Anterior Chamber Intraocular Lens Implantation Versus Four-Flanged Scleral Fixation Technique for Patients With Loss of Capsular Support During Routine Cataract Surgery.

PURPOSE: To compare the outcomes of anterior chamber intraocular lens (AC-IOL) implantation versus the four-flanged scleral fixation technique in eyes with loss of capsular support during routine cataract surgery. METHODS: This was a retrospective cohort study of all patients in whom an IOL was implanted either during or after short-term aphakia due to loss of capsular and sulcus support in a routine cataract surgery with at least 6 months of follow-up time between 2015 and 2023 in a tertiary medical center in Israel. Two different IOL implantation techniques were compared: the implantation of an angle-supported ACIOL and four-flanged scleral fixation. Main outcome measures included postoperative complications such as pseudophakic bullous keratopathy, loss of intraocular pressure control and glaucoma, IOL subluxation, and retinal detachment. RESULTS: Sixty-five eyes of 65 patients were included in the study, 33 eyes in the AC-IOL group and 32 eyes in the flange group. Follow-up time was 29.92 ± 20.02 months in the AC-IOL group and 20.17 ± 15.56 months in the flange group (P = .087). Pseudophakic bullous keratopathy was observed in 10 (30.3%) patients in the AC-IOL group and in 1 (3.1%) patient in the flange group (P = .04). This association remained significant using survival analysis (P = .006). In 4 (12.1%) patients in the AC-IOL group, a glaucoma filtering procedure was performed to control the intraocular pressure compared with none in the flange group (P = .042). CONCLUSIONS: In the setting of loss of capsular support during routine cataract surgery, four-flanged scleral fixation showed an overall lower rate of complications and significantly reduced rate of subsequent surgical interventions. [J Refract Surg. 2024;40(8):e520-e526.].

[INTERVENTIONAL GLAUCOMA - A SHIFT IN THE TREATMENT PARADIGM].

INTRODUCTION: Glaucoma is a progressive optic neuropathy and is the leading cause of preventable irreversible blindness worldwide. Glaucoma causes progressive visual field loss and can have significant implications on the patient's quality of life. Lowering intraocular pressure (IOP) is the only treatment proven to prevent vision loss from glaucoma. It is achieved using medication, laser treatment and surgery. The treatment paradigm of glaucoma has been one whereby surgical intervention has been left for advanced cases due to a variety of reasons, mainly concerning safety and long term success. The past two decades have seen a paradigm shift towards earlier IOP lowering interventions using a wide array of different technologies in the laser and surgical spaces. This review aims to understand the background to this paradigm shift, its necessity, and its potential impact on the vision and life of glaucoma patients.

Reproducibility of Manifest Refraction in Patients With Keratoconus Compared With Healthy Subjects: A Prospective Cohort Study.

PURPOSE: To measure and compare the inter-examiner reproducibility of manifest refraction in patients with keratoconus. DESIGN: Prospective, inter-examiner reliability analysis comparing cases and controls. METHODS: Patients with keratoconus (KC) and healthy subjects had undergone manifest refraction by the same 2 skilled optometrists; each was masked to the refraction of the other, on the same day. The KC group comprised patients with KC, who were recruited from the cornea clinic. The control group consisted of healthy individuals who wore spectacles and did not have KC. Participants for the control group were recruited from the clinic's staff, including doctors, technicians, nurses, and medical students. The study took place in 1 tertiary medical center in Israel from April 2021 to May 2022. The results of the manifest refraction and achieved corrected distance visual acuity (CDVA) were compared between groups. RESULTS: A total of 120 eyes of 60 patients were enrolled in the study, 30 in the keratoconus group and 30 in the control group. A difference of 0.67 ± 0.83 diopters (D) and 0.19 ± 0.21 D in the absolute manifest cylinder was observed between the optometrists in the keratoconus (95% LoA, -0.96, 2.30) and control group (95% LoA, -0.22, 0.61), respectively (P < .001). Multivariate analysis revealed a 22-fold higher likelihood of an error exceeding 0.75 D in cylinder measurements (odds ratio = 22.24; 95% CI = 2.39-206.95) and a 10-fold likelihood of a difference of at least 1 row on the Snellen chart for corrected distance visual acuity (odds ratio = 10.32; 95% CI = 2.39-44.44) in the KC group. CONCLUSIONS: When compared to healthy subjects, patients with KC exhibited greater variability in manifest refraction. This discrepancy has the potential to influence the decision-making process when managing patients with KC.

