Combined Femtosecond Laser-Assisted Keratotomy and Cataract Surgery for Enhancing Refractive Outcomes. An Indonesian Case Study.

Purpose: We evaluate the reduction of corneal astigmatism and the improvement of visual outcomes of this surgical method in the Indonesian population. We also assess the accuracy and predictability of using femtosecond laser astigmatic keratotomy (FLAK) combined with cataract surgery. Patients and Methods: In a retrospective study, a total of 275 subjects (78 with against-the-rule (ATR) astigmatism, 178 with with-the-rule (WTR) astigmatism, and 19 with oblique (OBL) astigmatism) with preexisting corneal astigmatism ranging from 0.75D to 3.00D underwent FLAK. All subjects completed a 3-month follow-up. The femtosecond laser used for creating paired AK 2.2 mm, primary incision, and paracentesis incision was the FEMTO Z8 NEO from Ziemer Ophthalmic System, Switzerland. The surgical approach was guided by the "NAPA" nomogram. Results: The reduction in postoperative astigmatism was 56.90% for the WTR group, 49.46% for the ATR group, and 47.33% for the oblique group. A significant reduction in astigmatism was observed at the 1-week, 1-month, and 3-month follow-up intervals in both the WTR and ATR groups. The reduction in astigmatism was more favorable in cases of moderate astigmatism within the WTR group, as compared to the ATR and oblique groups. Postoperative astigmatism reduction was found to be more predictable in the right eye than in the left eye. Conclusion: The combination of FLAK can be considered as a potential method for reducing corneal astigmatism ranging from 1.00D to <3.00D. The highest reduction was observed in the WTR group, along with a higher rate of intended correction without astigmatism meridian shift in the right eye for the WTR group. However, factors such as cyclotorsion resulting from the surgical technique, alignment of docking, incision length, and preoperative astigmatism need to be taken into account for further enhancement and predictability of astigmatism reduction with this method.

Serum apolipoprotein A1 and B are associated with 6-month persistent and incident diabetic macular oedema in type 2 diabetes.

AIMS: To investigate the associations of baseline apolipoprotein A1 (ApoA1) and B (ApoB) levels with persistent and incident diabetic macular oedema (DMO) after 6 months of follow-up. METHODS: This is a prospective cohort study of patients aged ≥30 years with untreated diabetic retinopathy. Examinations, fundus photography and spectral domain optical coherence tomography (SD-OCT) were assessed at baseline, 1, 3 and 6 months. Serum lipids and apolipoproteins were analysed at a pathology laboratory. DMO was confirmed using SD-OCT, classified as (1) incident DMO, (2) persistent DMO and (3) regressed DMO. Eye-specific data were used, controlling for covariates and cluster effect. RESULTS: We recruited 53 patients but only 38 completed the study [(62 eyes), 20 eyes (32.3%) with DMO]. Higher quartile of ApoA1 was associated with lower risk of persistent/incident DMO (p for trend 0.02), while higher ApoB/A1 was associated with higher risk of persistent/incident DMO (p for trend 0.02). Every 10 mg/dL increase in ApoA1 levels was associated with lower risk of persistent/incident DMO (OR 0.69; 95% CI 0.49 to 0.92; p value 0.016), whereas every 0.2 increase in ApoB/A1 was significantly associated with higher risk of persistent/incident DMO (OR 1.4; 95% CI 1.1 to 1.9; p value 0.013) at the end of the study. CONCLUSION: Individuals with diabetes with higher ApoA1 had lower risk of persistent/incident DMO and those with higher ApoB/A1 had higher risk of persistent/incident DMO at the end of 6 months. These suggest that serum ApoA1 and ApoB/A1 levels may be important risk factors for DMO and could be predictive of persistent/incident DMO despite anti-vascular endothelial growth factor treatment.

Effects of SGLT2 inhibitor administration on blood glucose level and body weight in type 1 diabetes rat model.

