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Purpose: The objective of this study is to compare the recurrence and complication rates of surgical treatment and interferon treatment for OSSN.
Participants: Ninety-eight patients with OSSN, 49 of whom were treated with interferon (IFN) a2b therapy and 49 of whom were treated with surgical intervention.
Methods: Patients with OSSN were treated with surgery versus IFNa2b therapy, either in topical or injection form. Median follow-up after lesion resolution was 21 months (range, 0e173 months) for the IFNa2b group and 24 months (range, 0.9e108 months) for the surgery group.
Main Outcome Measures: The primary outcome measure for the study was the rate of recurrence of OSSN in each of the treatment groups. 
Results: Mean patient age and sex were similar between the groups. There was a trend toward higher clinical American Joint Committee on Cancer tumor grade in the IFNa2b group. Despite this, the number of recurrences was equal at 3 per group. The 1-year recurrence rate was 5% in the surgery group versus 3%in the IFNa2b group (P ¼ 0.80). There was no statistically significant difference in the recurrence rate between the surgically and medically treated groups. Nonlimbal location was a risk factor for recurrence (hazard ratio, 8.96) in the entire study population. In patients who were treated successfully, the side effects of the 2 treatments were similar, with mild discomfort seen in the majority of patients in both groups. There was no limbal stem cell deficiency, symblepharon, or diplopia noted in either group. Two patients were excluded from the IFNa2b group because of intolerance to the medication.
Conclusions: No difference in the recurrence rate of OSSN was found between surgical versus IFNa2b therapy.


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      Specific red flag clinical signs in ophthalmology might indicate serious underlying systemic disease. This review illustrates five big  red flags in neuro ophthalmology of interest to comprehensive ophthalmologists. These clinical signs include: (i) retinochoroidal  venous collaterals, (ii) optic disc edema with a macular star, (iii) chronic red eyes refractory to topical therapy, (iv) aberrant regeneration not secondary to ischemia, and (v) the misdiagnosis of immune disease in immunosuppressed patients. We also describe the common causative factors suggested by these red flags (i.e., optic nerve sheath meningioma, infectious neuroretinitis, carotid  cavernous fistula, compressive third nerve lesions, and the incorrect diagnosis of Tolosa–Hunt syndrome [THS]), as well as the  distinctive laboratory or radiographic signs for each condition.

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In this post I would like to announce that I update my Ophthalmolgy Atlas with 40 high quality photos in the following topics:
 
-   Axenfeld-riger syndrome.
-   Boston keratoprosthesis.
-   Capsular phimosis.
-   Choroidal Tuberculoma.
-   Congenital Aniridia and cataract.
-   Epikeratoplasty.
-   Mooren ulcer.
-   Plyctenulosis.
-   Anterior Lenticonus.
  Cachet AC iol.
-   Hypotonus maculopathy.
-   Stem cell deficiency in AKC.
-   ICL with good and low vault.
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Objective: To describe the intraoperative complications and to evaluate the learning curve with femtosecond laser cataract surgery.
Design: Prospective, consecutive cohort study.
Participants: The first 200 eyes undergoing femtosecond laser cataract surgery and refractive lens exchange in a single center.
Methods: The initial 200 eyes undergoing cataract surgery between April 2011 and June 2011 by 6 surgeons were included in the study. The cases underwent anterior capsulotomy, lens fragmentation, and corneal incisions with the femtosecond laser. The procedure was completed by phacoemulsification and insertion of an intraocular lens. Data were collected about patient demographics, preoperative investigations and intraoperative complications. The cases were divided into 4 groups—group 1 included the first 50 cases, group 2 included cases 51 through 100, group 3 included cases 101 through 150, and group 4 included cases 151 through 200—and were analyzed.
Results: The mean age of patients included was 69.2 +/- 9.8 years. Of the 200 eyes, 74.5% underwent a complete procedure of laser capsulotomy, lens fragmentation, and corneal incisions. Five eyes had suction breaks during the laser procedure that led to the remainder of the laser procedure being aborted. Twenty-one (10.5%) eyes showed the presence of small anterior capsular tags. The number of eyes with free-floating capsulotomies was 35 (17.5%). The other complications during the study were anterior radial tears (n = 8; 4%), posterior capsular ruptures (n = 7; 3.5%), and dropped nucleus (n = 4; 2%). A significant difference was noted among the sequential groups with respect to the number of docking attempts (P<0.001), miosis after the laser procedure (P<0.001), and free-floating capsulotomies (P<0.001), suggesting an improving learning curve. The surgeons with prior experience with femtosecond lasers had fewer complications in the first 100 cases (P<0.001). No difference in complications was observed after the initial 100 cases.
Conclusions: In this case series, there was a clear learning curve associated with the use of femtosecond lasers for cataract surgery. Adjustment to surgical technique and prior experience with a femtosecond laser seemed to flatten the learning curve.
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                Post-keratoplasty astigmatismremains a challenge for corneorefractive surgeons.While maintaining a healthy graft is the most crucial issue in keratoplasty procedures, astigmatismis a limiting factor in the visual rehabilitation of otherwise successful corneal grafts. The management of post-keratoplasty astigmatism takes place at 2 stages: when sutures are still present at the graft–host junction and when all sutures have been removed. Excessive suture-in post-keratoplasty astigmatism is usually managed by selective suture manipulation, ie, suture adjustment and/or suture removal along the steep meridian of astigmatism. A small amount of suture-out post-keratoplasty astigmatism can be managed by spectacles. Higher magnitudes of astigmatism can be addressed by contact lenses or surgical intervention, such as relaxing and compressing procedures. Laser lamellar refractive surgery can also be used to manage post-keratoplasty astigmatism, and toric phakic intraocular lenses have recently been recommended. In this review, we discuss the etiology and management of post-keratoplasty astigmatism and provide recommendations and tips to minimize it.


