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Background: Exposure to high-altitude conditions during flight or similar activities affects many aspects of visual function, which is critical not only for flight safety but for any altitude-related activity. We aimed to summarize the available literature pertaining to ocular changes during flight or equivalent short-term high-altitude exposure (e.g., hypobaric chamber, effortless ascent lasting ≤ 24 h) and to highlight future research priorities., Methods: Using the PubMed/MEDLINE and Web of Science/ISI Web of Knowledge databases with structured search syntax, we conducted a systematic review of the literature spanning a 40-year period (January 1, 1983, to October 10, 2023). Articles pertaining to ocular changes during flight or flight-equivalent exposure to altitude were retrieved. The reference lists of retrieved studies were also searched, and citations of these references were included in the results., Results: Of 875 relevant PubMed and ISI publications, 122 qualified for inclusion and 20 more were retrieved from the reference lists of initially selected records, for a total of 142 articles. Reported anterior segment changes included deterioration in tear film stability and increased dry eye incidence, increased corneal thickness, discomfort and bubble formation in contact lens users, refraction changes in individuals with prior refractive surgery, decreased intraocular pressure, and alterations in pupillary reaction, contrast sensitivity, and visual fields. Photoreceptor-visual pathway changes included alterations in both photoreceptors and neuro-transduction, as evidenced in dark adaptation, macular recovery time, reduction in visual field sensitivity, and optic neuritis (likely an element of decompression sickness). Retinochoroidal changes included increases in retinal vessel caliber, retinal blood flow, and choroidal thickness; central serous chorioretinopathy; and retinal vascular events (non-arteritic ischemic optic neuropathy, high-altitude retinopathy, and retinal vein occlusion)., Conclusions: The effect of short-term high-altitude exposure on the eye is, in itself, a difficult area to study. Although serious impairment of visual acuity appears to be rare, ocular changes, including tear film stability, contact lens wear, central corneal thickness, intraocular pressure, contrast sensitivity, stability of refractive surgeries, retinal vessels, visual fields, and macula recovery time, should be considered in civilian aviators. Our report provides guidance to climbers and lowlanders traveling to altitude if they have pre-existing ocular conditions or if they experience visual symptoms while at altitude. However, key outcomes have been contradictory and comprehensive studies are scarce, especially those pertaining to the choroid and retina. Such studies could not only deepen our understanding of high-altitude ocular pathophysiology, but could also offer valuable information and treatment possibilities for a constellation of other vision-threatening diseases., Competing Interests: None., (© Author(s).)

Macular edema (ME) is a major cause of reduced vision following intraocular surgery. Although the pathophysiology of ME is not completely understood, inflammatory mediators play a key role. The incidence of ME following pars plana vitrectomy with silicone oil tamponade varies between 13% and 27%. ME usually resolves spontaneously following silicone oil removal, but treatment may be required for resistant cases. In this review, the mechanisms of ME formation after pars plana vitrectomy, its incidence, and its possible therapeutic approaches are discussed., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Kontou et al.)

Purpose: To analyse the demography, etiology, and classification of uveitis at a tertiary academic referral center., Methods: An observational study was conducted on the archives of uveitic patients at the Ocular Inflammation Service of the Department of Ophthalmology at the University Hospital of Ioannina (Greece) from 1991 to 2020. This study aimed to investigate the epidemiological profile of patients, including their demographics and the main etiologic factors of uveitis., Results: Out of 6191 cases with uveitis, 1925 were infectious, 4125 were non-infectious, and an overall of 141 masquerade syndromes were recorded. Among these cases, 5950 patients were adults, with a slight female predominance, while 241 were children (< 18 years old). Interestingly, 24.2% of cases (1500 patients) were associated with 4 specific microorganisms. Herpetic uveitis (HSV-1 and VZV/HZV) was the most common cause of infectious uveitis (14.87%), followed by toxoplasmosis (6.6%) and tuberculosis (2.74%). In 49.2% of non-infectious uveitis cases, no systematic correlation was found. The most frequent causes of non-infectious uveitis included sarcoidosis, white dot syndromes, ankylosing spondylitis, lens-induced uveitis, Adamantiades-Behçet disease, and idiopathic juvenile arthritis. Infectious uveitis was more common in the rural population, whereas non-infectious uveitis was more frequently recorded in the urban population CONCLUSIONS: Although our study was conducted on a predominantly white Caucasian population, it also reflects the effect of increasing immigration, improvements of diagnostic techniques, changes in referral patterns, and various actual changes in disease incidence., (© 2023. The Author(s).)

Purpose: The aim of this study was to evaluate and compare the changes in Intraocular Pressure (IOP) and other ocular parameters: the Anterior Chamber Angle (ACA), Anterior Chamber Volume (ACV), and Anterior Chamber Depth (ACD) during phacoemulsification surgery in Greek patients with normotensive eyes and those with well-controlled Open-Angle Glaucoma (OAG). Additionally, parameters such as the Corneal Thickness (CCT), Axial Length (AL), Central Macular Thickness (CMT), and Retinal Nerve Fibre Layer (RNFL) were also examined., Patients and Methods: This was a prospective observational case-control study that included 50 phakic eyes, 25 normotensive (Group 1), and 25 with OAG: 15 Primary Open-Angle Glaucoma (POAG) and 10 Exfoliation Glaucoma (EXG) (Group 2). Ophthalmic assessment included IOP measurements, ocular biometry, and anterior and posterior segment optical coherence tomography evaluation of the aforementioned ocular parameters, prior and 6 months after phacoemulsification surgery., Results: At the 6 months post-operative review, a greater IOP reduction was recorded in eyes with OAG, in comparison to normotensive ones (5.3mmHg and 1.6 mmHg respectively). In addition, a significant but similar increase was recorded in the values of the ACA, ACV, and ACD of both groups between the pre- and the post-op period. Furthermore, the CCT and AL values remained unaltered. Finally, there was a non-statistically significant change in the mean CMT and the mean average RNFL of both groups., Conclusion: Eyes with OAG tend to undergo a greater reduction in IOP post-phacoemulsification surgery, in comparison to normotensive eyes. This reduction may not be solely attributed to ocular anatomical changes after phacoemulsification surgery but may also be due to the remodeling of the trabecular meshwork and the ciliary body. This may be especially true in the case of OAG eyes, which already start off with a compromised trabecular endothelium prior to surgery., Competing Interests: The authors report no conflicts of interest in this work., (© 2023 Xirou et al.)

