Combination of a monofocal and one type of extended depth-of-focus (zonal refractive) intraocular lens (COMEDI) in bilateral cataract surgery protocol: a monocentric, randomised, parallel group trial in cataract surgery.

INTRODUCTION: Modern intraocular lens (IOL) designs for cataract treatment can be broadly classified into three focal range categories; monofocal, extended depth-of-focus (EDOF) and multifocal IOLs.Monofocal IOLs allow spectacle independence for one focus, typically distance. In contrast, EDOF IOLs provide a greater range of vision, extending spectacle independence to intermediate distance, while multifocal IOLs enable spectacle independence at all distances with the drawback of positive dysphotopsias and reduced contrast perception.EDOF lenses are an attractive compromise with fewer dysphotopic side effects than multifocals. The purpose of this study is to assess whether implanting an EDOF IOL in the second eye of a patient who received a monofocal IOL in the first eye can improve spectacle independence while maintaining the same optical quality as bilateral monofocal IOL implantation. METHODS AND ANALYSIS: This study compares combined monofocal and EDOF IOL implantation versus bilateral monofocal IOL implantation in terms of clinical and patient-reported outcomes in a monocentric, randomised, patient-masked and assessor-masked, parallel group trial in 88 bilateral cataract patients. The primary outcome measure is binocular photopic distance corrected intermediate visual acuity. The secondary outcome measures include (un)corrected distance and near visual acuity, reading speed at intermediate distance, quality of visual function assessments, patient-reported spectacle independence, contrast sensitivity, aberrometry, stereopsis and straylight measurement at the 3-month follow-up. ETHICS AND DISSEMINATION: The protocol was approved by the ethical committee of the University Hospital of Brussels (BUN 23219_EDOF). TRIAL REGISTRATION NUMBER: NCT06002399.

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.

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.

Emphysema of the periorbital region and mediastinum in a young child following a dental procedure.

A 5-year-old boy presented with periorbital swelling due to craniofacial emphysema after a dental procedure. Computed tomography also revealed emphysema of the mediastinum. Pneumoparotitis and anesthesia mumps were considered in the differential diagnosis; however, Stensen's duct as well as the parotid itself appeared normal. It was determined that the most probable cause was dissection of soft tissues around the tooth using air-driven dental handpieces or air syringes, causing air to spread from the buccal, sublingual, and submandibular spaces to the mediastinal compartment inferiorly and cervicofacial compartment superiorly.

Bilateral Corneal Perforation in a Patient Under Anti-PD1 Therapy.

ABSTRACT: Immune checkpoint inhibition has improved the clinical outcomes for numerous patients with cancer. However, the downside is a whole new spectrum of immune-related adverse events. We report a 68-year-old man with a history of nonsmall cell lung cancer presenting with a spontaneous corneal perforation in the right eye after 22 cycles of pembrolizumab. In addition, a chronic central nonhealing epithelial defect developed after performing a penetrating keratoplasty. Treatment with autologous serum drops resulted in complete healing of the corneal ulcer, where other conventional therapies had no effect. One month after reinitiating pembrolizumab therapy, our patient presented again with a corneal perforation in the fellow eye. This case describes relapsing sterile ulcerations associated with pembrolizumab use and presents an unexpected cure.

Epidemiology of bacterial corneal ulcers at tertiary centres in Vancouver, B.C.

OBJECTIVE: To report the epidemiology of culture-positive bacterial corneal ulcers in Vancouver, B.C., Canada. DESIGN: Retrospective, observational case series. METHODS: Predetermined search terms were entered into the hospitals' electronic microbiology databases to create a cohort of patients who had undergone corneal scrapings for ulcers from April 2006 to March 2011. All specimens were plated on culture media. Cultured species were identified, and antimicrobial sensitivities were obtained. Clinical charts were then reviewed to identify associated risk factors. RESULTS: In total 281 corneal scrapings were included, with a positive culture recovery rate of 75%. Bacterial keratitis accounted for 84.8% of culture-positive ulcers, followed by fungi (10%) and finally Acanthamoeba (5.2%); 73% of ulcers were monomicrobial in origin and 28% polymicrobial. We found an increase in Gram-negative micro-organisms over time. General sensitivity to antibiotics did not change over time. A major risk factor for Gram-positive involvement was ocular surface disease, whereas contact lens wear was a major risk factor for Gram-negative involvement. CONCLUSIONS: Bacterial keratitis was found to be the major cause of infectious keratitis in Vancouver, B.C. The majority of bacterial ulcers were caused by Gram-positive bacteria. However, we found an increase in Gram-negative involvement over time. Contact lens wear was identified as the major risk factor for development of Gram-negative ulcers. Pre-existing ocular disease was associated with Gram-positive infection. Susceptibility of Gram-negative bacteria to common broad-spectrum antibiotics was high, but susceptibility of Gram-positive bacteria to these antibiotics was lower and more variable.

Dose-response in choroidal melanoma.

