Peripheral Ulcerative Keratitis Associated With Lichen Planus.

PURPOSE: The aim of this study was to report a case of peripheral ulcerative keratitis (PUK) associated with lichen planus. METHODS: A 42-year-old woman with histological confirmation of lichen planus from an oral buccal mucosa biopsy presented with bilateral peripheral stromal thinning and an epithelial defect, in keeping with PUK. RESULTS: All screening for known causes of PUK were negative, and lichen planus was presumed as the etiological factor. Oral prednisolone 1 mg/kg was initiated, alongside topical steroids and topical ciclosporin. The PUK resolved after 3 months, and a slow-tapering regimen of oral prednisolone was needed to prevent a relapse of ocular surface inflammation. Topical steroids were also tapered and discontinued after 5 months, and the ocular surface remained stable with topical ciclosporin with no relapse after 1 year. CONCLUSIONS: Ocular manifestations of lichen planus are rare and mostly involve the conjunctiva; however, PUK might also develop, presumably due to its similar mechanisms with other T-cell autoimmune diseases. Systemic immunosuppression is required initially but further control of the ocular surface can be achieved successfully with topical ciclosporin.

Necrotizing Blepharoconjunctivitis and Keratitis in Human Monkeypox.

Importance: Ophthalmic manifestations occur in less than 5% of patients with human mpox (monkeypox), most commonly presenting with self-limiting conjunctivitis and keratitis. Cases with severe ophthalmic complication are uncommon. Objective: To present a case of human mpox with sight-threatening necrotizing blepharoconjunctivitis. Design, Setting, and Participants: This is a report of a patient who developed necrotizing conjunctivitis due to the monkepox virus at a large university hospital. Data were collected from July to October 2022. Main Outcomes and Measures: Description of the progression and clinical evaluation of the ocular condition and the management. Results: A 63-year-old HIV-positive man presented initially with conjunctivitis and eyelid swelling and developed skin lesions from monkeypox virus 2 days later. Despite remaining stable systemically, after 4 days, his ophthalmic condition evolved to necrotizing blepharoconjunctivitis for which systemic antiviral treatment with tecovirimat was given along with topical trifluoridine, 1%, eye drops. In addition, he required repeated tissue debridement with amniotic membrane grafting to preserve the eye integrity. Conclusions and Relevance: The severity of this observation was associated with a coexisting immunocompromised state and appeared similar to findings associated with other orthopoxviruses. Ophthalmic manifestations could be the initial presentation of human mpox and could also be severe. Early recognition and intervention may limit the likelihood of substantial ocular morbidity.

Safety-Net Suture for Aphakic Descemet Membrane Endothelial Keratoplasty.

PURPOSE: The purpose of this research was to describe a low-cost, accessible method for reducing the risk of posterior donor dislocation in Descemet membrane endothelial keratoplasty (DMEK) performed in eyes with aphakia and a large iris defect (unicameral eyes)-the "safety-net suture." METHODS: We review 3 cases of aphakic bullous keratopathy in unicameral eyes treated successfully using DMEK aided by a simple technique to create a temporary, partial barrier between the anterior and posterior chambers. The safety-net suture technique is based on a continuous 10-0 polypropylene suture placed across the anterior chamber in a cat's-cradle pattern anterior to the trabecular meshwork. At the end of surgery, after air tamponade of the DMEK donor, the 10-0 polypropylene suture is removed. RESULTS: All 3 cases were completed with no intraoperative posterior dislocation. A partial postoperative detachment in 1 case was successfully treated with repeat air tamponade. The corneas remain clear in early follow-up, 1 to 10 months after surgery. CONCLUSIONS: The safety-net suture is a simple, low-cost method of reducing the risk of intraoperative posterior dislocation for DMEK in unicameral, aphakic eyes.

"The Spinning Technique" for Unfolding Tightly Scrolled DMEK Grafts.

