Cold bandage contact lens use reduces post-photorefractive keratectomy or corneal collagen-crosslinking pain perception in patients

Purpose: To compare post?operative pain perception using bandage contact lens (BCL) stored at 2–8?C (Cold BCL, CL?BCL) or room temperature (23 – 25?C, RT?BCL) after photorefractive keratectomy (PRK) or corneal collagen?crosslinking (CXL) and determine status of nociception associated factors. Methods: In this prospective interventional study, 56 patients undergoing PRK for refractive correction and 100 keratoconus (KC) undergoing CXL were recruited following approval from the institutional ethics committee with informed consent. Patients undergoing bilateral PRK received RT?BCL on one eye and CL?BCL on the other. Pain was graded by Wong–Baker scoring on the first post?operative day (PoD1). Expression of transient receptor potential channels (TRPV1, TRPA1, TRPM8), calcitonin gene?related peptide (CGRP) and IL?6 was measured in cellular content from used BCLs collected on PoD1. Equal number of KC patients received RT?BCL or CL?BCL post?CXL. Pain was graded by Wong–Baker scoring on PoD1. Results: Pain scores on PoD1 were significantly (P < 0.0001) reduced in subjects receiving CL?BCL (Mean ± SD: 2.6 ± 2.1) compared to RT?BCL (6.0 ± 2.4) post?PRK. 80.4% of subjects reported reduced pain scores with CL?BCL. 19.6% reported no change or increased pain scores with CL?BCL. TRPM8 expression was significantly (P < 0.05) increased in BCL of subjects reporting reduced pain with CL?BCL compared to those who did not. Pain scores on PoD1 were significantly (P < 0.0001) reduced in subjects receiving CL?BCL (3.2 ± 2.1) compared to RT?BCL (7.2 ± 1.8) post?CXL. Conclusion: The simple approach of using a cold BCL post?operatively substantially reduced pain perception and could overcome post?operative pain?related limited acceptance of PRK/CXL.

Artificial intelligence–based stratification of demographic, ocular surface high-risk factors in progression of keratoconus

Purpose: The purpose of this study was to identify and analyze the clinical and ocular surface risk factors influencing the progression of keratoconus (KC) using an artificial intelligence (AI) model. Methods: This was a prospective analysis in which 450 KC patients were included. We used the random forest (RF) classifier model from our previous study (which evaluated longitudinal changes in tomographic parameters to predict “progression” and “no progression”) to classify these patients. Clinical and ocular surface risk factors were determined through a questionnaire, which included presence of eye rubbing, duration of indoor activity, usage of lubricants and immunomodulator topical medications, duration of computer use, hormonal disturbances, use of hand sanitizers, immunoglobulin E (IgE), and vitamins D and B12 from blood investigations. An AI model was then built to assess whether these risk factors were linked to the future progression versus no progression of KC. The area under the curve (AUC) and other metrics were evaluated. Results: The tomographic AI model classified 322 eyes as progression and 128 eyes as no progression. Also, 76% of the cases that were classified as progression (from tomographic changes) were correctly predicted as progression and 67% of cases that were classified as no progression were predicted as no progression based on clinical risk factors at the first visit. IgE had the highest information gain, followed by presence of systemic allergies, vitamin D, and eye rubbing. The clinical risk factors AI model achieved an AUC of 0.812. Conclusion: This study demonstrated the importance of using AI for risk stratification and profiling of patients based on clinical risk factors, which could impact the progression in KC eyes and help manage them better

Modulation of mucin secretion using combined polyethylene glycol–propylene glycol topical formulation in a hyperosmotic stress-based explant model

