Validity and reliability of the Thai version of the ASCRS SPEED II preoperative OSD questionnaire in Thai cataract surgery candidates.

OBJECTIVES: To develop a Thai version of the American Society of Cataract and Refractive Surgery (ASCRS)-modified Standard Patient Evaluation of Eye Dryness (SPEED) II© preoperative ocular surface disease (OSD) questionnaire (ASCRS SPEED II-Thai) and evaluate its validity and reliability in Thai cataract surgery candidates. METHODS: The original English version of the questionnaire was translated and adapted cross-culturally to Thai language. The ASCRS SPEED II-Thai was evaluated for content validity, internal consistency, and test-retest reliability. Five experts in the ocular surface field critically reviewed the ASCRS SPEED II-Thai to measure the content validity indexes (CVI). A total of 105 cataract surgery candidates were recruited from an ophthalmology clinic to complete the questionnaire. Cronbach's alpha and intraclass correlation coefficient (ICC) were calculated to assess internal consistency and test-retest reliability, respectively. RESULTS: During the translation and cross-cultural adaptation processes, only two minor modifications were made to the original version for clarification without changing their meaning. All items in the ASCRS SPEED II-Thai had an item-level CVI of 1.00, representing complete agreement among content experts. The scale-level CVI was 1.00, indicating excellent content validity of the questionnaire. The participants found no difficulty in understanding each question in the pilot test. Cronbach's alpha for the ASCRS SPEED II-Thai was 0.82, indicating good internal consistency. The test-retest reliability was good to excellent, with ICC values ranging from 0.83 to 1.00 (P < 0.001). CONCLUSIONS: The ASCRS SPEED II-Thai is a valid clinical tool with adequate reliability for preoperative OSD screening among Thai cataract surgery candidates.

12-Month Outcomes of Small Incision Lenticule Extraction With Proper Head Positioning but No Reference Marking for the Correction of Astigmatism.

PURPOSE: To investigate the 12-month outcomes of small incision lenticule extraction (SMILE) with proper head positioning but no reference marking for correcting astigmatism. METHODS: This was a retrospective cohort study of 3,541 patients (5,953 eyes) who underwent SMILE between July 2010 and April 2021. Patient positioning on the treatment bed was meticulously done in every patient to avoid face turn, head tilt, and chin-up or chin-down posture. The corrected distance visual acuity (CDVA), uncorrected distance visual acuity (UDVA), manifest refraction, astigmatic outcomes, and adverse events were evaluated at 1, 3, and 12 months postoperatively. RESULTS: The mean preoperative manifest spherical equivalent and manifest cylinder were -5.15 ± 2.24 diopters (D) (range: -0.13 to -12.88 D) and -1.00 ± 0.77 D (range: -0.25 and -6.00 D), respectively. Of all eyes, 88.4% and 98.6% had the spherical equivalent within ±0.50 and ±1.00 D of emmetropia at 12 months. The percentage of eyes with UDVA of 20/20 or better was 92.5%. Six eyes (0.1%) lost two or more lines of CDVA at the 12-month visit. The predictability of cylinder correction was excellent, with 88.1% within ±0.50 D and 98.9% within ± 1.00 D of astigmatism correction at 12 months. The mean correction index (CI) at 12 months was 1.09 ± 0.45 (range: 0.17 to 4.99), indicating a slight astigmatism overcorrection. The high cylinder group tended to have undercorrection with greater residual astigmatism, whereas the low cylinder group was likely to have overcorrection with lesser residual astigmatism (P < .001). No serious adverse events were observed. CONCLUSIONS: SMILE with proper head positioning but no reference marking produces safe, efficient, predictable, and stable outcomes for astigmatism correction over a 12-month period. [J Refract Surg. 2023;39(10):683-692.].

Epstein-Barr Virus Keratouveitis-Induced Malignant Glaucoma After Penetrating Keratoplasty: A Case Report and Literature Review.