PURPOSE: We present a no-touch Descemet membrane endothelial keratoplasty (DMEK) technique which assists in unfolding of tightly scrolled grafts from young donors. METHODS: The technique was developed following a wet-laboratory experiment using human corneas created to observe the behavior of the graft during spinning within the artificial anterior chamber. This approach involves injecting short bursts of balanced salt solution to make the scroll spin continuously in a 360-degree manner. Spinning of the graft over the surface is accompanied by rotation on its horizontal axis resulting in opening in the correct orientation. Unfolding is then completed with standard bimanual tapping maneuvers. The spinning technique was then performed in 4 patients who all had tight DMEK scrolls from young donors. RESULTS: The wet laboratory confirmed that directed jets of fluid to generate spinning and rotation open the graft in the correct orientation in most occasions. All 4 cases in this study received grafts from young donors (range 37-48 years old), and the technique achieved rapid unfolding with no complications. Two of our patients had glaucoma drainage devices, 1 had anterior chamber intraocular lens, and all other cases had clear corneas and good endothelial cell count after the 1-year follow-up. CONCLUSIONS: Our novel technique provides a safe and effective method to unscroll tight DMEK grafts that surgeons could incorporate into their armamentarium. Success is optimized by slightly undersizing the graft (7.5-8.0 mm).

Corneal Perforation in Patients Under Treatment With Dupilumab for Atopic Dermatitis.

PURPOSE: We report, for the first time, 2 cases of corneal ulceration and perforation after treatment with dupilumab for atopic dermatitis. METHODS: A 30-year-old woman and a 44-year-old man developed unilateral severe corneal ulceration and perforation while on dupilumab therapy after 3 and 9 months, respectively. RESULTS: Corneal cultures were negative in both cases except for scanty growth of Staphylococcus species on enrichment. Both cases progressed to perforation despite intensive topical antibiotic treatment. The first case required a tectonic keratoplasty to restore globe integrity after failed attempts of corneal gluing and multilayer amniotic membrane transplantation, and the second case was managed successfully with a cyanoacrylate glue patch. CONCLUSIONS: Although there have been previous reports of conjunctival injection and dry eye after dupilumab, these are the first 2 reports of corneal ulceration with rapid progression to perforation in patients under treatment with dupilumab. The underlying pathophysiology for ulcerative keratitis in these cases remains unknown, but there is no doubt that cessation of dupilumab prevented progression of the melting. Severe ocular symptoms while on dupilumab require a prompt discussion with the dermatology team to potentially switch treatment and halt further keratitis progression.

Corneal Neurotization Using the Great Auricular Nerve for Bilateral Congenital Trigeminal Anesthesia.

PURPOSE: The purpose of this study was to describe an indirect corneal neurotization (CN) technique for congenital bilateral trigeminal anesthesia using the greater auricular nerve (GAN) as a donor. METHOD: CN was performed to preserve the integrity of the only seeing eye in a 4-year-old boy with pontine tegmental cap dysplasia and bilateral trigeminal anesthesia. He had recurrent corneal ulceration and scarring despite full medical treatment. The GAN was used as a donor, and the sural nerve was harvested and used as a bridge which was tunneled to the sub-Tenon space in the inferior fornix. The fascicles were distributed into the 4 quadrants and sutured to the sclera near the limbus. RESULT: This technique resulted in providing corneal sensation and improving stability of the epithelium. Corneal opacity gradually decreased allowing significant visual improvement evidenced in the early postoperative months. CONCLUSIONS: Using the GAN technique for CN bypasses trigeminal innervation and has the potential to improve corneal sensation. The GAN is a large caliber nerve and provides a large amount of axons and robust neurotization. This technique would be desirable for cases with bilateral congenital trigeminal anesthesia, such as pontine tegmental cap dysplasia.

Mini-DSAEK for Macro Corneal Perforations.

