Cost-effectiveness analysis of endoscopic dacryocystorhinostomy using Markov modelling

OBJECTIVE

To determine the cost-effectiveness of endoscopic dacryocystorhinostomy (DCR).

METHODS

We constructed a Markov model in which patients with nasolacrimal duct obstruction received endoscopic DCR or no surgery. Incremental cost-effectiveness ratios, 1-way sensitivity analyses, and probabilistic sensitivity analyses were used to evaluate for model sensitivity to multiple model inputs.

RESULTS

Endoscopic DCR was found to be cost-effective with an incremental cost-effectiveness ratio of US$2162 per quality-adjusted life-year. The model was most sensitive to the health utility deduction from epiphora. Probabilistic sensitivity analysis found endoscopic DCR to be cost-effective over no surgery 93.7% of the time.

CONCLUSIONS

Endoscopic DCR is a cost-effective treatment for patients with epiphora. The model is very sensitive to the negative effect epiphora has on quality of life. With the advancement of health care technology and surgical techniques, the success rates of endoscopic DCR continue to improve and to be an even more efficacious and economical treatment for nasolacrimal duct obstruction.

Axial length and pharmacologic pupillary dilation in highly myopic patients

PURPOSE

To determine how high myopia impacts pharmacological pupillary dilation, and to evaluate the relationship between the extent of pharmacologic pupillary dilation and axial length.

METHODS

Patients were grouped into high myopes, defined as one or both eyes having a refractive error greater than - 6 diopters, and controls (between - 2 and + 2 diopters). Dilation was achieved with 1 drop each of tropicamide 1% and phenylephrine 2.5%. Pupil size was measured at full and dim light prior to dilation, then 15 and 30 min after dilation. Biometry was measured for each patient. Statistical analyses were performed using the Mann-Whitney-Wilcoxon tests, two-sample Welch's t-tests, and linear mixed effect models and generalized estimating equations models accounting for inter-eye correlation.

RESULTS

Forty patients (20 high myopes and 20 controls, 80 eyes total) participated in the study. High myopes had larger pupils at baseline and achieved significantly greater pupillary size (7.08 mm, 95% CI: 6.97 to 7.19 mm) than controls (6.23 mm, 95% CI: 5.94 to 6.52 mm) after 30 min of dilation (P < .0005). Fully dilated pupil size at 30 min was significantly correlated with both refractive error (r =  - 0.57, P < .0005) and axial length (r = 0.47, P < .0005). Generalized estimating equations and linear mixed effect models identified other predictive variables of pupil size after dilation including age and white-to-white diameter.

CONCLUSIONS

Highly myopic patients dilate to a larger pupillary size compared to other patients. Predicting dilation based on extent of myopia could facilitate intraocular surgery planning and reduce clinic wait times for myopic patients.

Impact of scleral tunnel length on the position of IOLs in flanged intrascleral haptic fixation

PURPOSE

To investigate the effect of scleral tunnel length on the effective lens position and tilt of the intraocular lens (IOL) in flanged intrascleral haptic fixation (ISHF) using anterior segment optical coherence tomography (AS-OCT).

SETTING

Tertiary institution.

DESIGN

Retrospective case-control study.

METHODS

This study included 55 and 42 eyes that underwent ISHF with 1.0- and 2.0-mm scleral tunnels, respectively. Twenty-three eyes that underwent sutured fixation were used as a control. The anterior chamber depth (ACD), scleral tunnel length, incident angle of haptic, and tilting of optic were analyzed using AS-OCT.

RESULTS

The mean postoperative ACD, vertical tilt angle, and spherical equivalent of the 1.0-mm were 5.27 ± 0.39 mm, 6.04 ± 4.87°, and 0.38 ± 1.03 D, respectively. The ACD and vertical tilt angle of the 1.0-mm were larger than those of the others (p<0.001 and p<0.05, respectively), and the postoperative spherical equivalent was more hyperopic (p<0.05). The 2.0-mm exhibited a lower frequency of tilting greater than 7°. The inter-eye difference in ACD between in-the-bag fixation and ISHF of the1.0-mm tunnel was significantly greater than that in the 2.0-mm tunnel (p<0.05). The 1.0 mm tunnel had a significantly larger incident angle and a longer tunnel length (p<0.001, respectively) and showed a greater difference in the tunnel length on both sides (p<0.05).

CONCLUSION

A shorter tunnel yielded a more unstable IOL position, greater variation in angle and tunnel length, and longer ACD during ISHF. An exact 2.0-mm tunnel must be created on both sides to achieve a stable and predictable IOL position.

A multi-ancestry GWAS of Fuchs corneal dystrophy highlights the contributions of laminins, collagen, and endothelial cell regulation

Fuchs endothelial corneal dystrophy (FECD) is a leading indication for corneal transplantation, but its molecular etiology remains poorly understood. We performed genome-wide association studies (GWAS) of FECD in the Million Veteran Program followed by multi-ancestry meta-analysis with the previous largest FECD GWAS, for a total of 3970 cases and 333,794 controls. We confirm the previous four loci, and identify eight novel loci: SSBP3, THSD7A, LAMB1, PIDD1, RORA, HS3ST3B1, LAMA5, and COL18A1. We further confirm the TCF4 locus in GWAS for admixed African and Hispanic/Latino ancestries and show an enrichment of European-ancestry haplotypes at TCF4 in FECD cases. Among the novel associations are low frequency missense variants in laminin genes LAMA5 and LAMB1 which, together with previously reported LAMC1, form laminin-511 (LM511). AlphaFold 2 protein modeling, validated through homology, suggests that mutations at LAMA5 and LAMB1 may destabilize LM511 by altering inter-domain interactions or extracellular matrix binding. Finally, phenome-wide association scans and colocalization analyses suggest that the TCF4 CTG18.1 trinucleotide repeat expansion leads to dysregulation of ion transport in the corneal endothelium and has pleiotropic effects on renal function.

Light adjustable intraocular lenses in cataract surgery: considerations

PURPOSE OF REVIEW

Light adjustable intraocular lens (LAL) is a promising concept in cataract surgery. This review explores considerations for the use of LALs.

RECENT FINDINGS

Through updates, the safety of LALs and light delivery devices have been enhanced, enabling more efficient treatment with lower ultraviolet (UV) energy. Preoperative topography and aberration are essential for understanding indications for LALs. Furthermore, when determining intraocular lens power, it is crucial to factor in potential postoperative myopia or hyperopic adjustments. This is achieved by establishing a proper postimplantation refractive target and considering potential wavefront changes. Postoperative adjustments for defocus and astigmatism have demonstrated excellent outcomes. Monovision strategy by adjustable blended vision of LALs revealed distance vision of 20/20 along with near vision of J2 in 96% of patients. However, the results of clinical studies on postrefractive cataract surgery showed contrasting outcomes at distance, indicating the need for further research results regarding its effectiveness. A new postoperative workflow needs to be designed to enable a systematic follow-up process.

