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Machine learning can be used to identify risk factors associated with graft rejection after corneal transplantation for keratoconus. The study included all keratoconus eyes that underwent primary corneal transplantation from 1994 to 2021. Data relating to the recipient, donor, surgery, and postoperative course that might be associated with the occurrence of a graft rejection reaction were compiled. This study used five supervised learning algorithms including artificial neural network, support vector machine, gradient boosting, extra trees classifier, and random survival forests to select the most predictive factors for graft rejection. A total of 1214 consecutive eyes of 985 keratoconus patients were included in the study, and the technique of keratoplasty included penetrating keratoplasty in 574 eyes (47.3%) and deep anterior lamellar keratoplasty in 640 eyes (52.7%). The overall prevalence of first graft rejection was 28.1%. All five models had similar ability in identifying predictive factors for corneal graft rejection. Technique of keratoplasty was associated with an increased risk of graft rejection in all models. Other identified risk factors included patient age, keratoplasty in the fellow eye, donor age, graft endothelial cell density, duration of corticosteroid application, time from keratoplasty to complete suture removal, and suture-associated complications. It is advisable that in the absence of any contraindication, post-transplant keratoconus eyes receive a low dose topical corticosteroid until all sutures are removed., Competing Interests: Declarations. Competing interests: The authors declare no competing interests. Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the ethics committee of Shahid Beheshti University of Medical Sciences, Tehran, Iran (IR.SBMU.ORCREC.11786.151), and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards., (© 2024. The Author(s).)

Purpose: This study aimed to investigate the association between variants in the interleukin (IL)-1 gene cluster and susceptibility to keratoconus (KC) in an Iranian population., Methods: In the case group, there were 188 KC patients diagnosed by clinical findings and corneal tomography. The control group included all 205 healthy controls with no personal or family history of eye-related, metabolic, or immune system-related disease. Using the standard salting out extraction procedure, genomic DNA was isolated from peripheral blood leukocytes. The genotypes were determined by applying agarose gel electrophoresis for the IL-1RN 86 bp VNTR and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) for rs16944 and rs1143634., Results: The results showed a significant association between the IL-1β rs1143634 (rs1143634 T allele, P = 0.008) and IL-1RN 86 bp VNTR polymorphisms (LL and LS genotype, P = 0.048 and 0.012 respectively) and susceptibility to KC in the Iranian population. The genotype distributions of rs1143634 (P = 0.004) and rs2234663 (P = 0.042) significantly differed between case and control groups, with certain genotypes demonstrating a protective effect against KC. Logistic regression analysis revealed a protective effect of the IL-1RN L allele [odds ratio (OR) = 0.367, 95% confidence interval (CI): 0.240-0.562; P = 0.000] and certain haplotypes (OR = 0.628, 95% CI: 0.447-0.884; P = 0.007) against KC. However, no significant association was found for the IL-1β rs16944 polymorphism., Conclusion: This study provides evidence for an association between variants in the IL-1 gene cluster and susceptibility to KC in an Iranian population. Further research on larger and more diverse populations is warranted to validate these findings and explore the underlying mechanisms involved., (© 2024. The Author(s).)

Purpose: The purpose of this study is to determine the incidence of suture-related complications, their risk factors, and effects on the clinical outcomes after deep anterior lamellar keratoplasty (DALK) for keratoconus., Methods: In this retrospective, comparative, interventional study, the records of consecutive patients with keratoconus who underwent DALK were reviewed for suture-related complications. Univariate analyses were used to identify risk factors for suture complications. We compared groups with and without suture-related complications to evaluate the effects of these complications on clinical outcomes after DALK., Results: Of the 633 DALKs, 438 eyes (69.2%) developed suture complications including loose sutures (32.7%), spontaneous suture rupture (30%), sterile suture abscesses (22.8%), suture tract vascularization (16.4%), suture erosion (10.3%), and suture cheese wiring (6.8%). Vernal keratoconjunctivitis increased the incidence of sterile suture infiltration, premature suture loosening, and suture tract vascularization. Loose suture was observed more commonly in larger graft size, while spontaneous suture rupture was associated with late suture removal. There was no statistically significant difference in postoperative outcomes including visual acuity, refraction, graft rejection, and failure in eyes with and without suture complications. However, suture-related complications were directly associated with sight-threatening ocular morbidities, including graft rejection (39 eyes), ulcer (1 eye), and failure (2 eyes)., Conclusion: Suture-related complications frequently occurred after DALK for keratoconus. Ocular surface inflammation, large grafts, and late suture removal increased the risk of suture-related complications. While these complications had no negative impact on clinical outcomes in the majority of cases, some of them led to sight-threatening morbidity, underlining the importance of early diagnosis and treatment., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

This review explores contemporary challenges in penetrating keratoplasty (PK), focusing on technical intricacies, technological advancements, and strategies for preventing graft rejection. A systematic literature search from January 2018 to July 2023 was conducted across PubMed, Cochrane, Web of Science, Scopus, and EMBASE. The inclusion criteria comprised studies on PK and its comparison with other corneal pathologies, with emphasis on keratoconus (KC). Two independent reviewers screened studies, extracting relevant data. The review covers PK evolution, highlighting infra-red femtosecond lasers' impact on graft shapes, minimizing astigmatism, and enhancing wound healing. Graft rejection, a primary complication, is examined, detailing risk factors and preventive measures. Preoperative considerations, diagnostic techniques for rejection, and PK in KC are discussed. Postoperative care's significance, including intraocular pressure monitoring and steroid administration, is emphasized. The paper concludes with a comprehensive approach to prevent graft rejection, involving topical and systemic medications. An outlook on evolving monoclonal antibody research is presented. As the field progresses, personalized approaches and ongoing therapeutic exploration are expected to refine strategies, enhancing PK outcomes., Competing Interests: The authors declare that there are no conflicts of interests of this paper., (Copyright: © 2024 Taiwan J Ophthalmol.)

Deep anterior lamellar keratoplasty (DALK) has emerged as a transformative approach in managing corneal pathologies, notably keratoconus (KC), providing a viable alternative to penetrating keratoplasty (PK). This systematic review explores the intricacies of DALK, comparing its preoperative, intraoperative, and postoperative considerations with PK. Extensive literature searches revealed a wealth of data regarding DALK's advantages and challenges, with an emphasis on graft survival, visual outcomes, and complications. In the preoperative phase, DALK showcases its versatility, catering to a wide spectrum of patients, including those with KC and ocular surface disorders. Intraoperatively, it offers innovative techniques to address emphysema, bubble formation, and Descemet's membrane perforation, all while maintaining a strong focus on patient-centered outcomes. Postoperatively, DALK's lower rejection rates and decreased complications underscore its potential superiority over PK, although unique challenges such as graft failure from nonimmunologic factors demand vigilant management. This comprehensive review not only serves as a valuable resource for ophthalmic surgeons but also sheds light on the evolving landscape of corneal transplantation, highlighting DALK's role as a transformative force in the field., Competing Interests: Prof. Jorge L. Alió, an international editorial board member at Taiwan Journal of Ophthalmology, had no role in the peer review process of or decision to publish this article. The other authors declared no conflicts of interest in writing this paper.., (Copyright: © 2024 Taiwan J Ophthalmol.)

The remarkable recent advances in managing keratoconus, the most common corneal ectasia, encouraged researchers to conduct further studies on the disease. Despite the abundance of information about keratoconus, debates persist regarding the detection of mild cases. Early detection plays a crucial role in facilitating less invasive treatments. This review encompasses corneal data ranging from the basic sciences to the application of artificial intelligence in keratoconus patients. Diagnostic systems utilize automated decision trees, support vector machines, and various types of neural networks, incorporating input from various corneal imaging equipment. Although the integration of artificial intelligence techniques into corneal imaging devices may take time, their popularity in clinical practice is increasing. Most of the studies reviewed herein demonstrate a high discriminatory power between normal and keratoconus cases, with a relatively lower discriminatory power for subclinical keratoconus.

