Outcomes of the Boston Type I Keratoprosthesis as the Primary Penetrating Corneal Procedure.

PURPOSE: To report the outcomes of the Boston type I keratoprosthesis (KPro) as the primary penetrating corneal procedure. METHODS: In this retrospective review of all KPro procedures performed by 2 surgeons from May 1, 2004, to December 31, 2015, indications and outcomes were compared between KPros performed as the primary keratoplasty procedure (primary KPro) versus after failed keratoplasty (previous keratoplasty). RESULTS: A total of 262 KPros were implanted in 231 eyes, including 67 primary KPro procedures. The most common indications for primary KPros were corneal scarring/vascularization (43%), Stevens-Johnson syndrome (22%), and chemical/thermal injury (22%). Although preoperative corrected distance visual acuity (CDVA) was similar in the 2 groups (P = 0.36), a significantly higher proportion of the eyes in the primary KPro group had a CDVA ≥ 20/200 each of the first 4 years after surgery (all P ≤ 0.023). The most common postoperative complications in the primary KPro and previous keratoplasty groups were retroprosthetic membrane (40% vs. 51%, P = 0.15), persistent epithelial defect (37% vs. 24%, P = 0.05), and elevated intraocular pressure, which was the only complication significantly more common in either group (31% vs. 18%, P = 0.03). No difference in KPro retention was observed between the 2 groups (P = 0.63). CONCLUSIONS: In the setting of preexisting ocular comorbidities in which PK is associated with poor outcomes and KPros have been associated with an increased incidence of postoperative complications, primary KPro is associated with significantly greater % of eyes with CDVA ≥ 20/200 in the first 4 years. However, given a significantly higher incidence of postoperative intraocular pressure elevation in these eyes, longer follow-up is needed to determine whether the difference in CDVA is maintained.

Ptosis Sensitivity Threshold for the Lay Observer.

PURPOSE: This study aims to understand the degree to which ptosis is recognizable to a layperson. METHODS: Fifteen color drawings of a gender-neutral human face were created. Six faces exhibited right-sided ptosis (decreased margin reflex distance 1 and lengthened tarsal platform show) of 0.5 mm, 1 mm, 1.5 mm, 2 mm, 2.5 mm, and 3 mm, respectively. Six more faces exhibited left-sided ptosis of the same amounts. The 12 ptotic faces and 3 symmetrical faces were randomly placed on three 11-inch by 14-inch sheets of paper with 5 faces on each page. Lay observers were provided 6 seconds per face to indicate whether it appeared to be asymmetrical. Statistical tests examined the observers' ability to detect asymmetry better than chance. Sex differences in correctly recognizing asymmetry in ptosis at each 0.5 mm increment were analyzed. RESULTS: One hundred thirty-one lay observers were enrolled in the study. Fifty-seven were women and 74 were men. Lay people were able to correctly recognize ptosis better than chance when the asymmetry was 1.5 mm or greater. Moreover, females were more accurate in recognizing ptosis at 1.5 mm, 2.0 mm, and 2.5 mm of asymmetry. CONCLUSIONS: Lay observers tend to recognize between 1.0 mm and 1.5 mm of ptosis on one side as being abnormal. This may have implications in the selection of candidates for ptosis surgery and the analysis of subsequent surgical outcomes.

PROGRESSION OF MACULAR ATROPHY IN EYES WITH TYPE 1 NEOVASCULARIZATION AND AGE-RELATED MACULAR DEGENERATION RECEIVING LONG-TERM INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY: An Optical Coherence Tomographic Angiography Analysis.

