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Samir Jabbour, Kraig S Bower The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USACorrespondence: Samir JabbourThe Wilmer Eye Institute, Johns Hopkins School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21287, USATel +1 410 583-2843Email samir.jabbour2@gmail.comPurpose: Describe three-year outcomes of spherical implantable Collamer lens (ICL) followed by excimer laser enhancement (bioptics) in eyes with high myopic astigmatism.Patients and Methods: Retrospective case series of thirty-four cases that underwent bioptics enhancement at the Johns Hopkins Wilmer Eye Institute. All eyes had a preoperative sphere of − 6.00 D or more with a cylinder of at least 2.00 D. Uncorrected and corrected distance visual acuity (UDVA and CDVA), manifest spherical equivalent refraction (MSE), ICL vault measurements and central corneal thickness (CCT) were collected. Endothelial cell counts (ECC), root mean square (RMS) of higher order aberrations (HOAs), adverse events and subsequent surgeries were also assessed.Results: All patients had a minimum follow-up of 3 years. Preoperative UDVA was 2.29 ± 0.46 logMAR and improved to 0.03 ± 0.23 logMAR at 3 years (p< 0.05). MSE was − 12.30 ± 4.05 preoperatively and changed to − 0.21 ± 0.46 at 3 years (p< 0.05). The efficacy and safety indices were 1.28 ± 0.32 and 1.47 ± 0.27 at 3 years post-enhancement. HOA did not significantly change throughout the follow-up (p< 0.05). Endothelial cell loss at 12 months was calculated at 5.7%. Two eyes required ICL exchange due to vault-related issues.Conclusion: Bioptics offered excellent long-term safe, predictable, and efficient outcomes for high myopic astigmatism and can be considered an option if toric ICL is not available. Results confirm that wavefront-guided photoablation remains an excellent option to manage residual refractive error after phakic IOL.Keywords: bioptics, implantable collamer lens, enhancement, excimer laser

We retrospectively reviewed the records of 107 U.S. military personnel referred to the Walter Reed Army Medical Center ophthalmology service with eye diseases and nonbattle injuries diagnosed during Operation Enduring Freedom and Operation Iraqi Freedom. Ocular diseases and nonbattle injuries ranged from minor to vision-threatening, represented a broad variety of conditions, and required the expertise of a number of ophthalmic subspecialists. The most common diagnoses were uveitis (13.1%), retinal detachment (11.2%), infectious keratitis (4.7%), and choroidal neovascularization (4.7%). Eighty-four patients (78.5%) met Army retention standards and were returned to duty. Twenty patients (18.7%) were referred to a medical evaluation board, seven (6.5%) of whom failed to meet retention standards for eye and vision; the retention status of three patients (2.8%) remains to be determined. [ABSTRACT FROM AUTHOR]

A 25-year-old active duty Army E-5 developed severe infectious keratitis in his left eye secondary to soft contact lens (CL) wear while deployed in Iraq, necessitating evacuation to Walter Reed Army Medical Center for further evaluation and treatment. Initial clinical examination at Walter Reed Army Medical Center was suggestive of Acanthamoeba keratitis, a serious corneal pathogen associated with CL wear. In vivo confocal microscopy demonstrated Acanthamoeba cysts in the epithelium and anterior stroma, and smears and cultures from an epithelial biopsy specimen confirmed the diagnosis of Acanthamoeba keratitis. To our knowledge this is the first reported case of Acanthamoeba keratitis in a soldier wearing CLs in the combat theater. Because of the inability to maintain proper lens hygiene in a combat or field environment, the risk of developing a potentially sight-threatening corneal infection is significant. This unfortunate case of a devastating eye infection serves as a reminder of the current Army policy, which prohibits the use of CLs during gas chamber exercises, field training, and combat. [ABSTRACT FROM AUTHOR]

