Lacritin proteoforms prevent tear film collapse and maintain epithelial homeostasis.

Lipids in complex, protein-enriched films at air/liquid interfaces reduce surface tension. In the absence of this benefit, the light refracting and immunoprotective tear film on eyes would collapse. Premature collapse, coupled with chronic inflammation compromising visual acuity, is a hallmark of dry eye disease affecting 7 to 10% of individuals worldwide. Although collapse seems independent of mutation (unlike newborn lung alveoli), selective proteome and possible lipidome changes have been noted. These include elevated tissue transglutaminase and consequent inactivation through C-terminal cross-linking of the tear mitogen lacritin, leading to significant loss of lacritin monomer. Lacritin monomer restores homeostasis via autophagy and mitochondrial fusion and promotes basal tearing. Here, we discover that lacritin monomer C-terminal processing, inclusive of cysteine, serine, and metalloproteinase activity, generates cationic amphipathic α-helical proteoforms. Such proteoforms (using synthetic peptide surrogates) act like alveolar surfactant proteins to rapidly bind and stabilize the tear lipid layer. Immunodepletion of C- but not N-terminal proteoforms nor intact lacritin, from normal human tears promotes loss of stability akin to human dry eye tears. Stability of these and dry eye tears is rescuable with C- but not N-terminal proteoforms. Repeated topical application in rabbits reveals a proteoform turnover time of 7 to 33 h with gradual loss from human tear lipid that retains bioactivity without further processing. Thus, the processed C-terminus of lacritin that is deficient or absent in dry eye tears appears to play a key role in preventing tear film collapse and as a natural slow release mechanism that restores epithelial homeostasis.

POSTERIOR SEGMENT INJURIES IN OPERATION IRAQI FREEDOM AND OPERATION ENDURING FREEDOM: 2001 to 2011.

BACKGROUND/PURPOSE: To characterize the nature of posterior segment ocular injuries in combat trauma. METHODS: Eyes in the Walter Reed Ocular Trauma Database were evaluated for the presence of posterior segment injury. Final visual outcomes in open-globe versus closed-globe injuries and by zone of injury and the types of posterior segment injuries in open-globe versus closed-globe injuries were assessed. RESULTS: Four hundred fifty-two of 890 eyes (50.8%) had at least one posterior segment injury. The mechanism of injury was most commonly an improvised explosive device in 280 (62.0%) eyes. Sixty-one patients (13.5%) had a Zone I injury, 50 (11.1%) a Zone II injury, and 341 (75.4%) a Zone III injury. Patients with Zone I injuries were more likely to have a final visual acuity of 20/200 or better compared with patients with either a Zone II (P < 0.001) or Zone III injury (P = 0.007). Eyes with a closed-globe injury were more likely to have a final visual acuity of 20/200 or better compared with those with an open-globe injury (P < 0.001). Furthermore, closed-globe injury compared with open-globe injury had a lower risk of vitreous hemorrhage (odds ratio 0.32, P < 0.001), proliferative vitreoretinopathy (odds ratio 0.14, P < 0.001), and retinal detachment (odds ratio 0.18, P < 0.001) but a higher risk of chorioretinal rupture (odds ratio 2.82, P < 0.001) and macular hole (odds ratio 3.46, P = 0.004). CONCLUSION: Patients with combat ophthalmic trauma had similar posterior segment injury patterns to civilian trauma in open-globe versus closed-globe injuries. Zone II and III injuries were associated with a worse visual prognosis.

Neuro-Ophthalmic Injuries With Systemic Neurologic Injury or Traumatic Brain Injury in Operation Iraqi Freedom and Operation Enduring Freedom.

BACKGROUND: To analyze the final visual acuity (VA) of neuro-ophthalmologic injuries (NOI) in combat ocular trauma and to study the association of NOI with systemic neurologic injury (SNI) and traumatic brain injury (TBI). METHODS: The Walter Reed Ocular Trauma Database was reviewed. Inclusion criteria were any US service member and Department of Defense civilians who suffered NOI, SNI, or TBI in Operation Iraqi Freedom or Operation Enduring Freedom. The primary outcome measure was the rate of poor final VA in patients with an NOI with secondary outcome measures the rate of SNI and TBI. in patients with NOI. RESULTS: One hundred seventy-eight (20.00%) of 890 eyes had an NOI. Optic nerve injury was observed in 79 (44.38%) eyes, other cranial nerve injury in 68 (38.20%), Horner syndrome in 4 (2.25%), diplopia in 45 (25.28%), and ptosis in 13 (7.30%). In patients with NOI, 76 (42.69%) eyes had a final VA less than 20/200. In injured eyes (n = 359) of patients (n = 251) with TBI, 154 eyes (34.26%) had a final VA less than 20/200. In multivariate analysis, optic nerve injury (P < 0.001), unlike TBI (P = 0.47), was associated with final VA less than 20/200. SNI (n = 229) had a statistically significant association (odds ratio 29.8, 95% confidence interval 19.2-47.8, P < 0.001) with NOI. Optic nerve injury and cranial nerve injury were associated with TBI and SNI (all, P < 0.001). CONCLUSION: Optic nerve injury and cranial nerve injury are associated with TBI and SNI. Optic nerve injury, but not TBI or cranial nerve injury, is associated with a poor final VA.

