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Jeffrey Ma,1,2 Chintan Pathak,1 Abhijit Ramaprasad,1 Surendra Basti1 1Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; 2Department of Ophthalmology, UC Davis Eye Center, University of California Davis, Sacramento, CA, USACorrespondence: Surendra BastiDepartment of Ophthalmology, Feinberg School of Medicine, Northwestern University, 645 North Michigan Avenue, Suite 440, Chicago, IL, 60611, USATel +1 312 908 8152Fax +1 312 503 8152Email sbasti@northwestern.eduPurpose: To assess the efficacy of IOLMaster 700 (IOLM) biometer swept-source optical coherence tomography (SS-OCT) in detecting macular pathology before cataract surgery and to compare IOLM SS-OCT characteristics of foveal pathology with a widely used spectral-domain OCT (SD-OCT) system.Patients and Methods: Retrospective analysis of 1156 consecutive eyes with IOLMaster 700 SS-OCT undergoing cataract surgery from January to June 2017 was performed. Approximately a third of these eyes (327 eyes) also had a SD-OCT scan performed previously. A single reviewer assessed each SS-OCT scan and identified them as “normal” or “abnormal.” SS-OCT sensitivity and specificity in identifying foveal pathology was assessed using findings on Spectralis SD-OCT scans as the gold standard.Results: Of 327 eyes with both IOLM SS-OCT and Spectralis SD-OCT scans, 121 eyes (37.0%) had abnormal SS-OCT scans. Of these 121 eyes, SD-OCT scans confirmed pathology in 104 eyes (86.0%). Of the remaining 206 eyes graded to have normal SS-OCT scans, 84 eyes (40.8%) had normal SD-OCT scans, and 122 eyes (59.2%) had pathologic findings on SD-OCT scans. For each pathologic condition, subtle but definitive differences existed in the appearance of the IOLM SS-OCT and SD-OCT images.Conclusion: Using a normal or abnormal Spectralis SD-OCT scan as confirmation of absence or presence of foveal pathology respectively, we found a high positive predictive value (86.0%) of an abnormal IOLM SS-OCT scan and a high specificity (83.2%) but low sensitivity (46.0%) and negative predictive value (40.8%) of a normal-appearing SS-OCT scan. These results suggest that an abnormal IOLM SS-OCT scan in an eye without known pathology is a strong indicator of an abnormal macula and should prompt further evaluation of the retina to identify pathology prior to cataract surgery. Importantly, IOLM SS-OCT scans do not detect all macular pathology and cannot be used as a screening test for identifying macular pathology.Keywords: optical biometry, macular OCT, cataract surgery preoperative testing

Introduction: During endothelial keratoplasty, anterior chamber gas is titrated to a desired fill, which is difficult to optimize by visualization alone. This study evaluates how an anterior chamber gas fill correlates with intraocular pressure (IOP) and iris-angle configuration as identified by optical coherence tomography (OCT)., Methods: Eleven cadaveric eyes were studied in three configurations: baseline, air-fill just spanning limbus-to-limbus ("full-fill"), and air-fill maximally filling the anterior chamber ("overfill"). At each configuration, IOP was measured by Tonopen and iris-angle was determined by analyzing OCT images., Results: No differences in IOP or irisangles were identified between baseline and full-fill configurations (p=0.113 and p=0.152, respectively). When compared to overfill configuration, differences in IOP and iris-angles were identified for baseline (p<0.001 and p=0.001, respectively) and full-fill configuration (p=0.001 and p=0.039, respectively)., Discussion: These findings highlight that en-face visualization of full-fill may not be indicative of IOP elevation. A significant difference in IOP and iris-angle exists between full-fill and overfill configurations. Intraoperative OCT can serve as a useful surrogate to identify the extent of fill., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Tseng, Thau, Berkowitz, Ramaprasad and Basti.)

Difpad-Onco (nursing screening of the frailty of elderly people, at home, with oncological disease) aims to facilitate and complement the identification of frailties in elderly cancer patients by private practice nurses in the patient's home. It consists of the G8 Oncodage, a Mini-Cog screening for cognitive impairment, a history of falls, and social frailty. It is aimed at all cancer patients aged 70 and over. Around 80% of patients assessed have a G8 score ≤ 14/17, indicating geriatric frailty, and over 60% have more than one frailty (social, dietary, cognitive, falls). The DIFPAD-Onco project represents an innovative experiment in care pathways for elderly cancer patients., (Copyright © 2024. Published by Elsevier Masson SAS.)

Background: Keratoconus in children is often more severe and rapidly progressive compared to adults. While Scheimpflug imaging (Pentacam) improves screening, there are no established pediatric guidelines. Due to challenges in diagnosis, we aimed to correlate clinical factors with abnormal imaging results to aid in the development of screening protocols., Methods: A single-center retrospective cohort analysis of patients 3-18 years screened for keratoconus with ophthalmic examination and initial Scheimpflug imaging between 2021 to 2023. Scheimpflug indices including final D, ART max, and calculated CAIRO 8, which is a corneal metric combining pachymetry, ART max, and elevation, were compared to published pediatric ranges for normal and keratoconus corneas., Results: Seventy-eight patients (11.8 ± 3.9 years) were screened with the majority referred due to high and/or progressive astigmatism (74 patients, 94%). Forty-nine patients (63%) were male and 48 (62%) self-reported Hispanic ethnicity. Average astigmatism was 4.9 ± 1.8 D and 86% had with-the-rule astigmatism. Fourteen patients (18%) had corneal findings on slit lamp. Average LogMAR CDVA was 0.243 ± 0.274 D. By Pentacam, 55 (70%) patients had ≥ 1 indeterminate or keratoconus value. Patients stratified as keratoconus by all parameters were older (15 vs. 11 years, p = 0.015-0.02), had worse visual acuity (p < 0.0001), and were more likely to have oblique astigmatism (0.0002-< 0.0001) and corneal abnormalities on examination (p < 0.00001) compared to eyes with normal or indeterminate indices., Conclusions: Older age, lower visual acuity, oblique astigmatism, and corneal findings were more commonly found in patients with abnormal screening Pentacam. Most patients clinically suspicious for keratoconus had ≥ 1 indeterminate/abnormal indices. Future studies will follow these patients to identify clinical risk factors for progression., (© 2024. The Author(s).)

