Topical Insulin for Ocular Surface Disease.

Background: Insulin and insulin-like growth factor (IGF)-1 receptors are present in ocular tissues such as corneal epithelium, keratocytes, and conjunctival cells. Insulin plays a crucial role in the growth, differentiation, and proliferation of corneal epithelial cells, as well as in wound healing processes in various tissues. Purpose: This review explores the potential role of topical insulin in the treatment of ocular surface diseases. Specifically, it examines its impact on corneal nerve regeneration, sub-basal plexus corneal nerves, and its application in conditions like corneal epithelial defects, dry eye disease, and diabetic keratopathy. Methods: The review analyzes studies conducted over the past decade that have investigated the use of topical insulin in ocular surface diseases. It focuses on indications, drug preparation methods, side effects, efficacy outcomes, and variations in insulin concentrations and dosages used. Results: While off-label use of topical insulin has shown promising results in refractory corneal epithelial defects, its efficacy in dry eye disease is yet to be demonstrated. Variations in concentrations, dilutions, and dosing guidelines have been reported. However, limited data on ocular penetration, ocular toxicity, and systemic side effects pose challenges to its widespread utility. Conclusion: This review synthesizes findings from ocular investigations on topical insulin to assess its potential applicability in treating ocular surface and corneal diseases. By highlighting indications, preparation methods, side effects, and efficacy outcomes, it aims to provide insights into the current status and future prospects of using topical insulin in ophthalmic practice.

Undesirable High Astigmatism after Penetrating Keratoplasty in Pseudophakia Corrected with an Add-On Toric Intraocular Lens.

The purpose of the present case is to report the visual outcomes of a pseudophakic patient with high post-penetrating keratoplasty astigmatism treated with implantation of toric AddOn® intraocular lens (IOL) in the sulcus. A 79-year-old man with a ophthalmologic history of pseudoexfoliative glaucoma and Fuchs endothelial dystrophy had a graft failure after Descemet's stripping automated endothelial keratoplasty procedure on his right eye. Consequently, a penetrating keratoplasty was performed, and a high corneal astigmatism of -9.8 D to 140° resulted in that eye after selective suture removal. A secondary AddOn® toric IOL customized for the patient with a manufacturer-calculated power of +11.0 D was implanted to 50° in sulcus of the right eye. Subjective refraction was used for IOL calculation. Final refraction was +1.0 D of sphere and -2.0 D of cylinder power to 105°, with spherical equivalent of 0.0 D. Best corrected visual acuity was logMAR 0.1 (20/25, 0.8 decimal) 1 year after the IOL implant. Our case report demonstrates that the toric AddOn® secondary IOL can be effective and safe in correcting residual refractive error of high regular astigmatism after keratoplasty in pseudophakic eyes.

Cryotherapy after Topical Interferon Alpha 2b to Treat Conjunctival Primary Acquired Melanosis.

When primary acquired melanosis (PAM) with atypia affects the tarsal conjunctiva, a radical surgery can be mutilating, requiring reconstructive surgery of the eyelid. Topical chemotherapy associated to local cryotherapy may be an alternative. A 64-year-old Caucasian female presented with diffuse PAM of the right eye involving the inferior tarsal conjunctiva, fornix, and inferotemporal bulbar conjunctiva. Histological study showed a PAM with atypia (C-MIN 5). Given the extent of the lesion and its location, a wide mutilating excision was ruled out. Topical interferon alpha 2b (IFN-α2b) treatment (1,000,000 IU/mL, 4 times a day) was administered during 10 weeks. However, the regression was very slow. Then local cryotherapy was proposed (8 s at -80°C per application) to the entire pigmented lesion. This afforded progressive depigmentation, which was completed 2 months later. No recurrence of the lesion has been noted during 3 years of follow-up. The combination of the two procedures reduces IFN-α2b eyedrop administration time, enhancing patient compliance. The combination may eradicate the tumor without compromising ocular cosmesis.

Accuracy of 10 IOL power calculation formulas in 100 short eyes (≤ 22 mm).

