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There are close to two billion individuals globally living with presbyopia. In spite of its ubiquitous and progressive nature, there is no widely accepted, formal guideline or consensus statement on the classification of presbyopia by degree of severity. A panel of leading eye care professionals representing both optometrists and ophthalmologists convened virtually to discuss and document their combined assessments from the body of literature and clinical practice expertise in this commentary. In light of emerging therapies, classifying presbyopia by mild, moderate, or advanced severity may help provide consistency of diagnosis among eye care providers and may aid in managing patient expectations with different treatment options.

Jay S Pepose,1,2 Paul J Hartman,3 Harvey B DuBiner,4 Marc A Abrams,5 Robert J Smyth-Medina,6 Sayoko E Moroi,7 Alan R Meyer,8 Mina P Sooch,8 Reda M Jaber,8 Konstantinos Charizanis,8 Seth A Klapman,8 Arin T Amin,8 Jonah E Yousif,8 Eliot S Lazar,9 Paul M Karpecki,10 Charles B Slonim,11 Marguerite B McDonald12 1Pepose Vision Institute, St. Louis, MO, USA; 2Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, MO, USA; 3Department of Ophthalmology, University of Rochester, Rochester, NY, USA; 4Clayton Eye Center, Morrow, GA, USA; 5Case Western Reserve University, Cleveland, OH, USA; 6North Valley Eye Medical Group, Mission Hills, CA, USA; 7The Ohio State University Wexner Medical Center, Columbus, OH, USA; 8Ocuphire Pharma Inc, Farmington Hills, MI, USA; 9elCON Medical, Buffalo, NY, USA; 10Kentucky College of Optometry, University of Pikeville, Pikeville, KY, USA; 11Oculos Development Services, LLC, Tampa, FL, USA; 12Department of Ophthalmology, New York University Langone Medical Center, New York, NY, USACorrespondence: Konstantinos CharizanisOcuphire Pharma, Inc., 37000 Grand River Ave, Farmington, MI 48335, USATel +1 (352) 328 9117Email kcharizanis@ocuphire.comPurpose: Phentolamine mesylate ophthalmic solution (PMOS), applied to the eye topically, was shown previously to have beneficial effects in patients with dim light vision disturbances (DLD), including decreased pupil diameter (PD), improved best-corrected distance visual acuity (BCDVA), as well as lower intraocular pressure (IOP). The ORION-1 trial evaluated the long-term safety and efficacy of PMOS in a glaucomatous, presbyopic population.Patients and Methods: In this randomized, double-masked, multi-center, placebo-controlled, multiple-dose Phase 2b trial, 39 patients with elevated IOP were randomized to receive one evening dose of study medication or placebo for 14 days. The primary outcome measure was mean change in diurnal IOP, and the key secondary outcome measures included changes in PD, distance-corrected near visual acuity (DCNVA), and conjunctival hyperemia.Results: Use of 1% PMOS did not lead to a statistically significant decrease in diurnal IOP compared to placebo (P = 0.89) but trended toward a greater decrease in patients with lower IOP baselines. PMOS produced a statistically significant mean 20% PD reduction under both photopic and mesopic conditions that was sustained for 36 hours post-dosing. A statistically significant number of patients with PMOS compared to placebo demonstrated ≥ 1 line of improvement in photopic DCNVA at day 8 (P = 0.0018), day 15 (P = 0.0072), and day 16 (P = 0.0163), with a trend for 2- and 3-line improvements at all time points. There was no statistical difference in conjunctival hyperemia compared to placebo.Conclusion: Although mean IOP was not lowered significantly, daily evening dosing of 1% PMOS was found to be well tolerated with no daytime conjunctival redness and demonstrated improvement in DCNVA with sustained PD reduction in a glaucomatous and presbyopic population. Smaller pupil size can have beneficial effects in improving symptoms of presbyopia and DLD, which will be the focus of further studies.Keywords: IOP, presbyopia, night vision disturbances, dim light vision disturbances, pupil diameter, ORION-1

The purpose of this article is to review the current status of presbyopia amelioration with surgical and pharmacologic procedures that partially compensate for loss of accommodation in advance of cataract surgery and lens replacement. Over the last few years, several corneal surgical and topical pharmacological approaches for the treatment of presbyopia have been introduced to the marketplace or are in the developmental pipeline. The approaches vary in invasiveness, duration of effect, reversibility, risk/benefit ratio, and clinical results. The advantages and disadvantages for each are discussed. Corneal surgical interventions aim to provide improved near and intermediate vision in patients with presbyopia through refractive means that extend ocular depth of focus through shape modification. The use of miotic drops or corneal lamellar implants extend depth of focus with the “pinhole” aperture size reduction effect. Unlike in adults younger than 40 years, the refractive status of the patient with presbyopia is not stable. Hence, procedures that provide a permanent refractive change may not provide long-term full correction; eye drops or other treatments that are self-reversing in time or are easily reversible may be used as needed. On the horizon, procedures are being explored that may add years of functional lens accommodation by preserving the deformable gel properties of the lens. [ J Refract Surg . 2021;37(6 Suppl):S20–S27.]

Dry eye disease (DED) is a multifactorial disorder of the ocular surface and tear homeostasis that can result in discomfort, pain, and visual disturbance. Untreated, DED can become chronic, progressive, and significantly affect an individual's quality of life. Women are disproportionately affected by DED, are diagnosed at a younger age, and experience more severe symptoms compared with men. DED is associated with a wide range of comorbid conditions; there is a strong association between DED and autoimmune disorders, especially those that affect women at many times the rate of men. Treatment response questionnaires indicate women respond better to a wellness model of treatment for DED than men. Furthermore, women's health care-seeking behaviors provide opportunities for general practitioners, specialists, and women's health centers to help identify women with DED or at risk for DED for referral to an eye care specialist. This review of the prevalence of DED in women, and gender and sex-specific aspects of DED, highlight a significant opportunity for action. Earlier diagnosis and treatment of this common but burdensome condition could significantly improve a woman's quality of life.

SIGNIFICANCE After a dilated eye examination, many patients experience symptoms of prolonged light sensitivity, blurred vision, and cycloplegia associated with pharmacological mydriasis. Phentolamine mesylate ophthalmic solution (PMOS) may expedite the reversal of mydriasis in patients, potentially facilitating return to functional vision and reducing barriers to obtaining dilated eye examinations. PURPOSE The protracted reversal time after pharmacologically induced pupil dilation impairs vision. We tested the hypothesis that PMOS rapidly reduces pupil diameter in this acute indication. METHODS In this double-masked placebo-controlled, randomized, two-arm crossover phase 2b trial, we evaluated the effects of one drop of 1% PMOS applied bilaterally in subjects who had their pupils dilated by one of two common mydriatic agents: 2.5% phenylephrine or 1% tropicamide. End points included change in pupil diameter, percent of subjects returning to baseline pupil diameter, and accommodative function at multiple time points. RESULTS Thirty-one subjects completed the study (15 dilated with phenylephrine and 16 with tropicamide). Change in pupil diameter from baseline at 2 hours after maximal dilation with 1% PMOS was -1.69 mm and was significantly greater in magnitude compared with placebo for every time point beyond 30 minutes (P < .05). At 2 hours, a greater percentage of study eyes given 1% PMOS returned to baseline pupil diameter compared with placebo (29 vs. 13%, P = .03), which was this also seen at 4 hours (P < .001). More subjects treated with PMOS in the tropicamide subgroup had at least one eye returning to baseline accommodative amplitude at 2 hours (63 vs. 38%, P = .01). There were no severe adverse events, with only mild to moderate conjunctival hyperemia that resolved in most patients by 6 hours. CONCLUSIONS Phentolamine mesylate ophthalmic solution at 1% reversed medically induced pupil dilation more rapidly than placebo treatment regardless of which mydriatic was used (adrenergic agonists and cholinergic blockers) with a tolerable safety profile.

