Risk factors for a phacodonesis surprise during cataract surgery in patients with pseudoexfoliation.

PURPOSE: To evaluate the association of different pre-operative parameters with surprise phacodonesis during cataract surgery among patients with pseudoexfoliation (PXF). MATERIALS AND METHODS: This is a retrospective charts review of all PXF patients who underwent cataract surgery between the years 2013 and 2018. Pre-operative parameters (demographics, biometry, intraocular pressure (IOP), endothelial cell count, pupil size, cataract density, glaucoma status, cup to disc ratio, number of glaucoma medications, prior intra-vitreous injections, risk for intraoperative floppy iris syndrome) were compared between patients with and without surprise phacodonesis. Binary logistic regression was used to calculate the predictive value of each parameter. RESULTS: Out of 396 surgical cases with computerized pre-operative assessment, we included 127 eyes of 120 PXF patients without evidence of phacodonesis preoperatively. The mean age was 77.8 ± 12.0 years, 63 (52.7%) were male, and 106 (84.2%) underwent phacoemulsification surgery. We identified 10 cases of surprise phacodonesis during surgery (8.2%). Compared to PXF cases without intraoperative phacodonesis, they had higher pre-operative IOP (23.0 ± 11.0 mmHg vs. 14.9 ± 3.8 mmHg, p < 0.001) and a higher rate of B scan use due to dense cataract obscuring posterior pole evaluation [4 (40%) vs. 15 (12.8%), p = 0.04]. Multivariant binary logistic regression confirmed that only baseline IOP contributed to the prediction of surprise phacodonesis (OR 1.22 CI 1.04-1.43, p = 0.014). CONCLUSIONS: Among patients with PXF undergoing cataract surgery, elevated IOP and poor posterior segment visibility requiring B scan use were associated with zonular instability putting these patients at risk for intra-operative complications.

Effect of Rho-associated kinase inhibitor on human corneal endothelial cell apoptosis.

PURPOSE: To evaluate whether exposure to Rho-associated protein kinase (ROCK) inhibitor will promote human-cultured corneal endothelial cells (CECs) survival in a commercial storage medium. SETTING: Edith Wolfson Medical Center, Holon, and Sheba Medical Center, Tel Hashomer, Israel. DESIGN: Experimental study. METHODS: Fragments of human donor corneolimbal rings were stored in commercial storage media for 1 week, half with the addition of 10 µM ROCK inhibitor (Y-27632). Evaluation of CECs for early and late apoptosis\necrosis rates was performed using anti-human CD166 antibody and flow cytometric double staining analysis of propidium iodide and Annexin V. RESULTS: CECs of 6 corneolimbal rings demonstrated a reduced early apoptosis rate (4.35% ± 1.07% vs 12.18% ± 5.5%, P = .026) and a reduced late apoptosis\necrosis rate (5.5% ± 2.39% vs 9.43% ± 2.61%, P = .004) compared with control. Subsequently, the rate of apoptotic CECs expressing ROCK was significantly lower in cells exposed to ROCK inhibitor compared with cells that were not (19.01% ± 4.17 vs 30.42% ± 4.27, P < .001). CONCLUSIONS: ROCK inhibitor reduced endothelial cell loss in vitro and might be used to limit or slow CEC loss in donor corneal tissue during eye banking. This might be a promising new method for promoting future graft survival.

Prophylactic exposure of human corneal endothelial cells to Rho-associated kinase inhibitor reduced apoptosis rate after phacoemulsification: Ex vivo study.

PURPOSE: To evaluate whether prophylactic exposure of corneal endothelial cells (CECs) to a selective Rho-associated kinase (ROCK) inhibitor will inhibit CEC apoptosis after phacoemulsification. SETTING: Laboratory evaluations at the Edith Wolfson Medical Center, Holon, Israel and the Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel and the Chaim Sheba Medical Center, Tel-Hashomer, Ramat-Gan, Israel. DESIGN: Experimental study. METHOD: Human donor corneolimbal rings were divided into fragments that were stored in commercial storage media with or without the addition of 10 mM ROCK inhibitor for 1 week and were then exposed to phacoemulsification energy. Samples were dissociated into single cells by trypsin digestion and CECs were targeted using the antihuman CD166 antibody, a new biomarker. The CEC survival was evaluated for early and late apoptosis rate with flow cytometric analysis of annexin-V and propidium iodide (PI) double staining. RESULTS: Six corneoscleral rings from 4 donors were studied. After phacoemulsification, CEC exposed to ROCK inhibitor demonstrated a 37.06% reduction in early apoptosis rate (29.36% ± 4.33% [SD] versus 46.65% ± 1.51%, P = .006) and 45.27% reduction in late apoptosis rate (17.6% ± 16.81% versus 32.16% ± 26.30%, P = .007), compared with controls. Subsequently, ROCK levels in apoptotic CECs were significantly lower in cells incubated with ROCK inhibitor than the control medium. CONCLUSIONS: In this ex vivo study, ROCK inhibitor reduced endothelial loss and thus, could be used to limit or slow down CEC loss. Rho-associated kinase inhibitor might be used before cataract surgery, especially in high risk patients. This might be a promising new method for preventing pseudophakic bullous keratopathy.

