"En bloc" combined 270-degree keratolimbal allograft with central lamellar keratoplasty for severe limbal stem cell deficiency secondary to mustard gas exposure.

BACKGROUND: Severe limbal stem cell deficiency (LSCD) resulting from chronic and delayed-onset mustard gas keratopathy (MGK) presents substantial management challenges. This article introduces an "en bloc" surgical procedure combining a 270-degree keratolimbal allograft (KLAL) with central lamellar keratoplasty (CLK) as a novel approach to treat this condition. METHODS: A retrospective case series was conducted at Labbafinejad Medical Center in Tehran, Iran, from 2002 to 2019, including 13 eyes from 13 male patients diagnosed with chronic and delayed-onset MGK. Each patient underwent the combined 270-degree KLAL and central LK procedure. A 270-degree peritomy, sparing the superior quadrant, was performed. A lamellar dissection using a crescent blade and a blunt Melles dissector was carried out, extending 2 mm from the limbus. Fresh donor tissue with intact 270-degree limbo-conjunctiva, obtained from a whole globe, was prepared to match the recipient bed and sutured into place. Postoperative outcomes and success including ocular surface integrity, graft longevity, and best-corrected visual acuity (BCVA), were evaluated. RESULTS: The average follow-up period was 87.6 ± 49.8 months. Surgical success was achieved in 12 of 13 patients (92.3 %). Preoperative BCVA improved from 1.07 ± 0.24 (approximately 20/250) logMAR to 0.63 ± 0.30 (approximately 20/80) logMAR postoperatively. One patient experienced immune rejection of the KLAL graft, while two patients had episodes of corneal rejection, all successfully managed with aggressive immunosuppressive therapy. CONCLUSIONS: The "en bloc KLAL + CLK" procedure demonstrates promising long-term outcomes in managing chronic and delayed-onset MGK associated with severe LSCD. This approach offers advantages, including reduced surgical complexity, minimized antigenic load, and better anatomical alignment, leading to successful ocular surface restoration and improved visual acuity.

Clinical Outcomes of Stage 2 (Pivotal) Use of a Modified Keratoprosthesis Device (ORC-KPro) in Patients with End-stage Corneal Blindness.

Purpose: To investigate the short-term results and performance of a modified Boston keratoprosthesis device manufactured by the Ophthalmic Research Center (ORC-KPro) in patients with end-stage corneal blindness. Methods: This prospective interventional case series was conducted on patients with corneal blindness who were candidates for KPro. The inclusion criterion comprised patients with a best-corrected visual acuity (BCVA) of less than 20/200 in both eyes, in whom the main reason for vision loss was corneal pathology. The ORC-KPro was implanted using the method previously described for Boston KPro. Results: This study focused on 12 eyes of 12 patients with an average age of 45.9 ± 16.8 (range, 19 to 70) years. Eleven patients were male. The KPro indication was corneal blindness due to chemical burns in nine patients (75%) and failure of multiple previous corneal grafts in three patients (25%). Anatomical success was achieved in all patients. The preoperative BCVA was light perception (LP) in 10 eyes and hand motion in 1 eye. Except for one patient who was diagnosed with grade C proliferative vitreoretinopathy during the surgery, the vision of all other patients (91.6%) improved after surgery. The retroprosthetic membrane (RPM) was formed in two eyes (18.1%) after six months. Of the 12 patients, 10 (83.3%) were under treatment with two antiglaucoma medications before surgery. The intraocular pressure of three eyes (25%) was estimated to be high by tactile palpation; however, it decreased in two eyes to the acceptable range. One patient underwent retinal surgery due to total retinal detachment, and two patients (16.7%) underwent vitrectomy due to endophthalmitis. Conclusion: The current study showed that, in the short term, the use of ORC-KPro achieved favorable anatomical success in patients with corneal blindness. However, the functional success rate was limited by the low visual potential due to advanced glaucoma in most patients.

Safety and Efficacy of Topical Vitamin D in the Management of Dry Eye Disease Associated With Meibomian Gland Dysfunction: A Placebo-Controlled Double-Blind Randomized Controlled Trial.