Objective: To investigate the effect of laser refractive surgery on night weapons firing.Methods: Firing range performance was measured at baseline and postoperatively following photorefractive keratectomy and laser in situ keratomileusis. Subjects fired the M-16A2 rifle with night vision goggles (NVG) at starlight, and with iron sight (simulated dusk). Scores, before and after surgery, were compared for both conditions.Results: No subject was able to acquire the target using iron sight without correction before surgery. After surgery, the scores without correction (95.9 +/- 4.7) matched the preoperative scores with correction (94.3 +/- 4.0; p = 0.324). Uncorrected NVG scores after surgery (96.4 +/- 3.1) exceeded the corrected scores before surgery (91.4 +/- 10.2), but this trend was not statistically significant (p = 0.063).Conclusion: Night weapon firing with both the iron sight and the NVG sight improved after surgery. This study supports the operational benefits of refractive surgery in the military. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to evaluate the effect of outpatient celiac plexus block on acute pain reduction in patients with suspected median arcuate ligament syndrome., Methods: This is an Institutional Review Board approved, retrospective chart review. Data were collected and analyzed from patients who received celiac plexus blocks from November 1, 2021 through April 6, 2023. The primary outcome was pain reduction, determined by the change in numerical pain rating scale (NPRS) from pre-procedure to post-procedure. Additional data collected include patient demographics, comorbidities, preoperative symptoms and duration of symptoms., Results: There were 33 patients identified in this study. Thirty-one patients were included in the data analysis. The median age of the cohort was 29 years, and the median BMI was 20.4. 94% of the cohort was female. These patients were referred as part of an evaluation for symptomatic vascular compression disorders. For many patients, positive response to celiac plexus block was used as an indication to proceed with surgical MALS resection. We provide a diagnostic algorithm for MALs. All patients endorsed preoperative symptoms. Patients experienced a median pain reduction of -4 from baseline to immediately post-procedure., Conclusions: Celiac plexus blocks continue to be a tool for ruling out neurogenic median arcuate ligament syndrome in patients who have undergone extensive previous imaging and assessments for vascular compression disorders. Our data suggest that patients with suspected MALS may experience substantial immediate pain relief from temporary blocks of the celiac ganglion as guided by fluoroscopy in an outpatient setting., (© 2024 World Institute of Pain.)

Purpose: To assess the refractive accuracy of eight intraocular lens (IOL) formulas in eyes that underwent combined phacovitrectomy., Methods: A retrospective chart review of 59 eyes that underwent uncomplicated phacovitrectomy between 2017 and 2020 at the Johns Hopkins Wilmer Eye Institute. Inclusion criteria were postoperative best corrected visual acuity of 20/40 or better within 6 months of surgery and IOL implantation in the capsular bag. The Barrett Universal II (BUII), Emmetropia Verifying Optical (EVOv2.0), Hill-Radial Basis Function (Hill-RBFv3.0), Hoffer Q, Holladay I, Kane, Ladas Super Formula (LSF), and SRK/T formulas were compared for accuracy in predicting postoperative spherical equivalents (SE) using Wilcoxon rank sum tests. Pearson's correlation coefficients were used to assess correlations between biometric parameters and errors for all formulas., Results: Prediction errors of SE ranged from - 1.69 to 1.43 diopters (D), mean absolute errors (MAE) ranged from 0.39 to 0.47 D, and median absolute errors (MedAE) ranged from 0.23 to 0.37 D among all formulas. The BUII had the lowest mean error (- 0.043), MAE (0.39) and MedAE (0.23). The BUII also had the highest percentage of eyes with predicted error within ± 0.25 D (51%) and ± 0.50 D (83%). Based on MedAE however, no pairwise comparisons resulted in statistically significant differences. Axial length (AL) was positively correlated with the error from the Hoffer Q and Holladay I formulas (correlation coefficients = 0.34, 0.30, p values < 0.01, 0.02 respectively)., Conclusion: While all eight IOL formulas had comparable accuracy in predicting refractive outcomes in eyes undergoing combined phacovitrectomy, the BUII and Kane formulas had a tendency to greater accuracy., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: The aim of this study was to identify factors associated with receipt of standard fluence epithelium-off crosslinking (CXL) for keratoconus (KCN)., Methods: This retrospective, cross-sectional study reviewed electronic health records of treatment-naive patients with KCN seen at the Wilmer Eye Institute between January 2017 and September 2020. Tomographic data were derived from Pentacam (Oculus, Wetzlar, Germany) devices. Multivariable population-average model using generalized estimating equations adjusting for age, sex, race, national area deprivation index, vision correction method, and disease severity was used to identify factors associated with receipt of CXL., Results: From 583 patients with KCN, 97 (16.6%) underwent CXL for KCN. Patients who received CXL in at least 1 eye were significantly younger (mean 24.0 ± 7.8 years) than patients who had never undergone CXL (33.4 ± 9.3 years) ( P < 0.001). In multivariable analysis, Black patients had 63% lower odds of receiving CXL for KCN (OR: 0.37, 95% CI, 0.18-0.79) versus White patients, and older age was protective against receipt of CXL (OR: 0.89 per 1-year increase, 95% CI, 0.86-0.93). Comparison of characteristics by race demonstrated that Black patients presented with significantly worse vision, higher keratometric indices (K1, K2, and Kmax), and thinner corneal pachymetry at baseline versus White or Asian patients., Conclusions: In this clinical cohort of patients with KCN from a tertiary referral center, Black patients were less likely to receive CXL presumably because of more advanced disease at presentation. Earlier active population screening may be indicated to identify and treat these patients before they become ineligible for treatment and develop irreversible vision loss. Such strategies may improve health equity in KCN management., Competing Interests: None of the authors has any relevant conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: This study aimed to report an experiment designed to determine anatomical changes in porcine corneas following placement of a novel polymer implant into the cornea., Methods: An ex vivo porcine eye model was used. A novel type I collagen-based vitrigel implant (6 mm in diameter) was shaped with an excimer laser on the posterior surface to create three planoconcave shapes. Implants were inserted into a manually dissected stromal pocket at a depth of approximately 200 μm. Three treatment groups were defined: group A (n=3), maximal ablation depth 70 μm; Group B (n=3), maximal ablation depth 64 μm; and group C (n=3), maximal ablation depth 104 μm, with a central hole. A control group (D, n=3) was included, in which a stromal pocket was created but biomaterial was not inserted. Eyes were evaluated by optical coherence tomography (OCT) and corneal tomography., Results: Corneal tomography showed a trend for a decreased mean keratometry in all four groups. Optical coherence tomography showed corneas with implants placed within the anterior stroma and visible flattening, whereas the corneas in the control group did not qualitatively change shape., Conclusions: The novel planoconcave biomaterial implant described herein could reshape the cornea in an ex vivo model, resulting in the flattening of the cornea. Further studies are needed using in vivo animal models to confirm such findings.

