Long-Term Visual Quality and Pupil Changes after Small-Incision Lenticule Extraction for Eyes without Preoperative Cylinder Refraction.

Purpose: To investigate the long-term changes in visual quality and pupil size after small incision lenticule extraction (SMILE) for eyes without preoperative cylinder refraction. Methods: Thirty-three myopic eyes (33 patients) without preoperative cylinder refraction were corrected using SMILE. Refractive outcomes, corneal curvature, aberrations, contrast sensitivity (CS), and pupil diameter were evaluated preoperatively, and 30 months postoperatively. Results: The 30-month postoperative uncorrected and corrected distance visual acuity (UDVA and CDVA, LogMAR) were -0.10 ± 0.09 and -0.14 ± 0.06, respectively, whereas the preoperative CDVA (LogMAR) was -0.07 ± 0.05. Cylinder refraction of -0.11 ± 0.21 D (ranging from -0.50 to 0.00) was observed at 30 months postoperatively, increasing from the preoperative cylinder refraction of 0.00 ± 0.00 D (P=0.004). Moreover, the centroid coordinates x, y of corneal anterior astigmatic vectors were -0.19 ± 0.22, 0.81 ± 0.33 at 30 months postoperatively, and 0.02 ± 0.28, 0.76 ± 0.51 preoperatively (Px < 0.001 and Py=0.810, respectively). Furthermore, a 15° axis change in the mean anterior corneal astigmatic vector was observed at 30 months postoperatively from the preoperative state, as measured by Pentacam. At 30 months postoperatively, the photopic Log CS reduced significantly with glare at three and six cycles/degrees (P < 0.001 and P=0.015, respectively), a decreased photopic pupil diameter (3.27 ± 0.55 mm vs. 3.10 ± 0.66 mm, P=0.030), and an increased Coma (Z31) and Trefoil (Z3-3) at 4 mm diameter area analysis. However, a significant linear regression relationship was only observed between changes in photopic pupil diameter and changes in photopic Log CS with glare at 12 cycles/degree (P=0.038 and ß = 0.282). Conclusion: Slight cylinder regression was observed with thicker corneal lenticular extraction after SMILE correction of nonastigmatic eyes 30 months postoperatively. This regression was mainly because of the axis changes in anterior corneal astigmatism power. Therefore, a cylinder nomogram modification of 0.25 to 0.50 D is considerable for correcting nonastigmatic myopic eyes with a predicted spherical lenticular thickness over 100 µm.

Metformin protects retinal pigment epithelium cells against H2O2-induced oxidative stress and inflammation via the Nrf2 signaling cascade.

PURPOSE: Dysfunctions of retinal pigment epithelium (RPE) attributed to oxidative stress and inflammation are implicated with age-related macular degeneration (AMD). A debate on the curative role of metformin in AMD has been raised, though several recent clinical studies support the lower odds by using metformin. This study aimed to determine whether metformin could exert cytoprotection against RPE oxidative damages and the potential mechanisms. METHODS: A cellular AMD model was established by treating ARPE-19 cells with hydrogen peroxide (H2O2) for 24 h. The reactive oxygen species (ROS) generation, expression of antioxidant enzymes, and levels of pro-inflammatory cytokines were monitored under administrations with H2O2 with/without metformin. The expression and DNA-binding activity of transcription factor erythroid-related factor 2 (Nrf2) were determined by western blot, immunofluorescence, and electrophoretic mobility shift assay. Knockout of Nrf2 was conducted by CRISPR/Cas9 gene deletion system. RESULTS: Metformin pretreatment significantly improved the H2O2-induced low viability of ARPE-19 cells, reduced ROS production, and increased contents of antioxidative molecules. Concurrently, metformin also suppressed levels of pro-inflammatory cytokines caused by H2O2. The metformin-augmented nuclear translocation and DNA-binding activity of Nrf2 were further verified by the increased expression of its downstream targets. Genetic deletion of Nrf2 blocked the cytoprotective role of metformin. CONCLUSION: Metformin possesses antioxidative and anti-inflammatory properties in ARPE-19 cells by activating the Nrf2 signaling. It supports the potential use for the control and prevention of AMD.

Long-term Vector Outcomes of SMILE in Correcting Moderate to High With-the-Rule Astigmatism Under Astigmatism Axis Marked Condition.

