Expert consensus on the identification, diagnosis, and treatment of neurotrophic keratopathy.

BACKGROUND: Neurotrophic keratopathy (NK) is a relatively uncommon, underdiagnosed degenerative corneal disease that is caused by damage to the ophthalmic branch of the trigeminal nerve by conditions such as herpes simplex or zoster keratitis, intracranial space-occupying lesions, diabetes, or neurosurgical procedures. Over time, epithelial breakdown, corneal ulceration, corneal melting (thinning), perforation, and loss of vision may occur. The best opportunity to reverse ocular surface damage is in the earliest stage of NK. However, patients typically experience few symptoms and diagnosis is often delayed. Increased awareness of the causes of NK, consensus on when and how to screen for NK, and recommendations for how to treat NK are needed. METHODS: An 11-member expert panel used a validated methodology (a RAND/UCLA modified Delphi panel) to develop consensus on when to screen for and how best to diagnose and treat NK. Clinicians reviewed literature on the diagnosis and management of NK then rated a detailed set of 735 scenarios. In 646 scenarios, panelists rated whether a test of corneal sensitivity was warranted; in 20 scenarios, they considered the adequacy of specific tests and examinations to diagnose and stage NK; and in 69 scenarios, they rated the appropriateness of treatments for NK. Panelist ratings were used to develop clinical recommendations. RESULTS: There was agreement on 94% of scenarios. Based on this consensus, we present distinct circumstances when we strongly recommend or may consider a test for corneal sensitivity. We also present recommendations on the diagnostic tests to be performed in patients in whom NK is suspected and treatment options for NK. CONCLUSIONS: These expert recommendations should be validated with clinical data. The recommendations represent the consensus of experts, are informed by published literature and experience, and may improve outcomes by helping improve diagnosis and treatment of patients with NK.

Current and Future Pharmacological Therapies for the Management of Dry Eye.

Dry eye disease (DED) is among the most common reasons for visiting eye care practitioners and represents a substantial health and cost burden. Disease prevalence ranges from 5% to 33% and is increasing in the younger population. The core mechanism of DED involves a vicious cycle where hyperosmolarity leads to an inflammatory cascade resulting in ocular surface damage. No cure is available for DED, and patients require ongoing disease management. Over-the-counter medications can provide temporary symptom relief but do not tackle the inflammatory pathophysiology of DED. A number of medications with anti-inflammatory activity are available, but there is a need for development of pharmacotherapies with novel delivery methods and targets to widen the variety of treatment options. This review discusses current anti-inflammatory pharmacotherapies approved in the United States and Europe for DED and highlights novel drugs that have been recently approved or are in development.

Clinical Outcomes of Lifitegrast 5% Ophthalmic Solution in the Treatment of Dry Eye Disease.

PURPOSE: To evaluate the clinical characteristics, outcomes, and adverse reactions after the use of lifitegrast 5% ophthalmic solution for the treatment of patients with dry eye disease (DED). METHODS: Retrospective chart review was performed in 121 patients seen at the Duke Eye Center with DED who were prescribed lifitegrast 5% and seen for follow-up after treatment initiation. Charts were reviewed for meibomian gland dysfunction (MGD) grading, conjunctival and corneal staining scores, and tear breakup time (TBUT), as well as matrix metalloproteinase-9 (MMP-9) levels. Ocular Surface Disease Index (OSDI) questionnaire scores and self-reported adverse reactions were also assessed. RESULTS: The average patient age was 60.5 years (range, 22-88 years); 87.6% were female, and 20.7% had a previous autoimmune disease diagnosis. Of the 54 eyes with an initial positive MMP-9, 21 eyes (38.9%) normalized after treatment. The ocular symptoms OSDI subscore demonstrated an improvement of -2.43±6.85 (P=0.011) after treatment. Corneal staining scores showed an average change of -0.15 (P=0.007). The average change in TBUT was 1.9 sec (P<0.001). Self-reported adverse reactions were noted in 31.4% of patients. There was no statistically significant change in MGD grading. Patients with moderate-severe DED showed statistically significant improvements in conjunctival and corneal staining scores and TBUT (-0.17±0.66, P=0.0442; -0.54±0.65, P<0.001; +2.02±2.63, P=0.004, respectively). CONCLUSION: Lifitegrast 5% is a useful therapeutic option for DED with a moderate proportion of self-reported adverse reactions, all of which were related to ocular discomfort. Treatment with lifitegrast was associated with statistically significant improvements in MMP-9 levels, ocular symptoms, corneal staining, and TBUT.

