Pseudophakia as a surprising protective factor in neovascular age-related macular degeneration.

PURPOSE: To assess the impact of lens status on macular function among patients treated for neovascular age-related macular degeneration (nvAMD) in whom scheduled intravitreal injections were delayed. METHODS: We reviewed demographic and clinical data as well as macular optical coherence tomographic images of 34 patients (48 eyes) who did not follow their injection schedule during the first wave of COVID-19 in Israel. Functional worsening was defined as a loss of at least 0.1 in decimal best-corrected visual acuity (BCVA). Morphological worsening was defined as new or increased subretinal/intraretinal fluid or a new hemorrhage. OCT indices of quality were used as a measure for cataract density and progression. RESULTS: Pseudophakia was associated with a better functional outcome than phakic status: there was a loss of 0.06±0.12 vs. 0.15±0.10 decimal BCVA in the pseudophakic and phakic eyes, respectively (P=.001). A similar trend was observed for morphological changes over the same period: there was an increase in macular thickness of 9±26% vs.12±40%, respectively (P=0.79). During the first wave of COVID-19, the index of OCT quality remained stable for phakic eyes (26±3.6 before the first wave of COVID-19, 26±2.9 afterward; P=1) and pseudophakic eyes (30±2.4 before the first wave of COVID-19, 30±2.6 afterward; P=1). CONCLUSION: Pseudophakic eyes with nvAMD that missed their scheduled intravitreal injections experienced fewer morphological and functional complications than phakic eyes with nvAMD.

Central serous chorioretinopathy following the BNT162b2 mRNA vaccine.

BACKGROUND AND PURPOSE: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has accelerated vaccine development. The BNT162b2 messenger RNA (mRNA) vaccine is being administered worldwide. The purpose of this case series is to report a possible association between the BNT162b2 mRNA vaccine and Central serous chorioretinopathy (CSC). Although rare, CSC has been reported following the administration of anthrax, influenza and smallpox vaccines. METHODS: Four individuals who developed CSC following the BNT162b2 mRNA vaccine were examined in our institution using multimodal imaging of the retina, and their demographic data were analyzed and compared to all the similar cases published to date. RESULTS: Four patients (3 males, 1 female) between the ages of 35 and 65 presented with acute CSC (n=3) and relapsed CSC (n=1) within the first week following the administration of the BNT162b2 mRNA vaccine. Three individuals demonstrated hyper-reflective foci in the outer segments of the retina. CONCLUSIONS: The timing of the BNT162b2 mRNA vaccine administration relative to the development of CSC suggests a possible causal relationship. Further research is necessary to explore this possible association.

Thinning of specific retinal layers as a novel biomarker for adverse outcomes in high-risk pregnancy.

PURPOSE: To investigate a potential association between retinal layer thinning and pregnancy-related adverse outcomes. METHODS: A prospective observational study included 32 pregnant women between the ages of 18 and 45. Seventeen had uneventful pregnancies, and 15 experienced an adverse obstetrical outcome. Macular swept-source ocular coherence tomography was performed, and selective layers of the retina were evaluated. Adverse obstetrical outcome was defined as any of the following: preterm delivery, preeclampsia, pregnancy-induced hypertension, elevated liver function tests, thrombocytopenia and need for magnesium. RESULTS: The inner superior ganglion cell layer (GCL) was found to be thinner in the cohort with composite adverse obstetrical outcomes than in the cohort without complications (84.5±6.9 vs. 89.5±6.1µm respectively; P=0.04). Total inner superior (295.5±39.1 vs. 302.5±12.7µm; P=0.03) and inferior retinal thickness (289.0±13.9 vs. 301.0±17.1µm; P=0.03) as well as total macular volume (7.5±0.3 vs. 7.7±0.3 mm3; P=0.02) were also lower in women with adverse obstetrical outcomes. CONCLUSION: Thinning of the macular ganglion cell layer was associated with adverse outcomes in pregnancy. Larger studies are necessary to assess the potential role of macular GCL analysis in pregnancy.

Granulomatous kerato-conjunctivitis as a manifestation of Hodgkin lymphoma.

