Frosted Branch Angiitis Associated With Cytomegalovirus in a Pediatric Autologous Stem Cell Transplant Patient: Case Report and Review of the Literature.

BACKGROUND: Frosted branch angiitis (FBA) is a rare phenomenon of panuveitis which may occur secondary to cytomegalovirus (CMV) causing acute visual disturbances. CMV infection is a known complication in allogenic stem cell transplant (SCT) patients but is uncommon following autologous SCT. OBSERVATION: We describe a 17-month-old medulloblastoma patient with sudden onset visual impairment following second autologous SCT. The patient was CMV seropositive, polymerase chain reaction negative before second SCT. At the time of presentation with visual complaints, the patient was diagnosed with FBA associated with CMV reactivation. Treatment included antivirals and immunosuppressive medication with visual recovery. CONCLUSION: FBA induced by CMV should be considered as a differential diagnosis in pediatric patients undergoing autologous bone marrow transplant with rapidly progressive visual impairment.

The burden of flashes and floaters in traditional general emergency services and utilization of ophthalmology on-call consultation: a cross-sectional study.

PURPOSE: To characterize the healthcare utilization and clinical characteristics of patients presenting with flashes and/or floaters (F/F) in general emergency service (GES) settings. METHODS: All adults presenting to GESs (emergency departments (EDs) and urgent care centers (UCCs)) with symptoms of F/F in Hamilton, Ontario between Jan. 1 - Dec. 31, 2018 were reviewed. Primary outcome was the proportion of patients presenting to GESs with F/F for which ophthalmology emergency services (OESs) were consulted. Secondary outcomes included features predictive of OES consultation by logistic regression and cost of GES utilization. RESULTS: Of 6590 primary eye-related visits to GESs, 10.4% (687) involved symptoms of F/F. Mean age of patients with F/F was 57 ± 15 years, and 61% were female. Consultation rate to OESs for F/F presentations was 89% (608/687). Logistic regression identified symptoms ≤ 2 weeks (OR 8.0; 95% CI 2.3-28), ≥ 45 years age (OR 2.4; 95% CI 1.4-4.3), UCC setting (OR 2.7; 95% CI 1.6-4.6), headache (OR 0.22; 95% CI 0.12-0.41), and neurologic symptoms (OR 0.1; 95% CI 0.19-0.49) as variables predictive of OES consultation. Mean time from triage to discharge in GESs for F/F patients was 2.43 ± 2.36 h. Mean cost per visit was $139.11 ± $113.93 Canadian dollars. Patients for which OES were consulted waited a total of 1345 h in GESs and accounted for $81,879.70 in costs. CONCLUSION: Patients presenting with F/F in GESs consume considerable resources in healthcare expenditure and time spent in GESs and most receive OES consultation. Identifying these patients at triage may allow for increased efficiency for the healthcare system and patients.

Transepithelial versus Epithelium-off Corneal Collagen Cross-linking for Corneal Ectasia: A Systematic Review and Meta-analysis.

