The Asia-Pacific Journal of Ophthalmology

Editorial

Refractive Surgery: History in the Making Faith, Samuel C.; Jhanji, Vishal
Refractive corneal sculpting, keratomileusis, once considered an elusive fleeting cirrus cloud, was envisioned and perfected by Jose I. Barraquer Moner.1 Far gone are the days of Barraquer’s freezing disc, stromal scraping technique. Later Barraquer, Krumeich, and Swinger developed a nonfreeze stromal bed sculpting with flap replacement technique.1 First came suturing of the flap, then sutureless flap replacement, followed by the hinged flap. It was not long before the automated microkeratome emerged, and variations and permutations of this technique developed and evolved quickly.

Original Study - Basic Science

Evaluation of Interleukin-17 and Interleukin-23 in Pterygium: Immunohistochemistry Study Tiong, Kiew Ing; Mohd. Zahidin, Aida Zairani; Sumugam, S. Kala A/P; Uchang, Joseph; Mohd. Isa, Hazlita Dato’
Purpose: To compare the interleukin-17 (IL-17) and interleukin-23 (IL-23) positive cell counts between pterygium and normal conjunctiva.







Design: A case-control study.







Methods: This study received ethical approval (NMRR Research ID 23957) and informed consent was obtained from all participants. It involved 20 participants with 20 samples of pterygium and 20 samples of normal conjunctiva that were obtained from the same eye of each participant. All the participants underwent history taking, slit lamp examination, and pterygium excision surgery. Both samples underwent immunohistochemistry procedure. Pretreatment procedure was conducted using heat-induced epitope retrieval with PT link, subsequently followed by EnVision FLEX staining procedure and incubation with anti‒IL-17 antibody and anti‒IL-23 antibody. Slides were examined in high-power fields (400x) for both samples in 3 different fields. Total positive stained cell counts in all 3 fields with IL-17 and IL-23 between pterygium and normal conjunctiva were analyzed by using Wilcoxon signed rank test.







Results: IL-17 positive cell counts for normal conjunctiva showed mean 196.10 ± 80.487 but for pterygium was 331.10 ± 108.416. As for IL-23, the mean for positive cell counts for normal conjunctiva was 62.10 ± 33.462 and IL-23 positive cell counts for pterygium showed mean 102.95 ± 41.378. Both IL-17 and IL-23 were significantly increased in pterygium compared with normal conjunctiva (P < 0.001).







Conclusions: Both IL-17 and IL-23 were found to be significantly higher in the pterygium group than in the normal conjunctiva group with P < 0.001 by Wilcoxon signed rank test.

Original Study - Clinical

Long-Term Stability of Minimally Invasive Radial Keratotomy for Mild to Moderate Keratoconus Fujimoto, Kahoko; Osawa, Hideya; Moriyama, Takashi; Miyamoto, Takako; Irie, Tomomi; Nishimura,Tetsuya; Inoue, Tomoyuki
Purpose: this study aimed to evaluate the long-term stability of mini-mally invasive radial keratotomy (mini-rK) for eyes with mild to moder-ate keratoconus.

Design: retrospective observational case series.

Methods: Eleven eyes from 6 patients with hard contact lens (Hcl)-intolerant keratoconus underwent mini-rK and were followed up for more than 5 years. the mini-rK consisted of 8 radial incisions with depths of 90% of the thinnest corneal thickness, based on the lindstrom nomogram. Best-corrected visual acuity (BcVa), keratometry, and cor-neal endothelial cell density (Ecd) were examined preoperatively and for 5 to 10 years postoperatively. Changes in keratometric astigmatism were evaluated using power vector analysis. Severities of keratoconus preoperatively and 1 year postoperatively were graded using the amsler-Krumeich classification. Results: the postoperative observation periods were from 6 to 10 years (mean, 7.9 years). there were no changes in the BcVa, Ecd, and kera-tometric astigmatism. the mean keratometric refraction significantly de-creased from 47.5 diopters (d) preoperatively to 44.0 d at 1 month after mini-rK (P = 0.037) and was stable over 5 years, whereas keratometric astigmatism did not change from the preoperative through the postop-erative period (P > 0.59). Keratoconus of grade 2 or higher improved to lower grades.

Conclusions: the mini-rK treatment was safe and effective for Hcl-intolerant eyes with mild to moderate keratoconus.
Intraocular Pressure and Big Bubble Diameter in Deep Anterior Lamellar Keratoplasty: An Ex-Vivo Microscope-Integrated OCT With Heads-Up Display Study Bhullar, Paramjit K.; Carrasco-Zevallos, Oscar M.; Dandridge, Alexandria; Pasricha, Neel D.; Keller, Brenton; Shen, Liangbo; Izatt, Joseph A. Toth, Cynthia A.; Kuo, Anthony N.
PURPOSE: To investigate the relationship between intraocular pressure (IOP) and big bubble (BB) formation in a model of deep anterior lamellar keratoplasty (DALK).





