Clinical performance after implantation of an EDOF intraocular lens in the dominant eye and a presbyopia-correcting intraocular lens in the nondominant eye.

PURPOSE: To evaluate subjective and objective outcomes after combined implantation of an extended depth-of-focus (EDOF) intraocular lens (IOL) and a combined technology multifocal lens (CT-IOL). SETTING: 2 clinical practices (Carolina Eyecare Physicians, Center For Sight) in the United States. DESIGN: Prospective, unmasked, multicenter, nonrandomized bilateral eye study. METHODS: Patients interested in reducing their dependence on spectacles were implanted with an EDOF IOL in the dominant eye and a CT-IOL in the nondominant eye. Refractive and visual acuity (VA) data at various distances (4 m, 66 cm, 40 cm, and 33 cm) were collected 3 months postsurgery, along with the distance-corrected binocular defocus curve and responses to questionnaires related to spectacle independence, visual disturbances, and overall visual function. RESULTS: Data from 37 participants were analyzed. The distance-corrected binocular defocus curve showed a mean VA better than 0.1 logMAR (20/25) at all vergences from +1.00 to -2.50 diopters (D). 36 participants (97%) had an uncorrected binocular VA of 0.3 logMAR or better, at all test distances. 70% of participants (26/37) reported never wearing spectacles at any distance, and 84% (31/37) were "completely" or "mostly" satisfied with their overall vision after surgery. Halos were the disturbance reported most frequently and reported as most bothersome, with difficulty driving at night the most common visual function issue. Difficulty reading was the next most reported issue. Overall eyesight was rated as "excellent" or "good" by 92% (34/37) of participants. CONCLUSIONS: This combined EDOF/CT-IOL approach was well-tolerated by participants and provided some potential benefits relative to bilateral implantation of either lens.

United States Regulatory Approval of Topical Treatments for Dry Eye.

PURPOSE: To report the heterogeneity in methodology of clinical trials submitted to the US Food and Drug Administration (FDA) for approval of topical dry eye treatments. DESIGN: Comparative analysis of clinical trials' methods. METHODS: We reviewed the online, publicly available FDA database, application review files, ClinicalTrials.gov registry records, and journal articles for each FDA-approved topical dry eye treatment. For each trial, we extracted information about the study, patient demographics, treatment names and doses, sample size in each arm, and the measurement instrument in a systematic fashion. RESULTS: Fourteen trials were included that assessed 5 topical treatments for dry eye (cyclosporine 0.05%, cyclosporine 0.09%, lifitegrast 5%, and loteprednol 0.25% eye drops and varenicline 0.03-mg nasal spray). Median treatment duration was 12 weeks (range, 2-24 weeks). In all trials, treatments, including varying concentrations of the same treatment, were compared with vehicle. Twelve trials (85.7%) evaluated a primary clinician-measured clinical sign, and 10 trials (71.4%) evaluated a primary patient-reported symptom. Corneal staining was the most frequently evaluated clinical sign primary outcome, reported in half (6 of 12) of the trials, and was graded using 4 different scoring systems. Conjunctival staining, conjunctival hyperemia, and tear production were each measured using 2 different scoring systems. Ocular discomfort, the only patient-reported symptom primary outcome, was measured using 5 different instruments. CONCLUSION: A variety of outcome measures were used in these clinical trials. Clinically meaningful dry eye outcome measures and standardized measurements can optimize the assessment of and comparison of therapeutic benefits.

Usability of Patient Education-Oriented Cataract Surgery Websites.

