Bevacizumab in High-Risk Corneal Transplantation: A Pilot Multicenter Prospective Randomized Control Trial.

PURPOSE: To determine the efficacy of local (subconjunctival and topical) bevacizumab (Avastin) treatment in patients undergoing vascularized high-risk corneal transplantation. DESIGN: Pilot, prospective, randomized, double-blind, placebo-controlled clinical trial conducted at 5 clinical centers in the United States, India, and Brazil. PARTICIPANTS: Patients aged > 18 years undergoing high-risk penetrating keratoplasty, defined as corneal neovascularization (NV) in 1 or more quadrants ≥2 mm from the limbus or extension of corneal NV to the graft-host junction in a previously failed graft. METHODS: Patients were randomized to receive subconjunctival bevacizumab (2.5 mg/0.1 ml) or placebo at the time of surgery, followed by topical bevacizumab (10 mg/ml) or topical placebo, administered 4 times per day for 4 weeks. MAIN OUTCOME MEASURE: The 52-week endothelial immune rejection rate. RESULTS: Ninety-two patients were randomized to receive bevacizumab (n = 48) or control (n = 44). The 52-week endothelial rejection rate was 10% in the bevacizumab group and 19% in the control group (P = 0.20). Post hoc, extended follow-up at the lead study site showed an endothelial rejection rate of 3% in the bevacizumab group and 38% in the control group (P = 0.003). Treatment with bevacizumab was found to have a hazard ratio of 0.15 (95% confidence interval, 0.03-0.65, P = 0.01) in a post hoc Cox regression analysis. CONCLUSIONS: In patients undergoing vascularized high-risk corneal transplantation, there was no statistically significant difference in the rate of endothelial rejection at 1 year in the bevacizumab treatment group compared with the control group. This study may have been underpowered to detect a difference between treatment groups, and taken together, our data suggest that, in the current trial design, bevacizumab has a positive but not (yet) significant effect on endothelial rejection.

Clinical Experience With PROSE Fitting: Significance of Diagnosis and Age.

OBJECTIVE: To compare ease of adoption of the BostonSight Prosthetic Replacement of the Ocular Surface Ecosystem device, a custom-fit scleral lens, by patients in different age and diagnosis groups. METHODS: In this prospective study, patients were categorized by age as younger than 60 or 60 years and older and by diagnosis as corneal irregularity (CI) or ocular surface disease (OSD). Ease of adoption of the scleral device was assessed by (1) number of devices and visits required to complete the fitting process, (2) time needed for device insertion and removal, (3) adaptation to the device, as assessed by daily wear time and by time needed to achieve full-time wear (defined as 8 hours per day), and (4) patients' subjective rating of ease of device insertion and removal. The length of the fitting process was also assessed. RESULTS: There was no significant difference in the number of devices and visits needed between age group younger than 60 and age group of 60 and older or between CI and OSD groups. Patients in all groups achieved full-time wear in less than 2 weeks. Average wear time per week did not differ significantly between age or diagnosis groups. Similarly, the time needed for daily insertion and removal during the fitting period, as well as patients' subjective rating of ease of device insertion and removal, did not differ between age or diagnosis categories. The length of the fitting process was significantly longer in the OSD group compared with the CI group (P<0.001); however, factors not related to ease of adoption of the scleral device may be responsible for this difference. CONCLUSIONS: Patients in both younger and older patient groups adopted the use of a scleral device with equal ease, as did patients in the CI and OSD diagnosis groups.

Light as a drug: prospective randomized evaluation and comparison of the effect of decreased illumination on visual recovery after cataract surgery.

PURPOSE: To compare the effect of decreased illumination on the rate of postoperative visual recovery, and the incidence of cystoid macular edema (CME) with surgical visualization achieved with a traditional analog operating microscope compared with a 3D digital visualization system. SETTING: Ambulatory surgery center, New York. DESIGN: Prospective, randomized, consecutive, single-surgeon series. METHODS: Patients undergoing routine cataract surgery were randomized into either (1) visualization through the binoculars of a standard operating microscope ("traditional group") or (2) visualization through a 3D digital visualization system affixed to the same operating microscope ("digital group"). Note was made in each case of light intensity used, light exposure time, cumulative dissipated energy (CDE), femtosecond laser use, preoperative medical and ocular conditions, intraoperative and/or postoperative complications, and preoperative and postoperative visual acuities and optical coherence tomography confirmed CME. RESULTS: The study comprised 118 eyes in the traditional group and 96 eyes in the digital group. There were no differences in preoperative visual acuity, light exposure time, CDE, or femtosecond laser use between groups, but the light intensity used in the digital group was significantly less (19.5% ± 0.5%) than in the traditional group (48.6% ± 0.6%; P < .001). Furthermore, the digital group achieved a better decimal postoperative day 1 visual acuity (0.60 ± 0.03) with less rates of CME (2.1%) when compared with that of the traditional group (0.51 ± 0.02, P = .03; and 9.2%, P = .03), respectively. CONCLUSIONS: Visual recovery and CME rates were significantly better in patients who underwent cataract surgery assisted by the 3D digital visualization platform without an increase in complications or surgical time.

