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Purpose To investigate the safety and feasibility of topical injection of bone marrow derived mesenchymal stem cells (BM-MSCs) in acute severe ocular burns. Methods In this open-label，single-arm study, subconjunctival injection of allogenic BM-MSCs combined with standard treatment was given to 16 patients with acute severe ocular burns (Dua's grade IV to VI) within 2 weeks after injury. The primary outcome was efficacy rate which referred to the proportion of complete corneal epithelialization patients without perforation. The secondary outcome was safety, visual acuity, the number of symblephara, and elevated intraocular pressure. Results One patient was lost to follow-up. During the follow-up period, no corneal perforation was developed. Complete corneal epithelialization was noted 8 (ranged 4–10 weeks) weeks after treatment in 13 eyes (81.3%). The efficacy rate was 87.5% (95% confidence interval, CI: 61.7–98.4). Hypopyon was detected and later well controlled in 1 eye. Partial or total limbal stem cell deficiency (LSCD) was noted in all eyes. Improvement of visual acuity was achieved in 5 out of 16 eyes (31.3%). Seven eyes’ visual acuity was reached 0.1. Symblepharon with varied severity was noted in 5 eyes. Two eyes had elevated intraocular pressure. Conclusions This study confirms the safety of subconjunctival injection of BM-MSCs as an innovative and convenient procedure in ocular burns. The overall result is promising considering the absence of perforation, the low severity of symblepharon and visual acuity improvement.

Background: Stevens Johnson syndrome (SJS) is a collection of acute and life threatening skin symptoms caused by an allergic drug reaction. SJS also attacks the other mucous membranes, one of which is the eye. SJS is a rare case. The initial complaint of SJS is the eruption on the skin in the form of redness followed by blisters and attacking other mucous membranes. The ocular manifestations of SJS are conjunctivitis, corneal erosion, corneal ulcers, and blepharitis. Methods: Treatment of SJS’s ocular manifestation is administration of drugs and surgical intervention. Administration of drugs that often done in the acute phase is antibiotic eye drops with steroids to prevent complications. Complications that can occur include symblepharon, districhiasis, and keratitis. This complication can cause a sharp decrease in vision. Results: This case report discusses a 68 year old male patient with blisters all over his body accompanied by swelling in both eyes, redness in both eyes, and difficult to open eyes. Patients with history of taking the new drug a month ago. No history of drug allergy. The patient suffered from hypertension, non-hemorrhagic stroke, and epilepsy with irregular treatment. Patient was performed a fluorescein test. In this case, the patient is given antibiotic ointment and artificial tears with steroids. In this case there were no complications. Conclusion: The ocular manifestations of SJS if handled quickly and properly can prevent long-term complications.

Dupilumab is a monoclonal antibody that is used for the treatment of atopic dermatitis (AD) in adults. However, increasing reports of ocular complications including conjunctivitis and dry eye disease have been documented. In this report, we describe a case of a patient who developed limbal stem cell deficiency (LSCD) after prolonged Dupilumab use. A 56-year-old Caucasian male with a history of AD presented with gradual onset cloudy vision and extensive diffuse symblepharon resulting from Dupilumab treatment. He was diagnosed with cicatrizing blepharoconjunctivitis and secondary LSCD after slit lamp examination. In conclusion, LSCD secondary to cicatricial disease is a severe adverse ocular complication caused from long-term Dupilumab treatment.

Aim To report the preliminary outcomes and elucidate the possible rationale of alloSLET for primary ocular surface reconstruction following excision of extensive ocular surface tumors. Methods Retrospective interventional case series with a minimum postoperative follow up of 1 year. AlloSLET was performed along with wide surgical excision and cryotherapy in 3 eyes. Results Of the 2 eyes with extensive OSSN and one with an extensive pigmented lesion, there was no occurrence of symblepharon in all 3 eyes. No features suggestive of LSCD was noted in 2 eyes. In the child with xeroderma pigmentosum and OSSN, early peripheral vascularization was noted at 1 year of follow up with reduced vision secondary to amblyopia. Conclusion Primary alloSLET could be an alternative to primary autoSLET in eyes with extensive ocular surface tumors, commonly seen with ocular surface squamous neoplasia (OSSN) and pigmented lesions. This facilitates ocular surface reconstruction with reduced occurrence of symblepharon formation as well as limbal stem cell deficie4ncy (LSCD). It possibly, is the only option in eyes with OSSN with coexistent bilateral limbal insufficiency. It may obviate the need for autoSLET, primary or secondary in eyes with adequate residual limbus.

To systematize clinical variants of symblepharon and to analyze rehabilitation availability boundaries in patients with different forms of symblepharons. Retrospective analysis of clinical cases included 26 patients with local, subtotal, and total symblepharon (ankyloblepharon) with a normal or anophthalmic orbit. In all patients, symblepharon was operated using split- or full-thickness oral mucosal autografts and their fixation with U-shaped stitches and compression plates. Preoperatively and postoperatively, best-corrected visual acuity, IOP, extraocular motility, results of Schirmer I test, and tear break-up time with slit-lamp biomicroscopy were analyzed, as well as additional ultrasound and electrophysiological studies were performed in some cases. Follow-up period lasted from 1.5 to 6 years. The proposed surgical technique using mucosal autografts in all patients allowed complete anatomical restoration of conjunctival fornices and cavity. It resulted in improvement of visual function in patients with local symblepharon, full restoration of ocular motility in patients with a presence of the eye and provided an opportunity to wear artificial eye in patients with anophthalmia. Nonetheless, loss of conjunctival Krause’s and Wolfring lacrimal glands, goblet cells, meibomian glands, and limbal stem cells prevents from further optic keratoplasty in patients with total or subtotal symblepharon on potentially sighted eye. The most difficult patients for visual rehabilitation were the ones with subtotal or total symblepharon (ankyloblepharon) on potentially sighted eye due to the loss of conjunctival goblet cells, meibomian glands, and limbal stem cells.

Purpose: This study aimed to report the surgical outcomes of autologous Simple limbal epithelial transplantation (SLET) performed for unilateral limbal stem cell deficiency (LSCD) following chemical injury. Materials and Methods: This was single centre prospective case series of patients who developed unilateral LSCD after chemical injury and underwent SLET between December 2018 and September 2019 with follow up of 3-6 months. Primary outcome was restoration of completely epithelized avascular corneal surface. The secondary outcome was percentage of eyes which gained vision. Results: This study included 5 eyes of 5 patients with follow up of 3-6 months. Stable corneal surface was obtained clinically in 4 cases out of 5 and visual acuity gain seen in 3 patients. The factors associated with failure of vision improvement were time of chemical injury (during childhood), duration of injury to SLET procedure and previous history of surgical procedure. Complications seen are haemorrhage under hAM, focal recurrence, symblepharon, keratitis and loss of explants post operatively. Conclusion: Autologous SLET is an effective and safe modality for the treatment of unilateral LSCD. It causes stabilization of ocular surface and also facilitates visual improvement. In a developing country like India, with limited facilities in the healthcare system, auto-SLET is a boon for patients with unilateral LSCD. Keywords: Chemical injury, Simple limbal epithelial, transplantation, Limbal stem cell deficiency.

AimTo study the morphological features of the palpebral lobe of the main lacrimal gland in normal and dry eyes.MethodsThis cross-sectional study included 25 healthy subjects and 83 patients with dry eye disease (DED). The aetiological groups of DED were cicatrising conjunctivitis (CC, n=35), evaporative dry eyes (EDE, n=25) and Sjogren’s syndrome (SS, n=23). The palpebral lobes in both eyes were evaluated using slit-lamp biomicroscopy and photography for size (exposed area in mm2), shape (convex or flat), presence of cicatrisation (scarring and/or symblepharon) and appearance of the overlying conjunctival vessels.ResultsThe palpebral lobes in the normal and EDE group were similar in terms of size (41.5±15.6 mm2 vs 39±12.2 mm2, p=0.203), convex shape (100%) and absence of cicatrisation or vascular engorgement (0%). However, as compared to normal controls, the size of the palpebral lobe was markedly reduced in the SS (27.9±12.3, pConclusionThe morphological features of the palpebral lobe of the main lacrimal gland are significantly distorted in aqueous deficient dry eyes due to CC and SS; however, the lobes in patients with EDE are similar to normal eyes.

Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) form a spectrum of vesiculobullous disorders affecting skin and mucous membranes. Although rare, they are associated with a high mortality rate of up to 35% in adults and up to 17% in children.1 2 Ocular involvement is common and is present acutely in 43–81% of hospitalised patients.3 4 This ranges from conjunctival injection and membrane formation to epithelial sloughing of eyelid, conjunctiva and cornea. Chronic ocular complications occur in 20–79% of patients.1 Fusion between bulbar conjunctiva and fornices leads to symblepharon, while tarsal conjunctival scarring is associated with lid keratinisation and cicatricial lid changes including entropion, trichiasis and distichiasis.5 All of these changes contribute to corneal complications including limbal stem cell deficiency (LSCD) and eventual ocular surface failure with poor visual prognosis.6 Prompt treatment during the acute inflammatory stage of SJS/TEN is important in preventing chronic sequelae.1 Use of amniotic membrane transplantation (AMT) to suppress inflammation and promote healing during the acute phase was first reported by John et al in 2002.7 Amniotic membrane contains anti-inflammatory cytokines and suppresses innate immunity, thus having anti-inflammatory as well as anti-scarring effects.8 Its effectiveness has also been demonstrated in other ocular surface disorders such as chemical burns, persistent epithelial defect and ocular cicatricial pemphigoid.9–12 Since then, AMT has been shown to reduce inflammation and promote healing in the acute stage of SJS/TEN in several case series.8 13–15 In a large retrospective study, Hsu et al have showed the benefit of early AMT in patients with moderate and severe ocular involvement from SJS/TEN compared with medical management alone.16 Recently, Shanbhag et al reported that patients who received AMT in the acute period had significantly reduced vision-threatening complications; however, complications still occurred in this group mostly …

AIM: To evaluate chronic ocular sequelae in patients with symblepharon caused by ocular burns and propose an objective grading system. METHODS: This was a retrospective, single-center clinical study. Patients with symblepharon caused by ocular burns at least six months later were assessed. Chronic ocular sequelae were classified into 3 categories (eyelid, conjunctiva, and cornea) and 9 chronic ocular sequelae [friction factors, exposure factors, conjunctival hyperemia, length of symblepharon, scope of adhesion, lacrimal area adhesion, loss of the palisades of Vogt (POV), corneal neovascularization, and corneal opacification]. Each ocular sequela was graded from 0 to 3, depending on the increasing severity. The 9 ocular sequelae were evaluated to obtain the total severity score for each eye. The total severity score was defined as Grade I (1-9), Grade II (10-18), and Grade III (19-27). Moreover, the correlation between the severity of chronic ocular sequelae and visual acuity, surgical strategy, and the prognosis was analyzed, respectively. RESULTS: Cases of 79 eyes with symblepharon caused by ocular burns were included in this study. Of these, 20 (25.32%) were defined as Grade I, 43 (54.43%) as Grade II, and 16 (20.25%) as Grade III. Eyes with a high total severity score had reduced visual acuity, required complicated surgery strategies, and poor prognosis (P

Ocular cicatricial pemphigoid (OCP) is an autoimmune ocular disease that causes severe dry eye syndrome, conjunctival scarring with inferior fornix shortening and entropion along with trichiasis. Corneal keratinization and corneal ulcers may lead to permanent vision loss. The therapeutic approach of OCP is a challenging one. Thus, the treatment consists of a systemic therapy that includes immunosuppressive as well as corticosteroid medication. Also, surgical procedures for modifications of eyelid position, symblepharon and cataract may aggravate the evolution of the disease. Dry eye syndrome, which is known to be a multifactorial disorder of the ocular surface secondary to qualitative or quantitative alteration of the tear film, is a severe and frequent complication of OCP. In this article, we presented 3 patients diagnosed with OCP, who developed severe dry eye syndrome, entropion, corneal erosions and ultimately, permanent vision loss.

Purpose To investigate the details of the long-term progression of ocular surface cicatrization in eyes with ocular sequelae caused by Stevens-Johnson syndrome (SJS)/toxic epidermal necrosis (TEN). Methods In 105 eyes of 66 patients with SJS/TEN, the severity of ocular sequelae was retrospectively evaluated using an ocular surface grading score (OSGS) at 2 time points separated by a greater than 5-year interval. The OSGS included 7 ocular surface components (conjunctivalization, neovascularization, opacification, keratinization, symblepharon, and upper/lower conjunctival-sac shortening) evaluated into grades 0 to 3 (maximum total OSGS: 21), with the worsening of each component and total OSGS evaluated at the greater than 5-year interval. Moreover, we evaluated whether upper-tarsus and lid-margin scarring are factors that affect ocular surface cicatrization progression. Results In 35 (33.3%) of 105 eyes, the total OSGS worsened during the follow-up period. Partial conjunctivalization (score 1-2) progressed more frequently to total conjunctivalization (score 3) than to no conjunctivalization (score 0) (OR [95% CI]; 5.6 [1.6-20.3]). Partial keratinization (score 1-2) also had a high risk of progression into total keratinization (41.0 [6.3-266.5]). In all cases, keratinization progressed only in the eyes with total conjunctivalization (conjunctivalization score 3). Severity of upper-tarsus scarring or lid-margin scarring affected the worsening of the total OSGS. Conclusions In 66 patients with chronic-phase SJS/TEN, ocular surface cicatrization progressed in 33.3% of the 105 eyes during the long-term follow-up period of over 5 years. More than 50% of the partial conjunctivalization eyes progressed toward total conjunctivalization. The partial keratinization eyes had a high possibility of progressing to total keratinization; that is, the so-called "end-stage" status.

Purpose: To report more conservative management of ocular cicatricial pemphigus (OCP) lesions by performing an initial corneal partial amniotic membrane graft without disturbance of the inflamed conjunctiva. Methods: A case report of a patient having a stage 3 OCP in his left eye with a corneal ulcer. He was managed by partial corneal amniotic membrane (AM) graft. Results: The course was favorable with complete corneal ulcer healing and incidentally there was an important regression of associated ocular surface inflammatory signs with a less prominent inferior symblepharon strand. Conclusion: We propose to manage newly diagnosed patients having advanced ocular cicatricial pemphigus disease with partial corneal amniotic membrane graft before performing radical adnexal surgery with prior immunosuppressive treatment.

A donor corneo-scleral button was dissected into four parts using a simple manual technique. The anterior corneal lamellae was stripped from the Descemet's Membrane (DM) and Deep Anterior Lamellar Keratoplasty (DALK) was performed in a patient with advanced keratoconus after removing the recipient's stroma using the big bubble technique. Descemet's Membrane Endothelial Keratoplasty (DMEK) was done with the stripped donor DM in a patient with Fuch's endothelial dystroph (FECD). The cadaveric limbal stem cells from the tissue were used for simple limbal epithelial transplantation (SLET) in a Steven- Johnson Syndrome (SJS) with localized limbal stem deficiency and symblepharon. The sclera was used to revise a leaking hypotonus bleb in an advanced single-eyed glaucoma patient. No intraoperative or postoperative complications were observed. At 1 year, all the 4 cases retained healthy transplanted tissues with good visual outcomes. Shortage of donor eyes is a global problem and with the present COVID-19 scenario the situation is bound to worsen. The advent of customized component corneal transplantation using simple cost-effective techniques will be the future trend in the years to come.

The purpose of this case report is to describe a new surgical method for sutureless placement of the amniotic membrane with a symblepharon ring in a pediatric patient with acute toxic epidermal necrolysis (TEN). A 1-year-old girl developed severe ocular surface inflammation with large corneal and conjunctival epithelial defects secondary to TEN. She was treated by applying a large (4 cm x 4 cm) amniotic membrane graft and non-sterile symblepharon ring under sedoanalgesia at bedside in the intensive care unit. The ocular surface was completely epithelized by post-treatment week 6 in the right and week 8 in the left eye. Two years after amniotic membrane transplantation, both eyes were quiet with no symblepharon, scar formation, or limbal stem cell deficiency. Performing bilateral amniotic membrane transplantation under a symblepharon ring at bedside provided sufficient acute coverage of the ocular surface and led to excellent clinical outcomes by reducing inflammation and protecting the ocular surface.

Symblepharon in Linear IgA Bullous Dermatosis A 73-year-old man presented to the eye clinic with blurred vision, photophobia, and a rash. Eye examination showed symblepharon. Linear IgA bullous der...

