Advances in Contact Lens Care Solutions: PVP-I Disinfectant and HAD Wetting Agents From Japan.

ABSTRACT: Half of the individuals who wear contact lenses use reusable lenses that require proper care. Improper contact lens (CL) care and using inadequate disinfecting solutions can lead to lens contamination, CL-related microbial keratitis, and Acanthamoeba keratitis. Oxidative disinfecting solutions, such as hydrogen peroxide, show higher efficacy than multipurpose solutions. Povidone-iodine (PVP-I), an oxidative disinfectant used in ophthalmic surgery, has been proven to be safe and effective. The PVP-I system, a CL disinfecting solution developed in Japan, has demonstrated excellent antimicrobial and antiviral properties. Although CL discomfort does not have a risk of ocular disorders with poor visual prognosis, such as keratitis, CL discomfort can still lead to lens dropout and thus needs to be addressed. To mitigate CL discomfort, it is essential to use disinfecting solutions containing surfactants and wetting agents that improve wettability of the lens surface. A CL solution containing hyaluronic acid derivatives (HADs) as wetting agents that permanently adhere to the lens surface to improve wettability of the lens surface was developed in Japan. There is potential for HAD to be integrated into various solutions. This article reviews the efficacy of novel PVP-I-based disinfecting solution and HAD wetting agents.

What Happens 20 to 30 years After Radial Keratotomy? Case Series.

ABSTRACT: Radial keratotomy (RK) was commonly performed in the 1980s and 1990s. We aimed to clarify the current status of post-RK refractive correction and treatment. We retrospectively reviewed the charts of 70 patients with a history of RK. Of the 70 patients, 44 were identified for clinical outcomes. Refractive or therapeutic intervention (rigid gas-permeable contact lens fit, spectacle prescription, corneal surgery, and use of pilocarpine hydrochloride for photophobia) was possible in 59% of patients with postoperative visual deterioration after RK; in the remaining 41%, therapeutic intervention was not possible. Rigid gas-permeable contact lens fit for corneal irregular astigmatism was the most common refractive intervention and was effective in 36% of cases in the university hospital.

Continuous Corneal Endothelial Damage by Chlorhexidine Alcohol Used for Disinfection in Nonophthalmic Surgery.

PURPOSE: To report a case of corneal endothelial damage caused by alcohol-containing chlorhexidine gluconate (CG-A) and its progression over time. METHODS: This was a case report. RESULTS: A 22-year-old man underwent neurosurgery under general anesthesia. CG-A (1%) was used for disinfection after the application of corneal protection tape. Postoperatively, the patient presented with hyperemia and swelling of the left conjunctiva and was referred to our department. Initial examination revealed left corneal epithelial erosion and corneal edema, which improved on postoperative day 14. The corneal endothelial cell density (ECD) was 3,345 cells/mm 2 on day 14, decreased rapidly to 2,090 cells/mm 2 on day 42, and slowly reduced to 1,122 cells/mm 2 on day 168. Thereafter, no decrease in ECD was observed. CONCLUSIONS: CG formulations can lead to a persistent decrease in ECD over several months, even after improvement of acute corneal edema.

A Comprehensive Wavefront Assessment of Keratoconus Using an Integrated Scheimpflug Corneal Tomographer/Hartmann-Shack Wavefront Aberrometer.

OBJECTIVES: To characterize higher-order aberrations (HOAs) in different severities of keratoconus (KC) from the anterior and posterior corneal surfaces and whole eye using an integrated Scheimpflug corneal tomographer/Hartmann-Shack wavefront aberrometer. METHODS: This study included eyes with clinical KC, topographic KC (no clinical signs), fellow eyes with very asymmetric ectasia with normal topography and no clinical signs (VAE-NT), and control eyes. Corneal and ocular wavefront aberrations were obtained using an integrated Scheimpflug tomographer/Hartmann-Shack wavefront aberrometer. The diagnostic capability of distinguishing VAE-NT from the control was also tested. RESULTS: This study included 68 eyes with clinical KC, 44 with topographic KC, 26 with VAE-NT, and 45 controls. Clinical KC had significantly greater total HOAs and coma from the anterior and posterior corneal surfaces and whole eye than the other groups ( P <0.05). Although topographic KC had significantly greater values in all wavefront parameters than the control ( P <0.05), ocular and corneal HOAs did not differ between the VAE-NT and control groups. The coma from the anterior cornea in topographic KC was significantly greater than that in VAE-NT ( P <0.05); the coma from the posterior cornea and whole eye did not differ. Total HOAs from the anterior corneal surface exhibited the highest area under the receiver operating characteristic curve value of 0.774 (sensitivity, 73%; specificity, 78%). CONCLUSION: A comprehensive wavefront assessment can be used to quantitatively evaluate corneal and ocular HOAs across various severity of KC. Total HOAs from the anterior corneal surface exhibited the potential ability in distinguishing VAE-NT from the control eyes.

