Femtosecond thin-flap laser assisted in situ keratomileusis for correction of post-penetrating keratoplasty ametropia: long-term outcome.

PURPOSE: To evaluate the long-term clinical outcomes of femtosecond thin-flap LASIK (femto-LASIK) for correction of refractive error after penetrating keratoplasty in keratoconus-affected eyes. SETTING: a private ophthalmology clinic. DESIGN: Prospective interventional case series. METHODS: This prospective interventional case series enrolled 22 eyes of 22 patients who underwent femto-LASIK for the management of post-penetrating keratoplasty ametropia. The refractive error, uncorrected (UDVA), and corrected (CDVA) distance visual acuities and vector analysis were reported in short-term and long-term period after surgery. RESULTS: The mean age was 32.7 ± 7.5 years (range, 23 to 47 years) at the surgery time. The average time between PK and femto-LASIK was 42.5 ± 31.7 months. The average follow-up duration after femto-LASIK was 81.2 ± 18.6 months. The mean preoperative UDVA significantly improved from 0.47 ± 0.15 logMAR to 0.35 ± 0.14 logMAR at 12 months (P = 0.048) and 0.4 ± 0.17 at final follow-up exam (P = 0.007). CDVA was 0.22 ± 0.1 at baseline which improved to 0.18 ± 0.15 and 0.15 ± 0.1 logMAR at 12 and 81 months, respectively. (Ps = 0.027, 0.014). The mean cylinder before surgery was - 5.04 ± 1.4D which significantly decreased to -1.5 ± 0.8 D at 12 months postoperatively. (P < 0.001). There was a significant increase in refractive astigmatism from 12 months to 81 months postoperatively (-3.1 ± 2.0, P = 0.002). At the final visit, the efficacy index was 0.83, and the safety index was 1.16. CONCLUSIONS: Despite the short-term outcome indicated that femo-LASIK was effective for correction of post-keratoplasty ametropia during short-term period, a notable regression in its effect was observed in the long-term follow-up. Therefore, the predictability of this technique might decrease in the long-term.

Indications and outcomes of intraocular Lens Exchange among pseudophakic eyes in a Tertiary Referral Center.

PURPOSE: To determine the indications and surgical outcomes of intraocular lens (IOL) exchange in pseudophakic patients at Labbafinejad Tertiary Referral Center between 2014 and 2019. METHODS: In this retrospective interventional case series, the medical records of 193 patients with a history of IOL exchange were reviewed. Preoperative data, including clinical characteristics, indications of the first and second IOL implantation, intra- and postoperative complications due to IOL exchange, and the pre-and postoperative refractive error and best-corrected visual acuity (BCVA) were considered the outcome measures in this study. All postoperative data were analyzed at least six months after follow-up. RESULTS: The mean age of our participants was 59.13 ± 20.97 years old at the time of the IOL exchange, with a male percentage of 63.2%. The mean follow-up after the IOL exchange was 15.72 ± 16.28 months. The main indications of IOL exchange were IOL decentration (50.3%), corneal decompensation (30.6%), and residual refractive errors (8.3%). 57.10% of patients with the postoperative spherical equivalent at -2.00 diopter (D) to + 2.00D. The mean best-corrected visual acuity was 0.82 ± 0.76 LogMAR before the IOL exchange and was improved to 0.73 ± 0.79 LogMAR after the surgery. Corneal decompensation (6.2%), glaucoma (4.7%), retinal detachment (4.1%), cystoid macular edema (2.1%), and uveitis (1%) were found as the postoperative complications. There was only one case with suprachoroidal hemorrhage during IOL exchange. CONCLUSIONS: IOL decentration followed by corneal decompensation was the most common indication of IOL exchange. After IOL exchange, the most complications during follow-up were corneal decompensation, glaucoma, retinal detachment, and cystoid macular edema.

Optical coherence tomography angiography parameters after cataract surgery.

