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Contacts Vs. Iols for Congenital Cataract

Contacts Vs. Iols for Congenital Cataract

in Review News commentary and perspectives

Contacts vs. IOLs for Congenital

he verdict is in on the issue of optical correction

in children who undergo unilateral cataract

surgery before age 7 months: , corrected

with a contact , is a better option than an T CONTACT LENS PATIENT. Dr. Lambert examines a 6-year-old (IOL) for 55 others who received an aphakic girl in the IATS trial. This child was prescribed a most of these babies. IOL (median VA in contact lens in one at 1 month of age and could insert “Primary IOL implan- both groups, 0.90 logMAR her own contact lens by the age 4 years. tation should be reserved [20/159]). for those infants where, in More complications. pillary membranes occurred one normal eye. But the the opinion of the , However, a significantly 10 times more often in the thing about children is that the cost and handling of greater number of the pseu- pseudophakic . they’re going to live for a a contact lens would be so dophakic eyes required one Scott R. Lambert, MD, very long time, and it is burdensome as to result in or more additional intra- a professor of ophthalmol- important for them to have significant periods of uncor- operative procedures over ogy at Emory University in the best possible visual acu- rected aphakia,” stated the the course of the study (41 Atlanta and the lead inves- ity in their problem eye,” investigators in the Infant patients compared with tigator in the trial, credited he said, particularly in case Aphakia Treatment Study.1 12 in the aphakic group; advocacy by the pediatric anything should happen to Comparable VA. This p < .001), the researchers ophthalmology community their other eye. multicenter randomized found. At least one adverse for the National Eye Insti- About half of the chil- clinical trial determined event had occurred in a tute (NEI) decision nearly dren in both groups had that, at age 4.5 years, visual significantly greater num- a decade ago to support the at age 4.5 years outcomes were equivalent ber of IOL eyes (46 patients study, despite the rarity of of 20/200 or worse. But the between 57 aphakic children compared with 31 in the . study also demonstrated whose cataract was removed aphakic group; p < .02). Long-term outlook. the potential for excellent

emory eye center eye center emory at age 1 to 6 months and Lens proliferation and pu- “These children may have visual outcomes, he added.

eyenet 17 News in Review

“The very best child in our wise be available.” ogists might be called on to their eyes are doing well.” study ended up with 20/12 Dr. Lambert said the in- treat in the future. —Linda Roach vision in both eyes and vestigators now are examin- “We know that an IOL normal depth perception,” ing their data to determine puts them at increased risk 1 The Infant Aphakia Treatment Dr. Lambert noted. “I really which children with IOLs of having if they Study Group. JAMA Ophthal- think that this child’s life is are most likely to develop had when mol. 2014 March 6. [Epub ahead going to be different than if complications later in life, they were young,” he said. of print]. he were blind in one eye. It such as glaucoma or retinal “So these patients will need creates a lot of opportunities detachment—problems that ongoing eye care the rest of Dr. Lambert reports no related in life that would not other- comprehensive ophthalmol- their lives, to be sure that financial interests.

Cornea Caveats which are not available in all practices or centers, exacer- bating diagnostic delay.” Dangers of Steroids in Further impacting the outcomes—even after ac- curate diagnosis is finally Misdiagnosed made—the treatment of AK requires compounded anti-amoebic drugs that are he first cohort study in a binary (yes/no) clas- AK SIGN. The presence of not immediately available in optimized to ex- sification, they found that it radial perineuritis can aid smaller centers. Tamine the impact increased the risk of a sub- in the diagnosis of Acan- “Comprehensivists of topical optimal visual outcome by thamoeba keratitis. confronted with indolent on visual outcomes from almost fourfold after adjust- keratitis should consider re- ment for confounding vari- contact lens wearers, were ferring the patient to a cor- (AK) reported that steroid ables. Second, they classified initially misdiagnosed with nea specialist, who has the use before diagnosis of AK patients into three catego- HSV keratitis,” she said. resources and expertise in is not only widespread but ries by duration of steroid The early clinical signs managing unusual microbi- also highly detrimental to use (1-13 days, 14-30 days, of AK are highly variable al keratitis that’s unrespon- patients with this relatively and more than 30 days). and often appear very simi- sive to standard treatment,” uncommon disease.1 Given the small sample size lar to HSV keratitis, with Dr. Robaei advised. Study details. A chart in each category, the authors epithelial irregularity and Key takeaways. “Our review identified 196 pa- chose not to publish those dendritiform lesions. Pain study highlights the critical tients diagnosed with AK results in the article, ac- often—but not always—ac- importance of 1) having a at Moorfields Eye Hospital, cording to first author Dana companies early AK, and high index of suspicion for London, between January Robaei, MBBS, MPH, PhD, a lack of pain can mislead AK in contact lens wearers, 1991 and April 2012. Of FRANZCO, at the Univer- clinicians toward an HSV particularly before making these, 22 were excluded for sity of Sydney in Australia. diagnosis. Moreover, long- a diagnosis of HSV keratitis, missing data, leaving 174 pa- But, she said, more than 30 term contact lens wear is and in non–contact lens tients available for analysis. days of use was associated associated with reduced cor- users who have a persistent Half of the patients (87) had with an almost eightfold neal sensation, which also keratitis; and 2) the need for used topical steroids before increased risk of a poor may be incorrectly ascribed judicious use of topical cor- the diagnosis of AK. visual outcome, compared to HSV. Finally, photopho- ticosteroids when the pos- The primary outcome with 1-13 days (odds ratio, bia is associated with both sibility of AK has not been measure was a suboptimal 7.92; confidence interval, HSV keratitis and AK. definitively ruled out,” said visual outcome, defined as 2.0-32.1). “AK is an unusual cause Dr. Robaei. a final best-available visual Widespread misdiag- of microbial keratitis, and —Gabrielle Weiner acuity of 20/80 or worse nosis. This harmful use of general ophthalmologists (recorded after completion steroids is largely due to ini- seldom encounter it,” said 1 Robaei D et al. . of therapy for AK), corneal tial misdiagnosis of AK as Dr. Robaei. “Diagnosis 2014 March 17. [Epub ahead of perforation, or need for herpes simplex virus (HSV) often relies on ancillary print]. keratoplasty. keratitis. “In our study, techniques, such as confocal Researchers studied ste- 52.3 percent of all patients, microscopy and PCR [poly- Dr. Robaei reports no related fi-