Diagnostic capabilities of ChatGPT in ophthalmology.

PURPOSE: The purpose of this study is to assess the diagnostic accuracy of ChatGPT in the field of ophthalmology. METHODS: This is a retrospective cohort study conducted in one academic tertiary medical center. We reviewed data of patients admitted to the ophthalmology department from 06/2022 to 01/2023. We then created two clinical cases for each patient. The first case is according to the medical history alone (Hx). The second case includes an addition of the clinical examination (Hx and Ex). For each case, we asked for the three most likely diagnoses from ChatGPT, residents, and attendings. Then, we compared the accuracy rates (at least one correct diagnosis) of all groups. Additionally, we evaluated the total duration for completing the assignment between the groups. RESULTS: ChatGPT, residents, and attendings evaluated 126 cases from 63 patients (history only or history and exam findings for each patient). ChatGPT achieved a significantly lower accurate diagnosis rate (54%) in the Hx, as compared to the residents (75%; p < 0.01) and attendings (71%; p < 0.01). After adding the clinical examination findings, the diagnosis rate of ChatGPT was 68%, whereas for the residents and the attendings, it increased to 94% (p < 0.01) and 86% (p < 0.01), respectively. ChatGPT was 4 to 5 times faster than the attendings and residents. CONCLUSIONS AND RELEVANCE: ChatGPT showed low diagnostic rates in ophthalmology cases compared to residents and attendings based on patient history alone or with additional clinical examination findings. However, ChatGPT completed the task faster than the physicians.

Quantum Molecular Resonance Effects on Patients With Dry Eye Disease: A Randomized Controlled Trial.

PURPOSE: The aim of the study was to evaluate the efficacy and safety of quantum molecular resonance in the treatment of dry eye disease. METHODS: This study was a double-blind randomized control trial in 1 academic medical center, for 2 years. Participants received treatment or a placebo with the Rexon-Eye device, once per week for 4 weeks. The primary outcome was the change in dry eye symptoms assessed by the Ocular Surface Disease Index (OSDI). Secondary outcomes were clinical findings associated with the dry eye such as meibomian gland dysfunction (MGD) score, tear break-up time (TBUT), corneal fluorescein staining, Schirmer test, and best-corrected visual acuity (BCVA). RESULTS: Forty patients were recruited, 20 in each arm. The mean age was 63.5 ± 15.1 years and 27 (67.5%) were female. The mean OSDI score significantly improved in the intervention group from 19.15 ± 10.3 to 10.5 ± 7.0 ( P < 0.001), whereas the control group showed no significant change (14.4 ± 8.4 to 15.5 ± 8.6, P = 0.830). MGD scores significantly improved in the intervention group (1.57 ± 1.2 to 0.8 ± 0.9, P = 0.006), whereas showing no significant change in the control group (1.60 ± 0.9 to 1.99 ± 1.0, P = 0.244). The corneal staining score also showed significant improvement in the intervention group ( P = 0.045) and a nonsignificant decline in the placebo group ( P = 0.50). No significant difference was seen in TBUT, visual acuity, and Schirmer scores between groups. No harm resulting from treatment was reported during the duration of the trial. CONCLUSIONS: High-frequency electrotherapy may have a positive effect on symptoms and signs of dry eye. This emerging technology may become part of the arsenal of therapeutic modalities for this condition.

Between-eye correlation of ocular parameters.

OBJECTIVE: It is accepted that ocular parameters are more correlated with the fellow eye. This poses a challenge in ophthalmic research. There is a relative scarcity of data concerning the extent of correlation. The aim of this study was to analyze and quantify the correlation of different ocular parameters. DESIGN: Historical registry analysis. PARTICIPANTS: All patients examined in a 10-year period (2011-2021) in one academic tertiary medical centre in central Israel. METHODS: Data from optical coherence tomography examinations and biometry of a single examination of both eyes taken at the same time from each patient was included. Pearson's r values were calculated to estimate the extent of correlation. RESULTS: A total of 17,212 patients were included. Mean age was 73 ± 12.7 years, and 54.5% were female. All examined parameters were highly statistically significantly correlated between eyes (all with p < 0.1 × 10-36), whereas the strength of correlation differed. Very weak correlation was seen in central macular thickness (r = 0.189), and a weak correlation was seen in anterior-chamber depth (r = 0.379) and retinal nerve fibre layer thickness (r = 0.479). A strong correlation was seen in central corneal thickness (r = 0.754), and a very strong correlation was seen in axial length (r = 0.900). CONCLUSIONS: In a retrospective analysis of optical coherence tomography and biometry measurements of >10,000 patients, all examined parameters were highly statistically significantly correlated. Correlation magnitude varied, with structural characteristics more correlated than functional ones. Including both eyes in an outcome analysis likely will introduce bias. We recommend adjusting for inter-eye correlation in all studies assessing ocular outcome measures.