PURPOSE: To report atypical kerato-conjunctivitis as a manifestation of Hodgkin disease. METHODS: Case report. RESULTS: A 19-year old woman presented with conjunctival nodules and corneal infiltrates. Diffuse lymph node enlargement occurred, but not in the preauricular or submandibular areas. Extensive microbiologic examination was negative. Conjunctival biopsy showed noncaseating granulomas. Inguinal lymph node biopsy showed Hodgkin lymphoma, and chemotherapy was instituted. Ocular signs resolved after 6 weeks, but a corneal scar remained. CONCLUSIONS: The appearance of conjunctival granulomas and corneal infiltrates may represent a clinical manifestation of Hodgkin lymphoma.

Combined timolol and pilocarpine vs pilocarpine alone and timolol alone in the treatment of glaucoma.

We compared the effects of pilocarpine 4% alone, timolol 0.5% alone, and a combination of timolol 0.5% and pilocarpine 4% in the treatment of glaucoma. We treated 43 patients with glaucoma using each drug and then with the combination of drugs for four weeks each. Only patients with a morning intraocular pressure of at least 24 mm Hg without treatment were included. The patients were examined, after one and four weeks of treatment with pilocarpine, timolol, or combined timolol 0.5% and pilocarpine 4%, before the morning dose and at two and five hours after it. At the end of the study, the mean reduction in intraocular pressure from baseline was 9.2 +/- 5.1 mm Hg (28.5% +/- 12.7%) with combined timolol 0.5% and pilocarpine 4%, 5.6 +/- 3.6 mm Hg (17.6% +/- 9.7%) with pilocarpine, and 7.5 +/- 5.0 mm Hg (21.2% +/- 12.6%) with timolol. Intraocular pressure was consistently lower with the combination treatment than with timolol or pilocarpine alone. We believe that this combined solution of timolol-pilocarpine is a valuable contribution to the treatment of open-angle glaucoma.

Intraocular pressure measurement in patients with instrastromal corneal ring segments.

PURPOSE: To study the measurement of intraocular pressure after implantation of Intacs (ICRS) intrastromal corneal ring segment, a device that is positioned circumferentially in the peripheral corneal stroma to correct myopia. The device changes the corneal curvature by shortening arc length. Since the ring segments are made of polymethylmethacrylate, this may cause localized changes in corneal elasticity so intraocular pressure measurement may be affected. METHODS: We measured the intraocular pressure of 12 eyes in which the ICRS had been in place longer than 6 months. We used Goldmann applanation and Tono-Pen tonometers over the central corneal and the paracentral corneal areas. We also measured the intraocular pressure with the Tono-Pen applanated directly over the intrastromal corneal ring segments. RESULTS: The resulting intraocular pressure measurements were similar for the Tono-Pen tonometer readings over the central cornea, paracentral cornea, and the Goldmann applanation tonometer readings over the central cornea (P < .01). Our measurements using the Goldmann applanation tonometer on the paracentral corneal area showed artificially elevated intraocular pressure in the 40 to 60 mmHg range. We were not able to obtain consistent results when we measured the intraocular pressure using the Tono-Pen on the corneal area directly overlying the intrastromal corneal ring segment implants. CONCLUSION: Consistent intraocular pressure measurements on eyes with the ICRS can be obtained with the Goldmann applanation tonometer over the central corneal area or with the Tono-Pen tonometer over the central or paracentral corneal areas.

Lens opacity after neodymium: YAG laser iridectomy for phakic intraocular lens implantation.

We describe a previously unreported complication of a posterior chamber intraocular lens (IOL) implanted in a phakic eye. The left eye of a 25-year-old patient with high myopia was treated prophylactically with neodymium: YAG (Nd: YAG) laser iridotomy prior to phakic IOL implantation. Slitlamp examination of the left eye disclosed an opacity of the anterior capsule of the crystalline lens under the iridotomy site. This case demonstrates a complication associated with Nd:YAG iridotomy prior to implantation of a phakic IOL.

Refractory intraocular pressure increase after photorefractive keratectomy.

A patient with developmental angle anomaly developed a corticosteroid-induced refractory increase in intraocular pressure (IOP) after photorefractive keratectomy (PRK). Trabeculectomy was required to reduce the pressure. Although rare, corticosteroid-induced refractory IOP increase is a serious complication of PRK and may necessitate trabeculectomy. More frequent monitoring of IOP in post-PRK patients and a re-evaluation of postoperative treatment are indicated.

