The relationship between dry eye disease and human microbiota: A review of the science.

A complex relationship exists between human microbiota and the risk for ophthalmic disease. While the homeostatic composition of human microbiota is still being established, including what defines dysbiosis (i.e. changes in diversity and abundance), pilot research has begun to identify the potential influence of demographics, geography, and co-morbidities on the microbiota and describe their impact on ocular health. This review specifically focuses on the scientific relationships of the human oral and gut microbiota to dry eye disease (DED), a set of conditions impacting the tear film and ocular surface. Although data are sparse and often conflict across studies, the literature generally supports associations between microbial imbalance (dysbiosis) and DED and alterations in microbial diversity and abundance to specific aspects of DED. This review examines the relevant science and mechanistic relationships linking gut and oral dysbiosis and DED. Various physiochemical factors and therapeutic approaches that alter microbiota, including medications and fecal transplants are examined in relation to DED.

Low cardiorespiratory fitness is associated with elevated intraocular pressure among apparently healthy adults.

PURPOSE: To evaluate the association of cardiorespiratory fitness with elevated intraocular pressure (IOP) in healthy adults. METHODS: In this cross-sectional study, we evaluated 17,990 asymptomatic self-referred adults free of diabetes or cardiovascular disease who were screened in a preventive healthcare setting. All subjects underwent measurement of IOP and completed a maximal exercise stress test according to the Bruce protocol. Fitness was categorized into age and sex-specific quintiles according to the treadmill time and dichotomized to low (lowest quintile) and non-low fitness groups. Elevated IOP was defined as ≥ 21 mmHg. RESULTS: Median age was 45 (IQR 39-52) years and 12,073 (67%) were men. There were 3,351 (19%) subjects in the low fitness group. Median IOP was 14 mmHg (IQR 12-16) with elevated IOP documented in 188 (1%) subjects. Univariate binary logistic regression model demonstrated that compared with non-low fitness group, subjects in the low fitness group were 2.2 times more likely to have elevated IOP (95% CI 1.598-2.95, p<0.001). Multivariate binary logistic regression with adjustment to known cardiovascular risk factors (age, sex, hypertension, smoking, overweight, regular physical activity, low HDL cholesterol, high triglycerides, and fasting glucose levels) successfully demonstrated that lower fitness was independently and significantly associated with a 90% increased likelihood of elevated IOP (95% CI 1.37-2.61, p<0.001). Subgroup analysis revealed that the association was more pronounced among women compared with men (OR 3.8 vs. 1.6, p for interaction = 0.069). CONCLUSIONS: Low cardiorespiratory fitness is independently associated with increased IOP among apparently healthy adults.

Effect of direct oral anticoagulants on bleeding during and after cataract surgery.

PURPOSE: To assess the risk for intraoperative and postoperative ocular bleeding associated with direct oral anticoagulant treatment in patients undergoing phacoemulsification surgery. METHODS: Consecutive patients had phacoemulsification and intraocular lens implantation while taking uninterrupted direct oral anticoagulants (dabigatran, rivaroxaban, or apixaban). Gender and age-matched patients without antithrombotic therapy were used as the control group. Patients were examined one week postoperatively. Intraoperative and postoperative hemorrhagic and non-hemorrhagic complications were assessed. RESULTS: Forty patients (56 eyes) on direct oral anticoagulants and 120 patients (172 eyes) without anticoagulation, at a mean age of 77 years, had phacoemulsification. There was no significant difference between the groups in the rate of intraoperative and postoperative bleeding. One eye (1.8%) in the treatment group and 3 eyes (1.7%) in the control group had hyphema (p = 0.72). No patient had thromboembolic event during or after surgery. CONCLUSIONS: Cataract surgery was safely performed while continuing direct oral anticoagulation.

Ocular blood flow biomarkers may predict long-term glaucoma progression.