PURPOSE: The aim of this study was to investigate the safety and efficacy of topical vitamin D in the management of dry eye disease associated with meibomian gland dysfunction (MGD). METHODS: In this randomized controlled trial, patients with symptomatic MGD were divided into 2 groups to receive topical vitamin D drops or placebo in their randomized eyes. The exclusion criteria consisted of patients with vitamin D deficiency, previous ocular surgery, and patients with ocular diseases affecting the tear film. Patients and researchers were masked to the study groups. The outcomes included the score of Dry Eye Questionnaire (DEQ) 5 and Ocular Surface Disease Index (OSDI), corneal and conjunctival staining score, tear breakup time (TBUT), Schirmer, and MG expressibility score evaluated at baseline and weeks 4 and 8. RESULTS: Twenty-eight eyes of 28 patients were recruited in each group. In addition to the improvement of subjective parameters in both groups, there was a statistically significantly greater improvement in the vitamin D group compared with control for average scores of OSDI (13.38 ± 7.32 vs. 27.94 ± 7.49) and DEQ5 (9.67 ± 1.86 vs. 14.14 ± 2.45) at week 8 (Ps <0.001). In addition, a significant improvement in TBUT and Schirmer test was observed in both groups in weeks 4 and 8 ( P value <0.05). There was a significant difference between the treatment and control groups after 8 weeks for OSDI, DEQ5, Schirmer, TBUT, corneal fluorescein staining, and MG expressibility score ( P value <0.05). CONCLUSIONS: The preliminary results of this randomized controlled trial suggested that use of topical vitamin D drops with a lipid vehicle could be safe and might significantly improve the symptoms and signs of dry eye associated with MGD.

Severe intraocular pressure rise after implantable collamer lens implantation.

A 22-year-old woman with a history of high myopia (-8.00 -3.75 × 011, right eye; -6.75 -3.75 × 174, left eye) presented to our clinic for implantable collamer lens (ICL) evaluation. Medical history was noncontributory. The patient's father had a history of glaucoma. Slitlamp and dilated fundus examination were unremarkable with a cup-to-disc ratio of 0.5 in both eyes and a myopic fundus. Intraocular pressures (IOPs) were 20 mm Hg in the right eye and 19 mm Hg in the left eye. Galilei G4 (Ziemer USA, Inc.) measured a white-to-white (WTW) distance of 12.98 mm in the right eye and 13.05 mm in the left eye and central corneal thickness of 512 µm in the right eye and 504 µm in the left eye. Ultrasound biomicroscopy (UBM) (Sonomed Escalon) displayed a sulcus-to-sulcus distance of 12.76 mm in the right eye and 12.75 mm in the left eye and an anterior chamber depth (ACD) of 3.57 mm in the right eye and 3.79 mm in the left eye (Figure 1JOURNAL/jcrs/04.03/02158034-202409000-00014/figure1/v/2024-08-19T175148Z/r/image-tiff). Prednisolone acetate 0.1% ophthalmic suspension eye drops and ofloxacin 0.3% ophthalmic solution eye drops 4 times daily were prescribed prophylactically 2 days preoperatively. A -12.5 and -12 D EVO+ Visian toric ICL -13.2 mm (STAAR Surgical Co.) was implanted along the 180-degree meridian in the right eye and left eye, respectively. Immediate postoperative IOPs were 23 mm Hg in both eyes. The patient was instructed to continue ofloxacin drops for 1 week and taper prednisolone acetate drops over 1 month. On postoperative day (POD) 1, uncorrected distance visual acuity (UDVA) was 20/20 in the right eye and 20/25 in the left eye. The patient's IOP was 24 mm Hg in the right eye and 26 mm Hg in the left eye. Anterior chambers (ACs) were unremarkable with minimal edema at the clear temporal corneal incision sites. Anterior segment optical coherence tomography (AS-OCT) vault measurements were 766 µm in the right eye and 697 µm in the left eye. Subsequently, the prednisolone dosage was reduced to 3 times a day, and brimonidine eye drops 3 times a day in both eyes were added to the regimen. On POD 5, the patient returned to the clinic reporting sudden-onset blurred vision with severe retro-orbital pain in the left eye upon awakening. Her UDVA was 20/25 in the right eye and 2/40 in the left eye. IOP was 30 mm Hg in both eyes. The ACs were deep, and there was minimal corneal edema in both eyes. Vaults were 674 µm in the right eye and 623 µm in the left eye (Figure 2JOURNAL/jcrs/04.03/02158034-202409000-00014/figure2/v/2024-08-19T175148Z/r/image-tiff). The patient was instructed to reduce prednisolone to 2 times a day, discontinue brimonidine, and start brimonidine/timolol (Combigan) 2 times a day and latanoprost at bedtime in both eyes. At the routine 1-week postoperative appointment, the patient's IOP was 30 mm Hg in the right eye and 29 mm Hg in the left eye. The patient was instructed to reduce prednisolone to once a day, continue brimonidine/timolol 2 times a day and latanoprost at bedtime, and start acetazolamide (Diamox) 250 mg 2 times a day. The patient was told to return to the office in a few days for an IOP check. What are the differential diagnoses concerning this case? What is the most likely mechanism underlying this patient's elevated IOP? What additional diagnostic workup would aid you in making the correct diagnosis?

Anwar versus Melles deep anterior lamellar keratoplasty for keratoconus: a prospective randomized clinical trial.