PURPOSE: To evaluate the changes in macular blood flow after cataract surgery through optical coherence tomography angiography (OCT-A). METHODS: In this prospective case series, 50 patients who underwent uncomplicated cataract surgery by the resident were included. OCT-A images and complete ocular examinations were performed at baseline, 1 and 3 months postoperatively. The changes in OCT-A parameters including foveal avascular zone (FAZ) area, vessel density (VD) of superficial and deep plexus, and central macular thickness were assessed before and after surgery. Cataract grading, intraocular inflammation, and duration of surgery were analyzed. RESULTS: FAZ was significantly reduced from 0.36 ± 0.13 mm2 at baseline to 0.32 ± 0.12 mm2 at month 1 (P < 0.001) and this reduction continued until month 3. In the superficial layer, vessel density of the fovea, parafovea, and whole image significantly increased from 13.9 ± 6.8, 43.7 ± 4.7, and 43.2 ± 4.4 at baseline to 18.4 ± 7.9, 45.7 ± 4.9, and 44.9 ± 4.5 at month 1. The increase in the vessel density of the deep layer was similar to the superficial layer. Accordingly, CMT at the fovea was significantly increased from 240.5 ± 21.99 µm at baseline to 253.1 ± 23.2 microns at month 1 (P < 0.001) and the increase significantly continued and reached 259.5 ± 22.6 µm at month 3 (P < 0.001). Accordingly, the FAZ area significantly reduced one month postoperatively. In regression analysis, CMT changes positively correlated with cataract grading. FAZ area negatively correlated with intraocular inflammation on the first postoperative day. CONCLUSION: The present study shows that CMT and vessel density of the macula significantly increase after uncomplicated cataract surgery, while the FAZ area reduces. Postoperative inflammation could be the possible explanation for the findings of this study.

Macular vessel density reduction in patients recovered from COVID-19: a longitudinal optical coherence tomography angiography study.

BACKGROUND/AIMS: To quantify the longitudinal changes of the macular microvasculature and the foveal avascular zone (FAZ) parameters in patients recovered from coronavirus disease-2019 (COVID-19) using optical coherence tomography angiography (OCTA) analysis. METHODS: This observational, longitudinal study was performed on patients recovered from COVID-19. The OCTA images were recorded at baseline and after 1 and 3 months at the follow-up examination. Vessel density (VD) of the retinal superficial (SCP) and deep capillary plexus (DCP), as well as the area of the FAZ of patients who had recovered from COVID-19, were measured. RESULTS: In total, 36 eyes of 18 patients (62.2% female) with a mean age of 34.5 ± 7.5 years old were included. Regarding SCP, while the VDs of the whole image, fovea, and parafovea were comparable at different time points, the mean VDs in inferior hemifield, as well as superior and inferior regions of perifovea, underwent significant reductions at month 3, compared to the baseline. In DCP, the mean of VD in the whole image was 54.3 ± 2.7 at the first visit which significantly decreased to 52.1 ± 3.8(P = 0.003) and 51.4 ± 2.7(P = 0.001) after 1 and 3 months, respectively. The VDs in all regions of parafovea and perifovea revealed a significant reduction after 1 and 3 months, compared to the first visit. The mean FAZ area was 0.27 ± 0.08 mm2, 0.26 ± 0.08 mm2, and 0.27 ± 0.08 mm2 at the baseline, month 1, and month 3, respectively (P > 0.05). CONCLUSION: Based on the results, the patients who had recovered from COVID-19 had a progressive decrease of VD at the follow-up visit 3 months after COVID-19 infection.

The effect of the hypertensive phase on the long-term outcomes of Ahmed glaucoma valve (AGV) implantation.

BACKGROUND: To investigate the long-term effect of hypertensive phase (HP) on the clinical outcomes of Ahmed glaucoma valve (AGV) implantation. METHOD: The records of patients with different etiologies of glaucoma who underwent AGV implantation with at least 3 years of follow-up were retrospectively reviewed. HP was defined as the IOP > 21 mm Hg during the first three months after surgery. The main outcome measure was cumulative success defined as 5 < IOP ≤ 21 mmHg and 20% reduction from the baseline with or without IOP lowering medications. Results that do not achieve cumulative success or undergo glaucoma reoperation during the follow-up period are considered failures. The secondary outcome measures were intraocular pressure (IOP) and the number of glaucoma medications. RESULTS: A total of 120 patients (28 patients of HP, 92 patients without HP) with an average age (± SD) of 48.9 ± 19.6 years and a mean follow-up of 4.5 ± 1.4 years were enrolled. The mean duration of survival was 5.3 ± 0.5 years in HP which was significantly shorter than 6.4 ± 0.2 years in non-HP (log rank = 4.2, P = 0.04). Mean IOP and number of IOP lowering agents were higher in postoperative visits at 1,2, 3, and 4 years in HP patients compared with non-HP (all Ps < 0.01). Higher baseline IOP was significantly associated with higher rates of surgical failure. CONCLUSION: In the long-term follow-up, the duration of survival was significantly longer in the non-HP group. In the non-HP group, the failure rate was significantly lower than the HP group.

