Laser flare-cell photometry: methodology and clinical applications

Laser flare photometry in eyes receiving brolucizumab intravitreal injections for age related macular degeneration

PURPOSE

To measure aqueous flare levels in treatment naïve eyes suffering from wet age- related macular degeneration (wAMD) treated with intravitreal brolucizumab.

METHODS

Patients with treatment naïve wAMD in one eye were prospectively enrolled. Flare levels were measured with laser flare photometry at baseline, 1 day and 1 month after each of the 3 monthly injections during the loading phase.

RESULTS

Twenty-two eyes from 22 patients aged 76.7 ± 6.0 years were enrolled. Flare values were 10.6 ± 3.7 photons/msec at baseline and 12.6 ± 5.8 photons/msec at the last follow up visit, 1 month after the third injection (p = 0.289, repeated measures ANOVA). The mean change in flare after the first injection was 4.2 ± 3.6. photons/msec, 6.6 ± 8.9 photons/msec after the 2nd and 8.6 ± 20.8 photons/msec after the 3rd injection (p = 0.640, repeated measures ANOVA). No patient had clinical signs of intraocular inflammation.

CONCLUSIONS

Eyes receiving brolucizumab injections for wAMD showed similar flare at baseline, during and 1 month after completion of three-monthly intravitreal injections. There was no evidence of subclinical inflammation during the loading phase of brolucizumab based on laser flare photometry measurements.

Monkeypox-related ophthalmic disease (MPXROD): Monitoring the antiviral effect of tecovirimat with monkeypox virus detection in tear samples

INTRODUCTION

Although monkeypox-related ophthalmic disease (MPXROD) is rare, visual impairing complications have been reported. At present, tecovirimat is the standard-of-care antiviral treatment. In this MPXROD case, the effect of tecovirimat was assessed with PCR analysis of tear samples and concurrent monitoring of inflammation with laser flare photometry (LFP).

CASE DESCRIPTION

The patient presented with a palpebral lesion and a corneal ulcer in his right eye, with complete absence of the corneal epithelium, high intraocular pressure and anterior uveitis. MPXV-DNA was detected in tear samples with real-time PCR (RT-PCR). A total volume of 0.5 ml tear-wash was aspirated from the inferior fornix, following instillation of saline onto the ocular surface. In addition, LFP was used to quantify inflammation in both eyes. Viral load in tear samples was detected prior to treatment initiation. In the left eye, tear samples tested negative for MPXV-DNA one week post-treatment while MPXV-DNA was still detected in the right eye, before reaching undetectable levels four weeks post-treatment. Objective quantification of anterior chamber inflammation through LFP demonstrated gradual decrease that was more pronounced in the affected right eye and coincided with the clinical improvement of the corneal ulcer.

CONCLUSIONS

This case of Mpox related corneal ulcer with associated uveitis manifests the feasibility of monitoring the antiviral effect of tecovirimat with virus detection in tear samples and LFP. Our observations indicate that tecovirimat resulted in viral load reduction in both eyes. RT-PCR MPXV detection in tear samples and LFP represent noninvasive tools that could assist with treatment response monitoring.

Inflammatory reaction in eyes with late in-the-bag intraocular lens dislocation

PURPOSE

To investigate the inflammatory reaction in eyes with late in-the-bag intraocular lens (IOL) dislocation.

METHODS

This prospective clinical study with fellow-eye comparison consists of 76 of the patients (76 eyes) with late in-the-bag IOL dislocation enrolled in the LION trial. The main outcome measure was anterior chamber flare before surgery measured with a laser flare meter in photon counts per millisecond (pc/ms). The dislocation was graded as 1 (small: optic still covering the visual axis), 2 (optic equator close to the visual axis) or 3 (optic decentred beyond the visual axis, but the IOL-capsule complex partly visible in the pupillary area). The secondary aim was to compare intraocular pressure (IOP) before surgery.

RESULTS

Flare levels before surgery were significantly higher in the dislocation eyes than in the fellow eyes with a median flare of 21.5 (range 5.4-135.7) pc/ms versus 14.1 (2.0-42.9) pc/ms, respectively (p ˂ 0.001). A regression analysis of log-transformed flare values showed that the dislocation eyes had a non-significant tendency towards higher flare in dislocation grade 1 with a median flare of 24.6 (5.4-135.7) pc/ms compared to grade 2; 19.6 (6.5-41.5) pc/ms (p = 0.06), and no significant difference compared to grade 3; 19.4 (10.2-53.5) pc/ms (p = 0.47). The IOP was significantly higher in the dislocation eyes than in the fellow eyes (p ˂ 0.001).

CONCLUSIONS

Eyes with late in-the-bag IOL dislocation had increased flare levels compared to their fellow eyes. This suggests that inflammation is part of the clinical picture of late in-the-bag IOL dislocation.

Anterior chamber flare and choroidal vascular index as inflammatory markers after uncomplicated phacoemulsification surgery

PURPOSE

To determine the effect of phacoemulsification surgery, which is one of the types of cataract surgery by using ultrasonic power to break up the crystalline lens and clean it with vacuum, on anterior chamber flare (ACF) and choroidal vascular index (CVI).

METHODS

For this cross-sectional study, patients were included if they had cataract with nucleus hardness grade 2 or 3, no systemic inflammatory disease, and not use of anti-inflammatory drugs/prostaglandins preoperatively. ACF using a laser flare meter and CVI in patients underwent uncomplicated phacoemulsification was recorded preoperatively, on the postoperative 1st day, 1st week, and 1st month.

RESULTS

Fifty-six eyes were included. ACF was 9.00 ± 2.90 ph/ms preoperatively. Although ACF increased significantly on postoperative day-1 (39.38 ± 23.31ph/ms) and decreased gradually until the 1st month (14.03 ± 6.03ph/ms) after the operation, it was still significantly higher at the 1st month (p < 0.001). Macular and peripapillary CVI increased significantly on postoperative day-1 (0.64 ± 0.03/0.63 ± 0.05) and week-1 (0.64 ± 0.04/0.62 ± 0.04) (p = 0.01, p < 0.001); the postoperative 1st month was similar to the preoperative one (0.59 ± 0.06/0.58 ± 0.06). The relationship between the change in ACF and the change in CVI was not significant.

CONCLUSION

Phacoemulsification causes raises in ACF and CVI due to increased intraocular inflammation. The fact that ACF was significantly higher in postoperative month-1 and CVI returned to its preoperative value suggests that the effect of uncomplicated phacoemulsification surgery on the increase in inflammation in the anterior segment lasts longer than in the posterior segment. These results suggest that ACF and CVI follow-up may be clinically important in the follow-up of postoperative inflammation.

Longitudinal Comparative Analysis of Semi-Automated Aqueous Flare Measurements with Clinical Grading and Visual Outcomes in Uveitic Eyes

PURPOSE

To evaluate the correlation between longitudinal changes in aqueous flare measured by laser flare photometer (LFP), best-corrected visual acuity (BCVA), and clinical grade using both Standardization of Uveitis Nomenclature (SUN) and modified SUN (MSUN) scales uveitis patients.

METHODS

Patients were classified according to both SUN and MSUN grading scales. LFP measurements were acquired (Kowa FM-700) at each visit. Mean change in LFP was assessed longitudinally, comparing with those in visual acuity, SUN, and MSUN grading scales.

RESULTS

Mean change in LFP was correlated to those in BCVA (p = .018), SUN scale (p < .001), and MSUN scale (p = .008). Cases within same initial SUN (0 and 1+) and MSUN (0.5+ and 1+) grades and different longitudinal flare prognosis (decreased/unchanged/increased) had significantly different initial LFP values (all p < .05).

CONCLUSIONS

LFP measurement is beneficial in monitoring inflammatory activity. Cases of identical clinical flare scores with different clinical prognosis may be predicted by LFP.

