Ioannis Athanasiadis

Sutureless and glue-free conjunctival autograft in pterygium surgery: a case series

AimsForeign materials used in ocular surface surgery may lead to local complications such as discomfort, scarring, or infection. Plasma-derived products such as fibrin glue may produce possible hypersensitivity reactions whereas the risk of viral transmission remains. We describe a simple method of achieving conjunctival autograft adherence during pterygium surgery avoiding potential complications associated with the use of fibrin glue or sutures.MethodsAfter pterygium excision and fashioning of the autologous conjunctival graft, the recipient bed is encouraged to achieve natural haemostasis and relative dessication before graft placement. Excessive haemorrhage in the graft bed is tamponaded. Graft adherence and positioning is examined 20 min after surgery.ResultsA total of 15 eyes of 12 patients (mean (SD) age 73.7 (11.2) years), 8 females underwent SGF autologous conjunctival graft post-pterygium excision. Mean graft area was 24(1.5) mm2. Mean follow-up time was 9.2 (2.2) months. Cosmesis was excellent in all cases and visual acuity improved in one patient. There were no intra- or post-operative complications requiring further treatment.ConclusionThis simple technique for pterygium surgery may prevent potential adverse reactions encountered with the use of foreign materials and in this small series provided safe and comparable results to current methods.

Herpes simplex virus keratitis: an update of the pathogenesis and current treatment with oral and topical antiviral agents.

Ophthalmic herpes simplex viral keratitis is responsible for a range of ocular manifestations from superficial epithelial disease to stromal keratitis and endotheliitis. The Herpetic Eye Disease Study has guided the management of herpetic eye disease for almost twenty years, but newer medications such as valacyclovir are now available and are considered to have better bioavailability than acyclovir. In this review, we examine the existing evidence on the pathogenesis of different ophthalmic herpes simplex viral keratitis disease modalities and the role of oral and topically administered antiviral drugs in the treatment of herpes simplex viral keratitis.

The international forum of ophthalmic simulation: developing a virtual reality training curriculum for ophthalmology

Background To investigate the effect of a structured, supervised, cataract simulation programme on ophthalmic surgeons in their first year of training, and to evaluate the level of skill transfer. Methods Trainees with minimal intraocular and simulator experience in their first year of ophthalmology undertook a structured, sequential, customised, virtual reality (VR) cataract training programme developed through the International Forum of Ophthalmic Simulation. A set of one-handed, bimanual, static and dynamic tasks were evaluated before and after the course and scores obtained. Statistical significance was evaluated with the Wilcoxon sign-rank test. Results The median precourse score of 101.50/400 (IQR 58.75–145.75) was significantly improved after completing the training programme ((postcourse score: 302/400, range: 266.25–343), p<0.001). While improvement was evident and found to be statistically significant in all parameters, greatest improvements were found for capsulorhexis and antitremor training ((Capsulorhexis: precourse score=0/100, range 0–4.5; postcourse score=81/100, range 13–87.75; p=0.002), (antitremor training: precourse score=0/100, range 0–0; postcourse score=80/100, range 60.25–91.50; p=0.001)). Conclusions Structured and supervised VR training can offer a significant level of skills transfer to novice ophthalmic surgeons. VR training at the earliest stage of ophthalmic surgical training may, therefore, be of benefit.

The development of a virtual reality training programme for ophthalmology: repeatability and reproducibility (part of the International Forum for Ophthalmic Simulation Studies)

PurposeTo evaluate the variability of performance among novice ophthalmic trainees in a range of repeated tasks using the Eyesi virtual reality (VR) simulator.MethodsEighteen subjects undertook three attempts of five cataract specific and generic three-dimensional tasks: continuous curvilinear capsulorhexis, cracking and chopping, cataract navigation, bimanual cataract training, anti-tremor. Scores for each attempt were out of a maximum of 100 points. A non-parametric test was used to analyse the data, where a P-value of <0.05 was considered statistically significant.ResultsHighly significant differences were found between the scores achieved in the first attempt and that during the second (P<0.0001) and third (P<0.0001) but not between the second and third attempt (P=0.65). There was no significant variability in the overall score between the users (P=0.1104) or in the difference between their highest and lowest score (P=0.3878). Highly significant differences between tasks were shown both in the overall score (P=0.0001) and in the difference between highest and lowest score (P=0.003).ConclusionThis study, which is the first to quantify reproducibility of performance in entry level trainees using a VR tool, demonstrated significant intra-novice variability. The cohort of subjects performed equally overall in the range of tasks (no inter-novice variability) but each showed that performance varies significantly with the complexity of the task when using this high-fidelity instrument.

