Purpose To comprehensively review the literature regarding recurrent corneal erosion (RCE) and to present treatment options and recommendations for management. Overview RCE usually presents with sharp, unilateral pain upon awakening, in an eye with an underlying basement membrane dystrophy, prior ocular trauma, stromal dystrophy or degeneration, or prior surgery for refractive errors, cataracts, or corneal transplantation. Making the correct diagnosis requires a careful slit-lamp examination of both eyes coupled with a high degree of suspicion. Several treatments are commonly used for RCE but new therapies have been introduced recently. Conservative treatment consists of antibiotic and preservative-free lubricating drops, with topical cycloplegics and oral analgesics to control pain. Patients who are unresponsive to these therapies may benefit from therapeutic bandage contact lenses (BCL). Newer therapies include oral matrix metalloproteinase (MMP) inhibitors, blood-derived eye drops, amniotic membrane graft application, and judicious application of topical corticosteroids. Once the epithelium is healed, a course of hypertonic saline solution and/or ointment can be used. Surgical procedures may be performed in patients who fail conservative therapy. Punctal occlusion with plugs increases the tear film volume. Epithelial debridement with diamond burr polishing (DBP), anterior stromal puncture (ASP), or alcohol delamination should be considered in selected patients. DBP can be used for patients with basement membrane dystrophies and is the preferred treatment overall due to a low recurrence rate. ASP can be used for erosions outside the central visual axis. Excimer laser phototherapeutic keratectomy is an attractive option in eyes with central RCE since it precisely removes tissue while preserving corneal transparency. In patients with RCE who are also candidates for refractive surgery, photorefractive keratectomy can be considered. Summary Newly introduced therapies for RCE enable therapy to be individualized and lower the recurrence rate.

Dry eye is one of the most commonly encountered problems in ophthalmology. Signs can include punctate epithelial erosions, hyperemia, low tear lakes, rapid tear break-up time, and meibomian gland disease. Current methods of diagnosis include a slit-lamp examination with and without different stains, including fluorescein, rose bengal, and lissamine green. Other methods are the Schirmer test, tear function index, tear break-up time, and functional visual acuity. Emerging technologies include meniscometry, optical coherence tomography, tear film stability analysis, interferometry, tear osmolarity, the tear film normalization test, ocular surface thermography, and tear biomarkers. Patient-specific considerations involve relevant history of autoimmune disease, refractive surgery or use of oral medications, and allergies or rosacea. Other patient considerations include clinical examination for lid margin disease and presence of lagophthalmos or blink abnormalities. Given a complex presentation and a variety of signs and symptoms, it would be beneficial if there was an inexpensive, readily available, and reproducible diagnostic test for dry eye.

Candidate HIV-1 vaccine regimens utilizing intramuscularly (i.m.) administered recombinant adenovirus (rAd)-based vectors can induce potent mucosal cellular immunity. However, the degree to which mucosal rAd vaccine routing might alter the quality and anatomic distribution of vaccine-elicited CD8 ؉ T lymphocytes remains unclear. We show that the route of vaccination critically impacts not only the magnitude but also the phenotype and trafficking of antigen-specific CD8 ؉ T lymphocytes in mice. I.m. rAd immunization induced robust local transgene expression and elicited high-frequency, polyfunctional CD8 ؉ T lymphocytes that trafficked broadly to both systemic and mucosal compartments. In contrast, intranasal (i.n.) rAd immunization led to similarly robust local transgene expression but generated low-frequency, monofunctional CD8 ؉ T lymphocytes with restricted anatomic trafficking patterns. Respiratory rAd immunization elicited systemic and mucosal CD8؉ T lymphocytes with phenotypes and trafficking properties distinct from those elicited by i.m. or i.n. rAd immunization. Our findings indicate that the anatomic microenvironment of antigen expression critically impacts the phenotype and trafficking of antigen-specific CD8 ؉ T lymphocytes.Acute human immunodeficiency virus type 1 (HIV-1) infection is accompanied by a massive, irreversible destruction of memory CD4ϩ T lymphocytes, particularly within the intestinal mucosa (11,26,30,42), as a result of the high proportion of effector/memory target cells within the intestinal lamina propria. Chronic HIV-1 infection is characterized by inflammation within the intestinal mucosa, breakdown of epithelialbarrier integrity, and translocation of gut microflora from the intestinal lumen (10, 24). These processes may drive systemic inflammation and contribute to HIV-1 disease progression. Therefore, vaccination strategies that enhance mucosal cellular immunity and attenuate the mucosal immunopathology of HIV-1 infection would be desirable.Recombinant adenovirus (rAd) vectors are potent inducers of cellular immunity (3, 12, 25), and we have recently demonstrated that intramuscular (i.m.) rAd immunization transiently activates peripheral antigen-specific CD8 ϩ T lymphocytes and allows them to migrate to mucosal surfaces and establish potent, durable mucosal cellular immunity (22). Moreover, we have shown that an i.m. delivered heterologous rAd primeboost regimen prevented the destruction of CD4 ϩ T lymphocytes within the intestinal mucosa and attenuated disease progression following simian immunodeficiency virus (SIV) challenge (29). Notably, this vaccine regimen did not contain the SIV Env protein, indicating that cellular mucosal immunity likely played a critical role in abrogating mucosal CD4 ϩ Tlymphocyte destruction.While our laboratory and others have observed potent mucosal CD8 ϩ T-lymphocyte responses after i.m. immunization with rAd vectors (2, 21, 28, 41) and other vaccine modalities (40-41), other studies have suggested that mucosal routing of vaccine vectors may opti...

