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.

Genetic screening of TGFBI in Iranian patients with TGFBI-associated corneal dystrophies and a meta-analysis of global variation frequencies.

PURPOSE: Transforming growth factor beta-induced (TGFBI)-associated corneal dystrophies (CDs) are a clinically heterogeneous group of CDs caused by mutations in the TGFBI gene. Nucleotide sequences encoding two arginine residues at positions 124 and 555 in TGFBI protein are mutation hotspots. We screened regions of TGFBI that include the hotspots in a cohort of Iranian patients with TGFBI-associated CDs. We also performed a meta-analysis for frequencies of all reported TGFBI mutations. METHODS: Twenty-four TGFBI-associated CD-diagnosed patients were recruited. Exons 4 and 12 of TGFBI were amplified by the polymerase chain reaction and sequenced by Sanger protocol. A meta-analysis on reported TGFBI sequence data was done by reviewing all published relevant articles available in NCBI. RESULTS: Twenty-two out of 24 patients had mutations in exons 4 or 12 of TGFBI. The most frequent mutations were p.Arg124Cys, p.Arg124His, and p.Arg555Trp; each of these was found in six families. Three other missense mutations including p.Arg555Gln, p.Ile522Asn, and p.Ala546Thr were also identified. The data suggested a fairly tight genotype/phenotype correlation for the most common CDs. Literature review evidenced that the reported mutations affected less than 30% of the amino acids of the TGFBI protein and that p.Arg124His, p.Arg124Cys, p.Arg555Trp, p.Arg124Leu, p.Arg555Gln, and p.His626Arg were the most frequent mutations. CONCLUSION: TGFBI mutation profile of Iranian patients is very similar to that of the rest of the world. The meta-analysis confirmed the worldwide prevalence of p.Arg124 and p.Arg555, showed that p.His626Arg is also relatively frequent, and evidenced the value of screening exons 4 and 12 of TGFBI.

Treatment of Persistent Chemosis after Upper Lid Blepharoplasty by Hand-Held Fine-Tip Cautery: Report of a Case.

Persistent chemosis is an uncommon complication of blepharoplasty, and its treatment is challenging. Herein, the authors report a case of persistent chemosis after a cosmetic upper lid blepharoplasty and present a simple, noninvasive, inexpensive, and successful method of treatment that uses hand-held cautery.

Perioperative prophylaxis for endophthalmitis after cataract surgery in iran.

PURPOSE: To describe prophylactic patterns employed against endophthalmitis after cataract surgery in Iran. METHODS: This cross-sectional study included 486 ophthalmologists filling in a self-administered questionnaire during the 20(th) Annual Congress of the Iranian Society of Ophthalmology in December 2010, Tehran, working in both private and academic medical centers. Prophylactic measures used preoperatively, intraoperatively and postoperatively and self-reported rates of endophthalmitis were assessed as the main outcome measurements. RESULTS: In the preoperative phase, 75.5% of surgeons used povidone-iodine in the conjunctival sac and 71.4% of them did not use antibiotics. The rate of intraoperative prophylaxis was 61.9% either in the form of intracameral antibiotics or subconjunctival injection (mostly cephazolin or gentamicin). Only 7.8% of participants used intracameral cephalosporins. Postoperative antibiotics [mostly chloramphenicol (57%) and ciprofloxacin (28%)] were used by 94.2% of surgeons. On average, ten years of practice were required to observe one case of endophthalmitis. CONCLUSION: The surgeons in present setting used various prophylactic regimens against endophthalmitis after cataract surgery. Setting a local and evidence-based clinical practice guideline seems necessary.

Sterile Keratitis following Collagen Crosslinking.

PURPOSE: To report a keratoconic eye that developed severe sterile keratitis and corneal scar after collagen crosslinking necessitating corneal transplantation. CASE REPORT: A 26-year-old man with progressive keratoconus underwent collagen crosslinking and presented with severe keratitis 72 hours after the procedure. The initial impression was infectious corneal ulcer and a fortified antibiotic regimen was administered. However, the clinical course and confocal microscopy results prompted a diagnosis of sterile keratitis. The eye developed severe corneal scars leading to reduced visual acuity and necessitating corneal transplantation. CONCLUSION: Sterile keratitis may develop after collagen crosslinking resulting in profound visual loss leading to corneal transplantation.

