New research from Chicago suggests that the incidence of stromal rejection in deep anterior lamellar keratoplasty is clinically significant and that these patients may benefit from corticosteroid regimens similar to those used in penetrating keratoplasty. 

The clinical records of 22 patients undergoing DALK by two surgeons between October 2006 and January 2008 were reviewed to identify patients who experienced stromal rejection. The diagnosis was made after the demonstration of acute stromal edema and/or stromal neovascularization in the absence of confounding preoperative conditions, such as herpetic keratitis. The incidence and clinical features of stromal rejection were compared with other descriptions found in the literature.

Five of 20 eligible patients experienced stromal rejection within 12 months. Two patients were on low-dose corticosteroids when diagnosed. Four of the five patients were treated aggressively with q1 to 3 hourly prednisolone acetate 1% eye drops. The fifth was treated less aggressively with a maximum dose of only q6 hourly prednisolone acetate 1% and subsequently experienced a second rejection episode less than five months later. All episodes resolved completely with treatment.
Olson E, Tu E, Basti S.

Retreatment with Anti-VEGF After Stabilization of AMD
European researchers evaluated the three-year therapeutic benefit of intravitreal bevacizumab in neovascular age-related macular degeneration and determined that while the functional and morphological benefits persisted for the first year after treatment, after this time both functional and morphological results were disappointing when visual acuity loss was the main retreatment criterion. 

In this interventional clinical study, 181 eyes of 160 consecutive patients with active neovascular AMD meeting recommended inclusion protocol criteria for anti-vascular endothelial growth factor therapy undergoing intravitreal bevacizumab monotherapy were observed. Data of treatment-naive eyes (Group 1, n=114) were analyzed separately from eyes that had undergone previous photodynamic therapy plus intravitreal triamcinolone (Group 2, n=67). Retreatment criteria were based on clinical outcomes following the official European label regimen. After one year of continuous service at an academic referral center, follow-up was performed in private practices in collaboration with the referral center. Main outcome parameters were best-corrected visual acuity and central retinal thickness.

After three years, BCVA decreased in the overall population (0.23 ±0.16 to 0.16 ±0.21, p=0.002) and in both groups compared with baseline (0.24 ±0.21 to 0.17 ±0.21, Group 1, p=0.03; 0.22 ±0.19 to 0.16 ±0.21, Group 2, p>0.05), whereas central retinal thickness increased in the overall population (291 ±92 to 319 ±110 μm, p=0.01) and in both groups (291 ±96 to 325 ±117 μm, Group 1, p>0.05; 290 ±83 to 308 ±96 μm, Group 2, p>0.05) because of chronic cystic degeneration changes of the macula. Mean treatment rate was 5.1 ±3.9 (Group 1) versus 3.7 ±2.7 (Group 2, p=0.01). Five cases of severe intraocular inflammation after intravitreal bevacizumab were documented. 
Dunavoelgyi R, Sacu S, Eibenberger K, Palkovits S, et al.

Retinovascular Pathology May Reflect Renal Disease
New findings from the Chronic Renal Failure Insufficiency Cohort (CRIC) study show a strong association between severity of retinopathy and its features and level of kidney function, after adjustment for traditional and non-traditional risk factors for chronic kidney disease, suggesting that retinovascular pathology reflects renal disease.

In this observational cross-sectional study, 2,605 patients of the CRIC study, a multicenter study of chronic kidney disease, were offered participation. Nonmydriatic fundus photographs of the disc and macula in both eyes were obtained in 1,936 of these subjects. The photographs were reviewed in a masked fashion at a central photograph reading center using standard protocols. Presence and severity of retinopathy (diabetic, hypertensive or other) and vessel diameter caliber were assessed by trained graders and a retinal specialist using protocols developed for large epidemiologic studies. Kidney function measurements and information on traditional and nontraditional risk factors for decreased kidney function were obtained from the CRIC study.

Greater severity of retinopathy was associated with lower estimated glomerular filtration rate after adjustment for traditional and nontraditional risk factors. The presence of vascular abnormalities usually associated with hypertension was also associated with lower estimated glomerular filtration rate. The authors found no strong direct relationship between estimated glomerular filtration rate and average arteriolar or venular calibers.
Grunwald J, Alexander J, Ying G, Maguire M, et al.

SLT an Effective Initial Therapy For OAG or Ocular Hypertension
Results from the Wills Eye Institute support the option of selective laser trabeculoplasty as a safe and effective initial therapy in open-angle glaucoma or ocular hypertension.