This paper evaluated topography-guided excimer ablations and recent US experience of this technology. Personal clinical experience, initial approval of the technique, and its application to a potential extended spectrum of clinical conditions was reviewed. Topography-guided ablation can precisely treat corneas with variable topographic indices and attempt to neutralize irregularities by combining myopic and hyperopic ablation profiles. The T-CAT Phase III study demonstrated the safety and efficacy of this technique, which earned FDA approval in 2013. Current literature has reinforced its efficacy and explored off-label investigations, such as its use to improve visual results in abnormal corneas (e.g., keratoconus, post-LASIK ectasia). Topography-guided ablation provides increased quality of vision without necessitating excess tissue removal in otherwise normal, keratoconic, ectatic, or post-corneal transplant eyes. In the future, we will likely see a combination of treatment strategies, enabling ophthalmologists to treat the entire refractive surface and refine these already remarkable results.

Dysfunctional tear syndrome (DTS) is a common and complex condition affecting the ocular surface. The health and normal functioning of the ocular surface is dependent on a stable and sufficient tear film. Clinician awareness of conditions affecting the ocular surface has increased in recent years because of expanded research and the publication of diagnosis and treatment guidelines pertaining to disorders resulting in DTS, including the Delphi panel treatment recommendations for DTS (2006), the International Dry Eye Workshop (DEWS) (2007), the Meibomian Gland Dysfunction (MGD) Workshop (2011), and the updated Preferred Practice Pattern guidelines from the American Academy of Ophthalmology pertaining to dry eye and blepharitis (2013). Since the publication of the existing guidelines, new diagnostic techniques and treatment options that provide an opportunity for better management of patients have become available. Clinicians are now able to access a wealth of information that can help them obtain a differential diagnosis and treatment approach for patients presenting with DTS. This review provides a practical and directed approach to the diagnosis and treatment of patients with DTS, emphasizing treatment that is tailored to the specific disease subtype as well as the severity of the condition.

Dry eye disease (DED) is a chronic and progressive multifactorial disorder of the tears and ocular surface, which results in symptoms of discomfort and visual disturbance. The aim of this systematic literature review was to evaluate the burden of DED and its components from an economic and health-related quality of life (HRQoL) perspective, and to compare the evidence across France, Germany, Italy, Spain, UK, USA, Japan, and China. PubMed, Embase, and six other resources were searched for literature published from January 1998 to July 2013. Of 76 titles/abstracts reviewed on the economic burden of DED and 263 on the HRQoL burden, 12 and 20 articles, respectively, were included in the review. The available literature suggests that DED has a substantial economic burden, with indirect costs making up the largest proportion of the overall cost due to a substantial loss of work productivity. In addition, DED has a substantial negative impact on physical, and potentially psychological, function and HRQoL across the countries examined. A number of studies also indicated that HRQoL burden increases with the severity of disease. Additional data are needed, particularly in Asia, in order to gain a better understanding of the burden of DED and help inform future health care resource utilization.

Marguerite B McDonald,1 Hosam Sheha,2–5 Sean Tighe,2,3 Susan B Janik,6 Frank W Bowden,7 Amit R Chokshi,8 Michael A Singer,9 Seema Nanda,10 Mujtaba A Qazi,11 Damon Dierker,12 Adam T Shupe,13 Brittany J McMurren14 1Ophthalmic Consultants of Long Island, Lynbrook, NY, USA; 2Ocular Surface Center and TissueTech, Inc., Miami, FL, USA; 3Florida International University Herbert Wertheim College of Medicine, Miami, FL, USA; 4Hofstra University School of Medicine, Hempstead, NY, USA; 5Research Institute of Ophthalmology, Cairo, Egypt; 6Solinsky Eye Care, Kensington, CT, USA; 7Bowden Eye & Associates, Jacksonville, FL, USA; 8Florida Eye Specialists, Jacksonville, FL, USA; 9Medical Center Ophthalmology Associates, San Antonio, TX, USA; 10TX Eye Institute, Houston, TX, USA; 11Pepose Vision Institute, Chesterfield, MO, USA; 12Eye Surgeons of Indiana, Indianapolis, IN, USA; 13Royo Eye Care, Marysville, CA, USA; 14Gordon and Weiss Vision Institute, San Diego, CA, USA Purpose: To evaluate the efficacy of cryopreserved amniotic membrane (CAM) in reducing signs and symptoms of dry eye disease (DED) in a large patient population. Methods: A retrospective chart review at 10 clinical sites was done of patients with refractory DED who received CAM and completed at least 3 months of follow-up. Data collected were demographics; medical history including previous and current ocular treatment, diagnosis, clinical presentations, comorbidity, duration and frequency of treatment with CAM; and concomitant medications. The primary outcome was the change in dry eye workshop (DEWS) score after treatment. Results: A total of 97 eyes of 84 patients exhibited severe dry eye despite maximal medical treatments including topical artificial tears, cyclosporine-A, serum, antibiotics, and steroids. Patients manifested with superficial punctate keratitis (86%), filamentary keratitis (13%), exposure keratitis (19%), neurotrophic keratitis (2%), and corneal epithelial defect (7%). After CAM treatment for 5.4±2.8 days, 74 (88%) patients demonstrated an improved ocular surface along with a notable reduction of the severity as the overall DEWS score was significantly reduced from 3.25±0.5 at baseline to 1.44±0.6 at 1 week, 1.45±0.6 at 1 month, and 1.47±0.6 at 3 months (p

PURPOSE: To explore the use of microperimetry in the evaluation of macular dysfunction in patients with cataract, to aid in proper intraocular lens selection (multifocal vs monofocal), and to set expectations for postoperative visual function. METHODS: One randomly chosen eye of 10 patients diagnosed as having mild (1+) to moderate (3+) cataract was evaluated before and 1 week after cataract surgery with the MAIA microperimeter (Centervue S.p.A, Padova, Italy). Corrected distance visual acuity, dilated and undilated biomicroscopy and indirect fundus examinations, intraocular pressure measurement, and a MAIA microperimeter test to measure macular sensitivity and fixation pattern were also performed. RESULTS: Two patients showed macular abnormalities before and after surgery that were noted on MAIA testing: one patient showed reduced average threshold sensitivity and abnormal percent reduced threshold, whereas the other patient showed fixation drift demonstrating eccentric fixation. Both eyes had reduced postoperative visual performance after uneventful cataract surgeries. CONCLUSIONS: Because not every macular lesion noted on fundus examination or optical coherence tomography may be clinically significant, microperimetry can be useful to detect clinically significant retinal dysfunction prior to cataract surgery. The outcome may aid in the selection of intraocular lens type and may yield a better documented surgical prognosis. Further studies are necessary to confirm these findings. [ J Refract Surg. 2015;31(10):690–696.]

