Ocular toxicities of FDA-approved antibody drug conjugates.

Antibody-drug conjugates (ADCs) are an emerging field of cancer treatments that are becoming more widespread in their use. However, there are potential ocular toxicities associated with these drugs that ophthalmologists need to be aware of to better maintain ocular health as patients undergo rigorous medical treatment for their conditions. While many ADCs have been approved by the Food and Drug Administration (FDA), many subsequent reports have been published regarding additional ocular side effects these drugs may cause. This review provides ophthalmologists with a practical guide on how to treat ocular toxicities associated with all FDA-approved ADCs to date. The potential pathophysiology of side effects is also discussed.

Inflammatory and genomic interactions within keratoconus susceptible patients: a nationwide registered case-control study.

PURPOSE: This study aimed to investigate the association between variants in the interleukin (IL)-1 gene cluster and susceptibility to keratoconus (KC) in an Iranian population. METHODS: In the case group, there were 188 KC patients diagnosed by clinical findings and corneal tomography. The control group included all 205 healthy controls with no personal or family history of eye-related, metabolic, or immune system-related disease. Using the standard salting out extraction procedure, genomic DNA was isolated from peripheral blood leukocytes. The genotypes were determined by applying agarose gel electrophoresis for the IL-1RN 86 bp VNTR and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) for rs16944 and rs1143634. RESULTS: The results showed a significant association between the IL-1ß rs1143634 (rs1143634 T allele, P = 0.008) and IL-1RN 86 bp VNTR polymorphisms (LL and LS genotype, P = 0.048 and 0.012 respectively) and susceptibility to KC in the Iranian population. The genotype distributions of rs1143634 (P = 0.004) and rs2234663 (P = 0.042) significantly differed between case and control groups, with certain genotypes demonstrating a protective effect against KC. Logistic regression analysis revealed a protective effect of the IL-1RN L allele [odds ratio (OR) = 0.367, 95% confidence interval (CI): 0.240-0.562; P = 0.000] and certain haplotypes (OR = 0.628, 95% CI: 0.447-0.884; P = 0.007) against KC. However, no significant association was found for the IL-1ß rs16944 polymorphism. CONCLUSION: This study provides evidence for an association between variants in the IL-1 gene cluster and susceptibility to KC in an Iranian population. Further research on larger and more diverse populations is warranted to validate these findings and explore the underlying mechanisms involved.

Evaluating the Accuracy of Artificial Intelligence (AI)-Generated Illustrations for Laser-Assisted In Situ Keratomileusis (LASIK), Photorefractive Keratectomy (PRK), and Small Incision Lenticule Extraction (SMILE).

