A Patient Who Developed Lagophthalmos Following Rhinoplasty.

ABSTRACT: Lagophthalmos, impairment of closing upper eyelids, can result from various reasons. However, lagophthalmus after a rhinoplasty is both unusual and frustrating. We report a patient experiencing lagophthalmos following rhinoplasty and its management.

Comparison of the Rate of Posterior Capsule Opacification Following Combined Treatment With Topical Dexamethasone 0.1% Plus Ketorolac 0.5% Eye Drops Versus Dexamethasone 0.1% Alone: A Two-Year, Randomized Clinical Investigation.

Background and aim The use of non-steroidal anti-inflammatory drugs in animals decreases the incidence of posterior capsular opacification (PCO) following cataract surgery. We evaluated the rate of PCO in patients with cataract surgery and foldable "in the bag" posterior chamber intraocular lens (PC-IOL) implantation treated with combined dexamethasone 0.1% plus ketorolac tromethamine 0.5% versus dexamethasone 0.1% alone. Materials and methods A total of 114 eyes of 101 patients underwent uneventful corneal small-incision phacoemulsification with primary implantation of a foldable acrylic PC-IOL (AcrySof®, Alcon, Fort Worth, USA). Postoperatively for four weeks, group 1 eyes were treated with dexamethasone 0.1% plus ketorolac tromethamine 0.5% ophthalmic solutions four times daily for each whereas group 2 eyes were treated with dexamethasone 0.1% alone. Other regiments were the same for each group. Patients were evaluated between one- and four-year following surgery. The frequency and timing of severe PCO following surgery that needed Nd:YAG laser posterior capsulotomy were recorded and evaluated. Results The mean (SEM) age of group 1 (n = 54) and group 2 (n = 60) at operation was similar (62.8 ± 2.2 vs. 60.6 ± 1.7 years, respectively). Eighty-eight patients had unilateral cataract and 13 cases had bilateral disease. Overall, the mean follow-up duration was 24.7 months postoperatively (range, 15-48). Clinically significant PCO that finally needed Nd:YAG laser application developed in two eyes (3.7%) in group 1 and in four eyes (6.6%) in group 2, and the difference was not statistically significant (p>0.05). The mean month at capsulotomy was 26.5 in group 1 and 24.3 months in group 2 eyes (p>0.05). Conclusions Topical instillation of ketorolac ophthalmic solution in the immediate period after phacoemulsification and PC-IOL implantation did not seem to influence the incidence of PCO formation two years after cataract surgery.

Investigation of Mitophagy Biomarkers in Corneal Epithelium of Keratoconus Patients.

PURPOSE: The pathological mechanisms of keratoconus (KC) have not been elucidated yet. Mitophagy is an important mechanism that eliminates damaged mitochondria under oxidative stress, and it could be one of the leading pathological causes of KC. This study aimed to find out the role of mitophagy in the keratoconic corneal epithelium. METHODS: The corneal epithelia were collected from the 103 progressive KC patients and the 46 control subjects. The real-time quantitative PCR was performed for PTEN-putative kinase-1 (PINK1), PARKIN, p62, and BNIP3 gene expressions in 31 KC and 9 control subjects. Western blot analyses were performed to investigate the protein expressions of PINK1, PARKIN, LC3B, ATG5, and BECLIN in the remaining 109 corneal epithelium samples from 72 patients and 37 control subjects. RESULTS: mRNA and protein expressions of PINK1 decreased significantly in the corneal epithelium of KC patients compared to the control subjects. No significant change was found in mRNA levels of PARKIN, p62, and BNIP3 in KC patients. The protein expression of PARKIN, LC3B, ATG5, and Beclin did not significantly differ between KC patients and control subjects. Gene expression levels of mitophagy biomarkers were not affected by the KC grade. CONCLUSIONS: PINK1/PARKIN-dependent mitophagy is affected in the keratoconic corneal epithelium. We found significant decreases in both mRNA and protein expressions of PINK1 in the keratoconic corneal epithelium. However, we did not observe any other significant change in mitophagy markers. Mitochondrial stress-related mitophagy pathways could be interrupted by the decreased levels of PINK1 in the keratoconic corneal epithelium, but solely PINK1 dysregulation is not likely to induce KC pathogenesis.