PURPOSE: To compare the outcomes of 2 techniques (Anwar vs. Melles) of deep anterior lamellar keratoplasty (DALK) in patients with keratoconus. DESIGN: Randomized, double-blind clinical trial. PARTICIPANTS: Fifty-seven eyes of 57 patients 20 to 35 years of age were enrolled. METHODS: Patients with clinical diagnosis of keratoconus who were contact lens intolerant and whose corrected distance visual acuity (CDVA) was less than 20/80 were enrolled. Eligible eyes were allocated randomly into 2 groups: the Anwar technique (23 eyes) or the Melles technique (25 eyes). MAIN OUTCOME MEASURES: The primary outcome measure was CDVA. Secondary outcomes were spherical equivalent, contrast sensitivity, corneal aberrations, corneal biomechanical properties, endothelial cell count, and central corneal thickness. All outcomes were compared 15 months after surgery. RESULTS: The CDVA was 0.17 ± 0.09 logarithm of the minimum angle of resolution (logMAR) units and 0.18 ± 0.11 logMAR units in the Anwar and Melles groups, respectively (P = 0.803). Spherical equivalent was -1.82 ± 2.7 diopters (D) and -2.69 ± 3.94 D in the Anwar and Melles groups, respectively (P = 0.155). Overall, the difference in photopic and mesopic contrast sensitivity function between the 2 groups was statistically significant (P<0.05). There was no significant difference between 2 groups in total and higher-order aberrations up to the fifth order (P>0.05 for all parameters). Corneal hysteresis was not significantly different between the 2 groups (9.9 ± 0.8 vs. 9.9 ± 0.6; P = 0.606). The corneal resistance factor was 10.02 ± 0.8 and 10.13 ± 0.76 (P = 0.509). There was no significant difference in percentage of endothelial cell loss between the 2 groups (1 ± 2% vs. 1 ± 3% in the Anwar and Melles groups, respectively; P = 0.869). Mean central corneal thickness was 525.56 ± 47.87 µm versus 504.64 ± 54.20 µm in the Anwar and Melles groups, respectively (P = 0.155). CONCLUSIONS: The Anwar and Melles techniques of DALK have comparable visual acuity and refractive outcomes, aberrometric profiles, biomechanical properties, corneal thicknesses, and endothelial cell densities. However, patients who underwent the Anwar technique showed better contrast sensitivity.

En Bloc Keratolimbal Allograft and Central Penetrating Keratoplasty: A Novel Surgical Technique in Severe Limbal Stem Cell Deficiency.

PURPOSE: The purpose of this study was to present a novel surgical technique combining 360-degree keratolimbal allograft (KLAL) and simultaneous central keratoplasty termed en bloc KLAL with the central penetrating keratoplasty (PKP) performed in those cases with total limbal stem cell deficiency (LSCD) and corneal scars. METHODS: Nine eyes of 9 patients underwent en bloc KLAL and central PKP between 2014 and 2016. All patients had bilateral total LSCD with total corneal opacity due to different etiologies. The exclusion criteria were previous limbal stem cell transplantation and the presence of active and uncontrolled ocular surface inflammation. The same donor globe was used for harvesting 360-degree KLAL and central PKP. The 1-piece integrity of the KLAL and PKP graft was preserved during the described technique. All patients received modified immunosuppressive regimens compatible with the Cincinnati solid organ transplantation protocol. RESULTS: The average age of patients was 58.6 ± 18.6 years. The diagnosis was mustard gas keratopathy in 6, herpes simplex keratitis in 1, and severe acid chemical burn in 2 patients. Seven patients were male. An integrated ocular surface without epitheliopathy and a clear cornea was achieved in 8 patients (88.8%) with an average of 6.5 years in follow-up. The average best-corrected visual acuity was 1.89 ± 0.18 (20/1600) preoperatively which improved to 1.02 ± 0.64 (20/200) logMAR in the postoperative period. Endothelial immune rejection episodes were observed in 3 patients. KLAL rejection was not observed in any patient. One patient required repeat PKP due to corneal graft failure. CONCLUSIONS: En bloc 360-degree KLAL and central PKP could simultaneously be performed in patients with total LSCD and corneal opacification.

How long does the recovery of corneal sensitivity in different corneal regions take after LASEK?

