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The aim of this study was to compare outcomes between cases of Acanthamoeba keratitis (AK) diagnosed and treated with or without the use of in vivo confocal microscopy (IVCM).We performed a retrospective comparative case series of 26 eyes of 23 patients diagnosed with AK at the Massachusetts Eye and Ear Infirmary over a 5-year period. The characteristics of all identified cases were summarized. We compared the time from presentation to diagnosis of AK (primary outcome), visual acuity, and rates of therapeutic penetrating keratoplasty between eyes diagnosed by culture-only group (n = 8) and by IVCM to diagnose AK (n = 9) and later confirmed by culture (IVCM/C group).The diagnostic delay was significantly longer in the culture only group (25 ± 29 days) compared with the IVCM/C group (3 ± 3 days, P0.01). At 6 months, there was a significant difference in best-corrected visual acuity between the culture-only group (1.46 ± 1.07, n = 7) and the IVCM/C group (0.22 ± 0.22, n = 8), after adjusting for initial baseline visual acuity (P = 0.02). Therapeutic penetrating keratoplasty was performed in 50% of culture-only (n = 7) and 11% of IVCM/C group eyes (n = 9), but this was not statistically significant (P = 0.13).IVCM can expedite the diagnosis of AK, and its use as an adjunct tool in the diagnosis of AK may result in better patient outcomes compared with basing treatment decisions on corneal cultures alone.

Hyunjoo J Lee, Manishi A Desai, Natalie Sadlak, Marissa G Fiorello, Wanjiku G Githere, Manju L SubramanianOn behalf of The Oral versus Intravenous Sedation Study GroupDepartment of Ophthalmology, Boston Medical Center, Boston, MA, USACorrespondence: Hyunjoo J Lee, Department of Ophthalmology, Boston Medical Center, 85 East Concord Street, 8th Floor, Boston, MA, 02118, USA, Tel +1 617 414 2020, Fax +1 617 414 2929, Email leehj@bu.eduPurpose: To determine whether oral sedation is as safe and effective as IV sedation for ophthalmic surgeries other than cataract surgery, we tested whether patient satisfaction with oral triazolam was non-inferior to IV midazolam for cornea and glaucoma surgeries.Patients and Methods: Seventy-five cornea and 49 glaucoma surgery patients 18 years and older at Boston Medical Center (Boston, MA) were randomized within each study group (cornea or glaucoma) to receive oral triazolam + IV placebo, or oral placebo + IV midazolam before surgery in a double-masked fashion. Supplemental IV anesthesia was administered as needed during surgery. The primary outcome measure was patient satisfaction with anesthesia, compared between oral and IV sedation groups via t-test for non-inferiority, based on 70 cornea and 43 glaucoma subjects completing the study. Secondary outcome measures included surgeon and anesthesia provider satisfaction with anesthesia, rate of supplemental IV anesthesia, and incidence of adverse events and surgical complications.Results: Using an a priori non-inferiority margin of 0.5, initial oral sedation was non-inferior to initial IV sedation in cornea (n=70, p< 0.001) and glaucoma (n=43, p=0.017) groups, even after excluding subjects administered supplemental IV anesthesia. There were no significant differences in anesthesia provider or surgeon satisfaction, intra-operative complications, adverse events, or supplemental anesthesia between groups, except for higher anesthesia provider satisfaction with oral sedation in an Ahmed or Baerveldt implant ± cataract surgery sub-group (p=0.04). Subjects receiving supplemental anesthesia included 6 oral (18.2%) and 5 IV (13.5%) in the cornea group (p=0.59), and 7 oral (29.2%) and 6 IV (31.6%) in the glaucoma group (p=0.50).Conclusion: Our results suggest that an initial dose of oral triazolam is equivalent to IV midazolam for non-cataract anterior segment surgeries. However, there was a relatively high need for supplemental IV anesthesia during some surgery types, particularly with glaucoma tube shunt implantation.Keywords: triazolam, midazolam, oral sedation, anesthesia, cornea, glaucoma, ophthalmic surgery

The purpose of this study was to investigate corneal endothelial cell density (ECD) and morphology between normal tension glaucoma (NTG) and controls. A cross-sectional, single center study of 24 NTG and 26 age-matched healthy eyes were included. ECD, mean cell size (MCA) and coefficient of variance (CV) were analyzed, controlling for age and number and duration of concurrent glaucoma medications. NTG subjects had significantly lower ECD (2307 ± 514.7 vs. 2558 ± 278.5, p = 0.044) and larger MCA (458.3 ± 94.8 vs. 386.7 ± 57.3, p = 0.004), but no difference in CV compared to healthy subjects. NTG subjects stratified by number of glaucoma medications showed significant differences in ECD (p = 0.024) and MCA (p = 0.021), but no difference in CV. There were no significant differences in ECD, MCA or CV between subjects stratified by duration of glaucoma medication usage. After age-adjusting, there was no dose-dependent relationship between mean ECD or MCA and number of glaucoma medications. Post hoc analysis demonstrated only NTG subjects on three or more glaucoma medications had statistically significant differences in ECD (p = 0.032) and MCA (p = 0.037) compared to NTG subjects on two glaucoma medications. This study suggests that NTG is associated with lower corneal endothelial cell density and mean cell size.