The prevalence of diabetes worldwide is increasing and 629 million people are projected to have diabetes by 2045, and the most significant burden of the disease being concentrated in low- and middle-income countries (LMICs). Type 2 diabetes is mainly treated with insulin adjunctive therapies such as metformin to improve insulin sensitivity and sodium-glucose co-transporter 2 (SGLT2) inhibitors to lower blood glucose levels. However, there was limited study on the application of SGLT2 inhibitors on type 1 diabetes, particularly empagliflozin. Therefore, this study aimed to determine the effect of SGLT2 inhibitors on blood glucose levels and body weights in a rat model of type 1 diabetes. To mimic type 1 diabetes, the rats were injected with streptozotocin 60 mg intra-peritoneally. Twenty-four rat models were randomly divided into four groups: normal rat group (negative control), untreated diabetic rat group (positive control), type 1 diabetic rats treated with metformin, and type 1 diabetic rats treated with empagliflozin. Blood glucose levels and body weight were recorded before and after induced with streptozotocin and on weeks 4, 6, 8 and 10 of the treatment with anti-diabetic drugs. This study found that the blood glucose levels before and after treatment significantly decreased in all groups (p<0.05), except in the negative control group. Similar results were observed in body weight of the rats, which all groups experienced weight loss, except the negative control. These results suggested that apart from being used in type 2 diabetes, SGLT2 inhibitors may also be used as a treatment for type 1 diabetes.

Modified tarsorrhaphy versus gold weight implant technique for paralytic lagophthalmos treatment in patients with leprosy: One-year observation of a randomized controlled trial study.

Trial design: This study was a multicenter, Prospective Randomized Open-label Blinded-Endpoint (PROBE) clinical trial, parallel-group study conducted in Indonesia (three sites). Methods: The aim of this study was to compare the effectivity and efficiency of modified tarsorrhaphy (MT) and gold weight implant (GWI) techniques in the surgical treatment of paralytic lagophthalmos in patients with leprosy. The study sample consisted of 23 eyes, with 11 eyes in the MT group and the remaining 12 eyes in the GWI group-the control group. Results: The central eyelid margin distance (lagophthalmos distance) decreased when gentle pressure was applied in the MT (3.09 mm to 0.43 mm) and GWI groups (3.21 mm to 0.83 mm) at postoperative year 1. The Ocular Surface Disease Index score, the tear break-up time, and the Schirmer test without and with anesthesia in the MT and GWI groups showed a p-value of > 0.05. Epitheliopathy improvement occurred in 54.55% of the MT group and 58.33% of the GWI group. Corneal sensitivity change in the inferior quadrant of the MT group (50.00 to 51.30 mm) and in the GWI group (49.61 to 52.93 mm) resulted in a p > 0.05. Postoperative complications occurred in 15% of patients in the GWI group. In addition, the surgery duration of both techniques was similar. Furthermore, the surgery cost in the MT and GWI groups yielded a p < 0.05. Conclusion: The MT technique is as effective as the GWI technique but more efficient than the GWI technique as a surgical treatment for paralytic lagophthalmos in patients with leprosy. Clinical trial registration: [www.ClinicalTrials.gov], identifier [NCT0494 4498].

Association Between Anterior Chamber Angle and Corneal Endothelial Cell Density in Chronic Angle Closure.

PURPOSE: To study the association between corneal endothelial cell density (ECD) and degree of anterior chamber angle (ACA) opening in eyes with chronic angle closure glaucoma. METHODS: The study was conducted at JEC Eye Hospitals in Indonesia. Treatment-naïve patients aged ≥40 years with IOP >21 mmHg and peripheral anterior chamber depth (ACD) grade 2 or less by Van Herick's technique were recruited. Trabecular iris angle (TIA; degree) was measured using anterior segment optical coherence tomography (AS-OCT) and classified as: grade 1 ≤10°, grade 2 11-20°, and grade 3 >20°. Noncontact specular microscopy was performed, and the following corneal parameters were obtained:ECD (cells/mm2), coefficient of variation (CV; µm2/cell), percentage of hexagonal cells, and central corneal thickness (CCT; µm). RESULTS: A total of 52 eyes from 52 subjects were recruited (16 grade 1 TIA, 24 grade 2 TIA, and 12 grade 3 TIA). Presenting IOP was not significantly different between groups. The median central corneal ECD was 2684.5 (1433-2934), 2587.0 (1902-3103), and 2441.0 (1659-3005) cells/mm2 in grade 1, 2, and 3 TIA, respectively, with no significant differences across the groups (P = 0.67). The CV was lowest in grade 3 TIA (36.4 ± 7.2 µm2/cell), and highest in grade 1 TIA (38.3 ± 9.6 µm2/cell), but the differences were not significant (P = 0.74). Likewise, the percentage of hexagonality and CCT was not significantly different. TIA was not correlated with IOP but was modestly correlated with age. CONCLUSION: The corneal ECD and morphological characteristics such as CV and hexagonality were not significantly different across various TIA grading in chronic angle closure. This may reflect the lack of chronic and gradual IOP insult on corneal endothelial parameters as TIA did not show direct effect towards IOP.

