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David Callanan,1 Rahul N Khurana,2 Raj K Maturi,3,4 Sunil Patel,5 Charles C Wykoff,6 David Eichenbaum,7,8 Arshad M Khanani,9,10 Tarek Hassan,11 Hanh Badger,12 Shraddha Mehta,12 Grace Le,12 Mayssa Attar,13 Jennifer Seal,13 Xiao-Yan Li12,14 1Texas Retina Associates, Arlington, TX, USA; 2Northern California Retina Vitreous Associates, Mountain View, CA, USA; 3Midwest Eye Institute, Indianapolis, IN, USA; 4Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, USA; 5West Texas Retina, Abilene, TX, USA; 6Retina Consultants of Houston, Retina Consultants of America, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA; 7Retina Vitreous Associates of Florida, St. Petersburg, FL, USA; 8Morsani College of Medicine, University of South Florida, Tampa, FL, USA; 9Sierra Eye Associates, Reno, NV, USA; 10University of Nevada, Reno School of Medicine, Reno, NV, USA; 11Associated Retinal Consultants, Royal Oak, MI, USA; 12Allergan plc, Irvine, CA, USA, at the time of this work; 13Allergan, an AbbVie company, Irvine, CA, USA; 14VivaVision Biotech, Inc, Shanghai, People’s Republic of ChinaCorrespondence: David Callanan, Texas Retina Associates, 801 West Randol Mill Road, Suite 101, Arlington, TX, USA, 76012, Tel +1 817-261-9625, Fax +1 817-261-9586, Email dcallanan@gmail.comPurpose: To evaluate the impact of modifying the abicipar pegol (abicipar) manufacturing process on the safety and treatment effect of abicipar in patients with neovascular age-related macular degeneration (nAMD).Methods: A new process for manufacturing abicipar was developed to reduce host cell impurities. In a prospective, Phase 2, multicenter, open-label, 28-week clinical trial, patients (n=123) with active nAMD received intravitreal injections of abicipar 2 mg at baseline (day 1) and weeks 4, 8, 16, and 24. Outcome measures included proportion of patients with stable vision (< 15-letter loss from baseline; primary endpoint), change from baseline in best-corrected visual acuity (BCVA) and central retinal thickness (CRT), and adverse events.Results: Overall, 8.9% (11/123) of patients experienced intraocular inflammation (IOI) and discontinued treatment. IOI cases were assessed as mild (2.4% [3/123]), moderate (4.9% [6/123]), or severe (1.6% [2/123]) and resolved with steroid treatment. Visual acuity in most patients with IOI (8 of 11) recovered to baseline BCVA or better by study end. No cases of endophthalmitis or retinal vasculitis were reported. Stable vision was maintained for ≥ 95.9% (≥ 118/123) of patients at all study visits. At week 28, treatment-naïve patients showed a greater mean improvement from baseline in BCVA compared with previously treated patients (4.4 vs 1.8 letters) and a larger mean CRT reduction from baseline (98.5 vs 45.5 μm).Conclusion: Abicipar produced using a modified manufacturing process showed a moderately lower incidence and severity of IOI compared with Phase 3 abicipar studies. Beneficial effects of treatment were demonstrated.Keywords: abicipar, age-related macular degeneration, inflammation

Jun Zhang, Li Zheng, Chenyao Zheng, Peihong Sun Department of Ophthalmology, Hangzhou MSK Eye Hospital, Hangzhou, People’s Republic of ChinaCorrespondence: Jun Zhang, Email zhangjun@mskyk.onaliyun.comPurpose: This study was designed to compare the clinical outcomes of three cylindrical treatment strategies using manifest, topographic, and Zhang & Zheng vector-compensated refraction (ZZ VR) cylinders, for topography-guided laser-assisted in situ keratomileusis (LASIK) and to identify the laser programming strategy that optimizes refractive astigmatism outcomes and visual acuity.Methods: Consecutive patients referred for therapeutic refractive surgery between March and September 2018 at a single center were prospectively analyzed. Using double-masked simple randomization, patients were randomly assigned to undergo treatment based on manifest cylinder, topographic cylinder, and ZZ VR cylinder strategies. Uncorrected distance visual acuity and astigmatic refraction were analyzed preoperatively and 6 months postoperatively.Results: A total of 138 eyes from 71 patients met the inclusion criteria. The manifest group consisted of 46 eyes in 24 patients, the topographic group consisted of 43 eyes in 22 patients, and the ZZ VR group consisted of 49 eyes in 25 patients. The absolute residual cylindrical refractions at 6 months postoperatively in these three groups were 0.69 ± 0.32 D, 0.58 ± 0.31 D, and 0.42 ± 0.19 D, respectively (P < 0.001; adjusted P < 0.01 for manifest vs ZZ VR, adjusted P = 0.08 for topographic vs ZZ VR). The percentages of postoperative absolute residual cylindrical power within 0.50 D in the manifest, topographic, and ZZ VR groups were 30.4%, 55.8%, and 59.2%, respectively (P = 0.01; adjusted P = 0.06 for manifest vs topographic, adjusted P = 0.02 for manifest vs ZZ VR).Conclusion: The ZZ VR strategy may achieve better outcomes, as determined by cylindrical correction and visual activity, during topography-guided LASIK.Clinical Trial Registration Number: ChiCTR1900025779.Keywords: astigmatism, corneal wavefront aberration, keratomileusis, laser in situ, refraction

Laura Hoffmann,1,2,&ast; Susanne Müller,1,3,&ast; Lucas M Bachmann,4,5 Daniela Claessens,6 Katja Hatz1,7 1Medical Retina & Research Department, Vista Eye Clinic Binningen, Binningen, Switzerland; 2Department of Ophthalmology, University Hospital Charité - Campus Benjamin Franklin, Berlin, Germany; 3Department for Health Sciences, Donau University Krems, Krems, Austria; 4Oculocare Medical, Medignition AG, Zurich, Switzerland; 5Faculty of Medicine, University of Zurich, Zurich, Switzerland; 6Gemeinschaftspraxis Augenheilkunde Lindenthal, Cologne, Germany; 7Faculty of Medicine, University of Basel, Basel, Switzerland&ast;These authors contributed equally to this workCorrespondence: Katja Hatz, Vista Augenklinik, Hauptstrasse 55, Binningen, 4102, Switzerland, Tel +41 61 426 60 79, Fax +41 61 426 60 01, Email katja.hatz@unibas.ch; katja.hatz@vista.chPurpose: To assess the ability of two self-monitoring digital devices to detect metamorphopsia in myopic choroidal neovascularization (mCNV) and compare their usability.Patients and Methods: This was a 12-month prospective observational study at a tertiary care eye hospital, Switzerland. Twenty-three Caucasian patients with mCNV were recruited, 21 eyes were analyzed. Primary and secondary outcome measures: Primary outcome measures were the metamorphopsia index scores as assessed by the two self-monitoring digital devices (Alleye App and AMD – A-Metamorphopsia-Detector software) at baseline, at 6 and 12 months and individual optional visits in between. Secondary outcome measures included best corrected visual acuity and morphological parameters (including disease activity) as evaluated by spectral-domain optical coherence tomography and fundus autofluorescence imaging. Location of mCNV was graded using the Early Treatment of Diabetic Retinopathy Study grid overlay. A usability questionnaire was administered at 12 months. Bland-Altman plots evaluated the limits of agreement of both devices. Linear regression analysis assessed the correlation between the difference and the average of the two scores.Results: A total of 202 tests were performed. Disease activity of mCNV was observed at least once in 14 eyes. Both scores concordantly detected metamorphopsia exhibiting a displaced scale of measurement yielding a coefficient of determination of 0.99. Concordance rate for pathological scores was 73.3%. Both scores were not significantly different in active and inactive mCNV. Overall, the usability scores were higher for the Alleye App than the AMD – A-Metamorphopsia-Detector software (4.61± 0.56 vs 3.31± 1.20; p< 0.001). In subjects aged > 75 years, scores were slightly lower (4.08± 0.86 vs 2.97± 1.16; p= 0.032).Conclusion: Whilst both self-monitoring devices concordantly identified metamorphopsia, they might act as an adjunct to hospital visits, but due to slight reactivations in mCNV and presence of metamorphopsia also in inactive disease the ability of detecting early mCNV activity might be limited.Keywords: myopic CNV, metamorphopsia, disease activity, self-monitoring, optical coherence tomography

Birhanu Belete Aragaw,1 Haile Woretaw Alemu,2 Aragaw Kegne Assaye,2 Yared Ayelign Belete,1 Henok Biruk Alemayehu1 1Department of Ophthalmology and Optometry, School of Medicine, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia; 2Department of Optometry, School of Medicine, College of Medicine and Health Sciences University of Gondar, Gondar, EthiopiaCorrespondence: Birhanu Belete Aragaw, Tel +251923701934, Email birhanubelete2009@hu.edu.etIntroduction: Acquired immune deficiency syndrome is a disease with common clinical ocular manifestations. Ocular manifestations lead to blindness, which has a common social and economic impact.Purpose: This study aimed to assess the prevalence and associated factors of ocular manifestations of acquired immune deficiency syndrome among adults at the University of Gondar Hospital, North West Ethiopia, 2021.Patients and Methods: A cross-sectional study was conducted on 401 patients from June to August 2021. Samples were selected based on a systematic random sampling technique. Data collection was done using structured questionnaires. Data extraction format was used to collect the clinical characteristics of patients including ocular manifestations. Data entry was done by EpiData version 4.6.0.6 and exported to the Statistical Package for the Social Sciences version 26 for data analysis. Associated factors were analyzed by binary logistic regression. P-value < 0.05 with a 95% confidence level was used to declare a significant association.Results: A total of 401 patients were involved with a response rate of 91.5%. The overall prevalence of ocular manifestations of acquired immune deficiency syndrome was 28.9%. The common ocular manifestations were seborrheic blepharitis at 16.4% and squamoid conjunctival growth at 4.5%. Age > 35 years (AOR=2.52, 95% CI: 1.19, 5.35), Clusters of differentiation 4 count < 200 cells/μL (AOR=4.76, 95% CI:2.50, 9.09), World Health Organization stage II (AOR=2.60, 95% CI: 1.23, 5.50), history of eye disease (AOR=3.05, 95% CI: 1.38, 6.72), and duration of Human Immunodeficiency Virus > 5 years (AOR=2.79, 95% CI: 1.29, 6.05) were statistically associated with the ocular manifestation of acquired immune deficiency syndrome.Conclusion and recommendations: In this study, the prevalence of ocular manifestation of acquired immune deficiency syndrome was high. Age, CD4 count, duration of HIV, eye disease history, and WHO clinical staging were the significant factors. Early eye checkups and regular ocular examinations of HIV patients would be helpful.Keywords: ocular manifestation, HIV/AIDS, Gondar, Ethiopia

Victor H Gonzalez,1 David L Wirta,2 Martin Uram,3 Audrey Schupp,4 Michelle Widmann,5 Gary D Novack6,7 1Valley Research Institute, McAllen, TX, USA; 2Eye Research Foundation, Newport Beach, CA, USA; 3American Genomics, LLC, Hobe Sound, FL, USA; 4CMC Turnkey Solutions, Bailey, CO, USA; 5Cal Clinical Solutions, Apex, NC, USA; 6PharmaLogic Development, Inc., San Rafael, CA, USA; 7Department of Ophthalmology & Vision Science, University of California, Davis, School of Medicine, Sacramento, CA, USACorrespondence: Gary D Novack, PharmaLogic Development, Inc., 17 Bridgegate Drive, San Rafael, CA, 94903, USA, Tel +1 415 472-2181, Email gary_novack@pharmalogic.comBackground: We wanted to develop a new topical ocular anesthetic with good bioavailability in anterior segment tissues. Given concerns about contamination and sterility in multi-dose products, we selected a unit-dose, nonpreserved presentation of AG-920 (articaine ophthalmic solution) in blow-fill-seal containers (similar to currently marketed pharmacological therapies for dry eye disease).Methods: Consistent with US Food and Drug Administration guidance, two pivotal, Phase 3, randomized, placebo-controlled, double-masked, parallel design studies conducted at two US private practices in 240 healthy subjects. A single dose of AG-920 or identical looking placebo into one (study) eye (2 drops 30 s apart). Subjects underwent a conjunctival pinch procedure and assessment of the pain associated with the pinch. The main outcome measure was the proportion of subjects with rating of “No pain at 5 minutes”.Results: AG-920 provided a rapid onset of local anesthesia (less than one minute) with clinically and statistically significantly greater effect in AG-920 (68% and 83%) than placebo (3% and 18% for Study 1 and Study 2, respectively, P< 0.0001). The most frequent adverse event was instillation site pain (27% vs 3%) followed by conjunctival hyperemia (probably related to the pinch, 9% vs 10%) in the AG-920 and placebo groups, respectively.Conclusion: AG-920 was found to be have a rapid onset and useful duration of local anesthesia with no major safety issues, and may be useful for the eye-care professional. Registered with clinicaltrials.gov as NCT04513652 and NCT04829344.Keywords: local anesthesia, articaine, controlled trial

