors. Clinical studies, particularly those pertaining to subretinal diseases, should consider these errors when incorporating OCT imaging in the study design.

Purpose To characterize a longitudinal relationship between highly active antiretroviral therapy immune recovery as defined by an increase in CD4 cell counts and any associated changes in intraocular pressure (IOP) in both patients with and patients without a history of cytomegalovirus (CMV) retinitis and to determine if human immunodeficiency (HIV)-induced reduction in IOP is reversible. Design Retrospective analysis of patient data collected from 1997 through 2004. Participants Cohort of patients from one eye center, including patients from the Longitudinal Study of Ocular Complications of Acquired Immunodeficiency Syndrome. Methods Linear regression analyses were conducted within the CMV and non-CMV groups to determine the change in IOP per 100-unit change in CD4 count. Average changes in IOP per change in CD4 count were compared between the CMV and the non-CMV groups using a Wilcoxon rank-sum test. Linear regression analyses were conducted within the CMV and non-CMV groups to determine the linear relationship between the 12-month change in IOP per 12-month 100-unit change in CD4 count. Main Outcome Measure Intraocular pressure in relation to changes in CD4 cell counts. Results Compared with the non-CMV group, the median IOP change per change in CD4 count was not statistically different from the CMV group (0.9 vs. 1.7 mmHg/100 CD4 cells, respectively; P = 0.20). Analysis of the linear relationship between the 12-month change in IOP and the 12-month change in CD4 count within both the CMV and non-CMV groups showed a strong linear relationship: 67% of the variability in a 12-month IOP change for the CMV group ( P P Conclusions Reduction in T-lymphocyte count in HIV infection is accompanied by a decrease in IOP in both CMV-infected and non–CMV-infected eyes, and immune recovery is associated with an increase in IOP.

To compare across four race-ethnic groups the baseline prevalence and extent of coronary calcium and the 7-year rate of progression in the extent of coronary calcium.The South Bay Heart Watch is a prospective cohort study designed to appraise the value of coronary calcium for predicting cardiovascular outcomes in asymptomatic adults with cardiac risk factors. Statistical analyses were conducted to evaluate ethnic differences in the prevalence, extent, and progression of coronary calcium among Caucasian, African-American, Hispanic, and Asian participants.Population-based study.Between December 1990 and December 1992, 1289 participants without coronary heart disease underwent baseline risk factor screening and computed tomography for coronary calcification (Cohort 1). Seven years later, 828 (64%) participants returned for follow-up evaluation and re-scanning (Cohort 2).Prevalence, extent, and progression of coronary artery calcium.In Cohort 2, compared to Whites, African Americans had a lower prevalence of coronary calcium at baseline (P=.012) and follow-up (P=.005), smaller calcium scores at baseline (P=.005) and follow-up (P=.0004), and less progression (P=.001); Hispanics had a lower prevalence of coronary calcium at follow-up (P=.04) with smaller calcium scores (P=.011), and less progression (P=.009). In contrast, no differences were seen between Whites and Asian/Pacific Islanders. Race-ethnic differences in progression persisted after adjusting for risk factors and participation bias (P.05).The present results lend further credence to the notion that race-ethnic differences exist in the prevalence and rate of progression of coronary calcification. The relationship between calcification and the incidence of coronary heart disease in these race-ethnic groups needs further exploration.

Associations have been found between long-term exposure to ambient air pollution and cardiovascular morbidity and mortality. The contribution of air pollution to atherosclerosis that underlies many cardiovascular diseases has not been investigated. Animal data suggest that ambient particulate matter (PM) may contribute to atherogenesis. We used data on 798 participants from two clinical trials to investigate the association between atherosclerosis and long-term exposure to ambient PM up to 2.5 microm in aerodynamic diameter (PM2.5). Baseline data included assessment of the carotid intima-media thickness (CIMT), a measure of subclinical atherosclerosis. We geocoded subjects' residential areas to assign annual mean concentrations of ambient PM2.5. Exposure values were assigned from a PM2.5 surface derived from a geostatistical model. Individually assigned annual mean PM2.5 concentrations ranged from 5.2 to 26.9 microg/m3 (mean, 20.3). For a cross-sectional exposure contrast of 10 microg/m3 PM2.5, CIMT increased by 5.9% (95% confidence interval, 1-11%). Adjustment for age reduced the coefficients, but further adjustment for covariates indicated robust estimates in the range of 3.9-4.3% (p-values, 0.05-0.1). Among older subjects (greater than or equal to 60 years of age), women, never smokers, and those reporting lipid-lowering treatment at baseline, the associations of PM2.5 and CIMT were larger with the strongest associations in women 60 years of age (15.7%, 5.7-26.6%). These results represent the first epidemiologic evidence of an association between atherosclerosis and ambient air pollution. Given the leading role of cardiovascular disease as a cause of death and the large populations exposed to ambient PM2.5, these findings may be important and need further confirmation.

