Optimum pinhole size determination in pinhole pupilloplasty for higher-order aberrations

PURPOSE

To determine optimal pinhole size (OPS) and establish a relationship with visual acuity (VA) and RMS (root mean square) values in cases with higher-order aberrations (HOAs) undergoing pinhole pupilloplasty (PPP).

SETTING

Private practice, India.

DESIGN

Prospective, interventional study.

METHODS

RMS value for 6-mm-diameter optical zone was determined by Scheimpflug imaging (Pentacam). Patients with RMS value >0.3 μm were included. Preoperatively, a hand-held pinhole gauge with varied apertures determined the OPS, and single-pass four-throw technique was used to perform pupilloplasty with Purkinje-1 reflex as a marker for centration. VA with OPS, correlation of RMS values with OPS and pupil size, and Strehl ratio were the main outcome measures.

RESULTS

29 eyes with HOAs were analyzed; all patients chose 1.0 or 1.5 mm as OPS. The mean preoperative and postoperative pupil size was 3.25 ± 0.81 mm and 1.8 ± 0.54 mm ( P = .000), respectively. Postoperative mean pupil size when compared with OPS denoted that 14 eyes had a difference of <0.1 mm, 8 eyes ranged from 0.2 to 0.45 mm, and 7 eyes had ≥0.6 mm (range from 0.6 to 1.8 mm) difference from OPS. Eyes with higher RMS values needed smaller pupil gauge to achieve better VA. Preoperatively, vision with OPS correlated well with preoperative 6-mm RMS HOAs ( r = 0.728; P = .00). Postoperative UDVA correlated well with VA measured with OPS ( r = 0.847; P = .00). The preoperative and postoperative mean Strehl ratio was 0.109 ± 0.07 and 0.195 ± 0.11 ( P = .001), respectively.

CONCLUSIONS

Higher RMS values required a smaller pupil to achieve optimum VA. PPP can help achieve pinhole size in accordance with patient's optimum pinhole requirement.

Outcomes of Pre-Descemet Endothelial Keratoplasty for Failed Therapeutic Penetrating Keratoplasty

PURPOSE

The aim of this study was to analyze the outcomes of pre-Descemet endothelial keratoplasty (PDEK) for failed therapeutic penetrating keratoplasty.

METHODS

This was a retrospective, interventional study that involved 12 eyes of 12 patients with failed therapeutic penetrating keratoplasty that underwent PDEK. All cases had a minimum follow-up of 12 months. The main outcome measures were best-corrected visual acuity, graft clarity, endothelial cell density loss, and graft survival. Corneal clarity was graded on a scale from 0 to 4, where grade 4 denoted an absolutely clear cornea and grade 0 denoted a totally opaque cornea. Three cases underwent PDEK, 6 cases PDEK with phacoemulsification, and 3 cases underwent PDEK with pupilloplasty.

RESULTS

The mean follow-up period for all cases was 18.5 ± 4.9 months. The mean preoperative and postoperative best-corrected visual acuity (in Snellen decimal equivalent) was 0.02 ± 0.01 and 0.54 ± 0.17, respectively, at the last follow-up. Postoperatively, corneal clarity grade 4 was present in 9 eyes, grade 3 in 2 eyes, and grade 2 in 1 eye. Mild subepithelial haze was noted in 2 eyes. The percentage of endothelial cell density loss was 28.2% ± 10.6%. No correlation was observed between the postoperative graft clarity and preoperative specular count (r = -0.021, P = 0.512). Rebubbling was performed for 1 eye that developed partial graft detachment in the first postoperative week. One patient had an episode of rejection that was managed with systemic and topical steroids.

CONCLUSIONS

In patients with failed therapeutic penetrating keratoplasty, PDEK can be a useful alternative for visual rehabilitation as it demonstrates favorable visual outcomes with a good graft survival rate.

Reverse four-throw technique for pupilloplasty

PURPOSE

To describe Reverse four-throw (RFT) technique for pupilloplasty.

METHODS

The technique involves making a single pass through the anterior chamber that helps achieve a posteriorly directed suture knot. A single arm 9-0 polypropylene suture attached to long arm needle engages the iris defects with the tip of the needle piercing the iris tissue from the posterior surface and emerging from the anterior aspect. The suture end is passed from the loop with four throws taken consecutively in the same direction that create a self-sealing and self-retaining lock like single-pass four-throw technique but with the difference that the knot slides on the posterior surface of the iris tissue.

RESULTS

The technique was performed in 9 eyes and the suture-loop easily slided along the posterior surface of iris tissue. The iris defect was well approximated in all the cases and the suture knot or suture tail was not visible in the anterior chamber. Anterior segment optical coherence tomography depicted smooth iris configuration with no suture extrusion in the anterior chamber.

CONCLUSIONS

The RFT technique provides an effective measure to seal the iris defect with the absence of knot in AC.