BACKGROUND/OBJECTIVES Laryngo-onycho-cutaneous syndrome (LOC) is a rare subtype of junctional epidermolysis bullosa (JEB), featuring aberrant granulation tissue formation in the skin, larynx, and eyes. So far, three mutations including the specific (founder) mutation in exon 39 of LAMA3 (c.151dup) have been identified, but sparse data exists regarding the natural history, the genotype-phenotype correlation, and its differentiation from other JEB types. METHODS We reviewed our pediatric EB database to identify English children with clinical and genetically diagnosed LOC within the last 15 years. Their demographic, clinical, and laboratory data were examined. We searched three databases for case reports of LOC between January 1986 and November 2020 and extracted clinical and molecular details. RESULTS We identified 6 LOC patients, all female (mean age 5.4 years). Periungual hypergranulation and skin fragility were the earliest presenting signs (0-3 months), followed by laryngeal stenosis, symblepharon (mean onset 10.7 and 11.8 months, respectively), and dental abnormalities. Five children developed anemia at an average of 19.2 months. We identified 22 published studies in English with 31 cases. CONCLUSIONS This study delineates the disease course of LOC and highlights the overlap with some forms of JEB. Classical signs/symptoms including anemia appear early in life. Genetic analysis revealed three new LOC-associated variants and underscores the finding that interpretation of skin immunolabeling and molecular diagnostics can be challenging. We provide recommendations on management of this complex syndrome.

The study aims to evaluate the effect of allogeneic cultivated limbal epithelial cell sheet transplantation (CLET) in reconstructing conjunctival sac for severe symblepharon after chemical and thermal burns. A retrospective, noncomparative case series. Thirty-six eyes (36 patients) underwent CLET for severe symblepharon and conjunctival sac stenosis or atresia. Inclusion criteria were: at least with 2 quarters of symblepharon, and conjunctival sac contraction; the pseudopterygium encroaching onto the cornea; limitation of eye and eyelid movement; 6 months after injury. Symblepharon was separated, and pseudopterygium was preserved to replace the palpebral conjunctiva. Allogeneic cultivated limbal epithelial cell sheet using human amniotic membrane as a carrier was transplanted into the recipient's eye to reconstruct the conjunctival sac. The effect of conjunctival sac reconstruction, eye and eyelid movement, ocular surface restitution, and symblepharon recurrence were analyzed after surgery. Symblepharon was completely relieved in 30 of the 36 eyes (83.3%) by a single surgical procedure, with fornix reconstruction, as well as free movement of eye globe and eyelids. Strip-like symblepharon remained in 6 eyes (16.7%) and was completely relieved after the second CLET. 20 patients without visual function received prostheses 3 months after surgery. During the follow-up period, no one had symblepharon recurrence. The transplantation of cultivated allogeneic limbal epithelial sheets offers an effective and safe alternative in the treatment of symblepharon and reconstruction of conjunctival sac in eyes with severe ocular burns, with donor cells obtained abundantly.

Purpose: To report a case of Stevens-Johnson syndrome-toxic epidermal necrolysis (SJS-TEN) overlap, with severe acute ocular manifestations successfully managed with sutureless Amniotic Membrane device ProKera® (Bio-Tissue, Inc., Miami, FL) and topical steroids, followed by late complications that were successfully managed with intravenous immunoglobulin (IVIG) therapy. Observations: A 24-year-old lady, known case of epilepsy, admitted to the burn unit with SJS-TEN overlap attributed to a recent change of her anti-convulsant therapy, with severe ocular manifestations, inability to open both eyes, and poor visual acuity. Early management included intensive topical steroids and lubrication, in addition to the application of a ProKera® device. Despite achieving full epithelialization within two weeks with the improvement of ocular manifestations, the patient presented three weeks later with recurrence of conjunctival epithelial defects, partial ankyloblepharon, and severely dry corneas. These late sequelae were managed with bandage contact lens (BCL) application, intensive topical steroid, and lubrication in addition to IVIG therapy. After six cycles of IVIG therapy, ocular manifestations improved significantly and the patient achieved uncorrected visual acuity of 6/9 in both eyes. Conclusion and importance: Existing evidence suggests that the use of IVIG in combination with systemic steroids in the early phase of SJS-TEN can reduce mortality, without affecting the final visual outcome in patients with ocular manifestations. This case highlights the possible role of IVIG therapy alone - without systemic steroids - in managing and preventing long-term ocular complications of SJS-TEN.

PURPOSE To compare the efficacy, safety and recurrence rate of platelet-rich fibrin (PRF) grafts and limbal conjunctival autografts (LCAs) following pterygium excision. METHODS A total of 108 patients (108 eyes) with primary pterygium were included in this study and were divided into group A (56 eyes) and group B (52 eyes). Patients in group A underwent excision of the pterygium followed by LCA while patients in group B underwent PRF grafts following pterygium excision. The PRF was produced using the patient's own whole-blood sample by centrifugation and extrusion. The surgery time, intraoperative complications, postoperative complications, recurrence rate, intraocular pressure (IOP) and follow-up period were recorded and evaluated between the two groups. RESULTS The mean surgery time was significantly shorter in group B (25.0 ± 4.2 min) than in group A (36.5 ± 6.3 min) (P

PURPOSE To describe a novel surgical technique using the Boston Keratoprosthesis (KPro) type I in a patient with advanced ocular cicatricial pemphigoid (OCP) using oral mucosa for covering the prosthesis. METHODS We present the case of an 85-year-old man previously diagnosed with type 2 diabetes and advanced OCP nonresponsive to immunosuppressive treatment, whose best-corrected visual acuity was light perception and projection in both eyes. After examination, Boston KPro type I in the right eye was contemplated because osteo-odonto KPro and Tibial bone KPro were not feasible because of the patient's osteoporosis and edentulism. Reconstruction of the ocular surface was first performed using oral mucosa to release the symblepharon and try to deep the fornices. Three months later, the oral mucosa was lifted, and the Boston KPro type I was implanted using the patient's own cornea. Then, a modification of the standard surgical technique was carried out, replacing the use of contact lens for covering the prosthesis with an oral mucosa graft with a central trephination as an alternative option in fornix foreshortening cases. RESULTS After 11 months, visual acuity was stable to 0.2 decimal. No postoperative complications have been encountered, and prosthesis was in place. CONCLUSIONS The surgical technique of transmucosal Boston KPro type I may be considered a surgical alternative in patients with advanced OCP who present with severe fornix foreshortening, where osteo-odonto KPro or Tibial bone KPro cannot be performed due to osteoporosis or edentulism or when the Boston KPro type II is not readily available.

To explore a new classification scheme for acute ocular burns. Medical records of 345 patients (450 eyes) with acute ocular burns treated at Shandong Eye Institute between January 2013 and January 2018 with a 12-month minimum follow-up were retrospectively reviewed. A total of 8 parameters in the acute phase were evaluated and graded on a scale from 0 to 3 according to their severity. The key factors affecting the prognosis of acute ocular burns were conjunctival involvement (386 eyes, 85.8%), corneal epithelial defect (349 eyes, 77.6%), and limbal ischemia (244 eyes, 54.2%). Visual acuity in 181/450 eyes (40.2%) was worse than 6/60. The injury severity of the cornea, limbus, bulbar conjunctiva, eyelid, and fornix and intraocular signs in the acute phase was significantly correlated with the logarithm of the minimum angle of resolution (logMAR) visual acuity (correlation coefficient [R] 0.481–0.933, P < 0.0001) and corneal opacification, neovascularization, and symblepharon scores in the stable phase (R 0.513–0.855, P < 0.0001). The mean total score for the 8 parameters in the acute phase was 5.34 ± 4.04 (range 0–14); higher scores indicated worse visual acuity (R = 0.899, P < 0.0001). The total score for acute-phase parameters was significantly correlated with that for the stable-phase parameters (R = 0.872, P < 0.0001). The severity of acute-phase parameters is significantly correlated with the final visual outcome and prognosis. The new grading scheme can help clinicians more accurately analyze the degree of ocular burns, determine a reasonable treatment protocol, and rationally evaluate the prognosis.

