Anti-inflammatory medication use after cataract surgery: online survey of practice patterns.

PURPOSE: To determine current prescribing patterns for topical or intraocular/periocular anti-inflammatory medications (AIMs) after routine cataract surgery. SETTING: kera-net online members. DESIGN: Cross-sectional survey. METHODS: An online survey was distributed to subscribers of kera-net, a global online platform sponsored by the Cornea Society. Questions were asked regarding the use of topical or intraocular/periocular AIM after cataract surgery and types of medications prescribed. RESULTS: Of 217 surgeon respondents (23% response rate), 171 (79%) practiced in the United States and 171 (79%) were cornea subspecialists. Most of the respondents (n = 196, 97%) prescribed topical corticosteroids after routine cataract surgery. The most frequently prescribed were prednisolone acetate (n = 162, 83%), followed by dexamethasone (n = 26, 13%), difluprednate (n = 24, 12%), and loteprednol etabonate (n = 13, 7%). Corticosteroids comprised (n = 40, 32%) of total intraocular/periocular injections, with triamcinolone acetonide 10 or 40 mg (n = 19, 47.5%) most commonly used. 23 surgeons (58%) who utilized intraocular/periocular corticosteroids also prescribed topical corticosteroids. Topical nonsteroidal anti-inflammatory drugs were prescribed postoperatively by 148 surgeons (73%). CONCLUSIONS: Most surgeons prescribed topical AIM after routine cataract surgery. Many surgeons injected intraocular or periocular AIM while prescribing topical AIM. The diversity of practice patterns may reflect the lack of clear evidence-based guidelines.

NSAIDs and Corticosteroids for the Postoperative Management of Age-Related Cataract Surgery: A Systematic Review and Meta-analysis.

PURPOSE: To evaluate the safety and efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids in the postoperative management of cataract surgery for age-related cataract in adults. DESIGN: Meta-analysis. METHODS: Cochrane, Embase, PubMed, Scopus, Web of Science and CINAHL were searched for articles using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42022364733). Randomized controlled trials of patients undergoing age-related cataract surgery treated with corticosteroids, NSAIDs, or a combination were included. RESULTS: A total of 19 studies were included, with 3473 patients (3638 eyes) treated following cataract surgery with NSAIDs (n = 1479), corticosteroids (n = 1307), or a combination (n = 687). Combination treatment demonstrated favorable best-corrected visual acuity compared to corticosteroids 4 to 6 weeks postoperatively (MD = -0.01 logMAR, 95% CI: -0.02, -0.01, I2 = 0%). NSAIDs had more favorable flare values than corticosteroids on day 7 (MD = -9.17 photons/ms, 95% CI = -16.52, -1.82, I2 = 94%), day 14 (MD = -5.23 photons/ms, 95% CI = -8.35, -2.11, I2 = 94%), and 4 to 6 weeks (MD = -1.62 photons/ms, 95% CI = -3.03, -0.20, I2 = 93%) postoperatively. Furthermore, 4 to 8 weeks postoperatively, patients treated with NSAIDs showed lower central macular thickness (MD = -13.26 µm, 95% CI = -18.66, -7.86, I2 = 81%) compared to those treated with corticosteroids. NSAIDs and combination treatment were associated with a lower incidence of central macular edema (OR = 0.16, 95% CI = 0.07, 0.35, I2 = 61%; OR = 0.21, 95% CI = 0.10, 0.45, I2 = 31%) than corticosteroids 4 to 8 weeks postoperatively. CONCLUSIONS: NSAIDs and combination treatments could be regarded as more effective and safer alternatives to corticosteroids alone in the postoperative management of cataract surgery. Further studies should be conducted to determine why this evidence has not been reflected in practice patterns, and to further compare the effectiveness of NSAIDs and combination treatments.

Factors Predictive of Refractive Error After Toric Lens Implantation.

