Clinical Outcomes of Secondary Scleral-Sutured Foldable Hydrophilic Acrylic Intraocular Lens Placement by Trainees: A Single-Site Analysis.

PURPOSE: To evaluate the outcomes of a 4-point scleral-fixated foldable Akreos AO60 intraocular lens (IOL) insertion using Gore-Tex suture performed by trainees under supervision of a single attending surgeon. METHODS: Retrospective chart review for 53 eyes of 50 patients whose surgery was performed by trainees under supervision of a single surgeon between 2015 and 2018 at a tertiary care hospital (Johns Hopkins Wilmer Eye Institute, Baltimore, MD). Indications for surgery, preoperative risk factors, and intraoperative techniques were analyzed. Outcome measures included final best-corrected visual acuity (BCVA), change in BCVA, difference between expected and final spherical equivalent (SE), and postoperative complications. RESULTS: Mean patient age was 62.8 years (range 26.9 to 88.4). The most common indication for surgery was IOL dislocation (59.6%) due to trauma in 21 cases (40.4%) and pseudoexfoliation in 6 (11.5%). Combined pars plana vitrectomy was performed simultaneously in 46 cases (88.5%). Mean BCVA improved from 20/100 to 20/40 (p < 0.001). The difference between expected and final SE was within 1.0 D in 28 cases (53.8%). Postoperative hypotony occurred in 12 eyes (21.2%) on day 1; all were resolved at last follow-up. Postoperative cystoid macular edema (CME) occurred in 20 cases (38.5%); 11 (21.2%) persisted through last follow-up. CONCLUSION: Scleral-fixation of Akreos AO60 IOL in absence of capsular support can be performed by trainees under supervision and results in effective visual rehabilitation. Postoperative CME occurred at a higher rate than previously reported in the literature. Future studies should assess the rates of postoperative complications amongst different techniques of secondary IOL fixation performed by trainees to determine which is the safest.

Trends in Corneal Transplantation in Keratoconus.

PURPOSE: To determine recent trends in and sociodemographic/comorbid conditions associated with penetrating keratoplasty (PK) and lamellar keratoplasty (LK) for keratoconus (KCN). METHODS: Patients with KCN and subsequent PK and LK procedures were identified using International Classification of Diseases, 9th revision (ICD-9) and Current Procedural Terminology (CPT) billing codes. The change in surgical rates was calculated over a decade, and multivariate analysis demonstrated factors associated with undergoing surgery. RESULTS: A total of 21,588 patients with KCN underwent 1306 PK procedures and 109 LK procedures during the study period. Individuals were significantly less likely to undergo PK from 2009 to 2012 compared with 2001 to 2008 [odds ratio (OR) 0.57, 95% confidence interval (CI) 0.47-0.68, P < 0.001]. Multivariate analysis revealed the factors that increased the likelihood of PK alone and included age 20 to 40 (OR 1.90, 95% CI, 1.19-3.04, P < 0.001), black race (OR 1.36, 95% CI, 1.06-1.74, P = 0.01), and education less than a bachelor's degree or only a high school diploma (OR 1.94-2.84, P < 0.001 for all comparisons). Female sex (OR 0.74, 95% CI, 0.63-0.88, P < 0.001) and household net worth either between 150 and 249k (OR 0.64, 95% CI, 0.48-0.84, P < 0.001) or more than $500,000 (OR 0.71, 95% CI, 0.51-0.99, P = 0.03) were traits associated with decreased odds of PK. No significant associations for LK were observed. CONCLUSIONS: The rate of PK in KCN is decreasing in the United States. The third or fourth decade of life, male sex, black race, lower education, and greater household net worth are associated with increased odds of PK.

Bilateral Urrets-Zavalia Syndrome After Descemet Stripping Automated Endothelial Keratoplasty.

PURPOSE: To report a case of bilateral Urrets-Zavalia syndrome (UZS) after Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: Case report. RESULTS: A 61-year-old patient with Fuchs endothelial dystrophy initially developed UZS in the left eye after DSAEK. Thirteen months later, she underwent combined cataract surgery and DSAEK in the right eye, and postoperatively she was noted to have elevated intraocular pressure and a fixed and dilated pupil on the first postoperative day. Both pupils showed partial improvement in reactivity over the course of weeks to months. This is the first case of bilateral UZS after DSAEK surgery and in a patient with Fuchs dystrophy. CONCLUSIONS: UZS may occur bilaterally after DSAEK. Because elevated intraocular pressure has been shown to be a risk factor for this condition, this should be monitored closely during the postoperative period.

Tolerability in the elderly population of high-dose alpha lipoic acid: a potential antioxidant therapy for the eye.

PURPOSE: Alpha lipoic acid (ALA) is an antioxidant and iron-chelating supplement that has potential benefits for geographic atrophy in dry age-related macular degeneration as well as other eye diseases. The purpose of this study was to determine the tolerability of ALA in the elderly population. PATIENTS AND METHODS: Fifteen subjects, age ≥65 years, took sequential ALA doses of 600, 800, and 1,200 mg. Each dose was taken once daily with a meal for 5 days. After each dose was taken by the subjects for 5 days, the subjects were contacted by phone, a review of systems was performed, and they were asked if they thought they could tolerate taking that dose of ALA for an extended period of time. RESULTS: The 600 mg dose was well tolerated. At the 800 mg dose, one subject had an intolerable flushing sensation. At the 1,200 mg dose, two subjects had intolerable upper gastrointestinal side effects and one subject had an intolerable flushing sensation. Subjects taking gastrointestinal prophylaxis medications had no upper gastrointestinal side effects. CONCLUSION: High-dose ALA is not completely tolerated by the elderly. These preliminary data suggest that gastrointestinal prophylaxis may improve tolerability. (ClinicalTrials.gov, NCT02613572).

