Difluprednate for the prevention of ocular inflammation postsurgery: an update

Eric D DonnenfeldOphthalmic Consultants of Long Island, Rockville Centre, NY, USAPurpose: To review the most recent published data regarding the novel potent steroid, difluprednate ophthalmic emulsion, 0.05%.Methods: A comprehensive search of recent published literature including difluprednate was performed. Clinical studies relevant to the characteristics and clinical efficacy of difluprednate in controlling postoperative inflammation were included, and a synopsis of each study was developed.Results: Several recent publications were identified in which difluprednate was shown to be efficacious in the treatment of postoperative inflammation in different clinical settings, including a novel perioperative regimen. Additional literature retrieved from this search included data on the relative potency of difluprednate, potential utility in the posterior segment, as well as the advantages of the emulsion formulation.Conclusion: Difluprednate has been studied extensively and shown in recent literature to be a safe and effective topical anti-inflammatory drug. The proven strength and unique formulation of difluprednate, along with its potent efficacy in treating and preventing inflammation, provides clinicians with a beneficial treatment option.Keywords: corticosteroids, anti-inflammatory, dose uniformity, relative potenc

Efficacy and wound-temperature gradient of WhiteStar technology phacoemulsification through a 1.2 mm incision

Journal ArticlePURPOSE: To evaluate the efficacy and wound-temperature gradients of WhiteStar micropulse technology using bimanual phacoemulsification without an irrigation sleeve through a 1.2 mm incision. SETTING: Island Eye Surgicenter, Carle Place, New York, USA. METHODS: Ten patients had bimanual phacoemulsification using micropulse technology without an irrigation sleeve through a 1.2 mm clear corneal incision. A thermocouple consisting of a 30-gauge copper wire was inserted into clear cornea directly adjacent to the wound to digitally record temperature gradients at the wound. Endothelial cell counts were evaluated preoperatively and postoperatively in all patients. RESULTS: All 10 patients maintained corneal clarity with no sign of thermal damage to the wound. The maximum corneal wound temperatures during phacoemulsification ranged from 24 degrees C to 34 degrees C, well below the temperature of collagen shrinkage. The endothelial cell loss at 3 months was 7%. CONCLUSIONS: Because of the decreased thermal effect with WhiteStar technology, an irrigation sleeve over the phacoemulsification needle is superfluous. As a result, bimanual phacoemulsification can be safely performed through a 1.2 mm incision

Visual Outcomes, Efficacy, and Surgical Complications Associated with Intracameral Phenylephrine 1.0%/Ketorolac 0.3% Administered During Cataract Surgery

Aim: The purpose of this study was to compare visual outcomes, surgical time, and perioperative surgical complications after intracameral use of either phenylephrine/ketorolac (P/K) or epinephrine (Epi) during cataract surgery.Methods: This was a single-center, retrospective case review of patients undergoing cataract surgery from August to November 2015. Of the 641 eyes of 389 patients who underwent cataract surgery, 260 eyes were administered phenylephrine 1.0%/ketorolac 0.3% and 381 eyes received Epi in the irrigation solution intraoperatively. All patients received a topical nonsteroidal anti-inflammatory drug regimen (bromfenac 0.07%, nepafenac 0.3%, or ketorolac 0.5%) for 3 days before surgery and topical tropicamide 1.0%, cyclopentolate 1.0%, and phenylephrine 2.5% on the day of surgery.Results: Mean length of surgery (LOS) was 15.4±0.6 minutes. Although a positive correlation was noted between patient age and LOS (p\u3c0.001), P/K was associated with a decrease in the LOS, when controlled for age quartiles. A statistically significant lower incidence of complications (1.1%) was observed with P/K use than Epi (4.5%; p=0.018). Among surgeons who used mydriatic-assist devices more frequently, P/K use was associated with a reduction in the use of these devices (p\u3c0.001). When controlling for age quartile, patients of age groups 69–76 and 76–92 years who received P/K had significantly better uncorrected visual acuity at postoperative day 1 than those receiving Epi (p=0.003).Conclusion: Intracameral use of phenylephrine 1.0%/ketorolac 0.3% during cataract surgery may be effective in maintaining mydriasis. It appears to be superior to intracameral Epi at reducing intraoperative and postoperative complications, need for pupillary dilating devices, and surgical time

Delphi Panel Consensus Regarding Current Clinical Practice Management Options for Demodex blepharitis