Orbital Fractures and Associated Ocular Injuries in Operation Iraqi Freedom and Operation Enduring Freedom Referred to a Tertiary Care Military Hospital and the Effect on Final Visual Acuity.

PURPOSE: To update the incidence of orbital fractures in U.S. Soldiers admitted to the former Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom and Operation Enduring Freedom. METHODS: Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were any U.S. Soldier or Department of Defense civilian with an orbital fracture injured in Operation Iraqi Freedom/Operation Enduring Freedom. Primary outcome measures were final visual acuity and the effect of orbital fracture, number of fractures, and anatomic location of fracture on final visual acuity. RESULTS: Eight-hundred ninety eye injuries occurred in 652 patients evacuated to Walter Reed Army Medical Center between 2001 and 2011. Orbital fractures occurred in 304 eyes (34.2%). A single wall was fractured in 140 eyes (46.05%), 2 in 99 (32.6%) eyes, 3 in 31 (10.2%), 4 in 28 (9.2%), and unknown in 6 (1.9%) eyes. Roof fractures were found in 74 (24.34%), medial wall in 135 (44.41%), lateral wall in 109 (35.9%), and floor fractures in 217 (71.4%). Final visual acuity was analyzed and 140 (46.05%) eyes had greater than 20/40 vision, 17 (5.59%) were 20/50 to 20/200, 26 (8.5%) were count fingers to light perception, and 95 (31.3%) were no light perception. In logistic regression analysis, roof (p = 0.001), medial (p = 0.009), and lateral fractures (p = 0.016) were significantly associated with final visual acuity less than 20/200, while floor fractures were not (p = 0.874). Orbital fracture and all fracture subtypes were significantly associated with traumatic brain injury, retrobulbar hematoma, optic nerve injury, but not for vitreous hemorrhage, commotio, hyphema, and choroidal rupture. Fracture repair was noted in 45 (14.8%). CONCLUSIONS: Orbital fractures occurred in a third of Operation Iraqi Freedom/Operation Enduring Freedom eyes of ocular trauma patients referred to one tertiary care military hospital. This resulted in approximately 40% of these eyes remaining legally blind after injury.Orbital fractures occur commonly during combat trauma and a significant number are legally blind despite appropriate treatment.

Lateral Canthotomy and Cantholysis in Operations Iraqi Freedom and Enduring Freedom: 2001-2011.

PURPOSE: To describe outcomes and associated ocular injuries of lateral canthotomy and cantholysis (LCC) as performed in combat ocular trauma. METHODS: Data from the Walter Reed Ocular Trauma Database of patients requiring LCC during Operations Iraqi Freedom and Enduring Freedom was reviewed as a retrospective cohort. Primary outcome measures included final visual acuity (VA) and Ocular Trauma Score. Secondary outcome measures were associated injuries and timing of surgery. RESULTS: Thirty-six LCCs were recorded on a total of 890 eyes (4.04 %) in the Walter Reed Ocular Trauma Database. Eighteen out of 36 eyes (50.00%) had a final VA of the affected eye of 20/200 or worse vision. From the initial available VA measured either at the time of injury or at Walter Reed Army Medical Center, 13 eyes (40.63%) had no change in VA, 15 eyes (46.88%) had improvement, and 4 (12.5%) had a decrease in VA (n = 32, data unavailable for 4 eyes). Ocular Trauma score 0-65 was noted in 14 (38.9%) and 66-100 (61.1%). Retinal detachment (6, 16.67%), optic nerve injuries (7, 19.44%), orbital fractures (20, 55.56%), and retrobulbar hematoma (25, 69.44%) were commonly associated injuries. Of the 36 LCC, 18 (50.00%) were performed as the first surgery performed at the combat support hospital, 13 (36.11%) as the second, 4 (11.11%) as the third, and 1 (2.78%) as the fourth. CONCLUSIONS: The largest subgroup of patients had an improvement in VA associated with performance of LCC; however, half of patients remained with a final VA of equal to or worse than 20/200 due to severe ocular trauma.