Purpose: The purpose of this study is to present the diagnostic and therapeutic algorithms, complications, and final outcome in the management of uveitic patients at a tertiary academic referral center., Design: Observational study., Methods: Analysis of the archives of 6191 uveitic patients at the Ocular Inflammation Service of the Department of Ophthalmology of the University Hospital of Ioannina in Greece from 1991 to 2020., Results: During the 30 years of the study, the diagnostic ability climbed from 45.43% (1991-1995) to 73.4% (2016-2020). This improvement was linked to several factors including the increase in the number of diagnostic paracenteses for the analysis of intraocular fluids, the range and quality of laboratory blood tests, the multimodal ophthalmic imaging, the proper use of nonophthalmic imaging, and the multidisciplinary approach. The degree of uveitis-related complications was related to the severity and cause of inflammation, the recurrence rate, inappropriate treatment, and the prolonged or initially inactive inflammation. The 3 most common complications included cataract, macular edema, and glaucoma. Apart from the modern treatments and surgical techniques, the 3-month preoperative control of inflammation played a critical role in the surgical outcomes. The percentage of patients with a successful outcome increased from 72% (2001-2005) to 90.50% (2016-2020). The center's experience, prompt referral, patient's compliance, and regular follow-ups are associated with a better outcome. The analysis of the results allowed the development of diagnostic and therapeutic algorithms., Conclusions: Developing diagnostic and therapeutic algorithms allows for the efficient management of uveitis, leading to better visual outcome and therefore a better quality of life., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 Asia-Pacific Academy of Ophthalmology. Published by Wolters Kluwer Health, Inc. on behalf of the Asia-Pacific Academy of Ophthalmology.)

Purpose: Emerging evidence suggests that choroidal microcirculation and microstructural changes after verteporfin photodynamic therapy (vPDT) for chronic central serous chorioretinopathy (CSC) can be shown in detail using OCT-Angiography (OCT-A). The use of OCT-A for the examination of choriocapillaris (CC) has attracted significant attention as the technique offers potential explanations for the effects of vPDT on choroidal tissue., Methods: A meticulous literature search was performed in the PubMed database without restriction on year of publication until June 2021. The reference list of all electronically retrieved articles was carefully reviewed for potentially relevant articles that had not been identified., Results: We identified and reviewed 11 studies reporting a comprehensive update on microvasculature and morphologic changes of the CC layer as seen on OCT-A in chronic CSC. The reviewed articles extensively analyze both the qualitative and quantitative characteristics of the CC flow pattern after applying vPDT safety-enhanced protocols. The changes in the CC plexus indicate the potential of beneficial or deleterious treatment effect on choroidal tissue remodeling. The reviewed series have revealed variability of flow pattern, vessel density, and perfusion of the CC over time., Conclusion: The CC plexus alterations during the post-vPDT period in chronic CSC may imply the treatment effect on choroidal tissue, indicating the potential of anatomical or functional recovery over time. The reviewed literature may confirm the diagnostic value of OCT-A in the assessment of the pathophysiology of eyes with CSC., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To characterize choroidal structure and vasculature after half-dose verteporfin photodynamic therapy (hd-vPDT) in eyes with chronic central serous chorioretinopathy using Enhanced Depth Imaging Optical Coherence Tomography (EDI OCT) and Optical Coherence Tomography Angiography (OCT-A)., Methods: This prospective case-control study included 10 eyes. Choroid was examined before and at 1 month following hd-vPDT. We measured choroidal thickness (CT) at subfoveal area and at 750 μm nasal and temporal of fovea and thickness of Haller and choriocapillaris/Sattler layers. Whole (WA), luminal (LA) and interstitial area (IA) at EDI-OCT, and perfusion density at OCT-A were analyzed. The unaffected fellow eyes were used for comparisons., Results: Mean CT at subfoveal area and at 750 μm nasal and temporal of fovea, values of Haller and choriocapillaris/Sattler layers and those of WA, LA and IA were reduced, while PD increased at 1 month after hd-vPDT (all p < 0.001). There was a significant (p < 0.05) negative correlation (ρ = -0.658) between PD and post-treatment logMARVA. None of analyzed parameters reached values of unaffected fellow eye., Conclusion: Following hd-vPDT, choroidal thickness with both luminal and interstitial components markedly decreased, while perfusion of choriocapillaris improved.

