Pseudoexfoliation and Cataract Syndrome Associated with Genetic and Epidemiological Factors in a Mayan Cohort of Guatemala.

The Mayan population of Guatemala is understudied within eye and vision research. Studying an observational homogenous, geographically isolated population of individuals seeking eye care may identify unique clinical, demographic, environmental and genetic risk factors for blinding eye disease that can inform targeted and effective screening strategies to achieve better and improved health care distribution. This study served to: (a) identify the ocular health needs within this population; and (b) identify any possible modifiable risk factors contributing to disease pathophysiology within this population. We conducted a cross-sectional study with 126 participants. Each participant completed a comprehensive eye examination, provided a blood sample for genetic analysis, and received a structured core baseline interview for a standardized epidemiological questionnaire at the Salama Lions Club Eye Hospital in Salama, Guatemala. Interpreters were available for translation to the patients' native dialect, to assist participants during their visit. We performed a genome-wide association study for ocular disease association on the blood samples using Illumina's HumanOmni2.5-8 chip to examine single nucleotide polymorphism SNPs in this population. After implementing quality control measures, we performed adjusted logistic regression analysis to determine which genetic and epidemiological factors were associated with eye disease. We found that the most prevalent eye conditions were cataracts (54.8%) followed by pseudoexfoliation syndrome (PXF) (24.6%). The population with both conditions was 22.2%. In our epidemiological analysis, we found that eye disease was significantly associated with advanced age. Cataracts were significantly more common among those living in the 10 districts with the least resources. Furthermore, having cataracts was associated with a greater likelihood of PXF after adjusting for both age and sex. In our genetic analysis, the SNP most nominally significantly associated with PXF lay within the gene KSR2 (p < 1 × 10-5). Several SNPs were associated with cataracts at genome-wide significance after adjusting for covariates (p < 5 × 10-8). About seventy five percent of the 33 cataract-associated SNPs lie within 13 genes, with the majority of genes having only one significant SNP (5 × 10-8). Using bioinformatic tools including PhenGenI, the Ensembl genome browser and literature review, these SNPs and genes have not previously been associated with PXF or cataracts, separately or in combination. This study can aid in understanding the prevalence of eye conditions in this population to better help inform public health planning and the delivery of quality, accessible, and relevant health and preventative care within Salama, Guatemala.

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

Clinical decision-making is based on knowledge, expertise, and authority, with clinicians approving almost every intervention-the starting point for delivery of "All the right care, but only the right care," an unachieved healthcare quality improvement goal. Unaided clinicians suffer from human cognitive limitations and biases when decisions are based only on their training, expertise, and experience. Electronic health records (EHRs) could improve healthcare with robust decision-support tools that reduce unwarranted variation of clinician decisions and actions. Current EHRs, focused on results review, documentation, and accounting, are awkward, time-consuming, and contribute to clinician stress and burnout. Decision-support tools could reduce clinician burden and enable replicable clinician decisions and actions that personalize patient care. Most current clinical decision-support tools or aids lack detail and neither reduce burden nor enable replicable actions. Clinicians must provide subjective interpretation and missing logic, thus introducing personal biases and mindless, unwarranted, variation from evidence-based practice. Replicability occurs when different clinicians, with the same patient information and context, come to the same decision and action. We propose a feasible subset of therapeutic decision-support tools based on credible clinical outcome evidence: computer protocols leading to replicable clinician actions (eActions). eActions enable different clinicians to make consistent decisions and actions when faced with the same patient input data. eActions embrace good everyday decision-making informed by evidence, experience, EHR data, and individual patient status. eActions can reduce unwarranted variation, increase quality of clinical care and research, reduce EHR noise, and could enable a learning healthcare system.

Systemic Disease and Ocular Comorbidity Analysis of Geographically Isolated Federally Recognized American Indian Tribes of the Intermountain West.

