Effect of digital ocular massage on intraocular pressure and Schlemm's canal dimensions.

Digital ocular massage has been reported to temporarily lower intraocular pressure (IOP). This could be related to an enhanced aqueous humor outflow; however, the mechanism is not clearly understood. Using anterior segment optical coherence tomography, the Schlemm's canal (SC) and trabecular meshwork (TM) can be imaged and measured. Here, 66 healthy adults underwent digital ocular massage for 10 min in their right eyes. The IOP and dimensions of the SC and TM were measured before and after ocular massage. All subjects demonstrated IOP reduction from 15.7 ± 2.5 mmHg at baseline to 9.6 ± 2.2 mmHg immediately after, and median of 11.6 mmHg 5-min after ocular massage (Friedman's test, p < 0.001). There was significant change in SC area (median 10,063.5 µm2 at baseline to median 10,151.0 µm2 after ocular massage, Wilcoxon test, p = 0.02), and TM thickness (median 149.8 µm at baseline to 144.6 ± 25.3 µm after ocular massage, Wilcoxon test, p = 0.036). One-third of the subjects demonstrated collapse of the SC area (-2 to -52%), while two-thirds showed expansion of the SC area (2 to 168%). There were no significant changes in SC diameter (270.4 ± 84.1 µm vs. 276.5 ± 68.7 µm, paired t-test, p = 0.499), and TM width (733.3 ± 110.1 µm vs. 733.5 ± 111.6 µm, paired t-test, p = 0.988). Eyes with a higher baseline IOP demonstrated a greater IOP reduction (Pearson correlation coefficient r = -0.521, p < 0.001). Eyes with smaller SC area at baseline showed greater SC area expansion (Pearson correlation coefficient = -0.389, p < 0.001). Greater IOP reduction appeared in eyes with greater SC area expansion (Pearson correlation coefficient r = -0.306, p = 0.01). Association between change in IOP and change in TM thickness was not significant (Spearman's ρ = 0.015, p = 0.902). Simple digital ocular massage is an effective method to lower IOP values, and change in the SC area was significantly associated with IOP changes.

Poster Session: Experimental assessment of scleral anisotropy using multi-meridian air-coupled ultrasonic optical coherence elastography.

Scleral biomechanics plays a key role in the understanding of myopia progression. In this study, we characterized the elastic properties of sclera using an air-coupled ultrasonic (ACUS) optical coherence elastography (OCE) system. New Zealand rabbit eyes (n=7) were measured (<24hr postmortem) in four scleral locations: superior/inferior temporal (ST, IT), and superior/inferior nasal (SN, IN) maintaining an intraocular pressure of 15 mmHg. Elastic waves were induced in the sclera, and wave propagation velocity and shear modulus were measured along two directions: circumferential (superior-inferior) and meridional (nasal-temporal). Wave velocity in scleral tissue ranged from 6 to 24 m/s and shear modulus from 11 to 150 kPa. Velocity was significantly higher (p<.001) in the circumferential vs. meridional directions in the following locations: ST:15.83±2.85 vs 9.43±1.68 m/s, IT:15.00±3.98 vs 8.93±1.53 m/s; SN:16.79±4.30 vs 9.27±1.47 m/s; and IN:13.92±3.85 vs 8.57±1.46 m/s. The average shear modulus in the circumferential was also significantly higher (p<.001) than in the meridional direction for all locations: 65.37±6.04 vs 22.55±1.36 kPa. These results show that the rabbit sclera is mechanically anisotropic with higher rigidity in the circumferential direction compared to the meridional direction. ACUS-OCE is a promising non-invasive method to quantify the biomechanical changes in scleral tissue for future studies involving myopia treatments.

Exploring the relationship between intestinal flora and the pathological mechanism of myopia in adolescents from the perspective of Chinese and Western medicine: A review.

