Visual Function After Implantation of Trifocal and Trifocal Toric Intraocular Lenses Using Intraoperative Aberrometry.

Purpose: To evaluate patient outcomes and visual function following trifocal and trifocal toric intraocular lens (IOL) implantation using intraoperative aberrometry at a single site in the US. Methods: This prospective, single arm study included 21 subjects that completed 3 month follow-up. Inclusion criteria were visually significant cataract and potential post-operative visual acuity of 20/25 or better. Endpoints included postoperative prediction error, refractive outcomes, uncorrected visual acuities at distance (UDVA), intermediate (UIVA), and near (UNVA), contrast sensitivity, and subject responses on the modified Visual Function Quality of Life Questionnaire (VF-14 QOL). Results: Binocular UDVA, UIVA, and UNVA were 20/25 or better in 100% (21/21), 100% (21/21), 90% (19/21) of subjects. The absolute prediction error was 0.50 D or less in 79% (33/42) of eyes, and 81% (34/42) and 86% (36/42) of eyes achieved ≤0.5 D of residual astigmatism and manifest refraction spherical equivalent, respectively. On the modified VF-14 QOL, driving at night, reading small print, and reading a newspaper or book were the tasks that had the lowest percentages of subjects reporting no difficulty or a little difficulty. Conclusion: Implantation with trifocal and trifocal toric IOLs using intraoperative aberrometry can provide high refractive precision, leading to excellent visual performance and low visual task difficulty at all ranges (distance, intermediate, and near).

An intraocular lens (IOL) is a clear artificial lens that can be used to replace the natural lens in the eye when the natural lens becomes opaque (develops a cataract). Monofocal IOLs are designed to provide good vision to see distant objects; however, spectacles may still be needed to see objects clearly up close (such as reading a book or using a digital device). Trifocal IOLs are designed to provide good vision to see objects at distance and up close, however, the power of the IOL must be accurately determined for the best visual outcomes. Devices called biometers are used by cataract surgeons to measure the eye and determine the most appropriate lens power to implant. Most biometers are used prior to surgery, however one type, intraoperative aberrometry (IA), can be used during surgery to measure the eye and determine the most appropriate lens power. The purpose of this study was to evaluate patient outcomes and visual function following trifocal IOL implantation using IA. The results of this study suggest that implantation with trifocal IOLs using IA can provide high refractive accuracy and excellent visual outcomes.

Dry Eye Disease: Early Recognition with Guidance on Management and Treatment for Primary Care Family Physicians.

Primary care presentations of dry eye disease (DED) are common and pose a diagnostic challenge due to the variety of symptoms and the absence of certainty for family practitioners. While there are many published articles on the topic, the 2017 Tear Film and Ocular Surface Society Dry Eye Workshop was a landmark report in distinguishing multifactorial differences. Redefined terms clarified the DED disorder. The ocular surface-the tear/air interface-is the primary refractive component of the eye, which is why DED is so significant and impacts vision. There is a high prevalence of DED in the community, ranging from 5% to 30% of people across multiple studies. Elderly patients have up to 75% increased risk of DED and receive more intensive treatment than younger age groups. DED is also more common in women than men, occurring in 9.8% of postmenopausal women. The causes of DED span defective lacrimal apparatus and systemic disorders. Despite its prevalence, up to one-half of patients with confirmed DED do not receive proper alleviating treatment. Risk factors on functional and environmental bases follow. Tools to elicit a diagnosis more confidently are outlined using the Ocular Surface Disease Index (OSDI) and the Symptom Assessment in Dry Eye questionnaires (SANDE). Lacritin, lutein, vitamin A, and balanced nutrition are essential contributors to maintaining healthy eyes with appropriate management and treatment. The authors hope that this paper will prompt a more accurate and expedient diagnosis of DED in primary care practice and an earlier recognition of specialist referrals.

