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Purpose To investigate the safety of face masks worn by patients during intravitreal injections. Methods A prospective, qualitative, interventional study performed in a tertiary university hospital. Healthy volunteers were asked to wear three different professional surgical face masks while air leaks around the eyes were monitored. Three types of masks were investigated as follows: 1) surgical face mask with four tying strips, 2) surgical face mask with elastic ear loops and 3) 2200 N95 tuberculosis particulate face mask. For each session the periocular area was inspected for air leak during normal respiration, speech, and deep respiration. Detection of air leak was performed using the following two professional thermal cameras: FLIR A310-thermal camera and EyeCGas 2.0-super sensitive infrared camera used for detection of minute fugitive emissions of industrial gases. Results Ten healthy volunteers were enrolled in this study. The experiment was repeated 45 times for each camera; 3 times for each of 3 mask types, on 5 volunteers, for a total of 90 trials. Air jets were detected originating from the superior edges of the masks radiating toward the eyes in 81% (73/90) of cases in total; 71% (32/45) with the FLIR camera and 91% (41/45) with the OPGAL camera. Air leaks were detected with all investigated mask types. Conclusion Patients wearing face masks during intravitreal injections may be at a higher risk of endophthalmitis. Until further data are available, we recommend verifying proper face mask fitting and either taping the upper edges of the face masks with a medical adhesive tape or using an adhesive surgical drape around the injected eye.

Purpose To describe the clinical characteristics and treatment of spontaneous Descemet membrane (DM) detachment occurring decades after penetrating keratoplasty (PK). Methods A multicenter interventional case series design was used. We reviewed the medical records of 4 patients with a history of PK presenting with spontaneous DM detachment at 3 university hospitals in Israel and an ocular surgery institute in The Netherlands in 2016 to 2019. Patient demographic and clinical data, postoperative best corrected visual acuity, findings on preoperative and postoperative anterior segment optical coherence tomography (AS-OCT), and graft survival were recorded. Results Patients were aged 46 to 50 years. All had undergone PK for keratoconus 20 to 26 years previously. Patients presented within 18 to 180 days of onset of visual disturbance. Symptoms included sudden painless visual loss (2 patients), gradual visual loss and foreign body sensation (1 patients), and visual loss not otherwise specified (1 patient). Slit-lamp examination showed corneal edema, and AS-OCT showed DM detachment of variable extent. In 2 patients, the initial diagnosis was graft rejection and failure. Treatment consisted of anterior chamber injection of air (n = 3) or 20% SF6 (n = 1). In 3 patients, the DM reattached and the cornea regained its clarity. The fourth patient had persistent DM detachment that required repeated PK. Conclusions Spontaneous DM detachment can mimic late graft failure in patients after PK. If diagnosed early, DM reattachment may be performed by air/gas injection, avoiding repeated keratoplasty. Eyes with presumed late penetrating graft rejection or failure should be examined by AS-OCT to exclude DM detachment.

Purpose To evaluate the effect of a single subconjunctival aflibercept injection on formed corneal neovascularization. Methods A prospective clinical trial, conducted at a single tertiary medical center. Included were consecutive patients with corneal pathologies complicated by corneal neovascularization, who were candidates for anti-vascular endothelial growth factor treatment at the discretion of a cornea specialist. A single subconjunctival injection of 0.08 mL of Aflibercept (Eylea 25 mg/mL) was administered near the limbus in proximity to the areas of maximal pathological neovascularization. Follow-up visits were scheduled on days 7, 30, 60, and 90 following injection. Best-corrected visual acuity (BCVA), intraocular pressure, slitlamp examination, digital cornea photography, specular microscopy, and anterior-segment optical coherence tomography were documented at each visit. The images were graded by a masked observer for density, extent, and centricity of corneal vascularization. Results Six eyes of six patients were analyzed. No clinically significant ocular or systemic adverse events were documented. No change was noted in extent, density, or centricity of corneal blood vessels at seven, 30, and 90 days after injection (P>0.1 for all time point comparisons, Friedman test). Best-corrected visual acuity fluctuated insignificantly in 5/6 patients during follow-up time, and objective but not subjective improvement of BCVA was noted in one patient with no concurrent change of neovascularization. The recruitment has therefore halted prematurely. Conclusions A single subconjunctival aflibercept injection seems to be well tolerated. However, it is ineffective for regressing formed corneal neovascularization.

