Advanced Corneal Imaging in Keratoconus: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the published literature on the diagnostic capabilities of the newest generation of corneal imaging devices for the identification of keratoconus. METHODS: Corneal imaging devices studied included tomographic platforms (Scheimpflug photography, OCT) and functional biomechanical devices (imaging an air impulse on the cornea). A literature search in the PubMed database for English language studies was last conducted in February 2023. The search yielded 469 citations, which were reviewed in abstract form. Of these, 147 were relevant to the assessment objectives and underwent full-text review. Forty-five articles met the criteria for inclusion and were assigned a level of evidence rating by the panel methodologist. Twenty-six articles were rated level II, and 19 articles were rated level III. There were no level I evidence studies of corneal imaging for the diagnosis of keratoconus found in the literature. To provide a common cross-study outcome measure, diagnostic sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) were extracted. (A perfect diagnostic test that identifies all cases properly has an AUC of 1.0.) RESULTS: For the detection of keratoconus, sensitivities for all devices and parameters (e.g., anterior or posterior corneal curvature, corneal thickness) ranged from 65% to 100%. The majority of studies and parameters had sensitivities greater than 90%. The AUCs ranged from 0.82 to 1.00, with the majority greater than 0.90. Combined indices that integrated multiple parameters had an AUC in the mid-0.90 range. Keratoconus suspect detection performance was lower with AUCs ranging from 0.66 to 0.99, but most devices and parameters had sensitivities less than 90%. CONCLUSIONS: Modern corneal imaging devices provide improved characterization of the cornea and are accurate in detecting keratoconus with high AUCs ranging from 0.82 to 1.00. The detection of keratoconus suspects is less accurate with AUCs ranging from 0.66 to 0.99. Parameters based on single anatomic locations had a wide range of AUCs. Studies with combined indices using more data and parameters consistently reported high AUCs. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Outcomes and Complications of Limbal Stem Cell Allograft Transplantation: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the published literature on the safety and outcomes of keratolimbal allograft (KLAL) transplantation and living-related conjunctival limbal allograft (lr-CLAL) transplantation for bilateral severe/total limbal stem cell deficiency (LSCD). METHODS: Literature searches were last conducted in the PubMed database in February 2023 and were limited to the English language. They yielded 523 citations; 76 were reviewed in full text, and 21 met the inclusion criteria. Two studies were rated level II, and the remaining 19 studies were rated level III. There were no level I studies. RESULTS: After KLAL surgery, best-corrected visual acuity (BCVA) improved in 42% to 92% of eyes at final follow-up (range, 12-95 months). The BCVA was unchanged in 17% to 39% of eyes and decreased in 8% to 29% of eyes. Two of 14 studies that evaluated the results of KLAL reported a notable decline in visual acuity over time postoperatively. Survival of KLAL was variable, ranging from 21% to 90% at last follow-up (range, 12-95 months) and decreased over time. For patients undergoing lr-CLAL surgery, BCVA improved in 31% to 100% of eyes at final follow-up (range, 16-49 months). Of the 9 studies evaluating lr-CLAL, 4 reported BCVA unchanged in 30% to 39% of patients, and 3 reported a decline in BCVA in 8% to 10% of patients. The survival rate of lr-CLAL ranged from 50% to 100% at final follow-up (range, 16-49 months). The most common complications were postoperative elevation of intraocular pressure, persistent epithelial defects, and acute allograft immune rejections. CONCLUSIONS: Given limited options for patients with bilateral LSCD, both KLAL and lr-CLAL are viable choices that may provide improvement of vision and ocular surface findings. The studies trend toward a lower rejection rate and graft failure with lr-CLAL. However, the level and duration of immunosuppression vary widely between the studies and may impact allograft rejections and long-term graft survival. Complications related to immunosuppression are minimal. Repeat surgery may be needed to maintain a viable ocular surface. Reasonable long-term success can be achieved with both KLAL and lr-CLAL with appropriate systemic immunosuppression. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Safety and Efficacy of Epithelium-Off Corneal Collagen Cross-Linking for the Treatment of Corneal Ectasia: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the evidence on the safety and effectiveness of epithelium-off corneal collagen cross-linking (CXL) for the treatment of progressive corneal ectasia. METHODS: A literature search of the PubMed database was most recently conducted in March 2024 with no date restrictions and limited to studies published in English. The search identified 359 citations that were reviewed in abstract form, and 43 of these were reviewed in full text. High-quality randomized clinical trials comparing epithelium-off CXL with conservative treatment in patients who have keratoconus (KCN) and post-refractive surgery ectasia were included. The panel deemed 6 articles to be of sufficient relevance for inclusion, and these were assessed for quality by the panel methodologist; 5 were rated level I, and 1 was rated level II. There were no level III studies. RESULTS: This analysis includes 6 prospective, randomized controlled trials that evaluated the use of epithelium-off CXL to treat progressive KCN (5 studies) and post-laser refractive surgery ectasia (1 study), with a mean postoperative follow-up of 2.4 years (range, 1-5 years). All studies showed a decreased progression rate in treated patients compared with controls. Improvement in the maximum keratometry (Kmax) value, corrected distance visual acuity (CDVA), and uncorrected distance visual acuity (UDVA) was observed in the treatment groups compared with control groups. A decrease in corneal thickness was observed in both groups but was greater in the CXL group. Complications were rare. CONCLUSIONS: Epithelium-off CXL is effective in reducing the progression of KCN and post-laser refractive surgery ectasia in most treated patients with an acceptable safety profile. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Thermal Pulsation in the Management of Meibomian Gland Dysfunction and Dry Eye: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the literature to determine the efficacy and safety of thermal pulsation technologies in improving signs or symptoms of meibomian gland dysfunction (MGD) and dry eye compared with no therapy or with conventional warm compress therapy or eyelid hygiene. METHODS: A literature search was conducted in the PubMed database in June 2022 and again in March 2023 to identify all studies in the English language on the use of thermal pulsation to treat MGD or dry eye. The search yielded 59 citations, and 11 articles met all of the inclusion criteria. The panel methodologist then assigned a level of evidence rating for each study; 8 studies were rated level I evidence and 3 studies were rated level II evidence. RESULTS: All included studies evaluated a single 12-minute session using the LipiFlow automated thermal pulsation system (TearScience, Inc, or Johnson & Johnson). Improvements were detected in subjective and objective metrics of MGD or dry eye in patients within 1 to 12 months of thermal pulsation treatment compared with nontreatment. Most of the studies (9/11) reported greater efficacy with thermal pulsation than with standard warm compress therapy and eyelid hygiene. Four of these studies showed relevant industry conflicts of interest. Two of the 4 level I studies without direct industry participation concluded that thermal pulsation treatment was not significantly different from conventional hygiene or warm compress therapy control treatments (in symptoms in one of the studies and in objective findings in the second study). No serious adverse events were reported in any of the 11 studies. CONCLUSIONS: According to the current literature, a single thermal pulsation session may improve subjective or objective parameters of MGD and dry eye safely. However, industry support and participation were present in 4 of the 8 level I studies. The durability beyond several months and cost efficacy remain uncertain. Because the inclusion parameters of this assessment captured only the LipiFlow system, the conclusions are limited to that product. High-quality independent studies are needed to assess the long-term benefits of this intervention. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Intraocular Lens Implantation in the Absence of Zonular Support: An Outcomes and Safety Update: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the published literature on the visual acuity results and complications of different surgical techniques for intraocular lens (IOL) implantation in the absence of zonular support. METHODS: Peer-reviewed literature searches were conducted last in PubMed and the Cochrane Library in July 2019. The searches yielded 734 citations of articles published in English. The panel reviewed the abstracts of these mostly retrospective case series studies, and 45 were determined to be relevant to the assessment objectives. Three articles were rated as level II evidence, and 42 articles were rated as level III evidence. RESULTS: Eight different types of IOL fixation techniques with at least 6-month follow-up were evaluated: anterior chamber IOL (ACIOL), iris-claw IOL, retropupillary iris-claw IOL, 10-0 polypropylene iris-sutured posterior chamber IOL (PCIOL), 10-0 polypropylene scleral-sutured PCIOL, 8-0 polypropylene scleral-sutured PCIOL, CV-8 polytetrafluoroethylene, and intrascleral haptic fixation (ISHF). Eight articles reported data comparing 2 techniques. The 45 studies had insufficient statistical power to compare the techniques conclusively. A qualitative analysis of similar types showed that trends in visual acuity outcomes were not inferior to those of ACIOL implantation, but the severity of preoperative pathologic features was not controlled for. Compared with ACIOL, complications of cystoid macular edema were higher in 10-0 polypropylene iris-sutured PCIOL and 8-0 polypropylene scleral-sutured PCIOL. Non-anterior chamber IOL techniques were less likely to report chronic uveitis. Chronic glaucoma was highest in the 8-0 polypropylene scleral-sutured PCIOL group. Although retinal detachment was infrequent overall, it was twice as common in both iris- and scleral-sutured PCIOLs (except CV-8 polytetrafluoroethylene suture) compared with nonsutured methods: ACIOL, iris-clipped IOL, and ISHF PCIOL. CONCLUSIONS: The evidence reviewed shows no superiority of any single IOL implantation technique in the absence of zonular support. The various techniques seem to have equivalent visual acuity outcomes and safety profiles. Each technique has its own profile of inherent risk of postoperative complications. Surgeons must educate patients on the importance of close, long-term follow-up as a result of the uncertain nature of these techniques. Large prospective studies are needed to confirm the long-term complication profiles of these various IOL implantation techniques.