Purpose: To identify factors related to suboptimal refractive outcomes after toric intraocular lens implantation. Patients and Methods: A retrospective case-control chart review of 446 eyes with toric lens insertion by the same surgeon at a university hospital from 2016 to 2020 was conducted. Pre-operative exam findings, biometry, and one month and three month post-operative vision and refraction were noted. Reviewed charts were considered cases if uncorrected distance visual acuity (UDVA) was worse than 20/40, spherical equivalent (SE) >1 diopter (D) off target, or cylinder >1 D off target. Results: Overall, 93.7% (n = 343) of eyes achieved UDVA of 20/40 or better, 92.7% (n = 306) were within 1 D of target SE, and 90.9% (n = 300) were within 1 D of target cylinder. UDVA cases had more eyes with prior LASIK (21.7% vs 7.0%, p = 0.01) and keratoconus (8.7% vs 0.6%, p < 0.001) than controls. More SE cases had prior radial keratotomy (RK) (8.3% vs 0%, p < 0.001) and keratoconus (12.5% vs 0%, p < 0.001) than controls. More cylinder cases had prior LASIK (30.0% vs 8.7%, p < 0.001) and higher mean astigmatism (2.3 vs 1.5 D, p = 0.02) than controls. More cases in all three analyses had higher toric cylinder power (T5-T9) than controls. Age, sex, eye laterality, axial length, anterior chamber depth, lens power, dry eye, anterior basement membrane dystrophy, and Fuchs' endothelial dystrophy differences were not significant. Conclusion: Prior LASIK or RK, keratoconus, and higher astigmatism may increase the chance of a suboptimal outcome.

Comparison of simultaneous vs sequential pars plana vitrectomy and cataract surgery.

BACKGROUND: To compare the clinical outcomes of patients undergoing sequential pars plana vitrectomy (PPV) followed by cataract extraction surgery (CE) [PPV/CE], simultaneous PPV and CE (PPV + CE), and sequential CE followed by PPV [CE/PPV]. METHODS: A retrospective observational cohort study of 427 eyes of 404 patients who underwent either sequential or simultaneous PPV and CE surgery between March 2016 and May 2021. Pre-operative and post-operative assessments (up to 2 years of follow-up visits) of uncorrected visual acuity (UCVA), corrected distance visual acuity (CDVA), spherical equivalent (SEQ), and refractive prediction error (RPE) was done. Main outcome measures were both visual (UCVA, CDVA) and refractive (RPE, SEQ). RESULTS: There was a statistically significant difference in CDVA of the PPV/CE, PPV + CE, CE/PPV groups (logMAR 0.34 ± 0.40, 0.65 ± 0.61, and 0.55 ± 0.60, respectively) at one month postoperatively (POM1) (P < 0.001), and at the POM12 visits (logMAR 0.25 ± 0.34, 0.53 ± 0.68, and 0.44 ± 0.48; P = 0.04). In the subgroup analysis of patients with a diagnosis of either epiretinal membrane or vitreous opacities, there was no statistically significant difference in SEQ (P = 0.09) and RPE (P = 0.13) at the combined 1 month and 3 month visits. CONCLUSION: Simultaneous PPV and cataract surgery demonstrated similar improvements in visual acuity and refractive outcomes, as well as comparable intraoperative and postoperative complication profiles to sequential surgery.

Outcomes of Secondary Intraocular Lens Implantation and Descemet Stripping Endothelial Keratoplasty-Comparing Staged Versus Combined Surgical Approach.

PURPOSE: The aim of this study was to compare the outcomes of staged versus combined surgical approach for secondary intraocular lens (IOL) implantation and Descemet stripping endothelial keratoplasty (DSEK). METHODS: This is a retrospective review of 124 eyes from 124 patients who underwent either staged or combined secondary IOL implantation in addition to DSEK over a 5-year period at 2 academic tertiary referral centers, between January 1, 2014, and October 1, 2019. Corrected distance visual acuity (CDVA), presence of graft detachment, primary graft failure (PGF), and cystoid macular edema were documented and analyzed. RESULTS: The CDVA for the 1- to 2- month follow-up period was significantly better in the staged group compared with the combined group ( P = 0.011). By the postoperative 6- to 9-month follow-up period, there was no significant difference in the CDVA between the groups ( P = 0.591). There was no significant difference in the incidence of PGF or graft detachment between the 2 groups ( P > 0.05). In addition, there was no significant difference in the CDVA or rate of postoperative complications between the different methods of IOL fixation. CONCLUSIONS: The short-term visual outcomes were significantly better in eyes that underwent staged secondary IOL implantation and DSEK versus the combined surgical approach, although the difference was no longer present at 6 to 9 months. There was no difference in the rate of PGF or graft detachment between the 2 groups.

Treatment of recalcitrant Acanthamoeba Keratitis with Photoactivated Chromophore for Infectious Keratitis Corneal Collagen Cross-Linking (PACK-CXL).