RATES OF RECURRENT RETINAL DETACHMENT AFTER VAGINAL VERSUS CESAREAN DELIVERIES: A Retrospective Analysis and Review of the Literature.

PURPOSE: To evaluate the risk of a retinal redetachment in women after vaginal delivery versus cesarean delivery. METHODS: Retrospective cohort analysis of patients diagnosed with retinal detachment (RD) who had later delivered in one tertiary medical center. Recurrence rates of RD were obtained from medical charts. RESULTS: A total of 967 women with RDs were evaluated, and 66 patients met the inclusion criteria. The mean age at the time of RD was 22.64 ± 5.81 SD years and 21.75 ± 5.47 SD years in the vaginal delivery group and the cesarean section group, respectively. None of the patients had a history of eye surgery or traumatic eye injury before the event of RD. In all patients, the detached retina was surgically reattached. Retinal detachment was not recorded in the fellow eye during follow-up. We report four cases of redetachment after birth in four women. In our study, there was a 5% rate (n = 2) of RD after a vaginal delivery as compared with a 7.5% (n = 2) redetachment rate for patients after a cesarean delivery ( P = 0.654). CONCLUSION: The risk of a redetachment of the retina in women is not increased after a vaginal delivery as compared with a cesarean delivery. Therefore, in our opinion, there is no ophthalmic benefit in a cesarean section for a woman with prior RD.

The outcomes of postoperative eye patching after cataract surgery in patients with Fuchs' endothelial corneal dystrophy.

PURPOSE: To investigate the influence of post-operative eye patching on corneal thickness, endothelial cells' loss and visual acuity in patients diagnosed Fuchs' endothelial corneal dystrophy (FECD). SETTING: Public healthcare centre, Shamir Medical Centre, Israel. METHODS: This randomized controlled trial included patients with FECD undergoing routine cataract surgery in a public medical centre. Patients were randomly assigned to 2 groups: the eye undergoing surgery was covered with a patch for 24 h in the first group (patched group), and a plastic shield was used in the second (non-patched group). Both groups received a unique dose of a local steroid and antibiotic post-operatively. The eyes were examined pre-operatively, and on days 1, 7 and 30 post-surgery . Examination included: best corrected visual acuity (BCVA), comeplete slit lamp examination, intra ocular pressure (IOP), anterior chamber depth (ACD), central corneal thickness (CCT) using the IOL Master 700 (Zeiss, Germany) and endothelial cell density (ECD) using Specular microscopy. Cumulative dissipated energy (CDE) and operation time were recorded for all cases. RESULTS: The study included 46 eyes of 46 patients diagnosed with FECD. Twenty-three eyes in the patched group, and 23 eyes in the non-patched group . Thirty days post-operatively the CCT in the patched group decreased by 60 ± 38 mµ (9%) compared to 92 ± 80 mµ (13.5%) in the non- patched group (p = 0.04). Seven days post-operatively the CCT in the patched group decreased by 31 ± 35 mµ (5%) compared to 58 ± 76 (8%) in the non-patched group, but this difference did not reach statistical significance (p = 0.081). There was no statistically significant difference in endothelial cells loss as well as BCVA at 1, 7 and 30 days post-operatively between the study groups. CONCLUSIONS: Avoiding eye patch post-operatively after cataract surgery in patients with FECD results in better corneal clarity recovery and reduced corneal edema one month post-operatively. Visual acuity and endothelial cell's loss were not influenced by patching.

Optic Neuritis After SARS-CoV-2 Vaccination.

