TFOS Lifestyle: Impact of elective medications and procedures on the ocular surface.

The word "elective" refers to medications and procedures undertaken by choice or with a lower grade of prioritization. Patients usually use elective medications or undergo elective procedures to treat pathologic conditions or for cosmetic enhancement, impacting their lifestyle positively and, thus, improving their quality of life. However, those interventions can affect the homeostasis of the tear film and ocular surface. Consequently, they generate signs and symptoms that could impair the patient's quality of life. This report describes the impact of elective topical and systemic medications and procedures on the ocular surface and the underlying mechanisms. Moreover, elective procedures performed for ocular diseases, cosmetic enhancement, and non-ophthalmic interventions, such as radiotherapy and bariatric surgery, are discussed. The report also evaluates significant anatomical and biological consequences of non-urgent interventions to the ocular surface, such as neuropathic and neurotrophic keratopathies. Besides that, it provides an overview of the prophylaxis and management of pathological conditions resulting from the studied interventions and suggests areas for future research. The report also contains a systematic review investigating the quality of life among people who have undergone small incision lenticule extraction (SMILE). Overall, SMILE refractive surgery seems to cause more vision disturbances than LASIK in the first month post-surgery, but less dry eye symptoms in long-term follow up.

PET/CT and PET/MRI in ophthalmic oncology (Review).

Orbital and ocular anatomy is quite complex, consisting of several tissues, which can give rise to both benign and malignant tumors, while several primary neoplasms can metastasize to the orbital and ocular space. Early detection, accurate staging and re­staging, efficient monitoring of treatment response, non­invasive differentiation between benign and malignant lesions, and accurate planning of external radiation treatment, are of utmost importance for the optimal and individualized management of ophthalmic oncology patients. Addressing these challenges requires the employment of several diagnostic imaging techniques, such as high­definition digital fundus photography, ultrasound imaging, optical coherence tomography, optical coherence tomography (OCT)­angiography, computed tomography (CT) and magnetic resonance imaging (MRI). In recent years, technological advances have enabled the development of hybrid positron emission tomography (PET)/CT and PET/MRI systems, setting new standards in cancer diagnosis and treatment. The capability of simultaneously targeting several cancer­related biochemical procedures using positron emitting­radiopharmaceuticals, while morphologically characterizing lesions by CT or MRI, together with the intrinsic quantitative capabilities of PET­imaging, provide incremental diagnostic information, enabling accurate, highly efficient and personalized treatment strategies. Aim of the current review is to discuss the current applications of hybrid PET/CT and PET/MRI imaging in the management of patients presenting with the most commonly encountered orbital and ocular tumors.

ND:YAG laser for preretinal hemorrhage in diabetic retinopathy.

PURPOSE: To present fundus images of a case with severe preretinal hemorrhage in diabetic retinopathy that was treated with posterior hyaloidotomy with an Nd:YAG laser. OBSERVATIONS: A 35-year-old diabetic patient presented with sudden painless loss of vision due to severe preretinal hemorrhage over the macular area and high risk proliferative diabetic retinopathy. Her visual acuity was counting fingers. Posterior hyaloid face was treated with Nd:YAG laser (posterior hyaloidotomy). Panretinal laser photocoagulation was first performed to control the proliferative diabetic retinopathy. Blood drained inferiorly into the vitreous cavity with clearance of the premacular area. CONCLUSIONS AND IMPORTANCE: Prompt treatment with Panretinal laser photocoagulation followed by posterior hyaloidotomy with the YAG laser is a viable option in order to avoid further proliferative diabetic retinopathy complications and vision loss. The current image clearly depicts treatment efficacy.

Mini descemet membrane stripping (m-DMES) in patients with Fuchs' endothelial dystrophy: A new method.

We present two cases with focal corneal edema due to Fuchs' endothelial dystrophy that were successfully treated with mini Descemet membrane stripping (m-DMES) (diameter of 3-4 mm; at the area of preexisting focal corneal edema) without endothelial replacement during cataract surgery. Specular microscopy demonstrated Fuchs' endothelial dystrophy and histopathologic evaluation confirmed the diagnosis. Anterior segment optical coherence tomography and confocal microscopy were used for the evaluation of the corneal tissue recovery course after the surgical procedure. In both patients, we observed an initial aggravation of corneal edema in the area of DM removal for two months followed by gradual improvement. At four months postoperatively, corneal edema had completely regressed resulting in corneal clearance and visual acuity improvement in both cases. M-DMES without graft insertion represents a promising alternative surgical technique that could be applied in specific cases of Fuchs' endothelial dystrophy with focal corneal edema.