The etiology of adolescent myopia involves genetic and environmental factors. The pathological mechanism of modern medicine includes blood perfusion, changes in blood molecules, neurotransmitters, and sclera remodeling. Chinese medicine believes that myopia is mainly related to the deficiency of liver blood and spleen and stomach disorders. The prevention and treatment of myopia in adolescents are very important, but in terms of the current incidence of myopia in adolescents and the level of clinical diagnosis and treatment, its prevention and treatment are insufficient. Modern medicine and traditional Chinese medicine both pay attention to integrity, so adolescent myopia should not only pay attention to eye changes but also pay attention to other body systems and other aspects of change. Intestinal flora has become a research hotspot in recent years, and it has been found that it is closely associated with multi-system and multi-type diseases. No studies have directly investigated the link between Intestinal flora and myopia in adolescents. Therefore, by summarizing the pathological mechanism of adolescent myopia and the connection between intestinal flora and the pathological mechanism of adolescent myopia, this paper analyzes the possible pathological mechanism of the influence of intestinal flora on adolescent myopia, providing a theoretical basis for future studies on the correlation between changes of intestinal flora and its metabolites and the incidence of adolescent myopia, which is of great significance for the study on the risk prediction of adolescent myopia.

Validating a Sclera-Based Smartphone Application for Screening Jaundiced Newborns in Ghana.

OBJECTIVES: Reducing the burden of bilirubin-induced neurologic complications in low-resource countries requires reliable and accessible screening tools. We sought to optimize and validate a sclera-based smartphone application, Neonatal Scleral-Conjunctival Bilirubin (neoSCB), for screening neonatal jaundice. METHODS: Using a cross-sectional design, consecutive eligible infants (aged 0-28 days, in the hospital, not critically ill) were enrolled in Ghana from March 2019 to April 2020. Jaundice screening was performed with neoSCB (Samsung Galaxy S8) to quantify SCB and JM-105 (Dräger) for transcutaneous bilirubin (TcB). Screening values were compared with total serum bilirubin (TSB) measured at the point of care. RESULTS: Overall, 724 infants participated in the optimization and validation phases of the study. The analysis for validation included 336 infants with no previous treatment of jaundice. Single neoSCB image captures identified infants with TSB >14.62 mg/dL (250 µmol/L) with reasonably high sensitivity, specificity, and receiver operating characteristic area under the curve at 0.94 (95% confidence interval [CI], 0.91 to 0.97), 0.73 (95% CI, 0.68 to 0.78), and 0.90, respectively. These findings were comparable to the sensitivity and specificity of JM-105 (0.96 [95% CI, 0.90 to 0.99] and 0.81 [95% CI, 0.76 to 0.86], respectively). The TcB/TSB had a larger correlation coefficient (r = 0.93; P < .01) than SCB/TSB (r = 0.78; P < .01). Performance of both devices was lower in infants with previous phototherapy (n = 231). CONCLUSIONS: The diagnostic performance of neoSCB was comparable to JM-105 and is a potential, affordable, contact-free screening tool for neonatal jaundice.

Anterior Scleral and Limbal Inflammatory Necrosis After Adjuvant Miltefosine for Recalcitrant Acanthamoeba Keratitis.

PURPOSE: The purpose of this study was to report a retrospective case series of anterior scleral and limbal inflammatory necrosis after adjuvant miltefosine for recalcitrant Acanthamoeba keratitis (AK). METHODS: A case series and literature review. RESULT: Four eyes of 3 patients with recalcitrant AK developed anterior scleral and limbal inflammatory necrosis with significant scleral-limbal thinning after treatment with miltefosine. The average age was 38 years, and the average duration of infection before miltefosine treatment was 239 days. All cases required urgent surgical intervention to either prevent or mitigate corneal-limbal perforation. CONCLUSIONS: Miltefosine has been observed to result in the resolution of AK when used as an adjunctive therapy. It may also lead to a consecutive inflammatory necrosis of the anterior sclera and limbus. This inflammatory response may be significant enough to cause rapid scleral-limbal thinning with subsequent perforation.

COMPARISON OF RETROBULBAR, SUB-TENON ANESTHESIA AND MEDIAL CANTHUS EPISCLERAL ANESTHESIA FOR 25-GAUGE POSTERIOR VITRECTOMY.