Laser Flare Photometry to Monitor Childhood Chronic Uveitis: A Preliminary Report of a Monocentric Italian Experience

Background: Childhood chronic non-infectious uveitis (cNIU) is a challenging disease that needs close monitoring. Slit lamp evaluation (SLE) is the cornerstone of ophthalmological evaluation for uveitis, but it is affected by interobserver variability and may be problematic in children. Laser flare photometry (LFP), a novel and objective technique, might be used in children with uveitis. Aim: The aim of this study was to attempt the use of LFP in cNIU clinical practice. Methods: Children, attending the Rheumatology Unit and who were scheduled to receive ophthalmological evaluation, were prospectively enrolled to concomitantly receive SLE and LFP. SLE was performed blind to LFP measure. Demographic, laboratory, clinical, and ophthalmology data were collected. Results: A total of 29 children (58 eyes) were enrolled, including 3 with juvenile idiopathic arthritis without uveitis (JIA-no-U), 15 with JIA-associated uveitis (JIA-U), and 11 with idiopathic chronic uveitis (ICU). We observed significantly higher LFP values in the eyes of children with uveitis compared to the others (10.1 IQR 7.1-13.6 versus 6.2 IQR 5.8-6.9, p = 0.007). Accordance between the SLE and LFP measures, at baseline (ρ.498, p < 0.001) and during the follow-up (LFP II ρ 0.460, p < 0.001, LFP III ρ 0.631, p < 0.001, LFP IV ρ 0.547, p = 0.006, LFP V ρ 0.767, p = 0.001), was detected. We evaluated significant correlation between LFP values and the presence of complications (ρ 0.538, p < 0.001), especially with cataract formation (ρ 0.542, p < 0.001). Conclusions: In this cohort, LFP measurements showed a good correlation with SLE. LFP values showed a positive correlation with the presence of complications. LFP might be considered as a reliable objective modality to monitor intraocular inflammation in cNIU.

Anterior chamber inflammation grading methods: A critical review

Assessing anterior chamber inflammation is highly subjective and challenging. Although various grading systems attempt to offer objectivity and standardization, the clinical assessment has high interobserver variability. Traditional techniques, such as laser flare meter and fluorophotometry, are not widely used since they are time-consuming. With the development of optical coherence tomography with high sensitivity, direct imaging offers an excellent alternative to assess objectively inflammation with the potential for automated analysis. We describe various anterior chamber inflammation grading methods and discuss their utility, advantages, and disadvantages.

The effect of one- and two-rectus muscle strabismus surgery on anterior chamber flare

PURPOSE

To investigate the effect of the most commonly performed strabismus surgery procedures on the blood-aqueous barrier using laser flare photometry (LFP).

METHODS

Patients who underwent unilateral or bilateral strabismus surgery between January 2020 and May 2021 were included. Eyes were grouped according to the number of rectus muscles operated: one rectus muscle procedure (recession) with or without inferior oblique anterization (IOA), ipsilateral two rectus muscle procedure (recession and resection) with or without IOA, and unoperated fellow eyes of patients undergoing unilateral surgery. Anterior chamber flare values were measured by LFP for each eye the day before the surgery and day 1, week 1, and month 1 postoperatively.

RESULTS

A total of 66 eyes of 33 patients (21 females) were included. There were 29 eyes in the one-muscle group, 22 in the two-muscle group, and 15 in the fellow-eye group. The mean flare values of the two-muscle group were significantly higher than those of the other groups at postoperative day 1 and week 1 (P = 0.001, for both). The mean postoperative day 1, week 1, and month 1 flare values of the two-muscle group were significantly higher than the mean preoperative flare value. There were no significant differences between pre- and postoperative flare values of the one-muscle or fellow-eye groups (P > 0.05, for both).

CONCLUSIONS

In our study cohort, LFP provided evidence of subclinical changes in the blood-aqueous barrier up to the first month postoperatively in otherwise healthy patients undergoing two-muscle surgery compared with those undergoing one-muscle surgery and unoperated fellow eyes.

Blood-Aqueous Barrier Disruption in Penetrating and Posterior Lamellar Keratoplasty: Implications for Clinical Outcome

BACKGROUND

The blood-aqueous barrier (BAB) separates immunoprivileged tissue of the eye from the blood circulation. Disruption of the BAB is therefore a risk factor for rejection after keratoplasty.

PURPOSE

The present work provides a review of the work of our group and others on BAB disruption in penetrating and posterior lamellar keratoplasty and its implications for clinical outcome.

METHODS

A PubMed literature search was performed to generate a review paper.

RESULTS

Laser flare photometry provides an objective and reproducible method to assess the integrity of the BAB. Studies of the flare after penetrating and posterior lamellar keratoplasty demonstrate a mostly regressive disruption of the BAB in the postoperative course, which is influenced in extent and duration by multiple factors. Persistently elevated flare values or an increase in flare after initial postoperative regeneration may indicate an increased risk of rejection.

DISCUSSION

In case of persistent or recurrent elevated flare values after keratoplasty, intensified (local) immunosuppression may potentially be useful. This could become important in the future, especially for the monitoring of patients after high-risk keratoplasty. Whether an increase of the laser flare is a reliable early indicator of an impending immune reaction after penetrating or posterior lamellar keratoplasty has to be shown in prospective studies.

Early Inflammation Control After Trabeculectomy by Steroid and Non-steroidal Eye Drops: A Randomized Controlled Trial

INTRODUCTION

To compare the effect of three different anti-inflammatory regimens consisting of preservative-free dexamethasone (DEX), diclofenac (DICLO) eye drops, and their combination (DEX + DICLO) following trabeculectomy on early postoperative inflammation.

METHODS

A prospective randomized controlled trial. Sixty-nine patients undergoing trabeculectomy were randomized to receive either postoperative treatment with topical DEX (n = 23), topical DICLO (n = 23), or a combination of topical DEX and topical DICLO (n = 23) after trabeculectomy. The primary outcome was the anterior chamber flare measurement in the first 3 months postoperatively. Secondary outcomes included intraocular pressure, central corneal thickness, conjunctival injection, and number of cells in the anterior chamber from baseline to 3 months postoperatively.

RESULTS

Anterior chamber flare reached a maximum 1 day after trabeculectomy with an increase of 55% (95% CI 37-73%) for DEX, 64% (95% CI 47-82%) for DICLO, and 57% (95% CI 39-75%) for DEX + DICLO and returned to near pre-operative values 6 weeks after surgery. There were no significant differences in anterior chamber flare [effect size for DICLO: 0.16 (95% CI - 4.3 to 4.6), effect size for DEX + DICLO: 0.09 (95% CI - 4.1 to 4.3)], intraocular pressure, central corneal thickness, conjunctival injection, or number of cells in the anterior chamber between DEX, DICLO, or DEX + DICLO groups.

CONCLUSION

We found that topical diclofenac was not statistically different from topical dexamethasone in controlling early postoperative inflammation after trabeculectomy, while combining diclofenac and dexamethasone offered no added anti-inflammatory control compared to dexamethasone alone.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov (NCT04054830).

The Value of Laser Flare Photometry as a Monitoring Tool for Uveitis

Laser flare (LF) photometry (P) is used to quantify the protein concentration in the aqueous humor, and therefore assess the blood-aqueous humor barrier. LFP is more reliable than the clinical assessment of the Tyndall effect, and is thus especially useful in the follow-up of uveitis patients. In active uveitis, LFP correlates well with the anterior chamber cell grading. Various studies have shown that high LF values are associated with an increased risk of uveitic complications, such as macular edema, glaucoma, and posterior synechiae. LFP can also be used to assess the response to anti-inflammatory treatments as well as the optimal timing and selection of the surgical technique for intraocular surgeries.

Correlation of Clinical Aqueous Flare Grading to Semi-Automated Flare Measurements Using Laser Flare Photometry

PURPOSE

To compare laser flare photometry (LFP) measurements of aqueous flare with Standardization of Uveitis Nomenclature (SUN) and modified SUN grading.

METHODS

In this prospective study with multicenter design, uveitis patients were classified according to SUN and modified SUN grading scales. LFP was performed with Kowa FM-700 flaremeter. Mean LFP values were compared with SUN and MSUN scores.

RESULTS

The study included 475 LFP measurements, of which 216, 48, 150, 31, 28 and 2 had 0, 0.5+, 1+, 1.5+, 2+ and 3+ flare, respectively. LFP values were significantly different between each two consecutive steps for both clinical gradings (all P < .05). Cut-off values for modified SUN grading steps were defined as 5.7, 9.7, 15.7 and 43.2 for 0/0.5+, 0.5+/ 1+, 1+/1.5+ and 1.5/2+ borders of clinical flare, respectively.

CONCLUSIONS

LFP proves to be an objective measurement in analyzing aqueous flare comparable to both SUN and MSUN clinical grading systems.

De novo Vogt-Koyanagi-Harada disease after vaccination for COVID-19, successfully treated with systemic steroid therapy and monitored with laser speckle flowgraphy

Purpose

Vogt-Koyanagi-Harada (VKH) disease after vaccination for coronavirus disease 2019 (COVID-19) is rare, and the prognosis for this condition and its effect on ocular blood flow remains unclear. The purpose of this paper is to present the first case of de novo VKH disease after the second vaccination for COVID-19 with an mRNA vaccine that was successfully treated with systemic steroid therapy and monitored with laser speckle flowgraphy (LSFG).

