Assessment of the duration of surgery and patient turnover after the incorporation of a standardized intracameral combination of mydriatics and anesthetics for cataract surgery.

PURPOSE: To evaluate changes in clinical outcomes, duration, and workflow of cataract surgery, before and after the introduction of a commercially available intracameral combination of 2 mydriatics (phenylephrine, tropicamide) and 1 anesthetic (lidocaine) (ICMA). SETTING: Service d'Ophtalmologie, Hôpital Bicêtre, Université Paris Sud., Le Kremlin-Bicêtre, France. DESIGN: Retrospective chart review. METHODS: Three series of patients who underwent cataract surgery were grouped according to when they had surgery: just before ICMA was approved (early 2016, Series I); just after implementation of ICMA as the standard procedure for surgery (late 2016, Series II); and 21 months after using ICMA routinely for surgery (2018, Series III). Data were collected on patient turnover during the day of surgery and surgical outcomes. RESULTS: The study population comprised of 51, 47, and 51 patients in Series I, II, and III respectively. There were no statistical differences between series in the mean change in corrected distance visual acuity from preoperatively to 1 month postoperatively and in complications (P > .05, all comparisons). The mean duration of surgery was significantly shorter in Series III and II, compared with Series I (13.18 ± 4.05 and 13.62 ± 5.26 vs 15.82 ± 6.01 minutes; P = .023 and P = .041, respectively). The mean patient rotation was statistically significantly shorter in Series III compared with Series I (41.50 ± 8.31 vs 47.79 ± 14.66 minutes, respectively; P = .028). CONCLUSIONS: Implementing ICMA as a routine procedure in cataract surgery resulted in similar vision and safety outcomes than the usual topical eyedrop regimen, while significantly reducing the total surgery and rotation times. Hence, patient turnover during the surgical session was optimized while maintaining safety and efficacy of the procedure.

Efficacy of a Topical Heparan Sulfate Mimetic Polymer on Ocular Surface Discomfort in Patients with Cogan's Epithelial Basement Membrane Dystrophy.

Purpose: Treatment of persistent ocular discomfort in patients with Cogan's epithelial basement membrane dystrophy (EBMD) is a challenge for ophthalmologists. This study aimed to determine the efficacy of a topical heparan sulfate mimetic polymer (HSMP) in reducing ocular discomfort in EBMD patients. Methods: This retrospective, noninterventional study included 22 consecutive patients in 3 tertiary ophthalmological units with spontaneous, recurrent, acute ocular pain, resistant to various topical lubricants. After EBMD diagnosis, HSMP treatment was initiated while lubricating eye drops were continued. The main study outcome was the change in ocular discomfort assessed using the ocular surface disease index (OSDI) from initiation of treatment to last follow-up visit. Results: The mean OSDI decreased from 46.7 ± 22.3 to 31.6 ± 17.4 (P < 0.001) at first visit and 32.5 ± 17.9 (P < 0.01) at last visit. The rate of patients with severe ocular surface disease (OSDI >33) decreased from 68.2% to 36.4% at first visit and 42.9% at last visit. After a median follow-up of 8.5 months, 7 (31.8%) patients discontinued the HSMP treatment due to a marked improvement in ocular surface comfort and no recurrence of ocular pain, 5 (22.7%) due to lack of efficacy, and 1 (4.5%) due to an ocular adverse event (not treatment related). Eight patients continued treatment after the last visit and 1 patient was lost to follow-up. Globally, HSMP prevented acute painful episodes in 11 (61.1%) of 18 patients followed for ∼4 months. Conclusions: Topical HSMP may be an option for alleviating ocular discomfort in patients with EBMD resistant to standard symptomatic treatments.

Recurrent herpetic keratitis despite antiviral prophylaxis: A virological and pharmacological study.

Recurrent herpes simplex keratitis (HSK) is a leading infectious cause of blindness in industrialized countries. Antiviral prophylaxis (AVP) may fail to prevent recurrence of HSK due to viral resistance, inadequate dosing, or poor patient compliance. In this prospective multicenter study, we enrolled immunocompetent patients with recurrent HSK despite AVP. Ocular samples were tested by PCR for herpes simplex virus 1 (HSV-1). HSV-1 drug resistance was assessed with a genotypic assay based on UL23 and UL30 gene sequencing. After curative full dose valacyclovir (VACV) treatment was started, peak and trough acyclovir (ACV) plasma concentrations were measured, and patient compliance to AVP was assessed with a questionnaire. The study sample was comprised of 43 patients. Six (14%) patients were positive for HSV-1 using PCR, of whom 5 (83%) harbored genotypically ACV-resistant (ACVR) virus, due to mutations in UL23 (n = 4) or UL30 (n = 1). Disease duration was statistically significantly longer in patients with viral resistance compared to other HSK patients [35.5 ± 23.4 years (range, 6.8-68.4 years) versus 11.1 ± 12.3 years (range, 0.8-56.3 year) respectively; Mann-Whitney p = 0.01)]. While patients were treated with full dose VACV, trough ACV plasma concentrations were below the threshold for ACV sensitivity in 9.5% of cases, and compliance was poor in 5.3% of cases. To summarize, HSV-1 resistance to ACV seems to be a significant cause of failure of prophylaxis in patients with HSK and is associated with longer disease duration. Most PCR-positive samples contained genotypically ACVR virus and identification may aid in adapting treatment. Incomplete 24-h drug coverage may also explain some cases of failure of prophylaxis.

