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Plasma cell granuloma is a rare non-neoplastic inflammatory condition of unknown etiology commonly involving lung and gastrointestinal tract. Conjunctival disease per se is very rare and usually associated with involvement of other organs. We report a case of conjunctival plasma cell granuloma without any systemic involvement in a 9-year-old girl who presented with bilateral reddish vascularised subconjunctival episcleral mass. An excision biopsy of the mass in the left eye followed by histopathologic examination and Immunohistochemistry confirmed the diagnosis. At 1 year follow-up, the child had no recurrence in the operated eye whereas the lesion remained the same in the other eye despite systemic treatment with immunosuppressants. This case is being reported for its rarity and to insist on the mandatory need for a thorough systemic workup to identify multiorgan involvement as well as to rule out other systemic disorders.

Resumo Atualmente a membra amniótica (MA) tem obtido importância devido à comprovada capacidade de reduzir inflamação, auxiliar a cicatrização e epitelização, possuindo propriedades antimicrobianas e antivirais, além de baixa imunogenicidade. As indicações de seu uso na oftalmologia têm aumentado muito nas duas últimas décadas. Objetivo: Descrever a estrutura básica e as propriedades biológicas da MA em relação aos componentes da sua matriz extracelular e fatores de crescimento, as consequências de diferentes técnicas empregadas na sua preservação e esterilização, métodos para remoção do epitélio e a comparação dos custos dos diferentes meios de conservação atualmente empregados. Métodos: Pesquisa nas bases de dados do Portal da Biblioteca Virtual em Saúde (BVS), Pubmed, Cochrane, Scielo e Lilacs com as palavras-chave: membrana amniótica, transplante, reconstrução da córnea, doenças da conjuntiva. Resultados: A literatura é vasta na descrição dos efeitos de diversos agentes e técnicas na preparação da MA, dentre elas sua preservação, esterilização e desepitelização. A membrana desnuda tem sido a escolha para a reconstrução da superfície ocular, pois facilita a cicatrização. Em relação aos agentes conservantes, o glicerol é o meio mais utilizado mundialmente pelo baixo custo e facilidade de manuseio. Conclusão: A comparação das diversas técnicas nos guia na elaboração de protocolos de preparo da MA para uso oftalmológico. A membrana desnuda facilita a cicatrização em relação a com células epiteliais. O glicerol é o meio de conservação mais utilizado pelo baixo custo e facilidade de manuseio. Abstract Currently, the amniotic membrane (AM) has obtained importance due to its ability to reduce inflammation, helping in the healing and epithelialization processes, having antimicrobial and antiviral properties and low immunogenicity. Its indications in ophthalmology have increased considerably in the past two decades. Objective: To describe the basic structure and biological properties of the AM, the components of the extracellular matrix and growth factors, the consequences of different techniques used in its preservation, and sterilization methods for the epithelium removal. To compare the costs of the different preservation solutions currently employed. Study design: literature review. Methods: Research in BVS databases, PubMed, Cochrane, Scielo and Lilacs with keywords: amniotic membrane transplantation, corneal reconstruction, conjunctival diseases. Results: The literature is vast in describing the effects of different agents and techniques used in the preparation of MA, including its preservation, sterilization and desepithelization. The naked membrane is the choice to reconstruct the ocular surface, as it facilitates the healing course. Regarding the preservatives, glycerol is the most used worldwide due its low cost and easy handling. Conclusion: Comparing different techniques guides us in developing a MA preparation protocol for ophthalmic use. The naked membrane facilitates the healing process compared with the presence of epithelial cells. The glycerol is the most used preservation method because of its low cost and easy handling.

A Bitot spot is a conjunctival lesion, classically associated with severe vitamin A deficiency. In this paediatric series, we describe conjunctival lesions indistinguishable from Bitot spots, seen in the presence of normal vitamin A levels. This descriptive case series was performed by retrospective review of case notes, including all patients with Bitot-like spots found to have normal serum vitamin A levels, seen at the Hospital for Sick Children, Toronto, between 2006 and 2016. Data collected included age at presentation, ophthalmic and systemic diagnoses, and the presence of recognised genetic mutations. Histopathology was reviewed in one case. Ten patients with Bitot-like spots with laboratory-confirmed normal serum vitamin A levels were identified. The conjunctival lesions were indistinguishable clinically and histopathologically from classic Bitot spots and were noted to occur in a range of anterior segment pathologies, including aniridia, WAGR syndrome, Axenfeld–Rieger syndrome, and blepharokeratoconjunctivitis. Bitot-like spots are found in children with a number of anterior segment pathologies in the absence of vitamin A deficiency. This study adds weight to the observation that Bitot-like spots can occur without vitamin A deficiency. We report their presence in children with predominantly genetic eye conditions of the anterior segment.

Rationale: Conjunctival papilloma is a benign neoplastic lesion of epithelial origin, with a minimal tendency toward malignancy and an exophytic growth type. Etiological factors that contribute to the appearance of papilloma are UV exposure, HPV infection, smoking, and immunodeficiency. A case report of limbal conjunctival papilloma treatment with topical interferon alpha-2b eye drops applied to the conjunctival sac. Patient concerns: A 49-year-old female patient treated in the Clinical Department of Ophthalmology for conjunctival lesion located in the temporal quadrant near the limbus of the right eye. Ocular examination of the patient's eye did not show any abnormalities: visual acuity—20/20, intraocular pressure—16 mmHg. Diagnoses: During physical examination, a broad-based pink lesion of size 4 mm × 6 mm was found in interpalpebral bulbar conjunctiva with prominent feeder vessels and soft consistency. Lesion in the biomicroscopic examination did not show any sign of malignancy. In Swept Source Optical Coherence Tomography (SS-OCT) there was no sign of infiltration into sclera or cornea. In vivo confocal microscopy (IVCM) examination, revealed loss of the normal conjunctival epithelium - hyper-reflective cells, variation of cell size. A clinical diagnosis of limbal conjunctival papilloma was made. Interventions: Interferon alpha-2b 1 million IU/ml eye drops were applied 4 times a day for 5 months. The treatment lasted 5 months without changing the dosing regimen. Three months after the start of the interferon treatment, a complete regression of the lesion was achieved. Treatment was continued for the following 2 months. Controlled IVCM after 6 months showed only few hyper-reflective cells and fibrotic tissue. Outcomes: Treatment of conjunctival papilloma with topical interferon alpha-2b led to the complete regression of the lesion. Although after the therapy the conjunctiva appears normal both in slit lamp and in the OCT examination, there is a noticeable fibrosis of the tissue in confocal microscopy. During the 14-month follow-up period, there were no recurrent lesions. Lessons: In this study, topical interferon alpha-2b has been shown to be an effective and safe therapy for small-to-medium-size conjunctival papilloma without any sign of malignancy.

