Mortality and Causes of Death Among Individuals With Keratoconus.

PURPOSE: The purpose of this study was to determine whether there is an increased risk of mortality among individuals with keratoconus. METHODS: This was a retrospective, case-control study using the Utah Population Database. Cases were defined as individuals diagnosed with keratoconus from 1996 to 2020 and were matched 5:1 with controls on birth year, sex, whether born in Utah, and follow-up time in Utah. Individuals diagnosed with trisomy 21 or connective tissue disease were excluded. Main outcome measures were the all-cause and cause-specific mortality among keratoconus cases compared with matched controls. Cox regression models were used, additionally adjusting for race and ethnicity. RESULTS: A total of 7847 keratoconus cases and 38,597 controls were studied in the final analyses. The mean age at index diagnosis was 43 ± 17 years, and mean age at last follow-up was 54 ± 17 years for both cases and controls. At last follow-up, 92% of cases were living compared with 91% of controls. After adjusting for covariates, there were no significant differences in all-cause mortality (P = 0.161), mortality from natural causes (0.222), or mortality from unnatural causes (P = 0.494) between cases and controls. When analyzed according to specific causes of death, keratoconus cases had a higher mortality risk from diseases of the nervous system and sense organs compared with their matching controls (hazard ratio 1.59; 95% confidence interval, 1.19-2.11; P = 0.002). CONCLUSIONS: There was no evidence of an increased risk of mortality among individuals with keratoconus. There may be an increased risk of death due to diseases of the nervous system and sense organs among individuals with keratoconus.

Chemical eye injuries: a 10 year retrospective review of acute presentations and clinical outcomes in Auckland, New Zealand.

To assess the aetiologies, clinical characteristics, treatment regimens, and outcomes of acute chemical injuries treated at an emergency eye clinic. Retrospective, observational study of all cases of chemical eye injury that presented acutely to the Greenlane Clinical Centre in Auckland, New Zealand from 1 January 2012 through 31 December 2021. Patient demographics, activity at the time of injury, causative chemical, clinical characteristics of injury at presentation, severity (Dua) classification, admission and discharge best corrected visual acuity (BCVA), treatment regimen, time to epithelisation and number of follow-up appointments were recorded. In total, 1522 cases involving 1919 eyes were studied. The mean age was 40.6 ± 18.8 years and 65% were male. The majority of cases occurred at home (62%) and cleaning was the most common activity (38%). There were 1490 Grade I (98%), 22 Grade II (1.5%), 5 Grade III (0.3%), 1 Grade IV (0.07%), 0 Grade V, and 4 Grade VI (0.3%) cases. An epithelial defect was noted in 409 cases (26.9%), of which re-epithelialisation occurred within one week for 378 cases (92%) and within 30 days for 384 cases (94%). Moderate vision loss (BCVA ≤ 6/12) attributed to the injury occurred in 152 (10%), while severe vision loss (BCVA ≤ 6/60) occurred in 30 (2%). Lack of irrigation at the scene was associated with an increased risk of severe injury and longstanding visual impairment (p = 0.0001). Most acute chemical injuries are mild with good clinical outcomes. Although rare, severe injuries are associated with a lack of irrigation at the scene and worse visual outcomes.

Predictive performance of corneal and lid margin sensitivity for dry eye disease: An investigator-masked, prospective, prognostic accuracy study.

PURPOSE: To evaluate the prognostic ability of non-contact esthesiometry corneal and lid margin sensitivity measurements in detecting symptoms and signs of dry eye disease, as defined by the global consensus TFOS DEWS II criteria. METHODS: A total of 87 community residents (58 females; mean ± SD age, 53 ± 16 years) were recruited in an investigator-masked, prospective, prognostic accuracy study. Dry eye symptomology, tear film parameters, and ocular surface characteristics were evaluated in a single clinical session, and non-contact esthesiometry corneal and lid margin sensitivity measurements performed by an independent masked assessor. RESULTS: Overall, 49 (56%) participants fulfilled the TFOS DEWS II criteria for dry eye disease, while 57 (66%) exhibited clinical symptoms, and 67 (77%) had positive signs. The prognostic abilities of corneal and lid margin sensitivity measurements were significantly greater than chance for the detection dry eye signs (both p ≤ 0.03), but not for symptoms or overall disease diagnosis (all p > 0.10). The Youden-optimal prognostic cut-offs for corneal and lid margin sensitivity thresholds were both ≥0.8 mbar for the detection of clinical dry eye signs. Lid margin sensitivity demonstrated marginally higher predictive performance than corneal sensitivity (C-statistic, 0.688 versus 0.658), and was significantly correlated with tear film stability, corneal, conjunctival and lid wiper staining (all p < 0.05). CONCLUSIONS: Corneal and lid margin sensitivity demonstrated moderate prognostic utility for detecting clinical dry eye signs. Future research is warranted to investigate the utility of incorporating non-contact esthesiometry in the workup for dry eye disease and neurotrophic keratopathy.