Enucleations and Eviscerations for Combat Ocular Trauma Performed During Operations Iraqi and Enduring Freedom: 2001 to 2011.

PURPOSE: To describe the demographics and clinical outcomes of patients who underwent posttraumatic enucleation or evisceration during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) from 2001 to 2011. METHODS: The Walter Reed Ocular Trauma Database is a retrospective case series of US Servicemembers and Department of Defense civilians who had combat ocular injuries in OIF and OEF. Data regarding posttraumatic enucleations and eviscerations performed during OIF and OEF were extracted. The main outcomes analyzed were the number of enucleations and eviscerations performed, location of the surgery, laterality, and graft type. The secondary outcome measures included: mechanism of injury and Ocular Trauma Score classification. RESULTS: One hundred nine enucleations and eviscerations were performed on the 890 eyes (12.24%). Sixty-three (57.80%) primary enucleations, 36 (33.03%) secondary enucleations, 5 (4.59%) postretinal detachment repair enucleations, and 5 (4.59%) primary eviscerations were completed. The surgeries were completed at a combat support hospital (57; 52.3%), or Walter Reed Army Medical Center (49; 45.0%). All surgeries were unilateral except in 2 patients. The most common graft type used was silicone (n = 56; 51.38%). Improvised explosive devices caused 76 (69.72%) eye injuries. Ocular Trauma Score were recorded as 56 (51.38%) between 0 and 44, 44 (40.37%) between 45 and 65, and unknown in 9 (8.26%). CONCLUSION: Posttraumatic enucleation or evisceration due to devastating ocular trauma is required in about 15% of ophthalmic patients in modern combat trauma. The psychosocial impact on veterans who have required an enucleation or evisceration from combat trauma has been poorly studied and requires further review.

Intraocular Foreign Body Trauma in Operation Iraqi Freedom and Operation Enduring Freedom: 2001 to 2011.

PURPOSE: We update the incidence of intraocular foreign bodies (IOFB) in soldiers admitted to Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom and Operation Enduring Freedom. DESIGN: This consecutive retrospective case series included 890 eyes of 652 patients. METHODS: Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were any American soldier or Department of Defense civilian with an IOFB injured in Operation Iraqi Freedom/Operation Enduring Freedom. Closed globe injuries with orbital foreign bodies, injury outside of a combat zone, or non-Department of Defense civilian trauma were the exclusion criteria. MAIN OUTCOME MEASURES: Primary outcome measures were final visual outcome and the number, size, and location of IOFBs. Secondary outcome measures included surgical procedures, use of eye protection, associated complications, source of injury and Ocular Trauma Score. RESULTS: There were 890 eye injuries in 652 patients evacuated to Walter Reed Army Medical Center between 2001 and 2011. IOFBs were found in 166 eyes of 149 patients (18.6%; 95% confidence interval [CI], 16.2%-21.3%). Most patients had a single IOFB (80.7%). An IOFB was positively associated with Ocular Trauma Score grade 1 or 2 (0-65) injuries (odds ratio [OR], 1.58; 95% CI, 1.07-2.38; P = 0.01). There were 130 eyes (78.33%) that had recorded time from initial visual acuity to final visual acuity and it ranged from 8 to 2421 days (mean, 433.24 days). Thirty-eight (25.16%; 95% CI, 18.89%-32.67%) eyes had no change in visual acuity, 98 (64.90%; 95% CI, 57.00%-72.07%) had improved visual acuity, and 15 (9.93%; 95% CI, 6.01%-15.84%) had decreased visual acuity. IOFB was not found to predict final visual acuity of <20/200 in multivariate analysis when other injury features were known (P = 0.1). Pars plana vitrectomy was completed on 124 eyes (74.70%). Removal of IOFB was performed in 118 eyes (71.08%; average of 31.67 days after initial injury) with a delayed procedure occurring after primary closure and antibiotics owing to a lack of surgical capacity in Iraq and Afghanistan. Retinal detachment occurred in 48 eyes (28.92%) and proliferative vitreoretinopathy in 44 eyes (26.5%). CONCLUSIONS: IOFBs occur frequently in combat ocular trauma and are significantly associated with more severe injuries. However, IOFBs were not found to be a significant risk factor for visual acuity of <20/200.

A cleavage-potentiated fragment of tear lacritin is bactericidal.

