Long-term outcomes of permanent keratoprosthesis.

PURPOSE OF REVIEW: To provide an update on recent advances in keratoprosthesis surgery with a focus on long-term outcomes. RECENT FINDINGS: Reports over the past year have focused on long-term outcomes showing good anatomical and functional results. In addition, preoperative diagnosis and surgical modifications that can impact postoperative outcomes are discussed. Outcomes of primary keratoprosthesis as an option for patients with poor prognosis for traditional keratoplasty are also presented in this review. SUMMARY: Keratoprosthesis is an option for visual rehabilitation in select patients. Current 5-year outcomes are promising but improvements in glaucoma prevention and management are needed to enhance long-term results.

Sudden-onset Blindness from a Spontaneous Carotid-cavernous Fistula with Secondary Central Retinal Artery Occlusion and Posterior Ischemic Optic Neuropathy.

Our case describes a patient diagnosed with a carotid-cavernous fistula (CCF) secondary to a spontaneously ruptured cavernous carotid aneurysm, presenting with sudden vision loss, and a concomitant central retinal artery occlusion as visualized by a cherry-red spot in the macula and posterior ischemic optic neuropathy. Computed tomography of the brain and orbits showed mild hydrocephalus, orbital fat haziness, and proptosis with concern for fluid in the basal cisterns. Cerebral angiography confirmed the suspected diagnosis of CCF. After angiography, a Magnetic resonance imaging of the brain demonstrated abnormal diffusion restriction in the posterior right optic nerve confirmed on the apparent diffusion coefficient map, consistent with ischemia of the optic nerve in this location. Two weeks after discharge, outpatient fundus photography showed resolution of her cherry-red spot, and optical coherence tomography showed thinning of the entire retinal nerve fiber layer as compared to the contralateral eye. In CCFs, congestive symptoms of proptosis, pain, and even central retinal vein occlusion findings are frequently described. However, our patient's no light perception vision and imaging findings suggest associated central retinal artery occlusion and ischemic optic neuropathy. These findings underscore the multitude of serious visual effects of high flow CCFs.

Meibomian Gland Disease: The Role of Gland Dysfunction in Dry Eye Disease.

TOPIC: To discuss the pathology, causes, and ocular surface impact of meibomian gland disease (MGD), as well as its relationship to dry eye. CLINICAL RELEVANCE: MGD is a common disorder with various contributing mechanisms and clinical manifestations. Understanding MGD pathophysiology and its relationship to dry eye is important in order to optimize diagnosis and treatment algorithms. METHODS: A review of current literature was performed to discern MGD in terms of pathophysiology, risk factors, and ocular surface impact, and the relationship to dry eye. RESULTS: Meibomian gland obstruction and meibocyte depletion are important components of MGD. Many pathologies can disrupt function of meibomian glands, ranging from congenital to acquired causes. Once gland disruption occurs, the quality and quantity of meibum is altered, with a negative impact on the ocular surface. Increased tear evaporation, tear hyperosmolarity, increased ocular surface staining, increased inflammation, symptomatic irritation of the eyelid and globes, as well as decreased visual acuity have all been observed. CONCLUSION: MGD leads to changes in meibum quality and quantity that can cause evaporative dry eye and ocular surface disruption, leading to dry eye symptoms in some individuals.

Human Tear Serotonin Levels Correlate with Symptoms and Signs of Dry Eye.

