Effect of Rho-associated kinase inhibitor on human corneal endothelial cell apoptosis.

PURPOSE: To evaluate whether exposure to Rho-associated protein kinase (ROCK) inhibitor will promote human-cultured corneal endothelial cells (CECs) survival in a commercial storage medium. SETTING: Edith Wolfson Medical Center, Holon, and Sheba Medical Center, Tel Hashomer, Israel. DESIGN: Experimental study. METHODS: Fragments of human donor corneolimbal rings were stored in commercial storage media for 1 week, half with the addition of 10 µM ROCK inhibitor (Y-27632). Evaluation of CECs for early and late apoptosis\necrosis rates was performed using anti-human CD166 antibody and flow cytometric double staining analysis of propidium iodide and Annexin V. RESULTS: CECs of 6 corneolimbal rings demonstrated a reduced early apoptosis rate (4.35% ± 1.07% vs 12.18% ± 5.5%, P = .026) and a reduced late apoptosis\necrosis rate (5.5% ± 2.39% vs 9.43% ± 2.61%, P = .004) compared with control. Subsequently, the rate of apoptotic CECs expressing ROCK was significantly lower in cells exposed to ROCK inhibitor compared with cells that were not (19.01% ± 4.17 vs 30.42% ± 4.27, P < .001). CONCLUSIONS: ROCK inhibitor reduced endothelial cell loss in vitro and might be used to limit or slow CEC loss in donor corneal tissue during eye banking. This might be a promising new method for promoting future graft survival.

Prophylactic exposure of human corneal endothelial cells to Rho-associated kinase inhibitor reduced apoptosis rate after phacoemulsification: Ex vivo study.

PURPOSE: To evaluate whether prophylactic exposure of corneal endothelial cells (CECs) to a selective Rho-associated kinase (ROCK) inhibitor will inhibit CEC apoptosis after phacoemulsification. SETTING: Laboratory evaluations at the Edith Wolfson Medical Center, Holon, Israel and the Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel and the Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel. DESIGN: Experimental study. METHOD: Human donor corneolimbal rings were divided into fragments that were stored in commercial storage media with or without the addition of 10 mM ROCK inhibitor for 1 week and were then exposed to phacoemulsification energy. Samples were dissociated into single cells by trypsin digestion and CECs were targeted using the antihuman CD166 antibody, a new biomarker. The CEC survival was evaluated for early and late apoptosis rate with flow cytometric analysis of annexin-V and propidium iodide (PI) double staining. RESULTS: Six corneoscleral rings from 4 donors were studied. After phacoemulsification, CEC exposed to ROCK inhibitor demonstrated a 37.06% reduction in early apoptosis rate (29.36% ± 4.33% [SD] versus 46.65% ± 1.51%, P = .006) and 45.27% reduction in late apoptosis rate (17.6% ± 16.81% versus 32.16% ± 26.30%, P = .007), compared with controls. Subsequently, ROCK levels in apoptotic CECs were significantly lower in cells incubated with ROCK inhibitor than the control medium. CONCLUSIONS: In this ex vivo study, ROCK inhibitor reduced endothelial loss and thus, could be used to limit or slow down CEC loss. Rho-associated kinase inhibitor might be used before cataract surgery, especially in high risk patients. This might be a promising new method for preventing pseudophakic bullous keratopathy.

Corneal Staining and Hot Black Tea Compresses.

BACKGROUND: Warm compresses are widely touted as an effective treatment for ocular surface disorders. Black tea compresses are a common household remedy, although there is no evidence in the medical literature proving their effect and their use may lead to harmful side effects. OBJECTIVES: To describe a case in which the application of black tea to an eye with a corneal epithelial defect led to anterior stromal discoloration; evaluate the prevalence of hot tea compress use; and analyze, in vitro, the discoloring effect of tea compresses on a model of a porcine eye. METHODS: We assessed the prevalence of hot tea compresses in our community and explored the effect of warm tea compresses on the cornea when the corneal epithelium's integrity is disrupted. An in vitro experiment in which warm compresses were applied to 18 fresh porcine eyes was performed. In half the eyes a corneal epithelial defect was created and in the other half the epithelium was intact. Both groups were divided into subgroups of three eyes each and treated experimentally with warm black tea compresses, pure water, or chamomile tea compresses. We also performed a study in patients with a history of tea compress use. RESULTS: Brown discoloration of the anterior stroma appeared only in the porcine corneas that had an epithelial defect and were treated with black tea compresses. No other eyes from any group showed discoloration. Of the patients included in our survey, approximately 50% had applied some sort of tea ingredient as a solid compressor or as the hot liquid. CONCLUSIONS: An intact corneal epithelium serves as an effective barrier against tea-stain discoloration. Only when this layer is disrupted does the damage occur. Therefore, direct application of black tea (Camellia sinensis) to a cornea with an epithelial defect should be avoided.

