Corneal Allograft Endothelial Rejection after Sinopharm COVID-19 Vaccination; Report of Six Cases.

AIM: To report the clinical characteristics of six patients with corneal allograft endothelial rejection after COVID-19 vaccination with Sinopharm and to review the literature. METHODS: This is a prospective case series describing corneal allograft rejection among subjects having received Sinopharm (BBIBP-CorV) vaccine, coming to cornea clinic at a university-based hospital (Rassoul Akram Hospital, Tehran, Iran) from September 2021 to March 2022 for regular follow-up examinations. Data on demographics, vaccination (based on vaccine card), and graft condition (based on recent examination and previous medical documents) were recorded. RESULTS: Out of 54 eyes (46 patients), 6 eyes (6 patients) had corneal allograft endothelial rejection after 3 to 117 days, post-vaccination. Three out of six rejections occurred within two weeks following vaccination. All of them were male with the mean age of 53.00 ± 19.66 years. The graft type of all patients was penetrating keratoplasty (PKP). The adverse event developed on average at 40.67 ± 34.33 months after surgery. Four patients were under maintenance treatment by topical steroid at the time of vaccination. One also received systemic immunomodulatory medication. Four grafts ended up with partial or complete graft failure. One case had received two doses of vaccine before undergoing the second corneal graft transplantation. CONCLUSION: COVID-19 vaccination with Sinopharm may trigger corneal allograft endothelial rejection even in individuals with low-risk graft and under maintenance topical and/or systemic immunomodulatory medications.

Supracor Multifocal Corneal Laser-Assisted In Situ Keratomileusis Procedure for the Correction of Presbyopia in Hyperopic Eyes.

Purpose: To investigate the outcomes of unilateral Supracor treatment to enhance near vision while maintaining good distance vision in hyperopic eyes. Methods: This prospective interventional study includes consecutive hyperopic patients with presbyopia. All eyes underwent femtosecond laser-assisted in situ keratomileusis treatment for hyperopia with an additional Supracor multifocal treatment algorithm in nondominant eyes. Monocular and binocular uncorrected and spectacle-corrected distance visual acuity (UCDVA and SCDVA), monocular and binocular uncorrected near visual acuity (UNVA), and distance-corrected near visual acuity at 40 cm and high-order aberration changes and complications were evaluated for 6 months. Results: Sixty-four patients with a mean age of 51.91 ± 3.64 were enrolled. After 6-month follow-up, the mean binocular UCDVA and UNVA were 0.03 ± 0.05 and 0.04 ± 0.06 logMAR, respectively. UCDVA (logMAR) of nondominant and dominant eyes was 0.30 ± 0.18 and 0.03 ± 0.05, respectively. Preoperative and postoperative mean ± standard deviation manifest refraction spherical equivalent was +1.84 ± 0.75 and -0.48 ± 0.57, respectively, in nondominant eyes and +1.77 ± 0.69 and +0.12 ± 0.33, respectively, in dominant eyes. No complications were observed. Conclusion: Supracor procedure in nondominant eyes may improve functional near, intermediate, and distance vision without significant photic phenomena in presbyopic patients with low and moderate hyperopia.

Comparing Pentacam HR Screening Indices in Different Normal Corneal Thicknesses among Refractive Surgery Candidates.

