Comparison of Scheimpflug Corneal Tomography and Anterior Segment Optical Coherence Tomography Measurements in Corneal Cystinosis: A Case Series.

PURPOSE: To report the clinical course and compare the utility of Scheimpflug tomography (ST) and anterior segment optical coherence tomography (AS-OCT) for central corneal thickness (CCT) and corneal densitometry (CD) assessment in patients with corneal crystals owing to nephropathic cystinosis. METHODS: A retrospective chart analysis of three patients with nephropathic cystinosis and the presence of corneal cystine crystals in both eyes was performed. All patients underwent clinical examination and anterior segment photography, ST, and AS-OCT scans. Corneal densitometry was exported from built-in proprietary software for ST and from custom-made validated software for AS-OCT. Anterior segment optical coherence tomography images were rescaled to grayscale units from 0 (maximum transparency) to 100 (minimum transparency) to match built-in ST densitometry readings. Furthermore, the mean pixel intensity, representative of CD, was calculated from the pixels corresponding to the segmented cornea. RESULTS: All three patients had pathognomonic cystine crystals deposits in the cornea and were treated with cysteamine medications that resulted in clinical improvement. The CCT measured using ST exhibited a range from 560 to 958 µm. Conversely, when assessed with AS-OCT, the CCT varied within the range of 548 to 610 µm. Both examinations could be performed, but in the more severe cases, AS-OCT showed far greater utility to estimate CD. In four of six eyes examined, ST showed disproportionate CCT values, compared with the AS-OCT, whereas reliable CD measurements were only available in AS-OCT. CONCLUSION: The AS-OCT could be considered a baseline ocular measurement in cystinosis and in the evaluation of disease progression and treatment efficacy.

The role of topical insulin in ocular surface restoration: A review.

Corneal epithelial defects are one of the most common ocular disorders. Restoring corneal integrity is crucial to reduce pain and regain function, but in cases of neurotrophic or desensitized corneas, healing can be significantly delayed. Treating neurotrophic corneas is challenging for ophthalmologists, and surgical intervention is often indicated to manage refractory cases that are unresponsive to medical therapy. Over the last decade, as more expensive therapeutics reach the market, topical insulin has returned to the forefront as an affordable option to improve corneal wound healing. There is still a paucity of data on the use and the efficacy of topical insulin, with no consensus regarding its indications, preparation, or posology. Here we review the literature on topical insulin for corneal and ocular surface pathologies, with a focus on the current evidence, its mechanisms of action, and its safety profile. Additionally, we share our experience in the field and provide a potential framework for future research.

"Keep on ROCKIn": Repurposed ROCK inhibitors to boost corneal endothelial regeneration.

The global shortage of corneal endothelial graft tissue necessitates the exploration of alternative therapeutic strategies. Rho-associated protein kinase inhibitors (ROCKi), recognized for their regenerative potential in cardiology, oncology, and neurology, have shown promise in corneal endothelial regeneration. This study investigates the repurposing potential of additional ROCKi compounds. Through screening a self-assembled library of ROCKi on B4G12 corneal endothelial cells, we evaluated their dose-dependent effects on proliferation, migration, and toxicity using live-cell imaging. Nine ROCKi candidates significantly enhanced B4G12 proliferation compared to the basal growth rate. These candidates were further assessed for their potential to accelerate wound closure as another indicator for tissue regeneration capacity, with most demonstrating notable efficacy. To assess the potential impact of candidate ROCKi on key corneal endothelial cell markers related to cell proliferation, leaky tight junctions and ion efflux capacity, we analyzed the protein expression of cyclin E1, CDK2, p16, ZO-1 and Na+/K+-ATPase, respectively. Immunocytochemistry and western blot analysis confirmed the preservation of corneal endothelial markers post-treatment with ROCKi hits. However, notable cytoplasm enlargement and nuclear fragmentation were detected after the treatment with SR-3677 and Thiazovivin, indicating possible cellular stress. In compared parameters, Chroman-1 at a concentration of 10 nM outperformed other ROCKi, requiring significantly 1000-fold lower effective concentration than established ROCKi Y-27632 and Fasudil. Altogether, this study underscores the potential of repurposing ROCKi for treating corneal endothelial dysfunctions, offering a viable alternative to conventional grafting methods, and highlights Chroman-1 as a promising candidate structure for hit-to-lead development.