Purpose: Social eating (SE) is a corner stone of daily living activities, quality of life (QoL), and aging well. In addition to feeding functional disorders, patients with head and neck cancer (HNC) face individual and social psychological distress. In this aging population, we intended to better assess the influence of age on these challenges, and the role of self-stigmatization limiting SE in patients with and beyond HNC., Methods: This was an exploratory multicenter cross-sectional mixed method study. Eligibility criteria were adults diagnosed with various non-metastatic HNC, before, during, or until 5 years after treatment. SE disorders were explored with the Performance Status Scale Public Eating rate (PSS-HN PE). In the quantitative part of the study, SE habits, Functional Assessment of Cancer Therapy Body Image Scale (FACT-MBIS) and specific to HNC (FACT-HN35) were also filled in by the patients. In the qualitative study, the semi-structured interview guide was drawn out to explore stigma, especially different dimensions of self-stigmatization., Results: A total of 112 patients were included, mean age 64.7 years, 23.2% of female. One-third (n = 35) of patients had an abnormal PSS-HN PE rate < 100. Younger patients had more often an impaired Normalcy of Diet mean (70.4 vs 82.7, p = .0498) and PE rates (76 vs 86.9, p = .0622), but there was no difference between age subgroups in MBIS nor FACT-HN scores. Seventy patients (72.2%) found SE and drinking « important» to « extremely important» in their daily life. The qualitative study reported self-stigmatization in two older patients and strategies they have developed to cope with in their behaviors of SE., Conclusion: This study confirms that SE remains of high concern in patients with and beyond HNC. Even in older patients experiencing less often functional feeding disorders, body image changes and SE issues are as impaired as in younger patients and need to be addressed., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The growing concern of aquatic heavy metal (HM) pollution is dependent on the toxic nature of its bio-available form. Thus, bio-availability is guided by the HM fractionation in water. This study was therefore conducted to evaluate the spatial impact on physicochemical fractionation of HM (Zn, Mn, Cu, and Fe) in the waters of the Hirakud reservoir in India. Speciation along different pores using a filtration technique was adopted to fractionate the HMs in water samples. The result suggests that the water of the study area is polluted with Cu (0.22-0.35 mg/L), Mn (0.15-0.23 mg/L), and Fe (1.90-3.10 mg/L) that have crossed their permissible limits while Zn (0.17-0.97 mg/L) was within the permissible standard. When studied for physical partitioning, the right dyke was comparatively more polluted than the left dyke. While the water samples were dominated by the dissolved fraction of heavy metals, it was construed that a large proportion of the HMs are in bio-available form. Further, a distinct impact of spatial variation on metal fractionation was also evident in the study with PCA revealing site-specific behaviour. Therefore, it can be concluded that multiple anthropogenic activities lead to the distribution and fractionation of HMs in water., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Mining activities lead to severe particulate matter (PM) pollution that consequently has a detrimental effect on ecosystem. A study was therefore conducted in a coal mining area of Odisha, India with an objective to assess the particulate matter pollution on the basis of differential aerodynamic size (PM 10 and PM 2.5 ) of the particles, the metallic (Zn and Fe) composition, and also to evaluate their nature of deposition on two identified plant species. The results suggest a significant variation in particle and heavy metal fractions in the ambient air of different sites ( p  < 0.05). Fe dominated the finer particle (PM 2.5 ) fraction while Zn dominated the coarser counterpart (PM 10 ) in the ambient air. When evaluated for the particle and heavy metal deposition on leaf surface, Shorea robusta performed better in trapping the coarser particles (PM 10 ) while Holarrhena floribunda was found to be an efficient scrubber of the finer particles (PM 2.5 ). Fe deposition on surface of leaves was comparatively higher than Zn irrespective of plant species or size fractions. Therefore, it is concluded that both S. robusta and H. floribunda should be planted in a schematic manner to tackle the particulate pollution in coal mining areas.

Cell-mediated immunity (CMI) is crucial in controlling the highly aggressive and progressive SARS-CoV-2 infection. Despite extensive researches on severe COVID-19 infection, the etiology and/or mechanisms of lymphopenia, decreased T cell-mediated responses in patients, cytokine release storms (CRS), and enhanced pro-inflammatory mediators are not fully understood. Several T cell subpopulations, including innate-like lymphocytes (ILLs) and conventional T cells, are involved in COVID-19 infection; however, their contribution to immunity and complications remains to be more elucidated. CD16+ T cells are among the effective players in the development of T helper1 (Th1) responses in COVID-19 infection, while their robust cytolytic properties contribute to lung tissue damage. While CD56-CD16bright NK cells play a protective role, natural killer T (NKT) cells, mucosal-associated invariant T (MAIT) cells, and γδ T cells and their roles in COVID-19 require further investigation. The involvement of the other T cell subsets, such as Th17, along with neutrophils, adds to the complexity of the situation. In this review, we presented and discussed the findings of recent studies on T cell responses and the contribution of each type of immune cells to COVID-19.

