The Effect of Blue-light Filtering Intraocular Lenses on the Development and Progression of Macular Atrophy in Eyes With Neovascular Age-related Macular Degeneration.

PURPOSE: To assess the effect of blue-light filtering (BLF) intraocular lenses (IOLs) on the development and progression of macular atrophy (MA) in eyes with neovascular age-related macular degeneration (nAMD). DESIGN: Retrospective, clinical cohort study. METHODS: The study included patients with nAMD with anti-vascular endothelial growth factor (VEGF) injections who underwent uneventful cataract surgery between 2007 and 2018 with follow-up until June 2023. Subsequent MA rates were compared between subjects who received a BLF IOL or a non-BLF IOL. All optical coherence tomography scans were manually reviewed in a masked manner regarding patient baseline variables and IOL status by an experienced research technician. By using Heidelberg software, the area of MA was manually evaluated and calculated (mm2) by the program. The overall risk of developing new-onset MA and the effect of IOL type on disease progression were assessed. Death was included as a censoring event. RESULTS: Included were 373 eyes of 373 patients (mean age, 78.6 ± 6.7 years at surgery; 67.4% were female). BLF IOLs were implanted in 206 eyes, and non-BLF IOLs were implanted in 167 eyes with comparable follow-up times (3164 ± 1420 days vs 3180 ± 1403 days, respectively, P = .908) and other baseline parameters (age, gender, corrected distance visual acuity, macular thickness, cumulative number of anti-VEGF injections). Nine preexisting and 77 new-onset MA cases were detected, with similar distribution between BLF and non-BLF eyes (P = .598 and P = .399, respectively). Both univariate Kaplan-Meier (P = .366) and multivariate Cox regression analyses adjusted for age and gender showed that BLF-IOLs were comparable to non-BLF IOLs regarding hazard for new-onset MA (hazard ratio [HR], 1.236; 95% CI, 0.784-1.949; P = .363). Final MA area at the last visit was 5.14 ± 4.71 mm2 for BLF IOLs and 8.56 ± 9.17 mm2 for non-BLF IOLs (P = .028), with the mean annual MA area increase of 0.78 ± 0.84 mm2 and 1.26 ± 1.32 mm2, respectively (P = .042). CONCLUSIONS: BLF IOLs did not show added benefit over non-BLF IOLs in terms of MA-free survival but were associated with less progression over time in a cohort of patients with nAMD.

[PETERS ANOMALY AND PETERS PLUS SYNDROME].

INTRODUCTION: Peters anomaly is characterized by a defect in the development of the anterior segment of the eye during fetal development (Anterior segment dysgenesis). This anomaly presents a broad clinical presentation ranging from minimal peripheral corneal opacity to extensive adhesions of the iris and lens with dense central corneal opacity that impairs vision. Peters Plus Syndrome is a recessive autosomal syndrome manifested by Peters anomaly, along with systemic disorders such as brachydactyly (short fingers and toes), short stature, a developmental delay, dysmorphic facial features, and may accompanied with heart and genitourinary malformations. The most common sign of Peters' anomaly is corneal opacity that appears at birth. This opacity can cause blockage of the central visual axis and cause the development of a deprivational amblyopia. In addition, the patient may suffer from glaucoma due to malformations in the angle structures as well as a shallow anterior chamber. Treatments are aimed at clearing the central visual axis as soon as possible in order to allow the visual system to mature and to avoid the development of amblyopia. Full-thickness corneal transplantation combined with Cataract surgery if necessary is the current standard of care. Optical iridoplasty is a milder surgical alternative in cases where the corneal opacity is not significant.

The Effect of Blue-Light Filtering Intraocular Lenses on the Development and Progression of Glaucoma.