Purpose: To evaluate the rate of complications in resident-performed phacoemulsification and influencing factors., Methods: In this retrospective cohort study, the outcomes of cataract surgeries performed by 18 ophthalmology residents were analyzed. The outcome of first 80 phacoemulsification cataract surgeries (1440 cataract surgeries) performed by each resident were analyzed. Outcome measures included the rate of intraoperative capsular rupture requiring anterior vitrectomy, nucleus drop, and incomplete attempts at uncomplicated procedures. Changes in the rate of complications over the surgical training course were also assessed., Results: The most common surgical complications were capsular rupture (7.5%), followed by incomplete attempt(s) (5.9%), and nucleus drop (1.1%). Comparing the first 40 and second 40 surgeries, the rate of complications decreased as a function of surgeon experience in all resident cohorts. Greater theoretical skills and younger surgeon age were associated with a lower rate of intraoperative capsular rupture (hazard ratios = 1.421 and 1.481, respectively; P = 0.047 and P = 0.041, respectively). The use of antianxiety drugs and number of surgeries in the first 6 months demonstrated no predictive value for a lower rate of intraoperative complications (hazard ratios = 0.929 and 1.002; P = 0.711 and P = 0.745, respectively)., Conclusion: The use of antianxiety medication and more surgeries in the first 6 months did not decrease the rate of intraoperative complications of phacoemulsification, while improvement of theoretical skills may have increased the safety of resident-performed cataract surgery., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Current Ophthalmology.)

Purpose: Mustard gas (MG) is a potent blistering and alkylating agent that has been used for military and terrorism purposes. Ocular surface injuries are common after exposure to MG. This review provides an update on the pathophysiology, ocular surface complications, and treatment options for MG-related ocular injuries., Methods: Required information was obtained by reviewing various databases such as Cochrane Library, Google Scholar, and PubMed until March 2022. Data were collected by using keywords: "mustard gas" OR "sulfur mustard" AND "eye" OR "cornea" OR "ocular complication" OR "keratitis" OR "keratopathy" OR "limbal stem cell deficiency" OR "dry eye.", Results: Chronic intracellular toxicity, inflammation, and ischemia have been shown to play an essential role in the pathogenesis of MG injury. Ocular surface injuries can have acute, chronic, and most distinctly a delayed-onset presentation leading to various degrees of limbal stem cell deficiency. To date, no treatment has been agreed on as the standard treatment for chronic/delayed-onset MG keratopathy. Based on the authors' experience, we propose a management algorithm for MG-related ocular surface injuries involving optimization of ocular health, anti-inflammatory therapy, and if needed surgical interventions. The management of chronic and delayed-onset presentation remains challenging., Conclusions: MG keratopathy is a unique form of chemical injury which can lead to a range of ocular surface pathologies. Long-term anti-inflammatory therapy even in patients with seemingly mild disease may potentially reduce the likelihood of the development of more severe delayed-onset disease., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To compare visual acuity, refractive error, and complications after penetrating keratoplasty (PK) vs deep anterior lamellar keratoplasty (DALK) in the management of advanced stage of keratoconus., Design: Retrospective, comparative, interventional study., Methods: This study enrolled 411 consecutive keratoconus eyes with preoperative mean keratometry ≥60 diopters (D) that received either PK (218 eyes) or DALK (193 eyes). The outcome measures were postoperative visual acuity, refraction, complications, and further surgical interventions., Results: The mean follow-up duration was 77.9±46.5 and 72.9±47.8 months in the PK and DALK groups, respectively (P = .28). Compared with baseline values, postoperative visual acuity and refraction significantly improved in both groups. Postoperative corrected distance visual acuity was 0.18±0.13 and 0.26±0.19 logMAR in the PK and DALK groups, respectively (P < .001). Postoperative spherical equivalent refraction was -2.89±2.89 D after PK and -4.58±3.62 D after DALK (P < .001). Final keratometric astigmatism was comparable between the 2 groups (P = .82). Suture-related complications were observed in 48.6% of the PK eyes and 72.0% of the DALK eyes (P < .001). The incidence of graft rejection was 33.5% after PK and 19.7% after DALK (P = .002). At the last visit, 98.2% of PK grafts and 94.8% of DALK grafts remained clear (P = .06)., Conclusion: Both techniques of corneal transplantation led to a significant improvement in the visual and refractive variables in eyes with advanced keratoconus. PK resulted in a better visual acuity and refraction with less suture-related complications compared to DALK. However, PK was associated with a higher rate of graft rejection. The 2 techniques were comparable in terms of graft survival., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: To compare the long-term safety and efficacy of laser in situ keratomileusis (LASIK) with Artisan phakic intraocular lens implantation to correct refractive errors after penetrating keratoplasty (PK) for keratoconus., Methods: This retrospective comparative interventional case series included a total of 33 consecutive keratoconus eyes that had previous PK and received subsequent LASIK (n = 16) or Artisan lens implantation (n = 17) were included in this study. Outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), refractive error, and complications., Results: Postoperatively, the UDVA of ≥20/40 was achieved in none of the LASIK group compared to 62.5% of eyes in the Artisan group (P < 0.001); the respective values for CDVA of ≥20/40 were 87.5 and 94.1% (P = 0.51). Spherical equivalent refraction decreased from - 6.97 ± 1.50 D preoperatively to - 4.20 ± 2.05 D postoperatively in the LASIK group (P < 0.001) and from - 10.79 ± 2.15 D preoperatively to - 2.13 ± 1.23 D postoperatively in the Artisan group (P < 0.001). There was no significant change in the refractive astigmatism in LASIK group (P = 0.30) or Artisan group (P = 0.11). The efficacy and safety indices were significantly better for Artisan (0.82 ± 0.34 and 1.13 ± 0.30, respectively) than for LASIK (0.22 ± 0.17 and 0.85 ± 0.24, respectively, P ≤ 0.006 for both comparisons). While refractive error changed significantly from postoperative year 3 to the final visit in the LASIK group, it remained stable in the Artisan group through follow-up period. No significant complications were observed in any group., Conclusion: Artisan lens implantation provided superior and stable visual outcomes compared to LASIK for the management of post PK refractive errors in keratoconus eyes., (© 2023. The Author(s).)

Purpose: Transforming growth factor beta-induced ( TGFBI )-associated corneal dystrophies (CDs) are a clinically heterogeneous group of CDs caused by mutations in the TGFBI gene. Nucleotide sequences encoding two arginine residues at positions 124 and 555 in TGFBI protein are mutation hotspots. We screened regions of TGFBI that include the hotspots in a cohort of Iranian patients with TGFBI -associated CDs. We also performed a meta-analysis for frequencies of all reported TGFBI mutations., Methods: Twenty-four TGFBI -associated CD-diagnosed patients were recruited. Exons 4 and 12 of TGFBI were amplified by the polymerase chain reaction and sequenced by Sanger protocol. A meta-analysis on reported TGFBI sequence data was done by reviewing all published relevant articles available in NCBI., Results: Twenty-two out of 24 patients had mutations in exons 4 or 12 of TGFBI . The most frequent mutations were p.Arg124Cys, p.Arg124His, and p.Arg555Trp; each of these was found in six families. Three other missense mutations including p.Arg555Gln, p.Ile522Asn, and p.Ala546Thr were also identified. The data suggested a fairly tight genotype/phenotype correlation for the most common CDs. Literature review evidenced that the reported mutations affected less than 30% of the amino acids of the TGFBI protein and that p.Arg124His, p.Arg124Cys, p.Arg555Trp, p.Arg124Leu, p.Arg555Gln, and p.His626Arg were the most frequent mutations., Conclusion: TGFBI mutation profile of Iranian patients is very similar to that of the rest of the world. The meta-analysis confirmed the worldwide prevalence of p.Arg124 and p.Arg555, showed that p.His626Arg is also relatively frequent, and evidenced the value of screening exons 4 and 12 of TGFBI .

