Severe epithelial ingrowth after pars plana vitrectomy ten years after LASIK relifting.

Epithelial ingrowth is one of the most significant complications of Laser in Situ Keratomileusis (LASIK) refractive surgery. We present the case of a 72-year-old male with a history of myopic LASIK (1999), who underwent cataract surgery and a second thin LASIK sub-Bowman flap to correct refractive error. Then, three months after pars plana vitrectomy for an epiretinal membrane, the patient complained of progressive vision loss. A diffuse haze of the corneal stroma that did not exist before surgery was observed. As the main suspicion was epithelial ingrowth, the flap was lifted and meticulous de-epithelialization of the stromal bed was performed. Mitomycin C 0.02% was applied, the flap was sutured with 10-0 Nylon, and a bandage contact lens was placed. The epithelialization of the interface after vitrectomy in a patient with LASIK could occur even when it is a rare complication and without obvious flap traumatism.

Corneal endothelial validation in the eye bank: differences in automated methods and repeatability.

PURPOSE: To evaluate reproducibility of endothelial cell density (ECD) measurements using the Konan Cell Check D in donor corneas by two different ophthalmologists and to compare the two automated cell count methods (center and flex-center) available in the software of this specular microscope. METHODS: ECD values were quantified in 54 donor corneas by two independent investigators using the Cell Check D (Konan Medical USA Inc) with both automated cell count methods. In the center method, at least 30 contiguous cells are marked. For the flex-center method, an area is delineated and only the cells within the designated area are counted. RESULTS: The mean ECD was 2473.81±378.22 cells/mm2. Good ECD intergrader reproducibility for the center (ICC=0.821) and the flex-center method (ICC=0.784) were noted. Poor reliability was observed for coefficient of variation and hexagonality (ICC≤0.265). When both methods for ECD analysis were compared, a moderate correlation for the two independent graders using the two manual (center and flex-center) methods was detected (correlation coefficient of 0.678 and 0.745 for each of the investigators). Comparison between methods yielded significantly higher ECD with the flex-center method (P=0.013). When corneas were divided by ECD, those under 2200 cells/mm2 and those between 2200 and 2700 cells/mm2 also had significantly higher ECD with the flex-center method (P<0.022). CONCLUSIONS: ECD values are reproducible with both methods, although the flex-center method ECDs tend to be higher, particularly in cases of low ECD. Eye banks and surgeons should exercise caution in making decisions based only on small differences in ECD.

Evaluation of the perception of physical and emotional health of ophthalmologists in Spain and the influence of the COVID-19 pandemic.

OBJECTIVE: The main objective was to study the perception of physical and emotional health of Spanish ophthalmologists and their health habits, as well as the possible influence of the COVID-19 pandemic. METHODS: An observational, cross-sectional, non-randomized and uncontrolled study was carried out among at Spanish ophthalmologists through an online survey of 47 questions on eating habits, tobacco, alcohol, physical exercise, workload, and perception of physical and emotional state. RESULTS: Of a total of 2,179 ophthalmologists, 260 (11.9%) of whom 55% were men responded to the survey, with a mean age of 52.9±11.4 years. 5.8% were smokers. In total, 51.5% reported good physical health, with a mean Body Mass Index of 24.4kg/m2. Overall, 53.5% reported depression, 66.9% tiredness, 34.6% difficulty sleeping, and 57.3% considered their work hard. Up to 28.5% of those surveyed had thought about leaving their job and 60.8% about reorganizing their workload. In total, 91.9% would continue to choose Ophthalmology as a specialty. In total, 36.2% reported an increase in workload, 42.3% worsening of physical state and 63.8% worsening of emotional state as a consequence of the COVID-19 pandemic. CONCLUSIONS: Spanish ophthalmologists have a positive perception of their physical and emotional health, despite having life habits that are not always healthy and feeling mostly down. The COVID-19 pandemic has had a negative influence on the physical and emotional health of ophthalmologists.