Objectives Our aim is to evaluate the safety, efficacy, predictability, and clinical outcome of femtosecond laser-assisted in situ keratomileusis (FS-LASIK) procedures performed on the day of the initial consultation relative to procedures performed at subsequent visits. Methods A retrospective cohort study design was used. The study group included patients with myopia of different severities who were treated with FS-LASIK in 2013 through 2014 in an optical outpatient clinic of a large private medical service. Inclusion criteria were at least 18 years of age, a stable refraction for 12 months, no history of autoimmune disease, ocular surgery, or eye disease, and complete medical records. Background, clinical, and outcome data were collected from the patient files. Results Femtosecond laser-assisted in situ keratomileusis was performed in 80 patients (160 eyes) at the first visit and 361 patients (719 eyes) at a subsequent visit. The mean±SD spherical equivalent (SE) refraction before surgery was -3.74±2.03 D in the first-visit group and -3.73±1.87 D in the subsequent-visit group (P=0.99). Efficacy index values were 0.97±0.15 in the first-visit group and 0.98±0.13 in the subsequent-visit group (P=0.92), and corresponding safety index values were 0.99±0.15 and 0.99±0.12 (P=0.81). The final SE measured -0.09±0.58 D in the first-visit group and -0.19±0.55 D in the subsequent-visit group (P=0.05). Types and rates of complications were similar in the two groups. Conclusions There is no significant difference in the results of refractive surgery with FS-LASIK between procedures performed at the initial or subsequent visits. In both conditions, FS-LASIK surgery is associated with excellent safety, efficacy, and predictability profiles.

The treatment of corneal endothelial dysfunction has experienced a revolutionary change in the past decades with the emergence of endothelial keratoplasty techniques: descemet stripping automated endothelial keratoplasty (DSAEK) and descemet membrane endothelial keratoplasty (DMEK). Recently, new treatments such as cultivated endothelial cell therapy, Rho-kinase inhibitors (ROCK inhibitors), bioengineered grafts, and gene therapy have been described. ,ese techniques represent new lines of treatment for endothelial dysfunction. ,eir advantages are to help address the shortage of quality endothelial tissue, decrease the complications associated with tissue rejection, and reduce the burden of postoperative care following transplantation. Although further randomized clinical trials are required to validate these findings and prove the long-term efficacy of the treatments, the positive outcomes in preliminary clinical studies are a stepping stone to a promising future. Our aim is to review the latest available alternatives and advancements to endothelial corneal transplant.

Background The purpose of this study was to compare the h-index, and subsequently the research productivity, among different ophthalmic subspecialties in the United States. Methods A cohort of over 15,000 academic ophthalmologists residing in the United States (US) was identified out of the physician list of the American Academy of Ophthalmology. Of them, 1000 ophthalmologists with at least one publication were randomly retrieved, 100 in each of the following 10 subspecialties: cataract, cornea/external disease, glaucoma, medical retina, neuro-ophthalmology, pediatric ophthalmology, plastic/reconstructive ophthalmology, refractive surgery, retina/vitreous surgery and uveitis. Data collected included: number of published papers, h-index score, annual increase in h-index and the mean number of authors on each paper. Results The mean h-index amongst all subspecialties was 9.87 ± 13.90, and the mean average annual increase in h-index was 0.22 ± 0.21. The mean number of papers published was 37.20 ± 80.08 and the mean number of authors on each paper was 3.39 ± 0.84. Uveitis was the most prolific subspecialty in mean number of papers (74.78 ± 131.37), in mean h-index (16.69 ± 20.00) and in mean annual increase in h-index (0.35 ± 0.28). The least fertile subspecialty with regards to research was cataract with 11.06 ± 27.65 mean number of papers, a mean h-index of 3.89 ± 5.84, and a mean annual increase in h-index of 0.11 ± 0.11. Conclusions This study describes the research productivity in each ophthalmic subspecialty in the US, thus providing information on the research performance of each field and on the expected academic accomplishments within it.