The potential influence of the ligament of Wieger on the crystalline lens shape.

This research uses mathematical modelling to evaluate the influence of the ligament of Wieger on the crystalline lens shape at rest, and during accommodation. An axisymmetric model of the anterior segment, including the ligament of Wieger, was created using the finite element method. Different conditions including variations of stiffness and positions of the ligament, with and without the ligament, were tested to see how they affected lens curvature and optical power. Adding the ligament of Wieger to the simulation had a noticeable impact on the optical power of the lens, particularly on the posterior surface power and total power. Ligament stiffness and width significant influenced the accommodative range of the eye by - 0.95D and - 2.39D for ligaments with the same and 3× the stiffness of the capsular bag, respectively. Ligament width and inner diameter had negligible effects on lens thickness but did have significant effects on posterior surface power and accommodation. In this simulation, we found that the ligament of Wieger can significantly affect the lens shape, both at rest and during accommodation, and may need to be considered in lens models.

Severe Corneal Damage After Minor Eyelid Surgery: A Case Series.

OBJECTIVES: To present three cases of serious corneal complications after seemingly minor and uncomplicated eyelid surgery. METHODS: These cases emphasize the real-world risk of corneal damage after oculoplastic surgery. RESULTS: The first case is a 46-year-old man referred to our department with a corneal perforation after bilateral blepharoplasty of both upper and lower eyelids. The second case concerns a 51-year-old woman who suffered an accidental coagulation of the cornea during the removal of upper eyelid papillomas, and the third case is a 55-year-old woman who had severe corneal thinning accompanied by visual loss after an upper lid blepharoplasty. All patients were stabilized without the need for corneal transplantation, although there were significant corneal scars and sequelae. CONCLUSIONS: Although complications after esthetic oculoplastic surgery are rare, the reported cases show that corneal damage can have a major impact on the patient's vision and quality of life. Strategies such as the use of a corneal shield can be used to mitigate these risks, but their use is debated. Nevertheless, diligent postoperative care is paramount. At the first postoperative visit, a basic visual acuity measurement should be performed. In cases where reduced vision is reported, particularly when accompanied by pain, patients should be urgently referred for specialized eye care.

Artificial Endothelial Layer Implantation After Multiple Failed Keratoplasties.

PURPOSE: Presenting the first case of noncellular corneal endothelial substitute after multiple failed penetrating keratoplasty (PK) and lamellar endothelial keratoplasty. METHODS: Our case presented with pseudophakic bullous keratopathy after a history of 2 rejected PKs and 1 rejected Descemet stripping automated endothelial keratoplasty. We implanted an artificial endothelial layer. RESULTS: The implant remained fully attached for a follow-up period of 12 months, and central corneal thickness decreased significantly. The patient reported improvement in her subjective vision, although ocular comorbidities limited the visual potential. CONCLUSIONS: This new device could serve as an alternative to lamellar endothelial corneal transplantation in cases where tissue rejection has occurred and is highly likely to recur. The technique is simple, and the deswelling effect on the cornea persisted, although the visual results require further validation in patients with a higher visual potential.

Combined or sequential DMEK in cases of cataract and Fuchs endothelial corneal dystrophy-A systematic review and meta-analysis.

