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AIM: To provide a new tool for the evaluation of altered ocular surfaces by using a combination of impression cytology, laser scanning confocal microscopy and advanced image analysis. METHODS: The expression of keratin 3 (K3), keratin 12 (K12), keratin 19 (K19) and mucin 1 (MUC1) was analysed by immunofluorescence on both histological sections of nine corneoscleral buttons from normal donors comprising conjunctiva, limbus and cornea and impression cytology specimens from six healthy normal subjects (12 eyes) and 12 patients with chronic ocular surface disorders. Levels of fluorescence expression of the different markers were quantified through quantitative fluorescence immunohistochemistry (Q-FIHC). RESULTS: Impression cytology specimens from normal and diseased ocular surfaces showed distinct expression patterns for K12 and MUC1. Healthy corneas expressed only K12 (but not MUC1), while conjunctivalised corneas from patients with limbal stem cell deficiency (LSCD) were characterised by the presence of MUC1 and the disappearance of K12. Similar clear-cut results were not seen with the K3/K19 markers, which showed lack of specificity and overlapping signals in cornea and conjunctiva impression cytology specimens. CONCLUSIONS: The ability of K12 and of the antibody against MUC1 to discriminate clearly between limbus/cornea and conjunctiva in impression cytology specimens could become a valuable diagnostic tool for ophthalmologists in order to evaluate alterations of the ocular surface and the grading of LSCD. [ABSTRACT FROM AUTHOR]

The exponential evolution of in vivo confocal microscopy (IVCM) has led to a significant enhancement in our knowledge of the living cornea in both its physiological and pathological states. Studies using white light and coherent light-based IVCM have enabled detailed quantitative analysis of sub-basal nerve parameters, and have also resulted in the elucidation of the two-dimensional architecture of the normal corneal sub-basal nerve plexus. However, accurate and repeatable methods for quantitative analysis of stromal nerves imaged by IVCM remain to be developed. The effect of corneal surgery on central corneal nerves has been well documented in many IVCM studies, and these studies provide an indication of the regenerative capacity of corneal nerves. IVCM has also clearly demonstrated the involvement of corneal nerves in diseases such as keratoconus, although it remains unclear whether these alterations are a cause of, or occur secondary to, the disease process. IVCM has also been proposed as non-invasive method of accurately diagnosing and assessing the progression of diabetic neuropathy, highlighting the potential application of this technique as an indicator of systemic disease. This review consolidates our knowledge of how IVCM has contributed significantly to our greater understanding of corneal nerves in the living human cornea in health and disease. [ABSTRACT FROM AUTHOR]

Aims: To quantify and establish baseline normative data for age-related differences in cellular and innervation density in the normal, healthy, human cornea using laser scanning in vivo confocal microscopy. Methods: Cross-sectional study of 85 normal subjects assessed via corneal topography and laser scanning in vivo confocal microscopy. Results: Mean age was 38 ± 16 years (range 18-87 years) and 60% of subjects were female. Anterior keratocyte density declined by 0.9% per year (r= -0.423, p<0.001), posterior keratocyte density declined by 0.3% per year (r=-0.250, p=0.021) and endothelial cell density declined by 0.5% per year (r= -0.615, p<0.001). Sub-basal nerve fibre density declined by 0.9% per year (r = -0.423, p<0.001). No association was observed between age and basal epithelial cell density, or between age and central corneal thickness, corneal astigmatism or horizontal corneal diameter (p>0.05). No association was observed between subject gender and corneal cell or innervation density. Conclusions: Using laser scanning in vivo confocal microscopy this study highlights a significant, and relatively linear, reduction in keratocyte and endothelial cell density with increasing subject age. Interestingly, corneal sub-basal nerve fibre density also significantly decreases with increasing age. In vivo laser scanning confocal microscopy provides a safe, non-invasive method for the establishment of normative data and assessment of alterations in human corneal microstructure following surgery or disease processes. [ABSTRACT FROM AUTHOR]

Background/aims: Constitutive expression of Fas ligand (CD95L) protects the eye against cell mediated immune responses by inducing apoptosis in infiltrating Fas bearing I cells. This study was designed to examine Fas ligand expression on acutely rejecting rat corneal grafts and to investigate the kinetics of induction of apoptosis in infiltrating leucocytes. Methods: Orthotopic penetrating corneal transplantation was performed beiween genetically disparate inbred rats. Fas ligand expression and the phenolype of infiltrating leucocytes were examined by immunohistochemistry. Apoptotic nuclei were visualised in sections of normal rat cornea, rejecting allografts, and time matched isografts by terminal deoxynucleotidyl transferase mediated dUTP biotin nick end labelling (TUNEL) and quantified by video image analysis. Staining with Hoechst dye 33258 was used to confirm the presence of apoptotic nuclei. Results: Fas ligand was expressed on corneal endothelial and epithelial cells during acute cornea1 graft relection. At all time points examined, including as early as the fifth postoperative day, the cells infiltrating both cornea I isog rafts and allog rafts were TUNEL positive. By the 15th postoperative day, over 90% of all nuclei, many of which were T cells, were apoptotic. Conclusion: Expression of Fas ligand is not downregulated on the cornea during allograft rejection and infiltrating leucocytes in both isografi's and allografts die rapidly in situ. Despite the death of the cells believed to be responsible for rejection, isografts survive indefinitely whereas allografts are irreparably damaged. [ABSTRACT FROM AUTHOR]

Background/aim An objective marker is needed to detect when corneal nerve abnormalities underlie neuropathic corneal pain (NCP), as symptoms often overlap with those of dry eye (DE). This study evaluated microneuroma (MN) frequency in various populations and investigated relationships between MN presence and DE clinical features in individuals with DE symptoms but without a history of refractive surgery, in order to eliminate refractive surgery as a potential confounder of nerve abnormalities. Methods This was a retrospective study that included individuals with and without DE symptoms who underwent a clinical evaluation for DE (symptom surveys and ocular surface evaluation) and in vivo confocal microscopy imaging. DE clinical features (including those suggestive of neuropathic pain) were compared based on MN presence using t-tests, X2 analyses and Pearson's correlation coefficients with 0.05 alpha level. Results MN frequencies did not significantly differ between individuals with DE symptoms (Dry Eye Questionnaire 5 score =6) and a history of refractive surgery (n=1/16, 6%), individuals with DE symptoms without a history of refractive surgery (n=26/119, 22%) and individuals without DE symptoms (n=2/18, 11%, p=0.22). Among individuals with DE symptoms without a history of refractive surgery, DE clinical features, including those indicative of NCP (burning sensation and sensitivity to light, wind and extreme temperatures), did not significantly differ based on MN presence (p>0.05). Conclusion MN frequencies did not significantly differ between individuals with and without DE symptoms. Their presence alone could not distinguish between DE subtypes, including features of NCP in our study population. [ABSTRACT FROM AUTHOR]

