A Case of Early Keratoconus Associated with Eye Rubbing in a Young Child.

INTRODUCTION: Keratoconus usually presents during puberty and is considered rare in young children. METHODS: Case report with clinical findings and computerized corneal tomography. RESULTS: We report the case of an 8-year-old girl with early bilateral keratoconus who presented with allergic conjunctivitis and persistent eye rubbing. Although our patient did not exhibit steep keratometry, early cones and inferotemporal thinnest corneal thicknesses were detected in both eyes using Scheimpflug imaging (Oculus GmbH Pentacam, Wetzlar, Germany). Belin/Ambrósio total D values were 1.85 on the right and 2.11 on the left. Improvement in best-corrected visual acuity was noted after treatment of allergic eye disease, and corneal tomographic findings remained stable 4 months after initial consult. CONCLUSION: This is a case of early diagnosed keratoconus in a young patient. Diagnosis of this condition in young children is challenging, as these patients are less likely to report visual complaints, and clinical examination is usually unremarkable. Keratoconus screening should be considered in children with atopy and eye rubbing behavior regardless of age, even in those with no other associated pathology and with negative family history.

Comparison of postoperative refractive outcome in eyes undergoing combined phacovitrectomy vs cataract surgery following vitrectomy.

BACKGROUND: To investigate the accuracy of preoperative biometry in eyes undergoing combined phacovitrectomy and to compare it with eyes having cataract surgery at a later point in time following vitrectomy. METHODS: Patients with epiretinal membrane or macular hole who underwent combined phacovitrectomy (group 1) or phacoemulsification following pars plana vitrectomy (PPV) (group 2) were included in this retrospective, comparative, interventional case series. The primary outcome measures were the intraocular lens power prediction error (PE) and the percentage of eyes with PE > ± 0.5D in the two groups. Secondary outcome measures included the correlation between epidemiological, clinical, or surgical factors and dioptric shift. In addition, the influence of optical coherence tomography characteristics to the PE was investigated. RESULTS: Group 1 and 2 consisted of 55 and 54 eyes, respectively, for a total of 109 eyes included in the study. The mean absolute PE was 0.59 D (range + 1.4 to - 2.5D) in group 1 and 0.35 (range + 1.0 to - 1.45D) in group 2 (p = 0.01). PE greater than 0.5D was observed in 47% of eyes in group 1 as opposed to 16.6% of eyes in group 2 (p = 0.027). The PE was associated with shallower anterior chamber depth (ACD), increased central macular thickness (> 300 µ), and worse baseline best-corrected visual acuity. Photoreceptor ellipsoid zone or external limiting membrane disruption was not associated with significantly greater postoperative refractive deviations. CONCLUSION: Combined phacovitrectomy may result in greater postoperative refractive prediction error compared to phacoemulsification alone following vitrectomy. Patients with worse vision, greater central macular thickness, and shallow anterior chambers require more caution since they are prone to inaccurate preoperative biometry.

Revisiting Ocular Allergy: Evaluating Symptoms, Benzalkonium Chloride and Efficacy of Topical Ketotifen 0.025.

This interesting study raises a scientific issue for revisiting three important elements on diagnosis, use of preservatives and selection of the appropriate topical treatment. Itchy feeling can be encountered in other ophthalmic conditions misdiagnosed as allergy, benzalkonium chloride is responsible for surface toxicity resulting in reduced efficacy and tolerability of topical allergy medications and it should be avoided on the management of ocular allergy. Unpreserved ketotifen 0,025% has been shown to be the least toxic formulation being the optimum option for efficacy and tolerability on the management of ocular allergy.

The Proteins of Keratoconus: a Literature Review Exploring Their Contribution to the Pathophysiology of the Disease.

