Corneal cross-linking for treatment of keratoconus relapse in post-keratoplasty eyes.

PURPOSE: Keratoconus relapse after penetrating keratoplasty is a rare condition that may result in severe visual deterioration and corneal graft thinning. Therefore, treatment to stabilize the cornea should be considered. The purpose of this study was to evaluate the safety and efficacy of Corneal Cross-Linking (CXL) in eyes with relapse of keratoconus after penetrating keratoplasty for keratoconus. MATERIALS AND METHODS: A retrospective review of eyes that developed keratoconus relapse following a penetrating keratoplasty and treated with CXL. The main outcome measures were change in maximal keratometry (Kmax), best-corrected distance visual acuity (BCVA), thinnest corneal thickness (TCT) and central corneal thickness (CCT), and complications. RESULTS: We identified 10 consecutive eyes of 9 patients. Preoperative median BCVA before the CXL and 1 year after the CXL procedure remained stable (p = 0.68). The median (IQR) of Kmax improved from 63.2 (24.9) D before the CXL procedure to 62.2 (27.1) D at 1 year postoperatively (P = 0.028). Median TCT and CCT also remained with no significant change 1 year after CXL. No complications were noted following the procedure. CONCLUSION: CXL in eyes with keratoconus relapse after keratoplasty is a safe and effective procedure enabling not only visual stabilization but also might bring keratometry improvement. Routine follow-up after keratoplasty should be performed for early detection of keratoconus relapse and CXL is timely advised when such a relapse is documented.

The Change in Corneal and Conjunctival Sensation Following Pterygium Surgery.

BACKGROUND: The cornea is one of the most densely innervated in the body. Pterygium surgery includes removal of the pterygium tissue from the cornea and conjunctiva followed by autologous conjunctival grafting. OBJECTIVES: To examine the change in corneal and conjunctival sensation post-pterygium surgery. METHODS: This prospective study included patients with primary pterygium. We collected and analyzed demographic data, visual acuity (VA), refraction, quantified sensation, and corneal tomography. Comparison in sensation in the cornea, conjunctiva, and conjunctival autograft was recorded the day of surgery and at least 6 months postoperatively. RESULTS: Nine patients participated in the study. Mean follow-up time was 9 months (9  3.3, 6-12.4). No complications were documented during or following surgery and no recurrences were found. Statistically significant increases in corneal sensation in the nasal corneal and in the nasal conjunctival areas were noted by the end of follow-up compared to before surgery (P = 0.05, paired samples t-test). There was a significant correlation between the increase in nasal corneal and conjunctival sensation with improved Schirmer testing outcomes and tear break-up time after surgery (P = 0.05, P = 0.01, Pearson correlation). There was a positive correlation between the changes in nasal corneal sensation after surgery and improved changes in VA (P = 0.02, Pearson correlation). CONCLUSIONS: We found improvement in sensation 9 months after pterygium surgery, which may be due to reinnervation of the cornea and conjunctival autograft from the neighboring non-injured nerve fibers. Larger studies with confocal microscopy should be conducted for further analysis.

Safety and Efficacy of Repeated Corneal Collagen Crosslinking in Progressive Keratoconus.

PURPOSE: Keratoconus is a progressive visually impairing disorder. Despite the beneficial effects of epithelial off-crosslinking (CXL) on the stabilization of keratoconus, progression may still occur. We report the efficacy and safety of a repeated CXL for significant progression of keratoconus after a single CXL procedure. METHODS: This retrospective study includes patients diagnosed with progressive keratoconus who were previously treated with CXL and underwent repeated CXL. Demographic, clinical, and surgical data were retrieved and analyzed. RESULTS: Ten consecutive eyes of nine patients who developed progressive keratoconus after CXL were identified. The mean age at diagnosis of keratoconus was 20.2 ± 6.0 years. The post-repeated CXL follow-up period was 2.1 ± 1.3 years. The mean best corrected visual acuity (BCVA) remained stable throughout the follow-up period. The mean Kmax at baseline was 60.4 ± 3.6 D. Before the repeated CXL, Kmax progressed significantly ( P = 0.018) and was 62.2 ± 6.3 D, and at the last follow-up, the value decreased significantly ( P = 0.037) and was 60.3 ± 6.4 D. The mean minimal pachymetry was 464.0 ± 27.0 µ at base line. Before the repeated CXL, minimal pachymetry was significantly lower ( P = 0.018), and after the repeated CXL, the minimal pachymetry was stable ( P = 0.2). No intra- or postoperative complications were noted. CONCLUSIONS: Repeated CXL is a safe and effective treatment option when failure of the initial CXL is diagnosed, even in young patients. This procedure may prevent visual deterioration and a potential need for keratoplasty.

