Tasmanian macular hole study: whole population-based incidence of full thickness macular hole.

PURPOSE: To determine the incidence of full thickness macular hole in the Tasmanian population. DESIGN: A whole population retrospective case series in Tasmania, Australia. METHODS: Patients diagnosed with full thickness macular hole (confirmed by optical coherence tomography (OCT) imaging) of both idiopathic and secondary causes were identified from April 2005 to April 2011 by a sole vitreoretinal surgeon servicing Tasmania. Baseline characteristics were recorded. The six-year incidence rate was calculated, based on the 2006 and 2011 Tasmanian census data. Incidence rates were age and sex standardized. PARTICIPANTS: One hundred forty-seven eyes of 136 patients. MAIN OUTCOME MEASURES: To determine the incidence (age and sex standardized) of full thickness macular holes in Tasmania, Australia. RESULTS: Idiopathic macular holes comprised 128 (87.1%). There were 116 cases of idiopathic Full Thickness Macular Hole in one or both eyes between 1 April 2005 and 31 April 2011. The six-year incidence of idiopathic full-thickness macular holes was 24.3 per 100 000 people, 4.05 per 100 000 per year, with the highest six-year incidence observed among women aged 70-79 years. CONCLUSION: This is the first global study to report OCT confirmed incidence rates of full thickness macular holes in a relatively static Australian population sub-group.

Zonular and capsular bag disorders: a hypothetical perspective based on recent pathophysiological insights.

The purpose of this article was to look at the pathophysiology behind and devise a classification system for the causes of zonular apparatus-capsular bag (ZACB) insufficiency. Also discussed is dystrophic bag syndrome, including clinical cases and addressing where it lies on the ZACB spectrum. There has been interest in the emergence of in-the-bag intraocular lens (IOL) subluxation, the prevalence of which is increasing. There has also been a recent report of dead bag syndrome, which the authors believe is part of the same disease spectrum. The authors put these phenomena into perspective and provide a classification system based on the possible causes of what they have termed ZACB insufficiency. The basic aspects of capsular bag-IOL ocular pathophysiology are summarized with a focus on functional aspects and the consequences for IOL fastening. Within this framework, dystrophic bag syndrome is a form of primary capsular ZACB insufficiency. The contribution of factors such as intraocular drugs may suggest a reconsideration of agents used and their mode of application.

Intraocular lens explantation following cataract surgery: Indications, techniques, and video demonstrations.

As techniques for modern cataract surgery have expanded and premium intraocular lens (IOL) use is now widespread, patient expectations are high. The need for IOL explantation, whilst still low, remains an ongoing issue. Intraocular lens explantation can be challenging for a number of reasons and as such we have introduced an additional technique to add to the surgeon's repertoire. Bimanual haptic stripping of fibrosis at the specific area where the haptic is adherent to the capsular bag is an effective strategy to aid in dissection of haptics without compromising the capsule or zonules. Given the challenges associated with IOL explantation, newly designed IOLs need to avoid these "sticking points" at which the IOLs interact with the fibrosed capsule. Techniques we have evolved and which are described below should assist anterior segment surgeons to facilitate IOL removal in an efficient and safe way.

Lens Epithelial Cell Removal in Routine Phacoemulsification: Is It Worth the Bother?

PURPOSE: To review the literature on crystalline lens epithelial cell (LEC) removal in routine phacoemulsification and determine whether it should be incorporated as part of a surgeon's standard technique. DESIGN: Perspective. METHODS: Expert commentary with video demonstrations on techniques of removal of LECs and associated potential complications. Discussion incorporates the importance of LEC removal, a review of techniques to prevent posterior capsular opacification (PCO), and the effects of intraocular lens design on LEC proliferation and PCO. RESULTS: The evidence suggests that LEC removal should be routinely performed as it can be carried out safely and with considerable short- and long-term benefits for patients. With effective cleanup, there is reduced anterior capsule opacification, fibrosis, and decentration of the capsular bag as well as reduced rates of posterior capsular opacification. Techniques for removal are easy to learn, with very low complication rates, and can reduce the risk of the long-term need for technically complex procedures such as intraocular lens explantation. CONCLUSIONS: LEC removal from both the anterior and posterior capsule is part of a continuous, incremental improvement of cataract surgery and should be introduced to ophthalmology trainees during their formative years as part of their regular cataract surgery armamentarium.

KAMRA presbyopic inlay refractive outcomes: a Canadian perspective.

