Online Questionnaire-Based Study on the Knowledge, Attitude, and Practices of Non-Ophthalmic Physicians-in-Training Regarding Exposure Keratopathy Among Patients Admitted in a Tertiary Referral Hospital.

Objective: This study aimed to determine the knowledge, attitude, and practices of non-ophthalmic physicians-in-training regarding recognition and prevention of exposure keratopathy among patients admitted in a tertiary referral hospital. Methods: This study was a single-center cross-sectional study. An anonymous self-administered online questionnaire was distributed among non-ophthalmic physicians-in-training at the Philippine General Hospital (PGH) using convenience and snowball sampling. Results: A total of 77 responses were recorded with a response rate of 37%. The majority of the respondents uniformly reported the absence of an established eye care protocol or policy being implemented for different subsets of patients at risk for developing exposure keratopathy. Ninety-six percent (96%) was aware of exposure keratopathy. The most urgent reason for referral to the ophthalmology service was the presence of whitish of opacity at 46.8%, while the least urgent reason was the presence of eye redness at 36.4%. Only 43% of the patients with incomplete eyelid closure was referred to the ophthalmology service. The most frequently used modality of prophylactic eye protection treatment was eyelid taping (84.4%) followed by lubricants (drops and gels, 79.1%). The most common reason for not referring was the absence of an established protocol on the appropriate indication for referral to the ophthalmology service. Conclusion: This study showed that the majority of non-ophthalmic physicians-in-training had adequate knowledge and favorable attitude regarding recognition and prevention of exposure keratopathy among patient admitted at the PGH; however, the absence or the unavailability of an eye care protocol among patients with inadequate eyelid closure in our institution on the prevention of exposure keratopathy and its early treatment and appropriate indications for ophthalmology referral resulted in non-uniformity and varied practice patterns on its management.

Cyclosporine Anionic and Cationic Ophthalmic Emulsions in Dry Eye Disease: A Literature Review.

Purpose: There are no clinical studies directly comparing anionic and cationic emulsions of cyclosporine for the treatment of dry eye disease (DED). We therefore conducted a literature review to evaluate the efficacy and safety of these different formulations.Methods: A literature search was performed in Embase and Medline from January 1999 to May 2019 to identify publications that evaluated clinical outcomes with either cyclosporine anionic or cationic emulsion in patients with moderate-to-severe or severe DED.Results: Thirteen publications met criteria. In patients with moderate-to-severe disease, evidence demonstrated improvement in the signs of DED with both formulations. However, improvement in symptoms was not consistently demonstrated. Studies specifically in severe DED were only identified with the cationic emulsion and showed improvement in the objective signs of DED. There were no obvious differences in tolerability between products.Conclusions: Both formulations are effective for the treatment of moderate-to-severe DED and are well tolerated.

Infectious endophthalmitis at a Philippine tertiary hospital: a ten-year retrospective study.

BACKGROUND: Endophthalmitis is a sight-threatening disease characterized by marked progressive inflammation of the vitreous and/or aqueous humors. Limited information is currently available regarding endophthalmitis in the Philippines. This study aimed to provide long-term summary data on endophthalmitis cases seen at the largest tertiary referral hospital in the Philippines. METHODS: All endophthalmitis cases diagnosed at the Philippine General Hospital from January 1, 2007 to December 31, 2016 were retrieved and classified by etiology. Data pertaining to history, associated risk factors, isolated microorganisms, management, and final visual outcomes for each patient were reviewed. RESULTS: A total of 202 cases diagnosed within the audit period were included in the study. These were classified as post-traumatic (55.94%), endogenous (14.36%), acute post-operative (10.40%), keratitis-induced (6.93%), chronic post-operative (5.44%), bleb-associated (3.96%), and suture-associated (2.97%) endophthalmitis. Males comprised 71.29% of the population, while the largest age group affected was 0-10 years (24.75%). The culture-positive rate was 57.89%. The predominant etiology was Gram-positive bacteria (38.18%), followed by Gram-negative bacteria and mixed pathogens (21.82% each), and fungi (18.18%). The most common organisms were Streptococcus, Staphylococcus, Pseudomonas, Aspergillus, and Candida, accounting for 56.45% of isolates. Pars plana vitrectomy was done for 62.87% of patients, intravitreal and other antibiotic therapy in 23.27%, and primary enucleation/evisceration in 10.89%. The final outcomes and best corrected visual acuities were: anophthalmia 11.86%, no light perception/no dazzle 27.84%, light perception 8.76%, hand motions 24.23%, counting fingers 5.15%, 3/200 to 20/50 12.89%, and 20/40 to 20/20 9.28%. CONCLUSIONS: There was a higher proportion of post-traumatic endophthalmitis cases compared to traditional estimates but consistent with studies from China and Thailand. The majority of these cases involved younger children as well as young to middle-aged males engaged in carpentry and construction work, implying a need for increased public health awareness and strengthening of childcare and workplace safety policies. Our microbiologic profile showed a lower proportion of Gram-positive infections and a higher proportion of mixed pathogen infections compared to other studies. There was also a higher proportion of fungi associated with post-operative and keratitis-induced endophthalmitis. The best outcomes were seen in acute post-operative and bleb-associated endophthalmitis, and the worst outcomes in endogenous and keratitis-induced endophthalmitis. Visual outcomes were poorer compared to other Western and Asian countries, with only 21.7% of patients improving from presentation.