Accelerated Versus Standard Corneal Collagen Crosslinking in the Treatment of Keratoconus: One-Year Results.

BACKGROUND: Keratoconus is a non-inflammatory disease characterized by progressive corneal steepening, which leads to decreased visual acuity secondary to high irregular astigmatism. OBJECTIVES: To compare the one-year outcomes of accelerated vs. standard collagen crosslinking (CXL) in the treatment of keratoconus. METHODS: A database search of patients who underwent CXL from 2009 to 2017 was conducted at the cornea clinic at Sheba Medical Center. Charts of 99 adult patients (124 eyes) were reviewed. All patients were diagnosed with keratoconus. Main outcome measures were change in keratometry, uncorrected visual acuity (UCVA), and best-corrected visual acuity (BCVA. RESULTS: We evaluated outcomes in two groups: CXL with standard (3 mW/cm2 for 30 minutes) vs. the accelerated (9 mW/cm2 for 10 minutes) protocol. There were no significant differences between the groups with regard to BCVA, UCVA, and mean spherical equivalent (P =0.83, 0.0519, 0.181, respectively). The corneal thickness in the center and thinnest location were higher in the accelerated group than the in the standard group (P = 0.126). Complication rates did not differ between the two groups. CONCLUSIONS: Accelerated and standard CXL are both safe and effective techniques. Accelerated CXL confers the added benefit of being a faster procedure to both patients and surgeons.

Topical Estrogen Therapy for Hyperopia Correction in Vivo.

Purpose: In vitro studies found that 17ß-estradiol (estrogen) modulates corneal biomechanical properties and reduces tissue stiffness. Therefore we hypothesized that topical estrogen might affect the refractive properties of the cornea, inducing a myopic shift. Methods: Twelve female New Zealand white rabbits 16 weeks old were used. The rabbits were randomly divided to either the treatment group receiving 1.5% (w/v) estrogen eye drops or a control group receiving vehicle only (n = 6 each group). Both groups were given drops (50 µL) to the right eye every 12 hours for 35 days. Ocular examination, pachymetry, intraocular pressure (IOP), keratometry ,and refraction were evaluated at baseline and on a weekly basis. Results: No significant differences were observed between the two groups at baseline in all outcome measures. Both groups displayed corneal flattening and a hyperopic shift. However, the change rate was slower in the treatment group. Repeated measurements analysis revealed a statistically significant difference in keratometry readings between groups (P = 0.034) with steeper keratometry by up to 0.6 diopters in the treatment group. The difference between the two groups diminished and became statistically insignificant after treatment cessation. No significant changes were observed in IOP and pachymetry throughout the study period. No side effects were observed in either group. Conclusions: Estrogen eye drops induced a myopic shift in keratometry readings. These results suggest that corneal refractive power might be manipulated pharmacologically. Further studies on the physiology behind this change are warranted to facilitate a pathway for development of novel pharmacologic treatments to correct refractive errors.

Repetitive magnetic stimulation protects corneal epithelium in a rabbit model of short-term exposure keratopathy.