To compare ex vivo results of donor corneas maintained in Sinasol with those stored in Optisol-GS and reporting clinical outcomes of grafted Sinasol-versus Optisol-GS-stored corneas. In phase I, paired donor corneas were maintained in Sinasol or Optisol-GS. Afterward, the corneas were subjected to slit-lamp biomicroscopic and specular microscopic examinations on days 1 and 7, and then to trypan blue staining on day 7. The same examinations were performed on the corneas that were kept in Sinasol or Optisol-GS for 14 days. In phase II, the post-operative reports of 72 consecutive corneal transplantations were recorded using Sinasol- or Optisol-GS-preserved corneas. In phase I, 128 corneas from 64 donors and 59 corneas from 33 donors were investigated for 7 and 14 days, respectively. The EC indices were comparable between the groups at the measurement periods. The EC losses over 7 and 14 days were 3.7% and 19.9% in Sinasol against 4.6% and 20.8% in Optisol-GS. Although fair quality corneas were more common in Optisol-GS group after 7 (P = 0.04) and 14 days (P = 0.034), changes of stromal edema, Descemet's fold, and other quality ratings during 14 days were not different between the groups. In phase II, all the transplanted corneas were postoperatively clear with no adverse reactions. The overall results indicate that Sinasol is a safe, effective, and affordable intermediate cold storage medium for preservation of corneas., (© 2021. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: To share our initial experience with the innovative use of topical erythropoietin for the treatment of necrotizing scleritis manifesting immediately after pterygium excision surgery., Methods: This study enrolled 3 patients who developed necrotizing scleritis immediately after undergoing pterygium excision. All cases with pterygium were primary, and topical mitomycin C and conjunctival autografts were used at the time of surgery. Noninvasive therapy that included ophthalmic lubricants and topical and systemic corticosteroids failed to improve the avascular scleral lesions. The patients were prescribed erythropoietin-containing drops (3000 U/mL) every 6 hours in addition to topical antibiotics and lubricant. The effect of topical erythropoietin on the healing process of avascular scleral lesions was investigated, and its ocular and systemic side effects were evaluated., Results: The mean age of the participants was 69.0 ± 14.8 years, and 2 of the 3 eyes belonged to male subjects. The time between pterygium surgery and presentation to our clinic was 33.0 ± 14.7 days. There were no infectious causes or underlying systemic diseases in any of the cases. After treatment with topical erythropoietin for an average of 34.3 ± 20.3 days, the lesions were completely vascularized in all 3 eyes without any ocular or systemic adverse effects. The patients were followed up for an average of 126 ± 94 days after discontinuation of erythropoietin. There was no evidence of recurrence during the last examination in any of the eyes., Conclusions: Topical erythropoietin might be a safe and an effective method for treating cases of necrotizing scleritis that manifests immediately after pterygium surgery., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To compare the outcomes of penetrating keratoplasty (PK) and deep anterior lamellar keratoplasty (DALK) for pediatric keratoconus., Design: Retrospective comparative interventional case series., Methods: This study included consecutive pediatric keratoconus cases (≤18 years of age) who received PK (n=45) or DALK (n=54) in 2 different time periods. Postoperative best spectacle-corrected visual acuity (BSCVA), refraction, and complications were compared between the study groups., Results: The mean follow-up was 83.3±46.1 and 63.3±45.6 months in the PK and DALK groups, respectively (P = .10). Postoperatively, BSCVA was 0.20±0.19 logMAR in the PK group and 0.26±0.19 logMAR in the DALK group (P = .11), with a BSCVA of ≥20/40 in 91.1% and 83.3% of eyes, respectively (P = .25). Two groups were comparable regarding postoperative refractive outcomes. Graft epitheliopathy and suture-associated complications were more commonly encountered after DALK, which was attributable to the effect of low-quality grafts on the clinical outcomes of DALK. Ten PK eyes (22.2%) and 9 DALK eyes (16.7%) experienced at least 1 episode of graft rejection within 5 years of corneal transplantation (P = .49). Rejection was reversible in 93.1% and 100% of episodes in the PK and DALK groups, respectively (P = .63). At the postoperative year 5, 95.6% of grafts in the PK group and 98.2% in the DALK group remained clear (P = .45)., Conclusion: No significant difference was observed in the outcomes between PK and DALK in pediatric keratoconus. Low-quality donor tissues in DALK increased the incidence of graft epithelial problems and suture-related complications as compared to PK., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: The purpose of the study is to compare outcomes after penetrating keratoplasty (PK) against deep anterior lamellar keratoplasty (DALK) for keratoconus in patients with vernal keratoconjunctivitis (VKC)., Methods: Keratoconic patients with VKC who received PK ( n  = 55, group 1) or DALK ( n  = 62, group 2) were retrospectively enrolled. The Student's t test, Mann-Whitney test, Fisher's exact test, chi-square test, and Kaplan-Meier survival curve were used to compare outcomes between the groups., Results: The follow-up period was 59.4 ± 44.1 and 62.4 ± 38.9 months in groups 1 and 2, respectively ( p  = 0.70). Postoperative best spectacle-corrected visual acuity was 0.24 ± 0.18 and 0.29 ± 0.19 logMAR, respectively ( p  = 0.13). Graft rejection occurred in 34.6% and 25.8% of eyes in groups 1 and 2, respectively ( p  = 0.30). Groups 1 and 2 were comparable in the rates of cataract (3.6% and 12.9%, respectively, p  = 0.07) and high intraocular pressure (3.6% and 8.1%, respectively, p  = 0.31). Compared with the eyes with inactive VKC, PK eyes that experienced postoperative disease reactivation had a higher rate of suture abscesses (10.9% versus 50.0%, respectively, p  = 0.01) and suture-tract vascularization (6.5% versus 33.3%, respectively, p  = 0.03). Similarly, disease reactivation significantly increased suture abscesses from 27.3% to 51.7% ( p  = 0.03) and suture-tract vascularization from 18.2% to 49.6% ( p  = 0.005) in the DALK group. The graft survival rates were 95.3% in group 1 and 87.9% in group 2 at the 4-year follow-up, with mean durations of 14.4 and 11.1 months, respectively ( p  = 0.20)., Conclusion: The results indicate no difference in outcomes between PK and DALK for keratoconus in patients with VKC. Postoperative VKC reactivation increased the rate of suture-related problems after both techniques of keratoplasty., Competing Interests: Conflict of interest statement: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s), 2021.)

Aim: To compare the clinical outcomes of a variety of multifocal intraocular lenses (MIOLs) in patients diagnosed with presbyopia or cataracts., Methods: This clinical trial study included 141 patients (282 eyes) with different MIOLs implantation. The Symfony (60 eyes), the ReSTOR (100 eyes), the AT LISAtri (60 eyes), and the PanOptix (62 eyes) intraocular lenses were evaluated in this prospective interventional study. The near, intermediate, and distant visual acuities, contrast sensitivity, and defocus curve were measured as valid criteria. To statistically analyze the results, we used the Statistical Package for Social Science software, the non-parametric Wilcoxon signed-rank t , the one-way analysis of variance and the Tukey's post-hoc test in our analysis. Moreover, we conducted a detailed literature search on the PubMed database in English about MIOLs, in total 59 studies were included in this review article., Results: The four approaches did not show any significant difference in the best-corrected distance visual acuity ( P >0.05). The defocus curves at the contrast of 100% showed that trifocal IOLs had better intermediate performance than the bifocal IOL ( P <0.05). There were no statistically significant differences between AT LISAtri and PanOptix lenses for visual acuity at all distances. The eyes with PanOptix, Symfony, and AT LISAtri IOL showed better contrast sensitivity than those ReSTOR at spatial frequencies of 1, 3, and 6 cpd in photopic and mesopic conditions ( P <0.001)., Conclusion: All four groups of the multifocal lenses were satisfying in terms of distance and near vision. Also, the group of trifocal lenses led to satisfactory outcomes in intermediate vision, without degradation in quality of vision., (International Journal of Ophthalmology Press.)