Predicting Refractive Surgery Outcome: Machine Learning Approach With Big Data.

PURPOSE: To develop a decision forest for prediction of laser refractive surgery outcome. METHODS: Data from consecutive cases of patients who underwent LASIK or photorefractive surgeries during a 12-year period in a single center were assembled into a single dataset. Training of machine-learning classifiers and testing were performed with a statistical classifier algorithm. The decision forest was created by feature vectors extracted from 17,592 cases and 38 clinical parameters for each patient. A 10-fold cross-validation procedure was applied to estimate the predictive value of the decision forest when applied to new patients. RESULTS: Analysis included patients younger than 40 years who were not treated for monovision. Efficacy of 0.7 or greater and 0.8 or greater was achieved in 16,198 (92.0%) and 14,945 (84.9%) eyes, respectively. Efficacy of less than 0.4 and less than 0.5 was achieved in 322 (1.8%) and 506 (2.9%) eyes, respectively. Patients in the low efficacy group (< 0.4) had statistically significant differences compared with the high efficacy group (≥ 0.8), yet were clinically similar (mean differences between groups of 0.7 years, of 0.43 mm in pupil size, of 0.11 D in cylinder, of 0.22 logMAR in preoperative CDVA, of 0.11 mm in optical zone size, of 1.03 D in actual sphere treatment, and of 0.64 D in actual cylinder treatment). The preoperative subjective CDVA had the highest gain (most important to the model). Correlations analysis revealed significantly decreased efficacy with increased age (r = -0.67, P < .001), central corneal thickness (r = -0.40, P < .001), mean keratometry (r = -0.33, P < .001), and preoperative CDVA (r = -0.47, P < .001). Efficacy increased with pupil size (r = 0.20, P < .001). CONCLUSIONS: This model could support clinical decision making and may lead to better individual risk assessment. Expanding the role of machine learning in analyzing big data from refractive surgeries may be of interest. [J Refract Surg. 2017;33(9):592-597.].

Induced De Novo Astigmatism After Hyperopic LASIK Versus Myopic LASIK Surgery in Nonastigmatic Eyes.

PURPOSE: To compare the astigmatism induced surgically (SIA) by spherical hyperopic laser in situ keratomileusis (H-LASIK) versus myopic laser in situ keratomileusis (M-LASIK) in nonastigmatic eyes. METHODS: A retrospective study of patients who underwent LASIK surgery between 2005 and 2014 at the Care-Vision Laser Center, Israel. We calculated the mean absolute SIA and performed risk factor analysis for induced astigmatism. Differences between H-LASIK and M-LASIK were analyzed. RESULTS: Eyes of 3877 patients who underwent M-LASIK and of 549 patients who underwent H-LASIK were nonastigmatic preoperatively and received a nonastigmatic treatment. Three months after surgery, hyperopic treatment induced more SIA (0.49 ± 0.48 D) than did myopic treatment (0.36 ± 0.4 D) (P < 0.001). In the H-LASIK group, the risk factors for induced astigmatism of >0.5 D were a higher preoperative refractive error (P = 0.003) and larger optical zone (7 vs. 6 mm). In the M-LASIK group, eyes with SIA >0.5 D tended to have steeper corneas preoperatively (43.8 ± 1.5 vs. 43.6 ± 1.4 D; P = 0.001), a higher spherical equivalent (-3.43 ± 1.53 Vs. -3.07 ± 1.45 P < 0.001), and smaller treatment zones (6 vs. 7 mm). In H-LASIK, the mean induced astigmatic axis was at 74.6 degrees. CONCLUSIONS: There was a consistent trend toward more SIA in H-LASIK and in higher refractive error correction. In H-LASIK larger optical zones induce more SIA and in M-LASIK smaller ones caused it.

Corneal Staining and Hot Black Tea Compresses.