PURPOSE: To investigate the effect of repetitive magnetic stimulation (RMS) on corneal epithelial permeability in a rabbit model of exposure keratopathy. METHODS: 61 female New Zealand White (NZW) rabbits were treated on one eye with repetitive magnetic stimulation (RMS) at a frequency of 20 Hz for 15 min. The other eye was untreated. Rabbit eyes were kept open for 2 h to induce acute corneal desiccation. The extent of fluorescein corneal staining was evaluated using EpiView software and the concentration of fluorescein in the anterior chamber was determined by a fluorometer. Safety was evaluated by electroretinogram, spectral domain optical coherence tomography (SD-OCT) and histopathology. Expression pattern of corneal cell markers was determined by immunofluorescence. RESULTS: A significant decrease in fluorescein concentration in the anterior chamber (54 ±â€¯8.4 ng/ml vs. 146.5 ±â€¯18.6 ng/ml, p = 0.000001) and in corneal surface fluorescein staining score (1.7 ±â€¯0.2 vs. 4.6 ±â€¯0.6, p = 0.00001) was obtained in RMS-treated eyes compared with control eyes, respectively. RMS treatment reduced by nearly 4 fold the percentage of corneal area with epithelial erosions by anterior segment SD-OCT. The therapeutic effect was maintained for at least 3 months. Increased expression of epithelial tight junction protein Zo-1 was observed in treated eyes. SD-OCT and histopathology analysis revealed no pathological changes in the treated or non-treated eyes. CONCLUSIONS: RMS treatment decreases epithelial corneal erosions in a rabbit model of exposure keratopathy, with no indication of pathological changes. RMS may present a novel treatment for protection of corneal epithelium from desiccation.

Epithelial ingrowth after late traumatic femtosecond laser-assisted laser in situ keratomileusis flap dislocation.

Traumatic flap displacement and epithelial ingrowth after microkeratome-assisted laser in situ keratomileusis (LASIK) is a widely described potentially sight-threatening complication. However, this complication is rare when a femtosecond laser is used to create the LASIK flap. We present a case of epithelial ingrowth after late traumatic femtosecond-assisted LASIK flap dislocation. A 25-year-old woman presented to our emergency department after being scratched in the right eye by her cat. The patient had bilateral myopic femtosecond-assisted LASIK surgery 5 years previously with good postoperative visual acuity. Ocular examination showed nasal dislocation of the flap. Follow-up examinations showed epithelial ingrowth. She was referred for reconstructive surgery in which the epithelial ingrowth was removed and the flap repositioned. Follow-up examinations showed an excellent result.

Multimodal Assessment of Corneal Erosions Using Optical Coherence Tomography and Automated Grading of Fluorescein Staining in a Rabbit Dry Eye Model.

PURPOSE: To evaluate the potential use of anterior segment spectral domain optical coherence tomography (AS-SD-OCT) combined with an automated grading of fluorescein staining for assessment of corneal erosions in a rabbit short-term dry eye model. METHODS: Twenty-one New Zealand white rabbits were anesthetized and eyes were kept open for 140 minutes to induce acute corneal desiccation. Rectangular scans of the cornea were performed using Spectralis AS-SD-OCT. Total corneal thickness, corneal epithelial thickness, and the percentage of epithelial erosion area (PEEA) were evaluated. Corneas were stained with fluorescein and graded automatically using EpiView and semi-automatically using ImageJ. Spearman's rank-order correlations were calculated to compare the AS-SD-OCT PEEA and the two corneal staining scores. RESULTS: Eye desiccation resulted in corneal epithelium erosions that covered 0.67% to 14.2% of the central cornea (mean ± SD: 3.95% ± 3.2%) by AS-SD-OCT. The percentage of corneal area positively stained with fluorescein ranged from 0.24% to 38.01% (mean ± SD: 12.24% ± 9.7%) by using ImageJ, correlating with the AS-SD-OCT PEEA (Spearman's ρ, 0.574; P = 0.007). The EpiView score ranged from 0.5 to 10.17 and was better correlated with the AS-SD-OCT PEEA score (Spearman's ρ, 0.795; P = 0.000017). CONCLUSIONS: Our study suggests that multimodal analysis of AS-SD-OCT and grading of fluorescein staining using EpiView software may enable quantitative assessment of corneal epithelial erosions in a rabbit short-term dry eye model. TRANSLATIONAL RELEVANCE: This multimodal imaging analysis may be applied for evaluation of superficial punctate keratitis associated with dry eye.

