Dexamethasone Intracanalicular Insert versus Standard Topical Steroids for the Prophylaxis of Inflammation after Cataract Surgery.

PURPOSE: To compare the efficacy of an intracanalicular dexamethasone intracanalicular insert (DII) to a topical prednisolone acetate 1% taper for preventing breakthrough inflammation (iritis or cystoid macular edema) during the first post-operative month (POM1) after cataract surgery DESIGN: Retrospective, non-randomized comparative interventional study METHODS: Patients received either DII or topical prednisolone acetate 1% eyedrops (control) during POM1. Exclusion criteria included history of iritis, glaucoma, intraoperative posterior capsular rupture or vitreous prolapse, immediate postoperative anterior chamber inflammation requiring treatment, or less than 1 month follow up post-operatively. Outcomes included development of breakthrough inflammation after >3 days postoperatively necessitating additional anti-inflammatory drops, cystoid macular edema, and increased intraocular pressure at POM1. RESULTS: 266 eyes of 174 patients were included in the DII group, and 258 eyes of 167 patients in the control group. Demographics, comorbidities, and baseline IOP were comparable between groups. The breakthrough inflammation rate was significantly higher in the DII group compared to control (9.0% vs 3.1%; p < .01); cystoid macular edema rates were similar between groups (4.9% vs 4.3%; p = .75). There were no cases of increased IOP >10mmHg at POM1 compared to baseline in either group. CONCLUSION: After cataract surgery, DII demonstrated a higher rate of breakthrough inflammation than a standard topical steroid regimen with no significant differences in CME rate or IOP increase; however, overall, the rate of postoperative complications was low. DII can be a safe and effective alternative to topical corticosteroid therapy after cataract surgery.

Acute Calcific Band Keratopathy as an Adverse Effect of Recombinant Human Nerve Growth Factor (Cenegermin): A Multicenter Case Series.

PURPOSE: Cenegermin, (OXERVATE) a recently Food and Drug Administration-approved topical formulation of recombinant human nerve growth factor, has been used for the treatment of neurotrophic keratopathy (NK). Corneal deposits have been previously reported as a potential adverse effect; however, the clinical characteristics, visual significance, and treatment options have not been fully described. The purpose of this article is to better characterize corneal deposits occurring during treatment with cenegermin for neurotrophic keratopathy. METHODS: This was a retrospective, multicenter consecutive case series. RESULTS: We identified 5 patients from 3 institutions who developed a white opacity in varying layers of the cornea, consistent with calcium deposition, during treatment with cenegermin. In all cases, the opacity occurred rapidly over the course of a few weeks after initiation of treatment. Histopathologic examination of the cornea from one corneal patient demonstrated extensive calcification of the stroma extending to 90% depth. Before treatment, all patients had stage 2 or 3 NK (Mackie classification). The deposits were visually significant in all patients and did not resolve after cessation of cenegermin. There were no differences in age, sex, etiology of the NK, corneal transplant status, or concurrent medications between the patients who developed a deposit and 15 other patients with stage 2 or 3 NK who did not. One patient was successfully treated with superficial keratectomy with ethylenediaminetetraacetic acid chelation, one patient underwent penetrating keratoplasty, and one patient received a Boston keratoprosthesis. CONCLUSIONS: We report the rapid onset of a corneal opacity after initiation of treatment with cenegermin in patients with stage 2 or 3 NK, consistent with acute calcific band keratopathy. This visually significant adverse finding has not previously been described. We could not identify any risk factors for development. We recommend close monitoring of patients receiving cenegermin therapy because the opacity may be irreversible and may require keratoplasty for visual rehabilitation.

Direct Injection of 5-Fluorouracil Improves Outcomes in Cicatrizing Conjunctival Disorders Secondary to Systemic Disease.

