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BACKGROUND/PURPOSE To characterize the nature of posterior segment ocular injuries in combat trauma. METHODS Eyes in the Walter Reed Ocular Trauma Database were evaluated for the presence of posterior segment injury. Final visual outcomes in open-globe versus closed-globe injuries and by zone of injury and the types of posterior segment injuries in open-globe versus closed-globe injuries were assessed. RESULTS Four hundred fifty-two of 890 eyes (50.8%) had at least one posterior segment injury. The mechanism of injury was most commonly an improvised explosive device in 280 (62.0%) eyes. Sixty-one patients (13.5%) had a Zone I injury, 50 (11.1%) a Zone II injury, and 341 (75.4%) a Zone III injury. Patients with Zone I injuries were more likely to have a final visual acuity of 20/200 or better compared with patients with either a Zone II (P < 0.001) or Zone III injury (P = 0.007). Eyes with a closed-globe injury were more likely to have a final visual acuity of 20/200 or better compared with those with an open-globe injury (P < 0.001). Furthermore, closed-globe injury compared with open-globe injury had a lower risk of vitreous hemorrhage (odds ratio 0.32, P < 0.001), proliferative vitreoretinopathy (odds ratio 0.14, P < 0.001), and retinal detachment (odds ratio 0.18, P < 0.001) but a higher risk of chorioretinal rupture (odds ratio 2.82, P < 0.001) and macular hole (odds ratio 3.46, P = 0.004). CONCLUSION Patients with combat ophthalmic trauma had similar posterior segment injury patterns to civilian trauma in open-globe versus closed-globe injuries. Zone II and III injuries were associated with a worse visual prognosis.

PURPOSE To assess early visual outcomes and military task performance after small-incision lenticule extraction (SMILE) among U.S. military service members. SETTING Warfighter Refractive Eye Surgery Program and Research Center and Night Vision and Electronic Sensors Directorate, Fort Belvoir, Virginia. DESIGN Single-center, prospective, observational study. METHODS The study was composed of active duty service members (n = 37) electing to undergo SMILE for myopia or myopic astigmatism. Testing performed preoperatively and at 1 month and 3 months postoperatively included uncorrected (UDVA) and corrected (CDVA) distance visual acuities, wavefront aberrometry, low-contrast visual acuity (LCVA), contrast sensitivity, and vision-related questionnaire. 14 participants underwent rifle marksmanship with spectacle correction before and without correction at 6 to 8 weeks postoperatively. RESULTS At 3 months postoperatively, the efficacy index was 0.96 and the safety index was 1.03. UDVA was ≥20/20 in 69 (96%) of eyes. LCVA change from baseline was significant under night vision condition. Eye problems contributed to 10% work and 20% activity impairments, both of which decreased to 0% (P = .001). The overall satisfaction rating for SMILE was high at 90.9 (95% CI, 85.3 to 96.5), and 95% of participants would be willing to undergo the procedure again. The median scores between preoperative and 6 to 8 weeks postoperative firing performance were comparable (34 vs 35, with and without correction, respectively; P = .247). CONCLUSIONS After the early recovery period, SMILE seems to preserve quality of vision, which appears to facilitate the accomplishment of tasks related to their work as military service members as well as performing activities outside of work.

BACKGROUND AND OBJECTIVE: To determine the risk factors associated with developing proliferative vitreoretinopathy (PVR) from combat ocular injuries in U.S. service members. PATIENTS AND METHODS: Retrospective review of associated risk factors and outcomes of PVR within the Walter Reed Ocular Trauma Database. Ocular injuries in U.S. service members wounded during Operation Enduring Freedom and Operation Iraqi Freedom from 2001 to 2011 were assessed, and of these all cases of PVR were studied. Principal outcome measures were the risk factors associated with PVR development and rate of final visual acuity (VA) less than 20/200. RESULTS: Eight hundred ninety eyes of 651 U.S. service members were evaluated. A total of 76 eyes (8.5%) of 66 patients developed PVR. Five patients had bilateral PVR. Nineteen patients had bilateral eye injuries. Sixty-one eyes (80.2%) had a final VA less than 20/200. PVR was found to be a significant risk factor for a poor final VA ( P < .001). Retinal detachment (RD) was found in 52 eyes (68.4%) of patients. In patients with a RD, intraocular foreign bodies (IOFBs) ( P < .001), unsuccessful repair ( P = .002), and macular hemorrhage ( P = .04) were significant risk factors for the development of PVR. Time to initial retina surgery was not found to be a risk factor for PVR development ( P = .5). Time to initial retina surgery was available in 41 patients and the time to surgery on average was 22.56 days (range: 3 to 87 days). CONCLUSIONS: PVR occurs frequently in combat trauma and is a significant cause of poor final VA. In patients with PVR and RD, injuries caused by an IOFB, macular hemorrhage, or unsuccessful repair were significant risk factors for the development of PVR. [ Ophthalmic Surg Lasers Imaging Retina. 2020;51:556–563.]

To update the epidemiology of ocular injuries in soldiers admitted to Walter Reed Army Medical Center (WRAMC) from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF).Data were collected in the Walter Reed Ocular Trauma Database. A Bayesian Network Analysis was completed to better understand the relationships between different ocular demographic variables, injuries, surgeries, ocular trauma scores (OTS) and visual outcomes.There were 890 consecutive globe or adnexal combat injuries, or both, sustained by 652 United States soldiers treated at WRAMC between 2001 and 2011.The primary mechanism of injury was improvised explosive device (62.47%). Many patients (62.0%) had final visual acuity (VA) grades of 1-2 (20/15 - 20/200), while 29.9% of patients had final VA grades of 3-5 (less than 20/200), and 8.1% had unknown final VA grades. Bayesian Network Analysis revealed that the injury variables of Retina (47.9%), Lens (44.6%), Posterior Segment (43.7%) and Anterior Segment (40.3%), and the surgical variables of Enucleation (97.6%) and cataract extraction and posterior capsule intraocular lens placement (CEPCIOL; 43.3%) all had probabilities greater than 40% for a poor final VA, while all other variables were less than 40%.Modern-day combat trauma results in complicated ocular injuries causing 30% of patients to be left legally blind in their injured eye. It is critical to maintain a wide variety of deployable, specialty trained ophthalmologists to ensure the best visual outcomes for wounded warriors and to maintain mission readiness.

