Umeå University's logo

PURPOSE: To assess Uveitis-Glaucoma-Hyphaema syndrome (UGH syndrome) with focus on resolution, glaucoma development and risk factors.

METHODS: This retrospective case-control study with a cross-sectional component was performed to compare three groups with 71 patients each: UGH syndrome, dislocated intraocular lens (IOL) without UGH syndrome and ordinary pseudophakia. Main outcome measures were resolution of the UGH syndrome, best-corrected visual acuity (BCVA) and the need of glaucoma therapy. We also assessed the IOL-iris contact signs and the use of blood thinners.

RESULTS: Uveitis-Glaucoma-Hyphaema (UGH) syndrome resolved in 77 % of patients who underwent various kind of IOL surgery. Intraocular pressure (IOP) decreased and BCVA improved in the operated cases (p = 0.02 and p < 0.001, respectively), but not in the cases treated conservatively. Intraocular pressure (IOP) ≥22 mmHg at the first haemorrhage predicted the need of glaucoma therapy after UGH syndrome resolution (p = 0.002, area under the curve = 0.8). Fifty-one per cent of patients without preexisting glaucoma needed glaucoma therapy after UGH syndrome resolution. Pseudophacodonesis was seen more frequently in the UGH group than in the ordinary pseudophakia group (p = 0.001). Iris defects were not more frequent in the UGH group than in the Dislocated group but the types of defects differed (p < 0.0001). Blood thinners were not more frequent in UGH.

CONCLUSION: In UGH syndrome, the results are better with surgical intervention than with conservative treatment, but surgery does not guarantee resolution. Pseudophacodonesis is a risk factor for UGH syndrome, but blood thinners are not, and iris defects are not specific to UGH syndrome. A high IOP at the first haemorrhage increases the risk for needing subsequent IOP-lowering therapy.

PURPOSE: To evaluate the efficacy and safety of iris suture fixation of out-of-the-bag dislocated three-piece intraocular lenses (IOL).

METHODS: In a retrospective interventional consecutive case series, a chart review was performed in two groups of patients: fourteen patients with a dislocated out-of-the-bag three-piece IOL that underwent IOL fixation to the iris using the Siepser sliding knot technique (Iris group) and 18 patients with in-the-bag dislocation that underwent IOL exchange with a new scleral-sutured IOL (Exchange group). The Iris and Exchange groups were compared regarding surgical safety and efficacy. The median follow-up time was 13.5 months [interquartile range (IQR), 10-20] in the Iris group and 12.5 (IQR, 10-14) in the Exchange group.

RESULTS: The best corrected visual acuity (BCVA) improved significantly in both groups (p = 0.005 and 0.00006, respectively). No difference in final BCVA was seen between the groups. Significantly less surgically induced astigmatism (p = 0.03) and a lower number of postoperative visits (p = 0.0006) was noted in the Iris group. Considering the type of surgery, there were few complications in the present material.

CONCLUSION: In the study, suturing dislocated three-piece IOLs to the iris appeared to be an acceptable surgical management with less surgically induced corneal astigmatism and fewer postoperative visits than IOL exchange. A larger study with a longer follow-up time would be desirable to confirm the results.

Purpose: The primary aim was to analyse regional incidences of retinopathy of prematurity (ROP) and frequencies of treatment and their relation to perinatal risk factors during a 3-year period. A secondary aim was to study adherence to the study screening protocol in the different regions. Methods: A population-based study of neonatal morbidity in extremely preterm infants in Sweden (EXPRESS) was performed during 2004-2007. Screening for ROP was to start at postnatal age 5weeks and to continue weekly until the retina was completely vascularized or until regression of ROP. Logistic regression analyses were used for evaluation of differences in incidence of Any ROP, ROP 3 or more and ROP Type 1 between the seven regions of the country. Results: The regional incidence of ROP varied between 54% and 92% for Any ROP, between 25% and 43% for ROP stage 3 or more and between 8% and 23% of infants with ROP Type 1, all of whom were treated. There was no significant difference between the regions regarding ROP Type 1, even when adjusting for known risk factors for ROP. Conclusion: The heterogeneity between the regions regarding the incidence of ROP was reduced with increasing severity of ROP, and there was no heterogeneity regarding frequency of treatment for ROP, which is the most important issue for the children. We cannot exclude observer bias regarding mild ROP and ROP stage 3 in this study.

Purpose: To determine whether intracameral acetylcholine can contract pupils dilated with intracameral mydriatics in phacoemulsification cataract surgery. Methods: A total of 60 patients were included in this prospective randomized masked study performed at ornskoldsviks Hospital Eye Clinic. The patients were randomized and were given either topical placebo and an intracameral mydriatic solution (ICM) (cyclopentolate 0.1%, phenylephrine 1.5% and xylocaine 1%) (n=30) or topical mydriatics (TM) (cyclopentolate 0.85% and phenylephrine 1.5%) and xylocaine 1% intracamerally (n=30) at the start of surgery. After intraocular lens (IOL) implantation, 0.15ml 1% acetylcholine was given intracamerally in all cases. The pupil size was registered preoperatively, 45seconds after intracameral injection, after ophthalmic viscosurgical device (OVD) evacuation, 30seconds after acetylcholine injection, 2min after acetylcholine injection and the day after surgery. Results: The pupil contraction and pupil size after acetylcholine injection showed no significant differences at 30seconds (contraction 1.0 +/- 0.4 in ICM group versus 0.9 +/- 0.4 in TM group; p=0.75; size 4.8 +/- 1.1 in the ICM group versus 5.2 +/- 1.1 in the TM group; p=0.24) or at 2min (contraction 1.5 +/- 0.6 in the ICM group versus 1.4 +/- 0.6 in the TM group; p=0.63; size 4.3 +/- 0.9 in the ICM group versus 4.7 +/- 1.0 in the TM group; p=0.13). No difference in baseline pupil size after ophthalmic viscosurgical device (OVD) evacuation was seen between the two groups (5.8 +/- 0.9 in the ICM group versus 6.1 +/- 1.2 in the TM group; p=0.28). Conclusion: We here show that intracameral acetylcholine contracts pupils as effectively after dilatation with intracameral mydriatics as after dilatation with topical mydriatics. Cataract surgeons can feel comfortable and safe when using intracameral mydriatics, even if pupil contraction with acetylcholine should be required.

Purpose: To compare refractive changes after corneal crosslinking with and without mechanical compression of the cornea.

Methods: In a prospective, open, randomized case-control study conducted at the Department of Ophthalmology, Umeå University Hospital, Sweden, sixty eyes of 43 patients with progressive keratoconus aged 18-28 years planned for corneal crosslinking and corresponding age- and sex-matched control subjects were included. The patients were randomized to conventional corneal crosslinking (CXL; n = 30) or corneal crosslinking with mechanical compression using a flat rigid contact lens sutured to the cornea during treatment (CRXL; n = 30). Subjective refraction and ETDRS best spectacle-corrected visual acuity (BSCVA), axial length measurement, keratometry and pachymetry were performed before and 1 and 6 months after treatment.

Results: The keratoconus patients had poorer BSCVA, higher refractive astigmatism and higher keratometry readings than the control subjects at baseline (p < 0.01). In the CXL group, BSCVA increased from 0.19 ± 0.26 to 0.14 ± 0.18 logMar (p = 0.03), and the spherical equivalent improved from -1.9 ± 2.8 D to -1.4 ± 2.4 D (p = 0.03). Maximum keratometry readings decreased after CXL from 53.1 ± 4.9 D to 52.6 ± 5.2 D (p = 0.02), and the axial length decreased in the CXL group, likely due to post-treatment corneal thinning (p = 0.03). In the CRXL group, all the above variables were unaltered (p > 0.05).

Conclusion: At 6 months, the refractive results from CRXL did not surpass those of conventional CXL treatment. Rather, some variables indicated a slightly inferior effect. Possibly, stronger crosslinking would be necessary to stabilize the cornea in the flattened configuration achieved by the rigid contact lens.

Purpose

To analyze changes over time in biometry prediction error (BPE) after cataract surgery with special reference to the impact of gender and the intra-ocular lens (IOL) calculation formula.

Methods

About 65% of Swedish cataract surgery units participating in the outcome registration of the National Cataract Register (NCR) were included in this prospective register study. Data for planned and postoperative refraction and keratometry during the month of March 2004-2013 were analyzed, divided by gender. The newly introduced variables axial length and IOL calculation formula were analyzed for March 2013. Gender differences in BPE with correct sign (BPESign) and absolute biometry prediction error (BPEAbs) were compared for the Haigis' and Sanders-Retzlaff-Kraff T (SRK/T) formulas.

