CYSTOID MACULAR EDEMA AFTER FOUR-POINT SCLERAL FIXATION OF INTRAOCULAR LENS.

PURPOSE: To assess the incidence of cystoid macular edema (CME) associated with 4-point Gore-Tex suture intraocular lens (IOL) scleral fixation, before and after institution of routine intravitreal triamcinolone acetonide prophylaxis and long-term topical nonsteroidal anti-inflammatory drug usage. METHODS: Consecutive patients were included after IOL implantation with concurrent pars plana vitrectomy for spontaneous IOL dislocation due to pseudoexfoliation syndrome. We compared short-term prophylactic nonsteroidal anti-inflammatory drugs only (Group A) to prophylactic intravitreal triamcinolone acetonide and long-term nonsteroidal anti-inflammatory drugs (Group B). RESULTS: Twenty-six eyes of 26 patients with pseudoexfoliation syndrome and spontaneous IOL dislocation were studied. Mean logMAR visual acuity improved from 1.27 ± 0.80 (20/375 Snellen equivalent) preoperatively to 0.46 ± 0.39 (Snellen 20/43) postoperatively (P < 0.001). Visual outcomes were similar for Groups A and B. In Group A, 10/16 eyes had CME, 4/16 had chronic CME longer than 6 months, and 1 longer than 12 months. In Group B, 1/10 had CME (which was both chronic and refractory). CONCLUSION: In eyes with pseudoexfoliation syndrome and spontaneous IOL dislocation, 4-point Gore-Tex suture IOL ab externo fixation yielded good visual outcomes, although CME was observed more than reported elsewhere. Prophylactic intravitreal triamcinolone acetonide and long-term nonsteroidal anti-inflammatory drugs seem to reduce the risk of postoperative CME.

LASIK versus PRK for high astigmatism.

PURPOSE: To compare the refractive outcomes of laser in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) for myopic astigmatism of 3 diopters (D) or more. STUDY DESIGN: Retrospective matched comparative study. METHODS: This study include consecutive myopic patients (SE 0 to -10 D) undergoing LASIK or PRK between 2007 and 2016 with astigmatism of 3 to 6 D, and postoperative follow-up of at least 30 days for LASIK and 60 days for PRK, compared outcomes of LASIK and PRK eyes. RESULTS: The LASIK and PRK groups comprised 175 eyes of 175 patients each, with median follow-up of 39 and 139 days, respectively (P < 0.001). Mean preoperative manifest astigmatism was -3.35 ± 0.46 and -3.42 ± 0.51 D (P = 0.92), postoperative SE was -0.43 ± 0.55 and -0.16 ± 0.64 D (P < 0.001), and arithmetic astigmatism was -0.59 ± 0.46 and -0.88 ± 0.60 D (P < 0.001), for the LASIK and PRK groups, respectively. Fifty-seven and 64.0% eyes had postoperative SE within ± 0.5 D of emmetropia (P = 0.19), and 57.7 and 38.8% eyes were within 0.5 D of attempted astigmatic correction (P < 0.001) for the LASIK and PRK groups, respectively. More PRK eyes were overtreated regarding both SE and astigmatism than LASIK eyes (P < 0.001). The efficacy and safety indices were close to 1.0 in both groups. The surgically induced astigmatism, magnitude of error, index of success, correction index and flattening index were all better in the LASIK group. CONCLUSION: Both LASIK and PRK achieve good outcomes in high astigmatism. LASIK achieved mild superiority over PRK.

PROGNOSTIC VALUE OF SUBRETINAL HYPERREFLECTIVE MATERIAL IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION TREATED WITH BEVACIZUMAB.

