Quality of life and satisfaction among physicians after wavefront-optimized vs topography-guided laser vision correction.

PURPOSE: To assess satisfaction, quality of life, occupational impact, and clinical outcomes of physicians who have undergone laser vision correction (LVC) using either wavefront-optimized (WFO) or topography-guided (TG) excimer laser ablation profile with femtosecond laser flap creation. SETTING: Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, USA. DESIGN: Retrospective survey study. METHODS: A 12-question survey was sent to all physicians who underwent laser in situ keratomileusis or photorefractive keratectomy at the Cole Eye Institute between 2011 and 2018 on the WaveLight Allegretto Wave Eye-Q Laser (Alcon Laboratories, Inc.). Visual outcomes were obtained from patient charts. RESULTS: Two hundred thirty-five physicians (454 eyes) met the study's inclusion criteria, including 181 physicians (353 eyes) who underwent WFO LVC and 54 physicians (101 eyes) who underwent TG LVC. One hundred seventeen physicians (49.8%) responded to the survey and reported an overall satisfaction rate of 98.3% among all physicians receiving LVC with 96.6% reporting they would have the procedure again. Visual outcomes showed a high level of surgical predictability, efficacy, and safety among WFO and TG eyes, with a higher percentage of eyes that received TG ablation achieving 20/10 vision (22% vs 4%, P < .0001) and 20/15 vision (87% vs 69%, P < .01) when compared with WFO eyes. CONCLUSIONS: Physicians who had undergone LVC with either WFO or TG excimer laser ablation reported high satisfaction and quality-of-life improvements. Both groups achieved excellent visual outcomes, with a higher percentage of TG eyes achieving 20/10 and 20/15 vision.

The Effect of Change in Intraocular Pressure on Choroidal Structure in Glaucomatous Eyes.

Purpose: Choroidal thickness increases linearly with intraocular pressure (IOP) lowering. We studied the relationship between the change in size of the choroidal vasculature and IOP lowering after glaucoma procedures. Methods: Thirty eyes of twenty-nine patients were examined pre- and postoperatively for up to 6 months with standard clinical assessment, enhanced depth imaging spectral-domain optical coherence tomography (OCT), and axial length measurement. Each enhanced depth imaging spectral-domain OCT image was analyzed using three separate methods to determine the choroidal thickness, choroidal vessel thickness, choroidal interstitial thickness, large choroidal vessel layer thickness, medium choroidal vessel layer thickness, and light-dark ratio. Bivariate linear regression analysis was completed with largest change in IOP as the independent variable. The dependent variables included choroidal thickness, choroidal vessel thickness, and choroidal interstitial thickness, at the largest change in IOP. Multivariable regression analysis using a generalized estimating equation to account for multiple measurements per eye was also completed. Results: Mean choroidal vessel thickness increases 1.5 µm for every 1 mm Hg decrease in IOP (P < 0.0001; 95% confidence interval [CI], 0.8, 2.1) and choroidal interstitial thickness increases 1.3 µm for every 1 mm Hg change in IOP (P < 0.0001; 95% CI, 0.8, 1.8). There was no significant association between change in IOP and change in large choroidal vessel layer temporally (P = 0.13), nasally (P = 0.20), or subfoveally (P = 0.18). There was also no association between IOP and the light-dark ratio (P = 0.16). Conclusions: The increase in choroidal thickness at lower IOP is associated with approximately equal increases in its intravascular and extravascular compartments.

Positive End-Expiratory Pressure as a Risk Factor for Severe Positive Vitreous Pressure During Combined Penetrating Keratoplasty and Cataract Extraction.

PURPOSE: To report the potential risk of severe positive vitreous pressure during combined penetrating keratoplasty, cataract extraction, and intraocular lens implantation (triple procedure), using positive end-expiratory pressure (PEEP) during general endotracheal anesthesia. METHODS: This is a case report of a 32-year-old man and a 48-year-old man who underwent penetrating keratoplasty, extracapsular lens extraction, and intraocular lens implantation during which severe positive posterior pressure was encountered during the open-sky lens extraction. RESULTS: In both cases, severe posterior vitreous pressure against an intact posterior capsule hindered intraocular lens implantation during the triple procedure. Despite exhaustive search for the cause of posterior pressure, no other risk factors were found other than the use of PEEP. CONCLUSIONS: During open-sky procedures, PEEP may be a risk factor for severe positive posterior vitreous pressure. Given the rising use of PEEP, surgeons should be aware and cautious of this potential complication.