PURPOSE: To assess the web accessibility and readability of patient-oriented educational websites for cataract surgery. DESIGN: Cross-sectional electronic survey. PARTICIPANTS: Websites with information dedicated to educating patients about cataract surgery. METHODS: An incognito search for "cataract surgery" was performed using a popular search engine. The top 100 patient-oriented cataract surgery websites that came up were included and categorized as institutional, private practice, or medical organization according to authorship. Each site was assessed for readability using 4 standardized reading grade-level formulas. Accessibility was assessed through multilingual availability, accessibility menu availability, complementary educational video availability, and conformance and adherence to the Web Content Accessibility Guidelines (WCAG) 2.0. A standard t test and chi-square analysis were performed to assess the significance of differences with regard to readability and accessibility among the 3 authorship categories. MAIN OUTCOME MEASURES: The main outcome measures were the website's average reading grade level, number of accessibility violations, multilingual availability, accessibility menu availability, complementary educational video availability, accessibility conformance level, and violation of the perceivable, operable, understandable, and robust (POUR) principles according to the WCAG 2.0. RESULTS: A total of 32, 55, and 13 sites were affiliated with institutions, private practice, and other medical organizations, respectively. The overall mean reading grade was 11.8 ± 1.6, with higher reading levels observed in private practice websites compared with institutions and medical organizations combined (12.1 vs. 11.4; P = 0.03). Fewer private practice websites had multiple language options compared with institutional and medical organization websites combined (5.5% vs. 20.0%; P = 0.03). More private practice websites had accessibility menus than institutions and medical organizations combined (27.3% vs. 8.9%; P = 0.038). The overall mean number of WCAG 2.0 POUR principle violations was 17.1 ± 23.1 with no significant difference among groups. Eighty-five percent of websites violated the perceivable principle. CONCLUSIONS: Available patient-oriented online information for cataract surgery may not be comprehensible to the general public. Readability and accessibility aspects should be considered when designing these resources. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Quality and Agreement With Scientific Consensus of ChatGPT Information Regarding Corneal Transplantation and Fuchs Dystrophy.

PURPOSE: ChatGPT is a commonly used source of information by patients and clinicians. However, it can be prone to error and requires validation. We sought to assess the quality and accuracy of information regarding corneal transplantation and Fuchs dystrophy from 2 iterations of ChatGPT, and whether its answers improve over time. METHODS: A total of 10 corneal specialists collaborated to assess responses of the algorithm to 10 commonly asked questions related to endothelial keratoplasty and Fuchs dystrophy. These questions were asked from both ChatGPT-3.5 and its newer generation, GPT-4. Assessments tested quality, safety, accuracy, and bias of information. Chi-squared, Fisher exact tests, and regression analyses were conducted. RESULTS: We analyzed 180 valid responses. On a 1 (A+) to 5 (F) scale, the average score given by all specialists across questions was 2.5 for ChatGPT-3.5 and 1.4 for GPT-4, a significant improvement (P < 0.0001). Most responses by both ChatGPT-3.5 (61%) and GPT-4 (89%) used correct facts, a proportion that significantly improved across iterations (P < 0.00001). Approximately a third (35%) of responses from ChatGPT-3.5 were considered against the scientific consensus, a notable rate of error that decreased to only 5% of answers from GPT-4 (P < 0.00001). CONCLUSIONS: The quality of responses in ChatGPT significantly improved between versions 3.5 and 4, and the odds of providing information against the scientific consensus decreased. However, the technology is still capable of producing inaccurate statements. Corneal specialists are uniquely positioned to assist users to discern the veracity and application of such information.

Evolution of eye banking in India - A review.

Corneal blindness ranks third among the causes of blindness worldwide, after cataract and glaucoma. Corneal transplantation offers us a means to address this, and is currently the most commonly performed transplantation procedure worldwide - restoring the gift of sight to many an eye. Eye banks play a very important role in these procedures. India was quick to develop its own eye bank in 1945 soon after the launch of world's first eye bank in 1944. The evolution over the past six decades has been tremendous, placing India on the top, with one of the largest eye-banking system in the world. As of 2023, around 740 members are registered under the Eye Bank Association of India. The highest-ever collection of 71,700 donor eyes was achieved in 2017-2018. The overall tissue utilisation rate ranged between 22 - 28 % for voluntary donations and 50% for hospital-based corneal retrieval programs. Though India has an excellent infrastructure and readiness for corneal transplantation surgery, the need of the hour is to create a strong and independent nodal system. It shall take care of the logistics and factor in technological advances - surgical and otherwise. Public awareness, a national corneal grid, and reducing the red-tape barriers, shall improve availability of grafts nationwide. This review aims to detail the evolution of eye banking in India, to provide a comprehensive understanding, and help the stakeholders focus on the road ahead to attain our targets faster.

Long-term outcomes of therapeutic corneal transplants performed in a tertiary eye care hospital in South India.

