Correlation Between Ischemic Retinal Accidents and Radial Peripapillary Capillaries in the Optic Nerve Using Optical Coherence Tomographic Angiography: Observations in 6 Patients

Background: Perfusion of the optic nerve has been widely studied using fluorescein angiography (FAG), which is currently regarded as the criterion standard. However, FAG has adverse effects associated with intravenous contrast administration and is limited in its capacity to characterize and stratify the different vascular layers of the optic nerve and retina. The use of new imaging techniques, such as optical coherence tomographic angiography (Angio-OCT), is therefore important. Aim: A qualitative description is made of the vascular layers of the optic nerve and of how vascular events affect radial peripapillary capillaries (RPC). Two patients with central retinal artery occlusion (CRAO), 1 with arteritic anterior ischemic optic neuropathy (AAION), and 3 healthy subjects were studied. Results: The Angio-OCT imaging afforded better visualization of the depth of the RPC and rest of the vascular layers of the retina compared with FAG. Optic nerve surface perfusion was affected in AAION and proved normal in CRAO. Conclusions: Our results indicate that perfusion of the papilla and RPC mainly arises from the papillary plexus that depends on the posterior ciliary artery.

The Role of Focal Laser in the Anti–Vascular Endothelial Growth Factor Era

Introduction: To review important studies examining focal laser for diabetic macular edema (DME), to examine real-world data regarding actual treatments patients are receiving, to present long-term visual outcomes in real-world practice, and to suggest an evidence-based approach for the use of focal laser. Methods: This study is a review of landmark studies evaluating focal laser and pharmacologic therapy for DME. In addition, the authors include a retrospective review of 102 consecutive eyes of 53 patients in our practice setting in rural Alabama. A chart review was performed, and patients were included if they were diagnosed with DME and were treated with both focal laser and bevacizumab. Bevacizumab and focal laser were given on a “as needed basis” at the discretion of one treating physician (J.O.M.). Worse visual acuity or worsening macular edema were indications for additional treatment. Statistical analysis was performed using frequencies and percentages. Best-corrected visual acuity (BCVA) was recorded at baseline and at the end of treatment (mean of 5 years) in the medical record. Primary outcome measures were BCVA, patients with better than 20/40 BCVA, patients with worse than 20/200 BCVA, and patients with stable BCVA. Results: Anti–vascular endothelial growth factor (VEGF) therapies are the first-line treatment for DME, but real-world claims data suggest that diabetic patients cannot come in for monthly injections as in large clinical trials. In our series, after a mean of 5 lasers and 5.5 injections, 90% of eyes had stable or better BCVA, 65% were ≥20/40, and only 13% were ≤20/200. Conclusions: Laser treatment for DME remains an important adjunctive therapy

Optical Coherence Tomographic Angiography Imaging in Age-Related Macular Degeneration

Optical coherence tomographic angiography (OCTA) is emerging as a rapid, noninvasive imaging modality that can provide detailed structural and flow information on retinal and choroidal vasculature. This review contains an introduction of OCTA and summarizes the studies to date on OCTA imaging in age-related macular degeneration.

American Insight Into Strabismus Surgery Before 1838

English surgeon John Taylor attempted to perform strabismus surgery in the 18th century. The field languished until, in Germany, treatment of strabismus by cutting an extraocular muscle was proposed by Louis Stromeyer in 1838 and performed by Johann Friedrich Dieffenbach in 1839. According to traditional teaching, there has never been any proof that anyone in the United States thought of the idea of strabismus surgery before Stromeyer’s report. In 1841, American surgeon William Gibson wrote that he had cut extraocular muscles to treat strabismus several times beginning in 1818 but never published his cases. Gibson’s former trainee Alexander E Hosack of New York confirmed Gibson’s memory. Interestingly, Hosack’s family had a connection with the family of New York oculist John Scudder Jr (1807-1843), whose reported cure of strabismus by cutting some of the fibers of an extraocular muscle was described in newspapers throughout the United States in 1837. Thus, Scudder’s report preceded that of Stromeyer. Scudder’s claim cannot be verified, but his description could have influenced Stromeyer, and demonstrates that the idea of strabismus surgery did exist in America before 1838.

Prof Lalit Prakash Agarwal (1922-2004)—The Planner of the First-Ever National Blindness Control Program of the World

Prof Lalit Prakash Agarwal drafted the National Programme for Prevention of Visual Impairment and Control of Blindness (now called National Programme for Control of Blindness) in India in 1976, first of its kind in the world. With his vision well ahead of his time, he brought the concept of super-specialty in Indian ophthalmology. He founded Dr. Rajendra Prasad Centre for Ophthalmic Sciences, the apex governmental ophthalmological center of India. His contributions to modern Indian Ophthalmology were so profound that we may not be mistaken by calling him “the father of modern Indian Ophthalmology.”

Simultaneous Bilateral Cataract Surgery in Outreach Surgical Camps

Objectives: The aim of this study was to evaluate the safety and visual outcomes of simultaneous bilateral cataract surgery (SBCS) with intraocular lens implantation performed in outreach surgical eye camps. Methods: The medical records of 47 consecutive patients who underwent simultaneous bilateral small-incision cataract surgery between January 2010 and December 2015 in outreach surgical camps in rural Cameroon were reviewed. The measures included postoperative visual outcomes and intraoperative and postoperative complications. Results: Data from 94 eyes of 47 participants (30 men, 17 women; mean age: 60.93 ± 13.58 years, range: 45-80 years) were included in this study. The presented best visual acuity (VA) was less than 3/60 in 100% of the eyes. At the 4-week follow-up, 84.04% of the eyes showed increased VA of 1 line or more ( P = .001).Of these, 71 (75.53%) achieved good VA (greater than 6/18). Intraoperative or postoperative complications occurred in 19 (20.21%) eyes. The most serious intraoperative complication was a posterior capsule rupture and vitreous loss (2 patients, 2 eyes). The postoperative complications included a transient elevation in the intraocular pressure (6 eyes), chronic corneal oedema (5 eyes), iris capture (3 eyes), lens decentration (2 eyes), and hyphema (1 eye). No cases of postoperative endophthalmitis were recorded. Conclusions: Under the strict observation of endophthalmitis prophylaxis, SBCS is an option to reduce the cataract blindness backlog in rural areas of developing countries.

