Trends and Clinical Outcomes of Fungal Keratitis in Canada: A 20-year Retrospective Multicentre Study.

PURPOSE: An increase in fungal and particularly filamentous keratitis has been observed in many geographic areas, mostly in contact lens wearers. This study seeks to characterize long-term trends in fungal keratitis in a continental climate area to provide guidance for diagnosis and treatment. DESIGN: Retrospective multicentric case series. METHODS: Cases of microbiology-confirmed fungal keratitis from 2003 to 2022 presenting to tertiary care centers across Canada were included. Charts were reviewed for patient demographics, risk factors, visual acuity, and treatments undertaken. RESULTS: A total of 138 patients were identified: 75 had yeast keratitis while 63 had filamentous keratitis. Patients with yeast keratitis had more ocular surface disease (79% vs 28%) while patients with filamentous keratitis wore more refractive contact lenses (78% vs 19%). Candida species accounted for 96% of all yeast identified, while Aspergillus (32%) and Fusarium (26%) were the most common filamentous fungi species. The mean duration of treatment was 81 ± 96 days. Patients with yeast keratitis did not have significantly improved visual acuity with medical treatment (1.8 ± 1 LogMAR to 1.9 ± 1.5 LogMAR, P = .9980), in contrast to patients with filamentous keratitis (1.4 ± 1.2 LogMAR to 1.1 ± 1.3 LogMAR, P = .0093). CONCLUSIONS: Fungal keratitis is increasing in incidence, with contact lenses emerging as one of the leading risk factors. Significant differences in the risk factors and visual outcomes exist between yeast keratitis and filamentous keratitis which may guide diagnosis and treatment.

Validation of preloaded DMEK donor tissues: a laboratory-based study on endothelial cell viability and comparison of two F-mark inks.

OBJECTIVE: To investigate endothelial cell loss (ECL) associated with Descemet membrane endothelial keratoplasty (DMEK) donor tissues preloaded in the DMEK RAPID transport system after 1 and 5 days and to compare prestamping with 2 different F-mark inks. METHODS: DMEK donor tissues were stripped, marked with gentian violet dye applied as an F-mark, trephined, stained with trypan blue, and then preloaded into the DMEK RAPID transport system by an eye bank technician. Preloaded DMEK tissues were then unfolded and stained with calcein AM after 1 or 5 days of storage. Tissues were imaged, analyzed for total tissue ECL, and immunostained for corneal endothelium markers zonular occludens-1 and xCD166. Additionally, ECL and the intensity of an F-mark caused by 2 different inks were quantified. RESULTS: Preloaded DMEK tissues displayed an average ECL of 11.9% ± 4.5% (n = 8) at 1 day and 9.9% ± 4.2% (n = 9) at 5 days. No difference was found between the 2 groups. Zonular occludens-1 and activated leukocyte cell adhesion molecule (ALCAM; also know as CD166) staining showed that the corneal endothelial monolayer remained intact on preloaded tissues. On 5-day preloaded DMEK tissues, the average ECL and mean grayscale caused by the Keir Surgical ink F-mark and the Cardinal Health ink F-mark were 4.3% ± 0.8% and 158.5 ± 13.9% and 5.0% ± 1.1% and 142.9% ± 20.0%, respectively. No difference was found between the F-mark inks. CONCLUSION: Preloaded DMEK donor tissues resulted in an acceptable ECL range after 1 and 5 days of storage and were deemed suitable for transplantation. Both F-mark inks are acceptable for prestamping preloaded DMEK tissues prior to surgical transplantation with comparable ECL and intensities.

Comparison of long-term outcomes of simultaneous accelerated corneal crosslinking combined with intracorneal ring segment or topography-guided PRK.