PURPOSE: To assess whether densitometry analysis appropriately monitors the development of haze in myopic patients after photorefractive keratectomy (PRK) when compared to subjective slit-lamp haze grade examinations, and whether sutureless cryo-preserved amniotic membrane reduced postoperative haze development when compared to the standard bandage contact lens. METHODS: In this retrospective cohort at the Center for Refractive Surgery, Walter Reed National Military Medical Center, a secondary analysis of prospectively collected data was performed. In the prospective study, participants underwent PRK for myopia. Postoperatively, a standard bandage contact lens was applied to the dominant eye and a sutureless cryo-preserved amniotic membrane graft to the nondominant eye. Participants were evaluated at 1, 3, and 6 months postoperatively for haze formation and corneal densitometry using slit-lamp biomicroscopy and Scheimpflug imaging, respectively. RESULTS: Densitometry measurements at 6 months postoperatively were positively and significantly associated with the presence or absence of haze as assessed by slit-lamp examination in 39 patients (78 eyes; age range: 21 to 44 years). Eyes with increased densitometry measurements had 2.3 to 3.4 times the odds ( P ⩽ .014) of having clinical haze on slit-lamp examination. Eyes with the amniotic membrane graft showed a positive correlation with increased corneal densitometry throughout most layers of the cornea. CONCLUSIONS: Densitometry analysis appears to be a useful tool to supplement slit-lamp examination in monitoring haze development after PRK. The amniotic membrane failed to show a reduction in corneal densitometry in myopic eyes after PRK. [ J Refract Surg . 2020;36(5):293–299.]

PURPOSE To update the incidence of orbital fractures in U.S. Soldiers admitted to the former Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom and Operation Enduring Freedom. METHODS Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were any U.S. Soldier or Department of Defense civilian with an orbital fracture injured in Operation Iraqi Freedom/Operation Enduring Freedom. Primary outcome measures were final visual acuity and the effect of orbital fracture, number of fractures, and anatomic location of fracture on final visual acuity. RESULTS Eight-hundred ninety eye injuries occurred in 652 patients evacuated to Walter Reed Army Medical Center between 2001 and 2011. Orbital fractures occurred in 304 eyes (34.2%). A single wall was fractured in 140 eyes (46.05%), 2 in 99 (32.6%) eyes, 3 in 31 (10.2%), 4 in 28 (9.2%), and unknown in 6 (1.9%) eyes. Roof fractures were found in 74 (24.34%), medial wall in 135 (44.41%), lateral wall in 109 (35.9%), and floor fractures in 217 (71.4%). Final visual acuity was analyzed and 140 (46.05%) eyes had greater than 20/40 vision, 17 (5.59%) were 20/50 to 20/200, 26 (8.5%) were count fingers to light perception, and 95 (31.3%) were no light perception. In logistic regression analysis, roof (p = 0.001), medial (p = 0.009), and lateral fractures (p = 0.016) were significantly associated with final visual acuity less than 20/200, while floor fractures were not (p = 0.874). Orbital fracture and all fracture subtypes were significantly associated with traumatic brain injury, retrobulbar hematoma, optic nerve injury, but not for vitreous hemorrhage, commotio, hyphema, and choroidal rupture. Fracture repair was noted in 45 (14.8%). CONCLUSIONS Orbital fractures occurred in a third of Operation Iraqi Freedom/Operation Enduring Freedom eyes of ocular trauma patients referred to one tertiary care military hospital. This resulted in approximately 40% of these eyes remaining legally blind after injury.Orbital fractures occur commonly during combat trauma and a significant number are legally blind despite appropriate treatment.

PURPOSE To assess the visual outcomes of small-incision lenticule extraction (SMILE) after the first year of treatments at a military refractive surgery center and compare with photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK) outcomes during the same period. SETTING Warfighter Refractive Eye Surgery Program and Research Center, Fort Belvoir, VA. DESIGN Retrospective study. METHODS Records of service members who underwent SMILE, PRK, or LASIK for myopia from March 2017 to February 2018 were reviewed. Preoperative and up to 6-month postoperative data were collected. Visual outcomes were compared between treatments. RESULTS Of 563 treated eyes, 173 (30.7%) underwent SMILE, 304 (54.0%) PRK, and 86 (15.3%) LASIK. In comparing SMILE with PRK 1 month postoperatively, SMILE (145 eyes [87.9%]) attained uncorrected distance visual acuity (UDVA) ≥20/20 more vs PRK (214 eyes [73.8%]; P < .01). Similarly, SMILE (152 eyes [94.4%]) achieved more eyes with manifest spherical equivalent (MSE) within ±0.50 diopters (D) from intended target vs PRK (250 eyes [85.9%]; P = .01). None lost ≥1 line of corrected distance visual acuity in SMILE vs PRK (16 eyes [5.5%]; P < .01). Thereafter, there were no other significant differences except SMILE had 117 eyes (95.1%) vs PRK with 224 eyes (99.6%) achieving UDVA ≥20/20 at 3 months postoperatively (P = .01). In assessing SMILE vs LASIK, all parameters were comparable; however, 77 SMILE eyes (96.3%) had MSE within ±0.50 D from target vs 31 LASIK eyes (83.8%) at 6 months postoperatively (P = .02). CONCLUSIONS The first year after SMILE treatments in a U.S. military center demonstrated early postoperative outcomes superior to PRK. SMILE seemed more predictable compared with LASIK.

