1. Recognize the causes of potentially treatable blindness in children and discuss the effectiveness of povidone iodine in its prevention.

2. Identify common ocular viral infections and manage them with appropriate diagnostic and therapeutic agents.

3. Summarize the recent trends in litigation involving refractive surgeries and employ actions and behaviors to avoid legal claims.

4. Implement effective strategies to manage the potential for itraoperative floppy iris syndrome in patients receiving medications such as selective α blockers.

5. Choose the appropriate treatment and duration of treatment for amblyopia.

Povidone Iodine for the Treatment of Bacterial Keratitis in Children
Tina Rutar, MD, Assistant Professor, Department of Ophthalmology, Pediatric Ophthalmology and Strabismus, University of California, San Francisco, School of Medicine

Epidemiology of childhood blindness: blindness occurs in 1.4 million children worldwide; untreatable in approximately one million (eg, retinal dystrophy, microphthalmus, cerebral visual impairment, optic atrophy or optic nerve hypoplasia); potentially treatable in 0.4 million (eg, corneal scarring, cataract, retinopathy of prematurity); regional and socioeconomic differences—primary causes in developed countries include retinal (retinopathy of prematurity), optic nerve (hypoplasia), and disorders of higher visual pathway (cerebral visual impairment); worldwide, bacterial corneal ulcers and scarring cause most avoidable childhood blindness (eg, 260,000 cases of blindness caused by scarring); predisposing conditions include trachoma, vitamin A deficiency, and ocular trauma; bacterial keratitis leads to corneal scarring and perforation

Strategies to decrease blindness caused by corneal scarring: eliminate predisposing conditions; vaccinate against measles; encourage use of protective eyewear; educate to reduce use of harmful traditional medications; provide prophylaxis for ophthalmia neonatorum to all newborns

Povidone iodine treatment for infectious keratitis: effective in preoperative preparation; in ophthalmology, also effective for postoperative prophylaxis, prevention of ophthalmia neonatorum, and treatment of bacterial conjunctivitis

Clinical study: randomized double-blind controlled trial conducted in India and Philippines of 1.25% solution of povidone iodine vs ciprofloxacin or neomycin, polymyxin, and gramicidin (Neosporin); 172 patients (156 adults and 16 children) enrolled

Pediatric participants: 7 randomized to povidone iodine and 9 to antibiotic arms; nurses administered drops every hour for first 3 days; later, medications tapered according to protocol

Primary outcome measure: probability of cure depended on rate of cure (closed epithelial defect with minimal conjunctival injection) and time to cure; other measures included rates of improvement, worsening, and failure

Results: 71% of children treated with povidone iodine achieved cure (vs 44% with antibiotics); cure or improvement seen in 82% of children treated with povidone iodine, compared to 89% with antibiotics; cure achieved in 6 days with povidone iodine vs 7 days with antibiotics; worsening on treatment observed in 1 child who received povidone iodine; 1 child failed treatment with ciprofloxacin

Outcome: in study including all 172 participants, patients treated with povidone iodine did as well as those treated with antibiotics

Other differences between children and adults: order of prevalence of bacterial species (ie, Pseudomonas, Streptococcus pneumoniae, and Moraxella in pediatric patients; Moraxella, Pseudomonas, and Streptococcus in adults); ulcer characteristics—pediatric patients had smaller stromal defects and hypopions than adults

New Concepts in Viral Eye Disease
Todd P. Margolis, MD, PhD, Professor of Ophthalmology and Director, Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco, School of Medicine

Prophylaxis for herpes simplex virus (HSV): trials have demonstrated safety and effectiveness of antiviral agents; however, large variation in dosing and cost; possible to increase typical prophylactic doses as needed; long- term prophylactic use safe; presentation (eg, staining patterns) of breakthrough episodes of HSV epithelial keratitis sometimes atypical

Drug-resistant HSV: rate of ocular resistance to acyclovir 2% to 6% in general population; less resistance occurs in patients taking continual prophylaxis; treatment—debridement and patching permit healing of epithelial dendrite; switch antiviral agents; acyclovir, trifluridine (Viroptic), and famciclovir (Famvir) have different mechanisms of action