PURPOSE: To study the correlation between subretinal hyperreflective material (SHRM) seen on spectral domain optical coherence tomography at baseline and visual outcomes after intravitreal bevacizumab injection in neovascular age-related macular degeneration. METHODS: Consecutive patient charts with treatment-naive center-involved neovascular age-related macular degeneration treated with 3 monthly intravitreal bevacizumab's, continued as needed, from 2011 to 2014 were reviewed. Baseline spectral domain optical coherence tomography SHRM parameters (height, width, area, reflectivity, border definition, and homogeneity) and established optical coherence tomography biomarkers of neovascular activity (intraretinal fluid, subretinal fluid, retinal volume, central retinal thickness, and pigment epithelial detachment presence) were collected. These baseline parameters were correlated with visual acuity at baseline, 3 and 12 months. RESULTS: Seventy-three eyes of 73 patients, 47 (64.4%) having central SHRM at baseline, were studied. Mean age was 79.2 ± 8.9 years. Mean best-corrected visual acuity was 0.70 ± 0.57 logarithm of the minimum angle of resolution (20/100), 0.73 ± 0.55 (20/107), and 0.76 ± 0.63 (20/115) at baseline, 3 and 12 months, respectively. Baseline parameters with a significant predictive value of 12-month visual acuity by univariate analysis were presence of intraretinal fluid, presence of SHRM, highly reflective SHRM, well-defined SHRM borders, and thick SHRM. These parameters, with the exception of high reflectivity, were significant on multivariate regression analysis. The most predictive baseline parameter was well-defined SHRM borders. CONCLUSION: This study supports the use of SHRM as a prognostic biomarker when interpreting optical coherence tomography in neovascular age-related macular degeneration. Baseline parameters predicting poorer vision 1 year after intravitreal bevacizumab treatment were as follows: presence of central SHRM, well-defined SHRM borders, intraretinal fluid, and thicker SHRM.

Modified treatment of distichiasis with direct tarsal strip excision without mucosal graft.

PURPOSE: To describe a new modified technique of direct tarsal excision for treatment of distichiasis. METHODS: Retrospective review of consecutive patients who underwent direct tarsal excision without grafting to treat distichiasis between December 2007 and November 2015. Gender, number of eyelids treated, follow-up time, and surgical outcome were recorded. The technique involved dividing the anterior and posterior lamella and excising a two mm tarsoconjunctival strip including the abnormal lash follicles, without suturing or mucosal graft. RESULTS: Seventeen eyelids of 12 patients (Fourteen upper eyelids and 3 lower eyelids) were studied. Sixteen eyelids had acquired distichiasis and one eyelid had congenital distichiasis. Mean age was 64.8 (SD 22.0; range, 25-86 years) Mean postoperative follow-up time was 53 months (SD = 31, range 8 - 104 months). During this period, no recurrence was documented. There were no complications. CONCLUSIONS: Direct tarsal excision without a graft is a safe, quick, and effective method for the treatment of distichiasis.

Impact of simulator training on resident cataract surgery.

BACKGROUND: Virtual reality surgery simulation training improves resident performance as measured by the simulator itself and wet-lab performance. This study aims to determine whether virtual surgery simulator training improves actual resident cataract surgery performance. METHODS: The first 50 phacoemulsification cases of 20 residents, at a single residency program (Henry Ford Hospital), were retrospectively compared as two groups: before (2007-8) and after (2009-10) introduction of the Eyesi virtual surgery simulator to the surgical training program. Primary outcomes were the incidence of posterior capsule tears and operation duration. All residents received traditional didactic and wet-lab training. Instructor surgeons were surveyed for their impression of the simulator's contribution to resident surgical training. RESULTS: The nonsimulator and simulator groups each comprised 500 cases with 40 and 35 posterior capsule tears respectively. Capsular tear rates for the nonsimulator and simulator groups were 8.8 % and 10 % respectively for the first 25 cases, and 7.2 % and 3.6 % (P = 0.11) respectively for cases 26 through 50 . The percentage of long cases (defined as >40 min) for cases 10 through 50 was 42.3 % and 32.4 % (P = 0.005) for the nonsimulator and simulator groups respectively. CONCLUSIONS: Virtual reality surgical simulator training mildly shortens the learning curve for the first 50 phacoemulsification cases. The less adept residents appear to benefit most.