Ala Paduca,1 Per O Lundmark,2 J Richard Bruenech2 1Ophthalmology Department, State University of Medicine and Pharmacy Nicolae Testemitanu, Chisinau, Republic of Moldova; 2Department of Optometry, Radiography and Lighting Design, Faculty of Health and Social Sciences, University of South-Eastern Norway, Kongsberg, NorwayCorrespondence: Ala Paduca, PhD Ophthalmology Department, State University of Medicine and Pharmacy Nicolae Testemitanu, bd Stefan cel Mare si Sfant 165, Chisinau, Republic of Moldova, Email ala.paduca@usmf.mdPurpose: It has been promoted that disturbance of ocular proprioception may play a role in the pathogenesis of concomitant strabismus and other types of oculomotor anomalies. The aim of the study was to obtain knowledge about how surgical foreshortening of the myotendinous region potentially affects the proprioceptors that resides in this area of the muscles and to test the hypothesis that avoiding disruption of ocular proprioceptors result in a more favorable long term postoperative result.Patients and Methods: The distal end of the lateral and medial rectus muscles from patients with manifest concomitant strabismus with a deviation of ≥ 15 prism diopters (PD) were collected during strabismus surgery and processed for light microscopy by standard histochemical techniques. Histological analysis served to differentiate between the tissue samples containing pure tendon, versus samples containing the myotendinous junction. Criteria for successful outcome was defined as a residual angle of deviation less than 10 PD. The binocular status of the patient was measured pre- and post-operatively at 6-months of follow-up.Results: Tissue samples from 43 patients (median age 19 years old, range 3– 58 years) were collected during surgery. Twenty-six of the samples contained pure tendon, while 17 contained muscle fibres. The evolution of the post-operative result revealed a moderate reduction in the residual angle of deviation in patient-samples containing pure tendon. In contrast, the residual angle of deviation clearly increased in patient-samples containing muscle fibres. The difference between the two groups reached statistical significance after 6 months. Successful outcome was found to be more than three times more likely in cases where surgery was performed in pure tendon, compared to muscle fibres.Conclusion: The current study supports the hypothesis that avoiding disruption of ocular proprioceptors, located in the distal myotendinous region, results in a more favorable postoperative result.Keywords: strabismus, surgical outcome, proprioception

Alexandre Assi,1 Ahmad M Mansour,2 Abdul Razzak Charbaji,3 Maurizio Battaglia Parodi4 1Beirut Eye Clinic and VitreoRetinal Department, Beirut Eye Specialist Hospital, Beirut, Lebanon; 2Department of Ophthalmology, American University of Beirut, Beirut, Lebanon; 3Department of Statistics and Research Methodology, Lebanese American University, Beirut, Lebanon; 4Department of Ophthalmology and IRCCS Ospedale San Raffaele, University Vita-Salute, Milan, ItalyCorrespondence: Ahmad M Mansour, Department of Ophthalmology, American University of Beirut, POB 113-6044, Beirut, Lebanon, Tel +9613377633, Email ammansourmd@gmail.comPurpose: To study the anatomic outcome of leaving vitreous cortex remnants (VCR) during pars plana vitrectomy (PPV) for primary rhegmatogenous retinal detachment (RRD).Methods: The study comprised patients with RRD who had PPV by a single surgeon between January 2019 and December 2020 and followed for 6 months. After intravitreal injection of triamcinolone acetonide, the topographic pattern of VCR at the periphery (p) and macula (m) was divided into 2 types by extent: complete or 4 quadrants (pVCR4Q), and between 2 and 4 quadrants ≥ 2 quadrants (pVCR> 2Q), or by location > 1 inferior retinal quadrant (pVCR> 1InfQ), and at the macula (mVCR). Anatomical failure or retinal re-detachment within 6 months after surgery was the primary outcome measures. The occurrence of grade C proliferative vitreoretinopathy (PVR) and epiretinal membrane (ERM) were used as secondary outcome indicators.Results: A 6-month prospective follow-up was performed on 103 patients. pVCR4Q was detected in 31 eyes, pVCR> 2Q in 40 eyes, pVCR> 1InfQ in 40 eyes and mVCR in 54 eyes. Recurrent RRD developed in 9 (8.7%) eyes, PVR grade C in 6 (5.8%) eyes and ERM in 11 (10.7%) eyes. According to multivariate regression analysis, the existence of any type of VCR did not correlate with anatomical failure, PVR or ERM.Conclusion: The initial success rate of PPV and the growth of PVR or ERM do not appear to be impacted by keeping VCR.Keywords: vitreous cortex remnants, pars plana vitrectomy, primary rhegmatogenous retinal detachment, epiretinal membrane, proliferative vitreoretinopathy

Anna Barkander,1 Mario A Economou,2,3 Gauti Jóhannesson1,4,5 1Department of Clinical Sciences, Ophthalmology, Umeå University, Umeå, Sweden; 2Division of Ophthalmology and Vision, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; 3Department of Ophthalmology, Capio Sophiahemmet Hospital, Stockholm, Sweden; 4Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden; 5Department of Ophthalmology, University of Iceland, Reykjavik, IcelandCorrespondence: Anna Barkander, Department of Clinical Sciences, Ophthalmology, Umeå University, Umeå, SE-901 85, Sweden, Tel +46 63 15 30 00, Email anna.barkander@regionjh.sePurpose: To evaluate the 2-year efficacy and safety of Kahook dual-blade (KDB) goniotomy in patients with medically uncontrolled glaucoma.Methods: This was a retrospective case-series study of 90 consecutive patients with primary open-angle glaucoma (POAG) or pseudoexfoliation glaucoma (PEXG) that underwent KDB goniotomy alone (KDB-alone group) or KDB goniotomy in combination with phacoemulsification (KDB-phaco group) during 2019– 2020. All patients were uncontrolled on three or more medications. Surgical success was defined as an IOP reduction ≥ 20% and/or a reduction of one or more medications at 24 months. We also report IOP levels and number of medications from baseline to 24 months, as well as the need for further glaucoma interventions.Results: At 24 months, mean IOP had reduced from 24.8± 8.3 to 15.0± 5.3 mmHg in the KDB-alone group (P< 0.001) and from 22.3± 5.8 to 13.9± 3.0 mmHg in the KDB-phaco group (P< 0.001). Medications had reduced from 3.5± 0.6 to 3.1± 0.9 in the KDB-alone group (P=0.047) and from 3.3± 0.5 to 2.3± 1.1 in the KDB-phaco group (P< 0.001). An IOP reduction ≥ 20% and/or a reduction with one or more medications was achieved by 47% of eyes in the KDB-alone group and by 76% of eyes in the KDB-phaco group. Eyes with PEXG and POAG responded equally well to the success criteria. During the 24-month follow-up, additional glaucoma surgery or transscleral photocoagulation was performed in 28% of eyes in the KDB-alone group and in 12% of eyes in the KDB-phaco group.Conclusion: In patients with medically uncontrolled glaucoma, KDB had a significant IOP-lowering effect after 24 months, but success rates were higher when KDB was performed in combination with cataract surgery compared to stand-alone treatment.Keywords: Kahook dual blade, medically uncontrolled glaucoma, phacoemulsification, pseudoexfoliation glaucoma, primary open-angle glaucoma

Ivan J Lee, James E Benjamin, Ghassan R Ghorayeb Department of Ophthalmology, West Virginia University Eye Institute, Morgantown, WV, USACorrespondence: Ivan J Lee, Department of Ophthalmology, West Virginia University Eye Institute, 1 Medical Center Drive, Morgantown, WV, 26506, USA, Tel +1 304-598-4820, Email Ivan.Lee@hsc.wvu.eduObjective: To report the incidence of postoperative epiretinal membrane (ERM) formation after primary pars plana vitrectomy (PPV) for giant retinal tear associated retinal detachment (GRT-RD) repair as well as its clinical characteristics and visual outcomes at a level one trauma and tertiary referral academic center.Patients and Methods: Patients with primary RD repair for GRT-RD at West Virginia University from September 2010 to July 2021 were identified using the ICD-10 codes (H33.031, H33.032, H33.033 and H33.039). Imaging studies including optical coherence tomography (OCT) were manually reviewed pre- and post-operatively for ERM formation after PPV for GRT-RD repair in patients who underwent PPV or combined PPV and scleral buckle (SB). Univariate analysis was performed to analyze clinical factors for ERM formation.Results: The study included 17 eyes of 16 patients who underwent PPV for GRT-RD. Postoperative ERM was observed in 70.6% (13 of 17 eyes) of the patients. Anatomic success was achieved in all patients. The mean (range) preoperative and final best corrected visual acuity (BCVA) in logMAR units by macula status was 0.19 (0– 0.5) and 0.28 (0– 0.5) for macula-on and 1.7 (0.5– 2.3) and 0.7 (0.2– 1.9) for macular-off GRT-RDs. Clinical variables including use of medium-term tamponade with perfluorocarbon liquid (PFCL), cryopexy, endodiathermy, number of tears or total clock hours of tears did not correlate with an increased risk of ERM formation.Conclusion: Post-vitrectomized eyes for GRT-RD repair have a significantly higher incidence of ERM formation, nearing 70% in our study. Surgeons may consider prophylactic ILM peel at the time of removal of tamponade agents or weigh in ILM peel at the time of primary repair, a more challenging surgical technique in our opinion.Keywords: giant retinal detachment, post-operative epiretinal membrane formation

Hirotsugu Takashina,1 Akira Watanabe,2 Tadashi Nakano2 1Department of Ophthalmology, Tokyo Rosai Hospital, Tokyo, Japan; 2Department of Ophthalmology, The Jikei University School of Medicine, Tokyo, JapanCorrespondence: Hirotsugu Takashina, Department of Ophthalmology, Tokyo Rosai Hospital, 4-13-21 Omori-minami Ota-ku, Tokyo, 143-0013, Japan, Tel +81-3-3742-7301 (ext. 8116), Fax +81-3-3744-9310, Email two-shina@s7.dion.ne.jpPurpose: We examine the safe removal of a sticky silicone oil (SO) with an inconspicuous perfluorocarbon liquid (PFCL) layer.Methods: In the first experiment, we injected PFCL into the SO bubble on the bottom of a transparent container or into the chili oil layer of an immiscible droplet composed of PFCL and chili oil on the posterior retina of a vitrectomized pig eye, in order to release the SO bubble or the chili oil layer from the downward adhesion. In the second experiment, we sucked out the SO layer of an immiscible droplet composed of PFCL and SO on the bottom of a transparent container or on the posterior retina of a vitrectomized pig eye using a fragmatome.Results: In the first experiment, the PFCL injection caused the SO bubble to move from the bottom of the transparent container and the chili oil to move from the posterior retina of the pig eye. In the second experiment, when the suction pressure was high, this made it easy and possible to remove the SO layer in the transparent container or the vitrectomized pig eye when emulsification was done by a fragmatome.Conclusion: Moving the SO layer of a sticky SO from the posterior retina after a PFCL injection followed by sucking out of the relocated SO layer using emulsification and high suction pressure through the utilization of a fragmatome can safely remove sticky SO with an inconspicuous PFCL layer.Keywords: silicone oil, perfluorocarbon, fragmatome, emulsification, vitrectomy

Marilyn A Marquez, Allie Nadelson, Maria Magraner, Luis J Haddock, Jorge A Fortun Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL, USACorrespondence: Jorge A Fortun, Email jfortun@med.miami.eduBackground and Objective: To evaluate the use of dynamic infrared (IR) imaging as a tool for the objective evaluation of symptomatic vitreous floaters and to correlate it with the patient symptomatology.Study Design/Materials and Methods: Retrospective study that examined 66 eyes of 44 patients with symptomatic and asymptomatic vitreous opacities. Patients were imaged using the Heidelberg Spectralis dynamic infrared (IR) image in video mode to record the vitreous movements and shadow artifacts within 30 degrees of the center of the macula. Patients were also asked how symptomatic their vitreous floaters were from absent to severe. After reviewing IR videos and OCT, a grading system was created to evaluate the floaters and a masked reader was asked to evaluate the videos and OCT based on the grading system created.Results: A total of 66 eyes were identified and examined with the IR videos, 50 were symptomatic, and 16 were asymptomatic. After masked review and analysis of the IR videos, there were 4 characteristics that correlated with the patient’s symptoms: size, location, movement, and density of obscuration of the OCT B Scan by the vitreous opacity. A table with grading of these characteristics was created to analyze how symptomatic patients were. A masked grader was asked to grade the videos and OCT using the grading system created. A positive correlation was found between the masked grader and the symptoms of patients. (0.70039; p < 0.00001).Conclusion: Dynamic IR video capture of vitreous opacities is a new imaging technique that can qualitatively assess vitreous opacities in a way that correlates to a patient’s symptoms. This imaging modality can provide a qualitative assessment of the patient’s severity of symptoms based on the location, density, and movement of the visualized vitreous opacities in the imaged video.Keywords: floaters, infrared imaging, vitreous opacities, vitreous gel, myodesopsias