PURPOSE: To describe a case of recalcitrant Acanthamoeba Keratitis (AK) complicated by medical non-compliance and medication intolerance that was successfully treated with photoactivated chromophore for infectious keratitis corneal collagen cross-linking (PACK-CXL). OBSERVATIONS: A 31-year-old male presented with right eye pain and redness in the setting of fresh water exposure and scleral contact lens wear. He had lack of a response to treatment with antiviral therapy for 3 months by an outside provider. Cultures were found to be positive for Acanthamoeba and the patient was treated with an extended course of various anti-amoebic therapies with poor compliance due to pain and toxicity. He was eventually treated with intrastromal voriconazole and Miltefosine without improvement and eventually had PACK-CXL with resolution of his infection and pain. CONCLUSION: PACK-CXL was associated with a dramatic improvement in a case of recalcitrant Acanthamoeba keratitis unresponsive to both traditional and novel therapies and may be a viable alternative or adjunctive therapy for Acanthamoeba keratitis.

Aqueous proteins help predict the response of patients with neovascular age-related macular degeneration to anti-VEGF therapy.

BackgroundTo reduce the treatment burden for patients with neovascular age-related macular degeneration (nvAMD), emerging therapies targeting vascular endothelial growth factor (VEGF) are being designed to extend the interval between treatments, thereby minimizing the number of intraocular injections. However, which patients will benefit from longer-acting agents is not clear.MethodsEyes with nvAMD (n = 122) underwent 3 consecutive monthly injections with currently available anti-VEGF therapies, followed by a treat-and-extend protocol. Patients who remained quiescent 12 weeks from their prior treatment entered a treatment pause and were switched to pro re nata (PRN) treatment (based on vision, clinical exam, and/or imaging studies). Proteomic analysis was performed on aqueous fluid to identify proteins that correlate with patients' response to treatment.ResultsAt the end of 1 year, 38 of 122 eyes (31%) entered a treatment pause (≥30 weeks). Conversely, 21 of 122 eyes (17%) failed extension and required monthly treatment at the end of year 1. Proteomic analysis of aqueous fluid identified proteins that correlated with patients' response to treatment, including proteins previously implicated in AMD pathogenesis. Interestingly, apolipoprotein-B100 (ApoB100), a principal component of drusen implicated in the progression of nonneovascular AMD, was increased in treated patients who required less frequent injections. ApoB100 expression was higher in AMD eyes compared with controls but was lower in eyes that develop choroidal neovascularization (CNV), consistent with a protective role. Accordingly, mice overexpressing ApoB100 were partially protected from laser-induced CNV.FundingThis work was supported by the National Eye Institute, National Institutes of Health grants R01EY029750, R01EY025705, and R01 EY27961; the Research to Prevent Blindness, Inc.; the Alcon Research Institute; and Johns Hopkins University through the Robert Bond Welch and Branna and Irving Sisenwein professorships in ophthalmology.ConclusionAqueous biomarkers could help identify patients with nvAMD who may not require or benefit from long-term treatment with anti-VEGF therapy.

Breastfeeding and Maternal Age-Related Cataract in the U.S. Population.

PURPOSE: An estimated 38 million and 50 million individuals will have cataract in the U.S. alone by 2030 and 2050, respectively. Breastfeeding is known to improve a number of health outcomes in both breastfed children and breastfeeding mothers. However, little is known about the relationship between breastfeeding and cataract, the leading cause of blindness worldwide, in breastfeeding mothers. This study was conducted to investigate the relationship between breastfeeding and maternal cataract extraction history in a nationally representative sample of the U.S. population. METHODS: A 10-year multistage, probability-sampling survey data was used to identify parous women aged ≥50 years who provided breastfeeding history and cataract extraction history (n = 4897). Breastfeeding history was considered positive if a participant reported breastfeeding at least one child for ≥1 month. The main outcome was cataract extraction history. Estimates are presented in odds ratios (OR) and 95% confidence intervals (95%CI). RESULTS: Approximately half of the studied women breastfed at least one child ≥1 month, and about 18% reported cataract extraction history. Participants with a positive breastfeeding history were less likely to have a positive cataract extraction history in both age-adjusted (OR = 0.814, 95%CI = 0.670-0.989) and multivariable logistic regression (OR = 0.794, 95%CI = 0.639-0.988). Higher number of breastfed children was also associated with a lower risk of cataract extraction history (OR = 0.934, 95%CI = 0.883-0.988). CONCLUSIONS: The findings suggest that breastfeeding may be associated with a decrease in the likelihood of age-related cataract extraction in parous women from the U.S. population.

