Reducing ophthalmic surgical waste through electronic instructions for use: a multisociety position paper.

Every ophthalmic surgical supply, including intraocular lenses (IOLs), IOL cartridges, and ophthalmic viscosurgical device syringes, is packaged with instructions for use (IFU). These pamphlets are printed in multiple languages and, in the case of an IOL, significantly increase the size and weight of the packaging. To eliminate this significant and unnecessary source of waste, we recommend that manufacturers move to Quick Response codes that link to online electronic IFU (e-IFU) as a sensible alternative. In addition to reducing carbon emissions and manufacturing costs, e-IFU can be updated more easily and accessed by surgeons in the clinic, where IOL models and powers are selected. Varying and inconsistent IFU requirements between different countries are a barrier to wider adoption of e-IFU by the ophthalmic surgical industry. Regulatory agencies in every country should allow and encourage e-IFU. This position paper has been endorsed by the 3 major societies that sponsor EyeSustain, a consortium of global societies dedicated to advancing sustainability in ophthalmology.

Therapeutic visual rehabilitation in a patient with high hyperopia and flat cornea years after radial keratotomy.

A 51-year-old man was referred for refractive surgery evaluation. Spectacle dependence and poor visual quality in both eyes was his chief complaint. He cannot tolerate contact lenses. Corrected distance visual acuity (CDVA) was 20/40 in both eyes. Manifest refraction was +5.25 -2.25 @ 90 (20/40) in the right eye and +6.25 -2.25 @ 105 (20/40) in the left eye. The patient had a history of radial keratotomy (RK) almost 30 years ago in both eyes and at the slitlamp presented 8 RK incisions, proportionally spaced between one another. All incisions were closed, and there were no relevant signs of scarring. The patient denied any history of ocular trauma, systemic disease, or medications. Corneal topography with different technologies revealed an irregular pattern with marked central flattening in both eyes, with some points below 30 diopters (D) (Supplemental Figures 1 and 2, available at http://links.lww.com/JRS/A862 and http://links.lww.com/JRS/A863, respectively). There were no signs of cataract, and fundus examination was normal. Optical coherence tomography (OCT) of the right eye revealed a more homogeneous thickness pattern, little variation between the thinnest and thickest areas, and adequate transparency (Figure 1JOURNAL/jcrs/04.03/02158034-202306000-00018/figure1/v/2023-05-31T172126Z/r/image-tiff). In the left eye, there is wide variability between the thinnest and thickest stromal points, with annular thinning and central thickening (Figure 2JOURNAL/jcrs/04.03/02158034-202306000-00018/figure2/v/2023-05-31T172126Z/r/image-tiff). Both eyes show marked epithelial irregularity. Considering this patient's current ocular status, how would you reach visual rehabilitation? Because he is contact lens intolerant, would you consider surface ablation, for example, photorefractive keratectomy (PRK) with mitomycin-C (MMC)? If that were the case, would you think of an optimized or a topography-guided (TG) treatment? Would you immediately consider a corneal transplant option? Would you instead consider a more conservative approach? Which one and why?

Femtosecond laser deep lamellar keratoplasty.

We aimed to develop a novel and effective technique for creating a smooth deep lamellar dissection of the cornea using a femtosecond (FS) laser for deep anterior lamellar keratoplasty (DALK), we conducted a retrospective eye bank study. Thirteen fresh human corneas were mounted on an artificial anterior chamber, and deep lamellar cuts were made with a 500-kHz VisuMax FS laser at a level of 50-80 µm anterior to the Descemet's membrane (DM). A posterior diameter of 8 mm with a side cut angle of 110° was used for the anterior penetrating side cut. The anterior lamellar tissue was bluntly dissected. The residual posterior stromal beds and side cuts were examined with microscopy and intraoperative optical coherence tomography (OCT) and post-cut endothelial cell evaluations. All corneas revealed a smooth residual posterior stromal bed without any visible irregularities or ridges by microscopy and OCT imaging. Six corneas were suitable for post-cut endothelial cell evaluation 2 days after laser cut, with no significant endothelial cell loss post-laser and blunt dissection of the posterior stroma. FS laser deep lamellar keratoplasty utilizing an ultrafast laser to produce a smooth deep stromal dissection followed by blunt dissection and removal of the anterior stromal tissue yields a consistent and smooth residual stromal bed. The creation of a smooth lamellar dissection in the deep posterior cornea may result in more consistent DALK without the need for air bubble or manual baring of DM that has the risk for DM perforation.

KPI-121 1% for pain and inflammation in ocular surgery.

Pain and inflammation are common experiences following ocular surgery and, if uncontrolled, can compromise patients' vision, functioning and quality of life. Corticosteroid drugs are available to manage inflammation and discomfort but have limitations in penetrating the ocular mucus barrier to reach the target ocular tissues. KPI-121 1% (INVELTYS®) is a novel formulation of loteprednol etabonate that employs innovative proprietary technology to deliver nanoparticle-sized mucus-penetrating particles to the cornea. Results from clinical trials demonstrate that KPI-121 1% is effective and well tolerated. KPI-121 1% uses mucopenetrative technology for ophthalmic use and is the only US FDA-approved twice-daily ocular corticosteroid indicated for the treatment of inflammation and pain after ocular surgery.

Toric intraocular lenses: Expanding indications and preoperative and surgical considerations to improve outcomes.