PURPOSE: Conjunctival cicatrizing conditions are vision threatening, with poor outcomes despite aggressive systemic therapy. This study tests the utility of serial injections of 5-fluorouracil (5-FU) into the fornices to treat conjunctival scarring in patients with ocular cicatricial pemphigoid or Stevens-Johnson syndrome/toxic epidermal necrolysis. METHODS: Retrospective cohort study. Fisher exact test and multivariable logistic regression analyses were used to compare clinical outcomes of patients who were administered 5-FU injections versus patients who were not injected. Model fit was examined for multivariable regression. RESULTS: One hundred twelve eyes (56 patients) met the inclusion criteria. Thirty-eight eyes (34%) had Stevens-Johnson syndrome/toxic epidermal necrolysis, and 74 eyes (66%) were diagnosed with ocular cicatricial pemphigoid. Twenty-five eyes received ≥1 injection of 5-FU. Sixteen eyes received 1-4 injections, while 9 received ≥5. Median follow-up until last encounter was 18 months. Analysis of each disease entity alone and in combination revealed that 5-FU injections were associated with improvement in final visual acuity, corneal scarring, trichiasis, need for/number of mucous membrane graft surgeries, and severity of symblephara. CONCLUSIONS: Serial injection of 5-FU in the affected fornices is a promising treatment for severe vision-threatening conjunctival scarring from ocular cicatricial pemphigoid and Stevens-Johnson syndrome/toxic epidermal necrolysis. Given the excellent safety profile of 5-FU around the eye, the solid biologic foundation for using 5-FU in this setting, and the severe risk of vision loss from these disorders, the authors suggest that serial 5-FU injections be adopted as therapy for conjunctival scarring from ocular cicatricial pemphigoid or Stevens-Johnson syndrome/toxic epidermal necrolysis despite the limitations of this retrospective study.

Recipient Factors Associated With Graft Detachment of a Subsequent Eye in Sequential Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To evaluate the recipient factors associated with graft detachment in the subsequent eye of patients who underwent sequential Descemet membrane endothelial keratoplasty (DMEK). METHODS: A retrospective, consecutive case series with 158 eyes of 79 patients who underwent DMEK surgeries in both eyes between October 2013 and April 2019 for treatment of Fuchs endothelial dystrophy. The main outcome measure was the presence of graft detachment (any amount of detachment) at postoperative 1 week in the subsequent eye. Preoperative, intraoperative, and postoperative factors were evaluated for association with graft detachment. RESULTS: Of 79 patients (158 eyes) with a mean follow-up of 11.7 ± 8.4 months, 18 patients (36 eyes) developed graft detachment in both eyes 1 week postoperatively. The risk of detachment in the subsequent eye was increased when the first eye had any amount of detachment [odds ratio = 2.8; 95% confidence interval (CI) = 1.1-7.3; P = 0.037]. When the first eye had a clinically significant detachment (>30% detached), the risk of detachment occurring in the subsequent eye was greater (odds ratio = 15.7; 95% CI = 1.8-134.5; P = 0.012). This risk of graft detachment in the subsequent eye increased 33% for every 5% increase in the detachment percentage in the first eye (odds ratio = 1.3; 95% CI = 1.1-1.6; P = 0.008). CONCLUSIONS: The presence of graft detachment after DMEK increases the risk of graft detachment in subsequent DMEK in the contralateral eye. Modification in perioperative care and surgical technique in the contralateral eye, such as a larger gas bubble, use of SF6 20%, and combining cataract surgery, may be needed when graft detachment occurs after DMEK in the first eye.

Endophthalmitis in Advanced Microbial Keratitis: Risk Factors and Examination Findings.