Observations

A 30s-year-old Japanese woman reported bilateral decreased visual function 2 weeks after receiving a second dose of the BNT162b2 mRNA vaccine. Best-corrected visual acuity was 20/50 OD and 20/70 OS. Optical coherence tomography revealed bilateral serous retinal detachment over the swollen choroidal layer. LFSG showed decreased blood flow in the peripapillary region of both eyes. This case was diagnosed as complete VKH syndrome, and the patient underwent systemic steroid therapy. After treatment, the retinal detachment disappeared, choroidal thickness decreased, and ocular blood flow increased. Three months later, visual acuity recovered to 20/20 in both eyes.

Conclusions

Caution should be exercised in cases with visual symptoms after COVID-19 vaccination, even after more than one dose and more than one week after vaccination. LSFG may be a useful way to measure the ocular blood flow response to treatment and determine the prognosis for VKH disease after COVID-19 vaccination.

Effect of light backscattering from anterior segment structures on automated flare meter measurements

BACKGROUND

To evaluate effect of maximal anterior cortical lens density, iris scatter and anterior chamber depth on laser flare photometry.

METHODS

Patients diagnosed with clinical uveitis were enrolled in the study. Clinical flare gradings were recorded upon the Standardization of Uveitis Nomenclature. Aqueous flare was measured with an automated device (Kowa FM-700). Back-scattering from anterior cortical lens and anterior iris surface was calculated from Scheimpflug images. A curvilinear regression model was used to calculate estimated values for each clinical grade. These values were used to split cases in Group I (laser flare photometry lower than estimated) and Group II (laser flare photometry higher than estimated). Mean anterior chamber depth, pupil aperture, maximal anterior cortical lens density and iris scatter values were compared between two groups. A stepwise multiple regression analysis was performed to determine the effect of clinical flare gradings and ocular parameters on aqueous flare measurements.

RESULTS

The study included 228 eyes of 114 cases. Scheimpflug images were obtained from 105 eyes. Estimated aqueous flare measurements (in photons/milliseconds) were 4.87, 8.50, 14.81, 25.83, 45.04 and 136.93 for 0, 0.5+, 1+, 1.5+, 2+ and 3+ clinical flare respectively. Group II had higher maximal anterior cortical lens density than Group I (96.6 ± 37.1 vs 77.9 ± 17.1 pixel unit, p = 0.001). The measured aqueous flare was significantly related to clinical flare, maximal anterior cortical lens density and pupil aperture (adjusted R2: 0.480, p < 0.001).

CONCLUSION

The back-scattered light from anterior cortical lens could affect laser flare photometry measurements. This effect might be quantified by Scheimpflug imaging.

Intraocular Inflammation in Eyes Operated for Late In-the-bag intraOcular lens dislocatioN (LION): A Randomized Clinical Trial

PURPOSE

To compare the intraocular inflammation after 2 surgical approaches for late in-the-bag intraocular lens (IOL) dislocation.

DESIGN

Prospective, randomized, parallel-group clinical trial.

METHODS

We randomly assigned 100 patients (100 eyes) referred to Oslo University Hospital (tertiary referral center) with late in-the-bag IOL dislocation into IOL repositioning by scleral suturing (n=49) or IOL exchange with retropupillary fixation of an iris-claw lens (n=51). Patients were examined before surgery and 2 weeks, 6 weeks, and 6 months after surgery. The main outcome measure was anterior chamber laser flare, measured with a laser flare meter as photon counts per millisecond (pc/ms).

RESULTS

Two weeks following surgery, median flare values were 28.9 pc/ms (range, 7.9-140) in the repositioning group and 31.6 pc/ms (range, 9.8-92.3) in the exchange group (P = .83). Flare levels were still elevated after 6 weeks with no difference between the groups (P = .93), whereas it decreased to baseline levels after 6 months. Six weeks following surgery, the central retinal thickness was similar (P = .97); cystoid macular edema (CME) was found in 4 and 5 patients, respectively (P = .85); and the mean best corrected visual acuity was 0.17 (95% CI 0.09, 0.25) and 0.21 (95% CI 0.09, 0.32) logarithm of the minimum angle of resolution, respectively (P = .61).

CONCLUSIONS

This study revealed similar levels of intraocular inflammation following IOL repositioning and IOL exchange. There was no significant difference regarding risk of CME and visual outcome. The prolonged elevation in postoperative flare indicates a possible requirement for an extended anti-inflammatory treatment period after these operations.

Effect of Fundus Fluorescein Angiography on Semiautomated Aqueous Flare Measurements

PURPOSE

To evaluate the effects of fluorescein fundus angiography (FFA) on semiautomated aqueous flare measurements.

METHODS

Laser flare photometer (LFP) measurements was performed at baseline, 30 min, and 4 h after the intravenous administration of sodium fluorescein dye. FFA was performed immediately after the baseline LFP measurement. LFP values at 30 min and 4 h after FFA were compared to baseline values. Mean change in LFP measurements at 30 min and 4 hafter baseline was compared between FFA arm and controls.

RESULTS

The mean flare measurement in the FFA and control arm dropped 6% (p value = 0.002) and 9% (p value = 0.04), respectively. Mean change in LFP measurement at 30 min and 4 h after baseline was not significant between FFA arm and controls.

CONCLUSIONS

Administration of fluorescein dye does not increase LFP values. The decrease in the LFP measurement following FFA may be attributed to dilation drops.

Aqueous Flare, Functional-Morphological Parameters, and Cytokines in Age-Related Macular Degeneration after Anti-VEGF Treatment

Purpose:

The role of inflammation and cytokines in AMD and anti-Vascular Endothelial Growth Factor (anti-VEGF) treatment remains unclear. Therefore, this study aimed to examine whether anti-VEGF treatment for exudative Age-related Macular Degeneration (AMD) affects aqueous flare value (an indicator of inflammation), functional-morphologic parameters, and aqueous humor levels of cytokines or inflammatory mediators.

Methods:

We compared aqueous humor levels of 8 cytokines, growth factors (including VEGF), and inflammatory mediators in 43 patients who received anti-VEGF treatment with aflibercept for AMD and 24 healthy controls by the suspension array method. In addition, we measured aqueous flare values with a laser flare meter and Central Macular Thickness (CMT) and Macular Volume (MV) by optical coherence tomography.

Results:

The patient group had a significantly higher aqueous flare value than the control group. At baseline, CMT showed significant correlations with aqueous humor levels of soluble intercellular adhesion molecule-1 (sICAM-1), monocyte chemoattractant protein 1 (MCP-1), interleukin (IL)-6, and IL-8 and MV, with aqueous humor levels of VEGF, sICAM-1, MCP-1, IL-6, and IL-8. Moreover, we found significant correlations between aqueous flare value and aqueous humor levels of MCP-1, IL-6, IL-8, and interferon-gamma–inducible protein 10. One month after anti-VEGF treatment, the patient group showed a significant correlation between the change in MV and improvement in best-corrected visual acuity (BCVA); CMT showed no such correlation.

Conclusion:

Inflammation appears to be involved in AMD. Change in MV may be an index of improvement in BCVA in patients receiving anti-VEGF treatment for AMD.

Anterior Chamber Laser Flare Photometry After Diode Laser Cyclophotocoagulation

BACKGROUND

The aim of this study was to evaluate changes in intraocular inflammation according to energy delivered per eye during transscleral diode laser cyclophotocoagulation (TDLC) in refractory glaucoma using laser flare (LF) photometry and to investigate the relationship between the change in anterior chamber flare values ​​and the success of TDLC.

METHODS

Patients who underwent TDLC for refractory glaucoma and had LF photometry data were analyzed retrospectively. We recorded the best-corrected visual acuity, intraocular pressure (IOP) with Goldmann applanation tonometer, number of anti-glaucoma medications, LF photometry values (ph/ms) on pre-and postoperative days 1, 10 and 30.

RESULTS

The mean laser power applied during TDLC procedure was 2.45±0.35W. The mean laser duration was 2.09±0.28sec. The mean total energy applied per eye was 114.69±16.13 J, the mean number of pulses was 22.43±4.3. While the mean LF value was 49.71±11.99ph/ms preoperatively, it was 63.94±12.41ph/ms at the postoperative 30^th day. Possible predictors of success of TDLC were investigated using linear regression analysis (R adjusted 0.454 p=0.001). The IOP decrease at postoperative 30^th day was significantly related to the difference between the postoperative 1^st day and the preoperative LF (p=0.025, B/95% CI -0.358/-0.107- -0.008), and total cyclodiode energy delivered per eye (joules) (p=0.016, B/95% CI -0.396/-0.287 - -0.031).