PURPOSE: Serotonin, a neurotransmitter known to be involved in nociceptor sensitization, is present in human tears. The purpose of this study was to correlate tear serotonin levels, as a marker of nociceptor sensitization, to facets of dry eye (DE), including symptoms and signs. DESIGN: Cross-sectional study. PARTICIPANTS: A total of 62 patients with normal eyelid and corneal anatomy were prospectively recruited from a Veterans Administration Ophthalmology Clinic over 11 months. METHODS: Dry eye symptoms (Ocular Surface Disease Index [OSDI]), signs (tear break-up time [TBUT], corneal staining, and Schirmer's score), and clinical descriptors of neuropathic ocular pain (NOP) (sensitivity to light or sensitivity to wind) were assessed. For tear analysis, each patient's tears were collected after instilling 50 µl of sterile saline to the lower cul-de-sac of each eye and using capillary action microcaps to collect the ocular wash. Tear serotonin levels were measured using enzyme-linked immunosorbent assay. MAIN OUTCOME MEASURES: Correlations between tear serotonin concentrations and DE symptoms and signs. RESULTS: The mean age of the population was 61±14 years, and 84% (n = 52) of the patients were male. Serotonin concentrations negatively correlated with Schirmer's scores (r = -0.28; P = 0.02) but did not correlate with other DE parameters, such as OSDI scores, sensitivity to light or wind, TBUT, and staining. According to our hypothesis, we divided patients into groups based on both DE symptoms and aqueous tear production; serotonin concentrations were significantly higher in DE group 1 (OSDI ≥6 and Schirmer's <8) compared with both DE group 2 (OSDI ≥6 and Schirmer's ≥8) and controls (OSDI <6 and Schirmer's ≥8). Patients in DE group 2 more frequently reported sensitivity to light (64%) and wind (67%) compared with DE group 1 (40% and 60%, respectively) and controls (8% and 17%, respectively). CONCLUSIONS: Patients with DE symptoms and aqueous tear deficiency had higher tear serotonin levels compared with those with DE symptoms but normal tear production and those without DE symptoms.

Intrastromal Corneal Ring Segment Explantation in Patients With Keratoconus: Causes, Technique, and Outcomes.

PURPOSE: To assess the causes for intrastromal corneal ring segment (Intacs; Addition Technology Inc., Lombard, IL) explantation in patients with keratoconus, and technique for explantation, long-term outcomes, and secondary procedures to correct visual acuity. METHODS: Ten eyes of 8 patients with a history of Intacs explantation between 2004 and 2012 were included in a retrospective study performed at the Bascom Palmer Eye Institute, Miami, Florida. Causes of Intacs removal, surgical technique, preoperative and postoperative corneal examination, and uncorrected and corrected distance visual acuity were documented. Additionally, corneal topography (Tomey, Nagoya, Japan) parameters such as average keratometry and corneal cylinder were assessed. RESULTS: Although the segments were well positioned, the most common cause of Intacs removal was worsening visual acuity (80%). There was no statistically significant difference between pre-Intacs placement, post-Intacs placement, and post-Intacs removal in uncorrected and corrected distance visual acuity, average keratometry, or corneal cylinder, except between 1-year post-Intacs placement corrected distance visual acuity (0.57 logMAR [20/75 Snellen]) and 1-month post-Intacs removal corrected distance visual acuity (0.25 logMAR [20/36 Snellen], P =.03). Four patients underwent penetrating keratoplasty after Intacs removal with good visual outcomes. CONCLUSION: This study demonstrates the visual and structural outcomes that returned to near baseline after Intacs explantation in keratoconic eyes.

Comparison of IOL power calculation methods and intraoperative wavefront aberrometer in eyes after refractive surgery.

PURPOSE: To compare preoperative methods for calculating intraocular lens (IOL) power versus the intraoperative wavefront aberrometer in eyes with a history of refractive surgery. METHODS: A retrospective study of 46 eyes (33 patients) with previous refractive surgery that underwent subsequent cataract surgery was conducted. Suggested IOL power predicted by ORange intraoperative wavefront aberrometer (WaveTec Vision Systems, Inc., Aliso Viejo, CA) was compared to power predicted by the (1) SRK-T formula using keratometry and axial length measurements from the IOLMaster (Carl Zeiss Meditec, Dublin, CA), (2) average central keratometry (Avg K) from corneal topography, and (3) average IOL power predicted by the American Society of Cataract and Refractive Surgery (ASCRS) web site. No historical information was used for the calculations. IOL power required for emmetropia was back-calculated using manifest refraction and implanted IOL power after cataract surgery. RESULTS: Mean age was 60 ± 7.9 years. Fifteen percent had a history of myopic photorefractive keratectomy (n = 7), 57% myopic LASIK (n = 26), 13% hyperopic LASIK (n = 6), and 22% radial keratectomy (RK) (n = 10). In 37% of cases, ORange predicted IOL power to within ±0.50 diopters (D) of emmetropia, compared to 30% for IOLMaster keratometry, 26% for Avg K, and 17% for ASCRS web site. In eyes after myopic treatment, ORange, IOLMaster, Avg K, and ASCRS web site predicted within ±0.50 D of emmetropia in 39%, 27%, 24%, and 18%, respectively, and within ±1.0 D in 60%, 39%, 39%, and 51%, respectively. In eyes after RK, ORange, Avg K, and ASCRS web site predicted to within ±0.50 D of emmetropia in 14% and the IOLMaster in 43% cases. CONCLUSIONS: Although the ORange most often predicted to within ±0.5 D of emmetropia, no method was able to achieve this accuracy more than 50% of the time. Predictions for eyes after RK were worse than for other types of refractive procedures.