Radial keratotomy and cataract surgery: A quest for emmetropia

A 75-year-old man with an ocular history of 8-cut radial keratotomy (RK) in both eyes presented for cataract surgery evaluation. He was previously correctable in spectacles in years prior despite his irregular corneas to 20/25 in the right eye and 20/30 in the left eye. He recently noticed a change in his overall visual function with significant nighttime glare and difficulty reading despite spectacle correction. Of note, he was unable to tolerate contact lenses and was resistant to refitting despite additional encouragement. Cataract surgery was delayed for many years, given he was correctable in spectacles and the concern of uncovering a highly aberrated cornea after removing his cataracts (Figures 1 and 2JOURNAL/jcrs/04.03/02158034-202308000-00021/figure1/v/2023-07-21T030437Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202308000-00021/figure2/v/2023-07-21T030437Z/r/image-tiff). Of note, the patient was interested in returning to the spectacle independence he enjoyed in the past. Ocular examination revealed a corrected distance visual acuity (CDVA) of 20/30 in the right eye and 20/60 in the left eye, with a manifest refraction of +4.50 -0.50 × 177 in the right eye and +5.75 -1.75 × 14 in the left eye. Glare testing was 20/50 in the right eye and 20/100 in the left eye, with retinal acuity meter testing of 20/25 in each eye. Pupils, confrontation visual fields, and intraocular pressures were normal. Pertinent slitlamp examination revealed corneal findings of 8-cut RK with nasal-gaping arcuate incisions in both eyes and lens findings of 2+ nuclear sclerosis with 2+ cortical changes in the right eye and 3+ nuclear sclerosis with 3+ cortical changes in the left eye. Cup-to-disc ratios of the optic nerves measured 0.5 with temporal sloping in the right eye and 0.6 with temporal sloping in the left eye. The dilated fundus examination was unremarkable. What intraocular lens (IOL) options would you offer this patient and how would you counsel regarding realistic expectations? What additional diagnostic testing would be helpful in your assessment? How would you calculate the IOLs?

Photo-induced high-temperature ferromagnetism in YTiO3

In quantum materials, degeneracies and frustrated interactions can have a profound impact on the emergence of long-range order, often driving strong fluctuations that suppress functionally relevant electronic or magnetic phases^1-7. Engineering the atomic structure in the bulk or at heterointerfaces has been an important research strategy to lift these degeneracies, but these equilibrium methods are limited by thermodynamic, elastic and chemical constraints⁸. Here we show that all-optical, mode-selective manipulation of the crystal lattice can be used to enhance and stabilize high-temperature ferromagnetism in YTiO₃, a material that shows only partial orbital polarization, an unsaturated low-temperature magnetic moment and a suppressed Curie temperature, T_c = 27 K (refs. ^9-13). The enhancement is largest when exciting a 9 THz oxygen rotation mode, for which complete magnetic saturation is achieved at low temperatures and transient ferromagnetism is realized up to T_neq > 80 K, nearly three times the thermodynamic transition temperature. We interpret these effects as a consequence of the light-induced dynamical changes to the quasi-degenerate Ti t_2g orbitals, which affect the magnetic phase competition and fluctuations found in the equilibrium state^14-20. Notably, the light-induced high-temperature ferromagnetism discovered in our work is metastable over many nanoseconds, underscoring the ability to dynamically engineer practically useful non-equilibrium functionalities.

Comparative Analysis of 10-2 Test on Advanced Vision Analyzer and Humphrey Perimeter in Glaucoma

Purpose

To evaluate diagnostic precision and prove equivalence of 2 devices, Advanced vision analyzer (AVA, Elisar Vision Technology) and Humphrey field analyzer (HFA, Zeiss) for the detection of glaucoma on 10-2 program.

Design

Prospective, cross-sectional, observational study.

Participants

Threshold estimates of 1 eye each of 66 patients with glaucoma, 36 control participants, and 10 glaucoma suspects were analyzed on 10-2 test with AVA and HFA.

Methods

Mean sensitivity (MS) values of 68 points and central 16 test points were calculated and compared. Intraclass correlation (ICC), Bland-Altman (BA) plots, linear regression of MS, mean deviation (MD), and pattern standard deviation (PSD) were computed to assess the 10-2 threshold estimate of the devices. Receiver operating characteristic curves were generated for MS and MD values, and the area under the curve (AUC) was compared with assessing diagnostic precision.

Main Outcome Measures

Mean sensitivity values of 68 points and central 16 points, AUC for MS and MD values, ICC values, BA plots, and linear-regression analysis.

Results

Bland-Altman plot showed significant correlation for MS, MD, and PSD values for both devices. For MS, the overall ICC value was 0.96 (P < 0.001) with a mean bias of 0.0 dB and limits of agreement range of 7.59. The difference in MS values between both devices was -0.4760 ± 1.95 (P > 0.05). The AUC for MS values for AVA was 0.89 and for HFA was 0.92 (P = 0.188); whereas it was similar at 0.88 for MD values (P = 0.799). Advanced vision analyzer and HFA identically discriminated between healthy and patients with glaucoma (P < 0.001), although HFA denoted marginally greater ability (P > 0.05).

Conclusions

Statistical results denote adequate equivalence between AVA and HFA because threshold estimates of AVA strongly correlate with HFA for 10-2 program.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

When the savior becomes a demon: Silicon oil synechia-induced glaucoma

Background

Silicon oil is an important adjunct for achieving internal tamponade in the treatment of retinal detachment. Silicone oil tamponade often leads to narrowing of the angle and development of adhesions between the iris and anterior chamber angle structures, with consequential elevation of the intraocular pressure. The video showcases the management of these challenging scenarios.

Purpose

To highlight the management of early synechial closures due to silicon oil tamponade.

Synopsis

The video highlights the management of early synechial closure following silicon oil tamponade. Surgical pupilloplasty has been demonstrated to break the peripheral anterior synechias on intraoperative gonioscopy as well as on anterior segment optical coherence tomography (AS-OCT). Performing pupilloplasty in the early phase of development of peripheral anterior synechias (PAS) helps to break the existing synechias and prevent angle closure and sequential deterioration of vision.

