Unilateral Malignant Glaucoma Postbilateral Implantable Collamer Lens: Effect of Miotics.

An implantable collamer lens® (ICL) V4c model (STAAR Surgical, Monrovia, CA, USA) was placed in the eye of a 31-year-old male patient with high myopia followed by the development of malignant glaucoma. After failing medical treatment for 5 days, a noncomplicated pars plana vitrectomy and anterior hyaloidectomy succeeded in breaking the aqueous misdirection. Sixteen months later, intraoperative miotics were purposefully withheld from the ICL surgery in the fellow eye and malignant glaucoma did not develop. Even though the patient's visual acuity postoperatively was 20/20, OU, a single small atrophic iris patch in the affected eye resulted in slightly more halos and glare in mesopic conditions as compared to the fellow eye. Earlier surgical intervention may have prevented iris ischemia and iridocorneal touch with its subsequent iris atrophy and resulted in an even more favorable visual outcome. Withholding intraoperative miotics during ICL surgery appeared to be beneficial in this case.

Bilateral corneal epithelial macrocysts following hyperopic laser in situ keratomileusis.

A 27-year-old woman had microkeratome-assisted laser in situ keratomileusis (LASIK) for moderate bilateral hyperopia. The preoperative ophthalmologic examination was unremarkable except for minimal lissamine green staining bilaterally on the nasal conjunctiva. On the first postoperative day, the uncorrected distance visual acuity (UDVA) was 20/20 bilaterally and the corneas were clear. Four days later, the patient presented with mild blur in both eyes. Examination showed diffuse bilateral epithelial cysts encompassing the central 6.0 to 7.0 mm of the flaps with overlying diffuse lissamine green staining. The UDVA was 20/30 bilaterally. Aggressive lubrication was administered. The epithelial cysts coalesced into larger ones over subsequent visits and began regressing over several months, along with improvement in vision. At 6 months, the cysts had completely resolved, the corneas were clear, and the UDVA was 20/20.

Toric ICL Implantation After Sequential Intracorneal Ring Segments Implantation and Corneal Cross-linking in Keratoconus: 2-Year Follow-up.

PURPOSE: To evaluate 6-month and 2-year safety and clinical outcomes of Visian toric Implantable Collamer Lens (toric ICL) (STAAR Surgical, Monrovia, CA) implantation for the treatment of residual refractive errors after sequential intracorneal ring segments (ICRS) insertion and cross-linking (CXL) in keratoconus. METHODS: This consecutive case series included the results of a three-step ICRS-CXL-toric ICL procedure in 16 eyes of 13 patients with moderate to severe keratoconus (stages II and III of Amsler-Krumeich classification). The ICRS and CXL procedures were performed sequentially with an interval of 4 weeks and the toric ICL implantation was performed at least 6 months after CXL. Data were collected preoperatively, at 6 months after sequential ICRS-CXL, and at 6 and 24 months following toric ICL implantation. All 16 eyes were evaluated at the 2-year follow-up. RESULTS: There was a significant decrease in keratometry (steep, flat, and maximum) and refraction (sphere and spherical equivalence, but not cylinder) and a significant increase in both uncorrected (UDVA) (from 1.06 to 0.76 logMAR, P = .004) and corrected (CDVA) (from 0.42 to 0.26 logMAR; P = .002) distance visual acuity 6 months following sequential ICRS-CXL, whereas UDVA and refraction significantly improved 6 months after ICL insertion (UDVA reached 0.33 logMAR, P = .001). At the 24-month follow-up, UDVA and keratometric readings were stable, whereas CDVA, sphere, and cylinder showed a significant improvement. CONCLUSIONS: Implantation of Visian toric ICL following sequential ICRS insertion and CXL is an effective and safe option for correcting high residual refractive error and improving visual acuity in patients with moderate to severe keratoconus in the long term. [J Refract Surg. 2017;33(9):610-616.].

Safety and Efficacy of Sequential Intracorneal Ring Segment Implantation and Cross-linking in Pediatric Keratoconus.

PURPOSE: To evaluate the safety and visual outcome of intracorneal ring segment (ICRS) implantation followed by cross-linking in pediatric keratoconus patients. DESIGN: Retrospective interventional case series. METHODS: This retrospective study included pediatric patients (aged ≤14 years) with keratoconus and poor corrected distance visual acuity (CDVA) that underwent ICRS implantation and cross-linking (CXL). ICRS were inserted under topical anesthesia after creating a corneal tunnel with a femtosecond laser. Cross-linking was performed 1 month subsequently. Records were reviewed and data collected preoperatively and at 6 months, 1 year, 2 years, and 4 years postoperatively. RESULTS: Twelve patients (17 eyes; 10 male, 2 female) aged 9-14 years (mean age 12.3 years) received ICRS implantation followed by CXL. Follow-up times ranged from 6 months to 4 years after surgery. At the 6-month follow-up all eyes were evaluated; at the 1-year, 2-year, and 4-year follow-up 11, 10, and 7 eyes were evaluated, respectively. At the 6-month follow-up, mean CDVA in comparison to preoperative levels improved significantly (P = .001) from 0.30 ± 0.19 logMAR to 0.12 ± 0.1 logMAR; mean uncorrected distance visual acuity (UDVA) also improved significantly from 0.90 ± 0.50 logMAR to 0.43 ± 0.31 logMAR. A significant decrease in both keratometry readings and spherical equivalent (from -4.0 to -1.56 diopters) was also noted after ICRS insertion. At the 1-year, 2-year, and 4-year follow-up refractive values remained relatively stable in comparison to the 6-month follow-up, except for a minor but significant improvement in cylinder and, at 4 years, in UDVA. All patients tolerated the surgery well and no intraoperative or postoperative complications were reported, except for 1 ring segment that had to be removed after 2 years owing to vascularization and corneal thinning. CONCLUSION: ICRS implantation is a safe and effective procedure for visual rehabilitation in children with keratoconus and poor CDVA.