Autologous Serum-Based Eye Drops for Treatment of Ocular Surface Disease: A Report by the American Academy of Ophthalmology.

PURPOSE: To describe the safety and effectiveness of using autologous serum-based eye drops for the treatment of severe dry eye and persistent corneal epithelial defect. METHODS: Literature searches of the PubMed and Cochrane Library databases were conducted most recently in March 2019. The searches identified 281 citations, which were reviewed in abstract form. Of these, 48 were selected for a full-text review, and 13 met the inclusion criteria and were assigned a quality-of-evidence rating by the panel methodologist. Eight of these studies were rated level II and 5 were rated level III; there were no level I studies. RESULTS: This analysis included 10 studies of the use of autologous serum-based eye drops for severe dry eye disease and 4 studies of persistent epithelial defect. Several studies showed good effectiveness, with some improvement in symptoms, signs, or both. Eight of the studies reported improved symptoms for severe dry eye disease, and all noted improvement in at least 1 clinical sign. For persistent epithelial defects, all of the studies showed improvement, with 3 of the 4 demonstrating an improvement rate of more than 90%. Adverse events were rare. CONCLUSIONS: Although autologous serum-based tears may be effective in the treatment of severe dry eye and persistent epithelial defect, conclusions are limited owing to the absence of controlled trials.

Descemet Membrane Endothelial Keratoplasty: Safety and Outcomes: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the published literature on the safety and outcomes of Descemet membrane endothelial keratoplasty (DMEK) for the surgical treatment of corneal endothelial dysfunction. METHODS: Literature searches were last conducted in the PubMed and the Cochrane Library databases most recently in May 2017. The searches, which were limited to English-language abstracts, yielded 1085 articles. The panel reviewed the abstracts, and 47 were determined to be relevant to this assessment. RESULTS: After DMEK surgery, the mean best-corrected visual acuity (BCVA) ranged from 20/21 to 20/31, with follow-up ranging from 5.7 to 68 months. At 6 months, 37.6% to 85% of eyes achieved BCVA of 20/25 or better and 17% to 67% achieved BCVA of 20/20 or better. Mean endothelial cell (EC) loss was 33% (range, 25%-47%) at 6 months. Overall change in spherical equivalent was +0.43 diopters (D; range, -1.17 to +1.2 D), with minimal induced astigmatism of +0.03 D (range, -0.03 to +1.11 D). The most common complication was partial graft detachment requiring air injection (mean, 28.8%; range, 0.2%-76%). Intraocular pressure elevation was the second most common complication (range, 0%-22%) after DMEK, followed by primary graft failure (mean, 1.7%; range, 0%-12.5%), secondary graft failure (mean, 2.2%; range, 0%-6.3%), and immune rejection (mean, 1.9%; range, 0%-5.9%). Overall graft survival rates after DMEK ranged from 92% to 100% at last follow-up. Best-corrected visual acuity after Descemet's stripping endothelial keratoplasty (DSEK) ranged from 20/34 to 20/66 at 9 months. The most common complications after DSEK were graft detachment (mean, 14%; range, 0%-82%), endothelial rejection (mean, 10%; range, 0%-45%), and primary graft failure (mean, 5%; range, 0%-29%). Mean EC loss after DSEK was 37% at 6 months. CONCLUSIONS: The evidence reviewed supports DMEK as a safe and effective treatment for endothelial failure. With respect to visual recovery time, visual outcomes, and rejection rates, DMEK seems to be superior to DSEK and to induce less refractive error with similar surgical risks and EC loss compared with DSEK. The rate of air injection and repeat keratoplasty were similar in DMEK and DSEK after the learning curve for DMEK.

