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Purpose: The purpose of this study was to report a novel clinical entity characterized by bilateral calcium deposits in the flap interface after uncomplicated laser in situ keratomileusis (LASIK)., Methods: Slit-lamp examination, anterior segment optical coherence tomography imaging, and histopathologic analysis of an interface opacity were performed to characterize and identify the origin of the interface opacities., Results: Two unrelated healthy young men who underwent LASIK in both eyes at 20 (case 1) and 44 (case 2) years of age were diagnosed with bilateral, white anterior stromal opacities 5 years after LASIK surgery. Slit-lamp examination and anterior segment optical coherence tomography imaging demonstrated that the opacities were located at the level of the LASIK interface in both eyes of both cases, with most of the opacities located at the temporal edge of the flap in each eye of case 2. An opacity from case 2 demonstrated birefringence using polarization microscopy and staining with Alizarin red, indicative of calcium deposition. The serum calcium level was borderline elevated in case 1 and within normal limits in case 2., Conclusions: Intrastromal calcium deposition can occur after LASIK surgery, with the deposits resembling dystrophic deposits located in the LASIK flap interface in individuals with granular corneal dystrophy type 2. Because the etiology and management of calcific and dystrophic interface deposition after LASIK are distinct, it is important for clinicians to differentiate the 2 entities based on the examination, diagnostic imaging, and, if necessary, molecular genetic analysis., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To examine the immunohistochemical alterations in the corneal stroma in Peters anomaly (PA) and congenital glaucoma (CG) compared with age-matched normals and acquired adult corneal scarring (AACS)., Methods: The clinical features of PA and CG patients who underwent penetrating keratoplasty were recorded. Immunohistochemistry of cornea and control tissue (normal and acquired corneal scars) was performed with antibodies against collagen types I, III, keratan sulfate, lumican, decorin, and smooth muscle actin followed by semiquantitative analysis of immunolabeling., Results: Clinical features in 2 groups were consistent with PA and CG. Microscopy showed thickened stromal collagen bundles in PA (n = 15), CG (n = 11), and AACS (n = 20) compared with normals (n = 18). PA and CG had distinct immunophenotypes compared with controls. Type I collagen labeling was more intense in CG compared with PA (intensity grading (IG) 2.73 vs. 2.07; P < 0.001). Decorin, lumican, and keratan sulfate labeling was significantly less intense in PA versus AACS (IG; 1.91, 0.38, 1.75 in PA and 2.7, 1.11, 2.61 in AACS. respectively; P = 0.002, P = 0.001 and P = 0.004) and normals (IG 1.92, 1.06, 2.59 respectively; P < 0.001, P < 0.001 and P = 0.005). Collagen I labeling was less intense in CG versus AACS (IG 2.73 vs. 3.09) (P = 0.007). Collagen III labeling was more intense in PA/CG than in normals (IG 0.9, 0.64, 0.62 retrospectively) (P < 0.001 in both)., Conclusions: The immunophenotype of the corneal scar in PA and CG differs from normal corneas and so does PA from AACS. The similarities between CG and AACS suggest that CG scarring has an acquired component.

Purpose: To compare the results of microkeratome-assisted sutureless anterior lamellar keratoplasty (SALK) with and without phacoemulsification., Methods: In this retrospective comparative interventional case series, patients with superficial anterior corneal opacity were divided into 2 groups. Eyes in group 1 (n = 6) had associated cataract and underwent SALK with phacoemulsification surgery (SALK triple). Eyes in group 2 (n = 6) did not have cataract and underwent only anterior lamellar keratoplasty. A 200-μm microkeratome head was used for host and donor cut. Fibrin glue was applied at the graft-host junction. Visual acuity, refractive error, topographic changes, and pachymetry were noted., Results: Mean follow-up was 9 ± 2.7 months. The best spectacle-corrected visual acuity (BSCVA) improved significantly over the preoperative value in both the groups at 1 month, 6 months, and the last follow-up (P = 0.028). The mean gain in BSCVA was 8.8 ± 3.4 lines and 6.8 ± 5.2 lines, respectively, for groups 1 and 2 at the last follow-up, with no statistically significant difference in the BSCVA of both groups at the last follow-up (P = 0.80). There was no statistical difference at the last follow-up between the 2 groups with respect to spherical equivalent (P = 0.6), cylinder (P = 0.81), topographic astigmatism (P = 0.75), and graft thickness (P = 0.81). One patient in group 1 underwent graft rejection, which completely reversed with treatment. No cases of graft dislocation, infection, epithelial ingrowth, vascularization, or recurrence of primary pathology were noted in either group., Conclusions: SALK triple is an effective surgery for early visual rehabilitation of patients with superficial anterior corneal opacity and concomitant cataract.

