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uncorrected proof article, Purpose: A survey in 2015 identified a high level of eye care practitioner concern about myopia with a reported moderately high level of activity, but the vast majority still prescribed single vision interventions to young myopes. This research aimed to update these findings 4 years later.Methods: A self-administrated, internet-based questionnaire was distributed in eight languages, through professional bodies to eye care practitioners globally. The questions examined: awareness of increasing myopia prevalence, perceived efficacy of available strategies and adoption levels of such strategies, and reasons for not adopting specific strategies.Results: Of the 1336 respondents, concern was highest (9.0 +/- 1.6; p < 0.001) in Asia and lowest (7.6 +/- 2.2; p < 0.001) in Australasia. Practitioners from Asia also considered their clinical practice of myopia control to be the most active (7.7 +/- 2.3; p < 0.001), the North American practitioners being the least active (6.3 +/- 2.9; p < 0.001). Orthokeratology was perceived to be the most effective method of myopia control, followed by pharmaceutical approaches and approved myopia control soft contact lenses (p < 0.001). Although significant infra-regional differences existed, overall, most practitioners did not consider single-vision distance under-correction to be an effective strategy for attenuating myopia progression (79.6 %), but prescribed single vision spectacles or contact lenses as the primary mode of correction for myopic patients (63.6 +/- 21.8 %). The main justifications for their reluctance to prescribe alternatives to single vision refractive corrections were increased cost (20.6 %) and inadequate information (17.6 %).Conclusions: While practitioner concern about myopia and the reported level of activity have increased over the last 4 years, the vast majority of eye care clinicians still prescribe single vision interventions to young myopes. With recent global consensus evidence-based guidelines having been published, it is hoped that this will inform the pr, This project was supported by many eye care organisations and individuals across the globe, in particular the Association of Malaysia Optometrists, British Contact Lens Association, College of Optometrists (UK), International Association of Contact Lens Educators, Optometry Today, Spanish General Council of the Colleges of Opticians-Optometrists, Contact Lens Spectrum and Caroline Christie.

The subcommittee reviewed the prevalence, incidence, risk factors, natural history, morbidity and questionnaires reported in epidemiological studies of dry eye disease (DED). A meta-analysis of published prevalence data estimated the impact of age and sex. Global mapping of prevalence was undertaken. The prevalence of DED ranged from 5 to 50%. The prevalence of signs was higher and more variable than symptoms. There were limited prevalence studies in youth and in populations south of the equator. The meta-analysis confirmed that prevalence increases with age, however signs showed a greater increase per decade than symptoms. Women have a higher prevalence of DED than men, although differences become significant only with age. Risk factors were categorized as modifiable/non-modifiable, and as consistent, probable or inconclusive. Asian ethnicity was a mostly consistent risk factor. The economic burden and impact of DED on vision, quality of life, work productivity, psychological and physical impact of pain, are considerable, particularly costs due to reduced work productivity. Questionnaires used to evaluate DED vary in their utility. Future research should establish the prevalence of disease of varying severity, the incidence in different populations and potential risk factors such as youth and digital device usage. Geospatial mapping might elucidate the impact of climate, environment and socioeconomic factors. Given the limited study of the natural history of treated and untreated DED, this remains an important area for future research.

Purpose: Myopia is a global public health issue; however, no information exists as to how potential myopia retardation strategies are being adopted globally. Methods: A self-administrated, internet-based questionnaire was distributed in six languages, through professional bodies to eye care practitioners globally. The questions examined: awareness of increasing myopia prevalence, perceived efficacy and adoption of available strategies, and reasons for not adopting specific strategies. Results: Of the 971 respondents, concern was higher (median 9/10) in Asia than in any other continent (7/ 10, p < 0.001) and they considered themselves more active in implementing myopia control strategies (8/ 10) than Australasia and Europe (7/10), with North (4/10) and South America (5/10) being least proactive (p < 0.001). Orthokeratology was perceived to be the most effective method of myopia control, followed by increased time outdoors and pharmaceutical approaches, with under-correction and single vision spectacles felt to be the least effective (p < 0.05). Although significant intra-regional differences existed, overall most practitioners 67.5 ( 37.8)% prescribed single vision spectacles or contact lenses as the primary mode of correction for myopic patients. The main justifications for their reluctance to prescribe alternatives to single vision refractive corrections were increased cost (35.6%), inadequate information (33.3%) and the unpredictability of outcomes (28.2%). Conclusions: Regardless of practitioners’ awareness of the efficacy of myopia control techniques, the vast majority still prescribe single vision interventions to young myopes. In view of the increasing prevalence of myopia and existing evidence for interventions to slow myopia progression, clear guidelines for myopia management need to be established., This project was supported by many eye care organisations across the globe and in particular the British Contact Lens Association.

Purpose To establish normative data of retinal nerve fibre layer (RNFL) thickness in the elderly and to determine the factors influencing its thickness. Methods Peripapillary RNFL thickness was measured with spectral domain OCT (SD-OCT) in 210 elderly participants from the Alienor population-based study who were aged 75 years or older. The measure was assessed in six segments (the superotemporal, temporal, inferotemporal, inferonasal, nasal and superonasal segments). RNFL data were analysed across age and sex strata in non-glaucoma participants. Mixed linear models were used to evaluate the associations of RNFL thickness with age, sex, ocular parameters and vascular risk factors. Results The mean global RNFL thickness was 91.4 μm (SD: 12.6), ranging from 55 to 122; the highest values were found in the inferotemporal and superotemporal segments. After adjustment for sex and ocular parameters, including axial length, increasing age was significantly associated with lower thickness globally (mean thinning per decade = 5.6 μm, p = 0.003), in the superotemporal (−12.7 μm per decade, p

Purpose To assess the quality of life in French keratoconus patients. Setting Fifty-seven Keratoconus National Reference Centers across France. Design Prospective case series. Methods Patients completed the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) and a French validated questionnaire on disability and dependency from February to June 2012 when they came for an ophthalmic examination at 57 participating centers across France. An ocular examination including refraction, corneal topography, pachymetry, and slitlamp biomicroscopy was performed. The composite or global NEI VFQ-25 score and the proportion of patients who were dependent (defined by the difficulties with activities of daily living) because of keratoconus were the main evaluation criteria in this study. Results The study comprised 550 keratoconus patients. Women, corrected distance visual acuity worse than 20/40, steep keratometry higher than 52.0 diopters, history of surgery (corneal transplant, intrastromal corneal ring segments, or corneal crosslinking), and more severe keratoconus according to the Amsler-Krumeich classification were associated with an increasingly negative impact on quality of life (overall scores are significantly lower). Moreover, 4.9% of participants reported having changed their jobs because of keratoconus and 7.8% received keratoconus-related disability. Sixty-nine (12.5%) patients reported having difficulties with activities of daily living and are considered dependent. Conclusion Keratoconus was associated with a significant reduction in quality of life but it did not result in social exclusion.