To compare the outcomes of Descemet membrane endothelial keratoplasty (DMEK) performed after phacoemulsification and intraocular lens (IOL) implantation (sequential DMEK) and DMEK combined with phacoemulsification and IOL implantation (combined DMEK) in patients with Fuchs endothelial corneal dystrophy (FECD) and cataract. Systematic literature review and meta-analysis performed according to the PRISMA guidelines and registered in PROSPERO. Literature searches were conducted in Medline and Scopus. Comparative studies reporting sequential DMEK and combined DMEK in FECD patients were included. The main outcome measure of the study was the corrected distance visual acuity (CDVA) improvement. Secondary outcomes were postoperative endothelial cell density (ECD), rebubbling rate and primary graft failure rate. Bias risk was assessed and a quality appraisal of the body of evidence was completed using the Cochrane Robin-I tool. A total of 667 eyes (5 studies) were included in this review, 292 eyes (43.77%) underwent a combined DMEK, while 375 (56.22%) eyes underwent a sequential DMEK surgery. We found no evidence of a difference between the two groups (mean difference, 95% CI) regarding: (1) CDVA improvement (-0.06; -0.14, 0.03 LogMAR; 3 studies, I2 : 0%; p = 0.86); (2) postoperative ECD (-62; -190, 67 cells/mm2 ; 4 studies, I2 : 67%; p = 0.35); (3) rebubbling (risks ratio: 1.04; 0.59, 1.85; 4 studies, I2 : 48%; p = 0.89); and primary graft failure rate (risks ratio: 0.91; 0.32, 2.57; 3 studies, I2 : 0%; p = 0.86). Of all the 5 non-randomized studies, all (100%) were graded as low quality. The overall quality of the analysed studies was low. Randomized controlled trials are needed to confirm no difference or superiority of one approach in terms of CDVA, endothelial cell count and postoperative complication rate between the two arms.

Definitions for Keratoconus Progression and Their Impact on Clinical Practice.

PURPOSE: There is currently no consensus on which keratoconus need cross-linking nor on how to establish progression. This study assessed the performance of diverse progression criteria and compared them with our clinical knowledge of keratoconus evolution. METHODS: This was a retrospective, longitudinal, observational study. Habitual progression criteria, based on (combinations of) keratometry (K MAX ), front astigmatism (A F ), pachymetry (P MIN ), or ABCD progression display, from 906 keratoconus patients were analyzed. For each criterion and cutoff, we calculated %eyes flagged progressive at some point (R PROG ), individual consistency C IND (%examinations after progression detection still considered progressive), and population consistency C POP (% eyes with CIND >66%). Finally, other monotonic and consistent variables, such as front steep keratometry (K 2F ), mean radius of the back surface (R mB ), and the like, were evaluated for the overall sample and subgroups. RESULTS: Using a single criterion (e.g., ∆K MAX >1D) led to high values of R PROG . When combining two, (K MAX and A F ) led to worse C POP and higher variability than (K MAX and P MIN ); alternative criteria such as (K 2F and R mB ) obtained the best C POP and the lowest variability ( P <0.0001). ABC, as defined by its authors, obtained R PROG of 74.2%. Using wider 95% confidence intervals (95% CIs) and requiring two parameters over 95CI reduced R PROG to 27.9%. CONCLUSION: Previous clinical studies suggest that 20% to 30% of keratoconus cases are progressive. This clinical R PROG value should be considered when defining KC progression to avoid overtreatment. Using combinations of variables or wider margins for ABC brings R PROG closer to these clinical observations while obtaining better population consistency than current definitions.

Cataract surgical training in Europe: European Board of Ophthalmology survey.

