Needham, MA, United States
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Reinhart W.J.,Case Western Reserve University | Musch D.C.,University of Michigan | Jacobs D.S.,Boston Foundation for Sight | Lee W.B.,Piedmont Hospital | And 2 more authors.
Ophthalmology | Year: 2011

Objective To review the published literature on deep anterior lamellar keratoplasty (DALK) to compare DALK with penetrating keratoplasty (PK) for the outcomes of best spectacle-corrected visual acuity (BSCVA), refractive error, immune graft rejection, and graft survival. Methods Searches of the peer-reviewed literature were conducted in the PubMed and the Cochrane Library databases. The searches were limited to citations starting in 1997, and the most recent search was in May 2009. The searches yielded 1024 citations in English-language journals. The abstracts of these articles were reviewed, and 162 articles were selected for possible clinical relevance, of which 55 were determined to be relevant to the assessment objective. Results Eleven DALK/PK comparative studies (level II and level III evidence) were identified that compared the results of DALK and PK procedures directly; they included 481 DALK eyes and 501 PK eyes. Of those studies reporting vision and refractive data, there was no significant difference in BSCVA between the 2 groups in 9 of the studies. There was no significant difference in spheroequivalent refraction in 6 of the studies, nor was there a significant difference in postoperative astigmatism in 9 of the studies, although the range of astigmatism was often large for both groups. Endothelial cell density (ECD) stabilized within 6 months after surgery in DALK eyes. Endothelial cell density values were higher in the DALK groups in all studies at study completion, and, in general, the ECD differences between DALK and PK groups were significant at all time points at 6 months or longer after surgery for all of the studies reporting data. Conclusions On the basis of level II evidence in 1 study and level III evidence in 10 studies, DALK is equivalent to PK for the outcome measure of BSCVA, particularly if the surgical technique yields minimal residual host stromal thickness. There is no advantage to DALK for refractive error outcomes. Although improved graft survival in DALK has yet to be demonstrated, postoperative data indicate that DALK is superior to PK for preservation of ECD. Endothelial immune graft rejection cannot occur after DALK, which may simplify long-term management of DALK eyes compared with PK eyes. As an extraocular procedure, DALK has important theoretic safety advantages, and it is a good option for visual rehabilitation of corneal disease in patients whose endothelium is not compromised. Financial Disclosure(s) Proprietary or commercial disclosure may be found after the references. © 2011 American Academy of Ophthalmology.


Kaufman S.C.,University of Minnesota | Jacobs D.S.,Boston Foundation for Sight | Lee W.B.,Piedmont Hospital and Eye Consultants of Altanta | Deng S.X.,University of California at Los Angeles | And 2 more authors.
Ophthalmology | Year: 2013

