BCLA CLEAR Presbyopia: Management with corneal techniques.

Corneal techniques for enhancing near and intermediate vision to correct presbyopia include surgical and contact lens treatment modalities. Broad approaches used independently or in combination include correcting one eye for distant and the other for near or intermediate vision, (termed monovision or mini-monovision depending on the degree of anisometropia) and/or extending the eye's depth of focus [1]. This report provides an overview of the evidence for the treatment profile, safety, and efficacy of the range of corneal techniques currently available for managing presbyopia. The visual needs and expectations of the patient, their ocular characteristics, and prior history of surgery are critical considerations for patient selection and preoperative evaluation. Contraindications to refractive surgery include unstable refraction, corneal abnormalities, inadequate corneal thickness for the proposed ablation depth, ocular and systemic co-morbidities, uncontrolled mental health issues and unrealistic patient expectations. Laser refractive options for monovision include surface/stromal ablation techniques and keratorefractive lenticule extraction. Alteration of spherical aberration and multifocal ablation profiles are the primary means for increasing ocular depth of focus, using surface and non-surface laser refractive techniques. Corneal inlays use either small aperture optics to increase depth of field or modify the anterior corneal curvature to induce corneal multifocality. Presbyopia correction by conductive keratoplasty involves application of radiofrequency energy to the mid-peripheral corneal stroma which leads to mid-peripheral corneal shrinkage, inducing central corneal steepening. Hyperopic orthokeratology lens fitting can induce spherical aberration and correct some level of presbyopia. Postoperative management, and consideration of potential complications, varies according to technique applied and the time to restore corneal stability, but a minimum of 3 months of follow-up is recommended after corneal refractive procedures. Ongoing follow-up is important in orthokeratology and longer-term follow-up may be required in the event of late complications following corneal inlay surgery.

Small-aperture intraocular lens combined with secondary piggyback intraocular lens during cataract surgery after previous radial keratotomy.

A 73-year-old woman with bilateral previous radial keratotomies (RK) and symptomatic cataracts was referred. The uncorrected distance visual acuity (UDVA) was 0.24 logarithm of the minimum angle of resolution (logMAR) in the left eye and 0.32 logMAR in the left eye. The American Society of Cataract and Refractive Surgery calculator for eyes with previous RK was used for intraocular lens (IOL) power calculation. The dominant left eye had uneventful cataract extraction with monofocal IOL implantation. For the nondominant right eye, a small-aperture posterior chamber IOL with the highest available power was used; this was followed by planned secondary piggyback sulcus IOL implantation for the expected residual refractive error. The UDVA after the primary procedure was 0.50 logMAR in the right eye and 0.10 logMAR in the left eye. After the planned secondary procedure, the UDVA was -0.10 logMAR in both eyes with a -0.50 diopter spherical equivalent and the patient did not require spectacles for near, intermediate, or distance vision.

Case-control study of risk factors for acute corneal hydrops in keratoconus.

