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To evaluate the sensitivity and specificity of the ABCD progression display for keratoconus progression.Data was collected from patients that underwent at least two Pentacam assessments 6 months apart. Sensitivity and specificity were calculated for the ABCD progression display. Progression was defined by criterion 1: change in two ABCD parameters above 80% confidence interval (CI) or criterion 2: change in one ABCD parameter above 95%CI. Receiver operating characteristic analysis compared the area under the curve (AUC) of all ABCD parameter combinations.Thirty eyes were evaluated over a median time of 10.3 months. Progression by criterion 1 resulted in a sensitivity of 61.9% and specificity of 88.9%. Progression by criterion 2 resulted in higher sensitivity (80.9%) and specificity (100%). Pairwise comparisons of the ROC curves show that the AUC achieved by criterion 2 was significantly higher than criterion 1 (0.905 vs. 0.754, p = 0.0332). Evaluation of all ABCD combinations with a significant change of 80% or 95% CI did not show superiority over criterion 1 or 2 regarding progression detection. The D parameter had a very low AUC (0.5-0.556).The ABCD progression display can assess keratoconus progression with high sensitivity and specificity, thus assisting the patients' decision-making process. The D parameter did not contribute to the sensitivity or specificity of this classification.

To assess the number of recruits for military service in the Israeli Defense Force (IDF) who underwent refractive surgery prior to enlistment and examine whether the procedure affected their ability to accomplish combat training.Medical records of IDF recruits.Retrospective analysis of medical records of recruits with ametropia who underwent or did not undergo refractive surgery prior to enlistment.Recruits were categorized into ametropes and recruits who underwent refractive surgery. Fitness and assignment to combat units and completion status of combat training were compared between the two groups.The study included 334,688 (182,969 males, 151,719 females) ametropes of which 5231 (4753 males, 478 females) underwent refractive surgery prior to recruitment. Refractive surgery prevalence increased from 9/1000 ametropes in 2005 to 18.5/1000 ametropes in 2018 (r = 0.912, p 0.001); 2643 of the operated recruits (50.5%) had their surgery at the age of 17-18. Dropout rates from combat training were significantly lower in the refractive surgery group during the study period (1.68% vs. 6.14%, respectively, p 0.001). Soldiers in the operated group were more frequently referred to ophthalmologists than those in the ametropes group and less frequently referred to optometrists.The prevalence of refractive surgery in IDF recruits has increased substantially during the last decade with more of them applying to combat units. Refractive surgery opened new possibilities for recruits who were unfit for combat duty prior to surgery and did not appear to impair the chances of successfully completing combat training.