BACKGROUND: To assess and compare the accuracy of 10 intraocular lens (IOL) power calculation formulas after cataract surgery in eyes with an axial length (AL) shorter than or equal to 22.00 mm. METHODS: A retrospective case series included 100 eyes with an AL ≤ 22.00 mm that underwent uneventful cataract surgery. The refractive prediction error (PE) was calculated using 10 different IOL power calculation formulas: Barrett Universal II, EVO 2.0, Haigis, Hill RBF 2.0, Hoffer Q, Holladay 1 and 2, Kane, SRK/T and SuperLadas. The median absolute prediction error (MedAE ± SD) and mean absolute prediction error (MAE ± SD) were calculated after adjusting the mean prediction error (ME) to 0. RESULTS: Hoffer Q obtained the lowest MedAE (0.292 D) after adjusting the ME to 0, followed very closely by EVO 2.0 (0.298 D) and Kane (0.300 D). EVO 2.0 and Kane obtained both the lowest MAE after adjusting the ME to 0 (0.386). Differences in MAE among the different formulas were not statistically significant (p > 0.05). CONCLUSIONS: Our study reflects a tendency of the EVO 2.0 formula and the Kane formula along with the older Hoffer Q formula, to predict more accurately the refractive outcomes in short eyes that undergo cataract phacoemulsification surgery compared to the other formulas, despite this difference could not be statistically proved.

Adjunctive Treatment with Interferon Alpha 2b in Conjunctival Melanoma.

Purpose: The aim of the study was to demonstrate the clinical outcomes after resection of conjunctival melanoma (CM) followed by topical interferon (IFN) alpha 2b after a long follow-up. Methods: Two consecutive CM patients were treated using tumor excision followed by topical IFN alpha 2b (1,000,000 UI/mL) four times a day for 12 weeks. The second case presented positivity due to the presence of tumor cells in the lower margin of the resection. TNM staging was T1c, N0b, M0, and T1b in the first case and T1b, N0b, M0 in the second case. Follow-up was 72 and 71 months, respectively. Results: No side effects were observable after the administration of topical IFN alpha 2b. After extensive evaluation and imaging with computed tomography, no regrowth or distant metastasis was noticed during the follow-up period in both cases. Conclusions: IFN alpha 2b could be used as a co-adjuvant treatment after CM resection, in an attempt to reduce the possibility of recurrences.

Use of interferon alpha 2b to manage conjunctival primary acquired melanosis and conjunctival melanoma.

Primary acquired melanosis (PAM) is acquired conjunctival pigmentation that can give rise to conjunctival melanoma (CM), a malignant tumor of the bulbar and palpebral conjunctiva or the caruncle. Surgical excision is the treatment of choice for this neoplasm. Topical chemotherapy is also used for patients with PAM with atypia or CM and, in patients with recurrent or extensive disease, this may be an important option. Of the several chemotherapeutic drugs used, topical interferon alpha 2b (IFN-α2b) has become popular because of its low toxicity. Clinical evidence from case reports and case series supports the efficacy of IFN-α2b as the preferred adjuvant treatment for PAM and CM. In addition, topical IFN-α2b has been successfully applied to melanocytic tumors refractory to other treatments, such as cryotherapy and topical mitomycin C. In patients with locally advanced CM, the combination of IFN-α2b and systemic immunotherapy may serve as an alternative to exenteration. Given the low frequency of CM, long-term multicenter studies are needed to demonstrate the efficacy of IFN-α2b for preventing local recurrence and distant metastasis.

The regression time of ocular surface squamous neoplasia using topical interferon alfa-2b does not depend on the initial tumor size.

PURPOSE: The aim of this study was to determine if the initial tumor size correlates with the time to regression after topical interferon alfa-2b (1 million IU/mL) therapy in the treatment of ocular surface squamous neoplasia. METHODS: A retrospective study was performed in 15 patients clinically diagnosed as having ocular surface squamous neoplasia and treated with topical interferon alfa-2b (1 million IU/mL, four times a day). All the cases of ocular surface squamous neoplasia included in the study had corneo-limbal involvement. The initial extension of the ocular surface squamous neoplasia was measured in square millimeters using the program ImageJ (LOCI, University of Wisconsin, Madison, USA) on images taken from the eyes of each patient immediately before the beginning of the treatment. The time until tumor resolution was measured for each case. RESULTS: Complete tumor resolution was achieved in all the cases, with a mean initial tumor extension of 26.71 mm² (standard deviation ± 17.21 mm²) and a mean time until resolution of 77 days (standard deviation ± 32 days). An increased tumor volume after 15 days of treatment was obser ved in 2 patients, which completely resolved. No significant correlation was found between the time to resolution and the initial tumor extension measured in square millimeters (Spear man test, p=0.347). CONCLUSIONS: Our study suggests that the duration of topical interferon alfa-2b treatment required does not depend on the initial tumor size of the ocular surface squamous neoplasia usually found in clinical practice.