In this prospective, randomized clinical trial, 69 patients (127 eyes) with open-angle glaucoma or ocular hypertension were randomized to SLT or medical therapy. Target intraocular pressure was determined using the Collaborative Initial Glaucoma Treatment Study formula. Patients were treated with SLT (100 360-degree applications) or medical therapy (prostaglandin analog). Six visits over one year followed initial treatment. If the target IOP range was not attained with SLT, additional SLT was the next step; in the medical arm, additional medications were added. The primary outcome measured was IOP, with the secondary outcome being the number of steps to achieve target IOP.

Data collection terminated with 54 patients reaching nine- to 12-months follow-up. Twenty-nine patients were in the SLT group and 25 patients in the medical group. Baseline mean IOP for all eyes was 24.5 mmHg in the SLT group and 24.7 mmHg in the medical group. Mean IOP (both eyes) at last follow-up was 18.2 mmHg (6.3 mmHg reduction) in the SLT arm and 17.7 mmHg (7 mmHg reduction) in the medical arm. By the last follow-up, 11 percent of the eyes received additional SLT and 27 percent required additional medication. There was no statistically significant difference between the SLT and medication groups.
Katz L, Steinman W, Kabir A, Molineaux J, et al.

Preventing Bleb Failure: Off-label Bevacizumab vs. MMC
In this pilot study, with a small number of subjects, short-term outcomes suggest that subconjunctival bevacizumab (1.25 mg in 0.05 mL) and 0.03% mitomycin-c are equally effective in reducing intraocular pressure, with a better safety profile for bevacizumab in the dosing schedule studied. However, bevacizumab soaked in a sponge appears to have no advantages over MMC. 

Thirty-eight consecutive patients with visually significant cataract and coexistent primary open-angle glaucoma or chronic angle-closure glaucoma were randomized into three groups. One group received conventional 0.03% MMC (n=13); the second group received three subconjunctival injections of bevacizumab (1.25 mg in 0.05 mL; n=13); and the third group received bevacizumab soaked in sponges (1.25 mg in 0.05 mL; n=12) intraoperatively on the sclera. Patients were followed up for six months. The primary outcome measure was treatment success and bleb morphology in the study eye at six-month follow-up.

All three groups showed significant reduction in mean IOP at one week after treatment, which was maintained at six months. However, 90 percent of the subconjunctival bevacizumab group had complete success as opposed to 60 percent in each of the other two groups (p=0.04). In both bevacizumab groups, bleb vascularity increased progressively over the six-month follow-up. (One patient in the subconjunctival bevacizumab group showed a local conjunctival necrosis.)
Sengupta S, Venkatesh R, Ravindran R.

Two-Year CXL Results in Pediatric Keratoconus Patients
European university researchers report that corneal cross-linking improved uncorrected visual acuity and best spectacle-corrected vision in patients up to age 18 years of age with progressive keratoconus, most likely by significantly reducing corneal asymmetry and corneal, as well as total, wavefront aberrations.

In the prospective, interventional case series, 40 eyes of pediatric patients underwent riboflavin-ultraviolet A-induced CXL. UCVA, BSCVA, sphere and cylinder, topography, aberrometry and endothelial cell counts were evaluated at baseline and at one, three, six, 12 and 24 months. 
The improvement in UCVA and BSCVA was significant throughout the postoperative follow-up (p=0.02). Mean logarithm of the minimum angle of resolution baseline UCVA and BSCVA were 0.79 ±0.21 and 0.39 ±0.10. Mean UCVA and BSCVA at two years were 0.58 ±0.18 and 0.20 ±0.09. Mean spherical equivalent refraction showed a significant decrease of 1.57 D at 24 months (p=0.02). Mean baseline simulated keratometry was 46.33 D in the flattest meridian and 51.48 D in the steepest meridian; at two years, the values were 45.3 D (p=0.04) and 50.21 D (p=0.07). For a 3-mm pupil, there was a significant reduction (p<0.05) in whole eye (total), corneal, higher-order and astigmatic wavefront aberrations at 24 months. A significant difference (p<0.05) in total coma and total spherical aberration two years after CXL was also observed. Mean baseline pupil center pachymetry decreased significantly (p=0.04) at six months, but recovered by 12 months and remained stable thereafter through the two-year follow-up. Endothelial cell count did not change significantly (p=0.32).
Vinciguerra P, Albé E, Frueh B, Trazza S, Epstein D.