BACKGROUND: Warm compresses are widely touted as an effective treatment for ocular surface disorders. Black tea compresses are a common household remedy, although there is no evidence in the medical literature proving their effect and their use may lead to harmful side effects. OBJECTIVES: To describe a case in which the application of black tea to an eye with a corneal epithelial defect led to anterior stromal discoloration; evaluate the prevalence of hot tea compress use; and analyze, in vitro, the discoloring effect of tea compresses on a model of a porcine eye. METHODS: We assessed the prevalence of hot tea compresses in our community and explored the effect of warm tea compresses on the cornea when the corneal epithelium's integrity is disrupted. An in vitro experiment in which warm compresses were applied to 18 fresh porcine eyes was performed. In half the eyes a corneal epithelial defect was created and in the other half the epithelium was intact. Both groups were divided into subgroups of three eyes each and treated experimentally with warm black tea compresses, pure water, or chamomile tea compresses. We also performed a study in patients with a history of tea compress use. RESULTS: Brown discoloration of the anterior stroma appeared only in the porcine corneas that had an epithelial defect and were treated with black tea compresses. No other eyes from any group showed discoloration. Of the patients included in our survey, approximately 50% had applied some sort of tea ingredient as a solid compressor or as the hot liquid. CONCLUSIONS: An intact corneal epithelium serves as an effective barrier against tea-stain discoloration. Only when this layer is disrupted does the damage occur. Therefore, direct application of black tea (Camellia sinensis) to a cornea with an epithelial defect should be avoided.

Comparison of the Tolerability of Diclofenac and Nepafenac.

PURPOSE: Topical nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used for the prevention and treatment of inflammation and pain following cataract surgery. Preservative-free diclofenac and nepafenac drops are commonly used ophthalmic NSAIDs. The purpose of this study was to compare the tolerability of diclofenac to that of nepafenac. METHODS: In this prospective patient-blinded study, consecutive patients undergoing cataract surgery were included. One drop of nepafenac 0.1% and diclofenac sodium 0.1% were instilled in the right and left eyes, respectively, one immediately after the other, 1 day before surgery. Visual analog scale (scale 0-10) was used to measure patient discomfort, itching, burning, and pain at 1 second (s), 15 s, 1 minute (min), and 5 min postadministration. RESULTS: Overall, 44 eyes of 22 patients were included in this study. Diclofenac and nepafenac had high and similar tolerability at all time points with no significant difference regarding all aspects of tolerability. A vast majority of patients (72%) did not prefer 1 drop over the other in terms of overall comfort. CONCLUSIONS: Both diclofenac and nepafenac seem to have similar high tolerability. Diclofenac may be an affordable alternative to nepafenac and therefore should be considered by prescribing physicians, specifically in preoperative cataract patients.

[Parents compliance to perform the voiding cystourethrogram test after urinary tract infection].

UNLABELLED: Urinary tract infections (UTIs) occur in 3-5% of girls and 1% of boys. UTIs have been considered an important risk factor for the development of renal insufficiency, hypertension or end-stage renal disease. Hence, there is a need for early diagnosis and management of UTI to prevent renal scarring. The guidelines concerning the prophylactic treatment and the imaging studies have changed during the past year. It was believed that reflux predisposed to renal infection (pyelonephritis) by causing renal injury or scarring and that imaging studies in children with UTI were meant to identify anatomic abnormalities that predispose them to infection and renal scaring. Today, this concept is no longer prevalent and there is no recommendation to perform voiding cystourethrogram (VCUG] after every UTI. AIM: To examine parents' compliance to perform a VCUG test after hospitalization due to UTI and factors affecting their decision. METHODS: We performed a retrospective study that included all children who were hospitalized and diagnosed with UTI at "Dana" Children's Medical Center during the period 1/2004 - 12/2005. Hospital file records were collected, and the relevant data were obtained. We collected data regarding the parents' compliance to perform a VCUG according to a telephone interview. RESULTS: A total of 227 children participated in the study; 179 (78.85%) parents agreed to partake in the interview. Overall, 52% of the children didn't perform the VCUG because of concern about exposure to radiation (55.91%), fear and distress from pain during the test (43.03%), fear of irreversible damage to the urinary tract (40.86%), lack of relevant information (35.48%] and the primary pediatrician's recommendation to postpone the test. The remaining 48% conducted the test because of the hospital doctor's recommendation (94.18%), Primary pediatrician recommendation (94.18%) and because of the desire to terminate prophylactic treatment (63.95%). There is a significant correlation between the doctors' recommendation and the extent and clarity of their explanation to the parents' understanding of the importance of the test, to the parents' satisfaction from the explanation and to the compliance to perform the test. CONCLUSIONS: There is a need to improve the doctors' explanation regarding the performance of VCUG test post UTI. This will improve the patients' compliance to perform their post discharge recommendation.