Poor re-epithelialization following corneal collagen crosslinking with riboflavin-uva for advanced bullous keratopathy: Case series.

OBJECTIVE: To assess safety and efficacy of corneal collagen crosslinking (CXL) for advanced bullous keratopathy (BK). MATERIAL AND METHODS: Eight eyes of eight patients subjected to Dresden CXL protocol. INCLUSION CRITERIA: BK history of at least one year, severe pain and no indication for keratoplasty due to poor visual prognosis. VARIABLES: best corrected visual acuity (BCVA), pain (decimal visual scale), central corneal thickness (CCT) by tomography (Pentacam®, Oculus Inc, Germany), corneal bullae and complications. RESULTS: Seven women and one man of median age 77.00 (range 58-79) years. The median follow-up was 7 (range 5-7) months. BCVA remained unchanged through follow-up. A significant decrease in pain was observed at the end of the follow-up period (median 6, range 5-6 vs. median 0, range 0-4, P=0.05). Corneal tomography could only be performed in three cases, due to poor vision or image quality. A reduction in mean CCT was observed in the first post procedural month (from 708.33±140.48 to 627±136.89µm). In all eight cases, the absence of corneal bullae only persisted for two months after CXL. In six patients, corneal re-epithelialization after CXL was poor; in four of these eyes, the problem was resolved with topical treatment, but in the remaining two eyes, amniotic membrane transplant and mechanical debridement were required. CONCLUSIONS: In this uncontrolled small case series, CXL treatment improved pain in patients with advanced BK. However, the high rate of poor re-epithelialization requiring surgical treatment observed in one third of cases makes this treatment controversial.

Biometry data and prevalence of corneal astigmatism in caucasian spanish candidates for cataract surgery.

PURPOSE: To describe ocular biometric parameters and the prevalence of corneal astigmatism as well as age and gender correlations in a population of cataract surgery candidates and to estimate the number of eyes that would be candidates for a toric intraocular lens (IOL). METHODS: In consecutive patients requiring cataract surgery over a one-year period (June 2016 to June 2017), the following optical biometry measurements were performed on an IOLMaster 700 or Lenstar 900: axial length (AL), anterior chamber depth (ACD), lens thickness (LT), mean keratometry (K), flat keratometry (K1), steep keratometry (K2), corneal astigmatism (Cyl) and white-to-white diameter (WTW). Descriptive statistics for the demographic and biometric data were analyzed. RESULTS: The study sample included 6111 eyes of 3332 patients (59.3% women), with a mean age of 74.78±9.7years. The means of the compiled data are as follows: AL 23.58±1.55mm, ACD 3.08±0.41mm, LT 4.55±0.52mm,K 44.15±1.54 diopters (D), K1 43.64±1.57 D, K2 44.69±1.61 D, Cyl 1.0±0.81. D and WTW 11.88±0.46mm. The male patients had significantly larger eyes (higher AL, ACD and WTW) and flatter corneas (lower flat and steep K). Older patients had significantly lower AL, ACD and WTW, while their LT values were higher. Corneas became significantly steeper with age. 60.5% of eyes had less than 1 D of corneal astigmatism, while 3.1% had ≥3.0 D. CONCLUSIONS: Less than 1 D of corneal astigmatism was present in the majority of cataract surgery candidates. 3.1% of eyes were candidates for a toric IOL. This study provides useful information on inventory requirements for planning hospital resources.

Corneal densitometry and topography in patients with primary congenital glaucoma.