Introduction: The aim of this study was to evaluate the correlation between several ocular parameters (intraocular pressure [IOP], corneal biomechanical properties) and the visual field (VF) mean deviation (VF MD) in eyes with open-angle glaucoma (OAG)., Methods: We conducted a cross-sectional, observational study in which we measured the IOP with Goldmann applanation tonometry, the central corneal thickness (CCT), and the corneal parameters obtained from the Ocular Response Analyzer® (ORA®) and the Corvis® ST non-contact tonometer, in newly diagnosed and treatment-naïve eyes with OAG, to investigate whether there was any correlation between these ocular parameters and the VF MD., Results: A total of 51 eyes were analyzed. A statistically significant correlation was found only between the VF MD and corneal hysteresis (CH) (P = 0.003, r 2  = 0.16) and CCT (P = 0.03, r 2  = 0.08)., Conclusions: These results demonstrate that CH and CCT are associated with the amount of VF damage in treatment-naïve OAG eyes., (© 2021. The Author(s).)

Purpose: Evaluation of spherical component (SC), regular astigmatism (RA), and irregular astigmatism (IA, ie, Asymmetry and Irregularities) 3 years after small incision lenticule extraction (SMILE) and comparison to femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK)., Methods: Thirty-two eyes of 21 patients who underwent SMILE for myopia and astigmatism were compared with 32 eyes of 21 patients treated with FS-LASIK. Scheimpflug images were obtained preoperatively and 3 years postoperatively. Fourier analysis of keratometric-derived parameters (SC, RA, Asymmetry, and Irregularities) of the anterior, posterior, and total cornea were evaluated at 4 concentric rings (ring 1, 2 mm diameter; ring 2, 4 mm; ring 3, 6 mm; ring 4, 8 mm) and over the entire 8-mm zone., Results: After FS-LASIK, over the 8-mm zone, the RA and IA of the anterior cornea increased significantly (P ≤ 0.002), whereas SMILE induced an insignificant increase in RA and Asymmetry (P ≥ 0.276) and a decrease in Irregularities (P = 0.770). At the 8-mm zone of the posterior cornea, the Irregularities increased significantly (P = 0.027) after FS-LASIK, whereas SMILE induced no significant changes in the examined variables (P ≥ 0.347). RA and IA of the total cornea increased significantly after FS-LASIK (P ≤ 0.001), whereas SMILE induced an insignificant increase in RA and Asymmetry (P ≥ 0.092) and a significant decrease in Irregularities (P < 0.001). FS-LASIK induced a greater decrease in SC of the total cornea at ring 4 (P = 0.009)., Conclusions: FS-LASIK resulted in a greater increase in RA and Irregularities and greater flattening of the midperiphery of the anterior and total cornea compared with SMILE. The posterior cornea remained unaffected after SMILE, whereas more Irregularities were induced after FS-LASIK over the 8-mm zone.

Purpose: To analyze the recovery of the subbasal nerve plexus in corneas treated with laser in situ keratomileusis (LASIK) at least 10 years prior compared with nonoperated corneas., Setting: Clínica Novovisión, Madrid, Spain., Design: Prospective nonrandomized observational study., Methods: Eyes that had LASIK surgery at least 10 years before (LASIK group) were compared with nonoperated healthy eyes (control group). The subbasal nerve plexus morphology (main nerves density, nerve length, nerve branches density, grade of nerve tortuosity, and reflectivity) and the dendritic cell density from the confocal images obtained with the Heidelberg Retina Tomograph II were analyzed., Results: The study comprised 47 eyes (27 eyes in the LASIK group and 20 eyes in the control group). The values were significantly lower in the LASIK group compared with the control group in main nerves density (9.15 nerves/mm 2  ± 3.46 [SD] versus 11.75 ± 2.86 nerves/mm 2 ; P = .009) and nerve branches density (2.96 ± 1.99 nerves/mm 2 versus 5.35 ± 3.05 nerves/mm 2 ; P = .002). No significant differences were found in nerve length, grade of nerve tortuosity, dendritic cell density, or subbasal nerve plexus reflectivity between the two groups., Conclusions: The outcomes suggested that the subbasal corneal nerve plexus did not completely recover its preoperative pattern at least 10 years after LASIK. Both main nerves density and nerve branches density continued to be significantly lower compared with virgin corneas after a mean 13-year follow-up, although other parameters of nerve morphology (nerve length, tortuosity, and reflectivity) returned to normal levels., (Copyright © 2019 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

During the last 2 decades, modifying the shape of the cornea by means of laser photoablation has emerged as a successful and popular treatment option for refractive errors. Corneal surface ablation techniques such as photorefractive keratectomy (PRK) and laser-assisted subepithelial keratomileusis (LASEK) offer good refractive results while having a minimal impact on corneal biomechanical stability. Past limitations of these techniques included the long-term regression of refractive outcome and a vigorous healing response that reduced corneal clarity in some patients (giving rise to what is clinically described as "haze"). Mitomycin C (MMC) was introduced as a healing modulator and applied on the corneal surface after refractive surgery to address these drawbacks. This article critically reviews the available evidence on the biological effects, safety, and clinical benefits of the off-label use of MMC in corneal refractive surgery.