Objective: To assess the outcomes and safety of current surgical options and adjuvants in the treatment of primary and recurrent pterygium. Methods: Literature searches of the PubMed and the Cochrane Library databases were last conducted in January 2011 using keywords and were restricted to randomized controlled trials reporting on surgical intervention for pterygium. The searches were limited to articles published in English and yielded 120 citations. Citation abstracts, and if necessary the full text, were reviewed to identify randomized controlled trials that reported recurrence as an outcome measure and had a mean follow-up of at least 6 months. Fifty-one studies comparing bare sclera excision, conjunctival or limbal autograft, intraoperative mitomycin C, postoperative mitomycin C, and amniotic membrane transplantation for primary and recurrent pterygia fit these inclusion criteria. Results: Four studies demonstrated that the conjunctival or limbal autograft procedure is more efficacious than amniotic membrane placement. Use of conjunctival or limbal autografts or mitomycin C during or after pterygium excision reduced recurrence compared with bare sclera excision alone in most studies of primary or recurrent pterygium. The outcomes of conjunctival or limbal autograft were similar to outcomes for intraoperative mitomycin C in the few studies that directly compared the 2 techniques. There is evidence that increased concentration and duration of exposure to intraoperative mitomycin C is associated with increased efficacy. Of the adjuvants studied, only mitomycin C was associated with vision-threatening complications, including scleral thinning, ulceration, and delayed conjunctival epithelialization; there is some evidence of increasing complications with increased concentration and duration of exposure. There is conflicting evidence as to whether increasing age is protective against recurrence, but the morphologic features of the pterygium were shown to affect the recurrence rate. Conclusions: Evidence indicates that bare sclera excision of pterygium results in a significantly higher recurrence rate than excision accompanied by use of certain adjuvants. Conjunctival or limbal autograft was superior to amniotic membrane graft surgery in reducing the rate of pterygium recurrence. Among other adjuvants, there is evidence that mitomycin C and conjunctival or limbal autografts reduce the recurrence rate after surgical excision of a pterygium. Furthermore, the data indicate that using a combination of conjunctival or limbal autograft with mitomycin C further reduces the recurrence rate after pterygium excision compared with conjunctival or limbal autograft or mitomycin C alone. Additional studies are necessary to determine the long-term effects, optimal route of administration, and dose and duration of treatment for mitomycin C. Factors such as availability of resources, primary or recurrent status of pterygium, age of patient, and surgeon or patient preference may influence the surgeon's choice of adjuvant because there are insufficient data to recommend a specific adjuvant as superior. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references. © 2013 American Academy of Ophthalmology.


Lim P.,Massachusetts Eye and Ear Infirmary | Ridges R.,Boston Foundation for Sight | Jacobs D.S.,Boston Foundation for Sight | Rosenthal P.,Boston Foundation for Sight
American Journal of Ophthalmology | Year: 2013

Purpose To report experience in the treatment of persistent corneal epithelial defect using overnight wear of a prosthetic device for the ocular surface. Design Retrospective interventional case series. Methods A clinical database of patients who underwent prosthetic replacement of the ocular surface ecosystem (PROSE) treatment from March 2003 to August 2008 was searched to identify patients treated for persistent corneal epithelial defect. In early 2003, overnight wear of a PROSE device and addition of commercially available, nonpreserved, topical ophthalmic moxifloxacin to the saline in the device reservoir became standard practice at this center when treating persistent corneal epithelial defect. Medical records were abstracted to obtain underlying diagnoses, previous treatments, days to re-epithelialization, and complications for subsequent analysis. Results PROSE treatment incorporating overnight wear, with adjunctive use of moxifloxacin, was employed in 20 eyes of 19 patients for a total of 372 days. Re-epithelialization occurred in 17 of 20 eyes. Median duration of treatment incorporating overnight wear was 8.5 days (range = 2-76 days). Healing occurred in ≤7 days in 12 eyes, 8-14 days in 3 eyes, and >14 days in 2 eyes (range = 1-35 days). There were no cases of microbial keratitis. Conclusions Overnight wear of a PROSE device is effective in promoting healing of persistent corneal epithelial defect. In comparison to an earlier series from this center, the rate of microbial keratitis as a complication of treatment has been reduced with the use of a nonpreserved topical fourth-generation fluoroquinolone in the device reservoir. © 2013 BY ELSEVIER INC. ALL RIGHTS RESERVED.


Papakostas T.D.,Massachusetts Eye and Ear Infirmary | Le H.-G.,Boston Foundation for Sight | Chodosh J.,Massachusetts Eye and Ear Infirmary | Jacobs D.S.,Massachusetts Eye and Ear Infirmary | Jacobs D.S.,Boston Foundation for Sight
Ophthalmology | Year: 2015

