Publications by authors named "Asaf Achiron"

65 Publications

Progression of Pediatric Keratoconus After Corneal Cross-Linking: A Systematic Review and Pooled Analysis.

Cornea 2021 Jul 22. Epub 2021 Jul 22.

Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Faculty of Medicine, Alexandria University, Egypt; Department of Ophthalmology, Shamir Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; and Genetics Institute, Tel Aviv Sourasky Medical Center & Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Purpose: Corneal collagen cross-linking (CXL) is an effective treatment to slow down keratoconus (KC) progression in adults. Several studies have also shown efficacious outcomes in pediatric populations, yet no systematic analysis has been performed and no accepted definition for progression is available in children after CXL. This study aimed to establish the most commonly used criteria for progression and to conduct a systematic review of the literature with pooled analysis to assess children's keratoconus progression after CXL.

Methods: A systemic literature review combined with pooled analysis was performed on full-length studies of KC after CXL treatment in a pediatric population and the methods used to report progression were analyzed.

Results: Thirty-seven studies (2078 eyes) were identified on the rates of KC progression after CXL. The most common method to report progression was increased Kmax, Kmean, or Ksteep by ≥1.0 diopter (78.3% of studies). Using these criteria, the mean pooled progression rate after epithelium-off CXL was 9.9% (95% confidence interval: 6.1% -14.6%, total pooled sample size: 1508 eyes) with high heterogeneity between studies [I2 = 86.48% (95% confidence interval: 80.98 - 90.39), P < 0.0001].

Conclusions: When considering KC progression after CXL in children, with an increase in Kmax, Kmean, or Ksteep ≥ 1.0 diopter, the progression risk was roughly 10%. We encourage clear quantitative reporting of KC progression in future studies evaluating CXL efficacy in pediatric populations.
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http://dx.doi.org/10.1097/ICO.0000000000002808DOI Listing
July 2021

Controversies on the Recommended Treatment for Central Retinal Artery Occlusion.

J Stroke Cerebrovasc Dis 2021 Jul 14:105970. Epub 2021 Jul 14.

Helsinki Retina Research Group, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Hygeia Clinic, Gdańsk, Poland. Electronic address:

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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.105970DOI Listing
July 2021

Relationship Between Prolonged Intraocular Inflammation and Macular Edema After Cataract Surgery.

Transl Vis Sci Technol 2021 06;10(7):15

Helsinki Retina Research Group, University of Helsinki, Helsinki, Finland.

Purpose: To assess whether aqueous flare is related to an increased risk of pseudophakic cystoid macular edema (PCME) following uneventful cataract surgery in nondiabetic and diabetic patients.

Methods: A post hoc analysis of five consecutive randomized clinical trials in the Department of Ophthalmology, Kymenlaakso Central Hospital, Finland. Aqueous flare levels were recorded in 448 eyes of 448 patients before surgery, and after the course of topical anti-inflammatory treatment 28 days and three months after cataract surgery.

Results: Aqueous flare increase of <50%, ≥50%, ≥100%, and ≥200% associated in central subfield macular thickness (CSMT) increase across the groups at 28 days and three months after surgery. Increase of aqueous flare ≥100% compared to those with <100% was associated with increased CSMT (P = 0.022 at 28 days, and P = 0.027 at three months). At three months, macular thickening (at least 10% CSMT increase) was observed in 12.7% compared to 4.6% of eyes when using a cutoff value of 100% increase in aqueous flare (P = 0.033). Although diabetic patients presented higher aqueous flare levels at baseline compared to nondiabetic patients (12.9 ± 11.8 vs. 9.8 ± 8.2 photon units/ms P < 0.001), the postoperative levels illustrated a similar profile in aqueous flare increase between the two groups.

Conclusions: At 28 days, aqueous flare increase was associated with macular thickening. A 100% cutoff value could potentially be used when studying anti-inflammatory efficacy of different treatment protocols. Flare values exceeding this cutoff value could be considered as an indication for extending anti-inflammatory therapy.

Translational Relevance: A 100% increase in aqueous flare at 28 days after cataract surgery from baseline predicted macular thickening up to three months postoperatively. Identifying a correlation between increased aqueous flare levels and pseudophakic cystoid macular edema may allow recognition of the most vulnerable patients, development of prophylactic treatment strategies and reduction of the number and severity of postoperative complications.
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http://dx.doi.org/10.1167/tvst.10.7.15DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8212433PMC
June 2021

Comparison of keratometry data using handheld and table-mounted instruments in healthy adults.

Int Ophthalmol 2021 Jun 9. Epub 2021 Jun 9.

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Purpose: To compare keratometry data between the handheld Retinomax K-plus 3 and the table-mounted IOLMaster 700.

Methods: Healthy adult volunteers were prospectively recruited to the study. All participants underwent 3 consecutive keratometry measurements using the Retinomax K-plus 3 and a single biometry assessment using the IOLMaster 700. Differences between the Retinomax K-plus 3 and the IOLMaster 700 were assessed using Wilcoxon test for paired samples, Spearman correlation, Bland-Altman and mountain plots.

Result: Twenty-eight healthy subjects with a median age of 37 years (interquartile range (IQR) 28-44 years) were included in the study. The median mean keratometry (mean K) reading was higher using the Retinomax K-plus 3 (44.04D; IQR 42.96-45.61D) compared to the IOLMaster 700 (43.78D; IQR 43.22-44.90D, p < 0.01), with a mean difference of 0.18D (95% confidence interval (CI) 0.11-0.23D). Mean K readings were highly correlated between the 2 devices (r = 0.995, p < 0.01). Bland-Altman plots showed 95% limits of agreement between -0.14D and 0.49D. Frequency histogram of mean K reading differences between the Retinomax K-plus 3 and the IOLMaster 700 showed that 56% of cases were between ± 0.2D, 93% of cases were between ± 0.4D and all cases were between ± 0.5D. Mean corneal astigmatism measurement was higher using the Retinomax K-plus 3 (1.01 ± 0.40D) compared to the IOLMaster 700 (0.77 ± 0.36D), with a mean difference of 0.23 ± 0.37D (p < 0.01) between the devices.

Conclusions: A good agreement exists between the Retinomax K-plus 3 and the IOLMaster 700 regarding keratometry readings. This enables cataract surgeons to safely use the Retinomax K-plus 3 device when indicated.
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http://dx.doi.org/10.1007/s10792-021-01909-8DOI Listing
June 2021

Ophthalmic emergency-room visits during the Covid-19 pandemic - a comparative study.

BMC Ophthalmol 2021 May 12;21(1):210. Epub 2021 May 12.

Department of Ophthalmology, Meir Medical Center, Kfar Saba, Israel.

Background: The goal of this study is to compare ophthalmic emergency room (OER) visits during the Coronavirus disease-19 (Covid-19) pandemic to those during a control period.

Methods: We compared all visits to the OER to Meir Medical Center in Israel, from March 15th to April 15th, 2020, during the Covid-19 pandemic and government mandated quarantine, to the same period in 2019. Factors analyzed were patient demographics, chief complaints, referral patterns, exam findings, treatments given, hospitalizations and surgical interventions.