An Update on Corneal Biomechanics and Architecture in Diabetes.

In the last decade, we have witnessed substantial progress in our understanding of corneal biomechanics and architecture. It is well known that diabetes is a systemic metabolic disease that causes chronic progressive damage in the main organs of the human body, including the eyeball. Although the main and most widely recognized ocular effect of diabetes is on the retina, the structure of the cornea (the outermost and transparent tissue of the eye) can also be affected by the poor glycemic control characterizing diabetes. The different corneal structures (epithelium, stroma, and endothelium) are affected by specific complications of diabetes. The development of new noninvasive diagnostic technologies has provided a better understanding of corneal tissue modifications. The objective of this review is to describe the advances in the knowledge of the corneal alterations that diabetes can induce.

Diabetes and Phacoemulsification Cataract Surgery: Difficulties, Risks and Potential Complications.

Diabetes mellitus is one of the most prevalent chronic diseases worldwide. Diabetic patients are at risk of developing cataract and present for surgery at an earlier age than non-diabetics. The aim of this study was to review the problems associated with cataract surgery in a diabetic patient. Corneal complications in diabetic patients include delayed wound healing, risk of developing epithelial defects or recurrent erosions due to the impairment of epithelial basement membranes and epithelial-stromal interactions. Diabetic patients present lower endothelial cell density and their endothelium is more susceptible to trauma associated with cataract surgery. A small pupil is common in diabetic patients making cataract surgery technically challenging. Finally diabetic patients have an increased risk for developing postoperative pseudophakic cystoid macular edema, posterior capsule opacification or endophthalmitis. In patients with pre-proliferative or proliferative diabetic retinopathy, diabetic macular edema or iris neovascularization adjunctive therapy such as an intravitreal anti-vascular endothelial growth factor injection, can inhibit exacerbation related to cataract surgery.

Immunocryosurgery as monotherapy for lentigo maligna or combined with surgical excision for lentigo maligna melanoma.

The incidence of lentigo maligna (LM), in situ (LM) or invasive (lentigo maligna melanoma, LMM), has increased during the last decades. Due to functional or cosmetic outcomes, optimal treatment with surgical excision may not be appropriate in some cases. We tried less invasive therapy, immunocryosurgery, as a single treatment for LM or combined with surgery for LMM, with better aesthetic results. Three patients with LM or LMM not amenable to complete surgical excision were selected. LMM patients underwent limited surgical resection of the invasive area. Subsequently, a combined treatment with topical imiquimod and cryosurgery was performed. The LM patient received immunocryosurgery directly. All of them were free of local and systemic disease at 48, 42 and 41 months after discontinuation of therapy. We consider that immunocryosurgery is an alternative option for LM or even for LMM (after removal of the invasive tissue with narrow margins) in poor surgical candidates, with good therapeutic, functional and cosmetic results.

Queratitis por Alternaria alternata / Alternaria alternata keratitis

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Calculation of iris-claw IOL power for correction of late in-the-bag IOL complex dislocation.

BACKGROUND: To assess the constants and formula for aphakia correction with iris-claw IOLs to achieve the best refractive status in cases of late in-the-bag IOL complex dislocation. METHODS: A literature search was performed. The following data were obtained: Iris-claw IOL model, Iridal or retroiridal enclavation, A-constant, ultrasound or optical biometry, formula employed and refractive outcomes. Acceptable emmetropia was considered if the resulting spherical equivalent (SE) was within ±1.00 D. RESULTS: The majority of the studies used SRK/T formula (66.6%). The 88.9% of the reports obtained a SE within ±1.00 D. Using A-115 for ultrasound biometry and A-115.7 for optical biometry and SRK/T formula, the emmetropia (±1.00 D) of SE, was able to get near 100% of reported cases over the pupil implantation. However, the emmetropia decreased to 80% when the enclavation is retropupilar using the same formula. The A-constant can vary from 116.7 to 117.5 for retropupilar enclavation. CONCLUSIONS: Using A-115 for ultrasound biometry and A-115.7 for optical biometry and SRK/T formula, ±1.00 D of SE, is able to get near 100% of cases. Nevertheless, ±1.00 D of SE decreased to 80% of the cases when the enclavation is retropupilar.