OBJECTIVE: To compare corneal densitometry and topography variables in patients with primary congenital glaucoma (PCG) and healthy subjects. MATERIAL AND METHODS: Cross sectional study, consecutive recruitment with gender- and age-matched control group. Forty eyes of 40 patients in each group were studied with Pentacam corneal topography. The variables compared between the two groups were: intraocular pressure (IOP), visual acuity (VA) and Pentacam (Oculus, Wetzlar, Germany) corneal topography measurements: mean and maximum keratometry (Km, Kmax), cylinder (Cyl), anterior elevation apex (AEA), central anterior elevation (CAE), maximum anterior elevation (MAE), posterior elevation apex (PEA), central posterior elevation (CPE), maximum posterior elevation (MPE), pachymetry and anterior, mid-stromal and posterior corneal densitometry in the 0-2mm, 2-6mm, 6-10mm zones. RESULTS: Significant differences between patients and healthy controls were detected in the topographic variables MAE (P=0.002) and MPE (P<0.001), and in all the densitometry variables (anterior, mid-stromal, posterior for the 0-2mm, 2-6mm and 6-10mm zones) (P<0.001 each). In the PCG group, negative correlation was observed between VA and total densitometry (r=-0.49; P=0.004). CONCLUSION: Patients with PCG and healthy subjects display differences in corneal densitometry and topographic measurements. PCG patients show greater corneal density with an inverse relationship between visual acuity and higher elevation (anterior and posterior values).

Assessment of ocular redness measurements obtained with keratograph 5M and correlation with subjective grading scales.

OBJECTIVE: To examine correlations between ocular redness scores provided by the Keratograph 5M and those determined using two image-based grading scales. METHODS: Observational prospective cross-sectional study. Two hundred and twenty six eyes of two hundred and twenty six participants (175 patients using anti-glaucoma eye drops and 51 subjects untreated). All subjects were scored automatically using the keratograph 5M. These redness scores (RS) were then correlated with the gradings provided by the Efron and McMonnies/Chapman-Davies scale (MC-D) scales (two observers). RESULTS: Excellent reproducibility was observed for both the Efron (weighted K=0.897, 95% CI 0.823-0.904) and MC-D (weighted K=0.783, 95% CI 0.752-0.795) scales. Keratograph RS and the scores obtained with both Efron (Spearman's Rho=0.43, P<0.001) and MC-D (Spearman's Rho=0.48, P<0.001) scales were significantly correlated. RS for the bulbar and limbal - nasal and temporal quadrants also correlated moderately with the two subjective scales. Through Bland Altman analysis, poor agreement was detected between the objective and subjective methods: agreement values for the Efron scale or MC-D scale (matching scorers between observers) versus overall RS showed high biases (-15.58 and -22.05 respectively) and wide limits of agreement (LOA) (-46.169 to 15.005 and -52.534 to 8.19 respectively). Lowest bias was observed between temporal limbal RS and Observer 2 Efron score (-0.04). CONCLUSIONS: Although it emerged as a reliable objective method, the keratograph 5M overestimated the scores compared with the subjective grading scales when used to grade the degree of ocular redness. Therefore, they should not be interchangeable methods.

Confocal biomicroscopy in four patients with polychromatic corneal dystrophy. / Biomicroscopia confocal en 4 pacientes con distrofia corneal policromática.

INTRODUCTION: Polychromatic corneal dystrophy is an unusual pre-descemet dystrophy, about which there are very few publications. The findings are presented in a case series of four patients with polychromatic corneal dystrophy, using a slit lamp, specular biomicroscopy, and confocal microcospy. CLINICAL CASES: Four women, between 36 and 72 year-old, with the diagnosis of polychromatic corneal dystrophy in routine reviews. None reported visual symptoms or ocular history of interest. Anterior biomicroscopy showed multiple and small multicoloured brilliant opacities in the posterior area of the corneal stroma, with normal epithelium and anterior stroma. The opacities were bilateral and distributed throughout the entire cornea. Direct family members were examined, but none of them showed opacities. In the specular biomicroscopy, a normal endothelium, with pre-descemet hypereflective particles, was observed. With confocal microscopy, there were no abnormalities in epithelium, Bowman layer, or sub-basal nervous plexus. In two cases, the anterior stroma showed hyper-reflective keratocytes and with small hypereflective particles among them. In the middle stroma, hyper-reflective keratocytes were seen in the four cases, two of them showed tiny hypereflective particles, and in the other two there were abnormal keratocytes with prominent cytoplasmic processes. Posterior stroma in the four cases showed a lot of hypereflective keratocytes and hypereflective particles of different sizes. These particles prevented examining the endothelium. CONCLUSIONS: Polychromatic corneal dystrophy has typical signs that allow it to be diagnosed and characterised. Although the biomicroscopy image only seems to show alterations in the posterior stroma, confocal microscopy shows that the dystrophy affects the entire corneal stroma.

