Clinical Performance and Surgeon Acceptability of a New Dual Mode Phacoemulsification System.

Purpose: The purpose of this first in-human study was to evaluate the overall clinical performance of the VERITAS™ Vision System in patients scheduled to undergo cataract extraction and to confirm overall surgeon acceptability. Patients and methods: This prospective, open-label multinational study included adults with cataracts scheduled for planned cataract extraction and posterior chamber IOL implantation. Standard small-incision phacoemulsification cataract surgery with the VERITAS Vision System was conducted. Surgeons completed a questionnaire regarding their clinical experience with the VERITAS Vision System for each patient following surgery and 1-day postoperative. Corneal clarity and adverse events (AEs) were assessed. Surgeon acceptability was scored on a 5-point scale, with acceptability considered favorable for scores of 4 and 5. Results: A total of 115 eyes (79 patients) were treated. The El Salvador site treated 41 patients (58 eyes), and the US site treated 38 patients (57 eyes). Overall, surgeons were satisfied with the clinical performance regardless of the cataract grade. The satisfaction with anterior chamber stability, post-occlusion surge, followability, holdability, cutting efficiency, usability, and overall satisfaction with the VERITAS Vision System was clinically favorable in ≥99% of cases. Overall satisfaction with the swivel handpiece, foot pedal, and enhanced ergonomics were clinically favorable in ≥97% of cases regardless of the cataract grade. Satisfaction with corneal clarity at same-day postoperative and 1-day postoperative, and 1-day overall clinical results of surgery with the VERITAS Vision System were clinically favorable in ≥94% of cases regardless of cataract grade. Conclusion: The new dual-mode phacoemulsification system with dual-durometer tubing, gas forced infusion, new swivel handpiece, and ergonomics improvements resulted in a high rate of user satisfaction with clinical performance and ergonomics. The VERITAS Vision System is safe and effective when used as indicated.

Metastatic Cutaneous Melanoma Presenting with Choroidal Metastasis Simulating Primary Uveal Melanoma.

PURPOSE: To report a case of metastatic cutaneous melanoma presenting with choroidal metastasis simulating primary uveal melanoma. DESIGN: Case report. METHOD: Presentation of clinical, radiographic, histopathologic, and tumor genetic findings in a patient with cutaneous melanoma with choroidal metastasis. RESULTS: A 50-year-old man with a remote history of stage 1A cutaneous melanoma presented with eye pain, peripheral vision loss, floaters, red eye, and choroidal mass that was originally diagnosed as a primary uveal melanoma at an outside institution; however, subsequent imaging and clinical evaluation demonstrated that this choroidal mass was the first manifestation of widely metastatic cutaneous melanoma (liver, pancreas, lung, bone, brain, and orbit lesions). Histopathologic analysis of the tumor after enucleation was consistent with cutaneous melanoma, and tumor genetic testing was positive for BRAF V600E mutation, confirming the choroidal lesion to be a cutaneous melanoma metastasis rather than a primary choroidal melanoma. CONCLUSIONS: Metastatic cutaneous melanoma to the orbit or globe occurs rarely. Tumor genetic testing may help differentiate metastatic cutaneous melanoma from primary uveal melanoma in cases where the diagnosis is uncertain, and can also inform therapy and prognostic counseling.

Choroidal Lymphoma Discovered on Ultrasound in a Patient with Suspected Corneal Tumor.

BACKGROUND/AIMS: To report the case of a 77-year-old male with a blind, painful eye, referred for suspected corneal mass, with finding of choroidal B-cell lymphoma on pathology of enucleated globe. METHODS: This is a retrospective case report of a single patient. RESULTS: A 77-year-old male with a longstanding history of poor vision in the left eye was referred for a scarred, vascularized corneal mass. The patient had reported occasional mild ocular discomfort in the left eye and loss of light perception over the last year. Visual acuity was 20/20 in the right eye and no light perception in the left eye. Intraocular pressure was 32 mm Hg in the left eye. Fundoscopic visualization was not possible due to corneal opacity. B-scan ultrasound showed an infiltrative, low-reflective choroidal lesion and inferior retinal detachment. Pathology from the enucleated globe revealed diffuse sheets of CD20+ small B cells replacing the choroid, characteristic of a low-grade small B-cell extranodal marginal zone lymphoma. CONCLUSION: This is an unusual presentation of choroidal lymphoma in an eye with severe corneal opacification and scarring, and underscores the diagnostic value of ultrasonography in examination of eyes without view to the posterior segment.

