Reversible Corneal Endothelial Abnormalities With Netarsudil.

PURPOSE: To report a case of reversible corneal endothelial abnormalities after treatment with netarsudil. OBSERVATION: A 68-year-old woman presented with the complaint of blurred vision soon after starting treatment with the fixed-dose combination of netarsudil and latanoprost (FC-netarsudil-latanoprost). She had been receiving the fixed-dose combination of dorzolamide and timolol and latanoprost for primary open-angle glaucoma until her ophthalmologist switched latanoprost to FC-netarsudil-latanoprost 2 months before referral to our center.Best-corrected visual acuity was 20/20-1 in the right eye and 20/20-3 in the left eye. The slit-lamp biomicroscopic examination was remarkable for a guttata-like abnormality of the corneal endothelium of both eyes. The intraocular pressure was 10 mm Hg in both eyes. Specular microscopy revealed irregularly shaped corneal endothelial cells with indistinct borders between cells. FC-netarsudil-latanoprost was replaced with latanoprost in the left eye but continued in the right eye. Nine weeks later, best-corrected visual acuity remained 20/20-1 in the right eye but it improved to 20/20 in the left eye. Repeat specular microscopy was unchanged in the right eye and was normal in the left eye. CONCLUSION AND IMPORTANCE: Topical therapy with netarsudil can result in guttata-like changes of the corneal endothelium and corneal endothelial cell abnormalities that can be detected with specular microscopy. These abnormalities seem to be transient and resolved upon the cessation of netarsudil. Ophthalmologists should consider the possibility of a corneal endothelial abnormality in patients treated with netarsudil who develop blurred vision.

[Efficacy of visual rehabilitation of patients with pellucid marginal degeneration fitted with SPOT® scleral contact lenses]. / Efficacité de la réhabilitation visuelle de patients atteints de dégénérescence marginale pellucide adaptés en lentilles sclérales SPOT.

PURPOSE: To assess visual improvement in patients with pellucid marginal degeneration (PMD) after fitting with SPOT® scleral contact lenses (Scleral Protection & Ocular Treatment, Laboratoires d'Appareillage Oculaire, Amphion-Les-Bains, France). METHODS: We report a case series of 5 patients with PMD and unsatisfactory refractive correction managed at Clermont-Ferrand university hospital from January to December 2018 fitted with customized SPOT scleral lenses. We assessed the best-corrected visual acuity (BVCA) before and after fitting with SPOT, keratometric data and tolerability of the scleral lenses. RESULTS: Nine eyes of 5 patients aged 51.8±8.47 years were fitted. The BVCA was significantly improved from 0.51 logMAR (±0.39) to 0.04 logMAR (±0.07) (P<0.001). Sixty-six percent of the patients recovered optimal BVCA. No serious adverse event was reported. The presence of whitish deposits and an inordinate amount of manipulation required were the main disadvantages of the lenses. Nevertheless, all the patients considered them to be comfortable. CONCLUSION: Fitting PMD patients who have failed conventional optical devices with SPOT scleral lenses significantly improves BCVA, without serious adverse events, allowing surgery to be deferred even when it appears to be unavoidable.

Efficacy of visual rehabilitation of patients with pellucid marginal degeneration fitted with SPOT® scleral contact lenses.

PURPOSE: To assess visual improvement in patients with pellucid marginal degeneration (PMD) after fitting with SPOT® scleral contact lenses (Scleral Protection & Ocular Treatment, Laboratoires d'Appareillage Oculaire, Amphion-Les-Bains, France). METHODS: We report a case series of 5 patients with PMD and unsatisfactory refractive correction managed at Clermont-Ferrand university hospital from January to December 2018 fitted with customized SPOT scleral lenses. We assessed the best-corrected visual acuity (BCVA) before and after fitting with SPOT, keratometric data and tolerability of the scleral lenses. RESULTS: Nine eyes of 5 patients aged 51.8±8.47 years were fitted. The BCVA was significantly improved from 0.51 logMAR (±0.39) to 0.04 logMAR (±0.07) (P<0.001). Sixty-six percent of the patients recovered optimal BCVA. No serious adverse event was reported. The presence of whitish deposits and an inordinate amount of manipulation required were the main disadvantages of the lenses. Nevertheless, all the patients considered them to be comfortable. CONCLUSION: Fitting PMD patients who have failed conventional optical devices with SPOT scleral lenses significantly improves BCVA, without serious adverse events, allowing surgery to be deferred even when it appears to be unavoidable.

