Calvin W. Roberts

Comparison of topical cyclosporine, punctal occlusion, and a combination for the treatment of dry eye.

Purpose: To compare the efficacy of topical cyclosporine, punctal occlusion, and a combination for the treatment of dry eye. Methods: Patients with dry eye (N = 30) seen in a university-affiliated private practice were randomized to 1 of 3 treatments: cyclosporine 0.05% ophthalmic emulsion (RESTASIS) twice daily, lower-lid punctal plugs (PARASOL), or a plugs-cyclosporine combination. Tear volume, ocular surface staining, and artificial tear use were assessed at baseline and 1, 3, and 6 months. Results: All treatments improved Schirmer scores by 6 months (P ≤ 0.005 vs. baseline), with plug-containing regimens favored at 1 and 3 months (P < 0.001 vs. cyclosporine alone). Cyclosporine-containing regimens, but not plugs alone, improved rose bengal staining at 3 and 6 months (P ≤ 0.010 vs. baseline). Artificial tear use decreased with plug-containing regimens at 1 month and with all treatments at 3 and 6 months (P ≤ 0.005 vs. baseline). Combination therapy produced the greatest overall improvements and was superior to plugs alone in decreasing artificial tear use at 6 months (P = 0.012). Conclusions: All 3 regimens effectively treated dry eye. Plug-containing regimens increased wetness initially; cyclosporine appeared to promote long-term ocular surface health. The effects may be additive. Patients with punctal occlusion may benefit from adjunctive cyclosporine.

Pretreatment with Topical Didofenac Sodium to Decrease Postoperative Inflammation

PURPOSE Anti-inflammatory medications are traditionally administered to the eye only postoperatively for control of inflammation. Because the presumed mechanism of action of nonsteroidal anti-inflammatory drugs (NSAIDs) is to inhibit the formation of prostaglandin mediators of inflammation, the author studied the effect that pretreatment with an NSAID had on postoperative inflammation. METHODS In a prospective study, 60 patients scheduled for phacoemulsification with silicone lens implantation were randomly assigned to receive either (1) pretreatment with one drop of diclofenac sodium 0.1% four times per day for the 3 days before surgery plus one drop of diclofenac sodium 0.1% every 15 minutes for four doses, beginning 1 hour before surgery along with the dilating drops; (2) no pretreatment, but one drop of diclofenac sodium 0.1% every 15 minutes for four doses beginning 1 hour before surgery along with the dilating drops; or (3) no diclofenac sodium drops at all before surgery. No anti-inflammatory medications were given either during or immediately after surgery, and all patients were begun on a regimen of one drop of diclofenac sodium 0.1% to the operated eye four times per day after being examined on the first postoperative day. Postoperative inflammation was measured on the first postoperative day and at 1 week with a laser cell and flare meter. RESULTS On the first postoperative day, the mean flare score for group A was 25.59 photons/millisecond; for group B, 29.69 photons/millisecond; and for group C, 33.07 photons/millisecond. The difference between groups A and C was statistically significant. The differences between groups A and B and between groups B and C were not statistically significant. There was no statistically significant difference for cell scores at 1 day or for cell or flare scores at 1 week. CONCLUSIONS The pretreatment with an NSAID before cataract surgery can reduce the amount of initial postoperative inflammation.

Wide-Field Specular Microscopy

Specular microscopy offers a unique opportunity to study living cells in vivo at high magnification. Many live cells may, of course, be observed in vitro, but in vivo the only live cells that can be seen are red blood cells flowing through capillaries or, with difficulty, endothelial cells in superficial blood vessels.

Cataract surgery in anticoagulated patients.

ABSTRACT A prospective study was performed on 31 patients having planned extracapsular cataract extraction with posterior chamber intraocular lens implantation. The patients were considered to be anticoagulated because of the medications, they were taking. The patients were instructed to continue their usual medications throughout the perioperative period including the day of surgery. All patients had routine narcoleptic sedation and retrobulbar anesthesia. The surgical technique was altered to use an inferior corneal traction suture and a single planed clear corneal incision. No intraoperative or postoperative anterior chamber bleeding was seen. The observed complications were increased awareness of corneal sutures, increased endothelial cell loss, delayed visual rehabilitation from with‐the‐rule astigmatism, and transient corneal edema. All patients achieved 20/40 or better visual acuity without corneal edema by three months post‐surgery.

