The effect of blue-light filtering intraocular lenses on the development and progression of macular atrophy in eyes with nAMD.

PURPOSE: To assess the effect of blue-light filtering (BLF) intraocular lenses (IOLs) on the development and progression of macular atrophy (MA) in eyes with neovascular age-related macular degeneration (nAMD). DESIGN: Retrospective clinical cohort study. METHODS: nAMD patients with anti-vascular endothelial growth factor (VEGF) injections who underwent uneventful cataract surgery between 2007 and 2018 with follow-up until June 2023. Subsequent MA rates were compared between subjects who received a BLF IOL or a non-BLF IOL. All OCT scans were manually reviewed in a masked manner regarding patient baseline variables and IOL status by an experienced research technician. Using the Heidelberg software, the area of MA was manually evaluated and calculated (mm2) by the program. The overall risk of developing new-onset MA and the effect of IOL type on disease progression were assessed. Death was included as a censoring event. RESULTS: Included were 373 eyes of 373 patients (mean age 78.6±6.7 years at surgery, 67.4% females). 206 eyes were implanted with BLF IOLs and 167 with non-BLF IOLs with comparable follow-up times (3164±1420 days vs. 3180±1403 days, respectively, P=0.908), and other baseline parameters (age, gender, corrected distance visual acuity, macular thickness, cumulative number of anti-VEGF injections). Nine pre-existing and 77 new-onset MA cases were detected, with similar distribution between BLF and non-BLF eyes (P=0.598 and P=0.399, respectively). Both univariate Kaplan-Meier (P=0.366) and multivariate Cox regression analysis adjusted for age and gender showed that BLF-IOLs were comparable to non-BLF IOLs regarding hazard for new-onset MA (HR 1.236, 95% CI 0.784-1.949, P=0.363). Final MA area at the last visit was 5.14±4.71mm2 for BLF IOLs and 8.56±9.17mm2 for non-BLF IOLs (P=0.028), with the mean annual MA area increase of 0.78±0.84mm2 and 1.26±1.32mm2, respectively (P=0.042). CONCLUSIONS: BLF IOLs did not show added benefit over non-BLF IOLs in terms of MA-free survival but were associated with less progression over time in a cohort of nAMD patients.

Comparison of flanged polypropylene scleral intraocular lens fixation with scleral sutured fixation.

OBJECTIVE: To compare the outcome of 2 intraocular lens (IOL) scleral fixation techniques: double-flanged polypropylene and Hoffman scleral pocket. METHODS: Retrospective case series of all patients who underwent IOL scleral fixation by either the flange (flange group) or Hoffman scleral pocket (Hoffman group) techniques at the Kaplan Medical Center and the Edith Wolfson Medical Center. RESULTS: A total of 140 patients were included (63 flange, 77 Hoffman). The final distance-corrected visual acuity was similar between the flange and Hoffman groups (0.42 ± 0.5 and 0.51 ± 0.5 logMAR, respectively; p = 0.23), but the spherical equivalent was less myopic in the flange group (-0.63 ± 2 and -2.3 ± 1.3 D, respectively; p = 0.003). In the flange group, there were more cases of elevated IOP (17.5% vs 5.2%; p = 0.02), corneal edema (11.1% vs 1.3%; p = 0.02), cystoid macular edema (15.9% vs 2.6%; p = 0.005), and IOL decentration (19% vs 7.8%; p = 0.07). The flange group had a higher rate of combined additional procedures during the fixation surgery (68.3% vs 32%; p < 0.001), but surgery duration was not prolonged (70 vs 77 minutes; p = 0.29). CONCLUSION: Comparison of scleral IOL fixations performed with the recently developed flange technique to the conventional Hoffman scleral pocket technique resulted in similar visual outcomes and less myopization. There were more complications in the newly adopted flange technique, which may be related to the higher rate of combined anterior vitrectomy and pars plana vitrectomy. The flange technique is effective, with a shorter learning curve and similar surgical time. Therefore, it can become a viable method for scleral IOL fixation in the absence of zonular support.

Efficacy comparison of combining cross-linking and refractive laser ablation in progressive keratoconus: systematic review and meta-analysis.