Visual performance of scleral lenses and their impact on quality of life in patients with irregular corneas / Desempenho visual das lentes esclerais e seu impacto na qualidade de vida de pacientes com córneas irregulares

ABSTRACT Purpose: We aimed to evaluate the visual quality performance of scleral contact lenses in patients with keratoconus, pellucid marginal degeneration, and post-keratoplasty astigmatism, and their impact on quality of life. Methods: We included 40 patients (58 eyes) with keratoconus, pellucid marginal degeneration, and post-keratoplasty astigmatism who were examined between October 2014 and June 2017 and fitted with scleral contact lenses in this study. Before fitting scleral contact lenses, we noted refraction, uncorrected distance visual acuity, spectacle-corrected distance visual acuity, uncorrected contrast sensitivity, and spectacle-corrected contrast sensitivity. We performed corneal topography on and applied a questionnaire that included the National Eye Institute Visual Functioning Questionnaire to all participants. We recorded corrected contrast sensitivity and corrected distance visual acuity on the third month after fitting scleral contact lenses and requested that subjects repeat the National Eye Institute Visual Functioning Questionnaire. Results: The mean age of patients was 28.12 ± 13.19 years. Mean logMAR uncorrected distance visual acuity, spectacle-corrected distance visual acuity, and corrected distance visual acuity with scleral contact lenses were 0.91 ± 0.21 (0.40-1.80), 0.57 ± 0.12 (0.10-1.80), and 0.16 ± 0.02 (0.00-1.30), respectively. We observed significantly higher corrected distance visual acuity with scleral contact lenses compared with uncorrected distance visual acuity and spectacle-corrected distance visual acuity (p<0.05). Mean uncorrected contrast sensitivity, spectacle-corrected contrast sensitivity and CCS with scleral contact lenses were 0.97 ± 0.12 (0.30-1.65), 1.16 ± 0.51 (0.30-1.80), and 1.51 ± 0.25 (0.90-1.80), respectively. Significantly higher contrast sensitivity levels were recorded with scleral contact lenses compared with those recorded with uncorrected contrast sensitivity and spectacle-corrected contrast sensitivity (p<0.05). We found the National Eye Institute Visual Functioning Questionnaire overall score for patients with scleral contact lens treatment to be significantly higher compared with that for patients with uncorrected sight (p<0.05). Conclusion: Scleral contact lenses are an effective alternative visual correction method for keratoconus, pellucid marginal degeneration, and post-keratoplasty astigmatism. A significant increase in visual acuity and contrast sensitivity can be obtained with scleral contact lenses in patients with irregular corneas.