PURPOSE: To report a case of Epstein-Barr virus (EBV) keratouveitis-induced malignant glaucoma after repeat penetrating keratoplasty (PK). METHODS: Retrospective review of the patient's medical records and review of literature on EBV corneal endotheliitis and/or anterior uveitis. RESULTS: A 78-year-old Thai female patient presented with a markedly edematous corneal graft, dense pigmented keratic precipitates, fibrinous anterior chamber reaction, uniformly flat anterior chamber, and ocular hypertension of 55 mmHg in the left eye on the first day after the third PK. An aqueous tap for polymerase chain reaction analysis was positive for EBV DNA but negative for other herpesviruses. The patient was diagnosed with EBV endotheliitis and anterior uveitis-induced malignant glaucoma; and successfully treated with oral valacyclovir and topical 2% ganciclovir eye drops. CONCLUSIONS: EBV endotheliitis and anterior uveitis can induce malignant glaucoma following PK. A high index of suspicion is required when a patient has a history of unexplained multiple graft rejections.

TFOS lifestyle: Impact of societal challenges on the ocular surface.

Societal factors associated with ocular surface diseases were mapped using a framework to characterize the relationship between the individual, their health and environment. The impact of the COVID-19 pandemic and mitigating factors on ocular surface diseases were considered in a systematic review. Age and sex effects were generally well-characterized for inflammatory, infectious, autoimmune and trauma-related conditions. Sex and gender, through biological, socio-economic, and cultural factors impact the prevalence and severity of disease, access to, and use of, care. Genetic factors, race, smoking and co-morbidities are generally well characterized, with interdependencies with geographical, employment and socioeconomic factors. Living and working conditions include employment, education, water and sanitation, poverty and socioeconomic class. Employment type and hobbies are associated with eye trauma and burns. Regional, global socio-economic, cultural and environmental conditions, include remoteness, geography, seasonality, availability of and access to services. Violence associated with war, acid attacks and domestic violence are associated with traumatic injuries. The impacts of conflict, pandemic and climate are exacerbated by decreased food security, access to health services and workers. Digital technology can impact diseases through physical and mental health effects and access to health information and services. The COVID-19 pandemic and related mitigating strategies are mostly associated with an increased risk of developing new or worsening existing ocular surface diseases. Societal factors impact the type and severity of ocular surface diseases, although there is considerable interdependence between factors. The overlay of the digital environment, natural disasters, conflict and the pandemic have modified access to services in some regions.

Impact of gender mismatch on corneal graft rejection and rejection-related graft failure in repeat penetrating keratoplasty.

PURPOSE: To explore the impact of gender mismatch on corneal allograft rejection and rejection-related graft failure in patients with repeat penetrating keratoplasty (PK). METHODS: A retrospective cohort was conducted at Ramathibodi Hospital, Bangkok, Thailand. Patients with repeat PK and follow-up period of at least 6 months were recruited. Demographic data, pre-operative ocular findings and donor information were collected. Patients were divided into 2 groups according to gender mismatch between donor and recipient (male to female vs others). Survival analysis was performed using the Kaplan-Meier method. The association between risk factors and the outcomes of graft rejection and rejection-related graft failure were analyzed using Cox proportional hazards regression. RESULTS: Of 68 patients with repeat PK, 26 patients (38.2%) were gender mismatched. There was no difference in 3-year rejection-free survival and graft survival between patients with gender mismatch and others (p = 0.698 and p = 0.402, respectively). Younger recipients (< 40 years) showed a significantly higher rejection rate compared to older recipients (hazard ratio; HR = 3.14, 95% confidence interval; CI 1.15 to 8.58), while patients with multiple PK (> 2 times) were found to be significantly associated with higher rejection-related graft failure compared to patients with 2 times or less PK (HR = 2.72, 95% CI 1.03 to 7.21). After multivariate analysis, only younger recipients demonstrated a statistical significance on graft rejection (adjusted HR = 2.86, 95% CI 1.04 to 7.84). CONCLUSIONS: Gender mismatch might not impact corneal graft rejection or rejection-related graft failure in patients with repeat PK. Younger age was found to be a strong factor associated with graft rejection. Gender matching might not be compulsory for repeat PK.

Assessing the Risk Factors For Diagnosed Symptomatic Dry Eye Using a Smartphone App: Cross-sectional Study.

