Publications by authors named "Roberto Pineda"

93 Publications

Pilot Study of Corneal Clearance With the Use of a Rho-Kinase Inhibitor After Descemetorhexis Without Endothelial Keratoplasty for Fuchs Endothelial Corneal Dystrophy.

Cornea 2021 Mar 8. Epub 2021 Mar 8.

Cornea and Refractive Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA.

Purpose: To investigate corneal clearance time using a topical rho-kinase inhibitor, netarsudil, after descemetorhexis without endothelial keratoplasty (DWEK).

Methods: Twenty eyes from 10 patients with Fuchs endothelial corneal dystrophy had DWEK with cataract surgery. For the first eye of each participant, netarsudil was administered immediately after surgery until corneal clearance. For the second eye, netarsudil was withheld 2 weeks beyond the time for corneal clearance of the first eye and then administered only if corneal edema was still present. Interpatient and intrapatient comparisons were made for pachymetry, endothelial cell count, intraocular pressure, and time to corneal clearance.

Results: Intrapatient comparison demonstrated no significant difference in preoperative pachymetry (P value 0.58), endothelial cell counts (P value 0.97), and intraocular pressure (P value 0.46) between eyes treated with netarsudil immediately after DWEK and those with delayed netarsudil use. Average time for corneal clearance in eyes treated with netarsudil immediately after surgery was 4.6 ± 1.7 weeks, which was significantly shorter than eyes not treated with netarsudil immediately at 8 ± 1.9 weeks (P < 0.01). Corneal clearance occurred in eyes between 1 and 2 weeks after addition of netarsudil as a "rescue" drop. Interpatient comparison demonstrated significantly greater endothelial cell counts in eyes treated with netarsudil immediately compared with eyes with a delay in netarsudil use (P = 0.05).

Conclusions: Netarsudil significantly reduces the time to corneal clearance after DWEK. Furthermore, increased endothelial cell counts in eyes with immediate netarsudil use versus delayed netarsudil use suggests that the immediate perioperative period is crucial in cell regeneration and migration.
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http://dx.doi.org/10.1097/ICO.0000000000002691DOI Listing
March 2021

A Biomechanical Study of Flanged Intrascleral Haptic Fixation of Three-Piece Intraocular Lenses: Biomechanical study of flanged intrascleral haptic fixation.

Am J Ophthalmol 2021 Feb 21. Epub 2021 Feb 21.

Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA. Electronic address:

Purpose: Flanged intrascleral haptic fixation (FISHF) is a useful method to secure intraocular lenses (IOLs) in eyes without capsular support. Biomechanical studies were conducted to support the use of this technique.

Design: Laboratory investigation METHODS: Haptics of 3-piece IOLs were passed through cadaveric human sclera using 30-gauge and 27-gauge needles. Flanges were created by melting 1.0 mm from the haptic ends using cautery. The forces required to remove the flanged haptic from the sclera and disinsert the haptic from the optic were measured using a mechanical tester and a custom-fabricated mount.

Results: The mean FISHF dislocation force using 30-gauge needles was greatest with the CT Lucia 602 (2.04 ± 0.24 N) compared to the LI61AO (0.93 ± 0.41 N; p=0.001), ZA9003 (0.70 ± 0.34 N; p=<0.001), and MA60AC (0.27 ± 0.19 N; p<0.001). Using 27-gauge needles with the CT Lucia resulted in a lower dislocation force (0.56 ± 0.36 N, p<0.001). The FISHF dislocation force was correlated with the flange-to-needle diameter ratio (r=0.975). The FISHF dislocation forces of the CT Lucia and LI61AO using 30-gauge needles were not significantly different from their haptic-optic disinsertion forces (p=0.79 and 0.27 respectively). There was no difference in flange diameter between 1.0 mm and 2.0 mm haptic melt lengths across the IOLs (p=0.15-0.85).

Conclusions: This data strongly supports the biomechanical stability of FISHF with the polyvinylidene fluoride haptics of the CT Lucia using small diameter instruments for intrascleral tunnel creation. 1.0 mm of haptic may be the optimal melt length.
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http://dx.doi.org/10.1016/j.ajo.2021.02.021DOI Listing
February 2021

Acute Benign Paroxysmal Positional Vertigo After Endothelial Keratoplasty-A Unique Cause of Postoperative Nausea and Headache.

Cornea 2020 Nov 19. Epub 2020 Nov 19.

Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA.

Purpose: To describe a case of new-onset benign paroxysmal positional vertigo (BPPV) after uncomplicated Descemet stripping automated endothelial keratoplasty.

Methods: Case report and review of literature.