PURPOSE: To utilize artificial intelligence (AI) platforms to generate medical illustrations for refractive surgeries, aiding patients in visualizing and comprehending procedures like laser-assisted in situ keratomileusis (LASIK), photorefractive keratectomy (PRK), and small incision lenticule extraction (SMILE). This study displays the current performance of two OpenAI programs in terms of their accuracy in common corneal refractive procedures. METHODS: We selected AI image generators based on their popularity, choosing Decoder-Only Autoregressive Language and Image Synthesis 3 (DALL-E 3) for its leading position and Medical Illustration Master (MiM) for its high engagement. We developed six non-AI-generated prompts targeting specific outcomes related to LASIK, PRK, and SMILE procedures to assess medical accuracy. We generated images using these prompts (18 total images per AI platform) and used the final images produced after the sixth prompt for this study (three final images per AI platform). Human-created procedural images were also gathered for comparison. Four experts independently graded the images, and their scores were averaged. Each image was evaluated with our grading system on "Legibility," "Detail & Clarity," "Anatomical Realism & Accuracy," "Procedural Step Accuracy," and "Lack of Fictitious Anatomy," with scores ranging from 0 to 3 per category allowing 15 points total. A score of 15 points signifies excellent performance, indicating a highly accurate medical illustration. Conversely, a low score suggests a poor-quality illustration. Additionally, we submitted the same AI-generated images back into Chat Generative Pre-Trained Transformer-4o (ChatGPT-4o) along with our grading system. This allowed ChatGPT-4o to use and evaluate both AI-generated and human-created images (HCIs). RESULTS: In individual category scoring, HCIs significantly outperformed AI images in legibility, anatomical realism, procedural step accuracy, and lack of fictitious anatomy. There were no significant differences between DALL-E 3 and MiM in these categories (p>0.05). In procedure-specific comparisons, HCIs consistently scored higher than AI-generated images for LASIK, PRK, and SMILE. For LASIK, HCIs scored 14 ± 0.82 (93.3%), while DALL-E 3 scored 4.5 ± 0.58 (30%) and MiM scored 4.5 ± 1.91 (30%) (p<0.001). For PRK, HCIs scored 14.5 ± 0.58 (96.7%), compared to DALL-E 3's 5.25 ± 1.26 (35%) and MiM's 7 ± 3.56 (46.7%) (p<0.001). For SMILE, HCIs scored 14.5 ± 0.68 (96.7%), while DALL-E 3 scored 5 ± 0.82 (33.3%) and MiM scored 6 ± 2.71 (40%) (p<0.001). HCIs significantly outperformed AI-generated images from DALL-E 3 and MiM in overall accuracy for medical illustrations, achieving scores of 14.33 ± 0.23 (95.6%), 4.93 ± 0.69 (32.8%), and 5.83 ± 0.23 (38.9%) respectively (p<0.001). ChatGPT-4o evaluations were consistent with human evaluations for HCIs (3 ± 0, 2.87 ± 0.23; p=0.121) but rated AI images higher than human evaluators (2 ± 0 vs 1.07 ± 0.73; p<0.001). CONCLUSION: This study highlights the inaccuracy of AI-generated images in illustrating corneal refractive procedures such as LASIK, PRK, and SMILE. Although the OpenAI platform can create images recognizable as eyes, they lack educational value. AI excels in quickly generating creative, vibrant images, but accurate medical illustration remains a significant challenge. While AI performs well with text-based actions, its capability to produce precise medical images needs substantial improvement.

Assessment of Generative Artificial Intelligence (AI) Models in Creating Medical Illustrations for Various Corneal Transplant Procedures.

PURPOSE: This study aimed to task and assess generative artificial intelligence (AI) models in creating medical illustrations for corneal transplant procedures such as Descemet's stripping automated endothelial keratoplasty (DSAEK), Descemet's membrane endothelial keratoplasty (DMEK), deep anterior lamellar keratoplasty (DALK), and penetrating keratoplasty (PKP).  Methods: Six engineered prompts were provided to Decoder-Only Autoregressive Language and Image Synthesis 3 (DALL-E 3) and Medical Illustration Manager (MIM) to guide these generative AI models in creating a final medical illustration for each of the four corneal transplant procedures. Control illustrations were created by the authors for each transplant technique for comparison. A grading system with five categories with a maximum score of 3 points each (15 points total) was designed to objectively assess AI's performance. Four independent reviewers analyzed and scored the final images produced by DALL-E 3 and MIM as well as the control illustrations. All AI-generated images and control illustrations were then provided to Chat Generative Pre-Trained Transformer-4o (ChatGPT-4o), which was tasked with grading each image with the grading system described above. All results were then tabulated and graphically depicted. RESULTS: The control illustration images received significantly higher scores than produced images from DALL-E 3 and MIM in legibility, anatomical realism and accuracy, procedural step accuracy, and lack of fictitious anatomy (p<0.001). For detail and clarity, the control illustrations and images produced by DALL-E 3 and MIM received statistically similar scores of 2.75±0.29, 2.19±0.24, and 2.50±0.29, respectively (p=0.0504). With regard to mean cumulative scores for each transplant procedure image, the control illustrations received a significantly higher score than DALL-E 3 and MIM (p<0.001). Additionally, the overall mean cumulative score for the control illustrations was significantly higher than DALL-E 3 and MIM (14.56±0.51 (97.1%), 4.38±1.2 (29.2%), and 5.63±1.82 (37.5%), respectively (p<0.001)). When assessing AI's grading performance, ChatGPT-4o scored the images produced by DALL-E 3 and MIM significantly higher than the average scores of the independent reviewers (DALL-E 3: 10.0±0.0 (66.6%) vs. 4.38±1.20 (29.2%), p<0.001; MIM: 10.0±0.0 (66.6%) vs. 5.63±1.82 (37.5%), p<0.001). However, mean scores for the control illustrations between ChatGPT-4o and the independent reviewers were comparable (15.0±0.0 (100%) vs. 14.56±0.13 (97.1%); p>0.05). CONCLUSION: AI is an extremely powerful and efficient tool for many tasks, but it is currently limited in producing accurate medical illustrations for corneal transplant procedures. Further development is required for generative AI models to create medically sound and accurate illustrations for use in ophthalmology.