Purpose: There are currently limited treatment options for aniridia. In this context, 3D printed iris implants may provide a cost-effective, cosmetically acceptable alternative for patients with aniridia. The purpose of this study was to develop a proof-of-concept workflow for manufacturing 3D printed iris implants using a silicone ink palette that aesthetically matches iris shades, identified in slit lamp images., Methods: Slit lamp iris photos from 11 healthy volunteers (3 green; 4 blue; 4 brown) were processed using k-means binning analyses to identify two or three prominent colors each. Candidate silicone inks were created by precisely combining pigments. A crowdsourcing survey software was used to determine color matches between the silicone ink swatches and three prominent iris color swatches in 2 qualifying and 11 experimental workflows., Results: In total, 54 candidate silicone inks (20 brown; 16 green; 18 blue) were developed and analyzed. Survey answers from 29 individuals that had passed the qualifying workflow were invited to identify "best matches" between the prominent iris colors and the silicone inks. From this color-match data, brown, blue, and green prototype artificial irises were printed with the silicone ink that aesthetically matched the three prominent colors. The iris was printed using a simplified three-layer five-branch starburst design at scale (12.8 mm base disc, with 3.5 mm pupil)., Conclusions: This proof-of-concept workflow produced color-matched silicone prosthetic irises at scale from a panel of silicone inks using prominent iris colors extracted from slit lamp images. Future work will include printing a more intricate iris crypt design and testing for biocompatibility.

Plant response to changing air pollution is a function of various factors including meteorology, type of pollutants, plant species, soil chemistry, and geography. However, the impact of altitude on plant behavior has received little attention to date. A study was therefore conducted to evaluate the impact of altitude on the air pollution tolerance index (APTI), heavy metal accumulation, and deposition in plant species. The results favor the hypothesis of a definite impact of altitude on biochemical and heavy metal accumulation in plants. While a significant decline (p < 0.05) in the relative water content (RWC), APTI, and heavy metal accumulation with increasing altitude was evident in the studied plant species, the behavior of ascorbic acid, leaf extract pH, chlorophyll content, and the particle heavy metal deposition was erratic and did not display any statistically significant differences. The metal accumulation index was in the following order: Ni > Zn > Cu > Pb > Cd > Co. Similarly, the particle heavy metal deposition on the leaf surface (µg/cm 2 ) displayed significant species variability (p < 0.05) and was in the order: Cu (0.303) > Pb (0.301) > Ni (0.269) > Zn (0.241) > Cd (0.044) > Co (0.025). The accumulated heavy metal and RWC showcased a significant positive correlation with the APTI, suggesting the dominant role of RWC in the plant's tolerance against air pollution in an altitudinal gradient. Future studies on the role of micrometeorological conditions in altering APTI may be fruitful in ascertaining these postulations., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Alteration in land use and land cover is the key factor affecting the soil carbon fractions and its distribution. A study was carried out to estimate the carbon fractions in soils of agricultural, forest and pasture lands in two different areas separated on the basis of industrial activities (spoiled and unspoiled) to get an insight on the long-term soil carbon storage potential. The results showed that the mean values of the total organic carbon (TOC) and various fractions are significantly different between the land use types (p < 0.05). Irrespective of the land uses, the forest land showed significantly higher TOC (7.97) than agricultural land (6.98) and pasture lands (6.68). Further, evaluation of carbon management index (CMI) indicated that forest lands had highest CMI value compared to the other land uses. The spoiled area had significantly higher TOC and carbon fractions than their respective counterparts in the unspoiled area (p < 0.05) due to the negative industrial impact on soil biological processes. The PCA separates the sources of different carbon fractions and revealed an association of N (nitrogen) and K (potassium) with VL (very labile) and L (labile) fractions and the association of P (phosphorous) with stable R (recalcitrant) form. Therefore, it can be inferred from the present study that alterations in land use not only result in soil quality degradation but also trigger a reduction in potential for long term soil C sequestration., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Purpose: To determine how much axial length (AL) and average keratometry (K) change over time in elderly patients and to assess clinical necessity of repeating biometry in instances where the second eye is operated on 6 months or more after the first., Setting: Northwestern Memorial Hospital, Chicago, Illinois., Design: Retrospective study., Methods: Inclusion criteria were patients older than 35 years, with 2 biometry measurements over 6 months apart, measured with the IOL Master 700 from January 1, 2016, to September 15, 2020. Patients were excluded if they had any other intraocular surgery besides cataract. A linear mixed model and SPSS software was used to compare measurements among timepoints., Results: 201 patients (402 eyes) were included (average age 73.3, 59.3% female). Average time between biometry measurements was 21.5 months (range 6 to 48 months). The mean change in AL was 0.04 mm (95% CI, 0.03 to 0.05, P = .10). The mean change in K was 0.01 diopters (95% CI, -0.10 to 0.30, P = .33). At the 6-month to 1-year interval (n = 73), mean change in AL was 0.04 mm. Mean change in AL did not significantly increase with greater time intervals. There was no correlation between time and ΔAL ( P = .70), nor between time and ΔK ( P = .98)., Conclusions: In this cohort, biometric parameters did not change significantly over time. Repeating biometry at a 1- to 2-year interval for elderly patients receiving monofocal implants may offer limited benefit., (Copyright © 2023 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: To develop and test a novel index (Cooke-Riaz-Wendelstein [CRW1]) that uses swept-source optical coherence tomography (SS-OCT) biometry measurements (IOLMaster700, Zeiss Meditec), including total keratometry, to alert clinicians that previous myopic laser vision correction (M-LVC) was present in a measured eye., Design: Retrospective, multicenter, comparative diagnostic analysis., Methods: The study took place at 6 centers in the United States and Austria. Anonymized SS-OCT biometry datasets acquired between 2018 and 2020 and containing 49,199 eyes were analyzed. The LVC status, as identified by the biometrist, was used to segregate eyes into LVC and non-LVC eyes. Data were split into training (10,780 eyes) and validation (38,419 eyes) sets. Subset analysis was performed for CRW1 Index accuracy compared to posterior/anterior corneal curvature ratio (R post /R ant ), topography with corneal analysis software (Atlas 9000 with Pathfinder II, Zeiss Meditec), tomography (Pentacam, Oculus), dual Scheimpflug-Placido system (Galilei G6, Ziemer), and a cloud-based platform for cataract surgery planning (Veracity, Zeiss Meditec). A positive predictive value (PPV) of ≥90% was targeted for the CRW1 index. True positives, true negatives, sensitivity, and specificity were recorded., Results: The CRW1 Index compared favorably against R post /R ant showing a higher PPV (93% vs 65%), with fewer false-positive results (29 vs 180). CRW1 performed similarly to topography software and better than the corneal imaging devices. The CRW1 cutoff value can be adjusted to increase sensitivity (CRW1-IS) to detect additional M-LVC eyes., Conclusions: The CRW1 and CRW1-IS indices offer surgeons and researchers a readily accessible method to use only SS-OCT biometry measurements to detect eyes with a high probability of previous M-LVC., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: To demonstrate a novel approach to scleral fixation of posterior chamber intraocular lenses and capsular tension rings and segments in deep-set eyes using the Finesse FlexLoop (Alcon Laboratories)., Methods: The technique described herein, based on previous approaches to scleral fixation of posterior chamber intraocular lenses, uniquely employs the FlexLoop to "lasso" Gore-Tex sutures that have already been threaded through the eyelets of a CZ70BD (Alcon Laboratories) IOL and externalize them., Results: All patients who underwent surgery with this technique experienced visual improvement. The only complication was of mild hyphema in the patient who had a capsular tension segment placed, which resolved with medical therapy., Conclusion: The advantages of this procedure include a smaller diameter instrument (FlexLoop) as compared to the 25-gauge forceps typically employed, an easier to perform surgical maneuver that alleviates the need for both precise placement and constant tension to be exerted by the surgeon to grasp the sutures, as well as an instrument that can function when bent up to 45° to help accommodate deep-set eyes requiring this procedure.

