José Manuel Benítez del Castillo

Tear osmolarity in the diagnosis and management of dry eye disease.

PURPOSE To evaluate the use of tear osmolarity in the diagnosis of dry eye disease. DESIGN A prospective, observational case series to determine the clinical usefulness of tear osmolarity and commonly used objective tests to diagnose dry eye disease. METHODS A multicenter, 10-site study consisting of 314 consecutive subjects between 18 and 82 years of age. Bilateral tear osmolarity, tear film break-up time (TBUT), corneal staining, conjunctival staining, Schirmer test, and meibomian gland grading were performed. Diagnostic performance was measured against a composite index of objective measurements that classified subjects as having normal, mild or moderate, or severe dry eye. The main outcome measures were sensitivity, specificity, area under the receiver operating characteristic curve, and intereye variability. RESULTS Of the 6 tests, tear osmolarity was found to have superior diagnostic performance. The most sensitive threshold between normal and mild or moderate subjects was found to be 308 mOsms/L, whereas the most specific was found at 315 mOsms/L. At a cutoff of 312 mOsms/L, tear hyperosmolarity exhibited 73% sensitivity and 92% specificity. By contrast, the other common tests exhibited either poor sensitivity (corneal staining, 54%; conjunctival staining, 60%; meibomian gland grading, 61%) or poor specificity (tear film break-up time, 45%; Schirmer test, 51%). Tear osmolarity also had the highest area under the receiver operating characteristic curve (0.89). Intereye differences in osmolarity were found to correlate with increasing disease severity (r(2) = 0.32). CONCLUSIONS Tear osmolarity is the best single metric both to diagnose and classify dry eye disease. Intereye variability is a characteristic of dry eye not seen in normal subjects.

Safety of posterior chamber phakic intraocular lenses for the correction of high myopia: Anterior segment changes after posterior chamber phakic intraocular lens implantation

OBJECTIVE To assess the safety of posterior chamber phakic intraocular lens (PCPIOL) implantation in patients with high myopia. DESIGN Prospective, noncomparative, interventional case series. PARTICIPANTS Twenty eyes of 10 patients were included. INTERVENTION Staar Collamer Implantable Contact Lens PCPIOLs were implanted for the correction of high myopia. MAIN OUTCOME MEASURES Intra- and postoperative complications were recorded. Specular microscopy, lens fluorophotometry, laser flare-meter, and ultrasound biomicroscopy were performed before surgery and at different stages of the follow-up period to evaluate endothelial cell density, crystalline lens transmittance, aqueous flare, and anatomic relations of the implanted lenses with the other structures of the anterior segment. RESULTS There were no intraoperative complications. One patient experienced pupillary entrapment by the lens in the immediate postoperative period, which was resolved without incident. Pigmentary dispersion or cataracts did not appear during the postoperative period. All the lenses remained correctly centered, and no patient reported night halos or glare. Anterior chamber depth showed a statistically significant reduction, between 9% and 12%. Central endothelial density was significantly decreased after surgery. The percentages of cell loss after 3, 6, 12, 18, and 24 months were 4.41%, 4.83%, 5.17%, 5.46%, and 6.57%, respectively. Aqueous flare increased by 49.19% in the first postoperative month in relation to preoperative values. Afterward, it decreased and then remained above preoperative values for the entire follow-up period (33.76% at month 3, 27.81% at month 6, 27.65% at month 12, 23.39% at month 18, and 27.27% at month 24). Crystalline lens transmittance decreased by 0.72% at month 3, by 1.44% at month 6, by 1.95% at month 12, by 2.25% at month 18, and by 2.24% at month 24. Finally, by ultrasound biomicroscopy it was observed that the PCPIOL and the crystalline lens were in contact on the peripheral level in 12 patients (60%) and in the center in another three patients (15%) during at least one checkup. In all the patients, contact between the PCPIOL and the posterior iris surface could be observed. CONCLUSIONS Posterior chamber phakic IOL implantation for the surgical correction of high myopia is a safe procedure with regard to immediate visual and refractive results. The short-term clinical benefit and lack of immediate surgical complications are impressive. However, the increase in flare, the endothelial cell loss, the decrease in crystalline lens transmittance, and the iris-PCPIOL and crystalline lens-PCPIOL contact are findings that suggest caution regarding the long-term safety of this lens implant.