Caroline Guerrero-de Ferran, Jorge E Valdez-García, I Jocelyn Rivera-Alvarado, Ángel E González-García, Daniel Bastán-Fabián, Melissa Rangel-Trejo Tecnológico de Monterrey, School of Medicine and Health Sciences, Department of Ophthalmology, Monterrey, MéxicoCorrespondence: Caroline Guerrero-de Ferran, Tecnológico de Monterrey, School of Medicine and Health Sciences, Av. Ignacio Morones Prieto 3000. Colonia Los Doctores. CP 64710, Monterrey, Nuevo León, México, Tel +52 (81) 88 88 05 51, Email jorge.valdez@tec.mxPurpose: We describe the ocular and periocular clinical features in patients with a facial palsy diagnosis of any etiology and to report the demographics, relevant medical history and treatment modalities in these patients.Patients and Methods: Retrospective and descriptive observational study. A total of 60 patients with a facial palsy diagnosis in the last 5 years were recruited from an ophthalmological clinic in northeastern Mexico. Demographic data, such as age, sex, disease evolution and etiology, visual acuity, ocular symptoms and ocular and periocular clinical features were obtained. Personal history of previous ophthalmologic surgery, as well as ocular and systemic diseases, were also recorded. Finally, a comparative analysis was done to determine association between signs, symptoms and treatment modalities.Results: A prevalence of 0.14% was reported, 56.7% of patients were female, and mean age of presentation was 55.63± 17.2 years. 76.7% of facial palsy was idiopathic in origin, followed by vascular disease in 8.30% and iatrogenic in 6.70%. 40% of patients had a history of arterial hypertension, 36.3% were diabetic, and 6.70% had cerebrovascular disease.Conclusion: Early diagnosis of facial palsy is crucial in establishing an effective treatment plan and avoiding complications. The impact of this disease in patients’ quality of life cannot be overlooked, and steps should be taken to address the different impairments that this ailment entails.Keywords: dry eye, ophthalmology, oculoplastics, facial palsy, epidemiology

Pawasoot Supasai, Kanwasee Kanjana, Yosanan Yospaiboon KKU Eye Center, Department of Ophthalmology, Faculty of Medicine, Khon Kaen University, Khon Kaen, ThailandCorrespondence: Yosanan Yospaiboon, KKU Eye Center, Department of Ophthalmology, Faculty of Medicine, Khon Kaen University, 123 Mitraparb Highway, Khon Kaen, 40002, Thailand, Tel +66-4336-3010, Fax +66-4334-8383, Email yyosanan@gmail.comPurpose: To compare the clinical characteristics of patients with direct and dural carotid cavernous sinus fistulas (CCFs).Methods: The medical records of 60 patients diagnosed with CCFs were retrospectively reviewed. The collected data included demographic characteristics, clinical findings, and ocular manifestation. The clinical characteristics of the direct and the dural CCFs were compared on head-to-head basis. Logistic regression analysis was used to demonstrate the direction and magnitude of the difference and reported as odds ratio with its 95% confidence interval.Results: There were 28 patients (46.67%) with direct CCFs, and 32 patients (53.33%) with dural CCFs. Patients with direct CCF were mostly male (p=0.023), younger age (p< 0.001), had history of trauma (p< 0.001), and more visual impairment at presentation (p=0.025), when compared to those with dural CCFs. In addition, patients with direct CCF had significantly more chemosis (p=0.005), proptosis (p=0.042), bruit (p< 0.001) and dilated retinal vessels (p=0.008) than those with dural CCF. Thirty patients (50%) had increased intraocular pressure (IOP). Mean IOP of the affected eyes was significantly higher than the unaffected eyes (p< 0.0001). In patients with normal IOP, mean IOP of the affected eyes was also higher than the unaffected eyes (p=0.0027).Conclusion: Patients with direct CCF were younger age, associated with trauma, and more visual impairment at presentation. Chemosis, proptosis, bruit and dilated retinal vessels were detected more in the direct CCF than the dural CCF. Despite normal IOP, affected eyes had significantly higher IOP than the unaffected eyes. Information on these clinical characteristics may be helpful in discrimination of the direct type, which is more urgent for further investigation and treatment.Keywords: direct carotid cavernous fistula, dural carotid cavernous fistula, clinical characteristics

Debdulal Chakraborty,1 Soumen Mondal,1 Subhendu Boral,1 Arnab Das,1 Tushar Kanti Sinha,1 Saptorshi Majumdar,1 Ranabir Bhattacharya,2 Ritobroto Maitra3 1Department of Vitreoretinal Services, Disha Eye Hospitals, Kolkata, West Bengal, India; 2Department of MIS, Disha Eye Hospitals, Kolkata, West Bengal, India; 3Radical Health Tech, New Delhi, IndiaCorrespondence: Debdulal Chakraborty, Department of Vitreoretinal services, Disha Eye Hospitals, Kolkata, West Bengal, India, Tel +91 33 66360000, Email devdc@rediffmail.comPurpose: To analyse outcomes of innovator ranibizumab (IRM) (Lucentis) and biosimilar ranibizumab (BRM) (Razumab) in Indian eyes with neovascular age-related macular degeneration (nAMD).Methods: Retrospective observational study in nAMD patients, who were treated with IRM or BRM (3 loading doses followed by pro re nata (PRN). Primary outcome measures were change in best corrected visual acuity (BCVA) and central macular thickness (CMT) along with safety analysis. Secondary outcomes measures were changes in the subretinal fluid (SRF) and intraretinal fluid (IRF).Results: Inclusion criteria were satisfied in 164 eyes (60.74%). A total of 87 eyes were treated with IRM, and 77 eyes received BRM. Baseline BCVA was 0.57± 0.27 logMAR in IRM group and 0.61± 0.25 in the BRM group. At 3, 6, 9, and 12 months BCVA was 0.27± 0.22 (p< 0.0001), 0.34± 0.23 (p< 0.0001), 0.39± 0.25 (p< 0.0001), and 12 months 0.41± 0.23 (p< 0.0001) in the IRM group and 0.24± 0.16 (p< 0.0001), 0.27± 0.16 (p< 0.0001), 0.34± 0.17 (p< 0.0001), 0.38± 0.18 (p< 0.0001) in the BRM group. Baseline CMT was 420.39± 54.45 μm in IRM group and 407.82± 53.07 μm in BRM group. At 3, 6, 9, and 12 months, CMT decreased to 258.28± 20.4 μm (p< 0.0001), 268.38± 19.5 μm (p< 0.0001), 269.51± 32.41 μm (p< 0.0001), and 278.28± 16.56 μm (p< 0.0001) in the IRM group and 258.84± 17.47 μm (p< 0.0001), 265.69± 17.29 μm (p< 0.0001), 273.64± 23.13 μm (p< 0.0001), and 283.09± 19.66 μm (p< 0.0001) in the BRM group. Similar improvements in IRF and SRF levels in the patients were noted in both groups. Required number of doses of IRM and BRM was similar over the 12 month period in both groups. A similar profile of adverse events was noted in both the groups.Conclusion: Intravitreal injection of IRM and BRM show similar efficacy and safety in Indian eyes with nAMD.Keywords: neovascular age-related macular degeneration, anti-VEGF, ranibizumab, biosimilar ranibizumab

Takafumi Suzuki,1,2 Takashi Fujishiro,2 Naoko Tachi,1,3 Yoshiki Ueta,1 Yasuhiro Okamoto,1 Takao Fukutome,1 Hirofumi Sasajima,1 Hidetoshi Ishida,1,4 Yuji Watanabe,1 Yoshihiro Hashimoto1 1Department of Ophthalmology, Shinseikai Toyama Hospital, Imizu, Japan; 2Department of Ophthalmology, The University of Tokyo Hospital, Bunkyo, Japan; 3Tachi Eye Clinic, Toyama, Japan; 4Department of Ophthalmology, Kanazawa Medical University, Ishikawa, JapanCorrespondence: Takashi Fujishiro, Department of Ophthalmology, University of Tokyo Graduate School of Medicine, 7-3-1 Hong&omacr;, Bunky&omacr;-ku, Tokyo, 113-8655, Japan, Tel +81-3-3815-5411, Email fujishiro.tky@gmail.comPurpose: This study investigated the long-term outcomes (> 3 years) of immediate primary phacoemulsification in eyes with acute primary angle closure (APAC) and in the fellow eyes with shallow anterior chamber to prevent APAC development.Patients and Methods: This is a retrospective study of phacoemulsification for APAC using bilateral eyes. Best-corrected visual acuity (BCVA), intraocular pressure (IOP), and number of IOP-lowering medications at the preoperative examination (Pre), postoperative month 1 (1m), year 3 (3y), and last visit were compared between 14 eyes with APAC and their 14 fellow eyes. The number of corneal endothelial cells (CECs) at Pre and at more than 2 weeks after phacoemulsification was compared. The visual field mean deviation (MD) within 1 year after phacoemulsification and at the last visit was also compared.Results: For APAC eyes, BCVA was significantly improved at 1m, 3y, and at the last visit as compared with Pre (p < 0.05). IOP significantly decreased at 1m, 3y, and at the last visit compared with Pre (p < 0.05). IOP-lowering medication use decreased significantly from Pre to 1m (p < 0.05). The number of CECs was not significantly different between Pre and more than 2 weeks after phacoemulsification. BCVA was significantly worse in APAC eyes than in fellow eyes at Pre (p < 0.05). IOP and the number of IOP-lowering medications were significantly higher in APAC eyes than in fellow eyes at Pre (p < 0.05).Conclusion: Primary phacoemulsification improved visual acuity for APAC eyes and maintained good IOP control without the need for reoperation. Moreover, it preserved the number of CECs for the APAC and fellow eyes in the long term.Keywords: acute primary angle closure, fellow eye, long-term outcome, phacoemulsification

Catherine Wang,1 Katherine A Joltikov,1,2 Sasha Kravets,2,3 Deepak P Edward2,4 1University of Illinois at Chicago College of Medicine, Chicago, IL, USA; 2Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA; 3Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, IL, USA; 4Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USACorrespondence: Deepak P Edward, Illinois Eye and Ear Infirmary, 1009 S Wood St, Chicago, IL, 60612, USA, Tel +1 312 996 6590, Fax +1 312 996 4255, Email deepedwa@uic.eduPurpose: The purpose of this study was to evaluate Computer Vision Syndrome (CVS) in undergraduate and medical students since transitioning to online learning during the COVID-19 pandemic.Patients and Methods: This was a cross-sectional single center survey-based study using a validated CVS questionnaire (CVS-Q). The survey was distributed to 20,080 undergraduate students and 680 medical students at the University of Illinois at Chicago. The primary outcome measures were prevalence of CVS (based on CVS severity score of 6 or more), frequency of CVS and intensity of CVS symptoms.Results: The survey was completed by 2300 undergraduate students (11.4% response rate) and 154 medical students (22.6% response rate). The prevalence of CVS was 77.1% in undergraduate students and 69.1% in medical students. CVS-Q severity scores were highest for headaches and eye dryness, with over half of students reporting worsening of symptoms since March 2020. Increased time spent on online learning (undergraduate: P < 0.001, medical: P = 0.018), blue light glasses usage (undergraduate: P < 0.001, medical: P = 0.0015), and increased number of device usage were associated with higher CVS severity scores (undergraduate: P < 0.001, medical: P = 0.0032).Conclusion: CVS among undergraduate and medical students has increased since the start of the COVID-19 pandemic. More focus should be placed on the management of CVS for students in higher education. Physicians should be cognizant of the consequences of online learning and be proactive about providing advice regarding preventative measures.Keywords: digital eye strain, screen time

Chai Kobkitsuksakul,1 Nasathapot Namphol,1 Bandit Sirilert,1 Thanaporn Kritfuangfoo,2 Ekachat Chanthanaphak,1 Mungkorn Apirakkan,1 Kittiphop Somboonnithiphol,1 Surawan Boonyakarnkul,1 Peerapong Lueangapapong,3 Thitiporn Thongborisuth,2 Tharikarn Sujirakul2 1Division of Interventional Neuroradiology, Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 2Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 3Department of Neurosurgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, ThailandCorrespondence: Tharikarn Sujirakul, Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Thanon Rama VI, Thung Phaya Thai, Ratchathewi, Bangkok, 10400, Thailand, Tel +6622011526, Fax +6622012729, Email tsujirakul@gmail.comPurpose: To investigate the efficacy and safety of selective intra-ophthalmic arterial combined nimodipine and alteplase infusion in patients with central retinal artery occlusion (CRAO).Design: Non-randomized, prospective interventional study.Methods: All patients with CRAO who presented at our institute within 24 hours from CRAO onset from August 2020 to July 2022 were included. Intra-arterial nimodipine and alteplase were given selectively into the ophthalmic artery. Visual acuity was recorded during and after the procedure. Change in best corrected visual acuity (BCVA) 1 month post-treatment, relative to baseline, was set as the primary outcome measure. Significant improvement in vision and adverse events are reported as secondary outcomes.Patients: Nine patients with non-arteritic CRAO were enrolled.Results: A total of nine patients with CRAO underwent selective intra-ophthalmic arterial nimodipine and alteplase injection. Overall, BCVA had statistically significantly improved by 0.78 logarithm of the minimum angle of resolution (logMAR) at 1 month compared with baseline (95% confidence interval: (− 1.24, − 0.31), p-value = 0.001). Seven (77.8%) patients had significant visual improvement (≥ 0.3 logMAR) at 1-month post-treatment. There were minor adverse events during administration of the nimodipine, including chemosis and headache, which resolved after the discontinuation of nimodipine. There were also asymptomatic thromboembolic events in 2 patients (22.2%) after the intervention procedure, without any morbidity or mortality.Conclusion: The use of selective intra-ophthalmic arterial combined nimodipine and alteplase was efficacious in improving BCVA at 1 month for patients with non-arteritic CRAO presenting between 24 hours from onset, with minor adverse events but no serious adverse events.Keywords: central retinal artery occlusion, thrombolysis, intra-ophthalmic arterial thrombolysis

