2009 saw multiple publications improving the way we screen, monitor, and treat ophthalmic disease. The following is a selection of those articles which have had the greatest impact on the clinical practice of ophthalmology.
Congenital Ptosis
Frontalis sling operation using silicone rod compared with preserved fascia lata for congenital ptosis a three-year follow-up study. Lee MJ, Oh JY, Choung HK, Kim NJ, Sung MS, Khwarg SI. Ophthalmology. 2009 Jan;116(1):123-9.
This study, whose results and conclusions are limited due to its retrospective nature, compared outcomes for frontalis sling operations with silicone rod (Vistec, Sarasota, FL) and preserved fascia lata after three years. The authors found that not only did silicone rods produce better cosmetic results, but recurrence rates were also much lower. As preserved fascia lata may be more cumbersome and expensive to procure, converting to silicone rods may not only benefit our patients but reduce health care expenses as well.
Postoperative Endophthalmitis
Analysis of diluted vitreous samples from vitrectomy is useful in eyes with severe acute postoperative endophthalmitis. Chiquet C, Maurin M, Thuret G, Benito Y, Cornut PL, Creuzot-Garcher C, Rouberol F, Pechinot A, Lina G, Romanet JP, Bron A, Vandenesch F; French Institutional Endophthalmitis Study (FRIENDS) group. Ophthalmology. 2009 Dec;116(12):2437-41.
Endophthalmitis, in spite of development of better antibiotics, continues to cause irreversible blindness following trauma and surgery every year. While a vitreous tap can provide excellent information about the best antibiotic or antifungal medication to use, it can have its own deleterious side effects. A safer alternative method of diagnostic sampling of the vitreous may be to perform analysis of a vitrectomy sample. The question, however, is whether or not our technology is capable of identifying orgranisms from a diluted vitreous sample. In this study it was proven that, when used with both traditional culture and eubacterial PCR technique, diluted vitreous samples sampled from Accurus (Alcon Laboratories, Inc., Fort Worth, TX) were equal to traditional vitreous tap specimens.
Intraocular Hypertension
Long-term incidence and timing of intraocular hypertension after intravitreal triamcinolone acetonide injection. Roth DB, Verma V, Realini T, Prenner JL, Feuer WJ, Fechtner RD. Ophthalmology. 2009 Mar;116(3):455-60.
Intravitreal therapy has become a significant advance in the treatment of ocular disease. With more injections performed every year, we have learned more of the potential risks of these injections. While the role of steroids and increased intraocular pressure has never been completely understood, we have always been aware of the correlation. In this study, nearly a thousand patients were evaluated following intravitreal injection of 4 mg of triamcinolone and, unfortunately, the risk for elevated intraocular pressure was quite high: for example, the incidence of eye with intraocular pressure > 25 mm Hg at 24 months post-injection was 28.2%. While many patients require intravitreal steroid for management of retinal edema, this study enforces our need to discuss the post-injection high risk of glaucoma with our patients.
Cataract Surgery
Correction of myopia after cataract surgery with a light-adjustable lens. Chayet A, Sandstedt C, Chang S, Rhee P, Tsuchiyama B, Grubbs R, Schwartz D. Ophthalmology. 2009 Aug;116(8):1432-5.
As cataract surgery evolves and patient expectations increase, the need for improved post-operative refractive outcomes grow. Additionally, the growing number of post-LASIK cataract patients can make the pre-operative workup much more labor intensive. In this study, patients were purposely targeted for myopic outcomes with light-adjustable lenses (Calhoun Vision, Inc., Pasadena, California.), then treated with a digital light delivery device (Carl Zeiss-Meditec, Jena, Germany) to change the refractive outcome and then lock in the correction. Following treatment, 13 of 14 eyes (92.9%) were within 0.25D of intended refraction.
Corneal Cross-Linking
Refractive, topographic, tomographic, and aberrometric analysis of keratoconic eyes undergoing corneal cross-linking. Vinciguerra P, Albè E, Trazza S, Rosetta P, Vinciguerra R, Seiler T, Epstein D. Ophthalmology. 2009 Mar;116(3):369-78.
Corneal cross-linking (CXL) has become one of the hottest topics in cornea today. With its potential to halt keratoconus progression and reverse post-lasik ectasia, physicians worldwide are watching to see the true benefits. In this study, the authors evaluated 28 eyes of 28 patients with advanced keratoconus 12 months following corneal crosslinking. Statistically significant improvements were seen in UCVA and BCVA, likely secondary to reductions in mean average pupillary power, apical keratometry, and corneal/total wavefront aberrations (measured with Nidek OPD Scan (Nidek, Gamagori, Japan)).
Age-Related Macular Degeneration
Evaluation of injection frequency and visual acuity outcomes for ranibizumab monotherapy in exudative age-related macular degeneration. Dadgostar H, Ventura AA, Chung JY, Sharma S, Kaiser PK. Ophthalmology. 2009 Sep;116(9):1740-7.
Anti-VEGF therapy has become a mainstay of treatment for wet age-related macular degeneration. However, a “proper dosing schedule” has been difficult to elucidate. In this study, the authors found that visual improvement was more related to the dosing frequency of Ranibizumab (Lucentis, Genentech, South San Francisco, CA) than the resolution of fluid by OCT (Carl Zeiss Meditec, Inc., Dublin, CA). They conclude that treatment of wet ARMD on a “as-needed” basis may actually result in undertreatment and less visual gain.
IOL Lens Exchange
Intraocular lens exchange surgery in dissatisfied patients with refractive intraocular lenses. Galor A, Gonzalez M, Goldman D, O'Brien TP. J Cataract Refract Surg. 2009 Oct;35(10):1706-10.
While intraocular lens exchange has been an agreed upon treatment for patients with dislocated, opacified, or otherwise malfunctional IOLs, the risks of this procedure has left some physicians telling their patients to “live with/get used to” their visual obscurations when dissatisfied following refractive IOL implantation. In this study, the authors retrospectively review patients who underwent IOL exchange following uncomplicated cataract surgery with refractive IOLs. The authors concluded that IOL exchange is a safe procedure that should not be withheld from patients unhappy with their visual outcomes.
In summary, research published in 2009 resulted in many practice changes behaviors, not only with our current practices but we have glimpsed the future of the changes that will be implemented in the next few years. These changes will ultimately allow us to improve our patients’ vision and preserve it for longer than ever before.
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What articles changed your practice in 2009? Leave your thoughts in the Comments section below.