Chronic inflammation as a proposed risk factor for ocular surface squamous neoplasia.

PURPOSE: Chronic inflammation is a predisposing factor for metaplastic changes and ultimately dysplasia. We describe cases of OSSN occurring in the setting of chronic ocular surface inflammation. METHODS: Sixteen eyes from 14 individuals were included from one ocular oncology clinic between 2010 and 2023. Patients presented with ocular surface squamous neoplasia (OSSN) in the setting of chronic inflammation. The diagnosis of OSSN was made using anterior segment high-resolution optical coherence tomography (HR-OCT) and confirmed by histopathological analysis in all cases. RESULTS: Median age on presentation was 61 [IQR 47.5-69.2] years. Eleven (86%) individuals were male and five (36%) identified as White Hispanic. Ten eyes were referred with ocular surface diagnoses including pannus (n = 4), scarring (n = 3), pterygium (n = 2), and herpetic keratitis (n = 1). Only six eyes were referred as possible neoplasia. All individuals had a history of ocular surface inflammation. The most common inflammatory conditions were ocular rosacea (seven individuals) and atopic keratoconjunctivitis (AKC) (five individuals). Two individuals were found to have bilateral OSSN, one in the setting of ocular rosacea and the other in the setting of AKC. All 16 eyes from 14 individuals were suspected to have OSSN based on HR-OCT findings which guided the location of the incisional biopsies that subsequently confirmed histopathological diagnosis in all cases. CONCLUSION: OSSN may arise in the setting of chronic inflammation on the ocular surface. Identification of the tumor can be challenging in these cases, and HR-OCT can be a key diagnostic tool in detecting OSSN.

New-Onset of Herpes Simplex Keratitis After Blepharoplasty, Case Series and Review of the Literature.

PURPOSE: To report 3 cases of new-onset herpes simplex keratitis (HSK) after uncomplicated extraocular plastic surgery and discuss potential risk factors. METHODS: This case series includes 3 patients who underwent uncomplicated blepharoplastic surgery. Within 2 weeks postoperatively, all patients reported ocular discomfort, and their ophthalmic examinations revealed corneal lesions suspicious of HSK. One case was confirmed as an active herpes infection, and the other 2 cases were clinically diagnosed with HSK. The patients were treated with oral acyclovir and followed up for up to 6 weeks. RESULTS: All patients demonstrated improvement without sequelae at follow-up visits from 5 days to 4 weeks after initiating acyclovir treatment. CONCLUSIONS: Risk factors for new-onset HSK after uncomplicated extraocular surgeries may be related to an immunocompromised state, postoperative administration of topical or periocular corticosteroids, or environmental factors such as psychological stress. Ophthalmologists, particularly plastic surgeons, should be vigilant for ocular discomfort following eyelid surgeries and consider the possibility of herpes infection. This report highlights the importance of recognizing and managing HSK in the context of extraocular plastic surgery.

Femtosecond Laser Capsulotomy in Previous Radial Keratotomy.

PURPOSE: The aim of this study was to describe clinical experience using femtosecond laser-assisted anterior capsulotomy in eyes with previous radial keratotomy. METHODS: Eyes of patients with previous radial keratotomy and cataract-related vision impairment who underwent phacoemulsification and intraocular lens implantation were retrospectively reviewed. Eyes with any vision impairment cause other than cataract or previous radial keratotomy were excluded. RESULTS: Sixteen postradial keratotomy eyes were included. In 5 patients, manual anterior capsulectomy was successfully performed. Six eyes underwent femtosecond laser capsulotomy using routine parameters (incision depth 500 µm and 4 µJ power), of which in 3 eyes capsulotomies were complete, whereas in the other 3 eyes incomplete capsulotomy was evident. In 3 patients, both incision depth and power parameters were doubled (incision depth 1000 µm and 8 µJ power), whereas in 2 patients, only the pulse energy was doubled (8 µJ power) and in all 6 cases, the capsulotomy was successfully completed. At the last follow-up, all capsulotomies were intact without radial tears, and the intraocular lenses were stable and central. CONCLUSIONS: Radial corneal scars after previous radial keratotomy may interfere with femtosecond laser-assisted anterior capsulotomy using routine parameters. Surgeons should be alert and ready to convert to manual anterior capsulectomy. Modification of the laser parameters may overcome this potential complication.