Results: We included in this study 1311 visits of 1158 patients, 477 during the 2020 Covid-19 pandemic and 834 during the same period in 2019. The demographic distribution (age, gender, and ethnicity) was similar between the two periods. LogMAR visual acuity at presentation was worse during the Covid-19 pandemic (0.42 ± 0.6 and 0.34 ± 0.5 in 2020 and 2019 respectively; p = 0.025) and the number of emergent surgeries was higher (3.7% in 2020 vs 1.8% in 2019, p = 0.026). In 2019 there was a higher likelihood of involvement of both segments of the eye (4.82% versus 1.2%, p < 0.01) and more diagnoses were given to each patient (1 ± 0.5 versus 0.93 ± 0.35, p = 0.001; During the Covid - 19 pandemic medications (both topical and systemic) were prescribed more often (1.22 ± 0.95 in 2020 and 0.84 ± 0.67 in 2019, p < 0.001).

Conclusions: OER visits were less frequent during the Covid - 19 pandemic as compared to 2019, though the demographics of the patients remained unchanged. Visits during the pandemic tended to be for more severe ocular conditions, with worse visual acuity at presentation and required more medical and surgical treatment which imply higher necessity of ocular evaluation. This analysis can aid healthcare resource management in similar scenarios in the future.
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http://dx.doi.org/10.1186/s12886-021-01976-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8114655PMC
May 2021

Correlation between systemic and intravitreal angiopoietin-2 protein levels in vitrectomized diabetic patients.

Retina 2021 Apr 2. Epub 2021 Apr 2.

Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom Helsinki Retina Research Group, Faculty of Medicine, University of Helsinki, Helsinki, Finland Department of Ophthalmology, Kymenlaakso Central Hospital, Kotka, Finland.

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http://dx.doi.org/10.1097/IAE.0000000000003184DOI Listing
April 2021

Descemet Membrane Endothelial Keratoplasty Outcomes between Young and Old Graft Recipients.

Curr Eye Res 2021 Apr 11:1-7. Epub 2021 Apr 11.

Department of Ophthalmology, Rabin Medical Center, Petah-Tikva, Israel.

: To evaluated Descemet's membrane endothelial keratoplasty (DMEK) outcomes in young and old graft recipients.: Data of 164 surgeries with a median age of 76 years (interquartile range 14 years) undergoing DMEK surgery between 2016 and 2018 was reviewed. Complications, graft survival, and visual acuity gain were compared between subjects in the 25th percentile (young recipients; aged 70 years and less, n = 21) and 75th percentile (old recipients; aged 85 years and over, n = 27) over the 2-year follow-up.: Young recipients had a lower rate of pre-operative glaucoma (14.3% vs. 51.9%, = .014) and pseudophakic bullous keratopathy (9.5% vs. 59.3%, < .001), and a higher rate of Fuchs endothelial dystrophy (57.1% vs. 14.8%, = .002) and combined cataract extraction at the time of DMEK surgery (52.4% vs. 7.4%, = .001) when compared to old recipients. Complications (primary graft failure, pupillary block, cystoid macular edema or infectious keratitis) were independent of graft recipient age. Descemet's membrane detachment requiring re-bubbling was observed more often in young compared to the old recipients (42.9% vs. 14.8%, = .049). Visual acuity gain between the groups remained comparable up to 1-year, whereas at 2-years old recipients showed significantly declined visual acuity gains compared to the young recipients (0.14 ± 0.68 vs. 0.74 ± 0.49, = .012). Graft recipients aged over 85 years had a considerably higher graft failure rate over the 24-months (40.7% vs. 4.8%, = .006) and shorter graft survival time ( = .002; log-rank) when compared to the recipients aged under 70 years. After adjusting for potential confounders such as Fuchs endothelial dystrophy, pseudophakic bullous keratopathy and glaucoma, the recipients aged over 85 remained at higher risk for graft failure (HR = 17.278, 95% CI = 1.787-167.1, = .014).: In aged DMEK recipients, regardless of the low incidence of early postoperative complications, the rate of postoperative graft failure was significantly higher and graft survival shorter than in younger recipients.
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http://dx.doi.org/10.1080/02713683.2021.1899245DOI Listing
April 2021

Effect of cataract surgery on wet age-related macular degeneration activity.

Acta Ophthalmol 2021 Apr 10. Epub 2021 Apr 10.

Helsinki Retina Research Group, University of Helsinki, Helsinki, Finland.

Background: Wet age-related macular degeneration (AMD) and age-related cataract are often coexisting causes of visual impairment. Yet, the timing of cataract surgery in wet AMD patients is controversial.

Methods: One hundred and eleven eyes of 111 patients with wet AMD underwent cataract surgery at Helsinki University Hospital in Finland during 2014-2018. Best-corrected visual acuity and central subfield macular thickness (CSMT) were analysed at the time of wet AMD diagnosis, at the last recording prior to cataract surgery and at the first recording and at 1 year after surgery. The cumulative number of antivascular endothelial growth factor (anti-VEGF) injections at surgery, systemic and topical medication and postoperative anti-VEGF burden were recorded.

Results: Mean age was 78.9 ± 5.6 years at the time of surgery. Central subfield macular thickness (CSMT) significantly decreased (280.1 ± 75.0 µm preoperatively to 268.6 ± 67.6 µm at the first postoperative recording, p = 0.001, and to 265.9 ± 67.9 µm at 1 year, p = 0.003), visual acuity improved (0.70 ± 0.46 logMAR units preoperatively to 0.39 ± 0.40 at the first postoperative recording, and to 0.33 ± 0.34 at 1 year, p < 0.001 for both) and anti-VEGF treatment intervals lengthened despite the surgery (6.53 ± 2.08 weeks prior to surgery to 7.03 ± 2.23 weeks at 1 year, p = 0.246, and to 7.05 ± 2.57 weeks at the last documented visit, p = 0.035). A CSMT increase of over 30% from the preoperative values was seen in only one case (1 out of 111 eyes, 0.9%). Macular status at surgery, wet AMD subtype, comorbidity of type II diabetes, systemic drugs and topical anti-inflammatory medication were not associated with macular changes nor with treatment intervals after surgery. The cumulative number of anti-VEGF injections correlated neither with CSMT change postoperatively (r = -0.051, p = 0.619) nor with CSMT change at 1 year (r = 0.091, p = 0.426).

Conclusion: Satisfactory visual outcomes and controlled disease activity were seen in patients with wet AMD undergoing cataract surgery. We found no evidence to support delaying surgery in patients who require it.
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http://dx.doi.org/10.1111/aos.14864DOI Listing
April 2021

Intracameral r-tPA for the management of severe fibrinous reactions in TASS after cataract surgery.

Eur J Ophthalmol 2021 Mar 15:11206721211002064. Epub 2021 Mar 15.

Ophthalmology Department, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Background: To describe the use of intracameral recombinant tissue plasminogen activator (r-tPA) in the treatment of severe fibrinous reactions in toxic anterior segment syndrome (TASS) after cataract surgery.

Methods: A case series of 59 eyes of 59 patients with severe fibrinous anterior chamber reaction following cataract surgery who received intracameral r-tPA (25 µg/0.1 ml). The main outcome measures after intracameral r-tPA were the incidence of complete fibrinolysis, time of maximal effect, visual acuity, and complications.

Results: Severe fibrinous reactions appeared 11.5 ± 5.3 days after cataract surgery. Fibrinolysis was observed 2.33 ± 2.70 days after rtPA use and 36 eyes (61%) exhibited resolution of the fibrin by the end of the first day following injection ( < 0.001). Transient corneal edema observed at 1-day after injection was the only complication reported during the injection of r-tPA or at follow-up. Eight eyes (13.6%) required a second r-tPA injection. Best-corrected visual acuity improved from 0.88 ± 0.67 logMAR units before rtPA injection to 0.48 ± 0.49 logMAR units at 1-month ( < 0.001).