Pediatric Keratoconus in a Tertiary Referral Center: Incidence, Presentation, Risk Factors, and Treatment.

PURPOSE: To report the incidence, clinical presentation, risk factors, and treatment outcome of pediatric keratoconus in a tertiary referral eye hospital in Beirut, Lebanon. METHODS: In this retrospective study, the authors evaluated all patients with keratoconus 14 years or younger newly diagnosed at the Beirut Eye Specialist Hospital, Beirut, Lebanon, between January 2010 and December 2014. The incidence of pediatric keratoconus among all pediatric patients and among patients with keratoconus of all ages was assessed. Patients with pediatric keratoconus were evaluated for keratoconus stage, initial presentation, uncorrected distance visual acuity, corrected distance visual acuity (CDVA), corneal topography, and pachymetry. Patients were classified according to different treatment regimen groups and different follow-up visits were evaluated. RESULTS: During 5 years, 16,808 patients were examined, of whom 2,972 were 14 years or younger. A total of 541 patients were diagnosed as having keratoconus; of those, 16 were 14 years or younger at the time of diagnosis. Hence, the incidence of keratoconus was 0.53% among pediatric patients and 3.78% among adult patients (> 14 years). Initial presentation was during routine checkup (1 of 16) for allergic conjunctivitis (3 of 16), reduced vision (10 of 16), and corneal hydrops (mimicking keratitis) (2 of 16). Except for 2 patients lost to follow-up, all eyes received corneal cross-linking treatment and 16 eyes received additional intracorneal ring segment implantation. CONCLUSIONS: The incidence of pediatric keratoconus indicates that increased awareness for keratoconus among children is needed, mainly in cases of family history of keratoconus, ocular allergy/pruritus, poor CDVA, corneal hydrops, and/or high astigmatism. [J Refract Surg. 2016;32(8):534-541.].

Acute corneal hydrops mimicking infectious keratitis as initial presentation of keratoconus in a 10-year-old child.

Purpose. To report a case of acute hydrops in a 10-year-old child with advanced keratoconus. Case Presentation. A ten-year-old boy diagnosed as having right eye (RE) infectious keratitis, not responding to antimicrobial therapy, was referred to our hospital. The diagnosis of infectious keratitis was established one month prior to his presentation following an episode of acute corneal whitening, pain, and drop in visual acuity. Topical fortified antibiotics followed by topical antiviral therapy were used with no improvement. Slit lamp examination showed significant corneal protrusion with edema surrounding a rupture in Descemet's membrane in the RE. The diagnosis of acute corneal hydrops from advanced keratoconus was highly suspected and confirmed with corneal topography. Conclusion. Although a relatively rare disease at the age of 10 years, keratoconus can be rapidly progressive in the pediatric group. Keratoconus should always be considered in the differential diagnosis of progressive vision loss in this age group.

Prevalence of dissociated strabismus in children with ocular misalignment: a population-based study.

PURPOSE: The purpose of this study was to report the prevalence of dissociated strabismus among a population-based cohort of children diagnosed with all forms of ocular misalignment. METHODS: The medical records of all children (<19 years of age) identified by the resources of the Rochester Epidemiology Project who were diagnosed with strabismus while residing in Olmsted County, Minnesota, from January 1, 1985, through December 31, 1994, were retrospectively reviewed for the prevalence of dissociated vertical (DVD) or horizontal (DHD) deviations. RESULTS: Of 627 children with strabismus, 12 (1.9%) were found to have DVD at their initial diagnosis at a mean age of 52 months (range, 3.5-206 months). During a mean follow-up of 10.4 years (range, 1-20 years), an additional 44 children were diagnosed with DVD, yielding a total of 50 children (7.9%). The common strabismus subtypes with the highest prevalence of DVD were, in declining order, congenital esotropia (53%), esotropia in the setting of a developmental deficit (25%), and accommodative esotropia (3.4%). None of the subjects were recorded as having DHD. CONCLUSIONS: In this patient cohort, DVD was relatively uncommon and occurred most frequently among those with early-onset strabismus and strabismus in the setting of a developmental deficit.

Slipped, severed, torn and lost extraocular muscles.

Slipped, severed, torn and lost extraocular muscles (EOM) are infrequently encountered in clinical practice but constitute significant complications of strabismus and other eye surgery and of orbital injuries. Knowledge of the clinical aspects of these various disease entities and their anatomical underpinnings are of utmost importance in providing effective recognition and treatment. These conditions share some common presenting signs, symptoms and clinical findings that are discussed in this review. The literature will be reviewed and management strategies will be presented.

Unilateral proptosis in a 60-year-old man.

A 60-year-old immunocompromised patient developed rapidly progressive proptosis that was secondary to mucormycosis. This life-threatening fungal infection usually is associated with chemosis, proptosis, ophthalmoplegia, and visual loss. The fungus may invade ocular structures, sinuses, and extend into the brain. The standard of care includes correction of the underlying condition, administration of liposomal amphotericin B with posaconazole, and surgical debridement of infected and necrotic tissue. We present a case of unilateral proptosis due to mucormycosis in an immunocompromised patient. The patient was successfully managed medically without exenteration. The indications for exenteration are currently unclear, and no clinical guidelines exist.