Oculo-visual changes and clinical considerations affecting older patients with dementia

Purpose: Dementia is associated with various alterations of the eye and visual function. Over 60% of cases are attributable to Alzheimer's disease, a significant proportion of the remainder to vascular dementia or dementia with Lewy bodies, while frontotemporal dementia, and Parkinson's disease dementia are less common. This review describes the oculo-visual problems of these five dementias and the pathological changes which may explain these symptoms. It further discusses clinical considerations to help the clinician care for older patients affected by dementia. Recent findings: Visual problems in dementia include loss of visual acuity, defects in colour vision and visual masking tests, changes in pupillary response to mydriatics, defects in fixation and smooth and saccadic eye movements, changes in contrast sensitivity function and visual evoked potentials, and disturbance of complex visual functions such as in reading ability, visuospatial function, and the naming and identification of objects. Pathological changes have also been reported affecting the crystalline lens, retina, optic nerve, and visual cortex. Clinically, issues such as cataract surgery, correcting the refractive error, quality of life, falls, visual impairment and eye care for dementia have been addressed. Summary: Many visual changes occur across dementias, are controversial, often based on limited patient numbers, and no single feature can be regarded as diagnostic of any specific dementia. Nevertheless, visual hallucinations may be more characteristic of dementia with Lewy bodies and Parkinson's disease dementia than Alzheimer's disease or frontotemporal dementia. Differences in saccadic eye movement dysfunction may also help to distinguish Alzheimer's disease from frontotemporal dementia and Parkinson's disease dementia from dementia with Lewy bodies. Eye care professionals need to keep informed of the growing literature in vision/dementia, be attentive to signs and symptoms suggestive of cognitive impairment, and be able to adapt their practice and clinical interventions to best serve patients with dementia.

Measurement of scleral thickness in humans using anterior segment optical coherent tomography

Anterior segment optical coherent tomography (AS-OCT, Visante; Zeiss) is used to examine meridional variation in anterior scleral thickness (AST) and its association with refractive error, ethnicity and gender. Scleral cross-sections of 74 individuals (28 males; 46 females; aged between 18-40 years (27.7±5.3)) were sampled twice in random order in 8 meridians: [superior (S), inferior (I), nasal (N), temporal (T), superior-temporal (ST), superior-nasal (SN), inferior-temporal (IT) and inferior-nasal (IN)]. AST was measured in 1mm anterior-toposterior increments (designated the A-P distance) from the scleral spur (SS) over a 6mm distance. Axial length and refractive error were measured with a Zeiss IOLMaster biometer and an open-view binocular Shin-Nippon autorefractor. Intra- And inter-observer variability of AST was assessed for each of the 8 meridians. Mixed repeated measures ANOVAs tested meridional and A-P distance differences in AST with refractive error, gender and ethnicity. Only right eye data were analysed. AST (mean±SD) across all meridians and A-P distances was 725±46μm. Meridian SN was the thinnest (662±57μm) and I the thickest (806 ±60μm). Significant differences were found between all meridians (p<0.001), except S:ST, IT:IN, IT:N and IN:N. Significant differences between A-P distances were found except between SS and 6 mm and between 2 and 4mm. AST measurements at 1mm (682±48 μm) were the thinnest and at 6mm (818±49 μm) the thickest (p<0.001); a significant interaction occurred between meridians and A-P distances (p<0.001). AST was significantly greater (p<0.001) in male subjects but no significant differences were found between refractive error or ethnicity. Significant variations in AST occur with regard to meridian and distance from the SS and may have utility in selecting optimum sites for pharmaceutical or surgical intervention.

Clinical evaluation of the Shin-Nippon SRW-5000 autorefractor in adults:an update

Purpose: The Shin-Nippon SRW-5000 is an open view autorefractor that superseded the Canon R-1 autorefractor in the mid-1990s and has been used widely in optometry and vision science laboratories. It has been used to measure refractive error, accommodation responses both statically and dynamically, off-axis refractive error, and adapted to measure pupil size. This paper presents an overview of the original 2001 clinical evaluation of the SRW-5000 in adults (Mallen et al., Ophthal Physiol Opt 2001; 21: 101) and provides an update on the use and modification of the instrument since the original publication. Recent findings: The SRW-5000 instrument, and the family of devices which followed, have shown excellent validity, repeatability, and utility in clinical and research settings. The instruments have also shown great potential for increased research functionality following a number of modifications. Summary: The SRW-5000 and its derivatives have been, and continue to be, of significant importance in our drive to understand myopia progression, myopia control techniques, and oculomotor function in human vision.