Results

The BPEAbs decreased throughout the study period. In 2004-2006, the BPEAbs was larger in women than in men (p<0.05), but this difference disappeared from 2007. For 2004 through 2009, the mean BPESign was -0.1050.79D for women, but -0.003 +/- 0.73D for men. After 2009, this myopic error for women gradually diminished. The Haigis' formula performed better in women than the SRK/T formula (p<0.001); the SRK/T formula rendered a BPESign similar to that from 2004 to 2009 in women. Women had steeper corneas and shorter axial lengths than men (p<0.001).

Conclusion

The myopic BPE in women - associated with steeper corneas and shorter axial lengths - is decreasing, possibly owing to an increased use of the Haigis' formula. Using the Haigis' formula to a higher extent can potentially further reduce the BPEs after cataract surgery.

Purpose: The primary objective of the ongoing Glaucoma Intensive Treatment Study (GITS) is to evaluate the effectiveness of immediate intensive treatment in comparison with the commonly recommended stepped regimen on the predicted visual field. The two treatment arms are also being compared regarding quality of life (QoL), intraocular pressure (IOP) reduction, frequency of reported side‐effects, adverse events and adherence to prescribed treatment.

Design: A randomized, two‐centre, prospective open‐labelled treatment trial for open‐angle glaucoma.

Participants: Individuals aged 40–78 years with previously untreated and newly diagnosed glaucoma with early to moderate visual field loss were eligible.

Methods: Patients were randomized to initial treatment either using drug monotherapy in accordance with common glaucoma guidelines or using a more intensive approach including eyedrops containing drugs from three different classes combined with 360° laser trabeculoplasty. The patients are to be followed for 5 years at visits including standard automated perimetry, optical coherence tomography (OPT) and tonometry. Change of treatment is allowed and decided upon jointly with the patient as in conventional glaucoma management.Main outcome: The estimated predicted preserved visual field and QoL at end of expected lifetime.

Results: A total of 242 patients, 45% females, mean age 68 years, were randomized. The median untreated IOP was 24 mm Hg, and the median visual field index (VFI), indicating the percentage of a full field, was 92%.

Conclusion: Glaucoma Intensive Treatment Study is a clinical trial in which two groups of patients randomized to different initial intensities of IOP‐reducing treatment are being compared with regard to rate of visual field progression and prediction of serious glaucomatous visual field loss at estimated at end of life.

Purpose: The aim of the study was to determine the perimetric rate of glaucoma progression in the ongoing Glaucoma Intensive Treatment Study (GITS) after 3 years of follow-up.

Design: This is a randomized, two-centre, prospective open-labelled treatment trial for open-angle glaucoma (OAG). Participants The participants of this study were treatment-naive patients with newly diagnosed OAG, aged 46-78 years, with early to moderate glaucomatous visual field loss scheduled to be followed for 5 years within the study.

Methods: Patients were randomized to initial treatment with either topical monotherapy or with an intensive approach using drugs from three different classes, plus 360 degrees laser trabeculoplasty. Changes in treatment were allowed. Standard automated perimetry and tonometry were performed and side-effects documented. All results are presented using intention-to-treat analysis.

Results: A total of 242 patients were randomized. After 3 years of follow-up, eight patients were lost to follow-up, six of whom were deceased. The median untreated baseline intraocular pressure (IOP) was 24 mmHg in both arms. The median IOP was almost constant over the 3 years of follow-up: approximate to 17 mmHg in the mono-arm and approximate to 14 mmHg in the multi-treatment arm. Treatment was intensified in 42% of the mono-treated patients and in 7% of the multi-treated patients. Treatment was reduced in 13% of the multi-treated patients. The median perimetric rate of progression was -0.5%/year in the mono-treated group and -0.1%/year in the multi-treated group (p = 0.03).

Conclusion: The rate of disease progression was significantly slower in the multi-treated patients than in the mono-treated patients. Further follow-up will show whether this difference is sustained over time.

Purpose: The primary objective was to evaluate prescribing trends for topical ocular hypotensive treatment in the Nordic region during the last decade and, by population projections, estimate the glaucoma burden in 2040. A secondary objective was to analyse national variations in prescription patterns across the Nordic region.

Methods: A retrospective analysis of national pharmacy data between 2008 and 2017 on the dispensation of topical ocular hypotensive treatment in the Nordic region was performed. Predictions of the glaucoma burden in 2040 were calculated from official population projections.

Results: The total number of patients with ocular hypotensive treatment in the Nordic region increased from 346 000 to 418 000 (21%) between 2008 and 2017. The number of patients with ocular hypotensive treatment in the age group of 50 years and older increased from 3.6% to 3.9%. The daily defined dose (DDD) per patient and day during the study period increased from 1.22 to 1.26. Adjusted for beta-blocker combinations, the same value increased from 1.49 to 1.67. Across the Nordic countries, Finland had almost twice as many DDD per patient and day in 2017 (2.1) compared with Iceland (1.1). Between 2008 and 2017, the annual treatment cost for ocular hypotensive treatment in the Nordic region decreased from 96 million to 87 million Euro (−9%). In 2040, the number of patients with ocular hypotensive treatment in the Nordic region is estimated to 633 000 individuals (+51% compared with 2017).

Conclusions: The study revealed an increased use of glaucoma medications in the Nordic region the last decade. This was mainly caused by an increased number of patients with ocular hypotensive treatment, but also because of a more intensive treatment. Marked national differences were detected. Due to the introduction of generic medications, the total cost for ocular hypotensive treatment did however decrease during the last decade. In 2040, the current number of individuals with ocular hypotensive treatment is estimated to have increased with an additional 50% due to a growing number of ageing individuals. This will lead to higher costs, not only for medications but also for diagnosing, monitoring and other aspects of glaucoma care.

Purpose: To evaluate phenotypes caused by different RLBP1 mutations in autosomal recessive retinitis pigmentosa of Bothnia type. Methods: Compound heterozygotes for mutations in the RLBP1 gene [c.677T>A]+[c.700C>T] (p.M226K+p.R234W), n=10, aged 7-84years, and homozygotes c.677T>A (p.M226K), n=2, aged 63 and 73years, were studied using visual acuity (VA), low-contrast VA, visual fields (VFs) and optical coherence tomography (OCT). Retrospective VA and VFs, standardized dark adaptation and full-field electroretinograms (ERGs) were analysed and prolonged dark adaptometry and ERG (at 24hr) were performed. Results: Progressive decline of VA and VF areas was age-dependent. Retinal degenerative maculopathy, peripheral degenerative changes and retinitis punctata albescens (RPA) were present. Early retinal thinning in the central foveal, foveal (O 1mm), and inner ring (O 3mm) in the macular region, with homogenous, high-reflectance RPA changes, was visualized in and adjacent to the retinal pigment epithelium/choriocapillaris using OCT. Reduced dark adaptation and affected ERGs were present in all ages. Prolonged dark adaptation and ERG (at 24hr), an increase in final threshold, and ERG rod and mixed rod/cone responses were found. Conclusions: The two RLBP1 genotypes presented a phenotypical and electrophysiological expression of progressive retinal disease similar to that previously described in homozygotes for the c.700C>T (p.R234W) RLBP1 mutation. The uniform phenotypical expression of RLBP1 mutations is relevant information for the disease and of importance in planning future treatment strategies.

Corneal dystrophies are a heterogeneous group of genetic disorders. We aimed to identify genetic cause of a dominantly inherited Epithelial Recurrent Erosion Dystrophy (ERED )‐like disease common in Northern Sweden. Examinations and interviews were performed at the Ophthalmology Clinics of the University Hospital of Umeå and Skellefteå Hospital. A total of 20 patients from Västerbotten were extensively examined and blood samples for genetic analysis collected. Four unrelated families were subject to genealogical studies. Known genes causative of corneal dystrophies were excluded by array‐based allele specific primer extension. Haplotype assessment was done by array genotyping and identification of potentially causative genomic variants by whole exome sequencing (WES ). The dystrophy common in Västerbotten has three phases; recurrent erosions during childhood, alleviated symptoms in the higher teens and finally, after the age 40, decreased visual acuity. Haplotype analysis and WES revealed a novel mutation, c.2816C>T, p.T939I, in the COL 17A1 gene coding collagen type XVII alpha1. It appeared to be a founder mutation that segregated with disease in a genealogically expanded pedigree dating back 200 years to a common ancestor, Theodor. Notably, the patients called the disease ‘Theodor's eyes’, but Theodor being unknown to them. Furthermore, COL 17A1 expression in cornea was demonstrated by RT ‐PCR and immunohistochemistry. We identified COL 17A1 mutation as a cause of ERED , revealing a novel corneal disease in Sweden, and highlighting the necessity of COL 17A1 screening in corneal dystrophies with erosions and no known genetic defect. Our genealogical analysis identified a common ancestor, Theodor, living 200 years ago.