Antimicrobial peptides are important as the first line of innate defense, through their tendency to disrupt bacterial membranes or intracellular pathways and potentially as the next generation of antibiotics. How they protect wet epithelia is not entirely clear, with most individually inactive under physiological conditions and many preferentially targeting Gram-positive bacteria. Tears covering the surface of the eye are bactericidal for Gram-positive and -negative bacteria. Here we narrow much of the bactericidal activity to a latent C-terminal fragment in the prosecretory mitogen lacritin and report that the mechanism combines membrane permeabilization with rapid metabolic changes, including reduced levels of dephosphocoenzyme A, spermidine, putrescine, and phosphatidylethanolamines and elevated alanine, leucine, phenylalanine, tryptophan, proline, glycine, lysine, serine, glutamate, cadaverine, and pyrophosphate. Thus, death by metabolic stress parallels cellular attempts to survive. Cleavage-dependent appearance of the C-terminal cationic amphipathic α-helix is inducible within hours by Staphylococcus epidermidis and slowly by another mechanism, in a chymotrypsin- or leupeptin protease-inhibitable manner. Although bactericidal at low micromolar levels, within a biphasic 1-10 nM dose optimum, the same domain is mitogenic and cytoprotective for epithelia via a syndecan-1 targeting mechanism dependent on heparanase. Thus, the C terminus of lacritin is multifunctional by dose and proteolytic processing and appears to play a key role in the innate protection of the eye, with wider potential benefit elsewhere as lacritin flows from exocrine secretory cells.

Polymorphism in THBS1 gene is associated with post-refractive surgery chronic ocular surface inflammation.

PURPOSE: To determine the association of single nucleotide polymorphisms (SNPs) of the thrombospondin 1 (THBS1) gene with development of chronic ocular surface inflammation (keratoconjunctivitis) after refractive surgery. DESIGN: Retrospective cohort study. PARTICIPANTS: Active duty U.S. Army soldiers (n = 143) who opted for refractive surgery. METHODS: Conjunctival impression cytology samples collected from participants before the surgery were used to harvest DNA for genotyping 5 THBS1 SNPs (rs1478604, rs2228262, rs2292305, rs2228262, and rs3743125) using the Sequenom iPLEX Gold platform (Sequenom, San Diego, CA). Samples collected after surgery were used to harvest RNA for gene expression analysis by real-time polymerase chain reaction (PCR). Participants were followed for 1 year after surgery to monitor the status of keratoconjunctivitis. MAIN OUTCOME MEASURES: Genetic basis of the development of chronic keratoconjunctivitis after refractive surgery. RESULTS: Carriers of minor alleles of 3 SNPs each were found to be more susceptible to developing chronic keratoconjunctivitis (rs1478604: odds ratio [OR], 2.5; 95% confidence interval [CI], 1.41-4.47; P = 2.5 × 10(-3); rs2228262 and rs2292305: OR, 1.9; 95% CI, 1.05-3.51; P = 4.8 × 10(-2)). Carriers of the rs1478604 minor allele expressed significantly reduced levels of thrombospondin 1 (TSP1) (P = 0.042) and increased levels of an inflammatory cytokine associated with keratoconjunctivitis, interleukin-1ß (P = 0.025), in their ocular surface epithelial cells compared with homozygous major allele controls. CONCLUSIONS: Genetic variation in the THBS1 gene that results in decreased expression of the encoded glycoprotein TSP1 in ocular surface epithelial cells significantly increases the susceptibility to develop chronic ocular surface inflammation after refractive surgery. Further investigation of THBS1 SNPs in a larger sample size is warranted.

The U.S. Army Surface Ablation Study: comparison of PRK, MMC-PRK, and LASEK in moderate to high myopia.

PURPOSE: To compare visual outcomes following photorefractive keratectomy (PRK), PRK with mitomycin C (MMC-PRK), and LASEK in moderate and high myopia in military personnel. METHODS: This prospective, randomized contralateral eye study included 167 patients 21 years or older with manifest spherical equivalent -5.99 ± 1.40 diopters (D) (range: -3.88 to -9.38 D) randomized to either MMC-PRK or LASEK treatment in their dominant eye and conventional PRK without MMC in the fellow eye. All procedures were performed using the LADARVision 4000 Excimer Laser System (Alcon Surgical Inc., Ft. Worth, TX). High- and low-contrast visual acuities, manifest refraction, endothelial cell count, and corneal haze were evaluated up to 12 months postoperatively. RESULTS: At 12 months postoperatively, visual outcomes were comparable among the treatment groups. Corneal haze of any grade was less common in MMC-PRK compared to PRK at 1 month (21.4% vs 31.0%; P < .01) and 3 months (12.8% vs 35.9%; P = .03) postoperatively; it was also less common in MMC-PRK compared to LASEK at 1 month (21.4% vs 55.9%; P < .01), 3 months (12.8% vs 42.4%; P < .01), and 6 months (12.2% vs 36.4%; P = .03) postoperatively. Haze rate (grade 0.5 or higher) was comparable between LASEK and PRK. Clinically significant haze (grade 2 or higher) developed after PRK (4 eyes) and LASEK (2 eyes), but not after MMC-PRK. CONCLUSIONS: MMC-PRK showed some benefits in minimizing corneal haze formation. One year after surgery, there was no discernible difference in the postoperative refractive outcomes among the three methods.

