A Detailed Analysis of Individuals Having Graft Failure After Corneal Transplantation.

PURPOSE: To describe demographic and clinical characteristics of patients with graft failure after keratoplasty, determine the cause of graft failure and outcomes. METHODS: The charts of patients between 2008-2013 in the Cornea Service at Wills Eye Hospital with a history of a corneal transplant before the end of 2012 were retrospectively reviewed. Included were patients who had graft failure after corneal transplantation and had at least one year of follow-up after transplantation. Penetrating keratoplasty (PK) and Descemet's stripping endothelial keratoplasty (DSEK) patients were analyzed separately. RESULTS: A total of 186 eyes of 170 patients with graft failure after a PK (156) or DSEK (30) procedures were identified. The baseline characteristics included 100 female and 70 male patients with an age between 0 and 90 years (median 63 years). At the time of surgery, 38% had three or more systemic diseases and 68% were using three or more systemic medicines. Mean follow up time for PK was nearly four times of DSEK. Only 2 DSEK eyes (7%) underwent a 3rd DSEK graft, while 47 (30%) PK eyes underwent a 3rd PK and 15 (10%) PK eyes underwent more than three PK procedures. CONCLUSIONS: Most DSEK failures occurred in 1st year, while graft failure in PKs is scattered over years. Failure in DSEK is mostly due to graft or surgical risk factors but in PK mostly due to factors in the host. DSEK does not appear to be as affected by the patients' demographic and clinical characteristics as much as PK.

New forays into measurement of ocular biomechanics.

PURPOSE OF REVIEW: The field of corneal biomechanics has rapidly progressed in recent years, reflecting technological advances and an increased understanding of the clinical significance of measuring these properties. This review will evaluate in-vivo biomechanical properties obtained by current technologies and compare them regarding their relevance to established biomechanical properties obtained by gold-standard ex-vivo techniques normally conducted on elastic materials. RECENT FINDINGS: Several new technologies have appeared in recent years, including vibrational optical coherence tomography (VOCT) and the corneal indentation device (CID). These techniques provide promising new opportunities for minimally invasive and accurate measurements of corneal viscoelastic properties. SUMMARY: Alterations in corneal biomechanics are known to occur in several corneal degenerative diseases and after refractive surgical procedures. The measurement of corneal biomechanical properties has the capability to diagnose early disease and monitor corneal disease progression. Several new technologies have emerged in recent years, allowing for more accurate and less invasive measurements of corneal biomechanical properties, most notably the elastic modulus.

IC3D Classification of Corneal Dystrophies-Edition 3.

PURPOSE: The International Committee for the Classification of Corneal Dystrophies (IC3D) was created in 2005 to develop a new classification system integrating current information on phenotype, histopathology, and genetic analysis. This update is the third edition of the IC3D nomenclature. METHODS: Peer-reviewed publications from 2014 to 2023 were evaluated. The new information was used to update the anatomic classification and each of the 22 standardized templates including the level of evidence for being a corneal dystrophy [from category 1 (most evidence) to category 4 (least evidence)]. RESULTS: Epithelial recurrent erosion dystrophies now include epithelial recurrent erosion dystrophy, category 1 ( COL17A1 mutations, chromosome 10). Signs and symptoms are similar to Franceschetti corneal dystrophy, dystrophia Smolandiensis, and dystrophia Helsinglandica, category 4. Lisch epithelial corneal dystrophy, previously reported as X-linked, has been discovered to be autosomal dominant ( MCOLN1 mutations, chromosome 19). Classic lattice corneal dystrophy (LCD) results from TGFBI R124C mutation. The LCD variant group has over 80 dystrophies with non-R124C TGFBI mutations, amyloid deposition, and often similar phenotypes to classic LCD. We propose a new nomenclature for specific LCD pathogenic variants by appending the mutation using 1-letter amino acid abbreviations to LCD. Pre-Descemet corneal dystrophies include category 1, autosomal dominant, punctiform and polychromatic pre-Descemet corneal dystrophy (PPPCD) ( PRDX3 mutations, chromosome 10). Typically asymptomatic, it can be distinguished phenotypically from pre-Descemet corneal dystrophy, category 4. We include a corneal dystrophy management table. CONCLUSIONS: The IC3D third edition provides a current summary of corneal dystrophy information. The article is available online at https://corneasociety.org/publications/ic3d .