A 46 year old white woman was referred for ophthalmologic evaluation of a pigmented lesion on the ocular surface of her left eye. The lesion had been noted during a routine eye examination by her general practitioner. She had first noticed the lesion six years earlier, believing it to be gradually increasing in size. Slit lamp biomicroscopy of the eye is shown in fig 1. No cysts were noted within the lesion and no other lesions were evident on complete ophthalmic examination, which included eversion of the eyelids and …

Background The coronavirus disease 2019 (COVID-19) has reportedly affected almost 23 million people, with more than 800 thousand deaths globally. There have been a few reports on the ocular manifestations of COVID-19 patients in China but no reports in Korea. The present study aimed to examine ocular manifestations of COVID-19 patients in Korea. Methods COVID-19 patients admitted from March 2020 to April 2020 at Keimyung University Dongsan Hospital and Keimyung University Daegu Dongsan Hospital were reviewed retrospectively for ocular manifestations. During the period of hospitalization, ocular symptoms as well as blood test results were noted and analyzed. Patients were then divided into the first-episode and relapsed group and ocular symptoms were analyzed in the groups. Results A total of 103 patients were included in this study. Among them, 71patients were in the first-episode group and 32 patients in the relapsed group. No significant differences were determined in terms of positivity of ocular symptoms between the first-episode group (12 patients, 16.9%) and the relapsed group (10 patients, 31.3%, P > 0.05). Symptoms of positive upper respiratory infection and lower creatine phosphokinase were determined to be related to positive ocular symptoms. Conjunctival congestion was noted in seven patients. In the subgroup analysis, the conjunctival congestion-positive patients exhibited higher positivity of upper respiratory infection symptoms (100%) as compared with those in the negative group (40%, P = 0.017). Conclusion Positive upper respiratory infection symptoms and lower creatine phosphokinase were determined to be related to ocular symptoms in COVID-19 patients. Among these patients, positive upper respiratory infection symptoms were associated with conjunctival congestion., Graphical Abstract

Purpose: To evaluate the ocular manifestation in patients hospitalized with coronavirus disease 2019 (COVID-19) and to search for the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in tears.Methods: This study was conducted in 29 hospitalized patients who were admitted to the COVID center at the Policlinic Hospital of the University of Messina, Italy.All patients underwent an ophthalmologic assessment comprising a Standardized Patient Evaluation of Eye Dryness (SPEED) questionnaire, anterior segment, and the ocular surface examination of both eyes using a portable slit lamp.The Schirmer I test was performed, and the filter paper strip was used to search for the presence of SARS-CoV-2 on the ocular surface by real-time quantitative polymerase chain reaction (RT-qPCR).Results: A total of 10 patients reported ocular symptoms; in particular, four reported eye burning, three reported foreign body sensation, and three reported tearing. Moreover, seven patients presented conjunctival hyperemia and/or chemosis, eleven patients presented blepharitis signs such as lid margin hyperemia and/or telangiectasia, crusted eyelashes, and meibomian orifices alterations. Tear analysis did not reveal the presence of SARS-CoV-2.Conclusion: Ocular symptoms are common in patients with COVID-19; although, tear analysis did not reveal the presence of SARS-CoV-2.

The prevalence of dry eye disease is high worldwide and poses a great burden on patients’ daily lives. Accurate diagnosis of the disease is important, and it requires application of various methods. Hyperosmolarity is believed to be the disease marker and thus measuring it provides useful information. In this study we investigated utility of tear osmolarity measured with TearLab osmometer, along with other diagnostic tests (Ocular Surface Disease Index questionnaire, Tear film break-up time, Ocular Protection Index, Ocular Surface Staining, Schirmer I test, Meibomian gland functionality in 757 patients (1514 eyes) with dry eye disease and 29 healthy controls (58 eyes). Statistical differences between the patient group and the control group were observed for all the tests apart from tear osmolarity, regardless of cut-off value (>308 mOsm/L, >316 mOsm/L, and inter-eye difference >8 mOsm/L). Moreover, in the receiver operating characteristics curve analyses tear osmolarity measurement could not discriminate dry eye disease pathological scores. Therefore, our study suggests that tear osmolarity measured with TearLab osmometer cannot be used as a key indicator of DED.

Purpose To analyze and provide an overview of the incidence, management, and prevention of conjunctival erosion in Argus II clinical trial subjects and postapproval patients. Methods This retrospective analysis followed the results of 274 patients treated with the Argus II Retinal Prosthesis System between June 2007 and November 2017, including 30 subjects from the US and European clinical trials, and 244 patients in the postapproval phase. Results were gathered for incidence of a serious adverse event, incidence of conjunctival erosion, occurrence sites, rates of erosion, and erosion timing. Results Overall, 60% of subjects in the clinical trial subjects versus 83% of patients in the postapproval phase did not experience device- or surgery-related serious adverse events. In the postapproval phase, conjunctival erosion had an incidence rate of 6.2% over 5 years and 11 months. In 55% of conjunctival erosion cases, erosion occurred in the inferotemporal quadrant, 25% in the superotemporal quadrant, and 20% in both. Sixty percent of the erosion events occurred in the first 15 months after implantation, and 85% within the first 2.5 years. Conclusion Reducing occurrence of conjunctival erosion in patients with the Argus II Retinal Prosthesis requires identification and minimization of risk factors before and during implantation. Implementing inverted sutures at the implant tabs, use of graft material at these locations as well as Mersilene rather than nylon sutures, and accurate Tenon's and conjunctiva closure are recommended for consideration in all patients.