PURPOSE: The aim of the study is to compare the efficacy, safety, and globe akinesia between retrobulbar anesthesia, sub-Tenon anesthesia, and medial canthus episcleral anesthesia for 25-gauge posterior vitrectomy. METHODS: A total of 340 25-gauge vitrectomy data sheets were retrospectively collected between November 2017 and June 2019. Ninety patients were included in the study. These patients were matched by sex and age to receive retrobulbar anesthesia (group 1, n = 30), sub-Tenon anesthesia (group 2, n = 30), and medial canthus episcleral anesthesia (group 3, n = 30). Globe akinesia was recorded after the injection of anesthetic at 2, 5, and 10 minute time intervals. Patients were asked to rate the pain during administration of anesthesia, during surgery, and postoperatively using the visual analog pain scale. RESULTS: For a perfect block, at 10 minutes, retrobulbar outperformed both sub-Tenon and medial canthus episcleral anesthesia which seemed quite similar. During administration, the three techniques did not show statistically different effects on pain. Regarding perioperative pain, retrobulbar outperformed medial canthus episcleral anesthesia. CONCLUSION: All three techniques allowed for safe surgery. Retrobulbar obtained the best results, although sub-Tenon proved to be a valid alternative. Medial canthus episcleral anesthesia obtained mostly good and fair blocks and acceptable pain levels during surgery. Further studies should investigate whether optimal anesthetic efficacy can be obtained with sub-Tenon and medial canthus episcleral techniques when higher volumes are used.

Stepwise candidate drug screening for myopia control by using zebrafish, mouse, and Golden Syrian Hamster myopia models.

BACKGROUND: We developed a preclinical protocol for the screening of candidate drugs able to control myopia and prevent its progression. The protocol uses zebrafish, C57BL/6 mice, and golden Syrian hamster models of myopia. METHODS: A morpholino (MO) targeting the zebrafish lumican gene (zlum) was injected into single-cell zebrafish embryos, causing excessive expansion of the sclera. A library of 640 compounds with 2 matrix metalloproteinase (MMP) inhibitors (marimastat and batimastat), which have the potential to modulate scleral remodelling, was screened to identify candidates for mitigating scleral diameter expansion in zlum-MO-injected embryos. The myopia-prevention ability of compounds discovered to have superior potency to inhibit scleral expansion was validated over 4 weeks in 4-week-old C57BL/6 mice and 3-week-old golden Syrian hamsters with form-deprivation myopia (FDM). Changes in the refractive error and axial length were investigated. Scleral thickness, morphology of collagen fibrils in the posterior sclera, messenger RNA (mRNA) expressions, and protein levels of transforming growth factor-ß2 (TGF-ß2), tissue inhibitor of metalloproteinase-2 (TIMP-2), MMP-2, MMP-7, MMP-9, and collagen, type I, alpha 1 (collagen Iα1) were investigated in C57BL/6 mice, and MMP-2, MMP-9, and MMP activity assays were conducted in these mice. FINDINGS: In the zebrafish experiment, atropine, marimastat, batimastat, doxycycline, and minocycline were the drugs that most effectively reduced expansion of scleral equatorial diameter. After 28-day treatment in diffuser-wearing mice and 21-day treatment in lid-sutured hamsters, myopic shift and axial elongation were significantly mitigated by eye drops containing 1% atropine, 50 µM marimastat, 5 µM batimastat, or 200 µM doxycycline. MMP-2 mRNA expression in mouse sclera was lower after treatment with atropine, marimastat, batimastat, or doxycycline. The protein levels and activity of MMP-2 and MMP-7 were significantly reduced after treatment with atropine, marimastat, batimastat, doxycycline, and minocycline. Furthermore, scleral thickness and collagen fibril diameter were not lower after treatment with atropine, marimastat, batimastat, or doxycycline than those of occluded eyes. INTERPRETATION: Stepwise drug screening in a range of models from zlum-MO-injected zebrafish to rodent FDM models identified effective compounds for preclinical myopia control or prevention. On the basis of the 640 compounds that were screened, MMP inhibitors may offer alternatives for clinical trials. FUNDING: This research was supported by grants from Taiwan's Ministry of Science and Technology and Ministry of Health and Welfare.

Intra-operative scleral rupture during 23 gauge pars plana vitrectomy: a case report.

