Validation of a web-based distance visual acuity test.

PURPOSE: To validate the Democritus Digital Acuity and Reading Test (DDART) as a distance VA (dVA) test against a series of prevalent conventional distance vision charts. SETTING: Ophthalmology Department, University Hospital of Alexandroupolis, Alexandroupolis, Greece; Ophthalmology Department, AHEPA University Hospital, Thessaloniki, Greece; and Ophthalmica Institute of Ophthalmology & Microsurgery, Thessaloniki, Greece. DESIGN: Prospective multicenter validation study. METHODS: The distance best spectacle-corrected visual acuity (dBSCVA) was compared in normal (NVG) and low (LVG) vision participants against 4 prevalent conventional distance vision charts (ETDRS, Snellen, Landolt C, and Tumbling E) by a predefined 2.5-symbol noninferiority margin and intraclass correlation coefficients (ICCs). DDART's test-retest (TRT) reliability was assessed with ICCs. RESULTS: 534 participants (471 and 63 with normal and low vision, respectively) were included in the study. The mean difference between dBSCVA measured with DDART and conventional charts ranged between -0.84 and +0.85 symbols, without exceeding the 2.5-symbol noninferiority margin. ICCs indicated an excellent level of agreement for all patient groups (from 0.848 to 0.985). TRT reliability indicated differences below 1 symbol both for the NVG and LVG, with ICCs ranging between 0.912 and 0.964 for the 4 DDARTs. CONCLUSIONS: DDART was a valid web-based dVA test that provided reliable measurements in clinical and telemedical settings, both for normal and low vision patients.

Unaccompanied Clinic Visits: Practical Consequences of a Stressor Imposed by the COVID-19 Pandemic.

One of the restrictive measures of COVID-19 (coronavirus disease 2019) pandemic control is the prohibition of accompanied clinic visits. The specific features of ophthalmological patients imply different degrees of dependency that directly affect their response to such measures. This study aims to assess the effects of unaccompanied medical appointments on outpatients' stress levels and their retention of medical advice. A questionnaire-based survey was conducted at a large ophthalmic clinic in northern Greece during September 2020. Suitable subjects were asked to self-administer a 7-item questionnaire addressing their subjective perception of stress and their ability to fully understand and remember their doctor's instructions, given the fact that they would be alone during the consultation. The analysis was based on 200 patients who completed the survey. Sixty-three patients (31.5%) reported that unaccompanied clinic visits increased their stress, with a median value of 7.5 (mean 6.77 ± .2.7) on a scale from 1 to 10. A large number of the patients (30%) claimed it was difficult to remember the doctor's comments or instructions, and 24.6% indicated that they would not fully understand them if they were to attend the clinic unaccompanied. A marked impact on women and on the elderly (up to threefold) over 70 years of age was identified. This is the first study specifically addressing practical repercussions of unaccompanied clinic visits during the COVID-19 pandemic. A negative effect on patients' emotional status and on counseling effectiveness was demonstrated. Female gender and advanced age were found to be determinants of the highest vulnerability.

Acute corneal graft rejection after anti-severe acute respiratory syndrome-coronavirus-2 vaccination: A report of four cases.

PURPOSE: This study intends to add to previous reports on acute corneal graft rejection following anti-severe acute respiratory syndrome-coronavirus-2 vaccination, providing data to corroborate a possible causative relationship between anti-COVID-19 immunization and corneal graft rejection, regardless of vaccine or graft type. METHODS AND RESULTS: This report describes 4 cases of acute-onset rejection as early as 5 days following the first dose of anti-severe acute respiratory syndrome-coronavirus-2 vaccine types not yet referred for corneal allograft. Patients were individually given the Moderna messenger RNA-1273 COVID-19 vaccine (2 patients) and the AstraZeneca COVID-19 vaccine, Vaxzevria, AZD1222 (2 patients). CONCLUSIONS: Even though a direct causative effect is hard to prove, temporal proximity between anti-severe acute respiratory syndrome-coronavirus-2 vaccines of different types and consecutive reports of corneal graft rejection indicates the need for further investigation. Consistent advice must be given to corneal transplant patients regarding such risk.