Trends and Sociodemographic Patterns in Keratoconus Management 2015-2020: An American Academy of Ophthalmology IRIS® Registry Analysis.

PURPOSE: Investigate trends in keratoconus (KCN) treatment patterns and diagnosis age from 2015 to 2020 and evaluate sociodemographic associations with the treatment approach. DESIGN: Retrospective cohort study. PARTICIPANTS: Patients with a new KCN diagnosis from 2015 to 2020 were identified in the Academy IRIS® Registry (Intelligent Research in Sight). METHODS: Associations between sociodemographic factors and treatment were evaluated using multivariable logistic regression. MAIN OUTCOME MEASURES: Outcomes included percentages and rates of each treatment (collagen crosslinking [CXL], keratoplasty, or no procedure) from 2015 to 2020, age at diagnosis during this period, and sociodemographic factors associated with treatment type. RESULTS: A total of 66 199 patients with a new diagnosis of KCN were identified. The percentage of patients undergoing CXL increased from 0.05% in 2015 to 29.5% in 2020 (P = 0.008). The average age (standard deviation) of KCN patients decreased from 44.1 (±16.9) years in 2015 to 39.2 (±16.9) years in 2020 (P < 0.001). In multivariable analyses comparing CXL versus no procedure and keratoplasty versus no procedure, patients undergoing CXL tended to be younger with the odds of having CXL decreasing with increasing age, for example, comparing CXL and no procedure patients, using ages 0-20 years as reference, the odds ratio (OR) (95% confidence interval [CI]) decreased from 0.62 (0.57-0.67; P < 0.0001) for patients aged 21-40 years to 0.03 (0.02-0.04; P < 0.0001) for patients aged > 60 years. Men were more likely than women to have CXL (OR, 1.31; 95% CI, 1.23-1.40; P < 0.0001) and keratoplasty (OR, 1.30; 95% CI, 1.19-1.42; P < 0.0001). Black patients were less likely than White patients to have CXL (OR, 0.70; 95% CI, 0.63-0.77; P < 0.0001) and more likely to have keratoplasty (OR, 2.24; 95% CI, 2.01-2.50; P < 0.0001). Likewise, Hispanic patients had higher odds of CXL (OR, 1.12; 95% CI, 1.00-1.24; P < 0.05) and keratoplasty (OR, 1.29; 95% CI, 1.12-1.50; P < 0.001) compared with non-Hispanic patients. Collagen crosslinking and keratoplasty also varied by region and insurance status. CONCLUSIONS: A significant increase in use of CXL was noted from 2015 to 2020. Sociodemographic differences in treatment among KCN patients may reflect differences in access, use, or care patterns, and future studies should aim to identify strategies to improve access for all patients. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Variations in Management of Zone 1 Open Globe Injuries Across Corneal Specialists.

PURPOSE: The aim of this study was to describe variations in practice patterns for the management of zone 1 open globe injuries among corneal specialists worldwide. METHODS: This cross-sectional study was performed using an online survey distributed to members of The Cornea Society. Responses were collected between September 9, 2021, and September 30, 2021. RESULTS: Of 94 responses included in analysis, respondents averaged 18.2 ± 14.5 years of postfellowship experience. Among respondents, 53 (56.4%) were affiliated with an academic institution and 41 (43.6%) with private practice. Ophthalmologists practicing in the United States were significantly more likely to use an eye shield preoperatively (98.5% vs. 85.7%, P = 0.03) and less likely to perform primary lensectomy in cases of lens involvement (40.9% vs. 75.0%, P = 0.002) compared with those practicing outside the United States. Ophthalmologists in practice fewer than 10 years were more likely to administer preoperative systemic antibiotics (91.4% vs. 66.1%, P = 0.006) and tetanus prophylaxis (88.6% vs. 67.8%, P = 0.03), and to obtain preoperative computed tomography scans (85.7% vs. 54.2%, P = 0.002) compared with more senior physicians. Ophthalmologists at academic institutions were more likely to perform preoperative B-scan (30.2% vs. 9.8%, P = 0.02), use general anesthesia (90.6% vs. 70.7%, P = 0.03), and admit for postoperative antibiotics (28.3% vs. 9.8%, P = 0.04), and were less likely to perform surgery overnight (45.3% vs. 70.7%, P = 0.02) compared with private practice physicians. CONCLUSIONS: There is significant variation in the practice patterns for the management of zone 1 open globe injuries among corneal specialists, which presents an opportunity to investigate whether certain treatment options lead to better outcomes in these injuries.