Assessment of the corneal biomechanical features of granular corneal dystrophy type 2 using dynamic ultra-high-speed Scheimpflug imaging.

PURPOSE: To evaluate the corneal biomechanical features of eyes with granular corneal dystrophy type 2 (GCD2) by analyzing corneal biomechanical indices obtained using a Corvis ST (CST) dynamic ultra-high-speed Scheimpflug imaging device. METHODS: In this retrospective case-control study, 35 CST parameters were compared in normal eyes (control) and eyes of patients with GCD2 treated at Osaka University Hospital, Osaka, Japan. The parameters included the Corvis Biomechanical Index (CBI), which is important in differentiating eyes with keratoconus from normal eyes. We measured the deposition rates of lesions in the central 7-mm region of the eye and assessed the correlation between the deposition rate and the CBI. RESULTS: Twenty-one eyes with GCD2 and 23 control eyes were analyzed. Eyes with GCD2 showed significantly less corneal stiffness in 15 CST parameters than did control eyes. In particular, the CBI was remarkably higher in eyes with GCD2 than in control eyes (P = 0.000006). Additionally, the deposition rate and the CBI were positively correlated. CONCLUSIONS: GCD2 eyes had softer corneas than did control eyes in most biomechanical CST parameters, and one of the parameters (the CBI) was linked to the rate of deposited lesions. Since IOP may be underestimated in GCD2 eyes, management should be especially careful in GCD2 cases complicated by glaucoma.

Evaluating the Differences Between Fluorescein Tear Break-up Time and Noninvasive Measurement Techniques.

OBJECTIVES: To compare fluorescein tear break-up time (BUT) and noninvasive BUT measured using interferometry and corneal topography. METHODS: We investigated 34 eyes of 34 patients with dry eye (mean age 39.2±8.3 years) and 16 eyes of 16 non-dry eye subjects (33.5±6.5 years). Tear film stability was measured using fluorescein BUT, noninvasive BUT (NIBUT)-DR1 with an interferometer, and noninvasive keratographic BUT (NIKBUT)-first and average using corneal topography. Correlations between fluorescein BUT and noninvasive BUT parameters were determined statistically. The noninvasive BUTs were compared between the dry eye and non-dry eye groups. The agreement between fluorescein and noninvasive BUTs was described using Bland-Altman analysis. RESULTS: Fluorescein BUT was significantly correlated with NIBUT-DR1, NIKBUT-first, and NIKBUT-average. The Bland-Altman analysis revealed bias and 95% limits of agreement between fluorescein BUT and noninvasive BUTs as follows: NIBUT-DR1: 2.07 s, -5.33 to 9.46 s; NIKBUT-first: 3.39 s, -5.46 to 12.24 s; NIKBUT-average: 6.61 s, -1.58 to 14.79 s. The noninvasive BUTs were significantly different between the two groups. When NIBUT-DR1, NIKBUT-first, and NIKBUT-average with Bland-Altman correction were used as an index for dry eye, the cut-off values were 7.1, 8.4, and 11.6 s, respectively. The sensitivities were 0.735, 0.818, and 0.727 and specificities were 0.500, 0.437, and 0.562, respectively. CONCLUSION: Fluorescein BUT and noninvasive BUTs were significantly correlated, and noninvasive BUTs had higher values than fluorescein BUT. Considering the differences between fluorescein BUT and noninvasive BUTs, noninvasive methods can be used as effective tool for diagnosing dry eye.

Comparison of Ocular Wavefront Aberration Measurements Obtained Using Two Hartmann-Shack Wavefront Aberrometers.