Srijana Adhikari,1 Ruth Marie Antoinette van Nispen,2 Ellen Bernadette Maria Elsman,2 Fleur van Rens,3 Ger van Rens2 1Department of Pediatric Ophthalmology and Strabismus, Tilganga Institute of Ophthalmology, Kathmandu, Nepal; 2Department of Ophthalmology, VU University Medical Centre and the Amsterdam Public Health Research Institute, Amsterdam, the Netherlands; 3Discipline of Exercise Science, Murdoch University, Murdoch, WA, AustraliaCorrespondence: Srijana Adhikari, Tilganga Institute of Ophthalmology, Gaushala, PO Box 561, Kathmandu, Nepal, Tel +977-9849287387, Email srij_a@yahoo.comPurpose: To study the causes of moderate and severe visual impairment (VI) and blindness and its changing trends in Nepalese children.Patients and Methods: A cross-sectional descriptive study was conducted. Participants, aged 7 to 17 years were recruited from integrated schools for the blind and the outpatient department of a tertiary eye hospital in Kathmandu. VI and blindness were categorized according to World Health Organization (WHO) categories and its protocol for eye examination of children with blindness and VI was followed. Findings were compared to former studies from Nepal.Results: A total of 200 children were included, of whom 45% had moderate VI, 5% had severe VI, and 50% were blind. Mean age of children with VI and blindness was 11.1 (SD = 3.3) and 12.9 (SD = 3) years, respectively. Forty percent of children with VI and 38% of blind children were female. In our study, retina (39%) and whole globe (32%) were the most common anatomical site of involvement in children with VI and blindness, respectively, while cornea was the most common anatomical site of involvement in former studies. Heredity (43%) was the most common etiological factor although in 24.5% of all children, etiology was unknown. In 43.5% of children, blindness and VI was due to avoidable causes.Conclusion: In relatively many children, the etiology of VI and blindness could be either prevented or treated. Compared to former studies from Nepal, there is a changing trend in the etiology of severe VI and blindness.Keywords: childhood blindness, Nepal, visual impairment, pediatric

Luai Abu-Ismail,1 Mohammad T Abuawwad,2 Mohammad J Taha,2 Almu’atasim Khamees,3 Dima Y Abu Ismail,4 Mohammad Sanwar,5 Yaqeen Al-Bustanji,6 Abdulqadir Nashwan,7 Omran Hamdan Alameri,8 Hamzeh Mohammad Alrawashdeh,9 Hashem Abu Serhan,10 Jocob Abu-Ismail11 1Department of Ophthalmology, Islamic Hospital, Amman, Jordan; 2Department of Clinical Medicine, Cairo University, Cairo, Egypt; 3Department of General Surgery, King Hussein Cancer Center, Amman, Jordan; 4Department of Clinical Medical Sciences, Faculty of Medicine, Hashemite University, Zarqa, Jordan; 5Department of Medicine, Jordan University Hospital, Amman, Jordan; 6Department of Clinical Medicine, School of Medicine, The University of Jordan, Amman, Jordan; 7Department of Nursing Education and Research, Hamad Medical Corporation, Doha, Qatar; 8Department of Pathology and Public Health, Faculty of Veterinary Medicine, Jordan University of Science and Technology, Irbid, Jordan; 9Sharif Eye Centers, Irbid, Jordan; 10Department of Ophthalmology, Hamad Medical Corporation, Doha, Qatar; 11Department of Ophthalmology, Specialty Hospital, Amman, JordanCorrespondence: Abdulqadir Nashwan, P.O. Box 3050, Doha, Qatar, Tel +974 40240487 ; +974 66473549, Email anashwan@hamad.qaIntroduction: Dry eye disease (DED) is a common and multifactorial disease of the ocular surface which causes visual disturbance and feelings of discomfort among patients. The prevalence rate among medical students is an important issue to consider. This study investigates the relationship between caffeine consumption, sleeping habits, use of electronic devices, and DED among a convenient sample of medical students in Jordan.Methods: This cross-sectional online survey enrolled medical students from all six medical schools in Jordan. The questionnaire, which was shared via social media platforms, assessed socio-demographics, caffeine consumption amounts and patterns, sleep quality, and the use of electronic devices and their relation to ocular discomfort, DED, and related symptoms. The ocular surface disease index (OSDI) questionnaire was also administered to quantify the symptoms of DED.Results: A total of 1223 students participated in this study (RR=24.46%); 64% were females, and 43% were in their clinical placement years. Of the participants, 317 (25.92%) had normal eyes, and 906 (74.08%) had symptomatic DED. Of the students, 1206 (98.6%) used electronic devices directly before bed, and only 399 (32.62%) used blue-light-protective glasses. Lower DED risk was linked to male gender (OR=0.535, 95% CI 0.392– 0.73, p < 0.01), clinical years of medical school (OR=0.564, 95% CI 0.424– 0.75, p< 0.01). Poor sleep quality corresponded to more incidence of DED, regardless of sleeping for 5– 6 hours (OR=3.046, 95% CI 1.299– 7.139, p=0.01) or for less than 5 hours (OR=3.942, 95% CI 1.824– 8.519, p< 0.01). Also, caffeine consumption only marginally affected its incidence, but the results were statistically insignificant.Conclusion: Female gender, basic science years, and spending more than 6 hours looking at screens were significantly associated with symptomatic DED. Caffeine consumption did not pose any significant risk to the incidence of DED.Keywords: caffeine, dry eye, medical students, screen exposure, sleep quality

Tomas Loureiro,1 Sandra Rodrigues-Barros,1 Ana Rita Carreira,1 Filipe Gouveia-Moraes,1 Pedro Carreira,1 Ana Vide Escada,1 Paul Campos,1 Ines Machado,1 Nuno Campos,1 Renato Ambrosio Jr,2 Timothy J Archer,3 Dan Z Reinstein3 1Ophthalmology Department, Hospital Garcia de Orta, Almada, Portugal; 2Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil; 3London Vision Clinic, London, UKCorrespondence: Tomas Loureiro, Ophthalmology Department, Hospital Garcia de Orta, Avenida Torrado da Silva, Almada, 2805-267, Portugal, Tel +351 913 513 175, Email loureiro.tomas@gmail.comPurpose: To evaluate the changes on epithelial thickness before and after topical treatment in primary Sjögren syndrome-associated dry eye disease (SS-DED).Methods: This was a prospective study that included referred women with SS-DED and healthy age-matched controls. Corneal epithelial thickness was evaluated using high-definition anterior segment optical coherence tomography (Cirrus 5000 HD-OCT) in the baseline first consultation, and four weeks after treatment with preservative free 1mg/1mL sodium hyaluronate. Schirmer test 1 (ST1), tear break-up time (TBUT), tear meniscus height (TMH), SICCA Ocular Surface Score (SICCA OSS) and Ocular Surface Disease Index (OSDI) were evaluated. Statistical significance was defined as p-value < 0.05.Results: The study included 40 eyes, 20 with SS-DED and 20 controls. At baseline, SS-DED patients had lower ST1 (11.1 ± 2.2mm vs 14.1 ± 3.1mm, p< 0.01), faster TBUT (9.1 ± 1.8s vs 13.2 ± 1.1s, p< 0.01) and lower TMH (211.2 ± 68.4 μm vs 217.2 ± 60.1μm; p< 0.01) than the control group, whereas SICCA OSS and OSDI were higher (p< 0.01). The superior epithelium was thinner in SS-DED group (41.1 ± 3.2 μm vs 43.1± 2.3 μm, p< 0.01). After treatment, ST1, TBUT, TMH, SICCA OSS, and OSDI improved (p< 0.01), and superior epithelium thickened (p< 0.01) in the SS-DED group.Conclusion: Treatment with sodium hyaluronate improved ST1, TBUT, TMH, SICCA-OSS, and OSDI score. Superior epithelium tends to be thinner in SS-DED but becomes thicker with treatment. Our results seem to illustrate the morphological changes in the corneal epithelium in DED, which could be further recognized as a clinical biomarker of SS-DED.Keywords: dry eye disease, Sjogren’s syndrome, epithelial thickness, AS-OCT

Daniel S Malach,1 John Michael Guest,1 Christopher Adam,1 Jonah Joffe,2 Kim Le,2 Chaesik Kim,1 Xihui Lin1 1Kresge Eye Institute/Wayne State University Department of Ophthalmology, Detroit, MI, USA; 2Henry Ford Hospital Department of Ophthalmology, Detroit, MI, USACorrespondence: Xihui Lin, Kresge Eye Institute/Wayne State University Department of Ophthalmology, 4717 St. Antoine, Detroit, MI, 48201, USA, Email xihui.lin@wayne.eduPurpose: To analyze visual outcomes and accuracy of intraocular lens (IOL) calculation formulas in predicting postoperative outcomes in patients undergoing flanged intrascleral IOL fixation.Design: Case Series.Subjects: Twenty-three patients who had undergone secondary IOL placement using flanged intrascleral fixation technique.Methods: Retrospective chart review.Main Outcome Measures: Corrected distance visual acuity (CDVA) and postoperative spherical equivalent based on manifest refraction.Results: Visual acuity improved from 20/577 to 20/58. Overall, the actual refraction was 0.06 D more myopic than predicted. Holladay 2, Sanders Retzlaff Kraff/Theoretical (SRK/T) and Barrett Universal II resulted in mild myopic surprise (− 0.55, − 0.18 and − 0.20 D). Haigis and Hill-RBF (Radial Basis Function) resulted in mild hyperopic surprise (+0.28 and +0.28 D). Hoffer Q and Holladay 1 were the most accurate (− 0.02D and − 0.08 D).Conclusion: Flanged intrascleral IOL fixation improved vision even in patients with other posterior segment pathologies. The effective lens positioning is likely similar to in-the-bag positioning. Hoffer Q and Holladay 1 formulas with in-the-bag calculations were the most accurate.Keywords: aphakia, cataract, flanged technique, refractive, secondary intraocular lens

Pankaew Tantirattanakulchai,1 Nuchanad Hounnaklang,1 Pear Ferreira Pongsachareonnont,2,3 Bharkbhum Khambhiphant,4 Suwanchai Hounnaklang,5 Nanda Win,1 Suchon Tepjan6 1College of Public Health Sciences, Chulalongkorn University, Bangkok, Thailand; 2Center of Excellence in Retina, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; 3King Chulalongkorn Memorial Hospital, Bangkok, Thailand; 4Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; 5Dhurakijpundit University, Bangkok, Thailand; 6VOICES-Thailand Foundation, Chiang Mai, ThailandCorrespondence: Nuchanad Hounnaklang, College of Public Health Sciences, Chulalongkorn University, Institute Building 2-3, Soi Chulalongkorn 62, Phyathai Road, Pathumwan, Bangkok, 10330, Thailand, Tel +66 2218 8205, Fax +66 2255 6046, Email Nuchanad.H@chula.ac.thBackground: Disability is globally recognized as a key cause of depression. Likewise, the COVID-19 pandemic has significantly increased the vulnerability of patients with low vision to health and health-related issues, especially mental health. This study aimed to examine the association between the impact of COVID-19 and depressive symptoms in patients with low vision and blindness.Methods: This cross-sectional study was conducted between February and July 2022 and involved face-to-face interviews. Patients with low vision and blindness diagnosed with depression were excluded. The following items were included in the questionnaire: sociodemographic information, Multi-Dimensional Scale of Perceived Social Support (MSPSS), the impact of COVID-19, and The Center for Epidemiological Studies-Depression (CES-D). Hierarchical linear regression analysis was used to examine the association between the impact of COVID-19 and depression.Results: The prevalence of depression among patients with low vision and blindness was 43.0%. Three factors were associated with depressive symptoms: compliance with COVID-19 prevention strategies (β = 0.16, p< 0.01), anxiety during COVID-19 (β = 0.24, p< 0.001), and social support (β = − 0.16, p< 0.01).Conclusion: The findings indicated that COVID-19 significantly increased depressive symptoms among patients with low vision and blindness. The psychological effects of the COVID-19 pandemic have been considered critical and emergent public health issues. Stakeholders, particularly public health organizations, need to urgently implement preventive and protective measures to help patients with physical and mental disabilities.Keywords: COVID-19, depressive symptoms, low vision, blindness