Aim.Analysis of the results of surgical treatment in patients with epibulbar malformations.Patients and Methods.The study included 126 patients with a preliminary diagnosis of “epibulbar neoplasm”, who received treatment from January 2013 to December 2017. Male patients were 57.9 % (n = 73), female — 42.1 % (n = 53). The age range was from 6 months to 82 years (13.0 ± 11.4). All patients underwent complex ophthalmological examination and surgical treatment with histological verification of the obtained material. In case of deficiency of own tissues, when the conjunctival defect was closed, plastic was made using an amniotic membrane.Results.67 (53.2 %) patients had a diagnosis of dermoid of the conjunctiva and / or cornea. In 14.3 % of cases, a diagnosis of lipodermoid with spreading into the eyelids fornix was established. In 7 patients there was a combined lesion, of them in 4 cases with Goldenhar syndrome, 1 case with Jadassohn syndrome and in 2 cases without syndromic disorders. In 10 patients, multicentric lesions were noted with the formation of several dermoids. Choristomas of different structures were identified in 41 patients (32.5 %). Complications of surgical treatment included limitation of eye mobility (n = 9), ptosis of the upper eyelid (n = 7), diplopia (n = 4), ocular deformity (n = 3), corneal perforation (n = 1), symblepharon (n = 1) and entropion (n = 1), which required additional surgical interventions with a favorable functional outcome.Conclusions.Diagnosis of epibulbar malformations requires a comprehensive ophthalmological examination to determine the prevalence of the process, the extent of the lesion in order to plan the timing and tactics of surgical treatment. Congenital epibulbar malformations of the eye are subject to surgical treatment with the growth of lesion, chronic inflammation, cosmetic dissatisfaction and spread to the central parts of the cornea. The use of the amniotic membrane improves normal epithelization and reduces the degree of postoperative scar deformation.

Figura A. Simblefaron, es decir adherencia de los bordes de los dos párpados (flecha blanca) y queratinización del limbo esclero-corneal (flecha amarilla) en el ojo derecho. Figura B. Ojo derecho: irregularidad del borde del párpado inferior con obstrucción completa y queratinización de los puntos de drenaje de las Glándulas de Meibomio, como consecuencia de la inflamación crónica secundaria al Síndrome de Stevens - Johnson. Figura C. Ojo derecho: conjuntivalización completa por falla del limbo y pérdida del epitelio corneal en el ojo derecho de la paciente, llevando a una córnea totalmente opaca como secuela del ojo seco severo crónico secundario al síndrome de Stevens - Johnson. Figura D. Ojo izquierdo: queratoprótesis de Boston Tipo I in situ. Se aprecia el cilindro central que permite el paso de la luz al interior del ojo. Los agujeros que translucen a través del tejido se encuentran en la placa de titanio que sostiene fijo el cilindro óptico al tejido corneal de un donante, que se suturó a la córnea periférica de la paciente. Ese tejido corneal donante se encuentra completamente conjuntivalizado y opaco, pero el extremo del cilindro óptico, al ser de material sintético, mantiene la transparencia. Se evidencia queratinización de la superficie con acúmulo de queratina en la interfase entre el material sintético del cilindro y el tejido corneal. Figure A. Symblepharon, i.e., adhesion from the edges of the two eyelids (white arrow) and keratinization of the sclerocorneal limbus (yellow arrow) in the right eye. Figure B. Right eye: irregularity from the edge of the lower eyelid with complete obstruction and keratinization of the excretory ducts of the Meibomian glands, due to chronicity of the inflammation in consequence to Stevens - Johnson syndrome. Figure C. Right eye: showing complete conjunctivalization due to limbus failure and loss of the corneal epithelium in the patient’s right eye, leading to corneal haze as a sequel to chronic severe dry eye secondary to Stevens - Johnson syndrome. Figure D. Left eye: Boston type I keratoprosthesis in situ. As showed, the central cylinder allows light to enter through the eye. The holes seen through the tissue are on the titanium plate that holds the optical cylinder in place on the corneal tissue of a donor, sutured to the patient’s peripheral cornea. This donor corneal tissue is completely conjunctivalized and hazy, but since the end of the optical cylinder is made of synthetic material, it remains transparent. Keratinization of the surface is evident, with an accumulation of keratin in the interface between the synthetic material of the cylinder and the corneal tissue. Figura A. Simbléfaro, ou seja, aderência das bordas das pálpebras (seta branca) e queratinização do limbo esclerocorneano (seta amarela) no olho direito. Figura B. Olho direito: irregularidade da borda da pálpebra inferior com obstrução completa e queratinização dos pontos de drenagem das glândulas meibomianas, como consequência da inflamação crônica secundária à síndrome de Stevens - Johnson. Figura C. Olho direito: conjuntivalização completa devido a falha do limbo e perda do epitélio corneano no olho direto da paciente, ocasionando uma córnea completamente opaca como sequela do olho seco crônico grave secundário à síndrome de Stevens-Johnson. Figura D. Olho esquerdo: ceratoprótese de Boston Tipo I in situ. O cilindro central que permite a passagem da luz para o olho é apreciado. Os orifícios translúcidos através do tecido estão na placa de titânio que segura o cilindro óptico ao tecido corneano de um doador, o qual foi suturado à córnea periférica da paciente. Esse tecido corneano doado está completamente conjuntivalizado e opaco, mas o extremo do cilindro óptico, por ser feito de material sintético, mantém a transparência. É evidente a queratinização da superfície com acúmulo de queratina na interface entre o material sintético do cilindro e o tecido corneano.

The purpose of this study is to provide a comprehensive review of the clinical characteristics in chronic Stevens-Johnson syndrome (SJS) patients within the United Kingdom population, their causative factors, treatment profile and prognosis. This retrospective series included 91 patients with chronic SJS treated at Moorfields Eye Hospital (London, United Kingdom). A chart review included visual acuity and presence of clinical findings (including lid abnormalities and ocular surface findings). All medical and surgical treatments were also recorded. Approximately a half of patients were White British but there were significant numbers of patients from other ethnic groups, South Asian and Black in particular. Oral antibiotics were the causative agent in almost a half of the patients with SJS, systemic infections in 14%, non-steroidal anti-inflammatory drugs in 8% and anticonvulsants in 7%. The age of onset was varied but a significant proportion of patients developed acute SJS in childhood. There was a significant correlation between visual acuity at initial referral to final recorded vision. Vision was found to continue to significantly deteriorate over time despite therapeutic interventions. Our regression model shows that ~62% of the variance in final vision can be explained by the initial vision and duration disease. The majority of our patients were on advanced ocular surface treatments including serum drops, topical ciclosporin and retinoic acid drops. Of particular significance, approximately a third of our patient cohort was also on systemic immune suppression. In conclusion, chronic SJS within the UK population under tertiary care remains an area of unmet clinical need. Current medical and surgical modalities prevent worsening of vision in severe ocular disease from SJS.

Purpose To evaluate the clinical outcomes and complications of oral mucosa autograft (OMAU) sutured to the sclera to treat symblepharon after severe chemical or fireworks burn. Methods Our surgical technique for OMAU sutured to the sclera is presented along with clinical data and outcomes of 7 symblepharon carriers. Our surgical technique was performed unilateral in all cases. An OMAU with a mean length of 3 cm and 2 cm wide was sutured to the bare sclera 1–3 mm behind the limbus. Amniotic membrane transplant was placed covering the rectus muscles and bare sclera proximal to the limbus. The fornix was secured into the skin with deepening bolster sutures. A temporary tarsorrhaphy was performed, and a symblepharon ring was placed on top of a bandage contact lens. Results There were no cases of intraoperative complications. Three years postoperatively, all patients had perfect integration of the OMAU and there were no cases of symblepharon's recurrence. Two patients developed mild superior entropion and 2 patients developed mild strabismus (one esotropia and another exotropia). Conclusion and Importance OMAU sutured to the sclera after symblepharon release caused by severe ocular burns, results in excellent cosmetic and anatomical outcomes with no recurrence.