Prevalence of subclinical keratoconus and impact on adults undergoing routine, uncomplicated age-related cataract extraction.

Aim: To determine the prevalence of subclinical keratoconus (SKCN) among individuals undergoing routine, uncomplicated age-related cataract surgery and its impact on visual and refractive outcomes. Patient and Methods: At a major academic ophthalmology department in the United States, we reviewed records of patients aged 50 years and older who underwent surgery from January 2011 to June 2022. We excluded patients who had poor-quality or unreliable tomographic data, previous corneal surgery, keratorefractive procedures, and significant vision-limiting ocular pathology. We defined SKCN if an eye had a Belin-Ambrósio enhanced ectasia index (BAD-D) ≥1.7, which was based on the results of a meta-analysis of large studies. In addition to the BAD-D cutoff, the eye had to deviate significantly on at least one of seven additional parameters: 1) posterior elevation at thinnest point, 2) index of vertical asymmetry, 3) index of surface variation, 4) total front higher order aberrations, 5) front vertical coma, 6) front secondary vertical coma, 7) back vertical coma. An individual had SKCN if at least one eye met the tomography-based classification and did not have manifest KCN in either eye. Visual and refractive outcomes data were acquired from patients of one experienced cataract surgeon with cases done from July 2021 to June 2022. Statistical significance was set at p < 0.05. Results: Among 5592 eyes from 3828 individuals, the prevalence of SKCN was 24.7% (95% CI, 23.4 - 26.1, 945 individuals), and the prevalence of KCN was 1.9% (95% CI, 1.6 - 2.4, 87 individuals). The prevalence of SKCN did not increase with age and was more prevalent among females and non-white races. Median post-operative month one distance-corrected visual acuity (DCVA) and proportion of eyes with improvement in DCVA were similar between normal and SKCN eyes. The proportion of eyes reaching ±0.5 and ±1.0 diopter within the refractive target were similar between normal and SKCN eyes. Conclusion: SKCN is highly prevalent and should be detected but is unlikely to have a significant deleterious effect on outcomes in routine, uncomplicated cataract surgery.

Pediatric Phlyctenular Keratoconjunctivitis at a Tertiary Care Center in the United States.

PURPOSE: The aim of this study was to evaluate characteristics and outcomes of pediatric phlyctenulosis at a tertiary care center in the United States. METHODS: A retrospective cohort study of phlyctenulosis diagnosis in patients younger than 18 years was conducted. Demographics, presenting features, treatment regimens, and outcomes were analyzed. RESULTS: Seventy patients (95 eyes) with phlyctenulosis were identified. Fifty-four patients (77.1%) were Hispanic, which was greater than the center's proportion of pediatric patients identifying as Hispanic (53.8%, P < 0.0001). Common comorbidities included adjacent external/lid disease (82.9%), allergic/atopic disease (18.6%), and viral infections (8.6%). Nine patients had tuberculosis testing which was negative in all cases. Five patients had vitamin A testing which revealed deficiency in 1 patient. Treatment regimens were diverse and included varying combinations of topical and systemic medications. Complications included corneal scarring (27.4%), corneal neovascularization (40.0%), amblyopia (16.8%), corneal perforation (3.2%), and severe limbal stem-cell deficiency (1.1%). 26.3% of affected eyes had final visual acuity worse than 20/40. Differences in rates of corneal complications between Hispanic and non-Hispanic patients were not statistically significant, although severe corneal complications including perforation occurred only in the Hispanic group. CONCLUSIONS: This study presents a modern cohort of phlyctenulosis at a tertiary center in the United States and includes a larger proportion of Hispanic patients than expected. Phlyctenulosis carries high corneal morbidity and may frequently result in reduced visual acuity. Similar rates of corneal complications were seen in Hispanic versus non-Hispanic patients, but severe corneal complications were seen only in the Hispanic group.