BACKGROUND To analyze the final visual acuity (VA) of neuro-ophthalmologic injuries (NOI) in combat ocular trauma and to study the association of NOI with systemic neurologic injury (SNI) and traumatic brain injury (TBI). METHODS The Walter Reed Ocular Trauma Database was reviewed. Inclusion criteria were any US service member and Department of Defense civilians who suffered NOI, SNI, or TBI in Operation Iraqi Freedom or Operation Enduring Freedom. The primary outcome measure was the rate of poor final VA in patients with an NOI with secondary outcome measures the rate of SNI and TBI. in patients with NOI. RESULTS One hundred seventy-eight (20.00%) of 890 eyes had an NOI. Optic nerve injury was observed in 79 (44.38%) eyes, other cranial nerve injury in 68 (38.20%), Horner syndrome in 4 (2.25%), diplopia in 45 (25.28%), and ptosis in 13 (7.30%). In patients with NOI, 76 (42.69%) eyes had a final VA less than 20/200. In injured eyes (n = 359) of patients (n = 251) with TBI, 154 eyes (34.26%) had a final VA less than 20/200. In multivariate analysis, optic nerve injury (P < 0.001), unlike TBI (P = 0.47), was associated with final VA less than 20/200. SNI (n = 229) had a statistically significant association (odds ratio 29.8, 95% confidence interval 19.2-47.8, P < 0.001) with NOI. Optic nerve injury and cranial nerve injury were associated with TBI and SNI (all, P < 0.001). CONCLUSION Optic nerve injury and cranial nerve injury are associated with TBI and SNI. Optic nerve injury, but not TBI or cranial nerve injury, is associated with a poor final VA.

Purpose We update the incidence of intraocular foreign bodies (IOFB) in soldiers admitted to Walter Reed Army Medical Center from 2001 to 2011 after sustaining combat injuries in Operation Iraqi Freedom and Operation Enduring Freedom. Design This consecutive retrospective case series included 890 eyes of 652 patients. Methods Data were collected in the Walter Reed Ocular Trauma Database. Inclusion criteria were any American soldier or Department of Defense civilian with an IOFB injured in Operation Iraqi Freedom/Operation Enduring Freedom. Closed globe injuries with orbital foreign bodies, injury outside of a combat zone, or non–Department of Defense civilian trauma were the exclusion criteria. Main Outcome Measures Primary outcome measures were final visual outcome and the number, size, and location of IOFBs. Secondary outcome measures included surgical procedures, use of eye protection, associated complications, source of injury and Ocular Trauma Score. Results There were 890 eye injuries in 652 patients evacuated to Walter Reed Army Medical Center between 2001 and 2011. IOFBs were found in 166 eyes of 149 patients (18.6%; 95% confidence interval [CI], 16.2%–21.3%). Most patients had a single IOFB (80.7%). An IOFB was positively associated with Ocular Trauma Score grade 1 or 2 (0–65) injuries (odds ratio [OR], 1.58; 95% CI, 1.07–2.38; P = 0.01). There were 130 eyes (78.33%) that had recorded time from initial visual acuity to final visual acuity and it ranged from 8 to 2421 days (mean, 433.24 days). Thirty-eight (25.16%; 95% CI, 18.89%–32.67%) eyes had no change in visual acuity, 98 (64.90%; 95% CI, 57.00%–72.07%) had improved visual acuity, and 15 (9.93%; 95% CI, 6.01%–15.84%) had decreased visual acuity. IOFB was not found to predict final visual acuity of Conclusions IOFBs occur frequently in combat ocular trauma and are significantly associated with more severe injuries. However, IOFBs were not found to be a significant risk factor for visual acuity of

PURPOSE: To compare contrast sensitivity among participants undergoing wavefront-guided or wavefront-optimized photorefractive keratectomy (PRK) or LASIK for the treatment of myopia or myopic astigmatism 12 months after surgery. METHODS: In a prospective, randomized clinical trial, 215 participants with myopia ranging from −0.50 to −7.25 diopters (D) and less than −3.50 D of manifest astigmatism electing to undergo either LASIK or PRK were randomized to receive wavefront-guided or wavefront-optimized treatment. Corrected Super Vision Test (Precision Vision, La Salle, IL) high contrast and small letter contrast sensitivity, uncorrected postoperative contrast sensitivity function, and uncorrected and corrected distance visual acuity were measured preoperatively and at 1, 3, 6, and 12 months postoperatively. RESULTS: There was a significant difference within each of the four groups over time when measuring high contrast visual acuity ( P < .001) and small letter contrast sensitivity ( P < .001), with the most significant decrease occurring 1 month postoperatively. However, there were no significant differences when comparing the four groups for high contrast sensitivity ( P = .22) or small letter contrast sensitivity ( P = .06). The area under the logarithm of contrast sensitivity function did not differ significantly over time ( P = .09) or between groups ( P = .16). A pairwise comparison of preoperative to 12-month CDVA showed a significant improvement in all groups ( P < .017). The change in CDVA was also significantly different between groups as determined by one-way analysis of variance ( P = .003). CONCLUSIONS: Wavefront-guided and wavefront-optimized PRK and LASIK procedures maintained high contrast, small letter contrast sensitivity, and contrast sensitivity function 12 months postoperatively. Although the recovery period for visual performance was longer for PRK versus LASIK, there was no significant difference in treatment type or treatment profile at 12 months postoperatively. [ J Refract Surg. 2018;34(9):590–596.]

Introduction Simulation training in medical education provides the ability to teach valuable surgical skills in an environment free of risk to patients. Surgical simulation in ophthalmology continues to evolve as new technologies advance, though widespread use in ophthalmology outside of cataract surgery simulation is lacking. Here, we present a study into the efficacy of surgical simulation for eyelid laceration repair when compared with standard tissue-based instruction. Materials and Methods The study included 43 ophthalmology residents and 16 staff ophthalmologists from the Ocular Trauma Surgery Laboratory (OTSL) at the Uniformed Services University of the Health Sciences (USUHS). After initial evaluation on their ability to repair marginal eyelid lacerations on a porcine eye, residents were randomized to receive training in marginal eyelid repair technique from faculty preceptors using either traditional porcine tissue or the Ocular and Craniofacial Trauma Treatment Training System (Medical Device and Simulation Laboratory). They were then reevaluated after training. Participating staff also underwent initial evaluation, self-guided training, and post-training evaluation. Outcome measures included successful repair of laceration, number of sutures required to close a 10-mm wound, time required to repair, and the following graded on a scale of 1–4 (1—poor, 2—fair, 3—good, 4—excellent): tarsal plate reconstruction and margin approximation. Results Among residents, improved scores in marginal approximation were noted after training when comparing scores both within the simulator-trained group (pre-training score: 2.0, post-training score: 3.0; p = 0.03) and between the simulator (SIM) and live tissue (LIVE) groups (SIM: 3.0, LIVE: 2.0 p = 0.03). Neither residents nor staff demonstrated significant differences between SIM versus LIVE in other metrics evaluated. Response in a post-study survey was favorable to simulator training, with 79% noting the simulator was helpful in teaching skills, and 83% noting they would use the simulator again. Conclusion Simulator technology for teaching marginal eyelid laceration repair appears to be noninferior to traditional tissue-based instruction. Additionally, it appears to be superior when evaluating the ability to approximate the eyelid margin appropriately. Simulators are safe and ethical alternatives to tissue-based instruction, and are favorably received among trainees, and therefore warrant additional investigation and development for ophthalmic surgical training.

