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A Patient-Centered Counseling Framework

Explain dysfunctional lens syndrome, set expectations for presbyopia-correcting lens optics, and troubleshoot early dissatisfaction.

Jason E. Stahl, MD

Cataract and Refractive Surgery Today

When I counsel patients on refractive lens exchange (RLE), I describe it as a four-in-one procedure. With today’s advanced technologies, we surgeons can correct patients’ distance vision, we can correct their near vision, we can prevent cataracts so they will not need cataract surgery later, and we can stabilize what I consider the unstable part of the optical system—the crystalline lens. I explain that we are treating dysfunctional lens syndrome not only to improve patients’ vision today but for the rest of their lives, and I describe RLE as the ultimate antiaging procedure. Twenty-five years ago, it was difficult to explain to patients with presbyopia why a lens-based approach might be preferable to corneal refractive surgery. That gap largely reflected what was lacking: a dysfunctional lens syndrome framework, advanced lens implants, and diagnostics that could show patients what was changing in the crystalline lens and why a lens-based approach might be a better long-term strategy than LASIK in the presbyopic age group. A SHARED FRAMEWORK: DYSFUNCTIONAL LENS SYNDROME The term dysfunctional lens syndrome (DLS) helped bridge the aforementioned gap by framing aging of the crystalline lens as a spectrum rather than a binary cataract/no cataract diagnosis. The DLS model breaks down as follows: Stage No. 1 is presbyopia—a loss of accommodation and “zoom”; Stage No. 2 reflects the progressive degradation of optical quality, including early lenticular opacification and an increasing magnitude of higher-order aberrations that can reduce contrast sensitivity, dampen brightness, and alter color perception; and Stage No. 3 is a visually significant cataract that interferes with the activities of daily living.1 MAKING LENTICULAR CHANGES VISIBLE: OBJECTIVE DIAGNOSTICS Objective diagnostics further improved patient education.

A Rare Case of Choroidal Vitiligo

Recognize this uncommon sign of varicella-zoster reactivation.

Tina Tang, MD, and Nauman Chaudhry, MD

Retina Today

A 66-year-old immunocompetent woman with a history of recurrent cutaneous lesions was referred for evaluation of retinal lesions in the left eye noted during a routine examination. Her cutaneous lesions were characterized as discrete erythematous macules and small papules on her lower back. Her BCVA was 20/20 OU with normal IOPs and anterior segment examination. Dilated fundus examination of her left eye showed irregular yellowish choroidal lesions temporal to the macula and focal areas of hypopigmentation nasal to the disc (Figure 1). OCT of her left eye showed trace epiretinal membrane with no definite mass lesion (Figure 1, Inset). Fundus autofluorescence revealed hyperautofluorescence corresponding to the yellow lesions, along with hyperfluorescent changes on fluorescein angiography. ICG angiography of the left eye revealed early blocked cyanescence in the area of the lesions temporal to the macula (Figure 2A) with late foci of hyperfluorescence nasal and temporal to the disc (Figure 2B). Work-up revealed positive varicella-zoster virus (VZV) immunoglobulin G, but immunoglobulin M was negative. The ocular oncology service ruled out ocular lymphoma. Her choroidal lesions slowly enlarged over the next 6 years with regular monitoring and no definite mass on OCT (Figure 3).