Incidence and management of acute endophthalmitis after intravitreal injection of bevacizumab.

PURPOSE: To report the incidence, management, and clinical outcomes of cases who developed acute endophthalmitis following the administering of the intravitreal bevacizumab (IVB) injection. METHODS: In this retrospective, non-comparative, single-center, cross-sectional study, the records of patients diagnosed with acute endophthalmitis following IVB injection between March 2013 and October 2019 were reviewed. Immediate injection of intravitreal antibiotics and early pars plana vitrectomy was performed for all cases after clinical diagnosis of acute post IVB endophthalmitis. RESULTS: A total of 28,085 IVB injections were performed during the study period. Nine eyes of nine patients developed acute post IVB endophthalmitis giving an overall incidence of 0.032% (95% CI, 0.01-0.06) (3.2 in 10,000 injections). Three cases (33%) were culture-positive (staphylococcus epidermidis). The mean time between IVB injection and presentation of endophthalmithis was 2.77 ± 1.25 days (Range, 1-6). The mean number of previously received IVB injections before developing of endophthalmitis was 4 ± 1.5 (range 2 to7). The mean best corrected visual acuity (BCVA) before IVB injection, at the presentation of endophthalmithis and three months after the treatment of endophthalmithis were 1.18 ± 0.62, 2.5 ± 0.42, and 1.94 ± 0.88 logMAR, respectively (P = 0.025). One eye developed phthisis bulbi. CONCLUSION: The incidence of acute endophthalmitis following Intravitreal injection of bevacizumab is very low. The time interval between injection and presentation is short. Prompt treatment with immediate intravitreal antibiotics and early pars plana vitrectomy are key in maximizing outcomes. The prognosis of post-IVB endophthalmitis is poor and may result in significantly visual impairment.

Facial and Abducens Nerve Palsies Following COVID-19 Vaccination: Report of Two Cases.

A broad spectrum of neurological side effects has been reported after immunisation for COVID-19, including functional neurological disorders, cerebral vascular events, cerebral venous thrombosis, intracerebral haemorrhage, neuroleptic malignant syndrome, cranial nerve palsies, and otologic manifestations. Multiple cranial neuropathies have also been reported following vaccination in which involvement of VII nerve is the most prevalent, followed by the VI, III, and IV nerves. We describe two male patients, one with with facial nerve palsy and the other with abducens nerve palsy following COVID-19 vaccination. The patient with facial nerve palsy received the AstraZeneca vaccine 2 days before the symptoms began. In contrast, the patient with the abducens palsy had received his first dose of the Sinopharm vaccine 7 days previously. Both patients demonstrated a gradual recovery within the next 2 months. Further studies are required to investigate the proper relationship between cranial nerve palsies and vaccinations.

Topical ketorolac as an adjunctive treatment with intravitreal bevacizumab in the management of diabetic macular edema: A double-masked placebo-controlled randomized clinical trial.