TOPIC: To evaluate the safety and efficacy of transepithelial corneal cross-linking in comparison with the established epithelium-off technique for corneal ectasia. CLINICAL RELEVANCE: Considerable debate exists regarding whether transepithelial and epithelium-off cross-linking are comparable in their safety and efficacy. METHODS: We searched 16 electronic databases, including Medline, Embase, Web of Science, and the grey literature, current to July 8, 2020, for randomized controlled trials comparing transepithelial and epithelium-off cross-linking for corneal ectasia. We excluded studies evaluating cross-linking for nonectatic indications, as well as non-randomized controlled trials. Our primary outcome was the change in maximal keratometry (Kmax) at 12 months after cross-linking, and we considered additional topographic, visual, and safety outcomes. We summarized our analyses by calculating weighted mean differences (MDs) with associated 95% confidence intervals (CIs) for continuous outcomes and relative risks (RRs) with corresponding 95% CIs for dichotomous outcomes. We conducted trial sequential analysis to determine whether the required information size was met for each outcome. The quality of individual trials was evaluated using the Cochrane Collaboration's risk of bias assessment tool, and the evidence was assessed at an outcome level using the Grading of Recommendations Assessment, Development, and Evaluation methodology. RESULTS: Twelve studies totaling 966 eyes were eligible. A significant difference was found between transepithelial and epithelium-off cross-linking groups in the change in Kmax at 12 months (MD, 0.75; 95% CI, 0.23-1.28; P = 0.004; primary outcome) and at longest follow-up (MD, 1.20; 95% CI, 0.62-1.77; P < 0.001; secondary outcome) after treatment. No significant difference was found between the 2 groups when examining uncorrected distance visual acuity (MD, 0.04; 95% CI, -0.06 to 0.14; P = 0.386) or corrected distance visual acuity (MD, 0.01; 95% CI, -0.06 to 0.09; P = 0.732). Transepithelial cross-linking was associated with significantly fewer complications than the epithelium-off approach (RR, 0.22; 95% CI, 0.06-0.79; P = 0.020), although it was associated with an increased rate of disease progression at 12 months after treatment (RR, 4.49; 95% CI, 1.24-16.25; P = 0.022). The required information size was met for our primary outcome and trial sequential analysis supported the conventional meta-analysis. The quality of evidence was rated as moderate using the Grading of Recommendations Assessment, Development, and Evaluation methodology. DISCUSSION: The efficacy of transepithelial cross-linking remains inferior to the epithelium-off approach, although it is significantly safer.

Fragility of Results in Ophthalmology Randomized Controlled Trials: A Systematic Review.

PURPOSE: Evidence-based medicine is guided by our interpretation of randomized controlled trials (RCTs) that address important clinical questions. Evaluation of the robustness of statistically significant outcomes adds a crucial element to the global assessment of trial findings. The purpose of this systematic review was to determine the robustness of ophthalmology RCTs through application of the Fragility Index (FI), a novel metric of the robustness of statistically significant outcomes. DESIGN: Systematic review. METHODS: A literature search (MEDLINE) was performed for all RCTs published in top ophthalmology journals and ophthalmology-related RCTs published in high-impact journals in the past 10 years. Two reviewers independently screened 1811 identified articles for inclusion if they (1) were a human ophthalmology-related trial, (2) had a 1:1 prospective study design, and (3) reported a statistically significant dichotomous outcome in the abstract. All relevant data, including outcome, P value, number of patients in each group, number of events in each group, number of patients lost to follow-up, and trial characteristics, were extracted. The FI of each RCT was calculated and multivariate regression applied to determine predictive factors. RESULTS: The 156 trials had a median sample size of 91.5 (range, 13-2593) patients/eyes, and a median of 28 (range, 4-2217) events. The median FI of the included trials was 2 (range, 0-48), meaning that if 2 non-events were switched to events in the treatment group, the result would lose its statistical significance. A quarter of all trials had an FI of 1 or less, and 75% of trials had an FI of 6 or less. The FI was less than the number of missing data points in 52.6% of trials. Predictive factors for FI by multivariate regression included smaller P value (P < 0.001), larger sample size (P = 0.001), larger number of events (P = 0.011), and journal impact factor (P = 0.029). CONCLUSIONS: In ophthalmology trials, statistically significant dichotomous results are often fragile, meaning that a difference of only a couple of events can change the statistical significance. An application of the FI in RCTs may aid in the interpretation of results and assessment of quality of evidence.

Unilateral Acute Idiopathic Blind Spot Enlargement following Second Dose of Covid-19 mRNA Vaccine.

Acute idiopathic blind spot enlargement (AIBSE) is a rare condition which is poorly understood. To our knowledge, this is the first report of acute idiopathic blind spot enlargement following covid-19 vaccination. We believe there is educational value for ophthalmologists to recognize the potential association of ocular inflammation and new mRNA vaccines.

Purtscher-Like Retinopathy Secondary to Medication Induced Calcium-Alkali Syndrome and Acute Pancreatitis in a Pregnant Female.

