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Sang Beom HanDepartment of Ophthalmology, Kangwon National University Hospital, Kangwon National University Graduate School of Medicine, Chuncheon, KoreaI read with interest the article entitled “Subconjunctival orbital fat prolapse and thyroid associated orbitopathy: a clinical association” by Chatzistefanou et al.1 The case-series study was undoubtedly well designed and conducted, in which the authors successfully revealed that subconjunctival orbital fat prolapse may occasionally be a predominant clinical manifestation of thyroid-associated orbitopathy (TAO) and suggested that the presence of subconjunctival orbital fat prolapse can alert the diagnosis of thyroid orbitopathy.However, I would like to point out that the mechanism underlying the association between the two conditions is still unclear. Subconjunctival fat prolapse is usually caused by forward herniation of intraconal fat tissue due to dehiscence of tenon capsule precipitated by aging process or trauma.2 In TAO, swelling and inflammation of orbital fat can lead to separation of the orbital septum from the capsulopalpebral fascia, which can cause fat prolapse into the orbit.3 Previous studies showed that intraorbital inflammation in TAO can lead to apical crowding in orbit and intracranial fat prolapse.4,5 Therefore, as the authors postulated, it would be plausible that elevated intraorbital pressure and increase in orbital fat in TAO can also allow anterior herniation of intraorbital fat.Authors’ replyKlio I Chatzistefanou,1 Christianna Samara,2 Ioannis Asproudis,3 Dimitrios Brouzas,1 Marilita M Moschos,1 Elisabeth Tsianta,1George Piaditis41First Department of Ophthalmology, National and Kapodistrian University of Athens Medical School, Athens, Greece; 2Department of Radiology and Endocrinology, 3Department of Ophthalmology, University of Ioannina, Ioannina, Greece; 4Athens General Hospital “G. Gennimatas”, Athens, GreeceWe appreciate Dr Han’s comments and interest in our article. Intracranial herniation of intraorbital fat through the superior orbital fissure has been reported at an incidence of 19% in patients with thyroid ophthalmopathy in one study,1 and its prevalence may vary between 24% and 82% in different studies1–3 among patients with dysthyroid ophthalmopathy.We reviewed again data from the patients’ charts for symptoms and signs of compressive optic neuropathy upon presentation with subconjunctival fat prolapse.4 There were no afferent pupillary defects or optic nerve head swelling or atrophy noted on fundoscopy in any of the patients reported in this series. Clinical suspicion for possible compressive optic neuropathy, prompting paraclinical investigation with visual field testing, had been raised for patient #2 who had a slight decrease in visual acuity to 0.9 in the right eye. Visual field testing by automated perimetry was within normal limits. Visual acuity improved to 1.0+ in the involved eye with a change in astigmatic correction.View original paper by Chatzistefanou et al

Purpose To assess the psychometric properties of the Greek Macular Disease Treatment Satisfaction Questionnaire (MacTSQ) and evaluate the factors that influence treatment satisfaction of patients with neovascular age-related macular degeneration (nAMD). Methods The MacTSQ was translated into Greek and administered to 176 patients. All patients completed the SF-12 Health Survey and the Macular disease Dependent Quality of Life Questionnaire (MacDQoL) and underwent vision measurements. For test-retest reliability, a subset of 19 participants completed the MacTSQ twice, two weeks apart. Stepwise multiple linear regression analyses were performed to identify predictors of treatment satisfaction. Change in MacTSQ scores over time was assessed on 83 patients who completed the MacTSQ at a follow-up visit, one year later. Results The intraclass correlation coefficients between the first and second test-retest administration ranged from 0.88 to 0.98 for the items and total score. Internal reliability of the total score was adequate (Cronbach's a = 0.837). Principal component analysis revealed three subscales (effectiveness, information provision and convenience, impact). The MacTSQ score showed significant correlations with SF-12 summary scales and MacDQoL scores (rho = 0.16-0.27). The most important factor that determined the satisfaction was mental health. Distance visual acuity (VA) in better eye was the best predictor of the effectiveness subscale, and the total number of injections was a negative predictor for the convenience subscale. Treatment satisfaction increased at one-year follow-up, despite the deterioration in distance VA. Conclusions The Greek MacTSQ is a reliable and valid instrument for assessing nAMD patients' perceptions of treatment satisfaction, especially using its three new subscales. Treatment satisfaction is multifactorial and was primarily determined by patients' mental health status.

To assess the psychometric properties of the Greek Macular Disease-Dependent Quality of Life Questionnaire (MacDQoL). The MacDQoL was translated in Greek and administered to 191 patients with neovascular age-related macular degeneration (AMD). To assess validity, all patients completed the Greek SF-12 health survey and underwent vision measurements. For test-retest reliability, a subset of twenty participants completed the MacDQoL twice, 2 weeks apart. Responsiveness was assessed on 102 patients who completed the MacDQoL at a follow-up visit, 1 year later. Rasch analysis was used to assess the Greek MacDQoL's response category functioning, precision, unidimensionality, targeting and differential item functioning. Internal and test-retest reliability of the average weighted impact (AWI) was 0.952 and 0.97, respectively. Test-retest reliability of MacDQoL items ranged from 0.78 to 0.99. Principal component analysis revealed three subscales (activities, embarrassment and family life), which were also confirmed by confirmatory factor analysis. Rasch analysis revealed poor functionality of response categories and that was resolved by collapsing response categories and using the impairment scores only. In terms of convergent validity, the AWI and revised MacDQoL scales showed significant correlations with SF-12 summary scales (rho = 0.21-0.30) and vision assessments (rho = 0.31-0.46). Poorer AMD-related QoL at 1-year follow-up was associated with deterioration in distance visual acuity and worse eye near visual acuity. The Greek MacDQoL is a reliable, valid and sensitive to change in vision instrument for assessing AMD patients' perceptions of QoL. However, Rasch analysis revealed that its multiplicative rating scale is flawed. Scientific measurement was restored with a number of revisions to the questionnaire.

