Clinicopathological Correlates of Ocular Surface Squamous Neoplasia.

Introduction: This study examined the distribution of histopathological disease severity amongst a cohort of patients treated for clinically suspected ocular surface squamous neoplasia and evaluated the relationship between various patient and clinical factors and the severity of pathological grade as well as treatment outcomes. Methods: A retrospective cohort study of demographic and clinicopathological factors of 150 patients clinically diagnosed with suspected ocular surface squamous neoplasia who underwent excision of lesion with histopathological diagnosis. Results: The study included 125 cases; the mean age at diagnosis was 64 years (SD = 11.26). 74% of cases were histologically confirmed as ocular surface squamous neoplasia. Pathological distribution was conjunctival intraepithelial neoplasia I (13.6%), conjunctival intraepithelial neoplasia II (16.8%), conjunctival intraepithelial neoplasia III (21.6%), carcinoma in situ (21.6%), and squamous cell carcinoma (2.4%). Lesion appearance was leukoplakic (18%), gelatinous (15%), dysplastic (11%), vascular (6%), papilliform (2%), nodular (2%). Lesion location was nasal (43%), temporal (42%), and superior or inferior (14%). Recurrence occurred in 7 cases (5.6%). A significant association was found between presence of leukoplakia and pathological grade (p = 0.05). Conclusions: Ocular surface squamous neoplasia is most frequently diagnosed in conjunctival intraepithelial neoplasia III and carcinoma in situ stages, and treatment outcomes are usually favourable.

Descemet Stripping Only Supplemented With Topical Ripasudil for Fuchs Endothelial Dystrophy 12-Month Outcomes of the Sydney Eye Hospital Study.

PURPOSE: To report early safety and efficacy of Descemet stripping only (DSO) supplemented with ripasudil. METHODS: A pre-post clinical trial with a historical control group for time to heal and cell count parameters. The study received ethics approval and was conducted with oversight of a data safety monitoring board. All enrolled patients had a superior endothelial cell count of >1000 cells/mm2 and were symptomatic from the presence of central guttata degrading vision and/or producing glare. DSO was carried out with a peeling technique and not combined with any other intervention. Ripasudil 0.4% was applied topically from day 1 postoperatively at a dose of 6 times/d until corneal clearance. Cases with relapse of edema were permitted to restart on ripasudil at a reduced dose of 2 drops/d for a further 2 weeks. Stopping rules with progression to a corneal graft were established. Baseline ocular and systemic investigations were carried out and repeated at varying intervals to monitor for local and systemic adverse events. RESULTS: Twenty-three eyes of 23 patients met the inclusion criteria and underwent DSO. Twenty-two of 23 eyes achieved corneal clearance at a mean time of 4.1 weeks. In all patients achieving clearance, improvement in vision was recorded. Improvement in mean uncorrected visual acuity was 0.20 Logarithm of the minimum angle of resolution (LogMar), and improvement in mean best spectacle corrected visual acuity was 0.156 LogMar. One patient failed to clear and underwent Descemet membrane endothelial keratoplasty at week 12. Twenty-one of 22 patients achieving corneal clearance expressed satisfaction with the procedure. The commonest systemic side effect of topical ripasudil was gastrointestinal upset (24%), and the commonest local side effect was ocular irritation (43%). No patient experienced a serious adverse event in the course of the trial. Thirty-nine percent of patients experienced a relapse of edema on ceasing ripasudil, with clearance again on recommencing. CONCLUSIONS: This trial of DSO supplemented with ripasudil included local and systemic safety analysis. We judge that this treatment option is emerging as a reliable intervention for select patients with Fuchs' Endothelial Corneal Dystrophy (FECD) with an acceptable safety profile. The observation of relapse edema is strong evidence of a drug effect. The longevity of these results remains unknown.

Temporo-Parietal Flap Incorporated Into a Modified Osteo-Odonto Keratoprostheses Protocol for Longevity of the Dental Lamina.

