Dysfunctional tear syndrome: dry eye disease and associated tear film disorders - new strategies for diagnosis and treatment.

Dysfunctional tear syndrome (DTS) is a common and complex condition affecting the ocular surface. The health and normal functioning of the ocular surface is dependent on a stable and sufficient tear film. Clinician awareness of conditions affecting the ocular surface has increased in recent years because of expanded research and the publication of diagnosis and treatment guidelines pertaining to disorders resulting in DTS, including the Delphi panel treatment recommendations for DTS (2006), the International Dry Eye Workshop (DEWS) (2007), the Meibomian Gland Dysfunction (MGD) Workshop (2011), and the updated Preferred Practice Pattern guidelines from the American Academy of Ophthalmology pertaining to dry eye and blepharitis (2013). Since the publication of the existing guidelines, new diagnostic techniques and treatment options that provide an opportunity for better management of patients have become available. Clinicians are now able to access a wealth of information that can help them obtain a differential diagnosis and treatment approach for patients presenting with DTS. This review provides a practical and directed approach to the diagnosis and treatment of patients with DTS, emphasizing treatment that is tailored to the specific disease subtype as well as the severity of the condition.

Rotational Stability and Visual Performance of Aberration-Free, Hydrophobic Acrylic Monofocal Toric IOL with Enhanced Material.

PURPOSE: To evaluate the rotational stability and visual performance of the enVista toric intraocular lens (IOL) (MX60ET) in cataract patients with pre-existing astigmatism. SETTING: 6 US sites. DESIGN: Prospective, multicenter. METHODS: Cataract patients ≥18 years with pre-existing astigmatism (0.77 D to 4.53 D) underwent phacoemulsification and implantation of enVista toric IOL (MX60ET). Outcome measures were the proportion of patients with absolute IOL axis rotation of ≤5°, uncorrected and corrected distance visual acuities (UDVA and CDVA) at 4 m, uncorrected intermediate visual acuity (UIVA) at 66 cm, manifest refraction, and adverse events (AEs). The patients were followed up on Days 1-2, 7-14, 30-60, and 120-180. RESULTS: Mean astigmatism of 101 eyes (101 subjects) reduced from 1.47 ± 0.64 D preoperatively to 0.38 ± 0.38 D at Days 120-180 (p <0.001) with 88.1% (N=89/101) of eyes achieving astigmatism within 0.75 D. Mean postoperative UDVA and UIVA were 0.10 ± 0.16 and 0.25 ± 0.15 logMAR respectively. While 79.2% (N=80/101) of patients had postoperative UDVA of 20/32 or better, 63.9% (N=62/97) had UIVA of 20/40 or better. The mean toric IOL rotation from the operative visit to Days 30-60 was 1.97 ± 2.06° with 97.4% (N=74/76) of eyes showing toric IOL rotation of 5˚ or less. CONCLUSION: The enhanced enVista toric IOL (MX60ET) demonstrated excellent rotational stability and astigmatic outcomes indicating good efficacy of the IOL for the correction of astigmatism during cataract surgery.

Evaluating the small aperture intraocular lens: depth of focus and the role of refraction and preoperative corneal astigmatism on visual performance.

