Faculty Bibliography

PURPOSE/OBJECTIVE:This study evaluates the correlation between corneal densitometry and epithelial ingrowth (EI) after laser in situ keratomileusis (LASIK). METHODS:Corneal densitometry of 3 patients who developed EI after LASIK was measured with the Oculus Pentacam. Corneal densitometry readings of each patient were obtained preoperatively and postoperatively after ingrowth was discovered. Densitometry was recorded at the central nest of opacity and at the leading edges of EI. RESULTS:For all patients, the most severe stages of EI observed on slit-lamp photographs correlated with the highest densitometry readings, with peak densitometry ranging from 73.3 to 95.1. These values were much higher than preoperative densitometry readings, which ranged from 21.8 to 27.2. In 2 cases, the Pentacam densitometry map revealed progression of EI toward the visual axis that was only faintly detectable or not detectable at all on the corresponding slit-lamp photographs. CONCLUSIONS:Corneal densitometry seems to be an objective measure of the severity and progression of EI after LASIK.

PURPOSE/OBJECTIVE:The aim was to report the aqueous humor moxifloxacin concentration and proteome profile of an individual with bilateral uveitis-like syndrome with pigment dispersion. METHODS:Multiple reactions monitoring mass spectrometry quantified the aqueous concentration of moxifloxacin in the affected individual. Shotgun proteomic analysis performed via liquid chromatography tandem mass spectrometry (LC-MS/MS) defined the protein profile in the affected individual and unaffected control samples. RESULTS:Moxifloxacin was present at higher than expected levels in aqueous humor 18 days following oral administration. One-third of the proteins were identified by significantly lower spectral counts in the aqueous of the individual with moxifloxacin associated uveitis compared to the unaffected control. CONCLUSION/CONCLUSIONS:Moxifloxacin was detected in aqueous humor 18 days following the completion of oral administration. These results suggest that moxifloxacin toxicity may be responsible for the uveitis-like syndrome with pigment dispersion syndrome induced by moxifloxacin therapy.

PURPOSE/OBJECTIVE:To identify risks factors for retreatment post-laser in situ keratomeliusis (LASIK). MATERIALS & METHODS/METHODS:A retrospective chart review from December 2008 to September 2012 identified 1,402 patients (2,581 eyes) that underwent LASIK treatment for myopia with the Intralaseâ„¢ FS, STAR S4 IRâ„¢ Excimer Laser, and WaveScan WaveFrontâ„¢ technology. In this group, 83 patients were retreated. All charts were reviewed for preoperative age, gender, initial manifest refraction spherical equivalent (MRSE), total astigmatism, and iris registration. RESULTS:Increased incidence rates of retreatment post-LASIK were preoperative age >40 years (p < 0.001), initial MRSE > -3.0 D (p = 0.02), and astigmatism >1D (p = 0.001). Iris registration capture did not significantly reduce the retreatment rate (p = 0.12). CONCLUSIONS:Risk factors for retreatment included preoperative age >40 years, initial MRSE > -3.0 D, and astigmatism >1D. There was no difference in retreatment rate for patients based on gender or iris registration capture.

PURPOSE/OBJECTIVE:To establish the efficacy of topical N-acetylcysteine (NAC) as a treatment to reduce protein deposition on the contact lens surface. METHODS:In this prospective, nonrandomized clinical trial, a total of 10 eyes (9 patients) were enrolled from a single center. All patients had a prior ocular history of either a Boston Keratoprosthesis type I or trichiasis from Stevens-Johnson syndrome, which necessitated full-time contact lens wear. Four visits were required to complete the study. During visit 1, a new contact lens was inserted and a baseline examination was performed. Visit 2 served as the control month, whereas visits 3 and 4 were month 1 and 2 on treatment with 20% NAC. At the end of each visit the contact lens was replaced. The lenses from visit 2 (control month-without NAC) and from visit 3 (treatment month-with NAC) were collected for proteomic analysis. The main outcome measures were to quantify protein deposition, as well as to assess the visual acuity and ocular surface symptoms before and after treatment. RESULTS:Topical NAC resulted in a 20% decrease in protein deposition. This correlated with a trend for improvement in visual acuity and increased subjective improvement in vision at month 1 (P=0.0153) and 2 (P=0.0016). CONCLUSIONS:NAC reduced protein deposition, decreased ocular surface symptoms, and improved contact lens transparency, thereby providing increased optical clarity.