Purpose: To investigate the anatomical and functional outcomes of acute-onset endophthalmitis after small-gauge vitrectomy. Methods: Retrospective case series of patients who underwent 23- or 25-gauge vitrectomy at four centres in Sweden between 2008 and 2012. Postvitrectomy endophthalmitis was identified through the search of the journal records of each institution, and the diagnosis was based on clinical criteria regardless of culture results. Results: Twenty-four patients (24 eyes) were included. The incidence of endophthalmitis following small-gauge vitrectomy was 0.14%. Indications for small-gauge vitrectomy enclosed epiretinal membrane (n=13), retinal detachment (n=5) and others (n=6). Surgical technique included 23- and 25-gauge vitrectomy (23:1). Four eyes had sutured sclerotomies, and two had postoperative hypotony <7mmHg. Days to endophthalmitis presentation varied between 1 and 21 (mean 66). Treatment methods included the following: tap and antibiotic injection (n=7), tap, antibiotic injection with subsequent vitrectomy (n=2) and prompt vitrectomy with antibiotics (n=15). Sixteen eyes (66.7%) were culture positive, whereas the other eight cases were culture negative. Anatomical results included evisceration (n=1), phthisis (n=1), and globe intact (n=22). Presenting best corrected visual acuity (BCVA) were hand motion (n=14), light perception (n=7), counting fingers (n=2), and no data (n=1). Functionally 19 eyes (79%) had Snellen VA 0.1; 11 eyes (46%) had VA 0.5 Mean logMar BCVA preoperatively and at the last follow-up were 2.07 +/- 0.6 and 0.79 +/- 0.99, respectively. Conclusions: In spite of good anatomical and functional results, this study showed higher rate of endophthalmitis than the latest reports suggesting that small-gauge vitrectomy has reached the safety level of standard 20-gauge vitrectomy when infectious endophthalmitis is concerned.

Purpose: To explore the relationship between acquisition of new spectacles after routine cataract surgery and vision‐related activity limitation (VRAL) postoperatively.

Methods: This cohort study with intervention (survey) included 1329 patients in Sweden who had undergone a second‐eye cataract surgery during March 2013. Data from the Swedish National Cataract Register were used, including evaluations of VRAL through the Catquest‐9SF questionnaire before and 3 months after cataract surgery. Five months after the second‐eye surgery, patients completed another five‐item questionnaire about spectacle use preoperatively and postoperatively including an item on surgeons’ advice about the need for spectacles. These responses were linked to the Rasch‐analysed Catquest‐9SF data to identify correlations with VRAL.

Results: A total of 1239 patients finally participated in the study after excluding those who did not fulfil the inclusion criteria. Patients who were advised about the need for spectacles postoperatively (n = 387) had a greater (p = 0.039) improvement in the postoperative VRAL compared to patients who were not advised (n = 691). Patients who obtained new spectacles postoperatively (n = 512) also had greater improvement (p = 0.032) compared to those who did not (n = 724).

Conclusion: The average improvements in the VRAL after surgery were significantly higher for patients who obtained new distance spectacles postoperatively and for patients who were informed about the need for spectacles by their practitioners.

PURPOSE: To explore patients' obtaining and use of spectacles after routine cataract surgery.

METHODS: The study included 1329 patients who underwent bilateral surgery with the second eye operated during March 2013 at 38 different clinics in Sweden. Five months after the second-eye surgery, patients completed a five-item questionnaire about their spectacle use preoperatively and postoperatively. The responses were linked to data from the registry on multiple variables including postoperative refraction, age and gender.

RESULTS: Of the 387 patients who were advised by their surgeons to obtain distance spectacles postoperatively, most did so (77.3%, n = 299), while of the 691 patients who were not so advised, most did not obtain spectacles (78.9%, n = 545). Nevertheless, almost 50% of patients with both spherical and cylindrical errors exceeding 1 dioptre (D) did not obtain new distance spectacles postoperatively, while about 25% of patients with bilateral emmetropia (spherical error <0.5 D, cylinder <1 D) obtained new distance spectacles postoperatively.

CONCLUSION: Patients' choices regarding obtaining and using new spectacles postoperatively are strongly correlated with advice given by the surgeon about the need for distance correction. The large difference between groups who were and were not advised to obtain spectacles for distance correction was only partially reflected in the postoperative refractive errors. Similarly, the patterns of preoperative spectacle use and gender or age differences did not explain this difference.

Purpose: Intrauterine undernutrition is associated with increased risk of type 2 diabetes. Children born premature or small for gestational age were reported to have abnormal retinal vascularization. However, whether intrauterine famine act as a trigger for diabetes complications, including retinopathy, is unknown. The aim of the current study was to evaluate long-term effects of perinatal famine on the risk of proliferative diabetic retinopathy (PDR).

Methods: We studied the risk for PDR among type 2 diabetes patients exposed to perinatal famine in two independent cohorts: the Ukrainian National Diabetes Registry (UNDR) and the Hong Kong Diabetes Registry (HKDR). We analysed individuals born during the Great Famine (the Holodomor, 1932–1933) and the WWII (1941–1945) famine in 101 095 (3601 had PDR) UNDR participants. Among 3021 (251 had PDR) HKDR participants, we studied type 2 diabetes patients exposed to perinatal famine during the WWII Japanese invasion in 1942–1945.

Results: During the Holodomor and WWII, perinatal famine was associated with a 1.76-fold (p = 0.019) and 3.02-fold (p = 0.001) increased risk of severe PDR in the UNDR. The risk for PDR was 1.66-fold elevated among individuals born in 1942 in the HKDR (p < 0.05). The associations between perinatal famine and PDR remained statistically significant after corrections for HbA1c in available 18 507 UNDR (padditive interaction < 0.001) and in 3021 HKDR type 2 diabetes patients (p < 0.05).

Conclusion: In conclusion, type 2 diabetes patients, exposed to perinatal famine, have increased risk of PDR compared to those without perinatal famine exposure. Further studies are needed to understand the underlying mechanisms and to extend this finding to other diabetes complications.

PURPOSE: To compare objective refraction using small-zone eccentric laser ray tracing (LRT) wavefront aberrometry to standard autorefraction in keratoconus (KC), and whether the visual acuities achieved with these refractions differ from corresponding values in healthy eyes.

METHODS: Twenty-nine eyes of 29 patients with KC and 29 eyes of 29 healthy controls were included in this prospective unmasked case-control study. The uncorrected (UCVA) and spectacle-corrected (SCVA) Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuities based on refractions derived from LRT in central and four eccentric zones were compared to those achieved with standard autorefraction. The spherical equivalent (M) and two astigmatic power vectors (C0 and C45) were calculated for all refractions. Pentacam HR(®) was used to generate keratometry readings of the corresponding zones.

RESULTS: In KC, the refraction from the upper nasal zone rendered a higher SCVA than the standard autorefraction more often than in the controls (p < 0.001). There were no significant variation in M between the different LRT measurement points in the control group, but central data provided the best SCVA. The UCVA:s and SCVA:s were worse in KC, and the KC eyes showed inferior myopia and superior hyperopia. Multiple refractions rendered similar SCVA:s in KC. Pentacam HR(®) showed higher keratometry readings infero-temporally, but also lower readings supero-nasally, compared to controls.

CONCLUSION: In KC, eccentric LRT measurements gave better SCVA than standard autorefraction more often than in healthy eyes. Eccentric LRT may become a valuable tool in the demanding task of subjective refraction in KC.

Purpose To investigate the central and paracentral astigmatism and the significance of centration and measurement zone diameter compared to a 3-mm pupil-centred measurement zone in keratoconus and in healthy eyes.

Methods Twenty-eight right eyes from 28 KC patients with an inferotemporal cone were selected according to specified criteria based on Oculus Pentacam HR (R) measurements and were matched with healthy control eyes. The flat (K1) and steep (K2) keratometry readings were registered from the Total Corneal Refractive Power' (TCRP) display as well as the anterior and posterior corneal astigmatism displays (ACA and PCA, respectively). Astigmatic power vectors KP0 and KP45 were calculated and analysed for a 6-mm and two 3-mm zones centred on the corneal apex and the pupil, and for 8 paracentral 3-mm zones.

Results The astigmatism was generally higher in KC. Many astigmatic values in KC differed between the 3-mm pupil-centred and the 3- and 6-mm apex-centred zones in KC. In the controls, no corresponding differences between measurement zones were seen, apart from PCA, which differed. The magnitude and direction of KP0 and KP45 varied greatly between the paracentral measurements in KC.