Is Dietary Milk Intake Associated with Cataract Extraction History in Older Adults? An Analysis from the US Population.

BACKGROUND: Galactose accumulation in the lens tissue is known to be cataractogenic. Whether consistent dietary intake of lactose-which consists of glucose and galactose-predisposes to senile cataract remains unclear. This study was conducted to investigate the association between a number of dietary milk intake indicators and cataract extraction history in a representative sample of older adults from the US population. Methods and Materials. This is a cross-sectional, population-based study. Participants of the United States National Health and Nutrition Examination Survey 2001-2008 who were ≥50 years old and provided a complete history of their usual daily dietary intake were included. Exclusion criteria were special diets, extreme daily energy intake, and missing outcome (i.e., cataract extraction history). Indicators of milk intake used were early-life intake regularity, current daily milk/total dairy intake amounts, and estimated lifelong milk exposure. Odds ratios (OR) and 99% confidence intervals (99% CI) were calculated with fitting weights to better represent the population-based estimates. RESULTS: Among the 5930 studied participants, early-life milk intake regularity was not associated with cataract extraction history in age/sex/ethnicity-adjusted and multivariable-adjusted models (p trend = 0.064 and 0.094, respectively). Current daily milk intake was associated with a slight reduction in the likelihood of cataract extraction in the age/sex/ethnicity-adjusted model (OR = 0.885 per cup equivalents, 99% CI = 0.795-0.986) and in the multivariable model (OR = 0.871 per cup equivalents, 99% CI = 0.746-0.993). However, no such association was observed between quartiles of current dietary milk intake and cataract extraction history (p trend = 0.064 and 0.094, respectively). Current daily milk intake was associated with a slight reduction in the likelihood of cataract extraction in the age/sex/ethnicity-adjusted model (OR = 0.885 per cup equivalents, 99% CI = 0.795-0.986) and in the multivariable model (OR = 0.871 per cup equivalents, 99% CI = 0.746-0.993). However, no such association was observed between quartiles of current dietary milk intake and cataract extraction history (p trend = 0.064 and 0.094, respectively). Current daily milk intake was associated with a slight reduction in the likelihood of cataract extraction in the age/sex/ethnicity-adjusted model (OR = 0.885 per cup equivalents, 99% CI = 0.795-0.986) and in the multivariable model (OR = 0.871 per cup equivalents, 99% CI = 0.746-0.993). However, no such association was observed between quartiles of current dietary milk intake and cataract extraction history (. CONCLUSION: There appears to be no direct relationship between several indicators of dietary milk consumption and cataract extraction history in the general American population.

Visual and refractive outcomes and complications in femtosecond laser-assisted versus conventional phacoemulsification cataract surgery: findings from a randomised, controlled clinical trial.

BACKGROUND/AIM: To compare visual and refractive outcomes, changes in intraocular pressure (IOP), and complications of femtosecond laser-assisted cataract surgery (FLACS) to conventional phacoemulsification surgery (CPS) in paired eyes from the same patients. METHODS: This is a secondary analysis of an intraindividual, randomised, controlled clinical trial including 110 paired eyes from 55 patients that were randomised into either FLACS or CPS groups. Outcomes were recorded at baseline and postoperatively during a 3-month follow-up period. RESULTS: Uncorrected distance visual acuity and corrected distance visual acuity were similar between FLACS and CPS over the follow-up period (p>0.05). The mean absolute refractive error was not significantly different between the two groups at postoperative month 1 (POM1) (0.3±0.2 D in FLACS vs 0.4±0.3 D in CPS, p=0.18) and month 3 (POM3) (0.3±0.3 D in FLACS vs 0.3±0.3 D in CPS, p=0.71). IOP was statistically higher in the FLACS group on postoperative day 1 (20.6±5.7 mm Hg for FLACS and 18.0±4.9 mm Hg for CPS, p=0.01). However, it was similar between the two groups subsequently (p>0.05). Intraoperatively, one case of posterior capsular block syndrome was observed in the FLACS group. Postoperatively, one case of newly developed glaucoma was observed in the FLACS group and one case of retinal tears in the CPS group. CONCLUSION: The 3-month postoperative refractive and visual outcomes were comparable between FLACS and CPS in paired eyes from the same patients. Complication rate was low in the study population.