BACKGROUND: The American Indian Navajo and Goshute peoples are underserved patient populations residing in the Four Corners area of the United States and Ibupah, Utah, respectively. METHODS: We conducted a cross-sectional study of epidemiological factors and lipid biomarkers that may be associated with type II diabetes, hypertension and retinal manifestations in tribal and non-tribal members in the study areas (n = 146 participants). We performed multivariate analyses to determine which, if any, risk factors were unique at the tribal level. Fundus photos and epidemiological data through standardized questionnaires were collected. Blood samples were collected to analyze lipid biomarkers. Univariate analyses were conducted and statistically significant factors at p < 0.10 were entered into a multivariate regression. RESULTS: Of 51 participants for whom phenotyping was available, from the Four Corners region, 31 had type II diabetes (DM), 26 had hypertension and 6 had diabetic retinopathy (DR). Of the 64 participants from Ibupah with phenotyping available, 20 had diabetes, 19 had hypertension and 6 had DR. Navajo participants were less likely to have any type of retinopathy as compared to Goshute participants (odds ratio (OR) = 0.059; 95% confidence interval (CI) = 0.016-0.223; p < 0.001). Associations were found between diabetes and hypertension in both populations. Older age was associated with hypertension in the Four Corners, and the Navajo that reside there on the reservation, but not within the Goshute and Ibupah populations. Combining both the Ibupah, Utah and Four Corners study populations, being American Indian (p = 0.022), residing in the Four Corners (p = 0.027) and having hypertension (p < 0.001) increased the risk of DM. DM (p < 0.001) and age (p = 0.002) were significantly associated with hypertension in both populations examined. When retinopathy was evaluated for both populations combined, hypertension (p = 0.037) and living in Ibupah (p < 0.001) were associated with greater risk of retinopathy. When combining both American Indian populations from the Four Corners and Ibupah, those with hypertension were more likely to have DM (p < 0.001). No lipid biomarkers were found to be significantly associated with any disease state. CONCLUSIONS: We found different comorbid factors with retinal disease outcome between the two tribes that reside within the Intermountain West. This is indicated by the association of tribe and with the type of retinopathy outcome when we combined the populations of American Indians. Overall, the Navajo peoples and the Four Corners had a higher prevalence of chronic disease that included diabetes and hypertension than the Goshutes and Ibupah. To the best of our knowledge, this is the first study to conduct an analysis for disease outcomes exclusively including the Navajo and Goshute tribe of the Intermountain West.

A Schlemm Canal Microstent for Intraocular Pressure Reduction in Primary Open-Angle Glaucoma and Cataract: The HORIZON Study.

OBJECTIVE: To compare cataract surgery with implantation of a Schlemm canal microstent with cataract surgery alone for the reduction of intraocular pressure (IOP) and medication use after 24 months. DESIGN: Prospective, multicenter, single-masked, randomized controlled trial. PARTICIPANTS: Subjects with concomitant primary open-angle glaucoma (POAG), visually significant cataract, and washed-out modified diurnal IOP (MDIOP) between 22 and 34 mmHg. METHODS: Subjects were randomized 2:1 to receive a single Hydrus Microstent (Ivantis, Inc, Irvine, CA) in the Schlemm canal or no stent after uncomplicated phacoemulsification. Comprehensive eye examinations were conducted 1 day, 1 week, and 1, 3, 6, 12, 18, and 24 months postoperatively. Medication washout and MDIOP measurement were repeated at 12 and 24 months. MAIN OUTCOME MEASURES: The primary and secondary effectiveness end points were the proportion of subjects demonstrating a 20% or greater reduction in unmedicated MDIOP and change in mean MDIOP from baseline at 24 months, respectively. Hypotensive medication use was tracked throughout the course of follow-up. Safety measures included the frequency of surgical complications and adverse events. RESULTS: A total of 369 eyes were randomized after phacoemulsification to Hydrus Microstent (HMS) and 187 to no microstent (NMS). At 24 months, unmedicated MDIOP was reduced by ≥20% in 77.3% of HMS group eyes and in 57.8% of NMS group eyes (difference = 19.5%, 95% confidence interval [CI] 11.2%-27.8%, P < 0.001). The mean reduction in 24-month unmedicated MDIOP was -7.6±4.1 mmHg (mean ± standard deviation) in the HMS group and -5.3±3.9 mmHg in the NMS group (difference = -2.3 mmHg; 95% CI, -3.0 to -1.6; P < 0.001). The mean number of medications was reduced from 1.7±0.9 at baseline to 0.3±0.8 at 24 months in the HMS group and from 1.7±0.9 to 0.7±0.9 in the NMS group (difference = -0.4 medications; P < 0.001). There were no serious ocular adverse events related to the microstent, and no significant differences in safety parameters between the 2 groups. CONCLUSIONS: This 24-month multicenter randomized controlled trial demonstrated superior reduction in MDIOP and medication use among subjects with mild-to-moderate POAG who received a Schlemm canal microstent combined with phacoemulsification compared with phacoemulsification alone.