Design: Ex-vivo.





Methods: Corneoscleral buttons from human donors were loaded onto an artificial anterior chamber connected to a column of balanced salt solution. A surgeon-in-training learned to perform DALK via the BB technique using swept-source microscope-integrated optical coherence tomography (SS-MIOCT) with heads-up display (HUD). DALK procedures were performed at 6 different IOPs (5, 10, 15, 20, 30, or 40 mm Hg; n = 6 per group) in a randomized fashion, with the surgeon-in-training masked to the pressure and guided by SS-MIOCT with HUD. For a subset of corneas within each pressure group, DALK was performed on matching donor tissue at a control IOP. BB diameter was recorded, and a diameter exceeding the trephine diameter was considered optimal.





Results: Wilcoxon rank sum test showed a difference in BB diameter among the different pressure groups (mean ± SD of 7.75 ± 1.60, 8.33 ± 1.99, 10.9 ± 0.92, 9.08 ± 1.07, 6.67 ± 3.33, and 3.42 ± 3.77 mm in the 5, 10, 15, 20, 30, and 40 mm Hg groups, respectively; P = 0.0014). Per Tukey test, this difference was attributable to comparisons between the 40 mm Hg group and the 5, 10, 15, or 20 mm Hg groups (P = 0.04, 0.02, 0.0001, 0.004, respectively).





Conclusions: In this ex-vivo model of DALK, the BB technique guided by SS-MIOCT with HUD yielded bubbles of optimal diameters only at physiologic pressures (10‒20 mm Hg). Extremely high IOP (40 mm Hg) resulted in BBs of significantly smaller diameter than BBs obtained at physiologic and low (5 mm Hg) IOPs.





Randomized Controlled Trial of Topical Insulin for Healing Corneal Epithelial Defects Induced During Vitreoretinal Surgery in Diabetics Fai, Seng; Ahem, Amin; Mustapha, Mushawiathi; Mohd Noh, Umi Kalthum; Bastion, Mae-Lynn Catherine
Purpose: To determine the effect of topical insulin of 3 concentrations [0.5, 1, and 2 units per drop 4 times per day (QID)] on postoperative corneal epithelial wound healing in diabetic patients. Design: A double blind randomized controlled hospital-based study involving diabetic patients with postoperative corneal epithelial defect after vitreoretinal surgery.Methods: Diabetic patients were randomized to 3 different concentrations of topical insulin (DTI 0.5, DTI 1, and DTI 2) or placebo in the control group (DNS). Primary outcome measure was the rate of corneal epithelial wound healing (mm2 per hour) over pre-set interval and time from baseline to minimum size of epithelial defect on fluorescein stained anterior segment digital camera photography. Secondary outcome measure was any adverse effect of topical insulin. Follow-up was 1 month.Results: Thirty-two eyes of 33 patients undergoing intraoperative corneal debridement with resultant epithelial defect (8 eyes per group) were analyzed. DTI 0.5 was superior to other concentrations achieving 100% healing rate within 72 hours of treatment compared with 62.5% in DNS, 75% in DTI 1, and 62.5% in DTI 2. Statistically, DTI 0.5 achieved significant results (P = 0.036) compared with the diabetic control group (DNS) in terms of mean rate of corneal epithelial wound healing from maximum to minimum defect size. No adverse effect of topical insulin was reported.Conclusions: Topical insulin 0.5 units QID is most effective for healing corneal epithelial defect in diabetic patients after vitrectomy surgery compared with placebo and higher concentrations. Topical insulin is safe for human ocular usage.
Nanosecond Laser Cataract Surgery in LOCS III Grade 4 and 5: A Case Series Sauder, Gangolf; Ruf, Elena; Moedl, Sarah; Thyzel, Reinhardt
PURPOSE:






A major obstacle to the widespread implementation of nanosecond laser cataract removal has been its limited efficacy in cases when the cataract is harder than Lens Opacities Classification System III (LOCS III ) grade 3. The latest technological modifications seem to have overcome this obstacle.






DESIGN:






A case series.






METHODS:






This study presents a case series of 17 consecutive patients with a cataract classified as harder than LOCS III grade 3 who underwent nanolaser cataract surgery. The basic surgical procedure included administration of topical or local anesthesia, capsulorhexis, hydrodissection, cataract removal with a nanosecond laser, cortical cleanup, intraocular lens implantation, and clear corneal incision closure with physiological solution.