Iris Nevus (Cogan-Reese) Syndrome Presenting with Zonular Dehiscence during Cataract Extraction.

The aim of this study was to report a novel presentation of Cogan-Reese syndrome presenting with zonular dehiscence during cataract extraction with intraocular lens placement. A 49-year-old woman presented with worsening vision over 2 years. The examination was significant for bilateral pupil miosis, visually significant cataracts, and unilateral glaucoma. No iris nodules or corneal endothelial disease was observed through slit-lamp examination and specular microscopy bilaterally. Cataract extraction on the left eye was complicated by significant zonular dehiscence. An iris sample taken during the procedure demonstrated histopathologic findings consistent with an iris nodule composed of melanocytic nevoid cells. Cogan-Reese, or iris nevus syndrome, is a subset of iridocorneal endothelial syndrome that usually presents with iridic stromal matting and stromal loss, nodule formation, and secondary unilateral angle-closure glaucoma. Here, we describe a presentation of Cogan-Reese syndrome that presented with pupillary miosis and glaucoma preoperatively, and zonular dehiscence during cataract extraction with no underlying corneal pathology.

Total Tear IgE Levels Correlate with Allergenic and Irritating Environmental Exposures in Individuals with Dry Eye.

Dry eye (DE) and allergic conjunctivitis may present similarly, and it remains unclear whether some individuals have an underlying allergic component to their DE. To better understand this relationship, we performed a cross-sectional study in 75 individuals with DE symptoms and/or signs. Immunoglobulin E (IgE) levels in tear samples were quantified and home environmental exposures assessed via standardized survey. Tears were collected by Schirmer strip, and total tear IgE levels were quantified using enzyme-linked immunosorbent assay (ELISA). Data were analyzed using descriptive statistics and linear and logistic regressions. The main outcome measures were total tear IgE levels and their association with environmental exposures. The mean age of the subjects was 66.2 ± 7.8 years. Sixty-two individuals had dry eye symptoms (Dry Eye Questionnaire-5 ≥ 6), and 75 had one or more signs of DE. Detectable total tear IgE levels were observed in 76% of subjects, and 17.3% had high levels (>1 ng/mL). Individuals with exposure to pet(s) (odds ratio (OR) 11.5, p = 0.002) and smoke (OR 38.6, p = 0.008) at home were more likely to have high IgE levels compared to those not exposed. Individuals with tears collected during spring or summer were 3.9 times (p = 0.028) more likely to have high IgE compared to those sampled at other times of year. Subjects born in the US were 3.45 times (p = 0.010) more likely to have high IgE compared to individuals born outside the US. To conclude, a majority of individuals with DE symptoms and/or signs had detectable IgE levels in their tears. High tear IgE levels were correlated with allergy season and exposures in the home linked with allergy.

Blepharoptosis repair.

PURPOSE OF REVIEW: To review recent advances on the mechanisms and management of acquired aponeurotic blepharoptosis. RECENT FINDINGS: Recent advances over the past year have focused on refining well known methods of ptosis repair, expanding and modifying techniques to treat difficult and more severe conditions, and uncovering the biomechanical and neurostimulatory mechanisms of ptosis and its repair. SUMMARY: Innovations in ptosis repair are discussed in the context of current treatment paradigms.

INTRAVENOUS IMMUNOGLOBULIN IN THE TREATMENT OF JUVENILE RETINITIS PIGMENTOSA-ASSOCIATED CYSTOID MACULAR EDEMA AND UVEITIS.