SUMMARY

LALs are safe and demonstrate promising refractive outcomes. To achieve appropriate results, understanding the changes in optical characteristics associated with adjustment and constructing a new postoperative workflow are necessary.

Oxidative stress and antioxidants in cataract development

PURPOSE OF REVIEW

Oxidative stress plays a central role in cataract pathogenesis, a leading cause of global blindness. This review delves into the role of oxidative stress in cataract development and key biomarkers - glutathione (GSH), superoxide dismutase (SOD), malondialdehyde (MDA), and 4-hydroxynonenal (4-HNE) - to clarify their functions and potential applications in predictive diagnostics and therapies.

RECENT FINDINGS

Antioxidants serve as pivotal markers in cataract pathogenesis. GSH affects the central lens due to factors such as enzyme depletion and altered connexin expression, impairing GSH diffusion. Age-related oxidative stress may hinder GSH transport via connexin channels or an internal microcirculation system. N-acetylcysteine, a GSH precursor, shows promise in mitigating lens opacity when applied topically. Additionally, SOD, particularly SOD1, correlates with increased cataract development and gel formulations have exhibited protective effects against posterior subscapular cataracts. Lastly, markers of lipid peroxidation, MDA and 4-HNE, have been shown to reflect disease severity. Studies suggest a potential link between 4-HNE and connexin channel modification, possibly contributing to reduced GSH levels.

SUMMARY

Oxidative stress is a significant contributor to cataract development, underscoring the importance of antioxidants in diagnosis and treatment. Notably, GSH depletion, SOD decline, and lipid peroxidation markers are pivotal factors in cataract pathogenesis, offering promising avenues for both diagnosis and therapeutic intervention.

Reticular Bullous Epithelial Corneal Edema after Netarsudil Use for Elevated Intraocular Pressure with Concurrent Fuchs Endothelial Corneal Dystrophy: A Case Report

Introduction

We describe a case of reticular bullous corneal epithelial edema associated with the use of netarsudil ophthalmic solution (0.02%) for elevated intraocular pressure.

Case Presentation

A 74-year-old man with a complex ocular medical history, including Fuchs dystrophy and primary open-angle glaucoma, developed progressively worsening loss of vision 3 weeks following the initiation of topical netarsudil for increased intraocular pressure. Visual acuity in the left eye was counting fingers at 3 feet and intraocular pressure in the left eye was 7 mm Hg. A characteristic "honeycomb" pattern epitheliopathy was seen on ocular examination.

Conclusion

Reticular bullous epithelial corneal edema is an uncommon finding associated with netarsudil use, which can be overlooked in favor of corneal edema associated with Fuchs dystrophy. This is especially relevant given Fuchs dystrophy itself is a predisposing risk factor for netarsudil-induced reticular bullous corneal epithelial edema. Improvement of both the corneal edema and visual acuity should be expected after discontinuing netarsudil and undergoing superficial keratectomy.

Intracameral antibiotics during cataract surgery: efficacy, safety, and cost-benefit considerations

PURPOSE OF REVIEW

We summarize evidence-based considerations regarding the use of intracameral antibiotics during cataract surgery.

RECENT FINDINGS

The use of intraoperative intracameral antibiotics reduced the incidence of postcataract surgery endophthalmitis 3.5-fold, with an odds ratio ranging from 0.14 to 0.19. A survey of the American Society of Cataract and Refractive Surgery showed usage of intracameral injections of antibiotics increased by 16% in the United States between 2014 and 2021. The frequency of vancomycin usage has sharply dropped to 6%, while moxifloxacin is now the dominant choice at 83% among respondents. One analysis showed that 2500 patients need to be treated with intracameral antibiotics to prevent one case of endophthalmitis. A 500 μg intracameral moxifloxacin at $22 dollars per dose is cost-effective, including for patients with posterior capsular rupture (PCR).

SUMMARY

Studies substantiate the safety and efficacy of intracameral antibiotics for endophthalmitis prophylaxis. Intracameral moxifloxacin and cefuroxime are the most common choices. While vancomycin shows potential for efficacy, further studies evaluating clinical outcomes are needed. Adverse events are rare and commonly due to errors in preparation. Topical antibiotics do not provide additional prophylactic benefits to intracameral regimens. Intracameral antibiotics given alone are cost-effective.

The effect of patient age on some new and older IOL power calculation formulas

PURPOSE

To assess the accuracy of intraocular lens (IOL) power calculation in different age groups using various IOL calculation formulas.

METHODS

Data from 421 eyes of 421 patients ≥60 years old (ages: 60-69, n = 131; 70-74, n = 105; 75-84, n = 158 and ≥85, n = 27), who underwent uneventful cataract surgery with SN60WF IOL implantation at John A. Moran Eye Center, Salt Lake City, USA, were retrospectively obtained. The SD of the prediction error (PE), median and mean absolute PEs and the percentage of eyes within ±0.25, ±0.50, ±0.75 and ±1.00 D were calculated after constant optimizations for the following formulas: Barrett Universal II (BUII), Emmetropia Verifying Optical (EVO) 2.0, Haigis, Hoffer Q, Hoffer QST, Holladay 1, Kane, Radial Basis Function (RBF) 3.0 and SRK/T. Results were compared between the different age groups.

RESULTS

Predictability rates within 0.25D were lower for the eldest age group compared with the other groups using the EVO 2.0 (33% vs. 37%-53%, p = 0.045), Kane (26% vs. 35%-50%, p = 0.034) and SRK/T (22% vs. 31%-49%, p = 0.002). Higher median absolute refractive errors for all formulas were observed in the oldest group [range: 0.39 D (Haigis, Hoffer QSR)-0.48 D (Kane)], followed by the youngest group [range: 0.30 D (RBF 3.0)-0.39 D (Holladay 1, SRK/T)] but did not reach statistical significance. No significant differences between the groups in the distribution parameter were seen.

CONCLUSION

Current IOL power calculation formulas may have variable accuracy for different age groups. This should be taken into account when planning cataract surgery to improve refractive outcomes.

Evaluating the accuracy of a cataract surgery simulation video in depicting patient experiences under conscious anesthesia

PURPOSE

To evaluate the accuracy of a point-of-view cataract surgery simulation video in representing different subjective experiences of patients undergoing the procedure.

METHODS

One hundred consecutive post-cataract-surgery patients were shown a short simulation video of the surgery obtained through a porcine eye model during the first postoperative week. Patients then answered a multiple-choice questionnaire regarding their visual and tactile intraoperative experiences and how those experiences matched the simulation.

RESULTS

Of the patients surveyed (n = 100), 78% (n = 78) recalled visual experiences during surgery, 11% recalled pain (n = 11), and 6.4% (n = 5) recalled frightening experiences. Thirty-six percent of patients (n = 36) were interviewed after their second cataract surgery; there was no statistically significant difference between anxiety scores reported before the first eye surgery and second eye surgery (p = 0.147). Among all patients who recalled visual experiences (n = 78), nearly half (47.4%) reported that the video was the same/similar to their experience. Forty-eight percent of the patients recommended future patients to watch the video before their procedures, and more than a third (36%) agreed that watching the video before surgery would have helped them to relax.