IntroductionThe goal of this study is to update the incidence of hyphema in Operation Iraqi (OIF) and Enduring Freedom (OEF). We wanted to assess associated ocular injuries and final visual acuity (VA) in open-globe versus closed-globe injuries with a hyphema.Materials and MethodsWe performed a retrospective review of the Walter Reed Ocular Trauma Database (WRTOD) to identify U.S. Service members and DoD civilians with hyphema who were evacuated to Walter Reed Army Medical Center between 2001 and 2011. Primary outcome measures were the final VA and differences in concomitant ocular injuries in open-globe hyphema and closed-globe hyphema.Results168 of 890 eyes (18.9%) in the WROTD had a hyphema. Closed-globe injuries were noted in 64 (38.1%) eyes and open-globe injuries in 104 (61.9%) eyes. A final VA of less than 20/200 was noted in 88 eyes (51.8%). Eyes with hyphema were more likely to have traumatic cataract formation (odds ratio (OR) 6.2, 95% confidence interval (CI) 4.2–9.2, P ConclusionsClose follow-up in patients with hyphema is important due to the associated development of traumatic cataract and retinal detachment and poor final visual outcome.

Purpose To evaluate the effect of sutureless cryopreserved amniotic membrane (Prokera) on corneal wound healing after photorefractive keratectomy (PRK). Setting Center for Refractive Surgery, Walter Reed Army Medical Center, Washington, DC, USA. Design Prospective nonrandomized control trial. Methods Patients had PRK for myopia with or without astigmatism. A 20% ethanol solution was used to create a standard 9.0 mm epithelial defect followed by photoablation with the Allegretto Wave Eye-Q 400 Hz laser. After surgery, a high-oxygen-transmissible bandage contact lens (Acuvue Oasys) was applied on the dominant eye and cryopreserved amniotic membrane on the nondominant eye. The postoperative regimen was otherwise identical for both eyes. Postoperatively, patients were evaluated daily until complete corneal reepithelialization occurred in both eyes and then at 2 weeks and 1, 3, 6, and 12 months. Reepithelialization was assessed daily with slitlamp examination, fluorescein staining, and photography. Secondary outcome measures included adverse effects, ocular comfort, visual outcomes, and corneal haze. Results Forty patients were enrolled. The amniotic membrane graft sped corneal reepithelialization 1 day after PRK but was not better than the bandage contact lens in hastening complete reepithelialization of the cornea. Visual outcomes, corneal clarity, and optical quality of the cornea were comparable between the amniotic membrane graft eyes and bandage contact lens eyes. Conclusion Although the amniotic membrane graft was reasonably well tolerated with few significant adverse effects, the role of amniotic membrane in modulating wound healing after PRK remains speculative. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.

PURPOSE: To assess vision-related quality of life and military readiness and capabilities among active duty U.S. military service members undergoing refractive surgery. METHODS: In this prospective, single-center, observational study, active duty U.S. military service members electing to undergo refractive surgery were asked to complete a military performance questionnaire and the National Eye Institute Refractive Error Quality of Life Instrument (NEI RQL-42) preoperatively and at 6 months postoperatively. On the military performance questionnaire, participants rated (1 = very bad to 5 = very good) how they felt their vision affected their military readiness and capabilities after refractive surgery. RESULTS: Among 360 participants at 6 months postoperatively, the overall mean military performance score increased from 3.6 ± 0.8 to 4.8 ± 0.3, a change of 1.2, with 91.7% of the participants indicating an overall improvement in readiness and capability ( P < .001). Scores measuring overall individual readiness, contribution to unit's mission, use of night vision goggles, function at night, weapons sighting ability, employment of personal masks, weather extreme environmental conditions, and optical support were significantly higher postoperatively ( P < .001). For the NEI RQL-42, scores were significantly higher postoperatively for the subscales clarity of vision, expectations, near vision, far vision, diurnal fluctuations, activity limit, glare, dependence on correction, worry, appearance, and satisfaction with correction (all P < .001), but not for symptoms after refractive surgery ( P = .403). CONCLUSIONS: Refractive surgery significantly improves military readiness and capabilities and vision-related quality of life of active duty U.S. military service members with refractive error. [ J Refract Surg. 2018;34(9):597–603.]

Purpose To evaluate dry-eye manifestations after photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK) and determine the incidence and predictive factors of chronic dry eye using a set of dry-eye criteria. Setting Walter Reed Army Medical Center, Washington, DC, USA. Design Prospective, non-randomized clinical study. Methods Dry-eye evaluation was performed before and after surgery. Main outcome measures included dry-eye manifestations, incidence, and predictive factors of chronic dry eye. Results This study comprised 143 active-duty U.S. Army personnel, ages 29.9 ± 5.2 years, with myopia or myopic astigmatism (manifest spherical equivalent −3.83 ± 1.96 diopters) having PRK or LASIK. Schirmer scores, corneal sensitivity, ocular surface staining, surface regularity index, and responses to dry-eye questionnaire significantly changed over time after PRK. After LASIK, significant changes were observed in tear breakup time, corneal sensitivity, ocular surface staining, and responses to questionnaire. Twelve months postoperatively, 5.0% of PRK and 0.8% of LASIK participants developed chronic dry eye. Regression analysis showed that pre-operatively lower Schirmer score will significantly influence development of chronic dry eye after PRK, whereas preoperatively, lower Schirmer score or higher ocular surface staining score will significantly influence the occurrence of chronic dry eye after LASIK. Conclusions Chronic dry eye was uncommon after PRK and LASIK. Ocular surface and tear-film characteristics during pre-operative examination might help to predict chronic dry-eye development in PRK and LASIK. Financial Disclosure The authors have no financial interest in any product, drug, instrument, or equipment discussed in this manuscript.

