Clinical correlations and impact of conjunctivochalasis in soft contact lens wearers.

PURPOSE: To evaluate the correlation between clinical tests, patient symptoms, and conjunctivochalasis in contact lens wearers and non-wearers. METHODS: This study comprised 40 eyes of 40 current soft contact lens users and 40 eyes of 40 control subjects. Cross-sectional areas of conjunctivochalasis at three locations (nasal, central, temporal) during straight and downward gazes were determined using anterior segment optical coherence tomography in all participants. Tear film break up time test and Schirmer test with anesthesia were performed and for evaluation of symptoms, the participants completed ocular surface disease index questionnaire. RESULTS: During straight gaze, the mean cross-sectional areas of conjunctivochalasis were 0.0112 ± 0.009 and 0.006 ± 0.005 mm2 at nasal, 0.0096 ± 0.007 and 0.002 ± 0.004 mm2 at central, 0.0176 ± 0.014 and 0.008 ± 0.009 mm2 at temporal in contact lens and control groups, respectively. Regardless of location and gaze direction, the mean cross-sectional conjunctivachalasis areas of the contact lens group were significantly higher than those of the controls (all, p < 0.05). Significant positive correlations between ocular surface disease index score and measured conjunctivachalasis areas (in all sites) during straight gaze and downward gaze were observed in the contact lens group (all, p < 0.05 and r > 0.450). CONCLUSION: Wearing soft contact lenses is associated with increased conjunctivochalasis areas. Anterior segment optical coherence tomography determined conjunctivochalasis area is an objective clinical measurement value that is positively correlated with patients' symptoms in soft contact lens wearers.

Evaluation of Dry Eye Severity and Ocular Surface Inflammation in Patients with Pemphigus and Pemphigoid.

PURPOSE: To evaluate ocular surface involvement, tear cytokine levels, and histopathological changes in pemphigus and pemphigoid patients. METHODS: A total of 22 patients (15 pemphigus and 7 pemphigoids) and 21 non-diseased controls were enrolled in our study. All participants underwent ocular surface evaluation, which included ocular surface disease index test, slit lamp observation, dry eye-related examination, tear multicytokine analysis, and conjunctival impression cytology. RESULTS: Pemphigus and pemphigoid patients presented much more severe conjunctivochalasis, corneal epithelial defects, corneal opacity, symblepharon   and dry eye. Severe ocular surface squamous metaplasia and a significant increase of tear macrophage inflammatory protein-1beta, tumor necrosis factor-alpha, interleukin (IL)-1ß, IL -6, and IL-8 occurred in pemphigus and pemphigoid patients. CONCLUSIONS: Our results revealed that ocular surface inflammation and dry eye persist in most pemphigus and pemphigoid patients, and do not occur in parallel with the systemic course. Regular ophthalmological examinations and local anti-inflammatory should be provided for pemphigus and pemphigoid patients.

Late-Onset Traumatic Corneal Conjunctival Epithelial Disorders due to Granular Formation After Cosmetic Suture Blepharoplasty.

PURPOSE: The purpose of this study was to report conjunctival granular formation as one of the causative factors of a traumatic corneal conjunctival epithelial disorder after plastic suture blepharoplasty. METHODS: Clinical charts of 7 patients who had visited Ohshima Eye Hospital with a symptomatic corneal epithelial disorder and history of suture blepharoplasty were reviewed. Clinical evidence of conjunctival granular formations was observed in all patients at the tarsal conjunctiva facing to corneal conjunctival traumatic epithelial disorders. The desired outcome was to alleviate the disorder. The assessment included tabulating results after the placement of a soft contact lens bandage and subsequent partial tarsal plate resection of the granular formation. RESULT: Seven women (mean age 45.0 ± 10.9 years) enrolled in this study had previously undergone suture blepharoplasty (mean 18.3 ± 6.9 years before). Soft contact lens bandages relieved all of the patients' complaints immediately. After resecting the granular formation, the traumatic corneal conjunctival epithelial disorder disappeared, and no recurrence was observed after surgery. CONCLUSIONS: The conjunctival granular formation within the tarsal conjunctiva after suture blepharoplasty caused the late-onset traumatic corneal conjunctival epithelial disorder. A complete cure was obtained after resection of the granular formation at the tarsal conjunctiva. To the best of our knowledge, this is the first report to identify the removal of granular formations in 7 patients with late-onset traumatic corneal conjunctival disorders many years after blepharoplasty. The resection of these lesions is a promising procedure to treat late-onset ocular epithelial disorder after suture blepharoplasty.

