The Current State in the Diagnosis of Eyelid Margin Disease: A Clinical Review.

The eyelid margin is vital to ocular surface integrity. Much peer-reviewed literature has been established in eyelid margin inflammation, better known as blepharitis. The purpose is to review and understand the impact of eyelid margin disease. Anterior blepharitis causes inflammation at the eyelash base, ciliary follicles, and the palpebral skin. Posterior blepharitis occurs when there is inflammation with the posterior eyelid margin disease. In common usage, the term "blepharitis" used alone almost always refers to anterior blepharitis. Classification of eyelid margin disease should be based on etiopathogenesis, location, primary vs. secondary, and chronicity. Blepharitis has several etiopathologies (infectious, inflammatory, squamous). MGD can refer to the functional and/or structural problems with the MG. Meibomitis (or meibomianitis) occurs when there is inflammation associated with the MGD. The presence of blepharitis and/or MGD (with or without inflammation) can impact the ocular surface and thereby affect anterior segment and cataract surgeries. This review article evaluates the differential diagnoses of eyelid margin disease, including various forms of blepharitis, MGD, and meibomitis.

EYELID MARGIN DISEASE (BLEPHARITIS AND MEIBOMIAN GLAND DYSFUNCTION): CLINICAL REVIEW OF EVIDENCE-BASED AND EMERGING TREATMENTS.

ABSTRACT: Blepharitis is a common ophthalmic condition with multiple etiologies and no definitive, universal treatment. The treatment modalities for managing lid margin diseases vary depending on the disease's cause, location, and severity. For anterior blepharitis, management options include eyelid hygiene with warm compresses, eyelid scrubs, baby shampoo, and over-the-counter eyelid cleansers. Topical antibiotics and antibiotic-steroid combination drops/ointments for the eye and eyelid may accompany these. For posterior blepharitis/meibomian gland dysfunction (MGD), at-home warm compress or in-office administration of heat therapy/thermal pulsation treatment that aims to clear obstruction in the meibomian glands and restore meibum secretions to maintain a healthy tear film, are recommended. In addition to the above treatment strategies, various other compounds to manage lid margin diseases are in the late stages of development. This review summarizes the available treatment modalities or those in the pipeline for treating blepharitis and MGD.

End-to-End Impact of a Cloud-Based Surgical Planning System on Efficiency in Cataract Surgery: A Time-and-Motion Study.

Purpose: Inefficiencies from manual data entry and non-integration exist throughout the cataract surgery workflow. The aim of this study was to evaluate the impact of SMARTCataract, an innovative cloud-based digital surgical planning platform (SPS) on efficiency in preoperative (diagnostic workup, surgery planning), intraoperative, and postoperative phases of cataract surgery. The primary objective aimed to assess time and number of manual transcription data points (TPs) required for all pre-, intra-, and postoperative devices that integrate with the SPS and surgery planning time across three patient types (post-refractive, astigmatic, conventional). The secondary objective aimed to assess the overall efficiency impact of the SPS on the surgery workflow for the three patient types by leveraging time-and-motion methods and workflow mapping. Patients and Methods: This prospective, observational, real-world, pre- and post-cohort time-and-motion study included patients undergoing evaluation for cataract surgery and/or surgery at the study site. Assessed variables included time and TPs required for clinical activities and devices associated with traditional manual methods (pre-cohort) versus the SPS (post-cohort). Statistical analyses (t-test) were performed comparing performance time using the SPS versus traditional methods for each integrated technology and surgery planning activity. Results: The SPS demonstrated statistically significant time savings over traditional methods in TP data input time taken across all integrated pre-, intra-, and postoperative devices (p<0.0001). The SPS additionally demonstrated statistically significant time savings in preoperative surgery planning across post-refractive (p<0.0001), astigmatic (p=0.0005), and conventional (p=0.0004) cataract patient groups. Overall, the SPS reduced end-to-end patient workflow time and TPs for post-refractive, astigmatic, and conventional cataract patients by averages of 13.2, 12.6, and 4.3 minutes and 184, 166, and 25 TPs per patient, respectively. Conclusion: Through the SPS' integration and surgery planning capabilities, substantial time efficiencies can be achieved for cataract surgery practices, clinicians, and patients compared to surgery planning with traditional manual methods.

The Anesthetic Implications of Aqueous Drainage Devices and Glaucoma: A Report of a Patient Undergoing Urgent Prone Cervical Decompression and Fusion.

The pathophysiology of glaucoma and perioperative visual loss is similar. A patient with glaucoma may be at increased risk of perioperative visual loss. For both, goals of management include optimizing ocular perfusion pressure and oxygen delivery. One treatment for refractory glaucoma is an aqueous drainage device; however, there is no published literature on the anesthetic management of patients with these devices. We present the case of a patient with recalcitrant glaucoma treated with an Ahmed Glaucoma Valve who underwent urgent prone surgery. Anesthetic implications of aqueous drainage devices and glaucoma are discussed, and recommendations are made.

Clinical Features and Outcomes of Retained Lens Fragments in the Anterior Chamber After Phacoemulsification.

