The effect of the glycemic control on the aqueous humor glucose levels in diabetic patients undergoing elective cataract surgery.

PURPOSE: Aqueous humor glucose levels play a role in the anterior segment disorders' pathophysiology, mainly in diabetics. Our purpose was to evaluate the ratio of aqueous humor glucose levels to blood glucose levels in diabetics and to evaluate the correlation between this ratio and blood glycated hemoglobin (HbA1c) levels. METHODS: This prospective study was performed in Sheba Medical Center during 2016-2018. The study included type 2 diabetic patients admitted for elective cataract surgery. Blood glucose levels were measured immediately before surgery. HbA1c was obtained within 3 months preoperatively. At the beginning of surgery, 0.05-0.1 mL aqueous humor was drawn. Main outcome measures were aqueous humor glucose/blood glucose ratio and the correlation between HbA1c and aqueous humor glucose/blood glucose ratio. RESULTS: Thirty-seven patients (mean age 75.2 ± 11.2 years) were recruited. The average aqueous humor glucose/blood glucose ratio was 0.69 ± 0.20. A significant positive correlation was found between aqueous humor and blood glucose levels, Pearson coefficient constant R = 0.63 (p < 0.01), and specifically stronger among older patients R = 0.89 (p < 0.01), females R = 0.74 (p < 0.01), patients with short-term disease (<10 years) R = 0.80 (p < 0.01), and patients treated with oral anti-diabetic treatment R = 0.74 (p < 0.01). A significant strong positive correlation was found between HbA1c levels and aqueous humor glucose/blood glucose ratio R = 0.62 (p < 0.01), and specifically stronger among older patients R = 0.82 (p < 0.01), males R = 0.70 (p < 0.01), patients with prolonged disease (⩾10 years) R = 0.540 (p < 0.05), and patients treated with oral anti-diabetic treatment R = 0.62 (p < 0.01). CONCLUSION: A significant strong correlation was found between aqueous humor glucose levels and blood glucose levels. Poor glycemic control was strongly correlated with an increased ratio, reflecting an increased anterior chamber's glucose permeability. Older age group was found to have stronger correlation of poor glycemic control with this ratio.

Safety of cataract surgery in patients treated with the new oral anticoagulants (NOACs).

PURPOSE: To evaluate the safety of phacoemulsification of cataract in patients taking new oral anticoagulants (NOACs). METHODS: In a prospective case series, consecutive patients on NOACs (dabigatran, rivaroxaban, or apixaban) who were referred for uncomplicated cataract surgery to the eye institute underwent a thorough ophthalmological and hematological evaluation. Rivaroxaban and apixaban anti-factor Xa tests, and diluted thrombin time for dabigatran, were used for monitoring anticoagulation levels in blood. Blood was drawn for these tests just prior to surgery and at a peak level of the drug at about 4 h post-surgery (2 h after the drug was given). All surgeries were videotaped and patients were examined at 1 and 7 days after the operation. The main outcome measures included assessment of intra-operative, postoperative ocular bleeding, and other related complications. RESULTS: Thirty-five eyes of 25 unrelated patients ranging in age from 63 to 92 years (mean 77.6 years) underwent phacoemulsification. Intra-operative bleeding was observed in 5 eyes from the conjunctiva or limbus at the main incision site. No intraocular bleeding occurred. No hemorrhagic complications were observed during the 1-week follow-up. According to anti-factor Xa levels prior to surgery and following surgery, 85% of the patients were on therapeutic levels of NOACs. CONCLUSIONS: Clear corneal incision phacoemulsification performed under topical anesthesia can be safely performed in simple cases of cataract without discontinuing NOAC treatment.

Consecutive appearance of corneal subepithelial infiltrates after intravitreous bevacizumab injections.

PURPOSE: To report a case of corneal subepithelial infiltrates appearing after intravitreous bevacizumab injections. METHODS: A review of the patient's history and clinical examination findings in a patient who had epidemic keratoconjunctivitis more then 20 years before treatment with bevacizumab for age-related macular degeneration. RESULTS: After the third and fourth bevacizumab injections, the patient presented with unilateral corneal subepithelial infiltrates. The infiltrates were accompanied by mild anterior chamber reaction and resolved with topical steroid treatment. CONCLUSIONS: Treatment with intravitreous bevacizumab may precipitate an immune response leading to the appearance of corneal subepithelial infiltrates.

Differences in the corneal biomechanical effects of surface ablation compared with laser in situ keratomileusis using a microkeratome or femtosecond laser.