Results: A 61-year-old woman with a history of steroid-induced glaucoma and penetrating keratoplasty for Fuchs endothelial dystrophy, and no history of BPPV or other vertigo, underwent Descemet stripping automated endothelial keratoplasty for penetrating keratoplasty graft failure. On the third postoperative day, she developed acute spinning vertigo, nausea, and headache on sitting up after 3 days of strict supine positioning. Her ophthalmic examination was benign, with no evidence of a pupillary block, and she was diagnosed by an otologist with BPPV. Her symptoms resolved after 1 week without further intervention.

Conclusions: BPPV is a benign but rare complication of nonotologic surgery and has not been previously reported with ophthalmic surgery. The overlap in symptomatology between BPPV and other serious and potentially vision-threatening causes of postoperative nausea and headache, such as pupillary block glaucoma, makes this a relevant etiology to consider in the spectrum of postendothelial keratoplasty complications.
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http://dx.doi.org/10.1097/ICO.0000000000002587DOI Listing
November 2020

Spontaneously Regressed Corneal Intrastromal Cyst.

Ophthalmology 2020 10;127(10):1383

Glick Eye Institute, Indiana University School of Medicine, Indianapolis, Indiana.

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http://dx.doi.org/10.1016/j.ophtha.2020.06.011DOI Listing
October 2020

Survival of the fittest: phacoemulsification outcomes in four corneal transplants by Dr Ramon Castroviejo.

Br J Ophthalmol 2020 Aug 28. Epub 2020 Aug 28.

Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA

Aim: To evaluate and report the outcomes following phacoemulsification on four eyes, 45 years or more after corneal transplantation.

Methods: A retrospective case series of four eyes in three patients (P1, P2, P3), undergoing phacoemulsification at least 45 years after corneal transplantation by Dr Ramon Castroviejo. Corneal graft survival outcome measures included central corneal thickness (CCT), best-corrected visual acuity (BCVA), corneal clarity and endothelial cell count (ECC).

Results: Phacoemulsification was successfully completed in all four cases with no instances of graft failure during the postoperative follow-up period, which ranged from 17 months to 76 months. At the conclusion of the follow-up period, all four grafts remained clear, and BCVA remained better than or similar to preoperative values. Long-term follow-up revealed no meaningful changes in CCT after phacoemulsification. All but one case experienced a decrease in ECC, with ECC values in the four cases ranging from 538 cells/mm to 1436 cells/mm at the conclusion of postoperative follow-up.

Conclusion: Limited data have been published on the long-term survival of corneal grafts after intraocular surgery, especially for extremely 'mature' corneal transplants. This case series demonstrates that with appropriate preoperative, intraoperative and postoperative measures, successful phacoemulsification can be performed in these cases with excellent long-term results.
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http://dx.doi.org/10.1136/bjophthalmol-2020-316435DOI Listing
August 2020

Learning Descemet Membrane Endothelial Keratoplasty: A Survey of U.S. Corneal Surgeons.

Cornea 2020 May;39(5):590-593

Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD.

Purpose: The transition to Descemet membrane endothelial keratoplasty (DMEK) is frequently challenging, requiring the adoption of new techniques, skills, and methods. We sought to draw on surgeons' initial experiences with DMEK to characterize the learning curve associated with this procedure and identify factors that could be linked to the frequency of primary graft failure (PGF) in the first 10 cases.

Methods: We invited corneal surgeons based in the United States who started performing the DMEK procedure within the past 2 years to answer a 12-question survey using an online survey platform. We analyzed quantitative and qualitative data. A Fisher exact test was used to determine whether preoperative approaches to preparation were associated with decreased PGF rates.

Results: A total of 100 US-based corneal surgeons replied from 34 of 50 states. Of these, 68% reported that DMEK comprised a majority of their endothelial keratoplasty cases. Approximately half of surgeons (52%) had performed more than 20 DMEK cases by the time of the survey, and 51% felt equally comfortable performing DMEK relative to Descemet stripping endothelial keratoplasty. Among the respondents, 37% answered that they had experienced PGF in the first 10 cases. Scrubbing in with an experienced colleague before surgery was associated with a decreased likelihood of at least one case of PGF (31%, P = 0.049), but not participation in a wet lab with an experienced instructor or mentor (38%, P = 0.50), nor having an eye bank representative present in the operating room (43%, P = 0.886).

Conclusions: The collective experience of 100 surgeons beginning DMEK confirms the importance of mentorship and that the accompaniment of an experienced colleague during the learning curve is associated with lower rates of PGF.
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http://dx.doi.org/10.1097/ICO.0000000000002203DOI Listing
May 2020

Retrospective comparative analysis of intraocular lens calculation formulas after hyperopic refractive surgery.