Purpose To qualitatively and quantitatively compare Optos© fundus camera fluorescein angiographic images of retinal vascular leakage with 9-field montage Topcon© fluorescein angiography (FA) images in patients with uveitis. We hypothesized that Optos images reveal more leakage in uveitis patients. Design Retrospective, observational case series. Methods Images of all uveitis patients imaged with same-sitting Optos FA and 9-field montage FA during a 9 month period at a single institution (52 eyes of 31 patients) were graded for the total area of retinal vascular leakage. The main outcome measure was area of fluorescein leakage. Results The area of apparent FA leakage was greater in Optos images than in 9-field montage images (median 22.5 mm2 vs. 4.8 mm2, P<0.0001). Twenty-two of 49 (45%) eyes with gradable photos had at least 25% more leakage on the Optos image than on the montage image. Two (4.1%) had at least 25% less leakage on Optos, and 25 (51%) were similar between the two modalities. Two eyes had no apparent retinal vascular leakage on 9-field montage but were found to have apparent leakage on Optos images. Twenty-three of the 49 eyes had posterior pole leakage, and of these 17 (73.9%) showed more posterior pole leakage on the Optos image. A single 200 degree Optos FA image captured a mean 1.50x the area captured by montage photography. Conclusion More retinal vascular pathology, both in the periphery and the posterior pole, is seen with Optos FA in uveitis patients when compared with 9-field montage. The clinical implications of Optos FA findings have yet to be determined.

Purpose To quantify differences in the age, gender, race, and clinical complexity of Medicare beneficiaries treated by ophthalmologists and optometrists in each of the United States. Design Cross-sectional study based on publicly accessible Medicare payment and utilization data from 2012 through 2017. Methods For each ophthalmic and optometric provider, demographic information of treated Medicare beneficiaries was obtained from the Medicare Provider Utilization and Payment Data from the Centers for Medicare and Medicaid Services (CMS) for the years 2012 through 2017. Clinical complexity was defined using CMS Hierarchical Condition Category (HCC) coding. Results From 2012 through 2017, ophthalmologists in every state treated statistically significantly older beneficiaries, with the greatest difference (4.99 years in 2014) between provider groups seen in Rhode Island. In most states there was no gender difference among patients treated by the providers but in 46 states ophthalmologists saw a more racially diverse group of beneficiaries. HCC risk score analysis demonstrated that ophthalmologists in all 50 states saw more medically complex beneficiaries and the differences were statistically significant in 47 states throughout all six years. Conclusions Although there are regional variations in the characteristics of patients treated by ophthalmologists and optometrists, ophthalmologists throughout the United States manage older, more racially diverse, and more medically complex Medicare beneficiaries.

Purpose: To quantify differences in the age, gender, race, and clinical complexity of Medicare beneficiaries treated by ophthalmologists and optometrists in each of the United States.

Introduction:To the author's knowledge, this is the first reported case of a delayed intracapsular hematoma after complex femtosecond laser–assisted cataract surgery (FLACS) and the use of iris retractor hooks for intraoperative floppy-iris syndrome. It is important that cataract surgeons be aware of this association.Patient and Clinical Findings:An 83-year-old man underwent FLACS with astigmatic keratotomy and intraocular lens implantation. Iris retractor hooks were used to counter intraoperative miosis. Hyphema, corneal edema, and subconjunctival hemorrhage were observed on postoperative day (POD) 1. The patient returned on POD 3 with further decrease in vision due to Descemet folds, advanced corneal edema, layered hyphema, and a dense intracapsular hematoma.Diagnosis, Intervention, and Outcomes:Minimal improvement of the hematoma occurred through 4 weeks, at which time the hematoma was drained with Nd:YAG laser posterior capsulotomy. The hematoma reabsorbed within 1 month with full recovery of vision.Conclusions:The iris retractor hooks in the setting of complex FLACS likely caused postoperative bleeding with accumulation of blood within the capsule. Nd:YAG laser posterior capsulotomy is an effective treatment option for nonclearing intracapsular hematoma.

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