Photoreceptor Integrity Predicts Response to Anti-VEGF Treatment.

PURPOSE: Assessing changes in foveal photoreceptor microstructure (FPM) following intravitreal anti-VEGF treatment may serve as a prognostic marker in patients with macular edema (ME). METHODS: Sixteen eyes belonging to newly diagnosed patients with ME were included in this prospective longitudinal study. FPM integrity was evaluated at baseline and at the end of a series of anti-VEGF injections. RESULTS: Treatment led to a significant improvement in mean visual acuity (VA) and central macular thickness. A larger FPM defect was associated with lower VA, both before and after treatment. Patients with larger FPM defects at baseline had smaller VA improvements, and the improvement in FPM integrity was associated with VA improvement (every 100-µm FPM recovery contributed to a gain of 0.04 logMAR). CONCLUSIONS: Recovery of FPM after anti-VEGF treatment was significantly associated with a VA improvement. Direct measurement of photoreceptor integrity might provide an additional tool for the assessment of retinal function and treatment response in patients newly diagnosed with ME.

TOPICAL APRACLONIDINE REDUCES PAIN AFTER INTRAVITREAL INJECTIONS: A Double-Blind Randomized Controlled Trial.

PURPOSE: To evaluate the efficacy of topical apraclonidine in reducing pain and subconjunctival hemorrhage (SCH) after intravitreal injections (IViT). METHODS: A prospective, randomized, double-blinded study. Thirty-nine patients were examined twice, at each monthly IViT of 1.25 mg/0.05 mL bevacizumab. Patients were randomly assigned to receive either topical apraclonidine 0.5% or placebo to the treated eye, 30 minutes before the first IViT. At their second IViT, the intervention was switched. Thirty minutes after the injection, SCH size was measured by a slit lamp, and pain was assessed by the numerical rating scale (NRS-11). RESULTS: Mean pain score was 1.69 (SD ±1.44) in the apraclonidine group and 3.28 (SD ±2.27) in the control group (P < 0.001). Phakic patients had a greater pain reduction after topical apraclonidine (P < 0.001). Subconjunctival hemorrhage incidence was 41% in the apraclonidine group and 51.3% in the control group (P = 0.503). Mean SCH size was 1.71 mm (SD ±5.83) in the apraclonidine group and 3.25 mm (SD ±6.41) in the control group (P = 0.253). After topical apraclonidine, there was a smaller reduction in SCH size in patients with choroidal neovascularization or hypertension (P = 0.003 and 0.044, respectively), and a greater reduction in phakic patients (P = 0.048). CONCLUSION: Topical apraclonidine 0.5%, administered 30 minutes before IViT, significantly decreased pain by a factor of 1.94. It did not decrease the incidence or size of SCH in the entire cohort, but only in several subpopulations.

Blood-Flow Velocity in Glaucoma Patients Measured with the Retinal Function Imager.

PURPOSE: Circulatory abnormalities in the retina, optic nerve and choroid have been detected by various technologies in glaucoma patients. However, there is no clear understanding of the role of blood flow in glaucoma. The purpose of this study was to compare retinal blood-flow velocities using the retinal function imager (RFI) between glaucoma and healthy subjects. MATERIALS AND METHODS: Fifty-nine eyes of 46 patients with primary open-angle glaucoma (POAG), 51 eyes of 31 healthy individuals and 28 eyes of 23 patients with glaucomatous optic neuropathy (GON) but normal perimetry were recruited for this study. Three eyes of 2 patients in the glaucoma group and 2 eyes of 1 patient in the GON group had normal pressure at the time of diagnosis. Eighty-three percent of the glaucoma patients and 73% of the patients in the GON group were treated with anti-glaucoma medications. All patients were scanned by the RFI. Differences among groups were assessed by mixed linear models. RESULTS: The average venous velocity in the GON group (3.8 mm/s) was significantly faster than in the glaucoma (3.3 mm/s, p = 0.03) and healthy (3.0 mm/s, p = 0.005) groups. The arterial velocity in the GON group was not different from any of the other study groups (4.7 mm/s). The arterial and venous velocity in the POAG eyes was not different than in the healthy eyes (arterial: 4.3 versus 4.2 mm/s, p = 0.7; venous: 3.3 versus 3.0 mm/s, p = 0.3). A subgroup of 13 glaucoma patients who had perimetric glaucoma in 1 eye and normal visual field (VF) in the fellow eye showed a trend of lower velocity in the glaucoma eyes. CONCLUSIONS: Changes in retinal blood-flow velocity were detected only in the pre-perimetric state, but not in perimetric glaucoma. These findings might represent early dysregulation in the retinal vasculature.