Suppression of Neovascularization by Topical and Subconjunctival Bevacizumab After High-Risk Corneal Transplantation.

Purpose: To assess the effectiveness of topical and subconjunctival bevacizumab in suppressing vascularization in graft and host bed after high-risk corneal transplantation. Design: Secondary analysis of prospective, randomized, double-blind, placebo-controlled multicentric clinical trial. Participants: The study includes patients aged > 18 years who underwent high-risk penetrating keratoplasty, which was defined as corneal vascularization in ≥ 1 quadrants of the corneal graft and host bed, excluding the limbus. Methods: Patients were randomized to treatment and control groups. The patients in the treatment group received subconjunctival injection of bevacizumab (2.5 mg/0.1 ml) on the day of the procedure, followed by topical bevacizumab (10 mg/ml) 4 times per day for 4 weeks. The patients in control group received injection of vehicle (0.9% sodium chloride) on the day of procedure, followed by topical vehicle (carboxymethylcellulose sodium 1%) 4 times a day for 4 weeks. Main Outcome Measures: Vessel and invasion area of vessels in the corneal graft and host beds. Results: This study included 56 eyes of 56 patients who underwent high-risk corneal transplantation, with equal numbers in the bevacizumab and vehicle (control) treatment groups. The mean age of patients who received bevacizumab was 61.2 ± 15.9 years, and the mean age of those treated with vehicle was 60.0 ± 16.1 years. The vessel area at baseline was comparable in the bevacizumab (16.72% ± 3.19%) and control groups (15.48% ± 3.12%; P = 0.72). Similarly, the invasion areas were also similar in the treatment (35.60% ± 2.47%) and control (34.23% ± 2.64%; P = 0.9) groups at baseline. The reduction in vessel area was significantly higher in the bevacizumab-treated group (83.7%) over a period of 52 weeks compared with the control group (61.5%; P < 0.0001). In the bevacizumab-treated group, invasion area was reduced by 75.8% as compared with 46.5% in the control group. The vessel area was similar at 52 weeks postprocedure in cases of first (3.54% ± 1.21%) and repeat (3.80% ± 0.40%) corneal transplantation in patients who received bevacizumab treatment. In the vehicle-treated patients, the vessel area was significantly higher in repeat (9.76% ± 0.32%) compared with first (8.06% ± 1.02%; P < 0.0001) penetrating keratoplasty. In the bevacizumab treatment group, invasion areas at week 52 were comparable in first (11.70% ± 3.38%) and repeat (11.64% ± 1.74%) procedures, whereas invasion area was significantly higher in repeat (27.87% ± 2.57%) as compared with first (24.11% ± 2.17%) penetrating keratoplasty in vehicle-treated patients. Conclusions: In patients undergoing vascularized high-risk corneal transplantation, bevacizumab is efficacious in reducing vascularization of corneal graft and host bed, thereby reducing the risk of corneal graft rejection in vascularized host beds. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Current ophthalmologic treatment strategies for acute and chronic Stevens-Johnson syndrome and toxic epidermal necrolysis.

PURPOSE OF REVIEW: To review the newer, effective ophthalmologic treatments for acute Stevens-Johnson syndrome (SJS) as well as the emerging treatment options for patients with chronic, severe ocular surface damage from the disease. RECENT FINDINGS: Amniotic membrane transplantation (AMT) applied to the eyes and eyelids in the acute phase of SJS can prevent the devastating scarring and visual problems that characterize the chronic phase of the disease. The severity of ocular inflammation in the acute phase does not always correlate to the severity of skin and systemic involvement. Thus, it is crucial that all patients with SJS be evaluated by an ophthalmologist familiar with the current management of the disease, the potential urgency of the situation and the option of AMT. Although challenging, the severe, chronic ocular problems of SJS can be at least partially alleviated with autologous serum drops, mucous membrane grafting to replace scarred tarsal conjunctiva, specialized contact lenses (PROSE), conjunctival replacement surgery (COMET), limbal stem cell transplantation and kerotoprostheses. SUMMARY: Early AMT is an effective treatment of acute SJS. Emerging treatments offer increased hope for those who have already suffered damage from SJS, but emphasis on the prevention of damage in the acute phase is most crucial.