Vernal keratoconjunctivitis (VKC) is a chronic, bilateral, allergic conjunctivitis with episodes of acute exacerbations. Although VKC has a self-limiting course, chronic recurrent inflammation can cause long-term visual impairment due to corneal complications including shield ulcers, infectious keratitis, keratoconus, corneal opacities, and limbal stem cell deficiency. The initial step in the management of corneal involvement is medical treatment of the acute stage of VKC and prevention of recurrences. Giant papillae not responding to medical treatment can be removed surgically in the case of corneal involvement. Shield ulcer with no inflammatory plaque usually heals with appropriate medical therapy. For shield ulcer with inflammatory plaque, however, surgical debridement with or without amniotic membrane transplantation might be necessary. Keratoconus may develop in chronic and severe VKC. An annual evaluation of these patients with corneal topography and/or tomography is essential for early detection of keratoconus and its timely management that includes collagen cross-linking and intrastromal corneal ring segment implantation. Corneal transplantation may be required in the advanced stage of keratoconus. Both penetrating keratoplasty and deep anterior lamellar keratoplasty can result in excellent visual outcomes in keratoconic eyes with concomitant VKC. Appropriate management of inflammation in the perioperative period is crucial for achieving successful outcomes after corneal transplantation. Limbal stem cell deficiency, a rare complication of long-standing and severe VKC, might be treated with living-related conjunctival limbal allograft., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background/aims: SLC4A11 is the only known causative gene of congenital hereditary endothelial dystrophy (CHED). Mutation screenings have shown that most but not all patients with CHED harbour mutations in SLC4A11 , suggesting that other CHED-causing genes may exist. We aimed to screen SLC4A11 in Iranian patients to learn the mutation spectrum of this gene among Iranians and to gain further knowledge on potential contribution of other genes to CHED aetiology., Methods: SLC4A11 was screened in 21 Iranian patients with CHED by sequencing. Previously unreported variations were checked in at least 200 controls, and segregation analysis within families and bioinformatics predictions on effects of variations were performed. Exome sequencing was done for the single patient without an SLC4A11 mutation and for her parents., Results: Nine previously reported and 10 unreported SLC4A11 mutations were observed among 20 patients; a mutation was not found in one patient. A mutation in MPDZ was identified as the only candidate cause of CHED in this patient. Her mother who carried the same mutation was diagnosed with Fuchs endothelial corneal dystrophy (FECD)., Conclusion: SLC4A11 mutations are the usual cause of CHED in Iranians. The 10 novel mutations observed contribute significantly to the approximately 85 mutations reported since discovery of the role of the gene in CHED pathogenesis more than 10 years ago. MPDZ mutations may be a cause of CHED and even FECD in a minority of patients. Proposed functions of MPDZ with respect to tight junctions and maintenance of the corneal endothelial barrier are in accordance with a role in corneal endothelial pathobiology., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To investigate the correlations between preoperative, operative, and postoperative factors and corneal graft topographic parameters after deep anterior lamellar keratoplasty (DALK) performed in keratoconus-affected eyes., Methods: This prospective, interventional study enrolled 44 eyes. Graft topographic parameters, including keratometric astigmatism and the surface regularity index (SRI), were assessed after complete suture removal. Univariate analyses were used to evaluate the effects of preoperative factors (donor quality, donor and recipient age, keratoconus severity), operative factors (graft size, donor button roundness, roundness and centration of the donor-recipient junction), and postoperative factors (time point of suture removal) on postoperative topographic parameters., Results: The roundness of the donor-recipient junction after complete suture removal had a significant association with the roundness of the donor button after trephination (P = 0.04) and the amount of graft decentration relative to the limbus (P = 0.03). A significant correlation was found between the value of graft decentration relative to the limbus and postoperative keratometric astigmatism (P = 0.001) and between the roundness of the donor-recipient junction and the postoperative SRI (P = 0.02). The flat axis of the keratometric astigmatism and the longer axis of the graft lay in the direction of graft displacement. Other investigated factors had no significant association with postoperative topographic indices., Conclusion: Graft displacement relative to the limbus and roundness of the donor-recipient junction were the main predictors of graft astigmatism and regularity, respectively, after DALK. Noncircularity of the donor button after trephination could increase the graft surface irregularity indirectly by influencing the roundness of the surgical wound.

Purpose: To measure and compare corneal biomechanics in patients with macular corneal dystrophy (MCD), versus those who underwent penetrating keratoplasty (PK) for MCD, versus normal subjects., Design: Cross-sectional study., Methods: This study enrolled 24 eyes with MCD, 25 eyes that underwent PK in patients with preoperative diagnosis of MCD, and 28 normal eyes. The ocular response analyzer was used to measure corneal biomechanical properties, including corneal resistance factor (CRF) and corneal hysteresis (CH). Intraocular pressure (IOP) was measured using a Goldmann applanation tonometer, and central corneal thickness (CCT) was measured using an ultrasonic pachymeter. The CCT, CRF, CH, and IOP were compared among the study group., Results: CCT was significantly lower in the MCD group (423 ± 47 mμ) than in the PK group (541 ± 31 mμ; P < .001) and the controls (540 ± 26 mμ; P < .001). Meanwhile, CCT was comparable between the PK and control groups (P = .98). CRF did not differ between the MCD (8.34 ± 2.12 mm Hg) and the PK (8.66 ± 1.66 mm Hg) groups (P = .89); however, both of these groups had lower CRF values than the control (9.76 ± 1.83 mm Hg, P = .02) group. No significant differences were observed among the 3 groups in CH (P = .13). IOP values did not differ between the MCD (11.25 ± 1.69 mm Hg) and PK (12.0 ± 2.67 mm Hg) groups (P = .95); however, the IOP values for both of these groups differed significantly from those of the controls (13.46 ± 2.17 mm Hg; P = .006)., Conclusions: CRF was significantly reduced in MCD and did not return to normal values even after PK. The reduced corneal rigidity could result in underestimating IOP in patients with MCD and in those undergoing PK for this stromal dystrophy., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the outcomes and complications of deep anterior lamellar keratoplasty (DALK) performed for pediatric keratoconus., Methods: This retrospective study enrolled 44 consecutive eyes of 39 keratoconus-affected children (≤ 18 years of age). All patients underwent big-bubble DALK from March 2004 to June 2016. The outcome measures included postoperative best spectacle-corrected visual acuity (BSCVA), manifest refraction, keratometry readings, and complications., Results: The mean participant age was 16.8 ± 1.4 years, and the mean follow-up period was 68.5 ± 39.9 months. Successful big bubble was achieved in 33 eyes (75.0%), while the surgical technique was predescemetic DALK in 11 (25.0%). The mean BSCVA changed from 1.34 ± 0.49 LogMAR preoperatively to 0.24 ± 0.10 LogMAR postoperatively (P < 0.001). The mean keratometry decreased from 59.54 ± 5.17 D preoperatively to 46.23 ± 2.17 D postoperatively (P < 0.001). The complications encountered during the study period were intraoperative Descemet's membrane perforation (n = 5, 11.4%), the Urrets Zavalia syndrome (n = 1, 2.3%), graft epithelial problems (n = 3, 6.8%), subepithelial graft rejection (n = 5, 11.4%), high intraocular pressure (n = 8, 18.2%), and traumatic wound dehiscence (n = 2, 4.6%). Suture-related complications included premature loosening (n = 13, 29.6%), broken sutures (n = 12, 27.3%), suture-tract vascularization (n = 6, 13.6%), suture-associated abscesses (n = 5, 11.4%), and suture cheese wiring (n = 2, 4.6%). A clear graft was found in 40 eyes (90.9%) at the last follow-up examination., Conclusion: This study showed promising results with big-bubble DALK in keratoconus-affected children. A frequent and close follow-up with dedicated parental involvement is essential for the early recognition and management of postoperative complications.

Purpose: To investigate endothelial keratoplasty lenticules prepared from fresh whole eyes via Gebauer SLc Original (SLc) versus Moria CBm Carriazo-Barraquer (CBm), and those prepared from corneoscleral buttons via SLc versus Moria One-Use Plus (OUP) in terms of eye bank preparation criteria., Methods: Fresh whole eyes-dissected endothelial keratoplasty lenticules with SLc were compared with CBm in terms of thickness profile measurements, over/under dissection values, endothelial cell loss, and postoperative graft failures. A similar comparison was made between corneoscleral buttons-dissected endothelial keratoplasty lenticules with SLc and OUP., Results: Means of central thicknesses and increase of thickness toward periphery were not significantly different between 33 fresh whole eyes-dissected endothelial keratoplasty lenticules with SLc and 33 fresh whole eyes-dissected ones with CBm. There was no significant difference between 19 corneoscleral buttons-dissected endothelial keratoplasty lenticules with SLc and 19 corneoscleral buttons-dissected ones with OUP in terms of mean central thickness and post-cut endothelial cell loss. However, in the corneoscleral buttons-dissected endothelial keratoplasty lenticules, a mean increase of thickness was significantly different from central to two pericentral locations with OUP (P = 0.001) and from central to two peripheral parts with SLc (P = 0.011). Both CBm and OUP systems showed deeper dissection depths than head descriptions as compared to SLc (P < 0.001)., Conclusion: Unlike fresh whole eyes-dissected endothelial keratoplasty lenticules with SLc or CBm, thickness profiles of corneoscleral buttons-dissected endothelial keratoplasty lenticules with both SLc and OUP systems showed a partial asymmetric increase of thickness toward the periphery. A high agreement was observed between endothelial keratoplasty lenticules thicknesses and SLc nomograms., Competing Interests: None

To investigate the possible risk factors for failure of transplanted eye bank-prepared Descemet stripping automated endothelial keratoplasty (DSAEK) tissues. In a retrospective study between March 2011 and March 2019, all the failed DSAEK cases (131 cases) reported to the Central Eye Bank of Iran were compared with a surgeon-matched successful DSAEK group (control, 126 cases) in terms of the donor, DSAEK tissue, and recipient characteristics. Univariate analysis indicated that the DSAEK tissue preparation from excised corneoscleral tissues (OR 2.17; P = 0.026) and donor conjunctival hyperemia (OR 1.62; P = 0.042) were more common in the re-DSAEK group than in the controls. Other donor and recipient characteristics as well as other DSAEK tissue criteria were not significantly different between the re-DSAEK and control groups. DSAEK lenticules in both re-DSAEK and control groups demonstrated symmetric contours. Subgroup analyses in the re-DSAEK group revealed a higher rate of surgeons' low to moderate experience in comparison to those of high experience (P < 0.001). Additionally, failed DSAEK was observed more commonly in donors aged over 50 years than among those under 30 years (P < 0.001). Our study showed that DSAEK tissues prepared from excised corneoscleral tissues and from donors with conjunctival hyperemia were associated with higher rates of re-DSAEK due to failed DSAEK. An increasing trend of re-DSAEK was observed with shorter surgeons' experience and more advanced donor's age.

