Definition and Diagnostic Criteria for Pediatric Blepharokeratoconjunctivitis.

Importance: Pediatric blepharokeratoconjunctivitis (PBKC) is a chronic, sight-threatening inflammatory ocular surface disease. Due to the lack of unified terminology and diagnostic criteria, nonspecific symptoms and signs, and the challenge of differentiation from similar ocular surface disorders, PBKC may be frequently unrecognized or diagnosed late. Objective: To establish a consensus on the nomenclature, definition, and diagnostic criteria of PBKC. Design, Setting, and Participants: This quality improvement study used expert panel and agreement applying the non-RAND modified Delphi method and open discussions to identify unified nomenclature, definition, and definitive diagnostic criteria for PBKC. The study was conducted between September 1, 2021, and August 14, 2022. Consensus activities were carried out through electronic surveys via email and online virtual meetings. Results: Of 16 expert international panelists (pediatric ophthalmologists or cornea and external diseases specialists) chosen by specific inclusion criteria, including their contribution to scientific leadership and research in PBKC, 14 (87.5%) participated in the consensus. The name proposed was "pediatric blepharokeratoconjunctivitis," and the agreed-on definition was "Pediatric blepharokeratoconjunctivitis is a frequently underdiagnosed, sight-threatening, chronic, and recurrent inflammatory eyelid margin disease associated with ocular surface involvement affecting children and adolescents. Its clinical spectrum includes chronic blepharitis, meibomitis, conjunctivitis, and corneal involvement ranging from superficial punctate keratitis to corneal infiltrates with vascularization and scarring." The diagnostic criteria included 1 or more suggestive symptoms accompanied by clinical signs from 3 anatomical regions: the eyelid margin, conjunctiva, and cornea. For PBKC suspect, the same criteria were included except for corneal involvement. Conclusions and Relevance: The agreements on the name, definition, and proposed diagnostic criteria of PBKC may help ophthalmologists avoid diagnostic confusion and recognize the disease early to establish adequate therapy and avoid sight-threatening complications. The diagnostic criteria rely on published evidence, analysis of simulated clinical cases, and the expert panel's clinical experience, requiring further validation with real patient data analysis.

Patients satisfaction and clinical outcomes of binocular implantation of a new trifocal intraocular lens.

PURPOSE: To evaluate the clinical outcomes following bilateral implantation of PanOptix intraocular lens (IOL). METHODS: This study included consecutive patients scheduled to undergo cataract or refractive lens exchange surgery between October 2017 and June 2018 at two centers. Manifest refraction, uncorrected distance visual acuity (UDVA), uncorrected intermediate visual acuity (UIVA, 60 cm) and uncorrected near visual acuity (UNVA, 40 cm), defocus curves, presence of dysphotopsia, need for spectacles, presence of posterior capsule opacification and visual function were evaluated at 6 months after surgery. RESULTS: The IOL was implanted in 138 eyes of 69 patients. The mean binocular UDVA was 0.02 ± 0.05 logMAR, UIVA 0.06 ± 0.07 logMAR and UNVA 0.05 ± 0.07 logMAR. Defocus curve showed two peaks at 0.00 D and - 1.50 D. Complete spectacle independence was reported in 94.2% of the patients. The mean VF-14 test result was 97.7 ± 2.2 (93.2-100). Only one patient (1.4%) reported seeing bothersome halos. The presence of posterior capsule opacification was noted in seven eyes (10%), whereas Nd:Yag capsulotomy was required only in one eye. CONCLUSIONS: This trifocal IOL provided excellent visual outcomes at all distances with high spectacle independence and patient's satisfaction.

Comparison of Mix-and-Match Implanted Bifocal IOLs and Bilateral Implanted Trifocal IOLs After Femtosecond Laser-Assisted Cataract Surgery.

