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Herein we describe a technique for management of large inadvertent full-thickness trephination during deep anterior lamellar keratoplasty using the big-bubble technique without converting to penetrating keratoplasty. First, the anterior chamber is formed with an ophthalmic viscosurgical device (OVD). Then, the full-thickness wound is secured with one X-type 10-0 nylon suture. A 27-gauge needle is attached to a 2 mlair-filled syringe and inserted into the corneal stroma in the meridian opposite to the site of full-thickness trephination. Air is gently injected to produce a limited area of "big-bubble" detaching Descemet's membrane (DM) from the corneal stroma. The "big bubble" is slowly expanded with injection of OVD. Finally, the recipient stroma is removed, the donor lenticule is placed and the DM tear is secured with one full thickness 10-0 nylon suture. [ABSTRACT FROM AUTHOR]

A response by Siamak Zarei-Ghanavati, Mehran Zarei-Ghanavati, and Arturo Ramirez-Miranda to a letter to the editor regarding their article "Reverse big bubble: a new technique for preparing donor tissue of Descemet membrane endothelial keratoplasty" in the 2010 issue is presented.

Purpose: To evaluate the repeatability of a pyramidal wavefront-based refraction (WFR) measurement and its agreement with dry autorefraction (DR), cycloplegic autorefraction (CR), and subjective refraction (SR) in myopic refractive surgery candidates., Methods: One hundred eighty-nine eyes from 189 participants were evaluated. PERAMIS aberrometry (PERAMIS; SCHWIND eye-tech-solutions, Kleinostheim, Germany), DR, and CR, as well as SR, were completed for all candidates. The repeatability of PERAMIS measurements was assessed, and the Bland-Altman plots were used to test the agreement between different methods., Results: Repeatability of the PERAMIS aberrometer was very high in the measurement of all refractive elements (Sphere, cylinder, spherical equivalent [M], J0, and J45) (interclass correlation coefficient >0.980 for all). A significant myopic shift was found with WFR compared to CR (0.45 diopter [D]) and SR (0.28 D) ( P < 0.05). For the M component, there was a significant difference between WFR and CR ( P < 0.05). J0 component measured with WFR was significantly different from SR and CR ( P < 0.05). For the J45 variable, all three refraction methods were comparable (all, P > 0.05). In M > 5.00 D, a difference of 0.79 D (limit of agreement: -3.50-1.90) was found between WFR and CR., Conclusions: In lower degrees of myopia, WFR was in good agreement with the manifest autorefraction. WFR, CR, and SR techniques were comparable in measuring astigmatism, especially in oblique astigmatism., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Journal of Current Ophthalmology.)