INTRODUCTION: Keratoconus (KC) is a complex, genetically heterogeneous multifactorial degenerative disorder characterized by corneal ectasia and thinning. Its incidence is approximately 1/2000-1/50,000 in the general population. KC is associated with moderate to high myopia and irregular astigmatism, resulting in severe visual impairment. KC structural abnormalities primarily relate to the weakening of the corneal collagen. Their understanding is crucial and could contribute to effective management of the disease, such as with the aid of corneal cross-linking (CXL). The present article critically reviews the proteins involved in the pathophysiology of KC, with particular emphasis on the characteristics of collagen that pertain to CXL. METHODS: PubMed, MEDLINE, Google Scholar and GeneCards databases were screened for relevant articles published in English between January 2006 and June 2018. Keyword combinations of the words "keratoconus," "risk factor(s)," "genetics," "genes," "genetic association(s)," "proteins", "collagen" and "cornea'' were used. In total, 272 articles were retrieved, reviewed and selected, with greater weight placed on more recently published evidence. Based on the reviewed literature, an attempt was made to tabulate the up- and down-regulation of genes involved in KC and their protein products and to delineate the mechanisms involved in CXL. RESULTS: A total of 117 proteins and protein classes have been implicated in the pathogenesis and pathophysiology of KC. These have been tabulated in seven distinct tables according to their gene coding, their biochemistry and their metabolic control. CONCLUSION: The pathogenesis and pathophysiology of KC remain enigmatic. Emerging evidence has improved our understanding of the molecular characteristics of KC and could further improve the success rate of CXL therapies.

Update in treatment of uveitic macular edema.

Macular edema (ME) represents the most common cause for visual loss among uveitis patients. The management of uveitic macular edema (UME) may be challenging, due to its often recalcitrant nature. Corticosteroids remain the mainstay of treatment, through their capability of effectively controlling inflammation and the associated ME. Topical steroids may be effective in milder cases of UME, particularly in edema associated with anterior uveitis. Posterior sub-Tenon and orbital floor steroids, as well as intravitreal steroids often induce rapid regression of UME, although this may be followed by recurrence of the pathology. Intra-vitreal corticosteroid implants provide sustained release of steroids facilitating regression of ME with less frequent injections. Topical nonsteroidal anti-inflammatory drugs may provide a safe alternative or adjuvant therapy to topical steroids in mild UME, predominantly in cases with underlying anterior uveitis. Immunomodulators including methotrexate, mycophenolate mofetil, tacrolimus, azathioprine, and cyclosporine, as well as biologic agents, notably the anti-tumor necrosis factor-α monoclonal antibodies adalimumab and infliximab, may accomplish the control of inflammation and associated ME in refractory cases, or enable the tapering of steroids. Newer biotherapies have demonstrated promising outcomes and may be considered in persisting cases of UME.

A Modified Surgical Technique to Treat Strabismus in Complete Sixth Nerve Palsy.

INTRODUCTION: A lot of different techniques have been proposed in order to manage abduction limitation secondary to sixth nerve palsy; however, anterior segment ischemia remains a concern. The aim of this study was to evaluate the results of augmented vertical recti muscle transposition (VRT) with partial recession of medial rectus muscle (MR) for complete, chronic sixth nerve palsy, a new modified technique that could also minimize the risk for anterior segment ischemia (ASI). METHODS: In this nonrandomized 8-year (2009-2017) retrospective review, 20 patients with complete sixth nerve palsy and contracted MR were enrolled. All of them underwent augmented VRT and partial recession of the MR, following a new proposed surgical technique. Only the central part of the MR tendon and belly was recessed by 6.5 mm, leaving 1.5 mm of the upper pole and 1.5 mm of the lower pole of the muscle intact, preserving the circulation of two anterior ciliary arteries. RESULTS: Twenty patients with a mean age of 43 years (range 12-71), all unilateral cases, were enrolled in this study. The mean preoperative deviation was 64.25 ± 10.9 prism diopters (PD) base out (range 50 to 90). In 17 cases (88%), the postoperative deviation was within 10 PD of orthotropia. Two patients (10%) had residual esotropia (15 PD and 20 PD, respectively), and one patient (5%) had 10 PD of hypotropia. The mean preoperative abduction limitation of -5.9 improved to -3.1 (p < 0.0001). None of the cases presented with ASI (success rate 100%). CONCLUSION: Partial recession of the MR preserving the two anterior ciliary arteries (Kozeis modified technique) with augmented vertical recti muscle transposition is an effective procedure, with a high success rate and is probably less risky for ASI.