PURPOSE: To compare the visual performance of mix-and-match implanted bifocal intraocular lenses (IOLs) and bilateral implanted trifocal IOLs from the same manufacturer with the same IOL platform after femtosecond laser-assisted cataract surgery (FLACS). METHODS: This prospective, comparative, non-randomized study included patients who underwent FLACS (LenSx; Alcon Laboratories, Inc., Fort Worth, Texas) with bilateral implantation of bifocal IOLs (ReSTOR +2.50 D/+3.00 D; Alcon Laboratories, Inc.) or trifocal IOLs (PanOptix; Alcon Laboratories, Inc.). Visual acuities, manifest refraction, defocus curve, contrast sensitivity, quality of life measured by the Visual Function Index (VF-14), and spectacle independence were assessed at 6 months after surgery. RESULTS: A total of 70 eyes of 35 patients were included in this study. There was no difference in patient demographics and preoperative measurements between groups (P > .05). There was no difference in uncorrected distance visual acuity and corrected distance visual acuity outcomes between groups (P > .05), but uncorrected intermediate visual acuity and uncorrected near visual acuity outcomes were significantly better in the PanOptix group (P < .01). Correspondingly, the binocular defocus curve of the PanOptix IOLs showed significantly better visual acuity between -1.00 and -3.00 diopters compared to the ReSTOR IOLs (P < .05). The PanOptix group showed higher contrast sensitivity scores than the ReSTOR group for 12 and 18 spatial frequencies in photopic conditions and for 18 spatial frequencies in mesopic conditions (P < .05). The average VF-14 score was similar between groups (P = .78). None of the patients required spectacles. CONCLUSIONS: Bilateral implanted PanOptix IOLs seem to provide better intermediate and near vision, defocus curve, and contrast sensitivity compared to mix-and-match implanted ReSTOR IOLs. However, similar vision-related quality of life and spectacle independence were achieved with both IOLs. [J Refract Surg. 2019;35(9):559-564.].

Role of corneal nerves in ocular surface homeostasis and disease.

Corneal nerves are key components of the physiological system that controls ocular surface homeostasis. The cornea is primarily innervated by the ophthalmic branch of the trigeminal nerves (cranial nerve V), which distend bilaterally from the pons. The nasociliary branch (afferent) of the ophthalmic nerve is sensory for cornea, eyelid and conjunctiva. These nerve fibres play a role in sensing temperature, chemical and mechanical stimuli, and pain, whereas, branches of the facial nerve (cranial nerve VII) contain motor nerves that control blinking and autonomic (sympathetic and a paucity of parasympathetic) fibres that stimulate tear production and secretion via feedback loops between the ocular surface, lacrimal glands and brain. Disruption of these nerves with interruption of neural feedback loops between the ocular surface and lacrimal glands can lead to corneal diseases such as dry eye disease (DED) and neurotrophic keratopathy (NK). Inversely, hypersensitivity of the nerve fibres and/or dysregulation of pain-controlling nervous centres may lead to neuropathic pain. Recently, medications that specifically target regeneration of corneal nerves have started to become available - and considering the high prevalence of diseases associated with corneal nerve dysfunction, these agents promise to fulfil a hitherto important unmet need. In this review, we explore the physiology of corneal nerves, the pathology of corneal nerve diseases and how these relate to neuropathic pain, NK and DED. We also discuss what novel treatments may be useful against diseases involving corneal nerves.

Controlled Adverse Environment Chambers in Dry Eye Research.

Dry eye disease (DED) is a common condition with signs and symptoms that vary depending on a wide range of environmental factors to which people are exposed in their daily lives. Factors such as variable temperature, airflow velocity, relative humidity, seasonality, and pollutants can alter the rate of tear film evaporation, improving or exacerbating symptoms of DED. Results from currently available clinical tests do not always correlate well with patient-reported symptoms, and the continually changing environment and variability in DED symptoms present challenges for the design and conduct of clinical trials. Controlled adverse environment chambers allow standardization of temperature, humidity, and airflow and may minimize potential confounding factors in clinical investigations. Their use can promote accurate study of the pathophysiology of DED, discovery of disease biomarkers, and assessment of the effect of various therapeutic approaches on patients' symptoms. Controlled adverse environment chambers have been used to simulate indoor surroundings such as airplane cabins and to test their effects on contact lens wearers. This review summarizes how these chambers may be useful for the development, approval, and differentiation of potential new treatments for DED.

Emerging strategies for the diagnosis and treatment of meibomian gland dysfunction: Proceedings of the OCEAN group meeting.

