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Ana Filipa Moleiro,1,2 Gonçalo Godinho,3 Carolina Madeira,4 Ana Faria Pereira,1 Elisete Brandão,1 Fernando Falcão-Reis,1,2 João Nuno Beato,1,2 Susana Penas1,2 1Department of Ophthalmology, Centro Hospitalar e Universitário de São João, Porto, Portugal; 2Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; 3Department of Ophthalmology, Centro Hospitalar de Leiria, Leiria, Portugal; 4Department of Ophthalmology, Centro Hospitalar Gaia-Espinho, Gaia, PortugalCorrespondence: Ana Filipa Moleiro, Department of Ophthalmology, Centro Hospitalar e Universitário de São João, Alameda Hernani Monteiro, Porto, 4200-426, Portugal, Tel +351 915689259, Email anafomoleiro@gmail.comPurpose: This work aimed to longitudinally assess the peripapillary (PPCT) and subfoveal (SFCT) choroidal thickness (CT), in patients diagnosed with central (CRVO) or branch retinal vein occlusions (BRVO), correlating SFCT with central macular thickness (CMT) and PPCT with peripapillary retinal nerve fiber layer thickness (pRNFL).Patients and Methods: This was a retrospective longitudinal study of 71 eyes from 71 patients with treatment-naïve retinal vein occlusion (24 CRVO and 40 BRVO). Spectral-domain optical coherence tomography (SD-OCT, Spectralis HRA-OCT, Heidelberg) was used to measure PPCT, SFCT, pRNFL and CMT of the affected and fellow eyes at baseline (acute phase) and at 3 and 9 months post anti-VEGF treatment. IBM SPSS Statistics version 27.0 (IBM Corp., Armonk, NY, USA) was used for statistical analysis. A p-value ≤ 0.05 was considered statistically significant.Results: Affected eyes presented a thicker baseline PPCT and SFCT compared to their fellow eyes both in CRVO and BRVO (p < 0.05). Both groups presented a significant decrease of PPCT in the affected eyes at 3 months compared to baseline (p < 0.05). At 9 months, compared to 3 months, PPCT remained stable (p > 0.05). Similarly, affected eyes’ SFCT significantly decreased at 3 months (p < 0.05) in both groups. At 9 months, compared to 3 months, SFCT decreased in the CRVO patients (p = 0.047) but remained stable in the BRVO patients (p = 0.850). No correIations between SFCT and CMT were seen at any timepoint in both groups (p > 0.05). PPCT correlates with pRNFL in CRVO at 3 months, although no other correlations were found during the follow-up. In BRVO, PPCT did not show any significant correlation with pRNFL.Conclusion: Both in CRVO and BRVO eyes, PPCT and SFCT at diagnosis are significantly thicker compared to the fellow eye, suggesting a possible increase in CT immediately after the occlusion, which is followed by a decrease at an early follow-up stage.Keywords: biomarkers, vascular retinal diseases, retinal vein occlusions, choroidal thickness, optical coherence tomography

Ana Filipa Moleiro,1,2 Gonçalo Godinho,3 Carolina Madeira,4 Ana Faria Pereira,1 Elisete Brandão,1 Fernando Falcão-Reis,1,2 João Nuno Beato,1,2 Susana Penas1,2 1Department of Ophthalmology, Centro Hospitalar e Universitário de São João, Porto, Portugal; 2Department of Surgery and Physiology, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; 3Department of Ophthalmology, Centro Hospitalar de Leiria, Leiria, Portugal; 4Department of Ophthalmology, Centro Hospitalar Gaia-Espinho, Gaia, PortugalCorrespondence: Ana Filipa Moleiro, Department of Ophthalmology, Centro Hospitalar e Universitário de São João, Alameda Hernani Monteiro, Porto, 4200-426, Portugal, Tel +351 915689259, Email anafomoleiro@gmail.com

