Purpose: To evaluate a novel software program (SpikeFinder) that improves quality of measurements obtained by optical low coherence reflectometry (OLCR) biometry (Lenstar) Setting: Tertiary care academic center Design: Retrospective case series Method ology: After applying inclusion criteria, 12,988 eyes scanned with OLCR biometry and swept-source OCT (SS-OCT) biometry (IOLMaster700) were analyzed. Measurements, including axial length (AL), anterior chamber depth (ACD), and lens thickness (LT), were compared. SpikeFinder was applied to eyes with the most prominent ACD and LT measurement differences. Statistical testing was performed using Wilcoxon (two variables) and Kruskal-Wallis ANOVA tests (multiple variables) with Tukey post-hoc adjustments. Heteroscedastic testing (WHWK Statistics Package) was used to assess differences after software application. Results: 99.1% of AL measurements were within 0.01 mm between the two biometers. SS-OCT LT was significantly longer than the OLCR LT: 33% differed by ≥ 0.50 mm (p<0.001). Correspondingly, SS-OCT ACD was significantly shorter than OLCR ACD: 14% differed by ≥ 0.50 mm (p<0.001). SS-OCT biometer – OLCR biometer values for ACD and LT before applying SpikeFinder were -0.64 ± 0.31 mm and 1.15 ± 0.38 mm, respectively (p<0.001). After applying SpikeFinder to a subgroup of 337 eyes, these differences were -0.02 ± 0.03 mm and 0.01 ± 0.11 mm, respectively. SpikeFinder ACD and LT values were similar to SS-OCT biometer-measured ACD (p=0.872) and LT (p=0.987) values. Conclusion: The SpikeFinder program can help improve the accuracy of ACD and LT measurements obtained by the OLCR biometer, which may enhance the performance of formulas that utilize these measurements.

Purpose:To determine roles of patient history, donor tissue characteristics, tissue preparation methods, and surgeon technique for graft detachment requiring rebubbling after Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK) procedures. Methods:Retrospective analysis of all eyes undergoing first-time DSAEK or DMEK at the study institution between 2013 and 2022. Data were collected regarding recipients' history, donors' medical history, tissue preparation methods, intraoperative details, and postoperative clinical outcomes. Multivariate statistical analysis was conducted to identify risk factors for graft detachment necessitating rebubbling. Results:Of 1240 eyes meeting inclusion criteria, 746 (60.2%) underwent DSAEK, and 494 (39.8%) underwent DMEK. DSAEK procedures had 12.5% rebubbling rate, whereas DMEK procedures had 18.4% rebubbling rate (P = 0.005). Sub50-DSAEK (<50 mu m) grafts had 16.0% rebubble rate, whereas sub100-DSAEK (51-99 mu m) and >100 mu m DSAEKs had rebubble rate of 9.9% and 9.5%, respectively (P = 0.006). Significant risk factors for DSAEK graft detachment included history of retinal surgery (OR = 2.59), preloaded tissue (OR = 2.70), forceps insertion (OR = 2.33), use of sub50-DSAEK lenticules versus sub100-DSAEK (OR = 2.44) and >100 mu m DSAEK (OR = 2.38) lenticules, and donor history of noninsulin-dependent diabetes mellitus (OR = 4.18). DMEK risk factors included recipient history of cancer (OR = 2.51) and use of higher SF6 gas concentration (OR = 1.09). Although rebubbled DMEK eyes had comparable refractive outcomes to nonrebubbled eyes (P >0.05), rebubbled DSAEK eyes had worse refractive outcomes at all time points (P < 0.05). Conclusions:Graft detachments in DSAEK and DMEK are influenced by various factors, including donor tissue characteristics, tissue preparation, and surgical technique. Identifying and understanding these factors can potentially improve postoperative outcomes.