Wound closure and tissue adhesives in clear corneal incision cataract surgery.

PURPOSE OF REVIEW: Achieving secure wound closure in clear corneal incision cataract surgery remains highly desired for its role in reducing infection risk and leak-related complications, including hypotony, corneal edema, and lens dislocation. Although classic techniques of stromal hydration or wound suturing represent traditional approaches, the introduction of newer and more effective ocular surface adhesives has increased the options that are available. This review aims to provide an update on the peer-reviewed literature regarding wound closure and the currently available and investigational tissue adhesives used to seal clear corneal incisions in cataract surgery. RECENT FINDINGS: Stromal hydration and sutured closure of clear corneal incisions remain viable options for wound closure. Wound sealants, particularly polyethylene glycol (PEG)-based hydrogels, have been found to provide watertight wound seal with less foreign-body sensation and surgically induced astigmatism compared with sutures, and less adverse effects and greater ease of use compared with cyanoacrylate and fibrin glues. SUMMARY: Stromal hydration, sutured closure, and use of a corneal adhesive are all wound closure options for clear corneal incisions. Of the currently available tissue adhesives, PEG hydrogel sealants have become the most widely accepted, with an improved side-effect and biocompatibility profile.

Femtosecond laser-assisted keratotomy.

PURPOSE OF REVIEW: To review the recent literature on femtosecond laser-assisted astigmatic keratotomy and its applications to naturally occurring as well as postoperative astigmatism in multiple settings. RECENT FINDINGS: Femtosecond laser technology has improved the safety and efficacy of astigmatic keratotomy in the treatment of astigmatism. Intrastromal femtosecond astigmatic keratotomy (ISAK) may have even lower complication rates, though long-term results are still being established. Femtosecond laser-assisted keratotomy (FSAK) in the surgical setting, such as at the time of or after cataract surgery, keratoplasty, and glaucoma surgery, has been investigated with overall good results. There have been some reports of overcorrection and undercorrection of astigmatism, particularly in the setting of high and nonorthogonal astigmatism. Further refinement of nomograms in these settings is indicated. Complications such as full thickness FSAK and ISAK incisions are rare but have been reported, and may be mitigated by the integration of dynamic optical coherence tomography (OCT) into femtosecond laser systems. SUMMARY: FSAK is an effective and safe way to correct astigmatism. These procedures have some advantages over manual astigmatic keratotomy, including increased accuracy of incision depth and placement. As nomograms are refined and technologies such as dynamic OCT are further incorporated into femtosecond systems, results are likely to continue improving.

Intense pulsed light therapy for the treatment of evaporative dry eye disease.

PURPOSE OF REVIEW: Evaporative dry eye disease is one of the most common types of dry eye. It is often the result of chronic meibomian gland dysfunction (MGD) and associated ocular rosacea. Evaporative dry eye and MGD significantly reduce patient's quality of life. Traditional treatments, such as artificial tears, warm compresses, and medications, such as topical cyclosporine, azithromycin, and oral doxycycline, provide some relief; however, many patients still suffer from dry eye symptoms. Intense pulsed light (IPL) therapy, which has been used extensively in dermatology to treat chronic skin conditions, is a relatively new treatment in ophthalmology for patients with evaporative dry eye disease. RECENT FINDINGS: There are very few studies published on the use of IPL in patients with dry eye disease. The present review describes the theoretical mechanisms of IPL treatment of MGD and ocular rosacea. Personal clinical experience and recently presented data are reported as well. SUMMARY: IPL therapy has promising results for evaporative dry eye patients. There are statistically significant improvements in clinical exam findings of dry eye disease. More importantly, patients report subjective improvement in their symptoms. More research is needed in this area to help understand the mechanism of dry eye disease and how it can be effectively treated.

Outcomes of photorefractive keratectomy enhancement after LASIK.