Determinants of Clinical Outcomes After Infectious Scleritis.

PURPOSE: The aims of this study were to describe the clinical course of microbial infectious scleritis and identify factors associated with poor visual outcomes. METHODS: Data from 26 eyes of 26 patients with culture-proven bacterial or fungal scleritis presenting at a single tertiary center from January 1, 2007, to July 1, 2021, were reviewed. Thirty-six variables were analyzed for associations with poor vision [best-corrected visual acuity (BCVA) <20/200] or loss of vision (no light perception vision or requirement for enucleation or evisceration) at final visit. RESULTS: The mean age at initial presentation was 67.1 ± 14.0 (range: 34-92) years with a mean follow-up of 2.1 ± 2.2 (0.05-8.45) years. The mean presenting logarithm of minimal angle of resolution (logMAR) BCVA was 1.3 ± 1.0 (∼20/400) and mean final logMAR BCVA was 1.6 ± 1.2 (∼20/800). Fourteen eyes (53.8%) exhibited poor vision and 7 (26.9%) had loss of vision at final follow-up. History of necrotizing scleritis and poor presenting vision were associated with poor final vision (OR = 19.1; P = 0.017 and OR = 7.5; P = 0.047, respectively), whereas fungal scleritis was associated with loss of vision (odds ratio [OR] = 30.3, P = 0.013). Subconjunctival antimicrobial treatment was inversely associated with loss of vision (OR = 0.06, P = 0.023). There was no difference in vision between medical and combined medical-surgical management, although infection resolution time was shorter for combined intervention (16.8 ± 10.6 vs. 53.7 ± 33.8 days; P = 0.005). CONCLUSIONS: Infectious scleritis is often successfully treated, but loss of vision or eye removal is common. Poor baseline vision, history of necrotizing scleritis, and fungal etiology were prognostic for worse clinical outcomes. Surgical intervention was associated with quicker resolution compared with medical treatment alone.

Applications of Mitomycin C in Cornea and External Disease.

Isolated from Streptomyces caespitosus, mitomycin C (MMC) has various applications in the management of corneal and external disease due to its ability to modulate cellular proliferation. It has been employed in pterygium surgery, ocular surface neoplasia, and refractive surgery. Currently, there is no definite consensus on the treatment protocols for each of the aforementioned applications. Although its benefits in the management of corneal and external diseases are promising, MMC use has potential complications including endothelial cell loss, corneal perforation, scleral melt, secondary glaucoma, iritis, and endophthalmitis. This article will review the literature regarding the use of MMC in the field of cornea and external disease and describe protocols employed with corresponding outcomes.

Demodex Blepharitis: A Comprehensive Review of the Disease, Current Management, and Emerging Therapies.

ABSTRACT: Demodex blepharitis is a common disease of the eyelid, affecting approximately 25 million Americans. This article reviews what is known about the mechanisms and impact of Demodex blepharitis, risk factors, signs and symptoms, diagnostic techniques, current management options, and emerging treatments. Demodex mites contribute to blepharitis in several ways: direct mechanical damage, as a vector for bacteria, and by inducing hypersensitivity and inflammation. Risk factors for Demodex blepharitis include increasing age, rosacea, and diabetes. The costs, symptom burden, and psychosocial effects of Demodex blepharitis are considerable. The presence of collarettes is pathognomonic for Demodex blepharitis. Redness, dryness, discomfort, foreign body sensation, lash anomalies, and itching are also hallmarks of the disease. Although a number of oral, topical, eyelid hygiene and device-based options have been used clinically and evaluated in studies for the management of Demodex blepharitis, none have been FDA approved to treat the disease. Recent randomized controlled clinical trials suggest that lotilaner ophthalmic solution, 0.25%, is a topical treatment with the potential to eradicate Demodex mites and eliminate collarettes and eyelid redness for an extended period.

Severe ocular alkali injury managed with an externally sutured amniotic membrane and customized symblepharon ring.

