Shahriar Amjadi

What Is New HLA-B27 Acute Anterior Uveitis?

Acute anterior uveitis (AAU) is the most common form of uveitis, accounting for approximately 90% of all cases. Half of all cases of AAU are HLA-B27 positive. The disease is typically acute in onset, unilateral, nongranulomatous inflammation involving the iris and ciliary body, with a tendency to recurrent attacks. Approximately 50% of all patients with HLA-B27 AAU develop an associated seronegative arthritis (SNA), while approximately 25% of the patients initially diagnosed with HLA-B27 SNA develop AAU. Environmental factors play a critical role in the pathogenesis of AAU; in particular, bacterial triggers have been strongly implicated in the development of this disease. Topical corticosteroids and cycloplegic agents remain the cornerstones of treatment for AAU. Salazopirine and methotrexate are effective in decreasing recurrent attacks. Biological agents such as anti-TNF and anti-CD20 therapy may be effective in refractory severe AU but are rarely required.

The Role of Lumican in Ocular Disease

Lumican is keratan sulfate proteoglycan of the small leucine rich proteoglycan family. Through studies in animal models lumican has been found to be critical in maintaining corneal clarity. It maintains ordered collagen fibrils which are vital in keeping the cornea transparent. It may also be important in primary open angle glaucoma influencing aqueous outflow. Lumican deficiency in mice results in increased axial length with fibromodulin deficiency and thinner sclerae. There is evidence suggesting that this characteristic may be pertinent in humans and lumican gene polymorphisms could be related to high myopia. Lumican plays a fundamental role in inflammation and wound healing. It localises macrophages to the site of corneal injury and recruits neutrophils in lipopolysaccharide-induced keratitis in mice. It has also been shown to bind lipopolysaccharide which may be critical in inflammatory diseases such as uveitis. Lumican is also important in wound healing revealing decreased synthesis in scar tissue and mediating Fas-Fas ligand interactions. It is present in human placenta and amniotic membrane suggesting that it may ensure viable amniotic membrane grafts. Lumican may also be involved in the formation of posterior capsular opacification following cataract surgery. Research into the pivotal role of lumican in the pathogenesis of ocular disease has resulted in greater understanding of the key role which proteoglycans play in human disease.

Comparison of macular morphology between femtosecond laser–assisted and traditional cataract surgery

Comparison of macular morphology between femtosecond laser–assisted and traditional cataract surgery After reading the article by Nagy et al. on femtosecond laser–assisted cataract surgery technology, we have significant methodological concerns about the risk for postoperative cystoid macular edema (CME). These render the conclusions drawn by the authors difficult to support. The incidence of CME following cataract surgery is variable. Differing definitions of CME make it difficult to determine accurately its incidence; a recent review reported the incidence as 0.1% to 2.5%. It is essential to differentiate clinical CME, in which visual impairment is present, from angiographic or subclinical macular edema, in which visual acuity is not impaired. Flach identified 20 factors that could affect the reported incidence of postoperative CME. These factors relate to the patient (underlying vascular diseases such as diabetes mellitus, hypertension, and chronic kidney disease), research methodology, and surgical technique. The numerous shortcomings we find in the Nagy et al. study methodology are as follows. 1. Relevance of subclinical macular edema. The authors state that the incidence of subclinical macular edema after uneventful cataract surgery has become an issue of safety. This is in fact not the case. Subclinical macular edema is defined and diagnosed using fundus fluorescein angiography. It is considered a precursor process that might predispose to CME. The major objective outcome parameter after cataract surgery remains corrected distance visual acuity (CDVA). While macular edema is a critical determinant of surgical success, it is only so when it is clinically significant and results in an adverse effect on CDVA. The authors suggest that the mean CDVA was similar in the traditional phacoemulsification group and the femtosecond laser–assisted cataract surgery group, but no statistical analysis was performed. 2. Methodological bias. Specific patient factors such as age, sex, and refractive error were accounted for, but systemic illnesses (cited above) known to affect the risk for CME were not documented. Despite the study being documented as a prospective case-control series, the criteria for allocation to the traditional phacoemulsification cohort versus the femtosecond laser–assisted cataract surgery cohort were not addressed. There was no record of masking the observers during follow-up and optical coherence tomography (OCT). The mean follow-up was stated to be similar in the 2 cohorts, but there was no statistical