OBJECTIVE:To establish the safety and efficacy of infliximab for the treatment of refractory noninfectious uveitis. DESIGN/METHODS:Retrospective, interventional, noncomparative cohort study. PARTICIPANTS/METHODS:Eighty-eight patients from a single-center private practice. METHODS:Patients with chronic, recalcitrant uveitis treated with infliximab (Remicade; Janssen Biotech, Inc., Titusville, NJ) were identified through an electronic medical record database. All charts were reviewed for sex, diagnosis, location of inflammation, presence of vasculitis, prior immunomodulatory treatments, duration of infliximab treatment, dose received, secondary side effects, and other medications continued while receiving treatment with infliximab. MAIN OUTCOME MEASURES/METHODS:The primary outcome measures were the rate of remission, time to remission, relapse rate, failure rate, and patient tolerance. Additional analysis aimed to identity risk factors that would predict a higher success rate of infliximab to treat various types of noninfectious uveitis. RESULTS:Of the 72 patients (81.8%) who achieved clinical remission while being treated with infliximab, 42 (58.3%) required additional immunomodulatory medications. At 7, 18.1, and 44.7 weeks, 25%, 50%, and 75% of patients, respectively, achieved clinical remission off all corticosteroids. Thirty-two patients (36.4%) experienced at least 1 side effect while on infliximab therapy, and 17 patients (19.3%) discontinued treatment secondary to 1 or more intolerable side effects. The most common adverse effects were skin rash (9.1%) and fatigue (8%). Factors associated with a higher chance to achieve clinical remission were nonidiopathic uveitis (P < 0.001), intermediate or panuveitis (P < 0.001), absence of vasculitis (P < 0.001), and a starting dose ≥5 mg/kg (P < 0.011). CONCLUSIONS:Infliximab induces a high rate of complete clinical remission in recalcitrant uveitis and is well tolerated by most patients.

PURPOSE/OBJECTIVE:To analyze the success rate of pulsed intravenous (IV) cyclophosphamide (CyP) for noninfectious ocular inflammatory disease and to identify risk factors for failure of therapy. DESIGN/METHODS:Retrospective, interventional, noncomparative cohort study. PARTICIPANTS/METHODS:One hundred ten eyes of 65 patients. METHODS:Through a computer search of the Massachusetts Eye Research and Surgery Institution's database, we identified patients who were treated with IV CyP between May 2005 and April 2012. We obtained demographic and clinical information through review of the electronic health record of each patient. MAIN OUTCOMES MEASURES/METHODS:Clinical response, corticosteroid-sparing effect, recurrence rate, calculated "risk factors" for failure, visual acuity, and adverse reactions. RESULTS:Pulsed IV CyP achieved complete remission of inflammation (for ≥ 2 visits) in 54 patients (84.4%). Sustained remission of inflammation occurred in 70% of patients within 3 months, 86.6% of patients within 6 months, and 91.7% within 9 months. The mean time to achieving quiescence was 3.5 months. The success rate in reducing corticosteroid to prednisone ≤ 10 mg/d within 6 months, while maintaining control of ocular inflammation, was 89.7% (95% confidence interval [CI], 81.1-93.5%). The mean duration of clinical remission for those patients who had a positive response to CyP was 32.67 months (95% CI, 25.91-39.43). Relapse of vasculitis was observed in 1 patient (1.5%) after completing the course of therapy. Early initiation of therapy during the course of the disease was correlated with a lesser rate of recurrence (P = 0.028). The most common adverse effects were nausea (29%) and transient lymphopenia (26%). The mean best-corrected visual acuity (BCVA) improved from 0.59 ± 0.66 at baseline to 0.30 ± 0.54 at 6 months of follow-up (P<0.001). The mean follow-up period was 31.61 ± 20.47 months. CONCLUSIONS:Pulsed IV CyP employing our protocol results in an extremely high rate of sustained complete remission in patients with recalcitrant and fulminant, vision-threatening ocular inflammatory disorders, with an excellent safety profile in the hands of physicians trained and skilled in the art of this therapy. It also allows tapering and discontinuing corticosteroids in most patients. Early initiation of therapy may decrease the risk of relapses. FINANCIAL DISCLOSURE(S)/BACKGROUND:The authors have no proprietary or commercial interest in any materials discussed in this article.

