Presumed Melanocytoma-Associated Choroidal Neovascular Membrane with Hemorrhage Successfully Treated with Intravitreal Aflibercept Injections.

A patient presented with melanocytoma and associated choroidal neovascular membrane with hemorrhage involving the macula. The patient was treated with monthly aflibercept (Eylea) injections with significant improvement of best corrected visual acuity. In this report, we explore the development of a choroidal neovascular membrane (CNVM) formation in a patient with melanocytoma and the effect of intravitreal aflibercept (Eylea) on disease course. Case report study used patient data obtained from examination and imaging. The patient was treated with monthly intravitreal aflibercept injections leading to complete resolution of CNVM and hemorrhage, with significant improvement of best corrected visual acuity. Awareness and proper monitoring for the sequelae of melanocytoma are important for early detection and prevention of visually threatening outcomes. In cases of melanocytoma-associated CNVM formation with large subretinal hemorrhage, intravitreal aflibercept can be an effective tool for inducing CNVM regression and allowing improvement of visual acuity.

Less Complex Contact Lens Required for a Patient With Keratoconus After Topography-Guided Photorefractive Keratectomy.

ABSTRACT: In this report, we discuss contact lens (CL) fitting in a patient with a history of keratoconus (KC), before and after undergoing topography-guided photorefractive keratectomy (TG PRK). Before TG PRK, the patient failed multiple CL modalities and reported difficulty with his habitual CLs and inadequate spectacle-corrected visual acuity to perform his activities of daily living. In this case, a collaborative, comprehensive approach to visual management in a patient with KC was used, and after TG PRK was performed to improve his corneal contour and symmetry, our patient was fit with a standard soft CL and additionally had improved spectacle-corrected visual acuity.

Long-Term Outcomes After Corneal Cross-linking for Progressive Keratoconus and Corneal Ectasia: A 10-Year Follow-Up of the Pivotal Study.

OBJECTIVES: To report on the topographic and visual outcomes 10 years after corneal cross-linking in patients with progressive keratoconus and corneal ectasia after refractive surgery. METHODS: Cross-sectional cohort study of an original, prospective, randomized, clinical trial. Patients treated in a single center cornea and refractive surgery practice as part of the U.S. pivotal trials, which led to the Food and Drug Administration approval of corneal cross-linking, were recruited for a 10-year follow-up examination. LogMar lines (LL) of uncorrected visual acuity (UCVA) and best spectacle--corrected visual acuity (BSCVA), maximum keratometry, and thinnest pachymetry were evaluated. In addition, the Belin ABCD progression display was used to determine progression (95% confidence interval) of the anterior curvature, posterior curvature, and corneal thickness of each individual eye included. RESULTS: Nineteen eyes of 13 patients treated with standard cross-linking returned for a 10-year follow-up examination. Mean maximum keratometry changed from 58.2±12.0 diopters (D) to 58.3±10.1 D, thinnest pachymetry changed from 440.6±51.6 µm to 442.3±54.4 µm, UCVA changed from 0.79±0.42 LL to 0.86±0.46 LL, and BSCVA changed from 0.38±0.26 LL to 0.33±0.34 LL, 10 years after cross-linking. Individually, 68.5% of the entire cohort, 81.8% of keratoconus eyes, and 50% of eyes with corneal ectasia remained topographically stable 10 years after standard cross-linking. CONCLUSIONS: In the entire cohort, visual acuity and topography remained stable 10 years after cross-linking. Over the long-term, eyes with keratoconus seem to be more stable than those with corneal ectasia.

Correlation of Manifest Refraction and Simulated Keratometry to Tomography Characteristics in Patients With Keratoconus.

OBJECTIVES: To report on baseline refractive and keratometric values and their correlation with tomographic characteristics of eyes with keratoconus (KC). METHODS: Retrospective chart review of patients treated in a single-center cornea and refractive surgery practice. Baseline topographic measurements were reviewed for 1,012 keratoconic eyes of 586 patients between 2008 and 2018. The manifest refraction, thinnest pachymetry (P thin ), corneal astigmatism (K astig ), and the maximum (K max ), steep (K steep ), flat (K flat ), and mean (K mean ) keratometry were analyzed. The location of K max (x, y) was used to determine central (<1 mm), paracentral (1-3 mm), pericentral (3-5 mm), or peripheral (>5 mm) cone locations. RESULTS: In the entire cohort, the mean manifest sphere was -2.2±4.4 diopters (D) and the cylinder was -3.2±2.3 D. In total, 48.6% of patients had against the rule (ATR) manifest astigmatism (M astig ). The average K astig was 3.8±2.7 D, and unlike the manifest axis, 50.2% of patients had with the rule (WTR) K astig . Patients with a K max less than 50 D had an M astig of -1.9±1.6 D, 45.9% of which was ATR M astig . With respect to baseline tomography measurements, K max , K steep , K flat , and K mean were 58.0±9.4, 50.6±6.5, 46.8±5.9, and 48.6±6.1 D, respectively. There was a weak correlation between K max and simulated keratometry (K steep , K flat , and K mean ) for patients with a K max less than 60 D. CONCLUSIONS: Simulated keratometry is poorly correlated with KC severity until the disease is more severe. M astig ≥2 D and ATR M astig were correlated with KC at all levels of severity. M astig ≥2 D and ATR M astig may serve as a simple, inexpensive, and widely available indicator for topographic analysis to identify possible KC and suggest further workup; however, further prospective studies are needed to confirm its utility.