Purpose To report the visual outcomes of prosthetic replacement of the ocular surface ecosystem (PROSE) treatment in patients with ocular surface disease related to Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN). Design Retrospective cohort study. Subjects We included 86 patients (167 eyes) with history of SJS/TEN who underwent PROSE treatment from January 1, 2006, to January 1, 2011. Methods Etiology, previous interventions, change in visual acuity, change in visual function, and duration of follow-up are reported. Paired t test and Friedman test with Dunn's post hoc test for multiple comparisons were used for statistical analysis. Main Outcome Measures Visual acuity at last follow-up and visual function based on the National Eye Institute 25-item Visual Functioning Questionnaire (NEI VFQ-25) at 6 months. Results We treated 35 males and 51 females with a history of SJS/TENS; median age was 36 years. The most common reported etiologies for SJS/TENS were antibiotics (n = 25), ibuprofen (n = 15), and lamotrigine (n = 11). The median visual acuity at the initial visit was 20/60 (range, 20/400-20/25; 0.48 logarithm of the minimum angle of resolution [logMAR]), and the visual acuity at completion of customization was 20/25 (range, 20/200-20/20; 0.096 logMAR; P < 0.001), with no decline in median acuity at the end of follow-up. Median duration of follow-up was 16 months. There was a significant improvement in the visual function of the patients based on the NEI VFQ-25 questionnaire (mean of 48 points at baseline vs. mean of 72 points at 6 months; P < 0.001). In addition, there was also an improvement in the self-reported general health of the patients (mean of 57 points at baseline vs. mean of 65 points at 6 months; P < 0.01). Conclusions In a large cohort of patients with chronic ocular surface disease related to SJS/TEN, PROSE treatment offers sustained and significant large improvement in visual function and acuity. © 2015 American Academy of Ophthalmology.


Keating A.M.,Massachusetts Eye and Ear Infirmary | Jacobs D.S.,Boston Foundation for Sight
Ocular Surface | Year: 2011

Vascular endothelial growth factor (VEGF) is an angiogenic factor shown to be a critical secreted cytokine in tumorigenesis and retinal neovascularization (NV). Currently, there are two anti-VEGF agents, pegaptanib and ranizumab, approved by the United States Food and Drug Administration (FDA) for intravitreal use in the treatment of wet age-related macular degeneration (AMD). Bevacizumab is FDA-approved for intravenous administration in the treatment of several cancers and is in widespread use, off-label, as an intravitreal injection to treat a variety of retinal pathologies. Animal studies demonstrate the role of VEGF in corneal NV. There are now a number of human case series reporting the use of anti-VEGF agents, primarily bevacizumab, to treat corneal NV. This review summarizes reports to date on the use of anti-VEGF agents in the treatment of corneal NV in humans, noting the limitations of current data and the need for further studies. The experience of one clinician with the use of an anti-VEGF drug in the treatment of active corneal NV is presented. ©2011 Ethis Communications, Inc.


Rosenthal P.,Boston Foundation for Sight | Borsook D.,Harvard University
Ocular Surface | Year: 2012

The traditional model of dry eye disease based on tear deficiency has presented us with many unanswered questions. Recent studies support the notion that dry eyelike symptoms represent non-specific corneal pain and provide new insights into the mechanisms that sustain the integrity of the optical tear layer. Thus, this enigmatic disease can be viewed with a new perspective, which involves the dysfunctional corneal pain system as a central pathogenetic feature of a series of disorders collectively known today as dry eye. © 2012 Elsevier Inc.


Theophanous C.,University of Southern California | Jacobs D.S.,Boston Foundation for Sight | Jacobs D.S.,Harvard University | Hamrah P.,Harvard University
Optometry and Vision Science | Year: 2015