AIM: To determine the corneal sensitivity recovery period after laser-assisted sub-epithelial keratectomy (LASEK) refractive surgery and investigate the effects of ablation depth on it. METHODS: In this study examinations were performed on 90 right eyes of 90 people (34 males and 56 females) with an age range of 20-35 and an average of 22.26±3.8 years old. A sensation of 5 corneal regions, including the center and 4 mid-peripheral regions, i.e., nasal, inferior, temporal, and superior, each at a distance of 2 mm from the center of the cornea were measured with a Cochet-Bonnet esthesiometer device in 3-time points including before LASEK, 1 and 3mo after the surgery, respectively. LASEK was performed on individuals with stabilized myopia of -1.00 to -7.00 diopters and astigmatism of less than 2.00 diopters. Furthermore, the individuals were divided into three groups regarding ablation depth. RESULTS: The highest level of corneal sensitivity before surgery was related to the center of the cornea (59.1±7.76), and the highest level of corneal sensitivity loss was also related to this region. The sensation of all measured corneal regions significantly reduced 1mo postoperatively and returned to their preoperative levels 3mo after surgery (mean of 5 corneal regions in levels of preoperation: 58.2±6.48, 1mo postoperation: 57.3±5.84, 3mo postoperation: 58.2±5.49; P<0.05). A significant relationship was found between ablation depth and corneal sensitivity changes in the center and temporal regions (P<0.05). CONCLUSION: Corneal sensitivity in myopia and low astigmatism decreases after LASEK and reaches the preoperative level within 3mo. The depth of ablation during surgery affected the recovery of corneal sensitivity.

Penetrating Keratoplasty Versus Deep Anterior Lamellar Keratoplasty for Advanced Stage of Keratoconus.

PURPOSE: To compare visual acuity, refractive error, and complications after penetrating keratoplasty (PK) vs deep anterior lamellar keratoplasty (DALK) in the management of advanced stage of keratoconus. DESIGN: Retrospective, comparative, interventional study. METHODS: This study enrolled 411 consecutive keratoconus eyes with preoperative mean keratometry ≥60 diopters (D) that received either PK (218 eyes) or DALK (193 eyes). The outcome measures were postoperative visual acuity, refraction, complications, and further surgical interventions. RESULTS: The mean follow-up duration was 77.9±46.5 and 72.9±47.8 months in the PK and DALK groups, respectively (P = .28). Compared with baseline values, postoperative visual acuity and refraction significantly improved in both groups. Postoperative corrected distance visual acuity was 0.18±0.13 and 0.26±0.19 logMAR in the PK and DALK groups, respectively (P < .001). Postoperative spherical equivalent refraction was -2.89±2.89 D after PK and -4.58±3.62 D after DALK (P < .001). Final keratometric astigmatism was comparable between the 2 groups (P = .82). Suture-related complications were observed in 48.6% of the PK eyes and 72.0% of the DALK eyes (P < .001). The incidence of graft rejection was 33.5% after PK and 19.7% after DALK (P = .002). At the last visit, 98.2% of PK grafts and 94.8% of DALK grafts remained clear (P = .06). CONCLUSION: Both techniques of corneal transplantation led to a significant improvement in the visual and refractive variables in eyes with advanced keratoconus. PK resulted in a better visual acuity and refraction with less suture-related complications compared to DALK. However, PK was associated with a higher rate of graft rejection. The 2 techniques were comparable in terms of graft survival.

Long-Term Clinical Outcomes of Keratolimbal Allograft Alone or in Combination With Keratoplasty in Chronic and Delayed-Onset Mustard Gas Keratopathy.

PURPOSE: The purpose of this study was to investigate the long-term clinical outcome of keratolimbal allograft (KLAL) alone or in combination with keratoplasty, in the management of patients with chronic and delayed-onset mustard gas keratopathy (MGK). METHODS: Patients who had KLAL for MGK with or without corneal transplantation between 2002 and 2016 were recalled to be enrolled in this retrospective interventional case series. The primary outcome was the success rate of the KLAL demonstrated by Kaplan-Meier cumulative survival analysis. The secondary outcomes were postoperative BCVA and the need for further surgery. RESULTS: A total of 108 eyes of 68 patients with MGK underwent KLAL. All patients were male with an average age of 54 ± 6 years with an average follow-up duration of 81.9 ± 38.4 months. Sectoral KLAL alone was performed in 62 eyes (57.4%), combined with lamellar keratoplasty (LKP) in 40 eyes (37%) and combined with penetrating keratoplasty in 6 eyes (5.6%). The cumulative probability of success was 75% within the follow-up duration. The mean duration of successful KLAL survival was 80.6 ± 38 months. 88.1% of these eyes needed only 1 operation to stabilize the ocular surface. Average BCVA did not improve significantly after KLAL alone, except in those accompanied by keratoplasty. KLAL combined with LKP achieved the superior clinical outcome compared with KLAL alone. Infectious keratitis occurred in 6 eyes (5.5%). No adverse event due to postoperative systemic immunosuppression was observed. CONCLUSIONS: KLAL alone or combined with LKP is effective, durable, and visually acceptable in the reconstruction of ocular surface in patients with limbal stem cell deficiency secondary to MGK.

Risk Factors Associated with Keratoconus in an Iranian Population.