To present the outcomes of attempts to salvage total graft detachment following Descemet's membrane endothelial keratoplasty (DMEK).A search of the electronic medical records of two tertiary medical centers for all patients who underwent DMEK yielded six cases of postoperative total graft detachment (2.54%). Graft salvage was attempted in all cases using repeated intracameral graft staining, unfolding, and reattachment to the stroma under 20% hexafluoride gas.In all cases, a free-floating totally detached graft was identified in the anterior chamber shortly after surgery. Salvage surgery resulted in a central, well-oriented, and fully attached graft. In three cases, the primary graft failed, and in two, the corneas cleared at first but failed after 2 months and 1 year respectively. In one case, the cornea remained clear during 1 year of follow-up but had a very low endothelial cell density.Reattachment of fully detached DMEK graft is technically possible, but graft manipulation during the primary and secondary operations is likely to damage the endothelial cells, resulting in primary or early graft failure. If graft salvage is attempted, the probability of primary or early graft failure should be discussed with the patient, and expectations should be tempered accordingly.ZIEL: Präsentation der Ergebnisse der Rettungsversuche nach vollständiger Transplantatablösung nach Descemet-Membran-Transplantation (Descemetʼs membrane endothelial keratoplasty – DMEK-Methode).Datenbankrecherche des Rabin Medical Center und des Rambam Medical Center in Israel für alle Patienten, die zwischen Januar 2015 und Januar 2020 eine Hornhauttransplantation erhielten, wobei bei 236 Patienten eine DMEK durchgeführt wurde, in 6 Fällen wurde eine vollständige Transplantatablösung beobachtet (2,54%). Die Rettung des Transplantats wurde mit erneuter intrakameraler Transplantatfärbung, -entfaltung und erneuter Anheftung an das Stroma mit 20% Hexafluoridgas versucht.In allen Fällen konnte in der Vorderkammer ein komplett abgelöstes Transplantat kurz nach der Operation gefunden werden. Mit der Revisionsoperation gelang es in allen Fällen, ein zentriertes, richtig orientiertes, total angebrachtes Transplantat wiederherzustellen. In 3 Fällen ist die Hornhaut nach der Revisionsoperation nicht aufgeklart. In 2 Fällen waren die Hornhäute zuerst klar, aber das Transplantat versagte nach 2 Monaten und 1 Jahr. In einem Fall war die Hornhaut 1 Jahr lang klar, hatte dann aber eine sehr niedrige Endothelzelldichte.Das erneute Anbringen eines frei schwimmenden DMEK-Transplantats nach vollständiger Ablösung ist technisch möglich, aber die Manipulation des Transplantats während der primären und sekundären Operation kann die Endothelzellen beschädigen, was zu einem primären oder frühen Versagen des Transplantats führt. Wenn eine Transplantatrettung versucht wird, sollte die Wahrscheinlichkeit eines primären oder frühen Transplantatversagens mit dem Patienten besprochen und seine Erwartungen entsprechend relativiert werden.

Purpose: To examine the clinical outcomes, efficacy, safety, and predictability of transepithelial photorefractive keratectomy (Trans-PRK) operations performed on the day of the first screening visit in comparison with operations scheduled at a following appointment. Methods: Data of consecutive patients with myopia of various degrees, who underwent Trans-PRK, were retrospectively analyzed. Findings were compared between patients who underwent Trans-PRK on the same day of first consultation to patients that underwent surgery at subsequent visits, following initial consultation on a different day. Results: The study included 599 eyes treated on the initial visit day and 1936 eyes treated on a subsequent visit. Mean final spherical equivalent was close to emmetropia in both groups ( p = 0.183). Efficacy indices were 0.928 ± 0.192 in the initial-visit group and 0.945 ± 0.163 in the second-visit group ( p = 0.152). Safety indices were 0.954 ± 0.156 and 0.955 ± 0.151 ( p = 0.707), respectively. No differences between the groups were seen in uncorrected visual acuity (UDVA) of ⩾20/20, ⩾20/25, and ⩾20/32. Only the sub-analysis of patients reaching UDVA of 20/40 or better was slightly lower in the first-visit (95.5%) compared with the second-visit group (97.9%, p = 0.001). Results of attempted correction within ±0.50 D were: 63.3% and 69.0%, respectively ( p = 0.009). Complications profiles in the two groups were comparable. Conclusions: Trans-PRK completed on the day of the first screening appointment demonstrated a similar safety outcome compared with subsequent-visits procedures, and slightly lower, yet comparable, results regarding efficacy and predictability.

The study aimed to examine the effect of cataract extraction on ophthalmologists’ ability to detect pseudoexfoliation (PXF) syndrome. A total of 31 patients admitted for elective cataract surgery were enrolled in this prospective comparative study. Prior to surgery, patients underwent slit-lamp examination and gonioscopy conducted by experienced glaucoma specialists. Subsequently, patients were re-examined by a different glaucoma specialist and comprehensive ophthalmologists. Pre-operatively, 12 patients were diagnosed with PXF on the basis of a Sampaolesi line (100%), anterior capsular deposits (83%), and pupillary ruff deposits (50%). The remaining 19 patients acted as controls. All patients were re-examined 10–46 months post-operatively. Of the 12 patients with PXF, 10 (83%) were correctly diagnosed post-operatively by glaucoma specialists and 8 (66%) by comprehensive ophthalmologists. There was no statistically significant difference in PXF diagnosis. However, detection of anterior capsular deposits (p = 0.02), Sampaolesi lines (p = 0.04), and pupillary ruff deposits (p = 0.01) were significantly lower post-operatively. Diagnosis of PXF is challenging in pseudophakic patients as the anterior capsule is removed during cataract extraction. Therefore, PXF diagnosis in pseudophakic patients relies mainly on the presence of deposits at other anatomical sites, and careful attention to these signs is required. Glaucoma specialists may be more likely than comprehensive ophthalmologists to detect PXF in pseudophakic patients.

