Survey of ptosis practice patterns among surgeons in Asia Pacific Society of Ophthalmic Plastic and Reconstructive Surgery (APSOPRS).

OBJECTIVE: To characterize the preferred ptosis practice patterns and variations among oculoplastic surgeons in the Asia-Pacific region. METHODS: A web-based questionnaire was sent to both members and non-members registered under the Asia Pacific Society of Ophthalmic Plastic and Reconstructive Surgery (APSOPRS)'s email database. The survey included preoperative testing practices, surgical preferences for adult aponeurotic and congenital ptosis, various surgical techniques (anterior and posterior approach ptosis procedures, and frontalis sling procedures) and postoperative practices. RESULTS: A total of 386 survey invitations were sent. There was a response rate of 68.7% from respondents from 20 countries in the Asia-Pacific region. There was variation in the preoperative evaluation and management of ptosis. Anterior approach ptosis surgery (96.6%) and frontalis sling procedures (86.8%) were performed by more surgeons than posterior approach ptosis surgery (47.2%). There was a deviation from the traditional frontalis sling procedures for patients with poor levator function. CONCLUSIONS: Our survey results provide insight into the variation in the assessment and management of ptosis amongst oculoplastic surgeons in the Asia-Pacific region. It also demonstrates some differences between practice patterns in Asia-Pacific and America.

Management of the subluxated crystalline lens: A review.

Cataract surgery for the subluxated crystalline lens is challenging. A thorough preoperative evaluation is important to determine the appropriate surgical approach for lens removal and the subsequent technique of intraocular lens placement. Important considerations include the extent and location of zonular weakness, and whether the zonular deficiency is caused by a static or progressive disease. The capsular bag should be preserved where possible. Creating a good-sized and centred continuous curvilinear capsulorhexis is crucial to facilitate the use of capsular retractors and capsular tension devices, which provide capsular stability. Nucleus sculpting and rotation should be minimised to reduce zonular stress. Being cognisant of the possible intraoperative complications that may occur at each stage of the surgery and knowing how to reduce the risk of these complications occurring will enable surgeons to perform safe cataract surgery in these complex cases.

Keratic Precipitates: The Underutilized Diagnostic Clue.

The morphology of keratic precipitates (KPs) may yield important diagnostic clues. However, KPs have not been described in a standardized manner and the traditional classification of granulomatous or non-granulomatous KPs is not helpful in differentiating infectious from noninfectious uveitis. A granulomatous uveitis may initially appear non-granulomatous. We suggest three ways to examine KPs that may aid in differentiating the infectious from noninfectious etiologies. The first method is the in vivo confocal microscopy (IVCM) description and classification of KPs, in which the "non-granulomatous" subset of dendritiform and infiltrative KPs should be differentiated from smooth-rounded KPs and globular KPs which are "granulomatous." The second and third clues are the distribution and color of the KPs. KPs that extend beyond the midline may suggest an infective cause, and fresh pigmented KPs suggest a viral cause. Careful examination of the KPs may immediately reveal the clues to the diagnosis, minimizing unnecessary tests and costs.

Femtosecond laser-assisted cataract surgery for the white cataract.

AIM: To report the capsulotomy and lens fragmentation outcomes of white cataracts managed with the femtosecond laser (FL). METHODS: Outcomes of a prospective, observational consecutive case series of white cataracts (June 2012-November 2016) that underwent FL-assisted cataract surgery (FLACS) (Victus, Bausch+Lomb, Munich, Germany) at the Singapore National Eye Centre were audited. Data collected: patient demographics, type of white cataract, levelness of docking, anterior capsule position following laser, completeness of capsulotomy and fragmentation, best-corrected visual acuity (BCVA) at 1 month, intraoperative complications. Outcome measures: capsulotomy integrity, fragmentation capability and BCVA at 1 month. RESULTS: 58 eyes of 54 patients underwent FLACS. White cataract types included dry white (24 eyes), intumescent (28 eyes) and Morgagnian (6 eyes). Docking was level in 22 eyes (38.6%). Following FL, the anterior capsule level dropped in 20 eyes (34.5%). Incomplete capsulotomies occurred in 10 eyes (17.2%). Lens fragmentation attempted in 38 eyes was effective or partially effective in 31 eyes (81.6%). No anterior or posterior capsule tears occurred. LogMAR BCVA at 1 month was 0.073 (SD 0.09). Risk factors for incomplete capsulotomy were Morgagnian cataract and lens thickness (multiple logistic regression, p<0.01 and p=0.03, respectively). CONCLUSION: The main complication of FLACS in white cataracts was incomplete capsulotomy (17.2%), significantly associated with Morgagnian cataracts and increased lens thickness. Lens fragmentation was effected in four-fifths of white cataracts but should be avoided in Morgagnian cataracts due to possible overlap of the lens fragmentation plan and the anterior capsule.