Visual outcomes after Epi-LASIK and PRK for low and moderate myopia.

PURPOSE: To evaluate visual outcomes following epi-LASIK compared to photorefractive keratectomy (PRK). METHODS: Of a total 294 patients aged ≥21 years, 145 (290 eyes) underwent epi-LASIK and 149 (298 eyes) underwent PRK for low to moderate myopia or myopic astigmatism. Epi-LASIK was performed with the Amadeus II epikeratome (Abbott Medical Optics) and PRK with the Amoils rotary epithelial brush (Innovative Excimer Solutions). All ablations were performed using the same excimer laser system. Outcome measures included intraoperative complications, corneal reepithelialization, postoperative pain, uncorrected distance visual acuity (UDVA), manifest refraction spherical equivalent (MRSE), corrected distance visual acuity (CDVA), corneal haze, and quality of vision. RESULTS: Mean preoperative MRSE was -2.97±1.19 diopters (D) for epi-LASIK versus -2.95±1.06 D for PRK. Complete reepithelialization was achieved by postoperative day 4 in 46.9% of epi-LASIK eyes versus 92.4% of PRK eyes, with superior UDVA at postoperative day 1 in the PRK group (P=.002). Using Fisher exact test, a significantly higher percentage of epi-LASIK eyes compared to PRK eyes achieved 20/15 or better at 1 month (25.8% vs 17.8%, P=.031), 3 months (62.3% vs 49.3%, P=.004), 6 months (77.1% vs 57.9%, P<.001), and 12 months (75.9% vs 61.9%, P=.002). A change in MRSE >0.50 D occurred in 8.4% of epi-LASIK eyes within the 3- and 12-month interval versus 17.7% of PRK eyes (P=.04). No differences were noted between the two procedures in CDVA or clinically significant haze. CONCLUSIONS: Epi-LASIK showed superior refractive efficacy and stability but required more time for wound healing, resulting in inferior early visual outcomes and a tendency to overcorrect higher refractive errors compared to PRK. Both treatments were safe and comparable in terms of pain and haze formation.

Alcohol versus brush PRK: visual outcomes and adverse effects.

BACKGROUND AND OBJECTIVE: A smooth corneal surface prior to laser ablation is important in order to achieve a favorable refractive outcome. In this study, we compare PRK outcomes following two commonly used methods of epithelial debridement: Amoils epithelial scrubber (brush) versus 20% ethanol (alcohol). STUDY DESIGN/PATIENTS AND METHODS: We reviewed records of patients who underwent wavefront-optimized PRK for myopia or myopic astigmatism between January 2008 and June 2010. Two treatment groups (brush vs. alcohol) were compared in terms of uncorrected distance visual acuity (UDVA), manifest refraction spherical equivalent (MRSE), corrected distance visual acuity (CDVA), and complications at postoperative months 1, 3, 6, and 12. RESULTS: One thousand five hundred ninety-three eyes of 804 patients underwent PRK during the study period: 828 brush-treated eyes and 765 alcohol-treated eyes. At 6 months postoperatively UDVA was ≥20/20 in 94.7% of brush-treated eyes versus 94.4% of alcohol-treated eyes (P = 0.907). At 1 month a higher percentage of brush-treated eyes maintained or gained one or more lines CDVA compared to alcohol-treated eyes (P = 0.007), but there were no other differences in UDVA, MRSE, or CDVA at any point postoperatively. At 1 month 75.4% of brush-treated eyes versus 70.4% of alcohol-treated eyes were free of complications (P = 0.032), and there were fewer brush-treated eyes with corneal haze (4.0% vs. 6.9%, P = 0.012) and dry eye (8.9% vs. 14.4%, P = 0.001). Although corneal haze was slightly more frequent in the alcohol group, most was trace and not significant. CONCLUSIONS: Although alcohol-assisted PRK had more minor complications in the early postoperative period, including corneal haze and dry eye, results for both groups beyond 1 month were comparable.

Risk Factors for Failure of Final Anatomic Surgical Reattachment in Retinal Detachments From Combat Ocular Trauma.