Ocular chemical burn is an ophthalmological emergency. Therefore, chemical injuries should be promptly addressed in order to initiate the appropriate treatment as soon as possible and optimize the visual prognosis. We present a retrospective study of ten cases with ocular chemical burn including one with superglue and one with a liquid plaster material injury and describe their clinical course.Ten adult patients (34 - 92 years, 8 males) presented with moderate to severe alkali or neutral chemical burns in our emergency clinics. They exhibited a variable degree of conjunctival injection, limbal ischemia, corneal erosion, and Descemet's folds.Patients were treated and complete corneal epithelial closure was achieved in all cases without significant signs of limbal stem cell insufficiency. Corneal endothelial insufficiency was observed in all cases. Nine patients had to be listed for corneal endothelial keratoplasty and one was treated with Descemet's stripping endothelial automated keratoplasty.Isolated corneal endothelial decompensation after chemical burns has not yet been described. The pathophysiological explanation of this observation remains, however, unknown. In view of this rare complication, it is important to follow patients after chemical ocular burn for possible development of endothelial decompensation.Die Augenverätzung ist ein ophthalmologischer Notfall, der eine umgehende zielgerichtete Therapie erfordert, um das Sehvermögen bestmöglich zu erhalten. Wir berichten über 10 Patienten mit einer okulären Verätzung einschließlich einer Verletzung mit Sekundenkleber und Flüssigpflaster.Zehn Patienten im Alter zwischen 34 und 92 Jahren wurden in unseren Notfallaufnahmen mit leichten bis mittelschweren Verätzungen durch Laugen oder neutralem Agens behandelt. Es fanden sich unterschiedliche klinische Ausprägungen der Bindehautinjektionen, Reaktionen des Randschlingennetzes, Hornhauterosion und Ausbildung von Descemet-Falten.Die Patienten wurden entsprechend der Klinik behandelt. In allen Fällen erfolgte ein kompletter Epithelverschluss ohne signifikante Zeichen einer limbalen Stammzellinsuffizienz. Jedoch entwickelten alle Patienten eine Hornhautendothelinsuffizienz. Bei 9 Patienten wurde eine Descemet Membrane Endothelial Keratoplasty und bei 1 Patient eine Descemet Stripping Automated Endothelial Keratoplasty durchgeführt.Eine isolierte Hornhautdekompensation nach Verätzung wurde bisher in der Literatur nicht beschrieben. Der Pathomechanismus dieser Beobachtung ist nicht bekannt. Bei Augenverätzungen muss diese seltene Komplikation jedoch bedacht werden.

Aim: To compare the efficacy of aflibercept (Eylea®), a potent antivascular endothelial growth factor (VEGF) agent, with betamethasone (Celestone®) and placebo for the treatment of formed corneal neovascularization in a rabbit model. Methods: A central corneal chemical burn was created in the right eye of 24 New Zealand albino rabbits. Four weeks later, the rabbits were randomly divided into 4 equal groups for subconjunctival injection of aflibercept, betamethasone, aflibercept+ betamethasone, or saline (control). Digital photographs taken at weekly intervals were rated by 2 masked observers for extent, centricity, and density of corneal neovascularization according to a predefined scale. The percentage of corneal surface involved by neovascularization was quantified by image analysis software (Fiji-J). The change in corneal neovascularization from treatment administration (4 weeks after injury) to 4 weeks later (8 weeks after injury) was assessed. The rabbits were then euthanized, and their eyes were enucleated and processed for histopathological and immunofluorescence studies. Results: There was no significant difference in the change in corneal neovascularization after treatment among the 4 groups according to the digital images (p > 0.15) or histological evaluation with hematoxylin and eosin (p > 0.08). On immunofluorescence assay, a lower VEGF concentration was observed in all treatment groups compared to the control group. Conclusions: In this rabbit model, corneal neovascularization induced by chemical burn failed to regress with treatment with aflibercept, betamethasone, or their combination.

To assess the outcomes of Descemet membrane endothelial keratoplasty (DMEK) in patients with ocular hypotony after glaucoma surgery.retrospective case series.Setting: Multicenter retrospective case series.Hypotonic eyes with prior glaucoma surgery that underwent DMEK between January 2013 and July 2019 in Israel (2 centers) and Canada (1 center).Pre/postoperative corrected distance visual acuity, complications, 3- to 6-month endothelial cell loss, and intraocular pressure (IOP).The study included 11 DMEK procedures performed in 10 eyes of 4 males and 6 females aged 65-84 years. Indications for DMEK included 7 cases of pseudophakic bullous keratopathy, 2 cases of failed DMEK, and 1 case of failed Descemet stripping automated endothelial keratoplasty. All patients had at least 1 previous trabeculectomy operation. One patient had 2 trabeculectomy procedures and 1 tube placement procedure. Two patients had 1 previous trabeculectomy and 1 tube placement procedure. The corrected distance visual acuity improved significantly from 1.52 ± 0.68 logarithm of minimal angle of resolution preoperatively to 0.49 ± 0.32 logarithm of minimal angle of resolution 3 months postoperatively (P.001). Rebubbling occurred in 3 of 11 procedures (27%). Endothelial cell loss 6-12 months postoperatively was 60% ± 16% (range, 41%-89%). At the last follow-up visit, 6 of 11 (54%) of the grafts were clear. The remaining 5 grafts failed at 1-4 years postoperatively. The preoperative IOP was 5.1 ± 1.6 mm Hg (range, 1-7 mm Hg). In all but one patient, the postoperative IOP did not increase to more than 13 mm Hg. In 2 cases, the IOP decreased from 5 and 7 mm Hg preoperatively to 1 mm Hg 1 year postoperatively.DMEK is a valid procedure for the treatment of corneal edema in hypotonic eyes after glaucoma procedures. These eyes benefit from improvement in vision after DMEK.

