Alanna S. Nattis

Preoperative ketorolac tromethamine 0.4% in phacoemulsification outcomes: Pharmacokinetic-response curve

PURPOSE: To assess the clinical benefit, relative efficacy, and pharmacokinetic‐response curve of preoperative and postoperative ketorolac tromethamine 0.4% (Acular LS) to improve outcomes during and after cataract surgery. SETTING: Private clinical practice. METHODS: One hundred patients were randomized in a double‐masked fashion to 4 groups of 25 to receive ketorolac for 3 days, 1 day, or 1 hour or a placebo before phacoemulsification. All treatment groups received ketorolac 0.4% for 3 weeks postoperatively; the placebo group received vehicle. Outcomes measures were preservation of preoperative mydriasis, phacoemulsification time and energy, operative time, corneal clarity, endothelial cell counts, postoperative inflammation, intraoperative and postoperative discomfort, complications, and incidence of clinically significant cystoid macular edema (CME). RESULTS: Maintenance of pupil size with 3‐day ketorolac dosing was significantly better than with 1‐day dosing (P<.01), which was significantly better than with 1‐hour or placebo dosing (P<.01). Both 3‐day and 1‐day dosing were superior to 1‐hour or placebo dosing. No patient receiving ketorolac 0.4% for 1 or 3 days developed CME compared with 12% of patients in the control (placebo) group and 4% in the 1‐hour group. Three‐day and 1‐day dosing of ketorolac reduced surgical time, phacoemulsification time and energy, and endothelial cell loss and improved visual acuity in the immediate postoperative period compared with 1‐hour predosing and the placebo (P<.05). CONCLUSION: The preoperative use of ketorolac tromethamine 0.4% for 3 days followed by 1‐day of predosing provided optimum efficacy and superior outcomes relative to 1‐hour pretreatment and a placebo.

Pterygium Excision with Conjunctival Autograft

Pterygium is characterized by encroachment of an abnormal fibrovascular tissue from the bulbar conjunctiva onto the cornea (Arch Ophthalmol 115:1235–1240, 1997). Upon reaching the corneal surface, this fibrovascular tissue exerts cicatricial traction that flattens the caruncle and obliterates the semilunar fold (Arch Ophthalmol 130:39–49, 2012). The indications for pterygium surgery include reduced vision due to obscuration of the optical center of the cornea, irregular astigmatism, chronic irritation, recurrent inflammation, motility restriction, and cosmesis. Numerous surgical techniques have been described, but the main concern of pterygium surgery is the unpredictable rate and timing of recurrence (Ocul Surf 12:112–119, 2014). The underlying cause of pterygia is thought to be secondary to UV light exposure and arid conditions. Patients should have been evaluated and deemed appropriate for such surgical intervention. Patients should have been educated about the risks and benefits of the procedure, including alternatives.

Topography-Guided Ablations: Early US Experience and Utility Across the Refractive Landscape

Purpose of ReviewThis paper evaluated topography-guided excimer ablations and recent US experience of this technology. Personal clinical experience, initial approval of the technique, and its application to a potential extended spectrum of clinical conditions was reviewed.Recent FindingsTopography-guided ablation can precisely treat corneas with variable topographic indices and attempt to neutralize irregularities by combining myopic and hyperopic ablation profiles. The T-CAT Phase III study demonstrated the safety and efficacy of this technique, which earned FDA approval in 2013. Current literature has reinforced its efficacy and explored off-label investigations, such as its use to improve visual results in abnormal corneas (e.g., keratoconus, post-LASIK ectasia).SummaryTopography-guided ablation provides increased quality of vision without necessitating excess tissue removal in otherwise normal, keratoconic, ectatic, or post-corneal transplant eyes. In the future, we will likely see a combination of treatment strategies, enabling ophthalmologists to treat the entire refractive surface and refine these already remarkable results.

Pterygium Excision with Conjunctival Pedicle Graft

Pterygium is characterized by encroachment of an abnormal fibrovascular tissue from the bulbar conjunctiva onto the cornea (Arch Ophthalmol 115:1235–1240, 1997). Upon reaching the corneal surface, this fibrovascular tissue exerts cicatricial traction that flattens the caruncle and obliterates the semilunar fold (Arch Ophthalmol 130:39–49, 2012). The indications for pterygium surgery include reduced vision due to obscuration of the optical center of cornea, irregular astigmatism, chronic irritation, recurrent inflammation, motility restriction, and cosmesis. Numerous surgical techniques have been described, but the main concern of pterygium surgery is the unpredictable rate and timing of recurrence (Ocul Surf 12:112–119, 2014). The underlying cause of pterygia is thought to be secondary to UV light exposure and arid conditions. Patients should have been evaluated and deemed appropriate for such surgical intervention. Patients should have been educated about the risks and benefits of the procedure, including alternatives.