Purpose: The purpose of this study was to describe a new method of femtosecond (FS) laser-assisted corneal tattooing and to report the results of this method in a case series., Methods: The study involved 6 eyes of 6 patients with total or partial corneal opacity. An FS laser was used for lamellar dissection and to make a side cut with a hinge, creating a corneal flap. Laser parameters were adjusted depending on ocular condition and the location of the corneal opacity. After lifting the corneal flap, further lamellar dissection with a diamond blade was performed up to the periphery of the limbal area. Using a cannula, dye was injected into the lamellar stromal bed and the space of the lamellar dissected pocket in the limbus, after which the flap was repositioned., Results: The design and application of the FS laser for dissection and flap creation were successful in all cases. There were no significant complications other than an incomplete cut under band keratopathy in 1 eye. The cosmetic effects were satisfactory in all cases. No patient complained of pain for more than 1 day after surgery., Conclusions: The advantages of the FS laser-assisted corneal tattooing include a customized design, speed, decreased pain, reduced risk of perforation, and good wound healing. This procedure provides improvements over current corneal tattooing techniques, although it is relatively expensive.

Purpose: To describe the histopathology of the cornea in microphthalmia with linear streaks (MLS) syndrome., Methods: Two patients with MLS syndrome underwent penetrating keratoplasty. This study describes the histopathology and investigates immunophenotype of the corneal extracellular matrix by using keratan sulfate and collagen type III antibodies., Results: Clinical examination revealed bilateral sclerocornea and characteristic skin changes. By light microscopy, central corneal stroma in both patients showed vascularization and irregular thick collagen lamellae typical of sclerocornea. In addition, corneal thinning, anterior synechiae, and the absence of the Descemet membrane were noted, which was suggestive of Peters anomaly. Diffuse and intense anti-keratan sulfate staining and minimal anti-collagen type III stromal staining were seen in both corneal buttons., Conclusions: The cornea in MLS may clinically resemble sclerocornea. Histologic features resemble those previously described in sclerocornea and also seen in anterior segment dysgeneses. Keratan sulfate and collagen type III labeling suggests that the corneal extracellular matrix resembled cornea and not sclera.

Purpose: To report the in vivo confocal microscopic findings of combined polymorphic amyloid degeneration and posterior crocodile shagreen and correlate these findings with clinical presentations and previous histopathologic analysis., Methods: Case reports with confocal microscopic analysis and literature review., Results: Three patients with bilateral corneal opacities presented to the Emory Eye Center Cornea Clinic for evaluation. The first patient, a 65-year-old woman, was noted to have bilateral, discrete, punctate, and filamentous refractile stromal opacifications that appeared to be concentrated in the deep stroma. The second patient, a 50-year-old man, had bilateral deep central stromal haze in a mosaic pattern with intervening cracklike clear zones. The third patient, an 80-year-old woman, had bilateral deep stromal deposits similar to patient 1 in addition to bilateral deep central stromal haze in a mosaic pattern with intervening cracklike clear zones similar to patient 2. Confocal microscopy showed bright, enhancing punctate lesions in the deep stroma and anterior stroma, with unaffected areas between these regions in patients 1 and 3, and central acellular opacification of irregular intensity with intermittent linear clear zones within the normal posterior stromal bed in cases 2 and 3. The first patient was diagnosed with isolated polymorphic amyloid degeneration, the second patient was diagnosed with isolated posterior crocodile shagreen, and the third patient was diagnosed with combined polymorphic amyloid degeneration and posterior crocodile shagreen., Conclusion: These cases are, to our knowledge, the first to report confocal microscopic findings in isolated polymorphic amyloid degeneration and combined polymorphic amyloid degeneration with posterior crocodile shagreen.

