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Hany Ahmed Helaly,&ast; Osama Ramadan Elnaggar,&ast; Mohsen Abou Shousha, Amr Mohamed Elhady Ophthalmology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt&ast;These authors contributed equally to this workCorrespondence: Hany Ahmed Helaly, Email hany209209@yahoo.comPurpose: To assess the accuracy of axial length (AXL) measurements using two swept-source optical coherence biometers, IOLMaster 700 (Carl Zeiss Meditec AG, Jena, Germany) and ARGOS (Alcon, Inc. Fort Worth, TX), for macula-off rhegmatogenous retinal detachment (RRD).Methods: This retrospective study included 100 eyes with phakic primary macula-off RRD. Preoperative AXL measurements were performed using different methods: applanation A-scan ultrasound (U/S) biometry, combined applanation vector A/B-scan biometry, and optical biometry measurements were obtained using IOLMaster 700 (Carl Zeiss, Meditec, Jena, Germany) and ARGOS (Alcon, Inc. Fort Worth, TX). All patients underwent pars plana phacovitrectomy. At 8– 10 weeks postoperatively, optical biometry was performed to record AXL.Results: Mean preoperative AXL measured using vector-A/B-scan ultrasonography was higher than that of postoperative AXL measured using IOLMaster (p < 0.05). Mean AXL measured by the standard mode of the ARGOS optical biometer was lower than mean AXL measured by both enhanced retina visualization (ERV) mode and user-adjusted method (p < 0.05). Mean same-eye AXL measured using IOLMaster was lower than that measured using ARGOS (p < 0.05). The least difference was observed with combined vector-A/B-scan ultrasound (on the positive side), followed by fellow eye AXL measured using IOLMaster optical biometry (on the negative side).Conclusion: Optical biometry of fellow eye in macula-off RRD was noted to be highly correlating with postoperative optical biometry of same eye using IOL Master 700 in eyes without anisometropia. IOLMaster 700 showed less accuracy in the AXL measurements for same eye. The ARGOS optical biometer may have a good potential for measuring same eye AXL. Using ERV mode or a user-adjusted method for the ARGOS optical biometer may improve accuracy of AXL measurements. Most accurate method for measuring AXL in same eye was vector-A/B-scan ultrasound.Keywords: macula-off, optical biometry, fellow eye, RRD, IOL calculation, ARGOS, IOLMaster

Collin Chase,1 Amr Elsawy,2 Taher Eleiwa,3 Eyup Ozcan,4 Mohamed Tolba,2 Mohamed Abou Shousha2 1Morsani College of Medicine, University of South Florida, Tampa, FL, USA; 2Cornea Department, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL, USA; 3Department of Ophthalmology, Faculty of Medicine, Benha University, Benha, Egypt; 4Department of Ophthalmology, Net Eye Medical Center, Gaziantep, TurkeyCorrespondence: Mohamed Abou ShoushaCornea Department, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, 900 NW 17th Street, Miami, FL, 33136, USATel +1 305-326-6000Email Mshousha@med.miami.eduObjective: To evaluate a deep learning-based method to autonomously detect dry eye disease (DED) in anterior segment optical coherence tomography (AS-OCT) images compared to common clinical dry eye tests.Methods: In this study, 27,180 AS-OCT images were prospectively collected from 151 eyes of 91 patients. Images were used to train and test the deep learning model. Masked cornea specialist ophthalmologist diagnoses were used as the gold standard. Clinical dry eye tests were performed on patients in the DED group to compare the results of the model. The dry eye tests performed were tear break-up time (TBUT), Schirmer’s test, corneal staining, conjunctival staining, and Ocular Surface Disease Index (OSDI).Results: Our deep learning model achieved an accuracy of 84.62%, sensitivity of 86.36%, and specificity of 82.35% in the diagnosis of DED. The positive likelihood ratio was 4.89, and the negative likelihood ratio was 0.17. The mean DED probability score was 0.81 ± 0.23 in the DED group and 0.20 ± 0.27 in the healthy group (P < 0.01). The deep learning model accuracy in the diagnosis of DED was significantly better than that of corneal staining, conjunctival staining, and Schirmer’s test (P < 0.05). There was no significant difference between the deep learning diagnostic accuracy and that of the OSDI and TBUT.Conclusion: Based on preliminary results, reliable autonomous diagnosis of DED with our deep learning model was achieved, when compared with standard dry eye clinical tests that correlated significantly more or similarly to diagnoses made by cornea specialist ophthalmologists.Keywords: dry eye disease, artificial intelligence, optical coherence tomography