João N Beato,1,2 João Esteves-Leandro,1 David Reis,3 Manuel Falcão,1,2 Vítor Rosas,1 Ângela Carneiro,1,2 Fernando Falcão Reis1,2 1Department of Ophthalmology, São João Hospital, Porto, Portugal; 2Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal; 3Faculty of Medicine, University of Porto, Porto, PortugalCorrespondence: João N BeatoDepartment of Ophthalmology, São João Hospital, Al Prof Hernâni Monteiro, Porto 4200-319, PortugalTel +351 225 51 2168Fax +351 225 51 3669Email joao.nuno.beato@gmail.comPurpose: To compare corneal structure and endothelial morphological features between patients with type 2 diabetes mellitus (DM) and non-diabetic patients; and determine if the DM duration, glycated hemoglobin (HbA1c) levels, and diabetic retinopathy (DR) stage affect corneal morphological properties.Patients and Methods: Sixty diabetic patients and 47 age- and sex-matched controls were enrolled in this cross-sectional study. DM group was analyzed according disease duration, HbA1c levels, and presence of retinopathy. Endothelial cell density (ECD) and morphology (average and coefficient of variation [CV] of cell size, percentage of hexagonal cells) were recorded using non-contact specular microscopy. Central corneal thickness (CCT) and corneal volume were measured by scheimpflug tomography. Univariate and multivariate linear regression analyses were performed to evaluate the relationship between demographical, clinical, and ocular variables with CCT and ECD.Results: There were no statistically significant differences in the endothelium cell density or morphology between DM and non-DM groups (p> 0.05). Also, there was no statistical difference between groups for CCT or corneal volume (p> 0.05). Multivariate linear regression analysis showed that older age (p=0.028) was significantly associated with lower ECD; CCT was found to be significantly greater in males (p< 0.001) and positively associated with corneal volume (p< 0.001).Conclusion: The present study did not find any statistically significant differences between the corneal structural and endothelial characteristics of diabetic and non-diabetic subjects; other demographical parameters, such as age and gender, seem to be more determinant for the corneal properties.Keywords: diabetes mellitus, endothelium, central corneal thickness

Purpose: The aim of this study was to compare corneal structure and endothelial morphological changes after uneventful phacoemulsification cataract surgery between type 2 diabetic and nondiabetic patients and to determine the preoperative and intraoperative factors that may predict greater endothelial cell density loss., Methods: Forty-five diabetic pa-tients (45 eyes) and 43 controls (43 eyes) with age-related cataract were enrolled in this prospective observational study. Corneal (thickness and volume) and anterior segment parameters were measured by Scheimpflug tomography; endothelial cell density and morphology (coefficient of variation of cell size, hexagonal cells) were recorded using noncontact specular microscopy. Patients were evaluated preoperatively and at one and six months after surgery. Univariate and multivariate linear regression analyses were performed to evaluate the relationship between demographic, clinical, ocular, and intraoperative parameters and postoperative endothelial cell density changes at six months., Results: Significant postoperative endothelial cell loss occurred one month after surgery in both groups (p<0.001), which remained stable until month 6; there were no differences between patients with and without diabetes mellitus at any time point. The mean postoperative central corneal thickness at one and six months did not change significantly from the mean preoperative value in either group (p>0.05). Multivariate linear regression analysis showed that older age (p=0.042) and higher cataract grades (p=0.001) were significantly associated with greater endothelial cell density reduction at six-month follow-up., Conclusion: This study showed that older age and denser cataracts might be associated with greater endothelial cell density reduction after cataract surgery. Other factors, such as diabetes mellitus and preoperative anterior segment parameters, did not influence postoperative changes in endothelial cell density.

Purpose: To compare corneal biomechanical changes after uneventful phacoemulsification cataract surgery between type 2 diabetic (DM) and nondiabetic patients., Methods: Forty-four diabetic (44 eyes) and 44 (44 eyes) age and sex-matched non-DM controls with age-related cataract were enrolled in this prospective observational study. Corneal hysteresis (CH), corneal resistance factor (CRF), and corneal-compensated intraocular pressure (IOPcc) were evaluated by using the ocular response analyzer; central corneal thickness was recorded by using the Pentacam HR. Patients were evaluated preoperatively and 1 and 6 months after surgery., Results: In the DM group, CH was observed to be significantly lower than preoperative value (9.8 ± 1.5 mm Hg) at 1 month (9.4 ± 1.2 mm Hg, P = 0.040), but not at the 6-month follow-up (9.6 ± 1.6 mm Hg, P = 0.437),whereas it did not change significantly in the non-DM group (preoperative 9.8 ± 1.3 mm Hg vs. 1 month 9.6 ± 1.1 mm Hg vs. 6 months 10.1 ± 1.1 mm Hg, P > 0.05). CRF was significantly lower than the preoperative values at 1 and 6 months in both groups (P ≤ 0.001). Postoperative CH change was significantly associated with preoperative CH (P < 0.001), preoperative IOPcc (P = 0.004), and IOPcc change (P < 0.001), whereas CRF change was only correlated with preoperative CRF (P < 0.001). There was a significant postoperative IOPcc reduction 6 months after surgery (P < 0.001) in both DM and non-DM groups; however, central corneal thickness was not found to significantly change in the postoperative period (P > 0.05)., Conclusions: This study showed that phacoemulsification causes a significant and persistent decrease in intraocular pressure and CRF in both groups, whereas CH recovered to preoperative values, although more slowly in patients with diabetes.