Bilateral acute iris transillumination following systemic administration of antibiotics.

OBJECTIVES: To describe the demographic characteristics, clinical features, and potential prognostic factors of bilateral acute iris transillumination (BAIT) following oral antibiotic uptake. METHODS: A retrospective study of 16 consecutive patients who developed BAIT following treatment with systemic antibiotics. Detailed past medical and ocular history was obtained, presenting signs and symptoms were documented and demographic characteristics were analyzed. All patients underwent a complete ocular examination and laboratory investigation. The course of best corrected visual acuity (BCVA), anterior chamber activity, and intraocular pressure (IOP) during the follow-up period were recorded and possible correlations with potential prognosticators were investigated. RESULTS: Fourteen females and two males were included in the present study. The mean age (SD) of the patients was 43 (14) years. All individuals presented conjunctival injection and photophobia and developed bilateral transillumination defects, fixed mid-dilated pupils and pigment dispersion in the anterior chamber. Systemic antibiotics were previously prescribed in all cases (13 patients with moxifloxacin and three patients with clarithromycin) and the mean (SD) interval between onset of symptoms and antibiotic administration was 17 (4) days. Ocular hypertension complicated all eyes and required antiglaucoma medication in 25 eyes. Severe anterior chamber pigment dispersion and higher IOP during the first week after presentation was significantly associated with longer duration of ocular hypertension (OHT) (p = 0.019). CONCLUSIONS: BAIT represents a rare clinical entity with characteristic features. Although etiopathogenesis of this condition remains unclear, a series of cases that indicate a strong correlation between systemic antibiotic administration and BAIT is herein presented.

Update on the Treatment of Uveitis in Patients with Juvenile Idiopathic Arthritis: A Review.

Chronic uveitis is a common extra-articular manifestation of juvenile idiopathic arthritis. The classic clinical picture is one of chronic anterior uveitis, which usually remains asymptomatic until ocular complications arise. The risk of uveitis is increased in girls with an early onset of oligoarthritis and positive antinuclear antibodies. Even though the inflammation in patients with juvenile idiopathic arthritis is initially limited in the anterior part of the eye, chronic active inflammation may eventually cause significant damage to the posterior pole. Complications may include band keratopathy, cataract, secondary glaucoma, posterior synechiae, cystoid macular edema, and hypotony. The cooperation of ophthalmologists with rheumatologists may help define the best treatment plan. The ophthalmic therapeutic regimen includes topical corticosteroids and mydriatics, while in severe cases immunosuppressive and biological agents are introduced. Surgical management of complications might be needed.

Collagen Cross- Linking for Paediatric Keratoconus.

BACKGROUND: Since the late 1990s corneal crosslinking (CXL) has been proposed as a new treatment option which can stop progression of keratoconus with promising results in adults. OBJECTIVE: Keratoconus presents a higher rate and faster progression in paediatric patients and for this reason prompt and effective treatment is essential. Due to its success in adult keratoconus patients, CXL has been recently applied to children in order to stop or slow progression of keratoconus in paediatric patients. CONCLUSIONS: This article will present an update of the literature on the topic of CXL in this age group.

A Review of Minimally Invasive Strabismus Surgery (MISS): Is This the Way Forward?

Minimally invasive surgery is rapidly becoming the norm in medicine, as it often leads to better outcomes and earlier rehabilitation. This article reviews the principles and different techniques employed to perform minimally invasive strabismus surgery (MISS). In these techniques, strabismus surgery is performed through keyhole openings, thus reducing the risk of postoperative corneal complications, minimizing postoperative discomfort, and better preserving muscle function. MISS can be used to perform all types of strabismus surgery, namely rectus muscle recessions, resections, plications, reoperations, retroequatorial myopexy, transpositions, oblique muscle recessions, or plications even in the presence of limited motility. Of note, ocular alignment outcomes with MISS versus more traditional techniques have not been compared in randomized trials. Consequently, more controlled evidence is still needed to better delineate the future role and value of MISS in clinical management.

