Researchers in Chicago have determined that the use of topical proparacaine drops, compared to 4% lidocaine solution or 3.5% lidocaine gel, provides a very effective and cost-effective anesthesia during office-based intravitreal injections.

One hundred and twenty sequential patients undergoing intravitreal injections were randomized to one of three groups: proparacaine 0.5% drops (Group 1); proparacaine + 4% lidocaine-soaked cotton-tipped swabs (Group 2); or 3.5% lidocaine gel (Group 3). Discomfort associated with the lid speculum, with the needle and with burning sensation was graded on a scale of 0 (no pain) to 10 (worst pain ever). The overall injection experience was graded as excellent, very good, fair, poor or awful.

The average lid speculum pain score  was 0.85 (Group 1), 0.50 (Group 2) and 0.65 (Group 3) (p=0.32). The average needle pain score for Group 1 was 1.78, Group 2 was 1.75 and Group 3 was 1.48 (p=0.38). The average burning pain score was 1.45 for Group 1, 1.58 for Group 2 and 1.13 for Group 3 (p=0.23). Overall satisfaction was rated as excellent or very good in 95 percent, 97.5 percent and 92.5 percent of Group 1, 2 and 3 patients (p=0.64).

Davis M, Pollack J, Shott S.

Treating Ocular Squamous Cell Carcinoma with Ranibizumab 
A two-year non-randomized, single center, Phase I pilot study has shown that subconjunctival ranibizumab induced regression of squamous cell carcinoma of the conjunctiva and cornea. Anti-VEGF chemotherapy may offer a new strategy for treatment, complement excision and cryotherapy, or provide an alternative to radiation and/or exenteration.

Five male patients with biopsy-proven, recurrent squamous cell carcinoma of the conjunctiva and cornea were enrolled to test the safety, tolerability and efficacy of subconjunctival ranibizumab as an alternative to radiation or exenteration. Tumors were multifocal and involved between eight and 12 clock hours of the limbus. Subconjunctival ranibizumab (0.5 mg) was given on a monthly or twice monthly basis. A median of 22 injections (r: 12 to 27) was given over a mean of 19 months (r: six to 24). Patients were examined for safety, tolerability and efficacy using visual acuity, blood pressure, urinalysis, comparative slit lamp biomicropsy with photography and high frequency ultrasound imaging.

Three patients had a complete response (no clinically apparent disease) during the two-year study, while two failed treatment despite demonstrating an initial partial response. Treatment was well-tolerated, as four patients demonstrated stable or improved visual acuity and none had significant systemic or ocular side effects.

Finger P, Chin C.

Distribution of Evaporative and Aqueous-Deficient Dry Eye
Doctors evaluating patients in a general clinic-based cohort report that the proportion of subjects exhibiting signs of evaporative dry eye resulting from meibomian gland dysfunction far outweighs that of subjects with pure aqueous-deficient dry eye.

Schirmer tests and MGD (Foulks-Bron scoring) were evaluated in both eyes of 299 normal subjects and dry-eye disease patients (218 women and 81 men) across 10 sites in the European Union and the United States. Using the more severe measurement of the two eyes, subjects were considered to have pure aqueous-deficient dry eye with Schirmer values of <7 mm and MGD grades of ≤5. Patients were classified as purely evaporative dry eye with MGD grades of >5 and Schirmer values of ≥7 mm. Subjects were placed in the mixed (hybrid) category if they exhibited both a low Schirmer value of <7 and evidence of MGD with a grade >5.

Of the 244 subjects classified with DED, 159 were classified into one of three categories: 79 were classified with only MGD; 23 were classified as purely aqueous deficient; and 57 showed evidence of both MGD and aqueous deficiency. Overall, 86 percent of these qualified DED patients demonstrated signs of MGD. The remaining 65 patients showed evidence of DED through other clinical signs, without overt evidence of MGD or ADDE, possibly because of the inherent variability of these signs.

Lemp M, Crews L, Bron A, Foulks G, Sullivan B.