Tono-Pen versus Goldmann tonometry after excimer laser photorefractive keratectomy.

PURPOSE: To compare intraocular pressure (IOP) measurements by the Tono-Pen 2 tonometer and Goldmann applanation tonometer (GAT) in post-photorefractive keratectomy (PRK) patients. SETTING: Refractive Surgery Center, Assaf Harofeh Medical Center, Zerifin, Israel. METHODS: In 18 patients, IOP was measured by GAT and then by Tono-Pen 2 tonometer 2 to 18 months following PRK (mean 6.6 months +/- 5.1 [SD]). Photorefractive keratectomy had been performed in 1 eye of each patient; the fellow eyes served as controls. Corneal curvature and thickness were evaluated. Ten of the 18 patients were treated with topical steroids. RESULTS: In the post-PRK eyes, mean GAT IOP was 1.8 +/- 3.1 mm Hg lower than mean Tono-Pen IOP (P = .012); there was no significant IOP difference in the control (fellow) eyes. In steroid-treated post-PRK eyes, mean GAT IOP (12.2 mm Hg) was 2.2 +/- 1.3 mm Hg lower than mean Tono-Pen IOP (14.4 mm Hg) (P = .0007). Mean Tono-Pen IOP in steroid-treated post-PRK eyes was 4.3 +/- 3 mm Hg higher than in the fellow eyes (P = .0014); mean GAT IOP was only 2.3 +/- 3.5 mm Hg higher (P = .04). In post-PRK eyes without topical steroid treatment, mean GAT IOP was 2.0 +/- 1.18 mm Hg lower than in the fellow eyes (P = .001); there was no significant difference in Tono-Pen IOP. There was a negative correlation between the difference in IOP values (Tono-Pen minus GAT) and corneal curvature in post-PRK eyes (r = 0.76, P = .0108, n = 15). CONCLUSIONS: The Tono-Pen tonometer appeared to be less affected than the GAT by the relative flattening, thinning, and anterior stromal decreased rigidity of the central cornea that occur following PRK. Post-PRK steroid-induced IOP elevation may be masked by the artifactual decrease in GAT IOP.

Stability after laser in situ keratomileusis in moderately and extremely myopic eyes.

OBJECTIVE: To evaluate the stability, mechanism, and degree of regression following laser in situ keratomileusis (LASIK) in cases with moderate to extreme myopia after 2 years of follow-up. SETTING: Single-center clinical trial. METHODS: Fifty-two eyes of 38 patients were enrolled in the study. One year follow-up was available for 47 eyes of 35 patients and 2 year follow-up for 39 eyes of 27 patients. Eyes were divided into 2 groups based on the level of preoperative myopia: Group 1, moderate to high myopia > or =15.0 diopters (D) (range -7.0 to -15.0 D, n = 24); Group 2, extreme myopia >15.0 D (range -15.3 to -25.8 D, n = 15). Laser in situ keratomileusis was performed using the Chiron Automated Corneal Shaper(R) microkeratome and the Summit OmniMed excimer laser. Manifest spherical equivalent, mean central keratometry, and central corneal thickness (CCT) were measured preoperatively and 12 and 24 months postoperatively. RESULTS: Group 1 exhibited a mild myopic shift (mean -0.07 +/- 0.28 D; P >.2) and a mild increase in keratometry (mean 0.05 +/- 0.46 D; P >.6), with an accompanying increase in CCT (mean 7.5 +/- 12.2 microm; (P =.006) at 24 months. Group 2 displayed a significant myopic shift (mean -0.7 +/- 0.7 D; P =.001) and a significant increase in keratometry (mean 0.4 +/- 0.5 D; P =.01), with a mild increase in CCT (mean 2.4 +/- 9.7 microm; P =.35) at 24 months. Corneal ectasia was evident in 1 eye in the extreme myopia group. CONCLUSION: The refractive effect of myopic LASIK up to -15.0 D remained reasonably stable during the second postoperative year. Significant regression of the refractive effect occurred in eyes with higher levels of myopia (>15.0 D), with the risk of progressive ectasia. Extreme caution is recommended when myopic LASIK is performed in eyes with higher levels of myopia.

Excimer laser phototherapeutic keratectomy for recurrent corneal erosion.