Ocular Graft-Versus-Host Disease: A Review.

Hematopoietic stem cell transplantation is important in the management of several lymphoproliferative and bone marrow disorders. Graft-versus-host disease (GVHD) involves inflammatory manifestations that arise after transplant and can affect many organs. Ocular manifestations of GVHD are common, and eye care providers must understand this disease entity. The ocular surface is most commonly involved, but GVHD can affect all parts of the eye. Ocular GVHD can be relapsing and remitting, can decrease quality of life, and can be challenging to diagnose and adequately treat. The diagnostic criteria for and grading of ocular GVHD continue to evolve. This review aims to summarize current definitions, clinical findings, diagnostic criteria, and management of ocular GVHD. The care of patients with ocular GVHD requires a multidisciplinary approach.

Insights Into Eye Care Accessibility: Geospatial Distribution of Eye Care Providers and Socioeconomic Factors by ZIP Code.

Purpose: In the United States, the ZIP Code has long been used to collect geospatial data revealing disparities in social determinants of health. This cross-sectional study examines the distribution of eye care access in association with local socioeconomic factors at a ZIP Code level. Methods: Data from the 2020 Centers of Medicare and Medicaid Services and American Community Survey were used to examine locations of 47,949 providers (17,631 ophthalmologists and 30,318 optometrists) and corresponding local socioeconomic variables (education, employment, and income). Multivariable zero-inflated negative binomial regression was used to model eye care provider count per capita in each ZIP Code area with socioeconomic factors as independent covariates. Results: For every 1% increase in percentage of population over 25 years with a bachelor's degree or higher, the expected number of providers increases by 4.4% (incidence rate ratio [IRR] = 1.044; 95% confidence interval [CI], 1.041-1.046; P < 0.001). For every 1% increase in percentage unemployment, the expected number of providers decreases by 2.7% (IRR = 0.973; 95% CI, 0.964-0.983; P < 0.001). However, for every $1000 increase in median household income, the expected number of providers decreases by 1.6% (IRR = 0.984; 95% CI, 0.983-0.986; P < 0.001). Conclusions: Disparities in access exist in areas of lower employment and educational attainment, as both have positive correlations with eye care provider access. Conversely, areas of greater median household income have lower access to providers. Translational Relevance: This research contributes to a greater field studying social determinants of health and may inform public health strategies on allocation of providers to improve equitable access to vision care.

Characterizing Extremely Negative Reviews of Ophthalmologists on Yelp.Com.

PURPOSE: To perform a retrospective characterization of one-star reviews of ophthalmologists on Yelp.com and to increase understanding of patient complaints on Yelp.com. METHODS: A search was performed for reviews on Yelp.com using the keyword "ophthalmologist" for the top 8 most population-dense metropolitan areas in the United States. One-star reviews were collected and classified as procedural or nonprocedural. Complaints were also categorized as clinical, nonclinical, or both. Clinical complaints cited issues such as complications, reoperations, uncontrolled pain, misdiagnosis, unclear treatment plan, etc. Nonclinical complaints included comments such as physician bedside manner, other staff interpersonal manner, wait time, brevity of appointment time, etc. RESULTS: 5,532 total reviews were assessed, of which 477 (9%) one-star reviews were included in the study for analysis. These reviews amounted to 1,120 distinct complaints. 287 (26%) were clinical in nature and 833 (74%) were nonclinical. Technical incompetence or error (50: 4%), unsatisfactory results (46: 4%), and complications (43: 4%) represented the most common clinical complaints while office staff interpersonal manner (182: 16%), wait time (174: 16%), and physician interpersonal manner (141: 13%) were the most common nonclinical complaints. Refractive surgery was the most frequently mentioned subspecialty (89: 8%). Patients undergoing an ophthalmic procedure (surgery, injection, etc.) wrote 64 reviews that resulted in 193 (17%) complaints. Nonprocedural patients wrote 413 reviews that resulted in 927 (83%) complaints. Compared with procedural reviews, nonprocedural reviews were less likely to include a clinical complaint (rate ratio, 0.3: P < .001). DISCUSSION: The majority of one-star reviews of ophthalmologists included in this study were nonclinical. Complaints referencing a procedural episode were more likely to include a clinical component in the review. In the era of intense medical consumerism and increased physician and health care institution competition for patient acquisition and retention, the characterization of excessively negative reviews allows identification of potential areas of concern for patients that use online review sites such as Yelp.com.

