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We discuss how ophthalmic endoscopy was used in the management of 6 cases with atypical uveitis glaucoma hyphema syndrome. For case 1, the endoscope was used to remove a retained haptic foreign body after intraocular lens (IOL) exchange with an iris sutured IOL for a complete capsular bag-IOL complex dislocation. In case 2, the endoscope was key in identifying the presence and location of vascular lesions at the site of previous pars plana sclerotomies. In case 3, the endoscope enabled visualization of a large segmental Soemmering's Ring pushing a 3-piece IOL haptic into the posterior iris. For case 4, the endoscope allowed viewing of the sharp edge of the optic where the haptic of a one-piece lens had been amputated, and the sharp edge of the cut optic was anteriorly oriented and continuing to rub the posterior iris. In case 5, the endoscope confirmed the presence of one haptic of a one-piece lens out of the capsular bag and in the sulcus space. Also, it showed that the capsular bag had inadequate zonular support to attempt repositioning of the haptic into the bag. In case 6, the endoscope was helpful in identifying a one-piece plate haptic IOL in the sulcus, with synechiae and anterior location causing iris bulging inferiorly.

Using demographic, clinical, visual field, and optical coherence tomography (OCT) variables to study the association of 5-year glaucomatous progression in glaucoma suspect eyes.This is a retrospective longitudinal clinical study. Inclusion criteria consisted of glaucoma suspect eyes (i.e., concerning cup-to-disk ratio and/or intraocular pressure (IOP)21 mm Hg), age ≥ 30 years old, follow-up time of 5 years, best-corrected visual acuity (BCVA) of 20/100 or better, spherical equivalent (SE) higher than 8 diopters and an astigmatism less than 3 diopters. Eyes with glaucoma-determined by two consecutive, reliable visual field tests-were excluded, as well as any eyes with any clinically significant retinal or neurological disease. The percentage of glaucoma suspect eyes, which progressed to glaucoma within a 5-year period, was calculated. Study subjects were divided into the following groups: eyes that progressed to glaucoma and those that did not.In the 288 patients which we looked at, 365 total eyes, 323 eyes had concerning cup-to-disk ratio and 42 had ocular hypertension. Bivariate analysis showed that the eyes which progressed to glaucoma had significantly worse mean deviation, increased pattern standard deviation (PSD), and less visual field index (VFI). Our bivariate analysis also showed a thinner average, superior and inferior retinal nerve fiber layer thickness (RNFL), and more severe average, superior, and inferior RNFL damages (i.e., color grading scale) at baseline. Logistic regression analysis showed that only PSD and severe inferior RNFL damage (i.e., red color) to be significantly associated with 5-year glaucomatous progression.Segmental RNFL damage and pattern standard deviation are associated with 5-year glaucomatous progression in glaucoma suspect eyes.Nassiri N, Das S, Patel V

"Consensual ophthalmotonic reaction" refers to changes in intraocular pressure (IOP) in one eye, which is accompanied by a corresponding change in IOP in the contralateral eye. This study evaluates whether monocular administration of selective laser trabeculoplasty (SLT) leads to a consensual ophthalmotonic reaction and how long this effect lasts.A retrospective chart review was performed on patients receiving SLT at Kresge Eye Institute in Detroit, MI, from January 2015 to August 2016. Patients were excluded if they had previous history of glaucoma incisional and/or laser procedures; required additional laser trabeculoplasty; had glaucoma medication changes during the follow-up period; experienced no decrease in IOP during the follow-up period; or had a diagnosis of angle closure on gonioscopy. Various demographic, clinical, and surgical data were collected. IOP measurements were collected at baseline and postoperatively at 1-3 months, 4-9 months, and 12-15 months.At all follow-up periods, the IOP of the treated eye was decreased from baseline IOP (This study showed that monocular administration of SLT results in a consensual ophthalmotonic reaction. The consensual ophthalmotonic reaction appears to last for up to 4-9 months.Therefore, although SLT does lead to a consensual ophthalmotonic reaction, monocular administration of SLT is not a reliable method of long-term IOP control for the contralateral non-SLT-treated eye.Nassiri N, Mei F, Tokko H

To compare three-year surgical outcomes of trabeculectomy versus Ahmed valves in patients with prior failed trabeculectomy.This is a longitudinal retrospective comparative study of one-hundred twenty adult patients with prior failed trabeculectomy who underwent a repeat trabeculectomy or Ahmed valve implant. Demographic and clinical data were collected up to 3 years on all study participants at the Kresge Eye Institute from 2004 to 2016. Visual acuity, intraocular pressure, number of intraocular pressure reducing medications, and success rates at various time points up to 3 years after repeat surgery were the main outcome variables.Sixty-five and sixty eyes were included in the trabeculectomy and the Ahmed valve groups, respectively. Baseline intraocular pressure significantly decreased in both groups at 3 years (p 0.01). The number of medications was relatively similar to baseline in both study groups at 3 years (p 0.05). There was no statistically significant difference between the two groups in visual acuity, percentage of intraocular pressure reduction, number of medications, or success rates at any follow-up time points (p 0.05 for all).After 3 years, both trabeculectomy and Ahmed valves significantly reduced intraocular pressure from baseline, but with relatively similar number of medications compared to baseline. There was no significant difference in any outcome measure between trabeculectomy and Ahmed valves at any follow-up time points. These results may suggest neither trabeculectomy or Ahmed valves are superior in patients with previously failed trabeculectomies.

Purpose: This study determines whether fluorescein angiography (FA) with a 250-mg dose of fluorescein (half dose) is equal in quality to the standard 500-mg dose of fluorescein (full dose) when using digital ultra-widefield (UWF) technology. Methods: In a randomized, prospective study using a UWF imaging system, FAs performed with half dose were compared with angiograms performed with full dose. Imaging studies were reviewed by 4 reviewers based on 6 characteristics: dye transit, macrovasculature, macula detail, microvasculature, leakage, and overall quality. The scores for macrovasculature, macula detail, microvasculature, and overall quality were converted to a fuzzy rating score to confirm results. Results: Seventy-nine FAs from 67 patients were reviewed for this study, including 12 patients who had both half-dose and full-dose FAs. Of all the factors studied, only microvasculature received a significantly different score between full dose and half dose that was confirmed by the fuzzy rating scale (3.79 vs 3.53; P = .04). Among those eyes that received both full and half dose, there was no significant difference in any of the 6 factors. Conclusions: In a UWF imaging system, aside from looking at fine microvascular abnormalities, the 250-mg dose of fluorescein provided similar results to a 500-mg dose. The images were not significantly different in overall quality.