To compare microstructural changes along the optical radiations and brain structure volumes between glaucoma and control subjects using in vivo magnetic resonance imaging and to analyze their association with severity of the disease.A total of 50 open-angle glaucoma subjects and 50 healthy age- and sex-matched controls underwent detailed ophthalmologic examinations (including visual field testing [VF], funduscopy, and spectral-domain optical coherence tomography) as well as diffusion tensor imaging (DTI) using 3.0-Tesla magnetic resonance imaging. Fractional anisotropy (FA), mean diffusivity, radial diffusivity (RD), and axial diffusivity (AD) were quantified semiautomatically along the optical radiations. DTI parameters and volumes of specific brain structures were compared between cases and controls using conditional logistic regression. Association between DTI metrics and the severity of the disease was studied using linear mixed regression analyses.In glaucoma subjects, optic radiations FA was significantly lower (0.57 vs. 0.59; P = 0.02) and RD was significantly higher (52.78 10-5 mm2/s vs. 49.74 10-5 mm2/s; P = 0.03) than in controls. Optic radiations FA was significantly correlated with homolateral functional and structural damage of glaucoma (mean deviation of VF [P = 0.03], retinal nerve fiber layer thickness [P = 0.03], vertical cup to disc ratio [P = 0.0007]). Volume and DTI parameters of other brain structures (including hippocampus) were not significantly different between glaucoma patients and controls.We evidenced microstructural modifications along visual pathways of glaucoma patients and these alterations were correlated with disease severity. The association of glaucoma with other neurodegenerative alterations would need further exploration and a prospective follow-up of our cohort of subjects. (ClinicalTrials.gov number, NCT01621841).

Purpose To assess diagnostic accuracy of spectral-domain optical coherence tomography (SD-OCT) to discriminate glaucoma and control subjects in an elderly population. Methods The antioxidants, essential lipids, nutrition and ocular maladies study (ALIENOR: "Antioxydants, Lipides Essentiels, Nutrition et Maladies Oculaires") is a population-based study. From 2009 to 2010, a total of 624 subjects, aged 74 years or older underwent a complete eye examination, including optic disc color photography and SD-OCT examination of the macula and the optic nerve head. Glaucoma diagnosis was made using retinophotography of the optic nerve head and International Society for Epidemiologic and Geographical Ophthalmology criteria. Average and sectorial peripapillary retinal nerve fiber layer thicknesses (RNFLT) were compared between glaucoma and control subjects using area under the receiver operating characteristic curves (AUC), positive and negative likelihood ratios (LR+/LR-), and diagnostic odds ratios (DOR). Results A total of 532 subjects had complete data, 492 were classified as controls and 40 were classified as glaucoma. Mean age was 82.1 ± 4.2 years and average RNFLT was significantly different between both groups (controls: 88.7 ± 12.2 μm, glaucoma: 65.4 ± 14.4 μm, P < 0.001). Highest AUC values were observed for average (0.895), temporal-inferior (0.874), and temporal-superior (0.868) RNFLT. Temporal-superior RNFLT had the highest DOR (25.31; LR+, 4.65; LR-, 0.18), followed by average RNFLT (DOR: 24.80; LR+, 6.36; LR-, 0.26). When using the normative database provided by the machine, DOR increased to 31.03 (LR+, 1.75; LR-, 0.06) if at least one parameter was considered abnormal (at P < 0.05). Conclusions Parameters of SD-OCT RNFL may provide valuable information in a screening strategy to improve glaucoma detection in a general population of elderly people.

Resume Objectifs Analyser les aspects epidemiologiques du keratocone chez l’enfant. Methodes Nous avons realise une etude retrospective sur les patients dont le keratocone a ete diagnostique avant 15 ans et apres 27 ans. L’âge, le sexe, le motif de consultation, l’ethnie, les antecedents personnels et familiaux, le terrain allergique, le frottement oculaire, la prise en charge optique et chirurgicale et l’insertion scolaire et professionnelle ont ete releves. Les donnees de chaque groupe sont comparees par le test du Chi2. Resultats Quarante-neuf enfants et 167 adultes ont ete etudies. L’ethnie caucasienne etait majoritaire. Les enfants etaient plus frequemment de sexe masculin (p = 0,0386), avec un terrain allergique associe (67,35 % contre 47,31 % chez les adultes ; p = 0,0136). Parmi les enfants, (91,84 %) et 70,06 % des adultes declaraient se frotter les yeux (p = 0,002). Des enfants (12,24 %) presentaient des antecedents familiaux de keratocone contre 14,97 % des adultes (p = 0,6324). Au total, 68,09 % des enfants etaient equipes en lentilles rigides, contre 15,66 % des adultes (p = 0,0909). Parmi les enfants, 80,5 % etaient pris en charges chirurgicalement ont beneficie d’un cross-linking contre 30 % des adultes. Discussion Les jeunes patients sont plus souvent des garcons, les femmes etant plus âgees au diagnostic. Le terrain allergique est frequemment associe. Cependant, 25 % des enfants sont allergiques dans la population generale. Enfin, ils se frottent frequemment les yeux, soit du fait d’un prurit oculaire souvent present ou de l’ametropie induite. Conclusion Pour depister la maladie precocement, une topographie corneenne pourrait etre systematique chez les jeunes garcons, allergiques, se frottant les yeux et presentant un astigmatisme corneen d’apparition recente.