Stanton Heydinger,1 Rafael Ufret-Vincenty,2,3 Zachary M Robertson,2,3 Yu-Guang He,2,3 Angeline L Wang2,3 1University of Texas Southwestern Medical School, University of Texas Southwestern, Dallas, TX, USA; 2Department of Ophthalmology, University of Texas Southwestern, Dallas, TX, USA; 3Department of Ophthalmology, Parkland Hospital, Dallas, TX, USACorrespondence: Stanton Heydinger, Department of Ophthalmology, University of Texas Southwestern, 5323 Harry Hines Blvd, Dallas, TX, USA, Tel +1 816-500-9088, Email Stanton.Heydinger@utsouthwestern.eduPurpose: To compare the outcomes of primary uncomplicated rhegmatogenous retinal detachment (RRD) repair using pars plana vitrectomy (PPV), scleral buckling (SB), or combined scleral buckling with vitrectomy (SB/PPV).Patients and Methods: Single-institution, retrospective, observational study of 179 patients with primary RRD managed at a large academic hospital system. We excluded patients with less than 6 months of follow-up, previous vitrectomy or buckle, giant retinal tears, aphakia, recurrent forms of RRD, or extensive proliferative vitreoretinopathy (Grade C or worse) documented on exam or requiring membrane peel. Outcome measures included primary anatomical success at 6 months, functional success defined as BCVA ≥ 20/200, and best corrected visual acuity (BCVA) using logMAR scoring. Subgroup analysis was performed in the following patient groups: phakic, pseudophakic, inferior detachments, and prior pneumatic retinopexy.Results: Primary anatomical success was achieved in 145 of 179 eyes (81.0%), with SB/PPV showing a significantly greater success rate (p = 0.046) when compared to SB and PPV. Functional success was achieved in 137 of the 145 anatomically successful eyes (94.5%), with values ranging between 92% and 97% amongst the interventions (p = 0.552). No difference was found in final BCVA (p = 0.367). Patients with inferior detachment had an odds ratio of 2.15 for primary anatomic failure. Prior pneumatic retinopexy did not significantly affect any of the primary outcomes.Conclusion: SB/PPV yielded a significantly better primary anatomical success rate when compared to SB and PPV. Functional success and final BCVA was similar amongst the interventions. Inferior detachments were associated with worse primary anatomic outcomes. Prior pneumatic retinopexy did not significantly affect surgical outcomes.Keywords: anatomical success, retina, scleral buckling, vitrectomy

Malak Bamashmoos,1 Khalid Emara,2 Bashair Alshahri,3 Esra Alsahaf,2 Nada N Alwohaibi4 1Department of Ophthalmology, Dhahran Eye Specialist Hospital, Dhahran, Kingdom of Saudi Arabia; 2Department of Ophthalmology, Division of Pediatric Ophthalmology, Dhahran Eye Specialist Hospital, Dhahran, Kingdom of Saudi Arabia; 3College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia; 4King Abdulaziz Medical City, Ministry of National Guard, Riyadh, Kingdom of Saudi ArabiaCorrespondence: Malak Bamashmoos, Department of Ophthalmology, Dhahran Eye Specialist Hospital, 7630 H.E Ali Naimi St, Aljamiah District, Dhahran, 34257, Kingdom of Saudi Arabia, Tel +966531888432, Email Malak.bamashmoos@hotmail.comPurpose: This study aimed to evaluate surgical outcomes, compare success rates, and identify potential risk factors for failure of various surgical procedures for consecutive exotropia.Patients and Methods: This retrospective cohort study was conducted at a tertiary eye hospital in Saudi Arabia and included patients with consecutive exotropia treated between 2007 and 2020. Patients with a follow-up of < 3 months were excluded. The type of surgery performed was based on surgeon experience and factors, such as the angle of deviation, adduction limitation, and intraoperative findings. Successful outcome was defined as a deviation of ≤ 10 prism diopters (PD) at the last follow-up visit.Results: A total of 59 patients were included in this study. Preoperatively, the mean near and distance deviations were 33 ± 14 PD and 32 ± 14 PD, respectively. Among the included patients, 27.1% underwent medial rectus advancement with or without resection, 28.8% underwent lateral rectus recession, and 44.1% underwent combined surgery. At 12 months postoperatively or the last follow-up visit, the overall success rate of distance-deviation correction and near-deviation correction were 80.6% and 67.8%, respectively. Success rates of different surgeries were not significantly different. The severity of amblyopia and number of muscles operated on did not influence the success rate.Conclusion: Medial rectus advancement and combined medial rectus advancement with lateral rectus recession were associated with better surgical outcomes than lateral rectus recession alone, although the difference was not statistically significant. The only factor that negatively affected the outcome was a high preoperative near angle of deviation.Keywords: consecutive exotropia, medial rectus advancement, lateral rectus recession

Ahmed Ali Amer,1,* Esam Ahmed Ghanem Abu El Wafa Ali,2,* Esam Sayed Ahmed,2,* Mohamed Ateto Hamed,3,* Wael el Shazly Eata,1,* Ibrahim Amer2,* 1Ophthalmology Department, Qena Faculty of Medicine, South Valley University, Qena, Egypt; 2Ophthalmology Department, Al Azhar University, Assuit, Egypt; 3Ophthalmology Department, Luxor University, Luxor, Egypt*These authors contributed equally to this workCorrespondence: Ahmed Ali Amer, Tel +20 101 182 7000, Email AhmedALi.ophth@gmail.comPurpose: This study aimed to compare the short-term outcome of implanting the Visian implantable collamer lens V4 ICL versus the Visian V4c ICL in patients with moderate and high myopia.Patients and Methods: This is a retrospective that was conducted on patients with moderate or high myopia who were scheduled for ICL implantation at our institution, Patients who underwent V4 ICL implantation with peripheral iridectomy were assigned to group A, and those who underwent V4c ICL implantation without peripheral iridectomy were assigned to group B. In group A, a preoperative peripheral iridectomy was performed. In group B, the patients received cycloplegic and dilating agents. The patients underwent a complete ocular examination preoperatively and during the follow-up visits that were conducted at 3, 6, and 12 months postoperatively.Results: This study included 214 eyes from 107 patients; group A included 110 eyes, and group B included 104 eyes. Postoperatively, the UCVA and BCVA showed statistically significant improvement across the follow-up time points (p< 0.001), with no significant difference between the two groups. No statistically significant difference was found between the two groups in the mean achieved correction or the residual refraction. Both groups showed a strong correlation between the target and the achieved correction, with R2 = 0.99 in the two groups. No significant difference was found between the two groups in the IOP across all time measures. However, the intraocular pressure showed a statistically significant postoperative increase in group A (p=0.004), and no significant change in group B (p=0.817). There was a downward slope in the vaults of both groups across time, with significant variation in the last follow-up measure compared to the 3-month measure in the two groups (p< 0.001).No significant difference was found between the two groups across all time measures.Conclusion: The current study adds new evidence concerning the feasibility, safety, and efficacy of ICL V4c implantation for the treatment of moderate and high myopia, with safer postoperative IOP.Keywords: moderate and high myopia, Visian implantable collamer lens, central hole, peripheral iridectomy

Christian Nilsen,1 Per Graae Jensen,1 Morten Gundersen,1 Øygunn A Utheim,2– 4 Bjørn Gjerdrum,1 Kjell Gunnar Gundersen,1 David Jahanlu,5 Rick Potvin6 1iFocus Øyeklinikk, Haugesund, Norway; 2The Norwegian Dry Eye Clinic, Oslo, Norway; 3Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway; 4Department of Ophthalmology, Oslo University Hospital, Oslo, Norway; 5Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway; 6Science in Vision, Bend, OR, USACorrespondence: Christian Nilsen, iFocus Øyeklinikk, Strandgaten 203, Haugesund, 5004, Norway, Tel +47-97189598, Email christian@ifocusstord.noPurpose: The purpose of this study was to evaluate the diagnostic value of inter-eye osmolarity differences in relation to dry eye symptoms and other non-osmolar signs of dry eye disease.Patients and Methods: One hundred ninety one participants who attended a larger interventional study of dry eye disease prior to and after cataract surgery were analyzed for dry eye disease (DED). Dry eye diagnostics were performed for all subjects according to the DEWS II criteria: tear osmolarity was collected from both eyes with the TearLab system, non-invasive Tear film break up time (NIKBUT) was obtained on the test eye with Keratograph and ocular surface staining (OSS) was evaluated using the Oxford schema. The Ocular Surface Disease Index (OSDI) questionnaire was used to assess symptoms. Inter-eye osmolarity greater than 8, which is considered as a sign of DED according to the TearLab user manual, was evaluated and compared with other non-osmolar signs of DED.Results: The 191 subjects were divided into three groups according to osmolarity measurements. Sixty-five subjects had normal osmolarity (below 308 mOsmol/L in both eyes and less than 9 mOsmol/L difference between the eyes), 107 had high osmolarity (308 mOsmol/L or higher in one of the eyes) and 19 had an inter-eye difference > 8 mOsmol/L or higher, with neither eye having osmolarity higher than 307 mOsmol/L. Signs and symptoms in this last group were not correlated with the high osmolarity group or the normal group, though they appeared more similar to the normal group.Conclusion: The diagnostic value of inter-eye osmolarity difference in predicting symptoms or other non-osmolar signs of dry eyes appears weak. Our study suggests that the criterion of an inter-eye difference of 8 mOsmol/L is not a useful cut-off for diagnosing dry eyes based on osmolarity.Keywords: dry eye disease, osmolarity, DEWS II

Zain S Hussain,1,2 Asher Khan,2,3 Asad Loya,4 Kaushal Shah,5 Fasika A Woreta,6 Kamran M Riaz2 1University of Medicine and Health Sciences, Basseterre, Saint Kitts and Nevis; 2Department of Ophthalmology, Dean McGee Eye Institute, Oklahoma City, OK, USA; 3College of Medicine, University of Oklahoma, Oklahoma City, OK, USA; 4Department of Ophthalmology, Baylor College of Medicine, Houston, TX, USA; 5Department of Psychiatry and Behavioral Sciences, Oklahoma State University, Tulsa, OK, USA; 6Department of Ophthalmology, Johns Hopkins Wilmer Eye Institute, Baltimore, MD, USACorrespondence: Kamran M Riaz, Dean McGee Eye Institute/University of Oklahoma, 608 Stanton L Young Blvd, Suite 313, Oklahoma City, OK, 73104, USA, Tel +1-405-271-1095, Fax +1-405-271-3680, Email Kamran-Riaz@dmei.orgPurpose: To investigate the association between early lifetime substance use on the development of severe visual acuity impairment or blindness on a national level.Methods: National Survey of Drug Use and Health data was used to identify cases of substance use before 21* years of age, within the past year, and cases of self-reported blindness or visual impairment. Univariable and multivariable binary logistic regression with time-dependency was performed to evaluate odds of visual impairment influenced by 16 substances separated into three classes: prescription, non-prescription, and illicit drugs. Adjusted variables of interest included gender, marital status, race, level of education, total family income, poverty level, population density, and history of chronic disease.Results: 55,824 total responses were analyzed with 2577 (4.6%) cases of self-reported blindness or significant visual impairment. All early-use substance categories, including prescription, non-prescription, and illegal substances, were significantly associated with self-reported VI (OR 2.068, CI 1.451– 2.949, p< 0.001; OR 1.352, CI 1.227– 1.489, p< 0.001); OR 1.211, CI 1.086– 1.352, p< 0.001), respectively). Non-prescription substances displayed parallel significances amongst all constituents (alcohol, cigarettes, inhalants, and marijuana) (OR=1.227, CI 1.12– 1.344, p< 0.001; OR 1.363, CI 1.243– 1.495, p< 0.001; OR 1.418, CI 1.134– 1.774; OR 1.388, CI 1.27– 1.518, p< 0.001, respectively). Univariable and multivariable analysis revealed several significant demographical and clinical adjustors.Conclusion: Early lifetime use of all three classes of substances is associated with enhanced odds of subsequent visual impairment or blindness. Several readily available and commonly used substances have a greater risk. These findings may help clinicians and public health agencies in mitigation ventures including education, prevention, and rehabilitation efforts.Keywords: substance use, ophthalmology, vision loss