Profile of cataract surgery in Varamin Iran: a population-based study.

BACKGROUND: Cataract is the most popular cause of blindness. This study addresses some aspects of cataract surgery in an Iranian population. DESIGN: A cross-sectional study. PARTICIPANTS: 3000 adults over 50 in Varamin district. METHODS: Cataract surgical coverage was defined as the proportion of (pseudo) aphakic eyes of all operable and operated eyes with cataract. If there was obvious lens opacity in either or both eyes in combination with best corrected visual acuity less than 6/18, the person was asked why the operation for cataract was not done to find out about barriers of cataract surgery. Outcomes of cataract surgery were categorized as good, intermediate and poor using presenting visual acuity which were defined as visual acuity ≥ 6/18, 6/60 ≤ visual acuity < 6/18 and visual acuity < 6/60, respectively. MAIN OUTCOME MEASURES: Cataract surgical coverage, barriers and outcomes of cataract surgery. RESULTS: Out of 5638 examined eyes, 526 eyes (9.3%) had history of cataract surgery. 156 subjects (45.7%) had a unilateral and 185 subjects (54.2%) had bilateral operated eyes. Cataract surgical coverage was 66.4% in visually impaired eyes (visual acuity < 6/18), 90.4% in blind eyes (visual acuity < 3/60), 80.5% in visually impaired persons and 97.6% in blind persons. Cataract surgery in the majority of eyes (71.9%) had a good visual outcome. The main barrier of cataract surgery was unawareness of treatment. CONCLUSION: Overall, the cataract services in the studied population were acceptable, although it should be improved, to achieve vision 2020 objectives.

Impression cytology in eyes with clinical and confocal scan features of acanthamoeba keratitis.

PURPOSE: To report impression cytology findings in specimens obtained from eyes with clinical and confocal microscopic features of Acanthamoeba keratitis (AK). METHODS: In this interventional case series, impression cytology was obtained from corneas of patients with clinical and confocal microscopic features indicative of AK. Specimens were stained with Periodic acid-Schiff/Papanicolaou (PAS/PAP) and examined for the presence of PAS-reactive Acanthamoeba cysts and/or hyperchromatic pear-shaped trophozoites. All specimens were then decolorized and re-stained with calcofluor white (CFW) for the presence of chemofluorescent cysts. RESULTS: Fifty-six eyes of 50 patients with mean age of 25.5±9.3 (range, 17 to 78) years were evaluated. Forty-one (82%) cases were female and 51 (91.1%) eyes had history of contact lens wear. PAS-reactive Acanthamoeba cysts and/or hyperchromatic pear-shaped trophozoites were identified in 53 eyes (94.6%), 2 of which demonstrated only trophozoite- like structures. CFW staining was able to reveal the presence of chemofluorescent cysts in all 51 specimens (91.1%) in which cysts had been demonstrated with PAS/PAP staining. Trophozoites were not detected with CFW due to background staining of the cellulose acetate strip used for impression cytology. CONCLUSION: Corneal impression cytology, stained with PAS/PAP or with CFW, successfully detects Acanthamoeba and can be employed for early noninvasive diagnosis of AK.

Prevalence of refractive errors; the yazd eye study.