Concept and application of relaxing radial retinectomy for retinal detachment with advanced proliferative vitreo-retinopathy.

PURPOSE: To revisit the concept of retinectomy and the theory of mechanical forces on the retina occurring in rhegmatogenous retinal detachment (RRD) and to describe the potential application of radial retinectomy in RRD with advanced proliferative vitreoretinopathy (PVR). METHODS: A literature search was performed to identify all English language articles reporting the use of retinectomy for the management of RRD with PVR. We reviewed the theoretical background of mechanical forces occurring in RRD. RESULTS: Detachment of the retina from the retinal pigment epithelium (RPE)/choroid is influenced by disequilibrium of several physical forces: tangential forces on the epiretinal membrane T 1 and radial traction on the retina F R exceeding the retinal adhesion force to the RPE T 1 + F R > F A . PVR may exaggerate the amounts of tangential and radial forces ( T 1 and F R ) that pull the retina off. Relaxing radial retinectomy, by the nature of its cutting pattern, may theoretically decrease the amounts of both forces, therefore restoring the equilibrium between tensile and adhesive forces on the retinal surface T 1 + F R = F A . CONCLUSION: Relaxing radial retinectomy may potentially be applied in RRD with advanced PVR but has rarely been reported to date. Future studies are needed to evaluate its outcomes and long-term complications.

Prevalence of Dry Eye and its Subtypes in an Elderly Population with Cataracts in Indonesia.

PURPOSE: To describe the prevalence of dry eye disease (DED) and its subtypes in elderly population with cataracts prior to surgery in Jakarta, Indonesia. PATIENTS AND METHODS: Forty-nine eyes of 49 patients (16 males, 33 females; mean age: 66.6 years) planned for phacoemulsification surgery were consecutively recruited from two tertiary eye hospitals in this hospital-based cross-sectional study. Symptoms were assessed using the Ocular Surface Disease Index (OSDI) questionnaire, and the patient was defined as symptomatic if their OSDI score was ≥13. Objective examinations included the noninvasive tear film break up time (NIBUT) and Schirmer tests. The results were deemed abnormal if they were <10 seconds and <10 mm for NIBUT and Schirmer, respectively. RESULTS: Participants were classified into four groups: DED (positive symptoms and short NIBUT), preclinical dry eye (positive symptoms without short NIBUT), predisposition to dry eye (short NIBUT without symptoms), and normal group. Median OSDI score was 12.5 (0-45.0), NIBUT was 10.4 (5.1-28.9) seconds, and Schirmer score was 8.0 (2.0-28.0) mm. The prevalence of DED, preclinical dry eye, and predisposition to dry eye were 22.5%, 22.5%, and 26.5%, respectively, while the other 28.5% subjects were normal. The DED group had significantly lower Schirmer test results (4.0 [2-17] mm) compared to all other groups. Older age (>70 years) was associated with poorer NIBUT and Schirmer test results and a significant difference between age groups was observed, especially in males. CONCLUSION: Dry eye is a common problem among the elderly population with cataracts in Indonesia. Almost half of the subjects presented with dry eye symptoms and either categorized as DED or preclinical dry eye, while more than one quarter were predisposed to dry eye. Care must be taken prior to cataract surgery to rule out existing dry eye with additional attention on those presenting without any symptoms as dry eye may develop after surgery.

Sensitivity change in cornea and tear layer due to incision difference on cataract surgery with either manual small-incision cataract surgery or phacoemulsification.

