Igor Kaiserman

The association of keratoconus with immune disorders.

Purpose: To evaluate the association between keratoconus (KC) and immune disorders (IDs). Methods: A retrospective observational case-control study of all the members in the Central District of Clalit Health Services in Israel who were diagnosed to have KC (years 2000-2007; n = 426) and 1704 age- and gender-matched controls. We calculated the prevalence of the following IDs: rheumatoid arthritis, ulcerative colitis, arthropathy, amyloidosis, systemic lupus erythematosus, celiac disease, multiple sclerosis, myasthenia gravis, polymyalgia rheumatica, idiopathic thrombocytopenic purpura, Crohn disease, Hashimoto thyroiditis, autoimmune hepatitis, irritable bowel syndrome, asthma, and environmental allergy. The odds ratio (OR) of having IDs among patients with KC was compared with controls. Results: The association between KC and the following IDs was statistically significant: rheumatoid arthritis [OR = 8.1; 95% (confidence interval) CI: 1.5-44.2], ulcerative colitis (OR = 12.1; CI: 1.3-116), autoimmune chronic active hepatitis (OR = 6; CI: 1.01-36), Hashimoto thyroiditis (OR = 2.0; CI: 1.2-3.3), arthropathy (OR = 1.4; CI: 1.1-1.8), asthma (OR = 2.1; CI: 1.4-3.2), environmental allergy (OR = 1.3; CI: 1.02-1.75), and irritable bowel syndrome (OR = 5; CI: 2.1-12.1). Two autoimmune diseases, multiple sclerosis (OR = 2; CI: 0.2-22) and Crohn disease (OR = 1.6; CI: 0.3-8.3), were more prevalent among patients with KC but did not reach statistical significance. Conclusion: Some strong associations between KC and several immune conditions of autoimmune diseases and allergic IDs may point to the role of the immune system in the pathogenesis of KC.

The effect of combination pharmacotherapy on the prescription trends of glaucoma medications.

Purpose:To describe prescription trends within a managed care setting for glaucoma medications and to examine the effect of introduction of Cosopt® -a fixed combination of dorzolamide and timolol. Patients and Methods:All prescriptions dispensed to any of the 470,350 members of an Israeli health maintenance organization were monthly scanned for patients treated for glaucoma, between January 2000 and May 2003. The monthly mean number of glaucoma patients was 3899 ± 104 (mean ± SD). All topical glaucoma prescriptions were documented, and the monthly prescription rate of each medication was calculated and plotted. The monitored glaucoma medications were: β-adrenergic antagonists, dorzolamide, latanoprost, pilocarpine, brimonidine, Cosopt®, and others. Results:β-adrenergic antagonists were the top prescribing drug (>35% of all glaucoma prescriptions). The prescription rates of pilocarpine and β-adrenergic antagonists were in constant decline, while latanoprost and brimonidine increased steadily. The introduction of Cosopt® changed the prescription trends of dorzolamide from increasing to rapidly decreasing, and accelerated the long-term decline of β-adrenergic antagonists. Concomitant with the introduction of Cosopt® the prescription rate of β-adrenergic antagonists temporarily increased. This was due to a total increase in glaucoma prescriptions. When Cosopt® was introduced, 37.5% of patients were prescribed Cosopt® together with β-adrenergic antagonists, and 16.5% also received dorzolamide. Thereafter the co-prescription decreased steadily. Conclusions:Introduction of a combination drug should be accompanied by physicians, pharmacists, and patients education to prevent its inappropriate usage together with its components.

The effect of successful rebubbling after descemet stripping automated endothelial keratoplasty on endothelial cell counts.