PURPOSE: The purpose of this study was to assess the associations of biomechanical properties of the cornea with metabolic and environmental factors in an elderly population. METHODS: The ALIENOR (Antioxydants, Lipides Essentiels, Nutrition, and Maladies OculaiRes) study is a population-based study. In 2009-2010, 624 subjects, aged 74 years or more, underwent an eye examination, including intraocular pressure (IOP), central corneal thickness (CCT), and biomechanical properties of the cornea measurements using the Ocular Response Analyzer. Socio-demographic, lifestyle, and medical history data were collected using standardized questionnaires. Mean lifetime ambient ultraviolet (UV) exposure was estimated using residential history and statistics of UV radiation at each location using the Eurosun UV database. RESULTS: Mean age was 82.2 ± 4.3 years. Mean corneal hysteresis (CH), corneal resistance factor (CRF), and CCT were 9.4 ± 1.9, 9.8 ± 1.9 mm Hg, and 551.6 ± 36.8 μm, respectively. In the multivariate analysis, CH and CRF values were significantly lower in subjects older than 80 years (-0.56; 95% confidence interval [CI]: -0.89;-0.24); P < 0.001 and -0.48; 95% CI: -0.75;-0.20; P < 0.001, respectively), in subjects having higher ambient UV exposure (-0.50; 95% CI: -0.88;-0.12; P < 0.01; and -0.46; 95% CI: -0.78;-0.13); P < 0.05, respectively), and in subjects with high plasma LDL cholesterol (CH: -0.46; 95% CI: -0.86;-0.03; P < 0.05; and CRF: -0.37; 95% CI: -0.72;-0.008; P < 0.05). Central corneal thickness was significantly higher in former smokers than in never smokers (+11.01; 95% CI: 0.48;21.55; P < 0.05) and was not significantly associated with age, ambient UV exposure, diabetes, or LDL cholesterol. CONCLUSIONS: Biomechanical properties of the cornea are modified by metabolic and lifetime environmental factors, especially UV exposure. The manner these factors may influence onset and progression of ocular diseases or IOP measurements need further investigation.

Resume Introduction Les keratites infectieuses constituent une preoccupation majeure de sante pour les millions de porteurs de lentilles de contact, ainsi que pour leurs ophtalmologistes. Certains facteurs de risque infectieux sont bien connus (defaut d’hygiene, port permanent des lentilles…), d’autres sont seulement evoques, voire meconnus et gagneraient ainsi a etre demontres. Patients et methodes Une etude multicentrique prospective regroupant 12 centres hospitaliers universitaires francais (Besancon, Bordeaux, Dijon, Fort-de-France, Grenoble, Limoges, Lyon, Nancy, Nantes, Paris, Marseille et Strasbourg) comparant des patients souffrant d’une keratite infectieuse sous lentilles de contact (cas) a des porteurs sains de lentilles de contact (temoins) a l’aide d’un questionnaire standardise anonyme regroupant 51 items donnant des informations sur des facteurs de risques potentiels et developpe pour l’etude a ete debutee en juillet 2007. Resultats Deux cent cinquante-six cas et 113 temoins ont participe a cette etude. Une part importante des abces sous lentilles de contact est survenue sous lentilles cosmetiques (risque relatif [RR] : 16,5). Un delai de consultation chez l’ophtalmologiste superieur a un an (RR : 3,4) ou l’adaptation des lentilles par un non-ophtalmologiste (RR : 7,6) a entraine une augmentation du risque de survenue d’abces sous lentilles. Le non-respect des regles d’hygiene (lavage des mains : RR : 2,2 ; ou absence de rub and rinse : RR : 2,7) a aussi augmente le risque d’infection sous lentilles. Discussion Un questionnaire standardise, remis a tout patient presentant un abces de cornee sous lentilles de contact, semble etre un outil pertinent pour l’etude des facteurs de risque de keratite infectieuse sous lentilles de contact et l’education au bon maniement des lentilles de contact des porteurs.

International audience; Background: Worldwide, degenerative eye diseases (age-related maculopathy (ARM), cataract, glaucoma) are the main causes of visual impairment and blindness, which contribute to disability in the elderly. Mainly three types of nutritional factors are investigated for their potential protection against eye ageing: antioxidants; lutein and zeaxanthin (carotenoids which accumulate specifically in the eye); omega 3 polyunsaturated fatty acids. Few epidemiological studies have been conducted in this field, particularly in Europe. Objective: The Alienor (Antioxydants, Lipides Essentiels, Nutrition et maladies OculaiRes) Study aims at assessing the associations of eye diseases with nutritional factors, determined from plasma measurements and estimation of dietary intakes. Design, setting and participants: Subjects were recruited in Bordeaux (France) from the ongoing population-based 3C study. In 2006-2008, 963 subjects from the 3C Study, aged 73 years or more, had an eye examination and will have follow-up eye examinations every 2 years. Measurements: Vascular, genetic and nutritional factors were assessed at baseline (1999-2001) and follow-up examinations of the 3C Study. Eye diseases were classified according to international classifications. Results: Nutritional status and vascular disease and risk factors were similar between participants and non participants, except for a slight difference in plasma triglycerides and HDL-cholesterol. As expected, the prevalence of eye diseases was high: early and late ARM (28.4 % and 5.6 %, respectively), open-angle glaucoma and treated ocular hypertension (4.8 % and 10.0 %, respectively), cataract extraction (45.2 %), retinopathy (8.4 %), retinal vein occlusion (1.1 %), epiretinal membrane (3.9 %), current use of artificial tears (17.3 %). Conclusions: This study confirms the high prevalence of eye diseases in the elderly. Its main strength is the combination of nutritional, vascular and genetic information, collected over a 7 year period of time before the first eye examination. It may help design future interventional studies, which might be common with other age-related disorders, because of common nutritional factors.

