Posterior Corneal Astigmatism Does Not Influence Manifest-Treated Topography-guided LASIK Outcomes.

PURPOSE: To investigate whether the magnitude of posterior corneal astigmatism (PCA) impacts refractive and visual outcomes of primary topography-guided laser in situ keratomileusis (LASIK) and to provide guidance on treating eyes with high PCA. METHODS: Comparative retrospective analysis of 4,541 consecutive eyes treated with Contoura (Alcon Laboratories, Inc) on the manifest refractive astigmatism. Standard outcomes of the 1,514 eyes with the lowest PCA (first tercile; low PCA group) were compared to the 1,514 eyes with the highest PCA (last tercile; high PCA group). Pearson correlation coefficient was used to assess relationships between variables. RESULTS: Preoperatively, 20.9% of eyes presented with PCA of 0.50 diopters (D) or greater. The mean PCA was 0.18 ± 0.07 D in eyes with low PCA, and 0.50 ± 0.11 D in eyes with high PCA. An equivalent number of eyes achieved a cumulative postoperative unilateral uncorrected distance visual acuity of 20/20 in both the low PCA and high PCA groups (95.3% vs 94.7%; P = .4489). The efficacy index of both low and high PCA eyes was identical (0.99 ± 0.06 vs 0.99 ± 0.08; P = .3192), as was the safety index (1.00 ± 0.02 vs 1.00 ± 0.03; P = .0110). The magnitude of preoperative PCA was weakly correlated with postoperative refractive astigmatism (R = 0.1323), but not with postoperative defocus equivalent (R = -0.0414) or spherical equivalent (R = -0.0128). CONCLUSIONS: PCA does not negatively impact the outcomes of topography-guided LASIK targeting the manifest refraction, having identical accuracy, efficacy, and safety in eyes with both low and high PCA. There is no scientific basis to measure and consider PCA in topography-guided LASIK planning software or nomograms if the excimer laser treatment input targets the manifest refraction. [J Refract Surg. 2022;38(12):780-790.].

Characterising the chronicity of dupilumab-associated ocular surface disease: an analysis of a retrospective case series.

BACKGROUND/AIMS: To describe the clinical presentation and treatment response of dupilumab-associated ocular surface disease (DAOSD). METHODS: This is a retrospective case series of atopic dermatitis patients with DAOSD treated with dupilumab. All consecutive patients with atopic dermatitis referred by dermatologists for suspicion of DAOSD between May 2018 and June 2020 were systemically assessed by a single ophthalmologist. Presenting signs of DAOSD, duration of treatment and associated response are described. RESULTS: Twenty-eight patients had DAOSD during the study period. Average age was 45.6±14.8 years and 13 (46%) were female. Average follow-up was 15±10 months. Most presentations consisted in diffuse, inflammatory conjunctivitis (n=19, 68%). Other signs included peripheral corneal infiltrates (n=7, 25%), limbal nodules (n=7, 25%) and dry eye syndrome (n=6, 21%). To control ocular symptoms, tapering of corticosteroid eyedrops was slow: taper duration of strong and mild corticosteroid eyedrops averaged 10±8 weeks and 49±34 weeks, respectively. Four patients (14%) required an increase of corticosteroid eyedrops during taper due to clinical deterioration. Corticosteroid eyedrops were still required at final follow-up among 10 patients (36%). Dupilumab was temporarily stopped in 3 patients (11%), one of which did not wish to resume dupilumab for unrelated reasons. Symptomatic improvement and/or complete resolution was achieved in 25/26 patients at follow-up (96%) with empirical treatment. CONCLUSIONS: DAOSD may follow the course of a chronic illness. Long-term corticosteroid eyedrops were required in many patients and when taper was possible, this was done after a prolonged treatment duration. Most patients' ocular symptoms could be controlled, allowing dupilumab continuation.

OUTCOMES IN PRIMARY UNCOMPLICATED RHEGMATOGENOUS RETINAL DETACHMENT REPAIR USING PARS PLANA VITRECTOMY WITH OR WITHOUT SCLERAL BUCKLE.