Association between subconjunctival hemorrhage and hemorrhagic disorders: a nationwide population-based study.

Subconjunctival hemorrhage (SCH) is a benign eye condition that is often noticeable and leads to medical attention. Despite previous studies investigating the relationship between SCH and cardiovascular diseases, the relationship between SCH and bleeding disorders remains controversial. In order to gain further insight into this association, a nationwide cohort study was conducted using data from the National Health Insurance Service-National Sample Cohort version 2.0 from 2006 to 2015. The study defined SCH using a diagnostic code and compared the incidence and risk factors of intracerebral hemorrhage (ICH) and gastrointestinal (GI) bleeding in 36,772 SCH individuals and 147,088 propensity score (PS)-matched controls without SCH. The results showed that SCH was associated with a lower risk of ICH (HR = 0.76, 95% CI = 0.622-0.894, p = 0.002) and GI bleeding (HR = 0.816, 95% CI = 0.690-0.965, p = 0.018) when compared to the PS-matched control group. This reduced risk was more pronounced in females and in the older age group (≥ 50 years), but not observed in males or younger age groups. In conclusion, SCH dose not increase the risk of ICH and major GI bleeding and is associated with a decreased incidence in females and individuals aged ≥ 50 years.

Sutureless Amniotic Membrane Transplantation Using Pediatric Nasogastric Tube for Patients With Acute Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis.

PURPOSE: Evaluation of the results of sutureless amniotic membrane transplantation (AMT) using a pediatric nasogastric tube (NGT) for patients with acute Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) was aimed. METHODS: Twenty-six eyes of 13 patients with SJS/TEN with ocular involvement at a single tertiary care hospital between May 2020 and January 2022 were included in the study. An amniotic membrane was implanted to the ocular surface and conjunctival fornix using a modified symblepharon ring (MR) created by inserting NGT end-to-end. Patients were followed for at least 6 months. The mean duration of the surgery was recorded. The presence of corneal epithelial defect and vascularization, meibomian gland dysfunction (MGD) grade, conjunctival scarring, eyelid margin keratinization, symblepharon, and trichiasis were recorded. RESULTS: The mean age of the patients was 38.4±17.6 years. Amniotic membrane transplantation was performed only once for eight patients and twice for five patients. The mean duration of the surgery was 3.2±0.4 min. The modified symblepharon ring was removed 28 days after its application. At the first examination, 20 eyes (76.9%) had a corneal epithelial defect and 6 (23.1%) had early symblepharon. At the postoperative 6 months, although seven eyes (26.9%) had conjunctival scarring and 5 (19.2%) had eyelid margin keratinization, all patients were without any corneal defect, corneal vascularization, or symblepharon. Only 11 eyes (42.3%) showed MGD, and 1 eye (3.8%) showed trichiasis. CONCLUSIONS: This study showed that sutureless AMT using pediatric NGT could be a potentially fast and inexpensive treatment option for the treatment of SJS/TEN with ocular involvement at the bedside without the need for general anesthesia.

Ocular tuberculosis presenting with a conjunctival granuloma.