Use of PROSE for long-term ocular surface support in patients with a permanent keratoprosthesis.

Purpose: To describe the long-term outcome of the use of a specialized scleral lens known as a prosthetic replacement of the ocular surface ecosystem (PROSE) device to support the ocular surface in patients with a Boston Keratoprosthesis (KPro) Type I. All patients in this series were unable to pursue continuous wear of a bandage soft contact lens (BSCL) - a critical aspect of post KPro implantation management intended to protect the corneal carrier tissue from desiccation and stromal melting. Observations: Four eyes of four patients with a Boston KPro Type I were included. All four had failed BSCL wear and were instead treated with PROSE device wear. All four patients had underlying diagnoses associated with a diseased ocular surface (Stevens-Johnson Syndrome [one patient], prior failed penetrating keratoplasty associated with herpes zoster-related neurotrophic keratopathy [one patient], and prior failed penetrating keratoplasty associated with severe dry eye disease [two patients]). Causes of failure of BSCL wear included poor retention, discomfort, and poor vision. PROSE device wear was initiated on average seven and a half (range four to 14) months post-KPro implantation. The wear schedule varied and ranged from waking-hour wear only to 24-h wear. The average duration of device wear was 59.3 (range 28-103) months. Two patients exhibited persistent corneal epithelial defect formation with waking-hour wear, which resolved within 10 days with 24-h device wear. All patients exhibited improvement in vision with PROSE compared to baseline, averaging six and a half (range six to eight) lines of improvement in Snellen acuity, and all patients reported increased comfort. There was no incidence of microbial keratitis, KPro device instability, or other complication throughout the duration of device wear. Conclusions and Importance: This report offers a novel alternate approach to long-term support of the ocular surface in patients with a Boston KPro who fail standard continuous BSCL wear.

Surface epithelialization of the type I Boston keratoprosthesis front plate: immunohistochemical and high-definition optical coherence tomography characterization.

BACKGROUND: The aim of this work is to characterize a transparent tissue layer partially covering the anterior surface of the type I Boston permanent keratoprosthesis front plate in four patients. METHODS: The tissue over the front plate was easily scrolled back as a single transparent layer using a sponge. In two cases, histopathologic analysis was undertaken and immunofluorescent staining with a cytokeratin 3-specific antibody was performed. The relationship of the tissue to the keratoprosthesis device was further characterized using spectral domain high-definition optical coherence tomography (HD-OCT). RESULTS: Histopathologic analysis revealed the tissue to be non-keratinized squamous epithelium. No goblet cells were seen, suggesting the cells were of corneal, and not conjunctival, epithelial origin. Immunofluorescent staining of all cells was positive for cytokeratin 3, a protein strongly associated with corneal epithelium. The tissue was easily discerned by HD-OCT and was of substantial thickness near the external junction between the keratoprosthesis device and the carrier corneal tissue. In three cases, visual acuity was unaffected by the presence or absence of this tissue. In one case, a prominent tissue margin temporarily obscured the visual axis and reduced visual acuity; this resolved with mechanical central debridement and has not recurred. CONCLUSIONS: The transparent tissue layer covering the anterior surface of the type I Boston keratoprosthesis front plate was found to represent non-keratinized squamous epithelium, most likely of corneal epithelial origin. This potentially represents a further step in bio-integration of the keratoprosthesis device. In particular, epithelial coverage of the critical junction between the device and the carrier corneal tissue might serve an important barrier function and further reduce the incidence of infection and extrusion of the type I Boston permanent keratoprosthesis.

Multicenter prospective validation study for international chronic ocular graft-versus-host disease consensus diagnostic criteria.