Prediction of postoperative refraction following posterior lamellar keratoplasty is crucial for choosing proper intraocular lens power in combined surgeries. Femtosecond laser-assisted Descemet stripping endothelial keratoplasty (FS-DSEK) creates thin, planar grafts while microkeratome-assisted Descemet’s stripping automated endothelial keratoplasty (DSAEK) creates non-planar, concaved grafts. We evaluated whether this fundamental difference affects the refractive outcomes in cataract surgery combined with FS-DSEK compared to cataract surgery combined with microkeratome-assisted DSAEK. A retrospective analysis of 28 patients who underwent FS-DSEK combined with phacoemulsification and intraocular lens (IOL) implantation (group A) compared to 26 patients who underwent microkeratome-assisted DSAEK combined with phacoemulsification and IOL implantation (group B). Pre- and 1-year postoperative best-corrected visual acuity (BCVA), keratometry values, corneal thickness, central-to-peripheral graft thickness ratio (C/P ratio), and target postoperative spherical equivalent (SE) versus actual postoperative SE were analyzed. Target postoperative SE and actual postoperative SE significantly shifted toward hyperopia in group B, but not in group A. Postoperative hyperopic shifts were 0.14 D and 1.13 D in groups A and B, respectively (P

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

Purpose To evaluate whether punching Descemet membrane endothelial keratoplasty (DMEK) corneal grafts onto a contact lens scaffold reduces endothelial cell loss at the graft margin in comparison to punching the graft directly onto the donor stroma. Methods DMEK grafts were prepared using 2 different methods after peeling the graft from the stroma: punching onto a contact lens and punching onto the donor stroma. The grafts were then evaluated for the width of Descemet membrane devoid of endothelial cells in the peripheral ring, measured at 4 points at the graft margin. Results Our study included 6 grafts, harvested from 3 donors aged 66.3 ± 5.1 years. Grafts prepared on a contact lens scaffolding had more of their Descemet membrane margin populated by endothelial cells than did grafts that were punched directly onto the donor stroma (total denuded area: 0.06 ± 0.08 mm vs. 1.17 ± 0.02 mm, P = 0.018; maximal width of denuded area: 59.6 ± 28.4 μm vs. 100.2 ± 59.7 μm, P = 0.07). Donor grafts on contact lens had approximately 2.5% more endothelial cells available for transplantation (2425 cells/mm vs. 2367 cells/mm). Graft preparation time did not significantly differ between the methods (6.4 ± 0.49 vs. 9.8 ± 3.7 minutes, P = 0.46). Conclusions Punching DMEK grafts onto a contact lens reduces endothelial loss at the grafts' margins and may prolong their survival.

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

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

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

To describe the first clinical implantation of the CorNeat™ keratoprosthesis, which utilizes a polymeric scaffold for biointegration within ocular tissue.The CorNeat keratoprosthesis was implanted in the right eye of a patient with bilateral corneal opacification and neovascularization secondary to multiple failed grafts. The following surgical technique was used: 360 degree peritomy; epithelial scraping and corneal marking; pre-placement of three corneo-scleral sutures through the implant; central trephination using a 7 mm trephine and host cornea removal; keratoprosthesis placement and sutures tightening while fitting the corneal edge into the posterior groove of the CorNeat keratoprosthesis; and repositioning of the conjunctiva over the implant skirt and fixation with sutures and Fibrin sealant.Twelve months postoperatively visual acuity improved to 1/16 from hand movement. The keratoprosthesis was properly positioned. Tactile intraocular pressure was assessed as normal. Regional, mostly nasal, conjunctival retraction of 4-5 mm over the nano-fibre skirt was seen throughout follow-up. The anterior chamber was quiet and well-formed. No other postoperative complications were observed.This initial case may imply a potential breakthrough in the treatment of corneal disease not amenable to standard corneal transplant. Long follow-up and additional implantations are desired to prove the long-term safety and efficacy of this device.