PURPOSE: To determine risk factors for the development of acute corneal hydrops in keratoconus in the UK in a case-controlled study. METHODS: Between November 2009 and December 2010, we prospectively identified 73 individuals who developed acute corneal hydrops. We then identified 174 controls from nine regions in the UK with keratoconus who had not had hydrops. For cases and controls we recorded demographics and clinical features. Univariate and multivariable logistic regressions were performed to identify risk factors. RESULTS: Univariate analysis suggested strong associations between the odds of hydrops and each of vernal keratoconjunctivitis (OR 4.08, 95% CI 1.45 to 11.49, p=0.008), asthma (OR 2.70, CI 1.34 to 5.47, p=0.006), atopic dermatitis (OR 3.13, CI 1.50 to 6.56, p=0.002), learning difficulties (OR 7.84, CI 2.86 to 21.46, p<0.001), previous hydrops (OR 40.2; CI 6.2 to ∞, p<0.001), black ethnicity (OR 2.98, CI 0.98 to 8.99; p=0.05), visual acuity in the worse eye (OR 8.76 CI 3.86 to 19.88; p<0.001) and minimum keratometry of ≥48 D prior to the hydrops (OR 4.91, CI 1.07 to 22.6, p=0.041). The use of a contact lens correction was also found to be associated with the odds of hydrops (OR 0.08; CI 0.03 to 0.19, p<0.001). Multiple variable regression indicated that having vernal keratoconjunctivitis (adjusted OR (AOR) 15, 95% CI 1.30 to 173.7; p=0.03), asthma (AOR 4.92, CI 1.22 to 19.78; p=0.025), visual acuity in worse eye (AOR 4.11, CI 1.18 to 14.32; p=0.026) and a high keratometry value (AOR 4.44, CI 0.85 to 23.18; p=0.077) were independently associated with the odds of hydrops in subjects with keratoconus. CONCLUSION: Some individuals with keratoconus are at high risk of developing acute corneal hydrops. These patients could be managed more aggressively to reduce their risk of developing this complication of their disease.

Reshaping procedures for the surgical management of corneal ectasia.

UNLABELLED: Corneal ectasia is a progressive, degenerative, and noninflammatory thinning disorder of the cornea. Recently developed corneal reshaping techniques have expanded the treatment armamentarium available to the corneal specialist by offering effective nontransplant options. This review summarizes the current evidence base for corneal collagen crosslinking, topography-guided photorefractive keratectomy, and intrastromal corneal ring segment implantation for the treatment of corneal ectasia by analyzing the data published between the years 2000 and 2014. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Excimer laser refractive surgery versus phakic intraocular lenses for the correction of moderate to high myopia.

BACKGROUND: Myopia is a condition in which the focusing power (refraction) of the eye is greater than that required for clear distance vision. There are two main types of surgical correction for moderate to high myopia; excimer laser and phakic intraocular lenses (IOLs). Excimer laser refractive surgery for myopia works by removing corneal stroma to lessen the refractive power of the cornea and to bring the image of a viewed object into focus onto the retina rather than in front of it. Phakic IOLs for the treatment of myopia work by diverging light rays so that the image of a viewed object is brought into focus onto the retina rather than in front of the retina. They can be placed either in the anterior chamber of the eye in front of the iris or in the posterior chamber of the eye between the iris and the natural lens. OBJECTIVES: To compare excimer laser refractive surgery and phakic IOLs for the correction of moderate to high myopia by evaluating postoperative uncorrected visual acuity, refractive outcome, potential loss of best spectacle corrected visual acuity (BSCVA) and the incidence of adverse outcomes. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 1), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to February 2014), EMBASE (January 1980 to February 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 11 February 2014. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing excimer laser refractive surgery and phakic IOLs for the correction of myopia greater than 6.0 diopters (D) spherical equivalent. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. We performed data analysis. We summarised data for outcomes using odds ratios. We used a fixed-effect model as only three trials were included in the review. MAIN RESULTS: This review included three RCTs with a total of 228 eyes. The range of myopia of included patients was -6.0 D to -20.0 D of myopia with up to 4.0 D of myopic astigmatism. The percentage of eyes with uncorrected visual acuity (UCVA) of 20/20 or better at 12 months postoperative was not significantly different between the two groups. Phakic IOL surgery was safer than excimer laser surgical correction for moderate to high myopia as it results in significantly less loss of best spectacle corrected visual acuity (BSCVA) at 12 months postoperatively. However there is a low risk of developing early cataract with phakic IOLs. Phakic IOL surgery appears to result in better contrast sensitivity than excimer laser correction for moderate to high myopia. Phakic IOL surgery also scored more highly on patient satisfaction/preference questionnaires. AUTHORS' CONCLUSIONS: The results of this review suggest that, at one year post surgery, phakic IOLs are safer than excimer laser surgical correction for moderate to high myopia in the range of -6.0 to -20.0 D and phakic IOLs are preferred by patients. While phakic IOLs might be accepted clinical practice for higher levels of myopia (greater than or equal to 7.0 D of myopic spherical equivalent with or without astigmatism), it may be worth considering phakic IOL treatment over excimer laser correction for more moderate levels of myopia (less than or equal to 7.0 D of myopic spherical equivalent with or without astigmatism). Further RCTs adequately powered for subgroup analysis are necessary to further elucidate the ideal range of myopia for phakic IOLs. This data should be considered alongside comparative data addressing long-term safety as it emerges.