PURPOSE: To evaluate the additional effect of ketorolac eye drops on therapeutic effects of intravitreal Bevacizumab in patients with diabetic macular edema (DME) METHODS: In a randomized clinical trial, 50 patients with center involved DME (macular thickness ≥ 300 microns accompanied by decreased VA (24 < BCVA ≤ 70 ETDRS letters) were enrolled consecutively and randomized 1:1 to receive either bevacizumab plus topical ketorolac (25 patients) or bevacizumab plus artificial tears (25 patients). Patients with proliferative diabetic retinopathy, history of intraocular surgery, intravitreal injection in less than three months, macular photocoagulation less than 6 months and any other concomitant ocular pathologies were excluded from the study. All the patients received three consecutive monthly injections of intravitreal bevacizumab (IVB). After that, patients were examined every 6 weeks and reinjection was administered based on the "as needed" protocol if macular thickness was 300 microns or more and VA was 70 ETDRS letters or less.. Patients also received either topical ketorolac or artificial tears three times a day over the study period (6 months). Changes in central subfield thickness (CST), best-corrected visual acuity (BCVA, ETDRS letters), and number of IVB injections were compared between the study groups. RESULTS: Fifty eyes of 50 patients were included (25 eyes in each group). Mean CST was significantly decreased in both study groups at 14th week (-87 ± 98 µm, P = 0.012 and -100 ± 147 µm, P = 0.006 in bevacizumab plus ketorolac and bevacizumab plus artificial tears groups, respectively). Nevertheless, the changes of mean CST remained significant only in bevacizumab plus ketorolac group up to 26th week (-147 ± 124 µm, P < 0.001 and -51 ± 145 µm, P = 0.245, respectively). Comparing two groups, reduction of mean CST from baseline was significantly greater in bevacizumab plus ketorolac group compared with the control group at 26th week. (difference = -97 µm, 95%CI = -182 to -11, P = 0.017). In the study group, mean BCVA significantly increased at both 20th week (6.2 ± 10.1, P = 0.04) and 26th week (8.2 ± 10.9, P = 0.03). In contrast, visual acuity did not significantly improve at any time points in bevacizumab plus artificial tears group, While insignificant, the 26-week mean change of visual acuity from baseline was greater in bevacizumab plus ketorolac group (difference = 6.5 ETDRS letter; 95%CI = -14.4 to 1.4) Two groups were comparable regarding number of IVB injections (P = 0.99). CONCLUSION: Topical ketorolac 0.5% three times a day could enhance and sustain the efficacy of intravitreal bevacizumab in the treatment of DME.

Corona virus disease 2019-associated Stevens-Johnson syndrome: a case report.

BACKGROUND: To report Stevens-Johnson syndrome (SJS) in a patient with acute pneumonia secondary to SARS-CoV-2 infection. CASE PRESENTATION: A 45-years-old woman with a diagnosis of acute pneumonia secondary to SARS-CoV-2 infection who had received azithromycin and naproxen. Three days after starting the medication, she appeared ill and developed ocular discomfort, photophobia, dysuria, and macular rashes on the trunk and the extremities. On ophthalmological examination, a total epithelial defect was seen in both eyes. According to the examination, Stevens-Johnson syndrome was diagnosed and the patient was admitted to receive systemic and ocular support and medical care. The patient's condition improved during the 3 weeks and recovered from both COVID-19 and SJS life-threatening complications but ocular complications, including the destruction of the meibomian glands, irregularity of the eyelid margin, and corneal scarring remained for the patient. CONCLUSIONS: Although, it is not clear whether the cause of Stevens-Johnson syndrome in COVID-19 patients is the virus itself or whether the use of medication, but patients with COVID-19, especially patients receiving medication, should be screened for symptoms of Stevens-Johnson syndrome.

The role of primary needle revision after Ahmed glaucoma valve (AGV) implantation.

PURPOSE: To evaluate the efficacy and safety of primary needle revision after Ahmed Glaucoma Valve (AGV) implantation in comparison with glaucoma medication use. METHODS: In this interventional case series, 23 eyes of 23 patients who underwent AGV implantation were enrolled. Needle revision was performed when the intraocular pressure was higher than the target pressure before glaucoma medications. Using a 30-gauge needle, the Tenon's capsule over the plate was incised and the bleb was reformed. Patients were examined on a postoperative day one, weekly (for four weeks), and every 1-3 months. Two criteria were used to define cumulative success as a minimum 20% reduction in IOP and 5 < IOP ≤ 21 mmHg (Criteria A) or 5 < IOP ≤ 18 mmHg (Criteria B) without (Complete success) or with (Qualified success) glaucoma medication. RESULTS: In this pilot study, we enrolled 23 patients with a mean age of 53.8 ± 12.4 years (25-78 years) who underwent AGV implantation and a one-year follow-up period. The mean number of primary needle revision was 2.2 ± 1.6 (1-6). One year postoperatively, the cumulative success rate was 91.4% and 86.9% based on Criteria A and B, respectively. The average of preoperative IOP was 28.26 ± 8.86 mmHg (range 15-46 mmHg), reaching 13.78 ± 3.54 mmHg (range 8-20) at the end of the one-year follow-up. (P < 0.001) The mean preoperative medication significantly decreased from a median of 4 (range 3-4) at baseline to 2 (range 1-4) after the one-year follow-up (P < 0.001). One patient experienced leakage over the plate, which was successfully treated via conservative management. CONCLUSION: This pilot study showed that primary needle revision is a safe and effective method for controlling IOP after AGV implantation with a lower need for medication.