Advances in Refractive Surgery: June 2014 to July 2015.

PURPOSE: The objective of this study was to review the advances in the field of refractive surgery as reported in the peer-reviewed literature during the previous year. DESIGN: A literature review. METHODS: In this review, we highlight the most pertinent articles in the field from June 2014 to the end of July 2015. RESULTS: This past year has seen a growing body of research on small-incision lenticule extraction, presbyopic inlays, and phakic intraocular lenses, as more clinicians are adopting these techniques into their armamentarium. CONCLUSIONS: Laser-assisted in situ keratomileusis and photorefractive keratectomy continue to dominate the keratorefractive literature, as they remain the most frequently performed refractive surgeries.

Treatment options for thyroid eye disease.

OPINION STATEMENT: Patients with thyroid eye disease (TED) experience hypertrophy of their extraocular muscles and an increase in intraorbital fat volume leading to eyelid retraction, proptosis, double vision, and optic nerve compression. These orbital changes are thought to be due to a cross-reaction of thyroid stimulating hormone (TSH) with antigens in the orbit. Therefore, the key to treatment is achievement of a euthyroid state in patients with abnormal thyroid function. Cigarette smoking is the strongest modifiable risk factor linked with progression and poor response to treatment. All TED patients should be counseled and offered help with smoking cessation. The treatment of TED symptoms must be customized to each patient, as the degree of orbital involvement can vary. During the active state, evaluation of sight-threatening compressive optic neuropathy and treatment of corneal exposure by an ophthalmologist is crucial to avoid irreversible damage. In most patients, local therapy with artificial tears, gels, and ointments can offer symptomatic relief of irritation and dryness. In addition, antioxidant therapy with selenium has been shown to improve quality of life in patients with mild orbital involvement. Some patients will require systemic oral or IV steroids at the onset of an active inflammatory state. However, approximately one third of patients will not be responsive to steroid therapy alone. In these patients, the addition of orbital radiation or use of immune modulation has shown value. Orbital decompression surgery should be considered for cases of vision-threatening optic neuropathy despite maximal medical therapy. Approximately 3-6 months after cessation of the active state and stabilization of symptoms, rehabilitative treatment may be offered. Treatment is offered in a 3-stage surgical approach with orbital decompression surgery, followed by strabismus surgery for any resultant binocular diplopia, and finally eyelid surgery to address eyelid retraction. Meanwhile, symptomatic diplopia may be addressed with monocular patching or prisms.

Change in choroidal thickness and axial length with change in intraocular pressure after trabeculectomy.

BACKGROUND/AIMS: We studied the change in choroidal thickness (CT) and axial length (AL) after intraocular (IOP) changes produced by trabeculectomy. METHODS: Twenty-one eyes of 20 patients were studied preoperatively, and then postoperatively at 1 week, 1, 3, and 6 months. Variables measured included IOP, AL, keratometry, refractive error, central corneal thickness, and average CT in the posterior 6 mm centred on the fovea using enhanced depth imaging spectral domain optical coherence tomography (OCT). RESULTS: OCT images in 17 eyes (58 images, preoperatively and postoperatively) were of sufficient quality to determine CT. In every patient, CT increased with IOP lowering postoperatively. For each 1 mmHg decrease in IOP, there was a mean increase of 3.4 µm in CT (p<0.0001; univariate regression, 95% CI 2.5 to 4.3). This represented a CT increase of 1.7% per mm Hg decrease (p<0.0001; 95% CI 1.3 to 2.0%). AL decreased by 6.8 µm per mm Hg decrease in IOP (p<0.0001, univariate regression, 95% CI 4.9 to 8.6). CONCLUSIONS: The dynamic relationship between change in IOP and the state of sclera and choroid was confirmed by sequential measurements in postoperative trabeculectomy patients, providing estimates of the magnitude of choroidal swelling and scleral volume decrease with IOP lowering.