roid use in two ways. First, the majority of whom were merase chain reaction], nancial interests. dana robaei, mbbs, mph, phd, franzco

18 june 2014 News in Review

Uveitis Therapy thrombocytopenia are also worrisome and, unfortu- nately, not rare. Chloram- Chlorambucil & Remission bucil also carries the risk of sterility, which is important to discuss with younger pa- In Sympathetic Ophthalmia tients.” However, she noted, the drug is well tolerated subjectively, with little or hort-term, high-dose 441 months). Chlorambucil no fatigue, nausea, or other chlorambucil prolongs controlled inflammation SYMPATHETIC OPHTHAL- bothersome symptoms. Sdrug-free remissions in all patients, 13 of whom MIA. Peripapillary and mul- “We know that in sym- for patients with sympa- (81.3 percent) maintained tifocal choroiditis with exu- pathetic ophthalmia, as thetic ophthalmia, accord- vision of 20/40 or better in dative . in other forms of , ing to a study conducted the sympathizing eye. outcomes are better with in Chicago and Buenos After stopping systemic true disease remission that earlier diagnosis and aggres- Aires.1 Lead author Debra A. therapy, four patients re- persists when all therapy has sive therapy,” Dr. Goldstein Goldstein, MD, director of lapsed at a median of 83 been discontinued.” added. “It is always discour- Northwestern University’s months (mean, 131 months). The advantages of chlo- aging to see a patient with uveitis service, further re- Topical treatment alone rambucil must be weighed potentially blinding posteri- ported that no systemic ma- controlled 75 percent of against the risks. “Certainly, or segment disease who has lignancies occurred among these relapses, which con- the risk of malignancy is the been managed for months the 16 patients treated with sisted of only mild anterior most worrisome, although or years with topical therapy the drug, although one pa- chamber inflammation. its occurrence is rare,” she only. Early consultation tient developed conjunctival “Long-term, drug-free said, adding that although with a specialist may help to Kaposi sarcoma. remission of sympathetic this study did not find an improve outcomes.” ­ The patients were given ophthalmia has not been increased risk of malig- —Marianne Doran chlorambucil for a median reported with nancy with the high-dose, of 14 weeks (mean, 14.5 therapy or other nonalkyl- short-term protocol, the 1 Patel SS et al. Ophthalmology. weeks; range, 12-19 weeks), ator-based treatments,” Dr. possibility must always be 2014;121(2):596-602. and the median follow-up Goldstein said. “In con- considered. was 98.5 months (mean, trast, short-term, high-dose “The development of Dr. Goldstein reports no related 139.1 months; range, 48- chlorambucil may result in profound neutropenia and financial interests.

Neuro News normally sighted drivers. made another important “Failure to scan sufficiently finding: Drivers with far into the blind hemifield complete HH may have Driving With Hemianopia could be due to a lack of the same amount of visual cues from peripheral vision field loss, yet differ greatly on that side,” she said. in their ability to compen- esearchers at Drivers with HH showed Due to inadequate scan- sate by scanning and to Schepens Eye Re- compensatory head scan- ning (either failing to scan detect potential hazards R search Institute ning by usually scanning or not scanning far enough), on their blind side. That’s used a driving simulator to first to the blind side. They drivers with left hemianopia why referring people with compare the head scanning also scanned more often to- detected only 46 percent, hemianopia for individual- behaviors of 14 drivers with ward that side than control and drivers with right ized driving assessments complete homonymous drivers did. However, they hemianopia detected only and training is essential, she hemianopia (HH) against 12 sometimes completely failed 8 percent, of blind-side pe- said. —Annie Stuart normally sighted (control) to scan toward the blind destrians at the extreme left drivers when approaching side, said lead author Alex and right of the intersection, 1 Bowers AR et al. Invest Oph- intersections.1 They also Bowers, PhD, assistant sci- respectively. thalmol Vis Sci. 2014;55(3):1540- evaluated the ability of driv- entist at Schepens. These results point to an 1548. ers to detect pedestrians on The magnitude of their area of potential concern, the right or left side at cer- head scans also tended to said Dr. Bowers. However, Dr. Bowers reports no related fi-

ramana s. moorthy, md, bcsc section 9, 2013-2014 tain intersections. be smaller than those of this and other studies have nancial interests.

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