Endothelial keratoplasty: is Descemet membrane endothelial keratoplasty the Holy Grail of lamellar surgery? No

Endothelial keratoplasty: is Descemet membrane endothelial keratoplasty the Holy Grail of lamellar surgery? No

Herpes simplex virus keratitis: an update of the pathogenesis and current treatment with oral and topical antiviral agents - response: Herpes simplex virus keratitis

1. Tsatsos M, MacGregor C, Athanasiadis I, Moschos MM, Hossain P, Anderson D. Herpes simplex virus keratitis: an update of the pathogenesis and current treatment with oral and topical antiviral agents. Clin Exp Ophthalmol 2016; 44: 824–37. 2. Serna-Ojeda JC, Ramirez-Miranda A, Navas A, Jimenez-Corona A, Graue-Hernandez EO. Herpes simplex virus disease of the anterior segment in children. Cornea 2015; 34: S68–71. 3. Liu S, Pavan-Langston D, Colby KA. Pediatric herpes simplex of the anterior segment: characteristics, treatment, and outcomes. Ophthalmology 2012; 119: 2003–8. 4. Schwartz GS, Holland EJ. Oral acyclovir for the management of herpes simplex virus keratitis in children. Ophthalmology 2000; 107: 278–82. 5. Hsiao CH, Yeung L, Yeh LK, et al. Pediatric herpes simplex virus keratitis. Cornea 2009; 28: 249–53.

Training and oculoplastics: past, present and future.

Abstract Purpose: To describe the evolution of ophthalmic plastic surgical training since the establishment of an oculoplastic subspecialty. Methods: A systematic search and consultation was undertaken, involving various oculoplastic societies and selected members, to better define the previous and currently evolving training paradigms in oculoplastics. The salient events along with variances that exist in programs across the world today are analysed. Results: Oculoplastics emerged as a distillation of expertise from other specialties following World War 2 where a high rate of ophthalmic and oculoplastic trauma had occurred. Following this, learned individuals began aggregating on a regular basis resulting in the formation of dedicated oculoplastic forums, initially in the United States (ASOPRS) and then emerging in Europe (ESOPRS), the UK (BOPSS), South America (SOPANOC), the Far East (APSOPRS), Australia and New Zealand (ANZSOPS), the Middle East and Africa (MEAOPS) and South Africa (SASOPS). More structured and specialist training programmes which were dedicated to clinical and surgical management of adnexal disorders began to develop in parallel. This has resulted in the emergence of specialist adnexal fellowships with regional variation, differences in duration and the opportunity for further subspecialisation. Conclusions: Oculoplastic surgery has evolved as a highly specific and rapidly growing sub-specialty dedicated to eyelid, lacrimal and orbital care. Its ever increasing popularity has been mirrored by progressively more structured and recognised training programmes globally.