Purpose To compare visual outcomes following Visx Star S4 Customvue wavefront-guided and Allegretto Wave Eye-Q 400 Hz wavefront-optimized photorefractive keratectomy (PRK). Setting Warfighter Refractive Eye Surgery Program and Research Center, Fort Belvoir, Virginia, and Walter Reed National Military Medical Center, Bethesda, Maryland, USA. Design Prospective randomized clinical trial. Methods Active-duty United States military soldiers were randomized to have wavefront-guided (Visx Star S4 Customvue) or wavefront-optimized PRK. Participants were followed up to 12 months postoperatively. Primary outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and manifest spherical equivalent (SE). Secondary outcome measures included refractive astigmatism, higher-order aberrations (HOAs), contrast sensitivity, subjective visual complaints, and patient satisfaction. Results The study evaluated 108 soldiers (mean age 30.3 years ± 6.3 [SD]; mean manifest SE −3.51 ± 1.63 D). At 12 months postoperatively, achieved UDVA, CDVA, manifest SE, and refractive astigmatism were comparable between wavefront-guided and wavefront-optimized groups (P > .213). Spherical aberration and total HOAs significantly increased from baseline in both groups (P .254) were comparable between groups. There were fewer losses of photopic low-contrast visual acuity (LCVA) at 5% contrast after wavefront-guided compared to wavefront-optimized treatment (P = .003). There was no significant difference between treatment groups in visual symptoms, overall vision expectation, and satisfaction (P > .075). Conclusion Wavefront-guided treatment offered a small advantage in photopic LCVA. Refractive outcomes, HOAs, self-reported visual difficulties, overall vision expectation, and satisfaction were otherwise comparable between wavefront-guided and wavefront-optimized treatments. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

To examine the incidence and the etiology of corneal and corneoscleral injuries in the setting of combat ocular trauma, and to determine what effect these injuries have on overall visual impairment from combat ocular trauma.Retrospective, noncomparative, interventional case series, analyzing U.S. service members who were evacuated to the former Walter Reed Army Medical Center (WRAMC). Primary outcome measures were types of corneal injuries, length of follow-up at WRAMC, globe survival, and anatomical causes of blindness. Secondary outcome measures included surgical procedures performed, use of eye protection, source of injury, and visual outcomes.Between 2001 and 2011, there were 184 eyes of 134 patients with corneal or corneoscleral injuries. The average age was 26 years (range, 18-50); 99.3% were male, 31.9% had documented use of eye protection. The average follow-up was 428.2 days (3-2,421). There were 98 right-eye and 86 left-eye injuries. There were 169 open-globe and 15 closed-globe injuries with corneal lacerations occurring in 73 eyes with injuries to Zone I. Most injuries were attributable to an intraocular foreign body (IOFB; 48%), followed by penetrating (19.6%) and perforating (16.3%) injuries. The most common presenting visual acuity was hand motion/light perception (45.7%), yet, at the end of the study, visual acuity improved to 20/40 or better (40.8%). The majority of injuries in eyes with visual acuity worse than 20/200 involved the cornea and retina (58%). Injuries solely to the cornea accounted for only 19% of all injuries sustained.Ocular injuries in military combat have led to significant damage to ocular structures with a wide range of visual outcomes. The authors describe corneal and corneoscleral injuries in combat ocular trauma by classifying injuries by the anatomical site involved and identifying the main source of decreased visual acuity. In combat ocular trauma, corneal or corneoscleral injuries are not the sole etiology for poor vision. A cohesive approach among multiple ophthalmic subspecialties is needed when treating combat ocular trauma.

To compare visual performance, marksmanship performance, and threshold target identification following wavefront-guided (WFG) versus wavefront-optimized (WFO) photorefractive keratectomy (PRK).In this prospective, randomized clinical trial, active duty U.S. military Soldiers, age 21 or over, electing to undergo PRK were randomized to undergo WFG (n = 27) or WFO (n = 27) PRK for myopia or myopic astigmatism. Binocular visual performance was assessed preoperatively and 1, 3, and 6 months postoperatively: Super Vision Test high contrast, Super Vision Test contrast sensitivity (CS), and 25% contrast acuity with night vision goggle filter. CS function was generated testing at five spatial frequencies. Marksmanship performance in low light conditions was evaluated in a firing tunnel. Target detection and identification performance was tested for probability of identification of varying target sets and probability of detection of humans in cluttered environments.Visual performance, CS function, marksmanship, and threshold target identification demonstrated no statistically significant differences over time between the two treatments. Exploratory regression analysis of firing range tasks at 6 months showed no significant differences or correlations between procedures. Regression analysis of vehicle and handheld probability of identification showed a significant association with pretreatment performance.Both WFG and WFO PRK results translate to excellent and comparable visual and military performance.

To determine whether patients without dry eye preoperatively have an altered conjunctival goblet cell density and mucin secretion postoperatively and to explore what factors affect changes in goblet cell density and mucin secretion.The former Walter Reed Army Medical Center, Washington, DC, USA.Prospective nonrandomized clinical study.Impression cytology was used to determine conjunctival goblet cell density before and 1 week, 1 month, and 3 months after photorefractive keratectomy (PRK) or laser in situ keratomileusis (LASIK). The McMonnies questionnaire, Schirmer test, tear breakup time, corneal sensitivity, rose bengal staining, and computerized videokeratoscopy were also performed to assess tear-film and ocular-surface health.The ratio of goblet cell to total cells changed postoperatively from baseline in both groups (P .001). The most significant change was a median 29% decrease 1 month postoperatively. However, there were no significant differences between groups over time (P = .772). The ratio of filled goblet cell to total goblet cell did not change significantly over the same time period (P = .128), and there were no significant differences between the PRK group and the LASIK group over time (P = .282).Patients without apparent dry eye had an altered conjunctival goblet cell population after PRK or LASIK. The conjunctival goblet cell population tended to decrease in the early postoperative period after either surgery and was most affected by preoperative goblet cell density. The changes in the tear film and ocular surface did not seem to affect goblet cell mucin secretion after either procedure.None of the authors has a financial or proprietary interest in any material or method mentioned.