Purpose: To present a pediatric case series in which the flanged intrascleral intraocular lens (IOL) fixation technique (Yamane technique) was used to correct aphakia., Methods: The surgical database of a single tertiary children's hospital was reviewed to identify all patients who underwent secondary IOL implantation by a single surgeon from May 2018 to January 2020. The medical records and operative reports of all patients operated on using the Yamane technique were reviewed retrospectively. Intra- and postoperative complications and pre- and postoperative vision and refraction were documented to assess outcomes., Results: A total of 12 eyes of 10 consecutive patients were included. Mean age at surgery was 10 ± 6 years. Indications for scleral fixation were ectopia lentis (secondary to Marfan syndrome [n = 3] or idiopathic [n = 1]), lens subluxation with intermittent pupillary block secondary to Weill- Marchesani syndrome (n = 2), early childhood lensectomy with insufficient residual capsular support (n = 5), and traumatic aphakia after an open globe (n = 1). Mean follow-up was 8 ± 5 months. No major intraoperative complications occurred. Postoperatively 1 patient required IOL repositioning 1 week after surgery. The location of one haptic was noted to be intrascleral but superficial in another patient, who did not require surgical intervention. The mean postoperative astigmatism was 2 ± 2 D. Good visual results were achieved in all eyes., Conclusions: With slight modifications, the Yamane technique can be adapted to the pediatric eye. This technique has significant surgical and anatomic advantages and provides stable IOL fixation. Visual outcomes and adverse events compare favorably with older techniques., (Copyright © 2020. Published by Elsevier Inc.)

Purpose: To describe the diagnosis and management of a patient with rupture of the posterior capsule (PC) following blunt trauma to the left eye., Observation: 68 year-old man presented with complaints of left eye pain, blurry vision and photophobia after getting hit in the left eye with a baseball. He was found to have a posterior capsule rupture, as well as mydriasis and zonular dialysis without formation of intumescent traumatic cataract. Femtosecond laser associated cataract surgery (FLACS) was performed to facilitate creation of an anterior capsulotomy and segmentation of the nucleus without additional strain on the posterior capsule, facilitating placement of a capsular tension ring segment and a 3-piece IOL in the sulcus. At three-month post-operative visit, his BCVA was 20/30 in the left eye with a well-centered IOL., Conclusions and Importance: Isolated PC tear following high-speed blunt trauma is relatively rare and prior reports have managed these cases using standard phacoemulsification and IOL insertion. Our case highlights the advantages of using FLACS in management of traumatic PC tears and outlines modifications to this technique for such cases., Competing Interests: The authors have no financial disclosures., (© 2020 Published by Elsevier Inc.)

Objective: Bullying and victimization are common and serious problems in schools resulting in development of emotional and behavioral disorders in adolescents. This study aimed at examining the prevalence of bullying behavior and some of its associated factors among students. Method : This was a cross sectional analytic study involving junior high schoolers in grades seven, eight and nine. This study was part of an international study that used a questionnaire as a tool for data collection. The questionnaire investigated some of the characteristics and qualities possessed by most juveniles and some occasional problems which they may experience. Also, it was used to examine participants' experiences with bullying and victimization. This questionnaire comprised of 15 sections on demographic characteristics, individual health, family status and types of bullying experiences at school and outside of school, along with the Strengths and Difficulties Questionnaire (SDQ), which is an instrument for screening emotional and behavioral problems in children and adolescents. A multistage cluster sampling from five regions, consisting of the north, south, west, east, and central regions of Tehran, was conducted and 1456 questionnaires were completed by the students. Results: According to the results of this study, prevalence rate for bullying and victimization was 17.4% and 25.8%, respectively. The results indicated that gender had a significant relationship with bullying and victimization, with boys being more likely to be bullies and also more prone to victimization than girls (p < 0.001). Other parameters such as emotional, behavioral, and environmental influence also had a significant relationship with bullying and victimization. Conclusion: Bullying is more prevalent in boys than in girls, and boys are more likely to be victimized as well. Emotional and behavioral problems are identified as risk factors, and future interventions should focus on these risk factors to develop preventive measures., (Copyright © Psychiatry & Psychology Research Center, Tehran University of Medical Sciences.)