Spontaneous corneal clearance despite graft removal in Descemet stripping endothelial keratoplasty in Fuchs endothelial dystrophy.

PURPOSE: To report spontaneous corneal clearing with improved visual acuity and central endothelial cell repopulation after the removal of a dislocated donor button following Descemet stripping endothelial keratoplasty (DSEK). METHODS: Interventional case report. RESULTS: An 84-year-old woman with decreased visual acuity in the right eye secondary to Fuchs endothelial dystrophy and cataract underwent combined cataract extraction, intraocular lens implantation, and DSEK. After primary graft failure, the resulting detached, opaque, and retracted donor lenticule was removed from the eye 2 months after the initial surgery and not replaced. The cornea started to clear after the donor button removal with central endothelial cell repopulation. CONCLUSIONS: Corneal deturgescence is not strictly dependent on donor lenticule adhesion to the host posterior stromal surface. Endothelial cell migration and repopulation of the central cornea can occur after DSEK and after the removal of the failed endothelial graft, with corneal clearing and improved visual outcomes.

Intravitreal low molecular weight heparin and 5-Fluorouracil for the prevention of proliferative vitreoretinopathy following retinal reattachment surgery.

BACKGROUND: Proliferative vitreoretinopathy (PVR) is a significant cause of failure in retinal reattachment surgery. Various pharmacological agents have shown potential benefit in reducing postoperative PVR risk. OBJECTIVES: This review aimed to compare the use of intravitreal low molecular weight heparin (LMWH) alone or with 5-Fluorouracil (5-FU) versus placebo, as an adjunct in the prevention of PVR following retinal reattachment surgery. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 9), MEDLINE (January 1950 to October 2012), EMBASE (January 1980 to October 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 15 October 2012. SELECTION CRITERIA: We only included randomised controlled trials (RCTs) that compared intravitreal LMWH alone or with 5-FU, versus placebo for the prevention of postoperative PVR in patients undergoing primary vitrectomy for rhegmatogenous retinal detachment repair. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. The review authors contacted study authors for additional information. MAIN RESULTS: We included two RCTs (with a total of 789 participants) comparing LMWH with 5-FU infusion and placebo. However, we did not perform a meta-analysis because of significant heterogeneity between these studies. One study found a significant beneficial effect of LMWH with 5-FU in reducing postoperative PVR compared to placebo (RR: 0.48, 95% confidence interval: 0.25 to 0.92), in 174 patients who were viewed at high-risk of developing postoperative PVR. The other study included 615 unselected cases of rhegmatogenous retinal detachment and could not show a difference between LMWH with 5-FU infusion and placebo in reducing PVR rates (RR:1.45, 95% confidence interval: 0.76 to 2.76). AUTHORS' CONCLUSIONS: Results from this review indicate that there is inconsistent evidence from two studies on patients at different risk of PVR on the effect of LMWH and 5-FU used during vitrectomy to prevent PVR. Future research should be conducted on high risk patients only, until a benefit is confirmed at least in this patient subgroup.

Relationship of Bell phenomenon with Salzmann nodular degeneration.