Purpose To correlate intraoperative aphakic autorefraction to conventional emmetropic intraocular lens (IOL) calculations and derive an empiric predictive model for IOL estimation based on optical refractive biometry without axial length and keratometry measurements. Setting Institutional Review Board of the University of Southern California, Los Angeles County General Hospital, Los Angeles, California, USA. Methods A pilot group of 22 eyes of 22 patients scheduled for cataract surgery were enrolled in a prospective trial. All patients had a standard preoperative workup with subsequent cataract extraction and IOL implantation according to conventional biometric measurements and IOL calculations. Intraoperative autorefractive retinoscopy was used to obtain aphakic autorefraction and to measure the aphakic spherical equivalent before lens implantation. A linear regression analysis was used to correlate the aphakic spherical equivalent to the final adjusted emmetropic IOL power to empirically derive a refractive formula for IOL calculation (optical refractive biometry method). A second validation series of 16 eyes was used in a head-to-head comparison between the optical refractive biometry and the conventional IOL formulas. A subset of 6 eyes from the validation series were post-refractive cases having subsequent cataract surgery. Results Intraoperative retinoscopic autorefraction was successfully obtained in all 22 patients in the pilot group and all 16 patients in the validation group. The spherical equivalent of the aphakic autorefraction correlated linearly with the final adjusted emmetropic IOL power ( P r 2 =.9985). The relationship was sustained over an axial length range of 21.43 to 25.25 mm and an IOL power range of 12.0 to 25.5 diopters (D). In a subsequent validation series of 10 standard and 6 post-laser in situ keratomileusis (LASIK) cataract cases, the optical refractive biometry method proved to be a better predictive model for IOL estimation than conventional formulas; 83% of the LASIK eyes and 100% of the normal eyes were within ±1.0 D of the final IOL power when aphakic autorefraction was used, compared with 67% of LASIK eyes and 100% of the normal eyes, using the conventional methodology. Conclusions A new model for IOL power calculation was derived based on an optical refractive methodology that breaks away from the conventional art introduced by Fyodorov in the 1960s. A purely refractive algorithm is used to predict the power of the IOL at the time of surgery without the need for axial length and keratometry measurements. This method bypasses some limitations of conventional biometry and shows promise in the post-refractive cataract cases.

The aim of this study is to investigate the long-term, mechanical biocompatibility of a polymer microtechnology that can be used to position electrodes in close proximity to the retina. Poly(dimethylsiloxane) (PDMS) arrays were manufactured by soft-lithography at Lawrence Livermore National Laboratory. The PDMS implant measured 4 mm x 40 mm x 55-60 microm and included 4-8 electrodes. Micromolded ribs were placed at the perimetry for strength and ease of manipulation. The PDMS arrays were implanted epiretinally in four normal dogs, with a single retinal tack used in each case to hold the device on the retina. The mechanical effects of the implant were followed up after surgical implantation by photography, fluorescein angiography, optical coherence tomography (OCT), and electrophysiologic tests. An intraoperative retinal tear occurred in the first implanted dog, causing retinal detachment and necessitating termination. The remaining dogs experienced no gross complications secondary to the array implantation procedure. During the follow-up period of 2 months in one eye and 6 months in three eyes, OCT demonstrated that the arrays were in close contact with the retina. Fluorescein angiography showed good perfusion of the retina under the array. At the end of 6 months, there was no statistical difference from baseline in mean retinal thickness under the array (P=0.43) or peripapillary retinal nerve fibre layer thickness corresponding to the implanted area (P=0.34). The mean distance between the array and the retinal surface varied from 32 to 68 microm throughout the follow-up. Histopathologic evaluation of the retinal implantation site in eyes followed for 6 months showed a general preservation of the normal, layered retinal structure, except for some localized retinal thinning in two eyes, where the array frame had been in direct retinal contact. The PDMS substrate micro array is a new and promising technology that can be scaled to support a high-density retinal stimulating array. Its implantation and handling is surgically manageable, and it forms a mechanically stable, acceptable interface with the inner retinal surface.