Conjunctivochalasis and Tear Osmolarity Are Associated With Reduced Conjunctival Epithelial Thickness in Dry Eye.

PURPOSE: To investigate the hypothesis that ocular surface epithelial thickness is correlated with tear osmolarity, conjunctivochalasis (CCh), and dry eye clinical tests. DESIGN: A case-control study. METHODS: A total of 50 patients with different types of dry eye disease (DED) and 15 age- and sex-matched control subjects were enrolled in this study. We performed a detailed diagnostic assessment of tear film and ocular surface parameters, including Ocular Surface Disease Index questionnaire, visual analog scale questionnaire, topographic surface regularity and surface asymmetry indices, tear film break-up time, corneal and conjunctival dye staining, Schirmer I test, and tear osmolarity. The corneal and bulbar conjunctival epithelial thickness (CET) were obtained using the latest version of spectral domain optical coherence tomography (SDOCT). RESULTS: Patients with aqueous-deficient DED (ADDED) had lower bulbar CET values, particularly in the temporal region, than those of normal subjects and patients with evaporative-type DED (EDED); however, the difference did not quite reach a statistically significant level. Patients with DED and CCh had lower bulbar CET values in temporal (38.52 ± 9.58 µm) and inferior regions (50.79 ± 9.10 µm) compared to those with DED without CCh (47.39 ± 11.71 µm, 60.38 ± 14.36 µm, respectively, P < .02). In the DED group, tear osmolarity was found to be negatively correlated with CET values in temporal bulbar region (P = .006 and r = -0.403) and central corneal epithelial thickness values (P = .029 and r = -0.325). CONCLUSIONS: CCh and tear osmolarity are associated with reduced conjunctival epithelial thickness in DED.

On the Horizon: Biologics and Nutrients for Neurotrophic Keratitis.

ABSTRACT: Neurotrophic keratitis (NK), a potentially sight-threatening corneal disease, still does not have a specific treatment. The reduction or complete loss of corneal sensation, the most important factor in its pathogenesis, is one of the most important factors that complicate the treatment of corneal wound healing. In addition, the visual outcome may be adversely affected because of aggressive stromal fibrosis in severe NK cases. Basically, the current management of NK aims to accelerate wound healing and prevent the progression. However, new therapeutic agents, particularly developed depending on cell type-specific healing mechanisms are required for better visual outcomes. In recent years, several studies have started to use new promising areas of translational research, including gene therapy, stem cell therapy, miRNA, and bioengineering. Evidence has emerged that future treatment strategies for NK will be designed by the results of these studies. In this review, it is aimed to summarize scientific data of new treatment modalities for NK.

Reliable, Noncontact Imaging Tool for the Evaluation of Meibomian Gland Function: Sirius Meibography.

OBJECTIVES: To investigate the correlation between the clinical grading of the severity of meibomian gland dysfunction (MGD) and meibomian gland area (MGA) loss detected using Sirius meibography in the upper and lower eyelids and to correlate these parameters with dry eye signs and symptoms. METHODS: One hundred thirty eyes of 130 volunteer patients were enrolled. Meibomian gland dysfunction was defined as the presence of signs consistent with meibomian gland terminal duct obstruction and categorized between grades 1 and 4. Upper and lower MGA loss percentages were evaluated using Sirius meibography by two blinded examiners. Patients were categorized into two groups (positive and negative for MGD) based on their Ocular Surface Disease Index (OSDI) scores (≥15 and <14, respectively) and MGD grades (≥1 and 0, respectively). RESULTS: The MGA loss percentage and ocular surface test results of the MGD group were greater than in the non-MGD group in both eyelids (P=0.001). Meibomian gland dysfunction grade and MGA loss for the lower eyelid was greater than that of the upper eyelids (P=0.002 and P<0.001, respectively). The OSDI score, tear film break-up time, and lissamine green staining were all significantly correlated with MGD grade and MGA loss in both eyelids (P<0.001). For the average measures of the MGA loss percentage in each scan, the intraclass correlation value was found as 0.994 (95% confidence interval [CI]: 0.992-0.995) for reader 1 and 0.988 (95% CI: 0.982-0.992) for reader 2. CONCLUSIONS: Our findings suggest that Sirius meibography, a noncontact imaging device, is a reliable tool for evaluating meibomian gland structure in patients with MGD and non-MGD of various ages and regardless of sex.