PURPOSE: To describe corneal sensitivity changes caused by different incision methods-manual small-incision cataract surgery (manual SICS) and phacoemulsification-and their influence on tear film quantity and quality. METHODS: This was a prospective observational study conducted in 30 subjects undergoing manual SICS or phacoemulsification. Corneal sensitivity was assessed before and 1, 7, and 15 days after surgery by Cochet-Bonnet esthesiometer. Tear meniscus, noninvasive breakup time, lipid pattern, and Schirmer test results were evaluated. Patient symptoms were reviewed based on the Ocular Surface Disease Index. RESULTS: In the group undergoing phacoemulsification, corneal sensitivity decreased at the incision site and at other sites on days 1, 7, and 15 after surgery, whereas in the group undergoing manual SICS, no change in corneal sensitivity was noted. Between-group difference in corneal sensitivity was significant on days 1, 7, and 15. Aqueous production significantly (P = 0.016) increased on the first day in both groups and returned to presurgery level on day 15. Tear film quality decreased on day 1 only in the group undergoing manual SICS (P = 0.035). Tear meniscus and tear lipid profile showed no change in either group. Patient symptoms significantly increased on day 1 in both groups, and the difference between the 2 groups was significant on day 15 (P = 0.044). CONCLUSIONS: Compared with manual SICS, temporal-side incision in phacoemulsification decreased corneal sensitivity in the incision site and other sites until day 15 and changes in tear film quantity and patient symptoms only on day 1.

AlphaCor cases: comparative outcomes.

PURPOSE: To describe clinical outcomes after a novel type of corneal surgery, implantation of an artificial cornea, AlphaCor , and to evaluate outcomes in comparison with alternative keratoprostheses and high-risk grafts. METHODS: Case reports and data from a noncontrolled clinical trial and a literature review. RESULTS: The probability of AlphaCor retention to 1 year is 80%. Postoperative best corrected visual acuity ranges from Perception Light to 20/30. The most significant complications are stromal melts and optic depositions, for both of which the main risk factors have been identified. Complications can be managed without loss of the eye. CONCLUSION: Results from the clinical trial period have helped to determine the indications and risk factors for AlphaCor surgery and to refine surgical techniques. Continued monitoring of outcomes as the series increases will allow a more accurate determination of comparative outcomes. The series provides preliminary evidence that AlphaCor may have a lower incidence of complications than traditional keratoprostheses and may prove to be preferable to a donor graft in high-risk cases.

Outcomes of implantation of an artificial cornea, AlphaCor: effects of prior ocular herpes simplex infection.

PURPOSE: To review outcomes of AlphaCor artificial cornea implantation in patients with and without a history of ocular herpes simplex virus (HSV) and to determine whether herpetic eye disease is an indication for AlphaCor surgery. METHODS: Outcomes of the initial 40 implantations were reviewed and stratified by the presence of a history of ocular disease caused by HSV. Outcomes measures (complications, visual acuity gained) were compared. RESULTS: Eight of the 40 AlphaCor implantations (20%) were in patients with a history of ocular HSV. Six of these eight patients (75%) developed melt-related complications after AlphaCor insertion. Half of the affected patients required removal of the AlphaCor and replacement with a donor corneal graft to restore ocular integrity. In comparison, only six of the 32 (18.8%) patients without HSV developed a melt after AlphaCor insertion. Patients with HSV with devices in situ exhibited a mean loss of 0.3 line of best-corrected visual acuity compared with the preoperative visual acuity, whereas patients without HSV exhibited a mean gain of 1.4 lines of best-corrected visual acuity. CONCLUSIONS: The extensive lamellar corneal surgery involved in AlphaCor implantation may precipitate reactivation of latent HSV such that reactivation and resultant inflammation reduce device biointegration and facilitate melting of corneal stromal tissue anterior to the device. Although there may be some benefit from systemic antiviral medication, the current series is not large enough to demonstrate such a benefit, and melting can occur despite medication. The statistically significant difference in outcomes between recipients of AlphaCor with and without HSV is evidence that a history of HSV should be an exclusion factor for AlphaCor surgery.