PURPOSE: To evaluate the vector outcomes of small incision lenticule extraction (SMILE) in correcting moderate to high myopic astigmatism under astigmatic axis marked condition. METHODS: In a prospective, longitudinal, interventional study, 71 eyes (71 patients) that had with-the-rule preoperative cylinder refraction exceeding 1.50 diopters (D) were corrected with the VisuMax femtosecond laser (Carl Zeiss Meditec AG) at Zhongshan Ophthalmic Center. Refractive outcomes and astigmatic vector were evaluated preoperatively and at 1, 3, 6, and 30 months postoperatively. RESULTS: At 30 months postoperatively, the efficacy and safety indexes were 1.04 ± 0.18 and 1.15 ± 0.17, respectively. The magnitude of the surgically induced astigmatism (SIA) (2.13 ± 0.71 D at 1 month [P1m-pre = .018], 2.12 ± 0.72 D at 3 months [P3m-pre = .006], 2.13 ± 0.69 D at 6 months [P6m-pre = .010], and 2.19 ± 0.72 D at 30 months [P30m-pre < .001]) was slightly higher than that of the target induced astigmatism (TIA) (2.07 ± 0.69 D). Only the y-coordinate of the SIA vector had a significant overcorrection compared to that of the TIA vector (P1m-pre = .033, P3m-pre = .011, P6m-pre = .012, P30m-pre < .001). The corrected index (CI = |SIA|/|TIA|) varied from 1.03 ± 0.07 at 1 month to 1.06 ± 0.10 at 30 months, which was higher when correcting moderate astigmatism than when correcting high astigmatism (P = .041) at 30 months postoperatively. CONCLUSIONS: SMILE had long-term safety, efficacy, predictability, and stability when correcting moderate to high myopic astigmatism under astigmatism axis marked condition. Meanwhile, a cylinder overcorrection was observed due to the overcorrection of y-coordinate astigmatic power, which implied that the vector adjustment of the cylinder refraction nomogram should be considered. [J Refract Surg. 2020;36(9):585-591.].

Safety and Efficacy of Corneal Minimized-Volume Ablation With Accelerated Cross-Linking in Improving Visual Function for Keratoconus.

PURPOSE: To evaluate the safety and efficacy of corneal minimized-volume ablation with accelerated cross-linking in improving visual function in keratoconus eyes. METHODS: Through a pilot study, 25 eyes of 25 consecutive patients with keratoconus grade I-III were recruited that underwent corneal transepithelial photorefractive keratectomy with "minimized volume" ablation profile and accelerated corneal cross-linking in the same session. Corrected and uncorrected distance visual acuities, manifest refraction, corneal curvature and higher-order aberrations, endothelial cells, and the ocular modulation transfer function were assessed preoperatively and postoperatively, with a minimum follow-up of 6 months. A P value < 0.05 was the threshold of statistical significance. RESULTS: At 8.2 ± 3.6 months postoperatively, the mean corrected and uncorrected distance visual acuities (LogMAR) were 0.07 ± 0.15 and 0.45 ± 0.39, significantly improving from the baseline of 0.24 ± 0.24 (P8m-before = 0.005) and 1.12 ± 0.33 (P8m-before < 0.001), respectively. Spherical equivalent was -2.80 ± 2.72 diopters (D), significantly decreasing from the baseline of -6.61 ± 3.06 D (P8m-before < 0.001), whereas the attempted corrected spherical equivalent was-2.30 ± 1.22 D. Meanwhile, a significant reduction was found in higher-order aberration, along with the postoperative improvement in ocular modulation transfer function. Corneal surface morphological parameters were found with significant decreases postoperatively (index of surface variance: P8m-before = 0.003; index of vertical asymmetry: P8m-before = 0.005; keratoconus index: P8m-before = 0.004; center keratoconus index: P8m-before = 0.003; and index of height decentration: P8m-before < 0.001). Nevertheless, no significant change was found in posterior corneal curvature or endothelial cell density between pre- and post-operative periods. CONCLUSIONS: Corneal minimized-volume ablation with accelerated cross-linking was an effective and safe option for correction of mild refractive error, leading to significant improvement of visual function in patients with keratoconus.

Screening Candidates for Refractive Surgery With Corneal Tomographic-Based Deep Learning.