Outcomes and complications of iris-fixated intraocular lenses in cases with inadequate capsular support and complex ophthalmic history.

BACKGROUND: To report the indications, visual outcomes, and intra-operative and post-operative complications of iris-sutured posterior chamber intraocular lens (IOL) in eyes with inadequate capsular support and complex ocular history. METHODS: A chart review and data analysis of eyes that underwent iris fixation of posterior chamber (PC) IOL for correction of aphakia, dislocated and subluxed IOLs, ectopia lentis, and IOL exchange. Data included clinical risk factors, associated eye conditions, previous surgeries, and concomitant procedures. The pre-operative and post-operative vision, manifest refraction, endothelial cell density, intraocular pressure (IOP), as well as intra-operative and post-operative complications were also recorded. RESULTS: One hundred and seventeen eyes from 114 patients were examined with a mean follow-up of 22.4 months. The most common identifiable predisposing risk factor was high myopia in 23 eyes. A significant improvement in uncorrected and best corrected visual acuity compared with baseline was observed. The most common post-operative complications included recurrent IOL subluxation in 16 (13.7%) eyes, IOP spike in 7 (5.9%) eyes, cystoid macular oedema in 5 (4.3%) eyes, and epiretinal membrane formation in 4 (3.4%) eyes. There was one (0.85%) case of sterile endophthalmitis. CONCLUSIONS: Iris suture fixation of PC IOLs is a good treatment option for eyes with inadequate capsular support and complex ocular history.

Corneoscleral xanthogranuloma treated with chemotherapy: The room for nonsurgical management.

PURPOSE: To describe a clinical case of corneoscleral xanthogranuloma, a rare manifestation of juvenile xanthogranuloma, and xanthoma disseminatum, which responded well to chemotherapy. METHODS: Interventional case report and literature search. RESULTS: A 9-year-old female patient with a disseminated disease showed complete regression of her corneoscleral xanthogranuloma with methotrexate and azathioprine therapy. CONCLUSION: Since they are potentially blinding, corneoscleral xanthogranulomas are commonly surgically excised. While surgical resection has been widely advocated in the literature, immunosuppressive therapy alone may be a pertinent management line of corneoscleral xanthogranuloma, especially with systemic involvement.

Comparison of changes in corneal endothelial cell density and central corneal thickness between conventional and femtosecond laser-assisted cataract surgery: a randomised, controlled clinical trial.

BACKGROUND/AIM: To identify changes in endothelial cell density (ECD) and central corneal thickness (CCT) in eyes undergoing femtosecond laser-assisted cataract surgery (FLACS) compared with conventional phacoemulsification surgery (CPS). METHODS: This is an intraindividual randomised, controlled clinical trial. One eye was randomised to receive FLACS, while the contralateral eye of the same patient received CPS. The femtosecond laser pretreatment included creating main and side-port corneal incisions, capsulotomy and lens fragmentation. Non-contact endothelial cell microscopy and pachymetry were performed preoperatively and at postoperative day 1, week 1, month 1 and month 3. RESULTS: A total of 134 paired eyes from 67 patients were included in the analysis. ECD was not significantly different between the two groups at either postoperative month 1 (2370±580 cells/mm2 and 2467±564 cells/mm2 in FLACS and CPS groups, respectively; p=0.18) or at postoperative month 3 (2374±527 cells/mm2 and 2433±526 cells/mm2 in FLACS and CPS groups, respectively; p=0.19). No significant difference was observed in the mean CCT values between the two groups over the follow-up period (p>0.05). CONCLUSION: Postoperative corneal ECD and CCT were comparable between FLACS and CPS during the 3 months' follow-up period.

Refractive and Visual Outcomes and Rotational Stability of Toric Intraocular Lenses in Eyes With and Without Previous Ocular Surgeries: A Longitudinal Study.