PURPOSE: To report a case of Purtscher-like retinopathy secondary to acute pancreatitis caused by medication-induced calcium-alkali syndrome in a pregnant woman. METHODS: Case report. RESULTS: A 39-year-old 23-week pregnant patient complained of visual disturbances during admission for acute pancreatitis precipitated by calcium-alkali syndrome. History revealed the acute ingestion of over 2,400 mg of elemental calcium from over the counter medication in the background of longstanding use. Visual acuity was counting fingers at 1 foot bilaterally. Posterior segment exam revealed Purtscher-flecken in the posterior pole with scattered dot hemorrhages. Optical coherence tomography (OCT) revealed inner retinal thickening and increased hyper-reflectivity. OCT angiography demonstrated loss of flow primarily in the superficial capillary plexuses. The patient was diagnosed with Purtscher-like retinopathy and observed. Two months follow up revealed resolution of the funduscopic findings and visual acuity improved minimally to 20/200 in the right eye and counting fingers in the left eye. CONCLUSION: Common over the counter medication can potentiate a calcium-alkali syndrome capable of causing a Purtscher-like retinopathy.

Nontraumatic subperiosteal orbital hemorrhage in a laboring patient with gestational immune thrombocytopenic purpura.

PURPOSE: To describe a case of nontraumatic subperiosteal orbital hemorrhage (NTSOH) in a laboring patient with gestational immune thrombocytopenic purpura. OBSERVATIONS: A 28-year-old G3P2 laboring patient was urgently evaluated by our ophthalmology unit after she developed sudden onset left eye proptosis, headache, and diplopia in the final hour of pushing. The patient's platelet count was markedly decreased at 45,000 and subsequent work-up established a diagnosis of gestational immune thrombocytopenic purpura. On examination, visual acuity was 20/25 bilaterally and there was a minus two restriction in upgaze in the left eye and a left hypotropia in primary position. Computed tomography demonstrated an elliptical, hyperdense collection at the left orbital roof consistent with NTSOH. The patient was deemed clinically stable through serial examinations and symptoms resolved with conservative management. CONCLUSIONS AND IMPORTANCE: NTSOH is a rare, potentially sight-threatening condition that requires timely ophthalmological evaluation. To our knowledge, this is the first report in the literature of NTSOH in a laboring patient with gestational immune thrombocytopenic purpura. Consideration of the possibility of NTSOH as a complication in this population may allow for appropriate diagnosis, monitoring, and treatment when indicated.

Accuracy of a Popular Online Symptom Checker for Ophthalmic Diagnoses.

Importance: Because more patients are presenting with self-guided research of symptoms, it is important to assess the capabilities and limitations of these available health information tools. Objective: To determine the accuracy of the most popular online symptom checker for ophthalmic diagnoses. Design, Setting, and Participants: In a cross-sectional study, 42 validated clinical vignettes of ophthalmic symptoms were generated and distilled to their core presenting symptoms. Cases were entered into WebMD symptom checker by both medically trained and nonmedically trained personnel blinded to the diagnosis. Output from the symptom checker, including the number of symptoms, ranking and list of diagnoses, and triage urgency were recorded. The study was conducted on October 13, 2017. Analysis was performed between October 15, 2017, and April 30, 2018. Main Outcomes and Measures: Accuracy of the top 3 diagnoses generated by the online symptom checker. Results: The mean (SD) number of symptoms entered was 3.6 (1.6) (range, 1-8). The median (SD) number of diagnoses generated by the symptom checker was 26.8 (21.8) (range, 1-99). The primary diagnosis by the symptom checker was correct in 11 of 42 (26%; 95% CI, 12%-40%) cases. The correct diagnosis was included in the online symptom checker's top 3 diagnoses in 16 of 42 (38%; 95% CI, 25%-56%) cases. The correct diagnosis was not included in the symptom checker's list in 18 of 42 (43%; 95% CI, 32%-63%) cases. Triage urgency based on the top diagnosis was appropriate in 7 of 18 (39%; 95% CI, 14%-64%) emergent cases and 21 of 24 (88%; 95% CI, 73%-100%) nonemergent cases. Interuser variability for the correct diagnosis being in the top 3 listed was at least moderate (Cohen κ = 0.74; 95% CI, 0.54-0.95). Conclusions and Relevance: The most popular online symptom checker may arrive at the correct clinical diagnosis for ophthalmic conditions, but a substantial proportion of diagnoses may not be captured. These findings suggest that further research to reflect the real-life application of internet diagnostic resources is required.