CONCLUSIONS

Anterior chamber flare values increases after TDLC, though it does not regress to the preoperative level on the postoperative 30th day. Total cyclodiode energy delivered per eye and the difference between the postoperative 1^st day and the preoperative LF can be used to predict TDLC response.

Correlation between intraocular pressure reduction and anterior chamber aqueous flare after micropulse transscleral cyclophotocoagulation

BACKGROUND

Micropulse transscleral cyclophotocoagulation (MP-CPC) is a technique that has been approved in recent years to treat glaucoma. MP-CPC causes anterior chamber inflammation; a relationship with reduced intraocular pressure (IOP) has not been reported. Therefore, we analyzed the correlation between IOP and anterior chamber aqueous flare after MP-CPC.

METHODS

This retrospective study included 37 eyes of 37 patients who underwent MP-CPC between November 2018 and October 2020. IOP and flare values were measured at 1, 4, and 12 weeks after MP-CPC. Correlations were assessed between the percentage IOP reduction and flare elevation by calculating Spearman's rank correlation coefficient.

RESULTS

The percentage IOP reduction at 1 week after surgery was correlated with the flare elevation at 1 week after surgery (ρ = 0.47, P = 0.006). The percentage IOP reduction at 12 weeks after surgery was correlated with the flare elevation at 4 weeks after surgery (ρ = 0.53, P = 0.006).

CONCLUSIONS

A short-term correlation was implied between reduced IOP and flare elevation after MP-CPC.

[Specular microscopy findings in active uveitis]

PURPOSE

To study the effect of ocular inflammation in active uveitis on the corneal endothelium.

MATERIALS AND METHODS

This is a prospective cross-sectional study involving 63 eyes of 38 patients with active newly-diagnosed uveitis. Eighty-four eyes of 42 non-uveitic subjects served as a control group. All patients underwent detailed ophthalmic examination, laser flare photometry, and non-contact specular microscopy. Eyes with uveitis had a follow-up visit at one month after initiation of treatment, including laser flare photometry and specular microscopy.

RESULTS

The mean age of the active uveitis patients was 33 (range: 9-67 years) with 21 men (55%) and 17 women (45%). For the uveitis patients at baseline, the mean flare value was 32ph/ms (range: 15-100ph/ms) with flare photometry value ≥50ph/ms in 13 eyes (21%) and<50ph/ms in 50 eyes (79%). At baseline, cell density (CD) of the uveitis patients was similar to CD in control eyes (p꞊0.16). The percent of hexagonality was significantly lower (p<0.0001), and the coefficient of variance (CV) (p<0.0001) and central corneal thickness (CCT) (p<0.0001) were significantly higher than in the control group. After one month, there was a significant decrease in flare photometry values (p<0.0001), with a mean flare value of 14.5ph/ms (range: 4-60ph/ms). In the active uveitis group, the overall results of specular microscopy did not significantly vary between the initial examination and the 1-month examination. For eyes with flare photometry value ≥50ph/ms at baseline, CD and hexagonal cell count significantly increased on the 1-month examination (p꞊0.01 and p꞊0.02 respectively), while CV and CCT decreased significantly at the one-month follow-up visit (p꞊0.007/p꞊0.03 respectively). For eyes with flare photometry value at baseline <50ph/ms, there was no significant differences in specular microscopy results between the initial examination and the 1-month examination.

CONCLUSIONS

In eyes with newly-diagnosed uveitis and active anterior chamber inflammation, specular microscopy shows transient qualitative abnormalities of the corneal endothelium that depend on the severity of the anterior chamber inflammation as measured by the laser flare meter.

Structural Endpoints and Outcome Measures in Uveitis

Most uveitis entities are rare diseases but, taken together, are responsible for 5-10% of worldwide visual impairment which largely affects persons of working age. As with many rare diseases, there is a lack of high-level evidence regarding its clinical management, partly due to a dearth of reliable and objective quantitative endpoints for clinical trials. This review provides an overview of available structural outcome measures for uveitis disease activity and damage in an anatomical order from the anterior to the posterior segment of the eye. While there is a multitude of available structural outcome measures, not all might qualify as endpoints for clinical uveitis trials, and thorough testing of applicability is warranted. Furthermore, a consensus on endpoint definition, standardization, and "core outcomes" is required. As stipulated by regulatory agencies, endpoints should be precisely defined, clinically important, internally consistent, reliable, responsive to treatment, and relevant for the respective subtype of uveitis. Out of all modalities used for assessment of the reviewed structural outcome measures, optical coherence tomography, color fundus photography, fundus autofluorescence, and fluorescein/indocyanine green angiography represent current "core modalities" for reliable and objective quantification of uveitis outcome measures, based on their practical availability and the evidence provided so far.

Evaluation of Aqueous Flare Intensity in Eyes Undergoing Intravitreal Bevacizumab Therapy to Treat Neovascular Age-Related Macular Degeneration

Purpose: To evaluate the effect of repeated intravitreal bevacizumab injections on blood-aqueous barrier permeability in eyes with neovascular age-related macular degeneration (AMD).

Patients and Methods: Forty-eight consecutive patients with neovascular AMD received 3 intravitreal bevacizumab injections (1 mg) every 30–40 days. Subjects were followed for a period of 4 months and were examined at baseline, 1 day and 1 month after each injection. A control group comprised of 19 neovascular AMD patients waiting to begin anti-vascular endothelial growth factor (VEGF) therapy. Anterior chamber (AC) inflammation was evaluated with biomicroscopy and laser flare photometry.

Results: None of the subjects treated with bevacizumab had detectable ocular inflammation during follow-up. An analysis for variance (ANOVA) of the mixed-effects model has shown neither an effect between treatment and control group (p = 0.921), nor over the time course of the follow-up (p = 0.773). Before treatment, median AC inflammation was 6.7 photons/ms (range: 3.5–18.2 photons/ms). One month after the first, second, and third injections, median laser flare was 6.4, 6.8, and 6.6 photons/ms, respectively, none of which were significantly different from baseline (all p > 0.05). Blood-aqueous barrier permeability did not change between injections and was not different from the control group.

Conclusion: Inflammation induced by intravitreal bevacizumab was not detected by examination or flare photometry. This suggests that monthly bevacizumab dosing seems to be safe. The absence of AC inflammation could also reflect the known anti-inflammatory properties of anti-VEGF agents.

The Correlation of Inflammation and Microvascular Changes with Diabetic Retinal Neurodegeneration

Purpose: To evaluate the effect of aqueous flare intensity as a measurement of inflammation and microvascular changes on retinal neurodegeneration in diabetic eyes.Materials and Methods: In cross-sectional study diabetic patients were assigned into 2 groups according to the presence of retinopathy: patients with nonproliferative diabetic retinopathy (group 1) and diabetic patients without clinically overt retinopathy (group 2). As a control group (group 3), age-matched healthy controls were included in the study. All subjects underwent visual acuity measurement, slit-lamp examination, ophthalmoscopy, spectral-domain optic coherence tomography (SD-OCT), optic coherence tomography angiography (OCTA), and laser flare-cell meter (LFCM).Results: The study enrolled 99 eyes of 99 patients in group 1; 99 eyes of 99 patients in group 2, and 50 eyes of 50 age-matched healthy controls in group 3. The eyes in group 1 had higher flare intensity, decreased ganglion cell layer (GCL) thickness, enlarged foveal avascular zone (FAZ) area, and enlarged capillary non-flow area compared to those in group 2 (p < .005). In group 1, decreased GCL thickness was statistically significantly correlated with increased aqueous flare intensity, enlarged FAZ area, and enlarged capillary non-flow area (p < .005).Conclusion: The results demonstrated a correlation of the retinal neurodegeneration with the aqueous flare levels and macular ischemia indices in the early stages of diabetic retinopathy. This finding supports the role of inflammation in the pathogenesis of diabetic retinal neuropathy.

The Effect of Perioperative Uveitis Control on the Success of Glaucoma Surgery in Uveitic Glaucoma

Purpose

To study the effects of perioperative uveitis control (PUC) on postoperative intraocular pressure (IOP) and uveitis activity in uveitic glaucoma (UG) patients who required glaucoma surgeries.