Long-term outcomes of anti-vascular endothelial growth factor treatment in peripapillary choroidal neovascularisation due to age-related macular degeneration.

OBJECTIVE: To report the long-term outcomes of anti-vascular endothelial growth factor (VEGF) treatment in eyes with peripapillary choroidal neovascularisation (PPCNV) associated with age-related macular degeneration (AMD). METHODS: A retrospective cohort study included patients with AMD-related PPCNV. Eyes were treated with anti-VEGF according to pro re nata regimen. Inactivation index was calculated as the proportion of disease inactivity from the total follow up time. RESULTS: Sixty-seven eyes of 66 consecutive patients were included in the study; mean follow-up time was 53.2 months. Best corrected visual acuity (BCVA) remained stable for the first four years of follow up, with a significant deterioration in BCVA thereafter. Baseline BCVA was a significant predictor of final BCVA (p < 0.001). The mean inactivation index was 0.38 ± 0.23. Subretinal fluid (SRF) at presentation was significantly associated with decreased inactivation index (p < 0.05). Worse baseline BCVA, SRF and pigment epithelium detachment (PED), male sex, and younger patient age were associated with increased risk for recurrence after first inactivation (p < 0.05). CONCLUSION: The use of anti-VEGF agents in the treatment of AMD-related PPCNV managed to preserve BCVA in the first four years of follow-up. Male sex, SRF and PED at presentation and baseline BCVA are associated with increased risk for PPCNV recurrence after the first inactivation, and should prompt careful follow-up in these patients.

Risk factors for early flap misalignment following microkeratome-assisted laser in situ keratomileusis: A retrospective large database analysis.

PURPOSE: To determine factors associated with early flap misalignment following microkeratome-assisted laser in situ keratomileusis. MATERIALS AND METHODS: This retrospective study included the right eyes of consecutive patients who underwent laser in situ keratomileusis procedure between 2005 and 2016 at Care-Vision Laser Centers, Tel-Aviv, Israel. Patients were divided into two groups according to whether or not they subsequently developed early flap misalignment. RESULTS: A total of 14,582 eyes (mean age of patients: 32.4 ± 10.3 years) were included. Post-laser in situ keratomileusis early flap misalignment developed in 158 eyes (1.1%). Misalignment was more frequent during the spring (32.3% vs 22.8%, p = 0.003) and in a higher operating room temperature (23.34 ± 1.06 vs 22.98 ± 1.26, p < 0.001). In addition, in the misalignment group, there was a higher rate with the of use of the a Moria M2 microkeratome (rather than sub-Bowman's keratomileusis microkeratome) head (55.2% vs 40.5%, respectively, p < 0.001). In a multivariable analysis adjusted for surgeon and year of surgery, high operating room temperature (odds ratio = 1.22, p = 0.006), treatment zone of 9.0 mm (as opposed to smaller treatment zones, odds ratio = 1.54, p = 0.04), and springtime (odds ratio = 1.58, p = 0.02) were associated with flap misalignment. There was a significant difference in misalignment rates between surgeons (p = 0.02). CONCLUSION: This study found that larger treatment zones, higher operating room temperature, operating during the spring, and the use of Moria M2 microkeratome were associated with increased flap misalignment rates. The association with operating room temperature and seasonal variation is of interest and merits further research.

Initial High-Dose Prophylaxis and Extended Taper for Mushroom Keratoplasty in Vascularized Herpetic Scars.

