A 62-year-old woman with a history of moderate myopia, long-standing open-angle glaucoma (OAG), and Fuchs dystrophy in both eyes was referred for consultative care. She had prior trabeculectomy in 1984 and 1992 in the left and right eyes, respectively. She is 3 months post–Descemet-stripping endothelial keratoplasty (DSEK) in the left eye, now referred with uncontrolled intraocular pressure (IOP) despite maximum tolerated medical therapy. Current medical therapy for IOP consists of acetazolamide 250 mg by mouth 2 times a day, brimonidine 2 times a day in the left eye, dorzolamide 2 times a day in the left eye, and timolol 2 times a day in the left eye. The patient has a history of presumed steroid response; however, her corneal surgeon has requested that the steroid be continued for the next several months because of the recent DSEK. The IOP in the left eye has ranged from the mid-20s to mid-30s since DSEK. The right eye has consistently had pressure in the low teens and below for many years without topical antihypertensive medications. Examination revealed stable visual acuity at 20/30 and 20/40 in the right and left eyes, respectively, IOP was 12 mm Hg in the right eye and 25 mm Hg in the left eye by Goldman applanation, irregular but reactive pupils without afferent defect, and full confrontational visual fields. Slitlamp examination showed superior low avascular bleb, moderate-to-severe guttae, and posterior chamber IOL in the right eye. The left eye showed superior low diffuse bleb, clear DSEK graft, quiet chamber, superonasal iridectomy, and posterior chamber IOL with an open posterior capsule. The conjunctiva was moderately scarred but a repeat trabeculectomy or Xen Gel stent (Abbvie) appeared possible. The angles were wide open in each eye. Fundus examination was normal aside from myopic, anomalous-appearing nerves with an approximate cup-to-disc ratio of 0.90 in both eyes. Humphrey visual field showed nonspecific changes on the right and moderate nasal defect on the left eye, stable to previous examinations dating back to 2018 (Figure 1 JOURNAL/jcrs/04.03/02158034-202407000-00018/figure1/v/2024-07-10T174240Z/r/image-tiff and Figure 2 JOURNAL/jcrs/04.03/02158034-202407000-00018/figure2/v/2024-07-10T174240Z/r/image-tiff ). Optical coherence tomography (OCT) of the retinal nerve fiber layer (RNFL) revealed moderated thinning in both eyes that was also stable to prior examinations (Figure 3 JOURNAL/jcrs/04.03/02158034-202407000-00018/figure3/v/2024-07-10T174240Z/r/image-tiff ). Her axial length measured 25.23 and 26.34 mm in the right and left eyes, respectively. Central corneal thickness was 553 μm in the right eye and 563 μm in the left eye before her DSEK procedure. What would be your approach to management of this patient's left eye, addressing the following: Rationale for your procedure of choice? Would you over-rule the corneal surgeon and stop the steroid in an attempt to obviate the need for glaucoma surgery? Does the age of onset of glaucoma affect your surgical decision making? Note that patient age at the time of trabeculectomy was 22 years. Are some procedures better suited for patients after DSEK surgery?

Vascular Similarly Measurement (VSM) is an important tool in many biomedical applications. However, designing a robust computational VSM remains a challenge. We investigate different wavelet families and their orders to find their efficacy as feature extractors for computational VSM. Using a 50-subject dataset of RGB ocular surface vasculature images, we show that a compact feature vector composed of wavelet packet energies derived from Db1 wavelets, in conjunction with Fisher linear discriminant analysis and judged by the ensuing ROCs, is best suited for this task. Coif1 and Rbio2.4 were found to be the next best two wavelets for this purpose. Repetition of the same experiments using neural networks confirmed the optimality of the above suite of features for VSM.

Although biometric utility of ante-mortem human iris tissue has been long established, post-mortem study of human iris tissue for its biometric utility has only been speculated. Given obstacles in measuring and analyzing biometric capability of post-mortem human iris tissue, an investigation into the feasibility of using post-mortem Sus scrofa domesticus iris tissue as a biometric is undertaken. The contributions of our work are two-fold: first, our method discusses a feasible alternative to human iris for study of post-mortem iris biometric analysis. Second, we report the performance of iris biometrics over a period of time after death. Previous studies have only reported qualitative changes in iris after death while for the first time we measure the biometric capacity of post-mortem iris tissue.

To determine whether there is a statistically significant difference in the decrease in intraocular pressure (IOP) after selective laser trabeculoplasty (SLT) between patients receiving a 5–7 days co-administration of loteprednol versus no loteprednol over the course of 1 year.