Large graft tectonic penetrating keratoplasty in a case of severe aspergillus keratitis.

Penetrating keratoplasty is indicated for cases of severe microbial keratitis, particularly if associated with impending corneal perforation. The case report details a 45-year-old male farmer who consulted for blurring of vision in the left eye after an incident wherein mud was flung onto his eye during farming. He noted eye redness and a growing opacity on his left eye. He was initially treated with topical antimicrobial and corticosteroid medication which did not resolve his symptoms. He presented with a visual acuity of hand movement on the affected eye. Slit lamp examination showed a large protruding mound-like plaque, occupying almost the entire corneal surface of the left eye, with associated scleritis. The ocular ultrasound was unremarkable. The patient was diagnosed with fungal keratitis, which culture from corneal scraping showed to be from an infection with Aspergillus. A tectonic penetrating keratoplasty with 360-degree iridectomy, lens extraction, and anterior vitrectomy was immediately done, and a regimen consisting of topical natamycin was started. Despite the severe presentation of the fungal corneal infection, the eye was fortunately salvaged.

Corneal melt following corneal tattooing with carbon-based ink.

PURPOSE: to report a case of corneal melting following corneal tattooing with carbon-based ink. OBSERVATIONS: A 67 year old female with a phthisical eye underwent corneal tattooing with carbon-based ink for purpose of cosmesis. The procedure was uncomplicated. At 8 weeks postoperatively, she presented with almost complete corneal melt with uveal prolapse. There was no evidence of infection. The patient underwent evisceration. Histopathologic examination of the excised corneal button showed melting of the epithelium and anterior stromal layers, diffuse inflammation of the deeper stromal layers, and disorganized Descemet membrane and endothelium with adherent iris tissue. CONCLUSIONS AND IMPORTANCE: Corneal melting can occur as a rare complication of corneal tattooing with carbon-based ink.

A New Perspective on Dry Eye Classification: Proposal by the Asia Dry Eye Society.

The 2017 consensus report of the Asia Dry Eye Society (ADES) on the definition and diagnosis of dry eyes described dry eye disease as "Dry eye is a multifactorial disease characterized by unstable tear film causing a variety of symptoms and/or visual impairment, potentially accompanied by ocular surface damage." The report emphasized the instability of tear film and the importance of visual dysfunction in association with dry eyes, highlighting the importance of the evaluation of tear film stability. This report also discussed the concept of tear film-oriented therapy, which stemmed from the definition, and which is centered on provision of insufficient components in each tear film layer and ocular surface epithelium. The current ADES report proposes a simple classification of dry eyes based on the concept of tear film-oriented diagnosis and suggests that there are three types of dry eye: aqueous-deficient, decreased wettability, and increased evaporation. It is suggested that these three types respectively coincide with the problems of each layer: aqueous, membrane-associated mucins, and lipid/secretory mucin. Although each component cannot be quantitatively evaluated with the current technology, a practical diagnosis based on the patterns of fluorescein breakup is recommended. The Asia Dry Eye Society classification report suggests that for a practical use of the definition, diagnostic criteria and classification system should be integrated and be simple to use. The classification system proposed by ADES is a straightforward tool and simple to use, only through use of fluorescein, which is available even to non-dry eye specialists, and which is believed to contribute to an effective diagnosis and treatment of dry eyes.