OBJECTIVE: This study assessed the effect of combining corneal collagen cross-linking (CXL) with refractive laser ablation techniques for the treatment of keratoconus, a progressive corneal disorder. METHODS: We performed a systematic review and meta-analysis to assess the effect of combined CXL and refractive techniques. We included all published clinical trials or observational studies published by September 1, 2023. We calculated and compared the standardized mean difference (SMD) between CXL alone and CXL plus laser ablation for uncorrected distance visual acuity, best-corrected distance visual acuity, spherical equivalent manifest refraction, sphere and cylinder, flat keratometry (K1), steep keratometry (K2), and central corneal thickness. RESULTS: We identified 13 studies that fulfilled our inclusion and exclusion criteria. The average follow-up was 21.3 ± 11.8 months. The CXL plus laser ablation group showed improvement in uncorrected distance visual acuity logMAR (SMD, -0.35; 95% CI, -0.67 to -0.04; p = 0.029), best-corrected distance visual acuity logMAR (SMD, -0.17; 95% CI, -0.30 to -0.03; p = 0.014), spherical equivalent manifest refraction (SMD, -0.28; 95% CI, 0.06-0.50; p = 0.013), and change in maximal corneal curvature (Kmax; SMD, -0.41; 95% CI, -0.69 to -0.13; p = 0.004) compared with CXL alone. However, central corneal thickness decreased further among patients who underwent CXL plus laser ablation (SMD, -0.37; 95% CI, -0.66 to -0.07; p = 0.016). No effect was observed in terms of sphere (p = 0.878), cylinder (p = 0.859), K1 (p = 0.907), or K2 (p = 0.169). Ectasia was not observed as an adverse effect resulting from the additional corneal ablation performed during the CXL treatments. CONCLUSIONS: This study showed that combining refractive laser ablation techniques with standard or accelerated CXL treatment improved visual and refractive outcomes and anterior corneal curvature values.

Type 1 and type 2 diabetes predisposed to higher Nd:YAG capsulotomy rates following cataract surgery: analysis of 53,471 consecutive cases.

OBJECTIVE: To assess the effect of diabetes type on Nd:YAG capsulotomy rates following cataract surgery. DESIGN: A retrospective cohort study. METHODS: All patients who underwent cataract extraction at the Department of Ophthalmology, Bristol Eye Hospital, Bristol, UK, between 2003 and 2017 were included. The Nd:YAG capsulotomy rate following cataract surgery was assessed and compared between nondiabetic, type 1 diabetes (T1D), and type 2 diabetes (T2D) patients. Multivariate Cox regression analysis controlling for age and sex was used to estimate hazard ratios for Nd:YAG laser capsulotomies. RESULTS: Included were 53,471 consecutive cataract surgeries. Overall, 42,651 eyes (79.8%) were in nondiabetic patients, 823 eyes (1.5%) were in T1D patients, and 9,997 eyes (18.7%) were in T2D patients. The mean follow-up time was 6.8 ± 4.2 years. In univariate analysis, the eyes of T1D patients (p < 0.001) and T2D patients (p = 0.003) had significantly higher Nd:YAG laser capsulotomy rates than the eyes of nondiabetic patients. In Cox regression analysis adjusted for the patient's age and sex, DM1 (HR 1.692, 95%CI 1.390-2.059, P<0.001) and DM2 (HR 1.157, 95%CI 1.075-1.244, P<0.001) remained significantly predictive for higher Nd:YAG laser capsulotomy rates. CONCLUSION: In our large cohort study, patients with T1D and T2D were predisposed to high risk for Nd:YAG capsulotomy following cataract surgery. This study may be beneficial and raise awareness regarding the assessment of posterior capsular opacification development in pseudophakic diabetic patients, particularly those with T1D. The significance of ophthalmology screening for diabetes individuals is further supported by this issue.

Correlation of Refractive Error with Anisometropia Development in Early Childhood.