BACKGROUND: Dry eye (DE) is a chronic inflammatory disease of the ocular surface of the eye that affects millions of people throughout the world. Smartphone use as an effective health care tool has grown exponentially. The "Dry eye or not?" app was created to evaluate the prevalence of symptomatic DE, screen for its occurrence, and provide feedback to users with symptomatic DE throughout Thailand. OBJECTIVE: The purpose of this study was to compare the prevalence of symptomatic dry eye (DE), blink rate, maximum blink interval (MBI), and best spectacle-corrected visual acuity (BSCVA) between people with and without symptomatic DE and to identify risk factors for symptomatic DE in Thailand. METHODS: This cross-sectional study sourced data from the "Dry eye or not?" smartphone app between November 2019 and July 2020. This app collected demographic data, Ocular Surface Disease Index (OSDI) score, blink rate, MBI, BSCVA, and visual display terminal (VDT) use data. The criterion for symptomatic DE was OSDI score ≥13. RESULTS: The prevalence of symptomatic DE among individuals using this smartphone app in Thailand was 85.8% (8131/9482), with the Northeastern region of Thailand having the highest prevalence, followed by the Northern region. Worse BSCVA (median 0.20, IQR 0.40; P=.02), increased blink rate (median 18, IQR 16; P<.001), reduced MBI (median 8.90, IQR 10.80; P<.001), female sex (adjusted OR 1.83; 95% CI 1.59-2.09; P<.001), more than 6 hours of VDT use (adjusted OR 1.59; 95% CI 1.15-2.19; P=.004), and lower than bachelor's degree (adjusted OR 1.30; 95% CI 1.03-1.64; P=.02) were significantly associated with symptomatic DE. An age over 50 years (adjusted OR 0.77; 95% CI 0.60-0.99) was significantly less associated with symptomatic DE (P=.04). CONCLUSIONS: This smartphone DE app showed that the prevalence of symptomatic DE in Thailand was 85.8%. Signs and risk factors could be also evaluated with this smartphone DE app. Screening for DE by this app may allow for the development of strategic plans for health care systems in Thailand.

Compliance with Lid Hygiene in Patients with Meibomian Gland Dysfunction.

Purpose: To evaluate the level and predictor of compliance with lid hygiene of the patients with meibomian gland dysfunction (MGD) by a specially designed and validated questionnaire. Patients and Methods: A cross-sectional, descriptive study was conducted among patients with symptomatic meibomian gland dysfunction visiting at Ramathibodi Hospital from April 2019 to December 2020. Dry eye symptom, fluorescein tear breakup time (TBUT), ocular surface staining, lid morphology, meibum quality, and meibum expressibility were evaluated. All patients were instructed to perform lid hygiene two times daily. Eight weeks after receiving the instruction, the patients were asked to complete a newly developed seven-item questionnaire to assess compliance. The associated factors limiting treatment adherence were evaluated. Proper statistical analyses were used to determine the relationships between compliance and non-compliance and a group of relevant baseline variables. P < 0.05 was considered to be statistically significant. Results: A total of 77 patients were recruited into the study. Sixty-three patients (81.8%) were female. The mean age was 66.71 ± 8.17 years old (42-87 years). Good compliance with lid hygiene was reported by 42 patients (54.6%). Patient demographic factors or the number of concurrent systemic or ophthalmic drugs were not significantly different between the compliance and non-compliance groups. Some clinical signs, including the higher scores of meibomian gland expressibility and moderate to severe ocular surface staining, were significantly positively associated with lid hygiene compliance (χ 2 = 10.13, P = 0.001 and χ 2 = 10.48, P = 0.001, respectively). A lack of time was the most notable reason for non-compliance. Conclusion: Approximately half of the patients with symptomatic MGD had good compliance with lid hygiene by the specific questionnaire. Appropriate patient education and optimization methods of lid hygiene may promote patient compliance.

Agreement of implantable collamer lens sizes using parameters from different devices.