Does PACK-CXL Change the Prognosis of Resistant Infectious Keratitis?

PURPOSE: To examine the clinical characteristics, treatments, and prognosis of all cases of infectious keratitis resistant to conventional therapy and treated by photo-activated chromophore for keratitis corneal cross-linking (PACK-CXL) in one institution between 2012 and 2016. METHODS: A database search of patients who underwent PACK-CXL (ultraviolet-A for 10 minutes for irradiance of 9 mW/cm2) for infectious keratitis unresponsive to medical treatment at a tertiary care hospital was conducted. The following parameters were documented: patient demographic information, corrected distance visual acuity (CDVA) before the procedure and at the end of follow-up, characteristics of the ulcer, antibiotic treatment prior to CXL, culture results, and long-term complications. Cases with less than 1 year of follow-up were excluded. RESULTS: PACK-CXL was performed in 18 consecutive eyes. CDVA at the time of presentation was 1.47 logMAR (mean 1.47 ± 0.72 logMAR, range: 0.00 to 2.79 logMAR). Culture results were positive in 72% of eyes (13 of 18 patients) and no pathogens were identified in 28% of eyes (5 of 18 patients). All patients were treated with more than one antibiotic. The mean CDVA at the end of follow-up was 1.22 logMAR (mean: 1.22 ± 0.89 logMAR, range: 0 to 2.07 logMAR). There was no significant change between CDVA at presentation to CDVA at the end of follow-up (matched pair, P = .126). One eye underwent an emergency therapeutic penetrating keratoplasty. CONCLUSIONS: Patients with large, central corneal ulcer and poor CDVA who were resistant to conventional treatment underwent PACK-CXL. At the end of follow-up, only one eye required emergency penetrating keratoplasty. This low rate might be attributed to a good response to CXL. [J Refract Surg. 2018;34(8):559-563.].

Characteristics of patients with ocular cicatricial pemphigoid referred to major tertiary hospital.

OBJECTIVE: To evaluate the demographic and clinical characteristics of patients referred to a tertiary care hospital cornea clinic for ocular cicatricial pemphigoid (OCP) assessment. DESIGN: Retrospective, nonrandomized, consecutive case series. PARTICIPANTS: Thirty three patients with OCP who were treated at the corneal clinic of Toronto Western Hospital from 2003 to 2012. METHODS: Database search of patients from 2003 to 2012 with a referral request or diagnosis of OCP was conducted at a tertiary care hospital cornea clinic. Charts of 33 patients (64 eyes) were reviewed. Outcome measures included patient demographics, methods of diagnosis, visual acuity, ocular features, and disease staging using Foster's staging system, systemic modes of treatment, disease progression, and presence of systemic involvement. RESULTS: Mean patient age at presentation was 69.8 years (range 40-91), and 81% (27/33) were female. At presentation, disease staging consisted of stage I (subepithelial fibrosis) 7.8% (5/64), stage II (shortened fornices) 21.8% (14/64), stage III (symblepharon formation) 65.6% (42/64), and stage IV (keratinization with or without globe immobility) 4.6% (3/64). At the final follow-up visit, the proportions of the involved eyes for stages I to IV were 1.5% (1/64), 10.9% (7/64), 76.5% (49/64), and 10.9% (7/64), respectively. Conjunctival biopsies were obtained from 81% (27/33) of patients and reported as positive in 30% (8/27), negative in 63% (17/27), and inconclusive in 7% (2/27) of patients. Mean duration of follow-up was 6.8 ± 5.6 years (range 0.5-22), and 66.6% (22/33) of patients had progressive disease. Systemic mucocutaneous involvement was noted in 36.3% (12/33) of patients. CONCLUSIONS: The high rate of disease progression suggests the need for improved therapeutic options. Additional modalities are needed in addition to conjunctival biopsy to confirm a diagnosis of OCP in patients with clinical signs of the disease.