Corneal tissue addition keratoplasty: new intrastromal inlay procedure for keratoconus using femtosecond laser-shaped preserved corneal tissue.

PURPOSE: To report results of Corneal Tissue Addition Keratoplasty (CTAK) for keratoconus (KC) and ectasia after laser in situ keratomileusis. SETTING: Cornea and refractive surgery practice. DESIGN: Single center, prospective, open label clinical trial. METHODS: 21 eyes of 18 patients underwent CTAK. A tissue inlay of preserved corneal tissue was cut to customized specifications with a femtosecond laser and placed in a laser-created channel in the host cornea. Postoperative uncorrected and corrected distance visual acuity (UDVA, CDVA), manifest refraction spherical equivalent (MRSE), topographic mean keratometry (Kmean), maximum keratometry (Kmax), and the point of maximum flattening (Kmaxflat) were measured. RESULTS: Average UDVA improved from 1.21 ± 0.35 logMAR lines (LL) (20/327) to 0.61 ± 0.25 LL (20/82) ( P < .001). Average CDVA improved from 0.62 ± 0.33 LL (20/82) to 0.34 ± 0.21 LL (20/43) ( P = .002), and average MRSE improved from -6.25 ± 5.45 diopters (D) to -1.61 ± 3.33 D ( P = .002). Individually, 20 eyes (95.2%) gained more than 2 lines of UDVA, with 10 eyes (47.6%) gaining more than 6 lines, and no eyes worsening. 12 eyes (57.1%) gained at least 2 lines of CDVA, with 1 eye worsening by more than 2 lines. At 6 months, average Kmean flattened by -8.44 D ( P = .002), Kmax flattened by -6.91 D ( P = .096), and mean Kmaxflat was -16.03 D. CONCLUSIONS: CTAK is a promising procedure to improve visual acuity and topography in patients with KC and ectasia.

Despite Equivalent Medicare Reimbursement, Facility Costs for Outpatient Total Knee Arthroplasty Are Higher Than Unicompartmental Knee Arthroplasty.

BACKGROUND: With the recent removal of total knee arthroplasty (TKA) from the Centers for Medicare and Medicaid Services (CMS) Inpatient Only list, facility reimbursement for outpatient TKA now falls under the Outpatient Prospective Payment System at the same rate as unicompartmental knee arthroplasty (UKA). The purpose of this study was to compare true facility costs of patients undergoing outpatient TKA with those undergoing UKA. METHODS: We reviewed a consecutive series of 2310 outpatient TKA and 231 UKA patients from 2018 to 2019. Outpatient status was defined as a hospital stay of less than 2 midnights. Facility costs were calculated using a time-driven, activity-based costing algorithm. Implants, supplies, medications, and personnel costs were compared between outpatient TKA and UKA patients. A multivariate analysis was performed to control for confounding medical and demographic variables. RESULTS: When compared with patients undergoing UKA, outpatient TKA patients had higher implant costs ($3403 vs $3081; P < .001) and overall hospital costs ($6350 vs $5594; P < .001). Outpatient TKA patients had a greater length of stay (1.2 vs 0.5 days; P < .001) and greater postoperative personnel costs ($783 vs $166; P < .001) than UKA patients. When controlling for comorbidities, outpatient TKA was associated with a $803 (P < .001) increase in overall facility costs compared with UKA. CONCLUSION: Despite equivalent reimbursement from CMS as UKA, outpatient TKA has increased facility costs to the hospital. Although implant costs can vary greatly by institution, CMS should consider appropriately reimbursing outpatient TKA for the additional personnel costs when compared with UKA.

In Kinematically Aligned Total Knee Arthroplasty, Failure to Recreate Native Tibial Alignment Is Associated With Early Revision.

BACKGROUND: The goal of kinematically aligned (KA) total knee arthroplasty (TKA) is to restore native knee anatomy. However, there are concerns about patellofemoral tracking problems with this technique that lead to early revision. We measured the differences between preoperative anatomic alignment and postoperative component alignment in a consecutive series of KA TKA and evaluated the association between alignment changes and the likelihood of early revision. METHODS: The charts of 219 patients who underwent 275 KA TKA procedures were reviewed. Preoperative anatomic alignment and postoperative tibial and femoral component alignment were measured radiographically. The difference in component alignment compared with preoperative anatomic alignment was compared between patients who underwent aseptic revision and those who did not at a minimum of 12 months of follow-up. Receiver operating characteristic curves were created for statistically significant variables, and the Youden index was used to determine optimal alignment thresholds with regard to likelihood of revision surgery. RESULTS: Change in tibial component alignment compared with native alignment was greater (P = .005) in the revision group (5.0° ± 3.7° of increased varus compared with preoperative anatomic tibial angle) than in the nonrevision group (1.3° ± 4.2° of increased varus). The Youden index indicated that increasing tibial varus by >2.2° or more is associated with increased likelihood of revision. Preoperative anatomic alignment and change in femoral alignment and overall joint alignment (ie, Q angle) were not associated with increased likelihood of revision. CONCLUSION: Small increases in tibial component varus compared with native alignment are associated with early aseptic revision in patients undergoing KA TKA.