OBJECTIVE: To retrospectively analyze the visual outcomes of KAMRA (AcuFocus Inc, Irvine, Calif.) inlay insertion in a cohort of patients reporting success of procedure, complications, patient satisfaction, and refractive outcomes. DESIGN: Retrospective trial at the TLC Laser Centre, Toronto. METHODS: A total of 5 surgeons at the practice inserted 35 KAMRA inlays in 35 patients between October 2012 and June 2014. Some patients had a sole KAMRA inlay insertion, whereas others had combined laser vision correction (LVC) and KAMRA inlay on either the same day or sequentially. There was a small cohort of patients who had previous unrelated LVC. Mean time of follow-up was 299 days. RESULTS: After KAMRA inlay insertion there was a significant improvement in uncorrected near visual acuity (p = 0.00009), uncorrected intermediate visual acuity (p = 0.00006), and uncorrected distance visual acuity (p = 0.02), but levels of patient dissatisfaction were 43%. The most common cause for dissatisfaction was requirements for readers (23%), followed by dysphotopsias (11%). The explantation rate was 11.42%, and 28.5% of patients required enhancements after inlay insertion. CONCLUSIONS: The KAMRA corneal inlay has significant improvements in uncorrected near visual acuity, uncorrected intermediate visual acuity, and uncorrected distance visual acuity when used in isolation or combined with LVC. Appropriate patient selection is crucial. This procedure should not be used as first-line presbyopia management because of low levels of patient satisfaction, biocompatibility concerns, and explantation rates.

Visual performance and positional stability of a capsulorhexis-fixated extended depth-of-focus intraocular lens.

PURPOSE: To examine the 6-month outcomes of visual performance and positional stability of a capsule-fixated intraocular lens (IOL), FEMTIS Comfort MF15, extended depth-focus (EDOF) version, after cataract surgery performed using femtosecond laser-assisted cataract surgery capsulotomy. SETTING: Vision Eye Institute, Sydney, Australia. DESIGN: Prospective open-label postregistration data collection. METHODS: Three-month and 6-month outcomes were measured including visual function, stability of IOL position, and quantitative measurement of glare and halo. Subjective patient satisfaction and spectacle independence rates were documented with a subjective questionnaire. A computer simulator was used to quantify the incidence and severity of unwanted visual phenomena allowing comparison with other EDOF and multifocal IOLs. RESULTS: Forty-four eyes of 25 patients were included in the study. There were 19 bilateral cases. The median shift in IOL position over 6 months (from surgery to 6 months) was 0.095 ± 0.09 mm. There was a marked improvement in uncorrected and corrected distance visual acuity from the preoperative to the 6-month mark. Patient satisfaction and spectacle independence levels were high. There was no IOL enclevation, negative dysphotopsia, decentration, or capsular phimosis. CONCLUSIONS: To the authors' knowledge, this is the first study to report outcomes after insertion of the FEMTIS capsulorhexis-fixated EDOF IOL. This IOL offers excellent refractive predictability, functional range of vision, and minimal unwanted visual phenomena. The attachment to the anterior capsulorhexis is shown to be stable over time with no significant shift in the position or capsular phimosis. There was high patient satisfaction with spectacle independence.

The Incidence of Ocular Tuberculosis in Australia Over the Past 10 Years (2006-2015).

PURPOSE: To determine the incidence and clinical phenotype of ocular tuberculosis in Australia based on the mandatory jurisdictional health notification records for TB. METHODS: A whole population retrospective case series (Australia). Patients diagnosed with ocular tuberculosis were identified over the past 10 years (1 January 2006 to 31 December 2015) as recorded by individual Health Department jurisdictions per mandatory health notifications. The incidence rates were calculated based on the available Australian census data. Incidence rates were age and sex standardized. RESULTS: A total of 162 cases of ocular tuberculosis were identified across Australia over a 10-year time period. Of these, 156 participants were overseas born. The 10-year Australian incidence of ocular tuberculosis was 0.77 per 100,000 people. While there has been a downward trend in overall TB annual incidence rates from 2010 to 2015, over the same period the annual incidence of ocular TB has increased compared to the 4 previous years. Descriptive clinical data regarding the ocular manifestations of TB was available in 73/157 patients. In these 73 patients the commonest manifestations of ocular TB were unspecified uveitis (50.1%), focal, multifocal or serpiginous choroiditis or chorioretinitis (12.3%) and retinal vasculitis (11.0%). Of patients with ocular TB, 4/162 (2.47%) had associated pulmonary TB and 8/162 (4.94%) had associated systemic (non-pulmonary) TB. Systemic anti-TB therapy was administered to 161 patients. CONCLUSIONS: The annual Australian incidence of ocular tuberculosis was 0.077 per 100,000 people. Increasing notifications in the past 6 years may demonstrate increased awareness and changing diagnostic criteria of the disease in the Australian population.

Femtosecond laser-assisted cataract surgery versus standard phacoemulsification cataract surgery: outcomes and safety in more than 4000 cases at a single center.