Keratoconus (KC) is a corneal thinning dystrophy that leads to visual impairment. While the cause of KC remains poorly understood, changes in sex hormone levels have been correlated with KC development. This study investigated circulating gonadotropin-releasing hormone (GnRH) in control and KC subjects to determine if this master hormone regulator is linked to the KC pathology. Plasma and saliva were collected from KC subjects (n = 227 and n = 274, respectively) and non-KC controls (n = 58 and n = 101, respectively), in concert with patient demographics and clinical features. GnRH levels in both plasma and saliva were significantly lower in KC subjects compared to controls. This finding was retained in plasma when subjects were stratified based on age, sex, and KC severity. Control and KC corneal fibroblasts (HKCs) stimulated with recombinant GnRH protein in vitro revealed significantly increased luteinizing hormone receptor by HKCs and reduced expression of α-smooth muscle actin with treatment suggesting that GnRH may modulate hormonal and fibrotic responses in the KC corneal stroma. Further studies are needed to reveal the role of the hypothalamic–pituitary–gonadal axis in the onset and progression of KC and to explore this pathway as a novel therapeutic target.

Purpose: To evaluate the effectiveness and safety of ab-interno canaloplasty (ABiC) for managing intraocular pressure (IOP) in patients following keratoplasty over a three-year period. Methods: This retrospective analysis focused on post-keratoplasty patients treated with ABiC with the iTrack microcatheter (Nova Eye Medical, Fremont, CA, USA) at a single institution. The study assessed the procedure's impact on IOP control, graft survival, and reliance on topical hypotensive medications, with additional observation for any postoperative complications. Surgical success criteria included the percentage of eyes with IOP <= 15 mmHg, IOP <= 18 mmHg, >= 20% IOP reduction, medication-free eyes, and eyes with concurrent IOP and medication reductions. Results: ABiC was performed successfully in a cohort of 16 post-keratoplasty (7 penetrating keratoplasty and 9 endothelial keratoplasty (EK)) eyes. Preoperative mean IOP of 25.8 +/- 7.2 mmHg was significantly reduced to 13.4 +/- 2.9 mmHg (p<0.001) at 1 year postoperatively and maintained at 13.1 +/- 3.9 mmHg (p=0.009) at 3 years postoperatively. The mean number of glaucoma medications was 3.5 +/- 1.7 at baseline, 2.8 +/- 1.3 at 1 year (p=0.107), and 2.5 +/- 1.2 at 3 years postoperatively (p=0.088). Eight eyes (66.7%) maintained IOP <= 15 mmHg, and 10 eyes (83.3%) maintained >= 20% IOP reduction at 3 years. The mean IOP and medication reductions from baseline at 3 years were -49.2% and -28.6%, respectively. Graft clarity was preserved in all patients except for one case of late graft failure that necessitated a repeat EK procedure. Post-ABiC complications included transient hyphema in two patients, neither of which led to long-term adverse outcomes. Conclusion: ABiC appears to be an effective and safe surgical intervention for sustained IOP reduction in post-keratoplasty patients. Graft survival trends are encouraging, and there was a low incidence of complications over a three-year follow-up period.

PURPOSE:To evaluate the effectiveness and stability of refractive astigmatism reduction after penetrating femtosecond laser-assisted arcuate keratotomy performed at the time of femtosecond laser-assisted cataract surgery. METHODS:Non-randomized retrospective data analysis of all patients that underwent femtosecond laser-assisted cataract surgery with femtosecond laser-assisted arcuate keratotomy over a 4-year period with a non-toric monofocal intraocular lens (2017-2021) at a tertiary care academic center. Postoperative visual acuity, manifest refraction, and predicted residual refractive error were also recorded at 1 month, 3-6 months, 12-18 months, and 2 years postoperatively. Preoperative keratometric astigmatism was compared to postoperative refractive astigmatism using vector calculations and the ASCRS double-angle plot tool. RESULTS:This study comprised 266 eyes (179 patients) that met inclusion criteria. The mean preoperative keratometric astigmatism magnitude was 0.99 ± 0.53 D. At 1 month, 3-6 months, 12-18 months, and 2 years postoperatively, the mean refractive cylinder was 0.49 ± 0.45 D, 0.49 ± 0.45 D, 0.55 ± 0.54 D, and 0.52 ± 0.46 D, respectively. Horizontal against-the-rule astigmatism showed a higher tendency toward undercorrection than vertical with-the-rule astigmatism, which had a slightly higher tendency toward overcorrection. With-the-rule astigmatism had smaller difference vectors between target-induced astigmatism and surgically induced astigmatism. CONCLUSIONS:Femtosecond laser-assisted arcuate keratotomy performed at the time of femtosecond laser-assisted cataract surgery was an effective option for correcting low-to-moderate corneal astigmatism for up to 2 years.