Herpes zoster: 25 case examples showed mucus plaque keratopathy in patients with herpes zoster who had late dendriform keratitis; all showed presence of varicella zoster virus (VZV) DNA; patients responded to increasing usage of antiviral agents and decreasing use of topical steroids or systemic immune suppression; recurrence possible; VZV also causes chronic or recurrent iritis; adult vaccination—reduces incidence by 51%; reduces severity and duration of disease; decreases incidence of post-herpetic neuralgia by 66%; recommended for adults older than 55 to 60 yr of age

Cytomegalovirus (CMV): causes iritis and corneal endotheliitis in immunocompetent individuals (often 25 to 50 yr of age); usually unilateral; causes chronic or recurrent iritis, elevated intraocular pressure (IOP), and white, gray, or brown keratic precipitates (KP); not associated with synechia; possibly associated with changes in iris and endotheliitis; patients—experience poor long-term response to topical steroids for iritis or endotheliitis; often have viral DNA and immune response to CMV in aqueous; respond clinically to ganciclovir

Management: confirm diagnosis using polymerase chain reaction (PCR) or treat empirically; treat with topical, intravitreal, oral, or IV ganciclovir

Other disorders: Fuchs heterochromic cyclitis—study showed 31% of patients had CMV DNA in aqueous and responded to ganciclovir; also caused by rubella; Posner-Schlossman syndrome—recurrent unilateral episodes of high IOP; few KP; heterochromia possible; caused by HSV and by CMV in 33%

Diagnosis: molecular techniques amplify viral DNA; limitations—judgment necessary to evaluate clinical significance of PCR signal; ocular fluids may inhibit PCR; treatment lowers DNA levels; negative result does not rule out infection

Analysis of Ophthalmic Mutual Insurance Company (OMIC) Refractive Surgery Claims: What We Have Learned
Richard L. Abbott, MD, Health Sciences Clinical Professor of Ophthalmology, and Thomas W. Boyden Endowed Chair in Ophthalmology, University of California, San Francisco, School of Medicine, Beckman Vision Center; Research Associate, Francis I. Proctor Foundation, San Francisco, CA

Study: conducted between 1993 and 2007, and included 3700 insured individuals; number of claims decreased since 2003; refractive surgery claims peaked in 2002; current total, 246 claims

Settlements: increased for laser in situ keratomileusis (LASIK; claims increased in severity); average of $161,000 for refractive surgery overall

Key findings: claims decreased in number from 51 in 2002 to 19 in 2007; average settlement increased; since 2002, more claims for cataracts than for LASIK; average settlement higher for LASIK; 5 in 10 refractive surgery claims in 2007 involved signs of keratoconus (preoperatively) or ectasia (postoperatively)

Preventing claims: before refractive surgery—rule out ocular and psychologic contraindications; evaluate preoperative topography; assess, disclose, and document possible influence of comorbidities (eg, dry eye, glaucoma); verify refractive stability and cause of decreased visual acuity; identify activities potentially affected by outcome; refer patients to education manual; assess patients’ goals; verify maintenance and functioning of equipment; follow recommendations of American Academy of Ophthalmology (AAO) and American Society of Cataract and Refractive Surgery (ASCRS) for verification of correct patient, eye, and laser settings; after surgery—document protocol for comanagement (if applicable); retain patient if complications occur; refund fees for patients with flap complications and aborted procedures; maintain adequate documentation

Future directions: study planned to evaluate patient satisfaction

Update on Intraoperative Floppy Iris Syndrome (IFIS)
David F. Chang, MD, Clinical Professor of Ophthalmology, University of California, San Francisco, School of Medicine

Effects of nonselective α-blockers vs tamsulosin

ASCRS survey: of 1000 respondents, 90% reported higher likelihood of IFIS in patients taking tamsulosin; clinical trial showed tamsulosin more likely than alfuzosin to cause IFIS ; supported by in vitro investigation of iris dilator muscle pharmacology showing greater antagonism by tamsulosin than alfuzosin; 95% of survey respondents had observed IFIS in patients who had taken (but discontinued use of) α-blockers; 33% said IFIS seen infrequently in patients taking drugs other than α-blockers

