Allon Barsam

Reshaping procedures for the surgical management of corneal ectasia.

&NA; Corneal ectasia is a progressive, degenerative, and noninflammatory thinning disorder of the cornea. Recently developed corneal reshaping techniques have expanded the treatment armamentarium available to the corneal specialist by offering effective nontransplant options. This review summarizes the current evidence base for corneal collagen crosslinking, topography‐guided photorefractive keratectomy, and intrastromal corneal ring segment implantation for the treatment of corneal ectasia by analyzing the data published between the years 2000 and 2014. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Anterior segment slitlamp photography using the iPhone.

(17.9%, 7/39) or incision (5.1%, 2/39). Most respondents reported no serious ocular hemorrhagic events from continuing antithrombotic agents (92.3%, 36/39) or serious thrombotic events from discontinuing them (94.4%, 34/36). Most (75.0%, 30/40) reported a greater concern about a perioperative thromboembolic event from discontinuing antithrombotic agents than about a perioperative ocular hemorrhage from continuing them. These results indicate that in most VHA hospitals, oral antithrombotic agents are not discontinued prior to cataract surgery. This finding is similar to the finding in a recent report from the Canadian Society of Cataract and Refractive Surgery 2 that most members (74.4%) did not discontinue antithrombotic therapy before cataract surgery. The rationale for this practice pattern appears to be a greater concern about the systemic risks of discontinuing antithrombotic agents than the risks of perioperative hemorrhagic ocular complications from continuing them. This rationale is supported by reports that ocular hemorrhages in cataract surgery patients on antithrombotic agents generally do not affect visual outcomes. 4,5,6 The weaknesses of a survey-based study have been described 3 and include limitations in generalizability due to distinct setting (most respondents worked in teaching hospitals rather than ambulatory surgery centers) and patient population (U.S. veterans) and potential bias due to a response rate of 45%. This study provides more insight into how cataract surgeons in the VHA currently manage patients on antithrombotic agents. Further research is needed to determine whether differences in management of antithrombotic therapy during cataract surgery are associated with distinct patient outcomes.

Spontaneous corneal clearance despite graft removal in Descemet stripping endothelial keratoplasty in Fuchs endothelial dystrophy.

Purpose: To report spontaneous corneal clearing with improved visual acuity and central endothelial cell repopulation after the removal of a dislocated donor button following Descemet stripping endothelial keratoplasty (DSEK). Methods: Interventional case report. Results: An 84-year-old woman with decreased visual acuity in the right eye secondary to Fuchs endothelial dystrophy and cataract underwent combined cataract extraction, intraocular lens implantation, and DSEK. After primary graft failure, the resulting detached, opaque, and retracted donor lenticule was removed from the eye 2 months after the initial surgery and not replaced. The cornea started to clear after the donor button removal with central endothelial cell repopulation. Conclusions: Corneal deturgescence is not strictly dependent on donor lenticule adhesion to the host posterior stromal surface. Endothelial cell migration and repopulation of the central cornea can occur after DSEK and after the removal of the failed endothelial graft, with corneal clearing and improved visual outcomes.

A spontaneous suprachoroidal haemorrhage: a case report

IntroductionWe present a case of spontaneous suprachoroidal haemorrhage in a patient taking Warfarin. This is only the second case reported of a patient whose anticoagulation was within the therapeutic range.Case presentationAn 84 year old white male with a history of end stage atrophic age related macular degeneration presented with angle closure glaucoma. The patient was taking warfarin and had a therapeutic International Normalized Ratio (INR). Ultrasound examination revealed a spontaneous suprachoroidal haemorrhage.ConclusionAnticoagulation is common in those with cardiovascular disease, which increases the risk of haemorrhagic complications. These patients are also more likely to suffer from age related macular degeneration. Suprachoroidal haemorrhage should be considered in such patients presenting with suspicious signs and a low threshold should be had for investigating for this condition in such circumstances. Early detection may reduce the morbidity.

Prospective randomized controlled trial to compare the effect on the macula of AquaLase liquefaction and ultrasound phacoemulsification cataract surgery.

PURPOSE: To compare the effect of ultrasound (US) phacoemulsification and AquaLase liquefaction (Alcon Laboratories) cataract surgery on the macula using optical coherence tomography (OCT). SETTING: Department of Ophthalmology, Queen Marys Hospital, London, United Kingdom. METHODS: Sixty‐three patients having cataract surgery were randomized to receive US phacoemulsification or AquaLase liquefaction cataract surgery. Macular thickness and volume were evaluated by OCT preoperatively and 2 and 6 weeks postoperatively. The primary outcomes were OCT central macular thickness and best corrected visual acuity at 6 weeks. Secondary outcomes were OCT macular volume and perioperative and postoperative complications. RESULTS: Over the 6‐week study, the median increase in foveal thickness in the study eye compared with that in the fellow eye was 11 μm (interquartile range [IQR] −21 to 23 μm) in the AquaLase group and 17 μm (IQR −11 to 33 μm) in the phacoemulsification group (P = .229). A subgroup analysis of diabetic patients found a median increase in foveal thickness in the study eye versus the fellow eye of 2 μm (IQR −14 to 23 μm) in the AquaLase group and 29 μm (IQR 11 to 41 μm) in the phacoemulsification group (P = .07). CONCLUSIONS: The results in this study suggest that AquaLase liquefaction cataract extraction is as safe as standard US phacoemulsification cataract extraction and may carry less risk for the development of postoperative cystoid macular edema. This may be most evident in diabetic patients.