BACKGROUND: Use of perfluorocarbon liquid (PFCL) has been increasingly growing as an adjuvant in vitreo-retina surgeries. Some commonly encountered complications with its use include subretinal migration, formation of sticky silicone oil or retained PFCL in vitreous cavity and anterior chamber. Scleral rupture during PFCL injection has a rare occurrence. We report an unexpected event of scleral rupture during PFCL injection and discuss the management challenges faced by the surgeon. CASE PRESENTATION: A 66 year indo-aryan male was undergoing pars-plana vitrectomy (PPV) with diagnosis of subtotal rhegmatogenous retinal detachment (RD) with Proliferative Vitreo-retonipathy (PVR)-B. After near total vitrectomy PFCL was being injected and then there was sudden poor visualization of fundus with development of bullous RD and globe hypotony. The surgeon was not able to figure out the cause of hypotony and air was switched on in the infusion cannula. This further complicated the situation resulting in migration of air in the anterior chamber, posterior dislocation of intraocular lens complex, 180° inferior retinal dialysis and ballooning of the conjunctiva which gave a clue of probable scleral rupture. Conjunctival peritomy was performed superiorly and scleral defect was noted. Intraocular tissue incarceration and air leak was visible from the wound. This confirmed scleral rupture during PFCL injection. Repositioning of incarcerated retina was not possible and retinectomy was performed followed by repair of scleral rupture with lots of difficulty in a vitrectomised eye. CONCLUSION: PFCL injection, a crucial step of vitreoretina surgery, should be performed slowly with extreme caution maintaining an optimal intraocular pressure to prevent devastating complications like scleral rupture.

Treatment of Severe Infectious Keratitis With Scleral Contact Lenses as a Reservoir of Moxifloxacin 0.5.

PURPOSE: To report the outcomes of using scleral contact lenses as antibiotic reservoirs as a therapeutic approach in a case series of severe infectious keratitis and to discuss the clinical potential. METHODS: This was a prospective consecutive case series study of 12 eyes treated for infectious keratitis at the "Conde de Valenciana" Institute of Ophthalmology. A scleral lens (SL) filled with 0.5% moxifloxacin was used as a reservoir and replaced every 24 hours until epithelization was complete or the culture report and/or antibiogram demonstrated either a microorganism not susceptible to or resistant to moxifloxacin. RESULTS: The study included 12 eyes of 12 patients (7 women; 58.33%; average age of 63 ± 20.11 years). All patients completed at least 1 month of follow-up. Patients had a diagnosis of infectious keratitis, and the SL was fitted on initial consultation. Of the 12 eyes, 7 had culture-positive bacterial infection, 2 eyes were mycotic, and 3 eyes had no culture growth. In 3 eyes, SL was discontinued because of the lack of response (one eye) and to the presence of mycotic infection (2 eyes). All infections resolved favorably at the final follow-up. CONCLUSIONS: The use of SLs could be an alternative for antibiotic impregnation and treatment of infectious keratitis. No complications or side effects were observed related to the use of the scleral contact lens as a reservoir for the antibiotic. This treatment modality could offer a comfortable treatment for the patient, ensuring good impregnation and maintenance of antibiotic concentrations during the 24-hour wear periods.

Innovative intraocular lens design to manage surgical aphakia in an eye with a filtering bleb.

An innovative intraocular lens (IOL), the CM-T Flex IOL, was used to correct surgical aphakia without disturbing a functioning filtering bleb. A 66-year-old man presented with aphakia in the left eye. Cataract extraction and trabeculectomy was performed in the left eye 2 years previously elsewhere. Corrected distance visual acuity (CDVA) in the left eye was 6/18, and, on examination, it showed a filtering bleb that encroached on the limbus and superior cornea. The cornea was clear with a deep anterior chamber. Retinal examination was normal. Disc cupping was noted with a cup-to-disc ratio of 0.8. Refractive correction was performed by implanting the CM-T Flex IOL. This IOL has a unique design that eliminates the need for maneuvering the IOL haptics extraocularly. It entails a simple grasp, exteriorize, and release technique that anchors the IOL firmly to the scleral bed. At 6 months, CDVA in the left eye was 6/9 with a stable, centered IOL.

Dietary Melatonin Therapy Alleviates the Lamina Cribrosa Damages in Patients with Mild Cognitive Impairments: A Double-Blinded, Randomized Controlled Study.