PURPOSE: To evaluate the efficacy of intravenous immunoglobulin in the treatment of cystoid macular edema and uveitis caused by juvenile retinitis pigmentosa in a woman interested in planning a pregnancy. METHODS: Descriptive case report. A 25-year-old woman with retinitis pigmentosa presented with decreased visual acuity, interested in a second opinion. RESULTS: Intravenous immunoglobulin therapy was begun at 2-week intervals. Visual acuity improved from 20/100 to 20/70 by 6 weeks, where it stabilized for the remaining year. Serial optical coherence tomography imaging revealed marked improvement in cystoid macular edema after 2 treatments of intravenous immunoglobulin at 2 weeks of follow-up, with complete resolution noted at 4 months, a finding that persisted at 1 year of follow-up. CONCLUSION: Our findings support the use of intravenous immunoglobulin as a therapeutic option for the resolution of cystoid macular edema and management of uveitis secondary to juvenile retinitis pigmentosa.

Post-Laser In Situ Keratomileusis Epithelial Ingrowth: Treatment, Recurrence, and Long-Term Results.

PURPOSE: To study outcomes after surgical removal of epithelial ingrowth (EI) in post-laser in situ keratomileusis patients, specifically comparing visual results and recurrence rates between 2 different EI management techniques. METHODS: In this retrospective chart review of 67 eyes of 54 patients who underwent surgical treatment for EI after laser in situ keratomileusis between July 1999 and July 2014 at the Bascom Palmer Eye Institute, Miami, FL, surgical techniques, recurrence rates, visual acuity (VA), and refractive error were assessed. RESULTS: Of the 67 eyes, 56 eyes (83.6%) had flap lift + scraping alone, and 11 eyes (16.4%) had flap lift + scraping + suturing. After mean follow-up of 2.5 years, 11 of 56 eyes (19.6%) treated with flap lift + scraping alone had EI recurrence, whereas no eyes treated with flap lift + scraping + suturing had EI recurrence. VA results and refractive errors were better in eyes treated with lift + scraping alone compared with lift + scraping + suturing at 1 month. In the 67 eyes with 1-year follow-up, VA and refractive errors improved from preoperative values and were comparable between groups. CONCLUSIONS: Scraping alone provides significantly better initial visual outcomes but higher EI recurrence rates compared with scrape-suturing. Long-term visual outcomes are comparable between 2 techniques.

High-Resolution Optical Coherence Tomography in the Differentiation of Inflammatory Versus Noninflammatory Peripheral Corneal Thinning.

PURPOSE: To evaluate whether high-resolution optical coherence tomography (HR-OCT) can aid in differentiation of inflammatory versus noninflammatory causes of peripheral corneal thinning. METHODS: Retrospective chart review of 10 patients with peripheral corneal thinning and their respective slit-lamp photographs and HR-OCT images. RESULTS: Ten patients were identified who had peripheral corneal thinning and HR-OCT images. Five had a clinical history consistent with Terrien marginal degeneration (TMD), whereas 5 had thinning believed to be inflammatory in origin. In the eyes with presumed TMD, patients denied pain or inflammation. HR-OCT images demonstrated stromal thinning in the presence of an intact epithelium. The stroma underneath the epithelium in the area of thinning had a similar reflectivity pattern as the nonaffected cornea. There was epithelial marsupialization evident in 2 of the 5 images. In the 4 patients with a clinical history of inflammation (bulbar hyperemia and pain), and in the 1 patient with active inflammation at the time of HR-OCT imaging, HR-OCT also demonstrated thinning with an intact epithelium. In contrast to the TMD group, in the group with signs of inflammation, a dense hyperreflective band was noted in the stroma directly below the epithelium in the area of thinning, suggestive of scarring and/or cellular infiltration. CONCLUSIONS: In patients with a clinical history of inflammation and corneal thinning, HR-OCT revealed a hyperreflective band directly under the epithelium in the area of thinning, which was not seen in patients with presumed noninflammatory melts and thinning.

Impact of Eyelid Laxity on Symptoms and Signs of Dry Eye Disease.