Aim: To evaluate inter-device agreement of anterior keratometry obtained by the IOLMaster ® 500 and Pentacam ® HR in type 2 diabetic and non-diabetic patients., Methods: Corneal measurements were sequentially performed in 60 diabetes mellitus (DM) and 48 age and sex-matched controls undergoing cataract surgery. Variables recorded included flat and steep keratometry, mean keratometry (K m ), astigmatism magnitude, axis location, J0 and J45 components. Bland-Altman plots and intraclass correlation coefficients were used for examination of agreement. Subgroup analyses were performed for astigmatism magnitude, diabetes duration, hemoglobin A1c (HbA1c) levels and diabetic retinopathy (DR) stage., Results: Agreement for K m and astigmatism magnitude were considered good and moderate, with 95% limits of agreement (LoA) of -1.09 to 1.23 diopters (D) and -0.83 to 0.86 D in DM group, respectively; and -0.59 to 0.72 D and -0.98 to 0.75 D in non-DM group, respectively. In contrast, the 95% LoA for corneal axis exceeded the clinically relevant margins in both groups. In the total sample, only 41 eyes (38%) had a smaller than 5-degree difference. Diabetes duration, HbA1c levels and DR stage were not found to significantly affect agreement. Logistic regression showed that higher corneal power ( P =0.021) and astigmatism magnitude ( P =0.011) were associated with a decreased risk of having a difference in axis location greater than 10-degrees., Conclusion: In both groups, IOLMaster and Pentacam agree well for corneal power and moderately for astigmatism. However, axis location disagreement is frequent in eyes with flatter corneas and small amounts of astigmatism., (International Journal of Ophthalmology Press.)

Purpose: To analyze and compare choroidal thickness between keratoconus (KC) patients and age-matched non-KC subjects., Methods: A cross-sectional, case-control study. One hundred and thirty-four keratoconic eyes and 78 control eyes, from individuals aged from 12 to 30 years old, were studied. Patients with KC followed in Corneal Department of Centro Hospitalar São João, Porto, Portugal, were identified and consecutively included between December 2017 and February 2018. A spectral-domain optical coherence tomography (OCT) using depth enhanced imaging was performed, and choroidal thickness in the center of the fovea and at 500  μ m intervals along a horizontal section was measured and compared., Results: The statistical analysis showed that keratoconic eyes present a thicker choroid in every measured location ( p < 0.05). Mean subfoveal choroidal thickness (SFCT) values obtained were 375.86 ± 89.29 and 322.91 ± 85.14 in keratoconus and control groups, respectively ( p < 0.001). In a multivariate analysis, SFCT was significantly associated with spherical equivalent ( p =0.004) and the presence of keratoconus ( p < 0.001), but not with age ( p =0.167), gender ( p =0.579), or best-corrected visual acuity ( p =0.178). In a "fixed model," keratoconus patients were found to have a 67.55  μ m (95% CI 36.61-98.49) thicker subfoveal choroid compared to controls., Conclusion: Keratoconus patients seem to have a thicker choroid than healthy individuals. The exact pathophysiological mechanism resulting in a thicker choroid in KC patients is not known, but it could possibly be associated with inflammatory choroidal mechanisms., Competing Interests: The authors declare no conflicts of interest regarding the publication of this paper., (Copyright © 2019 João Pinheiro-Costa et al.)

Purpose: To compare intraocular pressure (IOP) and anterior segment (AS) morphometry changes after uneventful phacoemulsification between nonglaucomatous eyes with open-angles from patients with and without type 2 diabetes mellitus (DM) and determine which factors may predict greater IOP-lowering effect., Methods: Forty-five diabetic (45 eyes) and 44 (44 eyes) age- and sex-matched non-DM patients with age-related cataract were enrolled in this prospective observational study. Goldmann applanation tonometry and AS Scheimpflug tomography (Pentacam® HR) were performed preoperatively and at 1- and 6-month follow-up. Linear regression analysis was performed to evaluate the clinical variables related to postoperative IOP changes at 6 months., Results: There was a significant postoperative IOP reduction 6 months after surgery ( p < 0.001) by an average of 2.9 ± 2.9 mmHg (15.5%) and 2.4 ± 2.8 mmHg (13.0%) in the DM group and non-DM groups ( p = 0.410), respectively. All AS parameters (anterior chamber depth, volume, and angle) increased significantly postoperatively ( p < 0.001). Multivariate linear regression analysis showed that higher preoperative IOP was significantly associated with IOP reduction at 6-month follow-up ( p < 0.05)., Conclusion: Nonglaucomatous eyes with open-angles from both type 2 diabetic and nondiabetic patients experienced similar AS changes and IOP reductions following uneventful phacoemulsification, and this IOP-lowering effect was strongly correlated with preoperative IOP.