As bacterial adhesion to contact lenses may contribute to the pathogenesis of keratitis, the aim of our study was to investigate in vitro adhesion of clinically relevant bacteria to conventional hydrogel (standard HEMA) and silicone-hydrogel contact lenses using a bioluminescent ATP assay.Four types of unworn contact lenses (Etafilcon A, Galyfilcon A, Balafilcon A, Lotrafilcon B) were incubated with Staphylococcus epidermidis (two different strains) and Pseudomonas aeruginosa suspended in phosphate buffered saline (PBS). Lenses were placed with the posterior surface facing up and were incubated in the bacterial suspension for 4 hours at 37 degrees C. Bacterial binding was then measured and studied by bioluminescent ATP assay. Six replicate experiments were performed for each lens and strain.Adhesion of all species of bacteria to standard HEMA contact lenses (Etafilcon A) was found to be significantly lower than that of three types of silicone-hydrogel contact lenses, whereas Lotrafilcon B material showed the highest level of bacterial binding. Differences between species in the overall level of adhesion to the different types of contact lenses were observed. Adhesion of P. aeruginosa was typically at least 20 times greater than that observed with both S. epidermidis strains.Conventional hydrogel contact lenses exhibit significantly lower bacterial adhesion in vitro than silicone-hydrogel ones. This could be due to the greater hydrophobicity but also to the higher oxygen transmissibility of silicone-hydrogel lenses.

PURPOSE To compare two preservative-free hydrating agents, in multidose (ABAK) bottles, in contact lens wearers experiencing symptoms of ocular dryness. METHODS The endpoint of this 4-week multicenter, randomized, double-blind, parallel-group study comparing a 2% polyvinylpyrrolidone (PVP) solution with a 0.9% NaCl solution was to assess ocular discomfort using a visual analog scale. A biomicroscopic examination and a test of tolerability on instillation were also performed, and adverse events were recorded. RESULTS Thirty-nine subjects were enrolled (23 PVP; 16 NaCl). The average age was 30; subjects were predominantly female, and mostly wore frequent-replacement contact lenses. They were all exposed to environmental factors such as routine use of video monitors or air conditioning. The two groups were similar at baseline (D0). Both PVP and NaCl improved the comfort of contact lens wear (P = 0.0003), with no difference between them (P = 0.25). The mean daily duration of lens wear and the daily number of instillations to relieve discomfort (4.2 +/- 2.0 for PVP ABAK; 4.6 +/- 1.9 for NaCl ABAK) were comparable. However, PVP use led to more favorable evolution of fluorescein-staining corneal punctuations (P = 0.028). Safety was good, with minimal adverse events considered unrelated to the products. Lens wettability was excellent, and there were no clinically relevant deposits. Most subjects also found the ABAK bottles convenient. CONCLUSIONS Ocular hydration improves comfort in contact lens wearers. NaCl is an appropriate first-line treatment, but for subjects with fluorescein-staining punctuations, lubrication with PVP is preferable.

Purpose. This article reports clinical results comparing a high-oxygen permeable (HDk) silicone hydrogel soft contact lens with a low-oxygen permeable (LDk) soft hydroxyethyl methacrylate contact lens when worn on an extended-wear basis. Methods. Six practitioners in France enrolled 134 subjects in this 4-month, open-label, multicenter, prospective, randomized, cross-over study. Subjects were randomized to receive either an HDk lotrafilcon A or an LDk etafilcon A soft contact lens. Subjects crossed over to the alternative lens after either 3 months' experience with the HDk lens or 1 month's experience with the LDk lens. Clinical and subjective data were collected at scheduled follow-up visits. Results. The subjective data has been reported in a separate article. Both types of lenses gave similar performance for visual acuity. Biomicroscopic examination findings averaged below grade 1 (trace) for both lenses throughout the study. A statistically significant difference for limbal redness was found at 1 week (HDk = 0.11; LDk = 0.33; paired-t test, P

Purpose This article reports the subjective results of a study comparing extended-wear high-oxygen permeable (HDk) silicone hydrogel soft contact lenses with low-oxygen permeable (LDk) hydroxyethyl methacrylate lenses. Methods Six practitioners in France enrolled 134 subjects in this 4-month, open-label, multicenter, prospective, randomized, cross-over study. Subjects were randomized to receive prescriptions of either an HDk lotrafilcon A or an LDk etafilcon A soft contact lens. Subjects then crossed over to the alternative lens after either 3 months' experience with the HDk lens or 1 month's experience with the LDk lens. Clinical and subjective data were collected at scheduled follow-up visits. Results The clinical data has been reported in a separate article. After 1 month of wear. HDk lenses were rated better than LDk lenses for all aspects of comfort and overall average symptoms. Subjects were satisfied with both lenses, and lens features were comparable through 1 month. The preference was higher for HDk lenses after crossing over, either from or to LDk lenses. Eighty-six percent of HDk and 85% of LDk subjects reported wearing their lenses while sleeping for 7 nights per week during the study. Seventy-seven percent of HDk and 21% of LDk subjects reported wearing their lenses while sleeping for 22 to 31 nights during the study. Conclusions Based on subjective results, therefore, the HDk lens offers another option to patients and practitioners for extended-wear or continuous-wear soft contact lenses.

Purpose. To evaluate subclinical inflammation and mucus production of the conjunctiva in asymptomatic contact lens (CL) wearers, and to obtain an estimation of the chronologic variations in each group. Methods. Eighteen eyes fitted with rigid CL (RCL) and 28 eyes with soft CL (SCL) worn daily were compared with 10 eyes from five healthy non-CL wearers. Impression cytology (IC) specimens were collected after clinical examination and were analyzed by flow cytometry using antibodies directed to HLA DR and intercellular adhesion molecule type 1 (ICAM-1) (CD 54), as inflammatory markers, and to the peptidic core of the conjunctival mucin (M1/MUC5AC) for mucus and goblet cell detection. The percentage of positive cells was calculated, and levels of fluorescence expression were quantified and compared between each group. Results. A significant increase of HLA DR and ICAM-1 was observed in the SCL group in comparison with the control group. The two inflammatory markers were highly positively correlated with each other. Mucin detection with M1/MUC5AC did not find a significant difference between each group in terms of percentage of positive cells, but analyses of mean levels of fluorescence showed a significant decrease in the two CL groups. Evolution in time was different for each group, with a regular low level of inflammation in the RCL group in the first 10 years in comparison with the SCL group. In the SCL group, inflammation seemed to be higher before 2 years and after 10 years of wear. Mucin expression was variable in time, but without significant difference at any time. Conclusion. This study confirms difference in expression of subclinical conjunctival inflammation in asymptomatic CL wearers, with lower levels for RCL than SCL wearers with daily or extended wear. The mucin system is also modified by this low but chronic aggression of the ocular surface, with a tendency to decrease with time in the RCL and SCL groups.