Trochleitis has been recognized as one of the causes of eye pain and migraine headaches. This study attempts to investigate the effect of ibuprofen on reducing eye pain and migraine headaches caused by trochleitis.In this before-after clinical trial, out of 1100 clinically examined patients with eye pain and migraine symptoms, 33 patients were diagnosed with having trochleitis and trochleodynia confirmed by orbital magnetic resonance imaging images. Ibuprofen (400 mg/6-8 h) was prescribed to the subjects for 15-30 days. The main outcomes were a reduction in tenderness and pain that were evaluated 2 weeks, a month, and 6 months after the prescription. The data were analyzed by STATA (version 14) and using Wilcoxon and McNemar tests.The results revealed that 28 of the subjects (84.8%) experienced a significant reduction in tenderness 2 weeks after undergoing the treatment (The findings revealed that noninvasive treatment (ibuprofen) has reduced eye pain, tenderness, and migraine headaches caused by trochleitis. What is important to mention is that trochleitis should be diagnosed properly.

To evaluate outcomes of repeat pars plana vitrectomy for proliferative vitreoretinopathy after previous failed pars plana vitrectomy.This is a retrospective case series including 51 eyes of 50 patients who underwent repeat surgery after failed previous pars plana vitrectomy for proliferative vitreoretinopathy from 2000 to 2015 at the Kresge Eye Institute, Detroit, MI. Patients were classified into successful and unsuccessful groups. Success was defined as retinal reattachment, silicone oil removed, and best-corrected visual acuity (BCVA) ≥5/200 at the final follow-up visit.Forty-three eyes (84.3%) were successfully reattached at the last follow-up. Seventeen (33.3%) eyes were deemed successful and 34 (66.7%) eyes unsuccessful according to our criteria. Compared with the successful group, eyes in the unsuccessful group had more eyes with preoperative BCVA5/200 (P0.001), preoperative BCVA of hand motion or worse (P = 0.002), preoperative flare ≥Grade 2+ (P = 0.03), preoperative posterior breaks (P = 0.02), previous retinectomy (P = 0.04), and final postoperative hypotony (intraocular pressure ≤ 5 mmHg) (P = 0.005). Eyes with silicone oil removed were more likely to have BCVA ≥5/200 (P0.001) at the final follow-up visit. Location of patients100 miles (P = 0.04) from Detroit and preoperative BCVA of hand motion or worse (P = 0.01) were significantly associated with failure in the logistic regression analysis.Success after repeat surgery for proliferative vitreoretinopathy should include ambulatory vision, retinal reattachment, and silicone oil removal. We identified several preoperative and perioperative factors that were associated with success in the bivariate and logistic analyses. The decision to perform surgical reoperation in these patients should be based on multiple factors, most importantly preoperative BCVA.

Nader Nassiri,1 Saeedeh Ghorbanhosseini,2 Ebrahim Jafarzadehpur,2 Sara Kavousnezhad,3 Nariman Nassiri,4 Kourosh Sheibani5 1Imam Hossein Medical Center, Shahid Beheshti University of Medical Science, Tehran, Iran; 2Department of Optometry, Iran University of Medical Sciences, Tehran, Iran; 3Vanak Eye Clinic, Tehran, Iran; 4Jules Stein Eye Institute, University of California at Los Angeles, Los Angeles, CA, USA; 5Basir Eye Health Research Center, Basir Eye Clinic, Tehran, Iran Purpose: The purpose of this study was to evaluate the visual acuity as well as endothelial cell density (ECD) and polymegathism after iris-fixated lens (Artiflex® AC 401) implantation for correction of moderate to high myopia.Patients and methods: In this retrospective cross-sectional study, 55 eyes from 29 patients undergoing iris-fixated lens implantation for correction of myopia (−5.00 to −15.00D) from 2007 to 2014 were evaluated. Uncorrected visual acuity, best spectacle-corrected visual acuity, refraction, ECD and polymegathism (coefficient of variation [CV] in the sizes of endothelial cells) were measured preoperatively and 6months postoperatively.Results: In the sixth month of follow-up, the uncorrected vision acuity was 20/25 or better in 81.5% of the eyes. The best-corrected visual acuity was 20/30 or better in 96.3% of the eyes, and more than 92% of the eyes had a refraction score of ±1D from the target refraction. The mean corneal ECD of patients before surgery was 2,803±339 cells/mm2, which changed to 2,744±369cells/mm2 six months after surgery (p=0.142). CV in the sizes of endothelial cells before the surgery was 25.7%±7.1% and six months after surgery it was 25.9%±5.4% (p=0.857).Conclusion: Artiflex iris-fixated lens implantation is a suitable and predictable method for correction of moderate to high myopia. There was no statistically significant change in ECD and polymegathism (CV in the sizes of endothelial cells) after 6months of follow-up. Keywords: cornea, endothelial cell, density, Artiflex, refractive surgery&nbsp

Introduction: Neurotrophic keratitis is a rare degenerative corneal disease caused by an impairment of trigeminal corneal innervation, leading to a decrease or absence of corneal sensation. Here, we present a case of neurotrophic keratopathy caused by B12 deficiency in a 34 years old man who had a progressive decrease in visual acuity and corneal involvement since 3 months before being referred to our ophthalmology clinic. Result and Discussion: Based on our clinical findings and with the diagnosis of B12 deficiency we started B12 treatment for the patient. After 3 weeks the patient showed a dramatic response with corneal sensation reversal, an increase of visual acuity, improved neurotrophic keratopathy and significantly improved neurological findings. To the best of our knowledge, there is no report regarding vitamin B12 deficiency induced keratopathy and this is the first report that describes this aspect of vitamin B12 deficiency.