Background Retreatments are sometimes necessary to correct residual or induced refractive errors following refractive surgery. Many different combinations of primary treatment methods and retreatment techniques have been studied, however, few studies have investigated wavefront-optimized (WFO) technology for retreatment following primary refractive surgery. This study aimed to report the outcomes of WFO photorefractive keratectomy (PRK) retreatments of refractive error following previous laser refractive surgery with PRK, laser in situ keratomileusis (LASIK), or laser-assisted subepithelial keratectomy (LASEK). Methods We reviewed records of patients who underwent WFO PRK retreatments using the Allegretto Wave Eye-Q 400 Hz Excimer Laser System (Alcon Surgical) between January 2008 and April 2011 at Walter Reed Army Medical Center and Madigan Army Medical Center. Outcomes were recorded in terms of uncorrected distance visual acuity (UDVA), manifest refraction spherical equivalent (MRSE), corrected distance visual acuity (CDVA), and complications at 1 month (M), 3 M, and 6 M post-op. Results Seventy-eight patients (120 eyes) underwent WFO PRK retreatment during the study period. Primary surgery was surface ablation in 87 eyes (78 PRK, 9 LASEK) and LASIK in 33 eyes. The mean spherical equivalent before retreatment was −0.79 ± 0.94 D (−3.00 to 1.88 D). UDVA was ≥ 20/20 in 69 eyes (60.0 %) at 1 M, 54 eyes (71.1 %) at 3 M, and 27 eyes (73.0 %) at 6 M follow-up. MRSE was within ±0.50 D of emmetropia in 78 eyes (67.8 %) at 1 M, 59 eyes (77.6 %) at 3 M, and 25 eyes (67.6 %) at 6 M follow-up. CDVA was maintained within ±1 line of pre-op in 113 of 115 eyes (98.3 %) at 1 M, 74 of 76 eyes (97.4 %) at 3 M, and 37 eyes (100 %) at 6 M follow-up. Conclusion Although follow-up was limited beyond 3 M, WFO PRK retreatments in patients with residual refractive error may be a safe and effective procedure. Further studies are necessary to determine the long-term safety and stability of outcomes.

PURPOSE: To evaluate visual outcomes following epi-LASIK compared to photorefractive keratectomy (PRK). METHODS: Of a total 294 patients aged ≥21 years, 145 (290 eyes) underwent epi-LASIK and 149 (298 eyes) underwent PRK for low to moderate myopia or myopic astigmatism. Epi-LASIK was performed with the Amadeus II epikeratome (Abbott Medical Optics) and PRK with the Amoils rotary epithelial brush (Innovative Excimer Solutions). All ablations were performed using the same excimer laser system. Outcome measures included intraoperative complications, corneal reepithelialization, postoperative pain, uncorrected distance visual acuity (UDVA), manifest refraction spherical equivalent (MRSE), corrected distance visual acuity (CDVA), corneal haze, and quality of vision. RESULTS: Mean preoperative MRSE was −2.97±1.19 diopters (D) for epi-LASIK versus −2.95±1.06 D for PRK. Complete reepithelialization was achieved by postoperative day 4 in 46.9% of epi-LASIK eyes versus 92.4% of PRK eyes, with superior UDVA at postoperative day 1 in the PRK group ( P =.002). Using Fisher exact test, a significantly higher percentage of epi-LASIK eyes compared to PRK eyes achieved 20/15 or better at 1 month (25.8% vs 17.8%, P =.031), 3 months (62.3% vs 49.3%, P =.004), 6 months (77.1% vs 57.9%, P P =.002). A change in MRSE >0.50 D occurred in 8.4% of epi-LASIK eyes within the 3- and 12-month interval versus 17.7% of PRK eyes ( P =.04). No differences were noted between the two procedures in CDVA or clinically significant haze. CONCLUSIONS: Epi-LASIK showed superior refractive efficacy and stability but required more time for wound healing, resulting in inferior early visual outcomes and a tendency to overcorrect higher refractive errors compared to PRK. Both treatments were safe and comparable in terms of pain and haze formation.

Purpose To compare the efficacy of oral gabapentin versus placebo for the control of severe pain after photorefractive keratectomy (PRK). Setting Center for Refractive Surgery, Walter Reed Army Medical Center, Washington, DC, USA. Design Randomized masked clinical trial. Methods This single-center clinical trial comprised active-duty United States Army soldiers aged 21 years or older having bilateral PRK for myopia with or without astigmatism. Patients received gabapentin 300 mg or placebo 3 times daily for 7 days beginning 2 days before and continuing for 4 days after surgery. Current and maximum pain levels were assessed using the Visual Analog Pain scale 2 hours after surgery and then daily on days 1 through 4. Repeated-measures analysis of variance (ANOVA) was used to compare the current and maximum pain scores over time between the gabapentin group and the placebo group. The Fisher exact test was used to determine whether there was a difference in severe pain (>7/10) between the 2 groups. Results Forty-two patients received gabapentin and 41 patients, placebo. The repeated-measures ANOVA showed no significant difference between the 2 groups in current pain ( P =.84) or in maximum pain over time ( P =.35). Oxycodone–acetaminophen use in the gabapentin group was significantly higher than in the placebo group 1 day postoperatively ( P =.034). Conclusion When added to a standardized postoperative pain regimen, gabapentin use led to no additional improvement in PRK pain control compared with a placebo at the dose and the time intervals tested. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

PURPOSE: To compare visual outcomes following photorefractive keratectomy (PRK), PRK with mitomycin C (MMC-PRK), and LASEK in moderate and high myopia in military personnel. METHODS: This prospective, randomized contralateral eye study included 167 patients 21 years or older with manifest spherical equivalent −5.99 ± 1.40 diopters (D) (range: −3.88 to −9.38 D) randomized to either MMC-PRK or LASEK treatment in their dominant eye and conventional PRK without MMC in the fellow eye. All procedures were performed using the LADARVision 4000 Excimer Laser System (Alcon Surgical Inc., Ft. Worth, TX). High- and low-contrast visual acuities, manifest refraction, endothelial cell count, and corneal haze were evaluated up to 12 months postoperatively. RESULTS: At 12 months postoperatively, visual outcomes were comparable among the treatment groups. Corneal haze of any grade was less common in MMC-PRK compared to PRK at 1 month (21.4% vs 31.0%; P < .01) and 3 months (12.8% vs 35.9%; P = .03) postoperatively; it was also less common in MMC-PRK compared to LASEK at 1 month (21.4% vs 55.9%; P < .01), 3 months (12.8% vs 42.4%; P < .01), and 6 months (12.2% vs 36.4%; P = .03) postoperatively. Haze rate (grade 0.5 or higher) was comparable between LASEK and PRK. Clinically significant haze (grade 2 or higher) developed after PRK (4 eyes) and LASEK (2 eyes), but not after MMC-PRK. CONCLUSIONS: MMC-PRK showed some benefits in minimizing corneal haze formation. One year after surgery, there was no discernible difference in the postoperative refractive outcomes among the three methods. [ J Refract Surg. 2014;30(4):256–264.]