CONCLUSIONS

Our model reflects the wide range of subjective patient experiences during and after surgery. The high percentage of patients who found the video accurate in different ways suggests that, with more development, point-of-view cataract simulation videos could prove useful for educational or clinical use. Further research may be done to confirm the simulation's utility, by screening the video for subjects before operations.

Cost-Effectiveness Analysis of Light Adjustable Lens Compared to Monofocal Intraocular Lens in Cataract Surgery

PURPOSE

To analyze the cost-effectiveness of the Light Adjustable Lens (LAL; RxSight) in comparison to a monofocal intraocular lens (IOL) for individuals undergoing cataract surgery in both eyes.

METHODS

A cost-effectiveness analysis was performed using a Markov model that simulated the patient outcomes and costs associated with undergoing cataract surgery with the LAL or monofocal IOL. Cost-effectiveness was determined using the incremental cost-effectiveness ratio (ICER), a measure that quantifies the incremental cost in dollars per quality-adjusted life year (QALY) gained. Treatments with the ICER below the willingness-to-pay threshold (WTP) of $50,000/QALY were considered cost-effective. The model was also evaluated for the impact of uncertainties in parameters using one-way sensitivity and probabilistic sensitivity analyses.

RESULTS

The cost-effectiveness analysis showed that the LAL is cost-effective compared to monofocal IOLs in patients undergoing cataract surgery, with ICERs of $9,792/QALY (health care perspective) and $10,072/QALY (societal perspective) both significantly below the WTP. The model was most sensitive to patient age, market cost of the LAL, and proportion of patients with residual astigmatism following cataract surgery. The probabilistic sensitivity analysis showed that cataract surgeries in patients starting at age 65 years were cost-effective in 94% of the simulations at a WTP of $50,000/QALY.

CONCLUSIONS

From both health care and societal perspectives, the study shows cataract surgeries performed with the LAL are cost-effective when compared to those performed with a monofocal IOL. More studies are needed to compare the LAL to other premium lenses that also provide patients with excellent visual outcomes at a higher cost. [J Refract Surg. 2023;39(11):777-782.].

Refractive Changes After Implantation of Reversed Intraocular Lens in Cataract Surgery: A Mathematical Model

PURPOSE

To develop a mathematical model that can predict the amount of refractive change caused by implantation of an intraocular lens (IOL) in a reversed position during cataract surgery.

METHODS

A theoretical mathematical formula based on the Gullstrand eye model was constructed to estimate the refractive change of the eye after implantation of a reversed IOL. The refractive change caused by implantation of the IOL in a reversed position was calculated based on the exchange of the anterior curvature with the posterior curvature of the IOL, and the lengthening of the distance between the IOL and the retina. In case of a three-piece IOL with angulation, the amount of refractive change was calculated based on its angle and the total refractive power of the eye, which is dependent on the focal length of the eye.

RESULTS

Calculated refractive change for one-piece IOLs was less than 0.10 diopter (D). For three-piece IOLs, the calculated refractive change makes the eye on average 0.77 D more myopic and can increase with the total refractive power of the patient's eye. The mathematical model was applied to seven previously published cases of reverse IOL implantation.

CONCLUSIONS

This calculation demonstrates that with an upside-down IOL, there is a small refractive change in the one-piece IOL, including a toric IOL without angulation, but there can be a large refractive change in the three-piece IOL with angulation, especially using a higher power IOL or with a shorter axial length. [J Refract Surg. 2023;39(5):326-331.].

Ultraviolet light exposure and its penetrance through the eye in a porcine model

AIM

To determine the amount of ultraviolet (UV) light irradiance that various layers of the eye receive as sunlight passes through the eye, and to investigate the protective benefits of UV light-blocking contact lenses.

METHODS

Twenty-four porcine eyes were prepared in one of three ways: isolated cornea, cornea and lens together, or whole eye preparation. UV light irradiance was measured with a UV-A/B light meter before and after the eye preparations were placed over the meter to measure UV light penetration in each eye structure. In the whole eye preparation, a hole was placed in the fovea to measure light as it passed through the vitreous. Subsequently, UV-protective contact lenses were placed over the structures, and UV light penetrance was measured. Measurements of UV light exposure were taken outdoors at various locations and times.

RESULTS

Cornea absorbed 63.56% of UV light that reached the eye. Cornea and lens absorbed 99.34% of UV light. Whole eye absorbed 99.77% of UV light. When UV-protective contact lenses were placed, absorption was 98.90%, 99.55%, and 99.87%, respectively. UV light exposure was dependent on directionality and time of day, and was greatest in areas of high albedo that reflect significant amounts of light, such as a beach.

CONCLUSION

Cornea absorbs the majority of UV light that reaches the eye in this model. UV-protective contact lenses reduce UV exposure to the eye. Locations with high albedo expose the eye to higher levels of UV light.

Role of FGF10/FGFR2b Signaling in Homeostasis and Regeneration of Adult Lacrimal Gland and Corneal Epithelium Proliferation

Purpose

Fibroblast growth factor 10 (FGF10) is involved in eye, meibomian, and lacrimal gland (LG) development, but its function in adult eye structures remains unknown. This study aimed to characterize the role of FGF10 in homeostasis and regeneration of adult LG and corneal epithelium proliferation.

Methods

Quantitative reverse transcription PCR was used for analysis of FGF10 expression in both early postnatal and adult mouse LG, and RNA sequencing was used to analyze gene expression during LG inflammation. FGF10 was injected into the LG of two mouse models of Sjögren's syndrome and healthy controls. Flow cytometry, BrdU cell proliferation assay, immunostaining, and hematoxylin and eosin staining were used to evaluate the effects of FGF10 injection on inflammation and cell proliferation in vivo. Mouse and human epithelial cell cultures were treated with FGF10 in vitro, and cell viability was assessed using WST-8 and adenosine triphosphate (ATP) quantification assays.

Results

The level of Fgf10 mRNA expression was lower in adult LG compared to early postnatal LG and was downregulated in chronic inflammation. FGF10 injection into diseased LGs significantly increased cell proliferation and decreased the number of B cells. Mouse and human corneal epithelial cell cultures treated with FGF10 showed significantly higher cell viability and greater cell proliferation.

Conclusions

FGF10 appears to promote regeneration in damaged adult LGs. These findings have therapeutic potential for developing new treatments for dry eye disease targeting the ability of the cornea and LG to regenerate.

The Effect of Anti-Inflammatory Topical Ophthalmic Treatments on In Vitro Corneal Epithelial Cells

Purpose

To compare the effect of three commonly prescribed anti-inflammatory eye drops on corneal epithelial cells in vitro.