PURPOSE: To determine the relationship of Bell phenomenon with the presence and the location of Salzmann nodular degeneration. METHODS: This is a noninterventional observational case series study. We reviewed the medical records of 10 patients with Salzmann nodules between 2001 and 2012. The mean age of participants was 60 years with 8 women and 2 men. A complete history and eye examination was performed with regular follow-up visits to document the progression of the disease. The data collected were as follows: age, gender, Snellen visual acuity, manifest refraction, Salzmann nodule location, presence of Bell or inverse Bell phenomenon, treatment, and associated conditions. Slit-lamp pictures to document the location of the Salzmann nodules and the direction of the Bell phenomenon were obtained. RESULTS: Five patients had inferior Salzmann nodules with a normal Bell phenomenon and 5 patients had superior nodules with inverse Bell phenomenon. Nine of 10 patients had moderate to severe meibomian gland disease and dry eye syndrome as associated conditions. Two of the patients underwent removal of the nodules with lamellar keratectomy and 1 with phototherapeutic keratectomy, all with mitomycin-C application and without recurrence of the nodules at 1 year of follow-up. CONCLUSIONS: In all 10 patients the direction of the globe rotation during a normal or inverse Bell phenomenon was directly correlated to the location of the Salzmann nodules. Specifically, patients with inverse Bell phenomenon presented with superior nodule formation, whereas patients with a normal Bell phenomenon presented with inferior nodules.

A survey of ocular sports trauma and the role of eye protection.

PURPOSE: The incidence of sports associated ocular injuries presenting to emergency departments is rising. Despite this, eye protection is not widely used in the general population. This survey was conducted to determine the spectrum of ocular sports injuries that presented to the emergency department of an ophthalmic hospital, which serves a large sector of inner city London. The role of eye protection in preventing ocular sports injuries was also investigated. METHODS: All patients who attended the emergency department with sports associated ocular injuries between May and July 2008 were identified. Medical records of these patients were examined. RESULTS: There were a total of 16999 ophthalmic emergency attendances. 48 (0.28%) patients presented with sports related ocular injuries. The outcomes of the consultations were: 13 (27.1%) patients discharged from the emergency department, 17 (35.4%) had reviews arranged in the emergency department, 18 (37.5%) referred to subspecialties. The mean presenting LogMAR visual acuities of patients that were discharged, reviewed in the emergency department, and referred to subspecialties were 0.01 (±0.33), 0.48 (±0.75), and 0.31 (±0.61) respectively. Visual acuities were better by 0.39 (95% CI 0.01-0.77, p=0.042) in patients who were discharged compared to patients who were reviewed in the emergency department or referred to subspecialties. Evaluation of records revealed that no patients wore eye protection and none were given advice regarding prevention of future injuries. CONCLUSION: Results from this survey show that ocular sports injuries account for a proportion of ophthalmic emergency attendances with a potential impact on service provision. It is essential that ophthalmologists, optometrists and other healthcare professionals are aware of the potential ocular morbidity from sports trauma and the importance of providing advice on the prevention of such injuries.

Photorefractive keratectomy with mitomycin-C for the combined treatment of myopia and subepithelial infiltrates after epidemic keratoconjunctivitis.

PURPOSE: To report the use of photorefractive keratectomy (PRK) with mitomycin-C (MMC) to treat concomitant myopia and visually significant infiltrates associated with epidemic keratoconjunctivitis (EKC). SETTING: Ophthalmic Consultants of Long Island, Nassau University, Long Island, New York, USA. DESIGN: Interventional case series. METHODS: Consecutive patients with myopia and recalcitrant subepithelial infiltrates after EKC were treated with custom wavefront PRK (Visx S4 IR) and MMC with a target of emmetropia in all cases. RESULTS: The study evaluated 6 eyes of 3 patients. One year after treatment, all eyes attained an uncorrected distance visual acuity of 20/20 or better. There was no recurrence of infiltrates within the ablation zone in any eye. CONCLUSION: The use of topical MMC in conjunction with PRK to treat subepithelial infiltrates due to EKC provided good visual and refractive results.

Argon laser iridoplasty to improve visual function following multifocal intraocular lens implantation.