Patients and Methods

A retrospective chart review of 109 patients (120 eyes) which had glaucoma surgery for UG. A total of 66 eyes which had PUC were compared to 54 eyes which did not have. Measurements of IOP and uveitis activity were recorded preoperatively and over 2 years postoperatively. Average number of antiglaucoma medications and frequency of surgical failure were obtained in both groups.

Results

Over 2 years postoperatively, average IOP was lower in eyes which had PUC. Significant differences in IOP were found at 3 months (P = 0.004), 6 months (P = 0.001), 1 year (P < 0.001), and 2 years (P < 0.001). Lower grades of anterior chamber (AC) inflammation were found in eyes which had PUC. Significant differences were found at 1 month (P < 0.001), 3 months (P < 0.001) and 6 months (P = 0.001). Mean number of antiglaucoma medications at last visit was 0.7 ± 1.1 for eyes which had PUC and 2.6 ± 1.5 for eyes which did not have PUC (P < 0.001). Among eyes which had PUC, only two eyes required second glaucoma surgeries, while 16 eyes with no PUC required further glaucoma surgeries after 27.7 ± 12.5 months (P < 0.001).

Conclusion

Proper PUC in patients going for UG surgeries results in lower IOP levels and less AC inflammation over 2 years postoperatively. A comprehensive PUC regimen is needed for uveitic glaucoma patients going for surgeries.

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Uveitis Specialists Harnessing Disruptive Technology during the COVID-19 Pandemic and Beyond

Spurred by the coronavirus disease pandemic and shortage of eye care providers, telemedicine is transforming the way ophthalmologists care for their patients. Video conferencing, ophthalmic imaging, hybrid visits, intraocular inflammation quantification, and portable technology are evolving areas that may allow more uveitis patients to be evaluated via telemedicine. Despite these promising disruptive technologies, there remain significant technological limitations, legal barriers, variable insurance coverage for virtual visits, and lack of clinical trials for uveitis specialists to embrace telemedicine.

Laser flare and cell photometry to measure inflammation after cataract surgery: a tool to predict the risk of cystoid macular edema

PURPOSE

To review the current adoption of laser flare and cell photometry (LFCP) in the setting of modern cataract surgery to analyze inflammation aiming to identify evidence of a correlation between LFCP values and the risk of cystoid macular edema (CME) development.

METHODS

An extensive PubMed literature search was performed to review all the published studies investigating inflammation by LFCP after uncomplicated phacoemulsification. The following keywords were used: cataract surgery, cystoid macular edema, anterior chamber inflammation, laser flare, and cell photometry.

RESULTS

Seventy-eight original articles investigating inflammation by LFCP were selected. Macula alterations were searched in 12 (15%) trials, by optical coherence tomography or fluorescein angiography in 11 (14%) and 1 (1%) studies, respectively. Among them, 9 (12%) papers investigated the correlation between LFCP values and cystic changes to the macula: 7 (9%) and 2 (3%) studies identified a positive and negative correlation, respectively. Three (4%) papers did not perform any correlation analysis.

CONCLUSION

CME, as a consequence of uncontrolled postoperative inflammation, is a common cause for unfavorable visual outcomes following uncomplicated phacoemulsification with IOL implantation. After surgery, intraocular inflammation is generally assessed by qualitative methods. Although well-established and practical in uveitis, they are inadequate to detect the modest inflammatory response that usually occurs after uneventful phacoemulsification. LFCP correlate with the chance of macula alteration after surgery and higher the values higher the risk of CME. The quantitative analysis of intraocular inflammation by LFCP after cataract surgery might be a tool to predict the risk of pseudophakic CME.

Effect of anti-inflammatory regimen on early postoperative inflammation after cataract surgery

PURPOSE

To investigate whether a combination of topical nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids were superior in controlling early postoperative inflammation after cataract surgery compared with topical NSAIDs alone and with dropless surgery where a sub-Tenon depot of steroid was placed during surgery.

SETTING

Department of Ophthalmology, Rigshospitalet-Glostrup, Denmark.

DESIGN

Prospective randomized controlled trial with masked statistical analyses.

METHODS

Patients undergoing phacoemulsification for age-related cataract were randomized to 1 of 5 regimens: ketorolac and prednisolone eyedrops combined (Pred+NSAID-Pre [control group] and Pred+NSAID-Post group) vs ketorolac monotherapy (NSAID-Pre and NSAID-Post groups) vs sub-Tenon depot of dexamethasone (dropless group). Drops were used until 3 weeks postoperatively, starting 3 days preoperatively in the Pre groups and on the day of surgery in the Post groups. Aqueous flare was measured at baseline and 3 days postoperatively.

RESULTS

Four hundred fifty-six participants, with a mean age of 72.1 (SD 7.0) years and 283 (62%) women, were included. Flare increased significantly more in the dropless group compared with the control group (Pred+NSAID-Pre), but none of the other groups differed significantly from the control group. Intraocular pressure decreased in all groups but significantly less in groups receiving prednisolone eyedrops (Pred+NSAID-Pre and Pred+NSAID-Post groups) compared with NSAID monotherapy and dropless groups. No differences in postoperative visual acuity were found compared with the control group.

CONCLUSIONS

No differences were found between groups randomized to NSAID monotherapy or combination of NSAID and steroid in controlling early inflammation after cataract surgery, but sub-Tenon depot of dexamethasone was less efficient. Initiating prophylactic eyedrops prior to surgery did not influence early postoperative anterior chamber inflammation.

French recommendations for the management of Behçet's disease

Behçet's disease (BD) is a systemic variable vessel vasculitis that involves the skin, mucosa, joints, eyes, arteries, veins, nervous system and gastrointestinal system, presenting with remissions and exacerbations. It is a multifactorial disease, and several triggering factors including oral cavity infections and viruses may induce inflammatory attacks in genetically susceptible individuals. BD vasculitis involves different vessel types and sizes of the vascular tree with mixed-cellular perivascular infiltrates and is often complicated by recurrent thrombosis, particularly in the venous compartment. Several new therapeutic modalities with different mechanisms of action have been studied in patients with BD. A substantial amount of new data have been published on the management of BD, especially with biologics, over the last years. These important therapeutic advances in BD have led us to propose French recommendations for the management of Behçet's disease [Protocole National de Diagnostic et de Soins de la maladie de Behçet (PNDS)]. These recommendations are divided into two parts: (1) the diagnostic process and initial assessment; (2) the therapeutic management. Thirty key points summarize the essence of the recommendations. We highlighted the main differential diagnosis of BD according to the type of clinical involvement; the role of genetics is also discussed, and we indicate the clinical presentations that must lead to the search for a genetic cause.

Disruption of blood-aqueous barrier in dry eye disease

PURPOSE

To evaluate level of flare in aqueous humor of dry eye disease (DED) and compare it with normal controls.

METHODS

In this cross-sectional study, we compared the anterior chamber flare between 28 patients with DED (the DED group) and 27 normal age- and gender-matched controls (the control group). DED group was divided in Sjӧgren's syndrome dry eye (SDE, n = 10) and non- Sjӧgren's syndrome dry eye (non-SDE, n = 18) groups.

RESULTS

This study enrolled 55 participants including 28 patients with DED and 27 normal controls. The mean age was 53.4 ± 14.7 years in the DED group and 48.5 ± 14.7 years in the control group (P = 0.086). Mean flare was significantly higher in DED group (12.1 ± 10.2 ph/ms, range 2.7-68.3) compared to the control group (5.0 ± 3.9 ph/ms, range 1.30-30.0, P < 0.001). There was no statistically significant difference in the flare intensity between the Sjӧgren syndrome dry eye (SDE) group (14.5 ± 14.4 ph/ms) and the non-Sjӧgren dry eye (non-SDE) group (10.8 ± 6.9 ph/ms, P = 0.330). A significant correlation was observed between the flare intensity and the ocular surface staining in the SDE group (r = 0.62, P = 0.018).

CONCLUSION

There is a significant increase in aqueous humor flare in patients with DED. Such finding, which is a marker of disruption of blood-aqueous barrier, demonstrates deeper tissue involvement than ocular surface in these patients.

Laser Flare Photometry: A Useful Tool for Monitoring Patients with Juvenile Idiopathic Arthritis-associated Uveitis

PURPOSE

We evaluated laser flare photometry (LFP) values in patients with juvenile idiopathic arthritis (JIA)-associated uveitis.

METHODS

Retrospective study. A decrease of the LFP value between baseline visit and 1 month after anti-inflammatory treatment intensification allowed us to define two groups of patients: group 1 (decreased LFP value ≥50%) and group 2 (<50%). We evaluated the prevalence of vision-threatening complications in both groups.