PURPOSE: To compare outcomes after primary uncomplicated rhegmatogenous retinal detachment repair using pars plana vitrectomy (PPV) or PPV with scleral buckle (PPV-SB). METHODS: This is a retrospective cohort study with propensity score analysis in a single tertiary care center between 2014 and 2018 comparing patients with primary uncomplicated rhegmatogenous retinal detachment repaired using PPV only or PPV-SB (full cohort: n = 1,516, propensity-matched cohort: n = 908). The primary outcome was single surgery anatomic success, whereas secondary outcomes were 3-month and final pinhole visual acuity in logarithm of the minimum angle of resolution and final retina status. RESULTS: In the full cohort, single surgery anatomic success was achieved in 745 (91%) PPV patients versus 623 (89%) PPV-SB patients (P = 0.13). This was 390 (92%) versus 314 (88%) in phakic patients (P = 0.06) compared with 353 (91%) versus 301 (90%) in pseudophakic patients (P = 0.79), respectively. After matching, single surgery anatomic success was achieved in 424 (93%) PPV patients versus 412 (91%) PPV-SB patients (P = 0.14). Median pinhole visual acuity after PPV was better at 3 months (PPV: 20/40 vs. PPV-SB: 20/50; both cohorts: P < 0.001) and final follow-up (PPV: 20/29 vs. PPV-SB: 20/38; full cohort: P < 0.001 and PPV: 20/29 vs. PPV-SB: 20/36; matched cohort: P < 0.001). CONCLUSION: Addition of scleral buckle does not significantly change the rate of single surgery anatomic success compared with PPV only in primary uncomplicated rhegmatogenous retinal detachment. It is also associated with worse pinhole visual acuity at follow-up.

Bilateral simultaneous postoperative endophthalmitis: review of cases reported over the past 50 years.

A detailed retrospective analysis and literature review were conducted for all previously published reports of bilateral simultaneous postoperative endophthalmitis (BSPOE) since 1970. There have been 7 (9, with 2 currently being reported elsewhere) cases of BSPOE after immediately sequential bilateral cataract surgery (ISBCS) reported over 50 years. Generally, in these cases, the surgical protocol recommended by the International Society of Bilateral Cataract Surgeons ( i SBCS) was breached or uncertain. Bacterial causes were Pseudomonas aeruginosa (3), Staphylococcus epidermidis (3), and Burkholderia cepacia complex (1). One case showed negative results for bacterial infection and 1 was not determined. Visual recovery was light perception, or worse, for Pseudomonas cases, generally good for Staphylococcus and Burkholderia cases, and mixed in cases of unknown etiology. Therefore, BSPOE is rare and causes vary. Strict adherence to the i SBCS General Principles of Excellence in ISBCS 2009 surgical protocol and care with operating room construction seem to considerably lessen the risk.

Immediately sequential bilateral cataract surgery: an academic teaching center's experience.

PURPOSE: To evaluate the safety and outcomes of immediately sequential bilateral cataract surgery (ISBCS) at a Canadian academic teaching center. SETTING: Tertiary university teaching hospital of Laval University, Quebec City, Canada. DESIGN: Retrospective cohort study. METHODS: 2003 consecutive patients (4006 eyes) who underwent ISBCS under topical anesthesia from January 2019 to December 2019 were included. All charts were retrospectively reviewed. Outcome measures included intraoperative and postoperative complications, postoperative uncorrected distance (UCVA) and pinhole (PHVA) visual acuities, and autorefraction measurements. RESULTS: 4006 eyes from 1218 (60.8%) female and 785 (39.2%) male patients with a mean age of 74 ± 8 years had a mean preoperative visual acuity of 0.503 logMAR (Snellen 20/63). The mean axial length was 23.53 ± 1.37 mm. Most eyes had monofocal intraocular lenses (IOLs) implanted (n = 3738, 93.3%) followed by toric (n = 226, 5.6%), multifocal (n = 25, 0.6%), and multifocal toric (n = 17, 0.4%) IOLs. Intraoperative complications included 14 (0.3%) posterior capsule ruptures with 5 (0.1%) requiring sulcus IOL placement, and 7 (0.2%) partial zonulysis, with 3 requiring capsular tension rings (0.07%). There were no cases of endophthalmitis or toxic anterior segment syndrome. Mean 5-week postoperative UCVA was 0.223 (Snellen 20/33), PHVA was 0.153 (Snellen 20/28) with a mean spherical equivalent of -0.21 diopters. CONCLUSIONS: ISBCS performed following International Society of Bilateral Cataract Surgeons recommended guidelines is a safe procedure. This cohort of 4006 eyes had very few complications, with none attributable to the surgery being done bilaterally. The UCVA, PHVA, and refractive outcomes were good.

Conjunctival Infiltration in a Child as a Rare Manifestation of IgG4-Related Disease.