Conclusion Centration and measurement zone diameter have great impacts on the astigmatic values in KC. A small pupil-centred measurement zone should be considered when evaluating the astigmatism in KC.

Purpose: To evaluate photorefractive intrastromal cross‐linking (PiXL) treatment for low‐grade myopia, comparing three treatment protocols.

Methods: Healthy individuals, 25.6 ± 3.6 years of age, with low‐grade myopia underwent epi‐on PiXL with either: 4‐mm zone treated in high oxygen environment (4 mm‐HIGH; n = 15), 4‐mm/room air (4‐mm LOW; n = 6), or 6‐mm/high oxygen (6‐mm HIGH; n = 6). Efficacy was determined by change in uncorrected visual acuity (UCVA), manifest refractive spherical equivalent (MRSE) and corneal curvature (K_mean) over a 12‐month follow‐up. Safety was determined by best spectacle corrected visual acuity (BSCVA), corneal endothelial cell loss and registration of side‐effects.

Results: Twenty‐seven subjects were included. Due to insufficient effect with the 4‐mm LOW treatment and an unacceptable degree of initial light sensitivity/ocular irritation in the 6‐mm HIGH group, the inclusions to these treatments were stopped after inclusion of 6 patients in each group. The 4‐mm HIGH treatment showed a significantly larger improvement in UCVA (−0.45 ± 0.27 LogMAR) and MRSE (+0.99 ± 0.44 D) at 1, 6 and 12 months compared with the 4‐mm LOW treatment (p < 0.05). At 12 months posttreatment, endothelial cell count and BSCVA were unaltered. More initial side‐effects were noted with the 6‐mm HIGH treatment, compared with the 4‐mm HIGH treatment (p < 0.05).

Conclusion: Epi‐on PiXL may become a safe and effective non‐ablative treatment for low‐grade myopia. The effect is augmented by high oxygen environment and remains stable for 12 months. The initial ocular irritation is acceptable with a 4‐mm treatment zone. The present results justify further clinical studies on PiXL, including refinements of the technique and long‐term results.

Purpose: To analyse the temperature of the corneal surface in keratoconus during corneal customized crosslinking (CXL) with a preserved epithelium (epi-on) under oxygen flow, and epi-off CXL in room air, and to assess the effect of pre-heating the oxygen.

Methods: This masked, intra-individual comparing randomized study included 14 participants with bilateral progressive keratoconus treated with bilateral CXL: one eye with epi-on CXL under a flow of 2.5 L/min oxygen; the fellow eye with epi-off CXL in room air. In a second setting involving 12 healthy participants, room-tempered oxygen was flushed over one eye and oxygen pre-heated to 37°C over the fellow eye. The corneal surface temperature was assessed with infrared photography.

Results: A reduction in corneal surface temperature was seen from the pre-treatment application of topical riboflavin in the epi-off group (−1.1 ± 1.0°C, p < 0.001). The temperature increased during the first half of the CXL treatment in both groups (+0.7 ± 1.2°C, p = 0.041 for epi-on; +0.7 ± 0.9°C, p = 0.023 for epi-off CXL, respectively). In epi-on CXL an overall temperature increase was seen during the treatment (+0.8 ± 1.2°C, p = 0.016). In the second setting, pre-heating the oxygen rendered a surface temperature increase of +1.8 ± 0.2°C (p < 0.001).

Conclusion: In epi-off CXL, the application of topical room-tempered riboflavin decreases the corneal surface temperature, likely due to increased evaporation. A slight temperature increase is seen during CXL with both epi-on and epi-off CXL, albeit far below the corneal safety limit. The corneal temperature can, however, be increased by applying pre-heated oxygen, a possible approach to modify or augment the treatment effect in CXL.

Purpose To study the occurrence of severe visual impairment (SVI) and treatment outcome at 12months in patients treated for wet age-related macular degeneration (AMD) by use of data from the Swedish Macula Register (SMR) and referrals to the regional low vision clinics in five northern counties.

Methods Referrals to low vision clinics during 2005, 2009 and 2013 and treatment outcome at 12months from the SMR database from 2008 until 2013 in patients >65years of age in five northern counties were included in the survey.

Results The rate of referral due to AMD was significantly reduced during the time period (-48%; p<0.001). At 12months, a significant slight mean improvement in logMAR visual acuity (VA) was observed (-0.01, SD 0.37; p<0.001) after a mean of 5.02.3 anti-vascular endothelial growth factor (VEGF)-injections were administered. Age and low baseline VA was associated with less favourable visual outcome (p<0.001).

Conclusion Referral rate to low vision clinic is a valuable tool for estimating occurrence of SVI and fell between the years 2005 until 2013. Data from the SMR showed improvement in visual acuity on the whole, but also identified patients at high risk for developing SVI during anti-VEGF-treatment.

Purpose: Retinopathy of prematurity (ROP) causes childhood blindness globally in prematurely born infants. Although increased levels of oxygen supply lead to increased survival and reduced frequency of cerebral palsy, increased incidence of ROP is reported.

Methods: With the help of a Swedish register for ROP, SWEDROP, national and regional incidences of ROP and frequencies of treatment were evaluated from 2008 to 2015 (n = 5734), as well as before and after targets of provided oxygen changed from 85–89% to 91–95% in 2014.

Results: Retinopathy of prematurity (ROP) was found in 31.9% (1829/5734) of all infants with a gestational age (GA) of <31 weeks at birth and 5.7% of the infants (329/5734) had been treated for ROP. Analyses of the national data revealed an increased incidence of ROP during the 8‐year study period (p = 0.003), but there was no significant increase in the frequency of treatment. There were significant differences between the seven health regions of Sweden, regarding both incidence of ROP and frequency of treatment (p < 0.001). Comparison of regional data before and after the new oxygen targets revealed a significant increase in treated ROP in one region [OR: 2.24 (CI: 1.11–4.49), p = 0.024] and a borderline increase in one other [OR: 3.08 (CI: 0.99–9.60), p = 0.052].

Conclusion: The Swedish national ROP register revealed an increased incidence of ROP during an 8‐year period and significant regional differences regarding the incidence of ROP and frequency of treatment.

PurposeTo investigate whether recent Swedish guidelines for Retinopathy of Prematurity (ROP) screening, that is, a gestational age (GA) at birth of <31weeks (w), are applicable in a new national cohort of prematurely born infants. MethodsSWEDROP is a national register for ROP, initiated in 2006. The present paper reports on data from the register on various aspects of screening for ROP in infants born between 2010 and 2011 and compares the results with those for a previously published cohort born between 2008 and 2009. ResultsDuring the study period, 1744 infants were screened for ROP. Mean GA was 28.4w (22-31), and mean birth weight was 1239g (382-2615). Screening started at postnatal age (PNA) 5.4w (0.4-13.3) and postmenstrual age (PMA) 33.8 w (24.9-50.1) Mean number of examinations was 5.4 per infant (1-38). Mild (stages 1-2) and severe ( stage 3) ROP was found in 15.4% and 8.7%, respectively. Treatment was performed in 4.2% (73/1744) of the infants, but in none with a GA of 30weeks or more. The first treatment was performed at a mean PNA and PMA of 12.7 w (7.7-25.4) and 37.4 w (32.1-51.4), respectively. ConclusionsRecently introduced new guidelines for ROP screening in Sweden remain applicable. Reassuringly, in infants born between 2010 and 2011, incidence of ROP, frequency and timing of treatment, frequency and timing of examinations and national coverage of ROP screening remained almost identical to those for a previous cohort from 2008 to 2009. The two SWEDROP cohorts provide a basis for discussion among Swedish ophthalmologists and neonatologists on the question of further lowering the upper screening limit with 1week.

Purpose: This study aimed to investigate various aspects of treatment for retinopathy of prematurity (ROP) in Sweden over the past 14 years, nationally and at a hospital level.

Methods: Data on screening and treatment for ROP in infants born in Sweden from 2008 to 2021 were extracted from the national ROP register, SWEDROP. During this period, Swedish screening guidelines were reduced from gestational age (GA) < 32 weeks to <31 weeks in 2012 and to <30 weeks in 2020.