Purpose: The purpose of this study was to determine the safety and outcomes of myopic laser in situ keratomileusis (LASIK) in patients who were secondarily diagnosed with hypermobile Ehlers-Danlos syndrome (EDS)., Methods: We conducted a case series study on patients with hypermobile EDS who underwent myopic LASIK surgery. Visual acuity, manifest refraction, a full dilated eye examination, biometry measurements, and Scheimpflug imaging were performed in the Wilmer outpatient clinic., Results: There were 24 eyes of 12 patients included in this study. All participants were White women with a mean age of 46.58 years (SD 8.91 years). Participants were seen at an average of 13.83 years (SD 4.3 years, range 6-21 years) after undergoing LASIK. None of the patients in the series had a diagnosis of hypermobile EDS before LASIK surgery. Overall, 92% of patients were happy they got LASIK. The uncorrected distance visual acuity was 20/20 or better in 68% of eyes, and the best-corrected visual acuity was 20/20 or better in 92% of eyes. Manifest refraction was within 1 diopter of plano in 79% of patients. Dry eye symptoms were present in 83% of patients, and 46% of eyes had either punctate epithelial erosions or decreased tear break-up time. One of the 12 patients developed corneal ectasia in both eyes., Conclusions: Patients with hypermobile EDS are generally satisfied with myopic LASIK correction, with good visual acuity outcomes and low rates of myopic regression. However, the risk of corneal ectasia may prevent laser vision correction from being a viable treatment option in these patients. Further studies are needed to make a definitive recommendation., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To evaluate whether unilateral crosslinking (CXL) and conservative follow-up of the fellow eye is an acceptable management strategy in patients with keratoconus (KC)., Methods: Seventy-nine fellow eyes of KC subjects that initially underwent unilateral CXL were included. Thirty fellow eyes ultimately received CXL (group 1) whereas 49 fellow eyes were followed (group 2). Best spectacle corrected visual acuity (BSCVA) and corneal tomographic parameters were collected in all eyes preoperatively and at the last follow-up., Results: Subjects who received CXL in the fellow eye (group 1) were younger than subjects who did not (group 2, p =0.026). Group 1 eyes had higher baseline K1 ( p =0.026), K2 ( p =0.006), Km ( p =0.01), and Kmax ( p =0.002) compared to group 2 eyes. Amongst the 49 naïve fellow eyes (group 2), 19 eyes showed evidence of progression. Progressing naïve eyes had higher baseline K1, K2, Km, and Kmax ( p < 0.01); progressors also had thinner pachymetry at the pupil, apex, and thinnest point ( p < 0.01). Baseline values of K1 ≥ 43.5 Diopter (D), K2 > 45.1D, Km > 44.3D, K max  > 47.9D, astigmatism > 1.4D, pachymetry at the pupil <475  μ m, and thinnest pachymetry <478  μ m were tentative predictors of progression in the naïve fellow eye., Conclusions: Unilateral CXL with vigilant follow up of the fellow eye may be an acceptable management strategy in a subset of KC eyes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Gavin Li et al.)