Objective To evaluate the use of INTACS micro-thin prescription inserts (Kera Vision, Inc., Fremont, CA) for the treatment of keratoconus. Design Prospective, nonrandomized (self-controlled) comparative trial. Participants/intervention Ten patients from our prospective clinical study who had completed 12 months of follow-up were evaluated. All patients had keratoconus with clear central corneas and were contact lens intolerant. After reviewing corneal pachymetry and topography of individual patients, INTACS inserts of 0.45-mm thickness were placed in the inferior cornea to lift the cone and INTACS of 0.25-mm thickness were inserted superiorly to counterbalance and flatten the overall anterior corneal surface. Main outcome measures Differences between preoperative and postoperative uncorrected visual acuity, best spectacle-corrected visual acuity, manifest refraction, and keratometry values were statistically assessed. Changes in corneal ectasia were evaluated by reviewing corneotopographic maps. Results No intraoperative complications occurred in this series of patients. Spherical equivalent error and refractive astigmatism were reduced with INTACS inserts treatment. Postoperative month 12 uncorrected visual acuity (logarithm of the minimum angle of resolution [logMAR] mean, 0.35, standard deviation [SD], 0.16 [∼20/50, ∼2 lines]) was significantly better than preoperative (logMAR mean, 1.05; SD, 0.33 [∼20/200, ∼3 lines]; P ≤ 0.05). Average best spectacle-corrected visual acuity at postoperative month 12 was improved by approximately two lines compared with baseline (logMAR mean, 0.22; SD, 0.12 [∼20/32, ∼1 line]; logMAR mean, 0.38; SD, 0.13 [∼20/50, ∼1 line], respectively). Topographic corneal shape (size and height of the cone) was improved for all subjects after insert placement. Conclusions INTACS micro-thin prescription inserts seem to provide a viable method for treating clear corneal keratoconus for patients who are contact lens intolerant. The corneal steepening and astigmatism associated with keratoconus were reduced, and visual acuity was improved with treatment in almost all eyes.

High dietary intakes of n3 (ω3) polyunsaturated fatty acids (PUFA) and fish have been consistently associated with a decreased risk for age-related macular degeneration (AMD). We assessed the associations of late AMD with plasma n3 PUFA, a nutritional biomarker of n3 PUFA status. The Antioxydants Lipides Essentiels Nutrition et Maladies Occulaires (Alienor) Study is a prospective, population-based study on nutrition and age-related eye diseases performed in 963 residents of Bordeaux (France) aged ≥73 y. Participants had a first eye examination in 2006-2008 and were followed for 31 mo on average. Plasma fatty acids were measured by GC from fasting blood samples collected in 1999-2001. AMD was graded from non-mydriatic color retinal photographs at all examinations and spectral domain optical coherence tomography at follow-up. After adjustment for age, gender, smoking, education, physical activity, plasma HDL-cholesterol, plasma triglycerides, CFH Y402H, apoE4, and ARMS2 A69S polymorphisms, and follow-up time, high plasma total n3 PUFA was associated with a reduced risk for late AMD [OR = 0.62 for 1-SD increase (95% CI: 0.44-0.88); P = 0.008]. Associations were similar for plasma 18:3n3 [OR = 0.62 (95% CI: 0.43-0.88); P = 0.008] and n3 long-chain PUFA [OR = 0.65 (95% CI: 0.46-0.92); P = 0.01]. This study gives further support to the potential role of n3 PUFAs in the prevention of late AMD and highlights the necessity of randomized clinical trials to determine more accurately the value of n3 PUFAs as a means of reducing AMD incidence.

Objective Previous research has suggested an association between dementia and glaucoma through common risk factors or mechanisms. Our aim was to evaluate the longitudinal relationship between open-angle glaucoma (OAG) and incident dementia. Methods The Three-City–Bordeaux–Alienor study is a population-based cohort of 812 participants with a 3-year follow-up period. All participants were aged 72 years or older. An eye examination was performed on all subjects. An OAG was determined based on optic nerve damage and visual field loss. Incident dementia was actively screened for and confirmed by a neurologist. Results A total of 41 participants developed dementia over the 3-year follow-up period. Future incident dementia cases had an increased prevalence of OAG (17.5% vs 4.5% for nondemented participants, p = 0.003). After adjustment for age, gender, education, family history of glaucoma, vascular comorbidities, and apolipoprotein e4, our results showed that participants with an OAG were four times more likely to develop dementia during the 3-year follow-up period (odds ratio = 3.9, 95% confidence interval = 1.5–10.4, p = 0.0054). An increased risk of dementia was also associated with 2 markers of optic nerve degeneration (vertical cup:disk ratio and minimal rim:disk ratio). However, no association was found between a high intraocular pressure and/or the use of intraocular pressure-lowering medications and incident dementia. Interpretation If the association between OAG and dementia is confirmed, direct and noninvasive quantification of the amount of retinal ganglion cell axonal loss may be a useful biomarker of cerebral axonal loss in the future. It may also offer new breakthroughs in understanding the underlying pathophysiological mechanisms of both diseases.