Treatment of myopic choroidal neovascularization with intravitreal ranibizumab injections: the role of age.

PURPOSE: The aim of this study was to explore the role of age as a prognostic factor for the outcome of myopic choroidal neovascularization (CNV) treatment with intravitreal ranibizumab injections. METHODS: A retrospective review of charts of patients treated with intravitreal injections of ranibizumab for the treatment of myopic CNV was done. Patients with other ophthalmic disease were excluded. Patients were followed for at least 2 years. The correlation between age and the change in visual acuity and the number of injections during treatment was investigated. RESULTS: Age of the patients was significantly correlated with the number of injections that the patients received (Pearson's r=0.585, P=0.005). Also, it was significantly correlated with improvement in corrected distance visual acuity, defined as the difference between final and initial LogMAR corrected distance visual acuity (Pearson's r=0.614, P=0.003). CONCLUSION: Age significantly affects the visual outcome of myopic CNV treatment with ranibizumab. Younger patients in our study needed fewer intravitreal injections and achieved a more significant improvement in vision.

Effects of Short-term Preoperative Topical Ketorolac on Pupil Diameter in Eyes Undergoing Femtosecond Laser-Assisted Capsulotomy.

PURPOSE: To assess pupil diameter before and after femtosecond laser-assisted capsulotomy in patients who were pretreated with a short-term topical nonsteroidal anti-inflammatory drug (NSAID) (ketorolac) versus those without pretreatment. METHODS: This prospective, randomized, observational case series included consecutive patients scheduled to undergo cataract extraction using the Catalys femtosecond laser platform (Abbott Medical Optics, Inc., Santa Ana, CA) to perform only capsulotomies. The same protocol for preoperative medical mydriasis was used for all patients, whereas pupil diameter was assessed using a surgical ruler immediately before and 3 minutes after femtosecond laser-assisted capsulotomy. The patients were divided into two groups: one received short-term topical ketorolac preoperatively and the other did not receive NSAID pretreatment (control). RESULTS: A total of 42 eyes of 42 patients (1 eye per patient) were included in the study. Mean pupillary miosis was 0.79 ± 1.08 and 1.57 ± 1.19 mm for the ketorolac and control groups, respectively. There was a statistically significant decrease in pupil diameter for both groups individually (P < .05). There was also a statistically significant difference between the two groups (P < .05) with the induced miosis in the eyes that did not receive topical NSAIDs prior to cataract extraction being twofold greater when compared with the miosis of the eyes that received ketorolac pretreatment. CONCLUSIONS: Short-term topical use of ketorolac prior to femtosecond laser-assisted cataract surgery seems to induce significantly less pupillary miosis in comparison to eyes that did not receive NSAID pretreatment. NSAID use is advised prior to femtosecond laser-assisted cataract surgery to minimize pupil miosis-related surgical difficulties or complications during cataract extraction. [J Refract Surg. 2017;33(4):230-234.].

Long-Term Comparison of Simultaneous Topography-Guided Photorefractive Keratectomy Followed by Corneal Cross-linking versus Corneal Cross-linking Alone.