Purpose: The purpose of this study was to assess visual and health-related quality of life (QOL) among U.S. military service members who sustained combat ocular trauma (COT) with or without associated traumatic brain injury (TBI)., Methods: This was a single-center, prospective observational study of U.S. service members (n = 88) with COT who were treated at Walter Reed National Military Medical Center. Participants completed the National Eye Institute Visual Function Questionnaire (VFQ-25) at enrollment and at follow-up (>1 year) and supplemental surveys: Neurobehavioral Symptom Inventory, the Medical Outcomes 36-item Short Form Survey (SF-36), and Mayo-Portland Adaptability Inventory., Results: Initial and follow-up VFQ-25 showed a statistically significant increase in median scores for near activities (initial: 75.0, follow-up 83.3; P = .004) and peripheral vision (initial: 50.0, follow-up: 75.0; P = .009) and in composite scores (initial: 79.5, follow-up: 79.8; P = .022). Comparing those who did (n = 78) and did not (n = 8) have a TBI history, there were no significant differences in median change in VFQ-25 composite scores (with TBI: 2.3 vs. no TBI: 10.7; P = .179). Participants with a TBI history had a significantly lower median SF-36 General Health score (with TBI: 67.5 vs. no TBI: 92.5; P = .009)., Conclusions: Vision-related QOL of COT patients is generally good in the long term. However, those with both COT and a history of TBI conditions showed significantly worse functioning in several domains than those without TBI. As TBI is a common finding in COT, this association is an important factor impacting this population's overall clinical presentation and daily functions., (© The Association of Military Surgeons of the United States 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: To identify global gene expression changes in the corneal epithelium of keratoconus (KC) patients compared to non-KC myopic controls., Methods: RNA-sequencing was performed on corneal epithelium samples of five progressive KC and five myopic control patients. Selected results were validated using TaqMan quantitative PCR (qPCR) on 31 additional independent samples, and protein level validation was conducted using western blot analysis on a subset. Immunohistochemistry was performed on tissue microarrays containing cores from over 100 KC and control cases. WNT10A transcript levels in corneal epithelium were correlated with tomographic indicators of KC disease severity in 15 eyes. Additionally, WNT10A was overexpressed in vitro in immortalized corneal epithelial cells., Results: WNT10A was found to be underexpressed in KC epithelium at the transcript (ratio KC/control = 0.59, P = 0.02 per RNA-sequencing study; ratio = 0.66, P = 0.03 per qPCR) and protein (ratio = 0.07, P = 0.06) levels. Immunohistochemical analysis also indicated WNT10A protein was decreased in Bowman's layer of KC patients. In contrast, WNT10A transcript level positively correlated with increased keratometry (Kmax ρ = 0.57, P = 0.02). Finally, WNT10A positively regulated COL1A1 expression in corneal epithelial cells., Conclusions: A specific Wnt ligand, WNT10A, is reduced at the mRNA and protein level in KC epithelium and Bowman's layer. This ligand positively regulates collagen type I expression in corneal epithelial cells. The results suggest that WNT10A expression in the corneal epithelium may play a role in progressive KC.

Introduction: The purpose of this non-comparative, prospective, observational study was to evaluate the post-US Food and Drug Administration approval outcomes of epithelium-off, full-fluence, Dresden protocol corneal collagen crosslinking (CXL) for the treatment of progressive keratoconus (KCN) and post-refractive corneal ectasia at a US academic tertiary medical center., Methods: This study involved 125 eyes of 97 patients with KCN and 13 eyes of 12 patients with post-refractive ectasia which underwent CXL between November 2016 and September 2019. Best spectacle-corrected visual acuity (BSCVA) and corneal topographic parameters were measured preoperatively, at postoperative month 1 (POM-1), and between postoperative months 3 and 24 (POM 3-24)., Results: Best spectacle-corrected visual acuity, flat keratometry, steep keratometry, and mean corneal power worsened at POM-1 (p < 0.01) with a return to preoperative values at POM 3-24. Maximum keratometry (Kmax) steepened at POM-1 and then improved beyond preoperative levels at POM 3-24 (p < 0.01 and p = 0.03, respectively). Pachymetry at the apex and pupil decreased at POM-1 and POM 3-24 (p = 0.03). Pachymetry at the thinnest point decreased at POM-1 and trended toward reduction at POM 3-24 (p < 0.001 and p = 0.06, respectively). Visual and tomographic outcomes were similar between pediatric and adult populations, and between KCN and post-refractive ectasia patients., Conclusions: Real-world results of CXL in the USA are similar to those reported in prior studies, demonstrating an initial worsening of BSCVA, pachymetry, and keratometry followed by corneal flattening and preservation of visual acuity. Improvements in Kmax and stability in visual acuity were observed over 24 months in children and adults with progressive KCN or post-refractive ectasia.