Zeba A Syed,1 Gustavo Rosa Gameiro,1 Marco Ruggeri,1 Amr Elsawy,1,2 Ibrahim Sayed-Ahmed,1 Vatookarn Roongpoovapatr,1 Mohamed Abdel-Mottaleb,2 Mohamed Abou Shousha11Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA; 2Department of Electrical and Computer Engineering, University of Miami College of Engineering, Coral Gables, FL, USAObjective: We present a novel method for screening eye bank donor corneas using high definition optical coherence tomography (HD-OCT). This technology allows for the quantification of endothelial/Descemet membrane (En/DM) complex thickness ex vivo.Design: Prospective interventional study.Participants: Fifty-two corneal grafts from 27 donors were included in this study. Twenty additional control eyes and 11 eyes with Fuchs’ endothelial corneal dystrophy were also evaluated for comparison.Methods: A custom built, high speed HD-OCT device (Envisu R2210, Bioptigen, Buffalo Grove, IL, USA) was used to obtain images, and custom-made graph-based segmentation software was used to automatically deconstruct corneal images into micro-layers. HD-OCT imaging was used to scan through the sealed sterile case of donor corneas stored in McCarey-Kaufman medium to image their En/DM complex through the center of the cornea.Results: This technology allowed for quantification of En/DM complex thickness in all donor corneas through the sealed sterile container used to transport graft tissue. Mean En/DM complex thickness of donor corneas was 17±4 μm. The difference between donor cornea En/DM thickness and that of control subjects (16±2 μm) was not statistically significant (p=0.3), suggesting that the transport container and media do not affect measurements. There was a significant difference between En/DM thickness of Fuchs’ endothelial corneal dystrophy eyes (25±5 μm) and both donor corneas (p

Purpose: To describe 4 cases of posterior pole retinal detachment (RD) in patients with pathologic myopia that were repaired with a prototype myopia support device. Methods: A case series was evaluated. Results: Four cases of posterior pole RD were treated, 3 of which were accompanied by myopic maculoschisis and 1 that was accompanied by a choroidal neovascular membrane and a macular hole (MH). Preoperative and postoperative assessments included visual acuity, optical coherence tomography and fluorescein angiography findings, and axial lengths when available. Three patients had vitrectomy and device placement, while the other patient received device placement alone. All cases had successful repair of the RD, with complete resolution of maculoschisis and MH when present. The myopia support device provided the desired indentation, aiding in the repair. Follow-up varied between 2 months and 17 months. Conclusions: The myopia support device is a valuable addition for repair of posterior pole RDs in patients with pathologic myopia, with or without maculoschisis or MH. It can be used in conjunction with vitrectomy or as a standalone technique., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of the article., (© The Author(s) 2024.)

Prcis: This study of inter-test comparability of a novel visual field application installed on an augmented-reality portable headset and Humphrey field analyzer Swedish interactive thresholding algorithm (SITA) Standard visual field test demonstrates the excellent correlation of mean deviation (MD) and mean sensitivity (MS)., Purpose: To determine the correlation between visual field testing with novel software on a wearable headset versus standard automated perimetry., Patients and Methods: Patients with and without visual field defects attributable to glaucoma had visual field testing in one eye of each patient with 2 methods: re:Imagine Strategy (Heru, Inc.) and the Humphrey field analyzer (Carl Zeiss Meditec, Inc.) SITA Standard 24-2 program. Main outcome measures included MS and MD, which were evaluated by linear regression, intraclass correlation coefficient (ICC), and Bland Altman analysis for assessment of the mean difference and limits of agreement., Results: Measurements from 89 eyes of 89 patients (18 normal and 71 glaucomas) were compared with both instruments. Linear regression analysis demonstrated an excellent Pearson correlation coefficient of r = 0.94 for MS and r = 0.95 for MD. ICC analysis demonstrated high levels of concordance (ICC = 0.95, P < 0.001 for MS and ICC = 0.94, P < 0.001 for MD). Bland-Altman analysis determined a small mean difference between the two devices (Heru minus Humphrey) of 1.15 dB for MS and 1.06 dB for MD., Conclusions: The Heru visual field test correlated well with SITA Standard in a population of normal eyes and eyes with glaucoma., Competing Interests: Disclosure: M.A.S. is an equity holder, officer, and sits on the Board of Directors for Heru, Inc. M.D., A.N., V.L., M.C., C.A.D., R.K., and C.O.-B., are employed by or have been employed by Heru, Inc. The remaining authors declare no conflict of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: This study aims to compare a new prototype for a portable anterior eye segment imaging system with the standard method for ophthalmology examination., Methods: The new imaging system consisted of two IMX219 Arducam autofocus sensors (Arducam, China, Nanjing) for Raspberry Pi V2 camera module connected to a Raspberry Pi Zero W (Raspberry Pi Foundation, UK, Cambridge) that clips to a wearable headset. The 2D videos of the anterior eye segment were recorded with the new system and a 720p FaceTime HD camera (Apple, Cupertino, CA). Afterward, ophthalmologists evaluated the videos using a standard clinical eye examination form. These evaluations were compared with the standard slit-lamp clinical assessment performed during the patient's visit., Results: Thirty-five eyes were evaluated. The sensitivity and specificity percentages were statistically significant between the two imaging modalities (P ≤ 0.001). The evaluations performed from videos obtained with the new imaging system had better sensitivity and specificity percentages overall. However, statistically significant differences were only observed in cornea, anterior chamber, iris, and lens., Conclusions: Specificity percentages were higher than sensitivity percentages in both imaging modalities, indicating that video evaluations are less accurate for pathological screening. Nevertheless, the new system evaluations were significantly better than the webcam evaluations., Translational Relevance: This study presented an alternative system to assess eye conditions for telemedicine, one that provides more details than the current standard and uses new wearable headsets technologies.