Purpose: This study aimed to review the demographics, clinical characteristics, and long-term outcomes of therapeutic penetrating keratoplasty (TPK) performed in a tertiary eye care hospital. Methods: Case records of 149 therapeutic transplants (135 patients) that were performed during the calendar year 2016 were retrospectively analyzed, and outcomes were measured until 3 years of follow-up. Information on demographics, presentation characteristics, keratoplasty indications, offending microbe, and secondary surgical interventions was studied. The final outcome was classified in terms of therapeutic, anatomical, and functional outcomes. Results: The median age of the recipients was 55 years with 61% men. The most common indications for TPK were perforated infectious ulcer (45.9%), nonhealing ulcers (29.9%), and graft infections (17.4%). Fungal etiology was noted in 61.2% and bacterial etiology in 17.4% of the eyes. Therapeutic success was achieved in 130 eyes (89%) at the end of 1 month. Anatomical success was achieved in 130 (98.5%) and 88 patients (86.3%) at the end of 1 and 6 months, respectively. At the 6-month time point, 78 patients (76.5%) attained functional success with vision better than light perception. Three-year follow-up data were available for 23.7% of recipients, of which only 12 patients (37.5%) retained a clear graft either after a primary therapeutic or secondary optical keratoplasty. Conclusion: Therapeutic keratoplasty is highly effective in eradicating infection and providing anatomical integrity. However, timely intervention can aid in achieving the best functional outcome.

Comparison of simultaneous vs sequential pars plana vitrectomy and cataract surgery.

BACKGROUND: To compare the clinical outcomes of patients undergoing sequential pars plana vitrectomy (PPV) followed by cataract extraction surgery (CE) [PPV/CE], simultaneous PPV and CE (PPV + CE), and sequential CE followed by PPV [CE/PPV]. METHODS: A retrospective observational cohort study of 427 eyes of 404 patients who underwent either sequential or simultaneous PPV and CE surgery between March 2016 and May 2021. Pre-operative and post-operative assessments (up to 2 years of follow-up visits) of uncorrected visual acuity (UCVA), corrected distance visual acuity (CDVA), spherical equivalent (SEQ), and refractive prediction error (RPE) was done. Main outcome measures were both visual (UCVA, CDVA) and refractive (RPE, SEQ). RESULTS: There was a statistically significant difference in CDVA of the PPV/CE, PPV + CE, CE/PPV groups (logMAR 0.34 ± 0.40, 0.65 ± 0.61, and 0.55 ± 0.60, respectively) at one month postoperatively (POM1) (P < 0.001), and at the POM12 visits (logMAR 0.25 ± 0.34, 0.53 ± 0.68, and 0.44 ± 0.48; P = 0.04). In the subgroup analysis of patients with a diagnosis of either epiretinal membrane or vitreous opacities, there was no statistically significant difference in SEQ (P = 0.09) and RPE (P = 0.13) at the combined 1 month and 3 month visits. CONCLUSION: Simultaneous PPV and cataract surgery demonstrated similar improvements in visual acuity and refractive outcomes, as well as comparable intraoperative and postoperative complication profiles to sequential surgery.

Racial and Ethnic Disparities in Dry Eye Diagnosis and Care.

PURPOSE: To investigate health disparities in racial and ethnic minorities with dry eye. METHODS: Medical records were reviewed for demographics, socioeconomic factors, treatments, and objective dry eye parameters. Race/ethnicity was self-reported as delineated by the U.S. Census. The reference group comprised of randomly selected White patients, with number equal to the largest minority group. RESULTS: The study included 465 patients (157 Black, 157 White, 85 Asian, and 66 Hispanic). Compared to White (3.2%) patients, larger proportion of minorities used Medicaid or lacked health insurance (Black 8.3%, P = .054; Asian 10.6%, P = .019; Hispanic 18.2%, P < .001). Black and Hispanic patients had lower estimated median household income than Whites (White $98,472, Black $75,554, P < .001; Asian $105,503, P = .088; Hispanic $86,839, P = .030). Prior to presentation, fewer minority patients received prescription treatments or procedures (White 61.8%; Black 30.6%, P < .001; Asian 43.5%, P = .006; Hispanic 43.9%, P = .014). Although at baseline visit minorities had worse mean conjunctival (White, 1.7; Black 2.2, P = .136, Asian 2.4, P = .022; Hispanic 2.6, P = .005) and corneal staining scores (White, 1.6; Black 2.5, P < .001; Asian 2.3, P = .003; Hispanic 2.4, P = .001), no differences were noted at final visit. CONCLUSION: Minorities presented with worse objective dry eye parameters, and less prior dry eye care. Income and health care access may not fully explain the observed undertreatment at presentation. Differential management by eye care providers and patient attitudes warrant further investigation.