PURPOSE: We present a technique that preserves good vision in paracentral macroperforations and avoids challenges of tectonic lamellar or penetrating keratoplasty in eyes with poor visual potential. METHOD: A wet laboratory was implemented for mini-Descemet stripping endothelial keratoplasty to seal macroperforations ab interno. This included a suture support technique designed to prevent graft herniation. We also present 3 cases who were treated successfully with this technique. RESULTS: The laboratory test confirmed that mini-Descemet stripping endothelial keratoplasty can successfully seal macroperforations without the need of large incisions. The minidisc is introduced through the perforation, and a double mattress suture prevents graft herniation. The technique allowed us to preserve 20/15 unaided vision in a case with paracentral macroperforation. It also restored eye globe integrity and achieved long-term stability in 2 cases with limbal stem-cell deficiency. CONCLUSIONS: Mini-Descemet stripping-automated endothelial keratoplasty technique can be an alternative approach to avoid poor visual outcomes of tectonic keratoplasty in paracentral perforations. It also offers host tissue preservation in eyes with high risk of rejection for tectonic grafts.

Severe Keratitis and Corneal Perforation by Paenibacillus glucanolyticus.

PURPOSE: To report the first case of Paenibacillus glucanolyticus, a spore-forming bacteria, to be isolated in a human ocular infection. METHODS: We describe a severe case of noncontact lens-related microbial keratitis due to P. glucanolyticus presenting with a large corneal abscess, severe ocular inflammation, and a large epithelial defect. RESULTS: The corneal scrapes with no growth initially cultured P. glucanolyticus on blood agar after 48 hours, with sensitivity to gentamicin and fluoroquinolones. No other organism was cultured. The patient had severe keratitis with a protracted course requiring cyanoacrylate glue patching because of keratolysis and perforation. The patient may benefit from a penetrating keratoplasty and extracapsular cataract extraction in due course to aid visual rehabilitation. CONCLUSIONS: This is the first reported ocular case of P. glucanolyticus demonstrating its bacterial virulence and pathogenic potential when infecting the cornea. Rapid identification with newer technology enable us to accurately identify these opportunistic bacteria and may give a more favorable visual outcome as correct sensitivities lead to timely treatment administration.

Descemet Membrane Detachment After Penetrating Keratoplasty for Keratoconus.

PURPOSE: To describe the risk factors, management, and outcome of delayed Descemet membrane (DM) detachment after penetrating keratoplasty (PK) for keratoconus. METHODS: We report 7 eyes from 6 cases and combine these data with 7 previous case reports identified by a search of PubMed. RESULTS: DM detachment occurred at a median of 25 years (range, 7-33 years) after PK. One individual had bilateral detachments. There was typically a mild ocular discomfort accompanied in some cases by a rapid onset of visual blur. Cases were often treated for allograft rejection before a DM detachment was suspected and confirmed by optical coherence tomography. Detachments were limited to the donor tissue in 11 eyes, but a DM break was identified at the time of onset in only 4 eyes. Thinning of the host corneal rim with ectasia was reported in 8 eyes (57%). In 3 eyes, the detachment resolved spontaneously, but in 2 eyes, a detachment was still present at 12 months. Gas tamponade to reattach the DM was performed in 9 eyes and was effective in 4 eyes. Five eyes underwent a repeat PK or endothelial keratoplasty. Histology showed fibroblastic proliferation on the stromal surface of the folded DM. CONCLUSIONS: The cause for DM detachment many years after PK is unknown, although progressive thinning of the host cornea and secondary graft ectasia may be implicated. Gas tamponade can be effective, but a repeat keratoplasty might be necessary. DM detachment should be included in the differential diagnosis for late-onset corneal edema after PK.

Paracentesis as valve re-bubbling technique for Descemet's membrane endothelial keratoplasty (DMEK) graft detachment.