Persistent Impairment of Quality of Life in Patients with Herpes Simplex Keratitis.

PURPOSE: To evaluate the quality of life (QoL) in patients with quiescent herpes simplex keratitis compared with control patients without ocular herpes. DESIGN: Prospective, case-control study. PARTICIPANTS: Thirty-three patients with a unilateral and relapsing herpes simplex keratitis (HSK group) that was quiescent during evaluation (no acute episode in the past 3 months) and 66 patients with no history of HSK (control group). Both groups were age and gender matched. METHODS: Three previously validated QoL questionnaires were used in this study: the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25), Glaucoma Quality of Life 17 (Glau-QoL17) questionnaire, and Ocular Surface Disease Quality of Life (OSD-QoL) questionnaire. Each questionnaire covered various aspects of the disease. MAIN OUTCOME MEASURES: The outcomes of the 3 questionnaires were compared between groups. For the HSK group, the results were correlated to the clinical findings and the history of herpetic disease. RESULTS: The mean total questionnaire scores of the 3 QoL questionnaires were significantly lower in the HSK group compared with controls (NEI VFQ-25: 70.5±3.8 vs. 91.1±0.8, P < 0.0001; Glau-QoL17: 68.2±3.1 vs. 87.9±1.0, P < 0.0001; and OSD-QoL: 65.4±2.9 vs. 93.1±0.6, P < 0.0001, respectively). In the HSK group, the level of visual acuity (VA) in the affected eye had the greatest impact on QoL, inducing lower QoL results related to "general vision," "distance activities," "dependency," "peripheral vision," "self-image," "daily living," and "driving" dimensions. Decreased VA in the unaffected eye also negatively affected "self-image" and "driving" results. Patients with frequent HSK relapses had lower QoL related to "ocular pain" and "acknowledgement." CONCLUSIONS: Even during a quiescent phase of the disease, unilateral and relapsing HSK significantly impairs the QoL of patients to a similar level as most sight-threatening diseases. The decrease of VA has the greatest overall effect, but other factors also significantly affect QoL, such as the frequency of relapses.

Diffusion tensor magnetic resonance imaging of trigeminal nerves in relapsing herpetic keratouveitis.

BACKGROUND: Corneal hypoesthesia is the landmark of HSV and VZV keratitis and can lead to neurotrophic keratitis. Diffusion tensor imaging (DTI) is a new magnetic resonance imaging (MRI) derived technique, which offers possibilities to study axonal architecture. We aimed at assessing the potential impact of recurrent HSV or VZV-related keratitis on the axonal architecture of trigeminal nerves using DTI. DESIGN: Prospective non-interventional study. PARTICIPANTS: Twelve patients and 24 controls. METHODS: DTI using MRI of the trigeminal fibers and corneal esthesiometry using the Cochet-Bonnet esthesiometer were acquired for patients affected by unilateral and recurrent HSV or VZV-related keratitis (3 months after the last corneal inflammatory event), and control subjects with no history of ocular or neuronal disease affecting the trigeminal pathways. MAIN OUTCOME MEASURES: Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) were compared between the 2 eyes of both patients and controls, and correlated with corneal esthesiometry. RESULTS: FA was lower in the trigeminal fibers ipsilateral to the affected eye compared to the non-affected side (0.39±0.02 versus 0.46±0.04, P=0.03). This difference was more important than the intra-individual variability observed in controls. Concomitantly, the asymmetry in ADC results was significantly correlated with the loss of corneal sensitivity in the affected eye. CONCLUSIONS: Corneal hypoesthesia related to HSV and VZV keratitis is associated with persistent modifications in the architecture and functionality of the trigeminal fibers. These results add further explanation to the pathogenesis of HSV and VZV-induced neurotrophic keratitis, which may occur despite an apparent quiescence of the disease.

Optical aberrations in patients with recurrent herpes simplex keratitis and apparently normal vision.

