The role of novel DMEK graft shapes in facilitating intraoperative unscrolling.

PURPOSE: To evaluate whether the preparation of Descemet membrane endothelial keratoplasty (DMEK) grafts into various shapes affect their propensity to scroll as compared with the conventional circular graft design. METHODS: Prospective randomized laboratory-based study, using nine pre-stripped DMEK corneal grafts unfit for transplantation. Each graft was trephinated into a standard circular 8-mm shape, stained with trypan blue, and then immersed in balanced salt solution (BSS). The width of the DMEK graft scroll was measured, and photographs were obtained. The graft was then cut into one of three pre-selected shapes (four peripheral punches, four radial cuts, Maltese cross). These newly shaped grafts were then replaced in BSS and again photographed. The scroll widths, as well as pre- and post-preparation scroll width-to-height ratios, were calculated and compared. RESULTS: Nine pre-stripped DMEK corneal grafts (mean donor age ± SD 73.1 ± 9.3 years, range 58-85 years) were included. The mean pre-cut scroll widths for the three selected shapes were statistically similar. Following graft preparation into their assigned shapes, the mean post-preparation scroll widths (and corresponding change from pre-preparation measurements) were 1.73 ± 0.16 mm (- 3.6%) for the 4-peripheral punches, 2.59 ± 0.35 mm (+ 0.2%) for the 4-radial cuts and 4.13 ± 0.63 mm (+ 20.1%) for the Maltese cross (P = 0.0013). Therefore, the Maltese cross design resulted in a wider scroll than its pre-preparation control. CONCLUSIONS: Certain DMEK graft shapes may be less prone to scrolling than others. The Maltese cross graft design scrolled less tightly than the other experimental graft shapes. Future studies may elucidate intraoperative scrolling behavior of these DMEK graft shapes within the anterior chamber.

Ophthalmic diseases in meningitis within the pediatric population.

OBJECTIVE: Meningitis may lead to ophthalmic complications in pediatric populations. The visual aftermath in developed countries has been poorly studied. This study aims to highlight the potential ocular and neuro-ophthalmic sequela of meningitis in the pediatric population of a tertiary pediatric hospital. DESIGN: A retrospective chart review of all pediatric patients, between 2006 and 2015, diagnosed with meningitis at the Montreal Children's Hospital was conducted. Study approval was obtained by the Institutional Review Board of the McGill University Health Centre and adhered to the tenets of the Declaration of Helsinki. METHODS: Records of all pediatric meningitis patients were extracted and further refined by isolating all who received an ophthalmology consultation. Relevant demographic data, general medical information, ocular findings, and imaging results were extracted. The proportion of ocular abnormalities was calculated and analyzed. RESULTS: Seventy-two of 861 meningitis patients (8.4%) received an ophthalmology consultation. Forty-six patients met the inclusion criteria, and 31 of those (67.4%) demonstrated ocular abnormalities. Children presented most frequently with abnormalities involving visual acuity (8 of 32), extraocular movements and alignment (14 of 28), optic nerve (10 of 41), pupillary reactivity (4 of 35), and periorbital/orbital cellulitis (4 of 46). Older patients were more likely to have ophthalmologic findings. CONCLUSION: This chart review highlights the ocular abnormalities found in children who suffer from meningitis and present to a tertiary-care centre in a high sociodemographic index country. Complications may be lasting. Treating ophthalmologists should be cognizant of potential ocular abnormalities among meningitis patients. We advocate for increased awareness of this association among health care providers.

Histopathological Rate of Ocular Surface Squamous Neoplasia in Clinically Suspected Pterygium Specimens: 10-Year Results.

PURPOSE: The aim of this study was to evaluate the prevalence of histopathologically confirmed ocular surface squamous neoplasia (OSSN) in clinically diagnosed pterygium samples at a tertiary center in Northern California, over a 10-year period (2009-2019). METHODS: A retrospective chart review of patients older than 18 years with clinically diagnosed benign pterygium requiring excision was conducted. Clinically suspected pterygia were excised using standard techniques and routinely submitted to the University of California Davis for pathologic evaluation. Demographic, clinical, surgical, and pathological information were recorded and analyzed. The prevalence rate of OSSN was calculated. RESULTS: A total of 348 consecutive specimens were evaluated. The mean (±SD) age of the patients was 58 ± 12 years, with a near equal sex representation. A total of 57 (16%) pterygia were recurrent at initial presentation. Histopathologic results demonstrated a single case of OSSN. This patient did not have a documented history of carcinoma in other organs or any history of herpes virus, human papilloma virus, or human immunodeficiency virus infection. CONCLUSIONS: The prevalence of histopathological OSSN in clinically suspected pterygia within our sample was approximately 0.3%. Because of shared clinical characteristics of pterygia and OSSN, a high index of suspicion and judicious use of anterior segment optical coherence tomography enable for effective preoperative diagnosis of OSSN. However, in the absence of clinical expertise or high-resolution optical coherence tomography, routine tissue pathologic examination may be warranted.