Implications of Celiac Disease in Prospective Corneal Refractive Surgery Patients: A Narrative Review.

Celiac disease (CeD) is a prevalent autoimmune disorder incited by gluten consumption, resulting in intestinal damage. Affecting approximately one in 133 people globally, CeD often remains undiagnosed due to its varied clinical presentations. The prevalence and diagnosis of CeD are influenced by several factors, including demographics and genetics, and it often coexists with other autoimmune diseases. Thus, the objective of this paper was to review the literature on ophthalmic manifestations of CeD and to create preliminary considerations for these patients wishing to undergo elective corneal refractive surgery (CRS). A literature review was conducted through July 2024, and relevant search terms were used to identify contributing papers. The review enabled the development of detailed considerations for the ocular manifestations of CeD and recommended management strategies for healthcare teams before and following CRS. The 24 papers included in this study illustrate that nutritional deficiencies and autoimmune concerns linked to CeD have distinctive ocular presentations. Based on these findings, patients with CeD may exhibit unconventional ocular manifestations beyond their typical gastrointestinal symptoms, such as decreased endothelial cell density (ECD), vitamin A deficiency leading to dryness, altered corneal nerve density, cataracts, uveitis, changes in choroidal thickness, papilledema, and neurological issues such as nystagmus. Patients with CeD may also experience synergistic impacts from concomitant autoimmune conditions such as Type 1 Diabetes Mellitus (T1DM) in addition to the coexistence of thyroid ophthalmopathy. Recognizing that CeD is an autoimmune disorder that can be exacerbated by other conditions, it is essential to conduct a thorough evaluation for elective CRS. Due to the variability in ocular manifestations among CeD patients, individualized evaluations are crucial for determining surgical candidacy and optimizing outcomes, especially for patients who may not be well controlled. Evaluations are likely to encompass a subjective assessment through a questionnaire exploring the patient's past medical history related to CeD. These questions can range from inquiring about general past medical history related to CeD regarding dietary gluten intake and weight loss to joint pain and cognitive impairments such as brain fog. Clinicians should also perform a comprehensive objective assessment utilizing slit-lamp biomicroscopy, Schirmer test, tear break-up time (TBUT), optical coherence tomography (OCT), Scheimpflug imaging, or fundoscopy. Although there is currently no specific information regarding CRS recommendations for patients with CeD, we believe the considerations outlined in this paper should serve as preliminary guidelines for clinicians. While our findings have formed considerations for future healthcare teams, further research is needed to fully understand the impact of CeD on CRS outcomes and refine these recommendations.

The Utilization of Brillouin Microscopy in Corneal Diagnostics: A Systematic Review.

Corneal biomechanical data has been used since 2005 to screen for keratoconus and corneal ectasia by corneal specialists. Older technology uses force applanation techniques over a 3 mm area in the central cornea, making it highly dependent on extraneous variables and unable to calculate the elasticity of the tissue. Brillouin microscopy is a newer method that uses a natural shift in the frequency of light as it passes through a material. This frequency shift can be used to estimate the viscoelasticity of the tissue. The advantage of Brillouin microscopy is that it can create a full three-dimensional (3D) map of the entire cornea without direct contact. A literature search was conducted using the databases PubMed, Google Scholar, and Ovid regarding the applications of Brillouin microscopy in corneal diagnostics. A final total of 16 articles was included describing the various ex vivo and in vivo studies conducted using Brillouin microscopy. Applications of this technology spanned from keratoconus diagnosis to post-corneal refractive surgery evaluation. All studies evaluated corneal biomechanics and other corneal properties through the quantification of Brillouin frequency shifts. Many of the studies found that this diagnostic device is capable of detecting subtle changes in corneal thickness and biomechanics in keratoconic corneas at a high level of specificity and sensitivity. However, limitations of Brillouin microscopy may include the duration of time required for use and fluctuations in accuracy depending on the corneal hydration state. Future technology seems to be geared toward a combination of optical coherence tomography (OCT) and Brillouin microscopy, using OCT as a three-dimensional pupil-tracking modality. Further research and understanding of the technology involved will lead to better care of patients in the field of ophthalmology.