PURPOSE: To determine the prevalence of refractive errors in Yazd, central Iran. METHODS: This population-based study was performed in 2010-2011 and targeted adults aged 40 to 80 years. Multi-stage random cluster sampling was applied to select samples from urban and rural residents of Yazd. Manifest refraction, visual acuity measurement, retinoscopy and funduscopy were performed for all subjects. Myopia, hyperopia, astigmatism and anisometropia were defined as spherical equivalent (SE) <-0.50 diopters (D), SE >+0.50 D, cylindrical error >0.5 D and SE difference ≥1 D between fellow eyes, respectively. RESULTS: From a total of 2,320 selected individuals, 2,098 subjects (90.4%) participated out of which 198 subjects were excluded due to previous eye surgery. The prevalence (95% confidence interval) for myopia, hyperopia, astigmatism, anisometropia, -6 D myopia or worse, and 4 D hyperopia or worse was 36.5% (33.6-39.4%), 20.6% (17.9-23.3%), 53.8% (51.3-56.3%), 11.9% (10.4-13.4%), 2.3% (1.6-2.9%) and 1.2% (0.6-1.8%), respectively. The prevalence of hyperopia, astigmatism and anisometropia increased with age. The prevalence of myopia was significantly higher in female subjects. The prevalence of with-the-rule, against-the-rule and oblique astigmatism was 35.7%, 13.4% and 4.6%, respectively. The prevalence of against-the-rule astigmatism increased with age (P<0.001); with-the-rule astigmatism was more common in women (P=0.038). CONCLUSION: More than half of the study population had refractive errors; the prevalence of myopia and astigmatism was higher than earlier studies in Iran. Since refractive errors are a major cause of avoidable visual impairment, their high prevalence in this survey is important from a public health perspective.

Simultaneous penetrating keratoplasty and cataract surgery.

PURPOSE: To determine the clinical outcomes of simultaneous penetrating keratoplasty (PK), cataract removal and intraocular lens implantation (triple procedure), and to compare the safety and efficacy of two different cataract extraction techniques during the course of PK. METHODS: This retrospective comparative study was conducted on patients who had undergone a triple procedure. The technique of cataract extraction was either open- sky extracapsular cataract extraction (ECCE) or phacoemulsification (PE). In the ECCE group, the posterior chamber intraocular lens (PCIOL) was implanted in the ciliary sulcus, while in the PE group PCIOLs were fixated within the capsular bag. Outcome measures included best spectacle corrected visual acuity (BSCVA), refractive results, graft clarity and complications. RESULTS: Seventy-six eyes of 69 consecutive patients with mean age of 61.4±14.2 years were enrolled. Mean follow-up period was 61.4±37.2 months over which mean BSCVA was significantly improved from 1.40±0.68 to 0.44±0.33 LogMAR (P<0.001). Mean postoperative spherical equivalent refractive error was -2.13±3.02 D, which significantly differed from the target refraction (-0.73±0.29 D, P=0.004). At final follow-up, 89.5% of the corneal grafts remained clear. CONCLUSION: The triple procedure is a safe and effective approach to restore vision in patients with coexisting corneal pathologies and cataracts. However, unacceptable postoperative refractive error can be anticipated.

A population-based survey of the prevalence and types of glaucoma in central Iran: the Yazd eye study.

PURPOSE: To describe the prevalence and types of glaucoma in Yazd, central Iran. DESIGN: Population-based, cross-sectional study. PARTICIPANTS: Iranian adults aged 40 to 80 years, residing in Yazd, Iran, in 2010 and 2011. METHODS: Eligible samples were selected using cluster random sampling. Each participant underwent an interview and ophthalmologic examinations, including refraction, determination of uncorrected and best-corrected visual acuity, slit-lamp biomicroscopy, Goldmann applanation tonometry, gonioscopy, dilated fundus examination, central corneal thickness measurement, visual field testing, and stereoscopic fundus photography. MAIN OUTCOME MEASURES: Prevalence of different types of glaucoma. RESULTS: Of 2320 eligible individuals, 2098 (response rate, 90.4%) participated in the study and 1990 completed all evaluations for glaucoma diagnosis. Overall, 47 persons (2.4%) were categorized with ocular hypertension, 32 persons (1.6%) were categorized with primary angle-closure suspect (PACS), and 16 persons (0.8%) were categorized with primary angle closure (PAC). The total number of subjects with glaucoma was 87 (4.4%; 95% confidence interval, 3.3-5.4), consisting of primary open-angle glaucoma (POAG, 3.2%, including high-tension glaucoma [1.7%] and normal-tension glaucoma [NTG], 1.5%]), primary angle-closure glaucoma (PACG, 0.4%), pseudoexfoliation glaucoma (0.4%), and other secondary glaucomas (0.4%). The mean age of subjects with glaucoma was 63.3 ± 11 years, and 57.5% of them were female. Seventy-eight individuals (89.7%) were unaware of their disease. Positive family history of glaucoma was present in 6.9% of glaucoma subjects. CONCLUSIONS: The prevalence of glaucoma in Yazd (4.4%) is comparable to that in other population-based studies in Asia, with POAG accounting for the majority of cases. Most affected subjects were unaware of their disease. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Unifocal langerhans cell histiocytosis simulating a limbal papilloma.