Background: Sulfur mustard (SM) exposure produces extensive systemic and ocular adverse effects on the victims. One of the most important effects is immunological insults that can lead to other organ damages, including the eyes., Methods: In this descriptive study, 128 SM-exposed veterans with severe eye injury were compared with 31 healthy controls. Tear levels of tumor necrosis factor (TNF)-α and serum concentrations of interleukin (IL)-1α, IL-1β, IL1Ra, IL-6, TNF-α, granulocyte-macrophage colony-stimulating factor (GM-CSF), and Fas Ligand (FasL) were compared between the two groups., Results: Meibomian gland dysfunction (MGD); tear breakup time (TBUT < 10″); and conjunctival, limbal, and corneal abnormalities were more frequent among the cases (MS-exposed veterans) than the controls. Ocular involvement was mild in 14.8%, moderate in 24.2%, and severe in 60.9% of the cases. Serum levels of IL-1α and FasL were significantly higher among the cases than among the controls (P < 0.001 and P = 0.037, respectively). Also, a significant decrease was observed in serum and tear levels of TNF-α in the cases as compared with controls (P < 0.001, P < 0.001, respectively). Serum levels of FasL were significantly higher in cases with severe ocular involvement than in the controls (P = 0.03). Nonetheless, serum levels of IL-1β, IL-1Ra, IL-1α/IL-1Ra, and IL-6 were not significantly different between the two groups., Conclusion: Serum levels of IL-1α and FasL may cause different ocular surface abnormalities in SM-exposed patients. Lower tear TNF-α concentration may be due to lower serum levels of this cytokine in these patients., Competing Interests: Declaration of Competing Interest All authors declared no conflict of interest., (Copyright © 2019 Elsevier B.V. All rights reserved.)

The present study was designed to investigate the effect of topical erythropoietin on the healing process of induced necrotizing scleritis and to evaluate the ocular side effects of this treatment modality in a rabbit model. Necrotizing scleritis was induced in 8 New Zealand albino rabbits. The animals were then randomly divided into one of two groups: a treated group administered a topical erythropoietin-containing cellulose-based gel every 8 h or a control group treated with a cellulose-based gel without erythropoietin every 8 h. The sizes of the lesions measured at different time points were compared between the groups. After three months, the rabbits' eyes were enucleated and histologically and immunohistochemically evaluated for angiogenesis and apoptosis. The lesions were completely vascularized in all eyes of the treated group and 50% of eyes of the control group. The mean interval from the induction of scleral necrosis to a complete improvement was 28 days in the treated group and 62.5 days in the control group (P = 0.04). Histological examination revealed that erythropoietin enhanced the improvement of necrotizing scleritis by stimulating angiogenesis and reducing apoptosis. Neovascularization of the cornea, iris, or retina was not observed in the treated group. We observed a significantly faster recovery to complete improvement of necrotizing scleritis in rabbit eyes treated with erythropoietin compared to those of the control group. Treated eyes had a higher rate of complete healing and had no ocular safety concerns. This therapeutic modality represents a promising treatment for scleral necrosis following various types of ocular surgery., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: The serum and tear levels of four inflammatory chemokines were evaluated in sulfur mustard (SM)-exposed with serious ocular problems., Materials and Methods: In this study, 128 SM-exposed patients and 31 healthy control participants participated. Tear and serum levels of chemokines were assessed by ELISA method., Results: There was no significant difference in the serum level of IL-8/CXCL8, CX3CL1/fractalkine, CCL2/MCP-1, and CCL5/RANTES between all SM-exposed subjects and control groups. The tear level of IL-8 in the SM-exposed group was lower than the control group, but the difference was not significant. In the SM-exposed group with the abnormalities in tear breakup time (TBUT) test, fundus and pannus formation were significantly higher than SM-exposed patients without these problems. CX3CL1 levels have significantly increased in SM-exposed group with blepharitis, pterygium, and conjunctival pigmentation as compared with the control group. Besides, significantly higher levels of CX3CL1 were observed in SM-exposed group with or without bulbar conjunctival hyperemia and abnormal vessels a well as with fundus abnormality compared to the control group. Only, SM-exposed group with subconjunctival fibrosis had significantly lower levels of CCL5 than SM-exposed group without this problem., Conclusion: The higher level of CX3CL1 and consistent levels of IL-8/CXCL8, MCP-1/CCL2, and RANTES/CCL5 in SM-exposed individuals may indicate an anti-inflammatory response against the destructive effects of SM gas. High tear level of IL-8/CXCL8 reflects the severity of ocular surface abnormalities, yet significantly low tear level found in mild SM-exposed subgroup compared with the control group. The lower levels of CX3CL1 and RANTES/CCL5 may represent the different pathophysiology which requires further studies., (Copyright © 2019. Published by Elsevier B.V.)

Purpose: To determine the roundness of recipient corneal cuts after mechanical trephination and to investigate possible factors that could affect the corneal bed configuration in deep anterior lamellar keratoplasty (DALK)., Methods: This study enrolled 85 eyes with keratoconus that underwent DALK. Recipient corneas were partially trephined using a new, unused, disposable Hessburg-Barron suction trephine. Photographs that best represented the recipient corneal cut were selected, and ImageJ software was used to evaluate the roundness of recipient bed. The effect of potential variables on the roundness of cuts was investigated using the univariate analyses., Results: The mean patient age was 31.0 ± 9.0 years. The mean recipient trephine size was 8.04 ± 0.29 mm (range 7.5-8.50 mm). The recipient cut roundness was 0.922 ± 0.070, varying from 0.78 to 1.0. The roundness of the corneoscleral limbus (0.874 ± 0.074) which represented the shape of recipient cornea was the main predictor of the configuration of recipient cut (r = 0.84, P < 0.001). Other preoperative characteristics investigated were mean keratometry (P = 0.63), keratometric astigmatism (P = 0.18), central corneal thickness (P = 0.64), keratoconus severity (P = 0.37), and trephine size (P = 0.50) that demonstrated no significant associations with the roundness of cut., Conclusions: The recipient corneal cut after mechanical trephination may not be circular. The roundness of recipient bed was primarily affected by the roundness of corneoscleral limbus, indicating that the shape of recipient cut tends to follow the original shape of the cornea.

Introduction: In this study, the serum levels of soluble intercellular adhesion molecule 1 (ICAM-1), P-, E-, and L-selectins were investigated in seriously eye-injured patients exposed to sulfur mustard (SM)., Material and Methods: A total of 128 individuals with SM-induced serious eye injuries and 31 healthy male controls were included in this study. The serum concentration of soluble forms of adhesion molecules was measured by enzyme-linked immunosorbent assay (ELISA) method., Result: The serum level of soluble ICAM-1 was significantly higher in the SM-exposed individuals with an abnormality in tear meniscus height, corneal verticillata, and pannus compared with SM-exposed individuals without these abnormalities. There were no significant differences in the level of all three measured selectins between the SM-exposed group and the control groups. SM-exposed individuals with corneal defect had a significantly higher level of soluble E-selectin than SM-exposed individuals without this abnormality. The serum level of soluble P-selectin in the SM-exposed group with limbal abnormality was significantly lower than that in the SM-exposed without this abnormality; also it was significantly higher in SM-exposed group with fundus abnormality compared to that in the control group or SM-exposed group without this abnormality., Conclusion: The changes in the levels of selectins and ICAM-1 in the SM-exposed group with various ocular abnormalities is a defense mechanism against the toxicity of SM. Further analysis is required to understand the molecular mechanisms of the relationship between adhesion molecules with ocular complications in SM-exposed individuals., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Purpose: To report histopathological findings for different types of polymers proposed as support for a Pintucci-type keratoprosthesis., Methods: Six polymers, including three types of polyesters ( # 1-3), one type of polytetrafluoroethylene (PTFE, # 4), polyethylene ( # 5), and expanded polytetrafluoroethylene (ePTFE, # 6) were evaluated. Four samples of each material were placed under the orbicularis oculi muscles of 12 rabbits. After five weeks, the samples were removed and evaluated histopathologically. Fibrovascular tissue ingrowths were investigated in terms of tissue penetration depth into the materials (graded as none, mild, moderate, and intense) and fibrovascular ingrowth area at the ultimate level of tissue penetrance. ImageJ software was used to calculate fibrovascular tissue area between the material fibers, and the mean area values were compared between the materials., Results: Polyester materials # 1 and # 3 demonstrated intense fibrovascular tissue penetration with a large fibrovascular ingrowth area; no overt tissue ingrowth was observed into material #6. The mean area of penetrated fibrovascular tissues was significantly different between materials ( P < 0.001). Materials # 2, # 4, and # 5 showed moderate fibrovascular tissue ingrowth and the area of presented fibrovascular tissue at the paracentral parts of material # 4 was significantly smaller than that of materials # 1 ( P = 0.02) and # 3 ( P = 0.01)., Conclusion: Two polyester materials that had relatively large pore sizes demonstrated a deep and large area of fibrovascular ingrowth. Given that material #3 is thicker and more consistent than material # 1, the former can be used as the appropriate material for supporting the Pintucci-type keratoprosthesis., Competing Interests: There are no conflicts of interest., (Copyright © 2019 Rahmani et al.)