Inter-Rater Agreement in the Assessment of Video Recordings of Eye Drop Instillation by Glaucoma Patients.

PURPOSE: To create a standardized method for evaluating the video recordings of patients self-instilling eye drops and to determine the level of agreement of eye drop instillation efficacy, safety and efficiency ratings by three masked graders. DESIGN: Prospective cross-sectional study. PARTICIPANTS: 78 patients with open-angle glaucoma or ocular hypertension who had at least 6 months of experience with the use of eye drop medications. METHODS: Participants were video recorded while self-instilling artificial tears sequentially to both eyes. Three masked observers graded these video recordings on three criteria: efficacy (the determination of whether an eye drop was instilled on the ocular surface), safety (assessment of whether the tip of the medication bottle made contact with the ocular surface or eyelids), and efficiency (the number of eye drops expressed from the bottle). MAIN OUTCOME MEASURES: After grading the video recordings based on efficacy, safety, and efficiency, kappa statistics were used to estimate inter-rater agreement. RESULTS: The mean kappa level of agreement for efficacy, safety, and efficiency was 0.64 (95% confidence interval (CI), 0.42-0.87), 0.73 (95% CI, 0.58-0.88), and 0.62 (95% CI, 0.42-0.81), respectively. CONCLUSIONS: We demonstrated good inter-rater reproducibility of the masked analysis of video recordings of patients self-instilling eye drops based on three criteria: efficiency, safety, and efficacy.

Correlation Between Inter-Eye Difference in Average Retinal Nerve Fiber Layer Thickness and Afferent Pupillary Response as Measured by an Automated Pupillometer in Glaucoma.

PURPOSE: To assess the correlations between the relative afferent pupillary defect measured by a binocular, computerized, and commercially available pupillometer and the inter-eye differences in average retinal nerve fiber layer (RNFL) thickness measured by spectral-domain optical coherence tomography (SD-OCT) and visual field index (VFI) and mean deviation (MD) measured by automated static perimetry in patients with glaucoma. DESIGN: Cross-sectional study. PARTICIPANTS: Thirty four patients with open-angle glaucoma. METHODS: Pupillary constriction amplitudes were measured with an automated pupillometer. SD-OCT imaging of the circumpapillary RNFL and automated static perimetry were performed within 6 months of pupillometry. MAIN OUTCOME MEASURES: Main outcome measures included Spearman correlation coefficients between relative afferent pupillary defect as measured by pupillometry and inter-eye differences in average RNFL thickness, VFI, and MD. RESULTS: Correlation coefficients between relative afferent pupillary defect and inter-eye difference in average RNFL thickness, MD, and VFI were -0.81 (P<0.001), -0.73 (P<0.001), and -0.68 (P<0.001), respectively. CONCLUSIONS: The automated pupillometer quantifies asymmetry in afferent pupillary responses in proportion to structural and functional asymmetry as measured SD-OCT and automated static perimetry.

Correlation between intereye difference in visual field mean deviation values and relative afferent pupillary response as measured by an automated pupillometer in subjects with glaucoma.

PURPOSE: To evaluate the effectiveness of a new binocular infrared computerized pupillometer in the quantitative measurement of the relative afferent pupillary response in patients with glaucoma by assessing the correlation of the intereye difference in visual function as measured by standard automated perimetry (SAP) with the intereye difference in the afferent pupillary response. METHODS: Twenty-three patients with glaucoma underwent examination with a prototype, automated, binocular pupillometer. Correlation between the intereye difference in the afferent pupillary response and the intereye difference in mean deviation (MD) was explored. RESULTS: Within 7 months of pupillography, all patients underwent SAP using the Humphrey Field Analyzer IIi, 24-2, Swedish Interactive Threshold Algorithm. The intereye differential pupillary response was 0.69±0.59 (log units, mean±SD). The intereye difference in MD was 5.67±5.29 dB (mean±SD). There was a strong correlation between the intereye difference in the afferent pupillary response and the intereye difference in MD (Spearman correlation coefficient, r = -0.77; P<0.001). CONCLUSIONS: A new, binocular computerized pupillometer provides an automated method for the quantitative assessment of the afferent pupillary response. The intereye asymmetry in the pupil response correlates strongly with asymmetry in visual function, as measured by SAP, in patients with glaucoma.

Sleepwalking through history: medicine, arts, and courts of law.

Somnambulism, or sleepwalking, has always been of interest to theologians, writers, philosophers, physicians, and others fascinated by unusual behaviors. This parasomnia, which was defined less precisely in the past than it is today, has long been featured in medical dissertations and books of medicine. Further, Shakespeare, Bellini, and Brown, among others, incorporated it into their plays, operas, and novels. Because some somnambulists turned violent and committed other acts detrimental to society, sleepwalking also demanded attention from legal systems, and guidelines were set for whether somnambulists could be held responsible for their actions. This historical review focuses on these developments pertaining to somnambulism through the seventeenth, eighteenth, and nineteenth centuries.