Paraproteinemic Keratopathy: The Expanding Diversity of Clinical and Pathologic Manifestations.

PURPOSE: To describe 7 patients with paraproteinemic keratopathy and to highlight the clinical and pathologic diversity of this rare entity and the importance of timely, systemic evaluation. DESIGN: Retrospective, multicenter collaborative case series. PARTICIPANTS: Seven patients with paraproteinemic keratopathy. METHODS: Clinical and pathologic records were reviewed to identify patients with well-documented corneal immunoglobulin deposits. Detailed ophthalmologic and medical histories were assembled. In 6 patients, corneal tissue was evaluated histochemically and immunohistochemically; in selected cases, corneal tissue was evaluated by in situ hybridization and ultrastructurally. MAIN OUTCOME MEASURES: Visual acuity and anterior segment examination at presentation and follow-up; local therapy; systemic diagnosis and management; and histopathologic, immunohistochemical, in situ hybridization, and ultrastructural findings. RESULTS: Seven patients were identified with corneal immunoglobulin deposition. In addition to previously reported crystalline, nummular, patch-like, and lattice-like corneal opacities, prominent corneal vascularization was present in 2 patients mimicking interstitial keratitis and limbal stem cell deficiency. All patients had evidence of paraproteinemia in a setting of monoclonal gammopathy of undetermined significance, smoldering plasma cell myeloma, or Waldenström macroglobulinemia. Corneal findings were the first manifestation of systemic disease in 4 patients, and the diagnosis was not suspected in 3 of these patients. Pathologic evaluation of biopsied corneal and conjunctival tissues demonstrated immunoglobulin deposits. Previously unreported ultrastructural patterns in the cornea were noted: large scroll-like immunotactoid deposits, immune complex-like deposits, and randomly arranged fibrils morphologically intermediate between amyloid and immunotactoid deposits. Surgical intervention to improve vision was performed in 4 patients, with recurrence of deposits in 3 patients. Three patients underwent systemic therapy with diminution of the deposits and improvement in vision in 1 patient. CONCLUSIONS: The clinical and pathologic expressions of corneal immunoglobulin deposits are protean and present a diagnostic challenge. Early recognition of this rare entity is important to address the potentially serious associated systemic disease.

Endophthalmitis caused by Achromobacter xylosoxidans after cataract surgery.

PURPOSE: To report Achromobacter xylosoxidans as a cause of both acute-onset and delayed-onset postoperative endophthalmitis after cataract surgery. METHODS: A noncomparative consecutive case series of patients with culture-proven A. xylosoxidans endophthalmitis between 1970 and 2012. Cataract surgery and intraocular lens placement were performed in all patients before endophthalmitis. Positive cultures were obtained from the vitreous, capsular bag, and/or the removed intraocular lens. RESULTS: The clinical diagnosis was confirmed in four patients with positive cultures. Two patients with endophthalmitis had a preliminary culture report of Pseudomonas species. In addition to receiving intravitreal antibiotics, all patients underwent capsulectomy and intraocular lens removal at the time of pars plana vitrectomy. Visual acuity at last follow-up was 20/40 or better in 2 (50%) of the 4 patients, but the remaining 2 patients were 20/200 or worse. CONCLUSION: A. xylosoxidans may be a cause of acute, recurrent, and delayed-onset postoperative endophthalmitis after cataract surgery. Complete capsulectomy and intraocular lens removal can be considered in recurrent and recalcitrant patients.

Patient-related and system-related barriers to glaucoma follow-up in a county hospital population.

PURPOSE: To identify the barriers to glaucoma follow-up and to assess how ethnicity influences the effect of such barriers among patients in a county hospital population. METHODS: This cross-sectional study included 152 patients, 76 with poor clinic follow-up and 76 with good clinic follow-up, who were recruited at the San Francisco General Hospital glaucoma clinic as part of a case-control study. All subjects were required to be established patients with glaucoma initially seen and diagnosed in the clinic at least 1 year before enrollment. An oral questionnaire pertaining to the barriers to follow-up for glaucoma, as well as patient ethnicity, was administered to all participating subjects. The main outcome measure was the prevalence of significant barriers to follow-up, both overall and stratified by ethnicity. RESULTS: The most prevalent barriers to follow-up included long clinic waiting times (75%), appointment scheduling difficulties (38%), the effect of other medical or physical comorbidities (29%), and difficulties related to medical interpretation (23%). While several barriers were cited as being important across different ethnicities, Latinos and Asian-Pacific Islanders were particularly affected by difficulties related to medical interpretation (P = 0.0001) and long waiting times in the clinic (P = 0.048). CONCLUSIONS: Understanding patient-reported barriers to glaucoma follow-up and their variation based on ethnicity may give providers insight as to why patients do not adhere to follow-up recommendations. Strategies to improve follow-up may include reduced clinic wait times, simplified appointment scheduling, and provision of appropriate education and counseling regardless of the patient's native language and ethnicity.