Meibomian gland dysfunction (MGD) is a common and chronic disorder that has a significant adverse impact on patients' quality of life. It is a leading cause of evaporative dry eye disease (DED), as meibomian glands play an important role in providing lipids to the tear film, which helps to retard the evaporation of tears from the ocular surface. MGD is also often present in conjunction with primary aqueous-deficient DED. Obstructive MGD, the most commonly observed type of MGD, is the main focus of this article. MGD is probably caused by a combination of separate conditions: primary obstructive hyperkeratinization of the meibomian gland, abnormal meibomian gland secretion, eyelid inflammation, corneal inflammation and damage, microbiological changes, and DED. Furthermore, skin diseases such as rosacea may play a part in its pathology. Accurate diagnosis is challenging, as it is difficult to differentiate between ocular surface diseases, but is crucial when choosing treatment options. Ocular imaging has advanced in recent years, providing ophthalmologists with a better understanding of ocular diseases. This review presents a literature update on the 2011 MGD workshop and an optimized approach to accurate diagnosis of MGD using currently available methods and tests. It also outlines the emerging technologies of interferometry, non-contact meibography, keratography and in vivo confocal laser microscopy, which offer exciting possibilities for the future. Selected treatment options for MGD are also discussed.

Visual acuity and quality of life in dry eye disease: Proceedings of the OCEAN group meeting.

Dry eye disease (DED) results in tear film instability and hyperosmolarity, inflammation of the ocular surface and, ultimately, visual disturbance that can significantly impact a patient's quality of life. The effects on visual acuity result in difficulties with driving, reading and computer use and negatively impact psychological health. These effects also extend to the workplace, with a loss of productivity and quality of work causing substantial economic losses. The effects of DED and the impact on vision experienced by patients may not be given sufficient importance by ophthalmologists. Functional visual acuity (FVA) is a measure of visual acuity after sustained eye opening without blinking for at least 10 s and mimics the sustained visual acuity of daily life. Measuring dynamic FVA allows the detection of impaired visual function in patients with DED who may display normal conventional visual acuity. There are currently several tests and methods that can be used to measure dynamic visual function: the SSC-350 FVA measurement system, assessment of best-corrected visual acuity decay using the interblink visual acuity decay test, serial measurements of ocular and corneal higher order aberrations, and measurement of dynamic vision quality using the Optical Quality Analysis System. Although the equipment for these methods may be too large or unaffordable for use in clinical practice, FVA testing is an important assessment for DED.

Revisiting the vicious circle of dry eye disease: a focus on the pathophysiology of meibomian gland dysfunction.

Meibomian gland dysfunction (MGD) is the most frequent cause of dry eye disease (DED). Eyelid inflammation, microbial growth, associated skin disorders as well as potentially severe corneal complications culminate to make MGD a complex multifactorial disorder. It is probable that MGD is a heterogeneous condition arising from any combination of the following five separate pathophysiological mechanisms: eyelid inflammation, conjunctival inflammation, corneal damage, microbiological changes and DED resulting from tear film instability. The pathogenesis of both MGD and DED can be described in terms of a 'vicious circle': the underlying pathophysiological mechanisms of DED and MGD interact, resulting in a double vicious circle. The MGD vicious circle is self-stimulated by microbiological changes, which results in increased melting temperature of meibum and subsequent meibomian gland blockage, reinforcing the vicious circle of MGD. Meibomian gland blockage, dropout and inflammation directly link the two vicious circles. MGD-associated tear film instability provides an entry point into the vicious circle of DED and leads to hyperosmolarity and inflammation, which are both a cause and consequence of DED. Here we propose a new pathophysiological scheme for MGD in order to better identify the pathological mechanisms involved and to allow more efficient targeting of therapeutics. Through better understanding of this scheme, MGD may gain true disease status rather than being viewed as a mere dysfunction.

Does topical bevacizumab prevent postoperative recurrence after pterygium surgery with conjunctival autografting?

AIM: To assess the effect of topical bevacizumab use on postoperative pterygium recurrence in eyes who underwent pterygium excision with limbal-conjunctival autograft transplantation (LCAT). METHODS: Eighty-eight eyes of 88 patients with primary pterygium were included. Pterygia were graded preoperatively from type 1 to type 3 (type 1 atrophic, type 3 inflamed) according to the inflammatory status. The eyes were preoperatively randomized to receive topical steroid and antibiotic treatment (group 1, 46 eyes) and additional topical bevacizumab (5 mg/mL; group 2, 42 eyes) in the postoperative period. All eyes underwent pterygium excision and LCAT. Medications were tapered and discontinued at one month. Postoperative complications and recurrence rates were recorded. RESULTS: The mean follow-up duration was 29.3±4.2mo (24-52mo) and 28.5±3.4 (24-48mo) in group 1 and 2, respectively (P>0.05). There were no statistically significant differences regarding the age or gender between groups (P>0.05). Also, the difference between groups with respect to pterygium type was not significant. During the follow-up period, recurrence developed in 2 eyes (4.3%) in group 1, whereas in one eye (2.4%) in group 2. No statistically significant difference between groups was found in recurrence rates (P>0.05). No re-operation for recurrence was necessary during the follow-up period in both groups. CONCLUSION: Topical bevacizumab seems to have no additonal effect on pterygium recurrence after LCAT.