Demystifying viral anterior uveitis: A review.

A viral aetiology should be suspected when anterior uveitis is accompanied by ocular hypertension, diffuse stellate keratic precipitates or the presence of iris atrophy. The most common viruses associated with anterior uveitis include herpes simplex virus, varicella-zoster virus, cytomegalovirus and rubella virus. They may present as the following: Firstly, granulomatous cluster of small and medium-sized keratic precipitates in Arlt's triangle, with or without corneal scars, suggestive of herpes simplex or varicella-zoster virus infection. Secondly, Posner-Schlossman syndrome with few medium-sized keratic precipitates, minimal anterior chamber cells and extremely high intraocular pressure; this is mainly associated with cytomegalovirus. Thirdly, Fuchs uveitis syndrome, with fine stellate keratic precipitates diffusely distributed over the corneal endothelium, with diffuse iris stromal atrophy but without posterior synechiae, is associated mainly with rubella or cytomegalovirus infection. In rubella, the onset is in the second to third decade. It presents with posterior subcapsular cataract, may have iris heterochromia and often develops vitritis without macular oedema. Cytomegalovirus affects predominantly Asian males in the fifth to seventh decade, the keratic precipitates may be pigmented or appear in coin-like pattern or develop nodular endothelial lesions, but rarely vitritis. Eyes with cytomegalovirus tend to have lower endothelial cell counts than the fellow eye. As their ocular manifestations are variable and may overlap considerably, viral AU can pose a diagnostic dilemma. Thus, quantitative polymerase chain reaction or Goldmann-Witmer coefficient assay from aqueous humour samples are preferred to confirm the aetiology and determine the disease severity as this impacts the treatment.

Suture snare technique for scleral fixation of intraocular lenses and capsular tension devices.

Polytetrafluoroethylene (Gore-Tex) suture is preferred for scleral fixation of intraocular lenses or capsular tension devices as it is more resilient to breakage than polypropylene 10-0. However, manipulation of the thick calibre and overcurved configuration of the Gore-Tex needle within the eye poses a risk of damage to the intraocular structures. Existing techniques that overcome the problem of needles within the anterior chamber involve special instruments to retrieve the suture. We describe a technique that creates a suture snare from a short segment of the Gore-Tex suture borne on a 26-gauge needle, which is used to retrieve the Gore-Tex suture safely at the scleral fixation site. The suture is threaded into the bore of the needle leaving a short length extending from the hub which is secured by inserting a 1 cc syringe acting as a handle. The needle is inserted at the scleral fixation site, and the suture trailing from the needle tip forms a loop which is externalised at the main incision. This suture snare is used to retrieve the end of the Gore-Tex suture bearing the device to the scleral fixation site when the needle and the loop of the suture are withdrawn from the eye. This technique eliminates the inappropriate needle and the need for a large sclerostomy, and is cost-effective and can also be used in combination with the conjunctival-sparing Hoffman corneoscleral pocket.

Pediatric Uveitis.

Pediatric uveitis differs from adult-onset uveitis and is a topic of special interest because of its diagnostic and therapeutic challenges. Children with uveitis are often asymptomatic and the uveitis is often chronic, persistent, recurrent, and resistant to conventional treatment. Anterior uveitis is the most common type of uveitis in children; the prevalence of intermediate, posterior, and panuveitis varies geographically and among ethnic groups. Regarding etiology, most cases of pediatric uveitis are idiopathic but can be due to systemic inflammatory disorders, infections, or a manifestation of masquerade syndrome. Ocular complications include cataracts, hypotony or glaucoma, band keratopathy, synechiae formation, macular edema, optic disc edema, choroidal neovascular membranes, and retinal detachment. These complications are often severe, leading to irreversible structural damage and significant visual disability due to delayed presentation and diagnosis, persistent chronic inflammation from suboptimal treatment, topical and systemic corticosteroid dependence, and delayed initiation of systemic disease‒modifying agents. Treatment for noninfectious uveitis is a stepwise approach starting with corticosteroids. Immunomodulatory therapy should be initiated in cases where quiescence cannot be achieved without steroid dependence. Patients should be monitored regularly for complications of uveitis along with systemic and ocular adverse effects from treatments. The goals are to achieve steroid-free durable remission, to reduce the risk of sight-threatening complications from the uncontrolled ocular inflammation, and to avoid the impact of lifelong burden of visual loss on the child and their family. Multidisciplinary management will ensure holistic care of affected children and improve the support for their families.

A Biodegradable, Sustained-Released, Tacrolimus Microfilm Drug Delivery System for the Management of Allergic Conjunctivitis in a Mouse Model.