Purpose: The aim was to assess the repeatability of Fourier transfom analysis of videokeratographic data using Pentacam in normal (CG), keratoconic (KC) and post-CXL (CXL) corneas., Methods: This was a prospective, clinic-based, observational study. One randomly selected eye from all study participants was included in the analysis: 62 normal eyes (CG group), 33 keratoconus eyes (KC group), while 34 eyes, which had already received CXL treatment, formed the CXL group. Fourier analysis of keratometric data were obtained using Pentacam, by two different operators within each of two sessions. Precision, repeatability and Intraclass Correlation Coefficient (ICC), were calculated for evaluating intrassesion and intersession repeatability for the following parameters: Spherical Component (SphRmin, SphEcc), Maximum Decentration (Max Dec), Regular Astigmatism, and Irregularitiy (Irr). Bland-Altman analysis was used for assessing interobserver repeatability., Results: All parameters were presented to be repeatable, reliable and reproductible in all groups. Best intrasession and intersession repeatability and reliability were detected for parameters SphRmin, SphEcc and Max Dec parameters for both operators using ICC (intrasession: ICC > 98%, intersession: ICC > 94.7%) and within subject standard deviation. Best precision and lowest range of agreement was found for the SphRmin parameter (CG: 0.05, KC: 0.16, and CXL: 0.2) in all groups, while the lowest repeatability, reliability and reproducibility was detected for the Irr parameter., Conclusions: The Pentacam system provides accurate measurements of Fourier tranform keratometric data. A single Pentacam scan will be sufficient for most clinical applications.

Purpose: To evaluate the long-term changes in anterior and posterior corneal irregular astigmatism and curvatures after small incision lenticule extraction (SMILE)., Methods: Fifty eyes of 28 patients underwent SMILE for myopic astigmatism. All procedures were performed using the VisuMax® femtosecond laser. A Scheimpflug camera was used for preoperative and 3-year postoperative tomography. Anterior and posterior corneal Fourier parameters (spherical component, regular astigmatism, asymmetry, and irregularity) and curvature data were evaluated and compared within 2 subgroups according to the magnitude of the refractive correction (low myopia group: spherical equivalent (SEQ) ≥ -6 D; high myopia group: (SEQ) < -6 D). Associations between all studied parameters were examined., Results: Three years postoperatively, an increase in anterior corneal curvatures and Fourier parameters was detected and the results were strongly correlated with the preoperative SEQ, lenticule thickness, and volume. At the posterior cornea, the flattest radius, corneal astigmatism, spherical component, regular astigmatism, and irregularity decreased only in the high myopia group. A correlation was found between changes in posterior astigmatism and changes in anterior radii (R = 0.349, P = 0.014), SEQ (R = 0.396, P = 0.0049), and lenticule thickness (R = -0.414, P = 0.0031). Moreover, changes in posterior corneal irregularity correlated with the changes in anterior and posterior radii (R = -0.3, P = 0.034, and R = 0.449, P = 0.0012, respectively), changes in preoperative SEQ (R = 0.284, P = 0.0477), and lenticule thickness (R = -0.311, P = 0.0298)., Conclusions: Three years after SMILE, there was a reduction of posterior astigmatism in high refractive corrections. This could result in undercorrection in high refractive treatments. Total irregularities increased despite the compensatory effect of the posterior corneal surface.

A systematic review of the recent literature regarding a series of ocular diseases involved in European telemedicine projects was performed based on the PubMed, Google Scholar and Springer databases in June 2017. Literature review returned 44 eligible studies; among them, emergency ophthalmology, diabetic retinopathy, glaucoma, age-related macular disease, cataract and retinopathy of prematurity. The majority of studies indicate teleophthalmology as a valid, reliable and cost-efficient method for care-provision in ophthalmology patients which delivers comparable outcomes to the traditional examination methods.

A systematic review of the recent literature regarding pseudophakic monovision as a reliable methods for presbyopia correction was performed based on the PubMed, MEDLINE, Nature and the American Academy of Ophthalmology databases in July 2015 and data from 18 descriptive and 12 comparative studies were included in this narrative review. Pseudophakic monosvision seems to be an effective method for presbyopia with high rates of spectacles independence and minimal dysphotopsia side-effects, that should be considered by the modern cataract surgeons.

Aim: To compare the efficacy of modified deep sclerectomy combined with Ex-PRESS shunt versus trabeculectomy in primary open angle glaucoma., Methods: This is a prospective cohort comparative single-center study. Forty-nine eyes of 49 patients were enrolled in the study. Patients were randomly divided into two groups. Group A (22 patients) underwent classic trabeculectomy and group B (27 patients) underwent modified deep sclerectomy combined with insertion of Ex-PRESS model P50 drainage device., Results: Mean age was 69±7y in group A and 64±8y in group B ( P =0.03). The mean reduction was 11.1±5.7 mm Hg in group A compared to 15.8±5.7 mm Hg in group B at 6mo ( P =0.006), and 9.8±4.9 mm Hg and 15.4±4.7 mm Hg respectively at 1y ( P =0.0001). Regarding the postoperative glaucoma medication, significant difference was observed between the two groups (in favour of group B) only at 6mo ( P =0.017). At the end of the follow-up period complete success rate in group A was 68.2% compared to 92.6% in group B ( χ 2 test, P =0.07) and qualified success rate was 100% in both groups., Conclusion: Modified deep sclerectomy combined with Ex-PRESS shunt may provide comparable IOP reduction with fewer complications in management of primary open angle glaucoma.