Purpose: To examine the effect of successful repositioning/rebubbling of the graft on endothelial cell counts (ECCs) in eyes after Descemet stripping automated endothelial keratoplasty. Methods: This retrospective study reviewed the outcomes of 58 eyes that underwent Descemet stripping automated endothelial keratoplasty. Fifty-one eyes were attached after surgery. Seven were detached and underwent rebubbling with minimal manipulation in 5 and significant manipulation in 2, after which the graft was attached and clear. Visual outcomes and endothelial cell loss at 6 months were compared between eyes that underwent repositioning/rebubbling and those that did not. The following were excluded: 2 eyes that had primary failure, 2 eyes that had rejection, 1 eye that failed to attach after rebubbling, 2 eyes that failed to clear after rebubbling, and 24 eyes that did not have ECC at 6 months. Results: The 2 groups were comparable considering age, preoperative best-corrected visual acuity, surgical variables, combined procedures, donor cell count, and graft size. The mean postoperative spherical equivalent, manifest and topographic astigmatism, uncorrected visual acuity, and best-corrected visual acuity did not differ significantly between the 2 groups at 6 months. Mean pre- and postoperative ECC did not differ significantly between the group that underwent repositioning/rebubbling and the group that did not (preoperative counts 2742 ± 268 vs. 2747 ± 353 and postoperative counts 1590 ± 367 vs. 1746 ± 491, respectively). Endothelial cell loss also did not differ significantly between the 2 groups, although there was a trend to greater cell loss in the reattachment group (−39.4% ± 11.1% vs. −38.3% ± 16.2%, respectively; P = 0.6). Conclusion: Successful reattachment procedure does not seem to cause significant endothelial cell loss.

Severe Blepharoconjunctivitis Induced by a Peeling Mask Containing Trichloroacetic Acid

Purpose: To report a case of severe blepharoconjunctivitis induced by a peeling mask. Methods: A 32-year-old healthy female was examined one day after undergoing a face-peeling procedure with a mask containing trichloroacetic acid. She complained of severe burning, redness, and epiphora in her left eye that started several hours after the procedure. Results: Her vision was LE 0.2, RE 0.8. Mild upper eyelid edema of the right eye and severe edema of the left eyelids, LE inferior ectropion, and LE blepharoconjunctivitis were noted. The conjunctiva was severely hyperemic with papillary reaction and chemosis. The corneas, anterior chambers, irides, lenses, and posterior segments were normal. The patient was treated with Dexamethasone 0.1% q2h and ocular lubrication. The reaction subsided after 3–4 days. Conclusion: Face-peeling masks containing trichloroacetic acid can sometimes severely irritate the eyelids and the ocular surface.

Factors Predicting the Need for Retreatment After Laser Refractive Surgery.

Purpose: To identify the potential risk factors that increase the likelihood of requiring retreatment after refractive surgery. Methods: This retrospective study included patients who underwent laser in situ keratomileusis or photorefractive keratectomy between January 2005 and December 2012 at the Care-Vision Laser Centers, Tel-Aviv, Israel. Patients were divided into 2 groups according to whether they underwent additional refractive surgery (retreatment) during the study period. Results: Overall, 41,504 eyes (n = 21,313) were included in the final analysis of this study. Throughout the study period, there was a significant reduction in the 2-year annual retreatment rates with a decline from 4.52% for primary surgeries done in 2005 to 0.18% for surgeries performed in 2012 (quadratic R2 = 0.96, P < 0.001). The retreatment group had significantly higher preoperative age, maximum keratometric power, sphere, cylinder, and better best-corrected visual acuity. They were more likely to have preoperative hyperopia, photorefractive keratectomy as opposed to laser in situ keratomileusis, intraoperative higher humidity conditions and lower temperature, and higher ablation depths. Significant differences in retreatment rates were found between the 5 high-volume surgeons (>1500 procedures performed) ranging from 0.48 to 3.14% (P < 0.0001). Multiple logistic regression analysis demonstrated that age, astigmatism, hyperopia, temperature, and surgeons experience all significantly affected the need for retreatment. Conclusions: The following factors significantly increase the need for refractive retreatment: older preoperative age, higher degrees of astigmatism, hyperopia, colder operating room temperature, and less surgeon experience. Some of these factors may be incorporated into nomograms to reduce future retreatment rates.