Visual function, digital behavior and the vision performance index.

Historically, visual acuity has been the benchmark for visual function. It is used to measure therapeutic outcomes for vision-related services, products and interventions. Quantitative measurement of suboptimal visual acuity can potentially be corrected optically with proper refraction in some cases, but in many cases of reduced vision there is something else more serious that can potentially impact other aspects of visual function such as contrast sensitivity, color discrimination, peripheral field of view and higher-order visual processing. The measurement of visual acuity typically requires stimuli subject to some degree of standardization or calibration and has thus often been limited to clinical settings. However, we are spending increasing amounts of time interacting with devices that present high-resolution, full color images and video (hereafter, digital media) and can record our responses. Most of these devices can be used to measure visual acuity and other aspects of visual function, not just with targeted testing experiences but from typical device interactions. There is growing evidence that prolonged exposure to digital media can lead to various vision-related issues (eg, computer vision syndrome, dry eye, etc.). Our regular, daily interactions (digital behavior) can also be used to assess our visual function, passively and continuously. This allows us to expand vision health assessment beyond the clinic, to collect vision-related data in the whole range of settings for typical digital behavior from practically any population(s) of interest and to further explore just how our increasingly virtual interactions are affecting our vision. We present a tool that can be easily integrated into digital media to provide insights into our digital behavior.

Exfoliation Syndrome and Cataract Surgery.

Cataract extraction in exfoliation syndrome requires careful preoperative assessment and planning. Knowledge of the degree of pupil dilation and zonular integrity are essential for safely perform cataract surgery in these eyes. Capsule rhexis should be 5.5 mm and all intraoperative maneuvers should be designed to minimize zonular stress. The surgeon should be versatile in various nuclear disassembly techniques and consider use of capsular support devices when warranted. Cortical cleanup should proceed via a tangential approach and attempts should be made to removal residual lens epithelial cells so as to minimize postoperative capsular contraction syndrome.

Long-term outcomes for pediatric patients having transscleral fixation of the capsular bag with intraocular lens for ectopia lentis.

PURPOSE: To report the long-term outcomes of transscleral fixation of capsular tension rings (CTR) with intraocular lens (IOL) placement in pediatric patients with ectopia lentis. SETTING: John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. DESIGN: Retrospective case series. METHODS: Pediatric patients requiring lens extraction with transscleral capsular bag fixation with a CTR and IOL for ectopia lentis between January 2006 and January 2016 were analyzed. RESULTS: Thirty-seven patients (67 eyes) who had transscleral fixation of the capsular bag using a CTR fixated with 9-0 or 10-0 polypropylene (Prolene), 8-0 polytetrafluoroethylene (Gore-Tex), or 9-0 nylon were identified. The mean age at time of surgery was 7.25 years (2 to 18 years) and the mean follow-up was 35.3 months (0.25 to 120 months). The proportion of eyes showing improvement in corrected distance visual acuity (CDVA) postoperatively was 78.5%, which demonstrated significance with a 95% confidence interval. In the immediate postoperative period, 1 eye developed a hyphema and 1 eye required IOL repositioning. Long-term complications included posterior capsule opacification in 35 eyes (52%) and uveitis-glaucoma-hyphema syndrome in 1 eye (1.5%). Three eyes (4.4 %) required IOL repositioning for spontaneous delayed IOL dislocation, 2 sutured with 8-0 polytetrafluoroethylene at postoperative month 8 and postoperative year 3 and 1 sutured with 9-0 polypropylene at postoperative year 7. CONCLUSION: Transscleral fixation of the capsular bag using a CTR improved CDVA and provided IOL stability in pediatric patients with ectopia lentis.

New capsular tension segment with 2-point fixation for zonular weakness.