OBJECTIVES: To assess agreement between measurements of ocular wavefront aberrations obtained using the Pentacam AXL Wave (Oculus Optikgeräte GmbH) (Aberrometer A) and KR-1W (Topcon Corp) (Aberrometer B), both of which are based on the Hartmann-Shack principle. METHODS: In this prospective case-control study, ocular wavefront aberrations measurements were obtained using both aberrometers in patients with keratoconus (KC) and control participants. Ocular wavefront aberrations were measured through the natural pupil without dilation using both devices in a dark room. For both aberrometers, accommodation was inhibited by automatically adding fogging. The individual Zernike coefficients from the second to fourth order were compared between the two aberrometers for a 4-mm pupil diameter. RESULTS: Twenty-six KC and 29 control eyes were assessed. Statistically significant correlations ( P <0.05) were observed for all Zernike coefficients, except for Z 4-2 in the control group. Bland-Altman analysis indicated good agreement between aberrometers and no statistically significant differences in the control group. However, in the KC group, patterns of proportional error were observed in vertical coma Z 3-1 (r=0.338, P =0.008), trefoil Z 4-4 (r=0.701, P =0.003), secondary astigmatism Z 4-2 (r=0.348, P =0.025), and spherical aberrations Z 40 (r=0.407, P =0.012). CONCLUSIONS: The Zernike coefficient values measured by the two aberrometers were well correlated in the control and KC groups. However, in eyes with KC, Aberrometer B tended to present greater values in several Zernike coefficients than Aberrometer A, suggesting that wavefront measurements obtained using the two aberrometers are not interchangeable in patients with KC.

Long-Term Corneal Refractive Power Changes Two Decades After Radial Keratotomy With Microperforations.

ABSTRACT: We retrospectively examined corneal refractive power in three patients who had been followed up for more than 20 years after radial keratotomy (RK) with microperforations (MPs). All patients underwent RK in both eyes and were referred to our clinic because of postoperative decreased vision. MP was observed in five of the six eyes at the initial visit. The corneal refractive power of the anterior and posterior surfaces of the 6-mm-diameter cornea was examined using Fourier analysis based on corneal shape analysis using anterior segment optical coherence tomography. The spherical components decreased in all three cases. The asymmetry and higher-order irregularity components and fluctuations in corneal refractive power were markedly greater in the two cases with MP in both eyes. Fluctuations in corneal refractive power were observed at more than 20 years after RK with MP. Therefore, careful observation is necessary, even after a long-term postoperative follow-up period.

Optical Quality and Visual Performance With Different Toric Contact Lens Designs.

OBJECTIVES: To evaluate the optical quality of different toric contact lens (CL) designs and compare their on-eye visual correction performance. METHODS: Twenty soft CL wearers aged 20 to 39 years were enrolled. Two daily disposable silicone-hydrogel toric CLs were tested: the "Eyelid Stabilized Design" (ESD-CL) and prism-ballast design (PB-CL); a spherical daily disposable silicone hydrogel CL (spherical CL) was used as a control. On-eye performance was compared for corrected distance visual acuity (CDVA), astigmatism, and ocular higher-order aberrations (HOAs); astigmatism and ocular HOAs were measured with a wavefront sensor. The subjective quality of vision, rated for "blurred vision" and "double vision," lens rotation, and fitting were also compared. RESULTS: The ESD-CLs, PB-CL, and no-CL provided better CDVA than spherical CL ( P <0.05). Compared with spherical CL and no CL, PB-CL and ESD-CLs caused significantly lesser astigmatism ( P <0.05). Coma was significantly lesser with ESD-CLs than that with PB-CL ( P <0.05); total HOAs did not differ among the four conditions. The subjective ratings for blurred and double vision were significantly lower with ESD-CLs than those with spherical CL ( P <0.05). CONCLUSIONS: Toric CLs provide a better CDVA than spherical CLs. However, differences in coma and subjective symptoms may occur because of the design of toric CLs.

Characteristics of Higher-Order Aberrations in Different Stages of Keratoconus.