PURPOSE: To describe the use of argon laser iridoplasty following implantation of a multifocal intraocular lens (IOL) to improve visual function. METHODS: Argon laser spots of 500-mW power, 500-µm spot diameter, and 500-ms duration were placed in the midperipheral iris in the area in which the iris was encroaching on the IOL. RESULTS: Argon laser iridoplasty provided statistically significant improvement in visual function including corrected distance visual acuity (CDVA) and subjective quality of vision in 14 eyes from 11 patients. Mean CDVA improved from 0.24 (20/35 Snellen) to 0.10 (20/25 Snellen) logMAR (P<.0001), and mean subjective quality of vision improved from 2.9 to 7.5 (P<.0001). CONCLUSIONS: Argon laser iridoplasty should be considered in correcting visual problems associated with decentered multifocal IOLs.

Excimer laser refractive surgery versus phakic intraocular lenses for the correction of moderate to high myopia.

BACKGROUND: Myopia is a condition in which the focusing power (refraction) of the eye is greater than that required for clear distance vision. There are two main types of surgical correction for moderate to high myopia; excimer laser and phakic intraocular lenses (IOLs). Excimer laser refractive surgery for myopia works by removing corneal stroma to lessen the refractive power of the cornea and to bring the image of a viewed object into focus onto the retina rather than in front of it. Phakic IOLs for the treatment of myopia work by diverging light rays so that the image of a viewed object is brought into focus onto the retina rather than in front of the retina. They can be placed either in the anterior chamber of the eye in front of the iris or in the posterior chamber of the eye between the iris and the natural lens. OBJECTIVES: The aim of this review is to compare the effect of excimer laser refractive surgery versus phakic IOLs for the correction of moderate to high myopia. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 11), MEDLINE (January 1950 to November 2011), EMBASE (January 1980 to November 2011), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to November 2011), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 28 November 2011. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing excimer laser refractive surgery and phakic IOLs for the correction of myopia greater than 6.0 diopters (D) spherical equivalent. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. We performed data analysis. We summarised data for outcomes using odds ratios. We used a fixed-effect model as only three trials were included in the review. MAIN RESULTS: This review included three RCTs with a total of 228 eyes. The range of myopia of included patients was -6.0 D to -20.0 D of myopia with up to 4.0 D of myopic astigmatism. The percentage of eyes with uncorrected visual acuity (UCVA) of 20/20 or better at 12 months postoperative was not significantly different between the two groups. Phakic IOL surgery was safer than excimer laser surgical correction for moderate to high myopia as it results in significantly less loss of best spectacle corrected visual acuity (BSCVA) at 12 months postoperatively. However there is a low risk of developing early cataract with phakic IOLs. Phakic IOL surgery appears to result in better contrast sensitivity than excimer laser correction for moderate to high myopia. Phakic IOL surgery also scored more highly on patient satisfaction/preference questionnaires. AUTHORS' CONCLUSIONS: The results of this review suggest that phakic IOLs are safer than excimer laser surgical correction for moderate to high myopia in the range of -6.0 to -20.0 D and phakic IOLs are preferred by patients. While phakic IOLs might be accepted clinical practice for higher levels of myopia (greater than or equal to 7.0 D of myopic spherical equivalent with or without astigmatism), it may be worth considering phakic IOL treatment over excimer laser correction for more moderate levels of myopia (less than or equal to 7.0 D of myopic spherical equivalent with or without astigmatism). Further RCTs adequately powered for subgroup analysis are necessary to further elucidate the ideal range of myopia for phakic IOLs.

Meta-analysis of randomized controlled trials comparing excimer laser and phakic intraocular lenses for myopia between 6.0 and 20.0 diopters.