PURPOSE: To compare the results of corneal collagen cross-linking (CXL) alone with combined simultaneous topography-guided photorefractive keratectomy plus CXL (tPRK-CXL) for progressive keratoconus for a 3-year interval. DESIGN: Prospective, comparative interventional case series. PARTICIPANTS: Forty-eight patients (60 eyes) with progressive keratoconus. METHODS: Thirty eyes underwent combined tPRK with a solid-state laser (maximum ablation depth, 50 µm) followed by CXL, and 30 eyes underwent CXL alone. Groups were matched in terms of age and keratoconus stage. MAIN OUTCOME MEASURES: Corrected distance visual acuity (CDVA), uncorrected distance visual acuity (UDVA), keratometry, and corneal confocal microscopy. RESULTS: Mean follow up was 39±11 months. Mean age at operation was 28±5.82 years. Before surgery, average CDVA in the tPRK-CXL group was 0.26±0.17 logarithm of the minimum angle of resolution (logMAR), and in the CXL group was 0.24±0.18 logMAR (P = 0.58). At last follow-up, CDVA was 0.09±0.10 logMAR in the tPRK-CXL group and 0.15±0.12 logMAR in the CXL group (P < 0.05). In both groups, no patient lost more than 2 lines of Snellen visual acuity, whereas 19 eyes and 8 eyes in the tPRK-CXL group and in the CXL group, respectively, gained 2 or more lines of CDVA. Before surgery, average UDVA was 0.83±0.54 logMAR in the tPRK-CXL group and 0.86±0.62 logMAR in the CXL group (P = 0.79). At last follow-up, UDVA was 0.27±0.25 logMAR in the tPRK-CXL group and 0.69±0.58 logMAR in the CXL group (P < 0.001). Before surgery, steep and flat keratometry had no significant differences between groups, and at last follow-up, both steep and flat keratometry readings were significantly flatter in the tPRK-CXL group compared with the CXL group. Depth of CXL treatment, as evaluated by confocal microscopy, was 269.8±31.8 µm in the CXL group and 299.7±29.8 µm in the tPRK-CXL group (P < 0.001). No differences were found in endothelial cell density. CONCLUSIONS: Simultaneous tPRK followed by CXL in this series of keratoconus patients offered significantly improved vision to treated patients in comparison with CXL alone, and similar results regarding postoperative stability. Safety concerns regarding corneal thickness were taken into account in treatment planning.

Femtosecond laser-assisted cataract surgery in a patient with posterior chamber phakic intraocular lens.

We describe a case of modified femtosecond laser settings for cataract extraction in a patient with a posterior chamber phakic intraocular lens (PIOL), to avoid incomplete treatment patterns and treatment displacement. Modification of laser settings (increased depth for the capsulotomy, increased vertical spot spacing for the capsulotomy and increased anterior and posterior capsule safety margins for lens fragmentation) seems to make femtosecond laser-assisted cataract surgery feasible in patients with posterior chamber PIOLs, as complete treatment patterns are achieved.

Effect of Glaucoma Medication in Tear Film Osmolarity of Patients Without Symptoms of Ocular Discomfort.

PURPOSE: To evaluate tear film osmolarity in patients with no symptoms of ocular discomfort treated with intraocular pressure (IOP)-lowering medication and compare it with tear film osmolarity of controls. METHODS: This was a cross-sectional study of 61 patients with glaucoma or ocular hypertension (study group) and 32 age-matched normals (control group). Neither group of patients reported ocular discomfort. Tear film osmolarity was measured with the TearLab Osmolarity System (TearLab Corp, San Diego, CA), and results were compared between groups. Correlation of osmolarity with parameters associated with medication use (time, number of medications, and number of instillations) was assessed. RESULTS: Mean age of the patients in the medication group was 71±10.18 years and in the control group was 69±10.23 years (P=0.247). In the medication group, the tear film osmolarity was 295.56±12.54 mOsms/L and in the control group, it was 294.84±14.73 mOsms/L (P=0.807). Regarding the percentage of patients with tear film hyperosmolarity (osmolarity≥316 mOsms/L), in the group of normal patients, 3 had osmolarity more than or equal to the selected cutoff value (9.3%) and in the medication group, 7 patients (8.2%). Difference of the percentage between groups was not statistically significant (P=0.999, chi-square test). Tear film osmolarity in the medication group was not correlated to any of the parameters related to treatment. CONCLUSIONS: Patients treated with IOP-lowering medication do not exhibit tear film hyperosmolarity as long as they do not report symptoms of ocular discomfort.

Central retinal vein occlusion and pseudoexfoliation syndrome.