An 18-year-old female patient was referred with complaints of tearing and redness in the left eye for 3 months after a mild ocular trauma with a turkey feather. She was treated with topical antibiotics and corticosteroids with no improvement. Slit-lamp examination of the left eye showed a vascularized lesion with a polypoidal appearance due to multiple contiguous micronodules on the temporal and inferior bulbar conjunctiva. Results of the anterior and posterior segment examination were unremarkable in both eyes. A biopsy specimen of the conjunctival mass showed multiple tuberculoid granulomas composed of epithelioid histiocytes with associated Langhan's type multinucleate giant cells and a necrotic nodule surrounded by histiocytes and giant cells. The Mantoux test was positive with induration of 15mm. The patient was prescribed antituberculosis therapy. Three months after treatment initiation, the conjunctival lesions had resolved. Mycobacterium tuberculosis should be considered in cases of unilateral chronic recalcitrant conjunctivitis. Biopsy of a conjunctival mass is of utmost importance to establish a definite diagnosis.

Significance of subconjunctival hemorrhage in predicting ocular pathology for patients with orbital fracture.

OBJECTIVE: Subconjunctival hemorrhage (SCH) is a common presentation in patients with orbital trauma and often warrants investigation of underlying ocular pathology. Our study aims to assess the significance of SCH severity, graded in a spatial 0-360° manner, as a predictor for ocular pathology in patients with orbital fracture. DESIGN: Retrospective chart review. PARTICIPANTS: Patients with fractured orbits (n = 265) presenting to a level 1 trauma centre between August 2015 and January 2018. METHODS: Key elements of ophthalmic assessment, including visual acuity, SCH (0-360°), anterior- and posterior-segment examination, Hertel exophthalmometry, and ocular pathology, were recorded. Simple logistic regression assessed for association between SCH severity and ocular pathology. Odds ratios (ORs) were calculated with 95% CI. RESULTS: Among the 265 fractured orbits, 158 (59.6%) presented with no SCH, and 107 (40.4%) had some degree of SCH. Ocular pathology was noted in 24 fractured orbits (9%). Most common pathologies included entrapment (22.2%), hyphema (16.7%), traumatic optic neuropathy (8.3%), and commotio retinae (8.3%). Simple logistic regression revealed a higher incidence of ocular pathology with increasing severity of SCH from 0-360° (OR = 1.004; 95% CI 1.001-1.007; p = 0.0085). In addition, χ2 analysis demonstrated a higher proportion of ocular pathology in 181-270° (25.0%; p = 0.0466) and 271-360° SCH subgroups (26.3%; p = 0.0031) compared with the 0° SCH subgroup (6.3%). CONCLUSIONS: Our findings suggest that there is some correlation between the extent of SCH and ocular pathology. However, patient care and investigations should continue to be directed by a full clinical assessment of patients with orbital trauma.

Spontaneous resolution of a wooden foreign-body granuloma in the conjunctiva of a child.

A conjunctival foreign-body (FB) granuloma may result following trauma with synthetic and non-synthetic materials including organic and non-organic objects. Children usually manifest with FB granulomas that develop due to inoculation of FBs from soft toys, blankets or woollen clothes. Encapsu- lation of these FBs following a granulomatous inflammatory response results in a nodular swelling in the conjunctiva. Reports of a wooden FB granuloma in the conjunctiva in children are anecdotal. A 5-year-old boy suffered an un- witnessed direct ocular trauma to his left eye (OS) with a wooden arrow while playing. He developed redness and nodular swelling at the inferotemporal aspect of the OS without any visual complaints. The diagnosis of a wooden FB granuloma is a challenge to ophthalmologists and may go undetected in children who neglect their symptoms. It characteristically presents as a unilateral conjunctival nodule. Surgical excision is the definitive management. However, spontaneous extrusion of the FB might be observed due to protective blinking and tearing mechanisms in the eye.

Long-term clinical outcomes and predictive factors in patients with chronic ocular graft-versus-host disease.