RESUMO Objetivo: Avaliar o desempenho da qualidade visual das lentes de contato esclerais em pacientes com ceratocone, degeneração marginal transparente e astigmatismo pós-ceratoplastia e seu impacto na qualidade de vida. Métodos: Foram incluídos 40 pacientes (58 olhos) com ceratocone, degeneração marginal transparente ou astigmatismo pós-ce­ratoplastia que foram examinados entre outubro de 2014 e junho de 2017 e adaptados com lentes de contato esclerais neste estudo. Antes de ajustar as lentes de contato esclerais, registrou-se refração, acuidade visual à distância não corrigida, acuidade visual à distância corrigida por óculos, sensibilidade ao contraste não corrigida e sensibilidade ao contraste corrigida por óculos. Rea­lizamos topografia da córnea e aplicamos um questionário que incluía o Questionário de Funcionamento Visual do National Eye Institute para todos os participantes. Registramos a sensibilidade ao contraste corrigida e corrigimos a acuidade visual à distância no terceiro mês após a adaptação das lentes de contato esclerais e solicitamos aos participantes que repetissem o Questionário de Funcionamento Visual do National Eye Institute. Resultados: A idade média dos pacientes foi de 28,12 ± 13,19 anos. A acuidade visual à distância não corrigida logMAR média, a acuidade visual à distância corrigida por óculos e a distância visual corrigida com as lentes de contato esclerais foram 0,91 ± 0,21 (0,40-1,80), 0,57 ± 0,12 (0,10-1,80), 0,16 ± 0,02 (0,00-1,30), respectivamente. Observamos uma acuidade visual à distância corrigida significativamente maior com lentes de contato esclerais em comparação à acuidade visual à distância não corrigida e à acuidade visual à distância corrigida por óculos (p<0,05). Sensibilidade ao contraste médio não corrigido, sensibilidade ao contraste corrigida por óculos e CCS com lentes de contato esclerais foram 0,97 ± 0,12 (0,30-1,65), 1,16 ± 0,51 (0,30-1,80), 1,51 ± 0,25 (0,90-1,80), respectivamente. Significativamente maiores níveis de sensibilidade ao contraste foram registrados com lentes de contato esclerais em comparação com aqueles registrados com sensibilidade ao contraste não corrigida e sensibilidade ao contraste corrigida por óculos (p<0,05). Descobrimos que a pontuação geral do Questionário de Funcionamento Visual do National Eye Institute para pacientes em tratamento com lentes de contato esclerais é significativamente maior em comparação com pacientes com visão não corrigia (p<0,05). Conclusão: As lentes de contato esclerais constituem um método alternativo eficaz de correção visual alternativa para o ceratocone, degeneração marginal transparente e o astigmatismo pós-ceratoplastia. Um aumento significativo na acuidade visual e sensibilidade ao contraste pode ser obtido com lentes de contato esclerais em pacientes com córneas irregulares.

Visual performance of scleral lenses and their impact on quality of life in patients with irregular corneas.

PURPOSE: We aimed to evaluate the visual quality performance of scleral contact lenses in patients with keratoconus, pellucid marginal degeneration, and post-keratoplasty astigmatism, and their impact on quality of life. METHODS: We included 40 patients (58 eyes) with keratoconus, pellucid marginal degeneration, and post-keratoplasty astigmatism who were examined between October 2014 and June 2017 and fitted with scleral contact lenses in this study. Before fitting scleral contact lenses, we noted refraction, uncorrected distance visual acuity, spectacle-corrected distance visual acuity, uncorrected contrast sensitivity, and spectacle-corrected contrast sensitivity. We performed corneal topography on and applied a questionnaire that included the National Eye Institute Visual Functioning Questionnaire to all participants. We recorded corrected contrast sensitivity and corrected distance visual acuity on the third month after fitting scleral contact lenses and requested that subjects repeat the National Eye Institute Visual Functioning Questionnaire. RESULTS: The mean age of patients was 28.12 ± 13.19 years. Mean logMAR uncorrected distance visual acuity, spectacle-corrected distance visual acuity, and corrected distance visual acuity with scleral contact lenses were 0.91 ± 0.21 (0.40-1.80), 0.57 ± 0.12 (0.10-1.80), and 0.16 ± 0.02 (0.00-1.30), respectively. We observed significantly higher corrected distance visual acuity with scleral contact lenses compared with uncorrected distance visual acuity and spectacle-corrected distance visual acuity (p<0.05). Mean uncorrected contrast sensitivity, spectacle-corrected contrast sensitivity and CCS with scleral contact lenses were 0.97 ± 0.12 (0.30-1.65), 1.16 ± 0.51 (0.30-1.80), and 1.51 ± 0.25 (0.90-1.80), respectively. Significantly higher contrast sensitivity levels were recorded with scleral contact lenses compared with those recorded with uncorrected contrast sensitivity and spectacle-corrected contrast sensitivity (p<0.05). We found the National Eye Institute Visual Functioning Questionnaire overall score for patients with scleral contact lens treatment to be significantly higher compared with that for patients with uncorrected sight (p<0.05). CONCLUSION: Scleral contact lenses are an effective alternative visual correction method for keratoconus, pellucid marginal degeneration, and post-keratoplasty astigmatism. A significant increase in visual acuity and contrast sensitivity can be obtained with scleral contact lenses in patients with irregular corneas.