Purpose: To investigate the drug release profiles of a tacrolimus-loaded poly(D,L-lactide-co-ε-caprolactone) (PLC) microfilm, and to evaluate its efficacy on the treatment of allergic conjunctivitis using a mouse model. Methods: The in vitro and in vivo drug release profiles were first characterized. Balb/c mice were immunized with short ragweed (SRW) injection followed by re-challenges with topical SRW solution. The mice were divided into six groups (n = 12 in each): negative control (NC); positive control (PC); tacrolimus eye drops (Te); subconjunctival tacrolimus microfilm (Tm); dexamethasone eye drops (De); and tacrolimus + dexamethasone eye drops (Te+De). The mice were evaluated for 28 days by a scoring system for allergic conjunctivitis. Histopathologic and immunohistochemical staining with CD11c, CD4, and IL-4 were performed. Results: The microfilms were biocompatible and delivered clinically sufficient dose in a sustained manner, with a steady rate of 0.212 to 0.243 µg/day in vivo. Compared to the PC groups, the Te, Tm, De, and Te+De groups significantly reduced the allergic clinical scores throughout the study period (all P < 0.01; 0.0 ± 0.0, 5.6 ± 0.9, 3.3 ± 0.9, 3.2 ± 0.9, 1.9 ± 0.4 and 1.7 ± 0.8 for the NC, PC, Tm, Te, De, and Te+De groups, respectively, at 4 weeks after treatment). The suppressed eosinophils, CD11c, CD4, and IL-4 expression were also observed in all treatment groups, with more reduction in the Te+De group. Conclusions: Tacrolimus-loaded microfilms display good biocompatibility and desirable sustained drug release. It was as effective as conventional tacrolimus eye drops on the treatment of allergic conjunctivitis, providing a promising clinically applicable alternative for controlling allergic disease activity, or other immune-mediated ocular diseases.

Clinical Features of CMV-Associated Anterior Uveitis.

Cytomegalovirus (CMV) anterior uveitis is the most common ocular manifestation of CMV disease in immunocompetent individuals. It is thought to be due to a local reactivation of latent CMV and is usually unilateral. The acute form presents as Posner-Schlossman Syndrome, a recurrent hypertensive anterior uveitis with few granulomatous keratic precipitates. There are geographic differences in the chronic form of CMV anterior uveitis. Asian patients commonly present as Fuchs Uveitis Syndrome with diffuse stellate keratic precipitates, while the European patients present with a chronic hypertensive anterior uveitis with fewer keratic precipitates that are brown in color and located inferiorly. Characteristic features of CMV anterior uveitis include mild anterior chamber inflammation, elevated intraocular pressure, stromal iris atrophy. Synechiae, macular edema and retinitis are typically absent. CMV disease may also be associated with the development of corneal endotheliitis with a reduced endothelial cell count. Long-term complications include glaucomatous optic neuropathy and cataract formation.

Decision-making and management of uveitic cataract.

The visual outcome of uveitic cataract surgery depends on the underlying uveitic diagnosis, the presence of vision-limiting pathology and perioperative optimization of disease control. A comprehensive preoperative ophthalmic assessment for the presence of concomitant ocular pathology, with particular emphasis on macula and optic nerve involvement, is essential to determine which patients will benefit from improved vision after cataract surgery. Meticulous examination in conjunction with adjunct investigations can help in preoperative surgical planning and in determining the need for combined or staged procedures. The eye should be quiescent for a minimum of 3 months before cataract surgery. Perioperative corticosteroid prophylaxis is important to reduce the risk of cystoid macular edema and recurrence of the uveitis. Antimicrobial prophylaxis may also reduce the risk of reactivation in eyes with infectious uveitis. Uveitic cataracts may be surgically demanding due to the presence of synechiae, membranes, and pupil abnormalities that limit access to the cataract. This can be overcome by manual stretching, multiple sphincterotomies or mechanical dilation with pupil dilation devices. In patients <2 years of age and in eyes where the inflammation is poorly controlled, intraocular lens implantation should be deferred. Intensive local and/or oral steroid prophylaxis should be given postoperatively if indicated. Patients must be monitored closely for disease recurrence, excessive inflammation, raised intraocular pressure, hypotony, and other complications. Complications must be treated aggressively to improve visual rehabilitation. With proper patient selection, improved surgical techniques and optimization of peri- and post-operative care, patients with uveitic cataracts can achieve good visual outcomes.

Capsule milking: Modification of capsulorhexis technique for intumescent cataract.

We describe a single-stage modification of the continuous curvilinear capsulorhexis that facilitates creation of a well-sized round and centered capsulorhexis in an intumescent cataract. This is done without special instrumentation. The modification is based on overcoming the problem of high intralenticular pressure. It involves physically flattening the central anterior capsule, specifically over the site of puncture, simultaneous puncture and aspiration for decompression, followed by flattening of the midperiphery of the lens where the capsulorhexis can be safely initiated. This minimizes the tendency of capsulorhexis runaway and allows 1-stage creation of a well-sized capsule opening for phacoemulsification.