Predicting cataract surgery time based on preoperative risk assessment.

PURPOSE: Operating room (OR) time is an expensive resource that should be optimized to reduce costs. Individualpreoperative risk parameters (PORS) assessment may aid in predicting cataract surgery time. METHODS: Dedicated software was developed and known risk factors for cataract surgery were integrated into it.Preoperative risk parameters were assigned to each patient in the preoperative meeting and the risk score wascalculated. A total of 153 patients were divided according to a standard classification into low-risk group (PORS≤2) and high-risk group (PORS >5). Duration of surgery for each group was compared by Student t test and linearregression analysis was used to calculate the relation between change in OR time and change in risk score. RESULTS: Patients in the high PORS group had longer surgery times when compared with patients in the low PORSgroup (37.6 vs 19.6, p<0.001). Risk scores positively correlated with surgery time (r = 0.30, p<0.001). Predictionequations for the OR time demonstrated for 2 surgeons that every increase in 1 risk point added 2.2 or 3.3 minutesto the OR time. Outliers (more than 1 standard deviation [SD] from each surgeon's surgery mean time) hadmore than twice the risk score of cases within 1 SD from the mean. CONCLUSIONS: The PORS system may be a useful tool for predicting OR time based on individual patient risk andmay improve OR scheduling.

Quantification of metamorphopsia using the MacuFlow test before and after vitreoretinal surgery.

BACKGROUND AND OBJECTIVE: This pilot study evaluated the clinical utility of the MacuFlow software in measuring metamorphopsia prior to and following surgery in patients with vitreoretinal diseases. PATIENTS AND METHODS: Four patients with vitreoretinal disorders causing metamorphopsia were included in this pilot study. Visual acuity (VA), optical coherence tomography and MacuFlow scores were recorded prior to and following surgical intervention. RESULTS: The mean preoperative VA was 0.59 ± 0.09 logMAR, central macular thickness 491.2 ± 41.3 µm and calculated macular volume 8.99 ±1.47 mm(3). These parameters improved postoperatively to a mean VA of 0.30 ± 0.22 logMAR, central macular thickness of 372.8 ± 85.4 µm and macular volume of 7.94 ± 1.34 mm(3) but did not reach statistical significance. The mean preoperative MacuFlow score was 14.02 ± 8.21, which significantly improved postoperatively to 5.4 ± 3.13 (p = 0.045). CONCLUSIONS: This is the first study to demonstrate the clinical utility of MacuFlow for the quantification of metamorphopsia and its improvement or resolution following surgery. This simple method may be a valuable addition for the clinical assessment and monitoring of patients with retinal diseases causing metamorphopsia.

Quantifying metamorphopsia in patients with diabetic macular oedema and other macular abnormalities.

PURPOSE: To quantify subjective visual metamorphopsia in newly diagnosed patients suffering from diabetic macular oedema (DME) and other macular abnormalities and to evaluate anti-VEGF treatment effect. METHODS: Patients with DME, subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD) or retinal venous occlusion (RVO) were recruited. Metamorphopsia score (Mscore) was calculated using M-Charts at baseline and at the end of a series of anti-VEGF injections. RESULTS: Fifteen eyes of 10 patients with DME, 14 eyes of 13 patients with AMD-CNV and five patients with RVO were included in this study. At baseline, positive Mscore was observed in 46.6% of eyes with DME, 50% of eyes with AMD-CNV and four of five eyes with RVO. Treatment led to a complete metamorphopsia reduction (Mscore = 0) in 71.4% of DME patients, 35.7% of AMD and 0% of RVO patients. CONCLUSION: We suggest that the M-charts may serve as an additional test for diagnosis and follow-up, complementary to morphological evaluation by imaging, in diabetic patients facing their first anti-VEGF treatment.