PURPOSE: To compare the effects of different flap creation techniques on the biomechanical properties of the cornea in patients having myopic laser refractive surgery. SETTING: UCLA Laser Refractive Center of the Jules Stein Eye Institute, Los Angeles, California, USA. METHODS: In this retrospective case series, eyes that had myopic laser refractive surgery were categorized according to the type of flap creation: mechanical microkeratome (MK) LASIK (n=32), femtosecond laser (FSL) LASIK (n=32), or no flap creation (PRK) (n=33). The preoperative central corneal thickness, intraoperative flap thickness, and planned ablation depth (AD),and the preoperative and postoperative manifest refraction spherical equivalent, corneal hysteresis (CH), and corneal resistance factor (CRF) were recorded. RESULTS: The mean change in CH (DeltaCH) was 2.2 mm Hg, 1.9 mm Hg, and 2.3 mm Hg in the MK, FSL, and PRK groups, respectively. There were no significant differences in AD, DeltaCH, or DeltaCRF between the 3 groups. The correlation between AD and DeltaCH was significant in all 3 groups. The correlation was strongest in the FSL group (r=0.82, P<.0001) and weaker in the PRK group (r=0.47, P= .006) and MK group (r=0.46, P= .008). CONCLUSIONS: The biomechanical measures of CH and CRF decreased similarly after PRK and LASIK using laser or mechanical flap creation. However, LASIK using femtosecond laser flap creation caused a significantly more predictable change in corneal biomechanics, which correlated strongly with AD, than the change with PRK and LASIK with microkeratome flap creation.

Corneal biomechanical measurements before and after laser in situ keratomileusis.

PURPOSE: To study the correlation between corneal biomechanical properties and surgical parameters in myopic patients before and after laser in situ keratomileusis (LASIK). SETTING: UCLA Laser Refractive Center of the Jules Stein Eye Institute, Los Angeles, California, USA. METHODS: In 43 eyes of 43 patients, the Ocular Response Analyzer was used to measure corneal hysteresis (CH), corneal resistance factor (CRF), Goldmann-correlated intraocular pressure (IOPg), and corneal-compensated IOP (IOPcc) before and 1 month after LASIK. Manifest refraction spherical equivalent (MRSE), preoperative central corneal thickness (CCT), flap thickness (FT), and ablation depth (AD) were also recorded. Changes in these parameters after LASIK were calculated and the correlations between the change in CH (DeltaCH), change in CRF (DeltaCRF) and the AD, change in MRSE (DeltaMRSE), and CCT were examined. The relationship between DeltaCRF and DeltaMRSE was examined by linear regression analysis. RESULTS: The preoperative mean CH and mean CRF (11.52 mm Hg +/- 1.28 [SD] and 11.68 +/- 1.40 mm Hg, respectively) were significantly higher than postoperative values (9.48 +/- 1.24 mm Hg and 8.47 +/- 1.53 mm Hg, respectively) (P < .0001). A higher attempted correction was correlated with a larger DeltaCH and DeltaCRF (AD, r = 0.47 and r = 0.65, respectively; DeltaMRSE, r = 0.51 and r = 0.66, respectively). No correlation was found between DeltaCH, DeltaCRF, and preoperative CCT. CONCLUSIONS: Changes in CH and CRF after LASIK suggest alteration in corneal biomechanics correlating with attempted correction. The CRF parameter may be more useful than the CH parameter in assessing biomechanical changes resulting from LASIK.

A novel variant of combined granular-lattice corneal dystrophy associated with the Met619Lys mutation in the TGFBI gene.

OBJECTIVE: To report a novel mutation in TGFBI (GenBank NM_000358), p.Met619Lys, associated with a variant of combined granular-lattice corneal dystrophy. METHODS: Slitlamp examination and DNA collection from the proband and affected and unaffected relatives. All 17 exons of TGFBI were amplified and sequenced in the proband. Exon 14 was amplified and sequenced in the proband's family members and in 100 controls. Histopathologic examination of the excised corneal buttons from the proband and 3 family members was also performed. RESULTS: Affected individuals demonstrated an age-dependent phenotype, with the progression from central subepithelial needlelike deposits in younger individuals to polymorphic anterior stromal opacities in older family members. Screening of TGFBI in the proband demonstrated a novel mutation, p.Met619Lys, which was also present in all affected family members. Histopathologic examination revealed stromal deposits that stained with the Congo red and Masson trichrome stains as well as an antibody to the protein product of TGFBI. CONCLUSIONS: We present a unique corneal dystrophy phenotype associated with the novel p.Met619Lys mutation in TGFBI. Clinical Relevance The atypical and variable phenotype and the demonstration of both hyaline and amyloid stromal deposits indicate that neither clinical nor histopathologic features may be relied on to accurately diagnose and classify the corneal dystrophies.