Subconjunctival bevacizumab in the impending recurrent pterygia.

The aim of this study is to evaluate the efficacy and safety of subconjunctival bevacizumab injection(s) in the treatment of impending recurrent pterygia. Twenty-three eyes of 23 patients who developed impending recurrence after pterygium surgery with conjunctival autografting and were treated with subconjunctival bevacizumab injection(s) (2.5 mg/0.1 mL) were included in the study. Anterior segment photographs were taken prior to and at 1 week, 1, 3 and 6 months after the injection, and at the end of the follow-up period. Image analysis was performed using an image processing and analysis software program. Recurrence rate and complications were recorded. The mean age and follow-up time of the patients were 51.2 ± 6.2 (31-60 years) and 16.8 ± 3.1 (12-22 months), respectively. The average number of injections was 2 ± 0.78 (1-3). Sixteen eyes required re-injection (two injections in nine eyes, three injections in seven eyes), due to progression of vascularization. There were significant differences between size percentage of lesions before injection and at 1 week, 1, 3 and 6 months after the injection (p < 0.05 for all). Corneal recurrence developed in only one patient and no ocular or systemic side-effects of bevacizumab were observed. Repeated injections of bevacizumab may help to prevent the high recurrence rate of residual impending pterygium, due to its adjuvant role in decreasing lesion size, especially in the first year after surgery.

Role of hyperosmolarity in the pathogenesis and management of dry eye disease: proceedings of the OCEAN group meeting.

Dry eye disease (DED), a multifactorial disease of the tears and ocular surface, is common and has a significant impact on quality of life. Reduced aqueous tear flow and/or increased evaporation of the aqueous tear phase leads to tear hyperosmolarity, a key step in the vicious circle of DED pathology. Tear hyperosmolarity gives rise to morphological changes such as apoptosis of cells of the conjunctiva and cornea, and triggers inflammatory cascades that contribute to further cell death, including loss of mucin-producing goblet cells. This exacerbates tear film instability and drives the cycle of events that perpetuate the condition. Traditional approaches to counteracting tear hyperosmolarity in DED include use of hypotonic tear substitutes, which have relatively short persistence in the eye. More recent attempts to counteract tear hyperosmolarity in DED have included osmoprotectants, small organic molecules that are used in many cell types throughout the natural world to restore cell volume and stabilize protein function, allowing adaptation to hyperosmolarity. There is now an expanding pool of clinical data on the efficacy of DED therapies that include osmoprotectants such as erythritol, taurine, trehalose and L-carnitine. Osmoprotectants in DED may directly protect cells against hyperosmolarity and thereby promote exit from the vicious circle of DED physiopathology.

Astigmatic changes following pterygium removal: comparison of 5 different methods.

AIMS: To investigate the effect of surgery type on the postoperative astigmatism in pterygium surgery. SETTINGS AND DESIGN: Retrospective comparative clinical trial. MATERIALS AND METHODS: Data of 240 eyes that underwent pterygium excision were investigated. Following removal of the pterygium, patients underwent 5 different types of surgeries: Conjunctival autograft with sutures (CAG-s) or fibrin glue (CAG-g), conjunctival rotational flap (CRF), or amniotic membrane transplantation with either suture (AMT-s) or with glue (AMT-g). The preoperative and postoperative keratometric measurements, evaluated using an automated keratorefractometer, were noted. STATISTICAL ANALYSIS: The overall changes in BCVA and astigmatic degree were evaluated using Wilcoxon signed rank test. The difference in astigmatic values between groups was calculated using one way analysis of variance (ANOVA). RESULTS: The most commonly performed procedure was CAG-s (N = 115), followed by CAG-g (N = 53), CRF (N = 47), AMT-s (N = 15), and AMT-g (N = 10). Following surgery, astigmatic values decreased from 3.47 ± 2.50 D to 1.29 ± 1.07 D (P < 0.001, paired t test). The changes in astigmatism was significantly related to the preoperative size of the pterygium (ρ = 3.464, P = 0.005). The postoperative astigmatism correlated with preoperative astigmatism (ρ = 0.351, P < 0.001, Spearman correlation analysis). The changes in astigmatic values was not related to the method of surgery (P = 0.055, ANOVA). CONCLUSION: Pterygium results in high corneal astigmatism, which decreases to an acceptable level following excision. According to our study, the type of grafting as CAG, CRF or AMT or the use of suture or glue to fixate the graft does not have a significant effect on the change in astigmatism degree.