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

To compare the biomechanical properties of the unilateral operated corneas in patients who had undergone Descemet membrane endothelial keratoplasty (DMEK) for pseudophakic bullous keratopathy (PBK) with those of the contralateral normal corneas. This was a retrospective cohort study conducted at university hospitals (Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel, and S. Fyodorov Eye Microsurgery State Institution, Moscow, Russia). Forty eyes of 20 patients who underwent DMEK for unilateral PBK 3.5 to 36 months ago and with normal fellow eyes were included in the study. An ocular response analyzer was used to measure the corneal biomechanical properties in the operated and normal fellow eyes. The main outcome measures were corneal hysteresis (CH) and corneal resistance factor (CRF). The mean CH (8.4 ± 1.5 mmHg vs. 8.2 ± 1.5 mmHg, P = 0.707) and the mean CRF (8.7 ± 1.6 mmHg vs. 8.3 ± 1.6 mmHg, P = 0.419) values did not show any statistically significant difference between the operated and the normal fellow eyes. In our study, the corneas that underwent DMEK for PBK showed normal values for biomechanical parameters. These findings support the previous studies that have reported near complete visual, functional, and ultra-structural rehabilitation of the corneas following DMEK.

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

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

The purpose of this study was to evaluate the effect of Descemet membrane endothelial keratoplasty (DMEK) graft storage time on its elastic properties, measured using atomic force microscopy (AFM).Twenty human corneas (from 10 donors), unsuitable for transplantation, were obtained from the eye bank (S. Fyodorov Eye Microsurgery State Institution, Moscow). Ten DMEK grafts were prepared and stored in the corneal storage medium, Optisol-GS at 4°C after preparation, and AFM analysis was performed within 12 hours after preparation (group A). Ten paired corneas from the respective donors were stored in Optisol-GS at 4°C for 1 week after preparation before AFM analysis (group B). Data were analyzed using the Hertz model for the evaluation of the Young modulus of elasticity.Force-distance curve analysis showed an increase in the Young modulus of elasticity in group B in comparison with that in group A, and the mean values were 10.4 ± 1.8 kPa and 6.77 ± 2.25 kPa, respectively (P0.001). There was no correlation between the Young modulus of elasticity and donor age (r = 0.110, P = 0.644), endothelial cell count (r = -0.145, P = 0.541), and procurement interval (r = 0.14, P = 0.755).A longer graft storage time in cold storage medium was found to significantly reduce the elasticity of the DMEK graft. Clinically, this could potentially influence the unfolding of the DMEK graft within the anterior chamber during surgery and the postoperative detachment rate.

To validate the effectiveness of the multi-metric D-index by Pentacam in detecting keratoconus (KC) progression.This was a retrospective study of KC patients at the Rabin Medical Center, Petah Tikva, Israel, during 2016-2018 with at least two corneal tomography examinations six months apart. Agreement between clinical diagnosis of progression (1.5D increase in mean keratometric value, 1D increase in Kmax, a 5% decrease in central corneal thickness (CCT), worsening of visual acuity by more than one line, or deterioration of manifest corneal astigmatism 1.5D) and the D-index was evaluated. Receiver operating characteristic (ROC) analysis was used to find the D-index's optimal cutoff value to show progression.We included KC eyes in the stable group (N = 7) and the progression group (N = 54). Patient demographics and tomographic parameters at baseline were similar between the groups. The D-index change was significantly higher in the progression group than in the stable group (median + 1 and 0.0, respectively, p = 0.024). Based on the ROC analysis, the optimal D-index cutoff change within at least six months was 0.32 (59.3% sensitivity and 100% specificity (area under the curve [AUC] = 0.771, Youden = 0.592). Subjects with a D-index change above this value had a 21.1-fold increase in odds for corneal ectasia progression requiring CXL (OR: 21.1, 95%CI 1.17-398.8, p = 0.038).The multi-metric D-index can serve as a clinically feasible parameter to detect KC progression and guide patients' referral for further interventions.

