Tomographic Predictors of Ectasia Development After Keratorefractive Surgery.

PURPOSE: The aim of this study was to identify the risk factors for postkeratorefractive surgery ectasia in unsuspicious tomographies and to report a new index coined diameter of peak locations (DPLs). METHODS: All patients who underwent keratorefractive surgery between 2011 and 2018 at Care-Vision Laser Centers, Israel, and later developed ectasia were included. For each ectasia case, 3 matched controls were selected. Demographic and preoperative, intraoperative, and postoperative data were collected. Multivariate analysis was performed to evaluate the interdependence of the variables. RESULTS: The retrospective study included 19 ectasia and 58 control eyes. There were no significant differences between the groups in ablation depth ( P = 0.73), preoperative spherical equivalent ( P = 0.12), percent tissue altered ( P = 0.71), residual stromal bed ( P = 0.73), and Ectasia Risk Score System ( P = 0.60). The anterior and the posterior symmetry index were significantly higher ( P < 0.001), and DPL was significantly tighter in the ectasia group ( P = 0.01). Binary multiple logistic regression found the symmetry index of the posterior cornea and DPL to be better predictors than age, percent tissue altered, Ectasia Risk Score System, residual stromal bed, and ablation depth. CONCLUSIONS: A higher posterior symmetry index and a tighter DPL are predictors of ectasia in patients with otherwise normal tomographies. A tight DPL implies a weak area in the cornea, which is thin and slightly bulging, increasing the risk of this area becoming ectatic.

Tel-Aviv Protocol for Postrefractive Surgery Corneal Ectasia: A Case Series.

PURPOSE: The aim of this study was to describe the safety and efficacy of the Tel-Aviv Protocol (epithelial photorefractive keratectomy and corneal cross-linking) as a treatment for postrefractive surgery corneal ectasia. METHODS: This study includes 8 eyes from 7 patients, each diagnosed with postrefractive surgery ectasia years after refractive surgery and treated with the Tel-Aviv Protocol. The procedure included transepithelial PRK using the EX500 excimer laser, a 50-µm laser ablation of the epithelium and anterior stroma, delivered on the visual axis with cyclotorsion correction, treating up to 50% of refractive astigmatism. After the epithelial photorefractive keratectomy, all patients underwent corneal cross-linking. RESULTS: The mean keratometry (K) and maximal K both decreased [from 43.37 ± 2.23 to 41.84 ± 2.01 ( P = 0.03) and from 44.95 ± 3.08 to 42.78 ± 2.19 ( P = 0.03), respectively]. Astigmatism was significantly reduced (from 3.53 ± 2.36 to 0.88 ± 0.89 diopter; P = 0.02). Uncorrected visual acuity improved significantly in all patients from a mean of 0.56 ± 0.32 to 0.15 ± 0.14 logMAR ( P = 0.01). Best-corrected visual acuity improved from 0.22 ± 0.24 to 0.06 ± 0.06 logMAR ( P = 0.07; 1-tail P = 0.04). All patients maintained visual acuity during the follow-up period, up to 25 months, mean = 329 days. The Tel-Aviv Protocol was found to be safe [mean safety index: 1.63 ± 1.03 (range: 1.00-4)] and effective [mean efficacy index: 1.29 ± 0.66 (range: 0.71-2.1)]. CONCLUSIONS: The Tel-Aviv Protocol, developed initially for keratoconus treatment, is a safe and promising procedure to stop postrefractive surgery ectasia progression while significantly improving vision, thereby avoiding keratoplasty.

Ophthalmologists' Attitudes, Knowledge, and Willingness to Report Child Abuse.

The aim of the present study was to explore ophthalmologists' attitudes, knowledge, and willingness to report child abuse. One-hundred-and-seven ophthalmologists employed in various hospitals in Israel completed an online questionnaire. Less than half the ophthalmologists (44.9%) reported that they had treated children whom they identified or suspected as being victims of child abuse, while only 43.9% of these reported child abuse. Despite generally positive attitudes towards reporting of child abuse among the ophthalmologists, their average level of knowledge was low. Ophthalmologists who had received training on child abuse and residents displayed a higher level of knowledge. In addition, female ophthalmologists tended to agree more that ophthalmologists are obligated to screen for and report child abuse. Moreover, female ophthalmologists expressed higher willingness to report child abuse. The present study reveals that underreporting of child abuse, and more precisely the discrepancy between identification and reporting, is present among ophthalmologists. It seems that lack of knowledge regarding identification and reporting of child abuse is the main barrier to reporting, especially among medical specialists. These findings underscore the importance of training programs on child abuse, both during formal education in medical school, and post-qualification, for all ophthalmologists, irrespective of seniority.