Aims To compare the shape of the anterior surface of the peripapillary sclera (PPS) between glaucoma and healthy subjects. Methods 88 primary open angle glaucoma (POAG), 98 primary angle closure glaucoma (PACG) and 372 age-matched and gender-matched healthy controls were recruited in this study. The optic nerve head of one randomly selected eye of each subject was imaged with spectral domain optical coherence tomography. The shape of the PPS was measured through an angle defined between a line parallel to the nasal anterior PPS boundary and one parallel to the temporal side. A negative value indicated that the PPS followed an inverted v-shaped configuration (peak pointing towards the vitreous), whereas a positive value indicated that it followed a v-shaped configuration. Results The mean PPS angle in normal controls (4.56±5.99°) was significantly smaller than that in POAG (6.60±6.37°, p=0.011) and PACG (7.90±6.87°, p<0.001). The v-shaped PPS was significantly associated with older age (ß=1.79, p<0.001), poorer best-corrected visual acuity (ß=3.31, p=0.047), central corneal thickness (ß=-0.28, p=0.001), peripapillary choroidal thickness (ß=-0.21, p<0.001) and presence of POAG (ß=1.94, p<0.009) and PACG (ß=2.96, p<0.001). The v-shaped configuration of the PPS significantly increased by 1.46° (p=0.001) in healthy controls for every 10-year increase in age, but not in glaucoma groups. Conclusions The v-shaped configuration of the PPS was more pronounced in glaucoma eyes than in healthy eyes. This posterior bowing of the PPS may have an impact on the biomechanical environment of the optic nerve head. [ABSTRACT FROM AUTHOR]

Purpose To validate estimation of Goldmann applanation tonometer (GAT) intraocular pressure (IOP) from scleral Schiotz IOP measurements using a regression model in normal eyes and eyes with type-1 keratoprostheses. Methods In this prospective cross-sectional study, cohort-1 had 253 normal anterior segment eyes, and cohort-2 had 100 eyes with type-1 keratoprostheses. Scleral Schiotz IOP measurements were used (in a non-linear model) to predict GAT IOP values for these eyes. Accuracy of predicted GAT IOP values was assessed using actual GAT IOP values for normal eyes, while for type-1 keratoprosthetic eyes, finger tension (FT) IOP assessments by an experienced glaucoma specialist were used. Primary outcome was agreement between FT IOP (assessed by an experienced glaucoma specialist) and predicted GAT IOP-derived clusters. Results The actual values of GAT IOP measurements in normal eyes (n=253; mean age ±SD, 51.35±15.56 years) ranged between 6 mm Hg and 62 mm Hg (mean=22±10.05 mm Hg). Estimated and actual GAT IOP values for normal eyes were very similar (mean difference=0.05 mm Hg with limits of agreement: -5.39 to 5.5 by Bland-Altman plot). Of the 100 eyes with type-1 keratoprostheses, 68 were classified as having digitally normal IOP, 28 as borderline and 4 as high. The agreement between classification by FT assessment and model-predicted GAT IOP values was substantial (Kappa=0.81, 95% CI 0.69 to 0.93). The accuracy of the model in assessing IOP was found to be 91% (95% CI 0.84 to 0.96). Conclusion Scleral Schiotz IOP values along with our predictive model can be an alternative objective method to FT IOP in assessing IOP in eyes with type-1 keratoprostheses. [ABSTRACT FROM AUTHOR]

Background/aims To evaluate the clinical outcomes of deep anterior lamellar keratoplasty performed by stromal peeling in eyes that have previously undergone penetrating keratoplasty (PK) for keratoconus. Methods Standardised stromal exchange included (1) 9 mm trephination of the recipient bed outside the old PK wound, (2) creation of a partial anterior corneal flap through lamellar dissection across the PK wound, (3) opening the stromal component of the old PK wound using blunt- tipped Vannas scissors until a plane of separation is reached, (4) severing the attachment of the PK surgical scar from the recipient host, (5) peeling the stroma of the PK graft from the underlying tissue and (6) suturing the donor anterior corneal lamella prepared by microkeratome dissection (450 µm depth, 9 mm diameter). Main outcome measures were success rate, best spectacle-corrected visual acuity (BSCVA) and endothelial cell loss (ECL). Results Of 21 post- PK eyes, stromal exchange succeeded in all but three cases, which were converted to a two-piece mushroom PK. After complete suture removal, mean BSCVA significantly improved from 0.95±0.39 logMAR preoperatively to 0.23±0.17 logMAR (p<0.001). Mean ECL was 5.4±23.2%. Double anterior chamber formation occurred in eight cases (44%), which all resolved after a single re- bubbling. Conclusion In post-PK eyes, stromal exchange can be performed by means of simple peeling without deep anterior lamellar dissection of the previous PK graft. Large-diameter (9 mm) repeat keratoplasty through stromal peeling yields excellent visual outcomes and minimal ECL. Double anterior chamber formation may complicate the postoperative course, but prompt intervention allows successful management. [ABSTRACT FROM AUTHOR]

Background/Aims We aimed to investigate the refractive changes in the posterior corneal surface in keratoconus (KC) associated with wearing spherical corneal rigid gas-permeable contact lenses (corneal GPs) with apical touch or three-point touch fitting and the effect of spherical corneal GPs on corneal biomechanics. Methods Patients with KC wearing corneal GPs every day without facing complications were enrolled as a single group. Corneal tomographic data were obtained using a three-dimensional anterior segment optical coherence tomography from the same eye with and without corneal GPs. Dioptric data from the central 3-mm zone of the posterior corneal surface were decomposed into spherical, regular astigmatism, asymmetry and higher-order irregularity components using Fourier harmonic analysis. The corneal biomechanical indices were deformation amplitude ratio within 2 mm, integrated radius, stiffness parameter at first applanation and linear Corvis Biomechanical Index. Correlations between the difference in Fourier indices with and without corneal GPs and the corneal biomechanical parameters were analysed. Results Thirty-two eyes of 32 patients with KC were enrolled. Spherical, regular astigmatism and asymmetry components were significantly smaller with corneal GP wear than without the wear (all p<0.001). All biomechanical indices were significantly correlated with the difference in the spherical components with and without corneal GPs. Conclusion Corneal biomechanical properties of KC were correlated with posterior corneal surface flattening induced by wearing corneal GPs on the spherical components. This effect is greater in biomechanically weaker corneas. [ABSTRACT FROM AUTHOR]

Background/Aim We compared the quality of human donor corneas stored in a cold storage medium containing 2.5 μg/ml of amphotericin B (Kerasave, AL.CHI.MI.A. S.R.L., Ponte San Nicolò, Italy) and Optisol-GS (Bausch & Lomb Inc., Bridgewater, NJ, USA) for 14 days. Methods Sixteen pairs of human donor corneas were collected in Eusol-C (AL.CHI.MI.A. S.R.L., Ponte San Nicolò, Italy). Next, all tissues underwent the first evaluation that included the assessments of central corneal thickness (CCT), endothelial cell density (ECD) measured using both trypan blue staining and specular microscopy, endothelial cell (EC) mortality and morphology, and corneal transparency within 24 hours from recovery (Day 1). Afterwards, one cornea of each pair was transferred into Kerasave or Optisol-GS. ECD and CCT were also assessed at Day 7, and all the metrics were evaluated again at the end of the storage period (Day 14). Results At all tested time points, no differences were found in the qualitative (corneal transparency, EC morphology) and quantitative metrics (ECD, CCT, EC mortality) between the Kerasave and the Optisol-GS storage groups. At Day 14, the corneas stored in Kerasave and Optisol-GS showed ECD of 2312±98 and 2335±128 cells/mm² (p=0.886), CCT of 717±17 and 697±19 μm (p=0.454) and central EC mortality of 0.54%±0.40% and 0.14%±0.14% (p=0.719), respectively. Conclusions The new amphotericin B−containing medium Kerasave was comparable to Optisol-GS in terms of preservation of corneal characteristics at 2–8°C for 14 days. [ABSTRACT FROM AUTHOR]