Purpose: To evaluated Descemet’s membrane endothelial keratoplasty (DMEK) outcomes in young and old graft recipients.Materials and Methods: Data of 164 surgeries with a median age of 76 years (inte...

Purpose: To evaluate the effect of velocity and angle of the intravitreal injection of anti-vascular endothelial growth factors on pain sensation.Methods: Patients were randomly assigned to one of four injection methods: straight and fast, straight and slow, tunneled and fast, and tunneled and slow. Later, they graded their pain sensation on a Visual Analog Scale (range 0-10).Results: The cohort included 180 patients. Mean pain score was 2.81 ± 2.34. There was no statistically significant difference in mean pain score among the four groups (p = .858); between the slow-injection (straight and tunneled) and fast-injection groups (p = .514); and between the straight-injection (fast and slow) and tunneled-injection groups (p = .992), nor other background variables.Conclusion: Velocity and angle of intravitreal injections are unrelated to the pain sensation. Therefore, the method may be left to the clinician's discretion. This implies that the sensation is mostly subjective.

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

Introduction: The purpose of this study was to compare the outcomes of transepithelial photorefractive keratectomy (Trans-PRK) with femtosecond laser assisted in situ keratomileusis (FS-LASIK) for the correction of low to moderate myopia. Methods: A retrospective cohort study design was used. The study group included patients with myopia less than −6.0 D, with or without concomitant astigmatism under 2.0 D, who were treated with FS-LASIK or Trans-PRK in 2013 through 2014. Background, clinical and outcome data were collected from the patient files. A comparison between eyes treated with FS-LASIK or Trans-PRK was performed. Results: The Trans-PRK group was comprised of 1793 eyes and the FS-LASIK group of 666 eyes. Mean ± SD spherical equivalent (SE) refraction prior to surgery was −3.43 ± 1.27 D in the Trans-PRK group and −3.18 ± 1.34 D in the FS-LASIK group ( p Conclusions: Both Trans-PRK and FS-LASIK demonstrated excellent results, mostly comparable with the current literature. FS-LASIK achieved better results than Trans-PRK surgery in the efficacy and safety parameters.

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

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

Prediction of postoperative refraction following posterior lamellar keratoplasty is crucial for choosing proper intraocular lens power in combined surgeries. Femtosecond laser-assisted Descemet stripping endothelial keratoplasty (FS-DSEK) creates thin, planar grafts while microkeratome-assisted Descemet's stripping automated endothelial keratoplasty (DSAEK) creates non-planar, concaved grafts. We evaluated whether this fundamental difference affects the refractive outcomes in cataract surgery combined with FS-DSEK compared to cataract surgery combined with microkeratome-assisted DSAEK.A retrospective analysis of 28 patients who underwent FS-DSEK combined with phacoemulsification and intraocular lens (IOL) implantation (group A) compared to 26 patients who underwent microkeratome-assisted DSAEK combined with phacoemulsification and IOL implantation (group B). Pre- and 1-year postoperative best-corrected visual acuity (BCVA), keratometry values, corneal thickness, central-to-peripheral graft thickness ratio (C/P ratio), and target postoperative spherical equivalent (SE) versus actual postoperative SE were analyzed.Target postoperative SE and actual postoperative SE significantly shifted toward hyperopia in group B, but not in group A. Postoperative hyperopic shifts were 0.14 D and 1.13 D in groups A and B, respectively (P 0.001). BCVA improved after surgery in both groups, with no significant difference between the groups. Postoperative C/P ratio differed significantly between the groups and was negatively correlated with postoperative hyperopic shift (r = - 0.616, P 0.001).Refractive outcomes of cataract surgery combined with FS-DSEK are relatively neutral, whereas those of cataract surgery combined with microkeratome-assisted DSAEK cause significant hyperopic shift. Clinicians should select accordingly an appropriate intraocular lens power when performing these surgeries.