PurposeMolecular pathogenesis underlying persistent ocular surface inflammation in chronic Stevens-Johnson syndrome (SJS) still remains largely unexplored. The present study investigates the expression of matrix metalloproteinase 2 (MMP2), MMP3, MMP9, MMP11 and TIMP1 (tissue inhibittor of matrix metalloproteinase 1) in pannus tissues of chronic ocular SJS undergoing cultivated oral mucosal epithelial transplantation (COMET) and their prognostic relevance.MethodsIn this prospective study, 45 eyes with chronic SJS underwent COMET for visual and anatomical rehabilitation. Preoperative and postoperative clinical parameters were documented. MMP2, MMP3, MMP9, MMP11 and TIMP1 expression were assessed using immunohistochemistry and quantitative real time PCR. Inflammadry MMP9 assay was performed at 1-year follow-up. Kaplan-Meier curves and Cox proportional hazard models were used to correlate protein expression with clinicopathological parameters and COMET graft survival outcomes.ResultsMMP9 and MMP11 positivity was seen in both pannus epithelia (48% and 55%, respectively) and in stromal layer (57% and 33%, respectively) while MMP2 and MMP3 showed only pannus epithelial positivity in 35% and 51% cases, respectively. High MMP9 stromal expression was significantly associated with preoperative corneal keratinisation (p=0.011), conjunctival hyperaemia (p=0.014), symblepharon (p=0.028). High MMP9 and MMP3 epithelial expression were found to be independent risk factors for poor best-corrected visual acuity (BCVA) outcomes post-COMET (p=0.022 and p=0.048). Multivariate analysis revealed MMP9 to be the best prognostic marker (p=0.050).ConclusionOur findings suggest that differential expression of MMPs and TIMP1 is seen in SJS in chronic stage. Emergence of MMP9 as a poor prognostic predictor of BCVA post COMET and postoperative MMP9 immunoassay positivity could be a useful tool in further studies to understand the unresolved ocular surface inflammation seen in SJS.

Purpose To share our experience with pediatric orbital expansion using eye conformers for anophthalmia and microphthalmia and parental feedback on outcomes. Methods Cases of congenital anophthalmia and severe microphthalmia were managed with eye conformers for orbital expansion and formation of lid fornices at the anaplastology clinic of King Khaled Eye Specialist Hospital, Saudi Arabia. Data were collected on the globe adaptation process and the perceived achievements by the parents at different follow-up visits. Parental feedback was collected on their acceptance of eye conformer use to address anophthalmia and microphthalmia. Results The anophthalmia/microphthalmia annual prevalence was 1.7 per 10,000 live births in Saudi Arabia. Of the 45 sockets treated for orbital expansion since 2014, 15 children were managed by using eye conformers. Six children had a bilateral birth defect. Severe microphthalmia was in seven children while eight children had anophthalmos. At the first visit, small eye conformers (nine), stem eye conformer (four), symblepharon ring (one), and hydrogel eye conformer (one) were fitted. After multiple visits and follow-ups, at the two-year follow-up, seven (46.7%) children were fitted while three (20%) were under the process of prosthesis fitting, as volume expansion was satisfactory. Parents of these children replied that they prefer this method over others and would recommend others to follow the same. Conclusions Orbital expansion and lid fornices formation by using an eye conformer is effective, easy, and acceptable to parents. It can be initiated in the early months of a child's life.

Persistent corneal graft erosion or persistent epithelial corneal defect is a frequent complication of penetrating keratoplasty. Its development can be contributed by the dry eye syndrome, rare blinking, lagophthalmos, symblepharon, viral infection, autoimmune aggression, and the use of epithelial-toxic eye drops. The article presents three clinical observations of patients who developed persistent corneal graft erosion after penetrating keratoplasty. Due to the ineffectiveness of local conservative therapy for more than 3 weeks, anterior stromal corneal micropuncture was performed. After the procedure, there was a gradual epithelial proliferation, complete healing of the corneal surface was observed 10-16 days after the manipulation, the follow-up period was at least 1 year. The mechanism of action of stromal micropuncture is associated with the creation of a porous surface with better adhesion properties, as well as with the activation of the production of extracellular matrix glycoproteins such as fibronectin, type IV collagen and laminin, which are necessary for stable adhesion of the epithelium. The use of stromal micropuncture of the donor flap in the treatment of post-keratoplasty persistent corneal epithelial defect was proposed for the first time.Персистирующая эрозия трансплантата роговицы, или персистирующий эпителиальный дефект роговицы, — частое осложнение сквозной кератопластики. Его развитию могут способствовать синдром сухого глаза, редкое моргание, лагофтальм, симблефарон, вирусная инфекция, аутоиммунная агрессия, применение эпителиотоксичных капель. В статье представлено три клинических наблюдения пациентов, у которых развилась персистирующая эрозия трансплантата роговицы после сквозной кератопластики. В связи с неэффективностью местной консервативной терапии, продолжавшейся более 3 нед, была выполнена передняя стромальная микропункция роговицы. После процедуры отмечалось постепенное нарастание эпителия; полное заживление поверхности роговицы определялось на 10—16-е сутки после манипуляции, срок послеоперационного наблюдения составил не менее 10 мес. Механизм действия стромальной микропункции связывают с созданием пористой поверхности с лучшими адгезионными свойствами, а также с активацией выработки внеклеточных матриксных гликопротеинов — фибронектина, коллагена IV типа и ламинина, необходимых для стабильной адгезии эпителия. Применение стромальной микропункции донорского лоскута в лечении персистирующей эрозии трансплантата роговицы после сквозной кератопластики предложено нами впервые.

The advent of integrated intraoperative optical coherence tomography (i2OCT) has opened the door for safer and more complex surgeries in the retina and cornea. However, to limit its use to just two subspecialties within ophthalmology is an opportunity lost for many other subspecialties. Here, we describe the use of i2OCT in oculoplastic surgery. It can be used in cases of severe symblepharon where the cornea is heavily involved, so that the surgeon is aware of the depth of the pannus when trying to remove it. It can also be used when the corneal planes are difficult to identify. In oculoplastic surgery the technology allows for identification of tissue planes when en face visualization is difficult due to developmental abnormalities and repeated surgeries. Our experience reflects some of the many uses of iOCT in ophthalmic surgery, highlighting its added value in surgical precision.

Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) can lead to severe ophthalmologic sequelae. The main risk factor is the severity of the initial ocular involvement. There are no recommendations for ocular management during acute phase.We conducted a national audit of current practice in the 11 sites of the French reference center for toxic bullous dermatoses and a review of the literature to establish therapeutic consensus guidelines. We sent a questionnaire on ocular management practices in SJS/ TEN during acute phase to ophthalmologists and dermatologists. The survey focused on ophthalmologist opinion, pseudomembrane removal, topical ocular treatment (i.e. corticosteroids, antibiotics, antiseptics, artificial tear eye drops, vitamin A ointment application), amniotic membrane transplantation, symblepharon ring use, and systemic corticosteroid therapy for ophthalmologic indication. Nine of 11 centers responded. All requested prompt ophthalmologist consultation. The majority performed pseudomembrane removal, used artificial tears, and vitamin A ointment (8/9, 90%). Combined antibiotic-corticosteroid or corticosteroid eye drops were used in 6 centers (67%), antibiotics alone and antiseptics in 3 centers (33%). Symblepharon ring was used in 5 centers (55%) if necessary. Amniotic membrane transplantation was never performed systematically and only according to the clinical course. Systemic corticosteroid therapy was occasionally used (3/9, 33%) and discussed on a case-by-case basis.The literature about ocular management practice in SJS/ TEN during acute phase is relatively poor. The role of specific treatments such as local or systemic corticosteroid therapy is not consensual. The use of preservatives, often present in eye drops and deleterious to the ocular surface, is to be restricted. Early amniotic membrane transplantation seems to be promising.

Introduction: Even though the recent outbreak of a novel coronavirus does not severely affect the pediatric population, a previously healthy 15-year-old female, who had started with bilateral conjunctivitis, progressed to toxic epidermal necrolysis (TEN) and multisystem inflammatory syndrome (MIS) in 12 hours. The RT-PCR for SARS-CoV-2 infection was positive with an epidemiologic link 72 hours before onset of symptoms. Methods: The patient was referred to Gutierrez Children’s Hospital intensive care unit (ICU), where she was diagnosed with TEN, bibasal pneumonia and MIS, gammaglobulin and corticosteroids therapy was indicated. She had severe ocular compromise, with bilateral bullous lesions on eyelids and extensive corneal ulcer. We performed amniotic membrane transplantation and placed a symblepharon ring in order to minimize the destructive inflammation and damage of the ocular surface during acute phase. Results: Patient evolution was favorable. She was transferred to the COVID-19 unit after 10 days. Complete reabsorption of amniotic membrane was confirmed in 15 days, symblepharon ring was removed and continued with preservative-free lubricant, cyclosporine 0.05% and serum tears drops. After 35 days of hospitalization, she was discharged with regulated multidisciplinary controls. The patient achieved best-corrected visual acuity 20/20 in both eyes, with moderate dry eye symptoms and localized trichiasis. Conclusion/Relevance: In this case, a strong correlation of COVID-19 with TEN was suspected. TEN is a potentially devastating disease that involves permanent painful visual problems. We emphasize early and intensive treatment because the management of the sequelae is extremely challenging, many of the chronic problems are impossible to repair completely.