PURPOSE: This study aims to investigate the relationship between the type and severity of refractive error and anisometropia development in preschool children. DESIGN: Retrospective cohort study. METHODS: Data from Maccabi Healthcare Services, Israel's second-largest Health Maintenance Organization (HMO), were analyzed. The study included all isometropic children aged 1 to 6 years, re-examined for refraction at least 2 years following their initial examination between 2012 and 2022. Anisometropia was defined as a ≥1 diopter interocular difference in spherical equivalent. Relationships were assessed using logistic regression models adjusted for key sociodemographic factors. RESULTS: Among 33,496 isometropic children (51.2% male, mean age 3.2 ± 1.5 years), the prevalences of emmetropia, myopia, and hyperopia were 26.7% (n = 8944), 4.2% (n = 1397), and 69.1% (n = 23,155), respectively. Over a mean follow-up period of 5.1 ± 2.4 years, 2593 children (7.7%) were diagnosed with anisometropia. Adjusted odds ratios (ORs) for anisometropia gradually increased with baseline refractive error severity, reaching 13.90 (5.32-36.34) in severe myopia and 4.19 (3.42-5.15) in severe hyperopia. This pattern was also evident in cylindrical anisometropia, where ORs increased with greater baseline astigmatism, peaking at 12.10 (9.19-15.92) in children with high astigmatism (≥3 D). Associations remained consistent in sensitivity and subgroup analyses including across both sexes and when using a stricter anisometropia criterion. CONCLUSIONS: Children aged 1 to 6 years, initially without anisometropia but showing increasing severity of myopia, hyperopia, or astigmatism, are more likely to develop anisometropia. This underscores the importance of follow-up refractive measurements within this population to promptly diagnose and treat anisometropia and prevent potential visual complications.

Femtosecond LASER-Assisted Double Intraocular Lens Exchange in Nanophthalmic Eyes.

Introduction: Though patients with nanophthalmos frequently endure decreased quality of vision with contact lenses or spectacles, refractive surgery is generally an inadequate alternative due to the associated high refractive error. A refractive lens exchange (RLE) is an alternative option but is technically challenging, requiring accuracy in biometry measurements and procedures. Case Presentation: This case discusses a 27-year-old female with nanophthalmos (axial lengths 17.6 mm and 17.4 mm, right and left eyes, respectively) who underwent a femtosecond laser-assisted (FLA) RLE with simultaneous implantation of a monofocal and a Sulcoflex trifocal (Rayner, Britain) lens in each eye. Preoperative cycloplegic refraction was +11.50/-0.75 × 145 and +12.00/-1.00 × 35 in the RE and LE, respectively. Best-corrected visual acuity (BCVA) at distance and near in the RE and LE was 6/7.5 and J1, 6/8.5 and J2, respectively. Uncorrected visual acuity (UCVA) was >6/120 and >J14 for each eye. FLA RLE was performed in the RE, then in the LE 2 weeks later. In each eye, a monofocal (44.0 D, RE, and LE) and a Sulcoflex trifocal lens (both implants, Rayner, Britain) were implanted in one procedure. Distance and near UCVA measured 6 weeks post-op RE and 1-month post-op LE at 6/8.5 and J1 in the RE, 6/10 and J1 in the LE. The RE and LE refraction and BCVA were +0.50/-1.00 × 115, 6/7.5, and plano/-1.00 × 55, 6/8.5, respectively. The post-op outcomes were uneventful. Conclusion: A single procedure concurrently implanting a monofocal and Sulcoflex trifocal intraocular lens in nanophthalmic eyes resulted in an excellent UCVA. This procedure can be considered esthetic and reconstructive as it significantly improves patient appearance and function.

Pain control and subconjunctival haemorrhage after intravitreal injection using cooled anaesthetic eyedrops and antiseptics: A prospective, double-blind, randomized controlled trial.