Purpose: To compare the outcomes of femtosecond laser assisted in situ keratomileusis (FS-LASIK) with transepithelial photorefractive keratectomy (T-PRK) for the correction of high-grade astigmatism. Methods: Medical records of patients with astigmatism of 2 diopters (D) or higher, who were treated with FS-LASIK or T-PRK in 2013 through 2014 at a private practice laser clinic, were retrospectively analyzed. Efficacy, safety, predictability and vector analysis of astigmatism correction were compared between the treatment groups. Results: The study included 93 eyes treated with FS-LASIK and 186 eyes treated with T-PRK. No significant differences in postoperative spherical equivalent (−0.10 ± 0.7 D and −0.11 ± 0.7 D, respectively, p = 0.958) and postoperative refractive astigmatism (0.79 ± 0.54 D and 0.82 ± 0.63 D, respectively, p = 0.685) were demonstrated. A significant advantage of FS-LASIK over T-PRK was seen for the efficacy (1.00 ± 0.18 and 0.86 ± 0.22, respectively, p Conclusion: Both procedures demonstrated desirable post-operative SE outcomes for high-grade astigmatism correction. However, FS-LASIK achieved better results than T-PRK in the efficacy and safety parameters.

Purpose: To compare changes in anterior segment parameters following ExPRESS Mini Glaucoma Shunt surgery vs. trabeculectomy using the Pentacam rotating Scheimpflug camera. Methods: In this prospective, comparative study, 27 patients with glaucoma treated at the Rabin Medical Center from 2009 to 2013 were enrolled in this prospective comparative study: 19 participants (19 eyes) underwent ExPRESS shunt implantation and 12 (13 eyes) underwent trabeculectomy. Changes in anterior chamber parameters at postoperative day 1 and postoperative month 3 were evaluated on Scheimpflug images. Results: Intraocular pressure decreased significantly from baseline in both groups. The decrease in both groups was similar at postoperative month 3 (p=0.82). ExPRESS surgery caused a transient increase in posterior corneal astigmatism (p=0.008) and a transient decrease in anterior chamber depth (p=0.016) and volume (p=0.006) on postoperative day 1. At postoperative month 3, these parameters were no longer statistically significant (p=0.65, p=0.51, and p=0.57 respectively). Trabeculectomy caused a transient increase in anterior and posterior corneal astigmatism on postoperative day 1 (p=0.003 and p=0.005, respectively), which were not evident at postoperative month 3 (p=1.0 and p=1.0, respectively). At postoperative month 3, both ExPRESS and trabeculectomy showed similar changes in anterior chamber parameters. Conclusions: Both ExPRESS mini glaucoma implant and trabeculectomy significantly decreased intraocular pressure and had transient effects on anterior segment parameters, with minor differences between the methods. RESUMO Objetivo: Comparar as alterações nos parâmetros do segmento anterior após a cirurgia ExPRESS Mini Glaucoma Shunt vs. trabeculectomia usando a câmera Scheimpflug Pentacam rotativa. Métodos: Neste estudo comparativo prospectivo, 27 pacientes com glaucoma tratados no Centro Médico Rabin de 2009 a 2013 foram incluídos neste estudo comparativo prospectivo: 19 participantes (19 olhos) foram submetidos ao implante de derivação ExPRESS e 12 (13 olhos) foram submetidos à trabeculectomia. Alterações nos parâmetros da câmara anterior no dia 1 e em 3 meses de pós-operatório foram avaliadas pelas imagens de Scheimpflug. Resultados: A pressão intraocular diminuiu significativamente em relação aos valores iniciais nos dois grupos. A diminuição nos dois grupos foi semelhante no 3º mês pós-operatório (p=0,82). A cirurgia com ExPRESS causou um aumento temporário do astigmatismo posterior da córnea (p=0,008) e uma diminuição temporária da profundidade da câmara anterior (p=0,016) e do volume (p=0,006) no primeiro dia do pós-operatório. Ao final de três meses, esses parâmetros não foram mais estatisticamente significativos (p=0,065, p=0,51 e p=0,57, respectivamente). A trabeculectomia causou um aumento temporário do astigmatismo anterior e posterior da córnea no primeiro dia do pós-operatório (p=0,003 e p=0,005, respectivamente), mas isso não foi observado ao final de 3 meses (p=1,0 e p=1,0, respectivamente). Após 3 meses, tanto o EXPRESS quanto a trabeculectomia mostraram alterações semelhantes nos parâmetros da câmara anterior. Conclusões: O implante ExPRESS Mini para glaucoma e a trabeculectomia diminuíram significativamente a pressão intraocular e tiveram efeitos temporários nos parâmetros do segmento anterior, com pequenas diferenças entre os métodos.