Fibrin glue conjunctival autograft for primary pterygium: Overall outcomes and outcomes in expert versus trainee ophthalmologists.

INTRODUCTION: To determine outcomes of conjunctival autograft attached with fibrin glue (FG) for primary pterygium, and compare these outcomes in expert versus closely supervised trainee ophthalmologists. METHODS: This was a retrospective, comparative, non-randomized, interventional study. Patients were recruited among those with primary nasal pterygium undergoing FG conjunctival autograft. Surgery was performed by expert (136 eyes) or closely supervised trainee (128 eyes) ophthalmologists. Mean follow-up was 7.82±8.23months. Main outcome measures were recurrence rate, reoperation rate and complications. RESULTS: The study sample comprised 264 eyes of 225 patients. Participants were of mean age 47.09±12.89years; 46.7% were male, 28.4% Caucasian and 70.5% Hispanic. Recurrence was recorded in 6.4%: 5.9% in the expert group and 7% in the trainee group (P=0.704) and reoperation in 1.9%: 0.7% and 3.1% (P=0.202), respectively. Both groups showed similar rates of complications such as transient graft edema, graft dehiscence, hematoma or ocular hypertension. Reoperation was slightly more frequent in patients younger than 40years (P=0.064). CONCLUSIONS: Good outcomes were observed for FG conjunctival autografting in primary pterygium surgery, with no differences recorded between supervised trainee and expert surgeons. Our findings suggest the need to supervise pterygium surgeries during training.

Agreement and clinical comparison between a new swept-source optical coherence tomography-based optical biometer and an optical low-coherence reflectometry biometer.

PurposeTo compare measurements taken using a swept-source optical coherence tomography-based optical biometer (IOLmaster 700) and an optical low-coherence reflectometry biometer (Lenstar 900), and to determine the clinical impacts of differences in their measurements on intraocular lens (IOL) power predictions.MethodsEighty eyes of 80 patients scheduled to undergo cataract surgery were examined with both biometers. The measurements made using each device were axial length (AL), central corneal thickness (CCT), aqueous depth (AQD), lens thickness (LT), mean keratometry (MK), white-to-white distance (WTW), and pupil diameter (PD). Holladay 2 and SRK/T formulas were used to calculate IOL power. Differences in measurement between the two biometers were determined using the paired t-test. Agreement was assessed through intraclass correlation coefficients (ICC) and Bland-Altman plots.ResultsMean patient age was 76.3±6.8 years (range 59-89). Using the Lenstar, AL and PD could not be measured in 12.5 and 5.25% of eyes, respectively, while IOLMaster 700 took all measurements in all eyes. The variables CCT, AQD, LT, and MK varied significantly between the two biometers. According to ICCs, correlation between measurements made with both devices was excellent except for WTW and PD. Using the SRK/T formula, IOL power prediction based on the data from the two devices were statistically different, but differences were not clinically significant.ConclusionsNo clinically relevant differences were detected between the biometers in terms of their measurements and IOL power predictions. Using the IOLMaster 700, it was easier to obtain biometric measurements in eyes with less transparent ocular media or longer AL.

Effect of pharmacological pupil dilation on measurements and iol power calculation made using the new swept-source optical coherence tomography-based optical biometer.