Ethnic variation in optic disc size by fundus photography.

PURPOSE: To compare optic disc size among Caucasian, Chinese, African, Filipino and Hispanic subjects recruited from a university-based general ophthalmology clinic. METHODS: In this retrospective cross-sectional study, optic disc size was calculated from fundus photographs. Differences in age, sex and spherical equivalent among the ethnic groups were examined with either Kruskal--Wallis test or Chi-square test. Ethnic differences in optic disc size were evaluated with linear mixed-effects regression models that adjusted for age, sex, spherical equivalent, glaucoma status, lens status and use of both eyes in the same subject. RESULTS: Five hundred and seventy-four eyes of 305 subjects were analyzed. The mean and standard deviation of the optic disc size were 2.16 ± 0.41 mm(2) for Caucasian, 2.30 ± 0.56 mm(2) for Chinese, 2.31 ± 0.41 mm(2) for Filipino, 2.38 ± 0.40 mm(2) for African and 2.40 ± 0.38 mm(2) for Hispanic subjects. Age and spherical equivalent differed among the ethnic groups by Kruskal--Wallis test (p < 0.05). Sex differed among the ethnic groups by Chi-square test (p < 0.05). Ethnic differences in optic disc size were not observed among African, Hispanic, Filipino and Chinese subjects in linear mixed-effects regression analyses (p > 0.05). However, Caucasian differed from the other ethnicities in linear mixed-effects regression analyses (p < 0.05). CONCLUSIONS: Optic disc size was significantly smaller in Caucasian compared to the other ethnic groups. Optic disc size differences among non-Caucasian ethnic groups were not significant.

Diagnosis of ocular surface lesions using ultra-high-resolution optical coherence tomography.

PURPOSE: To assess the use of ultra-high-resolution (UHR) optical coherence tomography (OCT) in the diagnosis of ocular surface lesions. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Fifty-four eyes of 53 consecutive patients with biopsy-proven ocular surface lesions: 8 primary acquired melanosis lesions, 5 amelanotic melanoma lesions, 2 nevi, 19 ocular surface squamous neoplasia lesions, 1 histiocytosis lesion, 6 conjunctival lymphoma lesions, 2 conjunctival amyloidosis lesions, and 11 pterygia lesions. INTERVENTION: Ultra-high-resolution OCT imaging of the ocular surface lesions. MAIN OUTCOME MEASURES: Clinical course and photographs, UHR OCT image, and histopathologic findings. RESULTS: Ultra-high-resolution OCT images of all examined ocular surface lesions showed close correlation with the obtained histopathologic specimens. When clinical differential diagnosis of ocular surface lesions was broad, UHR OCT images provided optical signs indicating a more specific diagnosis and management. In cases of amelanotic melanoma, conjunctival amyloidosis, and primary histiocytosis and in 1 case of ocular surface squamous neoplasia, UHR OCT was instrumental in guiding the diagnosis. In those cases, UHR OCT suggested that the presumed clinical diagnosis was incorrect and favored a diagnosis that later was confirmed by histopathologic examination. CONCLUSIONS: Correlations between UHR OCT and histopathologic findings confirm that UHR OCT is an adjunctive diagnostic method that can provide a noninvasive means to help guide diagnosis and management of ocular surface lesions. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Prevalence, treatment, and outcomes of coexistent ocular surface squamous neoplasia and pterygium.