William B Trattler,1 Parag A Majmudar,2 Eric D Donnenfeld,3 Marguerite B McDonald,4 Karl G Stonecipher,5 Damien F Goldberg6 On behalf of the PHACO Study Group 1Center for Excellence in Eye Care, Miami, FL, USA; 2Chicago Cornea Consultants, Chicago, IL, USA; 3Ophthalmic Consultants of Long Island, Garden City, NY, USA; 4Ophthalmic Consultants of Long Island, Lynbrook, NY, USA; 5University North Carolina School of Medicine, Chapel Hill, NC, USA; 6Wolstan & Goldberg Eye Associates, Torrance, CA, USA Purpose: To determine the incidence and severity of dry eye as determined by the International Task Force (ITF) scale in patients being screened for cataract surgery.Patients and methods: This was a prospective, multi-center, observational study of 136patients, at least 55 years of age, who were scheduled to undergo cataract surgery. The primary outcome measure was the incidence of dry eye as evaluated by grade on the ITF scale and secondary outcome measures include tear break-up time (TBUT), ocular surface disease index score, corneal staining with fluorescein, conjunctival staining with lissamine green, and a patient questionnaire to evaluate symptoms of dry eye.Results: Mean patient age was 70.7 years. A total of 73.5% of patients were Caucasian and 50% were female. Almost 60% had never complained of a foreign body sensation; only 13% complained of a foreign body sensation half or most of the time. The majority of patients (62.9%) had a TBUT ≤5 seconds, 77% of eyes had positive corneal staining and 50% of the eyes had positive central corneal staining. Eighteen percent had Schirmer’s score with anesthesia ≤5 mm.Conclusion: The incidence of dry eye in patients scheduled to undergo cataract surgery in a real-world setting is higher than anticipated. Keywords: cataract surgery screening, dry eye, International Task Force scale, observational study

The Gundersen’s conjunctival flap involves the transposition of conjunctiva over a deepithelialized cornea. Patients with refractory infectious ulcerations, ocular surface disorders with persistent epithelial defect, neurotrophic ulcer, severe dry eye conditions, exposure keratopathy, refractory stromal thinning, peripheral ulcerative keratitis, bullous keratopathy in an eye with poor visual potential, or Mooren’s ulcer can be considered for this procedure. Patients should have been evaluated and deemed appropriate for such surgical intervention. Patients should have been educated about the risks and benefits of the procedure, including alternatives.

Patients should have been evaluated and deemed appropriate for such surgical intervention. Surgical indication for cataracts includes those that impair visual acuity, create visual disability, affect activities of daily living, or deemed medically necessary for monitoring or further surgical procedures. Additionally, intraoperative floppy iris syndrome can occur in any individual with a current or past history of alpha-1 antagonist use. All patients should be screened regarding past and current medication use, as well as all medical conditions. Patients should have been educated about the risks and benefits of the procedure, including alternatives.

Objective: The purpose of this work was to evaluate the effect of loteprednol etabonate (LE) before the initiation of topical cyclosporine A (tCsA) therapy in patients with mild-to-moderate dry eye disease. Prospective, multicenter randomized double-masked parallel group clinical study (NCT00407043). Methods: Hundred and eighteen patients with dry eye disease were randomized to receive either LE and tCsA (n=61) or artificial tears (AT) and tCsA (n=57). Hundred and twelve patients completed the study (LE: n=57, AT: n=55) and are included in the data analysis. Patients selfadministered either LE or AT for 2 weeks 4 times per day, followed by tCsA twice per day accompanied by either LE twice per day or AT twice per day for an additional 6 weeks of treatment. Primary outcome measures included the Ocular Surface Disease Index (OSDI) questionnaire, the Likert scale using standardized facial expressions, lissamine green staining, fluorescein staining, and the Schirmer test. Additional measures included global self-assessment, and safety outcomes included slitlamp examination, intraocular pressure, and assessment of visual acuity. Results: Loteprednol etabonate pretreatment significantly reduced tCsA stinging (P,0.05). Both groups showed significantly improved OSDI scores at the 14-, 30-, and 60-day visits. Loteprednol etabonate showed significantly more OSDI improvement than AT. Both pretreatment strategies improved global self-assessment scores, Schirmer test, fluorescein staining, lissamine staining, and adjunctive AT use. Loteprednol etabonate showed superior improvement in Schirmer test, fluorescein staining, and lissamine staining. Intraocular pressure did not increase in either group. Conclusions: Loteprednol etabonate induction therapy 2 weeks before the initiation of long-term tCsA treatment for chronic dry eye disease provides more rapid relief of dry eye signs and symptoms with greater efficacy than tCsA and AT alone.

Ocular surface disorder--and dry eye, in particular--is a leading reason for visits to eye care professionals. It has been generally accepted that meibomian gland dysfunction (MGD) is a leading cause of evaporative dry eye, as well as being associated with aqueous-deficient dry eye. Yet, researchers and clinicians have lacked a global consensus on the definition of MGD, its epidemiology, pathophysiology, and management. Various systemic diseases and medications have been associated with the progression of both dry eye and MGD, as have several ocular disorders beyond those directly affecting the surface. It is in the best interest of patients for clinicians to be able to better identify and diagnose MGD, differentiating it from other ocular surface disorders, and to recognize the effects of MGD on the ocular surface, and thus initiate appropriate therapy. This CME activity provides expert insight into the Tear Film and Ocular Surface Society's International Workshop on MGD consensus report, offering practical application of its findings to better manage MGD patient care, particularly for those patients facing or undergoing ocular surgery.

Purpose To evaluate the efficacy of cyclosporine 0.05% in alleviating dry-eye signs and improving visual quality after multifocal intraocular lens (IOL) implantation. Setting Private practice and university medical center, New York, New York, USA. Methods This randomized prospective contralaterally controlled double-masked trial comprised patients scheduled to have bilateral phacoemulsification with implantation of a refractive multifocal IOL (ReZoom). Patients received twice-daily cyclosporine 0.05% in 1 eye and an artificial tear in the other eye from 1 month before to 2 months after second-eye surgery. Outcomes were evaluated at baseline and 2 months after second-eye surgery. Results The study enrolled 28 eyes of 14 patients. At baseline, there were no statistically significant between-group differences in outcome measures. Two months postoperatively, the cyclosporine group had significantly lower mean uncorrected distance visual acuity than the artificial tear group (0.11 logMAR ± 0.03 [SD] [20/25 Snellen equivalent] versus 0.19 ± 0.05 logMAR [20/30]; P = .045) as well as significantly lower mean corrected distance visual acuity (0.0 ± 0.02 logMAR [20/20] versus 0.1 ± 0.02 logMAR [20/25]; P = .005) and corneal staining scores (0.210 ± 0.07 versus 0.645 ± 0.18; P = .034). Treatment with cyclosporine 0.05% also improved contrast sensitivity, conjunctival staining, and tear breakup time. Significantly more patients preferred the eye treated with cyclosporine 0.05% to the eye treated with artificial tears (57.1% versus 14.3%; P = .007). Conclusion Cyclosporine 0.05% therapy reduced dry-eye signs and improved visual quality after multifocal IOL implantation. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

Purpose Determine the degree of postoperative pain and rate of healing in eyes treated with either ketorolac tromethamine 0.4% (Acular LS) or nepafenac sodium 0.1% (Nevanac) after flapless surface ablation [epi-laser in situ keratomileusis (LASIK)]. Methods Prospective, randomized, double-masked, paired-eye comparison. Patients undergoing flapless surface ablation were randomized to receive ketorolac in 1 eye and nepafenac in the other. Drops were instilled immediately after the surgical procedure, and patients continued to instill the masked drops 3 times daily for 5 days. Study follow-up visits were at days 1 and 5 postoperatively. Patients were queried by phone regarding their level of pain at 5 hours postoperatively and on days 2, 3, and 4. Outcome measures included postoperative pain levels including need for additional rescue medications, rate of healing, and adverse events. Results Although the original target population was 60 eyes of 30 patients, this study was halted after only 14 eyes of 7 patients because of concern for patient safety, because most patients in 1 arm developed haze. Eyes treated with nepafenac healed at a slower rate than eyes treated with ketorolac in 57% of patients. Mean time to healing was 5.7 +/- 1.1 days with ketorolac and 7.9 +/- 2.1 days with nepafenac (P = 0.066). Moreover, eyes treated with nepafenac exhibited statistically significant greater mean hazing scores at week 2 (P = 0.024) and month 1 (P = 0.039). Throughout the study, a greater percentage of nepafenac-treated eyes exhibited haze than did ketorolac-treated eyes. This difference was statistically significant at week 2 (P = 0.005) and month 1 (P = 0.039). Patients reported significantly more pain in nepafenac-treated eyes at day 3 when pain was at its peak (P = 0.046). Conclusions In patients undergoing epi-LASIK, a statistically significant trend postoperative toward increased corneal haze was seen with nepafenac compared with ketorolac. Nepafenac therapy resulted in a non-statistically significant trend toward delayed healing. The study was halted because of safety concerns.