PRCIS: Among patients who underwent uneventful cataract surgery, an advantage was seen to blue-light filtering (BLF) intraocular lenses (IOLs) in terms of glaucoma-free survival and glaucoma procedure-free survival. Among patients with preexisting glaucoma, no advantage was seen. PURPOSE: To assess the effect of BLF IOLs on the development and progression of glaucoma after cataract surgery. PATIENTS AND METHODS: A retrospective cohort study of patients who underwent uneventful cataract surgery between 2007 and 2018 at Kymenlaakso Central Hospital, Finland. Survival analyses for the overall risk of developing glaucoma or undergoing glaucoma procedures were assessed between patients who received a BLF IOL (SN60WF) and a non-BLF IOL (ZA9003 and ZCB00). A separate analysis was performed on patients with preexisting glaucoma. RESULTS: Included 11,028 eyes of 11,028 patients with a mean age of 75 ± 9 years (62% females). The BLF IOL was used in 5188 eyes (47%) and the non-BLF IOL in 5840 eyes (53%). During the follow-up (mean: 55 ± 34 mo), 316 cases of glaucoma were diagnosed. Glaucoma-free survival rates showed an advantage to the BLF IOL ( P = 0.036). In a Cox regression analysis controlling for age and sex the use of a BLF IOL was again associated with a lower ratio of glaucoma development (hazard ratio:0.778; 95% CI: 0.621-0.975). Furthermore, glaucoma procedure-free survival analysis revealed an advantage to the BLF IOL (hazard ratio:0.616; 95% CI: 0.406-0.935). Among 662 cases, which already had glaucoma at the time of surgery, no significant differences were seen in any outcome. CONCLUSIONS: Among a large cohort of patients who underwent cataract surgery, the use of BLF IOLs was associated with favorable glaucoma outcomes compared with the use of non-BLF IOLs. Among patients with preexisting glaucoma, no significant advantage was seen.

Evaluation of IOL power calculation with the Kane formula for pediatric cataract surgery.

PURPOSE: To assess the accuracy of the Kane formula for intraocular lens (IOL) power calculation in the pediatric population. METHODS: The charts of pediatric patients who underwent cataract surgery with in-the-bag IOL implantation with one of two IOL models (SA60AT or MA60AC) between 2012 and 2018 in The Hospital for Sick Children, Toronto, Ontario, CanFada, were retrospectively reviewed. The accuracy of IOL power calculation with the Kane formula was evaluated in comparison with the Barrett Universal II (BUII), Haigis, Hoffer Q, Holladay 1, and Sanders-Retzlaff-Kraff Theoretical (SRK/T) formulas. RESULTS: Sixty-two eyes of 62 patients aged 6.2 (IQR 3.2-9.2) years were included. The SD values of the prediction error obtained by Kane (1.38) were comparable with those by BUII (1.34), Hoffer Q (1.37), SRK/T (1.40), Holaday 1 (1.41), and Haigis (1.50), all p > 0.05. A significant difference was observed between the Hoffer Q and Haigis formulas (p = 0.039). No differences in the median and mean absolute errors were found between the Kane formula (0.54 D and 0.91 ± 1.04 D) and BUII (0.50 D and 0.88 ± 1.00 D), Hoffer Q (0.48 D and 0.88 ± 1.05 D), SRK/T (0.72 D and 0.97 ± 1.00 D), Holladay 1 (0.63 D and 0.94 ± 1.05 D), and Haigis (0.57 D and 0.98 ± 1.13 D), p = 0.099. CONCLUSION: This is the first study to investigate the Kane formula in pediatric cataract surgery. Our results place the Kane among the noteworthy IOL power calculation formulas in this age group, offering an additional means for improving IOL calculation in pediatric cataract surgery. The heteroscedastic statistical method was first implemented to evaluate formulas' predictability in children.

Effect of cataract surgery on wet age-related macular degeneration activity.

BACKGROUND: Wet age-related macular degeneration (AMD) and age-related cataract are often coexisting causes of visual impairment. Yet, the timing of cataract surgery in wet AMD patients is controversial. METHODS: One hundred and eleven eyes of 111 patients with wet AMD underwent cataract surgery at Helsinki University Hospital in Finland during 2014-2018. Best-corrected visual acuity and central subfield macular thickness (CSMT) were analysed at the time of wet AMD diagnosis, at the last recording prior to cataract surgery and at the first recording and at 1 year after surgery. The cumulative number of antivascular endothelial growth factor (anti-VEGF) injections at surgery, systemic and topical medication and postoperative anti-VEGF burden were recorded. RESULTS: Mean age was 78.9 ± 5.6 years at the time of surgery. Central subfield macular thickness (CSMT) significantly decreased (280.1 ± 75.0 µm preoperatively to 268.6 ± 67.6 µm at the first postoperative recording, p = 0.001, and to 265.9 ± 67.9 µm at 1 year, p = 0.003), visual acuity improved (0.70 ± 0.46 logMAR units preoperatively to 0.39 ± 0.40 at the first postoperative recording, and to 0.33 ± 0.34 at 1 year, p < 0.001 for both) and anti-VEGF treatment intervals lengthened despite the surgery (6.53 ± 2.08 weeks prior to surgery to 7.03 ± 2.23 weeks at 1 year, p = 0.246, and to 7.05 ± 2.57 weeks at the last documented visit, p = 0.035). A CSMT increase of over 30% from the preoperative values was seen in only one case (1 out of 111 eyes, 0.9%). Macular status at surgery, wet AMD subtype, comorbidity of type II diabetes, systemic drugs and topical anti-inflammatory medication were not associated with macular changes nor with treatment intervals after surgery. The cumulative number of anti-VEGF injections correlated neither with CSMT change postoperatively (r = -0.051, p = 0.619) nor with CSMT change at 1 year (r = 0.091, p = 0.426). CONCLUSION: Satisfactory visual outcomes and controlled disease activity were seen in patients with wet AMD undergoing cataract surgery. We found no evidence to support delaying surgery in patients who require it.