Objective: To assess agreement and repeatability of white-to-white (WTW) and anterior chamber depth (ACD), and agreement of implantable collamer lens (ICL) size using these measurements from different devices. Methods and analysis: A retrospective review of 83 eyes with ICL implantation (42 patients) was conducted. The agreement of WTW (measured with WaveLight Topolyzer and Orbscan IIz) and ACD (measured with WaveLight Oculyzer and Orbscan IIz) was analysed. Correlation of ICL sizes and difference of eyes with unacceptable vaults between two data sets (WaveLight platform; Topolyzer and Oculyzer and Orbscan IIz) were assessed. Results: Average WTW measured by Orbscan IIz and Topolyzer demonstrated good agreement (Ρ 0.884) with low systematic bias (-0.03±0.1 mm) and narrow 95% limits of agreement (LoA) of -0.28 to 0.22. Average ACD measured by Orbscan IIz and Oculyzer also showed good agreement (Ρ 0.903) with low systematic bias (-0.04±0.1 mm) and relatively narrow 95% LoA (0.2 to 0.12). ICL size selected according to two data sets showed moderate to strong level of agreement (Kappa=0.81). There was a statistically significant difference (p<0.001) in the proportion of eyes with unacceptable postoperative vaults when using the Wavelight platform data set (five eyes, 6.02%) and the Orbscan IIz data set (12 eyes, 14.46%). Conclusion: Although the agreement of WTW and ACD between devices was good, there was a significant difference in proportion of eyes with unacceptable postoperative vaults when using two data sets. Therefore, Topolyzer and Oculyzer might not be suitable for operating interchangeably with Orbscan IIz for ICL size selection.

Association of HLA polymorphisms and acetaminophen-related Steven-Johnson syndrome with severe ocular complications in Thai population.

BACKGROUND/AIMS: To investigate the association of genetic polymorphisms of human leucocyte antigens (HLA) class I and II genes with acetaminophen-related Steven-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN) who developed severe ocular complications (SOC) in the Thai population. METHODS: A prospective case-control study including 20 unrelated Thai acetaminophen-related SJS/TEN patients with SOC and 60 Thai healthy volunteers, recruited at three university hospitals in Bangkok, Thailand, from September 2014 to August 2019. HLA genes were analysed using PCR amplification followed by hybridisation with sequence-specific oligonucleotide (SSO) probes with bead-based typing kits. The carrier and gene frequencies of individual HLA alleles in patients were compared with those in control volunteers based on dominant assumption using Fisher's exact test. RESULTS: Among HLA class I polymorphisms, HLA-A*33:03, HLA-B*44:03 and HLA-C*07:01 were significantly associated with acetaminophen-related SJS/TEN and SOC with high ORs (95% CI, corrected p value; Pc) in carrier frequency of 5.4 (1.8 to 16.3, Pc=0.0274), 9.0 (95% CI 2.7 to 30.4, Pc=0.0034), and 9.3 (2.8 to 30.2, Pc=0.0022), respectively. There were no significant HLA class II associations with the disease after corrected for a total number of alleles tested. CONCLUSION: HLA-B*44:03 was strongly associated with acetaminophen-related SJS/TEN patients who developed SOC in Thai population. In addition, we also found moderate to strong associations with HLA-A*33:03 and HLA-C*07:01 suggesting their potential roles in the pathogenesis of SOC in acetaminophen-related SJS/TEN.

Short-term Efficacy and Safety of Biological Tear Substitutes and Topical Secretagogues for Dry Eye Disease: A Systematic Review and Network Meta-analysis.

PURPOSE: The purpose of this study was to assess short-term efficacy and safety of tear promotion eye drops (biological tear substitutes and topical secretagogues) for treating dry eye disease. METHODS: Randomized controlled trials comparing short-term effects of biological tear substitutes or topical secretagogues versus placebo or other topical dry eye treatments in adults with dry eye disease were identified from the MEDLINE, Embase, Scopus, ClinicalTrials.gov , and World Health Organization International Clinical Trials Registry Platform databases. Pairwise meta-analysis and network meta-analysis were performed. Outcomes were ocular symptoms, ocular surface staining, tear break-up time, Schirmer test, and adverse events. The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations approach. RESULTS: Thirty-nine randomized controlled trials (3693 patients) were eligible. Using artificial tears as a reference, autologous platelet lysate was the most effective treatment for lowering ocular surface disease index (unstandardized mean difference [USMD] -31.85; 95% confidence interval [CI]: -43.19 to -20.51) and platelet rich plasma showed the most reduction in corneal fluorescein staining scores (standardized mean difference -2.52; 95% CI: -3.23 to -1.82). Cord blood serum was the most effective treatment for increasing tear break-up time (USMD 2.67; 95% CI: 0.53-4.82), and eledoisin was superior to others in improving Schirmer scores (USMD 2.28; 95% CI: 0.14-4.42). Most interventions did not significantly increase ocular adverse events compared with artificial tears. CONCLUSIONS: Biological tear substitutes, including autologous serum, autologous platelet lysate, platelet rich plasma, and cord blood serum, might be the most effective treatment among tear promotion eye drops in relieving dry eye symptoms without increasing adverse events. However, there remains uncertainty around these findings because of low/very low certainty of evidence.