PURPOSE OF REVIEW/OBJECTIVE:Exfoliation syndrome is the most common identifiable cause of glaucoma in the world. It has been associated with many ocular problems, such as secondary open angle glaucoma, corneal dysfunction, cataract, and zonular weakness, and may have systemic manifestations as well. This review focuses on recent genetic and pathophysiologic discoveries in the disease process. RECENT FINDINGS/RESULTS:Exfoliation syndrome is a progressive age-related condition of the extracellular matrix (ECM), which has various ocular implications, most notably open angle glaucoma, zonular abnormalities, and cataract formation. The pathophysiology behind exfoliation syndrome appears to involve both genetic and environmental components. The underlying genetic mechanisms are thought to be due to disruption of regulatory genes (lysyl oxidase-like and clusterin) that are involved in both the production and the breakdown of ECM material. Disease manifestations involve the accumulation and deposition of ECM fibrils throughout the eye thought to be engendered by an increased oxidative stress state. SUMMARY/CONCLUSIONS:A greater understanding of the genetic and pathophysiologic mechanisms underlying the disease may lead to the development of new approaches in its treatment and management.

PURPOSE OF REVIEW/OBJECTIVE:Antiphospholipid syndrome is a rare cause of ocular vaso-occlusive disease, but is associated with significant systemic morbidity and mortality. Thus, early diagnosis and treatment is essential. RECENT FINDINGS/RESULTS:Although the pathophysiology of antiphospholipid syndrome continues to be poorly understood, there has been continued progress with regard to the relationship between antiphospholipid antibody and its target, β-2-glycoprotein I. Due to numerous limitations with standard serologic evaluation, new approaches to the evaluation of patient serum are being considered. New guidelines for the treatment and management of antiphospholipid antibody syndrome have been established by the 13th International Committee on Antiphospholipid Antibodies. SUMMARY/CONCLUSIONS:A better understanding of the pathophysiology behind antiphospholipid antibody syndrome has led to novel approaches in the diagnosis and treatment of this disease.

PURPOSE/OBJECTIVE:To compare the visual outcomes and prevalence of long-term complications in patients with quiescent uveitis after phacoemulsification with traditional in-the-bag intraocular lens (IOL) implantation versus primary or secondary anterior chamber (AC) IOL implantation due to inadequate capsule support. SETTING/METHODS:Single-center private practice. DESIGN/METHODS:Retrospective observational cohort study. METHODS:Patients with quiescent uveitis who had cataract surgery with subsequent AC IOL implantation were identified through an electronic medical record database. They were age matched with patients with uveitis who had conventional placement of a posterior chamber (PC) IOL. The rate of postoperative complications and corrected distance visual acuity (CDVA) were reviewed preoperatively and 1, 3, and 6 months and 1, 2, 3, and 4 years postoperatively. RESULTS:The incidence of postoperative complications was not statistically different for any criterion except posterior capsule opacification development in the PC IOL cohort (relative risk, 0.071). The mean follow-up was 36.11 months ± 17.3 (SD) in the AC IOL group and 53.72 ± 20.4 months in the PC IOL group. The mean preoperative CDVA was 1.49 ± 1.07 logMAR in the AC IOL group and 0.5 ± 0.26 logMAR in the PC IOL group. Both groups had a significant improvement in CDVA visual acuity 3 years postoperatively (P=.001 and P=.010 respectively). CONCLUSIONS:In uveitic eyes with inadequate capsule support, AC IOL implantation was safe and effective in providing satisfactory improved CDVA without a significant increase in long-term complications compared with eyes that had PC IOL placement.

PURPOSE: To report the use of photorefractive keratectomy (PRK) with mitomycin-C (MMC) to treat concomitant myopia and visually significant infiltrates associated with epidemic keratoconjunctivitis (EKC). SETTING: Ophthalmic Consultants of Long Island, Nassau University, Long Island, New York, USA. DESIGN: Interventional case series. METHODS: Consecutive patients with myopia and recalcitrant subepithelial infiltrates after EKC were treated with custom wavefront PRK (Visx S4 IR) and MMC with a target of emmetropia in all cases. RESULTS: The study evaluated 6 eyes of 3 patients. One year after treatment, all eyes attained an uncorrected distance visual acuity of 20/20 or better. There was no recurrence of infiltrates within the ablation zone in any eye. CONCLUSION: The use of topical MMC in conjunction with PRK to treat subepithelial infiltrates due to EKC provided good visual and refractive results.