Getenet Shumet Birhan,1 Gizachew Tilahun Belete,1 Biruk Lelisa Eticha,1 Fisseha Admassu Ayele2 1Department of Optometry, School of Medicine, University of Gondar, Comprehensive Specialized Hospital, Gondar, Ethiopia; 2Department of Ophthalmology, School of Medicine, University of Gondar, Comprehensive Specialized Hospital, Gondar, EthiopiaCorrespondence: Biruk Lelisa Eticha, POB: 196, Tel +251921950568, Fax +251-58-114 1240, Email biruklel.75@gmail.comIntroduction: Coping strategy is the mechanism by which patients adjust to the condition they face. It can be adaptive or maladaptive. A maladaptive coping strategy is a harmful and ineffective way of dealing with stress or anxiety. It is common among patients with chronic illnesses. Despite Ethiopia having a greater glaucoma prevalence, there was no evidence of patients with glaucoma using maladaptive coping mechanisms.Objective: The main goal of this study was to evaluate the magnitude of maladaptive coping strategy use and the factors that associate with it among adult glaucoma patients enrolled in the Tertiary Eye Care and Training Center at the University of Gondar in Northwest Ethiopia in 2022.Methods and Materials: At the University of Gondar, Tertiary Eye Care and Training Center, a facility-based cross-sectional study was carried out on a sample of 423 glaucoma patients chosen by a systematic random sampling technique from May 15 to June 30, 2022. Optometrists conducted an interview with the study subject and reviewed the medical record, and administered a pretested, structured questionnaire of the brief cope inventory assessment. In the multivariable logistic regression, binary logistic regression was performed to identify the related factors, and significance was taken into account when the p-value was less than 0.05 at the 95% confidence interval.Results: The study found that among study participants 50.1% (95% CI: 45.1– 54.5%) had a maladaptive coping strategy. Female sex (AOR=2.031, 95% CI:1.185– 3.480), chronic medical illness (AOR=1.760, 95% CI:1.036– 2.989), bilateral glaucoma (AOR=2.321, 95% CI: 1.328– 4.055), receiving both drug and surgery treatment (AOR=1.895, 95% CI: 1.002– 3.585), severe visual impairment (AOR=2.758, 95% CI:1.110– 6.852), absolute glaucoma (AOR=2.543, 95% CI:1.048– 6.169), duration of diagnosis > 12 months (AOR=3.886, 95% CI: 2.295– 6.580) were significantly associated with a maladaptive coping strategy.Conclusion and Recommendation: Half of the participants had a maladaptive coping strategy. It is better to set and plan strategies that enable the integration of coping strategy care into the current treatment of patients with glaucoma to encourage positive coping strategies instead of maladaptive ones.Keywords: adult, Ethiopia, Gondar, maladaptive coping strategy

Nikola Tomagova,&ast; Sina Elahi, Kristof Vandekerckhove&ast; Clinical Study Department, Vista Alpina Eye Clinic, Visp, Switzerland&ast;These authors contributed equally to this workCorrespondence: Kristof Vandekerckhove, Clinical Study Department, Vista Alpina Eye Clinic, Bahnhofplatz 1a, Visp, 3930, Switzerland, Tel +41279467000, Email vandekerckhove@vista-alpina.chPurpose: To assess visual acuity, binocular defocus curve, spectacle independence, and photic phenomena after bilateral same-day cataract surgery with implantation of an extended depth-of-focus intraocular lens (IOL) with mini-monovision.Methods: Single-center retrospective study including 124 eyes from 62 patients who underwent bilateral implantation of an isofocal EDOF lens [Isopure® (BVI)] with mini-monovision (− 0.50 D). Refraction, visual acuity at different distances, binocular defocus curves, spectacle independence, and subjective ratings of picture-referenced photic phenomena were assessed one to two months postoperatively.Results: The mean postoperative refractive spherical equivalent was − 0.15± 0.41D in the dominant eyes and − 0.46± 0.35D in the mini-monovision eyes (p< 0.01). Overall, 98.4% and 87.7% of the eyes were within ± 1.00D and ± 0.50D of the target refraction, respectively. Postoperative monocular corrected distance visual acuity was − 0.04± 0.07 logMAR. Binocular uncorrected visual acuity was − 0.02± 0.07, 0.13± 0.11and 0.40± 0.20 logMAR for far, intermediate and near, respectively. At the visual acuity threshold of 0.20 logMAR (or better) the defocus curve ranged from − 1.6D to +0.9D. Reported spectacle-independence was 96% for far distance, 95% for intermediate, and 34% for near. Five percent of patients reported halos, 16% starburst, and 16% glare. Only 7% of all patients considered them bothersome.Conclusion: In patients undergoing same-day bilateral cataract surgery, an isofocal EDOF lens provided an extended range of functional vision, up to 63 cm, resulting in useful uncorrected near vision, good uncorrected intermediate vision, and excellent uncorrected distance vision. Subjective patient satisfaction in terms of spectacle independence and photic phenomena was high.Keywords: EDOF, extended-depth-of-focus, mini-monovision, same-day bilateral cataract surgery, Isopure

Antony William, Raoul Verma-Fuehring, Sophia Kuehnel, Dorothee Schwabe, Daniel Kampik, Winfried Goebel, Jost Hillenkamp Department of Ophthalmology, University Hospital Würzburg, Würzburg, GermanyCorrespondence: Antony William, Department of Ophthalmology, University Hospital Würzburg, Joseph–Schneider Straße 11, Würzburg, 97080, Germany, Tel +4993120120646, Email William_a@ukw.dePurpose: To evaluate the morphological macular changes and fluid dynamics under brolucizumab treatment in eyes refractory to previous anti–vascular endothelial growth factor (anti-VEGF) treatment for neovascular age-related macular degeneration (nAMD) compared with treatment-naive eyes.Methods: Retrospective study of all eyes treated with brolucizumab for nAMD between 2020 and 2021 with a fixed injection regimen and one year follow-up. Treatment-naive eyes (TN) were compared with eyes refractory to previous treatment with bevacizumab, ranibizumab, or aflibercept (RT). The primary outcome measure was change of best-corrected visual acuity (BCVA). Secondary outcome measures included foveal central thickness (FCT), presence of intra- or subretinal fluid (IRF, SRF) and presence of pigment epithelial detachment (PED) at any time point during treatment in both groups.Results: Seventeen TN eyes and 17 RT eyes were included. Mean BCVA and mean FCT in TN eyes had significantly improved after 3 months and continued to improve during treatment (p< 0.05 and p=0.001, respectively). In RT eyes, mean BCVA did not change significantly while mean FCT had improved after 3 months of treatment and remained stable thereafter. SRF or PED were more frequent in RT eyes compared with TN eyes (p=0.003 and p=0.005, respectively).Conclusion: After 3 months of treatment, the BCVA increased significantly only in TN eyes, while the FCT was significantly reduced in both groups. IRF appears to be similarly seen in both groups after the loading phase; however, SRF and PED appear to be more frequent in the RT eyes compared with TN eyes.Keywords: treatment naïve, TN, refractory treatment, RT

Marrie van der Mooren,1 Aixa Alarcon,1 Mark D Jenkins Sanchez,1 Daniel H Chang2 1Johnson & Johnson Surgical Vision, Inc., Groningen, Netherlands; 2Empire Eye and Laser Center, Bakersfield, CA, USACorrespondence: Marrie van der Mooren, Johnson & Johnson Surgical Vision, AMO Groningen BV, Van Swietenlaan 5, Groningen, 9728, NX, Netherlands, Tel +31620709324, Email Mvande97@its.jnj.comPurpose: To assess the experimental visual performance and dysphotopsia characteristics of the new Tecnis Symfony OptiBlue extended-depth-of-focus with violet light-filtering (ZXR00V) intraocular lens (IOL) compared with the colorless Tecnis Symfony (ZXR00) IOL.Methods: Range of vision was assessed with simulated visual acuity defocus curves, predicted by white light through focus modulation transfer function (MTF) measurements. The clinical visual acuity defocus curve of the ZXR00 IOL was used to validate the predicted range of vision. Image quality was compared by measuring white light MTF at a spatial frequency of 15 cycles per degree (c/deg) for 3 mm and 5 mm pupil diameters with optical powers of 5 D, 20 D, and 34 D using the average corneal eye (ACE) model with the average spherical and chromatic aberration of the cataract population. Effects on dysphotopsias were predicted by measurement and computer simulation of light scatter (straylight parameter) and subsequent determination of retinal veiling luminance (RVL) in vitro. Contrast enhancement under challenging light conditions was calculated based on the effects in RVL.Results: The simulated visual acuity defocus curves and image quality outcomes were comparable between the ZXR00V and ZXR00 IOLs. The area under the straylight curve for the straylight parameter showed a 19% improvement in halo performance with ZXR00V versus ZXR00. A 12% to 17% reduction in RVL was achieved in favor of ZXR00V over ZXR00, which enhanced contrast vision by 9% to 13% under challenging light conditionsConclusion: The violet light-filtering technology and improved manufacturing of ZXR00V delivers a comparable range of vision and tolerance to refractive error to ZXR00 while mitigating dysphotopsias and enhancing contrast vision.Keywords: dysphotopsia profile, presbyopia-correcting IOL, retinal veiling luminance, straylight parameter, violet light-filtering IOL

Tanner J Ferguson,1,2 Caroline W Wilson,3 Brian M Shafer,4 John P Berdahl,1,2 Daniel C Terveen1,2 1Vance Thompson Vision, Sioux Falls, SD, USA; 2University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA; 3Wolfe Eye Clinic, Cedar Rapids, IA, USA; 4Chester County Eye Care, Malvern, PA, USACorrespondence: Tanner J Ferguson, Vance Thompson Vision, 3101 W. 57th Street, Sioux Falls, SD, 57108, USA, Email tannerferg@gmail.comPurpose: To evaluate the clinical outcomes of a non-diffractive, wavefront-shaping extended depth-of-focus (EDOF) intraocular lens (IOL) in eyes with mild open-angle glaucoma (OAG).Setting: Private practice; Sioux Falls, South Dakota.Design: Prospective, open-label, interventional study.Methods: In total, 52 eyes of 26 patients with mild OAG were enrolled and completed the study. All patients were bilaterally implanted with a non-diffractive, wavefront-shaping EDOF IOL. Seventy-seven percent of the patients were implanted with a trabecular microbypass stent at the time of surgery. Primary outcome measures included binocular corrected and uncorrected distance visual acuity (CDVA and UDVA), uncorrected intermediate and near visual acuity (UIVA and UNVA) and contrast sensitivity as measured by a Pelli-Robson chart. A subjective questionnaire was also administered to patients.Results: At 4 months postoperative, the mean binocular UDVA and CDVA was 0.03 ± 0.12 and − 0.06 ± 0.07, respectively. The mean UIVA and UNVA were 0.18 ± 0.12 and 0.31 ± 0.18, respectively. Eighty-five percent of the subjects achieved ≥ 20/25 UDVA and 77% of the subjects achieved ≥ 20/32 UIVA at 4 months postoperative. The mean binocular mesopic contrast sensitivity was 1.76 ± 0.16 at a spatial frequency of 1 cycle-per-degree (cpd). Eighty-five percent of the subjects reported they would choose the same lens and 1 subject reported they would choose a different IOL if it meant reduced spectacle independence.Conclusion: The non-diffractive, wavefront-shaping EDOF IOL can be safely implanted in eyes with mild, pre-perimetric open-angle glaucoma with favorable uncorrected distance and intermediate visual acuity. The contrast sensitivity measurements were favorable and the subjective questionnaire revealed satisfactory spectacle independence and patient satisfaction.Keywords: EDOF IOL, extended depth-of-focus IOL, cataract surgery, refractive cataract surgery, cataract surgery in glaucoma

Omar Abdallah Khan, Gorka Sesma, Abeer Alawi, Manal AlWazae Pediatric Ophthalmology and Strabismus Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi ArabiaCorrespondence: Gorka Sesma, Pediatric Ophthalmology and Strabismus Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia, Tel +966114849700, Fax +966114821908, Email gsesma@kkesh.med.saPurpose: To compare the outcomes of non-penetrating deep sclerectomy (NPDS) for primary congenital glaucoma (PCG) performed by experienced vs trainee surgeons.Patients and Methods: This retrospective cohort study was conducted in 2022 in Saudi Arabia. Consultants (Gr-1) and trainee pediatric ophthalmologists (Gr-2) performed NPDS on pediatric patients with PCG. Success was defined as an intraocular pressure (IOP) less than 21 mmHg at 6 months after surgery. Complications, glaucoma medications, and additional procedures were also observed in the two groups.Results: Gr-1 and Gr-2 operated on 14 and 39 eyes with PCG, respectively. The absolute success rates were 90.9% (95% confidence interval [CI]: 73.9, 100) in Gr-1 and 96.7% (95% CI: 90.2, 100) in Gr-2 (odds Ratio=1.1; 95% CI: 0.87, 1.3; P=0.54). Survival analysis suggested that the failure rate in the first 6 months after NPDS was not significantly different between the two groups (hazard ratio=1.45; 95% CI: 0.13, 16.0; P=0.767). The complications included hypotony (2 cases), vitreous hemorrhage (1 case), and total flap penetration (1 case). Only one eye in Gr-2 needed glaucoma medication after surgery. There was no significant difference in the success rates of one surgeon before and after training (P=0.43). The age (P=0.59) and sex (P=0.77) of patients, type of surgeon (P=0.94), and preoperative IOP (P=0.59) were not significant predictors of a stable IOP at 6 months after NPDS.Conclusion: At 6 months after NPDS surgery performed by experienced and trainee pediatric ophthalmologists, the outcomes (stabilization of IOP) were similar between the two groups.Graphical Abstract: Keywords: pediatric glaucoma, learning curve, medical education, surgical training, intraocular pressure, glaucoma surgery