Central retinal artery occlusion as a presenting symptom in Eales' disease: a case report.

BACKGROUND: Eales' disease is an idiopathic peripheral retinal vasculopathy characterized by retinal phlebitis, ischemia, retinal neovascularization, and recurrent vitreous hemorrhages. But CRAO is an unusual presentation. CASE PRESENTATION: A 27-year-old healthy female nurse of Indian descent presented with sudden vision loss in her right eye upon awakening. Central retinal artery occlusion (CRAO), combined with mild central retinal vein occlusion (CRVO), was diagnosed. During the second of three consecutive sessions of hyperbaric oxygen treatments, her vision rapidly improved. One week later, she developed peripheral phlebitis in the same eye. Infectious, inflammatory, and hematologic etiologies were excluded. The systemic evaluation was normal except for a positive Mantoux tuberculin skin test. Following systemic steroidal treatment, she experienced gradual improvement of her vasculitis. Two weeks later, mild retinal phlebitis appeared in her left eye. Eales' disease was diagnosed after the exclusion of other diseases. CONCLUSION: This is an unusual Eales' disease case, which presented as combined CRAO with mild CRVO. The association of CRAO and Eales' disease is reported here for the first time, to our best knowledge.

The role of parental health beliefs in seeking an eye examination for their child.

BACKGROUND: We aimed to explore the role of parental health beliefs in parent seeking of eye examinations for their children, using the Health Belief Model. METHODS: In this quantitative correlational survey study, 100 parents who presented to Barzilai University Medical Center in July 2021 to perform an eye examination to their child completed a questionnaire. RESULTS: Only 29.6% of the parents knew that a vision screening is performed in first grade, and 10% of the parents were unsure about where to find local eye care for their kids. Moreover, 19% of the parents indicated that they were concerned that their child would be prescribed glasses unnecessarily, and 10% believed that wearing glasses would weaken their child's eyes. Various parental health beliefs regarding children's eye examinations were found associated with parent seeking of eye examinations for their child. Thus, perceived susceptibility (r = 0.52, p < 0.01), perceived benefits (r = 0.39, p < 0.01), and perceived barriers (r=-0.31, p < 0.01) are associated with parent seeking of eye examinations for their child. Also, parents' level of knowledge was associated with seeking eye examinations for their child (r = 0.20, p < 0.01). CONCLUSION: Parent perceptions of the child's susceptibility to vision problems and perceived barriers to seeking eye examinations predicted parents seeking of eye examinations for their child. Interventions aimed at increasing timely eye examinations among children should focus on raising parent awareness of vision problems in childhood, dispelling misconceptions, and providing parents with practical information regarding available services.

[AUTOLOGOUS SERUM AS A TREATMENT FOR THE OCULAR SURFACE DISEASE].

INTRODUCTION: The autologous serum drops treatment is an advanced, effective and safe treatment for severe dry eye and recurrent epithelial erosions. It contains growth factors, proteins, and vitamins, similar to the tear layer. In a recent review by the American Academy of Ophthalmology, many studies included showed a significant effect of serum drops in treating dry eye and recurrent epithelial erosions. Notwithstanding the above, to date, no randomized controlled clinical trials have investigated the effectiveness of autologous serum drops. Moreover, serum drops concoction has strict regulations, and in Israel, it is available in a small handful of hospitals, which causes limited accessibility to this valuable treatment. Precautions must be taken when using serum drops to avoid bottle contamination and infections during storage.

[ROCK (RHO-KINASE INHIBITORS) FOR THE TREATMENT OF OPEN-ANGLE GLAUCOMA AND OCULAR HYPERTENSION].

INTRODUCTION: Netarsudil ophthalmic solution 0.02% is a new treatment for open-angle glaucoma and ocular hypertension, which was approved for treatment in the United States and in the European Commission. The drug is a rho- kinase inhibitor (ROCK) that lowers intraocular pressure by enhancing the outflow at the trabecular meshwork and decreasing both aqueous humor production and episcleral venous pressure. This literature review aims to present this new treatment, characterize its specific mechanism of action, and discuss its effect and adverse events profile. The efficacy and safety of the drug were studied in the ROCKET and MERCURY clinical trials, in which Netarsudil was compared to other common drugs, including Timolol (Beta-blocker), Latanoprost (Prostaglandin analog), and a combination drop containing Netarsudil and Latanoprost. These trials showed a reduction of 16%-21% in the intraocular pressure (IOP) when using Netarsudil. Moreover, it was found that when using a combination of Netarsudil and Latanoprost, 64.5% of these patients achieved ≥30% reduction in mean diurnal IOP versus 28.8% of patients treated only with Netarsudil and 37.2% of patients treated only with Latanoprost (P<0.0001). The most common adverse event reported was conjunctival hyperemia, which was more frequent in patients using Netarsudil. However, this did not significantly affect the drug tolerance.