Protocol for a systematic review, meta-analysis, and trial sequential analysis of clinical outcomes following accelerated versus conventional corneal collagen cross-linking for corneal ectasia.

BACKGROUND: Collagen cross-linking (CXL) is an evolving procedure that enhances the biomechanical rigidity of the cornea and can slow or halt ectatic disease. CXL requires delivery of 5.4 J/cm2 of ultraviolet A (UVA) radiation to a cornea saturated with riboflavin in order to induce cross-link formation. The conventional CXL procedure achieves this fluence by exposing the cornea to a 3 mW/cm2 UVA lamp for 30 min; however, some surgeons have proposed accelerated protocols which achieve the same fluence in a shorter period of time by using a higher power light source. Whether accelerated protocols are as effective in arresting ectasia as the established conventional procedure remains unclear. Accordingly, this study will systematically review and synthesise the evidence on accelerated CXL and compare it to the conventional approach across an array of clinical outcomes. METHODS: We will search 16 electronic databases, including MEDLINE, Embase, and the Cochrane Library, from inception to February 1, 2019. We will include all randomised controlled trials comparing accelerated and conventional CXL for any corneal ectatic disease. Two reviewers will independently screen search results to identify eligible articles, complete data collection, and conduct quality assessment. The quality of individual trials will be assessed using the Cochrane Collaboration's Risk of Bias Assessment Tool. Our primary outcome will be the change in maximal keratometry (Kmax) at 12 months following treatment. Additional outcomes will include: incidence of disease progression, incidence of serious adverse events, as well as change in Kmax at longest follow-up, mean stromal demarcation line depth, mean uncorrected distance visual acuity, mean corrected distance visual acuity, mean Kmax, mean endothelial cell density, mean central corneal thickness, mean spherical equivalent, mean intraocular pressure, and mean corneal power, at 12 months following treatment. We will calculate relative risks and 95% confidence intervals (CIs) for dichotomous outcomes and weighted mean differences and corresponding 95% CIs for continuous outcomes. Prespecified subgroup analyses will be performed to investigate heterogeneity. We will rate the overall quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. DISCUSSION: This review will provide a comprehensive evaluation of the evidence on accelerated and conventional CXL approaches and serve to inform clinical practice, medical device design, and future research. Evaluating variations of the CXL protocol aimed at reducing treatment duration is of critical importance and a prerequisite to expanding treatment availability to more patients. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018104151.

Transepithelial versus epithelium-off corneal collagen cross-linking for corneal ectasia: protocol for a systematic review, meta-analysis and trial sequential analysis of randomised controlled trials.

INTRODUCTION: Corneal ectasias are progressive, degenerative ocular diseases defined by abnormal structural changes in the cornea, leading to distortion of vision and substantial reduction in quality of life. Corneal collagen cross-linking (CXL) increases the biomechanical rigidity of the cornea and has been shown to halt ectatic processes. The established CXL protocol requires removal of the corneal epithelium. However, some surgeons have proposed transepithelial approaches to enhance patient recovery and minimise adverse events. Whether novel transepithelial approaches are as effective in arresting ectasia as the established epithelium-off protocol remains unclear. This study will systematically review the evidence on transepithelial CXL approaches and compare it to the epithelium-off protocol. METHODS AND ANALYSIS: We will include randomised controlled trials (RCTs) comparing transepithelial and epithelium-off CXL for any corneal ectasia. We will search 16 electronic databases including MEDLINE and Embase, as well as the grey literature. Two reviewers will independently screen search results to identify eligible studies, complete data abstraction and conduct quality assessment. We will assess the quality of individual RCTs using the Cochrane risk of bias assessment tool. Our primary outcome will be the change in maximal keratometry at 12 months after treatment, and we will examine 11 additional outcomes. We will summarise our analyses by measures of association (relative risk or odds ratio) and corresponding 95% confidence intervals (CIs) for dichotomous outcomes and weighted mean differences with 95% CIs for continuous outcomes. Prespecified subgroup analyses will be conducted to explore heterogeneity. The overall quality of evidence will be rated using the Grading of Recommendations Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION: Ethics approval is not required for this systematic review as it draws from previously published data. Results of the study will be submitted to a peer-reviewed journal for publication and discussed at conferences and seminars. PROSPERO REGISTRATION NUMBER: CRD42018102069.