Severity of Sjögren's Syndrome Keratoconjunctivitis Sicca Increases with Increased Percentage of Conjunctival Antigen-Presenting Cells.

This study investigated the relationship between clinical severity and percentage of conjunctival antigen-presenting cells (APCs) in Sjögren's syndrome (SS)-associated keratoconjunctivitis sicca (KCS). KCS clinical severity was based on symptom severity, tear volume, tear break-up time, and ocular surface dye staining. Conjunctival goblet cell density (GCD) was measured in periodic acid Schiff (PAS)-stained membranes. Conjunctival cells obtained by impression cytology were used for flow cytometry to measure percentages of CD45⁺HLA-DR⁺ APCs and mature CD11c⁺CD86⁺ dendritic cells (DCs). Compared to normal conjunctiva, the percentages of HLA-DR⁺ and CD11c⁺CD86⁺ cells were higher in the conjunctiva of the KCS group (p < 0.05). The percentage of CD45⁺HLA-DR⁺ cells positively correlated with clinical severity (r = 0.71, p < 0.05) and negatively correlated with GCD (r = -0.61, p < 0.05). Clinical severity also negatively correlated with GCD (r = -0.54, p < 0.05). These findings indicate that a higher percentage of APCs and mature DCs in the conjunctiva is associated with more severe KCS in SS. These APCs may contribute to the generation of the pathogenic Th1 cells that cause goblet cell loss in KCS.

Comparison of Different Measurement Tools and Dimensional Parameters of Pterygium to Investigate its Impact on Refractive Indices and Ocular Aberrations.

OBJECTIVES: The aim of this study was to compare different measurement tools and parameters, including a new computer-assisted image processing technique for the quantitative analysis of the percentage of pterygium on the corneal surface, horizontal/vertical lengths obtained using slitlamp beam and surgical compass. METHODS: A total of 21 pterygia of 17 patients were included in the study. The pterygia were measured by three different methods: a slitlamp beam, a surgical compass, and a new computer-assisted image processing method. Refractive indices and higher-order aberrations were analyzed in all cases. RESULTS: The new computer-assisted image processing technique revealed excellent intraclass correlation coefficients for intraobserver and interobserver reliability (0.999 and 0.995, respectively). However, horizontal and vertical lengths revealed more deviation between the measurements obtained with slitlamp beam and surgical compass. Although uncorrected visual acuity did not show any significant correlation between horizontal and vertical lengths of pterygia measured by either slitlamp beam or surgical compass, it was correlated with the digital pterygium ratio (rho, 0.462; P=0.035). All ocular aberration (total, higher-order, coma, trefoil, quatrefoil, spherical, and higher-order astigmatism) Root-mean-square values more strongly correlated with higher percentage values of pterygium that covers the cornea, measured by the new computer-assisted image processing technique. CONCLUSION: The percentage of pterygium covering the corneal surface seems to be more associated with the pterygium-related visual disturbances than with horizontal and vertical lengths measured by conventional techniques. Moreover, the new computer-assisted image processing technique can accurately and reliably measure the percentage extension of pterygium on cornea.