To evaluate dry-eye signs, symptoms, and refractive outcomes in patients with dry-eye disease having laser in situ keratomileusis (LASIK).In this randomized parallel double-masked prospective clinical trial, 42 eyes of 21 myopic patients (mean spherical equivalent -4.3 diopters [D], range -1.00 to -10.63 D) with dry-eye disease were treated with unpreserved artificial tears or cyclosporine 0.05% ophthalmic emulsion twice a day beginning 1 month before LASIK. Treatment with the study drug was discontinued for 48 hours post surgery and then resumed for 3 additional months. Both groups used additional artificial tears as needed. Study visits occurred pretreatment (baseline), before surgery, and at 1 week and 1, 3, 6, and 12 months after surgery.Statistically significant increases from baseline were found in Schirmer scores for artificial tears at 1 month (P = .036) and for cyclosporine 0.05% before surgery and 1 week, 1 month, and 6 months after surgery (P.018). There were no significant differences from baseline or between groups in responses to the Ocular Surface Disease Index questionnaire or best corrected visual acuity (BCVA), nor were there significant between-group differences in superficial punctate keratitis or uncorrected visual acuity. Mean refractive spherical equivalent in cyclosporine-treated eyes was significantly closer to the intended target at 3 and 6 months after surgery than in artificial-tears-treated eyes (P = .007). A greater percentage of cyclosporine eyes was within +/-0.5 D of the refractive target 3 months after surgery than artificial tears eyes (P = .015).Successful outcomes after LASIK were achieved for dry-eye disease patients. Treatment with cyclosporine 0.05% provided greater refractive predictability 3 and 6 months after surgery than unpreserved artificial tears.

To provide 6-month results of a 1-year clinical trial evaluating conductive keratoplasty (CK) for the treatment of presbyopic symptoms in emmetropic and hyperopic eyes.A total of 143 patients with presbyopic symptoms were enrolled in this 1-year United States FDA clinical trial and treated to improve near vision in 1 eye (unilateral treatment). In addition, 33 fellow eyes were treated to improve distance vision (bilateral treatment). For near vision correction, the target refraction was up to -2.0 D in the nondominant eye, and for distance vision correction, 0.0 D. Enrolled patients had a preoperative spherical equivalent of plano to +2.00 D, no more than 0.75 D of refractive astigmatism, and were 40 years of age or older. No retreatments were performed.Of the eyes treated for near, 77% had uncorrected near vision of J3 or better at 6 months postoperatively. A total of 85% of all patients had binocular distance UCVA of 20/25 or better along with J3 or better near, a combination that represents functional acuity for a presbyope. Sixty-six percent of eyes treated for near had a manifest refractive spherical equivalent (MRSE) within +/- 0.50 D of intended at 6 months. In 89% of eyes, the MRSE changed 0.05 D or less between 3 and 6 months postoperatively. After month 1, the incidence of variables associated with safety was 1% or lower. Seventy-six percent were very satisfied or satisfied with their procedure.CK appears to be very safe and effective in producing functional visual acuity in presbyopic eyes up to 6 months following the procedure. Patient satisfaction with the procedure is similar to that of monovision LASIK.

Objective To document the 1-year safety, efficacy, and stability results of 355 eyes treated in the multicenter study of conductive keratoplasty (CK) used to correct low to moderate hyperopia. Design Nonrandomized comparative (self-controlled) trial. Participants Twenty surgeons at 13 centers performed CK on the eyes of all patients enrolled in a multicenter, 2-year, U.S. phase III clinical trial. Treated eyes had +0.75 to +3.00 diopters (D) of hyperopia and ≤0.75 D of cylinder. Patients were 40 years of age or older. Intervention Low-energy, high-frequency current was applied directly into the peripheral corneal stroma through a delivery tip inserted at 8 to 32 treatment spots. The number of treatment spots was increased for increasing levels of hyperopia, but the amount of radiofrequency energy remained constant. Emmetropia was intended. All eyes were treated once (there were no retreatments). Main outcome measures Data from 355 eyes with 1 year of follow-up were analyzed for safety and stability, and data from 318 eyes were analyzed for efficacy and predictability, as well as stability and safety. All patients reported on satisfaction and quality of vision after surgery. Results At 1 year, uncorrected visual acuity was ≤20/20 in 56%, ≤20/25 in 75%, and ≤20/40 in 92% of eyes. The manifest refractive spherical equivalent refraction was within 0.50 D in 63%, within ±1.00 D in 89%, and within ±2.00 D in 99%. Seven of 355 eyes lost 2 lines of best spectacle-corrected visual acuity at 1 year, but no eye lost >2 lines. One eye of 355 had induced cylinder of >2.00 D. The cycloplegic refractive spherical equivalent changed a mean of 0.25 ± 0.50 D between months 3 and 6, 0.11 ± 0.41 D between months 6 and 9, and 0.11 ± 0.35 D between months 9 and 12. Refractive stability seemed to be attained by 6 months and remained stable through 12 months. Histology and confocal microscopy showed deep penetration of the treatment into the stroma. Endothelial cell counts were not changed by the treatment. Conclusions CK seems to be safe, effective, and stable for correcting low to moderate spherical hyperopia in patients 40 years old or older. Treatment penetration is deep and cylindrical in shape, and it does not damage the corneal endothelium. Uncorrected visual acuity, predictability, and stability are as good as or better than those obtained with other techniques used to correct hyperopia.

Objective To document the 1-year postoperative clinical results of the safety, efficacy, and stability of conductive keratoplasty (CK) to correct low to moderate hyperopia. Design Prospective, nonrandomized, self-controlled trial. Participants Five surgeons at four centers performed CK on the first 54 eyes of a multicenter, 2-year clinical trial. Treated eyes had +0.875 to +4.00 diopters (D) of hyperopia and ≤0.75 D of cylinder. The nature of this procedure was explained to all participating patients who signed informed consent forms prior to undergoing the procedure. Intervention Low energy, high-frequency current was applied directly into the peripheral corneal stroma through a delivery tip inserted at 16 or more treatment spots. An early nomogram was used for the first 54 eyes with an intended refraction of plano. Main outcome measures Data from all 54 eyes were analyzed for safety and stability. A subset of 30 of the 54 eyes was found that had been treated with the appropriate number of spots with the early nomogram. These eyes were categorized as current nomogram eyes; the data for these eyes were analyzed for efficacy and predictability, as well as stability and safety. All patients reported on satisfaction and quality of vision after surgery. Results Preoperatively, the manifest refractive spherical equivalent refraction (MRSE) of the 30 current nomogram eyes was +1.57 D. At 1 year postoperatively, uncorrected visual acuity was 20/20 or better in 57% of the eyes and 20/40 or better in 93%. The MRSE was within 0.50 D in 46%, within ±1.00 D in 93%, and within ±2.00 D in 100%. No eye lost ≥2 lines of best spectacle-corrected visual acuity at 1 year postoperatively nor had an induced cylinder of ≥2.00 D. The MRSE changed a mean of 0.25 D ± 0.43 between 3 and 6 postoperative months, 0.16 D ± 0.38 between 6 and 9 postoperative months, and 0.07 D ± 0.38 between 9 and 12 postoperative months. Refractive stability appeared to be attained by 6 months postoperatively. Conclusions Conductive keratoplasty appears to be safe, effective, and stable for correcting low to moderate spherical hyperopia. Stability appeared by the 6-month follow-up visit. For the eyes treated with the current CK nomogram, uncorrected visual acuity, predictability, and stability are as good as or better than those obtained with hyperopic laser in situ keratomileusis or noncontact laser thermal keratoplasty.