Dry eye disease (DED) poses a diagnostic challenge to primary care physicians. The condition involves the tear/air interface, at the corneal (ocular) surface, where light enters the eye. Any change in light refraction affects regular sight. Symptoms of DED include itching, grittiness, foreign body sensation, redness, excessive tearing, and visual blurring, the lattermost being the most common presentation. Ultimately, the untreated disease leads to continued discomfort and visual deficit, but when severe, it can result in blindness. Up to 30% of the population suffers from DED, with the elderly, particularly women, more affected. Unfortunately, up to 50% of those affected have inadequate treatment. Questionnaires help in diagnosis. Simple office tests can indicate the severity of eye problems. Technology with smartphone photography can take high-resolution images, which are useful in education and teaching. A multitude of conditions cause DED, including blepharitis, an infection of the eyelids. Environmental risks also abound. Proper nutrition is essential in maintaining eye health. Intermittent eye symptoms are likely to be underrated by the public, by purchasing over-the-counter products such as artificial tears rather than seeking a proper medical check. Newer prescription medications are now available for DED relief before advancing to debility requiring specialist treatment. Dry Eye Disease: Early Recognition with Guidance on Management and Treatment for Primary CareFamily Physicians (MP4 95031 kb).

A case of the blues: Inadvertent ocular injury from accidental instillation of blue ink.

PURPOSE: Many consumer products and non-ophthalmic medications are packaged in plastic "eye dropper" bottles, posing a risk of accidental ocular chemical injury when these substances are mistaken for eye drops. OBSERVATIONS: We present the case of an elderly glaucoma patient who mistook blue stamper ink for the glaucoma medication Combigan®, and suffered ocular injury as a result. CONCLUSIONS AND IMPORTANCE: The packaging of non-ophthalmic products in plastic "eye dropper" bottles poses a significant risk of accidental ocular chemical injury. Elderly individuals with low vision and/or cognitive deficits may be at particular risk of accidental injury. Ophthalmologists have been calling for a greater distinction between the packaging of ophthalmic and non-ophthalmic products for over 35 years, but to date little progress has been made in this regard.

Evaluating the efficacy of an educational ergonomics module for improving slit lamp positioning in ophthalmology residents.

OBJECTIVE: To characterize changes in body positioning while performing a standardized slit lamp examination after exposure to an educational module on ergonomics. DESIGN: Prospective interventional pilot study. PARTICIPANTS: Ten ophthalmology residents. METHODS: An educational module discussing ergonomic issues in ophthalmology was created. In a standardized examination lane, participants were recorded performing 3 trials of an indirect slit lamp examination of a volunteer patient, adjusting equipment as they saw fit. Participants were then sent the module and within 2 weeks repeated the trial process. Data were processed using biomechanical software to obtain the Rapid Upper Limb Assessment (RULA) injury risk score, elbow and shoulder joint reaction moments, neck and trunk flexion angles, and spinal curvature magnitudes. RESULTS: The RULA injury risk scores decreased after completion of the module (95% CI 2.10-2.77), indicating a lesser risk for injury to the resident. Shoulder flexion and elbow abduction moments also decreased (95% CI -3.2 to -1.5 and -0.44 to -0.04, respectively), suggesting a more neutral body posture. The trunk flexion angle increased after completion of the module (95% CI -5.1 to -1.6), signifying a more upright trunk posture; this was confirmed by the lumbar spine curvature, which flattened postmodule (95% CI 6.6-940). CONCLUSIONS: These results suggest a promising ability for an educational module to mitigate some injury risk in this population during indirect slit lamp examination. It also delineated some awkward postures that persisted despite the module. These results will be reintegrated into the module to optimize its educational utility.

The utility of a normal tear osmolarity test in patients presenting with dry eye disease like symptoms: A prospective analysis.

OBJECTIVE: To explore the diagnostic utility of normal tear osmolarity in patients with symptoms suggestive of dry eye disease (DED). METHODS: Prospective observational cohort study of 100 patients that underwent tear osmolarity testing (TearLab™) if they endorsed one or more symptoms of potential DED. Patients were included for the study if they had a normal tear osmolarity test (value <308 mOsm/L in each eye, and an inter-eye difference <8 mOsm/L). The main outcome measure was the presence of any alternate diagnosis to explain the patient's symptoms. Results were recorded and descriptive and univariate statistics were employed. RESULTS: Mean tear osmolarity was 293.40 mOsms/L (±6.82), with a mean absolute difference of 2.85 mOsms/L (±1.98) between the eyes. A possible alternate diagnosis was established in 89% of patients with normal tear osmolarity testing. The most frequent diagnoses included anterior blepharitis (26%) and allergic conjunctivitis (21%). CONCLUSIONS: Common symptoms of DED overlap significantly with a wide variety of other ocular surface diseases, and a normal tear osmolarity test should increase clinical suspicion for alternate causes of those symptoms. Anterior blepharitis and allergic conjunctivitis were the most common diagnoses made in symptomatic patients with normal tear osmolarity who may have otherwise been misdiagnosed and treated for DED.

Prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation.

PURPOSE: To report the prevalence of ocular surface dysfunction in patients presenting for cataract surgery evaluation. SETTING: Duke University Eye Center and Weill Cornell Ophthalmology, single-physician practices. DESIGN: Prospective case series. METHODS: Consecutive patients presenting for cataract surgery evaluation were identified. Patient information including demographics, medical history, slitlamp findings, tear osmolarity, and tear matrix metalloproteinase-9 (MMP-9) levels were recorded. Patients were considered to have ocular surface dysfunction if any of the following outcomes were present: visually significant abnormal corneal surface examination, positive MMP-9 test, or abnormal osmolarity values (>307 mOsm/L or >7 mOsm/L intereye difference). Patient symptoms were recorded using the ocular surface disease index (OSDI) or Symptom Assessment iN Dry Eye questionnaires. RESULTS: There were 120 patients (69% women), mean age 69.5 years ± 8.4 (SD). Abnormal osmolarity was found in 68 patients (56.7%), and abnormal MMP-9 in 76 patients (63.3%). Clinical findings showed that 47 patients (39.2%) had positive corneal staining on presentation, 9 patients (7.5%) had epithelial basement membrane dystrophy, and 2 patients (1.6%) had Salzmann nodules. Questionnaire data showed 54 (54.0%) of 100 patients reported symptoms suggestive of ocular surface dysfunction. In the asymptomatic group of 46 patients, 39 (85%) had at least 1 abnormal tear test (osmolarity or MMP-9) and 22 (48%) had both tests abnormal. Overall, 96 (80%) of 120 patients had at least 1 abnormal tear test result suggestive of ocular surface dysfunction and 48 patients (40%) had 2 abnormal results. CONCLUSIONS: Objective ocular surface dysfunction findings were common among patients presenting for cataract surgery, yet many presented undiagnosed. Clinicians should be aware of this high prevalence and consider screening with tear testing before surgery.

Punctal Plug Retention Rates for the Treatment of Moderate to Severe Dry Eye: A Randomized, Double-Masked, Controlled Clinical Trial.

PURPOSE: To compare retention rates of Super Flex (Eagle Vision, Memphis, Tennessee, USA; Softplug-Oasis Medical Inc, Glendora, California, USA) vs Parasol (Odyssey Medical, Memphis, Tennessee, USA; Beaver Visitec International, Waltham, Massachusetts, USA) punctal plugs. DESIGN: Randomized, double-masked, interventional controlled clinical trial. METHODS: Institutional study at Hotel Dieu Hospital (Queen's University) of 50 eyes, from patients with moderate to severe dry eye. Each eye from eligible patients was separately randomized to receive Super Flex or Parasol punctal plugs. The main outcome measure was plug retention at 6 months. Secondary outcome measures included objective tests of Schirmer I (mm), tear meniscus height (mm), tear break-up time (s), inferior fluorescein corneal staining (National Eye Institute [NEI] scale), and average lissamine green conjunctival staining (NEI scale). RESULTS: Punctal plug retention was significantly different at 6 months (P = .011). Sixty-eight percent of Parasol plugs were retained compared to 32% of Super Flex plugs. Parasol plugs required less frequent artificial tear use at 6 months (P = .024). There was a statistically significant improvement in all secondary outcome measures (Schirmer, tear meniscus height, tear break-up time, fluorescein corneal staining) at 6 months within plug groups except conjunctival staining. There were no additional significant differences between groups and no plug complications reported. CONCLUSIONS: Punctal plugs improve symptoms of moderate to severe dry eye; however, retention rates differ significantly. These data will allow us to guide patient decision making for the safe and effective treatment of punctal plugs for moderate to severe dry eye.

Evaluation of a new technique for preparation of endothelial grafts for descemet membrane endothelial keratoplasty.