Comparison of Small Incision Lenticule Extraction (SMILE) and Femtosecond Laser In-Situ Keratomileusis (F-LASIK) for the correction of myopia and astigmatism: 1-year clinical outcome

@#<p style="text-align: justify;"><strong>OBJECTIVE:</strong> To compare the efficacy, refractive predictability, stability and safety of Small Incision Lenticule Extraction (SMILE) and Femtosecond Laser In-Situ Keratomileusis (F-LASIK) for the correction of myopia and astigmatism.</p> <p style="text-align: justify;"><strong>METHOD:</strong> This study was approved by the Institutional Review Committee of the St. Luke's Medical Center. A retrospective chart review was conducted at the Vision Laser Center of the St. Luke's Medical Center-Global City. All patients that underwent SMILE from January 2014 to July 2014, with adequate follow-up at 1 day, 1 week, 1 month, 3 months and 1 year, were included in the study. Age-matched and refraction-matched patients, who underwent F-LASIK from January 2012 to April 2014, were chosen as comparators. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), attempted refraction versus achieved refraction and adverse events at 1 day, 1 week, 1 month, 3 months and 1 year were compared postoperatively in both groups. Primary outcome measures were efficacy expressed as the percentage of eyes achieving UCVA of 20/25 or better during the postoperative follow-up, refractive predictability, safety and stability. </p> <p style="text-align: justify;"><strong>RESULTS:</strong> Thirty-five eyes of 18 patients who underwent SMILE and 38 eyes of 19 patients who underwent FLASIK were included in the study. The mean preoperative spherical equivalent of both groups had no statistical difference, with -3.84 ± 1.31 D and -4.07 ± 1.39 D for SMILE and F-LASIK, respectively (p=0.801). At 1 week postoperatively, 51% and 97% achieved UCVA of 20/25 or better in the SMILE and F-LASIK groups. At 3 months, 97% had 20/25 vision or better for the SMILE group, while 100% had 20/25 vision or better for the F-LASIK group. At 1 year, both groups achieved 100% 20/25 or better vision. Three percent lost one line of BCVA in both groups at 1 year. Mean spherical equivalent (SE) between groups at 1 year showed no statistically significant difference (p=0.21), with 0.05 ± 0.18 D in the SMILE group and -0.1 ± 0.15 D in the F-LASIK group. No significant change in mean SE was observed within groups from 1 day to 1 year post op, p=0.166 for SMILE and p=0.226 for F-LASIK. At 1 year, 100% of the SMILE and F-LASIK groups were within ± 0.5 D of target refraction. No adverse events were noted in either group. </p> <p style="text-align: justify;"><strong>CONCLUSION:</strong> SMILE was comparable to F-LASIK in terms of visual outcomes (efficacy, refractive predictability, stability) and safety for the treatment of myopia and astigmatism. However, a slight delay in visual improvement during the first week was observed in the SMILE group.</p>

Nontuberculous mycobacterial infection after clear corneal phacoemulsification cataract surgery: a report of 13 cases.

PURPOSE: To review the patient profile, clinical presentation, management, and outcomes of nontuberculous mycobacterial (NTM) infection after clear corneal phacoemulsification. METHODS: Review of consecutive cases diagnosed with NTM infection after phacoemulsification from 2004 to 2009. Demographic data, clinical characteristics, diagnosis, treatment, and outcomes were analyzed. RESULTS: Thirteen eyes of 13 patients with mean age of 61.1 years, consisting of 7 men and 6 women were included. Twelve of 13 eyes (92%) underwent uncomplicated clear cornea phacoemulsification with posterior lens implant. Mean interval from surgery to onset of symptoms was 6.3 weeks, and time to referral ranged from 2 days to 9 months. Ten eyes (77%) presented with stromal wound abscess, whereas 3 (23%) appeared as iridocyclitis with posterior capsule plaques. Five eyes were clustered while the rest were isolated cases. All cases were culture positive for NTM. Two cases were treated medically, 3 had removal of lens implant and capsule, and 8 had penetrating keratoplasty with or without removal of lens implant, iridectomy, and/or pars plana vitrectomy. After a mean follow-up of almost 22 months, best-corrected visual acuity of 20/40 or better was achieved in half of the cases (54%). One case of recurrence was noted. CONCLUSIONS: NTM infection should be suspected in patients presenting with corneal stromal wound abscess or iridocyclitis with posterior capsular plaques 6 to 7 weeks after phacoemulsification. Early diagnosis and treatment can lead to good outcomes, and management should include a combination of medical and surgical therapies.