Purpose: To determine associated factors for keratoconus (KCN) in the Iranian population. Methods: In this retrospective case-control study, 100 KCN patients and 200 age- and sex-matched individuals, who were either candidates for photorefractive keratectomy or healthy referrals from the Torfeh Eye Hospital, were included as the case and control groups, respectively. KCN patients were all registered at the Iranian National Registry of Keratoconus (KCNRegⓇ). Demographic characteristics, patients' symptoms and their habits, as well as systemic and ocular disorders were documented. Clinical examinations included best corrected visual acuity (BCVA) and refractive error measurements, biomicroscopic examination, and corneal imaging. Results: In this case group, the frequency of mild, moderate, and severe KCN was 38%, 28%, and 34%, respectively. Parental consanguinity (odds ratio [OR] = 1.758, P = 0.029), positive familial history in patients' first degree (OR = 12.533, P < 0.001) and second degree (OR = 7.52, P < 0.001) relatives, vernal keratoconjunctivitis (OR = 7.510, P = 0.003), severe eye rubbing (OR = 10.625, P < 0.001), and systemic diseases including migraine, hypertension, and thyroid disease (OR = 6.828, P = 0.021) were found as associated factors for KCN. Lesser frequency of KCN was observed in patients with Fars ethnicity (OR = 0.583, P = 0.042), with higher levels of wealth indices (OR = 0.31, P < 0.001) and higher levels of education (OR = 0.18, P = 0.024). Conclusion: Severe eye rubbing, vernal keratoconjunctivitis, parental consanguinity and positive familial history of KCN, low socioeconomic status, and low levels of education were significantly associated with KCN in our study population.

Acute central corneal haze and thinning with atypical keratitis presentation.

A 24-year-old woman presented with a 7-day history of blurry vision, redness, and extreme pain in her right eye. She had no pertinent medical or ocular history and did not use spectacles or contacts. Uncorrected distance visual acuity (UDVA) was 20/40 in the right eye and could not be improved with refraction. Slitlamp examination revealed a 1.5 × 1.5 mm central epithelial defect with surrounding white blood cell recruitment. Confocal microscopy (Figure 1JOURNAL/jcrs/04.03/02158034-202304000-00020/figure1/v/2023-03-24T200747Z/r/image-tiff) was performed, and she was treated with chlorhexidine 0.02% drops every hour in the right eye. 2 weeks later, the cornea had completely re-epithelialized; however, persistent corneal haze, decreased visual acuity, and corneal thinning and flattening was noted. Pachymetry was 484 µm in the right eye and UDVA was 20/40 (Supplemental Figure 1, available at http://links.lww.com/JRS/A836). In the following 2 weeks, UDVA improved to 20/25. 6 months after the initial presentation, UDVA was unchanged and faint central corneal haze was noted on examination (Figure 2JOURNAL/jcrs/04.03/02158034-202304000-00020/figure2/v/2023-03-24T200747Z/r/image-tiff). Of interest, her family history is significant for her younger 16-year-old brother with 3 prior episodes of a similar type of keratitis/keratopathy over the course of 2 years in both eyes with similar central paracentral corneal haze, thinning, and flattening and similar confocal findings (Figure 3JOURNAL/jcrs/04.03/02158034-202304000-00020/figure3/v/2023-03-24T200747Z/r/image-tiff). He also was unresponsive to topical antibiotics and antivirals except topical chlorhexidine. Her brother has been our patient for the last several years prior to her first visit to our clinic. What is your diagnosis? What medical diagnostic tests, if any, would you recommend? Is this an infectious or simply an inflammatory response? Is there any genetic or familial predisposition?

Use of erythropoietin in ophthalmology: a review.

Erythropoietin (EPO) is a glycoprotein hormone that regulates hematopoiesis in the human body. The presence of EPO and its receptors in different tissues indicates that this hormone has extramedullary effects in other tissues, including the eye. We focus on the biological roles of this hormone in the development and normal physiologic functions of the eye. Furthermore, we explore the role of EPO in the management of different ocular diseases - including diabetic retinopathy, retinopathy of prematurity, inherited retinal degeneration, branch and central retinal vein occlusion, retinal detachment, traumatic optic neuropathy, optic neuritis, methanol optic neuropathy, nonarteritic anterior ischemic optic neuropathy, glaucoma, and scleral necrosis.

Ocular Biometric Values and Prevalence of Corneal Astigmatism in Patients Candidate for Cataract Surgery.