Comparative Study of Refractive Errors, Strabismus, Microsaccades, and Visual Perception Between Preterm and Full-Term Children With Infantile Cerebral Palsy.

The purpose of this study was to examine the refractive status, orthoptic status and visual perception in a group of preterm and another of full-term children with cerebral palsy, in order to investigate whether prematurity has an effect on the development of refractive errors and binocular disorders. A hundred school-aged children, 70 preterm and 30 full-term, with congenital cerebral palsy were examined. Differences for hypermetropia, myopia, and emmetropia were not statistically significant between the 2 groups. Astigmatism was significantly increased in the preterm group. The orthoptic status was similar for both groups. Visual perception was markedly reduced in both groups, but the differences were not significant. In conclusion, children with cerebral palsy have impaired visual skills, leading to reading difficulties. The presence of prematurity does not appear to represent an additional risk factor for the development of refractive errors and binocular disorders.

Macular hole formation after toxoplasmic retinochoroiditis.

A 56-year-old female patient presented with toxoplasmic retinochoroiditis (TR) in the right eye. Optical coherence tomography revealed a full-thickness macular hole (MH) in the affected eye. Fluorescence angiography and indocyanine green-angiography disclosed focal choroidal ischaemia in the area of inflammation. Heidelberg retinal flowmetry confirmed the significant hypoperfusion in this area. Proper medication was administered. Ophthalmological examination 4 weeks later revealed an improvement of the clinical findings without visual restoration. This case supports the clinical hypothesis that retinochoroidal ischaemia due to TR may induce the development of MH, indicating that patients with TR may have a certain risk for MH formation.

Ipsilateral posterior subcapsular cataract in a young patient with hourglass-like narrowing of the inferior temporal retinal artery.

We present an interesting and rare case of subcapsular cataract coexisting with ipsilateral narrowing of the inferior temporal retinal artery in a young woman. The possible role of retinal vessel malformation in cataract pathophysiology is discussed.

Keratitis in reactive arthritis (Reiter syndrome) in childhood.

PURPOSE: To present a rare ocular manifestation of reactive arthritis (Reiter syndrome) in a child. METHODS: A 10-year-old girl who was admitted to our hospital with low-grade fever, arthritis, and aching left eye with blurred vision was diagnosed with Reiter reactive arthritis. At the time of admittance, the ophthalmologic examination revealed keratitis; this mildly affected the vision. RESULTS: Keratitis resolved under treatment with topical steroids and antibiotic drops after 1 month, without scarring. Although 75% of the patients with reactive arthritis present ophthalmic manifestations, keratitis is a very rare finding in reactive arthritis and even rarer in children. CONCLUSIONS: It should be kept in mind that keratitis could be an ocular manifestation of reactive arthritis in young patients.

A management dilemma: infectious keratitis associated with soft contact lens use and dubious treatment compliance.

Purpose. To present a case of infectious keratitis caused by the microorganism Serratia marcescens in a contact lens user and further to confer on the most advantageous management of comparable situations. Case. After altering the routine that she used for contact lens disinfection, a 24-year-old patient presented with pain and conjunctival redness in both eyes. Slit-lamp examination revealed two infiltrates in the inferior part of the cornea in the right eye and five smaller infiltrates in the superior half of the left cornea. Appropriate treatment, after hospitalization, improved the symptoms while culture of the contact lens material revealed Serratia marcescens as the responsible infectious factor. Conclusion. Enhancing the availability of information with respect to contact lens users and customized analysis regarding treatment for a particular complication could be beneficial in order to reduce the frequency of admission to the eye clinic due to infectious keratitis. In addition, rapid laboratory testing of the infected materials should be a priority for selection of the optimal treatment regimen.