Purpose: To compare the refractive accuracy of legacy and new no-history formulas in eyes with previous myopic laser vision correction (M-LVC).Design: Retrospective cohort study.Methods:Setting: Two academic centersStudy Population: 576 eyes (400 patients) with previous M-LVC that underwent cataract surgery between 2019-2023. A SS-OCT biometer was used to obtain biometric measurements, including standard (K), posterior (PK), and total keratometry values (TK).Observation Procedures: Refractive prediction errors were calculated for 11 no-history formulas: two legacy M-LVC formulas, four new M-LVC formulas using K values only, and five new M-LVC formulas using K with PK or TK.Main Outcome Measures: Heteroscedastic testing was used to evaluate relative formula performance, and formulas were ranked by root mean square error (RMSE).Results: New M-LVC formulas performed better than legacy M-LVC formulas. New M-LVC formulas with PK/TK values performed better than versions without PK/TK values. Among new M-LVC formulas with PK/TK values, EVO 2.0-PK was superior to Hoffer QST-PK (p<0.005). Among new M-LVC formulas using K only, Pearl DGS-K and EVO 2.0-K were both superior to Hoffer QST-K and Barrett True K NH-K formulas (all p<0.005).Conclusions: Surgeons should favor using new no-history post M-LVC formulas over legacy post M-LVC formulas whenever possible. The top-performing M-LVC formulas (EVO 2.0-PK, Pearl DGS-PK, and Barrett True K-TK) utilized posterior corneal power values. Among formulas utilizing K alone, the EVO 2.0-K and Pearl DGS-K performed best.

center dot PURPOSE: To develop and test a novel index (Cooke-Riaz-Wendelstein [CRW1]) that uses swept -source optical coherence tomography (SS-OCT) biom-etry measurements (IOLMaster700, Zeiss Meditec), in-cluding total keratometry, to alert clinicians that previous myopic laser vision correction (M-LVC) was present in a measured eye. center dot DESIGN: Retrospective, multicenter, comparative diag-nostic analysis. center dot METHODS: The study took place at 6 centers in the United States and Austria. Anonymized SS-OCT biom-etry datasets acquired between 2018 and 2020 and con-taining 49,199 eyes were analyzed. The LVC status, as identified by the biometrist, was used to segregate eyes into LVC and non-LVC eyes. Data were split into train-ing (10,780 eyes) and validation (38,419 eyes) sets. Sub-set analysis was performed for CRW1 Index accuracy compared to posterior/anterior corneal curvature ratio (Rpost/Rant), topography with corneal analysis software (Atlas 9000 with Pathfinder II, Zeiss Meditec), tomogra-phy (Pentacam, Oculus), dual Scheimpflug-Placido sys-tem (Galilei G6, Ziemer), and a cloud-based platform for cataract surgery planning (Veracity, Zeiss Meditec). A positive predictive value (PPV) of >90% was targeted for the CRW1 index. True positives, true negatives, sen-sitivity, and specificity were recorded. center dot RESULTS: The CRW1 Index compared favorably against Rpost/Rant showing a higher PPV (93% vs 65%), with fewer false-positive results (29 vs 180). CRW1 per-formed similarly to topography software and better than the corneal imaging devices. The CRW1 cutoff value can be adjusted to increase sensitivity (CRW1-IS) to detect additional M-LVC eyes. center dot CONCLUSIONS: The CRW1 and CRW1-IS indices of-fer surgeons and researchers a readily accessible method to use only SS-OCT biometry measurements to detect eyes with a high probability of previous M-LVC. (Am J Ophthalmol 2023;247: 79-87. (c) 2022 Elsevier Inc. All rights reserved.)