Giant fornix syndrome (GFS) results in chronic, relapsing conjunctivitis in elderly patients with enophthalmos and enlarged fornices, in which infectious material collects and perpetuates inflammation. A 98-year-old woman presented with persistent, bilateral, purulent conjunctivitis; corneal epithelial defects and progressive blepharospasm that did not respond to artificial tears, topical antibiotics and steroids and amniotic membrane grafts. Additional findings of deep-set orbits with enlarged upper fornices were diagnostic of GFS. Over the next 2 months, she responded to a combination of topical and systemic antibiotics, autologous serum eye drops, povidone-iodine forniceal rinses, and hypochlorous acid treatment of the eyelashes. GFS is an important diagnostic consideration in elderly patients with chronic conjunctivitis and deep-set orbits.

Importance Excessive ocular sun exposure is linked to various eye pathologies. Conjunctival ultraviolet autofluorescence (CUVAF) is a method of detecting sun-related conjunctival damage; however, the custom-built camera system required is not readily available. Background We investigated whether blue laser autofluorescence (BAF) on a commonly used confocal scanning laser ophthalmoscope (cSLO) can be utilized to measure CUVAF area. Design Cross-sectional evaluation of a diagnostic technology at a medical research institute. Participants Sixty-four participants recruited from three on-going observational eye studies in Western Australia. Methods All participants had four images, two of each eye, captured using the CUVAF camera and BAF on the same day. Participants with pterygium or poor quality images were excluded from the analysis. Two graders measured CUVAF area in each image twice. CUVAF area measured by BAF was then compared to measurements determined with the conventional camera system. Main outcome measures CUVAF area. Results After exclusions, 50 participants' images were analysed. Intra- and inter-observer repeatability were similar between the two systems. When comparing CUVAF area measured by BAF to the camera measurement, grader 1 had a mean difference of +1.00 mm2 , with 95% limits of agreement -5.75 to 7.77 mm2 . Grader 2 had a mean difference of +0.21mm2 , with 95% limits of agreement -7.22 to 7.64 mm2 . Conclusions and relevance BAF on a commercially available cSLO is a valid method for measuring CUVAF area. This finding provides broader opportunity for identifying, monitoring and educating patients with sun-exposure-related ocular conditions and for researching the ocular impacts of sun exposure.

Objectives This study aimed to analyze the influencing factors of meibomian gland loss in patients with ocular chronic graft-versus-host disease (GVHD) and its correlation with other clinical ocular surface assessment indexes. Methods The clinical data of patients with ocular chronic GVHD from the ocular surface and corneal outpatient clinic of the First Affiliated Hospital of Soochow University were reviewed from June 2012 to June 2016. The relationship between the percentage of meibomian gland acinar area and the influencing factors, such as patient's sex, age, transplantation method, human leukocyte antigen (HLA) matching, the time when eye discomfort appeared after transplantation (month), and the severity of ocular chronic GVHD, was investigated. Moreover, the correlation between the percentage of meibomian gland acinar area and other ocular surface assessment indexes, such as subjective ocular symptom score, eyelid margin score, tear film break-up time, corneal and conjunctival staining score, and the Schirmer test, was analyzed. Results A linear relationship was found between the percentage of meibomian gland acinar area and the severity of ocular chronic GVHD, but no linear relationship existed between the percentage of meibomian gland acinar area and the factors such as sex, age, transplantation method, HLA matching, and the time when eye discomfort appeared after transplantation. A negative correlation was observed between the percentage of meibomian gland acinar area and eyelid margin score. Conclusions The percentage of meibomian gland acinar area can reflect the severity of ocular chronic GVHD. The clinical significance of the percentage of meibomian gland acinar area needs further investigation.

This review offers recommendations for monitoring disease status in ocular cicatricial pemphigoid as well therapeutic options including local and systemic therapies.A negative biopsy on direct immunofluorescence does not preclude a diagnosis of OCP. If a patient's cicatrization is active and/or progressive, systemic immunosuppression should be commenced.OCP is a chronic systemic autoimmune disease that requires systemic immunosuppression.

Background Sustained drug delivery is a large unmet clinical need in glaucoma. Here, we incorporated a Myocardin-Related Transcription Factor/Serum Response Factor inhibitor, CCG-222740, into slow release large unilamellar vesicles derived from the liposomes DOTMA (1,2-di-O-octadecenyl-3-trimethylammonium propane) and DOPC (1,2-dioleoyl-sn-glycero-3-phosphocholine), and tested their effects in vitro and in vivo. Results The vesicles were spherical particles of around 130 nm and were strongly cationic. A large amount of inhibitor could be incorporated into the vesicles. We showed that the nanocarrier CCG-222740 formulation gradually released the inhibitor over 14 days using high performance liquid chromatography. Nanocarrier CCG-222740 significantly decreased ACTA2 gene expression and was not cytotoxic in human conjunctival fibroblasts. In vivo, nanocarrier CCG-222740 doubled the bleb survival from 11.0 ± 0.6 days to 22.0 ± 1.3 days (p = 0.001), decreased conjunctival scarring and did not have any local or systemic adverse effects in a rabbit model of glaucoma filtration surgery. Conclusions Our study demonstrates proof-of-concept that a nanocarrier-based formulation efficiently achieves a sustained release of a Myocardin-Related Transcription Factor/Serum Response Factor inhibitor and prevents conjunctival fibrosis in an established rabbit model of glaucoma filtration surgery.