Comparison of the Barrett Universal II formula to previous generation formulae for paediatric cataract surgery.

PURPOSE: To compare the accuracy of the Barrett Universal II (BUII) five-variable formula to previous generation formulae in calculating intraocular lens (IOL) power following paediatric cataract extraction. METHODS: Retrospective study of consecutive paediatric patients who underwent uneventful cataract extraction surgery along with in-the-bag IOL implantation between 2012 and 2018 in the Hospital for Sick Children, Toronto, Ontario, Canada. The accuracy of five different IOL formulae, including the BUII, Sanders-Retzlaff-Kraff Theoretical (SRK/T), Holladay I, Hoffer Q and Haigis, was evaluated. Constant optimization was performed for each IOL and for each formula separately. Mean prediction error (PE) and the mean and median absolute PE (APE) were calculated for the five different IOL formulae investigated. RESULTS: Sixty-six eyes of 66 children (59% males) with a median age at surgery of 6.2 years (IQR, 3.2-9.2 years) were included in the study. The mean IOL power that was implanted was 23.3 ± 5.1 D (range; 12.0-39.0 D). Overall, the BUII had a comparable median APE to the Hoffer Q, Holladay I, SRK/T and Haigis formulae (BUII: 0.49D versus 0.48D, 0.61D, 0.74D and 0.58D respectively; p = 0.205). The BUII, together with Hoffer Q, produced better predictability within 0.5D from target refraction compared with the SRK/T formula (BUII:51.5%, Hoffer Q:51.5% versus SRK/T:31.8%, p = 0.002 for both). CONCLUSION: The BUII formula had comparable accuracy to other tested formulae and outperformed the SRK/T formula, when calculating IOL power within the 0.5D range from target refraction in paediatric eyes undergoing cataract surgery with in-the-bag IOL implantation.

Outcomes of Repair of Total Graft Detachment following Descemet's Membrane Endothelial Keratoplasty. / Rettungsversuche einer vollständigen Transplantatablösung nach Descemet-Membran-Endothelkeratoplastik.

OBJECTIVE: To present the outcomes of attempts to salvage total graft detachment following Descemet's membrane endothelial keratoplasty (DMEK). METHODS: A search of the electronic medical records of two tertiary medical centers for all patients who underwent DMEK yielded six cases of postoperative total graft detachment (2.54%). Graft salvage was attempted in all cases using repeated intracameral graft staining, unfolding, and reattachment to the stroma under 20% hexafluoride gas. RESULTS: In all cases, a free-floating totally detached graft was identified in the anterior chamber shortly after surgery. Salvage surgery resulted in a central, well-oriented, and fully attached graft. In three cases, the primary graft failed, and in two, the corneas cleared at first but failed after 2 months and 1 year respectively. In one case, the cornea remained clear during 1 year of follow-up but had a very low endothelial cell density. CONCLUSION: Reattachment of fully detached DMEK graft is technically possible, but graft manipulation during the primary and secondary operations is likely to damage the endothelial cells, resulting in primary or early graft failure. If graft salvage is attempted, the probability of primary or early graft failure should be discussed with the patient, and expectations should be tempered accordingly.

Descemet Membrane Endothelial Keratoplasty Outcomes between Young and Old Graft Recipients.