RESULTS:






The nanosecond laser system effectively removed the cataract in all patients. This result was statistically significant (P < 0.000001) compared with an expected conversion rate to ultrasound phacoemulsification of 100%.






CONCLUSIONS:






Harder cataracts should no longer be considered a limitation for the use of nanosecond laser in cataract surgery.
The Effect of Eye Patching on Clear Corneal Incision Architecture in Phacoemulsification: A Randomized Controlled Trial Ho, Fui Li; Salowi, Mohamad Aziz; Bastion, Mae-Lynn Catherine
Purpose: To investigate the effects of postoperative eye patching on clear corneal incision architecture in phacoemulsification.

Design: A single-center, randomized controlled trial.

Methods: A total of 132 patients with uncomplicated phacoemulsification were randomly allocated to the intervention or control group. The intervention group received postoperative eye patching for approximately 18 hours, whereas the control group received eye shield. The clear corneal incision architecture was examined postoperatively at 2 hours, 1 day, and 7 days after surgery using optical coherence tomography.

Results: Epithelial gaping was significantly reduced on postoperative day 1 in the intervention group (52.4%) compared with control (74.2%) (P = 0.01). No differences were found for other architectural defects. Descemet membrane detachment was associated with lower intraocular pressure on postoperative day 7 (P = 0.02). Presence of underlying diabetes mellitus did not seem to influence architectural defects.

Conclusions: Postoperative eye patching facilitated epithelial healing and reduced the occurrence of epithelial gaping on postoperative day 1. It may play a role in protecting and improving corneal wounds during the critical immediate postoperative period.
Adult Orbital and Adnexal Xanthogranulomatous Disease Davies, Michael J.; Whitehead, Kevin; Quagliotto, Gary; Wood, Dominic; Patheja, Rajan S.; Sullivan, Timothy J.
Purpose: Adult xanthogranulomatous disease of the orbit and ocular adnexa is a rare disease that can cause serious morbidity and mortality. Ophthalmologists are commonly the first clinicians to come in contact with affected patients and an understanding of the clinical features is essential.










Design: We present a retrospective case series of patients seen in the oculoplastic unit of a large tertiary referral hospital over a 20-year period.










Methods: The clinical files of 7 patients with adult xanthogranulomatous disease of the orbit and ocular adnexa were reviewed. Clinical, radiological, histopathological, and immunohistochemical findings were examined.










Results: Periocular clinical features included cutaneous xanthogranulomatous lesions, decreased visual acuity, proptosis, diplopia, skin ulceration, cicatricial ectropion, and mechanical ptosis. Systemic features included adult-onset asthma, disseminated xanthogranulomatous lesions with long bone involvement, and hematological disturbances such as monoclonal gammopathy and lymphoplasmacytic lymphoma. Lipid-laden macrophages and Touton multinucleated giant cells were histological hallmarks in all subtypes. Most lesions were strongly CD 8 positive on immunohistochemistry. Radiologically, the lesions were diffuse and infiltrative in nature. Various treatments were employed with varying success including surgical excision, systemic and intralesional corticosteroids, other immunosuppressants, and systemic chemotherapy.










Conclusions: Adult xanthogranulomatous disease of the orbit and ocular adnexa, although rare, may be sight or life threatening. Recognition by the ophthalmologist is critical as periocular features often constitute the initial presentation.
Laser and Anti–Vascular Endothelial Growth Factor Agent Treatments for Retinal Arterial Macroaneurysm Chen, Yen-Yi; Lin, Lo-Yi; Chang, Pei-Yao; Chen, Fang-Ting; Mai, Elsa L.C.; Wang, Jia-Kang
Purpose: To describe the efficacy of laser and intravitreal injection of anti‒vascular endothelial growth factor (anti-VEGF) agents for patients with symptomatic retinal arterial macroaneurysm (RAM). Design: From 2009 to 2016, we collected patients with exudative or hemorrhagic RAM all treated by focal laser photocoagulation.Methods: Nd:YAG laser was performed in patients with subinternal limiting membrane (sub-ILM) hemorrhage. Intravitreal anti-VEGF agents were given in eyes with macular exudation as adjuncts. Changes of visual acuity and central foveal thickness before and after treatment were recorded and compared with Wilcoxon signed-rank test. Results: Thirty-five eyes that underwent a single session of laser photocoagulation for RAM resulted in macroaneurysm regression. The hemorrhagic group included 24 eyes having ruptured macroaneurysms without macular exudation. Five eyes with simultaneous sub-ILM hemorrhage receiving Nd:YAG laser membranotomy had resolution of preretinal hemorrhage. Exudative RAM having cystoid macular edema or submacular fluid with or without ruptured macroaneurysms was treated by focal laser photocoagulation alone in 3, or combined with single intravitreal anti-VEGF agent in 8 eyes. All patients had significantly improved vision when comparing visual acuity at baseline and final follow-up (P = 0.00016). Significant reduction of macular thickness was also observed after laser monotherapy or combined treatment in exudative RAM (P = 0.018). Conclusions: Focal laser photocoagulation was helpful for the management of ruptured or leaky RAM. Combined focal laser and intravitreal anti-VEGF agents could better reduce macular exudation caused by RAM. Additionally, Nd:YAG laser was a safe and effective method to remove the sub-ILM hemorrhage caused by RAM.
Personality and Total Health Through Life Project Eye Substudy: Methodology and Baseline Retinal Features Wijngaarden, Peter van; Keel, Stuart; Hodgson, Lauren A.B.; Kumar, Dinesh K.; Aliahmad, Behzad; Paim, Cristiane C.; Kiely, Kim M.; Cherbuin, Nicolas; Anstey, Kaarin J.; Dirani, Mohamed
Purpose: To describe the methodology and present the retinal grading findings of an older sample of Australians with well-defined indices of neurocognitive function in the Personality and Total Health (PATH) Through Life project.