We describe clinical applications and surgical techniques for a new type of capsular tension segment (CTS) for use during cataract surgery. The Ambati CTS is distinguished from other CTS devices by having 2 eyelets close to each other, which allows it to distribute tension to 2 points, avoiding too much stress at a single point on the anterior capsulotomy, which prevents peaking of the capsulorhexis, and potentially reducing the risk for anterior capsule tear. Two of these CTS devices could possibly be used to provide 4-point fixation of a capsular bag in eyes with near-complete zonular instability. We describe 4 cases and 2 surgical techniques for implanting the new CTS, 1 technique in an adult patient with zonular weakness secondary to trauma and the other in 3 children with subluxated lenses due to Marfan syndrome.

Adherence to Glaucoma Medications Over 12 Months in Two US Community Pharmacy Chains.

UNLABELLED: This study determined the degree of adherence to medications for glaucoma among patients refilling prescriptions in community pharmacies. METHODS: Data abstracted from the dispensing records for 3615 adult patients (18 years or older, predominantly over 45) receiving glaucoma medications from two retail pharmacy chains (64 stores in total) were analyzed. From a 24-month historic data capture period, the 12-month levels of adherence were determined using standard metrics, the proportion of days covered (PDC) and the medication possession ratio (MPR). The overall 12-month mean PDC was only 57%, and the mean MPR was 71%. Using a criterion by which 80% coverage was considered satisfactory adherence, only 30% had satisfactory overall 12-month PDC coverage, and only 37% had satisfactory overall 12-month MPR coverage. Refill adherence increased with age and was highest in the 65-and-older age group (p < 0.001). Differential adherence was found across medication classes, with the highest satisfactory coverage seen for those taking alpha2-adrenergic agonists (PDC = 36.0%; MPR = 47.6%) down to those taking direct cholinergic agonists (PDC = 25.0%; MPR = 31.2%) and combination products (PDC = 22.7%; MPR = 31.0%). Adherence to glaucoma medications in the community setting, as measured by pharmacy refill data, is very poor and represents a critical target for intervention. Community pharmacists are well positioned to monitor and reinforce adherence in this population.

Minimally invasive external mini-glaucoma shunt implantation without conjunctival dissection.

The current method for implantation of the Ex-PRESS Glaucoma Filtration Device requires a conjunctival peritomy and shunt insertion under the guarded protection of a scleral flap. This technique requires suture closure of the flap and conjunctiva. A new minimally invasive technique for Ex-PRESS shunt implantation allows for insertion through a scleral tunnel originating from a grooved clear corneal incision. This new method avoids the need for conjunctival dissection and closure and offers the advantages of eliminating conjunctival wound leaks while maintaining the protection of a partial thickness scleral covering. This new technique may offer a faster safer means for shunt implantation with the potential for less conjunctival scarring.

Ab externo scleral fixation of intraocular lens.

UNLABELLED: We describe an ab externo technique that facilitates IOL scleral fixation and reduces the risk associated with previous ab externo scleral fixation techniques. This technique uses a microvitreoretinal blade and an internal limiting membrane forceps to create sclerotomies and retrieve the suture, respectively. FINANCIAL DISCLOSURE: Dr. Cionni is a consultant to Morcher GmbH, Stuttgart, Germany. Dr. Crandall is a consultant to Alcon Laboratories, Inc., Ft. Worth, Texas, USA. No other author has a financial or proprietary interest in any material or method mentioned.

Glaucoma diagnostic accuracy of ganglion cell-inner plexiform layer thickness: comparison with nerve fiber layer and optic nerve head.