PURPOSE: To evaluate whether cooled anaesthetic eyedrops and antiseptics alleviate pain and minimise subconjunctival haemorrhage following intravitreal injection. METHODS: A prospective, double-masked, randomised controlled trial of 100 participants receiving either cooled (n = 50) or room temperature (n = 50) topical anaesthetic eyedrops and antiseptics before receiving an injection of bevacizumab. Baseline tolerability was estimated using a self-reported pain sensitivity questionnaire. RESULTS: Overall tolerability was comparable between the study group and the control group (0.75 ± 0.13 vs. 0.74 ± 0.14, respectively, p = 0.99). Subconjunctival haemorrhage incidence was similar in both groups (80% vs. 86%, respectively, p = 0.113), as was subconjunctival haemorrhage size (2.75 ± 5.51 mm2 vs. 5.53 ± 10.72 mm2 , respectively, p = 0.11). Sub-group analysis demonstrated that the participants taking daily ocular eyedrops who received cooled anaesthetic eyedrops and antiseptics reported less pain at 10 min and less burning sensation at 24 h compared with matched controls (0.67 ± 1.50 vs. 2.50 ± 3.03, respectively, p = 0.040 and 0.00 ± 0.00 vs. 1.44 ± 2.96, respectively, p = 0.045). Participants who received cooled eyedrops and did not use antithrombotic therapy had smaller-sized subconjunctival haemorrhages compared with matched controls (1.55 ± 1.87 mm2 vs. 8.29 ± 14.61 mm2 , respectively, p = 0.038). Participants with hypertension who received cooled eyedrops had smaller-sized subconjunctival haemorrhage compared with matched controls (2.33 ± 4.99 mm2 vs. 6.89 ± 12.41 mm2 , respectively, p = 0.045). CONCLUSION: The benefit of using cooled anaesthetic eyedrops and antiseptics to alleviate pain and minimise subconjunctival haemorrhage following intravitreal injection was not proven in the general population. It may be beneficial in part for some patients, such as those who regularly use eyedrops, patients with hypertension or those not on antithrombotic therapy.

Accelerated high fluence photoactivated chromophore for infectious keratitis-corneal cross-linking (PACK-CXL) at the slit lamp: a pilot study.

Introduction: Photoactivated Chromophore for Infectious Keratitis-Corneal Cross-Linking (PACK-CXL) has garnered substantial interest among researchers and ophthalmologists due to its high promise as a potential treatment for infectious keratitis. The aim of this study is to evaluate the efficacy and safety of high fluence PACK-CXL, using 10.0 J/cm2 (30 mW/cm2, 5 min, and 33 s) at the slit lamp. Methods: This prospective interventional, nonrandomized cohort study included 20 eyes of 20 patients with bacterial, fungal, or mixed origin keratitis who underwent high fluence PACK-CXL treatment as an adjunct therapy to conventional antimicrobial therapy per American Academy of Ophthalmology treatment guidelines. The re-epithelization time was recorded, and corneal endothelial cell density was counted before and after treatment. Results: The average re-epithelization time was 8.2 ± 2.8 days (range 3-14 days). After PACK-CXL treatment, eight patients (40%) were directly discharged, while the remained patients stayed in the hospital for an average of 5.6 ± 3.5 days. No eyes required keratoplasty. Endothelial cell density counts before and after the PACK-CXL procedure were 2,562.1 ± 397.3, and 2,564.8 ± 404.5 cells/mm2, respectively (p = 0.96). Conclusion: although it was not a randomized control trial, we conclude that high fluence PACK-CXL as an adjuvant therapy is safe with no complications observed, and efficient as time to re-epithelization was less than 14 days for all patients and no patients underwent tectonic keratoplasties. Further research is needed to compare it to the current standard of care.

Risk factors for a phacodonesis surprise during cataract surgery in patients with pseudoexfoliation.

PURPOSE: To evaluate the association of different pre-operative parameters with surprise phacodonesis during cataract surgery among patients with pseudoexfoliation (PXF). MATERIALS AND METHODS: This is a retrospective charts review of all PXF patients who underwent cataract surgery between the years 2013 and 2018. Pre-operative parameters (demographics, biometry, intraocular pressure (IOP), endothelial cell count, pupil size, cataract density, glaucoma status, cup to disc ratio, number of glaucoma medications, prior intra-vitreous injections, risk for intraoperative floppy iris syndrome) were compared between patients with and without surprise phacodonesis. Binary logistic regression was used to calculate the predictive value of each parameter. RESULTS: Out of 396 surgical cases with computerized pre-operative assessment, we included 127 eyes of 120 PXF patients without evidence of phacodonesis preoperatively. The mean age was 77.8 ± 12.0 years, 63 (52.7%) were male, and 106 (84.2%) underwent phacoemulsification surgery. We identified 10 cases of surprise phacodonesis during surgery (8.2%). Compared to PXF cases without intraoperative phacodonesis, they had higher pre-operative IOP (23.0 ± 11.0 mmHg vs. 14.9 ± 3.8 mmHg, p < 0.001) and a higher rate of B scan use due to dense cataract obscuring posterior pole evaluation [4 (40%) vs. 15 (12.8%), p = 0.04]. Multivariant binary logistic regression confirmed that only baseline IOP contributed to the prediction of surprise phacodonesis (OR 1.22 CI 1.04-1.43, p = 0.014). CONCLUSIONS: Among patients with PXF undergoing cataract surgery, elevated IOP and poor posterior segment visibility requiring B scan use were associated with zonular instability putting these patients at risk for intra-operative complications.