PURPOSE: To evaluate visual and refractive outcomes and rotational stability of toric intraocular lens (IOL) implantation in eyes with previous ocular surgeries. METHODS: This controlled, longitudinal cohort study included a total of 133 eyes (59 study cases with a history of corneal, vitreoretinal, and/or glaucoma surgery and 74 randomly selected controls without a history of ocular surgery) that had cataract and corneal astigmatism treated with toric IOL implantation. Postoperative outcomes were recorded at postoperative 1 month and 3 to 12 months. RESULTS: Refractive prediction errors were within ±1.00 diopter (D) of target in 93.5% and 88.4% of the study cases at postoperative 1 month and 3 to 12 months, respectively. They were within ±0.50 D of target in 56.5% and 60.5% of the cases during the same follow-up intervals, respectively. Study cases showed statistically significantly inferior uncorrected distance visual acuity (UDVA) compared to controls at 1 month postoperatively (0.27 ± 0.24 and 0.17 ± 0.21 logMAR, respectively, P = .027) but not during the later follow-up (0.19 ± 0.19 and 0.16 ± 0.19 logMAR, respectively, P = .431). Corrected distance visual acuity (CDVA) was slightly lower in the study cases than in controls at 1 month postoperatively (0.13 ± 0.16 and 0.07 ± 0.14, respectively, P = .005) and subsequent follow-up months (0.10 ± 0.13 and 0.03 ± 0.10, respectively, P < .001). Of the examined study cases, 93.9% and 88.4% had IOL axes within 5° of intended axis at postoperative 1 month and 3 to 12 months, respectively. CONCLUSIONS: Toric IOLs provided significant and sustained improvement in visual acuity and refraction in eyes with a history of prior ophthalmic surgery. Refractive outcomes achieved postoperatively were comparable to those in eyes without a prior history of ophthalmic surgery, although the rate of visual recovery may be different. [J Refract Surg. 2019;35(12):781-788.].

Small Molecule Modulation of the Integrated Stress Response Governs the Keratoconic Phenotype In Vitro.

Purpose: The degenerative corneal disease keratoconus is a leading indicator for corneal transplant with an unknown etiology. We recently identified the activation of the integrated stress response (ISR) in ex vivo human corneas and in vitro cell culture. Utilizing small molecules to modulate the ISR we sought to investigate the effects of stimulating the ISR in healthy cells to recapitulate aspects of the in vitro keratoconic phenotype and whether relieving the ISR signaling would recover the disease phenotype. Methods: Corneal fibroblasts were extracted from patients undergoing corneal transplant or unaffected cadaverous donor limbal rings. Cells were exposed to the DNA damage-inducible protein (GADD34) inhibitor SAL003 to stimulate the ISR, or Trans-ISRIB to relieve ISR signaling pathway. Collagen production was assessed through hydroxyproline production, Sirius Red incorporation, or quantitative (q)PCR. Western blotting, hydroxyproline, and qPCR were used to assess components of the ISR pathway and collagen production. Results: ISR stimulation through SAL003 resulted in significant decrease of hydroxyproline and COL1A1 transcription and eventual apoptosis in normal fibroblasts. Patient (KC) fibroblast production of hydroxyproline was increased in response to ISRIB, while matrix metalloproteinase (MMP)9 production was lowered. The prospective biomarker of keratoconus prolactin-inducible factor was also upregulated in KC fibroblast cultures in response to ISRIB. Inflammatory markers TNFα and IL-1ß were unaffected. Conclusions: Activation of the ISR is sufficient to recapitulate many key aspects of the KC phenotype in unaffected cells in vitro. Inhibition of the ISR also relieves many of the hallmarks of KC in affected cells. Therefore, targeting of the ISR through small molecules is a potential therapeutic path for small molecule treatment of keratoconus.

Femtosecond laser-assisted cataract surgery in patients with zonular weakness.

PURPOSE: To present the clinical value of femtosecond laser assisted cataract surgery (FLACS) in eyes with compromised zonules. OBSERVATIONS: We present two cases of femtosecond laser assisted cataract surgery (FLACS) in eyes with compromised zonules. Three eyes from two patients with zonular weakness and cataract underwent FLACS (Alcon LenSx Lasers Inc., Aliso Viejo, CA). One patient underwent bilateral FLACS in the setting of spherophakia with zonular weakness. The other patient had Marfan's syndrome with associated ectopia lentis. Laser assisted capsulotomy was achieved in all eyes. One eye had vitreous prolapse during surgery and required an iris-sutured lens. All eyes had a postoperative corrected distance visual acuity of 20/25 or better. CONCLUSIONS AND IMPORTANCE: FLACS is a safe and effective alternative to conventional phacoemulsification cataract surgery in patients with zonular weakness.

Donor, Recipient, and Operative Factors Associated With Increased Endothelial Cell Loss in the Cornea Preservation Time Study.