Purpose: To evaluated Descemet's membrane endothelial keratoplasty (DMEK) outcomes in young and old graft recipients.Materials and Methods: Data of 164 surgeries with a median age of 76 years (interquartile range 14 years) undergoing DMEK surgery between 2016 and 2018 was reviewed. Complications, graft survival, and visual acuity gain were compared between subjects in the 25th percentile (young recipients; aged 70 years and less, n = 21) and 75th percentile (old recipients; aged 85 years and over, n = 27) over the 2-year follow-up.Results: Young recipients had a lower rate of pre-operative glaucoma (14.3% vs. 51.9%, p = .014) and pseudophakic bullous keratopathy (9.5% vs. 59.3%, p < .001), and a higher rate of Fuchs endothelial dystrophy (57.1% vs. 14.8%, p = .002) and combined cataract extraction at the time of DMEK surgery (52.4% vs. 7.4%, p = .001) when compared to old recipients. Complications (primary graft failure, pupillary block, cystoid macular edema or infectious keratitis) were independent of graft recipient age. Descemet's membrane detachment requiring re-bubbling was observed more often in young compared to the old recipients (42.9% vs. 14.8%, p = .049). Visual acuity gain between the groups remained comparable up to 1-year, whereas at 2-years old recipients showed significantly declined visual acuity gains compared to the young recipients (0.14 ± 0.68 vs. 0.74 ± 0.49, p = .012). Graft recipients aged over 85 years had a considerably higher graft failure rate over the 24-months (40.7% vs. 4.8%, p = .006) and shorter graft survival time (p = .002; log-rank) when compared to the recipients aged under 70 years. After adjusting for potential confounders such as Fuchs endothelial dystrophy, pseudophakic bullous keratopathy and glaucoma, the recipients aged over 85 remained at higher risk for graft failure (HR = 17.278, 95% CI = 1.787-167.1, p = .014).Conclusions: In aged DMEK recipients, regardless of the low incidence of early postoperative complications, the rate of postoperative graft failure was significantly higher and graft survival shorter than in younger recipients.

High Agreement between Barrett Universal II Calculations with and without Utilization of Optional Biometry Parameters.

PURPOSE: To examine the contribution of anterior chamber depth (ACD), lens thickness (LT), and white-to-white (WTW) measurements to intraocular lens (IOL) power calculations using the Barrett Universal II (BUII) formula. METHODS: Measurements taken with the IOLMaster 700 (Carl Zeiss, Meditec AG, Jena, Germany) swept-source biometry of 501 right eyes of 501 consecutive patients undergoing cataract extraction surgery between January 2019 and March 2020 were reviewed. IOL power was calculated using the BUII formula, first through the inclusion of all measured variables and then by using partial biometry data. For each calculation method, the IOL power targeting emmetropia was recorded and compared for the whole cohort and stratified by axial length (AL) of the measured eye. RESULTS: The mean IOL power calculated for the entire cohort using all available parameters was 19.50 ± 5.11 diopters (D). When comparing it to the results obtained by partial biometry data, the mean absolute difference ranged from 0.05 to 0.14 D; p < 0.001. The optional variables (ACD, LT, WTW) had the least effect in long eyes (AL ≥ 26 mm; mean absolute difference ranging from 0.02 to 0.07 D; p < 0.001), while the greatest effect in short eyes (AL ≤ 22 mm; mean absolute difference from 0.10 to 0.21 D; p < 0.001). The percentage of eyes with a mean absolute IOL dioptric power difference more than 0.25 D was the highest (32.0%) among the short AL group when using AL and keratometry values only. CONCLUSIONS: Using partial biometry data, the BUII formula in small eyes (AL ≤ 22 mm) resulted in a clinically significant difference in the calculated IOL power compared to the full biometry data. In contrast, the contribution of the optional parameters to the calculated IOL power was of little clinical importance in eyes with AL longer than 22 mm.

Nd:YAG capsulotomy is not a risk factor for retinal detachment after phacoemulsification cataract surgery.