PURPOSE: The purpose of this study was to investigate the existence of pseudoexfoliation syndrome (PXF) as a risk factor for the development of central retinal vein occlusion (CRVO). METHODS: This was a retrospective, comparative study of the prevalence of pseudoexfoliation in three groups of patients: 48 patients with CRVO, 164 patients with branch retinal vein occlusion (BRVO), and 70 control patients (70 eyes). All patients were phakic and had no previous diagnosis of glaucoma. Patients were matched in terms of age and systemic hypertension. All patients had normal intraocular pressure (IOP) at presentation (defined as less than or equal to 21 mmHg). RESULTS: In the CRVO group, 14 out of 48 patients were diagnosed as having PXF (29.17%). In the BRVO group, 14 out of 164 patients had PXF (8.5%), and in the control group, six out of 70 patients had PXF (8.6%). Differences of percentage between groups were statistically significant (P<0.001, χ(2) test). When comparing patient subgroup with ischemic CRVO with subgroup with non-ischemic CRVO, we found that in the ischemic CRVO group, 13 out of 27 patients were diagnosed as having PXF (48.15%), and in the non-ischemic CRVO group, one out of 21 patients was diagnosed as having PXF (4.7%; P<0.001, χ(2) test). The relative odds of having CRVO in patients with PXF versus patients without PXF were 4.406 (confidence interval [CI], 2.03-9.54). CONCLUSION: PXF and CRVO, especially ischemic, are strongly associated in our study. Our results indicate that PXF might be an independent factor for CRVO, as it is related with CRVO independently from glaucoma.

Clinical and spectral-domain optical coherence tomography findings of patients with incomplete visual recovery after anatomically successful retinal detachment surgery.

Purpose. To identify causes of incomplete visual recovery in patients with anatomically successful retinal detachment surgery. Methods. This was a retrospective study of 61 eyes of 61 patients with at least 12-month follow-up and complete preoperative, intraoperative, and postoperative record. Postoperative visual acuity (VA) more than 0.18 logMAR was considered as incomplete visual recovery. Complete ophthalmic examination and Spectral-Domain OCT (SD-OCT) imaging were performed at last follow-up. Results. Twenty-nine eyes (47.5%) had a postoperative VA < 0.18 logMAR and 32 eyes (52.5%) had a postoperative VA ≥ 0.18 logMAR. Mean follow-up was 32.8 ± 17.3 months. Incomplete visual recovery was strongly correlated with presence of macular pathology (P = 0.002), a detached macula preoperatively (P = 0.02), retinotomy (P = 0.025), and pars plana vitrectomy and use of silicon oil as a tamponade agent (P = 0.009). Also, although there was a strong correlation between ellipsoid zone disruption and incomplete visual recovery, a distinct, more course pathology could be identified in all cases of poor visual recovery related to edema, thickening, or atrophy of the macula. Conclusion. The careful postoperative evaluation of the macula using biomicroscopy and SD-OCT can help in diagnosis of alterations that can be associated with incomplete visual recovery.

Femtosecond Laser-Assisted Intra-Corneal Drug Delivery.

PURPOSE: To present a case of fungal keratitis that was successfully treated with direct intrastromal medication delivery through a corneal incision created with the femtosecond laser. METHODS: A 71-year-old female patient with recurrent episodes of an unresponsive, deep stromal keratitis for six months' duration, resistant to various therapeutic approaches, was referred to our institute. The 150 kHz Intralase iFS laser (Abbott Medical Optics Inc., Santa Ana, CA) was used to create a corneal pocket in an attempt to permit drug delivery directly into the corneal abscess. RESULTS: Five days after the intrastromal injections, the clinical condition was improved. Two years after the procedure, the cornea is stable and free of any clinical signs or symptoms of recurrence. CONCLUSIONS: In this case report, an alternative application of femtosecond laser technology is presented, performing intrastromal drug delivery through a corneal incision for the treatment of fungal keratitis.

Prospective comparison of low-fluence photodynamic therapy combined with intravitreal bevacizumab versus bevacizumab monotherapy for choroidal neovascularization in age-related macular degeneration.

PURPOSE: To evaluate combination treatment with reduced-fluence photodynamic therapy (RDPDT) with Verteporfin and intravitreal bevacizumab, compared to bevacizumab alone, for choroidal neovascularization (CNV) in age-related macular degeneration. METHODS: This was a prospective, randomized comparative study comprising 95 patients with CNV. 49 patients received RDPDT (25 J/cm(2)) followed by intravitreal bevacizumab 1.25 mg one hour later, while 46 received intravitreal bevacizumab alone. Patients were followed for 12 months at four-week intervals with visual acuity (VA) assessment and Optical Coherence Tomography (OCT) of the macula. Bevacizumab re-injections were performed as needed. RESULTS: On average, patients were re-injected 4.45 times in the combination group and 6.96 times in the bavacizumab group (p < 0.001). At 12 months, VA improved by 8.64 letters in the bevacizumab group and by 8.37 letters in the combination group (p = 0.922). CONCLUSION: Adding a reduced-fluence PDT arm in combination with bevacizumab offers similar results to those of intravitreal bevacizumab alone with significantly reduced number of injection repetitions.