Keratoconus in Down syndrome: Prevalence, risk factors, severity and corneal tomographic characteristics.

BACKGROUND: This study investigated the prevalence, risk factors and severity of corneal tomographic features of keratoconus in Down syndrome (DS). Additionally, previous studies indicate anomalous corneal features in DS, without keratoconus, this study characterised corneal features in DS without keratoconus. METHODS: This prospective observational study included participants with DS ≥10 years old. Keratoconus diagnosis, risk factors and corneal tomographic characteristics were recorded. Participants underwent slit-lamp biomicroscopy, Scheimpflug corneal tomography, corneal topography and autorefraction. A diagnosis of keratoconus (DS-KC), suspect keratoconus (DS-SK) and non-keratoconus (DS-NK) was made based on expert review of scans by three fellowship trained anterior segment ophthalmologists. Corneal tomography parameters from one eye of each participant were analysed. RESULTS: Keratoconus affected 50 (26.3%) of 190 participants, diagnosed by corneal tomography, topography or slit-lamp signs. Corneal hydrops affected 14.0% of DS-KC participants. Eye rubbing was a significant risk factor for keratoconus (p = 0.036). 175 (92%) participants could undertake corneal tomography of which tomography assessment alone identified 47 (26.9%) DS-KC participants, 64 (36.6%) DS-SK participants and 64 (36.6%) DS-NK participants. Significant differences (p < 0.001) were identified when the DS-KC, DS-SK and DS-NK groups were compared in maximum keratometry and posterior elevation at the thinnest point respectively: median (interquartile range) 50.20 (10.30D), 47.60 (1.95D), 46.50 (2.40D); 24.0 (38.00 µm), 10.00 (13.75 µm), 8.00 (6.00 µm). The DS-SK and DS-NK cohorts had similar minimum pachymetry, however, had several significantly different parameters among which included greater maximum keratometry, posterior elevation at the thinnest point in the DS-SK group. CONCLUSIONS: Keratoconus is common in DS. Keratoconus screening with corneal tomography is recommended for early detection.

Comparison of Ectasia Detection in Early Keratoconus Using Scheimpflug-Based Corneal Tomography and Biomechanical Assessments.

PURPOSE: The aim of this study was to determine the detection of keratoconus using corneal biomechanical parameters only, a corneal tomographic parameter only, and a parameter that combines corneal biomechanical and tomographic indices. METHODS: The discriminatory power of the Pentacam Random Forest Index (PRFI), Belin/Ambrósio Enhanced Ectasia Display (BAD-D) index, Corvis Biomechanical Index (CBI), and Tomographic and Biomechanical Index (TBI) to differentiate between normal eyes (n = 84), eyes with very asymmetric corneal ectasia (VAE-E, n = 21), and the fellow eyes without apparent ectasia based on normal tomography (VAE-NT, n = 21) was assessed. Statistical analyses were completed with R software using t -tests, Wilcoxon rank sum tests, and receiver operating characteristic (ROC) curves. The DeLong test was used to compare the area under the ROC curve (AUROC). RESULTS: The TBI and PRFI had the highest AUROC when distinguishing between normal and VAE-E corneas (AUROC = 1.00, 95% CI = 1.00-1.00); however, they were not statistically superior to the CBI (AUROC = 0.97, P = 0.27) or BAD-D (AUROC = 1.00, P = 0.34). The TBI (AUROC = 0.92, 95% CI = 0.86-0.98) was superior to CBI (AUROC = 0.78, P = 0.02) and BAD-D (AUROC = 0.81, P = 0.02) when distinguishing between healthy and VAE-NT corneas. At a threshold of 0.72, the TBI had 99% sensitivity, 67% specificity, and 92% accuracy in distinguishing normal and VAE-NT corneas. CONCLUSIONS: The TBI is a useful parameter for the screening of subclinical and frank keratoconus in tomographically normal eyes.