Prevalence and risk factors of dry eye disease among University Students in Bangkok, Thailand.

PURPOSE: To investigate the prevalence of dry eye disease (DED) and its associated risk factors among Thai university students. METHODS: A cross-sectional study using an electronic survey was conducted in two Rajabhat universities in Bangkok, Thailand. The woman's health study questionnaire was used to determine students with DED. The prevalence of DED along with 95% confidence interval (CI) were calculated. Logistic regression model was used to identify the associated risk factors. RESULTS: A total of 4,111 university students joined and completed the survey questionnaires. Mean age was 18.8 ± 1.1 years with female predominance (2874 students, 69.91%). Clinically diagnosed DED was reported in 136 students (3.31%), while severe symptoms of eye dryness and irritation were reported in 227 students (5.52%). The prevalence of DED among Thai university students was 8.15% (95% CI 7.33% to 9.02%). History of contact lens use and high screen time (> 8 hours per day) were reported in 868 students (21.11%) and 2101 students (51.11%), respectively. Male gender, contact lens use and high screen time were significantly associated with higher risk of DED with the adjusted ORs (95% CI) of 1.39 (1.09, 1.77), 2.49 (1.96, 3.17), and 1.43 (1.14, 1.80), respectively. CONCLUSIONS: DED is not rare among Thai university students. Contact lens use and high screen time are two significant modifiable risk factors of DED in our students. These findings can raise awareness of DED in youth population and provide valuable information for public health promotion in university students.

Efficacy and outcome of simple limbal epithelial transplantation for limbal stem cell deficiency verified by epithelial phenotypes integrated with clinical evaluation.

PURPOSE: To evaluate the efficacy and outcome of simple limbal epithelial transplantation (SLET) for limbal stem cell deficiency (LSCD) using epithelial phenotype detection integrated with clinical manifestation. METHODS: This prospective multicenter study included patients with LSCD who underwent autologous SLET (autoSLET) and living-related allogenic SLET (Lr-alloSLET). All patients were assessed by slit-lamp biomicroscopy, in vivo confocal microscopy (IVCM), and impression cytology with immunofluorescence staining (ICIF) before and after surgery. The criteria for success were the presence of a clinically non-conjunctivalized cornea and corneal epithelium detected by IVCM or ICIF. Otherwise, the case would be considered a failure. Visual improvement and risk factors for SLET failure were analyzed. RESULTS: A total of 28 eyes of 26 patients (11 autoSLET and 17 Lr-alloSLET) were included. The median age was 53 years (range, 35-63), and the follow-up time was 29.5 months (range, 17.5-39.8). The overall survival rate was 89.3% at 2 years and 75.6% at 3 years with no difference between autoSLET and Lr-alloSLET (p = 0.24). Seven eyes subsequently underwent penetrating keratoplasty. Immunohistochemistry analysis showed that all corneal buttons had corneal epithelium and limbal stem cell markers. Visual improvement was achieved in both SLET groups (p < 0.001). Failed SLET developed between 5 and 32 months postoperatively. However, absolute risk factors for SLET failure were unidentified. CONCLUSION: The efficacy of autoSLET and Lr-alloSLET for LSCD was excellent. Limbal explants can regenerate and restore the corneal surface while maintaining the characteristics of limbal stem cells as shown by epithelial phenotype detection and immunohistochemistry integrated with clinical evaluation.