Highlights

Surgical pupilloplasty helps to relieve the post silicon oil-induced secondary angle closure glaucoma by breaking the peripheral anterior synechias and significantly opening the anterior chamber angles.

Online Video Link

https://youtu.be/xe2NGlhPBF4.

Control of structure and spin texture in the van der Waals layered magnet CrSBr

Controlling magnetism at nanometer length scales is essential for realizing high-performance spintronic, magneto-electric and topological devices and creating on-demand spin Hamiltonians probing fundamental concepts in physics. Van der Waals (vdW)-bonded layered magnets offer exceptional opportunities for such spin texture engineering. Here, we demonstrate nanoscale structural control in the layered magnet CrSBr with the potential to create spin patterns without the environmental sensitivity that has hindered such manipulations in other vdW magnets. We drive a local phase transformation using an electron beam that moves atoms and exchanges bond directions, effectively creating regions that have vertical vdW layers embedded within the initial horizontally vdW bonded exfoliated flakes. We calculate that the newly formed two-dimensional structure is ferromagnetically ordered in-plane with an energy gap in the visible spectrum, and weak antiferromagnetism between the planes, suggesting possibilities for creating spin textures and quantum magnetic phases.

Twofold technique for iridodialysis repair

Background

Disinsertion of iris leads to debilitating sequelae like diplopia and glare. Hence, iridodialysis repair is essential to optimize the visual quality. Iris base repair often leads to corectopia that necessitates an additional procedure to optimize the pupil shape and size. Twofold technique helps to achieve both the aspects.

Purpose

To highlight the technique of twofold iridodialysis repair.

Synopsis

The video highlights the method of twofold iridodialysis repair, wherein nonappositional repair is followed by single-pass four-throw (SFT) pupilloplasty that allows adequate closure of varied degrees of iridodialysis along with centration of eccentric pupil.

Highlights

The twofold technique is a combination of nonappositional iris repair and SFT procedure. It can be clinically applied in all cases of iridodialysis with varied degrees of severity.

Online Video Link

https://youtu.be/OncBdz2UIBY.

Innovation Urrets-Zavalia syndrome

Background

Surgeons often notice unexplained dilation of the pupil following an uncomplicated intra-ocular surgery. No definite line of treatment has been proposed for managing Urrets-Zavalia syndrome (UZS). The authors have previously documented the results of surgical pupilloplasty and have outlined this modality of treatment for cases with UZS.

Purpose

To highlight the aspect of development of UZS post-operatively in the eyes following an intra-ocular surgery.

Synopsis

The video highlights the aspect of prevalence of the persistently dilated pupil that is non-responsive to topical miotics. Apart from associated glare, these cases often have raised intra-ocular pressure because of appositional closure of the anterior chamber angle. Surgical pupilloplasty pulls the iris tissue centrally, eventually releasing the mechanical blockage and often breakage of the peripheral anterior synechias as demonstrated by intra-operative gonioscopy and anterior segment optical coherence tomography.

Highlights

Performing a surgical pupilloplasty can resolve the UZS, and timely intervention can also prevent the development of secondary glaucoma because of fallback of the iris tissue on the structures of the anterior chamber angle.

Online Video Link

https://youtu.be/IF_w8dVk5_w.

Nanoscale lattice dynamics in hexagonal boron nitride moiré superlattices

Twisted two-dimensional van der Waals (vdW) heterostructures have unlocked a new means for manipulating the properties of quantum materials. The resulting mesoscopic moiré superlattices are accessible to a wide variety of scanning probes. To date, spatially-resolved techniques have prioritized electronic structure visualization, with lattice response experiments only in their infancy. Here, we therefore investigate lattice dynamics in twisted layers of hexagonal boron nitride (hBN), formed by a minute twist angle between two hBN monolayers assembled on a graphite substrate. Nano-infrared (nano-IR) spectroscopy reveals systematic variations of the in-plane optical phonon frequencies amongst the triangular domains and domain walls in the hBN moiré superlattices. Our first-principles calculations unveil a local and stacking-dependent interaction with the underlying graphite, prompting symmetry-breaking between the otherwise identical neighboring moiré domains of twisted hBN.

Here, the authors investigate the lattice dynamics of twisted hexagonal boron nitride layers via nano-infrared spectroscopy, showing local and stacking-dependent variations of the optical phonon frequencies associated to the interaction with the graphite substrate.

Pinhole Pupilloplasty for Higher Order Aberrations: Assessment of Visual Quality and Depth of Focus

PURPOSE

To evaluate visual quality and depth of focus under photopic and mesopic light conditions of patients treated with pinhole pupilloplasty (PPP) for corneal higher order aberrations.

METHODS

This was a prospective, noncomparative, interventional series and PPP was performed with a single-pass four-throw procedure in 14 eyes of 14 patients. After PPP, patients were analyzed with the Clinical Trial Suite machine (M & S Technologies, Inc) that offers a standardized method of recording visual quality. The luminance levels of 85 and 3 cd/m² were set for photopic and mesopic lighting conditions, respectively, and uncorrected and corrected distance visual acuity were recorded for distance (4 m), intermediate (66 cm), and near (44 cm). Low contrast acuity (LCA) at 10% and mesopic contrast sensitivity function (CSF) with glare on and off at four spatial frequencies of 1.5, 3, 6, and 12 cycles per degree (cpd) and defocus curve were assessed.