Acute zonal occult outer retinopathy with atypical findings.

Background. To report a case of acute zonal occult outer retinopathy (AZOOR) with atypical electrophysiology findings. Case Presentation. A 23-year-old-female presented with visual acuity deterioration in her right eye accompanied by photopsia bilaterally. Corrected distance visual acuity at presentation was 20/50 in the right eye and 20/20 in the left eye. Fundus examination was unremarkable. Visual field (VF) testing revealed a large scotoma. Pattern and full-field electroretinograms (PERG and ERG) revealed macular involvement associated with generalized retinal dysfunction. Electrooculogram (EOG) light rise and the Arden ratio were within normal limits bilaterally. The patient was diagnosed with AZOOR due to clinical findings, visual field defect, and ERG findings. Conclusion. This is a case of AZOOR with characteristic VF defects and clinical symptoms presenting with atypical EOG findings.

Corneal confocal microscopy findings in sporadic cases of pre-descemet corneal dystrophy.

PURPOSE: To present corneal confocal microscopy (CCM) findings in a series of patients with pre-Descemet corneal dystrophy (PDCD). METHODS: A 28-year-old man, a 50-year-old man, a 30-year-old woman, and a 31-year-old man were clinically diagnosed with PDCD on slit lamp microscopic evaluation. All patients were evaluated by means of CCM. The parents of the patients were clinically evaluated. Two of the patients underwent photorefractive keratectomy. RESULTS: In all the patients, CCM revealed highly reflective stromal particles and pleomorphic structures that included particles in the deep stroma, immediately anterior to the Descemet membrane extending up to 60 µm from endothelium. No evidence of PDCD was observed clinically in the parents of the patients. Postoperative course of photorefractive keratectomy was uneventful for both of the patients. CONCLUSIONS: With the use of CCM, a specific pattern of findings seemed to be related with PDCD in this series of sporadic cases.

Comparative study of stromal bed of LASIK flaps created with femtosecond lasers (IntraLase FS150, WaveLight FS200) and mechanical microkeratome.

BACKGROUND/AIM: To compare stromal bed smoothness in LASIK flaps created with two different femtosecond lasers (IntraLase FS150 and WaveLight FS200) and a mechanical microkeratome (MMK) (Carriazo-Pendular microkeratome). METHODS: Sixty freshly enucleated porcine eyes were used for the study. Twenty flaps were created and constitute each of the following three groups: IntraLase FS150 (IFS group), WaveLight FS200 (WFS group) and MMK (MMK group). In each of the three groups, 10 flaps were created with intended thickness of 110 µm and another 10 flaps with 130 µm. Images were assessed with light microscopy and scanning electron microscopy. Qualitative surface roughness grading of the images was performed by five masked observers and statistical comparisons of scores were made between groups. RESULTS: The results of qualitative surface roughness grading demonstrated that there was no significant difference between the two femtosecond (FS) lasers when comparing the subgroups with the same flap thickness (p>0.05 in both comparisons, Mann-Whitney U test). In addition, there was no statistically significant difference (p>0.05) in each flap maker group between different thickness subgroups. However, the scores of the FS laser subgroups were significantly better than the scores of the MMK subgroups with corresponding flap thicknesses (p<0.05, Mann-Whitney U test). CONCLUSIONS: Our study demonstrates that the IntraLase FS150 and the WaveLight FS200 had a similar performance and provided flaps with smooth surfaces. In comparison to the MMK, the studied femtosecond laser systems had a superior performance in terms of smoothness.

Cross-linking as an adjuvant treatment for tectonic corneal lamellar graft preparation.

