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Purpose To determine the improvement in patient adherence to topical ocular hypotensive therapy by introducing a personalized illustrated medication reference chart and telereminder. Design Prospective randomized controlled clinical trial. Participants Fifty-nine patients with glaucoma who were using at least 3 or more eye drops were recruited from the ophthalmology clinic at the National University Hospital of Singapore. Methods Participants were randomized into 3 groups: control, reference chart only, and reference chart with telereminder. They completed a survey on demographics, barriers to glaucoma medication adherence, and self-adherence (measured by the Morisky adherence scale) before and 6 weeks after intervention. Logistic regression analysis was performed on the barriers that contribute to nonadherence and paired t tests were conducted for the preimplementation and postimplementation effects of intervention on adherence score. Main Outcome Measures Changes in mean adherence score based on the Morisky adherence scale before and after intervention in participants from all 3 groups. Results In our study, 71% of participants who were nonadherent to medications had multiple barriers to adherence, with lack of self-efficacy and forgetfulness being the most common factors. Only the reference chart with telereminder group showed a statistically significant increase in mean adherence score, from 7.18 to 7.69 (P = 0.047). Conclusions Adherence to medication in chronic diseases like glaucoma is an important healthcare issue to address. Most of these patients have poor adherence because of multiple factors, and hence interventions aimed at improving adherence should be multifaceted to target these barriers.

Variants of uncertain significance (VUS) are commonly found following genomic sequencing, particularly in ethnically diverse populations that are underrepresented in large population databases. Functional characterization of VUS may assist in variant reclassification, however these studies are not readily available and often rely on research funding and good will. We present four individuals from three families at different stages of their diagnostic trajectory with recurrent acute liver failure (RALF) and biallelic

Background Descemet's stripping endothelial keratoplasty (DSEK) is the most common procedure for corneal transplantation. The effect of a pre-existing glaucoma drainage device on long-term surgical outcomes is uncertain. Methods A retrospective chart review of all DSEK cases at an academic hospital over a 10-year period was conducted. Results 37 eyes who had undergone DSEK were included for analysis. These consist of 12 eyes with pre-existing GDD (GDD group), 13 eyes with glaucoma but no previous GDD (no-GDD group), and a control group of 12 patients with no ocular comorbidities apart from the indication for DSEK (control group). Visual acuity (VA) was significantly improved amongst all 3 groups, and there was no significant difference in VA between the GDD and no-GDD groups. There were no significant differences in absolute or increase in IOP between all three groups at 3 years. Graft survival rates of the 3 groups were not significantly different at 12 months. However, at 36 months, graft survival was 63% in the GDD group compared to 81% in the no-GDD group and 92% in the control group. In the GDD group, an increase in number of preoperative glaucoma drops, and a tube location in the anterior chamber were associated with an increased hazard ratio for failure. Conclusions Presence of a GDD adversely affects graft survival whereas glaucomatous eyes which were medically managed or surgically managed without a GDD had survival rates comparable to controls. Glaucoma-filtering surgeries may confer graft survival advantage over tube shunt surgeries after DSEK.

Purpose To compare the outcome in patients with Fuchs endothelial dystrophy (FED) who underwent standard phacoemulsification vs femtosecond laser–assisted cataract surgery (FLACS) in the treatment of visually significant cataracts. Design Retrospective, comparative, interventional case series. Methods Patient or Study Population : Between April 2013 and December 2016, 140 FED eyes with cataracts of all densities were included. Seventy-two eyes underwent phacoemulsification and 68 eyes underwent FLACS. Intervention or Observation Procedures : Automated noncontact specular microscopy was performed at baseline and postoperatively over a mean of 17.91 ± 10.47 months. Parameters collected include visual acuity, slit-lamp examination findings, and intraoperative findings. Main Outcome Measures : Pachymetry, endothelial cell density (ECD), and coefficient of variance (COV) were compared. Results Phacoemulsification had significantly greater postoperative median loss of ECD of 229.0 cells/mm2 (14.2%) compared to FLACS ECD of 133.0 cells/mm2 (6.5%) (U = 1343.0, Z = -2.241, P = .025). Mean loss of ECD was 346.524 ± 420.472 cells/mm2 and 119.964 ± 434.882 cells/mm2 for phacoemulsification and FLACS, respectively (P = .005). Mean percentage loss of ECD was 15.3% ± 17.5% for phacoemulsification and 4.4% ± 25.0% for FLACS (P = .006). Eyes that underwent phacoemulsification had 10.7% ± 15.4% mean ECD loss in the mild cataract group, and in the moderate/hard cataract group 19.5% ± 18.0%, P = .045. Eyes that underwent FLACS had 0.9% ± 22.5% mean ECD loss in the mild cataract group, and 8.2% ± 26.3% in the moderate/hard cataract group, P = .291. Comparison between procedures of mean ECD loss for moderate/hard cataracts was significant (P = .043). Conclusions FLACS is shown to be superior to phacoemulsification in reducing postoperative endothelial cell loss in FED patients, which translates to a lower risk of corneal decompensation, especially in patients with moderate/hard cataract densities.