Purpose A randomised trial to test the hypothesis that human leucocyte antigen (HLA) class II matching reduces the risk of allograft rejection in high-risk penetrating keratoplasty (PK). Methods All transplants were matched for HLA class I antigens (=2 mismatches at the A and B loci) and corneas were allocated to patients by cohort minimisation to achieve 0, 1 or 2 HLA class II antigen mismatches. The corneal transplants (n=1133) were followed for 5 years. The primary outcome measure was time to first rejection episode. Results Cox regression analysis found no influence of HLA class II mismatching on risk of immunological rejection (HR 1.13; 95% CI 0.79 to 1.63; p=0.51). The risk of rejection in recipients older than 60 years was halved compared with recipients =40 years (HR 0.51; 95% CI 0.36 to 0.73; p=0.0003). Rejection was also more likely where cataract surgery had been performed after PK (HR 3.68; 95% CI 1.95 to 6.93; p<0.0001). In univariate analyses, preoperative factors including chronic glaucoma (p=0.02), vascularisation (p=0.01), inflammation (p=0.03), ocular surface disease (p=0.0007) and regrafts (p<0.001) all increased the risk of rejection. In the Cox model, however, none of these factors was individually significant but rejection was more likely where=2 preoperative risk factors were present (HR 2.11; 95% CI 1.26 to 3.47; p<0.003). Conclusions HLA class II matching, against a background of HLA class I matching, did not reduce the risk of allograft rejection. Younger recipient age, the presence of =2 preoperative risk factors and cataract surgery after PK all markedly increased the risk of allograft rejection. [ABSTRACT FROM AUTHOR]

Aims To compare the efficacy of compression sutures combined with intracameral air injection (CSAI) and thermokeratoplasty (TKP) for the management of acute corneal hydrops in keratoconus. Methods In this multi-centre randomised clinical trial, 20 patients with keratoconus (20 eyes) with acute corneal hydrops were enrolled and randomised to receive either CSAI or TKP and followed-up for a period of 6 months. Results There were no significant differences in patient demographics, severity of corneal hydrops and preoperative duration of symptoms between the two groups. In both groups, corneal oedema resolved within 2 weeks. The maximum thickness of the corneal scars following CSAI and TKP was not significantly different. Best spectacle-corrected visual acuity was superior in the CSAI group at 6-month follow-up (CSAI vs TKP, 0.52 (0.37, 0.85) vs 0.96 (0.70, 1.34) LogMAR, p=0.042). CSAI resulted in greater corneal endothelial cell density (CSAI vs TKP, 2677.8±326.7 vs 1955.3±298.1 cells/mm2, p<0.001) and flatter corneal curvature (CSAI vs TKP: mean keratometry value, 52.13±4.92 vs 63.51 ±5.83D, p<0.001; maximum keratometry value, 65.21 ±7.42 vs 77.13±12.01D, p=0.016) at the 6-month follow-up. Conclusion Although both CSAI and TKP resulted in resolution of acute corneal hydrops in keratoconus, CSAI was associated with superior clinical outcomes in this study. [ABSTRACT FROM AUTHOR]

An endoscope is a useful adjunct for the retinal surgeon to overcome haze of a compromised anterior segment. It allows early surgery in trauma and infections which translates to better results. Intraocular glass foreign body is a challenging condition, demanding highly skilled surgical expertise. We present endoscopic removal of an intraocular foreign glass body in a badly traumatised and infected eye. The surgical challenge was accentuated by an imaging misdiagnosis of ’twin metallic foreign bodies’. [ABSTRACT FROM AUTHOR]

Background/aims We developed a novel technology consisting of violet light (VL)-emitting glasses and defined the combination of VL irradiation and riboflavin treatment as KeraVio. Our goal was to evaluate the clinical results of KeraVio in patients with progressive corneal ectasia. Methods Eyes were exposed to VL (375 nm, irradiance 310 µW/cm2)-emitting glasses for 3 hours daily for 6 months, and a riboflavin solution was administered onto the corneal epithelium six times during each 3-hour VL irradiation. The primary end point was a change in the maximum keratometry (Kmax) value over 6 months compared with that over the 1 year before baseline. Results The efficacy of KeraVio was evaluated in 20 eyes with severe progression, and its safety was evaluated in all 40 eyes. The mean changes in Kmax over the 1 year before baseline and during the 6-month observation period were 6.03±3.41 dioptres (D) and -0.81±3.34 D, respectively (p=0.002). At 6 months, the Kmax value decreased by more than 2 D in 4 eyes (20%), remained within 2 D in 13 eyes (65%), and increased by 2 D or more in 3 eyes (15%). The corneal stromal demarcation line was identified in 16 eyes (80%), and its depth was 206.3±54.9 µm at 1 month. No significant decrease in endothelial cell density, lenticular opacity or transient corneal haze was noted. Conclusion Based on our 6-month results, daily treatment of progressive corneal ectasia with KeraVio can halt disease progression without any safety concerns. [ABSTRACT FROM AUTHOR]

Both eyes of 16 patients who had undergone unilateral penetrating keratoplasty were examined in this study. The mean corneal oxygen uptake rate in the centre of the graft was 3.88 (SD 0.55) mmHg/s and in the control eye was 4.29 (SD 0.62) mmHg/s. In the temporal host periphery the results for the grafted and control eyes were 4.52 (SD 0.54) mmHg/s and 4.26 (SD 0.52) mmHg/s respectively. The differences in the oxygen uptake rate between the centre of the graft cornea and the contralateral control eye and between the centre and periphery of the graft eye were statistically significant (p less than 0.01). The central corneal touch threshold of the graft eye showed good recovery in four patients, while the remaining 12 had no or minimal recovery. The central and temporal epithelial and corneal thicknesses of the graft and the control eyes were not significantly different. The central endothelial cell density was 1383 cells/mm2 in the graft and 3053 cells/mm2 in the control eye. As corneal oxygen uptake reflects changes in aerobic epithelial metabolism, it is possible that there is a link between loss of neural integrity of graft epithelium and lowered epithelial aerobic metabolism following penetrating keratoplasty. [ABSTRACT FROM PUBLISHER]

Three cases of primary band-shaped spheroidal degeneration of the cornea from two consanguineous families are reported. In all cases vision deteriorated slowly, the deterioration beginning in childhood. Photophobia in childhood was also a common symptom, and two patients suffered from intermittent painful sensations. The occupational and environmental histories had no bearing on the cases. Histochemical study of the yellow, oily appearing deposits suggested that this material has a complex composition, with staining characteristics of both protein and acid-fast lipid. [ABSTRACT FROM PUBLISHER]

Unusual giant nodules on the posterior surface of Descemet's membrane were observed in two out of over 400 corneae examined during routine histopathological reporting. Both of the patients, a 60-year-old man and a 26-year-old woman, had histories of corneal trauma. Neither was associated with chronic keratitis or corneal dystrophy. Light microscopy showed these nodules to be composed of material resembling Descemet's membrane. Histochemical and electron microscopical preparations identified oxytalan fibres within the outer layers of the nodules. These fibres are not a feature of the normal adult Descemet's membrane. The findings are discussed and compared with other nodular lesions of Descemet's membrane. [ABSTRACT FROM PUBLISHER]