Five-year clinical outcomes of combined phacoemulsification and trabectome surgery at a single glaucoma center.

PURPOSE: To analyze the 5-year results of trabectome ab interno trabeculectomy of a single glaucoma center. METHOD: In this retrospective interventional single-center case series, data of 93 patients undergoing ab interno trabeculotomy between September 2010, and December 2012 were included. Kaplan-Meier analysis was performed using success criteria defined as postoperative intraocular pressure (IOP) ≤ 21 mmHg, and > 20% reduction from preoperative IOP, and no need for further glaucoma surgery. Risk factors for failure were identified using Cox proportional hazards ratio (HR). RESULTS: The retention rate for 5-year follow-up was 66%. The cumulative probability of success at 1, 2, 3, 4, and 5 years was 82.6%, 76.7%, 73.9%, 72.3%, and 67.5%. Risk factors for failure were lower baseline IOP (HR = 0.27, P = 0.001), younger age (HR = 0.25, P = 0.02), and higher central corneal thickness (HR = 0.18, P = 0.01). Exfoliative glaucoma was associated with a higher success rate (HR = 0.39, P = 0.02). IOP was decreased significantly from 20.0 ± 5.6 mmHg at baseline to 15.6 ± 4.6 mmHg at 5-year follow-up (P = 0.001). The baseline number of glaucoma medications was 1.8 ± 1.2, which decreased to 1.0 ± 1.2 medications at 5 years. CONCLUSION: Trabectome surgery was associated with a good long-term efficacy and safety profile in this single-center case series with a high retention rate.

Factors associated with lamina cribrosa displacement after trabeculectomy measured by optical coherence tomography in advanced primary open-angle glaucoma.

PURPOSE: To investigate the relationship of lamina cribrosa displacement to corneal biomechanical properties and visual function after mitomycin C-augmented trabeculectomy. METHOD: Eighty-one primary open-angle eyes were imaged before and after trabeculectomy using an enhanced depth spectral domain optical coherence tomography (SDOCT). Corneal biomechanical properties were measured with the ocular response analyzer before the surgery. The anterior lamina cribrosa (LC) was marked at several points in each of the six radial scans to evaluate LC displacement in response to intraocular pressure (IOP) reduction. A Humphrey visual field test (HVF) was performed before the surgery as well as 3 and 6 months, postoperatively. RESULTS: Factors associated with a deeper baseline anterior lamina cribrosa depth (ALD) were cup-disc ratio (P = 0.04), baseline IOP (P = 0.01), corneal hysteresis (P = 0.001), and corneal resistance factor (P = 0.001). After the surgery, the position of LC became more anterior (negative), posterior (positive), or remained unchanged. The mean LC displacement was - 42 µm (P = 0.001) and was positively correlated with the magnitude of IOP reduction (regression coefficient = 0.251, P = 0.02) and negatively correlated with age (regression coefficient = - 0.224, P = 0.04) as well as baseline cup-disk ratio (Regression coefficient = - 0.212, P = 0.05). Eyes with a larger negative LC displacement were more likely to experience an HVF improvement of more than a 3 dB gain in mean deviation (P = 0.002). CONCLUSION: A larger IOP reduction and younger age was correlated with a larger negative LC displacement and improving HVF. The correlation between lower SDOCT cup-disc ratio and postoperative negative LC displacement was borderline (P = 0.05). Corneal biomechanics did not predict LC displacement.

Impact of same-session trabectome surgery on Ahmed glaucoma valve outcomes.