Purpose: Ocular surface discomfort and dry eye disease are caused by a dysfunctional tear film. The efficacy of lubricating eye drops on the human eye is known, but the compositions may show differential effects on rescuing the tear film. Mucins form a critical layer of the tear film, a reduction of which may be causative for ocular surface conditions. Therefore, it is essential to develop relevant human?derived models to test mucin production. Methods: Human corneoscleral rims were obtained from a healthy donor (n = 8) post?corneal keratoplasty and cultured in DMEM/F12 media. Hyperosmolar stress mimicking dry eye disease was induced by exposing the corneoscleral rim tissues to +200 mOsml NaCl?containing media. The corneoscleral rims were treated with polyethylene glycol–propylene glycol (PEG–PG)?based topical formulation. Gene expression analysis was performed for NFAT5, MUC5AC, and MUC16. Secreted mucins were measured by enzyme?linked immunosorbent assay (ELISA) (Elabscience, Houston, TX, USA) for MUC5AC and MUC16. Results: The corneoscleral rims responded to hyperosmolar stress by upregulating NFAT5, a marker for increased osmolarity, as observed in the case of dry eye disease. The expression of MUC5AC and MUC16 was reduced upon an increase in hyperosmotic stress. The corneoscleral rim tissues showed induction of MUC5AC and MUC16 expression upon treatment with PEG–PG topical formulation but did not show significant changes in the presence of hyperosmolar treatments. Conclusion: Our findings showed that PEG–PG?based topical formulation slightly alleviated hyperosmolar stress?induced decrease in MUC5AC and MUC16 gene expression that is encountered in DED

Nexus of ocular motility and dry eye

Purpose: To evaluate the effectiveness of vision therapy (VT) in patients with chronic presumed refractory dry eye disease (DED) and concurrent nonstrabismic binocular vision anomalies (NSBVAs). To propose an algorithmic approach to manage patients with refractory DED. Methods: Thirty?two patients with chronic (>1 year) presumed refractory DED and NSBVA were prospectively evaluated. The baseline dry eye evaluation and comprehensive orthoptic evaluation were done. VT was administered by a trained orthoptist for 2 weeks. The binocular vision (BV) parameters and percentage subjective improvement were assessed after the VT. Results: On evaluation, 12 patients (37.5%) had both DED and NSBVA, and 20 patients (62.5%) had only NSBVA. Twenty?nine patients (90.62%) showed significant improvement in BV parameters following VT. Binocular near point of accommodation (median, range) improved from 17 (8–40) to 12 (5–26) mm (P value < 0.0001), and near point of convergence (median, range) improved from 6 (3–33) to 6 (5– 14) (P value 0.004) with VT. Thirty?one patients (96.87%) reported symptomatic improvement after VT, and 62.5% of these showed more than 50% improvement in symptoms. Conclusion: The present study confirms the beneficial role of VT in the treatment of patients with DED with concurrent NSBVA. It is essential to diagnose and treat NSBVA in patients with DED to ensure complete relief of symptoms and patient satisfaction. As there is a significant overlap between symptoms of dry eye disease and that of NSBVA, a complete orthoptic evaluation is recommended in all patients presenting with refractory dry eye disease related symptoms

Assessing clinical and molecular outcomes of prophylactic thermal pulsation therapy on ocular surface health following refractive surgery

Purpose: To study ocular surface signs, symptoms, and tear film composition following prophylactic thermal pulsation therapy (TPT) prior to refractive surgery, and to compare these outcomes with those who underwent TPT after refractive surgery. Methods: Patients with mild?to?moderate evaporative dry eye disease (DED) and/or meibomian gland dysfunction (MGD) undergoing refractive surgery were included. Group 1 patients received TPT (LipiFlow) prior to laser?assisted in situ keratomileusis (LASIK; n = 32, 64 eyes), and Group 2 patients received TPT three months after LASIK (n = 27, 52 eyes). Ocular Surface Disease Index (OSDI) score, Schirmer’s test (ST1, ST2), Tear Breakup Time (TBUT), meibography, and tear fluid were obtained preoperatively and at three months postoperatively in Groups 1 and 2. Additional postoperative evaluation was performed three months after TPT in Group 2. Tear soluble factor profile was measured by multiplex enzyme?linked immunosorbent assay (ELISA) using flow cytometry. Results: Postoperative OSDI score was significantly lower and TBUT was significantly higher when compared with matched preoperative values of Group 1 participants. On the other hand, the postoperative OSDI score was significantly higher and TBUT significantly lower when compared with matched preoperative values of Group 2 participants. TPT significantly reduced the postoperative elevation in OSDI and significantly reduced the postoperative reduction in TBUT in Group 2 participants. Tear Matrix metalloproteinase?9/ Tissue inhibitor matrix metalloproteinase 1 (MMP?9/TIMP1) ratio was significantly higher, postoperatively, when compared with matched preoperative levels in Group 2. However, MMP9/TIMP1 ratio remained unaltered in Group 1 participants. Conclusion: TPT prior to refractive surgery improved postsurgical ocular surface signs and symptoms and reduced tear inflammatory factors, thereby suggesting the plausibility of reduced post?refractive surgery DED in patients.