PURPOSE: To determine whether pupil dilation affects biometric measurements and intraocular lens (IOL) power calculation made using the new swept-source optical coherence tomography-based optical biometer (IOLMaster 700©; Carl Zeiss Meditec, Jena, Germany). PROCEDURES: Eighty-one eyes of 81 patients evaluated for cataract surgery were prospectively examined using the IOLMaster 700© before and after pupil dilation with tropicamide 1%. The measurements made were: axial length (AL), central corneal thickness (CCT), aqueous chamber depth (ACD), lens thickness (LT), mean keratometry (MK), white-to-white distance (WTW) and pupil diameter (PD). Holladay II and SRK/T formulas were used to calculate IOL power. Agreement between measurement modes (with and without dilation) was assessed through intraclass correlation coefficients (ICC) and Bland-Altman plots. RESULTS: Mean patient age was 75.17±7.54 years (range: 57-92). Of the variables determined, CCT, ACD, LT and WTW varied significantly according to pupil dilation. Excellent intraobserver correlation was observed between measurements made before and after pupil dilation. Mean IOL power calculation using the Holladay 2 and SRK/T formulas were unmodified by pupil dilation. CONCLUSIONS: The use of pupil dilation produces statistical yet not clinically significant differences in some IOLMaster 700© measurements. However, it does not affect mean IOL power calculation.

Study of the relationship between myopia and personality.

OBJECTIVE: To study the correlation between the myopic refractive error and certain personality traits, and to determine whether there is a correlation between the degree of myopia and an increased frequency in personality disorders. METHODS: Cross-sectional observational multicenter study conducted on 82 subjects (26 men, 56 women) age over 18 years with myopia (spherical defect ≤ -0.5 D), with 30 subjects having high myopia (<-6 D). DATA COLLECTED: age and gender, academic level, result in the Neo PI-R personality test, autorefractometry, myopic pathology, and ophthalmological treatment. RESULTS: Correlation (Spearman's) between the magnitude of the spherical defect and the 5 personality traits studied in the total sample was not statistically significant: neuroticism (-0.057; P=.610), extroversion (-0.020; P=.857), openness (-0.032; P=.774), kindness (-0.060; P=.592), and responsibility (-0.034; P=.765). By dividing them into subgroups of low and high significance (t-test), a significant (P=.002) upward trend of the myopic defect with increasing scores on extraversion was found. When comparing high myopic subjects to the non-high myopic ones, there were significant differences between the 2 groups in terms of the associated pathology (P=.001), received treatment (P=.001) and the level of studies (P=.013). There were no differences in the variables of personality: neuroticism (P=.852), extroversion (P=.199), openness (P=.560), kindness (P=.584), and responsibility (P=.722). CONCLUSIONS: A low correlation was found between myopia and personality. There was no difference in the degree of myopia between the groups with different education levels. Subjects with more severe ocular pathology associated with myopia had higher scores in neuroticism, without finding any significant association.

[Charles Bonnet syndrome precipitated by brimonidine]. / Síndrome de Charles Bonnet desencadenado por brimonidina.

CASE REPORT: An 81-year-old woman with age-related macular degeneration and pseudoexfoliative glaucoma developed visual hallucinations (faces, flowers and frames) shortly after beginning brimonidine drops. Neurologic and psychiatric examination was normal. Visual hallucinations disappeared within 10 days after discontinuing the drug. DISCUSSION: The Charles Bonnet syndrome (CBS) is characterised by complex visual hallucinations in elderly patients in the setting of significant visual impairment without any psychiatric symptoms. Awareness of CBS among ophthalmologist is essential. Clinicians should treat visual impairment and be aware of possible visual hallucinations in patients treated with brimonidine.

Acute glaucoma in a patient with an Artisan® due to trabecular blockage after combined intravitreal treatment for macular oedema.