Excimer laser surface ablation - a review

Corneal surface laser ablation procedures for the correction of refractive error have enjoyed a resurgence of interest, especially in patients with a possible increased risk of complications after lamellar surgery. Improvements in the understanding of corneal biomechanical changes, the modulation of wound healing, laser technology including ablation profiles and different methods for epithelial removal have widened the scope for surface ablation. This article discusses photorefractive keratectomy, trans-epithelial photorefractive keratectomy, laser-assisted sub-epithelial keratomileusis and epithelial-laser-assisted in situ keratomileusis. © 2010 The Authors. Journal compilation © 2010 Royal Australian and New Zealand College of Ophthalmologists.

Ciliary muscle morphology in emmetropia and ocular biometric correlates

Purpose: Recent studies have documented a link between axial myopia and ciliary muscle morphology; yet, the variation in biometric characteristics of the emmetropic ciliary muscle are not fully known. Ciliary muscle morphology, including symmetry, was investigated between both eyes of emmetropic participants and correlated to ocular biometric parameters. Methods: Anterior segment optical coherence tomography (Zeiss, Visante) was utilised to image both eyes of 49 emmetropic participants (mean spherical equivalent refractive error (MSE) ≥ -0.55; < +0.75 D), aged 19 to 26 years. High resolution images were obtained of nasal and temporal aspects of the ciliary muscle in the relaxed state. MSE of both eyes was recorded using the Grand Seiko WAM 5500; axial length (AXL), anterior chamber depth (ACD) and lens thickness (LT) of the right eye were obtained using the Haag-streit Lenstar LS 900 biometer. A bespoke semi-objective analysis programme was used to measure a range of ciliary muscle parameters. Results: Temporal ciliary muscle overall length (CML) was greater than nasal CML, in both eyes (right: 3.58 ± 0.40 mm and 3.85 ± 0.39 mm for nasal and temporal aspects, respectively, P < 0.001; left: 3.65 ± 0.35 mm and 3.88 ± 0.41 mm for nasal and temporal aspects, respectively, P < 0.001). Temporal ciliary muscle thickness (CMT) was greater than nasal CMT at 2 mm and 3 mm from the scleral spur (CM2 and CM3, respectively) in each eye (right CM2: 0.29 ± 0.05 mm and 0.32 ± 0.05 mm for nasal and temporal aspects, respectively, P < 0.001; left CM2: 0.30 ± 0.05 mm and 0.32 ± 0.05 mm for nasal and temporal aspects, respectively, P < 0.001; right CM3: 0.13 ± 0.05 mm and 0.16 ± 0.04 mm for nasal and temporal aspects, respectively, P < 0.001; left CM3: 0.14 ± 0.04 mm and 0.17 ± 0.05 mm for nasal and temporal aspects, respectively, P < 0.001). AXL was positively correlated with ciliary muscle anterior length (AL) (e.g. P < 0.001, r2 = 0.262 for left temporal aspect), CML (P = 0.003, r2 = 0.175 for right nasal aspect) and ACD (P = 0.01, r2 = 0.181). Conclusions: Morphological characteristics of the ciliary muscle in emmetropic eyes display high levels of symmetry between the eyes. Greater CML and AL are linked to greater AXL and ACD, indicating ciliary muscle growth with normal ocular development.

Self-refraction, ready-made glasses and quality of life among rural myopic Chinese children: a non-inferiority randomized trial.

PURPOSE: To study, for the first time, the effect of wearing ready-made glasses and glasses with power determined by self-refraction on children's quality of life. METHODS: This is a randomized, double-masked non-inferiority trial. Children in grades 7 and 8 (age 12-15 years) in nine Chinese secondary schools, with presenting visual acuity (VA) ≤6/12 improved with refraction to ≥6/7.5 bilaterally, refractive error ≤-1.0 D and <2.0 D of anisometropia and astigmatism bilaterally, were randomized to receive ready-made spectacles (RM) or identical-appearing spectacles with power determined by: subjective cycloplegic retinoscopy by a university optometrist (U), a rural refractionist (R) or non-cycloplegic self-refraction (SR). Main study outcome was global score on the National Eye Institute Refractive Error Quality of Life-42 (NEI-RQL-42) after 2 months of wearing study glasses, comparing other groups with the U group, adjusting for baseline score. RESULTS: Only one child (0.18%) was excluded for anisometropia or astigmatism. A total of 426 eligible subjects (mean age 14.2 years, 84.5% without glasses at baseline) were allocated to U [103 (24.2%)], RM [113 (26.5%)], R [108 (25.4%)] and SR [102 (23.9%)] groups, respectively. Baseline and endline score data were available for 398 (93.4%) of subjects. In multiple regression models adjusting for baseline score, older age (p = 0.003) and baseline spectacle wear (p = 0.016), but not study group assignment, were significantly associated with lower final score. CONCLUSION: Quality of life wearing ready-mades or glasses based on self-refraction did not differ from that with cycloplegic refraction by an experienced optometrist in this non-inferiority trial.