Purpose To investigate the clinical features and risk factors of atypical mycobacterial infection in anophthalmic sockets with porous orbital implant exposure. Design Case-control study. Methods The medical records of all patients who had undergone surgical correction of porous orbital implant exposure were consecutively reviewed, and the patients were stratified as those with atypical mycobacterial infection (AM infection group) and others (non-AM group). Results Five and 21 patients were included in the AM infection and non-AM groups, respectively. All patients of the AM infection group had a peg or motility coupling post (MCP) and showed implant exposure around it. Following up on implant exposure, 2 patients abruptly presented with severe conjunctival injection and new lesions such as erythematous nodules or eyelid masses. They underwent immediate orbital implant exchange and atypical mycobacterial infection was diagnosed. Three patients who were not suspected of having infection underwent surgery for orbital implant exposure. Results revealed erythematous eyelid nodule or recurrent exposure shortly after surgery and patients were diagnosed with atypical mycobacterial infection. In the non-AM group, 7 (33.3%) patients underwent insertion of a peg or MCP. Statistical analysis showed that the insertion of a peg or MCP was the only risk factor showing a significant difference between the 2 groups. Conclusions The most important underlying risk factor for atypical mycobacterial infection in the anophthalmic socket is thought to be peg- or MCP-related exposure of the porous orbital implant. Surgical removal of the infected orbital implant and long-term antibiotic medication are needed for treatment.

Introduction: We report a case of patient who underwent bilateral eyeball tattoo procedure for cosmetic purpose complicated with intraocular dye injection which led to ocular inflammation, secondary glaucoma, and cataract. Case description: A 21-year-old female presented to emergency department with severe right eye pain and photophobia 21 days after conjunctival tattooing procedure. Slit-lamp examination revealed right-sided eyelid edema and black deposits of tattoo ink under the bulbar conjunctiva. Dye deposits were also present in anterior chamber, covering corneal endothelium, iris and anterior lens’ capsule. Ocular inflammation and secondary glaucoma were diagnosed. The patient underwent surgical treatment to control ocular inflammation. Intraocular pressure remained stable after Nd:YAG iridotomy and on topical drugs. Moreover, during the follow-up, in contralateral eye, we observed “conjunctival lumps”—local hypersensitivity reaction to the dye, which were asymptomatic to the patient. Conclusion: Eyeball tattooing complications are new challenges that ophthalmologist may have to face nowadays. We also reviewed for the first time possible complications of eyeball tattooing described in available literature.

Introduction: To report a case of ocular dirofilariasis in Central Italy (Pisa, Tuscany) and review the previous cases of ocular dirofilariasis reported in Italy. Case description: A 67-year-old man complained about recurrent ocular redness and discomfort previously treated as conjunctivitis. The slit-lamp examination showed a round, translucent cystic swelling under the bulbar conjunctiva of the right eye, near the lateral canthus. Inside this lesion was observed the presence of a motile worm. A surgical procedure was immediately performed, excising a thin, segmented, greyish worm identified as Dirofilaria repens. After the excision, no recurrence of the symptomatology was recorded. Conclusion: Ocular dirofilariasis can lead to misdiagnosis due to its rare ocular manifestations and it is considered an emergent zoonosis in European countries. In Italy from 2001 to January 2018, seven new cases were reported in the literature. In our opinion, it is critical to record all the new cases to assess the epidemiological situation and increase the awareness of this rare infection.

Background The surgical management of patients with uncontrolled glaucoma and scleroderma is challenging, as the hostile ocular surface poses a challenge to surgery. A serious complication is tube erosion, with the risk of subsequent endophthalmitis. Here, we present a novel technique of harvesting autologous tissue to successfully manage recurrent tube extrusion. Case presentation MG is a 60-year-old Arabic lady diagnosed with scleroderma, that was previously managed with systemic corticosteroids. She has chronic open angle glaucoma, with a failed left eye trabeculectomy, which was then managed by a Baerveldt tube (BVT) insertion. Eight months after this primary surgery, she developed an anterior uveitis. This was further complicated by conjunctival erosion, tube exposure, leak around the sclerostomy site and hypotony. The erosion was likely secondary to her tight eyelids as a result of her scleroderma. She was taken back to theatre for tube revision, with single layer amniotic membrane transplant (AMT) over the exposed area, but the tube was eroding again after 2 months. She eventually underwent tube extraction, pars plana tube plate stabilisation, pars plana vitrectomy (PPV), pars plana tube insertion, phacoemulsification and intra-ocular lens insertion, jointly with the vitreo-retinal surgeons and with high dose prednisolone cover both pre- and post-operatively. We harvested the capsule which had grown over the end plate of the original tube. We sutured this over the new tube, specifically over a single layer of tutoplast prior to conjunctival closure. Almost a year on, the pars plana tube remains in place with no complications. Conclusions This case highlights the role of a pars plana tube in cases of cicatricial disease, with the use autologous tissue instead of grafts wherever possible. In patients with systemic disease such as scleroderma, pre-operative immunosuppression helps to reduce the of erosion in difficult cases.

Purpose Ocular adnexal amyloidosis (OAA) may represent localized manifestation of an underlying systemic process. Accurate identification of the amyloid fibrils can guide the systemic evaluation and treatment. The aim of this study was to characterize subtypes of OAA using immunohistochemistry and mass spectrometric analysis and to correlate with ocular involvement and systemic association. Design Retrospective case series. Methods Review of patients with OAA subtyped by immunohistochemistry and mass spectrometric analysis at the Cleveland Clinic from June 1995 to June 2017. Results While immunohistochemistry identified AL amyloid protein in 67% (4/6) of specimens tested, mass spectrometry identified AL amyloid protein in all specimens (10/10). AL lambda was identified in 5 (50%) samples, kappa in 3 (30%), and both kappa and lambda light chains in 2 (20%). The 5 cases of conjunctival amyloidosis were either AL lambda only (3 cases) or both lambda and kappa (2 cases). There were 3 cases that had associated systemic involvement. Two of these had eyelid skin involvement and AL kappa amyloidosis and the other patient had uveal involvement and AL lambda amyloidosis. Conclusions Primary amyloidosis-AL is the most common form diagnosed by mass spectrometric analysis in patients with OAA. Immunohistochemistry is ineffective in the characterization of the amyloid deposits in a significant number of cases. Evaluation to exclude systemic involvement or associated underlying lymphoproliferative disorder is warranted.

