Dry Eye Post-Laser-Assisted In Situ Keratomileusis: Major Review and Latest Updates

Dry eye is one of the most common complications occurring after laser-assisted in situ keratomileusis (LASIK), with virtually all patients experiencing some degree of postoperative dry eye symptoms. Enhanced understanding of the pathophysiology and mechanism of dry eye development in addition to preoperative screening of patients who are prone to dry eye is essential for better patient satisfaction and for improving short-term visual outcome postoperatively. This article reviews the latest studies published on LASIK-associated dry eye, including epidemiology, pathophysiology, risk factors, preoperative assessment, and management

Corneal Blood Staining after Complicated Cataract Surgery

Purpose: To report the case of a patient with corneal blood staining after a complicated cataract surgery. Observations: We report on a 68-year-old woman who developed corneal blood staining secondary to hyphema after cataract surgery, despite the fact that intraocular pressure was not increased for a prolonged time. The corneal staining spontaneously cleared from the periphery towards the center. It was fully resolved after 2.5 years of follow-up. Conclusions and Importance: In case of hyphema induced by cataract surgery, performance of early anterior chamber washout should be considered to prevent corneal blood staining and poor visual outcome

Outcomes of Congenital Nasolacrimal Duct Obstruction Surgery Converted into Balloon Dilation and Silicone Intubation due to Probing Difficulty

Background. To report the outcomes of balloon catheter dilatation and silicone intubation as a sequential secondary surgery under the same anesthesia, a stepwise approach for congenital nasolacrimal duct obstruction (NLDO) when probing and irrigation as primary procedure fails. Methods. A retrospective study included children with NLDO who underwent probing and irrigation only, and those who underwent in the same surgery under anesthesia, adjunct balloon catheter dilation and silicone intubation due to difficulty of the probe passage or fluid regurgitation from the punctum. The primary outcome was surgical success defined as resolution of preoperative symptoms and signs at 1 month. Results. A total of 105 NLDO cases were included. Eighty-four cases underwent probing and irrigation only, whereas 21 cases required balloon dilation and silicone intubation consecutively after the first procedure. Patient age at surgery was higher for those requiring balloon dilatation and intubation (30.3 +/- 8.0 months) when compared to those with probing and irrigation only (22.4 +/- 10.3 months, p < 0.001). The onset of symptoms, preoperative clinical findings regarding tearing and discharge and gender distribution of patients were comparable between the two groups. During the follow-up, the overall success rate for probing and irrigation only was 76.2% (64 out of 84 cases) and for balloon dilatation and silicone tube intubation was 90.5% (19 out of 21 cases). Conclusions. The surgical team may prepare to proceed with secondary surgery under the same anesthesia after the initial attempt of probing and irrigation. This stepwise two-stage approach in patients with congenital NLDO failing primary surgery resulted in a high success rate with minimal interventions, avoiding repeated general anesthesia.Peer reviewe

A Simple Pre-Operative Nuclear Classification Score (SPONCS) for Grading Cataract Hardness in Clinical Studies

Background: The aim of this study was to evaluate whether a simplified pre-operative nuclear classification score (SPONCS) was valid, both for clinical trials and real-world settings. Methods: Cataract classification was based on posterior nuclear color: 0 (clear), 1 (subcapsular/posterior cataract with clear nucleus), 2 (mild “green nucleus” with plus sign for yellow reflection of the posterior cortex), 3 (medium “yellow nucleus” with plus sign for brown/red posterior cortex reflection), 4 (advanced with 4 being “red/brown nucleus” and 4+ white nucleus), and 5 (hypermature/Morgagnian nucleus). Inter- and intra-observer validity was assessed by 30 Ophthalmologists for 15 cataract cases. The reliability of the cataract grading score in a surgical setting was evaluated. Correlation of nuclear scores was compared with phacoemulsification cumulative dissipated energy (CDE) in 596 patients. Results: Analysis of mean intra-observer Cohen kappa agreement was 0.55 with an inter-observer score of 0.54 for the first assessment and 0.49 for the repeat assessment one week later. When evaluating results by nuclear color alone, there was a substantial agreement for both the intra-observer (0.70) and inter-observer parameters: 0.70 for the first test, and 0.66 on repetition with randomization of the cases after a week. CDE levels were found to be significantly different between all SPONCS score groups (p < 0.001), with a lower CDE related to a lower SPONCS score. A strong correlation was found between the SPONCS score and CDE (Spearman′s rho = 0.8, p < 0.001). Conclusion: This method of grading cataract hardness is both simple and repeatable. This system can be easily incorporated in randomized controlled trials to lower bias and confounding effects regarding nuclear density along with application in the clinical setting