Purpose: To report initial surgical experience and learning curve with a novel finger-controlled, ultrasoundless lens extractor device and provide insights for future surgical endeavors., Setting: Bascom Palmer Eye Institute (Miami, FL)., Design: Single-center, non-comparative, retrospective, consecutive case series., Methods: 61 eyes of 51 individuals with cataract. All surgeries were performed with the miCOR® 700 lens extractor (Carl Zeiss Meditec Inc, Dublin, CA) by a single experienced physician. Nuclear density was graded preoperatively. Corrected distance visual acuity (CDVA), intraocular pressure (IOP) and pachymetry were evaluated pre- and postoperatively. Surgical videos were reviewed to collect data on time for each surgical step and complications. Regression analyses assessed the learning curve, performance improvement and effects of nuclear density on surgical time and postoperative pachymetric variation., Results: Subjects had a mean age of 72.2 ± 7.6 years. Increased surgical experience significantly reduced procedure time (P < 0.001), nuclear removal time (P = 0.018) and cortex removal time (P = 0.002). Higher nuclear density resulted in longer procedure (P < 0.001) and nuclear removal time (P < 0.001). One posterior capsular rent occurred, not attributed to the lens extractor. No thermal damage to the corneal wound was observed. Postoperative CDVA improved significantly (P < 0.001 for eyes without ocular comorbidities, P = 0.016 for eyes with ocular comorbidities). All cases of corneal edema and IOP spikes resolved within a month., Conclusions: The miCOR® 700 lens extractor offers an innovative, cost-effective approach to cataract surgery. Further research is needed to compare it with conventional phacoemulsification techniques., (Copyright © 2024 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Abstract: Cataracts can cause visual impairment in diabetic patients. Diabetes mellitus (DM) affects different parts of the eye and causes many complications and problems before, during and after intraocular surgeries. In this review, we will discuss the effects of diabetes on different aspects of cataract surgery and review the current management of diabetic cataracts. Careful preoperative examination of the patient's ocular surface, cornea, iris and posterior segment, as well as the use of advanced phacoemulsification techniques, new intraocular lenses (IOLs) and the appropriate use of auxiliary medications such as non-steroidal anti-inflammatory drugs (NSAIDs) and anti-vascular endothelial growth factors (VEGFs) have improved the outcomes of cataract surgery in diabetic patients., (Copyright © 2024 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: To investigate peripapillary retinal nerve fiber layer (pRNFL) thickness changes in preterm children with or without retinopathy of prematurity (ROP) history compared to full-term children., Methods: A retrospective comparative cohort study assessing pRNFL thickness was completed in children aged 4-8 years. Four groups of children were included ( n = 30 each group): children with a history of ROP who were treated with intravitreal bevacizumab, children with ROP who received no treatment, and preterm children without ROP compared to age- and gender-matched full-term children., Results: A total of 120 eyes from 120 children were enrolled in this study. Both treated and regressed ROP children showed a significantly thinner pRNFL in the nasal quadrant compared to full-term children ( P = 0.017 and P = 0.008, respectively). The pRNFL in the superior quadrant of treated ROP children was thinner than the preterm and control groups ( P = 0.015 and P = 0.023, respectively), whereas the inferior quadrant of treated ROP children was thinner than the preterm group alone ( P = 0.008). The pRNFL thickness in the temporal quadrant was comparable between groups ( P = 0.129). The average spatial distribution profile of pRNFL thickness in treated ROP children was significantly thinner than in the preterm group ( P = 0.041)., Conclusion: pRNFL thickness is significantly altered in children with a prior history of treated ROP with thinning of the nasal and superior quadrants compared to full-term children., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Journal of Current Ophthalmology.)

Introduction: Open globe injuries (OGI) represent a main preventable reason for blindness and visual impairment, particularly in developing countries. The goal of this study is evaluating key variables affecting the prognosis of open globe injuries and validating internally and comparing different machine learning models to estimate final visual acuity., Materials and Methods: We reviewed three hundred patients with open globe injuries receiving treatment at Khatam-Al-Anbia Hospital in Iran from 2020 to 2022. Age, sex, type of trauma, initial VA grade, relative afferent pupillary defect (RAPD), zone of trauma, traumatic cataract, traumatic optic neuropathy (TON), intraocular foreign body (IOFB), retinal detachment (RD), endophthalmitis, and ocular trauma score (OTS) grade were the input features. We calculated univariate and multivariate regression models to assess the association of different features with visual acuity (VA) outcomes. We predicted visual acuity using ten supervised machine learning algorithms including multinomial logistic regression (MLR), support vector machines (SVM), K-nearest neighbors (KNN), naïve bayes (NB), decision tree (DT), random forest (RF), bagging (BG), adaptive boosting (ADA), artificial neural networks (ANN), and extreme gradient boosting (XGB). Accuracy, positive predictive value (PPV), recall, F-score, brier score (BS), Matthew correlation coefficient (MCC), receiver operating characteristic (AUC-ROC), and calibration plot were used to assess how well machine learning algorithms performed in predicting the final VA., Results: The artificial neural network (ANN) model had the best accuracy to predict the final VA. The sensitivity, F1 score, PPV, accuracy, and MCC of the ANN model were 0.81, 0.85, 0.89, 0.93, and 0.81, respectively. In addition, the estimated AUC-ROC and AUR-PRC of the ANN model for OGI patients were 0.96 and 0.91, respectively. The brier score and calibration log-loss for the ANN model was 0.201 and 0.232, respectively., Conclusion: As classic and ensemble ML models were compared, results shows that the ANN model was the best. As a result, the framework that has been presented may be regarded as a good substitute for predicting the final VA in OGI patients. Excellent predictive accuracy was shown by the open globe injury model developed in this study, which should be helpful to provide clinical advice to patients and making clinical decisions concerning the management of open globe injuries., (© 2024. The Author(s).)

