Difluprednate for the prevention of ocular inflammation postsurgery: an update

Eric D DonnenfeldOphthalmic Consultants of Long Island, Rockville Centre, NY, USAPurpose: To review the most recent published data regarding the novel potent steroid, difluprednate ophthalmic emulsion, 0.05%.Methods: A comprehensive search of recent published literature including difluprednate was performed. Clinical studies relevant to the characteristics and clinical efficacy of difluprednate in controlling postoperative inflammation were included, and a synopsis of each study was developed.Results: Several recent publications were identified in which difluprednate was shown to be efficacious in the treatment of postoperative inflammation in different clinical settings, including a novel perioperative regimen. Additional literature retrieved from this search included data on the relative potency of difluprednate, potential utility in the posterior segment, as well as the advantages of the emulsion formulation.Conclusion: Difluprednate has been studied extensively and shown in recent literature to be a safe and effective topical anti-inflammatory drug. The proven strength and unique formulation of difluprednate, along with its potent efficacy in treating and preventing inflammation, provides clinicians with a beneficial treatment option.Keywords: corticosteroids, anti-inflammatory, dose uniformity, relative potenc

Efficacy and wound-temperature gradient of WhiteStar technology phacoemulsification through a 1.2 mm incision

Journal ArticlePURPOSE: To evaluate the efficacy and wound-temperature gradients of WhiteStar micropulse technology using bimanual phacoemulsification without an irrigation sleeve through a 1.2 mm incision. SETTING: Island Eye Surgicenter, Carle Place, New York, USA. METHODS: Ten patients had bimanual phacoemulsification using micropulse technology without an irrigation sleeve through a 1.2 mm clear corneal incision. A thermocouple consisting of a 30-gauge copper wire was inserted into clear cornea directly adjacent to the wound to digitally record temperature gradients at the wound. Endothelial cell counts were evaluated preoperatively and postoperatively in all patients. RESULTS: All 10 patients maintained corneal clarity with no sign of thermal damage to the wound. The maximum corneal wound temperatures during phacoemulsification ranged from 24 degrees C to 34 degrees C, well below the temperature of collagen shrinkage. The endothelial cell loss at 3 months was 7%. CONCLUSIONS: Because of the decreased thermal effect with WhiteStar technology, an irrigation sleeve over the phacoemulsification needle is superfluous. As a result, bimanual phacoemulsification can be safely performed through a 1.2 mm incision

Visual Outcomes, Efficacy, and Surgical Complications Associated with Intracameral Phenylephrine 1.0%/Ketorolac 0.3% Administered During Cataract Surgery

Aim: The purpose of this study was to compare visual outcomes, surgical time, and perioperative surgical complications after intracameral use of either phenylephrine/ketorolac (P/K) or epinephrine (Epi) during cataract surgery.Methods: This was a single-center, retrospective case review of patients undergoing cataract surgery from August to November 2015. Of the 641 eyes of 389 patients who underwent cataract surgery, 260 eyes were administered phenylephrine 1.0%/ketorolac 0.3% and 381 eyes received Epi in the irrigation solution intraoperatively. All patients received a topical nonsteroidal anti-inflammatory drug regimen (bromfenac 0.07%, nepafenac 0.3%, or ketorolac 0.5%) for 3 days before surgery and topical tropicamide 1.0%, cyclopentolate 1.0%, and phenylephrine 2.5% on the day of surgery.Results: Mean length of surgery (LOS) was 15.4±0.6 minutes. Although a positive correlation was noted between patient age and LOS (p\u3c0.001), P/K was associated with a decrease in the LOS, when controlled for age quartiles. A statistically significant lower incidence of complications (1.1%) was observed with P/K use than Epi (4.5%; p=0.018). Among surgeons who used mydriatic-assist devices more frequently, P/K use was associated with a reduction in the use of these devices (p\u3c0.001). When controlling for age quartile, patients of age groups 69–76 and 76–92 years who received P/K had significantly better uncorrected visual acuity at postoperative day 1 than those receiving Epi (p=0.003).Conclusion: Intracameral use of phenylephrine 1.0%/ketorolac 0.3% during cataract surgery may be effective in maintaining mydriasis. It appears to be superior to intracameral Epi at reducing intraoperative and postoperative complications, need for pupillary dilating devices, and surgical time