PURPOSE: To compare long-term outcomes of simultaneous accelerated corneal crosslinking (CXL) with intrastromal corneal ring segments (CXL-ICRS) with simultaneous accelerated CXL with topography-guided photorefractive keratectomy (CXL-TG-PRK) in progressive keratoconus (KC). SETTING: Kensington Eye Institute and Bochner Eye Institute, Toronto, Canada. DESIGN: Prospective nonrandomized interventional study. METHODS: The change in visual and topographical outcomes of CXL-ICRS and CXL-TG-PRK 4 to 5 years postoperatively were compared using linear regression models adjusted for preoperative corrected distance visual acuity (CDVA) and maximum keratometry (Kmax). RESULTS: 57 eyes of 43 patients with progressive KC who underwent simultaneous accelerated (9 mW/cm 2 , 10 minutes) CXL-ICRS (n = 32) and CXL-TG-PRK (n = 25) were included. Mean follow-up duration was 51.28 (9.58) and 54.57 (5.81) months for the CXL-ICRS and CXL-TG-PRK groups, respectively. Initial mean Kmax was higher in the CXL-ICRS group compared with the CXL-TG-PRK group (60.68 ± 6.81 diopters [D] vs 57.15 ± 4.19 D, P = .02). At the last follow-up, change (improvement) in logMAR uncorrected distance visual acuity (UDVA) compared with that preoperatively was significant with CXL-ICRS (-0.31 ± 0.27, P < .001, which is equivalent to approximately 3 lines) and not significant with CXL-TG-PRK (-0.06 ± 0.42, P = .43). The logMAR CDVA improved significantly with CXL-ICRS (-0.22 ± 0.20, P < .001), but not with CXL-TG-PRK (-0.05 ± 0.22, P = .25). Adjusting for baseline Kmax and CDVA, the improvement in UDVA was significantly greater with CXL-ICRS than with CXL-TG-PRK (-0.27, 95% CI, 0.06-0.47, P = .01). Improvement in CDVA was not significantly different. CONCLUSIONS: In this cohort of progressive KC with long-term follow-up, UDVA showed more improvement with accelerated CXL-ICRS than with CXL-TG-PRK.

The Efficacy and Safety of Standard versus Soft Topical Steroids after Cataract Surgery: A Systematic Review and Meta-analysis.

TOPIC: Review of the efficacy and safety of standard versus soft topical steroid application after cataract surgery. CLINICAL RELEVANCE: The control of postoperative inflammation is the mainstay of treatment after cataract surgery. However, no consensus exists regarding the postoperative steroid of choice. Basing the choice of topical postoperative steroidal treatment on high-quality data regarding both risks and benefits of various drugs would be advantageous for both patients and clinicians. METHODS: A systematic search of the PubMed, Scopus, and Embase electronic databases for all peer-reviewed published randomized control trials that included clinical outcomes of topical steroidal treatment after uneventful cataract surgery was performed. Individual study data were extracted and evaluated in a weighted pooled analysis including grading of total anterior chamber (AC) inflammation, AC cells, AC flare, postoperative visual acuity (VA), intraocular pressure (IOP), and rate of adverse events (AEs). RESULTS: Overall, 508 studies were found, of which 7 were eligible for the systematic review and ultimately were included for analysis, reporting on 593 patients from 5 countries. Age of included patients, when available, ranged between 3.7 and 73.4 years. Follow-up data were available for analysis at 1, 7, and 28 days after surgery. Except for a significantly lower grade of AC flare in the standard steroid group at day 7 (standardized mean difference, 0.26; 95% confidence interval, 0.05-0.47; I2 = 0%), inflammatory activity measurements displayed insignificant differences at every other follow-up (days 1 and 28 after surgery). Pooled analysis of IOP at each follow-up demonstrated a higher IOP at the 7-day visit in the standard steroid group, whereas IOP at other time points was comparable among the groups. Qualitative analysis of ocular AEs showed similarities among the groups. DISCUSSION: The findings of this study suggest that for the average patient, both groups produce a comparable effect on both AC inflammation and postoperative IOP and VA. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Systemic antibiotic treatment for meibomian gland dysfunction-A systematic review and meta-analysis.

PURPOSE: To review the efficacy and safety of oral doxycycline antibiotics versus macrolides in the treatment of meibomian gland dysfunction (MGD). DESIGN: Systematic review and meta-analysis. METHODS: We performed a systematic search of electronic databases for all peer-reviewed published studies which included clinical outcomes of oral antibiotic MGD treatment. Individual study data were extracted and evaluated in a weighted pooled analysis, including total sign and symptom scores, meibomian gland secretion score, tear break-up time (TBUT), fluorescein staining score and rate of complications. RESULTS: Two thousand nine hundred and thirty-three studies were found, of which 54 were eligible for the systematic review, and six prospective studies were ultimately included for analysis, reporting on 563 cases from three countries. Age of affected patients ranged between 12 and 90 years. Overall, both treatment methods induced improvement in MGD signs and symptoms. In pooled analysis, macrolides were significantly superior in the total signs score (pooled standardized mean difference (SMD) -0.51, 95% confidence interval (CI): -0.99 to -0.03), meibomian gland secretion score (pooled SMD -0.25, 95%CI: [-0.48, -0.03]), TBUT (SMD -0.31, 95%CI: [-0.50, -0.13]) and fluorescein staining score (SMD -1.01, 95%CI: [-1.72, -0.29]). Moreover, while no severe complications were reported for both treatments, the macrolide group exhibited significantly less adverse events (pooled odds ratio 0.24 with a 95% CI of 0.16 to 0.34). CONCLUSIONS: Both macrolides and tetracyclines are effective treatments for MGD. In this study, macrolides exhibited better efficacy and safety profile compared to tetracyclines.