PURPOSE: To survey recently graduated European ophthalmologists concerning cataract surgery (CS) training opportunities. SETTING: Countries affiliated to the European Board of Ophthalmology (EBO). DESIGN: Cross-sectional study of anonymous survey results. METHODS: A 23-question online survey was emailed to candidates who sat the EBO Diploma Examination as residents between 2018 and 2022. RESULTS: 821 ophthalmologists from 30 countries completed the survey. The mean residency duration was 4.73 (SD 0.9) years. The mean reported number of entire CS procedures performed was 80.7 (SD 100.6) at the end of residency, but more than 25% of respondents (n = 210) had received no live CS training during their residency. The self-confidence (scale, 1 to 10) to perform a simple case or challenging case, manage posterior capsular rupture, and realize a corneal stitch were rated 4.1, 3.2, 4.2, 2.4, respectively. We observed extensive variation in clinical exposure to CS and self-reported confidence to perform CS between European trainees. Females reported a mean of 18% fewer entire procedures than their male colleagues and were also less confident in their surgical skills (P < .05). Trainees in residency programs longer than 5 years performed fewer procedures and were less confident than trainees in residences of shorter duration (P < .001). The importance of fellowships to complete surgical education was rated 7.7 out of 10. CONCLUSIONS: CS training across European countries lacks harmony. Female ophthalmology trainees continue, as in other specialties, to experience apparent gender bias. European level recommendations seem necessary to raise and harmonize competency-based CS training programs and promote post-residency fellowship training programs.

Preoperative surgeon evaluation of corneal endothelial status: the Viability Control of Human Endothelial Cells before Keratoplasty (V-CHECK) study protocol.

INTRODUCTION: The success of keratoplasty strongly depends on the health status of the transplanted endothelial cells. Donor corneal tissues are routinely screened for endothelial damage before shipment; however, surgical teams have currently no means of assessing the overall viability of corneal endothelium immediately prior to transplantation. The aim of this study is to validate a preoperative method of evaluating the endothelial health of donor corneal tissues, to assess the proportion of tissues deemed suitable for transplantation by the surgeons and to prospectively record the clinical outcomes of a cohort of patients undergoing keratoplasty in relation to preoperatively defined endothelial viability. METHODS AND ANALYSIS: In this multicentre cohort study, consecutive patients undergoing keratoplasty (perforating keratoplasty, Descemet stripping automated endothelial keratoplasty (DSAEK), ultra-thin DSAEK (UT-DSAEK) or Descemet membrane endothelial keratoplasty) will be enrolled and followed-up for 1 year. Before transplantation, the endothelial viability of the donor corneal tissue will be evaluated preoperatively through trypan blue staining and custom image analysis to estimate the overall percentage of trypan blue-positive areas (TBPAs), a proxy of endothelial damage. Functional and structural outcomes at the end of the follow-up will be correlated with preoperatively assessed TBPA values. ETHICS AND DISSEMINATION: The protocol will be reviewed by the ethical committees of participating centres, with the sponsor centre issuing the final definitive approval. The results will be disseminated on ClinicalTrials.gov, at national and international conferences, by partner patient groups and in open access, peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05847387.

Belgian Endothelial Surgical Transplant of the Cornea (BEST cornea) protocol: clinical and patient-reported outcomes of Ultra-Thin Descemet Stripping Automated Endothelial Keratoplasty (UT-DSAEK) versus Descemet Membrane Endothelial Keratoplasty (DMEK) - a multicentric, randomised, parallel group pragmatic trial in corneal endothelial decompensation.

OBJECTIVES: Corneal blindness is the third most frequent cause of blindness globally. Damage to the corneal endothelium is a leading indication for corneal transplantation, which is typically performed by lamellar endothelial keratoplasty. There are two conventional surgical techniques: Ultra-Thin Descemet Stripping Automated Endothelial Keratoplasty (UT-DSAEK) and Descemet Membrane Endothelial Keratoplasty (DMEK). The purpose of this study is to compare both techniques. METHODS AND ANALYSIS: The trial compares UT-DSAEK and DMEK in terms of clinical and patient reported outcomes using a pragmatic, parallel, multicentric, randomised controlled trial with 1:1 allocation with a sample size of 220 participants across 11 surgical centres. The primary outcome is the change in best-corrected visual acuity at 12 months. Secondary outcomes include corrected and uncorrected vision, refraction, proportion of high vision, quality of life (EQ-5D-5L and VFQ25), endothelial cell counts and corneal thickness at 3, 6 and 12 months follow-up appointments. Adverse events will also be compared 12 months postoperatively. ETHICS AND DISSEMINATION: The protocol was reviewed by ethical committees of 11 participating centres with the sponsor centre issuing the final definitive approval. The results will be disseminated at clinical conferences, by patient partner groups and open access in peer-reviewed journals. GOVERNANCE OF THE TRIAL: Both, trial management group and trial steering committee, are installed with representatives of all stakeholders involved including surgeons, corneal bankers, patients and external experts. TRIAL REGISTRATION NUMBER: NCT05436665.