PURPOSE: Ocular manifestations of immunoglobulin G4 (IgG4)-related disease are common in children although remain ill-defined because of the disease's rarity. We describe a pediatric case of IgG4-related orbital disease (IgG4-ROD) who presented with persistent conjunctival infiltration before developing lacrimal gland enlargement 3 years later. METHODS: This was a case report. RESULTS: An 8-year-old girl developed forniceal salmon-patch-like conjunctival lesions in her left eye that were refractory to topical corticosteroids. Investigations, including an orbital MRI and 2 conjunctival biopsies, were negative for lymphoma. She was treated with topical corticosteroids and then nonsteroidal antiinflammatory drops. The lesions decreased mildly, and no new lesion emerged. After 3 years, the patient developed a ptosis, new salmon-patch conjunctival lesions, and papillae. Vision deteriorated to 20/80 because of severe punctate epithelial erosions in the left eye, and the Schirmer test was significantly reduced. A repeat MRI revealed an enlarged left lacrimal gland. A biopsy was performed and was compatible with IgG4-ROD. An elevated IgG4 level of 4.61 g/L was also found. The patient was successfully treated with oral prednisone but flared on tapering the dosage. Rituximab was therefore initiated with excellent clinical response, and prednisone was discontinued. Vision returned to 20/20 after aggressive lubrification, punctal plugs, and autologous serum eye drops. Tear function came back to normal, and local treatments were stopped. CONCLUSIONS: This case describes a pediatric case of IgG4-ROD presenting initially with conjunctival follicular reaction, later developing lacrimal gland involvement. Therefore, it is important to consider IgG4-ROD in chronic atypical follicular conjunctival lesions in children, even in the absence of orbital disease.

Retinal Displacement: Providing New Insights for Retinal Detachment Surgery.

PURPOSE: To review the current literature on retinal displacement and provide a discussion of potential risk factors, postoperative outcomes, and future directions. METHODS: Two databases, MEDLINE and EMBASE, were mined using a directed search strategy to identify all articles on retinal displacement. RESULTS: We identified 1522 articles. A total of n = 14 articles were retained. We provide an overview on the potential influence of surgical type (n = 4), tamponade agents (n = 5), postoperative posture (n = 6), and preoperative retinal status (n = 5) on incidence of retinal displacement and visual outcomes (n = 8). Discussion. Pars plana vitrectomy (PPV) with gas tamponade is associated with displacement rates of up to 72%, typically in a downward direction. Meanwhile, pneumatic retinopexy and PPV with silicone oil may offer similar surgical success with a significantly lower risk of displacement. The impact of heavy liquids such as perfluorocarbon liquid, postoperative positioning and preoperative extent of detachment on displacement remains inconclusive. Patients with displacement had a significantly lower visual acuity and higher rates of distortion than those without displacement. However, not all patients with displacement experienced visual symptoms. CONCLUSION: Retinal displacement is a new concept in our understanding of retinal detachment. Additional studies are needed to better define its impact on postsurgical outcomes.

Optic Pit Maculopathy: Adjunctive Treatment Using Oral Spironolactone and Topical Dorzolamide.

PURPOSE: There is no consensus for the treatment of optic disc pit maculopathy (ODPM). We describe a case of ODPM refractory to vitrectomy that was successfully treated with systemic spironolactone and topical dorzolamide 2%. METHODS: Case report. RESULTS: A 27-year-old male was referred for decreased vision in the right eye secondary to macular edema. Fundus examination and optical coherence tomography imaging revealed an optic pit maculopathy with significant macular schisis and intraretinal fluid. After an initial observation period, we performed pars plana vitrectomy with internal limiting membrane peeling, fibrin glue, and gas endotamponade. At the 2 months postoperative follow-up, anatomic and functional outcomes remained unimproved. Oral spironolactone and topical dorzolamide 2% were, therefore, added. Significant reduction in the intraretinal fluid and macular schisis was demonstrated at the last follow-up 2 years postoperative. CONCLUSION: The mechanisms underlying optic disc pit maculopathy remain controversial, and treatment guidelines are unclear. To our knowledge, this is the first description of an OPDM treated with a combination systemic mineralocorticoid receptor antagonist and topical carbonic anhydrase inhibitor as adjuvant therapy to vitrectomy with favorable outcomes. We also review the literature and propose mechanisms through which these treatment entities may act.

Effect of the Vectorial Difference Between Manifest Refractive Astigmatism and Anterior Corneal Astigmatism on Topography-Guided LASIK Outcomes.