Purpose: To analyze the biometric values and the prevalence of corneal astigmatism in cataract surgery candidates. Methods: This is a prospective study. Ocular biometric values and corneal keratometric astigmatism were measured by optical low-coherence reflectometry (Lenstar LS 900) before surgery in patients who were candidates for cataract extraction surgery. Descriptive measurements of biometric dimensions and keratometric cylinder data and their correlations with sex and age were evaluated. Results: Ocular biometric and keratometric values from 2084 eyes of 2084 patients (mean age 66.43, range 19-95 years) were analyzed. The mean values were as follows: corneal astigmatism 0.89 diopter (D), mean corneal keratometry 44.29 D, central corneal thickness 534 µ, internal anterior chamber depth (ACD) 3.11 mm, lens thickness 4.50 mm, and axial length 23.35 mm. Corneal astigmatism was <1.25 D in 1660 (79.5%) of eyes. Astigmatism was with-the-rule in 976 (46.8%) of eyes, against-the-rule (ATR) in 702 (33.7%), and oblique in 406 (19.5%). Analysis of corneal astigmatism revealed a change toward "ATR" with age which was not statistically significant. The ACD was correlated with age. The amount of corneal astigmatism had no correlation with age and sex. Conclusion: Corneal astigmatism was higher than 1.25 D in about 21% of cataract surgery candidates with slight differences between the various age ranges and had no correlation with age and sex.

Bilateral posterior central corneal steepening with decreased visual acuity.

A 40-year-old woman was referred for the assessment of bilateral corneal opacities with gradual visual decline over the course of the past decade. Her past ocular history is significant for bilateral amblyopia and strabismus surgery in both eyes before age 5. The patient's parents were told by her childhood ophthalmologist that she had a hereditary disorder. Her systemic review was significant for anal fissure and human leukocyte antigen-B27 ankylosing spondylitis. Her past ocular record revealed corrected distance visual acuity (CDVA) of 20/80 in both eyes in 2018 with central corneal haze. On presentation, her uncorrected distance visual acuity was 20/150 in both eyes. Her CDVA was 20/100 in both eyes with manifest refraction of +0.50 -2.50 × 075 in the right eye and +5.00 -2.25 × 094 in the left eye. Corneal topography reflected keratometry of 35.75/38.97 × 171 in the right eye and 36.45/38.35 × 32 in the left eye. Central corneal thickness was 669 µm and 652 µm, respectively. External slitlamp examination revealed a central faint stromal opacity inferior to the visual axis in the right eye and a central faint stromal opacity in the left eye, and both were associated with steep posterior curvature of the cornea (Figure 1). Further findings included 0.5 corneal haze with mild guttata, normal irides, and clear lenses in both eyes. Intraocular pressure was 23 mm Hg and 26 mm Hg, respectively (Figure 2, Supplemental Figures 1 and 2, http://links.lww.com/JRS/A543). Gonioscopy was unremarkable. Dilated fundus examination revealed a 0.15 cup-to-disc ratio bilaterally, but otherwise no pertinent vitreoretinal pathologies were noted. What is the most likely diagnosis? What medical or surgical interventions would you recommend for this patient? What is the prognosis for this patient?

Management of mustard gas-induced limbal stem cell deficiency and keratitis.

PURPOSE: To report the clinical findings and compare outcomes of different surgical techniques evolved over time in a large series of patients with delayed-onset mustard gas keratitis (MGK). DESIGN: Retrospective, comparative, interventional case series. PARTICIPANTS: Ninety Iranian male survivors (175 eyes) of Iraqi chemical warfare with chronic or delayed-onset MGK. METHODS: The symptoms and clinical findings of patients are presented, and medical and surgical interventions to address dry eye, limbal ischemia and limbal stem cell deficiency (LSCD), and corneal involvements are explained. The results of limbal stem cell transplantation techniques (living-related conjunctival-limbal allograft [lrCLAL] versus keratolimbal allograft [KLAL]) as well as corneal transplantation techniques (penetrating keratoplasty [PK] versus lamellar keratoplasty [LK]) are compared in terms of clinical outcomes and graft survival rates. MAIN OUTCOME MEASURES: Ocular findings and appropriate surgical approach for LSCD and corneal involvements. RESULTS: A total of 175 eyes of 90 cases (all male) between 34 and 68 years of age were followed up for 101±30.3 months (range, 36-198 months). The most common ocular involvements were chronic blepharitis and dry eye. Conjunctival vascular abnormalities and limbal ischemia were observed in 27.4% and 29.7% of eyes, respectively. Limbal stem cell deficiency necessitating stem cell transplantation developed in 41.1% of eyes. The most common corneal sign was central and peripheral anterior stromal opacity (58.9%), followed by corneal stromal thinning (36.0%) and neovascularization (27.4%). Living-related conjunctival-limbal allograft was performed in 32 eyes, and KLAL was performed in 40 eyes. The rejection-free graft survival rate was 39.1% in the lrCLAL group and 80.7% in the KLAL group at month 40, with a mean length of 24.9 and 68.8 months, respectively (P = 0.02). Thirty eyes underwent PK and 51 underwent LK. Corneal graft failure was observed in 9 PK eyes and in 6 LK eyes. The rejection-free graft survival rate was 39.0% in the PK group and 90.3% in the LK group at month 28, with a mean length of 29.6 and 85.0 months, respectively (P<0.001). CONCLUSIONS: Chemical warfare victims who initially have mild symptoms ultimately may experience significant ocular involvements requiring surgical intervention. Limbal and corneal abnormalities can be managed best by KLAL and LK, respectively.