PURPOSE: The purpose of this study was to determine the prevalence of ocular surface squamous neoplasia (OSSN) coexisting with pterygia in South Florida and to study the treatment and related outcomes. DESIGN: Noninterventional retrospective study. PARTICIPANTS: A total of 2005 patients with surgically excised pterygia at the Bascom Palmer Eye Institute from 2000 to 2010. METHODS: Pathology reports of patients with pterygia were reviewed for evidence of OSSN. Patients were divided into the following groups: pterygium and no OSSN (group 1), clinically suspected OSSN with pterygium (group 2), and unexpected OSSN with pterygium found on histopathology (group 3). Clinical charts of patients in groups 2 and 3 were reviewed. MAIN OUTCOME MEASURES: Period prevalence, treatment, and outcome. RESULTS: In surgically excised pterygia, the prevalence of coexistent OSSN was 1.7% (n = 34), of which 41% (n = 14) were clinically suspected preoperatively (group 2) and 59% (n = 20) were unexpectedly found on histopathology (group 3). Clinically suspected OSSN with pterygia was generally treated with wide surgical margins and cryotherapy, whereas unexpected OSSN with pterygia was treated with simple excision, followed by adjuvant interferon treatment in 30% (n = 6). After a mean follow-up of 2 years, there were no recurrences in the suspected OSSN group and 2 recurrences in the unexpected OSSN group. The recurrence rate in the latter group was 11% at 1 year and 24% at 2 years. CONCLUSIONS: Ocular surface squamous neoplasia is uncommonly found to coexist with pterygium. The prognosis in suspected OSSN cases is excellent, with no recurrences noted despite positive margins in 50% of cases. The recurrence rates of unexpected OSSN mirrors that of OSSN not associated with pterygium, and thus vigilance for recurrence is important.

Clinicopathologic correlation of ocular surface squamous neoplasms at Bascom Palmer Eye Institute: 2001 to 2010.

PURPOSE: To describe the clinical and histologic characteristics of ocular surface squamous neoplasia (OSSN) lesions and provide clinicopathologic correlation to determine clinical features that may indicate higher-grade lesions. DESIGN: Retrospective case series. PARTICIPANTS: A total of 612 consecutive OSSN lesions sent to the Bascom Palmer ocular pathology laboratory from January 1, 2001 to September 20, 2010. METHODS: Pathologic examination of lesions by a single experienced ocular pathologist (S.R.D.). Review of pathology records and patient charts. MAIN OUTCOME MEASURES: Correlation of clinical factors and histology of higher-grade OSSN. RESULTS: Over the studied period, 33% of submitted specimens were characterized as mild, moderate, or severe dysplasia; 52% were classified as carcinoma in situ; and 11% were graded as squamous cell carcinoma. Characteristics associated with higher-grade OSSN lesions included male gender, biopsy at Bascom Palmer Eye Institute, temporal and superior locations, lack of corneal involvement, papillomatous and nodular appearance, microscopic multifocality, and positive margins on biopsy. CONCLUSIONS: Certain clinical factors are associated with higher-grade histologic lesions. These findings may help clinicians more accurately evaluate and anticipate the pathologic grade of conjunctival and corneal lesions suspected to be OSSN.

The effect of topical pranoprofen 0.1% on the clinical evaluation and conjunctival HLA-DR expression in dry eyes.

PURPOSE: To investigate the effect of topical pranoprofen 0.1% on the clinical evaluation and conjunctival human leukocyte antigen II (HLA-DR) expression in dry eyes. METHODS: Sixty patients with dry eyes were randomized to 2 groups. Patients in group 1 received topical pranoprofen 0.1% plus topical sodium hyaluronate 0.1%; and patients in group 2 received sodium hyaluronate without pranoprofen. Ocular surface disease index (OSDI), tear film break-up time (TBUT), Schirmer I test, ocular surface staining (OSS), and conjunctival HLA-DR expression were evaluated before treatment and at 15 and 30 days after treatment. RESULTS: On day 15, patients in group 1 had significantly lower OSDI, OSS, and HLA-DR-positive cells compared with patients in group 2 (P < 0.01), and the TBUT was significantly longer in patients in group 1 than that of patients in group 2 (P < 0.01). On day 30, the difference between the 2 groups in OSS lost significance; however, there continued to be significant differences in the OSDI, TBUT, and HLA-DR expression between the 2 groups (P < 0.01). On days 15 and 30, the values in group 1 patients had significant improvement compared with their baseline values in terms of the above-mentioned parameters. The comparisons within group 2 did not reveal any significant differences. There was no significant effect in the Schirmer I test value in eyes of patients in group 1 or group 2 at days 15 or 30 (P > 0.05). CONCLUSIONS: Topical pranoprofen 0.1% has a beneficial effect in reducing the ocular signs and symptoms of dry eyes and decreasing the inflammatory markers of conjunctival epithelial cells.