Cyclosporine 0.05% to improve visual outcomes after multifocal intraocular lens implantation.

PURPOSE: To evaluate the efficacy of cyclosporine 0.05% in alleviating dry‐eye signs and improving visual quality after multifocal intraocular lens (IOL) implantation. SETTING: Private practice and university medical center, New York, New York, USA. METHODS: This randomized prospective contralaterally controlled double‐masked trial comprised patients scheduled to have bilateral phacoemulsification with implantation of a refractive multifocal IOL (ReZoom). Patients received twice‐daily cyclosporine 0.05% in 1 eye and an artificial tear in the other eye from 1 month before to 2 months after second‐eye surgery. Outcomes were evaluated at baseline and 2 months after second‐eye surgery. RESULTS: The study enrolled 28 eyes of 14 patients. At baseline, there were no statistically significant between‐group differences in outcome measures. Two months postoperatively, the cyclosporine group had significantly lower mean uncorrected distance visual acuity than the artificial tear group (0.11 logMAR ± 0.03 [SD] [20/25 Snellen equivalent] versus 0.19 ± 0.05 logMAR [20/30]; P = .045) as well as significantly lower mean corrected distance visual acuity (0.0 ± 0.02 logMAR [20/20] versus 0.1 ± 0.02 logMAR [20/25]; P = .005) and corneal staining scores (0.210 ± 0.07 versus 0.645 ± 0.18; P = .034). Treatment with cyclosporine 0.05% also improved contrast sensitivity, conjunctival staining, and tear breakup time. Significantly more patients preferred the eye treated with cyclosporine 0.05% to the eye treated with artificial tears (57.1% versus 14.3%; P = .007). CONCLUSION: Cyclosporine 0.05% therapy reduced dry‐eye signs and improved visual quality after multifocal IOL implantation. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

Comparison of diclofenac sodium and flurbiprofen for inhibition of surgically induced miosis

Purpose: To compare the efficacy of two topical nonsteroidal anti‐inflammatory drugs, diclofenac sodium and flurbiprofen, commonly used prior to cataract surgery to inhibit surgically induced miosis. Setting: Department of Ophthalmology, Cornell University Medical College, The New York Hospital, New York, New York. Methods: Fifty‐one patients having phacoemulsification were randomly assigned to receive topical treatment with either diclofenac sodium 0.1 % or flurbiprofen 0.03% every 15 minutes for four doses along with their dilating drops beginning 1 hour before surgery. All surgeries were videotaped, with the magnification calibrated. The videotapes were analyzed and the horizontal and vertical diameters of the pupil were measured just before the initial conjunctival incision (baseline) and then every 5 minutes during the procedure. Measurements were also made at the beginning of capsulorhexis, the beginning of phacoemulsification, the end of phacoemulsification, the end of cortical cleanup, and before and after implantation of an intraocular lens. Results: There was no statistically significant difference between the two treatment groups in baseline pupil dilation; however, regardless of the drug received, the light irides were, on average, more dilated at baseline than the dark ones. After surgery began, there were no statistically significant differences between the two groups at any time or surgical interval except at the start of phacoemulsification, at which point the flurbiprofen‐treated eyes were more dilated than the diclofenac‐treated eyes. Conclusion: Diclofenac sodium and flurbiprofen were equally effective in maintaining intraoperative mydriasis during cataract surgery.

Intraocular miotics and postoperative inflammation

ABSTRACT Sixty patients scheduled for planned extracapsular cataract extraction with intraocular lens (IOL) implantation were randomly assigned to receive acetylcholine chloride, carbachol, or balanced salt solution (BSS) immediately after IOL placement and at the end of the surgical case. As part of the postoperative evaluation, patients were examined at the first and eighth postoperative day with a Kowa FC‐1000 laser flare and cell meter to assess objectively the amount of postoperative inflammation. At day one and day eight, the amount of cell and flare in the carbachol group was significantly greater than in the acetylcholine group or in the BSS control group. The acetylcholine group had significantly less flare than the BSS group at day one; yet there was no difference between the two groups at day eight, nor was there a significant difference in the amount of cells between day one and day eight. It is presumed that the prolonged miosis seen in the carbachol group delays the re‐establishment of the blood‐aqueous barrier after surgery, causing the inflammatory response.