Chronic subclinical inflammation in phakic eyes with intraocular lenses to correct myopia

Purpose: To evaluate whether either of two anterior chamber intraccular lenses (IOLs) implanted in myopic, phakic eyes induced an inflammatory response that was measurable with a laser flare‐cell meter but that could not be measured by other methods. Setting: Jiménez‐Díaz Foundation and San Carlos University Hospital, Madrid, Spain. Methods: Thirty eyes with a Worst‐Fechner IOL and 30 eyes with a Baikoff ZB5M IOL were evaluated using the flare mode of a laser flare‐cell meter. Patients in each group were divided into three subgroups of 10 eyes each according to when the postoperative flare measurements were done: 12 months, 18 months, and 24 months. Thirteen phakic eyes with myopia greater than −6.00 diopters were used as controls. Results: Postoperative flare in the Worst‐Fechner group was 27.05 ± 19 photons per millisecond (photons/ms) (mean ± SD) at 12 months, 18.09 ± 17.38 photons/ms at 18 months, and 31.03 ± 28.8 photons/ms at 24 months. Postoperative flare in the Baikoff group was 21.1 ± 5.9 photons/ms at 12 months, 16.13 ± 8.3 photons/ms at 18 months, and 21.05 ± 23.5 photons/ms at 24 months. Flare in the control group was 4.24 ± 2.8 photons/ms. Postoperative flare values were significantly higher in both IOL groups than in the control group at all follow‐ups (Mann‐Whitney test, P < .05). Postoperative flare values in the Worst‐Fechner group were higher than in the Baikoff group at 12, 18, and 24 months, although the difference was not significant (Mann‐Whitney test, P > .05). Conclusions: Our study shows chronic subdinical inflammation between 1 and 2 years after implantation of both IOL types.

Ultrasound biomicroscopy examination of posterior chamber phakic intraocular lens position

OBJECTIVE To better elucidate the in vivo position of the Collamer posterior chamber phakic intraocular lens (PCPIOL) and its relationship to the iris and the crystalline lens and to analyze possible variations over time. DESIGN Prospective observational case series. PARTICIPANTS Eighteen eyes of nine patients were included. INTERVENTION A Staar Collamer implantable PCPIOL was implanted for the correction of high myopia. MAIN OUTCOME MEASURES The eyes were studied with a 50-MHz ultrasound biomicroscopy UBM 840. The exact PCPIOL position and the distances between it and the crystalline lens were measured at 3, 6, and 12 months after surgery. RESULTS There were no intraoperative complications. In 13 eyes (72.22%), contact between the PCPIOL and the crystalline lens was found at some time during follow-up. In 3 eyes (16.6%), central contact could be demonstrated. We also observed that the contact zone and its extension can vary over time. In 2 eyes, rotation of the lens was observed. CONCLUSIONS We found contact between the PCPIOL and the crystalline lens in a high percentage of cases. There was also mobility of the lens in the posterior chamber, especially in the anteroposterior plane, and, as a consequence, both the contact zone and its extension would vary over time.

Diagnosing the severity of dry eye: a clear and practical algorithm

Dry eye disease (DED) is a distressing ocular condition. Due to its multifactorial nature, clinical and biological signs of DED can be inconsistent and sometimes discordant with symptomatology. Consequently, no gold-standard model for determining DED severity exists. This can impact treatment decisions and complicate evaluation of disease progression, particularly within the stringent context of clinical trials. The multinational ODISSEY European Consensus Group is comprised of ophthalmologists who contend with ocular surface disease issues on a daily basis. This group convened to establish a clear and practical algorithm for evaluation and diagnosis of severe DED. Using a consensus-based approach, they assessed 14 commonly used DED severity criteria. The panel agreed that following confirmed DED diagnosis, just two criteria, symptom-based assessment and corneal fluorescein staining were sufficient to diagnose the presence of severe DED in the majority of patients. In the event of discordance between signs and symptoms, further evaluation using additional determinant criteria was recommended. This report presents the ODISSEY European Consensus Group recommended algorithm for DED evaluation, which facilitates diagnosis of severe disease even in the event of discordance between signs and symptoms. It is intended that this algorithm will be useful in a clinical and developmental setting.

Effects of Estrogen Use on Lens Transmittance in Postmenopausal Women

OBJECTIVE Lens autofluorescence originates from an accumulation of fluorescent substances that are associated with the process of cataractogenesis and lens aging. The aim of this study was to determine whether postmenopausal estrogen use reduces age-related nuclear sclerosis in women. DESIGN The authors designed a case-controlled study. PARTICIPANTS Nineteen postmenopausal women reporting estrogen use for more than 4 years (group 1), 20 postmenopausal women reporting no estrogen use (group 2), and 23 age-matched men (group 3) were studied. INTERVENTION The authors performed fluorophotometry. MAIN OUTCOME MEASURES Corneal and lens autofluorescence and lens transmittance were measured. RESULTS Lens transmittance values were 0.905 +/- 0.03, 0.839 +/- 0.08, and 0.841 +/- 0.08 in the three groups, respectively. There was a statistically significant difference between group 1 and the other two groups (P < 0.01). CONCLUSIONS These data are suggestive of a protective effect of estrogen use on the lenses of postmenopausal women.