Retinal blood flow velocity in metabolic syndrome.

BACKGROUND: Metabolic syndrome (MetS) is characterized by obesity, insulin resistance, dyslipidemia, and hypertension. The Retinal Function Imager (RFI) is a new technique for measuring retinal blood-flow velocity. This study aims to compare retinal blood flow velocity between MetS and healthy subjects. METHODS: Twenty eyes of 20 MetS males and 21 eyes of 21 aged-matched healthy males underwent RFI and carotid-femoral pulse wave velocity (PWV) measurement as well as assessment of MetS parameters. The results in MetS and healthy subjects were compared. RESULTS: The average venular velocity in the MetS patients was significantly higher than in the healthy subjects (2.7 ± 0.0 mm/sec versus 2.5 ± 0.0 mm/sec respectively, P=0.013), following adjustment for age, heart rate and systolic blood pressure. Carotid-femoral PWV was higher in the MetS population than the healthy controls (10.3 ± 1.2 mm/sec versus 9.3 ± 1.5 mm/sec respectively, P=0.005). The diastolic blood pressure and MAP were correlated strongly with the arterial blood flow velocities in healthy subjects (r=0.503, P=0.020 and r=0.474, P=0.030 respectively) but not in MetS subjects. CONCLUSIONS: The RFI was able to distinguish between the retinal blood flow of normal and MetS subjects. Higher venular blood flow velocity and the poor correlation between velocity and blood pressure of MetS subjects suggest that MetS causes microvascular damage.

Monovision surgery in myopic presbyopes: visual function and satisfaction.

PURPOSE: To describe our experience with monovision excimer laser correction in individuals with myopic presbyopia. METHODS: This prospective interventional case series was conducted in a private refractive surgery center on 40 patients with presbyopia aged 40 years and older, who were treated with monovision refractive surgery between 2010 and 2011. The dominant eye was corrected for distance vision and the nondominant eye was corrected for near vision, with anisometropia of ≥1.00 diopters (D). All patients underwent comprehensive objective and subjective visual assessments, including a questionnaire that was filled out preoperatively and at 6 and 12 months postoperatively. The primary outcomes were preoperative and postoperative refraction, binocular visual acuity, stereopsis, contrast sensitivity, glare, and questionnaire results. RESULTS: The 1-year follow-up was completed by 38 patients (95%). Preoperative and 1-year postoperative refraction of the distance eye spherical equivalent (SE), anisometropia SE, and uncorrected visual acuity were -4.05 ± 1.94 and -0.01 ± 0.22 D, 0.45 ± 0.50 and 1.73 ± 0.56 D, and 0.87 ± 0.2 and 0.09 ± 0.11 logMAR, respectively. Best-corrected visual acuity was unchanged. Both mean distance and near stereopsis decreased, from 52 to 142 seconds of arc and from 54 to 57 seconds of arc, respectively. Contrast sensitivity and glare decreased significantly. Patient satisfaction improved from 41.5 ± 30.4% to 85.2 ± 5.0% (range, 40 to 100%) at the 1-year follow-up. CONCLUSIONS: Monovision excimer laser correction provides both effective and satisfactory results and should be considered as an option for individuals with myopic presbyopia suitable for, and interested in, refractive surgery.

CENTRAL RETINAL VEIN OCCLUSION WITH SEVERE MACULAR EDEMA IN EARLY PREGNANCY.