PURPOSE: To evaluate clinical and ultrasonographic findings associated with advanced microbial keratitis with concurrent endophthalmitis. METHODS: We performed a retrospective analytical study of patients with severe microbial keratitis who underwent ocular ultrasonography for possible endophthalmitis at our institution over a 5-year period. Ocular and medical history, ocular examination findings, microbiology results, and ultrasonographic features were collected. RESULTS: Of the 81 included eyes, 15 were diagnosed with endophthalmitis based on clinical findings and evidence of vitritis on ultrasound. Historical factors and physical examination findings more common in the endophthalmitis group than the keratitis-only group include presenting vision of light perception or no light perception (73.3% vs. 31.8%, P = 0.003), history of cataract surgery (80.0% vs. 45.5%, P = 0.02), and full thickness ulcer or perforation (33.3% vs. 9.1%, P = 0.03). Gram-positive organisms were more common in the endophthalmitis group (60.0% vs. 30.3%, P = 0.04). Ultrasound findings of choroidal thickening and retinal detachment were more common in the endophthalmitis group (26.7% vs. 3.4%, P = 0.01 and 13.3% vs. 8.4%, P = 0.04) in addition to the expected preponderance of membranous and dispersed vitreous opacities in that group. Final visual acuity was worse in the endophthalmitis group (2.3 vs. 3.5 LogMAR, P = 0.02). CONCLUSIONS: Diagnosing endophthalmitis can be difficult in eyes with advanced microbial keratitis, and the visual outcomes are often extremely poor. Clinicians should have a particularly high index of suspicion in eyes presenting with light perception or no light perception vision, history of cataract extraction, full thickness ulcer or perforation, or choroidal thickening or retinal detachment on ultrasound.

Teleophthalmic Approach for Detection of Corneal Diseases: Accuracy and Reliability.

PURPOSE: Corneal and anterior segment diseases cause most of the urgent visits to eye care professionals. We evaluated the diagnostic accuracy of detecting corneal diseases using external photographs from 2 portable cameras for telemedicine purposes. METHODS: This is a prospective study of adults with a clinical diagnosis of corneal pathology including corneal abrasions, ulcers, scars, and pterygia. A cornea specialist provided the gold standard diagnosis by slit-lamp examination. Images of both eyes were obtained using iTouch 5S and Nidek VersaCam cameras in multiple gazes and interpreted by 3 cornea specialists for the presence of pathology. Accuracy to detect disease was compared with gold standard diagnosis, stratified by the camera and grader. Reliability was evaluated with weighted kappa statistics. Graders assessed image quality on a Likert scale from 1 (poor) to 9 (optimal). RESULTS: A total of 198 eyes (110 subjects) were photographed. By gold standard diagnosis, 59 eyes (30%) had corneal scars, 34 (17%) had ulcers, 13 (7%) had abrasions, 10 (5%) had pterygia, and 82 (41%) were normal. Sensitivity to detect AS pathology ranged from 54% to 71% for the iTouch and 66% to 75% for the Nidek, across graders; specificity ranged from 82% to 96% for the iTouch and 91% to 98% for the Nidek. The intergrader reliability was moderate to strong (kappa ranges: 0.54-0.71 for the iTouch; 0.75-0.76 for the Nidek). Quality ratings were variable between graders. CONCLUSIONS: External photographs taken by standard, nonenhanced portable cameras and interpreted remotely by ophthalmologist graders yielded sensitivity values that are not yet suitable for telemedicine applications. Additional work is needed to improve the ability to detect AS pathology remotely.

The effect of humidity and temperature on visual outcomes after myopic corneal laser refractive surgery.

OBJECTIVE: To determine whether procedure room environmental conditions are associated with outcomes after myopic laser in situ keratomileusis (LASIK) or laser-assisted keratomileusis (LASEK). DESIGN: Retrospective chart review. PARTICIPANTS: Eight hundred sixty-three eyes of 458 consecutive patients at a university-based academic practice. METHODS: We reviewed the medical records of consecutive patients who underwent LASIK or LASEK over a 3-year period. Linear mixed regression models were used to investigate the association of laser room temperature and humidity with the outcomes of visual acuity and postoperative manifest spherical equivalent refraction. Repeated measures logistic regression models were used for the outcomes of diffuse lamellar keratitis (DLK) and need for enhancement surgery. RESULTS: Subjects were on an average 38.6 years old at the time of surgery (standard deviation [SD] =10.3) and the average spherical equivalent refraction of eyes was 3.8 diopters (SD =2.03). Regression models did not reveal a significant association between temperature and uncorrected distance visual acuity (UDVA) or corrected distance visual acuity (CDVA), or between humidity and UDVA (P>0.05 for all). However, increased humidity was associated with a small but statistically significant improvement in CDVA after LASIK at 1 day, 1 month, 3 months, and 1 year postoperatively (P<0.05 for all). There was no significant association between temperature and humidity and the need for enhancement, the incidence of DLK, or postoperative manifest refraction. CONCLUSION: While increased laser room humidity was consistently associated with small improvements in CDVA after myopic LASIK over time, variations in room temperature and humidity were not associated with UDVA, the need for enhancement, the incidence of DLK, or refraction after myopic LASIK or LASEK.