RESULTS

Under photopic and mesopic conditions, a significant difference was observed postoperatively in uncorrected and corrected distance visual acuity for distance, intermediate, and near. The defocus curve demonstrated extended depth of focus that ranged from +1.50 to -2.50 diopters and LCA at 10% demonstrated significant improvement for all cases. For mesopic CSF, a significant improvement was noted at spatial frequencies of 3 and 6 cpd with glare on. With glare off, an improvement was seen at spatial frequencies of 1.5, 3, and 6 cpd, but not at 12 cpd.

CONCLUSIONS

Early results demonstrate that PPP provides improved visual quality and extended depth of focus and can be a useful option in cases with higher order aberrations. [J Refract Surg. 2020;36(12):812-819.].

Pinhole pupilloplasty after previous radial keratotomy

The multiple radial stromal deep corneal incisions placed in radial keratotomy (RK) lead to higher-order aberrations and pose a surgical challenge to performing any further corrective procedure on the cornea because of fear of inducing an incisional dehiscence. A method to perform pinhole pupilloplasty (PPP) in the setting of previous RK is presented. Application of pinhole optics by performing PPP leads to significant improvement in image quality and helps to optimize visual potential in post-RK cases.

Trocar assisted nonappositional repair of iridodialysis

PURPOSE

To describe trocar-assisted method of Nonappositional repair of iridodialysis.

METHODS

The technique described involves placement of a 25 G trocar at the limbus wherein the lumen of the cannula works as a guide to introduce a double arm polypropylene suture attached to the long arm needle thereby preventing any accidental entrapment of corneal fibers into the needle.

RESULTS

The technique was performed in 7 cases and no entrapment of corneal tissue was observed while maneuvering the suture needle through paracentesis incision during an iridodialysis repair procedure. Anterior segment optical coherence tomography demonstrated closure of the limbal trocar wound at 1-week follow-up. No incidence of wound leak or Descemets membrane detachment was observed.

CONCLUSION

The technique allows performing iridodialysis repair in technically challenging situations by directing the needle appropriately and preventing any undulating movement inside the anterior chamber. The trocar-assisted method serves as an effective method to perform non-appositional iridodialysis repair.

Modified posterior-assisted levitation with intraocular lens scaffold and glued IOL for sinking nucleus in eyes with inadequate sulcus support

Posterior-assisted levitation is used to retrieve and levitate a sinking nucleus in cataract surgery associated with posterior capsule rupture. After the nucleus is levitated in the anterior chamber, the intraocular lens (IOL) scaffold procedure helps emulsify the nuclear remnants with the phacoemulsification probe and glue-assisted intrascleral haptic fixation (glued IOL) enables appropriate placement of an IOL in cases with insufficient capsule support. We describe a triumvirate procedure for a sinking nucleus in the absence of capsule support that combines modified posterior-assisted levitation, in which the nucleus is levitated from the existing sclerotomy sites of glued IOL surgery, with the IOL scaffold technique, enabling a closed-chamber approach when performed concurrently.

An Integrated Chikungunya Virus Database to Facilitate Therapeutic Analysis: ChkVDb

Background:

Chikungunya infection flare-ups have manifested in nations of Africa, Asia, and Europe including Indian and Pacific seas. It causes fever and different side effects include muscle torment, migraine, sickness, exhaustion and rash. It has turned into another, startling general medical issue in numerous tropical African and Asian countries and is presently being viewed as a genuine risk. No antiviral treatment or vaccine is yet available for this ailment. The current treatment is centered just on mitigating its side effects.

Objective:

The objective was to encourage the study on this viral pathogen, by the development of a database dedicated to Chikungunya Virus, that annotates and unifies the related data from various resources. associations while known disease-lncRNA associations are required only.

Method:

It undertook a consolidated approach for Chikungunya Virus genomic, proteomic, phylogenetics and therapeutic learning, involving the entire genome sequences and their annotation utilizing different in silico tools. Annotation included the information for CpG Island, usage bias, codon context and phylogenetic analysis at both the genome and proteome levels.

Results:

This database incorporates information of 41 strains of virus causing Chikungunya infection that can be accessed conveniently as well as downloaded effortlessly. Therapeutics section of this database contains data about B and T cell Epitopes, siRNAs and miRNAs that can be used as potential therapeutic targets.

Conclusion:

This database can be explored by specialists and established researchers around the world to assist their research on this non-treatable virus. It is a public database available from “www.chkv.in”.</P>

Double-infusion cannula technique for glued fixation of intraocular lens with endothelial keratoplasty

OBJECTIVE

To describe double-infusion cannula technique (DICT) that involves the placement of 2 infusion cannulas in a combined surgical approach of glued intrascleral haptic fixation of intraocular lens (glued IOL) with endothelial keratoplasty (EK) in patients with aphakic bullous keratopathy.

DESIGN

Prospective, single-centre, interventional study.

PARTICIPANTS

Five eyes of 5 patients.

METHODS

The first cannula placed for fluid infusion at pars plana stabilises the globe and facilitates vitrectomy with the glued IOL procedure. Secondary IOL fixation compartmentalises the eye into anterior and posterior chamber and a continuous posterior fluid infusion prevents globe collapse in an already vitrectomized eye. The second cannula is placed at the level of limbus for pressurised air infusion that facilitates an EK procedure. When the donor graft is being unfolded, air infusion is stopped and fluid from the posterior infusion pushes up the iris IOL diaphragm and facilitates graft unfolding.