PURPOSE: To evaluate the efficacy and survival rates of same session ab interno trabeculectomy with the trabectome and Ahmed glaucoma valve implant (AT) in comparison to the Ahmed glaucoma valve alone (A). METHOD: A total of 107 eyes undergoing primary glaucoma surgery were enrolled in this retrospective comparative case series, including 48 eyes which underwent AT and 59 eyes which received A alone. Participants were identified using the procedural terminology codes, and their medical records were reviewed. The primary outcome measure was success defined as IOP > 5 mmHg, ≤ 21 mmHg and ≥ 20% reduction of IOP from baseline at two consecutive visits after 3 months, and no need for glaucoma reoperation. Secondary outcome measures were IOP, the number of glaucoma medications, incidence of a hypertensive phase, and best corrected visual acuity (BCVA). RESULTS: The cumulative probability of success at 1 year was 70% in AT, and 65% in A (p = 0.85). IOP decreased significantly from 26.6 ± 10.1 mmHg at baseline to 14.7 ± 3.3 mmHg at the final follow-up in AT (p = 0.001). The corresponding numbers for A were 27.8 ± 10.2 and 16.7 ± 4.9, respectively (p = 0.001). The final IOP was significantly lower in AT (p = 0.022). The number of medications at baseline was comparable in both groups (2.6 ± 1.2 in AT and 2.5 ± 1.3 in A, p = 0.851). Corresponding number at 1 year visit was 1.2 ± 2 in AT and 2.8 ± 1.8 in A (p = 0.001). The incidence of a hypertensive phase was 18.7% in AT and 35.5% in A (p = 0.05). HP resolved in only 30% of eyes. The criteria for HP resolution were fulfilled in 9 eyes (30%). There was no difference in the rate of resolution of the hypertensive phase between AT and A (33.3 and 28.5%, respectively, p = 0.67). CONCLUSION: Ahmed glaucoma valve implant with same session trabectome surgery significantly decreased the rate of the hypertensive phase and postoperative IOP as well as the number of glaucoma medications.

Recurrent focal choroidal excavation following multiple evanescent white dot syndrome (MEWDS) associated with acute idiopathic blind spot enlargement.

PURPOSE: To present a recurrent case of conforming focal choroidal excavation (FCE) following multiple evanescent white dot syndrome (MEWDS) in a 25-year-old woman. METHODS: Following spontaneous MEWDS sings resolution our patient noted a recurrent decrease in vision. Repeated OCT revealed elevation and mild disruption of RPE layer at fovea without previous angiographic MEWDS signs. At this time, short-term systemic steroid therapy was started and visual acuity became normal. RESULTS: Following quiescence of the new-onset phase, the conforming type of FCE located in inferior macula appeared in OCT. In the following next 2 years recurrence of presumptive focal subfoveal choriocapillaritis occurred for three times presenting with blurred vision. During every acute attack, above-mentioned FCE disappeared and returned back again after resolution of presumptive focal choriocapillaritis. CONCLUSIONS: This is the first and unique case of recurrent type of FCE following MEWDS. It seems to disappear during active phase of presumptive focal choriocapillaritis and then returns after the eye has become quiescent.

Worldwide inequality in production of systematic reviews.

BACKGROUND: Investment in science is vital for the development and well-being of societies. This study aims to assess the scientific productivity of countries by quantifying their publication of systematic reviews taking the gross national income per capita (GNIPC) into account. METHODS: Medline and ISI Web of Science were searched for systematic reviews published between 1st January 2006 and 31st December 2010. The productivity of each country was quantified by exploring the authors' affiliation. The GNIPC was used according to the World Bank Report. Concentration index (CI) was calculated as the index of inequality. RESULTS: CI of percentage of systematic reviews as a function of percentage of countries ranked by GNIPC was 0.82 which indicates inequality in production of systematic reviews in pro rich countries. Countries with high income produced 206.23 times more systematic reviews than low income countries, while this ratio for lower middle and upper middle countries was 9.67 and 12.97, respectively. The highest concentration index was observed in clinical sciences (0.76) and the lowest in public health (0.61). CONCLUSION: This study demonstrates a significant gap between industrialized and nonindustrialized countries in the production of systematic reviews. Addressing this gap needs tremendous national and international efforts.

Late-Onset Haze and Severe Corneal Flattening after Combined Corneal Collagen Cross-Linking and Photorefractive Keratectomy (CXL Plus): A Case Report.