A Family of Early English Oculists (1600-1751), With a Reappraisal of John Thomas Woolhouse (1664-1733/1734)

Introduction: John Thomas Woolhouse (1666-1733/1734), who practiced in Paris, was part of a family with 5 generations of English oculists. Some historians have derided him as a “charlatan” and have criticized him for adhering to the old notion that a cataract was a membrane anterior to the lens. Methods: We reviewed treatises and digital records related to Woolhouse and his family and the handwritten notes of his 1721 lecture series at the Royal Society of Medicine. Results: We have identified 5 generations of oculists in Woolhouse’s family, by the names of Atwood, Stepkins, Ivy, and Beaumont. Woolhouse taught students from across Europe. He was one of the early proponents in Europe, inspired by Asian medical practices, to perform paracentesis to release aqueous for a new condition called hydrophthalmia. In Woolhouse’s system, some of these cases probably described angle-closure glaucoma. He was the first to attach the name glaucoma to the palpably hard eye in 1707. He may also have been the first to teach that a soft eye was unlikely to recover vision. Credit for these teachings has traditionally gone to one of his students, Johannes Zacharias Platner, in 1745. Some historians have stated that he proposed iridectomy as a theoretical procedure, which was later performed by Cheselden. In fact, Woolhouse described techniques he had performed which today would be called pupilloplasty, synechiolysis, or pupillary membrane lysis. He was also a pioneer in dacryocystectomy for chronic dacryocystitis and in congenital cataract surgery. His writings from 1716 onward repeatedly (and correctly) stressed that most of the patients with visual disorders required depression of the crystalline lens (for what he called glaucoma), as opposed to removal of an anterior membrane (which he called cataract). Conclusions: Woolhouse was a bold ophthalmic innovator and teacher who made major contributions which have lasted to this day. Although he did not admit it, he ultimately adopted much of the evolving understanding of the nature of lens opacities. However, his stubborn refusal to adopt the newer semantics has detracted from a full appreciation of his contributions.

Primary Synovial Sarcoma of the Orbit

Purpose: To describe the clinical, pathological, and immunohistochemical characteristics and therapies of a rare case of primary synovial sarcoma in the orbit. Design: Retrospective interventional case report. Participant: A 6-year-old girl with pathologically proven synovial sarcoma in the orbit. The diagnosis was confirmed by immunohistochemistry. Methods: The patient was treated with right lateral orbital and right temporal tumor resection, followed by chemotherapy. She was followed up every 3 months for 1 year. Results: The tumor was excised, and the patient received 5 courses of chemotherapy. She did well during the initial first-year follow-up with no recurrent signs. Conclusions: We reported the sixth case of primary synovial sarcoma in the orbit and the first case of a 6-year-old girl.

Conjunctival Flora of Human Immunodeficiency Virus Patients on Antiretroviral Treatment

Objectives: To determine the conjunctival flora of human immunodeficiency virus (HIV) patients on antiretroviral treatment (ART). Methodology: A total of 104 conjunctival swabs from 104 HIV patients on ART underwent microbiological evaluation to describe the flora. Result: There were 71 (68.26%) women and 33 (31.74%) men. The mean age was 42.9 ± 9.77 (range: 22-70) years. Negative cultures were found in 39 (37.50%) cases. Bacterial growth occurred in 65 (62.50%) cases. Coagulase-negative Staphylococcus was found in 59 eyes (90.76%), and coagulase-positive in 3 eyes (4.61%). There was a significant correlation between the duration of ART, the degrees of immunosuppression, and bacterial growth. Conclusions: Knowledge of the conjunctival flora in HIV patients may provide a better guideline in the choice of antibiotic for the management of ocular surface infections.

Ophthalmology in North America: Early Stories (1491-1801)

New World plants, such as tobacco, tomato, and chili, were held to have beneficial effects on the eyes. Indigenous healers rubbed or scraped the eyes or eyelids to treat inflammation, corneal opacities, and even eye irritation from smoke. European settlers used harsh treatments, such as bleeding and blistering, when the eyes were inflamed or had loss of vision with a normal appearance (gutta serena). In New Spain, surgery for corneal opacity was performed in 1601 and cataract couching in 1611. North American physicians knew of contralateral loss of vision after trauma or surgery (sympathetic ophthalmia), which they called “sympathy.” To date, the earliest identified cataract couching by a surgeon trained in the New World was performed in 1769 by John Bartlett of Rhode Island. The American Revolution negatively affected ophthalmology, as loyalist surgeons were expelled and others were consumed with wartime activities. After the war, cataract extraction was imported to America in earnest and academic development resumed. Charles F Bartlett, the son of John, performed cataract extraction but was also a “rapacious privateer.” In 1801, a doctor in the frontier territory of Kentucky observed anticholinergic poisoning by Datura stramonium (Jimsonweed) and suggested that this agent be applied topically to dilate the pupil before cataract extraction. John Warren at Harvard preferred couching in the 1790s, but, after his son returned from European training, recommended treating angle closure glaucoma by lens extraction. Other eye procedures described or advertised in America before the 19th century included enucleation, resection of conjunctival lesions or periocular tumors, treatment of lacrimal fistula, and fitting of prosthetic eyes.