Purpose To illustrate that corneal neuralgia may be the basis for refractory dry eye syndrome after laser-assisted in situ keratomileusis (LASIK). Methods The methodology used is that of a retrospective medical record review of a small case series. Results Three male patients, aged 30 to 48 years, referred in 2012 for dry eye syndrome refractory to treatment within 1 year of LASIK or LASIK enhancement are reported. Each patient gave history of eye pain, light sensitivity, and difficulty with visual activities beginning within 2 months of LASIK or LASIK enhancement. Best-corrected visual acuity was 20/15 or 20/20 in each of the six eyes. Tear-centered models and metrics did not explain persistent symptoms, which was consistent with inadequate response to standard dry eye treatments used before referral and reported here. In vivo confocal microscopy was abnormal at presentation in each case and was followed over time. Treatments undertaken subsequent to referral included autologous serum tears (three cases), PROSE (Prosthetic Replacement of the Ocular Surface Ecosystem) treatment (two cases), and systemic agents for pain, anxiety, or depression (three cases). By the end of 2013, at a mean of 23 months after LASIK or LASIK enhancement, symptoms improved in all three patients. Conclusions Patients with persistent dry eye symptoms out of proportion to clinical signs after LASIK have a syndrome that may best be classified as corneal neuralgia. In vivo confocal microscopy can be informative as to the neuropathic basis of this condition. In keeping with current understanding of complex regional pain syndrome, early multimodal treatment directed toward reducing peripheral nociceptive signaling is warranted to avoid subsequent centralization and persistence of pain. Distinguishing this syndrome from typical post-LASIK dry eye remains a challenge. © 2015 American Academy of Optometry.


Gire A.,Baylor College of Medicine | Kwok A.,Boston Foundation for Sight | Marx D.,Baylor College of Medicine
Ophthalmic Plastic and Reconstructive Surgery | Year: 2013

Prosthetic replacement of the ocular surface ecosystem is a treatment developed by the Boston Foundation for Sight that uses a Food and Drug Administration-approved prosthetic device for the treatment of severe ocular surface disease to improve vision and discomfort in addition to supporting the ocular surface. Facial nerve paralysis has multiple causes including trauma, surgery, tumor, stroke, and congenital lagophthalmos. Subsequent lagophthalmos leading to exposure keratitis has been treated with copious lubrication, tarsorrhapy, eyelid weights, chemodenervation to yield protective ptosis, and palpebral spring insertion. Each of these treatments, however, has limitations and potential complications. The prosthetic replacement of the ocular surface ecosystem device provides a liquid bandage to protect the cornea from eyelid interaction and dessication in addition to improving vision. This report describes 4 patients with exposure keratitis who were successfully treated with prosthetic replacement of the ocular surface ecosystem devices at 2 clinical sites. © 2013 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.


Parminder A.,Boston Foundation for Sight | Jacobs D.S.,Boston Foundation for Sight
Current Opinion in Ophthalmology | Year: 2015

Purpose of review: The last two decades have brought advances in materials and manufacturing of large diameter rigid gas-permeable contact lenses, and a greater appreciation of the role of scleral lenses for therapeutic indications. The purpose of this review is to provide an update on the use of rigid gas-permeable scleral lenses in the management of patients with complications after refractive surgery. Recent findings: There are recent reports on clinical experience with specific scleral lens designs from single institutions in cohorts that include patients who have undergone refractive surgery. Typically, these are patients with 'irregular corneas' after radial keratotomy or LASER assisted in-situ keratomileusis, but patients with keratectasia, dry eye syndrome, and corneal neuralgia are also reported. Visual outcomes and wearing success rates are high in these reports, although outcomes for refractive surgery patients are not reported separately. Summary: Clinicians who encounter patients with complications after corneal refractive surgery should be aware of advances in scleral lenses. Scleral lenses are an alternative to surgical intervention in patients who might otherwise be considered poor contact lens candidates. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.


Borsook D.,Harvard University | Rosenthal P.,Boston Foundation for Sight
Pain | Year: 2011

Pain and focal dystonias have been associated with chronic pain conditions such as complex regional pain syndrome. Corneal pain, frequently known as "dry eye", may be a neuropathic pain condition with abnormalities of the nerve plexus. Here we present 5 case histories of patients with defined corneal pain (with associated neuropathic features) and objective measures of changes in the nerve plexus and associated blepharospasm. A putative relationship between pain and blepharospasm suggests potential involvement of the basal ganglia in both these conditions. © 2011 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

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