PURPOSE: To evaluate the size and location of macular atrophy in eyes with Type-1 neovascularization (NV) and age-related macular degeneration receiving chronic intravitreal anti-vascular endothelial growth factor therapy. METHODS: A retrospective review of a case series of 27 eyes with Type-1 NV and retinal pigment epithelial detachment (PED) having a minimum of 12 months follow-up was performed. Demographic information and visual acuity at baseline and the final follow-up were collected. Spectral-domain optical coherence tomography (OCT) and near-infrared reflectance were analyzed at 6-month intervals to detect and measure macular atrophy. Location and area (in square millimeter) of macular atrophy were measured using Heidelberg software tools. Also, OCT angiography was used to colocalize the area of Type-1 NV flow versus the location of atrophy. RESULTS: Twenty-seven eyes of 27 patients were included in this analysis. The median visual acuity was 20/50, mean age was 82.7 years, and mean number of injections was 29.5. A larger percentage of eyes (59.3%) developed atrophy predominantly eccentric to the PED versus predominantly overlying the PED (11.1%) when measured with spectral-domain OCT and near-infrared imaging. At the final follow-up, there was a larger area of atrophy surrounding the fibrovascular PED (mean, 3.326 mm) than overlying it (mean, 0.542 mm), and this was statistically significant (P = 0.0118). En-face OCT images were overlaid with OCT angiography in 11 eyes, and a predominantly eccentric pattern of atrophy was identified in 9 of 11 eyes. Using this method, the mean area of atrophy predominantly overlying the Type-1 NV was 1.652 mm (range of 0-10.464 mm), whereas the area of atrophy predominantly eccentric to the neovascular complex was 4.345 mm (range of 0.705-13.758 mm), and this was statistically significant (P = 0.0465). The average rate of atrophy progression was 1.04 mm/year (SD 0.938). CONCLUSION: With long-term anti-vascular endothelial growth factor therapy for eyes with Type-1 NV secondary to age-related macular degeneration, macular atrophy tends to develop predominantly eccentric to the PED and the neovascular flow imaged on OCT angiography. With chronic vascular endothelial growth factor suppression, Type-1 NV may evolve into a multilayered PED that may confer a protective effect to the overlying retinal pigment epithelium and outer retina.

A Technique to Reduce Incidence of Opaque Bubble Layer Formation During LASIK Flap Creation Using the VisuMax Femtosecond Laser.

PURPOSE: To identify risk factors for opaque bubble layer (OBL) formation and compare the incidence of OBL using a cone modification technique versus the original technique for LASIK flap creation using the VisuMax laser (Carl Zeiss Meditec, Jena, Germany). METHODS: This retrospective study examined videos of flap creation using the VisuMax laser to identify OBL occurrence. Eyes were divided into three groups: eyes where OBL occurred using the original technique (OBL group), eyes where OBL did not occur using the original technique (no OBL group), and eyes in which the cone modification technique was used for LASIK flap creation (larger flap diameter) (cone modification technique group). Preoperative measurements including simulated keratometry (flat and steep) values, white-to-white distance (WTW), pachymetry, patient age and gender, amount of correction, flap parameters, energy setting, corneal hysteresis, and corneal resistance factor were analyzed to identify parameters with statistical difference between the OBL and no OBL groups. Incidence of OBL was compared between the original and cone modification techniques. RESULTS: OBL incidence was significantly lower with the cone modification technique (7.6%; 7 of 92 eyes) than with the original technique (28.8%; 34 of 118 eyes) (Fisher's exact test, P = .0009). Factors identified with a significant difference between eyes with and without OBL using the original technique were: corneal thickness (OBL: 561.2 µm, no OBL: 549.6 µm, P = .0132), WTW diameter (OBL: 11.6 mm, no OBL: 11.9 mm, P = .0048), corneal resistance factor (OBL: 10.4 mm Hg, no OBL: 9.6 mm Hg, P = 0.0329), and corneal astigmatism (OBL: 0.80 diopter, no OBL: 1.00 diopter, P = .0472) CONCLUSIONS: Less astigmatic, thicker, denser, and smaller corneas increased the risk of OBL using the original technique for flap creation. The cone modification technique was associated with lower risk of OBL formation, even in eyes with significant risk factors for OBL using the original technique. [J Refract Surg. 2017;33(9):584-590.].