Corneal cross linking and infectious keratitis: a systematic review with a meta-analysis of reported cases

BackgroundCollagen cross linking (CXL) of the cornea has been developed recently as a new treatment for multidrug-resistant infectious keratitis. The aim of this study is to summarize the previously published data and evaluate the effectiveness of this treatment.ResultsThe search identified 12 articles. The number of eyes was 104. The infectious keratitis was associated with bacteria in 58 eyes (57f%): Gram-positive bacteria in 44 (43%; 4 of which were infected with Mycobacterium (3.6%)) and Gram-negative bacteria in 14 eyes (13%), fungus in 13 eyes (12%), and Acanthamoeba in 7 eyes (7%). In 26 eyes (25%), the microbiological culture was negative or not performed. The mean time of re-epithelization after CXL was 20.7±28.1 days (minimum of 3, maximum of 145). Sixteen eyes underwent deep or lamellar keratoplasty. The pooled analysis suggested that CXL has a favorable effect on the block of corneal melting in 85% (95%; CI 0.77, 0.91) of eyes.ConclusionAlthough randomized controlled trials are needed, the available evidence supports the use of CXL in the treatment of infectious keratitis.

Fluorophotometry in Myopic Phakic Eyes With Anterior Chamber Intraocular Lenses to Correct Severe Myopia

Implanting an anterior chamber intraocular lens in a phakic eye is an effective surgical procedure for the correction of severe myopia. However, the potential risks on the anterior segment structures are scarcely known. We conducted a prospective study to evaluate the permeability of the blood-aqueous barrier and the lens transmittance changes after Worst-Fechner lenses were implanted to correct myopia. Preoperative and serial postoperative fluorophotometry was done in 15 eyes that had a Worst-Fechner lens implanted to correct myopia. Lens transmittance was evaluated by lens autofluorescence, and permeability of the blood-aqueous barrier was estimated by anterior vitreous fluorophotometry, which was carried out before and after intravenous injection of fluorescein. Preoperative lens transmittance was 0.971 +/- 0.002 (mean +/- standard error), and, after the operation, lens transmittance decreased to 0.970 +/- 0.002 at one month, 0.966 +/- 0.001 at three months, 0.964 +/- 0.002 at six months, and 0.962 +/- 0.003 at 14 months. At three, six, and 14 months after the operation, lens transmittance values were significantly lower than preoperative values (P = .038 at three months, P < .001 at six months, and P = .005 at 14 months). Fluorescein concentration in the anterior vitreous was 18.522 +/- 1.797 ng/ml (mean +/- standard error) preoperatively and was 21.328 +/- 1.667 ng/ml at one month, 27.518 +/- 1.412 ng/ml at three months, 27.150 +/- 1.474 ng/ml at six months, and 27.012 +/- 1.980 ng/ml at 14 months postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

Bilateral ocular toxocariasis demonstrated by aqueous humor enzyme-linked immunosorbent assay.

PURPOSE/METHODS A 14-year-old girl with a history of contact with puppies and chronic bilateral panuveitis was examined. The fundus of the right eye showed an inferotemporal pars plana exudate. The fundus of the left eye showed an elevated posterior mass. RESULTS/CONCLUSION Toxocara antibodies in the aqueous humor detected by enzyme-linked immunosorbent assay had a Goldmann-Witmer coefficient of 8.63 in the right eye and 8.94 in the left eye. Toxocariasis may be a cause of bilateral panuveitis.

Intraocular lidocaine in phacoemulsification an endothelium and blood-aqueous barrier permeability study

OBJECTIVE To evaluate the effects of intraocular lidocaine hydrochloride (HCI) on the corneal endothelium and of blood-aqueous barrier (BAB) permeability in ultrasound phacoemulsification. DESIGN Nonrandomized, comparative trial. PARTICIPANTS Sixty patients who underwent uneventful, single-surgeon, clear cornea phacoemulsification were studied prospectively. METHODS Sub-Tenons anesthesia was administered to 30 patients (group 1), and intraocular lidocaine hydrochloride was administered to an additional 30 patients (group 2). An endothelial study of at least 120 cells per patient, using a noncontact specular microscope and a digital image analysis system, was performed before surgery and 1 month after surgery. Blood-aqueous barrier permeability was evaluated preoperatively and postoperatively (48 hours, 1 week and 1 month) using a laser flare meter. MAIN OUTCOME MEASURES Endothelial parameters (cell density, hexagonality, and coefficient of variation in cell area) and BAB permeability. RESULTS No significant differences were found between groups when comparing the postoperative changes produced in endothelial cell density (95% confidence interval [CI], 0.46, 4.7; P = 0.10), hexagonality (95% CI, -2.5, 3.5; P = 0.72), and coefficient of variation in cell area (95% CI, -8.3, 4.6; P = 0.57). A multivariate study detected no significant differences in mean flare values between groups during follow-up (P = 0.40). No clinically significant differences were found between mean preoperative and 1 month postoperative flare values in either group. CONCLUSIONS The recovery of BAB permeability 1 month after surgery seems to suggest that no additional inflammation was induced by intraocular lidocaine HCI. The fact that no differences in postoperative changes in endothelial parameters were found between groups indicates that no further corneal endothelial damage (other than that caused by surgical manipulation) was incurred. According to our results, intracameral lidocaine HCI appears to be safe for the average phacoemulsification patient in the absence of ocular pathologic conditions.