PURPOSE: To compare early corneal healing following conventional, transepithelial, and accelerated corneal collagen cross-linking (CXL) protocols. METHODS: Twenty-four patients with progressive keratoconus were divided into three groups to receive conventional, transepithelial, or accelerated CXL. In vivo corneal confocal microscopy was performed on each patient preoperatively and at 1, 3, and 6 months postoperatively. RESULTS: Closure of the epithelial wound was complete 3 days following conventional and accelerated CXL. The subbasal nerve plexus was essentially obliterated immediately following conventional and accelerated CXL, and virtually no nerve fibers had regenerated by 6 months. The anterior stroma showed significant changes 1 month following conventional CXL; these changes were similar but more pronounced following accelerated CXL. Observed stromal changes included complete obliteration of keratocytes, increased tissue reflectivity, a honeycomb-like appearance, and circular lacunae. Some recovery of keratocyte density was noted after 6 months. These changes were less pronounced in the mid-stroma, and there were no apparent changes to the posterior stroma or endothelium. The cornea appeared to be unaltered following transepithelial CXL. CONCLUSIONS: In vivo corneal confocal microscopy analysis of the postoperative impact of CXL on the cornea revealed clear differences among conventional, accelerated, and transepithelial CXL protocols. Accelerated CXL had a greater impact than conventional CXL on the anterior cornea, whereas transepithelial CXL did not appear to alter corneal morphology.

Free to read Purpose The aim was to determine the extent of daily disposable contact lens prescribing worldwide and to characterise the associated demographics and fitting patterns. Methods Up to 1,000 survey forms were sent to contact lens fitters in up to 40 countries between January and March every year for five consecutive years (2007 to 2011). Practitioners were asked to record data relating to the first 10 contact lens fits or refits performed after receiving the survey form. Survey data collected since 1996 were also analysed for seven nations to assess daily disposable lens fitting trends since that time. Results Data were collected in relation to 97,289 soft lens fits, of which 23,445 (24.1 per cent) were with daily disposable lenses and 73,170 (75.9 per cent) were with reusable lenses. Daily disposable lens prescribing ranged from 0.6 per cent of all soft lenses in Nepal to 66.2 per cent in Qatar. Compared with reusable lens fittings, daily disposable lens fittings can be characterised as follows: older age (30.0 ± 12.5 versus 29.3 ± 12.3 years for reusable lenses); males are over-represented; a greater proportion of new fits versus refits; 85.9 per cent hydrogel; lower proportion of toric and presbyopia designs and a higher proportion of part-time wear. There has been a continuous increase in daily disposable lens prescribing between 1996 and 2011. The proportion of daily disposable lens fits (as a function of all soft lens fits) is positively related to the gross domestic product at purchasing power parity per capita (r2 = 0.55, F = 46.8, p < 0.0001). Conclusions The greater convenience and other benefits of daily disposable lenses have resulted in this modality capturing significant market share. The contact lens field appears to be heading toward a true single-use-only, disposable lens market.

PURPOSE. Previous studies have suggested a lower risk for agerelated maculopathy (ARM) in subjects with high dietary intake of long-chain omega-3 polyunsaturated fatty acids (PUFA). The authors report the associations of ARM with past dietary intakes in French elderly subjects. METHODS. The Alienor Study is a population-based epidemiologic study on nutrition and age-related eye diseases performed in residents of Bordeaux 73 years of age and older. Six hundred sixty-six subjects (1289 eyes) with complete data were included in the analyses. ARM was classified from retinal photographs taken in 2006 to 2008 in five exclusive stages: late neovascular ARM (n 21 subjects, 29 eyes); late atrophic ARM (n 19 subjects, 33 eyes); large soft indistinct drusen and/or reticular drusen and/or large distinct drusen with pigment abnormalities (early ARM2, n 67 subjects, 100 eyes); large soft distinct drusen alone or pigment abnormalities alone (early ARM1, n 119 subjects, 163 eyes); and no ARM (n 440 subjects, 964 eyes). Dietary intakes were estimated from a 24-hour dietary recall performed by dieticians (2001‐2002). Associations were estimated using logistic Generalized Estimating Equation. RESULTS. After multivariate adjustment, subjects with high intake of long-chain omega-3 PUFA showed a decreased risk for early ARM1 (odds ratio [OR], 0.83; 95% confidence interval [95% CI], 0.71‐0.98; P 0.03) and late neovascular ARM (OR, 0.26; 95% CI, 0.08‐0.83; P 0.02). Associations with late atrophic ARM were in the same direction but did not reach statistical significance (OR, 0.74; 95% CI, 0.52‐1.06; P 0.10). Overall, high intakes of long-chain omega-3 PUFA were associated with reduced risk for late ARM (OR, 0.59; 95% CI, 0.39‐ 0.88; P 0.01). CONCLUSIONS. These results confirm a decreased risk for ARM in subjects with high intake of long-chain omega-3 PUFA. (Invest Ophthalmol Vis Sci. 2011;52:6004‐6011) DOI:10.1167/iovs.117254

Purpose To report refractive, topographic, and biomechanical outcomes, efficiency, and safety of corneal collagen crosslinking (CXL) 1, 3, 6, and 12 months after treatment. Setting National Reference Centre for Keratoconus, Bordeaux and Toulouse, France. Design Case series. Methods This retrospective uncontrolled double-center study comprised eyes with progressive keratoconus. Uncorrected distance visual acuity, corrected distance visual acuity (CDVA), corneal pachymetry, endothelial cell count, and corneal hysteresis and corneal resistance factor were evaluated at baseline and at 1, 3, 6, and 12 months. Results One hundred forty-two eyes were enrolled in the study. At 6 months, the CDVA had stabilized in 53 eyes (48.1%), improved in 36 eyes (32.7%), and decreased in 18 eyes (16.3%). At 12 months, the CDVA had stabilized in 31 eyes (47.6%), improved in 26 eyes (40.0%), and decreased in 8 eyes (12%). At 6 months, keratoconus progression had stopped in 51 eyes (49.03%) and the maximum keratometry (K) value had decreased by more than 1.0 diopter (D) in 37 eyes (35.5%); it continued to progress in 16 eyes (15.3%). At 12 months, keratoconus progression had stopped in 42 eyes (68.8%) and the maximum K value had decreased by more than 2.0 D in 13 eyes (21.3%). The complication rate with loss of vision was 3.5%. Conclusions Ultraviolet-A light associated with riboflavin CXL is an efficient procedure to stabilize and improve progressive keratoconus. The results reinforce previous studies highlighting the efficacy and safety of the procedure. A large prospective randomized clinical trial is needed. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