PURPOSE: To report the outcomes of initial high-dose and extended taper of antiviral and steroid prophylaxis for the treatment of eyes with high-risk vascularized herpetic corneal scars that underwent 2-piece mushroom keratoplasty (MK). DESIGN: Prospective interventional case series. METHODS: In this single-center study, 52 consecutive eyes with vascularized (≥2 quadrants) herpetic corneal scars underwent 2-piece microkeratome-assisted MK. Initial high-dose and extended taper of combined oral and topical antiviral and steroid prophylaxis was administered. Outcome measures were best spectacle-corrected visual acuity (BSCVA), refractive astigmatism (RA), endothelial cell density, immunologic rejection, herpetic recurrence, and graft failure rates. RESULTS: Excluding patients with vision-impairing comorbidities, baseline BSCVA (1.73 ± 0.67 logMAR) significantly improved annually during the first 2 years (P < .001, P = .016), reaching 0.17 ± 0.18 logMAR at year 2, and remaining stable up to 10 years (P = .662). At 2 years, 86% of eyes saw ≥20/40, 55% saw ≥20/25, and 18% saw ≥20/20 Snellen BSCVA. RA exceeded 4.5 diopters in 7% of cases after wound revision for high-degree astigmatism in 7 cases. Endothelial cell loss was 40.9% at 1 year with an annual decline of 3.1% over 10 years. The 10-year cumulative risk for immunologic rejection, herpetic recurrence, and graft failure was 9.7%, 7.8%, and 7.6%, respectively. CONCLUSIONS: Initial high dose and extended taper of antiviral and steroid prophylaxis for MK in high-risk, vascularized herpetic corneal scars achieves clinical outcomes that remain stable for up to 10 years after surgery with minimal risk of immunologic rejection, herpetic recurrence and graft failure.

Obstructive Sleep Apnea and Keratoconus: A Systematic Review and Meta-analysis.

BACKGROUND: Despite the increasing number of studies focused on the association between obstructive sleep apnea (OSA) and keratoconus (KC), to date, no comprehensive meta-analysis or systematic review was published. OBJECTIVE: The objective of this study was to evaluate the association between OSA and KC. DATA SOURCES: Sources of data were PubMed, Scopus, and Web of Science databases. STUDY ELIGIBILITY CRITERIA: The criteria for study eligibility were case-control studies and cohort studies reporting data on the association of OSA with KC with risk ratio, odds ratio, or hazard ratio with 95% confidence intervals or sufficient raw data for calculation. STUDY APPRAISAL AND SYNTHESIS METHODS: Meta-analysis was conducted with a random-effects model using odds ratio with 95% confidence interval as the effect size. Heterogeneity was evaluated using the Q and I tests. Sensitivity analysis and assessment of publication bias were performed. RESULTS: Five studies (four case-control studies and one cohort study) published between 2012 and 2016 and involving 33,844 subjects (16,922 patients with KC, 16,922 controls) were included in this meta-analysis. A significant association between OSA and KC has been shown (pooled odds ratio, 1.841; 95% confidence interval, 1.163 to 2.914; P = .009). A significant heterogeneity was observed (Q = 15.8, I = 74.6%). There was no evidence of significant publication bias (P = .07). The sensitivity analyses indicated the stability of results. LIMITATIONS: Heterogeneity across the studies was observed. Data from four hospital-based case-control studies and one large population-based cohort study were combined. Most of the included studies ascertained OSA by the Berlin Questionnaire, which is a screening tool. CONCLUSIONS: This meta-analysis provides significant evidence that OSA is associated with KC. Therefore, a proper screening for OSA is warned for KC patients for the prevention of various cardiovascular comorbidities. Further prospective studies are warranted to explore more in-depth the casual relationship between the two conditions.

Peripheral Intrastromal Hydration Facilitates Safe, Deep Trephination in Corneas of Irregular Thickness.

PURPOSE: To evaluate the feasibility of regularizing the peripheral corneal thickness before deep trephination in highly irregular corneas undergoing deep anterior lamellar keratoplasty (DALK) by means of intrastromal hydration with saline. METHODS: This is an interventional case series including all eyes with irregular peripheral corneal thickness undergoing DALK for any indication between January 1, 2016, and January 1, 2017, at a single tertiary center in Forli, Italy. Before trephination, 1 mL of normal saline was injected intrastromally into each clock hour of peripheral thinning (determined using preoperative pachymetry) using a 30-gauge needle. A deep trephination of 400 to 450 µm was then performed, and DALK was completed as per our previously described technique. Primary outcome measures were perforation during trephination and intraoperative complications, with secondary outcomes of best corrected visual acuity and refraction. RESULTS: Peripheral intrastromal hydration was performed in 61 eyes of 61 patients. Intrastromal hydration ensured a safe trephination without perforation into the anterior chamber (AC) in 59 of 61 eyes. In the 2 cases in which perforation occurred, the perforation site was sutured with a full-thickness suture and the surgery was completed successfully. No cases required conversion to penetrating keratoplasty. Intrastromal injection of 1 mL of normal saline resulted in an increase in corneal thickness of 31%. After surgery, double AC was observed in 3 cases (4.9%), with all cases being managed successfully by air injection into the AC. CONCLUSIONS: Zonal peripheral intrastromal hydration is a feasible technique to enable safe, deep trephination even in corneas of highly irregular thickness.

