1040-5488/14/9101-0129/0 VOL. 91, NO. 1, PP. 129Y130 OPTOMETRY AND VISION SCIENCE Copyright * 2013 American Academy of Optometry

CLINICAL PEARLS This month, ‘‘Clinical Communications,’’ under the clinical editorship of Editorial Board member Larry Alexander, OD, FAAO, includes color image content and optional supplementary digital content, with no cost to our authors. Each article in this section is followed by a clinical comment by our clinical editor, emphasizing the clinical take-home message. We provide these ‘‘Clinical Pearls’’ of the publication following the article’s title, authors, and abstract. The full text and illustrations are found online with the colored images and any video clips. Dr. Larry Alexander provides all of the clinical comments (‘‘Clinical Pearls’’) on each article in ‘‘Clinical Communications.’’ This is all part of our OVS program to enrich the clinical content of OVS and make it very accessible, in color and motion, to clinicians, readers, and authors alike. Tony Adams, OD, PhD, FAAO Editor in Chief

Clinical Cases A New Portable Digital Meniscometer Stefan Bandlitz, Christine Purslow, Paul J. Murphy, Heiko Pult, and Anthony J. Bron Purpose. The aims of this study were (i) to develop a new portable slit-lamp mounted digital meniscometer (PDM) and (ii) to test its accuracy and repeatability compared to the existing Yokoi et al. videomeniscometer (VM). Methods. We developed a novel application for an iPod or iPhone, which created an illuminated target of parallel black and white bands. This was used as a portable device with which to perform reflective meniscometry. The medians of three consecutive measurements on five glass capillaries (internal radii, 0.100 to 0.505 mm) were compared between VM and PDM at two different sessions. Also, the central lower tear meniscus radius (TMR) in 20 normal subjects (10 males and 10 females; mean [SD] age, 32.3 [9.3] years) was measured using both techniques. Correlations between the instruments were analyzed using the Pearson coefficient. Differences between sessions and instruments were analyzed using Bland-Altman plots, coefficient of repeatability, and paired t-tests. Results. The PDM and VM were accurate in vitro (95% confidence interval [CI] of difference: PDM j0.0134 to +0.0074 mm, p = 0.468; VM j0.0282 to +0.0226 mm; p = 0.775) and reproducible between sessions (95% coefficient of repeatability, 0.019 and 0.018, respectively). The mean difference between the PDM and VM in vitro was 0.0002 mm (95% CI, j0.0252 to +0.0256; p = 0.984). In human subjects, mean (SD) TMR measured with the PDM (0.34 [0.10] mm) and VM (0.36 [0.11] mm) was significantly correlated (r = 0.940; p G 0.001), and there was no statistically significant difference between the measured TMR of the instruments (p = 0.124). Conclusions. This new slit-lamp mounted digital meniscometer produces accurate and reliable measurements and provides similar values for tear meniscus radius, in human studies, to the existing VM. The instrument is suitable for use in both research and clinical practice.

Clinical Pearls—Larry J. Alexander, OD, FAAO & Lets look for an easier and less expensive way to obtain quantifiable information on tear film. A new iPod or iPhone app? The authors present a unique slit lamp mounted digital meniscometer (tear meniscus measurement). What elegance in simplicity. All of you tear centric doctors, and that should be all of us, must read this and look at the methods of adaptation that have been created and presented.

Optometry and Vision Science, Vol. 91, No. 1, January 2014

Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.

130 Clinical PearlsVAdams

Uveal Melanoma Gene Expression Status Post Radiotherapy Aaron S. Gold, Timothy G. Murray, Arnold M. Markoe, Fiona Ehlies, Azeema Latiff, Andrea Wildner, and Ernesto Bermudez Purpose. Gene expression profiling has been shown to yield two distinct molecular genetic signatures for uveal melanoma. These class designations tend to predict tumor aggressiveness and the likelihood of metastasis. Tumors with a class 1 genetic signature are generally much less aggressive than tumors with a class 2 genetic signature. Gene expression analysis for previously treated uveal melanoma has not yet been reported. The authors report three cases where genetic analysis was successfully obtained from uveal melanoma that was previously treated years earlier with radiotherapy. Case Report. The patients in all three cases received globe-conserving radiotherapy for treatment of choroidal melanoma before gene expression profiling was readily available. The patients in cases 1 and 2 received 125I plaque brachytherapy while the patient in case 3 received proton irradiation therapy. When secondary surgery was necessary to stabilize these eyes from the effects of radiation retinopathy, fine-needle aspiration biopsy was also performed for gene expression profiling. Genomic analysis revealed a class 1 molecular signature for the patient in case 1 and a class 2 molecular signature for the patients in cases 2 and 3. Conclusions. Gene expression profiling for uveal melanoma may be obtained from patients who were previously treated with radiotherapy; however, the implication of these results will benefit from ongoing clinical evaluation.

Clinical Pearls—Larry J. Alexander, OD, FAAO & The future of genomic application to eyecare is now. The authors present their findings showing important predictive genetic information from previously treated uveal melanomas may assist in the long-term management of patients. The authors present information that, in fact, boggles my clinical mind. Genomic analysis has become more important in all of our lives and this paper points to the fact that analysis of uveal melanomas adds to the overall long-term management of the patient. In this case they report that even status post therapy, they were able to assess the class of the melanoma and have a better sense of how aggressive the tumor may be.

Corneal Confocal Microscopy for Vision Disturbance After an Epithelial Abrasion Gabriela Mahelkova, Kvetoslava Ferrova, Pavel Pochop, Milan Odehnal, and Dagmar Dotrelova Purpose. To demonstrate the use of in vivo corneal confocal microscopy to reveal the reason for persistent disturbance of vision after a corneal abrasion. Case Report. A 49-year-old man presented with a decrease in visual acuity and monocular diplopia after a traumatic corneal abrasion. Anterior segment optical coherence tomography was not beneficial. In vivo corneal confocal microscopy showed abnormal folding in the basal epithelial layer of the cornea. Based on these findings, a therapeutic abrasion of the affected epithelium was performed. Visual acuity returned to 1.0 after therapeutic abrasion, and overall findings on the eye were within physiological limits. Control corneal confocal microscopic examination confirmed reparation of the structure of epithelial cell layers. Conclusions. The in vivo corneal confocal microscopy can reveal corneal pathologic abnormality even in cases where other methods are not beneficial. Alongside other modern methods, it may become an important tool to help locate pathologic abnormality accurately and choose the proper therapeutic strategy.

Clinical Pearls—Larry J. Alexander, OD, FAAO & In vivo corneal confocal microscopy offers another tool to assist in anterior segment disorders. Confocal corneal microscopy has always fascinated me. I have worked with the technology in the past and was impressed but was not sure of the overall applicability. This technology may not be for the typical eye care practice. However, knowledge of the availability will give the clinician the option of consulting for confocal corneal microscopy that could be of assistance in recalcitrant or difficult cases. This is clearly a valuable tool for the corneal centric practices as well as for referral centers and academic institutions.

Optometry and Vision Science, Vol. 91, No. 1, January 2014

Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.

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