Purpose: To report a multidisease deep learning diagnostic network (MDDN) of common corneal diseases: dry eye syndrome (DES), Fuchs endothelial dystrophy (FED), and keratoconus (KCN) using anterior segment optical coherence tomography (AS-OCT) images., Study Design: Development of a deep learning neural network diagnosis algorithm., Methods: A total of 158,220 AS-OCT images from 879 eyes of 478 subjects were used to develop and validate a classification deep network. After a quality check, the network was trained and validated using 134,460 images. We tested the network using a test set of consecutive patients involving 23,760 AS-OCT images of 132 eyes of 69 patients. The area under receiver operating characteristic curve (AUROC), area under precision-recall curve (AUPRC), and F1 score and 95% confidence intervals (CIs) were computed., Results: The MDDN achieved eye-level AUROCs >0.99 (95% CI: 0.90, 1.0), AUPRCs > 0.96 (95% CI: 0.90, 1.0), and F1 scores > 0.90 (95% CI: 0.81, 1.0) for DES, FED, and KCN, respectively., Conclusions: MDDN is a novel diagnostic tool for corneal diseases that can be used to automatically diagnose KCN, FED, and DES using only AS-OCT images., (Copyright © 2021. Published by Elsevier Inc.)

Background: To describe the diagnostic performance of a deep learning algorithm in discriminating early-stage Fuchs' endothelial corneal dystrophy (FECD) without clinically evident corneal edema from healthy and late-stage FECD eyes using high-definition optical coherence tomography (HD-OCT)., Methods: In this observational case-control study, 104 eyes (53 FECD eyes and 51 healthy controls) received HD-OCT imaging (Envisu R2210, Bioptigen, Buffalo Grove, IL, USA) using a 6 mm radial scan pattern centered on the corneal vertex. FECD was clinically categorized into early (without corneal edema) and late-stage (with corneal edema). A total of 18,720 anterior segment optical coherence tomography (AS-OCT) images (9180 healthy; 5400 early-stage FECD; 4140 late-stage FECD) of 104 eyes (81 patients) were used to develop and validate a deep learning classification network to differentiate early-stage FECD eyes from healthy eyes and those with clinical edema. Using 5-fold cross-validation on the dataset containing 11,340 OCT images (63 eyes), the network was trained with 80% of these images (3420 healthy; 3060 early-stage FECD; 2700 late-stage FECD), then tested with 20% (720 healthy; 720 early-stage FECD; 720 late-stage FECD). Thereafter, a final model was trained with the entire dataset consisting the 11,340 images and validated with a remaining 7380 images of unseen AS-OCT scans of 41 eyes (5040 healthy; 1620 early-stage FECD 720 late-stage FECD). Visualization of learned features was done, and area under curve (AUC), specificity, and sensitivity of the prediction outputs for healthy, early and late-stage FECD were computed., Results: The final model achieved an AUC of 0.997 ± 0.005 with 91% sensitivity and 97% specificity in detecting early-FECD; an AUC of 0.974 ± 0.005 with a specificity of 92% and a sensitivity up to 100% in detecting late-stage FECD; and an AUC of 0.998 ± 0.001 with a specificity 98% and a sensitivity of 99% in discriminating healthy corneas from all FECD., Conclusion: Deep learning algorithm is an accurate autonomous novel diagnostic tool of FECD with very high sensitivity and specificity that can be used to grade FECD severity with high accuracy., Competing Interests: Competing interestsTaher Eleiwa and Eyup Ozcan: Nothing to declare. Mohamed Abou Shousha and Amr Elsawy: United States Non-Provisional Patents (Application No. 8992023 and 61809518), and PCT/US2018/013409. Patents and PCT are owned by University of Miami and licensed to Resolve Ophthalmics, LLC. Mohamed Abou Shousha is an equity holder and sits on the Board of Directors for Resolve Ophthalmics, LLC, and is consultant of Avedro., (© The Author(s) 2020.)

Purpose : To characterize the three-dimensional (3D) thickness profile and age-related changes of Bowman's layer (BL), and endothelium/Descemet's membrane (En/DM) complex among healthy individuals using Corneal Microlayer Tomography (CML-T), and to describe its repeatability and accuracy. Methods : Sixty-six eyes of 41 healthy volunteers; 27 eyes (< 40 years old), and 39 eyes (>40 years old) were imaged using HD-OCT. Automatic and manual segmentation of the corneal layers was performed, and 3D thickness maps were generated, using custom-built CML-T software. A regional analysis of mean thickness parameters between the 2 age groups was performed. A regression analysis was used to assess the correlation between age, and thickness maps. Intraclass Correlation Coefficients (ICC), Coefficients of Variation (COV), and Bland-Altman plots were used to assess the reliability of the repeated measurements in 198 locations. Results : CML-T successfully mapped the BL and En/DM in all included eyes. Thickness maps showed a significant increase in corneal thickness (CT), BL thickness (BMT), and En/DM complex thickness (DMT) toward the periphery with a mean difference 28 µm ( p < .001), 1.1 µm ( p < .001), and 1.4 µm ( p < .001), respectively. There was a strong correlation between age and central DMT (r = 0.61; p < .001), while there was no correlation between age and both CT, and BMT. ICC values ranged from 0.9 (BMT) to 0.997 (DMT), and from 0.808 (BMT) to 0.979 (CT) for intraoperator repeatability of manual measurements, and the accuracy of auto matic measurements, respectively. COV values were lower than 7.5% in all cases. Conclusion : CML-T is a novel tool that can generate 3D-thickness maps of both BL and En/DM. CT, BMT, and DMT increase toward the periphery in healthy corneas. DMT increases with aging, while BMT does not. We also report excellent repeatability, accuracy and good agreement between automatic and manual measurements.