PURPOSE: To report the outcomes of photorefractive keratectomy (PRK) enhancement after LASIK for patients diagnosed as having hyperopic and myopic refractive errors. METHODS: In this retrospective case series at a single private practice in the United States, all patients undergoing PRK enhancement after LASIK were identified. Patients with visually significant cataract, non-plano targets, and follow-up of fewer than 226 days were excluded. The primary outcome measure was uncorrected distance visual acuity (UDVA) with secondary measures of corrected distance visual acuity (CDVA) and postoperative refractive error. Linear regression analysis was performed for actual versus targeted change in spherical equivalent. RESULTS: Mean UDVA improved from 20/39 to 20/24 for hyperopes (n = 14; P < .002) and from 20/45 to 20/22 for myopes (n = 29; P < .0000001) after enhancement. All patients had a UDVA of 20/40 or better at their most recent follow-up visit. Fifty percent of hyperopes and 65.5% of myopes were 20/20 or better. The mean refractive error for hyperopes changed from +1.10 ± 0.71 (range: +0.13 to +2.25 diopters [D]) to +0.38 ± 0.66 D (range: -0.75 to +1.38 D) and from -1.21 ± 0.61 (range: -3.25 to -0.38 D) to +0.34 ± 0.45 D (range: -0.25 to +1.75 D) for myopes. The manifest refraction cylinder decreased from 0.84 to 0.46 D in hyperopes (P = .02) and from 0.64 to 0.26 D in myopes (P < .002). CDVA was maintained in both groups, with only one patient in each worse than 20/20. There was a nonsignificant trend toward less haze in the patients receiving mitomycin C (5.1% vs 25%, P = .14). Linear regression showed a tendency toward overtreatment in the myopic group. CONCLUSIONS: PRK is safe and highly effective for patients who previously underwent LASIK and in whom the surgeon would prefer not to perform a flap-lift enhancement.

Sensitivity and specificity of SS-OCT for detecting macular pathologies vs SD-OCT.

PURPOSE: To evaluate the sensitivity and specificity of swept-source optical coherence tomography (SS-OCT) biometer compared with the gold standard spectral-domain optical coherence tomography (SD-OCT) for detecting macular pathology in patients with cataract. SETTING: Eye Centers of Tennessee, Crossville, TN. DESIGN: Prospective, cross-sectional, observational, examiner-masked. METHODS: The study included 132 participants aged 50 years and older, who underwent precataract surgery work-up. All participants underwent fixation check retinal scans using SS-OCT biometer (IOLMaster 700) as well as full macular scans using Cirrus SD-OCT. 3 independent masked examiners evaluated the scans if they were normal or had a suspected pathology. Different measures of diagnostic accuracy were calculated for 3 examiners. RESULTS: True positive rate (sensitivity) ranged from 71.1% (32/45) to 79.2% (42/53), and false negative rate was between 20.8% (11/53) and 28.9% (13/45) for the 3 examiners. True negative rate (specificity) ranged from 86.8% (59/68) to 94.1% (64/68), and false positive rate was between 5.9 (4/68) and 13.2% (9/68). The fitted receiver operating characteristic area ranged from 0.83 to 0.95. CONCLUSIONS: Using retinal SS-OCT biometer scans as a replacement of the dedicated macular SD-OCT for screening or diagnosing macular health would not be appropriate because of its low sensitivity. SS-OCT biometer may potentially fail to identify approximately one-fourth of patients who actually have the disease. Therefore, the final decision on macular health should be based on the gold standard SD-OCT scans. When full macular SD-OCT scans are not accessible, the limited retinal scan information from SS-OCT biometer may still provide useful insights into the macular health.

The Effectiveness and Safety of a Novel Crosslinked Hyaluronate Canalicular Gel Occlusive Device for Dry Eye.

PURPOSE: Evaluate effectiveness and safety of a crosslinked hyaluronate (HA) canalicular filler (Lacrifill Canalicular Gel) compared to a commercially available hydrogel canalicular plug (Form Fit). SETTING: 5 sites in United States. DESIGN: Prospective, multicenter, controlled, double-masked, randomized 2:1 (filler:plug). METHODS: Adults (≥22 years) with Schirmer test (with anesthesia) ≤10 mm/5 minutes, presence of corneal staining, ocular surface disease index (OSDI) of ≥23 with ≤3 responses of "not applicable," patent lacrimal drainage system, and bilateral best-corrected distance visual acuity of 20/40 or better. Filler or plugs were instilled bilaterally in the inferior canaliculi. Primary effectiveness endpoint was non-inferiority of the mean within subject change from baseline to Month 3 in Schirmer score for patients receiving filler compared to plugs. The key secondary effectiveness endpoint was non-inferiority of the proportion of patients with filler achieving improvement from baseline to Month 3 in OSDI by a minimal clinically important difference (MCID). Additional endpoints included the mean change from baseline to 3 and 6 months in tear meniscus height, OSDI, corneal staining, tear break-up time, and safety. RESULTS: 157 patients were randomized; 99 patients with crosslinked HA filler and 52 patients with hydrogel plugs completed the study. Filler was non-inferior to plugs in the mean Schirmer score change from baseline and in the proportion of patients achieving a clinically important improvement in OSDI. CONCLUSIONS: Crosslinked HA filler is a safe, well-tolerated, and effective method to treat dry eye. Clinically and statistically significant improvements in signs and symptoms of dry eye were sustained through 6 months.