RESULTS

Fifty-four patients (87 eyes) were followed for 9.9 ± 5 years. Group 1 eyes (n = 54) had significantly fewer ocular complications than group 2 eyes (n = 33) at both 5 years visit (p = .03) and final visit (p = .047). At the final visit, group 2 eyes had significantly more band keratopathy, trabeculectomy, cataract surgery, glaucoma and papille edema. Group 1 eyes kept a better visual acuity (p < .0001).

CONCLUSION

The decrease of LFP values ≥50% of the initial value 1 month after treatment intensification is a good early prognostic factor.

Quantitative Analysis of Anterior Chamber Inflammation Using the Novel CASIA2 Optical Coherence Tomography

PURPOSE

We evaluated the clinical utility of a novel anterior segment optical coherence tomography (AS-OCT) device, CASIA2, to evaluate parameters indicative of anterior chamber (AC) inflammation severity in uveitis, including AC cell number, flare, and keratic precipitates (KPs).

DESIGN

Prospective evaluation of a diagnostic device.

METHODS

Uveitis eyes were classified into active and inactive groups. The number of hyperreflective dots representing AC cells and optical density ratio (aqueous-to-air relative intensity [ARI] index) for flare qualification were calculated from AS-OCT images. In addition, a program was designed to quantify the posterior corneal surface smoothness (PCSS) of each image for KPs evaluation. The maximum, minimum, and average PCSS values were calculated from 128 images per eye and compared among active uveitis, inactive uveitis, and control eyes. Correlations between Standardization of Uveitis Nomenclature grade and both hyperreflective dot number and ARI index were evaluated. Receiver operating characteristic (ROC) curves were constructed to test the values of these indicators for uveitis diagnosis.

RESULTS

AC hyperreflective dot count, ARI index, and maximum and average PCSS values were all significantly higher in the active uveitis group than in the inactive and control groups. Hyperreflective dot count and ARI index were associated with Standardization of Uveitis Nomenclature cell and flare grade. According to ROC curve analysis, maximum PCSS was the best indicator for the diagnosis of uveitis involving the anterior segment, meanwhile the hyperreflective dot number was the best to identify active AC inflammation from the inactive.

CONCLUSIONS

Quantification of AC cell number, flare, and KPs using the CASIA2 device is a promising strategy for the objective assessment of AC inflammation.

A case of severe flare reaction observed in HLA B27 associated acute anterior uveitis

Background

Anterior chamber flare reaction refers to the light reflection from the protein in aqueous humor. We report a case of very severe flare reaction observed in human leukocyte antigen (HLA)- B27 associated acute anterior uveitis (AAU).

Case presentation

An age 43 male patient visited the uveitis clinic complaining of decreased visual acuity in the right eye which developed 1 week before. The detailed ophthalmic examination revealed very severe flare reaction in the anterior chamber with diffuse conjunctival hyperemia in the right eye. Pupil margin and iris details were barely observable. Oral prednisolone 20 mg daily with topical 1% prednisolone acetate (Pred Forte, Allergan, CA) every 2 h and 1% topical cyclopentolate (Cyclogyl, Alcon, TX) three times daily were immediately prescribed. The next day, the flare reaction of the right eye decreased significantly and inflammatory cells in the anterior chamber were visible. Detailed fundus examination revealed no inflammatory signs on the retina and ciliary body. Later, the blood test revealed positive HLA B27 and autoantibodies against lupus anticoagulant with mild elevation of C reactive protein. There were no signs for ankylosing spondylitis. Continued treatment and tapering of topical 1% prednisolone acetate for 4 weeks led to the complete resolution of the anterior uveitis.

Conclusions

We experienced HLA-B27 AAU with the feature of a very severe flare reaction. Conventional uveitis treatment was successful to acquire the complete resolution of the inflammation.

Changes in intraocular pressure and aqueous flare in eyes with multiple evanescent white dot syndrome

PURPOSE

To study the changes in intraocular pressure (IOP) and aqueous flare in eyes with multiple evanescent white dot syndrome (MEWDS) during the disease course.

STUDY DESIGN

Retrospective observational study.

METHODS

Twenty-one patients with unilateral MEWDS were retrospectively evaluated. IOP values were compared between the affected and fellow eyes 2 weeks, 1 month, and 3 months following disease onset in 17 patients, and within 7 days from disease onset in 11 patients. Aqueous flare values measured using a laser flare-cell meter in ten eyes between 1 weeks and 1 month from disease onset were compared between the affected and fellow eyes.

RESULTS

IOP values were significantly lower in the affected eyes than in the fellow eyes at both 2 weeks (P=0.002) and 1 month from disease onset (P=0.02). However, IOP values of affected eyes did not show significant differences from the fellow eyes within 7 days ((P=0.11) and 3 months of onset (P=0.30). Aqueous flare values were significantly increased in the affected eyes compared to those in the fellow eyes (P=0.010) and significantly correlated with IOP values (r=-0.67, P=0.035).

CONCLUSION

IOP values mildly decreased in association with aqueous flare values in the acute phase in eyes with MEWDS.

Evaluation of choroidal thickness, macular thickness, and aqueous flare after cataract surgery in patients with and without diabetes: a prospective randomized study

BACKGROUND

In diabetic eyes, various choroidal abnormalities are noted in addition to changes in the retinal circulation, and the risk of increased aqueous flare and retinal thickening after cataract surgery is higher in diabetic eyes. Inflammation caused by surgery induces breakdown of the blood-retinal barrier and affects the retina, although the influence on the choroid is unknown. Several researchers have evaluated the choroidal thickness (CT) after cataract surgery in patients with diabetes; however, the results are inconsistent. The purpose of this study was to evaluate the influence of uneventful small-incision phacoemulsification cataract surgery on the subfoveal choroidal thickness (SCT), the central macular thickness (CMT), and aqueous flare in patients with diabetes.

METHODS

This study included 59 randomly selected eyes (33 eyes of patients with diabetes and 26 eyes of control patients without diabetes) undergoing small-incision cataract surgery. Among the diabetic eyes, 26 were without diabetic retinopathy, and the remaining eyes had non-proliferative diabetic retinopathy. Aqueous flare, CMT, and SCT measurements were performed before and at 1 week, 1 month, and 3 months after surgery.

RESULTS

The postoperative CMT continued to increase significantly until 3 months in both groups. Although the CMT was more in patients with diabetes than in patients without diabetes during the follow-up period, there was no significant difference between the two groups. The aqueous flare value increased until 3 months after surgery in both groups. Although the increase was significant at 3 months after surgery in patients with diabetes, the increase in controls was not significant. The aqueous flare values differed significantly between the two groups before and at 3 months after surgery. There was no significant within-group or between-group difference in pre- and postoperative SCT values.

CONCLUSION

In diabetic eyes with early stage of retinopathy, even small-incision cataract surgery can induce increased aqueous flare and macular thickening until 3 months, although there is no significant change in the choroidal thickness. Further studies are essential to evaluate choroidal changes after the cataract surgery in diabetic eyes.

Role of Inflammation in Retinal Microcirculation in Diabetic Eyes: Correlation between Aqueous Flare and Microvascular Findings

PURPOSE

To investigate the correlation between aqueous flare and macular microvascular status assessed by optic coherence tomography angiography (OCTA) in diabetes mellitus.

METHODS

A cross-sectional study was conducted on 52 diabetic patients with nonproliferative retinopathy, 44 diabetic patients without retinopathy, and 20 nondiabetic age-matched controls. Spectral domain OCT, OCTA, and laser flare-cell meter were performed.

RESULTS

Compared to eyes without retinopathy, eyes with retinopathy had higher flare intensity (p = 0.024), enlarged capillary nonperfusion area (p < 0.001), and enlarged foveal avascular zone (p < 0.001). There was a significant correlation between flare intensity and capillary nonperfusion areas (p < 0.001, r = 0.511) and superficial capillary density (p = 0.005, r = -0.388) in diabetic eyes with retinopathy.

CONCLUSION

The results demonstrated a positive correlation between aqueous flare levels, an indicator of intraocular inflammation, and microvascular damage demonstrated by OCTA in the early stages of diabetic retinopathy (DR). This finding supports the role of inflammation in the pathogenesis of DR.