PURPOSE: To evaluate depth of focus (DOF) and visual acuities (VAs) by manifest refractive spherical equivalent (MRSE) and degree of preoperative corneal astigmatism with the IC-8® small aperture intraocular lens (SA IOL) (AptheraTM, Bausch & Lomb, Inc). SETTING: 21 investigational sites in the United States. DESIGN: Prospective, multi-center, open-label, parallel-group, non-randomized, examiner-masked, one-year clinical study. METHODS: Included patients had cataract and ≤1.5D preoperative corneal astigmatism. Patients received either the SA IOL in one eye targeted to -0.75D and a monofocal or monofocal toric IOL in the other targeted to plano (SA IOL Group) or bilateral monofocal/monofocal toric IOLs targeted to plano (Control Group). Monocular and binocular assessments included defocus curves and uncorrected VAs (distance, intermediate, and near) by postoperative MRSE; monocular VAs were assessed by degree of preoperative corneal astigmatism. RESULTS: The SA IOL Group (n=343) achieved 0.82D additional binocular DOF versus the Control Group (n=110), and SA IOL eyes achieved 0.91D additional monocular DOF over fellow eyes. Across all MRSEs, the SA IOL Group achieved monocular uncorrected VAs of 20/40 or better and binocular uncorrected VAs of 20/32 or better across all distances. Additionally, SA IOL eyes with higher (1.0-1.5D) versus lower (<1.0D) preoperative corneal astigmatism achieved equivalent monocular uncorrected VAs. CONCLUSIONS: The SA IOL provides increased DOF versus monofocal/monofocal toric IOLs and consistent monocular and binocular vision across several postoperative MRSEs and up to 1.5D of preoperative corneal astigmatism, giving patients with cataract and mild astigmatism the potential for an extended range of vision and reliable visual outcomes.

Therapeutic visual rehabilitation in a patient with high hyperopia and flat cornea years after radial keratotomy.

A 51-year-old man was referred for refractive surgery evaluation. Spectacle dependence and poor visual quality in both eyes was his chief complaint. He cannot tolerate contact lenses. Corrected distance visual acuity (CDVA) was 20/40 in both eyes. Manifest refraction was +5.25 -2.25 @ 90 (20/40) in the right eye and +6.25 -2.25 @ 105 (20/40) in the left eye. The patient had a history of radial keratotomy (RK) almost 30 years ago in both eyes and at the slitlamp presented 8 RK incisions, proportionally spaced between one another. All incisions were closed, and there were no relevant signs of scarring. The patient denied any history of ocular trauma, systemic disease, or medications. Corneal topography with different technologies revealed an irregular pattern with marked central flattening in both eyes, with some points below 30 diopters (D) (Supplemental Figures 1 and 2, available at http://links.lww.com/JRS/A862 and http://links.lww.com/JRS/A863, respectively). There were no signs of cataract, and fundus examination was normal. Optical coherence tomography (OCT) of the right eye revealed a more homogeneous thickness pattern, little variation between the thinnest and thickest areas, and adequate transparency (Figure 1JOURNAL/jcrs/04.03/02158034-202306000-00018/figure1/v/2023-05-31T172126Z/r/image-tiff). In the left eye, there is wide variability between the thinnest and thickest stromal points, with annular thinning and central thickening (Figure 2JOURNAL/jcrs/04.03/02158034-202306000-00018/figure2/v/2023-05-31T172126Z/r/image-tiff). Both eyes show marked epithelial irregularity. Considering this patient's current ocular status, how would you reach visual rehabilitation? Because he is contact lens intolerant, would you consider surface ablation, for example, photorefractive keratectomy (PRK) with mitomycin-C (MMC)? If that were the case, would you think of an optimized or a topography-guided (TG) treatment? Would you immediately consider a corneal transplant option? Would you instead consider a more conservative approach? Which one and why?

Prospective, Randomized, Fellow Eye-Controlled Study of Postoperative Pain and Inflammation Control with an Intracanalicular Dexamethasone 0.4 mg Ophthalmic Insert Following Small Incision Lenticule Extraction.