Rates of Herpes Simplex Virus Types 1 and 2 in Ocular and Peri-ocular Specimens.

PURPOSE: To evaluate the rates of Herpes Simplex Virus types 1 (HSV-1) and 2 (HSV-2) in ocular specimens. METHODS: Retrospective case series of all patients with a positive laboratory evaluation for ocular HSV performed at the Auckland District Health Board, Auckland, New Zealand between 1 January 2006 and 31 December 2017 were included in the study. RESULTS: A total of 423 specimens were positive for HSV-1 (99.3%, n = 419) or HSV-2 (0.7%; n = 4). The majority of positive tests were identified through DNA amplification (n = 352; 83%) testing while the remainder were obtained by viral culture (n = 71; 17%). Ocular disease caused by HSV-2 in this study included acute retinal necrosis (n = 2), keratitis (n = 1), and blepharitis (n = 1). CONCLUSIONS: HSV type 2 is a rare cause of ocular and peri-ocular infection but may cause severe, vision threatening disease.

Progression of keratoconus in children and adolescents.

AIMS: To evaluate the rates of keratoconus progression and associated factors in eyes of children and adolescents. METHODS: Retrospective, cohort study of individuals ≤18 years old at the time of keratoconus diagnosis and with at least 6 months of follow-up. Corneal tomography was performed using an Orbscan tomographer (Bausch & Lomb, Rochester, New York, USA) to determine whether progression occurred. Tomographic progression of keratoconus was defined as a change in any of the investigated parameters (keratometry values, KMAX, maximum anterior or posterior elevation, central pachymetry, thinnest pachymetry) beyond the limits of repeatability. RESULTS: 148 eyes of 106 patients with a mean age of 15.2±2.5 years were studied over a mean follow-up period of 2.9±2.2 years. The overall rate of tomographic progression was 77.0% (114/148 eyes). Eyes that progressed had more advanced disease at presentation with higher anterior curvature (KMAX55.4±6.3 vs 52.2±5.4 dioptres; p<0.01), posterior elevation (108.2±40.9 vs 86.3±35.6 µm; p<0.01) and lower central pachymetry measurements (442.1±56.7 vs 454.4±47.5 µm; p=0.01). Age at presentation, gender, atopy, documented eye rubbing, ethnicity and duration of follow-up were not significantly associated with progression in the multivariate analyses. There was a higher rate of bilateral progression if at least one eye had severe keratoconus (73.9%) compared with no severe keratoconus in either eye (36.8%; p=0.03). CONCLUSIONS: A high rate of progression was identified in keratoconic eyes of children and adolescents. More advanced disease at initial presentation may increase the risk of further keratoconus progression.

Prompt Antiviral Therapy Is Associated With Lower Risk of Cerebrovascular Accident Following Herpes Zoster Ophthalmicus.

PURPOSE: To examine risk factors associated with cerebrovascular accident (CVA) following herpes zoster ophthalmicus (HZO). DESIGN: Retrospective cohort study. METHODS: Review of medical records of all patients with HZO seen at the department of Ophthalmology, Auckland District Health Board, New Zealand, between January 1, 2006, and December 31, 2016. The main outcome measure was cerebrovascular accident within 12 months of diagnosis. RESULTS: A total of 869 patients diagnosed with HZO were included in the study. The median age at onset of HZO was 65.5 years (interquartile range [IQR] 52.9-75.4), and 52.5% (n=456) were male. Antiviral therapy was started in 765 participants (88.0%), not used in 95 (10.9%), and not documented in 9 participants (1.0%). Four hundred sixty-eight participants (54.9%) received prompt oral antiviral therapy (≤72 hours of rash onset). A CVA occurred in the 12 months following HZO in 14 patients (1.6%) and was most common in older patients, occurring in 2.5% aged ≥65 years, 0.7% aged 40-65 years, and 0.9% aged <40 years. Hazard of CVA was highest immediately following HZO, with median time to CVA of 2.3 months (IQR 0.8-5.9 months). Patients who received prompt acyclovir had a 76.2% lower hazard of CVA (0.9% vs 2.6%, P = .022) on multivariate analysis. CONCLUSIONS: Cerebrovascular accident occurs in a low proportion of individuals within 1 year following HZO. Antiviral treatment for HZO may reduce the risk of subsequent CVA when given within 72 hours of rash onset.