PURPOSE: To evaluate the cumulative incidence and risk factors of pseudophakic retinal detachment (PRD) following phacoemulsification cataract surgery. METHODS: Cataract surgeries performed between the years 2007 and 2016 at the Ophthalmology Unit of Kymenlaakso Central Hospital, Kotka, Finland, were included. The cumulative incidence of PRD was estimated through Kaplan-Meier analysis. Patient mortality was incorporated as one of the censoring events. Cox regression analyses were used to evaluate potential risk factors, including age, gender, intraocular lens (IOL) power and previous neodymium-doped yttrium aluminium garnet (Nd:YAG) laser capsulotomy. RESULTS: A total of 17 688 eyes of 12 003 patients were included. The mean patient age at surgery was 75.2 ± 9.1 years with 63.5% females (n = 11 228). During the mean follow-up time of 4.3 ± 2.7 years, 83 laterality-matched PRDs were registered (incidence 0.11% per year). Univariate analyses showed that age (HR 0.93; 95% CI 0.92-0.95), male gender (HR 3.99; 95% CI 2.52-6.33) and IOL power (HR 0.86; 95% CI 0.83-0.90) were significantly associated with PRD (p < 0.001 for all) and remained significant in a multivariate analysis. Neither univariate (HR 1.45; 95% CI 0.82-2.54, p = 0.201) nor multivariate (HR 1.03; 95%CI 0.57-1.88, p = 0.919) analyses showed any association between Nd:YAG capsulotomy and PRD. CONCLUSIONS: Male gender, low IOL power and younger age were confirmed as risk factors for PRD after phacoemulsification surgery. Real-world evidence suggests that Nd:YAG capsulotomy does not increase the risk for PRD.

Academic background, professional experience, and research achievements of United States academic ophthalmology leadership.

PURPOSE: To characterize the academic background, professional experience, and scholarly achievements of United States (US) academic ophthalmologists serving in leadership positions. METHODS: This is a cross-sectional study. An online search of publicly available resources was conducted for demographics, background, research productivity, and academic appointments of academic ophthalmologists in leadership positions: chairperson (CP), vice chair (VC), service director (SD), and program director (PD). RESULTS: Five hundred and fifty-one academic ophthalmologists in leadership positions were analyzed. A male predominance was found in all positions, ranging from 86% male CPs to 68% of SDs. Eighty-nine percent were graduates of US medical schools, and 97% completed their residency in a US ophthalmology program. Harvard Medical School and The Johns Hopkins University School of Medicine and their affiliated programs were the most frequently attended by leaders. The most common subspecialties among leaders were surgical retina (21%), cornea (18%), and glaucoma (16%). Overall, 18% of leaders are endowed professors, 34% are full professors, 25% are associate professors, and 20% are assistant professors. Overall, 28% of department leaders were residents and 16% were fellows in their current program. Chairpersons, followed by their vice, are the most academically proficient leaders within their departments, having the largest number of publications and h, hc, hm, and AWCR bibliometric indices. CONCLUSIONS: Ophthalmology leaders in all positions are highly accomplished with an established interest in research. Typically, CPs and their VCs have a longer duration of professional experience with a greater research output and a superior median academic appointment. Gender discrepancies within leadership positions are evident.

The Effect of Blue-Light Filtering Intraocular Lenses on the Development and Progression of Neovascular Age-Related Macular Degeneration.

PURPOSE: To assess the effect of blue-light filtering (BLF) intraocular lenses (IOLs) on the prevention of neovascular age-related macular degeneration (nAMD) after cataract surgery. DESIGN: Cohort study. PARTICIPANTS: Patients who underwent uneventful cataract surgery between 2007 and 2018 at the Ophthalmology Unit of Kymenlaakso Central Hospital, Kotka, Finland. METHODS: Subsequent nAMD rates were compared between patients who received BLF IOLs and those who received non-BLF IOLs. Kaplan-Meier and Cox regression analyses for the overall risk of nAMD developing were assessed. Best-corrected visual acuity (BCVA), foveal thickness, treatment interval, and total number of intravitreal injections were secondary outcomes. A separate analysis was performed on patients with pre-existing nAMD to assess the effect of BLF IOLs on nAMD progression. A single eye of each patient was included. MAIN OUTCOME MEASURE: Neovascular age-related macular degeneration-free survival. RESULTS: Included were 11 397 eyes of 11 397 patients with a mean age of 75.4 ± 8.3 years (62.5% women). The BLF IOL was used in 5425 eyes (47.6%), and the non-BLF IOL was used in 5972 eyes (52.4%). During follow-up (BLF IOL group, 55.2 ± 34.1 months; non-BLF IOL group, 50.5 ± 30.1 months; P < 0.001), 164 cases of new-onset nAMD were recorded (BLF group, n = 88; non-BLF group, n = 76). The nAMD-free survival was similar between the groups (P = 0.465, log-rank test). In a Cox regression analysis controlling for age, gender, and a documented diagnosis of macular degeneration, the use of a BLF IOL was not predictive of nAMD development (hazard ratio [HR], 1.075; 95% confidence interval [CI], 0.79-1.47; P = 0.652). In nAMD patients, secondary clinical outcomes at 1 year were comparable for BCVA (0.57 ± 0.4 logarithm of the minimum angle of resolution vs. 0.45 ± 0.4 logarithm of the minimum angle of resolution; P = 0.136), foveal thickness (285 ± 109 µm vs. 299 ± 103µm; P = 0.527), number of anti-vascular endothelial growth factor injections (6.5 ± 2.5 vs. 6.2 ± 2.7; P = 0.548), and treatment interval (7.5 ± 2.4 weeks vs. 8.1 ± 2.4 weeks; P = 0.271) for BLF and non-BLF IOLs, respectively. Similarly to patients in whom nAMD developed after the surgery, among patients with nAMD before surgery (BLF, n = 71; non-BLF, n = 74), the clinical outcomes again were comparable (all P > 0.05). CONCLUSIONS: In a large cohort of patients who underwent cataract surgery, the use of a BLF IOL resulted in no apparent advantage over a non-BLF IOL in the incidence of nAMD or its progression, nor in clinical variables related to nAMD severity.