PURPOSE: To compare the intraoperative complications and safety of femtosecond laser-assisted cataract surgery and conventional phacoemulsification cataract surgery. SETTING: Single center. DESIGN: Prospective consecutive comparative cohort case series. METHODS: Eyes had femtosecond laser-assisted cataract surgery (study group) or phacoemulsification (control group) by 1 of 5 surgeons. The technique comprised manual corneal incisions and capsulorhexis or laser-assisted anterior capsulotomy, lens fragmentation, corneal incisions, phacoemulsification, and intraocular lens implantation. RESULTS: The study group comprised 1852 eyes and the control group, 2228 eyes. Patient demographics were similar between groups. There was a significant improvement in vacuum/docking attempts, surface recognition adjustments, treatment, and vacuum time during the laser procedure in the study group. Anterior capsule tears occurred in 1.84% of eyes in the study group and 0.22% of eyes in the control group (P < .0001). There was no difference in the incidence of anterior capsule tears between the first half and second half of laser-assisted cases. Anterior capsulotomy tags occurred in 1.62% study group eyes. There was no significant difference in posterior capsule tears between the 2 groups (0.43% versus 0.18%). The incidence of significant intraoperative corneal haze and miosis was higher and the effective phacoemulsification time significantly lower in the study group (P < .001). CONCLUSIONS: Significant intraoperative complications likely to affect refractive outcomes and patient satisfaction were low overall. The 2 cataract surgery techniques appear to be equally safe. Although anterior capsule tears remain a concern, the safety of femtosecond-assisted cataract surgery in terms of posterior capsule complications was equal to that of phacoemulsification. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Intraocular pressure during femtosecond laser pretreatment: comparison of glaucomatous eyes and nonglaucomatous eyes.

PURPOSE: To compare changes in intraocular pressure (IOP) during femtosecond laser pretreatment of cataract between glaucomatous eyes and nonglaucomatous eyes. SETTING: Launceston Eye Institute and Launceston Eye Hospital, Launceston, Australia. DESIGN: Nonrandomized interventional prospective case series. METHODS: Patients with clinically stable primary open-angle glaucoma (POAG) having femtosecond laser pretreatment were compared with a concurrent cohort of patients with healthy eyes having the same procedure. Pretreatment was performed using a fluid-filled optical docking system (Liquid Optics Interface). With the patient supine, the IOP was measured at 4 time points using a rebound tonometer (Icare Pro). RESULTS: The study comprised 143 eyes of 97 patients. Forty-three eyes (30.1%) had documented glaucoma. The mean baseline IOP was 20.2 mm Hg ± 4.2 (SD) in glaucomatous eyes and 18.9 ± 4.0 mm Hg in nonglaucomatous eyes (P = .06). The mean change in IOP values between each time frame and baseline was as follows: vacuum-on, 13.8 ± 9.9 mm Hg and 11.1 ± 6.9 mm Hg, respectively (P = .06); after treatment, 17.4 ± 7.4 mm Hg and 14.1 ± 7.2 mm Hg, respectively (P = .014); after undocking of vacuum, 9.9 ± 5.4 mm Hg and 8.7 ± 5.7 mm Hg, respectively (P = .24). CONCLUSIONS: Femtosecond pretreatment caused a greater transient rise in IOP after treatment and a higher residual IOP after vacuum undocking in glaucomatous eyes than in nonglaucomatous eyes. This is well tolerated short term; however, long-term implications for eyes with glaucoma are unknown at present. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Effect of biologic therapy on radiological progression in rheumatoid arthritis: what does it add to methotrexate?

There have been substantial advances in the treatment of rheumatoid arthritis in recent years. Traditional disease-modifying antirheumatic drugs (DMARDs) have been shown to have small effects on the progression of radiographic damage. This quantitative overview summarizes the evidence for biologic DMARDs and radiographic damage either alone or in combination with methotrexate. Two outcomes were used (standardized mean difference and odds of progression). A total of 21 trials were identified of which 18 had useable data. For biologic monotherapy, tocilizumab, adalimumab, and etanercept were significantly better than methotrexate, with tocilizumab ranking first in both outcomes while golimumab was ineffective in both outcomes. For a biologic in combination with methotrexate compared with methotrexate alone, most therapies studied (etanercept, adalimumab, infliximab, certolizumab, tocilizumab, and rituximab) were effective at slowing X-ray progression using either outcome, with infliximab ranking first in both outcomes. The exceptions to this were golimumab (no effect on standardized mean difference) and abatacept (no effect on odds of progression). This effect was additional to methotrexate; thus, the overall benefit is moderate to large in magnitude, which is clearly of major clinical significance for sufferers of rheumatoid arthritis and supports the use of biologic DMARDs in those with a poor disease prognosis.