Methods

Three different lines of human corneal epithelial cells were tested: primary cells cultured from donor tissue, commercially available primary cells, and immortalized cells. Cells were seeded on 96-well plates and treated with the following eye drops: cyclosporine 0.05%, lifitegrast 5%, and tacrolimus 0.03% or 0.1%. Exposure times tested were 30 seconds, 1 minute, 2 minutes, 1 hour, 2 hours, 4 hours, and 24 hours. Brightfield images and viability assays were analyzed 48 to 72 hours after the initiation of treatments. At least five replicates were tested per drug and time exposure.

Results

Commercially obtained primary cells showed reduced viability following 1 hour with tacrolimus 0.1% (8%; P = 0.043%) and 4 hours with tacrolimus 0.03% (17%; P = 0.042%). Lifitegrast exposure reduced primary cell viability after 4 hours (10%; P = 0.042). Cell viability in primary cells was not deleteriously affected following exposure to cyclosporine for up to 4 hours. A similar trend was observed in both primary cells cultured from donor tissue and immortalized human corneal epithelial cells, demonstrating greater decreases in cell viability in tacrolimus compared to lifitegrast and cyclosporine. Light microscopy imaging for analysis of cell morphology and confluence supported the results.

Conclusions

Tacrolimus showed the highest impact on corneal epithelium survival in vitro, and cyclosporine proved the most protective.

Translational Relevance

Comparing anti-inflammatory eye drops on corneal epithelial cells in vitro may inform eye drop selection and development for clinical purposes.

Bruch Membrane Opening Detection Accuracy in Healthy Eyes and Eyes With Glaucoma With and Without Axial High Myopia in an American and Korean Cohort

PURPOSE

To determine the predictors of Bruch membrane opening (BMO) location accuracy and the visibility of the BMO location in glaucoma and healthy individuals with and without axial high myopia.

DESIGN

Cross-sectional study.

METHODS

Healthy eyes and eyes with glaucoma from an American study and a Korean clinic population were classified into 2 groups: those with no axial high myopia (axial length [AL] <26 mm) and those with axial high myopia (AL ≥26 mm). The accuracy of the automated BMO location on optic nerve head Spectralis optical coherence tomography radial scans was assessed by expert reviewers.

RESULTS

Four hundred thirty-eight non-highly myopic eyes (263 subjects) and 113 highly myopic eyes (81 subjects) were included. In healthy eyes with and without axial high myopia, 9.1% and 1.7% had indiscernible BMOs while 54.5% and 87.6% were accurately segmented, respectively. More than a third (36.4%) and 10.7% of eyes with indiscernible BMOs were manually correctable (respectively, P = .017). In eyes with glaucoma with and without high myopia, 15.0% and 3.2% had indiscernible BMOs, 55.0% and 38.2% were manually corrected, and 30.0% and 58.7% were accurately segmented without the need for manual correction (respectively, P = .005). Having axial high myopia, a larger AL, a larger BMO tilt angle, a lower BMO ovality index (more oval), and a glaucoma diagnosis were significant predictors of BMO location inaccuracy in multivariable logistic regression analysis.

CONCLUSIONS

As BMO location inaccuracy was 2.4 times more likely in eyes with high axial myopia regardless of diagnosis, optical coherence tomography images of high myopes should be reviewed carefully, and when possible, BMO location should be corrected before using optic nerve head scan results for the clinical management of glaucoma.

Peripheral ulcerative keratitis secondary to severe hidradenitis suppurativa

Purpose

To describe a unique case of peripheral ulcerative keratitis secondary to isolated, severe hidradenitis suppurativa (HS).

Observation

A 31-year-old male with HS presented with a red painful right eye with best corrected visual acuity of count fingers at 3 feet with peripheral corneal thinning, inferior descemetocele, and adjacent infiltrate. Work-up revealed negative corneal cultures and positive ANA, ANCA, and rheumatoid factor without other autoimmune or rheumatologic history or symptomatology. He was treated with topical corticosteroids with improvement until he was lost to follow-up before tumor necrosis factor-a inhibitor therapy could be started. Upon re-presentation, he was found to have corneal perforation.

Conclusions and importance

Coexistence of inflammatory eye disease and HS is known but rare, and most commonly manifests as anterior uveitis. Here we present a unique case of peripheral ulcerative keratitis secondary to HS and demonstrate the importance of ophthalmologists’ familiarly with this systemic disease and its variety of ocular manifestations.

Recent developments in anterior capsulotomy for cataract surgery

PURPOSE OF REVIEW

Successful anterior capsulotomy is an important step in cataract surgery. This article reviews the various anterior capsulotomy techniques available to surgeons to optimize the step, including those that have become available since the introduction of femtosecond-laser-assisted cataract surgery (FLACS). Studies comparing the relative advantages of each technique will be emphasized.

RECENT FINDINGS

Manual continuous curvilinear capsulorhexis (CCC) and FLACS remain the two most widely studied techniques for achieving anterior capsulotomy. Each technique has been shown to be effective for a wide range of patients and cataract surgery complications. Meta-analyses have shown that FLACS provides similar results to manual CCC for long-term cataract surgery outcomes. Several alternative methods for anterior capsulotomy have been described, which aim to provide some of the advantages of laser capsulotomy at a lower cost; among these, precision pulse capsulotomy (PPC) and selective laser capsulotomy (SLC) have been investigated the most in the literature so far.

SUMMARY

Cataract surgeons have an increasing number of techniques for anterior capsulotomy available. Manual CCC and FLACS remain the most widely used, and most well studied. The latest techniques, PPC and SLC, have shown promise in the few studies performed since they were introduced.

Disease Expression and Familial Transmission of Fuchs Endothelial Corneal Dystrophy With and Without CTG18.1 Expansion

Purpose

To characterize inheritance, penetrance, and trinucleotide repeat expansion stability in Fuchs endothelial corneal dystrophy (FECD).

Methods

One thousand unrelated and related subjects with and without FECD were prospectively recruited. CTG18.1 repeat length (CTG18.1_L) was determined via short tandem repeat assay and Southern blotting of leukocyte DNA. Multivariable logistic regression and generalized estimating equation models were employed.

Results

There were 546 unrelated FECD cases (67.6% female; 70 ± 10 years) and 235 controls (63.8% female; 73 ± 8 years; all ≥ 50 years). CTG18.1 expansion (CTG18.1exp+) was observed in 424 (77.7%) cases and 18 (7.7%) controls (P = 2.48 × 10^–44). CTG18.1 expansion was associated with FECD severity (P = 5.62 × 10^–7). The family arm of the study included 331 members from 112 FECD-affected families; 87 families were CTG18.1exp+. Autosomal dominant inheritance with variable expression of FECD was observed, regardless of expansion status. FECD penetrance of CTG18.1 expansion increased with age, ranging from 44.4% in the youngest (19–46 years) to 86.2% in the oldest (64–91 years) age quartiles. Among 62 parent–offspring transmissions of CTG18.1exp+, 48 (77.4%) had a change in CTG18.1_L ≤ 10 repeats, and eight (12.9%) were ≥50 repeats, including five large expansions (∼1000–2000 repeats) that contracted. Among 44 offspring who did not inherit the CTG18.1exp+ allele, eight (18.2%) exhibited FECD.