Purpose: To analyze and compare corneal structural and biomechanical properties, characterized by corneal hysteresis (CH) and resistance factor (CRF), between patients with and without type 2 diabetes mellitus (DM), and determine the main ocular variables that influence them., Methods: Sixty diabetic and 48 age- and sex-matched non-DM patients were enrolled in this cross-sectional study. The DM group was analyzed according to DM duration (

Introduction: To evaluate the safety and impact on visual acuity, retinal and choroidal morphology of simultaneous cataract surgery and intravitreal anti-vascular endothelial growth factor on patients with visually significant cataracts and previously treated exudative age-related macular degeneration., Material and Methods: Prospective study, which included 21 eyes of 20 patients with exudative age-related macular degeneration submitted to simultaneous phacoemulsification and intravitreal ranibizumab or bevacizumab. The patients were followed for 12 months after surgery using a pro re nata strategy. Visual acuity, foveal and choroidal thickness changes were evaluated 1, 6 and 12 months post-operatively., Results: There was a statistically significant increase in mean visual acuity at one (13.4 letters, p < 0.05), six (11.5 letters, p < 0.05) and twelve months (11.3 letters, p < 0.05) without significant changes in retinal or choroidal morphology. At 12 months, 86% of eyes were able to maintain visual acuity improvement. There were no significant differences between the two anti-vascular endothelial growth factor drugs and no complications developed during follow-up., Discussion: Simultaneous phacoemulsification and intravitreal anti- vascular endothelial growth factor is safe and allows improvement in visual acuity in patients with visually significant cataracts and exudative age-related macular degeneration. Visual acuity gains were maintained with a pro re nata strategy showing that in this subset of patients, phacoemulsification may be beneficial., Conclusion: Cataract surgery and simultaneous anti-vascular endothelial growth factor therapy improves visual acuity in patients with exudative age-related macular degeneration.

A 47-year-old man presented to our emergency department complaining of acute ocular pain and redness of his left eye. Ophthalmological antecedents included use of semi-rigid contact lens and primary open-angle glaucoma. Slit-lamp examination revealed a small central corneal ulcer associated with stromal inflammatory infiltrate. Scraping from the corneal ulcer was positive for Elizabethkingia meningoseptica. He was empirically treated with topical 0.5% levofloxacin and 0.3% gentamicin, and five weeks later the infection had resolved. In this case report we describe the uncommon association between contact lens and Elizabethkingia meningoseptica. Despite possible serious complications associated with this atypical agent, prompt diagnosis and adequate treatment lead to good visual prognosis.

Purpose: To report the clinical outcomes of intravitreal aflibercept therapy in eyes with refractory and recurrent neovascular age-related macular degeneration (AMD) switched from intravitreal bevacizumab or ranibizumab., Methods: This is a retrospective review of eyes with neovascular AMD switched to intravitreal aflibercept with at least 1 year of follow-up after the switch. All patients had had a minimum of 3 injections of bevacizumab or ranibizumab before the switch. Aflibercept was used in patients considered refractory to bevacizumab (group 1) and in recurrent patients on therapy with ranibizumab due to an institutional policy decision (group 2). Changes in best-corrected visual acuity, fluid on optical coherence tomography (OCT), central retinal thickness (CRT) and the frequency of injections were compared., Results: Eighty-five eyes of 69 patients were analyzed, 39 eyes in group 1 and 46 in group 2. The mean follow-up time was 31.6 months prior to the switch and 14.7 months on treatment with aflibercept. One year after the switch, there was a nonsignificant mean decrease of 2 letters in visual acuity in both groups (group 1: from 58.2 to 55.8 letters, p = 0.086; group 2: from 56.4 to 54.5 letters, p = 0.168), but the mean number of injections per month was significantly lower (from 0.76 to 0.57, p < 0.001). With the switch, 90.6% of the patients showed anatomic improvement with a reduction of fluid on OCT, and both groups presented significant improvement in CRT (group 1: 65.3 µm, p = 0.051; group 2: 91.0 µm, p < 0.001)., Conclusion: Aflibercept appears to be a valuable tool for the management of patients with poor responses to other anti-vascular endothelial growth factor drugs. These patients could have anatomic improvement, and the injection intervals could be extended.