PURPOSE: To report the clinical course and treatment outcomes of a patient with central retinal vein occlusion with severe macular edema in early pregnancy. METHODS: Interventional case report. RESULTS: A 39-year-old woman with gestational diabetes mellitus and a 15-pack year smoking history presented at 7 weeks gestation with decreased vision due to central retinal vein occlusion with marked macular edema. One month later, visual acuity had decreased to 20/400, and macular edema had worsened to a central subfield thickness of 1,432 µ m. She was treated with a single intravitreal dexamethasone implant at 16 weeks gestation. She responded well with visual acuity improving to 20/40+ and complete resolution of macular edema. At 33 weeks gestation, the cystoid macular edema recurred, but the patient refused treatment. The cystoid macular edema spontaneously resolved 3 weeks postpartum but recurred 3 months later with visual acuity worsening to 20/50. This macular edema resolved completely after a single 1.25 mg bevacizumab injection. She required no further treatment, and 23 months later, her macula was dry with visual acuity of 20/25. Her baby was healthy. CONCLUSION: Although pregnancy seems to aggravate central retinal vein occlusion -associated macular edema, the visual loss may be reversible. Intravitreal steroid seems to be effective during pregnancy with no apparent systemic or fetal complications. Young patients with retinal vein occlusion and center-involving macular edema may stabilize with minimal treatment.

Ganglion Cell Layer Thickness Change in Neovascular Age-Related Macular Degeneration Treated With Anti-VEGF Injections.

Purpose: This work assesses bilateral ganglion cell layer-inner plexiform layer (GCL-IPL) thickness changes in patients with unilateral neovascular age-related macular degeneration (nAMD) treated with antivascular endothelial growth factor (anti-VEGF). Methods: In this single-center, retrospective, cohort study, the medical records of patients with unilateral nAMD treated with anti-VEGF were reviewed. The treated group included eyes with newly diagnosed nAMD that subsequently underwent treatment with intravitreal anti-VEGF injections. The control group was the fellow eye with dry AMD. Eyes receiving at least 10 intravitreal injections were included. Measurement of GCL-IPL thickness was performed at different time points using spectral domain-optical coherence tomography. Results: A total of 216 eyes of 108 patients met the inclusion criteria. The mean age ± SD was 80.1 ± 10.7 years. Eyes in the treated group underwent a mean ± SD of 20.2 ± 7.2 injections in 21.3 ± 6.8 months. At baseline, average mean ± SD of GCL-IPL thickness was 73.71 ± 8.81 µm and 73.84 ± 8.26 µm in the treated and fellow eye, respectively (P = .795). After 10 injections the average thickness was 65.41 ± 14.08 µm and 68.77 ± 13.24 µm in the treated and fellow eye, respectively (P = .007). The absolute decrease in thickness was significantly greater in the treated eye than the fellow eye (mean ± SD, 8.31 ± 11.19 µm vs 5.07 ± 10.83 µm, respectively; P = .002). Conclusions: GCL-IPL thickness decreased significantly in the treated group more than in the control group after 10 anti-VEGF injections. The mechanism and clinical significance of this observation warrants further study.

A 12-month prospective study to evaluate the efficacy of using the treat-and-extend regimen with intravitreal aflibercept as a Second-Line Treatment for Diabetic Macular Oedema (the TADI Study).

PURPOSE: To evaluate the efficacy of intravitreal aflibercept as a second-line therapy in eyes with persistent diabetic macular oedema (DMO) despite receiving initial bevacizumab treatment. METHODS: A prospective multicentre study was conducted in nine academic clinics in Israel. Starting from the first follow-up visit, a treat-and-extend regimen was applied in which the treatment intervals were extended by 2 weeks based on macular thickness using SD-OCT. The primary outcome was central subfield thickness (CST) at week 52. RESULTS: Forty-four patients (n = 48 eyes) were recruited to the study, and 43 eyes completed 52 weeks of follow-up. Patients received a mean (±SD) of 7.9 ± 3.5 bevacizumab injections before enrolment. The mean (±SD) CST under aflibercept therapy decreased from 468 ± 131 µm at baseline to 303 ± 67 µm at 52 weeks (p = 0.002), and best corrected visual acuity improved from 64 ± 15 ETDRS letters at baseline to 75 ± 8 letters at week 52 (p = 0.001). Twenty (46%) eyes met the treat-and-extend criteria and received a mean (±SD) of 10.9 ± 2 aflibercept injections. CONCLUSIONS: Eyes with persistent DMO following initial bevacizumab therapy had a marked reduction in macular thickness and improved visual acuity following 1 year of treatment with intravitreal aflibercept. Less than half of the patients met eligibility criteria for extension of the treatment interval; for these patients, the treat-and-extend regimen resulted in a maximum treatment interval of 10 weeks during the first year.