OBJECTIVES: To characterize higher-order aberrations (HOAs) in clinical and subclinical keratoconus (KC). METHODS: The study included 33, 36, and 26 patients with clinical, topographic (no clinical signs), and pretopographic (normal topography and no clinical signs) KC and 30 controls. Ocular and corneal HOAs for the 4-mm pupils were measured using a wavefront sensor and expanded up to the sixth order of Zernike polynomials. The magnitudes of trefoil, coma, tetrafoil, secondary astigmatism, and spherical aberration were calculated via Zernike vector analysis and used as HOA parameters along with total HOAs. Area under the receiver operating characteristic curve (AUROC) values for each wavefront parameter for pretopographic KC were compared. RESULTS: Control eyes and eyes with pretopographic KC had significantly lower ocular or corneal total HOAs and Zernike vector terms than those with clinical KC and topographic KC, except for ocular tetrafoil between topographic KC and pretopographic KC and spherical aberration among all groups. The AUROCs for corneal total HOAs and corneal coma for pretopographic KC and control eyes were 0.781 (100% sensitivity and 47% specificity) and 0.735 (73% sensitivity and 73% specificity), respectively. CONCLUSION: Corneal total HOAs and corneal coma exhibited a potential ability to discriminate pretopographic KC from normal control eyes.

Severe Ocular Complications Associated With Wearing of Contact Lens in Japan.

OBJECTIVES: To examine the severe ocular complications associated with contact lens wearing in Japan. METHOD: A questionnaire was sent to 964 ophthalmologist training facilities inquiring for cases of contact lens-associated complications from April 2016 to March 2018. The inclusion criteria were as follows: (1) corrected distance visual acuity ≤0.1 decimal after treatment for 3 months, (2) corneal perforation observed during follow-up, and (3) requiring surgery. A secondary analysis was conducted, inquiring for further information on the type of contact lens, clinical manifestations, and course of treatment. RESULTS: Forty-two patients with infectious keratitis met the inclusion criteria. Eight patients were users of rigid gas-permeable contact lens, and 34 were users of soft contact lens. Microbiological tests were positive in 73.0%. The organisms isolated in microbiological culture were bacteria in 11 patients (Pseudomonas aeruginosa in 9 patients), fungi in 2 patients, and Acanthamoeba in 14 patients. Ten patients were treated with local antibiotics, 11 with a combination of systemic antibiotics, and 21 with a combination of surgical approaches, including 13 with corneal transplantation. CONCLUSIONS: The major cause of serious contact lens-associated ocular complications was microbial keratitis, and P. aeruginosa and Acanthamoeba were the major pathogens in Japan.

COVID-19 and Dry Eye.

ABSTRACT: The aim of this article is to review the literature on the impact of coronavirus disease 2019 (COVID-19) on dry eye disease (DED). A literature search on dry eye and COVID-19 was performed. Most current studies focus on DED in patients diagnosed with COVID-19 or dry eye symptoms in random populations of students and medical staff. Real-world dry eye practices revealed a variety of responses, possibly related to local environmental factors and lifestyle. Patients recovered from COVID-19 warrant ocular surface surveillance for DED. Pandemic mitigation strategies including remote work/school/leisure and mask wearing affect dry eye practices globally. Heightened reiteration of dry eye management for environmental and behavioral modifications, visual display terminals, and mask wearing with attention to its effects on the ocular surface is increasingly important as this pandemic continues.

The Characteristics and Risk Factors of Very Asymmetric Keratoconus.

PURPOSE: To characterize very asymmetric keratoconus (KC) in terms of clinical demographics and risk factors in the Japanese population. METHODS: We retrospectively reviewed the clinical records of patients with very asymmetric KC attending a university hospital. Patients with very asymmetric KC had defined clinical KC in one eye and normal topography in the fellow eye. All patients completed a questionnaire on potential risk factors (family history of KC, atopy, asthma, allergy, heart disease, sleep apnea, Down syndrome, eye rubbing, prone sleep position, and dominant hand). These data were compared with those of patients with clinical or topographic KC in both eyes. Subgroup analysis of very asymmetric KC eyes were performed based on the KC status: mild and severe. RESULTS: We retrospectively investigated 66 patients with very asymmetric KC and 505 patients with KC. Patients reported eye rubbing (53%-56%), allergy (62%-63%), and atopy (28%-29%) in both groups. There was no significant difference in terms of risk factors between the two groups. Approximately half of the 66 patients with very asymmetric KC had KC eyes ipsilateral to the dominant hand. Subgroup analysis of very asymmetric KC showed that atopy and asthma were more frequent in the mild KC group than in the severe KC group. Forty-four of 60 patients (73.3%) were using corneal, rigid, gas-permeable contact lenses (corneal GPs) for the KC eye, of which 30 patients (68.2%) were also using a corneal GP for the fellow eye. CONCLUSIONS: The patient-reported frequency of eye rubbing, allergy, and atopy were similar between KC and very asymmetric KC. Furthermore, we found no association between hand dominance and KC laterality.