Ocular Behçet Disease-Clinical Manifestations, Treatments and Outcomes According to Age at Disease Onset.

Behçet disease (BD) is a multisystemic disease that commonly involves the eyes. Although it affects patients in all age groups, data on ocular disease by age of onset are limited. This retrospective, multicenter study aimed to compare epidemiology, systemic and ocular manifestations, treatments and outcomes between three age groups: juvenile (<18 years), adult (18-39 years) and late (≥40 years) disease onset. The study included 175 ocular BD patients (303 eyes) from Israel and Palestine: juvenile-onset (n = 25, 14.3%), adult-onset (n = 120, 68.6%) and late-onset (n = 30, 17.1%). Most patients in all groups were male. Systemic manifestations were similar in all groups. Systemic co-morbidities were more common in late-onset patients. Bilateral panuveitis was the most common ocular manifestation in all patients. Non-occlusive retinal vasculitis, peripheral vessel occlusions, cataract and elevated intraocular pressure were found more commonly among juvenile-onset eyes. Anterior uveitis and macular ischemia were most common among late-onset eyes, while branch retinal vein occlusion was most common in adult and late-onset eyes. All patients were treated with corticosteroids. Methotrexate, immunomodulatory combinations and biologic treatments were more commonly used for juvenile-onset patients. All groups had a similar visual outcome. Our study showed that patients with ocular BD have varied ocular manifestations and require different treatments according to age of disease onset, but visual outcome is similar.

Retinal vascular occlusions in ocular Behçet disease - a comparative analysis.

PURPOSE: The literature on retinal vascular occlusions in Behçet disease (BD) patients is limited. The aim of this study is to thoroughly investigate retinal vascular occlusions among ocular BD patients. METHODS: Retrospective, multicentre case-control study. Three-hundred and three eyes of 175 patients with ocular BD, from 13 hospitals in Israel and Palestine, were included. Patients were assigned into two groups according to the presence of retinal vascular occlusion. Epidemiology, systemic and ocular manifestations, treatments and outcomes were compared between the groups and risk factors for retinal vascular occlusions were identified. RESULTS: One hundred twenty-five patients (71.4%) were male. The mean age at presentation was 28.2 ± 0.86 years. Retinal vascular occlusions were found in 80 eyes of 54 (30.9%) patients, including branch retinal vein occlusion (51.3%), peripheral vessels occlusions (32.5%), central retinal vein occlusion (13.8%) and arterial occlusions (7.5%). Systemic manifestations were similar among both groups. Anterior uveitis was more common in non-occlusive eyes (p < 0.01). Non-occlusive retinal vasculitis (p = 0.03) and ocular complications were more common in occlusive eyes (p < 0.01). Treatments including mycophenolate mofetil, Infliximab or a combination therapy of anti-metabolite and calcineurin inhibitor were more commonly used by occlusive patients (p < 0.05). Occlusive patients underwent more cataract surgeries (p = 0.03). The occlusive group had worse mean best-corrected visual acuity (BCVA) throughout follow-up (p < 0.01). Risk factors for retinal vascular occlusions included male sex and Jewish ethnicity (p < 0.05). CONCLUSION: Retinal vascular occlusions were found in a third of ocular BD patients. Occlusive eyes had a worse prognosis. Risk factors for vascular occlusions were identified.

CENTRAL RETINAL VEIN OCCLUSION WITH SEVERE MACULAR EDEMA IN EARLY PREGNANCY.