PURPOSE: In choroidal melanoma the radiation threshold dose for local control remains largely unknown. The present study examined a group of patients that received a wide range of minimum tumor dose in order to investigate a dose-response relationship. A literature review is performed to compare our results with available evidence in brachytherapy and charged particle external beam radiotherapy. MATERIALS AND METHODS: A retrospective study was conducted on all choroidal melanomas treated with Strontium-90 (Sr-90) at the University Hospital of Leuven between 1983 and 2012. Local failure was defined as primary endpoint and was estimated according to the competing risk method. RESULTS: In 135 patients, the minimum tumor dose (Dmin) ranged from 0 Gy to 287 Gy (median: 27.6 Gy). Multivariable analysis revealed Dmin ≥ 65 Gy (p = 0.04; HR = 0.09) and tumor distant from the optic disc (p < 0.001, HR = 0.09) to be independent variables favoring local control. The scleral dose, the tumor diameter and tumor height did not significantly affect local failure in multivariate analysis. CONCLUSION: This is the first study to examine a group of patients treated with a Dmin ranging from 0 Gy to >250 Gy. Treatment with a Dmin of 65 Gy is necessary to achieve durable tumor response. The dose-response data provided by our study could be used for the design of future trials examining the ideal dose for the treatment of choroidal melanoma with brachytherapy or charged particle external beam radiotherapy.

Focal limbal stem cell deficiency associated with soft contact lens wear.

OBJECTIVE: The aim of this study is to summarize the clinical characteristics of patients with contact lens-associated focal limbal stem cell deficiency (FLSCD) from a tertiary corneal referral centre. DESIGN: Retrospective, observational case series in a tertiary care centre. METHODS: Patients with contact lens-associated FLCSD were identified in our database. Clinical data were retrieved by chart review. A questionnaire asking for contact lens brand, type, cleaning solution, and duration of contact lens wear was sent to the patients with telephone follow-up. Clinical features and recovery time were identified. RESULTS: Twenty-seven eyes of 17 patients were identified with superior corneal whorl-like patches of opaque epithelium, sometimes accompanied by neovascularization. Of the patients, 17/17 used soft contact lenses, with a mean wearing duration of 11.4 hours per day. Patients had been wearing lenses for an average of 18.1 years. Silicone hydrogel lenses were noted in 12/17 cases. LSCD was superior in all 27 eyes, and all of them improved with contact lens wear cessation, preservative-free topical steroids, and preservative-free artificial tears. Visual acuity improved from 20/28 to 20/22 (p < 0.001). CONCLUSIONS: Contact lens-associated FLSCD typically presents in the superior cornea with whorl-like epithelial opacities advancing from the limbus. Conservative medical treatment is available and shows a high success rate after a slow recovery.

Unilateral Keratoconus after Chronic Eye Rubbing by the Nondominant Hand.

INTRODUCTION: To report the development of unilateral keratoconus in a healthy male after persistent unilateral eye rubbing by the nondominant hand which was not needed for professional activities. METHODS: Observational case report. RESULTS: A 60-year-old male was first seen in our clinic due to decreased vision in his left eye. Slit-lamp biomicroscopy of the left eye revealed Vogt's striae, stromal thinning, and a stromal scar. Corneal topography showed a stage 4 keratoconus. Clinical examination and corneal topography of the right eye were normal. Medical history revealed a habit of chronic eye rubbing only in the left eye because of the right hand being occupied for professional needs. During follow-up of 5 years, Scheimpflug images of the right eye stayed normal while the left eye showed a stable cone. DISCUSSION: This case report supports the hypothesis of mechanical fatigue of the cornea due to repetitive shear stress on the surface caused by eye-rubbing.

Corneal Cross-Linking in Pediatric Patients With Progressive Keratoconus.

PURPOSE: To evaluate corneal cross-linking (CXL) in the treatment of keratoconus in pediatric patients. Specifically, this study investigates the impact of CXL on uncorrected distance visual acuity (UDVA), best-corrected distance visual acuity (BDVA), manifest refraction, keratometry (K) measurements, and higher order aberrations. METHODS: This is a retrospective, observational case series of patients 18 years old or younger with progressive keratoconus who underwent CXL from January 2009 to August 2013. Preoperative and 1-year postoperative data including BDVA, manifest refraction, mean K readings, and corneal aberration measurements were extracted from clinical charts and topographical imaging. Visual acuity was converted to logarithm of the minimum angle of resolution (logMAR) scale, and mean refractive spherical equivalent (MRSE) was calculated from manifest refraction. RESULTS: The group consisted of 39 eyes from 28 patients, including 21 males and 7 females (mean age = 16.3 years, range: 11-18, standard deviation [SD] = 1.81). UDVA did not change significantly (preoperative UDVA = 1.20 logMAR, SD = 0.57, and postoperative UDVA = 0.90 logMAR, SD = 0.67, P = 0.19). BDVA did not change significantly (preoperative BDVA = 0.34 logMAR, SD = 0.27, and postoperative BDVA = 0.34 logMAR, SD = 0.23, P = 0.50). There was no significant change in mean K (preoperative K = 48.49, SD = 5.44, and postoperative K = 48.25, SD = 4.74, P = 0.34). Mean MRSE did not change significantly (preoperative MRSE = -3.29 D, SD = 4.04, and postoperative MRSE = -3.53 D, SD = 4.07, P = 0.31). Corneal aberration measurements were available for 10 eyes, and stability of measurements was demonstrated. There were no complications noted. CONCLUSIONS: This study suggests that CXL is a safe and effective procedure that halts the progression of keratoconus in pediatric patients at 1-year follow-up. To validate these findings, longer follow-up is required.