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.]., (Copyright 2020, SLACK Incorporated.)

A 24-year-old man was involved in a high-velocity motor vehicle accident with polytrauma 2 years after implantation of a copolymer phakic IOL (pIOL) (Visian ICL). After being released from the intensive care unit, he reported decreased vision, pain, glare, and photophobia and was treated for hyphema without globe rupture. He was found to be aniridic during anterior chamber washout of the hyphema. In the first reported case, to our knowledge, of aniridia after pIOL placement, blunt trauma likely caused expulsion of the iris through dehiscence of the previously placed wound for pIOL implantation., (Published by Elsevier Inc.)

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.]., (Copyright 2018, SLACK Incorporated.)

Objectives: To describe the visual outlook and quality of life of service members after combat ocular trauma., Methods: In a single-center, prospective observational study of service members sustaining ocular trauma, participants underwent a series of ocular examinations and noninvasive tests, including the National Eye Institute Visual Functioning Questionnaire (VFQ-25)., Results: Of the 165 enrolled participants, 137 completed the VFQ-25. The mean VFQ-25 composite score was 74.4 ± 20.7 (range: 1.4-100). Among 118 participants with visual acuity assessment, 92% had best corrected visual acuity (BCVA) of 20/20 or better in at least one eye. Among participants with severe vision loss (BCVA ≤20/200), there was no statistically significant difference in self-reported general health compared to those without severe vision loss (p = 0.17). However, there was a significantly lower visual quality of life reported in the composite score and all of the 11 subscales of the VFQ-25., Conclusions: While this study provides evidence that combat ocular trauma is associated with a lower visual quality of life, limitations include the relatively small sample size and the limited documentation of the use of eye protection at time of injury among participants., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)

Objectives: 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., Methods: 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., Results: 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., Conclusions: 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., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)

Purpose: To compare visual performance, marksmanship performance, and threshold target identification following wavefront-guided (WFG) versus wavefront-optimized (WFO) photorefractive keratectomy (PRK)., Methods: 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., Results: 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., Conclusions: Both WFG and WFO PRK results translate to excellent and comparable visual and military performance., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)

Purpose: 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., Setting: The former Walter Reed Army Medical Center, Washington, DC, USA., Design: Prospective nonrandomized clinical study., Methods: 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., Results: 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)., Conclusions: 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., Financial Disclosure: None of the authors has a financial or proprietary interest in any material or method mentioned., (Copyright © 2016 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

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., (Published by Elsevier Inc.)

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 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., (Copyright © 2015 ASCRS and ESCRS. All rights reserved.)

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 < .006). The change in coma, trefoil, spherical aberration, and total HOAs (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., (Copyright © 2015 ASCRS and ESCRS. All rights reserved.)

Corneal dystrophies are a rare group of hereditary disorders, that are bilateral, non-inflammatory, and progressive. Clinically, they can be classified based on the anatomic layer of the cornea affected. Refractive surgery and phototherapeutic keratectomy (PTK) can be performed with caution in patients with certain corneal dystrophies, but should be avoided in others. For epithelial basement membrane dystrophy, photorefractive keratectomy (PRK) is the procedure of choice for treatment of refractive error, and PTK may be performed for the treatment of recurrent erosions or irregular astigmatism. PRK and laser-assisted in situ keratomileusis (LASIK) have been associated with exacerbation of combined granular-lattice corneal dystrophy. LASIK and PRK appear to be safe in mild forms of posterior polymorphous corneal dystrophy, whereas LASIK should be avoided in Fuchs dystrophy. The safety of refractive surgery and PTK in the remainder of epithelial, Bowman layer, and stromal dystrophies has yet to be established., (Copyright © 2015 Elsevier Inc. All rights reserved.)

