Use of Cryopreserved Amniotic Membrane During Pterygium Excision: Health Economic Analysis.

Purpose: To determine the health economic opportunity cost or gain associated with performing pterygium excision surgery using the TissueTuck technique with cryopreserved amniotic membrane (AM) instead of conjunctival autograft (CAU). Methods: We performed a literature review to determine the average surgical duration of pterygium surgery using CAU with fibrin glue or sutures to calculate the average time saved with the TissueTuck technique. Such time savings was then used to determine the opportunity revenue gain per national average Medicare reimbursement if adjusted to the average surgical duration of cataract surgery. Results: The time savings achieved using the TissueTuck technique over CAU with fibrin glue is 8.9 min per procedure, which can be applied to additional MSICS or phacoemulsification procedures to generate an opportunity revenue gain of $1167 or $762 per 2022 National Average Medicare reimbursement, respectively. After subtracting the current list cost of AmnioGraft (ie, $645), the opportunity gain is $522 or $117 if the time saving is applied to the above procedures, respectively. Alternatively, the time savings achieved by using the TissueTuck technique over CAU with sutures is 23.4 min per procedure, which can be applied to additional MSICS or phacoemulsification procedures to generate an opportunity revenue gain of $3068 and $2004 per TissueTuck procedure or $2423 or $1359 when accounting for the list cost of AmnioGraft, respectively. Conclusion: The TissueTuck surgical technique using cryopreserved AM for pterygium takes less time, has lower recurrence rates, and provides an opportunity gain compared to pterygium excision with CAU.

Cryopreserved Amniotic Membrane Using the TissueTuck Technique: A Sutureless Approach for Pterygium Surgery.

PURPOSE: The purpose of this study was to evaluate the clinical outcomes of the TissueTuck technique in the management of pterygium. METHODS: This was a single-center, retrospective review of patients with primary or recurrent pterygium that underwent surgical excision followed by application of cryopreserved amniotic membrane (AM) using the TissueTuck technique. All patients underwent surgery between January 2012 and May 2019. Patient profile, surgical time, complications, and rates of pterygium recurrence were analyzed. RESULTS: A total of 582 eyes of 453 patients (328 female patients; 65.1 ± 13.9 years) were included for analysis and initially presented with primary (92%) pterygium. The average duration of pterygium excision surgery was 14.7 ± 5.2 minutes (median: 14, range: 4-39 minutes) with mitomycin C administration in 257 (45%) eyes. At the last follow-up of 30.2 ± 22.2 months (median: 24.5, range: 3-94 months), BCVA significantly improved from logMAR 0.23 at baseline to logMAR 0.19 ( P < 0.0001). Recurrence rate was 2.3% but only 0.7% (2/274) in those cases with primary, single-headed pterygium without mitomycin C treatment. Other postoperative complications in that cohort included granuloma (7.9%), scarring (3.8%), and diplopia in extreme lateral gaze (2.5%). The AM remained secured to the ocular surface throughout the postoperative period. CONCLUSIONS: The TissueTuck surgical technique with cryopreserved AM can be performed in minimal time and result in a low recurrence and complication rate after pterygium surgery.

Intense pulsed light improves signs and symptoms of dry eye disease due to meibomian gland dysfunction: A randomized controlled study.