PURPOSE: To describe a novel pedicled temporo-parietal flap to delay laminar resorption in a modified osteo-odonto keratoprosthesis (MOOKP) and measure resorption of the dental lamina by an objective method. METHODS: A retrospective case series was performed on patients who received an osteo-odontokeratoprosthesis for Steven-Johnson-Syndrome. Surgeries were performed between October 2016 and November 2017 by the same surgical team (G.M. and S.W.). A modified temporo-parietal flap was incorporated into stage 1 of the MOOKP procedure. CT Scans were performed post op and on follow up. Volumetric evaluation was achieved by automated software analysis of 3D reconstructed CT images (Vitrea, Software Version 6.7.6, Cannon Medical Systems ANZ Pty Ltd). RESULTS: The procedure was performed in 3 eyes from 3 patients. Patients were followed up for stage 2 review at 9.6 months on average (22-55 weeks). One case was complicated by early postoperative hematoma of the buccal graft; however, this was managed conservatively. Another case required relaxing incisions at the time of flap creation due to increased vascularized collagenous tissue. On follow up, volume changes in the dental lamina were minimal. CONCLUSIONS: Loss of laminar volume can potentially jeopardize the success of the MOOKP, and consequently cause significant visual, graft or globe complications. The long-term success of this method needs further evaluation; however, initial results suggest a possible role for pedicle grafts in maintenance of the dental lamina. Furthermore, objective CT-based calculation of laminar volume may reduce inter-study variability and standardize comparison of techniques.

Descemet's stripping without endothelial keratoplasty.

PURPOSE OF REVIEW: To summarize the recent literature regarding descemetorhexis stripping without endothelial keratoplasty (DWEK), increasingly referred to as Descemet's stripping only (DSO). To report the characteristic clinical, confocal and histologic findings associated with this procedure. RECENT FINDINGS: Reported clearance rates following DSO range from 63 to 100% in recent series, with variation between surgical techniques. Topical Rho-kinase inhibitor has been reported as successfully salvaging failing cases. Its use as an adjuvant to the surgery is gaining widespread adoption with the results of early series now arriving. Apart from a phenotype of central guttata with clear periphery, patient characteristics which determine success remain elusive. Surgical factors affecting success are increasingly well understood, with stromal injury felt to be a retardant to healing. Characteristic clinical signs have been observed and are described herein. Clinical, confocal and light microscopic images are obtained from patients in clinical trials of DSO with ripasudil. SUMMARY: DSO is gaining acceptance as a surgical option for a subset of patients with Fuchs' Dystrophy. The addition of Rho-associated kinase inhibitor appears to improve predictability but further results to this effect must be published and scrutinized.

Conjunctival oedema as a potential objective sign of intracranial hypertension: a short illustrated review and three case reports.

Periorbital and conjunctival oedema has been reported anecdotally by patients with raised intracranial pressure states. We present three clinical cases of this phenomenon and discuss the current evidence for pathways by which cerebrospinal fluid (CSF) drains in relation to conjunctival oedema. We reviewed the available literature using PubMed, in regards to conjunctival oedema as it relates to intracranial hypertension, and present the clinical history, radiology and orbital photographs of three cases we have observed. Only one previous publication has linked raised intracranial pressure (ICP) to conjuctival oedema. The weight of evidence supports the observation that the majority of CSF drains along the cranial nerves as opposed to via the arachnoid projections. Conjunctival oedema may be a clinical manifestation of CSF draining via the optic nerve in elevated ICP states.

A 12-month prospective trial of inject and extend regimen for ranibizumab treatment of age-related macular degeneration.

PURPOSE: To evaluate the safety and efficacy of a strictly applied inject and extend protocol for ranibizumab treatment of age-related macular degeneration. METHODS: This is a prospective, multicenter, nonrandomized trial. Patients underwent standard induction with 3 intravitreal doses of 0.5 mg ranibizumab, each 1 month apart. Following this induction, patients were evaluated and received an injection at each visit. If they did not meet set criteria for signs of exudative disease the interval to the next visit was extended by 2 weeks and if exudative disease was present the interval was shortened by 2 weeks. RESULTS: Vision improved by 1.3 lines (P = 0.008); 26% gained ≥3 lines of vision, 74% lost no lines of vision, and 95% avoided loss of ≥3 lines of vision. CONCLUSION: This study shows that the Inject and Extend protocol is safe and efficacious for the treatment of age-related macular degeneration. Head-to-head studies are needed to compare directly with other regimens currently in use, as well as economic analysis to investigate the financial implications.