The Safety Profile of FDA-Approved Epithelium-Off Corneal Cross-Linking in a US Community-Based Healthcare System.

Purpose: To determine the occurrence of early post-operative complications following FDA-approved epithelium-off corneal cross-linking in the United States. Materials and Methods: This multicenter, retrospective cohort study identified patients who underwent epithelium-off (epi-off) corneal cross-linking (CXL) for keratoconus and post-refractive keratectasia within the Kaiser Permanente Northern California healthcare system between 2016 and 2018. Post-operative complications including delayed epithelial healing, infection, and loss of visual acuity were recorded. Results: The study included 878 eyes of 654 patients. The mean age was 27±9.4 years (range 7-71). Five hundred ninety-nine patients (91.6%) had keratoconus while 55 had post-refractive corneal ectasia (8.4%). Forty-seven eyes had prolonged follow-up because of the occurrence of complications in the early post-operative period. The respective rates of delayed epithelial healing, and keratitis were 3.9% (95% CI 2.7-5.3%), and 1.5% (95% CI 0.8-2.5%). Four approaches for management of delayed epithelial healing were compared; epithelium healing duration was the longest in the repeat bandage contact lens (BCL) group (23.8 days) and the shortest in the antibiotic ointment group (14.3 days), with statistically significant differences (p < 0.05) in the healing time between these 2 groups. Conclusion: The concern for early clinical complications after epi-off CXL often leads to delayed CXL intervention and further keratoconus progression with increased economic burdens. A large retrospective review of 878 eyes found that FDA-approved epi-off CXL protocol appears to be safe with low occurrence rates of early post-operative complications. The recommended management for delayed epithelial healing is using antibiotic ophthalmic ointment.

Recurrent Bleeding, Survival, and Longitudinal Pulmonary Function following Bronchial Artery Embolization for Hemoptysis in a U.S. Adult Population.

PURPOSE: To report outcomes of bronchial artery embolization (BAE) for hemoptysis, including recurrent bleeding, survival, and longitudinal pulmonary function. MATERIALS AND METHODS: A prospective database identified 69 patients who underwent 97 BAE procedures (n = 1-7 per patient) at a tertiary academic medical center over a period of 11 years. Technical and clinical success were determined. Recurrent bleeding and survival were compared by etiology of lung disease. Rates of change in pulmonary function (forced expiratory volume in 1 s [FEV1] and forced vital capacity [FVC]) were measured and compared before and after index BAE by linear regression in 17 patients. RESULTS: The technical success rate of BAE was 90%. Clinical success rates at 24 hours and 30 days were 82% and 68%, respectively. Thirty percent of patients had recurrent bleeding that required bronchoscopy (7%) or additional embolization (23%). Median time to recurrent bleeding was 29 days among the 13 patients with sarcoidosis, compared with 293 days among patients without sarcoidosis (P = .0013). The hazard ratio for death in patients with sarcoidosis compared with those without sarcoidosis was 4 (95% confidence interval, 2.6-14.6). Analyzing all instances of pulmonary function tests, slopes of decline in FEV1 and FVC were significantly different (FEV1, P = .0048; FVC, P < .0001) before and after index BAE, with an improvement after BAE (FEV1, 0.8%/y; FVC, 1%/y) and a decrease before BAE (FEV1, -1.6%/y; FVC, -1.4%/y). CONCLUSIONS: BAE is an effective therapy for hemoptysis, but patients with sarcoidosis are at significant risk of recurrent bleeding and death compared with patients with other lung diseases. BAE does not accelerate deterioration in lung function.

Complications related to a cosmetic eye-whitening procedure.

PURPOSE: To report sight-threatening complications following extensive bulbar conjunctival resection and postoperative mitomycin C therapy for cosmetic eye-whitening in the United States. DESIGN: Retrospective noncomparative case series. METHODS: Multicenter report of 9 patients referred for evaluation and management of complications following bilateral cosmetic eye whitening. RESULTS: Seventeen eyes of 9 patients underwent cosmetic eye-whitening performed between 2 and 48 months prior to referral to one of the centers. Sixteen of the 17 eyes had persistent conjunctival epithelial defects, with 10 eyes requiring amniotic membrane grafting to facilitate re-epithelialization. Four eyes of 2 patients developed limbal stem cell compromise confirmed with in vivo confocal laser scanning microscopy. One patient developed infectious scleritis and diplopia resulting from Tenon capsule scarring. Another patient developed scleral necrosis, secondary infectious scleritis, and infectious endophthalmitis. This patient subsequently developed noninfectious scleritis that required 3-drug-regimen immunosuppression. CONCLUSION: Severe adverse effects can occur after extensive cosmetic conjunctival resection followed by topical mitomycin C application. Patients and physicians should be aware of the potential sight-threatening complications associated with this eye-whitening procedure.