Donor and Recipient Sex Matching and Corneal Graft Failure in High-Risk and Non-High-Risk Patients

Purpose. It is controversial whether donor-recipient sex mismatch is a risk factor associated with corneal graft failure. The purpose of this study was to investigate the effect of sex mismatch on corneal graft failure in high-risk and non-high-risk patients. Design. A retrospective study. Methods. The medical charts of patients who underwent corneal transplantations by one surgeon between 2012 and 2017 were reviewed. Patients were defined as high-risk for failure if they had glaucoma, ocular surface disease, or corneal vascularization. Graft failure rates were compared using the Kaplan-Meier survival curves between sex matched and mismatched subjects and between male-to-female grafting and other patients. Results. One hundred and thirteen patients with a minimum follow-up of 18 months were included. In 62 non-high-risk patients, graft failure rates were similar between the sex mismatched and the sex matched recipients (p=0.645, log-rank) and in male donor to female recipient transplantations and in the other transplantations (p=0.496, log-rank). Analysis of fifty-one eyes of 51 high-risk graft recipients (mean age of 73.4 +/- 12.7 years, N = 26 females) showed that graft failure rates were significantly higher in the sex mismatched than sex matched recipients (p=0.022, log-rank) and in male donor to female recipient transplantations than in the other transplantations (p=0.002, log-rank). Conclusions. Sex matching for every patient bares logistic difficulties; however, in patients who are at high-risk for graft failure, it may be a simple way to improve outcomes and better utilize corneal grafts.Peer reviewe

Spontaneous Scleral Perforation of an Anterior Chamber Intraocular Lens

A routine eye examination of a 69-year-old man revealed a scleral perforation of one of the haptics of the anterior chamber intraocular lens (AC IOL) which had been implanted many years ago. The patient was asymptomatic with good visual acuity. His history was negative for any trauma, eye rubbing, topical corticosteroid use, or autoimmune disease. The horizontal and vertical white-to-white diameters of the cornea in the right eye were 11.5 and 10.5 mm, respectively. Anterior segment optical coherence tomography showed the anterior chamber length to be 12.28 mm horizontally and 10.63 mm vertically. The patient underwent an IOL exchange, and the length of the explanted AC IOL was measured to be 12 mm. We speculate that the AC IOL, which was vertically aligned, was oversized. This case demonstrates the need for proper sizing and positioning of an AC IOL. In complex cases where AC IOL may be used, measuring the horizontal and vertical lengths of the anterior chamber by anterior segment optical coherence tomography prior to surgery may be useful

Spontaneous Scleral Perforation of an Anterior Chamber Intraocular Lens

A routine eye examination of a 69-year-old man revealed a scleral perforation of one of the haptics of the anterior chamber intraocular lens (AC IOL) which had been implanted many years ago. The patient was asymptomatic with good visual acuity. His history was negative for any trauma, eye rubbing, topical corticosteroid use, or autoimmune disease. The horizontal and vertical white-to-white diameters of the cornea in the right eye were 11.5 and 10.5 mm, respectively. Anterior segment optical coherence tomography showed the anterior chamber length to be 12.28 mm horizontally and 10.63 mm vertically. The patient underwent an IOL exchange, and the length of the explanted AC IOL was measured to be 12 mm. We speculate that the AC IOL, which was vertically aligned, was oversized. This case demonstrates the need for proper sizing and positioning of an AC IOL. In complex cases where AC IOL may be used, measuring the horizontal and vertical lengths of the anterior chamber by anterior segment optical coherence tomography prior to surgery may be useful