Tomoko Miyakubo, Ryo Mukai, Hidetaka Matsumoto, Masahiro Morimoto, Maki Takahashi, Kazuki Nagai, Kosuke Nakamura, Junki Hoshino, Hideo Akiyama Department of Ophthalmology, Gunma University, Graduate School of Medicine, Maebashi, Gunma, JapanCorrespondence: Ryo Mukai, Department of Ophthalmology, Gunma University Graduate School of Medicine, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511, Japan, Tel +81-27-220-8338, Fax +81-27-233-3841, Email rmukai@gunma-u.ac.jpPurpose: To compare the efficacies of photodynamic therapy (PDT) combined with intravitreal aflibercept (IVA) injections and IVA monotherapy using a treat-and-extend regimen (TAE) for treatment-naïve polypoidal choroidal vasculopathy (PCV).Patients and Methods: One hundred and nine eyes treated with PDT combined with IVA (PDT+IVA group: 51 eyes) or IVA monotherapy (IVA group: 58 eyes) were assessed for 2 years. The main outcome measures included best-corrected visual acuity (BCVA), central macular thickness (CMT), central choroidal thickness (CCT), number of IVA injections, and macular atrophy (MA). Polypoidal lesions before and after the loading phase were assessed using indocyanine green angiography.Results: In both groups, BCVA significantly improved after the loading phase and was maintained for 2 years. CMT and CCT were significantly reduced in both groups, without significant differences after 2 years between the groups (P=0.2708). The mean number of IVA injections in the IVA and PDT+IVA groups during the 2 years were 13.2± 3.3 and 12.7± 1.8, respectively, without a significant difference (P=0.06). The frequencies of MA expansion in the IVA and PDT+IVA groups during the 2 years were 25.9% and 33.4%, respectively, with no significant difference in the incidence (odds ratio: 1.40, P=0.4253). The ratios of polyp regression after the loading phase in the IVA and PDT+IVA groups were 55.2% and 94.1%, respectively, with a significant difference (P< 0.0001).Conclusion: PDT combined with IVA injections using a TAE regimen is effective for anatomical and visual function improvement, without a significant difference as compared to IVA monotherapy. It can facilitate complete regression of polyps with higher odds.Keywords: polypoidal choroidal vasculopathy, aflibercept, photodynamic therapy, treat-and-extend, macular atrophy

Mário Lima-Fontes,1,2 Daniel Martinho-Dias,3– 5 Mariana Leuzinger-Dias,1 Ana Maria Cunha,1 Pedro Neves Cardoso,1 Luís Torrão,1 Raúl Moreira,1 Fernando Falcão-Reis,1,6 João Pinheiro-Costa1,6 1Department of Ophthalmology, Centro Hospitalar Universitário São João, Porto, 4200-319, Portugal; 2Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, 4050-313, Portugal; 3Department of Community Medicine, Information and Decision in Health, University of Porto Faculty of Medicine, Porto, 4050-313, Portugal; 4CINTESIS – Center for Health Technology and Services Research, University of Porto, Porto, 4050-313, Portugal; 5Family Health Unit Ao encontro da Saúde, ACES Santo Tirso-Trofa, Trofa, 4745-559, Portugal; 6Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, 4050-313, PortugalCorrespondence: Mário Lima-Fontes, Department of Ophthalmology, Centro Hospitalar Universitário São João, Alameda Prof. Hernâni Monteiro, Porto, 4200-319, Portugal, Email marioruifontes@gmail.comPurpose: The Covid-19 pandemic introduced significant changes in our daily life, including the widespread use of face masks. The purpose of this study was to assess if significant changes occurred in the microbiological profile of infectious keratitis.Patients and Methods: A retrospective study was performed, based on a survey review of the electronic medical records of all patients with presumed infectious keratitis, between March 2020 and October 2021. The microbiological isolates in this sample (pandemic group) were compared with those obtained in our center between 2009 and 2018 (pre-pandemic group).Results: A total of 194 samples were included in the pandemic group. We obtained a culture-positivity rate of 43.3%, which was significantly higher when compared with the pre-pandemic data (35.15%, p = 0.033). Several further significant differences were found between the pandemic and the pre-pandemic groups: the proportion of bacteria, including gram-positive and gram-negative groups, was higher in our sample (pre-pandemic vs pandemic: 76.78% vs 83.33%, p = 0.010; 53.35% vs 60.71%, p = 0.016; 23.43% vs 34.52%, p = 0.005, respectively); two populations of Gram-positive bacteria found in this study were not isolated in the pre-pandemic sample – Dolosigranulum pigrum and Propionibacterium spp.; and two bacterial isolates were significantly increased in our sample – Corynebacterium spp. (18.41% vs 29.76%, p = 0.003) and Pseudomonas aeruginosa (9.00% vs 16.66%, p = 0.012).Conclusion: In conclusion, significant changes were found in the microbiological profile of infectious keratitis in our center during the Covid-19 pandemic. While these changes could be related to face mask use, more observational and experimental studies are needed to explore this possible association.Keywords: infectious keratitis, Covid-19, face mask, microbiology

Robert Edward T Ang Cataract and Refractive Surgery Department, Asian Eye Institute, Makati City, PhilippinesCorrespondence: Robert Edward T Ang, Asian Eye Institute, 8th Floor PHINMA Plaza, Rockwell Center, Makati City, Philippines, Email angbobby@hotmail.comPurpose: To show the visual and refractive outcomes in Asian eyes with cataract when bilaterally implanted with either a hydrophobic FineVision POD F GF or a hydrophilic FineVision POD F intraocular lens (IOL).Methods: Forty-six patients were randomized to receive POD F GF or POD F IOLs. Visual and refractive outcomes were assessed up to 24 months post-surgery. Measurements included uncorrected-distance visual acuity, corrected-distance visual acuity (CDVA), distance-corrected intermediate visual acuity (DCIVA), distance-corrected near visual acuity (DCNVA), refraction, defocus curve, photopic and mesopic contrast sensitivity, and patient-reported outcomes.Results: Mean spherical equivalent was close to emmetropia for both groups and stable across postoperative visits. Overall, 97.73% and 100% of eyes in the POD F GF IOL group and 95.65% and 100%, of eyes in the POD F IOL group were within ± 1.00D of the target refraction at 12 and 24 months, respectively. All patients showed a CDVA of ≥ 20/25 at 12- and 24-months post-surgery. In both groups, 24 months post-surgery 91% of patients presented a DCIVA of ≥ 20/25 and 83.3% of patients had a DCNVA of ≥ 20/25. Defocus curve showed continuous visual acuity, being 20/32 or better in both groups over a 4.00D range between 1.00D and − 3.00/-3.50D. Both groups showed good contrast sensitivity values for photopic and mesopic conditions. Overall, 86.4%, 86.4%, and 72.7% of patients implanted with the POD F GF IOL reported not wearing glasses at all for distance, intermediate, and near vision, respectively. These values were 81.8%, 86.4%, and 90.9% for patients implanted with the POD F IOL. Both groups of patients reported similar satisfaction percentages (100% very satisfied/satisfied) and would recommend the procedure (100% definitively yes/probably yes).Conclusion: This study demonstrates good visual and refractive outcomes for both the FineVision POD F GF and the FineVision POD F IOLs when implanted in Asian eyes.Keywords: trifocal, Asian, glistening-free, intraocular lens, cataract

Supaporn Srithawatpong,1,2 Pareena Chaitanuwong,1,2 Yosanan Yospaiboon3 1Department of Ophthalmology, Rajavithi Hospital, Ministry of Public Health, Bangkok, Thailand; 2Department of Ophthalmology, College of Medicine, Rangsit University, Bangkok, Thailand; 3Department of Ophthalmology, Faculty of Medicine, Khon Kaen University, Khon Kaen, ThailandCorrespondence: Yosanan Yospaiboon, Department of Ophthalmology, Faculty of Medicine, Khon Kaen University, 123 Mitraparb Highway, Khon Kaen, 40002, Thailand, Tel +66-4336-3010, Fax +66-4334-8383, Email yyosanan@gmail.comPurpose: To study visual recovery and identify the factors that may affect it in patients with ethambutol-induced optic neuropathy (EON).Patients and Methods: Medical charts of patients who developed optic neuropathy after ethambutol (EMB) treatment for tuberculosis infection were retrospectively reviewed. Demographic details and clinical data were examined to assess visual recovery after discontinuation of ethambutol treatment. The univariate and multivariate relationships between various factors and visual recovery were evaluated using regression analysis.Results: Of 5394 patients diagnosed with tuberculosis infection and treated with EMB, 23 patients (0.43%) were diagnosed with EON. Logistic regression analysis found that female sex was the categorical factor significantly associated with good visual recovery with an odds ratio of 12.0 (95% confidence interval 1.56, 92.29; p = 0.02), while linear regression analysis identified good initial visual acuity as the numerical factor significantly related with it (p < 0.001). After adjustment with multivariate analysis, initial visual acuity was found to be the only significant factor associated with visual recovery. All patients with initial visual acuity of better than 20/200 at first visit achieved good visual recovery.Conclusion: The incidence of EON in patients treated with EMB was 0.43% in this hospital-based study. Good visual recovery was noted in 39.13% of these patients, and initial visual acuity was the factor that affected visual recovery. It is recommended that patients on EMB have regular screening by an ophthalmologist for early detection of the disease, and if it is discovered, that the use of the drug be immediately discontinued in order to prevent potentially devastating visual loss.Keywords: ethambutol, optic neuropathy, visual recovery

Jun Zhang, Li Zheng, Yixuan Zhang, Ke Wang Department of Ophthalmology, Hangzhou MSK Eye Hospital, Hangzhou, People’s Republic of ChinaCorrespondence: Jun Zhang, Department of Ophthalmology, Hangzhou MSK Eye Hospital, Hangzhou, People’s Republic of China, Tel +86-18667046602 ; +86-0571 85064148, Email zhangjun@mskyk.onaliyun.comPurpose: To analyze the corneal asphericity, longitudinal spherical aberration (LSA), and related factors in Chinese myopic adult eyes.Methods: This was a retrospective study of myopic adult patients. The corneal asphericity and LSA were measured at 3.0, 4.0, 5.0, 6.0, and 7.0 mm diameter apertures using corneal tomography. Age and refractive power were recorded for correlation analysis.Results: In total, 531 females and 384 males were included. At the above five diameter settings the corneal asphericity values (Q) of the anterior surface were − 0.09± 0.21, − 0.14± 0.16, − 0.15± 0.13, − 0.17± 0.11, and − 0.20± 0.11, and those of the posterior surface were 0.23± 0.49, 0.06± 0.29, − 0.01± 0.22, − 0.07± 0.16, and − 0.08± 0.15, respectively. The anterior corneal LSA values at these diameters were 0.39± 0.19, 0.63± 0.27, 0.97± 0.36, 0.90± 0.30, and 0.83± 0.29 D, respectively and the whole corneal values were 0.26± 0.20, 0.44± 0.27, 0.70± 0.36, 0.66± 0.30, and 0.59± 0.28 D, respectively. Corneal asphericity and peripheral LSA showed no or weak correlation with age or spherical equivalent (all r < 0.2).Conclusion: Corneal anterior and posterior Q values in myopia patients are negatively correlated with corneal diameter. Corneal anterior and whole corneal LSA increased significantly with diameter up to 5 mm, then decreased slightly with diameter. Corneal asphericity and peripheral LSA showed very weak or no correlation with age or spherical equivalent.Clinical Trial Registration Number: ChiCTR1800015985.Keywords: wavefront aberration, asphericity, longitudinal spherical aberration, myopia

Guilherme Castela,1– 3 Joana Providência,1,2 Madalena Monteiro,1 Bárbara Oliveiros,2 Sónia Silva,4 Manuel Brito,4 Egídio Machado,5 Joaquim Neto Murta,1,2 Miguel Castelo-Branco,2,3,&ast; Zélia Correa6,&ast; 1Department of Ophthalmology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; 2Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal; 3Coimbra Institute for Biomedical Imaging and Translational Research (CIBIT), Coimbra, Portugal; 4Department of Pediatric Oncology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; 5Department of Medical Imaging, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; 6University of Miami, Bascom Palmer Eye Institute, Miami, FL, USA&ast;These authors contributed equally to this workCorrespondence: Guilherme Castela, Department of Ophthalmology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof Mota Pinto, Coimbra, 3004-561, Portugal, Tel +351919702206, Email gcastela@hotmail.comPurpose: We aim to report about effectiveness and safety in the context of our centers’ setting in the management of retinoblastoma with intra-arterial chemotherapy (IAC) in a 5-year retrospective analysis of the Portuguese population.Patients and Methods: Retrospective analysis of consecutive cases of retinoblastoma selected to initiate IAC between 2015 and 2020, at the Portuguese National Reference Center. All included patients underwent complete ophthalmological evaluation under anesthesia with fundus photography. Diagnosis and classification of retinoblastoma was made according to the International Classification of Intraocular Retinoblastoma (ICRB). The patients were further divided into two groups: Group I for primary IAC and Group II for secondary IAC. Tumor recurrence or relapses, systemic metastasis and deaths were documented. Main efficacy outcome included ocular salvage and recurrence-free survival rates estimated using the Kaplan–Meier method.Results: Twenty-eight eyes (19 eyes included in Group I and 9 eyes included in Group II) were eligible and a total of 130 IAC procedures were performed, with a median number of sessions of 4 (range 1– 8) for each treated eye, during a median follow-up of 21 months (range 4– 64). Of the included eyes, 22 (78.6%) were preserved. An overall survival of 100% was achieved. Considering the preserved eyes, the overall median decimal visual acuity achieved at the last visit was 0.15 (range 0.02– 0.8). Three patients had permanent adverse events related to IAC (cataract, vitreous hemorrhage and choroidal ischemia). Considering the survival analysis of recurrence, the mean survival without recurrence was 84.2% for Group I and 66.7% for Group II, and the mean survival without enucleation was 78.6% (no events in Group II).Conclusion: IAC has been shown to be an effective and safe treatment for children with intraocular retinoblastoma. This study demonstrates that IAC is effective even in moderate sample sizes, when a multidisciplinary approach is available.Keywords: retinoblastoma, intra-arterial chemotherapy, ocular oncology, pediatric oncology