Outcomes of Sjögren's versus non-Sjögren's related dry eye in a longitudinal, tertiary clinic-based sample.

PURPOSE: To assess the long-term treatment outcomes of dry eye in patients with and without underlying primary Sjögren's syndrome (SS). DESIGN: Retrospective longitudinal cohort. METHODS: SS and non-SS dry eye patients with clinic visits for a minimum of 5 consecutive years at a tertiary, dedicated dry eye clinic were included. Electronic health records were reviewed to collect data regarding demographics, objective dry eye parameters, treatments utilized at baseline and final visit, and corneal complications observed during follow-up. RESULTS: Two hundred and two patients (101 SS and 101 randomly selected non-SS), with a mean follow-up of 7.1 years were included. At baseline, mean conjunctival lissamine green staining score was 2.9 and mean corneal fluorescein staining score was 2.0. At last visit, notable improvement in staining score for cornea (-1.1, P < .001) and conjunctiva (-1.8, P < .001) was seen equally in both dry eye groups. Most patients (88.1%) had an escalation of treatment by the final visit, with similar rates in both groups (P = .51). Half (48.9%) of the patients had no conjunctival staining, and a third (34.4%) had no corneal staining at their last visit. Twenty (9.9%) patients experienced a vision-threatening corneal complication, including ulcers and melt, with no difference in occurrences between the groups (P = .64). CONCLUSIONS: The majority of patients in this longitudinal, tertiary clinic-based sample demonstrated improvement in their ocular surface staining score by the final visit with escalation in treatment. Treatments used, improvement achieved, and corneal complication rates leading to loss of vision were similar in both SS and non-SS dry eye groups.

Impact of COVID-19 Pandemic on Infectious Keratitis Outcomes: A Retrospective Multicenter Study in Tertiary Eye Hospitals of South India.

PURPOSE: The purpose of this study was to report the adverse effects of the COVID-19 pandemic on the clinical outcomes of infectious keratitis in South India. METHODS: Two hundred fifty-eight patients presented with infectious keratitis at 6 tertiary care centers when strict travel restrictions were in place from March 24 to May 31, 2020. Case records were collected retrospectively and analyzed for demographics, type of initial treatment, length of delay in presentation, microbiological diagnosis, clinical course, and final treatment outcome. RESULTS: The mean age of the patients was 49.2 years, with most of them (61.2%) being male. Forty-one patients (15.9%) did not receive any treatment for at least a week after the onset of symptoms. One hundred eight patients (41.9%) presented with severe ulcer (32 had a frank perforation). Resolution of the infection was achieved only in 103 patients (45.6%). A total of 90 patients (39.8%) with ulcers had a perforation, yet only 29 patients (32.2%) could receive keratoplasty because of the unavailability of donor tissues. At the end of 6-month follow-up, 47 patients had anatomical failure (loss of globe) and 12 additional patients had functional failure (total permanent vision loss). CONCLUSIONS: Delay in presentation and acute shortage of donor corneal tissues for emergency keratoplasty because of the COVID-19 pandemic had a grave impact, resulting in irreversible blindness in a significant number of patients.

Surgeon Preference for Keratoplasty Techniques and Barriers to Performing Deep Anterior Lamellar Keratoplasty.