Since the introduction of the first toric intraocular lens (IOLs) in the early 1990s, these lenses have become the preferred choice for surgeons across the globe to correct corneal astigmatism during cataract surgery. These lenses allow patients to enjoy distortion-free distance vision with excellent outcomes. They also have their own set of challenges. Inappropriate keratometry measurement, underestimating the posterior corneal astigmatism, intraoperative IOL misalignment, postoperative rotation of these lenses, and IOL decentration after YAG-laser capsulotomy may result in residual cylindrical errors and poor uncorrected visual acuity resulting in patient dissatisfaction. This review provides a broad overview of a few important considerations, which include appropriate patient selection, precise biometry, understanding the design and science behind these lenses, knowledge of intraoperative surgical technique with emphasis on how to achieve proper alignment manually and with image-recognition devices, and successful management of postoperative complications.

Femtosecond laser-assisted big bubble for deep anterior lamellar keratoplasty.

PURPOSE: To assess the utility of a femtosecond laser-assisted stromal channel to assist the creation of a big bubble (BB) for deep anterior lamellar keratoplasty (DALK) surgery in cadaveric corneas. SETTING: L V Prasad Eye Institute, Hyderabad, India. DESIGN: Experimental study. METHODS: An attempt to create a BB was made on 10 donor pairs of human cadaveric corneoscleral tissues. The 20 corneas were split into 2 groups: Group A underwent femtosecond laser pretreatment and Group B had conventional manual deep lamellar technique. Laser pretreatment was performed using the VisuMax femtosecond laser system to create a stromal channel using the intracorneal ring segment treatment module for direct insertion of the 27-gauge air cannula for pneumodissection at a predetermined depth. RESULTS: Of the 20 corneas studied, type 1 BB was achieved in 9 of 10 corneas in Group A and in 7 of 10 corneas in Group B. One cornea from Group A had a combined type 1 and 2 BB, whereas no BB was achieved in 1 cornea. CONCLUSIONS: Creation of an intrastromal channel using a femtosecond laser at a predetermined depth seemed to be a promising option to increase the chances of achieving a BB when compared with the conventional air injection technique of BB DALK.

Loteprednol Etabonate for the Treatment of Dry Eye Disease.

Dry eye disease (DED) is a common ocular condition that can impair vision and may adversely impact quality of life. Due to the inflammatory nature of this disorder, topical corticosteroids are an effective treatment option, particularly for moderate-to-severe DED when first-line treatments, such as ocular lubricants, are insufficient. Loteprednol etabonate (LE) is a retrometabolically designed corticosteroid with a low propensity to cause corticosteroid-related adverse effects, such as elevated intraocular pressure (IOP). This review was conducted to provide an assessment of published studies on the use of LE for treatment of inflammation associated with DED. Twelve prospective and 2 retrospective studies evaluating LE ophthalmic suspension 0.5% and 2 prospective studies evaluating LE ophthalmic gel 0.5% were identified. LE given as monotherapy or with artificial tears (AT) improved signs of DED, especially among patients with a more pronounced inflammatory component, and also improved DED symptoms compared to baseline and/or control. Treatment with LE before cyclosporine A (CsA) therapy reduced stinging upon CsA initiation and provided more rapid relief of DED signs and symptoms than CsA plus AT alone. In patients with meibomian gland dysfunction, LE alone, or in addition to eyelid scrubs/warm compresses, reduced clinical signs and symptoms, and tear proinflammatory cytokine levels. Overall, LE was safe and well tolerated, with minimal effects on IOP. While larger and longer-term studies are warranted, these data support the use of LE as a safe and effective treatment option for DED.

Intracameral antibiotics: Safety, efficacy, and preparation.

UNLABELLED: Endophthalmitis is a rare but potentially devastating complication of cataract surgery. This article presents an overview of endophthalmitis prophylaxis and the use of intracameral antibiotics. It highlights available intracameral antibiotics with respect to pharmacology, spectrum of activity, dosage and preparation, safety, and efficacy profiles, as well as toxic anterior segment syndrome risks to better define the potential use of these medications in the prevention of endophthalmitis. FINANCIAL DISCLOSURE: Proprietary or commercial disclosures are listed after the references.

Multifocal intraocular lenses: relative indications and contraindications for implantation.

UNLABELLED: This article presents an extensive overview of best clinical practice pertaining to selection and use of multifocal intraocular lenses (IOLs) currently available in the United States. Relevant preoperative diagnostic evaluations, patient selection criteria, counseling, and managing expectations are reviewed, as well as how to approach patients with underlying ocular intricacies or challenges and best practices for intraoperative challenges during planned implantation of a multifocal IOL. Managing the unhappy multifocal IOL patient if implantation has been performed is also addressed. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Prevention, diagnosis, and management of acute postoperative bacterial endophthalmitis.

This distillation of the peer-reviewed scientific literature on infection after cataract surgery summarizes background material on epidemiology, etiology, and pathogenesis, describes the roles of surgical technique and antibiotic prophylaxis in prevention, and discusses diagnostic and therapeutic interventions in cases of suspected endophthalmitis.

Patient-centered care and refractive cataract surgery.

PURPOSE OF REVIEW: Cataract surgery has evolved significantly during the last few years. The introduction of aspheric, presbyopic correcting and toric intraocular lenses have shifted the emphasis of cataract surgery from just treating patients' functional symptoms to optimizing the refractive outcome of the procedure. RECENT FINDINGS: Studies emphasizing patient satisfaction and refractive visual outcomes have shifted the focus of cataract surgery to a more patient-centered approach. Refractive surgical technologies such as limbal relaxing incisions, laser-assisted in-situ keratomileusis, photorefractive keratectomy and conductive keratoplasty can be used in conjunction with traditional cataract surgical techniques. The wide array of intraocular lens choices has broadened the scope of refractive cataract surgery providing surgeons and patients with more options in determining refractive outcomes. SUMMARY: Cataract surgery has expanded into the realm of refractive surgery and there is a new emphasis on patient-centered care and an optimization of the refractive outcome of the procedure. This trend will continue as newer presbyopic correcting intraocular lenses become available.