Hybrid contact lenses for visual management of patients after keratoplasty.

AIM: This study aims to report the outcomes of new-generation hybrid contact lenses for visual rehabilitation of postkeratoplasty patients. MATERIALS AND METHODS: Twenty eyes of twenty postkeratoplasty patients were fitted with hybrid lenses. Each patient's keratometric values, ocular surface irregularity indices, central corneal thickness (CCT), uncorrected visual acuity (UCVA), spectacle-corrected visual acuity, contact lens-corrected visual acuity, contact lens fitting data, and contact lens daily wearing time were recorded. Follow-up examinations were performed at 1st week, 1st month, and 3rd month visit after successful fitting of the lenses. RESULTS: The mean age of the patients was 38.42 ± 4.89 years. The mean spherical component of refractive error was -4.46 ± 2.1 D, and the mean astigmatism was -5.31 ± 1.55 D. The median UCVA was 1.00 logarithm of the minimum angle of resolution (logMAR) which improved to 0.40 logMAR after spectacle correction. The median visual acuity with hybrid contact lenses was 0.05 logMAR. The median CCT was 544.4 µm and increased to 549.2 µm at 3 months after contact lens wear. The difference was not statistically significant (P = 0.38). The mean follow-up of patients was 4.32 ± 0.45 months. Eighteen of twenty patients reported a mean of 8.37 ± 1.95 h comfortable wearing time per day during this period. Two patients discontinued contact lens wearing due to conjunctival hyperemia. No graft-related complications such as decompensation, rejection, and infection were documented during the follow-up period. CONCLUSION: The new-generation hybrid contact lenses can be considered helpful in the visual management of postcorneal graft patients, particularly who are unable to achieve an adequate visual outcome with spectacles.

[Evaluation of the quality of life of patients fitted with scleral lenses using a Moroccan version of NEI-VFQ 25]. / Évaluation de la qualité de vie des patients équipés en verres scléraux à l'aide d'une version marocaine du NEI-VFQ 25.

PURPOSE: To evaluate the contribution of scleral lenses in terms of improving quality of life and vision. METHODS: We conducted a retrospective study of the quality of life (QOL) of patients fitted with scleral lenses, between November 2015 and November 2016 in the Marrakech university hospital department of ophthalmology. QOL was assessed before and after scleral lens (ICD) adaptation using a version of the National Eye Institute Visual Function Questionnaire 25 translated into the Moroccan dialect of Arabic. RESULTS: We included 48 patients (68 eyes). The main indications included severe corneal ectasia followed by post-keratoplasty eyes, post-traumatic corneas and patients with ocular surface disease. The average duration of scleral lens wear was 6 months, and the average wearing time was 12hours per day. BCVA increased from 0.8 to 0.2±0.5 LOGMAR. The average scores on the NEI-VFQ 25 of patients after scleral lens fitting were significantly higher, 80.5 versus 42.6 before wearing scleral lenses, thus an increase of 38.1. DISCUSSION: Quality of life has become a major issue in the healthcare field, which has seen a renewed interest in ophthalmology lately. The results of our study support the data from previous studies regarding the impact of scleral lenses on the quality of life of patients. CONCLUSION: High oxygen permeability scleral lenses are a satisfying therapeutic alternative, allowing a significant improvement in the quality of life of patients for whom the usual therapeutic means are limited.

Clinical outcomes of scleral Misa lenses for visual rehabilitation in patients with pellucid marginal degeneration.