ContextGuidelines advise that all adults undergo coronary heart disease (CHD) risk assessment to guide preventive treatment intensity. Although the Framingham Risk Score (FRS) is often recommended for this, it has been suggested that risk assessment may be improved by additional tests such as coronary artery calcium scoring (CACS).ObjectivesTo determine whether CACS assessment combined with FRS in asymptomatic adults provides prognostic information superior to either method alone and whether the combined approach can more accurately guide primary preventive strategies in patients with CHD risk factors.Design, Setting, and ParticipantsProspective observational population-based study, of 1461 asymptomatic adults with coronary risk factors. Participants with at least 1 coronary risk factor (>45 years) underwent computed tomography (CT) examination, were screened between 1990-1992, were contacted yearly for up to 8.5 years after CT scan, and were assessed for CHD. This analysis included 1312 participants with CACS results; excluded were 269 participants with diabetes and 14 participants with either missing data or had a coronary event before CACS was performed.Main Outcome MeasureNonfatal myocardial infarction (MI) or CHD death.ResultsDuring a median of 7.0 years of follow-up, 84 patients experienced MI or CHD death; 70 patients died of any cause. There were 291 (28%) participants with an FRS of more than 20% and 221 (21%) with a CACS of more than 300. Compared with an FRS of less than 10%, an FRS of more than 20% predicted the risk of MI or CHD death (hazard ratio [HR], 14.3; 95% confidence interval [CI]; 2.0-104; P = .009). Compared with a CACS of zero, a CACS of more than 300 was predictive (HR, 3.9; 95% CI, 2.1-7.3; P

Purpose To determine whether treatment with valganciclovir will improve visual acuity in eyes with immune recovery uveitis complicated by macular edema. Design Prospective open label controlled Phase II drug study. Methods Five patients with chronic macular edema as a result of immune recovery uveitis were studied. Baseline fluorescein angiograms, best-corrected ETDRS visions, and cytomegalovirus (CMV) lymphoproliferative T-cell function assays were obtained and repeated after three months of valganciclovir therapy (900 mg daily) and again three months after withdrawal of therapy. Results Vision improved by a mean of 11 letters in the treatment phase ( P = .05). Graded angiograms showed three patients had treatment reduction of macular edema. One patient had rebound increase in macular edema after the withdrawal phase. The CMV lymphoproliferative response was not affected by the valganciclovir. Conclusion Results suggest valganciclovir treatment may benefit visual acuity in patients with macular edema from immune recovery uveitis.

To describe and evaluate a refraction-derived method and a clinically derived method to calculate the correct corneal power for intraocular lens (IOL) power calculations after laser in situ keratomileusis (LASIK) and to compare the results to the commonly used history-derived method.Interventional case series.Retrospective analysis of consecutive cases from clinical practice. Two hundred randomly selected eyes from 200 patients were evaluated before and after LASIK surgery. For each patient, we established the pre-LASIK and post-LASIK spectacle refraction, the pre-LASIK (Kpre) and post-LASIK K readings (Kpost). We then calculated for each case the pre- and post-LASIK refraction at the corneal plane and the amount of correction obtained by the refractive surgery (CRc). The cases were divided into two groups. Group I was used to derive the two formulas. The K values were calculated using the history-derived method (Kc.hd) in which Kc.hd = Kpre - CRc. Kc.hd was compared with Kpost. The average difference was 0.23 diopters for every diopter of myopia corrected. This value was used to calculate the corneal power using the refraction-derived method (Kc.rd) where Kc.rd = Kpost -0.23CRc. A regression equation was used to develop a clinically derived method (Kc.cd) where Kc.cd = 1.14Kpost -6.8. The values obtained with the two methods were compared with the Kc.hd values in group II to validate the results.Both Kc.rd and Kc.cd values correlated highly with Kc.hd when plotted on a scattergram (P.001), and there was no statistically significant difference between the mean keratometric values (P.5).The corneal power measurements for intraocular lens power calculations after LASIK need to be corrected to avoid hypermetropia after cataract surgery by either the history-derived method, the refraction-derived method, or the clinically derived method.