Purpose: To evaluate the contribution of Fourier analysis of videokeratographic data in the diagnosis of subclinical keratoconus and keratoconus., Setting: Eye Institute of Thrace, Democritus University, Alexandroupolis, Greece., Design: Observational case series., Methods: The following Pentacam-derived parameters, resulting from Fourier decomposition of keratometric data, were evaluated for their diagnostic capacity using receiver operating curves: spherical component and eccentricity, maximum decentration, regular astigmatism in the center and in the periphery, mean astigmatism, irregularities, regular astigmatism in the center plus the irregularities, and total astigmatism. Logistic regression was performed to identify a combined diagnostic model., Results: The study comprised 80 keratoconus eyes, 55 eyes diagnosed with subclinical keratoconus, and 50 normal eyes. Significant differences were detected in spherical eccentricity, maximum decentration, irregularities, regular astigmatism in the center and in the periphery, regular astigmatism in the center plus the irregularities, mean astigmatism, and total astigmatism parameters between the groups. Almost all parameters had high diagnostic ability in both study groups (area under the curve >90%). Among individual parameters, those with the highest predictive accuracy were the regular astigmatism in the center plus the irregularities (subclinical keratoconus 97.6%, keratoconus 98.8%) and the maximum decentration (subclinical keratoconus 91.4%, keratoconus 98.5%). Sufficient predictive accuracy (subclinical keratoconus 99.4, keratoconus 100%) was identified in a diagnostic model that combined the regular astigmatism in the center plus the irregularities and the maximum decentration., Conclusion: Fourier decomposition of keratometric data provided parameters with high accuracy in differentiating corneas with subclinical keratoconus from normal corneas and should be included to allow prompt diagnosis of keratoconus., Financial Disclosure: None of the authors has a financial or proprietary interest in any material or method mentioned., (Copyright © 2016 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

A systematic review of the recent literature regarding the implementation of the liquefaction in cataract surgery and its short-term and long-term outcomes in various parameters that affect the quality of patients' life, including visual rehabilitation and possible complications was performed based on the PubMed, Medline, Nature and the American Academy of Ophthalmology databases in November 2013 and data from 14 comparative studies were included in this narrative review. Liquefaction is an innovative technology for cataract extraction that uses micropulses of balanced salt solution to liquefy the lens nucleus. Most studies reported that liquefaction is a reliable technology for mild to moderate cataracts, while fragmentation difficulties may be encountered with harder nuclei.

Purpose: To evaluate the reproducibility of different Scheimpflug imaging-derived reference bodies in normal, keratoconus (KC), and crosslinked (CXL) eyes., Methods: In this prospective, observational study, 40 participants populated the control group (CG), while 33 and 34 patients formed the KC group and the CXL group, respectively. One eye was randomly selected when both were eligible. Elevation measurements were obtained using Scheimpflug camera, by applying the following reference bodies: the best fit sphere (BFS), the best fit toric ellipsoid (BFTE), the best fit toric ellipsoid with fixed eccentricity of 0.4 (BFTEF), the best fit ellipsoid (BFE), and the best fit torus, by 2 operators in 2 sessions. The variability of different reference bodies' parameters was assessed using intraclass correlation coefficient (ICC)., Results: Differences between operators were nonsignificant for all reference bodies' parameters in all study groups (p&gt;0.1). Regarding CG, BFS for both operators and BFTE for operator 1 presented the best intrasession repeatability (majority of ICCs &gt;0.90), while average interobserver reliability was recorded for the majority of reference bodies' parameters. Regarding KC and CXL groups, BFS, BFTEF, and BFE reference bodies demonstrated the best intrasession and interobserver reproducibility (majority of ICCs &gt;0.90) for both groups. Steep and flat radius parameters presented the best overall reproducibility, with the majority of ICCs for all reference bodies ranging above 0.90, in all study groups., Conclusions: High variability was encountered for most reference surfaces. Ellipsotoric surfaces presented acceptable repeatability in KC and post-CXL corneas.

Aim: To analyze the features of the filtering blebs following implantation of the Ex-PRESS glaucoma device (model P-50) with the aid of the Visante anterior segment optical coherence tomography (AS-OCT)., Methods: Five patients with open angle glaucomas were included in the study. They all underwent implantation of the Ex-PRESS device under a scleral flap. The surgical procedure was augmented with the use of mitomycin C subconjunctivally. The filtering blebs were analyzed with the Visante AS-OCT with the scans taken along the axis of the implantation of the glaucoma device., Results: All filtering blebs were graded as diffuse functioning. The morphological characteristics of the blebs were similar to those of the trabeculectomy. However the use of the Ex-PRESS implant tend to form a characteristic episcleral lake at the site of the plate of the implant., Conclusion: The use of the Ex-PRESS implant produces filtering blebs similar to those of the trabeculectomy with the formation of a characteristic episcleral lake at the site of the plate of the implant.