INTRODUCTION: We present a variation in the slit-lamp microscope re-bubbling technique for DMEK detachment in which a paracentesis is used as a self-sealing valve. METHODS: Of twenty-eight consecutive DMEK cases, five (18%) required re-bubbling. A 20-gauge side port blade was used to make a paracentesis in the inferior temporal quadrant. A 30-gauge cannula mounted on a 3 ml syringe was employed to inject air using the paracentesis as a valve allowing better control over intraocular pressure and percentage anterior chamber air fill. RESULTS: Graft re-attachment was achieved in all cases. One case required two re-bubbling procedures. There were no cases of pupil block glaucoma or other complications. CONCLUSION: Slit-lamp re-bubbling is a practical and safe alternative to taking patients back to the operating room. Using a new paracentesis for valve action control over air injection with a blunt cannula adds better control and may help to reduce complications.

Serious corneal complications and undiagnosed floppy eyelid syndrome; A case series and a 10-year retrospective review.

PURPOSE: To describe three individuals with severe keratitis and a substantial delay before floppy associated eyelid syndrome (FES) was identified, and to estimate the prevalence of severe corneal disease in individuals with FES. METHODS: We defined severe keratitis as corneal ulceration, vascularization or scar that affected vision. We recorded the clinical characteristics, the duration of symptoms before the diagnosis of FES, subsequent management and outcome. Then, to determine the proportion of individuals with FES who had severe corneal disease, we interrogated the Moorfields Eye Hospital electronic patient record (EPR) for the diagnosis of FES made in the ten-year interval from 2008. RESULTS: Three individuals presented with severe progressive keratitis (median duration of symptoms 19 months, range 2-48 months). All were male and with a high body mass index (BMI, range 38.9-41.2). In each the etiology of the keratitis was unclear before FES was identified. All had very lax lids and were aware they had periods of lid malposition during sleep. None mentioned symptoms of obstructive sleep apnoea (OSA) until they or their partner were directly questioned. The management of keratitis included both medical and surgical corneal treatments, with tarsorrhaphy and lid shortening surgery. We identified an additional 104 cases of FES from the EPR, of which 4 (3.8%) had severe keratitis. CONCLUSIONS: FES can be missed unless signs of lid laxity are directly elicited. A delay in diagnosis can result in clinical deterioration, with unnecessary investigations and treatments. An assessment for FES should be included as part of the evaluation of individuals with severe or chronic keratitis.

The Osteo-odonto-keratoprosthesis to restore vision after severe dog bite injury.

PURPOSE: To present our experience in Osteo-odonto-keratoprosthesis (OOKP) as the only option to restore vision after severe ocular dog bite injuries. METHODS: We describe our results in OOKP performed in two patients with previous severe dog bite facial injuries that required exenteration of one eye and facial reconstruction. RESULTS: Both cases achieved initially successful anatomical and visual outcome; however, one case suffered retinal detachment after one year. Buccal mucosa (BM) ulcerations and tilted lamina were present as a result of extraocular muscles loss, and both were difficult to treat. CONCLUSION: OOKP has the capability to restore vision in the most challenging cases of ocular trauma; however, refractory BM ulcerations and tilted lamina could be expected as a result of an ischemic ocular surface and orbital pulleys loss.

Urrets-Zavalia syndrome with interface fluid syndrome following laser in situ keratomileusis.

PURPOSE: We describe the case of a 41-year-old male that underwent laser in situ keratomileusis (LASIK) complicated by Urrets-Zavalia syndrome with interface fluid syndrome and epithelial ingrowth. OBSERVATION: The patient presented at our institution with headache and blurred vision three weeks after a right microkeratome-assisted LASIK procedure. On examination, the visual acuity was hand movements and the intraocular pressure (IOP) was 45 mmHg with fluid in the flap interface, a fixed pupil in moderate mydriasis, iris transillumination and cells in the anterior chamber. A Baerveldt tube implant was necessary to control the IOP. After three months, the corrected visual acuity was 20/40 with normal IOP and an early cataract. CONCLUSION AND IMPORTANCE: To our knowledge this is the first report of a case of combined Urrets-Zavalia syndrome and interface fluid syndrome after LASIK. We speculate that steroid induced ocular hypertension was the primary cause.