RESULTS

The mean follow-up was 14 ± 5 months (range 9-21 months). The donor age ranged from 35-57 years, and the mean percentage of endothelial cell loss calculated at 9 months follow-up was 27.32% ± 3.65%. The mean preoperative and postoperative best-corrected visual acuity was 1.02 ± 0.164 and 0.276 ± 0.173 logMAR, respectively (p = 0.000). No incidence of primary graft failure, graft rejection, or retinal detachment was reported during the entire follow-up period in any of the eyes.

CONCLUSION

DICT prevents hypotony and intraoperative pressure fluctuations, assists graft unrolling, promotes adherence to the recipient bed tissue, and prevents seepage of air into the vitreous cavity and loss of air tamponade in the anterior chamber.

Single-pass four-throw pupilloplasty for secondary angle-closure glaucoma associated with silicon oil tamponade

PURPOSE

To describe the feasibility and efficacy of performing single-pass four-throw pupilloplasty for secondary angle-closure glaucoma post silicon oil tamponade.

METHODS

The procedure was performed in five eyes of five patients. All the cases underwent silicon oil removal with single-pass four-throw pupilloplasty. Single-pass four-throw procedure involves a single pass of needle through the iris tissue that is to be apposed followed by taking four throws by passing the suture end through the loop that is withdrawn from the anterior chamber as in a modified Siepser's slip-knot technique. Both the suture ends are pulled and this leads to sliding of the loop into the anterior chamber. Surgical pupilloplasty stretches the peripheral iris tissue and helps in breaking the peripheral anterior synechia. Intraoperative gonioscopy and anterior segment optical coherence tomography were performed in all the cases.

RESULTS

Intraoperative gonioscopy and anterior segment optical coherence tomography demonstrated opening of the anterior chamber angles with breakage of peripheral anterior synechia. The mean preoperative and postoperative best-corrected visual acuity in logarithm of minimum angle of resolution was 1.24 ± 0.23 and 0.56 ± 0.18, respectively (p < 0.001). The mean preoperative and postoperative intraocular pressure was 38.2 ± 4.97 and 13.0 ± 2.35 mm Hg, respectively. There was a significant decrease in intraocular pressure and marked improvement in visual acuity in all the cases.

CONCLUSION

Surgical pupilloplasty helps to relieve the post-silicon oil-induced secondary angle-closure glaucoma by breaking peripheral anterior synechia and significantly opening the anterior chamber angles.

Sensitivity and specificity of screening tools and smear microscopy in active tuberculosis case finding

SETTING

Community based five pulmonary tuberculosis (PTB) surveys among adults.

OBJECTIVES

Estimate sensitivity and specificity of screening tools for PTB and sputum microscopy.

METHODS

For each survey site, we estimated sensitivity and specificity of different screening criteria and microscopy against culture; pooled estimates were obtained using Random Effects Model.

RESULTS

Sensitivity of cough alone, screening for any symptom (persistent cough ≥2 weeks, fever or chest pain ≥1 month, hemoptysis), any symptom or history of anti-TB treatment (h/o ATT) were 56.2%, 66% and 71.2% respectively; specificities were 95.3%, 93.8% and 92.7% respectively. X-ray when used alone for primary screening had sensitivity and specificity of 76.6% and 97.3% respectively. When used along with screening for cough, these figures were 94.3% and 93.1%, and 100% and 97.3% when used with any symptom and h/o ATT. When used for secondary screening, sensitivity and specificity of X-ray was 66.8% and 87.8% respectively after primary screening for cough, 65.0% and 89.8% after screening for any symptom, and 67.1% and 86.7% when used after screening for any symptom or h/o ATT. Pooled sensitivity and specificity of smear was 46.2% and 99.3% respectively.

CONCLUSION

Program managers may use these estimates while evaluating algorithms for active case finding.

Phacoemulsification with single-pass four-throw pupilloplasty and pre-Descemet's endothelial keratoplasty for management of cosmetic iris implant complication

Placement of an anterior chamber iris implant for cosmetic reasons has been associated with development of various complications. Even after the implant has been explanted from the eye, it leaves a trail of after effects that necessitate surgical management. We describe a technique that comprises of performing phacoemulsification with single-pass four-throw pupilloplasty and a pre-Descemet's endothelial keratoplasty procedure for this eye with cosmetic iris implant complication.

Single-pass four-throw pupilloplasty for Urrets-Zavalia syndrome

PURPOSE

To demonstrate the efficacy and initial results of single-pass four-throw pupilloplasty in cases of Urrets-Zavalia syndrome.

METHODS

In this prospective interventional study, single-pass four-throw was performed to reconstruct the pupil in all symptomatic cases with Urrets-Zavalia syndrome. Applanation tonometry, indentation gonioscopy, and anterior segment optical coherence tomography for anterior chamber angle assessment were performed in all the cases.

RESULTS

Out of 10 cases that were identified with Urrets-Zavalia syndrome, the procedure was performed in 7 cases, whereas 3 cases were left untreated, as they did not have any visual complaints. Five out of seven eyes had preoperative raised intraocular pressure with appositional closure of the angle. Postoperatively, intraocular pressure was controlled in all the eyes, whereas one eye required antiglaucoma medications to control the intraocular pressure. The mean preoperative and postoperative best-corrected visual acuity was 1.1 ± 1.2 and 0.4 ± 0.4 LogMar, respectively. There was a significant improvement in the best-corrected visual acuity (p = 0.0169) in the postoperative period. The mean preoperative and postoperative intraocular pressure was 26.6 ± 11.23 and 16.3 ± 2.98 mm Hg, respectively (p = 0.0168). All the patients had a minimum of 6-month follow-up period (range = 6-8 months).