Improper suturing may cause an inadequate wound healing process and wound dehiscence as well as infection and even graft rejection in case of corneal transplantation. Hence, training surgeons in correct suturing procedures and objectively assessing their surgical skills is desirable. Two complementary methods for assessment of suturing skills in two medical fields (general surgery and ocular microsurgery) were demonstrated. Suturing quality is assessed by computer vision software. Evaluation of stitching flow of operation is based on measuring strain induced in an optical fiber that is placed in proximity to the wound and parallel thereto and is pressed and passed by wound stitches. Our software generated a score for suturing outcome in both general surgery and ocular microsurgery when the stitching was done on a patch. Every trainee received a score in the range 0–100 that describes his/her performance. Strain values were recognized when using a patch in general surgery and a rubber patch in ocular microsurgery, but were less distinct in (disqualified) human cornea. We proved a concept of an objective scoring method (based on various image processing algorithms) for assessment of suturing performance. It was also shown that fiber optic strain sensors are sensitive to the flow of stitching operation on a patch but are less sensitive to the flow of stitching operation on a human cornea. By combining these two methods, we can comprehensively evaluate the suturing performance objectively.

Purpose To describe the ghost Descemet's membrane endothelial keratoplasty (DMEK) technique that allows for real-time evaluation of DMEK graft orientation, location, and folding status within the anterior chamber, by simple observation at the surgical microscope. Methods This is a retrospective case series done in a university hospital. The study included 10 patients who underwent ghost DMEK surgery because of corneal endothelial insufficiency for Fuchs' endothelial dystrophy (N = 5), pseudophakic bullous keratopathy (N = 2), and failed previous posterior lamellar keratoplasty (N = 3). Cases were reviewed for feasibility of graft preparation, intra- and postoperative complications, postoperative clearing of the cornea, corrected distance visual acuity, and endothelial cell loss. Results All graft preparations were uneventful. The circular staining was readily apparent and did not fade away during surgery. Graft orientation and folding status were determined using only direct observation through the operating microscope. Complications included one intraoperative hyphema, one graft detachment requiring rebubbling, and one pupillary block on the first postoperative day, which was resolved surgically. At last visit, 8 of 10 eyes had visual acuity of 6/12 or better and 7 of 10 eyes had visual acuity of 6/8.5 or better. Mean cell loss rates 1 to 3 months postoperatively were 48% ± 17% (range, 22%-71%). All corneas were clear by the first to second postoperative month. Mean follow-up time was 3 months (range, 1-8 months). Conclusions Peripheral staining of DMEK grafts (ghost DMEK) is a simple and effective method for graft visualization in the anterior chamber, obviating the need for trypan blue staining and other techniques and devices currently used for the identification of graft orientation and folding status, thus simplifying and shortening surgery.

The aim of the study was to examine the outcomes of transepithelial photorefractive keratectomy (Trans-PRK) and Femtosecond Laser-assisted in situ keratomileusis (Z-LASIK) for the correction of high myopia. A retrospective cohort study design was used. The study group included 792 eyes with high-grade myopia (− 6.0 diopters or higher) or high-grade myopia with astigmatism that were treated with Z-LASIK or Trans-PRK in 2013 through 2014 in an optical outpatient clinic of a large private medical service. The Trans-PRK group comprised of 674 eyes with a spherical equivalent (SE) of − 7.87 ± 1.46 and the Z-LASIK group comprised of 118 eyes with a SE of − 7.19 ± 0.81 (P

Corneal melting with perforation is a severe ophthalmic complication of autoimmune disorders such as rheumatoid arthritis. It requires urgent medical management in order to maintain the integrity of the globe and preserve vision. Treating this complication by penetrating keratoplasty is problematic due to the high rate of recurrence of corneal melting as well as other complications. We describe the use of a tectonic fresh-tissue corneolimbal covering graft. An interventional case series including three patients that presented to our tertiary center between 2000 and 2015 with corneal melting and perforation, secondary to rheumatoid arthritis. Emergency surgery included suturing of a 13.00- to 13.50-mm full-thickness fresh-tissue corneolimbal covering graft to the patient’s posterior limbal zone. The corneolimbal graft maintained the integrity of the cornea in all cases, by sealing the perforation and promoting the creation of a fibrovascular scar at the area of corneal melting. There were no complications, recurrences of host corneal melting, or perforation during the follow-up period. Fresh-tissue full-thickness corneolimbal grafts may be used to cover emergency corneal melting and perforations secondary to rheumatoid arthritis.