A de novo mutation in PITX2 underlies a unique form of Axenfeld-Rieger syndrome with corneal neovascularization and extensive proliferative vitreoretinopathy.

BACKGROUND: Axenfeld-Rieger syndrome is characterized by a spectrum of anterior segment dysgenesis involving neural-crest-derived tissues, most commonly secondary to mutations in the transcription factor genes PITX2 and FOXC1. MATERIALS AND METHODS: Single retrospective case report. RESULTS: A full-term infant presented at 5 weeks of age with bilateral Peters anomaly and Axenfeld-Rieger syndrome, with development of atypical features of progressive corneal neovascularization and proliferative vitreoretinopathy. Despite surgical interventions, the patient progressed to bilateral phthisis bulbi by 22 months of age. Genetic testing revealed a novel de novo p.Leu212Valfs*39 mutation in PITX2, leading to loss of a C-terminal OAR domain that functions in transcriptional regulation. CONCLUSIONS: It is important to consider mutations in PITX2 in atypical cases of anterior segment dysgenesis that also present with abnormalities in the angiogenesis of the anterior and posterior segments.

Anti-inflammatory Medication After Cataract Surgery and Posterior Capsular Opacification.

PURPOSE: To assess the role of anti-inflammatory medication following cataract surgery on the formation of posterior capsular opacification. DESIGN: Cohort study. METHODS: A retrospective registry analysis of 25,818 consecutive patients who underwent cataract surgery between the years 2014 and 2018 at Helsinki University Hospital in Finland. Nd:YAG laser capsulotomy rates were compared between patients treated postoperatively with topical steroids, nonsteroidal anti-inflammatory medications (NSAIDs), or their combination. Kaplan-Meier and Cox regression analyses were used. A single eye of each patient was included. Main outcomes were confirmed against a second independent dataset. RESULTS: A total of 13,368 patients were included in the analysis, with a mean age of 73.2 ± 9.7 years; 61.7% were female. Pseudoexfoliation was noted in 10.1% of cases. The mean follow-up time was 22.8 ± 15.7 months. Patients were treated with steroid monotherapy (28.9% of cases), NSAID monotherapy (62.2%), or a combination of both (8.9%). Treatment with steroids resulted in significantly lower Nd:YAG capsulotomy rates compared to NSAIDs (hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.62-0.93, P = .009). Treatment with combination therapy of steroids and NSAIDs showed no added benefit over steroid monotherapy (HR 1.11, 95% CI 0.68-1.80, P = .674). Cox regression analysis adjusted for patients' age, sex, pseudoexfoliation, and risk stratification remained significantly predictive for lower capsulotomy rates with steroid treatment over NSAIDs (HR 0.70, 95% CI 0.52-0.88, P = .001). CONCLUSIONS: Postoperative treatment with steroids among patients undergoing uncomplicated cataract surgery was associated with lower rates of clinically significant posterior capsule opacification compared to treatment with NSAIDs alone. Combination therapy of steroids and NSAIDs had no added benefit over steroids alone.