Purpose: To compare Pentacam indices in normal eyes with different corneal thicknesses. Methods: It is a retrospective observational study. Ninety-six normal eyes of 96 patients who were referred for refractive surgery in a tertiary university-based hospital from October 2015 to April 2019 were recruited consecutively. Corneal keratometry as well as Pentacam's software Belin-Ambrósio Enhanced Ectasia Display (BAD) parameters including pachymetry progression indices (PPIs), maximum Ambrosio's relational thickness (ART-max), corneal elevations, normalized deviations, BAD total deviation value (BAD-D), and anterior surface indices were measured by Pentacam HR (Type 70900). The included were classified as thin (26 eyes), average (45 eyes), and thick (25 eyes) corneas with the thinnest point thickness of ≤496 µm, 497-595 µm, and ≥596 µm, respectively. The specificities of all parameters were calculated based on routine cut-off values. Results: The refraction, keratometry, and elevations were not different (P > 0.05). All PPIs (minimum, average, and maximum) of thick corneas were significantly lower than average and thin corneas (P < 0.001). ART-max increased by thickening of the cornea (P < 0.001). BAD-D score and normalized indices of pachymetric parameters decreased with the increase of thickness (P < 0.001), while specificities of all indices increased with corneal thickening. More than 96% of thick corneas were classified as normal PPI-max (24/25), ART-max (25/25), and BAD-D (25/25), while nearly <54% of thin corneas (14/26 for PPI-max, 9/26 for ART-max, and 12/26 for BAD-D) were normal. Conclusions: The pachymetry-related indices and BAD-D were different among normal corneas with various thicknesses. The specificities of PPIs, ART-max, and BAD-D of thin corneas were lower than in thick corneas.

Ocular Biometric Values and Prevalence of Corneal Astigmatism in Patients Candidate for Cataract Surgery.

Purpose: To analyze the biometric values and the prevalence of corneal astigmatism in cataract surgery candidates. Methods: This is a prospective study. Ocular biometric values and corneal keratometric astigmatism were measured by optical low-coherence reflectometry (Lenstar LS 900) before surgery in patients who were candidates for cataract extraction surgery. Descriptive measurements of biometric dimensions and keratometric cylinder data and their correlations with sex and age were evaluated. Results: Ocular biometric and keratometric values from 2084 eyes of 2084 patients (mean age 66.43, range 19-95 years) were analyzed. The mean values were as follows: corneal astigmatism 0.89 diopter (D), mean corneal keratometry 44.29 D, central corneal thickness 534 µ, internal anterior chamber depth (ACD) 3.11 mm, lens thickness 4.50 mm, and axial length 23.35 mm. Corneal astigmatism was <1.25 D in 1660 (79.5%) of eyes. Astigmatism was with-the-rule in 976 (46.8%) of eyes, against-the-rule (ATR) in 702 (33.7%), and oblique in 406 (19.5%). Analysis of corneal astigmatism revealed a change toward "ATR" with age which was not statistically significant. The ACD was correlated with age. The amount of corneal astigmatism had no correlation with age and sex. Conclusion: Corneal astigmatism was higher than 1.25 D in about 21% of cataract surgery candidates with slight differences between the various age ranges and had no correlation with age and sex.

Femtosecond Laser-assisted Allogenic Additive Stromal Keratoplasty With or Without Excimer Laser Donor Keratomileusis for Management of Keratoconus.

We describe a modified allogenic intrastromal lenticule implantation technique for management of keratoconus (KCN). Patients with advanced KCN already scheduled for corneal transplantation were enrolled. An allogenic corneal lenticule was implanted inside a stromal pocket created by femtosecond laser. In three cases, the estimated refractive error of the recipient eyes was corrected on the donor lenticules using an Excimer laser. All operated eyes underwent corneal crosslinking at the time of surgery. This method was named "Femtosecond Laser-assisted Allogenic Stromal Keratoplasty Without and With Excimer Laser-assisted Donor Keratomileusis"; briefly called FASK and FASK Plus EDK, respectively. Two out of five patients were satisfied with the results. There was a decrease in the average simulated keratometric values as well as myopia when FASK Plus EDK was performed. Increased corneal thickness was achieved in all cases. Graft edema gradually decreased over weeks but interface wrinkling and lenticule folds in the visual axis remained as a problem during follow-up period. No other complications were encountered.

Femtosecond laser-assisted peripheral additive stromal keratoplasty for treatment of primary corneal ectasia: Preliminary outcomes.