PURPOSE: To report the clinical outcomes of scleral Misa® lenses (Microlens Contactlens Technolgy, Arnhem, Netherlands) for visual rehabilitation in patients with pellucid marginal degeneration (PMD). MEHODS: In this prospective interventional case series, 24 eyes of 12 PMD patients were fitted with scleral Misa® lenses. Patients were followed regularly for continuous daily wearing time (CDWT), contact lens handling issues, visual acuity, and any subjective or objective contact lens related complications. RESULTS: The mean patient age was 35.0±13.8 years (range, 23-47 years). The average length of follow-up was 14.1±3.7 months (range, 8.5-18 months). All eyes were fit with mini Misa® scleral lenses with a diameter of 16.5 or 17mm. The mean Snellen best-corrected visual acuity (BCVA) before scleral lenses with spectacle correction was 0.42±0.15 (range, 0.2-0.6). With scleral lenses, mean BCVA was 0.75±0.15 (range, 0.5-0.9), (p=0.003) with a mean gain of 3.3 lines of BCVA. More than half (16 eyes, 67%) reported wearing their scleral lenses for 8h or more on a daily basis. Three patients (6 eyes, 25%) abandoned scleral lens wear. Patients who abandoned the scleral lens wear tended to have a better spectacle corrected visual acuity and less gain of lines. CONCLUSIONS: Scleral lenses can be used succesfully in patients with PMD who are intolerant to other types of contact lenses. Patients who have a low spectacle BCVA and a higher gain of visual acuity with scleral lenses are good candidates for scleral lens use.

Global Survey of Corneal Transplantation and Eye Banking.

IMPORTANCE: Corneal transplantation restores visual function when visual impairment caused by a corneal disease becomes too severe. It is considered the world's most frequent type of transplantation, but, to our knowledge, there are no exhaustive data allowing measurement of supply and demand, although such data are essential in defining local, national, and global strategies to fight corneal blindness. OBJECTIVE: To describe the worldwide situation of corneal transplantation supply and demand. DESIGN, SETTING, AND PARTICIPANTS: Data were collected between August 2012 and August 2013 from a systematic review of published literature in parallel with national and international reports on corneal transplantation and eye banking. In a second step, eye bank staff and/or corneal surgeons were interviewed on their local activities. Interviews were performed during international ophthalmology or eye-banking congresses or by telephone or email. Countries' national supply/demand status was classified using a 7-grade system. Data were collected from 148 countries. MAIN OUTCOMES AND MEASURES: Corneal transplantation and corneal procurements per capita in each country. RESULTS: In 2012, we identified 184,576 corneal transplants performed in 116 countries. These were procured from 283,530 corneas and stored in 742 eye banks. The top indications were Fuchs dystrophy (39% of all corneal transplants performed), a primary corneal edema mostly affecting elderly individuals; keratoconus (27%), a corneal disease that slowly deforms the cornea in young people; and sequellae of infectious keratitis (20%). The United States, with 199.10-6 corneal transplants per capita, had the highest transplantation rate, followed by Lebanon (122.10-6) and Canada (117.10-6), while the median of the 116 transplanting countries was 19.10-6. Corneas were procured in only 82 countries. Only the United States and Sri Lanka exported large numbers of donor corneas. About 53% of the world's population had no access to corneal transplantation. CONCLUSIONS AND RELEVANCE: Our survey globally quantified the considerable shortage of corneal graft tissue, with only 1 cornea available for 70 needed. Efforts to encourage cornea donation must continue in all countries, but it is also essential to develop alternative and/or complementary solutions, such as corneal bioengineering.

Mini-scleral lenses in the visual rehabilitation of patients after penetrating keratoplasty and deep lamellar anterior keratoplasty.