BACKGROUND: To describe recent cases of optic neuritis in patients who received a vaccine for COVID-19. METHODS: Retrospective case series of patients diagnosed with optic neuritis after a recent COVID-19 vaccination with BNT162b2 (Pfizer-BioNTech), in one university-affiliated tertiary hospital, from January 2021 to June 2021. Data were obtained from medical charts. RESULTS: We describe 7 patients who developed optic neuritis after immunization with the BNT162b2 vaccine. CONCLUSIONS: A causal relationship cannot be deduced, and the importance of COVID-19 vaccination is not challenged. However, the authors encourage a prospective monitoring and reporting system for all patients receiving COVID-19 vaccines, to further assess the spectrum of adverse events in large databases.

Three-year follow-up of accelerated versus standard corneal cross-linking in paediatric Keratoconus.

PURPOSE: Standard corneal collagen cross-linking (S-CXL) is an effective treatment to arrest Keratoconus (KC) progression in children. Less is known on the long-term efficacy of accelerated CXL (A-CXL) in paediatric populations. METHODS: A historical cohort analysis of paediatric patients (≤18 years) with KC who underwent S-CXL and A-CXL at two tertiary referral centres in Israel between 2010-2017. Preoperative and 3-year postoperative evaluation included changes in visual acuity (best spectacle corrected [BSCVA]) and uncorrected [UCVA]), refractive errors, and keratometric data. RESULTS: Ninety-three eyes of 93 patients were analysed (A-CXL: n = 39; S-CXL: n = 54). Baseline characteristics were similar between groups. Both groups showed a significant improvement in visual acuity compared to baseline (S-CXL: 0.810-0.602 LogMAR UCVA; A-CXL: 0.890-0.306 LogMAR UCVA, p < 0.05 for both). Improvement in BSCVA and UCVA following A-CXL was non-inferior to S-CXL (< ± 0.2 LogMAR). Kmax decreased by a mean of 0.98 ± 5.56 dioptres following S-CXL (p = 0.02) and by 1.48 ± 8.4 dioptres following A-CXL (p = 0.015). Thinnest pachymetry decreased following both treatments (S-CXL: by 26.8 ± 40.7 µm, p = 0.001, A-CXL: by 10.2 ± 13.4 µm, p = 0.028), the difference between groups was within the non-inferiority margin (< ± 10 µm). CONCLUSIONS: Paediatric patients followed for three years after A-CXL showed improved visual function, reduced corneal astigmatism and Kmax, and decreased thinnest corneal thickness. A-CXL was non-inferior to S-CXL at three years in terms of best-corrected and uncorrected visual acuity, thinnest pachymetry, and astigmatism. For Kmax, non-inferiority could not be concluded.

Predictive accuracy of the ABCD progression display among patients with keratoconus: A historic cohort analysis.

OBJECTIVE: To evaluate the accuracy of the ABCD Progression Display and the ABCD grading system in a population of adult patients with keratoconus. METHODS: A retrospective cohort analysis of all adult patients with keratoconus followed at the Shamir Medical Center between 2012 and 2017. A recommendation by the cornea specialist to undergo corneal crosslinking (CXL) was used as a surrogate of ectasia progression. The ABCD grading was not available to the treating physician and was computed post-hoc. Sensitivity and specificity of the ABCD Progression Display was calculated, and multivariate regression was used to estimate the risk to undergo CXL when the ABCD Progression Display indicated progression. The ABCD grading was compared between patients who required CXL to those who did not. A single eye of each patient was included. Sensitivity and specificity of the ABCD Progression Display were 82% and 73%, respectively. A multivariable model adjusted for possible confounders, found that ABCD Progression was associated with a 7-fold risk of undergoing CXL compared to a patient in whom progression was not recorded in the ABCD Progression Display (OR = 7.55; 95% CI = 3.82-14.93, p < 0.001). RESULTS: 293 eyes of 293 patients were analysed. Mean age at presentation was 26.92 ± 6.12 years. In 68 eyes, progression of keratoconus was recorded and CXL was performed (CXL-group). CONCLUSION: The ABCD Progression Display demonstrated adequate sensitivity and specificity and high predictive capabilities of keratoconus progression. It can be effectively utilized as an initial screening test in adults with keratoconus.

Accuracy of Intraocular Lens Calculation Formulas for the Four-Flanged Fixation Technique in Eyes With No Capsular Support.