Scrolling Characteristics of Pre-Descemet Endothelial Keratoplasty Tissue: An Ex Vivo Study.

PURPOSE: To evaluate the scrolling propensity of pre-Descemet endothelial keratoplasty (PDEK) tissue and to compare it with each component of the PDEK tissue, namely the pre-Descemet layer (Dua's layer [PDL]) and the Descemet membrane (DM). DESIGN: Experimental laboratory investigation. METHODS: Fourteen human donor sclerocorneal discs in which a type 1 big bubble was obtained by stromal injection of air were studied. The wall of the type 1 big bubble was excised and its grade of scrolling noted. The components of the wall (ie, the DM and PDL) were then separated and the scrolling of each was individually graded. Statistical comparison of the grade of scrolling of each layer and correlation with age was carried out; 25-µm slices of anterior and posterior stroma obtained with the femtosecond laser from 4 control samples were used for comparison. The main outcome measure was the grade of scrolling of PDEK tissue in comparison with PDL and DM. RESULTS: Mean donor age was 67 years. The mean grade of the scroll formed by PDEK tissue was1.6 compared to 0.64 for PDL alone and 3.6 for DM alone. The difference was statistically significant. No correlation between donor age and degree of scrolling for any of the tissues tested was found. CONCLUSION: PDEK tissue scrolls less than DM. PDL scrolls the least. This demonstrates that PDL tissue splints the DM and reduces its scrolling in PDEK. This feature has relevance to tissue preparation, handling, and unscrolling in the eye during endothelial keratoplasty.

The influence of prior hyperthyroidism on euthyroid graves' ophthalmopathy.

Background. To investigate the influence of previous exposure to elevated thyroid hormones in euthyroid Graves' ophthalmopathy. Design. Retrospective, observational case series in university setting Median follow-up of 1 year with ranges of 0,8-7,6 years. Study performance of 10 years. Participants. We reviewed the clinical records of 731 Graves' ophthalmopathy patients. There were 88 (12%) patients with onset of Graves' ophthalmopathy during euthyroidism: 37 (5%) patients had ophthalmopathy without known history of thyroid dysfunction (group A) and 51 patients (6%) had onset of ophthalmopathy 6 months or more euthyroid after completion of antithyroid therapy (group B). Main Outcome Measures. Graves' ophthalmopathy was graded using the EUGOGO severity criteria. Unilaterality was investigated. TSH receptor antibody and thyroid peroxidase antibody were measured as markers of Graves' disease. Results. Group A had more often a normal ocular motility (46%) and less proptosis (14 ± 4 mm) compared to group B (22%, 16 ± 4 mm) (P = 0.032 and 0.028, resp.). TSH receptor antibody was more frequently elevated in group B (94%) than in group A (17%) (P < 0.001). Conclusion. Patients with euthyroid Graves' ophthalmopathy present more often with ocular muscle restriction and proptosis when previously exposed to elevated thyroid hormones.

Series of extranodal natural killer/T-cell lymphoma, nasal type, with periorbital involvement.

PURPOSE: To describe the clinical presentation, diagnosis and treatment of periorbital extranodal natural killer/T-cell lymphoma, nasal type. METHODS: Case series of three patients with periorbital involvement of extranodal natural killer/T-cell lymphoma, nasal type, of whom clinical data, orbital imaging and immunohistochemical analysis were collected. For the purpose of this study, all histopathological and immunohistochemical slides were re-examined. RESULTS: All patients presented with painless eyelid swelling and a history of sinonasal disease, of whom one with bilateral panuveitis, not responding to systemic antibiotics. Extraocular muscle involvement was present in 2 cases upon presentation and in 1 case later on. Initial paranasal and orbital biopsies were negative in 2 patients, with only the second orbital biopsy leading to the diagnosis. Natural killer/T-cell and cytotoxic markers were present in all cases, as well as Epstein-Barr virus encoded RNA in situ hybridization. The patients died respectively 5, 9 and 35 months from diagnosis despite treatment with chemotherapy and radiotherapy. CONCLUSION: Extranodal natural killer/T-cell lymphoma, nasal type, should be suspected in a painless periorbital cellulitis with chronic sinusitis, not responding to conventional therapy. A high index of suspicion is necessary in biopsies showing angiodestruction and necrosis. Epstein-Barr virus encoded RNA in situ hybridization and expert hematopathologist consultation is necessary to decrease the delay in diagnosis.