Comparison of postoperative refractive outcome in eyes undergoing combined phacovitrectomy vs cataract surgery following vitrectomy.

BACKGROUND: To investigate the accuracy of preoperative biometry in eyes undergoing combined phacovitrectomy and to compare it with eyes having cataract surgery at a later point in time following vitrectomy. METHODS: Patients with epiretinal membrane or macular hole who underwent combined phacovitrectomy (group 1) or phacoemulsification following pars plana vitrectomy (PPV) (group 2) were included in this retrospective, comparative, interventional case series. The primary outcome measures were the intraocular lens power prediction error (PE) and the percentage of eyes with PE > ± 0.5D in the two groups. Secondary outcome measures included the correlation between epidemiological, clinical, or surgical factors and dioptric shift. In addition, the influence of optical coherence tomography characteristics to the PE was investigated. RESULTS: Group 1 and 2 consisted of 55 and 54 eyes, respectively, for a total of 109 eyes included in the study. The mean absolute PE was 0.59 D (range + 1.4 to - 2.5D) in group 1 and 0.35 (range + 1.0 to - 1.45D) in group 2 (p = 0.01). PE greater than 0.5D was observed in 47% of eyes in group 1 as opposed to 16.6% of eyes in group 2 (p = 0.027). The PE was associated with shallower anterior chamber depth (ACD), increased central macular thickness (> 300 µ), and worse baseline best-corrected visual acuity. Photoreceptor ellipsoid zone or external limiting membrane disruption was not associated with significantly greater postoperative refractive deviations. CONCLUSION: Combined phacovitrectomy may result in greater postoperative refractive prediction error compared to phacoemulsification alone following vitrectomy. Patients with worse vision, greater central macular thickness, and shallow anterior chambers require more caution since they are prone to inaccurate preoperative biometry.

The Proteins of Keratoconus: a Literature Review Exploring Their Contribution to the Pathophysiology of the Disease.

INTRODUCTION: Keratoconus (KC) is a complex, genetically heterogeneous multifactorial degenerative disorder characterized by corneal ectasia and thinning. Its incidence is approximately 1/2000-1/50,000 in the general population. KC is associated with moderate to high myopia and irregular astigmatism, resulting in severe visual impairment. KC structural abnormalities primarily relate to the weakening of the corneal collagen. Their understanding is crucial and could contribute to effective management of the disease, such as with the aid of corneal cross-linking (CXL). The present article critically reviews the proteins involved in the pathophysiology of KC, with particular emphasis on the characteristics of collagen that pertain to CXL. METHODS: PubMed, MEDLINE, Google Scholar and GeneCards databases were screened for relevant articles published in English between January 2006 and June 2018. Keyword combinations of the words "keratoconus," "risk factor(s)," "genetics," "genes," "genetic association(s)," "proteins", "collagen" and "cornea'' were used. In total, 272 articles were retrieved, reviewed and selected, with greater weight placed on more recently published evidence. Based on the reviewed literature, an attempt was made to tabulate the up- and down-regulation of genes involved in KC and their protein products and to delineate the mechanisms involved in CXL. RESULTS: A total of 117 proteins and protein classes have been implicated in the pathogenesis and pathophysiology of KC. These have been tabulated in seven distinct tables according to their gene coding, their biochemistry and their metabolic control. CONCLUSION: The pathogenesis and pathophysiology of KC remain enigmatic. Emerging evidence has improved our understanding of the molecular characteristics of KC and could further improve the success rate of CXL therapies.

Update in treatment of uveitic macular edema.