Purpose: To investigate the visual, refractive, and biomechanical outcomes of small incision lenticule extraction (SMILE) with two different cap thicknesses., Methods: Thirty-four patients were included in this prospective, randomized, contralateral eye study. Subjects were randomized to receive SMILE surgery with a 110-m cap thickness in one eye and 145-µm cap thickness in the fellow eye. Uncorrected and corrected distance visual acuity, contrast sensitivity (CS), total higherorder aberrations (THOAs) and corneal biomechanical properties were compared 3 months after surgery., Results: Postoperative refractive and visual outcomes, CS and THOAs were similar between the two groups ( P > 0.05 for all parameters). At 3 months postoperatively, there was a significant difference in Corvis ST Biomechanical Index (CBI); stiffness parameter at first applanation (SP A1), and Integrated Radius between the two groups (all P < 0.05)., Conclusions: Eyes with thicker SMILE corneal caps showed no advantage regarding visual acuity, CS and THOAs over eyes with thinner caps. However, higher cap thickness may result in better corneal biomechanical properties postoperatively., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To assess the agreement between biometric parameters measured by a spectral-domain optical coherence tomography optical biometer device (Optopol Revo NX) with a validated swept-source biometer (IOLMaster 700) and a validated optical low-coherence reflectometry biometer (Lenstar LS 900), in cataract surgery candidates., Methods: In this prospective comparative study, 100 patients (100 eyes) who were eligible for cataract surgery were involved. Bland-Altman plots were used to assess agreement between devices for biometric parameters including axial length (AL), anterior chamber depth (ACD), lens thickness (LT), and central corneal thickness (CCT)., Results: AL measurements were successful in 82 eyes (82.0%) with Revo NX, in 91 eyes (91.0%) with Lenstar LS 900, and in 97 eyes (97.0%) with IOLMaster 700. When Revo NX was compared to IOL Master 700 and Lenstar LS 900, the mean differences were as follows: -0.02 ± 0.02 mm and -0.02 ± 0.03 mm (P = 0.313, P = 0.525) for AL, 0.01 ± 0.03 mm and 0.10 ± 0.03 mm (P = 0.691, P = 0.002) for ACD, -0.15 ± 0.03 mm and 0.001 ± 0.04 mm (P < 0.001, P = 0.95) for LT, and -2.29 ± 0.92 μm, and 0.73 ± 1.43 μm (P = 0.015, P = 0.612) for CCT. Three devices were highly correlated for AL, ACD, LT, and CCT (interclass correlation coefficient > 0.75). Bland-Altman plots showed a narrower 95% limit of agreement (-0.35 to 0.31) between Revo NX and IOLMaster 700 in measuring AL., Conclusions: Despite the higher measurement failure rate in eyes with cataract, the Revo NX showed very good agreement with the IOLMaster 700 and Lenstar LS 900 optical biometers in measuring AL, ACD, LT, and CCT. However, ACD and LT measurements cannot be considered interchangeable between these devices., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Current Ophthalmology.)