Randomized Controlled Crossover Trial Comparing the Impact of Sham or Intranasal Tear Neurostimulation on Conjunctival Goblet Cell Degranulation.

PURPOSE: The aim of the study was to investigate the effects of the Allergan Intranasal Tear Neurostimulator (ITN) on conjunctival goblet cell (GC) degranulation. DESIGN: A randomized, double-masked, placebo-controlled crossover trial. METHODS: A total of 15 subjects (5 normal and 10 dry eye) were enrolled in a 3-visit study consisting of 1 screening and 2 separate randomized-masked ITN treatments (sham extranasal or intranasal). Tear meniscus height (TMH) was measured by anterior segment optical coherence tomography before and after applications. Impression cytology (IC) was taken from the bulbar conjunctiva of the right eye for periodic acid-Schiff staining and from the left eye for MUC5AC mucin immunostaining at baseline and after each treatment. The ratio of degranulated to nondegranulated GCs was measured as a marker of secretion. RESULTS: In all participants, both inferior bulbar (IB) and temporal bulbar (TB) cytology specimens stained for MUC5AC revealed a significantly higher ratio of degranulated to nondegranulated GCs after the ITN (IB: 2.28 ± 1.27 and TB: 1.81 ± 1.01) compared to baseline (IB: 0.56 ± 0.55, P = .015) (TB: 0.56 ± 0.32, P = .003) and extranasal sham application (IB: 0.37 ± 0.29, P = .001) (TB: 0.39 ± 0.33, P = .001). When the same analysis was repeated in the dry eye or control groups, the ratio was significantly higher after ITN than the baseline ratio and ratio after extranasal application in both groups (P < .05). Moreover, although control subjects had a higher ratio of degranulated to nondegranulated GCs at baseline (0.75 ± 0.52) compared with the dry eye group (0.41 ± 0.27), the ratio became slightly higher in dry eye (2.04 ± 1.12 vs 1.99 ± 1.21 in control) after the ITN application. There was no significant difference between the IB or TB conjunctiva locations in terms of the effectiveness of the ITN application on conjunctival goblet cell secretory response. CONCLUSIONS: These preliminary results document that the Allergan ITN can stimulate degranulation of goblet cells in the conjunctiva, which is a promising new approach for the management of dry eye.

A New Matrix Therapy Agent for Faster Corneal Healing and Less Ocular Discomfort Following Epi-off Accelerated Corneal Cross-linking in Progressive Keratoconus.

PURPOSE: To investigate the hypothesis that a new matrix therapy agent (ReGeneraTing Agent, [RGTA]) would speed up the corneal reepithelialization, improve stromal healing, and reduce ocular symptoms after epi-off corneal cross-linking (CXL). METHODS: Sixty eyes of 60 patients with progressive keratoconus were enrolled in the study. Epi-off accelerated CXL was performed in all patients. Sixty eyes were randomized into two groups according to use of RGTA eye drops prior to contact lens fitting at the end. Identical medical agents were started postoperatively for the two groups. All participants were monitored on 3 consecutive days after the CXL. Ocular pain, burning, stinging, tearing, photophobia, conjunctival hyperemia, and corneal healing status were evaluated. RESULTS: By day 2, 25 eyes (83.3%) with RGTA revealed complete healing compared to 4 eyes (13.3%) that revealed complete healing in the control group (P < .001). All eyes had complete corneal epithelial defect closure by day 3 in both groups. Ocular pain scores were lower in the RGTA group on days 0, 1, and 2 (all P < .05). Burning scores were lower on days 1 and 2; stinging scores on days 2 and 3; tearing scores on days 2 and 3; and photophobia on days 1 and 2 (P < .05) in the RGTA group compared to the control group. CONCLUSIONS: RGTA ophthalmic solution facilitates corneal healing by reconstructing the extracellular matrix in the wound area, leading to an earlier relief of symptoms for patients. [J Refract Surg. 2017;33(3):163-170.].