Results: Altogether, 10 959 infants were screened and 600 infants treated for ROP during the study period. Parallel to changed guidelines, the number of screened infants decreased (p < 0.000) and the incidence of ROP and frequency of treatment increased (p < 0.001), while both remained similar in infants with a GA below 30 weeks. Among treated infants, GA and BW were reduced over the years (p < 0.001). Laser treatment (85.2% of primary treatments) became less common and anti-VEGF injections (13.6%) became more common over time (p < 0.001). Altogether 16 eyes were treated with the encircling band and 13 with vitrectomy. The total frequency of retreatment (32.7% of treated eyes) remained similar over time but was more common after primary anti-VEGF injection (67.7%) than laser treatment (27.2%). There were differences between the seven university hospitals regarding type of treatment and number of retreatments (p < 0.001).

Conclusion: The frequency of treatment and retreatment for ROP remained similar over time, but the type of treatment changed and anti-VEGF injections became more common. Differences between treating hospitals emphasize the importance of centralizing the most severe cases.

Purpose: To compare the mydriatic effect of intracamerally injected isoprenaline plus phenylephrine to phenylephrine alone and to epinephrine in a porcine eye model, aiming to eventually find the best combination of adrenergic substances for surgical mydriasis in humans.

Methods: In this study, we used 89 intact eyes from newly slaughtered pigs, pretreated with 2.0 mg of intracameral acetylcholine. After waiting 60 seconds for miosis to develop, 0.15 ml 0.3% isoprenaline and 0.15 ml 3.0% phenylephrine were injected sequentially with a 90-second interval in 21 eyes. In another 22 eyes, the same substances were given in the reverse order. In 20 eyes, 0.15 ml of 0.025% epinephrine was injected, and as a negative control 0.15 ml of balanced salt solution was injected in 26 eyes. The pupils were filmed during the treatments, and the mean pupil diameters were measured every 15 seconds from the video recordings.

Results: Phenylephrine injected after isoprenaline had a larger mydriatic effect than epinephrine (p < 0.01). Without isoprenaline pretreatment, the mydriatic effect of phenylephrine was significantly smaller than that of epinephrine (p < 0.05). Isoprenaline also exhibited a small mydriatic effect of its own.

Conclusions: The β-receptor stimulator isoprenaline enhances the mydriatic effect of intracameral phenylephrine, indicating a role for the β-receptor in the mydriatic response. Mydriasis mediated by β-receptors may explain why nonspecific adrenergic stimulators such as epinine and epinephrine can have larger mydriatic effects than the specific α(1) -receptor stimulator phenylephrine.

Purpose:

To investigate the effects of repeated measurements of intraocular pressure (IOP) using Goldmann applanation tonometry (GAT) and applanation resonance tonometry (ART) to identify mechanisms contributing to the expected IOP reduction.

Methods:

A prospective, single-centre study with six healthy volunteers. Consecutive repeated series (six measurements/serie/method) were made alternately on both eyes for 1 hr with oxybuprocaine/fluorescein in the right eye and tetracaine in the left. The left eye was Pentacam((R)) photographed before and repeatedly for 20 min after the IOP measurements. On a separate occasion, the same volunteers received the same amount of anaesthetic drops for 1 hr but without repeated IOP measurements.

Results:

A significant IOP reduction occurred with both ART and GAT in the oxybuprocaine-treated eye, -4.4 mmHg and -3.8 mmHg, respectively and with ART in the tetracaine eye, -2.1 mmHg. There was a significant difference in IOP reduction between the oxybuprocaine and tetracaine eyes with ART. There was a significant drop in anterior chamber volume (ACV) immediately after the IOP measurements, -12.6 mu l that returned to pretrial level after 2 min. After 1 hr of receiving anaesthetic eye drops (without IOP measurements), the IOP decreased significantly in the oxybuprocaine eye for both ART and GAT, -3.1 and -1.7 mmHg, respectively, but not in the tetracaine eye (p = 0.72).

Conclusion:

The IOP reduction cannot be explained solely by aqueous humor being pressed out of the anterior chamber. While significant IOP reduction occurred with both tetracaine and oxybuprocaine after repeated mechanical applanation, the IOP reduction was significantly greater with oxybuprocaine.

Purpose

Inherited retinal dystrophies (IRDs) represent a group of progressive conditions affecting the retina. There is a great genetic heterogeneity causing IRDs, and to date, more than 260 genes are associated with IRDs. Stargardt disease, type 1 (STGD1) or macular degeneration with flecks, STGD1 represents a disease with early onset, central visual impairment, frequent appearance of yellowish flecks and mutations in the ATP‐binding cassette subfamily A, member 4 (ABCA4) gene. A large number of intronic sequence variants in ABCA4 have been considered pathogenic although their functional effect was seldom demonstrated. In this study, we aimed to reveal how intronic variants present in patients with Stargardt from the same Swedish family affect splicing.

Methods

The splicing of the ABCA4 gene was studied in human embryonic kidney cells, HEK293T, and in human retinal pigment epithelium cells, ARPE‐19, using a minigene system containing variants c.4773+3A>G and c.5461‐10T>C.

Results

We showed that both ABCA4 variants, c.4773+3A>G and c.5461‐10T>C, cause aberrant splicing of the ABCA4 minigene resulting in exon skipping. We also demonstrated that splicing of ABCA4 has different outcomes depending on transfected cell type.

Conclusion

Two intronic variants c.4773+3A>G and c.5461‐10T>C, both predicted to affect splicing, are indeed disease‐causing mutations due to skipping of exons 33, 34, 39 and 40 of ABCA4 gene. The experimental proof that ABCA4 mutations in STGD patients affect protein function is crucial for their inclusion to future clinical trials; therefore, functional testing of all ABCA4 intronic variants associated with Stargardt disease by minigene technology is desirable.

Purpose: Compare (a) nonmitomycin C (MMC) trabeculectomy and 1.5% dexamethasone nanoparticle (DexNP) eye drops postoperatively with (b) trabeculectomy with MMC and Maxidex® eye drops postoperatively.

Methods: Randomized prospective single masked clinical trial with 20 patients with primary open‐angle glaucoma undergoing primary trabeculectomy. The study group consisted of 10 patients without MMC intraoperatively and postoperative DexNP eye drops, and the control group consisted of 10 patients treated with MMC intraoperatively and postoperative Maxidex®. The drops were tapered out over 8 weeks. The main outcome measures were as follows: rates of complete success, that is intraocular pressure (IOP) within target pressures at different time‐points without IOP‐lowering medication, or reoperation. Secondary outcome measures included the following: relative success rate (with IOP‐lowering medications), number of glaucoma medications and reoperations. Patients were followed for 36 months.

Results: Both groups showed similar postoperative course and IOP reduction. Intraocular pressures (IOPs) in the DexNP group and in the control group were 25.6 and 24.4 mmHg, respectively, at baseline. Intraocular pressures (IOPs) were reduced to 13.2 and 14.5 mmHg at 12 months, 11.7 and 12.6 mmHg at 24 months and 11.7 and 12.1 mmHg at 36 months, respectively. There were no statistically significant differences between the groups in absolute (p = 0.36) or relative (p = 1.0) success rates, number of medications (p = 0.71) or reoperations (p = 1.0) between the groups at any time‐point.

Conclusions: DexNP eye drops are effective postoperative treatment following trabeculectomy. The potent anti‐inflammatory and antifibrotic effect of DexNP may offer an alternative to mitomycin C in glaucoma surgery.

PURPOSE: We have developed nanoparticle γ-cyclodextrin dexamethasone (DexNP) and dorzolamide (DorzNP) eye drops that provide sustained high drug concentrations on the eye surface. To test these characteristics, we measured dexamethasone and dorzolamide levels in tear fluid in humans following eye drop administration.

METHODS: Concentration of dexamethasone was measured by mass spectrometry. One drop of DexNP was instilled into one eye. Tear fluid was sampled with microcapillary pipettes at seven time-points after drop instillation. Control eyes received Maxidex(®) (dexamethasone). The same procedure was performed for dorzolamide with DorzNP and Trusopt(®) .

RESULTS: Six subjects were included in each group. The peak concentration (μg/ml ± standard deviation) of dexamethasone for DexNP eye drops (636.6 ± 399.1) was up to 19-fold higher than with Maxidex(®) (39.3 ± 18.9) (p < 0.001). At 4 hr, DexNP was still 10 times higher than Maxidex(®) . In addition, DexNP resulted in about 30-fold higher concentration of dissolved dexamethasone in the tear fluid of extended time period allowing more drug to partition into the eye tissue. The overall concentration of dorzolamide was about 50% higher for DorzNP (59.5 ± 76.9) than Trusopt(®) (40.0 ± 76.7) (p < 0.05).

CONCLUSION: The results indicate high and extended concentration of dissolved dexamethasone with DexNP, which can explain the greater and longer lasting effect of dexamethasone in the cyclodextrin nanoparticle drug delivery platform. Dexamethasone seems to fit the cyclodextrin nanoparticle suspension drug delivery platform with longer duration and higher concentrations in tear fluid than available commercial drops, while dorzolamide is less suitable.