Purpose To evaluate the intraoperative use of ultrasound biomicroscopy (UBM) during Descemet's membrane endothelial keratoplasty (DMEK) to determine graft's orientation. Methods Prospective interventional study of eight eyes of seven patients who underwent DMEK. Following the identification of correct graft orientation using 'Blue cannula tip' sign during DMEK surgery, UBM was used to ascertain graft's orientation. The rate of successful DMEK graft orientation determined by the UBM was registered and verified postoperatively by anterior segment-optical coherence tomography (OCT). Intra- and postoperative complications, postoperative clearance of the cornea, corrected distance visual acuity and endothelial cell loss were also noted. Results The study included five males and two females aged 54-82 years with corneal oedema due to Pseudophakic bullous keratopathy (n = 5), Fuchs' endothelial dystrophy (n = 2). In all cases, the technique allowed proper determination of the graft's orientation. In one case, 'blue cannula tip' sign showed correct orientation while UBM identified an upside-down graft. The graft was inverted in the anterior chamber using fluid jets, and repeat 'blue cannula tip' sign and UBM examination both showed correct orientation. In all cases, postoperative anterior segment-OCT demonstrated correct graft orientation. Conclusions Use of intraoperative UBM to determine graft orientation during DMEK correlated with proper graft orientation, as was verified postoperatively by anterior segment-OCT. The use of UBM can be particularly helpful in cases of poor graft visibility due to opaque corneal stroma, pigment or blood in the anterior chamber during surgery, or when the blue tint of the graft fades rapidly, which may preclude proper determination of graft's orientation.

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

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

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

BACKGROUND In this study, we examined a novel variant of 'big-bubble' deep anterior lamellar keratoplasty using trypan-blue-stained viscoelastic device for the creation of a pre-descemetic bubble. METHODS Ten corneoscleral rims were mounted on an artificial anterior chamber (AC). The AC was filled with air through a limbal paracentesis. A Melles' triangulated spatula was inserted through the paracentesis, with its tip penetrating the AC, was then slightly retracted and pushed into the deep stroma above the roof of the paracentesis. A mixture of trypan blue and viscoelastic device (Healon, Abbott Medical Optics, Abbott Park, Illinois) was injected into this intra-stromal pocket using a 27-G cannula to create a pre-descemetic separation bubble. Bubble type and visualization of dyed viscoelastic device were noted. The method was later employed in three cases. RESULTS In all 10 corneoscleral rims, the technique successfully created a visible pre-descemetic (type 1) bubble that could be expanded up to the predicted diameter of trephination. Subsequent trephination and the removal of corneal stroma were uneventful. In two out of four clinical cases, a type 1 bubble was created, while in two others, visco-dissection failed and dyed viscoelastic was seen in the AC. CONCLUSIONS The presented technique holds promise of being a relatively easy to perform, predictable and well-controlled alternative for achieving a type 1 bubble during deep anterior lamellar keratoplasty surgery. The trypan-blue-stained viscoelastic device facilitates proper visualization and control of the separation bubble and assists in identifying the penetrance to the separation bubble prior to removal of the stromal cap.