HLA-B27 Anterior Uveitis: Immunology and Immunopathology

ABSTRACT Acute anterior uveitis (AAU) is the commonest type of uveitis and HLA-B27 AAU is the most frequently recognized type of acute anterior uveitis and anterior uveitis overall. Recent evidence indicates that acute anterior uveitis is a heterogenous disease, is polygenic and is frequently associated with the spondyloarthropathies (SpA). Studies of patients with AAU and animal models of disease indicate a role for innate immunity, the IL-23 cytokine pathway and exogenous factors, in the pathogenesis of both SpA and acute anterior uveitis. Recently described genetic associations cluster around immunologic pathways, including the IL-17 and IL-23 pathways, antigen processing and presentation, and lymphocyte development and activation. Patients with ankylosing spondylitis (AS) and AAU share other genetic markers, such as ERAP-1, which show strong evidence of gene–gene interaction and point to new mechanisms of disease pathogenesis. These observations have major implications for understanding the pathogenesis of HLA-B27 diseases, such as AAU, and may lead to the development of more specific therapy for AAU. Received 6 January 2016; revised 6 February 2016; accepted 18 February 2016; published online 31 May 2016

Role of adequate wound closure in preventing acute postoperative bacterial endophthalmitis

Role of adequate wound closure in preventing acute postoperative bacterial endophthalmitis We were delighted to read the excellent review of the current knowledge of acute postoperative bacterial endophthalmitis by Packer et al. This timely review definitely provides “a foundation for future research, [enabling] surgeons to assess current options and practices.” While treatment of acute postoperative bacterial endophthalmitis is well established, emphasizing timely recognition and rapid “tap and inject,” the authors rightly note that prevention of acute postoperative bacterial endophthalmitis is characterized by a notable absence of conclusive evidence. They confirm that “the primary risk factor for endophthalmitis seems to be increased intraocular exposure to the patients own normal adnexal and ocular surface flora.” Thus, the primary issue in preventing acute postoperative bacterial endophthalmitis is likely to be the prevention of intracameral ingress of these pathogens. It is acknowledged that bacteria may enter the anterior chamber and be cultured from it following cataract surgery. Particulate and microscopic matter regularly enters the eye during surgery, yet we are uncertain why more patients do not develop acute postoperative bacterial endophthalmitis. A notable case from Australia found postoperative intracameral migration of topical chloramphenicol ointment, requiring removal from the anterior chamber 2 months after an uncomplicated operation. Intraoperatively, a large volume of circulating sterile balanced salt solution (BSS) may flush out potential pathogens. Hence, in acute postoperative bacterial endophthalmitis, pathogen ingress is probably more important in the postoperative period. Taban et al. report a low incidence of acute postoperative bacterial endophthalmitis until sutureless clear corneal incisions (CCIs) were introduced. Prior to CCIs, phacoemulsification wounds were rarely sutured with subconjunctival sclerocorneal tunnel incisions, in which conjunctiva effectively excluded the tear films postoperative bacterial load. By contrast, the external aspect of the CCI is continuously exposed to the tear-film contents and the blinking lid. Puvanachandra and Humphry reported a case of bilateral endophthalmitis following simultaneous bilateral cataract surgery. We demonstrated that the intracameral antibiosis used in this case was statistically unlikely to have been able to prevent this patients acute postoperative bacterial endophthalmitis (probability of 1 in 4 000 000). This case illustrates that intracameral antibiotics may have a limited preventive role in the development of acute postoperative

Technique to exclude temporal lash incursion in phacoemulsification surgery

&NA; We describe the use of a Steri‐Strip to exclude lashes in cataract surgery cases in which the lashes impinge on the operative field. The technique has been used in 25 cases and achieved uniformly successful lash exclusion. In 6 cases, the strip became partially dislodged and required repositioning intraoperatively, after which it achieved complete lash exclusion. No complications have been observed. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Assessment of adequate removal of ophthalmic viscoelastic device with irrigation/aspiration by quantifying intraocular lens ‘Judders’

To assess the efficacy of ‘Judders’ as a technique reflecting adequacy of removal of ophthalmic viscoelastic device in cataract surgery.