A 24-year-old man was referred for postrefractive surgery evaluation. The patient had a history of uneventful laser in situ keratomileusis (LASIK) in both eyes 3 months previously. According to the surgeon who originally performed the surgery, on slitlamp examination, only microstriae in the left eye was detected on postoperative day 1 and a more conservative follow-up approach was adopted without further immediate intervention. The patient returned only 3 months after surgery, complaining of low vision in the left eye that, according to the patient, had been present since postoperative week 2. The patient was then referred for examination and surgical procedure with a diagnosis of significant postoperative striae. The slitlamp examination revealed a LASIK flap with striae, epithelial filling, and a wrinkled appearance (Figure 1JOURNAL/jcrs/04.03/02158034-202312000-00017/figure1/v/2023-11-20T151558Z/r/image-tiff). There were no signs of infection or inflammation. Originally, the LASIK flap was programmed to be 110 μm. Preoperative manifest refraction in the right eye was -5.25 (20/20) and in the left eye was -5.25 (20/20). Assuming it is a case of late-approach LASIK flap striae, how would you proceed? Would you try to hydrate and lift the flap and just reposition it? Would you avoid lifting and associate phototherapeutic keratectomy (PTK) with excimer laser on top of the flap? Would you consider topo-guided surgery with regularization of the visual axis or even amputation of the flap?, (Copyright © 2023 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Introduction: In thyroid eye disease (TED), all ocular components and adnexa such as extraocular muscles, orbital adipose tissues, eyelids, and tear glands could be affected. This study aimed to study the orbital biomechanical parameters in patients with TED, in terms of differences with healthy individuals and correlation with clinical findings, using Corvis ST (CST, Oculus Wetzlar)., Materials and Methods: In this study, 26 consecutive patients with TED were recruited. Demographic data were collected, and patients with TED were assessed for exophthalmos, intraocular pressure, and clinical activity score. Biomechanical response parameters of one randomly-chosen eye of each patient, including whole eye movement length (WEMl) and time (WEMt), were evaluated by the CST, and data were compared between patients and age- and gender-matched healthy controls., Results: The mean age was 39.88 ± 11.61 years old for patients with TED and 34.38 ± 8.57 years old for the healthy subjects. Nine out of 26 patients with TED and nine of 26 healthy individuals were male. The median duration of thyroid disease was 36 (IQR 54) months and the median duration of thyroid ophthalmopathy was 27 (IQR 27) months. Four out of 26 patients (7.7%) had active disease. The mean WEMl was 206.15 ± 61.58 µm in the TED group and 254.23 ± 64.01 μm in the healthy group, the difference of which was statistically significant (p = 0.008). The median of WEMt was 20.90 (1.15) msec in the TED group and 21.45 (0.93) msec in the healthy group (p < 0.001). Also, the mean of WEMl and WEMt were lower in patients with active disease compared to patients with quiescent disease., Conclusion: The CST-derived WEMl was significantly smaller in patients with thyroid eye disease compared to normal subjects. The WEMl and WEMt were relatively shorter in the patients with active TED compared to the patients with quiescent TED, although small numbers of patients with active TED limits took a statistically significant conclusion. WEMl and WEMt might be useful in evaluating the compliance of the orbit in patients with TED., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: To assess the therapeutic efficacy of a combinational therapy, including conventional treatment and intense pulsed light (IPL) technique on sleep quality of patients with meibomian gland dysfunction (MGD)., Methods: Fifty participants with a clinical diagnosis of MGD were enrolled in this study. Participants underwent three sessions of IPL therapy. There was a 2-week interval between IPL sessions 1 and 2 and 1 month between sessions 2 and 3. Treatment was supplemented with conventional home-based therapy (including lid hygiene, warm compress, eyelid massage, and lid margin scrub) for MGD. Dry eye symptomatology, tear film, and ocular surface parameters were evaluated at baseline (day 0) and days 15, 45, and 75. Sleep quality was assessed before and after the study using Pittsburgh Sleep Quality Index (PSQI)., Results: PSQI components improved significantly at day 75 in comparison with the baseline (all P < 0.05). Ocular Surface Disease Index (OSDI) score, noninvasive Keratograph tear break-up time (NIKBUT), fluorescein tear break-up time (FTBUT), meibomian gland expressibility, meibum quality score, and tear osmolarity improved at follow-up visits ( P < 0.05). Younger patients showed more improvement in NIKBUT, sleep quality, and duration ( P = 0.024, P = 0.047, and P = 0.008). Sleep latency decreased with increased NIKBUT and FTBUT and decreased OSDI score ( P = 0.001, P = 0.005, and P = 0.041)., Conclusions: The treatment of MGD is effective for improving sleep quality. Younger patients may preferentially benefit from the treatment., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Current Ophthalmology.)