Purpose To determine the association of single nucleotide polymorphisms (SNPs) of the thrombospondin 1 ( THBS1) gene with development of chronic ocular surface inflammation (keratoconjunctivitis) after refractive surgery. Design Retrospective cohort study. Participants Active duty U.S. Army soldiers (n = 143) who opted for refractive surgery. Methods Conjunctival impression cytology samples collected from participants before the surgery were used to harvest DNA for genotyping 5 THBS1 SNPs (rs1478604, rs2228262, rs2292305, rs2228262, and rs3743125) using the Sequenom iPLEX Gold platform (Sequenom, San Diego, CA). Samples collected after surgery were used to harvest RNA for gene expression analysis by real-time polymerase chain reaction (PCR). Participants were followed for 1 year after surgery to monitor the status of keratoconjunctivitis. Main Outcome Measures Genetic basis of the development of chronic keratoconjunctivitis after refractive surgery. Results Carriers of minor alleles of 3 SNPs each were found to be more susceptible to developing chronic keratoconjunctivitis (rs1478604: odds ratio [OR], 2.5; 95% confidence interval [CI], 1.41–4.47; P = 2.5×10 −3 ; rs2228262 and rs2292305: OR, 1.9; 95% CI, 1.05–3.51; P = 4.8×10 −2 ). Carriers of the rs1478604 minor allele expressed significantly reduced levels of thrombospondin 1 (TSP1) ( P = 0.042) and increased levels of an inflammatory cytokine associated with keratoconjunctivitis, interleukin-1β ( P = 0.025), in their ocular surface epithelial cells compared with homozygous major allele controls. Conclusions Genetic variation in the THBS1 gene that results in decreased expression of the encoded glycoprotein TSP1 in ocular surface epithelial cells significantly increases the susceptibility to develop chronic ocular surface inflammation after refractive surgery. Further investigation of THBS1 SNPs in a larger sample size is warranted.

Purpose. To evaluate the use of ocular imaging to enhance management and diagnosis of war-related anterior segment ocular injuries.Methods. This study was a prospective observational case series from an ongoing IRB-approved combat ocular trauma tracking study. Subjects with anterior segment ocular injury were imaged, when possible, using anterior segment optical coherence tomography (AS-OCT), confocal microscopy (CM), and slit lamp biomicroscopy.Results. Images captured from participants with combat ocular trauma on different systems provided comprehensive and alternate views of anterior segment injury to investigators.Conclusion. In combat-related trauma of the anterior segment, adjunct image acquisition enhances slit lamp examination and enables real timeIn vivoobservation of the cornea facilitating injury characterization, progression, and management.

Purpose To evaluate resident refractive surgery caseload and surgical outcomes in an academic medical center. Setting Walter Reed Army Medical Center, Washington, DC, USA. Design Comparative case study. Methods Keratorefractive procedures performed by residents at the Walter Reed Center for Refractive Surgery between 2002 and 2010 were reviewed. Outcomes of surgeries performed by the graduating classes of 2008 to 2010 were compared with those of cases performed by staff. The uncorrected distance visual acuity (UDVA), manifest refraction spherical equivalent, corrected distance visual acuity (CDVA), and complications were analyzed. Results Between 2002 and June 2010, residents performed 1566 procedures (1414 photorefractive keratectomy [PRK], 152 laser in situ keratomileusis), for a mean of 20.2 procedures from 2002 to 2004, 51.6 from 2005 to 2007, and 99.9 from 2008 to 2010. Outcomes analysis was performed on 333 resident eyes and 977 staff eyes treated between 2008 and June 2010. Six months postoperatively, 96.1% of resident-treated eyes and 94.6% of staff-treated eyes had a UDVA 20/20 or better (P=.312) and 61.3% and 64.3%, respectively, had a UDVA 20/15 or better (P=.324). The percentage of eyes within ±0.50 diopter of emmetropia at 6 months was 94.0% for residents and 91.1% for staff (P=.105). The postoperative CDVA was within 2 lines of preoperative baseline in all resident cases and 99.8% of staff cases (P=.999). Conclusions Resident experience grew steadily over the period studied. Overall safety and efficacy of resident-performed surgery, albeit mainly PRK based, matched that of fellowship-trained refractive surgeons. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

PURPOSE: To report the results of photorefractive keratectomy (PRK) in patients with pigment dispersion syndrome. METHODS: The pre- and postoperative records of patients with pigment dispersion syndrome who underwent PRK between January 2002 and March 2009 were reviewed. Data for analysis included gender, age, ablation depth, surgical complications, manifest refraction spherical equivalent, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), intraocular pressure (IOP), central corneal thickness (CCT), cup-to-disc (c/d) ratio, and postoperative complications. RESULTS: Thirty-seven eyes of 19 patients (17 men and 2 women) with a mean age of 37.5±6.9 years were included for review. At final follow-up, mean 404.1±119.5 days postoperative, UDVA was 20/15 or better in 67.6%, 20/20 or better in 91.9%, and 20/25 or better in 100% of eyes; 94.6% of eyes were within 0.50 diopters (D) and 100% were within 1.00 D of emmetropia. Corrected distance visual acuity was unchanged from preoperative in 73% and improved by one line in 27% of eyes. No eye lost 1 or more lines of CDVA. When corrected for change in CCT and curvature, mean postoperative IOP was elevated from baseline (16.7±3.8 mmHg) at 1 month (18.1±4.9 mmHg, P =.044) but unchanged at any other time postoperatively. Two (11%) of 19 patients were steroid responders, requiring a single topical agent until completing the course of steroids. No significant change was noted in mean c/d ratio from baseline (0.35±0.12) to final postoperative (0.35±0.13, P =.99). CONCLUSIONS: Although PRK in patients with pigment dispersion syndrome resulted in excellent UDVA, retention of CDVA, and low incidence of adverse effects 1 to 2 years after surgery, long-term safety and efficacy outcomes of PRK in this cohort remain speculative.