PURPOSE: To report the clinical course and treatment outcomes of a patient with central retinal vein occlusion with severe macular edema in early pregnancy. METHODS: Interventional case report. RESULTS: A 39-year-old woman with gestational diabetes mellitus and a 15-pack year smoking history presented at 7 weeks gestation with decreased vision due to central retinal vein occlusion with marked macular edema. One month later, visual acuity had decreased to 20/400, and macular edema had worsened to a central subfield thickness of 1,432 µ m. She was treated with a single intravitreal dexamethasone implant at 16 weeks gestation. She responded well with visual acuity improving to 20/40+ and complete resolution of macular edema. At 33 weeks gestation, the cystoid macular edema recurred, but the patient refused treatment. The cystoid macular edema spontaneously resolved 3 weeks postpartum but recurred 3 months later with visual acuity worsening to 20/50. This macular edema resolved completely after a single 1.25 mg bevacizumab injection. She required no further treatment, and 23 months later, her macula was dry with visual acuity of 20/25. Her baby was healthy. CONCLUSION: Although pregnancy seems to aggravate central retinal vein occlusion -associated macular edema, the visual loss may be reversible. Intravitreal steroid seems to be effective during pregnancy with no apparent systemic or fetal complications. Young patients with retinal vein occlusion and center-involving macular edema may stabilize with minimal treatment.

Central serous chorioretinopathy imaging biomarkers.

PURPOSE: To identify the factors predicting the visual and anatomical outcomes in eyes with central serous chorioretinopathy (CSCR) through 12 months. METHODS: Patients with diagnosis of CSCR, either acute or chronic, were included in this multicentric, retrospective study. Demographic factors; systemic risk factors; central macular thickness (CMT), subfoveal choroidal thickness (SFCT), linear extent of ellipsoid zone (EZ) and interdigitation zone damage on optical coherence tomography; details of leak on fluorescein angiography and indocyanine green angiography were included as predictors of anatomical and visual outcomes. Regression analysis was performed to correlate the changes in best corrected visual acuity (BCVA) and resolution of disease activity. RESULTS: A total of 231 eyes of 201 patients with a mean age (49.7±11.8 years) were analysed. A total of 97 and 134 eyes were classified as acute and chronic CSCR. BCVA (0.35±0.31 to 0.24±0.34; p<0.001), baseline optical coherence tomography (OCT) parameters including CMT (p<0.001), subretinal fluid (SRF) height (p<0.001) and SFCT (p=0.05) showed a significant change through 12 months. Multivariate regression analysis showed change in CMT (p≤0.01) and SRF height at baseline (p=0.05) as factors predictive of good visual outcome. Logistic regression analysis revealed changes in both CMT (p=0.009) and SFCT (p=0.01) through 12 months to correlate with the resolution of disease. CONCLUSION: OCT parameters such as changes in both CMT and SFCT along with subfoveal EZ damage can be predictive of disease resolution whereas changes in CMT and baseline SRF height correlate well with changes in BCVA through 12 months.

PIGMENT EPITHELIAL DETACHMENT IN AGE-RELATED MACULAR DEGENERATION: Long-Term Visual Acuity May Improve With Higher Injection Index.

PURPOSE: To define injection index (II) and assess its impact on visual acuity (VA) in pigment epithelial detachment from age-related macular degeneration over 5 years. METHODS: Injection index is defined as the mean anti-vascular endothelial growth factor injections per year from presentation. A retrospective study of 256 eyes in 213 patients was performed. Patients were stratified by II (high: ≥9, low: <9). RESULTS: Baseline characteristics showed no differences across II groups. Mean (range) follow-up, in years, was 5.02 (1.04-12.74) for all patients. Mean logMAR VA (Snellen VA) were 0.60 (20/80) and 0.56 (20/73) at baseline, 0.52 (20/66) and 0.59 (20/78) at Year 1, 0.45 (20/56) and 0.67 (20/94) at Year 2, 0.38 (20/48) and 0.66 (20/91) at Year 3, 0.41 (20/51) and 0.89 (20/155) at Year 4, and 0.35 (20/45) and 0.79 (20/123) at Year 5 for the high and low II groups, respectively. Linear regression analysis showed a gain of 0.5 approxETDRS letters with each additional injection per year. CONCLUSION: Increased II was associated with better mean VA, suggesting that long-term continuous vascular endothelial growth factor suppression may improve VA in eyes thought to carry poor prognoses.

CYSTOID MACULAR EDEMA AFTER FOUR-POINT SCLERAL FIXATION OF INTRAOCULAR LENS.

