Neurostimulation for tear production.

PURPOSE OF REVIEW: Dry eye disease (DED) is a chronic multifactorial disease that affects millions of people worldwide. Despite ongoing research, treatment for DED remains a challenge. Neurostimulation for tear production is a rapidly evolving field that culminated in the development of the intranasal tear neurostimulator (ITN). In this article, we review the neuroanatomy and pathophysiology of tear production and the evolution of neurostimulation for the treatment of DED. RECENT FINDINGS: The ITN was approved for commercial use in April 2017. This innovation stemmed from the success of lacrimal nerve and anterior ethmoid nerve stimulation animal studies. Since then, numerous pilot studies and multicenter randomized controlled trials demonstrate increased aqueous tear production, improved DED-related symptoms, and device safety. Recent studies also report the positive effects of intranasal stimulation on mucin and lipid secretion. SUMMARY: Neurostimulation for enhanced tear production is a promising new treatment option for DED. Stimulation of the lacrimal nerve and anterior ethmoid nerve both effectively increase tear volume. The ITN is a noninvasive device that effectively increases aqueous tear volume and may improve tear composition, including mucin and lipid concentrations. Further studies are needed to determine proper patient selection and the long-term efficacy of neurostimulation for DED.

Engaging Stakeholders to Develop a Roadmap for Dry Eye and MGD PCORI-Funded Research.

Introduction: Although affecting an estimated 35% of the population, Dry Eye is not well understood by patients and the medical community. As a result, both in research and clinical settings, diagnostic and treatment protocols tend to be non-specific, ad hoc, and inadequate, with a narrow industry-driven focus. The purpose of this convening was to propose a research roadmap that orients Dry Eye researchers toward a comprehensive patient-centered approach to diagnosing and treating Dry Eye, Meibomian gland dysfunction (MGD), and related comorbidities with a goal of improving clinical outcomes for Dry Eye/MGD patients. Methods: Sixteen participants, including Dry Eye/MGD patients, caregivers, and patient advocates together with a group of experts in Dry Eye, MGD and other fields identified gaps in research on Dry Eye and MGD diagnostic and treatment approaches (age range 20-80; male to female ratio of 7:11; patients: 7). During a 2-day virtual convening, participants were assigned to topic-specific focus-group sessions to discuss and develop research questions pertaining to Dry Eye and MGD. The research questions were compiled into a proposed patient-centered roadmap for Dry Eye and MGD research. Two additional participants contributed to the proposed roadmap following the convening. Results: The focus groups identified over 80 patient-centered research questions important to patients and other stakeholders and compiled these into a proposed research roadmap. Conclusion: The convened stakeholders aim to establish a cohesive and comprehensive patient-centered approach to treating Dry Eye, Meibomian Gland Dysfunction, and comorbidities. The research roadmap will serve as a reference for researchers, educational institutions, clinicians, and others evaluating diagnostic and treatment protocols in Dry Eye and MGD.

New Indicator of Children's Excessive Electronic Screen Use and Factors in Meibomian Gland Atrophy.

PURPOSE: To evaluate the association of children's daily electronic screen use with severe meibomian gland atrophy (MGA). DESIGN: Retrospective cross-sectional study. METHODS: Children (aged 6-17years) presenting at clinical practice December 2016 - October 2017 were evaluated for ≥grade 2 MGA vs age-matched controls with insignificant atrophy (

Clinical pseudophakic cystoid macular edema. Risk factors for development and duration after treatment.