CONCLUSION

Single-pass four-throw can be employed for cases with Urrets-Zavalia syndrome, and single-pass four-throw helps to prevent the postoperative glare and narrows down the pupil size effectively. Single-pass four-throw helps to alleviate the anterior chamber angle apposition in patients with Urrets-Zavalia syndrome by mechanically pulling the peripheral iris centrally as demonstrated on anterior segment optical coherence tomography. The study also reports the occurrence of Urrets-Zavalia syndrome after glued intraocular lens surgery.

Abstract P3-05-13: The neo-epitope landscape of breast cancer: Implications for immunotherapy

Introduction: Immune checkpoint blockade is an effective immunotherapy for multiple cancers, including a subset of TNBCs. The clinical response to checkpoint blockade correlates with high tumor mutational burden. Cancer-induced mutations are predicted to generate new HLA-binding epitopes (neo-epitopes), which are potential targets of T cells. To determine the neo-epitope load in breast cancer, we developed a rapid bioinformatics pipeline and filtering strategy, EpitopeHunter, to identify and prioritize clinically relevant neo-epitopes from the landscape of somatic mutations. Here, we determined the specificity and frequency of neo-epitopes from the TCGA dataset of invasive breast cancers.

Methods: We analyzed 842 tumor and normal breast cancer exome sequencing from the TCGA dataset. Subgroup analysis was performed based on the IHC status of ER, PR and HER2: (i) TNBC (n=98); (ii) ER and/or PR(+), Her2(-) (n=604); and (iii) ER and PR(+/-), Her-2(+) (n=140). Cancer specific mutations were called uniformly for the aligned tumor and normal pairs using VarScan2. For each annotated non-synonymous mutation, we generated all possible neo-epitopes (up to 11-mers) including the mutant amino acid. HLA typing of A, B and C MHC class I genes of each patient was determined using the POLYSOLVER algorithm. We selected high affinity binding epitopes using the IEDB prediction algorithm based on the known epitopes to identify likely binding of each neo-epitope within the suite of patient-specific HLA alleles (IEDB score &lt; 500). We then filtered the epitopes based on tumor transcript abundance using RNAseq expression for 837/842 patients. An expression value of FPKM &gt; 2 was used as a cut-off for the expressed neo-epitopes.

Results: Total mutational burden was highest for TNBC (median=53, range: 2-1162); followed by ER and PR(+/-), Her-2(+) (median=40, range: 6-4983); and lowest for ER and/or PR (+), Her-2(-) (median=30, range: 0-5515). About 15% of the nonsynonymous mutations led to the generation of neo-epitopes. The neo-epitope load (high affinity neo-epitopes with IEDB score &lt;500) is highly correlated with the mutational burden (R2= 0.8-0.9). Number of patients with at least one neo-epitope expressed in each category was: TNBC (n= 79/97, 81%); ER and/or PR(+), Her2(-) (n=478/600, 79%); and ER and PR(+/-), Her-2(+) (n=115/140, 82%). Overall, 672/837 patients have at least one predicted high affinity neo-epitope expressed, with an average of 14.7 (1-525) neo-epitopes expressed per patient.

Conclusions: We have developed a rapid bioinformatics pipeline, EpitopeHunter, for the identification of neo-epitopes from tumor sequencing data. Eighty percent of breast cancer patients have at least one expressed neo-epitope, which may serve as candidates for targeted immunotherapy.

Citation Format: Narang P, Chen M, Sharma AA, Anderson KS, Wilson Sayres MA. The neo-epitope landscape of breast cancer: Implications for immunotherapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-05-13.

Single-pass four-throw pupilloplasty for angle-closure glaucoma

Angle-closure glaucoma is characterized by appositional or synechial closure of the anterior chamber angle with glaucomatous field defects that may or may not be associated with a pupillary block. Surgical pupilloplasty with single-pass four-throw technique helps to alleviate the appositional closure along with the breakage of peripheral anterior synechia, thereby increasing the aqueous outflow and decreasing intraocular pressure.

Glued intrascleral haptic fixation of an intraocular lens

Glued intrascleral haptic fixation of an intraocular lens (glued IOL) has evolved as a technique with various modifications that are adopted and practiced by several surgeons. With adequate and appropriate haptic tuck, glued IOL imparts a stable IOL fixation and is a secured method of secondary IOL placement with no pseudophacodonesis.

Predescemetocele: A distinct clinical entity

The case report incorporates a Fourier-domain optical coherence tomography (OCT) examination for demonstration of the existence of pre-Descemet's layer (PDL; Dua's layer) overlying a descemetocele and demonstrates predescemetocele as a separate clinical entity. The prospective analysis was done in two cases that had descemetocele, and OCT demonstrated the presence of PDL over an unruptured descemetocele that offers resilience and can be treated with an elective deep anterior lamellar keratoplasty or a penetrating keratoplasty. A descemetocele, when covered with PDL, should be correctly designated as a predescemetocele. Loss of PDL leads to baring of Descemet's membrane that eventually ruptures.