Purpose: To describe the outcomes and demographics of patients undergoing mechanical pupil dilation (MPD) during cataract surgery.

Setting: All cataract procedures performed in Umeå University Hospital and Sunderbyn, Gällivare and Piteå hospitals reported to the Swedish National Cataract Register (NCR) during 2013–2019.

Design: Retrospective cohort study based on the Swedish NCR and electronic patient records.

Methods: The number of control visits, pre- and postoperative visual acuities, surgical complications/intraoperative difficulties, ocular comorbidities and postoperative treatment regimens were retrieved for all cataract procedures with MPD. For each procedure, the consecutive procedure in the NCR from the same clinic without MPD was chosen to form a control group. A multinominal regression analysis with MPD as the dependent variable was performed to identify factors and outcomes independently associated with MPD.

Results: A total of 25 349 patients aged 18–97 years underwent cataract surgery in these hospitals during the study period. Of these, 653 (2.6%) had MPD. Factors such as pseudoexfoliations and capsule staining were over-represented among MPD eyes. As a group, eyes with MPD had more postoperative visits and more postoperative anti-inflammatory drops, and more frequently needed augmentation of the anti-inflammatory treatment at the first postoperative visit.

Conclusions: MPD is independently associated with a more complicated intra- and postoperative course with more follow-up visits and requires more anti-inflammatory treatment postoperatively. This information could be added to the postoperative counselling, and more postoperative anti-inflammatory treatment could be considered in cases with MPD.

Purpose: To study the prioritization effects of the of COVID-19 pandemic on Swedish cataract surgery using a national healthcare registry with high coverage.

Setting: A study from the Swedish National Cataract Register (NCR), involving all patients undergoing cataract surgery in Sweden during 2019–2022 – before, during and after the COVID-19 pandemic.

Results: With the pandemic outbreak, the number of cataract surgeries fell by 22% in 2020 (15 369 procedures), albeit with large regional differences (−43% to +58%). The numbers recovered in 2021, and in 2022, a new top notation was seen (n = 149 952). On a national level, the patients were younger (−0.46 years, p < 0.001), with a larger proportion of less difficult cases (p < 0.001) and the proportion of males was higher (p < 0.001) during the pandemic, but all these variables also differed substantially between different regions and clinics.

Conclusion: A national registry with high coverage can map the consequences of an event disrupting elective surgery in detail. During the COVID-19 pandemic, the impact on Swedish cataract surgery varied largely between different regions, clinics, and healthcare providers, leading to inequality in the availability of surgery. These differences likely owed to variations in healthcare policy approaches in different parts of the country. The present study shows that outcomes at one clinic or region cannot be extrapolated to larger regions under these circumstances. It actualizes the need to aim for a healthcare on equal terms, but it also shows a system that delivers care to many despite difficult times.

Purpose: To examine feasibility of phase-contrast magnetic resonance imaging (PCMRI) and to assess blood flow rate in the ophthalmic artery (OA) in patients with normal tension glaucoma (NTG) compared with healthy controls.

Methods: Sixteen patients with treated NTG and 16 age- and sex-matched healthy controls underwent PCMRI using a 3-Tesla scanner and ophthalmological examinations. OA blood flow rate was measured using a 2D PCMRI sequence with a spatial resolution of 0.35 mm(2).

Results: The blood flow rate in the NTG group was 9.6 +/- 3.9 ml/min [mean +/- SD] compared with 11.9 +/- 4.8 ml/min in the control group. Resistance Index (RI) and Pulsatility Index (PI) were 0.73 +/- 0.08 and 1.36 +/- 0.29, respectively, in the NTG group and 0.68 +/- 0.13 and 1.22 +/- 0.40, respectively, in the healthy group. The mean visual field index (VFI) was 46% +/- 25 for the worse NTG eyes. The measured differences observed between the NTG group and the control group in blood flow rate (p = 0.12), RI (p = 0.18) and PI (p = 0.27) were non-significant.

Conclusions: This case-control study, using PCMRI, showed a slight, but non-significant, reduction in OA blood flow rate in the NTG patients compared with the healthy controls. These results indicate that blood flow may be of importance in the pathogenesis of NTG. Considering that only a limited portion of the total OA blood flow supplies the ocular system and the large inter-individual differences, a larger study or more advanced PCMRI technique might give the answer.

Purpose: To study newly diagnosed glaucoma patients given mono‐ or multi‐therapy regarding differences in initial intraocular pressure (IOP) reduction, target IOP levels reached and influence of untreated baseline IOP on IOP reduction.

Methods: Patients newly diagnosed with manifest primary open‐angle glaucoma and included in the Glaucoma Intensive Treatment Study (GITS) were randomized to immediate intensive treatment with any of three different IOP‐lowering substances supplied in two bottles plus 360° laser trabeculoplasty or to conventional stepwise treatment starting with a single‐drug. Intraocular pressure reduction was analysed 1 month after initiation of treatment.

Results: One hundred eighteen patients (143 eyes) received mono‐therapy and 122 patients (152 eyes) multi‐therapy. Median baseline IOP was 24.0 (min: 9.7, max: 56.0) mmHg in mono‐therapy eyes and 24.0 (min: 12.3, max: 48.5) mmHg in multi‐therapy eyes (p = 0.56). After 1 month in the two groups, respectively, values for median IOP reduction were 6.3 (range: −5.3–31.0) and 11.0 (range: 0.7–34.5) mmHg, and for mean relative decline 26.8 (range: −32.0–55.4) and 46.0 (range: 4.6–81.6) % (p = 0.000). A larger proportion of the multi‐therapy patients reached each target IOP level (p = 0.000). The higher the baseline IOP, the larger the observed pressure reduction, considering both absolute and relative figures. The effect was more pronounced in eyes with multi‐therapy than in those with mono‐therapy (p = 0.000). For every mmHg higher IOP at baseline, the IOP was reduced by an additional 0.56 (mono‐therapy) or 0.84 (multi‐therapy) mmHg.

Conclusion: Intensive treatment led to considerably greater IOP reduction than mono‐therapy. Among patients with IOP ≥30 mmHg at diagnosis an IOP of <16 was reached in 2/3 of those with multi‐therapy but in none with mono‐therapy. The IOP reduction was highly dependent on the untreated IOP level.

Purpose: To report the results from a nationwide survey on glaucoma management in Sweden, performed as a part of an Open Angle Glaucoma project conducted by the Swedish Council on Health Technology Assessment 2004-2008. Methods:  In 2005, a survey was distributed to all providers of glaucoma care in Sweden: public eye departments, public outpatient departments and private practices. The questionnaire included questions on number of examined patients, types of examinations during one defined week, internal organization and access to diagnostic equipment. The questionnaire was endorsed by the Swedish Ophthalmological Society. Reminders were sent out to nonresponders. Results:  Response rate was high; 97% (33/34) of eye departments, 85% (39/46) of outpatient departments and 55% (69/125) of private practices. Out of 29 282 visits in ophthalmic care during the study week, 7737 (26%) were related to glaucoma. Diagnostic equipment was generally available; all public eye facilities and 92% of private practices had at least one computerized perimeter, while equipment for fundus photography/imaging was available at 100% of eye departments, 82% of outpatient departments and 62% of private practices. The number of visual field tests and fundus images was rather low. Survey results indicate that patients on the average underwent bilateral field testing every 2nd year and fundus imaging every 8th year. Conclusion:  Glaucoma care generated about a quarter of all patient visits in Swedish ophthalmic care. Access to diagnostic facilities was good. To meet modern standards of glaucoma care, glaucoma damage must be measured and followed more closely than at the time of the survey.

Purpose: To evaluate the long-term safety of intracameral mydriatics (ICM) in phacoemulsification cataract surgery compared with conventional topical mydriatics (TM). Methods: A total of 45 patients were examined 6 years after phacoemulsification cataract surgery. The patients had previously participated in a prospective randomized double-blind study including 60 patients, operated with either ICM or TM. The follow-up included best-corrected visual acuity (BCVA), intraocular pressure (IOP), grade of posterior capsule opacification (PCO), YAG laser capsulotomy rate, pupil size, corneal thickness and endothelial morphology. Results: No differences in postoperative BCVA, IOP, pupil size, PCO or YAG rate were observed between the groups. Endothelial cell loss, endothelial morphology and corneal thickness were also equivalent. Conclusions: Intracameral mydriatics is a safe alternative to topical mydriatics in phacoemulsification cataract surgery with no long-term disadvantages at 6-year follow-up.