This study aimed to clarify predictive biomarkers of mild and severe ocular complications of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) by examining the cytokines in tears. In 121 chronic-phase SJS/TEN eyes, cytokines in tear samples collected using Schirmer test strips were measured, and ocular sequelae severity was evaluated using an Ocular Surface Grading Score (OSGS) involving 7 components (conjunctivalization, neovascularization, opacification, keratinization, symblepharon, and upper/lower conjunctival-sac shortening), with findings categorized into grades 0–3 (maximum total OSGS: 21). Changes in cytokines between the mild and severe groups (mild: total OSGS of 10 or less, severe: total OSGS of 11 or more), and changes between SJS/TEN cases with and without each of the 7 components, were compared. In the severe group, there was significant upregulation of interleukin (IL)-8 (P P P

Conjunctival involvement in sarcoidosis is commonly characterized by epibulbar nodules or follicular conjunctivitis. The authors describe an apparently healthy woman who developed extensive monocular cicatricial conjunctivitis with symblepharon. The array of conditions presenting with cicatricial conjunctivitis was considered, with mucous membrane pemphigoid leading the diagnostic possibilities. Conjunctival biopsy disclosed the non-infectious, non-caseating granulomas of sarcoidosis and a systemic evaluation disclosed pulmonary nodules and hilar lymphadenopathy. As the patient had no respiratory symptoms and an old history of hepatic steatosis, oral hydroxychloroquine and topical cyclosporin were chosen for therapy rather than systemic corticosteroids.

Purpose To report an outcome of a patient with complete ankyloblepharon successfully managed with simple oral mucosal epithelial transplantation (SOMET). Methods A 55-year-old woman presented with complete adhesion of both lids to the ocular surface as a complication from Stevens-Johnson syndrome. We performed 2-staged reconstructive surgeries: the first stage was to perform ankyloblepharon lysis and surface reconstruction with a mucosal graft on the palpebral area and an amniotic membrane on the bulbar area, and the second stage was to reconstruct the bulbar area with a transplantation of small pieces of oral mucosa (SOMET technique). Postoperatively, the patient was evaluated for ocular surface stability, recurrent symblepharon, in vivo confocal microscopy, and impression cytology with immunofluorescence staining. Results Complete epithelialization of cornea-like epithelium was observed within 6 weeks after SOMET was performed. The ocular surface was stable over 1 year. Both fornices remained deep. In vivo confocal microscopy showed cornea-like epithelium mixed with conjunctival epithelium, as confirmed with immunofluorescence staining, which revealed cytokeratin 3, cytokeratin 7, and cytokeratin 12 positivity. Conclusions SOMET is a simple modified technique using minimal oral mucosal tissue to regenerate epithelialization for complicated ocular surface reconstruction such as a complete ankyloblepharon repair. Although there was evidence of conjunctival invasion, stable ocular surface and deep fornices can be achieved for further visual rehabilitative procedure.

Mucous membrane pemphigoid is a chronic autoimmune disease that mainly affects mucous membranes. Skin lesions occur in 10–43% of patients. The conjunctiva is involved in about 70% of patients. The component of the disease that affects the conjunctiva, regardless of involvement of nonocular sites, is commonly called ocular cicatricial pemphigoid. It is a bilateral, asymmetric, sight-threatening disease characterized by progressive conjunctival cicatrization associated with trichiasis, eyelid entropion, symblepharon, secondary corneal neovascularization, and scarring. It is characterized by IgG, IgA, or C3 (complement component) deposition in a linear fashion along the epithelial basement membrane zone. The disease usually presents between the ages of 30 and 90 years; it affects males twice as often as females.

Yu Monden, Chikako Nagashima, Noriko Yokote, Fumi Hotokezaka, Satoshi Maeda, Kensuke Sasaki, Ryoji Yamakawa, Shigeo Yoshida Department of Ophthalmology, Kurume University School of Medicine, Fukuoka, JapanCorrespondence: Yu MondenDepartment of Ophthalmology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830 0011, JapanTel +81-942-317574Fax +81-942-370324Email you@med.kurume-u.ac.jpPurpose: The aim of this study was to evaluate the clinical outcomes of management of recurrent pterygium with severe symblepharon using mitomycin C, double amniotic membrane transplantation, cryopreserved limbal allograft, and a conjunctival flap.Patients and Methods: This retrospective case series included 10 eyes of 10 patients with recurrent pterygium with severe symblepharon. Eight patients have diplopia in primary gaze. All patients underwent pterygium excision, application of mitomycin C (MMC), double amniotic membrane transplantation (AMT), cryopreserved limbal allograft (CLA) transplantation, and placement of a conjunctival flap. Outcome measures were visual acuity, astigmatism, and recurrence. Recurrence was defined as the presence of fibrovascular proliferative tissue crossing the limbus.Results: The patients’ mean age was 73.8 years. The mean follow-up period was 3.0 years. The mean preoperative and postoperative best-corrected visual acuities (logMAR conversion) were 0.43 and 0.30, respectively. The mean preoperative and postoperative astigmatism were – 3.89 diopters and – 1.54 diopters, respectively, and there was a significant difference. No recurrence occurred in any of the eyes. Symblepharon was released in all eyes. Diplopia in primary gaze was resolved in all eyes.Conclusion: Management of recurrent pterygium with severe symblepharon using MMC, double AMT, CLA, and a conjunctival flap was an effective treatment.Keywords: pterygium, symblepharon, limbal allograft, amnion, mitomycin C

Purpose: To compare recurrence rate of primary pterygium following excision with mitomycin c verses excisionwith amniotic membrane transplant.Study Design: Quasi experimental study.Place and Duration of Study: Qazi Hussain Ahmad Medical Complex, Nowshera, from January 2019 to June2019.Material and Methods: One hundred and two patients presenting for the first time with pterygium were includedin the study and were divided into two groups. Patients having conjunctivitis, blephritis, keratitis or any otherocular inflammatory condition and patients having history of chemical burns and symblepharon were excludedfrom the study. Group A underwent surgical excision with 0.02% mitomycin–C application for 3 minutes andGroup B was surgically treated with application of amniotic membrane. Patients of both groups were followed upfor six months to detect recurrence of pterygium. Data was analyzed using SPSS version 20. Frequency andpercentages were calculated for categorical data like age, gender and recurrence rate. Recurrence rate wasstratified among age and sex to see the effect modifiers.Results: Mean age in both groups was 39.98 ± 9.11 years. In group A, 64.70% patients were males and in groupB, 62.74% patients were male. Recurrence of Pterygium was seen in 21.5% patients in group A and 7.84% ingroup B. The difference was statistically significant with a p value of 0.05.Conclusion: Recurrence rate of primary pterygium following excision with mitomycin C is higher than excisionwith amniotic membrane transplant

Background/objectives To evaluate the management of conjunctival melanoma with local excision and adjuvant brachytherapy. Subjects/methods Data of all patients who received local excision and adjuvant brachytherapy for conjunctival melanoma between 1999 and 2016 in a Dutch national referral centre were reviewed. A protocol with Sr-90 was used until 2012, a protocol with Ru-106 was used hereafter. Local recurrence, metastasis, survival, visual acuity and treatment complications were assessed. Results A total of 58 patients was identified: 32 patients were treated with Sr-90 and 26 with Ru-106. Mean follow-up time was 97.3 months (143.1 months after Sr-90, and 40.2 months after Ru-106). All lesions were epibulbar, the median tumour thickness was 0.9 mm. Local recurrence occurred in 13/58 cases (22%), with a 5-year recurrence rate of 21%. Local recurrence occurred equally often in both protocols, with 5-year recurrence rates of 19% (Sr-90) versus 23% (Ru-106) (p = 0.68). Metastasis developed in 3/58 cases (5%), with 2 cases after Sr-90, and 1 after Ru-106 (p = 1.00). The most reported complications were pain (29%), dry eyes (21%), symblepharon (9%), ptosis (12%) and cataract (9%). No severe corneal or scleral complications were observed. Median visual acuity was 1.00 pre-surgery, at the end of follow-up this was 1.00 (Sr-90) and 0.95 (Ru-106). Conclusion Local excision with adjuvant brachytherapy provides good tumour control with excellent visual outcome and mild side effects in patients with limited conjunctival melanoma. Results after Sr-90 or Ru-106 were comparable; a choice for either treatment may be based on experience of the clinician and availability of materials.