PURPOSE: To evaluate the outcome of excimer laser phototherapeutic keratectomy (PTK) for recurrent corneal erosion. SETTING: Laser Institute, Assay Harofeh Medical Center, Zerifin, Israel. METHODS: Twenty-three patients with a mean age of 50.56 years +/- 13.87 (SD) were referred between 1991 and 1995 for recurrent corneal erosion that did not respond to conservative treatment. All were treated by excimer laser PTK. Patients were interviewed and examined before and after treatment. RESULTS: Disease duration ranged from 2 months to 10 years. Frequency of attacks ranged from weekly to three to four times a year. Re-epithelialization of the cornea was established within an average of 3 days after PTK treatment. Follow-up was 12 to 60 months (mean 38.43 +/- 12.08 months). Nineteen (83%) patients were free of recurrences, and 3 had one recurrence treated successfully by patching. One patient who had two recurrences had a second PTK procedure and was symptom free for 14 months. No patient reported reduced visual acuity or quality. Postoperative best corrected visual acuity was unaltered in 21 eyes and improved in 2. There was no significant difference between preoperative and postoperative manifest refractions. CONCLUSION: Excimer laser PRK appears to be a safe and effective treatment for recurrent erosions of the cornea.

Pneumotonometry versus Goldmann tonometry after laser in situ keratomileusis for myopia.

PURPOSE: To assess the reliability of intraocular pressure (IOP) measurement by Goldmann applanation tonometry (GAT) versus pneumotonometry in patients after laser in situ keratomileusis (LASIK) for myopia. SETTING: Shiley Eye Center, University of California San Diego, La Jolla, California, USA. METHODS: In this prospective study, 31 eyes of 17 patients were evaluated before and 1 month after having LASIK for myopia. A masked observer measured preoperative and postoperative IOP by GAT centrally and by pneumotonometry at the center and the periphery of the cornea. Central corneal thickness and curvature were evaluated. RESULTS: Preoperative IOP showed a good correlation between GAT and pneumotonometry values (r = 0.82). Mean postoperative IOP by GAT was lower by 3.8 mm Hg +/- 2.2 (SD) (26.3% +/- 15.2%) than by pneumotonometry: 2.3 +/- 2.8 mm Hg (15.4% +/- 10.7%) (P = .01). There were no statistically significant differences in central IOP versus peripheral IOP measured by pneumotonometry (P = .4). Regression analysis showed no statistically significant differences in IOP as a function of change in corneal thickness or change in corneal curvature with either device. CONCLUSION: Postoperatively, there was a decrease in IOP measured by central GAT that was statstically significant. Differences in pneumotonometry were less substantial, with greater reliability of pneumotonometry than GAT after LASIK.

The effect of anthocyanosides in a multiple oral dose on night vision.

PURPOSE: In view of research demonstrating the ability of anthocyanosides in a multiple oral dose to improve night vision in normal individuals, we assessed their effect on three night vision tests: full-field absolute scotopic retinal threshold (SRT), dark adaptation rate (DAR) and mesopic contrast sensitivity (MCS). METHODS: In a double-masked, placebo-controlled, cross-over study, 18 young normal volunteers were randomly assigned to one of three different regimens of multiple oral administrations of 12 and 24 mg anthocyanosides, and a placebo, given twice daily for 4 days. A 2 week washout period was allowed between each 4 day treatment period. SRT, DAR and MCS was tested 1 day before and at days 1, 2, 3 and 4 during the treatment period. RESULTS: No significant effect was found on any of the three above-mentioned night vision tests. The study had a power of 0.95 to detect a 0.1 log unit improvement in SRT and 0.5 log unit improvement in MCS. CONCLUSIONS: Multiple oral administrations of 12 and 24 mg anthocyanosides twice a day appear to lack significant effect on night vision tests.

Hyperopic laser in situ keratomileusis with the Nidek EC-5000 excimer laser.