PURPOSE: To assess the refractive prediction error of four intraocular lens (IOL) calculation formulas in eyes that have undergone scleral fixation using the four-flanged technique. METHODS: This was a retrospective cohort analysis of patients who underwent scleral fixation using the four-flanged technique at the Shamir Medical Center between 2020 and 2021. Refractive prediction errors for four IOL prediction formulas (Barrett Universal II, Holladay 1, SRK/T, and Kane) were obtained by subtracting the predicted spherical equivalent from the postoperative spherical equivalent. Mean arithmetic refractive prediction error and mean absolute error were calculated and compared. RESULTS: Twenty-three eyes of 23 patients were included in the analysis. The Akreos AO60 IOL (Bausch & Lomb, Inc) was implanted in 9 eyes and the BunnyLens HP IOL (Hanita Lenses) in 14 eyes. Mean age was 72.84 ± 13.2 years. All formulas produced myopic mean arithmetic refractive prediction error. Mean arithmetic refractive error and mean absolute error were equal in absolute number. Mean arithmetic refractive prediction errors were -0.72 diopters (D) for Barrett Universal II, -0.61 D for Holladay 1, -0.77 D for SRK/T, and -0.94 D for Kane formulas. The refractive outcome differed significantly from the predicted refraction in all formulas. There were no statistically significant differences in prediction errors between the formulas. CONCLUSIONS: Refractive outcomes of the four-flanged fixation technique produced myopic results compared to the predicted refraction for all formulas tested. This suggests that the effective lens position is more anterior than in-the-bag IOL implantation. [J Refract Surg. 2022;36(10):668-673.].

Routine use of non-absorbable sutures in bi-medial rectus recession as a measure to reduce the incidence of consecutive exotropia.

OBJECTIVE: To evaluate the incidence of consecutive exotropia following bilateral medial rectus muscle recession surgery (BMR) for esotropia using non-absorbable compared with absorbable sutures in children undergoing strabismus surgery. METHODS: A retrospective cohort study of all children with esotropia who underwent BMR by a single surgeon in a tertiary public hospital. As of February 2018, only non-absorbable sutures were used. The primary outcome was the incidence of consecutive exotropia. RESULTS: A total of 121 children were included in the analysis, 3.66 ± 2.62 years, 53% were male. In 80 children (66%) non-absorbable sutures were used (non-absorbable group) and in 41 children (34%) absorbable sutures were used (absorbable group). Consecutive exotropia (≥ 8 prism dioptres) occurred in ten children (24%) in the absorbable group and in three children (4%) in the non-absorbable group (OR = 8.28, 95% CI = 2.13-32.13; P = 0.002). This difference between groups remained significant after adjustment for potential confounders and follow-up time (HR = 4.98, 95% CI = 1.30-19.05, P = 0.019). Mean follow-up time was 22 and 12 months in the absorbable and non-absorbable groups, respectively (P < 0.001). Two children in the non-absorbable group had pyogenic granuloma that resolved after 3 months of topical steroidal therapy. CONCLUSION: Routine use of non-absorbable sutures in BMR surgery for esotropia may be a preferable alternative to absorbable sutures for the prevention of consecutive exotropia.

Postoperative supine position after primary Descemet-stripping automated endothelial keratoplasty reduces graft detachment rate.

OBJECTIVE: To characterize the association between prolonged supine postoperative positioning of patients undergoing Descemet-stripping automated endothelial keratoplasty (DSAEK) and graft dislocation rate. METHODS: In this retrospective cohort study, medical records of patients who underwent uncomplicated DSAEK surgery at Yitzhak Shamir Medical Center between 2010 and 2019 were reviewed. Nursing documentation of patients' adherence to supine positioning during the postoperative hospitalization period was collected. A patient was considered compliant if he or she was documented as cooperative with supine positioning throughout the first 24 hours. RESULTS: A total of 170 eyes of 138 patients were found eligible. Main indications for surgery were pseudophakic bullous keratopathy (50.6%), previous graft failure (25.9%), and Fuch's endothelial dystrophy (FED; 20.6%). Twelve surgeries were combined with cataract extraction. Postoperative graft detachment occurred in 26 eyes (15.3%) after an average period of 1 day (range, 0-20 days). Compliance with supine positioning was documented in 84.1% (n = 143 patients). Noncompliance rates during the first 24 hours in the detached and nondetached groups were 26.9% (n = 7) and 14.4% (n = 20), respectively; after adjustment for possible confounders, the odds ratio (OR) was 1.44 (p = 0.249). Graft dislocation was observed in 13.3% (19 of 143) and 25.9% (7 of 27) of cooperative and noncooperative patients, respectively (p = 0.17). Subanalysis of 120 eyes with either BPK or FED for which it was the first transplantation demonstrated a protective effect of supine positioning (OR 3.42, confidence interval 1.095-10.700; p = 0.034). Findings for both groups remained unchanged in multivariate analysis. CONCLUSIONS: We found a statistically significant protective effect of 24 hours of postoperative supine positioning against graft detachment after DSAEK in eyes with no prior transplantations.