Of 50 cases of strabismus having surgical operations designed on the basis of A scan ultrasonography 45 (90%) had less than 10 dioptres eso- or exodeviation two months postoperatively; 22 eso-, 25 exo-, and 3 vertical deviations were included in the series. A scan ultrasonography is done preoperatively to find the diameter and thus the circumference of the globe. This is used with the angle of deviation to estimate the amount of recession and/or resection necessary to correct the deviation. Attention is drawn to the oculomotor axis, which is 10-12 degrees divergent to the anteroposterior axis and around which the recti muscles act. The oculomotor equator is at right angles to this axis and is closer to the limbus medially than laterally, so that excessive recession of the medial rectus is more likely than of the lateral rectus. [ABSTRACT FROM PUBLISHER]

Ten eyes with progressing Mooren's or similar ulcers were treated by excising a 3 to 4 mm ring of limbal conjunctiva adjacent to the ulcer. Eight eyes healed within 3 weeks. Seven of these eyes have remained healed, while one eye has had repeated ulcers which healed when re-treated with conjunctival exicision. [ABSTRACT FROM PUBLISHER]

Background/Aims To analyse graft detachments prior to rebubbling, the influence of rebubbling on the postoperative outcome after Descemet membrane endothelial keratoplasty (DMEK) and the need for rebubbling on the contralateral eye. Methods In this retrospective cohort study, out of 1541 DMEKs, optical coherence tomography scans and clinical records of 499 eyes undergoing rebubbling after DMEK at the University Hospital of Cologne, Cologne, Germany, were examined. Main Outcome measures were (a) number, localisation and size of graft detachments; (b) influence of rebubbling/s on postoperative outcome after 12 months; and (c) rebubbling risk of the contralateral eye after DMEK. Results Mean number of detachment areas was 2.02 ±0.9. Mean lateral diameter of all detachments was 4534.76±1920.83 µm. Mean axial diameter was 382.53 ±282.02 µm. Detachments were equally distributed over all regions of the cornea. Best spectacle corrected visual acuity (BSCVA) after 12 months was 0.197±0.23 logarithm of the minimum angle of resolution, endothelial cell density (ECD) was 1575.21±397.71 cells/mm2 and mean central corneal thickness (CCT) was 566.37 ±68.11 µm. BSCVA, CCT, ECD or endothelial cell loss of all rebubbled patients were not influenced by the number of rebubblings or the time between DMEK and rebubbling. Of the rebubbled patients, which received a DMEK subsequently on the other eye, 193 (58.8%) also received a rebubbling, which was significantly higher, when compared to the overall rebubbling rate of 32.3% (p=0.000). Conclusions The overall number of rebubblings has no influence on the postoperative outcome after DMEK, if a rebubbling becomes necessary. Patients who received a rebubbling on one eye have an elevated risk for a rebubbling on the fellow eye. [ABSTRACT FROM AUTHOR]

Aim In patients who underwent multiple intraocular surgeries, we evaluated determinants of decreased corneal endothelial cell density (CECD) after sulcus placement following Ahmed and Baerveldt drainage device surgery. Methods We retrospectively reviewed consecutive patients with glaucoma who underwent sulcus placement with an Ahmed glaucoma valve or a Baerveldt glaucoma implant. We compared presurgical and postsurgical CECD and risk factors for decreased CECD. Results We examined 41 eyes of 41 patients. Postsurgical CECD measurements were assessed 2.0±1.0 times during a median follow-up period of 28 months. The mean intraocular pressure (IOP) decreased from 28.4 ±11.6 mmHg to 12.2±5.3 mmHg 24 months after the operation. At 24 months, CECD decreased 14.6±5.4% after considering the variability in the number and time points of CECD determinations. History of prior surgery and higher preoperative IOP were significantly associated with a trend for a time-dependent decrease in CECD. Conclusions Risk factors for decreased CECD after sulcus placement during Ahmed and Baerveldt drainage device surgery included the number of previous intraocular surgeries and higher presurgical IOP. [ABSTRACT FROM AUTHOR]

A woman in her late twenties presented with blurring of vision in the right eye for 6 years. Retinoscopy showed a scissoring reflex in the right eye with best spectacle-corrected visual acuity of 20/40 in the right eye and 20/20 in the left eye. Slit-lamp examination of the right eye showed superior crescentic thinning with conjunctivalisation and lipid deposition while the left eye was normal. Corneal topography of the right eye showed inverse crab-claw pattern suggestive of Terrien’s marginal degeneration (TMD) and the left eye showed inferior steepening with posterior elevation and thinning suggestive of keratoconus-like topography. This case shows that evaluation of the other apparently normal eye with 20/20 vision might show changes on topography in cases of unilateral TMD and needs follow-up to assess any further progression. A woman in her late twenties presented with blurring of vision in the right eye for 6 years. Retinoscopy showed a scissoring reflex in the right eye with best spectacle-corrected visual acuity of 20/40 in the right eye and 20/20 in the left eye. Slit-lamp examination of the right eye showed superior crescentic thinning with conjunctivalisation and lipid deposition while the left eye was normal. Corneal topography of the right eye showed inverse crab-claw pattern suggestive of Terrien’s marginal degeneration (TMD) and the left eye showed inferior steepening with posterior elevation and thinning suggestive of keratoconus-like topography. This case shows that evaluation of the other apparently normal eye with 20/20 vision might show changes on topography in cases of unilateral TMD and needs follow-up to assess any further progression. [ABSTRACT FROM AUTHOR]

Several refractive techniques are available for the treatment of hyperopia. Conductive keratoplasty (CK) is a safe and non-ablative procedure suitable for the treatment of low hyperopia and presbyopia. Due to the high rate of regression, it is not a commonly used technique. There is minimal literature about the use of refractive procedures for the treatment of hyperopic regression after CK. We report a case of a 49-year-old man who had undergone bilateral CK 15 years before for the correction of his hyperopia. He experienced a regression, with sph +2.75 cyl −0.50(20) in the right eye and sph +2.50 cyl −0.75(170) in the left eye. Transepithelial photorefractive keratectomy (tPRK) was performed with Schwind Amaris 750 s. After 12 months, his best-corrected visual acuity was 20/20, with −0.25 sph in both eyes. To the best of our knowledge, this is the first reported case of tPRK performed after CK. [ABSTRACT FROM AUTHOR]

Purpose To study the longitudinal effect of anterior chamber inflammation on the corneal endothelium in children. Methods In this prospective longitudinal observational study, children (aged <18 years) with anterior chamber inflammation and those at risk of developing uveitis due to juvenile idiopathic arthritis (JIA) were included. Changes in central endothelial cell density (ECD) and morphological variables were determined by non-contact specular microscopy, and their correlations with uveitis activity and surgical interventions were analysed. Results Ninety-nine eyes of 99 children (mean age (±SD): 10.0±4.1 years) with a history of anterior chamber inflammation were recruited. Mean follow-up was 12.3±3.5 months. Eleven children, who were under surveillance but had not developed JIA-associated uveitis were included as controls. While there were no significant differences in mean ECD between controls and subjects without prior surgery (group 1) at all time points, those who had prior ophthalmic surgery (group 2) displayed significantly lower ECD than the controls at recruitment (p=0.002) and at follow-up (p=0.004). However, longitudinal ECD assessments did not show significant changes in either group (group 1, p=0.07, group 2, p=0.54). On regression analysis, once the patient's age was adjusted for, only the occurrence of intraocular procedures during the study (r=0.43, adjusted p=0.03) was associated with a significant annual rate of ECD loss. Conclusion During the study period, longitudinal ECD changes among children with uveitis were associated with intraocular surgery for uveitis-related complications but not uveitis activity. By reducing the need for surgical intervention, the corneal endothelium in these children may be preserved. [ABSTRACT FROM AUTHOR]