BACKGROUND AND OBJECTIVE: The goal of this study was to determine the anatomic outcome of traumatic retinal detachment (RD) from combat ocular trauma. MATERIALS AND METHODS: Retrospective study of patients sustaining a traumatic RD in Operation Iraqi Freedom and Operation Enduring Freedom who were evacuated to Walter Reed Army Medical Center from 2001 to 2011. The Fisher exact test, Wilcoxon rank sum test, and Agresti and Coull methods were used for analyses. RESULTS: There were 143 eyes of 134 patients in which a traumatic RD developed, of a total of 890 eyes of 652 patients in the Walter Reed Ocular Trauma Database. Based on our results, predictors for failure to reattach the retina include maculaoff status (P = .0002), open-globe injury (P = .03), proliferative vitreoretinopathy postoperatively (P = .002), and presence of hyphema (P = .02). Intraocular foreign body and time to initial retinal surgery did not increase risk for failure. Thirty-four percent (34%) of eyes failed to be reattached. CONCLUSIONS: Traumatic RD due to injury sustained in a combat zone resulted in poor prognosis, with 82.09% of eyes with RD having a best-corrected visual acuity worse than 20/200. The anatomic success of RD repair was shown to be 65.71%, likely owing to the severity of the injuries, concomitant systemic injuries, and delayed surgical intervention. [Ophthalmic Surg Lasers Imaging Retina 2022;53:493-501.].

Correlative Factors for Traumatic Brain Injury in Combat Ocular Trauma.

INTRODUCTION: Traumatic brain injury (TBI) remains a significant source of disability for active duty service members in both deployed and training settings as well as those who have left active service. Service members with ocular trauma are at risk for a TBI and should be screened appropriately. Early detection results in treatment to minimize long-term sequelae which can often be debilitating. This study is the first to evaluate different combat-related ocular injuries and their associations with TBI. MATERIALS AND METHODS: A secondary analysis of existing data was conducted from a prospective study of patients who sustained combat ocular trauma (COT) during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) between 2006 and 2020. Clinical data of a total of 88 participants were gathered and each case reviewed, including patient demographics, injury-related factors, history of TBI, and treatments rendered. All cases were then categorized to compare COT (n = 13) versus COT-T (Combat Ocular Trauma associated with TBI; n = 75). The Fisher's exact test was completed for each category to assess for predictive factors of TBI within the ophthalmic trauma cohort. Odds ratios were calculated with their 95% CI. RESULTS: When compared to COT, COT-T was significantly associated with closed globe injuries (56%; OR 4.24, 95% CI 1.08-16.67), blast injuries (89.3%; OR 3.72, 95% CI 0.93-14.9), multiple surgeries (89%; OR 2.51, 95% CI 0.57-11.08), anterior segment injuries (69.3%; OR 1.41, 95% CI 0.42-4.79), optic nerve injuries (24%; OR 1.05, 95% CI 0.26-4.25), orbital fractures (48%; OR 2.08, 95% CI 0.59-7.34), enucleation (17.3%; OR 2.52, 95% CI 0.300-21.08), the use of eye protection (68.6%; OR 2.18, 95% CI 0.57-8.32), and the need to undergo plastic surgery (78.7%; OR 2.30, 95% CI 0.66-8.02). Significant factors associated with COT included penetrating injury (30.8%; OR 0.027, 95% CI 0.07-1.08), posterior segment injuries (92%; OR 0.264, 95% CI 0.032-2.17), bilateral injuries (76.9%; OR 0.678, 95% CI 0.17-2.69), and bilateral blindness (7.7%; OR 0.857, 95% CI 0.092-7.99). CONCLUSIONS: Patients who have sustained combat-related ocular injuries, specifically blast injury, anterior segment injury, or an orbital fracture, were noted to be more likely to have also sustained a TBI. However, of the evaluated variables in predicting the co-occurrence of TBI, only closed globe injury was identified as statistically significant. Service members with injuries requiring multiple surgical procedures, reconstructive plastic surgery, or enucleation of an eye were also more likely to be diagnosed with a TBI, but these variables were not found to be predictive of TBI among ocular trauma patients. The presence of eye protection was not protective against TBI. Further studies are needed to find significant predictors of TBI in combat ocular trauma patients to assist in the early and accurate detection of TBI.

The Impact of Combat Ocular Trauma and Traumatic Brain Injury on Vision- and Health-Related Quality of Life Among U.S. Military Casualties.