PURPOSE: To report the preliminary results of a new surgical modality for the treatment of primary corneal ectasia, which consists of implanting allogeneic corneal tissue into the peripheral corneal stroma using a femtosecond laser system or femtosecond laser-assisted peripheral allogeneic stromal additive keratoplasty or FA-PASAK. METHODS: This prospective, noncomparative case series includes patients with primary corneal ectasia including keratoconus and pellucid marginal degeneration. In the operating room, one or two ring or crescent-shaped allogeneic corneal segments were prepared using a handmade double-bladed punch, which were then implanted by a specially designed device, into stromal channels in the peripheral recipient cornea fashioned with a femtosecond-laser system. RESULTS: A total of 15 eyes of 13 patients with mean age of 31.73 years were operated. There were significant improvements in uncorrected (0.68 to 0.3 logMAR) and corrected (0.44 to 0.16 logMAR) visual acuity, mean sphere, mean spherical equivalent refractive error, and mean keratometry (steep, flat, and average). Topographic and refractive astigmatism did not change significantly. Complications included a single case of bacterial keratitis secondary to epithelial defect, which was controlled with topical antibiotics eventually leading to an uncorrected vision of 20/25 one year after surgery. CONCLUSION: The use of allogeneic corneal ring or crescent shape segments may be a safe and cost-effective treatment for primary corneal ectasia, whereas a nomogram is necessary to be devised for general use of the technique.

Topical 0.03% tacrolimus versus systemic mycophenolate mofetil as adjuncts to systemic corticosteroids for preventing graft rejection after repeat keratoplasty: one-year results of a randomized clinical trial.

PURPOSE: To compare the efficacy of topical 0.03% tacrolimus in combination with systemic corticosteroids versus systemic mycophenolate mofetil (MMF) and corticosteroids in preventing corneal allograft rejection after repeat keratoplasty. METHODS: This prospective, randomized clinical trial enrolled 63 consecutive eyes of 63 patients who underwent repeat keratoplasty after a failed penetrating keratoplasty. Group 1 (32 eyes) received MMF orally 1 g twice daily for the first 6 months and then 1 g daily for the next 6 months, and group 2 (31 eyes) received topical 0.03% tacrolimus four times a day for 12 months. All patients were treated with topical and oral corticosteroids postoperatively. The participants were observed closely for signs of graft rejection, and the rates of rejection-free graft survival were calculated and compared between the two groups at postoperative month 12. RESULTS: The groups were balanced in patient's age and risk factors for graft rejection (e.g., original diagnosis, number of previous grafts, and quadrants of corneal vascularization). Endothelial graft rejection occurred in 5 eyes (15.6%) of group 1 and 6 eyes (19.4%) of group 2 (P = 0.75). Irreversible endothelial graft rejection resulting in graft failure occurred in 3 eyes of each group (P = 0.99). The rate of rejection-free graft survival was 84.4% in group 1 and 80.6% in group 2 at postoperative month 12 (P = 0.74). CONCLUSION: Topical 0.03% tacrolimus was as effective as systemic MMF as adjuncts to topical and systemic corticosteroids in reducing endothelial graft rejection with 12 months follow up after repeat keratoplasty.

Recurrent Pterygium: A Review.