OBJECTIVE: To evaluate fitting feasibility, efficacy, and safety of mini scleral contact lenses in correcting post corneal graft vision. METHODS: Prospective interventional case series, 56 visually unsatisfied post corneal graft eyes of 45 patients were fitted with miniscleral lenses (15.8 mm). Keratometric values, UCVA and BSCVA, fit, best corrected vision with the lens, decision to order lens, comfortable daily wearing time (CDWT), contact lens handling issues, and contact lens related complications were documented. RESULTS: The mean age was 34.6 years (SD: 10.9), ranging from 8 to 63 years. Forty-three eyes had history of full thickness corneal graft, 12 eyes had deep anterior lamellar graft (DALK) and 1 eye had the rotational graft. The mean UCVA was 1.05 logMar (SD: 0.54), ranging from 0.30 to 2.52 logMar. The mean BSCVA was 0.73 logMar (SD: 0.50) ranging from 0.09 to 2.00 which improved to 0.17 logMar (SD: 0.19) with the miniscleral lens. All eyes had ideal (40 eyes) or acceptable (16 eyes) fits. Nineteen patients (23 eyes) ordered their lenses of whom 11 (14 eyes) continued using the lens with a mean follow up time of 21.92 months (SD: 6.8). These patients reported a mean CDWT of 9.62 h/day (SD: 4.5). Five eyes of 4 patients discontinued the lens. Four eyes were lost to follow-up. The main reported barriers for ordering the lenses were economic and handling concerns. CONCLUSION: Miniscleral contact lenses can be considered helpful in the visual management of post corneal graft patients. Other factors may influence the acceptance of the lenses.

An analytical approach to corneal mechanics for determining practical, clinically-meaningful patient-specific tissue mechanical properties in the rehabilitation of vision.

Patient-specific biomechanical properties of the human cornea are rarely used with finite elements analysis. In order for that to be possible, a proper formulation for biomechanical properties that is based on patient-specific measurable values must be used. In this study, we propose a formula that simulates hyperelastic stress-strain curves based on non-invasive clinical measurements that can be acquired in vivo. These consist of, but are not limited to, center corneal thickness and center corneal curvature as well as corneal resistance factor and applanation diameter that are measured during non-contact tonometry. The presented formulation was demonstrated and validated through several computer simulations. First, mean values that were reported in literature were inputted into the formula to simulate a curve that represents a healthy case. This case was compared to two independent in vitro studies. Then, a sensitivity analysis was carried to identify inputs that have the most dominant effect. Finally, a finite element analysis simulating elevations in intraocular pressure was conducted; the corneal model comprised of patient-specific corneal geometry that was measured in vivo in our clinic as well as the current formulation for patient-specific corneal biomechanics. "Strong" and "weak" corneal tissue cases were simulated and deformations as well as instantaneous curvature optical maps were derived. Results for the simulated healthy curve showed good agreement with the in vitro studies. The sensitivity analysis found the corneal resistance factor and applanation diameter to have the most dominant influence. The finite element analysis of strong and weak biomechanical properties resulted in corneal deformations and instantaneous curvature optical maps that are common for healthy and pathological conditions respectively. In conclusion, the presented modeling technique can be used to assess corneal biomechanics in vivo and therefor may enhance follow-up on the effectiveness of clinical treatments, rehabilitation of vision and perhaps improve the diagnosis of pathologies that are related to corneal biomechanics.

[Modern endothelial keratoplasty-based options for visual rehabilitation of patients with bullous keratopathy and concomitant glaucoma].

PURPOSE: To develop endothelial keratoplasty-based surgical treatment and management policy for patients with bullous keratopathy complicated by glaucoma. MATERIAL AND METHODS; A total of 41 patients (41 eyes) with bullous keratopathy and concomitant II-III stage glaucoma were enrolled. All patients underwent endothelial keratoplasty of different modification--DSAEK, utDSAEK, DMAEK. Two types of glaucoma drainage surgery were applied--intrascleral amniotic drainage and implantation of a domestically manufactured silicone tubular drainage wrapped in amnion. RESULTS: Intraocular pressure (IOP) was compensated in 11 of 12 patients, on whom a glaucoma procedure was performed. In 29 post-keratoplasty patients, whose IOP was compensated both before and after the surgery, the mean IOP at the 2-year follow-up visit was 2 mm Hg higher than the preoperative values. Medication regimen was adjusted in 7 cases in order to enhance the hypotensive effect. No evident correlation between graft thickness and IOP change was found. CONCLUSION: Based on a study of 41 patients (41 eyes) with bullous keratopathy and concomitant glaucoma who underwent endothelial keratoplasty, surgical treatment and therapeutic management policy is developed, which takes into account whether or not the IOP is compensated and whether or not its further decrease is required and implies the use of own original drainage techniques.