Alterations in the ocular surface and tear film following keratoplasty.

The purpose of this study was to evaluate any alterations in the tear film and ocular surface beyond the early postoperative period following penetrating keratoplasty (PK) and deep anterior lamellar keratoplasty (DALK). This cross-sectional, contralateral-eye study compared ocular surface and tear film parameters of eyes with a previous PK or DALK in one eye and no prior surgery in the contralateral eye. Overall, 14 (87.5%) participants underwent PK, and 2 (12.5%) underwent DALK using a mechanical dissection. The median time from surgery was 3.4 years (range 1.5 to 38.7 years). The indication for unilateral keratoplasty was keratoconus in 15 (94%) participants, and corneal scarring in 1 (6%) eye, secondary to microbial keratitis. Operated eyes exhibited poorer non-invasive tear film breakup time, lower corneal sensitivity, lower sub-basal nerve density and more severe fluorescein staining scores than unoperated fellow eyes (all Q < 0.05). There were no significant differences in tear film lipid layer quality, tear meniscus height, conjunctival hyperaemia, lissamine green staining score, or meibography grade between operated and fellow eyes (all Q ≥ 0.20). Higher corneal esthesiometry threshold (lower corneal sensitivity) was correlated with shorter non-invasive tear film breakup time (Spearman's rho = - 0.361, p = 0.04) and increased fluorescein staining score (Spearman's rho = 0.417, p = 0.02). Keratoplasty can induce persistent changes in the ocular surface and tear film, including: increased fluorescein staining, decreased tear film breakup time, decreased corneal sub-basal nerve plexus density, and reduced corneal sensitivity.

Case Report: Acute Corneal Hydrops despite Accelerated Transepithelial Corneal Cross-linking.

SIGNIFICANCE: Corneal cross-linking is a well-established treatment to reduce or halt the progression of keratoconus. This case demonstrates that acute corneal hydrops may develop several years after corneal cross-linking even despite apparent treatment effect with corneal flattening, and patients should be monitored accordingly. PURPOSE: This study aimed to describe a case of continued progression in the form of corneal hydrops despite prior corneal cross-linking and evidence of treatment effect. CASE REPORT: A 19-year-old woman underwent bilateral accelerated transepithelial corneal cross-linking for progressive keratoconus. At 2 years after the procedure, significant flattening of the central cornea of >3 D was measured in the left eye, indicating a significant treatment response, although continued thinning was noted on tomography. At 3.5 years after the procedure, this eye developed acute corneal hydrops with subsequent corneal scarring necessitating corneal transplantation. CONCLUSIONS: Patients should continue to be monitored for several years after corneal cross-linking, and retreatment should be considered if there is progressive corneal thinning.

Neurotrophic Keratopathy After Herpes Zoster Ophthalmicus.

PURPOSE: The aim of this study was to describe risk factors for neurotrophic keratopathy (NK) after herpes zoster ophthalmicus (HZO). METHODS: This study was a retrospective review of all patients seen at the Auckland District Health Board with HZO from 2006 through 2016. Cox proportional hazards analysis was performed to examine time to development of neurotrophic keratitis. RESULTS: Eight hundred sixty-nine patients were included in the study with a median follow-up of 6.3 years (5504.4 patient-years). The median age was 65.5 years (interquartile range 52.9-75.4), and 456 subjects (52.5%) were male. NK developed in 58 patients (6.7%), with the highest hazard 1 to 2 years after onset of HZO. On univariate analysis, age, White ethnicity, best-corrected visual acuity (BCVA) at presentation, intraocular pressure, corneal involvement, uveitis, and number of recurrences were associated with increased risk of NK. On multivariate analysis, the following factors were significant: age (hazard ratio [HR] = 1.03; P = 0.021), White ethnicity (HR = 3.18; P = 0.015), BCVA (HR = 1.81; P = 0.026), uveitis (HR = 3.77; P = 0.001), and recurrence (HR = 1.34; P < 0.001). Vision loss (BCVA ≤6/15) was more frequent in subjects with NK (65.5% vs. 16.3%, P < 0.001). CONCLUSIONS: NK is a relatively common and serious complication of HZO and occurs more frequently in older White individuals, those with poor visual acuity at presentation, and those with uveitis. Vision loss occurs in approximately two-thirds of patients.