LASIK Versus PRK Based on Increased Risk of Corneal Haze: Assessing Current Decision-Making Capabilities of Six Artificial Intelligence Models in Refractive Surgery.

PURPOSE: To investigate the current decision-making capabilities of 6 different artificial intelligence (AI) models by assessing their refractive surgery recommendations (laser in-situ keratomileusis [LASIK] or photorefractive keratectomy [PRK]) for a theoretical patient with a history of keloid formation. METHODS: Claude-2 (Anthropic, 2023), GPT-4 (OpenAI, 2023), GPT-3.5 (OpenAI, 2022), Gemini 1.0 (Google DeepMind, 2023), Microsoft Copilot (Microsoft AI, 2023), and Google-PaLM (Google AI, 2022) underwent three systematic queries to determine the most appropriate surgical plan (LASIK or PRK) for a theoretical patient with an increasing manifest refraction of -3.50, -5.00, and -7.00 diopters (D) in both eyes, an uncomplicated ocular examination, and history of keloid formation. They were then tasked with providing published scientific references to support their responses. The AI models' recommendations were compared to those of a group of 6 experienced ophthalmologists, serving as a benchmark. RESULTS: The group of ophthalmologists unanimously recommended LASIK (6/6 ophthalmologists), in contrast to the unanimous initial recommendation for PRK from the AI models (6/6 models). Of the 42 references provided by the AI models, 55% were fictitious and 45% were authentic. Only 1 of the 6 models altered its initial recommendation to LASIK when presented with the same patient with a history of keloid formation but with increasing severity of myopia (-3.50 to 5.00 to 7.00 D). DISCUSSION: It is evident that current AI models lack the critical-thinking abilities required to accurately analyze and assess apparent risk factors in clinical scenarios, such as the risk of corneal haze after PRK at higher levels of myopia, particularly in cases with a history of keloid formation. [J Refract Surg. 2024;40(8):e533-e538.].

Visual Outcomes of Cataract Surgery in Patients with Previous History of Implantable Collamer Lens.

Background/Objectives: This retrospective case series analyzed visual outcomes in patients with a prior history of implantable collamer lens (ICL) implantation who underwent cataract extraction (CE). A secondary aim was to investigate the relationship between vault height and the rate of cataract development. Methods: Visual acuity and refraction measurements were collected after CE at one week, one month and six months. Vault height measurements were correlated to the time until symptomatic cataracts were removed. Results: A total of 44 eyes were analyzed at six months after CE with efficacy and safety indexes of 1.20 ± 1.11 and 1.50 ± 1.06, respectively. In addition, 70% of eyes had a post-operative uncorrected distance visual acuity (UDVA) within one line of pre-operative corrected distance visual acuity (CDVA). Refractive predictability at six months demonstrated that 43% and 69% of eyes were within ±0.25 D and ±0.50 D of SEQ target, respectively. Astigmatism measured by refractive cylinder was ≤0.25 D in 17% and ≤0.50 D in 34% of eyes pre-operatively compared to 40% and 60% of eyes, respectively, at six months post-operatively. Vault heights one week after ICL (p < 0.0081) and one week before CE (p < 0.0154) demonstrated a positive linear regression with the time until CE. Conclusions: This sample population achieved favorable visual outcomes six months after CE, similar to six months after ICL implantation. Patients with a history of ICL implantation will similarly have a good visual prognosis after CE.

Episodic Angle Closure after Visian™ Implantable Collamer Lens Implantation in a Patient Using Adderall®.