The monocular trial has been proposed as a test to help control for diurnal fluctuations in eye pressure when assessing medication effectiveness. We undertook a prospective study to determine the sensitivity and specificity of the monocular trial as a test for determining the effectiveness of a glaucoma medication. The efficacy of the monocular trial was compared to the diagnostic paradigm of repeated pre- and post-treatment measurements in determining whether an intraocular pressure (IOP)-lowering drug is effective. Forty-two patients with newly diagnosed open-angle glaucoma completed five visits: visit 1 for determining eligibility, obtaining consent, and measuring IOP, visit 2 for a second pressure measurement, and visit 3 for a third pressure reading. The new medication was then started in one eye. IOP measurements were made at weeks 4 and 6. The gold standard IOP change was defined as the difference in mean between the pre- and post-medication visits. A medication was deemed effective if this difference was at least 15%. The monocular trial pressure change was defined as the IOP change in the treated eye between the visit immediately before and immediately after the medication addition, corrected by subtracting the pressure change in the untreated eye. All 42 patients completed the full protocol with good compliance. Twenty-five of 42 (60%) medication additions were considered effective by the gold standard method, and 25/42 (60%) by the monocular trial method. However, the two methods agreed in only 26 patients (17 Yes/Yes, 9 No/No). The calculated sensitivity was low (0.68), with a specificity of 0.53. The monocular trial can give useful clues as to whether a medication is effective, but should not be the only information used in making this determination. To obtain the most valid results, multiple pressure checks should be done before and after starting a new medication.

BACKGROUND:Tissue adhesives for ophthalmologic applications were proposed almost 50 years ago, yet to date no adequate tissue glues have been identified that combine strong sealing properties with adequate safety and absence of postsurgical side effects. In recent years, cataract surgeries and Descemet's stripping with endothelial keratoplasty procedures have significantly increased the number of clear corneal incisions performed. One of the obstacles to discovery and development of novel tissue adhesives has been the result of nonstandardized testing of potential tissue glues.METHODS:We developed an instrument capable of controlling intraocular pressure in explanted porcine and bovine eyes in order to evaluate sealants, adhesives, and surgical closure methods used in ophthalmic surgery in a controlled, repeatable, and validated fashion. We herein developed and validated our instrument by testing the adhesive properties of cyanoacrylate glue in both porcine and bovine explant eyes.RESULTS:The instrument applied and maintained intraocular pressure through a broad range of physiological intraocular pressures. Cyanoacrylate-based glues showed significantly enhanced sealing properties of clear corneal incisions compared with sutured wounds.CONCLUSION:This study shows the feasibility of our instrument for reliable and standardized testing of tissue adhesive for ophthalmological surgery.