Comparative activity of antimicrobials against Pseudomonas aeruginosa, Achromobacter xylosoxidans and Stenotrophomonas maltophilia keratitis isolates

Background/aims Achromobacter xylosoxidans and Stenotrophomonas maltophilia are emerging corneal pathogens, which are closely related to Pseudomonas aeruginosa, and have intrinsic resistance to many commonly available antimicrobials. The purpose of this study is to compare the in vitro efficacy of 12 antimicrobial agents against A. xylosoxidans, S. maltophilia and P. aeruginosa isolates recovered from clinical cases of keratitis.MethodsRecovered corneal isolates (n=58) were identified and extracted from the Microbiology Data Bank of the Bascom Palmer Eye Institute. Comparative in vitro minimum inhibitory concentration (MIC) susceptibility profiles for fluoroquinolones, aminoglycosides, beta-lactams and miscellaneous antibiotics were recorded using the E-test methodology. Pharmacodynamic indices (Cmax/MIC) were calculated.Results A. xylosoxidans and S. maltophilia isolates were resistant to fluoroquinolones, aminoglycosides and ceftazidime (susceptibility rate ranging from 0% to 30%) while P. aeruginosa isolates showed a susceptibility rate of 95%–100% to these antimicrobials (P<0.00001 for the various antimicrobials). Exception was moxifloxacin with 80% of susceptibility rate to S. maltophilia isolates and Cmax/MIC=10.19. Ninety to 100% susceptibility rates were found for minocycline and trimethoprim/sulfamethoxazole for both A. xylosoxidans and S. maltophilia. One hundred per cent of the A. xylosoxidans isolates were susceptible to piperacillin/tazobactam and ticarcillin/clavulanic acid.ConclusionsThere is a significant difference in susceptibility patterns between A. xylosoxidans, S. maltophilia and P. aeruginosa. Fluoroquinolones and aminoglycosides may not be effective against A. xylosoxidans and S. maltophilia. Antibiotics that are not commercially available as eye drops, such as beta-lactams for A. xylosoxidans, and trimethoprim/sulfamethoxazole and minocycline for both A. xylosoxidans and S. maltophilia should be considered

Effect of Hemodialysis on Retinal Thickness in Patients with Diabetic Retinopathy, with and without Macular Edema, Using Optical Coherence Tomography

Background. Effects of hemodialysis (HD) treatment on retinal thickness and macular edema are unclear. Objective. To evaluate changes in retinal thickness using optical coherence tomography (OCT) in end stage renal disease (ESRD) patients with diabetic retinopathy (DR), with and without diabetic macular edema (DME), undergoing HD. Methods. Nonrandomized prospective study. Forty eyes of DR patients with ESRD treated with HD were divided into two groups: patients with macular edema and patients without macular edema. Both eyes were analyzed. Patients underwent an ophthalmic examination including OCT measurements of retinal thickness, blood albumin and hemoglobin A1C levels, blood pressure, and body weight, 30 minutes before and after HD. Results. We found no significant effects of HD on retinal thickness among patients both with and without DME. The former showed a trend towards reduction in retinal thickness in foveal area following HD, while the latter showed an increase. There was no correlation between retinal thickness and mean blood pressure, weight, kinetic model value—Kt/V, glycemic hemoglobin, or albumin levels before and after HD. Conclusions. HD has no significant effect on retinal thickness among patients with or without DME. Further studies on larger cohorts and repeated OCT examinations are needed to confirm the preliminary findings in this study