Introduction: Amphetamine-based medications such as Adderall®, used for the treatment of attention deficit-hyperactivity disorder (ADHD), may theoretically elicit angle closure through their adrenergic mechanisms. The relationship between the use of implantable collamer lenses (ICLs) and angle closure has been extensively investigated based on appropriate vault and lens sizing and postoperative changes in the anterior chamber angle (ACA) and corneal morphology. This case reflects a synergistic impact from both Adderall® use and ICL implantation for the proposed mechanism of angle closure. Case Presentation: A 36-year-old myopic female with ADHD controlled with Adderall® underwent toric ICL implantation in the right eye after undergoing preoperative laser peripheral iridotomy. Shortly after, the patient developed episodic angle closure in the right eye, with episodes mainly occurring after taking an additional dose of Adderall® in a dimly lit environment. The patient later had an ICL exchange with a smaller sized EVO+ toric ICL in the right eye and remained asymptomatic after. Conclusion: Additive mechanisms from both the ICL and Adderall® were present in our patient. The ICL caused crowding of the ACA through a pseudophacomorphic mechanism, and the Adderall® caused increased iridotrabecular contact secondary to pharmacologic mydriasis. This resulted in episodic angle closure with subsequent spikes in the intraocular pressure. There are no current reports or studies in the current literature describing the combined mechanisms of ICL implantation and Adderall® use in the potential development of angle closure. Further studies may be done to assess interactions of such medications in patients after ICL implantation.

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?

Learning the Randleman Criteria in Refractive Surgery: Utilizing ChatGPT-3.5 Versus Internet Search Engine.

Introduction Large language models such as OpenAI's (San Francisco, CA) ChatGPT-3.5 hold immense potential to augment self-directed learning in medicine, but concerns have risen regarding its accuracy in specialized fields. This study compares ChatGPT-3.5 with an internet search engine in their ability to define the Randleman criteria and its five parameters within a self-directed learning environment. Methods Twenty-three medical students gathered information on the Randleman criteria. Each student was allocated 10 minutes to interact with ChatGPT-3.5, followed by 10 minutes to search the internet independently. Each ChatGPT-3.5 conversation, student summary, and internet reference were subsequently analyzed for accuracy, efficiency, and reliability. Results ChatGPT-3.5 provided the correct definition for 26.1% of students (6/23, 95% CI: 12.3% to 46.8%), while an independent internet search resulted in sources containing the correct definition for 100% of students (23/23, 95% CI: 87.5% to 100%, p = 0.0001). ChatGPT-3.5 incorrectly identified the Randleman criteria as a corneal ectasia staging system for 17.4% of students (4/23), fabricated a "Randleman syndrome" for 4.3% of students (1/23), and gave no definition for 52.2% of students (12/23). When a definition was given (47.8%, 11/23), a median of two of the five correct parameters was provided along with a median of two additional falsified parameters. Conclusion Internet search engine outperformed ChatGPT-3.5 in providing accurate and reliable information on the Randleman criteria. ChatGPT-3.5 gave false information, required excessive prompting, and propagated misunderstandings. Learners should exercise discernment when using ChatGPT-3.5. Future initiatives should evaluate the implementation of prompt engineering and updated large-language models.

Visual Prognosis Following Cataract Surgery in Highly Myopic Patients with Prior History of Verisyse Phakic Intraocular Lens Implantation.

Background/Objectives: This study aimed to evaluate the visual outcomes and prognosis after cataract surgery in patients with prior history of Verisyse phakic intraocular lens (pIOL) implantation. Methods: A retrospective cohort study involving 215 Verisyse pIOL implantations and 17 explantations was conducted. The Verisyse pIOL was disenclaved and removed through a superior scleral tunnel incision. Cataract extraction with phacoemulsification was then performed through a temporal clear corneal incision. Results: An occurrence rate of 7.9% of eyes with cataract formation was found. Both uncorrected (UDVA) and corrected visual acuity (CDVA) three months after cataract surgery were significantly improved (0.24 ± 0.30 vs. 0.73 ± 0.48; p < 0.001 and 0.10 ± 0.14 vs. 0.30 ± 0.31; p = 0.004, respectively). The UDVA was 20/20 or better in 41% of eyes and 20/40 or better in 65% of eyes. The CDVA was 20/20 or better in 53% of eyes and 20/40 or better in 88% of eyes. The safety and efficacy indices were 1.96 ± 1.68 and 1.60 ± 1.36, respectively. Conclusions: Various complications including cataracts may develop in these patients. Verisyse pIOLs have a lower incidence of cataract formation and are more likely to lead to age-related cataracts rather than the anterior subcapsular cataracts commonly seen in implantable collamer lens (ICL) patients. Patients with a prior history of Verisyse pIOL can expect to have a good visual prognosis after cataract extraction.