PURPOSE: To evaluate the mydriatic effect of topical cyclopentolate 1% when combined with topical phenylephrine 10% and intracameral lidocaine 1% in phacoemulsification cataract surgery.

METHODS: We performed a prospective, double-masked, randomized trial including 20 patients with age-related cataract, who were scheduled for unilateral phacoemulsification and intraocular lens (IOL) implantation. Patients were given either two drops of phenylephrine 10% at 30 mins and 15 mins prior to surgery (group 1), or two drops each of cyclopentolate 1% and phenylephrine 10% at the same time points (group 2). All patients were also given lidocaine 1% intracamerally at the beginning of the procedure. Intraoperative pupil sizes were assessed from video-recordings.

RESULTS: Initially, pupil sizes were significantly smaller in group 1 (4.8 +/- 1.2 mm versus 6.5 +/- 1.4 mm; p = 0.0098), but the lidocaine injection increased the pupil sizes in group 1 significantly, so that pupil sizes in both groups were equalized throughout the surgical procedure.

CONCLUSIONS: Preoperative topical cyclopentolate does not enhance mydriasis in phacoemulsification surgery when using intracameral lidocaine and can be omitted when intracameral lidocaine is used.

Purpose: To investigate and compare the long-term subjective and objective visual functional results of phacoemulsification in diabetics and non-diabetics. Methods: A prospective, longitudinal, population-based study comprising 57 diabetics and 473 non-diabetics, who had cataract surgery during a 1-year period at Norrlands University Hospital, Umeå, Sweden. Visual acuity data, visual function questionnaire (VF-14) responses, and level of diabetic retinopathy were recorded pre- and postoperatively as well as 5 years after surgery. Results: Four months postoperatively, the median VF-14 total score for both the diabetics and the non-diabetics was 100; at 5 years, the score decreased to 96.4 and 97.2, respectively (p = 0.81). The median best corrected visual acuity (BCVA) of the operated eye was logMAR 0.046 (Q1:Q3 = 0:0.15) for both the diabetics and the non-diabetics 4-8 weeks postoperatively. Five years later, the BCVA for the diabetics was logMAR 0.14 (Q1:Q3 = 0.02:0.34) and for the non-diabetics 0.1 (Q1:Q3 = 0.02:0.3), (p = 0.34). Five years after surgery, 26% of the diabetics and 22% of the non-diabetics had a reduction in VF14-score of 10 points or more (p = 0.64) compared with 4 months postoperatively. One-third of both the diabetics (18/57) and the non-diabetics (149/473) had lost more than 0.1 log MAR unit in BCVA of the operated eye (p = 0.86). Conclusion: Subjective and objective visual function 5 years after cataract surgery remained stable in most surviving diabetics and non-diabetics. The longitudinal visual function in diabetics was not significantly worse compared with non-diabetics.

Purpose:  To compare the mydriatic effect of intracameral mydriatics injected into the anterior or the posterior chamber in routine phacoemulsification cataract surgery. Methods:  Forty-four patients planned for unilateral phacoemulsification surgery were included after informed consent. Mydriasis was achieved by injecting 150 μl of a mixture of phenylephrine 1.5% and lidocaine 1.0% at the beginning of the procedure. The patients were randomly assigned to injection into the anterior or the posterior chamber. The pupils were filmed during the procedures, and the mean pupil diameters were measured at predetermined intervals from the video recordings by an independent observer. Results:  Immediately after the injection, the pupils were larger after posterior chamber injection (3.8 ± 0.8 versus 3.1 ± 0.7 mm; p = 0.004). A similar difference was seen after the phacoemulsification (6.4 ± 0.7 versus 5.9 ± 1.0 mm; p = 0.031). The mydriatic durability was also better after posterior injection (p = 0.004-0.041). Conclusions:  Apart from immediately after the injection, the initial mydriatic response was similar with both injection techniques, but the durability of the mydriasis was slightly better after a posterior chamber injection of ICM.

Purpose: To compare the efficacy and intra-operative safety of intracameral mydriatics to topical mydriatics in patients undergoing refractive lens exchange (RLE) surgery. Methods: In a randomized intra-individually comparing study performed at Koskelas Eye Clinic, Lulea, and Department of Clinical Sciences/Ophthalmology, Umea University Hospital, Umea, Sweden, 56 patients undergoing same-day bilateral RLE were included. Pupils were randomly dilated with topical mydriatics in one eye and intracameral mydriatics in the fellow eye. Pupil sizes were recorded intra-operatively throughout the procedures. Perceived pain/discomfort and glare were assessed immediately postoperatively using a visual analogue scale from 0 to 10. Results: Topical mydriatics and intracameral mydriatics both give satisfactory pupil dilation in routine RLE. However, there was noticeable iris billowing in 17 eyes dilated with topical mydriatics but only one eye with intracameral mydriatics (p < 0.001). Pupils were initially slightly larger in the topical mydriatics group but contracted during surgery. There was no perceived difference with regards to glare, pain or discomfort between the treatments. The surgeon graded intracameral mydriatics eyes as easier to operate on. Conclusion: Both topical mydriatics and intracameral mydriatics give satisfactory mydriasis for RLE, but pupil constriction and iris billowing are more pronounced with topical mydriatics.

Purpose: To analyse trends of ISBCS reported to the Swedish National Cataract Register (NCR) over a 10-year period.

Methods: Since 2010 the NCR contains social security number of all individuals in the list of parameters reported to NCR after each cataract procedure. Bilateral surgeries were mapped out using social security numbers. When dates of both-eye surgeries are identical for an individual it is classified as an immediate sequential bilateral cataract surgery (ISBCS). This study includes all data reported during the period 1st of January 2010 to 31st of December 2019. During the study period 113 cataract surgery clinics affiliated to the NCR reported their data on consecutive cataract cases.

Results: For the whole period 54 194 ISBCS were reported. The total number of bilateral cataract extractions was 422 300. There was a significant trend of increasing ISBCS over time with linear regression (Beta = 1.75, p < 0.001). In ISBCS the occurrence of an ocular comorbidity decreased over time. The use of a capsular tension ring was significantly more common in ISBCS than in delayed sequential bilateral cataract surgery (DSBCS). All other measures taken during surgery were more common in DSBCS. The use of multifocal IOL was significantly more frequent in ISBCS compared to DSBCS (p < 0.001).

Conclusions: The use of ISBCS has increased over the study period. The operated eyes have less risk factors than eyes going through a DSBCS, but both ocular comorbidities and surgical complications occur in ISBCS eyes.

Purpose: To analyse the development of neovascular age-related macular degeneration (nAMD) in the fellow eye in patients initially presenting with unilateral nAMD, using data from the Swedish Macula Register.MethodsThis observational study included data on treatment-naïve patients who initially underwent unilateral treatment for nAMD, and then required bilateral treatment, between 2010 and 2018, according to the Swedish Macula Register (SMR). The data were also stratified according into three time periods (2010–2013; 2014–2016; 2017–2018). Treatment duration, best-corrected visual acuity (BCVA) in the first and second eye, number of injections in the first eye before falling ill in the second, and the time between the last injection in the first eye and the start of treatment of the fellow eye were analysed.

Results: 5216 out of 28 670 (18%) patients treated for nAMD subsequently required bilateral treatment. The mean age was 77.7 ± 7.3 years, and 69% were female. The mean duration of treatment of the first eye before nAMD was diagnosed in the fellow eye was 1.58 years, and the mean number of injections in the first eye was 8.9 ± 8.6. Best-corrected visual acuity, according to the ETDRS chart, was higher in the second eye at the time when treatment started in that eye compared to treatment start in the first eye: 62.8 (14.7) versus 57.6 (15.5); p < 0.001, and was higher in the 66% whose first eye was still undergoing treatment: 63.6 ± 14.5 versus 61.0 ± 14.8; p = 0.001.

Conclusions: The mean duration of treatment of the first eye before treatment started in the fellow eye was 19 months, and treatment of the second eye had started within 2 years in 61% of the patients. Best-corrected visual acuity was higher in the second eye than in the first eye at the start of treatment of that eye and was higher in the second eye at the start of treatment of that eye when the first eye was still being treated.

PURPOSE: To assess mean change in visual acuity (VA) overall and stratified by baseline VA after 1 and 2 years' treatment with aflibercept in a real-life setting.

METHODS: This was an observational cohort study using nationwide data from the Swedish Macula Register. Treatment-naïve patient eyes with wet age-related macular degeneration and prescribed aflibercept from January 2013 to December 2014 were followed for 1 year (2478 eyes) or 2 years (831 eyes) to assess VA. Eyes were grouped by baseline VA.