PURPOSE: To characterize the preoperative vectorial difference between manifest refractive astigmatism and anterior corneal astigmatism, termed ocular residual astigmatism (ORA), and to investigate its influence on topography-guided laser in situ keratomileusis (LASIK) outcomes. METHODS: Comparative retrospective analysis of 21,581 consecutive eyes treated on the manifest refractive astigmatism. Standard outcomes of the 7,180 eyes with the lowest ORA (first tercile: 0.35 ± 0.13 diopters [D]) were compared to the 7,208 eyes with the highest ORA (last tercile: 1.13 ± 0.25 D). RESULTS: The ORA followed a right-skewed normal distribution (R2 = 0.99) with a mean ± standard deviation of 0.73 ± 0.36 D. The efficacy index of eyes with low versus high ORA was identical (0.98 ± 0.07 vs 0.98 ± 0.08; P = .99), with a similar percentage having a spherical equivalent within ±0.50 D of the intended target (94.7% vs 94.1%; P = .11). The safety index (1.00 ± 0.04 vs 1.00 ± 0.04; P = .99) and Alpins correction index (1.01 ± 0.37 vs 1.00 ± 0.43; P = .10) were identical. A greater number of eyes with high versus low ORA had postoperative residual astigmatism of 0.75 D or greater (6.1% vs 3.9%). Eyes with very high ORA (ORA ⩾ 1.50 D; 2.5% of the population) marginally reduced the efficacy index from 0.98 to 0.97 (P < .001). CONCLUSIONS: The contribution of ORA to topography-guided clinical outcomes in most virgin eyes is negligible, with excellent efficacy, accuracy, and safety in both low ORA and high ORA groups. Myopic eyes with high ORA treated on the manifest refraction should not be excluded from topography-guided LASIK. [J Refract Surg. 2020;36(7):449-458.].

Systematic Review of Recommendations on the Use of Disease-Modifying Antirheumatic Drugs in Patients With Rheumatoid Arthritis and Cancer.

OBJECTIVE: To evaluate consensus recommendations regarding management of rheumatoid arthritis (RA) in patients with cancer. METHODS: We searched electronic databases, guideline registries, and relevant web sites for cancer-specific recommendations on RA management. Reviewers independently selected and appraised the recommendations according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. We identified similarities and discrepancies among recommendations. RESULTS: Of 4,077 unique citations, 39 recommendations were identified, of which half described their consensus process. Average scores for the AGREE II domains ranged from 33% to 87%. Cancer risk in RA was addressed in 79% of recommendations, with acknowledgement of increased overall cancer risk. Recommendations did not agree on the safety of using disease-modifying antirheumatic drugs (DMARDs) in RA patients with cancer, except for the contraindication of tumor necrosis factor inhibitors in patients at risk for lymphoma. Most recommendations agreed that RA treatment should be stopped and re-evaluated with a new diagnosis of cancer. Recommendations for patients with a history of cancer differed depending on the drug, cancer type, and time since cancer diagnosis. Few recommendations addressed all issues. CONCLUSION: Recommendations for the treatment of RA in patients with cancer often fail to meet expected methodologic criteria. There was agreement on the need for caution when prescribing DMARDs to these patients. However, several areas continue to lack consensus, and given the paucity of evidence, there is an urgent need for research and expert opinion to guide and standardize the management of RA in patients with cancer.

Primary Topography-Guided LASIK: Treating Manifest Refractive Astigmatism Versus Topography-Measured Anterior Corneal Astigmatism.

PURPOSE: To investigate whether topography-guided laser in situ keratomileusis (LASIK) with anterior corneal astigmatism measured on the WaveLight Contoura (Alcon Laboratories, Inc., Fort Worth, TX) leads to better refractive outcomes compared to treating on the clinically measured manifest refractive astigmatism axis in eyes with primary myopic astigmatism. METHODS: Retrospective analysis of 1,274 consecutive LASIK eyes treated on the topography-measured anterior corneal astigmatism axis compared to eyes treated on the conventional clinical manifest refractive astigmatism axis. RESULTS: In eyes with a small axis discrepancy between anterior corneal astigmatism and refractive astigmatism of 5° to 20°, there was no significant difference in efficacy index, refractive astigmatism accuracy, and most Alpins vector analysis parameters. Both treatment modalities achieved 20/20 uncorrected distance visual acuity (UDVA) in 90% of eyes, with 95% having postoperative cylinder of 0.50 diopters (D) or less. In eyes with a large axis discrepancy between 21° and 45° treated on the anterior corneal astigmatism axis, outcomes were both statistically and clinically inferior. Fewer eyes achieved UDVA of 20/20 (88.9% vs 73.6%; P = .01) and fewer had a defocus equivalent of 0.25 (65.6% vs 52.7%), 0.50 (86.9% vs 80.0%), and 0.75 (97.5% vs 90.9%) D or less (P < .05 for all). Significantly more eyes achieved an angle of error greater than 15° (25.4% vs 8.1%; P = .004), had postoperative residual astigmatism of 0.75 D or less (18.2% vs 7.4%; P = .03), and needed an excimer laser re-treatment (11% vs 1.6%; P = .007). CONCLUSIONS: Topography-guided myopic astigmatism LASIK treated on the topography-measured anterior corneal astigmatism axis resulted in inferior refractive and visual outcomes compared to treating on the clinical manifest refractive astigmatism axis. [J Refract Surg. 2019;35(1):15-23.].