AimTo identify risk factors for the development of dupilumab-induced ocular surface disease (DIOSD) in adult patients with atopic dermatitis (AD) and describe outcomes of treatment.MethodsA retrospective institutional cohort study performed at the Rabin Medical Center, Petach Tikva, Israel. Adult patients with AD who received dupilumab from March 2018 to June 2019 were included. Demographics, AD severity scores, blood IgE levels, previous atopic keratoconjunctivitis (AKC), dermatological response to dupilumab, ophthalmological evaluation and treatment were noted. Univariate and multivariate analyses were used to identify risk factors for DIOSD.ResultsSixteen of 37 patients who were included in the study (43%) had new or exacerbated symptoms of ocular surface disease starting at 2 weeks following the first treatment. Three patients reported transient dry eye sensation which lasted 2 weeks; nine patients reported chronic dry eye sensation, and four patients (25%) had marked blepharoconjunctivitis. The presence of severe AD was the strongest predictor of DIOSD. Not a single patient with moderate AD had DIOSD. In multivariate analysis, prior AKC was a risk factor for DIOSD (R2=15.78, OR=23.28, p=0.005) while a family history of atopy was protective of DIOSD (R2=6.22, OR=0.13, p=0.05). All four patients with blepharoconjunctivitis had resolution of signs, and symptoms within days of starting periocular 0.03%–0.1% tacrolimus ointment.ConclusionsDIOSD is common in patients with AD receiving dupilumab. While most cases are mild, some patients can develop blepharoconjunctivitis which responds well to tacrolimus ointment. AD severity, and previous AKC are risk factors for DIOSD.

PURPOSE We aimed to evaluate the efficacy of subconjunctival aflibercept, a vascular endothelial growth factor trap compound, for the treatment of corneal neovascularization in a rat model. METHODS Chemical burn was produced in the central cornea of 31 male Sprague-Dawley rats. Animals were randomized to receive treatment with subconjunctival injection of 0.08 mL aflibercept (25 mg/mL), 0.05 mL bevacizumab (25 mg/mL), or 0.05 mL physiologic saline. Corneal neovascularization was evaluated on postinjury days 1, 3, 7, 9, and 13 by corneal photographs. The rats were killed on day 21 and samples were collected for histological and flat-mount immunofluorescence analyses. RESULTS In all rats, vascular sprouting began on day 3, reached maximum density on days 7-9, and spontaneously regressed thereafter. Mean burn area in the central cornea comprised ∼15% of the total corneal area. The aflibercept group had a significantly smaller relative area of neovascularization than both control group (P < 0.05, 12.27 ± 9.91, 29.66 ± 9.96 days 7) and bevacizumab group (P < 0.05, 12.27 ± 9.91, 21.27 ± 8.19 days 7 and 15.5 ± 10.25, 32.38 ± 9.44 days 9; Mann-Whitney test). On histological study, hematoxylin and eosin staining revealed blood vessels extending to the central cornea in the control and bevacizumab groups and limited to the periphery in the aflibercept group. Immunofluorescence study with an endothelial marker revealed a smaller area of staining in the aflibercept group. CONCLUSIONS Aflibercept effectively inhibits corneal neovascularization in a rat model of chemical burn-induced neovascularization and warrants further study for potential use in humans.

PURPOSE: To assess Descemet’s membrane endothelial keratoplasty (DMEK) without performing a peripheral iridotomy (PI) prior to or during surgery (“PI-less DMEK”). MATERIALS AND METHODS: This retrospective study included consecutive patients that underwent PI-less DMEK by a single surgeon (E.L) between February 2016 and February 2017 at the Rabin Medical Center, a Tertiary Hospital. Intraoperative and postoperative complications were assessed. RESULTS: Thirty-one patients, mean age 75.9 ± 7.9 years with 58.1% female were included. Leading indications for surgery were pseudophakic bullous keratopathy (18/31) and Fuchs’ endothelial dystrophy (9/31). Preoperative best-corrected distance visual acuity was 1.13 ± 0.59 logMAR (~6/80 Snellen). For 12/31 that had postoperative endothelial cell count measurements, cell loss was 49 ± 20%. Intraoperative complications included anterior chamber (AC) hyphema during graft insertion requiring reinsertion (n = 1), and minor hyphema from the main corneal incision (n = 1). Partial slit lamp gas evacuation was performed in all patients 1.5 h postoperatively. Postoperative complications included partial graft detachment requiring rebubbling (n = 5), self-resolving minimal peripheral graft detachment (n = 5), uncontrolled intraocular hypertension requiring trabeculectomy in a patient with a history of medically controlled glaucoma (n = 1), postoperative cystoid macular edema that resolved medically (n = 1) and graft failure 5 months postoperatively (n = 1). No patients developed pupillary block. Excluding graft failure (n = 1), preoperative amblyopia (n = 2) and premature loss to follow-up (n = 1), final corrected distance visual acuity was 0.18 ± 0.14 logMAR (~20/30 Snellen) with 44.4% reaching 6/7.5 (Snellen) or more. CONCLUSIONS: PI-Less DMEK is a safe, technically easy, and effective modification that avoids the time and complications associated with performing a PI before or during surgery.