Study: compared to controls, thinner dilator muscle region than sphincter muscle region (SMR) shown by slit lamp optical coherence tomography (OCT) in patients on tamsulosin; may explain mechanism of loss of rigidity and prolapse during surgery

Histologic evaluation of autopsy eyes: compared to controls, 26 eyes from patients on tamsulosin showed significantly thinner dilator muscle

Strategies: discontinuation of tamsulosin—66% of respondents never recommend discontinuing tamsulosin; 11% routinely do; other—57% do not use preoperative atropine; 20% routinely do; many respondents routinely use epinephrine, intracameral agent, and iris hooks; intracameral agents (α-agonists) have 1% rate of hypertensive spikes and toxic anterior segment syndrome (TASS)

Preferred initial therapy for IFIS: compensatory strategies include 1) preoperative topical atropine, 2) iris retractors, 3) intracameral epinephrine/phenylephrine, 4) use of viscoadaptive ophthalmic viscosurgical device with reduced fluidic parameters (eg, sodium hyaluronate 2.3% [Healon5]), or 5) pupil expansion device (eg, Malyugin ring); according to survey, 1 in 3 clinicians prefer to use multiple (≥2) strategies; study of risks—among 167 consecutive eyes from patients taking tamsulosin, low (0.6%) rate of posterior capsule rupture when compensatory strategies used

Patients beginning treatment with α-blocker: 21% of respondents recommended that all patients beginning tamsulosin first see ophthalmologist; 38% recommended ophthalmologist visit if decreased vision or cataract present

Primary care physicians (PCPs): study found that 97% of PCPs had not heard of IFIS, although 80% prescribed α- blockers

Pharmacologic options: silodosin (Rapaflo)—recently approved by Food and Drug Administration; specific for α1A receptor subtype (like tamsulosin) and probably equally likely to cause IFIS; alfuzosin—nonselective with less postural hypotension; 5-α reductase inhibitors—block production of dihydrotestosterone and shrink prostate slowly, eg, finasteride (Proscar), dutasteride; shown to decrease rate of prostate cancer by 30%

When Can You Stop Treating Amblyopia?
Jonathan C. Horton, MD, PhD, William F. Hoyt Professor of Ophthalmology, Neurology, and Physiology, University of California, San Francisco, School of Medicine, Beckman Vision Center

Background: animal studies show critical period exists for development of ocular preference of cortical cells; fibers from thalamic relay station (lateral geniculate body) synapse in separate zones in layer 4 of cortex; in normal cats, monkeys, and humans, ocular dominance columns equal in width and both eyes have equal access to cells in cortex; when one eye deprived of vision, shrinkage seen in ocular dominance columns serving deprived eye; geniculate fiber terminals in cortex serving deprived eye much sparser; fewer synapses made onto cells in cortex

Therapy: patching of good eye and optical correction of deficit in amblyopic eye considered gold standard; useful for patients with early and severe amblyopia induced by monocular deprivation; questionable usefulness for most patients who have milder, later-onset form induced by strabismus, anisometropia, or both; study—demonstrated shrinkage of ocular dominance columns in patients with early form; patients with anisometropic and strabismic amblyopia had normal ocular dominance columns; possible to rectify changes in milder forms at later age than for deprivation amblyopia

Treatment for strabismic or anisometropic amblyopia

Trial in children at 3 to 7 yr of age (atropine vs patching): found greater mean improvement in acuity at 5 wk for children treated with patches than with atropine; no significant difference seen at 6 mo; poor compliance with patch probably explains apparent parity of treatments

Children 7 to 17 yr of age: compared patching and atropine vs glasses; found treatment arm superior to glasses alone in children 7 to 12 yr of age; no difference between arms in children >12 yr of age; study limitations—actual improvement in visual acuity marginal; no comparison to placebo

Recommendations: AAO recommends treatment until 10 yr of age; speaker suggests treating early, using patches as primary treatment (if child complies), and using atropine as second-line treatment if patch fails