Background/objectives: To characterize and evaluate the use of corneal epithelial profile maps generated by an ultrahigh-resolution optical coherence tomography (UHR-OCT) in the diagnosis and management of dry-eye disease (DED)., Subjects/methods: This prospective, interventional case-control study included 115 eyes of 71 subjects (52 DED and 19 controls) imaged using an UHR-OCT. Average, maximum, and minimum, range of corneal epithelial thicknesses were extracted from epithelial profile maps. Surface regularity was quantified using the range and variance of the epithelial thickness measured along a horizontal UHR-OCT scan. The variance of thickness measurements along a scan was named epithelial irregularity factor (EIF). Symptoms of 31 DED patients (55 eyes) were quantified by questionnaire and correlated to epithelial profile findings, fluorescein staining, tear breakup time, and Schirmer's test. Twenty-one DED eyes were administered autologous serum drops and follow-up UHR-OCT images were captured., Results: DED patients had a highly irregular corneal epithelial surface compared with controls. Epithelial thickness profile variance (EIF) and range were significantly higher in DED as compared with controls (5.79 vs. 0.77, p < 0.001 and 7.6 vs. 4.6 μm, p < 0.001). Both parameters were highly significantly correlated with questionnaire scores (EIF: r = 0.778; p < 0.001, range: r = 0.737; p < 0.001). Follow-up showed a statistically significant reduction in epithelial thickness profile variance and range of treated patients ( p < 0.001)., Conclusions: DED patients have irregular epithelial surface that can be quantified using UHR-OCT generated CEP maps. Epithelial thickness profile range and EIF correlate accurately with patients' symptoms and could be used to follow-up patients and response to treatment.

Purpose: This case series demonstrate diagnostic features, treatment options, and challenges for Brittle Cornea Syndrome. Observations . Three cases presented with bluish sclera and extremely thin cornea. Genetic workup was performed and confirmed the diagnosis of Brittle Cornea Syndrome, a rare autosomal recessive disorder characterized by corneal thinning and blue sclera. Case 1 was a 4-year-old boy who developed cataract and glaucoma after undergoing right tectonic penetrating keratoplasty (PK) secondary to a spontaneous corneal rupture. Glaucoma was controlled medically. Later, the kid underwent right transcorneal lensectomy and vitrectomy with synechiolysis. After 6 weeks, he sustained graft dehiscence that was repaired using onlay patch graft. Case 2 was a 7-year-old boy who underwent PK in the right eye, then a pericardial patch graft in the left eye following spontaneous corneal rupture. Glaucoma in both eyes was controlled medically. Case 3 was the 2-year-old sister of the 2 nd case. She had a pachymetry of 238  μ m OD and 254  μ m OD and 254 ., Conclusions: Long-term follow-up of children diagnosed with Brittle Cornea Syndrome is paramount to minimize the morbidity of corneal rupture and late-onset extraocular conditions., Competing Interests: The authors have no financial disclosures: (TE, MR, NP, AB, AG, and MA)., (Copyright © 2020 Taher Eleiwa et al.)