Purpose: To assess the possible association between keratoconus (KC) and serum levels of 25-hydroxyvitamin D (25OHD), Selenium (Se), Zinc (Zn), and Copper (Cu) and to compare it with age-matched healthy subjects., Methods: One hundred patients with KC and 100 normal subjects were included. The two groups were compared for serum 25OHD and serum levels of three trace elements: Se, Zn, and Cu. These factors were also compared between groups with different KC stages., Results: Serum levels of vitamin D, Zn, Cu, and Se were significantly different between the KC and normal groups ( P = 0.006, P = 0.015, P = 0.004, and P = 0.038, respectively). Although a lower level of 25OHD was found in severe stages of KC, it was not significantly different among different KC groups ( P = 0.441). KC stage groups were not significantly different for mean serum Zn, Cu, and Se ( P = 0.130, P = 0.98, P = 0.113, respectively). Although the Cu/Zn ratio was higher in cases than in controls, there was no significant difference between the two groups and between KC stages ( P = 0.168, P = 0.143, respectively)., Conclusion: Lower serum 25OHD, Cu, Zn, and Se were found in the KC group compared to the control group. The results of this study suggest that a lower antioxidative activity may be involved in the possible etiology of KC., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Current Ophthalmology.)

Purpose: To determine 4-year changes of ocular biometric and dioptric components in Iranian children aged 7-11 years following the first phase., Methods: 468 children were evaluated in the first phase of the study in 2012 and again in 2016-2017. Multi-stage stratified cluster sampling was applied to select the participants. The Topcon autorefractometer and the LENSTAR/BioGraph biometer (WaveLight AG, Erlangen, Germany) were used for cycloplegic refraction and biometry, respectively. All measurements were repeated at 4 years as the baseline assessments., Results: Of 468 children, 251 (53.6%) were boys. Spherical equivalent (SE) showed a marked myopic shift ( P  = 0.000) in the second phase which was significantly higher in boys (0.24 vs. 0.18 D) ( P  < 0.001). Axial length (AL) and anterior chamber depth (ACD) increased by 0.49 ± 0.05 and 0.12 ± 0.02 mm, while lens thickness (LT) and lens power (LP) decreased by 0.08 ± 0.01 mm and 1.59 ± 0.12 D, respectively ( P  < 0.05). The mean corneal curvature and thickness did not change significantly during 4 years. All biometric component changes were greater in boys. Biometric changes in different age groups showed a decreased LP, increased AL, and increased ACD in most age groups ( P  < 0.05), while LT and SE did not change significantly in the age groups 9 and 11 years and 8 and 9 years, respectively. Changes in the corneal thickness, diameter, curvature, and refractive astigmatism were not significant in any of the age groups ( P  > 0.05)., Conclusions: Statistical and clinical changes were seen in AL, ACD, LP, and LT. The changes observed in biometric components (AL, ACD, and LT) had a sinus rhythm.

Purpose: To develop clinical practice guidelines (CPGs) for prevention, diagnosis, treatment and follow-up of ocular injuries caused by exposure to mustard gas., Methods: The clinical questions were designed by the guideline team. Websites and databases including National Guidelines Clearinghouse, National Institute for Clinical Excellence, Cochrane, and PubMed were searched to find related CPGs and explore possible answers to the clinical questions. Since there were no relevant CPGs in the literature, related articles in Persian and English languages were extracted. Each article along with its level of evidence was summarized. Additionally, hand search was performed by looking the reference list of each article. Consequently, recommendations were developed considering the clinical benefits and side effects of each therapeutic modality. The recommendations were re-evaluated in terms of customization criteria. All recommendations along with the related evidence were scored from 1 to 9 by experts from all medical universities of Iran. The level of agreement among the experts was evaluated by analyzing the given scores., Results: The agreement was achieved for all recommendations. The experts suggested a number of minor modifications which were applied to the recommendations. Finally, CPGs were developed with 98 recommendations under three major domains including prevention of injury, diagnosis and management of the acute and delayed-onset mustard gas ocular injuries., Conclusion: Considering the lack of CPGs for the prevention, diagnosis, and management of mustard gas-induced keratitis, these recommendations would be useful to prevent the serious ocular complications of mustard gas and standardize eye care services to the affected individuals., Competing Interests: There are no conflicts of interest.