Purpose: To compare the effect of monovision correction and multifocal intraocular lens (IOL) implantation on patient satisfaction, spectacle dependence, visual acuity, and dysphotopsia in cataract patients., Setting: University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece., Design: Prospective randomized trial., Methods: Patients with a diagnosis of senile cataract with stage 2 nuclear opalescence were randomly assigned to 2 groups: monovision and multifocal IOL implantation. Uncorrected (UDVA) and corrected (CDVA) distance visual acuity, Visual Function Index-14 (VF-14) scores, and spectacle dependence were assessed prior to surgery and 6 months postoperatively., Results: The monovision group comprised 38 patients and the multifocal IOL implantation group, 37 patients. Both techniques provided excellent refractive outcomes in UDVA and VF-14 scores (all P < .01). No significant intergroup differences were detected in VF-14 scores at the final postoperative examination. The monovision group patients presented significantly more spectacle dependence for near vision but less glare., Conclusions: Monovision and multifocal IOL implantation provided excellent refractive outcomes for distance vision. Multifocal IOL insertion was associated with less dependence on glasses overall but significantly more dysphotopsia., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the beliefs and preferences of 6th year Greek medical students, regarding medical profession and the specialty selection process, in the years of financial crisis., Setting: Democritus University of Thrace, Medical School, Alexandroupolis, Greece., Material and Methods: A custom questionnaire based on former similar studies was developed and administered to senior medical students. Further to demographics, the questionnaire gathered information on perceptions and trends regarding medical profession, the specialty and residency selection processes. Total question scores were summed for comparisons among questions. Mean scores and standard deviations were calculated for comparisons between student groups., Results: 111 students responded successfully to the instrument. "Helping patients" and the "scientific basis of medicine" were the fundamental reasons for choosing the medical profession. Compared to women, male students placed greater importance on the "financial allowances" (men: 3.73±1.03, women: 3.05±1.30, p=0.01). Regarding the selection criteria for a certain specialty, "challenging specialty" and "bedside specialty", were the main influence factors. Men more strongly preferred a specialty that could "financially support their desired lifestyle" (men: 3.93±0.88, women: 3.41±1.30, p=0.02). Concerning selection criteria of a residency program, students chose a "well structured" program at a "recognized hospital/department". Regarding the country of preference for their residency, 86% planned to continue abroad, primarily in Germany and the United Kingdom., Conclusion: Greek medical students perceive the medical profession and the specialty process in a similar way like their colleagues form Western countries. However, the vast majority identify that migration to another country is the most promising alternative choice for their medical career., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To evaluate the diagnostic capacity of the Ocular Response Analyzer's keratoconus match index (KMI) and keratoconus match probability (KMP) classification in keratoconus-suspect eyes., Setting: Department of Ophthalmology, University Clinics Saarland, Homburg, Germany., Design: Comparative case series., Methods: The KMI and KMP parameters in keratoconus-suspect eyes and normal eyes (control group) were compared. The quantitative keratoconus percentage index was calculated for all suspect eyes. According to the thinnest corneal thickness (TCT), keratoconus-suspect eyes were divided into 2 subgroups: subgroup 1 (TCT <520 μm) and subgroup 2 (TCT >520 μm). The KMI's overall predictive accuracy was assessed using receiver operating characteristic (ROC) curves. The relationship between KMI and a series of Scheimpflug-derived keratoconus-related indices was evaluated using Spearman analysis., Results: The mean KMI was 0.41 ± 0.29 (SD) in the keratoconus-suspect group (50 eyes) and 0.94 ± 0.29 in the control group (50 eyes) (P<.001). Nonsignificant KMI differences were detected between the keratoconus-suspect subgroups (subgroup 1, 27 eyes; subgroup 2, 23 eyes) (P=.059). Nonsignificant correlations were found between Scheimpflug indices and the KMI. The KMP identified 27.65% of control eyes as keratoconus suspect and 10.71%, 28.57%, and 3.57% of keratoconus-suspect eyes as being normal, having mild keratoconus, or having moderate keratoconus, respectively. The ROC analysis for the KMI indicated a predictive accuracy of 94% (cutoff point 0.72)., Conclusions: The KMI seems to be a valuable index in the early diagnosis of keratoconus-suspect eyes. The KMP identified a significant percentage of topographically defined keratoconus-suspect eyes as normal or keratoconic., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2014 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the diagnostic capacity of the keratoconus match index (KMI) and keratoconus match probability (KMP) classification from a dynamic bidirectional applanation device (Ocular Response Analyzer) in eyes with pellucid marginal degeneration (PMD)., Setting: Department of Ophthalmology, University Clinics Saarland, Homburg, Germany., Design: Cross-sectional study., Methods: Pellucid marginal degeneration eligibility was confirmed by inferior peripheral thinning, corneal protrusion, and irregular astigmatism. The KMI and KMP parameters in PMD eyes (study group) were compared with those in normal eyes (control group). The KMI's overall predictive accuracy was assessed operating characteristic (ROC) curves. The relationship between KMI and corneal hysteresis (CH), the corneal resistance factor (CRF), and a series of Scheimpflug camera indices was evaluated with Spearman analysis (r)., Results: The mean KMI in the study group (40 eyes) and control group (40 eyes) was 0.34 ± 0.43 (SD) and 0.95 ± 0.30, respectively (P<.001). The KMI correlated significantly with the CH, CRF, and most Scheimpflug camera indices. Regression analysis indicated that the index of height decentration (r = -0.877, P<.001) was the primary determinant of the KMI. Moreover, the KMP index identified 50.0%, 29.16%, and 20.83% of PMD eyes as ectatic, suspect for ectasia, and normal, respectively. The ROC curve analysis of the KMI parameter indicated a predictive accuracy of 94.8% (cutoff point 0.626; sensitivity 85.71%; specificity 90.1%)., Conclusions: The KMI seems to be a promising diagnostic index for PMD. In contrast, the KMP index identified a significant percentage of topographically defined PMD eyes as normal, limiting its diagnostic value in PMD., Financial Disclosures: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2014 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Corneal collagen cross-linking (CXL) was first described over a decade ago and is now considered to be one of the most important surgical innovations of modern ophthalmology. Prior to its introduction, no interventions were available to arrest, or slow down ectatic disease progression, with corneal transplantation required in the majority of cases. Unlike earlier treatments of corneal ectasias that attempted to only improve the consequences of the disease, CXL aims to address the corneal biomechanical weakening itself. The long-term safety and efficacy of CXL have been established in several studies that have documented significant improvements in all outcome measures (visual acuity, spherical equivalent, astigmatism, and keratometric findings). The emerging combination of CXL with other interventions (termed 'CXL plus') optimizes the visual and topographic outcomes. This, along with the expansion of the techniques' indications for other clinical conditions, such as microbial keratitis, highlights the continuous improvement of the initial technique and confirms its wide acceptance. Overall, CXL has already demonstrated much promise and has several clinical indications, representing a clear example of recent advances in ocular therapy.