Patient stratification using point of care biomarkers in dry eye disease

With changes in lifestyle, such as the increasing use of digital screens and rising demand for refractive surgery, dry eye disease has become increasingly prevalent in recent times. While we are equipped with a number of diagnostic modalities and a myriad of treatment forms, ranging from topical medication to procedural therapies, the condition remains an enigma in terms of varied patient satisfaction. An understanding of the molecular basis of a disease may open up new avenues in the customization of its treatment. We attempt to simplify this in the form of a stepwise protocol to incorporate biomarker assays in dry eye management.

Role of artificial intelligence in determining factors impacting patients’ refractive surgery decisions

Purpose: To create a predictive model using artificial intelligence (AI) and assess if available data from patients’ registration records can help in predicting definitive endpoints such as the probability of patients signing up for refractive surgery. Methods: This was a retrospective analysis. Electronic health records data of 423 patients presenting to the refractive surgery department were incorporated into models using multivariable logistic regression, decision trees classifier, and random forest (RF). Mean area under the receiver operating characteristic curve (ROC?AUC), sensitivity (Se), specificity (Sp), classification accuracy, precision, recall, and F1?score were calculated for each model to evaluate performance. Results: The RF classifier provided the best output among the various models, and the top variables identified in this study by the RF classifier excluding income were insurance, time spent in the clinic, age, occupation, residence, source of referral, and so on. About 93% of the cases that did undergo refractive surgery were correctly predicted as having undergone refractive surgery. The AI model achieved an ROC?AUC of 0.945 with an Se of 88% and Sp of 92.5%. Conclusion: This study demonstrated the importance of stratification and identifying various factors using an AI model which could impact patients’ decisions while selecting a refractive surgery. Eye centers can build specialized prediction profiles across disease categories and may allow for the identification of prospective obstacles in the patient’s decision?making process, as well as strategies for dealing with them.

Impact of crossplay between ocular aberrations and depth of focus in topo-guided laser-assisted in situ keratomileusis outcomes

Purpose: To develop a nomogram in cases with mismatch between subjective and Topolyzer cylinder, and based on the magnitude of the mismatch, customize a treatment plan to attain good visual outcomes post?laser?assisted in situ keratomileusis (LASIK) surgery. Methods: The patients were evaluated preoperatively using corneal tomography with Pentacam. Five optimal corneal topography scans were obtained from the Topolyzer Vario were used for planning the LASIK treatment. For the nomogram purpose, the patients were divided into three categories based on the difference between the subjective cylinder and Topolyzer (corneal) cylinder. The first group (group 1) consisted of eyes of patients, where the difference was less than or equal to 0.4 D. The second group (group 2) consisted of eyes, where the difference was more than 0.4 D and the subjective cylinder was lesser than the Topolyzer cylinder. The third group (group 3) included eyes where the difference was more than 0.4 D but the subjective cylinder was greater than the Topolyzer cylinder. LASIK was performed with the WaveLight FS 200 femtosecond laser and WaveLight EX500 excimer laser. Assessment of astigmatism correction for the three groups was done using Aplins vector analysis. For comparison of proportions, Chi?square test was used. A P value less than 0.05 was considered statistically significant. Results: The UDVA was statistically significantly different when compared between groups 1 and 2 (P = 0.02). However, the corrected distance visual acuity (CDVA) was similar among all the three groups (P = 0.1). Group 3 showed an increase of residual cylinder by ?0.25 D, which was significant at intermediate and near reading distances (P < 0.05). Group 3 showed significantly higher target?induced astigmatism (TIA) compared to groups 1 and 2 (P = 0.01). The mean surgically induced astigmatism (SIA) was the least in group 2, which was statistically significant (P < 0.01). Conclusion: The outcomes for distance vision using our nomogram postoperatively were excellent, but further refinement for improving the near vision outcomes is required