Visual results with the use of prismatic lenses in the treatment of congenital nystagmus: a clinical case

Purpose: It is important to establish a differential diagnosis between the different types of nystagmus, in order to give the appropriate clinical approach to every situation and to improve visual acuity. The nystagmus is normally blocked when the eyes are positioned in a particular way. This makes the child adopt a posture of ocular torticollis that reduces the nistagmiformes movements, improving the vision in this position. A way to promote the blocking of the nystagmic movements is by using prismatic lenses with opposite bases, to block or minimize the oscillatory movements. This results in a vision improvement and it reduces the anomalous head position. There is limited research on the visual results in children with nystagmus after using prisms with opposing bases. Our aim is to describe the impact on the visual acuity (VA ) of theprescription prism lenses in a nystagmus patient starting at 3 months of age. Methods: Case report on thirty month old caucasian male infant, with normal growth and development for their age, with an early onset of horizontal nystagmus at 3 months of age. Ophthalmic examination included slit lamp examination, fundus, refractive study, electrophysiological and magnetic resonance tests, measurement of VA over time with the Teller Acuity Cards (TAC ) in the distance agreed for the age. At age ten months, the mother noted a persistent turn to the right of the child’s head, which became increasingly more severe along the months. There’s no oscillopcia. At 24 months, an atropine refraction showed the following refractive error: 0D.: -1,50, OS: -0,50 and prismatic lens adapting OD 8 Δ nasal base and OE 8 Δ temporal base. Results: Thirty month old child, with adequate development for their age, with onset of idiopatic horizontal nystagmus, at 3 months of age. Normal ocular fundus and magnetic ressoance without alterations, sub-normal results in electrophysiological tests and VA with values below normal for age. At 6 months OD 20/300; OE 20/400; OU 20/300. At 9 months OD 20/250; OE 20/300; OU 20/150 (TAC a 38 cm). At 18 months OD 20/200; OE 20/100; OU 20/80 (TAC at 38 cm), when the head is turned to the right and the eyes in levoversão, the nystagmus decreases in a “neutral” area. At 24 month, with the prismatic glasses, OD 20/200 OE 20/100, OU20/80 (TAC at 54 cm, reference value is 20/30 – 20/100 para OU e 20/40 – 20/100 monocular), there was an increase in the visual acuity. The child did visual stimulation with multimedia devices and using glasses. After adaptation of prisms: at 30 months VA (with Cambridge cards) OD e OE = 6/18. The child improved the VA and reduced the anomalous head position. There is also improvement in mobility and fine motricity. Conclusion: Prisms with opposing bases., were used in the treatment of idiopathic nystagmus. Said prisms were adapted to reduce the skewed position of the head, and to improve VA and binocular function. Monitoring of visual acuity and visual stimulation was done using electronic devices. Following the use of prismatic, the patient improved significantly VA and the anomalous head position was reduced.

Ophthalmic findings in albinism

Purpose: Albinism is a rare genetic disorder of melanin production, which can affect only eyes or simultaneously eyes and skin/hair, resulting respectively in ocular (OA) or oculocutaneous albinism (OCA). Through of a case report of a child with OCA we pretend review ophthalmological manifestations of albinism. Case Report: A girl of West African descent was referenced to our appointment for ophthalmological evaluation of oculocutaneous albinism. Visual acuity was 20/310 OD e 20/630 OS by teller cards. In biomicroscopy, iris hypopigmentation and transillumination was visible, allowing to see spiral vessels and other iris details. Fundoscopy showed a denser and complex choroidal circulation due to lack of pigment in retinal pigment epithelium. Foveal hypoplasia was assumed because foveal pit is not apparent and vessels become less respectful of normal arcade and transverse the macula. Results: Melanin plays an important role in the development of the optic system and it’s absence leads to diverse ocular manifestations, such as: iris hypopigmentation and transillumination , reducted pigmentation of retinal pigment epithelium cells, photoreceptor rod cell deficits, foveal hypoplasia, optic nerve hypoplasia and misrouting of optic nerve at the chiasm, with temporal retina fibers inappropriately routed contralaterally instead of ipsilaterally. Photophobia, nystagmus, reduced visual acuity, color impairment and strabismus are other manifestations usually seen in albinism. Conclusion: Ophthalmologists must be familiar with the specific visual manifestations and needs of these patients. It is essential to correct refractive error to optimize visual acuity. Patients should also be advised to wear tinted glasses and sunblock. In more severely affected children they may benefit of low vision consultation and specialized low vision aids like telescopes.