PURPOSE: To study the relationship between eyelid laxity and ocular symptoms and signs of dry eye (DE). METHODS: A total of 138 patients with normal external anatomy were prospectively recruited from a Veterans Administration hospital. Symptoms (via the Dry Eye Questionnaire 5 and Ocular Surface Disease Index) and signs of DE were assessed along with presence or absence of eyelid laxity. RESULTS: It was observed that 71% of participants (n = 98) had clinical evidence of eyelid laxity (upper and/or lower) compared with 29% (n = 40) with no eyelid laxity. Individuals with eyelid laxity were older (67 ± 10 vs. 55 ± 8 years without laxity, P < 0.005) and more frequently male (76% of males had laxity vs. 18% females, P < 0.005). Patients with eyelid laxity had increased symptoms and signs of DE compared with their counterparts without laxity including ocular pain described as grittiness (63% vs. 45%, P = 0.049), decreased tear break-up time (8.6 ± 3 vs. 10.3 ± 4 seconds, P = 0.02), increased corneal staining (2.5 ± 3 vs. 1 ± 2, P = 0.002), decreased Schirmer score (14±6 vs. 17±7 mm, P = 0.01), increased meibomian gland drop out (2 ± 1 vs. 0.8 ± 0.8, P < 0.005), increased eyelid vascularity (0.8 ± 0.8 vs. 0.2 ± 0.5, P < 0.005), and more abnormal meibum quality (2 ± 1.3 vs. 1.4 ± 1.2, P = 0.02). In a multivariable analysis considering both signs of DE and laxity, lower eyelid laxity remained significantly associated with ocular surface disease index scores, suggesting a direct effect of laxity on symptoms of DE. CONCLUSIONS: The presence of eyelid laxity associates with abnormal tear parameters compared with the absence of eyelid laxity. Based on these data, it is important for clinicians to test for eyelid laxity in patients with symptoms and/or signs of DE.

The Effect of LASIK on Timing of Cataract Surgery.

PURPOSE: To compare the age at the time of cataract surgery in patients who have undergone microkeratome-assisted LASIK versus individuals matched for axial length, cataract grade, and visual acuity with no history of refractive surgery. METHODS: Retrospective chart review of patients who underwent cataract extraction between September 2013 and March 2015 at the Bascom Palmer Eye Institute. Patients had a history of either microkeratome-assisted LASIK or no prior ocular surgery. Corrected distance visual acuity (CDVA) before and after cataract extraction, uncorrected distance visual acuity (UDVA) before cataract extraction, gender, axial length, and cataract grade were assessed, along with age at the time of LASIK, age at the time of cataract extraction, and the time lapse between LASIK and cataract extraction. RESULTS: Fifty eyes of 38 patients were included in the LASIK group and 155 eyes of 136 patients were included in the control group. There was no significant difference between these groups with respect to gender (P = .87), CDVA before cataract extraction (P = .11), UDVA before cataract extraction (P = .09), axial length (P = .67), and cataract grade (P = .46). Mean age at the time of cataract extraction for patients in the LASIK group and control group were 64 ± 7 and 73 ± 8 years, respectively (P < .005). Negative correlations were found between age at time of cataract extraction and axial length in the LASIK and control groups (r = -0.18, P = .20 vs r = -0.36, P =. 01, respectively). CONCLUSIONS: Microkeratome-assisted LASIK seems to be correlated with earlier cataract extraction. Patients with a history of microkeratome-assisted LASIK under-went cataract surgery a decade sooner than patients with similar demographic and ocular characteristics. [J Refract Surg. 2016;32(5):306-310.].

Long-Term Outcomes of Radial Keratotomy, Laser In Situ Keratomileusis, and Astigmatic Keratotomy Performed Consecutively over a Period of 21 Years.