Purpose: Descemet stripping endothelial keratoplasty (DSEK), currently the most common procedure for managing corneal endothelial dysfunction, may be repeated following DSEK failure from a variety of causes. This multicenter study reports the risk factors and outcomes of repeat DSEK., Methods: This was an institutional review board-approved multicenter retrospective chart review of patients who underwent repeat DSEK. Twelve surgeons from 5 Midwest academic centers and 3 private practice groups participated. The Eversight Eye Bank provided clinical indication and donor graft data. We also assessed the role of the learning curve by comparing cohorts from the first and second 5-year periods., Results: A total of 121 eyes from 121 patients who underwent repeat DSEK were identified. The average age of the patients was 70 ± 12 years. The most common indication for repeat DSEK was late endothelial graft failure without rejection (58%, N = 63). Average preoperative and 12-month postoperative repeat DSEK corrected distance visual acuities were 20/694 and 20/89, respectively. Visual acuity outcomes, endothelial cell density, and cell loss did not significantly vary between the 2 cohorts. Initial graft rebubble rates for the first and second cohorts were 51% and 25%. The presence of glaucoma, prior glaucoma surgery, or a history of penetrating (full thickness) keratoplasty did not significantly affect visual outcomes. The median, mean, and range of intraocular pressures before repeat DSEK were 15.0, 15.7, and 6 to 37 mm Hg, respectively. Patients with higher intraocular pressures before repeat DSEK had improved postoperative corrected distance visual acuities., Conclusions: Repeating DSEK improves vision following failed or decompensated DSEK surgery. Higher preoperative repeat DSEK IOPs were associated with improved visual outcomes, and initial graft rebubble rates, which decreased over time, were likely due to surgeon experience.

Purpose: To report a case of recurrent conjunctival myofibrosarcoma treated with wide surgical excision, cryotherapy, and triple sequential applications of episcleral brachytherapy., Methods: A single case of recurrent conjunctival myofibrosarcoma., Results: A 54-year-old man with a history of a renal transplant presented with a recurrent conjunctival tumor. Histopathologic diagnosis was established through immunohistochemistry. In total, 3 iodine radiation episcleral plaques were used over a period of 49 weeks. After cicatricial ectropion repair and cataract surgery, visual acuity was 20/20 at 4.5-year follow-up without evidence of recurrence or radiation retinopathy., Conclusions: Myofibrosarcoma is a rare mesenchymal tumor that can present as ocular surface tumor. Final histopathologic diagnosis can be challenging, and immunohistochemistry is important for evaluation. Myofibrosarcoma should be considered in the clinical differential diagnosis of atypical ocular surface lesions and the histopathologic differential diagnosis of ocular spindle neoplasms.

Purpose: To analyze the impact of learning curve on operating room (OR) times, femtosecond laser times, procedure time (time for laser and non-laser steps combined), and surgical time (procedure time minus transfer and preoperative times) during transition to femtosecond laser-assisted cataract surgery (FLACS) and comparison with conventional phacoemulsification., Methods: In this retrospective, comparative case series, patients undergoing FLACS by an experienced surgeon between November 2012 and June 2014 were reviewed using the Catalys Precision Laser system (Abbott Medical Optics, Santa Ana, CA). The cohort was divided into five sequential groups of roughly equally sized cohorts (n = 33 for groups 1 to 4, n = 34 for group 5) and temporal change in surgical times was compared. For controls, 50 consecutive patients who underwent phacoemulsification concurrently were reviewed., Results: There were 166 eyes evaluated that underwent FLACS. Femtosecond laser time shortened through the first three groups (group 1: 4.37 minutes vs group 3: 3.37 minutes, P < .05) but plateaued thereafter (group 4: 3:43 minutes, group 5: 3:35 minutes, P > .05). Total FLACS OR time reduced through sequential groups (group 1: 44 minutes vs group 5: 34 minutes, P < .001). Procedure time reduced from 33 (group 1) to 23 (group 5) minutes (P < .001). However, surgical and total OR time for group 5 (0:17 ± 0.02 and 0:34 ± 0:04 minutes, respectively) remained longer than phacoemulsification (0.14 ± 0:04 and 0:29 ± 0:05 minutes, respectively, both P < .05)., Conclusions: Despite significant reduction in OR times with increasing surgeon experience, FLACS required longer overall procedure times and surgical times compared to phacoemulsification, even when approaching 200 cases. Surgeons and institutions should budget for increased surgical times and associated costs when transitioning to FLACS. [J Refract Surg. 2016;32(5):311-317.]., (Copyright 2016, SLACK Incorporated.)

Femtosecond laser-assisted cataract surgery (FLACS) putatively offers several advantages over conventional phacoemulsification. We review the current status of FLACS and discuss the evolution of femtosecond lasers in cataract surgery and the currently available femtosecond laser platforms. We summarize the outcomes of FLACS for corneal wound creation, limbal relaxing incisions, capsulotomy, and lens fragmentation. We discuss surgical planning, preoperative considerations, clinical experiences including the learning curve and postoperative outcomes with FLACS, and also the cost effectiveness of FLACS. We present the intraoperative complications and management of challenging cases where FLACS offers an advantage and also speculate on the future directions with FLACS. Further advancements in laser technology to refine its efficacy, advancement in intraocular lens design to harness the potential benefits of FLACS, and a reduction in cost are needed to establish a clear superiority over conventional phacoemulsification., (Copyright © 2016 Elsevier Inc. All rights reserved.)