New keratoconus staging system based on OCT.

PURPOSE: To establish a numerical spectral-domain optical coherence tomography (SD-OCT)-based keratoconus (KC) staging system and compare it with existing KC staging systems. SETTING: Eye Hospital of Wenzhou Medical University, Wenzhou, China. DESIGNS: Retrospective case-control study. METHODS: Scheimpflug tomography, air-puff tonometry, and SD-OCT were performed on 236 normal and 331 KC eyes. All SD-OCT-derived parameters of the corneal epithelium and stroma were evaluated based on their receiver operating characteristic (ROC) curves, area under the curve (AUC), sensitivity, and specificity to discriminate between normal and KC eyes. The best performing parameters were subsequently used to create an OCT-based staging system, which was compared with existing tomographic and biomechanical staging systems. RESULTS: 236 eyes from 236 normal patients and 331 eyes from 331 KC patients of different stages were included. The highest ranked AUC ROC SD-OCT parameters, derived from stroma and epithelium, were stroma overall minimum thickness (ST: AUC 0.836, sensitivity 90%, specificity 67%) and epithelium overall SD (EP: AUC 0.835, sensitivity 75%, specificity 78%). A numerical SD-OCT staging system called STEP including 2 parameters-"ST" and "EP"-with 5 stages was proposed. CONCLUSIONS: The new SD-OCT-based KC staging system is the first to take the epithelium with its sublayer stroma information into account, showing a strong agreement to the existing staging systems. This system could be incorporated into daily practice, potentially leading to an overall improvement in KC treatment and follow-up management.

Ocular Surface Homeostasis After Scleral Lens Usage.

OBJECTIVES: The aim of this prospective study is to examine the effects of 5 hours of well-fitted, mini-scleral contact lens (mini-SL) wear on the tear film cytokine expression in healthy eyes. METHODS: Twenty-three healthy participants were included in the study. One eye of each participant was selected at random, and a mini-SL measuring 16.5 mm in diameter was fitted by an experienced contact lens specialist. The contact lens remained in place for 5 hours. Precorneal tear fluid was collected using capillary tubes at three different time points: baseline before SL insertion (T0), after 5 hours of SL wear (T1), and 3 hours after SL removal (T2). The concentration of 40 inflammatory cytokines at the three different time points was determined using multiplex bead assay. RESULTS: Mini-scleral lens wear did not result in significant changes in the cytokine-to-protein ratio after 5 hours of wear on a healthy eye. CONCLUSIONS: Although a well-fitted mini-SL reduces the rate at which the precorneal tear film is refreshed, 5 hours of lens wear did not appear to significantly affect the tears cytokine-to-protein ratio, suggesting that scleral lenses have minimal impact on corneal cytokine expression.

Early and late-onset cell migration from peripheral corneal endothelium.