PURPOSE: To determine the diagnostic performance of macular ganglion cell-inner plexiform layer (GCIPL) thickness measured with the Cirrus high-definition optical coherence tomography (HD-OCT) ganglion cell analysis (GCA) algorithm (Carl Zeiss Meditec, Dublin, CA) to discriminate normal eyes and eyes with early glaucoma and to compare it with that of peripapillary retinal nerve fiber layer (RNFL) thickness and optic nerve head (ONH) measurements. DESIGN: Evaluation of diagnostic test or technology. PARTICIPANTS: Fifty-eight patients with early glaucoma and 99 age-matched normal subjects. METHODS: Macular GCIPL and peripapillary RNFL thicknesses and ONH parameters were measured in each participant, and their diagnostic abilities were compared. MAIN OUTCOME MEASURES: Area under the curve (AUC) of the receiver operating characteristic. RESULTS: The GCIPL parameters with the best AUCs were the minimum (0.959), inferotemporal (0.956), average (0.935), superotemporal (0.919), and inferior sector (0.918). There were no significant differences between these AUCs and those of inferior quadrant (0.939), average (0.936), and superior quadrant RNFL (0.933); vertical cup-to-disc diameter ratio (0.962); cup-to-disc area ratio (0.933); and rim area (0.910), all P>0.05. CONCLUSIONS: The ability of macular GCIPL parameters to discriminate normal eyes and eyes with early glaucoma is high and comparable to that of the best peripapillary RNFL and ONH parameters. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Length and frequency of intraoperative occlusive events with new torsional phacoemulsification software.

PURPOSE: To evaluate the efficiency profile of new torsional phacoemulsification software. SETTING: Eye Institute of Utah, Salt Lake City, Utah, USA. DESIGN: Comparative case series. METHODS: Routine cataract surgeries were performed using standard torsional (Ozil) and new torsional (Ozil IP) software. The new software uses occasional pulses of longitudinal energy that are operator specified and system controlled to manage potential occlusion. The new software was compared with the previous standard software, which did not include this option. The video monitor system was recorded in high definition. Measurement of cumulative dissipated energy, balanced salt solution use, and amount of time spent in occlusion were measured in a frame-by-frame review of the recorded videos. Data were categorized for analysis by software group and cataract grade (1 to 4). RESULTS: The study comprised 59 eyes that had cataract removal using the new torsional software and 59 eyes using the standard torsional software. Cumulative dissipated energy was not statistically significantly different between the 2 groups. Balanced salt solution use, time spent in occlusion, and the mean longest continuous occlusion were significantly lower with the new torsional software; these differences were greater as the cataract grade increased. CONCLUSIONS: The new torsional software significantly decreased occlusion time and balanced salt solution use over standard torsional software, particularly with denser cataracts. The net result was a relatively better safety cataract surgery profile. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Randomized comparison of postoperative use of hydrogel ocular bandage and collagen corneal shield for wound protection and patient tolerability after cataract surgery.

PURPOSE: To compare the safety and efficacy of a hydrogel bandage and a collagen corneal shield in providing wound protection and relief of pain/discomfort in the acute period after uneventful unilateral clear corneal phacoemulsification cataract surgery with foldable intraocular lens (IOL) implantation. SETTING: Seventeen investigational sites in the United States. DESIGN: Prospective randomized single-masked parallel study. METHODS: The study comprised patients scheduled to have unilateral clear corneal cataract surgery with posterior chamber intraocular lens implantation. The patients were examined preoperatively and frequently for 30 days postoperatively. The design was a noninferiority study of the 2 primary endpoints, device performance and maximum reported postoperative pain. RESULTS: The device performance success was 78.6% (228/290) for the hydrogel bandage and 26.5% (26/98) for the corneal shield (P<.0001 for noninferiority). Analyses indicated that the hydrogel bandage was superior to the corneal shield in device performance (P<.001; difference = 52.1%; 95% confidence interval, 41.6%-61.4%). The maximum postoperative pain/discomfort score of the hydrogel bandage (mean 1.3 ± 1.8 [SD]; scale 0 to 10) was noninferior to that of the corneal shield (1.1 ± 1.6) in the first 4 hours after surgery (P<.001). Adverse events in the cataract surgeries were reported in 22.2% (70/316) and 36.5% (38/104) of hydrogel bandage patients and corneal shield patients, respectively (P = .0045). CONCLUSION: The hydrogel bandage was safe and effective for ocular surface protection and relief of pain/discomfort when applied topically to clear corneal incisions used in cataract or IOL implantation surgery. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

Pseudoexfoliation and the cataract surgeon: preoperative, intraoperative, and postoperative issues related to intraocular pressure, cataract, and intraocular lenses.