Pterygium Excision with Amniotic Membrane Graft

Pterygium is characterized by encroachment of an abnormal fibrovascular tissue from the bulbar conjunctiva onto the cornea (Arch Ophthalmol 115:1235–1240, 1997). Upon reaching the corneal surface, this fibrovascular tissue exerts cicatricial traction that flattens the caruncle and obliterates the semilunar fold (Arch Ophthalmol 130:39–49, 2012). The indications for pterygium surgery include reduced vision due to obscuration of the optical center of cornea, irregular astigmatism, chronic irritation, recurrent inflammation, motility restriction, and cosmesis. Numerous surgical techniques have been described, but the main concern of pterygium surgery is the unpredictable rate and timing of recurrence (Ocul Surf 12:112–119, 2014). The underlying cause of pterygia is thought to be secondary to UV light exposure and arid conditions. Patients should have been evaluated and deemed appropriate for such surgical intervention. Patients should have been educated about the risks and benefits of the procedure, including alternatives.

Operative Dictations in Ophthalmology

Pterygium is characterized by encroachment of an abnormal fibrovascular tissue from the bulbar conjunctiva onto the cornea (Arch Ophthalmol 115:1235– 1240, 1997). Upon reaching the corneal surface, this fibrovascular tissue exerts cicatricial traction that flattens the caruncle and obliterates the semilunar fold (Arch Ophthalmol 130:39–49, 2012). The indications for pterygium surgery include reduced vision due to obscuration of the optical center of the cornea, irregular astigmatism, chronic irritation, recurrent inflammation, motility restriction, and cosmesis. Numerous surgical techniques have been described, but the main concern of pterygium surgery is the unpredictable rate and timing of recurrence (Ocul Surf 12:112–119, 2014). The underlying cause of pterygia is thought to be secondary to UV light exposure and arid conditions. Patients should have been evaluated and deemed appropriate for such surgical intervention. Patients should have been educated about the risks and benefits of the procedure, including alternatives.

Cataract Extraction, the Use of Iris Hooks for Intraoperative Floppy Iris Syndrome (IFIS)

Patients should have been evaluated and deemed appropriate for such surgical intervention. Surgical indications for cataracts include those that impair visual acuity, create visual disability, affect activities of daily living, or deemed medically necessary for monitoring or further surgical procedures. Additionally, intraoperative floppy iris syndrome can occur in any individual with a current or past history of alpha-1 antagonist use. All patients should be screened regarding past and current medication use, as well as all medical conditions. Patients should have been educated about the risks and benefits of the procedure, including alternatives.

Glued Intrascleral Haptic Fixation of an Intraocular Lens

Patients should have been evaluated and deemed appropriate for such surgical intervention. Patient was noted to have a dislocated lens, intraoperative posterior capsular rupture, Marfan syndrome, traumatic dislocation of lens, or aphakia that was creating visual disability and/or affecting activities of daily living that necessitated further surgical intervention. Patients should have been educated about the risks and benefits of the procedure, including alternatives.

Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK)

Patients evaluated and deemed appropriate for such surgical intervention. Endothelial dysfunction, pseudophakic corneal edema, bullous keratopathy, ICE syndrome, or any other pathology needing further surgical intervention. Patients should be educated about the risks and benefits of the procedure, including alternatives.

Limbal Relaxing Incision

Limbal relaxing incisions (LRIs) are corneal incisions placed adjacent to the limbus, just anterior to the vascular arcade. They are used to relax the steep axis of corneal astigmatism, while steepening the flat axis (coupling effect). LRIs must be as accurate as possible to yield the best result. LRI is performed for correction of corneal astigmatism and may be performed during cataract surgery, post-cataract extraction, or post-PKP. Prior to LRI, confirmation of corneal astigmatism with manual keratometry, evaluation of corneal topography to identify irregular astigmatism, and pachymetry at sites of planned incision(s) to avoid corneal perforation should be performed. LRI has been proven to be a convenient, practical, and cost-effective way of managing astigmatism.