We report 2 cases involving femtosecond laser-assisted cataract surgery following a retinal-detachment repair performed 1 and 2 years earlier using silicone oil endotamponade that was subsequently removed. Preoperative slitlamp examination did not show emulsified silicone oil in the anterior chamber. Intraoperatively, however, emulsified silicone oil was seen on anterior segment optical coherence tomography (AS-OCT) as a distinct hyperreflective retrocorneal line and there was no penetration of the OCT signal or delivery of the femtosecond laser treatment through this area, resulting in incomplete capsulotomy and lens fragmentation in both cases. Because silicone oil has a lower density than aqueous and migrates superiorly, careful preoperative gonioscopic examination to evaluate for emulsified silicone oil in the superior angle is warranted in eyes having femtosecond laser-assisted cataract surgery after a vitrectomy with silicone-oil endotamponade. Review of intraoperative OCT images can detect emulsified silicone oil, which would allow the procedure to be modified appropriately to prevent complications., (Copyright © 2014 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Unlabelled: We report a patient with phacomorphic angle closure having femtosecond laser-assisted cataract surgery. A staged procedure was followed to achieve mydriasis and deepen the anterior chamber with bisulfate-free epinephrine (epi-Shugarcaine) and an ophthalmic viscosurgical device (OVD) prior to the femtosecond procedure. After the femtosecond laser was docked, the patient complained of discomfort in her eye and intraoperative optical coherence tomography imaging revealed a reverse pupillary block configuration. Software modifications were required to complete the procedure, following which partial OVD removal and anterior tenting of the pupil margin relieved the reverse pupillary block. In the fellow eye, intracameral bisulfate-free epinephrine alone was injected above and below the iris plane for intraoperative mydriasis and to deepen the anterior chamber, which prevented a reverse pupillary block., Financial Disclosure: Neither 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 describe the clinical features and management strategies in patients whose limbal stem cell (LSC) disease reversed with medical therapy., Design: Retrospective case series., Participants: Twenty-two eyes of 15 patients seen at 3 tertiary referral centers between 2007 and 2011 with 3 months or more of follow-up., Methods: Medical records of patients with medically reversible LSC disease were reviewed. Demographic data, causes, location and duration of disease, and medical inventions were analyzed., Main Outcome Measures: Primary outcomes assessed included resolution of signs of LSC disease and improvement in visual acuity., Results: Causes of the LSC disease included contact lens wear only (13 eyes), contact lens wear in the setting of ocular rosacea (3 eyes), benzalkonium chloride toxicity (2 eyes), and idiopathic (4 eyes). Ophthalmologic findings included loss of limbal architecture, a whorl-like epitheliopathy, or an opaque epithelium arising from the limbus with late fluorescein staining. The superior limbus was the most common site of involvement (95%). The corneal epithelial phenotype returned to normal with only conservative measures, including lubrication and discontinuing contact lens wear in 4 patients (4 eyes), whereas in 11 patients (18 eyes), additional interventions were required after at least 3 months of conservative therapy. Medical interventions included topical corticosteroids, topical cyclosporine, topical vitamin A, oral doxycycline, punctal occlusion, or a combination thereof. All eyes achieved a stable ocular surface over a mean follow-up of 15 months (range, 4-60 months). Visual acuity improved from a mean of 20/42 to 20/26 (P < 0.0184)., Conclusions: Disturbances to the LSC function, niche, or both may be reversible with medical therapy. These cases, which represent a subset of patients with LSC deficiency, may be considered to have LSC niche dysfunction., (Copyright © 2014 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe a surgical technique and intraoperative modifications to create a secondary capsulotomy using the femtosecond cataract laser in an eye with traumatic aphakia and aniridia., Methods: The expanded use of the femtosecond cataract laser (Catalys Precision Laser System; Optimedica, Sunnyvale, CA) for creation of a well-centered and circular secondary capsulotomy in the capsular remnants of an eye with traumatic aphakia and aniridia., Results: Using software modifications based on intraoperative anterior segment spectral-domain optical coherence tomography imaging, and customizing the capsulotomy settings, the femtosecond cataract laser was able to penetrate through most of the fused anterior and posterior capsular leaflets and a circular capsulotomy was achieved. The latter permitted optic capture and excellent centration of a three-piece intraocular lens placed in the sulcus with good postoperative visual rehabilitation., Conclusion: The femtosecond cataract laser can be customized to create a well-centered and circular secondary capsulotomy in aniridic and aphakic eyes where optic capture is critical for long-term intraocular lens stability., (Copyright 2014, SLACK Incorporated.)

Purpose: To compare the morphology of clear corneal incisions (CCIs) created with a femtosecond laser (Catalys) or a keratome (2.65 mm steel) during phacoemulsification using anterior segment optical coherence tomography (AS-OCT) and analyze the intended versus the achieved morphologic characteristics of femtosecond laser-generated CCIs., Setting: Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA., Design: Comparative case series., Methods: Eyes with femtosecond CCIs and age-matched eyes with the keratome CCIs underwent AS-OCT of the incisions 1 month after phacoemulsification. ImageJ software was used to evaluate AS-OCT images for CCI length, endothelial gaping, endothelial misalignment, and Descemet membrane detachment., Results: In the femtosecond group (20 eyes) and keratome group (16 eyes), the mean values were CCI length, 1.99 mm±0.07 (SEM) versus 2.04±0.23 mm (P=.39); endothelial gaping, 0.14±0.03 mm versus 0.19±0.09 mm (P=.03); endothelial misalignment, 0.04±0.03 mm versus 0.08±0.06 mm (P=.022). No eye in the femtosecond group and 3 eyes in the keratome group had a Descemet membrane detachment (P=.04). Six femtosecond eyes and 11 keratome eyes had posterior wound retraction (P=.02). The mean CCI length was 94.9% of the intended 2.1 mm, the posterior plane depth was 93.3% of the intended 70%, and the posterior side-cut angle was 91.7% of the intended 45 degrees., Conclusion: Femtosecond laser-generated CCIs had significantly lower endothelial gaping, endothelial misalignment, Descemet membrane detachment, and posterior wound retraction than keratome-created CCIs and were within 10% of the intended length, depth, and angle measurements., Financial Disclosure: Neither 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.)