Purpose: To examine an image remapping method for peripheral visual field (VF) expansion with novel virtual reality digital spectacles (DSpecs) to improve visual awareness in glaucoma patients., Design: Prospective case series., Methods: Monocular peripheral VF defects were measured and defined with a head-mounted display diagnostic algorithm. The monocular VF was used to calculate remapping parameters with a customized algorithm to relocate and resize unseen peripheral targets within the remaining VF. The sequence of monocular VF was tested and customized image remapping was carried out in 23 patients with typical glaucomatous defects. Test images demonstrating roads and cars were used to determine increased awareness of peripheral hazards while wearing the DSpecs. Patients' scores in identifying and counting peripheral objects with the remapped images were the main outcome measurements., Results: The diagnostic monocular VF testing algorithm was comparable to standard automated perimetric determination of threshold sensitivity based on point-by-point assessment. Eighteen of 23 patients (78%) could identify safety hazards with the DSpecs that they could not previously. The ability to identify peripheral objects improved with the use of the DSpecs (P = 0.024, chi-square test). Quantification of the number of peripheral objects improved with the DSpecs (P = 0.0026, Wilcoxon rank sum test)., Conclusions: These novel spectacles may enhance peripheral objects awareness by enlarging the functional field of view in glaucoma patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: To assess the efficacy of novel Digital spectacles (DSpecs) to improve mobility of patients with peripheral visual field (VF) loss., Design: Prospective case series., Methods: Binocular VF defects were quantified with the DSpecs testing strategy. An algorithm was implemented that generated personalized visual augmentation profiles based on the measured VF. These profiles were achieved by relocating and resizing video signals to fit within the remaining VF in real time. Twenty patients with known binocular VF defects were tested using static test images, followed by dynamic walking simulations to determine if they could identify objects and avoid obstacles in an environment mimicking a real-life situation. The effect of the DSpecs were assessed for visual/hand coordination with object-grasping tests. Patients performed these tests with and without the DSpecs correction profile., Results: The diagnostic binocular VF testing with the DSpecs was comparable to the integrated monocular standard automated perimetry based on point-by-point assessment with a mismatch error of 7.0%. Eighteen of 20 patients (90%) could identify peripheral objects in test images with the DSpecs that they could not previously. Visual/hand coordination was successful for 17 patients (85%) from the first trial. The object-grasping performance improved to 100% by the third trial. Patient performance, judged by finding and identifying objects in the periphery in a simulated walking environment, was significantly better with the DSpecs (P = 0.02, Wilcoxon rank sum test)., Conclusions: DSpecs may improve mobility by facilitating the ability of patients to better identify moving peripheral hazardous objects., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the performance of 3-dimensional (3D) endothelium/Descemet membrane complex thickness (En/DMT) maps vs total corneal thickness (TCT) maps in the diagnosis of active corneal graft rejection., Design: Cross-sectional study., Methods: Eighty-one eyes (32 clear grafts and 17 with active rejection, along with 32 age-matched control eyes) were imaged using high-definition optical coherence tomography (HD-OCT), and a custom-built segmentation algorithm was used to generate 3D color-coded maps of TCT and En/DMT of the central 6-mm cornea. Regional En/DMT and TCT were analyzed and compared between the studied groups. Receiver operating characteristic curves were used to determine the accuracy of En/DMT and TCT maps in differentiating between studied groups. Main outcome measures were regional En/DMT and TCT., Results: Both regional TCT and En/DMT were significantly greater in actively rejecting grafts compared to both healthy corneas and clear grafts (P < .001). Using 3D thickness maps, central, paracentral, and peripheral En/DMT achieved 100% sensitivity and 100% specificity in diagnosing actively rejecting grafts (optimal cut-off value [OCV] of 19 μm, 24 μm, and 26 μm, respectively), vs only 82% sensitivity and 96% specificity for central TCT, OCV of 587 μm. Moreover, central, paracentral, and peripheral En/DMT correlated significantly with graft rejection severity (r = 0.972, r = 0.729, and r = 0.823, respectively; P < .001)., Conclusion: 3D En/DMT maps can diagnose active corneal graft rejection with excellent accuracy, sensitivity, and specificity. Future longitudinal studies are required to evaluate the predictive and prognostic role of 3D En/DMT maps in corneal graft rejection., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: To evaluate corneal edema in different-aged pediatric patients with Peters anomaly and to correlate in vivo with ex vivo histopathologic findings., Methods: A retrospective cross-sectional study was performed. The medical records of patients diagnosed with Peters anomaly who underwent examination under anesthesia (EUA) between 2011 and 2015 were reviewed. Eyes in which central corneal thickness (CCT) measurements were taken were included. The thickest point in the CCT pachymetric map was used to objectively quantify corneal edema. Correlation between CCT and age was calculated. Additionally, a retrospective review of histopathologic studies of excised corneal buttons from pediatric eyes with Peters anomaly between 2011 and 2015 was performed., Results: Eighteen eyes of 12 children were included. Mean age was 14 ± 15 months, and mean CCT was 842 ± 304 µm. A significant inverse correlation was noted between the CCT and the age of the patients, with lower CCT values in older children (r = 0.6; P = 0.01). Seven excised corneal buttons that underwent penetrating keratoplasty were reviewed. All corneal buttons showed absence of Descemet membrane and localized absence of endothelium. However, three specimens showed presence of corneal endothelium in areas of absent or attenuated Descemet membrane., Conclusions: In Peters anomaly, the CCT decreases with age, possibly due to a decrease in corneal edema. Histopathologic studies show cases of endothelial expansion in areas of absent or attenuated Descemet membrane. This may contribute to improved endothelial function and decreased edema with age.

Purpose: To identify the incidence of endophthalmitis and visual outcomes in eyes with Boston type 1 keratoprosthesis combined with pars plana vitrectomy and silicone oil insertion (KPro + PPV + SOI) as compared to eyes receiving Boston type 1 keratoprosthesis (KPro) alone., Patients and Methods: Retrospective chart review of 29 eyes of 27 patients with KPro having at least 12-month follow-up. Thirteen of these eyes had hypotony and/or retinal detachment in addition to corneal pathology and thus received KPro + PPV + SOI. Polymyxin-trimethoprim with a quinolone was used as chronic topical antibiotic prophylaxis in both groups after the first postoperative month. Outcome measures recorded at the 1-, 3-, 6-, 12-, and 24-month follow-up visits included best-corrected visual acuity (BCVA) and rates of postoperative complications., Results: All the patients had completed 24-month follow-up except one case in the KPro group who lost to follow-up after 12-month visit. In the KPro + PPV + SOI group, no eyes had developed endophthalmitis by the 24-month follow-up visit versus 5 eyes of 5 patients in the uncombined KPro group ( P =0.048). The 2-year cumulative endophthalmitis incidence was 31.2% in the KPro group versus zero in the KPro + PPV + SOI group ( P =0.030). Four of these 5 eyes had vitreous taps with positive cultures; 2 were positive with Staphylococcus aureus , 1 with coagulase-negative staphylococci, and 1 with Streptococcus pneumoniae . Other complications included KPro extrusion (1 in each group), retinal detachment (2 in the KPro and 1 in the KPro + PPV + SOI group), newly developed glaucoma (2 in each group), and retroprosthetic membrane (9 in the KPro and 5 in the KPro + PPV + SOI group). The KPro group had better average preoperative BCVA compared to those of the KPro + PPV + SOI group (-2.29 ± 0.72 LogMAR, versus -2.95 ± 0.30 LogMAR; P =0.004). No statistically significant difference in BCVA was noted in subsequent follow-up visits., Conclusion: The addition of PPV and SOI to the KPro implantation in the eyes with corneal pathology, as well as hypotony and/or retinal detachment, is a safe and effective procedure for visual rehabilitation. Pars plana vitrectomy and silicone oil insertion may have a protective effect against the development of postoperative endophthalmitis in eyes receiving KPro., Competing Interests: The authors declare that there are no conflicts of interest.