To evaluate the long-term safety and efficacy of Intacs segments (Addition Technology, Inc.) for the treatment of keratoconus in terms of intraoperative and postoperative complications, visual outcome, restoration of contact lens tolerance, and inhibition of disease progression.Service d'Ophtalmologie, CHU Pellegrin, Bordeaux, France.This prospective, 2-year follow-up study comprised 100 keratoconic eyes with clear central corneas and contact lens intolerance. The best spectacle-corrected visual acuity (BSCVA), uncorrected visual acuity (UCVA), refractive error, keratometry, pachymetry, and slitlamp examination were assessed preoperatively and 1 and 2 years after Intacs implantation.At 2 years, the UCVA and BCVA improved in 80.5% and 68.3% of eyes, respectively (P.001). The proportion of eyes with a BCVAor=0.5 (20/40) increased from 22.0% at baseline to 51.2% and 53.7% at 1 year and 2 years, respectively (P.001). The manifest refraction spherical equivalent improved from a mean of -6.93 diopters (D) +/- 3.91 (SD) preoperatively to -4.01 +/- 3.16 D at 1 year and -3.80 +/- 2.73 D at 2 years (P.001). The mean keratometry readings decreased from 50.1 +/- 5.6 D preoperatively to 46.4 +/- 5.3 D at 1 year and 46.8 +/- 4.9 D at 2 years (P.001). Contact lens tolerance was restored in over 80% of cases. Postoperative slitlamp observations revealed no clinically significant issues. The segments were removed from 4 eyes without complications or sequelae.Intacs implantation was a safe and efficacious treatment for keratoconus. Significant and sustained improvements in objective visual outcomes were achieved in most cases, with restoration of contact lens tolerance.

Purpose. To report the wearer experience, biomicroscopy signs, and stability of refractive error after 3 years’ use of lotrafilcon A lenses. Methods. Seventy-four subjects from a multicenter clinical trial with lotrafilcon A lenses were queried on aspects of lens wear. Biomicroscopy signs and refractive error were compared to baseline measurements. Results. A total of 66% of subjects reported continuing to wear lotrafilcon A lenses, usually for more than 21 nights, with high satisfaction. Signs of limbal, palpebral, and bulbar redness improved significantly. Average refractive error remained stable. Conclusions. Long-term use of lotrafilcon A lenses resulted in high wearer satisfaction, reduction of ocular redness, and stable refractive error.

Keratoconus is a non-inflammatory, bilateral, asymmetric, progressive steepening and thinning of the central cornea. Classification of the four stages has evolvedwith inclusion of new criterias such as corneal CCT, sphero-cylindric refraction and mean keratometric values. The currentmanagement strategy of this disease has also largely evolved during the past years with the introduction of new medico-surgical options. Corneal cross linking is now indicated in evolving keratoconus, deep lamellar corneal graft (KLAP) have replaced penetrating keratoplasty (decreasing corneal rejection risk), intra-corneal rings are routinely used in contact lens intolerant patients since femtolaser channels are easily performed for their insertion. Indications and contra-indications of these different medicosurgical treatments will be reviewed. However, corneal GP contact lenses remain the primary visual management for keratoconus and play a major role. New designs allow better mechanical alignment but contact lens tolerance is still an issue for some patients. Up-date materials combinations (hybrid lenses, piggy-backing) and others lens types (silicone softs, sclerals...) are interesting alternatives in such cases to obtain a better lens tolerance and they will be presented and discussed. Lens fitting philosophy of GP corneal lenses, scleral lenses and soft silicone lenses will be largely detailed.Indications in the current contact lens strategicmanagement of keratoconus at different stages of the disease including lens fitting after medico-surgical treatments will be presented.Advancements in care of keratoconus and improvements of lens material and designs science will certainly provide a better quality of vision and quality of life for these patients. This presentation, after the recent classification of the four stages of keratoconus,will focus ondifferent lens types fitted in keratoconic eyes. New medico-surgical treatments are part of care of the disease such cross-linking, lamellar corneal graft, intra corneal rings. However, contact lenses keep a major place in visual rehabilitation and their indications and fitting will be reviewed in non-operated corneas and in operated corneas.

Purpose To evaluate the potential of intrastromal corneal ring technology (Intacs™, KeraVision) to correct keratoconus without central corneal scarring. Setting Department of Ophthalmology, Brest University Hospital, Brest, France. Methods In this prospective, noncomparative, interventional case series, Intacs segments were implanted in 10 keratoconic eyes with clear central corneas and contact lens intolerance after corneal pachymetry was checked. Segment thicknesses varied based on corneal topography analysis. Results No intraoperative complications occurred. The mean follow-up was 10.6 months. Postoperative results revealed a reduction in astigmatism and spherical correction and an increase in topographical regularity and increased uncorrected visual acuity. Conclusion Intacs technology can reduce the corneal steepening and astigmatism associated with keratoconus.

PURPOSE To explore the association of AMD with long-term average blood pressure (BP) parameters, including pulse pressure (PP). METHODS The ALIENOR study is a population-based study on age-related eye diseases in 963 residents of Bordeaux, France, aged 73 years or older. AMD was graded from nonmydriatic color retinal photographs, in three exclusive stages: no AMD (1015 eyes), large soft distinct drusen and/or large soft indistinct drusen and/or reticular drusen and/or pigmentary abnormalities (early AMD, 276 eyes), and late AMD (66 eyes). BP parameters were measured at four occasions over a 7-year period. PP was defined as systolic BP minus diastolic BP. Associations of AMD with BP parameters were estimated using generalized estimating equation logistic regressions. Statistical analyses included 702 subjects (1357 eyes) with complete data. RESULTS After adjustment for age, sex, educational level, smoking, body mass index, plasma HDL and LDL cholesterol, CFH Y402H, ApoE2, ApoE4, and ARMS2 A69S polymorphisms, elevated PP was significantly associated with an increased risk of late AMD (odds ratio [OR] = 1.37 for a 10-mm Hg increase, 95% confidence interval [CI]: 1.03-1.82). Associations were similar for late atrophic and late neovascular AMD (OR = 1.39, 95% CI: 1.01-1.92, P = 0.04, and OR = 1.43, 95% CI: 0.90-2.23, P = 0.13, respectively). Association with early AMD was in the same direction but did not reach statistical significance (OR = 1.12, 95% CI: 0.98-1.28). Early and late AMD were not significantly associated with systolic or diastolic BP, hypertension, or use of antihypertensive medications. CONCLUSIONS This study suggests that high PP may be associated with increased risk for AMD.