PURPOSE: To compare the safety and efficacy of intense pulsed light (IPL) followed by meibomian gland expression (MGX), against monotherapy of MGX. METHODS: Patients with moderate to severe meibomian gland dysfunction (MGD) were 1:1 randomized to 4 sessions of intense pulse light + MGX at 2-week intervals, or 4 sessions of Sham + MGX at 2-week intervals. Both patients and examiners were blinded to the allocation. Outcome measures, evaluated at the baseline (BL) and at a follow-up (FU) conducted 4 weeks after the last IPL session, included fluorescein tear breakup time (TBUT) as the primary outcome measure, OSDI (Ocular Surface Disease Index) questionnaire, Eye Dryness Score (EDS, a visual analog scale (VAS)-based questionnaire), Meibomian gland score (MGS, a score of meibum expressibility and quality in 15 glands on the lower eyelid), daily use of artificial tears, and daily use of warm compresses. In addition, during each treatment session, the number of expressible glands was counted in both eyelids, the predominant quality of meibum was estimated in both eyelids, and the level of pain/discomfort due to MGX and IPL was recorded. RESULTS: TBUT increased from 3.8±0.2 (µ±standard error of mean (SEM)) to 4.5±0.3 seconds in the control arm, and from 4.0±0.2 to 6.0±0.3 in the study arm. The difference between arms was statistically significant (P < .01). Other signs/symptoms which improved in both arms but were greater in the study arm included MGS (P < .001), EDS (P < .01), the number of expressible glands in the lower eyelids (P < .0001) and upper eyelid (P < .0001), the predominant meibum quality in the lower eyelid (P < .0001) and upper eyelid (P < .0001), and the level of pain due to MGX (P < .0001). Outcome measures which improved in both arms with no significant differences between the two were OSDI (P = .9984), and the daily use of artificial tears (P = .8216). Meibography, daily use of warm compresses, and severity of skin rosacea did not show statistically significant changes in either arm. No serious adverse events were observed. There was a slight tendency for more adverse events in the control group (P = 0.06). CONCLUSIONS: The results of this study suggest that, in patients with moderate to severe symptoms, combination therapy of intense pulse light (IPL) and meibomian gland expression (MGX) could be a safe and useful approach for improving signs of dry eye disease (DED) due to meibomian gland dysfunction (MGD). Future studies are needed to elucidate if and how such improvements can be generalized to different severity levels of MGD.

Crystalline lens endocapsular fragmentation using an elastic loop filament.

PURPOSE: To describe a novel mechanical endocapsular fragmentation technique of the crystalline lens during cataract surgery using a loop elastic-thin filament. METHODS: An alternative method to mechanically fragment the crystalline lens utilizing a nitinol loop is described. This device achieves lens sectioning in multiple pieces, decreasing ultrasonic energy expenditure during cataract surgery. RESULTS: Endocapsular fragmentation of crystalline lens was achieved using a nitinol loop filament, without the use of ultrasound energy. CONCLUSION: This surgical technique demonstrates that a micro loop filament may be used as an alternative surgical approach for energy-free mechanical endocapsular nucleus disassembly and fragmentation.

Cyclorotation during femtosecond laser-assisted cataract surgery measured using iris registration.

PURPOSE: To assess ocular cyclorotation of eyes having femtosecond laser-assisted cataract surgery using iris registration. SETTING: Eye Institute of West Florida, Largo, Florida, USA. DESIGN: Retrospective cases series. METHODS: Charts of patients who had femtosecond laser-assisted cataract surgery with preoperative and intraoperative iris registration in 1 or 2 eyes between November 2015 and March 2016 were reviewed. Cyclorotation was assessed via iris-registration acquired preoperatively using the Cassini topographer (patient in upright position) and intraoperatively using the iris registration option of the Lensar laser system (patient in supine position) acquired immediately before the laser treatment. RESULTS: The study comprised 241 patients (337 eyes). The mean age of the 107 men and 134 women was 68.0 years ± 9.0 (SD) (range 37 to 90 years). The mean absolute value of cyclorotation was 5.81 ± 4.20 degrees (range 0 to 17 degrees), which was statistically significant when comparing the preoperative axis with the intraoperative axis deviation (P < .0001). Overall, incyclorotation (67.4%) was more common than excyclorotation (30.9%). In patients having bilateral femtosecond laser-assisted cataract surgery, bilateral incyclorotation (47.37%) was the most common occurrence. CONCLUSIONS: During femtosecond laser-assisted cataract surgery, clinically significant cyclotorsion that might influence astigmatism correction outcomes can occur in patients having cataract extraction. Iris registration was useful in accounting for cyclorotation during this procedure when corneal or intraocular lens-based forms of astigmatic corrections will be used.

Comparison of prediction error: labeled versus unlabeled intraocular lens manufacturing tolerance.