BACKGROUND/AIM: To examine the relationship between baseline blood flow biomarkers and long-term open-angle glaucoma (OAG) progression. METHODS: 112 patients with early to moderate OAG (mean age 64.9±11.0 years; 68 female) were evaluated at baseline and every 6 months from 2008 to 2013. Biomarkers of retinal capillary blood flow were assessed by Heidelberg retinal flowmetry. Functional disease progression was monitored via Humphrey visual field examinations, defined as two consecutive visits with a mean deviation decrease ≥2 decibels and/or Advanced Glaucoma Intervention Study score increase ≥2 compared with baseline. Structural progression was monitored with optical coherence tomography and Heidelberg retinal tomograph, defined as two consecutive visits with retinal nerve fibre layer thickness decrease ≥8% and/or horizontal or vertical cup/disk ratio increase ≥0.2 compared with baseline. Mixed-model analysis of covariance was used to test for significant change from baseline to 5-year follow-up. Times to functional and structural progression were analysed using Cox proportional hazards models. RESULTS: Lower HRF retinal capillary blood flow in the superior retina was significantly associated with structural progression (p=0.0009). CONCLUSION: In our OAG sample, baseline lower retinal capillary perfusion in the superior retina was predictive of structural progression after 5 years. TRIAL REGISTRATION NUMBER: NCT01145911.

Association of Variants in TMEM45A With Keratoglobus.

IMPORTANCE: Keratoglobus is a rare corneal disorder characterized by generalized thinning and globular protrusion of the cornea. Affected individuals typically have significantly decreased vision and are at risk of corneal perforation. The genetic basis and inheritance pattern of isolated congenital keratoglobus are currently unknown. OBJECTIVE: To identify the genetic basis of isolated congenital keratoglobus. DESIGN, SETTING, AND PARTICIPANTS: This case series and molecular analysis studied 3 unrelated nonconsanguineous families with keratoglobus at a medical center in Israel. Data were collected from June 2019 to March 2021 and analyzed during the same period. EXPOSURES: Whole-exome sequencing and direct Sanger sequencing, expression analysis by real-time polymerase chain reaction, splice-site variant analysis, immunohistochemical staining, and histological evaluation of a knockout mouse model. MAIN OUTCOMES AND MEASURE: Molecular characteristics associated with keratoglobus. RESULTS: Four pediatric patients (3 male individuals) from 3 families had clinical findings consistent with keratoglobus. These included globular protrusion, corneal thinning more prominent at the periphery, and high astigmatism. Truncating and splice site variants were identified in the TMEM45A gene, which fully segregate with the disorder. All affected individuals were homozygous or compound heterozygous for variants in the TMEM45A gene, while unaffected family members were heterozygous carriers. Expression analysis in healthy controls showed that TMEM45A was expressed 23 times higher in the human cornea compared with peripheral blood. Immunohistochemical staining of the TMEM45A protein in normal corneas confirmed its expression in the corneal stroma and epithelium. A TMEM45A knockout mouse model showed structural features consistent with keratoglobus. CONCLUSIONS AND RELEVANCE: Expression of TMEM45A has been previously shown to result in upregulation of extracellular matrix components and fibrosis. These results suggest that isolated congenital keratoglobus is an autosomal recessively inherited disorder associated with variants in the TMEM45A gene.

Refractive outcomes of high-magnitude astigmatism correction using femtosecond LASIK versus transepithelial PRK.

PURPOSE: To compare the outcomes of femtosecond laser assisted in situ keratomileusis (FS-LASIK) with transepithelial photorefractive keratectomy (T-PRK) for the correction of high-grade astigmatism. METHODS: Medical records of patients with astigmatism of 2 diopters (D) or higher, who were treated with FS-LASIK or T-PRK in 2013 through 2014 at a private practice laser clinic, were retrospectively analyzed. Efficacy, safety, predictability and vector analysis of astigmatism correction were compared between the treatment groups. RESULTS: The study included 93 eyes treated with FS-LASIK and 186 eyes treated with T-PRK. No significant differences in postoperative spherical equivalent (-0.10 ± 0.7 D and -0.11 ± 0.7 D, respectively, p = 0.958) and postoperative refractive astigmatism (0.79 ± 0.54 D and 0.82 ± 0.63 D, respectively, p = 0.685) were demonstrated. A significant advantage of FS-LASIK over T-PRK was seen for the efficacy (1.00 ± 0.18 and 0.86 ± 0.22, respectively, p < 0.001) and safety (1.03 ± 0.17 and 0.89 ± 0.21, respectively, p < 0.001) indices. Results remain statistically significant in a multivariate analysis model. Vector analysis for the astigmatism correction showed no significant difference between the surgery methods in the surgically induced astigmatism, difference vector, correction index and index of success. CONCLUSION: Both procedures demonstrated desirable post-operative SE outcomes for high-grade astigmatism correction. However, FS-LASIK achieved better results than T-PRK in the efficacy and safety parameters.