PURPOSE:To compare the prediction accuracy of standard keratometry (K) and total keratometry (TK) for intraocular lens (IOL) power calculation in eyes undergoing combined cataract surgery and Descemet membrane endothelial keratoplasty (triple DMEK).SETTING:Tertiary care academic referral center.DESIGN:Retrospective case series.METHODS:Review of 83 eyes (63 patients) that underwent triple DMEK between 2019 and 2021. Biometry measurements were obtained using a swept-source optical biometer (IOLMaster 700). 63 eyes were used for statistical analysis. Mean error, mean absolute error (MAE), SD, median absolute error, maximum absolute error, root mean squared prediction error, and the percentage of eyes within prediction errors of ±0.50 diopters (D) and ±1.00 D were calculated for 9 multivariate and third-generation formulas using K and TK values (Barrett Universal II, Yeo EVO 2.0, Cooke K6, Kane, Pearl-DGS, Haigis, Holladay 1, Hoffer Q, and SRK/T). Formulas were additionally tested by using the prediction for an IOL power 1 D below the IOL used (IOLup1D).RESULTS:For all formulas, MAE was lower for K than for TK by an average of 0.21 D. The lowest MAE value observed was 0.67 D for "adjusted" SRK/T using K, and the highest MAE values observed were 1.24 D and 1.24 D for nonadjusted Hoffer Q and Haigis using TK, respectively. Overall, lower MAE values were observed for multivariate formulas and SRK/T.CONCLUSIONS:In triple DMEK eyes, the prediction accuracy of K was higher than that of TK. The most accurate formulas were SRK/T and multivariate formulas using K with the IOLup1D adjustment.

PURPOSE:The purpose of this study was to report clinical outcomes of ab interno canaloplasty (ABiC) with the iTrack microcatheter (Nova Eye Medical, Fremont, CA) for surgical management of intraocular pressure (IOP) in postkeratoplasty patients.METHODS:This study was a single-center retrospective case series of postkeratoplasty eyes undergoing ABiC. Efficacy was evaluated based on graft survivability and mean reduction in IOP at 12 months postoperatively. Secondary end points consisted of visual acuity outcomes, number of topical hypotensive medications, and rate of complications.RESULTS:ABiC was successfully performed in 17 eyes after keratoplasty (8 penetrating keratoplasty, 6 DSAEK, 2 penetrating keratoplasty + DSAEK, and 1 DMEK) with elevated IOP refractory to topical hypotensive medications. The baseline mean IOP was 26.2 ± 8.4 mm Hg and reduced significantly to 15.0 ± 4.21 mm Hg at 6 months and 13.0 ± 2.99 mm Hg at 12 months ( P < 0.005). The best-corrected visual acuity improved from 0.61 ± 0.55 logMAR at baseline to 0.47 ± 0.59 and 0.49 ± 0.64 at 6 and 12 months, respectively, following ABiC (not statistically significant: P = 0.6769). The baseline mean number of topical hypotensive medications was 3.7 ± 1.8 and reduced to 2.7 ± 1.4 and 2.9 ± 1.3 at 6 and 12 months, respectively ( P = 0.096). One patient developed a hyphema which required anterior chamber washout. One patient required additional glaucoma surgery 19 months after ABiC. No patients experienced graft failure.CONCLUSIONS:ABiC is a clinically safe and effective treatment that can be performed in postkeratoplasty patients to reduce IOP for at least 1 year without any significant complications.

Keratoconus (KC) affects the corneal structure, with thinning and bulging outward into a conelike shape. Irregular astigmatism and decreased visual acuity appear during puberty and progress into the mid-30s, with unpredictable disease severity. The cause of KC is recognized as multifactorial, but remains poorly understood. Hormone imbalances are a significant modulator of the onset of KC. This study sought to investigate the role of gonadotropins, follicle-stimulating hormone (FSH), and lutei-nizing hormone (LH) in KC, using a three-dimensional, self-assembled matrix in vitro model. Healthy corneal fibroblasts and human KC cells in the corneal stroma were isolated, cultured, and stimulated with stable vitamin C to promote extracellular matrix assembly. Cultures were further stimulated with 2.5 or 10 mIU/mL FSH and 5 or 35 mIU/mL LH. Samples were evaluated for cell proliferation and morphology via BrdU assay and imaging; protein expression was assessed via Western blot analysis. Proliferation was significantly greater in human KC cells compared to healthy corneal fibroblasts with LH stimulation, but no changes were found with FSH stimulation. Additionally, in sex hormone receptors, fibrotic markers, proteoglycans, and members of the gonadotropin signaling pathway were significantly changed, largely driven by exogenous LH. The impact of exogenous FSH/LH in the KC stromal micro-environment was demonstrated. These results highlight the need to further examine the role of FSH/LH in KC and in human corneal homeostasis.