Analysis of competency in phacoemulsification trainees using the cumulative sum analysis.

PURPOSE: To determine the number of cases required to achieve competency in phacoemulsification in terms of the posterior capsule rupture rate. SETTING: Singapore National Eye Centre, Singapore. DESIGN: Retrospective cohort study. METHODS: The posterior capsule rupture rate of the first 300 phacoemulsification cases performed by each trainee in the Singapore National Eye Centre (2004 to 2012) was charted using cumulative sum graphs. Competency was primarily defined as a posterior capsule rupture rate of 2% or lower and secondarily as 5% or lower. RESULTS: Twenty trainees fulfilled the inclusion criteria. Four trainees (20%) and 19 trainees (95%) achieved a posterior capsule rupture rate of 2% and 5%, respectively. At least 41 cases were required to achieve a 5% posterior capsule rupture rate (mean 106, median 83). CONCLUSIONS: There was considerable variation in the trainees' abilities. Only 20% of the trainees achieved a posterior capsule rupture rate of 2% or lower and required at least 212 cases.

Epidemiology and Diagnosis of Myopic Choroidal Neovascularization in Asia.

BACKGROUND: This article aims to review recent advances in the understanding of epidemiology and risk factors for the development of myopic choroidal neovascularization (CNV) and highlight the diagnostic features of myopic CNV and signs seen on the noninvasive optical coherence tomography technology, which may be particularly useful for the purpose of screening. Choroidal neovascularization is a sight-threatening complication of pathologic myopia. Because myopic CNV frequently affects individuals during their working life, its socioeconomic impact is significant, especially in Asian countries where the prevalence of pathologic myopia is high. EPIDEMIOLOGY: Pathological myopia is the most common cause of CNV in patients less than 50 years old, and it is estimated that 5.2% to 11.3% of individuals with pathologic myopia develop myopic CNV. RISK FACTORS: The risk of developing myopic CNV increases with the severity of myopia and macular changes, such as diffuse atrophy, lacquer cracks, and patchy atrophy, which progress to myopic CNV in a significant proportion. Vascular endothelial growth factor (VEGF) may contribute to the development of myopic CNV. NATURAL COURSE AND PROGNOSIS: Untreated myopic CNV carries a poor visual prognosis, with an estimated 89% of the patients having marked visual impairment within 5 years of onset. TREATMENT: Anti-VEGF therapy is efficacious in treating myopic CNV. Although this significantly improves the short-term prognosis of myopic CNV, the long-term visual loss due to the sequela of myopic CNV including macular atrophy and scarring remains.

Use of anterior segment optical coherence tomography to predict corneal graft rejection in small animal models.

PURPOSE: To correlate the degree of anterior chamber (AC) inflammation and corneal thickness evaluated by anterior segment optical coherence tomography (ASOCT) with corneal graft rejection status and to explore the value of ASOCT in assisting the diagnosis or prediction of graft rejection using a rat penetrating keratoplasty (PK) model. METHODS: A total of 40 PKs were performed using Fisher rats (allogeneic groups) and Lewis rats (syngeneic group) as donors and Lewis rats as recipients: isograft control group (n=10), allograft untreated group (n=10), and allograft with 1% prednisolone acetate treatment group (n=20). All the grafts were evaluated for 28 days by a scoring rejection index (RI) to assess the graft opacity, edema, and neovascularization using slit lamp biomicroscopy. The AC inflammation and corneal graft thickness were assessed using ASOCT. RESULTS: All the allogeneic control grafts and four of the 20 allogeneic steroid-treated grafts developed rejection episodes. In the allogeneic treated group, the rejected grafts had a significantly higher mean AC inflammation grade at 1 week (grade 3.25±0.49 vs. 1.83±0.36, P<0.001), significantly thicker central graft thickness at 2 weeks (455.25±42.42 µm vs. 381.247±12.51 µm, P=0.047), and a significantly higher RI at 4 weeks (7.75±0.63 vs. 4.60±0.13, P<0.001) compared to the nonrejected grafts. Eyes with ≥grade 3 AC inflammation at 1 week, or with ≥400 µm central graft thickness at 2 weeks, were significantly associated with graft rejection (odds ratio [OR], 15.15, P=0.009, and OR, 9.75, P=0.014, respectively). CONCLUSIONS: The use of ASOCT to evaluate AC inflammation and corneal thickness aids in the early evaluation and diagnosis of graft rejection in animal models. Early increased AC inflammation was an early predictor of graft failure prior to definitive clinical evaluation.