Conclusions: The application of r-tPA was a quick and efficacious therapeutic approach for the management of severe fibrinous reactions in TASS after cataract surgery. In a clinical setting, intracameral r-tPA may be useful when rapid visual recovery is needed.
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http://dx.doi.org/10.1177/11206721211002064DOI Listing
March 2021

High Agreement between Barrett Universal II Calculations with and without Utilization of Optional Biometry Parameters.

J Clin Med 2021 Feb 2;10(3). Epub 2021 Feb 2.

Department of Ophthalmology, Rabin Medical Center, Petah-Tikva 49100, Israel.

Purpose: To examine the contribution of anterior chamber depth (ACD), lens thickness (LT), and white-to-white (WTW) measurements to intraocular lens (IOL) power calculations using the Barrett Universal II (BUII) formula.

Methods: Measurements taken with the IOLMaster 700 (Carl Zeiss, Meditec AG, Jena, Germany) swept-source biometry of 501 right eyes of 501 consecutive patients undergoing cataract extraction surgery between January 2019 and March 2020 were reviewed. IOL power was calculated using the BUII formula, first through the inclusion of all measured variables and then by using partial biometry data. For each calculation method, the IOL power targeting emmetropia was recorded and compared for the whole cohort and stratified by axial length (AL) of the measured eye.

Results: The mean IOL power calculated for the entire cohort using all available parameters was 19.50 ± 5.11 diopters (D). When comparing it to the results obtained by partial biometry data, the mean absolute difference ranged from 0.05 to 0.14 D; < 0.001. The optional variables (ACD, LT, WTW) had the least effect in long eyes (AL ≥ 26 mm; mean absolute difference ranging from 0.02 to 0.07 D; < 0.001), while the greatest effect in short eyes (AL ≤ 22 mm; mean absolute difference from 0.10 to 0.21 D; < 0.001). The percentage of eyes with a mean absolute IOL dioptric power difference more than 0.25 D was the highest (32.0%) among the short AL group when using AL and keratometry values only.

Conclusions: Using partial biometry data, the BUII formula in small eyes (AL ≤ 22 mm) resulted in a clinically significant difference in the calculated IOL power compared to the full biometry data. In contrast, the contribution of the optional parameters to the calculated IOL power was of little clinical importance in eyes with AL longer than 22 mm.
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http://dx.doi.org/10.3390/jcm10030542DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7867297PMC
February 2021

Nd:YAG capsulotomy is not a risk factor for retinal detachment after phacoemulsification cataract surgery.

Acta Ophthalmol 2021 Jan 10. Epub 2021 Jan 10.

Helsinki Retina Research Group, University of Helsinki, Helsinki, Finland.

Purpose: To evaluate the cumulative incidence and risk factors of pseudophakic retinal detachment (PRD) following phacoemulsification cataract surgery.

Methods: Cataract surgeries performed between the years 2007 and 2016 at the Ophthalmology Unit of Kymenlaakso Central Hospital, Kotka, Finland, were included. The cumulative incidence of PRD was estimated through Kaplan-Meier analysis. Patient mortality was incorporated as one of the censoring events. Cox regression analyses were used to evaluate potential risk factors, including age, gender, intraocular lens (IOL) power and previous neodymium-doped yttrium aluminium garnet (Nd:YAG) laser capsulotomy.

Results: A total of 17 688 eyes of 12 003 patients were included. The mean patient age at surgery was 75.2 ± 9.1 years with 63.5% females (n = 11 228). During the mean follow-up time of 4.3 ± 2.7 years, 83 laterality-matched PRDs were registered (incidence 0.11% per year). Univariate analyses showed that age (HR 0.93; 95% CI 0.92-0.95), male gender (HR 3.99; 95% CI 2.52-6.33) and IOL power (HR 0.86; 95% CI 0.83-0.90) were significantly associated with PRD (p < 0.001 for all) and remained significant in a multivariate analysis. Neither univariate (HR 1.45; 95% CI 0.82-2.54, p = 0.201) nor multivariate (HR 1.03; 95%CI 0.57-1.88, p = 0.919) analyses showed any association between Nd:YAG capsulotomy and PRD.

Conclusions: Male gender, low IOL power and younger age were confirmed as risk factors for PRD after phacoemulsification surgery. Real-world evidence suggests that Nd:YAG capsulotomy does not increase the risk for PRD.
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http://dx.doi.org/10.1111/aos.14757DOI Listing
January 2021

The effect of hemodialysis on individual retinal layer thickness.

Int Ophthalmol 2021 Apr 3;41(4):1233-1240. Epub 2021 Jan 3.

Department of Nephrology and Hypertension, Edith Wolfson Medical Center, Holon, Israel.

Purpose: The aim of this study was to employ newly developed advanced image analysis software to evaluate changes in retinal layer thickness following hemodialysis.

Methods: A non-randomized prospective study of patients with end-stage renal disease assessed on the same day before and after hemodialysis. Intraocular pressure and central corneal thickness were analyzed, and spectral domain optical coherence tomography results were automatically segmented using the Orion software and then compared. All patients had normal retinal optical coherence tomography findings before hemodialysis.

Results: Of the 31 suitable end-stage renal disease patients treated with hemodialysis who provided consent to participate, seven were unable to complete all evaluations, leaving 24 patients for analysis in the final study group. Their mean age was 66.67±14.3 years (range: 35-88), and 62.5% were males. Mean central corneal thickness did not change following hemodialysis (563.4±30.2 µm to 553.1±47.2 µm, p=.247), while mean intraocular pressure decreased (14.48±2.5 mmHg to 13.16±2.28 mmHg, p=.028). Individual mean retinal layer thickness showed no significant change, including the retinal nerve fiber layer (40.9±6.8 µm to 40.1±5.2 µm, p=.412), the ganglion cell and the inner plexiform layer (68.66±8 µm to 69.03±7.6 µm, p=.639), and the photoreceptor layer (50.26±2.8 µm to 50.32±3.1 µm, p=.869). Total retinal thickness similarly remained constant, with a mean of 303.7±17.3 µm before and 304.33±18.4 µm after hemodialysis (p=.571).

Conclusions: Thickness of retinal layers, as assessed by individual segmentation, and central corneal thickness were not affected by hemodialysis treatment, while intraocular pressure was significantly reduced among patients with end-stage renal disease without pre-existing ocular pathology who were undergoing hemodialysis. These results support the view that hemodialysis does not have a negative impact on the retinal morphology of end-stage renal disease patients, who comprise a population with high rates of diabetic and/or hypertensive retinopathy as well as vision-threatening complications.
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http://dx.doi.org/10.1007/s10792-020-01677-xDOI Listing
April 2021

Interdigitation and Ellipsoid Zones Disruption Correlate with Visual Outcomes among Treatment-Naive Patients with Diabetic Macular Edema.

Ophthalmic Res 2021 20;64(3):476-482. Epub 2020 Nov 20.

Department of Ophthalmology, Edith Wolfson Medical Center, Holon, Israel and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel,

Introduction: We have recently shown that defects in interdigitation and ellipsoid zones (IZ and EZ) can predict response to anti-VEGF therapy in a small group of treatment-naive diabetic macular edema (DME) patients. The aim of the current study is to further evaluate this association in a larger study group of patients over a longer follow-up time.