We investigate long-term clinical outcomes and predictive factors associated with poor vision outcomes in patients with ocular graft-versus-host disease (oGVHD). This retrospective cohort study involved 94 patients with chronic oGVHD, classified into severe (n = 25) and non-severe (n = 69) groups. Factors associated with oGVHD severity and poor vision outcomes were examined using multivariate logistic regression. In the severe oGVHD group, the disease activity pattern tended to be persistent, whereas flare-up episodes were more frequent and occurred over shorter intervals in this group. Myelodysplastic syndrome (MDS) and lung GVHD were more common and systemic calcineurin inhibitors were used more frequently in the severe group than in the non-severe group. Finally, 5-year survival rates were poorer in the severe group. Multivariate analysis revealed that MDS, lung GVHD involvement, and no history of systemic calcineurin inhibitor use were risk factors for severe oGVHD. Risk factors for poor vision outcomes were conjunctival scarring and persistent epithelial defects. In conclusion, MDS, lung GVHD, and no history of systemic calcineurin inhibitors are associated with severe oGVHD. Conjunctival scarring and persistent epithelial defects are risk factors for poor vision outcomes.

Prevalence and Causes of Subconjunctival Hemorrhage in Children.

OBJECTIVE: Subconjunctival hemorrhage (SCH) is a reported sign of occult abusive injury, but there are limited published data about SCH during childhood. We sought to determine the prevalence and causes of SCH in children. METHODS: This is a retrospective cross-sectional study of children seen by pediatric ophthalmologists in an outpatient setting over 4 years. Primary outcomes were prevalence and causes of SCH, based on history, physical ocular and nonocular findings, and laboratory and imaging studies. Subconjunctival hemorrhage prevalence was determined including and excluding eye surgery to reduce bias in the prevalence estimate. RESULTS: We studied 33,990 children, who underwent 86,277 examinations (median age, 5 years; range, 2 days to 18 years; 9282 younger than 2 years, 13,447 age 2-7 years, 11,261 age 8-18 years). There were 949 cases of SCH (1.1%; 95% confidence interval, 1.0-1.2). When surgery was excluded, there were 313 cases (prevalence, 0.4%; 95% confidence interval, 0.3-0.4), of which 261 (83%) were due to trauma; 40 (13%) ocular surface inflammation, including infectious conjunctivitis; 7 (2%) orbital or conjunctival lesion; 3 (1%) vessel rupture from choking or cough; and 2 (1%) coagulopathy related. Across all ages, including less than 2 years, trauma and inflammation together accounted for 94% to 97% of all cases of SCH. CONCLUSIONS: Subconjunctival hemorrhage is uncommon in children. The great majority of cases are due to trauma. All children with SCH, including infants and young children, should be closely examined to identify other ocular or nonocular signs of trauma.

Does the conjunctivochalasis accompanied by pseudoexfoliation syndrome affect the ocular surface and anterior segment structures?

PURPOSE: The probability of the coexistence of conjunctivochalasis and pseudoexfoliation syndrome (PES) in the same individual may increase with aging. We investigated the effects of conjunctivochalasis accompanied by PES on the ocular surface (OS) and anterior segment (AS) structures. METHODS: Cases with only conjunctivochalasis were determined as Group 1 (n = 62), cases with conjunctivochalasis accompanied by PES as Group 2 (n = 45), and healthy individuals as Group 3 (n = 56). The OS and AS parameters of the groups were compared. RESULTS: There were a higher grade-3 conjunctivochalasis rate (17.7% vs. 46.7%, p = 0.039), a greater "mean grade of conjunctivochalasis" value (1.72 ± 0.24 vs. 2.29 ± 0.32, p = 0.036), and a higher "total conjunctivochalasis score" (4.27 ± 1.13 vs. 6.12 ± 1.35, p = 0.025) in Group 2 than in Group 1. Additionally, Group 2 had a shorter tear film break-up time (TBUT) (9.17 ± 2.53 vs. 5.41 ± 1.32, p = 0.010) and a greater OS disease index (OSDI) score (16.28 ± 3.15 vs. 27.36 ± 4.12, p = 0.037) than Group 1. Moreover, both Group 1 and Group 2 had shorter TBUTs (Group 1-3: p = 0.004; Group 2-3: p < 0.001) and greater OSDI scores (Group 1-3: p = 0.042; Group 2-3: p = 0.019) compared to Group 3. The groups' ocular surface staining scores, Schirmer 1 tests, central corneal thicknesses, keratometries, axial lengths, anterior chamber depths, lens thicknesses, and intraocular pressures were similar (p > 0.05). CONCLUSIONS: To our knowledge, this was the first study comprehensively investigating the effects of conjunctivochalasis accompanied by PES on the OS and AS structures together. We found that conjunctivochalasis might cause the OS disease, while the presence of PES in conjunctivochalasis cases might worsen both the OS disease and conjunctivochalasis findings.

