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 Table of Contents  
Year : 2016  |  Volume : 28  |  Issue : 1  |  Page : 76-78

Journal review

Department of Ophthalmology, Little Flower Hospital, Angamaly, Kerala, India

Date of Web Publication11-Nov-2016

Correspondence Address:
Karthika Ajith
Department of Ophthalmology, Little Flower Hospital, Angamaly, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0976-6677.193863

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How to cite this article:
Ajith K. Journal review. Kerala J Ophthalmol 2016;28:76-8

How to cite this URL:
Ajith K. Journal review. Kerala J Ophthalmol [serial online] 2016 [cited 2019 Sep 21];28:76-8. Available from: http://www.kjophthal.com/text.asp?2016/28/1/76/193863

Adjuvant Role of Amniotic Membrane Transplantation in Acute Ocular Steven Johnson Syndrome-A Randomized Control Trials

Namratha Sharma, S. A. Thenarasun, Manpreet Kaur, Neelam Pushker, Neena Khanna, Tushar Agarwal, Rasik B. Vajpayee; Ophthalmology 2016;123:484-91.

The study was designed to evaluate the adjuvant role of amniotic membrane transplantation in cases of acute ocular Steven–Johnson syndrome (SJS). It was a prospective randomized controlled clinical trial conducted at Dr. Rajendra Prasad Centre For Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. Twenty Five patients (50 eyes) with acute ocular SJS who presented within 4 weeks of onset of symptoms were recruited during the time period of May 7, 2013 to May 15, 2014.

The patients were randomized into two groups using a computer-generated random number table. Group 1 (n = 25) underwent amniotic membrane transplantation (AMT) with standard medical therapy (MT) and group 2 received standard MT alone. The patients were evaluated at presentation and during follow-up at 1 week, 1 month, 3 months, and 6 months. The parameters evaluated were the best corrected visual acuity (BCVA), Schirmer test, tear film break up time (TBUT), conjunctival congestion, corneal haze, vascularization, conjunctivalization, and limbal stem cell involvement; lid edema, symblepharon, ankyloblepharon, ectropion, entropion, trichiasis, and metaplastic lashes were also analyzed. Maintenance of BCVA and stale ocular surface were considered as the main outcome measures.

The conventional conservative treatment consisted of topical antibiotics, topical steroids, topical lubricants, and regular sweeping of the fornices.

The patients were followed up until December 12 2014. At the end of 6 months, the mean BCVA was significantly better in the AMT group (0.068 ± 0.10 logMAR units) compared with the MT group (0.522 ± 0.52 logMAR units; P = 0.042). The mean TBUT in the AMT and MT groups was 9.92 ± 4.1 and 6.96 ± 4.5 seconds, respectively (P = 0.015). The mean Schirmer test results in the AMT and MT groups were 15.4 ± 6.3 mm and 8.64 ± 5.4 mm, respectively (P < 0.001). Conjunctival congestion persisted in 44% (11/25) in the MT group compared with 4% (1/25) in the AMT group (P = 0.03) at the end of the 6 month follow up. No case in the AMT group demonstrated corneal haze, limbal stem cell deficiency, symblepharon, ankyloblepharon, or lid-related complications. Among the eyes in the MT group, corneal haze occurred in 44% (11/25; P = 0.001), corneal vascularization and conjunctivalization in 24% (6/25; P = 0.03), symblepharon in 16% (4/25; P = 0.12), ankyloblepharon in 4% (1/25; P = 1.00), ectropion and entropion in 8% (6/25; P = 0.03) eyes.