Methods: Thirty eyes of 30 treatment-naive DME patients were analyzed in this retrospective study. The integrity of foveal IZ and EZ was evaluated using optical coherence tomography at the diagnosis of DME and following anti-VEGF injections. The defect size was correlated with best-corrected visual acuity (BCVA) and central macular thickness (CMT).

Results: The mean patients' age at baseline was 63.0 ± 10.0 years. Patients underwent 3.9 ± 2.9 anti-VEGF injections for a mean of 9.1 ± 4.8 months. Following treatment, the mean Snellen visual acuity (VA) improved from 20/52 to 20/44 (p = 0.05), CMT decreased from 432.5 ± 141.4 μm to 375.2 ± 121.4 µm (p = 0.05) and IZ/EZ defect size decreased from 259.83 ± 375.94 µm to 65.34 ± 143.97 µm (p = 0.001). In patients with no IZ/EZ defects at baseline, the mean Snellen VA was better when compared to those with IZ/EZ defects (20/36 vs. 20/70, p = 0.031). The number of eyes with IZ/EZ defects decreased from 17 (57%) at baseline to 6 (20%) at end of follow-up (p < 0.01). BCVA gain correlated with IZ/EZ defect size reduction (r = 0.41, p = 0.02) but not with improvement in CMT (r = 0.28, p = 0.121).

Conclusions: IZ/EZ defect size correlated not only with baseline BCVA but also predicted the change in BCVA after anti-VEGF treatment. Possible future automatic measurement of IZ/EZ defect size might prove helpful for the evaluation of treatment response.
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http://dx.doi.org/10.1159/000513204DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8259069PMC
November 2020

A Simple Pre-Operative Nuclear Classification Score (SPONCS) for Grading Cataract Hardness in Clinical Studies.

J Clin Med 2020 Oct 29;9(11). Epub 2020 Oct 29.

Department of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv 6243906, Israel.

Background: The aim of this study was to evaluate whether a simplified pre-operative nuclear classification score (SPONCS) was valid, both for clinical trials and real-world settings.

Methods: Cataract classification was based on posterior nuclear color: 0 (clear), 1 (subcapsular/posterior cataract with clear nucleus), 2 (mild "green nucleus" with plus sign for yellow reflection of the posterior cortex), 3 (medium "yellow nucleus" with plus sign for brown/red posterior cortex reflection), 4 (advanced with 4 being "red/brown nucleus" and 4+ white nucleus), and 5 (hypermature/Morgagnian nucleus). Inter- and intra-observer validity was assessed by 30 Ophthalmologists for 15 cataract cases. The reliability of the cataract grading score in a surgical setting was evaluated. Correlation of nuclear scores was compared with phacoemulsification cumulative dissipated energy (CDE) in 596 patients.

Results: Analysis of mean intra-observer Cohen kappa agreement was 0.55 with an inter-observer score of 0.54 for the first assessment and 0.49 for the repeat assessment one week later. When evaluating results by nuclear color alone, there was a substantial agreement for both the intra-observer (0.70) and inter-observer parameters: 0.70 for the first test, and 0.66 on repetition with randomization of the cases after a week. CDE levels were found to be significantly different between all SPONCS score groups (p < 0.001), with a lower CDE related to a lower SPONCS score. A strong correlation was found between the SPONCS score and CDE (Spearman's rho = 0.8, p < 0.001).

Conclusion: This method of grading cataract hardness is both simple and repeatable. This system can be easily incorporated in randomized controlled trials to lower bias and confounding effects regarding nuclear density along with application in the clinical setting.
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http://dx.doi.org/10.3390/jcm9113503DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7694099PMC
October 2020

Clinical Course of Pseudophakic Cystoid Macular Edema Treated with Nepafenac.

J Clin Med 2020 Sep 21;9(9). Epub 2020 Sep 21.

Helsinki Retina Research Group, University of Helsinki, FI-00290 Helsinki, Finland.

Background: To evaluate the clinical course of pseudophakic cystoid macular edema (PCME) treated with topical non-steroidal anti-inflammatory drugs (NSAIDs).

Methods: An analysis of the clinical course of PCME consisting of 536 eyes of 536 patients from five consecutive randomized clinical trials aimed at the optimization of anti-inflammatory medication in patients undergoing routine cataract surgery. PCME was classified as (i) grade 0a; no macular thickening, (ii) grade 0b; macular thickening (central subfield macular thickness (CSMT) increase of at least 10%) without signs of macular edema, (iii) grade I; subclinical PCME, (iv) grade II; acute PCME, (v) grade III; long-standing PCME. Eyes with PCME classification from grade I onwards were treated with nepafenac 1 mg/mL t.i.d. for two months.

Results: CSMT increase of at least 10% at any postoperative timepoint with cystoid changes-a criterion for PCME-was found in 19 of 536 eyes (total incidence 3.5%). Of these 19 eyes, 13 eyes (total incidence 2.4%) had clinically significant PCME. PCME was considered clinically significant when both of the following visual acuity criteria were fulfilled. At any timepoint after the cataract surgery both the corrected distance visual acuity (CDVA) gain was less than 0.4 decimals from that of preoperative CDVA, and the absolute CDVA level remained below 0.8 decimals. Only one of the 19 eyes with criteria for PCME (total incidence 0.2%, incidence of PCME eyes 5.3%) showed no macular edema resolution within 2 months after topical nepafenac administration. PCME in most cases is self-limiting using topical nepafenac without any further need for intravitreal treatment.
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http://dx.doi.org/10.3390/jcm9093034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7563612PMC
September 2020

The Effect of Blue-Light Filtering Intraocular Lenses on the Development and Progression of Neovascular Age-Related Macular Degeneration.

Ophthalmology 2021 03 24;128(3):410-416. Epub 2020 Jul 24.

Helsinki Retina Research Group, University of Helsinki, Helsinki, Finland; Eye Centre, Kymenlaakso Central Hospital, Kotka, Finland. Electronic address:

Purpose: To assess the effect of blue-light filtering (BLF) intraocular lenses (IOLs) on the prevention of neovascular age-related macular degeneration (nAMD) after cataract surgery.

Design: Cohort study.

Participants: Patients who underwent uneventful cataract surgery between 2007 and 2018 at the Ophthalmology Unit of Kymenlaakso Central Hospital, Kotka, Finland.

Methods: Subsequent nAMD rates were compared between patients who received BLF IOLs and those who received non-BLF IOLs. Kaplan-Meier and Cox regression analyses for the overall risk of nAMD developing were assessed. Best-corrected visual acuity (BCVA), foveal thickness, treatment interval, and total number of intravitreal injections were secondary outcomes. A separate analysis was performed on patients with pre-existing nAMD to assess the effect of BLF IOLs on nAMD progression. A single eye of each patient was included.

Main Outcome Measure: Neovascular age-related macular degeneration-free survival.