Purpose: To investigate the frequency of conjunctival erosions in a series of patients who underwent Ahmed valve implantation in a tertiary referral center and to study risk factors associated with the conjunctival erosions. Methods: This is a single-center, retrospective case-control study of all patients who underwent Ahmed valve implantation between October 2006 and July 2016 at the Kresge Eye Institute in Detroit, Michigan. The series consisted of 306 eyes (277 patients) that underwent Ahmed valve implantation. The rate of conjunctival erosions was determined. Univariate, bivariate, and Cox-proportional hazard analyses were performed to identify factors associated with conjunctival erosions. Results: During the study period, 23 erosions occurred in 306 eyes (7.52%). Aphakia was significantly more common in eyes with erosions (P < 0.05). Aphakia (P = 0.02), uveitic glaucoma (P = 0.03), and longer post-operative use of topical steroids (P < 0.04) significantly increased the risk of erosions based on the Cox model. There were similar rates of erosions with each type of patch graft. No conjunctival erosion was observed after using the modified scleral tunnel method (n = 10). Conclusions: The overall erosion rate was 7.52% in our series. Uveitic glaucoma, aphakia, and longer post-operative use of topical steroids were significantly associated with conjunctival erosions.

Patients treated with allogeneic stem cell transplantation (allo-SCT) often develop ocular complications. To investigate the ocular findings in young long-term survivors after allo-SCT without TBI, we examined 96 patients more than 5 years after transplantation. All patients were under 30 years of age at transplantation. The mean follow-up time was 16.8 years (range 6.0–26.1 years). The study was a part of the Norwegian Allo Survivorship Study investigating health impairments in young survivors after allo-SCT. Ophthalmological examination included visual acuity, tear break-up time, corneal fluorescein staining, Schirmer I test, tear film osmolarity, biomicroscopy and dilated ophthalmoscopy. In patients with known systemic chronic GVHD (cGVHD), ocular GVHD (oGVHD) diagnosed by clinical examination was compared with diagnosis using National Institutes of Health (NIH) or International Chronic Ocular Graft-vs-Host-Disease (ICCGVHD) Consensus Group criteria. We diagnosed dry eye disease (DED) in 52 patients (54%), cataract in 3 patients (3%) and retinopathy in 1 patient (1%). Systemic cGVHD was a risk factor for DED (OR 4.40, CI 1.33–14.56, p = 0.02). Comparison of diagnostic criteria suggests that the more stringent ICCGVHD criteria can better differentiate DED from oGVHD after allo-SCT as compared with the NIH criteria.

Introduction: Dry eye disease (DED) is an important public health problem considering its prevalence, morbidity, and cost implications. In the last two decades, new insight on the pathogenesis of dry eye has resulted in development of novel therapeutic modalities.Areas covered: This review will discuss current and emerging pharmacological modalities in treatment of DED to include tear supplements, anti-inflammatory therapy, antibiotics, vitamin A, other vitamins and antioxidants, free amino acids, essential fatty acids, hormone replacement therapy, mucolytics, tear stimulation (secretagogues) and biological tear substitutes. In preparing this review, a Medline, PubMed and Cochrane Database search of the medical literature for the period between January 1978 and July 2016 using a wide range of keywords was conducted. Only treatment modalities that had their efficacy and safety investigated in clinical studies are included.Expert commentary: Many patients have multiple mechanisms contributing to DED...

Determining risk factors for posterior capsule opacification will allow for further interventions to reduce the risk of development and thus additional procedures.The purpose of this study was to investigate risk factors associated with development of clinically significant posterior capsule opacification requiring yttrium aluminum garnet (YAG) capsulotomy.Medical records of patients (≥18 years) who underwent cataract surgery between January 1, 2011, and March 31, 2014, at Kresge Eye Institute were reviewed. Three hundred eyes requiring YAG capsulotomy up to 3 years after cataract surgery were included in the YAG capsulotomy group. Three hundred eyes not requiring YAG capsulotomy up to 3 years after cataract surgery were selected via age-matched simple randomization (control group).The YAG capsulotomy group included patients with younger age (65.8 ± 11.3 vs. 70.1 ± 10.6 years, P.001), more men (42.67 vs. 34.67%, P = .04), fewer patients with hypertension (73.00 vs. 83.00%, P.001), and more patients with hydrophilic intraocular lenses (74.67 vs. 47.00%, P.001). Logistic regression analysis demonstrated a negative association between YAG capsulotomy and age (coefficient, -0.04; 95% confidence interval [CI], 0.95 to 0.98; P.001) and hydrophobic intraocular lenses (coefficient, -1.50; 95% CI, 0.15 to 0.33; P.001), and a positive association with presence of glaucoma (coefficient, 0.88; 95% CI, 1.39 to 4.17; P = .002). Elapsed time to YAG capsulotomy was sooner in patients with a history of uveitis (95% CI, 5.10 to 9.70 months; P = .02) and insertion of hydrophilic intraocular lenses (95% CI, 18.67 to 21.57 months; P.001).Results of this study suggest that development of visually significant posterior capsule opacification is associated with younger age, glaucoma, and hydrophilic intraocular lenses, and it occurs earlier among those with hydrophilic intraocular lenses and a history of uveitis.

Purpose: To study angular and temporal vein engorgement following periorbital hyaluronic acid gel (HAG) injection. Methods: In this retrospective study, the authors reviewed the photographs of 805 patients who had periorbital HAG injection at Jules Stein Eye Institute Oculoplastic Clinic between January 2004 and January 2014. HAG injections were used to fill the orbital hollow, zygomatic hollow, septal confluence hollow, and cheek. The inclusion criteria were patients who had at least 1 pre-, immediate post-, and late postinjection photographs. Immediate postinjection photographs were taken right after HAG injection, and late postinjection photographs were taken at the following visit before any injection. The exclusion criteria were patients with any previous ocular surgery 6 months before filler injection, patients with orbital diseases, and patients who had HAG injections for functional purposes. The photographs were evaluated for the presence of angular and temporal vein engorgement at any of the injections during the follow-up visits. The photographs of eyes with vein engorgement were graded on a scale of 0 (no engorgement), 1 (mild engorgement), 2 (moderate engorgement), and 3 (severe engorgement). Results: There were 78 eligible patients (156 orbits; 68 females and 10 males) with average age of 59.4 ± 13.4 years. The authors found 18 orbits of 12 patients (15.4%; 6 unilateral and 6 bilateral) with angular vein engorgement at least 1 time after HAG injection during the follow-up visits. The frequency of temporal vein engorgement was 9.1%. The mean ± SD of angular vein grading for engorgement increased from 0.72 ± 0.51 on preinjection photographs to 1.45 ± 0.88 on immediate postinjection photographs (p = 0.0001) and 0.89 ± 0.50 on late postinjection photographs (p = 0.04). The mean ± SD of angular vein grading for engorgement was 0.67 ± 0.55 on the first preinjection photographs, which increased to 1.10 ± 0.50 on the last late postinjection photographs. The difference was statistically significant (p = 0.001). Conclusions: Angular and temporal vein engorgement occurred following HAG injection in the periorbital region. The engorgement occurred immediately after injections and decreased considerably but not completely in the following visit.