PURPOSE: To report a rare presentation of unifocal Langerhans cell histiocytosis (LCH) simulating a limbal papilloma. CASE REPORT: A 24-year-old man presented with a limbal mass in his left eye which had initially been suspected to be a papilloma based on clinical findings. The mass was excised and a histopathological diagnosis of "acute bullous inflammation with granulation tissue" was made. The lesion relapsed 10 months later which necessitated repeat resection along with corneoscleral patch grafting. Histopathological studies of the excised lesion led to a final diagnosis of LCH. CONCLUSION: To the best of our knowledge, this is the second report of a rare presentation of LCH in the limbus which recurred after excision of the primary mass. The recurrent lesion was diagnosed based on histopathology and managed accordingly.

Intraocular lens power calculation after corneal refractive surgery.

PURPOSE: To report refractive outcomes following phacoemulsification (PE) and posterior chamber intraocular lens (PCIOL) implantation in eyes with previous corneal refractive surgery. METHODS: In this retrospective comparative study, 18 consecutive eyes of 14 patients with previous keratorefractive surgery for myopia including photorefractive keratectomy (PRK, 6 eyes; 33.3%) and laser in situ keratomileusis (LASIK, 12 eyes; 66.7%) underwent PE+PCIOL. Computerized corneal topography was employed to determine the flattest keratometric reading within the 3-mm central zone. This value was inserted into the Sanders-Retzlaff-Kraff/T (SRK/T) formula to calculate IOL power. IOL power selected for implantation was 1 D greater than the calculated value described above. RESULTS: Mean age and follow-up period were 54.1±11.5 years and 29.9±26.3 months, respectively. Mean implanted lens power was 18.56±3.86 D which was not significantly different from mean back-calculated IOL power for target refraction (19.04±4.16 D) (P=0.28). There was no significant difference between mean target refraction (-0.94±0.52 D) and achieved postoperative spherical equivalent refractive error (-0.62±1.06) at final follow-up (P=0.28). The achieved spherical equivalent refractive error was within ±0.50 D of intended refraction in 8 (44.4%) eyes, within ±1.0 D in 11 (61.1%) eyes, and within ±2.0 D in 16 (88.9%) eyes. In a subgroup of patients (5 eyes) with complete pre-refractive surgery data, the difference between post-refractive surgery keratometry method and all other methods (P=0.02) and between the current method and the Feiz-Mannis method (P=0.01) was statistically significant. CONCLUSION: The method suggested herein is simple and independent of pre-refractive surgery data with results comparable to other commonly used methods.

Bilateral Terrien's Marginal Degeneration and Posterior Polymorphous Dystrophy in a Patient with Rheumatoid Arthritis.

PURPOSE: To report an interesting case of concomitant bilateral Terrien's marginal degeneration-like corneal ectasia and posterior polymorphous corneal dystrophy in a young man with quiescent rheumatoid arthritis. CASE REPORT: A 24-year-old man with history of rheumatoid arthritis presented with bilateral decreased vision since four years ago. Slit lamp examination revealed bilateral circumferential peripheral corneal thinning and bulging with vascularization and lipid deposition in addition to band-like lesions in descemet's membrane. Previous records revealed no gross corneal abnormalities up to 4 years ago. Corneal lesions were compatible with bilateral circumferential Terrien's marginal degeneration concomitant with posterior polymorphous dystrophy. CONCLUSION: To our knowledge, this is the first report of concomitant bilateral Terrien's marginal degeneration with peripheral corneal ectasia and posterior polymorphous dystrophy in a patient with rheumatoid arthritis. Bilateral circumferential involvement, younger age at presentation and total peripheral corneal ectasia as observed in this case are not typical for classic Terrien's marginal degeneration.