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This review of wavefront technology looks at 2 aspects. The first is the basics and principles of the optics of the eye, how to decompose the wavefront in a more adequate way for interpretation and how these aberrations affect the visual acuity. It addresses the diversity and complexity of wavefront sensors; how these devices transform the principles into clinically useful data, with the advantages and limitations of each system. The second major aspect is the clinical uses of the technology: wavefront-guided and newer and enhanced profiles related to wavefront as well as the limitations of the technology. Recent innovations made possible by wavefront technology that are not limited to refractive surgery are reviewed.

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  Iris prolapse is not an uncommon occurrence during cataract surgery. It usually occurs through the main incision during hydrodissection and is commonly associated with floppy-iris syndrome; however, it can manifest in cases with no known predisposition and can occur at any stage during surgery. The mechanism is explained by the Bernoulli principle and its effect on iris position during the movement of fluid within the eye. Predisposing factors are iris configuration, anterior chamber depth, and position and architecture of the corneal tunnel. Strategies for prevention and management include the use of pharmacological agents, ophthalmic viscosurgical devices, and iris retractors. These strategies can be augmented by alteration and adaptation of the surgeon’s technique.
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Animated instruction
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Surgical Technique
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Purpose: To compare the success and complications of trabeculectomy performed with limbus-based and fornix-based conjunctival approaches.
Design: Retrospective case series with some prospective data collection.
Main Outcome Measures: (1) Success rate of trabeculectomy, as determined by the achievement of each of our different IOP goals, with or without IOP-lowering medications; and (2) incidence of surgical complications.
Results: During the 4 years after surgery, the success rates of limbus-based and fornix-based trabeculectomy were not statistically different for any of our IOP criteria. Blebs after limbus-based surgery were more likely to be graded as higher and to be avascular (GEE model, both P 0.0001). Four percent of eyes experienced late-onset bleb leaks within 4 years after both limbus- and fornix-based operations; however, limbus-based cases developed bleb leaks significantly later than did fornix-based cases (2.1 vs. 1.0 years; P 0.002, GEE model). Late bleb-associated infection during the first 4 years after surgery occurred more often in limbus-based operations, although statistical significance was borderline (P 0.054, Cox model). Symptomatic hypotony during all available follow-up was more common with fornix-based operations (P 0.01, GEE model). Eyes undergoing the fornix-based operation had a greater risk of cataract surgery in the 4-year period after surgery (P 0.02, Cox model), and fornix-based cases requiring cataract surgery had the operation earlier than limbus-based cases(P 0.002, GEE model).
Conclusions: Success rates are similar between limbus-based and fornix-based trabeculectomy. Limbus-based procedures produce higher, more avascular blebs, with a greater risk of infection. Fornix-based procedures have more symptomatic hypotony and more and earlier cataract development.