The authors claim this to be the first prospective randomized study comparing the adjuvant use of AMT with MT alone. They screened all patients who presented within 4 weeks of onset of symptoms of SJS-TEN at the dermatology department of All India Institute of Medical Sciences regardless of the presence of any obvious signs or symptoms so that even mild ocular involvement cases that are missed in other retrospective studies were taken into account. In this study, anticonvulsants were found to be the main inciting agents (40%). Others involved antipyretics, nonsteroidal anti-inflammatory drugs, allopurinol, antipsychotics, highly active antiretro viral therapy, and ciprofloxacin. Ocular involvement was found in 100% of patients with acute SJS-TEN seeking treatment there, with most eyes having mild involvement only. Its only in the medical therapy alone group that most of the complications were noted; the adjunctive use of AMT also helped to prevent intermediate-term ocular cicatricial sequelae.

Efficacy of Intravitreal Injection of Conbercept in Polypoidal Choroidal Vasculopathy-Subgroup Analysis of the Aurora Study

Jinfeng Qu, Yong Cheng, Xiaoxin Li, Liyun Yu, Xiao Ke, on behalf of the AURORA study group; Retina 2016;36:926-37.

There is no widely accepted and effective method for treating polypoidal choroidal vasculopathy (PCV). Nowadays, PDT is the most widely used treatment because most studies using PDT monotherapy for PCV have reported favorable short to midterm results, with stable or improved vision and regression of polyps achieved in 80% to 95% of eyes. However, PDT was not effective in occluding branching vascular networks. Moreover, the mean BCVA usually decreases below baseline with a recurrence rate of 59–79% at 3 years or 5 years after the initiation of PDT monotherapy. Furthermore, several serious complications after PDT were reported, such as massive subretinal hemorrhages, retinal pigment epithelium tears, and retinal atrophy.

The purpose of this study was to evaluate the efficacy of different doses of conbercept (KH902; Chengdu Kanghong Biotech Co, Ltd, Sichuan, China, the most recent member of the anti-VEGF family) in patients with PCV in the AURORA study.

It is a retrospective subgroup analyses of 12-month data from the AURORA study. Fifty-three patients (32 in 0.5-mg group and 21 in 2.0-mg group) diagnosed with PCV in the AURORA study were retrospectively evaluated. Efficacy outcomes were compared between the two dosage groups. At each monthly visit, all patients undertook ophthalmologic examinations, including BCVA testing, ophthalmoscopy, color fundus photography, and optical coherence tomography. Fluorescein angiography and indocyanine green angiography (ICGA) were performed at baseline and at months 3, 8, and 12.

At month 12, mean changes in BCVA from baseline were 14.4 ± 14.1 letter scores for the 0.5-mg group and 14.2 ± 21.0 letter scores for the 2.0-mg group; mean central retinal thickness decreased by 104.5 ± 127.3 mm in the 0.5-mg group and 140.7 ± 127.9 mm in the 2.0-mg group; mean total macular volume decreased by 0.9 ± 2.3 mm 3 and 1.0 ± 1.2 mm 3 in the 0.5-mg and 2.0-mg groups, respectively. The mean subretinal fluid thickness decreased by 111.9 ± 122.5 mm and 76.3 ± 112.6 mm in the 0.5-mg and 2.0-mg groups, respectively. The mean pigment epithelial detachment height decreased by 79.3 ± 217.8 mm and 61.3 ± 161.5 mm in the 0.5-mg and 2.0-mg groups, respectively. The mean area of polyps decreased by 0.46 ± 0.76 mm 2 and 0.55 ± 1.34 mm 2 in the 0.5-mg and 2.0-mg groups, respectively. The mean total lesion area decreased by 2.51 ± 5.94 mm 2 (P = 0.088) and 4.62 ± 5.51 mm 2 in the 0.5-mg group and 2.0-mg groups, respectively. Complete regression of polyps was observed in 56.5% of patients in the 0.5-mg group and 52.9% of those in the 2.0-mg group, whereas partial regression was observed in 26.1% and 35.3% of patients in the 0.5-mg and 2.0-mg groups, respectively.