Purpose: To identify alterations in neuropathic and inflammatory pain gene expression associated with contact lens (CL) wear and CL discomfort (CLD).Methods: Eight non-wearers, eight asymptomatic C...

We present the case of a 3-year-old male child with an epibulbar bone choristoma. The patient presented with a hard consistency subconjunctival mass of 8×10mm in the superior-temporal quadrant of his right eye along with vascularisation and a long cilium of approximately 8 to 10mm that touched the corneal surface. The histopathology study showed the presence of trabeculae of mature, compact bone surrounded by fibrous tissue, as well as Havers channels with concentric rings of laminar bone without bone marrow, and with normal osteocytes which defined the diagnosis of epibulbar bone choristoma. Osseous choristoma is the rarest type of the ocular choristoma and should be considered as a differential diagnosis among paediatric epibulbar tumours.

To evaluate histopathological characteristics of conjunctival pigmented lesions and analyze clinical features related to histologic classification in Asian population, we analyzed medical records, anterior segment photographs, and histological specimen of 85 eyes who had undergone biopsy for pigmented conjunctival lesions at Seoul National University Hospital between 1999 and 2018. Compound nevus was the most common type of conjunctival pigmented lesions (67.1%), followed by conjunctival melanocytic intraepithelial neoplasia (primary acquired melanosis)(11.8%), subepithelial nevus (8.2%), and malignant melanoma (MM)(7.1%). Patients with compound nevus were younger than those with non-compound nevus (22.1 ± 17.0 vs 39.9 ± 18.8 years, p p = 0.053), and feeder vessels were associated with most of compound nevus (98.2% vs 78.6% of non-compound nevus, p = 0.005). The lesion in MM was larger, involved multiple quadrants, and had extrabulbar location than lesions without melanoma (p p p = 0.002, respectively). Together, the results would help clinicians to distinguish benign conjunctival pigmentations from malignant counterparts in clinical practice without biopsy.

To find safer and more effective drugs than mitomycin C to prevent conjunctival fibrosis in a rabbit model.Twenty-four rabbits were involved and randomly divided into four groups. Limbus-based peritomy was performed at the superior cornea, and normal saline (NS group), mitomycin C (MMC group), SR (SR group), or TC (TC group)-coated silicone plate was inserted at the sub-Tenon's space in each group. Conjunctival congestion was evaluated at 1 and 4 weeks postoperatively. At 4 weeks, the numbers of inflammatory cells, fibroblasts, myofibroblasts, blood vessels, and goblet cells were counted in the conjunctiva and Tenon's capsule around the silicone plate.At 4 weeks, conjunctival congestion was significantly less than that observed at 1 week in the SR and TC groups (p0.05), whereas the number of myofibroblasts was significantly lower in the MMC and TC groups (p0.05). The conjunctiva was significantly less congested in the TC group versus the other groups at 1 week and 4 weeks (p0.05). The TC group had the lowest number of inflammatory cells and MMC group had the lowest number of goblet cells among all groups (p0.05).The TC-coated silicone plate was more effective in inhibiting inflammation and fibrosis versus the MMC-coated silicone plate and was associated with fewer adverse effects in the rabbit model.

BackgroundTo develop targeted antifibrotic therapy for glaucoma filtration surgery; this study determines the effectiveness of small interfering RNA (siRNA) to reduce in vivo secreted protein acidic and rich in cysteine (SPARC) expression using the mouse model of conjunctival scarring.MethodsExperimental surgery was performed as described for the mouse model of conjunctival scarring. Scrambled (siScram) or Sparc (siSparc) siRNAs, loaded on layer-by-layer (LbL) nanoparticles, were injected into the conjunctiva immediately after surgery. Expression ofSparc,Col1a1,Fn1andMmp14was measured by real-time PCR and immunoblotting on days 7 and 14 postsurgery. Live imaging of the operated eyes was performed using slit lamp, anterior segment-optical coherence tomography and confocal microscopy. Tissue pathology was evaluated by histochemical and immunofluorescent analyses of operated conjunctival cryosections. Tissue apoptosis was quantitated by annexin V assay.Results siSparc, delivered via expanded LbL nanoparticles, significantly inhibitedSparctranscription in both day 7 (2.04-fold) and day 14 (1.39-fold) treated tissues.Sparcsuppression on day 7 was associated with a significant reduction ofCol1a1(2.52-fold),Fn1(2.89-fold) andMmp14(2.23-fold) mRNAs. At the protein level, both SPARC and collagen 1A1 (COL1A1) were significantly reduced at both time points with siSparc treatment. Nanoparticles were visualised within cell-like structures by confocal microscopy, while overt tissue response or apoptosis was not observed.Conclusions SPARC targeted therapy effectively reduced both SPARC and collagen production in the operated mouse conjunctiva. This proof-of-concept study suggests that targeted treatment of fibrosis in glaucoma surgery is safe and feasible, with the potential to extend to a range of potential genes associated with fibrosis.

PURPOSE To assess the ophthalmologic complications after oculofacial plastic and esthetic surgeries, including their incidence and management. METHODS A retrospective study was performed on 110 patients who presented with ocular complications followed by oculofacial plastic and esthetic surgeries from January 2014 to December 2015. The incidence and management of complications after each surgery or procedure were analyzed. RESULTS For lower eyelid blepharoplasty, the common complications were chemosis and lower eyelid ectropion. There was also a case of canalicular laceration. Exposure keratitis and corneal abrasion were the most common complications after upper eyelid blepharoplasty. Chemosis frequently occurred after lateral cathoplasty, but other complications, such as ectropion, trichiasis, and lacrimal fistula, were also seen. Nasolacrimal duct obstruction occurred in some cases of orthognathic surgery, and was managed with endonasal dacryocystorhinostomy. Inflammatory lipogranuloma was a common complication after autologous fat transplantation. CONCLUSION Complications after oculofacial plastic and esthetic surgeries are not rare. Ophthalmologists must be aware of not only common complications but also rare and possibly serious conditions that may occur after such surgeries.