Comparison of conventional method of contact lens fitting and software based contact lens fitting with Medmont corneal topographer in eyes with corneal scar.

PURPOSE: To compare conventional method of contact lens fitting with software based contact lens fitting using Medmont corneal topographer in eyes with nebular and macular corneal scars. METHODS: Fifteen participants who were diagnosed with nebular and macular scars were fitted with rigid gas permeable lenses using conventional method of contact lens fitting. During the lens dispensing visit, participants underwent Medmont corneal topography. Agreement between the two methods of contact lens fitting was studied. RESULTS: Parameters of contact lenses which were concluded using conventional method was compared to that of software based fitting. Mean difference in base curve of contact lens between the two methods was 0.094 mm±0.147 mm (95% CI: +0.383 to -0.194). Mean difference in diameter of contact lens between the two methods was 0.16 mm±0.172 mm (95% CI: +0.497 to -0.177). Contact lens parameters that were achieved using two different methods of fitting showed good correlation. Correlation coefficients, as comparison of two methods in base curve and diameter were 0.96 (P<0.05) and 0.94 (P<0.05), respectively. CONCLUSION: Software based contact lens fitting would be useful for contact lens practitioners to predict initial base curve of contact lens in corneal scars.

Visual performance and the ocular surface in traumatic brain injury.

The pathophysiology of neurotrauma is reviewed and an original study investigating the prevalence of dry eye disease in a sample of veterans with traumatic brain injury (TBI) is presented. Fifty-three veterans with TBI were evaluated by history of injury, past ocular history, and medication use. Ocular Disease Surface Index (OSDI), ocular examination, cranial nerve evaluation, tear osmolarity, tear film break-up time (TFBUT), ocular surface staining and tear production testing were performed. A matched comparison group underwent similar testing. TBI causes were blast (44) or non-blast (9). TBI subjects scored significantly worse on the OSDI (P<.001), and ocular surface staining by Oxford scale (P<.001) than non-TBI subjects. Scores for tear film breakup (P=.6), basal tear production less than 3 mm (P=.13), and tear osmolarity greater than 314 mOsm/L (P=.15) were all higher in TBI subjects; significantly more TBI subjects had at least one abnormal dry eye measure than comparisons (P<.001). The OSDI related to presence of dry eye symptoms (P<.01). These effects were present in both blast and non-blast TBI. Seventy percent of TBI subjects were taking at least one medication in the following classes: antidepressant, atypical antipsychotic, anticonvulsant, or h1-antihistamine. There was no association between any medication class and the OSDI or dry eye measures. Reduced corneal sensation in 21 TBI subjects was not associated with OSDI, tear production, or TFBUT, but did correlate with reduced tear osmolarity (P=.05). History of refractive surgery, previous contact lens wear, facial nerve weakness, or meibomian gland dysfunction was not associated with DED. In summary, we found a higher prevalence of DED in subjects with TBI, both subjectively and objectively. This effect is unrelated to medication use, and it may persist for months to years. We recommend that patients with TBI from any cause be evaluated for DED using a battery of standard testing methods described in a protocol presented in this article. Further research into the pathophysiology and outcomes of DED in neurotrauma is needed.

Cornea Society nomenclature for ocular surface rehabilitative procedures.

PURPOSE: In the past 20 years, there has been tremendous development in ocular surface rehabilitation and, through better understanding and improvements in analytic and culture techniques, a variety of new procedures have been developed. Differing techniques have been used internationally and often similar terminology is used when procedures could be considered to be quite different or vice versa. To communicate clearly and to compare techniques and outcomes, it was determined that an agreed international nomenclature was necessary. METHODS: A subcommittee was established by The Cornea Society. An initial steering group of international experts with special interest in ocular surface was assembled and established broad principles for the nomenclature based on a previous nomenclature. RESULTS: The nomenclature for procedures was based on several parameters, including a) anatomic source of tissue transplanted, for example conjunctival, keratolimbal or mucosal, b) whether the source was autologous or allogeneic (cadaveric or living related), and c) cell culture techniques. For example, an expanded cell culture of cadaveric limbal tissue was named ex-vivo cultivated cadaveric limbal allograft (EvC-LAL). CONCLUSIONS: Agreed nomenclature for transplantation procedures used in ocular surface rehabilitation has been developed, and use of this common terminology should help communication among those involved in this field.