PURPOSE: Meta-analysis of randomized controlled trials (RCTs) comparing excimer laser refractive surgery and phakic intraocular lenses (pIOLs) for the correction of myopia between 6.0 and 20.0 diopters (D). pIOLs are an alternative surgical option to excimer laser for these patients. The evidence base comparing these 2 methods has never been assessed systematically. METHODS: Cochrane Eyes and Vision Group, International. We performed a comprehensive literature search using the Cochrane Collaboration methodology to identify RCTs. A meta-analysis on the results of RCTs was performed. We analyzed data for efficacy outcomes, accuracy outcomes, safety outcomes, adverse effects, and quality-of-life measures. RESULTS: This review included 3 RCTs with a total of 228 eyes. The range of myopia was 6.0 to 20.0 D with up to 4.0 D of astigmatism. The pIOL group was less likely to lose 2 or more lines of best spectacle-corrected visual acuity at 12 months (odds ratio, 0.35; 95% confidence interval, 0.19-0.66, P = 0.001). PIOL surgery scored more highly on patient satisfaction/preference questionnaires. CONCLUSIONS: The results of this systematic review show that pIOLs are safer within 1 year of follow-up compared with excimer laser surgical correction for myopia between 6 and 20 D. There is weaker evidence for superior visual quality in pIOL recipients. Further RCTs adequately powered for subgroup analysis with long-term follow-up are necessary to establish the ideal myopic range for excimer laser and pIOL treatments.

Optic disc assessment in the emergency department: a comparative study between the PanOptic and direct ophthalmoscopes.

Optic disc assessment is an essential part of the neurological examination of acutely unwell patients. This study compares the PanOptic ophthalmoscope with the direct ophthalmoscope for accuracy of diagnosis and ease of use. Patient satisfaction was also compared for the two instruments. A single-masked prospective observational study was carried out. The authors showed that the PanOptic ophthalmoscope was more sensitive (p=0.03) and specific (p=0.03) than the direct ophthalmoscope. The PanOptic ophthalmoscope was preferred by both doctors (p=0.001) and patients (p=0.04) in terms of comfort and ease of use.

The effect of decreasing the dosage of cyclosporine A 0.05% on dry eye disease after 1 year of twice-daily therapy.

PURPOSE: To evaluate the effect of decreasing topical cyclosporine 0.05% (tCSA) (Restasis; Allergan, Irvine, CA) from twice-daily dosing to once-daily dosing in patients who have already completed 12 months of twice-daily therapy for dry eye disease. DESIGN: Prospective, randomized, single-masked, parallel group comparison. PARTICIPANTS: One hundred patients who had already been treated with tCSA twice daily for more than 1 year were randomized either to continue tCSA twice daily (n = 50) or to decrease tCSA once daily (n = 50). METHODS: Clinical measurement of dry eye variables was performed for all patients at baseline, 3 months, and 6 months. Mean data were used for within-group (longitudinal analysis) and between-group comparisons (once daily vs. twice daily). MAIN OUTCOME MEASURES: Fluorescein tear break-up time, corneal fluorescein staining score, lissamine green staining score, Schirmer tear test, and ocular surface disease index. RESULTS: At the end of the study, patients whose treatment dose was decreased to once daily demonstrated statistically significant improvement in tear break-up time [4.13 seconds (n = 37) vs. 3.11 seconds at baseline (n = 50); P = 0.0003] and lissamine green staining score [4.42 (n = 37) vs. 6.51 at baseline (n = 50); P = 0.024]; fluorescein staining score, Schirmer test results, and ocular surface disease index did not change significantly (P > 0.05). Furthermore, the once-daily group demonstrated significantly superior ocular surface disease index compared with the twice daily group [15.91 (n = 37) vs. 22.62 (n = 48); P = 0.0496]. The remaining outcome measures between once daily and twice daily were not significantly different (P > 0.05). Seven of 50 patients (14%) in the once-daily group (vs. 0% in the twice-daily group) ended the study early because of worsening dry eye symptoms (P < 0.05) and went back to twice-daily dosing. CONCLUSIONS: For patients with dry eye that has been controlled with tCSA twice daily for at least 1 year, decreasing to tCSA once daily may still allow suppression of the dry eye disease.