Background: Thyroid associated orbitopathy (TAO) comprises a spectrum of well-recognized clinical signs including exophthalmos, eyelid retraction, soft tissue swelling, ocular misalignment, keratopathy as well as a number of less common manifestations. Subconjunctival fat prolapse is a rare clinical condition occurring typically spontaneously in elderly patients with a mean age of 65-72 years. We describe subconjunctival prolapse of orbital fat as an uncommon clinical association of TAO. Materials and methods: Observational study of six patients presenting with a subconjunctival protrusion under the lateral canthus in a series of 198 consecutive cases with TAO examined at a tertiary care referral center. Results: A superotemporally located yellowish, very soft, freely mobile subconjunctival protrusion developed unilaterally in two and bilaterally in four patients with TAO (incidence 3.03%). It was one of the presenting manifestations of TAO in four of ten eyes studied and incited the diagnostic work-up for TAO in two of six patients in this series. Magnetic resonance imaging of the orbit indicated fat density in continuity with intraorbital fat in the area of protrusion. A male to female preponderance of 4: 2 and an advanced mean age at onset of TAO is noteworthy for these six patients compared to the pool of 192 patients (64.8 versus 51.8 years, respectively, P=0.003) not bearing this sign. Conclusion: Subconjunctival orbital fat prolapse, a clinically impressive age-related ocular lesion, may occasionally predominate amid other clinical manifestations of TAO. It is a nonspecific sign developing most commonly among patients with a relatively advanced age at presentation. Awareness of this association may alert to the diagnosis of thyroid orbitopathy and reassure the patient and physician as to the benign character of the lesion.

Purpose: To evaluate the impact of macular ischemia on the functional and anatomical outcome after intravitreal injections of ranibizumab for the treatment of diabetic macular edema (DME). Procedures: Participants were 49 patients with diabetes mellitus, divided into two groups based on the presence of ischemia on fluorescein angiography: (i) nonischemic group (n = 32) and (ii) ischemic group (n = 17). All patients were treated with intravitreal ranibizumab and were followed up for 6 months. The main outcome measures were changes in visual acuity (VA) and central foveal thickness (CFT). Results: There was a statistically significant improvement in VA and CFT between baseline and the end of the follow-up in the nonischemic group, while in the ischemic group there was no significant difference in VA but CFT differed significantly at the 6-month follow-up. Conclusions: Macular ischemia may have a negative impact on functional outcomes 6 months after intravitreal ranibizumab treatment in patients with DME but has no effect on anatomical outcomes. (C) 2014 S. Karger AG, Basel

Purpose: To investigate the diagnostic value and to establish threshold criteria for the ice pack test as an office preliminary test in the differential diagnosis of myasthenic diplopia in comparison with blepharoptosis. Design: Prospective, comparative cohort study. Participants: Eighty-nine patients with a recent onset of diplopia, blepharoptosis, or both were evaluated with orbital cooling in a prospective manner. Forty-eight patients presented with diplopia, 25 patients with both blepharoptosis and ophthalmoplegia and 16 patients with blepharoptosis. Testing: All patients had the ice pack applied for 5 minutes on both eyelids at the initial orthoptic evaluation. Increasing the duration of cooling to 10 minutes was investigated in 36 diplopic patients. A complete diagnostic work-up was ordered and patients were followed up for a minimum of 6 months before diagnosis of myasthenia gravis was ascertained. Main Outcome Measures: Difference in cover test measurements in primary position or marginal reflex distance before and after the application of the ice pack, specific cause for diplopia and blepharoptosis. Results: Fifteen patients were diagnosed as myasthenic. The optimal cutoff point for a positive response to the ice pack test proved to be a reduction in ocular deviation in primary position by 50% or by 10 prism diopters (PD) or more for presenting deviations larger than 20 PD. By this criterion, sensitivity for the detection of myasthenic diplopia was 76.9% (95% confidence interval [CI], 49.06%-92.50%) for the 5-minute application, compared with 92.3% (95% CI, 63.5%-98.9%) sensitivity demonstrated for blepharoptosis. Increasing the time of application to 10 minutes did not improve the diagnostic value of the test. Specificity was high (98.3%; 95% CI, 90.3%-99.9%) and was demonstrated even in patients with coexisting myasthenic and dysthyroid ophthalmopathy. Patients with oculomotor nerve paresis and Horner syndrome invariably were nonresponsive to the test. Conclusions: The ice pack test demonstrated high specificity and an acceptable sensitivity in the differential diagnosis of myasthenic diplopia. Data from this series suggest that a partial rather than a complete response to the ice pack test may be expected for myasthenic diplopia. Standardization of the method of application of the ice pack is critical for the interpretation of its effect. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Ophthalmology 2009;116:2236-2243 (C) 2009 by the American Academy of Ophthalmology.