Seven years follow-up of corneal cross-linking (CXL) in pediatric patients: Evaluation of treated and untreated eye.

BACKGROUND: Retrospective cohort study evaluating long term keratoconus progression amongst cross-linking (CXL) treated pediatric patients in the treated and the fellow untreated eyes. METHODS: Data on 60 eyes of 30 patients, 18 years old or younger, who underwent CXL in at least one eye was collected and analyzed. Follow-up measurements taken from the treated and untreated eye up to 7 years after CXL treatment, were compared to baseline measurements. Parameters included uncorrected distance visual acuity (UCDVA), best-corrected spectacle visual acuity (BCSVA), manifest refraction, pachymetry, corneal tomography, and topography. RESULTS: Mean age of patients was 16 ± 2.1 years. For the treated eyes, during follow-up period mean UCDVA had improved (from 0.78 ± 0.22 at baseline to 0.58 ± 0.26 logMAR at 7 years; p = 0.13), as well as mean BCSVA (from 0.23 ± 0.107 at baseline to 0.172 ± 0.05 logMAR at 7 years; p = 0.37). The mean average keratometry showed a significant flattening (from 49.95 ± 4.04 to 47.94 ± 3.3 diopters (D); p < 0.001), However there was no change in the mean maximal keratometry. The mean minimal corneal thickness (MCT) showed a significant mild reduction of 26 µm (p = 0.006). Although statistically insignificant, the mean manifest cylinder was also reduced to 2D (p = 0.15). During the follow-up period, eight untreated eyes (26.6%) deteriorated and underwent CXL, while only one treated eye (3.33%) required an additional CXL. CONCLUSION: CXL is a safe and efficient procedure in halting keratoconus progression in the pediatric population, the fellow eye needs to be carefully monitored but only a 25% of the patients will require CXL in that eye during a period of 7 years.

Hyperbaric oxygen treatment for non-arteritic central retinal artery occlusion retrospective comparative analysis from two tertiary medical centres.

OBJECTIVES: To compare the visual outcome of patients treated for non-arthritic central retinal artery occlusion (CRAO) in a medical centre that uses hyperbaric oxygen therapy (HBOT) as part of the standard of care (SOC) to medical centres that does not. METHODS: The study included data from two tertiary medical centres. The medical records of all patients diagnosed with non-arthritic CRAO without a patent cilioretinal artery between January 2010 and December 2018 in two tertiary medical centres were reviewed. RESULTS: One hundred and twenty-one patients were treated by HBOT and 23 patients received only SOC. In the HBOT group, best-corrected visual acuity (BCVA) improved from 2.89 ± 0.98 logMAR at presentation to 2.15 ± 1.07 logMAR upon the end of HBOT (P < 0.001), while the SOC group had no significant improvement, from 3.04 ± 0.82 logMAR at presentation to 2.80 ± 1.50 logMAR (P = 0.24). With adjustment for age, gender, and the duration of symptoms, final BCVA in the HBOT group was significantly better compared to the control group (P = 0.023). Rates of patients achieving vision of 20/200 or better were similar between groups (17.4% vs. 19.8%, P = 0.523). CONCLUSION: Utilizing HBOT as part of the SOC for CRAO improves the final visual outcome. HBOT is safe and can be implemented, if available, as part of SOC in all tertiary medical centres.

The ABCD Keratoconus Grading System-A Useful Tool to Estimate Keratoconus Progression in the Pediatric Population.