& BULL; PURPOSE: To compare the utility of keratometry vs to-tal keratometry (TK) for intraocular lens power calcula-tions in eyes with keratoconus (KCN) using KCN and non-KCN formulae. & BULL; DESIGN: Retrospective cohort study. & BULL; METHODS: This study was conducted at 2 academic centers and included 87 eyes in 67 patients who under-went cataract surgery between 2019 and 2021. Biometry measurements were obtained using a swept-source opti-cal coherence tomography biometer (IOL Master 700). Refractive prediction errors, including root mean square error (RMSE), were calculated for 13 formulae. These in-cluded 4 classical formulae (Haigis, Hoffer Q, Holladay 1 [H1], and SRK/T), 5 new formulae (NF) (Barrett Uni-versal II [BU2], Cooke K6, EVO 2.0, Kane, and Pearl-DGS), 3 KCN formulae (BU2 KCN: M-PCA, BU2 KCN: P-PCA, and Kane KCN), and H1 with equivalent keratometry reading values (H1-EKR). Formulae were ranked by RMSE. Friedman analysis of variance with post hoc analysis and H-testing was used for statistical signif-icance testing. & BULL; RESULTS: KCN formulae had the lowest RMSEs in all eyes, and BU2 KCN:M-PCA performed the best among KCN formulae in all subgroups. In eyes with severe KCN, if TK values are unavailable, the BU2 KCN: P-PCA performed better than the top-ranked non-KCN for-mula (SRK/T). In eyes with nonsevere KCN, if TK val-ues are unavailable, EVO 2.0 K was statistically superior to the next competitor (Kane K). H1-EKR had the high-est RMSE. & BULL; CONCLUSIONS: KCN formulae and TK are useful for intraocular lens power calculations in KCN eyes, espe-cially in eyes with severe KCN. The BU2 KCN: M-PCA using TK values performed best for eyes with all severities of KCN. For eyes with nonsevere KCN, the EVO 2.0 TK or K can also be used. (Am J Ophthal-mol 2023;253: 206-214. & COPY; 2023 Elsevier Inc. All rights reserved.)

Purpose: To determine volume fill levels, estimated costs, and force expulsion requirements per bottle of topical ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs) commonly perioperatively in the United States. Setting: Tertiary care academic medical center. Design: Prospective laboratory investigation. Methods: 8 commercially available NSAIDs (3 branded, 5 generic) were tested: branded bromfenac 0.07%, generic bromfenac 0.09%, diclofenac 0.1%, flurbiprofen 0.03%, generic ketorolac 0.5%, branded ketorolac 0.5%, ketorolac 0.47%, and branded nepafenac 0.3%. 10 bottles of each medication were tested, with an additional bottle tested for expulsion force requirements. A double-blinded method was used to measure the actual bottle fill volume and number of drops per bottle. The total cost per drop was calculated using published cash prices. Force requirements were measured using a customized force gauge apparatus. Formulations were compared using the Kruskal-Wallis test, followed by pairwise comparisons with the Dwass, Steel, Critchlow-Fligner Method. Results: 2 branded NSAIDs (bromfenac and nepafenac) had slightly lower-than-sticker volumes while generics other than ketorolac had higher-than-sticker volumes. Diclofenac and branded bromfenac had the highest and lowest adjusted number of drops respectively. Generic bromfenac and generic ketorolac had the highest and lowest adjusted volume compared with sticker volume respectively. Branded bromfenac was the most expensive medication, while generic diclofenac was the least expensive. Force expulsion requirements varied significantly among generic and branded NSAIDs. Conclusions: Volume fill levels, patient-incurred costs, and expulsion force requirements per bottle of topical NSAID medications vary significantly. Surgeons may wish to consider these factors when deciding how best to use these medications perioperatively.