Corneal endothelial diseases are leading indications for corneal transplantations. With significant advancement in medical science and surgical techniques, corneal transplant surgeries are now increasingly effective at restoring vision in patients with corneal diseases. In the last 15 years, the introduction of endothelial keratoplasty (EK) procedures, where diseased corneal endothelium (CE) are selectively replaced, has significantly transformed the field of corneal transplantation. Compared to traditional penetrating keratoplasty, EK procedures, namely Descemet's stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK), offer faster visual recovery, lower immunological rejection rates, and improved graft survival. Although these modern techniques can achieve high success, there are fundamental impediments to conventional transplantations. A lack of suitable donor corneas worldwide restricts the number of transplants that can be performed. Other barriers include the need for specialized expertise, high cost, and risks of graft rejection or failure. Research is underway to develop alternative treatments for corneal endothelial diseases, which are less dependent on the availability of allogeneic tissues - regenerative medicine and cell-based therapies. In this review, an overview of past and present transplantation procedures used to treat corneal endothelial diseases are described. Potential novel therapies that may be translated into clinical practice will also be presented. [ABSTRACT FROM AUTHOR]

Purposes To evaluate the effect of YAG laser peripheral iridotomy (LPI) on corneal endothelial cell density (ECD) and morphology in primary angle closure suspects (PACS) over 72 months. Methods The Zhongshan Angle Closure Prevention Trial is a single-centre randomised controlled trial. Subjects with bilateral PACS received YAG LPI prophylactic treatment in one eye randomly, while the fellow eye served as control. Central corneal ECD and morphology were assessed using non-contact specular microscopy (SP-2000P, Topcon) at baseline, 6, 18, 36, 54 and 72 months postoperatively. Mixed model analysis was conducted to compare the difference between treated and fellow eyes. Results A total of 875 participants were included, with a mean age of 59.3±5.0 years and 83.5% female. The ECD declined significantly (p<0.001) over time in both treated and fellow eyes, but the treated eyes showed more progressive cell loss with increasing time (p<0.001). The difference in ECD loss between LPI-treated and fellow eyes was not significant at each follow-up until 72 months (4.9% in LPI eyes vs 4.2% in non-LPI eyes, p=0.003). Mean cell areas increased significantly over time in both treated and fellow eyes (p<0.001), but no longitudinal change was observed for hexagonality. In LPI-treated eyes, no significant correlation was found between age, gender, ocular biometrics, intraocular pressure and laser settings with endothelium change, except for time effect (p<0.01). Conclusion ECD decreases over time primarily due to ageing effect. YAG LPI does not appear to cause clinically significant corneal endothelial damage over 72 months after treatment. [ABSTRACT FROM AUTHOR]

A female patient in the age group 55–60 years presented to us with blurring of vision in both eyes. On slit-lamp examination, numerous circular to oval flecklike discrete blue opacities at the level of deep corneal stroma and Descemet’s membrane was observed. These lesions were predominantly seen in the central two-thirds of the cornea. Considering the age of presentation and the clinical features, the probable diagnosis of ’deep blue dot corneal degeneration’ was made. [ABSTRACT FROM AUTHOR]

A man with a history of blind eye due to trauma 22 years earlier consulted at 53 years of age with a large conjunctival neoplastic lesion, compromising almost the entire temporal limbus, and reaching a size of approximately 16mm on its larger diameter, in the conjunctiva. Management was started with topical and subconjunctival chemotherapy (interferon alpha-2b) in order to perform immunoreduction, but a dramatic response with total disappearance of the lesion was observed. In the follow-up time period of more than 7 years, there were no signs of recurrence. [ABSTRACT FROM AUTHOR]

Aims: To describe the in vivo confocal microscopy (IVCM) features of human limbal nerve corpuscles (LNCs) and correlate these with the histological features. Methods: We examined 40 eyes of 29 healthy living subjects (17 female, 12 male; mean age=47.6) by IVCM. Four limbal quadrants were scanned through all epithelial layers and stroma to identify the LNCs and associated nerves. Ten fresh normal human corneoscleral discs from five deceased patients with a mean age of 67 years and 17 eye-bank corneoscleral rims with a mean age of 57.6 years were stained as whole mounts by the acetylcholinesterase (AChE) method to demonstrate LNCs and corneal nerves. Stained tissue was scanned in multiple layers with the NanoZoomer digital pathology microscope. The in vivo results were correlated to the histological findings. Results: On IVCM, LNCs were identified in 65% of the eyes studied and were mainly (84%) located in the inferior or superior limbal regions. They appeared either as bright (hyper-reflective) round or oval single structures within the hyporeflective, relatively acellular fibrous core of the palisades or were clustered in groups, often located anterior to the palisades of Vogt. They measured 36 µm in largest diameter (range 20-56 µm). The in vivo features were consistent with the histology, which showed LNCs as strongly AChE positive round or oval structures. Conclusion: The strong correlation with histology will enable use of IVCM to study LNCs in normal and disease conditions. [ABSTRACT FROM AUTHOR]

Background: To review the changes in intraocular pressure (IOP) following topical hypotensive medications washout in patients with primary open angle glaucoma (POAG), ocular hypertension (OHT) and uveitic glaucoma (UG)/OHT. Methods: The study included 120 patients with POAG, OHT and UG recruited from prospective clinical trials between February 2013 and July 2017. We excluded 20 eyes with IOP of ≤21 mm Hg, 11 eyes with previous incisional surgery and 17 eyes with incomplete data. UG eyes with active inflammation and on steroid treatment were excluded. Participants underwent a 1-month washout period from topical ocular hypotensive medications before IOP phasing. Comparisons were made between pre/post-washout IOP, and highest-recorded (peak) and post-washout IOP. Results: A total of 110 eyes with POAG, 33 eyes with OHT and 43 eyes with UG were included for analysis. The mean pre-washout IOP was 18.1±3.3 mm Hg in POAG, 18.8±3.3 mm Hg in OHT and 17.9±8.8 mm Hg in UG; the mean post-washout IOP was 26.6±4.8 mm Hg, 26.4±3.9 mm Hg, 23.1±10.1 mm Hg in POAG, OHT and UG, respectively. The mean increase in IOP after washout was significantly lower in UG compared with POAG and OHT eyes (p=0.01). The percentage of eyes with post-washout IOP <22 mm Hg was 12.7% in POAG, 6.1% in OHT and 51.2% in UG. Conclusion: Active inflammation and steroid treatment contributes to elevated IOP in uveitis. Therefore, IOP may revert to normal once inflammation subsides. We recommend ocular hypotensive treatment washout to be considered in UG eyes that have IOP under control in the absence of recurrence of uveitis. [ABSTRACT FROM AUTHOR]