Background: To evaluate the efficacy of swept -source optical coherence tomography angiography (SS-OCTA) in grading macular perfusion in retinal vein occlusion., Methods: Retrospective observational case series including patients with different types of retinal vein occlusion (RVO). SS-OCTA utilizes OCTARA algorithm to examine the retinal vascular plexuses for the presence of morphological signs of ischemia according to a predetermined grading scheme. The findings were compared with fundus fluorescein angiography (FFA), and swept-source optical coherence tomography (SS-OCT) features. Bivariate correlation, coefficient of determination, and crosstabs procedures were used to calculate inter-variable linear correlation, relative contribution of the tested variables, and multivariate association, respectively., Results: The study included 144 eyes of 138 patients. The most common type of RVO was branch retinal vein occlusion (BRVO) (53%). The superficial capillary plexus (SCP) and the deep capillary plexus (DCP) did not correlate with each other in all parameters tested. Increased central macular thickness (CMT) and disrupted retinal outer layers (DROL) were associated with increased severity of ischemia in DCP. Disorganized retinal inner layers (DRIL) correlated significantly with the presence of perifoveal capillary ischemia in the SCP and the DCP. Macular ischemia on FFA correlated with ischemia in the SCP layer only. Increased CMT, DROL and DRIL on SS-OCT, and SCP and DCP ischemia on SS-OCTA contributed significantly to diminished best-corrected visual acuity (BCVA)., Conclusion: SS-OCTA is more precise in defining the extent and location of maximum ischemic insult following RVO compared to FFA, hence represents a more efficient grader for ischemic damage in the posterior pole. Increased CMT, DRIL, and DROL on SS-OCT, and SCP and DCP ischemia on SS-OCTA are significant predictors of poor visual outcome.

Purpose: To assess the safety and stability in cases of small incision lenticule extraction with collagen cross-linking (SMILE Xtra)., Methods: This study was a retrospective interventional comparative study that included 60 eyes of 30 patients divided equally into two groups: SMILE Xtra and SMILE alone. The inclusion criteria were patients >18 years of age, myopic error >6 D, thinner cornea <520 microns, and abnormal corneal topography. Outcome data were recorded including uncorrected distance visual acuity and corrected distance visual acuity (UDVA and CDVA), manifest refraction spherical equivalent (MRSE), central corneal thickness, average keratometry, endothelial cell density, corneal resistance factor (CRF), and corneal densitometry. The follow-up period was 24 months., Results: There was a significant difference between the 2 groups regarding UDVA, CDVA, and MRSE at 1 month. In the SMILE Xtra group, 90% of eyes had postoperative UDVA of 20/20 and 97% had UDVA of 20/30 at 24 months. At 24 months, 26 eyes (87%) vs. 25 eyes (84%) were within ±0.50 D of attempted correction in SMILE Xtra and SMILE groups, respectively. Regarding stability, both groups showed improvement of MRSE at 1 st month postoperatively and remained stable along the 24 months of follow-up. CRF and corneal densitometry were higher in the SMILE Xtra group along the whole follow-up period ( p =0.001)., Conclusion: Combining corneal cross-linking with SMILE procedure (SMILE Xtra) is a promising tool to prevent ectasia in high-risk patients. It is a safe and simple procedure that can be offered to patients undergoing SMILE with risk for ectasia. Trial registration no: PACTR201810577524718.

Purpose: To disclose, using an ex vivo study, the histopathological mechanism behind in vivo thickening of the endothelium/Descemet membrane complex (En/DM) observed in rejected corneal grafts (RCGs)., Methods: Descemet membrane (DM), endothelium, and retrocorneal membranes make up the total En/DM thickness. These layers are not differentiable by high-definition optical coherence tomography; therefore, the source of thickening is unclear from an in vivo perspective. A retrospective ex vivo study (from September 2015 to December 2015) was conducted to measure the thicknesses of DM, endothelium, and retrocorneal membrane in 54 corneal specimens (31 RCGs and 23 controls) using light microscopy. Controls were globes with posterior melanoma without corneal involvement., Results: There were 54 corneas examined ex vivo with mean age 58.1 ± 12.2 in controls and 51.7 ± 27.9 years in RCGs. The ex vivo study uncovered the histopathological mechanism of En/DM thickening to be secondary to significant thickening (P < 0.001) of DM (6.5 ± 2.4 μm) in RCGs compared with controls (3.9 ± 1.5 μm)., Conclusions: Our ex vivo study shows that DM is responsible for thickening of the En/DM in RCGs observed in vivo by high-definition optical coherence tomography and not the endothelium or retrocorneal membrane.