Introduction: This case study described refractive changes that can occur in the setting of Epstein-Barr virus (EBV)-associated nummular keratitis (NK) and highlighted the role that anterior segment optical coherence tomography can serve in diagnosis and management of this disease. Patient and Clinical Findings: A 15-year-old girl developed subepithelial and anterior stromal corneal lesions and experienced progressive decline in the corrected distance visual acuity. She also developed a significant myopic shift with increased keratometric and refractive astigmatism. Diagnosis, Intervention, and Outcomes Targeted laboratory testing was performed. A diagnosis of chronic EBV-associated NK was made, and the patient was treated with systemic valacyclovir and topical steroids. Clinical appearance of lesions and corrected distance visual acuity improved, although refractive and keratometric changes persisted. Conclusions: Significant and persistent refractive changes can occur in the setting of EBV-associated NK, similar to those seen after conductive keratoplasty. Anterior segment optical coherence tomography can be a potentially helpful supplementary diagnostic imaging modality to avoid invasive testing in such cases.

Purpose: To compare axial length (AL) measurements obtained by optical biometry (OB) and immersion ultrasound (iUS) to investigate the agreement between the 2 techniques and how to use OB constants for eyes with AL by iUS. Setting: Multicenter study. Design: Retrospective observational case series. Methods: Agreement between OB and iUS ALs was investigated in 4 subsets. Also, in a test database, the prediction error (PE) for iUS AL was assessed with 4 methods: (1) data-optimized constants; (2) user group for laser interference biometry (ULIB) constants with iUS biometry; (3) with recalibrated AL; and (4) ULIB A-constant - 0.23. Results: A Combined 1970 eyes were measured with both OB and iUS biometry. OB mean AL was 0.0873 mm longer than iUS AL. The latter was made equivalent to OB ALs with this equation: Recalibrated iUS AL = 1.0228 x iUS AL - 0.4556. In a fifth database (n = 1079) with OB AL measurements only, after AL was artificially shortened by 0.0873 mm, the original A-constant had to be reduced by 0.23 to maintain a zero PE. In a sixth database (n = 127) with iUS AL, the original ULIB A-constant provided the poorest outcomes. Using either recalibrated iUS AL or ULIB A-constant - 0.23 zeroed out the mean PE and achieved the lowest median absolute error. Conclusions: AL measurements by iUS can be used with ULIB constants for OB by subtracting 0.23 from the A-constant; alternatively, the iUS AL may be recalibrated. The recalibrated iUS AL should be treated as AL measurements obtained by OB. It is longer than iUS AL in long eyes.

Keratoconus (KC) is a progressive corneal thinning disease that manifests in puberty and worsens during pregnancy. KC onset and progression are attributed to diverse factors that include: environmental, genetics, and hormonal imbalances; however, the pathobiology remains elusive. This study aims to determine the role of corneal stroma sex hormone receptors in KC and their interplay with estrone (E1) and estriol (E3) using our established 3D in vitro model. Healthy cornea stromal cells (HCFs) and KC cornea stromal cells (HKCs), both male and female, were stimulated with various concentrations of E1 and E3. Significant changes were observed between cell types, as well as between males and females in the sex hormone receptors tested; androgen receptor (AR), progesterone receptor (PR), estrogen receptor alpha (ERα), and estrogen receptor beta (ERβ) using Western blot analysis. E1 and E3 stimulations in HCF females showed AR, PR, and ERβ were significantly upregulated compared to HCF males. In contrast, ERα and ERβ had significantly higher expression in HKC's females than HKC's males. Our data suggest that the human cornea is a sex-dependent, hormone-responsive tissue that is significantly influenced by E1 and E3. Therefore, it is plausible that E1, E3, and sex hormone receptors are involved in the KC pathobiology, warranting further investigation.