Importance: Evaluating corneal morphologic characteristics with corneal tomographic scans before refractive surgery is necessary to exclude patients with at-risk corneas and keratoconus. In previous studies, researchers performed screening with machine learning methods based on specific corneal parameters. To date, a deep learning algorithm has not been used in combination with corneal tomographic scans. Objective: To examine the use of a deep learning model in the screening of candidates for refractive surgery. Design, Setting, and Participants: A diagnostic, cross-sectional study was conducted at the Zhongshan Ophthalmic Center, Guangzhou, China, with examination dates extending from July 18, 2016, to March 29, 2019. The investigation was performed from July 2, 2018, to June 28, 2019. Participants included 1385 patients; 6465 corneal tomographic images were used to generate the artificial intelligence (AI) model. The Pentacam HR system was used for data collection. Interventions: The deidentified images were analyzed by ophthalmologists and the AI model. Main Outcomes and Measures: The performance of the AI classification system. Results: A classification system centered on the AI model Pentacam InceptionResNetV2 Screening System (PIRSS) was developed for screening potential candidates for refractive surgery. The model achieved an overall detection accuracy of 94.7% (95% CI, 93.3%-95.8%) on the validation data set. Moreover, on the independent test data set, the PIRSS model achieved an overall detection accuracy of 95% (95% CI, 88.8%-97.8%), which was comparable with that of senior ophthalmologists who are refractive surgeons (92.8%; 95% CI, 91.2%-94.4%) (P = .72). In distinguishing corneas with contraindications for refractive surgery, the PIRSS model performed better than the classifiers (95% vs 81%; P < .001) in the Pentacam HR system on an Asian patient database. Conclusions and Relevance: PIRSS appears to be useful in classifying images to provide corneal information and preliminarily identify at-risk corneas. PIRSS may provide guidance to refractive surgeons in screening candidates for refractive surgery as well as for generalized clinical application for Asian patients, but its use needs to be confirmed in other populations.

Up-regulation of P-gp via NF-κB activation confers protection against oxidative damage in the retinal pigment epithelium cells.

Dysfunction of retinal pigment epithelial (RPE) cells has been associated with the pathogenesis of age-related macular degeneration in relation to increased oxidative stress, subsequent mitochondrial dysfunction and cell death. Permeability-glycoprotein (P-gp), encoded by the multidrug resistance 1 gene (MDR1), is an active efflux pump involved in cell homeostasis and nuclear factor κB (NF-κB) shows potential involvement in P-gp regulation due to its binding to the promoter domains of MDR1 gene. This study sought to determine the role of P-gp expression regulated by NF-κB in RPE cells during oxidative stress. The human RPE D407 cells were exposed to increasing concentrations of hydrogen peroxide (H2O2) for 24 h. The small-interfering RNA (siRNA) transfection was used to down-regulate P-gp and NF-κB, and the expressions of P-gp and NF-κB p65 were determined by quantitative real-time PCR, western blot and immunofluorescence. The activity of NF-κB was detected by luciferase reporter assay. Mitochondrial membrane potential and cell death rate were detected by flow cytometry. We found that H2O2 exposure caused increasing rate of cell death and induced an elevated expression of P-gp as well as NF-κB activation and nucleus translocation in D407 cells. Inhibiting or silencing NF-κB led to a decrease in the oxidative-induced expression of P-gp. Down-regulation of P-gp by siRNA transfection further impaired the mitochondrial membrane potential and cell death rate in oxidative cells. Moreover, inhibition/knockdown of NF-κB decreased the high rate of cell death caused by H2O2. In conclusion, P-gp can provide moderate cytoprotection for the human RPE cells by ameliorating the mitochondrial dysfunction and NF-κB activation may be a potential regulator of P-gp expression response to oxidative stress.

High ocular CMV copies and mismatched receipts may predict poor visual prognosis in CMV retinitis patients following allogeneic haematopoietic stem cell transplantation.

BACKGROUND: To summarize the clinical characteristics and potential factors affecting the visual outcomes in patients with cytomegalovirus retinitis following allogeneic haematopoietic stem cell transplantation (HSCT). METHODS: This retrospective study enrolled 12 patients (19 eyes) with cytomegalovirus retinitis after HSCT at Guangzhou First People's Hospital in China between January 2013 and December 2014. Demographic and clinical characteristics, ocular manifestations and visual outcomes were evaluated by reviewing medical records at the Departments of Hematology and Ophthalmology. All patients were followed up at least 6 months after stopping antiviral therapy. The visual outcome was defined as improvement, stabilization and deterioration. RESULTS: The subjects were composed of 7 human leucocyte antigen-matched and 5 mismatched receipts. All patients received combined systemic and intravitreous antiviral therapy. Eleven eyes gained improved or stabilized visual acuity, while 8 eyes suffered deterioration. Eyes with cytomegalovirus load less than 1 × 104 copies/ml in vitreous accounted for higher rate in eyes with good visual prognosis than those with cytomegalovirus copies above 1 × 104 copies/ml (52.63% vs 5.26%, P < 0.001). Human leucocyte antigen-matched receipts gained better visual prognosis than those mismatched ones (47.37% vs10.53%, P < 0.05). The virus types, cytomegalovirus peak in the blood, involved retinal zone and size had no influence on the visual outcomes (all P > 0.05). CONCLUSIONS: High ocular cytomegalovirus copies and mismatched receipts may be potential adverse factors affecting visual outcomes in cytomegalovirus retinitis patients following allogeneic HSCT.