Alkali injuries are ocular emergencies that require immediate evaluation and therapy to preserve vision. Severe alkali injuries can result in long-term vision-threatening sequelae including symblepharon, corneal ulceration, corneal scarring, limbal stem cell deficiency, xerophthalmia, cicatricial changes of the eyelid and adnexa, glaucoma, uveitis, and permanent vision loss. Treatment is aimed at neutralizing the pH, controlling inflammation, and restoring the ocular surface. Here, we present the case of a 35-year-old male who sustained direct ocular exposure to sodium hydroxide, resulting in significant corneal and conjunctival epithelial defects despite aggressive initial medical therapy. The patient subsequently received a large, externally sutured amniotic membrane (AM) with a customized symblepharon ring to promote healing. The corneal and conjunctival defects resolved, and at 4 months after the initial injury, the patient's visual acuity had improved to 20/25. Clinicians should be aware of the various surgical techniques to place an AM transplantation and identify the best strategy based on clinical findings and the extent and severity of the injury.

Conjunctival and Lingual mucosal neuromas without multiple endocrine neoplasia type 2B.

Purpose: To report a patient with conjunctival and buccal neuromas and enlarged corneal nerves without Multiple Endocrine Neoplasia 2B (MEN2B). Observations: A 28-year-old female presented with progressively enlarging bilateral limbal conjunctival growths. Slit lamp examination was notable for enlarged corneal nerves and well-circumscribed gelatinous subepithelial limbal nodules. Systemic examination revealed similar lesions on the tongue. Conjunctival biopsy demonstrated a mucosal neuroma. The patient underwent endocrine workup for MEN2B and genetic testing for the RET-proto oncogene mutations, all of which were negative. Conclusions and Importance: The findings in our patient may be compatible with pure mucosal neuroma syndrome. The pattern of conjunctival neuromas and enlarged corneal nerves should raise concern for MEN2B, a hereditary tumor predisposition syndrome with almost 100% incidence of medullary thyroid cancer, unless prophylactic thyroidectomy is performed. Accurate diagnosis and prompt referral for endocrine and genetic testing is critical. Isolated mucosal neuromas without endocrine manifestations of MEN2B can rarely occur in a "pure mucosal neuroma syndrome," which is a diagnosis of exclusion in a setting of a negative workup.

Identification of the Vibrational Optical Coherence Tomography Corneal Cellular Peak.

Purpose: Our team previously identified the presence of five corneal resonant frequency (RF) peaks in healthy volunteers using vibrational optical coherence tomography (VOCT). Prior studies have suggested that the ≤100 Hz RF peak represents the cellular element of tissue. The aim of this study was to confirm that this peak reflects the human corneal cellular component using VOCT and histological analysis. Methods: Two human research globes were obtained from the same donor, and VOCT measurements were collected from the full-thickness corneas. A microkeratome was then used to create serial-free corneal caps from each cornea, with VOCT performed on the residual stromal bed after each excision. All lamellar sections from both globes were sent for histological analysis to determine cellularity. Cell counts on the specimens were performed by two independent observers. Results: The average of the normalized ≤100 Hz peak values before lamellar sectioning was significantly higher than the average of this peak values after the first, second, and third cuts (P = 0.023), which was 33.9% less than before any cuts. The cell count values in the first slice were significantly higher than the average cell count values of the three deeper slices (P < 0.001), and the cell count dropped 84.4% after the first slice was removed. Conclusions: The findings of this study suggest that the ≤100 Hz corneal peak identified by VOCT corresponds to the cellular component of the cornea. Translational Relevance: This work furthers our understanding of the origin of the corneal ≤100 Hz peak identified using VOCT.

Graft rejection in component keratoplasty.

Among the various indications for keratoplasty, failed graft is one of the commonest indications in many published series. It is well known that the major cause of graft failure is endothelial rejection. In the last two decades, there has been a major paradigm shift in the surgical management of corneal diseases, and component keratoplasty has emerged from the concept of replacing the layer that is actually diseased, rather than replacing the full-thickness cornea with the traditional penetrating keratoplasty. This has resulted in improved outcomes and the risk of endothelial rejection has reduced drastically, thus expanding the survival time of the graft. In recent years, reports of graft rejection in component keratoplasty have emerged, with each having a different presentation and responding to a different line of treatment. This review aims to summarize the presentation, diagnosis, and management of graft rejections in component keratoplasty.

