Almost fifteen years since its initial description, intraoperative floppy iris syndrome (IFIS) during phacoemulsification surgery remains a challenge for cataract surgeons in all its key aspects that include the stratification of the preoperative risk, preoperative prophylaxis treatment, surgery design and intraoperative management. Since its original association with tamsulosin intake, IFIS has been positively correlated with a plethora of risk factors which include: gender, age, hypertension, other a1-adrenergic receptor antagonists, finasteride, angiotensin II receptor inhibitors, benzodiazepines, antipsychotics, hypertension drugs and decreased dilated pupil diameter. The assessment and stratification of the preoperative risk is pivotal in screening patients prone to develop IFIS. For these patients, it is essential that preoperative prophylaxis, employment of necessary measures and surgical technique modifications are considered. A multidisciplinary approach of IFIS is a mandate, thus ophthalmologists, urologists and sometimes other specialties should cooperate to “educate” each other about the risks of their respective fields. They both must be aware of the joint statement on IFIS by the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery which suggests either the initiation of tamsulosin after phacoemulsification or the use of a non-selective a1-ARA for benign prostatic hyperplasia treatment. In conclusion, awareness of the risk factors associated with IFIS and their detailed preoperative documentation is crucial in addressing IFIS. The lack of such an awareness can turn a routine, uneventful surgery into one with significant visual morbidity.

Objective: To investigate the role of bandage contact lenses (BCL) and topical steroids as risk factors for the development of microbial keratitis after epithelium-off corneal collagen cross-linking (CXL).Methods and Analysis: Patients undergoing CXL between February 2011 and July 2017 were included. Patients were divided into two groups: those who were treated postoperatively with a BCL, topical antimicrobial and steroids (group 1) and those who received only a topical antimicrobial until healing of the epithelial defect before introduction of topical steroids (group 2).Results: 1273 eyes of 964 patients were included. Group 1 comprised 316 eyes and group 2 comprised 957 eyes. There were no significant differences in the presence of persisting corneal haze or scarring between the two groups (p=0.57). Microbial keratitis occurred in nine eyes (0.71% of eyes) of eight (0.83%) patients (one case was bilateral) out of 1273 eyes.Staphylococcus aureuswas cultured from corneal scrapes in seven out of nine (77.8%) cases and from contiguous sites in the two cases. All cases occurred in group 1 (incidence=2.85%) and none in group 2 (p<0.0001). A greater proportion of patients who developed microbial keratitis were atopic (75%, p=0.4).Conclusion: The use of BCL and topical steroids prior to healing of the epithelium is a significant risk factor for microbial keratitis.S. aureusis the most common micro-organism and is likely to originate from an endogenous site. Not using a BCL and delaying the introduction of topical steroids until epithelial healing significantly reduce the risk of developing microbial keratitis without increasing the risk of persistent corneal haze.

Five of 16 patients having uneventful cataract surgery over 2 consecutive days presented on the first postoperative day with painless, unexpected blurry vision; marked limbus-to-limbus corneal edema; and severe anterior chamber inflammation with hypopyon and fibrin formation. Review of the records showed the 5 patients had received an intracameral injection of generic trypan blue solution 0.06% to facilitate the capsulorhexis. Patients who had not received the trypan blue injection had an uneventful first-day check and subsequent course. Management comprised intense topical steroids and close follow-up, which led to gradual improvement in all cases. The batch of trypan blue vials was withdrawn, and there were no additional cases of toxic anterior segment syndrome (TASS). This TASS cluster highlights a rarely reported cause of the syndrome, underscoring the need for thorough documentation of solutions and/or medications used intraoperatively and surgeon awareness of possible adverse events.