High-resolution wide-field imaging of perfused capillaries without the use of contrast agent.

PURPOSE: Assessment of capillary abnormalities facilitates early diagnosis, treatment, and follow-up of common retinal pathologies. Injected contrast agents like fluorescein are widely used to image retinal capillaries, but this highly effective procedure has a few disadvantages, such as untoward side effects, inconvenience of injection, and brevity of the time window for clear visualization. The retinal function imager (RFI) is a tool for monitoring retinal functions, such as blood velocity and oximetry, based on intrinsic signals. Here we describe the clinical use of hemoglobin in red blood cells (RBCs) as an intrinsic motion-contrast agent in the generation of detailed noninvasive capillary-perfusion maps (nCPMs). PATIENTS AND METHODS: Multiple series of nCPM images were acquired from 130 patients with diabetic retinopathy, vein occlusion, central serous retinopathy, age-related macular degeneration, or metabolic syndrome, as well as from 37 healthy subjects. After registration, pixel value distribution parameters were analyzed to locate RBC motion. RESULTS: The RFI yielded nCPMs demonstrating microvascular morphology including capillaries in exquisite detail. Maps from the same subject were highly reproducible in repeated measurements, in as much detail and often better than that revealed by the very best fluorescein angiography. In patients, neovascularization and capillary nonperfusion areas were clearly observed. Foveal avascular zones (FAZ) were sharply delineated and were larger in patients with diabetic retinopathy than in controls (FAZ diameter: 641.5 ± 82.3 versus 463.7 ± 105 µm; P < 0.001). Also visible were abnormal vascular patterns, such as shunts and vascular loops. CONCLUSION: Optical imaging of retinal capillaries in human patients based on motion contrast is noninvasive, comfortable, safe, and can be repeated as often as required for early diagnosis, treatment guidance, and follow up of retinal disease progression.

Compliance with eye care in glaucoma patients with comorbid depression.

BACKGROUND: Comorbid depression may play an important role in non-compliance with medical treatment among patients with chronic illnesses. Glaucoma is a potentially blinding chronic disease requiring life-long commitment to medical therapy. Failure to adhere to anti-glaucoma treatment may lead to disease progression and visual loss. OBJECTIVES: To assess the prevalence of depressive symptoms in glaucoma patients and the association between these symptoms and non-compliance with anti-glaucoma therapy. METHODS: In this cross-sectional observational study, compliance with pharmacotherapy was assessed with the Morisky Medication Adherence questionnaire (eight items). Screening for depression was performed by means of the CES-D (Center for Epidemiologic Studies Depression scale). The association between depression and compliance rates was analyzed. RESULTS: The study group comprised 76 glaucoma patients; 19.7% of the subjects were classified as non-compliant (Morisky cutoff 10) and 21.1% suffered from depression (CES-D cutoff > or = 16). We found a similar level of non-compliance when comparing depressed with non-depressed glaucoma patients. However, a correlation was observed between the level of depression and the level of non-compliance (P = 0.04). CONCLUSIONS: Our study revealed a similar rate of depression in glaucoma patients and the general israeli population. The presence of depression was not associated with the presence of non-compliance, yet the level of depression was associated with the level of non-compliance.

Inter-device variability of the Stratus optical coherence tomography.

PURPOSE: To assess inter-device measurement variability with the Stratus optical coherence tomography (OCT). DESIGN: Evaluation of diagnostic test technology. METHODS: Eight eyes of eight healthy subjects were examined with four different Stratus machines in four medical centers during a period of five hours using fast retinal nerve fiber layer (RNFL) and fast macula protocols. Inter-device measurement variability and signal strength was assessed with standard deviation, coefficient of variance, and intraclass correlation coefficient (ICC). Spearman correlation coefficient was calculated between signal strength and thickness measurements. RESULTS: Statistically significant differences were not found for all macular parameters and all but one RNFL parameter. Mean signal strengths obtained with the four Stratus machines were significantly different; the newer the machine, the stronger signal strength it produced. Some RNFL parameters were moderately and statistically significantly correlated with signal strength. CONCLUSIONS: We did not observe statistically significant differences in any macular and all but one RNFL parameter between the four Stratus OCT machines. Signal strength was significantly different between the machines, and significantly correlated with some RNFL parameters. Inter-machine variability in RNFL measurements may have clinical significance. Signal strength should be included in the assessment of measurements obtained on different machines and in serial examinations with a single Stratus machine during patient follow-up.