Dry Eye Disease following LASIK, PRK, and LASEK: An Observational Cross-Sectional Study.

Dry eye disease is the most frequent non-refractive postoperative complication following refractive surgery. This prospective study investigated the development of dry eye disease after three common refractive laser surgeries: laser in situ keratomileusis (LASIK), photorefractive keratectomy (PRK), and laser-assisted sub-epithelial keratectomy (LASEK). Patients who underwent uneventful refractive surgery in a single private medical center between May 2017 and September 2020 were included. Ocular surface disease was graded according to the Dry Eye Workshop severity (DEWS) classification. Patients were examined 6 months following refractive surgery. The analysis included 251 eyes of 137 patients: 64 eyes (36 patients) after LASEK, 90 eyes (48 patients) after PRK, and 97 eyes (53 patients) after LASIK. At 6 months post-surgery, the DEWS score was higher for the LASIK than the PRK and LASEK groups (p = 0.01). For the total cohort, severe DEWS score (grades 3 and 4) at 6 months post-surgery was correlated with female gender (p = 0.01) and to the amount of refractive correction (p < 0.001), but not to age (p = 0.87). In conclusion, LASIK surgery and female gender were associated with dry eye. Patients, particularly those with high myopia, should be counseled about the risk of developing dry eye after refractive surgeries.

The Effect of Blue-Light Filtering Intraocular Lenses on the Development and Progression of Glaucoma.

PRCIS: Among patients who underwent uneventful cataract surgery, an advantage was seen to blue-light filtering (BLF) intraocular lenses (IOLs) in terms of glaucoma-free survival and glaucoma procedure-free survival. Among patients with preexisting glaucoma, no advantage was seen. PURPOSE: To assess the effect of BLF IOLs on the development and progression of glaucoma after cataract surgery. PATIENTS AND METHODS: A retrospective cohort study of patients who underwent uneventful cataract surgery between 2007 and 2018 at Kymenlaakso Central Hospital, Finland. Survival analyses for the overall risk of developing glaucoma or undergoing glaucoma procedures were assessed between patients who received a BLF IOL (SN60WF) and a non-BLF IOL (ZA9003 and ZCB00). A separate analysis was performed on patients with preexisting glaucoma. RESULTS: Included 11,028 eyes of 11,028 patients with a mean age of 75 ± 9 years (62% females). The BLF IOL was used in 5188 eyes (47%) and the non-BLF IOL in 5840 eyes (53%). During the follow-up (mean: 55 ± 34 mo), 316 cases of glaucoma were diagnosed. Glaucoma-free survival rates showed an advantage to the BLF IOL ( P = 0.036). In a Cox regression analysis controlling for age and sex the use of a BLF IOL was again associated with a lower ratio of glaucoma development (hazard ratio:0.778; 95% CI: 0.621-0.975). Furthermore, glaucoma procedure-free survival analysis revealed an advantage to the BLF IOL (hazard ratio:0.616; 95% CI: 0.406-0.935). Among 662 cases, which already had glaucoma at the time of surgery, no significant differences were seen in any outcome. CONCLUSIONS: Among a large cohort of patients who underwent cataract surgery, the use of BLF IOLs was associated with favorable glaucoma outcomes compared with the use of non-BLF IOLs. Among patients with preexisting glaucoma, no significant advantage was seen.

Use of corneal cross-linking beyond keratoconus: a systemic literature review.

PURPOSE: The success of corneal collagen cross-linking in altering keratoconus' clinical course has driven a search for further uses of this procedure. This literature review aims to analyze the scientific evidence available for the benefit of cross-linking in the management of ophthalmic diseases other than progressive keratoconus or ectasia induced by corneal refractive procedures. METHODS: A systemic literature review. RESULTS: We reviewed 97 studies. We found that collagen cross-linking can limit the progression of several other corneal ectasias, thus reducing and limiting the need for keratoplasty. Collagen cross-linking also can reduce the refractive power of the cornea and can be considered for a moderate degree of bacterial keratitis or when the organism is unidentified, which is refractive to antibiotics alone. However, the comparative rarity of these procedures has limited the extent of evidence. In fungal, Acanthamoeba, and herpes virus keratitis, the evidence is inconclusive of the safety and efficacy of cross-linking. CONCLUSION: Current clinical data is limited, and laboratory data has not fully correlated with published clinical data.