DOME-SHAPED MACULOPATHY: ENHANCED VISUALIZATION WITH RADIAL OPTICAL COHERENCE TOMOGRAPHY SCANS.

PURPOSE: To describe two cases of dome-shaped macula (DSM) and serous macular detachment, the diagnosis of which was enhanced with a radial optical coherence tomography (OCT) scanning protocol. METHODS: Retrospective case series of DSM associated with serous macular detachment. Multimodal retinal imaging was performed including spectral domain OCT with a radial scan protocol and en face OCT angiography. Anatomical outcomes before and after therapy are presented. RESULTS: Two cases of DSM associated with serous macular detachment are described. The dome-shaped macular bulge was more clearly elicited as the cause of serous macular detachment with the employment of a radial OCT scanning protocol. Subretinal fluid resolved in both cases using either intravitreal aflibercept injection or half-fluence photodynamic therapy. En face OCT angiography of the choroid demonstrated reduction in the caliber of choroidal vessels after treatment. CONCLUSION: A radial OCT scanning protocol should be considered in eyes with suspicion of DSM, especially in myopic eyes with subretinal fluid. Intravitreal aflibercept therapy or photodynamic therapy may be considered as a treatment for serous macular detachment because of DSM.

Simultaneous Implantation of an Ahmed and Baerveldt Glaucoma Drainage Device for Uncontrolled Intraocular Pressure in Advanced Glaucoma.

PURPOSE: To evaluate efficacy and safety of a novel technique, simultaneous implantation of Ahmed and Baerveldt shunts, for improved control of intraocular pressure (IOP) in advanced glaucoma with visual field defects threatening central fixation. PATIENTS AND METHODS: Retrospective case series; all patients receiving simultaneous Ahmed and Baerveldt implantation at a single institution between October 2004 and October 2009 were included. Records were reviewed preoperatively and at postoperative day 1, week 1, month 1, month 3, month 6, year 1, and yearly until year 5. Outcome measures included IOP, best-corrected visual acuity, visual field mean deviation, cup to disc ratio, number of glaucoma medications, and complications. RESULTS: Fifty-nine eyes were identified; mean (±SD) follow-up was 26±23 months. Primary open-angle glaucoma was most common (n=37, 63%). Forty-six eyes (78%) had prior incisional surgery. Mean preoperative IOP was 25.5±9.8 mm Hg. IOP was reduced 50% day 1 (P<0.001, mean 12.7±7.0 mm Hg), which persisted throughout follow-up. At year 1, cup to disc ratio and mean deviation were stable with decreased best-corrected visual acuity from logMAR 0.72±0.72(20/100) to 1.06±1.13(20/200) (P=0.007). The Kaplan-Meier survival analysis showed median and mean survival of 1205 and 829±91 days, respectively. Complication rate was 47%. CONCLUSIONS: IOP is markedly reduced postoperative day 1 following double glaucoma tube implantation with effects persisting over postoperative year 1 and up to year 5. Complications were higher than that seen in reports of single shunt implantation, which may be explained by patient complexity in this cohort. This technique may prove a promising novel approach for management of uncontrolled IOP in advanced glaucoma.

OCT Angiography of Paracentral Acute Middle Maculopathy Associated With Central Retinal Artery Occlusion and Deep Capillary Ischemia.

An 82-year-old man presented with acute, painless vision loss in the left eye associated with headaches, jaw claudication, and scalp tenderness. Clinical examination and fluorescein angiography confirmed the diagnosis of a central retinal artery occlusion of the left eye. Spectral-domain optical coherence tomography (OCT) of the left eye showed paracentral acute middle maculopathy (PAMM), and OCT angiography showed severe attenuation of the deep capillary plexus. This is the first case report of OCT angiography of PAMM associated with central retinal artery occlusion confirming the presence of ischemia of the deep retinal capillary plexus.

The role of complement dysregulation in AMD mouse models.