Results: Included were 11 397 eyes of 11 397 patients with a mean age of 75.4 ± 8.3 years (62.5% women). The BLF IOL was used in 5425 eyes (47.6%), and the non-BLF IOL was used in 5972 eyes (52.4%). During follow-up (BLF IOL group, 55.2 ± 34.1 months; non-BLF IOL group, 50.5 ± 30.1 months; P < 0.001), 164 cases of new-onset nAMD were recorded (BLF group, n = 88; non-BLF group, n = 76). The nAMD-free survival was similar between the groups (P = 0.465, log-rank test). In a Cox regression analysis controlling for age, gender, and a documented diagnosis of macular degeneration, the use of a BLF IOL was not predictive of nAMD development (hazard ratio [HR], 1.075; 95% confidence interval [CI], 0.79-1.47; P = 0.652). In nAMD patients, secondary clinical outcomes at 1 year were comparable for BCVA (0.57 ± 0.4 logarithm of the minimum angle of resolution vs. 0.45 ± 0.4 logarithm of the minimum angle of resolution; P = 0.136), foveal thickness (285 ± 109 μm vs. 299 ± 103μm; P = 0.527), number of anti-vascular endothelial growth factor injections (6.5 ± 2.5 vs. 6.2 ± 2.7; P = 0.548), and treatment interval (7.5 ± 2.4 weeks vs. 8.1 ± 2.4 weeks; P = 0.271) for BLF and non-BLF IOLs, respectively. Similarly to patients in whom nAMD developed after the surgery, among patients with nAMD before surgery (BLF, n = 71; non-BLF, n = 74), the clinical outcomes again were comparable (all P > 0.05).

Conclusions: In a large cohort of patients who underwent cataract surgery, the use of a BLF IOL resulted in no apparent advantage over a non-BLF IOL in the incidence of nAMD or its progression, nor in clinical variables related to nAMD severity.
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http://dx.doi.org/10.1016/j.ophtha.2020.07.039DOI Listing
March 2021

Association between intraocular lens diopter and posterior capsular opacification.

Clin Exp Ophthalmol 2020 09 6;48(7):889-894. Epub 2020 Aug 6.

Helsinki Retina Research Group, University of Helsinki, Helsinki, Finland.

Importance: Posterior capsular opacification (PCO) is the most common complication after cataract surgery.

Background: We aimed to assess the relationship between intraocular lens (IOL) diopter and formation of PCO among a consecutive real-world registry.

Design: Cohort study.

Participants: Included were 14 264 consecutive cases of uncomplicated cataract surgery performed during 2014 to 2018 in Helsinki University Hospital in Finland.

Methods: Nd:YAG capsulotomies were used as an estimate of clinically significant PCO. A single eye of each patient and a single type of IOL were included.

Main Outcome Measure: Nd:YAG posterior capsulotomy free survival.

Results: Mean age was 73.2 ± 9.9 years and 61.8% were female. Mean follow-up time was 25.4 ± 16.8 months. Overall PCO rates were 1.1% at 1-year, 3.0% at 2-year, 7.1% at 3-year and 10.2% at 4-year. Patients with IOL diopters (D) in the lower quartile (≤20.0 D) had significantly higher rates of PCO (1.3% at 1-year, 4.4% at 2-years, 9.4% at 3-years and 14.2% at 4-years, P < .001). A logistic regression model showed increased risk for PCO formation with lower diopter IOLs; for ≤20.0 D: OR 1.343 (95% CI: 1.132-1.593), for ≤10.0 D: OR 2.409 (95% CI 1.203-4.287), P < .001 for all comparisons. In a multivariant regression accounting for possible confounders, results remained consistent.

Conclusions And Relevance: Among a cohort of patients undergoing cataract surgery, use of lower diopter IOLs was associated with increased incidence of clinically significant PCO. Research into IOL biomechanics to decrease PCO may be warranted especially in lower diopter IOLs.
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http://dx.doi.org/10.1111/ceo.13821DOI Listing
September 2020

Reducing visible aerosol generation during phacoemulsification in the era of Covid-19.

Eye (Lond) 2021 05 26;35(5):1405-1410. Epub 2020 Jun 26.

Bristol Eye Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK.

Objective: To assess potential methods of reducing visible aerosol generation during clear corneal phacoemulsification surgery in the era of Covid-19.

Methods: Aerosol generation during phacoemulsification was assessed using a model comprising a human cadaveric corneoscleral rim mounted on an artificial anterior chamber. Typical phacoemulsification settings were used and visible aerosol production was recorded using high-speed 4K camera. Aerosolisation was evaluated under various experimental settings: Two different phacoemulsification tip sizes (2.2, 2.75 mm), varying levels of corneal moisture, the use of suction and blowing air in the surgical field, the use of hydroxypropyl methylcellulose (HPMC) coating of the cornea with a static and moving tip.

Results: This model demonstrates visible aerosol generation during phacoemulsification with a 2.75-mm phacoemulsification tip. No visible aerosol was noted with a 2.2-mm tip. The presence of visible aerosol was unrelated to corneal wetting. Suction in close proximity to the aerosol plume did not impact on its dispersion. Blowing air redirected the aerosol plume toward the ocular surface. Visible aerosol production was abolished when HPMC was used to coat the cornea. This effect lasted for an average of 67 ± 8 s in the static model. Visible aerosol generation was discerned during movement of the 2.2-mm tip toward the corneal wound.

Conclusions: We demonstrate visible aerosol production in the setting of a model of clear corneal phacoemulsification. Visible aerosol can be reduced using a 2.2-mm phacoemulsification tip and reapplying HPMC every minute during phacoemulsification.
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http://dx.doi.org/10.1038/s41433-020-1053-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7318901PMC
May 2021

Does Bariatric Surgery Affect Intraocular Pressure?

Obes Surg 2020 Oct;30(10):3742-3746

Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.

Purpose: The effect of body mass index (BMI) reduction following bariatric surgery on intraocular pressure (IOP) is not well established. We evaluated association between BMI reduction and IOP measurements and other ocular and metabolic parameters 1 year after bariatric surgery.

Materials And Methods: A retrospective study with over 1-year follow-up on patients who underwent weight reduction bariatric surgery between January 2016 and December 2016 at Wolfson Medical Center, Israel. Patient data was extracted from outpatient's bariatric and ocular clinic records. Metabolic, ocular, and clinical parameters were assessed including BMI changes, IOP, central corneal and retinal nerve fiber layer thickness, optical coherence tomography, and biometry results.

Results: Of 22 bariatric surgery patients, 15 underwent laparoscopic sleeve gastrectomy (LSG) and 7 laparoscopic mini gastric bypass (MGB). All were followed up for over 1 year after surgery. Average BMI decreased from 41.9 ± 7.3 to 25.5 ± 5.7 kg/m at 1-year follow-up (p < 0.001). Mean IOP decreased significantly by 21% after 1 year (p < 0.001). Decrease in IOP 1 year after surgery was correlated with decrease in IOP at 3-month follow-up (r = 0.677, p = 0.001), preoperative IOP (r = 0.837, p < 0.001), and corneal thickness (r = 0.589, p = 0.006), with no correlation between reduction in IOP and baseline weight, BMI, or the reduction in either (p > 0.05). Central corneal thickness and retinal nerve fiber layer thickness were also significantly decreased (p = 0.038) and (p = 0.018), respectively.

Conclusion: BMI reduction achieved by bariatric surgery was associated with significant and continued decline in IOP beyond 1 year after surgery. Clinical implications highlight the importance of considering bariatric surgery in patients with ocular hypertension.
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http://dx.doi.org/10.1007/s11695-020-04714-xDOI Listing
October 2020

Agreement of Corneal Endothelial Cell Analysis Between Konan-Noncon Robo SP-6000 and Tomey EM-3000 Specular Microscopes in Healthy Subjects.

Eye Contact Lens 2021 Apr;47(4):191-195

Department of Ophthalmology (D.J., G.A., I.B., U.E.), Rabin Medical Center, Petah-Tikva, Israel; Department of Ophthalmology, (D.J., A.A., G.A., I.H., I.B., U.E.), Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Ophthalmology (A.A.), Edith Wolfson Medical Center, Holon, Israel; Department of Ophthalmology (O.B.), Soroka University Medical Center, The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Department of Ophthalmology (I.H.), Shamir Medical Center, Be'er Ya'akov, Israel; Department of Ophthalmology (R.T.), Helsinki Retina Research Group, University of Helsinki, Helsinki, Finland; and Eye Centre (R.T.), Kymenlaakso Central Hospital, Kotka, Finland.