Ocular pharmacokinetics, safety and efficacy of intracameral moxifloxacin 0.5% solution in a rabbit model.

PURPOSE: This study was carried out to determine the ocular pharmacokinetics, efficacy and potential endothelial toxicity of moxifloxacin (MF) after a single intracameral bolus injection of 500 µg/0.1 ml in a rabbit model. MATERIALS AND METHODS: Forty-eight eyes of 24 New Zealand White Rabbits were separated into six groups, each including four rabbits. 0.1 ml of 0.5% intracameral moxifloxacin (500 µg) injection was injected to the right eyes and 0.1 ml of balanced salt solution to the left eyes (control). Aqueous humor (AH) and vitreous samples were collected at the 0.5th, 1st, 3rd, 6th, 12th and 24th hours from both eyes of group 1, 2, 3, 4, 5 and 6, respectively. MF concentrations were determined by high performance liquid chromatography. These were compared with the minimum inhibitory concentrations (MIC) and mutant prevention concentrations (MPC) for frequent endophthalmitis pathogens. Electron and light microscopical evaluation of the corneas were performed. RESULTS: Moxifloxacin reaches higher concentration than the MIC of all common endophthalmitis pathogens in the AH and exceeds the mutant prevention concentration levels for Streptococcus pneumonia, Streptococcus viridans, flouroquinolone susceptible Coagulase-negative staphylococcus and flouroquinolone susceptible Staphylococcus aureus for 6 h. The half-life of moxifloxacin in the AH was 2.2 h. Electron and light microscopic evaluation revealed no noticeable sign of toxicity. CONCLUSIONS: Peroperative intracameral moxifloxacin injection for endophthalmitis prophylaxis is a safe and effective method in uncomplicated phacoemulsification surgery.

Bilateral corneal infiltrates and uveitis in a pediatric patient with presumed ocular sarcoidosis.

PURPOSE: To report a pediatric case with presumed ocular sarcoidosis presented with bilateral corneal infiltrates and uveitis. DESIGN: Single case report. METHODS: A 9-year-old girl presented with a 1-month history of blurred vision and redness in both eyes. Ophthalmologic evaluation revealed midstromal infiltrates in cornea, granulomatous anterior uveitis, vitritis, snowball opacities, and localized perivenous exudates. RESULTS: She was treated with topical and oral steroids. During steroid tapering, oral cyclosporine A therapy was added. CONCLUSION: In patients with corneal infiltrates and uveitis, sarcoidosis should be considered in the differential diagnosis.

Tear osmolarity in unilateral pseudoexfoliation syndrome.

PURPOSE: The aim was to evaluate tear osmolarity of patients with clinically unilateral pseudoexfoliation (PEX) syndrome and to compare the values with otherwise normal subjects. METHODS: Sixty-two eyes of 31 patients with unilateral PEX syndrome and 31 eyes of 31 normal subjects were studied. The TearLab osmolarity system (OcuSense, Inc, San Diego, CA, USA) was used to measure tear osmolarity. Eyes were grouped as normal eyes of patients having unilateral PEX syndrome (group A), eyes of patients having unilateral PEX syndrome with deposits of PEX material (group B) and eyes of normal subjects (group C). Differences in tear osmolarity were compared among groups A, B and C. Independent t-tests and paired t-tests were used for statistical analysis. RESULTS: The mean tear osmolarity was 298.7 ± 7.8 mOsm/l (range 285 to 306) in the control group (group C), 306.3 ± 6.6 mOsm/l (range 290 to 314) in the eyes of patients having PEX syndrome with deposits of pseudoexfoliative material (group B) and 301.4 ± 7.1 mOsm/l (range 284 to 305) in the fellow eye of these patients (group A). There was a significant difference between tear osmolarity of groups C and B (independent t-test, p = 0.011). Also, there was a significant difference between the osmolarity of each eye of patients with unilateral PEX syndrome (groups A and B) (paired t-test, p = 0.001). The difference between tear osmolarity of groups A and C was not statistically significant (independent t-test, p = 0.146). CONCLUSION: In conclusion, tear osmolarity is higher in both eyes of patients when compared with normal subjects, using the independent t-test (although highest in clinically positive eyes of these patients). Both eyes of patients having PEX syndrome could be more prone to the development of dry eye syndrome.