Purpose To describe specific maneuvers and technical modifications to the standardized "no-touch" technique of Descemet membrane endothelial keratoplasty (DMEK) to successfully handle the presence of a glaucoma drainage device (GDD) tube in the anterior chamber of an eye with a failed primary penetrating keratoplasty (PK) graft. Methods A 42-year-old male patient underwent DMEK because of a failed primary PK graft in his phakic right eye. The patient was then evaluated at 3 and at 6 months after surgery. Results A modified no-touch DMEK technique proved a feasible treatment option for a decompensated primary PK graft in the presence of a long GDD tube. Conclusions With specific technical modifications DMEK can be successfully performed in eyes with decompensated primary PK grafts in the presence of a long GDD tube. The very thin DMEK graft allows positioning between the GDD tube and the failed PK graft, leaving the tube in place.

To report the failure rate of 2 graft preparation techniques for Descemet membrane endothelial keratoplasty (DMEK) and to evaluate how to minimize graft preparation failure.Retrospective, nonrandomized study at an eye bank specialized in graft preparation for lamellar keratoplasty. For 1416 donor corneas, the DMEK graft preparation failure rate was evaluated for 2 different techniques, technique I: "Standardized traditional technique" (n = 341) and technique II: "Standardized no-touch technique" (n = 933), and for grafts that were converted from technique II to technique I during preparation (n = 142).The overall failure rate averaged 3.9% (55/1416): 7.0% (24/341) for technique I and 2.9% (31/1075) for technique II (P0.05). Tissue preparations which were converted from technique II to technique I failed in 13.4% (19/142), whereas for grafts that were entirely prepared by technique II, the failure rate was only 1.3% (12/933). The endothelial cell density decrease (before compared with after preparation) did not differ for both techniques (1.1% vs. 0.2%, P0.05).Various DMEK graft preparation techniques may provide failure rates of4%. A "no-touch preparation" approach (technique II) may combine good graft quality (completely intact endothelial cell layer, ie, negligible preparation-induced endothelial cell density decrease) with low risk of dissection failure, leaving the possibility of conversion to "traditional preparation" (technique I) as a backup method.

Background/Aim: Corneal epithelial defects may heal slowly in patients with diabetes, limbal stem cell deficiency, extensive chemical burns or anesthetized corneas. Studies have shown that erythropoietin, a glycoprotein hormone that promotes red blood cell proliferation and inhibits apoptosis of erythroid progenitors, may also exert a cytoprotective, antiapoptotic effect on nonhematopoietic cells. The aim of the study was to examine the effect of erythropoietin on the healing process of corneal epithelial erosions in rabbit eyes. Methods: Fifteen New Zealand albino rabbits were divided into 3 groups following induction of unilateral uniform corneal epithelial erosions. The first group received local treatment with erythropoietin-containing cellulose-based gel 4 times daily; the second group received treatment with cellulose-based gel without erythropoietin 4 times daily, and the third group received no treatment. The healing process was monitored twice daily using cobalt-blue-filtered slit lamp photography and digital images of fluorescein-stained corneas until complete re-epithelization was achieved. Following re-epithelization, corneas were removed for histologic processing. One-way analysis of variance and Mann-Whitney tests were used for statistical analysis. Results: Mean ± SD time to complete re-epithelization was 55 ± 2.19 h in the group treated with erythropoietin-containing cellulose-based gel, 66.5 ± 14.25 h in the group treated with gel only and 62.2 ± 9.09 h in the untreated group (p = 0.16, not significant). There was no significant difference among the groups in the time to complete re-epithelization or the rate of epithelial healing. Histologic corneal evaluation revealed stromal vascularization in 2 of the 6 erythropoietin-treated rabbits and in neither of the control groups. Conclusion: Erythropoietin has no beneficial effect on the rate of healing of corneal epithelial erosions in rabbit eyes, and corneal stroma neovascularization seems to be a significant adverse effect.