Avoiding big bubble complications: outcomes of layer-by-layer deep anterior lamellar keratoplasty in children.

BACKGROUND/AIMS: To describe the visual and clinical outcomes of manual layer-by-layer deep anterior lamellar keratoplasty (DALK) in a paediatric population. METHODS: The charts of all children who underwent DALK surgery between January 2007 and January 2015 were reviewed retrospectively. Data collected included preoperative and postoperative spectacle-corrected distance visual acuity (CDVA), intraoperative and postoperative complications including graft rejection and failure. Residual posterior lamellar thickness (RPLT) and endothelial cell density (ECD) were measured in eyes with follow-up longer than 6 months. RESULTS: Fifty-one eyes of 42 patients were included in the study. The mean patient age at surgery was 11.2±5.2 years and the mean follow-up time was 36.5±23.7 months. The most common indications for surgery were mucopolysaccharidosis (29.4%) and keratoconus (23.5%). Nine eyes (17.6%) had intraoperative microperforation, none of which were converted to penetrating keratoplasty (PKP). Only one eye (2.0%) was converted to PKP. Five eyes (9.8%) had a stromal rejection episode of which one eye failed. Another four eyes (7.8%) experienced graft failure among which three eyes (75%) had infectious keratitis. Three of the five failed grafts had a successful repeat DALK. The average RPLT was 81.9±36.5µm. ECD was significantly lower in the operated eye compared with the normal eye (3096±333 cells/mm2 vs 3376±342 cells/mm2, n=11, P=0.003). The mean postoperative CDVA was 0.5±0.4 logarithm of the minimum angle of resolution (logMAR) reflecting a gain of 0.3 logMAR (P<0.001). CONCLUSION: Manual dissection DALK is a safe procedure in children with stromal opacities. Despite successful structural rehabilitation, functional recovery is still suboptimal mostly due to amblyopia.

Self-perceived Impact of Glaucomatous Visual Field Loss and Visual Disabilities on Driving Difficulty and Cessation.

PURPOSE: To investigate if glaucoma severity and the presence of self-reported glare and difficulty with dark adaptation are associated with driving difficulty or cessation. PATIENTS AND METHODS: Individuals with glaucoma, age 50+ and visual acuity in the better eye ≥20/50 were included. Glaucoma severity was defined by the visual field mean deviation (MD) in the better eye and was classified into 2 groups: mild (MD>-6 dB) and moderate/severe (MD≤-6 dB). Patient responses to the glare and dark adaptation subscales in Glaucoma Quality of Life-15 questionnaire were used to measure relevant visual disability. Associations were assessed utilizing prevalence ratios (PR). RESULTS: A total of 99 participants (57% female) were included with 19% (19/99) reporting driving cessation. Patients with moderate/severe glaucoma when compared with mild glaucoma reported a significantly higher percentage of driving cessation (33% vs. 8%; P=0.002), presence of glare (27% vs. 6%; P=0.012), and difficulty with dark adaptation (31% vs. 10%; P=0.011).Individuals with self-perceived difficulty with dark adaptation were about 4 times more likely than those without to have difficulty driving at night (adjusted PR=3.94; P<0.0001) or in poor driving conditions (adjusted PR=4.09; P=0.0002). Self-reported glare was associated with an increased risk of driving difficulty in poor driving conditions (PR=4.17; P=0.05). CONCLUSIONS: Patients with moderate/severe glaucomatous visual field loss reported significantly higher percentage of driving cessation, presence of glare and difficulty with dark adaptation. Difficulty with dark adaptation was significantly associated with difficulty driving at night or in poor driving conditions. Further studies are needed to confirm these findings.

Bilateral Multifocal Scleral Nodules.

This case report describes a 15-year-old boy with bilateral multifocal scleral nodules.

Corneal Endothelial Cell Density in Children: Normative Data From Birth to 5 Years Old.