PURPOSE: The purpose of this study was to assess visual and health-related quality of life (QOL) among U.S. military service members who sustained combat ocular trauma (COT) with or without associated traumatic brain injury (TBI). METHODS: This was a single-center, prospective observational study of U.S. service members (n = 88) with COT who were treated at Walter Reed National Military Medical Center. Participants completed the National Eye Institute Visual Function Questionnaire (VFQ-25) at enrollment and at follow-up (>1 year) and supplemental surveys: Neurobehavioral Symptom Inventory, the Medical Outcomes 36-item Short Form Survey (SF-36), and Mayo-Portland Adaptability Inventory. RESULTS: Initial and follow-up VFQ-25 showed a statistically significant increase in median scores for near activities (initial: 75.0, follow-up 83.3; P = .004) and peripheral vision (initial: 50.0, follow-up: 75.0; P = .009) and in composite scores (initial: 79.5, follow-up: 79.8; P = .022). Comparing those who did (n = 78) and did not (n = 8) have a TBI history, there were no significant differences in median change in VFQ-25 composite scores (with TBI: 2.3 vs. no TBI: 10.7; P = .179). Participants with a TBI history had a significantly lower median SF-36 General Health score (with TBI: 67.5 vs. no TBI: 92.5; P = .009). CONCLUSIONS: Vision-related QOL of COT patients is generally good in the long term. However, those with both COT and a history of TBI conditions showed significantly worse functioning in several domains than those without TBI. As TBI is a common finding in COT, this association is an important factor impacting this population's overall clinical presentation and daily functions.

Corneal biomechanics following epi-LASIK.

PURPOSE: To evaluate corneal biomechanical changes following epi-LASIK. METHODS: In this prospective study of 51 patients, corneal hysteresis (CH), corneal resistance factor (CRF), and intraocular pressure (IOP) were assessed using the Ocular Response Analyzer (ORA, Reichert Technologies) preoperatively and at 1, 3, 6, and 12 months after epi-LASIK. Repeated measures analysis of variance (ANOVA) was used to compare changes over time (alpha=.05). Intraocular pressure was also measured by Goldmann applanation tonometry. RESULTS: Corneal hysteresis decreased from 10.22±1.65 mmHg preoperatively to 8.17±1.25 mmHg at 1 month, 8.46±1.44 mmHg at 3 months, 8.63±1.31 mmHg at 6 months, and 8.53±1.49 mmHg at 12 months. Corneal resistance factor decreased from 10.01±1.80 mmHg preoperatively to 7.82±1.68, 8.03±1.85, 7.77±1.50, and 7.80±1.66 mmHg at 1, 3, 6, and 12 months, respectively. Repeated measures ANOVA showed a significant change over time for both CH and CRF (P<.0005). All measures of IOP changed significantly over time (P<.0005). CONCLUSIONS: Epi-LASIK resulted in a significant change in CH and CRF postoperatively. Although some recovery occurred over time, CH, CRF, and IOP did not revert to preoperative levels.

Visual and IOP outcomes after PRK in pigment dispersion syndrome.

PURPOSE: To report the results of photorefractive keratectomy (PRK) in patients with pigment dispersion syndrome. METHODS: The pre- and postoperative records of patients with pigment dispersion syndrome who underwent PRK between January 2002 and March 2009 were reviewed. Data for analysis included gender, age, ablation depth, surgical complications, manifest refraction spherical equivalent, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), intraocular pressure (IOP), central corneal thickness (CCT), cup-to-disc (c/d) ratio, and postoperative complications. RESULTS: Thirty-seven eyes of 19 patients (17 men and 2 women) with a mean age of 37.5 ± 6.9 years were included for review. At final follow-up, mean 404.1±119.5 days postoperative, UDVA was 20/15 or better in 67.6%, 20/20 or better in 91.9%, and 20/25 or better in 100% of eyes; 94.6% of eyes were within 0.50 diopters (D) and 100% were within 1.00 D of emmetropia. Corrected distance visual acuity was unchanged from preoperative in 73% and improved by one line in 27% of eyes. No eye lost 1 or more lines of CDVA. When corrected for change in CCT and curvature, mean postoperative IOP was elevated from baseline (16.7 ± 3.8 mmHg) at 1 month (18.1 ± 4.9 mmHg, P =.044) but unchanged at any other time postoperatively. Two (11%) of 19 patients were steroid responders, requiring a single topical agent until completing the course of steroids. No significant change was noted in mean c/d ratio from baseline (0.35±0.12) to final postoperative (0.35 ± 0.13, P = .99). CONCLUSIONS: Although PRK in patients with pigment dispersion syndrome resulted in excellent UDVA, retention of CDVA, and low incidence of adverse effects 1 to 2 years after surgery, long-term safety and efficacy outcomes of PRK in this cohort remain speculative

Ocular Trauma in Operation Iraqi Freedom and Operation Enduring Freedom from 2001 to 2011: A Bayesian Network Analysis.