Efficacy and Safety of CSF-1 (0.4% Pilocarpine Hydrochloride) in Presbyopia: Pooled Results of the NEAR Phase 3 Randomized, Clinical Trials.

PURPOSE: This study was undertaken to evaluate the safety and efficacy of CSF-1 (0.4% pilocarpine hydrochloride ophthalmic solution) for use in individuals with presbyopia. METHODS: Two Phase 3 multicenter, randomized, double-masked, vehicle-controlled, parallel-group clinical trials were conducted in 35 private ophthalmology clinics in the United States from October 2020 to February 2022. Key inclusion criteria were the following: (1) age 45-64 years, (2) distance-corrected near visual acuity (DCNVA) at 40 cm ≥0.40 and ≤0.90 logarithm of the minimum angle of resolution (logMAR, approximately 20/50-20/160 Snellen) in at least 1 eye, (3) manifest refraction (MR) between -4.50 and +2.00 diopter (D) sphere in each eye with ≤2.00D difference between eyes, (4) <2.00D of cylinder MR in each eye, (5) ≤0.04 logMAR (20/20-2 or better) corrected distance visual acuity (CDVA) at 4 m in each eye. Key exclusion criteria were the following: (1) >0.14 logMAR (7 letters) improvement in post-vehicle treatment in monocular DCNVA in either eye at visit 1, (2) introcular pressure (IOP) <9 or >22 mm Hg, (3) average dark-adapted pupillometry <3.5 mm in either eye, (4) prior refractive surgery or intraocular lens (IOL) implantation. Participants applied CSF-1 or vehicle twice per day for 2 weeks. Efficacy and safety assessments were performed at several times on days 1, 8, and 15. Response was defined as ≥3-line gain in DCNVA without loss of ≥1-line in CDVA in the study eye under mesopic room lighting conditions. The primary efficacy endpoint was measured 1 hour post-dose 1 on day 8. Key secondary endpoints were 2 hours post-dose 1, and 1 and 2 hours post-dose 2, also on day 8. Safety endpoints were ocular and non-ocular treatment-related adverse events (TRAE), conjunctival redness, drop comfort, slit-lamp biomicroscopy, intraocular pressure, indirect fundoscopy, and CDVA at 4 m. FINDINGS: Six hundred thirteen participants were randomized to CSF-1 (n = 309) or vehicle (n = 304). Participants were predominantly White (80.8%) and female (62.0%), with mean age (standard deviation) of 54.7 (4.8). CSF-1 met the primary and key secondary endpoints. At the primary endpoint, 40.1% of the CSF-1 group achieved response versus 19.1% of the vehicle group (P < 0.0001). The percentage of responders was significantly greater in CSF-1 compared with vehicle at all tested times. Changes from baseline in all safety endpoints were comparable between groups. Most adverse events (AEs) were mild and transient. Neither serious nor severe AEs were reported with CSF-1. IMPLICATIONS: CSF-1, a low-dose pilocarpine ophthalmic solution, demonstrated superiority to vehicle in improving near vision in individuals with presbyopia without compromising distance vision. CSF-1 demonstrated a favorable safety profile. CLINICALTRIALS: gov identifier: NCT04599933 (NEAR-1), NCT04599972 (NEAR-2).

How Can We Best Diagnose Severity Levels of Dry Eye Disease: Current Perspectives.