RESULTS: Mean number of injections in patients treated according to label (72%) versus patients treated not according to label was 8.0 ± 1.5 versus 4.4 ± 0.8 (p < 0.0001) at 1 year, and 12.5 ± 3.2 versus 7.3 ± 1.9 (p < 0.0001) at 2 years. Among all eyes, mean VA increased from 61.3 ± 13.4 Early Treatment Diabetic Retinopathy Study letters at baseline to 64.5 ± 15.6 at 1 year and 65.1 ± 15.1 letters at 2 years. At 2 years, eyes with good baseline vision (≥70 letters) lost a mean of 2.4 ± 11.3 to 72.3 letters, eyes with intermediate baseline VA (36-69 letters) gained 5.7 ± 14.1 to 62.7 letters, and eyes with poor baseline VA (≤35 letters) gained 13.2 ± 18.3 to 41.0 letters. Also at 2 years, 75% of treated eyes were stable or had improved VA. Among eyes with intermediate baseline VA, near vision was significantly better among those treated according to label versus not according to label at 3 (p = 0.019), 6 (p = 0.0002) and 12 months (p ≤ 0.0001).

CONCLUSION: While gain in vision was especially pronounced in eyes with poor baseline VA, good baseline VA was important for best prognosis.

Background: To report beta-trace protein (bTP) levels in the subretinal fluid (SRF) of four patients with a macular detachment associated with optic disc pit (ODP).

Methods: Four patients with a serous retinal detachment involving the macula was operated by pars plana vitrectomy (PPV) with C₂F₆ gas tamponade and peeling of internal limiting membrane (ILM). Patients with a follow-up period exceeding one year postoperatively were included in the study. The SRF was drained using a fine cannula without laser photocoagulation, and the samples were analysed using particle-enhancing nephelometry. The levels of bTP were compared to 20 routine cerebrospinal fluid (CSF) samples.

Results: In four of the five samples from SRF had relatively low bTP levels, with a mean concentration of 6.6 mg/l (range 2.0 to 23.1 mg/l) compared to 16.0 mg/ l (range 6.3-26.8 mg/l) in CSF. The only SRF sample within the range corresponding to normal CSF was the first sample from patient 4, and the analysis of the renewed aspirate during the second operation was 2.8 mg/l. Postoperatively, the regression of SRF was slow, but regression of SRF in the foveal region took place in all cases; however, visual acuity (VA) was improved in only half of the patients.

Conclusion: The results from the analysed SRF regarding bTP concentration in these patients indicate that the SRF in ODP is not identical to CSF, as the concentrations of bTP differ.

Purpose: To investigate the impact on visual function from light scattering and glistenings in intraocular lenses (IOLs) in patients who had cataract surgery 10 years previously. Setting: Eye clinic, Norrlands university hospital, Umeå, Sweden.

Methods: One hundred and three patients, who had phacoemulsification with implantation of Acrysof((R)) MA60BM IOLs 10 years previously, were evaluated with best corrected visual acuity (VA), and low contrast visual acuity (LCVA) 10% and 2.5%. The light scattering from the IOLs was measured by Scheimpflug photography. The degree of glistenings was also quantified at the slit-lamp. Eyes with coexisting pathology that could affect VA and LCVA were excluded.

Results: The patients were divided into various groups according to the degree of light scattering and grade of glistenings. In two subsets of patients, paired data from the patients' eyes were analysed. It was not possible to detect any significant impact on visual function, best corrected visual acuity (BCVA) and LCVA 10% and 2.5% in eyes with a more pronounced light scattering or a higher grade of glistenings seen at the slit-lamp. The correlation between IOL dioptric power and both the total light scattering of the IOL, and the subjective grading of the intensity of the glistenings at the slit-lamp was statistically significant (r(P) = 0.25; p = 0.012; r(S) = 0.23; p = 0.019, respectively).

Conclusion: Most patients in this case series operated 10 years previously had severe glistenings and a high level of light scattering from their intraocular lenses. No detectable impact on BCVA, LCVA 10% and 2.5% was found.

Purpose: To investigate the 20-year outcome, in best-corrected visual acuity (BCVA), and subjective visual function (VF-questionnaire, VF-14) after cataract surgery in type 2 diabetics, compared with non-diabetics.

Methods: 109 type 2 diabetics and 698 non-diabetics, who had cataract surgery during 1 year at one institution, were included in this prospective, longitudinal, population-based cohort study. BCVA and VF-14 responses were recorded pre- and postoperatively, and every 5 years up to 20 years after surgery. Retinopathy was graded before surgery.

Results: There was no significant difference between diabetics and non-diabetics, in change in BCVA from 10 years or more after surgery, p = 0.45, p = 0.44 and p = 0.83, at 10, 15 and 20 years, respectively, as well as in self-perceived visual function (VF-14) at any time after surgery, p = 0.72, p = 0.20 and p = 0.78, 10–20 years, respectively.

At any follow-up, there was no significant difference in BCVA in relation to retinopathy level before surgery, p = 0.1 at 20 years. There was a trend from 10 years after surgery and onward that patients with no retinopathy at baseline lost fewer letters during the 20 years than diabetics with retinopathy. Patients with known type 2 diabetes at surgery had a significantly lower survival compared with the non-diabetics at each follow-up, p = 0.003.

Conclusion: In surviving diabetics, BCVA and subjective visual function were retained in most cases up to 20 years after cataract surgery. Cataract extraction is effective in causing a sustainable improvement in visual function also in type 2 diabetics. Knowledge of these long-term outcomes is essential when counselling diabetics for cataract surgery.

Purpose:  To longitudinally report the changes in visual acuity (VA) and subjective visual function, 10 years after cataract surgery.

Methods: This population-based prospective study reviewed 335 patients (85% of survivors) who underwent cataract surgery during a 1-year period in 1997-98, 289 of whom were also re-examined. The patients underwent a routine eye examination and answered the same visual function questionnaire (VF-14), preoperatively, 4 months postoperatively, 5 years and 10 years after surgery.

Results: Ten years after surgery, the best corrected VA (BCVA) of the operated eye had deteriorated to a median of 0.06 (logMAR) (Snellen acuity: 20/23) from 0.046 (logMAR) (20/22) postoperatively (p = 0.001). More than two-thirds of the patients had <0.1 logMAR units worsening of BCVA compared with postoperatively. Approximately half of the patients had no deterioration in subjective visual function, and 77% had 10 points decline or less. Twelve per cent of the patients (42/335) had a worsening of more than 30 points. Effect size was calculated for the VF-14 total score at all three occasions of follow-up after surgery and was largest approximately 4 months postoperatively. Long-time follow-up of 10 years shows still moderate effect size.

Conclusion: These results confirm the effectiveness of cataract extraction, offering good long-term visual rehabilitation for the majority of the patients. The most common cause for large functional loss after 10 years is age-related macular degeneration.

Purpose: To compare two annular epithelium-on (epi-on) high oxygen photorefractive intrastromal cross-linking (PiXL) illuminations protocols for treatment of low-grade myopia.

Methods: In this randomized, single-masked, intra-individually comparative study, healthy individuals with bilateral low-grade myopia (manifest refractive spherical equivalent (MRSE) −0.75 diopters (D) to −2.50 D) were treated with high oxygen epi-on PiXL. One eye was randomized to receive pulsed accelerated 365-nm ultraviolet-A illumination in a central annular zone of 4.0 mm (1 second on, 1 second off; 30 mW/cm2), and the fellow eye in a 3.5 mm annular zone (0.5 second on, 1 second off; 45 mW/cm2). Uncorrected distance visual acuity (UDVA), MRSE, low-contrast visual acuity (LCVA), best spectacle corrected visual acuity (BSCVA), endothelial cell count (ECC) and Scheimpflug light scattering depths were assessed through 24-month follow-up.

Results: Twenty-seven participants (54 eyes) were included. The 3.5 mm protocol rendered less subjective ocular discomfort posttreatment and a larger improvement than the 4.0 mm protocol in UDVA: −0.52 (−0.72, −0.32) logMAR (medians and interquartile ranges, IQR) and −0.38 (−0.50, −0.22), p = 0.003 and MRSE: +1.25 D (0.75, 1.50) and +1.0 (0.75, 1.0), p = 0.037. The transient reduction in LCVA was larger with the 3.5 mm protocol (p < 0.01). No adverse events, and no reductions in ECC or BSCVA were noted.

Conclusion: Epi-on PiXL in high oxygen reduces myopia in healthy eyes. A larger reduction of myopia and less early posttreatment subjective ocular discomfort can be seen with a smaller treatment zone, but likely at the expense of a transient decrease in low-contrast visual acuity.