PURPOSE: To compare refractive outcomes, contrast sensitivity, higher-order aberrations (HOAs), and patient satisfaction after photorefractive keratectomy for correction of moderate myopia with two methods: tissue saving versus wavefront optimized. METHODS: In this prospective, comparative study, 152 eyes (80 patients) with moderate myopia with and without astigmatism were randomly divided into two groups: the tissue-saving group (Technolas 217z Zyoptix laser; Bausch & Lomb, Rochester, NY) (76 eyes of 39 patients) or the wavefront-optimized group (WaveLight Allegretto Wave Eye-Q laser; Alcon Laboratories, Inc., Fort Worth, TX) (76 eyes of 41 patients). Preoperative and 3-month postoperative refractive outcomes, contrast sensitivity, HOAs, and patient satisfaction were compared between the two groups. RESULTS: The mean spherical equivalent was −4.50 ± 1.02 diopters. No statistically significant differences were detected between the groups in terms of uncorrected and corrected distance visual acuity and spherical equivalent preoperatively and 3 months postoperatively. No statistically significant differences were seen in the amount of preoperative to postoperative contrast sensitivity changes between the two groups in photopic and mesopic conditions. HOAs and Q factor increased in both groups postoperatively ( P = .001), with the tissue-saving method causing more increases in HOAs ( P = .007) and Q factor ( P = .039). Patient satisfaction was comparable between both groups. CONCLUSIONS: Both platforms were effective in correcting moderate myopia with or without astigmatism. No difference in refractive outcome, contrast sensitivity changes, and patient satisfaction between the groups was observed. Postoperatively, the tissue-saving method caused a higher increase in HOAs and Q factor compared to the wavefront-optimized method, which could be due to larger optical zone sizes in the tissue-saving group. [ J Refract Surg. 2015;31(10):683–688.]

Orbital lymphaticovenous malformations consist of abnormal vascular channels lined by endothelial cells with a spectrum from venous to lymphatic characteristics. They may be venous-dominant or lymphatic-dominant. These lesions continue to present management challenges. Total excision or obliteration is not always achievable, recrudescence is common, and interventions carry a risk of damaging normal structures. Patients likely benefit most from a multidisciplinary approach, including both surgical and nonsurgical (e.g., sclerosants and liquid polymers) therapeutic modalities. Targeted biologic therapy would be ideal; nevertheless, this goal is complicated by the heterogeneous venous-lymphatic and stromal characteristics of these lesions. Ideally, antiangiogenic agents targeting both lymphatic and blood vascular endothelial cells will be developed to treat these lesions and reduce their regrowth. Further studies are warranted to enhance our understanding of these orbital lesions with regard to their angiogenic (proliferative) activities and profiles of marker expression, with a goal to produce effective medical therapies.

Purpose To determine the causes of lacrimal gland inflammation based on histopathology and systemic evaluation. Methods This is a retrospective case series study. From the University of British Columbia Orbit Clinic between January 1976 and December 2008, we reviewed the medical records of 60 patients who presented with inflammatory features of the lacrimal gland (i.e., erythema, edema, or tenderness) in which the diagnoses were not possible clinically and on imaging alone. As was our routine practice, all these patients underwent lacrimal gland biopsy before starting any treatment. Results The histopathologic findings of the 60 patients showed that 37 (61.7%) had identifiable types of lacrimal inflammation including 10 with Sjogren's syndrome, seven with sarcoidal reaction, six with feature of granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis), five with lymphoma, two with sclerosing inflammation, two with IgG4-related dacryoadenitis, and one patient each with infectious dacryoadenitis, myoepithelial carcinoma, xanthogranuloma, eosinophilic angiocentric fibrosis, and eosinophilic allergic granulomatous nodule. The histopathologic findings of the remaining 23 (38.3%) patients showed nonspecific inflammation of the lacrimal gland. 23 patients (38.3%) had associated systemic diseases. 48 patients (80%) were treated successfully and 10 (16.7%) had recurrence of inflammation. Conclusions We recommend that in patients presenting with lacrimal gland inflammation (i.e., erythema, edema, tenderness) in which the specific diagnosis cannot be made clinically and on imaging, biopsy is warranted for accurate diagnosis and appropriate treatment. We found that the majority of these patients (61.7%) had specific histopathology, and 38% had systemic diseases.

Purpose To report a patient with retinal and choroidal vascular occlusion as a presenting sign of sickle cell trait following the development of aqueous misdirection syndrome. Methods Retrospective chart review. Results A patient treated for bilateral chronic angle-closure glaucoma with sequential EX-PRESS glaucoma filtration device surgery developed sequential bilateral aqueous misdirection syndrome. The left eye developed retinal arterial and localized choroidal vascular occlusions subsequent to an acute elevation in intraocular pressure and possibly the use of oral acetazolamide. The patient was subsequently found to have sickle cell trait. The right eye developed aqueous misdirection with acute elevation of intraocular pressure as well, but the patient was not treated with oral acetazolamide and did not develop vascular occlusion. Conclusion Retinal and choroidal vascular occlusions can be the presenting sign of a patient with sickle cell trait. Sickle cell screening may be beneficial in African American or Middle Eastern patients after an acute rise in intraocular pressure, particularly before initiation of treatment with oral carbonic anhydrase inhibitors.