Clinical features and management of keratoconjunctivitis associated with inadequate tear drainage.

OBJECTIVE: To describe clinical features and management of toxic keratoconjunctivitis associated with punctal and (or) canaliculus stenosis (toxic soup syndrome). DESIGN: Retrospective observational case series. METHODS: Electronic medical record database search for the keywords "toxic soup syndrome" and retrospective chart review were performed. Thirty-five eyes of 25 patients were seen at a tertiary cornea clinic between January 2017 and December 2021. Sex, age, distance-corrected visual acuity, topical medications, symptoms, clinical signs, and outcomes after medical and surgical interventions were analyzed. The main outcome measured was improvement in ocular surface signs and symptoms after interventions. RESULTS: Overall, 35 eyes of 25 patients with a mean age of 66.8 ± 12.8 years, of which 72% were female, were included. The primary complaint was hyperemia and epiphora in all patients. Rosacea or meibomian gland disease were present in all patients, 7 (28%) had glaucoma, and 7 (28%) developed limbal stem cell deficiency. Twenty-two patients (88%) were using topical medications on presentation. All eyes had either punctal plugs, cauterized puncta, or punctal and (or) canaliculus stenosis. Management of all patients consisted of suspension of all preserved topical medications and institution of some type of anti-inflammatory therapy. Nineteen patients (76%) improved after improvement of lacrimal drainage. One patient with severe resistance in the canaliculus required ongoing preservative-free topical steroids. CONCLUSIONS: Chronic drug-induced or pooled inflammatory mediators causing toxic conjunctivitis may be aggravated by punctal and (or) canaliculus stenosis, leading to toxic soup syndrome. Clearance of punctal obstruction leads to improvement in most patients.

Monkeypox-Associated Disciform Keratitis.

PURPOSE: The purpose of this study was to describe a case of monkeypox (MPX)-associated disciform keratitis. METHODS: This is a case report. RESULTS: A 36-year-old male patient presented to the infectious diseases clinic with a 1-week history of disseminated pustular skin lesions, a 4-day history of constitutional symptoms, and redness in the left eye. Testing of blood, 2 skin lesions, and a conjunctival swab confirmed the presence of MPX virus by polymerase chain reaction. On ophthalmologic examination on the 17th day of illness, there was a corneal epithelial ridge that stained with fluorescein with disciform corneal edema and underlying keratic precipitates. The patient was treated with oral tecovirimat 600 mg twice a day for 14 days and topical prednisolone acetate 1% 4 times daily, starting 2 days later. On completion of oral treatment, his corneal findings had resolved except for a small subepithelial scar at which time topical steroids were tapered. CONCLUSIONS: MPX may cause disciform keratitis and scarring that closely resembles other ocular viral infections. Clinical trials are urgently needed to define the optimal management of human MPX infections and reduce vision loss.

Clinical Outcomes of Transscleral-Sutured Intraocular Lens Combined With Descemet Membrane Endothelial Keratoplasty.