In this study we describe peripheral corneal endothelial cell migration in vitro in the absence and presence of a ROCK-inhibitor. For this study, 21 corneal endothelial graft rims, with attached trabecular meshwork (TM), were prepared from Descemet membrane-endothelial cell sheets by 6.5 mm trepanation. For the initial proof-of-concept, 7 outer graft rims were cultured in a thermo-reversible hydrogel matrix for up to 47 days. To assess the effect of a ROCK-inhibitor, 14 paired outer rims were cultured either with or without ROCK-inhibitor for up to 46 days. At the end of culture, tissue was retrieved from the hydrogel matrix and examined for cell viability and expression of different endothelial cell markers (ZO-1, Na+/K+-ATPase, NCAM, glypican, and vimentin). All cultured rims remained viable and displayed either single regions (n = 5/21) or collective areas (n = 16/21) of cell migration, regardless of the presence or absence of ROCK-inhibition. Migration started after 4±2 days and continued for at least 29 days. The presence of ROCK-inhibitor seemed to contribute to a more regular cell morphology of migrating cells. In addition, 7 outer rims demonstrated a phenotypically distinct late-onset but fast-growing cell population emerging from the area close to the limbus. These cells emerged after 3 weeks of culture and appeared less differentiated compared to other areas of migration. Immunostaining showed that migrated cells maintained the expression patterns of endothelial cell markers. In conclusion, we observed 2 morphologically distinct migrating cell populations with the first type being triggered by a broken physical barrier, which disrupted contact inhibition and the second, late-onset type showing a higher proliferative capacity though appearing less differentiated. This cell subpopulation appeared to be mediated by stimuli other than loss of contact inhibition and ROCK-inhibitor presence. Further exploration of the differences between these cell types may assist in optimizing regenerative treatment options for endothelial diseases.

Combinations of Scheimpflug tomography, ocular coherence tomography and air-puff tonometry improve the detection of keratoconus.

PURPOSE: To determine whether combinations of devices with different measuring principles, supported by artificial intelligence (AI), can improve the diagnosis of keratoconus (KC). METHODS: Scheimpflug tomography, spectral-domain optical coherence tomography (SD-OCT), and air-puff tonometry were performed in all eyes. The most relevant machine-derived parameters to diagnose KC were determined using feature selection. The normal and forme fruste KC (FFKC) eyes were divided into training and validation datasets. The selected features from a single device or different combinations of devices were used to develop models based on random forest (RF) or neural networks (NN) trained to distinguish FFKC from normal eyes. The accuracy was determined using receiver operating characteristic (ROC) curves, area under the curve (AUC), sensitivity, and specificity. RESULTS: 271 normal eyes, 84 FFKC eyes, 85 early KC eyes, and 159 advanced KC eyes were included. A total of 14 models were built. Air-puff tonometry had the highest AUC for detecting FFKC using a single device (AUC = 0.801). Among all two-device combinations, the highest AUC was accomplished using RF applied to selected features from SD-OCT and air-puff tonometry (AUC = 0.902), followed by the three-device combination with RF (AUC = 0.871) with the best accuracy. CONCLUSION: Existing parameters can precisely diagnose early and advanced KC, but their diagnostic ability for FFKC could be optimized. Applying an AI algorithm to a combination of air-puff tonometry with Scheimpflug tomography or SD-OCT could improve FFKC diagnostic ability. The improvement in diagnostic ability by combining three devices is modest.

Matrix metalloproteinase-3 (MMP-3)-mediated gene therapy for glaucoma.

Approximately 80 million people globally are affected by glaucoma, with a projected increase to over 110 million by 2040. Substantial issues surrounding patient compliance remain with topical eye drops, and up to 10% of patients become treatment resistant, putting them at risk of permanent vision loss. The major risk factor for glaucoma is elevated intraocular pressure, which is regulated by the balance between the secretion of aqueous humor and the resistance to its flow across the conventional outflow pathway. Here, we show that adeno-associated virus 9 (AAV9)-mediated expression of matrix metalloproteinase-3 (MMP-3) can increase outflow in two murine models of glaucoma and in nonhuman primates. We show that long-term AAV9 transduction of the corneal endothelium in the nonhuman primate is safe and well tolerated. Last, MMP-3 increases outflow in donor human eyes. Collectively, our data suggest that glaucoma can be readily treated with gene therapy-based methods, paving the way for deployment in clinical trials.

Corneal Neurotization-Indications, Surgical Techniques and Outcomes.