Corneal Pseudodendritic Lesions Masquerading as Herpetic Keratitis in a Patient With Tyrosinemia Type I.

OBJECTIVE: To describe the clinical findings of a patient with tyrosinemia type I with noncompliance to a protein-restricted diet, treated with 2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione (NTBC). METHODS: Clinical findings at the initial examination and after strict compliance to a protein-restricted diet after 4 weeks follow-up are described in a patient with tyrosinemia type I on NTBC treatment, who had been treated with presumed herpetic keratitis. RESULTS: A 10-year-old girl diagnosed with hereditary tyrosinemia type I and on NTBC treatment presented with photophobia and ocular discomfort in both eyes. An ophthalmologic examination demonstrated bilateral dendritiform epithelial lesions in the central cornea, staining faintly with fluorescein. These lesions were subsequently intermittently treated with topical antivirals for presumed herpes simplex virus keratitis and lubricant eye drops for 9 months without resolution; however, when strict compliance with a protein-restricted diet was instituted, nearly a complete resolution of the lesions was noted at the 4-week follow-up. CONCLUSIONS: Although type II tyrosinemia is known to have corneal involvement, the natural course of tyrosinemia type I has not been shown to have corneal involvement. Corneal involvement in type I tyrosinemia may be an indicator of dietary noncompliance and may show complete resolution with a strict compliance to protein-restricted diet only.

Topical Coenzyme Q10 Eye Drops as an Adjuvant Treatment in Challenging Refractory Corneal Ulcers: A Case Series and Literature Review.

PURPOSE: The management of nonhealing corneal ulcers, particularly in patients with neurotrophic corneas, remains a challenging problem today. Some patients may fail to respond to conventional therapy, making new alternative agents necessary to treat these resistant cases. In this article, we aim to present six challenging cases of refractory corneal ulcers that revealed healing response to the adjuvant treatment with coenzyme Q10 (CoQ10) eye drops and to review the literature examining of new therapeutic agents. METHODS: Our study was designed as a descriptive case series demonstrating the use of novel coenzyme Q10 eye drops in refractory corneal ulcers. In our case series, CoQ10 eye drops were added to the existing therapies as an adjuvant agent in six cases: three cases with neurotrophic corneal ulcers, two cases with postinfectious corneal ulcers (one unknown etiology+one Acanthamoeba keratitis), and 1 case with Stevens-Johnson syndrome. All cases were monitored regularly and corneal images were taken at all visits. RESULTS: All nonhealing corneas with conventional therapy revealed recovery after the addition of CoQ10 eye drops. Except for two cases that responded to the CoQ10 eye drops more rapidly (within 1 to 2 weeks), complete corneal healing was observed in four cases between weeks 4 and 8. No adverse events were reported in these cases throughout the follow-up period. CONCLUSION: Coenzyme Q10 eye drops can be considered as an important adjuvant therapeutic agent promoting corneal epithelial wound healing in challenging cases.

A New Fitting Approach for Providing Adequate Comfort and Visual Performance in Keratoconus: Soft HydroCone (Toris K) Lenses.

OBJECTIVE: To evaluate the comfort and visual performance of soft HydroCone (Toris K) silicone hydrogel lenses in keratoconus patients. METHODS: Fifty eyes of 50 keratoconic patients who were fitted with the Toris K lens were included in the study. All patients were evaluated at baseline and after 2 weeks of lens wear. Uncorrected and best-corrected visual acuities were measured. Corneal topography, ocular aberrations, and point spread function (PSF) were obtained using NIDEK-OPD Scan. Comfort level and visual performance in daytime and nighttime conditions were scored from 0 to 5 after 2 weeks of lens wear. RESULTS: Best-corrected visual acuity was significantly better with the Toris K lens (P<0.001). Mean increase in visual acuity with the lens was 4.5 lines. Mean K1, K2, and Kmax values significantly decreased with the lens (P<0.001). Both total and higher-order root-mean-square errors were significantly corrected with the Toris K lens (P<0.001 and P=0.038, respectively). A significant correction of total coma and trefoil aberrations was achieved with the lens. Also, PSF values were significantly increased with the lens (P<0.001). Although comfort scores in 46 eyes (92.0%) were classified as good/excellent, only 4 eyes (8.0%) had moderate comfort scores. Visual acuity was classified as good/excellent in 46 eyes (92.0%) in daytime and in 38 eyes (76%) in nighttime conditions. CONCLUSIONS: Soft HydroCone silicone hydrogel keratoconus lenses should be considered as alternative visual correction for keratoconus patients. The soft and full-custom design provides optimal comfort and visual performance for the patients' daily requirements.