Purpose: To compare corneal endothelium parameters taken by two common noncontact specular microscopes in healthy subjects.

Methods: Healthy participants visiting the outpatient eye clinic at the Rabin Medical Center, Petah Tikva, Israel, were recruited prospectively. All participants underwent three consecutive corneal endothelial cell photographs with both the Konan-Noncon Robo SP-6000 and the Tomey EM-3000 specular microscopes. Endothelial cell density (ECD) was evaluated using the manual center technique in both machines. Bland-Altman graphs were used to assess the agreement between the devices, and intraclass correlation coefficient (ICC) served to assess intraobserver variability for each device.

Results: Recruited were 49 healthy subjects with a mean age of 48.9±15.6 years, 49 right eyes were included. The mean ECD was comparable between the Tomey EM-3000 and the Konan-Noncon Robo SP-6000 (2,713.2±242.4 vs. 2,700.8±300.5 cells/mm2, respectively, P=0.47) with a mean difference of 12.4 cells/mm2 (0.67%), a mean ECD absolute difference of 93.3 cells/mm2, and low 95% limits of agreement of -222.0 to +246.9 cells/mm2. A folded empirical distribution function curve showed that all differences fell within 525.4 cells/mm2, centered around a median of 13.3 cells/mm2. Intraclass correlation coefficient was high for both the Konan-Noncon Robo SP-6000 (0.93, 95% confidence interval [CI]: 0.89-0.95) and the Tomey EM-3000 (0.88, 95% CI: 0.82-0.93).

Conclusions: The difference in endothelial cell measurements between the Konan SP-6000 and the Tomey EM-3000 specular microscopes through the center and the L-count analyzing techniques, respectively, is clinically small and not statistically significant. Nevertheless, caution should be taken when used interchangeably because ECD difference between the two machines can be as high as 525.4 cells/mm2.
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http://dx.doi.org/10.1097/ICL.0000000000000712DOI Listing
April 2021

Punching a Graft for Descemet Membrane Endothelial Keratoplasty Onto a Contact Lens Reduces Endothelial Cell Loss at the Graft's Margin.

Cornea 2020 Aug;39(8):1027-1030

Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel.

Purpose: To evaluate whether punching Descemet membrane endothelial keratoplasty (DMEK) corneal grafts onto a contact lens scaffold reduces endothelial cell loss at the graft margin in comparison to punching the graft directly onto the donor stroma.

Methods: DMEK grafts were prepared using 2 different methods after peeling the graft from the stroma: punching onto a contact lens and punching onto the donor stroma. The grafts were then evaluated for the width of Descemet membrane devoid of endothelial cells in the peripheral ring, measured at 4 points at the graft margin.

Results: Our study included 6 grafts, harvested from 3 donors aged 66.3 ± 5.1 years. Grafts prepared on a contact lens scaffolding had more of their Descemet membrane margin populated by endothelial cells than did grafts that were punched directly onto the donor stroma (total denuded area: 0.06 ± 0.08 mm vs. 1.17 ± 0.02 mm, P = 0.018; maximal width of denuded area: 59.6 ± 28.4 μm vs. 100.2 ± 59.7 μm, P = 0.07). Donor grafts on contact lens had approximately 2.5% more endothelial cells available for transplantation (2425 cells/mm vs. 2367 cells/mm). Graft preparation time did not significantly differ between the methods (6.4 ± 0.49 vs. 9.8 ± 3.7 minutes, P = 0.46).

Conclusions: Punching DMEK grafts onto a contact lens reduces endothelial loss at the grafts' margins and may prolong their survival.
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http://dx.doi.org/10.1097/ICO.0000000000002342DOI Listing
August 2020

Demographic, clinical features, and outcomes of pediatric non-penetrating ocular foreign bodies.

Graefes Arch Clin Exp Ophthalmol 2020 Jul 15;258(7):1469-1474. Epub 2020 Apr 15.

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Purpose: Data regarding ocular foreign body (FB) in the pediatric population is sparse. The purpose of this study is to describe the demographic features and the outcomes of pediatric non-penetrating ocular FB.

Methods: The charts of all children with non-penetrating ocular FB who presented at a tertiary medical center between 2011 and 2018 were retrospectively reviewed. Data analyzed included demographics, ocular FB site, the need for general anesthesia, or sedation for FB removal and clinical outcomes.

Results: Three hundred and fifty-two children (58.8% boys) with a mean age of 7.7 ± 3.7 years were included. Two hundred and fifty-one (71.3%) children presented on the same day of injury. Patients with developmental delay presented more often with restlessness than patients without developmental delay (p < 0.0001). One hundred and forty-six (41.5%) of FBs were found on the conjunctiva, 128 (36.4%) under the eyelid, and 62 (17.6%) on the cornea. In 19 (4.5%) cases, general anesthesia or sedation was required for FB removal. A multivariate analysis identified young age (OR 0.976, 95% CI 0.961-0.992, p = 0.003), corneal FB (OR 50.84, 95% CI 10.08-256.37, p < 0.0001), and developmental delay (OR 18.56, 95% CI 1.22-283.45, p = 0.036), as significant predictors for the need of general anesthesia or sedation. Among patients with corneal FB, in two (3.2%) cases, the corneal FB was complicated by infectious keratitis, resulting in mild corneal scar.

Conclusion: The rate of general anesthesia for non-penetrating ocular FB removal in children is low. Children presenting with non-penetrating ocular FB have good prognosis without long-term complications.
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http://dx.doi.org/10.1007/s00417-020-04688-7DOI Listing
July 2020

Accelerated Corneal Cross-linking as an Adjunct Therapy in the Management of Presumed Bacterial Keratitis: A Cohort Study.

J Refract Surg 2020 Apr;36(4):258-264

Purpose: To compare the outcomes of accelerated photoactivated chromophore for keratitis corneal cross-linking (PACK-CXL) as an adjunct treatment for bacterial keratitis (PACK-CXL plus standard antibiotic therapy) for patients receiving only standard antibiotic therapy.

Methods: Retrospective cohort study of outcomes of patients with moderate infectious presumed bacterial keratitis (ulcer diameter 2 to 7 mm and stromal depth < 300 µm) were compared before and after initiation of a new treatment protocol of PACK-CXL in addition to standard antibiotic treatment.

Results: A total of 70 eyes of 70 patients were included: 39 eyes in the PACK-CXL plus antibiotic (PACK-ABX) group and 31 eyes in the antibiotic only (ABX) control group. The PACK-ABX group showed shorter times to complete reepithelialization (9.3 ± 6.0 vs 16.0 ± 12.7 days, P = .01) and did not require tectonic emergency keratoplasty (0% versus 19.4%, P = .006). The PACK-ABX group also showed a higher percentage of eyes with complete reepithelialization in 6 days or less (46.2% vs 6.5%, P < .001) and a trend for shorter hospitalizations (6.3 ± 5.0 vs 8.5 ± 4.5 days, P = .06). A multivariate analysis controlling for age showed that PACK-ABX treatment remained significantly associated with early ulcer reepithelialization (odds ratio = 0.09, 95% confidence interval = 0.02 to 0.48, P = .005).