Conclusions

CTG18.1 expansion was highly associated with FECD but demonstrated incomplete penetrance. CTG18.1_L instability occurred in a minority of parent–offspring transmissions, with large expansions exhibiting contraction. The observation of FECD without CTG18.1 expansion among family members in CTG18.1exp+ families highlights the complexity of the relationship between the FECD phenotype and CTG18.1 expansion.

Rationale for American Society of Retina Specialists Best Practice Recommendations for Conducting Vitreoretinal Surgery during the COVID-19 Era

PURPOSE

To detail the rationale behind recommendations recently published by the American Society of Retina Specialists (ASRS) outlining best practices for safety of vitreoretinal surgeons and staff while performing vitreoretinal surgery during the coronavirus disease (COVID)-19 pandemic.

METHODS

The committee for ASRS Best Practices for Retinal Surgery during the COVID-19 Pandemic reviewed existing evidence and information on SARS-CoV-2 transmission, and risk factors during vitreoretinal surgery. Recommendations were based on best available published data, cumulative clinical experiences, and recommendations and policies from other organizations. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the strength of recommendations and confidence in the evidence. These serve as interim recommendations which are routinely updated given gaps of knowledge and lack of high-quality data on this evolving subject.

RESULTS

Relevant existing literature related to methods of transmission, and ocular manifestations of SARS-CoV-2 are summarized. The data and clinical experiences driving recommendations for pre-operative, intraoperative and post-operative surgical considerations, anesthesia choice, as well as considerations for intravitreal injections are provided.

CONCLUSION

Recommendations are provided with the goal of protecting vitreoretinal surgeons and associated personnel from exposure to SARS-CoV-2 during interventional vitreoretinal procedures. This is a rapidly evolving topic with numerous remaining gaps in our current knowledge. As such, recommendations will evolve and the current manuscript is intended to serve as a foundation for continued dialogue on best practices.

Dupilumab-Associated Mucin Deficiency (DAMD)

Purpose

Dupilumab, a monoclonal antibody directed against the interleukin-4 receptor subunit α (IL-4Rα) of IL-4 and IL-13, is increasingly being used to control atopic disease. Dupilumab use has been associated with a poorly understood conjunctivitis. In this study, we sought to investigate the hypothesis that dupilumab use and the associated IL-13 blockade causes a relative ocular mucin deficiency.

Methods

Tear levels of mucin 5ac (Muc5AC) and total tear protein levels were evaluated from 28 eyes of 14 patients. Bilateral tear samples were acquired from seven patients on dupilumab and seven patients with no exposure to dupilumab. Study subjects were age and gender matched. In addition to tear samples, photographic documentation of ocular surface findings and a questionnaire of ocular surface symptoms were obtained. Between-group mean differences were calculated.

Results

Compared with control, ocular Muc5AC levels normalized to total tear protein was statistically significantly lower. The average Muc5AC levels for persons on dupilumab was 1.54 ± 0.58 ng/mg and that of controls was 7.99 ± 1.16 ng/ mg. Persons on dupilumab reported a statistically increased occurrence of ocular fatigue/eye strain, uncomfortable sensation, pain, red eye, and itching.

Conclusions

This study demonstrates for the first time, a relative deficiency of Muc5AC in patients on dupilumab.

Translational Relevance

The results of this study support the previously reported role of IL-13 in increasing goblet cell density and associated Muc5AC production. Further efforts are underway to better understand the relative contribution of Muc5AC deficiency in the overall presentation of conjunctivitis associated with dupilumab use.

Accuracy of IOL power calculations in the very elderly

Background/objectives

To analyze the refractive predictability and outcomes of cataract surgery in the very elderly (≥85 years old).

Subjects/methods

A retrospective case-series performed at the Shiley Eye Institute, University of California San Diego, USA. Electronically pulled data of 2444 surgeries revealed 147 surgeries on 133 very elderly patients. Chart review was conducted for all very elderly and corresponding control patients (75–84 years old). The first operated eyes of patients with final best-corrected visual acuity ≥20/40, axial length (AL) 22–26 mm, and implanted SN60WF IOL were included. Patients with ocular comorbidities and/or intra- or post-operative complications were excluded. Prediction errors of refractive outcome and percentage of eyes within ±0.50D and ±1.00D were compared between the groups for the Holladay 1 and Barrett Universal II (Barrett) formulas. Logistic regression analysis for achievement of ±1.00D was conducted.

Results

Final analysis included 90 eyes (n = 44, very elderly, n = 46, control patients). Median absolute refractive error (MedAE) with Holladay 1, but not Barrett formula, was significantly higher in the older group (p = 0.02 and p = 0.07, respectively). The MedAE in the older group was lower using the Barrett compared to Holladay 1 (p = 0.02). Fewer older patients than younger patients achieved refraction within ±0.50D and ±1.00D from goal, using the Holladay 1 (p = 0.049 and p = 0.002 respectively). Logistic regression analysis supported the relationship between Holladay 1 predictive refractive error of >1.00D and patient’s age (p = 0.046).

Conclusions

Very elderly patients undergoing cataract surgery may be prone to reduced refractive precision, particularly with utilization of the Holladay 1 formula.

The quest for homeopathic and nonsurgical cataract treatment

PURPOSE OF REVIEW

Age-related cataract occurs when crystallin proteins in the lens partially unfold and subsequently aggregate. Physicians and traditional healers alike have been exploring pharmacologic cataract treatment for hundreds of years. Currently, surgery is the only effective treatment. However, there are an abundance of homeopathic and alternative remedies that have been suggested as treatment for cataract. This article reviews the current understanding of cataract development and discusses several homeopathic remedies purported to treat age-related cataract. Additionally, we will present an overview of evidence regarding the development of pharmacologic cataract reversal therapies.

RECENT FINDINGS

Some homeopathic therapies have been shown to prevent cataract development in experimental models. More studies are required to elucidate the potential medicinal and toxic properties of the various alternative therapies. However, in recent years, scientists have begun to investigate substances that address cataract by reversing lens protein aggregation. One such compound, lanosterol, was reported to reverse cataract opacity in vitro and in animal models. Subsequently, 25-hydroxycholesterol and rosmarinic acid were identified as having similar properties.

SUMMARY

Although challenges and uncertainties remain, further research has the potential to lead to the development of a nonsurgical therapeutic option for age-related cataract.

Optimum on-time and off-time combinations for micropulse phacoemulsification in venturi vacuum mode

PURPOSE

To measure the time to fragment removal and number of chatter events using various combinations of micropulse on times and off times (measured in milliseconds) of longitudinal ultrasound (US) using a venturi-based phacoemulsification system.

SETTING

John A. Moran Eye Center, University of Utah, Salt Lake City, USA.

DESIGN

Experimental study.