PURPOSE: To validate the international chronic ocular graft-versus-host disease (GVHD) diagnostic criteria (ICCGVHD) compared to the National Institute of Health diagnostic criteria 2014 (NIH2014) for chronic ocular GVHD. METHODS: Between 2013 and 2019, the study enrolled 233 patients with or without chronic ocular GVHD combined with the presence or absence of systemic chronic GVHD in an internationally prospective multicenter and observational cohort from 9 institutions. All patients were evaluated for four clinical parameters of ICCGVHD. RESULTS: The relation between the ICCGVHD score (0-11) and NIH2014 eye score (0-4) was relatively high (r = 0.708, 95% CI: 0.637-0.767, p < 0.001). The sensitivity and specificity of ICCGVHD for NIH 2014 for 233 patients were 94.3% (95% CI: 89.6%-98.1%) and 71.7% (95% CI: 63.0-79.5%), respectively (cutoff value of the ICCGVHD score = 6). The positive predictive value was 77.1% (95% CI: 71.1%-82.1%), and the negative predictive value was 87.0% (95% CI:81.6-92.5%). For the patients with systemic GVHD (n = 171), the sensitivity and specificity were 94.2% and 67.2%, respectively (ICCGVHD-score cutoff value = 6). By receiver operating characteristic (ROC) curve analysis, the area under the curve (AUC) was 0.903 (95% CI: 0.859-0.948). For patients without systemic GVHD (n = 62), the sensitivity and specificity were 100% and 76.7%, respectively (ICCGVHD-score cutoff value = 6). The AUC was 0.891 (95% CI 0.673-1.000). CONCLUSIONS: Good sensitivity, specificity, predictive value and correlation were found between ICCGVHD and NIH2014. ICCGVHD scores ≥6 can be useful to diagnose ocular GVHD with or without systemic GVHD for clinical research.

Efficacy of 3D digital visualization in minimizing coaxial illumination and phototoxic potential in cataract surgery: pilot study.

PURPOSE: To compare the coaxial light intensity required during cataract surgery and rate of postoperative visual recovery, with surgical visualization achieved with a traditional analog operating microscope compared with a 3D digital visualization system. SETTING: Weill Cornell Medical Center, New York Presbyterian Hospital, New York, New York. DESIGN: Retrospective, consecutive, single-surgeon series. METHODS: Patients undergoing femtosecond laser-assisted cataract surgery were retrospectively grouped into either: (1) visualization using the binoculars of a standard operating microscope (traditional group) or (2) visualization using a 3D digital visualization system affixed to the same operating microscope (digital group). Note was made in each case of light intensity used, light exposure time, intraoperative and/or postoperative complications, and postoperative visual acuities. RESULTS: The study comprised 24 eyes in the traditional group and 27 eyes in the digital group. There were no intraoperative or postoperative complications in either group and no difference in mean light exposure time, but the mean light intensity used in the digital group was significantly less (18.5% ± 1.5%) than that in the traditional group (43.3% ± 3.7%; P < .001). Furthermore, the digital group achieved a postoperative day 1 visual acuity that was within 2 lines of the postoperative month 1 visual acuity a greater percentage of time than that in the traditional group (81.5% of eyes vs 54.2% of eyes; P = .04). CONCLUSIONS: Light intensity was significantly decreased in patients who underwent cataract surgery assisted by the 3D digital visualization platform without an increase in complications or surgical time and possibly with a faster postoperative visual recovery.

The ophthalmologist's role in the management of acute Stevens-Johnson syndrome and toxic epidermal necrolysis.

Stevens-Johnson syndrome (SJS) and its more severe variant, toxic epidermal necrolysis (TEN), are relatively rare but have high mortality rates. Survivors are frequently afflicted with severe blinding ocular surface diseases. Recent literature in the areas of ophthalmology and dermatology illustrate that the ophthalmologist's role should no longer be considered secondary in the acute management of SJS/TEN. Accurately differentiating SJS or TEN from erythema multiforme majus (EMM) at the onset of the disease is important, because the management approach to these disease entities differs. Systemic cyclosporine and intravenous immunoglobulin have shown some potential as treatments for SJS/TEN, but their efficacies remain controversial. Amniotic membrane transplantation and intravenous corticosteroid pulse therapy at the acute stage have shown promise for preventing late sight-threatening cicatricial complications. An improved staging system for the ocular surface involvement of acute SJS/TEN, as well as better understanding of the underlying destructive pathogenic mechanism, should further improve our ability to predict ocular involvement and develop new therapeutics to abort destructive processes at the acute stage.

A case of the blues: Inadvertent ocular injury from accidental instillation of blue ink.