Graft Outcomes After Temporary Keratoprosthesis in Combined Penetrating Keratoplasty and Vitreoretinal Surgery.

PURPOSE: Corneal pathology can obstruct the visualization required for surgical management of coexisting posterior segment diseases, and use of a temporary keratoprosthesis (TKP) permits combined penetrating keratoplasty (PK) and vitreoretinal surgery. We evaluated graft outcomes after TKP for combined PK and vitreoretinal surgery and analyzed risk factors for graft failure. METHODS: We reviewed the electronic medical records for patients who underwent TKP for PK combined with vitreoretinal surgery at Wills Eye Hospital between May 2007 and April 2021. Overall, 28 variables were analyzed. The main outcome measure was corneal graft failure, defined as irreversible graft edema or opacification. RESULTS: A total of 46 eyes of 46 patients underwent combined surgery and were included in the study. The mean age at surgery was 55.7 ± 18.6 years (range 19-86 years), and the mean follow-up was 31.8 ± 30.5 months (range 1.6-114.0 months). Multivariable analysis revealed 2 factors significantly associated with graft failure: history of trauma (hazard ratio = 5.38; 95% confidence interval, 1.53-18.91; P = 0.009) and intraocular silicone oil after transplant (hazard ratio = 5.67; confidence interval 1.66-19.44; P = 0.006). Corneal graft failure occurred in 60.9% of all cases over the course of follow-up, but the absence of both variables yielded a 33.3% failure rate. CONCLUSIONS: Although outcomes vary, previous ocular trauma and the presence of intraocular silicone oil are risk factors for failure that may facilitate patient selection and improve counseling about long-term graft potential after TKP for combined PK and vitreoretinal surgery.

Demographic and Socioeconomic Determinants of Penetrating Keratoplasty Outcomes.

PURPOSE: The aim of this study was to determine possible associations between demographic and socioeconomic factors and graft survival after penetrating keratoplasty (PK). METHODS: This study was a retrospective chart review of patients undergoing PK at a tertiary-care corneal practice at Wills Eye Hospital between May 1, 2007, and September 1, 2018. The first PK of the first eye was included. The primary outcome measure was graft failure, defined as irreversible and visually significant graft edema, haze, or scarring. Demographic and socioeconomic factors included yearly average adjusted gross income (AGI) based on residential zip code, age, sex, and race. Two income groups were created: 1) individuals from neighborhoods with the lowest 10% of AGI (N = 82, AGI=$32,100 ± 4000) and 2) the remaining 90% of individuals (N = 740, AGI=$86,900 ± 52,200). Logistic regression analysis was performed to identify factors predictive of graft prognosis. RESULTS: The 822 patients (822 eyes) included had a mean age of 57.1 ± 22.1 years at the time of PK. Over an average of 4.2 ± 3.1 years of follow-up, graft failure occurred in 35.3%. Age, sex, and follow-up duration were comparable between income groups (all P > 0.05). Black race was disproportionately represented in the lower-income group (50.0% vs. 11.5%, P < 0.001). Multivariable analysis identified predictors of graft failure including residing in a lower-income neighborhood [hazard ratio (HR) = 2.27, 95% confidence interval (CI) = 1.24-4.19, P = 0.008], younger age (HR = 0.99, 95% CI = 0.98-1.00, P = 0.046), and Black race (HR = 1.63, 95% CI = 1.03-2.56, P = 0.035). CONCLUSIONS: Individuals with a lower income, younger age, and Black race may be more vulnerable to graft failure after PK. Further studies are warranted to identify reasons for these associations.

Ophthalmic Trauma Malpractice in the Ophthalmic Mutual Insurance Company Database.