Cataract surgery in herpes simplex virus ocular disease.

PURPOSE: To investigate the outcomes and complications associated with cataract surgery in eyes with herpes simplex virus (HSV)-related anterior segment ocular disease. SETTING: Public tertiary center in Auckland, New Zealand. DESIGN: Retrospective observational cohort study. METHODS: Clinical records of patients diagnosed with HSV-related keratitis and/or anterior uveitis who underwent subsequent cataract surgery in the affected eye were reviewed. Main outcomes measured were visual outcome, complications, and recurrence. RESULTS: 37 eyes of 37 patients were included. Intraoperative complications occurred in 1 patient (2.7%) with iris prolapse. Keratitis or uveitis recurred postoperatively in 17 patients (45.9%) 8 patients (22.5%); 22.5% experienced recurrences in the first year postoperatively. 1 case (2.7%) of postoperative cystoid macular edema and 1 (2.7%) postoperative endophthalmitis occurred. Corrected distance visual acuity at 3 months was >20/50 in 21 patients (70.0%), 20/50 to 20/200 in 4 patients (12.9%), and ≤20/200 in 6 patients (19.4%). Vision improved in 26 eyes (83.9%) and worsened in only 1 eye (3.2%). Risk for recurrent inflammation was associated with a greater number of recurrences prior to surgery (hazard rate [HR] 1.31), time quiescent prior to surgery (HR 0.48), and iris transillumination defect at preoperative assessment (HR 57.66). CONCLUSIONS: Cataract surgery in eyes with previous HSV disease may improve visual acuity for most of the eyes but, overall, carries a guarded prognosis, particularly in eyes with corneal scarring. There is a significant risk for recurrent inflammation in the first year postoperatively. If possible, surgeons should ensure a period of disease quiescence prior to surgery.

Prospective one year study of corneal biomechanical changes following high intensity, accelerated cornea cross-linking in patients with keratoconus using a non-contact tonometer.

PURPOSE: To characterize corneal biomechanical properties utilizing a dynamic ultra-high-speed Scheimpflug camera equipped with a non-contact tonometer (CorVis ST, CST) in keratoconic corneas following continuous high intensity, high irradiance corneal cross-linking. DESIGN: Prospective longitudinal single-centre study at a tertiary referral center. METHODS: Corneal biomechanical properties were measured in patients with progressive keratoconus undergoing high intensity (30 mW/cm2), high irradiance (5.4 J/cm2), accelerated corneal cross-linking with continuous exposure to ultraviolet-A for 4 min. CST was used to assess corneal biomechanical properties pre-operatively and at 1, 3, 6 and 12 months post-operatively. CST output videos were further analyzed using several previously reported algorithms. RESULTS: A total of 25 eyes of 25 participants were examined. The mean age of participants was 20.9 ± 5.3 years; 56% were male and 80% were of Maori or Pacific Island origin. Energy absorbed area (mN mm), was the only significantly changed parameter compared to baseline at all time points measuring 3.61 ± 1.19 preoperatively, 2.81 ± 1.15 at 1 month (p = 0.037), 2.79 ± 0.81 (p = 0.033) at 3 months, 2.76 ± 0.95 (p = 0.028) at 6 months and 2.71 ± 1.18 (p = 0.016) at 12 months. CONCLUSIONS: The significant difference between the pre and post-operative energy absorbed area appears to reflect changes in corneal viscous properties that occur following corneal cross-linking.

Five-year results of a prospective, randomised, contralateral eye trial of corneal crosslinking for keratoconus.