OBJECTIVE: To evaluate the efficacy, safety, and predictability of hyperopic laser in situ keratomileusis (H-LASIK) using modified software. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: The first 72 consecutive eyes of 44 patients with up to +5.00 diopters (D) hyperopia. INTERVENTION: Hyperopic LASIK using the Automatic Corneal Shaper (ACS; Chiron Vision, Claremont, CA) and the Nidek EC-5000 excimer laser (Nidek, Tokyo, Japan). MAIN OUTCOME MEASURES: Uncorrected visual acuity, manifest spherical equivalent (MSE), best-corrected visual acuity (BCVA), and complications were studied. RESULTS: At 6 months, in the low hyperopia group (<3.00 D), mean MSE was +0.30 +/- 0.71 D, with 88.9% eyes within 1 D of emmetropia compared with +1.09 +/- 0.92 D and 51.8% within 1 D of emmetropia in the moderate hyperopia group (> or =3.00 D; P = 0.003). Uncorrected visual acuity was 20/40 or better in 43 of 45 eyes (95.6%) and in 21 of 27 (77.8%) eyes in the low and moderate hyperopia groups, respectively. Only one eye (1.4%) from the moderate hyperopia group lost two lines of BCVA. Eighteen eyes (25%) required retreatment to correct residual hyperopia, 9 eyes (20.0%) in the low hyperopia group and 9 eyes (33.3%) in the moderate hyperopia group. Retreatments resulted in an MSE of +0.02 +/- 0.45 D and +0.04 +/- 0.73 D in the low and moderate hyperopia groups, respectively. No flap-related complications were seen. CONCLUSIONS: Hyperopic LASIK with the ACS and the Nidek EC-5000 excimer laser using our modified software is a safe, effective, and predictable procedure for low hyperopia. Results are satisfactory up to moderate hyperopia. Significant regression can occur for low and moderate hyperopia. Retreatment can be performed safely and effectively to improve the visual and refractive results.

Factor VII deficiency in a patient with retinal arteriolar tortuosity syndrome.

PURPOSE: To report a pedigree with hereditary retinal arteriolar tortuosity with macular haemorrhage and abnormality of the coagulation system. METHODS: Case report and literature review. RESULTS: A 49-year-old woman was referred due to macular haemorrhage in both eyes. Her 16-year-old son had recurrent retinal haemorrhages which presented at age 16 years and had mild retinal arteriolar tortuosity. Coagulation studies in the son revealed normal activated partial thromboplastin time (APTT), prolonged prothrombin time (PT) and 30% activity of factor VII. CONCLUSIONS: Factor VII deficiency may aggravate the haemorrhages in retinal arteriolar tortuosity syndrome. We therefore suggest conducting routine coagulation studies (PT, APTT) in all patients with retinal arteriolar tortuosity syndrome. Determination of factor VII activity is warranted only in patients with normal APTT and prolonged PT.

Outcomes of retreatment after laser in situ keratomileusis.

OBJECTIVE: To evaluate the safety and efficacy of retreatment after myopic laser in situ keratomileusis (LASIK). DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: A total of 962 eyes of 566 patients underwent LASIK for up to -20.0 diopters (D) of myopia, of which 53 eyes (5.5%) were retreated. INTERVENTION: Retreatments were performed by lifting the original flap and using the Nidek EC-5000 excimer laser (Nidek Inc., Tokyo, Japan). MAIN OUTCOME MEASURES: Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BCVA), fogged manifest refraction, and complications were evaluated 6 months after retreatment. RESULTS: Overall, 53 (5.5%) of 962 eyes underwent LASIK retreatment. Before retreatment, the mean spherical equivalent (MSE) was -1.7 +/- 1.1 D (range, +0.3 to -5.0 D), UCVA ranged from 20/25 to 20/400, and BCVA ranged from 20/20 to 20/50. Six months after retreatment, the MSE was -0.09 +/- 0.29 D, 48 (90.6%) eyes were within +/-0.5 D, and all eyes were within +/-1.0 D of the attempted correction. The UCVA improved to 20/20 or better in 21 (39.6%) eyes and 20/40 or better in 51 (96.2%) eyes. The BCVA was maintained in 33 eyes (62.3%), 15 eyes (28.3%) gained 1 line or more of vision, whereas 5 eyes (9.4%) lost 1 line. All eyes had a BCVA of 20/50 or better. No retreated eye lost two or more lines of BCVA. No complications were observed. CONCLUSION: Retreatment for low amounts of residual myopia performed by lifting the original flap within the first year after surgery after myopic LASIK is safe, effective, and predictable.