PURPOSE: To establish a normative database of endothelial cell density (ECD) using in vivo specular microscopy in children under 5 years old. DESIGN: Cross-sectional study. METHODS: Specular microscopy was performed during a clinic visit in cooperative children in the standard upright position. In uncooperative children, specular microscopy was performed in the lateral decubitus position under general anesthesia, before surgery for other reasons. Corneal diameter (CD) was measured in children undergoing general anesthesia and was stratified according to age. RESULTS: One hundred and eighteen eyes of 118 patients were included in the study. The mean patient age was 2.6 ± 1.4 years (range 0.1-5 years) and the mean ECD was 3746 ± 370 cells/mm2 (range 3145-5013 cells/mm2). The mean CD under 2 years of age was 11.85 ± 0.57 mm (n = 40, range 10.50-12.75 mm). Up to 2 years of age, ECD was more inversely correlated with CD than with age (r = -0.61, P < .0001; r = -0.38, P = .01, respectively). In contrast, after the age of 2 years, the ECD was inversely correlated with age but not with CD (r = -0.27, P = .02; r = -0.24, P = .2). Between the first and second year of life, the rate of ECD decrease was significantly higher than between 2 and 5 years of age (8.2%, 334 cells/mm2 vs 2.7%, 100 cells/mm2 a year, respectively). CONCLUSION: In the first 2 years of life there is a rapid decline in ECD, which is likely related to growth in CD and hence surface area. After the cornea reaches adult size, the ECD decreases at a rate similar to that reported in adults.

Glaucoma Severity and Participation in Diverse Social Roles: Does Visual Field Loss Matter?

PURPOSE: To assess the association between glaucoma severity and participation in diverse social roles. DESIGN: Cross-sectional survey. PATIENTS AND METHODS: Individuals with glaucoma, 50+, with visual acuity in the better eye >20/50 were enrolled. They were classified into 3 groups based on visual field loss in the better eye: mild [mean deviation (MD)>-6 dB], moderate (MD, -6 to -12 dB), and severe (MD<-12 dB). The validated Social Role Participation Questionnaire assessed respondents' perceptions of the importance, difficulty, and satisfaction with participation in 11 social role domains (eg, community events, travel). Differences between groups were examined using multivariate linear regression analyses. RESULTS: A total of 118 participants (52% female) were included: 60 mild, 29 moderate, and 29 severe. All social role domains were rated as important by all participants except for education and employment. Women (P<0.01), those with a partner (P<0.01), and those who were less depressed (P=0.03) reported higher scores of perceived importance of participating in social activities. Compared with those with mild glaucoma, individuals with severe glaucoma reported significantly more difficulty participating in community/religious/cultural events (P<0.01), travelling (P<0.01), and relationships with family members (P=0.01). They also reported less satisfaction with travelling (P=0.01) and social events (P=0.04). CONCLUSIONS: Participation in diverse social roles is valued by individuals with glaucoma. Severe visual field loss impedes involvement in and satisfaction with activities in community/religious/cultural events, travelling, and relationships with family members. Appropriate community and targeted interventions are needed to allow people with severe glaucoma to maintain active social participation-a key component to successful aging.

Limbal Stem Cell Transplantation for Soft Contact Lens Wear-Related Limbal Stem Cell Deficiency.

PURPOSE: To describe the outcomes of limbal stem cell transplantation in eyes with limbal stem cell deficiency related to soft contact lens wear. DESIGN: Retrospective interventional case series. METHODS: Institutional database search at the Cincinnati Eye Institute revealed 9 patients (14 eyes) who underwent limbal stem cell transplantation with systemic immunosuppression for soft contact lens wear-related limbal stem cell deficiency. Outcome measures included patient demographics, symptoms, best-corrected visual acuity, ocular surface stability, adverse events, and additional surgeries required. RESULTS: Average patient age at time of surgery was 46.6 ± 11.1 years (range 20-60 years). Average duration of follow-up was 28 ± 19.1 months (range 12-70 months). Preoperative best-corrected visual acuity (BCVA) was 20/40 or worse in all eyes (average 20/70, range 20/40-20/250) and patient symptoms included foreign body sensation, tearing, redness, and/or pain. Four eyes (29%) underwent living-related conjunctival limbal allograft and 10 eyes (71%) underwent cadaver-donor keratolimbal allograft surgery. Topical and systemic immunosuppression was used in all patients. At final follow-up after limbal stem cell transplantation, there was a stable ocular surface in 12 of 14 eyes (86%) and improvement in BCVA to 20/30 or better and complete resolution of patient symptoms in all except 1 patient who had significant rosacea blepharokeratoconjunctivitis, whose BCVA remained at 20/150 and 20/60, in right and left eyes, respectively. The most common adverse event was an increase in intraocular pressure in 8 of 14 eyes (57%), requiring topical antiglaucoma treatment. Ten of 14 eyes (71%) underwent cataract extraction related to topical steroid use. No eyes required subsequent penetrating keratoplasty. CONCLUSION: Limbal stem cell transplantation is a viable option for the management of soft contact lens wear-related limbal stem cell deficiency in young healthy patients. Early intervention prior to subepithelial fibrosis can lead to good visual outcomes with no need for subsequent cornea transplant. Co-management with a solid organ transplant specialist is helpful for the monitoring and management of systemic adverse events related to patient systemic immunosuppression.