PLoS One 2019 7;14(11):e0224981. Epub 2019 Nov 7.

Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, United States of America.

Purpose: To compare the intraocular lens calculation formulas and evaluate postoperative refractive results of patients with previous hyperopic corneal refractive surgery.

Design: Retrospective, comparative, observational study.

Setting: Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA.

Methods: Clinical charts and optical biometric data of 39 eyes from 24 consecutive patients diagnosed with previous hyperopic laser vision correction and cataract surgery were reviewed and analyzed. The Intraocular lens (IOL) power calculation using the Holladay 2 formula (Lenstar) and the American Society of Cataract and Refractive Surgery (ASCRS) Post-Refractive IOL Calculator (version 4.9, 2017) were compared to the actual manifest refractive spherical equivalent (MRSE) following cataract surgery. No pre-Lasik / PRK or post-Lasik / PRK information was used in any of the calculations. The IOL prediction error, the mean IOL prediction error, the median absolute refractive prediction error, and the percentages of eyes within ±0.50 diopter (D) and ±1.00 D of the predicted refraction were calculated.

Results: The Holladay 2 formula produced a mean arithmetic IOL prediction error significantly different from zero (P = 0.003). Surprisingly, the mean arithmetic IOL prediction errors generated by Shammas, Haigis-L and Barret True K No History formulas were not significantly different from zero (P = 0.14, P = 0.49, P = 0.81, respectively).There were no significant differences in the median absolute refractive prediction error or percentage of eyes within ± 0.50 D or ± 1.00 D of the predicted refraction between formulas or methods.

Conclusion: In eyes with previous hyperopic LASIK/PRK and no prior data, there were no significant differences in the accuracy of IOL power calculation between the Holladay 2 formula and the ASCRS Post-refractive IOL calculator.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0224981PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6837514PMC
March 2020

Brillouin Microscopy Visualizes Centralized Corneal Edema in Fuchs Endothelial Dystrophy.

Cornea 2020 Feb;39(2):168-171

Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Purpose: To investigate the feasibility of using Brillouin microscopy for assessment of corneal edema in patients with Fuchs endothelial corneal dystrophy (FECD). Brillouin microscopy analyzes the frequency shift of light inelastically scattered by naturally occurring acoustic waves in a small volume of tissue. The resulting frequency shift is a measure of the local hydromechanical properties of the tissue.

Methods: Participants were scanned using a clinical Brillouin imaging system (780 nm laser, 5 mW), and a color-coded map of the mean Brillouin shift laterally across the corneal stroma was created.

Results: Brillouin maps of normal subjects (n = 8) were relatively homogeneous, whereas maps of patients with FECD (n = 7) exhibited significantly reduced Brillouin shifts (unpaired t test, P < 0.001) centrally. The mean difference of 83 MHz corresponds to approximately 3.9% higher water content (percentage difference in volume fraction) in central corneas of the FECD group relative to normal subjects. The Brillouin scan of a patient with FECD 1 month after Descemet membrane endothelial keratoplasty measured a 62 MHz increase in Brillouin shift relative to the preoperative level, indicating normalization of corneal hydration.

Conclusions: All patients with FECD scanned exhibited a centralized reduction in Brillouin shift, distinct from the normal subjects measured and consistent with centralized edema characterized by pachymetry. Brillouin scans revealed substantially reduced water content after Descemet membrane endothelial keratoplasty. These results suggest that Brillouin microscopy could aid treatment planning and assessment of FECD. Moreover, corneal hydration mapping may be useful in understanding fluid pump function dynamics of the cornea and developing early interventions for FECD.
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http://dx.doi.org/10.1097/ICO.0000000000002191DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6940527PMC
February 2020

Developments in Imaging of Corneal Biomechanics.

Int Ophthalmol Clin 2019 ;59(4):1-17

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http://dx.doi.org/10.1097/IIO.0000000000000286DOI Listing
January 2020

A Review of Machine Learning Techniques for Keratoconus Detection and Refractive Surgery Screening.

Semin Ophthalmol 2019 9;34(4):317-326. Epub 2019 Jun 9.

a Massachusetts Eye and Ear Infirmary , Harvard Medical School , Boston , MA , USA.