Predictors of ocular surface squamous neoplasia recurrence after excisional surgery.

PURPOSE: To identify predictors of ocular surface squamous neoplasm (OSSN) recurrence after operative resection. DESIGN: Retrospective case series. PARTICIPANTS: Three hundred eighty-nine consecutive patients who underwent excisional biopsy for OSSN lesions at the Bascom Palmer Eye Institute from January 1, 2001, to September 20, 2010. METHODS: Review of pathology records and patient charts. MAIN OUTCOME MEASURES: Identification of factors predictive of OSSN recurrence. RESULTS: Of 389 excised OSSN lesions, 44 recurred during follow-up. The 1-year recurrence rate was 10% and the 5-year recurrence rate was 21%, with a mean time to recurrence in those with a recurrence of 2.5 years (standard deviation, 3.4). Using the American Joint Committee on Cancer (AJCC) clinical staging system, T3 and T2 lesions portended a higher risk of recurrence compared with T1 (T2/T1 hazard ratio [HR], 2.05 [P = 0.04]; T3/T1 HR, 2.31 [P = 0.07]). In addition, a location characteristic that increased the risk of tumor recurrence was tarsal involvement (AJCC T3 stage lesion; HR, 4.12; P = 0.007). Nasal location was associated with a decreased risk of tumor recurrence (HR, 0.41; P = 0.008). Pathologic characteristics significantly associated with tumor recurrence were the presence of positive margins (HR, 2.73; P = 0.008) and higher grade lesions (carcinoma in situ and squamous cell carcinoma versus dysplasia; HR, 2.55; P = 0.02). Treatment with adjuvant cryotherapy significantly decreased the risk of tumor recurrence (HR, 0.51; P = 0.03). In those patients with positive margins, the use of postoperative topical interferon therapy lowered the recurrence rate to a level similar to that of patients with negative margins. CONCLUSIONS: Certain patient and tumor factors are associated with a higher risk of OSSN recurrence after operative excision, such as tarsal tumor location and positive surgical margins. Postoperative adjuvant therapy should be considered in patients with high-risk OSSN characteristics.

Bacterial contaminants of bandage contact lenses used after laser subepithelial or photorefractive keratectomy.

PURPOSE: To compare the locations and types of bacterial contamination of bandage disposable soft contact lenses after laser subepithelial keratectomy (LASEK) and photorefractive keratectomy (PRK). METHODS: Bandage disposable soft contact lenses were collected with sterile forceps from 30 eyes of 15 consecutive patients treated with LASEK (LASEK group) and 30 eyes of 15 consecutive patients who underwent PRK (PRK group) to correct myopia. Immediately after collection, each lens was cut in two parts with sterile scissors and placed onto chocolate agar with one piece outer face down and the inner face down for the other piece. The lenses were analyzed for bacterial colonization and evaluated for the amount of growth on the inner face and outer face, respectively. The antibiotic susceptibility tests were performed for the isolates using disk diffusion. RESULTS: Five positive cultures (16.7%) were found in LASEK group: 4 appeared in the inner face of the lens and1 appeared in the outer face. In PRK group, 2 of the 30 contact lenses (6.67%) had positive cultures; both of them appeared in the outer face of the lens. The difference of positive culture rate in the two groups was not statistically significant (χ=1.46, P=0.228). When comparing the positive colonization rate in location, the positive culture rate in the inner face of LASEK group was statistically significantly higher than that of PRK group (13.3% vs. 0%, χ=4.29, P=0.038); however, no clinical finding of infection was noted. In both groups, methicillin-sensitive coagulase-negative staphylococci (MSSCoN) were the most common isolate. Besides MSSCoN, the growth of methicillin-resistant coagulase-negative staphylococci, Corynebacterium, and Micrococcus were also present in this study. All the microorganisms were sensitive to tobramycin, which was used in conjunction with dexamethasone to treat the cases. CONCLUSIONS: Previous literature reports that the risk of infectious keratitis after LASEK or PRK is relatively low. However, within this study, the rate of positive cultures was relatively higher in LASEK group (16.7%) compared with that of PRK group (6.67%), especially in the inner face of the lens. The reason may be related to the procedure of keeping the epithelial flap in place, which could develop a local environment suitable for bacterial colonization and potential infection. Coagulase-negative staphylococci, a major element of the natural conjunctival flora, remain a major potentially infectious agent after LASEK and PRK.