One-year outcomes of Aflibercept for refractory diabetic macular edema in Bevacizumab nonresponders.

Purpose: A sub-population of patients with diabetic macular edema (DME) responds less effectively to off-label use of Bevacizumab. Approval of Aflibercept for DME has offered Bevacizumab nonresponders an alternative therapeutic option. Herein, we investigate the anatomical and functional changes associated with Aflibercept treatment in Bevacizumab nonresponders with chronic DME in a Canadian setting. Methods: A retrospective study of eyes with persistent DME that were switched to Aflibercept due to nonresponse following ≥6 consecutive monthly Bevacizumab injections was performed. Anatomical and functional changes and the predictors of response were assessed using patients' characteristics prior to receiving their first (baseline) and seventh consecutive Aflibercept injections (follow-up). Results: Twenty-four eyes were included, with a mean age of 63.9 ± 10.7 years, an average of 16.8 ± 8.5 Bevacizumab injections prior to switching to Aflibercept, and mean follow-up duration of 11.8 ± 1.7 months following switching to Aflibercept. Best-corrected visual acuity (BCVA) improved significantly from 0.49 ± 0.13 to 0.41 ± 0.11 logMAR (P < 0.001) and central subfield thickness (CST) decreased by 119.4 µm from 409.4 ± 85.8 µm to 290.0 ± 64.5 µm (P < 0.001), with 50% of eyes showing complete anatomical response. Worse BCVA and higher CST at baseline predicted greater vision improvements (P = 0.001 and P = 0.035, respectively) while a larger decrease in CST was associated with greater baseline CST (P = 0.001) and better glycemic control (P = 0.039). Conclusion: Our data from a real-world clinical setting highlight the efficacy of Aflibercept as an alternative therapeutic option for DME recalcitrant to Bevacizumab, with potential additional benefit to those with worse vision, greater CST, and better glycemic control at baseline.

Incremental effect of topical and oral moxifloxacin administration with surgical intracameral prophylaxis.

OBJECTIVE: To determine how supplemental perioperative topical or oral moxifloxacin administration impacts anterior chamber (AC) antibiotic concentrations beyond those achieved by intracameral (IC) administration alone for postoperative endophthalmitis (POE) prophylaxis. DESIGN: Mathematical modeling. METHODS: The mathematical model developed by Arshinoff, Modabber, and Felfeli was adapted to calculate all reported data. A literature review of pharmacokinetic data for topical and oral moxifloxacin was used to inform the expansion of the model. RESULTS: Our previously constructed IC model yields a dose of moxifloxacin in the AC sufficient to confer bactericidal coverage against the most common POE pathogen, methicillin-sensitive Staphylococcus aureus (MSSA), for ∼40 hours postoperatively. Topical 0.5% moxifloxacin eye drops alone, administered every 4 or 6 hours, achieve an AC concentration just above or at the mutant prevention concentration (MPC) for MSSA, respectively, whereas 8-hour dosing produces levels generally below the MPC. Combining topical moxifloxacin with IC increases the AC concentration above IC alone only after 20 or more hours and maintains the AC concentration at, or just below, the MPC for MSSA for as long as the drops are continued. Combined perioperative oral moxifloxacin with IC increases AC levels over IC alone only after 16 hours and maintains the AC concentration above the MPC for MSSA for an additional 5 hours, owing to the systemic reservoir. CONCLUSIONS: The addition of topical or oral moxifloxacin supplemental to IC can extend the duration of bactericidal coverage for the most common, but not the most resistant POE-causing pathogens.

Isolated bilateral congenital lacrimal gland agenesis-a case series.