Splenic infarction: an update on William Osler's observations.

BACKGROUND: Osler taught that splenic infarction presents with left upper abdominal quadrant pain, tenderness and swelling accompanied by a peritoneal friction rub. Splenic infarction is classically associated with bacterial endocarditis and sickle cell disease. OBJECTIVES: To describe the contemporary experience of splenic infarction. METHODS: We conducted a chart review of inpatients diagnosed with splenic infarction in a Jerusalem hospital between 1990 and 2003. RESULTS: We identified 26 cases with a mean age of 52 years. Common causes were hematologic malignancy (six cases) and intracardiac thrombus (five cases). Only three cases were associated with bacterial endocarditis. In 21 cases the splenic infarction brought a previously undiagnosed underlying disease to attention. Only half the subjects complained of localized left-sided abdominal pain, 36% had left-sided abdominal tenderness; 31% had no signs or symptoms localized to the splenic area, 36% had fever, 56% had leukocytosis and 71% had elevated lactate dehydrogenase levels. One splenectomy was performed and all patients survived to discharge. A post hoc analysis demonstrated that single infarcts were more likely to be associated with fever (20% vs. 63%, p < 0.05) and leukocytosis (75% vs. 33%, P = 0.06) CONCLUSIONS: The clinical presentation of splenic infarction in the modern era differs greatly from the classical teaching, regarding etiology, signs and symptoms. In patients with unexplained splenic infarction, investigation frequently uncovers a new underlying diagnosis.

Unilateral optic disc swelling in a fighter pilot.

Optic disc swelling occurs when there is an obstruction to axonal transport at the level of the lamina cribrosa. This may result from compression, ischemia, inflammation, or metabolic and toxic etiologies. Some of these etiologies may be life threatening and others may be self-limited. Thus, differentiating the different etiologies is important, albeit often difficult. We present a case of a 25-yr-old high-performance fighter aviator who presented with unilateral optic disc swelling 2 d after an F-16 flight, in which decompression was suspected. Visual acuity of the affected eye was decreased to 20/25, with enlarged blind spot and shallow arcuate scotomata on visual field testing. Pupil function, brightness intensity, and color vision were normal. Marked swelling of the entire optic disc, retinal flame-shaped hemorrhages, and engorgement of the retinal veins were seen. Since decompression sickness with nitrogen bubbles obstructing the optic nerve head vasculature was suspected, he was treated with hyperbaric oxygen. He rapidly improved, recovering full vision function within 6 d. No concurrent disease was found on extensive investigation. He returned to high-performance aviation 3 mo after onset of symptoms. No recurrence was seen during 3 yr of follow-up.

Rare Genetic Variants in Jewish Patients Suffering from Age-Related Macular Degeneration.

PURPOSE: To identify rare genetic variants in early age-related macular degeneration (AMD) utilizing whole-exome sequencing (WES). METHODS: Eight non-related early-AMD families of different Jewish ethnicities were ascertained. Initial mutation screening (phase-1) included common complement factor-H (CFH) p.Y402H; and age relatedmaculopathy susceptibility 2 (ARMS2) p.A69S; and rare variants complement factor-I (CFI) p.V412M; and hemicentin1 (HMCN1) c.4163delC identified previously in our population. Four families, whose initial screening for the aforementioned variants was negative, underwent WES (phase-2). Bioinformatics filtering was based on functionality (from a panel of 234 genes with proven or presumed association to AMD); predicted severity; and frequency (rare variants with minor allele frequency <1%). When applicable, further screening for specific rare variants was carried out on additional cases of similar ethnicities and phenotypes (phase-3). RESULTS: Phase-1 identified three families carrying CFI p.V412M mutation. WES analysis detected probable disease-related variants in three out of the remaining families. These included: a family with a variant in PLEKHA1 gene p.S177N; a family with previously reported variant p.R1210C in CFH gene; and two families with the C3 p.R735W variant. CONCLUSIONS: Rare, high-penetrance variants have a profound contribution to early-AMD pathogenesis. Utilization of WES in genetic research of multifactorial diseases as AMD, allows a thorough comprehensive analysis with the identification of previously unreported rare variants.