Purpose. To identify systemic factors that may influence the response to anti-VEGF therapy in patients with diabetic macular edema (DME). Methods. 35 patients undergoing anti-VEGF injections for centre-involving DME were studied in this prospective observational study. The primary outcome was change in macular thickness one month after treatment, measured using spectral-domain optical coherence tomography (OCT). At baseline, information on various systemic factors was collected including glycosylated hemoglobin (HbA1c), serum VEGF levels, lipid profile and markers of renal function, and blood pressure. Thirty-three of the 35 patients were included in this study. Nonparametric statistical tests were used for the analysis of the data in view of the nonnormal distribution of the outcome variables. Multivariate analysis was performed using logistic regression. Stata 12.1 software was used for the analysis. Main Outcome Measures. Reduction in macular central subfield thickness (on spectral-domain OCT) and change in logMAR visual acuity at one month after injection. Results. Lower HbA1c levels (7% or less) were significantly associated with greater reduction in central macular subfield thickness at one month after injection of bevacizumab or ranibizumab on both univariate analysis (p=0.012) and multivariate analysis (p=0.042). Conclusions. Better glycemic control is associated with a greater reduction in central macular thickness after the first injection of bevacizumab or ranibizumab in diabetic macular edema. Patients with high levels of HbA1c and poor response to anti-VEGF may benefit from strict control of their blood glucose.

To study the effect of intraocular pressure (IOP) on refractive outcomes after deep anterior lamellar keratoplasty (DALK).This retrospective study included eyes which underwent DALK. DALK technique involved either modified Anwar big-bubble if possible or manual anterior lamellar dissection. Our main outcome measures are postoperative IOP and refractive outcomes at postoperative week and months 1, 3, 6, and 12.Fifty-nine eyes of 59 patients were included. DALK was performed for optical (93.2%) and tectonic (6.8%) purposes. 76.3% of the patients had keratoconus. Anwar's big-bubble technique was successful in 30 cases. Linear mixed-model was used to analyze the effect of the highest postoperative IOP measured prior to measurement of postoperative cylinder. Patients with greater maximum postoperative IOP measured had worse postoperative cylinder (Our study shows a positive correlation between postoperative IOP and worse spherical equivalent and cylinder post-DALK, emphasizing the need for good IOP control with IOP-lowering medication(s).

Purpose To investigate the disease patterns of Microbial Keratitis(MK) in patients seen in a tertiary referral hospital, to evaluate the clinical outcomes of MK and the risk factors for poorer visual outcomes. Methods This is a retrospective case series of all culture-positive corneal scrapings between April 2012 and October 2016. A total of 230 patients(n = 230) were included into this study. Patient demographics, clinical information and microbiological characteristics of organisms are collected. Results 64.3% of patients with MK are contact lens(CL) users. Among CL users, there is a preponderance of females(68.9%) and they tend to be younger (27.1 ± 10.6 years). The most frequently isolated organism in this study is Pseudomonas aeruginosa(51.7%) with 69.6% of cases belonging to CL users. MK in non-CL users tend to involve other organisms, such as coagulase-negative Staphylococci, Staphylococcus aureus and Streptococcus pneumoniae. Pseudomonas aeruginosa exhibits good sensitivity rates to ciprofloxacin, levofloxacin and gentamicin. Non-Pseudomonas organisms display similar sensitivities to ciprofloxacin, levofloxacin and gentamicin. MK in non-CL users is related to predisposing factors of prior ocular trauma and concomitant ocular pathology. They tend to have worse visual acuity(VA) on presentation and after treatment compared to CL users. Poorer VA outcome is associated with larger ulcers, increasing age, trauma and non-CL wearers. Successful clinical outcome is achieved in 97.8% of patients, with only 2.2% requiring further surgical intervention. Conclusion CL use alters the disease patterns of MK as well as the underlying microbiological etiology. Fluoroquinolones and aminoglycosides are good empirical antibiotics for MK treatment. Early referral to a tertiary centre will likely allow for earlier treatment, which can result in better VA outcome, especially so in patients who are older, non-CL wearers and have larger ulcers with associated trauma.