[ROCK (RHO-KINASE INHIBITORS) FOR THE TREATMENT OF OPEN-ANGLE GLAUCOMA AND OCULAR HYPERTENSION].

INTRODUCTION: Netarsudil ophthalmic solution 0.02% is a new treatment for open-angle glaucoma and ocular hypertension, which was approved for treatment in the United States and in the European Commission. The drug is a rho- kinase inhibitor (ROCK) that lowers intraocular pressure by enhancing the outflow at the trabecular meshwork and decreasing both aqueous humor production and episcleral venous pressure. This literature review aims to present this new treatment, characterize its specific mechanism of action, and discuss its effect and adverse events profile. The efficacy and safety of the drug were studied in the ROCKET and MERCURY clinical trials, in which Netarsudil was compared to other common drugs, including Timolol (Beta-blocker), Latanoprost (Prostaglandin analog), and a combination drop containing Netarsudil and Latanoprost. These trials showed a reduction of 16%-21% in the intraocular pressure (IOP) when using Netarsudil. Moreover, it was found that when using a combination of Netarsudil and Latanoprost, 64.5% of these patients achieved ≥30% reduction in mean diurnal IOP versus 28.8% of patients treated only with Netarsudil and 37.2% of patients treated only with Latanoprost (P<0.0001). The most common adverse event reported was conjunctival hyperemia, which was more frequent in patients using Netarsudil. However, this did not significantly affect the drug tolerance.

Association of clear vs blue-light filtering intraocular lenses with mental and behavioral disorders and diseases of the nervous system among patients receiving bilateral cataract surgery.

PURPOSE: To analyze new-onset mental and behavioral disorders and nervous system diseases in patients with cataract implanted with either non-blue-light filtering (BLF) or BLF intraocular lenses (IOLs) in both eyes. SETTING: Department of Ophthalmology, Kymenlaakso Central Hospital, Kotka, Finland. DESIGN: A retrospective registry-based cohort study of patients operated between September 2007 and December 2018 who were followed until December 2021. We included 4986 patients who underwent bilateral cataract surgery. METHODS: Patients were implanted with either non-BLF IOLs (N = 2609) or BLF IOLs (N = 2377) in both eyes. Follow-up before the first-eye surgery and between the first-eye and the second-eye surgery was performed to acknowledge the preexisting disorders and diseases. After the second-eye surgery, the groups were analyzed for the new-onset mental and behavioral disorders and diseases of the nervous system subcategorized by the International Classification of Diseases codes. RESULTS: 1707 male and 3279 female patients, aged 73.2 ± 8.6 years at the first-eye surgery and 74.3 ± 8.8 years at the second-eye surgery, were identified. In univariate log-rank tests, the use of BLF IOLs showed no association in overall new-onset disorders or diseases over non-BLF IOLs, in any subtype diagnosis codes except for sleep disorders, which favored BLF IOLs ( P = .003). A multivariate analysis adjusted for age and sex identified no associations in any new-onset disorders or diseases. Multivariate analysis of sleep disorders showed a nonsignificant advantage for BLF-IOLs (hazard ratio 0.756, 95% CI 0.534-1.070, P = .114). CONCLUSIONS: BLF IOLs were not associated with mental and behavioral disorders or diseases of the nervous system.

The Antibacterial Efficacy of High-Fluence PACK Cross-Linking Can Be Accelerated.