Comparison of treatment efficacy between 100% platelet-rich plasma and 100% serum eye drops in moderate-to-severe dry eye disease: a randomised controlled trial protocol.

INTRODUCTION: Dry eye disease (DED) is a common eye problem. Although the disease is not fatal, it substantially reduces quality of life and creates a high economic burden, especially in patients with moderate-to-severe DED. Several biological tear substitutes (eg, autologous serum (AS), autologous platelet-rich plasma (APRP) and autologous platelet lysate) could effectively improve dry eyes. However, evidence on their comparative efficacy is controversial. This study aims to compare the efficacy of 100% APRP with 100% AS eye drops in patients with moderate-to-severe DED. METHODS AND ANALYSIS: The study is a single-centre, double-blinded randomised, parallel, non-inferiority trial. One hundred and thirty patients with moderate-to-severe DED, aged 18-70 years will be recruited from outpatient clinic, Department of Ophthalmology, Ramathibodi Hospital, Bangkok from February 2021 to January 2023. Patients will be randomised to receive either 100% APRP or 100% AS eye drops (1:1 ratio) for 4 weeks. The primary outcomes are ocular surface disease index (OSDI) and ocular surface staining (OSS) evaluated using the Oxford scale. Secondary outcomes are fluorescein break-up time, Schirmer's I test, meibomian gland parameters and adverse events. Other measured outcomes include best-corrected visual acuity, intraocular pressure and compliance. ETHICS AND DISSEMINATION: The study protocol and any supplements used in conducting this trial have been approved by the Ethics Committee of Faculty of Medicine, Ramathibodi Hospital, Mahidol University (MURA2020/1930). Informed consent will be obtained from all patients before study entry. Results will be presented in peer-reviewed journals and international conferences. TRIAL REGISTRATION NUMBER: NCT04683796.

Outcomes of Descemet Membrane Endothelial Keratoplasty in Bangkok, Thailand.

PURPOSE: To investigate the medium-term clinical outcomes and risk factors for primary graft failure after Descemet membrane endothelial keratoplasty (DMEK) in Thai patients. PATIENTS AND METHODS: This is a single-center retrospective cohort study. Sixty-two eyes of 62 patients who underwent DMEK at Ramathibodi Hospital, Bangkok, Thailand, with a minimum of 24-month follow-up were recruited. Preoperative donor and recipient characteristics, intraoperative data, and postoperative outcomes including best-corrected visual acuity (BCVA), graft clarity, endothelial cell density (ECD), central corneal thickness (CCT), and complications were evaluated at 1, 3, 6, 12, and 24 months after surgery. RESULTS: The mean age of the patients was 67.2 ± 9.9 years, and 52% were female. The mean follow-up time was 37.5 ± 11.0 months. The most common indications for DMEK were Fuchs' endothelial corneal dystrophy (FECD) (53.2%) and pseudophakic bullous keratopathy (PBK) (17.7%). Nearly half of patients had triple-DMEK. The median preoperative BCVA was 20/400. Postoperative BCVA of ≥ 20/40 was reached in 37.1% and of ≥ 20/20 in 6.5% after 1 month which increased to 54.8% and 17.7% after 3 months; and to 67.7% and 27.4% after 24 months. Endothelial cell loss (ECL) at 3, 6, 12, and 24 months was 30.5%, 33.8%, 44.4%, and 45.9%, respectively. Graft diameter was the single factor, showing a significant relationship with postoperative ECD. Most frequent postoperative complications included graft detachment (22.6%), increased IOP/glaucoma (17.7%), and primary graft failure (16.1%). In univariate analysis, death-to-operation time and the diagnosis of PBK were significantly associated with the occurrence of primary graft failure. CONCLUSION: DMEK is a safe, effective, and feasible treatment for endothelial failure in Asian eyes. Careful case selection, use of relatively fresh donor tissues, and appropriate surgical techniques can prevent primary graft failure and facilitate optimal outcomes following surgery.

Incidence and Risk Factors of Corneal Endothelial Failure after Phacoemulsification in Patients with Fuchs Endothelial Corneal Dystrophy: A 13-Year Retrospective Cohort.