Fracture of a polyimide-elastimide posterior chamber intraocular lens following blunt orbital trauma.

PURPOSE: Fracture of a three-piece polyimide-elastimide intraocular lens at the optic-haptic junction following blunt trauma is a possible complication after cataract surgery. We report a case of an isolated posterior chamber intraocular lens fracture caused by direct ocular blunt trauma. CASE: A 51-year-old patient underwent blunt orbital trauma caused by a raw chicken egg that was thrown at him, as he was walking. The posterior chamber intraocular lens was found in the anterior chamber, with a broken optic-haptic junction. The intraocular lens was exchanged, followed by iris fixation and pupilloplasty, with satisfactory postoperative anatomical and optical outcomes. DISCUSSION: The three-piece polyimide-elastimide intraocular lens was fractured at the optic-haptic junction. Although the fractured intraocular lens surface had a regular appearance, it has been previously reported that the polyimide haptic's durability is probably inferior to that of polymethylmethacrylate. Therefore, it is highly susceptible to shear stress induced by a blunt trauma. CONCLUSION: To our knowledge, this is an uncommon report of an implanted posterior chamber polyimide-elastimide intraocular lens fracture following blunt orbital trauma. Intraocular lens exchange and fixation had successful optical and anatomical results.

Endophthalmitis after intravitreal injections versus cataract surgery: a 15-year cohort.

PURPOSE: To compare the clinical features, visual outcomes and causative organisms between endophthalmitis secondary to cataract surgery or to intravitreal injections (IVI). SETTING: Meir Medical Center, Kfar Saba, Israel. DESIGN: Retrospective, non-randomized comparative chart review. METHODS: Medical records of patients with proven or suspected endophthalmitis admitted to the Ophthalmology Department at Meir Medical Center 2/2002-2/2017 were reviewed. Clinical characteristics including presenting and final visual acuity (VA) outcomes, causative organisms and time to admission were assessed. RESULTS: Among 84 patients in our study, 35 had preceding cataract surgery and 12 had preceding IVI. The post-cataract group showed a significant improvement in VA following treatment with a presenting and final VA (logMar ± SD) of (1.80 ± 0.54 and 1.39 ± 0.65, P < 0.01) as opposed to the post-IVI group (1.72 ± 0.26 and 1.81 ± 0.32, P = 0.692), while most patients in the cataract group exhibited some degree of VA recovery (70.96%). Patients undergoing cataract surgery were divided into two separate groups; those who underwent cataract surgery in a private center and those operated at a public center. Patients undergoing surgery at a private medical center showed improvement in VA outcomes following treatment (1.80 ± 0.57 and 1.13 ± 0.66, P < 0.01) as opposed to those operated on at our public medical center. CONCLUSIONS: Overall, patients with endophthalmitis following cataract surgery had better visual outcomes and were more likely to show a VA improvement following treatment when compared with endophthalmitis following IVI. Final VA outcomes of patients with endophthalmitis after cataract surgery performed in a private center were better than those operated on and treated in a public medical center.

The effect of colonoscopy on intraocular pressure: an observational prospective study.

PURPOSE: Colonoscopy is an endoscopic examination of the bowel. It requires insufflation of the large bowel lumen with gas which leads to intraabdominal hypertension (IAH). There is evidence suggesting that IAH positively correlates with intracranial pressure (ICP) and possibly with intraocular pressure (IOP). The aim of this study was to examine the effect of routine screening colonoscopy performed under sedation on the IOP in healthy individuals. PATIENTS AND METHODS: This was a prospective, single site, observational study. Healthy adults undergoing routine colonoscopy performed under sedation including propofol, fentanyl, and midazolam were recruited. Right eye IOP measurements were performed using Tonopen XL® in a left decubitus position at 5 time points during the procedure. Statistical analysis was performed using Student's t-test for paired samples. RESULTS: Twenty-three Caucasians were recruited. There are 14 males (60%) with a mean age of 60.4 ± 10.4 years (range 36-74). Colonoscopy was conducted under sedation and completed in 22 subjects. Mean baseline IOP was 19.9 ± 4.7 mmHg, 15.8 ± 4.8 mmHg immediately after sedation, 13.5 ± 2.3 mmHg when the colonoscope had reached the cecum, 15.4 ± 5.0 mmHg 5 min after colonoscopy beginning, and 16.5 ± 5.5 mmHg when located in the rectum. The IOP reduction during the procedure was statistically significant (P < 0.01). CONCLUSION: Routine colonoscopy performed under sedation using propofol, fentanyl, and midazolam does not increase the IOP in healthy adults.