Lacrimal drainage function after cheese wiring of lacrimal passage intubation.

PURPOSE: To investigate how cheese wiring affects lacrimal drainage function by quantitative assessment of tear function and punctal dimensions. METHODS: Patients who underwent lacrimal passage intubation between January 2017 and September 2018 were enrolled prospectively. Among these patients, those with postoperative cheese wiring who received lacrimal passage intubation in one eye met the criteria for further investigation. The subjective symptoms of epiphora, dimensions of puncta, lower tear meniscus, and tear clearance were assessed postoperatively in both the involved eye and untreated contralateral eye. Punctum dimensions were analysed using the digital slit-lamp image. Tear meniscus and tear clearance were assessed by anterior segment optical coherence tomography. RESULTS: Postoperative cheese wiring was observed in 68 of 314 eyes. Among these cases, 36 patients (age 70.5 ± 11.7 years) had cheese wiring only in one eye: with the involvement of both puncta in 15 patients (group A) and only the lower punctum in 21 patients (group B). There was no patient with the involvement of only the upper punctum. While tear function of the involved eyes in group B did not differ from that of the untreated eye, it was significantly decreased in group A compared with that in untreated control eyes (p < 0.05). The tear clearance rate correlated significantly with the upper punctum dimensions (p < 0.05), but not with the lower punctum. CONCLUSION: Analysis of cheese wiring after lacrimal passage intubation with tear function demonstrated that the integrity of the puncta and the canaliculus is important for lacrimal drainage.

Surgical Factors Affecting Changes in Ocular Surface Dynamics in the Early Postoperative Period After 25-Gauge Vitrectomy.

OBJECTIVES: Because vitrectomy-associated postoperative ocular surface changes are not well known, we evaluated such changes before and after vitrectomy in eyes with posterior segment diseases and investigated their associations with patients' characteristics and surgical procedures. METHODS: Thirty-five eyes of 32 consecutive patients (16 women; average age 66.6±11.1 years) were included in this prospective, noncomparative case series from tertiary care university hospital. Contact lens wearers and patients with history of ocular surgery or regular use of topical eyedrops were excluded. Patients had undergone primary 25-gauge vitrectomy at Osaka University Hospital in Japan between July and December 2016. Tear break-up time (TBUT), corneal and conjunctival fluorescein staining score (FSS), and tear meniscus height (TMH) were evaluated before, 1 week after, and 1 month after vitrectomy. RESULTS: Conjunctival FSS and TMH were significantly higher at 1 week after vitrectomy than preoperatively. However, they decreased significantly 1 month after. Changes in TBUT and corneal FSS showed a similar course at 1 week, but this was not statistically significant. Multiple linear regression analysis showed no significant correlation between significantly increased ocular parameters and patients' characteristics. By contrast, surgical time and combined cataract surgery significantly contributed to increased and decreased conjunctival FSS, respectively (P=0.011 and 0.033, respectively). Sclerotomy site suturing significantly contributed to increased TMH (P=0.025). CONCLUSIONS: We showed associations between ocular surface changes and specific surgical procedures. Caution should be exercised to minimize the effect of surgical procedures on the ocular surface during vitrectomy.

Fourier Analysis of Corneal Irregular Astigmatism Due to the Anterior Corneal Surface in Dry Eye.