Natalie Sadlak,1 Marissa G Fiorello,1 Howard J Cabral,2 Manju L Subramanian,1 Manishi A Desai,1 Hyunjoo J Lee1 1Department of Ophthalmology, Boston University School of Medicine, Boston, MA, USA; 2Department of Biostatistics, Boston University School of Public Health, Boston, MA, USACorrespondence: Hyunjoo J Lee, Boston University School of Medicine, 85 East Concord Street, 8th Floor, Boston, MA, 02118, USA, Tel +1 617 414-2230, Fax +1 617 638-8301, Email leehj@bu.eduPurpose: This secondary analysis of a clinical trial that measured surgeon, anesthesiologist, and patient satisfaction following ophthalmic surgery under monitored anesthesia care (MAC) with a benzodiazepine investigates the degree of association between patient satisfaction with anesthesia compared to surgeon and anesthesiologist satisfaction with anesthesia.Patients and Methods: Data from analogous 6-point surgeon satisfaction surveys and anesthesiologist satisfaction surveys were compared to data from a 6-point validated patient satisfaction survey collected from a clinical trial investigating satisfaction with different forms of benzodiazepine for patients undergoing cataract, retina, cornea, or glaucoma surgery. Relationships between measures were analyzed using Pearson’s correlation coefficient, with further subgroup analysis based on language groups and single-question measures of satisfaction.Results: A total of 283 ophthalmic surgical cases were analyzed. Mean surgeon satisfaction was 5.27 (range, 1.33– 6.00), mean anesthesiologist satisfaction was 5.12 (range, 1.17– 6.00), and mean patient satisfaction was 5.28 (range, 2.58– 6.00). The correlation between surgeon and patient satisfaction was 0.333 (p = 9.06e-9), while the correlation between anesthesiologist and patient satisfaction was 0.319 (p = 4.28e-8). There was no difference between English and non-English speaking patients in correlation between surgeon and patient satisfaction (p = 0.08) and anesthesiologist and patient satisfaction (p = 0.47).Conclusion: The data demonstrate a low level of association between patient satisfaction with anesthesia and provider satisfaction, even when patient language is taken into consideration. This suggests that providers are poor predictors of patient satisfaction with anesthesia and are unreliable judges of patient comfort perioperatively.Keywords: conscious sedation, quality measures, monitored anesthesia care, ocular procedures

To determine whether patient satisfaction with oral sedation is noninferior to intravenous sedation for cataract surgery.Prospective, randomized, double-masked clinical trial.A volunteer sample of patients 18 years or older from diverse backgrounds scheduled for cataract surgery. Patients who were allergic to benzodiazepines, older than 70 years with a failed delirium screening questionnaire, pregnant or nursing, using a medication inhibiting cytochrome 450 3A, or intoxicated on the day of surgery were excluded.Patients were randomized to receive either oral triazolam with intravenous placebo or intravenous midazolam with oral placebo before surgery.The primary outcome was patient satisfaction, measured by a survey administered on postoperative day 1. Secondary outcomes included surgeon and anesthesia provider satisfaction, need for supplemental anesthesia, and surgical complications.Among the 85 patients (42 men [49.4%]; mean age, 65.8 years; standard deviation, 9.5 years) completing the study, the mean satisfaction score was 5.34±0.63 (range, 3.75-6) in the oral sedation group and 5.40±0.52 (range, 4-6) in the intravenous group. With an a priori noninferiority margin of 0.5 and a difference in mean scores between the 2 groups of 0.06 (1-tailed 95% confidence interval [CI], -infinity to 0.27), our results demonstrate noninferiority of oral sedation with a P value of 0.0004. Surgeon and anesthesia provider satisfaction was similar between the 2 groups. Intraoperative complications occurred in 16.7% in the oral group and 9.3% in the intravenous group (difference, 7.4%; 95% CI, -6.9% to 21.6%; P = 0.31). The only major intraoperative complication-a posterior capsular tear-occurred in the intravenous group. Eight patients in the oral group (19.0%) and 3 in the intravenous group (7.0%) received supplemental intravenous sedation (difference, 12.1%; 95% CI, -2.0% to 26.2%; P = 0.097).The use of oral sedation in cataract surgery has been suggested as a cost- and space-saving measure, potentially allowing the transition of some patients from an operating to procedure room or office-based setting. We report the noninferiority of oral compared with intravenous sedation for cataract surgery in a diverse patient population in terms of patient satisfaction.