Unlabelled: We report the occurrence and management of intraoperative vertical gas breakthrough during clear corneal incision creation with the femtosecond laser (Catalys) in 2 patients. Both eyes were managed by creation of a keratome incision, and the surgery was completed uneventfully. There were no postoperative complications. We believe that wound architecture and corneal clarity in the area of wound creation predispose to the occurrence of vertical gas breakthrough. Careful inspection of wound integrity can provide clues to an incomplete wound., Financial Disclosure: Neither 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 report the first case series of patients with Fuchs corneal endothelial dystrophy (FCD) and keratoconus (KCN) who underwent Descemet stripping endothelial keratoplasty (DSEK)., Methods: This is a retrospective case series of 6 eyes of 4 patients with combined FCD and KCN who underwent DSEK at 3 different centers. Clinical information collected included corneal topography measurements, central corneal thickness, and endothelial cell count. Visual outcomes and change in keratometric measurements were evaluated., Results: The follow-up for patients ranged from 10 to 72 months. The best-corrected visual acuity was 20/40 or better in all 6 eyes. The mean keratometric measurements decreased in all cases (range of 0.5-5.8 diopters); however, topography still demonstrated an inferior steepening in each case., Conclusions: Patients with FCD and KCN have been previously reported as being managed with penetrating keratoplasty. We present 6 eyes of 4 patients who were managed with DSEK for the FCD. Topographically, the characteristic inferior steepening of KCN did not change; however, all patients with DSEK had flatter postoperative keratometric measurements with improved visual acuity. If a DSEK is performed for FCD before apical corneal scarring from KCN, a good visual outcome may be achieved.

Purpose: The aim was to determine which of 2 commonly used nonfold donor insertion techniques was advantageous for initial Descemet stripping automated endothelial keratoplasty (DSAEK) cases., Methods: This involved an ex vivo, prospective comparative case series of 20 randomized DSAEK lenticule insertions. DSAEK insertions were performed by a single novice corneal surgeon (PGY4 resident) in human cadaver eyes. Ten grafts were inserted using a Sheet glide (Surgical Glide; Beaver-Visitec International Inc, Waltham, MA) and 10 were inserted using an inserter device (EndoSerter; Ocular Systems Inc, Winston-Salem, NC). The grafts were explanted, stained with trypan blue and alizarin red S, and photographed for comparison with 5 control grafts. Endothelial damage was quantitatively evaluated using Adobe Photoshop 10.0 CS3 software (Adobe Systems, San Jose, CA)., Results: Endothelial cell loss (ECL) was 7.10% ± 2.27% in controls, 12.31% ± 4.74% in the inserter group, and 13.31% ± 5.46% in the Sheet glide group (P = 0.07). Early cases (cases 1-5) had a greater ECL compared with what later cases had (cases 6-10) for the Sheet glide group. This difference was significant for the Sheet glide group (40.42% reduction for cases 6-10, P = 0.04) but not for the EndoSerter group (32.5% reduction for cases 6-10, P = 0.11)., Conclusions: Quantitative analysis revealed no statistically significant difference in the ECL between the 2 methods. With surgeon experience, there was a trend toward less ECL using both methods but especially with the Sheet glide. A novice corneal surgeon may effectively use either of these nonfold methods for initial cases. The cadaver eye model described may be a potentially useful wet-laboratory tool for novice surgeons to practice DSAEK lenticule insertion.

Purpose: To describe the clinical stages and management of Achromobacter xylosoxidans keratitis with post-LASIK epithelial ingrowth in two patients., Methods: Retrospective chart review., Results: Both patients had been treated with topical antibiotics and corticosteroids for several weeks prior to presentation. Examination at presentation revealed significant areas of epithelial ingrowth without signs of acute inflammation, prompting an erroneous initial diagnosis of recurrent corneal erosion. A corneal infiltrate was eventually observed and A. xylosoxidans was cultured from both patients. Clinical resolution occurred with treatment consisting of topical fortified antibiotics. In one patient, the flap was lifted to obtain cultures and irrigate the stromal bed with fortified antibiotics., Conclusions: Post-LASIK epithelial ingrowth may have served as a risk factor for A. xylosoxidans infection. Classic signs of infectious keratitis were absent, delaying the diagnosis. Three clinical stages described herein may assist the clinician with diagnosis and customized management obviating the need for penetrating keratoplasty., (Copyright 2013, SLACK Incorporated.)

Purpose: Epidermal growth factor receptor (EGFR) inhibitors and kinases are commonly used in the treatment regimen of various solid tumors including non-small cell lung, colorectal, head and neck, breast, and pancreatic cancers. The aim of this study is to describe common ocular adverse effects associated with EGFR inhibitor treatment, outline successful management options, and provide data on intermediate-term follow-up of these patients., Methods: A retrospective chart review was performed of all patients presenting to the ophthalmology clinic with an adverse ocular effect while on an EGFR inhibitor. Duration of EGFR inhibitor treatment, symptoms, diagnosis, and treatment information were collected. Statistical analyses were done to ascertain differences in adverse effects based on duration and type of EGFR inhibitor treatment using the Fisher exact test., Results: The two most common EGFR inhibitors in this group of patients were erlotinib and cetuximab. The most common adverse ocular effects for patients on EGFR inhibitors were dysfunctional tear syndrome (DTS), followed by blepharitis and eyelash changes (trichomegaly and trichiasis). Two patients had epithelial defects (corneal abrasions). There was no significant difference in adverse effects based on specific EGFR inhibitor medication or duration of treatment. Almost all patients were successfully managed with treatment regimens that we have outlined in this paper. Intermediate-term follow-up (range 6-17 months) showed a persistence of DTS and eyelash changes., Conclusion: We present what is, to our knowledge, the largest reported cohort of patients with ocular toxicities from EGFR inhibitors--the spectrum of eye toxicities, their management, and the intermediate-term follow-up of patients with eye toxicities. Awareness of this information is important for oncologists and oncology nurses to facilitate proper counseling and management/referral of patients developing eye toxicity while on EGFR inhibitors.