Objective The objective of this article was to study longitudinal changes in bleb morphology (presence of microcysts and bleb height and vascularity) in subjects enrolled in the Singapore 5-Fluorouracil (5-FU) trabeculectomy study. Study design Retrospective subgroup analysis of a randomized controlled trial. Materials and methods Following trabeculectomy with either 5-FU or placebo, subjects were reviewed at day 1, weeks 1, 2, and 3, and months 3, 6, 9, 12, 16, 20, 24, 28, 32, and 36 and intraocular pressure (IOP), presence of microcysts and bleb height and vascularity graded and recorded. Statistical analyses were used to investigate baseline factors (demographics, eye drops use, IOP, treatment type, and comorbidities) that might account for long-term bleb changes and assess the influence of bleb morphology on mean, maximum, minimum, and variation in IOP following trabeculectomy. Results One hundred fifty-nine (61.2%) subjects completed follow-up and 71 subjects (44.7%) received 5-FU. Proportion of subjects with microcysts increased posttrabeculectomy till weeks 3 and 6 in 5-FU and placebo-treated eyes, respectively, before decreasing. Presence of microcysts at day 1 and week 2 was associated with lower mean (P=0.027 to 0.033), maximum (P=0.040), and minimum IOP (P=0.010). Mean bleb height decreased over 36 months and at months 20 and 36 was associated with maximum (P=0.031) and minimum IOP (P=0.032), respectively. Mean bleb vascularity decreased till month 9 and remained fairly constant after. Conclusions Microcysts seen early posttrabeculectomy is associated with lower IOP. Blebs reduce in height as they remodel and the relationship between bleb vascularity and IOP is complex.

Conjunctivochalasis (CCH) is a conjunctival condition characterized by loose, redundant conjunctival folds, most typically in the inferior bulbar conjunctiva of both eyes. Although CCH is a common cause of ocular irritation and discomfort, especially in the elderly, it is often overlooked in clinical practice. CCH may be associated with various ocular and nonocular conditions; however, the most important risk factor is aging. Although often asymptomatic, CCH may cause symptoms related to tear film instability and/or delayed tear clearance. Pathogenesis of CCH remains largely unknown but may involve different elements such as aged conjunctiva, unstable tear film, mechanical friction, ocular surface inflammation, and delayed tear clearance. Contradictory results have been reported on histopathologic changes in CCH, with some studies showing a normal microscopic structure. For symptomatic CCH, medical treatment may include lubrication and anti-inflammatory medications. For symptomatic patients who fail to respond to medical treatment, a surgical procedure may be considered. Although various surgical procedures have been used for CCH, more often, it consists of conjunctival cauterization or excision of the redundant conjunctiva, with or without amniotic membrane transplantation.

OBJECTIVE Chemosis is a common occurrence after orbital reconstruction surgery by the transconjunctival approach. The authors propose an early tarsorrhaphy approach for treating severe conjunctival chemosis following orbital fracture repair. METHODS All severe conjunctival chemosis patients following orbital fracture repair were divided into 2 groups: tarsorrhaphy performed immediately when the eyelids could not close completely due to prominent conjunctival edema (early tarsorrhaphy, n = 10); and tarsorrhaphy performed 3 days after the appearance of severe chemosis (delayed tarsorrhaphy, n = 10). Once the conjunctiva subsided, the sutures were immediately removed. The duration of conjunctival edema was recorded. RESULTS The average time to resolution of severe chemosis was significantly shorter in the early versus delayed tarsorrhaphy group (3.5 ± 0.5 versus 7.2 ± 1.73 days, P

Purpose: To describe the risk of developing ocular mucous membrane pemphigoid (MMP) or a new extraocular site of MMP, and to identify risk factors for new involvement. Methods: Retrospective chart review of 162 biopsy-proven MMP patients. Results: At presentation, 109 of 162 MMP patients (67.3%) had ocular involvement and 53 patients did not. Of the 53 patients without ocular involvement at presentation followed up to 22 years, the risk of developing ocular MMP was 0.014 per person-year (PY, 95% confidence interval [CI]: 0.005/PY, 0.034/PY). The risk of developing any new location of extraocular MMP was 0.020/PY (95% CI: 0.007/PY, 0.043/PY). Smoking was a risk factor for developing an additional extraocular MMP location (hazard ratio [HR] = 4.09, p = 0.04). Conclusions: Patients presenting with extraocular MMP are at risk for developing ocular MMP, and all MMP patients are at risk for developing secondary extraocular MMP locations, although the rates were low.

End-of-day (EOD) symptoms of dryness are too often the cause of poor soft contact lens (SCL) tolerance and abandonment of wear. This review examines an amplifying cascade model for these symptoms, which involve thin tear layers on contact lens (CL) front surfaces being susceptible to evaporation-related short tear breakup (TBU) times. Susceptibility to faster tear loss by evaporation may be exacerbated by other forms of tear instability, such as lipid and mucin deficiencies as well as lens surface soiling. Bulbar and palpebral conjunctival hyperaemia and associated faster evaporation of warmer pre-conjunctival tears could also contribute to evaporative dry eye EOD symptoms. In CL wearers, a cascade of increasing hyperaemia toward the end of day, associated increasing tear temperature and evaporative loss, shortened TBU times (TBUTs) and increased osmolarity, all elevate the risk of higher symptom levels according to progressive amplification of this cascade. Chronic wound healing responses to SCL wear, perhaps related to limbal conjunctival trauma, stem cell deficiency and persistent epitheliopathy, as well as one or more immune responses, may contribute directly or indirectly to inflammation and the amplifying evaporative dryness cascade. A diurnal cycle that culminates in EOD symptoms appears to involve a process of recovery from causal mechanisms after lens removal, which allows lenses to be worn comfortably, at least initially the next day. Possible recovery processes are discussed in this review as are procedures that may help de-amplify an inflammatory, evaporative dryness cascade and alleviate EOD symptoms. Evidence of an accrual of adverse responses over long periods of more or less successful lens wear indicate an incremental failure to recover from EOD hyperaemia. Such incremental failure could help explain how SCL wear too often needs to be abandoned after many years of comfortable wear.