PURPOSE: To review ophthalmic trauma malpractice claims in the Ophthalmic Mutual Insurance Company (OMIC) database to determine the frequency and causes of litigation. METHODS: A retrospective case series analysis of ophthalmic trauma claims from 2009 to 2019 was completed. Cases were selected only if the injury was secondary to trauma (e.g., fall, gunshot wound, paintball injury, etc.); iatrogenic traumatic surgical injuries were excluded. RESULTS: 31 closed cases associated with 40 total claims related to ophthalmic trauma out of 2565 claims (1.56%) in the OMIC database were analysed. 13 of the 31 cases (41.9%) were decided for the plaintiff. In decisions for the plaintiff, the median settlement amount was $330,000 (range $125,000-$1,000,000). The most frequent initial diagnoses were corneal abrasion (n = 10), hyphema (n = 5) and open-globe injury (n = 5), and the most common final diagnoses were endophthalmitis (n = 8), intraocular foreign body (n = 7) and retinal detachment (n = 7). The most common causes of malpractice litigation were a delay in referral or follow-up (n = 11) and failure to get appropriate imaging (n = 8). In the 13 cases decided for the plaintiff, experts concluded nine did not meet standard of care. CONCLUSIONS: Ophthalmic trauma malpractice claims are very uncommon in the United States, however, the payout is higher than non-trauma settlements, and approximately 40% of cases were decided for the plaintiff. Care could be improved with a careful history and complete ophthalmic examination (with dilated fundoscopy), imaging in appropriate patients, meticulous documentation, and early sub-specialist referral when the diagnosis or management plan was unclear.

Prior Contralateral Penetrating Keratoplasty Is a Risk Factor for Second Eye Graft Rejection.

AIMS: To determine whether prior penetrating keratoplasty (PK) in the contralateral eye increases risk of second eye PK graft rejection. METHODS: Cohort study of 593 consecutive PKs in transplant-naïve eyes (500 unilateral cases, 93 second eyes). Outcomes were compared between PKs performed in eyes with versus without a history of prior contralateral eye PK. Risks of rejection and failure were estimated using Cox proportional hazards models. RESULTS: Mean age was 53.7 ± 23.3 years; average follow-up was 4.00 ± 2.87 years. Rejection occurred in 211 (35.6%) grafts. The incidence of rejection was 34.0% in unilateral cases and 44.1% in second eyes with PK in the contralateral eye. Prior contralateral PK was a significant risk factor for graft rejection (HR = 1.42, 95% CI 1.01-2.01, p = .045). CONCLUSION: Contralateral PK is associated with increased risk of second eye graft rejection. Loss of ocular immune privilege is a possible mechanism.

Development of a Nomogram to Predict Graft Survival After Descemet Stripping Endothelial Keratoplasty.

BACKGROUND/PURPOSE: The purpose of this study was to analyze Descemet stripping endothelial keratoplasty (DSEK) outcomes and develop a nomogram to compute the probability of 3- and 5-year DSEK graft survival based on risk factors. STUDY DESIGN/METHODS: The medical records of 794 DSEK procedures between January 1, 2008, and August 1, 2019, were retrospectively reviewed to identify 37 variables. We also evaluated for the presence of corneal graft failure, defined as irreversible and visually significant graft edema, haze, or scarring. Variables were assessed by multivariable Cox models, and a nomogram was created to predict the probability of 3- and 5-year graft survival. RESULTS: Graft failure occurred in 80 transplants (10.1%). The strongest risk factors for graft failure included graft detachment [hazard ratio (HR) = 4.46; P < 0.001], prior glaucoma surgery (HR = 3.14; P = 0.001), and glaucoma (HR = 2.23; P = 0.018). A preoperative diagnosis of Fuchs dystrophy was associated with a decreased risk of graft failure (HR = 0.47; P = 0.005) compared with secondary corneal edema. Our nomogram has a concordance index of 0.75 (95% confidence interval, 0.69 to 0.81), which indicates that it may predict the probability of graft survival at 3 and 5 years with reasonable accuracy. We also analyzed graft rejection, which occurred in 39 cases (4.9%). The single risk factor found to be significantly associated with graft rejection was prior glaucoma surgery (HR = 2.87; P = 0.008). CONCLUSIONS: Our nomogram may accurately predict DSEK graft survival after 3 and 5 years based on 4 variables. This nomogram will empower surgeons to share useful data with patients and improve collective clinical decision-making.

Pilocarpine 1.25% and the changing landscape of presbyopia treatment.