Macular edema (ME) represents the most common cause for visual loss among uveitis patients. The management of uveitic macular edema (UME) may be challenging, due to its often recalcitrant nature. Corticosteroids remain the mainstay of treatment, through their capability of effectively controlling inflammation and the associated ME. Topical steroids may be effective in milder cases of UME, particularly in edema associated with anterior uveitis. Posterior sub-Tenon and orbital floor steroids, as well as intravitreal steroids often induce rapid regression of UME, although this may be followed by recurrence of the pathology. Intra-vitreal corticosteroid implants provide sustained release of steroids facilitating regression of ME with less frequent injections. Topical nonsteroidal anti-inflammatory drugs may provide a safe alternative or adjuvant therapy to topical steroids in mild UME, predominantly in cases with underlying anterior uveitis. Immunomodulators including methotrexate, mycophenolate mofetil, tacrolimus, azathioprine, and cyclosporine, as well as biologic agents, notably the anti-tumor necrosis factor-α monoclonal antibodies adalimumab and infliximab, may accomplish the control of inflammation and associated ME in refractory cases, or enable the tapering of steroids. Newer biotherapies have demonstrated promising outcomes and may be considered in persisting cases of UME.

Collagen Cross- Linking for Paediatric Keratoconus.

BACKGROUND: Since the late 1990s corneal crosslinking (CXL) has been proposed as a new treatment option which can stop progression of keratoconus with promising results in adults. OBJECTIVE: Keratoconus presents a higher rate and faster progression in paediatric patients and for this reason prompt and effective treatment is essential. Due to its success in adult keratoconus patients, CXL has been recently applied to children in order to stop or slow progression of keratoconus in paediatric patients. CONCLUSIONS: This article will present an update of the literature on the topic of CXL in this age group.

Corneal infiltrates after corneal collagen cross-linking.

PURPOSE: To present a case of advancing keratoconus treated with corneal collagen cross-linking (CXL) with ultraviolet A (UVA) light and riboflavin complicated with sterile infiltrates. METHODS: The patient's cornea was de-epithelialized and CXL was performed with application of riboflavin and exposure to UVA light (370 nm, 3 mW/cm2) for 30 minutes. RESULTS: Early in the postoperative period, the patient presented with 11 deep stromal infiltrates of 1 to 2 mm with clear demarked edges in a circle near the limbus with some clear cornea. Corneal cultures were negative. Treatment consisted of antibiotic ofloxacin and tobramycin four times daily, and dexamethasone drops six times daily. After 2 months, scars remained evident. CONCLUSIONS: This complication has not been reported previously and may be an individual hypersensitivity reaction to the riboflavin or UVA light in the anterior stroma.

Non-contact holmium:YAG laser thermal keratoplasty for hyperopia: two-year follow-up.

PURPOSE: We evaluated the safety and efficacy of the non-contact holmium:YAG laser thermal keratoplasty (LTK) for the treatment of mild to moderate hyperopia without astigmatism. METHODS: A prospective, non-comparative case series included 50 eyes of 28 patients (aged > or =40 years) who had stable refraction and an astigmatic component < +0.50 diopters (D). We applied the non-contact pulsed holmium:YAG laser to treat the hyperopic spherical component using the Hyperion LTK System. All patients had minimum 12-month follow-up and 64% (18 patients) had 24-month follow-up. RESULTS: The mean age of patients was 48.4 +/- 8.23 years (range: 40 to 62 years). The preoperative hyperopic mean spherical equivalent refraction was +2.32 +/- 0.975 D (range: +1.00 to +4.75 D). Postoperatively, the subjective manifest refraction decreased from the preoperative mean value of +2.32 D to a mean -0.09 D at 1 month after surgery and regressed to +0.315 D at the last follow-up examination, resulting in a mean correction of +2.005 +/- 0.81 D at 24 months after surgery. Preoperatively, mean uncorrected visual acuity in LogMAR units was 0.798 +/- 0.353 and at 12 months after surgery, it was a mean 0.108 +/- 0.136. Keratometric power increased from 42.595 +/- 1.949 D before surgery to 44.605 +/- 1.626 D at 24 months after surgery. CONCLUSIONS: Holmium:YAG LTK was an acceptable alternative for the correction of mild to moderate hyperopia in this middle-aged population.