Dynamic assessment of the tear film muco-aqueous and lipid layers using a novel tear film imager (TFI).

PURPOSE: The objective of the study was to assess a new technology, the tear film imager (TFI), which can dynamically image the muco-aqueous and lipid layers. METHODS: Prospective pilot case series of individuals with and without dry eye (DE). Two sequential images were obtained with the TFI. Measurements were assessed for reproducibility and compared with clinically derived DE metrics. Individuals were grouped into DE categories based on signs of DE. RESULTS: 49 patients participated in the study with a mean age of 58.8 years (SD 15.9) and a female majority (69%). Reproducibility of the muco-aqueous layer thickness (MALT) was excellent (r=0.88). MALT measurements significantly correlated with the Schirmer score (r=0.31). Lipid break up time (LBUT) as measured by the TFI significantly correlated with the clinical measure of tear break up time (TBUT) (r=0.73). MALT and LBUT were significantly thinner and shorter, respectively, in the DE groups (mild-moderate and severe) compared with the control group. When comparing TFI parameters to clinically assessed signs, sensitivity of the device was 87% and specificity was 88%. CONCLUSION: The TFI is the first machine capable of reproducibly measuring muco-aqueous thickness in human subjects which correlates with Schirmer score. In parallel, it assesses other important aspects of tear film function which correlate with clinician assessed DE metrics.

Fire Ant Punctate Keratopathy: A Novel Diagnosis Based on Clinical and Anterior Segment Optical Coherence Tomography Findings.

PURPOSE: To describe the ocular findings and the long-term outcomes of patients diagnosed with corneal injury due to little fire ants (LFAs). METHODS: This is a retrospective case series of patients evaluated with corneal injury due to LFAs from October 2015 to January 2018 at the Cornea Clinic in Meir Medical Center. Patients underwent anterior segment optical coherence tomography (AS-OCT) imaging during the follow-up. RESULTS: Four patients reported ocular contact with LFAs and presented to our department with unilateral, scattered, small, dense, round, bright white opacities in the anterior corneal stroma, which remained unchanged in appearance over time, despite topical antibiotic and steroid treatment. No inflammatory signs were noted in the anterior chamber. Follow-up was performed clinically using AS-OCT for periods of 9 to 26 months after the incidents. AS-OCT findings demonstrated small, subepithelial, hyperreflective foci at the level of the anterior stroma to a depth of 145 to 250 µm, with posterior shadowing that remained unchanged over time. These findings were well-correlated with biomicroscopy findings. CONCLUSIONS: LFA bites can cause long-lasting corneal injury in humans with characteristic clinical biomicroscopic findings. The corneal lesions do not respond to conventional topical treatment. AS-OCT imaging can be a useful modality for diagnosis and follow-up. Awareness by both patients and ophthalmologists of this clinical entity may be helpful in diagnosis and management.

Characterization of deeply embedded corneal foreign bodies with anterior segment optical coherence tomography.

PURPOSE: The purpose of the study was to describe findings demonstrated by anterior segment spectral domain optical coherence tomography (AS-OCT) in various types of deeply embedded corneal foreign bodies. METHODS: In this experimental study, an ex vivo model of calf eyes was used and seven different foreign bodies were deeply embedded in the cornea, consisting of five different materials: glass, plastic, metal, wood, and pencil graphite. The eyes were photographed and then scanned by AS-OCT. The images were analyzed to determine distinguishing characteristics for each material. RESULTS: Various materials presented unique characteristics in AS-OCT. The opaque materials (pencil graphite, metals, and wood) demonstrated a hyper-reflective anterior border, whereas the posterior border signal could not be clearly identified due to the shadowing effect. Moreover, a chain of signals was characteristic of both pencil graphite and metals though a "mirroring effect" was unique for metals. Wood, as an opaque material, appears as a hyper-reflective mass with a spectrum of penetrability depending on the degree of concentration. Transparent materials demonstrated hyper-reflective sharp borders when surrounded by air or fluid, as opposed to when being embedded purely in the corneal stroma. CONCLUSIONS: This study shows that AS-OCT was used to systematically define a novel set of distinguishing characteristics specific to various materials extruding from the cornea, fully embedded in the cornea, and intruding into the anterior chamber. Hopefully, the described characteristics of each material can aid clinicians in diagnosing the type of the material embedded and the depth of its involvement in ocular injury.

