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In This Issue of JAMA Ophthalmology
October 2015


JAMA Ophthalmol. 2015;133(10):1101. doi:10.1001/jamaophthalmol.2014.3742


To assess the feasibility and effect on surgical decision making of a microscope-integrated intraoperative optical coherence tomography (iOCT) system, Ehlers and colleagues report a single-site, multisurgeon, prospective consecutive case series regarding this investigational device. Among 227 eyes, successful imaging (eg, the ability to acquire an OCT image of the tissue of interest) was obtained for 99%. The iOCT data altered the surgeon’s decision making in 38% of lamellar keratoplasty cases (eg, complete graft apposition when the surgeon believed there was interface fluid) and in 19% of membrane peeling procedures (eg, lack of residual membrane or presence of membrane not otherwise visualized), affecting additional surgical maneuvers. The effect of these changes in decision making on outcomes remains unknown.

Invited Commentary

Continuing Medical Education and Videos 1, 2, 3, and 4

Video 1. Descemet Stripping Automated Endothelial Keratoplasty
Video shows initial portion of host Descemet membrane removal. Following removal the graft is placed in the anterior chamber and an air bubble infusion facilitates graft-host apposition. Residual interface fluid is visualized and decreases over time.
Video 2. Vitrectomy With Membrane Peeling for Complex Myopic Schisis
Following staining with triamcinolone and indocyanine green, the membrane is engaged and readily peeled from the retinal surface using a membrane loop. Following membrane removal, intraoperative optical coherence tomography reveals a prominent residual membrane that requires additional peeling.
Video 3. Intraoperative Optical Coherence Tomography During Vitrectomy for Proliferative Diabetic Retinopathy
During surgical repair, the surgeon directs the aiming beam throughout the posterior pole to identify areas of traction and potential areas for safe dissection.
Video 4. Intraoperative Optical Coherence Tomography During Choroidal Biopsy
Vitreous cutter is directly placed into the choroidal lesion. Intraoperative optical coherence tomography allows visualization of the entry into the lesion, the actual motion of the vitreous cutter, and the final depth of the biopsy.

To evaluate associations between body levels of trace metals and the prevalence of glaucoma, Lin and colleagues investigate blood or urine metallic element levels and information pertaining to ocular disease from 2680 individuals 19 years and older participating in the Korea National Health and Nutrition Examination Survey. After adjustment for potential confounders, the data suggested that blood manganese level was negatively associated with the odds of glaucoma diagnosis and blood mercury level was positively associated with glaucoma prevalence. The authors noted that prospective studies would be needed to confirm that the presence of such trace metals increases the chance of developing glaucoma.

Although there is little evidence beyond highly publicized case reports for or against the need for additional regulation of compounded bevacizumab, VanderBeek and colleagues suggest that current draft guidelines by the US FDA for compounded or repackaged medications might limit the availability and use of bevacizumab. To determine whether the distribution of bevacizumab through compounding pharmacies increases the risk for endophthalmitis compared with the distribution of single-use vials of ranibizumab from the manufacturer, the authors determined the odds of developing endophthalmitis after an intravitreous injection of bevacizumab compared with ranibizumab from a retrospective cohort study using medical claims data. Among 296 565 injections of bevacizumab given to 51 116 patients and 87 245 injections of ranibizumab given to 7496 patients, the endophthalmitis rate was 0.017% for bevacizumab and 0.025% for ranibizumab. The results suggest repackaged bevacizumab as currently used across the United States does not increase the risk for endophthalmitis.

Continuing Medical Education

Because deficient 25-hydroxyvitamin D (25[OH]D) concentrations have been associated with increased odds of age-related macular degeneration (AMD), Millen and colleagues examine whether this association is modified by genetic risk for AMD. Among postmenopausal women (N = 913) who were participants of the Carotenoids in Age-Related Eye Disease Study with available serum 25(OH)D concentrations (assessed 1993-1998), genetic data, and measures of AMD assessed in 142 participants from 2001-2004, 6.7-fold increased odds of AMD were observed among women with deficient vitamin D status (25[OH]D < 12 ng/mL) and 2 risk alleles for CFH Y402H. Significant additive and multiplicative interactions were observed for deficient women with 2 high-risk CFI (rs10033900) alleles. The results suggest a synergistic effect between vitamin D status and complement cascade protein function, although the findings may be due to chance or explained by residual confounding.