Season of birth, natural light, and myopia.

PURPOSE: To investigate the possible roles of season of birth and perinatal duration of daylight hours (photoperiod) in the development of myopia. DESIGN: Retrospective, population-based, epidemiological study. PARTICIPANTS: A total of 276 911 adolescents (157 663 male, 119 248 female) 16 to 22 years old. All were Israeli-born conscripts to the Israeli Defense Forces who were examined during the 5-year period 2000 through 2004. METHODS: Noncycloplegic refraction was determined by autorefractometer and validated by qualified optometrists. Myopia, defined on the basis of right eye spherical equivalence, was classified as mild (-0.75 to -2.99 diopters [D]), moderate (-3.0 to -5.99 D), or severe (-6.0 D or worse). The photoperiod was recorded from astronomical tables and classified into 4 categories. Using multivariate logistic regression models, we calculated odds ratios (ORs) for several risk factors of myopia including season of birth. MAIN OUTCOME MEASURE: The OR for photoperiod categories as risk factors for myopia. RESULTS: Overall prevalences of mild, moderate, and severe myopia were 18.8%, 8.7%, and 2.4%, respectively. There were seasonal variations in moderate and severe myopia according to birth month, with prevalence highest for June/July births and lowest for December/January. On multivariate logistic regression, the ORs of photoperiod categories for moderate and severe myopia were highly significant and demonstrated a dose-response pattern. Odds ratios for severe myopia were highest for the shortest versus the longest photoperiods (1.24; 95% confidence interval, 1.15-1.33; P<0.001). Mild myopia was not associated with season of birth or perinatal light exposure. Other risk factors were gender (1.14 for female), education level (1.32 for age above 12), and father's origin (1.31 for Eastern vs. Israeli origin). CONCLUSION: Myopia in this population is associated with birth during summer months. The exact associating mechanism is not known but might be related to exposure to natural light during the early perinatal period.

Modified sutureless sclerotomies for pars plana vitrectomy.

PURPOSE: To describe a modified technique for performing sutureless sclerotomies for pars plana vitrectomy and to examine its efficacy and safety. DESIGN: Retrospective, interventional case series. METHODS: Self-sealing sclerotomies were created in 35 consecutive cases by oblique penetration of the sclera with a 19G MVR blade. RESULTS: All but two (2.9%) of the sclerotomies were watertight without suturing at the end of surgery. A conjunctival bleb was observed during the first postoperative week in one case, but it resolved without intervention. CONCLUSIONS: Construction of sutureless sclerotomies by this technique is simpler and more rapid compared with previously described techniques. The resulting sclerotomies are more resistant to stretching and tearing of the tunnel's roof, they rarely need suturing, and insertion of instruments is facilitated.

Minimal astigmatism after sutureless planned extracapsular cataract extraction.

PURPOSE: To evaluate astigmatism after mini-nuc extracapsular cataract extraction (ECCE) in which a chevron incision is enlarged to 6.0 to 7.0 mm for easier nucleus removal and to compare the results with those using a 5.0 mm incision. SETTING: Department of Ophthalmology, The Edith Wolfson Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Holon, Israel. METHODS: Thirty eyes of 29 patients were enrolled in this study. Keratometry was performed preoperatively and 3 to 9 months postoperatively. The incision length was 6.0 mm in 6 eyes, 6.5 mm in 10 eyes, and 7.0 mm in 14 eyes that had mature cataract. RESULTS: The mean induced astigmatism calculated by simple subtraction was 0.12 diopter (D) +/- 0.51 (SD), 0.16 +/- 0.98 D, and 0.67 +/- 0.91 D for the 6.0 mm, 6.5 mm, and 7.0 mm incision, respectively. By vector analysis, the mean induced astigmatism was 0.60 +/- 0.30 D, 0.75 +/- 0.67 D, and 1.36 +/- 0.77 D, respectively. Results by both methods showed no significant difference between the previously reported 5.0 mm incision and the 6.0 mm and 6.5 mm incisions. The 7.0 mm group had statistically significantly greater induced astigmatism than the 5.0 mm group (P =.01, simple subtraction; P =.002, vector analysis). CONCLUSIONS: Enlarging the size of the chevron incision up to 7.0 mm resulted in a small increase in induced astigmatism. The enlarged incision simplified the operative technique.