Subjective complaints after cataract surgery: common causes and management strategies.

PURPOSE OF REVIEW: To describe the common causes of, and management strategies for, nonrefractive subjective visual complaints after cataract surgery. RECENT FINDINGS: Over the past decade, clinical observations and ray-tracing models have greatly increased our understanding of positive and negative dysphotopsias after cataract surgery. The primary factor behind positive dysphotopsias is the use of high refractive index square-edge intraocular lenses (IOLs). Primary and secondary factors that underlie negative dysphotopsias are now better characterized, which has led to successful interventions including IOL exchange and Nd:YAG laser anterior capsulotomy. SUMMARY: Positive and negative dysphotopsias occur after implantation of monofocal IOLs, and can rarely be disabling to patients. Visual complaints after multifocal IOL implantation are more common than after monofocal IOL implantation, but still rarely require significant intervention. A better understanding of the risk factors and optical causes of dysphotopsias will allow for IOL design and patient selection that maximize satisfaction after cataract surgery.

Prone positioning to facilitate graft adherence in the late postoperative period after descemet stripping automated endothelial keratoplasty.

PURPOSE: The aim of this study was to report the use of prone positioning to facilitate graft adherence in the late postoperative period after Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: A 75-year-old woman with Fuchs dystrophy had repeated endothelial graft detachments after simultaneous DSAEK and phacoemulsification cataract surgery. Multiple attempts in the operating room to reposition the tissue, including placement of air into the anterior chamber, postoperative face-up positioning, and the use of new donor tissue, were unsuccessful. In the late postoperative period, the patient was placed in a prone (face-down) position at home to promote graft adherence. RESULTS: After the maneuver, the endothelial graft was well attached, although it was slightly decentered. The remainder of the patient's postoperative course was routine, and her best-corrected visual acuity is 20/25 with a clear cornea 9 months later. CONCLUSIONS: Prone positioning can be used as a conservative maneuver to promote graft adherence after DSAEK when there is difficulty in achieving attachment postoperatively, especially when a return trip to the operating room may not be practical.

Effect of tamsulosin on iris vasculature and morphology.

PURPOSE: To determine whether preoperative iris vasculature and morphology are altered in patients who have taken tamsulosin (Flomax). SETTING: Academic multispecialty practice. DESIGN: Case series. METHODS: Patients with current or past tamsulosin use and age- and sex-matched control patients were included. Anterior segment optical coherence tomography (AS-OCT) and iris fluorescein angiography were performed to measure iris vasculature and thickness before cataract surgery. Data collected at surgery included pupil diameter, clinical signs of intraoperative floppy-iris syndrome, and surgical complications. RESULTS: Tamsulosin was currently used by 16 patients and in the past by 4 patients; the control group comprised 10 patients. Pharmacologically dilated pupil diameter was statistically significantly smaller preoperatively and immediately postoperatively in the tamsulosin group than in the control group (P=.009 and P=.003, respectively). There was a statistically significant decrease in pupil size intraoperatively in the tamsulosin group (P=.05) but not in the control group (P=.3). Iris-vasculature parameters, specifically time to first vessel fill and percentage of vessel fill on iris fluorescein angiography, were not significantly different between the 2 groups. The AS-OCT measurements of iris morphology were not statistically significantly different between the groups. No surgical complications occurred. No fluorescein dye leakage, staining, or other vascular anomalies were observed. CONCLUSIONS: Although there were differences in pupil measurements and intraoperative iris behavior between patients who had been on tamsulosin and control patients, there were no significant differences in iris vasculature on iris fluorescein angiography or in iris morphology on AS-OCT.