PURPOSE: To identify barriers and facilitators to adopting deep anterior lamellar keratoplasty (DALK) for nonendothelial corneal pathology. METHODS: An anonymous survey consisting of 22 multiple choice and free text questions was designed to gather information on demographic factors of surgeons and DALK surgical practices. The survey was emailed to members of the kera-net, a global online corneal surgeon/surgery platform. RESULTS: A total of 100 surgeons completed the survey, most of whom practice in the United States (73%). Most surgeons (89%) reported performing DALK. Surgeons who did not learn DALK during fellowship (34%) tended to be in practice for higher numbers of years (P < 0.001). Surgeons in private practice are more likely to perform DALK versus those in other settings (92.7% vs. 80.8%, P = 0.087). Surgeons performing more corneal surgeries (at least 100 per year) are more likely to perform DALK than those who perform fewer than 100 per year (52% vs. 14%, P = 0.01). Surgeons who perform Descemet membrane endothelial keratoplasty are more likely to perform DALK than those who do not (81.7% vs. 18.3%, P = 0.014). There was also a positive correlation between PK and DALK surgical volumes (Spearman rank correlation coefficient = 0.57, P < 0.001). The main reasons for surgeon preference for DALK over PK were a desire to preserve the endothelium, intraoperative safety, and decreased complications. Longer surgical time and low patient volume were cited as barriers to adoption of DALK. CONCLUSIONS: Alterations in DALK technique that reduce surgical time and providing more learning opportunities for DALK might improve adoption.

Extraglandular ocular involvement and morbidity and mortality in primary Sjögren's Syndrome.

PURPOSE: To report the significance of extraglandular ocular involvement and long-term systemic morbidity and mortality in primary Sjögren's Syndrome (SS). METHODS: This retrospective, longitudinal cohort study included consecutive patients with primary SS evaluated at a tertiary referral center. An electronic chart review was performed and all available data were extracted from clinic visits between October 1999 and March 2019. The primary outcome measures included occurrence of extraglandular ocular manifestations of SS, serological markers, prevalence of malignancy, and incidence of death. RESULTS: One hundred and twenty-six SS patients with minimum 3 years of follow-up (median 9.6, range 3.0-15.9 years, total of 1,235 patient-years) were included. Of those, 10 patients with inflammatory keratolysis or scleritis had 2.3 times greater likelihood of death compared to the rest of the cohort (OR = 2.3, 95% confidence interval [CI] 0.5 to 4.0, p = 0.01) due to SS related complications. The lifetime prevalence of any malignancy in the entire cohort was 15.5%. The most common hematologic malignancy was non-Hodgkin's lymphoma (4.8%) and the most common solid malignancy was breast cancer (6.0%). Men SS patients were more likely to have a history of or concurrent malignancy compared to women (30.0% versus 13.7%, p = 0.16) and double the mortality (OR = 2.1, 95% CI 0.09 to 1.4, p = 0.04), independent of malignancy. CONCLUSIONS: SS patients with serious ocular manifestations, particularly men, may be at greater risk for mortality due to SS complications. The eye seems to be the barometer of systemic disease activity.

Concurrent primary Sjögren's syndrome and isolated ocular sarcoidosis presenting with bilateral corneal scarring and dry eye.

PURPOSE: To report the case of a patient who presents with multiple progressive ocular diseases who is diagnosed with concurrent primary Sjögren's syndrome and isolated ocular sarcoidosis. OBSERVATION: A 60-year-old woman was referred for dry eye disease, bilateral interstitial keratitis, anterior uveitis, and progressive glaucoma. There was clinical suspicion of an autoimmune etiology due to her ocular history, risk factors, and presentation. Thorough diagnostic testing revealed both primary Sjögren's syndrome and ocular sarcoidosis. After 2.5 years of systemic treatment and follow up, the patient currently remains stable. CONCLUSIONS AND IMPORTANCE: Autoimmune disease may underlie those with progressive ocular disease with an unknown etiology. More than one autoimmune disease may be the cause of ocular findings, especially for patients with a complicated presentation. Proper awareness, clinical suspicion, and diagnosis of these diseases can greatly improve a patient's condition and prevent future ocular and systemic complications.

Sustained Gazing Causes Measurable Decline in Visual Function of Patients with Dry Eye.