Evaluation of the risk factors associated with conversion of intended deep anterior lamellar keratoplasty to penetrating keratoplasty.

BACKGROUND/AIMS: To identify and evaluate risk factors associated with the need to convert intended deep anterior lamellar keratoplasty (DALK) to penetrating keratoplasty (PK). METHODS: Retrospective institutional cohort study including all consecutive eyes undergoing intended DALK between May 2015 and October 2018 at 'Villa Igea' Hospital (Forli, Italy). The indications for surgery were categorised as (1) keratoconus without scarring; (2) keratoconus with scarring; (3) non-keratoconus without scarring; and (4) non-keratoconus with scarring. Multivariate binary logistic regression analysis was performed, introducing, as independent variables, those that reached a significance level of less than 0.05 in univariate analysis. The main outcome measure was whether or not conversion to a PK occurred. RESULTS: 705 eyes were included, with conversion to PK occurring in 16.2% (n=114) of cases. The factors that remained significant in multivariate analysis were corneal scarring (OR=3.52, p<0.001), manual dissection (OR=42.66, p<0.001), type 2 bubble (OR=90.65, p<0.001) and surgeon inexperience (OR=10.86, p<0.001). A receiver operating characteristic (ROC) curve based on the factors significant in the multivariate binary logistic regression analysis achieved a sensitivity of 89.5% (95% CI 82.3% to 94.4%) and a specificity of 80.2% (95% CI 76.8% to 83.3%) with an area under the ROC curve of 0.91 (95% CI 0.88 to 0.93) (p<0.001) CONCLUSION: Occurrence of a type 2 bubble, the need for manual dissection, the presence of scarring and surgeon inexperience are independent risk factors for the need to convert intended DALK to PK. Correct identification and management of the type of bubble achieved during pneumatic dissection is instrumental in minimising the rate of conversion to PK.

Fluid viscosity but not surface tension, determines the tamponade effect of intravitreal fluids in a novel in vitro eye model of retinal detachment.

PURPOSE: To determine the effect of varying surface tension and viscosity of fluids used as tamponade in an in vitro eye model of retinal detachment. METHODS: We used an in vitro eye model simulating retinal detachment. Fluids with varying surface tension and identical viscosity, and fluids with varying viscosities and identical surface tension were used as tamponade agents to prevent retinal detachment in the model, to determine which of these properties affects each fluid's effectiveness as a retinal tamponade. RESULTS: The membrane (simulating retinal detachment) changes over time in a vitro eye model were not affected by varying surface tension given constant fluid viscosity. However, membrane changes were proportional to the viscosity of the fluid, given constant surface tension. CONCLUSIONS: The tamponade effect of an intravitreal fluid against retinal detachment may not be related as previously assumed, solely to surface tension, but rather is proportionally related to its viscosity.

Successful Descemet Membrane Endothelial Keratoplasty in Proven Herpetic Endothelial Decompensation Requires Intensive Antiviral Therapy.