METHODS

Pig lenses were hardened with formalin and cut into 2.0 mm cubes. The time to fragment removal (efficiency) and frequency of fragments bouncing off the tip (chatter) were measured with the venturi-based system. Micropulse longitudinal US was tested. Parameters were combinations of 5, 6, and 7 milliseconds on, with 5, 6, and 7 milliseconds off. Twenty runs each of 9 combinations were completed.

RESULTS

There was a statistically significant difference between on/off duty cycle combinations. The 6 on/7 off group had higher efficiency than the 5 on/6 off and 7 on/7 off groups. Six on/5 off was more efficient than 5 on/6 off. When data were pooled and on times alone were used, 6 milliseconds on time was more efficient than 5 or 7 milliseconds. No efficiency differences in off times were found. No significant chatter differences were observed.

CONCLUSIONS

Using micropulse longitudinal US in venturi vacuum mode, 6 milliseconds on was the most efficient on time. Five, 6, and 7 milliseconds off times had similar efficiency. These data suggest that the most efficient setting with lowest US energy use is 6 milliseconds on and 7 milliseconds off.

Cost-Effectiveness Analysis of Multifocal Intraocular Lenses Compared to Monofocal Intraocular Lenses in Cataract Surgery

PURPOSE

To determine the cost-effectiveness of multifocal intraocular lenses (IOLs) compared to that of monofocal IOLs from a societal and health care sector perspective.

DESIGN

Cost-effectiveness analysis.

METHODS

A Markov model was constructed that simulated patients who received either multifocal or monofocal IOLs during cataract surgery. Postoperatively, patients could experience spectacle dependence, glare, and haloes. Cost-effectiveness was determined by measuring the incremental cost-effectiveness ratio (ICER) as the incremental cost in dollars per quality-adjusted life year (QALY) gained. Treatments with an ICER below the standard willingness-to-pay (WTP) threshold of $50,000/QALY were considered cost effective. One-way sensitivity analyses and probabilistic sensitivity analyses were used to evaluate model sensitivity to cost, utilities, and other model inputs.

RESULTS

Multifocal IOLs were associated with a 0.71 QALY increase at an increased cost of $3,415 compared with monofocal IOLs, leading to an ICER of $4,805/QALY from the societal and health care sector perspectives. The cost-effectiveness model was most sensitive to patient age, probability of spectacle dependence with multifocal IOLs and monofocal IOLs, and the disutility of glasses. Probabilistic sensitivity analysis found multifocal IOLs to be the cost-effective option compared with monofocal IOLs 99.9% of the time at a WTP threshold of $50,000/QALY.

CONCLUSIONS

From a societal and health care perspective, multifocal IOLs would be considered a cost-effective strategy compared to monofocal IOLs for patients who desire a higher chance to be spectacle-free. However, more studies need to be conducted to further evaluate the efficacy of multifocal IOLs.

Topical Recombinant Human Nerve Growth Factor (Cenegermin) for Neurotrophic Keratopathy: A Multicenter Randomized Vehicle-Controlled Pivotal Trial

PURPOSE

To evaluate the efficacy and safety of topical cenegermin (recombinant human nerve growth factor) in patients with neurotrophic keratopathy.

DESIGN

Multicenter, randomized, double-masked, vehicle-controlled trial.

PARTICIPANTS

Patients with neurotrophic persistent epithelial defect with or without stromal thinning.

METHODS

The NGF0214 trial, conducted among 11 sites in the United States, randomized 48 patients 1:1 to cenegermin 20 μg/ml or vehicle eye drops, 6 drops daily for 8 weeks of masked treatment. Follow-up was 24 weeks. Safety was assessed in all patients who received study drug. Efficacy was assessed by intention to treat.

MAIN OUTCOME MEASURES

The primary end point was healing of the neurotrophic lesion (persistent epithelial defect or corneal ulcer) after 8 weeks of masked treatment. Masked central readers measured neurotrophic lesions in randomized clinical pictures, then assessed healing status conventionally (<0.5 mm of fluorescein staining in the greatest dimension of the lesion area) and conservatively (0-mm lesion staining and no other residual staining). Secondary variables included corneal healing at 4 weeks of masked treatment (key secondary end point), overall changes in lesion size, rates of disease progression, and changes in visual acuity and corneal sensitivity from baseline to week 8.

RESULTS

Conventional assessment of corneal healing showed statistically significant differences at week 8: compared to 7 of 24 vehicle-treated patients (29.2%), 16 of 23 cenegermin-treated patients (69.6%) achieved less than 0.5 mm of lesion staining (+40.4%; 95% confidence interval [CI], 14.2%-66.6%; P = 0.006). Conservative assessment of corneal healing also reached statistical significance at week 8: compared to 4 of 24 vehicle-treated patients (16.7%), 15 of 23 cenegermin-treated patients (65.2%) achieved 0 mm of lesion staining and no other residual staining (+48.6%; 95% CI, 24.0%-73.1%; P < 0.001). Moreover, the conservative measure of corneal healing showed statistical significance at week 4 (key secondary end point). Compared to vehicle, cenegermin-treated patients showed statistically significant reductions in lesion size and disease progression rates during masked treatment. Cenegermin was well tolerated; adverse effects were mostly local, mild, and transient.

CONCLUSIONS

Cenegermin treatment showed higher rates of corneal healing than vehicle in neurotrophic keratopathy associated with nonhealing corneal defects.

Evaluating New Ophthalmic Digital Devices for Safety and Effectiveness in the Context of Rapid Technological Development

Importance

The US Food and Drug Administration's medical device regulatory pathway was initially conceived with hardware devices in mind. The emerging market for ophthalmic digital devices necessitates an evolution of this paradigm.

Objectives

To facilitate innovation in ophthalmic digital health with attention to safety and effectiveness.

Evidence Review

This article presents a summary of the presentations, discussions, and literature review that occurred during a joint Ophthalmic Digital Health workshop of the American Academy of Ophthalmology, the American Academy of Pediatrics, the American Association for Pediatric Ophthalmology and Strabismus, the American Society of Cataract and Refractive Surgery, the American Society of Retina Specialists, the Byers Eye Institute at Stanford and the US Food and Drug Administration.

Findings

Criterion standards and expert graders are critically important in the evaluation of automated systems and telemedicine platforms. Training at all levels is important for the safe and effective operation of digital health devices. The risks associated with automation are substantially increased in rapidly progressive diseases. Cybersecurity and patient privacy warrant meticulous attention.

Conclusions and Relevance

With appropriate attention to safety and effectiveness, digital health technology could improve screening and treatment of ophthalmic diseases and improve access to care.

Evaluation of incomplete blinking as a measurement of dry eye disease

PURPOSE

To investigate the association between partial blinking during spontaneous blinking as measured by interferometry and ocular exams for the assessment of dry eye disease (DED).