Various machine learning techniques have been developed for keratoconus detection and refractive surgery screening. These techniques utilize inputs from a range of corneal imaging devices and are built with automated decision trees, support vector machines, and various types of neural networks. In general, these techniques demonstrate very good differentiation of normal and keratoconic eyes, as well as good differentiation of normal and form fruste keratoconus. However, it is difficult to directly compare these studies, as keratoconus represents a wide spectrum of disease. More importantly, no public dataset exists for research purposes. Despite these challenges, machine learning in keratoconus detection and refractive surgery screening is a burgeoning field of study, with significant potential for continued advancement as imaging devices and techniques become more sophisticated.
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http://dx.doi.org/10.1080/08820538.2019.1620812DOI Listing
July 2019

Spatially-resolved Brillouin spectroscopy reveals biomechanical abnormalities in mild to advanced keratoconus in vivo.

Sci Rep 2019 05 16;9(1):7467. Epub 2019 May 16.

Harvard Medical School and Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, 02114, USA.

Mounting evidence connects the biomechanical properties of tissues to the development of eye diseases such as keratoconus, a disease in which the cornea thins and bulges into a conical shape. However, measuring biomechanical changes in vivo with sufficient sensitivity for disease detection has proven challenging. Here, we demonstrate the diagnostic potential of Brillouin light-scattering microscopy, a modality that measures longitudinal mechanical modulus in tissues with high measurement sensitivity and spatial resolution. We have performed a study of 85 human subjects (93 eyes), consisting of 47 healthy volunteers and 38 keratoconus patients at differing stages of disease, ranging from stage I to stage IV. The Brillouin data in vivo reveal increasing biomechanical inhomogeneity in the cornea with keratoconus progression and biomechanical asymmetry between the left and right eyes at the onset of keratoconus. The receiver operating characteristic analysis of the stage-I patient data indicates that mean Brillouin shift of the cone performs better than corneal thickness and maximum curvature respectively. In conjunction with morphological patterns, Brillouin microscopy may add value for diagnosis of keratoconus and potentially for screening subjects at risk of complications prior to laser eye surgeries.
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http://dx.doi.org/10.1038/s41598-019-43811-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6522517PMC
May 2019

Corneal Tomography Changes and Refractive Outcomes After Descemet Stripping Without Endothelial Keratoplasty.

Cornea 2019 Jul;38(7):817-819

Cornea and Refractive Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA.

Purpose: To investigate corneal tomography changes and refractive outcomes after Descemetorhexis without endothelial keratoplasty (DWEK).

Methods: Retrospective chart review of 25 eyes from 16 patients with Fuchs corneal endothelial dystrophy that underwent successful DWEK combined with cataract surgery.

Results: There was no significant change in anterior corneal curvature on tomography maps. However, all tomography maps demonstrated an increase in central posterior float and all but one demonstrated a decrease in pachymetry after DWEK. Only 7 of 25 eyes had increased irregular astigmatism on tomography after DWEK, of which 57% had preexisting irregular astigmatism before the procedure. The mean difference between the targeted and outcome refraction was +0.65 diopters (D) at the time of corneal clearance, but this improved to +0.38 D 1 month after corneal clearance. Postoperative refraction was within 1 D of target refraction for 92% of cases (23 eyes) but within 0.5 D of target refraction for only 48% of cases (12 eyes). The differences between expected and actual refractive outcomes were correlated with change in posterior corneal curvature and pachymetry.

Conclusions: DWEK induces an increased central posterior float localized to the site of Descemet membrane stripping, confirming the need for centralized stripping. Irregular astigmatism can occur after DWEK but is typically minimal and occurs more commonly in the setting of preoperative irregular astigmatism. DWEK induces about a 0.5 D hyperopic shift, which should be considered when determining intraocular lens power with simultaneous surgery.
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http://dx.doi.org/10.1097/ICO.0000000000001896DOI Listing
July 2019

Predicting Refractive Outcome of Small Incision Lenticule Extraction for Myopia Using Corneal Properties.

Transl Vis Sci Technol 2018 Sep 26;7(5):11. Epub 2018 Sep 26.

Tianjin Medical University, Tianjin, China.

Purpose: To investigate whether preoperative corneal topographic and biomechanical parameters (CTBPs) predict postoperative residual refractive error (RRE).

Methods: We retrospectively included 151 eyes from 151 patients of small-incision lenticule extraction (SMILE) with target RRE of plano and 3-month measurements of refractive error from Tianjin Eye Hospital. Multivariate linear/logistic regressions were performed to associate age, gender, preoperative refractive error, lenticule thickness, and CTBPs with postoperative RRE/the occurrence of myopic RRE ≤ -0.25 diopter (D). Stepwise regression was used for feature selection. Leave-one-cross-validation was used for model evaluation by the area under the receiver operating characteristic curve (AUC).