Purpose: To determine whether high-fluence photoactivated chromophore for keratitis cross-linking (PACK-CXL) can be accelerated. Methods: Solutions of Staphylococcus aureus and Pseudomonas aeruginosa with 0.1% riboflavin were prepared and exposed to 365 nm ultraviolet (UV)-A irradiation of intensities and fluences from 9 to 30 mW/cm2 and from 5.4 to 15.0 J/cm2, respectively, representing nine different accelerated PACK-CXL protocols. Irradiated solutions and unirradiated controls were diluted, plated, and inoculated on agar plates so that the bacterial killing ratios (BKR) could be calculated. Additionally, strains of Achromobacter xylosoxidans, Staphylococcus epidermidis, and Stenotrophomonas maltophilia were exposed to a single accelerated PACK-CXL protocol (intensity: 30 mW/cm2, total fluence: 15.0 J/cm2). Results: With total fluences of 5.4, 10.0, and 15.0 J/cm2, the range of mean BKR for S. aureus was 45.78% to 50.91%, 84.13% to 88.16%, and 97.50% to 99.90%, respectively; the mean BKR for P. aeruginosa was 69.09% to 70.86%, 75.37% to 77.93%, and 82.27% to 91.44%, respectively. The mean BKR was 41.97% for A. xylosoxidans, 65.38% for S. epidermidis, and 78.04% for S. maltophilia for the accelerated PACK-CXL protocol (30 mW/cm2, 15 J/cm2). Conclusions: The BKR of high-fluence PACK-CXL protocols can be accelerated while maintaining a high, but species-dependent, BKR. The Bunsen to Roscoe law is respected in fluences up to 10 J/cm2 in S. aureus and P. aeruginosa, whereas fluences above 10 J/cm2 show strain dependence. Translational Relevance: The high-fluence PACK-CXL protocols can be accelerated in clinical practice while maintaining high levels of BKR.

Use of a three-dimensional head-mounted digital visualization platform in cataract surgery.

OBJECTIVE: To report preliminary experience using the BeyeonicsOne (Beyeonics Vision, Haifa, Israel) digital visualization platform and the utilization of its three-dimensional (3D) head-mounted display (HMD) in cataract surgery. METHODS: An interventional case series including patients who underwent cataract surgery using the 3D HMD platform at the Tel Aviv Medical Center. The system uses the HMD unit to display high-resolution real-time 3D surgical field images. Collected data included patient demographics, ocular comorbidities, risk factors for complex cataract surgery, cataract grading, preoperative and postoperative best-corrected visual acuity (BCVA), and intra- and postoperative complications. RESULTS: In total, 60 eyes of 60 subjects (mean age 73.1 ± 8.4 years) were included. Mean preoperative BCVA was 0.40 ± 0.30 logMAR (Snellen equivalent ~20/50) and improved to 0.10 ± 0.10 logMAR (Snellen equivalent ~20/25, p < 0.001). None of the patients suffered BCVA loss. All procedures and follow-ups were uneventful except for one case of a posterior capsular tear and one case of post-surgical cystoid macular edema. CONCLUSION: The visualization platform and its embedded 3D head-mounted display can be easily used in routine cataract surgery with the added benefits of improved ergonomics, high picture quality and enhanced image control.

Modified "Top-up sandwich" technique for the management of corneal perforations: A case report and a literature review.

Purpose: We describe a modified technique for managing a peripheral, non-infected, corneal perforation using a "Sandwich" technique that combines posterior lamellar keratoplasty, an amniotic membrane patch and a Gundersen conjunctival flap. Observations: A 75-year-old female patient presented with Sjogren's syndrome-related corneal perforation. A mini-Descemet stripping automated endothelial keratoplasty (DSAEK) graft (5 mm) was introduced into the anterior chamber and was mobilized to plug the perforation. Then, two amniotic membrane patches were stacked over the perforation and glued. Finally, the whole area was covered with a Gundersen conjunctival flap, mobilized from the inferior conjunctiva and secured in place using interrupted 10-0 nylon sutures. A step-by-step guide is also described. At three months, the final visual acuity was 6/9. A literature review revealed ten cases in which a posterior lamellar graft was effectively employed to treat corneal perforations. Conclusions and Importance: We described a modified approach for treating peripheral corneal perforation surgically. This "sandwich" approach is simple to replicate and can give quick healing with few visual repercussions. Our detailed guide may be utilized to obtain similar results and may be added to the array of treatment options for peripheral corneal perforation.

Clinical comparison of manual and laser-cut corneal tunnel for intrastromal air injection in femtosecond laser-assisted deep anterior lamellar keratoplasty (DALK).