Diabetic macular edema treated with ranibizumab following bevacizumab failure in Israel (DERBI study).

PURPOSE:: To evaluate the outcome of second-line intravitreal ranibizumab treatment in eyes with diabetic macular edema having persistent edema following initial therapy with intravitreal bevacizumab. METHODS:: Diabetic macular edema treated with ranibizumab following bevacizumab failure in Israel was a retrospective, multi-center study. Consecutive eyes with persistent diabetic macular edema following at least three previous intravitreal bevacizumab injections prior to intravitreal ranibizumab, at least three-monthly intravitreal ranibizumab injections and at least 12 months of follow-up were included. Data collected included demographics, ocular findings, diabetes control, details of intravitreal bevacizumab and ranibizumab injections, and visual and anatomical measurements before and after intravitreal ranibizumab treatment. RESULTS:: In total, 202 eyes of 162 patients treated at 11 medical centers across Israel were included. Patients received a mean (±standard deviation) of 8.8 ± 4.9 intravitreal bevacizumab injections prior to the switch to intravitreal ranibizumab. A mean of 7.0 ± 2.7 intravitreal ranibizumab injections were given during the 12 months following the switch to intravitreal ranibizumab. The median central subfield retinal thickness (±interquartile range) by spectral-domain optical coherence tomography decreased from 436 ± 162 µm at baseline to 319 ± 113 µm at month 12 (p < 0.001). Median logMAR visual acuity (±interquartile range) improved from 0.40 ± 0.48 at baseline to 0.38 ± 0.40 at month 12 (p = 0.001). Linear regression suggested that higher number of intravitreal ranibizumab injections and higher pre-switch central subfield retinal thickness were associated with favorable visual outcome. Higher number of intravitreal bevacizumab injections and the presence of intraretinal fluid before the switch lessened the odds of favorable outcome. CONCLUSION:: Switching from bevacizumab to ranibizumab in persistent diabetic macular edema was associated with anatomical improvement in the majority of eyes and ⩾2 lines of vision improvement in 22% of eyes.

Visual loss after transscleral diode laser cyclophotocoagulation for primary open-angle and neovascular glaucoma.

BACKGROUND AND OBJECTIVE: Varying incidences of visual loss after transscleral diode laser cyclophotocoagulation for uncontrolled intraocular pressure (IOP) have been reported. This study compared the treatment response in primary open-angle (POAG) and neovascular (NVG) glaucoma, particularly regarding vision loss. PATIENTS AND METHODS: Case notes of consecutive patients who underwent transscleral diode laser cyclophotocoagulation between March 2001 and September 2005 were retrospectively reviewed. A diagnosis of POAG or NVG and at least 6 months of follow-up were required for inclusion. Conservative laser parameters were used. The treatment response of the POAG and NVG groups was compared. RESULTS: Twenty-five eyes of23 patients with POAG and 14 eyes of 14 patients with NVG were studied. Mean follow-up was 22.4 and 12.9 months in the POAG and NVG groups, respectively. Post-treatment, both groups had significant reduction in mean IOP of 7.3 (29.2%) and 13.2 (36.6%) mm Hg, respectively (between group P = .18). One eye in each group had mild hypotony of 4 mm Hg, and no eyes became phthisical. Oral acetazolamide treatment was significantly reduced in both groups. Visual acuity post-treatment decreased in both groups; the POAG eyes had better initial visual acuity and lost more visual acuity. Nine of 25 (36%) POAG and 4 of 8 (50%) NVG eyes lost 2 or more LogMAR lines. CONCLUSIONS: Transscleral diode laser cyclophotocoagulation reduced IOP and medication requirements in POAG and NVG. Patients should be warned that visual loss may occur, especially in endstage glaucoma.