Design: A cross-sectional study.

Methods: Three hundred twenty-six individuals from the PATH Through Life project were invited to participate. Participants completed a general questionnaire and 2-field, 45-degree nonmydriatic color digital retinal photography. Photographs were graded for retinal pathology according to established protocols.

Results: Two hundred fifty-four (77.9%) subjects, aged 72 to 78 years, agreed to participate in the eye substudy. Gradable images of at least 1 eye were acquired in 211 of 254 subjects (83.1%). Retinal photographic screening identified 1 or more signs of pathology in 130 of the 174 subjects (74.7%) with gradable images of both eyes. A total of 45 participants (17.7%) had self-reported diabetes and diabetic retinopathy was observed in 22 (48.9%) of these participants.

Conclusions: This well-defined sample of older Australians provides a unique opportunity to interrogate associations between retinal findings, including retinal vascular geometric parameters, and indices of neurocognitive function.

Review Article

Femtosecond Lasers and Corneal Surgical Procedures Marino, Gustavo K.; Santhiago, Marcony R.; Wilson, Steven E.
Our purpose is to present a broad review about the principles, early history, evolution, applications, and complications of femtosecond lasers used in refractive and nonrefractive corneal surgical procedures. Femtosecond laser technology added not only safety, precision, and reproducibility to established corneal surgical procedures such as laser in situ keratomileusis (LASIK) and astigmatic keratotomy, but it also introduced new promising concepts such as the intrastromal lenticule procedures with refractive lenticule extraction (ReLEx). Over time, the refinements in laser optics and the overall design of femtosecond laser platforms led to it becoming an essential tool for corneal surgeons. In conclusion, femtosecond laser is a heavily utilized tool in refractive and nonrefractive corneal surgical procedures, and further technological advances are likely to expand its applications.
Visual Quality After Femtosecond Laser Small Incision Lenticule Extraction Miao, Huamao; Han, Tian; Tian, Mi; Wang, Xiaoying; Zhou, Xingtao
Femtosecond laser small incision lenticule extraction (SMILE) is a newly developed form of “flapless” corneal refractive surgery with all-in-one technology. Femtosecond laser SMILE is increasingly attractive for both doctors and patients because it is minimally invasive and does not require a flap to be lifted during surgery. It exhibits many advantages in terms of morphology, biomechanical effects, corneal wound healing, and nerve rehabilitation. However, visual quality assessment after refractive surgeries is just as important as these advantages and correlates with patient satisfaction. Evaluation indexes for visual quality include visual acuity, contrast sensitivity, aberration, intraocular scattering, and so on. This paper reviewed visual quality and patient satisfaction after SMILE for myopia correction.
Grafts in Glaucoma Surgery: A Review of the Literature Thakur, Sahil; Ichhpujani, Parul; Kumar, Suresh
Patients with bleb leakage, dehiscence, or infection after trabeculectomy need urgent bleb salvaging to prevent vision loss. Patients who have undergone a glaucoma drainage device surgery may have tube erosion, which is yet another devastating and outcome-compromising complication. The bleb or the tube in such cases needs to be patched by a biologic tissue, which is roofed by the conjunctiva and acts as a barrier against external infections. Sclera, pericardium, cornea, and dura mater are the commonly used patch graft materials. This review reports the outcomes of several new and old graft materials used to repair the post trabeculectomy compromised bleb and tube exposure in glaucoma drainage device surgeries.
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