Seven Common Allergen Groups Causing Eyelid Dermatitis: Education and Avoidance Strategies.

OBJECTIVE: Eyelid dermatitis is most commonly attributed to allergic response. This retrospective clinical study identifies common allergens with eyelid involvement and addresses a literary gap by providing a clear approach for effective management of periorbital allergic contact dermatitis (ACD) recurrence. METHODS: Charts of 215 patients diagnosed with periorbital dermatitis who were patch tested with Mayo Clinic Standard Series, Extended Standard Series, and personal products from 2013 to 2017 were examined. Positive reaction rates for patients with eyelid involvement were compared to those without. Findings were also compared to North American Contact Dermatitis Group (NACDG) 2013-2014 and Mayo Clinic Contact Dermatitis Group (MCCDG) 2011-2015 general patch test populations. RESULTS: The 215 patients showed more common allergy to shellac, benzalkonium chloride, acrylates, and surfactants than the NACDG and MCCDG study populations. Periorbital ACD allergen groups eliciting the highest positive reaction rates were, in descending order: metals, shellac, preservatives, topical antibiotics, fragrances, acrylates, and surfactants. Of the corticosteroids, only tixocortol pivalate (the screening agent for prednisolone and fluorometholone) and budesonide elicited positive reactions. CONCLUSION: The top seven eyelid ACD allergen groups were identified. Avoidance of these allergens can be straightforward, with initial empiric counseling and free, online allergen avoidance programs. Patients who are unresponsive to avoidance should undergo patch testing.

Effects of Intense Pulsed Light on Tear Film TGF-ß and Microbiome in Ocular Rosacea with Dry Eye.

PURPOSE: To assess tear film transforming growth factor-beta (TGF-ß) and ocular microbiome changes after intense pulsed light with meibomian gland expression (IPL-MGX) vs only MGX in treating ocular rosacea with dry eye symptoms. METHODS: Twenty patients were randomly assigned to IPL-MGX or MGX. Patients were examined, treated, and administered the ocular surface disease index (OSDI) survey every 4-6 weeks for four total treatments. Tear film and conjunctival samples were collected at first and last visits, and analyzed for TGF-ß concentration and 16s rRNA amplicon sequencing of ocular microbiome. Wilcoxon Rank Sum and Sign-Rank were used to examine changes from baseline. RESULTS: OSDI revealed significantly greater improvement in symptoms after IPL-MGX (p=0.030) compared to MGX. There was no significant difference in mean TGF-ß1, 2, or 3 concentration after IPL-MGX (p=0.385, 0.709, 0.948, respectively). Quantities of Clostridium, Klebsiella, Brevibacterium, Lactobacillus, Neisseria, Streptococcus, Corynebacterium, Butyricicoccus, and Actinomyces were significantly reduced from baseline in both groups but without a significant difference between the two treatment groups. CONCLUSION: IPL-MGX improved dry eye symptoms more than MGX alone. IPL treatment offered no additional benefit to MGX in decreasing virulent bacteria present on the ocular surface and did not influence TGF-ß levels in tears. Prospective studies on IPL-MGX with larger sample sizes are needed to further investigate cytokines and IPL in patients suffering from ocular rosacea with dry eye symptoms. CLINICALTRIALSGOV IDENTIFIER: NCT03194698.

Nuclear Medicine and Molecular Imaging in Nodal Staging and Surveillance of Ocular Melanoma: Case Reports and Review of the Literature.

Ocular melanoma (OM) is a rare noncutaneous malignancy and consists of 2 different subtypes based on the anatomic location in the eye: uveal melanoma and conjunctival melanoma. Like cutaneous melanoma, OM benefits from nuclear medicine and molecular imaging in nodal staging and clinical management. Through the illustration of 2 distinctive cases, we aim to demonstrate the complementary roles of standard lymphoscintigraphy, advanced SPECT/CT, 18F-FDG PET/CT, and 18F-FDG PET/MRI in accurate nodal staging and surveillance of OM. We also review the epidemiology, existing staging guidelines, and management of uveal melanoma and conjunctival melanoma.

Climatic and Environmental Correlates of Dry Eye Disease Severity: A Report From the Dry Eye Assessment and Management (DREAM) Study.