Psychosocial assessment among ophthalmic patients attending tertiary eye care centre during the lockdown in times of COVID-19 pandemic

Purpose: The coronavirus disease (COVID?19) pandemic continues to play havoc in our lives. During the first “ lockdown” in 2020, we were keen on assessing the anxiety levels of patients who sought ophthalmic care despite the lockdown. Public health actions, such as social distancing, were necessary to reduce the spread of COVID?19. As a result, most people felt isolated and lonely, thereby causing increased levels of stress and anxiety in them. We aimed to assess the anxiety levels using the Hamilton Anxiety Scale and personality assessment using the 57?point Eysenck’s Personality Inventory (EPI) questionnaire among patients visiting a tertiary eye care hospital during the lockdown period. Methods: Consecutive patients attending an ophthalmic tertiary care hospital during the COVID?19 pandemic and lockdown were approached to be a part of this prospective cross?sectional survey. Results: In total, 1,088 responses were analyzed during the 2?month study period with the mean age being 45.7 + 16.9 years. The majority had completed graduation (78%) with 15 years or more of formal education. The purpose of the visit was an emergency consultation in 42% (n = 455), a review appointment in 42% (n = 457), and the remaining (16%, n = 176) came for a routine consultation. The majority of the patients (>90%) did not report experiencing any of the 14 sets of symptoms. A mild level of anxiety was noted in 1,086 (>99%) respondents, whereas only 2 (<1%) respondents showed mild–moderate levels of anxiety. Financial concerns such as affordability of medications (6% vs. 3%, P = 0.05) and fear of losing their job (16% vs. 11%, P = 0.02) were significantly more in those experiencing any anxiety compared to those with no anxiety. Conclusion: Our study revealed that patients visiting a tertiary ophthalmic center during lockdown were graduates, sought eye consultation primarily for emergency or a review, and had no major anxiety symptoms. In those with anxiety, the affordability of medicines and loss of jobs were the main concerns.

Impact of tear optics on the repeatability of Pentacam AXL wave and iTrace in measuring anterior segment parameters and aberrations

Purpose: To assess impact of tear optics on repeatability of a Scheimpflug device with a Hartmann Shack aberrometer and a ray tracing aberrometer. Methods: One hundred healthy and 100 postrefractive surgery eyes underwent dry eye evaluation including Schirmer抯 test and tear film break?up time (TBUT). They underwent optical quality analyzer (OQAS, Visio metrics S.L, Terrassa, Spain) to assess objective scatter index (OSI), three scans each on Pentacam AXL wave (OCULUS Optikgerate Gmbh, Wetzlar, Germany), iTrace (Tracey� Technologies, Texas, USA) for flat, steep keratometry, thinnest corneal thickness, root mean square higher?order aberrations (RMS HOA), RMS lower?order aberrations (LOA), spherical aberrations, RMS COMA. Repeatability of Pentacam AXL wave and iTrace in healthy and postrefractive eyes (OSI >1 vs OSI <1) was studied using within?subject standard deviation (Sw) test杛etest repeatability (TRT), coefficient of variation (COV). Results: OSI showed an inverse association with TBUT (P < 0.001). All measurements with Pentacam AXL wave with OSI < 1 had excellent repeatability, intraclass correlation coefficient (ICC) ranging from 0.88 for HOA, to 0.92 for LOA. The Sw, TRT, and COV of all aberration measurements were significantly lower (better) than those of iTrace. In eyes with OSI ?1, the repeatability with Pentacam AXL wave dropped with ICC ranging from 0.77 for HOA, to 0.84 for LOA with lower Sw, TRT, and COV of all aberration measurements as compared to iTrace. Maximum variation was seen with HOA and minimum with LOA. Conclusion: Tear optics affected repeatability of Pentacam wave and iTrace. Pentacam wave had better repeatability in eyes with a poor tear film as compared to iTrace. Thus, the tear film can impact repeatability of an instrument and it is important to assess the tear film prior to imaging patients, which can change the way we interpret and image these patients.