Modified Corneal Incisions for Cataract Surgery in Patients Treated with Tamsulosin: A Prospective Study.

PURPOSE: To evaluate modified anterior elongated corneal incisions as a simple technique to reduce the incidence and severity of intraoperative floppy iris syndrome (IFIS), in patients taking tamsulosin (a selective α1a-adrenergic receptor antagonist). METHODS: This prospective case series was conducted at Meir Medical Center, a tertiary care facility in Israel. Included were 45 eyes of 39 male patients taking tamsulosin, and thus prone to IFIS. Patients underwent phacoemulsification cataract surgery with anterior elongated corneal incisions. The primary outcomes were the incidence and severity of IFIS, the complication rate and the need for additional IFIS management techniques. The secondary outcome was to quantify the surgically induced astigmatism, using Alpin's vector analysis. The tamsulosin treatment period and pupil diameter during five stages of the surgery were also noted. RESULTS: The overall rate of IFIS was 33.33% (n = 15). The IFIS severity was rated as mild in 22.22% and moderate in 11.11% of the study eyes. No IFIS was noted in 66.67% of the eyes. There were no cases of severe IFIS, and no need for other IFIS management strategies. The complications rate was 2.22% (n = 1). Patients who developed IFIS had a significantly smaller pupil at the beginning of surgery (p < 0.05). There was no significant difference in tamsulosin treatment period between patients with and without IFIS (p = 0.19). The centroid - the mean SIA vector was 0.51 D @ 18° ±1.5 D (SD). CONCLUSIONS: In tamsulosin treated patients, using modified corneal incisions may be feasible in order to reduce the incidence and severity of IFIS during cataract surgery. Future randomized studies are warranted.

Risk Factors for Sporadic Diffuse Lamellar Keratitis After Microkeratome Laser-Assisted In Situ Keratomileusis: A Retrospective Large Database Analysis.

PURPOSE: To determine the factors associated with sporadic diffuse lamellar keratitis (DLK) after microkeratome laser-assisted in situ keratomileusis (LASIK). METHODS: This large database retrospective study included consecutive cases of LASIK performed between 2007 and 2016 at Care-Vision Laser Centers, Tel-Aviv, Israel. Patients were divided into 2 groups according to whether or not they subsequently developed DLK. RESULTS: A total of 24,026 eyes of 12,013 patients with a mean age of 32.9 ± 10.3 years were included. Post-LASIK DLK developed in 464 eyes (1.9%), and the annual rate decreased from 7.1% (2007) to 1.7% (2016) (P < 0.001). The DLK group had a higher proportion of males (58.5% vs. 52.1%, P = 0.006), greater preoperative central corneal thickness (549.5 ± 32.6 vs. 545.3 ± 30.5 µm, P = 0.005), and a lower proportion of high astigmatism (>3 D) (0.4% vs. 1.6%, P = 0.05). The DLK group had a higher proportion of previous LASIK treatment (2.8% vs. 1.3%, P = 0.006), Moria M2 (rather than the SBK) microkeratome (71.1% vs. 34.0%, P < 0.001), smaller suction ring number (P < 0.001), greater stop size (P < 0.001), and greater flap thickness (119.2 ± 50.4 vs. 110.8 ± 22.2, P = 0.007). In multivariable analysis, a smaller suction ring number [odds ratio (OR) 0.89, P = 0.04], Moria M2 microkeratome (OR 5.26, P < 0.001), larger optical zone (OR = 2.04, P = 0.01), and higher spherical equivalent (OR = 1.08, P = 0.02) were associated with DLK. CONCLUSIONS: In the modern LASIK era, the incidence of DLK continues to decrease. Higher preoperative ametropia, smaller suction ring number, an older type of microkeratome, and larger optical zones are associated with higher DLK rates after LASIK.

PROGNOSTIC VALUE OF SUBRETINAL HYPERREFLECTIVE MATERIAL IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION TREATED WITH BEVACIZUMAB.