Acute postoperative endophthalmitis (APE) is a serious, although infrequent, complication of eye surgery that can result in significant morbidity and costs. This review addresses APE risk factors, associated bacterial pathogens, antibiotic resistance, and prevention.

Objective To determine the effects of laser in situ keratomileusis (LASIK) on best-corrected visual acuity (BCVA) and contrast sensitivity. Design Prospective, observational case series. Participants One hundred twelve eyes, in 65 patients with myopia and myopia with astigmatism, who underwent LASIK. Testing and main outcome measures Best-corrected visual acuity using the Snellen visual acuity chart and contrast sensitivity using the CSV 1000 (Vector Vision, Dayton OH) was tested before surgery and 1 week, 1 month, and 3 months after surgery in patients who underwent LASIK. Results Contrast sensitivity was depressed for patient eyes with spherical equivalence (SE) between −1.25 diopters (D) and −13.75 D, at 12 cycles/degree for at least 3 months and at 18 cycles/degree for 1 week after LASIK. For patient eyes with SE between −1.25 D and −6.00 D, contrast sensitivity was depressed only at 12 cycles/degree for at least 3 months after LASIK. For patient eyes with SE between −6.00 D and −13.75 D, contrast sensitivity was depressed at 6, 12, and 18 cycles/degree 1 week after LASIK but returned toward preoperative levels by 1 month after surgery. Despite the slight decreases in contrast sensitivity, all scores were still within the range of normal values except for 12 cycles/degree for 3 months and 18 cycles/degree at 1 week after surgery in the high myopia group. Although highly myopic patients, compared with patients with low myopia, had slightly less BCVA before surgery, both groups maintained their preoperative BCVA at all postoperative visits. Conclusions Based on this study, we conclude that LASIK has little effect on BCVA and contrast sensitivity for up to 3 months after surgery.

Purpose: To present photorefractive keratectomy (PRK) results for myopia ranging from -4,00 to - 6,00 diopters performed with the VISX and Summit excimer lasers. Methods: To be eligible for this study, patients had to be 20 to 45 years of age, have -4.00 to -6.00 diopters of myopia and have no more than 1 D of astigmatism. The Summit group was composed of 51 eyes. The baseline preoperative spherical equivalent of myopia was -5.22 ± 0.17 and surgeries were performed with the Excimed UV 200 LA Excimer Laser. In the VISX group, there were 53 eyes and the baseline refractive error was -4.85 ± 0.16 and surgeries were performed with the Twenty/Twenty Excimer Laser. Results: At six-month examination, haze ranged from 0 to 1 (M:0.56 ± 0.07) in the VISX group and from 0 to 3 (M:0.58 ± 0.08) in the Summit group. Uncorrected vision at six months was 20/20 or better in 22% of eyes and 20/40 or better in 83% of eyes in the VISX group. In the Summit group, 25% of eyes were 20/20 or better and 71% were 20/40 or better at the six-month examination. Conclusion: It is reassuring that PRK of patients with -4.00 to -6.00 D of myopia results in acceptable results.Objetivo: Apresentar os resultados obtidos com ceratecto-mia fotorrefrativa (PRK) para a correção de miopia variando de -4,0 a -6,0 dioptrias realizadas com os excimer lasers VISX e Summit. Métodos: Para o estudo foram avaliados os resultados de PRK realizadas em pacientes com idade entre 20 e 45 anos, miopia entre -4,0 e -6,0 dioptrias e astigmatismo até 1,0 dioptria. O grupo operado com o laser da marca Summit era composto de 51 olhos. O equivalente esférico médio pré-operatório era de -5,22 ± 0,17 dioptrias e as cirurgias foram realizadas com o Excimed UV 200 LA Excimer Laser. O grupo operado com o laser VISX, era composto de 53 olhos e o erro refrativo preoperatório era de -4,85 ± 0,16 diop-trias e as cirurgias foram realizadas com o Twenty/Twenty Excimer Laser. Resultados: Exame seis meses após a cirurgia revelou "haze" variando de 0 a 1 (M:0,56 ± 0,07) no grupo VISX e variando de 0 a 3 (M:0,58 ± 0,08) no grupo Summit. Neste mesmo exa-me, acuidade visual sem correção era de 20/20 ou melhor em 22% dos olhos e 20/40 ou melhor em 83% dos olhos no grupo VISX. No grupo Summit, 25% dos olhos tinham visão melhor ou igual a 20/20 e 71% melhor ou igual a 20/40. Conclusão: Ceratectomia fotorrefrativa realizadas em olhos com miopia variando de --4,0 a ¾6,0 dioptrias apresenta re-sultados aceitáveis.

Purpose: To determine whether uneven corneal surface hydration during excimer laser photorefractive keratectomy (PRK) is related to postoperative occurrence of central islands. Setting: LSU Eye Center, New Orleans, Louisiana, USA. Methods: A retrospective study reviewed intraoperative videotapes and postoperative videokeratography of 49 eyes of 49 patients who had excimer laser PRK for myopia. The uniformity of corneal hydration within the photoablation zone, particularly the frosty appearance of the ablated zone, was characterized. The presence or absence of a topographic central island (steepening of at least 3.0 diopters and 1.5 mm in diameter) was determined from the 1 month postoperative videokeratographs. Results: Twelve eyes (24,5%) developed central islands postoperatively. A statistically significant association was observed between the uneven surface hydration (central accumulation of fluid) within the ablation zone intraoperatively and the formation of central islands postoperatively ( P P Conclusion: Nonuniform fluid distribution during photoablation was a risk factor for central island formation after PRK. Intraoperatively, the presence of excess fluid in the central cornea appeared as a shiny area. This mirror-like surface layer may reduce the rate of central ablation by reflecting and absorbing a significant amount of the incident excimer laser light.

To correlate new quantitative topographic indexes of corneal irregular astigmatism to best spectacle-corrected visual acuity (BSCVA) following excimer laser photorefractive keratectomy (PRK).Department of Ophthalmology, LSU Eye Center, and Refractive Surgery Center of the South, Ear, NoseThroat Hospital, New Orleans, Louisiana; Manhattan Eye, Ear and Throat Hospital, New York, New York, USA.Videokeratography data (TMS-1) were obtained preoperatively and 1, 3, 6, 12, 18, and 24 months postoperatively from 100 eyes having PRK for low to mild myopia. Algorithms measured fine local irregularity with the surface regularity index (SRIp), varifocality with the coefficient of variation of corneal power (CVPp), and central islands with the elevation/depression magnitude (EDM).The SRIp and CVPp increased after surgery and remained significantly higher than the preoperative levels throughout the 24 month follow-up (P.05). The increase in EDM was significant from 1 to 6 months (P.05) but not thereafter. Multiple regression analysis revealed that variables having a statistically significant relationship with postoperative BSCVA were CVPp and EDM at 1 month, CVPp at 3 months, and CVPp, haze, and age at 6 months. No statistically significant correlation between any measures of irregular astigmatism and BSCVA was found after 1 year of follow-up.The quantitative measures used in this study are sensitive methods by which irregular astigmatism after keratorefractive procedures can be classified, evaluated, and compared.