PURPOSE: To characterize the incidence, duration, and risk factors for and outcome of cystoid macular edema (CME) after cataract surgery and investigate the effects of treatment regimens on visual outcome and duration. SETTING: University-based comprehensive ophthalmology practice. METHODS: This study included 1659 consecutive cataract surgeries performed by residents between 2001 and 2006. Cases were classified according to the presence of CME. Subset analysis excluded patients with diabetes mellitus (DM). The CME groups were analyzed according to type of treatment to compare duration of CME and final best corrected visual acuity. RESULTS: The incidence of postoperative CME was 2.35% (39/1659), and history of retinal vein occlusion (RVO) was predictive of postoperative CME (odds ratio [OR], 47.12; P<.001). When patients with DM were excluded, the incidence of CME was 2.14% (29/1357) and history of RVO (OR, 31.75; P<.001), epiretinal membrane (ERM) (OR, 4.93; P<.03), and preoperative prostaglandin use (OR, 12.45; P<.04) were predictive of postoperative CME. Patients with DM and/or intraoperative complications did not have an increased risk for CME when treated with prophylactic postoperative nonsteroidal antiinflammatory drugs (NSAIDs) for 3 months. Groups treated with NSAIDs plus a steroid had significantly shorter resolution times than the untreated group (P = .004). CONCLUSIONS: A history of RVO, ERM, and preoperative prostaglandin use were associated with an increased risk for pseudophakic CME. Treatment with NSAIDs plus steroids was associated with faster resolution of CME than no treatment. Treating high-risk patients with NSAIDs after cataract surgery decreases the incidence of postoperative CME to that of patients who are not at high risk.

Intraoperative Fluorescein Staining of Cryopreserved Amniotic Membrane Grafts to Improve Visualization During and After Pterygium Surgery: A Novel Technique.

PURPOSE: To describe a new method of enhancing the visualization of amniotic membrane grafts with fluorescein staining during pterygium surgery. METHODS: Pterygium excision surgery using intraoperatively stained cryopreserved amniotic membranes was performed on 346 eyes. A sterile 0.6 mg sodium fluorescein strip was placed directly onto the amniotic membrane in the manufacturer's original packaging, and the stained allograft was then transplanted onto the planned site. Staining intensities, at 3, 5, and 10 minutes of dye immersion, were compared. Immediate postoperative pain rating (scale 0-10), visibility of the fluorescein-stained amniotic membrane graft, and conjunctival autograft and amniotic membrane graft elevation, dehiscence, retraction, or displacement were recorded. The recurrence rate of the study population was compared with that of a previous cohort of 121 patients who underwent pterygium excision with conjunctival autograft without stained amniotic membrane. RESULTS: Direct contact of the fluorescein strip on the amniotic membrane at 3, 5, and 10 minutes showed no differences in subjective staining intensity. Fluorescein-stained amniotic membrane was easily detected on the ocular surface during and 24 hours after pterygium surgery. The average immediate postoperative pain rating was 0.8 ± 1.8. No intraoperative complications or postoperative amniotic membrane graft dehiscence, retraction, or displacement occurred. The recurrence rate using fluorescein-stained amniotic membrane (3 patients, 0.9%, mean follow-up time 31.8 ± 18.6 weeks) did not differ from that of the previous cohort without the stained amniotic membrane (2.5%; χ(1) = 1.837, P = 0.183). CONCLUSIONS: Fluorescein strip staining of the amniotic membrane is a novel and safe intraoperative method to enhance visualization and handling of the graft during and after ocular surgeries.

Global Rating Assessment of Skills in Intraocular Surgery (GRASIS).

OBJECTIVE: The American Board of Ophthalmology in conjunction with the Accreditation Council for Graduate Medical Education has mandated the systematic assessment of surgical competence of ophthalmology residents at all residency programs. We present a tool complementary to the Objective Assessment of Skills in Intraocular Surgery (OASIS) to assess residents' surgical competence. PARTICIPANTS: Twenty experts in resident education, including the chiefs of all ophthalmology services and the chief resident at the Harvard Medical School Department of Ophthalmology. METHODS: A 1-page subjective evaluation form was developed in conjunction with the Objective Assessment of Skills in Intraocular Surgery evaluation form to assess the surgical skills of residents. A panel of surgeons at the Harvard Medical School Department of Ophthalmology at the Massachusetts Eye and Ear Infirmary reviewed the form and provided constructive feedback. RESULTS: Experts' comments were incorporated, establishing face and content validity. CONCLUSIONS: The Global Rating Assessment of Skills in Intraocular Surgery (GRASIS) has face and content validity. It can be used to assess a resident's surgical care of patients as well as a resident's surgical knowledge, preparedness, and interpersonal skills. Reliability and predictive validity will be determined at our institution. We believe the GRASIS evaluation form will be a valuable tool in conjunction with the OASIS evaluation form for assessing ophthalmology residents' surgical skills at other residency programs as well.