BACKGROUND: Few studies have evaluated corneal crosslinking (CXL) in a prospective, randomised fashion. This study aimed to determine the efficacy and safety of CXL to reduce the progression of keratoconus. METHODS: Prospective, unmasked, randomised, contralateral eye controlled trial at a tertiary eye centre. PARTICIPANTS: Individuals with bilateral progressive keratoconus. One eye from each subject was randomised to CXL and the contralateral, untreated eye acted as the control. PRIMARY OUTCOME MEASURE: change in maximum keratometry. SECONDARY OUTCOME MEASURES: uncorrected distance visual acuity, spectacle corrected distance visual acuity, spherical equivalent refraction, simulated keratometry, corneal astigmatism, minimum pachymetry and complications. RESULTS: Thirty-eight individuals (mean age 21.1 ± 6.7 years) were enrolled with one eye treated with CXL. At 5 years, there was a mean decrease in maximum keratometry of treated eyes (-1.45 ± 2.25 D) compared to an increase among the controls (1.71 ± 2.46 D; p < 0.001). There were significant differences between the treated and control groups in the mean change of Steep SimK (-1.07 ± 1.22 vs. 0.96 ± 1.97 D; p < 0.001), Flat SimK (-0.61 ± 1.34 vs. 0.43 ± 1.12 D; p < 0.001), corneal astigmatism (-0.45 ± 1.31 vs. 0.63 ± 1.52 D; p < 0.01) and minimum pachymetry (-32.49 ± 26.32 vs. -13.57 ± 24.11 µm; p < 0.01). Complications included sterile infiltrates (n = 2), microbial keratitis (n = 1), persistent corneal haze/scarring at 5 years (n = 4) and loss of ≥2 lines of corrected distance visual acuity (n = 3). CONCLUSIONS: CXL is an effective and relatively safe intervention to halt or reduce the progression of keratoconus in the majority of eyes for at least 5 years.

Evaluation of Online Information on Complementary and Alternative Treatments for Dry Eye Disease.

SIGNIFICANCE: Dry eye disease is a common condition with many complementary and alternative therapies promoted online. Patients may inquire about these therapies, and clinicians should be aware of the existence, safety, and efficacy of these therapies, as well as the quality of available online information. PURPOSE: Complementary and alternative medicine is a multibillion-dollar industry with increasing popularity. Dry eye disease is a chronic condition with many complementary and alternative therapies described online. Patients may inquire about and elect to forgo conventional treatments in favor of these therapies. This study identified alternative treatments for dry eye disease described online and evaluated the Web sites that described them. METHODS: An Internet search algorithm identified Web sites describing complementary and alternative therapies for dry eye disease. Web site quality was assessed using the Sandvik score to evaluate Web site ownership, authorship, source, currency, interactivity, navigability, and balance. The potential risk of Web sites to patients was assessed using a risk scoring system. A list of described therapies was compiled. RESULTS: Eight Web sites describing complementary and alternative therapies for dry eye disease were assessed. The Sandvik score classified more than half of the Web sites as "satisfactory" and none as "poor." The overall mean risk score was low at 0.9. One Web site displayed information that discouraged the use of conventional medicine, whereas no Web sites discouraged adhering to clinicians' advice. The Web sites listed 12 therapies with a further 32 found in Web site comments. The most common therapies were acupuncture, vitamin supplements, homeopathic eye drops, castor oil, coconut oil, and chamomile eye wash. CONCLUSIONS: The majority of analyzed Web sites were of satisfactory quality with a low potential risk to patients. However, some Web sites were biased toward their own therapies, lacked proper referencing, and/or did not identify authorship. Further research is required to ascertain the efficacy and safety of these therapies.

Herpes Zoster Ophthalmicus Clinical Presentation and Risk Factors for Loss of Vision.

PURPOSE: To determine the rate of moderate and severe vision loss following herpes zoster ophthalmicus (HZO) and to identify associated factors. DESIGN: Retrospective cohort study. METHODS: All subjects with acute HZO seen at a single center from 2006 to 2016 were included in the study. The primary outcome measure was the proportion of individuals with moderate and/or severe loss of vision following an acute episode of HZO. Secondary outcome measures included causes and factors associated with permanent loss of vision owing to HZO. RESULTS: A total of 869 patients with acute HZO were identified with a median follow-up time of 6.3 years (interquartile range 3.7-8.9 years). Ocular involvement of HZO was diagnosed at or within the first month of presentation in 737 individuals (84.8%). The most common sites of ocular involvement were conjunctivitis (76.1%), followed by keratitis (51.2%) and uveitis (47.6%). Moderate vision loss (≤20/50) secondary to HZO occurred in 83 eyes (9.6%) while severe vision loss (≤20/200) occurred in 31 eyes (3.6%). Causes of loss of vision included corneal scarring (94.0%), corneal perforation (4.8%), and secondary glaucoma (1.2%). Severe vision loss was associated with older age (hazard ratio [HR] 1.059, P = .001), immunosuppression (HR 3.125, P = .028), poor presenting visual acuity (HR 2.821, P = .002), and uveitis (HR 4.777, P = .004) on multivariate analysis. CONCLUSIONS: Among individuals with HZO, approximately 1 in 10 individuals may develop moderate or severe vision loss, primarily owing to corneal scarring. Older age, immunosuppression, and uveitis are associated with severe permanent loss of vision secondary to HZO.