Background: To evaluate near vision contrast sensitivity as a measure of visual performance after photorefractive keratectomy (PRK). Setting: LSU Eye Center, New Orleans, Louisiana. Methods: Using Holladay Contrast Acuity Test cards, near (reading) vision for five levels of contrast sensitivity was evaluated in a cross section of 53 eyes of 31 patients 25 to 732 days after PRK. Twenty-four normal eyes of 22 myopic patients served as controls. Results: Near contrast sensitivity decreased at all tested contrast levels for approximately 7 months after PRK and then returned to baseline. This phenomenon paralleled the fluctuation in best corrected distance Snellen acuity. Conclusions: These preliminary results indicate that Snellen visual acuity and near contrast sensitivity returned to baseline within 1 year after PRK.

Objectives To determine the clinical sensitivity, specificity, negative predictive value, and positive predictive value of a rapid point-of-care diagnostic test to detect elevated matrix metalloproteinase 9 levels (InflammaDry). Methods In a prospective, sequential, masked, multicenter clinical trial, InflammaDry was performed on 206 patients: 143 patients with clinical signs and symptoms of dysfunctional tear syndrome (dry eyes) and 63 healthy individuals serving as controls. Participants were assessed as healthy controls or for a clinical diagnosis of dry eye using the Ocular Surface Disease Index, Schirmer tear test, tear breakup time, and keratoconjunctival staining. Main Outcome Measures The sensitivity and specificity of InflammaDry were compared with clinical assessment. Results InflammaDry showed sensitivity of 85% (in 121 of 143 patients), specificity of 94% (59 of 63), negative predictive value of 73% (59 of 81), and positive predictive value of 97% (121 of 125). Conclusion Compared with clinical assessment, InflammaDry is sensitive and specific in diagnosing dry eye. Application to Clinical Practice Dry eye is often underdiagnosed resulting from poor communication between the clinical assessment of dry eye severity between clinicians and patients. This often leads to a lack of effective treatment. Matrix metalloproteinase 9 is an inflammatory biomarker that has been shown to be elevated in the tears of patients with dry eyes. The ability to accurately detect elevated matrix metalloproteinase 9 levels may lead to earlier diagnosis, more appropriate treatment, and better management of ocular surface disease. Preoperative and perioperative management of inflammation related to dry eyes may reduce dry eyes that develop after laser in situ keratomileusis, improve wound healing, and reduce flap complications. Recognition of inflammation may allow for targeted perioperative therapeutic management of care for patients who undergo cataract and refractive surgery and improve outcomes. Trial Registration clinicaltrials.gov Identifier: NCT01313351

Objective To compare the clinical sensitivity and specificity of the AdenoPlus test with those of both viral cell culture (CC) with confirmatory immunofluorescence assay (IFA) and polymerase chain reaction (PCR) at detecting the presence of adenovirus in tear fluid. Methods A prospective, sequential, masked, multicenter clinical trial enrolled 128 patients presenting with a clinical diagnosis of acute viral conjunctivitis from a combination of 8 private ophthalmology practices and academic centers. Patients were tested with AdenoPlus, CC-IFA, and PCR to detect the presence of adenovirus. Main Outcome Measures The sensitivity and specificity of AdenoPlus were assessed for identifying cases of adenoviral conjunctivitis. Results Of the 128 patients enrolled, 36 patients' results were found to be positive by either CC-IFA or PCR and 29 patients' results were found to be positive by both CC-IFA and PCR. When compared only with CC-IFA, AdenoPlus showed a sensitivity of 90% (28/31) and specificity of 96% (93/97). When compared only with PCR, AdenoPlus showed a sensitivity of 85% (29/34) and specificity of 98% (89/91). When compared with both CC-IFA and PCR, AdenoPlus showed a sensitivity of 93% (27/29) and specificity of 98% (88/90). When compared with PCR, CC-IFA showed a sensitivity of 85% (29/34) and specificity of 99% (90/91). Conclusion AdenoPlus is sensitive and specific at detecting adenoviral conjunctivitis. Application to Clinical Practice An accurate and rapid in-office test can prevent the misdiagnosis of adenoviral conjunctivitis that leads to the spread of disease, unnecessary antibiotic use, and increased health care costs. Additionally, AdenoPlus may help a clinician make a more informed treatment decision regarding the use of novel therapeutics. Trial Registration clinicaltrials.gov Identifier: NCT00921895

BACKGROUND: The rate of corneal epithelial wound healing may be determined, in part, by the characteristics of the stromal surface. The excimer laser has the ability to produce a highly uniform ablated surface, which may facilitate reepithelialization after photorefractive keratectomy (PRK). METHODS: The rate of corneal epithelial wound healing after excimer laser PRK was compared with the rate of reepithelialization after manual lamellar keratectomy. Ten rabbits received a 4-mm diameter ablation in one eye (fluence = 160 m J/cm2) and a shallow, 5-mm diameter, manual lamellar keratectomy in the contralateral eye. At 0, 4, 8, 12, 24, 36, 48, 60, and 72 hours after wounding, sodium fluorescein was instilled, and photographs were taken, converted to video images, and digitized. Wound area was calculated for each time point and converted to wound radius; the slopes of the wound radius, plotted over time, were compared to determine rates of healing. Scanning electron microscopy was performed immediately after wounding to examine surface regularity. RESULTS: By 24 hours after wounding, corneas that had undergone PRK demonstrated a significantly faster rate of epithelial wound healing compared with eyes that underwent lamellar keratectomy (33.4±1.9 um/hr vs 27.8±1.4 um/hr, respectively, for 12 to 72 hours) (p CONCLUSIONS: This study demonstrates that the rate of epithelial wound healing is significantly faster after excimer laser PRK than after lamellar keratectomy in the rabbit. Variations in surface regularity and wound edge profile may contribute to differences in wound healing. [J Refract Surg. 1996;12:352-357.]

Serious complications with photorefractive keratectomy are not common, but can be troublesome. Haze is usually mild, but can be severe in higher myopes and if reepithelialization is prolonged. Regression is also more common with higher attempted corrections and with smaller optical zones. Loss of best corrected visual acuity can occur and is attributed to haze, irregular astigmatism, decentration, and steroid-related cataracts. Treatments for some of the previously mentioned problems may include topical steroids, corneal scraping, and reablation. Loss of contrast sensitivity is usually mild and temporary. Problems with night vision, including glare and halos, similarly tend to decrease during the first postoperative months.Overcorrections persisting beyond 6 to 12 months may be managed with a bandage lens, diclofenac, corneal scraping, or pilocarpine drops. Decentration of the ablation usually does not cause significant visual symptoms, except in severe cases. Central islands are common in the immediate p...

Sudden phakic pupillary block occurred immediately upon cortical cleaving hydrodissection during cataract surgery in two patients. We believe this unique complication is related to the recent introduction of viscoelastics with properties that enhance the maintenance of the anterior chamber during capsulorhexis. We postulate that the cause of the block was a combination of O-ring capsulocortical and iridocapsular seals that tamponade hydrodissection fluid posteriorly. Additional precipitating factors were diabetes, poorly dilating pupils, and increased vitreous pressure, which may have contributed to the sudden and irreversible nature of this block. If this complication is not recognized, an aqueous misdirection syndrome may ensue, requiring pars plana vitrectomy. Immediate mechanical breakage of the pupillary and capsular block, resulting in an immediate decrease in intraocular pressure from greater than 70 mm Hg, may cause severe retinal vascular damage. These cases stress the importance of mechanical pupil dilation to prevent this serious complication of cataract surgery.