Hydropolish: a controlled trial on a technique to eradicate residual cortical lens fibers in phacoemulsification cataract surgery

Purpose To assess the efficacy and safety of a noncontact, fluid-based capsular polishing technique (hydropolish) to remove residual cortical fibers (RCFs) and epithelial cells from the posterior and equatorial capsule in phacoemulsification cataract surgery. Methods Hydropolish involved manual irrigation of the posterior and equatorial capsule after irrigation/aspiration, using a 27-G hydrodissection cannula. This prospective, consecutive, single surgeon controlled trial was conducted at a dedicated ophthalmic surgery center in Sydney, Australia, between December 20, 2006, and July 14, 2010. Single eyes of consecutive patients underwent cataract surgery without use of hydropolish (control group), while those on or after July 21, 2010, underwent hydropolish (intervention group). Corrected distance visual acuity (CDVA) up to 1 month postoperatively, surgical complications, and hydropolish time were documented. Results A total of 1531 eyes were included in this study (hydropolish n = 682; control n = 849). After adjusting for age, sex, and nuclear sclerosis grade, no significant difference was found between hydropolish and control groups when preoperative CDVA was compared against postoperative CDVA at 1 day, 1 week, and 1 month (p>0.05). Conclusions Hydropolish is a rapid and safe technique that can remove RCFs from the posterior and equatorial capsule in phacoemulsification cataract surgery. It does not compromise postoperative CDVA.

The grape: an appropriate model for continuous curvilinear capsulorhexis.

The cornerstone of helping surgical trainees achieve a cost-effective level of surgical expertise and competency is provision of adequate supervised training and repetition to consolidate newly learned skills. When helping trainees learn new surgical procedures, surgical tutors often recommend dividing the procedure into the component steps. We believe this philosophy is particularly beneficial in assisting trainees master the continuous curvilinear capsulorhexis (CCC) step of endocapsular phacoemulsification. Trainee surgeons have noted phacoemulsification and capsulorhexis as the most challenging steps of the procedure, and a recent publication suggests that sculpting and fragmentation are the most difficult. Experienced surgeons readily recognize that the most important early step in safe phacoemulsification is a high-quality capsulorhexis. The use of synthetic or animal eyes as well as surgical simulators have been described in learning this step. The attendant costs and limited access of animal models and surgical simulators pose significant problems in phacoemulsification training. We suggest the use of red globe grapes (Vitus vinifera) as an alternative model for CCC training. Grapes and tomatoes have been mentioned, to our knowledge with no literature support, as being useful for practicing capsulorhexis. The grape is readily available, irresistibly cheap, and has an elastic skin

Preseptal epidermal eyelid abscess related to unreported trauma in a patient with schizoaffective disorder.

9 months after nephrectomy (Fig. 3). First described by Victor Alexander Bochdalek in 1867, a Bochdalek hernia is a congenital hernia created by improper fusion of the posterolateral foramina of the diaphragm. These are the most common type of congenital diaphragmatic hernias. Over 95% of cases are diagnosed in the neonatal period due to associated pulmonary insufficiency. There are only 173 cases of symptomatic Bochdalek hernias reported in the adult population in worldwide literature. The mean age of presentation is 40 years old, but there is a wide age range, from 15 to 88 years. Adult presentations of Bochdalek hernias are often insidious and intermittent, with mainly vague gastrointestinal symptoms (abdominal pain, nausea, vomiting, constipation) or respiratory symptoms (chest pain, dyspnoea, wheezing). Others present with serious complications of incarceration or strangulation, necessitating emergency surgery. A precipitating factor was noted in only 25% of reported cases. Common precipitating factors were pregnancy and exertion, but also included trauma, large meals, retching and coughing. Surgical repair has been performed via five different approaches: laparotomy, thoracotomy, laparoscopy, thoracoscopy or a combination of these. For emergent cases, laparotomy was the most common approach; however, laparoscopic and thoracoscopic repairs have been performed successfully in the last two decades on an elective basis. More recent CT and autopsy studies have revealed that the incidence of asymptomatic Bochdalek hernia in adulthood is higher than previously thought, with an estimated range between 0.17% and 12.7%. Asymptomatic hernias are often associated with liver, gallbladder, kidney and/or omentum, and occur more commonly on the right side and in women. To our knowledge, this is the first case describing a previously asymptomatic congenital hernia unveiled after nephrectomy. Misdiagnosis of diaphragmatic hernias is common, regardless of aetiology, due to the wide variation in symptoms and the rarity of the defect. In the literature, only 65% of Bochdalek hernia cases were diagnosed preoperatively. Although uncommon in adults, these abnormalities should be known and managed appropriately to avoid potential dire consequences, and associated morbidity and mortality.