PURPOSE: To evaluate the ABCD grading system in pediatric keratoconus. METHODS: A retrospective cohort analysis of all children with keratoconus followed up at the Shamir medical center between 2010 and 2017. A recommendation by the treating physician to undergo corneal crosslinking (CXL) was used as an estimate for clinically significant disease progression. The ABCD grading was not available to the treating physician and was computed post hoc. The ABCD grading was compared between patients who required CXL with those who did not. A single eye of each patient was included. RESULTS: Fifty eyes of 50 children were analyzed. The mean age at presentation was 15.56 ± 1.36 years. In 23 eyes, progression of keratoconus was recorded and CXL was performed (CXL-group). On presentation, the stable and CXL groups did not differ significantly in their clinical parameters. In the CXL-group, a statistically significant increase was seen in the ABCD staging (P < 0.001). In the stable group, the ABCD staging did not change significantly in parallel visits (P = 0.87). An increase of 1 point in the sum of the ABCD staging showed a 5-fold risk for undergoing CXL (odds ratio = 5.28; 95% CI, 1.82-15.34). There was no significant change in the Amsler-Krumeich classification in the CXL group. CONCLUSIONS: Among a cohort of pediatric patients with keratoconus, worsening in the ABCD grading was associated with disease progression, whereas no significant change was demonstrated in the Amsler-Krumeich classification The ABCD grading system is a useful tool for initial assessment of disease progression in the pediatric population, in which early recognition is of paramount importance.

Modification of intraocular lens insertion using 4-flanged fixation with a standard cartridge and a 2.4 mm corneal incision in eyes with no capsular support.

A modification of intraocular lens (IOL) implantation, using the 4-flanged IOL fixation technique, through a 2.4 mm corneal incision using a standard cartridge and injector, is presented. An IOL with 4 eyelets is used, through which a 6-0 polypropylene suture is threaded on one side and then loaded into a provided cartridge and inserted to the anterior chamber through a 2.4 mm corneal incision. Using the handshake technique, the suture ends are eventually threaded through the eyelets and secured outside the eye with the creation of 4 flanges. This technique was used in 6 eyes of 5 consecutive patients with the absence of capsular support. During all follow-up visits, the IOLs were well centered and stable, and the flanges were buried in the sclera and covered with the conjunctiva. No complications were recorded. This modification simplifies the technique and reduces the well-known complications of large corneal incisions.

Association of COVID-19 Vaccination and Facial Nerve Palsy: A Case-Control Study.

Importance: Peripheral facial nerve (Bell) palsy has been reported and widely suggested as a possible adverse effect of the BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine. Israel is currently the leading country in vaccination rates per capita, exclusively using the BNT162b2 vaccine, and all residents of Israel are obligatory members of a national digital health registry system. These factors enable early analysis of adverse events. Objective: To examine whether the BNT162b2 vaccine is associated with an increased risk of acute-onset peripheral facial nerve palsy. Design, Setting, and Participants: This case-control study was performed from January 1 to February 28, 2021, at the emergency department of a tertiary referral center in central Israel. Patients admitted for facial nerve palsy were matched by age, sex, and date of admission with control patients admitted for other reasons. Exposures: Recent vaccination with the BNT162b2 vaccine. Main Outcomes and Measures: Adjusted odds ratio for recent exposure to the BNT162b2 vaccine among patients with acute-onset peripheral facial nerve palsy. The proportion of patients with Bell palsy exposed to the BNT162b2 vaccine was compared between groups, and raw and adjusted odds ratios for exposure to the vaccine were calculated. A secondary comparison with the overall number of patients with facial nerve palsy in preceding years was performed. Results: Thirty-seven patients were admitted for facial nerve palsy during the study period, 22 (59.5%) of whom were male, and their mean (SD) age was 50.9 (20.2) years. Among recently vaccinated patients (21 [56.7%]), the mean (SD) time from vaccination to occurrence of palsy was 9.3 (4.2 [range, 3-14]) days from the first dose and 14.0 (12.6 [range, 1-23]) days from the second dose. Among 74 matched controls (2:1 ratio) with identical age, sex, and admittance date, a similar proportion were vaccinated recently (44 [59.5%]). The adjusted odds ratio for exposure was 0.84 (95% CI, 0.37-1.90; P = .67). Furthermore, analysis of the number of admissions for facial nerve palsy during the same period in preceding years (2015-2020) revealed a relatively stable trend (mean [SD], 26.8 [5.8]; median, 27.5 [range, 17-35]). Conclusions and Relevance: In this case-control analysis, no association was found between recent vaccination with the BNT162b2 vaccine and risk of facial nerve palsy.