To determine whether patient-reported improvement in symptoms of dry eye syndrome, activities of daily living, and other quality-of-life measures after treatment with hydroxypropyl cellulose ophthalmic inserts correlates significantly with physician assessment of clinical outcomes.Patient registry of those treated for 1 month with inserts as monotherapy or in combination with existing treatments for moderate-to-severe dry eye syndrome. A total of 520 participants were enrolled. Of those, 418 patients completed the study. Results of this registry were evaluated and correlations were calculated to determine whether patient-reported symptoms, quality of life, and changes in disease severity based on the Ocular Surface Disease Index, and activities of daily living outcomes are predictive of physician assessment of clinical signs, symptoms, and adherence to therapy.Most patients reported overall improvement in their condition. Patient-reported improvements in the symptoms of dry eye syndrome and activities of daily living were significant predictors of physician assessment of compliance with insert therapy, improvement in symptoms and clinical signs, effectiveness of therapy, and acceptance of use as adjunctive therapy.Patient-reported symptoms and activities of daily living are predictors of patient compliance and treatment success with the use of inserts, as reported by treating physicians. The benefits were additive to the standard of care that was continued during the course of the study. These predictors, along with clinical diagnostic tests, can be used by eye care professionals to assess the efficacy of treatment for moderate-to-severe dry eye syndrome quickly and reliably.

Resistance to antibiotic agents is becoming increasingly prevalent among ocular infections. Between 19% and 60% of Streptococcus pneumoniae and Staphylococcus aureus isolates have been shown to be resistant to macrolide antibiotic agents, penicillin, and older fluoroquinolones. Although topical fluoroquinolones are considered first-line treatment of ocular infections, as much as 85% of methicillin-resistant S aureus isolates are resistant to ophthalmic fluoroquinolones, including the newer 8-methoxy fluoroquinolones, gatifloxacin and moxifloxacin. Besifloxacin, an 8-chlorofluoroquinolone, has a lower minimum inhibitory concentration against multidrug-resistant staphylococcal strains than other fluoroquinolones and less selective pressure for resistance development because of the lack of a systemic counterpart. In addition to the development of new antibacterial agents, antibiotic resistance in ocular infections may be reduced by following the same strategies used to minimize antimicrobial resistance in systemic infections.

BACKGROUND: Normal ranges of variability of refraction and visual acuity in adult myopic eyes are needed as a reference standard for assessing the stability of refractive corneal surgery. METHODS: We measured the changes in spectacle-corrected visual acuity and cycloplegic refraction during 5 years for the unoperated eye of 82 patients aged 21 to 57 years in the Prospective Evaluation of Radial Keratotomy Study. The changes were compared for contact lens and non-contact lens wearers. We also compared the 5-year cycloplegic and manifest refractions for these unoperated eyes. RESULTS: Of 77 eyes, 44% gained or lost one Snellen line and 48% experienced no change in spectacle-corrected visual acuity between baseline and 5 years. Only one eye (1%) lost two lines, and 7% gained two lines. The refractive change was less than 1.00 D for 84% of the 37 non-contact lens wearing eyes. Only 13% became more myopic by at least 1.00 D (maximum increase in myopia, 2.00 D), and 3% became less myopic by 1.00 D. Of 45 contact lens wearing eyes, 38% became more myopic by at least 1.00 D. The 5-year manifest refraction was 0.50 D to 1.50 D more myopic than the cycloplegic refraction for 37% of eyes. CONCLUSIONS: We recommend using two or more Snellen lines as the standard for a meaningful change in spectacle-corrected visual acuity in operated eyes, and 1 .00 D as a meaningful cutoff for stability of refraction. The wearing of contact lenses can confound the results of stability studies. The difference between the cycloplegic and manifest refractions suggests that the cycloplegic refraction should be used in planning for refractive surgery. [Refract Corneal Surg 1992;8:439-447.) RÉSUMÉ INTRODUCTION: La variation normale de l'erreur refractive et l'acuité visuelle chez les yeux myopiques d'adulte doivent être déterminées afin d'estimer la stabilité de la chirugie refractive cornéenne. MÉTHODES: Nous avons mesuré les changements de la meilleure acuité visuelle avec lunettes et de la réfraction cycloplégique pendant cing ans chez l'oeil non-opéré de 82 patients dans d'Etude Prospective de la Kératotomie Radiaire (PERK). Les changements ont été comparés entre ceux qui portaient des lunettes de contact et ceux qui n'en portaient pas. Nous avons donc comparé les réfractions et les réfractions cycloplégiques de ces yeux non-opéres. RÉSULTATS: Chez 77 yeux suivis pendant cing ans, 44% ont gagné ou perdu une ligne de Snellen et 48% n'ont pas éprouvé de changement en meilleure acuité visuelle avec lunettes. Un oeil seulement (1%) a perdu 2 lignes et 7% ont gagnés 2 lignes. Chez 84% des 37 yeux qui ne portaient pas de lentilles de contact, le changement de la réfraction fut inférieur à 1.00 dioptrie. Seulement 13% sont devenus plus myopiques d'au moins 1.00 dioptrie (l'augmentation maximum de la myopie étant de 2.00 dioptries) et 3% sont devenus moins myopiques d'au moins 1 .00 dioptrie. Chez 45 yeux qui portaient des lentilles de contact 38% sont devenus plus myopiques d'au moins 1 .00 dioptrie. La réfraction à cinq ans a été de 0.50 et 1.50 dioptries plus myopique que la réfraction cycloplégique chez 37% des yeux.

Obstetric forceps pressure strong enough to leave a periorbital depression and corneal injury would probably be severe enough to leave an occipital depression from the opposite forceps blade. The presence of a depression at the correct occipital position would support the diagnosis of forceps injury when the birth history is unknown and the cornea has decompensated enough to make observation of the Descemet's membrane scrolls difficult. We studied six patients with known or suspected obstetric forceps injury to the cornea. Complete ocular examinations included examination for periorbital forceps depressions and posterior skull depressions 180 degrees from the affected cornea (which correlates with the opposite blade of the forceps). All of the patients with Descemet's scrolls had posterior skull depressions. This method of palpation for a contralateral skull depression may assist in the diagnosis of forceps-induced corneal decompensation.

Objective: Acute conjunctivitis is an extremely common condition and can be associated with significant morbidity and economic burden. Despite this, considerable controversy exists pertaining to the prevalence, diagnosis, management, and treatment of the condition. A panel of ophthalmology experts was assembled to review and discuss the current evidence based literature as it pertains to each of these persistent controversies. Methods and scope: An acute conjunctivitis round table symposium was convened at the American Academy of Ophthalmology meeting in Atlanta, November 2008. The expert panelists consisted of four academic ophthalmologists in the field of cornea and external disease, whose discussion was informed by an English language literature survey carried out on the PubMed database for the period of January 1972 to October 2008. A narrative summary was generated from the literature review and direct transcription of this event, from which this Review article was developed. Findings and conclusions: Considerable light has been shed on acute microbial conjunctivitis and especially those cases caused by adenovirus. Many of the myths that have perpetuated for years have been debunked by emerging evidence. The advent and the implementation of better diagnostic tools and anti-viral medications will help clinicians to improve their diagnostic accuracy, improve management and treatment decisions, and ultimately benefit patients while saving overall healthcare costs.