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., (Copyright © 2014 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: Laser refractive surgery (LRS) is one of the most common elective procedures performed in the USA today. Patients should be rigorously screened for certain ocular and systemic conditions, which may represent contraindications to LRS. Before treating, the refractive surgeon should be aware of the Food and Drug Administration (FDA) labeling for the procedure as well as what other evidence, such as clinical studies, case series, cases reports, and anecdotal evidence, exists. The purpose of this article is to review contraindications to having LRS., Recent Findings: Ocular contraindications to LRS include unstable refractive error, corneal ectatic disorders, a history of herpetic keratitis, Avellino corneal dystrophy, significant cataract, and uncontrolled glaucoma. LRS should also be avoided in uncontrolled diabetes, collagen vascular disease (CVD), pregnancy, and in patients taking amiodarone and isotretinoin., Summary: Current contraindicatisons to LRS are based on FDA labeling and guidelines from the American Academy of Ophthalmology. Much of the evidence is based on case reports or series, anecdotal evidence, or known complications from nonlaser ocular surgery. More randomized clinical trials are needed to establish the safety of LRS in controversial conditions such as well controlled CVD.

This study was performed to evaluate the potential of a chondroitin sulfate-polyethylene glycol (CS-PEG) adhesive and collagen-based membrane (collagen vitrigel, CV) combination as a method to treat penetrating ocular injuries on the battlefield and to improve this method with two technologies: an antibiotic releasing CS-PEG adhesive and a corneal shaped CV. Burst testing using porcine cadaveric eyes, high-performance liquid chromatography, the Kirby-Bauer bacterial inhibition test, and CV implantations on the live and cadaveric rabbit eyes were performed. The ocular burst test showed CS-PEG adhesive could successfully repair 5-mm to 6-mm length wounds in the corneal and corneoscleral regions but would require CS-PEG + CV to treat larger wounds similar to those seen on the battlefield. In addition, high performance liquid chromatography and the Kirby-Bauer bacterial inhibition test presented evidence suggesting the vancomycin incorporated CS-PEG could inhibit Staphylococcus infection for 9 days. Furthermore, the curved CV showed an advantage by matching the corneal contour without any wrinkle formation. Although this pilot study showed a limited range of possible applications, we demonstrated that the combination of CS-PEG adhesive + CV is a promising method and the 2 technologies improve their applicability to the special demands of the battlefield., (Reprint & Copyright © 2014 Association of Military Surgeons of the U.S.)

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., (Copyright 2014, SLACK Incorporated.)

To assess the feasibility of using the Robotic Slave Micromanipulator Unit (RSMU) to remotely photocoagulate the ciliary body for the treatment of glaucoma with the diode laser. In fresh unoperated enucleated human eyes, the ciliary body was destroyed either with a standard contact transscleral cyclophotocoagulation 'by hand' diode laser technique, or remotely using the RSMU. The treated sections were fixed in formalin, paraffin-embedded, and stained with hematoxylin and eosin. Histological evaluation was performed by a masked observer using a standardized grading system based on the amount of damage to the ciliary body to evaluate effectiveness of treatment. Both methods of contact transscleral cyclophotocoagulation showed therapeutic tissue disruption of the ciliary processes and both the non-pigmented and pigmented ciliary epithelium. Histology examination of remote robotic contact transscleral cyclophotocoagulation and "by hand" technique produced similar degrees of ciliary body tissue disruption. Remote diode laser contact transscleral cyclophotocoagulation of the ciliary body in fresh enucleated human eyes is possible with the RSMU. Therapeutic tissue disruption of the ciliary body was achieved. Additional study is necessary to determine the safety and efficacy of robotically-delivered cyclophotocoagulation in live eyes.

Patients with underlying systemic disease represent challenging treatment dilemma to the refractive surgeon. The refractive error in this patient population is accompanied by a systemic disease that may have an ocular or even a corneal component. The literature is rather sparse about the use of laser refractive surgery (LRS) and such procedure is not approved by the United States Food and Drug Administration (FDA) in this patient population. Patients with collagen vascular disease, diabetes mellitus (DM), allergic and atopic disease, or human immunodeficiency virus (HIV) are never ideal for LRS. Patients with uncontrolled systemic disease or ocular involvement of the disease should not undergo LRS. However, a patient with well-controlled and mild disease, no ocular involvement, and not on multidrug regimen may be a suitable candidate if they meet stringent criteria. There is a need for a large, multicenter, controlled trial to address the safety and efficacy of LRS in patients with systemic disease before such technology can be widely adopted by the refractive surgery community.

Photorefractive keratectomy (PRK) is a refractive procedure gaining popularity that eliminates the risk of ectasia and flap complications that can occur after laser in situ keratomileusis. Post-operative discomfort is a major drawback after PRK and thus the management of pain and discomfort following PRK is of great importance. We summarize corneal pain pathways and summarize current approaches to pain management after PRK., (Copyright © 2013 Elsevier Inc. All rights reserved.)