Ethylenediaminetetraacetic Acid Chelation in Herpes Zoster Ophthalmicus Is Associated With a High Rate of Corneal Melt and Perforation.

PURPOSE: To examine the rate and risk factors for band keratopathy after herpes zoster ophthalmicus (HZO) and the outcomes of ethylenediaminetetraacetic acid (EDTA) treatment. METHODS: This is a retrospective review of all subjects with HZO seen at Auckland District Health Board between January 2006 and December 2016. RESULTS: A total of 869 subjects with HZO were included in the study. Median follow-up was 6.3 years (total 5504.4 patient-years). Band keratopathy developed in 13 subjects (1.5%). On multivariate analysis, older age at onset [hazard ratio (HR), 1.092; P = 0.034], intraocular pressure ≥30 mm Hg at presentation (HR, 5.548; P = 0.013), and number of recurrences (HR, 1.849; P < 0.001) were associated with increased risk for band keratopathy. Corneal melt occurred in 22 subjects (2.5%) during the follow-up period. On multivariate analysis, uveitis (HR, 8.618; P = 0.004) and disodium EDTA chelation (HR, 8.666; P < 0.001) were associated with increased risk for corneal melt. EDTA chelation was performed in 8 subjects. Corneal melt occurred after EDTA chelation in 4 subjects, and corneal perforation occurred in 2 subjects. One subject was eviscerated due to severe endophthalmitis after repeated corneal perforation and another required enucleation for recurrent corneal melt and microbial keratitis. CONCLUSIONS: Band keratopathy is an uncommon complication of HZO. Treatment with EDTA chelation might be associated with a significant risk for severe complications in these eyes and should be approached with caution.

Topographic screening reveals keratoconus to be extremely common in Down syndrome.

IMPORTANCE: Keratoconus disproportionately affects people with Down syndrome (DS). This is the first study of its kind in Australasia. BACKGROUND: To investigate the prevalence of keratoconus in DS. DESIGN: Cross-sectional study. PARTICIPANTS: Athletes with DS attending 2017 New Zealand Special Olympics National Summer Games. METHODS: Keratoconus was identified using corneal topography (TMS-4N, Tomey). Topography from both eyes was required to be included. Two independent quantitative criteria were used to indicate keratoconus. The first was keratoconus severity index ≥ 30%. The second, adapted from the literature, required at least four of eight topographic parameters to be abnormal. Data from the worse eye were analysed. Diagnosis in each group was subsequently confirmed qualitatively by three corneal fellowship-trained ophthalmologists. Those with a definitive diagnosis were grouped into Keratoconus Confirmed Group 1 (KCC1) and Keratoconus Confirmed Group 2 (KCC2), respectively. MAIN OUTCOME MEASURES: Keratoconus prevalence, severity, demographics. RESULTS: Of 110 athletes screened, N = 98 were included, mean age 30.0 ± 9.7 years. Using only topographic data, keratoconus was identified in 39 (39.8%) athletes by quantitative topographic criteria 1, and in 63 (64.3%) athletes by criteria 2. Keratoconus was confirmed by qualitative sub-specialist review in 30 (30.6%) (KCC1) and 38 (38.8%) (KCC2) athletes, respectively. Mean keratometry in groups KCC1 and KCC2 were 48.4 ± 3.2D and 48.2 ± 2.9D, respectively. Most were male (KCC1 63.3%, KCC2 76.3%) and of European ethnicity (KCC1 80%, KCC2 78.9%). CONCLUSIONS AND RELEVANCE: We report keratoconus in 30.6% to 38.8% of athletes with DS; therefore, we believe keratoconus screening is indicated in DS for early management.