Purpose: To investigate surgical outcomes following simultaneous Ahmed glaucoma valve implant and penetrating keratoplasty (PKP) in the management of refractory congenital glaucoma with corneal opacity., Methods: A retrospective review was undertaken of pediatric patients who underwent simultaneous Ahmed glaucoma valve implant and PKP at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia, between January 1994 and September 1999., Results: Twenty eyes of 17 patients were included in the study. Cumulative probabilities of success by Kaplan-Meier analysis showed 85%, 44%, and 33% IOP control and 85%, 43%, and 17% graft success at 2, 24, and 48 months. The most common cause of glaucoma failure that required subsequent surgery was subconjunctival scarring, which resulted in loss of long-term IOP control. Main graft-related complications included failure (13/20) and graft ulceration (6/20), and in 4/6 ulcerated grafts, Streptococcus pneumoniae was cultured positively. Subsequent surgery was the only significant clinical factor associated with poor outcome of glaucoma. However, low graft survival rate was significantly associated with delinquency of follow-ups, corneal ulcer, subsequent surgery, and postoperative complications., Conclusions: The long-term success of simultaneous Ahmed glaucoma valve implant and PKP in refractory congenital glaucoma associated with corneal opacity is low, and the complication rate is high.

Purpose: To report unusual bilateral corneal opacity and inferior corneal thinning in a patient with idiopathic multicentric osteolysis., Methods: A 17-year-old girl with a history of idiopathic multicentric osteolysis was evaluated for corneal opacities., Results: She was found to have bilateral, linear, posterior corneal opacity and inferior corneal thinning. Her vision did not appear to be affected. No progression of the corneal findings was noted over a period of 2 years., Conclusion: Posterior corneal opacity and inferior corneal thinning may be associated with idiopathic multicentric osteolysis, a rare disorder of unknown etiology characterized by bony abnormalities and nephropathy. Patients with idiopathic multicentric osteolysis should be evaluated by an ophthalmologist for the presence of corneal opacities.

Purpose: To determine the efficacy of planned secondary cataract surgery after keratoplasty., Methods: Twenty patients (22 eyes) with simultaneous corneal pathology and cataract were enrolled in a prospective, interventional, case-matched, nonrandomized comparative trial. Penetrating keratoplasty (PKP) and extracapsular cataract extraction (ECCE) with IOL insertion (triple procedure) were performed in 11 eyes, and planned phacoemulsification (PEA) with IOL insertion after PKP was performed in 11 case-matched eyes., Results: There were 10 eyes (91%) within +/-2.0 D of expected values in the secondary PEA group versus 5 patients (45%) in the triple procedure group. No difference was observed in endothelial cell density after 1-year follow-up., Conclusions: Planning for secondary PEA in PKP patients with cataracts is a safe and reliable procedure to obtain less post surgical refractive error. Performing a two-stage intervention has no effect on corneal endothelial viability after 1 year.

Purpose: To investigate the success of corneal graft and intraocular pressure (IOP) control after simultaneous penetrating keratoplasty (PKP) and Ahmed glaucoma valve implant in patients with coexisting corneal opacity and glaucoma., Methods: A retrospective review was undertaken of adult patients at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia, who underwent simultaneous PKP and Ahmed glaucoma valve implant between January 1994 and September 1999., Results: Twenty-five eyes of 25 patients were included in the study. Cumulative probabilities of success by Kaplan-Meier analysis showed 92% and 50% graft success and 92% and 86% IOP control at 1 and 3 years, respectively. The main postoperative complication was graft failure in 10 of 25 cases, and the majority of those failures resulted from immunologic graft rejection and tube endothelial touch., Conclusion: Ahmed glaucoma valve implant is effective in controlling IOP in a majority of eyes during a 3-year time span. However, corneal graft success continues to pose challenges.