This study aimed to describe the clinical features, surgical management of the eyelid and ocular surface, and outcomes of 16 patients implanted with a Boston type I keratoprosthesis (KPro). A retrospective, single-center, consecutive case series of 16 patients with Stevens–Johnson syndrome (1), ocular chemical burns (12), and ocular thermal burns (3) implanted with KPro was studied. All subjects were men aged 27–51 years. Surgical treatment and outcomes for eyelid malposition, symblepharon, and glaucoma were assessed. From September 2010 to February 2019, 29 patients were admitted to Zhongshan Ophthalmic Center for KPro implantation, of whom 16 (55%) required eyelid or ocular surface surgeries to maintain hydration and protect the corneal tissue, which is vulnerable to epithelial defects. Forty-one adnexal surgical procedures were performed. The most common indication for surgery was symblepharon, and the most frequent procedures were symblepharon lysis with ocular mucous membrane grafts and amniotic membranes (7) and full-thickness skin grafts to the eyelids (7). Preoperative conjunctival injection and corneal staining were documented in 9 (56%) and 8 (50%) eyes, respectively, and at up to 4 months postoperative follow-up (the last adnexal surgery before KPro) were recorded in 3 (19%, p = 0.03) and 2 (12%, p = 0.02) eyes, respectively. Glaucoma drainage devices were inserted in six patients. One patient with Stevens–Johnson syndrome underwent FP7 Ahmed glaucoma valve (AGV) implantation inferotemporally and developed plate exposure 2 months postoperatively. Five patients underwent FP8 AGV implantation with tube insertion into the vitreous cavity due to the scarred conjunctiva and limited subconjunctival space. In the study period, intraocular pressure (IOP) was in the normal range, and no tube or plate exposure was observed. The ocular environment is critical for successful KPro surgery. A multidisciplinary approach for any lid and ocular surface abnormality in ocular burns or Stevens–Johnson syndrome is important to improve the quality of the ocular surface and accommodate KPro and AGV, which is vital for maintaining vision after KPro surgery. FP8 AGV may be feasible for IOP control in adult KPro cases with restricted subconjunctival space.

Introduction In ophthalmology amniotic membrane is usually used for the treatment of corneal ulcerations and chemical burns of the ocular surface. Also, it is useful in the treatment of conjunctival defects. There are few publications on the long-term outcomes with the use of amniotic membrane to replace the conjunctiva. In our cases, we used it in patients with restrictive strabismus or conjunctival problems during or following complex eye muscle surgery. Materials and methods In this retrospective case study, we reviewed the charts of the patients who had been treated with Ambio5® (IOP Inc. USA) for the replacement of conjunctiva in the treatment of conjunctival problems during or following complex eye muscle surgeries in our ophthalmology department between 2009 and 2015. Ambio5® is a processed dry, multi-layered amniotic membrane of 110-micron thickness. Inclusion criteria were the use of it in the treatment of conjunctival problems during or following complex eye muscle surgery. Results Thirty-two patients were identified. Among the 32 identified patients, 7 patients (6 female, 1 male) had restrictive conjunctiva following complex strabismus surgery with functional problems or aesthetic conjunctival scarring requiring transplantation. The mean age of these patients was 47 years (range: 22-60 years). Mean follow-up time was 32 months (range 18-55 months). Only one of these seven patients suffered a discomfort related to conjunctival scarring. The other six patients had restrictive strabismus, four of them suffered from Graves' ophthalmopathy. All patients improved although three patients developed symblepharon. One of these patients needed revision because of a symblepharon. Discussion The result of our study indicates that commercially prepared amniotic membrane is a good alternative graft to replace conjunctiva. It helps to prevent or cure restrictive strabismus, scarring of the conjunctiva with discomfort, and lack of conjunctiva. It is possible that commercially storable products may increase the risk of symblepharon, the reason is unknown.

Purpose: We report a rare case of ocular injury due to potassium permanganate (KMnO4) granules in a child. Methods: This is a retrospective case report. Results: A 2-year-old boy was transferred to our emergency room with severe pain in his right eye, inflamed eyelids, and brownish stains on his fingers. Chemical injury was suspected. Copious eye irrigation was immediately performed. Diffuse brownish splotches were then observed at the inferior bulbar conjunctiva. Otherwise, systemic organs were intact. Complete eye exam under general anesthesia revealed a 5-mm epithelial defect at the central cornea, along with generalized conjunctival injection and limbal ischemia, inferiorly. Multiple semi-dissolved granules of KMnO4 trapped in the inferior fornix were identified. The chemical particles were gradually washed out and removed; however, the brownish stains remained. The patient received preservative-free steroid, antibiotic eye drops, and lubricants as regular management for mild to moderate degree of ocular burn. Pseudomembrane developed early and transformed into symblepharon within a few days after the injury. Membrane adhesion was lysed, and more aggressive medications were then substituted. Commercial amniotic membrane (PROKERA®) was also applied to promote wound healing and to prevent recurrence of symblepharon. The ocular surface was eventually restored, and corneal transparency was preserved. Conclusion: Ocular injury with the granular form of KMnO4 is rare. Its toxicity is comparable to concentrated KMnO4 solution. However, the dissolved particles that had been absorbed in the stained conjunctiva were continuously released and damaged the ocular surface more than we primarily anticipated. Awareness of this condition and prompt management yield a good treatment outcome.

WOS: 000429421300004, PubMed ID: 29576892, Objectives: To investigate the long-term efficacy and results of surgical management of conjunctival melanoma reconstructed with amniotic membrane transplantation. Materials and Methods: Conjunctival melanoma in 10 patients (5 female, 5 male) was totally excised with adjunctive cryotherapy to the surgical margins, corneal epitheliectomy with absolute alcohol in cases of corneal involvement, lamellar sclerectomy in cases with episcleral involvement, and ocular surface grafting with cryopreserved amniotic membrane. Complications and tumor control rates were evaluated. Results: The mean age of the patients was 57.4 +/- 15.2 (range, 37-84) years. The mean diameter of the tumors was 15.5 +/- 4.9 (range, 10-25) mm and histopathologically confirmed complete excision was performed in all cases. Mild limbal stem cell deficiency (2 eyes) and subclinical symblepharon (3 eyes) were observed as long-term complications. In a mean follow-up of 56.7 +/- 40.4 (range, 30-132) months, only one local tumor recurrence was detected. Despite retreatment, exenteration was performed in this patient due to re-recurrence. One patient died due to disseminated metastasis despite the absence of local recurrence. Conclusion: In large conjunctival melanomas, reconstruction of the ocular surface is usually very challenging. The use of cryopreserved amniotic membrane for conjunctival defect repair is safe and effective with mild complications, and allows the excision of wider margins around the tumor.

Purpose: This study aimed to report the long-term outcomes of autologous Simple Limbal Epithelial Transplantation (SLET) performed for unilateral limbal stem cell deficiency (LSCD) following chemical burn at a tertiary eye center in North India. Methods: This was a single-center prospective interventional case series of patients who developed unilateral LSCD after suffering from ocular surface burns and who underwent SLET between October 2012 and May 2016 with a follow-up period of at least 6 months. The primary outcome measure was restoration of a completely epithelized, stable, and avascular corneal surface. The secondary outcome measure was percentage of eyes, which reported visual gain. Results: The study included 30 eyes of 30 patients, 18 adults and 12 children, at a median follow-up of 1.1 years (range: 6 months to 3.5 years), 21 of 30 eyes (70%; 95% confidence interval, 53.6%–86.2%) maintained successful outcome. Visual acuity gain was seen in 71.4% of successful cases. The clinical factors associated with failure were identified as acid injury, severe symblepharon at the time of presentation, and SLET combined with penetrating keratoplasty (PK). Conclusion: Autologous SLET is an effective limbal cell transplantation technique for the treatment of unilateral LSCD. It is especially beneficial for centers where cell cultivation laboratory is unavailable. Presence of severe symblepharon, which requires PK peroperatively , has poor outcome.