PURPOSE: The aim of the study was to report clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK) combined with transscleral-sutured intraocular lens (IOL) compared with DMEK combined with phacoemulsification and posterior chamber IOL (Phaco-DMEK). METHODS: A retrospective chart review of all patients who underwent DMEK combined with transscleral-sutured intraocular lens fixation or combined with phacoemulsification for Fuchs endothelial corneal dystrophy from 2016 to 2021 at the Toronto Western Hospital or the Kensington Eye Institute (Toronto, ON, Canada) and had at least 18 months of follow-up was performed. Main outcomes were postoperative distance-corrected visual acuity, rebubbling rate, graft survival rate, and complications. RESULTS: Twenty-one cases of DMEK combined with transscleral-sutured IOL (DMEK-TSS-IOL) and 44 cases of Phaco-DMEK were evaluated. Twelve eyes (57.15%) had a foldable acrylic 3-piece IOL (AR40E) and 9 (42.85%) had a single-piece polymethylmethacrylate (PMMA) IOL (CZ70BD). LogMAR distance-corrected visual acuity improved significantly from 1.48 ± 0.62 (SD) to 0.86 ± 0.82 ( P = 0.01) 12 months after DMEK-TSS-IOL and from 0.41 ± 0.29 logMAR to 0.11 ± 0.11 logMAR ( P < 0.0001) after Phaco-DMEK. No statistically significant differences were observed in donor ( P = 0.97) or 1-year postoperative endothelial cell density ( P = 0.11) between the groups. Rebubbling was necessary in 33.33% of eyes in DMEK-TSS-IOL compared with 25% of Phaco-DMEK eyes ( P = 0.55). Graft survival rate was 76.19% in the DMEK-TSS-IOL group compared with 90.90% in the Phaco-DMEK group ( P = 0.13). CONCLUSIONS: Transscleral-sutured IOL combined with DMEK is an option for the management of endothelial diseases in aphakic eyes or those which require IOL exchange for the experienced surgeon. However, when compared with routine Phaco-DMEK, there are higher complication and lower survival rates at 18 months.

A randomized controlled trial comparing femtosecond-enabled deep anterior lamellar keratoplasty and standard deep anterior lamellar keratoplasty (FEDS Study).

OBJECTIVES: To compare outcomes of femtosecond-enabled deep anterior lamellar keratoplasty (FE-DALK) and standard deep anterior lamellar keratoplasty (S-DALK). METHODS: An open label, randomized controlled trial (Kensington Eye Institute, Toronto, ON, Canada) including 100 eyes of 97 participants with either keratoconus or corneal scarring, randomized to either FE-DALK (n = 48) or S-DALK (n = 49). PRIMARY OUTCOMES: postoperative astigmatism and surgically induced corneal astigmatism (SIA) - both at 15 months. SECONDARY OUTCOMES: 6-, 12- and 15-month postoperative uncorrected- and best spectacle-corrected visual acuity, steep and flat keratometry, manifest sphere and astigmatism, rate of conversion to penetrating keratoplasty (PK), big-bubble success, central corneal thickness, endothelial cell count and complications. RESULTS: In intention-to-treat analysis, mean postoperative astigmatism in the FE-DALK (n = 30) and S-DALK (n = 30) groups at 15 months was 7.8 ± 4.4 D and 6.3 ± 5.0 D, respectively (p = 0.282) with an adjusted mean difference of 1.3 D (95% CI -1.08, +3.65). Mean SIA (arithmetic) was 9.2 ± 7.8 and 8.8 ± 5.4 D, respectively (p = 0.838) with a mean difference of 0.4 D (95% CI -3.13, +3.85). In an analysis of successful DALK cases only, mean postoperative astigmatism in the FE-DALK (n = 24) and S-DALK (n = 20) groups at 15 months (after excluding 4 eyes with AEs) was 7.3 ± 4.4 and 6.2 ± 4.9 D, respectively (p = 0.531) with an adjusted mean difference of 0.9 D (95% CI -1.94, +3.71). Mean SIA (arithmetic) was 9.1 ± 7.8 and 7.9 ± 4.6 D, respectively (p = 0.547) with a mean difference of 1.2 D (95% CI -2.70,+5.02). Comparison of secondary outcomes showed only weak statistical evidence. CONCLUSIONS: In this randomized controlled trial, FE-DALK and S-DALK showed comparable functional and anatomical outcomes.

Economic appraisal of prosthetic replacement of ocular surface ecosystem in Canada.