Spatula scaffold: An iris-sparing technique for lensectomy

Lensectomy with vitrectomy is often performed for crystalline lenticular subluxation. We report a new technique and a practical approach that involves the placement of a spatula beneath the iris tissue that facilitates retroiridial removal of subluxated lens and acts as a scaffold by protecting the iris tissue from being accidentally trapped into the vitrectomy cutter port. Our technique facilitates management of the lens and vitreous without any trauma to the iris and secondarily obviates the need to perform an iris repair procedure that may arise due to iatrogenic reasons.

Clinical outcomes in traumatic pseudophacocele: A rare clinical entity

Purpose:

The purpose of this study is to evaluate the clinical outcomes in patients with traumatic pseudophacocele.

Methods:

In this retrospective, interventional case series, scleral wound repair with pars plana vitrectomy and glued intrascleral fixation of an intraocular lens (glued IOL) was performed in 5 eyes of 5 patients. Pupilloplasty was performed in 3 cases whereas aniridia glued IOL fixation was done in 1 case that had total avulsion and loss of iris tissue. The main outcome measures were best-corrected visual acuity (BCVA), intraoperative and postoperative complications during the entire follow-up period.

Results:

The preoperative vision ranged from hand movement to perception of light in all the patients. The mean postoperative BCVA was 0.42 ± 0.21 Snellen's decimal equivalent (SDE) at final follow-up. Postoperatively, all the cases retained good visual acuity with case 1 and case 2 reporting 0.5 SDE, case 3 had 0.33 SDE, case 5 had 0.67 SDE whereas case 4 had a final visual acuity limited to 0.1 SDE due to associated corneal opacity. The mean follow-up period was 20.2 ± 11.7 months (range from 9 months to 36 months). The IOL was well centered, all the wounds were well apposed and the mean postoperative intraocular pressure was 14.6 ± 1.95 mm Hg. No complications were reported in the entire follow-up period.

Conclusion:

The clinical outcomes of management of pseudophacocele were encouraging with retention of reasonably good visual potential in all cases.

Young donor-graft assisted endothelial keratoplasty (PDEK/DMEK) with epithelial debridement for chronic pseudophakic bullous keratopathy

OBJECTIVE

The aim of this study was to describe the applicability and report visual outcomes for the treatment of subepithelial fibrosis and anterior stromal scarring in cases of chronic pseudophakic bullous keratopathy (PBK) with epithelial debridement and endothelial keratoplasty (EK) (pre-Descemet endothelial keratoplasty [PDEK]; Descemet membrane endothelial keratoplasty [(DMEK]) using young donor tissue.

DESIGN

Prospective, single-centre, interventional study.

PARTICIPANTS

6 cases with chronic PBK (> 1 year duration).

METHODS

Case 1 underwent PDEK with glued intraocular lens (IOL) as a single-stage procedure, whereas cases 2 and 3 underwent glued IOL followed by DMEK and PDEK, respectively, as a second-stage procedure. Cases 4 and 6 underwent PDEK, whereas case 5 underwent DMEK. Epithelial debridement was performed in all cases at the time of EK, and young donor grafts were used. The main outcome measures were best spectacle-corrected visual acuity, clearance of corneal scar and haze, central corneal thickness (CCT), specular microscopy, and endothelial cell count (ECC).

RESULTS

Postoperatively, all cases demonstrated significant improvement in visual acuity. The mean value of depth of subepithelial haze was 121±71.7 µm and 25.3 ± 19.8 µm in the preoperative and postoperative periods, respectively (p = 0.028). At the 1-month follow-up, the mean preoperative CCT of 676 ± 92.7 µm was reduced to 534.6 ± 21.1µm. At the 6-month follow-up, the mean ECC loss resulting from the procedure was 36.5 ± 10.4%.

CONCLUSIONS

EK with epithelial debridement performed for the treatment of chronic PBK resulted in significantly improved visual acuity to a functional level, with the clearance of subepithelial fibrosis and anterior stromal scar, in most patients.

Pre-Descemet's endothelial keratoplasty

Endothelial keratoplasty (EK) has supplanted the penetrating keratoplasty procedure for corneal endothelial disorders. A review of literature on pre-descemet's EK, that is, a latest iterant in EK is described along with our experiences.

Vitrectomy-assisted phacoemulsification for lenticular coloboma

We describe a technique to prevent continuous vitreous hydration during phacoemulsification in eyes with lenticular coloboma. The hydration results from communication between the anterior and posterior chambers from the edges of the colobomatous defect. To avoid this, a valved trocar is placed at the pars plana site around the area of the lenticular defect, which allows a limited dry vitrectomy during phacoemulsification. Intermittent vitrectomy with a moderate cutting rate and low vacuum parameters accompanied by temporary halting of the phacoemulsification procedure prevents vitreous herniation into the anterior chamber and limits the extension of zonular compromise, facilitating safe phacoemulsification with appropriate capsule expansion and fixation devices and implantation of an intraocular lens.

Pupilloplasty for pupil size attenuation to prevent pupillary capture: Theory of quintet in glued IOL

We describe a pupilloplasty procedure to prevent a captive iris and to narrow the pupillary aperture and its associated complications. We also describe 5 surgical techniques in combination-vertical glued IOL, peripheral iridectomy, anterior sclerotomy, pupilloplasty, and application of a trocar anterior chamber maintainer-performed in eyes with a large WTW diameter; that is, the quintet in glued IOL.