Aims: To evaluate bilateral morphometric changes of corneal sub-basal nerve plexus (CSNP) occurring after unilateral cataract surgery by in vivo confocal microscopy (IVCM) images analysed with automated software. Methods: IVCM was performed before (V0) and 1 month after surgery (V1) in both operated eyes (OEs) and unoperated eyes (UEs) of 30 patients. Thirty age and sex-matched subjects acted as controls. Corneal nerve fibre density (CNFD), corneal nerve branch density (CNBD), corneal nerve fibre length (CNFL), corneal nerve total branch density (CTBD), corneal nerve fibre area (CNFA), corneal nerve fibre width, corneal nerve fractal dimension (CNFrD) and dendritic cells density were calculated. Results: Mean CNFD, CNBD, CNFL, CTBD, CNFA and CNFrD significantly decreased at V1 versus V0 in both eyes (respectively, 15.35±7.00 vs 21.21±6.56 n/mm² in OEs and 20.11±6.69 vs 23.20±7.26 in UEs; 13.57±12.16 vs 26.79±16.91 n/mm² in OEs and 24.28±14.88 vs 29.76±15.25 in UEs; 9.67±3.44 mm/mm² vs 13.49±3.42 in OEs and 12.53±3.60 vs 14.02±3.82 in UEs; 22.81±18.77 vs 42.25±24.64 n/mm² in OEs and 38.06±20.52 vs 43.93±22.27 in UEs; 0.0040±0.0021 vs 0.0058±0.0020 mm²/mm² in OEs and 0.0049±0.0016 vs 0.0057±0.0019 in UEs; 1.418±0.058 vs 1.470±0.037 in OEs and 1.466±0.040 vs 1.477±0.036 in UEs; always p<0.049). Conclusion: Patients undergoing cataract surgery exhibit bilateral alterations of CSNP. This finding could have broad implications in the setting of sequential cataract surgery. [ABSTRACT FROM AUTHOR]

Purpose To describe the indications and prognosis for keratoplasty in eyes with severe visual impairment and blindness due to corneal diseases in India. Methods This hospital-based cross-sectional study included 1 057 215 new patients presenting to a multitier ophthalmology network from 2016 to 2018. All patients with a central corneal pathology and best corrected visual acuity of less than 20/200 in the affected eye(s) were identified as cases and grouped according to laterality. The main outcome measure was the prognosis for keratoplasty, based on the surgical indication. Results A total of 28 824 (2.73%) patients were identified with severe visual impairment or blindness due to corneal diseases; of which, 22 582 (78.3%) had unilateral and 6242 (21.7%) had bilateral affliction. Overall, 85% of the corneal pathologies were due to avoidable causes, which accounted for 97% and 63% of the unilateral and bilateral cases, respectively (p<0.0001). The most common aetiologies were microbial keratitis (27.2%) and corneal opacification (25.5%) in unilateral cases; and corneal opacification (38.2%) and ectasias (14.5%) in bilateral cases. Overall, 60.1% of affected eyes carried a fair to poor prognosis for keratoplasty. However, while in unilateral cases only 29.9% of eyes carried good to excellent prognosis for keratoplasty, in bilateral cases, 58% of eyes carried good to excellent prognosis for keratoplasty (p<0.0001). Conclusions The indications and prognosis for keratoplasty varied greatly based on whether the affliction was unilateral or bilateral. Most of the eyes affected by corneal visual impairment or blindness, however, carried an unfavourable prognosis for keratoplasty. [ABSTRACT FROM AUTHOR]

A 6-year-old female child presented with severe acute ocular chemical burn in the right eye 2 days after injury with cement. She underwent removal of all foreign bodies from the ocular surface and amniotic membrane transplantation. Three months later, she developed unilateral total limbal stem cell deficiency (LSCD) with symblepharon in two quadrants. Three months after the acute injury, the patient underwent autologous simple limbal epithelial transplant in the right eye with one-clock hour of limbus harvested from the left eye. At the same sitting, she underwent symblepharon release in two quadrants of the right eye with conjunctival autograft harvested from the left eye followed by conjunctival graft suturing to the areas of bare sclera in the right eye. One year after surgery, the patient’s visual acuity improved from counting fingers close to face preoperatively to 20/50 (uncorrected) with no recurrence of LSCD or symblepharon. [ABSTRACT FROM AUTHOR]

Purpose Severe dry eye is widely prevalent yet difficult to treat. This study aims to evaluate for improvement in epithelial status and the risk factors for lack of improvement in a cohort of patients in Singapore with severe dry eye. Methods We retrospectively identified 1712 patients with severe dry eye (≥grade 3 Delphi) in at least one eye, referred to a tertiary centre dry eye clinic from 2006 to 2017. We included patients with central corneal staining grade of ≥2 at referral and minimum follow-up duration of 6 months (n=407). An epithelial staining grade of <2 at the last visit was considered a significantly improved outcome. Results The mean follow-up duration was 4.0±2.4 years, with 88.0% (358/407) of patients achieving significant improvement. Various treatment modalities including topical corticosteroids (32.4%), cyclosporine (52.8%) and punctal plugs (24.1%) were used. Risk factors for non-improvement of staining grade include autoimmune disease (OR 3.2, 95% CI: 1.7 to 6.1), rheumatoid arthritis (RA) (OR 3.4 (1.8 to 6.6)), graft-versus- host disease (GVHD) (OR 3.4 (1.0 to 11.7)), reduced baseline Schirmer's test (OR 2.1 (1.2 to 3.9)) and reduced tear break up time (OR 2.0 (1.0 to 3.8)). On multivariate analyses, RA and GVHD were still significant risk factors. Gender, age and meibum viscosity were not significantly associated with epithelial staining grade improvement. Conclusions Overall, a high rate of corneal epithelial improvement was achieved. Nevertheless, there is an unmet need for more effective measures to reduce epitheliopathy in severe dry eye, especially in patients with systemic immune-mediated disease. [ABSTRACT FROM AUTHOR]

Primary corneal neoplasia (PCN) is a rare cancerous lesion of cornea usually encountered in elderly. The clinical symptoms are generally non-specific, with ocular irritation, redness, cosmetic disfigurement and varying degrees of visual disturbances depending on visual axis involvement. Corneal neoplasia is usually associated with surrounding conjunctival lesions and incidentally detected PCN is rarely encountered in clinical practice. Presently, we report a case of isolated unilateral PCN diagnosed incidentally in an elderly man presenting with cataract. In vivo confocal microscopy aided in its diagnosis after impression cytology was repeatedly negative. Cataract surgery was deferred and the patient was administered three cycles of mitomycin C 0.04% 4 times/day. The tumour margins receded as evident on clinical examination and on anterior segment optical coherence tomography. We discuss the role of various corneal imaging modalities in diagnosis and management of PCN besides highlighting importance of comprehensive slit-lamp examination in patients planned for cataract surgery. [ABSTRACT FROM AUTHOR]

Aims To report the clinical manifestations, ultrastructure and evaluate the efficacy of therapeutic lamellarkeratectomy (TLK) and penetrating keratoplasty (PK) for microsporidial stromal keratitis (MSK). Methods Fourteen MSK cases between 2009 and 2018 were recruited. Each patient’s clinical presentation, light microscopy, histopathology, PCR and electron microscopy (EM) of corneal samples were reviewed. Results The patients were 70.0±4.7 years old (average follow-up, 4.5 years). Time from symptoms to presentation was 10.6±13.0 weeks. The corneal manifestations were highly variable. Corneal scrapings revealed Gram stain positivity in 12 cases (85.7%) and modified Ziehl-Neelsen stain positivity in 9 (64.3%). Histopathology revealed spores in all specimens, while sequencing of small subunit rRNA-based PCR products identified Vittaforma corneae in 82% of patients. EM demonstrated various forms of microsporidial sporoplasm in corneal keratocytes. All patients were treated with topical antimicrobial agents or combined with oral antiparasitic medications for >3 weeks. As all patients were refractory to medical therapy, they ultimately underwent surgical intervention (TLK in 7, PK in 6 and 1 received TLK first, followed by PK). Postoperatively, the infection was resolved in 78.6% of the patients. Nevertheless, a high recurrence rate (21.4%) was noted during 3-year follow-up, with only two patients retained a final visual acuity ≥20/100. Conclusion MSK usually presents with a non-specific corneal infiltration refractory to antimicrobial therapy. The diagnosis relies on light microscopic examinations on corneal scrapings and histopathological analyses. Surgical intervention is warranted by limiting the infection; however, it was associated with an overall poor outcome. [ABSTRACT FROM AUTHOR]