OBJECTIVE: To perform an economic appraisal of the Prosthetic Replacement of Ocular Surface Ecosystem (PROSE; BostonSight, Needham Heights, Mass.) lens in patients with a distorted corneal surface or ocular surface disease in Canada. DESIGN: Retrospective observational cohort study with cost, cost-utility, and benefit-cost analyses. PARTICIPANTS: Patients who received PROSE from the only PROSE clinic in Canada from 2018 to 2020. METHODS: Visual acuity (VA) outcomes of the participants were assessed. Benefits were defined as VA improvements that were converted into utilities and then quality-adjusted life years. Economic values were derived via government statements, clinic financial statements, and published literature. RESULTS: Average best-corrected VA (BCVA) improvement was -0.42 ± 0.41 logMAR (p = 2.68 × 10-13) or Snellen 20/53 for the overall cohort, -0.51 ± 0.48 (p = 5.42 × 10-8) or Snellen 20/65 for distorted corneal surface patients, and -0.31 ± 0.30 (p = 1.30 × 10-7) or Snellen 20/41 for ocular surface disease patients. This corresponded to discounted quality-adjusted life year gains of 0.51, 0.65, and 0.42, respectively, over an estimated 5-year PROSE device lifespan. Average cost to fit a patient with PROSE was USD$5 469.85 (CAD$7 087.28), of which USD$4 971.38 (CAD$6 441.42) was clinic cost and USD$498.47 (CAD$645.87) was patient cost. Cost-utility was USD$10 256.47 (CAD$13 289.31) for the overall cohort, USD$8 439.79 (CAD$10 935.44) for distorted corneal surface patients, and US$13 069.90 (CAD$16 934.67) for ocular surface disease patients. The benefit-cost ratio was 34.4 for all, 43.8 for distorted corneal surface patients, and 28.3 for ocular surface disease patients. CONCLUSIONS: Our economic appraisal demonstrated that PROSE treatment provides a significant, cost-effective benefit to Canadian patients with distorted corneal surfaces and ocular surface diseases. This indicates that PROSE clinics are an efficient investment.

Phototherapeutic keratectomy versus epithelial debridement combined with anterior stromal puncture or diamond burr for recurrent corneal erosions.

OBJECTIVE: To compare outcomes of phototherapeutic keratectomy (PTK) versus epithelial debridement combined with anterior stromal puncture (ASP) or diamond burr for the treatment of recurrent corneal erosions (RCES) in a large tertiary centre. METHODS: Patients with a diagnosis of RCES secondary to trauma or epithelial basement membrane dystrophy who underwent a surgical procedure between 2009 and 2019 were included in the study. The following data were collected: demographics, ocular history, prior medical treatment, ocular surgeries, intervention, complete epithelialization at postoperative week 1, recurrences, and complications. Recurrence was defined as either an objective finding of a corneal epithelial defect or symptoms suggestive of recurrent epithelial erosion on history. Recurrence rate and time to epithelialization were compared between groups. RESULTS: A total of 97 eyes (73 patients) were included in the study. Mean patient age was 51 ± 16.1 years, and mean follow-up was 474 days. RCES was secondary to epithelial basement membrane dystrophy in 80% (n = 78 of 97), trauma (15%, n = 15 of 97), or idiopathic (4%, n = 4 of 97). Epithelial debridement with ASP was performed in 34 eyes (35%), diamond burr in 33 eyes (33%), and PTK in 30 eyes (31%). Compared with epithelial debridement with ASP (recurrence 29.4%), the recurrence rate was significantly lower for both the diamond burr (9.1%, p = 0.031) and PTK groups (10%, p = 0.048). The diamond burr and PTK groups also had a significantly higher rate of complete epithelialization at 1 week (p < 0.05). CONCLUSION: Compared with epithelial debridement with ASP, diamond burr and PTK have significantly lower rates of recurrence and time to epithelialization and may be considered first for surgical management of RCES.

Five-Year Safety and Efficacy of Femtosecond Laser-Assisted Descemet Membrane Endothelial Keratoplasty.

PURPOSE: The purpose of this study was to evaluate 5-year safety and efficacy outcomes of femtosecond-enabled Descemet membrane endothelial keratoplasty (F-DMEK) in patients with Fuchs' endothelial dystrophy (FED). METHODS: This was a retrospective study, including patients with FED and cataract who underwent either F-DMEK (16 eyes of 15 patients) or manual DMEK (M-DMEK) (42 eyes of 37 patients) combined with cataract extraction. Outcome measures included visual acuity, graft detachment, graft survival, and endothelial cell loss. RESULTS: The average follow-up in F-DMEK and M-DMEK was 57.1 ± 12.4 months and 58.5 ± 17.3 months, respectively ( P = 0.757). The rates of primary failure (0% vs. 9.5%, P = 0.567), secondary failure (0% for both), and graft rejection (0% vs. 7.1%, P = 0.533) did not differ significantly between the groups. Improvement in best spectacle-corrected visual acuity was similar in F-DMEK and M-DMEK (0.32 ± 0.27 logarithm of the minimum angle of resolution and 0.35 ± 0.44 logarithm of the minimum angle of resolution, respectively, P = 0.165) and persisted at 2, 3, 4, and 5 years and at the last follow-up. The rates of graft detachment and rebubbling were significantly lower with 6.25% in F-DMEK and 33.3% in M-DMEK ( P = 0.035). Cell-loss rates were lower in F-DMEK compared with M-DMEK throughout the follow-up, significantly so up to 2 years with a difference of 8.6% at 1 year ( P = 0.023), 11.8% at 2 years ( P = 0.021), 7.6% at 3 years ( P = 0.088), 5.8% at 4 years ( P = 0.256), 13.6% at 5 years ( P = 0.169), and 7.1% at the final follow-up ( P = 0.341). CONCLUSIONS: F-DMEK had an excellent safety and efficacy profile which was maintained over 5 years of follow-up. Lower endothelial cell-loss rates in F-DMEK compared with M-DMEK may help extend the duration of graft survival.