Purpose: To report one case of a bilateral ring-shaped opacity in the mid-peripheral corneal stroma of unknown origin., Methods: Case report., Results: The authors describe the clinical history and ocular examination of an asymptomatic 82-year-old woman with a bilateral ring-shaped opacity located in the corneal stroma. This rare corneal anomaly was discovered by chance, and the etiology is unknown., Conclusion: An unusual bilateral corneal abnormality is reported.

Purpose: To evaluate the visual outcome after optical sector iridectomy in cases of corneal opacities., Methods: Seventeen eyes of 17 patients with preoperative visual acuity of <6/60 in the affected eye underwent sector iridectomy in a prospective clinical study at a tertiary eye care center. Of 17 cases, 11 had corneal opacities after healed keratitis, four after trauma, and one each due to alkali burns or trachoma. The sector iridectomy was undertaken in cases in which one sector of the cornea and lens was fairly clear. Success was defined as attainment of ambulatory visual acuity of 6/60 or better., Results: Mean age of the patients was 32+/-2.3 years. Most eyes had deep vascularized corneal scars (13 eyes). Optical sector iridectomy was performed most frequently in the lower nasal quadrant (11 eyes) followed by the lower temporal quadrant (four eyes). Of 17 eyes, 16 achieved a visual acuity of 6/60 or better. No intra-or postoperative complications were encountered., Conclusion: Optical sector iridectomy in cases of corneal opacities is a simple and safe procedure that can improve visual outcome and provide ambulatory vision to patients. It is a valuable alternative to penetrating keratoplasty if penetrating keratoplasty is not possible or not promising for various reasons.

A 10-year-old boy with Cockayne's syndrome had an aseptic perforation centered in a corneal opacity of the right eye. Exposure keratitis, which was caused by anhidrosis, loss of blinking, and lack of Bell's phenomenon, was considered responsible for this condition. A therapeutic soft contact lens was applied to heal the corneal wound.

Bilateral white crystalline opacities of the central corneas were found at autopsy in the eyes of a 17-day-old girl with Turner's Syndrome. Corticosteroid therapy had not been used. Histopathologic and electron microscopic evaluation revealed clusters of gram-negative rods between relatively intact stromal lamellae. Inflammation was mild and restricted to the limbus and peripheral cornea. This case represents an unusual presentation of an infectious crystalline keratopathy.

Severe congenital corneal clouding may be associated with abnormal anterior segment development (dysgenesis). Often, congenital corneal opacities preclude visualization of intraocular anatomy. In this report, five eyes of four patients with congenital corneal clouding and lens-corneal adhesion (LCA) are described. All had a ring- or doughnut-shaped haze within the stroma surrounding a central clear corneal zone delineating the adhesion. Recognition of LCA is pivotal in planning surgical therapy for eyes with congenital corneal clouding. As a clue to recognition of this anomaly, the ring-shaped stromal opacity may aid in diagnosis of this phenomenon and in avoidance of surgical complications.

Soft extended wear contact lenses were designed for and fitted to 12 eyes of 11 infant semiwild cynomolgus monkeys. The lenses were satisfactorily worn over observation periods of up to 465 days, the longest continuous period of lens wear being 69 days. However, some of the corneas were subject to a pattern of complications analogous to that in human contact lens wear. Nine eyes showed adverse responses, and of these, the ocular complications were severe enough in four cases to cause abandonment of lens wear. The most remarkable feature of the complications was the rapid recovery of severe reactions to near normality in less than 24 h, indicating an impressive ability of the cornea to tolerate and survive insult. Another feature was the recurrent nature of mild complications in certain monkeys despite apparent resolution from previous episodes. There appeared to be no correlation between duration of lens wear and appearance of the first or recurrent episodes of corneal infiltration and vascularization.