Optic disc assessment in the emergency department: a comparative study between the PanOptic and direct ophthalmoscopes.

Optic disc assessment is an essential part of the neurological examination of acutely unwell patients. This study compares the PanOptic ophthalmoscope with the direct ophthalmoscope for accuracy of diagnosis and ease of use. Patient satisfaction was also compared for the two instruments. A single-masked prospective observational study was carried out. The authors showed that the PanOptic ophthalmoscope was more sensitive (p=0.03) and specific (p=0.03) than the direct ophthalmoscope. The PanOptic ophthalmoscope was preferred by both doctors (p=0.001) and patients (p=0.04) in terms of comfort and ease of use.

Advanced technology IOLs in cataract surgery: management of the unhappy patient.

Create realistic expectations for patients considering presbyopic intraocular lens (IOL) implantation. Outline the possible causes and treatment of unhappy patients after presbyopic IOL implantation. Describe the keys to prevention of untoward effects after presbyopic IOL implantation. Discuss the techniques to enhance patients to achieve emmetropia after refractive IOL implantation. Surgical techniques to improve outcomes with presbyopic IOLs. To understand the optics of presbyopic IOLs.

Meta-analysis of randomized controlled trials comparing excimer laser and phakic intraocular lenses for myopia between 6.0 and 20.0 diopters.

Purpose Meta-analysis of randomized controlled trials (RCTs) comparing excimer laser refractive surgery and phakic intraocular lenses (pIOLs) for the correction of myopia between 6.0 and 20.0 diopters (D). pIOLs are an alternative surgical option to excimer laser for these patients. The evidence base comparing these 2 methods has never been assessed systematically. Methods Cochrane Eyes and Vision Group, International. We performed a comprehensive literature search using the Cochrane Collaboration methodology to identify RCTs. A meta-analysis on the results of RCTs was performed. We analyzed data for efficacy outcomes, accuracy outcomes, safety outcomes, adverse effects, and quality-of-life measures. Results This review included 3 RCTs with a total of 228 eyes. The range of myopia was 6.0 to 20.0 D with up to 4.0 D of astigmatism. The pIOL group was less likely to lose 2 or more lines of best spectacle–corrected visual acuity at 12 months (odds ratio, 0.35; 95% confidence interval, 0.19–0.66, P = 0.001). PIOL surgery scored more highly on patient satisfaction/preference questionnaires. Conclusions The results of this systematic review show that pIOLs are safer within 1 year of follow-up compared with excimer laser surgical correction for myopia between 6 and 20 D. There is weaker evidence for superior visual quality in pIOL recipients. Further RCTs adequately powered for subgroup analysis with long-term follow-up are necessary to establish the ideal myopic range for excimer laser and pIOL treatments.

Relationship of Bell phenomenon with Salzmann nodular degeneration.

Purpose: To determine the relationship of Bell phenomenon with the presence and the location of Salzmann nodular degeneration. Methods: This is a noninterventional observational case series study. We reviewed the medical records of 10 patients with Salzmann nodules between 2001 and 2012. The mean age of participants was 60 years with 8 women and 2 men. A complete history and eye examination was performed with regular follow-up visits to document the progression of the disease. The data collected were as follows: age, gender, Snellen visual acuity, manifest refraction, Salzmann nodule location, presence of Bell or inverse Bell phenomenon, treatment, and associated conditions. Slit-lamp pictures to document the location of the Salzmann nodules and the direction of the Bell phenomenon were obtained. Results: Five patients had inferior Salzmann nodules with a normal Bell phenomenon and 5 patients had superior nodules with inverse Bell phenomenon. Nine of 10 patients had moderate to severe meibomian gland disease and dry eye syndrome as associated conditions. Two of the patients underwent removal of the nodules with lamellar keratectomy and 1 with phototherapeutic keratectomy, all with mitomycin-C application and without recurrence of the nodules at 1 year of follow-up. Conclusions: In all 10 patients the direction of the globe rotation during a normal or inverse Bell phenomenon was directly correlated to the location of the Salzmann nodules. Specifically, patients with inverse Bell phenomenon presented with superior nodule formation, whereas patients with a normal Bell phenomenon presented with inferior nodules.

Photorefractive keratectomy with mitomycin-C for the combined treatment of myopia and subepithelial infiltrates after epidemic keratoconjunctivitis

PURPOSE: To report the use of photorefractive keratectomy (PRK) with mitomycin‐C (MMC) to treat concomitant myopia and visually significant infiltrates associated with epidemic keratoconjunctivitis (EKC). SETTING: Ophthalmic Consultants of Long Island, Nassau University, Long Island, New York, USA. DESIGN: Interventional case series. METHODS: Consecutive patients with myopia and recalcitrant subepithelial infiltrates after EKC were treated with custom wavefront PRK (Visx S4 IR) and MMC with a target of emmetropia in all cases. RESULTS: The study evaluated 6 eyes of 3 patients. One year after treatment, all eyes attained an uncorrected distance visual acuity of 20/20 or better. There was no recurrence of infiltrates within the ablation zone in any eye. CONCLUSION: The use of topical MMC in conjunction with PRK to treat subepithelial infiltrates due to EKC provided good visual and refractive results. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.