Importance: Determining factors associated with endothelial cell loss after Descemet stripping automated endothelial keratoplasty (DSAEK) could improve long-term graft survival. Objective: To evaluate the associations of donor, recipient, and operative factors with endothelial cell density (ECD) 3 years after DSAEK in the Cornea Preservation Time Study. Design, Setting, and Participants: This cohort study was a secondary analysis of data collected in a multicenter, double-masked, randomized clinical trial. Forty US clinical sites with 70 surgeons participated, with donor corneas provided by 23 US eye banks. Individuals undergoing DSAEK for Fuchs dystrophy or pseudophakic/aphakic corneal edema were included. Interventions: The DSAEK procedure, with random assignment of a donor cornea with a preservation time of 0 to 7 days or 8 to 14 days. Main Outcomes and Measures: Endothelial cell density at 3 years as determined by a reading center from eye bank and clinical specular or confocal central endothelial images. Results: The study included 1090 participants (median age, 70 years) with 1330 affected eyes (240 bilateral cases [22.0%]), who underwent DSAEK for Fuchs dystrophy (1255 eyes [94.4%]) or pseudophakic/aphakic corneal edema (PACE) (75 eyes [5.6%]). Of these, 801 eyes (60.2%) belonged to women and 1207 (90.8%) to white individuals. A total of 749 participants (913 eyes; 164 [21.9%] bilateral cases) had functioning grafts with acceptable endothelial images preoperatively and at 3 years postoperatively and were included in this analysis. Factors associated with a lower ECD at 3 years (estimated effect with 99% CI) in the final multivariable model included donors with diabetes (-103 [-196 to -9] cells/mm2), lower screening ECD (-234 [-331 to -137] per 500 cells/mm2), recipient diagnosis of PACE (-257 [-483 to -31] in cells/mm2), and operative complications (-324 [-516 to -133] in cells/mm2). Endothelial cell loss (ECL) from a preoperative measurement to a 3-year postoperative measurement was 47% (99% CI, 42%-52%) for participants receiving tissue from donors with diabetes vs 43% (99% CI, 39%-48%) without diabetes; it was 53% (99% CI, 44%-62%) for participants diagnosed with PACE vs 44% (99% CI, 39%-49%) for those diagnosed with Fuchs dystrophy, and 55% (99% CI, 48%-63%) in participants who experienced operative complications vs 44% (99% CI, 39%-48%) in those who did not. No other donor, recipient, or operative factors were significantly associated with 3-year ECD. Conclusions and Relevance: Donor diabetes, lower screening ECD, a PACE diagnosis in the recipient, and operative complications were associated with lower ECD at 3 years after DSAEK surgery and may be associated with long-term graft success. While causation cannot be inferred, further studies on the association of donor diabetes and PACE in recipients with lower 3-year ECD warrant further study.

Factors Associated With Graft Rejection in the Cornea Preservation Time Study.

PURPOSE: To identify factors related to graft rejection following Descemet stripping automated endothelial keratoplasty (DSAEK) in the Cornea Preservation Time Study (CPTS). DESIGN: Cohort study within a multicenter randomized clinical trial. METHODS: A total of 1330 eyes of 1090 subjects undergoing DSAEK were randomized to receive a donor cornea with preservation time (PT) of 0-7 days (n = 675) or 8-14 days (n = 655) and followed for 3 years. Central endothelial cell density (ECD) was determined by a central image analysis reading center. Multivariable Cox models adjusted for PT, recipient diagnosis, and surgeon effect were used to identify factors associated with rejection. RESULTS: Cumulative probability of definite graft rejection was 3.6% (99% confidence interval 2.5%-5.3%). Younger recipient age was associated with graft rejection (P < .001; hazard ratio: 0.53 [0.33, 0.83] per decade). PT, donor-recipient sex mismatch, recipient diagnosis, recipient race, graft size, discontinuation of topical corticosteroids and immune-modulators, prior immunizations within 3 months, and prior glaucoma surgery were not associated with rejection (P > .01). Among clear grafts with an ECD measurement at baseline and 3 years (n = 913), endothelial cell loss (ECL) was greater in eyes that experienced a rejection episode (n = 27) than in those that did not (n = 886) (48% vs 38%, P = .03). Twelve of 44 eyes (27%) with definite graft rejection subsequently failed, comprising 15% of the 79 failures in the CPTS. CONCLUSIONS: Graft rejection is uncommon after DSAEK and more likely with younger age, in a study cohort mostly > 50 years old. Rejection increases ECL, but it is not a leading cause of DSAEK failure.