Carbomer versus carbomer with triglyceride in the treatment of dysfunctional-tear syndrome

Purpose: To compare the efficacy of carbomer alone and carbomer with triglyceride in relieving ocular discomfort and improving ocular-surface condition and tear-film stability in patients with dysfunctional-tear syndrome. Methods: We conducted an institution-based, double masked, randomized, controlled trial involving 45 patients (90 eyes) diagnosed with dysfunctional-tear syndrome who were randomly assigned to receive either carbomer alone (Vidisic) or carbomer with triglyceride (Lipolin) eye gels. Corneal and conjunctival staining with fluorescein and lissamine green, tear-breakup time (TBUT), Schirmer test with anesthesia, and subjective gradings of ocular discomfort were measured at baseline and at 1, 2,4, and 8 weeks after treatment. Outcome measures from both groups were subjected to statistical analyses. Results: Fifteen patients in the Vidisic group and 20 patients in the Lipolin group completed the study. The mean age was 53 +/- 12 years (range, 21 to 71). Both groups exhibited significant improvement from baseline in conjunctival lissamine green staining (p=0.001), TBUT (p=0.001), and subjective improvement of symptoms (/> = 0.001) after 8 weeks of treatment. The decrease in conjunctival staining by lissamine green and improvement in Schirmer test were significantly greater for Vidisic (p=0.03 for both). Conjunctival fluorescein staining worsened in the Lipolin group (p=0.02). Corneal fluorescein (p=0.25) and lissamine green (p=0.08) staining, and Schirmer test (p=0.28) were not significantly different for both groups. Conclusion: Vidisic and Lipolin are both well tolerated and effective in reducing dry-eye symptoms, improving ocular-surface integrity, and stabilizing the tear film. There is a trend toward better treatment response with Vidisic.

A mysterious case of bilateral stromal keratitis

OBJECTIVES: To describe a rare case of bilateral stromal keratitis and demonstrate the effectiveness of penetrating keratoplasty in the management of toxocara keratitis. METHOD: This is a case report. RESULTS: A 53-year-old male farmer had a 10-month history of bilateral corneal opacity, photophobia, redness, foreign body sensation, and eye pain. The diagnosis was central microbial keratitis with the following etiologies considered: Epstein-Barr virus, herpes simplex, fungal, syphilis, tuberculosis (TB), myobacteria other than TB, and acanthamoeba. Despite treatment with topical steroids and antibiotics, both eyes worsened. Penetrating keratoplasty markedly improved the patient's visual acuity. Histopathology of the left corneal button revealed toxocara keratitis. CONCLUSION: Good history taking, complete systemic and ocular examinations, and a histopathology of the corneal tissues are vital to the diagnosis of toxocara keratitis. Penetrating keratoplasty was shown to be effective in its management. Emphasis is given on prevention to decrease the incidence of the disease.

Comparison of fibrin glue and sutures for attaching conjunctival autografts after pterygium excision.

PURPOSE: To compare the efficacy and safety of fibrin glue and suturing for attaching conjunctival autografts among patients undergoing pterygium excision. DESIGN: Prospective, randomized, interventional case series. PARTICIPANTS: Twenty-two patients undergoing excision of primary pterygium. METHODS: A superior conjunctival autograft was harvested and transferred onto bare sclera after pterygium excision. Fibrin glue (Beriplast P) was used to attach the autograft in 11 eyes and nylon 10-0 suture was used to attach the autograft in 11 eyes. The patients were followed up for 2 months. MAIN OUTCOME MEASURES: Graft success, recurrence rate, operating time, patient comfort. RESULTS: All conjunctival autografts in both groups were successfully attached and were intact after 2 months. The average operating time for the fibrin glue group was significantly shorter (P<0.001). Postoperative symptoms were fewer for the fibrin glue group than the suture group. One patient (9%) from the fibrin group experienced subconjunctival hemorrhage, and 1 patient (9%) from the suture group experienced partial graft dehiscence. CONCLUSIONS: Fibrin glue is a safe and effective method for attaching conjunctival autografts. The use of fibrin glue results in shorter operating times and less postoperative discomfort.