We evaluated the effect of AAV2- and 17-AAG (17-N-allylamino-17-demethoxygeldanamycin)-mediated upregulation of Hsp70 expression on the survival of retinal ganglion cells (RGCs) injured by optic nerve crush (ONC). AAV2-Hsp70 expression in the retina was primarily observed in the ganglion cell layer. Approximately 75% of all transfected cells were RGCs. RGC survival in AAV2-Hsp70-injected animals was increased by an average of 110% 2 weeks after the axonal injury compared with the control. The increase in cell numbers was not even across the retinas with a maximum effect of approximately 306% observed in the inferior quadrant. 17-AAG-mediated induction of Hsp70 expression has been associated with cell protection in various models of neurodegenerative diseases. We show here that a single intravitreal injection of 17-AAG (0.2 ug ul(-1)) results in an increased survival of ONC-injured RGCs by approximately 49% compared with the vehicle-treated animals. Expression of Hsp70 in retinas of 17-AAG-treated animals was upregulated approximately by twofold compared with control animals. Our data support the idea that the upregulation of Hsp70 has a beneficial effect on the survival of injured RGCs, and the induction of this protein could be viewed as a potential neuroprotective strategy for optic neuropathies.

To describe the association of lacrimal gland inflammation with alopecia areata.We reviewed the medical records of 4 patients diagnosed with lacrimal gland inflammation who had an antecedent or subsequent episode of alopecia. Data was collected on the presentation age, gender, medical history, disease onset, symptoms and signs, imaging, histopathology, systemic evaluation, management and outcome. Pathology and imaging results were correlated with clinical findings.Three patients were Asian and one Caucasian. Two developed alopecia after presentation for lacrimal inflammation. The remaining two had a history of alopecia totalis (2 years and 10 years). Three of the 4 patients presented or developed other systemic disorders, including seizures, thrombocytopenia, optic neuritis, ulcerative colitis, allergic rhinitis, lymphadenopathy, vasculitic rash and positive p-ANCA values. All received oral corticosteroids, with the addition of methotrexate therapy in one for relapsing inflammation.Lacrimal gland inflammation and alopecia areata are autoimmune processes that can be seen in association with each other.

To review indications and clinical outcomes in a series of orbitocranial tumors treated surgically through a transorbital extradural approach without craniotomy.In this retrospective case series, all patients who underwent surgery through a transorbital extradural approach without craniotomy for benign orbitocranial tumors involving the dura or extending into the anterior or middle cranial fossae were analyzed.Twenty-seven patients (20 females and 7 males) were included. Median age was 47.0 years (range: 6-74 years) and median follow-up time was 43.5 months (range: 3-148 months). The median preoperative best-corrected visual acuity (logMAR) was improved from 0.35 (range: 0-2.6) to 0.1 (range: 0-2.6) at the last follow-up (p 0.03). The mean ± SD preoperative exophthalmos significantly decreased from 20.4 ± 3.4 mm to 13.1 ± 3.5 mm at the last follow-up visit (p 0.01). Four postoperative complications were noted and included one case each of ptosis, numbness, diplopia (transient for 6 months), and cranial nerve VI palsy (transient for 4 months).The transorbital extradural approach provides access to the deep orbit and adjacent extradural cranial spaces. Benign orbital tumors that have eroded through the orbital roof, are located in the orbital apex abutting the anterior cavernous sinus and tumors requiring debulking are all processes that can be potentially approached through the transorbital extradural route. Compared to open craniotomy, the incision is smaller, the access more direct and specific risks of open craniotomy are reduced.

OBJECTIVE To describe the surgical technique and outcomes of implantation of a glaucoma drainage device (GDD) at the time of Boston type I keratoprosthesis (KPro) procedure. METHODS Consecutive cases of combined GDD and KPro surgery performed between January 2005 and January 2011 with at least 6 months of follow-up were reviewed. Outcome measures included visual acuity, number of glaucoma medications, and complications. RESULTS Twenty-nine eyes (29 patients) underwent combined GDD and KPro surgery. 82.8% of KPro were retained at a mean follow-up of 34.4±17.7 months. Major complications included corneal necrosis (3 eyes, 10.3%), retinal detachment (3 eyes, 10.3%), endophthalmitis (1 eye, 3.4%), sterile vitritis (1 eye, 3.4%), and loss of light perception (2 eyes, 6.9%). Final corrected distance visual acuity improved in 17 (58.6%), remained unchanged in 7 (24.1%), and worsened in 5 eyes (17.2%). Mean numbers of glaucoma medications required postoperatively from 3 to 36 months were lower than the preoperative number, but the differences were not statistically significant. The tube of the GDD was able to be inserted into the anterior chamber or the ciliary sulcus in 27 eyes (91.3%). In 14 eyes with anterior segment ocular coherence tomographic evaluation, blockage of the ostium of the tube was noted in 2 eyes (14.3%). CONCLUSIONS Combined GDD and KPro surgery provides the opportunity of additional IOP management and restoring vision in the same setting, saving the patient from additional glaucoma surgery, and is not associated with an increased KPro retention failure rate or other secondary complications.

Purpose: To compare the intraocular pressures (IOP) and ocular pulse amplitudes (OPAs) in patients with primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (PXG), and to evaluate ocular and systemic factors associated with the OPA. Materials and Methods: In this prospective study, on 28 POAG and 30 PXG patients, IOP was measured with the Goldmann applanation tonometry (GAT) and the Pascal dynamic contour tonometry (DCT). Other measurements included central corneal thickness (CCT), vertical cup-to-disc ratio (CDR), and systolic and diastolic blood pressure. Statistical significance was defined as P < 0.05. Results: In each of the POAG and PXG groups, GAT IOP was correlated with CCT (r = 0.40, P = 0.03 and r = 0.35, P = 0.05, respectively), whereas DCT IOP and CCT were not correlated. In all patients and in the POAG group, OPA was positively correlated with DCT IOP (r = 0.39, P = 0.002). OPA was not correlated with CCT in the POAG ( P = 0.80), nor in the PXG ( P = 0.20) group, after adjusting for DCT IOP. When corrected for DCT IOP and CCT, there was a significant negative correlation between OPA and vertical CDR in all patients (r = −0.41, P = 0.002). There was no significant difference in OPA between groups ( P = 0.55), even when OPA was adjusted for IOP and systolic and diastolic pressure ( P = 0.40), in a linear regression model. Conclusion: DCT IOP and OPA are not correlated with CCT. There is no significant difference between the OPA of PXG and POAG eyes. OPA is correlated with DCT IOP, and is lower in eyes with more advanced glaucomatous cupping.