We report 2 pediatric cases of isolated bilateral congenital lacrimal gland agenesis (CLGA). Patient 1 (1 year of age) and patient 2 (2 years of age) presented with symptoms of alacrimia and were diagnosed with bilateral isolated CLGA based on magnetic resonance imaging. Both patients were otherwise healthy, with no systemic associations. Molecular analysis for genetic causes of CLGA were negative. Both have been successfully medically managed.

Aqueous level abatement profiles of intracameral antibiotics: A comparative mathematical model of moxifloxacin, cefuroxime, and vancomycin with determination of relative efficacies.

PURPOSE: To create a model of the abatement profiles of the three most commonly employed endophthalmitis prophylaxis intracameral (IC) antibiotics-cefuroxime, vancomycin, and moxifloxacin-to enable comparison of their durations of efficacy against common endophthalmitis pathogens. SETTINGS: Humber River Hospital and The Eye Foundation of Canada, Toronto, Ontario, the University of Toronto, Ontario, and McGill University, Montreal, Quebec, Canada. DESIGN: Literature review, as well as review of our clinical experience with 4797 consecutive cases with IC vancomycin, followed by 9185 consecutive cases with IC moxifloxacin. METHODS: A detailed review of the prophylactic antibiotic literature was performed. Exponential decay models of the selected IC antibiotics were updated from previous work by the study authors with decay constants adjusted to agree with the available published objective data. RESULTS: The graphs generated by the study data demonstrate the relative duration of IC bactericidal activity of moxifloxacin, cefuroxime, and vancomycin. They suggest that at present, IC moxifloxacin, when administered in appropriate doses, is the most effective agent in preventing postoperative endophthalmitis. Unlike vancomycin and cefuroxime, bacterial resistance to moxifloxacin is dose-dependent, and it is overcome in the vast majority of cases with doses that can safely be achieved intracamerally. The graphs can serve as a useful tool to assess the expected efficacy of each antibiotic in reference to local pathogen resistances. CONCLUSION: The model shows IC moxifloxacin, cefuroxime, and vancomycin durations of bactericidal efficacy post-cataract surgery, which correlate well with the published objective data.

Crystalline Keratopathy in Post-LASIK Ectasia: A Case Report.

PURPOSE: To report an unusual case of bilateral crystalline keratopathy presenting several years after a laser in situ keratomileusis (LASIK) procedure. METHODS: Case report and review of the literature. RESULTS: A healthy 42-year-old woman with post-LASIK ectasia, treated with long-term corneoscleral contact lenses, developed new-onset crystalline keratopathy in both eyes. Anterior segment optical coherence tomography demonstrated bilaterally symmetric paracentral rings of hyperreflectivity, involving the LASIK corneal flaps. There was good clearance of the corneoscleral contact lenses with no corneal-lens touch in all quadrants. There was no evidence of infectious or systemic etiologies. Genetic testing for the UBIAD1 gene for Schnyder corneal dystrophy was negative. Continued clinical observations have exhibited progressive corneal crystalline deposition, yet the patient has remained visually asymptomatic. CONCLUSIONS: This is the first known reported case of significantly delayed progressive noninfectious crystalline keratopathy in post-LASIK ectasia. The pathophysiology of this condition remains elusive to date and highlights the challenges of noninvasive diagnostic techniques and yet the utility of molecular genetic analysis in elucidating the etiology of this unique clinical presentation.

Retrobulbar anaesthesia for adjustable strabismus surgery in adults: a prospective observational study.