We describe a rapid and easy technique for the preparation of pre-stripped Descemet membrane (DM) endothelial keratoplasty (DMEK) tissue in the eye bank, without the use of dye or trephining by the eye bank technician. After drawing 2 radial marks 90° apart on the scleral rim of the cornea, a circumferential incision was made internal to the trabecular meshwork and the edge of the DM opposite to the marked area was scored and gently peeled towards the marked area. Finally, the peeled DM was gently unrolled and attached to the posterior stromal bed via absorbing excess liquid from the periphery. The prepared DMEK tissue while reattached on the posterior aspect of the cornea was subjected to slit-lamp biomicroscopic and specular microscopic examinations. In case of proper preparation of DMEK tissue and suitability of endothelial cells for DMEK surgery, the tissue was distributed for transplantation. At the time of surgery, trypan blue staining was performed by the cornea surgeon before DM trephination. Duration of DMEK tissue preparation, uneventful preparation, post-preparation endothelial cell loss, surgeon's satisfaction, and intra- and post-operative attachment of the tissue were investigated variables in this study. Over a 2-year period, 28 DMEK tissues were successfully prepared from 30 corneas using our new technique. The median duration of DMEK preparation was 100 s. The area of endothelial cell loss was 1.8% ± 1.2% centrally and 6.2% ± 1.8% in areas close to the forceps contacts. Seven out of the 28 (25%) DMEK tissues were ruined by surgeons during surgery and the overall rate of re-bubbling in 19 transplanted DMEK tissues was 16%. The presented method, which uses no trephining or vital dye, has simplified and expedited the preparation process of pre-stripped DMEK tissue in the eye banks.

Purpose: To evaluate the effect of keratoconus severity on the visual and refractive outcomes and complications after deep anterior lamellar keratoplasty (DALK)., Design: Consecutive interventional case series., Methods: This study enrolled 227 keratoconus-affected eyes that underwent DALK. Amsler-Krumeich keratoconus classification was used to categorize the patients: stage II, 47 eyes; stage III, 60 eyes; and stage IV, 120 eyes. The outcome measures, including postoperative best spectacle-corrected visual acuity (BSCVA), spherical equivalent refraction, mean keratometry, keratometric astigmatism, and complications, were analyzed and compared based on keratoconus stage., Results: The mean patient age was 27.6 ± 8.0 years, and the mean follow-up period was 38.0 ± 19.8 months. No significant differences were observed in postoperative BSCVA (P = .55), spherical equivalent refraction (P = .27), mean keratometry (P = .09), and keratometric astigmatism (P = .14) among the groups. Improvement in BSCVA were significantly greater in stage III and stage IV compared with stage II (P = .04 and P < .001, respectively). The decrease in spherical equivalent was significantly greater in stages III and IV compared with stage II (P = .04 and P = .001, respectively). Mean keratometry decreased to a greater degree in stage IV compared with stages II and III (P < .001 for both comparisons). The study groups were comparable with respect to intraoperative Descemet membrane perforation, the rate of successful big-bubble formation, suture-related complications, and graft rejection., Conclusions: DALK is a safe and effective procedure for the treatment of all stages of keratoconus. This technique of corneal transplantation is more effective in eyes with severe keratoconus compared with those with moderate keratoconus., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: To compare donor lenticule thickness reported by the eye bank with lenticule thickness measured at 6 months after Descemet stripping automated endothelial keratoplasty (DSAEK)., Methods: This prospective, interventional case series enrolled 30 eyes from 30 patients who underwent DSAEK using precut eye bank tissue. Preoperative thickness measurements of the donor lenticules were taken centrally and at pericentral and peripheral graft areas using an anterior segment optical coherence tomography system. The same measurements were repeated 6 months postoperatively. The preoperative and postoperative values were compared, and the relationships between these measurements were investigated using Pearson correlation coefficients., Results: The mean donor age was 47.7 ± 10.7 years. The mean preoperative endothelial cell density was 3017 ± 361 cells/mm, which decreased to 1645 ± 482 cells/mm postoperatively (P < 0.001). The graft thickness of the precut tissue, as reported by the eye bank, was 136.8 ± 24.9 μm at the center, 149.4 ± 27.3 μm at the pericentral area, and 198.4 ± 32.8 μm at the periphery. The corresponding postoperative values were 119.2 ± 29.8 μm (P = 0.004), 124.5 ± 34.6 μm (P = 0.002), and 156.3 ± 45.4 μm (P < 0.001), respectively. The graft thickness measured by the eye bank was significantly associated with that measured in vivo at 6 months at the central (r = 0.63, P = 0.001) and pericentral (r = 0.50, P = 0.009) graft areas. However, the correlation between preoperative and postoperative peripheral graft thickness was insignificant (P = 0.14)., Conclusion: Compared with preoperative values, central, pericentral, and peripheral graft thicknesses were reduced by 10.4%, 14.2%, and 18.4%, respectively, 6 months after DSAEK. Postoperative graft thinning was greater at the periphery compared with the central and pericentral areas.

Purpose: To analyze the growth trends in ophthalmic education in Iran since 1979, and to discuss their implications on the profession., Methods: This comprehensive national study was performed by the Academy of Medical Sciences of I.R. Iran. The data were gathered from the Specialty Training Council of the Ministry of Health and from the Medical Council of Iran., Results: Our analysis revealed ten important current growth trends and seven future trends and implications. Between 1979-80 and 2015-16, the number of residents annually admitted to ophthalmology increased from 21 to 84 and related fellowships and from 0 to 34. The number of ophthalmologists graduating in the country increased from 21 (45%) in 1979 to 69 (98%) in 2015. The ratio of ophthalmologists per 100,000 people averaged 1.91 in 1979 and 3.00 in 2016. Considering migrant and retired ophthalmologists, there are approximately 2400 active ophthalmologists in Iran. In 1979, there was one active ophthalmologist per 52,112 people; in 2014, there was one per 33,333 people. This represents a per capita increase of 57%. Since 1979, the number of active ophthalmologists has increased by 234%. The number of active women ophthalmologists has increased by more than 600%, from 65 (9%) in 1979 to 470 (20%) in 2016., Conclusion: Equitable geographic distribution and balanced combination of ophthalmologists (women/men and specialists/fellowships) are necessary to optimize community eye health. We propose further studies on the effects of fellowship training growth and work patterns of female and male ophthalmologists., Competing Interests: There are no conflicts of interest.

Purpose: To investigate the rate and agents of contamination in bandage soft contact lenses fitted for management of persistent corneal epithelial defects., Methods: This prospective comparative case series enrolled 57 consecutive eyes fitted with bandage contact lenses for treatment of persistent corneal epithelial defects. The lenses were collected at the time of epithelial closure or when it was necessary to exchange contact lenses and were immediately placed in sterile tubes containing an enriched thioglycolate liquid medium. When contamination of the contact lens was detected, the microorganism was cultured in different media and identified based on various tests. All isolates were tested for susceptibility to various antibiotics. Univariate analyses were used to evaluate the influence of different variables (duration of contact lens use, use of topical corticosteroids, presence of blepharitis, contact lens deposits, and presence of sutures) on bandage contact lens contamination., Results: Seventeen of the contact lenses (29.8%) were contaminated. The most commonly isolated pathogen was Staphylococcus epidermidis (n = 10), followed by Enterobacter cloacae (n = 3), Staphylococcus aureus (n = 1), Streptococcus viridans (n = 1), and Alcaligenes spp. (n = 1). One contact lens yielded a mixed infection with E. cloacae and Candida spp. Infectious keratitis was not observed in any eyes. Correlations between contact lens contamination and patient- and lens-related variables were not statistically significant., Conclusions: Most bandage contact lenses (70.2%) used for treatment of persistent corneal epithelial defects did not show bacterial growth. Staphylococcus epidermidis was the most common microorganism isolated from the contaminated contact lenses.