Descemet Membrane Endothelial Keratoplasty (DMEK) Graft Dislocation Into the Vitreous Cavity.

PURPOSE: To present our experience of Descemet stripping endothelial keratoplasty (DMEK) graft luxation into the vitreous cavity in 2 cases. METHODS: DMEK was performed in 2 patients with aphakic bullous keratopathy. The indications for keratoplasty were endothelial failure caused by chronic intermediate uveitis and glaucoma in 1 case and decompensated previous penetrating keratoplasty in the other. Both cases had enlarged pupils and had previously undergone pars plana vitrectomy. In both cases, the DMEK graft dislocated into the vitreous cavity during unfolding maneuvers and could not be retrieved during the same procedure. RESULTS: No signs of retinal detachment were observed during follow-up (6 months and 1 year). Although visualization of the graft was not possible on examination, B-scan confirmed the presence of the lenticule lying over the retina. One case underwent repeat DMEK, and 1 case underwent repeat penetrating keratoplasty. In 1 case, the graft was retrieved after a month and sent for histopathology. In both cases, corneal transparency and corrected visual acuity improved to full potential after the final procedure. Histopathology of the retrieved graft showed only endothelial cell loss and no fibrocellular proliferation. CONCLUSIONS: The risk of fibrous proliferation and retinal detachment after posterior dislocation of DMEK grafts may be less than in grafts including corneal stroma, but pars plana vitrectomy and retrieval of the dislocated corneal transplant are still indicated after revision corneal transplant surgery where visual symptoms or signs of fibrotic change around the dislocated graft are evident.

Phakic intraocular lens as a temporary barrier in aphakic Descemet's membrane endothelial keratoplasty.

BACKGROUND: Descemet's membrane endothelial keratoplasty has a lower risk of endothelial rejection than Descemet's stripping automated endothelial keratoplasty. In aphakic eyes requiring endothelial transplantation, approaches aimed at reducing the risk of posterior graft dislocation in Descemet's stripping automated endothelial keratoplasty are not transferable to Descemet's membrane endothelial keratoplasty. TECHNIQUE: Here we describe the use of an implantable collamer lens placed over the iris to provide a temporary intraoperative platform, to facilitate graft unfolding and to avoid posterior graft dislocation in an aphakic, vitrectomised eye with a fixed, dilated pupil in a young patient with chronic uveitis and previous failed Descemet's stripping automated endothelial keratoplasty.

Acute Glaucoma Following Cyanoacrylate Glue Patch for Corneal Perforation.

PURPOSE: To describe a case of acute glaucoma after cyanoacrylate gluing for a nontraumatic central corneal perforation. METHODS: A 55-year-old woman with history of rheumatoid arthritis and severe dry eye presented to emergency with a right central corneal perforation. She was treated successfully with the use cyanoacrylate glue patch but iridocorneal adhesions remained. The next day she presented with ocular pain, headaches, and vomiting. On examination she had shallow anterior chamber (AC) with no aqueous leakage but her intraocular pressure (IOP) was 56 mm Hg measured with rebound tonometry. An anterior segment optical coherence tomography scan showed a 360 degrees central iris adhesion with shallow AC. Topical and oral treatment for acute glaucoma was given that decreased her IOP. She then underwent urgent surgery to release the iridocorneal adhesions and restore aqueous flow that was achieved without replacing the glue patch. RESULTS: One day postoperatively her right eye was comfortable and her IOP measurement remained within normal limits. The AC was deep with no iridocorneal adhesions. CONCLUSIONS: Close monitoring of the IOP is recommendable in central corneal perforations with iris adhesions managed with cyanoacrylate glue due to the potential developing of aqueous blockage.