Dry eye disease (DED) is a common ocular condition, but the diagnosis relative to other ocular conditions and the evaluation of severity of the condition has often been difficult. This challenge can be due to clinical signs and symptoms not always correlating with each other. An understanding of the various components which create the condition, as well as the diagnostic measures used to evaluate these components, is useful to the clinician working with DED patients. This review paper will discuss traditional diagnostic options, diagnostic imaging, and Advanced Point of Care testing capabilities to determine the severity level of dry eye disease more adequately.

Clinical diagnosis and management of Demodex blepharitis: the Demodex Expert Panel on Treatment and Eyelid Health (DEPTH).

BACKGROUND: Twelve ocular surface disease experts convened to achieve consensus about Demodex blepharitis (DB) using a modified Delphi panel process. METHODS: Online surveys were administered using scaled, open-ended, true/false, and multiple-choice questions. Consensus for questions using a 1 to 9 Likert scale was predefined as median scores of 7-9 and 1-3. For other question types, consensus was achieved when 8 of 12 panellists agreed. Questions were randomized, and results of each survey informed the following survey. RESULTS: Twelve practitioners comprised the Demodex Expert Panel on Treatment and Eyelid Health (DEPTH). Following 3 surveys, experts agreed that DB is chronic (n = 11) and recurrent (n = 12) and is often misdiagnosed. Consensus was achieved regarding inflammation driving symptoms (median = 7; range 7-9), collarettes as the most common sign (n = 10) and pathognomonic for DB (median = 9; range 8-9), and itching as the most common symptom (n = 12). Panellists agreed that DB may be diagnosed based on collarettes, mites, and/or patient symptoms (n = 10) and felt that patients unresponsive to typical therapies should be evaluated for DB (n = 12). Consensus about the most effective currently available OTC treatment was not reached. CONCLUSIONS: The Delphi methodology proved effective in establishing consensus about DB, including signs, symptoms, and diagnosis. Consensus was not reached about the best treatment or how to grade severity. With increased awareness, eyecare practitioners can offer DB patients better clinical outcomes. A follow-up Delphi panel is planned to obtain further consensus surrounding DB treatment.

Delphi Panel Consensus Regarding Current Clinical Practice Management Options for Demodex blepharitis.

Purpose: To obtain consensus on Demodex blepharitis (DB) treatment using a modified Delphi panel process. Methods: Literature search identified gaps in knowledge surrounding treatment of DB. Twelve ocular surface disease experts comprised the Demodex Expert Panel on Treatment and Eyelid Health (DEPTH). They completed a live roundtable discussion in addition to 3 surveys consisting of scaled, open-ended, true/false, and multiple-choice questions pertaining to the treatment of DB. Consensus for scaled questions using a 1 to 9 Likert scale was predefined as median scores of 7-9 and 1-3. For other question types, consensus was achieved when 8 of 12 panelists agreed. Results: The experts agreed that an effective therapeutic agent for treatment of DB would likely decrease the necessity of mechanical intervention, such as lid scrubs or blepharoexfoliation (Median = 8.5; Range 2-9). When treating DB, panelists believed that collarettes serve as a surrogate for mites, and that eliminating or reducing collarettes should be the main clinical goal of treatment (Median = 8; Range 7-9). The panelists would treat patients with at least 10 collarettes, regardless of other signs or symptoms and agreed that DB can be cured, but there is always the possibility for a reinfestation (n = 12). There was also consensus that collarettes, and therefore mites, are the primary treatment target and the way by which clinicians can monitor patient response to therapy (Median = 8; Range 7-9). Conclusion: Expert panelists achieved consensus on key facets of DB treatment. Specifically, there was consensus that collarettes are pathognomonic for DB, that DB patients with >10 collarettes should be treated even in the absence of symptoms, and that treatment efficacy can be tracked by collarette resolution. By increasing awareness about DB, understanding the goals of and monitoring treatment efficacy, patients will receive better care and, ultimately, better clinical outcomes.

TFOS Lifestyle: Impact of lifestyle challenges on the ocular surface.