Recurrent keratoconus in a corneal graft after deep anterior lamellar keratoplasty.

PURPOSE: To report the recurrence of keratoconus 49 months after deep anterior lamellar keratoplasty (DALK). CASE REPORT: A 21-year-old man with history of bilateral keratoconus who had undergone DALK in his right eye, presented with gradual visual loss 49 months after corneal transplantation. Slit lamp biomicroscopy revealed graft ectasia together with Vogt's striae in the posterior stroma and corneal topography demonstrated inferior steepening. With a diagnosis of recurrent keratoconus in the graft, the patient underwent penetrating keratoplasty (PK) and histopathological examination confirmed the diagnosis of keratoconus in the graft. CONCLUSION: Similar to PK, keratoconus can recur in the transplanted cornea after DALK. However, the time interval from transplantation to recurrence seems to be much shorter in DALK grafts.

Bilateral nocardia keratitis after photorefractive keratectomy.

PURPOSE: To report the clinical, confocal scan, and histopathologic features of nocardia keratitis in a patient who developed bilateral infection following photorefractive keratectomy (PRK). CASE REPORT: A 23-year-old woman underwent bilateral PRK for low myopia. On postoperative day 3, dense central stromal infiltrates were noticed in both eyes. Empirical antibiotic therapy was initiated which was converted into specific therapy after a definite diagnosis was made based on clinical features and confirmed by confocal scan and histopathologic findings. Clinical and confocal scan features were consistent with the diagnosis of Nocardia keratitis, and topical 2% amikacin eye drops were started. Because of poor response to medical therapy, lamellar keratectomy was performed in both eyes which shortened the treatment course. Histopathologic examination reconfirmed the initial diagnosis. CONCLUSION: Familiarity with clinical and confocal scan features facilitates early diagnosis of Nocardia keratitis leading to proper management and hence a rapid therapeutic response.

Specular microscopic features of corneal endothelial vacuolation.

PURPOSE: To introduce a specular microscopic reference image for endothelial vacuolation in donated corneas. METHODS: Two corneas from a donor with diffuse, round to oval dark areas at the endothelial level on slit lamp biomicroscopy and one normal-appearing donor cornea underwent specular microscopy, histopathologic evaluation and transmission electron microscopy. RESULTS: Specular microscopy of the two corneas with abnormal-looking endothelium revealed large numbers of dark, round to oval structures within the endothelium in favor of endothelial vacuolation. Light microscopy disclosed variable sized cyst-like structures within the cytoplasm. Transmission electron microscopy showed electron-lucent and relatively large-sized intracytoplasmic vacuoles. These features were not observed in the endothelium of the normal cornea. CONCLUSION: The specular microscopic features of endothelial vacuolation in donated corneas were confirmed by light microscopy and transmission electron microscopy, therefore the specular image may be proposed as a reference to eye banks.

Immunologic corneal graft rejection after administration of topical latanoprost: a report of two patients.

PURPOSE: To report endothelial corneal graft rejection after administration of topical latanoprost eye drops. CASE REPORT: Two eyes of two patients with a history of multiple intraocular procedures prior to penetrating keratoplasty developed endothelial graft rejection one month after administration of topical latanoprost. Cystoid macular edema developed simultaneously in one patient. CONCLUSION: Latanoprost may trigger endothelial graft rejection in susceptible eyes.

Dry eye syndrome.

Our understanding of keratoconjunctivitis sicca (KCS), also known as dry eye syndrome, has been changed over recent years. Until lately, the condition was thought to be merely due to aqueous tear insufficiency. Today, it is understood that KCS is a multifactorial disorder due to inflammation of the ocular surface and lacrimal gland, neurotrophic deficiency and meibomian gland dysfunction. This change in paradigm has led to the development of new and more effective medications.