Purpose: To evaluate the visual and refractive results of photorefractive keratectomy (PRK) in eyes with atypical inferior corneal steepening (AICS). Setting: Department of Ophthalmology, Hopital Morvan, University of Brest, France. Methods: Using videokeratopography, we screened 310 eyes that had PRK from November 1992 through November 1993 and found that 35 eyes exhibited topographic patterns consistent with AICS with no clinical findings. The results at 6 months and 1 year were compared with those of 185 eyes with normal topography treated concurrently. Results: There were no statistically significant differences between the two groups in mean spherical equivalent, mean uncorrected visual acuity, and mean best spectacle-corrected visual acuity 6 months and 1 year after PRK. Conclusion: After 1 year, PRK in eyes with AICS appeared to give results similar to those in eyes with normal topography. Further follow-up is needed.

PURPOSE: Videokeratography has enabled detection of inferior steepening patterns in patients thereby designated as keratoconus suspects. Since no information about the corneal thickness of these eyes is available, we studied several patients with such patterns, and compared the corneal thickness of their eyes with that of normals. METHODS: Three groups of patients who had undergone videokeratography were studied with ultrasonic pachymetry centrally and in four quadrants at the 3-mm clear zone: 44 eyes with true keratoconus, 23 eyes of individuals with inferior steepening of the cornea who were family members of patients with keratoconus; and 44 normal eyes never fitted with contact lenses. The corneal thickness of the eyes in the first two groups was then compared with that in the third using ANOVA and Student's t test. RESULTS: Corneal thickness in the normal eyes and in those with inferior steepening was similar in all except the inferotemporal quadrant. In this quadrant, the corneas of the eyes with inferior steepening were thinner than those of the normal eyes: 544 ± 32 µm vs 581 ± 30 µm (p < .05) CONCLUSION: Eyes with inferior steepening on videokeratography have thinner inferotemporal corneas than normal eyes. [J Refract Surg. 1996;12:697-699.]

Lomefloxacin is known to have an excellent corneal penetration. The therapeutic effect of two specific treatment regimens with lomefloxacin 0.3% eye drops was studied in a Pseudomonas aeruginosa-induced keratitis model in guinea pigs. An initial loading dose of 1 drop every 5 min for 5 times was used in all groups. Its purpose was to obtain high bactericidal corneal levels in the two actively treated groups. The follow-up treatment for 7 days was by a twice daily regimen in one group and 3 times daily in the other treated group. There were two control groups - one with no treatment and the other with vehicle treatment (initial loading dose followed by twice daily regimen). Clinical signs of cornea, conjunctiva and eye adnexae improved significantly within 2 days in both lomefloxacin regimens, whereas clinical signs deteriorated with vehicle treatment. Fifty percent of the animals treated with lomefloxacin showed no colonies in the swab culture after 2 days of therapy, while all vehicle-treated animals were positive even at day 6, with 5 out of 9 animals continuing to be positive at day 8. Pseudomonas in the range of 100-2,300 colonies was isolated from the grounded and cultured cornea at the end of the study in 4 out of 9 vehicle-treated animals but in none of the lomefloxacin-treated guinea pigs. The biggest difference in the degree of secondary inflammation between lomefloxacin and vehicle-treated groups was observed in the cornea which was the target tissue of infection. An unexpected observation was the lower degree of corneal inflammation in the twice daily treated animals when compared to the 3 times daily treatment group. This finding may be due to the somewhat lower initial degree of corneal inflammation in this group and suggests that the course of corneal recovery is predominately dependent on the initial degree of infection with both dosage regimens of lomefloxacin capable of eradicating corneal organisms.

PURPOSE. To assess the associations of complement factor H (CFH) Y402H polymorphism and smoking with specific features of early AMD (type, location, and area). METHODS. The ALIENOR study is a population-based study of age-related eye diseases in 963 residents of Bordeaux (France), aged 73 years or more. AMD features were graded from nonmydriatic color retinal photographs. CFH Y402H was genotyped by using DNA extracted from blood. Statistical analyses included 796 subjects with complete data. RESULTS. CFH CC genotype was strongly associated with late neovascular AMD (OR, 6.0; 95% confidence interval [CI], 1.5‐ 23.5) but not with late atrophic AMD (OR, 0.9; 95% CI, 0.2‐ 4.3). Among early characteristics, it was associated with central soft drusen (within 500 m of the fovea), whether of intermediate (63‐125 m; OR, 2.7; 95% CI, 1.5‐4.8), or large (125 m; OR, 5.9; 95% CI, 2.2‐15.7) size, but not with pericentral soft drusen (500‐3000 m from the fovea). It was also strongly associated with a large central area of soft drusen (OR, 5.7; 95% CI, 1.7‐19.2). Similarly, heavy smoking (20 pack-years) was strongly associated with central large drusen (OR, 3.9; 95% CI, 1.6‐9.6) and a large central area of drusen (OR, 3.5; 95% CI, 1.2‐10.0), but not with pericentral soft drusen. By contrast, both CFH CC and smoking tended to be more strongly associated with pericentral pigmentary abnormalities. CONCLUSIONS. Location of abnormalities, together with type and area, may prove useful for the identification of subjects at high risk for late AMD. (Invest Ophthalmol Vis Sci. 2011;52: 5955‐5962) DOI:10.1167/iovs.10-6235