PURPOSE: To summarize the recent evidence regarding different aspects of pterygium recurrence. METHODS: Human-based studies from PubMed, Scopus, and Google Scholar were identified using the following keywords: conjunctival disease, pterygium, recurrent pterygium, pterygium recurrence, pterygium management/surgery, conjunctival autograft (CAU), amniotic membrane graft/transplant, and adjuvant therapy (January 2009 to February 2021). We reviewed risk factors associated with the recurrence of pterygium, timing of recurrence, medical treatments to prevent from recurrence, and nonsurgical and surgical alternatives for management of recurrence. RESULTS: Dry eye disease, black race, and young age are considered definite risk factors for recurrence. However, fleshy appearance of the pterygium and preoperative size remain controversial. Surgical techniques such as excessive suturing, insufficient conjunctival graft size, thick conjunctival graft with remained Tenon tissue, and postoperative graft retraction are considered possible risk factors for recurrence. Using fibrin glue instead of sutures can further reduce recurrence rates. Although recurrence could occur even after many years, most recurrences happen in the first 3-6 months after surgery. Multiple kinds of adjuvant medications are used before, during, or after the operation including mitomycin C (MMC), 5-fluorouracil (5-FU), corticosteroids, and anti-vascular endothelial growth factors (anti-VEGFs). Multiple weekly subconjunctival 5-FU injections are shown to be safe and effective in halting the progression of recurrent pterygium. Although topical bevacizumab is found to inhibit the growth of impending recurrent pterygium, the effect is mostly temporary. CAU is superior to amniotic membrane transplantation in the treatment for recurrent pterygia. CONCLUSIONS: There is yet to be a panacea in treating recurrent pterygium. Currently, there is not a globally accepted recommendation for treating recurrent pterygium with anti-VEGFs or 5-FU as a nonsurgical treatment. We strongly recommend using MMC as an adjunct to surgery in recurrent cases, with consideration of its specific complications. CAU is the most effective surgical treatment for recurrent pterygium, and other new surgical therapies need further investigation.

Change in Lower Eyelid Position After Ptosis Repair in Patients With Unilateral Myogenic Versus Aponeurotic Blepharoptosis.

PURPOSE: To compare preoperative and postoperative lower eyelid scleral show in patients with unilateral myogenic (MP) and aponeurotic (AP) ptosis, analyze the factors correlated with them, and assess the rate of postoperative lower eyelid symmetry in both groups. METHODS: Patients (older than 5 years old) with unilateral MP (58) and AP (20) were included from June 2015 to April 2017. Excluded were patients with previous eyelid surgery, strabismus, levator function of ≤3, and associated procedures. Margin reflex distance (MRD) 1 and 2 and levator function were measured by the same observer before and at least 6 months after the ptosis repair. RESULTS: Lower scleral show was observed in 56.8% and 80% of MP and AP, respectively. Margin reflex distance 2 was significantly (r = -0.37, p = 0.002) associated with MRD1 in the MP group (multiple regression analysis). Both groups showed a significant improvement of MRD2, postoperatively resulting in symmetric MRD2 in 91.4% of MP and 80% of AP group. It was not changed in 43% of MP and 25% of AP group. Multiple regression analysis showed that preoperative MRD2 was the only significant factor associated with postoperative improvement of scleral show in the MP group. CONCLUSIONS: Lower scleral show was significantly improved after ptosis repair in both MP and AP. The more severe MP was significantly associated with more severe preoperative scleral show. Preoperative MRD2 was the only factor predicting postoperative improvement of scleral show in the MP. No factor was significantly associated with MRD2 in the AP group.

Outcomes and factors affecting them in patients with rhino-orbito-cerebral mucormycosis.

AIM: To report the frequency and factors affecting patients', globe and vision survivals in rhino-orbito-cerebral mucormycosis (ROCM). METHODS: This is a retrospective study of 63 patients (79 eyes) with biopsy-proven ROCM at a university hospital 2008-2016. Systemic and ophthalmic manifestations, imaging, management and final outcomes were recorded. Globe survival was defined as no exenteration and vision survival as final visual acuity of light perception and more. RESULTS: Mean age was 55.5 (SD 12.9) years with no gender preference. Diabetes was the most common underlying disease (68.3%). Patient survival was observed in 57.1 % (36/63). Presence of frozen eye (OR 4.6), nasal mucosal involvement (OR 7.3) and shorter duration of antifungal therapy (OR 1.03) were significantly associated with lower patient survival. Exenteration did not significantly change the survival. Globe survival was detected in 43% (34/79). Higher white blood cell (WBC) count was associated with a lower globe survival (p=0.02). Vision survival was observed in 25.3% (20/79) in whom younger age was significantly associated with a worse vision survival. CONCLUSION: Patient, globe and vision survivals were 57%, 43% and 25%, respectively. Exenteration did not affect the patients' survival. While frozen eye and nasal mucosal involvement were significantly associated with a lower survival, higher WBC count significantly increased the risk of exenteration.