PURPOSE: To describe a new surgical approach for the tectonic reconstruction of the anterior ocular segment and the management of scleral and conjuctival melting. METHODS: Case series of patients demonstrating anterior segment anomalies, such as scleral and conjunctival melting. The anterior stromal part of a pre-cut corneal graft for Descemet's stripping automated endothelial keratoplasty (DSAEK) was cross-linked with riboflavin and ultraviolet A irradiation and was used to cover scleral (scleral melting in a patient with necrotizing scleritis, one case) and conjuctival (dehiscence of the conjunctiva in patients with anti-glaucomatous valve exposure, two cases) areas. The endothelial part of all corneal grafts was used for DSAEK in patients with need of corneal endothelial transplantation. RESULTS: Repair of scleral and conjuctival melting was successful in all cases. No intra- or post- operative complications occured. Visual acuity of all patients remained stable during the follow up period. One year postoperatively the corneal graft remained in place and no signs of inflammation were evident, while all grafts were epithelialized. CONCLUSIONS: The use of cross-linked corneal graft for the tectonic reconstruction of the anterior ocular segment represents an adequate surgical approach for the management of scleral and conjuctival melting; while, at the same time it offers the advantage of using one corneal graft for two recipients.

Effect of corneal collagen cross-linking on corneal innervation, corneal sensitivity, and tear function of patients with keratoconus.

PURPOSE: To evaluate the effect of corneal collagen cross-linking (CXL) on corneal innervation, corneal sensitivity, and tear function in patients with keratoconus. DESIGN: Prospective, interventional case series. PARTICIPANTS: Twenty-four patients with bilateral keratoconus (30 eyes) who presented to the Institute of Vision and Optics, University of Crete, from May 2008 to October 2008. METHODS: Patients underwent CXL. Confocal microscopic analysis of corneal sub-basal nerve plexus (total nerve length per image), corneal sensitivity (assessed with the Cochet-Bonnet esthesiometer), basic tear secretion (assessed with Schirmer's I test with anesthesia), and tear film stability (evaluated by means of tear film break-up time [TFBUT]) were assessed preoperatively and at 1, 3, 6, 9, 12, 18, and 24 months postoperatively. MAIN OUTCOME MEASURES: Comparisons between preoperative and each postoperative value of total nerve length per image, corneal sensitivity, Schirmer's I test results, and TFBUT. RESULTS: Total nerve length per image and corneal sensitivity were significantly decreased until postoperative month 6 (for both parameters: P<0.05 paired-samples t test at 1, 3, and 6 months postoperatively). Total nerve length per image tended to increase up to 2 years postoperatively, when it reached the preoperative level, but differences with the preoperative values after the sixth post-CXL month were insignificant. The results of Schirmer's I test and TFBUT had no statistically significant difference at any time point. CONCLUSIONS: A transient decrease in corneal innervation and corneal sensitivity can be observed up to 6 months after CXL. No significant effect of CXL could be detected on basic tear secretion and tear film stability in our group of patients. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

In vitro effect of corneal collagen cross-linking on corneal hydration properties and stiffness.

BACKGROUND: The purpose of this study is to evaluate in-vitro the immediate effect of corneal collagen cross-linking (CXL) on corneal hydration and stiffness. METHODS: Forty-two corneal buttons from freshly enucleated porcine eyes were immersed in riboflavin 0.1% in dextran 20% dilution for 3 h in order for their hydration to reach equilibrium. Corneal buttons where divided into two groups; the first group was stored in dark conditions while the other group was irradiated with UV radiation (370 nm) for 30 min to simulate CXL according to the clinically applied protocol. After irradiation, all corneas were immersed in dextran 20% solution for 3 additional hours. Subsequently, each button underwent weighing, thickness measurement, and was mounted in a special device for the measurement of force versus deformation by compression. Finally, all corneal buttons were dehydrated for 48 h in a desiccating oven set at 62 °C and weighed again to obtain their dry mass. Hydration (%) of each button was calculated. RESULTS: Mean corneal hydration in the irradiated and the non-irradiated group of corneas was 69.8 and 72.2%, respectively (p < 0.001). Differences in thickness and compressibility were not statistically significant. Thickness and hydration were positively correlated (Pearson's r = 0.714, p < 0.001). CONCLUSIONS: CXL causes corneal dehydration that can be detected immediately after the procedure. This phenomenon may contribute to increased mechanical stiffness of the cornea. A change in stiffness by means of compressibility could not be detected in porcine corneas.