Measuring Anterior Chamber Inflammation After Cataract Surgery: A Review of the Literature Focusing on the Correlation with Cystoid Macular Edema

Cystoid macular edema (CME) is an infrequent, though potentially visually impairing, complication after uneventful cataract surgery. Rupture of the blood-aqueous barrier, with leakage of serum proteins into the aqueous humour, is the main pathogenic factor. However, only a few studies investigated the potential correlation between anterior chamber (AC) inflammation and the risk of cystoid macular changes occurring after surgery. This review aims to identify evidence of a correlation between AC inflammation and the risk of pseudophakic CME. One hundred eighty-seven prospective trials investigating AC inflammation after uncomplicated cataract surgery were identified. Methods of analysis of AC inflammation and the frequency of macular changes were recorded. In the majority (51%) of the studies, inflammation was assessed by clinical grading, followed by laser flare and cell photometry (LFCP) (42%) and aqueous humour sample (4%). Few studies (4%) adopted a combined LFCP and aqueous sample or clinical grading analysis. Sixteen (9%) studies investigated AC inflammation and macular changes by OCT (7%) or fluorescein angiography (2%). Correlation between the amount of postoperative AC inflammation and frequency of CME was documented in 7 studies, not confirmed in 2 studies, and not examined in the other 7. LFCP, more than the other methods of analysis, correlated with the frequency of CME postoperatively. Investigation of the relationship between AC inflammation and the risk of CME changes requires the adoption of quantitative methods of analysis of the inflammatory response after surgery. For this purpose, due to the low level of inflammation in the AC after uncomplicated cataract surgery, LFCP, more than subjective clinical grading, seems a more sensitive and reproducible method of measurement. Inflammation assessment after cataract surgery has a potential role in predicting the risk of CME development and may help to titrate the duration and intensity of treatment in relation to the surgical inflammatory response.

Risk of Nonarteritic Anterior Ischemic Optic Neuropathy After Cataract Surgery

PURPOSE

To determine whether the development of nonarteritic anterior ischemic optic neuropathy (NAION) is increased after receiving cataract surgery in a large general population.

DESIGN

Nationwide, population-based, retrospective cohort study.

METHODS

Setting: A 12-year nationwide, population-based, retrospective cohort study including 1,025,340 beneficiaries in the 2002-2013 Korean National Health Insurance Service database.

PATIENTS

We identified 40,356 patients who had undergone cataract surgery and matched non-cataract surgery controls (1:2) using estimated propensity scores in reference to age, sex, demographics, comorbidities, and co-medications.

OBSERVATIONS

Kaplan-Meier curves and Cox proportional hazard models were generated to determine the risk of developing NAION in the cataract surgery group compared to the non-cataract surgery group.

MAIN OUTCOME MEASURES

Effect (hazard ratio [HR]) of cataract surgery on NAION development.

RESULTS

The 10-year incidence probability of NAION was 0.70% (95% confidence interval [CI], 0.55%-0.86%) in the cataract surgery group and 0.27% (95% CI, 0.25%-0.29%) in the non-cataract surgery group (P < .0001, log-rank test). The cataract surgery group had an increased risk of developing NAION compared to the non-cataract surgery group (HR = 1.80; 95% CIs, 1.46-2.21) even after adjusting for demographics, comorbidities, Charlson comorbidity index, and co-medications.

CONCLUSION

Our results suggest that patients undergoing cataract surgery have an increased risk of NAION.

Effect of Tropicamide on Laser Flare Meter Measurements in Patients with Pseudoexfoliation

PURPOSE

To investigate the effect of 1% tropicamide on anterior chamber aqueous flare (ACAF) measurements acquired with laser flare meter in patients with pseudoexfoliation.

METHODS

Thirty-three eyes of 33 patients with pseudoexfoliation were enrolled. Patients with the history of other ocular diseases, intraocular surgeries, and the presence of severe posterior synechia were excluded. Besides routine ophthalmological examination, ACAF levels were measured by laser flare meter device (Kowa FM 600) before and after instillation of 1% tropicamide.

RESULTS

The mean age of 33 patients was 67.3±7.1 (53-85) years. Patients had a mean best corrected visual acuity of 0.25±0.41 (1.80-0.00) logMAR, cup-to-disc ratio of 0.45±0.22 (0.2-1), and IOP of 15.33±2.82 (9-20) mmHg. Although the mean ACAF value increased from 14.68±8.40 (3.4-40.4) photon/ms predilation to 15.41±10.74 (3.8-46.8) photon/ms post-dilation, the difference was not statistically significant (p=0.835).

CONCLUSIONS

ACAF values in patients with pseudoexfoliation did not significantly differ after instillation of 1% tropicamide.

Comparison of the Treatment Results for Behçet Uveitis in Patients Treated with Infliximab and Interferon

Purpose: To compare the efficacy and safety of infliximab and interferon in patients with refractory Behçet uveitis.Methods: Medical records of 20 patients treated with infliximab (IFX) and 33 patients treated with interferon (IFN) were retrospectively analyzed by evaluating the number of uveitis attacks, visual acuity and ocular inflammation at 6 and 12 months after initiation of treatment.Results: Mean duration of treatment was 22 ± 18 months in IFX group and 30.3 ± 22.5 months in IFN group. Sixteen patients of IFX group (80%) and 28 patients of IFN group (85%) achieved remission. In both groups, the mean best-corrected visual acuity and all inflammatory parameters improved. In terms of these parameters, there was no significant difference between the two groups.Conclusion: Infliximab and interferon improve control of ocular inflammation and efficiently decrease the relapse rate. Our results determined no significant difference between two agents in controlling intraocular inflammation.

Instrument-based tests for measuring anterior chamber cells in uveitis: a systematic review protocol

BACKGROUND

Uveitis describes a group of inflammatory conditions affecting the eye. The ability to monitor inflammatory changes in anterior uveitis is crucial in clinical practice for making treatment decisions and in clinical trials for testing therapeutic agents. The current standard for quantifying anterior segment inflammation is clinical slit-lamp examination findings classified using the Standardisation of Uveitis Nomenclature (SUN) grading system. Such clinical grading systems rely on a subjective estimation using the slit lamp and are often non-linear and non-continuous scales, with large increases in cell count between each grade. Novel instrument-based technologies have emerged over the last few decades, which can provide objective and quantifiable measurements. This review will evaluate the reliability of such technologies and their level of agreement with anterior chamber (AC) cell count using clinical slit-lamp examination.

METHODS

Standard systematic review methodology will be used to identify, select and extract data from studies that report the use of any instrument-based technology in the assessment of AC cells. Searches will be conducted through bibliographic databases (MEDLINE, EMBASE and Cochrane Library), clinical trial registries and the grey literature. No restrictions will be placed on language or year of publication. The outcomes of interest are the correlation of index test measurements of AC cells with clinical grading systems using slit-lamp examination and the reliability of each index test identified. Quality assessment will be undertaken using QUADAS2. Degree of correlation between the index and reference test measures will be pooled and meta-analysed if appropriate.

DISCUSSION

A number of instrument-based tools are available for measuring AC cells. This review will evaluate the technologies available and measure the level of correlation of these alternative methods with clinical grading systems as well as their performance in reliability and repeatability. The findings of this review will identify those objective, instrument-based technologies which show good utility for measuring AC cells in a quantifiable way and which warrant further exploration for their sensitivity and reliability over the current standard.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017084156 (Liu X, Moore DJ, Denniston AK). Instrument-based tests for measuring anterior chamber (AC) cells in uveitis: a systematic review. 2017). Study screening stage is complete. Data extraction stage has not yet commenced.

Efficacy of Intravitreal Dexamethasone Implant in Patients of Uveitis Undergoing Cataract Surgery

Purpose: To assess postoperative inflammation using laser flare photometer, following phacoemulsification with or without single intraoperative intravitreal dexamethasone implant in addition to standard of care, in patients of uveitis with cataract.Methods: Prospectively, 30 eyes with uveitic cataract were randomized into 2 groups (i) standard of care (SOC group) (ii) Dexamethasone implant (DEXA group). Both the groups underwent phacoemulsification with intraocular lens implantation and standard of care treatment for uveitis, but DEXA group additionally received intraoperative intravitreal dexamethasone implant. Patients were followed at least till 6 months.Results: DEXA group had significantly less postoperative flare (LFP values) (P<0.05) as compared to SOC group and also recovery of flare to preoperative value occurred much early in DEXA group. 37.5% cases developed CME in SOC group but none in DEXA group. Mean CMT (267.81±34.26μm) and final logMar BCVA (0.036±0.063) was significantly better in DEXA group (p<0.04).Conclusions: Intraoperative intravitreal dexamethasone implant is a safe and effective option for preventing and managing the postoperative inflammation in uveitic cataract.