Introduction: Significant corneal flattening and haze are important complications that can occur after combined corneal collagen cross-linking (CXL) and photorefractive keratectomy (PRK) procedures (CXL Plus). Case Presentation: We present a 24-year-old man who underwent combined standard CXL and PRK. The patient experienced satisfactory vision for approximately 4 years after the surgery. However, after this period, he began to complain of visual blurring. Subsequent examination revealed significant corneal haze, excessive flattening in both eyes, and thinning (thinnest point 227 µm in the right eye, 244 µm in the left eye) 4 years postoperatively. Upon presentation, the corrected distance visual acuity (CDVA) was 20/200 in the right eye and 20/400 in the left eye. The presenting refraction was +2.50 sph, -3.50 cyl *114 in the right eye and +11.5 sph, -9.75 cyl *81 in the left eye. With rigid gas permeable contact lenses, the corrected visual acuity was 20/50 in both eyes. Before the CXL Plus surgery, initial refraction and CDVA were 20/50 in the right eye (-5.50 sph, -3.00 cyl *175) and 20/30 in the left eye (-5.50 sph, -2.75 cyl *175). The patient was treated by penetrating keratoplasty. The CDVA reached 20/30 at the final follow-up. Conclusion: Our report highlights significant corneal haze and flattening that occurred 4 years after combined CXL and PRK treatment. These findings suggest that this procedure might not be safe in suspected patients of keratoconus. Further long-term follow-up research is necessary to evaluate the safety of combined CXL and PRK procedures.

Superior Oblique Muscle Extramedullary Plasmacytoma in a Patient with Multiple Myeloma and a Review of Literature.

Introduction: Multiple myeloma (MM), a plasma cell malignancy, is a systemic disease affecting various body organs. Plasmacytoma of bone and extramedullary disease (EMD) are presentations of MM. EMD is usually the sign of a more aggressive form of the disease. Herein, we report a patient with refractory MM presenting with extramedullary plasmacytoma in the superior oblique (SO) muscle. Case Presentation: A 51-year-old female presented complaining of gradual protrusion of the left eye and ocular pain from 20 days prior. She received bone marrow transplantation 1 year prior and was on a chemotherapy regimen for MM for the past 1 year. Ocular examination revealed proptosis of the left eye and mild limitations of adduction and elevation. Orbital magnetic resonance imaging demonstrated remarkable enlargement of the left SO muscle with focal contrast enhancement. The patient underwent a biopsy and mass debulking. The histopathologic exam revealed fibromuscular tissue containing a neoplasm composed of sheets of plasmacytoid cells in a varying degree of differentiation with intervening scantly vascularized stromal components. The plasmacytoid cells were diffusely positive for a cluster of differentiation 138 (CD138), leading to a diagnosis of EMD involving the EOM and soft tissue of the orbit. The patient underwent palliative radiotherapy and a systemic workup. The PET-CT scan revealed involvement of the pelvic bone and left calf. Accordingly, the chemotherapy regimen was upgraded to reflect the aggressive nature of the disease. In the last follow-up, there was no sign of tumor reactivation in the orbital soft tissues. Unfortunately, the patient succumbed to her illness 7 months following her most recent presentation. Conclusion: Early recognition of disease recurrence is lifesaving in MM patients; ophthalmic manifestations should be seriously considered as a sign of MM activity.

Safety and Efficacy of Topical Vitamin D in the Management of Dry Eye Disease Associated With Meibomian Gland Dysfunction: A Placebo-Controlled Double-Blind Randomized Controlled Trial.

PURPOSE: The aim of this study was to investigate the safety and efficacy of topical vitamin D in the management of dry eye disease associated with meibomian gland dysfunction (MGD). METHODS: In this randomized controlled trial, patients with symptomatic MGD were divided into 2 groups to receive topical vitamin D drops or placebo in their randomized eyes. The exclusion criteria consisted of patients with vitamin D deficiency, previous ocular surgery, and patients with ocular diseases affecting the tear film. Patients and researchers were masked to the study groups. The outcomes included the score of Dry Eye Questionnaire (DEQ) 5 and Ocular Surface Disease Index (OSDI), corneal and conjunctival staining score, tear breakup time (TBUT), Schirmer, and MG expressibility score evaluated at baseline and weeks 4 and 8. RESULTS: Twenty-eight eyes of 28 patients were recruited in each group. In addition to the improvement of subjective parameters in both groups, there was a statistically significantly greater improvement in the vitamin D group compared with control for average scores of OSDI (13.38 ± 7.32 vs. 27.94 ± 7.49) and DEQ5 (9.67 ± 1.86 vs. 14.14 ± 2.45) at week 8 (Ps <0.001). In addition, a significant improvement in TBUT and Schirmer test was observed in both groups in weeks 4 and 8 ( P value <0.05). There was a significant difference between the treatment and control groups after 8 weeks for OSDI, DEQ5, Schirmer, TBUT, corneal fluorescein staining, and MG expressibility score ( P value <0.05). CONCLUSIONS: The preliminary results of this randomized controlled trial suggested that use of topical vitamin D drops with a lipid vehicle could be safe and might significantly improve the symptoms and signs of dry eye associated with MGD.