Aqueous Tear Deficiency Increases Conjunctival Interferon-γ (IFN-γ) Expression and Goblet Cell Loss.

PURPOSE: To investigate the hypothesis that increased interferon-γ (IFN-γ) expression is associated with conjunctival goblet cell loss in subjects with tear dysfunction. METHODS: Goblet cell density (GCD) was measured in impression cytology from the temporal bulbar conjunctiva, and gene expression was measured in cytology samples from the nasal bulbar conjunctiva obtained from 68 subjects, including normal control, meibomian gland disease (MGD), non-Sjögren syndrome (non-SSATD)-, and Sjögren syndrome (SSATD)-associated aqueous tear deficiency. Gene expression was evaluated by real-time PCR. Tear meniscus height (TMH) was measured by optical coherence tomography. Fluorescein and lissamine green dye staining evaluated corneal and conjunctival disease, respectively. Between-group mean differences and correlation coefficients were calculated. RESULTS: Compared to control, IFN-γ expression was significantly higher in both ATD groups, and its receptor was higher in SSATD. Expression of IL-13 and its receptor was similar in all groups. Goblet cell density was lower in the SSATD group; expression of MUC5AC mucin was lower and cornified envelope precursor small proline-rich region (SPRR)-2G higher in both ATD groups. Interferon-γ transcript number was inversely correlated with GCD (r = -0.37, P < 0.04) and TMH (r = -0.37, P = 0.02), and directly correlated with lissamine green staining (r = 0.51, P < 0.001) and SPRR-2G expression (r = 0.32, P < 0.05). CONCLUSIONS: Interferon-γ expression in the conjunctiva was higher in aqueous deficiency and correlated with goblet cell loss and severity of conjunctival disease. These results support findings of animal and culture studies showing that IFN-γ reduces conjunctival goblet cell number and mucin production.

Effects of chronic smoking on color vision in young subjects.

AIM: To evaluate the effects of chronic smoking on color vision in young subjects. METHODS: This study included 91 smokers and 88 non-smokers (a total of 179 volunteers) without any ophthalmologic and systemical disorders. The subjects were between 18-40 years of age with a best corrected visual acuity (BCVA) of 20/20, normal anterior and posterior segment examinations and normal intraocular pressure. The color vision of the subjects were evaluated with Farnsworth-Munsell 100 Hue test (FMHT). The total error scores and axis calculation were performed for each subject and the results correlated. RESULTS: Mean age and the standard deviation was 28±5y in the smokers group, and 26.7±5.5y in the control group (P=0.101). Sex distribution was similar in the two groups (P=0.365). There was no significant correlation between age and FMHT total error scores (P=0.069). Median of FMHT total error scores of smokers and non-smokers were 65 and 50.50, respectively. FMHT total error scores was found significantly higher in smokers than non-smokers (P=0.004). There was no statisticaly significant difference between smoker and non-smoker groups with respect to axis ratio calculation (P=0.611). There was no significant correlation with FMHT total error scores with neither smoking duration nor number of cigarettes smoked per day (P=0.405, P=0.454, respectively). CONCLUSION: This study suggested that chronic smoking affects the color vision of young smokers but this may not be sector selective.