Purpose: To evaluate the geometry of donor corneal buttons after mechanical trephination and to determine whether there were any possible variables that could influence the accuracy of cutting corneal buttons in deep anterior lamellar keratoplasty., Methods: This cross-sectional study included 85 sclerocorneal buttons that were transplanted during deep anterior lamellar keratoplasty. Donor corneas were punched from the posterior surface. Photographs that most clearly represented the entire edges of the donor corneas were taken from the punched corneas and systematically analyzed using ImageJ software. The univariate analyses were used to investigate the influence of potential variables on the precision and roundness of the donor cut., Results: The epithelial side of the grafts was significantly larger than the posterior side in diameter, perimeter, and area. The perimeter and area of the donor posterior surface and the trephine used for punching the grafts were the same, whereas the epithelial side had a significantly larger perimeter and area than those of the trephine. Graft roundness varied from 0.78 to 1.0 at the epithelial side and from 0.77 to 1.0 at the posterior side. The roundness of the scleral spur, which represented the shape of the donor cornea, was identified as the main predictor of the roundness of the donor cut (P < 0.001)., Conclusions: The donor buttons after mechanical trephination from the posterior surface may not be circular and of the intended diameter; the epithelial surface dimensions were significantly larger than the posterior surface and trephine dimensions. The roundness of the punched graft was primarily affected by the roundness of the cornea before trephination.

Purpose: To evaluate the effects of donor graft thickness on postoperative best spectacle-corrected visual acuity (BSCVA), refractive outcomes, endothelial cell density (ECD) and function, intraocular pressure (IOP), and postoperative complications after Descemet stripping automated endothelial keratoplasty (DSAEK)., Methods: This retrospective, interventional case series enrolled 77 eyes of 64 patients who underwent DSAEK with or without simultaneous cataract surgery. Clinical outcomes, including BSCVA, refraction, keratometric astigmatism, IOP, and ECD were assessed at the final follow-up examination. Univariate analyses were used to investigate the effects of postoperative donor graft thickness on clinical outcomes and complications., Results: The mean patient age was 62.3 ± 15.6 years, and the patients were followed for 26.2 ± 20.9 months postoperatively. The mean postoperative central graft thickness was 102.4 ± 31.6 μm. In the univariate analysis, postoperative central graft thickness was significantly associated with postoperative IOP ( P = 0.005), central recipient thickness ( P = 0.002), and ECD ( P = 0.016). No significant association was found for central graft thickness with postoperative BSCVA ( P = 0.70), spherical equivalent refraction ( P = 0.33), keratometric astigmatism ( P = 0.27), graft detachment ( P = 0.16), graft decentration ( P = 0.17), high IOP ( P = 0.53), or endothelial rejection ( P = 0.88)., Conclusion: This study failed to demonstrate any significant correlation between graft thickness and BSCVA. Attempting to minimize graft thickness might not have the desired outcome regarding endothelial cell density and function. Increased graft thickness could negatively impact the accuracy of IOP measurements after DSAEK., Competing Interests: There are no conflicts of interest.

Purpose: To evaluate the long-term stability of subjective refraction after deep anterior lamellar keratoplasty (DALK) performed in keratoconus-affected eyes., Methods: This retrospective, comparative interventional case series analyzed the data of 73 eyes in 69 patients with keratoconus who underwent DALK. Only patients with clear grafts who had all sutures removed for at least 12 months were enrolled. The corrected distance visual acuity (CDVA) and manifest refraction were measured several months after all sutures were removed. The CDVA, spherical equivalent refraction, refractive astigmatism, and vector components of refractive astigmatism (J0 and J45) were recorded and compared at different time points., Results: Mean age of patients was 28.3 ± 8.3 years at the time of keratoplasty. No significant changes in the CDVA were observed during the follow-up period. Spherical equivalent refraction measured at 1 month (-3.18 ± 3.41 D) and 3 months (-4.29 ± 4.26 D) after complete suture removal differed significantly from that measured at the last examination (-4.70 ± 3.75 D; P = 0.001 and 0.03, respectively). This measurement stabilized from 6 months after complete suture removal onward. Refractive astigmatism and its vector components (J0 and J45) did not change over time after complete suture removal., Conclusions: Refraction stabilized 6 months after complete DALK suture removal. Therefore, postponing refractive surgery until this time is advisable to manage post-DALK refractive errors.

This study was conducted to analyze the preoperative thickness profile and endothelial rating of ultrathin Descemet's stripping automated endothelial keratoplasty (UT-DSAEK) tissues prepared with a single versus double microkeratome pass from donated whole eyes and corresponding eye bank postoperative results. Microkeratome-assisted UT-DSAEK tissues were prepared from freshly donated whole eyes with single-pass (SP) and double-pass (DP) technique in the Central Eye Bank of Iran. Preoperative thickness profiles and endothelial cell densities of UT-DSAEK tissues were obtained from optical coherence tomography and specular microscopy, respectively, and compared between groups. Corneal perforation rates during the eye bank preparation and postoperative reports of transplanted UT-DSAEK tissues were also compared. Over a 15-month period, 342 UT-DSAEK tissues were prepared: 248 via SP and 94 with DP technique. Mean donor corneal central thickness was 610 ± 58 µm with SP and 790 ± 100 µm with DP technique. Mean central thickness of UT-DSAEK tissues was not statistically different between the groups (84.8 ± 11.0 µm with SP and 85.1 ± 10.5 µm with DP technique, P = 0.857). Mean increase of UT-DSAEK thickness from central to pericentral and peripheral cornea was not significantly different with both techniques. Mean differences between thicknesses of 2 pericentral locations and between those of 2 peripheral locations were not statistically different in the study groups. Corneal perforation of 1.6 and 1.1% occurred in SP and DP groups, respectively. Failed graft was reported 6 months postoperatively in 4 (1.6%) cases with SP and in 1 (1.1%) case with DP technique. Preoperative thickness profiles of UT-DSAEK tissues prepared from donated whole eyes via SP technique were not significantly different from those prepared with DP, showing a symmetric increase of thickness towards peripheral locations.

Purpose: The aim of this study was to report the results of the use of real-time polymerase chain reaction (PCR) for the diagnosis of hepatitis B virus (HBV) infection in cornea donors at the Central Eye Bank of Iran., Methods: Between 2014 and 2016, all cornea donors that had negative screening serologic results for hepatitis B (HB) surface antigen, HB surface antibody (Ab), hepatitis C virus Ab, human immune deficiency virus Ab, human T-cell leukemia virus Ab, and syphilis, and positive serology for HB core Ab were subjected to real-time PCR with a detection limit of 400 IU/mL to identify HBV DNA. Positive results for HBV DNA were considered occult HBV infections in these donors., Results: Over the 3-year period, 122 out of 10448 cornea donors had negative screening serologic tests outside of HB core Ab. Of which, 90 cases were subjected to real-time PCR. Occult HBV was detected in 11 cases (12.2%), resulting in the rejection of the corresponding corneas. The remaining 79 cases (87.8%) had negative results for HBV DNA and the corresponding corneas were used for transplantation., Conclusion: Implementation of PCR for the detection of occult HBV in cornea donors is necessary to not only increase the security level of cornea donation but also minimize the rejection rate of donors that have isolated HB core Ab reactivity., Competing Interests: There are no conflicts of interest.

Purpose: To directly measure internal astigmatism and evaluate its agreement with posterior corneal astigmatism in pseudophakic eyes., Methods: This prospective study enrolled 32 eyes of 32 patients (18 women, 56.3%) who underwent phacoemulsification with implantation of a non-toric monofocal intraocular lens (IOL). Two months postoperatively, posterior corneal astigmatism was measured using a Pentacam Scheimpflug analyzer (Oculus Optikgeräte GmbH, Wetzlar, Germany). Manifest refractive astigmatism was measured after fitting a spherical hard contact lens. This refractive astigmatism that was vertexed to the corneal plane was considered internal astigmatism. The magnitudes of internal and posterior corneal astigmatism were compared. The relationship and agreement between these two astigmatisms were investigated using the Spearman correlation coefficient and Bland-Altman plots, respectively., Results: The mean patient age was 56.3 ± 9.6 years. IOL decentration or tilt and posterior segment abnormalities were not encountered in any cases postoperatively. The mean refractive astigmatism measured before fitting the hard contact lens was -0.81 ± 0.56 diopters (D). Internal astigmatism (-0.17 ± 0.21 D) was significantly different from posterior corneal astigmatism (-0.30 ± 0.15 D; P = .046). Regression analysis demonstrated a weak association between internal astigmatism and posterior corneal astigmatism (r 2 = 0.22, P = .013). Bland-Altman plots produced 95% limits of agreement for these two astigmatisms from -0.49 to 0.75 D., Conclusions: A significant but weak correlation was found between the magnitudes of internal astigmatism and posterior corneal astigmatism in the pseudophakic eyes. This result indicates that Pentacam measurement of the posterior cornea did not compare well with a "gold standard" of refraction-derived values. [J Refract Surg. 2018;34(6):379-386.]., (Copyright 2018, SLACK Incorporated.)