Purpose: To better characterize stromal rejection in the context of deep anterior lamellar keratoplasty (DALK) to improve early diagnosis and proper management., Methods: The clinical records of 22 patients undergoing DALK by 2 surgeons between October 2006 and January 2008 were reviewed to identify patients who experienced stromal rejection. The diagnosis was made after the demonstration of acute stromal edema and/or stromal neovascularization in the absence of confounding preoperative conditions, such as herpetic keratitis. The incidence and clinical features of stromal rejection were compared with other descriptions found in the literature., Results: Five of 20 eligible patients experienced stromal rejection within 12 months. Two patients were on low-dose corticosteroids when diagnosed. Four of the 5 patients were treated aggressively with q1-3 hourly prednisolone acetate 1% eye drops. The fifth was treated less aggressively with a maximum dose of only q6 hourly prednisolone acetate 1% and subsequently experienced a second rejection episode less than 5 months later. All episodes resolved completely with treatment., Conclusions: The incidence of stromal rejection in DALK is clinically significant, suggesting that these patients may benefit from corticosteroid regimens similar to those used in penetrating keratoplasty and implies that stromal rejection may be more common in penetrating keratoplasty than previously reported. If misdiagnosed or left untreated, stromal rejection can compromise graft clarity but prompt recognition and aggressive treatment can result in good anatomic and visual outcomes.

Unlabelled: We describe modifications to previously described techniques for evacuation of Soemmerring ring during secondary intraocular lens (IOL) implantation in aphakic eyes following previous pediatric cataract surgery. A new anterior capsulotomy is initiated using a cystotome to incise the anterior capsule close to its attachment to the posterior capsule. A curved microscissor is used to cut circumferentially, completing the capsulotomy, and a dispersive ophthalmic viscoelastic device (OVD) is used to viscoexpress Soemmerring ring material from the capsular bag. A 2-handed maneuver is used to manually divide the Soemmerring ring. Finally, slow-motion phacoemulsification is used to emulsify and remove the pieces. Viscoexpression of fragments of Soemmerring ring is done if there is a posterior capsulotomy. The residual capsular bag is filled with OVD and a foldable 3-piece IOL injected into the bag and dialed in. This technique allows complete evacuation of Soemmerring ring and placement of a secondary IOL in the capsular bag., Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: Protein kinase C (PKC) α plays a major role in the parasympathetic neural stimulation of lacrimal gland (LG) secretion. It also has been reported to have antiapoptotic properties and to promote cell survival. Therefore, the hypothesis for the present study was that PKCα knockout ((-/-)) mice have impaired ocular surface-lacrimal gland signaling, rendering them susceptible to desiccating stress and impaired corneal epithelial wound healing. In this study, the lacrimal function unit (LFU) and the stressed wound-healing response were examined in PKCα(-/-) mice., Methods: In PKCα(+/+) control mice and PKCα(-/-) mice, tear production, osmolarity, and clearance rate were evaluated before and after experimental desiccating stress. Histology and immunofluorescent staining of PKC and epidermal growth factor were performed in tissues of the LFU. Cornified envelope (CE) precursor protein expression and cell proliferation were evaluated. The time course of healing and degree of neutrophil infiltration was evaluated after corneal epithelial wounding., Results: Compared with the PKCα(+/+) mice, the PKCα(-/-) mice were noted to have significantly increased lacrimal gland weight, with enlarged, carbohydrate-rich, PAS-positive acinar cells; increased corneal epithelia permeability, with reduced CE expression; and larger conjunctival epithelial goblet cells. The PKCα(-/-) mice showed more rapid corneal epithelial healing, with less neutrophil infiltration and fewer proliferating cells than did the PKCα(+/+) mice., Conclusions: The PKCα(-/-) mice showed lower tear production, which appeared to be caused by impaired secretion by the LG and conjunctival goblet cells. Despite their altered tear dynamics, the PKCα(-/-) mice demonstrated more rapid corneal epithelial wound healing, perhaps due to decreased neutrophil infiltration.

This NCCN Task Force Report describes the management of dermatologic and ocular toxicities that occur in patients treated with epidermal growth factor receptor (EGFR) inhibitors. Task force members are from NCCN member institutions and include oncologists, dermatologists, an ophthalmologist, and a mid-level oncology provider. This report describes commonly used therapies that the task force agreed are appropriate standards of care for dermatologic and ophthalmologic toxicities associated with EGFR inhibitors, which generally are supported only by anecdotal evidence. Few recommendations are evidence based; however, some commonly used therapies have data supporting their use. Conclusions from completed clinical trials are generally limited by the small numbers of patients enrolled. The information in this report is based on available published data on treating toxicities associated with EGFR inhibitors, data from treatment of clinically similar toxicities from different etiologies, and expert opinion among the NCCN Task Force members.

Corneal opacification due to limbal stem cell deficiency (LSCD) is an important cause for ocular morbidity, resulting from a number of intrinsic and extrinsic factors. While the extrinsic factors include conditions such as chemical or thermal injuries, intrinsic include dysfunction, or reduction in the number of stem cells either due to pathological changes in autoimmune diseases or secondary to certain clinical conditions such as diabetes, dry eye disorders, or multiple previous eye surgeries. LSCD is characterized by a classic triad of signs -- conjunctivalization, neovascularization and decrease in vision. With the increasing knowledge of limbal stem cells, the treatment of this condition has evolved from simple debridement to use of biological materials, direct transplantation of the healthy limbal tissue from the contralateral eye, or allogenic source to the use of cultivated limbal epithelial sheets. This chapter provides an update on the disease pathology, various treatment methodologies, with specific emphasis on the fast developing field of cell therapy and tissue engineering.