Introduction: This study aimed to describe and compare corneal graft survival and optical outcomes following deep anterior lamellar keratoplasty (DALK) and Descemet's stripping automated endothelial keratoplasty (DSAEK) with penetrating keratoplasty (PK), and to document tectonic success of patch grafts. Materials and Methods: This was a retrospective, non-randomised, comparative and descriptive cohort study. A total of 139 eyes that underwent primary keratoplasty between 2000 and 2016 were included, and the following data was extracted: demographics, clinical diagnosis and primary indication, pre- and intraoperative risk factors, postkeratoplasty outcomes, and complications. Optical success was defined as good graft clarity and best corrected visual acuity (BCVA) of 6/12 or better. Graft failure was defined as irreversible corneal oedema and loss of clarity. Tectonic success in patch grafts was defined as tectonic integrity with no repeat tectonic surgical procedure required in the postoperative period. Results: The mean follow-up duration was 3.24 ± 3.47 years in the PK group (n = 16), 1.89 ± 0.86 years in the DALK group (n = 37), 2.36 ± 1.24 years in the DSAEK group (n = 53), and 2.17 ± 1.09 years in the patch graft group (n = 33). The 3-year probabilities of survival for PK, DALK, DSAEK and patch graft were 60.9%, 94.1%, 89.9%, and 67.1%, respectively. The overall percentage of complications was significantly higher for PK (81.3%), compared to DALK (48.6%), DSAEK (49.1%), and patch graft (21.2%). In the PK and DALK groups, 100% achieved BCVA of 6/12 or better, while in the DSAEK group, 96.43% achieved BCVA of 6/12 or better. Conclusion: From a similar study cohort of Asian eyes, graft survival was superior and complications were reduced for DALK and DSAEK compared to PK, but optical outcomes were comparable. Graft survival for patch graft was expectedly lower, but the incidence of complications was low. Key words: Cornea, Keratoplasty, Survival

Peripheral melting disorders require surgical intervention when medical treatment is insufficient and there is continual tissue destruction and the impending risk of perforation. The previous chapter (Chap. 6) discussed the indications and timing of surgical intervention in active peripheral ulcerative keratitis, as well as the principles and concepts of surgery, which is both tectonic and therapeutic. The chapter also dealt with the optically acceptable end-result and also addressed the reduction of ectasia and irregular astigmatism associated with the primary melting condition. Our surgical procedure of choice, which is also aimed at limiting surgery to diseased areas and avoiding unnecessary replacement of healthy adjacent corneal tissue, and endothelial replacement, takes the form of peripheral, lamellar “C”-shaped patch grafts. Peripheral lamellar “C”-shaped grafts can effectively restore tectonic integrity, while maintaining a reasonable corneal contour to enhance visual acuity. This chapter details the exacting and detailed surgical techniques to perform lamellar “C”-shaped patch grafts in peripheral ulcerative keratitis which has failed to respond to conventional medical and adjunctive therapies.

Peripheral Ulcerative Keratitis (PUK) resulting from a myriad of conditions is extremely challenging to manage. Patients have to be co-managed with internal physicians and care has to be individualized. Management aims to firstly establish the diagnosis and underlying cause of the PUK, and to commence both local and systemic therapies when appropriate. The role of the Ophthalmologist is to manage the primary disease, monitor for complications and intervene surgically if necessary. With advancements in surgical techniques and better knowledge of the disease, earlier interventions have a role in curbing the disease process and reducing morbidity. Surgical interventions are not only useful in the active, progressive phase of the disease when conservative measures fail, but also play an important role in visual rehabilitation of the patient. This chapter aims to explore the various available surgical approaches to management of PUK, principles of surgical management and our technique of choice in management of these complex cases. We will illustrate with two case examples, the use of tectonic, C-shaped lamellar corneal grafts, and the appropriate postoperative management of the patient.

PURPOSE Compare the efficacy and safety profile of viscocanalostomy versus trabeculectomy in uncontrolled glaucoma. PATIENTS AND METHODS We looked through various search engines for randomized controlled trials directly comparing viscocanalostomy with trabeculectomy. Outcome measurements we examined were mean intraocular pressure difference at 6 months, 12 months, and 24 months, mean difference in postoperative number of antiglaucomatous medications and relative risk of adverse events. Subgroup analysis looked at studies that included 1 eye per patient, studies that included only white patients, studies with only primary open angle glaucoma, studies that did not allow the use of intraoperative mitomycin C in trabeculectomy treatment, studies that did not allow any postoperative use of antimetabolites, and studies with and without the use of postviscocanalostomy Nd:YAG goniopuncture. RESULTS Ten randomized controlled trials were selected and included in the meta-analysis with a total of 458 eyes of 397 patients with medically uncontrolled glaucoma. At 6 months, mean intraocular pressure difference was 2.25 mm Hg (95% confidence interval 1.38-3.12), at 12 months it was 3.64 mm Hg (2.74, 4.54), whereas at 24 months it was 3.42 mm Hg (1.80, 5.03). Trabeculectomy was found to have a significantly better pressure-lowering outcome (P