A prospective 3-year follow-up trial of implantation of two trabecular microbypass stents in open-angle glaucoma

PURPOSE: To evaluate 3-year safety and intraocular pressure (IOP) following two trabecular microbypass stents in phakic and pseudophakic subjects with open-angle glaucoma (OAG) not controlled on preoperative medication. PATIENTS AND METHODS: In this prospective pilot study, phakic or pseudophakic subjects with OAG and IOP between 18 mmHg and 30 mmHg on one preoperative topical ocular hypotensive medication underwent medication washout. Thirty-nine qualified subjects with preoperative unmedicated IOP ≥22 mmHg and ≤38 mmHg received two stents. Postoperative examinations were scheduled at Day 1, Week 1, Months 1, 3, 6, and 12, and semiannually through Month 60. Ocular hypotensive medication was considered if postoperative IOP exceeded 21 mmHg. IOP, medication use, and safety were assessed at each visit. Subject follow-up through Month 36 was completed. RESULTS: Thirty-six eyes (92.3%; 95% confidence interval [CI] 79.1%, 98.4%) achieved the primary efficacy end point of Month 12 reduction in IOP ≥20% from baseline (unmedicated IOP) without ocular hypotensive medication. Four subjects required medication during the Month 36 follow-up period. Mean IOP at 36 months for subjects not taking medication was 15.2 mmHg. At 36 months, subjects sustained mean IOP decrease of 9.1±2.7 mmHg (95% CI 8.0 mmHg, 10.14 mmHg), or 37% IOP reduction, from unmedicated baseline IOP. Compared to preoperative medicated IOP, subjects had mean reduction at Month 36 of 5.5±2.7 mmHg (95% CI 4.5 mmHg, 6.6 mmHg), or 26% reduction. Both measures of IOP reduction were highly significant (P<0.001). Other than one case of early postoperative hyphema that resolved at 1 week, no postoperative adverse events were attributed to stent implantation. CONCLUSION: In a pilot study, two trabecular microbypass stents to treat OAG subjects on one preoperative medication provided statistically significant, sustained, and safe reduction of IOP to ≤15 mmHg without medication through 36 months

Visual and Keratometric Outcomes of Keratoconus Patients After Sequential Corneal Crosslinking and Topography-Guided Surface Ablation: Early United States Experience

PURPOSE: To evaluate a sequential treatment algorithm for visual and keratometric improvement in keratoconus patients after corneal crosslinking (CXL) followed by topography-guided photorefractive keratectomy (PRK). SETTING: Ophthalmic Consultants of Long Island, Garden City, New York, USA. DESIGN: Retrospective case series. METHODS: This study reviewed patients with keratoconus who had CXL followed by custom topography-guided PRK between April 2016 and December 2016. The following data were collected at baseline, the time of CXL, and 3 months and 6 months after PRK: uncorrected (UDVA) and corrected (CDVA) distance visual acuities, keratometric astigmatism, spherical equivalent, maximum and mean keratometry readings, and corneal thickness at the cone apex. Demographic data, age at time of CXL and PRK, and time elapsed between CXL and PRK were analyzed for significance and a correlation with visual and astigmatic outcomes. RESULTS: The study comprised 56 patients (62 eyes), 34 who had both topographic and refractive treatment and 28 patients who had treatment of topographic irregularities only. The mean age was 38.08 years +/- 13.07 (SD) at CXL and 40.33 +/- 13.44 years at topography-guided PRK. Six months after PRK, there was a significant improvement in UDVA and CDVA in the refractive group (20/60 and 20/30, respectively) versus the nonrefractive group (20/100 and 20/40, respectively). Ninety-three percent of eyes that had refractive treatment had 20/40 or better CDVA. There were no significant adverse events in any case. CONCLUSIONS: The data support the use of refractive treatment in addition to topographic treatment for visual improvement in patients with keratoconus having CXL and PRK

Randomized Prospective Evaluation of the Wound Integrity of Primary Clear Corneal Incisions Made With a Femtosecond Laser Versus a Manual Keratome