Addressing corneal opacity after herpes zoster infection.

A 15-year-old boy was referred for corneal opacity evaluation. The patient had a previous herpes zoster virus (HZV) infection-varicella-zoster virus (VZV)-with ocular manifestation 1 year ago. After the infection, he developed a central corneal scar and decreased corrected distance visual acuity (CDVA) in the right eye. The slitlamp examination showed the right eye with central corneal opacity (involving anterior stroma), lacuna area between the haze, fluorescein negative, and no vascularization near the scar (Figure 1JOURNAL/jcrs/04.03/02158034-202406000-00019/figure1/v/2024-07-10T174224Z/r/image-tiff). The patient had been treated with oral valacyclovir and topical corticosteroids without any improvement of visual acuity or changes in opacity within the 1-year follow-up. His CDVA was 20/200 (-4.50 -0.75 × 25) in the right eye and counting fingers (-4.00) in the left eye. Intraocular pressure was 12 mm Hg in both eyes. Fundoscopy was normal in the right eye, but he had a macular scar in the left eye (diagnosed when he was 7 years). The left eye had no cornea signs. The patient has no comorbidity or previous surgeries. Considering this case, a corneal central scar in a 15-year-old boy, legally single eye only, and assuming it is an opacity in the anterior stroma, would you consider surgery for this patient? If so, which would you choose: Would you consider an excimer laser treatment of his ametropia while partially removing his opacity, a phototherapeutic keratectomy (PTK), or a PTK followed by a topography-guided treatment, femtosecond laser-assisted anterior lamellar keratoplasty (FALK), or deep anterior lamellar keratoplasty (DALK) or penetrating keratoplasty (depending on the scar depth)? Would you consider prophylactic acyclovir during and after surgery? Would you consider any other surgical step to prevent delayed corneal healing-persistent epithelial defect? Before the surgical approach, would you consider treating this patient with topical losartan (a transforming growth factor [TGF]-ß signaling inhibitor)? Would you first perform the surgery (which one) and then start the medication? Furthermore, if so, how long would you treat this patient? Would you consider treatment with another medication?

The Utilization of Topical Insulin for Ocular Surface Diseases: A Narrative Review.

Various etiologies, including diabetic keratopathy (DK), dry eye disease (DED), and neurotrophic keratopathy (NK), can disrupt corneal homeostasis, exacerbating corneal epithelial defects. Topical insulin has emerged as a promising therapy for promoting corneal wound healing and addressing underlying pathologies. This review systematically evaluates the efficacy of topical insulin across different corneal disorders. A literature review was conducted across the PubMed, Google Scholar, and Scopus research databases. The search resulted in a total of 19 articles, consisting of clinical trials, retrospective studies, and case reports. In DK, topical insulin accelerates corneal wound healing post-vitreoretinal surgery with lower concentrations showing higher outcomes when compared to conventional therapy, possibly due to improved epithelial stem cell migration. In comparison, the dry-eye disease results are inconclusive regarding patient-reported outcomes and corneal staining. For NK, topical insulin accelerates corneal wound healing and restores corneal nerve sensation. Other persistent epithelial defect (PED) etiologies that have been treated with topical insulin are infection, immune-mediated, mechanical and chemical trauma, and chronic ocular surface alterations. Although individual mechanisms for the benefits of topical insulin for each of these etiologies have not been studied, the literature demonstrates that topical insulin is efficacious for PEDs regardless of etiology. Future clinical trials need to be conducted to further evaluate optimal dosing, duration, and use of topical insulin for the restoration of the corneal surface.