Ocular morbidity in natural disasters: field hospital experience 2010-2015.

PURPOSE: To determine the characteristics of ocular injuries treated by Israel Defense Forces (IDF) field hospital following three natural disasters: the 2010 earthquake in Haiti, the 2013 typhoon in the Philippines, and the 2015 earthquake and avalanche in Nepal. The purpose was to provide data, which would assist allocation of ocular resources for future disasters. DESIGN: Retrospective database study. METHODS: Ocular clinical data collected from the IDF database. Time postdisaster was divided into three periods: 4-8, 9-12, and 13-16 days. Diagnoses were categorized as disaster-related (DRD), defined as directly resulting from the disaster (mostly ocular trauma), and nondisaster-related (NDRD), defined as preexisting conditions or results of postevent living conditions problems. RESULTS: The field hospitals began functioning 3-8 days after the disaster and continued for 10.3 ± 1.5 days. Ocular conditions were treated in 265 (4.9%) of the total 5356 patients. Sixty-five cases were DRD and 200 were NDRD. Around day 9 postdisaster the predominant ocular referral changed from DRD to NDRD. CONCLUSIONS: Deployment of a field hospital to a natural disaster area should take into account the type and geographic location of the disaster as well as the high number of nontraumatic ocular conditions.

Vision improvement in pilots with presbyopia following perceptual learning.

Israeli Air Force (IAF) pilots continue flying combat missions after the symptoms of natural near-vision deterioration, termed presbyopia, begin to be noticeable. Because modern pilots rely on the displays of the aircraft control and performance instruments, near visual acuity (VA) is essential in the cockpit. We aimed to apply a method previously shown to improve visual performance of presbyopes, and test whether presbyopic IAF pilots can overcome the limitation imposed by presbyopia. Participants were selected by the IAF aeromedical unit as having at least initial presbyopia and trained using a structured personalized perceptual learning method (GlassesOff application), based on detecting briefly presented low-contrast Gabor stimuli, under the conditions of spatial and temporal constraints, from a distance of 40 cm. Our results show that despite their initial visual advantage over age-matched peers, training resulted in robust improvements in various basic visual functions, including static and temporal VA, stereoacuity, spatial crowding, contrast sensitivity and contrast discrimination. Moreover, improvements generalized to higher-level tasks, such as sentence reading and aerial photography interpretation (specifically designed to reflect IAF pilots' expertise in analyzing noisy low-contrast input). In concert with earlier suggestions, gains in visual processing speed are plausible to account, at least partially, for the observed training-induced improvements.

Effect of G-force on bicuspid aortic valve in aviators.

BACKGROUND AND AIMS: Bicuspid aortic valve (BAV) is a common congenital cardiac malformation. The major complications are aortic stenosis (AS), aortic regurgitation (AR), infectious endocarditis and aortic dissection. This paper aims to assess the hemodynamic importance of incidentally-found BAV in military aviators and evaluate the effect of high G-force on disease progression. METHODS: Aviators with BAV were detected by reviewing all cardiac assessment records between 1987 and 2005. All aviators underwent annual flight surgeon examination. Echocardiography was performed as recommended by our cardiologists and flight surgeons. RESULTS: Eight newly diagnosed cases of BAV were found. All of the aviators continued active aviation throughout the study period. Repeat echocardiography demonstrated progressive widening of the aortic diameter in five of the eight aviators. No worsening of valve dysfunction was seen in those with mild aortic regurgitation at diagnosis. Left ventricular dimensions and function did not deteriorate. No new valve complications, including infectious endocarditis, were seen. The age at diagnosis strongly correlated with the root diameter change; both total (r = 0.74, p = 0.02) and annualized (r = 0.78, p = 0.02) change. Over a mean follow-up period of 12.1 years, no difference was seen in the progression of BAV in high-performance as compared to low-performance aviators. CONCLUSIONS: Exposure to G-force and anti-G maneuvers does not appear to worsen cardiac and valve function in aviators with BAV.