En Bloc Keratolimbal Allograft and Central Penetrating Keratoplasty: A Novel Surgical Technique in Severe Limbal Stem Cell Deficiency.

PURPOSE: The purpose of this study was to present a novel surgical technique combining 360-degree keratolimbal allograft (KLAL) and simultaneous central keratoplasty termed en bloc KLAL with the central penetrating keratoplasty (PKP) performed in those cases with total limbal stem cell deficiency (LSCD) and corneal scars. METHODS: Nine eyes of 9 patients underwent en bloc KLAL and central PKP between 2014 and 2016. All patients had bilateral total LSCD with total corneal opacity due to different etiologies. The exclusion criteria were previous limbal stem cell transplantation and the presence of active and uncontrolled ocular surface inflammation. The same donor globe was used for harvesting 360-degree KLAL and central PKP. The 1-piece integrity of the KLAL and PKP graft was preserved during the described technique. All patients received modified immunosuppressive regimens compatible with the Cincinnati solid organ transplantation protocol. RESULTS: The average age of patients was 58.6 ± 18.6 years. The diagnosis was mustard gas keratopathy in 6, herpes simplex keratitis in 1, and severe acid chemical burn in 2 patients. Seven patients were male. An integrated ocular surface without epitheliopathy and a clear cornea was achieved in 8 patients (88.8%) with an average of 6.5 years in follow-up. The average best-corrected visual acuity was 1.89 ± 0.18 (20/1600) preoperatively which improved to 1.02 ± 0.64 (20/200) logMAR in the postoperative period. Endothelial immune rejection episodes were observed in 3 patients. KLAL rejection was not observed in any patient. One patient required repeat PKP due to corneal graft failure. CONCLUSIONS: En bloc 360-degree KLAL and central PKP could simultaneously be performed in patients with total LSCD and corneal opacification.

A Review of Monkeypox Ocular Manifestations and Complications: Insights for the 2022 Outbreak.

Monkeypox (MPVX) infection has been associated with multiorgan presentations. Thus, monkeypox infection's early and late complications are of particular concern, prompting health systems to decipher threatening sequels and their possible countermeasures. The current article will review the clinical signs and symptoms of the present and former outbreaks, differential diagnoses, workup and treatment of the ocular manifestations of MPXV infection in detail. One of the uncommon yet considerable MPXV complications is ocular involvement. These injuries are classified as (1) more frequent and benign lesions and (2) less common and vision-threatening sequels. Conjunctivitis, blepharitis and photophobia are the most uncomplicated reported presentations. Moreover, MPXV can manifest as eye redness, frontal headache, orbital and peri-ocular rashes, lacrimation and ocular discharge, subconjunctival nodules and, less frequently, as keratitis, corneal ulceration, opacification, perforation and blindness. The ocular manifestations have been less frequent and arguably less severe within the current outbreak. Despite the possibility of underestimation, the emerging evidence from observational investigations documented rates of around 1% for ocular involvement in the current outbreak compared to a 9-23% incidence in previous outbreaks in the endemic countries. The history of smallpox immunization is a protective factor against these complications. Despite a lack of definite and established treatment, simple therapies like regular lubrication and prophylactic use of topical antibiotics may be considered for MPXV ocular complications. Timely administration of specific antivirals may also be effective in severe cases. Monkeypox usually has mild to moderate severity and a self-limited course. However, timely recognition and proper management of the disease could reduce the risk of permanent ocular sequelae and disease morbidity.