[Effect of Electroacupunctrue Stimulation at "Fenglong"(ST 40) on Expression of SREBP-1 c in Non-alcoholic Fatty Liver Disease Rats].

OBJECTIVE: To observe the effect of electroacupuncture(EA) stimulation at "Fenglong"(ST 40) on expression of sterol regulatory element binding protein-1 c(SREBP-1 c) in non-alcoholic fatty liver disease(NAFLD) rats, so as to reveal its mechanism underlying improving NAFLD. METHODS: Male SD rats were randomly divided into normal diet group, high-fat diet group, ST 40 manual acupuncture (MA) group, ST 40 EA group and "Zusanli"(ST 36) EA group(n=12 in each group). Apart from the normal diet group, rats in other groups were fed with high-fat diet to replicate NAFLD model. ST 40 MA group was treated with filiform needling for 20 min, EA (4 Hz/20 Hz, 5 mA) was applied to bilateral acupoints of ST 40 and ST 36 respectively for 20 min in the ST 40 EA group and ST 36 EA group, once a day for 4 weeks. The pathological changes of hepatic tissue were observed by HE staining. The contents of serum free fatty acid (FFA), alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were detected by colorimetry. The expression of SREBP-1 c mRNA and protein in the hepatic tissue were detected by reverse transcription-polymerase chain reaction(RT-PCR) and Western blot, respectively. RESULTS: HE staining showed that hepatocytes disorganized with diffuse bullous fat vacuolar changes in rats of the high-fat diet group, and small vesicle steatosis appeared in the ST 40 MA group. The liver cells arranged orderly and the steatosis decreased in the ST 40 EA group and ST 36 EA group. The contents of FFA, ALT, AST in serum and the expression levels of SREBP-1 c mRNA and protein in the hepatic tissue were significantly higher in the high-fat diet group than in the normal diet group(P<0.01), while significantly lower in the MA and EA groups than in the high-fat diet group(P<0.01). Furthermore, the effects of treatment in the ST 40 EA group were better than those in the ST 40 MA group(P<0.01, P<0.05). The FFA contents in serum and the expression levels of SREBP-1 c mRNA and protein were decreased in the ST 40 EA group in comparison with the ST 36 EA group(P<0.05). CONCLUSIONS: EA at ST 40 and ST 36 have a positive regulating effect on NAFLD rats, which may be related to down-regulating the expression of SREBP-1 c mRNA and protein in hepatic tissue, improving the endoplasmic reticulum stress and regulating lipid metabolic disorder, so as to relieve the inflammatory injury in hepatic tissue, and ST 40 works better.

Mitochondrial expression and activity of P-glycoprotein under oxidative stress in outer blood-retinal barrier.

AIM: To investigate the role of oxidative stress in regulating the functional expression of P-glycoprotein (P-gp) in mitochondria of D407 cells. METHODS: D407 cells were exposed to different ranges of concentrations of H2O2. The mitochondrial location of P-gp in the cells subjected to oxidative stress was detected by confocal analysis. Expression of P-gp in isolated mitochondria was assessed by Western blot. The pump activity of P-gp was evaluated by performing the efflux study on isolated mitochondria with Rhodamine 123 (Rho-123) alone and in the presence of P-gp inhibitor (Tariquidar) using flow cytometry analysis. The cells were pretreated with 10 mmol/L N-acetylcysteine (NAC) for 30min before exposing to H2O2, and analyzed the mitochondrial extracts by Western blot and flow cytometry. RESULTS: P-gp was co-localized in the mitochondria by confocal laser scanning microscopy, and it was also detected in the mitochondria of D407 cells using Western blot. Exposure to increasing concentrations of H2O2 led to gradually increased expression and location of P-gp in the mitochondria of cells. Rho-123 efflux assay showed higher uptake of Rho-123 on isolated mitochondria in the presence of Tariquidar both in normal and oxidative stress state. H2O2 up-regulated P-gp in D407 cells, which could be reversed by NAC treatment. CONCLUSION: H2O2 could up-regulate the functional expression of P-gp in mitochondria of D407 cells, while antioxidants might suppress oxidative-stress-induced over-expression of functional P-gp. It is indicative that limiting the mitochondrial P-gp transport in retinal pigment epithelium cells would be to improve the effect of mitochondria-targeted antioxidant therapy in age-related macular degeneration-like retinopathy.