Variations in several complement genes are now known to be significant risk factors for the development of age-related macular degeneration (AMD). Despite dramatic effects on disease susceptibility, the underlying mechanisms by which common polymorphisms in complement proteins alter disease risk have remained unclear. Genetically modified mice in which the activity of the complement has been altered are available and can be used to investigate the role of complement in the pathogenesis of AMD. In this mini review, we will discuss some existing complement models of AMD and our efforts to develop and characterize the ocular phenotype in a variety of mice in which complement is either chronically activated or inhibited. A spectrum of complement dysregulation was modeled on the APOE4 AMD mouse model by crossing these mice to complement factor H knockout (cfh-/-) mice to test the impact of excess complement activation, and by crossing them to soluble-complement-receptor-1-related protein y (sCrry) mice, in which sCrry acts as a potent inhibitor of mouse complement acting in a manner similar to CFH. In addition, we have also generated humanized CFH mice expressing normal and risk variants of CFH.

Progression of intermediate age-related macular degeneration with proliferation and inner retinal migration of hyperreflective foci.

PURPOSE: Drusen and migrating retinal pigment epithelium have been associated with hyperreflective foci (HF) detected by spectral-domain optical coherence tomography (SD-OCT). This study sought to quantify the change in intraretinal HF distribution and its correlation with age-related macular degeneration (AMD) disease progression. DESIGN: Prospective observational study from the multicenter Age-Related Eye Disease Study 2 (AREDS2) Ancillary SD-OCT Study. PARTICIPANTS: Patients (n=299) with 1 enrolled eye with intermediate AMD and baseline SD-OCT, followed by SD-OCT imaging at 1-year and 2-year visits. METHODS: The number and location of HF were scored in SD-OCT scans of all 299 eyes. The change in transverse (horizontal) and axial (vertical) distribution of HF in the macula were evaluated with pairwise signed-rank tests. Two-year inner retinal HF migration was determined by the change in HF-weighted axial distribution (AxD) score calculated for each eye. The correlation of HF with SD-OCT features of AMD progression was evaluated with logistic regression analysis. MAIN OUTCOME MEASURES: The mean change in number of HF, transverse and axial distribution of HF in the macula, and AxD per eye. RESULTS: In 299 study eyes, the 2-year increase in the number of HF (P<0.001) and the AxD (P<0.001) per eye represented longitudinal proliferation and shift to inner retinal layers, respectively. Eyes with geographic atrophy (GA) at 2 years were correlated with the presence of baseline HF (P<0.001; odds ratio [OR], 4.72; 95% confidence interval [CI], 2.43-9.80), greater number of baseline HF (P<0.001; OR, 1.61 per HF; 95% CI, 1.32-2.00), and greater baseline AxD (P<0.001; OR, 1.58 per AxD point; 95% CI, 1.29-1.95). CONCLUSIONS: Proliferation and inner retinal migration of SD-OCT HF occurred during follow-up in eyes with intermediate AMD. These characteristics were associated with greater incidence of GA at year 2; therefore, SD-OCT HF proliferation and migration may serve as biomarkers for AMD progression. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

A method for full genome sequencing of all four serotypes of the dengue virus.

The availability of whole genome sequencing has contributed to many aspects of dengue research, and its use in dengue virus (DENV) surveillance for early epidemic warning has been proposed. Methods to sequence the genomes of individual dengue serotypes have been described previously, but no single method is known to be applicable for all four serotypes. This report describes a method for sequencing the entire genome of all four DENV serotypes. Using tagged oligonucleotide primers designed for the 3' end, viral RNA was reverse transcribed into a cDNA spanning the entire genome of each of the four serotypes (DENV-1 to -4). This was followed by amplification of the entire cDNA in five overlapping amplicons. A sequence tag was added to the sense primer annealing to the 5' UTR sequence and the antisense primer annealing to the 3' UTR sequence to ensure no terminal nucleotides were omitted during PCR. Sixty-one virus isolates were sequenced: 58 DENV-2, one DENV-1, one DENV-4 and one DENV-3 published previously. The method described could be applied readily for viral biology studies and incorporated into proactive dengue virologic surveillance.