PURPOSE: Many consumer products and non-ophthalmic medications are packaged in plastic "eye dropper" bottles, posing a risk of accidental ocular chemical injury when these substances are mistaken for eye drops. OBSERVATIONS: We present the case of an elderly glaucoma patient who mistook blue stamper ink for the glaucoma medication Combigan®, and suffered ocular injury as a result. CONCLUSIONS AND IMPORTANCE: The packaging of non-ophthalmic products in plastic "eye dropper" bottles poses a significant risk of accidental ocular chemical injury. Elderly individuals with low vision and/or cognitive deficits may be at particular risk of accidental injury. Ophthalmologists have been calling for a greater distinction between the packaging of ophthalmic and non-ophthalmic products for over 35 years, but to date little progress has been made in this regard.

Chemical Burns of the Eye: The Role of Retinal Injury and New Therapeutic Possibilities.

PURPOSE: To propose a new treatment paradigm for chemical burns to the eye - in the acute and chronic phases. METHODS: Recent laboratory and clinical data on the biology and treatment of chemical burns are analyzed. RESULTS: Corneal blindness from chemical burns can now be successfully treated with a keratoprosthesis, on immediate and intermediate bases. Long term outcomes, however, are hampered by early retinal damage causing glaucoma. New data suggest that rapid diffusion of inflammatory cytokines posteriorly (TNF-α, etc) can severely damage the ganglion cells. Prompt anti-TNF-α treatment is markedly neuroprotective. Long term profound reduction of the intraocular pressure is also vital. CONCLUSION: A new regimen, in addition to standard treatment, for severe chemical burns is proposed. This involves tumor necrosis factor alpha (TNF-α) inhibition promptly after the accident (primarily for retinal neuroprotection), prophylactic maximal lowering of the intraocular pressure (starting immediately), and keratoprosthesis implantation in a later quiet state.

Cicatrizing Conjunctivitis in a Patient Diagnosed With Drug Reaction With Eosinophilia and Systemic Symptoms/Drug-Induced Hypersensitivity Syndrome but With Features of Stevens-Johnson Syndrome.

PURPOSE: Severe cutaneous adverse reactions to drugs (SCARs) such as Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) and drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome (DRESS/DIHS) serve as one of the main reasons for inpatient ophthalmic consultation. Although it is well-recognized that SJS/TEN is associated with severe ocular mucosal inflammation and cicatrizing, potentially blinding, sequelae, this association has not been described in relation to other SCARs. We present a patient fulfilling the diagnostic criteria for probable DRESS/DIHS but not for SJS/TEN, yet exhibiting the severe ocular surface involvement characteristic of SJS/TEN. METHODS: Case report. RESULTS: A 64-year-old man presented with bilateral pseudomembranous conjunctivitis and conjunctival denudation (sloughing) in the setting of a maculopapular rash, fever, liver dysfunction, and hematologic abnormalities 1 month after initiating several medications. A skin biopsy was not consistent with SJS/TEN. The patient was diagnosed with probable DRESS/DIHS and treated with high-dose systemic corticosteroids. The ocular surface inflammation was addressed with intensive topical corticosteroid ointment. The pseudomembranes resolved over a 6-week period, but the patient exhibited residual conjunctival scarring of all palpebral surfaces. CONCLUSIONS: The development of severe ocular surface mucosal inflammation and denudation with cicatrizing sequelae in a patient carrying a diagnosis of DRESS/DIHS has diagnostic and therapeutic implications for the ophthalmologist. Careful ophthalmic assessment is indicated in any SCAR patient with ophthalmic symptoms, regardless of formal diagnosis. Furthermore, the early therapeutic interventions recently recommended in SJS/TEN to limit the ophthalmic cicatricial sequelae, such as systemic or topical corticosteroids, may be indicated.

Acute and Chronic Ophthalmic Involvement in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis - A Comprehensive Review and Guide to Therapy. II. Ophthalmic Disease.

Our purpose is to comprehensively review the state of the art with regard to Stevens- Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with particular attention to improving the management of associated ocular surface complications. SJS and TEN are two ends of a spectrum of immune-mediated disease, characterized in the acute phase by a febrile illness followed by skin and mucous membrane necrosis and detachment. Part I of this review focused on the systemic aspects of SJS/TEN and was published in the January 2016 issue of this journal. The purpose of Part II is to summarize the ocular manifestations and their management through all phases of SJS/TEN, from acute to chronic. We hope this effort will assist ophthalmologists in their management of SJS/TEN, so that patients with this complex and debilitating disease receive the best possible care and experience the most optimal outcomes in their vision and quality of life.

Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis--A Comprehensive Review and Guide to Therapy. I. Systemic Disease.