Background/aims: To compare the impact of liquefaction and torsional IP cataract extraction methods on endothelial cell count (ECC), central corneal edema, and central corneal sensitivity (CCS) in a sample of cataract patients., Methods: The liquefaction (LG) and torsional IP (TG) group consisted of 47 and 48 grade 2 cataract eyes, respectively. Uncorrected and best spectacle-corrected visual acuity, ECC, central corneal thickness (CCT), and CCS were measured 1 day prior to surgery, 10 days, 1 and 3 months postoperatively., Results: Significant difficulties in the nucleus fragmentation were encountered in 2 LG eyes, and they were excluded from the study. Both techniques provided excellent refractive outcomes (LG, p < 0.001; TG, p = 0.02). Nonsignificant differences were detected in CCT values at the final postoperative examination; however, TG patients presented higher CCT on the first postoperative day (p = 0.04). Both groups presented comparable significant reductions in ECC (LG, p < 0.001; TG, p < 0.001) and CCS (LG, p = 0.02; TG, p = 0.02)., Conclusion: Both methods provide excellent refractive outcomes, with comparable impact on ECC and CCS. Liquefaction seems to provide less corneal edema; however, difficulties in nucleus fragmentation may be encountered even in grade 2 cataracts., (Copyright © 2012 S. Karger AG, Basel.)

Purpose: To determine the variability in Scheimpflug image-derived posterior elevation measurements in eyes with keratoconus or corneal collagen crosslinking (CXL)., Setting: Eye Institute of Thrace, Alexandroupolis, Greece., Design: Prospective observational study., Methods: Two operators in 2 sessions obtained posterior elevation measurements using the Pentacam Scheimpflug system. Variability in measurements was assessed using Bland-Altman analysis and intraclass correlation coefficients (ICCs). Measurements were associated with a series of Scheimpflug-derived keratoconus indices using the Pearson correlation and multivariate linear-regression analysis., Results: Mean interobserver differences for the central elevation point (e1) and the highest elevation point (HEP) in the keratoconus group were -0.9 μm (95% limits of agreement [LoA], 5.7 to -7.5 μm) and 1.7 μm (95% LoA, 26 to -22.6 μm), respectively. In the CXL group, the mean differences were 0.2 μm (95% LoA, 6.0 to -5.5 μm) and -6.1 μm (95% LoA, 16.8 to -29 μm), respectively. The ICC values in the keratoconus group were satisfactory for most elevation points; the ICC values were unsatisfactory for a series of points in the lower corneal hemisphere. The ICC values for points in both hemispheres were unsatisfactory in the CXL group; HEP had adequate reproducibility. The e1 and HEP parameters correlated significantly with most Scheimpflug-derived indices (P<.05) in the keratoconus group but not in the CXL group. Regression analysis indicated that the central keratoconus index was the primary determinant of the variability in keratoconus eyes., Conclusions: Scheimpflug-derived posterior elevation measurements had acceptable reproducibility in keratoconus eyes and post-CXL eyes. Less consistent measurements were obtained in the lower hemisphere., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Background: To evaluate corneal hysteresis (CH) and corneal resistance factor (CRF) in keratoconic (KC) eyes before and after corneal collagen cross-linking (CXL). Furthermore, to determine potential correlations with a series of corneal and demographic factors., Methods: The study consisted of 50 KC eyes that underwent CXL. CH and CRF were measured by the ocular response analyzer (ORA). Correlations were attempted with uncorrected visual acuity (UVA), best spectacle-corrected visual acuity (BSCVA), central corneal thickness (CCT), mean keratometry (Km), astigmatism (Astig.), residual astigmatism, age, and gender. Fifty non-KC eyes served as controls., Results: CH and CRF (mean ± SD) for non-KC eyes were 10.1 ± 1.9 mmHg and 9.7 ± 2.4 mmHg respectively, while for KC eyes preoperatively they were 8.2 ± 1.4 mmHg (p = 0.007) and 7.4 ± 2.3 mmHg (p = 0.01) respectively. Non-significant differences were detected between preoperative and postoperative CH and CRF measurements in KC eyes (p = 0.518 and p = 0.479 respectively). Significant correlations were found between ORA parameters and BSCVA, CCT, Km, Astig. and residual astigmatism., Conclusions: ORA parameters demonstrate significant differences between KC and non-KC eyes. Both CH and CRF present significant correlations with visual acuity and corneal parameters. CXL exerts a non-significant impact on ORA measurements.

Autophagy is a self-degradation mechanism by which cells recycle their own cytoplasmic constituents. It has been claimed that, under certain conditions, such a process may be associated with tumor progression. In this study, the autophagic activity was investigated in a series of 99 uveal melanomas after immunohistochemical staining for the autophagy-associated proteins MAP1LC3A and BECN1, most commonly known as LC3A and Beclin 1, respectively. These were assessed in parallel with the hypoxia-inducible factor 1α (HIF1A) and its downstream protein lactate dehydrogenase 5 (composed by five LDHA subunits). Increased autophagic reactivity, detected by MAP1LC3A or BECN1, was associated with intense pigmentation and tumor hypoxia. Uveal melanomas with extensive overexpression of BECN1 or those with underexpression of this protein were associated with the worst prognosis, but the former manifested metastases much earlier than the latter; only 58% of patients with extensive BECN1 overexpression were alive at 4 years, compared with 80% of patients with underexpressed patterns. It is concluded that autophagy is commonly upregulated in uveal melanomas, and may be associated with hypoxia and intense pigmentation. There is a strong association between extensive BECN1 overexpression and early metastases/poor prognosis, and between underexpression of this protein and late metastases/better prognosis.