Structural consequences after intravitreal bevacizumab injection without increasing apoptotic cell death in a retinopathy of prematurity mouse model.

PURPOSE: To evaluate the effect of different bevacizumab concentrations on retinal endothelial cell proliferation, retinal structures and apoptotic activity after intravitreal injection in a retinopathy of prematurity (ROP) mouse model. METHODS: A total of 35 of C57BL/J6 mice were exposed to 75±2% oxygen from postnatal day 7 to postnatal day 12. On day 12, 10 mice (group C) were injected with 2.5 µg intravitreal bevacizumab (IVB), 11 mice (group D) were injected with 1.25 µg IVB, and 14 mice (group E) were injected with 0.625 µg IVB in one eye. The contralateral eyes were injected with isotonic saline (control group=group B). Four nonexposed mice served as negative controls (group A). Neovascularization was quantified by counting the endothelial cell proliferation on the vitreal side of the inner limiting membrane of the retina. Histological and ultrastructural changes were examined by light and electron microscopy. Terminal deoxynucleotidyl transferase deoxy-UTP-nick end labelling (TUNEL) was used to detect apoptosis. RESULTS: The endothelial cell count per histological section was lower in groups C (p<0.0001), D (p<0.0001) and E (p<0.0001) compared with the control group B. Histological evaluation showed no retinal toxicity in any group. Electron microscopy revealed hyperoxia-induced mitochondrial dysmorphology in group B. Mitochondrial dysmorphology displayed dose-dependent gradual increase in IVB-injected eyes. Intravitreal bevacizumab induced no significant increase in apoptotic cell death. CONCLUSION: Bevacizumab suppresses endothelial cell proliferation in a ROP mouse model. In addition to hyperoxia-induced mitochondrial dysmorphology of C57BL/J6 retina, morphological findings implicate further mitochondrial vulnerability because of bevacizumab without increase in apoptotic cell death.

Diurnal variation of the tear osmolarity in normal subjects measured by a new microchip system.

PURPOSE: To show the diurnal variation of tear osmolarity in normal subjects. METHODS: Thirty volunteers were recruited. Tear osmolarity was measured with TearLab osmolarity system at 3-hour regular intervals between 8:00 am and 5:00 pm. One-way analysis of variance test was used for statistical analysis. RESULTS: Thirty healthy volunteers (all men) with a mean age of 29.6 ± 4.3 years (range 18-45) were recruited. The difference between measurements at 8:00 am and 11:00 am, 8:00 am and 2:00 pm, 8:00 am and 5:00 pm, 11:00 am and 2:00 pm, 11:00 am and 5:00 pm, and 2:00 pm and 5:00 pm were not statistically significant (one-way analysis of variance test, p>0.05). CONCLUSIONS: In normal subjects, tear osmolarity seems to have a stable profile during the daytime.

Recurrent iris cyst discharge.

A 23-year-old woman with the diagnosis of anterior uveitis in the left eye was referred to our clinic. Circumferential midzonal iris epithelial cysts were observed in the right eye and corneal endothelial pigment precipitates and diffuse pigment discharge in the anterior chamber of the left eye. Topical prednisolone acetate was prescribed. After 2 days, hyperemia and pain decreased in the left eye and started in the right eye. During the following 3 months, the patient experienced 3 similar episodes, which resulted in diffuse pigment deposition in the anterior chamber angles. Intraocular pressure (IOP) elevation was observed after 1 week and 3 weeks in the left eye and right eye, respectively. Topical antiglaucomatous medication was prescribed. Nine months after the last episode, the uncorrected distance visual acuity was 20/20 and the IOP was 15 mm Hg bilaterally. The iris showed diffuse transillumination, and the pupils were unresponsive to light.