Associated morbidity of chalazia.

Purpose: Chalazion may be associated with some local and systemic conditions. We studied the prevalence of various conditions among patients with chalazion. Methods: A retrospective observational case–control study of all the members who were diagnosed with chalazion in the Central District of Clalit Health Services in Israel (years 2000–2008; n = 9119) and 9119 age- and gender-matched controls randomly selected from the district members. We calculated the prevalence of various ocular, systemic, and demographic conditions as risk factors for chalazion. Results: Demographically, a significant (P < 0.0001) tendency to develop chalazion was found in the population of lower socioeconomic class, in the population living in urban areas, in young females (10–29 years), in older men (older than 60 years), and in non-Ashkenazi Jews. The following risk factors of chalazion were statistically significant: blepharitis [odds ratio (OR), 6.2], rosacea (OR, 2.9), gastritis (OR, 1.4), anxiety (OR, 1.5), irritable bowel syndrome (OR, 1.7), and smoking (OR, 1.2). Diabetes (OR, 0.8) and hypothyroidism (OR, 0.8) were significantly less prevalent among chalazion patients. Conclusions: Some systemic conditions are significantly more prevalent and some are significantly less prevalent among patients with chalazion. Better understanding of the pathophysiological association between those diseases and chalazion may help in its treatment and prevention.

Comparison of Three Epithelial Removal Techniques in PRK: Mechanical, Alcohol-assisted, and Transepithelial Laser.

PURPOSEnTo compare the visual and refractive results obtained after photorefractive keratectomy (PRK) in patients who underwent one of three different epithelial removal techniques.nnnMETHODSnThe authors reviewed the medical files of consecutive eyes with myopia and myopic astigmatism that were treated during a 10-year period by mechanical PRK, alcohol-assisted PRK, or transepithelial PRK (in the phototherapeutic keratectomy mode), and observed for more than 1 year.nnnRESULTSnA total of 3,417 patients (3,417 eyes) were included in this study. At 3 and 6 months postoperatively, the outcome of alcohol-assisted PRK was superior both in efficacy (P < .01) and safety (P < .001) to those of both mechanical PRK and transepithelial PRK, which were similar. At more than 1 year postoperatively, the mean efficacy index was still high for alcohol-assisted PRK, but low for the transepithelial PRK, corresponding to a mean uncorrected visual acuity of more than one Snellen line lower than those of the other two techniques (P < .0001). All three techniques showed a regression toward myopia more than 1 year postoperatively, with significant undercorrection obtained in eyes treated with transepithelial PRK (P < .0001).nnnCONCLUSIONSnSignificant differences were detected in both the visual outcomes and the refractive results of the three epithelial removal techniques. The long-term outcomes were best for alcohol-assisted PRK.

Changes in anterior segment parameters after insertion of Ex-PRESS miniature glaucoma implant.

Purpose:The aim of this study was to evaluate the effect of Ex-PRESS Miniature Glaucoma Implant surgery on corneal curvature and anterior segment parameters obtained with the Pentacam rotating Scheimpflug camera (Oculus Inc.). Patients/Methods:In this prospective study, a total of 19 eyes of 19 consecutive patients (11 men, 8 women) were evaluated preoperatively, on the first postoperative day, and at 1 week, 1 month, and 3 months postoperatively with the Pentacam. We compared measurements of anterior and posterior corneal curvature, anterior and posterior corneal astigmatism, anterior chamber depth (ACD), anterior chamber volume (ACV), and anterior chamber angle before and after surgery. All study eyes were pseudophakic. Results:Intraocular pressure decreased significantly from 31.9±10.1 mmHg preoperatively to 6.1±5.7 mmHg on the first postoperative day (P<0.0001) and 15.7±3.6 mmHg at 3 months after surgery (P=0.0011). On the first postoperative day, the anterior corneal astigmatism increased from 2.6±3.3 to 4.7±3.1 D (P=0.19), the posterior corneal astigmatism increased from 0.4±0.2 to 0.9±0.5 D (P=0.008), the ACD decreased from 4.3±0.7 to 3.5±1 mm (P=0.015), and the ACV decreased from 193±35 to 160±49 mm3 (P=0.006). All of these changes in anterior segment parameters were not statistically significant at 3 months after surgery. Conclusions:Ex-PRESS Miniature Glaucoma Implant surgery significantly decreased intraocular pressure and had a transient effect on anterior segment parameters. Corneal curvatures, ACD, ACV, and anterior chamber angle were not affected at 3 months of follow-up.