Three-Month Comprehensive Outcomes of Topography-Guided LASIK Versus Keratorefractive Lenticule Extraction (KLEx): A Prospective Contralateral Study.

INTRODUCTION: The aim of this study was to compare outcomes of topography-guided laser-assisted in situ keratomileusis (TG-LASIK) and small incision lenticule extraction (SMILE®) for correcting myopia and myopic astigmatism. METHODS: In this prospective, randomized contralateral study, 34 patients (68 eyes) received TG-LASIK in one eye, and SMILE in their fellow eye. Efficacy, safety, predictability, higher-order aberrations, corneal tomography, biomechanics, and patient-reported outcomes (PROs) were assessed preoperatively and up to 3 months postoperatively. RESULTS: Both platforms showed comparable efficacy at 3 months (TG-LASIK 1.08 ± 0.19; SMILE 0.98 ± 0.17, p = 0.055). However, TG-LASIK demonstrated quicker visual recovery, with 63% and 89% achieving uncorrected distance visual acuity (UDVA) of 20/16 or better at 1 day and 1 week, respectively, compared to SMILE (34% and 63%; p < 0.05). Safety index at 3 months did not significantly differ between TG-LASIK and SMILE (p = 0.223). TG-LASIK and SMILE had 44% and 56% of eyes within 0.13 D of spherical equivalent (SEQ) target, respectively. SMILE induced more total higher-order aberrations (HOAs), vertical coma, and oblique trefoil than TG-LASIK at 3 months (p < 0.05). Both platforms showed similar increases in epithelial remodeling, but SMILE induced thicker epithelium than TG-LASIK at the 7.0-mm nasal zonal area. No significant differences were found in corneal hysteresis (CH) or corneal resistance factor (CRF) at 3 months (p > 0.05). Reported symptoms of glare, halos, rings, starbursts, or dry eye did not significantly differ between groups at 3 months (p > 0.05). Overall, 59% of patients preferred their TG-LASIK treated eye at 1 month, but 65% of patients had no specific eye preference at 3 months. CONCLUSION: TG-LASIK and SMILE demonstrate excellent and comparable efficacy, safety, and predictability at 3 months, but TG-LASIK offers faster postoperative visual recovery at 1 day and 1 week. TG-LASIK induces fewer HOAs than SMILE, but both procedures affect corneal biomechanics similarly. TRIAL REGISTRATION: ClincialTrials.gov identifier, NCT05611294.

Perioperative Recommendations for Corneal Refractive Surgery Patients With Inherited Bleeding Disorders.

PURPOSE: To synthesize the current literature regarding patients with inherited bleeding disorders and suggest comprehensive evaluation and preoperative recommendations for these patients before undergoing corneal refractive surgery. METHODS: The literature search was conducted through PubMed, Embase, and Google Scholar databases for publications through January 4, 2024 for reports of ocular bleeding manifestations in patients with inherited bleeding disorders and reports of patients without a history of bleeding disorders who had intraoperative or postoperative hemorrhagic complications with corneal refractive surgery. Additional cases from the literature and a retrospective chart review at a corneal practice were obtained describing patients with inherited bleeding disorders who underwent corneal refractive surgery. RESULTS: Four articles were found detailing ocular bleeding manifestations in patients with inherited bleeding disorders who underwent ocular surgery other than corneal refractive surgery. Thirty articles were found detailing intraoperative and postoperative bleeding manifestations in patients without a history of inherited bleeding disorders who underwent corneal refractive surgery. Eight cases (3 patients from the literature search and 5 patients from a retrospective chart review) were found regarding patients with inherited bleeding disorders who underwent corneal refractive surgery. CONCLUSIONS: For corneal refractive surgery with topical anesthesia, the perioperative risk and need for any hemostasis intervention in individuals with an inherited bleeding disorder depends on the type of disorder, status of preoperative factor level concentrations, or a prior history of bleeding. If required, clotting factor optimization should be tailored to each candidate on a case-by-case basis.

Recurrent Posterior Capsular Opacification in Adults: A Case Report and an Overview of Literature.