Purpose To investigate the long-term safety and efficacy of accelerated transepithelial corneal cross-linking (ATE-CXL) in children with progressive keratoconus. Methods Fifty-three eyes of 41 paediatric patients (34 boys, 7 girls; mean age 14.81±1.96 years) undergoing ATE-CXL were enrolled in the study. Corrected distance visual acuity (CDVA) and manifest refraction were assessed preoperatively and 36 months postoperatively. Corneal keratometry, corneal thickness and posterior elevation were measured using Pentacam preoperatively and 1, 6, 12 and 36 months postoperatively. Pachymetry and epithelial thicknesses were measured using optical coherence tomography preoperatively and 6, 12, and 36 months postoperatively. Results Thirty-six months postoperatively, CDVA improved from 0.32±0.28 to 0.26±0.25 in logarithm of the minimum angle resolution (p=0.025). Maximum keratometry was 58.73±9.70 D preoperatively and 59.20 ±10.24, 58.28±9.33, 57.88±9.99 and 58.98±10.79 D at 1, 6, 12 and 36 months postoperatively throughout the 36-month follow-up period (p>0.05). Similarly, corneal central thickness, which was 492.42±33.83 μm postoperatively, also remained stable during the 36- month follow-up (p>0.05). Both posterior central elevation and posterior highest elevation were stable at 12 months after ATE-CXL (p>0.05), but increased at 36 months postprocedure (p<0.05). Corneal pachymetry and epithelial thicknesses remained stable throughout the follow-up period (p>0.05). Conclusions ATE-CXL is a safe and effective treatment in paediatric progressive keratoconus patients, leading to stable keratometry and corneal thickness throughout the 36-month follow-up. [ABSTRACT FROM AUTHOR]

Purpose To determine the relationships between lens thickness (LT), lens density and anterior segment parameters in patients with mild to moderate cataracts. Setting Oftalmosalud Instituto de Ojos, Lima, Perú. Design Prospective, single-centre, cross-sectional study. Methods 169 eyes with age-related mild to moderate cataracts had lens density assessed using the Lens Opacification Classification System III, the built-in Pentacam HR Nucleus Staging software and ImageJ software. LT and axial length (AL) were measured with the IOLMaster 700, and angle parameters were measured using anterior segment optical coherence tomography. Pearson correlation coefficients and Kruskal-Wallis tests were used for statistical analyses. Results Nuclear colour score was the only clinical parameter with a weak significant correlation with LT (r=0.24, p=0.003) after accounting for age, AL, gender and anterior chamber depth (ACD). The maximum value of average lens density and the mean nuclear density were significantly correlated with LT (r=0.24, p=0.003 and -0.17, p=0.03, respectively) after controlling for the same factors. Central LT greater than 4.48 mm was present in 54.5% of the eyes with a nuclear opalescence grade 1. Conclusions LT is independent of lens density in mild to moderate cataracts after accounting for age, AL, ACD and gender contrary to previous studies. [ABSTRACT FROM AUTHOR]

This paper describes a case of cardiac arrest during femtosecond laser enabled penetrating keratoplasty (FLEK) in a young, healthy patient with no known cardiac risk factors and discusses the risk of cardiac arrest during intraocular surgery. A healthy 22-year-old man who underwent repeat FLEK under general anaesthesia developed bradycardia and subsequent cardiac arrest while open sky during surgery. After resuscitation and completion of the transplant surgery, the patient recovered and the graft has survived with excellent uncorrected visual acuity over 1 year after surgery. Understanding the risks of cardiac arrest and death during intraocular surgery is imperative to discussing the systemic risks of surgery during the preoperative informed consent. [ABSTRACT FROM AUTHOR]

Aim To study relationships between reported risk factors for glaucoma and neuroretinal rim area in normal eyes. Methods The Kumejima study participants, 3762 of the 4632 eligible Kumejima residents 40 years and older, underwent a detailed ocular examination including sequential disc stereo photography. In a randomly chosen eye of a subject whose both eyes met the inclusion criteria, fundus photographs of 2474 ophthalmologically normal eyes of the 2474 subjects were analysed by computer-assisted planimetry to measure the disc, rim and β-peripapillary atrophy (PPA) areas. The rim was divided into the superior and inferior halves by a line connecting the fovea and disc centre. Results The disc, superior and inferior halves rim and β-PPA areas averaged 2.53±0.50 (SD), 0.82±0.15, 0.84 ±0.16 and 0.45±0.66 mm². After adjustment for other systemic and ocular factors including age, disc and β-PPA areas, disc–fovea distance (p=0.013, 0.016) correlated positively and intraocular pressure (IOP) (p=0.004, 0.006) and axial length (AL) (p<0.000, 0.004) negatively with the superior and inferior halves rim area, respectively; central corneal thickness (CCT) (p=0.008) and mean blood pressure (mBP) (p=0.020) correlated positively and male gender (p=0.012) negatively only with the superior half rims. Conclusions Besides previously reported risk factors for glaucoma such as age or IOP, thinner CCT, lower mBP and male gender were newly found to significantly correlate with smaller rim area only in the superior half disc, and a greater disc–fovea distance with greater superior and inferior half rim areas in normal adult eyes. [ABSTRACT FROM AUTHOR]

Aims The goal was to find if changes in Fabry keratopathy were clinically observable over time. Also observed were variations of Fabry keratopathy, supplemental features, unique presentations and differences between keratopathies of right and left corneas and the same family and genotype. Methods Biomicroscopic images of Fabry keratopathy in 10 persons with classic Fabry disease, 5 men and 5 women, were captured over an 18-month period. The keratopathies were categorised and scrutinised for changes over time, and differences between corneas of the same individual, family and genotype. Results Fabry keratopathy ranged from mild change to marked change over 18 months. There was a great variety of whorl patterns. A few keratopathies were amorphous without vortices and many vortices were supplemented with amorphous features. All keratopathies were accompanied by diffuse epithelial haze. There was a range from negligible difference to marked difference between right and left eyes of the same individuals with similarities appearing as imprecise mirror images of each other. In some corneas, prominent vertical streams from the superior limbus integrated into the primary keratopathy. Comparisons between persons with the same family and genotype were obscured by gender and differences between right and left eyes. Conclusions Practitioners should be better able to detect Fabry disease having a fuller understanding of the variety of presentations of the dynamic, pathognomonic Fabry keratopathy. Routes of continuous centripetal renewal of corneal epithelium are spatially unique to each eye, in some cases subsidised by direct contribution of basal cells streamed from the superior limbus. [ABSTRACT FROM AUTHOR]