Background— Epidemiological studies have demonstrated an inverse relationship between vitamin E intake and cardiovascular disease (CVD) risk. In contrast, randomized controlled trials have reported conflicting results as to whether vitamin E supplementation reduces atherosclerosis progression and CVD events. Methods and Results— The study population consisted of men and women ≥40 years old with an LDL cholesterol level ≥3.37 mmol/L (130 mg/dL) and no clinical signs or symptoms of CVD. Eligible participants were randomized to DL-α-tocopherol 400 IU per day or placebo and followed every 3 months for an average of 3 years. The primary trial end point was the rate of change in the common carotid artery far-wall intima-media thickness (IMT) assessed by computer image-processed B-mode ultrasonograms. A mixed effects model using all determinations of IMT was used to test the hypothesis of treatment differences in IMT change rates. Compared with placebo, α-tocopherol supplementation significantly raised plasma vitamin E levels ( P P =0.03), and reduced LDL oxidative susceptibility ( P Conclusions— The results are consistent with previous randomized controlled trials and extend the null results of vitamin E supplementation to the progression of IMT in healthy men and women at low risk for CVD.

PURPOSE To study the effects of antiviral agents on human keratocytes in vitro. METHODS Cultured human keratocytes were incubated with either ganciclovir, idoxuridine, trifluridine, or cidofovir at concentrations from 0.0001 to 10 mg/mL. Phase-contrast microscopy and XTT (sodium [2,3-bis [2-methoxy-4-nitro-5-sulphophenyl]-2h-tetrazolium-5-carboxanilide, inner salt) colorimetric assay were performed after 24, 48, and 72 hours of incubation. RESULTS When adjustments were made for time of incubation and concentration, trifluridine reduced cell viability significantly more than ganciclovir, idoxuridine, and cidofovir (p

Objective To compare the effectiveness of scanning laser entoptic perimetry with static automated perimetry as a noninvasive instrument for screening for glaucomatous damage in visually asymptomatic subjects within the central 60° (diameter) of vision. Design A masked cross-sectional study comparing entoptic perimetry to achromatic threshold perimetry. Participants Twenty-three subjects and controls from the Sharp Rees-Stealy Hospital and the Shiley Eye Center at the University of California, San Diego. Testing Virtual reality–based entoptic perimetry was compared with achromatic threshold perimetry. Main outcome measures For each testing session, we compared the presence of a disturbance in the entoptic perimetry stimulus with the presence of defects in visual function as measured by Humphrey automated visual field perimetry. Results Scanning laser entoptic perimetry reasonably estimates the overall visual field loss for moderate-to-severe scotomas as measured by the pattern deviation in standard visual field perimetry. Scanning laser entoptic perimetry has a sensitivity from 27% to 90% and a specificity from 50% to 100% for screening moderate-to-severe visual field defects caused by glaucoma within the central 60° diameter of vision. Conclusions Scanning laser entoptic perimetry may be an effective and inexpensive screening test in hospitals and community clinics for diagnosing visual field loss caused by glaucoma.

Purpose The purpose of this study was to compare nonmydriatic digital images with 35-mm slide images for the detection of diabetic retinal findings. Study design Comparative, observational case series. Participants Forty patients with diabetes. Methods Diabetic patients underwent digital (nonmydriatic fundus camera attached to a digital back) and standard dilated 35-mm retinal photography of three areas: posterior pole, nasal retina, and temporal retina. The images were reviewed by a single masked grader for the presence or absence of specific retinal findings. Primary outcome measures Presence or absence of neovascularization of the disc (NVD), neovascularization elsewhere (NVE), venous beading (VB), nerve fiber layer (NFL) hemorrhage, dot–blot hemorrhage, microaneurysm (MA), clinically significant macular edema, cotton wool spot, intraretinal microvascular anomaly (IRMA), hard exudate (HE), and retinal pigment epithelial (RPE) pigmentary changes. Results Forty eyes of 22 patients underwent both imaging procedures. The agreement between image type was highest for IRMA (97.5%) and VB (95%) and lowest for RPE pigmentary changes (65%) and MA (62.5%). Sensitivity ranged from 25% (NVD) to 100% (VB). Specificity ranged from 90% (RPE pigmentary changes) to 100% (NVD, NVE, VB, NFL hemorrhage, HE). Positive predictive value ranged from 50% (IRMA) to 100% (NVD, NVE, HE, NFL, VB). Negative predictive value ranged from 48% (MA) to 100% (IRMA). Conclusions Nonmydriatic digital fundus imaging for detection of diabetic retionopathy has a low sensitivity rate and a high specificity rate and is less clinically useful than standard dilated 35-mm fundus slide images.