Results: From linear regression, more myopic RRE was associated with higher preoperative myopia, intraocular pressure (IOP), flattest curvature of anterior cornea (AC), and highest concavity deformation (HCD), and was associated with lower anterior elevation, anterior asphericity, steepest curvature of AC, and second applanation velocity. The occurrence of ≤ -0.25 D RRE was associated with higher myopia, IOP, posterior elevation and asphericity, flattest curvature of AC, first applanation velocity and HCD, and was associated with lower first applanation stiffness parameter, central corneal thickness, anterior elevation and asphericity, steepest curvature of AC, and second applanation velocity as well as thinner lenticule thickness. Compared to the baseline model using age, gender, and preoperative refractive error, adding CTBPs significantly ( < 0.001) improved the AUC performance to 0.771 from 0.615.

Conclusions: Postoperative outcomes of SMILE can be predicted by individual CTBPs.

Translational Relevance: Our findings could be used to customize a refractive nomogram based on individual corneal properties improving outcomes and patient satisfaction.
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http://dx.doi.org/10.1167/tvst.7.5.11DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6159733PMC
September 2018

Descemetorhexis Without Endothelial Keratoplasty (DWEK): Proposal for Nomenclature Standardization.

Cornea 2018 04;37(4):e20-e21

Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA.

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http://dx.doi.org/10.1097/ICO.0000000000001528DOI Listing
April 2018

Phacoemulsification with intraocular lens implantation after previous descemetorhexis without endothelial keratoplasty.

J Cataract Refract Surg 2017 11;43(11):1471-1475

From Boston University School of Medicine (Kaufman), the Department of Ophthalmology (Nosé, Pineda), Massachusetts Eye and Ear Infirmary, Harvard Medical School, and Harvard Medical School (Lu), Boston, Massachusetts, USA. Electronic address:

A 58-year-old woman with bilateral Fuchs endothelial corneal dystrophy presented with predominantly central guttata in the left eye causing visually significant stromal edema. A 4.0 mm descemetorhexis without endothelial keratoplasty was performed. At the 6-week follow-up, the central cornea had cleared completely and the central endothelial cell density (ECD) was 541 cells/mm. The central corneal clearing remained stable for 2 years after the procedure; however, vision declined because of a visually significant cataract in the left eye. Uneventful phacoemulsification with intraocular lens implantation was performed with a target refraction of -0.50 diopters. At 1.5 months postoperatively, the uncorrected distance visual acuity was 20/20 with a manifest refraction of -0.25 -0.25 × 60 and the central ECD was 2373 cells/mm (increased from 1471 cells/mm prior to phacoemulsification). Cataract surgery by phacoemulsification years after descemetorhexis without endothelial keratoplasty appears to be well-tolerated, with good clinical and predictive refractive outcomes.
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http://dx.doi.org/10.1016/j.jcrs.2017.10.028DOI Listing
November 2017

Cataract surgery outcomes and complications in retinal dystrophy patients.

Can J Ophthalmol 2017 Dec 22;52(6):543-547. Epub 2017 Jul 22.

Cornea and Refractive Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA.

Objective: To investigate intraoperative complications, postoperative findings, and visual acuity outcomes in patients with retinal dystrophy after cataract surgery.

Design: Retrospective chart review at an academic tertiary referral centre.

Participants: Thirty eyes from 18 patients with retinitis pigmentosa and other retinal dystrophies (Usher syndrome, Refsum disease, and Leber congenital amaurosis) who underwent cataract surgery were identified by searching the electronic medical record system from January 2010 to September 2015 for all patients treated by a single physician with billing codes for retinal dystrophy and cataract surgery.

Methods: Cases were reviewed to determine indication for surgery, intraoperative complications, postoperative findings, preoperative visual acuity, 1-month postoperative visual acuity, and patient subjective satisfaction.

Results: Mean best-corrected visual acuity significantly improved after cataract surgery, from 1.09 ± 0.69 preoperatively to 0.614 ± 0.448 at 1 month postoperatively, on logMAR scale (p = 0, Wilcoxon test). The most common postoperative finding was posterior capsule opacification in 20 eyes (66.7%). Visually significant cystoid macular edema occurred in 4 eyes (13.3%) despite the postoperative eye drop regimen. Patient satisfaction at 1 month postoperatively was noted as 93.3% (28 eyes) and attributed mostly to improved central vision and reduced glare symptoms.