Comparative evaluation of four Descemet membrane endothelial keratoplasty graft preparation techniques.

OBJECTIVE: To compare subjective and objective outcomes of 4 different Descemet membrane endothelial keratoplasty (DMEK) peeling techniques performed by novice surgeons at different stages in their surgical career. DESIGN: An ex vivo prospective study. METHODS: In the first round, 2 DMEK peeling techniques were pitched against each other: the peripheral scoring and Sinskey dissection technique with the peripheral scoring and microhoe dissection and the peripheral blunt microhoe dissection against the scleral spurectomy and microhoe dissection. Three surgeons with different operative experience performed the peeling. Outcome measures included graft peeling time, surgeon's peeling difficulty grading (on a scale of 1-10, 1 being the easiest and 10 the hardest), number of radial and circumferential tears before and after trephination, and tissue loss. The 2 techniques that performed the best from the first round proceeded to the final round to identify the best overall technique. RESULTS: In total, 90 tissues (45 pairs) were peeled by 3 surgeons. Following the first-round results, the peripheral scoring and Sinskey dissection and peripheral blunt microhoe dissection proceeded to the final round. There were no significant differences between the groups in terms of peeling times, subjective feeling of difficulty, post-trephination tears, and peeling success rates (P > 0.05 for all). However, the peripheral scoring and Sinskey dissection technique had significantly fewer pretrephination radial tears (1.3 ± 1.3 vs 6.1 ± 5.2, P = 0.007) and circumferential tears (0.6 ± 0.9 vs 1.8 ± 2.1, P = 0.02). CONCLUSIONS: This study demonstrates that the learning curve can be overcome quickly with appropriate DMEK peeling techniques. The peripheral scoring and Sinskey dissection peeling technique allows efficient peeling with fewer related tears.

Cost-Effectiveness of Preoperative Topical Antibiotic Prophylaxis for Endophthalmitis Following Cataract Surgery.

PURPOSE: To determine the cost-effectiveness of preoperative topical antibiotic prophylaxis for the prevention of endophthalmitis following cataract surgery. DESIGN: Cost-effectiveness analysis using a decision-analytic microsimulation model. METHODS: Preoperative topical antibiotic prophylaxis vs no-prophylaxis costs and effects were projected over a life-time horizon for a simulated cohort of 500 000 adult patients (≥18 years old) requiring cataract surgery in theoretical surgical centers in the United States. Efficacy and cost (2021 US dollars) values were obtained from the literature and discounted at 3% per year. RESULTS: Based on inputted parameters, the mean incidence of endophthalmitis following cataract surgery for preoperative topical antibiotic prophylaxis vs no-prophylaxis was 0.034% (95% CI 0%-0.2%) and 0.042% (95% CI 0%-0.3%), respectively-an absolute risk reduction of 0.008%. The mean life-time costs for cataract surgery with prophylaxis and no-prophylaxis were $2486.67 (95% CI $2193.61-$2802.44) and $2409.03 (95% CI $2129.94-$2706.69), respectively. The quality-adjusted life-years (QALYs) associated with prophylaxis and no-prophylaxis were 10.33495 (95% CI 7.81629-12.38158) and 10.33498 (95% CI 7.81284-12.38316), respectively. Assuming a cost-effectiveness criterion of ≤$50 000 per QALY gained, the threshold analyses indicated that prophylaxis would be cost-effective if the incidence of endophthalmitis after cataract surgery was greater than 5.5% or if the price of the preoperative topical antibiotic prophylaxis was less than $0.75. CONCLUSIONS: General use of preoperative topical antibiotic prophylaxis is not cost-effective compared with no-prophylaxis for the prevention of endophthalmitis following cataract surgery. Preoperative topical antibiotic prophylaxis, however, would be cost-effective at a higher incidence of endophthalmitis and/or a substantially lower price for prophylaxis.