Purpose: To evaluate the utility of endothelial/Descemet membrane complex (En/DM) characteristics in diagnosing corneal graft rejection., Design: Diagnostic reliability study., Methods: One hundred thirty-nine eyes (96 corneal grafts post penetrating keratoplasty or Descemet stripping automated endothelial keratoplasty: 40 clear, 23 actively rejecting, 24 rejected, and 9 nonimmunologic failed grafts; along with 43 age-matched control eyes) were imaged using high-definition optical coherence tomography. Images were used to describe En/DM and measure central corneal thickness (CCT) and central En/DM thickness (DMT). En/DM rejection index (DRI) was computed to detect the relative En/DM thickening to the entire cornea., Results: In actively rejecting grafts, DMT and DRI were significantly greater than controls and clear grafts (28, 17, and 17 μm and 1.5, 1 and 1, respectively; P < .001). Rejected grafts had the highest DMT and DRI compared to all groups (59 μm and 2.1; P < .001). DMT and DRI showed excellent accuracy, significantly better than that of CCT, in differentiating actively rejecting from clear grafts (100% and 96% sensitivity; 92.5% and 92.5% specificity), actively rejecting from rejected grafts (88% and 83% sensitivity; 91% and 83% specificity), and nonimmunologic failed from rejected grafts (100% and 100% sensitivity; 88% and 100% specificity). DMT correlated significantly with rejection severity (P < .001)., Conclusions: In corneal grafts, in vivo relative thickening of the En/DM is diagnostic of graft rejection as measured by DMT and DRI. These indices have excellent accuracy, sensitivity, and specificity in detecting graft immunologic status, superior to CCT. DMT is a quantitative index that correlates accurately with the severity of rejection., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To assess the accuracy of axial length measurements in cases of macula-off retinal detachment using different methods (optical biometry, A-scan ultrasound, and combined applanation vector-A/B-scan biometry)., Methods: This prospective clinical study included 100 eyes of 100 patients who underwent vitrectomy alone or phacovitrectomy for macula-off retinal detachment. All patients included signed an informed consent. Preoperative examination of the patients included recording the axial length measurements using optical biometry, A-scan ultrasound, and combined applanation vector-A/B-scan biometry., Results: The mean postoperative IOLMaster axial length after macular reattachment was 26.11 ± 2.91 mm. The mean preoperative IOLMaster axial length with macula-off was 25.32 ± 2.72 mm. The mean preoperative A-scan axial length with macula-off was 25.29 ± 2.80 mm. The mean preoperative vector-A/B-scan axial length with macula-off was 26.03 ± 2.90 mm. The preoperative vector-A/B-scan mean absolute error was 0.59 ± 0.48 D (range, 0.10-2.25 D)., Conclusions: Regular methods (optical biometry and A-scan biometry) of measuring the axial length in cases with a detached macula proved to be variable and less accurate. The vector-A/B-scan offered good measurements of the actual axial length in the patients. This was reflected on more accurate postoperative refractive outcome., (Copyright © 2016 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the incidence of and analyze risk factors for suction loss during femtosecond laser-assisted small incision lenticule extraction in the management of myopia or myopic astigmatism., Setting: Roayah Vision Correction Center, Alexandria, Egypt., Design: Retrospective comparative case-control study., Methods: All eyes that had femtosecond laser-assisted small-incision lenticule extraction for the correction of myopia and myopic astigmatism performed between August 2010 and April 2014 were included. Eyes that developed suction loss were identified. Their characteristics, including demographic data (age and sex), eye laterality, manifest refraction, flat keratometry (K) reading, steep K reading, K astigmatism, optical zone, central corneal thickness, and corneal cap diameter and thickness, were compared with those in randomly selected control eyes to determine the risk factors for developing suction loss., Results: Of the 3376 eyes that had femtosecond laser-assisted small-incision lenticule extraction during the study, 70 (2.1%) developed loss of suction. The incidence decreased with surgical experience (5.06% in 2010, 3.59% in 2011, 3.41% in 2012, 2.32% in 2013, and 1.84% in 2014), suggesting a learning curve. A multivariate logistic regression model showed that eyes with a larger cap diameter were significantly more likely to develop suction loss (P = .023; odds ratio, 9.60)., Conclusions: Surgical experience significantly decreased the risk for suction loss during femtosecond laser-assisted small incision lenticule extraction for the correction of myopia or myopic astigmatism but did not eliminate it. A larger cap diameter significantly increased the risk for developing the suction loss., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2016 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the use of Bowman's layer (BL) vertical topographic thickness maps in diagnosing keratoconus (KC)., Design: Prospective, case control, interventional case series., Participants: A total of 42 eyes: 22 eyes of 15 normal subjects and 20 eyes of 15 patients with KC., Intervention: Bowman's layer 2-dimensional 9-mm vertical topographic thickness maps were created using custom-made ultra high-resolution optical coherence tomography., Main Outcome Measures: Bowman's layer average and minimum thicknesses of the inferior half of the cornea, Bowman's ectasia index (BEI; defined as BL minimum thickness of the inferior half of the cornea divided by BL average thickness of the superior half of the cornea multiplied by 100), BEI-Max (defined as BL minimum thickness of the inferior half of the cornea divided by BL maximum thickness of the superior half of the cornea multiplied by 100), keratometric astigmatism (Ast-K) of patients with KC, and average keratometric (Avg-K) readings., Results: In patients with KC, BL vertical thickness maps disclosed localized relative inferior thinning of the BL. Inferior BL average thickness (normal = 15±2, KC = 12±3 μm), inferior BL minimum thickness (normal = 13±2, KC = 7±3 μm), BEI (normal = 91±7, KC = 48±14), and BEI-Max (normal = 75±8; KC = 40±13) all showed highly significant differences in KC compared with normal subjects (P< 0.001). Receiver operating characteristic (ROC) curve analysis showed excellent predictive accuracy for BEI and BEI-Max with 100% sensitivity and specificity (area under the curve [AUC] of 1) with cutoff values of 80 and 60, respectively. The AUC of inferior BL average thickness and minimum thickness were 0.87 and 0.96 with a sensitivity of 80% and 93%, respectively, and a specificity of 93% and 93%, respectively. Inferior BL average thickness, inferior BL minimum thickness, BEI, and BEI-Max correlated highly to Ast-K (R = -0.72, -0.82, -0.84, and -0.82, respectively; P< 0.001) and to Avg-K (R = -0.62, P< 0.001; R = -0.59, P = 0.001; R = -0.60, P< 0.001; and R = -0.59, P = 0.001, respectively)., Conclusions: Bowman's layer vertical topographic thickness maps of patients with KC disclose characteristic localized relative inferior thinning. Inferior BL average thickness, inferior BL minimum thickness, BEI, and BEI-Max are qualitative and quantitative indices for the diagnosis of KC that accurately correlate with the severity of KC. In our pilot study, BEI and BEI-Max showed excellent accuracy, sensitivity, and specificity in the diagnosis of KC., (Copyright © 2014 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to develop and characterize a new contact lens-associated fungal keratitis rat model and to assess the ability of non-invasive spectral-domain optical coherence tomography (SD-OCT) to detect pathological changes in vivo in fungal keratitis., Methods: We used SD-OCT to image and measure the cornea of Sprague Dawley rats. Fusarium infection was initiated in the rat eye by fitting Fusarium solani-soaked contact lenses on the experimental eye, while the control animals received contact lenses soaked in sterile saline. The fungal infection was monitored with periodic slit-lamp examination and in vivo SD-OCT imaging of the rat eye, and confirmed by histology, counting of viable fungi in the infected rat cornea, and PCR with specific primers for Fusarium sp., Results: We imaged and measured the rat cornea with SD-OCT. Custom-made contact lenses were developed based on the OCT measurements. Incubation of contact lenses in a F. solani suspension resulted in biofilm formation. We induced contact lens-associated Fusarium keratitis by fitting the rat eyes for 4 h with the Fusarium-contaminated contact lenses. The SD-OCT images of the cornea correlated well with the slit-lamp and histopathological results and clearly defined clinical signs of infection, namely, increased corneal thickening, loss of epithelial continuity, hyper-reflective areas representing infiltrates, and endothelial plaques characteristic of fungal infection. Moreover, in three cases, SD-OCT detected the infection without any clear findings on slit-lamp examination. Infection was confirmed with histological fungal staining, PCR, and microbiological culture positivity., Conclusions: We developed a highly reproducible rat contact lens model and successfully induced contact lens-associated Fusarium keratitis in this model. The clinical presentation of contact lens-associated Fusarium keratitis in the rat model is similar to the human condition. SD-OCT is a valuable tool that non-invasively revealed characteristic signs of the fungal infection and could provide sensitive, objective monitoring in fungal keratitis.