Conclusions: Patients with visually significant cataract in association with retinal dystrophy have significantly improved best-corrected visual acuity after cataract surgery and report subjectively improved visual functioning. This study confirms that several risks factors are greater in patients with retinal dystrophy, including zonular weakness, posterior capsular opacification, and cystoid macular edema, compared with the general cataract population.
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http://dx.doi.org/10.1016/j.jcjo.2017.04.002DOI Listing
December 2017

Chemical Burns of the Eye: The Role of Retinal Injury and New Therapeutic Possibilities.

Cornea 2018 Feb;37(2):248-251

Cornea Service and Boston Keratoprosthesis Laboratory, Massachusetts Eye and Ear Infirmary and Schepens Eye Research Institute, Harvard Medical School, Boston, MA.

Purpose: To propose a new treatment paradigm for chemical burns to the eye - in the acute and chronic phases.

Methods: Recent laboratory and clinical data on the biology and treatment of chemical burns are analyzed.

Results: Corneal blindness from chemical burns can now be successfully treated with a keratoprosthesis, on immediate and intermediate bases. Long term outcomes, however, are hampered by early retinal damage causing glaucoma. New data suggest that rapid diffusion of inflammatory cytokines posteriorly (TNF-α, etc) can severely damage the ganglion cells. Prompt anti-TNF-α treatment is markedly neuroprotective. Long term profound reduction of the intraocular pressure is also vital.

Conclusion: A new regimen, in addition to standard treatment, for severe chemical burns is proposed. This involves tumor necrosis factor alpha (TNF-α) inhibition promptly after the accident (primarily for retinal neuroprotection), prophylactic maximal lowering of the intraocular pressure (starting immediately), and keratoprosthesis implantation in a later quiet state.
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http://dx.doi.org/10.1097/ICO.0000000000001438DOI Listing
February 2018

Cataract surgery after proton-beam irradiation for uveal tumors.

J Cataract Refract Surg 2017 10;43(10):1328-1334

From the Massachusetts Eye & Ear Infirmary, Boston, Massachusetts, USA. Electronic address:

Purpose: To study the risks associated with cataract surgery in patients with previous proton-beam irradiation (PBI), focusing on preoperative risk factors, intraoperative findings, and postoperative complications.

Setting: Massachusetts Eye & Ear Infirmary, Boston, Massachusetts, USA.

Design: Retrospective case series.

Methods: Electronic medical records of patients who had PBI and cataract surgery between January 1, 2006, and October 1, 2016, were reviewed.

Results: The study comprised 29 eyes of 29 patients. Preoperative evaluation found dry eye (72.4%), posterior synechiae (24.1%), peripheral anterior synechiae (13.8%), anterior capsule fibrosis (10.3%), and iris atrophy (10.3%). Intraoperative findings included poor red reflex requiring trypan blue capsule staining (37.9%), synechiae requiring synechialysis (24.1%), evidence of previous inflammation prompting sub-Tenon triamcinolone injection (17.2%), and miosis (10.3%). Postoperative complications included posterior capsule opacification (PCO) by 1 year (48.3%), intraocular pressure spike of 23 mm Hg or greater at 1 day (24.1%), anterior chamber inflammation at 1 month (24.1%), and cystoid macular edema (CME) (17.2%). Proximity of the initial tumor to the posterior pole was associated with poor visual outcomes after cataract surgery. Compared with reference data, this cohort had higher rates of anterior chamber inflammation at 1 month, CME, fibrinous inflammation, PCO by 1 year, intraoperative requirement for trypan blue, and synechialysis.

Conclusions: Complications after cataract surgery performed after PBI were similar to those seen in patients with uveitis (prolonged inflammation, CME, fibrinous inflammation, early PCO). Steroid depot administration might be useful to prevent these complications, although further research is needed to determine an optimum regimen.
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http://dx.doi.org/10.1016/j.jcrs.2017.06.048DOI Listing
October 2017

Predictive Factors for Corneal Clearance After Descemetorhexis Without Endothelial Keratoplasty.

Cornea 2018 Feb;37(2):137-140

Cornea and Refractive Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA.

Purpose: To study preoperative factors that possibly contribute to corneal clearance after Descemetorhexis without endothelial keratoplasty (DWEK) and to determine the most successful surgical technique for the procedure.

Methods: Retrospective chart review of 17 eyes of 13 patients with Fuchs corneal endothelial dystrophy that underwent central 4-mm DWEK.

Results: Baseline age, pachymetry, and endothelial cell count were not statistically significantly different between eyes that cleared 0 to 2 months, 3 to 5 months, 6 to 8 months, or that failed to clear. All eyes that failed to clear had DWEK performed using scoring followed by the stripping technique. Postoperative endothelial cell counts steadily increased over time after the procedure, even in eyes that failed to clear.