To compare the incidence of intraoperative floppy-iris syndrome (IFIS) between male and female patients undergoing phacoemulsification cataract surgery, evaluate risk factors for its appearance in each sex, and assess any differences in the final visual outcomes. 2nd Department of Ophthalmology, Aristotle University of Thessaloniki, Greece. Comparative retrospective case-control study. Cataract patients with recorded IFIS of any severity occurring over 4 years in a tertiary care ophthalmic center during phacoemulsification surgery were identified and enrolled in a multivariate analysis. The study comprised 3811 eyes of 3213 patients. Of the 1678 female patients (1937 eyes) undergoing cataract surgery, IFIS was observed in 25 eyes (1.29%), whereas the incidence of IFIS in male eyes during the same period was statistically significantly higher (97 [5.17%] of 1874 eyes) (P < .0001). No statistically significant difference in age was found between male patients (72.92 years ± 6.5 [SD]) and female patients (72.04 ± 7.1 years) (P = .56). An intake of α1-receptor blockers was identified in 70 (72.2%) of 97 male IFIS cases and in none of the 25 female IFIS cases (P < .0001). The posterior capsule rupture rate was significantly higher in 7 (28%) of the 25 female IFIS cases compared with 9 (9.28%) of the 97 male IFIS cases (P = .02). The posterior capsule rupture incidence and final corrected distance visual acuity (with spectacles) were shown to correlate with the IFIS severity grade only in female patients (P < .001 and P = .02, respectively). Although the incidence of IFIS is rarer in female patients, it might significantly affect an increase in the intraoperative events rate and affect the final visual outcome correlating with the severity grade of its appearance. Predisposing risk factors differ between the sexes and surgeons should always be aware of the potentially catastrophic consequences of unforeseen IFIS.

Purpose: Experimental studies demonstrated an alteration of corneal collagen structure by prostaglandin analogues. The possible effect of the prostaglandin F _2α analogue travoprost 0.004% on the central corneal thickness (CCT) in newly diagnosed glaucoma patients was evaluated. Methods: Consecutive, interventional case series. Seventy-four patients/136 eyes with glaucoma were included in the statistical analysis. All patients received travoprost 0.004% (Travatan®) once daily in one or both eyes. CCT was measured by using noncontact optical low-coherence reflectometry prior to the treatment and after 6 and 12 months. Results: Mean CCT of all treated eyes ( n = 136) was 546.71 ± 34.63 μm at baseline, 535.14 ± 34.78 μm after 6 months, and 532.38 ± 34.18 μm after 12 months (ANOVA, P < 0.001). Ninety-five percent of all treated eyes showed a decrease of CCT. CCT reduction mainly developed within the first 6 months of the treatment period. After 12 months, a CCT reduction >30 μm occurred in 5.1% of all treated eyes. There was a significant correlation between the magnitude of corneal thinning and the initial CCT but not between corneal thinning and IOP reductions. Conclusions: Topical therapy with the prostaglandin derivate travoprost is accompanied by a significant reduction of CCT within one year of treatment. Further clinical studies are needed to evaluate the possible long-term effects of prostaglandins on the CCT of glaucoma patients.

Purpose: The aim of the present study was to evaluate the efficacy of diode laser cyclophotocoagulation (DCPC) and cyclocryotherapy (CCT) in the treatment of refractory glaucoma and compare the postoperative complications and discomfort rates. Methods: In a prospective, randomized, controlled clinical study, 40 eyes of 40 patients with refractory glaucoma were randomly assigned in 2 groups of 20 eyes each to receive either DCPC or CCT. Patients underwent follow-up examinations on the first 3 days and then 1 week and 1, 3, 6, and 12 months after initial treatment. Complications and discomfort after treatment using a visual pain analogue scale were recorded. Results: In the DCPC group, the mean intraocular pressure (IOP) decreased (p<0.05) from 44.3±16.4 mmHg preoperatively to 24.1±7.6 mmHg, 22.8±5.6 mmHg, and 22.5±5.1 mmHg 3, 6, and 12 months posttreatment, respectively. Regarding the CCT group, the mean IOP was reduced (p<0.05) from 46.5±10.4 mmHg to 26.6±12.2 mmHg, 21.2±7.7 mmHg, and 20.6±5 mmHg at the same time intervals. In the DCPC group, the mean IOP reduction was strongly correlated with the number of laser effects (r=0.65; p<0.01), but 35% needed retreatments. The mean postoperative pain was 5.6±2.9 (DCPC) vs 5.7±2.3 (CCT) (p=0.91). No severe complications were observed. Conclusions: Both DCPC and CCT proved to be safe and effective IOP-lowering methods in patients with refractory glaucoma. Diode laser cyclophotocoagulation should be considered as the primary treatment option in refractory glaucoma using an individual treatment dosage.