Avoiding big bubble complications: outcomes of layer-by-layer deep anterior lamellar keratoplasty in children.

BACKGROUND/AIMS: To describe the visual and clinical outcomes of manual layer-by-layer deep anterior lamellar keratoplasty (DALK) in a paediatric population. METHODS: The charts of all children who underwent DALK surgery between January 2007 and January 2015 were reviewed retrospectively. Data collected included preoperative and postoperative spectacle-corrected distance visual acuity (CDVA), intraoperative and postoperative complications including graft rejection and failure. Residual posterior lamellar thickness (RPLT) and endothelial cell density (ECD) were measured in eyes with follow-up longer than 6 months. RESULTS: Fifty-one eyes of 42 patients were included in the study. The mean patient age at surgery was 11.2±5.2 years and the mean follow-up time was 36.5±23.7 months. The most common indications for surgery were mucopolysaccharidosis (29.4%) and keratoconus (23.5%). Nine eyes (17.6%) had intraoperative microperforation, none of which were converted to penetrating keratoplasty (PKP). Only one eye (2.0%) was converted to PKP. Five eyes (9.8%) had a stromal rejection episode of which one eye failed. Another four eyes (7.8%) experienced graft failure among which three eyes (75%) had infectious keratitis. Three of the five failed grafts had a successful repeat DALK. The average RPLT was 81.9±36.5µm. ECD was significantly lower in the operated eye compared with the normal eye (3096±333 cells/mm2 vs 3376±342 cells/mm2, n=11, P=0.003). The mean postoperative CDVA was 0.5±0.4 logarithm of the minimum angle of resolution (logMAR) reflecting a gain of 0.3 logMAR (P<0.001). CONCLUSION: Manual dissection DALK is a safe procedure in children with stromal opacities. Despite successful structural rehabilitation, functional recovery is still suboptimal mostly due to amblyopia.

In Vivo Confocal Microscopy Reveals Corneal Reinnervation After Treatment of Neurotrophic Keratopathy With Corneal Neurotization.

PURPOSE: To document the presence and location of new sensory nerve fibers after corneal neurotization using in vivo confocal microscopy (IVCM) in 2 patients with neurotrophic keratopathy (NK). METHODS: Two patients with unilateral advanced NK received corneal neurotization to surgically reinnervate the cornea. IVCM was used to identify subbasal nerve fibers and document corneal reinnervation. In 1 patient (case 1), IVCM was performed before and after corneal neurotization; in the second patient (case 2), IVCM was performed after neurotization and corneal transplantation. RESULTS: In case 1, who had hand motion visual acuity due to NK-associated corneal perforation that necessitated cyanoacrylate gluing, preoperative IVCM identified no subbasal nerves; however, subbasal nerves were identified 6 months after corneal neurotization, and there were no further episodes of persistent epithelial defects. In case 2, in whom NK with a total absence of corneal sensation was the result of treated basal skull meningioma, corneal sensation, visual acuity, and ocular surface health improved after corneal neurotization. Deep anterior lamellar keratoplasty was performed 2.5 years after corneal sensation was reestablished. IVCM demonstrated corneal reinnervation at the stromal and subbasal level in a pattern different from the normal cornea. CONCLUSIONS: Corneal neurotization restores corneal sensation by reinnervating the stromal and subbasal layers of the cornea. In doing so, corneal neurotization may halt the process of NK and prevent further visual loss.

Corneal Endothelial Cell Density in Children: Normative Data From Birth to 5 Years Old.

PURPOSE: To establish a normative database of endothelial cell density (ECD) using in vivo specular microscopy in children under 5 years old. DESIGN: Cross-sectional study. METHODS: Specular microscopy was performed during a clinic visit in cooperative children in the standard upright position. In uncooperative children, specular microscopy was performed in the lateral decubitus position under general anesthesia, before surgery for other reasons. Corneal diameter (CD) was measured in children undergoing general anesthesia and was stratified according to age. RESULTS: One hundred and eighteen eyes of 118 patients were included in the study. The mean patient age was 2.6 ± 1.4 years (range 0.1-5 years) and the mean ECD was 3746 ± 370 cells/mm2 (range 3145-5013 cells/mm2). The mean CD under 2 years of age was 11.85 ± 0.57 mm (n = 40, range 10.50-12.75 mm). Up to 2 years of age, ECD was more inversely correlated with CD than with age (r = -0.61, P < .0001; r = -0.38, P = .01, respectively). In contrast, after the age of 2 years, the ECD was inversely correlated with age but not with CD (r = -0.27, P = .02; r = -0.24, P = .2). Between the first and second year of life, the rate of ECD decrease was significantly higher than between 2 and 5 years of age (8.2%, 334 cells/mm2 vs 2.7%, 100 cells/mm2 a year, respectively). CONCLUSION: In the first 2 years of life there is a rapid decline in ECD, which is likely related to growth in CD and hence surface area. After the cornea reaches adult size, the ECD decreases at a rate similar to that reported in adults.