Corneal neurotization is a promising surgical approach for the treatment of moderate to severe neurotrophic keratopathy. This technique aims to restore corneal sensation by transferring healthy nerves, either directly or via a conduit, to the anesthetic cornea. This review provides a report on the current state of development, evidence, and experience in the field. We summarize the data available from clinical reports and case series, placing an emphasis on the diversity of the surgical techniques reported. While these data are encouraging, they also highlight the need for a consensus in reporting outcomes and highlight how the next step will involve validating putative outcome parameters when researching and reporting corneal neurotization surgery.

Safety of the bag-in-the-lens implantation regarding the development of clinically significant pseudophakic cystoid macular edema: A retrospective case series study.

PURPOSE: To determine the incidence of clinically significant pseudophakic cystoid macular edema (CSPME) after phacoemulsification using the 'bag-in-the-lens' lens (BIL) implantation technique and to examine the influence of associated risk factors for clinically significant pseudophakic macular edema (CSPME), both ocular and systemic. METHODS: This retrospective study included 2419 first-operated eyes of 2419 adults who underwent phacoemulsification cataract surgery using the BIL implantation technique between January 2013 and December 2018 in the Antwerp University Hospital, Belgium. The significance of several risk factors (age, gender, previous history, intra- and postoperative complications) was examined by extraction of electronic medical files. RESULTS: The 3-month incidence of CSPME in the subgroup without risk factors was 0.00% (95% CI: 0.00 -NA). The 3-month incidence of CSPME in the subgroup with risk factors was 0.57% (95% CI 0.22-1.29%). The 3-month incidence of CSPME in the total population of 2419 patients was 0.29% (95% CI: 0.11-0.65%). The risk factors most significantly associated with CSPME included renal insufficiency (hazard ration [HR]: 5.42; 95% CI: 1.69-17.44; P = .014), exudative age-related macular degeneration (HR: 74.50, 95% CI: 25.75-215.6; P < .001) and retinal vein occlusion (HR: 22.48, 95% CI: 4.55-111.02; P = .005). CONCLUSIONS: In the absence of risk factors, the incidence of CSPME was zero. We can conclude that Primary Posterior Continuous Curvilinear Capsulorhexis (PPCCC) does not increase the risk for CSPME. Non-inferiority of the BIL implantation regarding the development of CSPME, relative to the traditional 'lens-in-the-bag' (LIB) implantation, confirms that BIL is a safe surgical technique. This study also illustrates a previously undescribed risk factor for developing CSPME, namely renal insufficiency.

The Management of Chemosis after Blepharoplasty.

Chemosis is a common, though typically temporary complication of both upper and lower blepharoplasty surgery, though it is much more common after the latter. It occurs due to extravasation of fluid into the subconjunctival space precipitated by desiccation, inflammation, and manipulation of the conjunctiva and associated lymphatic drainage. Intraoperatively, minimizing surgical exposure and manipulation as well as maintaining a moist ocular surface can reduce the risks. Postoperatively, we propose a stepwise approach, starting with lubricants and escalating to increasingly potent anti-inflammatories with compression bandaging and surgery reserved for persistent cases.

Wave-like calcification on the posterior surface of an acrylic hydrophilic bag-in-the-lens (BIL) implant.

Purpose: To report secondary opacification of a hydrophilic bag-in-the-lens (BIL) which is a rare manifestation that can happen years after initial surgery. Observations: We describe a case of a prominent wave-like, rippled opacification on the posterior surface of the BIL. The opacification was composed of calcium deposits and seems to start in the periphery as a ring and progresses to the centre of the posterior surface. Due to the specific design of the BIL, there is direct contact between the BIL and the posterior chamber, both with the space of Berger, and the anterior hyaloid, particularly in this very hyperopic eye. Conclusions and importance: Abnormal fluid flow and stagnation in an unusual retrolenticular space is a possible explanation for this unusual pattern of posterior surface opacification.