To investigate the prevalence of glaucoma, visual field abnormalities, as well as changes in retinal nerve fiber layer in patients with obstructive sleep apnea syndrome (OSAS).In this cross-sectional study, 51 patients with OSAS were included. Based on apnea hypopnea index (AHI), there were 26, 6 and 19 cases of severe (AHI⩾30), moderate (15⩽AHI30), and mild (5⩽AHI15) OSAS, respectively. The control group was matched for age, sex and body mass index. Prevalence of glaucoma and ocular hypertension as well as the following values were assessed and compared between two groups: best-corrected visual acuity, intraocular pressure, central corneal thickness (CCT), cup:disk ratio, mean deviation (MD), pattern standard deviation, and retinal nerve fiber layer (RNFL) parameters using glaucoma diagnosis measurement (GDx).Seven eyes (6.7%) had intraocular pressure (IOP)21mmHg; of these, four eyes (3.9%) had glaucoma. No significant difference was detected in CCT between the two groups. IOP was significantly higher in the OSAS group before (p0.001) and after (p0.001) correcting for CCT. There was a significant difference between groups in MD and most GDx parameters including DISK (temporal-superior-nasal-inferior-temporal) average (p=0.002), superior average (p=0.05) and nerve fiber indicator (NFI) (p=0.03), where those in the patient group showed lower values. There was a significant positive correlation between AHI and both IOP and NFI.OSAS patients had a higher prevalence of glaucoma and ocular hypertension. OSAS patients also had higher IOP, worse visual field indices, and lower RNFL parameters compared with the control group.

Purpose To analyze the impact of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) on the field of ophthalmology. Design A perspective on the effects of MACRA's Quality Payment Program after analysis of the proposed rule, final rule, and commentary submitted by relevant stakeholders. Results Physicians will need to use 1 of 2 payment structures: Merit-Based Incentive Payment Systems (MIPS) or Alternative Payment Models (APMs). APMs and MIPS will focus on bundling payments and reimbursing based on "fee-for-service-plus" models, which take into account clinical outcomes, coordination of care, clinical improvement, and electronic information exchange and security. APMs have substantial advantages, with eligible participants receiving a bonus and a higher rate of annual adjustment over the program's life. For most ophthalmology practices, MIPS may be more appropriate owing to its broader applicability and the current paucity of APMs for ophthalmologists. Conclusion The Quality Payment Program is a substantial improvement over the negative adjustments under the repealed Substantial Growth Rate model. Ophthalmologists will likely use the MIPS system; however, its comparatively lower reimbursements, as well as its cost, quality, and other reporting measures, may prove problematic.

To determine the effect of intravitreal administration of bevacizumab (1.25 mg/0.05 mL) on retrobulbar circulation of the injected and the fellow (uninjected) eyes in patients with neovascular age-related macular degeneration.In this prospective study, the retrobulbar hemodynamics of 43 patients with neovascular age-related macular degeneration was examined by color Doppler ultrasonography. Peak systolic velocity, end-diastolic velocity, and resistive index values in the central retinal artery and short posterior ciliary artery in both injected and uninjected fellow eyes were measured at baseline and 7 days after a single intravitreal injection of bevacizumab.At baseline, the peak systolic velocity, end-diastolic velocity, and the resistive index in the central retinal artery and short posterior ciliary artery of the injected eye were not significantly different compared with the fellow uninjected eye (P0.05 for all). However, intravitreal bevacizumab induced a significant reduction in the peak systolic velocity and end-diastolic velocity and a significant rise in the resistive index of the central retinal artery and short posterior ciliary artery of the injected eye (P ≤ 0.006 for all). Peak systolic velocity and end-diastolic velocity decreased in the central retinal artery (P = 0.023 and P = 0.030) and the short posterior ciliary artery (P = 0.001 and P0.000) in the uninjected eye while the resistive index did not significantly change in central retinal artery (P = 0.114) and short posterior ciliary artery (P = 0.082) of the fellow eyes.Intravitreal injection of bevacizumab significantly affects ocular hemodynamic parameters of both the injected and the uninjected fellow eyes with neovascular age-related macular degeneration.

PURPOSE: To investigate the effect of blunt foreign body impact on a human cornea after photorefractive keratectomy (PRK) and LASIK using a simulation model. METHODS: Computational simulations were performed using a finite element analysis program (LS-Dyna, Livermore Software Technology Corp). The blunt foreign body was set to impact at the center of the corneal surface models (after PRK and LASIK) with thicknesses of 500, 450, 400, 350, and 300 μm. Corneal rupture was assumed to occur at a peak stress of 9.45 MPa and at a strain of 18%. The foreign body projectile was blunt in shape, made from aluminum, contained plastic-kinematic properties, and had a density of 2700 kg/m 3 . RESULTS: The projectile was launched at the center of the cornea with velocities ranging from 20 to 60 m/s. The threshold of impact velocities creating rupture in corneal thicknesses of 500, 450, 400, 350, and 300 μm were 33, 32.8, 30.7, 27.9, and 22.8 m/s, respectively, in the PRK model. In the LASIK model, the thresholds creating rupture in the stromal bed of the corneas with thicknesses of 500, 450, 400, 350, and 300 μm were 40, 38.1, 35.6, 31.5, and 26.7 m/s, respectively. The 110-μm corneal flap in the LASIK model ruptured at all velocities. CONCLUSIONS: Ruptures occurred at lower velocities in the PRK cornea model than in the corneal stromal bed of the LASIK model following blunt foreign body impact.