Mechanisms for in-the-bag uveitis-glaucoma-hyphema syndrome.

We propose 2 mechanisms of uveitis-glaucoma-hyphema (UGH) syndrome in 2 patients with intracapsular or in-the-bag single-piece acrylic intraocular lenses (IOLs). In the first case, pseudophacodonesis secondary to zonular laxity from pseudoexfoliation syndrome caused chafing of the posterior iris by the square-edged haptic. In the second case, focal capsular fibrosis around the square-edged haptics combined with anteriorly rotated ciliary processes in plateau iris configuration caused points of chafing. Extensive capsular fibrosis of the haptic in both cases precluded IOL exchange. In the first case, a capsular tension ring redistributed zonular tension and reduced symptoms. In the second case, endoscopic cyclophotocoagulation relieved areas of chafing and resolved symptoms. In-the-bag square-edged haptics of single-piece acrylic IOLs are a potential source of iridociliary chafing in certain situations. The mechanisms observed here should be considered to promptly diagnose and treat UGH.

Influence of preoperative donor tissue characteristics on graft dislocation rate after Descemet stripping automated endothelial keratoplasty.

PURPOSE: To determine the influence of preoperative donor tissue characteristics on the graft dislocation rate after performing a Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: We retrospectively analyzed the associations between donor tissue characteristics and graft dislocation rates for consecutive DSAEK surgeries performed in a 4-year period at a single institution. RESULTS: From June 2007 to June 2011, 64 (18%) of 355 eyes underwent a procedure for graft dislocation. There were no differences in donor age, preoperative endothelial graft thickness, preprocessing endothelial cell density, change in endothelial cell density after processing, time from death to tissue processing, or time from tissue processing to surgery between eyes that experienced dislocations and those that did not (P > 0.05 for each). The graft recipient's corneal disease diagnosis, preoperative corneal thickness, preoperative visual acuity, glaucoma status, history of glaucoma surgery, and cataract surgery at the time of performing the DSAEK were not associated with an increased rate of dislocation (P > 0.05 for each). Recipients who experienced graft dislocation were significantly older (73.6 vs. 70.2 years, P = 0.03) and more likely to undergo subsequent repeat transplantation (29.7% vs. 10.7%, P < 0.0001). CONCLUSIONS: We found no correlation between any corneal donor tissue characteristic and graft dislocation after the DSAEK was performed. Graft dislocation was more common in older recipients. Patients with dislocation had a higher rate of subsequent transplantation.

Neodymium-yttrium-aluminum-garnet laser lysis of retained cortex after phacoemulsification cataract surgery.

PURPOSE: To describe the use of the neodymium-yttrium-aluminum-garnet (Nd:YAG) laser to lyse residual cortex after phacoemulsification cataract surgery and report the complications and outcomes of treatment. DESIGN: Interventional, retrospective case series. METHODS: Consecutive patients who underwent Nd:YAG laser treatment for residual cortex at the Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan were identified by review of laser logs from 2005 to 2011. The medical records were reviewed, and the course and complications of treatment were recorded. The main outcome measures were improvement in subjective vision and corrected distance visual acuity. RESULTS: Eighteen eyes of 18 patients, mean age 66 ± 11 years, were included. Eight eyes (44%) had intraoperative posterior capsule rupture. Before treatment with the Nd:YAG laser, all patients had subjective visual complaints, with 6 patients reporting counting fingers or worse visual acuity. Eleven patients (61%) were successfully treated with 1 session of cortical lysis, while 5 patients underwent 2 and 2 patients underwent 3 or more treatments. Five patients (28%) had elevated intraocular pressure (IOP) within 1 day of treatment, and 1 patient developed cystoid macular edema. All patients had resolution of subjective visual symptoms, and at final follow-up corrected distance acuity was 20/25 or better in 13 patients (72%). CONCLUSIONS: The Nd:YAG laser can be used to lyse residual cortex after uncomplicated cataract surgery or cases with intraoperative posterior capsular rupture, and results in an improvement in subjective and corrected distance visual acuity. Elevated IOP is a common complication.