Corneal collagen cross-linking (CXL) using riboflavin and ultraviolet-A irradiation is a common method of tissue stabilization and has been developed primarily to address the need of treating keratoconus. CXL's promising results on keratoconus indicated that it might be effective in other corneal diseases as well. This new treatment promises a slowing effect on the progression of these diseases and its initial results show that it is safe and reasonably curative. The purpose of this review is to critically evaluate this treatment, to explore its benefits, to highlight its limitations in terms of efficacy and long-term safety and finally to identify areas for future research in this topic with a significant potential to change the way we treat our patients. In addition, in this unbiased review we try to bring together all the scientific information from both laboratory and clinical trials that have been conducted during recent years and to review the most recent publications regarding the therapeutic indications of CXL.

Background: Carotid stenosis can produce visual changes. This study examines perimetric and retrobulbar blood flow changes following carotid endarterectomy (CEA) in patients without visual symptoms., Methods: Sixteen patients (13 male, three female) with bilateral carotid stenosis were included. Patients with a history of ophthalmic disease, including glaucoma, were excluded. Peak systolic velocity (PSV) in the ophthalmic artery (OA), central retinal artery (CRA), and short posterior ciliary arteries (SPCAs) was measured preoperatively and 12 months following CEA with color Doppler imaging (CDI), using a 7.5 MHz probe, at both the side operated upon and its fellow side. Automated static perimetry (Octopus 500 perimeter, G1x program) was performed at the same intervals. Mean sensitivity (MS), mean defect (MD), loss variance (LV) and corrected loss variance (CLV) were recorded., Results: Preoperative PSV in the OA was significantly lower in the side operated on. Preoperative perimetric parameters were significantly compromised, compared with normative data, in both eyes. Postoperatively, PSV had significantly improved in all vessels examined in the carotid that was operated on, but only in the OA and SPCAs in the fellow side. MD had significantly improved postoperatively for both eyes, whereas improvement in the other perimetric parameters examined was not statistically significant., Conclusions: Perimetric changes occur in carotid stenosis. CEA results in the improvement of retrobulbar blood flow and perimetric parameters. Further research will be required to determine whether perimetric parameters may be used as additional indicators for carotid endarterectomy.

Background: Previous studies have reported impaired blood flow in the ophthalmic artery (OA) and central retinal artery (CRA) in exfoliation syndrome and exfoliation glaucoma. This study evaluates blood flow at the long and short posterior ciliary arteries (LPCA and SPCA, respectively) in these conditions., Methods: Consecutively examined candidates for cataract surgery were included. Only one eye (OD) was included in the analyses for consistency. Patients were classified into non-glaucoma and non-exfoliation (controls), primary open angle glaucoma (POAG), exfoliation syndrome and exfoliation glaucoma groups, based on the findings of the OD. Sixty-eight patients (41 males, 60.3%) were included. Color Doppler imaging (CDI) of the nasal and temporal branches of LPCA and SPCA was performed using a 7.5 Mhz probe. The peak systolic velocity (PSV), end diastolic velocity (EDV) and resistivity index (RI) were recorded for the examined vessels., Results: EDV at the LPCA was significantly lower in exfoliation syndrome and glaucoma, compared with controls and POAG respectively. EDV was significantly lower and RI was significantly higher at the SPCA in exfoliation glaucoma, compared with exfoliation, whereas respective differences were statistically not significant between controls and POAG., Conclusions: The hemodynamic impairment at the LPCA in exfoliation syndrome and glaucoma supports an association between exfoliation and ischemic stress at the anterior ocular segment.

Background: Tear secretion and tear film stability seem to be influenced by pseudoexfoliation syndrome (PEX). Histopathological evaluation of conjunctival goblet cells in PEX patients might explain the influence on tear film stability., Methods: In a prospective, cross-sectional study, 40 eyes of 40 patients with PEX (study group) had measurement of Schirmer test with anesthesia and break-up time prior to cataract surgery. At the end of an uneventful operation, a 1 x 1.5 mm sample of conjunctival tissue was obtained and light and electron microscopy were performed. Results were compared with a control group. Histology evaluation was masked. Primary outcome measures included Schirmer test with anesthesia, break-up time, goblet cell density and morphological character of conjunctiva and conjunctival goblet cells., Results: Both Schirmer test and break-up time values were significantly lower (P= 0.01 and P= 0.001) in the PEX patients (mean 10.6 mm and 8.6 s respectively) than in the control group (13.4 mm and 12.3 s respectively). The number of goblet cells in patients with PEX compared with the control group showed no statistically significant difference (P= 0.66). Use of trichrome stain revealed significant differences in the staining properties of goblet cells between patients with PEX and controls. On electron microscopy, typical pseudoexfoliation filaments were found in the connective tissue of conjunctiva of PEX patients. Remarkable changes of mucin pockets in the study group were also noticed; they had extremely irregular distribution, various forms of size and appearance and even complete collapse., Conclusion: Pseudoexfoliation seems to alter basic features of goblet cell morphology, thus affecting tear film stability. Further studies are necessary to determine the exact mechanism.