PURPOSE: To update the epidemiology of ocular injuries in soldiers admitted to Walter Reed Army Medical Center (WRAMC) from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). METHODS: Data were collected in the Walter Reed Ocular Trauma Database. A Bayesian Network Analysis was completed to better understand the relationships between different ocular demographic variables, injuries, surgeries, ocular trauma scores (OTS) and visual outcomes. RESULTS: There were 890 consecutive globe or adnexal combat injuries, or both, sustained by 652 United States soldiers treated at WRAMC between 2001 and 2011.The primary mechanism of injury was improvised explosive device (62.47%). Many patients (62.0%) had final visual acuity (VA) grades of 1-2 (20/15 - 20/200), while 29.9% of patients had final VA grades of 3-5 (less than 20/200), and 8.1% had unknown final VA grades. Bayesian Network Analysis revealed that the injury variables of Retina (47.9%), Lens (44.6%), Posterior Segment (43.7%) and Anterior Segment (40.3%), and the surgical variables of Enucleation (97.6%) and cataract extraction and posterior capsule intraocular lens placement (CEPCIOL; 43.3%) all had probabilities greater than 40% for a poor final VA, while all other variables were less than 40%. CONCLUSION: Modern-day combat trauma results in complicated ocular injuries causing 30% of patients to be left legally blind in their injured eye. It is critical to maintain a wide variety of deployable, specialty trained ophthalmologists to ensure the best visual outcomes for wounded warriors and to maintain mission readiness.

Small-incision lenticule extraction in the U.S. military: prospective study of visual and military task performance.

PURPOSE: To assess early visual outcomes and military task performance after small-incision lenticule extraction (SMILE) among U.S. military service members. SETTING: Warfighter Refractive Eye Surgery Program and Research Center and Night Vision and Electronic Sensors Directorate, Fort Belvoir, Virginia. DESIGN: Single-center, prospective, observational study. METHODS: The study was composed of active duty service members (n = 37) electing to undergo SMILE for myopia or myopic astigmatism. Testing performed preoperatively and at 1 month and 3 months postoperatively included uncorrected (UDVA) and corrected (CDVA) distance visual acuities, wavefront aberrometry, low-contrast visual acuity (LCVA), contrast sensitivity, and vision-related questionnaire. 14 participants underwent rifle marksmanship with spectacle correction before and without correction at 6 to 8 weeks postoperatively. RESULTS: At 3 months postoperatively, the efficacy index was 0.96 and the safety index was 1.03. UDVA was ≥20/20 in 69 (96%) of eyes. LCVA change from baseline was significant under night vision condition. Eye problems contributed to 10% work and 20% activity impairments, both of which decreased to 0% (P = .001). The overall satisfaction rating for SMILE was high at 90.9 (95% CI, 85.3 to 96.5), and 95% of participants would be willing to undergo the procedure again. The median scores between preoperative and 6 to 8 weeks postoperative firing performance were comparable (34 vs 35, with and without correction, respectively; P = .247). CONCLUSIONS: After the early recovery period, SMILE seems to preserve quality of vision, which appears to facilitate the accomplishment of tasks related to their work as military service members as well as performing activities outside of work.

Comparison of Simulation-Based versus Cadaveric-Tissue-Based Ocular Trauma Training on Novice Ophthalmologists: Repair of Corneal Laceration Model.

Purpose The aim of this study was to evaluate whether the simulated tissue models may be used in place of animal-based model for corneal laceration repair for surgical skills acquisition. Design Prospective randomized controlled trial. Participants Seventy-nine military and civilian 2nd- and 3rd-year ophthalmology residents and 16 staff ophthalmologists participating in the Tri-Service Ocular Trauma Skills Laboratory at the Uniformed Services University (Bethesda, MD). Methods Resident ophthalmologists underwent preliminary evaluation of their ability to close a 5-mm linear, full-thickness corneal laceration involving the visual axis. They then were randomized to undergo 90 to 120 minutes of either simulator-based (SIM) or swine cadaveric-tissue-based (CADAVER) corneal laceration repair. The same evaluation was performed post training. On a more limited basis, the study was repeated for attending ophthalmologists to act as a pilot for future analysis and test efficacy for "refresher" training. Main Outcome Measures Successful wound closure with secondary outcomes of suture length, tension, depth, and orientation, as graded by attending ophthalmologists. Results No significant difference in CADAVER versus SIM groups in the primary outcome of watertight wound closure of the corneal laceration. CADAVER group performed better than SIM group for certain metrics (suture depth, p = 0.009; length, p = 0.003; and tension, p = 0.043) that are associated with poor wound closure and increased amount of induced corneal astigmatism. For attending ophthalmologists, six of the eight in each group (SIM and CADAVER) retained or improved their skills. Conclusions For resident ophthalmologists, SIM training is sufficient for achieving the primary outcome of watertight wound closure. However, CADAVER training is superior for wound metrics for the ideal closure. For attending ophthalmologists, SIM training may be useful for retention of skills.