This review provides a comprehensive assessment of intraocular pressure (IOP), phacoemulsification techniques, and intraocular lenses (IOLs) in pseudoexfoliation (PXF) eyes having cataract surgery. Pseudoexfoliation is ubiquitous and the most common cause for open-angle glaucoma worldwide. Cataracts occur with increased frequency in PXF eyes, and surgery is potentially complicated by the presence of small pupils and zonule laxity and significantly affects IOP in these eyes. Preoperative evaluation and the options for intraoperative management of cataract are presented with recommendations for the use of adjunctive pupil and zonule support devices. Postoperative complications such as capsule contraction and IOL instability are discussed and laser and surgical options to manage these special problems presented.

Intraoperative performance and postoperative outcomes of endocapsular ring implantation in pediatric eyes.

PURPOSE: To study the intraoperative performance and postoperative outcomes of Cionni modified capsule tension ring (CTR) and intraocular lens (IOL) implantation in the capsular bag in pediatric eyes with ectopia lentis. SETTING: John A. Moran Eye Center, Salt Lake City, Utah, USA. METHODS: Thirty-five eyes (22 children) with ectopia lentis and visually significant cataract that had lens aspiration and in-the-bag implantation of single-piece AcrySof IOL and Cionni CTR were included. Single- and double-eyelet CTRs were used. The rings were sutured to the sclera using 9-0 or 10-0 polypropylene (Prolene) sutures. Preoperative and postoperative best corrected visual acuity (BCVA), intraoperative performance, IOL centration, and complications were studied. RESULTS: The mean patient age was 8.2 years +/- 5.1 (SD) and the median follow-up, 28 months. A double-eyelet CTR was implanted in 12 eyes and a single-eyelet CTR, in 23 eyes. The mean BCVA at the final follow-up (0.37 +/- 0.25 logMAR, 33 eyes) was significantly better than preoperatively (0.78 +/- 0.42 logMAR, 28 eyes) (P = .003). At the last examination, the BCVA was 20/40 or better in 16 eyes (45.7%). Three eyes (8.5%) required resuturing for IOL decentration. Nineteen eyes (54.3%) had a secondary procedure for posterior capsule opacification. Other complications included anterior capsule opacification (2.85%), cystoid macular edema (5.71%), chronic uveitis (5.71%), and vitreous prolapse (2.85%). CONCLUSION: Implantation of the Cionni CTR and single-piece AcrySof IOL in the capsular bag in pediatric eyes with subluxated lenses was safe and effective and led to a stable IOL with few significant complications.

Corticocapsular cleavage during phacoemulsification: Viscodissection versus hydrodissection. Miyake-Apple view analysis.

PURPOSE: To compare the corticocapsular separation created by viscodissection and by hydrodissection using Miyake-Apple video-photographic analysis. SETTING: University-based center. METHODS: Fourteen cadaver eyes were randomized to hydrodissection (Group 1, n=7) or viscodissection (Group 2, n=7). Twelve eyes were prepared for Miyake-Apple viewing. One eye in each group was prepared to simulate a closed chamber. On Miyake-Apple viewing, corticocapsular separation was graded from 0 to 3 after hydrodissection/viscodissection and at the sculpting, nuclear division, and early and late fragment removal stages. The surgeon's subjective impression of the mechanical cushion effect was noted. Histopathology of the capsular bag was performed in 4 eyes in each group to determine the amount of residual lens epithelial cells (LECs). RESULTS: More space was created and maintained between the capsule and cortex in Group 2 than in Group 1. The mean scores in Groups 1 and 2 were endpoint of hydrodissection/viscodissection 1.92+/-0.38 and 2.58+/-0.38, respectively (P=.05); sculpting, 1.6+/-0.42 and 2.3+/-0.45, respectively (P=.05); nuclear division, 0.9+/-0.42 and 1.5+/-0.35, respectively (P=.13); early fragment removal, 0.6+/-0.22 and 1.0+/-0, respectively (P=.04); and late fragment removal, 0.1+/-0.22 and 0.4+/-0.22, respectively (P=.17). Although only early fragment removal achieved statistical significance, the surgeon's impression confirmed greater cushion effect with viscodissection. Residual LECs in the 2 groups were comparable. CONCLUSION: Viscodissection as an adjunct to hydrodissection created and maintained greater corticocapsular separation than hydrodissection alone during phacoemulsification.