Investigating the role of inflammation in keratoconus: A retrospective analysis of 551 eyes.

PURPOSE: Keratoconus (KCN), classically defined as a noninflammatory corneal ectasia, was recently associated with chronic inflammation. This study aimed to further evaluate the association between inflammation and KCN severity by assessing patient tear films. METHODS: Retrospective chart review of consecutive patients (July 2016-February 2020) referred to a tertiary KCN centre. Using tomography Kmax values, the worst-eyes of patients with a diagnosis of KCN and tear film test results were included. Eyes were stratified as matrix metalloproteinase-9 (MMP9) positive or negative and analyzed using independent t and Pearson chi-squared tests. A p-value ≤ 0.05 was considered significant. RESULTS: 551 (51.40%) unilateral eyes were included. Mean age was 30.1 years and 70.1% were male. 55.5% of the eyes were MMP9 positive. Mean corrected distance visual acuity was 20/30<συπ>-3 Snellen and Kmax was 60.1 Diopters. MMP9 positive eyes had a higher Kmax (p = 0.048), and were more likely from patients who were male (p < 0.001), had a paediatric history of asthma (p = 0.042), and used glasses (p = 0.041). MMP9 negative eyes more likely corresponded to soft contact lens users (p = 0.012). No other significant differences were found in risk factors, topography, tomography, and tear film osmolarity. CONCLUSION: MMP9 positive keratoconic eyes had significantly higher Kmax readings which may correlate with increased disease severity, supporting an association between keratoconus and inflammation. Further research is warranted to evaluate the role of targeted therapy and contact lens use on MMP9 levels in keratoconic eyes and whether disease progression is affected.

Outcomes of keratolimbal allograft from ABO compatible donors for severe bilateral limbal stem cell deficiency.

PURPOSE: To report outcomes of keratolimbal allograft (KLAL) compatible for both human leukocyte (HLA) and/or blood type using oral prednisone, mycophenolate, and tacrolimus, with basiliximab if panel reactive antibodies (PRA) are present. Intravenous immunoglobulin (IVIG) was used post-operatively if donor-specific anti-HLA antibodies (DSA) were present. METHODS: Retrospective interventional series of consecutive patients with KLAL for limbal stem cell deficiency (LSCD) from HLA and/or blood type compatible deceased donors with a minimum follow-up time of 12 months. Main outcome measures were ocular surface stability, visual acuity and systemic immunosuppression (SI) adverse events. RESULTS: Eight eyes of eight patients with mean age of 48.6 ± 10.1 years (range 34-65 years) were included. Mean follow-up time was 37.3 ± 22.7 months (range 12-71 months) following KLAL; four (50%) had combined LR-CLAL surgery. The etiologies of LSCD were Stevens-Johnson Syndrome (n = 4/8), aniridia (n = 2/8), chemical injury (n = 1/8) and atopic eye disease (n = 1/8). All patients had PRA present and received basiliximab infusions. 5/8 patients received IVIG based on DSA identified pre-operatively. At last follow-up, 7 eyes (87.5%) had a stable ocular surface; 1 eye (12.5%) developed failure and had keratoprosthesis implantation. There was a significant improvement in visual acuity from 1.65 ± 0.48 to 0.68 ± 0.34 logMAR (p = 0.01). SI was tolerated well with minimal adverse events. CONCLUSIONS: Preliminary outcomes of KLAL with ABO compatible tissue using the Cincinnati protocol, preoperative basiliximab (when PRA present) and post-operative IVIG (when DSA present) are encouraging. This protocol may allow for utilization of deceased donor tissue with results approximating those of living donor tissue transplanted for severe bilateral LSCD.

Long-Term Stability of Femtosecond Astigmatic Keratotomy After Treatment of High Postkeratoplasty Astigmatism.