BACKGROUND Alzheimer's disease (AD) is a degenerative disease that is characterized by massive neuron devastations in the hippocampus and cortex. Mild cognitive impairment (MCI) is the transitory stage between normality and AD dementia. This study aimed to investigate the melatonin induced effects on the lamina cribrosa thickness (LCT) of patients with MCI. MATERIAL AND METHODS The LCT data of patients with MCI were compared to LCT data of healthy controls. Subsequently, all MCI patients were randomly assigned into an experimental group (with melatonin treatment) or a placebo group (without any melatonin treatment). RESULTS The LCT of MCI patients decreased significantly compared with healthy controls. The univariate analysis showed that the lower the Mini Mental State Examination (MMSE) score (P=0.038; 95% CI: 0.876, -0.209), the smaller hippocampus volume (P=0.001; 95% CI: -1.594, -2.911), and the upregulated level of cerebrospinal fluid (CSF) T-tau (P=0.036; 95% CI: 2.546, -0.271) were associated significantly with the thinner LCT in MCI patients. There were 40 patients in the experimental group and 39 patients in the placebo group. The mean age of the experimental group was not significantly different from the placebo group (66.3±8.8 versus 66.5±8.3; P>0.05). The LCT and hippocampus volume of the melatonin treated group were significantly larger compared with the placebo group (P<0.001). On the other hand, the CSF T-tau level of the melatonin treated group was significantly lower compared with the untreated group (P<0.001). CONCLUSIONS LCT assessment might allow early diagnosis of MCI. Dietary melatonin therapy could provide an effective medication for MCI patients with LCT alterations.

Percutaneous Lower Blepharoplasty: A Novel Technique in Lower Eyelid Aesthetics.

BACKGROUND: More preservative approaches are being adopted in periorbital surgery each day. To avoid the possible complications of transcutaneous and transconjunctival blepharoplasty, the author has developed the safe and simple "Percutaneous Lower Blepharoplasty" technique, which he has been performing since 2008. The technique consists of the removal and transfer of lower orbital fat pads through 4-mm skin incisions with minimal dissection. PATIENTS AND METHODS: The study is designed as a retrospective analysis of the operations done by the author from 2008 to 2018. The author performed 297 percutaneous lower blepharoplasty operations alone or in combination with tear-trough deformity correction, pinch skin excision, and/or carbon dioxide laser application. The video of the technique is demonstrated in the supplemental digital content. RESULTS: The patients were followed for an average of 58.8 months. All the patients were satisfied with the result. There were no retractions or scleral show seen. The only complication was chemosis in 1 patient that subsided with steroid ointment. CONCLUSION: Percutaneous lower blepharoplasty is a novel technique that has the following advantages: Simple and fast, low complication rates, good cosmetic outcomes, tear trough deformity correction, better estimation of fat amount to be removed, and minimal dissection and avoidance of violation of lamellar structures. It can be performed safely alone or in combination with pinch excision and/or fractional laser resurfacing.

Suprachoroidal hemorrhage after removal of releasable suture with globe massage post-trabeculectomy.

A 19-year-old female, having aniridia with secondary glaucoma, presented with uncontrolled intraocular pressure (IOP) in the right eye (RE) on maximal topical and systemic medications. On examination, RE had a subluxated cataractous lens with advanced cupping. She underwent trabeculectomy with mitomycin C. On postoperative day 1, as the IOP was 32 mmHg, one releasable suture was removed followed by gentle bleb massage. On postoperative day 2, suprachoroidal hemorrhage was noted, for which the patient underwent two drainage procedures. Hemorrhagic choroidals resolved completely 4 weeks after drainage.

One-month IOP in mitomycin C-augmented trabeculectomy can predict long-term IOP control in chronic primary angle-closure glaucoma.