Long-Term Corneal Endothelial Cell Counts After Penetrating Keratoplasty in Infants.

PURPOSE: To report long-term endothelial cell counts after penetrating keratoplasty (PKP) in infants. METHODS: The charts of all children who have undergone PKP in their first year of life between 1998 and 2013 at the Hospital for Sick Children, Toronto, Canada, were reviewed retrospectively. Patients who had a single successful transplant with a valid endothelial cell density (ECD) analysis postsurgery were included in the study. Donor ECDs were provided by a local eye bank. Specular microscopy images were taken at a variable interval after surgery using a noncontact specular microscope (ROBO, Konan; Konan Medical) and endothelial cell loss was calculated. In young children images were taken in the lateral decubitus position under general anesthesia. RESULTS: Twenty-one eyes of 16 patients were included in the study. Median patient age at the time of surgery was 2.0 months [mode, 2.0; interquartile range (IQR), 1.6-2.6 months] and median follow-up time was 49.0 months (IQR, 33.0-99.5 months). The most common indication for surgery was Peters anomaly, in 16 eyes (76.2%). Ten eyes had additional intraocular surgeries posttransplant. The median ECDs prekeratoplasty and at last follow-up were 2958 cells per square millimeter (IQR, 2807-3205 cells/mm) and 1307 cells per square millimeter (IQR, 946-1613 cells/mm) respectively, reflecting a median endothelial cell loss of 59.2% (IQR, 44.3%-68.8%). Iris adhesions to the graft-host junction were strongly associated with low final ECD (P = 0.01). CONCLUSIONS: Despite technical challenges and difficult postoperative care, pediatric keratoplasty is associated with a lower endothelial cell loss over time compared with that reported in adults after PKP.

Characteristics of patients with ocular cicatricial pemphigoid referred to major tertiary hospital.

OBJECTIVE: To evaluate the demographic and clinical characteristics of patients referred to a tertiary care hospital cornea clinic for ocular cicatricial pemphigoid (OCP) assessment. DESIGN: Retrospective, nonrandomized, consecutive case series. PARTICIPANTS: Thirty three patients with OCP who were treated at the corneal clinic of Toronto Western Hospital from 2003 to 2012. METHODS: Database search of patients from 2003 to 2012 with a referral request or diagnosis of OCP was conducted at a tertiary care hospital cornea clinic. Charts of 33 patients (64 eyes) were reviewed. Outcome measures included patient demographics, methods of diagnosis, visual acuity, ocular features, and disease staging using Foster's staging system, systemic modes of treatment, disease progression, and presence of systemic involvement. RESULTS: Mean patient age at presentation was 69.8 years (range 40-91), and 81% (27/33) were female. At presentation, disease staging consisted of stage I (subepithelial fibrosis) 7.8% (5/64), stage II (shortened fornices) 21.8% (14/64), stage III (symblepharon formation) 65.6% (42/64), and stage IV (keratinization with or without globe immobility) 4.6% (3/64). At the final follow-up visit, the proportions of the involved eyes for stages I to IV were 1.5% (1/64), 10.9% (7/64), 76.5% (49/64), and 10.9% (7/64), respectively. Conjunctival biopsies were obtained from 81% (27/33) of patients and reported as positive in 30% (8/27), negative in 63% (17/27), and inconclusive in 7% (2/27) of patients. Mean duration of follow-up was 6.8 ± 5.6 years (range 0.5-22), and 66.6% (22/33) of patients had progressive disease. Systemic mucocutaneous involvement was noted in 36.3% (12/33) of patients. CONCLUSIONS: The high rate of disease progression suggests the need for improved therapeutic options. Additional modalities are needed in addition to conjunctival biopsy to confirm a diagnosis of OCP in patients with clinical signs of the disease.