PURPOSE: To review the clinical features, treatments, and outcomes of patients with retained lens fragments in the anterior chamber after phacoemulsification with an intact posterior capsule. DESIGN: Retrospective, interventional case series. METHODS: setting: Duke University Eye Center. STUDY POPULATION: Fifty-four eyes of 54 patients with a diagnosis of retained lens fragment in the anterior chamber following otherwise uncomplicated phacoemulsification cataract surgery. Patient demographics, clinical examination findings, ocular biometry measurements, treatment received, and pre- and post-lens fragment removal visual acuity were recorded. MAIN OUTCOME MEASURES: Corneal edema, time to surgical extraction of lens fragment, and visual acuity. RESULTS: All lens fragments were located in the inferior angle or the inferior anterior chamber, with 13% of cases requiring gonioscopy for diagnosis. Fifty-six percent of eyes had associated corneal edema, most often located inferiorly. Forty-four percent of patients were initially managed medically, but in all 54 cases the lens fragment was eventually removed surgically. The mean time to removal of the lens fragment from the date of cataract surgery was 70 days (range 1 day-30 months). Five patients had corneal edema that did not resolve following fragment extraction and 3 eventually received an endothelial keratoplasty. Best-corrected visual acuity improved from an average of 20/51 before lens fragment removal to 20/28 after surgical extraction (P < .00001). CONCLUSIONS: Corneal edema is common in the setting of retained lens fragments and can evolve to corneal decompensation requiring transplantation. Inferior corneal edema, in particular, should alert the practitioner to possible retained lens fragment. Surgical removal of retained lens fragments should be considered at the time of diagnosis.

Defining the human macula transcriptome and candidate retinal disease genes using EyeSAGE.

PURPOSE: To develop large-scale, high-throughput annotation of the human macula transcriptome and to identify and prioritize candidate genes for inherited retinal dystrophies, based on ocular-expression profiles using serial analysis of gene expression (SAGE). METHODS: Two human retina and two retinal pigment epithelium (RPE)/choroid SAGE libraries made from matched macula or midperipheral retina and adjacent RPE/choroid of morphologically normal 28- to 66-year-old donors and a human central retina longSAGE library made from 41- to 66-year-old donors were generated. Their transcription profiles were entered into a relational database, EyeSAGE, including microarray expression profiles of retina and publicly available normal human tissue SAGE libraries. EyeSAGE was used to identify retina- and RPE-specific and -associated genes, and candidate genes for retina and RPE disease loci. Differential and/or cell-type specific expression was validated by quantitative and single-cell RT-PCR. RESULTS: Cone photoreceptor-associated gene expression was elevated in the macula transcription profiles. Analysis of the longSAGE retina tags enhanced tag-to-gene mapping and revealed alternatively spliced genes. Analysis of candidate gene expression tables for the identified Bardet-Biedl syndrome disease gene (BBS5) in the BBS5 disease region table yielded BBS5 as the top candidate. Compelling candidates for inherited retina diseases were identified. CONCLUSIONS: The EyeSAGE database, combining three different gene-profiling platforms including the authors' multidonor-derived retina/RPE SAGE libraries and existing single-donor retina/RPE libraries, is a powerful resource for definition of the retina and RPE transcriptomes. It can be used to identify retina-specific genes, including alternatively spliced transcripts and to prioritize candidate genes within mapped retinal disease regions.

Human RPE expression of cell survival factors.

PURPOSE: To determine basal and tumor necrosis factor (TNF)-alpha-regulated expression of retinal pigment epithelial (RPE) cell survival factors and whether regulation is dependent on nuclear transcription factor (NF)-kappaB. METHODS: Cultured human RPE cells were infected with adenovirus encoding either mutant inhibitory (I)-kappaB or beta-galactosidase and treated with TNF-alpha for various times. Freshly prepared RPE/choroid and RPE samples were isolated from human donor eyes. Real-time reverse transcription-polymerase chain reaction, Western blot, and immunocytochemistry were used to determine survival factor gene expression, cellular protein levels, and localization, respectively. RESULTS: Multiple survival factor genes, including cellular inhibitor of apoptosis protein (c-IAP1), c-IAP2, TNF receptor-associated factor-1 (TRAF-1), TRAF-2, B-cell leukemia/lymphoma-2 (Bcl-2), Bcl-x, A1, and cellular Fas-associated death domain (FADD)-like interleukin-1beta-converting enzyme-like inhibitory protein (c-FLIP), were expressed in basal conditions in both cultured RPE cells and RPE cells in situ, whereas survivin was expressed only by cultured cells. TNF-alpha upregulated expression of TRAF-1, TRAF-2, c-IAP1, c-IAP2, c-FLIP, and A1. TRAF-1, c-FLIP, and to a lesser extent c-IAP2 protein levels were increased by TNF-alpha in a time-dependent manner, whereas c-IAP1, survivin, Bcl-x(L), and TRAF-2 protein levels were not influenced by TNF-alpha treatment at any time point tested. In contrast, Bcl-2 and A1 proteins were not detected under basal conditions or after TNF-alpha treatment. Overexpression of mutant IkappaB blocked TNF-alpha-induced TRAF-1, TRAF-2, c-IAP1, c-IAP2, c-FLIP, and A1 gene expression and downregulated TRAF-1 protein levels. TRAF-1 and Bcl-x(L) proteins were localized diffusely in RPE cytoplasm. CONCLUSIONS: Multiple RPE cell survival factors are expressed by human RPE cells. TNF-alpha regulates expression of some of these factors in an NF-kappaB-dependent manner, whereas others are not influenced by NF-kappaB. RPE cell survival factors may protect RPE cells from apoptosis normally and in diseases such as age-related macular degeneration (AMD) and proliferative vitreoretinopathy (PVR).