FINANCIAL DISCLOSURE

Neither author has a financial or proprietary interest in any material or method mentioned.

The "correct shake" for "handshake" in glued intrascleral fixation of intraocular lens

We hereby describe the correct method to perform a "handshake technique" and easy transfer of haptics from one hand to another for glued intrascleral fixation of an intraocular lens (glued IOL). The procedure was implemented in 57 cases that necessitated the application of performing a glued IOL procedure and it resulted in an appropriate and easy externalization of haptic in all the cases. The surgeons' positioning with reference to the scleral flap is an essential component and the surgeon should always be positioned perpendicular to the plane of scleral flaps and the plane of haptic maneuver. The surgeons who intend to perform glued IOL should adopt this technical point.

Evaluation of variants of carbol fuchsin solution to stain acid-fast bacilli in-situ by the pot method

BACKGROUND

Ziehl-Neelsen (ZN) staining requires heating, and pre-stained smears contain viable bacilli.

OBJECTIVE

To evaluate four variants of carbol fuchsin solution by the pot method and compare the results with ZN staining, taking culture as gold standard.

METHOD

Five hundred sputum samples from presumptive tuberculosis cases were homogenised and divided into two parts. One part was subjected to routine ZN staining and culture on solid medium, the other was equally distributed into four pots. Equal quantities of the basic fuchsin (BF) variant were added to each pot. Variant I contained 2% BF with 10% phenol and 4% ammonium sulphate (PhAS), while Variant II had 0.6% BF with PhAS; Variants III and IV contained respectively 2% and 0.6% BF with 10% phenol only. After 1 h, smears were made from each pot and culture was performed on Löwenstein-Jensen medium. Smear results were compared with the ZN results and evaluated against culture.

RESULTS AND CONCLUSION

Variant III gave excellent results compared to ZN (κ = 0.97), with sensitivity, specificity, and positive and negative predictive values similar to those of ZN, taking culture as gold standard. Pot contents were negative for Mycobacterium tuberculosis culture.

Clinical outcomes of the glued intraocular lens scaffold

PURPOSE

To report the visual outcomes and complications of the glued intraocular lens (IOL) scaffold procedure in patients with intraoperative posterior capsule rupture and retained nuclear fragments, subluxated cataract, and Soemmerring ring associated with aphakia and deficient posterior capsule.

SETTING

Dr. Agarwal's Eye Hospital, Chennai, India.

DESIGN

Retrospective noncomparative interventional case series.

METHODS

Medical records of patients who had a glued IOL scaffold procedure performed were reviewed. The main outcome measures were visual acuity at final follow-up and intraoperative and postoperative complications during the entire follow-up.

RESULTS

The mean preoperative and mean final postoperative corrected distance visual acuity (CDVA) (Snellen decimal equivalent) in 19 eyes of 17 patients were 0.39 ± 0.13 (SD) and 0.73 ± 0.27, respectively (P = .002, Wilcoxon test). No eye lost CDVA. The CDVA was stable in 7 eyes, improved 1 line in 2 eyes, and improved 2 lines or more in 10 eyes. Postoperatively, 20/20 visual acuity was attained in 9 eyes. Intraoperatively, Soemmerring ring drop into the vitreous cavity in 1 eye and hyphema in 2 eyes were observed. Postoperative complications included corneal edema (2 eyes), choroidal detachment (1 eye), mild vitritis (1 eye), ocular hypertension (1 eye), and fibrin reaction in the anterior chamber that resolved with medical management (2 eyes).

CONCLUSION

The glued IOL scaffold enabled a closed-chamber approach with proper placement of an IOL in cases with inadequate sulcus or iris support and allowed safe emulsification of the retained nuclear fragments with good visual outcomes.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Clinical outcomes of pars plicata anterior vitrectomy: 2-year results

Purpose:

To demonstrate the safety and outcome of a surgical approach that uses pars plicata site for anterior vitrectomy during phacoemulsification procedure complicated by posterior capsule rupture and residual cortical matter.

Design:

Single center, retrospective, interventional, noncomparative study.

Materials and Methods:

Medical records of a consecutive series of 35 eyes of 35 patients who underwent pars plicata anterior vitrectomy (PPAV) were reviewed. The main outcome measures were corrected and uncorrected distance visual acuity (CDVA, UDVA), early and late postoperative complications and intraocular pressure (IOP). Ultrasound biomicroscopic (UBM) evaluation of sclerotomy site and spectral domain optical coherence tomography analysis for central macular thickness (CMT) was performed. The final visual outcome at 2 years was evaluated.

Results:

At 2 years follow-up, the mean postoperative UDVA (logarithm of the minimum angle of resolution [logMAR]) and CDVA (logMAR) was 0.49 ± 0.26 and 0.19 ± 0.14, respectively. There was no significant change in the IOP (P = 0.061) and the mean CMT at 2 years was 192.5 ± 5.54 μm. The postoperative UBM image of the sclerotomy site at 8 weeks demonstrated a clear wound without any vitreous adhesion or incarceration. Intraoperative hyphema was seen in 1 (2.8%) case and postoperative uveitis was seen in 2 (5.7%) cases, which resolved with medications. No case of an iatrogenic retinal break or retinal detachment was reported.

Conclusions:

PPAV enables a closed chamber approach, allows thorough cleanup of vitreous in the pupillary plane and anterior chamber and affords better access to the subincisional and retropupillary cortical remnant with a significant visual outcome and an acceptable complication rate.