PURPOSE:To determine volume fill levels, estimated costs, and force expulsion requirements per bottle of topical ophthalmic steroids commonly used in the United States.SETTING:Tertiary care academic referral center.DESIGN:Prospective laboratory investigation.METHODS:8 commercially available medications were tested: loteprednol 0.5%, loteprednol gel 0.5%, loteprednol gel 0.38%, difluprednate 0.05%, generic fluorometholone 0.1%, branded fluorometholone 0.1%, generic prednisolone 1.0%, and branded prednisolone 1.0%. 10 bottles of each medication were tested. A double-blinded method was used to measure actual bottle fill volume and number of drops dispensed per bottle. The total perioperative cost per drop was calculated for each medication using a mean cash price. Force requirements were measured using a customized force gauge apparatus. Formulations were compared using Kruskal-Wallis 1way analysis of variances.RESULTS:All formulations were able to cover postoperative periods commensurate with commonly used dosing regimens for cataract surgery. All medications had greater than sticker volume. Loteprednol 0.5% suspension and branded fluorometholone had the highest and lowest number of drops among the medications tested, respectively. Loteprednol 0.38% gel was the most expensive medication, whereas generic prednisolone 1.0% was the least expensive. Gel and branded formulations of ophthalmic steroids required less expulsion force compared with other tested formulations.CONCLUSIONS:Volume fill levels, patient-incurred costs, and expulsion force requirements per bottle of topical steroid medications vary widely. Clinicians may wish to consider these findings when determining their perioperative prescribing regimen.

Purpose: To explore surgeons' perspectives and practice patterns in gray area surgical complications (GASCs) within cataract surgery. Setting: Tertiary care academic referral center. Design: Retrospective observational cross-sectional study. Methods: An anonymous, online survey consisting of 11 potential intraoperative GASC scenarios was developed and distributed to practicing and resident ophthalmologists in the U.S. Demographic data such as gender, experience, and practice settings were recorded. Using a Likert scale, respondents scaled their perception of likelihood that a GASC could lead to postoperative complications and their obligation toward patient disclosure and documentation in the operative report. Respondents also scaled their likelihood of agreement with a series of statements inserted to assess baseline anxiety levels and inherent perspectives regarding disclosure. Results: 389 responses were analyzed. Female surgeons were more likely than male surgeons to disclose GASCs to their patients and experience psychological anxiety regarding patient outcomes. Both early- and late-stage residents were more likely to believe that GASCs could lead to vision-limiting outcomes when compared with attending surgeons. Surgeons at academic centers were more likely than community-based surgeons to disclose GASCs in the operative report and experience psychological anxiety regarding patient outcomes. Conclusions: Significant differences based on gender, practice setting, and level of experience exist in disclosure and documentation of intraoperative GASCs. Additional studies are needed to further explore reasons for these differences, as reporting patterns may affect patient satisfaction, medicolegal risks, and postoperative surgeon-experienced anxiety.

1Riverwoods Eye Center, Provo, UT, USA; 2Dean McGee Eye Institute, University of Oklahoma, Oklahoma City, OK, USA; 3Excel Eye Center, Saratoga Springs, UT, USA Purpose: To describe surgical technique and report short-term visual outcomes after suturefixation of a single-piece eyelet-toric (SET) intraocular lens (IOL) for treatment of concurrent aphakia and astigmatism. Design: Retrospective, noncomparative, and non-consecutive case series. Methods: This was a case series of eleven eyes who underwent successful SET. Eligible eyes had loss of capsular support or aphakia with a minimum of symmetric corneal astigmatism 1.75 diopters (D). Outcome measures included uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), magnitude of residual refractive cylinder, and complications resulting from the SET procedure. Results: Preoperative UDVA and CDVA in logMAR scale were 1.46 and 0.45, respectively. Mean preoperative keratometric and refractive cylinder were 3.67 D and 2.52D, respectively. Postoperative UDVA and CDVA were 0.51 and 0.27, respectively, three months after surgery (POM3). Residual refractive cylinder at POM3 was 0.93 D. Conclusion: SET technique reduced refractive cylinder and improved UDVA and CDVA. SET may be adapted by surgeons using a readily available IOL and familiar scleral-fixation maneuvers.

Traumatic injury in the pediatric population often results in significant refractive errors that if left untreated can lead to amblyopia. Scleral contact lenses (ScCLs) have recently gained popularity in this population for efficacy in treatment of significant refractive errors, including irregularity astigmatism and corneal abnormalities. Scleral contact lens intolerance may limit the ability of practitioners to use this modality. Although a soft contact lens (SCL) is generally well tolerated, it cannot treat refractive error as effectively as an ScCL. We recently used an SCL followed by an SCL-ScCL combination ("piggyback" system) sequence in a pediatric patient to facilitate use of an ScCL alone. We hope that our results may provide practitioners with an additional option when treating this challenging patient population.