Objective: To assess the use of an ultra-high-resolution (UHR) optical coherence tomography (OCT) as an adjuvant diagnostic tool in distinguishing ocular surface squamous neoplasia (OSSN) and pterygia., Design: Prospective case series., Participants: Thirty-four eyes of 34 patients with conjunctival lesions clinically suspicious for OSSN or pterygia., Methods: All patients were photographed and then imaged with a custom-built UHR OCT device. Subsequently, each patient underwent excisional or incisional biopsy with histopathologic diagnosis., Main Outcome Measures: Comparison of preoperative UHR OCT images and the corresponding histopathologic specimen; comparison of epithelial thickness between the 2 groups as measured by UHR OCT., Results: Preoperative UHR OCT images of OSSN demonstrated similarities to the histopathologic specimens. Both optical and pathologic specimens showed a thickened layer of epithelium, often with an abrupt transition from normal to neoplastic tissue. Likewise, preoperative UHR OCT images of patients with pterygia were well correlated with the histopathologic specimens. As opposed to OSSN, both UHR OCT and pathologic images of pterygia demonstrated a normal thin epithelium, with underlying thickening of the subepithelial mucosal layers. Differences in the measured epithelial thickness on UHR OCT between OSSN and pterygia were statistically significant, with an average epithelial thickness of 346 μm (standard deviation [SD], 167) in OSSN patients and 101 μm (SD, 22) in pterygium patients (P<0.001). By receiver operating characteristic curve, the sensitivity and specificity of UHR OCT for differentiating between OSSN and pterygia was found to be 94% and 100%, respectively, using a cutoff value of 142 μm., Conclusions: Ultra-high-resolution OCT may show promise as a noninvasive diagnostic tool to evaluate ocular surface lesions. In addition to a statistically significant difference in epithelial thickness, a significant degree of morphologic correlation with the histopathologic results demonstrates its potential in evaluating ocular surface squamous neoplasia and pterygia., (Copyright © 2012 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Developments in optical coherence tomography (OCT) have expanded its clinical applications for ultra-high resolution imaging of the anterior segment of the human eye. This review presents the latest advances for imaging the anterior segment of the eye using ultra-high resolution OCT (UHR-OCT). Unique applications of UHR-OCT technology in clinical and basic scientific laboratory research are discussed and a summary of the results is provided. The authors focused on the use of UHR-OCT for imaging of tear dynamics, contact lens interactions with the corneal surface, and in vivo histological diagnosis of disorders of the cornea, as well as the future direction in this field., (Copyright 2011, SLACK Incorporated.)