The effect of astigmatism axis on visual acuity.

PURPOSE: To evaluate the effect of astigmatism axis on uncorrected distance visual acuity (UDVA) in emmetropic eyes that underwent laser refractive surgery. METHODS: This retrospective study included patients who underwent laser in situ keratomileusis or photorefractive keratectomy between January 2000 and December 2015 at the Care-Vision Laser Centers, Tel Aviv, Israel. Eyes with a 3-month postoperative spherical equivalent between -0.5 D and 0.5 D were included in this study. Eyes with ocular comorbidities and planned ametropia were excluded. Study eyes were divided into 3 groups according to the steep astigmatic axis: with the rule (WTR) (60-120), oblique (31-59 or 121-149), and against the rule (ATR) (0-30 or 150-180). The UDVA of these 3 groups was compared. The oblique group was divided into oblique ATR and oblique WTR, which were compared with each other. RESULTS: A total of 17,416 consecutive eyes of 8,708 patients were studied. The WTR eyes (n = 10,651) had significantly better UDVA (logMAR 0.01 ± 0.08) than the oblique (n = 3,141, logMAR 0.02 ± 0.09) and ATR eyes (n = 3,624, logMAR 0.02 ± 0.10) (p<0.001). The oblique WTR group had significantly better UDVA than the oblique ATR group (p<0.001). The UDVA of the oblique and ATR groups was similar. Stepwise multiple regression analysis showed that the group accounted for 15% of the UDVA variance (p = 0.04). CONCLUSIONS: The astigmatic axis has a small but significant effect on UDVA in emmetropic eyes; WTR was better than oblique and ATR astigmatism. Therefore, when correcting astigmatism, it may be preferable to err towards WTR astigmatism.

Predictors of myopic photorefractive keratectomy retreatment.

PURPOSE: To determine the factors associated with retreatment after photorefractive keratectomy (PRK) in myopic eyes. SETTING: Care-Vision Laser Centers, Tel-Aviv, Israel. DESIGN: Retrospective cohort study. METHODS: A large database on myopic PRK with mitomycin-C (MMC) performed from 2005 to 2012 was studied. Patients were divided into 2 groups according to whether they had retreatment. Multiple preoperative and intraoperative parameters were analyzed for association with retreatment. RESULTS: A total of 9699 eyes of 9699 consecutive patients were studied. The mean age was 25.9 years ± 7.3 (SD); 54.1% were men. The mean preoperative subjective spherical equivalent and astigmatism were -4.30 ± 2.18 diopters (D) (range -0.5 to -13.0 D) and 0.77 ± 0.83 D (range 0 to 6.0 D), respectively. Two hundred twenty-three eyes (2.30%) were retreated. The 2-year retreatment rate decreased from 42 (6.17%) for primary PRK treatments done in 2005 to 2 (0.10%) for primary PRK done in 2012 (R2 = 0.79, P < .001). Multiple binary logistic regression analysis showed that transepithelial PRK, astigmatism equal to or higher than 3.5 D, and surgeon factor significantly increased the odds of retreatment. Additional parameters significant on univariate analysis alone included age older than 40 years, low preoperative sphere, maximum ablation depth less than 45 µm, preoperative corrected distance visual acuity better than 20/20, MMC application longer than 40 seconds, and optical ablation zone smaller than 7.0 mm. CONCLUSION: The retreatment incidence of PRK has continued to decrease. High astigmatism and transepithelial PRK were associated with increased myopic PRK retreatment rates.