Algorithm for Correcting the Keratometric Error in the Estimation of the Corneal Power in Eyes With Previous Myopic Laser Refractive Surgery

Purpose: To calculate theoretically the errors in the estimation of corneal power when using the keratometric index (nk) in eyes that underwent laser refractive surgery for the correction of myopia and to define and validate clinically an algorithm for minimizing such errors. Methods: Differences between corneal power estimation by using the classical nk and by using the Gaussian equation in eyes that underwent laser myopic refractive surgery were simulated and evaluated theoretically. Additionally, an adjusted keratometric index (nkadj) model dependent on r1c was developed for minimizing these differences. The model was validated clinically by retrospectively using the data from 32 myopic eyes [range, −1.00 to −6.00 diopters (D)] that had undergone laser in situ keratomileusis using a solid-state laser platform. The agreement between Gaussian (PGaussc) and adjusted keratometric (Pkadj) corneal powers in such eyes was evaluated. Results: It was found that overestimations of corneal power up to 3.5 D were possible for nk = 1.3375 according to our simulations. The nk value to avoid the keratometric error ranged between 1.2984 and 1.3297. The following nkadj models were obtained: nkadj= −0.0064286r1c + 1.37688 (Gullstrand eye model) and nkadj = −0.0063804r1c + 1.37806 (Le Grand). The mean difference between Pkadj and PGaussc was 0.00 D, with limits of agreement of −0.45 and +0.46 D. This difference correlated significantly with the posterior corneal radius (r = −0.94, P < 0.01). Conclusions: The use of a single nk for estimating the corneal power in eyes that underwent a laser myopic refractive surgery can lead to significant errors. These errors can be minimized by using a variable nk dependent on r1c.

Error induced by the estimation of the corneal power and the effective lens position with a rotationally asymmetric refractive multifocal intraocular lens

AIM: To evaluate the prediction error in intraocular lens (IOL) power calculation for a rotationally asymmetric refractive multifocal IOL and the impact on this error of the optimization of the keratometric estimation of the corneal power and the prediction of the effective lens position (ELP). METHODS: Retrospective study including a total of 25 eyes of 13 patients (age, 50 to 83y) with previous cataract surgery with implantation of the Lentis Mplus LS-312 IOL (Oculentis GmbH, Germany). In all cases, an adjusted IOL power (PIOLadj) was calculated based on Gaussian optics using a variable keratometric index value (nkadj) for the estimation of the corneal power (Pkadj) and on a new value for ELP (ELPadj) obtained by multiple regression analysis. This PIOLadj was compared with the IOL power implanted (PIOLReal) and the value proposed by three conventional formulas (Haigis, Hoffer Q and Holladay). RESULTS: PIOLReal was not significantly different than PIOLadj and Holladay IOL power (P>0.05). In the Bland and Altman analysis, PIOLadj showed lower mean difference (-0.07 D) and limits of agreement (of 1.47 and -1.61 D) when compared to PIOLReal than the IOL power value obtained with the Holladay formula. Furthermore, ELPadj was significantly lower than ELP calculated with other conventional formulas (P<0.01) and was found to be dependent on axial length, anterior chamber depth and Pkadj. CONCLUSION: Refractive outcomes after cataract surgery with implantation of the multifocal IOL Lentis Mplus LS-312 can be optimized by minimizing the keratometric error and by estimating ELP using a mathematical expression dependent on anatomical factors.

Clinical validation of an algorithm to correct the error in the keratometric estimation of corneal power for normal eyes

To validate clinically an algorithm for correcting the error in the keratometric estimation of corneal power by using a variable keratometric index of refraction (nk) in a normal healthy population.