CASE REPORT: We present a 71-year-old patient with an Artisan(®) implant and macular oedema associated with unsatisfactory response to repeated intravitreal corticosteroids. An intravitreal Trigon(®) and Avastin(®) combined injection was given, and acute glaucoma developed. Anterior chamber washout was performed to resolve the rise in intraocular pressure. In spite of an excellent macular response, this was only temporary, and the corneal endothelium, which had remained competent so far, suffered irreversible damage. DISCUSSION: The combination of both treatments, along with the particular anatomic features in these patients, may have been precipitating factors in this unfortunate outcome.

[Pupillary block acute glaucoma due to acrylic intraocular lens posterior dislocation after Nd:YAG capsulotomy]. / Glaucoma agudo por bloqueo pupilar secundario a luxación posterior de lente acrílica intraocular tras capsulotomia Nd:YAG.

CASE REPORT: We present the clinical case of a 68 year-old woman who developed a pupillary block acute glaucoma due to vitreous hernia into anterior chamber following posterior dislocation of the intraocular lens one month after an Nd:YAG capsulotomy. DISCUSSION: We should consider these symptoms in the differential diagnosis of pseudophakic acute glaucoma, especially when visualisation of the anterior chamber is difficult due to corneal oedema and Nd:YAG capsulotomy was done.

[Intravitreal ranibizumab (Lucentis®) in the treatment of choroidal neovascular membrane secondary to punctate inner choroidopathy]. / Ranibizumab (Lucentis®) intravítreo en el tratamiento de membrana neovascular coroidea secundaria a coroidopatía punctata interna.

CLINIC CASE: A 25 year old patient with high myopia diagnosed of metachronic choroidal neovascularisation in both eyes secondary to punctate inner choroidopathy leading to visual impairment and metamorphopsia. First eye was treated with four injections of ranibizumab after photodynamic therapy and the second eye only with charge dose of ranibizumab, reaching inactivity with good final visual acuity in both eyes. DISCUSSION: Ranibizumab is useful in the treatment of this illness. Prospective studies are needed to investigate the usefulness of a combination with adjuvant therapies such as photodynamic therapy.

The effect of preservative-free HP-Guar on dry eye after phacoemulsification: a flow cytometric study.

PURPOSE: To assess the effect of hydroxypropyl (HP)-Guar added to regular post-phacoemulsification treatment in dry eye signs and symptoms, and its influence on the expression of various inflammatory markers by flow cytometry (FCM) in impression cytology specimens. METHODS: This prospective, interventional, single-centre study included 48 eyes of 48 patients with age-related cataract. After phacoemulsification, patients were randomised to the usual treatment group (UT), with 21 patients who received tobramycin and dexamethasone eye drops (Tobradex, Alcon Cusí, Spain), and the HP-Guar group, with 27 patients who received the UT plus preservative-free artificial tears (Systane UD, Alcon Cusí, Spain). Corneal and conjunctival staining with fluorescein and lissamine green, tear film break-up time (TBUT), Schirmer's I test with anaesthesia (Jones test), tear clearance, and ocular surface disease index (OSDI) were assessed preoperatively and 1 month after surgery. Besides, conjunctival impression cytology was performed in order to investigate inflammatory markers (CD3, CD11b, and HLA-DR) using FCM. RESULTS: HP-Guar group shows statistical better results compared with the UT group in TBUT (6.4+/-0.7 vs 9+/-2.5, P=0.0004), OSDI (11.5+/-8.2 vs 3.3+/-2.5, P=0.0002), ocular symptoms subscale (7.3+/-6.1 vs 1.7+/-1.8, P=0.0004), vision-related function subscale (2.2+/-1.8 vs 0.4+/-0.6, P=0.0002), CD3 (2.5+/-1.4 vs 1.1+/-1.1, P=0.011), and HLA-DR (6.8+/-4.5 vs 1.8+/-1.7, P=0.0002). CONCLUSION: The addition of HP-Guar to regular treatment after cataract surgery reduces ocular surface inflammation and dry eye signs and symptoms.