UNLABELLED: Purpose. To describe a case of 3 refractive procedures performed in one eye over 2 decades. Methods. CASE REPORT: Results. A 41-year-old patient presented for refractive surgery evaluation. His ocular history includes bilateral radial keratotomy performed 21 years ago for moderate myopia: spherical equivalence of -4.25 D bilaterally. Postoperative uncorrected visual acuity (UCVA) was 20/30; however, over time he developed a hyperopic shift and UCVA decreased to 20/40 in the right eye. Thus, laser-assisted in situ keratomileusis (LASIK) was performed at an outside institution 6.5 years later, and the patient had initial improvement of UCVA to 20/25. Due to a change in refractive error, the patient underwent uneventful astigmatic keratotomy 13 years after LASIK in the right eye, and 1.5 years after surgery best-corrected visual acuity was 20/25 with manifest refraction of -1.00 + 5.50 × 134°. Conclusion. We report the outcomes and natural refractive progression in a patient who underwent three corneal refractive procedures over two decades. This case underlines the difficulties of long-term management of post-RK hyperopia and astigmatism.

The impact of conjunctivochalasis on dry eye symptoms and signs.

PURPOSE: The purpose of this project was to study the relationship between conjunctivochalasis (Cch) and ocular signs and symptoms of dry eye. METHODS: Ninety-six patients with normal eyelid and corneal anatomy were prospectively recruited from a Veterans Administration hospital over 12 months. Symptoms (via the dry eye questionnaire 5 [DEQ5]) and signs of dry eye were assessed along with quality of life implications. Statistical analyses comparing the above metrics among the three groups included χ(2), analysis of variance, and linear regression tests. RESULTS: Participants were classified into three groups: nasal conjunctivochalasis (NCch; n = 31); nonnasal conjunctivochalasis (non-NCch; n = 41); and no conjunctivochalasis (no-Cch; n = 24). Patients with NCch had more dry eye symptoms than those with non-NCch (DEQ5: NCch = 13.8 ± 5.0, non-NCch = 10.2 ± 5.0, no-Cch = 11.6 ± 5.8; P = 0.014), and more ocular pain than those with Non-NCch and no-Cch (numerical rating scale [NRS]: NCch = 4.5 ± 3.0, non-NCch = 2.3 ± 2.8, no-Cch = 3.3 ± 2.6; P = 0.008). They also had worse dry eye signs compared to those with no-Cch measured by Schirmer score with anesthesia (NCch = 14.5 ± 6.9, non-NCch = 16.8 ± 8.2, no-Cch = 19.9 ± 6.4; P = 0.039); meibomian gland dropout (NCch 1.8 ± 0.9, non-NCch = 1.4 ± 1.0, no-Cch = 1.0 ± 1.0; P = 0.020); and eyelid vascularity (NCch = 0.84 ± 0.8, non-NCch = 0.74 ± 0.7, no-Cch = 0.33 ± 0.6; P = 0.019). Moreover, those with NCch more frequently reported that dry eye symptoms moderately to severely impacted their quality of life (NCch = 87%, non-NCch = 51%, no-Cch = 58%; P = 0.005). CONCLUSIONS: The presence of NCch associates with dry eye symptoms, abnormal tear parameters, and impacts quality of life compared with non-NCch and no-Cch. Based on these data, it is important for clinicians to look for Cch in patients with symptoms of dry eye.

Persistent corneal opacity after descemet stripping automated endothelial keratoplasty suggesting inert material deposits into the interface.

PURPOSE: To report a case of interface deposits after Descemet stripping automated endothelial keratoplasty (DSAEK) imaged by means of an electron microscope. METHODS: An 88-year-old man was referred with a history of corneal edema resulting from pseudophakic bullous keratopathy. A DSAEK was performed on his left eye without complications; however, the follow-up examination revealed a well-attached graft with persistent interface opacities at the donor-recipient interface. The DSAEK was repeated in this eye 1 year after the first surgery because of these corneal opacities that interfered with his vision. RESULTS: In the immediate postoperative period, the patient had adequate visual acuity with intact graft placement and a clear interface. Pathology and electron microscope analysis were performed on the removed endothelial graft, which revealed diffuse particles on the stromal surface of the endothelial graft. CONCLUSIONS: A repeated DSAEK procedure sufficiently removed this patient's corneal opacities and improved the visual acuity. The opacity is believed to have occurred because of residual viscoelastic material, which was used to maintain anterior chamber volume during surgery. This solution must be thoroughly removed to avoid similar complications.