Many factors in the domains of mental, physical, and social health have been associated with various ocular surface diseases, with most of the focus centered on aspects of dry eye disease (DED). Regarding mental health factors, several cross-sectional studies have noted associations between depression and anxiety, and medications used to treat these disorders, and DED symptoms. Sleep disorders (both involving quality and quantity of sleep) have also been associated with DED symptoms. Under the domain of physical health, several factors have been linked to meibomian gland abnormalities, including obesity and face mask wear. Cross-sectional studies have also linked chronic pain conditions, specifically migraine, chronic pain syndrome and fibromyalgia, to DED, principally focusing on DED symptoms. A systematic review and meta-analysis reviewed available data and concluded that various chronic pain conditions increased the risk of DED (variably defined), with odds ratios ranging from 1.60 to 2.16. However, heterogeneity was noted, highlighting the need for additional studies examining the impact of chronic pain on DED signs and subtype (evaporative versus aqueous deficient). With respect to societal factors, tobacco use has been most closely linked to tear instability, cocaine to decreased corneal sensitivity, and alcohol to tear film disturbances and DED symptoms.

The Current Burden and Future Solutions for Preoperative Cataract-Refractive Evaluation Diagnostic Devices: A Modified Delphi Study.

Purpose: To obtain consensus on the key areas of burden associated with existing devices and to understand the requirements for a comprehensive next-generation diagnostic device to be able to solve current challenges and provide more accurate prediction of intraocular lens (IOL) power and presbyopia correction IOL success. Patients and Methods: Thirteen expert refractive cataract surgeons including three steering committee (SC) members constituted the voting panel. Three rounds of voting included a Round 1 structured electronic questionnaire, Round 2 virtual face-to-face meeting, and Round 3 electronic questionnaire to obtain consensus on topics related to current limitations and future solutions for preoperative cataract-refractive diagnostic devices. Results: Forty statements reached consensus including current limitations (n = 17) and potential solutions (n = 23) associated with preoperative diagnostic devices. Consistent with existing evidence, the panel reported unmet needs in measurement accuracy and validation, IOL power prediction, workflow, training, and surgical planning. A device that facilitates more accurate corneal measurement, effective IOL power prediction formulas for atypical eyes, simplified staff training, and improved decision-making process for surgeons regarding IOL selection is expected to help alleviate current burdens. Conclusion: Using a modified Delphi process, consensus was achieved on key unmet needs of existing preoperative diagnostic devices and requirements for a comprehensive next-generation device to provide better objective and subjective outcomes for surgeons, technicians, and patients.

Practical Guidance for the Use of Loteprednol Etabonate Ophthalmic Suspension 0.25% in the Management of Dry Eye Disease.

Dry eye disease (DED) is a prevalent ocular surface disease. Like with any chronic disease, patients with DED can experience episodic flares. There are many existing and upcoming treatments for the chronic treatment of DED, yet treatments for DED flares are limited. Loteprednol etabonate 0.25% is an FDA approved treatment modality for the short-term treatment of the signs and symptoms of DED. This medication is formulated with the customized mucus-penetrating particle (MPP) technology, which has a greater ability to penetrate the ocular surface and more effectively deliver the active steroid to the ocular surface tissues as compared with conventional steroid preparations. There is also increasing utility of loteprednol etabonate 0.25% in the treatment of DED before and/or after cataract or refractive surgery or as induction therapy prior to starting chronic immunomodulatory medication for DED.

The Effect of OTX-101 on Tear Production in Patients with Severe Tear-deficient Dry Eye Disease: A Pooled Analysis of Phase 2b/3 and Phase 3 Studies.

PURPOSE: Impaired tear production - a common sign of keratoconjunctivitis sicca (KCS) - is associated with qualitative or quantitative tear deficiency. OTX-101 0.09% is a novel, nanomicellar formulation of cyclosporine A approved in the US for increasing tear production in patients with KCS. We present a pooled analysis of the phase 2b/3 and phase 3 studies evaluating the effect of OTX-101 on tear production in a subgroup of patients with keratoconjunctivitis sicca with severely impaired tear production (Schirmer's score <5 mm in either eye at baseline). METHODS: In these randomized, double-masked studies, patients instilled 1 drop OTX-101 or vehicle per eye twice daily for 84 days. Pooled efficacy endpoints included percent (%) of patients with ≥10 mm change from baseline and mean change from baseline in Schirmer's score at day 84. Pooled safety endpoints included adverse event monitoring. RESULTS: Subgroup analyses included 133 and 113 patients receiving OTX-101 and vehicle, respectively. Mean baseline (BL) Schirmer's score ± standard deviation was 2.7 ± 1.2 for OTX-101 and 2.5 ± 1.1 mm for vehicle (P = .3203). On day 84, number (%) of patients with ≥10 mm Schirmer's score change from baseline was 30 (22.6%) and 12 (10.6%, P = .0168); mean change from baseline ± standard deviation was 5.5 ± 8.0 and 3.6 (6.0, P = .0405) mm for OTX-101 and vehicle, respectively. Adverse events were mostly mild and did not require treatment. CONCLUSION: OTX-101 administered twice daily for 84 days significantly improved tear production vs vehicle in patients with severely impaired tear production, as evidenced by significantly larger proportion of patients with ≥10 mm increases from baseline and higher mean change from baseline in Schirmer's scores.