We believe that smartphones are valuable tools in the field of ophthalmology. It is estimated that 1 out of every 2 physicians uses a personal digital assistant (PDA) or smartphone, and this number is expected to rise.1More Physicians Use Smartphones, PDAs in Clinical Care.http://www.ihealthbeat.org/Articles/2009/1/6/More-Physicians-Use-Smartphones-PDAs-in-Clinical-Care.aspxGoogle Scholar While smartphones have been used for some time as electronic references, these devices have evolved over recent years and are now far more than a simple combination of a PDA and a cellular phone.2Gillingham W. Holt A. Gillies J. Hand-held computers in healthcare: what software programs are available?.N Z Med J. 2002; 115: U185PubMed Google Scholar We believe that all smartphones have great utility in the field of ophthalmology. However, the iPhone (Apple Inc, Cupertino, CA) stands out among other phones because of its unique interface and its vast supply of third-party add-on software. We would like to present various uses of smartphones, as well as their applicability in virtually every part of the ophthalmologic examination. Smartphones can combine many commonly used clinical evaluation and educational tools into one easy to use, portable interface. A near vision card, Amsler grid, Ishihara color plates, and a pupil gauge are some examples of simple to use applications that are readily accessible on a smartphone. While these tools will not replace office-based testing under ideal conditions, with appropriate standardization and acceptance of some testing variability, these tools can be particularly useful, especially in the setting of inpatient consults and emergency room visits. The smartphone can also display educational videos, diagrams, and clinical photographs that provide a convenient way to instruct patients and their families about various ophthalmic conditions and treatment options (Figure 1, available at http://aaojournal.org). As students, residents, educators and speakers, ophthalmologists often present clinical cases in conferences. The smartphone allows collection of acceptable quality presentation images for this purpose. In non-ideal clinical settings, such as in the emergency room, a smartphone can be used to document external photographs of the eye, slit-lamp pictures of the anterior segment, fundus biomicroscopy, and indirect ophthalmoscopy findings (Figure 2, Figure 3, available at http://aaojournal.org). We have also been successful in taking presentation-quality images and videos of surgical procedures through the operating microscope (Fig 4, available at http://aaojournal.org). In addition, the smartphone will display suitable images of magnetic resonance imaging and computed tomography scans directly from a liquid crystal display computer monitor (Figure 2). Most smartphones also have the ability to capture video. As mobile devices continue to integrate into ophthalmology, special consideration should be given to the Health Insurance Portability and Accountability act of 1996 (HIPAA) and patient confidentiality. While e-mail messages containing patient information and clinical photos can be sent securely with encryption, appropriate documentation of patient consent must be obtained. It should always be remembered that patient information must be protected and established guidelines adhered to.Figure 3Technique to capture slit-lamp pictures on the iPhone.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Image captured on the iPhone through operating microscope.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Many digital references (e.g., Epocrates [San Mateo, CA], Lexi-Comp [Hudson, OH], Taber's Medical Dictionary [Unbound Medicine, Inc., Charlottesville, VA])2Gillingham W. Holt A. Gillies J. Hand-held computers in healthcare: what software programs are available?.N Z Med J. 2002; 115: U185PubMed Google Scholar and diagnostic tools that have been available through other electronic devices are now available for smartphones. In addition, ophthalmologic-specific applications like “The Wills Eye Manual” and “Optics Clinical Calculator” are available. These phones also have transcription capability through third-party software. There has already been the development of an electronic medical record for the iPhone,3Allscripts Introduces iPhone MR.http://medgadget.com/archives/2009/04/allscripts_introduces_iphone_emr.htmlGoogle Scholar and novel devices like microscope and ultrasound attachments are being developed.4Fitzpatrick T. Ultrasound imaging now possible with a smartphone Imaging device fits in the palm of a hand.http://news-info.wustl.edu/tips/page/normal/13928.htmlGoogle Scholar, 5Low D.K. Pittaway A.P. The ‘iPhone' induction – a novel use for the Apple iPhone.Paediatr Anaesthes. 2008; 18 ([Epub 2008 Feb 2]): 573-574Crossref PubMed Scopus (30) Google Scholar The iPhone already has many uses and its ophthalmologic utility, as well as that of other comparable smartphones will continue to develop with time. The authors were able to facilitate the performance of an yttrium aluminum garnet (YAG) laser capsulotomy in a 2-year-old child using a video displayed on the iPhone as a fixation target. In addition, other medical specialties are finding novel uses for the iPhone and utilizing them to enhance patient care.5Low D.K. Pittaway A.P. The ‘iPhone' induction – a novel use for the Apple iPhone.Paediatr Anaesthes. 2008; 18 ([Epub 2008 Feb 2]): 573-574Crossref PubMed Scopus (30) Google Scholar We recently developed a free ophthalmology iPhone application called the “Eye Handbook.” This application includes international classification of diseases (ICD) 9 codes, an ophthalmic picture atlas, an ophthalmic dictionary, clinical studies reference list, ophthalmic instrument references, various ophthalmic study materials, and an ophthalmic English-Spanish translational guide (www.eyehandbook.com; Accessed November 19, 2009). Smartphones, like the iPhone, have many useful applications for any medical profession, especially ophthalmology. In addition to being a power-packed communication device and having all of the features available in a PDA, the smartphone's programs, and digital photography are altering the educational environment for ophthalmology residents at the University of Missouri-Kansas City. This dynamic interface has great functionality at present, and it has great potential for future growth in the field of ophthalmology. Vinay Shah and Ken Lord are equity owners in Company Digital Medicine LLC. Smartphone FundoscopyOphthalmologyVol. 119Issue 2PreviewMore ophthalmologists than ever carry a smartphone with them on a daily basis. There are many ophthalmic applications (apps) and reference texts available on a variety of platforms. Full-Text PDF

To determine current trends in resident laser in situ keratomileusis (LASIK) training in the United States, a comprehensive survey was sent to the residency coordinator, chairman, or refractive surgery director of all 113 ophthalmology training programs in the U.S. accredited by the Accreditation Council for Graduate Medical Education. The response rate was 64%. Of the respondents, 54% were from programs in which residents performed LASIK surgery, typically as third-year residents; residents in these programs performed a mean of 4 LASIK surgeries (range 1 to 10 surgeries) during residency. The Visx Star was the most commonly used excimer laser platform and the Hansatome the most commonly used microkeratome. Most programs had 1 attending physician teaching the residents refractive surgery, which was typically performed at the main residency facility. Most programs had significant discounted pricing (>50%) for resident-performed LASIK.