Functional and anatomic results of macular hole surgery complicated by massive indocyanine green subretinal migration.

PURPOSE: To report the functional and anatomic results of macular hole (MH) surgery complicated by massive subretinal migration of indocyanine green (ICG) dye. DESIGN: Interventional case report. METHODS: We performed standard pars plana vitrectomy surgery for a stage 3, senile idiopathic MH. After posterior vitreous detachment and vitreous removal, we instilled 2 ml of ICG (0.5%, 270 mOsm); the surgery was complicated by diffuse subretinal migration of the ICG dye but peeling of the internal limiting membrane (ILM) was performed (despite the obvious difficulties from the low contrast between the green-stained ILM overlying a green-stained subretinal space) and the rest of the procedure was completed with a final injection of 16% C3F8. RESULTS: Post-surgical optical coherence tomography confirmed the anatomic closure of the MH. Digital photography with the excitation and barrier filters for ICG showed a striking autofluorescence along the inferior vascular arcade, which remained intense 7 months after surgery. Despite the massive subretinal migration of ICG, visual acuity (VA) improved to 20/30. CONCLUSIONS: This is the first report of VA recovery despite massive subretinal migration of ICG dye during MH surgery. Subretinal migration of ICG dye may be a potential complication during MH surgery; this should alert the surgeon to limit its use, despite the possible absence of clinically apparent toxic effects.

Retinal complications of phakic intraocular lenses.

High myopia has always been a challenge for refractive correction. Current laser surgical techniques, however, fall short of correcting high refractive errors due to lack of predictability, regression, corneal ectasia, and introduction of high order optical aberration. Phakic intraocular lenses (IOL) have been proposed as an effective refractive surgical procedure for the correction of severe myopia, but, despite recent advances in implant material technology and design, their concept is still under clinical investigation. Most of the concern regarding the complications of phakic IOLs focuses on the anterior segment of the eye. This review examines the posterior segment complications associated with phakic IOL implantation, evaluates possible pathogenetic mechanisms and discusses posterior segment complications, prevention and management.

Sulcus implantation of a 3-piece, 6.0 mm optic, hydrophobic foldable acrylic intraocular lens in phacoemulsification complicated by posterior capsule rupture.

To evaluate the safety of implanting a 3-piece, 6.0 mm optic, foldable acrylic intraocular lens (IOL) in cases of posterior capsule rupture during phacoemulsification. Department of Ophthalmology, Ahepa Hospital, Aristotle University Medical School, and Interbalkan Medical Center, Thessaloniki, Greece. This prospective noncomparative case series included 28 eyes (28 patients) having phacoemulsification complicated by extensive posterior capsule rupture with or without vitreous loss. In all eyes, a 3-piece, 6.0 mm optic, foldable acrylic IOL (AcrySof MA60BM, Alcon) was implanted in the sulcus. Postoperative examination included best corrected visual acuity (BCVA), anterior segment biomicroscopy, IOL centralization and position, intraocular pressure (IOP), and fundus biomicroscopy. The follow-up was 6 months. The most common postoperative complications were transient corneal edema in 12 eyes and increased IOP in 11 eyes. Slight asymptomatic decentralization from the center of the pupil (1.0 to 2.0 mm) and pseudophacodonesis were observed in 5 eyes each. Friction of the IOL with the iris occurred in 1 eye. Clinically significant cystoid macular edema occurred in 3 eyes. The final BCVA was between 20/15 and 20/25 in 18 patients, 20/30 in 2, between 20/40 and 20/50 in 4, and between 20/60 and 20/200 in 4. AcrySof IOL implantation in the sulcus during phacoemulsification complicated by posterior capsule rupture preserved the advantages of small-incision surgery. The postoperative behavior and centralization of the IOLs resembled those of poly(methyl methacrylate) lenses.