PURPOSE: The purpose of this study was to assess long-term stability and outcomes of femtosecond astigmatic keratotomy (FSAK) after treatment of high postkeratoplasty astigmatism. METHODS: This retrospective study included patients who underwent FSAK for high astigmatism (≥4 D) after penetrating keratoplasty or deep anterior lamellar keratoplasty. Main outcome measures were corneal astigmatism, uncorrected visual acuity, and best-corrected visual acuity (BCVA) at 1 month and 1, 5, and 10 years. RESULTS: Overall, 61 eyes of 61 patients (mean age 56 ± 19 years, 54.1% male) were included in this study. Preoperative corneal astigmatism ranged from 4 to 25 D. One month after FSAK, mean corneal astigmatism was significantly reduced from 9.02 ± 3.97 D to 4.86 ± 3.10 D ( P < 0.001). Thereafter, corneal astigmatism remained stable at all visits up to 10 years ( P < 0.05 for all compared with baseline). After FSAK, there was a significant improvement in logMAR uncorrected visual acuity from 1.21 ± 0.48 to 0.87 ±0.54 ( P < 0.001) and logMAR BCVA from 1.03 ± 0.55 to 0.49 ± 0.45 ( P < 0.001) which remained stable up to 10 years. A mild reduction in BCVA improvement was seen between 1 month and 1 year. CONCLUSIONS: Femtosecond astigmatic keratotomy was effective and stable at reducing very high magnitudes of postkeratoplasty astigmatism over the long term. The procedure also had a stable effect on visual acuity, albeit some reduction in the degree of BCVA improvement was seen over the early postoperative period.

KAMRA presbyopic inlay refractive outcomes: a Canadian perspective.

OBJECTIVE: To retrospectively analyze the visual outcomes of KAMRA (AcuFocus Inc, Irvine, Calif.) inlay insertion in a cohort of patients reporting success of procedure, complications, patient satisfaction, and refractive outcomes. DESIGN: Retrospective trial at the TLC Laser Centre, Toronto. METHODS: A total of 5 surgeons at the practice inserted 35 KAMRA inlays in 35 patients between October 2012 and June 2014. Some patients had a sole KAMRA inlay insertion, whereas others had combined laser vision correction (LVC) and KAMRA inlay on either the same day or sequentially. There was a small cohort of patients who had previous unrelated LVC. Mean time of follow-up was 299 days. RESULTS: After KAMRA inlay insertion there was a significant improvement in uncorrected near visual acuity (p = 0.00009), uncorrected intermediate visual acuity (p = 0.00006), and uncorrected distance visual acuity (p = 0.02), but levels of patient dissatisfaction were 43%. The most common cause for dissatisfaction was requirements for readers (23%), followed by dysphotopsias (11%). The explantation rate was 11.42%, and 28.5% of patients required enhancements after inlay insertion. CONCLUSIONS: The KAMRA corneal inlay has significant improvements in uncorrected near visual acuity, uncorrected intermediate visual acuity, and uncorrected distance visual acuity when used in isolation or combined with LVC. Appropriate patient selection is crucial. This procedure should not be used as first-line presbyopia management because of low levels of patient satisfaction, biocompatibility concerns, and explantation rates.

Prosthetic Replacement of the Ocular Surface Ecosystem for Limbal Stem Cell Deficiency: A Case Series.

OBJECTIVES: To assess outcomes of limbal stem cell deficiency (LSCD) in patients treated with Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE). METHODS: Retrospective case series. Patients with LSCD who received PROSE treatment were included. Data including best-corrected visual acuity (BCVA) and LSCD staging before and after PROSE dispensing were collected to characterize each case. RESULTS: Five eyes of four patients were included. All patients were female, with an age range of 21 to 80 years. Each patient received a PROSE device with diameters ranging from 16 to 18.5 mm. Follow-up ranged from 11 to 29 months. Tolerated wear times ranged from 3.5 to 10 hr daily. Four eyes showed improved BCVA and unchanged LSCD staging as per the global consensus after PROSE treatment. Three of these eyes had stage 3 and one had stage 1C LSCD at diagnosis. The fifth eye had worse BCVA and recurrence of stage 3 LSCD post-living-related conjunctival limbal allograft transplant despite PROSE treatment. CONCLUSIONS: Prosthetic Replacement of the Ocular Surface Ecosystem may be a viable treatment for LSCD, including severe cases, because it can provide symptom relief and improve vision. Its customizability, as demonstrated in this study, is beneficial for troubleshooting issues with fitting. Future studies are needed to further assess PROSE as treatment for LSCD.