Conclusions: This study validates previous findings regarding the use of accelerated PACK-CXL in the treatment of bacterial keratitis. Adding PACK-CXL improved clinical outcomes (reducing healing time) when compared to antibiotics alone. [J Refract Surg. 2020;36(4):258-264.].
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http://dx.doi.org/10.3928/1081597X-20200226-02DOI Listing
April 2020

Effect of Rho-associated kinase inhibitor on human corneal endothelial cell apoptosis.

J Cataract Refract Surg 2020 04;46(4):612-616

From the Department of Ophthalmology, Edith Wolfson Medical Center (Achiron, Karmona, Pe'er, Avizemer, Bartov, Burgansky), Holon, Sackler Faculty of Medicine, Tel Aviv University (Achiron, Feldman, Karmona, Pe'er, Avizemer, Bartov, Burgansky, Rosner, Vishnevskia-Dai), Tel Aviv, The Multiple Sclerosis Center, Sheba Medical Center (Feldman), and The Goldschleger Eye Institute, Sheba Medical Center (Rosner, Vishnevskia-Dai), Tel Hashomer, Israel.

Purpose: To evaluate whether exposure to Rho-associated protein kinase (ROCK) inhibitor will promote human-cultured corneal endothelial cells (CECs) survival in a commercial storage medium.

Setting: Edith Wolfson Medical Center, Holon, and Sheba Medical Center, Tel Hashomer, Israel.

Design: Experimental study.

Methods: Fragments of human donor corneolimbal rings were stored in commercial storage media for 1 week, half with the addition of 10 μM ROCK inhibitor (Y-27632). Evaluation of CECs for early and late apoptosis\necrosis rates was performed using anti-human CD166 antibody and flow cytometric double staining analysis of propidium iodide and Annexin V.

Results: CECs of 6 corneolimbal rings demonstrated a reduced early apoptosis rate (4.35% ± 1.07% vs 12.18% ± 5.5%, P = .026) and a reduced late apoptosis\necrosis rate (5.5% ± 2.39% vs 9.43% ± 2.61%, P = .004) compared with control. Subsequently, the rate of apoptotic CECs expressing ROCK was significantly lower in cells exposed to ROCK inhibitor compared with cells that were not (19.01% ± 4.17 vs 30.42% ± 4.27, P < .001).

Conclusions: ROCK inhibitor reduced endothelial cell loss in vitro and might be used to limit or slow CEC loss in donor corneal tissue during eye banking. This might be a promising new method for promoting future graft survival.
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http://dx.doi.org/10.1097/j.jcrs.0000000000000115DOI Listing
April 2020

Anti-inflammatory Medication After Cataract Surgery and Posterior Capsular Opacification.

Am J Ophthalmol 2020 07 14;215:104-111. Epub 2020 Feb 14.

Helsinki Retina Research Group, University of Helsinki, Helsinki, Finland; Eye Centre, Kymenlaakso Central Hospital, Kotka, Finland.

Purpose: To assess the role of anti-inflammatory medication following cataract surgery on the formation of posterior capsular opacification.

Design: Cohort study.

Methods: A retrospective registry analysis of 25,818 consecutive patients who underwent cataract surgery between the years 2014 and 2018 at Helsinki University Hospital in Finland. Nd:YAG laser capsulotomy rates were compared between patients treated postoperatively with topical steroids, nonsteroidal anti-inflammatory medications (NSAIDs), or their combination. Kaplan-Meier and Cox regression analyses were used. A single eye of each patient was included. Main outcomes were confirmed against a second independent dataset.

Results: A total of 13,368 patients were included in the analysis, with a mean age of 73.2 ± 9.7 years; 61.7% were female. Pseudoexfoliation was noted in 10.1% of cases. The mean follow-up time was 22.8 ± 15.7 months. Patients were treated with steroid monotherapy (28.9% of cases), NSAID monotherapy (62.2%), or a combination of both (8.9%). Treatment with steroids resulted in significantly lower Nd:YAG capsulotomy rates compared to NSAIDs (hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.62-0.93, P = .009). Treatment with combination therapy of steroids and NSAIDs showed no added benefit over steroid monotherapy (HR 1.11, 95% CI 0.68-1.80, P = .674). Cox regression analysis adjusted for patients' age, sex, pseudoexfoliation, and risk stratification remained significantly predictive for lower capsulotomy rates with steroid treatment over NSAIDs (HR 0.70, 95% CI 0.52-0.88, P = .001).

Conclusions: Postoperative treatment with steroids among patients undergoing uncomplicated cataract surgery was associated with lower rates of clinically significant posterior capsule opacification compared to treatment with NSAIDs alone. Combination therapy of steroids and NSAIDs had no added benefit over steroids alone.
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http://dx.doi.org/10.1016/j.ajo.2020.02.007DOI Listing
July 2020

Chorio-retinal toxoplasmosis: treatment outcomes, lesion evolution and long-term follow-up in a single tertiary center.

Int Ophthalmol 2020 Apr 2;40(4):811-821. Epub 2019 Dec 2.

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Ocular toxoplasmosis is a common cause of ocular inflammation worldwide. The aim of this study is to characterize the clinical outcomes and lesion evolution of patients with ocular toxoplasmosis and to compare the primary and reactivation subgroups.

Methods: A retrospective population-based cohort study at one uveitis-specialized tertiary referral center. Patients presenting with active ocular toxoplasmosis between the years 2007-2016 were included. Primary ocular toxoplasmosis and reactivations were compared.

Results: Included were 22 patients, 64% female with a mean age of 29 ± 18 years, 59% (n = 13) were primary, 9% (n = 2) congenital and 32% (n = 7) reactivations. Visual acuity improved from 0.38 ± 0.44 to 0.20 ± 0.27 LogMAR (P = 0.026) after a mean of 37 ± 33 months. Initial lesion size was 2.38 ± 1.1 optic disc areas, reducing to 1.56 ± 1.24 following 2 months (34% reduction, P = 0.028) and to 1.17 ± 0.87 disc areas following one year (51% reduction, P = 0.012). Patients with macula-threatening lesions had worse visual acuity (0.50 ± 0.46 vs. 0.05 ± 0.07 LogMAR, P = 0.047). Primary and reactivation subgroups had similar presentations, visual outcomes and recurrence rates (all P > 0.05).

Conclusions: In this population, primary ocular toxoplasmosis was the most common presentation. Lesion size reduced during the initial months with limited change thereafter and a third of cases recurred. Macula-threatening lesions were associated with worse visual acuity, and no significant differences were seen between the primary and reactivation subgroups.
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http://dx.doi.org/10.1007/s10792-019-01242-1DOI Listing
April 2020

Corneal Cross-linking in Thin Corneas: 1-Year Results of Accelerated Contact Lens-Assisted Treatment of Keratoconus.

J Refract Surg 2019 Oct;35(10):642-648

Purpose: To evaluate the safety and efficacy of accelerated contact lens-assisted cross-linking (A-CACXL) for patients with keratoconus and thin corneas.

Methods: This retrospective study included consecutive patients undergoing A-CACXL for progressive keratoconus from 2015 to 2017. Patients with a minimum corneal thickness of 400 µm or less after epithelium removal who underwent A-CACXL (9 mW/cm for 10 minutes, using iso-osmolar 0.1% riboflavin solution and a 90-µm thick, daily disposable bandage soft contact lens) with a follow-up time of 12 months or more were included. The main outcome measures were uncorrected (UDVA) and corrected (CDVA) distance visual acuity and minimum corneal thickness at the last visit. Progression (increase) and flattening (decrease) were defined as a change of 1.00 diopters (D) or greater in maximum keratometry or 1.50 D or greater in mean keratometry.