Descemet’s membrane endothelial keratoplasty (DMEK) involves removal of the recipient’s Descemet membrane (DM) prior to transplanting the donor’s DM. When using balanced salt solution (BSS) or ophthalmic viscosurgical devices (OVDs), visualization of the host’s DM during its stripping may be inadequate and may result in Descemet remnants and could lead to sub-optimal surgical results. Previous articles described excellent visualization when utilizing air injection but this requires repeated air injection into the anterior chamber (AC). We present a pilot study that compares different techniques under which DM stripping can be performed: with continuous automated air infusion, with manual air infusion, and with BSS. We retrospectively compared video footage of DM stripping with BSS, with continuous air and with manual injection of air into the AC to determine DM stripping duration and the number of times the surgeon had to insert and retrieve a surgical instrument from the AC. Thirty videos of 10 consecutive cases of the three DM stripping techniques were evaluated. DM stripping duration was 3.26 (±1.32), 3.92 (±1.2) and 12.9 (±3.98) minutes for BSS, continuous air flow, and manual air injection, respectively. Frequency of instrument retrieval (FIR) was 3.6 (±1.71), 1.5 (±0.71) and 15.1 (±3.28) for BSS, continuous air flow, and manual air injection, respectively. Continuous air flow and BSS were both statistically different than manual air injection into the AC (p

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

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

To describe the clinical outcomes of using C3F8 as a tamponade agent for the attachment of partially detached Descemet membrane endothelial keratoplasty (DMEK) grafts after failure of previous rebubbling attempts.Interventional case series. We reviewed the medical records of all DMEK surgeries performed at Rabin Medical Center (Petach Tikva, Israel) between January 2016 and December 2018 in which 10% C3F8 tamponade was used for graft reattachments. Patient demographic details, indication for surgery, early postoperative endothelial cell loss, postoperative visual acuity, intraoperative and postoperative complications as well as graft survival were noted.Five patients were included in this case series. Indications for DMEK were pseudophakic bullous keratopathy (n = 3), failed penetrating graft (n = 1), and Fuchs endothelial dystrophy (n = 1). In 4 of 5 cases, SF6 tamponade was used at the end of the initial DMEK surgery. In 1 case, air tamponade was used. In all cases, partial graft detachment was seen 1 to 2 weeks postoperatively, and anterior chamber rebubbling was performed using 20% SF6 gas. A second C3F8-assisted rebubbling was performed 10 to 70 days after the primary DMEK surgery. In all cases, complete graft attachment was achieved, and the corneas cleared. Early endothelial cell loss rates averaged at 44% ± 26% (range 20%-74%). One case which had a previous trabeculectomy with chronic preoperative and postoperative hypotony had failed 6 months after surgery. All the other grafts were clear at last visit.Tamponade using nonexpansile 10% C3F8 gas can attach partially detached DMEK grafts after the failure of previous air- or SF6-assisted rebubbling attempts.

Previous studies demonstrated the potential pathogenic relationship between infestation of the eyelashes by the parasite Demodex and chronic blepharitis, whereas other studies did not demonstrate such relations and concluded that Demodex is a normal eyelid flora.This study examines the prevalence of Demodex in patients with blepharitis compared to a healthy control group in Israel, in order to further explore and establish its pathogenic role in cases of chronic blepharitis.A case-control study was conducted including 110 participants: 60 patients with chronic blepharitis attending a tertiary medical center and 50 subjects with no signs of blepharitis. Six to eight eyelashes were epilated from each participant and studied microscopically for the presence of Demodex by a blinded examiner. Fluorescein stain was added to the "clean" samples in order to reduce the false negative results.Demodex were identified on the eyelashes of 44 patients with blepharitis (73.3%) and 20 controls (40%) (p0.001). After adjusting for age, blepharitis was still a significant risk factor for the presence of Demodex (OR=2.96, CI 95% 1.2-7.3).This study supports previous studies demonstrating pathogenic relationship between Demodex infestation of the eyelashes to chronic blepharitis. The authors recommend epilating 6-8 lashes of patients with blepharitis for microscopic identification of these parasites. Fluorescein stain may have a limited role in the recognition of Demodex in parasite free samples.