Purpose: The objectives of this work were (i) to screen ocular hypotensive prostaglandin (PGF2 alpha) analogs-bimatoprost, latanoprost, and travoprost as well as their free acid forms-for interaction with efflux pumps on the cornea and (ii) to assess the modulation of efflux upon co-administration of these prostaglandin analogs.Methods: Cultured rabbit primary corneal epithelial cells (rPCEC) were employed as an in vitro model for rabbit cornea. Transporter-specific interaction studies were carried out using Madin-Darby canine kidney (MDCK) cells overexpressing MDR1, MRP1, MRP2, MRP5, and BCRP. Freshly excised rabbit cornea was used as an ex vivo model to determine transcorneal permeability.Results: Cellular accumulation studies clearly showed that all prostaglandin analogs and their free acid forms are substrates of MRP1, MRP2, and MRP5. Bimatoprost was the only prostaglandin analog in this study to interact with P-gp. In addition, none of these molecules showed any affinity for BCRP. K-i values of these prostaglandin analogs obtained from dose-dependent inhibition of erythromycin efflux in rPCEC showed bimatoprost (82.54 mu M) and travoprost (94.77 mu M) to have similar but higher affinity to efflux pumps than latanoprost (163.20 mu M). Ex vivo studies showed that the permeation of these molecules across cornea was significantly elevated in the presence of specific efflux modulators. Finally, both in vitro and ex vivo experiments demonstrated that the efflux of these prostaglandin analogs could be modulated by co-administering them together.Conclusion: Bimatoprost, latanoprost, travoprost, and their free acid forms are substrates of multiple drug efflux pumps on the cornea. Co-administration of these molecules together is a viable strategy to overcome efflux, which could simultaneously elicit a synergistic pharmacological effect, since these molecules have been shown to activate different receptor population for the reduction of intraocular pressure (IOP).

Background: To compare intraocular pressures obtained using a handheld pressure phosphene tonometer (PPT) (Proview, Bausch & Lomb Pharmaceuticals, Inc., Tampa, Fla.) with Goldmann applanation tonometry. Methods: Comparative case series of 30 randomly selected patients. Results: The readings obtained with the pressure phosphene tonometer display a higher mean and a larger standard deviation than those obtained with the Goldmann applanation tonometer (GAT). Differences between PPT and GAT readings tended to decrease as a function of increased Goldmann levels. The relation of Proview and Goldmann readings (r = 0.32) and the scatterplot were not consistent with the hypothesis that the 2 methods are equivalent. Interpretation: Our results indicate that the pressure phosphene-type handheld tonometry method, which does not appear to provide an accurate and consistent measure of intraocular pressure, is substantially less reliable than the Goldmann method.

PURPOSE:To determine current trends in resident glaucoma surgical training throughout the United States. METHODS:A comprehensive survey was sent to the residency director of all 121 ACGME-accredited ophthalmology training programs in the United States. RESULTS:The mean and median number of glaucoma procedures a resident will complete by the end of their training is 8.6 and 8 respectively for trabeculectomy, 5.3 and 4 for combined trabeculectomy/phacoemulsification, and 3.6 and 2 for tube-shunts. One percent of residents will gain experience as primary surgeon on trabeculectomies during their first year, 32% during their second year, and 67% during their third year. Seventy-five percent of residents are taught more than one trabeculectomy technique by more than one staff surgeon. Eighty-four percent of residents are taught glaucoma surgery almost exclusively by fellowship-trained glaucoma surgeons. Eighty-two percent of residents use antimetabolites (mitomycin C or 5-FU) as an adjunct to trabeculectomy most or all of the time. More than 96% of resident tube-shunt procedures use Ahmed, Baerveldt, or Molteno devices. Eighty percent of residents do not perform any pediatric glaucoma surgeries. Sixty-two percent of residents rotate out of their main facility to perform glaucoma surgery. CONCLUSIONS:Residents are being exposed to glaucoma surgery early in their residency training. Most are performing a variety of different procedures and techniques, and are taught by fellowship-trained surgeons. Residents gain very little exposure to pediatric glaucoma surgery. All programs reported compliance with minimum RRC requirements for glaucoma filtering surgery.

This is a report of a case of the development of acute bilateral cataracts in a diabetic patient. A 28-year-old man presented to the emergency room with a 4-day history of acutely diminished vision. The patient had a recent history of hyperglycemia. On examination, vision was noted to be count-fingers bilaterally; both lenses were intumescent with dense cortical opacities. After 4 weeks, the cataracts had not resolved and cataract extraction surgery was performed, with improvement of the patient's vision. A review of the mechanism of this infrequent presentation of cataract is presented.