PURPOSE: The most crucial step in deep anterior lamellar keratoplasty (DALK) is to achieve a bare Descemet's membrane. We aimed to assess a new femtosecond laser software that allows for a precise intrastromal tunnel creation for big bubble (BB) air injection using a real-time microscope-integrated optical coherence tomography. MATERIALS AND METHODS: A retrospective review of 61 eyes of 61 patients with keratoconus. Before introducing the new software update, DALK was performed using a partial-assisted femtosecond laser (partial-thickness circular cut followed by a lamellar cut) with manual intrastromal tunnel creation (partial FS-DALK group). After the software update, the femtosecond laser created the intrastromal tunnel (full FS-DALK group). RESULTS: In the full FS-DALK group, the BB's formation was significantly higher (64.3% vs. 36.4%, p = 0.04), and surgery time was shorter (21.8 ± 5.1 vs. 25.6 ± 6.8 min, p = 0.025) than in the partial FS-DALK. Penetrating keratoplasty conversion rate (7.1% vs. 15.1%, p = 0.432) was similar between the groups. Both groups showed statistically significant improvement in uncorrected and corrected distance visual acuity, central corneal thickness, surface asymmetry, and regularity indices. Endothelial cell density loss at 12 and 18 months was lower in the full compared with the partial FS-DALK group (12 months:10.0% vs. 16; 18 months: 10.7 vs. 16.5%, p < 0.001 for both comparisons). CONCLUSIONS: Creating the intrastromal guiding tunnel using FS laser for air injection resulted in a higher rate of BB formation, reduced long-term endothelial cell loss, and operating room time.

Changes in chorioretinal flow index after cataract surgery: an optical coherence tomography angiography study.

PURPOSE: Pseudophakic cystoid macular edema (CME) occurs in up to 2% of uneventful cataract surgeries. This study evaluates changes in macular blood flow succeeding uneventful phacoemulsification cataract extraction among otherwise visually healthy subjects. METHODS: This prospective study included 18 eyes of 18 patients undergoing routine phacoemulsification. Optical coherence tomography angiography (OCT-A) was performed using the Angio-Retina 6 × 6 mm protocol with the XR Avanti Angio-Vue system (Optovue Inc., Fremont, California) prior to the surgery and 4-8 weeks thereafter. Exclusion criteria included motion artifacts, segmentation errors and signal strength index (SSI) < 40. The main outcome measure was change in flow index (FI) measured in all 4 retinal segmentation layers within an area of 1 mm diameter around the foveal center. RESULTS: Following surgery, a significant increase in SSI (46.65 ± 8.62 versus 53.12 ± 8.07, p = 0.01), superficial plexus FI (0.98 ± 0.23 versus 1.16 ± 0.16, p = 0.02) and deep plexus FI (0.54 ± 0.46 versus 0.93 ± 0.39, p = 0.01) was found. No significant changes were noted in the outer retina or the choriocapillaris. CONCLUSION: The study demonstrates a significant increase in FI in the superficial and deep retinal plexus following uneventful cataract surgery, with the greatest changes occurring in the latter. These findings corroborate evidence from structural imaging and support the vascular etiology of pseudophakic CME.

ABCD progression display for keratoconus progression: a sensitivity-specificity study.

OBJECTIVE: To evaluate the sensitivity and specificity of the ABCD progression display for keratoconus progression. METHODS: Data was collected from patients that underwent at least two Pentacam assessments 6 months apart. Sensitivity and specificity were calculated for the ABCD progression display. Progression was defined by criterion 1: change in two ABCD parameters above 80% confidence interval (CI) or criterion 2: change in one ABCD parameter above 95%CI. Receiver operating characteristic analysis compared the area under the curve (AUC) of all ABCD parameter combinations. RESULTS: Thirty eyes were evaluated over a median time of 10.3 months. Progression by criterion 1 resulted in a sensitivity of 61.9% and specificity of 88.9%. Progression by criterion 2 resulted in higher sensitivity (80.9%) and specificity (100%). Pairwise comparisons of the ROC curves show that the AUC achieved by criterion 2 was significantly higher than criterion 1 (0.905 vs. 0.754, p = 0.0332). Evaluation of all ABCD combinations with a significant change of 80% or 95% CI did not show superiority over criterion 1 or 2 regarding progression detection. The D parameter had a very low AUC (0.5-0.556). CONCLUSIONS: The ABCD progression display can assess keratoconus progression with high sensitivity and specificity, thus assisting the patients' decision-making process. The D parameter did not contribute to the sensitivity or specificity of this classification.