Analysis of ocular inflammation in anterior chamber-involving uveitis using swept-source anterior segment OCT

PURPOSE

To evaluate the utility of swept-source (SS) optical coherence tomography (OCT) to objectively analyze the degree of anterior chamber (AC) inflammation.

METHODS

Thirty-eight eyes of 32 patients with uveitis and 20 control eyes were enrolled. SS OCT B-scans were obtained, and the number of cells in the B-scans was counted using two methods: (1) manual grading by Point Picker plug-in of Image J ( http://bigwww.epfl.ch/thevenaz/pointpicker/ ) and (2) automated grading by the Image J Particle Analysis algorithm ( http://imagej.net/Particle_Analysis ). The automated and manual AC cell counts were correlated with the Standardization of Uveitis Nomenclature score.

RESULTS

The average numbers of AC inflammatory cells counted by the automated method were 8 ± 4.0, 18 ± 3.0, 42 ± 14.0, 81 ± 32.0, 117 ± 57.0, and 275 ± 67.0 cells/mm² for grades 0, 0.5 + , 1 + , 2 + , 3 + , and 4 + , respectively. For the same clinical categories, the average manual cell counts were 6 ± 4.0, 18 ± 3.0, 34 ± 14.0, 72 ± 32.0, 92 ± 43.0, and 168 ± 65.0 cells/mm², respectively. Zero cells were detected in the AC of healthy eyes. The automated and manual methods were highly correlated (R = 0.98, p < 0.001) and showed good correlation with the clinical grading (R = 0.88, p < 0.001). A mean AC particle size of 117.4 ± 108.8 μm was obtained by the automated method.

CONCLUSIONS

Quantification of the AC cells imaged by SS AS-OCT shows good correlation with categorical clinical severity assessments in uveitis eyes. This approach may provide a more objective method for monitoring uveitis and response to uveitis therapy.

The Comparative Efficacy and Tolerability of Diclofenac 0.1% and Bromfenac 0.09% Ophthalmic Solutions after Cataract Surgery

PURPOSE

To compare the efficacy and tolerability of diclofenac and bromfenac ophthalmic solutions as adjunctive therapy after cataract surgery.

MATERIALS AND METHODS

This prospective randomized controlled study included 130 patients who underwent cataract surgery. One hundred patients were randomized to receive postoperatively diclofenac 0.1% (four times daily for 28 days, Group 1) or bromfenac 0.09% (twice daily for 14 days, Group 2) ophthalmic solutions in addition to steroid-antibiotic combination. Thirty patients instilled only steroid-antibiotic combination (Control Group 3). Laser flare-cell photometry and optical coherence tomography scans with central foveal thickness (CFT) measurement were performed before (V0) and 7 (V1), 14 (V2) and 28 days (V3) after surgery. Treatment tolerability was scored using the Ocular Comfort Grading Assessment.

RESULTS

Laser flare-cell photometry values were significantly higher at V1, V2 and V3 compared to V0 in all the groups (respectively 13.3 ± 1.0, 12.7 ± 0.9 and 9.6 ± 0.9 vs 8.4 ± 0.6 ph/ms for Group 1; 13.4 ± 1.0, 12.7 ± 0.9 and 12.7 ± 1.0 vs 8.1 ± 0.6 for Group 2; 15.9 ± 0.8, 15.4 ± 0.7 and 14.5 ± 0.7 vs 7.5 ± 0.5 for Group 3) (p < 0.001); flare increase was significantly lower in Group 1 compared to Groups 2 and 3 (p < 0.001). CFT values were higher after surgery in all the three groups; the increase was significantly lower in Group 1 compared to Groups 2 and 3 (p < 0.0002). The percentage of symptoms-free patients after study treatment was significantly higher in Group 2 compared to Group 1 (respectively 74% vs 14% of the total; p < 0.001).

CONCLUSION

The addition of diclofenac or bromfenac ophthalmic solutions contributed to further reduce both inflammation and cystoid macular edema after cataract surgery compared to steroid-antibiotic combination alone. Diclofenac appeared to be more effective in reducing postoperative intraocular inflammation with a more intense and prolonged regimen, while bromfenac more tolerated with lower daily dose and treatment duration.

Multiplex Cytokine Analysis of Aqueous Humor in Juvenile Idiopathic Arthritis-Associated Anterior Uveitis With or Without Secondary Glaucoma

Patients with juvenile idiopathic arthritis often develop chronic anterior uveitis (JIAU). JIAU patients possess a particularly high risk for developing secondary glaucoma when inflammatory inactivity has been achieved. By using multiplex bead assay analysis, we assessed levels of pro- and anti-inflammatory cytokines, chemokines, or metalloproteinases in the aqueous humor (AH) of patients with clinically inactive JIAU with (JIAUwG) or without secondary glaucoma (JIAUwoG), or from patients with senile cataract as controls. Laser-flare photometry analysis prior to surgery showed no significant differences between JIAUwG or JIAUwoG. Compared with the control group, levels of interleukin-8, matrix metalloproteinase-2, -3, -9, serum amyloid A (SAA), transforming growth factor beta-1, -2, -3 (TGFβ-1, -2, -3), and tumor necrosis factor-alpha in the AH were significantly higher in patients with clinically inactive JIAUwG or JIAUwoG. Samples from JIAwoG patients displayed significantly higher levels of SAA (P < 0.0116) than JIAUwG patients. JIAUwG patients showed an increased level of TGFβ-2 in AH samples compared with JIAUwoG (P < 0.0009). These molecules may contribute to the clinical development of glaucoma in patients with JIAU.

Quantitative Assessment of Aqueous Flare After Descemet Membrane Endothelial Keratoplasty for Fuchs Endothelial Dystrophy

PURPOSE

To assess aqueous flare as a measure of subclinical inflammation after Descemet membrane endothelial keratoplasty (DMEK) for Fuchs endothelial dystrophy.

METHODS

In this prospective cross-sectional and longitudinal case series at a tertiary referral center, 173 DMEK eyes of 169 patients and 19 age-matched healthy control eyes were included. Aqueous flare [photon count per millisecond (ph/ms)] was assessed by laser flare photometry at 1 day, 1 week, and 1 month after DMEK in group I (evaluation of postsurgical blood-aqueous barrier recovery; n = 25) and on average 28 (±19) months (range, 3-86 months) after DMEK in group II (evaluation of long-term inflammation; n = 148).

RESULTS

In group I, flare levels decreased from 1 day to 1 week [25.1 (±9.1) ph/ms vs. 13.4 (±4.8) ph/ms; P = 0.003] and remained stable up to 1 month after DMEK [12.1 (±3.2) ph/ms; P = 0.387]. However, average flare at 1 month was higher than that in healthy controls (P < 0.001). The long-term flare value after DMEK (group II) was 9.6 (±4.2) ph/ms and was higher in eyes associated with allograft rejection (n = 6) versus those without rejection [16.7 (±7.8) ph/ms vs. 9.3 (±3.8) ph/ms, respectively, P < 0.001]. All eyes associated with rejection had flare values above 10 ph/ms.

CONCLUSIONS

Aqueous flare after DMEK quickly decreased within the first postoperative month, indicating fast recovery of the blood-aqueous barrier. Long-term flare levels were higher in eyes associated with rejection, suggesting persistent subclinical inflammation. A flare level above 10 ph/ms may be used as a threshold for identifying eyes associated with or at risk of allograft rejection after DMEK.

Subclinical Inflammatory Response: Accelerated versus Standard Corneal Cross-Linking

Purpose: To compare the subclinical inflammatory response (as measured by anterior chamber flare) induced after standard (3 mW/cm², 30 min) and accelerated (18 mW/cm², 5 min) corneal cross-linking (CXL). Methods: In this comparative, non-randomized study, patients with progressive keratoconus who underwent standard or accelerated CXL were studied. Laser flare photometery (FM-600; Kowa, Tokyo, Japan) was used to measure anterior chamber flare preoperatively and at 1 week, 1 month, 3 months, and 6 months after the procedure. Results: Sixty eyes of 60 patients were studied; 30 eyes in each group. Mean baseline flare values were 4.15 ± 1.19 and 4.57 ± 2.17 ph/ms in standard and accelerated groups, respectively (p = 0.228).and after surgery increased in all follow-up measurements in the both groups similarly (P > 0.05). Conclusion: Both standard and accelerated CXL results in induction of a subclinical inflammatory response that persists up to 6 month. The response was similar between the two groups.