AIMS: To analyse high-order aberrations (HOA), modulation transfer function (MTF) and Strehl ratio in patients with a history of herpes simplex keratitis (HSK) and apparently normal vision. METHODS: Fifteen patients with a history of recurrent unilateral HSK and normal Snellen visual acuity (0 logMAR) were enrolled. Eyes with HSK (HSK group) were statistically compared with normal fellow eyes (Control group). HOA, MTF and Strehl ratio were measured using the OPD-SCAN II (Nidek Co, Gamagori, Japan) aberrometer. Measures were performed at least 3 months after the last episode of herpes. Statistical significance was indicated by p<0.05. RESULTS: Despite apparently normal vision in both eyes (as assessed by routine visual acuity charts), significantly higher total HOA, trefoil and tetrafoil were present in the HSK group compared with the Control group. The MTF and strehl ratio were lower in the HSK group compared with the Control group. In the HSK group, eyes with corneal opacities tended to present with greater optical aberrations than eyes with a clear cornea. CONCLUSIONS: Using patients as their own controls, the outcomes of this study indicate that eyes with recurrent HSK with no apparent decrease in visual acuity (0 logMAR) have significantly greater optical aberrations than eyes with no past history of herpetic disease. This outcome may explain some visual complaints of HSK patients, such as a decrease in contrast quality or reduced colour perception, compared with the unaffected contralateral eye despite apparently normal vision in both eyes.

Impairment of lacrimal secretion in the unaffected fellow eye of patients with recurrent unilateral herpetic keratitis.

PURPOSE: To assess the impact of recurrent unilateral herpetic keratitis (HK) on the tear secretion of the unaffected fellow eye. DESIGN: Prospective, noninterventional study. PARTICIPANTS AND CONTROLS: Thirty-five patients with a history of recurrent unilateral HK (clinically quiescent for at least 3 months) (HK group) and 35 patients who were age- and sex-matched with no history of corneal disease (control group). METHODS: Tear osmolarity, tear instability (tear break-up time [TBUT]), tear reflex (Schirmer's I test), and central corneal sensitivity with the Cochet-Bonnet esthesiometer (Luneau, France) were measured in the HK and control groups. MAIN OUTCOME MEASURES: Tear osmolarity, TBUT, Schirmer's I, and central corneal sensitivity were compared between the affected and unaffected eyes of the HK and control groups. RESULTS: Tear osmolarity and tear secretion reflex were similar between the affected and unaffected eyes of the HK group. Corneal sensitivity and TBUT were statistically lower in the affected eyes compared with the unaffected eyes in the HK group (P = 0.001 and P<0.001, respectively). The central corneal sensitivity of unaffected eyes in the HK group was not significantly different from that in the control group (P>0.05). The tear stability and tear secretion reflex were decreased and tear osmolarity was increased in the unaffected eyes of the HK group compared with the control group (P<0.05, all cases). The difference between unaffected and control eyes varied according to the type of HK. All 4 tests were modified in patients with neurotrophic keratitis (KN). In the keratouveitis subgroup, only corneal sensitivity was normal, whereas Schirmer's I results were also normal in patients with archipelago keratitis. Tear osmolarity was consistently affected in both eyes of herpetic patients. CONCLUSIONS: Tear function is impaired in the unaffected eyes of patients with unilateral recurrent HK, even when the disease is apparently quiescent. The higher severity of results in the unaffected fellow eye of patients with KN in comparison with other herpes subgroups suggests that recurrent HK induces a reduction in the afferent pathways of the tear secretion reflex from the affected eye, leading to tear dysfunction in the unaffected eye. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Retinal emboli in cholesterol crystal embolism.

Cholesterol crystal embolism (CCE) is a rare and severe multisystemic disorder. It results from a massive release of cholesterol crystals from widespread atherosclerotic disease. The main difference with atherosclerosis is the severity and the quantity of the embolic events that occur during the course of the disease, eventually leading to multivisceral failure and death. The symptoms are multiple and make it a diagnostic challenge. Fundoscopic examination can be of great help, showing retinal emboli in up to 25% of the cases, and has been rarely described in the ophthalmologic literature. We report the case of a 77-year-old man with acute renal failure after coronarography. Retinal emboli seen in the fundus confirmed the diagnosis of cholesterol crystal embolism and thus prevented any further invasive investigations. In this case, anticoagulants must be stopped and any further endovascular procedure proscribed. Although impossible for this patient, peritoneal dialysis should be preferred to hemodialysis because it does not need any anticoagulation. Systemic corticosteroid can be used in the acute phase. Fundoscopic examination should be performed each time cholesterol crystal embolism is suspected. When typical emboli are seen in the retina, it permits avoiding invasive investigations and saving precious time for the management of this potentially lethal disease.