Purpose To compare visual outcomes and contrast sensitivity after wavefront-optimized or conventional photorefractive keratectomy (PRK) in myopic patients with or without astigmatism. Setting Vanak Eye Surgery Center, Tehran, Iran. Design Comparative case series. Methods Patients with low to moderate myopia with or without astigmatism were allocated into 2 groups. The study group was treated with wavefront-optimized PRK (Allegretto Wave Eye-Q software version 2.020 default treatment) and the control group, with conventional PRK (Technolas 217z). In all cases, treatments were bilateral and performed with the same device. Baseline and 3-month postoperative measures were uncorrected and corrected distance visual acuities, manifest refraction, and contrast sensitivity. Results Each group comprised 66 eyes. The mean preoperative spherical equivalent refraction improved from −2.99 diopters (D) ± 1.02 (SD) preoperatively to −0.08 ± 0.26 D 3 months postoperatively in the study group and from −2.66 ± 0.95 D to 0.01 ± 0.30 D, respectively, in the control group. In both groups, the postoperative mesopic and photopic contrast sensitivity decreased significantly at most spatial frequencies. The postoperative decrease in contrast sensitivity in both groups was comparable except at spatial frequencies of 3 cycles per degree (cpd) under mesopic conditions and 12 cpd under photopic conditions, frequencies at which the control group had a greater reduction. Conclusions Visual acuity and refractive error outcomes were similar in both treatment groups. After 3 months, mesopic and photopic contrast sensitivity were significantly decreased in both groups; the reduction in the 2 groups was almost comparable. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Pediatric glaucoma is potentially a blinding disease. Although goniotomy and trabeculotomy are associated with good early success rates, eventually 20% of these procedures fail and many children will require additional surgery to control the IOP in the long-term. In this review, we reported that adequate IOP control can be achieved with the placement of Ahmed glaucoma valve and can last 5 or more years. However, most patients will need one or more glaucoma medications at some point after surgery. In addition, the implants may be associated with pupillary irregularities, lenticular opacification as well as tube-related complications, particularly in the first year of life, as the globe is enlarging with age.

Detection of visual field progression remains a challenging task despite the recent advances for better handling of longitudinal visual field data, some of which are incorporated in currently available perimeters. Standard achromatic perimetry remains the gold standard for detection of visual field progression. The authors present a practical and clinically relevant review of the main issues involved in detection of early glaucoma as well as detection of visual field progression in eyes with pre-existing glaucomatous damage. After discussing some basic concepts in perimetry, the authors present evidence-based recommendations for criteria to detect earliest evidence of glaucomatous damage with perimetry. The authors will review different event- and trend-based criteria and present data with regard to comparative performance of such criteria. Relevance of using absolute versus corrected threshold data with regard to different criteria is also addressed. At the end, the authors provide practical guidelines for detection of visual field progression in a clinical setting and review issues related to clinical trials.

To compare 1-site and 2-site phacotrabeculectomies with regard to visual acuity, intraocular pressure (IOP) control, antiglaucoma medication requirements, and postoperative complications.In a randomized controlled trial, 169 eyes with coexisting visually significant cataract and glaucoma were randomly allocated into 2 groups: eyes that had a trabeculectomy in a superior quadrant combined with phacoemulsification through the same incision (1-site group; n=85) or those with a separate, temporal, clear corneal incision for phacoemulsification (2-site group; n=84). Postoperative evaluation, including visual acuity, intraocular pressure (IOP), glaucoma medication requirements, and surgical complications, was for up to 18 months.After 18 months, there was no significant difference between the 2 groups with respect to visual acuity and antiglaucoma medication requirements. There was a 0.6 to 1.4 mmHg difference in mean IOP, with the 2-site technique demonstrating statistically significant advantage over the 1-site technique in some follow-up visits with nonparametric analysis; however, the difference cannot be clinically significant. Success rates (IOP21 mmHg with the maximum use of medication) of 1-site and 2-site groups were 85.9% and 92.8%, respectively, which was not statistically significant (p=0.153). Nevertheless, the incidence of failure in the 1-site group was almost twice that of the 2-site group (12 vs 6). Postoperative complications were comparable in both groups.Results for 18-month follow-ups of 1-site and 2-site phacotrabeculectomies were comparable in terms of visual acuity, antiglaucoma medication requirements, and postoperative complications. While lowering of IOP was more pronounced in the 2-site group, this was not clinically significant.

PURPOSE To compare the corneal endothelial cell (CEC) changes that occurred after phacotrabeculectomy performed at 1 or 2 sites. DESIGN A historical cohort study. METHODS The records of patients who had 1-site (n = 61) or 2-site (n = 52) limbus-based phacotrabeculectomy over a 4-year period (2002-2005) at 1 eye surgery center (Vanak Eye Surgery Center, Tehran, Iran) by a single surgeon were reviewed, and postoperative CEC indices were measured. Preoperative CEC indices, performed for a then-ongoing trial, were compared with postoperative measurements of the last follow-ups. The main outcome measure was endothelial cell count. RESULTS The median follow-up time was 12 months (range 9-24 months). There was no difference between the operations in improving visual acuity, lowering intraocular pressure, and decreasing the number of antiglaucoma medications required. However, 2-site surgery was associated with significantly more expansion in the CEC area (P < 0.001). On multivariate analysis, longer follow-up, 2-site surgery, and grade 4 cataract density were independently associated with more CEC loss, and longer follow-up, 2-site surgery, and steroid-induced glaucoma were associated with CEC area expansion. Postoperative complications were not markedly different between the 2 groups. CONCLUSIONS In both groups, the longer the follow-up time was, the higher the CEC loss and the CEC area expansion were. One-site surgery seems to cause less CEC damage than the 2-site operation during the median follow-up time of 1 year.

Purpose To evaluate the effect of intraoperative use of mitomycin-C (MMC) on the corneal endothelium during excimer laser photorefractive keratectomy (PRK). Setting Vanak Eye Surgery Center, Tehran, Iran. Methods This nonrandomized trial comprised 81 patients (162 eyes) with bilateral low to moderate myopia and adequate corneal thickness to allow PRK (estimated postoperative residual stromal thickness >350 μm without considering epithelial thickness). The indication for intraoperative application of MMC 0.02% (0.2 mg/mL) was an ablation depth of 75 μm or more. Patients were divided into 3 groups: bilateral (both eyes treated with MMC), unilateral (only 1 eye treated with MMC), and untreated (no eye treated with MMC). Visual acuity, refraction, endothelial cell density (ECD), and corneal thickness were measured preoperatively as well as 1 week and 1, 3, and 6 months postoperatively. Results Overall, 76 eyes were treated with MMC. Eyes treated with MMC and untreated eyes were comparable in postoperative visual acuity and refraction. Preoperative to postoperative changes in ECD were statistically significantly greater in the treated eyes (−14.8%) than in untreated eyes (−5.1%) 6 months after PRK ( P .001). Longer MMC contact time ( P P = .04) were the only factors independently associated with greater endothelial cell loss. Conclusions The prophylactic use of diluted intraoperative MMC 0.02% solution caused corneal endothelial cell loss. The rate of cell loss was correlated with the duration of MMC exposure.