PURPOSE: To compare the wound integrity of femtosecond laser-assisted 110-degree reverse side-cut clear corneal incisions (CCIs) with femtosecond laser-assisted 70-degree forward side-cut and manual CCIs in patients having cataract surgery. SETTING: Island Eye Surgicenter, Carle Place, New York, USA. DESIGN: Prospective case series. METHODS: Patients having cataract surgery were randomized into 3 treatment groups as follows: Group A had 110-degree femtosecond reverse side-cut CCIs, Group B had 70-degree femtosecond forward side-cut CCIs, Group C had manual CCIs. At the conclusion of surgery, the integrity of the CCI was measured by raising intraocular pressure (IOP) until the CCI began to leak. Postoperatively, the CCIs were assessed for wound leakage at 1 day, 2 weeks, and 1 month. RESULTS: The study comprised 45 patients (45 eyes, 15 in each treatment group). The mean IOP at which CCIs leaked (in response to anterior chamber balanced salt solution irrigation) was statistically significantly higher in Group A (28.20 mm Hg +/- 11.69 [SD]) than in Group B (15.07 +/- 10.64 mm Hg; P = .005) and Group C (9.93 +/- 9.90 mm Hg; P \u3c .001). At 1 day postoperatively, the Seidel test with pressure showed no leakage in any of the Group A eyes; however, 53% of eyes in Group B and 87% in Group C showed wound leakage. CONCLUSION: The femtosecond laser-created reverse side-cut CCIs required significantly higher IOP intraoperatively before leaking and resulted in better wound integrity with significantly less wound leakage postoperatively than laser-created forward side-cut or manual CCIs

Influence of Bacterial Burden on Meibomian Gland Dysfunction and Ocular Surface Disease

Purpose: Bacterial burden on the eyelid margin and within meibomian glands was evaluated for influence on specific ocular surface disease (OSD) markers across the meibomian gland dysfunction (MGD) spectrum. Methods: In this prospective, observational, single-center study, 40 patients were divided into 4 equal groups of 10 that encompassed increasingly worse MGD/OSD categories. All patients answered the standard Ocular Surface Disease Index questionnaire, and underwent tear osmolarity testing (TOT), Schirmer 1, matrix metalloproteinase 9 (MMP-9) testing, meibography, and lissamine green staining. Cultures of eyelid margins and meibomian gland secretions were directly plated on blood, chocolate, and Sabouraud agar; smears were sent for gram and Papinicolau evaluation. Results: Mean patient age was 55.25+/-17.22 years; there were 10 males and 30 females. TOT and MMP-9 testing were similar across groups. Culture positivity was 62.5% for right eyes, 70% for left eyes, and was not statistically different across groups (for both eyelid margin and meibomian glands). The majority of cultures were positive for coagulase-negative staphylococcus (CNS). Conclusion: This study is in concordance with others, citing the predominance of CNS within the biofilm of both normal and clinically significant MGD/OSD patients. Our study exemplifies that symptoms of OSD do not necessarily correlate with degree of clinical exam findings, nor culture positivity. These results argue that bacterial burden should be reconsidered as a direct risk factor and treatment target for MGD/OSD patients

Treating Allergic Conjunctivitis: A Once-daily Medication that Provides 24-hour Symptom Relief

Background Allergic conjunctivitis (AC) is a common ocular inflammatory manifestation of allergen exposure in sensitized individuals. Signs and symptoms of AC can decrease quality of life, interfere with productivity, and lead to considerable economic burden. Consistent suppression of conjunctival inflammation is necessary for managing AC, but currently available medications require frequent administration and exhibit limited duration of action. Methods In this review, we summarized AC pathogenesis, diagnosis, and current treatment options as well as their limitations. Findings from the literature were discussed in the context of the unmet need for a once-daily medication with sustained 24-hour effectiveness. Results Topical pharmacologic treatments are the most common approach for managing extant AC; however, most available medications require multiple daily instillations. Dual-acting antihistamine-mast cell stabilizing agents are currently considered first-line therapeutics for AC because they provide acute relief of signs and symptoms and block persistent inflammation to promote regression of AC. Recent studies of a newly-developed, higher-concentration formulation of a dual-acting antihistamine-mast cell stabilizer have demonstrated that this formulation provides a 24-hour duration of action with once-daily dosing. Conclusions Dual-acting AC medications exhibit a high degree of overall effectiveness and are well tolerated for chronic use. A newly available once-daily medication that manages signs and symptoms of AC for a full 24 hours may be considered a treatment of choice for patients experiencing seasonal or perennial AC. ClinicalTrials.gov NCT01743027 and NCT0147937