PURPOSE: To obtain consensus on Demodex blepharitis (DB) treatment using a modified Delphi panel process. METHODS: Literature search identified gaps in knowledge surrounding treatment of DB. Twelve ocular surface disease experts comprised the Demodex Expert Panel on Treatment and Eyelid Health (DEPTH). They completed a live roundtable discussion in addition to 3 surveys consisting of scaled, open-ended, true/false, and multiple-choice questions pertaining to the treatment of DB. Consensus for scaled questions using a 1 to 9 Likert scale was predefined as median scores of 7–9 and 1–3. For other question types, consensus was achieved when 8 of 12 panelists agreed. RESULTS: The experts agreed that an effective therapeutic agent for treatment of DB would likely decrease the necessity of mechanical intervention, such as lid scrubs or blepharoexfoliation (Median = 8.5; Range 2-9). When treating DB, panelists believed that collarettes serve as a surrogate for mites, and that eliminating or reducing collarettes should be the main clinical goal of treatment (Median = 8; Range 7-9). The panelists would treat patients with at least 10 collarettes, regardless of other signs or symptoms and agreed that DB can be cured, but there is always the possibility for a reinfestation (n = 12). There was also consensus that collarettes, and therefore mites, are the primary treatment target and the way by which clinicians can monitor patient response to therapy (Median = 8; Range 7-9). CONCLUSION: Expert panelists achieved consensus on key facets of DB treatment. Specifically, there was consensus that collarettes are pathognomonic for DB, that DB patients with \u3e10 collarettes should be treated even in the absence of symptoms, and that treatment efficacy can be tracked by collarette resolution. By increasing awareness about DB, understanding the goals of and monitoring treatment efficacy, patients will receive better care and, ultimately, better clinical outcomes

Single Cell Analysis of Short-Term Dry Eye Induced Changes in Cornea Immune Cell Populations

BACKGROUND: Twelve ocular surface disease experts convened to achieve consensus about Demodex blepharitis (DB) using a modified Delphi panel process. METHODS: Online surveys were administered using scaled, open-ended, true/false, and multiple-choice questions. Consensus for questions using a 1 to 9 Likert scale was predefined as median scores of 7-9 and 1-3. For other question types, consensus was achieved when 8 of 12 panellists agreed. Questions were randomized, and results of each survey informed the following survey. RESULTS: Twelve practitioners comprised the Demodex Expert Panel on Treatment and Eyelid Health (DEPTH). Following 3 surveys, experts agreed that DB is chronic (n = 11) and recurrent (n = 12) and is often misdiagnosed. Consensus was achieved regarding inflammation driving symptoms (median = 7; range 7-9), collarettes as the most common sign (n = 10) and pathognomonic for DB (median = 9; range 8-9), and itching as the most common symptom (n = 12). Panellists agreed that DB may be diagnosed based on collarettes, mites, and/or patient symptoms (n = 10) and felt that patients unresponsive to typical therapies should be evaluated for DB (n = 12). Consensus about the most effective currently available OTC treatment was not reached. CONCLUSIONS: The Delphi methodology proved effective in establishing consensus about DB, including signs, symptoms, and diagnosis. Consensus was not reached about the best treatment or how to grade severity. With increased awareness, eyecare practitioners can offer DB patients better clinical outcomes. A follow-up Delphi panel is planned to obtain further consensus surrounding DB treatment

Efficacy of two trabecular micro-bypass stents combined with topical travoprost in open-angle glaucoma not controlled on two preoperative medications: 3-year follow-up

PURPOSE: To evaluate the long-term intraocular pressure (IOP)-lowering effect and safety parameters following treatment with two trabecular micro-bypass stents and topical prostaglandin in phakic eyes with open-angle glaucoma (OAG) not controlled on two preoperative medications. METHODS: This prospective, single-arm, unmasked study enrolled 39 qualified phakic eyes with OAG not controlled on 2 medications, preoperative medicated IOP of 18–30 mmHg, and IOP following medication washout of 22–38 mmHg. Two trabecular micro-bypass stents were implanted as a standalone procedure, and travoprost was started on postoperative day 1. Evaluations included IOP, best-corrected visual acuity, medication use, fundus and slit-lamp examinations, visual field, cup:disc ratio, central corneal thickness, and ocular complications. Data through 18 months were summarized previously. Thirty-seven of the original 39 subjects have been followed for 3 years postoperatively; follow-up is continuing for 5 years. RESULTS: At 3 years postoperative, 97% of eyes had achieved an IOP reduction of ≥20% from baseline with a reduction of 1 medication. Eighty-six percent of eyes had IOP of ≤18 mmHg with a reduction of 1 medication. Mean medicated IOP decreased to 14.0±2.6 mmHg on 1 medication versus 22.4±2.3 mmHg on 2 medications preoperatively. The mean unmedicated IOP decreased to 17.7±1.7 mmHg at 37 months from 25.3±1.9 mmHg preoperatively. Long-term postoperative adverse events included cataract surgery in 3 eyes due to cataract progression, and trabeculectomy in 1 eye due to uncontrolled IOP of 23 mmHg. No intraoperative or device-related adverse events occurred. CONCLUSION: Significant and sustained reduction in IOP and medications with a favorable safety profile was shown through 3 years after implantation of 2 trabecular micro-bypass stents combined with postoperative travoprost in phakic OAG eyes uncontrolled on 2 preoperative medications. These findings demonstrate the long-term performance and safety of trabecular bypass stents in combination with topical prostaglandin for OAG patients