PURPOSE: To assess the effects of sustained gazing on visual function of dry eye patients. DESIGN: Prospective, comparative before-and-after study. METHODS: A total of 176 patients with dry eye and 33 control subjects ≥50 years old were included. Dry eye symptomatology along and clinical parameters were assessed. Out-loud reading speed was measured using the International Reading Speed Test (IReST) as words per minute (wpm). Reading speed was repeated using different IReST excerpts following 30-minute silent reading. RESULTS: At baseline, there were no differences between dry eye patients and control subjects with respect to reading speed (172 vs 180 wpm, respectively; P = 0.21) or the time to read the excerpt (33 vs 30 seconds, respectively; P = 0.17). After silent reading, the dry eye patients had decreased reading speed and increases in the length of time to read the passage compared to baseline (161 vs 172 wpm, respectively; P = 0.002; and 38 vs 33 seconds, respectively; P < 0.001). The control subjects did not show significant differences for either parameter. There were significant differences with respect to both parameters between the dry eye and control groups after sustained gazing (161 vs 188 wpm, respectively; P = 0.006; and 38 vs 31 seconds, respectively; P = 0.003). Each 1-point increase in baseline corneal staining score (0-6) led to a 5-wpm reduction in reading speed (95% confidence interval, -8 to -1; P = 0.01). CONCLUSIONS: Sustained gazing, such as in silent reading, has a measurable negative impact on visual performance of dry eye patients. Corneal staining represents a clinical parameter relevant to visual function.

Long-term clinical outcomes of keratoplasty using gamma-irradiated corneal lenticules.

OBJECTIVE: To report long-term clinical outcomes of gamma-irradiated corneal lenticules in partial and full-thickness keratoplasty. METHODS AND ANALYSIS: This multicentre, retrospective case series includes 23 patients who underwent surgery at three centres (India, Guatemala, and USA) between May 2009 and March 2018. The main outcome measures were epithelialization and retention for therapeutic keratoplasty and best spectacle-corrected visual acuity (BSCVA) for optical keratoplasty. RESULTS: Patients were categorised according to primary aetiology requiring corneal transplantation: non-inflammatory conditions, infectious keratitis and sterile keratolysis. Nine patients with non-inflammatory conditions underwent anterior lamellar keratoplasty (n=7) and Boston type 1 keratoprosthesis (n=2). All nine grafts remained intact and epithelialized during follow-up (median 24 months). In the seven patients who underwent anterior keratoplasty, the graft stayed optically clear during follow-up (median 12 months), with BSCVA between 20/20 and 20/40 in all but one patient who developed cataract. Nine patients with severe infectious keratitis had emergency patch grafting. Six of those grafts epithelialized and remained intact over a median of 30 months, providing tectonic support until optical keratoplasty with fresh tissue could be performed. Three grafts had recurrent infectious keratitis 1-3 months postoperatively, two of which underwent tectonic keratoplasty with fresh tissue which also eventually became infected during follow-up. In five additional patients with sterile keratolysis who underwent lamellar patch graft, two grafts remained intact during follow-up (median 36 months). Two patients had recurrent corneal melt within 1 month, and both had subsequent corneal surgery with fresh tissue which also failed. There were no donor-related complications. CONCLUSION: Gamma-irradiated sterile corneal stromal lenticules can be considered as a viable alternative to fresh tissue in various clinical settings.

Prevalence and Risk Factors of Exposure Keratopathy Across Different Intensive Care Units.

PURPOSE: To determine the prevalence and risk factors of exposure keratopathy (EK) across different intensive care units (ICU) at Columbia University Medical Center, including the Pediatric ICU (PICU), Medical ICU (MICU), and Neurologic ICU (NICU). METHODS: In this prospective cohort study, 65 patients were examined daily during their admission in the PICU (27 patients), MICU (15 patients), and NICU (23 patients). Data on eyelid position, conjunctival and corneal changes, Bell's and blink reflexes, medications, Glasgow Coma Scale rating, and ventilation type were collected. RESULTS: Overall EK percentages were as follows: PICU 19%, MICU 60%, and NICU 48%. The prevalence of EK was lowest in the PICU (P = 0.013). Factors associated with EK were lagophthalmos (P < 0.001), an absent Bell's reflex (P = 0.003), an absent blink reflex (P < 0.001), conjunctival injection (P < 0.001), a low Glasgow Coma Scale score (P < 0.001), intubation (P < 0.001), surgery before examination (P < 0.001), dialysis (P = 0.002), and administration of opioid (P < 0.001), sedative (P < 0.001), and neuromuscular blocking medications (P = 0.006). CONCLUSIONS: This is the first study to examine the rates and risk factors of EK across different ICU settings. The prevalence of EK was lowest in the PICU, which may partly be explained by the increased number of PICU patients receiving noninvasive ventilation and the absence of conjunctival chemosis.