METHODS

This retrospective study included 58 eyes of patients previously diagnosed with DED. Ocular surface assessment included ocular surface disease index (OSDI) score, tear film osmolarity, tear breakup time (TBUT), grading of corneal fluorescein staining, Schirmer I test, and dry eye parameters by the LipiView™ interferometer (TearScience, Morrisville, NC, USA), including lipid layer thickness of the tear film (LLT), meibomian gland dropout (MGd), number of incomplete and complete blinks per 20 s and the partial blinking rate (PBR). Generalized estimation equations (GEE) were used for association testing between each variable of interest. The working correlation for each GEE model was selected using the Corrected Quasi-likelihood under the Independence Model Criterion.

RESULTS

The number of incomplete blinks was significantly associated with TBUT (P = 0.006), OSDI (P = 0.000) and MGd (P = 0.000). PBR was significantly associated with OSDI (P = 0.032) and MGd (P = 0.000). The number of complete blinks was significantly associated with TBUT (P = 0.032), but not with other ocular surface parameters. MGd was significantly associated with TBUT (P = 0.002) and OSDI (P = 0.001). LLT was significantly associated with tear film osmolarity (P = 0.007), and tear film osmolarity was significantly associated with LLT (P = 0.000).

CONCLUSIONS

Incomplete blinking is associated with decreased TBUT, increased OSDI, and increased MGd possibly through its contribution to meibomian gland obstruction and subsequent loss of tear film homeostasis. It may, therefore, be considered an additive measure for mild-to-moderate DED assessment.

Adhesion Strength and Rolling Properties of Descemet Membrane Endothelial Keratoplasty Grafts in a Rabbit Eye Model

Purpose: To investigate the optimal time for Descemet membrane endothelial keratoplasty (DMEK) graft peeling, and to analyze the rolling properties of endothelial denuded grafts in a rabbit eye model. Materials and Methods: The vertical peeling force required to peel 1 mm wide Descemet membrane (DM) strips, was measured as the change in weight of the system during force application in a rabbit model. Twenty-one rabbit corneoscleral rims were stored in phosphate-buffered saline (PBS) at 4°C, and force analysis was performed at days 1, 5, or 21 after harvesting. After half of the strips of day 5 corneas were peeled and analyzed, the rims were moved to Optisol GS at 4°C, and the remaining strips were peeled off for force analysis at day 10. Separate DM grafts (n = 7) were analyzed by intraoperative optical coherence tomography (OCT) to determine the tissue rolling diameter before and after removal of endothelial cells by a swab. Unpaired t-test was used for statistical analysis. Results: There was a decrease in DM peeling force (p = .008) between days 1 and 5 (556.04 ± 111.76 and 324.30 ± 96.4 mg, respectively), and no difference between days 5 and 21 (p = .53). Peeling force for day 5 corneas placed in Optisol was higher at day 10 (324.30 ± 96.4 to 669.92 ± 166.24 mg, p = .005). The average rolling diameter of DM grafts was similar before and after the removal of endothelial cells (257.9 ± 131.1 and 249.8 ± 126.6 μm, respectively). Conclusions: DMEK Graft procurement could be potentially facilitated by lower DM-stromal adhesion strength at day five after obtaining corneoscleral rims, in a rabbit eye model. Time in the storage medium may influence adhesion strength. Endothelial cells do not appear to play a significant role in the rolling diameter of DM grafts.

Topical cyclosporine-A versus prednisolone for herpetic stromal keratitis: a randomized controlled trial

PURPOSE

To compare topical cyclosporine-A 2% eye drop (Cs-A) with prednisolone acetate 1% eye drop for treatment of herpetic stromal keratitis (HSK).

METHODS

In this randomized clinical trial, 38 eyes of 33 patients with HSK were randomly assigned to receive either 2% Cs-A or 1% prednisolone acetate eye drops. All subjects received oral acyclovir 400 mg twice a day. Slit-lamp examination, Scheimpflug tomography corneal optical densitometry (Pentacam®, Oculus Inc., Wetzlar, Germany), best-corrected visual acuity (BCVA), and intra-ocular pressure (IOP) were evaluated at the first visit, and 14 and 30 days after the treatment.

RESULTS

Within-group analysis revealed significant improvement of total cornea optical density after 30 days of treatment in both groups (30.3 ± 10.5 to 28.3 ± 9.8, p < 0.001 for prednisolone group, and 30.5 ± 8.8 to 28.8 ± 8.3 p < 0.001 for Cs-A group, mean ± SD). We were not able to disclose any significant difference between the two groups regarding the improvement of cornea optical density (p = 0.66). Best-corrected visual acuity (BCVA) logMAR significantly improved in both groups after 30 days of treatment (0.20 ± 0.52, p = 0.002 in prednisolone group, and 0.24 ± 0.31, p < 0.001 in Cs-A group, mean ± SD). Analysis between groups did not show a significant difference of BCVA improvement (p = 0.45). We did not observe any severe side effect attributable to drugs.

CONCLUSIONS

Cs-A 2% and prednisolone acetate 1% topical eye drops are effective for treatment of HSK.

Repeatability and Reproducibility of Corneal Epithelial Thickness Mapping With Spectral-Domain Optical Coherence Tomography in Normal and Diseased Cornea Eyes

PURPOSE

To evaluate the performance of the epithelial thickness mapping (ETM) of the iVue spectral-domain optical coherence tomography (SD-OCT) device (Optovue Inc, Fremont, California, USA) in normal and diseased cornea eyes.

DESIGN

Reliability and validity analysis.

METHODS

Sixty eyes of 60 subjects were recruited for the study, which included normal subjects (n = 12) and patients with corneal diseases (12 patients each: dry eye syndrome [DES], contact lens wear, post-laser refractive surgery, and keratoconus). Three repeated scans were acquired on 3 iVue SD-OCTs with device-designated operators from consented subjects. Each subject was scanned on each device. Repeatability (based on random error of repeated scans) and reproducibility (including the random error and the instrument/operator variability) were assessed based on spatial zones derived from a 6-mm-diameter corneal ETM centered on the pupil and compared between the groups.

RESULTS

Fifty-nine eyes qualified for final analysis. Seventy-one of 598 acquired scans (11.9%) were excluded owing to scan quality concerns. The percentage of disqualified scans was similar across normal (10.7%) and diseased eyes (12.1%). Of 527 qualified scans, 40 (7.6%) scans required manual edits of the segmentation lines. Repeatability and reproducibility results were similar, indicating minimal device/operator variability for both groups. Repeatability and reproducibility were similar in all subgroups of cornea patients, excluding the DES group, for which reproducibility was significantly lower (range 3.2%-5.5% for DES patients and 1.1%-2.9% for normal subjects).

CONCLUSIONS

The iVue SD-OCT provides good corneal ETM repeatability and reproducibility in normal and diseased cornea eyes through all map zones.

CTG18.1 Expansion in TCF4 Among African Americans With Fuchs' Corneal Dystrophy

Purpose

Studies of Fuchs' dystrophy have largely focused on individuals of European origin. Characterization of disease among African Americans is required to ensure prognostic factors and therapeutic approaches are applicable across diverse patient populations.