Minimizing the IOL Power Error Induced by Keratometric Power

Purpose. To evaluate theoretically in normal eyes the influence on IOL power (PIOL) calculation of the use of a keratometric index (nk) and to analyze and validate preliminarily the use of an adjusted keratometric index (nkadj) in the IOL power calculation (PIOLadj). Methods. A model of variable keratometric index (nkadj) for corneal power calculation (Pc) was used for IOL power calculation (named PIOLadj). Theoretical differences ($PIOL) between the new proposed formula (PIOLadj) and which is obtained through Gaussian optics (PIOL Gauss) were determined using Gullstrand and Le Grand eye models. The proposed new formula for IOL power calculation (PIOLadj) was prevalidated clinically in 81 eyes of 81 candidates for corneal refractive surgery and compared with Haigis, HofferQ, Holladay, and SRK/T formulas. Results. A theoretical PIOL underestimation greater than 0.5 diopters was present in most of the cases when nk = 1.3375 was used. If nkadj was used for Pc calculation, a maximal calculated error in $PIOL of T0.5 diopters at corneal vertex in most cases was observed independently from the eye model, r1c, and the desired postoperative refraction. The use of nkadj in IOL power calculation (PIOLadj) could be valid with effective lens position optimization nondependent of the corneal power. Conclusions. The use of a single value of nk for Pc calculation can lead to significant errors in PIOL calculation that may explain some IOL power overestimations with conventional formulas. These inaccuracies can be minimized by using the new PIOLadj based on the algorithm of nkadj.

Higher-order aberrations in amblyopia:an analysis of pre- and post-wavefront-guided laser refractive correction

For more than a century it has been known that the eye is not a perfect optical system, but rather a system that suffers from aberrations beyond conventional prescriptive descriptions of defocus and astigmatism. Whereas traditional refraction attempts to describe the error of the eye with only two parameters, namely sphere and cylinder, measurements of wavefront aberrations depict the optical error with many more parameters. What remains questionable is the impact these additional parameters have on visual function. Some authors have argued that higher-order aberrations have a considerable effect on visual function and in certain cases this effect is significant enough to induce amblyopia. This has been referred to as ‘higher-order aberration-associated amblyopia’. In such cases, correction of higher-order aberrations would not restore visual function. Others have reported that patients with binocular asymmetric aberrations display an associated unilateral decrease in visual acuity and, if the decline in acuity results from the aberrations alone, such subjects may have been erroneously diagnosed as amblyopes. In these cases, correction of higher-order aberrations would restore visual function. This refractive entity has been termed ‘aberropia’. In order to investigate these hypotheses, the distribution of higher-order aberrations in strabismic, anisometropic and idiopathic amblyopes, and in a group of visual normals, was analysed both before and after wavefront-guided laser refractive correction. The results show: (i) there is no significant asymmetry in higher-order aberrations between amblyopic and fixing eyes prior to laser refractive treatment; (ii) the mean magnitude of higher-order aberrations is similar within the amblyopic and visually normal populations; (iii) a significant improvement in visual acuity can be realised for adult amblyopic patients utilising wavefront-guided laser refractive surgery and a modest increase in contrast sensitivity was observed for the amblyopic eye of anisometropes following treatment (iv) an overall trend towards increased higher-order aberrations following wavefront-guided laser refractive treatment was observed for both visually normal and amblyopic eyes. In conclusion, while the data do not provide any direct evidence for the concepts of either ‘aberropia’ or ‘higher-order aberration-associated amblyopia’, it is clear that gains in visual acuity and contrast sensitivity may be realised following laser refractive treatment of the amblyopic adult eye. Possible mechanisms by which these gains are realised are discussed.

Prevalence of refractive errors and ocular disorders in preschool and school children of Ibiporã - PR, Brazil (1989 to 1996)

Purpose: To establish the prevalence of refractive errors and ocular disorders in preschool and schoolchildren of Ibiporã, Brazil. Methods: A survey of 6 to 12-year-old children from public and private elementary schools was carried out in Ibiporã between 1989 and 1996. Visual acuity measurements were performed by trained teachers using Snellen's chart. Children with visual acuity <0.7 in at least one eye were referred to a complete ophthalmologic examination. Results: 35,936 visual acuity measurements were performed in 13,471 children. 1.966 children (14.59%) were referred to an ophthalmologic examination. Amblyopia was diagnosed in 237 children (1.76%), whereas strabismus was observed in 114 cases (0.84%). Cataract (n=17) (0.12%), chorioretinitis (n=38) (0.28%) and eyelid ptosis (n=6) (0.04%) were also diagnosed. Among the 614 (4.55%) children who were found to have refractive errors, 284 (46.25%) had hyperopia (hyperopia or hyperopic astigmatism), 206 (33.55%) had myopia (myopia or myopic astigmatism) and 124 (20.19%) showed mixed astigmatism. Conclusions: The study determined the local prevalence of amblyopia, refractive errors and eye disorders among preschool and schoolchildren.