Combined penetrating keratoplasty and implantation of iris prosthesis intraocular lenses after ocular trauma

PURPOSE: To report the outcomes of implantation of intraocular lenses (IOLs) with a prosthetic iris to correct traumatic iris deficiency. SETTING: Department of Ophthalmology, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada. DESIGN: Case series. METHODS: The medical records of consecutive patients who had had implantation of an Ophtec or Morcher IOL combined with corneal transplantation were retrospectively reviewed. Preoperative data collected included demographics, etiology of the iris deficiency, previous surgeries, preoperative eye pathology, and visual acuity. Operative data and postoperative outcomes included visual acuity, subjective perception of glare and photophobia, and postoperative complications. RESULTS: The records of 11 patients were reviewed. The corrected distance visual acuity improved from 2.39 logMAR ± 0.53 (SD) preoperatively to 1.50 ± 1.11 logMAR postoperatively (P=.0037). Four (36.4%) of 9 patients reported an improvement in glare sensation; 5 (45.5%) reported no change in glare (P=.99). Postoperative complications included 2 graft rejection episodes in 2 patients during the first year after surgery, 1 case of increased inflammation that required removal of the IOL, and 2 cases of new‐onset glaucoma. At the last follow‐up visit, the centration and positioning of the IOLs were excellent. There were no cases of IOL dislocation, macular edema, or retinal detachment. CONCLUSIONS: Implantation IOLs with a prosthetic iris in traumatic aniridia improved visual acuity significantly in most patients and reduced photophobia and glare symptoms in many cases. Graft rejection, glaucoma, and postoperative inflammation are possible complications. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Prescription of Ocular β-Blockers in Patients with Obstructive Pulmonary Disease

AbstractObjectives: Topical β-blockers are contraindicated in obstructive pulmonary diseases (OPDs). In this study we aimed to evaluate through central or local electronic medical records (EMRs) the prescription patterns for topical ocular β-blockers for patients with glaucoma and OPD treated by ophthalmologists.n Methods: The study was carried out at the Leumit Health Maintenance Organisation (HMO) in Israel. The physicians at the HMO all work with an EMR, either a central EMR incorporating data from primary-care physicians and consultants, or a local one. The study population included all HMO members who filled at least one prescription for antiglaucoma medications in 2004. The patients were divided into two groups: those with a previous diagnosis of OPD (ICD-9 codes 493) and those with no known diagnosis of OPD.n Results: 7481 patients consumed topical antiglaucoma medications during the study period, and 14.5% had a diagnosis of OPD. 798 OPD patients were treated by ophthalmologists, and of the 61.8% who were treated with topical β-blockers, only 38 received betaxolol. In comparison with glaucoma patients without OPD, OPD patients received fewer β-blockers (p < 0.001), more selective β-blockers (p < 0.0001) and less timolol (p < 0.001). Of the OPD patients treated by ophthalmologists with a central EMR, 59.5% received β-blockers in comparison with 66.4% treated by ophthalmologists with a local EMR (p = 0.06). OPD patients treated by ophthalmologists with a central EMR received more non-β-blockers in comparison with patients treated by ophthalmologists with a local EMR (p = 0.02).n Conclusion: Most patients with OPD and glaucoma continued to receive topical β-blockers, mostly noncardioselective β-blockers. A central EMR with a comprehensive and highly available medical history reduced the prescription of β-blockers to OPD patients, but rates remained unacceptably high.