PURPOSE OF REVIEW: Despite affecting approximately 1.8 billion individuals worldwide, until recently, a pharmacologic treatment for presbyopia was not available. This special commentary reviews the treatment of presbyopia with a focus on the recently approved medication Vuity (pilocarpine 1.25%, Allergan, an AbbVie Company). RECENT FINDINGS: Vuity is a re-engineered formulation of pilocarpine 1.25% specifically designed for the treatment of presbyopia. Recently published results from the GEMINI 1 Phase 3 clinical trial reported improvement in distance corrected near vision without significant compromise in distance vision. No unexpected safety findings were reported with mild headache being the most common adverse event. Notably, there were no reported cases of retinal detachment or angle closure during the 30-day phase 3 clinical trials. SUMMARY: Vuity is the first treatment designed and FDA approved to treat the growing presbyopia market. Phase 3 clinical trials demonstrated its ability to improve near vision without significant compromise in distance vision. We recognize this paradigm shift in the treatment of presbyopia and anxiously await additional treatment options for this ubiquitous condition.

Descriptive analysis of cornea and anterior segment fellowship program directors in 2020.

PURPOSE: To investigate demographic characteristics, educational backgrounds, and academic achievements among program directors (PDs) of cornea and external disease and anterior segment fellowships in the United States in 2020. SETTING: Database study of U.S. fellowship programs. DESIGN: Cross-sectional study. METHODS: PDs of cornea and external disease and anterior segment fellowships were identified using the San Francisco Match website. Fellowship program features reviewed included academic or private practice type, number of cornea faculty, and sex of chairperson. PD demographic characteristics, educational and training background, and academic productivity were analyzed using publicly available profiles and databases. RESULTS: 76 cornea and external disease and 10 anterior segment fellowships were reviewed. Of 86 reviewed programs, 55 (64.0%) were considered academic, 30 (34.9%) were private practice, and 1 (1.2%) was hybrid. 76 cornea and external disease PDs and 12 anterior segment PDs were identified. Overall, 21 (23.9%) of PDs were women, and the mean age for all PDs was 52.6 ± 11.5 years. Of the 88 PDs, the average number of publications was 45.1 ± 55.9. The mean h-index was 16.7 ± 15.4 and was higher among cornea and external disease than anterior segment PDs (18.2 ± 15.5 vs 7.1 ± 11.4, P = .008) and also higher among academic than private practice PDs (19.9 ± 15.1 vs 11.2 ± 14.7, P = .011). More female PDs were in departments with a female chairperson compared with male PDs (6 [28.6%] vs 4 [6.0%], P = .011). CONCLUSIONS: Cornea and external disease and anterior segment fellowship PDs represent a wide array of backgrounds and scholarly achievements. Female PDs remain in the minority and are more common in departments with female chairpersons.

In Vivo Determination of the Human Corneal Elastic Modulus Using Vibrational Optical Coherence Tomography.

Purpose: To determine the in vivo elastic modulus of the human cornea using vibrational optical coherence tomography (VOCT). Methods: Vibrational analysis coupled with optical coherence tomography (OCT) was used to obtain the resonant frequency (RF) and elastic modulus of corneal structural components. VOCT corneal thickness values were measured using OCT images and correlated with corneal thickness determined with Pentacam (Oculus, Wetzlar, Germany). Moduli were obtained at two locations: central cornea (CC) and inferior cornea (IC). Measurements were obtained with and without anesthetic eye drops to assess their effect on the modulus measurements. Results: VOCT thickness values correlated positively (R2 = 0.97) and linearly (y = 1.039x-16.89) with those of Pentacam. Five RF peaks (1-5) were present, although their presence was variable across eyes. The RF for peaks 1 to 5 in the CC and IC ranged from 73.5 ± 4.9 to 239 ± 3 Hz and 72.1 ± 6.3 to 238 ± 4 Hz, respectively. CC and IC moduli for peaks 1 to 5 ranged from 1.023 ± 0.104 to 6.87 ± 0.33 MPa and 0.98 ± 0.15 to 6.52 ± 0.79 MPa, respectively. Topical anesthesia did not significantly alter the modulus (P > 0.05 for all), except for peak 2 in the CC (P < 0.05). Conclusions: This pilot study demonstrates the utility of VOCT as an in vivo, noninvasive technology to measure the elastic modulus in human corneas. The structural origin of these moduli is hypothesized based on previous reports, and further analyses are necessary for confirmation. Translational Relevance: This work presents VOCT as a novel approach to assess the in vivo elastic modulus of the cornea, an indicator of corneal structural integrity and health.