PURPOSE: To compare the prediction error between intraocular lenses (IOLs) available in 0.25 diopter (D) increments with a labeled manufacturing tolerance and IOLs available in 0.50 D increments without a labeled manufacturing tolerance. SETTING: Community-based multidisciplinary outpatient ophthalmic practices. DESIGN: Comparative case series. METHODS: Eyes with cataract had implantation of an IOL available in 0.25 D increments and labeled with a manufacturing tolerance of ± 0.11 D (labeled group) or an IOL available in 0.50 D increments without a labeled manufacturing tolerance (unlabeled group). Postoperatively, the prediction error was calculated and compared between groups. RESULTS: By the SRK/T formula, the mean error of prediction after optimization was -0.03 D ± 0.35 (SD) in the labeled group and -0.05 ± 0.46 D in the unlabeled group (P=.64). The mean absolute error of prediction was statistically significantly smaller in the labeled group (0.26 ± 0.23 D) than in the unlabeled group (0.37 ± 0.28 D) (P=.04). The mean and absolute errors were not statistically significantly different with the Holladay 1 or Hoffer Q formula. Sixty-three percent of patients in the labeled group and 43% in the unlabeled group (P=.03) were within ± 0.25 D of the prediction error; 84% and 69%, respectively, were within ± 0.50 D (P=.06). CONCLUSION: The IOLs available in 0.25 D increments with a labeled manufacturing tolerance of ± 0.11 D increased the percentage of patients within ± 0.25 D of the targeted refraction to a statistically significant and clinically meaningful level compared with unlabeled IOLs available in 0.50 D increments. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Use of a microvascular clip for iris fixation of an intraocular lens: a laboratory model.

Here we present a potential novel surgical technique consisting of fixation of a posterior-chamber intraocular lens to the iris that may be used in the treatment of aphakia or the management of intraocular lens complications when capsular support has been compromised. The technique was performed in a laboratory model using cadaveric human eyes. A commercially available neurovascular clip was used to securely fasten the intraocular lens to the iris with minimal trauma. The use of a metal clip has the advantage of avoiding potential risks of suture fixation such as suture breakage. Also, this technique is easier than suturing and may potentially serve as another tool in a cornea surgeon's armamentarium.

Secondary angle closure caused by air migrating behind the pupil in descemet stripping endothelial keratoplasty.

PURPOSE: To report secondary angle closure caused by air migrating behind the pupil in the context of intraocular pressure (IOP) elevation in the early postoperative period after Descemet stripping endothelial keratoplasty (DSEK). METHODS: A retrospective case series was conducted on 100 consecutive DSEK cases from 90 patients undergoing DSEK because of corneal disease from Fuchs corneal dystrophy, pseudophakic bullous keratopathy, aphakic bullous keratopathy, and iridocorneal endothelial syndrome. Preoperative and postoperative slit-lamp examinations and IOP measurements were ascertained for all 100 eyes. Main outcome measures included preoperative and postoperative IOP. RESULTS: Thirteen of 100 eyes developed an IOP rise of greater than 30 mm Hg on the first postoperative day. Six of these 13 patients developed angle closure from air migrating posterior to the iris and causing iridocorneal adhesions. One of these 13 patients developed pupillary block from air anterior to iris. Six of 13 patients developed increased IOP without pupillary block or iridocorneal adhesions and had a history of preexisting primary or secondary glaucoma. CONCLUSIONS: A secondary angle closure associated with DSEK is reported with air migrating behind the iris, resulting in extensive iridocorneal adhesions. An acute increase in IOP after DSEK can also be induced by air anterior to the iris causing pupillary block. IOP spikes are much more common in the first few postoperative days after DSEK. Medical treatment can occasionally resolve air posterior to the iris, but if iridocorneal adhesions are extensive and persistent, air removal and angle reformation may be necessary.

Presoaking donor corneas reduces graft detachment rates in descemet stripping endothelial keratoplasty.

PURPOSE: To present a novel method of reducing rates of graft detachment, the most common postoperative complication of Descemet stripping endothelial keratoplasty (DSEK). DESIGN: Retrospective, interventional case series. METHODS: Eighty-three consecutive patients undergoing DSEK for endothelial dystrophy were studied. DSEK was performed in 103 eyes by 2 surgeons (J.D.G. and W.J.S.) at one institution before (n = 83) and after (n = 20) presoaking donor grafts in balanced salt solution (BSS) Plus (Alcon, Fort Worth, Texas, USA). No significant change in the frequency of using other techniques was made during this time. Incidents of tissue detachment after surgery were recorded. RESULTS: Of 83 consecutive DSEK procedures carried out before presoaking the donor tissue in BSS Plus, detachment occurred in 25 (30%). After presoaking, the detachment rate was reduced significantly to 0 (0%) of 20 (P = .0019). CONCLUSIONS: Patients undergoing DSEK experienced a significant decrease in rates of graft detachment after adoption of this new technique. The results suggest that presoaking donor tissue in BSS Plus lowers the detachment rate of DSEK grafts.