Eyelash Ptosis in Unilateral Myogenic and Aponeurotic Blepharoptosis: A Prospective, Controlled, Before- and After-Study.

PURPOSES: The purposes of this study were to compare lash ptosis (LP) with contralateral eyelid in patients with unilateral myogenic (MP) and aponeurotic (AP) ptosis before and after the ptosis repair and to assess the correlation between postoperative eyelid height and LP symmetry. METHODS: Patients older than 5 years were included from June 2015 to April 2017. Eyelid examination, LP grading (0-3), and photography were performed before and at least 6 months after ptosis repair. Success of ptosis repair (levator resection) was defined as margin reflex distance 1 within 0.5 mm of the contralateral eyelid; LP improvement, as at least 1 grade improvement at the last follow-up; and LP symmetry, as 2 eyelids being within 1 grade. RESULTS: There were 58 patients with MP and 20 with AP, with mean age of 19.2 and 49.5 years and median follow-up of 10 months. Lash ptosis was observed in 89.5% of ptotic and 33.3% of control eyelids. Mean LP grade was significantly higher in the MP (1.5) than in the AP (1.1), which significantly improved to 0.6 and 0.4, respectively. However, it persisted in 50.9% of MP and 31.2% of AP postoperatively. Lash ptosis symmetry was observed in 97.4% of patients, which was not correlated with margin reflex distance 1 symmetry. Lower levator function was the only significant factor correlated with LP. CONCLUSION: Lash ptosis was significantly worse in MP than in AP. Lower LF was correlated with more severe LP. Ptosis repair resulted in significant improvement of LP and its symmetry with the contralateral eyelid. Lash ptosis symmetry did not correlate with eyelid height symmetry postoperatively.

Corrigendum to "Periorbital facial rejuvenation; applied anatomy and pre-operative assessment" [J. Curr. Ophthalmol. 29 (3), (September 2017) 154-168].

[This corrects the article DOI: 10.1016/j.joco.2017.04.001.].

Periorbital facial rejuvenation; applied anatomy and pre-operative assessment.

PURPOSE: Since different subspecialties are currently performing a variety of upper facial rejuvenation procedures, and the level of knowledge on the ocular and periocular anatomy and physiology is different, this review aims to highlight the most important preoperative examinations and tests with special attention to the eye and periocular adnexal structures for general ophthalmologist and specialties other than oculo-facial surgeons in order to inform them about the fine and important points that should be considered before surgery to have both cosmetic and functional improvement. METHODS: English literature review was performed using PubMed with the different keywords of "periorbital rejuvenation", "blepharoptosis", "eyebrow ptosis", "blepharoplasty", "eyelid examination", "facial assessment", and "lifting". Initial screening was performed by the senior author to include the most pertinent articles. The full text of the selected articles was reviewed, and some articles were added based upon the references of the initial articles. Included articles were then reviewed with special attention to the preoperative assessment of the periorbital facial rejuvenation procedures. RESULTS: There were 254 articles in the initial screening from which 84 articles were found to be mostly related to the topic of this review. The number finally increased to 112 articles after adding the pertinent references of the initial articles. CONCLUSION: Static and dynamic aging changes of the periorbital area should be assessed as an eyelid-eyebrow unit paying more attention to the anthropometric landmarks. Assessing the facial asymmetry, performing comprehensive and detailed ocular examination, and asking about patients' expectation are three key elements in this regard. Furthermore, taking standard facial pictures, obtaining special consent form, and finally getting feedback are also indispensable tools toward a better outcome.