Objective To compare the clinical and antimicrobial efficacy of besifloxacin ophthalmic suspension 0.6% with that of moxifloxacin ophthalmic solution 0.5% for the treatment of bacterial conjunctivitis. Design Multicenter, randomized, double-masked, parallel-group, active-controlled, noninferiority study. Participants Patients 1 year of age or older with clinical manifestations of bacterial conjunctivitis. Methods Eligible patients were randomized to either besifloxacin suspension or moxifloxacin solution, instilled in the infected eye(s) 3 times daily for 5 days, and participated in study visits on days 1, 5 (±1 day), and 8 (+1 day). Assessments included clinical evaluation of signs and symptoms, visual acuity, biomicroscopy, and culture of the infected eye(s) at each visit, as well as direct ophthalmoscopy on days 1 and 8. Main Outcome Measures The primary efficacy end points were clinical resolution and microbial eradication of baseline bacterial infection on day 5 in patients with culture-confirmed bacterial conjunctivitis. Secondary end points included clinical resolution and microbial eradication on day 8, individual clinical outcomes, microbial and clinical outcomes by bacterial species, and safety. Results A total of 1161 patients (533 with culture-confirmed bacterial conjunctivitis) were randomized. Based on the 95% confidence interval (CI) of the difference, besifloxacin was noninferior to moxifloxacin for clinical resolution on day 5 (58.3% vs. 59.4%, respectively; 95% CI, –9.48 to 7.29) and day 8 (84.5% vs. 84.0%, respectively, 95% CI, –5.6% to 6.75%) and for microbial eradication on day 5 (93.3% vs. 91.1%, respectively, 95% CI, –2.44 to 6.74) and day 8 (87.3% vs. 84.7%; 95% CI, –3.32 to 8.53). There was no statistically significant difference between the 2 treatment groups for either efficacy end points on days 5 or 8 ( P >0.05). Besifloxacin and moxifloxacin were well tolerated. The cumulative frequency of ocular adverse events was similar between treatments (12% and 14% with besifloxacin and moxifloxacin, respectively). However, eye irritation occurred more often in moxifloxacin-treated eyes (0.3% for besifloxacin vs. 1.4% for moxifloxacin; P = 0.0201). Conclusions Besifloxacin ophthalmic suspension was non inferior to moxifloxacin ophthalmic suspension and provided similar safety and efficacy (clinical and microbiological) outcomes when used for the treatment of bacterial conjunctivitis. Financial Disclosure(s) Proprietary or commercial disclosure may be found after the references.

Ten partially sighted and 19 normally sighted eyes underwent excimer laser photorefractive keratectomy for the correction of myopia. Nine of the partially sighted and 17 of the normally sighted eyes had 12 months of follow-up. Epithelial healing was complete in all eyes by day 6. None of the eyes had recurrent erosions, infections, or other medical complications. An increase in corneal haze after surgery was followed by a slow trend toward clearing. Average uncorrected visual acuity in the 7 normally sighted eyes with attempted corrections of 5 diopters (D) or less was 20/40 from month 2 on; the eyes with greater than 5 D attempted corrections had an average of 20/80- at month 2, which declined to 20/200- by month 6. Best spectacle-corrected visual acuity was within ±1 Snellen line of preoperative values in 14 of the normally sighted eyes, improved 2 or more lines in 2 eyes, and worsened two or more lines in two eyes. Hard contact lens overcorrection restored all of the two-line loss in 1 eye and 1 line of the 3-line loss in the other. Refraction and keratometry indicated corneal flattening without induced astigmatism.

In the Prospective Evaluation of Radial Keratotomy (PERK) Study, 793 eyes of 435 patients with 2 to 8 diopters (D) of myopia received a standardized surgery consisting of 8 incisions with a diamond-bladed knife set at 100% of the thinnest paracentral ultrasonic corneal thickness measurement and a diameter of the clear zone of 3.0 to 4.5 mm; 97 eyes (12%) received an additional 8 incisions. There were 757 eyes (95%) followed for 3 to 6.3 years. After surgery, uncorrected visual acuity was 20/40 or better in 88% of eyes

The purpose of this study was to compare the survival of epikeratophakia tissue lenses prepared with cryolathing and lyophilization (frozen lenses) and without (fresh lenses) in donorsensitized recipients with vascularized corneas. Fresh lenses placed in vascularized corneas of immune recipients were subjected to immune attack. Frozen lenses placed in vascularized corneas of immunized recipients did not elicit an immune reaction. Neither fresh nor frozen lenses elicited immune reactions in nonvascularized corneas of immune recipients or in nonvascularized, nonimmune recipients. These results indicate that although the fresh lenses are more antigenic than the lenses in which the cells have been killed by freezing and lyophilization, the fresh lenses prepared using the BKS-1000 technique containing living stromal keratocytes are not likely to stimulate allograft immune reactions in unsensitized patients with avascular graft sites. (Refract Corneal Surg 1991;7:141-145.)

The Prospective Evaluation of Radial Keratotomy Study is a nine-center clinical trial of a standardized technique of radial keratotomy in 435 patients who had simple myopia with a preoperative refraction between -2.00 and -8.00 diopters. We studied the stability of the refractive error during four years after surgery for each of 341 eyes first operated on that had a single surgical procedure. Between baseline and two weeks after surgery, all eyes became less myopic; between two weeks and three months, 161 eyes (59%) lost 1.00 D or more of the initial effect; and between three and six months, 266 eyes (95%) had a stable refraction with less than 1.00 D change. The change from six months to four years was less than 1.00 D for 246 eyes (72%). There was 1.00 D or more decrease in surgical effect (increased minus power) for 13 eyes (4%), and 1.00 D or more increase in surgical effect (decreased minus power) for 82 eyes (24%). Eyes with larger amounts of preoperative myopia and smaller diameter of the clear zone were more likely to have an increasing effect of the surgery. The duration of this continued increasing effect of the surgery is unknown.

Purpose To evaluate the clinical safety and efficacy of the ACI-7000 intracorneal inlay in increasing the depth of field in emmetropic presbyopic patients. Setting Beyoglu Eye Research and Education Hospital, Istanbul, Turkey. Methods This prospective unmasked study comprised 39 presbyopic patients; 12 were naturally emmetropic and 27 had emmetropia resulting from previous hyperopic laser in situ keratomileusis. The intracorneal inlay was placed over the pupil in the patient's nondominant eye after flap lift or creation of a conventional flap using a microkeratome. The inlay was centered on the visual axis. Postoperative follow-up was 1 year. Results Of the 39 inlays implanted, 3 were explanted during the study. At 1 year, the mean uncorrected near visual acuity improved from J6 (preoperatively) to J1 + . All eyes with an inlay had an uncorrected near acuity of J3 or better and 85.3%, of J1 or better. Binocularly, the mean uncorrected near acuity remained J1 or better throughout the study. The mean uncorrected distance visual acuity in eyes with an inlay did not change significantly from preoperatively and remained 20/20 throughout the study period. All 3 eyes with inlay explantation returned to within ±1.00 diopter of the preoperative refractive state for near and distance vision, with no loss of best corrected distance visual acuity. Conclusion The ACI-7000 intracorneal inlay showed the potential to provide safe, effective, and reversible treatment of presbyopia.

Post-RK patients present unique challenges for cataract surgeons and must be counseled regarding possible complications and a hyperopic result in the early postoperative period. Accurate IOL power calculations are more difficult in post-RK patients and require unique measurements of corneal power. RK incision rupture is a potential complication, especially if it is necessary to have the phaco hand piece directly under an RK incision. Zonular weakness and subsequent lens movement are also possible complications for post-RK patients. You may want to consider not using multifocal IOLs to reduce unwanted retinal images. Do not make any alterations or changes until several months have passed. Piggyback IOLs are the best method for enhancing refractive results in post-RK patients.

The management of monocular infantile cataract presents a difficult and challenging clinical problem. The methods used for optical correction after cataract removal include contact lenses, intraocular lenses and epikeratophakia. Epikeratophakia offers a permanent optical correction and eliminates the risks of intraocular procedures. Epikeratophakia is best suited for infants with uniocular aphakia who are contact lens non-compliant and who are still young enough to benefit from amblyopia therapy. The preoperative evaluation, the surgical technique, the postoperative management of epikeratophakia as well as the results of the Louisiana State University and the nationwide studies are presented. Future perspectives in the methods of preparation and preservation of epikeratophakia lenticules and the use of glues and synthetic materials are discussed.