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 time In vivo observation of the cornea facilitating injury characterization, progression, and management.

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 < .001 and 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., (Copyright © 2012 Elsevier Inc. All rights reserved.)

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., (Copyright © 2012. Published by Elsevier Inc.)

The serotonin type 3A (5-HT(3)A) receptor is a Cys-loop (pentameric) neurotransmitter-gated ion channel found in the central and peripheral nervous systems and implicated in numerous diseases. In previous studies with the endogenous agonist serotonin, we identified two interactions critical for receptor function: a cation-π interaction with W183 in loop B (TrpB) and a hydrogen bond to E129 in loop A. Here we employ mutant cycle analyses utilizing conventional and unnatural amino acid mutagenesis to demonstrate that a third residue, D124 of loop A, forms two functionally important hydrogen bonds to the backbone of loop B. We also show that these three interactions, the cation-π interaction, the backbone hydrogen bonds, and the E129 hydrogen bond, are tightly coupled to each other, suggesting they function as a single unit. We also identify key functional differences between serotonin and the competitive partial agonist m-chlorophenyl biguanide (mCPBG) at these residues. mCPBG displays no cation-π at TrpB and extreme sensitivity to the positioning of E129, on which it is reliant for initiation of channel gating.

Purpose: Several small proteomic studies suggest that the prosecretory tear protein lacritin may be selectively downregulated in dry eye syndrome and in blepharitis, yet little information is available about normal baseline levels. This study assessed lacritin levels in tears from healthy individuals and addressed whether they differ according to sex, age, or time of day., Methods: Rabbit antibodies against lacritin N-terminal peptide EDASSDSTGADPAQEAGTS (Pep Lac N-Term) were generated and characterized against human recombinant lacritin and N-65 truncation mutant. Basal tears were collected from 66 healthy individuals ranging in age from 18 to 52 years, and at four times during one 24-hour period from 34 other individuals. Lacritin levels were then analyzed by ELISA and Western blotting., Results: Anti-Pep Lac N-Term bound lacritin, but not truncation mutant N-65 that lacks the N-terminal antigenic site. Tear lacritin levels followed a normal distribution with a mean of 4.2 ± 1.17 ng/100 ng total tear protein. Levels differed little by age or sex, and decreased slightly between 4 and 8 hours in a 24-hour cycle. Tear-blocking effects were minimal, as suggested by spiking of tears with recombinant lacritin., Conclusions: Anti-Pep Lac N-Term-detectable lacritin comprises ~4.2 ng/100 ng total tear protein in healthy individuals, with no significant differences between males and females or among individuals between 18 and 52 years old. Levels decrease slightly in the late afternoon. These findings provide a baseline for future immunodiagnostic studies of lacritin in dry eye and other ocular diseases.

Purpose: To present a case of unilateral hypopyon uveitis that began 15 days after uneventful bilateral LASIK in a 24-year-old man with an undisclosed history of ulcerative colitis., Methods: Case report., Results: The hypopyon uveitis completely resolved after treatment with aggressive topical and oral steroid agents in combination with topical antibiotic coverage., Conclusions: Although rare, visually significant hypopyon uveitis may arise after LASIK in the setting of ulcerative colitis and positive human leukocyte antigen (HLA) B27. Early recognition and treatment can result in an excellent outcome. The exact relationship between hypopyon uveitis and LASIK is impossible to ascertain., (Copyright 2012, SLACK Incorporated.)

Background and Objective: A smooth corneal surface prior to laser ablation is important in order to achieve a favorable refractive outcome. In this study, we compare PRK outcomes following two commonly used methods of epithelial debridement: Amoils epithelial scrubber (brush) versus 20% ethanol (alcohol)., Study Design/patients and Methods: We reviewed records of patients who underwent wavefront-optimized PRK for myopia or myopic astigmatism between January 2008 and June 2010. Two treatment groups (brush vs. alcohol) were compared in terms of uncorrected distance visual acuity (UDVA), manifest refraction spherical equivalent (MRSE), corrected distance visual acuity (CDVA), and complications at postoperative months 1, 3, 6, and 12., Results: One thousand five hundred ninety-three eyes of 804 patients underwent PRK during the study period: 828 brush-treated eyes and 765 alcohol-treated eyes. At 6 months postoperatively UDVA was ≥20/20 in 94.7% of brush-treated eyes versus 94.4% of alcohol-treated eyes (P = 0.907). At 1 month a higher percentage of brush-treated eyes maintained or gained one or more lines CDVA compared to alcohol-treated eyes (P = 0.007), but there were no other differences in UDVA, MRSE, or CDVA at any point postoperatively. At 1 month 75.4% of brush-treated eyes versus 70.4% of alcohol-treated eyes were free of complications (P = 0.032), and there were fewer brush-treated eyes with corneal haze (4.0% vs. 6.9%, P = 0.012) and dry eye (8.9% vs. 14.4%, P = 0.001). Although corneal haze was slightly more frequent in the alcohol group, most was trace and not significant., Conclusions: Although alcohol-assisted PRK had more minor complications in the early postoperative period, including corneal haze and dry eye, results for both groups beyond 1 month were comparable., (Copyright © 2012 Wiley Periodicals, Inc.)