Comparison of corneal tomography measurements using Galilei, Orbscan II, and Placido disk-based topographer systems.

PURPOSE: To evaluate agreement in keratometry readings and anterior and posterior elevation map measurements among the Galilei V4.01 (Ziemer), Orbscan IIz (Bausch & Lomb), and Corneal Map topographer (Costruzione Strumenti Oftalmici) systems. METHODS: This prospective comparative study comprised 184 eyes of 92 consecutive refractive surgery candidates who were simultaneously examined with the Galilei (dual Scheimpflug), Orbscan II (scanning-slit), and Corneal Map topographer (Placido disk-based) systems. Keratometry readings and anterior and posterior elevation map measurements were compared using analysis of variance and paired t test, respectively. RESULTS: Mean keratometry reading was 44.30 ± 1.49 diopters (D), 44.11 ± 1.47 D, and 44.60 ± 1.56 D with the Galilei, Orbscan, and Corneal Map topographer, respectively. Despite a significant difference in mean keratometry (P<.001), the correlation among these three systems was strong. The maximum mean difference between two sets in simulated keratometry and astigmatism was <0.50 D. In the evaluation of anterior best-fit-sphere (BFS) and posterior BFS, the correlation between Galilei and Orbscan II was found to be 0.960 and 0.947, respectively. Maximum anterior central elevation measured by Orbscan II and Galilei was 9.2 ± 5.1 µm and 3.2 ± 1.8 µm, respectively. Maximum posterior central elevation by Orbscan II and Galilei was 33.8 ± 9.3 µm and 6.8 ± 3.8 µm, respectively. CONCLUSIONS: Despite significant differences in mean keratometry readings and anterior and posterior elevation measurements among the three systems, the keratometry readings can be used interchangeably, as this difference is not clinically significant.

Mechanical versus alcohol-assisted epithelial debridement during photorefractive keratectomy: a confocal microscopic clinical trial.

PURPOSE: To compare the effects of mechanical versus alcohol-assisted epithelial debridement on corneal cellular elements after photorefractive keratectomy (PRK) using confocal microscopy. METHODS: This randomized, clinical trial included 66 eyes from 33 patients with spherical equivalent refraction <-4.00 diopters (D). Mechanical versus alcohol-assisted epithelial debridement was performed during PRK. The right eye of each patient was randomly assigned to one group (mechanical group or alcohol-assisted group) and the fellow eye to the alternate group. Confocal examination was performed preoperatively and at 3 and 6 months postoperatively. Main outcome measures were keratocyte density and maximum anterior stromal light reflectivity. RESULTS: Mean epithelial healing time was 3.2 ± 0.4 and 3.0 ± 0.3 days in the mechanical and alcohol-assisted groups, respectively (P=.001). Anterior retroablation stromal keratocyte density was 704.3 ± 119.9 cells/mm² and 734.3 ± 103.7 cells/mm² at 3 months (P=.05) and 643.8 ± 134.4 cells/mm² and 696.7 ± 129.6 cells/mm² at 6 months (P=.02) in the mechanical and alcohol-assisted groups, respectively. No significant difference was noted in midstromal and posterior keratocyte density between the two groups. Maximum reflectivity was 61.56 ± 12.64 international units (IU) and 56.93 ± 7.86 IU in the mechanical and alcohol-assisted groups, respectively, 3 months after surgery (P=.018). Corresponding values were 49.46 ± 4.97 IU and 48.98 ± 4.60 IU, respectively, 6 months after surgery (P=.628). CONCLUSIONS: Due to more adverse effects of mechanical epithelial debridement on anterior keratocyte density and anterior stromal reflectivity, alcohol-assisted epithelial debridement is recommended as the procedure of choice for epithelial removal during PRK in patients with mild myopia.

Visual performance of four types of diffractive multifocal intraocular lenses and a review of articles.