Thus, intravitreal injection of conbercept appears to significantly improve visual acuity and anatomical outcomes in patients with PCV. Limitations of this study include its retrospective design, limited sample size, and the absence of a control group. Conbercept, as a novel anti-VEGF agent, has a higher affinity for all isoforms of VEGF-A than bevacizumab, ranibizumab, or aflibercept, and this could be one of the mechanisms for the better outcome for PCV. Overall, conbercept was well-tolerated, and the incidence of ocular adverse events was low. The most common adverse events were conjunctival hemorrhage caused by the intravitreal injection procedure. No other systemic or serious ocular adverse effect noted. The true incidence of ocular and nonocular adverse effects could not be calculated because of limited number of patients with PCV in the AURORA study.

The Cosmetic Outcome of External Dacryocystorhinostomy Scar and Factors Affecting it

Mostafa A. Waly, Osama E. Shalaby, Molham A. Elbakary, Aiman A, Hashish; Indian J Ophthalmol 2016;64:261-5.

There is an increasing demand on an oculoplastic surgeon from their patients and referring physicians to perform endonasal surgery. Young and middle-aged patients are increasingly aware of the endonasal approach and are easily dissuaded by a skin scar. While we wait for endonasal procedures to evolve and achieve comparable success rates, an external approach dacryocystorhinostomy (DCR) that can successfully hide the scar is highly desirable.

The aim of this study was to evaluate the cosmetic outcome of Ex-DCR among Egyptian patients and to identify the factors affecting it.

This was prospective randomized interventional study which included 40 patients who underwent Ex-DCR over a period of 18 months (July 2013 to December 2014). Patients were subjected to full ophthalmological evaluation and lacrimal system examination including fluorescein dye disappearance test, regurgitation test, diagnostic probing, and irrigation. Patients with punctal or canalicular pathology, acute dacryocystitis, or previous lacrimal surgery were excluded from the study. The patients were randomly distributed between two age and sex-matched groups, each one including 20 patients. In 20 patients, medial canthal vertical incision was used, and in the 20 twenty cases, subciliary incision was used. The skin was closed using vicryl 6-0 or prolene 6-0 interrupted sutures, and each one was randomly used in 20 patients (10 patients of each incision type). Cosmetic outcome was evaluated 6 months postoperatively by the patients and by an oculoplastic surgeon on a four-grade scale. Cosmetic results and its correlation to patients' age, sex, skin complexion, type of incision, and type of skin sutures were studied. The functional outcome was judged by symptomatic relief of epiphora and patent syringing of the lacrimal passages.

The mean scar grading was 0.98 ± 1.0 and 1.3 ± 1.0 in patients' and examiner's assessment. Approximately 27.5% described their scars as cosmetically significant. The cosmetic outcome was significantly affected by the type of incision with only 5% significant scars in subciliary incision group. Prolene 6-0 suture was associated with better cosmetic results with 15% significant scars. Fifty percent of dark-skinned patients showed cosmetically significant scars. Although no correlation was found between patients' age and cosmetic outcome, pediatric patients showed higher tendency to scar visibility with mean scar grade 1.2 ± 1.0 and 1.5 ± 0.9 in patients' and examiner's assessment, respectively.

The effect of the type of sutures used for skin closure on Ex-DCR scar was not studied before. The cosmetic advantage of subciliary incision was not reported prior in detail. Few studies have looked at the cosmetic significance of Ex-DCR scar, and there is no established method for patient assessment of surgical scars. Previously published studies about Ex-DCR have shown that patient satisfaction may not necessarily correlate with objective success rate, and in case of a cutaneous scar, the only reliable way to ascertain the significance of the scar is from patient feedback.

The study concluded that, although the cosmetic results of Ex-DCR scar were not affected by the patient's age, pediatric patients show higher tendency for visible scars. Dark-skinned patients are more prone to develop cosmetically-significant scars. The use of subciliary approach significantly improves the cosmetic outcome and the use of monofilament nonabsorbable sutures for skin closure (as prolene 6-0) is associated with less scar visibility.

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There are no conflicts of interest.

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