PURPOSE: To study the correlation between subretinal hyperreflective material (SHRM) seen on spectral domain optical coherence tomography at baseline and visual outcomes after intravitreal bevacizumab injection in neovascular age-related macular degeneration. METHODS: Consecutive patient charts with treatment-naive center-involved neovascular age-related macular degeneration treated with 3 monthly intravitreal bevacizumab's, continued as needed, from 2011 to 2014 were reviewed. Baseline spectral domain optical coherence tomography SHRM parameters (height, width, area, reflectivity, border definition, and homogeneity) and established optical coherence tomography biomarkers of neovascular activity (intraretinal fluid, subretinal fluid, retinal volume, central retinal thickness, and pigment epithelial detachment presence) were collected. These baseline parameters were correlated with visual acuity at baseline, 3 and 12 months. RESULTS: Seventy-three eyes of 73 patients, 47 (64.4%) having central SHRM at baseline, were studied. Mean age was 79.2 ± 8.9 years. Mean best-corrected visual acuity was 0.70 ± 0.57 logarithm of the minimum angle of resolution (20/100), 0.73 ± 0.55 (20/107), and 0.76 ± 0.63 (20/115) at baseline, 3 and 12 months, respectively. Baseline parameters with a significant predictive value of 12-month visual acuity by univariate analysis were presence of intraretinal fluid, presence of SHRM, highly reflective SHRM, well-defined SHRM borders, and thick SHRM. These parameters, with the exception of high reflectivity, were significant on multivariate regression analysis. The most predictive baseline parameter was well-defined SHRM borders. CONCLUSION: This study supports the use of SHRM as a prognostic biomarker when interpreting optical coherence tomography in neovascular age-related macular degeneration. Baseline parameters predicting poorer vision 1 year after intravitreal bevacizumab treatment were as follows: presence of central SHRM, well-defined SHRM borders, intraretinal fluid, and thicker SHRM.

Transscleral Selective Laser Trabeculoplasty Without a Gonioscopy Lens.

PURPOSE OF THE STUDY: The purpose of the study was to investigate results of selective laser trabeculoplasty (SLT) performed directly on the sclera without a gonioscopy lens. DESIGN: Interventional case series, prospective, randomized, masked, controlled clinical trial. METHODS: Setting: Meir Medical Center, Kfar-Saba, Israel. STUDY POPULATION: Adults with uncontrolled primary open angle or pseudoexfoliation glaucoma randomized into 2 groups. INTERVENTION: The controls underwent conventional SLT with 100 spots delivered using a gonioscopy lens for 360 degrees of the trabecular meshwork. The study group underwent irradiation using the same parameters with the laser applications administered on the perilimbal sclera. Study visits: 1 hour, 1, 7, 30, 60, 180, and 365 days postprocedure. MAIN OUTCOME MEASURES: Intraocular pressure (IOP) and side effects. RESULTS: Thirty adults were randomized into 2 groups. The mean (±SD) pretreatment IOP was 20.21±3.19 mm Hg for the study group (n=14) and 21.14±2.98 mm Hg for the controls (n=14; P =0.43), dropping to 15.50±3.77 and 15.00±4.08 mm Hg (P =0.74) after 6 months and to 16.00±3.31 and 14.00±2.45 mm Hg (P =0.22) after 12 months. The average IOP reduction after 6 and 12 months was 23.4% and 20.83% for the study group and 27.1% and 33.77% for the controls (P=0.528). Success (a decrease of ≥15% at 6 months with no additional medications, laser, or glaucoma surgery) was achieved in 12 (85.7%) study patients and 9 (69.2%) controls (P=0.385). Complications were mild and transient (n=30), although significantly higher in the controls (n=15; P <0.0001). CONCLUSIONS: SLT applied directly to the perilimbal sclera may be as efficacious as the conventional procedure for 1 year.

The Effect of Labor on the Intraocular Pressure in Healthy Women.