Deep anterior lamellar keratoplasty as an alternative to penetrating keratoplasty a report by the american academy of ophthalmology.

OBJECTIVE: To review the published literature on deep anterior lamellar keratoplasty (DALK) to compare DALK with penetrating keratoplasty (PK) for the outcomes of best spectacle-corrected visual acuity (BSCVA), refractive error, immune graft rejection, and graft survival. METHODS: Searches of the peer-reviewed literature were conducted in the PubMed and the Cochrane Library databases. The searches were limited to citations starting in 1997, and the most recent search was in May 2009. The searches yielded 1024 citations in English-language journals. The abstracts of these articles were reviewed, and 162 articles were selected for possible clinical relevance, of which 55 were determined to be relevant to the assessment objective. RESULTS: Eleven DALK/PK comparative studies (level II and level III evidence) were identified that compared the results of DALK and PK procedures directly; they included 481 DALK eyes and 501 PK eyes. Of those studies reporting vision and refractive data, there was no significant difference in BSCVA between the 2 groups in 9 of the studies. There was no significant difference in spheroequivalent refraction in 6 of the studies, nor was there a significant difference in postoperative astigmatism in 9 of the studies, although the range of astigmatism was often large for both groups. Endothelial cell density (ECD) stabilized within 6 months after surgery in DALK eyes. Endothelial cell density values were higher in the DALK groups in all studies at study completion, and, in general, the ECD differences between DALK and PK groups were significant at all time points at 6 months or longer after surgery for all of the studies reporting data. CONCLUSIONS: On the basis of level II evidence in 1 study and level III evidence in 10 studies, DALK is equivalent to PK for the outcome measure of BSCVA, particularly if the surgical technique yields minimal residual host stromal thickness. There is no advantage to DALK for refractive error outcomes. Although improved graft survival in DALK has yet to be demonstrated, postoperative data indicate that DALK is superior to PK for preservation of ECD. Endothelial immune graft rejection cannot occur after DALK, which may simplify long-term management of DALK eyes compared with PK eyes. As an extraocular procedure, DALK has important theoretic safety advantages, and it is a good option for visual rehabilitation of corneal disease in patients whose endothelium is not compromised.

Binocular visual function in patients with Boston type I keratoprostheses.

PURPOSE: To report the postoperative binocular function of patients with Boston type I keratoprostheses implantation for unilateral visual impairment. METHODS: Seventeen patients who underwent implantation of a Boston type I keratoprosthesis and had a best-corrected visual acuity better than 20/50 in the contralateral eye before surgery were evaluated. All subjects prospectively underwent sensory testing of binocular function including Bagolini lenses, Worth-4-dot test, stereoacuity at distance and near, and double Maddox rods. In addition, an assessment of ocular rotations and alignment was performed on each subject. RESULTS: Twenty patients with best-corrected visual acuity better than 20/50 in the contralateral eye at the time of keratoprothesis surgery were identified. Seventeen of the 20 patients underwent binocular visual testing, with 16 of 17 (94%) demonstrating binocular function. Second-degree fusion at near was demonstrated via the Worth-4-dot test in 13 of 17 (76%) patients. Third-degree fusion at near was demonstrated in 7 of 17 (41%) patients. Patients with better postoperative sensory binocular function tended to be of younger age (P = 0.05) and have better postoperative visual acuity (P = 0.006). Five patients were found to have some degree of ocular misalignment. Overall, patients with strabismus had worse binocularity (P = 0.04). CONCLUSIONS: Implantation of the Boston type I keratoprosthesis in patients with good preoperative visual acuity in the fellow eye is associated with useful binocular function in greater than 90% of patients.