The intent of this review is to comprehensively appraise the state of the art with regard to Stevens Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with particular attention to the ocular surface complications and their management. SJS and TEN represent two ends of a spectrum of immune-mediated, dermatobullous disease, characterized in the acute phase by a febrile illness followed by skin and mucous membrane necrosis and detachment. The widespread keratinocyte death seen in SJS/TEN is rapid and irreversible, and even with early and aggressive intervention, morbidity is severe and mortality not uncommon. We have divided this review into two parts. Part I summarizes the epidemiology and immunopathogenesis of SJS/TEN and discusses systemic therapy and its possible benefits. We hope this review will help the ophthalmologist better understand the mechanisms of disease in SJS/TEN and enhance their care of patients with this complex and often debilitating disease. Part II (April 2016 issue) will focus on ophthalmic manifestations.

Treatment of Refractory Persistent Corneal Epithelial Defects: A Standardized Approach Using Continuous Wear PROSE Therapy.

PURPOSE: To evaluate continuous wear of a fluid-ventilated, gas-permeable scleral PROSE device using a standardized protocol as treatment for refractory persistent corneal epithelial defects in patients with severe ocular surface disease. METHODS: Retrospective review of eight eyes of seven consecutive patients with persistent epithelial defects refractory to traditional therapies. The standardized treatment regimen consisted of: (1) 24-hour-a-day PROSE wear until re-epithelialization was achieved, (2) brief daily device removal, cleaning, disinfection, and reservoir fluid replacement, (3) addition of a benzalkonium chloride (BAK)-free fourth-generation fluoroquinolone antibiotic drop to the reservoir, and (4) transition to long-term, daytime PROSE wear upon re-epithelialization. RESULTS: All eight eyes exhibited resolution of the persistent epithelial defect. No eyes developed microbial keratitis. Four eyes exhibited recurrences; all recurrences promptly responded to reinstitution of continuous wear. CONCLUSIONS: Continuous wear of a PROSE device, using a strictly standardized regimen, constitutes an effective, safe treatment option for refractory persistent epithelial defects.

Corneal nerve structure and function after long-term wear of fluid-filled scleral lens.

PURPOSE: The aim of this study was to determine whether long-term wear of a fluid-filled scleral lens alters basal tear production, corneal sensation, corneal nerve density, and corneal nerve morphology in 2 disease categories. METHODS: Patients recruited from the Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) treatment program at the Weill Cornell Medical College were categorized into 2 groups: distorted corneas (DC) or ocular surface disease (OSD). We measured tear production, central corneal sensation, subbasal nerve density and tortuosity, and stromal nerve thickness before and after long-term wear of the prosthetic device used in PROSE treatment, defined as at least 60 days of wear for a minimum of 8 hours a day. RESULTS: Twenty patients were included in the study. After long-term wear of the prosthetic device, tear production decreased in patients with DC (21.2 ± 8.5 to 10.4 ± 4.6 mm; P < 0.0001) but did not change in patients with OSD (7.5 ± 5.2 to 8.7 ± 7.2 mm; P = 0.71). Corneal sensation increased in the DC group (45.6 ± 9.2 to 55.0 ± 5.6 mm; P < 0.05). There was no significant change in sensation in patients with OSD (45.0 ± 8.7 to 49.1 ± 14.8 mm; P = 0.37). Subbasal nerve density, subbasal nerve tortuosity, and stromal nerve thickness remained unchanged in both DC and OSD groups after long-term wear (P > 0.05). CONCLUSIONS: Patients with DC had significantly reduced basal tear production and increased corneal sensation after long-term wear of the scleral lens, but patients with OSD did not show any changes in tear production or corneal sensation.

Phacoemulsification and thermal wound injury.

The technique of lens nucleus phacoemulsification has revolutionized cataract surgery. However, the production of ultrasound energy is associated with heat generation that can result in damage to ocular tissue, in particular the corneoscleral wound site. Thermal damage to the corneoscleral wound site may result in difficulty with wound closure and consequent risk of wound leakage, as well as damage to the adjacent corneal stroma and endothelium, fistula formation, and the induction of high degrees of post-operative astigmatism. The loss of adequate flow of irrigation fluid around the phacoemulsification tip is the key factor in the development of phacoemulsification-induced thermal injury. Use of excessive ultrasound power and production of excessive frictional forces generated by contact of the vibrating phacoemulsification needle with the irrigation sleeve are also factors involved. In the event of a "phacoburn," a specialized "gape suture" may help minimize surgically-induced astigmatism. The degree of induced astigmatism tends to wane over time; astigmatic keratotomy is an option in the setting of high degrees of residual astigmatism.