Purpose To determine the demographic features of patients affected by limbal stem cell deficiency (LSCD), and to identify the underlying causes of LSCD. Design Retrospective, multicenter case series. Setting: Two large tertiary care ophthalmology hospitals. Subjects: Patients with a diagnosis of LSCD presenting from January 1, 2005 to December 31, 2014. Methods Records of patients with a clinical diagnosis of LSCD were reviewed. Demographic details and clinical features at presentation, as well as the underlying cause of LSCD (if identified), were noted. Descriptive statistical analysis and chart preparation were done. Main outcome measures were type of LSCD (unilateral or bilateral), age and sex of patients, extent of LSCD (clock hours of limbus involved), and underlying cause of LSCD. Results We found 1331 patients with LSCD in the 10-year period under study. Unilateral LSCD was more common (791 patients) than bilateral LSCD (540 patients). Out of 1331 patients, 875 (65.74%) were male. The median age of patients was 24 years. Extent of LSCD could be determined in 1849 eyes, of which 1239 eyes (67.00%) had total LSCD. The underlying cause of LSCD could be identified in 1512 eyes. In cases of unilateral LSCD, ocular surface burns was the commonest identifiable cause (83.73%). The leading identifiable causes of bilateral LSCD were ocular surface burns (29.95%), allergic conjunctivitis (29.48%), Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) (23.11%), aniridia (9.43%), and mucous membrane pemphigoid (3.54%). Lime ("chuna") injury was responsible for ocular surface burns in 352 out of 567 cases in which the agent was identified (62.08%). Conclusions In our study, unilateral LSCD was more common than bilateral LSCD. Young male subjects were commonly affected, with a majority of eyes suffering from total LSCD. Overall, ocular surface burns are the leading cause of LSCD. Unilateral and bilateral LSCD had a markedly different distribution of causes, necessitating different approaches to management.

Purpose of this study was to determine the frequency and spectrum of eye disorders presenting to the eye clinic of Damnhour, Behira Eye Hospital. Introduction: Epidemiological studies provide information on the prevention, treatment, and minimization of the impact of diseases on the society. Subjects and Methods: During November 2016 to December 2016, all patients who presented to Damnhour, Behira Eye Hospital suffering from ocular diseases other than refractive errors were included in this study.6252 patients were examined and evaluated for different eye diseases. Results: Conjunctival diseases were the most common disorders seen (33.7 %), followed by eye lid and lacrimal system diseases (27.4 %) and cataract (25.2 %). Conclusion: The most common causes of ocular morbidity in patients seen at Damnhour, Behira Eye Hospital were conjunctivitis, blepharitis, chalazia. These morbidities were preventable through community proper eye health education and proper hygiene. Cataract was the leading cause of visual impairment in elders. Proper intervention was needed to avoid visual impairment and blindness.

Conjunctivochalasis is a common cause of tear dysfunction due to the conjunctiva becoming loose and wrinkly with age. The current solutions to this disease include either surgical excision in the operating room, or thermoreduction of the loose tissue with hot wire in the clinic. We developed a near-infrared laser thermal conjunctivoplasty system. The system utilizes a 1460-nm programmable laser diode system as the light source. At this wavelength, a water absorption peak exists and the blood absorption is minimal, so the heating of redundant conjunctiva is even and there is no bleeding. A miniaturized handheld probe delivers the laser light and reshapes the laser into a 10 × 1 mm2 line on the working plane. A foot pedal is used to deliver a preset number of calibrated laser pulses. A fold of loose conjunctiva is grasped by a pair of forceps. The NIR laser light is delivered through an optical fiber and a laser line is aimed exactly on the conjunctival fold by a cylindrical lens. Ex vivo experiments using porcine eye was performed to investigate the induced shrinkage of conjunctiva and decide the optimal laser parameters. It was found that up to 45% of conjunctiva shrinkage could be achieved.

Purpose To evaluate the presence of atopy in patients with ocular cicatricial pemphigoid (OCP). Method Patient encounters between August 2005 and November 2016 at the Massachusetts Eye Research and Surgery Institute (MERSI) were searched to identify those with biopsy-proven OCP who had concurrent evidence of atopy. Results There were 230 patients with biopsy-proven OCP. Thirty-three of them were found to have clinical symptoms of atopy (asthma, hay fever, and eczema) and of these, 23 had evidence of atopy in their conjunctival biopsy specimens. All patients were administered immunomodulatory therapy for treatment of their OCP with 20 patients requiring additional antiallergy treatment to control residual atopic ocular symptoms. Among patients who used antiallergy medications, 80% showed improvement in residual symptoms. Rituximab and/or intravenous immunoglobulin is a preferred OCP medication for patients with OCP with some evidence of atopy. Conclusions Clinicians should consider the coexistence of atopy in patients with OCP, especially in those with persistent symptoms after initiation of immunomodulatory therapy.

Background/aimsTo determine the incidence of scarring in women in a trachoma low endemic district of rural Tanzania and to determine the effects of lifetime cooking fire exposure and markers of lower socioeconomic status on incidence of scarring in these women.MethodsA prospective cohort study was conducted over a 3.5-year period from 2013 to 2016 in 48 villages in Kongwa, Tanzania where trachoma at baseline was 5.2% in children. A random sample of 2966 women aged 15 and older who were at risk for incident scarring were eligible for follow-up. Data on demographic factors, cooking fire exposure and trachomatous scarring were gathered at baseline and follow-up. An index of lifetime exposure to cooking fire exposure was created and bivariate analysis, age-adjusted logistic regression and multivariable logistic models were used to look for associations of demographic factors and cooking fire exposure with incident trachomatous scarring.ResultsThe cumulative incidence of scarring was 7.1% or 2.0% per year. Incidence of scarring increased with age and exposure to markers of lower socioeconomic status. A multivariable logistic regression model adjusting for confounding factors did not find an association between lifetime cooking fire exposure and incidence of scarring (OR=0.92; 95% CI 0.68 to 1.24, P=0.58).ConclusionsThere was still incident scarring in women in Tanzania despite low rates of active trachoma. There was no association between exposure to cooking fires and incident scarring. More research is needed to understand the factors that contribute to new scarring in these women.