Contralateral eye comparison of descemet membrane endothelial keratoplasty and descemet stripping automated endothelial keratoplasty.

PURPOSE: To compare objective and subjective outcomes after Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK) in the fellow eye of the same patients. STUDY DESIGN: Single-center, retrospective case series. METHODS: Seventeen patients with bilateral Fuchs endothelial dystrophy who underwent DSAEK earlier in 1 eye, and later underwent DMEK in the contralateral eye, composed study population. A chart review was completed to obtain follow-up data for at least 6 months after each surgery. Outcome measures included best spectacle-corrected visual acuity (BSCVA) and endothelial cell density (ECD). Subjective questionnaires were used to assess patients' satisfaction. RESULTS: Preoperative BSCVA (logMAR) was similar in both groups, 0.66 ± 0.4 in DMEK and 0.59 ± 0.4 in DSAEK (P = .6). The DMEK group showed better BSCVA than the DSAEK group at the 6-month time point (0.25 ± 0.1 and 0.39 ± 0.1, for DMEK and DSAEK, respectively, P = .02). Preoperative ECD (cells/mm(2)) was similar in both groups (2647 ± 249 and 2768 ± 404, P = .3) in DMEK and DSAEK, respectively. There was statistically significant difference found in ECD at 6 months (2227 ± 565 for DMEK and 1780 ± 433 for DSAEK, P = .049). Subjective level of average satisfaction after DMEK was 6 and after DSAEK was 4.87 ± 1.19 (P = .002). CONCLUSIONS: DMEK provided better visual outcome and lower endothelial cell loss than DSAEK and a higher level of patient satisfaction when assessed at 6 months after surgery. Our results comparing the 2 procedures in the same patients support the benefits of DMEK, and suggest the need for long-term studies observing this new surgical procedure.

Cross-linking and intracorneal ring segments--review of the literature.

OBJECTIVES: To review and summarize relevant studies on combined use of corneal crosslinking and intracorneal ring segments (ICRS) for the treatment of corneal ectasia. METHODS: A literature search was performed using the key words "corneal collagen cross-linking" and "intra-corneal ring segments." RESULTS: Crosslinking is a well-accepted treatment option for corneal ectasia and can be combined with corneal ICRS insertion as needed. The advent of crosslinking has dramatically reduced the number of corneal transplants performed for patients with keratoconus or postrefractive ectasia. Intracorneal ring segments, although flatten the corneal surface, do not prevent the progression of corneal ectasia. This is why the combination of crosslinking and ICRS is potentially synergistic. Previous studies reported that combining these two complementary interventions has been shown to be safe and effective. CONCLUSIONS: The effects of ICRS are enhanced and stabilized by crosslinking, but the ideal combined technique is not known at present.

Fellow eye comparison of corneal thickness and curvature in descemet membrane endothelial keratoplasty and descemet stripping automated endothelial keratoplasty.

PURPOSE: To compare posterior corneal curvature in the fellow eye of the same patients after Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK). METHODS: This retrospective, case series comparative study included consecutive patients who underwent DSAEK in one eye and DMEK in the fellow eye. Each eye underwent corneal evaluation with Pentacam HR (Oculus, Wetzlar, Germany). Postoperative corneal curvature, corneal thickness, and visual acuity were assessed. RESULTS: Twenty eyes of 10 patients (5 women and 5 men) aged 72.5 ± 13.5 (range, 42-87) years were included. No significant differences were observed between front flat K's (43.01 ± 1.6 vs. 43.5 ± 0.9, P = 0.27) and front steep K's (44.17 ± 1.5 vs. 44.52 ± 0.7, P = 0.39) in DMEK vs. DSAEK eyes, accordingly. Posterior curvature was statistically significantly flatter in DMEK compared with DSAEK eyes; back flat K's (-6.30 ± 0.2 vs. -6.84 ± 0.6, P = 0.012), back steep K's (-6.64 ± 0.1 vs. -7.2 ± 0.3, P = 0.03), and back Km (-6.45 ± 0.1 vs. -6.99 ± 0.4, P = 0.005), accordingly. Corneas in DMEK eyes were significantly thinner than in DSAEK eyes (541.0 ± 61 vs. 627.9 ± 70 µm, P = 0.007). CONCLUSIONS: Eyes that underwent DSAEK surgery have thicker corneas with steeper posterior corneal curvature than fellow eyes that underwent DMEK. This difference may explain the hyperopic shift commonly observed after DSAEK and should be considered when choosing an intraocular lens for cataract surgery.