PURPOSE: To investigate the predictors of long-term intraocular pressure (IOP) in chronic primary angle-closure glaucoma (CPACG) treated with primary trabeculectomy. METHODS: This study systematically reviewed cases of CPACG treated with primary trabeculectomy. The scleral flaps in all cases were sutured with two stitches in situ and two releasable sutures to ensure watertight under normal IOP conditions during surgery. Mitomycin C was used in all eyes. All patients were followed for 2 years. Digital massage of the bulbus and removal of the releasable suture were performed according to the IOP and shape of the filtering bleb. Demographic data and clinical outcomes were recorded. Factors predicting long-term IOP were identified. RESULTS: A total of 72 patients (88 eyes) with a mean age of 58.51 ± 10.60 years were included in this study. The complete success rate was 89.77% after 2 years. The IOP began to stabilize after 7 days and reached its lowest point at the 1-month follow-up. The preoperative and early postoperative high or low IOP does not affect long-term effects (P > 0.05). There was a positive correlation between postoperative IOP at the 1-month and 2-year follow-ups (r = 0.64, P < 0.001). CONCLUSION: In CPACG patients undergoing primary trabeculectomy, scleral flaps sutured watertightly with two stitches in situ and two releasable sutures under normal IOP conditions can ensure controllable, effective and safe treatment of CPACG. The preoperative and early postoperative high or low IOP does not affect long-term effects. One-month postoperative IOP can be used as a predictor of long-term IOP control.

Decompression retinopathy following nonpenetrating deep sclerectomy for primary congenital glaucoma.

BACKGROUND: To describe a unique case of decompression retinopathy manifesting as pre-macular subhyaloid hemorrhage that occurs in a nine-day old child after undergoing a non-penetrating deep sclerectomy for primary congenital glaucoma. CASE PRESENTATION: We report a single case of a 9-day-old boy who was referred to our department of ophthalmology for bilateral buphtalmia and corneal edema. He presented marked elevation of the intraocular pressure in both eyes (22 mmHg and 26 mmHg, in the right eye and left eye respectively) associated with significant optic nerve cupping. Non-penetrating deep sclerectomy was performed for each eye, with effective reduction of the intraocular pressure during the first week postoperatively (11 mmHg and 7 mmHg in the right eye and left eye respectively). The right eye presented an isolated subhyaloid hemorrhage located in the pre-macular area, persisting 3 weeks after the initial surgery and requiring pars-plana vitrectomy to clear the visual axis. This uncommon complication was identified as decompression retinopathy. The intraocular pressure remained controlled in the normal range three years after initial surgery in both eyes, with reversal of optic disc cupping. CONCLUSIONS: Decompression retinopathy is a potential complication after non-penetrating deep sclerectomy in primary congenital glaucoma, requiring prompt treatment strategy to prevent potential organic amblyopia.

A novel surgical technique employing donor sclera in strabismus surgery.

We describe a novel surgical technique employing donor sclera as a spacer to solve the problem encountered in complicated cases of restrictive strabismus surgery when no more muscle or tendon is available for surgical extension of the eye muscle to correct the angle of deviation. This is often the case in patients who have previously undergone extensive surgery and in patients with mechanical restrictions, such as thyroid-associated orbitopathy (TAO).

Pharmacokinetic and Safety Evaluation of a Transscleral Sustained Unoprostone Release Device in Monkey Eyes.

Purpose: We evaluate the ocular tissue distribution and retinal toxicity of unoprostone (UNO) during 12 months, after transscleral sustained-UNO administration using a drug delivery device in monkey eyes. Methods: The device consisted of a reservoir, controlled-release cover, and a drug formulation of photopolymerized polyethylene glycol dimethacrylate. Six mg UNO was loaded into the device (length, 17 mm; width, 4.4 mm; height, 1 mm). The concentrations of M1, a primary metabolite of UNO, in the retina, choroid, vitreous, lens, aqueous humor, iris, ciliary body, and plasma were determined by liquid chromatography-tandem mass spectrometry at 3, 6, and 12 months after implantation. Retinal toxicity was evaluated by electroretinography (ERG), optical coherence tomography (OCT), and IOP at preimplantation, and at 6, 9, and 12 months after implantation. Focal ERGs were performed at 9 and 12 months after implantation. Results: M1 was detected in the choroid and retina with maximum peaks of 243.2 and 8.41 ng/g at 6 months, respectively. M1 in the ciliary body and iris was detected with maximum peaks of 7.66 and 10.4 ng/g at 6 and 12 months, respectively. Less than 1 ng/mL or ng/g of M1 was detected in the aqueous humor, vitreous, and lens. No changes were observed in retinal function as assessed by ERG, IOP, or macula thickness and retinal histology by OCT examinations during the 12-month period. No differences in focal ERG amplitudes, especially in the macula, were observed. Conclusions: The device provided intraocular sustained delivery of UNO for 12 months without producing severe retinal toxicity.