Purpose To describe the use of 360-degree Scheimpflug imaging as a diagnostic tool for detection and documentation of subtle corneal changes preceding upcoming allograft rejection after Descemet membrane endothelial keratoplasty (DMEK). Methods A total of 17 eyes (16 patients) were diagnosed with clinically manifest allograft rejection 2 to 42 months after DMEK. 360-degree Scheimpflug images of consecutive follow-up examinations (from 3-60 mo) of "asymptomatic" eyes before, during, and after rejection were retrospectively analyzed, to determine which abnormalities could be detected before allograft rejection became clinically manifest. The images were compared with DMEK control eyes (without rejection episode). Results Scheimpflug images at the time of rejection showed keratic precipitates as distinct retrocorneal nodular elevations and/or a significant increase in pachymetry of ≥7%. More subtle changes could be identified retrospectively in 9/17 eyes (53%) on an average at 8 (±5) months before rejection became clinically manifest; in all eyes, these subtle changes were not recognized at routine slit-lamp examinations by various ophthalmologists as inflammatory changes heralding allograft rejection. Secondary graft failure occurred in 4/17 eyes (24%). None of the control eyes showed relevant abnormalities with Scheimpflug imaging. Conclusions By screening the posterior corneal surface with 360-degree Scheimpflug imaging, subtle inflammatory retrocorneal deposits can be detected and recorded during consecutive follow-up visits. Hence, Scheimpflug imaging may have the potential to become a diagnostic tool for early detection of upcoming allograft rejection in asymptomatic DMEK eyes, that is, before the immune response becomes clinically manifest and before substantial endothelial cell damage occurs.

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

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

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

Objective To analyze repeatability and intrasession reproducibility of anterior segment measurements using the newly developed Sirius Scheimpflug system. Methods Three consecutive measurements on 100 eyes of 50 healthy subjects were performed on the same session by the same technician using the Sirius device at the Assuta Optic Laser Center, Tel-Aviv, Israel. For each eye, the following parameters were measured: anterior chamber angle (ACA), anterior chamber volume (ACV), and anterior chamber depth (ACD), thinnest corneal location, keratometry (anterior and posterior), cylinder, and axis. Repeatability was assessed using the coefficient of variation (CV). Intrasession reproducibility was assessed using intraclass correlation coefficient (ICC). Results Coefficient of variation of 2% and less was observed for ACA, ACD, thinnest corneal location, and anterior keratometry. Intraclass correlation coefficients were high for ACA, ACD, anterior keratometry measurements and moderate for anterior cylinder and axis. Higher CV with relatively low ICC values was noticed with ACV, posterior keratometry measurements, and posterior cylinder, and axis. The last 2 have the highest CV and lowest ICC: 48.79% (range: 37.64%-59.95%) and 0.38%, respectively. Conclusions The Sirius Scheimpflug system has a very high repeatability and intrasessional reproducibility when measuring the ACD, ACA, anterior curvature parameters, and the thinnest corneal location. Thus, it can be used with confidence in clinical practice.

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

In this study, we examined a novel variant of 'big-bubble' deep anterior lamellar keratoplasty using trypan-blue-stained viscoelastic device for the creation of a pre-descemetic bubble.Ten corneoscleral rims were mounted on an artificial anterior chamber (AC). The AC was filled with air through a limbal paracentesis. A Melles' triangulated spatula was inserted through the paracentesis, with its tip penetrating the AC, was then slightly retracted and pushed into the deep stroma above the roof of the paracentesis. A mixture of trypan blue and viscoelastic device (Healon, Abbott Medical Optics, Abbott Park, Illinois) was injected into this intra-stromal pocket using a 27-G cannula to create a pre-descemetic separation bubble. Bubble type and visualization of dyed viscoelastic device were noted. The method was later employed in three cases.In all 10 corneoscleral rims, the technique successfully created a visible pre-descemetic (type 1) bubble that could be expanded up to the predicted diameter of trephination. Subsequent trephination and the removal of corneal stroma were uneventful. In two out of four clinical cases, a type 1 bubble was created, while in two others, visco-dissection failed and dyed viscoelastic was seen in the AC.The presented technique holds promise of being a relatively easy to perform, predictable and well-controlled alternative for achieving a type 1 bubble during deep anterior lamellar keratoplasty surgery. The trypan-blue-stained viscoelastic device facilitates proper visualization and control of the separation bubble and assists in identifying the penetrance to the separation bubble prior to removal of the stromal cap.