Conclusions: DWEK when performed with a Descemetorhexis technique results in corneal clearance in the majority of cases regardless of baseline demographics, with clearance typically 3 months after the procedure. Further studies are needed to investigate environmental factors, such as possible growth factors in the anterior chamber, that may influence clearing in these cases.
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http://dx.doi.org/10.1097/ICO.0000000000001427DOI Listing
February 2018

Consultation Section: Cataract. August consultation #5.

Authors:
Roberto Pineda

J Cataract Refract Surg 2017 08;43(8):1122

Boston, Massachusetts, USA.

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http://dx.doi.org/10.1016/j.jcrs.2017.07.014DOI Listing
August 2017

Complications of Scleral-Fixated Intraocular Lenses.

Semin Ophthalmol 2018 12;33(1):23-28. Epub 2017 Sep 12.

a Department of Ophthalmology, Cornea and Refractive Surgery Service, Massachusetts Eye and Ear , Harvard Medical School , Boston , MA , USA.

Introduction: Understanding the evolution of complications after scleral-fixated lens placement demonstrates advantageous surgical techniques and suitable candidates.

Materials/methods: A literature search in PubMed for several terms, including "scleral intraocular lens complication," yielded 17 relevant articles.

Results: Reviewing complication trends over time, lens tilt and suture erosion have decreased, cystoid macular edema has increased, and retinal detachment has remained the same after scleral-fixated lens placement. The successful reduction in complications are attributed to several alterations in technique, including positioning sclerotomy sites 180 degrees apart and using scleral flaps or pockets to bury sutures. Possible reduction in retinal risks have been proposed by performing an anterior vitrectomy prior to lens placement in certain settings.

Discussion: Complications after scleral-fixated lens placement should assist patient selection. Elderly patients with a history of hypertension should be counseled regarding risk of suprachoroidal hemorrhage, while young patients and postocular trauma patients should be considered for concurrent anterior vitrectomy.
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http://dx.doi.org/10.1080/08820538.2017.1353808DOI Listing
February 2018

Anterior segment optical coherence tomography to look for Kayser-Fleischer rings.

Pract Neurol 2017 Jun 7;17(3):222-223. Epub 2017 Mar 7.

Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.

Ophthalmologists usually use slit lamp biomicroscopy to look for Kayser-Fleischer rings in Wilson's disease; anterior segment optical coherence tomography is a new alternative to identify the characteristic hyper-reflective layer in the deep corneal periphery at the level of Descemet's membrane. This method allows non-ophthalmologists to look for and to quantify Kayser-Fleischer rings.
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http://dx.doi.org/10.1136/practneurol-2017-001605DOI Listing
June 2017

Phakic Intraocular Lenses and their Special Indications.

J Ophthalmic Vis Res 2016 Oct-Dec;11(4):422-428

Keratorefractive Surgery Service, Massachusetts Eye and Ear Infirmary, Boston MA, USA.

Phakic intraocular lenses revolutionize refractive surgery and continue to serve as an excellent option for vision correction in patients who are not ideal candidates for laser vision correction. This article will review special indications of phakic intraocular lenses in the clinical practice.
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http://dx.doi.org/10.4103/2008-322X.194140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5139554PMC
December 2016

The Quest for Spectacle Independence: A Comparison of Multifocal Intraocular Lens Implants and Pseudophakic Monovision for Patients with Presbyopia.

Semin Ophthalmol 2017 28;32(1):111-115. Epub 2016 Oct 28.

a Massachusetts Eye and Ear Infirmary , Boston , MA , USA.

We performed a literature review comparing multifocal intraocular lens (IOL) implantation with pseudophakic monovision to treat presbyopia. Multifocal IOLs utilize refractive or diffractive principles to treat both distance and near vision, with a single lens implant. Monovision uses traditional monofocal lens implants to treat the dominant eye for emmotropia, and the non-dominant eye for myopia. This planned anisometropia is designed to enhance intermediate or near vision. Generally, distance vision was similar with both types of lens implantation, near vision was better with multifocal IOLs, and intermediate vision appeared to be better in the monovision group. For patients requiring cataract surgery, both multifocal IOLs and monovision appear to address presbyopia with a high level of patient satisfaction. More patients reported complete spectacle independence with multifocal IOLs, but more glare and halos were reported by multifocal IOL patients as well.
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http://dx.doi.org/10.1080/08820538.2016.1228400DOI Listing
February 2017

Cataract in the Adult Eye Preferred Practice Pattern®.

Ophthalmology 2017 02 13;124(2):P1-P119. Epub 2016 Oct 13.

Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan.

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http://dx.doi.org/10.1016/j.ophtha.2016.09.027DOI Listing
February 2017

In Vivo Brillouin Analysis of the Aging Crystalline Lens.

Invest Ophthalmol Vis Sci 2016 Oct;57(13):5093-5100

Wellman Center for Photomedicine, Massachusetts General Hospital, Cambridge, Massachusetts, United States 2Department of Dermatology, Harvard Medical School, Boston, Massachusetts, United States 5Harvard-MIT Health Sciences and Technology, Cambridge, Massachusetts, United States.

Purpose: To analyze the age dependence of the longitudinal modulus of the crystalline lens in vivo using Brillouin scattering data in healthy subjects.

Methods: Brillouin scans were performed along the crystalline lens in 56 eyes from 30 healthy subjects aged from 19 to 63 years. Longitudinal elastic modulus was acquired along the sagittal axis of the lens with a transverse and axial resolution of 4 and 60 μm, respectively. The relative lens stiffness was computed, and correlations with age were analyzed.

Results: Brillouin axial profiles revealed nonuniform longitudinal modulus within the lens, increasing from a softer periphery toward a stiffer central plateau at all ages. The longitudinal modulus at the central plateau showed no age dependence in a range of 19 to 45 years and a slight decrease with age from 45 to 63 years. A significant intersubject variability was observed in an age-matched analysis. Importantly, the extent of the central stiff plateau region increased steadily over age from 19 to 63 years. The slope of change in Brillouin modulus in the peripheral regions were nearly age-invariant.

Conclusions: The adult human lens showed no measurable age-related increase in the peak longitudinal modulus. The expansion of the stiff central region of the lens is likely to be the major contributing factor to age-related lens stiffening. Brillouin microscopy may be useful in characterizing the crystalline lens for the optimization of surgical or pharmacological treatments aimed at restoring accommodative power.
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http://dx.doi.org/10.1167/iovs.16-20143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5054731PMC
October 2016

Intraocular lens exchange surgery at a tertiary referral center: Indications, complications, and visual outcomes.

J Cataract Refract Surg 2016 09;42(9):1262-1267

From the Cornea and Refractive Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Purpose: To identify indications for and visual outcomes of intraocular lens (IOL) exchange to understand recent changes in this surgery.

Setting: Academic tertiary referral center.

Design: Retrospective case series.

Methods: Cases were identified by searching the institution's electronic medical records from January 2010 to September 2015 for patients treated by 1 staff physician with the American Medical Association's Current Procedural Terminology code for IOL exchange. These cases were reviewed to determine the surgical indication, type of IOL removed, type of IOL implanted, time between surgeries, surgical complications, and visual outcomes.

Results: The study comprised medical records of 109 eyes. The mean time between the primary cataract surgery and IOL exchange was 1657 days. Dislocation of an in-the-bag posterior chamber IOL (27.5%), intolerance of a multifocal IOL (18.3%), and uveitis-glaucoma-hyphema syndrome (11.9%) were the most frequent indications for IOL exchange. The final IOL position after exchange was most frequently in the capsular bag (43.1%), anterior chamber (25.7%), or sulcus (22%). The final visual acuity at 1 month was 20/40 or better in 78.9% of cases. Of those not achieving this level of acuity, pathology not related to exchange surgery was identified in 48% of cases. The most frequent complications after IOL exchange surgery were posterior capsule opacification (13.8%), cystoid macular edema (10.1%), and high astigmatism (>1.5 diopters) (8.3%).

Conclusions: The most frequent indication for IOL exchange surgery was dislocated IOLs; the second most frequent indication was patient dissatisfaction after multifocal IOL implantation. The increased ability to place an intracapsular IOL with few intraoperative complications and largely treatable postoperative complications enhances the effectiveness of IOL exchange surgery and patient satisfaction.

Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned.
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http://dx.doi.org/10.1016/j.jcrs.2016.06.031DOI Listing
September 2016

Intravitreal Ozurdex Implantation after Boston Type I Keratoprosthesis.

Ocul Immunol Inflamm 2018 6;26(3):449-451. Epub 2016 Sep 6.

d Keratorefractive Surgery Service, Massachusetts Eye and Ear Infirmary , Boston , Massachusetts , USA.

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http://dx.doi.org/10.1080/09273948.2016.1213858DOI Listing
June 2019

Persistent Blurry Vision After a Routine Eye Examination.

JAMA Ophthalmol 2016 09;134(9):1065-6

Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston.

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http://dx.doi.org/10.1001/jamaophthalmol.2016.0812DOI Listing
September 2016