Purpose: The purpose of this study is to report on the efficacy and safety of topical chemotherapy alone for giant ocular surface squamous neoplasia (OSSN). Methods: In this retrospective, interventional series, 10 eyes with giant OSSN underwent exfoliative biopsy to confirm the diagnosis followed by application of interferon alpha 2b (IFN α2b) and/or 5 fluorouracil, 1% (5FU). Reported outcome measures were tumor response, visual acuity, recurrence, systemic metastasis, and treatment complications. Results: Ten patients (3 female, 7 male) had a mean age of 73 (median, 69; range 40–89) years. Mean tumor diameter was 13.1 (median, 12.3; range 8.2–19.4) mm. Five (50%) eyes were treated with IFN-α2b alone; 1 (10%) with 5-FU alone and 4 (40%) required both IFN-α2b and 5-FU. The mean duration of treatment was 3, 0.5, and 6.4 months for IFN-α2b alone, 5-FU alone, and both IFN-α2b and 5-FU respectively. Complete tumor response was observed in all 10 cases at mean follow-up of 12.8 (median, 11.5; range, 3–25) months. Complications noted were transient irritation and burning (n = 4), dry eyes (n = 2), and transient flu-like symptoms (n = 2). There was no evidence of chemotherapy-related symblepharon, stem cell deficiency, scleral thinning, or corneal opacity. There were no tumor recurrences, and no patient required surgical excision or cryotherapy. Conclusion: Topical chemotherapy was a safe and effective treatment, inducing complete regression in all cases of giant OSSN in this series. There were no sight-limiting complications.

Purpose: To report a case of Laryngeal Onycho Cutaneous Syndrome in a 10 year old child presenting with an ocular surface mass. Methods: A 10 year old boy presented in the out-patient department with a painless mass in left eye. There was history of airway obstruction requiring tracheotomy in early childhood and recurrent skin ulcerations. Aslit lamp examination revealed fleshy mass arising from the supero-nasalconjunctiva of left eye. Systemic examination revealed ulcerative lesions on cheeks and ears with dystrophic nails in hands and feet. Results: The ocular surface lesion was treated successfully with topical steroid drops. Conclusion: Steroids may be useful in treating early lesion of ocular surface in LOCS. The importance of regular follow must be emphasized for timely management of frequent granulation tissue outgrowth in bid to avoid development of severe symblepharon and blindness.

Mucous membrane pemphigoid has been documented previously in only 19 patients under the age of 20 years. We report a 14-year-old female who had erosions of the oral, ocular, anal and genital mucosa, congestion, hoarseness of voice, dysphagia, and recurrent cough. Symblepharon formation in both eyes necessitated surgical correction. Biopsy of tissue from a solitary cutaneous lesion demonstrated a subepidermal bulla. Direct immunofluorescence showed the deposition of IgG in linear pattern along the dermoepidermal junction. Therapy was begun, consisting of prednisolone at 1 mg/kg/day, in combination with dapsone at 2 mg/kg/day. Azathioprine was added later for control of the disease. The patient showed good clinical response.

Purpose To report a case of hypertrophic herpes simplex virus (HSV) of the eyelid and cornea masquerading as IgG4-related disease. Observations A 37-year old African American female with a past medical history of human immunodeficiency virus (HIV) on highly active antiretroviral therapy (HAART) and a recent history of treated genital herpes, presented with an ulcerative lesion of the left upper and lower eyelids, and severe ocular inflammation with symblepharon. Initially, eyelid biopsy revealed findings consistent with IgG4-related disease, and the patient was treated with high dose oral prednisone. After one week of therapy, there was no improvement in the patient's symptoms, and she subsequently developed a corneal epithelial defect which progressed to chronic ulceration. Repeat biopsy and corneal cultures revealed herpes simplex virus type 2. The patient was treated with high dose acyclovir, and the lid lesion improved. The conjunctival inflammation and corneal epithelial defect resolved but symblepharon restricting her eye movement remained. She also developed corneal vascularization and opacification causing severe vision loss. Conclusions and importance Chronic hypertrophic herpes simplex virus infection is a rare condition reported in patients with HIV. While there have been few reports of hypertrophic HSV affecting the eyelid, this is the first reported case of hypertrophic HSV affecting the eye, resulting in severe vision loss.

INTRODUCTION Alcohol-based hand sanitizers (ABHS) are widely used for hand hygiene due to the coronavirus disease pandemic. However, risk awareness regarding its adverse effects is lacking. We aim to report a case of ocular chemical burn that showed severe clinical presentation associated with ABHS. PATIENT CONCERNS A 5-year-old girl presented with severe left eye pain after 62% gel-type ABHS splashed into her eye. DIAGNOSIS On slit lamp examination, a near total corneal and conjunctival epithelial defect with limbal pale on the lower half of the cornea was noted. Severe ocular burn by ABHS was prominent with suspected limbal stem cell damage. INTERVENTIONS She was hospitalized and was prescribed topical medications including antibiotics, steroid eye drops with preservative-free artificial tears, and oral nonsteroidal anti-inflammatory drugs. OUTCOMES Despite intensive medical treatments, the corneal and conjunctival epithelial defects showed no improvement up to the 4th hospital day. After additional instillation of autoserum eye drops to promote epithelial healing, the corneal epithelium barely recovered from the temporal limbus. On the third week of admission, the epithelial defect was completely resolved without corneal opacity, although with minimal symblepharon in the lower fornix. CONCLUSIONS Gel-type ABHS can cause severe form of ocular chemical burn such as delayed ocular surface healing. In clinical setting, immediate and thorough rinsing of alcohol-based gel and early intensive treatment are crucial.

The purpose of this case report was to have a further study of the proper management of ocular manifestations caused by Stevens-Johnson Syndrome, which aims to minimize the chances of complications. This case report will discuss the ocular manifestations of Stevens-Johnson syndrome. A case report. A 4 years old girl with the problem on admission was the adhesion of her membranes layer (conjunctiva) and eyelid on both of her eyes. The patient’s family also gave additional information on the patient’s eyes problem: pain on both her eyes, tearing, discharge which came out frequently from her eyes, and a white spot in the black section of her eyes. The fluorescein test revealed a positive result, with conjunctival hyperemia. The case was treated as symblepharon and corneal erosion post Stevens-Johnson syndrome, for temporary treatment using artificial tears and antibiotic eye ointment. Ocular manifestations occur in a significant number of patients, and the most severe form of Stevens-Johnson syndrome occurs in those at the end of the spectrum. The acute phase of the disease is characterized primarily by eyelid involvement. The lids are typically swollen and erythematous. Soon after that, or coincident with this, the conjunctiva is inflamed. Conjunctivitis frequently parallels the skin findings, with bullae formation and eruption. Membrane or pseudo-membrane formation then occurs. The healing process can result in cicatricial changes, including symblepharon, ankyloblepharon, eyelid margin rotation, severe dry eye, and conjunctivilization of the cornea.

Few studies have reported the physical complications among Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) survivors. The aim of this study was to comprehensively characterize the physical complications among SJS/TEN survivors and to learn about patients’ perspectives of surviving SJS/TEN. SJS/TEN survivors older than 18 years of age were assessed by different methods: a medical interview; a questionnaire assessing patients’ perspectives; thorough skin, oral mucous membrane, and ophthalmic examinations; and a retrospective assessment of medical records. Our cohort consisted of 17 patients with a mean time of 51.6 ± 74.7 months (median 9, range 1–228) following SJS/TEN. The most common physical complications identified in the medical examination were post-inflammatory skin changes (77%), cutaneous scars (46%), dry eyes (44%), symblepharon, and chronic ocular surface inflammation (33% each). Novel physical sequelae included chronic fatigue (76%) and pruritus (53%). We also found a novel association between the number of mucous membranes affected in the acute phase of SJS/TEN and hair loss during the 6 months following hospital discharge; hair loss was reported in 88% of the group of patients who had three or more mucous membranes affected versus 29% of patients who had less than three mucous membranes involved (p = 0.0406). Following hospital discharge due to SJS/TEN, 59% of patients were followed by a dermatologist, although 88% had dermatological complications; 6% were followed by an ophthalmologist, even though 67% had ophthalmological complications; and 6% of female survivors were followed by a gynecologist, even though 27% had gynecological complications. Survivors of SJS/TEN suffer from severe physical complications impacting their health and lives that are mostly under recognized and not sufficiently treated by medical professionals.