Posterior capsular opacification (PCO), also known as "secondary cataract", is a common complication following cataract surgery that can significantly impair visual acuity. The incidence of PCO varies widely in the literature, influenced by intraocular lens (IOL) type and patient risk factors. Neodymium-doped yttrium-aluminum-garnet (YAG) laser posterior capsulotomy is the standard treatment for PCO-related visual impairment. Recurrence of PCO after initial treatment with YAG capsulotomy, though more common in children, is rare in adults. Its underlying pathophysiological mechanisms are similar to that of primary PCO, which includes proliferation, migration, and/or clustering of lens epithelial cells (LECs), with subsequent reclosure of the posterior aperture. Potential risk factors for PCO recurrence that have been speculated through a comprehensive search of the current literature include younger age, female sex, high myopia, diabetes, vitrectomized status, uveitis, low-diopter IOLs, and certain IOL types with higher water content. We present a case of recurrent PCO in a highly myopic 48-year-old male following cataract surgery and implantable collamer lens (ICL) explantation who received a hydrophobic acrylic lens with 4% water content. Surgical techniques that may reduce recurrent PCO occurrence and appropriate postoperative care are emphasized to assist surgeons in their approach to patients at high-risk for this complication.

Refractive surgical approaches to keratoconus: A systematic review and network meta-analysis.

Advancements in diagnostic methods and surgical techniques for keratoconus (KC) have increased non-invasive treatment options. Successful surgical planning for KC involves a combination of clinical science, empirical evidence, and surgical expertise. Assessment of disease progression is crucial, and halting the progression should be the focus if it is progressive. While surgeons used to rely on experience alone to decide the surgical method, comparing the network of primary factors, such as visual acuity, across studies can help them choose the most appropriate treatments for each patient and achieve optimal outcomes. Meticulous tabulation methods facilitate interpretation, highlighting the importance of selecting the correct surgical and rehabilitation approach based on each patient's condition and stage of the disease. We detail the outcomes of a comprehensive network meta-analysis comparing the effectiveness of various combined therapeutic refractive treatments for KC at identical stages of the disease, spanning 4 distinct follow-up intervals. Additionally, the comprehensive analysis suggests that for corneas with optimal best corrected visual acuity (BCVA) preoperatively (classified as regular), combining phakic intraocular lenses with intracorneal ring segments (ICRS) and corneal cross-linking (CXL) could offer the best therapeutic approach provided the disease stage does not exceed stage 3. For irregular corneas, although initial follow-ups show a significant difference in BCVA with surface ablation, longer-term follow-ups recommend combining surface ablation with ICRS and CXL, especially at higher stages.

Merging Photorefractive Keratectomy and Collagen Crosslinking: An Analysis of Literature and a Guide to Prevalent Protocols.

PURPOSE: The purpose of this review was to summarize the different surgical approaches combining photorefractive keratectomy (PRK) and corneal crosslinking (CXL), present each protocol template in a simple format, and provide an overview of the primary outcomes and adverse events. METHODS: A literature review was conducted as outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Eight different databases were searched. Papers were included if PRK was immediately followed by CXL. RESULTS: Thirty-seven papers met the inclusion criteria of a total yield of 823. The latest research into simultaneous PRK and CXL has been shown to not only stabilize the cornea and prevent keratoconus progression but also improve the visual acuity of the patient. Improvements in uncorrected distance visual acuity and (spectacle) corrected distance visual acuity were found to be significant when considering all protocols. There were also significant reductions in K1, K2, mean K, Kmax, sphere, cylinder, and spherical equivalent. Random-effects analysis confirmed these trends. Corrected distance visual acuity was found to improve by an average of 0.18 ± 1.49 logMAR (Cohen's D [CD] 0.12; P <0.02). There was also a significant reduction of 2.57 ± 0.45 D (CD 5.74; P <0.001) in Kmax. Cylinder and spherical equivalent were also reduced by 1.36 ± 0.26 D (CD 5.25; P <0.001) and 2.61 ± 0.38 D (CD 6.73; P <0.001), respectively. CONCLUSIONS: Combining the 2 procedures appears to be of net benefit, showing stabilization and improvement of ectatic disease, while also providing modest gains in visual acuity. Since customized PRK and CXL approaches appear superior, a combination of these would likely be best for patients.