Objective Assessment of Skills in Intraocular Surgery (OASIS).

OBJECTIVE: To establish an objective ophthalmic surgical evaluation protocol to assess residents' surgical competency and improve residents' surgical outcomes. PARTICIPANTS: Eight experts in resident education from comprehensive ophthalmology, cornea, glaucoma, and retina services; 2 chief residents (postgraduate year 5 [PGY5]); and resident representatives from PGYs 2, 3, and 4 participated in the development of an objective assessment tool of skills in resident cataract surgery. METHODS: Analysis of all resident cataract surgeries performed at our service from July 2001 to July 2003 led to the development of a 1-page objective evaluation form to assess residents' skills in cataract surgery. A panel of surgeons at the Massachusetts Eye and Ear Infirmary reviewed the database and the evaluation form and provided constructive feedback. RESULTS: Development of a unique database of all resident cataract cases and constructive feedback by experts in resident teaching assisted in creating a 1-page evaluation form entitled Objective Assessment of Skills in Intraocular Surgery (OASIS). CONCLUSIONS: OASIS has face and content validity and can be used to assess, objectively, surgical events and surgical skill. We believe the OASIS evaluation form and database will be a valuable tool for assessing ophthalmology residents' surgical skills at other residency programs as well.

Incidence of intraoperative complications in cataract surgery performed by left-handed residents.

PURPOSE: To compare the incidence of intraoperative complications during cataract surgery performed by left-handed and right-handed residents and to find predictor variables for complications in resident-performed surgery. SETTING: Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA. METHODS: This retrospective chart review comprised cataract extractions performed by postgraduate fourth-year residents from July 1, 2001, to June 30, 2006. The incidence of posterior capsule tear and vitreous loss were the main outcomes. Univariate and multivariate logistic analyses incorporated the variables of patient age and sex; laterality of surgical eye; presence of diabetes mellitus, glaucoma, or age-related macular degeneration; history of vitrectomy; axial length; pseudoexfoliation; small pupils; white cataract; posterior polar cataract; handedness of resident; and academic quarter during which surgery occurred. RESULTS: Left-handed residents performed 170 (9.8%) of the 1730 surgeries. The incidence of posterior capsule tear and vitreous loss was significantly lower in surgeries performed by left-handed residents than in those performed by right-handed residents (P = .03 and P<.001, respectively). Multivariate logistic analysis showed that resident right-handedness and older patient age were predictive of an increased incidence of posterior capsule tear and vitreous loss. A small pupil was predictive of an increased incidence of vitreous loss. CONCLUSIONS: The incidence of posterior capsule tear and vitreous loss was significantly lower in cataract surgeries performed by left-handed residents. Handedness and patient age were significant predictor variables for these complications.

Multifocal nodular episcleritis and scleritis with undiagnosed Hodgkin's lymphoma.

PURPOSE: To report the case of a patient with undiagnosed Hodgkin's lymphoma who presented with coexistent unilateral nodular episcleritis and scleritis. DESIGN: Interventional case report and literature review METHODS: Review of clinical history, laboratory findings, histology of episcleral and cervical lymph node biopsies, and follow-up. RESULTS: A 20-year-old female presented with a 5-month history of redness and pain in her left eye, with associated symptoms of dyspnea, malaise, and fever. The patient was found to have multifocal nodular episcleritis and scleritis that was not responsive to topical steroids or systemic nonsteroidal anti-inflammatory treatment. Laboratory tests subsequently revealed evidence of systemic inflammation, and radiologic studies showed extensive mediastinal and cervical adenopathy. A cervical lymph node biopsy showed Reed-Sternberg cells and a chronic lymphocytic infiltrate consistent with nodular sclerosing Hodgkin's lymphoma. Histopathologic analysis of an episcleral nodule revealed a necrotizing granuloma with vasculitis. Systemic chemotherapy was instituted for the Hodgkin's disease; this therapy abolished the nodular scleritis. CONCLUSIONS: This case raises the possibility of concurrent undiagnosed systemic vasculitis with only an ocular manifestation with Hodgkin's lymphoma, either as a coincidence or as a paraneoplastic syndrome. Moreover, it emphasizes the important role of tissue biopsy in establishing diagnosis and directing treatment.