Purpose: To report the indications and techniques of corneal transplantation at a tertiary referral center in Tehran over a 3-year period., Methods: Records of patients who had undergone any kind of corneal transplantation at Labbafinejad Medical Center, Tehran, Iran from March 2004 to March 2007 were reviewed to determine the indications and types of corneal transplantation., Results: During this period, 776 eyes of 756 patients (including 504 male subjects) with mean age of 41.3±21.3 years underwent corneal transplantation. The most common indication was keratoconus (n=317, 40.8%) followed by bullous keratopathy (n=90, 11.6%), non-herpetic corneal scars (n=62, 8.0%), infectious corneal ulcers (n=61, 7.9%), previously failed grafts (n=61, 7.9%), endothelial and stromal corneal dystrophies (n=28, 3.6%), and trachoma keratopathy (n=26, 3.3%). Other indications including Terrien's marginal degeneration, post-LASIK keratectasia, trauma, chemical burns, and peripheral ulcerative keratitis constituted the rest of cases. Techniques of corneal transplantation included penetrating keratoplasty (n=607, 78.2%), deep anterior lamellar keratoplasty (n=108, 13.9%), conventional lamellar keratoplasty (n=44, 5.7%), automated lamellar therapeutic keratoplasty (n=8, 1.0%), and Descemet stripping endothelial keratoplasty (n=6, 0.8%) in descending order. The remaining cases were endothelial keratoplasty and sclerokeratoplasty., Conclusion: In this study, keratoconus was the most common indication for penetrating keratoplasty which was the most prevalent technique of corneal transplantation. However, deep anterior lamellar keratoplasty is emerging as a growing alternative for corneal pathologies not involving the endothelium.

Purpose: Intravitreal injections can cause several ocular complications, including vitreous hemorrhage, endophthalmitis, retinal detachment, and cataract, and clearly repeated injections can multiply the risk of these complications. Bevacizumab is used for the treatment of different ocular diseases. For improvement of drug availability after intravitreal administration, in this study, liposomal bevacizumab as a novel drug delivery system was prepared and compared with conventional formulas in the market., Methods: Bevacizumab was encapsulated into liposomes via the dehydration-rehydration method. After reducing the size of liposome to the nanoscale, the final liposomal formulation was tested in an animal model. Left eyes of rabbits received liposomal bevacizumab and the right eyes were injected by soluble bevacizumab. The free drug concentration in aqueous humor and vitreous samples at Days 3, 7, 14, 28, and 42 after the injection was determined by enzyme-linked immunosorbent assay., Results: Mean concentration of free bevacizumab in the eyes that received liposomal bevacizumab compared with the eyes injected with soluble bevacizumab was 1 (48 versus 28 microg/mL) and 5 (16 versus 3.3 microg/mL) times higher at Days 28 and 42, respectively. Mean concentration of free bevacizumab in the aqueous humor of both injected eyes was almost the same at the different intervals., Conclusion: The results of this study showed the beneficial effects of liposomes in prolonging the residency of bevacizumab in the vitreous.

Nocardia keratitis occurred in 4 eyes of 3 patients (2 women and 1 man) who had photorefractive keratectomy (PRK) by the same surgeon at the same center. Two eyes of the first 2 patients required lamellar keratectomy to debulk the involved stroma and obtain specimens for microbiological and histopathological evaluation. Light microscopic examination disclosed gram-positive and acid-fast filaments of Nocardia that were confirmed by the microbiological results. Diagnosis of Nocardia keratitis in the third case was not as challenging as in the first 2 cases because of a high index of suspicion. Confocal scans of all cases disclosed hyperreflective and slender, fibril-like structures in the corneal stroma. All eyes responded favorably to topical amikacin and the infection resolved without recurrence. The most probable cause of the outbreak was inadequate attention to sterility during surgery.