PURPOSE To investigate the effect of prostaglandin analog eyedrops on the periorbital soft tissue using high-resolution ultrasonography. METHODS In this cross-sectional study, the authors included patients with bilateral glaucoma on unilateral prostaglandin therapy for the past 12 or more contiguous months. High-resolution ultrasonography was performed bilaterally on the upper and lower eyelids of each subject to measure thicknesses of dermis, orbicularis oculi muscle, and skin to arcus marginalis distance. Comparisons were made between eyes on prostaglandin eyedrops versus those not on prostaglandin analogs. RESULTS Twenty patients (16 females, 4 males) with a mean age of 67.2 ± 6.4 years were recruited. The mean duration of prostaglandin analog therapy was 5.4 ± 3.9 years. The authors found that eyes on prostaglandin analog therapy had statistically significantly reduced thicknesses of dermis, orbicularis oculi muscle, and skin to arcus marginalis distance in the upper and lower eyelids compared with the fellow eyes (p < 0.05 for all). In univariate regression analysis, the amount of changes in thicknesses of dermis, orbicularis oculi muscle, and skin to arcus marginalis distance among eyes on prostaglandin analog therapy and the fellow eyes was not statistically significantly associated with different variables including age, gender, years of being on prostaglandin analog therapy, type of prostaglandin analog, history of glaucoma and/or cataract surgeries, intraocular pressure, and number of glaucoma medications. CONCLUSIONS The findings indicate that eyes on prostaglandin analog therapy have reduced thicknesses of dermis, orbicularis oculi muscle, and skin to arcus marginalis distance compared with the fellow eyes.

AIM: To investigate the effects of periocular injection of propranolol and celecoxib on ocular levels of vascular endothelial growth factor (VEGF) in a diabetic mouse model. METHODS: Forty 4-6wk BALB-C male mice weighing 20-25 g were used. The study groups included: non-diabetic control (group 1), diabetic control (group 2), diabetic propranolol (group 3), and diabetic celecoxib (group 4). After induction of type 1 diabetes by streptozotocin, propranolol (10 μg) and celecoxib (200 μg dissolved in carboxymethylcellulose 0.5%) were injected periocularly. The ocular level of VEGF was measured in all the study groups using enzyme-linked immuno sorbent assay (ELISA) method. RESULTS: Ocular VEGF level was significantly increased (1.25 fold) in the diabetic control group when compared to the non-diabetic group one week after induction with streptozotocin (P=0.002). Both periocular propranolol and celecoxib significantly reduced ocular VEGF levels (P=0.047 and P

Background The objective of this study was to determine the role of postoperative antibiotics in reducing complications in patients undergoing appendectomy for complicated appendicitis. Methods We performed a 5-year retrospective cohort study of adult patients who underwent appendectomy for acute appendicitis. Patients with complicated appendicitis (perforated or gangrenous) were analyzed on the basis of whether they received postoperative antibiotics. Main outcome measures were wound complications, length of stay (LOS), and readmission to hospital. Results Of 410 patients with complicated appendicitis, postoperative antibiotics were administered to 274 patients (66.8%). On univariate and multivariate analyses, postoperative antibiotics were not associated with decreased wound complications or readmission, but independently predicted an increased LOS ( P = .01). Conclusions Among patients with complicated appendicitis, postoperative antibiotics were not associated with a decrease in wound complications but did result in an increased hospital LOS.

PURPOSE To compare corneal stromal and endothelial cells after photorefractive keratectomy with intraoperative mitomycin C in alcohol-assisted versus mechanical epithelial debridement using confocal microscopy. METHODS This prospective randomized comparative study was performed on 88 eyes (44 patients) with myopia up to -6.00 diopters. The right eye of each patient was randomly assigned to either mechanical or alcohol-assisted groups, and the left eye was assigned to the alternate group. Confocal microscopy was performed preoperatively and at 3 months postoperatively. The main outcome measures were epithelial thickness; number of keratocytes in the anterior, mid-, and posterior stroma; and characteristics of the central corneal endothelial cells in terms of density, mean cell area, and polymegathism and hexagonality. RESULTS Three months after surgery, no statistically significant difference was noted between the study groups in terms of epithelial thickness. We also found no statistically significant difference in central corneal endothelial cells regarding cell density, mean cell area, hexagonality, or polymegathism. Compared with baseline values, the density of mid- and posterior stromal keratocytes showed no significant change in either group, whereas it decreased significantly in the anterior stroma in both groups 3 months after surgery. CONCLUSIONS We found that the adverse effects of photorefractive keratectomy with mitomycin C on central corneal endothelial cells were comparable between the mechanical and alcohol-assisted epithelial debridement groups and the significant decrease in postoperative keratocyte density in anterior stroma was comparable between the two groups. The choice of their application could be left to the discretion of the ophthalmologist.

To present our experience of removing middle to deep orbital tumors using a combination of minimally invasive soft tissue approaches, sometimes under local anesthesia.Methods.In this retrospective case series, 30 patients (13 males and 17 females) underwent tumor removal through eyelid crease (17 eyes), conjunctival (nine eyes), lateral canthal (two eyes), and transcaruncular (two eyes) approaches. All tumors were located in the posterior half of the orbit. Six cases were removed under monitored anesthesia care with local block, and 24 were under general anesthesia.Results.The median (range) age and follow-up duration were 48.5 (31–87) years old and 24.5 (4–375) weeks, respectively. Visual acuity and ocular motility showed improvement or no significant change in all but one patient at the latest followup. Confirmed pathologies revealed cavernous hemangioma (15 cases), pleomorphic adenoma (5 cases), solitary fibrous tumor (4 cases), neurofibroma (2 cases), schwannoma (2 cases), and orbital varix (1 case). None of the patients experienced recurrence.Conclusions.Creating a bony marginotomy increases intraoperative exposure of the deep orbit but adds substantial time and morbidity. Benign orbital tumors can often be removed safely through small soft-tissue incisions, without bone removal and under local anesthesia.