Incidence, occurrence rate, and characteristics of suture-related corneal infections after penetrating keratoplasty.

PURPOSE: To report the incidence, occurrence rate, and characteristics of suture-related infections after penetrating keratoplasty (PK). METHODS: Patients who underwent PK at our institution between January 1, 2002, and July 1, 2006, were cross-referenced with patients diagnosed with corneal infections between January 1, 2002, and July 1, 2007. All patient charts were reviewed retrospectively for occurrence of suture-related infections, duration of follow-up, and clinical characteristics. RESULTS: Of the 487 PKs performed in 412 patients, 22 eyes of 22 patients developed postoperative corneal infections. Of these, 5 eyes were identified as having suture-related graft infections, yielding an occurrence rate of 1.0%. The average follow-up was 3.46 years per PK, yielding an incidence of 2.96 infections per 1000 PK-years. The mean interval from surgery to infection was 8 months (range: 3-23 months). All culprit sutures were in the interpalpebral zone. No patients were using topical antibiotics at the time of infection, and all patients were using topical corticosteroid drops. Cultured organisms included Staphylococcus aureus (3 cases), coagulase-negative Staphylcoccus (1 case), and S. viridans (1 case). In 2 patients with isolated corneal involvement, topical moxifloxacin was initiated, and the patients responded favorably. In 3 patients with corneal infection and an associated hypopyon or endophthalmitis, vitreous biopsy, intravitreal injections of antibiotics, and fortified topical antibiotics were used. One patient required a repeat PK as a result of the infection. Two eyes eventually became phthisical. CONCLUSIONS: The rate of suture-related infections after PK may be lower than previously reported. In our patients, suture-related infections all occurred within the first 2 years after surgery, and some of them resulted in significant morbidity, underscoring the importance of patient identification of symptoms and early clinical recognition.

Male breast carcinoma metastatic to the choroid: report of 3 cases and review of the literature.

PURPOSE: To describe breast cancer as a source of choroidal metastasis in men and highlight the diagnostic and treatment modalities. METHODS: Retrospective, noncomparative case series of male patients with breast cancer metastatic to the choroid. A literature review of the previously reported cases was also conducted. RESULTS: Three cases of breast cancer metastatic to the choroid in male patients from one institution are described. All 3 patients eventually underwent treatment with radiotherapy. CONCLUSIONS: Breast cancer is a rare cause of choroidal metastases in men. Radiotherapy is effective as a palliative treatment for choroidal metastases.

Amantadine-associated corneal edema treated with descemet's stripping automated endothelial keratoplasty.

The authors report the successful use of Descemet's stripping automated endothelial keratoplasty (DSAEK) to treat a 45-year-old woman with amantadine-associated corneal edema. Discontinuation of the medication and treatment with corticosteroids did not result in resolution of the edema. The patient underwent sequential phakic DSAEK in both eyes with significant anatomic, visual, and functional improvement. Histopathologic analysis of Descemet's membrane by light microscopy revealed a paucity of endothelial cells. This case highlights the importance of considering amantadine toxicity in the differential diagnosis of corneal edema without an identifiable ocular cause and suggests the utility of DSAEK in the treatment of this rare condition.

Retinal Vasoproliferative Tumor in Association with Neurofibromatosis Type 1.

Retinal vasoproliferative tumor is an uncommon benign vascular tumor that most often occurs sporadically. Vision loss can occur secondary to retinal fibrosis, subretinal exudation, and neovascular glaucoma. This report describes a functionally monocular patient with neurofibromatosis type 1 who had a vasoproliferative tumor with neovascularization of the iris that was successfully treated with intravitreal bevacizumab and cryotherapy.