To evaluate the influence of Descemet stripping automated endothelial keratoplasty (DSAEK) on corneal curvature and the anterior segment parameters obtained with the Pentacam rotating Scheimpflug camera.A total of 9 eyes of 9 consecutive patients (3 men, 6 women) were evaluated preoperatively, at 1 and 3 months postoperatively with the Pentacam. We compared preoperative and 1- and 3-month postoperative measurements of anterior and posterior corneal curvature, anterior and posterior corneal astigmatism, anterior chamber depth (ACD), anterior chamber volume (ACV), anterior chamber angle (ACA) width, central corneal thickness (CCT), and the corneal volume (CV).Preoperative CCT decreased from 687 ± 85 microns to 631 ± 68 microns at 3 months after surgery (p = 0.07). Anterior mean K reading of the cornea flattened from 43.3 ± 1.65 diopter before surgery to 42.7 ± 1.5 diopter at 3 months (p = 0.03). Anterior corneal astigmatism did not change significantly. Posterior mean K reading of the cornea steepened significantly from -5.6 ± 0.6 diopter preoperatively to -7.2 ± 0.4 diopter at 3 months (p = 0.007). Posterior corneal astigmatism increased accordingly from 0.52 ± 0.17 diopter before surgery to 0.95 ± 0.57 diopter at 3 months (p = 0.07). CV increased significantly from 65.8 ± 5.6 µl before surgery to 85.2 ± 4.2 µl at 3 months (p = 0.007). ACA, ACD, and ACV did not change significantly following DSAEK surgery. The average postoperative spherical equivalent changed from 0.5 ± 2.5 D before surgery to 1.41 ± 0.59 D three months after surgery (p = 0.05).DSAEK significantly increased posterior corneal k-reading, posterior corneal astigmatism, and corneal volume, resulting in a mild hyperopic shift. This observation should be taken into consideration when performing a triple procedure.

The aim of this experimental study was to compare the efficacy of topical aflibercept and topical bevacizumab in preventing corneal neovascularization. A chemical burn was created in the right central cornea of male Sprague-Dawley rats, followed immediately by instillation of one drop (25 mg/ml, 20 μl volume) of aflibercept (15 eyes), bevacizumab (14 eyes), or saline (15 eyes). Treatment was repeated twice daily for 7 days. Corneal neovascularization was determined using corneal photographs (ImageJ) on days 1, 4, 7, 10, and histological and immunofluorescence studies, on day 10. Stromal immunoreactivity was evaluated 2 days after injury in 6 rats treated singly with bevacizumab or aflibercept. Corneal neovascularization was observed clinically on day 4 in all groups. In the aflibercept group, the area of neovascularization increased from 7.38 ± 2.23% on day 4 to 21.73 ± 14.59% on day 7 and 31.0 ± 23.61% on day 10. Corresponding values in the bevacizumab group were 6.04% ± 1.81%, 51.27 ± 15.50%, and 54.4 ± 11.33%, and in the control group, 8.99 ± 1.93%, 42.6 ± 19.59%, and 55.15 ± 11.54%. The area of neovascularization was significantly smaller on days 7 and 10 in the aflibercept group than in the control and bevacizumab groups (P

Purpose: To compare the prevalence of renal disorders in keratoconus patients with an age-matched, nonkeratoconic population.Methods: This retrospective, observational, comparative case-control study included all members of the Central District of Clalit Health Services in Israel with a diagnosis of keratoconus during the years 2000 to 2007 (study group; n=426) and 1704 healthy age- and sex-matched controls. We calculated the prevalence of chronic renal failure, other kidney diseases, renal malignancy and kidney transplant in both groups. We also evaluated the risk for osteoporosis, diabetes and hypertension in the patients with keratoconus. Data on medication use associated with renal diseases was collected as well. Results: On average, a significantly higher percentage of chronic renal failure were demonstrated in the study group (1.88%) compared to the controls (0.53%, OR=3.6 95% CI=1.4-9.4). This was also true for other kidney diseases (3.8% vs. 1.7%, OR=2.1, 1.1-3.9). In the patients with keratoconus, we also noted an increased prevalence of osteoporosis (OR=2.2, 1.1-4.2), diabetes (OR=1.8, 1.1-3.0) and hypertension (OR=1.4, 0.94-1.9), and a significant higher trend in the use of ACE inhibitors, alpha blockers, beta-blockers, corticosteroids, nonsteroidal anti-inflammatory drugs, immunosuppressant’s and biphosphonates. Conclusions: Renal disorders were significantly more common among keratoconus patients.