Risk for eye splash injury during administration of intraocular injections: a study of retina specialists and fellows.

OBJECTIVE: To evaluate the use of eye protection and frequency of eye splash events during intraocular injections as well as infection risk awareness among retina specialists and fellows in training. METHODS: In a prospective survey of practicing retina specialists and retina fellows, frequency of use and type of eye protection employed during intraocular injections, frequency of eye splash occurrences, description of the eye splash event, number of procedures performed, and awareness of transconjunctival infection risk were investigated. RESULTS: Sixty-four ophthalmologists responded to the questionnaire: 40 retina fellows and 24 retina specialists. The response rate was 100%. Twenty-five percent of the fellows and 33.3% of the specialists reported using eye protection, including corrective glasses, during all intraocular injections. Two of the retina fellows and none of the specialists used special forms of eye protection. Retina fellows had a mean +/- SD of 2.1 +/- 1.3 years experience and the specialists had a mean +/- SD of 10.4 +/- 6.7 years experience in performing intraocular injections. The mean number of injections +/- SD performed by the fellows and specialists was 23 +/- 14.6 and 35 +/- 11.9 per month, respectively. Twelve conjunctival or corneal splash occurrences were reported by six fellows and two retina specialists. Eleven splash events occurred due to reflux of fluid during administration of subconjunctival anesthetic injection, and one event occurred during an anterior chamber tap. Splash events were significantly more likely to occur during procedures performed by fellows, with a relative risk of 8.4 for unprotected procedures (P< 0.001, Fisher exact test). Most (87.5%) of the participants were aware of the risk for transconjunctival viral infection. CONCLUSION: Special eye protection is seldom used during administration of intraocular injections. Although the risk for eye splash during administration of subconjunctival anesthetic before intraocular injections is relatively small, protective measures may be considered when treating high-risk patients.

The slower the better: on the instability of gas jets in a model of pneumatic retinopexy.

PURPOSE: To investigate the effect of injection technique parameters on the formation of multiple gas bubbles in a porcine eye model for pneumatic retinopexy. METHODS: Three hundred twenty-four adult porcine eyes were injected with 0.4 mL of C3F8 with variations in the depth of injection, speed of injection, and size of needle bore. The number of gas bubbles in the eye was assessed with indirect ophthalmoscopy. RESULTS: Shallow injections resulted in a higher incidence of a single bubble than did deep injections (P < 0.001; Fisher exact and Wilcoxon rank sum tests). Slow injections were significantly advantageous in producing a single gas bubble during shallow as well as during deep injections (P < 0.001, Fisher exact and Wilcoxon rank sum tests). With a shallow needle insertion, the slow speed of injection produced a single bubble in 75.9% of the eyes, whereas moderately brisk injections resulted in one bubble in 50.9% of the eyes. During deep needle insertion, 44.4% of the eyes had one bubble if the gas was injected slowly and only 11.1% had a single bubble with moderately brisk gas injections. The bore of the needle did not significantly change the number of bubbles during deep or shallow injections. CONCLUSIONS: The factors that were found to be important in reducing the formation of multiple gas bubbles in the eye were shallow depth of injection and slow speed of gas delivery.

Primary congenital upper eyelid retraction in infants and children.

Four infants with unilateral or bilateral eyelid retraction were examined. A full clinical evaluation revealed no ocular or systemic pathology. In all cases, clinical examination, thyroid function tests, and neuroimaging of the brain and orbits revealed no underlying disease process. The eyelid retraction did not change over the follow-up period of 2 to 6 years. Unilateral or bilateral eyelid retraction in infants and children may be an isolated clinical entity without an associated underlying disease.

Eyelid splitting and extirpation of hair follicles using a radiosurgical technique for treatment of trichiasis.

BACKGROUND AND OBJECTIVE: To describe a new, simple, and rapid surgical modification for the treatment of trichiasis. PATIENTS AND METHODS: In this noncomparative, prospective, interventional case series, 12 eyelids of 8 consecutive patients suffering from acquired trichiasis were treated by splitting the eyelid margin using a radiosurgical technique and then extirpating the hair follicles. The main outcome measure was successful resolution of trichiasis without recurrence during a follow-up period of at least 1 year. RESULTS: Complete recovery of the trichiatic eyelashes at the site of the treatment occurred in 10 of the 12 eyelids treated. There were no complications during or after healing of the surgical wound during the follow-up period. CONCLUSION: Radiosurgery provides a simple and rapid modification of the surgical treatment for acquired trichiasis, with good functional results.