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PURPOSE: To compare visual, refractive, and satisfactory outcomes between a new-generation sectorial addition multifocal intraocular lens (IOL) (Lentis Mplus LS-312; study group) and a diffractive apodized multifocal IOL (Restor SN6AD1; control group).
SETTING: Private practice, Driebergen, and Department of Ophthalmology, Academic Medical Center, Amsterdam, The Netherlands.
METHODS: Refractive and visual outcomes at near and distance, patient satisfaction, and dysphotopsia scores were recorded 3, 6, and 12 months postoperatively.
RESULT: The study group comprised 90 eyes and the control group, 143 eyes. Three months postoperatively, the mean uncorrected distance visual acuity (UDVA) was not statistically significantly different between the study group and the control group (0.04G0.15 logMAR [SD] versus 0.06G 0.25 logMAR). The control group had significantly better uncorrected near visual acuity than the study group at 30 cm (0.05 G 0.14 logMAR versus 0.15 G 0.08 logMAR) and 40 cm (0.05 G 0.14 versus 0.16 G 0.21) (P<.01 and P<.03, respectively). Patients in the control group were more satisfied with their vision (P<.001). Dissatisfaction was related to younger age at surgery and male sex (P<.0001 and P<.033 respectively). Dysphotopsia occurred in approximately 18% of cases in both groups.
CONCLUSIONS: The new sectorial addition multifocal IOL performed comparably to the diffractive apodized multifocal IOL in terms of UDVA and the presence of dysphotopsia. The diffractive apodized multifocal IOL performed better at 30 cm and 40 cm reading distances and had higher patient satisfaction.
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PURPOSE: To report the 3-year postoperative safety and efficacy outcomes of the Acufocus corneal inlay.
DESIGN: Prospective nonrandomized noncomparative cohort study.
METHODS: The corneal inlay was implanted in the nondominant eye of naturally emmetropic presbyopic patients. Refraction, uncorrected near (UNVA), intermediate (UIVA), and distance (UDVA) visual acuities; corrected distance visual acuity(CDVA); contrast sensitivity; visual fields; subjective patient satisfaction and symptoms; and operative and postoperative adverse events and complications were evaluated.
RESULTS: The study enrolled 32 patients. The mean UNVA improved from Jaeger (J) 6 preoperatively to J1 at 3 years and the mean UIVA, from 20/40 to 20/25, respectively. At 3 years, 97% of eyes had a UNVA of J3 or better and 91% had a UIVA of 20/32 or better. The mean UDVA was 20/20, with all eyes achieving 20/32 or better. Nine eyes (28.3%) lost 1 line of CDVA, 1 eye (3.1%) lost more than 2 lines (3.8 lines), and 3 eyes (9.3%) gained 1 line. No inlay was explanted, and no inflammatory
reactions were observed. At 3 years, 15.6% of patients reported severe night-vision problems and 6.3% (versus 87.5% preoperatively) reported being dependent on reading glasses.
CONCLUSIONS: These 3-year results support the safety and efficacy of the corneal inlay to correct presbyopia in naturally emmetropic presbyopic patients. However, despite a significant gain in UNVA and UIVA, 28.3% of patients lost 1 line of CDVA.

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Purpose: To report 1-year outcomes of Descemet’s membrane endothelial keratoplasty (DMEK) performed at 2 centers.
Design: Prospective, consecutive, interventional series.
Participants: Patients with Fuchs’ endothelial dystrophy, pseudophakic bullous keratoplasty, or failed previous graft (n=136 eyes).
Intervention: The diseased central 7 mm of Descemet’s membrane (DM) was stripped from the recipient cornea and replaced with healthy DM and endothelium stripped from donor corneas through a 2.8-mm corneal incision. Descemet’s membrane endothelial keratoplasty was performed alone (n=110) or combined with either phacoemulsification and intraocular lens implantation (n=23) or pars plana vitrectomy (n =3).
Main Outcome Measures: Best spectacle-corrected visual acuity (BSCVA), manifest refraction, and endothelial cell density.
Results: Excluding eyes with pre-existing ocular comorbidities or those lost to follow-up, mean BSCVA at 1 year was 0.07 logarithm minimum angle of resolution (logMAR) units (20/24;range, 20/15–20/40; n=81), improving from 0.51 logMAR (20/65; range, 20/20–counting fingers); 41% of the patients achieved a BSCVA of 20/20 or better, 80% could be corrected to 20/25 or better, and 98% achieved 20/30 or better vision. A refractive hyperopic shift of +0.24+-1.01 diopters (D; range, –1.50 to 2.25 D) was found at 1 year, but it was not statistically significant (P=0.08). Also, there was no significant change in the preoperative astigmatism (P=0.17). The
endothelial cell loss at 1 year was 36+-20% (n=94; range, 13%–88%), with most of the loss being observed during the first 3 months after surgery: 31+-18% (range, 3%–77%). The DMEK graft creation could not be successfully completed in 6 cases (4.2%). All these unsuccessful attempts were among the initial 40 cases. Intracameral air was used to fix graft detachments, which usually were partial and peripheral, in 62% of the cases. Eleven grafts (8%) demonstrated primary failure and 1 eye (0.7%) had secondary failure resulting from endothelial rejection. Episodes of immunologic rejection were documented in 7 eyes (5.1%) during the first year of follow-up.
Conclusions: Descemet’s membrane endothelial keratoplasty had better visual acuity results in the first year after surgery than typically reported for other endothelial keratoplasty techniques, such as Descemet’s stripping automated endothelial keratoplasty, while having less refractive changes and similar endothelial cell counts but a higher rebubbling rate.