Anterior stromal puncture for the treatment of recurrent corneal erosion syndrome: patient clinical features and outcomes.

PURPOSE: To evaluate the clinical features and outcomes of patients with recurrent corneal erosion syndrome who underwent anterior stromal puncture. STUDY DESIGN: Retrospective, nonrandomized, consecutive case series. METHODS: Database search of patients from 2003-2013 who underwent anterior stromal puncture was conducted at a tertiary care hospital cornea clinic. Charts of 30 patients (35 eyes) were reviewed. Outcome measures included demographics, laterality, history of corneal trauma, prior ocular history, frequency and duration of symptoms, failed treatments, signs on examination, degree of symptom resolution, additional treatments needed, and complications. RESULTS: Mean patient age at presentation was 37 (± 11.5 SD) years, 60% were male. A total of 83.3% of patients had unilateral and 16.7% had bilateral involvement. In all, 62.9% of eyes had prior history of corneal trauma and 2.9% had prior laser-assisted in situ keratomileusis. Ninety-seven percent of eyes had symptoms of pain upon awakening refractory to conservative treatment. In 97% of eyes, there were findings of microcysts, fingerprint lines, loose epithelium, and/or faint scars. Mean follow-up was 14 months (range: 3-120 months). At final follow-up, 62.9% of eyes were symptom free and 37.1% experienced milder episodes. Seventeen percent required additional treatment: 16.6% superficial keratectomy, 66% repeat anterior stromal puncture, and 16.7% phototherapeutic keratectomy. No complications were observed. CONCLUSION: Anterior stromal puncture using a short (5/8 inch) 25 gauge bent needle is a simple, safe, and cost-effective procedure for symptomatic relief in patients with recurrent corneal erosion syndrome refractive to conservative measures. Repeat treatment may be performed prior to additional surgical intervention.

Relapsing migratory idiopathic orbital inflammation: six new cases and review of the literature.

AIMS: To present a case series of relapsing migratory idiopathic orbital inflammation. PATIENTS AND METHODS: Case series and review of the literature. The medical records of six patients with recurrent orbital myositis or idiopathic inflammation at different sites treated at the Goldschleger Eye Institute between April 2006 and December 2009 were collected and analysed; one patient treated at the orbital service in Priyamvada Birla Aravind Eye Hospital, Kolkata, India, was also included (June 2008 to August 2010). Orbital biopsy was performed in patients who failed to respond to steroids treatment. RESULTS: A total of six patients with recurrent episodes of orbital myositis or inflammation were identified. Four patients had orbital myositis of one extraocular muscle at the initial episode and recurrent myositis of a different extraocular muscle on the contralateral orbit. One patient had recurrent myositis of a different extraocular muscle on the same orbit. Two patients had a third episode of recurrence on a different site, that is, an extraocular muscle or an eyelid. One patient had eyelid and soft tissue involvement on one orbit and recurrence of orbital myositis on the contralateral eyelid. Histological findings in the latter case showed small perivascular lymphocytic aggregates and scattered histiocytes. The mean time for recurrence was 7.2 months. All patients were treated successfully with oral steroids and/or intralesional triamcinolone injection. CONCLUSIONS: Idiopathic orbital inflammation or orbital myositis can recur on a different extraocular muscle and on the contralateral orbit. These cases can be successfully treated with orally administered or intralesionally injected steroids.