PURPOSE: To investigate the effect of modern vaginal labor using epidural anesthesia on the intraocular pressure (IOP) and on the mean ocular perfusion pressure (MOPP) in healthy women. PATIENTS AND METHODS: In this prospective observational study, eligible candidates were healthy pregnant women for vaginal delivery with epidural anesthesia, with a singleton pregnancy, who were admitted to the delivery room in the first phase of the first stage of labor. Demographic data as well as medical and obstetric history were obtained at baseline, followed by performance of a biomicroscopic examination. IOP, maternal heart rate, systolic blood pressure, and diastolic blood pressure were measured in the first, second and third stages of labor, 24±2 and 48±2 hours postpartum. IOP was not measured during the contraction phase of stage 2. MOPP was expressed as the difference between the arterial blood pressure and the IOP. Measurements were performed throughout the different stages of labor and were compared with baseline values. RESULTS: Thirty healthy white women were enrolled. Four women dropped out due to unexpected cesarean sections. The average age was 31.8±4.7 years. Nineteen participants received oxytocin during delivery. Twenty-three women were placed in a supine position, whereas 3 in a left decubitus position. No statistically significant changes were recorded in IOP (P=0.50) or MOPP (P=0.17) throughout the different stages of vaginal labor in this study. CONCLUSIONS: Vaginal delivery under epidural anesthesia is unlikely to cause significant damage to the optic nerve in healthy women.

The effect of gatifloxacin 0.3% or moxifloxacin 0.5% on corneal healing, ocular tolerability and toxicity following pterygium surgery.

PURPOSE: To compare the rate of corneal epithelial healing and ocular tolerability following pterygium surgery between gatifloxacin and moxifloxacin. METHODS: In this double masked, prospective, controlled study 40 patients were randomized to receive prophylactic topical gatifloxacin 0.3% or moxifloxacin 0.5% following pterygium surgery. Patients were examined on days 1, 3, 7 and 21 post-operatively or until complete corneal epithelial healing. The primary outcome measure was the area of corneal epithelial defect during the post-operative period. Patients graded post-operative ocular pain, foreign body sensation, tearing, general burning sensation and burning sensation post-antibiotic drops instillation on a scale of 1-5. Conjunctival hyperemia and superficial punctate keratopathy (SPK) were measured on a scale of 0-3. RESULTS: No significant differences between groups were found in terms of corneal epithelial defect percentage over time (p = 0.989) and there was no significant difference between groups on each of the post-operative days. No significant differences were noted in terms of post-operative ocular pain, foreign body sensation, tearing, general burning sensation, burning sensation post-antibiotic drops instillation, conjunctival hyperemia and SPK. CONCLUSIONS: Gatifloxacin and moxifloxacin showed equivalent results in terms of corneal epithelial healing and ocular tolerability following pterygium surgery. This study suggests that there was no apparent added epithelial toxicity due to the presence of benzalkonium chloride in the gatifloxacin preparation when compared to moxifloxacin.

Modified corneal incisions in intraoperative floppy iris syndrome (IFIS)-prone patients.

BACKGROUND: We aimed to report a simple technique that involves modified anterior (to the limbus) elongated corneal incisions in order to reduce the incidence and severity of intraoperative floppy iris syndrome (IFIS) and related complications. METHODS: This was a retrospective study of phacoemulsification cataract surgeries performed by a single surgeon on patients receiving tamsulosin or alfuzosin between 1 January 2009 and 31 July 2012 at Meir Medical Center, Kfar-Sava, Israel. We recorded preoperative gender, age, α-antagonist medication, coexisting pseudoexfoliation (PXF), and intraoperative use of ophthalmic viscosurgical devices (OVDs), pupil size, complications, IFIS grading and the need for additional operative strategies to manage IFIS. Elongated corneal incisions were performed approximately 1 mm anterior to the limbus. RESULTS: Ninety-three eyes of 81 men were included. Mean age was 76.5 years (range 55 to 96 years). Forty-seven eyes (40 patients) had documented use of alfuzosin and 45 eyes (40 patients) of tamsulosin. One patient received both. The overall rate of IFIS was 22.6 % (n = 21). Eyes of patients who were treated with alfuzosin had a milder grading (p < 0.001) and an overall lower percentage of IFIS compared to tamsulosin (4.26 % versus 42.22 % respectively, p < 0.001). No additional strategies were used to manage IFIS during surgery. No intraoperative complications occurred. CONCLUSION: Anterior elongated incisions are simple and efficient in preventing IFIS, exempting the surgeon from the use of additional expensive devices or materials in most cases. They do not limit the surgeon to one strategy, and therefore, if necessary, another may be applied at any given time.

Iris Fixation of Unstable Anterior Chamber Intraocular Lenses.