OBJECTIVE: To evaluate the incidence of corneal endothelial failure (CEF) and determine the risk factors of developing CEF after phacoemulsification in patients with Fuchs endothelial corneal dystrophy (FECD). METHODS: A retrospective chart review of 2873 patients who underwent phacoemulsification with intraocular lens (IOL) implantation was conducted at Ramathibodi Hospital, Bangkok, Thailand from January 2007 to December 2019. Patient baseline characteristics, underlying diseases, levels of nuclear cataract, pre-operative specular microscopic parameters, intraoperative information (cumulative dissipated energy [CDE], mode of phacoemulsification, and complications), and occurrence of CEF were collected. Data were analyzed using Kaplan-Meier (KM) method and Cox proportional hazard model. RESULTS: Ninety-four patients diagnosed with FECD at follow-up time of more than 6 months were included for analysis. Mean age was 70.3 ± 7.7 years with female predominance (81.91%). Median follow-up time was 3.2 years. Nine (9.57%) patients developed CEF during follow-up period. The overall incidence rate of CEF after phacoemulsification was 26 per 1000 person years (95% confidence interval [CI]; 14 to 49 per 1000 person years). Only intraoperative complications showed significant association with CEF at hazard ratio (HR) of 6.03 (95% CI 1.50 to 26.50). No significant association was found among age, gender, underlying diseases, level of nuclear sclerosis and pre-operative specular microscopic parameters. CONCLUSION: Intraoperative complications should be considered as an important risk factor for developing post-operative CEF in FECD patients. Apart from assessing pre-operative parameters, surgeons should also consider the possibility of and try to avoid any intra-operative complications, which could potentially result in CEF after phacoemulsification for each individual patient.

Role of Intravenous Acyclovir in Treatment of Herpes Simplex Virus Stromal Keratitis with Ulceration: A Review of 2 Cases.

BACKGROUND Herpes simplex virus (HSV) stromal keratitis with ulceration is one of the most serious forms of herpes corneal infection and is one of the most difficult conditions in terms of clinical management. We assessed the efficacy of intravenous acyclovir in the treatment of this condition. CASE REPORT Two cases of HSV stromal keratitis with ulceration were reported in terms of clinical presentation, investigation, treatment, and outcome.Diagnosis was confirmed by polymerase chain reaction (PCR) analysis. PCR testing of corneal scraping samples identified HSV-1 in the first patient and HSV-2 in the second patient. The first patient initially presented with herpes geographic epithelial keratitis and progressed to HSV stromal keratitis with ulceration during treatment with a prophylactic dose of oral acyclovir. Despite oral acyclovir therapy, the cornea lesion continued to worsen. The treatment was switched to intravenous acyclovir. The stromal infiltration gradually improved, and the epithelial defect closed. The second patient, who had undergone penetrating keratoplasty for 13 years, presented with extensive corneal infiltration and corneal melting. The laboratory work-up was positive for HSV-2, and intravenous acyclovir was prescribed. The patient's corneal infiltration improved, but a persistent epithelial defect was present. Then, 100% autologous serum was used until the epithelial defect closed. Prophylactic treatment with oral acyclovir was prescribed to both patients to prevent disease recurrence. CONCLUSIONS Intravenous acyclovir might be considered as an alternative treatment for patients with HSV stromal keratitis with ulceration who do not respond to oral acyclovir or those with an extensive infection on a corneal graft.

Predisposing Factors, Clinical Presentations, and Outcomes of Contact Lens-Related Pythium Keratitis.

PURPOSE: To describe predisposing factors, clinical presentations, and treatment outcomes of contact lens (CL)-related Pythium keratitis. METHODS: This was an 11-year retrospective study of CL-related Pythium keratitis conducted from 2009 to 2019. Six eyes of 6 patients were identified. Demographics, predisposing factors, CL history, clinical presentation, diagnostic tests, treatments, and outcomes were reviewed. RESULTS: Mean age of the patients was 34 years (SD 16.3 years) with equal proportion between male and female patients. Five of 6 patients (83.3%) used soft CL, whereas 1 patient used rigid gas permeable lens. All patients had a history of water contamination (tap water and water from river and sea). Mean duration from the onset was 7.8 days (range 4-14 days). Mean size of the corneal lesion was 3.33 mm (SD 1.31 mm) in width. The typical feature of tentacle-like lesions radiating in a reticular pattern was observed in all patients. Feathery edge (1 eye), satellite lesions (2 eyes), and radial keratoneuritis (2 eyes) were also found. Every patient received therapeutic penetrating keratoplasty because of failed medical treatments. One patient subsequently underwent enucleation. Globe salvage was achieved in 5 patients (83.33%). CONCLUSIONS: Awareness of the history of water contamination, recognition of specific clinical features of Pythium keratitis, and performing surgical treatment are key for achieving globe salvage in patients with CL-related Pythium keratitis.