Cyclosporine A 1% eye drops for the treatment of subepithelial infiltrates after adenoviral keratoconjunctivitis.

PURPOSE: To describe the use of cyclosporine A (CSA) 1% eye drops for the treatment of symptomatic corneal subepithelial infiltrates (SEI) occurring as a sequelae of adenoviral keratoconjunctivitis (AK) that are resistant to tapering of corticosteroid eye drops. METHODS: This is a retrospective case series of patients seen at 2 institutions who had symptomatic corneal SEI occurring after AK that was resistant to tapering of corticosteroid eye drops and who were subsequently treated with CSA 1%. Information gathered included basic demographic information (age and sex), involved eye(s), duration of symptoms, initial best spectacle-corrected visual acuity (BSCVA), type of corticosteroid used, clinical course, and best spectacle-corrected visual acuity at the last follow-up visit. RESULTS: Twelve eyes of 7 patients had symptomatic SEI develop after AK that were responsive to corticosteroid eye drops but were resistant to tapering. After the initiation of CSA eye drops, the corticosteroid eye drops could be tapered, and all eyes could be maintained on CSA eye drops once per day or less. Mean follow-up time was 13.0 months (range, 4-28 months). CONCLUSIONS: CSA eye drops may be an effective corticosteroid-sparing agent for the treatment of SEI after AK. The use of CSA in this setting warrants further study.

Epidemiology of ulcerative keratitis in Northern California.

OBJECTIVE: To determine the incidence and associated risk factors for ulcerative keratitis in northern California. METHODS: In this large-population, retrospective, cohort study, all medical records with diagnosis coding for corneal ulcers during a consecutive 12-month period were reviewed. Incidence rates were calculated using a dynamic population model. Multivariate relative risk regression was conducted to evaluate potential risk factors for ulcerative keratitis. RESULTS: Within the target population of 1 093 210 patients, 302 developed ulcerative keratitis. The incidence of ulcerative keratitis was 27.6 per 100 000 person-years (95% confidence interval, 24.6-30.9). The incidence of corneal ulceration in contact lens wearers was 130.4 per 100 000 person-years (95% confidence interval, 111.3-151.7), with an adjusted relative risk of 9.31 (7.42-11.7; P < .001) compared with non-contact lens wearers, who had an incidence of ulcerative keratitis of 14.0 per 100 000 person-years (11.7-16.6). Seven of 2944 people known to be infected with human immunodeficiency virus developed ulcerative keratitis, with 5 being contact lens wearers. The incidence of ulcerative keratitis in human immunodeficiency virus-positive patients was 238.1 per 100 000 person-years (95% confidence interval, 95.7-490.5), with an odds ratio of 9.31 (7.42-11.7; P < .001) compared with human immunodeficiency virus-negative patients, who had an incidence of ulcerative keratitis of 27.1 per 100 000 person-years (24.1-30.3). CONCLUSIONS: The incidence of ulcerative keratitis in this population is higher than previously reported. This may be owing to the increasing prevalence of contact lens wear.

Diagnosis of conjunctival B-cell lymphoma by polymerase chain reaction heteroduplex analysis.

PURPOSE: To report a case initially assessed as giant papillary conjunctivitis and subsequently as B-cell lymphoma by the molecular technique of polymerase chain reaction heteroduplex analysis. DESIGN: Observational case report. METHODS: Clinical, histologic, immunohistochemical, and polymerase chain reaction heteroduplex analysis findings are presented. RESULTS: A 32-year-old man developed unilateral blepharoptosis secondary to an extensive palpebral conjunctival follicular-like process. Excisional biopsy showed a dense small lymphocyte infiltrate consistent with benign lymphoid hyperplasia by histology and immunohistologic marker studies. Polymerase chain reaction heteroduplex analysis revealed low-grade B-cell lymphoma, however. Systemic examination was negative. Focal radiation therapy was performed, and preliminary results show no signs of lymphoma. CONCLUSIONS: Polymerase chain reaction heteroduplex analysis established a diagnosis of conjunctival B-cell lymphoma in the absence of supporting histology and immunohistochemistry studies. This technique may provide independent, diagnostic distinction between benign lymphoid hyperplasia and low-grade B-cell lymphoma of the ocular adnexa.