PURPOSE: To assess the incidence of cystoid macular edema (CME) associated with 4-point Gore-Tex suture intraocular lens (IOL) scleral fixation, before and after institution of routine intravitreal triamcinolone acetonide prophylaxis and long-term topical nonsteroidal anti-inflammatory drug usage. METHODS: Consecutive patients were included after IOL implantation with concurrent pars plana vitrectomy for spontaneous IOL dislocation due to pseudoexfoliation syndrome. We compared short-term prophylactic nonsteroidal anti-inflammatory drugs only (Group A) to prophylactic intravitreal triamcinolone acetonide and long-term nonsteroidal anti-inflammatory drugs (Group B). RESULTS: Twenty-six eyes of 26 patients with pseudoexfoliation syndrome and spontaneous IOL dislocation were studied. Mean logMAR visual acuity improved from 1.27 ± 0.80 (20/375 Snellen equivalent) preoperatively to 0.46 ± 0.39 (Snellen 20/43) postoperatively (P < 0.001). Visual outcomes were similar for Groups A and B. In Group A, 10/16 eyes had CME, 4/16 had chronic CME longer than 6 months, and 1 longer than 12 months. In Group B, 1/10 had CME (which was both chronic and refractory). CONCLUSION: In eyes with pseudoexfoliation syndrome and spontaneous IOL dislocation, 4-point Gore-Tex suture IOL ab externo fixation yielded good visual outcomes, although CME was observed more than reported elsewhere. Prophylactic intravitreal triamcinolone acetonide and long-term nonsteroidal anti-inflammatory drugs seem to reduce the risk of postoperative CME.

UVEITIS AFTER THE BNT162b2 mRNA VACCINATION AGAINST SARS-CoV-2 INFECTION: A Possible Association.

PURPOSE: To describe uveitis cases after the BNT162b2 mRNA SARS-CoV-2 vaccination. METHODS: This is a multicenter, retrospective study. Vaccine-related uveitis diagnosis was supported by the classification of the World Health Organization Adverse Drug Terminology and the Naranjo criteria. RESULTS: Twenty-one patients (23 eyes) with a mean age of 51.3 years (23-78 years) were included. Eight of the 21 patients had a known history of uveitis. The median time from previous to current attack was 1 year (0.5-15 years). There were 21 anterior uveitis cases, two with bilateral inflammation. Eight cases occurred after the first vaccination and 13 after the second vaccination. All but three presented as mild to moderate disease. Two patients developed multiple evanescent white dot syndrome after the second vaccination. The mean time from vaccination to uveitis onset was 7.5 ± 7.3 days (1-30 days). At final follow-up, complete resolution was achieved in all but two eyes, which showed significant improvement. One case of severe anterior uveitis developed vitritis and macular edema after the second vaccination, which completely resolved after an intravitreal dexamethasone injection. CONCLUSION: Uveitis may develop after the administration of the BNT162b2 mRNA vaccine. The most common complication was mild to moderate anterior uveitis, while multiple evanescent white dot syndrome can also occur less frequently.

TRActional DIabetic reTInal detachment surgery with co-adjuvant intravitreal dexamethasONe implant: the TRADITION STUDY.

AIM: Main failure of diabetic tractional retinal detachment (TRD) surgery is the development of proliferative vitreoretinopathy (PVR), causing higher re-detachment rates. We investigated whether the use of dexamethasone (DEX) implant at the end of pars plana vitrectomy (PPV) with silicone oil tamponade might have an impact on these outcomes. DESIGN: Comparative, nonrandomized, retrospective study. PARTICIPANTS: A total of 148 eyes from 148 patients that underwent PPV with silicone oil tamponade for diabetic TRD (with DEX implant, n = 52; without DEX implant, n = 96). METHODS: Consecutive patients' records were reviewed for time between TRD diagnosis and surgery; lens status before surgery and after 6, 12, and 24 months; retina attachment rate after primary PPV; change in postoperative PVR severity; rate of re-detachment at 6, 12, and 24 months; use of IOP lowering treatment after 6, 12, and 24 months; surgery details; intra- and postoperative complications. Correlations between outcome measures, postoperative PVR severity, and re-detachment rates were analyzed. MAIN OUTCOME MEASURES: Change in postoperative PVR severity and retinal re-detachment rates with and without the adjuvant use of DEX implant. RESULTS: Retinal re-detachment rates were significantly higher in the group of patients that did not receive DEX implant [11/96 (11.5%) vs. 0/52 (0%), p = 0.049; 11/84 (12.9%) vs. 4/52 (7.7%), p = 0.007; 14/71 (19.7%) vs. 5/52 (10%) p < 0.001 at 6, 12, and 24 months, respectively]. PVR severity correlated with retinal status at 12 and 24 months (p = 0.018 and p = 0.027, respectively). The difference in PVR severity between the two groups was statistically significant at 6, 12, and 24 months (p < 0.001). CONCLUSIONS: DEX implant at the end of PPV in patients with diabetic TRD improves PVR severity and decreases re-detachment rates. This should be considered as an option in the customized treatment of TRD.