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Most clinical trials are designated as phase I, II, III, or IV, based on the type of questions that study is seeking to answer:

In Phase I clinical trials, researchers test a new drug or treatment in a small group of people (20-80) for the first time to evaluate its safety, determine a safe dosage range, and identify side effects.

In Phase II clinical trials, the study drug or treatment is given to a larger group of people (100-300) to see if it is effective and to further evaluate its safety.

In Phase III clinical trials, the study drug or treatment is given to large groups of people (1,000-3,000) to confirm its effectiveness, monitor side effects, compare it to commonly used treatments, and collect information that will allow the drug or treatment to be used safely.

In Phase IV clinical trials, post marketing studies delineate additional information including the drug's risks, benefits, and optimal use.

These phases are defined by FDA in the Code of Federal Regulations.
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Purpose: To determine trends in incidence, treatment and survival with primary uveal melanoma in the United States over a 36-year period from 1973 to 2008.
Participants: A total of 4070 patients with primary uveal melanoma
Methods: The significance of trends in age-adjusted incidence, treatment, and 5-year relative survival rates were determined using chi-square testing and 95% confidence intervals (CIs).
Conclusions: The age-adjusted incidence of uveal melanoma (5.1 per million) has remained unchanged from 1973 to 2008. Despite a shift toward more conservative treatments, survival has not improved during this time period.



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 The Acrysof Cachet phakic lens was designed to correct moderate to high myopia but later on it was withdrawn from the market due to the unacceptable endothelial cell loss that can cause.
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● PURPOSE: To provide an update on various features of idiopathic intracranial hypertension.
● DESIGN: Perspective.
● METHODS: Selected articles on the epidemiology, clinical and imaging features, natural history, pathophysiology, and treatment of idiopathic intracranial hypertension were reviewed and interpreted in the context of the authors’ clinical and research experience.

....................................Read The Full Article
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In this post I want to announce an update to my Atlas with more than 30 interresting cases under the following categories :
- Circumscribed choroidal haemangioma.- Punctate Inner Choroidopathy with CNVM.
- Subluxated lens in Homocystinemia.- Conjunctival cyst.- canalicular laceration.and more ,,,
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Here I am again after a vacation I spent between rivers, gardens, lakes, ice skating, skydiving or paragliding and more in Europe's paradise. I want to share with you the feeling as a compensation for my abscence from my blog. Keep around for more hot topics in ophthalmology that it is always up-to-date.

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Glaucoma, primarily a disease of the older population, may affect women of childbearing age. Pregnancy affects the intraocular pressure (IOP) of women with pre-existing glaucoma. Both elevations and reductions of IOP have been reported during pregnancy. Additionally, visual field test results may fluctuate during pregnancy. In managing the pregnant glaucoma patient with medical therapy, one must consider not only the systemic side effects on the mother, but also any potentially harmful effects on the developing fetus. All anti-glaucoma medications are categorized as class C by the Food and Drug Administration, except brimonidine and nonspecific adrenergic agonists, which belong to class B. In general, the lowest effective dosage of medication should be used. Systemic absorption can be reduced by punctal occlusion, eyelid closure, and blotting the excess drops away during administration. In those patients who need surgery, most local anesthetics may be used safely because they have not been shown to be teratogenic in humans. Antifibrotic agents commonly used adjunctively in trabeculectomy, however, should be avoided. Glaucoma laser procedures, such as laser peripheral iridotomy and laser trabeculoplasty, have been employed without identifiable teratogenic effects or increased risk of side effects for pregnant women.



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