Methods

We assessed all self-reported black and white patients aged older than 40 years at a tertiary care institution with a diagnosis of cataract over a 3-year period for concurrent diagnosis of Fuchs' dystrophy. Affected patients in a longitudinal cohort were invited to provide a blood sample from which we extracted genomic DNA. The CTG18.1 trinucleotide repeat length was determined using a two-step, triplet repeat primed PCR protocol. Expansion was defined as >40 CTG repeats. Demographic information, including race, was documented.

Results

Of 59,365 self-reported black and white adults who presented for cataract evaluation, the odds ratio of presenting with Fuchs' dystrophy among black compared to white patients was 0.6992 (95% confidence interval [CI], 0.6210–0.7872). A total of 60 black and 549 white patients with Fuchs' corneal dystrophy enrolled in the longitudinal study, of which 21 (35.0%) black and 343 (62.5%) white patients demonstrated trinucleotide repeat expansion, a significant difference (P = 7.7 × 10⁻⁵). In a multivariable linear regression model, repeat expansion but not race was significantly associated with mean clinical grading of severity.

Conclusions

Black patients with Fuchs' dystrophy were less likely than white patients to demonstrate CTG18.1 allele expansion. The data contribute to our understanding of population differences in clinical presentation, and highlight the need for considering diversity of patient populations in clinical research.

Generation of Human Corneal Endothelial Cells via In Vitro Ocular Lineage Restriction of Pluripotent Stem Cells

Purpose

We generate a renewable supply of corneal endothelial cells (CEC) from human pluripotent stem cells (PSCs) under defined culture conditions.

Methods

Corneal endothelial cell induction was driven by small molecules in a stepwise fashion of lineage specification. During the initial phase, PSC fate was restricted to the eye field-like state and became eye field stem cells (EFSCs). In the second phase, PSC-derived EFSCs were further directed toward either neural crest lineage or retinal lineage. The CECs were directly induced from ocular neural crest stem cells (NCSCs) by suppressing TGF-β and ROCK signaling.

Results

Under chemically defined conditions, PSCs were massively converted into EFSCs and subsequently NCSCs. Eye field cell identity was characterized by the expression of key fate restriction factors for early eye field cells, such as PAX6, LHX2, and VSX2. The induction of ocular NCSCs was initiated by promoting WNT signaling in EFSCs. Within 2 weeks of induction, the majority of cells expressed the typical neural crest markers p75NTR and HNK-1. Eye field stem cell-derived NCSCs can be propagated and cryopreserved. Subsequently, a CEC monolayer was induced from adherent NCSCs in the presence of small molecular inhibitors to suppress TGF-β and ROCK signaling. The polygon-shaped CEC-like cells became visible after a week in culture. The NCSC-derived CECs expressed typical CEC markers, such as N-Cadherin and Na+/K+-ATPase.

Conclusions

A novel small molecule-based approach was developed to derive human CECs from PSCs via ocular lineage specification. Moreover, EFSC-derived NCSCs could serve as an immediate source cell for rapid CEC induction in vitro.

Corneal Endothelial Cell Migration and Proliferation Enhanced by Rho Kinase (ROCK) Inhibitors in In Vitro and In Vivo Models

Purpose

To explore the role of Rho-associated kinases (ROCK) in corneal physiology and regeneration, and the effects of suppressing its activity in stimulating corneal endothelial cell proliferation and migration in vitro and in vivo.

Methods

Immunohistochemistry was performed to detect RhoA and ROCK-1 and ROCK-2 in human corneal tissue. Adult porcine corneal endothelial cells (CECs) were isolated, grown to confluence, and further characterized. Under the treatment of ROCK inhibitors, changes in the cellular distribution profile of ZO-1 and F-actin were examined by immunofluorescence staining. Corneal endothelial cells migration was evaluated by scratch assay and analyzed with Axiovision software. Cell proliferation was quantified using Click-iT EdU HCS Assay. In vivo, the corneal endothelia of rabbits were surgically injured and H-1152 was topically applied for 10 days. Progress of wound healing was evaluated daily by monitoring corneal edema, inflammation, and thickness using slit-lamp examination, photography, and pachymetry. Rabbits were euthanized and enucleated for further evaluation.

Results

H-1152 exhibited significant stimulatory effect on CEC migration and proliferation in vitro compared with both untreated and Y-27632–treated cells. Furthermore, topical administration of H-1152 led to marked reduction in corneal edema and formation of multinucleate CECs in vivo suggestive of proliferation associated with healing.

Conclusions

H-1152 exhibited a better stimulatory effect on CEC migration and proliferation in vitro than Y-27632. Our findings suggest that topical administration of H-1152 promotes healing of injured corneal endothelium in vivo. These results demonstrate the efficacy of ROCK inhibitors as a potential topical therapy for patients with corneal endothelial disease.

Genome-wide association study identifies three novel loci in Fuchs endothelial corneal dystrophy

The structure of the cornea is vital to its transparency, and dystrophies that disrupt corneal organization are highly heritable. To understand the genetic aetiology of Fuchs endothelial corneal dystrophy (FECD), the most prevalent corneal disorder requiring transplantation, we conducted a genome-wide association study (GWAS) on 1,404 FECD cases and 2,564 controls of European ancestry, followed by replication and meta-analysis, for a total of 2,075 cases and 3,342 controls. We identify three novel loci meeting genome-wide significance (P<5 × 10-8): KANK4 rs79742895, LAMC1 rs3768617 and LINC00970/ATP1B1 rs1200114. We also observe an overwhelming effect of the established TCF4 locus. Interestingly, we detect differential sex-specific association at LAMC1, with greater risk in women, and TCF4, with greater risk in men. Combining GWAS results with biological evidence we expand the knowledge of common FECD loci from one to four, and provide a deeper understanding of the underlying pathogenic basis of FECD.

Microbiological profiles of fungal keratitis: a 10-year study at a tertiary referral center

Background

Given the rise in cases of fungal keratitis in recent years, this study was performed to better elucidate the microbiological profile, risk factors, and surgical intervention rates of fungal keratitis at a tertiary referral center in the Southeastern USA.

Findings

This is a retrospective case series of fungal keratitis infections treated at Duke University Eye Center from January 1, 1998, to October 6, 2008. Of the 4651 culture-proven corneal ulcers identified, 63 (1.4 %) were positive for fungal keratitis with a total of 69 fungal organisms isolated. The majority of isolates were filamentous species (44 of 69, 64 %), and the most commonly isolated organism was Curvularia (11 of 69, 16 %). Bacterial coinfections were found in 24 of the 63 cases (38 %). The most commonly associated risk factors were contact lens wear (n = 15, 24 %) and prior penetrating keratoplasty (PKP) (n = 15, 24 %). Twenty-three cases (37 %) required surgical intervention. The rate of surgical intervention was highest in patients with prior PKP (7/15, 47 %).

Conclusions

In this study, the leading risk factors for fungal keratitis were contact lens wear and prior PKP. Filamentous species were the most common causative pathogens. A relatively high rate of mixed bacterial-fungal infections was found. Patients with prior PKP were more likely to require surgery than patients without history of keratoplasties.