Results: Overall, 24 eyes of 24 patients were included with a follow-up time of 18.2 ± 6.3 months and a mean minimum corneal thickness, after epithelial debridement, of 353.13 µm. There was a significant improvement in UDVA (P = .009), maximum keratometry (P = .03), anterior steep keratometry (P = .04), anterior astigmatism (P = .02), and posterior astigmatism (P = .04) with no significant change in minimum corneal thickness (P = .11). There was a significant improvement in UDVA (0.90 ± 0.63 to 0.64 ± 0.47 logMAR, P = .009), maximum keratometry (61.20 ± 6.30 to 59.90 ± 5.70 D, P = .03), anterior steep keratometry (55.10 ± 3.90 to 54.50 ± 4.10 D, P = .04), anterior astigmatism (5.50 ± 2.40 to 4.60 ± 2.10 D, P = .02), and posterior astigmatism (0.90 ± 0.40 to 0.80 ± 0.40 D, P = .04) with no significant change in minimum corneal thickness (from 399.8 ± 30.7 to 391.0 ± 43.8 μm, P = .11). Flattening occurred in 45.8% (n = 11) and progression in 20.8% (n = 5). There were no serious adverse events. Persistent clinically significant stromal haze occurred in one case and completely resolved by 6 months. There was no significant change in endothelial cell density (P = .10).

Conclusions: In patients with keratoconus and thin corneas, A-CACXL halted keratoconus progression in 80%, led to flattening in 45%, and significantly improved UDVA and keratometry values without any evidence of damage to the corneal endothelium or permanent adverse events. [J Refract Surg. 2019;35(10):642-648.].
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http://dx.doi.org/10.3928/1081597X-20190903-01DOI Listing
October 2019

B-cell related biomarkers associated with severity of the first demyelinating event of acute optic neuritis.

Eye (Lond) 2020 05 10;34(5):954-959. Epub 2019 Oct 10.

Neurogenomics Laboratory, Multiple Sclerosis Center, Sheba Medical Center, Ramat Gan, and Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.

Background: Optic neuritis (ON) is the most common cause of acute unilateral visual loss in young adults and frequently occurs as the presenting symptom of multiple sclerosis (MS). Recently, we reported activation of peripheral blood CD19 + ‏ B-cells in the early stage of ON. In the current study we aimed to identify peripheral blood ‏B-cell molecular markers associated with ON severity and visual outcome.

Methods: Expression of B-cell related biomarkers were analysed in patients with the first clinical presentation of acute unilateral ON. Logarithm of the Minimum Angle of Resolution (LogMAR). visual acuity, Optical Coherence Tomography (OCT) imaging, Expanded Disability Status Scale (EDSS) visual score and visual evoked responses were evaluated at onset and visual acuity and EDSS visual score were repeated at 6 months post-ON.

Results: Thirty patients with acute unilateral ON, 77% female, mean age 33 ± 2.0 years, were enroled in the study. Expression of CD19, CD79A and CD20 B-cell markers significantly correlated with LogMAR visual acuity of the affected eye (r = 0.44, p = 0.01, r = 0.37, p = 0.01 and r = 0.36, p = 0.04, respectively). The marker levels were elevated between 1.5 and 2.2-folds in the group with worse visual acuity (LogMAR>1.0) at onset (CD79A:×1.5, p = 0.013; CD19:×2.25, p = 0.007; CD20:×1.5, p = 0.015) and not correlated with 6 month visual outcome.

Conclusions: Among patient with a first event of acute ON, expression of B-cell biomarkers correlated with the severity of the disease. These results could add information on the role of B-cell dysfunction in the early stages of ON.
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http://dx.doi.org/10.1038/s41433-019-0614-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7182557PMC
May 2020

Traumatic Cataracts in Children, Long-Term Follow-up in an Israeli Population: A Retrospective Study.

Isr Med Assoc J 2019 Sep;21(9):599-602

Department of Ophthalmology, Kaplan Medical Center, Rehovot, Israel.

Background: Ocular trauma in the pediatric population may lead to cataract formation. Managing traumatic cataracts in a visually immature child is a major challenge and can result in poor visual outcome.

Objectives: To review our long-term surgical experience with childhood unilateral traumatic cataracts.

Methods: A retrospective observational study of children with unilateral traumatic cataracts with minimal follow-up of 5 years was conducted. Main outcomes included final visual acuity (VA) and occurrence of complications.

Results: Of the 18 children included in the study, 83% were male. Mean follow-up time was 12.5 years. Median age at injury was 7.5 years. Eleven patients (61%) presented with penetrating trauma injuries and 7 (39%) with blunt trauma. Sixteen patients (89%) had cataracts at presentation, while in two the cataracts developed during follow-up. Of the 18 total, cataract removal surgery was conducted in 16 (89%) with intraocular lens (IOL) implantation in 14 (87.5%), while 2 remained aphakic (12.5%). Two (11%) were treated conservatively. Long-term complications included IOL dislocation in 5 (36%), glaucoma in 8 (44%), and posterior capsular opacity in 10 (71%). No correlation was found between final visual acuity and the time interval between injury and IOL implantation nor between final VA and age at trauma. However, the final VA did correlate with time of follow-up.

Conclusions: Severe complications occurred in over 30% of the patients during a long follow-up (mean 12.5 years). This finding shows the importance of discussions between the operating physician and the parents regarding the prognosis and necessity of scheduled follow-up.
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September 2019

REDUCTION OF POSTINTRAVITREAL INJECTION PAIN USING ICE: An Open-Label Interventional Randomized Controlled Trial.

Retina 2020 Jul;40(7):1434-1438

Department of Ophthalmology, Edith Wolfson Medical Center, Holon, Israel.

Purpose: Intravitreal injections of intraocular therapeutic agents are a common and effective treatment for various retinal pathologies. Patient discomfort related to injection is a potential barrier to treatment. Our aim in this study was to evaluate whether cooling the eye using topical ice compresses before intravitreal injection will reduce pain or bleeding.

Methods: This randomized controlled open-label study included 42 patients. All patients received a standard topical anesthesia protocol and then were randomly assigned to either receive a placement of ice packs (intervention group) or a room-temperature pack (control group) on the eyelid, 2 minutes before the intravitreal injection. Patients' discomfort, itching, burning and pain (using visual analog scale), and bleeding size (using photographs) were measured 1 and 10 minutes after the injection. Tolerability was calculated by averaging patients' discomfort, itching, burning, and pain scores.

Results: At 1 minute, pain (1.95 vs. 4.27, P = 0.01) and overall tolerability (1.66 vs. 2.98, P = 0.03) were significantly lower in patients receiving ice packs. At 10 minutes, pain (1.6 vs. 3.73, P = 0.02), burning (0.9 vs. 3.09, P = 0.007), discomfort (2.1 vs. 4.27, P = 0.008), and overall tolerability (1.23 vs. 2.87, P = 0.004) were all significantly lower in the ice group compared with the controls. Bleeding size (area or circumference) was not statistical different between groups.

Conclusion: Topical ice patch administered before intravitreal injection significantly decreased pain and overall tolerability. This simple and inexpensive method may be used to ameliorated pain and improve tolerability.
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http://dx.doi.org/10.1097/IAE.0000000000002608DOI Listing
July 2020
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