Translational Devices, Technologies, and Medicines in Clinical Ophthalmology

Over the last few decades, there has been a rapid advance in the technologies contributing to clinical ophthalmology ranging from novel hardware and software to new imaging and laser modalities with the emergence of nanotechnologies and drug innovations. The stated aim of translational research is to apply discoveries from basic science to enhance medical practice and human health, with many of these already having a major impact. We are presently witnessing an array of developments emerging on the horizon that have the potential to enhance patient care, improve diagnosis, and deliver treatments. Wearable sensors for health and activity monitoring are growing in popularity with a multitude of devices, such as Fitbit and Withings, coming to market able to monitor vitals and measure activity levels and calorific consumption and expenditure. Their scope is now being extended to monitor disease as well. The application of contact lens sensors in ocular diagnostics offers a minimally invasive platform for constant monitoring of pertinent disease indices [1]. Advances in materials, electronics, and microfabrication techniques have expanded the remit of this medical device from a visual corrective aid in isolation to one that has diagnostic potential. The possibilities of its application have even caught the interests of Google, Novartis, and Microsoft [2–4]. Within this issue, S. C. Xu and colleagues review the applications of contact lens sensors (CLS) in detecting 24-hour intraocular pressure with its potential to change our approach and understanding in glaucoma. CLS have also been used to quantify blink rate and limbal strain and measure the circadian rhythm in a variety of disease states including normal tension glaucoma and thyroid eye disease. The ever-increasing power of computational hardware (as described by Moores Law) coupled with accelerating advances in software engineering has allowed swift evolution of this technology in ophthalmology. This special issue provides a report on an automated diabetic retinopathy detection software system using singular spectrum analysis to focus on microaneurysms. When applied to over 17,000 retinal images across different racial groups from six different countries, the authors report high levels of performance and the potential for scalability in diverse populations. Computational power also underpins virtual reality modeling and simulation has been used with success in nonmedical domains such as aerospace and the military. Inroads with this technology are now being made in medicine with cancer and surgical applications [5–7]. In this issue, E. Lanchares et al. describe a finite element model of …

Comparison of the Endosaver with noninjector techniques in Descemet's stripping endothelial keratoplasty

Purpose: Minimal loss of corneal endothelial cells during corneal transplantation is a major target but remains a point of controversy among specialists. Hence, the available method to best achieve this continues to stir progress in the field. The aim of this study is to evaluate the use of the Endosaver injector device for graft insertion in Descemets stripping endothelial keratoplasty (DSEK) and compare the visual outcomes and endothelial cell survival between the Endosaver injector and Goosey grasping forceps insertion techniques. Methods: This was a retrospective, interventional, consecutive case series undertaken at the University of Southampton Eye Department to assess outcomes of DSEK using the Endosaver injector device compared to noninjector DSEK insertion. Postoperative specular microscopy alongside manifest refraction at 6 and 12 months was evaluated and compared. Mann–Whitney U-test was employed for the statistical analysis of data. Results: Both the Endosaver and Goosey forceps groups showed an improvement in best corrected visual acuity. No significant statistical difference was found in preoperative and postoperative best-corrected visual acuity between the Endosaver and non-Endosaver insertion groups. Mean preoperative endothelial cell count was 2660 (±130) for the Endosaver group and 2608 (±66) for the non-Endosaver group. Postoperative endothelial counts at 6 and 12 months showed a significant difference between the Endosaver: 2104 (±199)–1896 (±226) and the non-Endosaver: 1492 (±207)–1314 (±224) (P < 0.005) groups, respectively. Conclusion: The Endosaver injection device is associated with less trauma to endothelium during graft insertion due to the minimal touch technique employed. A smaller insertion wound of 4.0 mm compared to noninjector cases enabled a more stable system during surgery with no or minimal anterior chamber shallowing. The combination of a stable host with minimal endothelial graft handling and subsequent trauma potentially leads to higher endothelial cell counts when the Endosaver injection device is used compared to forceps insertion.

Phytotherapy and intraoperative floppy iris syndrome: the implications

Intraoperative floppy iris syndrome (IFIS) was first recognised and described in 2005.1,2 It is characterised by poor pupil dilatation, billowing of iris stroma, iris prolapse through corneal incisions, and progressive intraoperative pupillary constriction.1 The incidence of IFIS can vary, representing between 2–3% of the entire cataract population, but it can be 450% in patients taking Tamsulosin—a selective α1-adrenergic blocker, compared to other nonselective α-adrenergic blockers such as Alfuzosin, Doxazosin, and Terazosin.1,3,4 Alpha-adrenergic antagonists are commonly used in the treatment of benign prostate hyperplasia (BPH).5 The last few years have seen a rise in the use of herbal treatment for BPH, with Saw Palmetto being the most common herbal alternative treatment. Saw Palmetto has been shown to have an α-adrenergic effect.6 As herbal medications and supplements are often not considered as medications by the patients and thus omitted during history taking unless directly prompted to do so, it is important for the surgeon to be aware of all medications and supplements that could potential cause IFIS.7