PURPOSE: To report the outcomes of Descemet membrane endothelial keratoplasty (DMEK) with intensive antiviral therapy for corneal edema secondary to herpes simplex virus type 1 (HSV-1)-mediated endotheliitis. METHODS: All eyes with polymerase chain reaction positive for HSV-1 undergoing DMEK for endothelial decompensation between January 2014 and January 2018 were followed up prospectively at our tertiary referral center. All eyes had been free of active inflammation for a minimum of 9 months and were treated prophylactically with high-dose systemic and topical antivirals, which were continued for a prolonged period of time. Primary outcomes were the occurrence of immunological rejection and/or recurrence of endotheliitis, eventually resulting in graft failure. Secondary outcomes were best spectacle-corrected visual acuity and endothelial cell loss. RESULTS: Four consecutive eyes of 4 patients were included with a mean (±SD) patient age of 68.5 ± 15.1 years. The postoperative follow-up averaged 22 months. No eyes exhibited any signs of immunologic rejection, recurrence of endotheliitis, or graft failure. Mean (±SD) decimal best spectacle-corrected visual acuity improved from 0.2 ± 0.1 to 0.7 ± 0.2 (P = 0.007), whereas mean (±SD) endothelial cell loss was 56% ± 10.2% at the final postoperative follow-up. CONCLUSIONS: DMEK is an effective option to treat corneal edema secondary to HSV-1-related endotheliitis. Intensive antiviral prophylaxis may reduce the risk of recurrence and subsequent graft failure.

Autologous Descemet Stripping Automated Endothelial Keratoplasty to Eliminate Endothelial Rejection in Eyes at High Risk.

PURPOSE: To determine whether autologous Descemet stripping endothelial keratoplasty is technically feasible and whether it eliminates the risk of endothelial rejection in "only eyes" at high risk of immunological rejection. METHODS: This is a prospective observational interventional study from 2016 to 2018 with a 24-month follow-up in a tertiary-level corneal referral center, Forlì, Italy. One 25-year-old woman with failed penetrating keratoplasty after endothelial rejection in the context of chronic panuveitis and a blind fellow eye due to retinal detachment underwent autologous Descemet stripping automated keratoplasty. An endothelial graft was harvested from the fellow eye by performing a hinged, microkeratome-assisted superficial stromal flap, with removal of the central posterior stromal bed. The posterior lamellar graft created was then transplanted into the other eye using a standardized Descemet stripping automated endothelial keratoplasty (DSAEK) technique. Main outcome measures were endothelial rejection, best spectacle-corrected visual acuity, and endothelial cell density. RESULTS: No endothelial rejection was seen during the 2-year follow-up duration. Stable improvement in best spectacle-corrected visual acuity from 0.2 to 0.4 (decimal Snellen) was observed. Endothelial cell density of 1465 (cells/mm) was recorded at the final follow-up. CONCLUSIONS: The use of this repeatable technique to harvest and transplant an autologous DSAEK graft eliminates endothelial rejection in high-risk eyes.

Diagnosis and Management Practice Patterns among Pediatric Ophthalmology Personnel in Israel.

PURPOSE: To investigate the diagnosis and management practice patterns of different aspects of pediatric ophthalmology among pediatric ophthalmologists and orthoptists in Israel. METHODS: A 21-question survey was delivered to all registered pediatric ophthalmologists and orthoptists in Israel. RESULTS: The response rate was 58.3%. Most pediatric ophthalmology personnel in Israel do not document intermittent exotropia (IXT) with a control scale, do not use modalities other than patching for amblyopia, and do not use distance stereoacuity tests. There was no consensus regarding patching and over minus treatments in IXT. In contrast to frequent use of prism adaptation test (PAT) for evaluating strabismus, most Israeli pediatric ophthalmology personnel do not use postoperation diplopia test (PODT). While most orthoptists use a questionnaire when diagnosing convergence insufficiency (CI), most pediatric ophthalmologists do not. CONCLUSION: This study highlights the current areas of consensus and disagreement regarding pediatric ophthalmology diagnosis and management practices in Israel. Adopting a uniform approach regarding diagnosing CI, including using a questionnaire by pediatric ophthalmologists and orthoptic exercises in the management of IXT, is warranted to enable unified treatment by pediatric ophthalmologist and orthoptists in Israel.

[NEW LENSES IN MODERN CATARACT SURGERY].

INTRODUCTION: During cataract surgery the natural opaque crystalline lens is replaced by an artificial intraocular lens that compensates for the optical loss following lens removal. The conventional intraocular lens is mono-focal and necessarily requires spectacle correction for the clear vision at various foci in the same eye. In recent years a variety of intraocular lenses were developed including multifocal (bifocal and trifocal), "toric" lenses to correct corneal astigmatism, lenses with extended depth of focus and their combinations. Modern cataract surgery not only enables the correction of quality of vision but also enhances quality of life and eliminates spectacle dependence following surgery at all distances; far, intermediate and near.