Solutions containing miotic agents: Effects on corneal transendothelial electrical potential difference

Abstract• Background: Anterior chamber miotic solutions are widely used during anterior chamber surgery. We examined the effects of solutions containing miotic agents such as carbachol and/or acetylcholine on corneal endothelial pumping activity. • Methods: We monitored, in vitro, the transendothelial electrical potential difference of isolated rabbit corneal endothelial preparations. As controls, we used solutions without miotics. • Results: We found that a solution containing 55 mM acetylcholine and minimal amounts of salts (Miochol E) maintains transendothelial electrical potential difference some 30% above control levels for up to 4 h. Two other solutions, one including balanced salts and 0.55 mM carbachol (Miostat), the other a mixture of 0.19 mM carbachol and 55 mM acetylcholine plus minimal salts, are adequate to maintain the potential difference at control levels. Lastly, a solution with acetylcholine but without any salts (Miochol) greatly decreases the potential difference, to 30% of the control level, in 100 min. • Conclusion: Our results indicate that: (1) 55 mM (1%) acetylcholine stimulates the endothelial electrical potential difference; (2) addition of 0.19 mM (0.003%) carbachol negates the stimulatory effect of acetylcholine; and (3) absence of electrolytes severely depresses the endothelial electrical activity.

Preoperative and postoperative use of nonsteroidal anti inflammatory drugs in cataract surgery

Nonsteroidal antiinflammatory drugs have unique properties that aid the cataract surgeon. In phacoemulsification surgery, patients routinely receive nonsteroidal antiinflammatory drugs along with their dilating drops to inhibit intraoperative miosis. After surgery, these drugs can control inflammation and inhibit the development of cystoid macular edema. We present two prospective randomized studies. In the first, diclofenac sodium was compared with prednisolone acetate for control of postoperative inflammation. In the second, diclofenac sodium was compared with flurbiprofen for inhibition of intraoperative miosis. Diclofenac sodium was found to be as effective as prednisolone acetate for control of postoperative inflammation and as effective as flurbiprofen for inhibition of intraoperative miosis. Thus, whereas in the past we used a nonsteroidal antiinflammatory drug before surgery for inhibition of intraoperative miosis and a steroid drop in the postoperative period to control postsurgical inflammation, we now have equal efficacy using the same drug in the entire perioperative period.

Effects of acetylcholine, carbachol, and mannitol on rabbit corneal endothelial function as assessed by corneal deturgescence

Abstract• Background: Anterior chamber miotic solutions are widely used in ophthalmic surgery to induce pupillary contraction. We investigated whether the acetylcholine, carbachol, or mannitol present in perfusing solutions can affect corneal endothelial function. • Methods: Freshly dissected deepithelized rabbit corneas were mounted in a Dikstein-Maurice chamber at 36 °C. The endothelial sides were perfused with six solutions: (A) 55 mM (1%) acetylcholine Cl plus modified balanced salts; (B) control for A, with acetylcholine Cl replaced by sucrose; (C) 0.55 mM (0.01%) carbachol Cl plus balanced salts; (D) balanced salts solution (BS; control for C); (E) 3% mannitol plus modified balanced salts; and (F) modified balanced salts (control for E, with mannitol replaced by sucrose). Corneal thickness was followed for 3 h in each experiment. The effect of solution E did not differ from that of solution F. • Results: The carbachol-containing solution produced a small increase in corneal thickness compared to the control solution, while the acetylcholine-containing solution resulted in corneal thickness lower than that in control preparations. • Conclusion: From these data, acetylcholine is harmless to the endothelium, and may actually stimulate its fluid pump mechanism. Carbachol, on the other hand, appears to have a detrimental effect.