Purpose: Correlate climate, weather parameters, and environmental exposures with the severity of symptoms and signs of dry eye disease (DED) in Dry Eye Assessment and Management (DREAM) study participants. Methods: Participants from five distinct climates completed the Ocular Surface Disease Index (OSDI) and were examined for corneal and conjunctival staining, tear breakup time (TBUT), and Schirmer's testing at baseline, 3, 6, and 12 months. Climate, weather parameters, and pollutants including ozone (O3), carbon monoxide (CO), nitrous oxides (NO2, NOx, NOy), sulfur dioxide (SO2), particulate matter, and optical depth were obtained from governmental databases. Multivariate analysis and partial correlation coefficients (ρ) were used to assess associations, adjusted for age, sex, and the presence of Sjögren disease. Results: Among 535 participants, 81% were female and mean age was 58 years. Participants from the Mediterranean climate demonstrated better corneal fluorescein staining, better TBUT, and higher Schirmer's test scores throughout the calendar year (each P < 0.0001). Greater corneal fluorescein staining was associated with lower humidity (P < 0.0038). TBUT measurements positively correlated with temperature, humidity, and dewpoint and inversely correlated with NO2 levels (P < 0.0038). Paradoxically, some airborne pollutants were associated with less severe signs of dry eye (P < 0.0038). Windspeed was not correlated with signs of DED, and OSDI scores did not correlate with individual environmental exposures. Conclusions: Dry eye signs differed between climates and local humidity levels. With the exception of NO2, airborne pollutants were not associated with detrimental dry eye features. Translational Relevance: These results support limiting dry air exposure for patients with DED.

Conjunctival subepithelial fibrosis and meibomian gland atrophy in ocular graft-versus-host disease.

PURPOSE: Dry eye symptoms greatly impact patients' quality of life in ocular graft-versus-host disease (oGVHD). Various ocular surface changes have been reported in oGVHD, including meibomian gland atrophy (MGA) and clinical conjunctival scarring or subepithelial fibrosis (CSEF). The relationships between CSEF, MGA, and other ocular surface changes in oGVHD were examined. METHODS: Charts of 21 consecutive GVHD patients examined by a single ophthalmologist were retrospectively reviewed. International Chronic Ocular Graft-vs-Host-Disease Consensus Group (ICCG) scores were calculated for each patient using previously published methods. The severity of CSEF by slit lamp examination and MGA by infrared meibography were also assessed for each patient. Infrared meibography images were analyzed using ImageJ to determine percent of MGA. Pearson correlation coefficients were calculated using SAS Studio 9.3 (SAS Institute, Cary, NC). RESULTS: In the 42 eyes, no significant correlations were identified among the variables examined (CSEF score, ICCG score, MGA). Further examination revealed asymmetric ocular findings in 20 of 21 patients. Analysis of the more severe eye alone (n = 21) revealed a weakly positive correlation between ICCG score and CSEF (r = 0.54; p = 0.01). No other statistically significant correlations were found. CONCLUSIONS: Clinical CSEF may be an important sign of GVHD impact on the ocular surface and may be relevant in oGVHD severity assessment. Though meibomian glands and conjunctiva are in close proximity, MGA did not correlate with clinical CSEF findings. Some ocular GVHD patients may present with asymmetrical ocular findings, with one eye displaying more severe pathological changes and symptoms despite the systemic nature of GHVD. Further studies are needed to examine these findings.

Is Intravenous Thrombolysis Safe and Effective in Central Retinal Artery Occlusion? A Critically Appraised Topic.

BACKGROUND: Central retinal artery occlusion (CRAO) is a neurological and ophthalmologic emergency associated with poor visual recovery. There is a dilemma regarding the appropriate treatment, as formal guidelines are lacking. Despite being considered an ocular equivalent of cerebral infarction, the time window of intravenous (IV) thrombolysis administration for maximum efficacy and safety in CRAO remains uncertain. OBJECTIVE: To critically assess the current evidence regarding the safety and effectiveness of IV thrombolysis in the treatment of patients with CRAO. METHODS: The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, and content experts in the fields of vascular neurology and ophthalmology. RESULTS: A recent patient-level meta-analysis was selected for critical appraisal. The study compared the visual recovery rates after IV thrombolysis in CRAO against the natural history of this illness and conservative therapies (ocular massage, anterior chamber paracentesis, and/or hemodilution). Time to thrombolytic therapy administration had a significant impact on visual recovery in CRAO (P<0.001). IV thrombolysis within the first 4.5 hours after symptom onset resulted in recovery of vision in 50.0% of the patients [95% confidence interval (CI), 32.4%-67.6%]. The rate of visual recovery was nearly 3 times higher than in the natural history cohort [odds ratio, 4.7 (95% CI, 2.3-9.6); P<0.001], with a 32.3% absolute risk reduction and a number needed to treat of 4.0 (95% CI, 2.6-6.6). There was no significant difference in the recovery rate after thrombolysis compared with the natural history cohort for those patients treated after 4.5 hours. No major hemorrhages occurred after alteplase administration in this meta-analysis. CONCLUSIONS: IV thrombolysis in CRAO seems to be safe and effective within the first 4.5 hours of symptom onset. A clinical decision based on this meta-analysis alone cannot be made due to several limitations. A randomized controlled clinical trial of early IV alteplase administration in CRAO is necessary to provide evidence-based therapeutic guidance.