Lower Corneal Hysteresis Associated With VF Progression
New York City researchers have determined that corneal biomechanical and physical properties, such as corneal hysteresis and central corneal thickness, are highly correlated and associated with visual field progression.

This retrospective study included glaucoma patients who underwent complete ophthalmic examination and tonometry using both the Goldmann applanation tonometer and the Ocular Response Analyzer. Only eyes with ≥5 SITA Standard 24-2 VF tests were included. Automated pointwise linear regression analysis was used to determine VF progression. One hundred fifty-three eyes (153 patients; mean age, 61.3  ±14 years; mean number of VF, 8.5 ±3.4; mean follow-up time, 5.3 ±two years) met the enrollment criteria.

The mean global rate of change was -0.34 ±0.7 dB/u. Twenty-five eyes (16 percent) reached a progression endpoint. Progressing eyes had lower CCT (525.0 ±34.2 versus 542.3 ±38.5 μm, p=0.04) and lower CH (7.5 ±1.4 versus 9.0 ±1.8 mmHg, p=0.01) compared with nonprogressing eyes. CH and CCT correlated significantly (r=0.33, p<0.01). By multivariate analysis, peak intraocular pressure (odds ratio=1.13 per mmHg higher, p<0.01), age (OR=1.57 per decade older, p=0.03) and CH (OR=1.55 per mmHg lower, p<0.01) remained statistically significant. As CH may describe corneal properties more completely than thickness alone, it may be a parameter that is better associated with progression.

De Morase C, Hill V, Tello C, Liebmann J, Ritch R.

Computer Tutorial Enhances Patient Informed Consent
Researchers in Germany suggest that an interactive, computer-based learning tutorial, combined with face-to-face discussion, achieves better informed consent for cataract surgery than the conventional informed-consent procedure.

Patients with bilateral cataract scheduled for cataract surgery at the same center were randomly allocated to a study group (60 patients) or control group (30 patients) in this controlled, triple-masked clinical trial. Patients in the study group were given an interactive computer-based tool (CatInfo) containing a detailed audiovisual presentation about cataract and its treatment. Patients in the control group watched a short sham computer presentation without cataract information. Then, all patients had a face-to-face informed consent discussion with a physician. Afterward, patients in both groups received the same validated questionnaire with cataract-related questions.

Patients in the study group were significantly better informed, answering more questions correctly than the control group patients (15 versus 12 of 19). The mean age was 73 years (r: 51 to 90) in the study group and 75 years (r: 48 to 94) in the control group. There was an age effect in the study group, with the computerized tool having a greater impact on elderly patients.

Wollinger C, Hirnschall N, Findl O.

Full-Cycle Steam Sterilization And Wrapped Instruments
Researchers have determined that wrapping instruments in conjunction with full-cycle steam sterilization does not affect the incidence of postoperative infection in patients undergoing ophthalmic surgery in a dedicated eye center, providing the first concrete data corroborating the positions of the Joint Commission, American Academy of Ophthalmology and American Society of Cataract and Refractive Surgery.

Two consecutive groups, each of approximately 19,000 ophthalmic surgical patients, were reviewed for postoperative infection. For both groups, the surgical instruments were sterilized using full-cycle steam sterilization. For the first group, the instruments were sterilized with equipment located adjacent to the operating room, and no wrapping of the instruments was used. The sterilization equipment for the second group was located at a central facility and the instruments were wrapped before being transported to the operating room.

In the unwrapped sterilization group, 17 presumed postoperative infections were identified, compared to nine presumed postoperative infections in the wrapped sterilization group. Because the observed infection rates for each group were so low, this apparent different is not statistically significant (p=0.16). Similarly, differences found in the incidence of culture-positive cases of endophthalmitis (five for unwrapped vs. three for wrapped) were not statistically significant (p=0.47). This provides strong evidence that if eye surgical facilities carefully clean surgical instruments and follow industry and manufacturer guidelines, they can, with confidence, use either of these two methods of sterilization.

Carpel E, Mancera A, Rowan L, Etine G, Etine O.