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<.001), and 12 months (75.9% vs 61.9%, 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., (Copyright 2012, SLACK Incorporated.)

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

Purpose: To describe the United States Army Ocular Teleconsultation program and all consultations received from its inception in July 2004 through December 2009., Design: Retrospective, noncomparative, consecutive case series., Methods: All 301 consecutive ocular teleconsultations received were reviewed. The main outcome measures were differential diagnosis, evacuation recommendations, and origination of consultation. Secondary measures included patient demographics, reason for consultation, and inclusion of clinical images., Results: The average response time was 5 hours and 41 minutes. Most consultations originated from Iraq (58.8%) and Afghanistan (18.6%). Patient care-related requests accounted for 94.7% of consultations; nonphysicians submitted 26.3% of consultations. Most patients (220/285; 77.2%) were United States military personnel; the remainder included local nationals and coalition forces. Children accounted for 23 consultations (8.1%). Anterior segment disease represented the largest grouping of cases (129/285; 45.3%); oculoplastic problems represented nearly one quarter (68/285; 23.9%). Evacuation was recommended in 123 (43.2%) of 285 cases and in 21 (58.3%) of 36 cases associated with trauma. Photographs were included in 38.2%, and use was highest for pediatric and strabismus (83.3%) and oculoplastic (67.6%) consultations. Consultants facilitated evacuation in 87 (70.7%) of 123 consultations where evacuation was recommended and avoided unnecessary evacuations in 28 (17.3%) of 162 consultations., Conclusions: This teleconsultation program has brought valuable tertiary level support to deployed providers, thereby helping to facilitate appropriate and timely referrals, and in some cases avoiding unnecessary evacuation. Advances in remote diagnostic and imaging technology could further enhance consultant support to distant providers and their patients., (Published by Elsevier Inc.)

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<.0005). All measures of IOP changed significantly over time (P<.0005)., 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., (Copyright 2011, SLACK Incorporated.)

Purpose: To evaluate the safety and efficacy of photorefractive keratectomy (PRK) in patients with posterior polymorphous dystrophy (PPMD) with vesicular and band subtypes., Setting: Walter Reed Center for Refractive Surgery, Washington, DC, USA., Design: Case series., Methods: The records of patients with PPMD who had PRK between January 2002 and May 2009 were reviewed. Data for analysis included sex, age, ablation depth, residual stromal bed thickness, manifest spherical equivalent, uncorrected (UDVA) and corrected (CDVA) distance visual acuities, central corneal thickness (CCT), endothelial cell density (ECD), intraocular pressure (IOP), and complications. Preoperative and postoperative results were compared using the Wilcoxon signed-rank test, with P < .05 considered significant., Results: Fourteen eyes of 7 men (mean age 29.1 years ± 9.1 [SD]; range 21 to 42 years) with at least a 6-month follow-up were reviewed. At the final follow-up (mean 19.5 months; range 6.3 to 58.3 months), all eyes had a UDVA of 20/15 and all eyes were within ± 0.50 diopter of emmetropia. The CDVA was unchanged from preoperatively in 71.4% of eyes and improved by 1 line in 28.6%. There were no significant complications. The IOP did not change significantly over the follow-up (P = .272). At the final visit, the mean ECD (2795.3 ± 366.0 cells/mm(2)) was unchanged from baseline (2809.1 ± 338.3 cells/mm(2)) (P = .114)., Conclusions: Photorefractive keratectomy in PPMD patients with vesicular and band subtypes resulted in excellent visual outcomes and a low incidence of adverse effects. Endothelial cell densities did not change significantly in the early postoperative period., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2011. Published by Elsevier Inc.)