Mycobacterium haemophilum scleritis: two case reports and review of literature.

BACKGROUND: Mycobacterium haemophilum is a rare and emerging nontuberculous mycobacteria (NTM). It normally causes localized or disseminated systemic diseases, particularly skin infections and arthritis in severely immunocompromised patients. There have been 5 cases of M. haemophilum ocular infections reported in the literature. Only 1 case presented with scleritis with keratitis. Here, we reported 2 cases of M. haemophilum scleritis. One of them was immunocompetent host and had keratitis with radial keratoneuritis as a presenting sign. CASE PRESENTATION: Case 1: A 52-year-old Thai female with rheumatoid arthritis presented with scleritis. Conjunctival scraping was carried out and the culture result was positive for M. haemophilum. Despite receiving systemic and topical antibiotics, her clinical symptoms and signs worsened. Surgical debridement was performed. After surgery, the lesion was significantly improved and finally turned to conjunctival scarring. Case 2: A 32-year old healthy Thai male without underlying disease presented with nodular scleritis and keratouveitis with multiple radial keratoneuritis. Surgical debridement of the scleral nodule was performed. Initial microbiological investigations were negative. Herpes ocular infections was suspected. Topical antibiotics, oral acyclovir, low-dose topical steroids and systemic steroids were started. The scleral inflammation subsided but later the keratitis relapsed, requiring corneal biopsy. Histopathology of the specimen revealed acid-fast bacteria and M. haemophilum was identified by polymerase chain reaction (PCR) and sequencing. The diagnosis of Mycobacterial keratitis was made. Although using the combination of systemic and topical antibiotics, his clinical status progressively deteriorated. Multiple therapeutic penetrating keratoplasties were required to eradicate the infection. No recurrence was found during the 1-year follow-up in both cases. CONCLUSIONS: M. haemophilum can cause scleritis and keratitis, even in immunocompenent host. Radial keraoneuritis is first described in M. haemophilum keratitis. NTM keratitis should be considered in the differential diagnosis of patients with radial keratoneuritis. Increased awareness and early diagnosis using appropriate culture conditions and molecular techniques are important for the proper treatment of this infection. Prompt surgical intervention appears to be vital for successful management of M. haemophilum scleritis and keratitis.

Recent update in diagnosis and treatment of human pythiosis.

Human pythiosis is an infectious condition with high morbidity and mortality. The causative agent is the oomycete microorganism Pythium insidiosum. The pathogen inhabits ubiquitously in a wet environment, and direct exposure to the pathogen initiates the infection. Most patients with pythiosis require surgical removal of the affected organ, and many patients die from the disease. Awareness of pythiosis among healthcare personnel is increasing. In this review, we summarized and updated information on the diagnosis and treatment of human pythiosis. Vascular and ocular pythiosis are common clinical manifestations. Recognition of the typical clinical features of pythiosis is essential for early diagnosis. The definitive diagnosis of the disease requires laboratory testing, such as microbiological, serological, molecular, and proteomic assays. In vascular pythiosis, surgical intervention to achieve the organism-free margin of the affected tissue, in combination with the use of antifungal drugs and P. insidiosum immunotherapy, remains the recommended treatment. Ocular pythiosis is a serious condition and earliest therapeutic penetrating keratoplasty with wide surgical margin is the mainstay treatment. Thorough clinical assessment is essential in all patients to evaluate the treatment response and detect an early sign of the disease recurrence. In conclusion, early diagnosis and proper management are the keys to an optimal outcome of the patients with pythiosis.