OBJECTIVE: To characterize the ocular response to retrobulbar anaesthesia and to evaluate the efficacy of retrobulbar anaesthesia for adjustable strabismus surgery in adults. DESIGN: Prospective observational study. PARTICIPANTS: Adult patients undergoing adjustable strabismus surgery under retrobulbar anaesthesia. METHODS: Surgical success was defined by ocular alignment within 10 prism diopters (PD) of orthotropia for horizontal rectus surgery and within 5 PD for vertical rectus surgery. After retrobulbar injection of Xylocaine with epinephrine, the onset time and the degree of visual impairment, ocular akinesia, and analgesia were evaluated. Postoperative parameters included the restoration of vision, onset of pain, resolution of ptosis, normalization of pupil, resolution of extraocular motility deficits, and the timing of postoperative adjustment. Perioperative complications were also documented. RESULTS: A total of 33 patients were initially included in this study. Two patients experienced complications (perioperative retrobulbar hemorrhage, postoperative suprachoroidal hemorrhage) and were excluded from data analysis. Of the remaining 31 patients (mean age, 50.2 ± 14.8 years), surgical outcome was satisfactory in 30/31 (96.8%) patients at the first postoperative visit and in 15/19 (78.9%) cases at last follow-up (mean, 6.1 ± 1.6 months). Excellent intraoperative ocular akinesia and analgesia was achieved with retrobulbar anaesthesia. After retrobulbar injection, visual impairment was the first to resolve to preoperative levels within (mean ± SD) 3.7 ± 1.9 hours postinjection, followed by onset of pain at 4.1 ± 1.0 hours, resolution of ptosis at 4.3 ± 1.9 hours, and normalization of pupil reactivity at 6.1 ± 1.0 hours. The resolution of anaesthesia upon extraocular motility occurred within 5.7 ± 1.0 hours postinjection (range, 4.5-8.0 hours), allowing for subsequent same-day postoperative adjustment. CONCLUSIONS: Retrobulbar anaesthesia in the context of adult, adjustable strabismus surgery is a relatively safe and effective technique. It provides excellent intraoperative analgesia and akinesia. Retrobulbar anaesthesia enables for same-day suture adjustments to be reliably performed.

Dose and administration of intracameral moxifloxacin for prophylaxis of postoperative endophthalmitis.

PURPOSE: To review current and past practices of intracameral antibiotic administration for infection prophylaxis in cataract surgery; to review the benefits and liabilities of available prophylactic drugs, dosage determination, and administration protocols; and to devise an optimum dose and administration protocol for intracameral moxifloxacin. SETTING: Humber River Hospital and the University of Toronto, Toronto, Ontario, Canada. DESIGN: Retrospective evaluation of treatment modality. METHODS: This study consisted of a detailed review of the history, drugs, and methods of intracameral prophylaxis and microbiological and pharmacodynamics analysis of options. A review of potential drug sources and doses was performed and 1 drug, dose, and administration protocol was selected. The current method's adoption reasons are described followed by the authors' experience. RESULTS: A single infection in 3430 cases occurred with a moxifloxacin-resistant strain of Staphylococcus epidermidis when moxifloxacin 100 mcg in 0.1 mL was used. Increasing the dose and changing the administration technique resulted in no infections in 4601 cases and no detrimental side effects or complications. CONCLUSION: Intracameral moxifloxacin prepared by dilution of 3 cc moxifloxacin 0.5% (Vigamox) with 7 cc balanced salt solution and with the administration of 0.3 to 0.4 cc (450 to 600 mcg.) as the final step in cataract surgery via the side port after the main incision has been sealed and hydrated showed advantages over alternative intracameral antibiotic prophylactic methods, with minimum risk. FINANCIAL DISCLOSURE: Neither author has a financial or proprietary interest in any material or method mentioned.

Laser iridotomy to treat uveitis-glaucoma-hyphema syndrome secondary to reverse pupillary block in sulcus-placed intraocular lenses: Case series.

PURPOSE: To present cases of uveitis-glaucoma-hyphema (UGH) syndrome due to reverse pupillary block in sulcus-placed posterior chamber intraocular lenses (PC IOLs) that were managed with laser peripheral iridotomy (LPI). SETTING: Community-based subspecialty clinics. DESIGN: Retrospective interventional case series. METHODS: A chart review of patients with a sulcus-placed PC IOLs presenting with UGH syndrome and reverse pupillary block with posterior iris bowing as diagnosed by gonioscopy and anterior segment optical coherence tomography was carried out. Laser peripheral iridotomy was performed in the eyes included in the study. The main outcome measure was clinical resolution of UGH syndrome. RESULTS: The study included 6 eyes of 6 patients with a mean age of 59.8 years (range 43.0 to 66.0 years) who presented with unilateral UGH syndrome a mean of 28.7 months (range 0.3 to 84.0 months) after PC IOL implantation. All patients were previously myopic, with 5 (83.3%) having a history of vitrectomy. The mean axial length was 27.0 mm ± 1.4 (SD). An LPI was used to treat the reverse pupillary block with resultant improvement in iris profile and resolution of UGH syndrome in all eyes. The mean intraocular pressure decreased from 30.5 ± 10.0 mm Hg on 0.5 ± 0.8 glaucoma medications to 15.5 ± 3.2 mm Hg postoperatively on 0.7 ± 1.2 medications. CONCLUSIONS: The UGH syndrome due to reverse pupillary block occurred after sulcus-placed PC IOLs in susceptible patients, those with axial myopia, and post-vitrectomized eyes. The cases were managed with LPIs. FINANCIAL DISCLOSURE: Dr. Ahmed is a consultant to Alcon Laboratories, Inc. and Abbott Medical Optics, Inc. No author has a financial or proprietary interest in any material or method mentioned.