Purpose: To compare postoperative anterior chamber inflammation, pain, and patient preference following small incision lenticule extraction (SMILE) in eyes treated with a dexamethasone 0.4 mg intracanalicular insert (DEX) or topical prednisolone acetate (PRED). Patients and Methods: In this prospective, randomized, fellow eye-controlled trial, 20 patients underwent same-day, bilateral SMILE. One randomly-selected eye of each patient received DEX placed immediately postoperatively, and the fellow eye received topical PRED tapered over 2 weeks. Postoperative evaluations were performed on day 1, week 1, month 1, and month 3. Primary outcomes included postoperative pain, incidence of anterior chamber cell and flare, and patient preference of steroid therapy. Results: No eyes in either group had any clinically evident cell or flare at any postoperative time point. Mean pain scores (0-10 by subjective report) and incidence of any pain were statistically similar at all postoperative visits. Uncorrected distance visual acuity improved in all eyes, 91% of which achieved 20/25 or better. No eyes lost any lines of corrected distance visual acuity. Three eyes developed a steroid-related rise in intraocular pressure, all of which resolved with 2 of the 3 eyes requiring topical therapy. At 1 week, 1 month, and 3 months, 70%, 65%, and 53% of patients preferred DEX over PRED therapy, respectively. Conclusion: The DEX insert was preferred by more patients and controlled postoperative inflammation and pain comparably to topical PRED in eyes undergoing SMILE. There were no statistically significant differences in visual outcomes between the two groups.

Diagnosis and management of postrefractive surgery ectasia.

Postrefractive surgery ectasia is a serious, sight-threatening complication seen after the following procedures: laser in situ keratomileusis, photorefractive keratectomy, small-incision lenticule extraction, radial keratotomy, and/or arcuate keratotomy. Specific risk factors may include age, corneal thickness, degree of refractive error, corneal topographic changes including irregular astigmatism, percent tissue ablation, and residual stromal bed. Biomarkers may be a new option to help indicate who is at greatest risk for ectasia. Visual aids including spectacles or contacts lenses are often required to achieve optimal vision. Collagen crosslinking is the only treatment believed to stop progression of ectasia and prevent keratoplasty. Other surgical options may include topography-guided phototherapeutic keratectomy and intrastromal corneal ring segments. Ultimately, an "ounce of prevention is a pound of cure," so careful preoperative screening and ultimately offering the safest and most effective treatments for patients is arguably the most important job of the refractive surgeon.

Comparative study of phacoemulsification parameters with and without nitinol filament nuclear disassembly.

PURPOSE: The purpose of this study was to evaluate the impact of nitinol microfilament lens disassembly using the miLOOP device on phacoemulsification parameters in routine cataract surgery. SETTING: Private practice in Cleveland, Ohio. DESIGN: Retrospective comparative consecutive case series. METHODS: A chart review of consecutive cataract surgery cases in a single center operated by a single surgeon was conducted. Eyes were grouped by whether they underwent nitinol filament nuclear disassembly. Phacoemulsification energy, phacoemulsification time, and irrigation/aspiration (I/A) recorded during the operation were compared. Bilateral eyes were included only if the contralateral eye was in the opposite group. RESULTS: A total of 212 eyes in 131 patients were eligible for analysis, including 81 subjects with both eyes. Most eyes (93%) had grade 2+ or 3+ nuclear sclerotic cataracts. A total of 102 eyes (48%) underwent nitinol filament nuclear disassembly preceding phacoemulsification. For all eyes, there was a 16% reduction in phacoemulsification energy, with a larger drop in grade 3+ eyes (-22%). Phacoemulsification and I/A times also reduced significantly (-19% and -37%, respectively, P < .02). CONCLUSIONS: Nitinol microfilament nuclear disassembly reduced total phacoemulsification energy and time during cataract surgery, particularly in severe cataracts.

The Effects of Glaucoma and Glaucoma Therapies on Corneal Endothelial Cell Density.

A healthy corneal endothelium is required for corneal clarity. Both the glaucoma disease state and its various forms of treatment can have adverse effects on the corneal endothelium. Both the presence of glaucoma and the magnitude of intraocular pressure elevation are related to endothelial cell loss (ECL). Topical medical therapy, laser procedures, and both traditional surgeries-trabeculectomy and tube-shunts-and newer minimally invasive glaucoma surgeries have variable effects on ECL. This review will summarize the reported effects of glaucoma and its treatment on ECL. Concerns for corneal endothelial cell health should be part of the decision-making process when planning glaucoma therapy for lowering intraocular pressure, with added caution in case of planned device implantation in eyes with preexisting ECL and low endothelial cell density at high risk for corneal endothelial decompensation.