Corneal Fine Needle Diathermy With Adjuvant Bevacizumab to Treat Corneal Neovascularization in Children.

PURPOSE: To report the outcomes of corneal fine needle diathermy (FND) with adjuvant intrastromal and subconjunctival bevacizumab injection for corneal neovascularization (CN) in children. METHODS: Medical records of all children who had undergone FND with adjuvant bevacizumab injection were reviewed retrospectively. Treatment efficacy was evaluated by changes in visual acuity, regression of CN, and clearing of lipid deposits with the aid of slit-lamp color images that were taken before surgical intervention and at last follow-up visit. Postoperative complications were recorded and served to assess the safety of the procedure. RESULTS: Nine eyes of 9 patients were included in the study. The mean age of the patients was 8.4 ± 4.2 years (4-15 years) and the mean follow-up time was 18.7 ± 12.2 months (5-35 months). Three eyes had a history of herpes simplex keratitis (HSK), 3 eyes had complete corneal anesthesia, 2 eyes had CN following suture tract infection after corneal transplant for HSK scar and limbal dermoid excision, and 1 eye had blepharokeratoconjunctivitis. After treatment, 8 eyes had complete CN resolution, and 1 eye with corneal anesthesia following brain tumor resection had partial regression in vessel distribution and size. Lipid deposition clearance lagged behind CN resolution. Mean duration of CN before treatment was 15.3 ± 14.0 months (1-37 months). Mean corrected distance visual acuity before and after surgery was 0.66 ± 0.31 and 0.50 ± 0.37 logMAR, respectively (P = 0.02). CONCLUSIONS: Corneal FND with adjuvant bevacizumab injection is effective at treating sectorial corneal vessels in children.

Transplantation of neural stem cells clonally derived from embryonic stem cells promotes recovery after murine spinal cord injury.

The pathology of spinal cord injury (SCI) makes it appropriate for cell-based therapies. Treatments using neural stem cells (NSCs) in animal models of SCI have shown positive outcomes, although uncertainty remains regarding the optimal cell source. Pluripotent cell sources such as embryonic stem cells (ESCs) provide a limitless supply of therapeutic cells. NSCs derived using embryoid bodies (EB) from ESCs have shown tumorigenic potential. Clonal neurosphere generation is an alternative method to generate safer and more clinically relevant NSCs without the use of an EB stage for use in cell-based therapies. We generated clonally derived definitive NSCs (dNSCs) from ESC. These cells were transplanted into a mouse thoracic SCI model. Embryonic stem cell-derived definitive neural stem cell (ES-dNSC)-transplanted mice were compared with controls using behavioral measures and histopathological analysis of tissue. In addition, the role of remyelination in injury recovery was investigated using transmission electron microscopy. The SCI group that received ES-dNSC transplantation showed significant improvements in locomotor function compared with controls in open field and gait analysis. The cell treatment group had a significant enhancement of spared neural tissue. Immunohistological assessments showed that dNSCs differentiated primarily to oligodendrocytes. These cells were shown to express myelin basic protein, associate with axons, and support nodal architecture as well as display proper compact, multilayer myelination in electron microscopic analysis. This study provides strong evidence that dNSCs clonally derived from pluripotent cells using the default pathway of neuralization improve motor function after SCI and enhance sparing of neural tissue, while remaining safe and clinically relevant.