Combination Therapy of Intense Pulsed Light Therapy and Meibomian Gland Expression (IPL/MGX) Can Improve Dry Eye Symptoms and Meibomian Gland Function in Patients With Refractory Dry Eye: A Retrospective Analysis.

PURPOSE: To assess the improvement in meibomian gland function and dry eye symptoms in patients with refractory dry eye treated with a combination therapy of intense pulsed light (IPL) and meibomian gland expression (MGX). METHODS: Medical records of 81 consecutive patients with dry eye treated with serial IPL/MGX were retrospectively examined to determine the outcome. All patients had a minimum of 6 months of follow-up after the first IPL/MGX treatment. Patients typically received 1 to 4 IPL treatments spaced 4 to 6 weeks apart. Each IPL session included MGX. Thirty-five charts had complete data for inclusion in analysis. We reviewed demographics, ocular histories, Standard Patient Evaluation of Eye Dryness 2 (SPEED2) symptom survey scores, slit-lamp examinations, and meibomian gland evaluations (MGE) at baseline and at each visit before IPL/MGX treatments. RESULTS: The paired t test showed a significant (P < 0.0001) decrease in SPEED2 with IPL/MGX therapy. Of the 35 patients, 8 (23%) had a ≥50% decrease in SPEED2, 23 (66%) had a 1% to 49% decrease in SPEED2, 1 (3%) had no change in SPEED2, and 3 (9%) had an increase in SPEED2. The Paired t test showed a significant increase in MGE in the left eye but not in the right eye (OD P = 0.163 and OS P = 0.0002). Thirteen patients (37%) had improved MGE bilaterally. Eight patients (23%) had either a decrease in MGE bilaterally or a decrease in 1 eye with no change in the other eye. CONCLUSIONS: This retrospective analysis shows that the combination of IPL and MGX can significantly improve dry eye symptoms (in 89% of patients) and meibomian gland function (in 77% of patients in at least 1 eye).

Lysosomal hydrolase staining of conjunctival impression cytology specimens in keratoconus.

PURPOSE: This study sought to assess the feasibility of impression cytology for the determination of conjunctival intracellular lysosomal hydrolase (acid esterase) levels in patients with keratoconus. METHODS: Twenty-two patients with keratoconus currently enrolled in the Collaborative Longitudinal Evaluation of Keratoconus (CLEK) Study and 22 age-and sex-similar controls underwent impression cytology. Samples were collected from each subject and control pair on the same day. The cells of the respective specimens were fixed immediately and were stained for acid esterase with use of identical batches of fixatives and stains. After staining, the specimens were cleared in xylene for mounting in synthetic resin on glass slides. The acid esterase staining intensity of each specimen was quantified as the percentage of light transmitted with use of an image analysis system (Zeiss). Multiple cells from each specimen were analyzed for each sample collected. RESULTS: Mixed model analysis was used to account for the subject-control pairings and for the multiple cells from each sample. With this method, the mean light transmission for normal controls (mean = 63.0; standard error [SE] = 3.0) was highly statistically significantly different from that for the keratoconus subjects (mean = 52.4; SE = 3.0) (two-tailed p= 0.0032). CONCLUSIONS: This study establishes the feasibility of adapting an acid esterase staining technique to conjunctival cells collected via impression cytology. Higher levels of lysosomal enzyme staining in patients with keratoconus have been previously reported by other investigators using full-thickness conjunctival specimens. We also demonstrate the value of using objective microspectrophotometry in measuring lysosomal enzyme staining with impression cytology specimens.