Ocular surface optimization before cataract surgery.

The evolution of refractive cataract surgery has increased patient expectations for visual outcomes following cataract surgery. Precise biometry and keratometry are critical for accurate intraocular lens (IOL) selection and favorable surgical outcomes. In patients with the ocular surface disease and corneal pathologies, preoperative measurements can often be erroneous, leading to postoperative refractive surprises and dissatisfied patients. Conditions such as dry eye disease, epithelial basement membrane dystrophy, Salzmann's nodular dystrophy, and pterygia need to be addressed thoroughly before performing cataract surgery to optimize the ocular surface, obtain high-quality preoperative measurements, and ultimately determine the appropriate IOLs. In this review, the various ocular surface pathologies affecting cataract surgery outcomes and options for treatment are discussed and the importance of optimization of the ocular surface before cataract surgery is reviewed.

A Case of Candida parapsilosis Stromal Keratitis after Descemet's Membrane Endothelial Keratoplasty: A Case Report and Review of the Literature.

A 68-year-old diabetic male with Fuchs endothelial corneal dystrophy cataract underwent combined DMEK and cataract surgery of the left eye. Post-operative course was complicated by a partial graft detachment on POD 3, treated with a re-bubbling procedure. The patient subsequently developed a corneal infiltrate, cultured by aqueous sample, that was found to be C. parapsilosis. Oral fluconazole and voriconazole, topical voriconazole 1%, and amphotericin B as well as intracameral and intrastromal voriconazole and amphotericin B were employed. By post-operative day 45, symptoms and signs of DMEK stromal C. parapsilosis keratitis had resolved, and a corneal scar remained. Best corrected visual acuity, at post-operative month 4, was 20/25-2 without correction. Post-DMEK fungal stromal keratitis is a rare post-operative complication. We present a case of C. parapsilosis DMEK stromal keratitis and describe diagnostic and therapeutic modalities that allowed for resolution of the infection, without explantation of the patient's graft, and preservation of visual acuity.

Impact of Heads-Up Display Use on Ophthalmologist Productivity, Wellness, and Musculoskeletal Symptoms: A Survey Study.

Purpose: To explore how ophthalmologist productivity, wellness, and musculoskeletal (MSK) symptoms are affected by heads-up display (HUD) use. Methods: A digital survey was emailed to the United States ophthalmologists. Questions covered topics including MSK health, surgical output, work hours, wellness hours, and factors related to HUD use. Results: One hundred and forty-four ophthalmologists responded, and 99 completed all eligible questions. HUDs were utilized by 33 respondents, 29 of whom submitted complete surveys. HUD users worked 353 more hours annually (P = 0.01) and performed 673 more cases (P = 0.07) than nonusers. MSK symptom presence (P = 0.79), severity (P = 0.80), and frequency (P = 0.86) were independent of use. Over half (n = 16/29) of users identified symptomatic improvement attributable to the device, mostly in the cervical and lumbar regions. Mean job stress was moderate-severe for both users and nonusers (P = 0.10), and there was no significant difference in wellness hours (P = 0.44). Retina specialists (P = 0.02) and males (P = 0.03) were more likely to have operated with the technology. Nearly half of heads-up surgeons (n = 12/29) had obtained new equipment to target MSK symptoms, versus 1.4% of nonusers (n = 1/70; P = 0.0009). Most of those who operated with HUDs would recommend them to others (69.0%, n = 20/29), but 44.8% (n = 13/29) indicated ergonomic challenges. Primary concerns included awkward viewing angles, setup difficulties, and a lack of access. Conclusions: HUD surgeons reported greater work output versus nonusers without significant compromises in wellness or MSK health. User feedback suggests that the technology may lessen neck and low back pains, but barriers including cost and system inconveniences may impede adoption.