Background/aims In a previous genome-wide association study of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) patients we reported the association between SJS/TEN and the prostaglandin E receptor 3 (PTGER3) gene, and that its protein PGE2 receptor 3 (EP3) was markedly downregulated in the conjunctival epithelium of SJS/TEN patients. Here we examined EP3 expression of the eyelid epidermis in SJS/TEN patients with severe ocular complications and investigated the function of EP3. Methods For the immunohistochemical study, we obtained eyelid samples from five SJS/TEN patients and five patients without SJS/TEN (control subjects) who were undergoing surgery to treat trichiasis, and investigated the expression of EP3 protein in the epidermis of those samples. To investigate the EP3 function in the human epidermal keratinocytes, we performed ELISA and quantitative reverse transcription polymerase chain reaction, since it is reported that PGE2 suppresses cytokine production via EP3 in human conjunctival epithelium. results The results of the immunohistochemical study revealed that EP3 expression in the eyelid epidermis of the SJS/TEN patients was the same as that in the controls. PGE2 and a selective EP3 agonist suppressed cytokine production and expression induced by polyinosine-polycytidylic acid stimulation, such as chemokine ligand 5 and chemokine motif ligand 10. Conclusion Our findings revealed that in chronic-phase SJS/TEN, EP3 protein was expressed in the eyelid epidermis and was not downregulated, unlike in conjunctival epithelium, and that PGE2 could suppress cytokine production via EP3 in human epidermal keratinocytes. Thus, EP3 expression in the epidermis might contribute to a silencing of skin inflammation in chronic-phase SJS/TEN. [ABSTRACT FROM AUTHOR]

Purpose To assess changes in the position of lamina cribrosa pores (LCPs) induced by acute intraocular pressure (IOP) elevation.///Methods A prospective observational study. Acute angle-closure suspects who underwent the 2-hour dark room prone provocative test (DRPPT) were included. At baseline and within 5 min after the DRPPT end, tonometry, fundus photography and optical coherence tomography were performed. Optic disc photos taken before and after the DRPPT were aligned and moving distance of each visible LCP was measured (LCPMD).///Results 38 eyes from 27 participants (age: 52.5±10.8 years) were included. The IOP rose from 16.7±3.2 mm Hg at baseline to 23.9±4.3 mm Hg at the DRPPT end. The mean lateral LCPMD was 28.1±14.6 µm (range: 5.0- 77.2 µm), which increased with higher IOP rise (p=0.01) and deeper optic cup (p=0.02) in multivariate analysis. The intralamina range and SD of the LCPMD increased with younger age (p=0.01 and p=0.02, respectively) and with wider optic cup (p=0.01 and p=0.02, respectively). The LCP movements were headed to the superior direction in 12 (33%) eyes, inferior direction in 10 (28%) eyes, temporal direction in 9 (25%) eyes, and nasal direction in 5 (14%) eyes.///Conclusions IOP rise is associated with LCP movements in the frontal plane, which are more pronounced with higher IOP rise and deeper optic cup. The intralamina variability in the IOP rise-associated LCPMD increased with younger age and wider optic cup. IOP variation-associated lateral LCP movements may be of interest to elucidate glaucomatous optic nerve damage. [ABSTRACT FROM AUTHOR]

Aims To describe clinical and in vivo confocal microscopy (IVCM) features of neuropathic corneal pain (NCP) without clinically visible signs.///Methods Prospective, observational study of 27 eyes of 14 patients who had continuous severe ocular pain for one or more years, with minimal or no ocular surface signs and were non-responsive to topical lubricants, steroids and/or ciclosporin. All patients were evaluated using Ocular Surface Disease Index, Oxford grading scale, Schirmer test 1, Cochet Bonnet esthesiometry and response to topical anaesthesia. Central and paracentral regions of the cornea of patients and seven healthy controls were studied by IVCM. Corneal epithelial thickness and sub-basal nerve density were measured in patients and controls.///Results Four patients responded to topical anaesthesia (responsive group (RG)), indicating peripheral NCP while 10 patients did not show any improvement (non-responsive group (NRG)), indicating central NCP. Schirmer-1 test was within normal limits in the RG but significantly greater in the NRG (p<0.001). None of the other clinical parameters nor corneal epithelial thickness were statistically significantly different. The sub-basal nerve density was significantly reduced (p<0.008) in patients compared with controls. Stroma of all patients demonstrated activated keratocytes and spindle, lateral and stump microneuromas. There was a statistically significant greater number of microneuromas (p<0.0001) and activated keratocytes in RG compared with NRG.///Conclusion NCP without visible clinical signs does not represent typical dry eye disease. Distinct signs demonstrated on IVCM suggest that peripheral NCP, which responds to topical anaesthesia, and central NCP, which does not, are separate entities. [ABSTRACT FROM AUTHOR]

Purpose To compare the diagnostic power of slit- lamp examination with the in vivo corneal confocal microscopy (IVCM) as the gold standard in assessing the presence of corneal epithelial deposits in patients with Fabry disease (FD). Methods Fourteen patients with FD (4 males, 10 females; mean age, 46.8 years) and eight healthy controls (4 males, 4 females; mean age, 36.75 years) were included. All subjects underwent slit- lamp examination and IVCM of both central and peripheral corneal quadrants with the Heidelberg Retina Tomograph- III in combination with the Rostock Cornea Module. results In patients with FD, 9 of 28 eyes (32%) showed the presence of cornea verticillata at the slit- lamp examination and 25 eyes (89%) showed the presence of epithelial hyper- reflective deposits at the IVCM. Of the 19 eyes negative at the slit- lamp examination, 16 eyes showed the presence of epithelial deposits at the IVCM. Compared with controls, patients with FD had a significantly reduced number, density and length of nerve fibres at the level of corneal sub- basal nerve plexus, but a significantly higher grade of fibres tortuosity. Conclusions The slit- lamp examination has a limited diagnostic power in the detection of epithelial deposits in patients with FD when compared with the IVCM. In fact, the slit- lamp examination suffers from a high number of false negative results and, consequently, from a low negative predictive value (16%). IVCM allows the detection of corneal microstructural changes in patients with FD and may represent a reliable tool for the early diagnosis and follow- up of the disease. [ABSTRACT FROM AUTHOR]

background/aims To investigate (1) the effect of reading or writing on a smartphone in terms of intraocular pressure (IOP) change in eyes with glaucoma, and (2) to determine whether previous glaucoma filtering surgery can affect IOP fluctuation during such work. Methods Forty eyes of 40 medically well IOP- controlled normal- tension glaucoma (NTG) patients and 38 eyes of 38 NTG patients who had undergone successful trabeculectomy (TLE) were enrolled. The participants were instructed to read a sample text and to then type it on a smartphone under low- light [100 lux] conditions. Three IOP measurements were obtained: baseline; during smartphone work (5, 15 and 25 min); post- work (5 and 15 min). results Baseline IOP did not significantly differ between the two groups (medication group: 13.9±1.6 mm Hg; TLE group: 13.6±1.7 mm Hg; p=0.426). After 5 min of smartphone work, the medication group showed significantly elevated mean IOP (15.5±1.8 mm Hg;+11.5%; p<0.001), along with further increases over the course of 25 min (17.5±2.2 mm Hg;+25.9%; p<0.001). 5 min after halting work, IOP dropped below the baseline (13.1±1.7 mm Hg; p<0.001). For the TLE group, IOP also was elevated after 5 min (14.9±1.7 mm Hg;+9.4%; p<0.001); however, it did not show further increase over the course of 25 min of work (15.0±1.6 mm Hg;+10.3%). At 5 min after cessation of work, IOP had restored to the pre- work level (14.0±1.9 mm Hg;+2.8%; p=0.053). Conclusion Working on a smartphone under lowlight condition can incur IOP elevation in treated NTG patients. However, among the participants in this study, IOP fluctuation was much smaller in those who had undergone TLE. [ABSTRACT FROM AUTHOR]