Heparanase (NP_001092010) is a heparin-binding endo-bD-glucuronidase expressed by normal lacrimal gland (GEO Profiles: GDS1361), corneal epithelia (Berk et al., 2004), retinal pigment epithelium/choroid, lens (NEIBank) and some non-ocular tissues. Heparanase is over-expressed in essentially all human tumors examined. Western blotting suggests that heparanase is a constituent of normal tears (Ma, Laurie, unpublished). 119 37 pg/ml of active heparanase has been detected in normal saliva. Heparanase belongs to the glycoside hydrolase family 79. The heparanase gene ‘HPSE’ comprises fourteen exons over 39.8 kb of human chromosome 4, and forty-three orthologues have been documented (Ensembl release 57). HPSE is wellconserved from bony fish to human. Secreted heparanase in humans is 508 amino acids long, with a theoretical molecular weight and pI of 57.7 kDa and 9.2, respectively. Migration in SDS PAGE is approximately 65 kDa, in keeping with N-linked high mannose glycosylation at as many as six predicted sites (NetNGlyc 1.0). No O-glycosylation is predicted above threshold (NetOGlyc 3.1). Three splice variants have been recently reported (Barash et al., 2010) which vary in amino acid length, predicted molecular weight and charge as follows: 1) ‘T5’: 15.6 kDa and pI 6.9; 2)

Purpose: To evaluate corneal biomechanical changes following epi-LASIK. Methods: In this prospective study of 51 patients, corneal hysteresis (CH), corneal resistance factor (CRF), and intraocular pressure (IOP) were assessed using the Ocular Response Analyzer (ORA, Reichert Technologies) preoperatively and at 1, 3, 6, and 12 months after epi-LASIK. Repeated measures analysis of variance (ANOVA) was used to compare changes over time (alpha=.05). Intraocular pressure was also measured by Goldmann applanation tonometry. Results: Corneal hysteresis decreased from 10.22±1.65 mmHg preoperatively to 8.17±1.25 mmHg at 1 month, 8.46±1.44 mmHg at 3 months, 8.63±1.31 mmHg at 6 months, and 8.53±1.49 mmHg at 12 months. Corneal resistance factor decreased from 10.01±1.80 mmHg preoperatively to 7.82±1.68, 8.03±1.85, 7.77±1.50, and 7.80±1.66 mmHg at 1, 3, 6, and 12 months, respectively. Repeated measures ANOVA showed a significant change over time for both CH and CRF ( P P Conclusions: Epi-LASIK resulted in a significant change in CH and CRF postoperatively. Although some recovery occurred over time, CH, CRF, and IOP did not revert to preoperative levels.

Purpose To evaluate occupational ultraviolet (UV) exposure during photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK) with the Allegretto Wave Eye-Q 400 Hz excimer laser. Setting Walter Reed Center for Refractive Surgery, Washington, DC, USA. Methods Intraoperative UV measurements were performed during PRK with epithelial removal using an Amoils brush, PRK with epithelial removal using 20% ethanol, or femtosecond LASIK. A LaserStar power/energy meter with a silicone detector (model PD-10) was used for the measurements. The maximum pulse energy 25.4 cm from the corneal surface was recorded for each surgical procedure. Measurements were evaluated using a worst-case scenario for exposure of operating room personnel, and the results were compared with the occupational exposure limit set by the International Commission on Non-Ionizing Radiation Protection. Results Measurements were taken during 15 cases of each procedure. The mean maximum exposure was 129.38 nJ/pulse ± 79.48 (SD) during brush PRK, 69.72 ± 68.80 nJ/pulse during ethanol PRK, and 29.17 ± 13.82 nJ/pulse during LASIK. The mean maximum exposure per eye was 0.085 mJ/cm 2 , 0.046 mJ/cm 2 , and 0.01 mJ/cm 2 , respectively. The worst-case cumulative exposure during a heavy workday of 20 patients (40 eyes) was calculated at 3.92 mJ/cm 2 , 1.51 mJ/cm 2 , and 0.79 mJ/cm 2 for brush PRK, ethanol PRK, and LASIK, respectively. Conclusion Results indicate that the excimer laser platform used in the study may yield greater UV exposure than previous systems; however, the levels did not exceed occupational exposure limits. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Purpose To evaluate the safety and efficacy of topical bevacizumab in the treatment of corneal neovascularization. Design Prospective, nonrandomized, interventional case series. Methods setting: Institutional, multicenter clinical trial. study population: Twenty eyes from 20 patients with stable corneal neovascularization. intervention procedures: Patients were treated with topical 1.0% bevacizumab for 3 weeks and were monitored for a total of 24 weeks. main outcome measures: Primary outcome measures included: neovascular area, defined as the area of the corneal vessels themselves; vessel caliber, defined as the mean corneal vessel diameter; and invasion area, defined as the fraction of the total cornea into which the vessels extended. The occurrence of ocular and systemic adverse events was monitored closely. Results As compared with the baseline visit, patients exhibited a statistically significant improvement in neovascular area by week 6 ( P = .007) and in vessel caliber by week 12 ( P = .006). At the final visit, neovascular area, vessel caliber, and invasion area were reduced by 47.5%, 36.2%, and 20%, respectively. The decreases in neovascular area and vessel caliber were statistically significant ( P P = .003, respectively); however, the reduction in invasion area did not reach statistical significance ( P = .06). There were no significant changes in the secondary outcomes, and there were no adverse events. Conclusions Short-term topical bevacizumab treatment reduced the extent of stable corneal neovascularization as measured by neovascular area and vessel caliber with no associated adverse events. Interestingly, the degree of treatment efficacy was inversely proportional to the baseline invasion area.