Clinical and histopathological features of conjunctival "Teddy bear" granuloma: A case series.

PURPOSE: To describe the clinical features, histopathological findings, and prognosis of conjunctival Teddy bear granuloma (TBG) diagnosed in a Mexican ophthalmologic referral center in a period of 64 years. METHODS: We reviewed clinical and histopathological material from all patients with documented conjunctival TBG. Patient's age, gender, location, clinical signs and symptoms, duration, treatment and, specimen size, were evaluated. Formalin-fixed paraffin embedded 5 microns hematoxylin-eosin stained slides and periodic acid-Schiff special stain as well as examination under polarized light microscopy were performed in all cases. RESULTS: A total of 5 conjunctival TBG were collected. The ages of the patients ranged between 2 and 11 with a mean of 6 years. Female to male ratio was 4:1. The right inferior fornix was involved in 4 cases (80%) with clinical diagnosis of conjunctival mass of unknown etiology. Treatment consisted of surgical removal by slit-lamp biomicroscopy (3 cases) and in the operating room (2 cases). No complications were informed in a short follow-up period. Histopathologically, numerous cross-sections of synthetic and non-synthetic fibers surrounded by multinucleated foreign body giant cells, epithelioid histiocytes, lymphocytes, plasma cells and sparse neutrophils were seen. Polarization light microscopy demonstrated numerous birefringent colorful foreign fibers. The follow-up period of the patients ranged between 1 and 32 weeks with a mean of 10 weeks. CONCLUSIONS: Most patients with TBG are children with vague, non-specific symptoms troubling precise clinical diagnosis. Treatment of choice involves surgical excision of the foreign body granuloma followed by topical corticosteroids. All surgical specimens obtained must be sent for histopathological examination. Special awareness is recommended during COVID-19 pandemic lockdown to prevent potential exposure to fibers that may cause conjunctival TBG.

Can bleeding in trabeculectomy be decreased? Effectiveness of brimonidine pre-treatment.

PURPOSE: To evaluate the efficacy of preoperative topical brimonidine use to maintain visibility during trabeculectomy and control intraoperative bleeding and postoperative subconjunctival hemorrhage. METHODS: The first group comprised 35 eyes of 34 patients administered brimonidine tartrate 0.15% (Brimogut, Bilim Ilac, Turkey) eye drops 6 and 3 min before surgery, and 33 eyes of 31 patients who received no medication for vasoconstriction formed the second group. Preoperative and postoperative photographs and operation video images were taken and vision analysis software used. Black-and-white images were obtained to identify the blood vessel and surface hemorrhage areas. The surface area of the hemorrhage was calculated by counting the black pixels with Image J software. RESULTS: There was no significant difference between two groups in terms of baseline (preoperative) eye redness (p > 0.05). In the first group, the eye redness values were 344.7 ± 19.5 pixels preoperatively and 244.1 ± 23.3 pixels at the beginning of the surgery, respectively (p < 0.001). However, no significant change was observed in the second group in eye redness (348.2 ± 17.5 pixels preoperatively and 360.7 ± 26.8 pixels at the beginning of the surgery, p > 0.05). Cautery was used for an average of 11.91 ± 1.96 s in the first group and 25.57 ± 4.66 s in the second to control intraoperative bleeding (P < 0.001). CONCLUSION: Preoperative topical brimonidine use in trabeculectomy surgery significantly decreased intraoperative bleeding and postoperative subconjunctival hemorrhage and facilitated bleeding control.