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.

Conjunctival epithelial inclusion cysts are an infrequent complication in anophthalmic sockets. The ocular prosthesis may become difficult to retain or it may cause local discomfort. Treatment options described include surgical resection, marsupialisation, and the use of injected sclerosing agents. We present a case of a 27-year-old female who developed a conjunctival epithelial inclusion cyst two years after a left eye evisceration. This invariably caused the ocular prosthesis to become cosmetically unacceptable. Trichloroacetic acid 20% (TCA) was injected intracystically as a minor procedure at the slit lamp. Four months later there was no recurrence of the cyst and the prosthesis retained an excellent position in the socket. This case highlights the successful treatment of a conjunctival epithelial inclusion cyst with TCA (20%) without the need for a surgical procedure.

PURPOSE To report the clinical course of a patient with ocular manifestations of hyperviscosity syndrome associated with Waldenstrom macroglobulinemia, and for the first time, video imaging of mobile emboli in the conjunctival and retinal vasculature. METHODS AND PATIENT A 60-year-old woman with newly diagnosed Waldenstrom macroglobulinemia, with no visual complaints was evaluated by the Ophthalmology service for a baseline ocular examination. RESULTS At presentation, ocular examination revealed a visual acuity of 20/25 in each eye. Slit lamp examination showed mobile white emboli throughout the conjunctival vasculature of both eyes, which was captured on video. Dilated fundus examination revealed peripheral vascular occlusion along with extensive collateral formation in both eyes and as dilation of vessels at the posterior pole of the left eye. Mobile arterial and venous emboli were also observed in the retinal vasculature, which were captured with slit-lamp color and infrared reflectance video imaging. CONCLUSION Hyperviscosity syndrome is a rare circulation sequelae that occurs when blood is thickened secondary to an increase in immunoglobulins or a hyperproliferation of blood components as in bone marrow dyscrasias. The increase in viscosity is plainly observable in the retinal circulation, and this syndrome is often diagnosed based on visual symptoms and fundus examination. We report a patient with Waldenstrom macroglobulinemia who presented with multiple ocular manifestations of hyperviscosity syndrome despite the absence of visual complaints. Ophthalmologists should be aware that regardless of the lack of any subjective visual changes, ocular findings of hyperviscosity syndrome should prompt quick referral to a Hematology Oncologist for evaluation of other end-organ damage. We also for the first time, provide video documentation of mobile emboli in the conjunctival and retinal vasculature.

Subconjunctival granulomata developed in 2 patients after use of GenTeal gel to lubricate the cornea during strabismus repair. We report the clinical findings and histopathology of the subconjunctival nodules. These lesions are similar to those previously reported following use of GenTeal gel in retinal surgery and use of similar large polymers in nonocular surgeries. Copious irrigation should be considered when conjunctival wounds are exposed to GenTeal gel, and alternative corneal wetting agents should be considered for use during strabismus surgery.

Purpose The present study was designed to investigate the role of myofibroblast transdifferentiation and the conjunctival renin-angiotensin system (RAS) in the pathogenesis of graft-versus-host disease (GVHD)-associated conjunctival fibrosis. Methods A mouse model of major histocompatibility-matched allogeneic transplantation was used to induce GVHD, with male B10.D2 mice as donors and female BALB/c mice as recipients. Male BALB/c to female BALB/c syngeneic transplantation was used as control. Y chromosome staining in the spleen cells obtained from female recipient mice was used to confirm engraftment. The phenol red thread test and fluorescein staining were used to quantify tears and corneal keratopathy. Eyes were harvested at 4 and 8 weeks after the transplant for alpha-smooth muscle actin (α-SMA), angiotensinogen, and angiotensin-converting enzyme (ACE) immunostaining. Conjunctiva was harvested for gene expression quantification of α-SMA, angiotensinogen, and ACE. Results More than 80% of the spleen cells in the recipient mice were chromosome Y positive, thus conforming successful engraftment. A significant decrease in tear secretion and a marked increase in corneal keratopathy score after allogeneic transplantation indicated the onset of ocular GVHD in these mice. A significant increase in α-SMA gene expression and the presence of a large number of α-SMA-positive cells was noted in the bulbar orbital conjunctiva of mice after allogeneic transplantation. Allogenic transplantation also caused a significant increase in the gene expression and protein expression of angiotensinogen and ACE in the subconjunctival eyelid area. Conclusions Results of the present study demonstrate that GVHD-associated conjunctival fibrosis is accompanied by myofibroblast formation and activation of the local conjunctival RAS.

Purpose To examine the clinical implications of positive or negative direct immunofluorescence biopsies (DIF) in patients with clinically typical ocular mucous membrane pemphigoid (MMP). Design Retrospective cohort study. Methods The study population was patients with clinically typical ocular MMP disease with documented DIF results who were followed for at least 1 year at the Duke University multidisciplinary ocular MMP clinic. Data were collected by chart review and included patient demographics, clinical examination findings, and history of autoimmune disease and/or malignancy, as well as topical, systemic, and surgical treatments received. Main outcome measures included MMP Disease Area Index, Foster stages, proportion legally blind, duration of follow-up, and use of systemic immunosuppression and ocular procedures in treatment. Results In multivariable analysis restricted to 55 patients, patients with negative and positive biopsies were similar in the outcome measures; however, positive-biopsy patients were more likely to be treated with systemic immunosuppression and were followed for longer at our clinic. Patients with isolated ocular disease were also more likely to have negative biopsies compared to those who also had extraocular disease. Patients who had conjunctival biopsies were more likely to have a negative direct immunofluorescence result than patients with biopsies from other sites. Conclusions We encourage clinicians and patients to consider treatment with systemic immunosuppression even in the absence of diagnosis confirmation by DIF. Furthermore, this study supports current standard of care to pursue a nonocular biopsy of normal-appearing, perilesional skin or oral mucosa when possible.