Purpose: To compare mean posterior corneal power and astigmatism in normal versus keratoconus affected eyes and determine the optimal cut-off points to maximize sensitivity and specificity in discriminating keratoconus from normal corneas., Methods: A total of 204 normal eyes and 142 keratoconus affected eyes were enrolled in this prospective comparative study. Mean posterior corneal power and astigmatism were measured using a dual Scheimpflug camera. Correlation coefficients were calculated to assess the relationship between the magnitudes of keratometric and posterior corneal astigmatism in the study groups. Receiver operating characteristic curves were used to compare the sensitivity and specificity of the measured parameters and to identify the optimal cut-off points for discriminating keratoconus from normal corneas., Results: The mean posterior corneal power was -6.29 ± 0.20 D in the normal group and -7.77 ± 0.87 D in the keratoconus group ( P < 0.001). The mean magnitudes of the posterior corneal astigmatisms were -0.32 ± 0.15 D and -0.94 ± 0.39 D in the normal and keratoconus groups, respectively ( P < 0.001). Significant correlations were found between the magnitudes of keratometric and posterior corneal astigmatism in the normal (r=-0.76, P < 0.001) and keratoconus (r=-0.72, P < 0.001) groups. The mean posterior corneal power and astigmatism were highly reliable characteristics that distinguished keratoconus from normal corneas (area under the curve, 0.99 and 0.95, respectively). The optimal cut-off points of mean posterior corneal power and astigmatism were -6.70 D and -0.54 D, respectively., Conclusion: Mean posterior corneal power and astigmatism measured using a Galilei analyzer camera might have potential in diagnosing keratoconus. The cut-off points provided can be used for keratoconus screening., Competing Interests: There are no conflicts of interest.

Purpose: To provide the clinical recommendations for the administration of intravitreal anti-vascular endothelial growth factor (VEGF) drugs especially bavacizumab for ocular vascular diseases including diabetic macular edema, neovascular age-related macular degeneration, myopic choroidal neovascularization, retinal vein occlusion and central serous chorioretinopathy., Methods: Twenty clinical questions were developed by the guideline technical committee. Relevant websites and databases were searched to find out the pertinent clinical practice guidelines to answer the questions. The technical committee provided possible answers (scenarios) according to the available evidences for each question. All scenarios along with their levels of evidence and the supported articles were sent to the experts for external review. If the experts did not agree on any of the scenarios for one particular clinical question, the technical committee reviewed all scenarios and their pertinent evidences and made the necessary decision. After that, the experts were asked to score them again. All confirmed scenarios were gathered as the final recommendations., Results: All the experts agreed on at least one of the scenarios. The technical committee extracted the agreed scenario for each clinical question as the final recommendation. Finally, 56 recommendations were developed for the procedure of intravitreal anti-VEGF injection and their applications in the management of ocular vascular diseases., Conclusion: The implementation of this guideline can standardize the management of the common ocular vascular diseases by intravitreal injection of anti-VEGF agents. It can lead to better policy-making and evidence-based clinical decision by ophthalmologists and optimal evidence based eye care for patients., Competing Interests: There are no conflicts of interest.

Purpose: To determine the factors that influence the endothelial cell density (ECD) of donor grafts after Descemet stripping automated endothelial keratoplasty (DSAEK)., Methods: This retrospective, interventional case series comprised 77 eyes of 64 patients who underwent DSAEK. Confocal microscopy was performed at the final follow-up examination to evaluate the endothelial cell count, cell morphology, and graft thickness. Univariate and multiple linear regression analyses were used to investigate recipient-, donor-, surgical-, and postoperative related variables capable of influencing graft endothelial cell counts after DSAEK., Results: The mean patient age was 62.3 ± 15.6 years; patients were followed-up for 26.2 ± 20.9 months postoperatively. Forty-six eyes (59.7%) underwent stand-alone DSAEK; 31 eyes (40.3%) underwent DSAEK combined with cataract surgery. The donor trephination size was 8.0 ± 0.21 mm. The mean donor age was 30.4 ± 11.2 years, and the mean preoperative endothelial cell density was 3127.4 ± 315.1 cells/mm 2 , which decreased to 1788.6 ± 716.5 cells/mm 2 postoperatively ( P < 0.001). The mean postoperative central graft thickness was 102.4 ± 31.6 μm. Univariate analysis revealed that postoperative ECD was significantly associated with death to preservation time ( P = 0.046), graft thickness ( P = 0.016), follow-up duration ( P = 0.005), and graft non-attachment ( P = 0.049). Multiple regression analyses identified graft thickness (β = 10.62, P = 0.003) and follow-up duration (β = -22.09, P = 0.001) as the significant characteristics influencing postoperative ECD., Conclusion: The primary predictors of ECD after DSAEK were graft thickness and duration of follow-up. Surgeons' requests for ultrathin DSAEK donor grafts to improve visual outcomes might not have the desired postoperative outcome with respect to ECD., Competing Interests: There are no conflicts of interest.

Purpose: To evaluate the effect of suture removal on refraction and keratometry measurements after deep anterior lamellar keratoplasty (DALK)., Methods: This retrospective study enrolled 54 keratoconus-affected eyes that underwent DALK. A combined suturing technique consisting of a 16-bite single running and 8-bite interrupted 10-0 nylon sutures was used at the time of keratoplasty. Selective interrupted suture removal was performed in a subgroup of patients to reduce postkeratoplasty astigmatism. In another subgroup, all sutures were removed at a single session. Adjustment of the running suture tension was not performed in any case. The effect of suture removal on refractive outcomes was investigated in the entire study group, and the 2 subgroups were compared., Results: Mean patient age was 26.6 ± 6.7 years at the time of keratoplasty. The mean interval from surgery to complete suture removal was 17.4 ± 5.9 months. Compared with the pre-suture removal values, there was a significant increase in the magnitude of myopia (-1.12 ± 1.73 D, P = 0.001), refractive astigmatism (-0.89 ± 2.47 D, P = 0.04), mean keratometry (1.39 ± 1.64 D, P = 0.001), and keratometric astigmatism (2.61 ± 2.43 D, P < 0.001) after complete suture removal. Subgroup analysis revealed that selective removal of interrupted sutures was effective as long as remaining interrupted and running sutures were left in place., Conclusions: Complete suture removal was followed by an unpredictable and significant increase in post-DALK refraction and keratometry readings. In the subgroup that underwent early selective removal of interrupted sutures before complete suture removal, the desirable effects of this procedure significantly diminished after all remaining sutures were completely removed.

Purpose: To describe the preparation and thickness profiles of endothelial keratoplasty lenticules harvested from eyes with previous photorefractive keratectomy (PRK)., Methods: Donor whole eyes that underwent PRK were subjected to microkeratome-assisted dissection for Descemet stripping automated endothelial keratoplasty. Specular microscopy and Visante optical coherence tomography were performed on precut corneas. Endothelial cell indices and thickness profiles of endothelial keratoplasty lenticules were statistically analyzed. Postoperative reports for transplanted lenticules were recorded., Results: Over a 6-month period, 2,929 whole eyes from 1,471 donors were screened for PRK. Twenty-five (0.85%) eyes from 14 donors were diagnosed with disciform haziness due to prior PRK and were used uneventfully for preparation of endothelial keratoplasty lenticules. Mean endothelial cell count was 3164.6 ± 311.0/mm 2 and mean central posterior lenticule thickness was 128 ± 34 μm. Posterior lenticules revealed an increase in thickness from the central to peripheral cornea (mean increase of 26.2 μm at pericentral and 90.4 μm at peripheral locations). Mean increase in thickness was statistically different between two peripheral locations (74.5 μm vs. 108.1 μm, P = 0.047). Postoperative reports of transplanted lenticules revealed no posterior flap detachment or loss of clarity at least three months after the surgery., Conclusion: PRK donor whole eyes are potential sources for preparation of microkeratome-assisted thin endothelial keratoplasty lenticules with a high endothelial cell count. Although an asymmetric and significant increase in thickness was present at the peripheral cornea, neither attachment nor clarity of transplanted lenticules was affected by variations in thickness of precut corneas., Competing Interests: There are no conflicts of interest.