OBJECTIVES: To evaluate corneal irregular astigmatism due to the anterior corneal surface using Fourier harmonic analysis with a Placido ring-based corneal topographer (Placido-based topographer) and three-dimensional anterior segment optical coherence tomography (OCT) in dry eyes. METHODS: Forty-four eyes of 44 subjects with dry eye and 20 eyes of 20 normal control subjects were enrolled. Corneal topographic data were obtained using a Placido-based topographer and OCT. Dioptric data from the central 3-mm zone of the anterior corneal surface were decomposed using Fourier harmonic analysis. Spherical, regular astigmatism, and irregular astigmatism (asymmetry and higher-order irregularity) refractive error components of the cornea from the two imaging modalities were compared. RESULTS: Both asymmetry and higher-order irregularity values were significantly greater in dry eyes than in control eyes for both the Placido-based topographer and OCT measurements (all P<0.05). In dry eyes, measured values of asymmetry and higher-order irregularities were significantly smaller when obtained with OCT than with the Placido-based topographer (both P<0.001). By contrast, these parameters were not significantly different between the two devices in control eyes. In dry eyes, severity of superficial punctate keratopathy in the central corneal region was correlated with irregular astigmatism. CONCLUSIONS: The amount of corneal irregular astigmatism, quantified using Fourier harmonic analysis, was significantly higher in dry eyes than in normal eyes. Measurements obtained with OCT and the Placido-based topographer differed in subjects with dry eyes. Therefore, caution should be practiced when trying to use these measurements interchangeably.

Hemorrhagic hypopyon as presenting feature of intravascular lymphoma, a case report.

BACKGROUND: Herpes uveitis has been previously reported to present with hyphema, but hemorrhagic hypopyon is rarely reported as a herpetic uveitis manifestation. We report a case of herpes simplex virus (HSV) presenting with hemorrhagic hypopyon, and speculate on the underlying pathophysiology with relation to an intravascular lymphoma which was subsequently diagnosed as a result. CASE PRESENTATION: We present a case wherein a 62-year-old Japanese rheumatoid arthritis woman, with HSV uveitis, presented with hemorrhagic hypopyon in the anterior chamber and a fever with photophobia. Patient was treated with antiviral drugs which improved the hyphema and corneal lesions, but lesions recurred 3 months later. This rare presentation of HSV induced uveitis, and its subsequent recurrence, aroused suspicion of an additional hypopyon-inducing pathology. On account of previous history of lung opacities and elevated LDH, intravascular lymphoma was eventually diagnosed via lung biopsy. She was treated for the lymphoma which also completely resolved all ocular symptoms without any recurrence as of 1.5 years later. CONCLUSION: The exceedingly rare presentation of hemorrhagic hypopyon may have been enabled by an interaction of the HSV with the intravascular lymphoma. HSV involvement was indicated by the dendritic lesions, IgG assay, and response to anti-viral drugs. The ocular involvement of the intravascular lymphoma seems to be indicated by virtue of the anti-tumor drugs completely resolving all ocular symptoms.

Diquafosol Ophthalmic Solution Increases Pre- and Postlens Tear Film During Contact Lens Wear in Rabbit Eyes.

OBJECTIVES: To investigate the behavior of prelens tear film (PLTF) and postlens tear film (PoLTF) after the instillation of diquafosol using an experimental rabbit model of eyes with contact lens. METHODS: Cross-sectional, anterior segment optical coherence tomographic images of the inferior midperipheral cornea were obtained at baseline and at 5, 15, 30, 60, 90, and 120 min after the instillation of 3% diquafosol ophthalmic solution in 10 Japanese white rabbits wearing contact lenses. From the obtained images, the areas of the PLTF and PoLTF were calculated. Both artificial tear solution and 0.1% sodium hyaluronate ophthalmic solution were used for comparison. RESULTS: Significant fluid accumulation in both the PLTF and PoLTF was observed after diquafosol instillation, whereas no fluid accumulation was visible after the instillation of artificial tear or sodium hyaluronate. The increase in PLTF area after diquafosol instillation was significantly higher (P<0.01) at 15 and 30 min than that after the instillation of artificial tear or sodium hyaluronate. The increase in PoLTF area up to 60 min after the instillation of diquafosol was significantly higher (P<0.01) than that after the instillation of either of the other two drugs. CONCLUSIONS: Instillation of 3% diquafosol ophthalmic solution increases PLTF and PoLTF in rabbit eyes with contact lenses. Diquafosol has potential as a treatment option for contact lens-related dry eye.