PURPOSE: The purpose of this study was to compare the Muraine technique, a relatively new method for preparing endothelial grafts for Descemet membrane endothelial keratoplasty (DMEK), with the current standard submerged cornea using backgrounds away (SCUBA) peeling technique. METHODS: This study was a prospective ex vivo investigation. In a wet-lab setting, 20 donor corneas were prepared for DMEK using The Muraine technique and 20 donor corneas using the SCUBA technique. In each of the technique groups, 10 corneas were prepared by a corneal surgeon and 10 were prepared by a corneal fellow. Primary outcome measures were the time needed to prepare endothelial grafts and the number of graft tears. RESULTS: In the SCUBA technique, median time to prepare grafts was shorter for both the surgeon (301 ± 85 seconds) and fellow (523 ± 58 seconds) compared with the Muraine technique (surgeon, 359 ± 83 seconds; fellow, 543 ± 44 seconds). However, these findings were not statistically significant (surgeon, P = 0.33; fellow, P = 0.24; pooled, P = 0.46). There was a statistically significant difference between surgeon time and fellow time for each technique (SCUBA technique, P = 0.0005; Muraine technique, P = 0.002). In the Muraine technique, there were 5 graft tears (surgeon = 2, fellow = 3), and no graft tears in the SCUBA technique, which was statistically significant (P = 0.047). CONCLUSIONS: The present study demonstrates that the SCUBA technique may be a more effective technique to prepare endothelial donor grafts for DMEK.

Evaluating the need for close follow-up after removal of a noncomplicated corneal foreign body.

PURPOSE: The purpose of this study was to evaluate the need for close follow-up after removal of noncomplicated corneal foreign bodies. METHODS: This is an observational prospective cohort study of 60 eyes in noncontact lens wearers with corneal foreign bodies outside the visual axis. Foreign bodies were removed and patients were followed as per the Wills Eye Manual guideline for 1 to 3 days after foreign body extraction, and every 3 to 5 days until resolution of the epithelial defect. Patients were asked to record their symptoms of eye pain, eye irritation, eye redness, and visual acuity on a visual analog scale to monitor symptoms related to development of infectious keratitis. The primary endpoint was resolution of the epithelial defect. RESULTS: The average time to resolution of the epithelial defect was 4.34 ± 1.56 days, with an average of 2.2 ± 1.23 follow-up visits after removal. One patient developed infectious keratitis (1.67%). Symptoms showed a statistically significant improvement in patients who had healed epithelial defects, and a statistically significant worsening in the 1 patient who developed infectious keratitis (sensitivity = 1 and specificity = 0.915). CONCLUSIONS: Few noncomplicated injuries develop infectious keratitis. We recommend fewer follow-ups for these injuries. However, if patients develop any worsening in eye pain, irritation, redness, or decrease in their visual acuity, they should return promptly for reassessment.

Rate of serious adverse effects in a series of bevacizumab and ranibizumab injections.

OBJECTIVE: To compare the rate of serious ocular and systemic adverse effects of intravitreal bevacizumab and ranibizumab in the treatment of a variety of eye diseases. DESIGN: Retrospective chart review. PARTICIPANTS: Consecutive series of intravitreal injections of bevacizumab (n = 693) and ranibizumab (n = 891). METHODS: Medical records of all patients receiving injections in the series were retrieved. We considered the rate of both serious ocular adverse effects (e.g., acute intraocular inflammation, infectious endophthalmitis, retinal detachment, vitreous hemorrhage) and of arterial thromboembolic events that occurred within 1 month of injection. RESULTS: Subjects who received bevacizumab were 12 times more likely to develop severe intraocular inflammation following each injection than were those who received ranibizumab (OR = 11.71; 95% CI 1.5-93). The 1 case of acute intraocular inflammation following ranibizumab injection was mild and not associated with vision loss. No other serious ocular complications were noted. A trend was also noted toward an increased risk for arterial thromboembolic events in patients receiving bevacizumab, although the confidence interval was wide (OR = 4.26; 95% CI 0.44-41). CONCLUSIONS: Significant concern still exists regarding the safety of off-label use of intravitreal bevacizumab. Patients receiving bevacizumab should be counselled regarding a possible increased risk for serious adverse events.