Timolol versus latanoprost for primary open-angle glaucoma

CLINICAL SCENARIO: A 46-year-old male consulted for refraction. Best-corrected visual acuity was 20/20 for both eyes (OU), Jaeger 1 for near. Slit-lamp examination was normal. Intraocular pressure (IOP) was 25 mm Hg OU. Gonioscopy revealed iridocorneal angles that were open up to the ciliary body band OU. Funduscopy revealed clear media with no exudates or hemorrhages in the retina. Cup-disc ratio was 0.7 vertically and 0.6 horizontally with notching of the inferotemporal neuroretinal rim OU. Automated visual-field examination showed superior arcuate scotomas OU with no threat to fixation. The working diagnosis upon consultation was primary open-angle glaucoma. After all treatment options had been explained to the patient, a trial of medical therapy was chosen. Given the severity of the glaucoma, a target IOP range was initially set at 15 to 17 mm Hg. Nonselective beta-adrenergic blockers and prostaglandin analogues are two classes of medications that will most probably lower the IOP to the desired levels CLINICAL QUESTION: Among patients undergoing initial medical therapy for primary open-angle glaucoma, would latanoprost be more effective in lowering the IOP compared with timolol? SEARCH METHOD: An electronic literature search was performed using Medline (PubMed). The key words used were "latanoprost" and "timolol." The search was further limited to randomized clinical trials or metaanalysis published in the English language. Table 1 shows the search process performed The search was narrowed down to 5 articles. Abstracts of the articles were reviewed. One article employed ocular hypertensive subjects while another compared brimonidine and timolol. These studies were, therefore, excluded. Among all the metaanalyses obtained from the search, Zhang et al.s had the most number of subjects and outcome measures. It was for this reason that the article was chosen for appraisal in resolving the clinical scenario. (Author)

Laser in situ keratomileusis (LASIK) for high myopia

EXCIMER laser vision correction in the form of LASIK and PRK/LASEK has been proved to be highly effective and safe in the treatment of low-to moderate myopia (less than -6 diopters [D]) and astigmatism. It is the most common refractive-surgery procedure done worldwide. However, the outcome of laser vision correction among those with high myopia (greater than -6D) may not be the same as in those with low to moderate myopia CLINICAL SCENARIO: A 26-year-old, female, myopic patient unhappy with spectacle correction and contact lenses heard about LASIK and sought opinion regarding the probability of her achieving 20/20 vision. Her last refraction was -7.00 sphere -1.00 cylinder x 100 in the right eye (OD) and -9.00 sphere -0.50 cylinder x 90 in the left eye (OS). Best-corrected visual acuity (BCVA) was 20/20 OD and 20/20 OS. Her refraction has been stable for 5 years CLINICAL QUESTION: The patient has high myopia and is concerned about her chances of seeing 20/20 after undergoing laser vision correction. Among patients with high myopia, how effective is LASIK in achieving 20/20 vision? SEARCH METHOD: An electronic literature search was performed using MEDLINE (PubMed). The following search terms were used: "Myopia," "LASIK," "laser in situ keratomileusis," "technology assessment." The search was further limited to the English language and human studies published from 1968 to April 2005. The search yielded 5 articles but only one was relevant to the clinical question CITATION: Sugar A, Rapuano CJ, Culbertson WW, et al. Laser in situ keratomileusis for myopia and astigmatism: safety and efficacy. A Report by the American Academy of Ophthalmology. Ophthalmology 2002; 109:175-187. (Author)

The hidden eye: A case of cryptophthalmos

Methods: This is a report of a case of cryptophthalmos seen at the University of the Philippines-Philippine General Hospital (UP-PGH). Differential diagnosis and management options are discussed. Results: A 12-day old boy presented with no right palpebral fissure, eyelashes, or eyebrow. The skin overlying the right orbit was continuous from the forehead to the cheek. Under this skin was a 17 mm x 15 mm soft, round, movable mass anterior to the globe. The left upper lid was colobomatous with no eyebrow and fornix. The left cornea measured 9 mm x 6 mm with exposure keratitis and large ulcer. Ultrasound of the right orbit identified the presence of the right globe with normal posterior segment. Cranial computed tomography (CT) showed a cystic mass anterior to the right globe with absent lens. Visual-evoked response of the left eye established nonspecific severe optic-nerve damage, delayed visual-pathway maturation and visual-pathway affectation. Conclusion: Management of complete cryptophthalmos is difficult and requires separation of the lids and placement of mucous membrane grafts to allow for fitting of prosthesis. Reconstruction of the lid coloboma is necessary to prevent exposure keratitis. Genetic counseling is also important in the management of cryptophthalmos.