PURPOSE: To present a surgical approach for the treatment of unstable anterior chamber intraocular lenses (ACIOLs). METHODS: We present a series of 8 patients who underwent iris fixation of an unstable open-looped ACIOL associated with progressive corneal damage. The loops of the intraocular lens were firmly fixated to the iris using 9-0 or 10-0 polypropylene sutures. In 2 cases, iris fixation was associated with penetrating keratoplasty. The other cases were performed using a relatively closed-system technique. RESULTS: All procedures were uneventful, with no intraoperative or postoperative complications. Suture fixation effectively prevented anterior-posterior or propelling movement. The ACIOLs in all cases were stable and well centered at the end of follow-up. CONCLUSIONS: Fixation of an existing unstable angle-supported ACIOL to the iris is an effective and simple alternative to intraocular lens exchange and posterior chamber fixation.

Conclusiveness of the Cochrane Eye and Vision Group Reviews.

BACKGROUND: To assess the conclusiveness of Cochrane Eye and Vision Group Reviews (EVGRs). We tested the hypotheses that: (1) the majority of EVGRs are inconclusive; (2) most reviews state the need for further and better studies; (3) the conclusiveness of a given review is affected by the number of randomized controlled trials (RCTs) included and the cumulative number of patients and eyes studied. METHODS: A retrospective study of all EVGRs available in the Cochrane Library in June 2013. For each EVGR we recorded the number of RCTs found by the reviewers, the number of RCTs included for final analysis as fulfilling inclusion criteria, the total cumulative number of patients and eyes studied, the stated need for further and better studies, the reason stated for further studies and the type of conclusion reached by the reviewer(s). We used the Kruskal-Wallis test to determine differences between ''conclusive'' and ''inconclusive'' studies in terms of the outcome variables studied. The correlation between the number of included studies and cumulative sample size was studied using regression analysis. RESULTS: Out of 106 EVGRs, 52.8% were conclusive. In 83.9% of the conclusive EVGRs one treatment/strategy/drug was found to be better than the alternative. The average number of available and included RCTs was significantly higher in conclusive EVGRs (P = 0.007 and P = 0.003 respectively). The total cumulative number of patients and number of eyes studied was approximately ten times higher in the conclusive EVGRs (P < 0.001 and P < 0.015 respectively). A similar percentage of RCTs was included in both conclusive and inconclusive reviews (76 vs. 73%). The vast majority of EVGRs, whether conclusive (84%) or inconclusive (96%), stated the need for further and better studies (P = 0.042). Fifty eight percent of the EVGRs justified the need for further studies for at least two reasons. The reason that was stated the most was a need for a larger amount of RCTs (67%). CONCLUSIONS: In approximately half of the cases, EVGRs allow the reader to reach a clinically applicable conclusion. Larger total cumulative participants, total cumulative number of eyes studied and number of RCTs performed all increase the likelihood of an EVGR to be conclusive.

The effects of the frequency of the initial treatment with intravitreal bevacizumab on macular volume and visual acuity.

PURPOSE: The ideal notion of monthly intravitreal injections is difficult to achieve when it comes to real-life scenarios. In reality, patients often are treated with larger intervals due to circumstances. The purpose of this study was to compare the results of intravitreal bevacizumab injections with shorter intervals versus longer intervals for the treatment of choroidal neovascularization (CNV) in age-related macular degeneration (AMD) in a real-life clinic. METHODS: A retrospective, consecutive cohort study of naive eyes of patients with CNV secondary to AMD treated with intravitreal bevacizumab. Patients included underwent at least 3 consecutive injections with intervals <45 days in between them (Group A) or >45 days (Group B). Best corrected visual acuity (BCVA) and optical coherence tomography were performed before the initial intravitreal injections and after the last injection. RESULTS: Group A consisted of 24 eyes of 18 patients and Group B 30 eyes of 25 patients. There was a significantly larger mean of consecutive (5.0 vs. 3.78, P = 0.013) and total (9.44 vs. 7.2, P = 0.021) injections in Group B. There was a significant improvement in average BCVA in Group A only (0.65-0.52, P=0.006). However, a significant and similar improvement in retinal volume was found in both groups (P < 0.05). CONCLUSION: This study emphasizes the importance of achieving consecutive injections with short intervals. Practitioners and decision makers should be mindful that providing additional resources to accomplish proper frequency may be more effective (visual outcome), cost effective (less injections), and safer (less exposure) for the patient.