Thermal versus impedance-based ablation of renal cell carcinoma: a meta-analysis.

BACKGROUND: Percutaneous radiofrequency ablation (RFA) of renal carcinoma has become an established treatment modality. However, thermal (TB) versus impedance-based (IB)-RF generators have not been previously compared. METHODS: A literature search on the application of RFA for renal masses using TB or IB-RF generators was performed. The safety, efficacy, and long-term outcomes of TB versus IB-based RFA were assessed using the outcome measures of technical success, local recurrence rate, complications, and preservation of renal function. RESULTS: Across the 27 included studies, pooled results suggested comparable results for technical success (TB-RFA 98.53 % vs. IB-RFA 98.78 %, P = 0.9813). Clinical efficacy results were also similar across both generators (91.0 % TB-RFA vs. 91.5 % IB-RFA; P = 0.73). At follow-up, no differences in renal function (relative risk [RR] 0.5, 95 % confidence interval [CI] 0.45-5.48), and local recurrence (RR 0.717, 95 % CI 0.49-1.50) were observed. The pooled proportion of overall complication rates was 13.1 % for TB-RFA and 11.5 % for IB-RFA. CONCLUSION: No differences in the observed parameters were found either during surgery or at follow-up.

Central venous disease in hemodialysis patients: an update.

Central venous occlusive disease (CVD) is a common concern among the hemodialysis patient population, with the potential to cause significant morbidity. Endovascular management of CVD, comprising percutaneous balloon angioplasty and bare-metal stenting, has been established as a safe alternative to open surgical treatment. However, these available treatments have poor long-term patency, requiring close surveillance and multiple repeat interventions. Recently, covered stents have been proposed and their efficacy assessed for the treatment of recalcitrant central venous stenosis and obstruction. Moreover, newly proposed algorithms for the surgical management of CVD warrant consideration. Here, we seek to provide an updated review of the current literature on the various treatment modalities for CVD.

Objective assessment of perceived age reversal and improvement in attractiveness after aging face surgery.

IMPORTANCE: Primary reasons why patients pursue aesthetic facial surgery are to look younger and more attractive; however, there is minimal literature about the effect of aesthetic facial surgery on perceived age and attractiveness. OBJECTIVES: To objectively and quantitatively evaluate the degree of perceived age change and improvement in attractiveness following aesthetic facial surgical procedures. DESIGN: Prospective evaluation by independent raters of preoperative and postoperative photographs of 49 consecutive patients who underwent aesthetic facial surgery between July 4, 2006, and July 22, 2010. The photographs of these patients were presented to 50 blinded raters, each of whom was randomly assigned to 4 rater groups. Raters were asked to estimate the age of each patient in the photographs presented and to rate the patient's attractiveness on a scale of 1 to 10. SETTING: Facial plastic surgery private practice in Toronto, Ontario, Canada. PARTICIPANTS: Patient inclusion criteria consisted of primary facial surgical procedures with a minimum 6-month follow-up period, use of standardized photographs, and no cosmetic procedures in the intervening period. Raters were chosen from the province of Ontario, randomly assigned to 1 of 4 rater groups, and blinded to the objectives of the study. MAIN OUTCOMES AND MEASURES: The mean "years saved" (true age minus guessed age) and change in attractiveness scores after facial aesthetic surgery. RESULTS: The mean overall years saved following aesthetic facial surgery was 3.1 years (range, -4.0 to 9.4 years). There was a small but insignificant increase in attractiveness scores in postprocedural photographs relative to preprocedural photographs (P > .54). CONCLUSIONS AND RELEVANCE: In this study, aesthetic facial surgery was effective in reducing the apparent age of patients but did not consistently improve their attractiveness. LEVEL OF EVIDENCE: 4.