Marjan Farid,1 Brandon D Ayres,2 Eric Donnenfeld,3 Ian Benjamin Gaddie,4 Preeya K Gupta,5 Edward Holland,6 Richard Lindstrom,7 Stephen C Pflugfelder,8 Paul M Karpecki,9 Kelly K Nichols,10 Christopher E Starr,11 Elizabeth Yeu12 1Gavin Herbert Eye Institute, UC-Irvine, Irvine, CA, USA; 2Wills Eye Hospital, Philadelphia, PA, USA; 3Ophthalmic Consultants of Long Island, Long Island, NY, USA; 4Gaddie Eye Centers, Louisville, KY, USA; 5Triangle Eye Consultants, Raleigh, NC and Tulane University, New Orleans, LA, USA; 6University of Cincinnati, Cincinnati, OH, USA; 7University of Minnesota, Minneapolis, MN, USA; 8Baylor College of Medicine, Houston, TX, USA; 9Kentucky Eye Institute, Lexington, KY, USA; 10University of Alabama at Birmingham, School of Optometry, Birmingham, AL, USA; 11Weill Cornell Medicine, New York, NY, USA; 12Virginia Eye Consultants, Norfolk, VA, USACorrespondence: Marjan Farid, University of California, 850 Health Sciences Road, Mail Code: 4375, Irvine, CA, 92697, USA, Tel +1 949 824-0327, Email mfarid@uci.eduPurpose: To obtain consensus on Demodex blepharitis (DB) treatment using a modified Delphi panel process.Methods: Literature search identified gaps in knowledge surrounding treatment of DB. Twelve ocular surface disease experts comprised the Demodex Expert Panel on Treatment and Eyelid Health (DEPTH). They completed a live roundtable discussion in addition to 3 surveys consisting of scaled, open-ended, true/false, and multiple-choice questions pertaining to the treatment of DB. Consensus for scaled questions using a 1 to 9 Likert scale was predefined as median scores of 7– 9 and 1– 3. For other question types, consensus was achieved when 8 of 12 panelists agreed.Results: The experts agreed that an effective therapeutic agent for treatment of DB would likely decrease the necessity of mechanical intervention, such as lid scrubs or blepharoexfoliation (Median = 8.5; Range 2– 9). When treating DB, panelists believed that collarettes serve as a surrogate for mites, and that eliminating or reducing collarettes should be the main clinical goal of treatment (Median = 8; Range 7– 9). The panelists would treat patients with at least 10 collarettes, regardless of other signs or symptoms and agreed that DB can be cured, but there is always the possibility for a reinfestation (n = 12). There was also consensus that collarettes, and therefore mites, are the primary treatment target and the way by which clinicians can monitor patient response to therapy (Median = 8; Range 7– 9).Conclusion: Expert panelists achieved consensus on key facets of DB treatment. Specifically, there was consensus that collarettes are pathognomonic for DB, that DB patients with > 10 collarettes should be treated even in the absence of symptoms, and that treatment efficacy can be tracked by collarette resolution. By increasing awareness about DB, understanding the goals of and monitoring treatment efficacy, patients will receive better care and, ultimately, better clinical outcomes.Keywords: collarettes, cylindrical dandruff, ocular surface disease, eyelid disease

Veshesh Patel, Landon J Rohowetz, Parastou Pakravan, Meghana Kalavar, Nicolas A Yannuzzi, Jayanth Sridhar Department of Ophthalmology, Bascom Palmer Eye Institute University of Miami, Miami, FL, USACorrespondence: Jayanth Sridhar, Department of Ophthalmology, Bascom Palmer Eye Institute, 900 NW 17th St, Miami, FL, 33136, USA, Tel +1 305 326-6124, Email jsridhar1@med.miami.eduObjective: To review clinical outcomes of patients with proliferative diabetic retinopathy (PDR) and vitreous hemorrhage (VH) who underwent pars plana vitrectomy (PPV) with endolaser panretinal photocoagulation (PRP) without retinal detachment (RD) repair.Methods: Retrospective chart review of the rate of postoperative clinical findings and visual acuity in patients with PDR from May 2014 to August 2021.Results: Pars plana vitrectomy with endolaser PRP was performed in 81 eyes of 81 patients (mean age of 62.1 ± 10.5 years). At a median follow-up of 18 months, mean Snellen best-corrected visual acuity (BCVA) significantly improved from 20/774 preoperatively to 20/53 at last follow-up (P < 0.001). Postoperative complications and clinical findings included VH (12.3%), diabetic macular edema (DME) (12.3%), ocular hypertension (8.6%), RD (4.9%), and need for additional PPV (6.2%). Eyes with PRP performed within 6 months before surgery had a lower frequency of developing postoperative VH (5.3%) compared to eyes that received PRP more than 6 months before surgery (27.3%, P = 0.04). Eyes that received preoperative anti-vascular endothelial growth factor (VEGF) treatment (2.0%) had a lower frequency of postoperative VH compared to eyes that did not receive anti-VEGF treatment (14.3%, P = 0.04). Eyes that received intraoperative sub-tenon triamcinolone acetonide developed postoperative DME (4.0%) less frequently than eyes that did not receive sub-tenon triamcinolone acetonide (26.7%, P = 0.04).Conclusion: In patients with PDR and VH, PPV with PRP yielded significant improvements in visual acuity and resulted in overall low rates of recurrent postoperative VH. Preoperative anti-VEGF and PRP laser treatment were associated with lower rates of postoperative VH. Furthermore, intraoperative use of sub-tenon triamcinolone acetonide was associated with a lower rate of postoperative DME. Pars plana vitrectomy with endolaser PRP in conjunction with the aforementioned pre- and intraoperative therapies is an effective treatment for patients with PDR and VH.Keywords: pars plana vitrectomy, panretinal photocoagulation, vitreous hemorrhage, vascular endothelial growth factor, sub-tenon triamcinolone acetonide

Li Xie,1 Ehsan Vaghefi,1,2 Song Yang,1 David Han,1,2 John Marshall,3 David Squirrell1,4 1Toku Eyes Limited, Auckland, New Zealand; 2School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand; 3Institute of Ophthalmology, UCL, London, UK; 4Department of Ophthalmology, Auckland District Health Board, Auckland, New ZealandCorrespondence: Ehsan Vaghefi, Tel +6493737599, Email e.vaghefi@auckland.ac.nzPurpose: To create an ensemble of Convolutional Neural Networks (CNNs), capable of detecting and stratifying the risk of progressive age-related macular degeneration (AMD) from retinal photographs.Design: Retrospective cohort study.Methods: Three individual CNNs are trained to accurately detect 1) advanced AMD, 2) drusen size and 3) the presence or otherwise of pigmentary abnormalities, from macular centered retinal images were developed. The CNNs were then arranged in a “cascading” architecture to calculate the Age-related Eye Disease Study (AREDS) Simplified 5-level risk Severity score (Risk Score 0 – Risk Score 4), for test images. The process was repeated creating a simplified binary “low risk” (Scores 0– 2) and “high risk” (Risk Score 3– 4) classification.Participants: There were a total of 188,006 images, of which 118,254 images were deemed gradable, representing 4591 patients, from the AREDS1 dataset. The gradable images were split into 50%/25%/25% ratios for training, validation and test purposes.Main Outcome Measures: The ability of the ensemble of CNNs using retinal images to predict an individual’s risk of experiencing progression of their AMD based on the AREDS 5-step Simplified Severity Scale.Results: When assessed against the 5-step Simplified Severity Scale, the results generated by the ensemble of CNN’s achieved an accuracy of 80.43% (quadratic kappa 0.870). When assessed against a simplified binary (Low Risk/High Risk) classification, an accuracy of 98.08%, sensitivity of ≥ 85% and specificity of ≥ 99% was achieved.Conclusion: We have created an ensemble of neural networks, trained on the AREDS 1 dataset, that is able to accurately calculate an individual’s score on the AREDS 5-step Simplified Severity Scale for AMD. If the results presented were replicated, then this ensemble of CNNs could be used as a screening tool that has the potential to significantly improve health outcomes by identifying asymptomatic individuals who would benefit from AREDS2 macular supplements.Keywords: AREDS, Simplified Severity Scale, AMD, neural networks

Paras P Shah,1 Aisha Hasan,2 Jules Winokur,1,2 Richard Braunstein,1,2 David C Ritterband,1,2 John A Seedor,1,2 Isha Cheela1,2 1Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; 2Department of Ophthalmology, Northwell Health/Manhattan Eye, Ear & Throat Hospital, New York, NY, USACorrespondence: Paras P Shah, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Blvd, Hempstead, NY, 11549, USA, Email pshah27@northwell.eduPurpose: Although several donor, recipient, and graft characteristics have been studied in relation to corneal transplantation outcomes, no study to our knowledge has assessed the impact of donor cooling times on postoperative outcomes longitudinally. With only one corneal graft available for every 70 needed worldwide, this study seeks to identify any factors that could alleviate this shortage.Methods: Patients undergoing corneal transplantation at the Manhattan Eye, Ear & Throat Hospital over a 2-year period were retrospectively studied. Study metrics included age, diabetic history, hypertensive history, endothelial cell density, death-to-preservation time (DTP), death-to-cooling time (DTC), and time-in-preservation (TIP). Postoperative transplantation outcomes, including best corrected visual acuity (BCVA) at 6- and 12-month follow-up visits, need for re-bubbling, and need for re-grafting, were assessed. Unadjusted univariate and adjusted multivariate binary logistic regressions were performed to determine the association of cooling and preservation parameters with corneal transplantation outcomes.Results: Among 111 transplants, our adjusted model found that DTC ≥ 4 hours was associated with significantly worse BCVA, but only at 6-month postoperative follow-up (odds ratio [OR]: 0.234; 95% confidence interval [CI]: 0.073– 0.747; p = 0.014). By 12-month follow-up, DTC > 4 hours was no longer associated with BCVA in a statistically significant manner (OR: 0.472; 95% CI: 0.135– 1.653; p = 0.240). A similar trend was found at a DTC cutoff of ≥ 3 hours. None of the other studied parameters, including DTP, TIP, donor age, or medical history were significantly correlated with transplantation outcomes.Conclusion: Longer DTC or DTP did not have a statistically significant effect on corneal graft outcomes after one year, though short-term outcomes were improved in donor tissues with DTC below four hours. None of the other studied variables correlated with transplantation outcomes. Given the global shortage of corneal tissue, these findings should be considered when determining suitability for transplantation.Keywords: corneal transplant, donor, recipient, outcome, cooling, refrigeration

Omar Trabelsi,1 Mejda Bouladi,2 Amel Ouertani,1 Ahmed Trabelsi1 1Clinique Ophtalmologique de Tunis, Tunis, Tunisia; 2Department of Surgery, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, TunisiaCorrespondence: Mejda Bouladi, Faculty of Medicine of Tunis, University of Tunis El Manar, 24, rue Amilcar, cité Wifec, 2070, La Marsa, Tunis, Tunisia, Tel +21698561086, Email mejda.bouladi@fmt.utm.tnBackground: To evaluate retinal reattachment, visual functional results, and complications rates after total tamponade (TT) with perfluorocarbon liquid (PFCL) and silicone oil (SO) for 2 days followed by PFCL-SO exchange in complex retinal detachment (RD).Methods: Retrospective study including 52 consecutive eyes with complex RD and advanced proliferative vitreoretinopathy, who underwent vitrectomy with TT. Patients underwent first surgery by 25-Gauge vitrectomy and partial PFCL-SO exchange (approximately 60% PFCL 40% SO fill) followed by second surgery with extraction of the PFCL and complete SO fill.Results: After a mean follow-up period of 25.15 ± 6.6 months, the retina remained reattached in 48/52 eyes (92.3%) including 28 eyes (58.3%) without SO and 20 eyes (41.7%) with prolonged SO tamponade. Visual acuity improved in 45 eyes (86.6%) (P< 0.001), remained stable in 4 eyes (7.7%) and decreased in 3 eyes (5.7%). Complications consisted in mild anterior chamber inflammation in 10 eyes, ocular hypertension in 12 eyes, and cataract in 10 eyes.Conclusion: Two-day TT with PFCL and SO may be considered in complex RD with advanced proliferative vitreoretinopathy especially in monocular patients. Further studies with longer follow-up period and retinal electrophysiologic assessment may be needed.Keywords: complex retinal detachment, proliferative vitreoretinopathy, monocular patient, perfluorocarbon liquid, silicone oil, positioning