AIM: To compare the clinical outcomes of a variety of multifocal intraocular lenses (MIOLs) in patients diagnosed with presbyopia or cataracts. METHODS: This clinical trial study included 141 patients (282 eyes) with different MIOLs implantation. The Symfony (60 eyes), the ReSTOR (100 eyes), the AT LISAtri (60 eyes), and the PanOptix (62 eyes) intraocular lenses were evaluated in this prospective interventional study. The near, intermediate, and distant visual acuities, contrast sensitivity, and defocus curve were measured as valid criteria. To statistically analyze the results, we used the Statistical Package for Social Science software, the non-parametric Wilcoxon signed-rank t, the one-way analysis of variance and the Tukey's post-hoc test in our analysis. Moreover, we conducted a detailed literature search on the PubMed database in English about MIOLs, in total 59 studies were included in this review article. RESULTS: The four approaches did not show any significant difference in the best-corrected distance visual acuity (P>0.05). The defocus curves at the contrast of 100% showed that trifocal IOLs had better intermediate performance than the bifocal IOL (P<0.05). There were no statistically significant differences between AT LISAtri and PanOptix lenses for visual acuity at all distances. The eyes with PanOptix, Symfony, and AT LISAtri IOL showed better contrast sensitivity than those ReSTOR at spatial frequencies of 1, 3, and 6 cpd in photopic and mesopic conditions (P<0.001). CONCLUSION: All four groups of the multifocal lenses were satisfying in terms of distance and near vision. Also, the group of trifocal lenses led to satisfactory outcomes in intermediate vision, without degradation in quality of vision.

Topical 0.03% tacrolimus versus systemic mycophenolate mofetil as adjuncts to systemic corticosteroids for preventing graft rejection after repeat keratoplasty: one-year results of a randomized clinical trial.

PURPOSE: To compare the efficacy of topical 0.03% tacrolimus in combination with systemic corticosteroids versus systemic mycophenolate mofetil (MMF) and corticosteroids in preventing corneal allograft rejection after repeat keratoplasty. METHODS: This prospective, randomized clinical trial enrolled 63 consecutive eyes of 63 patients who underwent repeat keratoplasty after a failed penetrating keratoplasty. Group 1 (32 eyes) received MMF orally 1 g twice daily for the first 6 months and then 1 g daily for the next 6 months, and group 2 (31 eyes) received topical 0.03% tacrolimus four times a day for 12 months. All patients were treated with topical and oral corticosteroids postoperatively. The participants were observed closely for signs of graft rejection, and the rates of rejection-free graft survival were calculated and compared between the two groups at postoperative month 12. RESULTS: The groups were balanced in patient's age and risk factors for graft rejection (e.g., original diagnosis, number of previous grafts, and quadrants of corneal vascularization). Endothelial graft rejection occurred in 5 eyes (15.6%) of group 1 and 6 eyes (19.4%) of group 2 (P = 0.75). Irreversible endothelial graft rejection resulting in graft failure occurred in 3 eyes of each group (P = 0.99). The rate of rejection-free graft survival was 84.4% in group 1 and 80.6% in group 2 at postoperative month 12 (P = 0.74). CONCLUSION: Topical 0.03% tacrolimus was as effective as systemic MMF as adjuncts to topical and systemic corticosteroids in reducing endothelial graft rejection with 12 months follow up after repeat keratoplasty.

Penetrating Keratoplasty Versus Deep Anterior Lamellar Keratoplasty in Children and Adolescents With Keratoconus.

PURPOSE: To compare the outcomes of penetrating keratoplasty (PK) and deep anterior lamellar keratoplasty (DALK) for pediatric keratoconus. DESIGN: Retrospective comparative interventional case series. METHODS: This study included consecutive pediatric keratoconus cases (≤18 years of age) who received PK (n=45) or DALK (n=54) in 2 different time periods. Postoperative best spectacle-corrected visual acuity (BSCVA), refraction, and complications were compared between the study groups. RESULTS: The mean follow-up was 83.3±46.1 and 63.3±45.6 months in the PK and DALK groups, respectively (P = .10). Postoperatively, BSCVA was 0.20±0.19 logMAR in the PK group and 0.26±0.19 logMAR in the DALK group (P = .11), with a BSCVA of ≥20/40 in 91.1% and 83.3% of eyes, respectively (P = .25). Two groups were comparable regarding postoperative refractive outcomes. Graft epitheliopathy and suture-associated complications were more commonly encountered after DALK, which was attributable to the effect of low-quality grafts on the clinical outcomes of DALK. Ten PK eyes (22.2%) and 9 DALK eyes (16.7%) experienced at least 1 episode of graft rejection within 5 years of corneal transplantation (P = .49). Rejection was reversible in 93.1% and 100% of episodes in the PK and DALK groups, respectively (P = .63). At the postoperative year 5, 95.6% of grafts in the PK group and 98.2% in the DALK group remained clear (P = .45). CONCLUSION: No significant difference was observed in the outcomes between PK and DALK in pediatric keratoconus. Low-quality donor tissues in DALK increased the incidence of graft epithelial problems and suture-related complications as compared to PK.